General Adult

Question 1

EPSEs

Answer 1

Medication history consider if dystonia and parkinsonism or Tardive dyskinesia

Start by asking about stiffness abnormal facial movements including if others have noticed anything, excess salivation, restlessness, shakiness

Get patient to hold hands out in front observe the tremor

Fingers to thumb test for Bradykinesia

Look at face and mouth abnormal lip movements asked to protrude tongue examine dentition

Examine tone in upper limbs one joint at the time -? Lead pipe cogwheeling or clasp knife

examine reflexes in upper limbs

Observed patient sitting in chair with palms on phis looking for akathesia

Lower limb tone and reflexes

Observe gait and also for Bradykinesia

Question 2

Neuroleptic malignant syndrome

Answer 2

Can occur between hours and months but typically within days

Neuroleptic naive patients, high-potency antipsychotics,
Atypical antipsychotics more often causal, dehydrated patients, organic brain disease

Features (FARM)

Fever

Autonomic instability with tachycardia labile blood pressure tachypnoea a pallor and sweating

Rigidity (more than SS)

Mental Status changes

Also
Excess salivation
Nystagmus 
Mutism etc (dysarthria/dysphasia)
Seizures 

Blood test would include CK also full blood count (high WCC) UEs (high K+)
Proteinuria

Treatment is withdraw offending agent dopamine agonist such as bromocriptine
muscle relaxant such as dantrolene

Supportive ventilation including sedation with benzos and ICU if necessary

Question 3

Serotonin syndrome

Answer 3

Can occur with Seretonergic drugs but classically with monoamine oxidase inhibitors and SSRIs together

Ataxia
Pyrexia
altered consciousness
Tremors

clonus and Hyperreflexia good for differentiating from NMS

Do not use bromocriptine ass will make worse in serotonin syndrome

Question 4

Akathesia

Answer 4

Treatment is not procyclidine rather propanolol as first line then benzodiazepines

Question 5

Thyroid exam

Answer 5

Excess tiredness cold intolerance weight gain loss of appetite

General observation looking for agitation and weight

Inspect hands look for tremor quality of nails and check pulse observing for tachycardia

Look up at head looking for Thinning hair, proptosis from front and side eye movements with ? lid lag

Inspects neck looking from front and side ask patient to swallow some water

Palpate

Palpate lymph notes

Percuss down onto sternum

Auscultate for Bruits (thyroid and carotid)

Lower limb for pre-tibial myxoedema ankle jerk

Question 6

Cranial nerve exam

Answer 6

1. Olfactory

Any changes with your smell recently? Check occlusions on the side by asking patient to occlude one and inhale with the other

2. Optic

Snellen chart, Visual fields covering one eye at a time. Pupils for light and accommodation.

Fundoscopy

3.4.6 oculomotor, trochlear and abducens

H shape

5 Trigeminal

Sensation
Soft touch and pain in three areas side to side using sternum as base line

Motor
Check strength of Masseters and jaw jerk reflex

7. Facial nerve

Furrow brow, raise eyebrows, squeeze eyes shut, blow cheeks out, taste

8. Vestibulocochlear

Whispered words ?Rinne’s/Weber’s

?Nystagmus from oculocephalic reflex

9.10. Glossopharyngeal and Vagus

Uvula, cough and speech (ggg, ppp, ttt)

11. Accessory

Shrug shoulders against resistance of observing sternocleidomastoid

12. Hypoglossal

Tongue (in cheek and side to side)

Question 7

Anxiety

Answer 7

Autonomic symptoms

Palpitations tachycardia hyperventilation sweating

Abdominal symptoms nausea abdominal pain diarrhoea

Mental symptoms

Derealisation, fear of losing control, dizzy or lightheaded

Fight or flight response -adrenaline and Noradrenaline
Imbalance of oxygen and carbon dioxide causes some symptoms like dizziness and nausea

Vicious circle

CBT can be very effective due to the link between force feelings and behaviours

Initially then relaxation exercises

Then identify a hierarchy of fears

Gradual graded exposure

Here and now

homework

Can take medication as well

Question 8

Alcohol exam

Answer 8

General assessment of appearance

Look at hands for Palmer erythema Tremor tobacco stain.

Check pulse ?AF

Look at that for JVP and palpate liver if necessary

Face

Foetor hepaticus
Eyes jaundice
Dentition

Abdomen for spider naevi hepatomegaly caput Medusa ascites

Cerebella exam

Danish

Question 9

DBT

Answer 9

CBT + individual and group

Focus on DSH in individual and hierarchy

Group

Distress tolerance
Interpersonal effectiveness
Core mindfulness
Emotional regulation

Question 10

Psychodynamic

Answer 10

Past unconsciousness

Question 11

Cognitive distortions

Answer 11

X6