James Bloomer Psych SBAs Flashcards
The MMSE assesses the following aspects of cognitive function EXCEPT:
a) Orientation
b) Long term memory
c) Registration and recall
d) Calculation
e) Language
b) Long term memory
You are working in general practice. Peter Townsend is a 32 year old man who has been treated for schizophrenia for the last 10 years. He wishes to discuss some symptoms that he thinks are related to his medication.
Which of the following is an example of extrapyramidal side effects of antipsychotic medication?
a) Mannerisms
b) Akathisia
c) Stereotypies
d) Compulsions
e) Tics
b) Akathisia
Akathisia is usually a relatively early side effect of antipsychotics, and is a subjective sense of restlessness. Patients feel unable to sit still, and may pace relentlessly to relieve this unpleasant feeling. Akathisia is associated with an increased risk of suicide. The other options are examples of repeated movements, but are not caused by antipsychotic use. Antipsychotics are sometimes used to treat tics.
During an assessment of a 40 year old woman in accident and emergency, you note that she seemingly becomes “stuck” on one answer, repeating it inappropriately in answer to a series of questions. You correctly recognize this as perseveration.
Which of the following is MOST likely to cause perseveration?
a) Mood disorders
b) Personality disorders
c) Substance misuse
d) Organic disorder
e) Schizophrenia
d) Organic disorder
Rufus Martinsdale is a 21 year old man with a diagnosis of schizophrenia. He experiences hallucinations and delusions.
Rufus is most likely to experience hallucinations in which of the following modalities?
a) Visual
b) Olfactory
c) Tactile
d) Gustatory
e) Auditory
e) Auditory
Most common type in schizophrenia
Cindy Goggins lives in London and is well known to psychiatric services with a diagnosis of paranoid schizophrenia. She has relapsed, following non-concordance with her olanzapine, and is now presenting with auditory hallucinations and persecutory delusions, in a manner almost identical to that of her previous relapse. Cindy has refused to engage with her Care Coordinator for the past three weeks, and her family report she is not eating and drinking, since she believes terrorists have spiked her food with ricin. The Community Mental Health Team are organizing a Mental Health Act Assessment to allow Cindy to be admitted to psychiatric hospital for treatment of her schizophrenia.
Which section of the Mental Health Act is most appropriate in this situation?
a) 2
b) 3
c) 5
d) 12
e) 136
b) 3
Section 3 of the Mental Health Act enables admission for treatment for a period of up to 6 months. If Cindy was an unknown patient, had presented differently to usual, or her diagnosis was in doubt for any reason, a Section 2 should be used, to admit her for assessment.
Dimitrios Bekas is a 22 year old man, who was admitted informally to a psychiatric ward following a suicide attempt. The nursing staff have contacted you, as the on-call doctor, because Mr Bekas has become agitated and wishes to leave the ward. You assess Mr Bekas, and are concerned that he is very distressed and remains at high risk of self-harm if he leaves hospital tonight. You inform the registrar on-call, and are advised to place Mr Bekas under Section 5(2) of the Mental Health Act.
How long can Mr Bekas be held in hospital under Section 5(2)?
a) 48 hours
b) 72 hours
c) 1 week
d) 1 month
e) 3 months
b) 72 hours
Section 5(2) allows a patient already on an inpatient ward to be detained for a maximum of 72 hours. It only requires the recommendation of 1 doctor, who does not need specialist Mental Health Act training. Only in extreme circumstances should a patient be detained under a Section 5(2) for the full 72 hours. Best practice is that the patient should receive a formal Mental Health Act assessment as soon as possible to decide whether they can go home or whether they should remain in hospital for assessment (Section 2) or treatment (section 3).
Mrs Bailey is an 82 year old woman, who lost her husband 3 months ago. She is admitted to Accident and Emergency with chest pain and a heart attack is diagnosed. Her condition and treatment options are explained to her, but she refuses treatment and wishes to return home. Her daughter, Emma, is her legal next of kin. Emma explains that her mother has ‘given up’, and hasn’t been herself since Mr Bailey’s death. Emma tearfully asks you to treat her mother.
a) She is likely to be suffering an abnormal grief reaction.
b) In accordance with the Mental Health Act, her medical condition can be treated under Section 3.
c) The incidence of myocardial infarction is increased in those who have recently suffered the loss of their spouse.
d) She is suffering severe depression and lacks the capacity to make decisions about her medical care.
e) An elderly patient can be treated at the behest of their next of kin if it is judged they lack the capacity to consent to treatment.
c) The incidence of myocardial infarction is increased in those who have recently suffered the loss of their spouse.
Abnormal grief reactions are not diagnosed unless there is something unusual or severe about the grief process. There is nothing here to suggest that Mrs Bailey’s reaction is abnormal, and she should not be expected to be “back to normal” after only 3 months since her loss. Medical conditions are not routinely treated under the Mental Health Act. There is insufficient information here to decide whether Mrs Bailey is depressed or lacks capacity to make decisions about her medical care. Even if she is found to lack capacity, her next of kin cannot consent on her behalf: no-one can give consent for treatment on behalf of an adult. Mrs Bailey’s capacity must be assessed urgently.
You are a student attached to a psychiatric firm. You are preparing to interview a patient.
Which of the following is TRUE?
a) Interviewing in pairs is intimidating to the patient and should be avoided as far as possible.
b) Formal dress is important since it implies respect for your patient; men should wear ties.
c) It is important to arrange the seating in the interview room prior to the interview.
d) Whilst patients are intoxicated their symptoms are easier to elicit due to disinhibition; it is often a good time to conduct an initial interview.
e) Violent outbursts often occur ‘out of the blue’ and are usually impossible to predict.
c) It is important to arrange the seating in the interview room prior to the interview.
Taking time to prepare a room prior to an interview can improve safety, allowing you to arrange the seating so that you can sit nearest the door and alarms. Ties and neck-wear (e.g. scarves or lanyards) can be hazardous if the patient becomes aggressive. Interviewing in pairs increases your personal safety. Interviews should not be conducted while patients are intoxicated with drugs or alcohol: intoxicated patients are more volatile and it is usually not possible to assess their underlying mental state. There are often clear warning signs of increasing tension prior to a violent outburst; be alert to early warning signs.
Mrs Jane Hopkins is a 27 year old designer who has come to her GP due to feeling sad and progressively more tired over the last month. She also has trouble getting to sleep and wakes up much earlier than she used to. She doesn’t enjoy her work anymore.
Which investigation is NOT considered routine when assessing the potential biological causes of this condition?
a) Physical examination
b) Computed tomography (CT)
c) Thyroid function tests (TFT)
d) Full blood count (FBC)
e) Glucose or HbA1c
b) Computed tomography (CT)
Feedback:
CT or MRI may however be helpful in ruling out suspected cerebral pathology in a minority of patients. Hypothyroidism, anaemia, and diabetes are common causes of tiredness.
Helen Santos is a 32 year old bank clerk who was diagnosed with depression two weeks ago and started on an antidepressant. She has been brought to A&E by her partner, John, who is very worried about her. He tells you that she seems to have suffered a “personality change” becoming very irritable, loud, and rude over the past week. Her sleep has been poor and this morning John found her cooking breakfast at 4am.
She is very fidgety during the consultation but says that she is enjoying her new job as a fashion designer.
Which of the following is the MOST LIKELY diagnosis:
a) Refractory depression
b) Multiple sclerosis
c) Hyponatraemia
d) Serotonin syndrome
e) Mania
e) Mania
Feedback:
Antidepressants can ‘switch’ some people from depression into mania, even without a previous history of mania.
Mrs Santos is started on lithium.
With regards to this treatment, which of the following options is INCORRECT?
a) The therapeutic range of lithium is 0.6 - 1.0mmol/litre.
b) Levels are taken 12 hours post-dose.
c) Lithium blood levels must be checked weekly until the treatment is stopped.
d) It may cause hypothyroidism and renal impairment.
e) Toxicity may be triggered by dietary changes or vomiting.
c) Lithium blood levels must be checked weekly until the treatment is stopped.
Feedback:
Lithium levels need to be checked weekly until therapeutic and stable. Then three monthly checkups together with U&Es and TFTs are sufficient.
Mrs Viola Jones lost her husband Harry four months ago. Initially she felt she was in a state of shock, and “everything passed in a slow blur”. She missed Harry dreadfully, and says that she cried for hours every day for the first few weeks. Now, although she isn’t crying for hours, she still spends much of her time thinking about Harry and the 37 years they spent together. She is easily moved to tears by little things that remind her of him.
She doesn’t seem to want to cook for herself anymore and instead buys sandwiches at the local shop. Although she seems to have regained the weight she lost in the first month, eating in this way is still very out of character for her. It would have been Harry’s birthday last week, and while the rest of the family got together to remember Harry, Viola “wanted to be alone” and seemed more tearful than ever.
Which of the following BEST describes Viola’s current situation?
a) Bereavement
b) Adjustment disorder
c) Prolonged bereavement
d) Depression
e) Pseudodementia
a) Bereavement
Feedback:
She is progressing through the normal stages of grief, which include numbness, pining, depression, recovery. There is evidence that she is moving forward, e.g. though she is still preoccupied by the loss, she is now intermittently - rather than constantly - tearful. A major anniversary is expected to bring on ‘the pangs of grief’ and it can be helpful to let patients and their relatives know this, to normalize it. Although Viola is not cooking for herself, she is still eating and caring for herself. It can be very hard to cook for ‘one’ after 37 years of cooking for ‘two’.
Six months later, Mrs Jones is still very low in mood when you pay her a home visit at her son’s request. She speaks slowly and quietly. She is tearful and avoids eye contact. You only have 30 minutes before the next house call.
What should you do when interviewing this patient?
a) Try to distract her to stop her from crying.
b) Speak louder to get her attention.
c) Show empathy by explaining that you know how she feels.
d) Give extra time for her to answer your questions.
e) Offer her a prescription for an antidepressant and arrange to review her in a week.
d) Give extra time for her to answer your questions.
Feedback:
All other options may make her close down and lose confidence in you.
Mr Reed is a 58 year old man with a history of depression. He presents to A&E following an overdose of 16 paracetamol, which he believed to be lethal. His wife came home from work at the usual time, and found him slumped on the couch in the lounge. She was able to tell you that that the front door was on the latch, and there was a suicide note beside him, which said that he was sorry, but couldn’t go on anymore. Mr Reed says he bought the paracetamol a week ago “just in case”, and is glad that he was found by his wife.
Which of the following REDUCE the likelihood that this was a serious attempt at suicide?
a) Took only 16 paracetamol.
b) Few precautions to avoid being found.
c) Left suicide note.
d) Purchased the paracetamol only a week in advance.
e) Isolation at the time of the act.
b) Few precautions to avoid being found.
Mr Reed now wants to self-discharge, though he has not yet received investigations or treatment for his overdose.
What will you do now?
a) Check paracetamol levels immediately.
b) Arrange compulsory admission to hospital under Section 2 of the Mental Health Act.
c) Assess his capacity to self-discharge.
d) Give naloxone.
e) Give N-acetyl cysteine.
c) Assess his capacity to self-discharge.
Xiu Mei is 16 and has been cutting herself for the past 3 years. She is worried about the longer term scarring and wants to cut down her self-harm.
Which of the following is a useful strategy to reduce the drive to self-harm?
a) Staying in a private place in order to calm down.
b) Looking at pictures of self-harm instead of performing it.
c) Avoiding talking to friends and family.
d) Using a washable red pen to mark the skin instead of cutting it.
e) Drinking a small amount of alcohol to relax.
d) Using a washable red pen to mark the skin instead of cutting it.
Which of the following is true of the epidemiology of suicide?
a) Men are more likely to attempt suicide than women.
b) Globally the suicide rate is decreasing as a result of reduced access to means.
c) It is the second largest cause of death in men aged 15 to 24.
d) 1 in 1000 deaths are suicides.
e) Women tend to use more violent methods than men
c) It is the second largest cause of death in men aged 15 to 24.
Feedback:
Road traffic accidents are the leading cause of death in this age group.
A 21 year old man is brought into A&E by his mother. He reports that MI5 agents are telling him to kill himself to avoid being tortured for information. He was recently diagnosed with schizophrenia following eight months of gradually worsening auditory hallucinations and the delusion that he was an undercover spy. His illness caused him to drop out of university where he studied ecology, though he hopes to return to complete his studies in a year’s time. He has never believed himself to be ill and has been poorly compliant with his medication.
In schizophrenia, which of the following REDUCES his risk of suicide?
a) Youth
b) Early stages of illness
c) Command hallucinations
d) Good premorbid functioning
e) Hope
e) Hope
Which of the following is true regarding the aetiological factors in schizophrenia?
a) The child of a person with schizophrenia has a 22% lifetime risk of developing schizophrenia.
b) Tetrahydrocannabinol has been shown to protect against the risk of developing schizophrenia, when used regularly by teenagers.
c) The incidence of schizophrenia is doubled in urban areas, compared with rural areas.
d) Summer birth is associated with an increased risk of schizophrenia.
e) Schizophrenia has a similar incidence across all social classes.
c) The incidence of schizophrenia is doubled in urban areas, compared with rural areas.
Which of the following is NOT one of Schneider’s first rank symptoms of schizophrenia?
a) Somatic passivity
b) Persecutory delusions
c) Outside agencies causing the person’s actions
d) Hallucinations of a running commentary on the person’s actions
e) Delusional perception
b) Persecutory delusions
Feedback:
The delusions that count as “first rank symptoms” are: delusional perception, thought insertion, thought withdrawal, thought broadcasting, passivity phenomena. Other first rank symptoms are hallucinations: thought echo; voices discussing or arguing about the patient; voices giving a running commentary on the patient’s actions.
A GP is called to the house of a 72 year old man after his sister expressed concerns that she hadn’t been able to contact him for 3 months. His house was very untidy and unclean. He had a blank expression, took a long time to answer questions, and said very little, speaking slowly with a monotonous tone.
Which of the following is LEAST likely to be the cause of these symptoms?
a) Cognitive impairment
b) Persistent delusional disorder
c) Parkinson’s disease
d) Antipsychotic medication side effects
e) Depression
b) Persistent delusional disorder
Feedback:
Although persistent delusional disorder might result in neglect of this man’s house (e.g. a belief that he was being spied upon might distract him from housework), it would not be associated with the blank facial expression and speech abnormalities. Cognitive impairment (e.g. delirium or dementia), Parkinson’s disease, parkinsonism secondary to antipsychotics, and depression could each cause the presentation.
Which of the following is TRUE of atypical antipsychotics?
a) They block 5-HT2 receptors.
b) They carry a higher risk of tardive dyskinesia than typical antipsychotics.
c) They block presynaptic D2 receptors.
d) They are the second line choice in schizophrenia.
e) Hyperprolactinaemia is the major problem with this drug group.
a) They block 5-HT2 receptors
Feedback:
Note that this is in addition to their antagonism of post-synaptic D2 receptors.
Which of the following is predictive of poor prognosis in schizophrenia?
a) Late onset
b) Abrupt onset
c) Short duration of untreated psychosis
d) Concordance with medication
e) Substance misuse
e) Substance misuse
Feedback:
The other answers are associated with a better prognosis in schizophrenia.
A young male, smelling of alcohol, is brought in to A&E by the police. He is verbally abusive to the staff, especially the nurse in charge, who asks you to see him straight away.
Which of the options below is the MOST APPROPRIATE first step in assessing this patient?
a) Prescribe some sedatives to calm the patient down.
b) Order a urine drug screen (UDS).
c) Ask the patient how many drinks he has had and calculate his weekly units.
d) Review the medical notes.
e) Give him an injection of thiamine to avoid delirium tremens.
d) Review the medical notes.
Feedback:
Reviewing the notes gives you the opportunity to look for evidence of substance misuse and past psychiatric history; they may also note risk issues. Diving straight into an assessment without a brief understanding of the situation is hazardous.
Having interviewed your intoxicated patient, you decide to request a urine drug screen (UDS).
Which of the substances below is NOT usually detected by a UDS?
a) Cannabis
b) LSD
c) Amphetamine
d) Heroin
e) Cocaine
b) LSD
Feedback:
LSD is rapidly removed by the body and very difficult to detect in the urine.
A confused, middle-aged woman, with a long-standing history of alcohol misuse is brought into A&E by her brother. He tells you that she’s been shaky and sweaty for the last two days, and has been terrified of dogs attacking her in her bedroom. He states that there are no dogs in the house.
Which of the options below is MOST LIKELY to have triggered her symptoms?
a) Subdural haematoma
b) Sepsis
c) Benzodiazepine overdose
d) Alcohol intoxication
e) Abstinence from alcohol
e) Abstinence from alcohol
Feedback:
The patient presents with physical signs of alcohol withdrawal (shaking, sweating) together with hallucinations, confusion, and affective changes. It is likely that she has been abstinent (or markedly reduced her alcohol intake) in the past 2-3 days. Her presentation strongly suggests delirium tremens and she should promptly receive benzodiazepines and parenteral thiamine. Though hallucinations can occur while drinking alcohol (alcoholic hallucinosis), these tend to be auditory hallucinations with a persecutory or derogatory content, and are experienced in clear consciousness.
Which of the following options are you LEAST likely to elicit on examination of a patient with Wernicke’s encephalopathy?
a) Confusion
b) Irreversible anterograde amnesia
c) Nystagmus
d) Ataxia
e) Ophthalmoplegia
b) Irreversible anterograde amnesia
Feedback:
Irreversible anterograde amnesia is characteristic of the Korsakoff syndrome (or the Korsakoff component of Wernicke-Korsakoff syndrome). In an acute confusional state such as Wernicke’s encephalopathy it is not possible to assess whether a patient has a true anterograde amnesia, and certainly not possible to predict whether it will be reversible.
A 32 year old man is suffering from heroin withdrawal.
Which of the symptoms below is LEAST likely to happen during this process?
a) Cramps and aches
b) Death
c) Nausea and vomiting
d) Lacrimation
e) Insomnia
b) Death
Feedback:
Opiate withdrawal may be very unpleasant but, in adults, does not directly cause death.
You are a medical student in urology clinic. A 72 year old man has been referred by his GP due to his increasing symptoms of urinary incontinence. You assist him into the room as he is very unsteady on his feet, with a shuffling gait. He is accompanied by his wife, who gives the history as he has become “very forgetful” recently.
He is referred for a head CT scan. What would you expect this to show?
a) Multiple small areas of ischaemia
b) Dilated ventricles
c) Caudate nucleus atrophy
d) Normal CT
e) Global atrophy
b) Dilated ventricles
Feedback:
The clinical triad of urinary incontinence, confusion, and unsteady gait is the clue to the diagnosis: normal pressure hydrocephalus. CT scan shows dilated ventricles.
You confirm the diagnosis of normal pressure hydrocephalus.
What would be the most appropriate treatment?
a) Acetylcholinesterase inhibitors
b) Levodopa
c) Diuretics
d) Ventriculo-atrial shunt
e) No specific treatment is yet available
d) Ventriculo-atrial shunt
