PAST PAPERS - MedSchool

Question 1

Discuss NMS- clinical presentation and management (10)

Answer 1

Tetrad of Sx develops over 1-3 days
1. Mental status change (usually delirium, also catatonia, decreased LOC)
2. Lead pipe rigidity
3. Hyperthermia (>38)
4. Autonomic instability (tachycardia, -pnoea, hypertension, dysrhythmias, diaphoresis)
CLINICAL DIAGNOSIS
Management
Stop all antipsychotics
Admit & monitor electrolytes, renal fx and CK
Supportive care: cooling, antipyretics& hydration
Benzos
ECT last resort for Tx resistance NMS

Question 2

Discuss clinical presentation of PTSD (10)

Answer 2

Symptoms for more than a month, including:

Intrusive symptoms:
Recurrent, involuntary distressing and intrusive memories of the event.
Recurrent, involuntary distressing and intrusive dreams of the event.
Dissociative Sxs (flashbacks)
Intense psychological distress to internal/external cues of the event.
Strong physiological reaction to cues of the event.

Avoidance symptoms:
Avoidance of distressing memories, thoughts or feelings
Avoidance of external reminders of the event (people, places, objects, environments)

Negative cognitive and affective symptoms:
Unable to recall specific details about the event
Persistent, distorted cognitions about the cause and consequences of the event (e.g. blames self or others)
Constant negative emotional state (feelings of anger, guilt, fear, shame)
Persistent negative beliefs of self, others and the world (I am bad, the world is dangerous, I can’t trust anyone, etc.)
Persistent ability to feel positive emotions (love, satisfaction and happiness)
Feels detached or estranged from others
Decreased interest or participation in activities

(Hyper)arousal and reactivity symptoms:
Irritable behaviour and angry outburst with little provocation
Recklessness or self-destruction
Hypervigilance
Sleep disturbance
Decreased concentration
Exaggerated startle response

Other ways PTSD patients could present:
With common comorbidities such as anxiety, depression, SUD, borderline PD or antisocial PD, BPMD, and somatic Sx and related disorders.
Increased risk of suicidality
Present to casualty with injuries from the actual traumatic event (e.g. MVA, stabbing, domestic violence).

Question 3

What is the role of the mental health review board? (5)

Answer 3

MHC Act 17 of 2002 stipulates that there must be a board
They are an independent body consisting of a psychiatrist, lawyer, social worker, member of the public and sometimes also a well, ex-MHCU.
Their role:
Ensure steps followed according to MHCA
Provide legal assistance to patient if requested
Checks forms completed correctly: ensure legitimacy of process and accuracy of forms (they have to fill in a form 13 to say that the hospital does have grounds to do the 72 hour assessment and hold the patient during this time)
Ensure no one is detained erroneously
Ensure procedures are followed
Reviews case if patient sends form 15 (for an appeal); MHCB needs to give notice of receiving application within 7 days and see patient within 30 days

Question 4

List the SEs of SSRIs (5)

Answer 4

Sexual dysfunction
GIT: N&V, appetite changes
CNS: sleep d/o, amnesia, confusion
Ear pain & tinnitus
Increased bleeding risk

Question 5

Discuss the mood stabilizer lithium in terms of monitoring and therapeutic levels, side effects, clinical presentation of toxicity and their use in women of child bearing age. (15)

Answer 5

Monitoring:
Renal and thyroid function before initiation and 6-12 monthly
Serum [] monitoring at one week after each does increment and then at 1, the 3 then 6 monthly intervals
Monitoring: trough levels (12 hours post intake)
Therapeutic range: 0.8-1.0mmol/l maintenance 0.6-0.8mmol/l
Side effects:
Ataxia, lethargy, weakness
GI disturbance: N&V
Weight gain
EPSEs
Polydipsia and polyuria
Presentation of toxicity
Change in mental state
GI symptoms
Apathy
Restlessness
Tremor (becomes coarser)
Dysarthria, ataxia
The convulsions, coma and death…
Women of child bearing age
Should be on a contraceptive & rule out pregnancy & thyroid dysfunction before starting on Li
In first trimester can cause Ebstein’s anomaly
2nd and 3rd trimester: goitre

Question 6

Discuss an approach to the management of an 8 year old presenting enuresis (10)

Answer 6

Assess (hx & examination)
Formulation (predisposing, precipitating, maintaining and protective factors)
Intervention (Biopsychosocial)

Question 7

Discuss the approach to a violent patient in casualty (10)

Answer 7

Identify potential violence: body language, behavior or verbal threats
Verbal de-escalation
Assess circumstance
Communication to facilitate cooperation & problem solving
Calm & non-threatening
Open ended questions
Manage the environment
Attempt to establish rapport
Physical restraint
Only if acutely dangerous
Requires team coordination
Note any physical injuries must be noted beforehand
Consider dignity & privacy
5 point approach
Swift and calmly as possible, for as short as possible
Seclusion
Short term solitary confinement
Reduces external stimulus
Prevents harm to self and others
Regular observations
Pharmacotherapy
Oral or IM
Haloperidol 5-10mg
Lorazepam 2-4 mg
Olanzapine 10mg

Question 8

Discuss the assessment of a depressed patient who you suspect might be suicidal in casualty (10)

Answer 8

Assess risk factors (SADPERSONS)
Ideation: content & duration of thoughts
Intent: self-harm vs parasuicide vs suicide
Plan: details/preparation/concealment/final acts

Question 9

Discuss the side effect profile of 1st generation antipsychotics (8)

Answer 9

Typicals are more like to cause extra pyramidal side effects such as:
Acute dystonia: (tongue protrusion, oculogyric crisis, muscle spasms in head & neck. Tx: anticholinergicBiperidin 5mg and lower the dose)
Pseudo-parkinsonism: (bradykinesia, rigidity, tremor. Tx lower dose and give orphenadrine 50mg and up)
Akathisia: (internal restlessness. Tx Lower dose and orphenadrine or BBlocker)
Tardive dyskinesia: (Appears after >6mo Tx. Orobuccofacial choreathetoid movements. Tx Discontinue antipsychotic drug & switch to SGA)
Hyperprolactinaemia:
Galactorrhoea
Infertility
Histamine blocking
Sedation
Weight gain

Question 9

Discuss the clinical presentation of borderline PD (7)

Answer 9

Often present with anxiety, depression or self harm
Pervasive pattern of instability & impulsivity
Unstable self-image
Fluctuating affect
Unstable personal relationships
Marked efforts to avoid rejection
Unable to control anger
Transient paranoia under stress
Chronic feelings of emptiness
Impulsive, reckless behavior
Intense relationships
Recurrent suicidal behavior

Question 9

Discuss the differences between delirium and dementia (10)

Answer 9

Delirium
- disturbance in attention
- develops acutely, fluctuates throughout the day and is off cognitive baseline
- disturbance in cognition
- not due to other neurocognitive disorder and not with significant reduced level of consciousness
- evidence of a cause

Onset - abrupt
Course - fluctuates
Duration - hours to weeks
Attention - impaired
Sleep-wake - disrupted
Alertness - impaired
Orientation - impaired
Behaviour - agitated, withdrawn, depressed, combination
Speech - incoherent, rapid/slowed
Thoughts - disorganized, delusional
Perceptions - hallucinations/illusions

Dementia
- impairment in memory and one or more associated cognitive defects
- significant cognitive decline from a previous level of performance
- interfere with independence for everyday activities
- not exclusively in delirium setting
- not better explained by another mental illness

Onset - usually insidiuous but can be abrupt in the case of stroke or trauma
Course - slow decline
Duration - months to years
Attention - intact early, impaired late
Sleep-wake - usually normal
Alertness - normal
Orientation - intact early, impaired late
Behaviour - intact early
Speech - word finding problems
Thoughts - impoverished
Perceptions - usually intact early

Question 10

Side effects of TCAs (8 marks)

Answer 10

TCAs
Inhibit serotonin and noradrenalin reuptake in synaptic cleft.
EG:
Amitriptyline
Imipramine
Indicated for depression, insomnia and, pain and panic disorders.
NOTE: No alcohol allowed
S/E:
Orthostatic hypotension
Sedation and delirium
Arrhythmias
Anticholinergic Sxs:
Cardio: tachy, hypotension, arrhyth
CNS: confusion, sedation
GI: constipation, dry mouth, nausea
GU: libido change, impotence
Ophth: blurred vision, mydriasis
General: fatigue, weight gain, sweating excessively

Question 10

Compare side effect profiles of typical vs atypical antipsychotics. Include monitoring requirements for clozapine in your answer (15 marks)

Answer 10

Both: sedation & weight gain
Typicals: EPSEs like:
Acute dystonia
Tardive dyskinesia
Psuedoparkinsonism
Akathisisa
NMS
Atypicals: More metabolic symptoms
Hyperglycaemia and -cholesterolaemia
Metabolic syndrome
Weight gain & diabetes
Hyperprolatinaemia with infertility & osteoporosis

WCC measured pre-treatment
WCC monitored weekly for 18 weeks then monthly thereafter
Withdraw therapy if WCC drops below 3x109/L

Question 11

Presentation and management of alcohol withdrawal/delirium tremens

Answer 11

Withdrawal:
Autonomic hyperreactivity (high BP and Temp)
Hand tremor
Insomnia
N&V
Transient hallucinations
Anxiety
Psychomotor agitation
GTCS
Mgx of acute withdrawal:
Minor symptoms above can be treated supportively
Withdrawal seizures are usual GTCS occur 12-48 hours after last drink
Can use benzos, phenobarbital or Propofol in status epilepticus
Hallucinations: at 12-48 hours, usually visual
Delirium tremens: hallucination, disorientation, tachycardia, hyperthermia, agitation and mm (Sweating) Typically starts 48-96 hours after last drink
Supportive care:
Benzos for agitation (IV diazepam best)
IV fluid
Nutritional support
Monitor vitals
Quite protective environment
Thiamine and glucose (prevent Wernicke’s)
Multivitamins including folate

Question 12

Diagnostic criteria for borderline personality disorder (7 marks)

Answer 12

Often present with anxiety, depression or self harm

Pervasive pattern of instability & impulsivity
Unstable self-image
Fluctuating affect
Unstable personal relationships
Marked efforts to avoid rejection
Unable to control anger
Transient paranoia under stress
Chronic feelings of emptiness
Impulsive, reckless behavior
Intense relationships
Recurrent suicidal behavior

Question 13

What is meant by pseudo dementia? (5 marks)

Question 14

What do you understand by ‘ Factitious Disorders’? (5 marks)

Question 14

Delirium - presentation and management.

Answer 14

Presentation is acute onset of:
Psychomotor agitation
Disturbances in sleep wake cycle
Impairment of cognition, recent memory, abstract thinking and orientation
Emotional lability
Thought disorder
Incoherent speech
PDs and hallucinations
Management
Psychosocial:
nurse in quiet, well-lit area with orientation techniques (like clocks and calendars)
explain mgx to pt
avoid restraints
insure adequate hydration and access to ablution facilities
MOST NB: find the cause and treat it

Pharm:
Only pharm management if pt risk to self or others
Single agent and titrate up slowly
Haloperidol 0.5-1mg PO or IM BD
OR Lorazepam 2-4mg PO

Question 15

Panic disorder presentation and biopsychosocial management

Answer 15

Symptoms:
Abrupt surge of fear with at least 4 of these present:
SOB
Dizziness
Hot flushes or chills
Feeling of choking
Palpitations
Nausea/ abdo discomfort
Sweating
Shaking
Derealization
Paresthesias
Fear of dying/losing control
At least 1 attack has been followed by a minimum period of persistent worry bout further attacks or significant maladaptive change related to attack
Management:
Pharm
1ST LINE= SSRI (FLUOXETINE?)
Can combine with CBT
Psychosocial:
CBT has been found to be the best psychotherapy choice for panic disorder. It assists the patient in countering their anxious beliefs, being exposed to fear cues, changing their anxiety-maintaining behaviour.
Does require highly motivated patient. And can be resource intensive.
Psychoeducation is also of use with CBT.

Question 16

Outpatient with schizophrenia been on antipsychotics for 3 months, but is still floridly psychotic. What could be the reasons for this? (10 marks)

Question 17

Disruptive child, rude, doesn’t finish tasks, bothers other students in class - approach and differentials (ADHD)

Question 18

Suicide risk assessment of 55 year-old depressed and divorced man.

Answer 18

Want to determine: High or low risk
Look at risk factors: SADPERSONS 5-6: medium risk, 7 or more: high risk
S: Male sex
A: Age (<19 or >45 years)
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness (GMC)

Then determine
ideation: content and duration of thoughts
intention: self-harm vs suicide
plan: detail, lethality, concealment and preparation

Question 19

Discuss 2 classes of antidepressant in terms of SE profile and therapeutic uses

Answer 19

SSRIs
Inhibit reuptake of serotonin at presynaptic neurons
EG: fluoxetine & citalopram
Indicated for depression, anxiety, OCD & bulimia
S/E:
Sexual dysfunction
GIT: N&V, appetite change
CNS: agitation, confusion (initially anxiogenic)
Ear pain, tinnitus
Serotonin syndrome

SNRIs
Inhibit reuptake of serotonin and noradrenalin with out significant cholinergic, histaminergic or dopaminergic affinity.
EG: Venlafaxine and Duloxetine
Indicated for mod-sever depression, anxiety disorders
S/E:
CNS: Headache, tremor, somnolence
GIT: anorexia, dry mouth, nausea
CVS: hypertension, tachy, palpitations
Rashes
Sexual dysfunction

Question 20

10 year old stabs someone with pencil and steals R100. How to assess and likely dx (10)

Question 20

What is your understanding of Somatic disorders (10)

Answer 20

Physical signs/symptoms lacking objective medical support in the presence of psychological factors that are judged to be important in the initiation, exacerbation or maintenance of the disturbance.
Cause significant distress or impairment in functioning.

Question 21

Side effects of carbamazepine (5)

Answer 21

Carbamazepine
Dry mouth
Dizziness
Ataxia
GI effects
SJS/TEN
Osteomalacia

Question 21

Indications for ECT

Answer 21

Indications:
Severe depression (high suicide risk)
Catatonia assoc w SCZ, MDD, BPMD
Treatment resistant mania, depression. SCZ
Where required therapies are contraindicated EG preganacy and severe depression or mania
Pregnancy related PND/PPPsychosis so as not to interfere with breastfeeding
Life threatening nutritional compromise
NMS

Question 21

Good and poor prognostic factors for schizophrenia

Question 21

Compare and contrast delirium and dementia, subcortical and cortical dementia with examples (13)

Answer 21

SUBCORTICAL DEMENTIA

Examples:
Parkinson’s disease
Progressive supranuclear palsy
Normal pressure hydrocephalus
Huntington’s disease
Creutzfeldt-Jakob disease
Chronic meningitis

Areas of the brain affected:
Thalamus
Striatum
Midbrain
Striatofrontal projections

Symptoms: behavioural changes, impaired affect and mood, motor slowing, executive dysfunction, less severe changes in memory, extrapyramidal findings

CORTICAL DEMENTIA
Examples:
Alzheimer’s disease
Diffuse Lewy Body Disease
Vascular dementia
Frontotemporal dementias

Areas of the brain affected:
Temporal cortex (medial)
Parietal cortex
Frontal lobe cortex

Symptoms:
Major changes in memory
Language deficits
Perceptual deficits
Praxis disturbances
Lack of extrapyramidal features

Question 22

Side effects of Na Valproate

Answer 22

GI Sxs most common: nausea, vomiting, constipation, reflux
Hypersensitivity: SJS, cytopenias
Alopecia
Tremor
Increased appetite & weight gain
Ammenohorea

Question 23

Approach to 10 year old with enuresis who was previously dry at age 4.

Question 24

Management of a person with a specific phobia of mice

Question 25

Compare schizophrenia and delusional disorder

Question 25

Lithium has a narrow therapeutic range. What does this mean? What are the signs of toxicity?

Answer 25

Serum concentration intervals between which it is effective, and it is toxic are close. IE it needs close monitoring.
Signs of toxicity:
Change in mental state
Dysarthria & ataxia
Tremor increases
Electrolyte abn and ECG changes
Apathy
Restlessness
GI Sx
Convulsions, Coma and death

Question 26

Discuss 3 mood stabilizers and side effects profile.

Answer 26

Lithium
Ataxia, lethargy, weakness
GI disturbance: N&V
Weight gain
EPSEs
Polydipsia and polyuria

Sodium Valproate
GI Sxs most common: nausea, vomiting, constipation, reflux
Hypersensitivity: SJS, cytopenias
Alopecia
Tremor
Increased appetite & weight gain
Ammenohorea

Carbamazepine
Dry mouth
Dizziness
Ataxia
GI effects
SJS/TEN
Osteomalacia

Question 27

Common side effects, complication and monitoring of clozapine.

Answer 27

S/E:
Agranulocytosis
Sedation
Metabolic Sx: hyperglycaemia, hypercholesterolemia, weight gain
GI: constipation(monitor for obstruction), hypersalivation
Orthostatic hypotension & syncope
*Drops seizure threshold
Monitoring:
WCC measured pre-treatment
WCC monitored weekly for 18 weeks then monthly thereafter
Withdraw therapy if WCC drops below 3x109/L

Question 28

What are the symptoms of atypical depression?

Answer 28

Hypersomnia
Hyperphagia
Hypersensitivity to rejection
Leaded paralysis
? strongly reactive mood

Question 29

Define treatment resistant schizophrenia and the treatment for it.

Answer 29

Treatment resistant schizophrenia is defined as insufficient improvement in target symptoms despite treatment at the recommended dosage for at least 6 weeks with at least 2 antipsychotic agents, one of which was a 2nd generation antipsychotic other than clozapine.

Treatment: Clozapine then ECT

Question 30

Discuss the reasons why a 25 year-old patient diagnosed with schizophrenia might not respond to antipsychotic oral medication after 3 months of being on treatment. (10)

Answer 30

Dose not high enough
Serum concentrations not high enough
Non-adherence
Ongoing substance use
Treatment resistance
Emotional stressors
Incorrect diagnosis

Question 31

Discuss the Bio-Psycho-Social management of a patient with social phobia. (12)

Answer 31

First line Tx is either pharmacotherapy or CBT. Both are equal. Based on ot preference & availability. (Pharm just has quicker onset of action)

BIO
First line is SSRI (Citalopram?) or SNRI (Venlafaxine)
Require 4-6 weeks to work, maximal at 16 weeks
Dose response effect
Clonazepam for non-responders with no SUD hx
May be prescribed on an “as needed” basis for those with performance only SAD

PSYCHO
CBT best form of psychotherapy (individual or group)
Pt must be highly motivated & well resourced
Must be maintained (maintenance sessions 2-3 times annually)
Gradual desensitization is effective
Stress management and relaxation techniques

SOCIAL
Family psychoeducation
Asses how it affects job, relationships, family, income etc

Question 32

Key clinical features needed to diagnose dementia.

Answer 32

Impairment in memory and one or more associated cognitive defects
1. Significant cognitive decline from a previous level of performance
2. Interfere with independence for everyday activities (not if mild NCD)
3.Not exclusively in delirium setting
4. Not better explained by another mental illness

Must be slow, insidious onset with progressive course. Memory impairment (short term then long term. Normal attention and alertness and usually intact orientation.

Question 33

Discuss the assessment of a depressed patient who you suspect might be suicidal in casualty (10)

Answer 33

Assess risk factors (SADPERSONS)
Ideation: content & duration of thoughts
Intent: self-harm vs parasuicide vs suicide
Plan: details/preparation/concealment/final acts

Question 34

Describe the process of doing an involuntary admission

Answer 34

Fill in a form 04: an application in the head of the health establishment for the assessment of a user. Specify that it is as an involuntary patient.
Needs to be filled out by:
Someone who knows patient well/sees daily
An associate
MHC practitioner if no one else (would have to specify why it is them filling it in, what efforts were made to find someone, and why you think they need to be admitted)
Everyone must be over 18!
Form 04 then needs to be commissioned
Once this is filled in, the patient needs to present within 2 days of the form being filled out.
Next, two separate doctors/MHC practitioners need to do independent assessments of the patient. At least one must be a doctor.
They both fill out a form 05, which is a continued application to say that they believe the patient needs further 72 hour assessment.
If their assessments agree, a form 07 is filled in, which is an application to the head of the health establishment to detail the patient for 72 hours for further care as a designated facility approved for this. When this is signed by the head of establishment, is when the 72 hours start.
During the 72 hours, patient needs to be seen daily by a medical doctor and continuous notes must be made.
After that time, two form 06s can be filled out (by two independent MHC practitioners, as least one is a doctor).
After 72 hour assessment, all forms submitted to MHC review board who must fill in a form 13 to say that the hospital has grounds to keep the patient in hospital.
If the head of head establishment believes that the patient needs further inpatient care after 72 hours, (s)he fills in a form 08.

If need to be admitted as emergency patient: form 01.
If transferring patient: form 11.