Psychiatry

Question 1

what diseases is cotard syndrome associated with? (2)

Answer 1

severe depression and psychotic disorders

Question 2

SSRI of choice post myocardial infarction

Answer 2

sertraline

Question 3

SSRI interactions

Answer 3

NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin
triptans - increased risk of serotonin syndrome
monoamine oxidase inhibitors (MAOIs) - increased risk of serotonin syndrome

Question 4

SSRI: when to review post starting?

Answer 4

Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 25 years or at increased risk of suicide should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.

Question 5

SSRI in pregnancy

Answer 5

• Use during the first trimester gives a small increased risk of congenital heart defects
• Use during the third trimester can result in persistent pulmonary hypertension of the newborn
• Paroxetine has an increased risk of congenital malformations, particularly in the first trimester

Question 6

Discontinuation symptoms SSRI

Answer 6

Gastrointestinal symptoms common. also:
- increased mood change
- restlessness
- difficulty sleeping
- unsteadiness
- sweating
- gastrointestinal symptoms: pain, cramping, diarrhoea, - vomiting
- paraesthesia

Question 7

which ATYPICAL antipsychotic has a generally good side-effect profile, particularly for prolactin elevation

Answer 7

aripiprazole

Question 8

Adverse effects of atypical antipsychotics

Answer 8

weight gain
hyperprolactinaemia
(stroke/ VTE risk)

Question 9

Seasonal affective disorder management

Answer 9

you would begin with psychological therapies and follow up with the patient in 2 weeks to ensure that there has been no deterioration. Following this an SSRI can be given if needed.

Question 10

clozapine side effects

Answer 10

agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation

Question 11

dose adjustment of cloazpine is needed if…

Answer 11

start or stop smoking

Question 12

ECT side effects

Answer 12

Short-term side-effects
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia

Long-term side-effects
some patients report impaired memory

Question 13

mirtazapine mechanism of action

Answer 13

alpha2-adrenergic receptorspeak incidence of seizures

Question 14

peak incidence of seizures alcoholics

Answer 14

36hr

Question 15

peak incidence delirium tremens

Answer 15

48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 16

when to admit people with ETOH

Answer 16

patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised

Question 17

when to NOT give chlordiazepoxide for withdrawal of ETOH

Answer 17

liver cirrhosis –> Lorazepam

Question 18

Anorexia features

Answer 18

most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia

Question 19

how long does section 136 last

Answer 19

24hr

Question 20

PHQ-9 score

Answer 20

PHQ-9 score <16 ‘less severe’ depression: encompasses what was previously termed subthreshold and mild depression

PHQ-9 score >16 ‘‘more severe’ depression: encompasses what was previously termed moderate and severe depression —> CBT and SSRI

Question 21

SSRI review - when to do 1 week

Answer 21

Patients ≤ 25 years who have been started on an SSRI should be reviewed after 1 week

Question 22

what type of medication is imipramine

Answer 22

strong anticholinergic effects due to their antagonism of muscarinic receptors. This anticholinergic activity leads to several characteristic side effects, with dry mouth (xerostomia) and blurred vision being amongst the most common. The blurred vision occurs due to paralysis of accommodation in the eye, whilst the dry mouth is due to reduced saliva production. These effects are predictable and commonly seen together in patients taking TCAs.

Question 23

Section 4

Answer 23

72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
a GP and an AMHP or NR
often changed to a section 2 upon arrival at hospital

Question 24

GAD first line treatment

Answer 24

sertraline

Question 25

Light’s criteria state that a pleural effusion is an exudate if:

Answer 25

Effusion lactate dehydrogenase (LDH) level greater than 2/3 the upper limit of serum LDH
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid protein divided by serum protein >0.5

Question 26

small cell lung cancer management

Answer 26

chemotherapy

Question 27

chronic heart failure: what role does cardiac resynchronisation have

Answer 27

Cardiac resynchronisation therapy
for patients with heart failure and wide QRS
biventricular pacing
improved symptoms and reduced hospitalisation in NYHA class III patients

Exercise training
improves symptoms but not hospitalisation/mortality

Question 28

PERC score

Answer 28

rule OUT PE

this should be done when you think there is a low pre-test probability of PE, but want more reassurance that it isn’t the diagnosis

Question 29

WELLS PE score >4

Answer 29

CTPA

if 4 or less –> D dimer

Question 30

PE possible CXR finding

Answer 30

possible findings include a wedge-shaped opacification

Question 31

how does Mitral stenosis cause AF? (1)

Answer 31

secondary to left atrial enlargement

Question 32

common cause mitral stenosis

Answer 32

Rheumatic fever

Question 33

mitral stenosis: management

Answer 33

asymptomatic patients: monitored with regular echocardiograms
percutaneous/surgical management is generally not recommended

symptomatic patients:
percutaneous mitral balloon valvotomy
mitral valve surgery (commissurotomy, or valve replacement)

Question 34

mitral stenosis

Answer 34

viral infections (Coxsackie)
tuberculosis
uraemia
post-myocardial infarction
early (1-3 days): fibrinous pericarditis
late (weeks to months): autoimmune pericarditis (Dressler’s syndrome)
radiotherapy
connective tissue disease
systemic lupus erythematosus
rheumatoid arthritis
hypothyroidism
malignancy
lung cancer
breast cancer
trauma

Question 35

PCKD valvular problems

Answer 35

mitral valve prolapse and mitral regurgitation. . As many as 1 in 4 adults with polycystic kidney disease develop mitral valve prolapse.

Question 36

mitral valve prolapse

Answer 36

Associations
congenital heart disease: PDA, ASD
cardiomyopathy
Turner’s syndrome
Marfan’s syndrome, Fragile X
osteogenesis imperfecta
pseudoxanthoma elasticum
Wolff-Parkinson White syndrome
long-QT syndrome
Ehlers-Danlos Syndrome
polycystic kidney disease

Question 37

mitral valve prolapse features

Answer 37

patients may complain of atypical chest pain or palpitations
mid-systolic click (occurs later if patient squatting)
late systolic murmur (longer if patient standing)
complications: mitral regurgitation, arrhythmias (including long QT), emboli, sudden death

Question 38

Individuals with type 1 diabetes who do not have established cardiovascular disease (CVD) risk factors should be offered atorvastatin 20 mg for primary prevention of CVD if they are:

Answer 38

Older than 40 years of age
Have had diabetes for more than 10 years
Have established nephropathy
Have other CVD risk factors (such as obesity and hypertension)

Question 39

obstructer sleep apnoea: causees

Answer 39

obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome

Question 40

obstructer sleep apnoea:
diagnosis

Answer 40

sleep studies (polysomnography) - ranging from monitoring of pulse oximetry at night to full polysomnography where a wide variety of physiological factors are measured including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry

Question 41

obstructer sleep apnoea:
management

Answer 41

weight loss
1st LINE= continuous positive airway pressure (CPAP) is first line for moderate or severe OSAHS
intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSAHS where there is no daytime sleepiness
the DVLA should be informed if OSAHS is causing excessive daytime sleepiness
limited evidence to support use of pharmacological agents

Question 42

drug causes of hyponatraemia

Answer 42

chlorpropramide, carbamazepine, selective serotonin reuptake inhibitor (SSRI) antidepressants, tricyclic antidepressants, lithium, MDMA/ecstasy, tramadol, haloperidol, vincristine, desmopressin, fluphenazine

Question 43

tests to odo before starting antipsychotics

Answer 43

Before starting antipsychotic medication, undertake and record the following baseline investigations: weight, waist circumference, pulse and BP, bloods (including fasting glucose, HbA1c, lipids and prolactin), assessment of movement disorders and nutritional status.

An ECG should also be offered if:
Specified in the summary of product characteristics (SPC)
Cardiovascular risk identified e.g. high BP
Personal history of cardiovascular disease
Service user is being admitted as an inpatient