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Welcome to the 2023 PT Consolidation Course Help us fill in this pre-course quiz and earn a raffle ticket for a giveaway! Brought to you by: 1Our Sponsors 2 Day 1: 03/06/2023 Topic Time Neurology & Psychiatry 09:00 – 10:40 Nephrology & Urology 10:40– 12:20 Lunch Break 12:20-13:00 Dermatology 13:00-14:40 Obstetrics & Gynaecology 14:40-16:20 Stalls 16:20-17:00 34NEUROLOGY 5 QUESTION 13 13. The mother of a 5-year-old boy is concerned that he is not physically keeping up with is peers. He is unable to run or jump. His calf muscles are larger than normal. When asked to stand from a squat he uses his hands to walk up his body. Select the most likely diagnosis. A. Motor neuron disease B. Duchenne muscular dystrophy C. Becker’s muscular dystrophy D. Limb girdle muscular dystrophy E. McArdle’s disease 6 Feras Sharouf Neurosurgical ST1 7 1. A 25-year-old builder presents with unilateral pain radiating down his left leg into the calf. It is worse when he coughs and associated with pins and needles. He has no difficulty toileting and has no muscle weakness. He had a similar episode 6 months ago which resolved after 2 weeks. Select the most likely diagnosis. A Cauda equina. B Multiple myeloma. C Prolapsed intervertebral disc. D Cervical stenosis. E Ankylosing spondylitis. A herniated disc can compress a nerve root causing pain, tingling and numbness, the sciatic nerve is commonly affected. Cauda Equina: low back pain, pain that radiates down the leg, perianal numbness, and sphincter disturbance. Multiple myeloma: Signs of hypercalcemia, Constitutional symptoms, upper motor neuron signs. Cervical stenosis: wrong level. Ankylosing spondylitis: back pain, stiffness, symptoms not resolving, arthritis. 8 1. A 25-year-old builder presents with unilateral pain radiating down his left leg into the calf. It is worse when he coughs and associated with pins and needles. He has no difficulty toileting and has no muscle weakness. He had a similar episode 6 months ago which resolved after 2 weeks. Select the most likely diagnosis. A Cauda equina. B Multiple myeloma. C Prolapsed intervertebral disc. D Cervical stenosis. E Ankylosing spondylitis. A herniated disc can compress a nerve root causing pain, tingling and numbness, the sciatic nerve is commonly affected. Cauda Equina: low back pain, pain that radiates down the leg, perianal numbness, and sphincter disturbance. Multiple myeloma: Signs of hypercalcemia, Constitutional symptoms, upper motor neuron signs. Cervical stenosis: wrong level. Ankylosing spondylitis: back pain, stiffness, symptoms not resolving, arthritis. 9 2. A 35-year-old woman presents with a one-day history of progressive lower back pain and right-sided lower limb weakness. She is now in urinary retention and has decreased perianal sensation and reduced anal tone on examination. Select the most likely diagnosis. A Cauda equina. B Multiple myeloma. C Prolapsed intervertebral disc. D Cervical stenosis. E Ankylosing spondylitis. Cauda Equina: low back pain, pain that radiates down the leg, perianal numbness, and sphincter disturbance. Multiple myeloma: Signs of hypercalcemia, Constitutional symptoms, upper motor neuron signs. A herniated disc can compress a nerve root causing pain, tingling and numbness, the sciatic nerve is commonly affected Cervical stenosis: wrong level. Ankylosing spondylitis: back pain, stiffness, symptoms not resolving, arthritis 10 2. A 35-year-old woman presents with a one-day history of progressive lower back pain and right-sided lower limb weakness. She is now in urinary retention and has decreased perianal sensation and reduced anal tone on examination. Select the most likely diagnosis. A Cauda equina. B Multiple myeloma. C Prolapsed intervertebral disc. D Cervical stenosis. E Ankylosing spondylitis. Cauda Equina: low back pain, pain that radiates down the leg, perianal numbness, and sphincter disturbance. Multiple myeloma: Signs of hypercalcemia, Constitutional symptoms, upper motor neuron signs. A herniated disc can compress a nerve root causing pain, tingling and numbness, the sciatic nerve is commonly affected Cervical stenosis: wrong level. Ankylosing spondylitis: back pain, stiffness, symptoms not resolving, arthritis 11 3. A 20-year-old man was stabbed in the right side of the neck during a fight. He has right sided weakness and reduced sensation in the left. Select the most likely diagnosis. A Anterior cord syndrome. B Posterior cord syndrome. C Brown-Sequard syndrome. D Central cord syndrome E amaurosis fugax Brown-Sequard: weakness or paralysis and proprioceptive deficits on the side of the body ipsilateral to the lesion and loss of pain and temperature sensation on the contralateral side . Anterior cord: Loss of power, pain and temperature. Ischaemia to anterior spinal artery. Posterior cord: Affects dorsal column: fine touch, vibration, proprioception. Demyelination, external compression, blockage in spinal artery. Central cord: Upper limbs> lower limbs, most common. Hyperextension. 12Amaursis fujax: …. 12 3. A 20-year-old man was stabbed in the right side of the neck during a fight. He has right sided weakness and reduced sensation in the left. Select the most likely diagnosis. A Anterior cord syndrome. B Posterior cord syndrome. C Brown-Sequard syndrome. D Central cord syndrome E amaurosis fugax Brown-Sequard: weakness or paralysis and proprioceptive deficits on the side of the body ipsilateral to the lesion and loss of pain and temperature sensation on the contralateral side . Anterior cord: Loss of power, pain and temperature. Ischaemia to anterior spinal artery. Posterior cord: Affects dorsal column: fine touch, vibration, proprioception. Demyelination, external compression, blockage in spinal artery. Central cord: Upper limbs> lower limbs, most common. Hyperextension. 13Amaursis fujax: …. 134. A 75-year-old female returns to the ward after having a hemiarthroplasty for an intracapsular neck of femur fracture. The nurse reports that the patient is confused, disorientated, and agitated. She is not known to have dementia and was orientated in time, place, and person before going to theatre. You suspect that she has delirium. Which of the following is not a risk factor for delirium? A Hearing impairment. B Pre-existing dementia. C Low albumin. D Alcohol misuse. E Female gender. 144. A 75-year-old female returns to the ward after having a hemiarthroplasty for an intracapsular neck of femur fracture. The nurse reports that the patient is confused, disorientated, and agitated. She is not known to have dementia and was orientated in time, place, and person before going to theatre. You suspect that she has delirium. Which of the following is not a risk factor for delirium? A Anterior cord syndrome. B Pre-existing dementia. C Low albumin. D Alcohol misuse. E Female gender. 1516 5. A 23-year-old intravenous drug user was admitted with sudden loss of vision in the left eye, heart murmur and pyrexia. Select the investigation most likely will confirm the diagnosis. A ECG. B Carotid dopplers. C Cholesterol screen. D Trans-thoracic echo. E FBC You are suspecting endocarditis. Diagnosis: Dukes criteria: 17 5. A 23-year-old intravenous drug user was admitted with sudden loss of vision in the left eye, heart murmur and pyrexia. Select the investigation most likely will confirm the diagnosis. A ECG. B Carotid dopplers. C Cholesterol screen. D Trans-thoracic echo. E FBC You are suspecting endocarditis. Diagnosis: Dukes criteria: 1819 6. A 40-year-old female presents with pain when she moves her right eye and deterioration in vision in the same eye. Fundoscopy shows optic atrophy, and she was diagnosed with optic neuritis. 12 months ago, she suffered from urinary incontinence, but this resolved a few weeks later. An MRI showed plaques in the optic nerve, brainstem, and spinal cord. She is diagnosed with relapsing-remitting MS. Which one of the following will not reduce relapses for this patient? A Interferon. B Glatiramer. C Ponesimod. D Methylprednisolone. E Natalizumab. Interferon Glatiramer, reduce relapse rate and progression. Ponesimod reduces rate of relapse but does not slow progression. Natalizumab used for severe advance MS. Steroids reduce duration and severity of relapse but have no impact on relapse rate. 20 6. A 40-year-old female presents with pain when she moves her right eye and deterioration in vision in the same eye. Fundoscopy shows optic atrophy, and she was diagnosed with optic neuritis. 12 months ago, she suffered from urinary incontinence, but this resolved a few weeks later. An MRI showed plaques in the optic nerve, brainstem, and spinal cord. She is diagnosed with relapsing-remitting MS. Which one of the following will not reduce relapses for this patient? A Interferon. B Glatiramer. C Ponesimod. D Methylprednisolone. E Natalizumab. Interferon Glatiramer, reduce relapse rate and progression. Ponesimod reduces rate of relapse but does not slow progression. Natalizumab used for severe advance MS. Steroids reduce duration and severity of relapse but have no impact on relapse rate. 21 7. A 40-year-old man presents with unilateral hand tremor. His mother had a bilateral hand tremor. The tremor improves with alcohol, and when concentrates on tasks using his hands, but worsens when he is tired or stressed. Select the most likely diagnosis. A Drug induced Parkinsonism. B Idiopathic Parkinson’s disease. C Benign essential tremor. D Thyrotoxicosis. E Progressive supra nuclear palsy. Benign essential tremor is familial: is affected by concentration, alcohol and emotional state. Drug induced? Parkinson’s: resting tremor, rigidity, bradykinesia. Thyrotoxicosis: No other thyroid symptoms, tremors are bilateral arms and legs. Progressive supra nuclear palsy: tremor is rare, axial rigidity, speech involvement, eye movement. 22 7. A 40-year-old man presents with unilateral hand tremor. His mother had a bilateral hand tremor. The tremor improves with alcohol, and when concentrates on tasks using his hands, but worsens when he is tired or stressed. Select the most likely diagnosis. A Drug induced Parkinsonism. B Idiopathic Parkinson’s disease. C Benign essential tremor. D Thyrotoxicosis. E Progressive supra nuclear palsy. Benign essential tremor is familial: is affected by concentration, alcohol and emotional state. Drug induced? Parkinson’s: resting tremor, rigidity, bradykinesia. Thyrotoxicosis: No other thyroid symptoms, tremors are bilateral arms and legs. Progressive supra nuclear palsy: tremor is rare, axial rigidity, speech involvement, eye movement. 23 8. A 65-year-old man presents with unilateral resting tremor. His wife has noticed that his facial expressions are less responsive, and he is slower than he used to be carrying out activities. You ask about his sense of smell, and he reports that he lost it many years ago. Select the most likely diagnosis. A Drug induced Parkinsonism. B Idiopathic Parkinson’s disease. C Benign essential tremor. D Thyrotoxicosis. E Progressive supra nuclear palsy. Benign essential tremor is familial: is affected by concentration, alcohol and emotional state. Drug induced? Parkinson’s: resting tremor, rigidity, bradykinesia. Thyrotoxicosis: No other thyroid symptoms, tremors are bilateral arms and legs. Progressive supra nuclear palsy: tremor is rare, axial rigidity, speech involvement, eye movement. 24 8. A 65-year-old man presents with unilateral resting tremor. His wife has noticed that his facial expressions are less responsive, and he is slower than he used to be carrying out activities. You ask about his sense of smell, and he reports that he lost it many years ago. Select the most likely diagnosis. A Drug induced Parkinsonism. B Idiopathic Parkinson’s disease. C Benign essential tremor. D Thyrotoxicosis. E Progressive supra nuclear palsy. Benign essential tremor is familial: is affected by concentration, alcohol and emotional state. Drug induced? Parkinson’s: resting tremor, rigidity, bradykinesia. Thyrotoxicosis: No other thyroid symptoms, tremors are bilateral arms and legs. Progressive supra nuclear palsy: tremor is rare, axial rigidity, speech involvement, eye movement. 25 9. A 45-year-old female presented with a seizure. She has been complaining of a headache in the last few weeks, which is worse in the morning or bending over. CT head indicates that she has a meningioma. The patient and her mum have a history of bilateral acoustic neuromas. Select the most likely diagnosis. A Neurofibromatosis Type 1. B Neurofibromatosis Type 2. C Tuberous sclerosis. D von Hippel-Lindau. E Wilson’s disease. NF1: café-au-lait macules, axillary freckling, neurofibromas, Optic pathway glioma, lisch nodules. NF2: bilateral acoustic neuromas. Tuberous sclerosis: hamartomas, ash leaf spots, shagreen patches, adenoma sebaceum. VHL: hemangioblastoma, phaeochromocytoma, pancreatic tumours. Wilsons disease: Kayser-Fleischer rings, Serum caeruloplasmin, liver biopsy. 26 9. A 45-year-old female presented with a seizure. She has been complaining of a headache in the last few weeks, which is worse in the morning or bending over. CT head indicates that she has a meningioma. The patient and her mum have a history of bilateral acoustic neuromas. Select the most likely diagnosis. A Neurofibromatosis Type 1. B Neurofibromatosis Type 2. C Tuberous sclerosis. D von Hippel-Lindau. E Wilson’s disease. NF1: café-au-lait macules, axillary freckling, neurofibromas, Optic pathway glioma, lisch nodules. NF2: bilateral acoustic neuromas. Tuberous sclerosis: hamartomas, ash leaf spots, shagreen patches, adenoma sebaceum. VHL: hemangioblastoma, phaeochromocytoma, pancreatic tumours. Wilsons disease: Kayser-Fleischer rings, Serum caeruloplasmin, liver biopsy. 27 10. A 14-year-old boy presents with foot drop, following removal of a below knee plaster cast. Select the affected nerve. A Tibial nerve. B Common peroneal nerve. C Superficial peroneal nerve. D Sural nerve. E Saphenous nerve. Plantar flexion: tibial. Dorsiflexion: Deep peroneal nerve. Superficial peroneal nerve: Eversion. Sural nerve: Sensory lateral. Saphenous nerve: Medial 28 10. A 14-year-old boy presents with foot drop, following removal of a below knee plaster cast. Select the affected nerve. A Tibial nerve. B Common peroneal nerve. C Superficial peroneal nerve. D Sural nerve. E Saphenous nerve. Plantar flexion: tibial. Dorsiflexion: Deep peroneal nerve. Superficial peroneal nerve: Eversion. Sural nerve: Sensory lateral. Saphenous nerve: Medial 2911. A 25-year-old man presents with decreases sensation over his little finger, lateral aspect of his ring finger and wasting of the hypothenar eminence following a supracondylar fracture of the humerus. Select the affected nerve. A Radial nerve. B Ulnar nerve. C Median nerve. D Musculocutaneous nerve. E Anterior interosseous nerve. 3011. A 25-year-old man presents with decreases sensation over his little finger, lateral aspect of his ring finger and wasting of the hypothenar eminence following a supracondylar fracture of the humerus. Select the affected nerve. A Radial nerve. B Ulnar nerve. C Median nerve. D Musculocutaneous nerve. E Anterior interosseous nerve. 3132 12. A 10-year-old boy presents with foot drop. His mother reports that he is rather clumsy and often falls. On examination it is noted that his legs look like inverted champagne bottles, and he has pes cavus and foot drop. His dad had similar problems. Select the most likely diagnosis. A Motor neuron disease. B Duchenne Muscular dystrophy. C Charcot-Marie-Tooth syndrome. D Guillain Barre syndrome. E Folate deficiency. Charcot-Marie-Tooth syndrome: inverted champagne bottle, pes cavus. MND: Motor symptoms only. DMS: Pseudohypertrophy of the calves, Gowers sign. 33 12. A 10-year-old boy presents with foot drop. His mother reports that he is rather clumsy and often falls. On examination it is noted that his legs look like inverted champagne bottles, and he has pes cavus and foot drop. His dad had similar problems. Select the most likely diagnosis. A Motor neuron disease. B Duchenne Muscular dystrophy. C Charcot-Marie-Tooth syndrome. D Guillain Barre syndrome. E Folate deficiency. Charcot-Marie-Tooth syndrome: inverted champagne bottle, pes cavus. MND: Motor symptoms only. DMS: Pseudohypertrophy of the calves, Gowers sign. 34 13. The mother of a 5-year-old boy is concerned that he is not physically keeping up with is peers. He is unable to run or jump. His calf muscles are larger than normal. When asked to stand from a squat he uses his hands to walk up his body. Select the most likely diagnosis. A Motor neuron disease. B Duchenne Muscular dystrophy. C Becker’s muscular dystrophy. D Limb girdle muscular dystrophy. E McArdle’s disease. Charcot-Marie-Tooth syndrome: inverted champagne bottle, pes cavus. MND: Motor symptoms only. DMS: Pseudohypertrophy of the calves, Gowers sign. Limb girdle MD: Shoulders and pelvic girdle. McArdle’s disease: painful muscle cramp, weakness. 35 13. The mother of a 5-year-old boy is concerned that he is not physically keeping up with is peers. He is unable to run or jump. His calf muscles are larger than normal. When asked to stand from a squat he uses his hands to walk up his body. Select the most likely diagnosis. A Motor neuron disease. B Duchenne Muscular dystrophy. C Becker’s muscular dystrophy. D Limb girdle muscular dystrophy. E McArdle’s disease. Charcot-Marie-Tooth syndrome: inverted champagne bottle, pes cavus. MND: Motor symptoms only. DMS: Pseudohypertrophy of the calves, Gowers sign. Limb girdle MD: Shoulders and pelvic girdle. McArdle’s disease: painful muscle cramp, weakness. 36 14. A 20-year-old has had persistent vertigo after she has taken some medication prescribed for her mother who had similar symptoms some months ago. After taking two tablets 8 hours apart she has developed involuntary eye rolling and facial spasms. Select the most likely drug involved. A Cyclizine. B Betahistine. C Prochlorperazine. D Procyclidine. E Amantadine. Drug induced: anti-psychotics, calcium channel blockers, prochlorperazine, metoclopramide. Procyclidine: treats drug induced parkinsonism. Amantadine: treats PA. 37 14. A 20-year-old has had persistent vertigo after she has taken some medication prescribed for her mother who had similar symptoms some months ago. After taking two tablets 8 hours apart she has developed involuntary eye rolling and facial spasms. Select the most likely drug involved. A Cyclizine. B Betahistine. C Prochlorperazine. D Procyclidine. E Amantadine. Drug induced: anti-psychotics, calcium channel blockers, prochlorperazine, metoclopramide. Procyclidine: treats drug induced parkinsonism. Amantadine: treats PA. 38 15. An 80-year-old man presents with tremor that occurs at rest. He also describes worms crawling across the floor, which his wife cannot see. He only sees the worms in the evenings. His wife also reports that he is low in mood and has slowed down recently. Select the most likely diagnosis. A Vascular dementia. B Dementia with Lewy bodies. C Pick’s disease D Alzheimer’s disease. E Delirium. Visual hallucination: Dementia with Lewy bodies plus Parkinson's disease. Vascular dementia: mode, slow concentration, vascular disease. Pick’s disease: Personality 39 15. An 80-year-old man presents with tremor that occurs at rest. He also describes worms crawling across the floor, which his wife cannot see. He only sees the worms in the evenings. His wife also reports that he is low in mood and has slowed down recently. Select the most likely diagnosis. A Vascular dementia. B Dementia with Lewy bodies. C Pick’s disease D Alzheimer’s disease. E Delirium. Visual hallucination: Dementia with Lewy bodies plus Parkinson's disease. Vascular dementia: mode, slow concentration, vascular disease. Pick’s disease: Personality 40PSYCHIATRY 41 Faris Hussain Previous SFP 1 and 2 -Wales CTF (F3 grade) 4216. A 65-year-old man is counselled for starting clozapine. He has schizophrenia, with paranoid delusions that have not responded to previous antipsychotics. He has a history of mixed COPD and asthma, and a previous episode of pericarditis two years ago. He currently smokes 20 cigarettes and drinks five cups of black coffee per day. What part of the patient’s history is an absolute contraindication to starting clozapine? A Asthma history B COPD history C Current daily coffee consumption D Current daily smoking E Previous pericarditis 43 Correct answer: E Absolute contraindications to clozapine include: • Alcoholic/toxic psychoses • Coma • History of neutropenia/blood dyscrasia/bone marrow disorders/agranulocytosis • Paralytic ileus • Severe CNS depression • History of myocarditis or pericarditis • History of circulatory collapse • History of cardiomyopathy • Severe renal disease • Severe cardiac disease • Active Liver disease/failure The BNF provides a more exhaustive list of contraindications and cautions. Pericarditis is a very rare complication of clozapine (<1%); however, having a history of pericarditis, myocarditis, or any severe cardiac disease prohibits initiation of clozapine in a patient. Asthma or COPD is not a caution nor contraindication for clozapine use. Clozapine can be used with caution in patients with diabetes but may increase the risk of blood glucose control worsening. Smoking itself increase clozapine clearance and may reduce thus the plasma concentration of clozapine. Caffeine has the opposite impact and decreases clozapine clearance. These habits, common in patients with schizophrenia, do not prohibit the use of clozapine. Advice should be given not to stop or increase smoking or caffein consumption dramatically whilst on clozapine, whilst the prescribing team would need to carefully monitor clozapine levels and dosing. 4417. A 58-year-old man presents with vision changes over the last few months. He has well controlled schizophrenia and has been on chlorpromazine for 20 years. What finding will most likely be seen on fundoscopy? A Corneal deposits B Glaucoma C Macular degeneration D Papilloedema E Retinal haemorrhage 45 Correct answer: A Chlorpromazine, a typical antipsychotic, increases your risk of developing corneal deposits. With these present, there is an increased risk of cellular damage after light exposure and blindness. Medications linked with glaucoma include risk has been associated with the use of steroids and the antiepileptic drug topiramate. Macular degeneration involves cumulative effects of lifetime oxidative stress. No specific identified medications that cause macular degeneration. Papilloedema is defined as optic disc (OD) oedema secondary to elevated intracranial pressure (ICP). Medications linked to this include; • Corticosteroids (prolonged course or withdrawal) • Hormones such as cyclosporine, leuprorelin acetate (LH-RH analog), growth hormone (GH, levothyroxine) or thyroid hormone (replacement), or oestrogen (levonorgestrel) • Sulfa-antibiotics • Tetracyclines • Nitrofurantoin • Nalidixic acid • Vitamin A analogs (retinoids) used in dermatological and cancer therapy such as liver cis-retinoic acid, all-trans-retinoic acid, retinol, isotretinoin, etretinate, and tretinoin; • Lithium • Fluvoxamine • Sertraline • Mirtazapine • Phenytoin 46 Correct answer: A Retinal haemorrhages are finding seen in shaken baby syndrome most commonly. They are not associated with any medication use. Smoking itself increase clozapine clearance and may reduce thus the plasma concentration of clozapine. Caffeine has the opposite impact and decreases clozapine clearance. These habits, common in patients with schizophrenia, do not prohibit the use of clozapine. Advice should be given not to stop or increase smoking or caffein consumption dramatically whilst on clozapine, whilst the prescribing team would need to carefully monitor clozapine levels and dosing. 4718. A 24-year-old man is brought to the emergency department by the police. He was found jumping up and down on top of a parked car in his underwear. The patient’s history reveals he has not slept for four days and that he has been hearing voices giving him instructions for about five weeks. The patient has been previously admitted to hospital 2 years ago for hearing voices and a similar episode of public disruption. They have no other relevant psychiatric history. What is the most likely diagnosis? A Bipolar affective disorder type 1 B Bipolar affective disorder type 2 C Schizoaffective disorder D Schizophrenia E Substance-induced psychotic disorder 48 Correct answer: C Schizoaffective disorder is characterized by symptoms of schizophrenia plus mood changes such as mania or depression. The Diagnostic and statistical manual of mental disorders (DSM) definition requires the presence of schizophrenia symptoms concurrent with the mood symptoms (depression or mania) and lasting for a considerable part of a 1-month period. The patient described here is hearing voices, consistent with schizophrenia, and is experiencing a manic episode, with features of public nudity and decreased need for sleep. This combination of presentations suggests schizoaffective disorder as the most likely diagnosis. Patients with bipolar disorder (type 1: mania and depression episodes, type 2: hypomania and depression episodes) experience usually a mixture of high and low mood periods. The presence of schizophrenic symptoms in this patient suggests a diagnosis beyond bipolar disorder. Schizophrenia is usually difficult to differentiate from schizoaffective disorder, as negative mood symptoms are very common with patients with schizophrenia. Mood symptoms in schizophrenia are typically of shorter length relative to the total duration of the episode of illness, limited to the prodromal phase or residual phases, or fail to satisfy the criteria for a mood episode (e.g. depressive episode). For this patient, the clear mania episode alongside symptoms of psychosis over a longer period suggests this is most likely schizoaffective disorder over schizophrenia. Substance-induced psychosis is difficult to differentiate from non-substance related episodes. Typically, a urine drug screen is done in practice to differentiate for this. Clinically in substance-induced psychosis, the delusions may be more fluctuate and less crystallised. 4919. A 21-year-old man is brought to the GP by his parents over behaviour concerns for 6 months. He has become more isolated, spending most of his time alone in his university room and own room at home. His parents have overheard him talking out loud with no one else in his room. The patient mentions that for 8 months at night a women’s voice encourages him to save the university from his housemates who will soon burn down the student’s union building. What is the most likely diagnosis? A Bipolar episode with psychosis B Depressive episode with psychosis C Schizoaffective disorder D Schizophrenia E Schizophreniform disorder 50 Correct answer: D The patient in the question stem meets the diagnostic criteria for schizophrenia. These include, according to ICD-11 and DSM V; ICD-11 • Combination of at least one first-rank psychotic symptom OR • At least two other symptoms, including other positive psychotic symptoms, disorganised thinking or speech, negative symptoms, or catatonia. The defined first-rank psychotic symptoms ICD-11 use include: • Thought echo, insertion, withdrawal, and/or broadcasting • Delusions of control, influence, or passivity • Delusional perception • Auditory hallucination (usually commenting on the patient's behaviour or talking about the patient in the third person) DSM-V • All the following must apply: o Two or more of the following must be present, with at least one positive symptom; § Delusions § Hallucinations § Disorganised speech § Disorganised/catatonic behaviour § Negative symptoms o Symptoms occur for at least 1 month and are associated with at least a 6-month period of functional decline. o Symptoms do not occur concomitantly with substance use or with a mood disorder episode. 51 Correct answer: D In bipolar affective disorder with psychosis, the affective symptoms occur before psychotic symptoms emerge with the psychosis usually congruent with the patient’s mood. In depressive episodes with psychosis, the affective depressive symptoms typically occur before psychotic symptoms emerge, usually congruent with the patient’s mood. Schizoaffective disorder has at least 2 weeks of stable mood with psychotic symptoms in addition to a major depressive, manic (or both) episode. In practice, with schizoaffective disorder, psychosis (i.e., delusions, hallucinations) and mood symptoms are closely related in time but present differently, nearly independent of each other, as symptoms. Schizophreniform disorder, a DSM-V diagnosis, shares similar symptoms as schizophrenia, but the duration is 1-6 months. 5220. A 21-year-old man presents feeling fatigued and constipated for 8 weeks. He has put on 5kg of weight in the last month and complains of feeling cold all the time. He has a history of bipolar affective disorder type 1. What medication is most likely responsible for these abnormalities? A Carbamazepine B Lamotrigine C Lithium D Quetiapine E Valproic acid 53 Correct answer: C Lithium The drug options are all potentials for mood stabilisation in patients with bipolar affective disorder. The bloods results indicate hypothyroidism with the elevated TSH and decreased free and serum T4. Lithium is a mood stabilizer used to treat bipolar disorder, often as a first line medication. Its exact mechanism of action is unknown. Lithium’s notable side effects include nausea and diarrhoea, hypothyroidism, polyuria/polydipsia, tremor, weight gain heart-block, cognitive impairment/sedation, decline in sexual function, acne, oedema, and leucocytosis. Lithium is known to have long term effects on the kidneys, thyroid gland, and parathyroid glands. The notable side effects of carbamazepine are diplopia/ataxia, agranulocytosis, aplastic anaemia, megaloblastic anaemia, hepatotoxicity, SIADH, and Stevens-Johnson syndrome. The notable side effects of lamotrigine include agitation, increased aggression, arthralgia, GI upset, and Steven-Johnson syndrome. The notable side effects of quetiapine include constipation, drowsiness, dry mouth, decline in sexual function, hyperprolactinaemia; hypotension (dose-related), weight gain and metabolic syndrome. The notable side effects of Valproic acid include pancreatitis, hepatotoxicity, tremor, alopecia, and weight gain. 5421. A 73-year-old woman presents with one week of suicidal thoughts. She has a history of recurrent depressive disorder, diagnosed five years ago. She has previously attempted suicide via paracetamol overdose, which required hospital admission. The patient lives alone and has no partner. What is this patient’s most significant risk factor for a completed suicide attempt? A Female sex B History of depression C Patient’s age D Previous suicide attempt E No partner 55 Correct answer: D Previous suicide attempt This is an elderly woman presenting with suicidal ideation. Personal history of a previous attempt is the most significant risk factor for a completed suicide attempt. The mnemonic SAD PERSONS covers the risk factors for completing suicide: S: sex, males more frequently complete suicide than females A: age, teenagers and elderly individuals D: history of depression P: previous history of suicide attempt E: ethanol or illicit drug use R: rational thought lost S: sickness/chronic illness O: organized suicide plan N: no spouse S: social support poor. 56 Correct answer: D Previous suicide attempt Patients who have previously attempted suicide have a 5-6 times greater risk of attempting suicide again. The greater the number of lifetime suicide attempts, the higher the likelihood of death by suicide. Elderly age is a risk factor for completing suicide but is not as strong as a previous suicide attempt. The highest risk group is white men above the age of 85 years. A psychiatric diagnosis, such as depression, does increase your risk of completing suicide but not as significantly as a previous suicide attempt. While women attempt suicide approximately twice as often as men, males complete suicide three times as often as females, mainly because men often choose more lethal methods (e.g. hanging) when attempting suicide. Being single is a risk factor for suicide, but a previous suicide attempt is the greatest risk factor. Any form of solitary living is a risk factor for completing suicide. 5722. A 20-year-old woman presents with her housemate to the emergency department acting “strangely” for the past 12 days. The housemate has noticed that the patient has been up all night pacing around the house, believing they are about to crack the ‘problem of life’. The patient has been previously hospitalized for a similar episode two years ago. She has previously been on sertraline for a depressive episode; she stopped taking the medication 12 months ago. The patient speaks very fast, frequently changing the topic of conversation; they deny anything is wrong, saying she has ‘made great progress’ on her plans. What is the most likely diagnosis in this patient? A Bipolar affective disorder type I B Bipolar affective disorder type II C Depressive episode with psychosis D Schizoaffective disorder E Schizophrenia 58 Correct answer: A Bipolar affective disorder type I This patient meets criteria for a manic episode with her grandiosity, flight of ideas, increase in activity, decreased need for sleep, and talkativeness. The ICD-11 criteria for bipolar diagnosis include: • Bipolar type I disorder o History of at least one manic or mixed episode. o Single manic or mixed episode is sufficient for o Typically characterised by recurrent depressive and manic or mixed episodes. • Bipolar type II disorder o History of at least one hypomanic episode and at least one depressive episode. o Typically characterised by recurrent depressive and hypomanic episodes. o There is no history of manic or mixed episodes. A manic episode is defined as a distinct period of abnormally elevated/irritated mood and persistently elevated energy levels. According to DSM-V, a manic episode must last at least seven days and should require a need for hospitalization or 3 of the following DIGFAST symptoms: • Distractibility • Irresponsibility • Grandiosity • Flight of ideas • Activity/agitation increase • Sleep requirement decreased • Talkativeness or pressured speech. 59 Correct answer: A Bipolar affective disorder type I Depression with psychosis typically presents with low mood symptoms followed by congruent psychotic symptoms appearing. Schizoaffective disorder has features of both schizophrenia and a mood disorder. ICD-11 defines the disorder as episodic, of at least 1 month period, and characterised prominent schizophrenia and affective symptoms during the same episode, either at the same time or within a few days of each other. This patient does not describe clear symptoms of schizophrenia, such as auditory hallucinations or thought phenomena. Schizophrenia would often have delusions and hallucinations occur before the mood disorder starts, and often the hallucinations and delusions may be incongruent with the mood of the patient . 6023. A 45-year-old woman presents with excessive cleaning behaviours at home. Over five months, she has spent two hours per day washing her hands due to worry over cleanliness, doing this before leaving her house and on returning home. Her employer has commented that her workplace performance has deteriorated in recent weeks. What is the most likely diagnosis? A Autism spectrum disorder B Delusion disorder C Generalised anxiety disorder D Obsessive compulsive disorder E Schizophreniform disorder 61 Correct answer: D Obsessive compulsive disorder Obsessive-compulsive disorder (OCD) is a psychiatric disorder where a patient has obsessions and compulsions that have a negative impact on a person’s functioning, such as an obsession for cleanliness and a compulsion to wash her hands a specific number of times. Autism spectrum disorder does not usually feature compulsions performed in response to a particular obsession. In autism spectrum disorder, repetitive behaviours usually include more stereotyped motor behaviours or insistence on routines. Delusional disorder patients usually exhibit psychotic symptoms, including delusions of grandeur, persecution, or jealousy, without the other features of schizophrenia. Generalised anxiety disorder (GAD) presents with anxiety and worries unrelated to any medication or social circumstance. OCD describes a particular pattern usually of obsessions and compulsions. Schizophreniform disorder describes symptoms of schizophrenia but with a presentation of less than 6 months. This is a very unlikely diagnosis as no delusions or hallucinations are described here. Template explanations page 6224. A 23-year-old man is brought by his parents to the emergency department owing to a change in behaviour, marked by agitation, eruptions of laughter, insomnia, and unusual thoughts. He believes nothing is wrong and claims to be writing all his university assignments at the same time. What medication is best for treating this patient’s symptoms? A Chlorpromazine B Clozapine C Diazepam D Lorazepam E Quetiapine 63 Correct answer: E Quetiapine This patient has presented with a manic episode with agitation. Most guidelines recommend initiating a patient with a manic episode on either monotherapy with an atypical antipsychotic or mood stabiliser or a combination therapy of a mood stabilising medication (e.g. lithium or valproate semisodium) and an atypical antipsychotic e.g. one with good evidence: haloperidol, risperidone, olanzapine, quetiapine, aripiprazole, or asenapine). In the UK, the National Institute for Health and Care Excellence recommends haloperidol, olanzapine, quetiapine, or risperidone as potential first-line antipsychotic options. Chlorpromazine, a typical/1 generation antipsychotic, is not recommended in these circumstances for mania management, mainly due to the lack of evidence for its use in this context. There is some recommendation to use chlorpromazine for mania without agitation with specialist input. Clozapine, though an atypical antipsychotic, is not usually prescribed acutely in patients with mania due to its extensive monitoring needs. Diazepam and lorazepam are not usually given as first line medications for mania. In situations where patients with mania and worsening agitation do not respond to the use of an oral anti-manic or antipsychotic medication, administration of a rapidly acting non-oral antipsychotic or benzodiazepine is appropriate. Options include IM olanzapine, inhaled loxapine, IM lorazepam, sublingual asenapine, oral risperidone, IM ziprasidone or IM haloperidol lactate. 6425. A 25-year-old woman presents with a 4-month history of insomnia and irritable mood. She expresses feelings of worthlessness and wonders sometimes what the point of living is. She has recently attempted suicide 2 months ago with paracetamol tablets. She currently has no plans for another suicide attempt. She has had previous episodes of depression on five previous occasions and has also been diagnosed with schizophrenia recently. She has been on several antidepressants in the past with limited improvement. The psychiatrist chooses to treat this patient with ECT. What is the strongest indication to utilise this treatment? A Patient’s antidepressant treatment history B Patient’s insomnia C Patient’s current suicidal ideation D Patient’s schizophrenia history E Patient’s suicidal behaviour history 65 Correct answer: A Patient’s antidepressant treatment history The main indications for ECT as per NICE guidelines, to achieve rapid improvement of severe psychiatric symptoms include: - Adequate trail of other treatment options (e.g. antidepressants) has failed - Life threatening Severe depression; often used early in treatment for depression with life-threatening psychotic symptoms, suicidality, or catatonia, or later in treatment for people with refractory depression or intolerance to antidepressants. - Patients with a prolonged or severe manic episode. A diagnosis of schizophrenia is not an indication for ECT; NICE actively recommends not treating schizophrenia symptoms with ECT. Though a patient being actively suicidal may warrant ECT, this patient’s lack of current plans suggests she is of less risk than she was 2 months ago. Template explanations page 6626. A 32-year-old woman presents 5 hours after taking 30 sertraline tablets intentionally to end her own life. She has symptoms of anxiousness, blurred vision and a new onset tremor. She has a pulse rate of 105 bpm, a temperature of 37.6 degrees Celsius, has hyperreflexia in both lower limbs and has bilateral ankle clonus. What is the most likely diagnosis? A Anticholinergic delirium B Malignant hyperthermia C Neuroleptic malignant syndrome D Serotonin syndrome E Sympathomimetic toxicity 67 Correct answer: D Serotonin syndrome Serotonin syndrome describes an excess of synaptic serotonin in the central nervous system manifesting as neuromuscular excitation (hyperreflexia, ankle clonus), autonomic effects (new onset tremor, tachycardia, pyrexia), and altered mental status (anxiousness). This is often triggered by exposure to serotonergic medication, drug overdose, or specific drug-drug interactions. Anticholinergic delirium presents usually following a history of exposure to History of exposure to anticholinergics (e.g., amitriptyline, oxybutynin). Presenting signs include confusion and altered mental status, absent bowel sounds and dry skin. Unlike serotonin syndrome, there is usually an absence of neuromuscular excitation. Malignant hyperthermia presents usually following a history of anaesthetic exposure perioperatively. There is typically also an absence of neuromuscular excitation. Neuroleptic malignant syndrome usually features a history of antipsychotic exposure or that the patient is on multiple drugs including serotonergic agents. Unlike serotonin syndrome, there is a slow onset of symptoms, usually over days and presenting features include bradykinesia, extrapyramidal effects, lead-pipe rigidity, and autonomic lability. Sympathomimetic toxicity presents usually following exposure to sympathomimetics including adrenaline or glucagon. There is typically also an absence of neuromuscular excitation. 6827. A 54-year-old man with presents to the emergency department with new onset delirium. He has a background of schizophrenia and has been started on regular haloperidol 7 days ago. He has a temperature of 38.9 degrees Celsius, a heart rate of 140 bpm, and generalised muscle rigidity. What investigation would be best confirming the most likely diagnosis? A Arterial blood gas B Serum creatinine kinase C Serum myoglobin D Serum toxicology E Urine myoglobin 69 Correct answer: B Serum creatinine kinase Neuroleptic malignant syndrome (NMS) is an uncommon, life-threatening complication of treatment with dopamine antagonists. Also occurring with other agents that block central dopamine pathways (e.g., metoclopramide, domperidone), it presents with symptoms including hyperthermia, muscle rigidity, and altered mental status. Though the diagnosis is largely clinical, NMS presents with a dramatic increase in serum CK (4 times the upper limit of normal range, typically >1000 units/L) because of the muscle damage. This is a highly sensitive marker for the diagnosis. An arterial blood gas may show respiratory failure or metabolic acidosis but neither of these findings are specific to NMS. High myoglobin in urine or serum indicates multi-organ damage and can suggest that the NMS presentation is severe. However, these findings may only present at a late stage in the progression of the illness. A toxicology screen would not help diagnose NMS but would help rule out other causes of the presentation, including an illicit drug overdose. 7028. A 33-year-old man with bipolar disorder presents with a bilateral hand tremor. He has been on multiple mood stabilising medications in the last five years. What medication is the most likely cause of this patient's tremor? A Carbamazepine B Lamotrigine C Lithium carbonate D Topiramate E Sodium valproate 71 Correct answer: C Lithium Carbonate Lithium carbonate is the most often used mood stabilising medication in Europe for bipolar affective disorder. Tremor is a common adverse effect of lithium carbonate, usually at a frequency of 8 to 10 Hz often related to peak serum lithium levels. Reducing the lithium carbonate dose and decreasing caffeine intake can decrease the tremor. The other options do not cause tremor as a common side effect. 7229. A 26-year-old man presents with severe restlessness, insomnia, anxiety, and generalized myalgia during the past two days. He has dilated pupils, excessive lacrimation, diaphoresis, and piloerection. The patient admits to taking an illicit substance and stopping recently. What drug is most likely responsible for the patient’s symptoms? A Amphetamine B Cannabis C Cocaine D Heroin E Modafinil 73 Correct answer: D Heroin Heroin, an opioid medication, can cause insomnia, pupil dilation, piloerection, diaphoresis, lacrimation or rhinorrhoea, and myalgia in withdrawal. Cannabis withdrawal symptoms would include anger, irritability, aggression, weight changes sleep disturbance, low mood, GI upset and tremors. Cocaine withdrawal symptoms include fatigue, vivid dreams, increased appetite, and psychomotor retardation or agitation. Amphetamine withdrawal is characterized by fatigue, psychomotor retardation or agitation, craving for stimulants, increased appetite, insomnia or hypersomnia, and bizarre or unpleasant dreams. Modafinil withdrawal would cause sleepiness (not insomnia). 7430. A 19-year-old woman presents with symptoms of depression for the past five months, following being sexually assaulted at a party. The patient says she was heavily intoxicated when the incident occurred and has little memory of the event, but she was embarrassed when she awoke at the scene and realized what had happened. She sought no medical care at that time. The patient says she has not told her friends about the incident, and she has continued to go to work. However, she says she constantly feels sad and anxious, has become tearful and withdrawn, and has had difficulty sleeping because of frightening nightmares. This patient most likely has which of the following psychiatric conditions? A Acute stress disorder B Generalized anxiety disorder C Major depressive disorder D Panic disorder E Post-traumatic stress disorder 75 Correct answer: E Post-traumatic stress disorder The patient described meets diagnostic criteria for post-traumatic stress disorder, with involvement in a traumatic event, duration of symptoms for more than one month, and significant effect on daily life due to low mood, anxiousness, nightmares, and social withdrawal. Acute stress disorder, is incorrect because of the duration of symptoms which typically begin immediately after or within four weeks of the event and last from three days to four weeks. Generalized anxiety disorder, involves symptoms occurring more most days for at least six months: restlessness, fatigue concentration issues, irritability, muscle tension, sleep disturbance. These symptoms also include excessive anxiety and worry about several events or activities. Major depressive disorder, is symptoms include low mood, anhedonia, anergia, significant weight loss without dieting, weight gain (more than 5% of body weight within one month), insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, loss of energy, recurrent thoughts of death, and suicidal ideation. Panic disorder describes a condition where recurrent, unexpected panic attacks occur that are not cued by stimuli that recall a specific trauma. 76 FEEDBACK FORM https://app.medall.org/feedback/feedback- flow?keyword=15e13ed2f8547f0de6de197e&organisatio n=cardiff-university-1d35ee05-c72b-48f9-840c- abb1560ca666 77 THANK YOU FOR ATTENDING TODAY! A big thank you to our speakers and the team who made this session possible! Please fill in the post-course survey to earn anotherwin a £30 revision aid book!ces to 78 RAFFLE TIME Many thanks for completing the pre- and post-course survey! We will do the raffle draw now. 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