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That's good. Hello, everyone. Welcome back to the year for academic provision tutorials, which is a week long series that covers all the specialties relevant to the Edinburgh medical school curriculum. This is the last session of the series where we'll be covering infectious diseases and psychiatry and we're very lucky to be joined by Sarah, fifth year medical student over to you, Sarah. Yeah. Can everyone hear me? Okay? I think you have to like, type in the chat with you. I don't know if I can, I don't know if there's people Lucas, if you can see the chat, I can't see anything just now. I don't know if that's my um, yeah, I can see the chart. Okay. I'm not sure why I can't. So if you click on the right side of the screen, you should be able to see the chat bubble and if you click on that it should come up, but otherwise that's fine. Two seconds. Let me see. Yeah, that's okay. Sorry, I think I'm back. I'm not sure what happened, but I can see that I can see the messages now so we can crack on if everyone's okay with that. Um, okay. So, yeah, this is um, a two hour session that's going to cover some MCQ on infection and sort of common infectious diseases and then also some psychiatry as well. Um I'm not sure that it will take the full two hours. Um, but we have two hours and we can take a little break in the middle. So once we finish infection before we move on to psychiatry, we can start for 10 minutes. Um You can get some water and stuff. Um So we'll just crack on. There's no mix. I believe. So if I'm like asking you a question, just type it in the chat and now that I can see it, that should be fine. So if everyone can see this okay. This is the first question. So a child presents with a history of fever and a rash. The rash is lazy in appearance and you can see it here on the face is start on the face and spread to the rest of the body once two days later, what's the most likely cause it of organism? And I've got a pool that should come up just now. Um So if I look on messages, so if everyone just like pops in what they think it could be okay. And then if I just stop pulling, does that come up for you guys? So most of you said para virus, if you've, you said measles, so this is, this is para virus um, there is a little bit of an explanation like a little bit further on, but this is the classic sort of presentation that you would see with para virus. It's called, um, slapped Cheek Syndrome or Slapped Cheek Disease because it looks at the child's been slapped in the cheek. Um, measles looks slightly different to this. Um, we can talk about that sort of when we get a little bit further on, but they just look a little bit different. And if you remember sort of the lacy appearance is one of those buzzwords that should make you think para virus if it was to be, for example, an exam question. Um And yeah, if you have any questions at any point, just take them in the chat. So a child presents the G P with the history of fever, malaise conjunctivitis, coryza and cough. She's widespread widespread blanching, macular popular rash associated with fine disclaimer discrimination which her mother says started behind her ears soles and palms are spared, which of the following are not usually associated with this disease. Okay. So have a little look, see what you think it's gonna be for a few more people to answer. Okay. So, okay. So a lot of you guys have gone for bronculitis. Um So does everyone um sort of know what this is referring to if anyone wants to pop the diagnosis in the chat? Okay. This is um so this is referring to measles virus um, the starting on her ears, sparing of the sores and palms. That's really, really typical of measles. So, if you see that you should have sort of alarm bells ringing in your head for measles. Um, so bronculitis is measles is actually a really common cause of bronchiolitis. Um, bronchiolitis is caused most commonly by RSV. Um But then the second most common is, or it's definitely like, one of the most common is measles. It's sort of like the same family as RSV, but um slightly different measles. Um And actually what you can get with measles is something called bronchiolitis, obliterans, which is like a really rare result in lung damage that you can get with measles after bronchiolitis, it's, it's not very common. But so that is not the right answer that is actually um usually associated with measles. Um A lot of you said in careful itis. Um So I think about one in 1000 Children get encapsulitis with measles. So it's uh it's not common, but it is associated. Um And then after that, a lot of people said Koplik spots. So Koplik spots are little spots that I think we have a photo later on that are present on the buccal mucosa with measles and they're quite path anomic for measles. So if you see those, you know that it's, it's measles. So they are associated. The answer is actually sensorineural deafness. Um We don't usually see that with, with measles. So moving on to the next question. Uh So there's no specific treatment for the condition. Um, but the GP recommends a few things to help believe the child symptoms, which the following is not recommended. So I don't know if I'd maybe like give it a bit easier by telling you what the diagnosis is. But um, wait for people to answer this. Yeah. So most of you got that spot on um, paracetamol, ibuprofen high fluid intake there all what you would tell the parents to do. Um or the the child if they're old enough um Aspirin, we don't give to Children. Um unless it's sort of a very specific circumstance, there is a small risk of something called Reyes syndrome if you give aspirin to a child with a viral illness and that's like a multi system disorder disorder, um affects all of the organs of the body, but like especially the brain and the liver. Um you get sort of acute increases of pressure and um accumulation of fat in the liver and it can cause some quite serious damage. So we don't give aspirin to Children routinely. Um This one is quite long this question. So, moving on to a new patient, an 18 year old man is three weeks of malaise fever, headaches and one week of a sore throat. He has large tonsils with exudate, a particular rash on the palate and accelerate an inguinal lymph done opathy. His temperature is 37.6 pulse rate is 84. The pressure 220 over 82 in respiratory rate is 12 breaths per minute. So he's got um an elevated white cell count. Um If you guys can see that, I know the logos a little makes it a little bit difficult. His lymphocytes are high and then you've got the rest of this sort of liver function test there. I won't read all those out. What investigation is most likely to confirm the diagnosis? Um Are you guys talents? Uh okay. So yeah, most of you are spot on their E B V serology. So this is looks like it could be Epstein Barr virus. So you test that with a B V serology. So most of you got that so well done moving on. Okay. So this we child with the rash shown which of the following is true, right? It's okay. You guys seem a lot better infectious diseases than I was last year. So I'm quite impressed. I definitely wouldn't have known this. Okay. So yeah, most of you are right. So this is most commonly caused by gram positive cocky. So this is most commonly caused by group air strap and staph aureus and those are gram positive cocky. Does anyone want to write the diagnosis in the chat? Yeah, spot on. So this is this is impetigo, this is really classic impetigo. It's really, really contagious. So if you have any sort of questions or a ski stations on um Children who present with impetigo, make sure you bear in mind. Um How contagious, how contagious it is. There's other kids at home, etcetera, the child should have their own towel and shouldn't be sharing with other people in the house, all that sort of stuff. Okay. So, moving on. So this is a little so of um bit of information for some of the conditions that we've gone through. So this is the Slapped Cheek Disease were talking about earlier. Um I'll let you, I'm not gonna read all of that out to you guys can see that. Uh And then this is like sort of what I was talking about earlier with the buzzwords. So when you hear a rash out behind the ears and move in downwards over the rest of the body, um the white spots inside of the mouth, that's the Koplik spots. You have to immediately think of measles, um rubella, low grade fever, prominent sub occipital lymphadenopathy and arthralgia. Think rubella. Um the Slapped Cheek syndrome is very typical of para virus. Um Roseola has that sort of risk of febrile convulsion. So if that's mentioned, you sort of have to think of that and then uh the question that we got an EBV, it's quite systemic. Um and you have the mono spot initial test. So uh those are all just sort of things that you have to learn. Um There's some photos so you can see the Koplik spot inside the cheek there on the mucosa. Um you can see the to slap cheeks that this child has in the middle, the para virus. Um and if you get a question that mentions nodules on the shins, the erythema nodosa um that you can see here, you can see that in cartoons, disease, but it's also quite typically associated with um Epstein Barr virus. So that can ring a few alarm bells for you there. Okay. So, moving on, I think we're moving out a little bit away from kids for the moment. So 65 year old man is on the general surgery would following a nissen from the application, he receives antibiotics for a surgical wound infection. Um He's on amLODIPine, Lisinopril, finasteride, tamsulosin salbutamol inhaler. Um That result in allopurinol. He develops profuse watery diarrhea. Um 10 to 15 times a day with severe painful abdominal cramps and a fever still culture confirms the presence of see death, which of his regular medications is most likely to be associated. I'll stop pull just there. Yeah. So most of you guys have got that right. That's um so his omeprazole is a meprazole makes you two times more likely to get a C diff infection. Um And does everyone know what like a listen, fun duplication is, it's where you sort of wrap the funders of the stomach around the esophagus and it anchors the lower esophageal sphincter below the diaphragm. So, if you have Gourd and reflux disease where it's coming through the diaphragm. It, that's what that's for. Um, so you would stop the, uh the uh Prempro Solagh. Um Which of the following antibiotics is not associated with the see death infection in hospital patient's? Mhm. There's like a, a pneumonic that you can use to remember this. Um Okay. So the answer for this one is actually Clarithromycin. Um I think we do have a slide a little bit further on that goes through this little bit more. I think we just have like one more question before that. So I'll sort of come back to it, but um it is associated with the Clindamycin. Um The KF Iraq seem and the co amoxiclav and it is associated with um tamsulosin as well. So just answer the next question, then we'll come back to that. So he undergoes a severity assessment. He has one severity marker, which is his pyrexia. His first episode of C diff infection. What is the most appropriate management? So, are you going to give this man? Um Yeah. So most of you said oral Vancomycin, which is absolutely correct. That is the first line treatment for a C diff infection if it's mild or moderate or severe. Um If you, if you put oral Vancomycin with IV Metronidazol, it's not a bad answer. If it was slightly more severe, that would be a really good thing to do. Um I just think he's not quite there yet. Um He's a bit Pyrexic but he doesn't quite need the, the IV treatment just yet, but you're not wrong. Um So c diff is one of those things that is worth learning about, um, is really, really common in hospital patient and they love to ask about it on exams. Um It's grand positive, uh it's risk factors. So, antibiotics use and this is the sort of you pneumonic I was mentioned earlier. So the foresees and PT, so a lot of antibiotics spearmint. See. So I don't know um how helpful that is. I don't know if there's like a better way of remembering which sees that it is maybe I'm just not aware of, but the forces are clindamycin, cephalosporins, co amoxiclav and Ciprofloxacin. And then PT is the Pepperell in Taszar back tam combination that's called uh terazosin together. And that's used quite a lot in neutropenic sepsis, especially in oncology. Patient's so patient's who are on um chemotherapy, the one that doesn't was um Clarithromycin. So another see, but um so from essence, not associated with increased risk of CF um So yeah, if you have like a patient who is on chemotherapy um for something like lung cancer or something else and they um yeah, I'll repeat them. Um Just a sec, I think actually there on the next slide, I'll just move on to the next slide and you can take a foot or whatever, write them down. Um Yeah, and you get a patient who comes in quite septic and you're worried about neutropenic sepsis. Um With chemotherapy, you would give terazosin, which is the piperacillin tazobactam combination at the bottom there. Um And then the only other thing it said in that previous slide was about, you would diagnose it, you would use a stool sample for C diff toxin. Um And the management is you'd isolate the patient to a side room because it's very contagious. Um And you'd give oral vancomycin for 10 days. Um Second line, I'll just go back so you can see there and then if it's life threatening, if it's really severe, you would add that IV Metronidazol. So um okay, moving on. So a 35 year old man from Pakistan presents with weight loss and him up to sis his chest X ray is shown what is the most likely under underlying diagnosis? I don't know if you guys can see that very well. Um If you can like sort of make it a bit bigger, I think the nice guidelines Claris, it was sort of um I'll have to, I would have to have a look. Um You might be right, to be honest, I didn't write these questions. So it's, it's more than possible. Um If the nice guidelines set then definitely trust that over me cause I'm, I'm not that knowledgeable. Okay. So I think, I think um take the four season PT as the learning point from this rather than um the point about Clarithromycin perhaps and hopefully that will still be quite useful. Um Okay. So the most likely underlying diagnosis. So most of you said tuberculosis, which I would agree with. Um So you can sort of see the lesion in the lung there. Um The fact that he's come from Pakistan is a bit of a risk factor. Um uh the other, so the other options, uh lung cancer is possible but it's not most likely. So it's one of those questions where um just cause you're not right, you're not wrong if that makes sense. Um Pneumocystis. So PCP is almost exclusively seen in immunocompromised patient's who are on chemotherapy or have um It's so if you see a question with PCP, um that's what you're sort of thinking and what is true regarding the treatment for TB. So he's got deep TB. What are you going to tell him about his treatment? Yeah. Okay. Um So most of you got that one, right? So, Pyrazinamide is contraindicated in patients with preexisting gout. So, pyrazinamide um alters the serum uric acid levels and it can precipitate a gout attack. So you wouldn't give that to somebody who had gout unless it was going to save their life or something. Um So, yeah, good job visual acuity should be checked before I start. So I think that's um a slightly confusing question because my son is it um can like a side effect of that can be blurred vision or loss of vision. So I think that's a bit of a red herring. It makes sense that you would check visual acuity if you're thinking about the side effects. So I understand why some of you have put that. It's one of those things. Um First time regimen is a triple therapy. So first line regimen is actually um it goes under the acronym ripe. So it's actually four drugs that you give. Um and the second option where you should add pyrazinamide uh eight weeks. Um That's not quite how it works either. We will go through um ripe and the treatment of TB in a second. Um And then the final one where it says that Reef Empson causes tears and saliva to turn green. It's another one of those nasty questions. It causes it to turn red, orange, not green isn't FM Butul that can reduce. Oh yeah, it might be actually, you might be right. Alice. That's probably why I was a little bit confused. I thought that was like a nasty question but actually I think I'm just getting and the mixed up. Um But yeah, that's sort of okay. So that's the, this is the ripe. Um I mean, I think it's easier if you, if you remember it's ripe rather than our head steady, but whatever works for you guys. Um So those are the four antibiotics that you would give, you would isolate the patient in a negative pressure room. It is contagious. You would want um multiple sputum samples. Um and there is a specific tuberculosis team that would deal with this. So we do see tuberculosis in Edinburgh relatively often. Um And you would give all four drugs for two months and then you would carry on the reef um person and ison eyes. It hit that word for a further two months and then that gives you a phone with the treatment. Okay, moving on uh another patient. So a 35 year old man returns from business trip in Ghana. Um Three weeks later, he goes to his GP complaining of feeling feverish for the sore throat and headache for the last few days on examination. He has a temperature of 38.4 and a macular popular rash on his chest and trunk, which single disease is it most important to test for in this man? Um There you go. Okay. So, um so the correct answer for this one is HIV. Um I'm not sure if this question is getting at the fact that hitch and IV is the most important one to exclude or whether it's um wanting you to be confident that this man definitely has HIV or potentially definitely has HIV. Um I don't think that testing for um measles or dengue fever and this man would be like the worst thing you could do. Um But it is pointing towards a picture of HIV um with the travel and the sort of systemic symptoms that he's presenting with. So, um moving on to the Yes. So this man has positive for HIV and it started on antiretroviral therapy. Four years later, he presents to healthcare services with the one week history of discipline where chest pain, fever and productive cough, chest X ray shows features suggestive of pneumonia patient admits to not taking his medication every day as he should. And his CD four count is at 300 which are the most likely organ is, which is the most likely organism responsible for this man's lower respiratory tract infection. Yeah. So um um potentially I'm not uh I don't know for sure. Yes or no. Um I'm not sure where hemorrhagic fever is endemic. I'd have to look it up. But yeah, that makes sense to me. You probably would want to exclude that if that's um endemic in West Africa. Yeah. So you guys were obviously listening to me like 2010 minutes ago, which is great. So um it's most likely gonna be PCP. So which of the following is true? I think this is a difficult question. So I'll give you a little bit longer. Okay. So I'm just gonna go through the answers. So PCP is best treated with Co amoxiclav. So it's called trim ox is all that you would give for PCP. Um similar. So totally valid for getting quiet with that one cryptic. So this is again, um Cryptococcal meningitis usually presents with sort of more of like a fever headache. Um, and neck pain, neck stiffness itself wouldn't necessarily make you think it was cryptococcal meningitis. It's a bit of a mean mean answer. Um Toxoplasmosis, prophylaxis should start when CD four count. Um reach is less than 100. So this is just a little bit um jumping the gun a bit at 3 50. Also, CMB reactivation is a concern with the CD four count of 100. Again, that's only really a concern when you get to 50 in real life. I don't know if it's sort of as rigid is that you maybe would still be concerned. But, um, for the purposes of an exam question, certainly you're looking at 50 for that. So, uh non hodgkin's lymphoma isn't, it's defining malignancy is correct. Uh Hang on. So, um, okay. So this is, this is, so what I was saying. So I think this is one of those things you sort of have to try and learn. I mean, um, obviously you have things that are more commonly seen with more immune suppression. But um, I would just sort of try and learn a few of these numbers for like almost like buzz words for exams. Okay. Um So four year old boy comes in so back to Pete. So the 24 hour history of lethargy and confusion, they've developed a fever and now have a rash over their legs. Um his temperature is 39 cap refill time is four seconds emergency transferred to hospital is arranged. What is the other drug that should be given at this time? So there's no pool for this one. I think you have to just sort of write it in the chat and then uh send it what you think it should be. Um And if you can put a route as well, that would be great. Yeah. Any advances on I am Benzel penicillin. Yeah, perfect. So it's I am Benzel penicillin. Um okay. Yeah, that's fine. So moving on, I thought it was another question about him but apparently not 65 year old woman becomes confused five days after an anterior resection for rectal carcinoma. She has COPD. Her medications include inhaled salmeterol and beclomethasone and sub cut delta parent temperatures. 38 pulse is 100 BP, 88/70 30 breaths per minute. Oxygen sats are 98% on 15 liters via non re breathe. She has inspiratory crackles at the right base abdominal central tenderness and guarding. She's getting IV fluids and blood cultures have been sent. What is the most appropriate next step? So she's quite compromised. Her BP is not as high as we'd like that to be. Um and her pulse is a little bit high. Okay. So this is like a sepsis. 66 response. She's already getting fluids and oxygen and um blood cultures have been sent I'm assuming she's also had her urine output monitored. Um So you would want to give some antibiotics. This is um an oncology patient. She has rectal carcinoma. So she, you would be a little bit concerned in this patient about neutropenic sepsis. So you'd start on pip taz or terazosin what I mentioned earlier. So, um most of you got that right. Which is fantastic. Um Yeah, perfect. Um Have a look. Yeah. So this is says in sepsis, um really important to understand sepsis and to know what to do and sort of what rough order to do it. And it's really important that you get blood cultures away and then you start antibiotics if possible because then your cultures are going to be much more accurate. Um And this is your sort of like markers here of your obs, okay? Um Yeah, and there's receptors six take three, give three is how I remember it. I've never seen Buffalo before, but if that works for you then perfect. Um But I usually just remember the three that you take three that you give and you do it so much that you like, you practice it so much that you, you do remember. Okay. Um A patient comes in for investigation. I don't think we have too much longer left for infection and we can like take a break because I feel like I'm really rattling through these. Um okay. So a patient comes in for an investigation for pyrexia of unknown origin on investigations. Billy Ruben is slightly high and viral serology is sent for the results are as follows. So, have a little look at those results and then decide what disease that this patient, you think this patient has? Yeah. Okay. Um, I'm gonna stop the pull out. So I get really, really confused about hepatitis. I'm not gonna lie. It's not my strong point. Um, the correct answer apparently is um chronic Hep B infection. Um because you have, so that's like the I G G positive would suggest that that's like a response against Hep B. Um and the surface antigen is negative. So it's not an acute infection. So that's why I believe it's a chronic Hep B infection. A lot of you put chronic HEP C infection, that's what most of you gone for. That's also what I would have gone for. Um So I'm not sure how much help I can be here. I do. So let's have a look. There is a slide um that goes through some of the basics for hepatitis and there is a side so we can come back to that. There's a slide that goes to the serology here. So the surface antigen develops an acute infections or active reservations. So if that's negative, they're not having an acute infection. Um anti HBC shows high infectivity, anti HBs shows immunity. So we know he's not immune. Um I don't know, they know they're not immune um because the anti HBs are negative. Um And I G anti HBC with negative h business is suggestive chronic effects. So we, we've got a suggestion that he's got a chronic infection. Um I can't, I'm not sure I can tell you why it's happy and not HEP C. Um but we'll go through some of the basics, just their of hepatitis. Um So there's a nice little A B C D E helpful pneumonic there. Um That helps you remember some of the salient facts about hepatitis. Um It will say that um hepatitis B endemic in Asia is as high as 8% prevalence just now. So if you see a recent travel to Asia, that could maybe be a little bit of a point or towards Hep B in your history. Um But yeah, I'm not going to read all of these out. This is you guys can read. Um And this is very much available on the internet. Um infectious diarrhea buzzwords. So very shortly after eating your thinking Staph aureus, reheated rice. I remember being in a lecture and one of the lectures was like getting sick from rice, be serious, be serious. That can happen. So, I don't know, it's a pretty awful joke, but it did stick with me. So um hopefully is testing the antibody to the Hep B core engine. There you go. Elizabeth answered it for us. So that's why. Um yeah, honestly, just really, really useless when it comes to happy I recommend watching like there might be a zero to finals, zero to finals video on it or something, which is just going to be a lot more clear than me trying to model my, my way through an explanation. Um Sure, let's have a look. Um And the answers are acute or chronic HEP B or HEP C. Why is it be? I'm not sure. Um I'm not sure. I don't know if there's gonna be a typo and that's supposed to say anti Hep B positive. In which case, it would make more sense to me. Um Yeah, I agree. I don't know if it's just a typo. I maybe there's a typo in which is the correct answer. I would put chronic Hep C infection. So I would have been wrong in this one according to this, the slides. But uh it could just, it's honestly, it could just be a typer. Ok, unless the C is for court and not HEP C I G anti pep core. Okay. Well, that makes more sense, I guess. So, surface antigen negative. So it's not an acute infection. I G positive. Court positive makes sense and it's not immune to happy. Okay. Okay. That makes sense. So if all of these are for happy, um that's probably just something that we have to remember. I probably will get this right. If I remember that I didn't recognize that HBC was Court in the future. So learning experience. Very nice. Very nice. Okay. Moving on from Hepatitis a little bit. Okay. Yeah. So be serious for a week, a advice um post barbecue. So compile it back to judge Lina is um not very well stored and prepared meat. Um That's also um for a compiler factor that's like like food that's been sitting out on a hot plate, like uh like a hospital canteen or something. That's also how it's sometimes presented in questions, nursing home outbreaks and also hospital outbreaks are really classic first c diff or if they're vomiting norovirus. Um In the first time I went on a ward for placement, everyone had norovirus and this woman in everywhere. Um So that's, that's a really memorable one for me. Um And then chronic foul smell, unfatty stools with abdominal distention associated with travel. You're talking about giardia. Okay. Yeah. So again, one of those things that you have to sort of remember pneumonias most commonly caused by strep pneumonia unless, yeah. No, I I did actually, I just, I didn't this, the trick is not really attending placement and then you don't pick up any um infections. So yeah. Um most common is strep pneumonia um or if they're a very immune suppressed, then it can be different organisms. I don't think we have a slide on that actually. Um But so for example, in the man that had HIV, we put PCP um or in Children, it can often be haemophilus influenza as well as strep pneumonia. So, um this is sort of healthy adults, the pneumonia, one um uti so most often it's e coli um which is gram negative. So that's treated with either trimethoprim or nitrofurantoin depending on whether you're in England or Scotland, first line joint infections in impetigo, you're talking gram positive. So yeah, uh staph aureus or group is strap um gas gangrene. So that's talking about if you see a question with um crinkly skin like skin that um what has it described? I think it's like tin foil. Like when you, when you press it, it's sort of like crinkles causes gas underneath the skin. That's really, really, really path anomic for necrotizing fasciitis. So you'd want it to like roll that out immediately or deal with it immediately. Um And then some gram negative Kokkai there. Okay. So I think that's the end of infection and we've got some slides on psychiatry coming up. Um Unless anyone has any questions that are hopefully not about hepatitis, then um we can take a break and come back in 10 minutes if that sounds good to everyone. Um 52. Okay. Uh If you have any questions, you can just type them in the chat and I will do my absolute best to answer them. But um and that yeah, go get some water and stuff and I'll see you back here in 10 minutes. Yeah, I'll go back to that question. Um, let me find out. Mm. It was, um, it was a lady who had rectal carcinoma. So that's why it was Pip Taz because we were thinking you Tribune accepts us that one, I think in real life. Um, she probably, she probably be having, um, an anterior section and also probably chemo which would make that a more likely scenario that should have been except us. Okay. Uh, not where they were getting pip tires. Uh huh. Yeah. Yeah. Uh maybe sorry. Actually that one. Is that the one you meant? No worries. Um So we gave him intramuscular Benzyl penicillin because we were thinking uh manager cockle disease, um meningitis. So you probably, you probably want that to say non blanching rash, but it sounds like uh we're concerned about meningococcal disease here. So I am Benzylpenicillin is what you've given that scenario. Um Give me two seconds because there is a situation where you give Kev tracks on. I'm just gonna go, I'm just gonna get the pediatric Vienna. Okay. So it says that um if meningococcal disease is suspected, you'd give Benda penicillin. I am before transport to hospital so long as this doesn't delay transfer, um careful taxi um can be given if there is a penicillin allergy. Um and then if you're in hospital and the child was over three months old. So it's not a neo net, you can give kept track, Seuin. Um Yeah, you wouldn't give, kept traction before they got to hospital. The fourth question. EBV. Just have a little question again. Yeah. Uh huh. Fourth question. Is that this one? Hmm. Here. Okay. Yeah. Yeah. It's, it's what you give while you're away in transferred hospital. Mhm. No problem. I'm just gonna, what, another minute and then we'll go back to psychiatry, which I think is much more fun than, uh, infectious diseases. But I don't know if everyone will agree with me. Okay. So, um the point was true. Um Do you mind if we come back to that at the end, Shirley if that's okay? Just because, okay, no problem. Just remind me if I forget because I might forget. But um, we can try about that at the end. Okay. So starting off with our first psychiatry question, um Mark 32 presents his GP with a two month history of low mood. He's unable to say what he enjoys doing no longer plays football with work friends or golf. Um He feels like he has no energy and he constantly feels tired which he puts down to poor sleep. Uh He's come to the G P now because he feels his relationship is breaking down mainly due to his loss of interest in sex, which is causing significant strength. So, in line with I C D 10, which two of the following uh associated symptoms of depression rather than cause symptoms of depression. So everyone's picked two options. Okay. So the two highest um selected answers that I've got are decreased appetite, which is correct and sleep disturbance, which is correct. So, an adonia um which is uh sort of like a loss of interest in doing things that is a core symptom depression. So it's fatigue and so is law mood for over two weeks. So, sleep disturbance and decreased appetite both associated with depression but not necessary to for diagnosis. I'm not always present. So still on mark. So he has a two month history of low mood, unable to say what enjoys during blah, blah, blah. Um Assuming Mark has no additional symptoms, what what is the diagnosis be under I CD 10 criteria. So if you know the I C D T D 10 criteria, um answer if you don't know how to guess, okay. So most of you have put a moderate depressive episode. Um We have the I C D 10 criteria in a few slides. So I'm going to come back to welcome back to this after we've had a look at that. So the GP refers mark for CBT but due to a long waiting list. Um So the answers for the associate symptoms. So associate symptoms were decreased appetite and sleep disturbance. Um They're not cause symptoms of depression. Uh G P refers mark for CBT due to the long waiting list. Um she also dis noise, also decides to prescribe him antidepressants in his drug history. She notes that he has prescribed amiodarone as a pill in pocket therapy for paroxysmal atrial fibrillation. So which of the following treatments are completely contraindicated in A F? Yeah. Yep. So most of you got that right. So, Citalopram, um we cannot give citalopram in atrial fibrillation. It is contraindicate. Given his main concerns. What would be the single most appropriate antidepressant to prescribe in the first instance, there's your options. So just to recount his concerns where um he's had two months of low mood, he has Antidonia. Um He no longer enjoys playing football with work friends or golf at the weekends, which he used to do regularly. No energy feels tired all the time because he's having poor sleep and he's come now because he fears his relationship is breaking down because he no longer wants to have sex. Yeah. Good. Okay. So um so you would go for an SSRI so in this situation, you go to, you go for a FLUoxetine because you can't give him Citalopram. So FLUoxetine is first line for someone who's very classically here to present in with uh which one did you met? Which one did you miss? Sorry? Which question answer? Just the previous one or? Oh. So um he has a tro fibrillation and uh uh it says which of the following treatments are completely contra indicated that was Citalopram use if can't give Citalopram an F which is why it's not an answer for this one. Um Although it is an SSRI, so FLUoxetine is your first line SSRI that you'd give, um Mirtazapine is indicated in the problem. It is indicated in depression. I'm not sure that what he has can be diagnosed as insomnia. He says he's like not sleeping quite as well. He's got a bit of sleep disturbance that, you know, we're not entirely sure why. Um So we're not really going down that route just yet. I think at this point he's got very, very classic presentation of depression. This is like something that you would get in an Oscar station and it would just be like you take every box for depression essentially. Um And then your first line is going to be an SSRI. So FLUoxetine is really um widely used one and amitriptyline, you're, you don't really use tricyclics anymore in a lot of cases for depression. Okay. So this is the I C D 10 criteria that we alluded to earlier. So you cause symptoms of depression are sadness or low mood for at least two weeks or longer Antidonia and then fatigue or lower energy. And then you've got a load of associate symptoms. So you can get low appetite or you can get increased appetite, disturbed sleep, or you can find that um patient's are sleeping a lot uh per concentration, indecisiveness, low self esteem, suicidal thoughts, agitation or slowing of movements. And then you can get a lot of guilt or self brim um associate with depression. So for a mild depressive episode, you would want to court symptoms and at least two cognitive symptoms. Um, uh, and then you sort of don't really, you don't need any of the somatic symptoms present for a moderate depressive episode, you'd need to court symptoms and at least three or four cognitive symptoms. And then for a severe depressive episode, you had one, all three core symptoms and at least five cognitive symptoms. And for these core symptoms of depression, it's at least one of these most is most of the time for at least two weeks. So, you know, if, if someone says they have um sorry, someone says they have low mood, for example, but they're only experience in low mood like once or twice a week or they've had like one or two days where they're not feeling so good, you can't really um you, it doesn't really count yet. So it has to be most days, most of the time for at least two weeks. Um And if any of these core symptoms are present. So if someone presents with law mood and adonia or fatigue, it doesn't have to be all three, you would ask about all these associated symptoms. So it's really important to ask about sleep. Um Even if you're not feeling law mood or you're not feeling fatigue, disturbed sleep can cause both of those things. You feel obviously rubbish. If you've not slept poor concentration, it's really important to ask about that. And also the effect on work. Um, if the patient is working has a job or school, if the patient's at school. Oh, there we go. I also don't, I mean, Mirtazapine would not, I still wouldn't have been first line. I, I wouldn't say, um, but that's a good point. I didn't realize that it's contraindicated with f, so you definitely wouldn't give it in that case. But I still would have gone with the FLUoxetine anywhere. Um, it's, it just is basically what you give for the first, for first line, um, in depression unless there's a reason not to, um, it's important to ask about appetite. Um, and it's important, it's really important obviously to ask about suicidal thoughts. That's something that you can't forget to ask, um, in an Oscar the or in real life. And, um, there's a misconception that a lot of people have that asking people if they have any suicidal thoughts, if they've ever experienced any suicidal thoughts increases the likelihood that they will like, it makes them more um conscious of it and it sort of puts an idea in their head that wouldn't have been there before. Um, there's no evidence to support that. So all of the psychiatrists on your placement when you have a cycle placement will tell you that's not true. Um You always ask about um, suicidal thoughts and it won't increase the likelihood that will do it. Um, agitation, sewing movements and then get on something. So if any of if a patient presents any of these core symptoms, ask about all of these associate ones. Um, when they say cognitive symptoms is that associate symptoms. Yes. Um, cognitive symptoms is probably. So you're poor concentration and decisiveness, suicidal thoughts. Um, guilt self, then those sorts of things I would say. Uh um So going back to Mark, I think his name is Mark. So he's got all three of the core symptoms. Um and he's also experiencing sleep disturbance and um a loss of interest in sex. So, and I'm not missing anything else. Uh So this is um classified on the slides as a moderate, sorry, a mild depressive episode. So if you put mild depress episode, that's right. Um And I mean, in real life, it's not, you don't really do it like that. It's, it's obviously more um sort of clinician judgment. E but according to the I C D in criteria, it's, that's what this is classified as. Um okay, so I need depressants. Uh Let me just catch up. So in mild depression, antidepressants aren't first line um treatment in a mild depressive episode. You would want watchful waiting, psychological therapy. CBT is proven to be really, really effective. I think it's something like 90% effective. Um like, and, and classic things you can say in, in our ski station is, you know, it's one of those symptom treatment, sorry, or one of those things where you get out what you put in so patient who are really willing to engage with CBT and really willing to put the work in. Um, do really, really well with CBT. People who don't necessarily aren't ready for that for whatever reason, which is often totally understandable. Um, it's not quite so effective, they don't get so much from it. Um It can be done online obviously. Um It doesn't have to be like in person therapy, there's loads of different types and it's challenging and changing patterns of thinking in your head. Um, if you do want to describe anti, um, depressants. So, antidepressants, um, take a little while to, yeah, they do, they do take, they do take a little while to work. I'm not sure if, um, the rate of improvement is how it's in the first two weeks of treatment. I'm not sure if that's, um, yeah, I would say some, sometimes they, they can sort of like when you start in depressants, it can sometimes make your symptoms a little bit worse before they get better. It's one of those things you have to want. Patient's that might happen. Um, it won't necessarily happen like it's not definite but it might, I don't know if it's maybe more of a, uh, placebo thing. Um, and that people think, you know, they've gone, they've seeked help for their low mood and they've talked to somebody about it and they're, they've been given some treatment and maybe that's why, um, or I don't know, I didn't write the slide maybe. Um, but it can get, can take a few weeks to work antidepressants. They're not like immediate overnight fix. Um, um, but they can also be very effective. Um So if someone is presenting with moderate to severe depression or um, they would like to try antidepressants, give them an antidepressant. Um, they're prescribed for depression, but they're also used in anxiety, panic disorders, OCD and PTSD. So SSRI S are used really, really widely in psychiatry. They're used for lots of different things. Um And lots of your psychiatric patient's are on them. Once someone is on antidepressants, you would want them to be feeling better or back to the normal self for at least 6 to 9 months before you would withdraw. So if someone presents to you with a moderate or severe depressive episode, you give them some CBT, you start them on a depressant and two months later they come back to you and they say I'm feeling loads better, I'm going to stop taking them. Um It's one of those conversations that's often quite difficult to have with patient's. Um And it's about education for trying to explain to them why that's not necessarily the best idea. Um And that actually you would want them to be feeling like that back to their normal selves and a lot better for at least six months before you would tippet and you wouldn't just remove the antidepressant. It's a gradual withdrawal. So you taper the dose down. Okay. Moving on. Um okay here. So, sorry, not moving on to more a depressants. So, first line is FLUoxetine or certainly into an SSRI. Um, if that fails, you would try Citalopram unless they have. Yeah. And then if there's no response to that, you would not be switched to an SNRI or a T C A something else if the third drug fails, think about augmentation with something like lithium or there's like older drugs that work E C T or electroconvulsive therapy is really, really effective. It's I believe the most, if one of the most, if not the most effective treatment that we have in medicine. So, um even just like on my time on psych, I've seen some people who are really like uh comatose um to the point where, you know, they can't leave their bed, they can't walk and after a few rounds of E C T, they're up and they're making dinner and stuff and it like the, the change in them is really, really dramatic and really quite impressive. But if you have severe treatment, resistant, depression or severe treatment, resistant schizophrenia, you can get the CT, to be honest, by this point, you would have psych psychiatric involvement probably so. Um okay, I think this is like, um it was supposed to be like an animation and I would like ask you and then I would answer, um I can ask the audience type thing, but it hasn't worked with this slide. I don't think they're in the right order though. So, um so I'll ask you like the first question, the ones in red are your options. Um So which depression treatments are associated with? So, gi upset sexual dysfunction, hyponatremia and older people. Which one do you think that is maybe they are in the right order? Actually, I'm not sure. Um Yeah. So, SSRI is one of the common things you can get is sexual dysfunction, James. Um sexual dysfunction though is also a feature of depression. So a lot of sometimes not a lot, but sometimes patient's would come to you saying, oh, you know, I started taking the FLUoxetine that you prescribed and um I'm going to stop taking it because um I've lost my sex drive and you do have to sometimes unpick whether that's a result of the SSRI or in fact, they, that's sort of like a, a symptom of the depression itself. Um Okay. So uh associated with weight gain and sedation. So, um so TCS can cause, well, again, um and sedition, I believe um Murtha's opinion can spike hunger. So, um uh like it's hard to say whether that's a cause of Wiccan because it's not like sort of the thing itself. So, Mirtazapine and tricyclic antidepressants, I think can both cause sedition. Controversially, tcs can cause Wiccan um high risk and overdose. Does anyone know that one? Yes, I would, I would put Mirtazapine and TCS for that one. Um And I would perhaps potentially just put tcs for, for a weekend and sedation. Um, hypertensive crisis. Does anyone know which answer? Yeah, I think um E C T S can potentially also precipitate hypertensive crisis. But I think to be honest, um yeah, I would agree with you there and then confusion in my algia, a really common thing from E C T is when someone comes around. Um they can have some confusion and acute sort of memory loss. Um And that's one of the things that you have to want patient's about as well. Okay. So that's our first case. So depression is um a really common presenting problem in psychiatry, but also in G P and just in general medicine. So it's, it's one of those things where you will see it no matter probably what type of doctor you become, you probably will see depression. Um At least sometimes. So it's good to know your stuff moving on to kiss to you. So, Shelly is 38 she presents to mental health services following referral from her GP. Her husband recounts, she has been behaving inappropriately, for example, jumping on his bosses back when he was around for dinner. And this is completely out of character for Shelly. And she's also embarked on new projects which she believes will help end world hunger. None of which she's been able to complete. These tasks have distracted her from picking her Children up from school. On multiple occasions, she barely sleeps but remains in an alerted mood with high energy. When her husband tries to talk to her about it, she gets very irritable and quite unkind. So based on Shelly's symptoms, so we're talking um behaving inappropriately out of character new projects which she abandons distraction from her tasks and responsibilities, barely sleeping, but in elated mood with high energy and she gets irritable and unkind. What is your initial diagnosis? Okay. Yeah, of course. Okay. So most of you have put bipolar disorder manic episode which I would agree with. Um Yeah, I think um this is quite typical of a manic presentation. Um sort of like acting out of character in the inappropriate behavior, the new projects and the sort of grandiose ideas, you know, she's going to help end world hunger, maybe she will, but more likely this is a bit grandiose and typical of mania also the election with um not having to sleep and irritability. Um So you speak with Shelley during the interview, you notice her speech is very pressured and at times you struggle to follow her sentences, not only is Shelly speaking quickly, she takes a long time to answer your question fully and often includes lots of unnecessary stories and information. So which of the following most accurately describes Shelly's speech? Okay. Okay. So there's a bit of a range of answers here. So um I think it is really easy to sort of, a lot of these things mean quite similar things when you, when you speak to somebody in real life. Um, you know, if, if it's, if it's three or four o'clock in the morning, you're on a night shift as an F Y and a patient presents to hospital with a mania. Um, and you speak to them and they're talking like this, very pressured. You struggle to follow. She takes a long time to answer a lot of unnecessary stories. Realistically, you're going to fall in the psych reg or whatever and you're gonna say there's evidence of a thought disorder. You're not gonna, that that person who's been woken up at three o'clock in the morning is not going to be interested in knowing whether this is circumstantial itty or flight of ideas. But um alas we have to know what this means. So um okay, so there's, yeah, there's a real mix between what you guys have put. So this is described as circumstantial reality. So that speech that's um circuitous, non direct thinking um or speech and it's where a patient will like digress from the main point. Um This is really nicely visualized. Um If you think of like a timeline, the sort of different sort of thought disorders, um flight of ideas is where you sort of like flick from like one thought to another, but that the things are very superficially related. So um it's really hard to replicate if you're not actually in that pattern of thinking. But, um, you know, someone might, you might ask somebody, um, I don't know, how long have you feel, been feeling like this? And they'll say, oh, well, you know, a while ago and I'll say maybe since, since this certain event and then they'll, they'll, they'll start talking about, you know, since basically, since, since my neighbor did this and then, like, uh, they'll, they'll start talking about their neighbor and then, like the neighbor might be into fishing and we'll start talking about fishing. It's, it's things that are very sort of like very superficially related, but actually, they're just rapidly flicking between like different thoughts and ideas and it's really difficult to follow along with, um, Tangie enteral thought is, um, yeah, I'm getting there. Um, tan gentle thought is like a person constantly digresses to really irrelevant, random, um, ideas and topics. And then circumstantiality is you digress from the main point of the conversation, but eventually do answer the, the question, which, uh, I sometimes do myself but is also evidence of a thought disorder. So in this case, Shelly is, um, you know, she's taken a long time and she's going on tangents and, and, and including lots of irrelevant detail, but at the same time, she is answering your question. Um, and then word salad is just like completely random, the words that mean nothing. So assuming that Shelley has bipolar disorder circumferential. Um I'm not sure I've, I don't think, I don't think I've seen circumferential to described, uh, used to describe like a parent of speech. So I'm not sure. I'm, I'm, you may be thinking of the same thing. Um, or our, I'm not aware of it either. Either could be true. Uh, so assuming that Shelley has bipolar disorder, which of the following treatments would be most appropriate to start at this current point. I hope that makes sense about the different thought disorders and patterns of speech in reality. Um You're gonna talk to patient's and interview patient's and you'll get used to hearing what mania sounds like and what different sort of flight of ideas, etcetera sounds like. Um And that's a lot easier than trying to visualize it from like an explanation. Um Maybe look at some youtube videos for examples of circumstantial or flight of ideas and that might make it a little more clear. Um So flight of ideas, I would say the way I think about it is a little bit more um extreme, maybe not the right word, but it's a little bit more severe than tangent reality. Like, yeah, like they sort of like go off on a tangent. Um And they don't necessarily come back to the original point. Whereas in flight of ideas, it's not like they're going on a tangent and telling you a story. It's like they're just flicking between random thoughts that like have some tenuous link in their mind. Um If that makes sense, like flicking between different points rather than going off telling you about a different story if that makes sense. Um Okay, so nice. Um most appropriate treatment. So a lot of you have put lithium. So lithium is not a bad uh answer. However, lithium takes a little while for the levels in the body to to build up to to like a therapeutic level. So it's not going to provide an acute treatment. So quite a pine would be something you would prescribe in this. You potentially would start them on lithium, but that would be something you may be initiated further down the line. Um whereas like quite a pine um works a little bit faster. Um Yeah, fine. Which of the following symptoms is indicative of mania rather than just hypomania have a guess. Okay. Oh, that's okay. Um So we put in this instance, we would give her a quite a pine which is just an an antipsychotic. Yeah. Okay. Um Okay. So again, there's a bit of a range of options. Um So irritability, poor attention span, sexual promiscuity and insomnia is are all things that you can see in hyper mania auditory hallucinations that would be more indicative of a true mania than just a hyper mania. Yeah. Thanks Gram. OK. Is everyone happy with that auditory hallucination hallucinations would make you think mania rather than hyper mania. Um So let's say she started on QUEtiapine, her mania settles down. She's no longer having a manic episode and her behavior turns back to normal and she started, uh she started on, I don't know, I'm not. According to this question, maybe if you have more up to debt guidelines that say insomnia go with that. Um But apparently it's auditory who's I think if someone was presented with auditory hallucinations, I don't know what the top guidelines say, But in real life, I would struggle to say that was just a hypomania if they're having hallucinations, that's pretty, you'd want to take that quite seriously. Not that you wouldn't take hyper mania seriously, but you don't take that seriously. Um So let's say she's starting to typing her manic episode dies down and she's then started on long term lithium therapy for maintenance on her stable mood. Which of the following is not a side effect you'd have to warn her about. Yeah. Thank you. Okay. So, antipsychotics are one of those classes of drugs where we see a lot of side effects. Um potentially occurring a lot of extrapyramidal side effects. So things like tremor, um we would see potentially with lithium neutropenia is the right answer here. Um So lithium doesn't affect your neutrophil count. Um So it can cause thirst, teratogenicity, renal impairment and fine tremor. Shelly is started on lamoTRIgine for prophylaxis of depressive episodes with her bipolar. She develops a macular popular rash concentric circles of erythema tous and pale skin on her hands and has a blister on her lip. What is the best management option? Uh Yeah. Okay. Okay. I'm gonna stop that there. So um does anyone know what we're worried about here? What the potential diagnosis is? Do you want to type it in the chap? Yeah. So, Steven Johnson syndrome is what we're concerned about here. So you would discontinue lamoTRIgine um immediately you wouldn't gradually withdraw. Steven Johnson's is really serious. Um or your skin can blister off. We don't want that. So it wouldn't be, it would be like an urgent referral to dermatology. Um It's not mycoplasma, it's not a virus. So you would need an antiviral and you would discontinue the lamoTRIgine immediately. Okay. So unipolar depression versus bipolar disorder. So more common to have depression than it is to have bipolar. Um It's depression is more common in females. It's uh bipolar is thought to be under diagnosed and often misdiagnosed as depression, especially in women. Um but they reckon there's still a female to male risk. Um, bipolar usually presents in a patient's mid twenties whereas depression can present earlier or older. Oh, Steven Johnson syndrome and it's a really serious uh like extreme drug reaction you can have where essentially um your skin just sort of blisters and, and comes off and it's very systemic. Um You do cover it in fifth year. I don't know if you're not 1/5 year yet. Um But if you, if you sort of, it's like you do it in your dermatology block, but just have a look at Steven Johnson syndrome and um T E and, and Children and, and it's, it's fairly simple to um just remember to recognize and like withdraw the drug. Um So, yeah, bipolar. The key thing here is probably like bipolar is less common and the presentation is often in the mid twenties, whereas unipolar depression can be younger or older. Um but there is a big overlap of mood disorder syndromes. There's a big overlap of psych disorders in general. Um depression and bipolar. It's a big overlap, obviously, um especially with late many a presentation or undetected mania, especially if someone's just in hypomania. Um or if someone just thought to be irritable when actually they're a bit manic. Um depression, schizophrenia, there's a big overlap there. A lot of schizophrenic like schizophrenia has a huge impact on people's lives. Um Depression can occur during our proceedings. Schizophrenia and depressed patients' can have a psychotic episode. This is something that we also see in um postpartum women. Um postpartum depression, psychosis is quite common and depression anxiety is also has a big overlap. Okay. So, um bipolar is at least two episodes of mood change and at least one episode needs to have been hypomania or mania or a mixed effective state. Um medical therapy for bipolar disorder. So, acute hypomania or mania, it would stop drugs if this is causing the hypomania or mania. And you'd optimize existing therapy, you'd start an antipsychotic. So for example, um QUEtiapine and then you'd add on lithium for maintenance therapy when that level builds up. Um And if it's an acute bipolar depression, instead of presenting as a mania, you would optimize whatever drug there on already. If they're already on therapy, further bipolar and it's just not controlling it well enough. Um And you give an SSRI with an antipsychotic long term, obviously, discussion with patient staying on a drug. So um adherence in bipolar is a really big issue. Patient's um you know, when they're manic, their moods very elected, they feel very good. Um It's quite nice to feel a bit hypomanic, but the problem is patient's don't take their medication because they feel good and they don't feel like they need it. And then actually hypomania if they're not taking their medication, justus ends up and up and up, it doesn't come back down, it just descends into mania and then they have a manic episode. Um So uh that's a discussion you have with the patient. Um adherence to medication is really important. Lithium is first line and um any convulsant mood stabilizers can be used there again. Um Yeah, so lithium, there's like a uh acronym you can use that almost spells out lithium. Um If you would find that to be helpful about some of the side effects. So, hypothyroid, it can cause absence anomaly or E C D changes similar to hypochelemia, diabetes, insipidus and wanted movements. Um Is your extrapyramidal side effects? Okay. So a 60 year old frequent attenders has presented to any after a fall. When looking at his notes, you notice he has a recent admission for acute pancreatitis and he drinks 100 plus units of alcohol per week. On further examination, you notice that he has several features suggestive of veronica's and cattle opathy, which of the following is not a feature of Veronica's and couple opathy. Uh Yeah. Mhm Yeah. Yeah. So most of you guys are getting this right. So I'll stop that there. Um Areflexia is not a future of Vancocin calf allopathy. Um ataxia confusion, nystagmus and up Thelma plegia or extraocular muscle paralysis are all features. Patient is commenced on IV pab relax for thymine replacement, which is a really big issue in people who have long term alcohol abuse, which further medications should be prescribed for this patient to prevent complications from alcohol withdrawal while in hospital. So alcohol withdrawal is really really dangerous. Um Thing to go through actually uh ideally be nice if people were undergoing it in hospital. Um realistically, that's not always the case and not very realistic. Um So it's important if you're ever helping someone withdraw from alcohol again, there's like an addictions team that would be dealing with this, but it's important to know still that you'd want them of the complications. Okay. So, okay. So there's a bit of a split between the most two, the two most common answers. So a lot of you have said diazePAM, a lot of you said chlordiazePOXIDE, it's chlordiazePOXIDE that you'd give to prevent delirium tremens, which is the big complication from alcohol withdrawal that we'd be concerned about. ChlordiazePOXIDE is just a long, like a long acting benzodiazepine. So people who have put diazePAM, you are like you, you are on the right lines, don't worry. Um chlordiazePOXIDE, it's just one of those words that you remember alcohol withdrawal, you give Clark diet Parkside in an exam. That's what you answer. It's just something you know. Um So following alcohol withdrawal, when is the peak incidence of D T have a guess? Okay. So, um delirium tremens is a really acute onset of confusion and psychosis, which is typical of um chronic alcoholics who withdraw. Um You can get tremors, you get hallucinations, they get very anxious and disorientated. Um And there's the classic picture of the pink elephant that appears and paciencia pink elephant. Um classic of DT. Uh So it's hallucinations essentially in psychosis. Um and it's really quite dangerous and uh it's 72 hours, you'd expect the the peak onset to be. So 72 hours, a lot of people get T T uh following successful alcohol detoxification, he has started on maintenance therapy, which of the following drugs is used to reduce cravings in alcohol dependence. Uh Okay. Um So you would give a cam prostate to reduce cravings. Um, and alcohol dependence. Disulfiram is something that is used to treat alcohol dependence. It's something which you, you take it and then if you drink like, um, yeah, cravings cravings the alcohol. That's right. Um If you, you take it and then if you like drink even a little bit of alcohol, you get like a really horrible reaction, like very flushed headachy, nauseous. Um LORazepam is a Benzo haloperidol. Haloperidol is like rapid tranquil ization. Um And the Luxon is um opioid reversal. Which of the following, do you mean the this question, Sophie or the one before it about CT if it is the one before it's like uh delirium tremens peak. Uh huh. Sorry, I'm getting lost. Peak incidence is 72 hours after withdrawal and oh, this is a calm prostate and again, just, just so I'm covering all the bases, 72 hours peak incidents for G T eircom prostate to reduce cravings. And um disulfiram is used for something else that's just used to give a really horrible reaction to I've never seen it used personally, but I uh potentially do, I don't know if they use it here. Um It gives you like a horrible reaction to, to alcohol but it can prostate is to reduce Krementz. Okay. Which of the following is not an official part of the I C D 10 criteria for a substance dependence. No problem. Okay. I'm just gonna speed up a little bit because I feel like I'm gonna run out of time. Um So the answer for this one is narrowing of repertoire. I'm not gonna lie. I don't really know what that means. If someone knows what that means and they want to answer, feel free. Um But all of the rest are part of the I C D 10 criteria for substance dependence. Again. Should you just go look at the I C D 10 criteria here is um look at that. So for detoxification, you'd use benzos and you'd give chlordiazePOXIDE in which is the long acting benzo um to prevent against D T. You give thiamine for um deficiency replacement and disulfiram, eircom prostate and naltrexone is used for relapse prevention and you can go and look at the I C D 10 in your own time if you'd like. So next case, a 75 year old man comes to clinic with his daughter. His family are concerned about his short term memory problems over the past eight months, he has been regularly forgetting to take things, sorry, has been regularly forgetting things, has episodes of dizziness at least be reminded to take his meds. He is behind on energy bills which he forgets to pay past medical history of type two diabetes, hypertension COPD and suffered a small stroke 12 months ago. He continues to smoke on an M M S E. He scores 21 out of 30 with an abnormal clock drawing. What is the most likely cause of this man's cognitive decline? So I'll go back to the question if you guys want to see it. Um Have a look at what you think is going on. Yeah, some really big clues in the history here. Yeah. Okay. So, um this is quite typical of vascular dementia which the vast majority of you have gone for. So the the stroke 12 months ago, the vascular event is the really big clue here. Vascular dementia also has like a step wise progression that we would look for. So, you know, at the start, they something's affected and then uh there's sort of a next step down, then all of a sudden they, you know, they declined quite rapidly. They all of a sudden stopped taking their meds and then they stop paying their electricity bills and these things that the family notice more than the patient's typically um have a step wise progression, which the following is pretty protective against dementia. Yeah. So um high level education is protective against dementia. Most of you have put that that's fine. Um which of the following drugs is not an S E hitch inhibitor. Okay. So, um yeah, most of you've gone for memantine, which is an an MD A receptor antagonist and it is used to slow the progression of Alzheimer's, but it's not an acetyl cholinesterase inhibitor. Hence, it's the right answer. Which of the following drugs is first line recommended treatment for vascular dementia a few more seconds. Okay. So, yeah, most of you didn't fall into the trap. So there's no treatment for vascular dementia. There's no drugs you can give. If they were diagnosed with Alzheimer's, you can prescribe and it's, and it's early enough and they're susceptible. You can prescribe like a cognitive enhancer um to try and slow down the progression. Ultimately, there's no treatment for Alzheimer's or dementia in general. But vascular dementia, there's the cognitive enhancers aren't indicate and which of the following side effects is unlikely to be seen with Donepezil. So which one would you not see? So the epistle is uh acetylcholinesterase inhibitor just to remind everyone. So yeah, constipation, you wouldn't be likely to see that in uh Donepezil use. You can see diarrhea but constipation is unlikely. Okay. Next case, a 74 year old woman has come in with her daughter. She describes noticing that her mother is progressively finding it difficult to remember words for common objects, describing many things as thingamabob. She's still independent around the house and is otherwise having no issues remembering to do things such as chores or appointments on examination. You find that on the marker, she scores particularly poorly on naming and abstraction sections. What is the most likely diagnosis? Yeah. Okay. So this is really um typical classical presentation of frontotemporal dementia. Um We've got some slides on dementia and the different types just now. So Alzheimer's so over 60 fives is usually what you see with Alzheimer's age is the single biggest risk factor. More common in women. There's an insidious onset. Usually people present quite late because there's a gradual progression of worsening symptoms and people put a lot of things down to just getting older. Um And it's the pathology, although not fully understood is amyloid plaques and neurofibrillary. I can't say that tangles, plaques and tangles um deposited in the brain dementia with Lewy bodies. So, if you have a history or presentation or Noski station where they hallucinations and they are usually visual hallucinations, but they can be other things. Um that's really path anomic of dementia with Lewy bodies. Um Again, ages your biggest risk factor. This one is more common in men. You can have a ram sleep disorder and parkinsonism associated too. But the hallucinations is really what's gonna point you towards that diagnosis. So, frontotemporal dementia is either um big behavior changing. So disinhibition, executive dysfunction, apathy, reduced, empathy, behavioral changes or language deficit. So, if people, you know, and, and these things tend to get progressively worse and that's what your classic frontotemporal dementia presentation is like. So these are your summary of recommendations. Um So, like I said, for vascular dementia, there's really nothing you can do. Well. No, no medicine you can give. Um and for a mild cognitive impairment, there's nothing that's indicated either, but you can give um cognitive enhancers here for Alzheimer's or a mixed dementia, dementia with Lewy bodies or dementia with Parkinson's disease. Um, as such, I think this is our last kiss. Um, okay. So a 14 year old girl, Sarah is at clinic with her mother, Sarah is struggling at school. She is, I didn't write this, by the way, I didn't give her the same name as me. If anyone's wondering. Um, I'm not that, uh, yeah, I didn't do that. Um, she's just significantly distressed about her ability to do well in exams, although that is reliable and have a successful future and is plagued by insecurities and worries about her appearance. These feelings are present more days than not. She requires constant reassurance from her parents and teachers and has started having trouble sleeping and concentrating is affecting her social life and she no longer hangs out with her friends like she used to. So what do you think is going on with Sarah? I'll go back to her kiss just so you can have a look. Uh uh Okay. Um Yeah, so again, overwhelmingly we've gone for generalized anxiety disorder, which I would totally agree with. I think this sounds very much like generalized anxiety disorder. She's feeling quite anxious about multiple different things. There's no specific cause that we can identify from this. Um This is quite a classic presentation. Um which of the following is most likely to present only after the age of 10. Okay. Um So, oops, if you guys remember earlier when we were discussing unipolar and bipolar depression, um I said that bipolar disorder is really common like it, it really uh is seen in the mid twenties is when the presentation happens and when the diagnosis is usually mid. So bipolar is the right answer here. Be very unlikely to see bipolar disorder in someone under 10, but autism A D H D anxiety and OCD as well. Um you can get in, in, in young kids um potentially not thought of like that as such. But and I think this is our last question. So um last poll, Sarah's mother is very concerned that her anxiety could develop into depression, which of the following is not indicated in the management of depression in young people. So just to clarify, I think Sarah is 14. Yeah, but there's something here that we don't use in young people. Okay. So yeah, so most of you have gone for paroxitine. So, Paroxitine is an SSRI like FLUoxetine but um studies haven't shown that it's effective in this age group. So we don't give paroxitine two Children. Um FLUoxetine, we can give to Children. Um CBT we can do with kids, support of therapy and guide itself help are all things that kids or young people can do. Oh yeah. So do not offer antidepressant medication to a child during person with moderate to severe depression except in combination with a concurrent psychological therapy. Um I think, you know, these kids or young people are. Um there's a lot that goes, goes on in life at this point and um psychological therapy can be very beneficial and their brains are nice and plastic. Um So A D and E so that was like CBT support therapy, guided self help. They can all be used in mild depression. Um First line is psychotherapy. Second line if psychotherapy is not working, um or the response isn't as good as you'd like, you can add an SSRI so you can add FLUoxetine if the young person is moderately or two severely depressed. Um in FLUoxetine is the only antidepressant for which clinical trial evidence shows that the benefits outweigh the risks in young people. So if it's a young person, psychological therapy is not cutting it and they're needing an anti depressant, you're going to go with FLUoxetine. Okay. Um Good luck. You'll be fine. Obviously, you can find to this point you'll be fine whether on does anyone have any questions about anything? Thank you very much, Sara, I'm sure you also can be saying this one out, but it'd be great if you could fill out the feedback form and chat. Um I believe Sarah will stick around for a bit to answer any questions that you might have. Um Otherwise thank you so much for joining the series over the last five days and I wish you all the best for your exams. Yeah. Thank you for answering the questions guys. Um makes it much more. Uh huh. Rewarding. You're very welcome. You're all very, very welcome. Uh huh. Yeah. Oh yeah. Okay. So um so the EBV question, let me, my memory is pretty shocking. So let me just go and have a look. Mhm. Okay. Where's it gone? Okay. So the person with EBV um had so large tonsils with an exodus, it a particular rash on the palate and axillary and inguinal lymphadenopathy. Um a bit of a temperature, a little bit high respiratory, right? Um No, no, don't worry, don't, don't be sorry, it's fine. Um So your question was why was it not straight? Why would you not be worried about strep throat? Is that what you were asking? Yeah. Okay. So um let's have a look. Yeah. So you know the rash, the lymphadenopathy, extra date on the on the tonsils. Yeah. All could point towards strep throat. I think that's really quite um quite reasonable. Um Yeah, I don't, I don't know why this would this wouldn't necessarily be strep throat I think is E B V potentially more common. Um Okay. So yeah, I think, I think, I think you're right. I don't know why I don't really have an answer for you. I'm sorry. That's really rubbish after like waiting all this time. Um um I mean, and to be, to be honest, uh yeah, that makes sense to me, to be honest in real life you would swab the throat especially if you saw a post there and you'd probably do the EBV test as well. Um, so I really think it's, it's one of those questions that is annoying for exams but actually in real life just isn't really an issue if that makes sense. Um, E P V. Yeah. Does any of you have Accident Councils? I think, I think, uh, E B V it's not necessarily that it would, would have, wouldn't have purse. I think if you see person the throat. EBV is still very much a likely option. Um, but yeah, you're totally right that this, this picture does sort of fit with strep throat as well. Unless I'm missing something. I can't see any reason why it couldn't be strep throat. Um, maybe, uh, I suppose the only thing is that the white cells aren't ridiculously raised, maybe you'd expect it to be more wrist and strep throat. But other than that, um, and maybe like the sort of, to be honest, I think if it's an okay also, it's an 18 year old man. So if we're talking about like a child strep throat, it's maybe more of a concern. But in an 18 year old man, I think EBV is more likely than strep throat. But, um, I think it's totally reasonable answer if that makes sense. Yeah. No, no problem. I'm sorry. I don't know. Um, thanks.