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Hello guys, we'll just, we'll give it a couple more minutes just so people can come through. Hello, everyone. Welcome, welcome to Psychiatry and Palliative care session. Um Thank you all for joining us. Um We've got um Ying today who's, who works in psychiatry um and is gonna be delivering the session, but we'll, we'll touch on that later on. So welcome, we're crash across finals. We're an initiative set up by a few medical students in the final year at the University of Aberdeen. So we aim to provide sort of a high yield sort of quick fire SBA style sessions for, for revision for medical finals. Um And we hope, II recognize a few of the names that you've been here before and you continue to join us and that you find it quite, very nice. Cool. So here's some of the systems that we've done and we continue to sort of update them. So be sure to sort of follow us on Instagram and medal just to keep up to date with when our sessions run. Um If you're a student and you're looking to expand your portfolio, um You can be an ambassador first. It's an incredibly low risk, uh not low risk, low effort job. Uh All you have to do is just sort of promote the events that we have uh in your respective universities. Cool. So the structure of the session will have 33 separate sections. We'll have six questions and easy, six medium questions and six hard questions. Um They're all SBA questions and there and there's a poll that comes up so fully anonymized, Don't be afraid to answer. Cool. So just some general housekeeping go on you any questions you have put it in the chat and we'll answer at the end of each round and just be respectful as well, which all you are. Um, there's a poll that comes up after each question. It kind of gets in the way. But if you click answer later, um Yeah. Uh you can read the question. We'll just give some, give ying um, some time to just introduce yourself and get on with the session. Cool. Hi, everyone. You can hear me. Ok. Yeah. Um I'm one of the trainee psychiatrists in Cornhill Aberdeen just now. And I'm the third year of training. Happy to run the session today and happy to answer any question. I might not be as good in the palliative care, but it is quite relevant in some part of psychiatry because we also do a lot of medical and, and life care for our patient in Corn Hill. So I'll try my best to answer those questions that people have. All right. Now, first question, a 56 year old man has presented to the GP with persistent low moot and Edon and altered sleep. He has a past medical history of hypertension and ischemic heart disease. He is diagnosed with depression and the GP decides to start him on Citalopram. What is the most important thing to check prior to starting citalopram? If you think about citalopram, it's an SSRI. And what sort of things do you think it is important to check? Right. Is that, is that one? So we'll just give a few more que a few more seconds for people to answer and be full. OK. So we'll talk about what we, we care a lot about psychiatry. The E CgA lot of our medication unfortunately could cause QT prolongation. It's advisable to take an E CG. Is not that common. Someone with Citalopram gets prolonged Q TC, even if they do get prolonged Q TC. Usually it's not never lifethreatening unless they're on some really strong doses of anti cortic. Citalopram is higher risk and sort of antidepressant, one of the highest risk, but it is also one of the antidepressant that GP commonly like to use. All right. Any questions we'll answer it at the end. Now, the second question, a young man is seen with his mother is concerned that she's concerned that he is socially withdrawn. He is bright and is doing well in his job as an engineer. During the consultation, he seemed emotionally cool and has little interest in either praise or criticism. What is the most likely diagnosis? A antisocial personality disorder? B schizotypal personality disorder, C schizoid personality disorder. The borderline personality disorder, right? Focus on emotionally and little interest in praise or criticism. Also, socially withdrawn is also a key that you want to focus on. We'll talk about the schizotypal schizoid. I know it can be confusing because they're a bit similar, pretty similar in the wording, but I'm gonna show you they are completely two different things. So a schizoid personality disorder, um schizoid personality disorder is the ones who are socially isolated and professor with solitary activity, emotionally cold and few friends other than family and very few interests also lack of interest in sexual interaction. Schizotypal is actually if you remem if you remember schizotypal is the one that is bordering on becoming schizophrenia, but it's just a lot of pseudopsychotic um encounter. That is the schizotypal patients. Schizoid is the one who doesn't like to interact with other people. They kind of magical thinking is schizotypal schizoid is emotionally cool and doesn't have much interest. Right now, the cluster A BCI don't expect you to remember. Cluster ABC might be useful. But if you remember the main type of uh personality disorder in the SM that your borderline, your antisocial or common one and narcissistic is fairly self-explanatory. Um schizoid and schizo type, I think is the one that gets people confused the most. Now question number three, a 65 year old woman with advanced lung cancer is admitted to a poly care unit due to worsening dyspnea and cough. She is bedbound and unable to effectively clear secretions on admission on examination. She has audible rare breast cells and evidence of pulling secretion in her oral pharynx. There is a question, what is the most appropriate management? A performing oral suctioning as needed? B continuous positive airway pressure therapy, CPAP therapy, C Hyosan hydromide D IV corticosteroids. Remember she is 65 and she is poly due to lung cancer. C hyos hydrobromide. Um It's so it used a lot. It's either hyos hydrobromide or hyzine butylbromide. But hyos hy hydrobromide is more commonly used for or usually in, in the strange pump and things is antimuscarine. It can, it can slow down the kind of secretion and dry patient up a little bit when they are struggling. Question number four, a 25 year old man is brought to the emergency department by his family due to bizarre behavior and disorganized speech upon examination. He appears unkempt and agitated with shovel clothing and poor hygiene. He reports hearing voices commenting on his actions and believes that he is being followed by government agents. He exhibits this organized speech jumping from topic to topic with loose associations. He denies any history of substance use considering the most likely diagnosis. What would be the most appropriate management for this condition. A haloperidol B, LORazepam C, cloZAPine D risperiDONE. So not just thinking at that moment in time, but as a general sense, if as a 25 year old man with this kind of symptoms, what would we like to try this man on? So the answer is Risperdone is a first line treatment that we give to treat any signs of schizophrenia. And this in this man, if it's less than six months, you can't diagnose someone with schizophrenia unless you convince the symptoms is a little bit longer than that. This is a psychotic episode. But regardless, risperiDONE is the first line thing. We use a couple of people choose haloperidol that will be appropriate in management of aggression. And if you are cons you are certain the person does not have a heart condition to begin with haloperidol might be appropriate. But in treatment of psychosis, usually we now start with atyp atypical antipsychotics. RisperiDONE will be the first choice. So number four, a 40 year old man is brought to the emergency department by his family following a workplace accident where he witnessed a colleague sustaining a severe injury since the incident. He has been experiencing recurrent nightmares, intrusive thoughts and avoidance of reminders of the event on examination. He appears hypervigilant and reports feeling edged constantly. What is the most appropriate initial management for this patient? A immediate referral to a psychiatrist for psychotherapy B psycho education about common reactions to trauma c assessment for possible posttraumatic stress disorder. The administration of benzodiazepine for acute symptoms relief, it's a bit more a tricky one. I think there are, there are pros and cons of each uh each option. But of course, you want the best option. So following a workplace accident or shall presume it's fairly recent. So it's the psychoeducation about common reactions to trauma and you got this all these um symptoms on that slide. But the reason is we, we psycho educate them is because it's following workplace trauma, you can only assess someone for PTSD only six months after the event had occurred. And this suggests that any dissociation or if you use benzodiazepine to numb them as the pro pro prognosis, long term is actually not as good. So it's better for them to face it instead of numb the feelings. Hence, uh wait for six months and then assess them for PTSD. No. Number six, a 16 year old girl is brought to her pediatrician by her parents. Due to concerns about her eating habits and weight loss. She admits to restricting her food intake and engaging in excessive exercise to maintain low body weight. She expresses intense fear of gaining weight and the satisfaction with her body shape on examination. She appears imas emaciated with her body BMI below the fifth percentile of her age based on nice guidelines. What is the recommended first line treatment in the case? A cognitive behavioral therapy. B. SSRI C anorexia focused family therapy, d inpatient nutritional rehabilitation. Now, this is her first episode and she is under 16 years old. Um It's a bit hard for you to guess the with the BM I below fifth percentile of her age. But in real life, we use how many percent um it's a percentage we use not percentile usually, right? So the answer is anorexia focused family therapy. The key thing is because she's under 18 years old, that should be over 18 and over CBT will be the first line of choice. So you're not wrong with CBT. But family based therapy is the first thing you would offer a patient under 18 years old with anorexia. Now before I start round two, anyone has any questions about any of the questions and answers earlier? Yeah. So if, if anyone has any questions, pop them in the chat, um we'll give you guys 30 seconds or so to ask any questions that you have that will just go on to the next round. OK. All good. Yeah. Any other questions just move on to the next round. Cool question number one, a 62 year old man presents to emergency department with tremor and confusion. He says he has been feeling very sweaty this morning. Uh on examination, he has hyperreflexia, he has his a history of depression for which he takes citalopram and has recently been experiencing back pain for which he has been started on traMADol. What is the most likely diagnosis? A neuro mignon syndrome? B, anticholinergic toxicity, C Serotonin syndrome. D malignant hyperthermia. I think of key, there's citalopram and traMADol. So the que the answer is serotonin syndrome is a long list. You should have the notes. But out of all the psychiatry side effects, serotonin syndrome is the only one that cause hyperreflexia and hyper uh not, not hyperthermia, sorry, hyperreflexia. That's the only thing that, that is uh serotonin syndrome that's different than everything else. And of course, traMADol and citalopram should not be co prescribed together. It will cause serotonin syndrome. All right, we can move on to the next one. You can read more about serotonin syndrome. Won't bother you with that. Now, number two, a 55 year old man is brought to the emergency department by his family due to confusion and agitation. He has a past medical history of alcohol dependence. He has been drinking heavily for the past several years but abruptly stopped drinking alcohol three days ago. On examination, he has a coarse tremor disorientated and is presenting with delusions. His vital signs revealed tachycardia and hypertension. What is the most appropriate initial management? A Phenytoin B, chlordiazePOXIDE C, carBAMazepine D carbonate. What would you give this patient? I think that pretty much every one. Yes, it's called the the site. So uh I know a few people choose PX. It is important, but that's not the initial management. Anyone with delirium, possible delirium trends and alcohol withdrawal. You have to give benzodiazepine and cause that the po site has not as much street value in its longest acting. And in patient with liver failure, you want to consider LORazepam and typical reducing dose protocol. Some hospital use go score. But in psychiatry, we just have a reducing regime. N question number three, a 35 year old woman with a history of treatment resistant schizophrenia presents with complaints of fever, sore throat and malaise on examination. She appears unwell and her temperature is elevated. What is the most important initial investigation? A full blood count b viral throat swab C ecg D chest X ray. So the key is treatment resistant schizophrenia and what they usually get in treatment resistant. Schizophrenia, what sort of medication they usually get prescribed if they have treatment resistance and what's all side effects that this medication might cause that you really will be concerned. So it's full blood count. So most treatment resistant schizophrenia gets cloZAPine and cloZAPine has a risk of causing agranulocytosis and neutropenia. That's why they get full blood count very regularly. It goes from once a week for the 1st 18 weeks and then to twice a week until up to a year. I'm sorry, twice every, once every two weeks for up to a year and after that, it will be monthly blood test. If not, they are not getting theine and of course the other. So this is palliative care question. A 65 year old woman with metastatic breast cancer is receiving around the clock opioid therapy for pain management. Despite this regimen, she experiences intermittent episodes of severe breakthrough pain, irregular oral medications including include 7.5 mg, morphine, T DSA Q DS and 1 g paracetamol Q DS. What dose or breakthrough? Morphine should be prescribed? 2.557 0.5 10, I'll give you a little bit of time to make some calculations. Breakthrough pain is how much of the total dose? H It's a portion of the total dose of the day. And what's the portion? So CVS is four times a day. Well, it's a portion. It does. Yes, it's 5 mg. So you want to at all, all the 7.5 it will be 30 mg a day and your breakthrough should be 1/6 of the total dose of your long acting morphine. So it's 5 mg in this case. Is that clear good? Now, a 55 year old man with a history of bipolar disorder presents to the emergency department with nausea, vomiting, tremors and confusion. He has been taking lithium carbonate for the management of bipolar disorder for past six months. On examination. He is tachycardic and hypertensive with signs of dehydration. Laboratory tests reveal elevated lithium level. What is the most appropriate initial management for this patient's condition? A administration of benzodiazepine for symptom control B, immediate cessation of lithium therapy C hemodialysis, the intravenous administration of fluids. So as initial management, what would you do if this is a lithium toxicity? What the best course of action? So is that yeah, still answering. So first initial management of this patient condition should be in IV fluids. So lithium lithium toxicity is suspected if the level comes back elevated. First thing you want to do is to hydrate the patient, especially this patient has signs of dehydration. Now, hemodialysis could be true. But uh yeah, you have to titrate the patient first. That's the key initial management. But it's rarely we do hemodialysis and lithium toxicity and um immediate cessation, lithium therapy. Bad idea, you'll make the patient go manic. So unless you discuss with psychiatry, do not touch the lithium, that will be our advice. So number six, a 42 year old woman presents to the emergency department with a history of recurrent hospital admissions for various unexplained medical complaints. She described complex medical history with multiple surgeries and treatments often at different hospitals, but no definitive diagnosis have been made on examination. She appears well versed in medical terminology and demonstrates and eagerness to undergo further tests and procedures. Which of the following is the most likely diagnosis for this patient's presentation. A hypochondriasis B fictitious disorder, C Somatization disorder, D conversion disorder. What might be a condition of this 42 year old woman with a lot of unexplained symptoms and seeking a lot of surgeries? Is it my, I understand it's a difficult one but different hospital. No different like nurses, various unexplained medical complaint, various is one of the key. It's all very vague. What might be the diagnosis? Ok. 28. So I presume, so it's factitious disorder. Now, it involves intentional fabrication or exaggeration of physical or psychological symptoms. Typically for the purpose of assuming the role of patient and receiving medical attention. II understand why people might choose, um, soma high disorder um, or conversion disorder. However, um, so uh with Somatization disorder, it shouldn't, it usually not various symptoms and they usually won't go to v they, they, there won't be various surgery that easily and they tend to go to the same hospital and will have very similar presentation and a lot of that will be similar of kind of my body is feeling pain here. That's more common soma and disorder hypochondriasis. There will be more specifics of why they are, why they are worried of. Have I got cancer worried that the doctor missed something they won't be getting off of those surgeries. So the most likely it will be fit disorder. Of course, there's only one or two cases as I can think of and, and the news that people actually get diagnosed, but we rarely diagnose that in patients. Now, any questions before we go to round three, give you 30 seconds. Ok. I presume there's no question. We'll go to round three, an 83 year old man attends his GP practice due to hallucinations. The patient reports that despite not owning any pets, he has been seeing two dogs around his house over the last few weeks, he's aware that these dogs do not exist but is concerned as he is currently seeing them. The patient is otherwise generally fit and well. Past medical history includes mild depression, hypertension type two diabetes and progressively worsening visual impairment with a central sma scotoma. The patient report having not attended the annual eye test for the last four months. What's the most likely diagnosis? A delirium B, dementia of your body. C Charles Bonnet syndrome. D Parkinson's disease. So he is last few weeks and visual impairment with scan, central scotoma, but generally feeling well and mild depression. So the answer to that is Charles Bonnet syndrome. So I know a lot of people choose dementia, some people choose dementia Lewy body, but this gentleman has visual impairment and he's generally feeling well and he goes to the GP his himself and express concerns himself. Hence, it's most commonly child Bonnet syndrome because he already has a visual impairment. In dementia, lower body, you do get visual hallucinations, but you also get cognitive impairment. You get kind of fluctuations in their, their sleep wake cycle, um not, not sleep wake cycle or agitation. Um They tend to not have as much insight and they won't be feeling well. Mild depression is not something that will be relatable and, and that might cause dementia of your body. Most likely it's Charles Bonnet syndrome. Things of Child Bonnet syndrome as like a phantom limb. But you know, you have your eyes no longer work properly. So it's a bit like a phantom limb. But in your eyes, that's how I like to remember. All right, a 57 year old man with chronic schizophrenia, presented with nausea and vomiting. He receives metoclopramide for his symptoms. 20 minutes later, he becomes agitated and develops mark oculogyric crisis and oromandibular dystonia. What is the most appropriate initial management? A procyclidine B with whole antipsychotic medications. C LORazepam B, tolterodine for most initial management. Most appropriate initial management. What might it be? What might this be? Yeah. Dystonia is probably your, your keyword. I think you not. Yes, it's procyclidine acute dystonia secondary secondary to antipsychotic usually is for Cyclidia. I am done with it. And the reason is metoclopramide works on a five ht three receptor in your brain, which a lot of antipsychotic also does, which is not ideal. So don't try not to use metoclopramide in patient with schizophrenia or, or nausea and vomiting. Um Yeah, and you've got, got all those symptoms in that box with all the psychotic medication not necessarily stop. The metoclopramide is probably a better shot, right? Um Number three, a 68 year old man with endstage pancreatic cancer is admitted to palliative care unit for symptom management. He has been experiencing persistent hiccups for the past 48 hours which are causing significant discomfort and distress despite attempts to alleviate the hiccups with home remedies such as drinking water and holding his breath, they have not subsided. What is the most appropriate step in management? A IV metoclopramide B IV Haloperidol C Baclofen therapy. D gabapentin. Oh, this is a bit tricky one I must admit. Um, so what would be your answer of your cups? Is that most people? Yes, it's IV Haloperidol. It's palliative care. There is some study, well, not definite from what I've gathered today is it works on the dopamine receptors. Um There's some problem with the dopamine receptors and hiccups in palliative care. So, hence I IV Aller um just remember Haloperidol and cups. H patient will work on a dopamine receptor. All right. Next question. A 25 year old man presents to his primary care physician with complaints of persistent intrusive thoughts and repetitive behavior that have been significantly interfering with his daily life. He has no significant past medical history other than a history of allergic reactions to S SSRI S. He describes recurrent thoughts about contamination and cleanliness which led him to excessively wash his hands and avoid touching certain objects. Despite recognizing that these thoughts and behavior are irrational, he feels compelled to perform them to reduce an anxiety. He has tried E pr but this hasn't been effective so far. What is the most appropriate management? A clomiPRAMINE B, FLUoxetine C referral to secondary care B sertraline. OK. What that? So the answer is clomiPRAMINE. Now, referral to secondary care, you're probably go going to do that, but it's probably gonna take a while. So while the patient is still struggling, you will want to try clomiPRAMINE. Usually after trying r um we would go for sertraline. Um but in this scenario, the patient is allergic to all FS ri hence, you will go for clomiPRAMINE. That will be your second choice on after sertraline. Number five, a 78 year old man with endstage renal disease due to diabetic nephropathy is admitted to the palliative care unit for management of severe pain related to metastatic prostate cancer. He has a history of hypertension and CO PD. His current medication including Lisinopril and salmeterol slash fluticasone inhaler. What is the most suitable management? A oxyCODONE B, fentaNYL C morphine B, pregabalin. What would be your first choice for palliative care? So, fentaNYL fentaNYL will be the recommendation. Um because of the endstage renal impairment, it's m metabolized by the liver and is suitable for endstage renal failure. Number six, a 55 year old woman with a history of schizophrenia presents to a psychiatrist for routine follow up appointment. She has been stable on the psychotic medication for several years. Recently. She has noticed involuntary movement of her tongue and lips as well as grimacing and repetitive chewing motions on examination. She exhibits cor cor movements of the oral facial re region. What's the most appropriate management for this patient's symptoms? A haloperidol B, OLANZapine C tetrabenazine, D pro cyclizine. So the key is she's been stable on this medication for years and we kind of corri form orofacial movements of the or form facial region. Um, it's better known as dyskinesia. That's probably your, the thing you wanna manage. So the key is for years, she's been on this for years. Nothing new, the grimacing. So I is tetrabenazine, although I rarely see that we use in real life. But, um, the difference is this is the Huntington's chorea, but of course, sorry, not dyskinesia. Part of dyskinesia is what sometimes happens when someone is on antipsychotic on a stable dose for a long time. And that's what we use. They tend to use tetrabenazine. Procyclidine is for acute dystonia and acute dystonia tends to happen when someone has something new started that works on the dopamine receptor. So that's the difference tetrabenazine is for tardive dyskinesia if you remember that way. Um Yeah, procyclidine is well, psychotic and these psychotic therapy of those. Um, that is new. All right. That's all any questions of regarding any of that. Thank you so much for running the session tonight. And we just wanted to say as well. This is just a quick QR code for a survey we're doing for any students in Scotland just to compare their sort of rural placements with their urban placements. So just if you have a minute. We do appreciate you filling out, but thank you so much again for running the session. It was a really useful session and if anyone has any questions, please feel free to put in the chat. Even if it wasn't for something covered, particularly tonight, I think we've got one so far question would then secretion will be the most appropriate initial management while she is gurgling away while she is not, She is uh she is not choking in that sense. You'll give medication first and that should go away. But yeah, I'm not that that's what the questions us. But removing secretion could be right in real life scenario, but it won't be your problem. It will be a nurse's phone. But no, usually if they have secretion, most facilities don't have suction as I can speak for Cornhill. For example, we just give Hyo and it will go away. All right, perfect. Thank you. And is there any other questions that anyone has feel free to put them in the chat? But for now, we'll just put up a wee reminder of where to find us on Instagram. And we've also got a link to you and that's just a notification there. And again, we've got our next session next week which is covering M SK. So it'll be also be next Tuesday or Wednesday, which just to confirm the date, it'll be next Tuesday or Wednesday. But again, thank you so much for coming and again, pop any questions in the chat that you might have and we'll just pop the feedback form in the chat. And once everyone completes the feedback form, we'll make the slides available for those who completed the feedback form. But thank you so much again and sit for a few minutes in case anyone has any questions. Ok. I don't think there's any more questions so far. So we'll probably head off now. But thank you so much again to you for running the session. And again, we'll make the slides available for those who complete the feedback form. You're welcome. So let everyone with the finals. Bye now. Bye. Thank you.