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Spring 2006 PMP - 60 questions with probes

17 posts in this topic

1. Male/16, obsessed with food and cleanliness, assess and manage. &nbsp:lol:dx: OCD, ED, Anakastic PD, Tourette, autistic spectrum disorder. Risk to this young gentleman.

2. Social phobia (same as superego 2005 autumn q. 58; Management and psychological therapies for social phobia. Differentials.

3. Antisocial PD with depression got a gun in black market and came to see me in follow up clinic. Discussions about detailed risk assessment and confidentiality issues. (Same as superego 2004 spring q. 29); (Who will be involving in managing this case. Duty of care to warn his care co-coordinator, ASW, GP, assertive outreach CPN, police, ward staff and others who are all involved in his care. Make sure that it is properly documented for future reference, in case CPN and ASW would want to see him again after discharge from hospital. Forensic referral would be a must.)

4. F/23-4 yr lady came to A&E took drug overdose of paracetamol due to break in the relationship with boyfriend, known a history of sexual abuse, had 3 previous ODs, has scars from DSH, two termination of pregnancy, substance misuse. How will you manage? (Probes: treatment for PD; how would you assess suicide risk, short term management, long term management, psychological management, would you admit and why, what you would like to achieve in this admission.)

5. M/59 with LD, epilepsy, cardiac problems and unstable diabetes the surgeon wants to operate on his gangrene but he is refusing how will you manage. (Probe: capacity.)

6. The lady with BPAD who are stable on lithium for three years and want to start a family how will you manage? (What would you tell her concerning her lithium, what are the risks when you stop, percentage of women who get psychotic in pregnancy if lithium stopped, what if she continues, side effects and effects on the baby, what if she wants to stop lithium- would you stop 'just like that' or do something else, over what period of time you would reduce lithium, what if she is well afterwards, would you restart lithium , how soon, what settings in, what if she remains well in this pregnancy and wants to have another baby- what would you advise re. risk of relapse- still high? What would you tell the patient re risk. What is the risk of relapse following birth?)

7. 76 yr old, aggressive, threats to neighbours, banging walls.

8. Treatment-resistant depression on paroxetine 50mg, poor compliance

9. 52 yr old in A&E wants to leave after an OD

10. 62/F w/ hx of recurrent depressive episode with suicidal intent admitted and got 6 ECT. Not effective. Assess and Mx (Probes: Initial acute Mx; Ddx and background info; If treatment resistant, causes; If chose to go on ECT, Mx)

11. 59 male working doctor drunkard, admit med for haemetemesis, 48 hrs got confusion and sexually harassed female nurses (Probes: acute mx , Ddx (put acute confusional disorder top), Ddx for delirium (put DT top!), Mx for DT, fitness to work as doctor)

12. 21 year old anorexic w/ heavy laxative use, not coming out of house not talking to anybody, group concerned, emaciated at last interview what you will do. (Warrant required, acute Mx in ward (must include bed-rest!), in-psychiatric ward Mx, Prognosis (include age)

13. 24 years old schizophrenic man on the ward. Still disturbed by delusions and hallucinations despite of treatment with oral antipsychotics and a depot. &nbsp:lol:iscuss Mx. (Rx-resistant schizophrenia: Gather background info, liaise with RMO, r/v previous notes and letters, physical conditions, which antipsychotic was it? Looking for reason for non effectiveness: dose? Length? Non-compliance? Psychosocial stressors? Substance abuse. NICE guidelines: try switching to atypical, try augmenting, and consider clozapine; psychosocial Rx: adherence therapy, family therapy for high EE, CBT; Prompts: what would guide choice? EPSE, previous partial response, current psychosocial circumstances)

14. 80 years old woman brought into hospital by police being found wandering in the streets. How would you manage? (Urgency of situation, very concerned for poor frail lady; Need to gather info: liaise with medical team to make sure she's fit and looking for a mobile phone/chain, etc pointing to identity in order to contact NOK/carer; Physical examination: neurology + signs of abuse/neglect; MSE A&B very important: smell? clothes? etc. Consciousness? Is she responding? Abnormal thoughts, responding to psychotic Sx? Cognitive Ax. &nbsp:lol:dx: Obvious delirium vs. dementia, psychotic, affective and exclude physical disorder. I stressed importance of liaising with physicians. Only at the end remembered alcohol and side effects of Rx. &nbsp:lol:idn't mention dissociation or grief reaction, feeling uneasy about it.

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15. 32 years old woman on orthopaedic ward having jumped off the window and fractured her hip following cessation of her paroxetine tablets. Her boyfriend is blaming the antidepressants. How would you deal with that? (Usual info gathering, need for urgency, liaison with orthopedic team and tactful approach, need to understand what they think and why discuss with boyfriend with permission. Withdrawal is a possibility but plenty more are, therefore Ax: what happened, what other factors associated/ fight? Alcohol? Drugs? Need to take full MSE and act on findings/ risk Ax. Didn't seem to want to hear my risk Ax asked what the most likely cause is. I said a combination of factors, most likely partly the altered mental state from paroxetine, inter-relational difficulties, alcohol intoxication or withdraw, impulsively jumping off. Suicidal attempt. Discontinuation syndrome. Would you restart her on paroxetine? Change it to prozac)

16. A 53/54 year old man has recently been diagnosed with Dementia. He cares for his wife who is totally dependent on him and she has a diagnosis of mild depression. Social service has raised concerns that they have made a suicide act. How would you assess and manage?

17. The single mother of a 14-yr-old boy is concerned about him. He has been playing truant from school, fire setting, aggressive and has recently been expelled from school. He has had similar problems several years ago. His father left the home several years ago.

How would you assess and manage?

18. Staff on a medical ward is concern about a 64/65 year old woman who is having chemotherapy for carcinoma of the thyroid. She is said to have recently become sexually abusive towards both female and male members of staff. They also report that this is out of character for her. How would you assess and manage?

19. 24-year-old paranoid schizophrenic on medium secure ward on high dose antipsychotic depot complains that staff interferes with him by scratching his face at night. He also complains of penile discharge. (Wanted me to say that high dose depot is related to sudden death; Ensure it's not really happening by staff or patients, is it hallucination (psychotic or hypnagogic, tactile), is it that he sees them do it, feels it or wakes up and believes it to have happened (delusional). Penile discharge again same as above, is it real, have samples been collected, urinalysis and if not then is it hallucinatory or delusional and has it happened since before during admission. Risk: is he going to attack the staff because he thinks they are scratching him. 'Are there any guidelines you are aware of regarding the high dose depot'. The College has guidelines. I answered that I would like to know has been on this high depot for years or has it been upped since admission, but that I would basically check to see if he had a proper trial of a typical, atypical and if that then has been trialed on clozapine.

20. 30/35-year-old woman referred by GP seeing you in your outpatient's clinic with her friend. Recently getting anxious. She has panic attacks every time she went out. She is terrified of leaving home. How would you asses and manage?

21. A 45-year-old civil servant is referred to you by GP. He has been drinking 3-4 bottles of vodka per week and few bottles of wine some days. How would you assess and manage?

22. A 55-year-old man with 6 year history of Parkinson’s referred by neurologist. Since last few weeks he is having visual hallucinations, small humans & animals in his room. He accused his wife of stealing his benefits money from his bank account. How would you assess and manage?

23. A GP has telephoned you regarding a 47-9-year-old lady divorced with 18 yr hx paranoid schizophrenia, not engaging with treatment for the last 3 years. Really barking (that was the gist), part of her delusions. Now concerns from local school authority regarding her threatening behaviour towards school kids whom she believes are laughing at her. Also believes she's being controlled by aliens. Thoughts of harming children, voices etc. Assess and manage (What sources of collateral information? What anticipated management difficulties? What section will you use? How long can treatment be enforced with Section 3? What will you do if after 3 months refuses treatment on section 3?)

24. 26-yr-old heroin addict turns up at casualty at 2am, saying he's suicidal. Last fix was 12 hours ago. Says he will kill himself, if he doesn't get what he wants. Assess and manage. (What other investigations & what emphasis on physical exam? Will you admit? What options available for treatment of opiate withdrawal? Will you section him? What will you do if he insists he is suicidal you offer admission and he declines?)

25. 30 yr borderline P.D. Had exploratory psychotherapy for 3 yrs, but still self harming. Assess and manage.

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26. Patient after first session psychodynamic therapy nearly strangled her child. Assess and manage. (Defense mechanisms involved, transference counter-transference, how as a supervisor in would mange and help a trainee who had counter-transference issues.)

27. Patient on antipsychotic has fever. Went into dd and then rapidly into NMS. &nbsp:lol:iagnosing, management etc. Pathophysiology of NMS.

28. Assess and manage a young chap puffing away on cannabis and getting psychotic.

29. 35 year-old lady arrested by police and charged with embezzling 1000 pounds in her post office job. Blew the loot on lotto tickets. She says she has irresistible urge to steal and gamble away the loot. Assess and manage. What are your differentials? Assume it's pathological gambling. How would u proceed? What is the prognosis? If she also has alcohol dependence. How would it affect your prognosis?

30. 15 year-old girl referred by GP with 1-yr hx of inducing vomiting and weight loss. Accompanied by both parents. Assess and manage. What are your differentials?

If it is anorexia, what are indications for admission? Is it your decision? What do you expect to find on physical examination / investigations? You mentioned family therapy. How will you involve the family?

31. 26 year-old doctor whose husband is also a doctor referred by GP. Had baby 3-wks ago. Now husband reports sadness and irritability. Assess and manage. What r the differentials?

Which is most likely? Why would u inform social services? IPT in long term Mx, &nbsp:lol:escribe IPT

32. 29 yr old school teacher referred by GP. History of increasing anxiety, palpitations, sweating and fear of dying. How will you assess and manage. &nbsp:lol:ifferential diagnosis - panic disorder. Management. What will your management as waiting list is high for psychotherapy? What psychological treatment would you give for this client? Risks later if does not respond?

33. 24 yr schizophrenic under your care is charged with arson. Court has requested you to prepare a report on this man. How would you go about it? What are sources of information you are looking for? What are the disposal options?

34. 23 yr has just delivered a baby. She is aloof, not feeding the baby and locking herself in a room. Found by husband with a bottle of paracetamol. How will you assess this lady? (Differential diagnosis - post partum psychosis, risks - management – admission; close observation, monitor MSE, physical treatments; what will do advise regard future? In the Inform the social workers before you assess.)

35. 35 yr old lady had recurrent depressions in the past, now feels some days good and some bad; son is having trouble with police; poor relationship with husband; GP referred; assess and manage?

36. Parents worried about son who is 10-year-old with poor academic performance; has repeated stereotyped behaviour; getting aggressive and irritable; never seen a psych before; assess and manage.

37. Surgeon refers lady 33y; appendicectomy 2 weeks ago; in ward; aggressive and irritable since yesterday. Assess and manage.

38. 40 yr old mother referred by GP, single parent of 8 and 10yr old children. She is facing redundancy. Mood low, loss of interest poor sleep. Not interested in antidepressants. How would you assess and manage the patient?

39. 12 weeks pregnant addict attending your clinic. Heroin, tamezepam and cocaine. Father of the child is a substance misuser. How would you manage?

40. 40 yr old man living with his mother. Now mother admitted to hospital with hip fracture. He is not engaging with services. He is a hoarder, collecting unusual items, paper cuttings etc. How would you asses and manage this patient?

41. 52 year old lady no physical problems became anxious in supermarket dropped stuff and ran. Does not go out anymore. Husband concerned. Assess and manage.

42. 19 year old mild/moderate LD attending college sexually inappropriate to LD females at class. Assess and manage.

43. 40 yr male after dosulepin overdose now an inpatient. Injunction against partner. History of assault. History of heavy alcohol misuse. On constant observation and threatening to staff. Assess and manage.

44. A mother of 27 yr old patient with schizophrenia wants to talk to you about her son. She and her husband are finding it very difficult to cope with their son who spends most of his time in bed, doing nothing. How will you proceed? (Why do you think mother is approaching you at this stage? What interventions will be helpful? Management of EPSEs. Confidentiality issues)

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45. You are asked to write a pre sentencing court report on a man with Borderline IQ, who has been convicted for indecent assault on 2 children. He had been physically and sexually abused as a teenager, when he was in a boarding school. He had counseling from the clinical psychologist in the past, but that did not help. Write a court report regarding your assessment and recommendations. (What is the relationship between the index offence and his past history? How will you manage? Counseling did not help in the past.

Any medication? (SOTP, CBT, abused becoming abuser, cyproterone acetate!)

46. A GP refers to you a 47 year old divorced lady who is being treated for depression for the last 10 years with various antidepressants without much improvement. She finds very difficult to go out and becomes very anxious. She lives with her 27 year old daughter who looks after her and herself become depressed now and is on antidepressants. They cannot cope any longer and are desperate for help. How will you proceed? (What are the options you have? Will you see them together? Treatment resistant depression for mum (Nice/ IP v OP/ ECT). Then touched upon family dynamics and possible change of role (as a carer) for daughter. Mentioned seeing them together and then apart.)

47. 84-year-old lady admitted to medical ward for repeated fall and confusion. The medical team would like to send her to nursing home, but the client refused. The staff asked you to come and assess her. (How to assess capacity; who could assess the capacity; who you would like to involve during the assessment; what are u going to do if the lady continue to refuse to go to nursing home.)

48. 48 year old man admitted to surgical ward after presented with acute abdominal pain. 48 hours later, he became agitated, aggressive and confused. You were asked to see him, how would you approach to do your assessment? (What medical illness you need to rule out, besides acute abdominal pathology; Likely DDx; For alcohol withdrawal, what management you would advise the surgical team; What other medications are needed, besides benzodiazepines, Vitamins B)

49. An 18 year old, with long history of AN since age of 13, she was admitted to medical ward after taken an overdose of paracetamol, soon after a therapeutic session with psychotherapist and she was told that she needed to be in hospital. Her BMI is 13.5 and low BP. She has 2 previous long admission for treatment of AN, and she also has OCD. How you would manage this patient. (Complication of rapid re-feeding; What is the protocol for re-feeding; What other route of re-feeding if patient refused to eat voluntarily; Could you use mental health act in the medical ward for this patient, or you would transfer her back to mental health unit for continuing the medical treatment. Prognosis of AN.)

50. A gentleman admitted to medical ward repeatedly for abdominal pain. All investigation negative. Assess and Mx. (DDx and Mx along the line of somatization disorder.)

51. 65 year man. Hx of psychotic depression. On Lithium and paroxetine. Admitted to medical ward for increased agitation. Wife said he presented with a very different clinical picture this time. CT brain showed generalized atrophy. (DDx; How to diagnose Li toxicity. Clinical features and lab results. What is the significance of the CT findings?)

52. A recently widowed man wants to take his brother of the psychiatric ward. Patient has chronic schizophrenia and has been an inpatient for 30 years. How to Mx? (What are the criteria for allowing discharge? What is the role of the inpatient team? Would you take patient's views into consideration?)

53. Lady in 30s or so referred to you with history of resilient depression and recurrent self harming. Has been few years in psychotherapy with no improvement. How will you assess and manage? (What may be responsible for failure to improve? What factors may make her not benefit specifically from psychotherapy? Which psychotherapeutic interventions are available in this case? Briefly describe what each entails? Which has best evidence in this case-recurrent DSH? What is the natural history of this case if left untreated?)

54. A chap with mild learning disability, epilepsy, diabetes and cardiac problems has leg to be amputated but refuses to give consent. (How would you assess capacity? Who else would you involve, what if he has schizophrenia with residual symptoms would it change your management, what if the condition is not immediately life-threatening yet the surgeons decide to go ahead quoting pt's best interest- what may happen in such case.)

55. A middle-aged woman is suffering from long standing depression. How will you assess her and manage her? (Tell me about Maudsley’s guidelines)

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56. 73-year-old woman comes to A&E after a fall. She is confused, tearful and frightened. She lives with her son who has mild L.D. Her G.P thinks she has dementia. What will you do? (Will you send her home? Where will you admit her? Whom will you involve? Differential diagnosis)

57. 52-year-old man who is on high dose antidepressants has become irritable and suspicious since 2 days. He comes driving his car to the clinic. He has a family history of cardiovascular accidents and is on antihypertensives since 3 years. Assess and manage

probes-differential diagnosis? (Investigations, what about him driving)

58. Middle aged lady with chronic pain, treated for many years. GP referral for ? depression. Pain relief is opioids and non-opioids plus amitriptylline. How do you assess and manage? Probes were about her analgesia and mechanism of action of amitriptylline for pain relief.

59. 40yr old barrister with alcohol dependency syndrome admitted to medical ward following a fit. He is asking for an in-patient detoxification. How would you assess and manage? Probes were all about management of detoxification and then further follow up in community.

60. 55yr old man charged with making obscene phone calls by police. GP referral. Wife says he lost his job a year ago and hasn't been the same since. (Sexual history and risk and the eventual diagnosis was impotence with some questions on management of impotence and risk of re-offending.)

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Thanks joyleung.

what's the plan though, do we try to tackle these on line or what did u have in mind?

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Joy thanx for the questions.

Do I know you?

funky: We can go online but I wonder an oral practise is better.

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We can go online but I wonder an oral practise is better.
Thank you joyleung for the list.

I agree with you. I guess we can post some pointers as to what we need to discuss in each case, but nothing will beat the face-to-face practice.

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I had 13 and 14 last exam

Royal college feedback

in resistant schizo, failed to mention psychological treatment ,in fact I mentioned compliance and family therapy , did not mentioned CBT because he was floridly psychotic

14 they that I did mention social worker, in fact I mentioned multidisiplinary approach

I think they could have mentioned many other important issues i failed to mention

Hope this would help

other people experiences and college feedback would help how the college marking

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It seems we need some motivational enhancement therapy

we still in pre-contemplation stage

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To be honest they gave me the creeps when I read 'em for the first time. It shouldnt be a big deal if people 'relax' as someone said...

Thanks to the contributer though.

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I also thank you the contributors as well... I just collect the questions from the forum here and there only.

And for those who attended Liverpool Course this weekend...

I finally realised what you mentioned about my name in superego cafe.... I thought it was not me because I thought you guys are talking about somebody writing books for superego cafe... (I wonder if there's any books from superego cafe?)

Anyway, it is nice to enjoy the 2-day course with you all and I could feel your warmth to greet someone from far away to take examination at half-a-globe's distance from home.

As I've replied to funky, I've not been here for a while because of PTSD-like anxiety for this second attempt. But hey, we still have time to rush!

Wish you all good luck. :D

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