- A 65 year old man with type 2 diabetes mellitus diagnosed 15 years ago attends clinic for his diabetes review. He has evidence of microalbuminuria on a urine sample which is a new finding. He has never had evidence of microalbuminuria before. His blood pressure is 120/80 mmHg. What is the next step in his management?
A Arrange 24h blood pressure monitoring
B Check his renal function
C Repeat the urine sample to confirm microalbuminuria
D Start an ACE inhibitor in view of microalbuminuria
C Repeat the urine sample to confirm microalbuminuria
A 59 year old lady presents 3 months after having broken her wrist falling down the stairs. She is still receiving physio to improve function though attendance at appointments has been sporadic. She says that the ‘painkillers’ are not working and so has been taking more than what she was prescribed initially by the hospital. This has resulted in many requests for ‘early’ prescriptions. She is angry to be asked to attend a GP appointment to discuss her request for more opioid analgesia. The GP also notes that she smells of alcohol at her afternoon appointment as she has done on occasions in the past. The GP notes her recent blood tests showed no abnormalities. What is the most likely diagnosis(es)?
A Harmful opiate and alcohol misuse
B Does not meet any opiate/alcohol diagnosis
C Opiate addiction and alcohol addiction
D Opiate dependence but not addiction, alcohol addiction
E No opiate diagnosis, alcohol misuse
A Harmful opiate and alcohol misuse
She is taking more opiate analgesia than prescribed. It appears that she is still on the initial dose prescribed by the hospital which is likely to be quite high from what you might expect 3 monts after her fall. Being on opiate analgesia for this length of time will mean she is dependent ie physiologically dependent. Although not described it is likely that she is tolerant and has withdrawal without her opiate analgesia. There are also other aspects eg getting angry with having to see the GP that suggests she is showing some signs consistent with addiction ie complex behaviours such as a ‘strong desire to take the drug’. However there is not enough information to say whether she is addicted eg loss of control, neglect of other interests to her opiate analgesia. Regarding her alcohol use – it would be unusual to present to a GP in the afternoon smelling of alcohol and it is recurrent but with normal blood test (eg MCV, LFTs) it is unlikely she is addicted.
Which symptom might point to a diagnosis of encephalitis rather than meningitis?
A. Stiff neck B. Photophobia C. Fever D. Behaviour change
E. Rash
D. Behaviour change
Stiff neck, rash and photophobia are more common in meningitis. Fever is observed in meningitis and encephalitis. Behaviour change is more commonly observed in encephalitis due to involvement of the brain.
In which order does motor unit recruitment occur during a voluntary movement?
E. Slow, fast fatigue resistant, fast fatigable
Motor units are recruited according to Henneman’s size principle. As more force is required during a voluntary contraction, motor units are recruited in a fixed order. The slowest units which produce the lowest force are recruited first. The faster units are recruited next, with the units which are resistant to fatigue recruited before the faster units which are fatigable
Which of the following best describes how antipsychotic medications are divided into ‘typical’ and ‘atypical’ antipsychotics?
A. Different movement side-effects at therapeutic doses
B. Different receptor targets
C. Different actions at receptor (antagonism vs partial agonism)
D. Different half-times in plasma
E. Different routes of administration
A. Different movement side-effects at therapeutic doses
The classification of antipsychotics into ‘typical’ and ‘atypical’ is based on their likelihood of causing extrapyramidal (movement) side effects at therapeutic doses. However, all antipsychotics can cause extrapyramidal side effects.
A patient has unusual sensations of head tilting, but these are not normally accompanied by spinning sensations. Dysfunction of which structures of the inner ear could account for these symptoms?
Utricle or saccule.
The utricle and saccule detect linear acceleration, either horizontal (utricle) or vertical (saccule). The semi-circular canals detect angular (rotatory) acceleration. The symptoms of tilt without spinning suggest that the semi-circular canals are not involved.
A 44 year old woman presents to her GP because she has not enjoyed anything, including things that she used to enjoy, for 5 weeks. What is the best term to describe this symptom?
Anhedonia
Anhedonia refers to a person losing the capacity to feel pleasure and is a core symptom of depression.
A patient dependent on alcohol is being admitted for surgery after an accident. They will therefore require medication to cover their alcohol withdrawal. What is the neurotransmitter system targeted by medication typically given for alcohol detoxification?
GABA-A
Benzodiazepines are typically given to medicate alcohol withdrawal and benzodiazepine receptors are part of the GABA-A receptor complex.
A patient is started on risperidone, an antipsychotic, and experiences side effects including galactorrhoea and gynaecomastia. The increased release of which hormone in response to treatment underpins these adverse effects?
Prolactin
Dopamine inhibits the release of prolactin from the anterior pituitary gland. Dopamine blockade by antipsychotics reduces this inhibition, leading to increased prolactin release. This can cause symptoms like galactorrhoea and gynaecomastia.
A 52 year old woman presents to her GP with symptoms of persistent low mood, increased sleep, increased appetite and suicidal thoughts. Which blood test would be the most useful when considering differential diagnoses?
Thyroid function tests
Hypothyroidism is an important differential diagnosis to consider when a patient presents with depression, as severe hypothyroidism can cause depressive symptoms. This patient is also sleeping and eating more, which can be associated with hypothyroidism as well as depression.
EFA7: Short Answer Question (SAQ) Answers A 33 year old single male presents for a morning appointment. The patient reports that they have been experiencing difficulty sleeping for several weeks, and have struggled to get up for work due to low energy. His mood has been persistently low for 3 weeks and his moods are worse in the morning. The patient used to attend the gym 3-4 times per week and play tennis with a friend each weekend, but has lost interested in these activities. They also report losing interest in food and eating less than normal. You note that he appears to be on his way to work, yet his appearance is unkempt: he has not shaved, his hair appears unwashed, and his shirt appears crumpled.
- Based on the history above, what is your working diagnosis of the patient? (1 mark)
- Identify one core and one biological symptom of depression that is missing from the initial information? (2 marks)
1) Depression
2) Core: anhedonia (1 mark)
Biological: loss of libido (1 mark)
- Suggest three other organic causes that may explain the symptoms the patient is displaying? (3 marks)
Any three from the list below (1 mark for each):
- Endocrine
- Infections
- Vitamin deficiencies
- Neurological conditions
- medications
- Give two reasons why would it be important to know whether the patient had previously experienced a manic episode? (2 marks)
Any two from the list below (1 mark for each):
- Anti-depressants can cause hypomania or mania
- Mostly ineffective in biopolar or as prophylaxis
- Have been shown worsen long term course of bipolar
- Clinically effective anti-depressants increase the levels of synaptic monoamines (including serotonin). Give two other pieces of evidence for the role of serotonin hypofunction in depression (2 marks)
Any two from the list below (1 mark for each):
- 5-HT depletion by the antihypertensive drug reserpine could cause depression
- Post-mortem evidence of reduced 5-HT levels in brainstem of individuals who committed suicide.
- Depression is associated with lower levels of 5-HT1A-receptors and 5-HT4-receptors
- Monoamine oxidase A is increased in MDD, which increases serotonin metabolism
- Blockade of serotonin synthesis by the tryptophan hydroxylase inhibitor pchlorophenylalanine prevents the antidepressant effects of both MAOIs and TCAs
- Tryptophan depletion depletes brain serotonin can trigger relapse in MDD successfully treated with SSRIs or cognitive behavioural therapy (CBT)
- Monoamine depletion correlates with reduced mood both in at risk and MDD in remission
