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MRCGP Preparation Course MCQ’s Part 2. Dr Kashaf Aziz. Format of the exam Paper 1 MCQs 200 Which is the SINGLE MOST likely diagnosis? Select ONE option only. Which is the SINGLE MOST appropriate treatment, according to the current edition of the BNF? Select ONE option only.

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slide2

Format of the exam Paper 1

  • MCQs 200
  • Which is the SINGLE MOST likely diagnosis? Select ONE option only.
  • Which is the SINGLE MOST appropriate treatment, according to the current edition of the BNF? Select ONE option only.
  •  Which is the SINGLE MOST appropriate investigation? Select ONE option only.
slide3

Example 1

A 65 year old lady falls onto an out stretched arm. You suspect a Colles fracture.

Which is the SINGLE MOST appropriate investigation,? Select ONE option only.

  • CT
  • MRI
  • US
  • X-ray AP
  • X-ray AP & lateral
slide4

Example 2

Your 42 year old patient attends for a 3rd BP check and is consistently found to have a reading of 155/ 96 with grade I hypertensive retinopathy.

Which is the SINGLE MOST appropriate treatment, according to the NICE guidelines? Select ONE option only.

  • Bendroflumethiazide
  • Doxazosin
  • Lisnopril
  • Nifedipine
  • Propranalol
slide5

Example 3

Your patient patient has a chronic paronychia despite several courses of augmentin.

 Which is the SINGLE MOST appropriate next investigation? Select ONE option only.

  • Check ESR
  • Check CP
  • Check urinalysis for protein
  • Serum fungal screen
  • Take a swab for microscopy and culture
slide7

1. Regarding seborrhoeic dermatitis in infants, which TWO of the following statements are correct? Select TWO answers only.

a. It usually affects the flexures of the elbow and at the back of the knees.

b. It usually disappears by three months.

c. If medical treatment is required, ketoconazole 2% cream is a suitable treatment.

d. A rare complication requiring urgent admission is Leiner's disease.

slide8

Regarding seborrhoeic dermatitis in infants, which TWO of the following statements are correct? Select TWO answers only.a. It usually affects the flexures of the elbow and at the back of the knees.b. It usually disappears by three months.c. If medical treatment is required, ketoconazole 2% cream is a suitable treatment.d. A rare complication requiring urgent admission is Leiner's disease.

The correct answers are C and D.In infants, seborrhoeic dermatitis usually affects the scalp (hence it is sometimes called 'cradle cap'). It can affect the face and body. It usually clears spontaneously within a few weeks or months (most cases clear by six to 12 months of age). If medical treatment is required, 2% ketoconazole cream or shampoo can be effective.

Leiner's disease is a rare complication requiring urgent admission. It presents with a sudden confluence of lesions leading to universal scaling redness of the skin. The infant is severely ill with anaemia, diarrhoea, and vomiting.

slide9

Regarding childhood febrile convulsions, which ONE of the following statements are correct? Select ONE answer only.

a. The incidence is 2% to 4%.

b. The peak incidence is at 12 months.

c. Usually focal seizures are observed.

d. Seizures usually last 20+ minutes.

slide10

Regarding childhood febrile convulsions, which ONE of the following statements are correct? Select ONE answer only.

a. The incidence is 2% to 4%.

b. The peak incidence is at 12 months.

c. Usually focal seizures are observed.

d. Seizures usually last 20+ minutes.

The correct answer is A.

A childhood febrile convulsion is a seizure occurring in a child aged six months to five years, associated with fever arising from infection or inflammation outside the central nervous system in a child who is otherwise neurologically normal. The peak incidence is at 18 months, and seizures are usually focal and last three to six minutes.

slide11

Regarding febrile convulsions in children, which THREE of the following are the MOST common causes of the fever? Select THREE answers only.

a. Urinary tract infection (UTI)

b. Post immunisation fever

c. Viral infection

d. Otitis media

e. Lower respiratory tract infection (LRTI)

f. Meningitis

slide12

Regarding febrile convulsions in children, which THREE of the following are the MOST common causes of the fever? Select THREE answers only.

a. Urinary tract infection (UTI)

b. Post immunisation fever

c. Viral infection

d. Otitis media

e. Lower respiratory tract infection (LRTI)

f. Meningitis

g. Tonsillitis

The correct answers are: C, D, and G. All of the options above were found to be causes of the fever in febrile convulsions, but the most common are viral infections and otitis media. Serious bacterial infections are an uncommon but potentially life threatening cause.

slide13

Regarding nappy rash in infants, which of the following is the most important causative microorganism? Select ONE answer only.

a. Staphylococcus aureus

b. Methicillin resistant S. aueus (MRSA)

c. Escherichia coli

d. Candida albicans

e. Pseudomonas

f. Streptococcus

g. Proteus

slide14

Regarding nappy rash in infants, which of the following is the most important causative microorganism? Select ONE answer only.

a. Staphylococcus aureus

b. Methicillin resistant S. aueus (MRSA)

c. Escherichia coli

d. Candida albicans

e. Pseudomonas

f. Streptococcus

g. Proteus

The correct answer is D.

Nappy rash is a dermatitis confined to the area covered by the nappy. It is not one distinct diagnosis, but a multifactorial problem with many possible causative factors including infrequent nappy changes, contact with faeces or urine, use of broad spectrum antibiotics and chemical irritants. Candida albicans is the most important causative microorganism.

slide15

Which of the following is NOT a risk factor for development and progression of diabetic retinopathy? Select ONE answer only

a. Poor glycaemic control

b. Raised blood pressure (BP)

c. Raised triglyceride levels

d. Raised cholesterol levels

e. Presence of microalbuminuria and proteinuria

slide16

Which of the following is NOT a risk factor for development and progression of diabetic retinopathy? Select ONE answer only

a. Poor glycaemic control

b. Raised blood pressure (BP)

c. Raised triglyceride levels

d. Raised cholesterol levels

e. Presence of microalbuminuria and proteinuria

The correct answer is D. Other risk factors include pregnancy and duration of diabetes. The progression of retinopathy can be minimized by early, rigorous control of blood glucose and BP.

slide17

Regarding acute angle closure glaucoma, which TWO of the following statements are correct? Select TWO answers only.

a. Patients present more commonly in the winter, and symptoms often present in the evening.

b. Pupils become constricted, with a pin prick appearance.

c. The eye is typically red and very painful.

d. Patients should be referred to an ophthalmologist for an outpatient appointment within two weeks of presentation.

e. The eye is typically red and painless.

slide18

Regarding acute angle closure glaucoma, which TWO of the following statements are correct? Select TWO answers only.

a. Patients present more commonly in the winter, and symptoms often present in the evening.

b. Pupils become constricted, with a pin prick appearance.

c. The eye is typically red and very painful.

d. Patients should be referred to an ophthalmologist for an outpatient appointment within two weeks of presentation.

e. The eye is typically red and painless.

The correct answers are A and C. Acute angle-closure glaucoma is a rapid and severe rise in intra ocular pressure caused by physical obstruction of the anterior chamber drainage angle. It often presents in the evening when reduced light causes mydriasis (thus it is more common in the winter), and presents with a red, painful eye. It requires URGENT admission (same day) as delay can cause blindness.

slide19

Regarding acute angle closure glaucoma, which THREE of the following are risk factors? Select THREE answers only.

a) Hypermetropia

b) Myopia

c) Amblyopia

d) Caucasian descent

e) Asian descent

f) Afro-Caribbean descent

g) Previous attack in the other eye

slide20

Regarding acute angle closure glaucoma, which THREE of the following are risk factors? Select THREE answers only.

a) Hypermetropia

b) Myopia

c) Amblyopia

d) Caucasian descent

e) Asian descent

f) Afro-Caribbean descent

g) Previous attack in the other eye

The correct answers are A, E and G. Acute angle closure glaucoma is rare, affecting 1 in 1,000 people over the age of 40. Other risk factors include increasing age, having shallow anterior chambers, and family history.

slide21

Regarding the following infectious organisms...

a. Staphylococcus aureus

b. Chlamydia trachomatis

c. Trichomonasvaginalis

d. Candida albicans

e. Pseudomonas

f. Streptococcus pneumonie

g. Proteus species

h. Dermatophytes

i. Enterobiusvermicularis

For each of the following presentations, which is the MOST likely causative organism? You may use each option ONCE, MORE than ONCE, or not at all.

A four year-old girl presents with intense perianal itching. This is much worse at night, and has caused poor sleep and uncharacteristic irritability. The symptoms have been present for two weeks. Her older sister (aged six) has had similar symptoms.

slide22

The correct answer is I. Enterobius vermicularis (threadworm) is the most common helminth infection in the UK. It can be asymptomatic, or present with intense perianal itching worse at night (when the eggs are laid). Adult threadworms live for upto six weeks. Good attention to hygiene is an essential part of treatment. Drug treatment of choice is Mebendazole, and all members of the household should be treated if possible.

slide23

Regarding the following infectious organisms...

a. Staphylococcus aureus

b. Chlamydia trachomatis

c. Trichomonas vaginalis

d. Candida albicans

e. Pseudomonas

f. Streptococcus pneumonie

g. Proteus species

h. Dermatophytes

i. Enterobius vermicularis

For each of the following presentations, which is the MOST likely causative organism? You may use each option ONCE, MORE than ONCE, or not at all.

A 15 year-old girl presents with vulval itching and a white odourless vaginal discharge. She also complains of dysuria. She was last seen in the surgery a week before and treated for an acute sinusitis. She is not sexually active.

slide24

The correct answer is D. These symptoms are common in vulvovaginal candidiasis. The most common causative agent is Candida albicans. It is often precipitated by another illness, or by the use of broad spectrum antibiotics. Chlamydia can also present with vaginal discharge and dysuria, but rarely causes itch.

slide25

Regarding the following infectious organisms...

a. Staphylococcus aureus

b. Chlamydia trachomatis

c. Trichomonas vaginalis

d. Candida albicans

e. Pseudomonas

f. Streptococcus pneumonie

g. Proteus species

h. Dermatophytes

i. Enterobius vermicularis

For each of the following presentations, which is the MOST likely causative organism? You may use each option ONCE, MORE than ONCE, or not at all.

A 20 year-old woman presents with vulval itching, dysuria and an offensive discharge. On examination there is a frothy yellow-green discharge. Her only regular medication is the oral contraceptive pill (OCP).

slide26

The correct answer is C. Trichomonas vaginalis is a flagellated protozoan which is usually transmitted sexually. Upto 50% of infected women may be asymptomatic. Symptoms include vulval itch, dysuria and a coloured, offensive discharge.

slide27

Regarding the known side effects of the following drugs...

a. Simvastatin

b. Ramipril

c. Prednisolone

d. Celecoxib

e. Methotrexate

f. Isotretinoin

g. Dermovate

h. Minocycline

i. Indometacin

For each of the following patients, select the drug most likely to be causing the side effects mentioned. You may use each option ONCE, MORE than ONCE, or not at all.

A 19 year-old girl with severe acne presents to accident and emergency after taking an overdose of alcohol. She says she does not want to live and had been feeling this way for the last two weeks.

slide28

Isotretinoin, which is used for treating severe acne. Patients who develop suicidal tendencies on Isotretinoin may need follow up even after the medication is stopped.

slide29

Regarding the known side effects of the following drugs...

a. Simvastatin

b. Ramipril

c. Prednisolone

d. Celecoxib

e. Methotrexate

f. Isotretinoin

g. Dermovate

h. Minocycline

i. Indometacin

For each of the following patients, select the drug most likely to be causing the side effects mentioned. You may use each option ONCE, MORE than ONCE, or not at all.

A 55 year-old man with known heart disease presents with severe muscle pains. He reports feeling "weak". Creatine kinase (CK) is 1,000 U/L.

slide30

The correct answer is A. Rhabdomyolysis/myositis is a well known potentially serious side effect of most statins. Many patients are started on a statin after a myocardial infarction (MI) or if at risk of heart disease. Patients often improve once the drug is stopped, and this can be monitored using CK levels.

slide31

Regarding the known side effects of the following drugs...

a. Simvastatin

b. Ramipril

c. Prednisolone

d. Celecoxib

e. Methotrexate

f. Isotretinoin

g. Dermovate

h. Minocycline

i. Indometacin

For each of the following patients, select the drug most likely to be causing the side effects mentioned. You may use each option ONCE, MORE than ONCE, or not at all.

A 40 year-old patient with systemic lupus erythematosus (SLE) presents with severe upper abdominal pain radiating to the back. Her medication was recently increased after a flare up of her SLE.

slide32

The correct answer is C. This presentation is in keeping with acute pancreatitis, which can be caused by steroid treatment. Prednisolone is a commonly used treatment for SLE.

slide33

Regarding megaloblastic anaemias, which ONE of the following statements is correct? Select ONE answer only.

a. Vitamin B12 deficiency due to pernicious anaemia accounts for 50% of megaloblastic anaemias.

b. Vitamin B12 deficiency due to pernicious anaemia accounts for 60% of megaloblastic anaemias.

c. Vitamin B12 deficiency due to pernicious anaemia accounts for 70% of megaloblastic anaemias.

d. Vitamin B12 deficiency due to pernicious anaemia accounts for 80% of megaloblastic anaemias.

e. Vitamin B12 deficiency due to pernicious anaemia accounts for 90% of megaloblastic anaemias.

slide34

The correct answer is D. Pernicious anaemia is caused by an autoimmune process causing gastritis resulting in reduced acid production and an absence of intrinsic factor, which is essential for the absorption of vitamin B12.

slide35

Which one of the following is the target BP for non diabetic patients recommended by the Joint British Society Guidelines (2005)? Select one answer only.

a. <140/85 mm Hg

b. <150/90 mm Hg

c. <145/85 mm Hg

d. <145/90 mm Hg

e. <150/85 mm Hg

slide36

The correct answer is A: <140/85. The maximum acceptable level according to the guidelines (the audit standard) is 150/90. This is the target adopted for gaining QOF points in the new GMS contract. For diabetics, the target is much lower: 130/80.

slide37

Which ONE of the following drugs is associated with the highest increased risk of suicide in adolescents AND adults?

a. Fluoxetine

b. Citalopram

c. Venlafaxine

d. Paroxetine

e. Duloxetine

slide38

The correct answer is D: Paroxetine. A recent report confirmed that there is a significantly increased risk of suicide in adults taking Paroxetine compared to placebo. There have already been many reports about an increased risk in adolescents.

slide39

Regarding statistics in screening, which TWO of the following statements are correct? Choose TWO answers only.

a. The sensitivity is the same as the false positive rate.

b. The specificity is the same as the false negative rate.

c. The specificity is the same as the true negative rate.

d. The sensitivity is the same as the true negative rate.

e. The predictive value negative is the probability that a person does not have the disease given a negative test.

slide40

The correct answers are C and E. Sensitivity is the probability that the screening test is positive given that the person actually has the disease. It is the same as the true positive rate. The specificity is the probability that the screening test is negative given that the person does NOT have the disease. It is the same as the true negative rate. The ideal screening tool would be 100% sensitive and 100% specific.

slide41

Developmental milestones in children include the following.

a. Startled by loud sounds

b. 20 words in the vocabulary (monolingual child)

c. Responds to name and mimics environmental sounds

d. First meaningful words

e. Follows commands and performs simple tasks

f. Localises sounds

Match each of the following age groups to the correct developmental milestones. You can use each option once, more than once, or not at all.

Six months

12 months

18 months

slide42

Developmental milestones in children include the following.

a. Startled by loud sounds

b. 20 words in the vocabulary (monolingual child)

c. Responds to name and mimics environmental sounds

d. First meaningful words

e. Follows commands and performs simple tasks

f. Localises sounds

Match each of the following age groups to the correct developmental milestones. You can use each option once, more than once, or not at all.

Six months

12 months

18 months

slide43

Developmental milestones in children include the following.

a. Startled by loud sounds

b. 20 words in the vocabulary (monolingual child)

c. Responds to name and mimics environmental sounds

d. First meaningful words

e. Follows commands and performs simple tasks

f. Localises sounds

Match each of the following age groups to the correct developmental milestones. You can use each option once, more than once, or not at all.

Six months F

12 months D

18 months E

Important developmental milestones in childhood include:

• <3 months Startled by loud sounds

• 6 months Localises sounds

• 9 months Responds to name and mimics environmental sounds

• 12 months First meaningful words

• 18 months Follows commands and performs simple tasks

• 24 months 20 words in the vocabulary (monolingual child)

slide44

Regarding 'frozen shoulder', which THREE of the following are correct? Choose THREE answers only.

a. Diagnosis requires abnormal clinical and x-ray findings.

b. It is characterized by insidious shoulder stiffness; severe pain, even at night; and severe loss of passive and active external rotation of the shoulder.

c. It is common in athletes aged 20 to 30.

d. Steroid injections offer no benefit over physiotherapy.

e. Difficult cases may need arthroscopic release.

f. It is associated with diabetes mellitus.

The correct answers are B, E, and F. Frozen shoulder is a clinical diagnosis. It is characterised by insidious shoulder stiffness; severe pain, even at night; and severe loss of passive and active external rotation of the shoulder. X-ray is often normal or may show periarticular osteopenia as a result of disuse. It is rare in patients under 40, and slightly more common in women than men. Physiotherapy alone is of little benefit, although it is useful in combination with steroid injection of the joint (which is the mainstay of treatment).

slide45

The correct answers are B, E, and F. Frozen shoulder is a clinical diagnosis. It is characterised by insidious shoulder stiffness; severe pain, even at night; and severe loss of passive and active external rotation of the shoulder. X-ray is often normal or may show periarticular osteopenia as a result of disuse. It is rare in patients under 40, and slightly more common in women than men. Physiotherapy alone is of little benefit, although it is useful in combination with steroid injection of the joint (which is the mainstay of treatment).

slide46

Which THREE of the following have a strong association with HLA-B27 (positive in at least 50% of cases)? Choose THREE answers only.

a. Ankylosing spondylitis

b. Juvenile rheumatoid arthritis

c. Psoriasis

d. Reactive arthritis

e. Systemic sclerosis

f. Myasthenia gravis

slide47

Which THREE of the following have a strong association with HLA-B27 (positive in at least 50% of cases)? Choose THREE answers only.

a. Ankylosing spondylitis

b. Juvenile rheumatoid arthritis

c. Psoriasis

d. Reactive arthritis

e. Systemic sclerosis

f. Myasthenia gravis

The correct answers are A, B, and D. HLA-B27 is associated with over 100 diseases. The strongest associations are with Ankylosing spondylitis, JRA, and reactive arthritis. It is weakly associated with psoriasis, but has a strong association in a subgroup of psoriatic patients who also have spondylitis.

slide48

Regarding the following women's health issues.

a. Vaginosis

b. Vaginismus

c. Ectopic pregnancy

d. Pelvic inflammatory disease (PID)

e. Bartholin's cyst

f. Polycystic ovarian syndrome (PCOS)

g. Endometriosis

h. Urinary tract infection (UTI)

For each of the following presentations, select the MOST likely diagnosis from the list. You can use each question once, more than once, or not at all.

A 33 year-old woman presents with a history of painful periods. This has been present for many years but is getting worse. She also complains of painful intercourse and spotting for several days before her periods. Clinical examination is unremarkable. She is married with an adopted child.

slide49

G. Endometriosis. This is common disorder which is characterized by the presence of endometrial glands and tissue outside the endometrial cavity. It is more common in women in their 30s and 40s, and often presents with deep dyspareunia, spotting before or after periods and worsening dysmenorrhea. It is associated with infertility in up to 40% of cases.

slide50

Regarding the following women's health issues.

a. Vaginosis

b. Vaginismus

c. Ectopic pregnancy

d. Pelvic inflammatory disease (PID)

e. Bartholin's cyst

f. Polycystic ovarian syndrome (PCOS)

g. Endometriosis

h. Urinary tract infection (UTI)

For each of the following presentations, select the MOST likely diagnosis from the list. You can use each question once, more than once, or not at all.

A 27 year-old woman presents for her first cervical smear. She has not responded to several previous reminders to attend. She is very anxious. You are unable to perform the examination as she screams in pain when you try to introduce the speculum. The patient tells you that she has delayed coming for fear of the examination. She has not been sexually active for a long time because she finds it very painful.

slide51

B. Vaginismus. Vaginismus is an involuntary spasm of the muscles surrounding the vagina, causing penetration to be painful/difficult, or even impossible. It can lead to severe anxiety and fear of intercourse. Patients may be unable to tolerate a vaginal/internal examination. Examination shows involuntary muscle contraction when the tip of the speculum or a finger is inserted into the vagina.

slide52

Regarding the following women's health issues.

a. Vaginosis

b. Vaginismus

c. Ectopic pregnancy

d. Pelvic inflammatory disease (PID)

e. Bartholin's cyst

f. Polycystic ovarian syndrome (PCOS)

g. Endometriosis

h. Urinary tract infection (UTI)

For each of the following presentations, select the MOST likely diagnosis from the list. You can use each question once, more than once, or not at all.

A 21 year-old woman presents with a two-day history of bilateral lower abdominal pain. She also complains of a two week history of pain during intercourse, dysuria and an irregular period. On examination she has bilateral abdominal tenderness and a cervical mucopurulent discharge. She has a temperature of 37.9C

slide53

PID. The most common presenting symptom is bilateral lower abdominal pain. Many patients are asymptomatic, with a diagnosis being made retrospectively. Other symptoms include vaginal discharge, dyspareunia, fever, and irregular menstruation. Bilateral lower abdominal tenderness is present in almost all cases. Vaginal discharge where present is normally mucopurulent. PID is associated with ectopic pregnancy and infertility.

slide54

According to the new NICE guidance (2006) on the management of hypertension, which ONE of the following class of medication is NOT recommended as first line therapy for any groups?

a. Angiotensinconverting enzyme (ACE) inhibitors

b. Thiazide diuretics

c. Angiotensin receptor blockers

d. Beta Blockers

e. Calcium channel blockers

slide55

The correct answer is D. The decision not to recommend beta-blockers for first line therapy is based on evidence that suggests that they perform less well than other drugs, particularly in the elderly, and the increasing evidence that the most frequently used beta-blockers at usual doses carries an unacceptable risk of provoking Type 2 diabetes.

slide56

The correct answer is D. The decision not to recommend beta-blockers for first line therapy is based on evidence that suggests that they perform less well than other drugs, particularly in the elderly, and the increasing evidence that the most frequently used beta-blockers at usual doses carries an unacceptable risk of provoking Type 2 diabetes.

slide57

Torsion of testis.....

a) Resolves spontaneously in the majority of cases

b) Antibiotics are the treatment of choice

c) Is more common in patients who have an absent scrotal ligament

d) Cannot occur during sleep

e) Right iliac fossa pain is a recognised presentation

slide58

Torsion of testis.....

a) Resolves spontaneously in the majority of cases [F]

b) Antibiotics are the treatment of choice [F]

c) Is more common in patients who have an absent scrotal ligament [T]

d) Cannot occur during sleep [F]

e) Right iliac fossa pain is a recognised presentation [T]

Torsion of the testes usually requires to be treated surgically. If not corrected infarction occurs due to venous obstruction leading to congestion and interstitial haemorrhage. Antibiotics are not routinely indicated. It usually occurs during sleep and can be mistaken for appendicitis, due to the testes' innervation

slide59

Paranoid features

a) May occur in depression.

b) May occur in mania.

c) May occur in encephalitis.

d) In the Othello syndrome may lead to murder.

e) In dementia may occur before the recognition of cognitive impairment.

slide60

Paranoid features

a) May occur in depression. [T]

b) May occur in mania. [T]

c) May occur in encephalitis. [T]

d) In the Othello syndrome may lead to murder. [T]

e) In dementia may occur before the recognition of cognitive impairment. [T]

Paranoid delusions may appear in severe depression and as an early feature in dementia. Those in mania tend to be grandiose and the patient may believe that people are conspiring against him due to his importance. In delirium eg due to encephalitis, paranoid ideas are due to an impaired grasp of what is going on leading to apprehension, misinterpretation and thence to suspicion. Morbid jealousy (Othello syndrome) may lead to violent attacks and even murder of the partner.

slide61

Drug treatment of depression:

a) May be stopped 3 months after symptoms disappear in a first episode.

b) Should be continued for 2 years after symptoms disappear in recurrent attacks.

c) Once established may be given on repeat prescription without seeing the patient.

d) Is needed in the majority of patients who suffer panic attacks.

e) Is required in all cases.

slide62

Drug treatment of depression:

a) May be stopped 3 months after symptoms disappear in a first episode. [F]

b) Should be continued for 2 years after symptoms disappear in recurrent attacks. [T]

c) Once established may be given on repeat prescription without seeing the patient. [F]

d) Is needed in the majority of patients who suffer panic attacks. [T]

e) Is required in all cases. [F]

To prevent relapse, anti-depressants should be continued 4-6 mths after an initial episode has resolved. In recurrent cases ie 2 or more attacks within 5 years, long-term treatment is required and anti-depressants should not be stopped for 2 years after symptoms have subsided. Poor compliance is a common problem so regular follow-up is required to ensure medication is taken correctly. 75% of patients suffering panic attacks will suffer from depression at some time. Minor depression may be more usefully treated with counselling rather than medication.

slide63

Grief Reaction:

a) Is more likely to be abnormal if the death was preceded by a long illness.

b) Is deemed abnormal if the bereaved experience hallucinations.

c) Should normally be subsiding after 6 months.

d) Is helped by viewing the body.

e) Is less intense if the survivor has young children.

slide64

Grief Reaction:

a) Is more likely to be abnormal if the death was preceded by a long illness. [F]

b) Is deemed abnormal if the bereaved experience hallucinations. [F]

c) Should normally be subsiding after 6 months. [T]

d) Is helped by viewing the body. [T]

e) Is less intense if the survivor has young children. [F]

Abnormal grief reactions ie when symptoms are more intense, delayed in onset or prolonged more than 6 months are more common in sudden, unexpected deaths and when the survivor has to care for young children so has to hide their grief. Viewing the body helps move the bereaved on from the early stage of denial. Vivid experiences of being in the presence of the deceased and hallucinations of the dead person's voice are commonly seen in normal grieving.

slide65

In depressed patients:

a) A smiling exterior indicates less severe disease.

b) Recovery from physical illness is delayed.

c) Eating well is a definite sign of recovery.

d) Mood may be normal.

e) Auditory hallucinations indicate severe disease.

slide66

In depressed patients:

a) A smiling exterior indicates less severe disease. [F]

b) Recovery from physical illness is delayed. [T]

c) Eating well is a definite sign of recovery. [F]

d) Mood may be normal. [T]

e) Auditory hallucinations indicate severe disease. [T]

Although most depressed patients look depressed a few maintain a happy expression despite deep feelings of depression. Also some patients do not report low mood although other features of depression are present.