Master CPS - Psychiatry/Neurology
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Core Concepts
Mental State Examination (MSE): Essential for psychiatric assessment – Appearance, Behaviour, Speech, Affect & Mood, Thought, Perception, Cognition, Insight, Risk.
Risk Assessment: Crucial for suicide, self-harm, harm to others, vulnerability (safeguarding), neglect.
Delirium vs. Dementia: Delirium is acute, fluctuating, attention-deficit, often reversible. Dementia is chronic, progressive cognitive decline, typically irreversible.
Stroke vs. TIA: Stroke involves irreversible brain tissue damage. TIA is a transient ischaemic attack, focal neurological deficit resolving without infarction (usually <1hr). Both are emergencies.
Common Headaches:
- Tension: Bilateral, band-like, mild-moderate.
- Migraine: Unilateral, throbbing, moderate-severe, often with aura, N/V, photophobia/phonophobia.
- Cluster: Unilateral periorbital, excruciating, with autonomic features (e.g., lacrimation, ptosis).
Clinical Presentation
- Depression: Persistent low mood, anhedonia, fatigue, sleep/appetite changes, poor concentration, feelings of worthlessness/guilt, suicidal ideation (SIGECAPS).
- Generalised Anxiety Disorder (GAD): Chronic, excessive worry, restlessness, fatigue, irritability, muscle tension, sleep disturbance.
- Panic Attack: Sudden, intense fear, palpitations, chest pain, shortness of breath, dizziness, derealization/depersonalization.
- Psychosis (e.g., Schizophrenia): Hallucinations (auditory common), delusions (paranoid), disorganised thought/speech, negative symptoms (alogia, avolition).
- Stroke/TIA: Sudden onset focal neurological deficit – unilateral weakness/numbness, dysphasia/dysarthria, visual field defect (FAST symptoms).
- Seizure:
- Generalised Tonic-Clonic: Loss of consciousness, rigidity (tonic), then jerking (clonic).
- Focal: May involve motor, sensory, autonomic, or cognitive symptoms, with or without impaired awareness.
- Parkinson's Disease: Bradykinesia, rigidity (cogwheel), resting tremor (pill-rolling), postural instability.
Diagnosis (Gold Standard)
Psychiatric Disorders: Clinical diagnosis based on detailed history, MSE, and symptoms meeting DSM-5/ICD-10 criteria. Always exclude organic causes.
Delirium: Clinical diagnosis (e.g., Confusion Assessment Method - CAM). Identify and treat underlying medical cause (infection, drugs, metabolic).
Stroke: Urgent CT head to rule out haemorrhage (guides thrombolysis). DWI-MRI is more sensitive for ischaemia.
Epilepsy: Clinical history of recurrent unprovoked seizures. EEG can support but normal EEG does not exclude. MRI brain to rule out structural causes.
Parkinson's Disease: Clinical diagnosis based on cardinal motor features. DaTscan can support in uncertain cases but is not typically first-line.
Dementia: Clinical diagnosis based on history, cognitive assessment (e.g., MMSE/MoCA), blood tests (exclude reversible causes), and structural brain imaging (CT/MRI) to exclude other pathology and show atrophy.
Management (First Line)
Depression (moderate-severe): Step 1: Psychological therapies (CBT). Step 2: SSRIs (e.g., Sertraline, Citalopram) AND psychological therapies.
Anxiety (GAD): Step 1: Self-help, psychoeducation. Step 2: CBT. Step 3: SSRI (e.g., Sertraline) OR CBT.
Psychosis (first episode): Atypical antipsychotic medication (e.g., Olanzapine, Risperidone), CBT for psychosis, family intervention.
Acute Ischaemic Stroke: Thrombolysis (alteplase) if eligible (<4.5h from symptom onset). Thrombectomy if large vessel occlusion (<6-24h). Secondary prevention: Aspirin, high-dose statin, BP control, lifestyle.
TIA: Urgent assessment (ABCD2 score). Secondary prevention: Aspirin, high-dose statin, BP control, lifestyle. Carotid endarterectomy if indicated.
Epilepsy: Anti-Epileptic Drugs (AEDs) (e.g., Levetiracetam, Lamotrigine). Valproate has teratogenicity risk for women of childbearing age.
Migraine (acute): Simple analgesics (paracetamol/NSAIDs), triptans (e.g., Sumatriptan), antiemetics. Prophylaxis if frequent/severe (e.g., beta-blockers, topiramate).
Parkinson's Disease: Levodopa (most effective for motor symptoms). Dopamine agonists (e.g., Ropinirole). Multidisciplinary team approach.
Exam Red Flags
- Sudden onset "thunderclap" headache: Subarachnoid haemorrhage. Immediate CT head.
- Acute focal neurological deficit (e.g., FAST symptoms): Stroke/TIA. Emergency assessment.
- New onset seizure in adult with focal features/progression: Consider brain tumour, structural lesion.
- Progressive neurological deficit (e.g., weakness) with autonomic dysfunction/respiratory compromise: Guillain-Barré Syndrome.
- Papilloedema: Raised intracranial pressure (e.g., tumour, hydrocephalus, idiopathic intracranial hypertension). Urgent neuroimaging.
- Acute confusion/fluctuating consciousness (Delirium): Always look for underlying medical cause (infection, drugs, metabolic).
- Active suicidal ideation with plan/intent: Urgent mental health assessment, consider inpatient admission.
- Acute behavioural disturbance/psychosis with risk to self or others: Urgent assessment, consider detention under MHA.
- New onset psychotic symptoms in a child/adolescent: Urgent specialist assessment.
- Rapid cognitive decline with focal neurological signs: Rule out rapidly progressive dementia or underlying neurological condition.
- Severe alcohol/benzodiazepine withdrawal symptoms: Can be life-threatening (seizures, delirium tremens).
- Any mental health presentation linked to safeguarding concerns (child/vulnerable adult): Immediate safeguarding actions.
- Organic cause for psychiatric symptoms (e.g., hyperthyroidism = anxiety, brain tumour = personality change): Always rule out.
Sample Practice Questions
A 30-year-old female presents with a 2-month history of fluctuating numbness and weakness in her left arm and leg, blurred vision in her right eye that resolved spontaneously, and occasional episodes of dizziness. She has no significant medical history. On examination, she has mild left-sided weakness and brisk reflexes. What is the most appropriate initial diagnostic investigation?
A 72-year-old female is brought to the clinic by her daughter due to progressive memory loss over the past 2 years. She frequently misplaces items, repeats questions, and has difficulty managing her finances. Her daughter also reports changes in her personality, becoming more irritable and withdrawn. Her medical history includes hypertension and type 2 diabetes. On cognitive assessment, she scores 20/30 on the Mini-Mental State Examination (MMSE). Which of the following is the most likely diagnosis?
A 75-year-old male with a history of atrial fibrillation and hyperlipidaemia presents with sudden onset of weakness in his left arm and leg, difficulty speaking, and facial asymmetry. These symptoms began approximately 2 hours ago. He is able to follow simple commands but his speech is slurred and he cannot raise his left arm against gravity. His blood pressure is 180/100 mmHg.
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