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 35-year-old woman presents to the emergency department reporting sudden onset of right-sided weakness and difficulty speaking, which started 30 minutes ago. She has no past medical history and takes no regular medications. On examination, she has a right facial droop and right arm weakness (MRC grade 3/5), but her speech is fluent with no dysphasia. She has no sensory loss, and her gait is normal. Her blood pressure is 130/80 mmHg, heart rate 72 bpm, and blood glucose 5.5 mmol/L. Considering the clinical presentation, which of the following is the MOST important investigation to perform immediately?
A 28-year-old male presents with a 6-month history of progressive weakness in his lower limbs, associated with muscle twitching and cramps. He denies sensory disturbances or bladder/bowel issues. On examination, he has fasciculations, hyperreflexia, and extensor plantar responses in both lower limbs. Cranial nerve examination is normal. His speech is clear, and he denies dysphagia. Which of the following is the most likely diagnosis?
A 35-year-old female presents with recurrent episodes of intense fear, palpitations, sweating, trembling, shortness of breath, and a feeling of impending doom. These episodes occur unpredictably and reach a peak within 10 minutes, lasting about 20-30 minutes. She avoids situations where she fears an attack might occur, especially crowded places. She reports significant distress and impairment in her social and occupational functioning. Physical examination and routine blood tests are normal. Which of the following is the most likely diagnosis?
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