MRCGP Preparation CourseMCQ’s Part 2

Dr Kashaf Aziz

3/27/2009 1

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.

3/27/2009 2

Example 1A 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.a)CTb)MRIc) USd)X-ray APe)X-ray AP & lateral3/27/2009 3

Example 2Your 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.

a) Bendroflumethiazideb) Doxazosinc) Lisnoprild) Nifedipinee) Propranalol3/27/2009 4

Example 3Your patient patient has a chronic paronychia despite

several courses of augmentin. Which is the SINGLE MOST appropriate next

investigation? Select ONE option only.a) Check ESRb) Check CPc) Check urinalysis for proteind) Serum fungal screene) Take a swab for microscopy and culture

3/27/2009 5

Question Time

11/13/2009 6

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.

11/13/2009 7

11/13/2009 8

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.

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.

11/13/2009 9

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.

11/13/2009 10

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 feverc. Viral infectiond. Otitis mediae. Lower respiratory tract infection (LRTI)f. Meningitis

11/13/2009 11

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 feverc. Viral infectiond. Otitis mediae. Lower respiratory tract infection (LRTI)f. Meningitisg. TonsillitisThe 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.

11/13/2009 12

11/13/2009 13

Regarding nappy rash in infants, which of the following is the most important causative microorganism? Select ONE answer only.a. Staphylococcus aureusb. Methicillin resistant S. aueus (MRSA)c. Escherichia colid. Candida albicanse. Pseudomonasf. Streptococcusg. Proteus

11/13/2009 14

Regarding nappy rash in infants, which of the following is the most important causative microorganism? Select ONE answer only.a. Staphylococcus aureusb. Methicillin resistant S. aueus (MRSA)c. Escherichia colid. Candida albicanse. Pseudomonasf. Streptococcusg. 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.

11/13/2009 15

Which of the following is NOT a risk factor for development and progression of diabetic retinopathy? Select ONE answer onlya. Poor glycaemic controlb. Raised blood pressure (BP)c. Raised triglyceride levelsd. Raised cholesterol levelse. Presence of microalbuminuria and proteinuria

11/13/2009 16

Which of the following is NOT a risk factor for development and progression of diabetic retinopathy? Select ONE answer onlya. Poor glycaemic controlb. Raised blood pressure (BP)c. Raised triglyceride levelsd. Raised cholesterol levelse. 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.

11/13/2009 17

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.

11/13/2009 18

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.

Regarding acute angle closure glaucoma, which THREE of the following are risk factors? Select THREE answers only.a) Hypermetropiab) Myopiac) Amblyopiad) Caucasian descente) Asian descentf) Afro-Caribbean descentg) Previous attack in the other eye

11/13/2009 19

Regarding acute angle closure glaucoma, which THREE of the following are risk factors? Select THREE answers only.a) Hypermetropiab) Myopiac) Amblyopiad) Caucasian descente) Asian descentf) Afro-Caribbean descentg) Previous attack in the other eyeThe 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.

11/13/2009 20

11/13/2009 21

Regarding the following infectious organisms...a. Staphylococcus aureusb. Chlamydia trachomatisc. Trichomonas vaginalis d. Candida albicanse. Pseudomonasf. Streptococcus pneumonieg. Proteus speciesh. Dermatophytesi. Enterobius vermicularisFor 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.

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.

11/13/2009 22

Regarding the following infectious organisms...a. Staphylococcus aureusb. Chlamydia trachomatisc. Trichomonas vaginalis d. Candida albicanse. Pseudomonasf. Streptococcus pneumonieg. Proteus speciesh. Dermatophytesi. 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.

11/13/2009 23

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.

11/13/2009 24

Regarding the following infectious organisms...a. Staphylococcus aureusb. Chlamydia trachomatisc. Trichomonas vaginalis d. Candida albicanse. Pseudomonasf. Streptococcus pneumonieg. Proteus speciesh. Dermatophytesi. 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).

11/13/2009 25

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.

11/13/2009 26

Regarding the known side effects of the following drugs...a. Simvastatinb. Ramiprilc. Prednisoloned. Celecoxibe. Methotrexatef. Isotretinoing. Dermovateh. Minocyclinei. 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.

11/13/2009 27

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.

11/13/2009 28

Regarding the known side effects of the following drugs...a. Simvastatinb. Ramiprilc. Prednisoloned. Celecoxibe. Methotrexatef. Isotretinoing. Dermovateh. Minocyclinei. 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.

11/13/2009 29

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.

11/13/2009 30

Regarding the known side effects of the following drugs...a. Simvastatinb. Ramiprilc. Prednisoloned. Celecoxibe. Methotrexatef. Isotretinoing. Dermovateh. Minocyclinei. 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.

11/13/2009 31

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.

11/13/2009 32

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.

11/13/2009 33

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.

11/13/2009 34

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 Hgb. <150/90 mm Hgc. <145/85 mm Hgd. <145/90 mm Hge. <150/85 mm Hg

11/13/2009 35

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.

11/13/2009 36

Which ONE of the following drugs is associated with the highest increased risk of suicide in adolescents AND adults? a. Fluoxetineb. Citalopramc. Venlafaxined. Paroxetinee. Duloxetine

11/13/2009 37

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.

11/13/2009 38

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.

11/13/2009 39

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.

11/13/2009 40

Developmental milestones in children include the following.a. Startled by loud soundsb. 20 words in the vocabulary (monolingual child)c. Responds to name and mimics environmental soundsd. First meaningful wordse. Follows commands and performs simple tasksf. 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 months12 months18 months

11/13/2009 41

Developmental milestones in children include the following.a. Startled by loud soundsb. 20 words in the vocabulary (monolingual child)c. Responds to name and mimics environmental soundsd. First meaningful wordse. Follows commands and performs simple tasksf. 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 months12 months18 months

11/13/2009 42

Developmental milestones in children include the following.a. Startled by loud soundsb. 20 words in the vocabulary (monolingual child)c. Responds to name and mimics environmental soundsd. First meaningful wordse. Follows commands and performs simple tasksf. Localises soundsMatch 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 F12 months D18 months EImportant 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)

11/13/2009 43

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).

11/13/2009 44

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).

11/13/2009 45

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 spondylitisb. Juvenile rheumatoid arthritisc. Psoriasisd. Reactive arthritise. Systemic sclerosisf. Myasthenia gravis

11/13/2009 46

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 spondylitisb. Juvenile rheumatoid arthritisc. Psoriasisd. Reactive arthritise. Systemic sclerosisf. Myasthenia gravisThe 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.

11/13/2009 47

Regarding the following women's health issues.a. Vaginosisb. Vaginismusc. Ectopic pregnancyd. Pelvic inflammatory disease (PID)e. Bartholin's cystf. Polycystic ovarian syndrome (PCOS)g. Endometriosish. 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.

11/13/2009 48

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.

11/13/2009 49

Regarding the following women's health issues.a. Vaginosisb. Vaginismusc. Ectopic pregnancyd. Pelvic inflammatory disease (PID)e. Bartholin's cystf. Polycystic ovarian syndrome (PCOS)g. Endometriosish. 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.

11/13/2009 50

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.

11/13/2009 51

Regarding the following women's health issues.a. Vaginosisb. Vaginismusc. Ectopic pregnancyd. Pelvic inflammatory disease (PID)e. Bartholin's cystf. Polycystic ovarian syndrome (PCOS)g. Endometriosish. 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

11/13/2009 52

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.

11/13/2009 53

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) inhibitorsb. Thiazide diureticsc. Angiotensin receptor blockersd. Beta Blockerse. Calcium channel blockers

11/13/2009 54

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.

11/13/2009 55

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.

11/13/2009 56

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

11/13/2009 57

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

11/13/2009 58

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.

11/13/2009 59

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.

11/13/2009 60

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.

11/13/2009 61

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.

11/13/2009 62

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.

11/13/2009 63

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.

11/13/2009 64

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.

11/13/2009 65

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.

11/13/2009 66

The End

11/13/2009 67