Wednesday, 13 September 2017

APRIL 2017 Previous (solved) Paper IMM

APRIL 2017 Previous (solved) Paper IMM

Q11 A 45-year male patient with several years history of mental illness was seen replying to some person abusing him when nobody was around. At the same time, he also reports that he can see a young girl skipping a rope behind his back. During the conversation, he recalled events related to his father's accidental death & burial that occurred two months back but was mostly smiling while mentioning it. He was convinced that his wife is not faithful to him and is having an illicit relationship with one of his friends, although no evidence suggesting, this is available. During his assessment, he was found constantly imitating the actions performed by his doctor and believed that a cart carrying armed personnel will land in his room by making a hole in the roof and will take away all his valuables to another planet.

Name the psychological disturbances present in phenomenological terms.

Q12 Outline the neurobiology of neglect and abuse in childhood. Enumerate psychological consequences.

Q13 A 6-year-old boy has been brought to the ER with multiple bruises on face black eye and lacerated upper lip. His father reported that the boy fell from the stairs a week ago. The casualty medical officer suspected physical abuse and called you. How would you assess factors predicting the risk of abuse?

Q14 You have been asked to examine a 7 years old boy with a history of low birth weight, developmental delays, and soft hyperextensible joints.

What other findings will you look for in this case?
What two psychometric instruments would you like to use?
What would be the finding in psychometric testing?

Q15 A young man married a year ago has been referred to you with impotence
Enlist the areas you will explore in the sexual history of this patient.

Q16 A 25-year male, married six months back, presented with depressed mood, irritability, poor sleep and irregular on his job. He believed that his wife has illicit relations and is always searching for proof.
What are the provisional diagnoses?
What risk factors would you look for in personal history?
What informational care is essential to be passed on to the attendant of this patient prior to discharge?

Q17. A dermatologist has referred A 32 years old shopkeeper for psychiatric evaluation for disorientation and impaired memory. Dermatologist noted vesicles and bullae on extremities that were symmetrical and bilateral on sun-exposed part and stomatitis. His wife reported he had reduced his physical and mental stamina, become agitated and depressed often and vomiting and diarrhoea for the fast three months.

What relevant mental state examination finding would you look for?
What is the most likely diagnosis?
What will be your management in this case?

Q19 According to standard guidelines, what is the status of clozapine administration in case of pregnancy, lactation, epilepsy, and Diabetes mellitus?

Q20 The obstetric team has requested you to give an opinion on pharmacological management of a pregnant woman who has developed depressive episode in her first trimester of pregnancy. Answer the following questions as per the recommendation of Maudsley guidelines:

Enlist three safer antidepressant choices.

If she:

Uses lithium, what anomaly could occur?

Requires a mood stabiliser, which one you would advise?

Develops psychotic features. What three antipsychotics would you offer?

Require psychotropic drugs in the postpartum period, what antidepressant, antipsychotic and anxiolytic (one drug from each group) which you would advise?

Tuesday, 6 June 2017

Causes of school refusal in children

  • Physical illness (most common) 

  • Anxiety and depression 

  • Deliberately kept home by parents 

  • Truancy

  • Miserable conditions at school e.g. Bullying 

Summary of Treatment Guidelines for ADHD

Summary of Treatment Guidelines  for ADHD



AAP Treatment Recommendations Nov 2019  



Second line  

Preschool children (4-5 years)  

Behaviour therapy  



Methylphenidate, if no significant improvement and moderate-to-severe functional impairment  

Elementary school (6–11 years)  

Behaviour therapy or medication, preferably both.   


stimulants > atomoxetine > guanfacine ER > Clonidine ER  

Summary, NICE Treatment Recommendations 2018  



Second line  

Children under 5 years  


Group parent-training program  



(Only a specialist can start)  

Start medications only after seeking advice from ADHD specialist services  

Children over 5 years  

Discussion and ADHD-focused Support   



Offer a minimum of 1 or 2 sessions of support, can be  



education on the causes and impact of ADHD  

advice on parenting strategies liaison with school, parents, and carers  


 Before starting treatment, discuss with the carers  

The benefits of a healthy lifestyle, including exercise The benefits and harms of non-pharmacological and pharmacological treatments Their preferences and concerns How other conditions affect treatment choices  

Importance of treatment  


Record the person's preferences and concerns   

Ask if they wish a carer to join discussions  

Reassure that they can revisit decisions  


      Children over 5  


Lisdexamfetamine, after 6weeks trial off the methylphenidate   



A 9-year-old child presented to you in the outpatient department, brought by his mother who was concerned because of his poor performance at school, saying his brother and sister are much more competent. On enquiry, she revealed that the child seems absent-minded, repeatedly loses items, does not seem to listen when being talked to, is fidgety and keeps running and bouncing ‘as if driven by a motor.’ His academic report revealed ‘below-average performance’ and he scored of 90 Weschler intelligence scale for children. The rest of the assessment was unremarkable.   

What would be your recommendation?   

  1. Atomoxetine  

  1. Clonidine  

  1. Methylphenidate  

  1. Lisdexamfetamine  

  1. Psychosocial Interventions   


The scenario best depicts a mild case of attention deficit hyperactivity disorder (ADHD).  

Most patients will need psychosocial interventions and medications combined. However, the National Institute of Clinical Excellence recommends psychosocial interventions as the first choice of therapy. American Academy of paediatrics recommends psychosocial interventions as a primary treatment strategy for preschool children (4-5 years of age) and combined psychosocial and pharmacological treatments for older children. Both NICE and AAP recommend methylphenidate as the preferred medication if you must start one. Similarly, Canadian guidelines for the management of ADHD recommend psychosocial interventions before a trial of medication. They recommend methylphenidate and lisdexamfetamine as first-line medication. Nonetheless, patient individualization is important. For instance, if a patient has a comorbid tic disorder, clonidine will treat both the tic disorder and symptoms of ADHD, while stimulants may worsen the tics. Likewise, a patient with comorbid conduct disorder will need other specific interventions.   

The best answer would be psychosocial interventions. Please let us know your thoughts. We have summarized the Recommendations of AAP and NICE on the next page.  


  1. Canadian ADHD Resource Alliance (CADDRA). Canadian ADHD practise guidelines (CAP-guidelines) [Internet]. 3rd. Toronto: CADDRA; 2011.  

  1. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Paediatrics. 2011;128(5):1007-1022. doi:10.1542/peds.2011-2654  

  1. Overview | Attention deficit hyperactivity disorder: diagnosis and management | Guidance | NICE. (2018). Retrieved from    



Which one of these disorders can not coexist with Hyperactivity disorder (according to ICD classification)?
  1. Anxiety disorder
  2. Depression 
  3. Autism
  4. Conduct disorder

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