Behavioural Medicine – AKP

CORRECT ANSWER:

The clinical picture describes akathisia, a distressing extrapyramidal side effect characterised by a subjective feeling of inner restlessness and a compelling urge to be in constant motion.

This patient's report of feeling "jittery" and needing to "crawl out of my skin," combined with the objective finding of being unable to sit still, is a classic presentation. While SSRIs are commonly used, it is crucial as per good medical practice to recognise and differentiate akathisia from a simple activating effect or worsening anxiety. Misinterpreting this as a need for a higher dose can dangerously worsen the symptoms. The priority is recognising this as a medication side effect, considering dose reduction or cessation, and providing supportive management.

WRONG ANSWER ANALYSIS:

Option B (Serotonin Syndrome) is incorrect because it is a medical emergency characterised by a triad of autonomic instability (fever, tachycardia), altered mental status (confusion), and neuromuscular hyperactivity (clonus, hyperreflexia), which are not described here.

Option C (A normal activating effect) is less likely as the severity of the restlessness and the profound inner sense of unease are more intense than the mild initial jitteriness sometimes seen with SSRIs.

Option D (Worsening of her underlying anxiety) is a valid differential, but the distinct quality of motor restlessness and the classic description of feeling the need to crawl out of one's skin are pathognomonic for akathisia.

Option E (Acute dystonic reaction) is incorrect as it involves involuntary muscle contractions leading to abnormal postures or twisting movements (e.g., oculogyric crisis, torticollis), not the generalised restlessness seen in this patient.

CORRECT ANSWER:

The most likely diagnosis is Separation Anxiety Disorder. The clinical features are classic: the somatic symptoms (stomach aches, headaches) and school refusal are specifically triggered by the prospect of separation from his mother.

The core feature is the excessive and age-inappropriate fear related to this separation, which distinguishes it from other anxiety disorders. Crucially, his fear is not about school itself, but a specific, catastrophic worry about harm befalling his mother in his absence.

This pattern of anxiety, linked directly to the attachment figure and manifesting as physical symptoms to avoid the separation, is the hallmark of this diagnosis. According to NHS guidance, while anxiety is normal, it requires professional assessment when it interferes with school and home life, as seen here.

WRONG ANSWER ANALYSIS:

Option A (Generalised Anxiety Disorder) is incorrect because the boy's anxiety is focused specifically on separation from his mother, not on a wide range of issues or worries.

Option B (School Phobia) is less likely as his fear is not directed at the school environment, but is a manifestation of his anxiety about leaving his mother.

Option D (Bullying) is not the primary diagnosis because his stated fear is for his mother's safety, not a direct threat to himself at school.

Option E (Somatic Symptom Disorder) is incorrect because the somatic complaints are clearly secondary to, and explained by, the primary separation anxiety.

CORRECT ANSWER:

The NICE guideline for paediatric OCD recommends a clear stepped-care approach. The first-line treatment is psychological therapy, specifically Cognitive Behavioural Therapy (CBT) incorporating Exposure and Response Prevention (ERP).

In this case, the patient has engaged in an adequate trial of high-quality CBT (14 sessions) but has shown minimal improvement, indicating a partial or non-response. The next evidence-based step for moderate to severe OCD is to augment the ongoing psychological therapy with a Selective Serotonin Reuptake Inhibitor (SSRI).

Sertraline is a first-line SSRI choice in this age group. Combining pharmacology with CBT is synergistic and offers the best chance of improvement when CBT alone is insufficient. This approach continues the established therapeutic relationship and psychological strategies while introducing a new modality to manage symptoms.

WRONG ANSWER ANALYSIS:

Option A (Refer for inpatient admission) is incorrect because inpatient care is reserved for severe, treatment-refractory cases with significant risk, which is not indicated at this stage.

Option B (Switch to psychodynamic psychotherapy) is incorrect as it is not the evidence-based treatment for OCD and would involve discontinuing the recommended first-line therapy.

Option D (Stop CBT and try Sertraline alone) is incorrect because discontinuing effective psychological strategies is not recommended; the combination of CBT and an SSRI is superior to medication alone.

Option E (Refer for family therapy) is incorrect because while family involvement is crucial, specific family therapy is not the primary next step for a partial response to first-line individual CBT for OCD.

CORRECT ANSWER:

This adolescent presents with a discrete social phobia, commonly known as performance anxiety. The key here is that the anxiety is predictable and linked to a specific event.

Propranolol, a non-selective beta-blocker, is an effective short-term strategy because it primarily targets the peripheral physical (somatic) symptoms of anxiety, such as tachycardia, tremor, and sweating, by blocking the effects of adrenaline. It is taken on an as-needed basis approximately one hour before the stressful event.

This approach is ideal as it mitigates the physical manifestations without causing the sedation or cognitive impairment that could negatively affect his presentation. While not a long-term cure, it is a practical and evidence-based management tool for isolated performance anxiety.

WRONG ANSWER ANALYSIS:

Option A (Sertraline) is incorrect because SSRIs are a first-line treatment for generalised social anxiety disorder, but they require 4-6 weeks to reach therapeutic effect and are not suitable for immediate, short-term use.

Option B (Diazepam) is inappropriate as benzodiazepines cause sedation and cognitive dulling, which would impair performance during a presentation, and they carry a risk of dependency.

Option D (Refer for urgent CBT) is incorrect because while Cognitive Behavioural Therapy is the gold-standard treatment for social anxiety, it is a longer-term intervention and would not provide a solution for the crucial presentation in two weeks.

Option E (Reassure him and advise him to practice more) is insufficient as it dismisses the clinical significance of his debilitating symptoms and fails to provide an effective management strategy.

CORRECT ANSWER:

According to NICE guidelines for anxiety disorders in children and young people, when a high-quality psychological intervention like CBT has proven ineffective, pharmacological treatment should be considered.

Sertraline is the only SSRI with a UK license for treating anxiety disorders (specifically obsessive-compulsive disorder) in the paediatric population. Although the license is for OCD, it is recognised as the first-line licensed choice for broader anxiety disorders, such as GAD, when medication is indicated. This decision should always be made following a multidisciplinary review, ideally involving a child and adolescent psychiatrist. The principle is to use a licensed medication where available before considering off-label alternatives.

WRONG ANSWER ANALYSIS:

Option A (Fluoxetine) is incorrect as, while licensed for moderate to severe depression in children over 8, it does not hold a UK license for anxiety disorders in this age group.

Option B (Propranolol) is not a first-line treatment for GAD but may be used cautiously for short-term management of somatic symptoms of anxiety.

Option C (Diazepam) is a benzodiazepine and is not recommended for routine management of anxiety in children due to the significant risk of tolerance and dependence.

Option E (Citalopram) is generally avoided in children and adolescents due to concerns regarding cardiac side effects, specifically QTc interval prolongation.

CORRECT ANSWER:

This diagnosis is indicated by the history of recurrent, discrete episodes of intense fear that peak rapidly, within 10 minutes. The patient's presentation includes classic somatic symptoms of a panic attack (palpitations, chest tightness) and cognitive symptoms (fear of dying or "going crazy").

The sudden, paroxysmal nature of these events, in the context of a normal emergency evaluation including an ECG and blood tests, makes an underlying organic cause less probable. According to NICE guidelines, recognising these hallmark features is crucial for diagnosing panic disorder and differentiating it from other anxiety disorders or medical conditions. The key is the episodic and overwhelming nature of the symptoms, which is distinct from the persistent worry seen in other anxiety states.

WRONG ANSWER ANALYSIS:

Option A (Generalised Anxiety Disorder) is incorrect because GAD is characterised by chronic, excessive, and pervasive worry about multiple issues, rather than the acute, intense, and episodic attacks described.

Option C (Supraventricular Tachycardia) is less likely as the profound fear of "going crazy" is more typical of a panic attack, and the ECG in A&E was normal.

Option D (Phaeochromocytoma) is a very rare diagnosis and would typically present with sustained or paroxysmal hypertension and other signs of catecholamine excess, not just isolated panic-like episodes.

Option E (Acute asthma attack) is incorrect as the primary symptoms would be respiratory, such as wheeze and shortness of breath, which are not mentioned in the clinical vignette.

CORRECT ANSWER:

The most likely diagnosis is Selective Mutism. This is an anxiety disorder characterised by a consistent, situation-specific failure to speak in social settings where speaking is expected (e.g., school), despite the child being able to speak fluently in other, more comfortable situations (e.g., home).

The six-month duration meets the diagnostic criteria, which require symptoms to persist for at least one month. According to NICE guidelines, the clinical priority is to recognise that the behaviour is anxiety-driven, not a wilful refusal to speak or a pervasive language disorder.

The key to the diagnosis in this vignette is the clear discrepancy in verbal communication between the home and school environments, which is the hallmark of Selective Mutism. Management focuses on reducing anxiety and graded exposure, often involving collaboration between parents, the school, and mental health services.

WRONG ANSWER ANALYSIS:

Option A (Autistic Spectrum Disorder) is incorrect because the communication difficulties in ASD are typically pervasive and would be present across all settings, not just at school.

Option B (Separation Anxiety Disorder) is less likely as the core feature is excessive distress concerning separation from attachment figures, not a specific failure to speak.

Option C (Oppositional Defiant Disorder) is incorrect because the child's silence stems from anxiety and fear, not from a pattern of defiant, hostile, and disobedient behaviour.

Option E (Childhood-onset psychosis) is not indicated, as this rare condition would present with features of disordered thought, such as hallucinations or delusions, which are not described.

CORRECT ANSWER:

The clinical presentation aligns perfectly with the core diagnostic criteria. The key features are excessive, uncontrollable worry about a number of different events or activities, occurring more days than not for at least six months.

In this adolescent, the worry is pervasive, covering school, health, and friendships, rather than being focused on a single trigger. Furthermore, the presence of associated somatic and psychological symptoms, such as irritability, sleep disturbance, and muscle tension, is crucial. According to NICE guidelines, this combination of chronic, widespread anxiety and associated functional impairment is characteristic of GAD, distinguishing it from other anxiety disorders and normal developmental worries.

WRONG ANSWER ANALYSIS:

Option B (Obsessive-Compulsive Disorder) is incorrect as the history lacks any mention of specific obsessions or compulsions, which are the defining features of OCD.

Option C (Panic Disorder) is less likely because the primary feature is constant worry, not the recurrent, unexpected panic attacks that characterise a panic disorder.

Option D (Social Anxiety Disorder) is not the best fit because the patient's anxiety is broad and not confined to social or performance-related situations.

Option E (Normal teenage worry) is incorrect because the duration of six months and the presence of significant physical symptoms and functional impairment indicate a clinical disorder, not typical adolescent stress.

CORRECT ANSWER:

This patient presents with classic features of catatonia secondary to his bipolar disorder. The "Lorazepam Challenge" is the first-line diagnostic and therapeutic step.

Catatonia is a neuropsychiatric emergency, and the patient's refusal to eat or drink poses a significant risk of dehydration and metabolic disturbance. An IV or IM dose of lorazepam (1-2mg) provides rapid, albeit often temporary, resolution of motor symptoms in responsive patients, typically within 5-15 minutes. This positive response confirms the diagnosis and initiates treatment simultaneously, making it the priority. British Association for Psychopharmacology guidelines recommend benzodiazepines as the first-line pharmacological treatment for catatonia.

WRONG ANSWER ANALYSIS:

Option A (Administer IV Haloperidol 5mg) is incorrect as first-generation antipsychotics can worsen catatonia and precipitate neuroleptic malignant syndrome (NMS).

Option C (An urgent CT head scan) is incorrect because while organic causes must be considered, the presentation in a patient with known severe mental illness makes catatonia the most likely diagnosis, and immediate treatment is the priority over imaging.

Option D (Send for urgent Electroconvulsive Therapy (ECT)) is incorrect as ECT is a highly effective, second-line treatment, used only after a benzodiazepine trial has proven insufficient.

Option E (Administer 3% hypertonic saline) is incorrect as there is no clinical evidence in the vignette to suggest hyponatraemia; the symptoms are not primarily metabolic.

CORRECT ANSWER:

Risperidone-induced hyperprolactinaemia is a common and expected finding, resulting from dopamine D2 receptor antagonism. The cornerstone of management is guided by the patient's symptoms, not solely the laboratory value.

Most guidelines do not recommend routine prolactin monitoring in asymptomatic patients. Since the patient is benefiting from the medication for his behavioural disturbance and has no clinical features of hyperprolactinaemia (such as gynaecomastia, galactorrhoea, or delayed puberty), the clinical priority is to maintain his behavioural stability. The most appropriate action is therefore to continue the effective treatment while monitoring him clinically for any emerging symptoms. This approach correctly balances the therapeutic benefits of risperidone against the potential, but currently absent, side effects.

WRONG ANSWER ANALYSIS:

Option A (Stop Risperidone immediately) is incorrect because sudden withdrawal of an effective antipsychotic risks severe behavioural relapse and is not warranted for an asymptomatic biochemical abnormality.

Option B (Add cabergoline to lower the prolactin) is incorrect as dopamine agonists are reserved for symptomatic hyperprolactinaemia and their use can risk worsening underlying psychotic symptoms.

Option C (Switch to Aripiprazole) is incorrect as an immediate step; while aripiprazole is a prolactin-sparing option, switching an effective medication in a stable, asymptomatic patient is unnecessary and introduces the risk of clinical destabilisation.

Option E (Refer to Endocrinology) is incorrect because the cause is clearly iatrogenic and specialist referral is only needed if symptoms develop, levels are extremely high, or an alternative diagnosis like a prolactinoma is suspected.

CORRECT ANSWER:

The choice of an antipsychotic in an adolescent requires a careful balance between efficacy and long-term side effects. Aripiprazole, a second-generation antipsychotic, is often a preferred first-line agent in this population.

Its mechanism as a partial agonist at dopamine D2 receptors and serotonin 5-HT1A receptors provides effective treatment for psychosis while mitigating the risk of adverse effects. Specifically, it has a lower propensity to cause hyperprolactinaemia, which is a significant concern with other antipsychotics and can lead to gynaecomastia and sexual dysfunction.

Furthermore, it carries a reduced risk of metabolic syndrome, including significant weight gain and glucose dysregulation, which are crucial considerations for the lifelong health of a young person commencing long-term therapy. NICE guidance supports considering the adverse effect profile when choosing an antipsychotic, making Aripiprazole a judicious initial choice.

WRONG ANSWER ANALYSIS:

Option A (Olanzapine) is less appropriate due to its very high risk of causing significant weight gain and metabolic syndrome.

Option B (Risperidone) is a less suitable first choice because it carries a particularly high risk of causing hyperprolactinaemia.

Option C (Haloperidol) is incorrect as this is a first-generation antipsychotic with a high propensity for causing distressing extrapyramidal side effects.

Option E (Chlorpromazine) is incorrect because this older, low-potency typical antipsychotic has a significant burden of sedative and anticholinergic side effects.

CORRECT ANSWER:

The triad of new-onset psychosis, confusion, and seizures in a previously well adolescent is a classic presentation of autoimmune encephalitis, most notably Anti-NMDAR receptor encephalitis. National guidance and expert consensus stress the importance of considering organic causes in first-episode psychosis, especially with atypical features like seizures.

This is a time-critical neurological emergency. Delaying the specific diagnostic test for Anti-NMDAR antibodies can lead to significant morbidity, as early treatment with immunotherapy offers the best chance of a good outcome. While other investigations are part of a comprehensive workup, identifying a treatable autoimmune cause is the most critical initial step to guide immediate, specific therapy.

WRONG ANSWER ANALYSIS:

Option B (Karyotype for 22q11 deletion) is incorrect because although 22q11 deletion syndrome is associated with psychosis, the presentation is typically more insidious and a seizure is not a classic feature.

Option C (Urine for organic acids) is incorrect as organic acidurias usually present in infancy or early childhood with metabolic decompensation, not with this acute neuropsychiatric syndrome in a 14-year-old.

Option D (Serum copper/caeruloplasmin) is incorrect because while Wilson's disease can cause neurological and psychiatric symptoms, the acute onset of psychosis with a seizure makes it a less likely primary diagnosis.

Option E (EEG) is incorrect because although an EEG is an important investigation that will likely be abnormal, it is not the most critical diagnostic test; it can support the diagnosis of encephalitis (e.g., showing an 'extreme delta brush' pattern) but is less specific than antibody testing.

CORRECT ANSWER:

The clinical presentation is a classic triad of acute behavioural disturbance, visual hallucinations, and significant sympathomimetic features (hypertension, tachycardia, mydriasis). This is highly suggestive of a substance-induced psychosis, likely from stimulants such as cocaine, amphetamines, or synthetic cathinones.

According to NICE guidance, it is crucial to assess for coexisting substance misuse in presentations of psychosis. A urine toxicology screen is the most important initial investigation because it provides rapid, objective evidence to confirm the underlying cause. This is a critical step in decision-making, as it directly informs immediate management, including the choice of sedation and the need for specific supportive care to mitigate cardiovascular risks. Identifying the substance helps differentiate this from a primary psychotic illness, which would have a different management pathway.

WRONG ANSWER ANALYSIS:

Option A (12-lead ECG) is incorrect because while it is an important investigation given the tachycardia and hypertension, identifying the toxicological cause is the immediate priority to guide management.

Option C (CT head scan) is incorrect because it is not indicated first-line without a history of head trauma, focal neurological signs, or persistent altered mental state once the metabolic and toxic causes are excluded.

Option D (Serum prolactin level) is incorrect as it has no role in the acute diagnosis of psychosis and is typically used to investigate non-convulsive seizures or monitor side effects of antipsychotic medication.

Option E (Full blood count) is incorrect because although it is a useful baseline test, it is very unlikely to reveal the primary diagnosis in this acute sympathomimetic crisis.

CORRECT ANSWER:

This patient presents with a classic triad of first-episode psychosis (FEP). The 3-week duration of significant psychotic symptoms necessitates an urgent specialist assessment.

NICE guideline CG155 is explicit that children and young people (from age 14) with a suspected FEP should be referred urgently to a dedicated Early Intervention in Psychosis (EIP) team. These multidisciplinary teams are specifically commissioned to provide intensive assessment and a comprehensive package of care, including medication, cognitive behavioural therapy (CBTp), and family interventions.

Early and intensive specialist management is critical as it is proven to improve long-term clinical outcomes and reduce the duration of untreated psychosis.

WRONG ANSWER ANALYSIS:

Option A (Refer to community CAMHS for CBT) is incorrect because while CAMHS is a specialist service, the EIP team holds the specific expertise and resources for the intensive management required in FEP.

Option B (Start fluoxetine for potential depressive-psychosis) is incorrect as initiating an antidepressant without a specialist psychiatric assessment is inappropriate, and antipsychotics, not SSRIs, are the primary pharmacological treatment for psychosis.

Option D (Admit to the paediatric ward for observation) is incorrect because a general paediatric ward is not a therapeutic environment for managing acute mental illness and lacks the required psychiatric expertise.

Option E (Reassure parents this is likely stress-related) is incorrect as this approach dangerously minimises clear psychotic symptoms, delaying essential treatment and potentially worsening the long-term prognosis.

CORRECT ANSWER:

The most significant risk is increased bleeding. Selective serotonin reuptake inhibitors (SSRIs) like sertraline impair platelet function.

Platelets require serotonin for normal aggregation and activation, but they cannot synthesise it themselves, relying on uptake from plasma via the serotonin transporter (SERT). By blocking SERT, SSRIs deplete intra-platelet serotonin stores, leading to a state of platelet dysfunction. This is particularly relevant in procedures like dental extractions where haemostasis is critical.

While routine screening for this is not standard, awareness of the potential for prolonged bleeding is a key safety consideration. The clinical priority is to anticipate this risk, ensure adequate local haemostatic measures are available, and advise the patient on postoperative monitoring for excessive bleeding or bruising.

WRONG ANSWER ANALYSIS:

Option A (Increased risk of QTc prolongation with local anaesthetic) is less likely, as although some SSRIs can affect the QTc interval, sertraline has a lower risk, and the systemic absorption of local anaesthetic is minimal.

Option C (Risk of precipitating Serotonin Syndrome) is incorrect because Serotonin Syndrome is typically caused by combining multiple serotonergic agents, not by a dental procedure under local anaesthetic.

Option D (Risk of poor wound healing and infection) is not the primary concern; while theoretical links exist, the immediate and well-established pharmacological risk is bleeding.

Option E (Risk of hyponatraemia post-procedure) is a recognised side effect of SSRIs (via SIADH) but is not an acute risk precipitated by a minor surgical event like a dental extraction.

CORRECT ANSWER:

The clinical presentation is highly suggestive of depression, which has a significant co-morbidity with chronic illnesses like Type 1 Diabetes. The patient's anhedonia and disengagement ("not caring") are classic features of a depressive episode, which is directly impacting his self-management and leading to poor glycaemic control.

NICE guidelines for diabetes in children and young people emphasise the importance of ongoing access to psychological support. The most critical first step is to formally assess his mental state. Using a validated screening tool is an objective and structured way to confirm the presence and severity of depressive symptoms. This assessment is essential to guide further management, which may include referral to Child and Adolescent Mental Health Services (CAMHS). Addressing the underlying psychological distress is paramount to re-engaging him in his diabetes care.

WRONG ANSWER ANALYSIS:

Option A (Admit for a variable-rate insulin infusion) is incorrect because it only addresses the immediate hyperglycaemia without tackling the root cause of the poor control, which appears to be psychological.

Option C (Change his insulin regimen to a simpler, twice-daily one) is inappropriate as it may compromise glycaemic control further and does not address the primary issue of burnout and low mood.

Option D (Refer him to social services for neglect) is incorrect as the problem is the adolescent's self-neglect secondary to his mental state, not neglect by his carers.

Option E (Start him on fluoxetine) is premature because medication should only be considered after a formal diagnostic assessment for depression has been completed.

CORRECT ANSWER:

The 6-month duration of symptoms following the bereavement is a key factor. While grief is a normal process, its persistence beyond several months, coupled with core depressive symptoms, indicates a transition to a pathological state.

According to NICE guidance, a major depressive disorder should be considered in a young person with persistent low mood. The presence of pervasive anhedonia (loss of interest or pleasure) and cognitions of worthlessness ("being a burden") are particularly significant. These features are not typical of a normal grief reaction, where self-esteem is usually preserved.

In grief, sadness often comes in waves, whereas in depression, the negative mood is more constant. The combination of symptom duration and specific "red flag" cognitions makes Major Depressive Disorder, or the closely related Prolonged Grief Disorder, the most appropriate diagnosis, necessitating a formal mental health assessment.

WRONG ANSWER ANALYSIS:

Option A (Normal grief reaction) is incorrect because the presence of persistent feelings of worthlessness and anhedonia at 6 months extends beyond the typical features of grief.

Option B (Adjustment disorder) is less likely as the symptoms meet the full criteria for a major depressive episode, which would take diagnostic precedence.

Option D (Post-Traumatic Stress Disorder) is not the primary diagnosis as the core symptoms described are of low mood and worthlessness, not re-experiencing, avoidance, or hyperarousal related to the death.

Option E (Anxiety-based school refusal) is incorrect because the clinical focus is on pervasive low mood and anhedonia, not a specific phobia or anxiety related to attending school.

CORRECT ANSWER:

The emergence or worsening of suicidal ideation with the formation of a specific plan constitutes a psychiatric emergency. National Institute for Health and Care Excellence (NICE) guidelines stipulate that any young person presenting with a high risk of suicide requires an immediate, same-day referral to a specialist Child and Adolescent Mental Health Service (CAMHS).

The absolute priority is an expert assessment of risk, the formulation of a robust safety plan, and a decision regarding the appropriate environment for care, which may include hospital admission. While an initial increase in suicidal thoughts is a known risk with SSRIs in this age group, the immediate life-preserving action is to ensure patient safety through specialist crisis intervention. Any decisions about medication are secondary to this and should be made by the specialist team.

WRONG ANSWER ANALYSIS:

Option A (Increase the fluoxetine dose) is incorrect because this may paradoxically worsen agitation and suicidality and fails to address the immediate safety risk.

Option B (Stop the fluoxetine and switch to sertraline) is incorrect as another SSRI carries a similar risk profile initially, and changing medication is secondary to a thorough risk assessment by CAMHS.

Option D (Reassure him this is a temporary side effect) is incorrect because it dangerously minimises a life-threatening presentation that requires urgent specialist intervention, not simple reassurance.

Option E (Add a low dose of olanzapine) is incorrect as adding an antipsychotic without a specialist psychiatric assessment and diagnosis is inappropriate in this acute emergency setting.

CORRECT ANSWER:

For young people aged 12-18 with moderate to severe depression, NICE guidelines recommend a specific stepped-care approach. Psychological therapy, such as CBT, is the initial treatment of choice.

However, when this is declined or proves ineffective, pharmacological treatment should be considered, always in combination with ongoing psychological support. Fluoxetine is the only antidepressant with a UK marketing authorisation for treating depression in under-18s, as it has the most robust evidence base demonstrating that its benefits outweigh the risks in this age group.

The decision to start an antidepressant must be made following assessment by a child and adolescent psychiatrist. Therefore, in this case of severe depression where CBT has been refused, initiating fluoxetine alongside attempts to engage in therapy is the correct next step.

WRONG ANSWER ANALYSIS:

Option A (Sertraline) is incorrect because, while it may be considered by specialists for non-response to fluoxetine, it is not the recommended first-line agent for depression in adolescents.

Option B (Citalopram) is incorrect as it is generally avoided as a first-line choice due to a lack of evidence for its efficacy and concerns about potential cardiac side effects (QTc prolongation) in this age group.

Option D (Venlafaxine) is incorrect because this SNRI is not a first-line treatment for depression in young people and is associated with a less favourable side-effect profile and significant discontinuation symptoms.

Option E (Mirtazapine) is incorrect as it is not licensed for paediatric depression and is typically reserved for specialist use, often targeting specific symptoms like insomnia, rather than as a primary antidepressant.

CORRECT ANSWER:

According to NICE guideline NG222 (Depression in children and young people), a stepped-care model is advocated. For a 15-year-old with moderate depression, as indicated by a PHQ-9 score of 10-14, the first-line management is a specific brief psychological therapy.

This typically involves 6-8 sessions of cognitive behavioural therapy (CBT), interpersonal therapy, or counselling. This approach prioritises the least intrusive, evidence-based intervention, recognising the psychosocial context of adolescent mental health. Pharmacological treatment is generally reserved for cases of moderate-to-severe depression that have not responded to psychological therapies, or where it is the patient's preference after a thorough discussion of the risks and benefits.

This patient requires active, evidence-based treatment, and psychological therapy is the recommended initial step.

WRONG ANSWER ANALYSIS:

Option A (Start fluoxetine 10mg daily) is incorrect because medication is not the first-line treatment for moderate depression and is typically considered only after a trial of psychological therapy.

Option C (Watchful waiting with a review in 4 weeks) is incorrect as it is only appropriate for subthreshold or very mild symptoms, whereas a PHQ-9 of 12 necessitates active intervention.

Option D (Start sertraline 25mg daily) is incorrect because not only is medication not first-line, but fluoxetine is the only SSRI licensed for treating depression in this age group in the UK.

Option E (Refer for formal family therapy) is incorrect as a first-line intervention for the individual's depression, as specific individual therapies like CBT are recommended initially.

CORRECT ANSWER:

The Mental Health Act (MHA) 1983 is the correct legal framework. At 17, this patient is treated as an adult under the MHA.

Her refusal of life-sustaining treatment is a direct manifestation of her severe mental disorder, Anorexia Nervosa. Given her life-threatening physical state (BMI 14, hypokalaemia), compulsory treatment is justified to prevent her death.

The MHA is specifically designed to allow for assessment, and if necessary, detention and treatment for a mental disorder, even if the patient has capacity to refuse. National guidance supports the use of the MHA when a young person with a severe eating disorder refuses essential treatment. This approach prioritises the preservation of life when judgement is critically impaired by a treatable mental illness.

WRONG ANSWER ANALYSIS:

Option B (Mental Capacity Act 2005) is incorrect because the patient is stated to have capacity, whereas the MCA is used for those who lack it.

Option C (Common Law) is incorrect as it is superseded by the specific statutory provision of the Mental Health Act for this scenario.

Option D (Children Act 1989) is incorrect because a 17-year-old with capacity cannot be overruled by parental consent.

Option E (Gillick competence assessment) is incorrect because it applies to assessing capacity in those under 16, and this patient's capacity is already established.

CORRECT ANSWER:

This presentation is highly suggestive of Gaming Disorder, a condition recognised in the ICD-11. The history indicates a persistent pattern of gaming behaviour leading to significant impairment in personal, family, and educational functioning.

The priority is a comprehensive assessment by a specialist Child and Adolescent Mental Health Service (CAMHS). National guidance and best practice for complex mental health presentations in young people emphasise a holistic evaluation to confirm the diagnosis and, crucially, to assess for common co-morbidities such as anxiety, depression, or ADHD, which frequently co-exist and require management.

This specialist assessment will also guide the formulation of a family-based therapeutic strategy, which is the cornerstone of management. The NHS has recognised the severity of this issue by establishing a National Centre for Gaming Disorders, which accepts referrals for children from age 13.

WRONG ANSWER ANALYSIS:

Option A (Prescribe methylphenidate) is incorrect because it presumes an ADHD diagnosis without a proper assessment, and medication is not the first-line treatment for Gaming Disorder itself.

Option B (Refer to social services) is incorrect as the parents are actively seeking help and showing appropriate concern, meaning there is no immediate safeguarding trigger for neglect.

Option C (Recommend a "digital detox") is incorrect because abrupt removal of devices is often counter-productive, leading to intense conflict and potentially worsening underlying issues without addressing the root cause.

Option E (Admit for inpatient detoxification) is incorrect as this is a drastic step reserved for severe substance addictions with physical withdrawal syndromes, which is not a feature of Gaming Disorder.

CORRECT ANSWER:

While bereavement is a normal life event, this adolescent's presentation at 8 months has features concerning for a major depressive episode or prolonged grief disorder.

The presence of core depressive symptoms, including anhedonia and feelings of worthlessness, coupled with significant functional impairment (school refusal), extends beyond a typical grief reaction. National Institute for Health and Care Excellence (NICE) guidance for depression in children and young people advocates for a specialist mental health assessment in cases of moderate to severe depression or where there is diagnostic uncertainty.

A referral to Child and Adolescent Mental Health Services (CAMHS) is the crucial next step to establish a formal diagnosis, assess risk, and formulate a comprehensive management plan, which may include psychological therapies and, if appropriate, medication.

WRONG ANSWER ANALYSIS:

Option A (Reassure that this is a normal part of the grieving process) is incorrect because it risks minimising a potentially serious mood disorder that requires active intervention.

Option C (Advise the school to give him 3 months off) is incorrect as this promotes avoidance and social withdrawal, which are likely to exacerbate his symptoms rather than address the underlying cause.

Option D (Start low-dose fluoxetine immediately) is incorrect because antidepressant medication should only be initiated following a specialist assessment and diagnosis, and typically in conjunction with psychological therapy.

Option E (Refer for family therapy) is incorrect because while potentially beneficial as part of a wider care plan, the immediate priority is a thorough psychiatric assessment of the individual adolescent to determine the primary diagnosis.

CORRECT ANSWER:

The paediatrician's primary role at the health-justice interface is to advocate for the child's health and wellbeing. For a child with neurodevelopmental disorders like ADHD and ODD, this involves providing a specialist report for the Youth Offending Team and the court.

This report is crucial as it explains how the young person's conditions affect their executive functions, such as impulse control, understanding of consequences, and decision-making. This directly informs the legal concept of 'mens rea' (the intention or knowledge of wrongdoing). The report should also recommend practical adjustments, such as the provision of an 'appropriate adult' during interviews and court proceedings, and suggest tailored community-based interventions instead of punitive measures, aligning with the 'Child First' principle in the youth justice system.

WRONG ANSWER ANALYSIS:

Option A (Provide a character reference for the court) is incorrect because a character reference is subjective and less impactful than an objective, evidence-based medical report detailing the child's specific neurodevelopmental challenges.

Option B (Prescribe a sedative to manage his behaviour) is incorrect as it is clinically inappropriate and unethical to sedate a child for non-medical reasons related to criminal behaviour.

Option D (Liaise with his parents to arrange a solicitor) is incorrect because while important, arranging legal representation is the responsibility of the parents or carers, not the paediatrician.

Option E (Refuse to provide information due to confidentiality) is incorrect because while confidentiality is vital, it can be overridden when there is a legal requirement and it is in the public interest and the child's best interest to share relevant clinical information with the justice system.

CORRECT ANSWER:

The cornerstone of managing mild, non-impairing tics in a child who is not distressed by them is psychoeducation and watchful waiting. National guidance and clinical consensus support a stepped-care approach.

The priority is to provide reassurance and information to the child, family, and school, explaining the waxing and waning nature of tics and the high likelihood of spontaneous improvement. This demystifies the condition, reduces anxiety, and prevents secondary psychosocial problems that can arise from negative reactions to the tics. Drawing attention to tics can make them worse. Since the child is functioning well academically and socially, and the school is supportive, there is no indication for active behavioural or pharmacological intervention. This conservative approach avoids unnecessary side effects from medication and empowers the family to manage the condition supportively.

WRONG ANSWER ANALYSIS:

Option A (Start a low dose of Aripiprazole) is incorrect because pharmacotherapy is reserved for severe tics causing significant functional impairment, pain, or distress, which is not the case here.

Option B (Refer for Habit Reversal Therapy) is less appropriate as behavioural therapies are typically initiated when tics are problematic for the child, whereas this boy is not bothered by them.

Option D (Start a low dose of Clonidine) is incorrect for the same reason as option A; medication is not indicated for mild, non-impairing tics.

Option E (Refer for a 24-hour video-EEG) is incorrect as the diagnosis of Tourette's is clinical, based on history and examination, and EEG is not required to investigate simple or complex tics.

CORRECT ANSWER:

Harmful sexualised behaviour that is graphic and directed towards others is highly atypical for an 8-year-old and is a significant safeguarding concern.

National guidance from bodies like NICE and the RCPCH emphasises that such behaviour is often a sign that the child has been a victim of, or witness to, sexual abuse. The immediate priority is therefore a safeguarding referral to children's social care. This initiates a multi-agency assessment to ensure the child's safety and investigate the underlying cause of the behaviour.

While therapeutic and educational interventions will be necessary, they cannot proceed safely or effectively until the child's environment has been assessed and any ongoing abuse is stopped. The core clinical duty is to first protect the child from harm.

WRONG ANSWER ANALYSIS:

Option A (An urgent referral to CAMHS for play therapy) is incorrect because while mental health support is vital, it is secondary to ensuring the child's immediate safety through safeguarding procedures.

Option C (An assessment for Autistic Spectrum Disorder) is incorrect as, although children with ASD can display inappropriate behaviours, this presentation is a specific red flag for sexual abuse which must be prioritised.

Option D (A prescription for risperidone to manage the behaviour) is incorrect because medicating the behaviour without understanding its origin is clinically inappropriate and fails to address the potential underlying trauma or abuse.

Option E (A recommendation to the school to exclude the child) is incorrect as it punishes a potential victim, fails to address the root cause, and misses a critical opportunity for protection and intervention.

CORRECT ANSWER:

National Institute for Health and Care Excellence (NICE) guideline NG225 is unequivocal: any child or young person who has self-harmed must be offered a psychosocial assessment by a specialist mental health professional before discharge.

This is a critical step to evaluate the young person's mental state, understand the drivers for the overdose, assess the immediate risk of further self-harm, and formulate a comprehensive and safe management plan. Given this is her second overdose, her risk of repetition is significantly elevated, making it unsafe to discharge without this specialist input from the Child and Adolescent Mental Health Services (CAMHS) RAID team.

This assessment is the cornerstone of safe and effective care and must precede any discharge decisions.

WRONG ANSWER ANALYSIS:

Option A (Discharge her to her parents with a 2-week GP follow-up) is incorrect as it fails to address the immediate, high-risk nature of repeat self-harm and bypasses the mandated specialist mental health assessment.

Option B (Discharge her with a "no harm" contract and a CAMHS outpatient appointment) is inappropriate because so-called 'no harm' contracts are not recommended by NICE and an outpatient appointment does not mitigate the immediate risk prior to leaving the hospital.

Option D (Start her on Fluoxetine 20mg and discharge her) is incorrect as prescribing an SSRI without a formal psychiatric assessment and diagnosis is clinically inappropriate and potentially dangerous in this acute context.

Option E (Refer to social services for consideration of foster care) is incorrect because while safeguarding is a key consideration, the immediate priority is the urgent mental health risk assessment by CAMHS, which will inform any necessary social care involvement.

CORRECT ANSWER:

NICE guidance for managing ODD in children aged 3-11 years recommends a group-based parent-training programme as the first-line intervention. This approach is based on a social learning model and has the strongest evidence base for improving child behaviour and parent-child relationships.

These programmes equip parents with behavioural strategies to manage defiant behaviours consistently. They typically involve 10-16 weekly sessions and focus on using modelling, rehearsal, and feedback to enhance parenting skills. The primary goal is to de-escalate conflict, promote positive interactions, and establish clear, consistent boundaries, which directly addresses the core features of ODD.

By empowering the parents, the child's environment is changed to one that supports positive behavioural change, making it the most effective initial step.

WRONG ANSWER ANALYSIS:

Option A (A trial of methylphenidate for underlying ADHD) is incorrect because medication is not the first-line treatment for ODD itself, and ADHD has not been diagnosed.

Option B (Individual play therapy for the child to express his anger) is incorrect as there is less evidence for its effectiveness as a sole first-line treatment compared to parent-led behavioural strategies.

Option D (Referral for family therapy) is incorrect because while it may be useful for complex cases, structured parent training is the specific, evidence-based initial intervention recommended by NICE.

Option E (A referral to social services for respite care) is incorrect as this does not address the underlying behavioural issues and is not a therapeutic intervention.

CORRECT ANSWER:

Selective mutism is an anxiety disorder where a child is consistently unable to speak in specific social situations, such as school, despite speaking fluently elsewhere.

The first-line management, supported by clinical consensus, is a structured behavioural therapy programme implemented in the setting where the mutism occurs. Approaches like stimulus fading or graded exposure aim to gradually reduce the child's anxiety around speaking, starting with non-verbal communication and progressing towards speech in a supportive, non-pressured environment.

This intervention is prioritised because it directly addresses the underlying phobia and is evidence-based. It is often delivered in collaboration with the school and may be coordinated by Child and Adolescent Mental Health Services (CAMHS) or a specialist Speech and Language Therapist with expertise in selective mutism.

WRONG ANSWER ANALYSIS:

Option A (Reassure parents) is incorrect because the problem has persisted for six months, indicating an established anxiety disorder requiring active intervention rather than watchful waiting.

Option B (An urgent assessment for Autistic Spectrum Disorder) is incorrect because, while communication difficulties can co-exist, the history is classic for selective mutism, which is the primary diagnosis to manage first.

Option D (A trial of an SSRI) is incorrect as pharmacotherapy is considered a second-line treatment, reserved for cases where behavioural interventions are insufficient or for older children with comorbid anxiety.

Option E (A referral to Speech and Language Therapy) is less appropriate as the primary intervention because the core issue is a situational anxiety or phobia, not a fundamental disorder of speech or language.

CORRECT ANSWER:

The correct management pathway for a young person presenting with persistent gender dysphoria is a referral to the specialist NHS Gender Identity Service. Following the Cass Review, these services are now delivered through new regional centres, which have replaced the former GIDS model.

This referral is the mandatory first step as per national guidance. These specialised, multi-disciplinary teams are the only services commissioned to undertake the comprehensive assessment required to explore the young person's gender identity and assess for any co-existing mental or physical health needs. They are responsible for coordinating care and are the sole prescribers of any potential medical interventions, such as puberty blockers (GnRH analogues), which are now only initiated under very strict protocols, typically within a research framework. This ensures a safe, consistent, and evidence-based approach to this complex clinical presentation.

WRONG ANSWER ANALYSIS:

Option A (Reassure this is a phase and offer watchful waiting) is incorrect as it invalidates the young person's expressed distress and fails to provide the necessary specialist assessment for gender dysphoria.

Option C (Refer to community CAMHS for CBT) is incorrect because while there may be a role for CAMHS in supporting associated mental health needs, they are not the commissioned specialist service for the primary assessment of gender identity issues.

Option D (Start a puberty-blocking (GnRH analogue) implant in primary care) is incorrect as these are highly specialised interventions that can only be considered and prescribed by the specialist gender service after a thorough MDT assessment.

Option E (Ask the parents to initiate a social transition) is incorrect because advising on social transition is a significant psychosocial intervention that should be guided by the comprehensive assessment from the specialist service, not directed by a non-specialist.

CORRECT ANSWER:

The 2021 NICE guideline for ME/CFS (NG206) fundamentally shifted management towards a personalised, supportive approach.

The cornerstone is an energy management plan, often called 'pacing'. This empowers the young person to understand their energy limits and stay within them to prevent post-exertional malaise (PEM), a key feature of the condition where symptoms worsen after minimal activity. This approach prioritises symptom stabilisation and improving quality of life over curative treatment.

The plan is developed collaboratively and integrated with support for sleep, diet, and emotional wellbeing, recognising ME/CFS as a complex, multi-system medical condition, not a psychological issue.

WRONG ANSWER ANALYSIS:

Option A (Graded Exercise Therapy) is incorrect because the 2021 NICE guidelines explicitly recommend against using GET, as it can be harmful and worsen symptoms.

Option C (A 12-week trial of Fluoxetine) is incorrect because antidepressants are not a primary treatment for ME/CFS itself, although they may be used for co-existing mood disorders.

Option D (High-dose vitamin B12 injections) is incorrect as there is no robust evidence to support routine use of vitamin B12 for treating ME/CFS.

Option E (Referral for inpatient rehabilitation) is incorrect because this is reserved for the most severely affected patients and is not the initial cornerstone of management for all.

CORRECT ANSWER:

Anxiety is a very common co-morbidity in children with Autism Spectrum Disorder (ASD). NICE guidelines recommend a psychosocial approach as the first-line intervention for anxiety in this population.

This involves making environmental adjustments, such as providing visual supports and considering sensory sensitivities, combined with a specific psychological intervention. Cognitive Behavioural Therapy (CBT) is the treatment of choice, but it must be adapted to the specific cognitive and communication profile of a child with ASD. Adaptations include using more concrete, literal, and visual materials, breaking down concepts into smaller steps, and explicitly teaching emotion recognition.

This combined approach addresses both external triggers and the child's internal responses, forming a comprehensive and evidence-based initial management strategy before considering pharmacological options.

WRONG ANSWER ANALYSIS:

Option A (Pharmacotherapy with risperidone) is incorrect because antipsychotic medication is reserved for severe, persistent challenging behaviour or when psychosocial interventions have failed, and is not first-line for anxiety.

Option B (A low-stimulus "sensory diet") is incorrect as, while sensory adjustments are a key part of environmental changes, a "sensory diet" alone is not a sufficient or evidence-based primary treatment for a significant anxiety disorder.

Option D (A trial of a gluten-free diet) is incorrect because there is no robust scientific evidence to support the use of special diets to treat the core features of ASD or associated anxiety.

Option E (Family therapy for the parents) is incorrect as, although parental support is vital, therapy focused solely on the parents does not directly address the child's specific anxiety symptoms and coping strategies.

CORRECT ANSWER:

The history of severe neglect combined with indiscriminate friendliness towards unfamiliar adults is characteristic of Disinhibited Social Engagement Disorder (DSED).

This is an attachment disorder where a child, due to a lack of a consistent caregiver, has not formed a selective attachment. According to NICE guidelines on attachment difficulties in children, the cornerstone of management is to enhance the current primary caregiving relationship.

The priority is therefore to support the foster carer in developing a secure and stable attachment with the child. Interventions such as Dyadic Developmental Psychotherapy (DDP) focus specifically on the carer-child dyad to build trust and safety, which is the only effective way to address the core pathology of the disorder.

WRONG ANSWER ANALYSIS:

Option A (Pharmacotherapy) is incorrect as DSED is a disorder of attachment, not a neurochemical imbalance, and there is no evidence base for medication.

Option B (Individual CBT) is less appropriate because the child's behaviours are not driven by cognitive distortions but by deeply rooted attachment patterns requiring a relational, dyadic intervention.

Option C (A standard ASD and ADHD assessment) is incorrect because while behaviours may overlap, the clear history of severe neglect makes an attachment disorder the primary diagnosis to address first.

Option E (Psychoeducation) is incorrect as the child's indiscriminate behaviour is a compulsive, attachment-seeking drive, not a knowledge deficit that can be corrected by teaching about "stranger danger".

CORRECT ANSWER:

This adolescent presents with a classic triad of positive and negative psychotic symptoms, highly suggestive of a first-episode psychosis.

National Institute for Health and Care Excellence (NICE) guidelines CG178 and QS80 mandate an urgent referral to a specialist Early Intervention in Psychosis (EIP) team for anyone aged 14 to 65 presenting with a suspected first episode of psychosis.

EIP services provide a comprehensive, multidisciplinary team (MDT) approach, including psychiatric, psychological, and social interventions. Early and effective treatment is critical in this age group to improve long-term outcomes, reduce the duration of untreated psychosis, and minimise disruption to social and educational development.

A general paediatrician's role is to recognise this serious presentation, exclude any immediate medical causes, and make a prompt referral to the correct specialised service.

WRONG ANSWER ANALYSIS:

Option A (Start Fluoxetine) is incorrect as an SSRI is not a first-line treatment for psychosis and initiating psychotropic medication should be done by a specialist after a full assessment.

Option B (Refer to standard community CAMHS) is less appropriate because while it is a mental health service, the specific expertise and intensive support required for a first-episode psychosis are provided by the dedicated EIP pathway.

Option C (Admit to the paediatric ward) is unnecessary unless there is an immediate and high risk of harm to self or others, or a need for urgent medical investigation that cannot be done in the community.

Option E (Reassure the parents) is inappropriate and potentially harmful as it dismisses clear red flag symptoms of a severe psychiatric disorder, which would delay essential, time-critical treatment.

CORRECT ANSWER:

The fundamental principle here is the avoidance of 'diagnostic overshadowing', where a child's existing diagnosis of autism and learning disability masks a new underlying physical problem.

National guidelines, including those from NICE and the Royal College of Paediatrics and Child Health, mandate that any new or escalating challenging behaviour in a non-verbal child must first be investigated for a physical cause. Pain is a primary trigger for such behaviours.

Therefore, a thorough physical examination to identify and treat common sources of distress such as dental pain, gastro-oesophageal reflux disease (GORD), constipation, or otitis media is the absolute first priority. Only after excluding physical pathology should behavioural or psychiatric causes be considered.

WRONG ANSWER ANALYSIS:

Option A (Prescribe low-dose risperidone) is incorrect because medication should not be the first-line response and is only considered after physical causes are excluded and non-pharmacological strategies have failed.

Option B (An urgent safeguarding referral) is less appropriate because while safeguarding must always be considered, self-injury is a recognised manifestation of distress in autism and a medical cause is more probable.

Option D (An urgent referral to CAMHS) is premature as a functional behavioural analysis is only appropriate after a thorough medical assessment has excluded pain or discomfort as the cause.

Option E (Immediate implementation of a padded helmet) is a reactive safety measure to manage a symptom, not a diagnostic step to identify and treat the underlying cause of the behaviour.

CORRECT ANSWER:

This intensive, community-based model addresses the multiple factors contributing to the behaviour by working with the young person in all their key environments or 'systems' – family, school, and peer groups.

The goal is to empower parents with skills and resources to manage their child's behaviour effectively. For a 15-year-old with a significant history of fire-setting and theft, this holistic, family-and-community-based approach is the most appropriate therapeutic pathway, aiming to prevent escalation to out-of-home placement.

WRONG ANSWER ANALYSIS:

Option A (Admission to a Tier 4 inpatient unit) is incorrect because intensive community-based interventions like MST should be trialled first, with admission reserved for cases where community management is not possible or has failed.

Option B (Referral for individual psychodynamic therapy) is incorrect as there is a limited evidence base for its effectiveness in managing severe antisocial behaviour in conduct disorder.

Option D (Placement in a Young Offender Institution) is incorrect because this is a punitive measure from the criminal justice system, not a therapeutic health intervention.

Option E (A high-dose SSRI and a mood stabiliser) is incorrect as medication is not a first-line treatment for conduct disorder itself, although it may be considered for co-morbid conditions.

CORRECT ANSWER:

According to the current NICE guideline (NG222) for depression in children and young people, the first-line pharmacological intervention is a trial of Fluoxetine, alongside concurrent psychological therapy.

If there is no response after an adequate trial period, typically 8-12 weeks, the recommended next step is to switch to a different Selective Serotonin Reuptake Inhibitor (SSRI), such as Sertraline or Citalopram. This approach is based on evidence that an individual may respond to a different medication within the same class, even if the first was ineffective.

This demonstrates a systematic, evidence-based approach to managing treatment-resistant depression in this age group before escalating to second or third-line agents.

WRONG ANSWER ANALYSIS:

Option B (Increase the Fluoxetine dose) is incorrect because a 12-week trial with no response at a standard therapeutic dose suggests treatment failure, not an inadequate dose, making a switch in agent more appropriate.

Option C (Stop Fluoxetine and start Venlafaxine) is incorrect as Venlafaxine, a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI), is considered a third-line agent by NICE, only to be used after two different SSRIs have been trialled.

Option D (Add a low dose of Aripiprazole) is incorrect as augmentation with an antipsychotic is a specialist strategy for complex treatment-resistant depression and not a standard second-line step.

Option E (Refer for Electroconvulsive Therapy) is incorrect because ECT is reserved for only the most severe, life-threatening, and treatment-refractory cases of depression.

CORRECT ANSWER:

NICE guideline CG31 clearly recommends cognitive behavioural therapy (CBT), including exposure and response prevention (ERP), as the first-line intervention for children and young people with moderate to severe OCD.

This patient's symptoms, which cause 2 hours of functional impairment daily, fit a moderate classification. The evidence-based approach prioritises psychological therapy to equip the patient with coping mechanisms before considering medication. This step-wise approach aims to treat the underlying cognitions and behaviours, minimising the potential side effects of pharmacotherapy in the paediatric population. The decision-making here hinges on matching the severity of the condition to the least invasive, effective treatment modality first.

WRONG ANSWER ANALYSIS:

Option A (Start Fluoxetine 10mg daily) is incorrect because an SSRI is only recommended as a second-line treatment if CBT is refused or proves ineffective, or for severe cases, often in conjunction with CBT.

Option B (Refer for family therapy) is incorrect because while family involvement is important, it is not the primary, evidence-based therapeutic modality for treating the core symptoms of OCD.

Option C (Admit to a specialist inpatient unit) is incorrect as inpatient care is reserved for severe, treatment-resistant cases or those with immediate, significant risk, which is not indicated here.

Option E (Reassure and review in 3 months) is incorrect as the patient has a diagnosed disorder with significant functional impairment requiring active intervention, not watchful waiting.

CORRECT ANSWER:

The clinical presentation, including re-experiencing (nightmares, flashbacks) and hyperarousal (hypervigilance) more than one month after a traumatic event, is characteristic of Post-Traumatic Stress Disorder (PTSD).

National Institute for Health and Care Excellence (NICE) guideline NG26, specific to PTSD, unequivocally recommends Trauma-Focused Cognitive Behaviour Therapy (TF-CBT) as the first-line psychological intervention for children and young people.

TF-CBT is a structured, evidence-based therapy that helps the child process the traumatic memory, understand and manage their emotional and physiological responses, and develop effective coping mechanisms. In clinical practice, the priority is to refer the patient to Child and Adolescent Mental Health Services (CAMHS) for this specific intervention.

WRONG ANSWER ANALYSIS:

Option A (Play therapy) is incorrect because while it can be a useful therapeutic medium, it is not the specific, evidence-based first-line treatment for processing trauma in PTSD.

Option C (Eye Movement Desensitisation and Reprocessing - EMDR) is incorrect because although it is a recognised and effective therapy for PTSD, NICE guidance recommends TF-CBT as the first-line approach for children and young people.

Option D (Family therapy) is incorrect as, while family support is vital, this modality does not directly address the individual's core trauma processing, which is the primary goal of PTSD treatment.

Option E (Pharmacotherapy with an SSRI) is incorrect because medication is not recommended as a first-line treatment for PTSD in children and is typically reserved for cases unresponsive to psychological therapy or for significant comorbidities.

CORRECT ANSWER:

This scenario describes Emotionally Based School Avoidance (EBSA). National guidance, including from NICE and the RCPCH, emphasises that prolonged absence from education is detrimental to a child's psychosocial development and worsens anxiety.

The priority is a rapid and supported return to the school environment. Option D is the most effective strategy because it involves a coordinated, multi-agency approach. This ensures that the school (providing educational adjustments), CAMHS (addressing the underlying anxiety), and paediatrics (managing the somatic complaints and providing medical oversight) work collaboratively with the family.

A graded return, starting with short, manageable periods and gradually increasing, is the cornerstone of management, helping to desensitise the child to the school environment while providing consistent support. This approach tackles the problem actively, rather than passively waiting for a resolution.

WRONG ANSWER ANALYSIS:

Option A (Admit to a paediatric ward) is incorrect as it inappropriately medicalises a psychosocial issue, reinforces illness behaviour, and is not indicated given normal investigations.

Option B (Refer to CAMHS and wait) is less appropriate because delaying the return to school until therapy is complete entrenches the avoidance and is contrary to evidence-based practice.

Option C (Advise parents to move him to a different school) is incorrect as it fails to address the core anxiety, which is likely to recur in any school setting.

Option E (Prescribe low-dose amitriptyline) is inappropriate because it only targets a symptom (headaches) without addressing the underlying psychological cause of the school avoidance.

CORRECT ANSWER:

This patient is experiencing an acute dystonic reaction, a common extrapyramidal side effect of dopamine D2 receptor antagonists like haloperidol.

The blockade of dopamine in the nigrostriatal pathway creates a relative cholinergic excess, leading to sustained, involuntary muscle contractions. The priority is rapid reversal of these distressing and painful symptoms.

Intravenous procyclidine, an anticholinergic agent, is the first-line treatment in UK practice for severe acute dystonia. It acts quickly to restore the dopaminergic-cholinergic balance, providing relief often within minutes. According to NICE guidelines, parenteral anticholinergic drugs are the recommended immediate treatment for acute dystonic reactions. The intravenous route is preferred over intramuscular for a more rapid and predictable onset of action in an emergency.

WRONG ANSWER ANALYSIS:

Option A (IV Lorazepam) is incorrect because while benzodiazepines can be used as a second-line adjunct for their muscle relaxant properties, they are not the primary, most effective treatment for reversing the underlying cholinergic excess.

Option C (IV Dantrolene) is incorrect as it is a muscle relaxant used specifically for treating malignant hyperthermia and neuroleptic malignant syndrome, a much more severe and distinct clinical entity.

Option D (IM Benztropine) is incorrect because although it is an appropriate anticholinergic agent, the intravenous route is superior for rapid relief in an acute setting, making IV procyclidine the preferred initial choice.

Option E (Oral Diazepam) is incorrect due to the oral route of administration, which has a much slower onset of action and is unsuitable for managing an acute, painful dystonic crisis.

CORRECT ANSWER:

This child presents with hyperactive delirium, a medical emergency characterised by acute confusion, agitation, and hallucinations. National guidelines emphasise that the cornerstone of management is to urgently identify and treat the underlying cause.

In a child with pneumonia, potential triggers include hypoxia, sepsis, metabolic disturbance, or adverse drug reactions. Therefore, the immediate priority is a comprehensive assessment, including a full septic screen (blood cultures, inflammatory markers, lactate, blood gas) and a thorough review of all medications to identify and reverse the precipitating factor. Sedating the child before establishing a cause can mask deterioration, delay definitive treatment, and potentially worsen the delirium.

WRONG ANSWER ANALYSIS:

Option A (Administer oral lorazepam 1mg) is incorrect because benzodiazepines can paradoxically worsen delirium, increase sedation, and cause respiratory depression, especially in an acutely unwell child.

Option B (Administer low-dose oral haloperidol) is incorrect as antipsychotics are not first-line; they are reserved for severe agitation unresponsive to other measures and can have significant side effects.

Option D (Ask his parents to hold him down) is incorrect because physical restraint is a last resort that can increase distress and agitation, and it fails to address the medical cause of the delirium.

Option E (Reassure him the spiders aren't real) is incorrect because while reorientation is a component of supportive care, it is not the priority and is insufficient management for a medical emergency.

CORRECT ANSWER:

This adolescent presents with acute behavioural disturbance, likely secondary to a manic episode. Key features include psychomotor agitation (pacing), pressured speech, and irritability.

In a manic state, cognitive processing is significantly impaired, with poor concentration and a reduced ability to process complex information. The primary goal of verbal de-escalation is to reduce arousal and ensure safety for the patient and staff. National Institute for Health and Care Excellence (NICE) guidelines advocate for creating a calm environment and using non-confrontational communication.

Employing short, simple, and clear sentences is the most effective technique. It minimises cognitive load, prevents misinterpretation, and helps to establish a therapeutic rapport without escalating the situation. This foundational step must be prioritised before considering any pharmacological interventions.

WRONG ANSWER ANALYSIS:

Option A (Speaking in a loud, firm voice) is incorrect because this approach is likely to be perceived as threatening and will escalate the patient's agitation.

Option B (Telling him to "stop being silly") is incorrect as this invalidates the patient's experience, is patronising, and will likely increase his irritability.

Option C (Asking complex questions about his beliefs) is incorrect because the patient's impaired cognitive state makes processing complex information difficult, leading to increased frustration.

Option E (Agreeing with his potentially grandiose beliefs) is incorrect as colluding with delusional beliefs is not therapeutic and can reinforce psychosis.

CORRECT ANSWER:

The priority in this situation is clinical assessment and psychoeducation. Post-ictal confusion, agitation, and aggression are well-recognised, transient phenomena following a generalised tonic-clonic seizure. This state is typically self-limiting and reflects cerebral recovery, not necessarily a worsening of the underlying epilepsy or a new psychiatric comorbidity.

The most appropriate initial management, in line with best practice, is to reassure the patient and family that this can be a normal part of the recovery process. This should be coupled with education on creating a safe, non-stimulating environment post-seizure, advising a non-confrontational approach until the confusion resolves. This approach de-escalates family distress and prevents unnecessary and potentially harmful medical interventions.

WRONG ANSWER ANALYSIS:

Option B (Start him on risperidone to prevent this.) is incorrect as introducing an antipsychotic is a significant intervention for what is likely a transient, self-limiting post-ictal state.

Option C (Refer for a video-telemetry EEG.) is incorrect because while useful for characterising seizures, it is not the immediate priority for managing a common post-ictal symptom after a clearly described GTCS.

Option D (Increase his anti-epileptic medication dose.) is incorrect as a single post-ictal event does not automatically indicate treatment failure or sub-therapeutic dosing; it may provoke unnecessary side effects.

Option E (Refer to CAMHS for anger management.) is incorrect because the aggression is directly related to the seizure context, not a baseline behavioural issue requiring psychiatric therapy.

CORRECT ANSWER:

The patient presents with a classic anticholinergic toxidrome, characterised by agitation, confusion, mydriasis, tachycardia, and hyperthermia ("mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone").

Haloperidol, a butyrophenone antipsychotic, is contraindicated as it possesses significant anticholinergic properties which would exacerbate the existing toxicity. Its use in this scenario increases the risk of severe complications, including cardiac arrhythmias (specifically QTc prolongation), seizures by lowering the seizure threshold, and worsening hyperthermia. National poisons guidelines, such as TOXBASE, advocate for the use of benzodiazepines to control agitation in anticholinergic poisoning. The priority is to sedate the patient safely without potentiating the life-threatening features of the toxidrome.

WRONG ANSWER ANALYSIS:

Option A (Lorazepam) is incorrect because it is a first-line benzodiazepine recommended for the management of agitation and seizures in anticholinergic toxicity.

Option B (Diazepam) is incorrect as it is another appropriate benzodiazepine used for sedation in patients with poisoning-induced agitation.

Option D (Midazolam) is incorrect because this short-acting benzodiazepine is a suitable choice for rapid tranquilisation in this clinical setting.

Option E (Phenobarbital) is incorrect as it may be considered a second-line agent for refractory agitation or seizures and is not absolutely contraindicated.

CORRECT ANSWER:

The immediate priority in any patient with an altered mental state, regardless of suspected alcohol intoxication, is to identify and treat rapidly reversible and life-threatening organic causes.

Alcohol metabolism can inhibit gluconeogenesis, leading to profound hypoglycaemia, which can present with agitation, confusion, and aggression, mimicking drunkenness. This is a medical emergency, as untreated hypoglycaemia can cause irreversible neurological injury. National guidelines emphasise excluding underlying medical reasons for an altered presentation before attributing all signs to the substance itself.

Therefore, a rapid capillary blood glucose check is the most critical first step to ensure patient safety, representing a fundamental "airway, breathing, circulation, disability, exposure" (ABCDE) approach where "disability" includes checking glucose.

WRONG ANSWER ANALYSIS:

Option A (Administer IM Haloperidol immediately) is incorrect because sedating a patient with a potentially reversible metabolic disturbance like hypoglycaemia is dangerous and can mask further deterioration.

Option C (Place him in a side room to "sleep it off") is incorrect as it constitutes unsafe observation; the patient could have a mixed overdose, a head injury, or develop complications like hypoglycaemia or respiratory depression.

Option D (Obtain a blood ethanol level) is incorrect because the result will not alter the immediate management priorities, takes time to process, and does not rule out other concurrent medical emergencies.

Option E (Refer to the CAMHS RAID team) is incorrect as this is a step for later management, addressing potential mental health or substance misuse issues, and is only appropriate once the patient is medically stable.

CORRECT ANSWER:

National Institute for Health and Care Excellence (NICE) guidance recommends oral lorazepam as the first-line medication for rapid tranquilisation in children and adolescents. Lorazepam, a benzodiazepine, is preferred due to its rapid onset of action and relatively short half-life.

This pharmacological profile effectively reduces agitation and distress without causing excessive or prolonged sedation, which is crucial for enabling ongoing assessment of the young person's mental state. The aim is to calm the patient, not to induce sleep. Using a benzodiazepine first is also appropriate when the diagnosis is unclear, as it avoids the potential side effects of antipsychotics.

WRONG ANSWER ANALYSIS:

Option A (Oral Diazepam 10mg) is incorrect because diazepam has a long half-life and active metabolites, increasing the risk of cumulative effects and prolonged sedation, which can complicate subsequent clinical evaluation.

Option B (Oral Haloperidol 5mg) is incorrect as it is a high-potency antipsychotic with a significant risk of acute extrapyramidal side effects, such as dystonic reactions, particularly in younger, antipsychotic-naive patients.

Option C (Oral Olanzapine 5-10mg) is an effective antipsychotic but is considered a second-line alternative to lorazepam in UK practice for the initial management of undifferentiated agitation.

Option D (Oral Chlorpromazine 50mg) is an older, low-potency antipsychotic with a less favourable side-effect profile, including significant postural hypotension and sedation, making it unsuitable for first-line use.

CORRECT ANSWER:

This 16-year-old patient is an inpatient on a general ward, presenting with an acute mental disorder that impairs her capacity to make decisions about her treatment.

Section 5(2) of the Mental Health Act (MHA) is the most appropriate immediate legal step. It allows the doctor in charge of her care, or their nominated deputy, to detain an informal inpatient for up to 72 hours. This holding power provides the legal authority to prevent her from leaving the hospital and to administer urgent treatment while a formal assessment for detention under Section 2 or 3 of the MHA is arranged.

This action prioritises her safety and addresses the significant risks of her acute illness, which supersedes considerations of parental consent in this specific context.

WRONG ANSWER ANALYSIS:

Option A (Call security to hold her down for an NG tube) is incorrect because using restraint without a legal framework for detention and treatment would be unlawful and constitute assault.

Option C (Apply to the Court of Protection) is incorrect because the Mental Health Act, not the Mental Capacity Act, is the primary legislation for compulsory treatment of a mental disorder of this nature.

Option D (Ask her parents to sign a consent form for treatment) is incorrect because parental consent cannot be used to enforce treatment against the will of a 16-year-old, and the MHA is the appropriate legal framework when capacity is lost due to mental illness.

Option E (Discharge her as she is refusing treatment) is incorrect as it would be a failure of duty of care to discharge a vulnerable patient who lacks capacity and is at high risk of harm.

CORRECT ANSWER:

Benzodiazepines, such as lorazepam, are potent central nervous system depressants. Their primary risk, particularly within the first hour after administration, is causing respiratory depression and over-sedation. National guidelines, including those from NICE, mandate careful monitoring for these effects.

The clinical priority is to identify and manage apnoea, hypoventilation, or airway obstruction. This is achieved by continuously monitoring the patient's respiratory rate and oxygen saturation. Simultaneously, assessing the level of consciousness, using a scale like the Glasgow Coma Scale (GCS) or AVPU, is crucial to detect excessive sedation, which can precede respiratory collapse. This combination of monitoring directly addresses the most immediate life-threatening complications of benzodiazepine administration in a 17-year-old, ensuring patient safety during procedural sedation.

WRONG ANSWER ANALYSIS:

Option A (Temperature and pupillary response) is incorrect because while these are part of a full neurological assessment, they are not the most critical initial parameters for detecting benzodiazepine-induced respiratory compromise.

Option B (Urine output and GCS) is incorrect as urine output is a marker of renal function and hydration status, which is not an immediate priority following sedation.

Option D (12-lead ECG and blood pressure) is less appropriate because although cardiovascular parameters are important, significant hypotension is less common than respiratory depression with benzodiazepines unless a profound overdose occurs.

Option E (Blood glucose and urinalysis) is incorrect because these investigations are not routine for monitoring the acute effects of lorazepam, which primarily affects respiratory and neurological systems.

CORRECT ANSWER:

This patient's presentation is characteristic of an autistic 'meltdown', an intense response to overwhelming sensory or emotional stimuli, rather than a behavioural tantrum. NICE guidelines (NG11) advocate for proactive, person-centred strategies that address the root cause of the distress.

The priority is de-escalation by reducing sensory input. Moving the boy to a quiet, low-stimulus environment is a key 'reasonable adjustment' under UK legislation. Using his established communication aids respects his needs and provides a means to understand the source of his distress, empowering him to regain control.

This approach is the least restrictive and most therapeutic, focusing on environmental modification before considering more invasive interventions. It is a fundamental principle of managing behaviour that challenges in individuals with learning disabilities or autism.

WRONG ANSWER ANALYSIS:

Option A (Prescribe PRN oral lorazepam) is incorrect as medication should only be considered for managing behaviour that challenges after psychosocial and environmental interventions have failed.

Option B (Initiate manual restraint) is incorrect because physical restraint is a highly restrictive, last-resort measure to prevent immediate, serious harm and should not be a first-line response to distress.

Option D (Call the CAMHS team for an urgent assessment) is less appropriate as the immediate priority is de-escalation; while CAMHS input may be valuable long-term, it does not address the acute environmental triggers.

Option E (Ask his parents to leave) is incorrect as parents are a crucial source of support, comfort, and expert knowledge about their child's specific needs and communication methods.

CORRECT ANSWER:

The patient is experiencing an acute post-operative delirium, which is a medical emergency causing a temporary loss of capacity. The immediate priority is the prevention of significant harm, such as the removal of intravenous lines, and the administration of urgent medical treatment.

In England and Wales, Common Law provides the legal justification to act in the best interests of a patient who lacks capacity. The doctrine of necessity allows for the use of the minimum necessary restraint to provide essential, life-sustaining treatment and prevent a serious deterioration in the patient's health. This legal framework is the most appropriate for this time-critical situation where the cause of confusion is organic and treatment cannot be delayed.

WRONG ANSWER ANALYSIS:

Option A (Mental Health Act 1983) is incorrect because it is used for the assessment and treatment of a mental disorder, not an acute delirium secondary to a physical health problem.

Option B (Mental Capacity Act 2005) is incorrect as this legislation applies to individuals aged 16 and over, and this patient is 14 years old.

Option D (Children Act 1989) is incorrect because parental consent to medical treatment does not provide the specific legal authority to use restraint on a child.

Option E (Gillick Competence) is incorrect as it relates to a child's capacity to consent to treatment, whereas this patient is acutely incapacitated and unable to consent.

CORRECT ANSWER:

Management of synthetic cannabinoid receptor agonist (SCRA) toxicity is primarily supportive. The immediate priority is de-escalation in a low-stimulus environment, such as a quiet room with dim lighting, to reduce agitation and sympathomimetic drive.

Benzodiazepines are the first-line pharmacological treatment for severe agitation, tachycardia, and preventing seizures. An oral formulation like diazepam is the least restrictive option and should be attempted first if the patient's level of cooperation allows. This combined approach of supportive care and oral benzodiazepines addresses the core pathophysiology without introducing the risks associated with antipsychotics or isolated cardiovascular agents. This strategy aligns with national guidance on managing new psychoactive substances, prioritising non-sedative measures first, followed by benzodiazepines if sedation is required.

WRONG ANSWER ANALYSIS:

Option A (IM Haloperidol) is incorrect because antipsychotics can lower the seizure threshold and prolong the QTc interval, risks already heightened by SCRAs.

Option B (IM Lorazepam) is less appropriate as the initial step; while a benzodiazepine is indicated, the least invasive (oral) route combined with supportive care should be the first consideration.

Option C (IV Labetalol) is incorrect as it treats the tachycardia in isolation without addressing the central agitation, risking unopposed alpha-adrenergic stimulation and potential hypertensive crisis.

Option D (Oral Risperidone) is incorrect for similar reasons to haloperidol, as atypical antipsychotics also carry risks of lowering seizure threshold and QTc prolongation in this context.

CORRECT ANSWER:

Intramuscular (IM) Lorazepam is the first-line medication for rapid tranquilisation (RT) in children and young people, as recommended by NICE guideline NG10. The primary goal of RT is to calm the patient to reduce immediate risk to themselves or others, not to induce sleep.

Lorazepam, a benzodiazepine, provides effective and rapid anxiolysis and sedation with a reliable absorption profile following IM administration. Crucially, it has a more favourable safety profile than antipsychotics, with a significantly lower risk of causing distressing extrapyramidal side effects (EPSEs), such as acute dystonia, which are more common in younger patients. This balance of predictable efficacy and superior safety makes it the priority choice in an emergency where de-escalation has failed and oral medication is refused.

WRONG ANSWER ANALYSIS:

Option B (IM Diazepam) is incorrect because its absorption after intramuscular injection is slow and erratic, leading to an unpredictable and delayed clinical response.

Option C (IM Aripiprazole) is an atypical antipsychotic that may be considered in specific situations by specialists but is not the recommended first-line agent for RT in paediatric practice.

Option D (IM Haloperidol) is less appropriate due to its significantly higher propensity to cause acute dystonias, akathisia, and other severe EPSEs, particularly in this age group.

Option E (IM Promethazine) is a sedating antihistamine and is not recommended as a first-line monotherapy for managing acute, severe behavioural disturbance.

CORRECT ANSWER:

When a patient's behaviour escalates to imminent violence, the immediate and overriding priority is the safety of everyone involved. National guidelines, including those from NICE, emphasise that managing aggression begins with ensuring a safe environment.

This involves creating space, removing other patients and vulnerable individuals from the immediate vicinity, and summoning appropriately trained help, such as the hospital security or response team. This foundational step is a prerequisite for any further therapeutic or medical intervention. Attempting any other action before the environment is secure places the patient, staff, and others at significant risk of physical harm. Only once the immediate threat is contained can the clinical team safely proceed with assessment and treatment.

WRONG ANSWER ANALYSIS:

Option B (Administer the patient's prescribed PRN olanzapine) is incorrect because medication cannot be safely administered to a physically threatening patient until the situation is controlled.

Option C (Discuss the legal framework for restraint with the team) is incorrect as this critical discussion should happen prior to, or after, an acute event, not during a crisis when immediate action is required.

Option D (Ask the patient's parents to come in and calm him down) is incorrect because this could place the parents in physical danger and may escalate the patient's agitation.

Option E (Conduct a full psychiatric risk assessment) is incorrect because a formal assessment is impossible and unsafe to perform while there is an active threat of violence.

CORRECT ANSWER:

This patient is in the escalation phase of agitation. National guidelines, including those from NICE, recommend verbal and non-verbal de-escalation as the priority.

The most appropriate initial action is to modify the environment to reduce stimuli and engage the patient verbally in a non-threatening manner. Moving the adolescent to a quieter room removes him from the stressful A&E waiting area, and a calm, non-confrontational tone helps to defuse anger and avert aggression.

This approach respects the patient's autonomy, aims to build a therapeutic relationship, and is the most effective first-line strategy to prevent progression to physical violence. It demonstrates a measured response, focusing on safety for the patient and staff by addressing the early signs of agitation before restrictive interventions are necessary.

WRONG ANSWER ANALYSIS:

Option A (Tell him to "calm down") is incorrect because such a command is dismissive and often perceived as provocative, which can escalate agitation.

Option B (Call hospital security) is incorrect as this is a disproportionate and premature use of a restrictive intervention when the patient is not yet physically violent.

Option C (Ask the accompanying nurse to prepare IM lorazepam) is incorrect because pharmacological intervention is not the first-line treatment for verbal aggression and de-escalation techniques must be attempted first.

Option E (Inform him that he will be removed) is incorrect because issuing threats or ultimatums is a confrontational tactic that will likely increase his hostility.

CORRECT ANSWER:

Sodium valproate is associated with two well-documented, serious idiosyncratic adverse effects: hepatotoxicity and haematological disorders. Consequently, performing baseline and regular monitoring of Liver Function Tests (LFTs) and a Full Blood Count (FBC) is a mandatory safety requirement as per MHRA and NICE guidelines.

Hepatotoxicity can be severe and potentially fatal, making vigilant LFT monitoring crucial, especially during the initial six months of therapy. Haematological effects commonly include a dose-related thrombocytopenia, but aplastic anaemia and pancytopenia can also occur, necessitating a routine FBC. This monitoring strategy is fundamental to safe prescribing in paediatrics, allowing for early detection and intervention to mitigate harm.

WRONG ANSWER ANALYSIS:

Option A (Creatine Kinase and Prolactin) is incorrect as these blood tests are primarily indicated for monitoring patients on antipsychotic medications.

Option C (Serum folate and B12) is less appropriate as, while some anticonvulsants interfere with folate metabolism, it is not a primary safety monitoring requirement for valproate.

Option D (Urea & Electrolytes and Glucose) is incorrect because these are the key investigations for monitoring lithium therapy or metabolic side effects of antipsychotics.

Option E (Serum amylase and lipids) is incorrect as serum amylase is only checked if the patient develops clinical signs of pancreatitis, a rare adverse effect of valproate, not for routine screening.

CORRECT ANSWER:

This patient has a seizure secondary to severe, symptomatic hyponatraemia (sodium 121 mmol/L), a known complication of SSRIs like fluoxetine causing SIADH.

The seizure is a direct result of cerebral oedema from the acute fall in serum sodium. National guidelines state that hyponatraemic seizures are a medical emergency that may be refractory to standard anticonvulsants. The definitive and immediate priority is to correct the underlying metabolic cause.

Administering a bolus of 3% hypertonic saline will rapidly, but controllably, increase the serum sodium concentration. This reverses the osmotic shift, reduces cerebral oedema, and treats the direct cause of the seizure. The initial aim is a small, rapid rise in sodium to terminate the seizure, not full correction.

WRONG ANSWER ANALYSIS:

Option B (Administer IV levetiracetam) is incorrect because while it is an anti-epileptic, it does not address the underlying life-threatening metabolic cause of the seizure, which will persist or recur if the hyponatraemia is not treated.

Option C (Repeat the fluoxetine dose) is incorrect as the fluoxetine is the likely cause of the SIADH and hyponatraemia, and therefore it must be withheld immediately.

Option D (Send for an urgent CT head) is incorrect as an immediate step because the clinical and biochemical evidence strongly points to a metabolic cause, and delaying life-saving metabolic correction for imaging would be inappropriate.

Option E (Administer 0.9% saline bolus) is incorrect because in SIADH, giving isotonic saline can paradoxically worsen the hyponatraemia as the body excretes the salt but retains the free water.

CORRECT ANSWER:

The presentation of vivid nightmares and morning grogginess (a 'hangover' effect) are well-recognised side effects of melatonin, typically indicating the dose is too high or administered too late in the evening.

The most appropriate initial management step, in line with best practice for paediatric sleep disorders, is to adjust the current prescription rather than cease the medication or investigate further. Reducing the dose to 1mg directly addresses the likely over-medication.

Administering it earlier, ideally 30-60 minutes before the desired sleep time, allows the peak therapeutic effect to align with sleep onset and ensures the medication is metabolised by morning, mitigating the grogginess. This approach represents a logical and conservative titration of therapy.

WRONG ANSWER ANALYSIS:

Option A (Stop melatonin and refer for a formal sleep study) is incorrect as a sleep study is not indicated for managing common, dose-related side effects of melatonin.

Option B (Increase the dose to 4mg) is incorrect because this would likely exacerbate the nightmares and morning sedation, which are symptoms of an excessive dose.

Option C (Reassure this is normal and will pass) is inappropriate as it fails to address the patient's distressing side effects, which are impacting his daytime functioning.

Option D (Stop the melatonin and trial a different brand) is incorrect as the side effects are related to the active ingredient and its dosage, not the specific formulation.

CORRECT ANSWER:

The clinical presentation of fever, autonomic instability (tachycardia), altered mental state (confusion), and severe "lead-pipe" muscle rigidity in a patient taking an antipsychotic like olanzapine is characteristic of Neuroleptic Malignant Syndrome (NMS).

NMS is a medical emergency. The intense and sustained muscle contraction results in rhabdomyolysis, the rapid breakdown of skeletal muscle. This process causes a massive release of intracellular muscle contents into the bloodstream.

Creatine Kinase (CK) is the most sensitive and specific laboratory marker for rhabdomyolysis. In NMS, CK levels are typically markedly elevated, often greater than 10,000 U/L, which is a key finding to help confirm the diagnosis and assess severity. Prompt recognition is vital for initiating supportive care and drug withdrawal.

WRONG ANSWER ANALYSIS:

Option A (Serum prolactin) is incorrect because while antipsychotics can cause hyperprolactinaemia, it is not a specific or acute marker for the diagnosis of NMS.

Option B (White cell count) is incorrect as a leucocytosis is common in NMS but is a non-specific finding of systemic stress or inflammation.

Option C (Liver transaminases) is incorrect because although they may be mildly elevated, this is a non-specific finding and not a primary diagnostic criterion for NMS.

Option E (C-reactive protein) is incorrect as this is a general marker of inflammation that lacks the specificity required to confirm NMS over other differential diagnoses like sepsis.

CORRECT ANSWER:

This patient is exhibiting clinically significant side effects of guanfacine, namely symptomatic orthostatic hypotension and bradycardia. Guanfacine is a centrally acting alpha-2 adrenergic agonist, and these are its expected dose-dependent effects.

The immediate priority is patient safety. Administering the next dose is likely to exacerbate these effects, potentially leading to syncope. National guidance and safe practice principles dictate that when a patient on a specialist medication develops significant adverse effects, the dose should be withheld and advice sought from the prescribing specialist (e.g., a community paediatrician or CAMHS consultant). This action demonstrates safe medication management and appropriate escalation.

WRONG ANSWER ANALYSIS:

Option A (Give the dose as normal) is incorrect because the patient is symptomatic with significant haemodynamic instability, making another dose unsafe.

Option B (Stop the guanfacine and switch to methylphenidate) is incorrect as abrupt cessation of an alpha-2 agonist can cause rebound hypertension, and a switch in medication requires specialist assessment.

Option C (Give an IV fluid bolus) is incorrect as it is an invasive, temporary measure that fails to address the underlying pharmacological cause of the hypotension.

Option E (Give half the normal dose) is incorrect because any dose modification for a specialist drug requires consultation with the specialist, as even a reduced dose may be unsafe in this context.

CORRECT ANSWER:

Selective serotonin reuptake inhibitors (SSRIs) like sertraline are a well-established cause of SIADH, which typically manifests within the first few weeks of initiating therapy.

The clinical presentation of nausea and headache, coupled with the laboratory findings of euvolaemic hyponatraemia (Na+ 124 mmol/L), normal potassium, and normal or low urea, is classic for SIADH. The underlying mechanism is non-physiological ADH release, leading to water retention and dilutional hyponatraemia. Recognising this adverse drug reaction is a critical step in management, which involves fluid restriction and potentially stopping the causative agent.

WRONG ANSWER ANALYSIS:

Option A (Dehydration from anxiety) is incorrect as dehydration would typically lead to hypernatraemia and an elevated urea level due to haemoconcentration.

Option C (Primary polydipsia) is less likely because although it causes hyponatraemia, the presentation is strongly linked in time to the introduction of a drug known to cause SIADH.

Option D (Adrenal insufficiency) is unlikely as it characteristically causes hyponatraemia with hyperkalaemia, whereas this patient's potassium is normal.

Option E (Lab error) should be considered, but it is improbable given the presence of corresponding clinical symptoms that fit a known side effect of her new medication.

CORRECT ANSWER:

This patient presents with classic features of SSRI Discontinuation Syndrome. The abrupt cessation of an SSRI with a short half-life, such as paroxetine, commonly leads to a cluster of symptoms including dizziness, nausea, anxiety, and pathognomonic sensory disturbances like "brain zaps".

According to NICE guidelines, the primary management is reassurance that the symptoms are not dangerous and are a direct result of stopping the medication. The most appropriate next step is to manage these symptoms. If they are severe, this involves restarting the paroxetine at the previous dose and then initiating a very gradual taper over several weeks or months. This approach directly addresses the underlying neurochemical imbalance and is the safest and most effective intervention, prioritising patient comfort and preventing further complications.

WRONG ANSWER ANALYSIS:

Option B (Admit for a CT head scan) is incorrect because the specific symptoms and clear history of medication cessation make a neurological emergency like a stroke highly unlikely and an urgent scan unnecessary.

Option C (Check U&Es for hyponatraemia) is incorrect as hyponatraemia is a potential side effect during SSRI treatment (SIADH), not a feature of its withdrawal syndrome.

Option D (Start him on a different SSRI) is incorrect because the standard management is to reinstate the original medication to stabilise the patient before planning a slow wean, not to introduce a new agent during an acute discontinuation phase.

Option E (Refer urgently to CAMHS for psychosis) is incorrect as the described sensory symptoms and anxiety are characteristic of discontinuation syndrome and do not indicate the presence of psychosis.

CORRECT ANSWER:

The most critical risk to manage is the extreme teratogenicity of sodium valproate. National guidelines from the MHRA mandate that for any female of child-bearing potential, enrolment and adherence to the Pregnancy Prevention Programme (PPP) is the absolute priority.

Sodium valproate carries a significant risk of major congenital malformations, including a 10% risk of neural tube defects, and a 30-40% risk of neurodevelopmental disorders. The oral contraceptive pill alone is not considered a highly effective method of contraception under the PPP; the guidance requires the use of a Long-Acting Reversible Contraception (LARC) or two complementary forms of contraception.

The paediatrician's role extends to ensuring this adolescent is fully counselled and has a robust contraceptive plan in place, superseding the management of other potential side effects.

WRONG ANSWER ANALYSIS:

Option A (Risk of pancreatitis) is incorrect as although pancreatitis is a recognised side effect of sodium valproate, it is rare and not the most pressing concern in this clinical scenario.

Option B (Risk of liver failure) is less appropriate because while hepatotoxicity is a known risk, it is more common in younger children, particularly those under two years of age with underlying metabolic disorders.

Option D (Risk of Stevens-Johnson Syndrome) is incorrect as this severe cutaneous reaction is more strongly associated with other anticonvulsants, such as lamotrigine.

Option E (Risk of bone marrow suppression) is less critical because haematological side effects like thrombocytopenia are possible but are not as significant or immediate as the teratogenic risk.

CORRECT ANSWER:

Gastrointestinal side effects, including nausea, dyspepsia, and poor appetite, are very common with atomoxetine, particularly during treatment initiation.

As per best practice, the most appropriate initial step is to implement simple, conservative measures. Administering the dose with or after food can significantly buffer the medication's effect on the gastric mucosa, reducing nausea and improving tolerability.

This practical adjustment is the priority as it is the least invasive and most effective first-line strategy to manage this known side effect. It avoids escalating treatment, such as changing medication or adding another agent, which would be premature. If symptoms were to persist despite this, splitting the daily dose could be considered.

WRONG ANSWER ANALYSIS:

Option A (Stop atomoxetine and switch to methylphenidate) is incorrect as this is a significant intervention for a common side effect that has not yet been managed with simple measures.

Option B (Advise taking the medication at bedtime) is less appropriate because atomoxetine can cause insomnia, so moving the dose to the evening may worsen sleep.

Option C (Add an anti-emetic like ondansetron) is incorrect as it introduces unnecessary polypharmacy when a non-pharmacological solution is likely to be effective.

Option E (Refer for a gastroscopy) is inappropriate as this is an invasive investigation for a well-documented medication side effect in the absence of any clinical red flags.

CORRECT ANSWER:

The patient's report of feeling "more jumpy," agitated, and like she could "crawl out of her skin" is a classic description of akathisia. This is a state of motor restlessness and a subjective feeling of inner tension, which is a recognised, and often distressing, early side effect of SSRIs.

NICE guidelines for depression in children and young people stress the importance of close monitoring for increased agitation and distress in the initial weeks of treatment. Differentiating this specific psychomotor restlessness from a general increase in anxiety is a key clinical skill. Misdiagnosing it as worsening depression could lead to the erroneous decision to increase the fluoxetine dose, which would likely exacerbate the akathisia. Management involves reviewing the need for the drug, considering dose reduction, or changing to an alternative treatment.

WRONG ANSWER ANALYSIS:

Option B (Serotonin Syndrome) is incorrect because this is a medical emergency presenting with a triad of autonomic instability, altered mental status, and neuromuscular hyperactivity such as clonus, none of which are described.

Option C (Worsening of her underlying depression) is less likely as the symptoms are specifically of physical restlessness, not a primary deterioration in mood, anhedonia, or other core depressive features.

Option D (Normal therapeutic effect of the drug) is incorrect because this level of agitation is a significant adverse effect requiring clinical action, not an expected or acceptable therapeutic response.

Option E (SSRI-induced psychosis) is incorrect as the clinical picture contains no evidence of psychotic phenomena like hallucinations or delusions.

CORRECT ANSWER:

The correct approach is watchful waiting. Tics are a recognised, relatively common side effect of stimulant medications like methylphenidate. However, their emergence is not an absolute contraindication to continuing treatment, particularly when the ADHD symptoms are well-controlled and the tic is mild and not causing functional impairment or distress to the child.

National Institute for Health and Care Excellence (NICE) guidance supports the principle of tolerating minor side effects if the overall benefit of treatment is significant. The natural history of tics is to wax and wane, and this new-onset tic may resolve spontaneously without any change in medication. Therefore, the most appropriate initial step is a period of observation and reassurance for the family.

WRONG ANSWER ANALYSIS:

Option A (Stop methylphenidate and start atomoxetine) is incorrect as this is an unnecessary change in medication for a mild side effect when the target ADHD symptoms are well-managed.

Option C (Add guanfacine to the methylphenidate) is not the first-line step, as adding a second medication for a mild, non-bothersome tic introduces polypharmacy and the risk of further side effects.

Option D (Refer for urgent neurological assessment) is inappropriate because a simple motor and vocal tic is a known side effect of this medication and does not warrant urgent specialist review in this context.

Option E (Stop methylphenidate and start lisdexamfetamine) is illogical as switching to another stimulant is unlikely to be helpful, given that tics are a class effect of these drugs.

CORRECT ANSWER:

Risperidone, a potent dopamine D2 receptor antagonist, is a common cause of significant hyperprolactinaemia, leading to distressing side effects like gynaecomastia.

The definitive management for symptomatic, antipsychotic-induced hyperprolactinaemia is to address the underlying cause. Switching to a "prolactin-sparing" agent is the recommended first-line strategy, especially when symptoms are troublesome.

Aripiprazole is a partial agonist at the D2 receptor; this unique mechanism allows it to lower prolactin levels effectively while maintaining therapeutic antipsychotic action. This approach directly resolves the pharmacological problem, prioritising the patient's physical well-being and treatment adherence without compromising their mental health management. Current guidance supports switching to an alternative agent like aripiprazole as a primary intervention.

WRONG ANSWER ANALYSIS:

Option A (Add cabergoline) is incorrect because dopamine agonists are not first-line for drug-induced hyperprolactinaemia and are typically reserved for cases where switching the antipsychotic is not feasible.

Option B (Reassure) is incorrect as gynaecomastia is a significant and often distressing physical side effect that warrants active management, not just observation.

Option C (Refer for surgery) is incorrect because surgical intervention is a last resort for persistent, severe gynaecomastia after medical management options have been exhausted.

Option D (Switch to olanzapine) is incorrect because olanzapine also carries a moderate to high risk of causing hyperprolactinaemia and would not be a suitable alternative.

CORRECT ANSWER:

Second-generation antipsychotics, particularly risperidone, are well-known to cause significant metabolic side effects. The patient's substantial 8kg weight gain and BMI on the 98th centile are clinical red flags for developing metabolic syndrome.

National guidelines from NICE recommend regular monitoring for these effects. This includes checking fasting blood glucose (or HbA1c) and a lipid profile to screen for hyperglycaemia and dyslipidaemia. Identifying and managing these metabolic changes promptly is the highest priority to prevent long-term cardiovascular morbidity and the development of type 2 diabetes, which carry more immediate and severe health risks than other potential side effects in this context.

WRONG ANSWER ANALYSIS:

Option A (Serum prolactin level) is less critical because while risperidone can cause hyperprolactinaemia, its complications are generally less acutely dangerous than untreated diabetes or severe dyslipidaemia.

Option B (12-lead ECG) is incorrect as, although some antipsychotics can affect the QT interval, it is not the most immediate concern given the prominent weight gain.

Option D (Full blood count) is not a routine investigation for monitoring risperidone side effects unless there is a specific clinical concern like infection.

Option E (Thyroid function tests) is incorrect because the clinical picture is highly suggestive of medication-induced metabolic changes, not primary thyroid dysfunction.

CORRECT ANSWER:

This patient is exhibiting a classic acute dystonic reaction, a distressing extrapyramidal side effect of dopamine D2 receptor antagonists like haloperidol.

The underlying pathophysiology is a drug-induced imbalance of dopaminergic and cholinergic activity in the nigrostriatal pathways. The immediate priority is to correct this imbalance. Intravenous procyclidine, a centrally-acting anticholinergic agent, is the first-line treatment as per UK practice guidelines.

The intravenous route is essential for a rapid therapeutic effect, as the symptoms, particularly an oculogyric crisis, are frightening, painful, and can be dangerous. Rapid resolution is expected within 5-10 minutes of IV administration. This intervention directly counteracts the pathological cholinergic overactivity, providing swift and effective relief.

WRONG ANSWER ANALYSIS:

Option A (Intravenous lorazepam) is incorrect because while it may provide some sedation and muscle relaxation, it does not address the core cholinergic-dopaminergic imbalance and is not the primary treatment.

Option C (Intravenous dantrolene) is incorrect as it is used to treat neuroleptic malignant syndrome, a much rarer and more severe reaction characterised by fever, autonomic instability, and generalised 'lead-pipe' rigidity.

Option D (Oral diazepam) is incorrect due to the oral route being too slow for this acute medical emergency, and it is not the specific antidote for the reaction.

Option E (Oral aripiprazole) is incorrect because administering another antipsychotic is not appropriate for managing an acute side effect and would be considered as part of a long-term medication review, not an emergency treatment.

CORRECT ANSWER:

This patient's presentation is a textbook example of serotonin toxicity, resulting from a fluoxetine overdose.

The diagnosis is clinical and based on the classic triad of altered mental state (agitation, confusion), autonomic dysfunction (hyperthermia, sweating), and neuromuscular excitation (hyperreflexia, inducible clonus). Recognising this toxidrome is a critical step.

According to UK guidance, immediate management involves ceasing the serotonergic agent and providing aggressive supportive care, focusing on managing hyperthermia and agitation, often with benzodiazepines. Severe cases require paediatric intensive care admission. The Hunter Criteria can be used to formalise the diagnosis.

WRONG ANSWER ANALYSIS:

Option A (Neuroleptic Malignant Syndrome) is incorrect because it is caused by dopamine antagonists and is characterised by "lead-pipe" rigidity and hyporeflexia, not the clonus seen here.

Option B (Anticholinergic toxidrome) is incorrect as it typically presents with dry, flushed skin and urinary retention, whereas this patient is profusely sweating.

Option D (SSRI Discontinuation Syndrome) is incorrect as this occurs upon cessation, not overdose, of an SSRI and presents with milder, flu-like symptoms.

Option E (Acute dystonic reaction) is incorrect because it involves focal, involuntary muscle spasms, such as torticollis or oculogyric crisis, not a widespread systemic illness like this.

CORRECT ANSWER:

According to NICE guidance, drug treatment for ADHD should only be initiated by a specialist. For prescribing responsibility to be transferred to a GP, a formal Shared Care Agreement (SCA) must be in place.

Methylphenidate is typically classified as an "amber" drug, meaning it requires specialist initiation and ongoing monitoring under a shared care arrangement. The SCA is a crucial medicolegal document that explicitly outlines the responsibilities of the specialist, the GP, and the patient/family.

It ensures clear communication protocols and defines roles for prescribing, monitoring physical health parameters (like growth, heart rate, and blood pressure), and managing any adverse effects. This structured approach is essential for the safe and effective long-term management of this controlled medication in primary care.

WRONG ANSWER ANALYSIS:

Option A (A transfer of care letter to the GP) is incorrect because a simple letter lacks the formal, agreed-upon structure and specific responsibilities detailed in an SCA.

Option B (A 3-way conversation with the parents) is incorrect as, while good practice for communication, it is not a substitute for the formal, documented agreement required for safe governance.

Option D (A referral to the adult ADHD team) is incorrect because the patient is 10 years old and remains under the care of paediatric services until transition planning begins much later.

Option E (A copy of the boy's EHC plan) is incorrect because an Education, Health and Care plan addresses educational and social needs and is not the clinical governance document for medication prescribing.

CORRECT ANSWER:

Guanfacine is a selective alpha-2A adrenergic receptor agonist used for ADHD, particularly when stimulants are not tolerated. Its primary mechanism involves modulating signalling in the prefrontal cortex and reducing central sympathetic outflow.

This reduction in sympathetic tone is responsible for its most common and clinically significant side effects. Therefore, parents must be counselled about the high likelihood of somnolence, which is often dose-limiting. Furthermore, NICE guidelines mandate baseline and ongoing monitoring of cardiovascular parameters, specifically bradycardia and hypotension, which can occur. These effects are most pronounced during initial dose titration. Recognising and monitoring these predictable side effects is a key safety consideration in clinical practice.

WRONG ANSWER ANALYSIS:

Option A (Severe insomnia and agitation) is incorrect as these are activating side effects characteristic of stimulant medications like methylphenidate.

Option B (Weight loss and appetite suppression) is incorrect because this side effect profile is also strongly associated with stimulant medications, not guanfacine.

Option D (Increased tics and motor restlessness) is incorrect as guanfacine is often used off-label for tic reduction and is not associated with causing or worsening them.

Option E (Liver derangement and jaundice) is incorrect as this is a rare but serious side effect associated with atomoxetine, another non-stimulant ADHD medication.

CORRECT ANSWER:

This patient presents with ADHD and significant anxiety, a common comorbidity. The first-line treatment, methylphenidate, has exacerbated her anxiety.

According to NICE guidelines, when a patient cannot tolerate a stimulant, a non-stimulant medication should be considered. Atomoxetine is a selective noradrenaline reuptake inhibitor (SNRI) licensed for ADHD. It is an appropriate choice as it treats core ADHD symptoms without the activating effects of stimulants that can worsen anxiety.

Furthermore, its SNRI properties can be effective in treating generalised anxiety disorder, addressing both conditions with a single medication. This approach simplifies the treatment regimen and avoids the potential for polypharmacy. The decision reflects a stratified approach to ADHD management, prioritising tolerability and treatment of co-existing mental health conditions.

WRONG ANSWER ANALYSIS:

Option A (Stop methylphenidate and start sertraline for the anxiety) is incorrect because it would leave the patient's significant ADHD symptoms untreated.

Option C (Stop methylphenidate and start lisdexamfetamine) is incorrect as lisdexamfetamine is another stimulant and is likely to cause similar anxiogenic side effects.

Option D (Add propranolol to the methylphenidate) is less appropriate as it adds another medication to treat a side effect, when a single, better-tolerated alternative exists.

Option E (Add a low dose of risperidone) is incorrect because antipsychotics are not indicated for GAD or ADHD in this context and carry a significant side effect burden.

CORRECT ANSWER:

The boy's symptoms of anxiety, sadness, and irritability appear specifically in the afternoons, which coincides with the expected "wearing off" period for Equasym XL, a modified-release methylphenidate preparation.

This phenomenon is known as rebound, where ADHD symptoms return, often with increased intensity, as the stimulant medication's effect diminishes. The temporal relationship between the symptom onset and the medication's duration of action is the key diagnostic clue.

NICE guidelines suggest that managing rebound can involve adjusting the medication regimen, such as switching to a longer-acting stimulant like lisdexamfetamine, or adding a small, immediate-release top-up dose in the afternoon to provide a smoother decline in medication effect. This approach directly addresses the pharmacokinetic cause of the symptoms rather than immediately assuming new pathology.

WRONG ANSWER ANALYSIS:

Option A (Development of a new co-morbid depression) is less likely because the symptoms are clearly time-linked to the medication wearing off, rather than being pervasive throughout the day.

Option C (Side effect of the atomoxetine he is taking) is incorrect as the vignette explicitly states the patient is taking Equasym XL (methylphenidate), not atomoxetine.

Option D (He is developing an eating disorder) is not supported by the primary symptoms presented, which are mood-related, although appetite suppression can be a side effect of stimulants.

Option E (This is a sign the dose is too high) is incorrect because symptoms of an excessive dose typically include emotional blunting, tics, or persistent anxiety while the medication is active, not when it wears off.

CORRECT ANSWER:

National Institute for Health and Care Excellence (NICE) guidelines mandate routine monitoring for children on stimulant medication for ADHD. Methylphenidate can have significant effects on growth and the cardiovascular system.

A key side effect is appetite suppression, which can lead to poor weight gain and impact linear growth; therefore, height and weight must be plotted on a centile chart at least every 6 months. As a stimulant, it can also increase heart rate and blood pressure. Regular monitoring of these cardiovascular parameters is essential to identify and manage potential adverse effects like sustained tachycardia or hypertension, ensuring the treatment remains safe.

WRONG ANSWER ANALYSIS:

Option B (Full blood count, urea & electrolytes) is incorrect as methylphenidate is not known to cause haematological or renal abnormalities that would require routine blood monitoring.

Option C (Liver function tests and serum lipids) is incorrect because methylphenidate is not associated with hepatotoxicity or dyslipidaemia, making these tests unnecessary for routine surveillance.

Option D (ECG and Echocardiogram) is incorrect as these investigations are only recommended before starting treatment if there is a specific cardiac history or clinical concern, not for routine 6-monthly follow-up in a stable patient.

Option E (Urine drug screen and TSH) is incorrect because a urine drug screen is not used for therapeutic monitoring, and there is no indication that methylphenidate directly impacts thyroid function.

CORRECT ANSWER:

Atomoxetine is a noradrenaline reuptake inhibitor known to carry risks of cardiovascular side effects, including increases in heart rate, blood pressure, and importantly, prolongation of the QTc interval.

NICE guidance specifies that while an ECG is not routinely required before starting atomoxetine, it is mandatory if there are specific cardiac risk factors. A history of sudden death in a first-degree relative under 40 years is a major red flag for a potential underlying hereditary cardiac channelopathy, such as Long QT syndrome.

Prescribing a QTc-prolonging medication like atomoxetine in this context without a baseline ECG would be dangerous, as it could precipitate a fatal arrhythmia. Therefore, a 12-lead ECG is the most critical investigation to screen for any baseline cardiac electrical abnormality before commencing treatment.

WRONG ANSWER ANALYSIS:

Option A (Echocardiogram) is incorrect because it assesses cardiac structure and function, whereas the immediate risk related to atomoxetine and the family history is of an electrical conduction abnormality.

Option C (24-hour ambulatory BP monitor) is less appropriate as a first-line investigation; baseline blood pressure is normal and while monitoring is required, it is not the priority over assessing for a potentially fatal arrhythmia.

Option D (Serum electrolytes) is incorrect as electrolyte disturbances can cause arrhythmias, but there is nothing in the history to suggest this is the primary concern over an inherited channelopathy.

Option E (Liver function tests) is incorrect because although atomoxetine can rarely cause liver injury and baseline LFTs are good practice, the immediate life-threatening risk highlighted by the family history is cardiac.

CORRECT ANSWER:

This patient's presentation is a textbook example of ADHD – Inattentive Presentation. According to NICE guidelines, a diagnosis is based on a full clinical and psychosocial assessment, including evidence of inattention causing at least moderate impairment in academic or social settings.

The key features here are persistent inattention ("quiet and dreamy"), disorganisation ("loses her things"), and making "careless mistakes," which directly map onto diagnostic criteria. This inattentive subtype is more prevalent in girls and is frequently missed because of the absence of disruptive hyperactive behaviour. The description "bright but lazy" is a common label applied to children whose intellectual ability is undermined by the executive dysfunction characteristic of ADHD, leading to underperformance. A specialist assessment by a paediatrician or CAMHS is the required next step for formal diagnosis.

WRONG ANSWER ANALYSIS:

Option A (Absence Seizures) is incorrect as seizures are brief, episodic lapses of consciousness, which would not account for the pervasive disorganisation and other chronic functional impairments described.

Option C (Generalised Anxiety Disorder) is less likely because, while anxiety can impair concentration, the core features are excessive worry and associated somatic symptoms, which are not mentioned in this case.

Option D (Autistic Spectrum Disorder) is not the primary diagnosis as the vignette lacks any features of impaired social communication or restricted, repetitive behaviours, which are the core diagnostic criteria for ASD.

Option E (Simple laziness) is incorrect because laziness is a subjective judgement, not a clinical diagnosis, and fails to recognise a consistent pattern of neurodevelopmental symptoms in a child otherwise considered bright.

CORRECT ANSWER:

The clinical vignette describes a persistent pattern of negativistic, hostile, and defiant behaviour. The core features mentioned – loss of temper, arguing, and deliberately annoying others – are hallmark characteristics of Oppositional Defiant Disorder (ODD).

According to NICE guidelines, ODD and Conduct Disorder are common co-morbidities to consider in children with ADHD. The key to this diagnosis is that the behaviours are present across multiple settings (home and school) and are not simply a reaction to tasks the child finds difficult due to inattention, which could be attributed to ADHD alone.

Recognising this co-morbidity is crucial as it requires a specific management approach, often involving parent-training programmes alongside ADHD treatment.

WRONG ANSWER ANALYSIS:

Option A (Generalised Anxiety Disorder) is incorrect because the primary features would be excessive worry and physiological symptoms of anxiety, not deliberate defiance.

Option C (Autistic Spectrum Disorder) is less likely as the core features are deficits in social communication and restricted interests, not the specific oppositional pattern described.

Option D (Conduct Disorder) is incorrect as it represents a more severe pattern of behaviour involving aggression, destruction of property, or serious violation of rules, which is not described.

Option E (Attachment Disorder) is inappropriate because it is characterised by specific difficulties in forming social and emotional bonds with caregivers, stemming from a history of inadequate care.

CORRECT ANSWER:

Insomnia is a very common side effect of stimulant medications. NICE guidelines recommend that management of ADHD should be part of a comprehensive programme addressing psychological and behavioural needs.

The first-line approach to managing stimulant-induced insomnia is non-pharmacological. Modified-release methylphenidate has a duration of action of approximately 8-12 hours. Administering the dose as early as possible in the morning ensures that the plasma concentration has fallen significantly by bedtime, minimising its stimulating effect on sleep onset. This is the most conservative and logical first step. Furthermore, reinforcing sleep hygiene is crucial, as children with ADHD often have co-existing behavioural sleep problems. This combination directly addresses the likely cause of the insomnia with the least invasive intervention.

WRONG ANSWER ANALYSIS:

Option A (Add a small dose of melatonin) is incorrect because adding a second medication is not the first-line approach before optimising the administration of the primary drug.

Option B (Add a dose of immediate-release methylphenidate at 4 pm) is incorrect as this would introduce a further stimulant dose closer to bedtime, exacerbating insomnia.

Option C (Stop the methylphenidate and switch to atomoxetine) is incorrect because this is a significant change in treatment for a common side effect that can often be managed with simple adjustments.

Option D (Advise taking the medication at 12 pm) is incorrect as this would shift the therapeutic window and peak plasma concentration later into the evening, worsening sleep-onset delay.

CORRECT ANSWER:

NICE guideline NG87, which covers the diagnosis and management of ADHD, explicitly recommends an ADHD-focused parent-training programme as the first-line intervention for children under 6 years of age. This approach prioritises psycho-social and behavioural strategies to empower parents with the tools to manage their child's symptoms.

The clinical reasoning is to trial non-pharmacological interventions before considering medication in this young age group, thereby avoiding potential side effects and focusing on environmental and behavioural modifications first. Pharmacological treatment should only be considered in this age group if parent-training has been tried and has been unsuccessful, and the child's symptoms are causing a significant and persistent negative impact on their development and family life.

WRONG ANSWER ANALYSIS:

Option A (Start low-dose methylphenidate) is incorrect because medication is not the first-line management for a pre-school child with ADHD as per national guidelines.

Option B (Start low-dose atomoxetine) is incorrect as it is typically a second or third-line medication and is not the appropriate initial step, particularly in this age group.

Option D (Refer the child for individual play therapy) is incorrect because while potentially helpful for other conditions, it is not the specific evidence-based first-line intervention for managing core ADHD symptoms.

Option E (Advise watchful waiting) is incorrect as a diagnosis has been confirmed and the family is seeking help, indicating that active intervention is clinically warranted.

CORRECT ANSWER:

NICE guideline NG87 provides a clear, structured pharmacological pathway for managing ADHD in children and young people. First-line treatment is methylphenidate.

If a 6-week trial of methylphenidate proves ineffective or is not tolerated, the guidance recommends switching to lisdexamfetamine. In this case, the patient has had inadequate responses to sequential trials of both first-line stimulant options.

The guideline explicitly states that for patients whose symptoms have not responded to separate 6-week trials of both methylphenidate and lisdexamfetamine, the next step is to offer a non-stimulant medication. Atomoxetine, a selective noradrenaline reuptake inhibitor, is a licensed non-stimulant treatment for ADHD and is therefore the most appropriate next choice. This demonstrates a systematic and evidence-based approach to escalating treatment when initial therapies are unsuccessful.

WRONG ANSWER ANALYSIS:

Option B (Add aripiprazole) is incorrect because aripiprazole, an atypical antipsychotic, is not a standard treatment for core ADHD symptoms and is reserved for specific co-existing conditions like severe aggression, under specialist advice.

Option C (Re-trial methylphenidate at a higher dose) is incorrect as the patient has already been trialled at the maximum tolerated dose, making further dose escalation inappropriate and unsafe.

Option D (Refer for psychodynamic psychotherapy) is less appropriate because while psychological support is important, the immediate priority after exhausting first-line medications is to establish an effective pharmacological regimen.

Option E (Stop all medication and offer behavioural support only) is incorrect because the failure of two medications does not warrant the cessation of pharmacological treatment altogether; rather, it indicates the need to trial a different class of medication.

CORRECT ANSWER:

The most appropriate long-term plan is a Shared Care Agreement (SCA) between the GP and a specialist service. According to NICE guideline NG87, a structured transition plan is essential for young people with ADHD.

For a patient who is stable on medication, an SCA provides a robust framework for safe and effective continuing care in adulthood. This arrangement allows the GP, who will be the patient's primary healthcare provider at university, to handle the regular prescribing of lisdexamfetamine.

Crucially, the specialist service, typically an Adult ADHD clinic, retains responsibility for periodic reviews (usually every 6-12 months) to monitor treatment efficacy, side effects, and overall management. This collaborative model ensures continuity of a specialist-initiated treatment within primary care, which is the cornerstone of managing long-term conditions post-transition.

WRONG ANSWER ANALYSIS:

Option A (Transfer prescribing to university mental health service) is incorrect as these services are generally not commissioned or equipped for the specialist prescribing and monitoring of controlled drugs for ADHD.

Option C (Continue to prescribe from the paediatric clinic) is incorrect because paediatric services are not commissioned to provide care for adults, and a formal transition before 18 is a clinical and organisational requirement.

Option D (Stop his medication) is clinically inappropriate as abruptly ceasing effective treatment upon reaching an arbitrary age risks significant symptomatic relapse and functional impairment.

Option E (Transfer his care to the local Adult ADHD service for re-assessment) is less suitable because while an initial review by adult services is necessary, the long-term prescribing for a stable patient is most appropriately managed via an SCA with primary care.

CORRECT ANSWER:

This patient presents with co-morbid ADHD and Tourette's syndrome, a common combination. According to NICE guidelines, while stimulants are first-line for ADHD, they can exacerbate tics. Given the significant worsening of tics with methylphenidate, switching to another stimulant is ill-advised.

The most appropriate next step is to use a non-stimulant medication licensed for ADHD that does not typically worsen tics. Atomoxetine, a selective noradrenaline reuptake inhibitor, is licensed for ADHD in children and has a good evidence base for treating both ADHD symptoms and reducing tic severity. It is therefore the recommended choice in this clinical scenario where stimulants are contraindicated due to their effect on the co-morbid tics. This approach addresses the impairing ADHD symptoms while simultaneously managing the tic disorder, representing a safe and effective strategy.

WRONG ANSWER ANALYSIS:

Option A (Lisdexamfetamine) is incorrect because it is a stimulant, and like methylphenidate, it carries a high risk of exacerbating this patient's tics.

Option B (Risperidone) is incorrect as it is an antipsychotic for severe tics and does not treat the core symptoms of ADHD, which are noted to be very impairing.

Option D (Clonidine) is incorrect because while it has a role in treating both conditions, atomoxetine is typically preferred as a second-line agent for ADHD management due to its more robust evidence base.

Option E (Sertraline) is incorrect as it is a selective serotonin reuptake inhibitor (SSRI) used for depression and anxiety, and has no licensed indication or established efficacy for treating ADHD or tics.

CORRECT ANSWER:

Weight loss is a well-recognised side effect of stimulant medications like methylphenidate, primarily due to appetite suppression.

In a child whose ADHD symptoms are effectively controlled, the clinical priority is to manage this adverse effect with minimal disruption to their established therapeutic regimen. NICE guidelines advocate for regular monitoring of height and weight. Where weight loss is a concern, strategies should be considered to mitigate this. A planned "drug holiday" (e.g., at weekends and during school holidays) is a standard and pragmatic first-line approach. This allows for a compensatory increase in appetite and caloric intake, promoting "catch-up" growth, without compromising the medication's benefits during school days. It is a conservative measure that avoids the need for switching or adding medications unnecessarily.

WRONG ANSWER ANALYSIS:

Option A (Stop methylphenidate and start atomoxetine) is incorrect because switching to a second-line medication is a significant step and not indicated when the current drug is effective for the primary symptoms.

Option B (Advise taking the medication after his evening meal) is incorrect as modified-release methylphenidate is designed for daytime coverage and an evening dose would cause significant insomnia.

Option C (Refer to CAMHS for eating disorder assessment) is incorrect because the weight loss is almost certainly a medication side effect, and this referral is premature without first attempting to manage the stimulant's impact.

Option E (Add cyproheptadine as an appetite stimulant) is incorrect as adding another medication to counteract a side effect (polypharmacy) is not the preferred initial step, especially when a simpler behavioural modification is available.

CORRECT ANSWER:

According to NICE guideline NG87, for children aged 5 years and over with a confirmed diagnosis of ADHD causing persistent, significant impairment, pharmacological treatment is the first-line management.

Methylphenidate is the recommended first-choice medication. In this 7-year-old boy, the diagnosis is supported by reliable tools and observations from multiple settings, and the symptoms are impacting his ability to complete tasks, indicating significant impairment.

Therefore, initiating modified-release methylphenidate is the most appropriate and evidence-based next step to manage the core symptoms of ADHD. Modified-release preparations are often preferred for convenience and improved adherence during school hours.

WRONG ANSWER ANALYSIS:

Option A (Watchful waiting for 6 months) is incorrect because the child has a confirmed diagnosis with significant functional impairment, which requires active intervention.

Option B (Referral for a parenting/education programme) is incorrect as this is the first-line treatment for pre-school children (under 5s), not for a school-aged child where medication is prioritised.

Option C (Referral for individual Cognitive Behavioural Therapy) is incorrect because CBT is not a first-line treatment for the core symptoms of ADHD, although it can be a useful adjunct for co-existing conditions.

Option E (Start atomoxetine) is incorrect because atomoxetine is a second-line medication, only to be considered if methylphenidate is ineffective, not tolerated, or contraindicated.

CORRECT ANSWER:

the statement "this is just stress" is damaging on multiple clinical and psychological levels. Effective and empathetic communication is a cornerstone of managing functional neurological disorders (FND).

Attributing the patient's distressing physical symptoms solely to stress is factually simplistic; FND has a complex pathophysiology and can occur without an identifiable stressor. This language invalidates the reality of the patient's symptoms, which is a key barrier to establishing a therapeutic alliance. It also implies the patient has conscious control and can simply "stop" the symptoms, which is unhelpful and can induce guilt. National guidance emphasises a biopsychosocial approach, where validating the patient's experience is the critical first step to engaging them in essential multidisciplinary therapies, such as physiotherapy and cognitive behavioural therapy. Poor communication risks alienating the patient and family, hindering acceptance of the diagnosis and engagement with treatment.

WRONG ANSWER ANALYSIS:

Option A (It is inaccurate; FND is not always caused by stress or trauma) is a correct statement but is an incomplete answer, as it only addresses the factual inaccuracy of the clinician's statement.

Option B (It is illegal to make a psychiatric diagnosis without being a psychiatrist) is incorrect because FND is a neurological diagnosis that can be made by a paediatrician or neurologist, and the term 'illegal' is inaccurate in this context.

Option C (It invalidates the patient's physical symptoms) is a crucial point and a primary reason the statement is harmful, but it represents only one facet of the overall problem.

Option D (It implies the patient can "just stop being stressed" and get better) is also correct in that it highlights the unhelpful oversimplification, but it does not encompass the other harmful aspects.

CORRECT ANSWER:

The diagnosis of Abdominal Migraine is made clinically, based on internationally recognised criteria such as Rome IV. This patient presents with the classic triad: paroxysmal, midline abdominal pain severe enough to interrupt normal activities; associated vasomotor symptoms (pallor); and a strong family history of migraine.

The episodic nature, with a complete return to baseline health between attacks, is a key diagnostic feature. In UK practice, recognising this pattern is crucial to avoid unnecessary investigations and to provide a positive diagnosis, allowing for appropriate management discussions. The pain is typically periumbilical or poorly localised and lasts for at least one hour. This constellation of symptoms makes Abdominal Migraine the most specific and likely diagnosis.

WRONG ANSWER ANALYSIS:

Option A (Somatic Symptom Disorder) is incorrect as it requires the presence of excessive and disproportionate thoughts, feelings, or behaviours related to the physical symptoms, which are not described here.

Option C (Irritable Bowel Syndrome) is less likely because the pain is not related to defecation, and there is no mention of altered stool frequency or form.

Option D (Functional Abdominal Pain Disorder) is distinguished by pain that is more continuous or occurs daily, unlike the discrete, severe episodes seen in this child.

Option E (Childhood periodic syndromes) is a correct but broad category that includes abdominal migraine; however, Abdominal Migraine is the most precise diagnosis given the specific clinical features.

CORRECT ANSWER:

The priority in the first consultation for a young person with multiple somatic symptoms is to build a strong therapeutic alliance. This is achieved by first validating their experience through a comprehensive history and examination.

This approach acknowledges the reality of the symptoms for the patient. The clinical focus should then shift from a potentially unrevealing search for an organic "cause" to exploring the functional impact of the symptoms on the adolescent's life (e.g., school attendance, social activities, sleep). This strategy, recommended in paediatric guidance, de-escalates conflict, builds trust, and reframes the problem towards rehabilitation and management of symptoms, rather than an elusive cure.

It lays the groundwork for a collaborative management plan, which may later involve psychological support.

WRONG ANSWER ANALYSIS:

Option A (Tell the family you will "find the cause" of the symptoms) is incorrect because it sets an unrealistic expectation that may lead to endless investigations and undermine long-term management if a single cause is not found.

Option B (Focus on the psychological trauma that must have caused this) is incorrect as it makes an unsupported assumption early in the consultation, which can alienate the patient and family.

Option D (Refer immediately to CAMHS, as this is not a paediatric issue) is incorrect because a thorough paediatric assessment is required first to exclude underlying organic disease and to manage the physical symptoms.

Option E (Discharge back to the GP with advice to "avoid stress") is incorrect as this is dismissive, invalidates the patient's significant symptoms, and fails to provide a constructive management plan.

CORRECT ANSWER:

The diagnosis is Conversion Disorder, also known as Functional Neurological Disorder (FND). This is a positive diagnosis based on clinical signs of inconsistency, not a diagnosis of exclusion.

The history of sudden-onset blindness following a traumatic event is a classic presentation. The key diagnostic findings are the intact pupillary light reflexes and the positive optokinetic nystagmus (OKN) test. Intact pupillary reflexes demonstrate the integrity of the afferent visual pathway from the retina to the brainstem. The positive OKN response, an involuntary tracking of a moving drum, confirms that the visual pathway to the brainstem is functional.

This proves the brain is processing visual information, even without conscious awareness of sight. This discrepancy between objective findings (intact pathways) and subjective experience (blindness) is the hallmark of a functional sensory deficit. National guidelines emphasise recognising these positive clinical signs to make a diagnosis and initiate appropriate multidisciplinary management, avoiding unnecessary investigations.

WRONG ANSWER ANALYSIS:

Option A (Optic neuritis) is incorrect because inflammation of the optic nerve typically causes a relative afferent pupillary defect, meaning the pupillary light reflexes would be abnormal.

Option B (Pituitary tumour) is less likely as it usually causes a gradual, progressive visual field defect (classically bitemporal hemianopia) rather than sudden total blindness, and may also affect pupillary reflexes.

Option C (Cortical blindness) is incorrect because although pupillary reflexes are preserved (as the reflex arc bypasses the visual cortex), the optokinetic nystagmus response would be absent as it requires cortical processing.

Option E (Malingering) is less appropriate because this implies conscious deception for external gain, whereas Conversion Disorder is a subconscious psychiatric response to stress, which is more likely in a child after a witnessed trauma.

CORRECT ANSWER:

Functional Neurological Disorders (FND), including functional motor disorders, are best understood as a problem with nervous system functioning, not structural damage. The first-line treatment is specialist physiotherapy, often as part of a multidisciplinary team approach.

The core principle is retraining movement patterns by leveraging the brain's neuroplasticity. Physiotherapists use techniques that focus on automatic movements, distraction, and positive reinforcement of normal function to help the patient regain control. This approach is based on a positive diagnosis (like Hoover's sign) and empowers the patient by treating the condition as genuinely experienced and reversible. Early engagement with this rehabilitative therapy is crucial for restoring function and preventing the secondary complications of inactivity.

WRONG ANSWER ANALYSIS:

Option B (Graded exercise therapy) is incorrect because it is a treatment primarily for chronic fatigue syndrome and is distinct from the specific motor retraining techniques required for FND.

Option C (Fluoxetine) is incorrect as it is an antidepressant and would only be considered if there was a significant co-morbid mood disorder, not as a primary treatment for the motor symptom itself.

Option D (Family-based therapy) is incorrect because while family involvement is vital for support, the primary intervention must directly address the patient's physical symptoms through specialist physiotherapy.

Option E (Inpatient admission for "rest") is incorrect as prolonged rest can reinforce illness behaviour, lead to deconditioning, and worsen outcomes in functional motor disorders.

CORRECT ANSWER:

The most likely diagnosis is Illness Anxiety Disorder. This adolescent displays a persistent preoccupation with having a serious illness, specifically a brain tumour, despite repeated normal investigations and a lack of corroborating clinical signs.

The core features are the excessive health-related anxiety and behaviours, such as repetitive "Googling" and seeking multiple medical opinions and scans, which are disproportionate to his actual physical state. Crucially, somatic symptoms are minimal or absent; the distress stems from the fear and interpretation of having an illness, not from a significant physical complaint like a severe headache.

According to diagnostic criteria, this pattern has persisted for well over six months. The key management principle involves acknowledging the patient's distress while avoiding collusion with the health anxiety through further unnecessary investigations, which can reinforce the belief and increase iatrogenic harm. Instead, a focus on managing the anxiety itself is the priority.

WRONG ANSWER ANALYSIS:

Option A (Somatic Symptom Disorder) is incorrect because it requires one or more distressing somatic symptoms that cause significant disruption, which are not the prominent feature here.

Option C (Conversion Disorder) is incorrect as it presents with neurological symptoms, such as weakness or seizures, that are clinically inconsistent with a neurological disease.

Option D (Factitious Disorder) is incorrect because there is no evidence of conscious falsification of symptoms to assume the sick role.

Option E (Delusional Disorder, somatic type) is less likely because the belief is not of a fixed, delusional intensity; the patient is still seeking reassurance through investigation, suggesting some level of doubt.

CORRECT ANSWER:

This presentation is highly suggestive of Fabricated or Induced Illness (FII), a serious form of child abuse and a safeguarding emergency. National guidance from the Royal College of Paediatrics and Child Health (RCPCH) and NICE mandates that when FII is suspected, the immediate priority is the child's safety.

This is achieved by initiating formal child protection procedures. An urgent safeguarding referral to children's social care and the prompt convening of a multi-agency strategy meeting are the correct first steps. This ensures a coordinated, legally robust plan is developed by all relevant agencies (paediatrics, social care, police) to protect the child from further harm. All other considerations are secondary to this primary safeguarding duty.

WRONG ANSWER ANALYSIS:

Option A (Confront the mother) is incorrect because direct confrontation is dangerous, potentially escalating harm, leading to the child's removal from a safe setting, or prompting the destruction of evidence.

Option B (Install covert video surveillance) is incorrect as an immediate step; CVS is a significant investigative tool that can only be authorised later, following a formal multi-agency strategy meeting decision.

Option C (Ask the mother to no longer stay) is incorrect as this is an unplanned, confrontational action that could precipitate harm and is not a substitute for a formal safeguarding plan.

Option E (Refer the child to clinical immunology) is incorrect because while excluding underlying pathology is part of the overall management, it is not the immediate priority when faced with such a significant and acute safeguarding concern.

CORRECT ANSWER:

This is a classic presentation of a functional somatic syndrome, such as chronic widespread pain. National guidelines, including those from NICE, advocate for a biopsychosocial approach.

The priority is to validate the patient's symptoms as real while simultaneously avoiding iatrogenic harm from unnecessary investigations. Further tests can reinforce unhelpful illness beliefs and anxiety, delaying the shift towards a rehabilitation-focused management plan. Acknowledging the parents' concerns is crucial for building a therapeutic alliance, but the clinician must then firmly and clearly explain the rationale for pivoting towards a multidisciplinary pain management programme, which is the cornerstone of effective treatment. This involves physiotherapy, psychological support, and a focus on functional recovery, such as returning to school and hobbies.

WRONG ANSWER ANALYSIS:

Option A (Order the MRI to reassure the parents and build rapport.) is incorrect because it medicalises the situation, has a very low diagnostic yield, and can increase anxiety by revealing incidental findings.

Option C (Refer to an infectious disease specialist for the Lyme test.) is incorrect as it validates a likely unhelpful diagnostic path based on parental request rather than clinical evidence, delaying appropriate management.

Option D (Tell the parents their anxiety is making the child ill.) is incorrect because it is accusatory, unprofessional, and will destroy the therapeutic relationship required to manage this complex condition.

Option E (Prescribe amitriptyline and discharge from paediatrics.) is incorrect because while amitriptyline may have a role, it should be part of a holistic management plan, and premature discharge without follow-up is inappropriate.

CORRECT ANSWER:

The management of Somatic Symptom Disorder requires a fundamental shift from a biomedical model focused on finding and fixing a pathology to a biopsychosocial approach prioritising rehabilitation.

The core principle is to improve function despite the persistence of symptoms. The entire multidisciplinary team, including paediatrics, physiotherapy, and CAMHS, must align on this goal. The focus is on shared, functional objectives, such as a phased return to school and social activities, which are negotiated with the patient and family.

This approach uses graded exposure and cognitive behavioural therapy (CBT) to challenge dysfunctional beliefs and replace illness behaviours with healthy ones. The aim is to break the cycle of symptom focus and avoidance, which perpetuates disability. Validating the reality of the symptoms is crucial, but the therapeutic momentum must be towards re-engagement with normal adolescent life.

WRONG ANSWER ANALYSIS:

Option A is incorrect because continuing to search for a single organic cause reinforces illness beliefs and can lead to unnecessary, invasive investigations.

Option B is incorrect as prolonged rest leads to physical deconditioning, social isolation, and worsens functional impairment, directly opposing the goal of rehabilitation.

Option D is incorrect because parenteral analgesia is inappropriate, highly medicalises the situation, and reinforces the idea that the pain is a purely biological problem requiring aggressive treatment.

Option E is incorrect because while the GP has a role, the complexity of this disorder necessitates coordinated management by a specialist paediatric and mental health MDT.

CORRECT ANSWER:

The core feature is the intentional falsification of physical or psychological signs or symptoms, associated with identified deception. This patient is observed deliberately causing oral bleeding to simulate haemoptysis.

The motivation in Factitious Disorder is to assume the sick role, seeking medical attention and investigation without any obvious external incentive. The normal chest X-ray, full blood count, and coagulation studies effectively rule out a genuine underlying medical cause for haemoptysis, strengthening the diagnosis. The nurse's observation is the crucial piece of information that points towards fabrication rather than a genuine, unexplained medical symptom.

WRONG ANSWER ANALYSIS:

Option B (Somatic Symptom Disorder) is incorrect because it involves genuine, distressing physical symptoms that the patient truly experiences, whereas this patient is consciously fabricating the sign.

Option C (Malingering) is incorrect as there is no evidence of an external incentive, such as financial gain or avoidance of duties, which is the primary motivation for malingering.

Option D (Conversion Disorder (FND)) is incorrect because it typically presents with neurological symptoms, such as weakness or seizures, that are incongruent with medical assessment.

Option E (Pulmonary haemosiderosis) is incorrect as this is a genuine cause of pulmonary haemorrhage which would be excluded by the normal chest X-ray and clinical observation.

CORRECT ANSWER:

The key to this diagnosis lies in understanding insulin metabolism. The pancreas secretes pro-insulin, which is cleaved into equimolar amounts of insulin and C-peptide. Therefore, any cause of endogenous hyperinsulinism will result in elevated levels of both.

The provided blood results show a high insulin level but a suppressed C-peptide level. This specific biochemical pattern is pathognomonic for the administration of exogenous insulin, as commercially produced insulin preparations do not contain C-peptide. In the context of symptoms occurring only when a specific carer is present, this strongly points towards Fabricated or Induced Illness (FII).

According to RCPCH guidance on child protection, any unexplained clinical presentation, particularly with discordant laboratory findings, should raise safeguarding concerns. The immediate priority is managing the hypoglycaemia, followed by a multi-agency safeguarding investigation.

WRONG ANSWER ANALYSIS:

Option A (Insulinoma) is incorrect because an insulin-secreting tumour would produce high levels of both insulin and C-peptide.

Option B (Glycogen storage disease) is incorrect as it typically presents with ketotic hypoglycaemia and suppressed insulin levels.

Option D (Factitious hypoglycaemia (Munchausen's)) describes the broader safeguarding diagnosis, but surreptitious administration of insulin is the specific mechanism proven by the biochemistry.

Option E (Ketotic hypoglycaemia) is incorrect as it is a diagnosis of exclusion characterised by low insulin levels during a hypoglycaemic episode.

CORRECT ANSWER:

The computer analogy is the most effective, non-stigmatising method for explaining FND to a child and their family. It validates the patient's symptoms as genuine while clearly stating that there is no underlying structural brain disease.

This model explains that the brain's processing (software) is not functioning correctly, despite the physical structure (hardware) being intact, as confirmed by normal scans. This approach aligns with best practice recommendations to provide a clear, understandable, and mechanistic explanation for the disorder.

It empowers the family by demystifying the condition, reducing blame or confusion, and laying a positive foundation for engaging with multidisciplinary therapies, which are the cornerstone of FND management.

WRONG ANSWER ANALYSIS:

Option B is incorrect because it prematurely labels the condition as purely psychiatric, which is stigmatising and an oversimplification of a complex neuropsychiatric disorder.

Option C is incorrect as stating "nothing is physically wrong" can be interpreted by the family as a dismissal of the child's very real and distressing physical symptoms.

Option D is incorrect because labelling FND a "pseudo-illness" is invalidating and harmful, and ignoring the symptoms is contrary to the active engagement required in therapy.

Option E is incorrect because it promotes over-investigation and diagnostic uncertainty, which can increase anxiety and is inappropriate once a positive diagnosis of FND is made based on clinical signs.

CORRECT ANSWER:

The clinical features described, including asynchronous thrashing movements, side-to-side head shaking, tightly closed eyes, and immediate return to full alertness after a prolonged event without cyanosis, are highly suggestive of a Non-Epileptic Seizure (NES), also known as a dissociative or functional seizure.

According to NICE guideline [NG217], the gold-standard investigation to confirm the diagnosis is video-telemetry EEG monitoring. This procedure involves simultaneous video recording of the patient's clinical behaviour and EEG monitoring to capture a typical event. A definitive diagnosis of NES is made when a characteristic clinical episode is recorded on video without any corresponding epileptiform electrical activity on the EEG. This is a crucial step to differentiate NES from epileptic seizures, thereby avoiding misdiagnosis and the inappropriate, and potentially harmful, initiation of anti-epileptic drugs.

WRONG ANSWER ANALYSIS:

Option A (Serum prolactin level) is incorrect because prolactin has poor sensitivity and specificity for distinguishing between epileptic and non-epileptic seizures in the paediatric population.

Option C (An urgent CT head scan) is not indicated as the primary investigation for a suspected NES in a patient with a normal neurological examination.

Option D (A therapeutic trial of IV lorazepam) is inappropriate as it is a treatment for status epilepticus and does not provide a definitive diagnosis; any response could be due to placebo or suggestion.

Option E (Checking for Babinski's sign) is an unreliable clinical sign in this context, as the plantar response can be variable and is not a definitive differentiator between seizure types.

CORRECT ANSWER:

The diagnosis of Somatic Symptom Disorder is based on positive clinical features, not merely the exclusion of organic disease. This patient presents with a chronic, distressing somatic symptom (abdominal pain) for over six months.

Crucially, this is coupled with excessive and disproportionate thoughts and behaviours, evidenced by significant school absenteeism and persistent requests for further investigation despite a comprehensive and negative workup. According to RCPCH guidance on medically unexplained symptoms, the management priority shifts from repeated investigations to a biopsychosocial approach focused on restoring function, such as school attendance.

The normal investigations make a new organic pathology highly improbable, and the clinical picture strongly supports a functional diagnosis where the focus is on managing the symptoms and their impact.

WRONG ANSWER ANALYSIS:

Option A (Abdominal migraine) is incorrect because it typically presents as paroxysmal, severe episodes with symptom-free periods, not a persistent six-month history of pain.

Option B (Inflammatory Bowel Disease) is very unlikely given the normal C-reactive protein and, most definitively, a normal endoscopy.

Option D (Factitious Disorder) is not supported as there is no evidence of conscious deception or induction of symptoms by the patient or carer.

Option E (Illness Anxiety Disorder) is less appropriate because the core feature is a prominent physical symptom (pain), whereas Illness Anxiety Disorder involves preoccupation with having a serious illness with minimal or no somatic symptoms.

CORRECT ANSWER:

The clinical presentation is classic for a functional neurological disorder (FND). The key diagnostic clue is the clinical inconsistency: formal examination reveals 0/5 power, yet the patient demonstrates preserved functional ability by standing on her tiptoes.

This is a positive clinical sign of FND, not a diagnosis of exclusion. The normal reflexes and MRI spine further argue against an organic pathology. National guidelines advocate for a multidisciplinary approach, with early involvement of physiotherapy being the cornerstone of management.

The focus is on rehabilitation and retraining neural pathways through functional movements, validating the patient's experience while promoting recovery. This approach avoids the potential harm of iatrogenic investigations and focuses on restoring function.

WRONG ANSWER ANALYSIS:

Option A (Repeat the MRI with contrast) is incorrect as the initial normal MRI makes a structural lesion highly improbable and further imaging would be an unnecessary investigation.

Option C (Prescribe a short course of diazepam for "stress") is incorrect because pharmacotherapy is not a first-line treatment for FND and risks medicalising a non-pharmacological condition.

Option D (Refer for lumbar puncture to exclude GBS) is incorrect as the presence of normal reflexes is inconsistent with the typical areflexia or hyporeflexia seen in Guillain-Barré syndrome.

Option E (Explain to her that the weakness is "not real") is incorrect because this approach is invalidating, damaging to the therapeutic alliance, and counterproductive to recovery as the symptoms are experienced as real by the patient.