KFP – Mental health (Psychiatry)

Linda Thompson, aged 42, presents to your general practice clinic accompanied by her husband. Over the past two months, her husband has noticed increasing social withdrawal, disrupted sleep, and weight loss. Linda describes ongoing feelings of worthlessness and guilt, stating that she “can’t go on much longer.” She is tearful throughout the consultation. She reports poor concentration and a lack of interest in her usual activities. She denies alcohol or illicit drug use.

Medications: None

Allergies: Nil known

Past history: GORD, treated with lifestyle measures

Family history: Mother had postnatal depression; no history of bipolar disorder or suicide

Social history: Married, two children aged 9 and 11, works part-time as a librarian. No recent life stressors. Non-smoker, occasional wine on weekends

Psychiatric history: No previous psychiatric diagnoses

Preventative Healthcare: Cervical screening up to date, BMI 22

Examination findings: No psychomotor agitation or retardation. Appears sad but cooperative. No abnormal movements. No delusions or hallucinations elicited on MSE.

What is the most appropriate next step in management? Select three (3) from the following list:

Mark Reynolds, a 22-year-old university student, is brought in by his parents due to concerning behavioural changes over the past 3 weeks. They report that Mark has become increasingly suspicious, stating that he is being watched through the television and that strangers on the street are talking about him. He has been sleeping poorly and has become socially withdrawn, spending most of his time alone in his room. Mark denies any drug use, but his parents are unsure. He is not currently taking any medication and has no known allergies.

Past history: No documented medical or psychiatric conditions

Family history: Paternal uncle diagnosed with schizophrenia

Social history: Lives with parents, previously outgoing and high-achieving, now failing university assignments. No romantic relationships. No employment.

Psychiatric history: None

Examination findings: On mental state examination, Mark appears guarded and distracted. He is reluctant to engage in conversation and avoids eye contact. He denies hallucinations but admits that he is “not safe at home” and that “they are trying to read my thoughts.” He does not report suicidal ideation. Physical examination is unremarkable.

What are the most appropriate next steps in management? Select four (4) from the following list:

Helen Armstrong, a 55-year-old woman, presents with her daughter due to increasing forgetfulness over the past year. Her daughter reports that Helen has started misplacing items, repeating questions, and forgetting recent conversations. Helen has also become more socially withdrawn and has difficulty following recipes she once cooked regularly. There have been no episodes of incontinence or significant changes in gait.

Medications: Ramipril 5 mg daily

Allergies: Nil known

Past history: Hypertension, hypercholesterolaemia

Family history: Father had dementia; died at 78

Social history: Lives with husband, retired teacher, non-smoker, drinks 1–2 glasses of wine per week. Independent in ADLs, no history of head trauma or stroke.

Examination findings: MMSE score is 23/30 with deficits in short-term memory and recall. Gait is normal. No focal neurological signs. Cardiovascular and respiratory exams are unremarkable.

What are the most appropriate next steps in investigation and management? Select three (3) from the following list:

Ravi Singh, a 17-year-old high school student, presents with his parents after an episode of deliberate self-harm where he superficially cut his forearm with a razor blade. His parents are distressed and report that Ravi has been increasingly withdrawn, irritable, and is refusing to attend school. He admits to feeling ’empty’ and ‘useless’ but denies any current suicidal ideation. He has not previously seen a psychologist or psychiatrist. He denies alcohol or drug use.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Maternal aunt with a history of depression and previous suicide attempt

Social history: Lives with both parents and younger sister. No known bullying. He was a high academic performer but has recently dropped in grades. No current romantic relationships. No previous involvement with child protection or youth justice.

Psychiatric history: None

Examination findings: On mental state examination, Ravi is quiet and guarded. His affect is flat. He maintains minimal eye contact and gives short responses. There are superficial linear lacerations visible on his left forearm. He denies suicidal ideation or psychotic symptoms. Insight is limited.

What are the most appropriate management actions? Select four (4) from the following list:

Barry Whitlam, a 48-year-old man, presents to your clinic at the request of his employer, who is concerned about Barry’s recent erratic behaviour and poor performance at work. Barry works as a construction foreman and has recently missed deadlines and displayed irritability with colleagues. He is loud and animated in the consultation, speaking rapidly and switching topics frequently. He insists he doesn’t need help but says he hasn’t been sleeping because he’s ‘too busy with plans’. He believes he’s come up with an idea that will ‘revolutionise the building industry’ but won’t share it because others might steal it.

Medications: None

Allergies: Nil known

Past history: Hypertension, no psychiatric history

Family history: Sister with bipolar disorder

Social history: Married with two children, occasional alcohol use, no illicit drug use. No forensic history.

Examination findings: On MSE, Barry is distractible, euphoric with pressured speech and grandiose ideas. He denies depressive symptoms, hallucinations, or suicidal ideation. He is oriented to time and place. Physical exam is normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sarah McKenzie, a 31-year-old woman, presents with her partner due to ongoing panic attacks that have worsened over the last three months. She describes sudden episodes of intense fear, palpitations, breathlessness, chest tightness, and a fear of dying. These episodes occur without a clear trigger and usually last about 10–20 minutes. She has visited the ED twice thinking she was having a heart attack, but investigations were normal. Between attacks, she reports anticipatory anxiety and avoids crowded places, fearing another attack. She has started missing work and avoids shopping centres and public transport.

Medications: None

Allergies: Nil known

Past history: Iron deficiency anaemia

Family history: Mother with generalised anxiety disorder

Social history: Lives with partner, works as a primary school teacher, non-smoker, no alcohol or drug use

Psychiatric history: Nil

Examination findings: Vitals normal. Cardiovascular, respiratory, and neurological exams are normal. Mental state examination shows anxious affect and mild hypervigilance. No suicidal ideation or psychosis.

What are the most appropriate next steps in management? Select four (4) from the following list:

Daniel O’Connor, a 64-year-old retired truck driver, presents at the request of his wife who is concerned about his low mood and social withdrawal since he stopped working 8 months ago. Daniel reports poor sleep, low energy, loss of interest in gardening and fishing, and feelings of hopelessness. He denies suicidal ideation but says he “wouldn’t mind if it all ended.” He has lost 6kg over the past two months unintentionally and has minimal appetite. He spends most days in bed or watching TV. He has not previously sought help for mental health issues.

Medications: Amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension, osteoarthritis in knees

Family history: No known psychiatric illness

Social history: Married, two adult children. Non-smoker, drinks 4–5 standard drinks daily. Lives in a rural town, no access to psychologist locally.

Psychiatric history: None documented

Examination findings: Appears dishevelled with slowed speech and psychomotor retardation. Affect is blunted. No hallucinations or delusions. Mini-mental examination score is 28/30.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amira Hussain, a 26-year-old university student, presents with a 6-month history of persistent low mood, fatigue, and difficulty concentrating. She reports feeling tense most of the time and worries excessively about academic failure, finances, and the wellbeing of her parents. She describes difficulty falling asleep and frequent muscle tension. She denies suicidal ideation or history of trauma. These symptoms have led to declining academic performance and social withdrawal. She has not tried any treatments to date.

Medications: None

Allergies: Nil known

Past history: Nil medical or psychiatric diagnoses

Family history: Mother with generalised anxiety disorder (GAD)

Social history: Lives in shared housing with other students, no drug or alcohol use, non-smoker

Examination findings: Alert, cooperative, appears anxious. MSE reveals anxious affect, logical thought process, no hallucinations or delusions, no suicidal ideation. Vitals and physical examination are normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Luke Hammond, a 36-year-old Aboriginal man, presents to your rural general practice for follow-up after a recent discharge from a metropolitan hospital where he was treated for alcohol withdrawal. He has a 10-year history of daily heavy alcohol use and reports drinking 12–16 standard drinks per day until two weeks ago. He completed a 7-day inpatient detoxification program and has returned to his home community. He reports strong cravings and is worried he might relapse. Luke says he wants to stay off alcohol for good this time and asks for help. He has no known liver disease but has lost weight and appears tired. He is currently unemployed and disconnected from family supports. He is open to referral if needed.

Medications: Nil

Allergies: Nil known

Past history: Hypertension, treated intermittently; no prior mental health diagnoses

Family history: Father died from alcohol-related liver disease at age 52

Social history: Lives alone in a remote Aboriginal community; limited access to health services; no access to psychologist locally

Examination findings: Appears thin, mildly tremulous. Vitals normal. No stigmata of chronic liver disease. MSE: low mood, good insight, no psychosis, no suicidal ideation.

What are the most appropriate next steps in management? Select four (4) from the following list:

Michelle Tran, a 19-year-old university student, is brought in by her roommate after expressing thoughts of hopelessness and posting concerning messages on social media. Michelle has recently broken up with her partner and has stopped attending classes. She reports sleeping poorly, crying most days, and having no appetite. When asked directly, she says she has been thinking about suicide but denies having a specific plan. She states, “I just don’t see the point anymore.” She has no prior psychiatric history and no current medications.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Maternal aunt with depression

Social history: Lives in shared housing, estranged from family, no drug or alcohol use

Examination findings: Flat affect, low volume of speech. Appears tearful and withdrawn. Oriented to time and place. No hallucinations or delusions. Mild psychomotor retardation. No signs of self-injury.

What are the most appropriate next steps in management? Select four (4) from the following list:

George Petrou, a 72-year-old retired accountant, presents with his daughter who is concerned about his increasing irritability, suspiciousness, and social withdrawal over the past 4 months. He believes his neighbours are stealing from his mailbox and that his food is being tampered with. He has started keeping curtains closed and has installed multiple locks on his doors. George is otherwise independent in his activities of daily living and has no known cognitive impairment. He has no history of mental illness and has always been described as private and reserved.

Medications: Atorvastatin 20 mg nocte, aspirin 100 mg daily

Allergies: Nil known

Past history: Hyperlipidaemia, stable coronary artery disease

Family history: Brother diagnosed with schizophrenia in his twenties

Social history: Widowed, lives alone, non-smoker, drinks 1–2 glasses of wine per week

Examination findings: Alert and oriented, no memory deficits on brief screen. MSE: guarded, suspicious, with persecutory delusions. No hallucinations or thought disorder. Insight is limited. Physical exam is unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Zhang, a 29-year-old postgraduate student, presents to your clinic at the request of her university counsellor. She has a long history of interpersonal difficulties, unstable relationships, and emotional outbursts. She reports intense fears of abandonment and has recently had several arguments with her partner, after which she engaged in impulsive behaviours such as binge drinking and self-cutting. Emily describes chronic feelings of emptiness and identity disturbance, alternating between idealising and devaluing others in her life. She denies suicidal intent but admits to recurrent self-harming behaviour. She has never been diagnosed with a psychiatric disorder and is not currently on any medications.

Medications: None

Allergies: Nil known

Past history: Nil medical or psychiatric diagnoses

Family history: Mother with depression

Social history: Lives alone, no substance abuse, occasional alcohol bingeing, studying psychology, no forensic history

Examination findings: Emily is tearful but cooperative. MSE reveals intense affective lability, low self-worth, and interpersonal mistrust. No psychotic features or suicidal ideation present. Evidence of superficial self-inflicted cuts on forearms.

What are the most appropriate next steps in management? Select three (3) from the following list:

Mohammed Khalil, a 46-year-old refugee originally from Syria, presents with ongoing sleep disturbance, hypervigilance, and irritability. He reports frequent nightmares about a traumatic incident involving a bombing that killed several family members five years ago. He avoids watching the news and avoids conversations that remind him of the war. He describes feeling emotionally numb, disconnected from his wife and children, and struggles to concentrate at work. Mohammed has never accessed mental health support before and is reluctant to talk about his experiences in detail. He has no history of substance use or suicidal ideation.

Medications: Nil

Allergies: Nil known

Past history: Hypertension, controlled

Family history: Nil psychiatric illness

Social history: Lives with wife and two children, employed part-time, fluent in Arabic with limited English. Attends local mosque regularly. No alcohol or drug use.

Examination findings: Quietly spoken, guarded, mildly anxious. Mental state examination reveals restricted affect, hypervigilance, and low mood. No psychosis or suicidal thoughts.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jessica Morgan, a 34-year-old primary school teacher, presents complaining of overwhelming fatigue, loss of interest in her usual activities, and feeling emotionally numb. She is 3 months postpartum with her second child and says she often feels detached from the baby. She cries most days and feels guilty for not being a ‘better mum’. Jessica reports difficulty sleeping despite the baby sleeping through the night and has frequent thoughts of being a burden to her family. She denies suicidal ideation or thoughts of harming the baby. Her first pregnancy was uneventful, with no prior mental health issues.

Medications: Nil

Allergies: Nil known

Past history: G2P2, otherwise healthy

Family history: Mother had postnatal depression

Social history: Married, supportive partner, no substance use

Examination findings: Jessica appears tearful with a flat affect. She is oriented and cooperative. No psychotic features. Edinburgh Postnatal Depression Scale (EPDS) score: 19.

What are the most appropriate next steps in management? Select three (3) from the following list:

Benjamin O’Leary, a 24-year-old university student, presents after being referred by campus security following an episode in which he was found pacing and talking to himself outside his dormitory late at night. He reports hearing voices that are critical and commanding, telling him he is ‘worthless’ and should ‘stay inside’. He believes his thoughts are being broadcast and that people around him can hear what he’s thinking. Benjamin recently stopped attending lectures and has withdrawn from social activities. He has no history of drug use and no known psychiatric history.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Maternal cousin with schizophrenia

Social history: Lives alone in student housing, no alcohol or drug use

Examination findings: On MSE, Benjamin appears distracted and guarded. He is responding to internal stimuli. Thought form is tangential and disorganised. Delusions of thought broadcasting and auditory hallucinations are present. No suicidal ideation noted.

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Russo, a 58-year-old woman, presents with her husband due to persistent low mood, loss of interest in daily activities, and early morning wakening. Her husband describes her as more withdrawn, with reduced appetite and increasing guilt about ‘being a burden’. Angela has a long-standing history of recurrent depression but has been stable for the past 10 years. She denies suicidal ideation but reports passive thoughts about ‘not wanting to wake up’. She recently stopped taking her sertraline 100 mg daily, which she had been on for several years, citing that she was ‘feeling fine and didn’t need it anymore’.

Medications: Previously on sertraline 100 mg daily (ceased 2 months ago)

Allergies: Nil known

Past history: Recurrent major depressive disorder, osteoarthritis

Family history: Sister with bipolar disorder

Social history: Married, retired teacher, non-smoker, drinks wine occasionally, no recent bereavement

Examination findings: Tearful with psychomotor slowing. Affect is low and thought content includes hopelessness and self-blame. No delusions or hallucinations. No acute risk behaviours.

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Yee, a 41-year-old man, presents with ongoing workplace stress and describes a pattern of feeling persistently ‘on edge’ for over a year. He reports difficulty relaxing, frequent muscle tension, insomnia, and chronic worry about job performance, finances, and his children’s wellbeing. He says he ‘can’t switch off his mind’ and often lies awake at night ruminating. There are no panic attacks, depressive symptoms, or substance use. He has not tried any previous treatments.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Sister with generalised anxiety disorder (GAD)

Social history: Married, two children, works full-time as an accountant. Drinks alcohol socially (1–2 drinks/week), no drug use. Non-smoker.

Examination findings: Alert, cooperative, with mild psychomotor agitation. MSE: anxious affect, no delusions or hallucinations, no suicidal ideation. Physical exam is unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Asha Patel, a 22-year-old university student, presents after experiencing a sudden episode of intense fear and physical symptoms while on a crowded train. She describes palpitations, chest tightness, dizziness, and a fear she was dying. The episode lasted about 15 minutes and resolved spontaneously. Since then, she has avoided public transport and feels anxious about leaving home in case it happens again. She reports ongoing anticipatory anxiety but no depressive symptoms, substance use, or other medical issues.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother with generalised anxiety disorder

Social history: Lives with friends in shared housing. No drug use, drinks alcohol socially

Examination findings: Appears anxious but cooperative. Vitals and physical examination are normal. MSE shows anxious affect, no suicidal ideation, no psychotic features.

What are the most appropriate next steps in management? Select three (3) from the following list:

John Bellamy, a 67-year-old retired bus driver, presents with his wife who is concerned about recent personality changes and emotional outbursts. Over the past 12 months, John has become increasingly disinhibited, rude in social settings, and impulsive with spending. He often makes inappropriate jokes, lacks insight into his behaviour, and has lost interest in hobbies. His memory is mostly intact, but he shows poor judgement and diminished empathy. There are no hallucinations or delusions. His wife denies any history of depression or mania. John has a history of hypertension and is on regular medication.

Medications: Perindopril 5 mg daily

Allergies: Nil known

Past history: Hypertension, mild hearing loss

Family history: Nil psychiatric or neurological conditions

Social history: Non-smoker, drinks 1–2 glasses of wine nightly, married with adult children, lives independently

Examination findings: Vitals stable. On cognitive screening (MoCA), memory is preserved, but executive function and abstract reasoning are impaired. MSE: inappropriate laughter and reduced insight, no psychosis or suicidal ideation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Natalie Green, a 38-year-old office worker, presents to your clinic with her partner due to persistent low mood, fatigue, and difficulty concentrating for the past 4 months. She describes feeling unmotivated and unworthy, with significant guilt about not fulfilling her responsibilities at work and at home. She has also experienced poor appetite and a 4 kg weight loss. Her partner is concerned as she has recently expressed that ‘everyone would be better off without me’. Natalie denies any specific suicide plan but admits to frequent passive thoughts of death. She has no previous psychiatric history.

Medications: Nil

Allergies: Nil known

Past history: Iron deficiency anaemia (resolved)

Family history: Father had major depressive disorder

Social history: Lives with partner, works part-time, non-smoker, no alcohol or substance use

Examination findings: Appears tired and tearful. Speech is slow but coherent. No psychosis. Passive suicidal ideation present, no intent or plan. PHQ-9 score: 20.

What are the most appropriate next steps in management? Select three (3) from the following list:

Samuel Peters, a 45-year-old logistics manager, presents after being encouraged by his wife due to chronic low mood, irritability, and excessive worry about minor problems. He describes feeling tense most days, having difficulty concentrating, and a constant sense of dread. These symptoms have been present for over a year and are affecting his performance at work. He denies panic attacks, suicidal ideation, or past mental health history. He has no history of substance use.

Medications: Nil

Allergies: Nil known

Past history: Hypercholesterolaemia, managed with diet

Family history: Father with generalised anxiety disorder

Social history: Married with two children, full-time employment, no alcohol or drug use, non-smoker

Examination findings: Alert, cooperative. Mild psychomotor agitation. MSE: anxious mood, worried thought content, no psychosis or suicidal ideation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Leah McDonald, a 30-year-old solicitor, presents to your clinic reporting that she has experienced two episodes of low mood in the past five years, both resolving with short courses of antidepressants. She now reports experiencing several days of increased energy, decreased need for sleep, and inflated self-esteem. She has recently spent a large sum of money impulsively on an online shopping spree and has been unusually talkative at work, interrupting others and feeling ‘unstoppable’. She denies hallucinations or current suicidal ideation, but says she has struggled to sleep and has racing thoughts. She stopped her antidepressants abruptly three weeks ago due to side effects.

Medications: None currently

Allergies: Nil known

Past history: Two prior episodes of major depression, no hospitalisations

Family history: Brother with bipolar disorder

Social history: Single, employed full-time, lives alone, no substance use

Examination findings: Pressured speech, elevated mood, distractibility. No delusions or hallucinations. Insight is poor. No suicidal ideation or intent.

What are the most appropriate next steps in management? Select three (3) from the following list:

Felicity Jones, a 52-year-old woman, presents at your clinic with a six-month history of intrusive thoughts about harming her family, which she finds highly distressing. She reports compulsively checking the stove, locking doors repeatedly, and avoiding kitchen knives. These behaviours have significantly impacted her daily routine, and she feels ashamed and anxious about her thoughts. She recognises the thoughts as irrational and has made several unsuccessful attempts to suppress them. Felicity denies hallucinations, delusions, or suicidal ideation. She has no history of mental illness and no substance use.

Medications: Nil

Allergies: Nil known

Past history: Migraine, well controlled

Family history: Mother with anxiety disorder

Social history: Lives with husband and two teenage children, works as a bookkeeper, non-smoker, no alcohol or drug use

Examination findings: Alert, cooperative. MSE: anxious mood, no psychosis, good insight, distress when discussing intrusive thoughts

What are the most appropriate next steps in management? Select three (3) from the following list:

Anthony Russo, a 61-year-old man, presents with his wife after he experienced a sudden episode of confusion and visual hallucinations while visiting his son interstate. He became agitated, insisted he was seeing people in the room who weren’t there, and was disoriented to time and place. These symptoms resolved over 48 hours, but since returning home, he has had fluctuating concentration and is easily startled. His wife reports he has been more forgetful lately and has developed a shuffling gait. He has no prior psychiatric history but has a longstanding history of type 2 diabetes and hypertension.

Medications: Metformin 1000 mg BD, amlodipine 5 mg daily

Allergies: Nil known

Past history: Type 2 diabetes, hypertension, osteoarthritis

Family history: No known psychiatric illness

Social history: Lives with wife, retired electrician, non-smoker, no alcohol

Examination findings: Alert but distracted. MMSE score 24/30. MSE: visual misperceptions, mildly slowed thought processes. Gait: slow, shuffling. Mild resting tremor. No rigidity. Vitals stable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Kylie Dawson, a 17-year-old high school student, presents with her mother due to ongoing low mood, poor concentration, and increased withdrawal from friends over the past 3 months. She reports sleeping poorly, loss of appetite, and frequent thoughts that life is not worth living. She denies suicidal intent but admits to occasional self-harming by scratching her forearms when distressed. Her academic performance has declined significantly. There is no history of substance use. She has not previously accessed mental health services.

Medications: None

Allergies: Nil known

Past history: Nil significant

Family history: Father with depression, maternal aunt with suicide attempt

Social history: Lives with both parents, Year 12 student, no alcohol or drug use

Examination findings: Appears flat, minimal eye contact. MSE: depressed mood, low affect, self-harm scars on forearms. No psychosis or suicidal plan. Good insight and engagement. PHQ-A score: 18.

What are the most appropriate next steps in management? Select three (3) from the following list:

Michael Lee, a 50-year-old accountant, presents with his wife due to a 6-month history of progressively worsening forgetfulness, difficulty following conversations, and missing appointments. His wife reports that he has been increasingly irritable, shows poor judgement, and has recently become suspicious that co-workers are conspiring against him. He has withdrawn from social events and shows little interest in previously enjoyed activities. There is no history of alcohol or substance use, head trauma, or psychiatric illness.

Medications: Nil

Allergies: Nil known

Past history: Hypertension, well controlled

Family history: No known history of dementia or psychiatric illness

Social history: Married, employed, non-smoker, no alcohol use

Examination findings: MMSE: 26/30 with impaired executive function and recall. MSE: suspicious thought content, flat affect, poor insight. No hallucinations. Physical exam: normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jasmine Noor, a 28-year-old retail worker, presents with her partner, who is concerned about Jasmine’s recent mood changes. Over the past month, Jasmine has been experiencing episodes of intense anxiety, palpitations, sweating, and nausea, particularly in social situations like work meetings or parties. She reports a fear of embarrassment, avoids speaking in groups, and feels people are constantly judging her. These symptoms began during adolescence but have worsened recently after a job promotion. She denies panic attacks occurring without a social context. No history of depression, substance use, or psychosis.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother with generalised anxiety disorder

Social history: Lives with partner, non-smoker, drinks alcohol occasionally, no drug use

Examination findings: Anxious but cooperative. MSE: anxious affect, no thought disorder, no delusions or hallucinations, good insight. Vitals and physical exam are normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Andrew Mitchell, a 62-year-old retired teacher, presents with a six-week history of persistent fatigue, reduced appetite, early morning wakening, and low mood. He has lost 5 kg unintentionally. He describes pervasive guilt about past parenting decisions and states, “I’ve let everyone down.” His wife reports that he has become socially withdrawn and rarely leaves the house. He denies hallucinations or delusions but admits to thoughts of death, though without active suicidal intent or plan. He has never previously been treated for depression.

Medications: Amlodipine 5 mg daily

Allergies: Nil known

Past history: Hypertension

Family history: Brother with depression

Social history: Lives with wife, two adult children, non-smoker, no alcohol or substance use

Examination findings: Appears older than stated age, flat affect, slow speech. MMSE: 28/30. No psychosis. Physical exam unremarkable. No suicidal plan.

What are the most appropriate next steps in management? Select three (3) from the following list:

Chloe Richards, a 24-year-old barista, presents with chronic difficulty falling asleep, non-restorative sleep, and persistent daytime fatigue over the past 8 months. She describes lying in bed for hours unable to ‘shut off her mind’, worrying about minor issues. She wakes feeling unrefreshed and finds it difficult to concentrate at work. She denies snoring, nightmares, or excessive daytime sleepiness. She has tried melatonin and herbal teas without benefit. She has no history of depression or substance use.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother with anxiety

Social history: Lives with flatmates, drinks 1–2 coffees daily, occasional alcohol on weekends, no recreational drug use

Examination findings: Vitals normal, BMI 22. No signs of thyroid disease or obstructive sleep apnoea. MSE: mildly anxious affect, no mood or psychotic features

What are the most appropriate next steps in management? Select three (3) from the following list:

Daniel Nguyen, a 33-year-old paramedic, presents with difficulty sleeping, irritability, and frequent nightmares about a traumatic accident he attended six months ago in which multiple children were injured. He reports experiencing flashbacks during the day and avoids driving past the accident site or watching medical dramas. He feels emotionally numb, struggles to connect with his partner, and startles easily at loud noises. Daniel has become socially withdrawn and has increased his alcohol intake to cope. He denies suicidal ideation but feels overwhelmed. He has no past psychiatric history.

Medications: Nil

Allergies: Nil known

Past history: Nil medical or psychiatric conditions

Family history: Father with alcohol dependence

Social history: Lives with partner, drinks 3–4 beers nightly, non-smoker, no illicit drugs

Examination findings: Alert, mildly anxious. MSE: constricted affect, no psychosis, no suicidal ideation. Avoidant body language when discussing trauma. Vitals stable. No cognitive deficits.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amelia Foster, a 19-year-old university student, presents with her mother expressing concern about recent behavioural changes. Over the past two months, Amelia has become increasingly socially withdrawn, suspicious of her housemates, and preoccupied with the belief that her lecturers are sending her secret messages through lectures. She has been sleeping poorly and has started neglecting personal hygiene. She was previously high-achieving academically and had no significant mental health history. There is no known substance use.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Paternal uncle with schizophrenia

Social history: Lives in student housing, non-smoker, no alcohol or drug use

Examination findings: Poor eye contact, dishevelled appearance, flat affect. MSE: thought broadcasting, persecutory delusions, and auditory hallucinations. Insight is limited. No suicidal or homicidal ideation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Hassan Ali, a 46-year-old small business owner, presents with a six-month history of persistent low mood, poor energy, and increasing feelings of hopelessness. He reports difficulty concentrating, frequent guilt about financial issues, and disrupted sleep. Over the past month, he has developed thoughts that others can read his mind and believes that a neighbouring shop owner is sending him threatening messages through signage. He denies auditory hallucinations or suicidal ideation. He has no past psychiatric history but has become socially isolated. He has not used any substances and is physically well.

Medications: Nil

Allergies: Nil known

Past history: Type 2 diabetes, well controlled

Family history: Brother with schizoaffective disorder

Social history: Married, has two children, does not smoke or drink alcohol

Examination findings: Flat affect, psychomotor retardation. MSE: thought broadcasting, persecutory delusions, no suicidal ideation, good orientation. Physical exam unremarkable.

What are the most appropriate next steps in management? Select three (3) from the following list:

Sophie Wallace, a 40-year-old marketing executive, presents complaining of low mood, sleep disturbance, and poor appetite over the past two months. She also reports episodes of increased energy, racing thoughts, decreased need for sleep, and impulsive online shopping, lasting several days. During these episodes, she feels ‘on top of the world’, speaks rapidly, and becomes irritable when interrupted. Her partner describes these as ‘highs and lows’ that are increasingly affecting their relationship. Sophie has never received mental health treatment before.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Sister with bipolar disorder

Social history: Lives with partner, no alcohol or drug use, non-smoker

Examination findings: Euthymic mood today, mildly pressured speech. MSE: no delusions or hallucinations. Insight into her fluctuating mood is limited.

What are the most appropriate next steps in management? Select three (3) from the following list:

Olivia Martin, a 65-year-old retired librarian, presents with her daughter due to recent changes in her mood and behaviour over the past four months. Olivia has become increasingly tearful, avoids social activities, and expresses feelings of worthlessness. She has difficulty sleeping, reduced appetite, and has lost 6 kg unintentionally. Her daughter is concerned because Olivia recently said, “I just don’t see the point anymore.” Olivia denies active suicidal ideation but admits to thinking about death. She has no previous psychiatric history and no significant physical illness.

Medications: Calcium and vitamin D supplements

Allergies: Nil known

Past history: Osteopenia

Family history: Sister had late-onset depression

Social history: Widowed for five years, lives alone, no smoking or alcohol use

Examination findings: Tearful, low energy, flat affect. MSE: passive thoughts of death, no delusions or hallucinations. MMSE: 28/30. Physical exam normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jack Morrison, a 36-year-old construction worker, presents following a referral from his employer after he was found crying in his car during lunch breaks. He reports feeling ‘numb’ and unable to enjoy anything for the past few weeks. He also describes waking frequently during the night, poor concentration, and fatigue. Jack reveals he has been experiencing distressing flashbacks of a workplace accident that occurred 2 months ago, in which a colleague was severely injured. He has started avoiding work-related activities and fears being seen as weak. He denies suicidal ideation or substance use.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother with anxiety

Social history: Lives with partner, no children, occasional alcohol use, non-smoker

Examination findings: Appears tense and guarded. MSE: anxious mood, blunted affect, hypervigilance, no psychosis or suicidal ideation. Vitals and physical exam normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Saunders, a 26-year-old nurse, presents with worsening anxiety symptoms over the past year. She reports frequent and excessive worry about her health, finances, and performance at work, which she finds difficult to control. She experiences muscle tension, difficulty sleeping, and frequent feelings of being ‘on edge’. She denies panic attacks or phobias, but says her anxiety is constant and exhausting. She has no significant past psychiatric history and is not on any medication.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother with generalised anxiety disorder

Social history: Lives with partner, works full-time in a busy emergency department. Non-smoker, drinks socially, no illicit substance use

Examination findings: Appears anxious and restless. MSE: anxious affect, worried thought content, no psychosis, good insight. Physical exam and vitals normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Peter Lawson, a 55-year-old mechanic, presents with worsening irritability, difficulty sleeping, and poor concentration over the last 4 months. His wife reports he is short-tempered and increasingly isolated from friends and family. Peter acknowledges feeling ‘tense all the time’, and describes persistent thoughts about a house fire that occurred in their neighbourhood last year, which triggered memories of a similar incident in his childhood. He avoids news reports about fires and refuses to use the stove. He drinks 4–6 beers most evenings to ‘calm down’ and says he has trouble relaxing. He denies hallucinations or suicidal ideation.

Medications: Nil

Allergies: Nil known

Past history: Hyperlipidaemia, diet controlled

Family history: Father with alcohol dependence

Social history: Married, has two adult children, works full-time, drinks alcohol daily, non-smoker

Examination findings: Anxious and hypervigilant. MSE: constricted affect, avoidant behaviour, no thought disorder. No neurological deficits or physical abnormalities.

What are the most appropriate next steps in management? Select three (3) from the following list:

Isabella Clarke, a 22-year-old university student, presents with her mother expressing concern about her recent eating behaviours. Over the past six months, Isabella has lost 10 kg despite already being underweight. She reports intense fear of gaining weight and frequently skips meals. She engages in excessive exercise and has rigid food rules. Her BMI is 16.2. She denies binge eating or purging but admits to daily body checking and weighing herself multiple times a day. Her menstrual periods have stopped. She has no known medical conditions and is not on any medications.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Mother had anorexia nervosa in adolescence

Social history: Lives with housemates, full-time student, no alcohol or drug use, non-smoker

Examination findings: Pale, bradycardic (HR 52 bpm), low blood pressure (90/58 mmHg). MSE: anxious affect, poor insight into low weight. No psychosis or suicidal ideation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Lucas Chen, a 45-year-old software engineer, presents with a four-month history of low mood, diminished interest in hobbies, and increasing social withdrawal. He reports feelings of guilt and poor concentration, as well as early morning waking. He has a long-standing history of depression, previously treated successfully with fluoxetine. He restarted fluoxetine two months ago after a gap of several years but has noticed little improvement. He also reports intermittent auditory hallucinations of a voice saying, “You’re worthless,” and has become increasingly suspicious of his co-workers. He denies suicidal ideation but has limited insight into these new symptoms.

Medications: Fluoxetine 40 mg daily

Allergies: Nil known

Past history: Recurrent major depressive disorder

Family history: Mother with schizophrenia

Social history: Lives alone, employed full-time, no alcohol or substance use, non-smoker

Examination findings: Flat affect, slowed speech, limited eye contact. MSE: thought content reveals persecutory delusions and second-person auditory hallucinations. Insight is poor.

What are the most appropriate next steps in management? Select three (3) from the following list:

Ruby Gallagher, a 31-year-old high school teacher, presents reporting recurrent panic attacks over the past two months. These episodes occur suddenly and include palpitations, shortness of breath, dizziness, and a fear of dying. She often experiences them while commuting or in crowded places and has begun avoiding public transport. She reports persistent worry about future attacks. She denies chest pain, substance use, or recent trauma. She has no previous psychiatric history.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Mother with generalised anxiety disorder

Social history: Lives with partner, works full-time, non-smoker, drinks alcohol occasionally

Examination findings: Alert and anxious. Vitals normal. Cardiovascular and respiratory examinations are unremarkable. MSE: anxious mood, no hallucinations or delusions, good insight.

What are the most appropriate next steps in management? Select three (3) from the following list:

Thomas Reid, a 60-year-old retired plumber, is brought in by his wife due to changes in his behaviour over the past year. He has become increasingly apathetic, socially withdrawn, and shows little interest in family activities. He frequently repeats questions, misplaces items, and becomes disoriented in unfamiliar places. Recently, he accused his wife of stealing his wallet, which he later found in the fridge. His insight appears limited, and he often laughs inappropriately. He has no history of stroke or head trauma, and no substance use.

Medications: Aspirin 100 mg daily

Allergies: Nil known

Past history: Hypercholesterolaemia

Family history: Mother had Alzheimer’s disease

Social history: Non-smoker, no alcohol, lives with wife

Examination findings: Alert, disinhibited behaviour noted. MMSE: 23/30. MSE: inappropriate affect, confabulation. Neurological exam: normal.

What are the most appropriate next steps in management? Select three (3) from the following list:

Amy Peterson, a 19-year-old university student, presents with her parents due to increasing social withdrawal, decreased academic performance, and unusual behaviour over the past three months. She spends most of her time alone in her room, has stopped attending lectures, and is frequently heard talking to herself. Amy believes that people on the internet are sending her hidden messages and has recently covered the windows in her room because she thinks she is being watched. She appears dishevelled and is minimally responsive during the consultation.

Medications: Nil

Allergies: Nil known

Past history: Nil

Family history: Maternal uncle with schizophrenia

Social history: Lives on campus, no known substance use, non-smoker

Examination findings: Poor eye contact, flat affect, minimal speech. MSE: auditory hallucinations, paranoid delusions, impaired insight, no suicidal ideation disclosed.

What are the most appropriate next steps in management? Select three (3) from the following list:

Nathan Brooks, a 35-year-old accountant, presents with worsening mood instability, periods of elevated energy, and recent impulsive behaviour. He reports a three-week period during which he needed very little sleep, spent excessively on luxury items, and felt unusually confident and talkative. This was followed by a crash where he became severely depressed, withdrew from work, and struggled to get out of bed. He has never been hospitalised and denies hallucinations or delusions. He is currently in a low mood and is unsure what is happening to him. He has no prior psychiatric diagnosis but a family history of bipolar disorder.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father diagnosed with bipolar I disorder

Social history: Lives alone, non-smoker, drinks socially, no illicit drug use

Examination findings: Low mood, slow speech, poor eye contact. MSE: no psychosis, impaired insight. Currently experiencing depressive symptoms but reports recent history consistent with hypomania.

What are the most appropriate next steps in management? Select three (3) from the following list:

Angela Wright, a 41-year-old social worker, presents with a six-month history of ongoing low mood, fatigue, and difficulty concentrating. She reports that she has felt emotionally numb and struggles to connect with friends or enjoy activities she once loved. She wakes early in the morning and feels exhausted throughout the day. She denies suicidal ideation. Despite trialling sertraline for three months and engaging in weekly psychological therapy, there has been minimal improvement. She wonders if something else is wrong with her.

Medications: Sertraline 100 mg daily

Allergies: Nil known

Past history: Major depressive disorder (first diagnosed at age 25)

Family history: Mother with treatment-resistant depression

Social history: Divorced, lives alone, full-time employment, no alcohol or drug use

Examination findings: Appears tired, slow speech. MSE: low mood, blunted affect, no psychotic symptoms, no suicidal ideation. PHQ-9 score: 19. No physical findings of note.

What are the most appropriate next steps in management? Select three (3) from the following list:

Samira Ahmed, a 29-year-old graduate student, presents with intense fear of gaining weight and a history of recurrent episodes of eating large quantities of food in a short time, followed by purging through self-induced vomiting. She reports these episodes occur at least twice a week and are accompanied by feelings of guilt and shame. She has normal body weight (BMI 21.5) but frequently engages in excessive exercise and uses laxatives intermittently. Her periods are regular. She has no medical comorbidities and has not previously sought help.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Mother had an eating disorder in her 20s

Social history: Lives with partner, non-smoker, drinks alcohol occasionally, no recreational drug use

Examination findings: Normal BMI, mildly dry skin, enamel erosion on upper teeth. MSE: anxious mood, preoccupation with body shape, good insight, no psychosis or suicidal ideation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Leo Bennett, a 38-year-old tradesman, presents with symptoms of excessive checking and intrusive thoughts. For the past year, he has been spending several hours each day checking locks, switches, and taps, often returning home multiple times to ensure they are off. He experiences distressing thoughts about accidentally harming others due to negligence and performs these rituals to reduce his anxiety. He is aware the thoughts are irrational but feels compelled to act on them. He reports increased anxiety, fatigue, and difficulty maintaining work productivity.

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Sister with generalised anxiety disorder

Social history: Lives with wife, non-smoker, drinks socially, no illicit substance use

Examination findings: Anxious, tense, good rapport. MSE: obsessive thoughts, compulsive behaviours, good insight, no hallucinations or delusions, no suicidal ideation.

What are the most appropriate next steps in management? Select three (3) from the following list:

Claire Morrison, a 72-year-old widow, presents with her daughter who is concerned about Claire’s forgetfulness and increasing confusion over the past year. Claire has been misplacing items, repeating questions, and occasionally getting lost in familiar places. She has become irritable and suspicious, recently accusing neighbours of stealing from her. Her daughter also reports difficulty with managing finances and cooking. Claire has no history of mental illness and has been physically well, aside from mild hypertension.

Medications: Perindopril 4 mg daily

Allergies: Nil known

Past history: Hypertension

Family history: Mother had dementia in her 80s

Social history: Lives alone with support from her daughter, non-smoker, no alcohol

Examination findings: MMSE: 22/30 (impaired recall and orientation). MSE: paranoid ideation, no hallucinations. Neurological examination normal. BP: 132/76 mmHg.

What are the most appropriate next steps in management? Select three (3) from the following list:

Jackson Lee, a 32-year-old warehouse worker, presents with his GP after his partner expressed concern about his increasingly erratic mood over the past 12 months. Jackson describes alternating periods of feeling ‘energised and unstoppable’ for several days — during which he sleeps little, takes on risky projects at work, and talks excessively — followed by weeks of feeling low, hopeless, and fatigued. During low phases, he struggles to get out of bed and withdraws socially. He has no history of psychosis or hospitalisation. He has tried sertraline in the past but felt it made his symptoms worse.

Medications: Nil currently

Allergies: Nil known

Past history: Trial of SSRI 2 years ago (self-discontinued)

Family history: Mother with bipolar disorder

Social history: Lives with partner, no substance use, non-smoker

Examination findings: Euthymic mood today. MSE: normal speech, good insight, no psychosis. Reports recent episodes consistent with hypomania and depressive symptoms.

What are the most appropriate next steps in management? Select three (3) from the following list:

Emily Tran, a 23-year-old university student, presents to the GP with distress over recurrent, unexpected panic attacks. She describes episodes of intense fear with physical symptoms including palpitations, chest tightness, shortness of breath, trembling, and fear of dying. These episodes peak within 10 minutes and resolve spontaneously. She reports persistent worry about having another attack and has started avoiding buses and crowded venues. There is no substance use or medical cause identified. She has no prior mental health diagnoses but says she’s always been a “worrier.”

Medications: Nil

Allergies: Nil known

Past history: Nil significant

Family history: Father with generalised anxiety disorder

Social history: Lives with housemates, no smoking or alcohol, no recreational drug use

Examination findings: Appears anxious, tachycardic (HR 98 bpm), BP 120/80. Respiratory and cardiovascular examinations unremarkable. MSE: anxious mood, no hallucinations or delusions, good insight.

What are the most appropriate next steps in management? Select three (3) from the following list:

Patrick O’Connell, a 48-year-old self-employed builder, presents to his GP with persistent low mood, reduced appetite, and poor sleep over the past four months. He reports feelings of worthlessness and difficulty concentrating on work tasks. His wife reports that he has become increasingly withdrawn and irritable, and has lost interest in family activities. He denies suicidal thoughts. He has previously experienced depressive episodes, but this one feels ‘different’. He also describes chronic pain from a shoulder injury sustained 10 years ago, which has worsened recently.

Medications: Paracetamol and ibuprofen as needed

Allergies: Nil known

Past history: Recurrent depression, chronic shoulder pain

Family history: Father had major depressive disorder

Social history: Lives with wife and teenage son, drinks 3–4 standard drinks most nights, non-smoker

Examination findings: Appears tired, slumped posture. MSE: low mood, no psychotic features, no suicidal ideation. PHQ-9 score: 21 (severe depression)

What are the most appropriate next steps in management? Select three (3) from the following list: