MISCELLANEOUS FACTS FROM ON EXAMINATION

Question 1

A 35-year-old woman presents with an isolated episode of mania which was controlled with medication after a two week period in a psychiatric hospital.
She remains compliant with her medication from which she suffers no adverse effects. She now has complete insight into her condition.
She wants to know after what time period she will be able to drive?

After a period of one month of remaining stable and well

After a period of two months of remaining stable and well

After a period of three months of remaining stable and well

After a period of four months of remaining stable and well

After a period of five months of remaining stable and well

Answer 1

After a period of three months of remaining stable and well

Question 2

A 30-year-old man is admitted to the psychiatric unit after abnormal behaviour in a police cell. He told police that there was a conspiracy against him and he began behaving irrationally.
Thirty six hours after admission to the psychiatric unit the patient has a grand-mal seizure.
Which of the following is the most likely cause of the seizure?

Amphetamine withdrawal

Hypercalcaemia

Idiopathic epilepsy

LSD withdrawal

Withdrawal from barbiturates

Answer 2

Withdrawal from barbiturates

Question 3

Which of the following is not associated with intellectual impairment?

McArdle’s disease

Phenylketonuria

Rubella in the first trimester of pregnancy

Trisomy 21

Tuberous sclerosis

Answer 3

McArdle’s disease

McArdle's disease is a glycogen storage disease of muscle, affected patients having a normal lifespan and normal intelligence.
Cognitive impairment develops in phenylketonuria unless the infant is placed on a phenylalanine-free diet.
Trisomy 21 (Down's syndrome), and rubella affecting the mother in the first trimester are associated with mental handicap.
Tuberous sclerosis is the combination of adenoma sebaceum, seizures and mental deficiency (which may be mild and one third of patients having normal intelligence).

Question 4

A patient presents with headache and double vision. Clinical examination reveals a left ptosis, a depressed and abducted globe and a dilated fixed pupil. What is the most likely diagnosis?

Anisocoria

Bell’s palsy

Holmes-Adie pupil

Horner’s syndrome

Oculomotor nerve palsy

Answer 4

Oculomotor nerve palsy

Question 5

A 77-year-old male presents with sudden loss of vision in his right eye, associated with a relative afferent pupillary defect. He has poorly controlled systemic hypertension and raised cholesterol. What is the most likely aetiology of his presentation?

Cataract

Chronic open angle glaucoma

Macular degeneration

Retinal vascular occlusion

Retinitis pigmentosa

Answer 5

Retinal vascular occlusion

The history of acute loss of vision affecting one eye suggests an acute vascular occlusion, especially given the associated vascular risks. The others cause a more chronic visual loss.

Question 6

A 40-year-old male with a history of daily alcohol consumption for the last seven years is brought to the hospital emergency room with acute onset of visual hallucinations, seeing spiders all around him. He does not recognise family members, is aggressive and has tremors.
There is a history of his having stopped drinking alcohol for two days.
Examination reveals a blood pressure of 170/100 mmHg, tremors, increased psychomotor activity, fearful affect, hallucinatory behaviour, disorientation, impaired judgment and insight.
Which of the following is the most likely diagnosis?

Alcoholic hallucinosis

Delirium tremens

Korsakoff’s psychosis

Wernicke encephalopathy

Answer 6

Delirium tremens

Question 7

Which of the following conditions is associated with dislocation of the lens?

Cushing’s syndrome

Diabetes mellitus

Homocystinuria

Osteogenesis imperfecta

Reiter’s syndrome

Answer 7

Homocystinuria

Question 8

A 35-year-old woman comes to your surgery because of difficulty reading, which has been noticeable during the past two weeks. She has never required glasses and takes no medication.
The pupils are normal size and react sluggishly to light. Both optic discs appear sharp, and there are no haemorrhages or exudates. Visual acuity is strikingly impaired and remains so when the patient uses a pinhole card. Five-beat nystagmus and double vision are noted on left lateral gaze.
Which of the following is the most likely diagnosis?

Diabetes mellitus

Drug toxicity

Multiple sclerosis

Myopia

Pseudotumour cerebri

Answer 8

Multiple sclerosis

This young woman has features suggestive of retrobulbar neuritis with also some cerebellar features (nystagmus) and the most likely diagnosis would be Multiple sclerosis.
The diagnosis can be further supported by visual evoked responses, MRI revealing demyelinating plaques and oligoclonal bands on CSF examination.

Question 9

A 28-year-old woman is admitted to a surgical ward for drainage of an abscess in her forearm.
She uses heroin intravenously and says that she is about to go into opioid withdrawal and shows early signs of doing so.
Which of the following is most appropriate for this patient?

Ask her how much heroin she uses per day and arrange for her to receive methadone syrup equivalent to this divided into four doses per day

Ask her how much heroin she uses per day and give her a dose of methadone syrup equivalent to this

Give her 60 mg of codeine phosphate and wait 30 minutes to determine its effect

Give her 200 mg of codeine phosphate and wait 60 minutes to determine its effect

Give her a bottle containing 100 mg of methadone syrup and tell her to adjust dosage herself

Answer 9

Give her 60 mg of codeine phosphate and wait 30 minutes to determine its effect

A good way of managing acute opioid withdrawal in patients who are actively using heroin is to titrate codeine to effect. It can be given in 30-60 mg doses and repeated each 30 minutes until the symptoms have begun to subside. Most trusts will have a local policy.
If a patients normally takes methadone then their dispensing pharmacy should be contacted to confirm their dose prior to administration. Codeine could be used in the meantime to alleviate symptoms of opioid withdrawal.

Question 10

A 41-year-old female is brought into the Emergency department after taking an uncertain quantity of paracetamol two hours previously and trying to hang herself.
She becomes agitated and insists that she wants to go home immediately. You judge that she is at high risk of suicide.
Which of the following is the most appropriate course of action for this patient?

Ask her to sign a ‘discharge against medical advice’ form and let her go

Call the duty psychiatrist, but let the patient go if she insists and the duty psychiatrist does not arrive in time to see her

Call the hospital security services, restrain her and sedate her

Detain her under section 5(2) of the Mental Health Act

Detain the patient under common law, seeking the help of hospital security services

Answer 10

Detain the patient under common law, seeking the help of hospital security services

Taking a paracetamol overdose in itself does not mean the patient has no capacity, but often capacity is lacking. The chance of suffering severe consequences if a paracetamol overdose goes untreated is high. Often, therefore these patients do not possess the level of capacity required for a decision of this importance. Family should be involved if possible.
In cases such as this the patient, if found to lack capacity, should be held under common law until the appropriate time to take a blood sample (four hours after the overdose).

Question 11

Causes of a small pupil include which of the following?

Carbon monoxide poisoning

Ethylene glycol poisoning

Holmes-Adie pupil

Pontine haemorrhage

Third nerve palsy

Answer 11

Pontine haemorrhage

Causes of small pupils include:

• Horner’s syndrome
• Old age
• Pontine haemorrhage
• Argyll Robertson pupil
• Drugs
• Poisons (opiates, organophosphates).

Question 12

Which of the following does not lead to the increased risk of developing schizophrenia or a schizophrenic-like illness?

Amphetamine addiction

Being brought up in an institution

Sibling with schizophrenia

Social class V

Temporal lobe epilepsy

Answer 12

Being brought up in an institution

Nurture in an institution does not predispose individuals to schizophrenia.
Schizophrenia is however more common in social classes IV and V.
The lifetime risk of developing schizophrenia in the United Kingdom is 1%. If there is an affected sibling the risk increases to 8-10%.
Temporal lobe epilepsy may cause hallucinations mimicking schizophrenia.
Amphetamines may cause a state resembling hyperactive paranoid schizophrenia with hallucinations.

Question 13

A 17-year-old girl presents after having ingested 50 of her mother’s fluoxetine tablets, approximately five hours previously.
Which one of the following clinical features is compatible with this history?
(Please select 1 option)

Heart rate of 30 beats per minute

Pupillary constriction

QRS duration of 120 ms (

Answer 13

Vomiting

Unlike the tricyclic antidepressants, fluoxetine, like many of the SSRIs are safe in overdose and cause very few adverse effects.

Rarely, reports would suggest that tachycardia can occur together with:
tremor
drowsiness
nausea, and
vomiting.

Pupillary constriction or respiratory suppression suggests opiates.
Prolonged QRS complex is consistent with TCA overdose.