MRCP 2 Masterclass – Psychiatry

A 52-year-old homeless alcoholic man presented to A&E with a 2-week history of general malaise, abulia, insomnia and worsening anorexia. For the last 3 days he had been unable to tolerate alcohol. He also described recent headache, sweating and palpitations. His GP had prescribed paroxetine 6 months earlier for depression without benefit, and he now presented severely depressed and suicidal.

Physical examination revealed signs of chronic liver disease. Sensation to pinprick and light touch was reduced in a stocking distribution and his leg
muscles were painful and tender. Tone was mildly raised in the lower limbs and the reflexes were symmetrically brisk, except at the ankles where they were absent. Urine drug screen was negative and paracetamol and salicylate were undetectable. His blood results were:

What is the most likely diagnosis?

A 52-year-ulcl homeless alcoholic man presented to A&E with a 2-week history of general malaise, abulia, insomnia and worsening anorexia. For the last 3 days he had been unable to tolerate alcohol. He also described recent headache, sweating and palpitations. His GP had prescribed paroxetine 6 months earlier for depression without benefit, and he now presented severely depressed and suicidal.

Physical examination revealed signs of chronic liver disease. Sensation to pinprick and light touch was reduced in a stocking distribution and his leg
muscles were painful and tender. Tone was mildly raised in the lower limbs and the reflexes were symmetrically brisk, except at the ankles where they were absent. Urine drug screen was negative and paracetamol and salicylate were undetectable. His blood results were:

He was admitted to an acute psychiatric ward and nursed one-to-one because of ongoing suicidal ideation. Four days after starting on chlordiazepoxide detoxification he became increasingly disorientated and confused and was seen responding to auditory hallucinations. He became convinced that the nurse with him planned to murder him in his sleep. He was incontinent of urine and faeces. On repeat examination he was found to be ataxic with extrapyramidal rigidity.

What additional diagnosis/complication has occurred?

A 52-year-ulcl homeless alcoholic man presented to A&E with a 2-week history of general malaise, abulia, insomnia and worsening anorexia. For the last 3 days he had been unable to tolerate alcohol. He also described recent headache, sweating and palpitations. His GP had prescribed paroxetine 6 months earlier for depression without benefit, and he now presented severely depressed and suicidal.

Physical examination revealed signs of chronic liver disease. Sensation to pinprick and light touch was reduced in a stocking distribution and his leg
muscles were painful and tender. Tone was mildly raised in the lower limbs and the reflexes were symmetrically brisk, except at the ankles where they were absent. Urine drug screen was negative and paracetamol and salicylate were undetectable. His blood results were:

He was admitted to an acute psychiatric ward and nursed one-to-one because of ongoing suicidal ideation. Four days after starting on chlordiazepoxide detoxification he became increasingly disorientated and confused and was seen responding to auditory hallucinations. He became convinced that the nurse with him planned to murder him in his sleep. He was incontinent of urine and faeces. On repeat examination he was found to be ataxic with extrapyramidal rigidity.

What treatment should be instigated immediately?

A 23-year-old Swedish student was brought to A&E by her boyfriend who was concerned that she had been acting strangely for 48 hours. She had become increasingly agitated and restless, claiming that her flatmate was monitoring her behaviour and trying to steal her identity. She had not slept for 2 nights. On two occasions she had become unresponsive, staring blankly ahead, following which she appeared confused and disorientated. She had vomited twice and was complaining of severe abdominal pain that she ascribed to menstruation. She had had two similar though less severe episodes around the time of menstruation in the last 2 months. She had been well until (> months previously, when she had became depressed at the time of her end-of-year exams and had been prescribed fluvoxamine by her CP.

On examination she appeared confused and was disorientated to time. Abdominal examination revealed central tenderness without guarding. Other than sinus tachycardia, the respiratory and cardiovascular examinations were unremarkable. Neurological exam revealed reduced sensation distally and reduced power on shoulder abduction bilaterally.

Some investigations are performed:

What two things should you do?

A 23-year-old Swedish student was brought to A&E by her boyfriend who was concerned that she had been acting strangely for 48 hours. She had become increasingly agitated and restless, claiming that her flatmate was monitoring her behaviour and trying to steal her identity. She had not slept for 2 nights. On two occasions she had become unresponsive, staring blankly ahead, following which she appeared confused and disorientated. She had vomited twice and was complaining of severe abdominal pain that she ascribed to menstruation. She had had two similar though less severe episodes around the time of menstruation in the last 2 months. She had been well until (> months previously, when she had became depressed at the time of her end-of-year exams and had been prescribed fluvoxamine by her CP.

On examination she appeared confused and was disorientated to time. Abdominal examination revealed central tenderness without guarding. Other than sinus tachycardia, the respiratory and cardiovascular examinations were unremarkable. Neurological exam revealed reduced sensation distally and reduced power on shoulder abduction bilaterally.

Some investigations are performed:

What is the likely diagnosis?

A 32-year-old man presents to A&E with his mother, who is concerned because he has become increasingly contused and agitated. He was incontinent of urine before she called the ambulance. He is unable to give a history and appears disorientated. His mother says that he has recently seen a psychiatrist who has prescribed aripiprazole.

On examination he appears sweaty; temperature is 38.6 °C. He is tachycardic at 132 bpm and his blood pressure is 180/105 mmHg. Neurological examination reveals symmetrically raised tone in all four limbs; the plantars are bilaterally down-going. Pupillary light reflexes are normal. The investigations show:

What is the most likely diagnosis?

A 32-year-old man presents to A&E with his mother, who is concerned because he has become increasingly contused and agitated. He was incontinent of urine before she called the ambulance. He is unable to give a history and appears disorientated. His mother says that he has recently seen a psychiatrist who has prescribed aripiprazole.

On examination he appears sweaty; temperature is 38.6 °C. He is tachycardic at 132 bpm and his blood pressure is 180/105 mmHg. Neurological examination reveals symmetrically raised tone in all four limbs; the plantars are bilaterally down-going. Pupillary light reflexes are normal. The investigations show:

What is the next investigation that you would perform?

A 32-year-old man presents to A&E with his mother, who is concerned because he has become increasingly contused and agitated. He was incontinent of urine before she called the ambulance. He is unable to give a history and appears disorientated. His mother says that he has recently seen a psychiatrist who has prescribed aripiprazole.

On examination he appears sweaty; temperature is 38.6 °C. He is tachycardic at 132 bpm and his blood pressure is 180/105 mmHg. Neurological examination reveals symmetrically raised tone in all four limbs; the plantars are bilaterally down-going. Pupillary light reflexes are normal. The investigations show:

Which two treatments are most appropriate?

A 36-year-old artist presented to A&E with a friend who was concerned that she had been acting strangely and had appeared intermittently confused over the last 3 days. She said that she had been feeling increasingly anxious and restless over the last week and had been to the health foodstore to buy some St lohn’s wort to pick her up. Her only other medication is venlafaxine prescribed by her GP. For 2 days she had been feeling nauseated and had developed diarrhoea.

On examination she was mildly disorientated in time, was shivering and
appeared restless. She was tachycardic at 120 bpm and her blood pressure was raised at 150/95 mmHg. Temperature was 37.6 °C. Neurological examination revealed a fine tremor in the upper limbs and multifocal myoclonus. Reflexes were symmetrically brisk, plantars down-going. There was no neck stiffness. Blood tests were unremarkable.

What is the most likely diagnosis?

A 40-year-old man from Uganda is brought in by the police under section 136 of the Mental Health Act. He was arrested because he was standing naked in a busy
street attempting to ‘direct’ the traffic. On examination he declared that he was the Minister of Transport. He spoke rapidly and paced around the room issuing orders in a loud voice. He was found to have oral thrush.

From the following choose the two LEAST likely diagnostic possibilities:

A very thin 18-year-old girl is referred for investigation of weight loss. You suspect that she has anorexia nervosa, but perform a range of screening tests.

Which one of the following would be compatible with the diagnosis of anorexia nervosa? 

A 78-year-old man, without significant past medical history and taking no regular medications, has become increasingly forgetful over the last 18 months, to the
point where he now finds it difficult to remember the names of some members of his family. He has recently been having visual hallucinations. On examination he
seems rather expressionless and has cogwheel rigidity of both arms.

The most likely diagnosis is:

A 42-year-old woman is referred to the medical outpatient clinic because she is ‘always exhausted’. She says that she cannot do anything that requires any physical effort and that she sleeps all the time. Her general practitioner cannot find any explanation for her symptoms. You consider the diagnosis of chronic fatigue syndrome.

Which one of the following findings would NOT be consistent with this diagnosis?