A 65-year-old man comes to the clinic complaining of confusion, difficulty walking, and urinary incontinence that have been getting worse over the past two months. Upon examination, he displays mild cognitive dysfunction and gait ataxia. A CT scan of his brain shows enlarged ventricles with no signs of obstruction to CSF outflow. A lumbar puncture reveals normal CSF pressure and constituents. What is the most effective management step to take?
A 25-year-old male is admitted after a paracetamol overdose. He took fifteen 500mg tablets. He states that he wants to end his life and that he sees no purpose in living anymore. He had left a note for his girlfriend. On mental state examination, he displays poverty of thought, a flat affect, and signs of nihilistic delusions. He has a history of severe depression. Although he is medically stable, he is transferred to a psychiatric unit for further evaluation due to persistent suicidal thoughts. During his stay, he develops catatonia and refuses to eat or drink.
Is there an absolute contraindication for electroconvulsive therapy in this case?
A 45-year-old man presents with significant mood swings that began a month after he had an asymptomatic thyroid nodule removed two years ago. He experiences about three weeks of intense energy, euphoria, and hyperactivity followed by a week of depression where he sleeps excessively and feels immobile. This pattern of alternating periods of depression and elation, with a few ‘normal’ days, has occurred multiple times since. The patient denies any substance abuse. Mild thyroid hypofunctioning was detected in his last thyroid function tests, but there are no clinical signs of thyroid disease on examination. What is the most probable diagnosis?
A 32-year-old male presents for follow-up. He has a history of schizophrenia that is currently being managed with quetiapine, as he did not respond well to olanzapine and risperidone in the past. He reports persistent derogatory auditory hallucinations in the third person. You decide to initiate clozapine therapy.
Before starting clozapine, what other essential investigation should be conducted?
Baseline blood tests reveal:
– Hemoglobin (Hb): 145 g/l
– Platelets: 320 * 109/l
– White blood cells (WBC): 6.8 * 109/l
– Neutrophils: 3.8 * 109/l
A 55-year-old male presents to the emergency department with a 4-week history of constipation not relieved by over the counter laxatives. His past medical history was significant for hypertension, COPD and schizophrenia. His current medications include ramipril, clozapine and tiotropium. He denied weight loss, poor appetite or other alarming symptoms. His family history was significant for bowel cancer with his father and uncle having died of colon cancer aged 78 and 82 respectively. His sister had a hysterectomy at the age of 72 but he was not sure why.
On examination, his blood pressure was 126/80 mmHg lying and 118/82 mmHg standing. Pulse was 65/min. Clinical examination did not reveal any significant findings.
Investigations:
Hb 135 g/l
MCV 83 fl
Platelets 410 * 109/l
WBC 6.8 * 109/l
Creatinine 91 umol/L
Urea 4.5 umol/L
Na+ 142 mmol/L
K+ 4.0 mmol/L
Corrected Calcium 2.4mmol/L
FOB negative
Abdominal X-ray faecal loading
What is the most likely cause of constipation in this case?
A 35-year-old man presents to the Emergency Department with complaints of sudden weakness in his left arm and leg for the past 30 minutes. He reports no significant medical history or family history of stroke or heart disease.
On examination, his blood pressure is 130/80 mmHg, heart rate 72 bpm, and respiratory rate 18 breaths/min. The power of the left arm and leg is 0/5, while the right arm and leg have full strength. The bilateral plantar response is flexor.
What is the most appropriate course of action for managing this patient?
A 32-year-old woman is found wandering the streets on Christmas Day and is brought by the police to the Emergency Department. She is wearing minimal clothing and appears to have marks across her back from a whip. On further questioning she tells you that she is Mary, and knows this because god spoke to her through the radio. She is happy to accept treatment from you because she believes you are one of her disciples. The nurses check her records against a driver’s license found in her pocket, and see that she has attended on 2 previous occasions because of drug intoxication. On examination her BP is 130/80 mmHg; pulse is 90/min and regular. She is sweating and looks anxious. General physical is unremarkable although she appears unkempt and her BMI is 20.2.
What is the most appropriate course of action in this situation?
A 40 year old caucasian man visits his doctor due to concerns about sudden weight gain. He has gained 8kg in the past 6 months despite maintaining his usual diet and exercise routine. The doctor decides to conduct further tests and discovers the following irregularities. The patient informs the doctor that he was previously taking medication for bipolar disorder, but it was changed a year ago due to abnormal movements. He has also been taking medication for nausea and recently started taking medication for breast enlargement.
Hemoglobin: 13.5 g/dl
Platelets: 150 * 109/l
White blood cells: 4.0 * 109/l
Neutrophils: 1.8 * 109/l
Lymphocytes: 1.2 * 109/l
Eosinophils: 1.0 * 109/l
Fasting blood sugar: 11.2 mmol/l
Prolactin: 270 mu/l
Electrocardiogram: sinus rhythm 80/min QTC 470 ms
Which medication is most likely responsible for these abnormalities?
A 42-year-old woman is brought to the Emergency Department by her husband. She tells you that she is not real and is living in a dream, that she does not exist in this world.
Her husband tells you that she barely eats, sleeps for long periods in the day and wakes in the early hours of the morning. She says she became preoccupied and very low in mood after some problems at work. Most recently, she had tried to jump out of the car whilst they were driving to the hospital.
On examination, she stares continuously at the wall, mumbling only that she is in a dream, nothing is real and she’s not really here. She looks unkempt and as if she has not been taking good care of herself.
Investigations:
Haemoglobin (Hb) 142 g/l 135 – 175 g/l
White cell count (WCC) 5.2 × 109/l 4.0 – 11.0 × 109/l
Platelets (PLT) 189 × 109/l 150 – 400 × 109/l
Sodium (Na+) 137 mmol/l 135 – 145 mmol/l
Potassium (K+) 4.2 mmol/l 3.5 – 5.0 mmol/
Creatinine (Cr) 90 µmol/l 50 – 120 µmol/l
Thyroid-stimulating hormone (TSH) 2.8 mu/l 0.4 – 5.0 mu/l
Which of the following treatments is most likely to be effective in this case?
Olivia, 27, has treatment resistant schizophrenia, with her usual symptoms being auditory hallucinations and persecutory delusions. She was recently prescribed clozapine, fluoxetine and lactulose. She has been complaining of constipation recently, but now presents to the emergency department with acute abdominal pain and vomiting. On examination abdomen is distended. What is the most probable reason for her symptoms?