Russell’s sign is usually associated with which one of the following disorders?
C. Russell’s sign was fi rst described in bulimia nervosa. This refers to the skin abrasions, on the dorsum of the hand overlying the fi ngers, found in patients with symptoms of bulimia. These are caused by repeated contact between the incisors and the skin of the hand which occurs during self-induced vomiting.
Reference:
On physical examination, you notice that a person with a history of substance misuse now has pilo-erection, dilated pupils, rhinorrhea, and he is yawning frequently.
Withdrawal from which of the following substances can cause this presentation?
B. These features are suggestive of opiate withdrawal. Classical withdrawal from opiates appears in 4 to 12 hours, peaks in 48 to 72 hours, and subsides in a week. It is characterized by symptoms of muscle aches and cramps, severe anxiety and agitation, insomnia, diarrhoea, shivering, yawning, and fatigue. Signs include tachycardia and hypertension, lacrimation, rhinorrhoea, dilated pupils, and ‘goose-fleshing’ (piloerection) of the skin (hence ‘cold turkey’ or ‘clucking’). Insomnia (with increase in REM sleep) and craving for the drug may persist for weeks. Opiate withdrawal is not usually life threatening.
A 50-year-old patient was brought to the A and E department in a confused state. On physical examination he has nystagmus, ocular palsy, and ataxia.
Which of the following parts of clinical assessment is likely to be most relevant to this presentation?
C. The features of acute confusion, nystagmus, ocular palsy, and ataxia are suggestive of Wernicke’s encephalopathy, possibly secondary to alcohol use in a 50-year-old male. In females, an additional likely cause of Wernicke’s encephalopathy is hyperemesis secondary to pregnancy or anorexia. Wernicke’s encephalopathy is an indirect result of thiamine deficiency. It may be precipitated on administration of glucose to a confused patient in the casualty department. Glucose causes a sudden depletion of the available thiamine stores (via thiamine-dependent transketolase). In people recovering from Wernicke’s encephalopathy, 80% develop a Korsakoff’s syndrome which is characterized by deficits in anterograde and retrograde memory, apathy, an intact sensorium, and relative preservation of other intellectual abilities.
An 18-year-old male, recently started on a medication, presents to the A and E department with slow, long-sustained, contorting, involuntary movements and postures involving proximal limb and axial muscles.
Which of the following medications is most likely to cause the above presentation?
C. The clinical situation given here is an example of an acute dystonic reaction in a young male, possibly a psychotic patient, who has been started on an antipsychotic. Given the options, risperidone is the most likely causative agent. Procyclidine may relieve the dystonic attack. Alternatively, a benzodiazepine or an antihistamine with anticholinergic action may be used. Risk factors of dystonia include male gender, age younger than 30 years, and using high dosages of high-potency, typical antipsychotics.
A 21-year-old female presented to the emergency department with complaints of recurrent attacks of severe dizziness, lasting for 10 to 20 minutes. On examination during the episode of dizziness, there was no evidence of nystagmus.
Which one of the following is true?
A. Absence of nystagmus during an attack of dizziness almost always rules out vertigo secondary to labyrinthine or brain stem pathology. The dizziness here is most likely to be psychogenic in origin – related to panic attacks. This may be accompanied by agoraphobia, which is described as a fear of being in places from where escape may seem impossible or difficult.
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