C1

History
A 54-year-old man presents with abdominal pain for several days. The pain is a constant
dull ache which is central and radiates to the right. He has had some associated vomiting
but the vomit is usually bile as he has not been eating well. He has on a few occasions
vomited some blood (haematemesis) but says that this was after particularly heavy
consumption of alcohol. He is not aware how many units he drinks in a week but
reluctantly admits he drinks every day. His breakfast often consists of a drink as he feels
very shaky otherwise. Once he has had a drink he feels better able to manage the day
ahead. He lives alone in a bedsit and eats poorly.
He says he was sacked for taking time off work for physical complaints. He has been
separated from his wife for 6 months and no longer has regular contact with his children
who he says have turned against him. The marriage had been difficult for some years
because he was unable to hold down a regular job. He held a middle managers post until
he turned 50. Since then he has had a series of short-term junior posts. He believes that
this is a result of changes in local government and not related to his drinking.
Physical examination
He has a ruddy complexion, several spider naevi on his face and red palms. He has a body
mass index of 32. He is slightly tender in the right hypochondrium and lumbar regions
and in the epigastric region of his abdomen.
Mental state examination
He smells of alcohol. He is reasonably well dressed. He looks unwell and is clearly
uncomfortable. He has good eye contact. His speech is normal. He admits he has felt low
as his life has deteriorated over the last few months but says he is not depressed. He can
still enjoy himself and is reactive at interview. He does not have any self-harm ideation.
He has little hope for the future. There is no evidence of psychosis.
He is orientated in time, place and person. His short-term memory is poor but there are no
long-term memory problems.

Haemoglobin 12.4 g/dL 13.317.7 g/dL

Mean corpuscular 109 fL 8099 fL
volume (MCV)
White cell count 8.8 109/L 3.911.0 109/L
Platelets 280 109/L 150440 109/L
Sodium 139 mmol/L 135145 mmol/L
Potassium 3.5 mmol/L 3.55.0 mmol/L
Urea 2.3 mmol/L 2.56.7 mmol/L
Creatinine 75 mol/L 70120 mol/L

C2
History
A 76-year-old retired surveyor is brought to surgery by his wife. She reports that he has
gradually stopped reading and writing, both activities he used to enjoy. He has a tendency
to repeat things many times during the day, apparently unaware that he has mentioned
them earlier. He also has more difficulty putting sentences together, and forgets the names
of common objects such as the radiator and the radio. He has become slightly more
clumsy. He recently failed to recognize a cousin whom he had not seen for a year. He tells
the doctor that he is fine and that his wife is making a fuss about nothing. The previous
week he wanted to return a form to claim a chance to win a large prize from a mailshot
designed to encourage him to attend a promotional Spanish Apartment Share meeting. He
would previously have recognized this as a promotion and put it straight in the bin. He
drinks a small bottle of beer twice a week, usually at the weekends, and is a non-smoker.
He has not been lethargic or disinhibited and continues to get great pleasure from
gardening. His wife describes that onset has been gradual, so much so that she was
prompted to take action by their daughter.
Mental state examination
Mental state examination shows that he has good eye contact and sits still in a chair
throughout the interview. His speech is slightly laboured and on several occasions he
seems to struggle to find the right word. None of his sentences are long or complex. He
has no pressure of speech or flight of ideas. Occasionally he will lose the thread of what
he is saying and stop talking or start on a different topic. He is uncertain why he is being
interviewed. There is no psychomotor retardation or agitation. There is no evidence of
hallucinations or psychosis, although his wife says that he sometimes wakes up in the
middle of the night thinking that there is an intruder in the bedroom. His Mini Mental
State Examination score is 19. He thinks he is in the general practitioner (GP) surgery
when in fact he is at the local hospital.
Physical examination is unremarkable, including neurological examination, and he is
well nourished. He has some mild eczema. He has good peripheral pulses, no carotid
bruits and a blood pressure of 115/70 mm Hg.

C3
History
A 66-year-old bank manager is brought to the emergency department by his wife and his
daughter, as he has had a flurry of blank episodes. He became unresponsive for a minute
or so and appeared confused for 23 minutes. He then reverted to his normal state with
little memory of what had happened. The final episode has left him with a drooping face,
which has now recovered. However, he seems to have word-finding difficulty. He took
early retirement 18 months ago after he developed slurred speech and confusion in a
similar episode. Following that episode, he recovered quite well but found it difficult to
concentrate at work. He had a similar episode 6 months ago following which he began
losing his way while driving. He has avoided driving over the past few weeks. He has
become increasingly forgetful and suspicious of late. His moods are variable and he gets
worked up quite easily. He was helping a charity with their accounts but has been asked
to leave as he made several simple errors and reacted in anger when confronted with his
errors. He lives with his wife, who is very supportive. He has no previous psychiatric
history but has suffered from hypertension for 20 years and diabetes type 2 for 15 years
treated adequately with enalapril and metformin, respectively. He has smoked 30
cigarettes a day for 50 years. He drinks socially and does not take any illicit drugs.
Physical examination
He appears as an overweight, well-dressed gentleman who walks with a slow shuffling
gait. His pulse rate is 86 beats per minute, regular, and blood pressure is 176/92 mm Hg.
Central nervous system examination reveals bilateral increased tone though strength and
reflexes are equal all over. There is no other physical finding of note. Funduscopic
examination is normal.
Mental state examination
His eye contact is good. He is pleasant, cooperative but a little perplexed. His speech is
slow and hesitant. There is evidence of psychomotor retardation and his mood is low and
anxious. There is no evidence of formal thought disorder, but he does have some ideas
of reference and persecution. There is evidence of cognitive impairment he scored
21/30 on Mini Mental State Examination (MMSE) losing points on attention, recall,
naming and construction. He seems to have a reasonable degree of insight and wants
help to get better.

C4

History
You visit a 67-year-old man at home who is reported as being confused. His wife is
distressed because he repeatedly asks her to swat the flies from the ceiling, when she can
see nothing there. He has been in bed for 3 days with a cold. He frequently gets up and
wanders around without knowing where he is going. His wife says on one occasion he
burst out laughing without any reason that she could discern. At other times he seems
bewildered. She describes that he becomes more confused in the evening and at night,
and has urinated in the cupboard. He has no diarrhoea. A week ago he was well and able
to do gardening. He has not been confused until recently. On questioning his wife says
that while he occasionally forgets the names of village acquaintances, his memory has
otherwise been fine. He is not a large user of alcohol and drinks only a small bottle of
beer or a sherry once per week. His wife has remained well throughout.
Mental state examination
When you visit he is lying in bed. He is initially suspicious of you and asks if you are an
undertaker. He is preoccupied with stripes on the wallpaper and asks his wife several
times to get some towels to mop up the water running down the wall. He makes poor eye
contact. He is slightly restless in bed and looks dishevelled. There is a strong body
odour. He looks perplexed and frightened. He does not appear to be responding to
voices, and his wife says he has not mentioned this. He is not able to answer questions
about passivity experiences. With respect to delusions his wife says that he thought that
she was going to stab him when she was trying to spoon-feed him some soup the
previous night. He pushed her away but has not hit her. He is unable to say what day of
the week it is or what time of day. He names the previous prime minister as the current
one, and cannot repeat back an address that you give him to remember. He thinks he is
in hospital. You need to repeat questions as he seems preoccupied with his own thoughts
or things that he is seeing.
Physical examination
There are no abdominal signs and the cardiovascular system seems normal with good
peripheral pulses. His heart rate is 96 beats per minute and his blood pressure is 110/68
mm Hg. His temperature is normal. He has poor air entry and crackles over the right side
of the lower lung, and he has bronchial breathing and dulled percussion in the same area.
He has an increased respiratory rate.

C5

History
A 50-year-old electrician presents to the emergency department with a 3-day history of
an unsteady gait and double vision when looking to the right. He appears confused and
gives a history of severe vomiting over the past 10 days with significant weight loss over
the past few months. He has been abusing alcohol for 30 years and has been diagnosed
with alcohol dependence. He underwent partial gastrectomy for carcinoma of the
stomach 12 years ago. He has no other previous medical or psychiatric history.
Mental state examination
His eye contact is variable. He is disorientated. He has poor orientation in time and does
not know where he is, but he is able to recognize his wife who accompanies him. He is
drowsy, has poor concentration but is readily rousable. He scores 14/30 on the Mini
Mental State Examination. A thorough mental state examination is difficult due to his
condition, but he does not appear to be responding to any unseen stimuli. He has little
insight into why he is here.
Physical examination
A general examination reveals bilateral pedal oedema and icterus. His blood pressure is
90/60 mm Hg and pulse is 120 beats per minute. Oxygen saturation on air is 96%. He
has palmar erythema and hepatomegaly. He has nystagmus. Neurological examination
reveals reduced power in both lower limbs. He has reduced sensation on pinprick and
two-point discrimination in both lower limbs. Deep tendon reflex at the ankle is reduced
bilaterally. He has an unsteady gait and is unable to stand without support.