8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 64 A 48-year-old white man presents to his optometrist with a 1-month history of blurred vision in his left eye Visual acuity is 6/12 in the affected eye (6/6 in the other eye) Fundal examination reveals some mottled pigmentary changes at the left macula, associated with some macular oedema On closer inspection, both fundi revealed reddish-brown bands deep to the retina radiating in a spoke-like pattern from the optic disc The optician referred the patient to his GP, who noted loose skin folds with yellow striations and puckering in the neck and flexor aspects of the joints What is the most likely diagnosis? A Ehlers-Danlos syndrome B Paget’s disease C Marfan’s syndrome D Sickle cell disease E Pseudoxanthoma elasticum Explanation Angioid streaks Pseudoxanthoma elasticum The fundal examination of this patient reveals the classic signs of angioid streaks, ie orangebrown bands radiating away from the optic disc The patient has presented to his optometrist with macular changes suggestive of macular degeneration This is a known complication of angioid streaks and occurs secondary to choroidal neovascularisation Although angioid streaks are idiopathic in up to 50% of patients the remaining 50% have associations with systemic disease The skin changes present on this patient’s neck and flexor surfaces are typical of those seen with pseudoxanthoma elasticum (the classic plucked chicken appearance) Other causes of angioid streaks - https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/8/2016 MyPastest Angioid streaks can be seen with Ehlers–Danlos syndrome, which is associated with hyperelasticity of the skin and loose joints Marfan syndrome is also associated with angioid streaks but is not associated with the skin changes described These lesions can also occur in patients with Paget’s disease, unlikely in a 48-year old man In patients of Afro-Caribbean descent, they can also be seen in sickle cell disease 3478 Next Question Previous Question Tag Question Feedback End Review Difficulty: Easy Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 64 Which one of the following is a cause of second-order-neurone Horner syndrome? A Cavernous sinus thrombosis B Craniopharyngioma C Internal carotid artery aneurysm D Pancoast’s tumour E Syringomyelia Explanation  The answer is Pancoast’s tumour – Horner syndrome is also known as oculo-sympathetic paresis and is characterised by miosis, ptosis and anhydrosis Lesions along the sympathetic chain along the head and neck region can cause these clinical appearances The causes of Horner syndrome can vary with age, and can be elicited by thinking about lesions that could affect its path The first-order (central) neurone descends from the hypothalamus to the cervical spine The second-order (preganglionic) neuroneexits the spinal cord and heads towards the head and neck It travels along its path with the cervical sympathetic chain, the brachial plexus, lung apices (Pancoasttumour) to synapse at the superior cervical ganglion This is located near the angle of the mandible and is in close proximity to the common carotid artery The third-order (postganglionic) neurone begins at the superior cervical ganglion and travels along the wall of the internal carotid artery into the cavernous sinus Lesions along its path affecting the internal carotid arteryor within the cranium can affect its function Cavernous sinus thrombosis (Option A) is incorrect The sympathetic chain does not pass along the cavernous sinus https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/8/2016 MyPastest Craniopharyngioma (Option B) is incorrect The first-order (central) neurone descends from the hypothalamus to the cervical spine (ciliospinal centre of Budge), and can be affected by craniopharyngioma Internal carotid artery aneurysm (Option C) is incorrect Lesions of the third-order neurone affect the internal carotid artery Syringomyelia (Option E) is incorrect The first-order (central) neurone descends from the hypothalamus to the cervical spine (ciliospinal centre of Budge), and can be affected by syringomelia 45529 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 64 A patient with controlled ocular myasthenia gravis develops an acute infection Which one of the following antibiotics is contraindicated? A Aminoglycosides B Macrolides C Metronidazole D Penicillins E Quinolones Explanation  The answer is Aminoglycosides – Aminoglycosides are contraindicated in patients with myasthenia gravis as they are known to interfere with and impair neuromuscular transmission Macrolides (Option B) is incorrect Macrolides have been associated with anecdotal reports of increased myasthenic weakness, although the mechanism is less clear, with rare published incidence Metronidazole (Option C) is incorrect Metronidazole is very rarely associated with the disease Penicillins (Option D) is incorrect Penicillins have been associated with anecdotal reports of increased myasthenic weakness, although the mechanism is less clear, with rare published incidence Quinolones (Option E) is incorrect Quinolones have been associated with anecdotal reports of increased myasthenic weakness, although the mechanism is less clear, with rare published incidence 45524 Next Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/8/2016 MyPastest Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 64 A patient presents with a first episode of a painful reduction in visual acuity in one eye The acuity is 6/60, ocular movements produce pain and the optic disc is normal Which one of the following investigations supports the diagnosis of optic neuritis? A Abnormal visual evoked potentials (VEP) B Abnormal electroretinogram (ERG) C Abnormal electro-oculogram (EOG) D Abnormal electroencephalogram (EEG) E Abnormal electronystagmogram (ENG) Explanation  The answer is Abnormal visual evoked potentials In optic neuritis, demyelination causes a reduction in the velocity of the propagation of action potentials and so the VEP response is delayed The ERG is normal as the retina is unaffected Abnormal electroretinogram (Option B) is incorrect The ERG measures retinal electrical activity and is often used to validate the significance of an abnormal VEP response (ie if the VEP is abnormal but so is the ERG, then the VEP abnormality might be secondary to an eye condition and be a false-positive for optic nerve disease) Abnormal electro-oculogram (Option C) is incorrect The EOG measures the overall electrical activity of the eye and is reduced in degenerative eye conditions affecting the pigment epithelial layer, such as Best’s disease Abnormal electroencephalogram (Option D) is incorrect An EEG is not an optimal investigation for assessing vision impairment Abnormal electronystagmogram (Option E) is incorrect The ENG is simply a method of documenting nystagmus using the electrical charge of the eye 41827 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/8/2016 MyPastest Next Question Previous Question Tag Question Feedback End Review Difficulty: Easy Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 64 A diabetic 46-year-old man is found in the Diabetic Clinic to have reduced visual acuity During a telephone referral to the Eye Clinic, the ophthalmologist asks if the patient has any risk factors for macular oedema Which one of the following should the referring physician bring to his attention? A Background diabetic retinopathy B Low glycosylated haemoglobin C Hypercholesterolaemia D Proteinuria E Peripheral vascular disease Explanation Diabetic macular oedema The Wisconsin Epidemiological Study showed that the incidence of macular oedema was 2– 6% in background diabetic retinopathy (DR), 20–63% in preproliferative DR and 70–74% in proliferative DR The prevalence increased with greater duration of diabetes, higher glycosylated haemoglobin and greater proteinuria levels 805 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 8/8/2016 MyPastest Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/8/2016 MyPastest vision is typically spared 41824 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 58 of 64 A 70-year-old woman with a history of rheumatoid arthritis comes to the Emergency Department with sudden painful loss of vision in her left eye She has a history of hypertension, which is managed with ramipril 10 mg daily and amlodipine mg, and she has type diabetes, which is controlled with metformin She is taking prednisolone and hydroxychloroquine for her rheumatoid arthritis and amitriptyline for depression On examination, her BP is 152/92 mmHg, there is increased intraocular pressure, more marked in the left eye than the right, fundoscopy is difficult due to the presence of probably inflammation, both pupils look partially dilated Which one of the following drugs is the most likely cause of these problems? A Hydroxychloroquine B Metformin C Prednisolone D Ramipril E Amitriptyline Explanation Glaucoma as a drug side-effect Drugs which cause acute closed-angle glaucoma include tricyclic antidepressants, antihistamines, anti-parkinsonian agents, antipsychotics and sulphonamides Treatment involves a combination of acetazolamide, ß-blocking eye drops, α-adrenergic eye drops and pilocarpine The causative medication should be stopped, although around a third of patients require permanent therapy to lower the intraocular pressure despite discontinuing the responsible medicine Hydroxychloroquine toxicity mimics open-angle glaucoma and prednisolone is a cause of chronic open-angle glaucoma 20773 Next Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 8/8/2016 MyPastest Previous Question Tag Question Feedback End Review Difficulty: Difficult Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 59 of 64 The medical FY2 telephones the consultant to say she has diagnosed a patient as having Behỗets disease The patient presented to the Emergency Department with reduction in vision in one eye Which one of the following features supports her diagnosis? A The patient is of Celtic extraction B There is a strong family history of blindness C The patient has a small-joint polyarthropathy D The patient has active oral ulceration E The patient’s visual loss is due to retinal artery occlusion Explanation  The answer is The patient has active oral ulceration Behỗets disease is more common in people of Turkish origin, and is the combination of oral and genital ulceration with uveitis It is a vasculitis associated with large-joint arthropathy and peripheral retinal venous occlusions Other features include erythema nodosum and a positive pathergy skin test (a sterile pustule appears 24–48 hours after skin puncture with a needle) – and a predilection for medical exams! Either colchicine or thalidomide is used in treatment The patient is of Celtic extraction (Option A) is incorrect Behỗets disease is more common in people of Turkish origin, not Celtic extraction There is a strong family history of blindness (Option B) is incorrect The family history is only positive in 6% The patient has a small-joint polyarthropathy (Option C) is incorrect This does not support the diagnosis of Behỗets disease The patients visual loss is due to retinal artery occlusion (Option E) is incorrect Although Behỗets disease can result in retinal artery occlusion, it is the presence of active oral https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 8/8/2016 MyPastest ulceration that most supports the diagnosis 41826 Next Question Previous Question Tag Question Feedback End Review Difficulty: Easy Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 60 of 64 A 35-year-old woman is found to have aortic regurgitation She is wearing aphakic spectacles Which one of the following diagnoses in the Eye Clinic sheds light on the cause of her valvular disease? A Cataract B Glaucoma C Kayser–Fleischer rings D Ectopia lentis E Iritis Explanation The lens in Marfan syndrome Dislocated lenses are a feature of Marfan syndrome, as is aortic regurgitation Aphakic spectacles are prescribed if the dislocated lenses have disappeared entirely from the pupil aperture (a kind of spontaneous cataract extraction) or after they have been surgically removed 827 Next Question Previous Question Tag Question Feedback End Review Difficulty: Easy Peer Responses https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 8/8/2016 MyPastest Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 61 of 64 A 26-year-old man presents with sudden-onset headache and double vision The doctor in the Emergency Department diagnoses a IIIrd (oculomotor) nerve palsy and notes a dilated pupil on that side Which one of the following is the most likely cause? A Posterior communicating artery aneurysm B Acoustic neuroma C Diabetes mellitus D Extradural haematoma E Ophthalmoplegic migraine Explanation  The answer is Posterior communicating artery aneurysm – The IIIrd (oculomotor) nerve emerges in the interpeduncular fossa, passes between the posterior cerebral and superior cerebellar arteries and pierces the dura at the lateral clinoid process to enter the lateral wall of the cavernous sinus Causes of palsy include: • Posterior communicating artery aneurysm – sometimes associated with headache and usually involving pupillary fibres causing an ipsilateral dilated pupil Patients with a new onset, pupil-involving, isolated oculomotor nerve palsy require urgent investigation for an aneurysm which may require urgent treatment to prevent sub-arachnoid haemorrhage Acoustic neuroma (Option B) is incorrect An acoustic neuroma does not typically affect the oculomotor nerve given its location Diabetes mellitus (Option C) is incorrect Diabetes mellitus causes a microvascular infarct of the nerve, and is more commonly painless and associated with sparing of the pupillomotor fibres https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 8/8/2016 MyPastest Extradural haematoma (Option D) is incorrect Palsy can be caused by pressure on the nerve in ‘coning’ – this however develops gradually and other neurological signs are often present Ophthalmoplegic migraine (Option E) is incorrect Ophthalmoplegic migraine is a much less common cause of a painful IIIrd nerve palsy and should be a diagnosis of exclusion 41816 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 62 of 64 A 40-year-old man presents to his GP with unequal pupils The GP considers that a IIIrd (oculomotor) nerve palsy is the likely diagnosis Which one of the following statements is true? A The pupil on the affected side is smaller B The pupil on the affected side reacts normally to light C The pupil on the contralateral side reacts normally to light shone into the affected eye D The pupil on the affected side reacts normally to accommodation E The pupil size difference is equal in bright and dim surroundings Explanation  The answer is The pupil on the contralateral side reacts normally to light shone into the affected eye The pupil on the affected side is smaller (Option A) is incorrect The IIIrd (oculomotor) nerve brings parasympathetic pupillomotor fibres to the iris sphincter – in a palsy, the pupil on the affected side is larger (not smaller) The pupil on the affected side reacts normally to light (Option B) is incorrect Light reactions of the pupil on the side of the IIIrd nerve palsy will be impaired, either to a direct (light shone into the ipsilateral eye) or consensual (light shone into the contralateral eye) stimulus Constriction as part of the near response will also be affected on the side of the IIIrd nerve palsy The pupil on the affected side reacts normally to accommodation (Option D) is incorrect There will be no impairment in the detection of light (IInd or optic nerve) by the eye on the side of the IIIrd nerve palsy, and therefore the contralateral eye’s consensual pupil reaction will be unaffected The pupil size difference is equal in bright and dim surroundings (Option E) is incorrect The pupil size difference is equal in bright and dim surroundings only in physiological anisocoria https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 8/8/2016 MyPastest In IIIrd nerve palsy the difference will be greater in bright light because of the failure of constriction of the abnormal pupil 41814 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 63 of 64 A 40-year-old woman with rheumatoid arthritis takes oral steroids She presents with watering of both eyes associated with intermittent blurred vision when using a computer What is the most likely diagnosis? A Cataract B Diabetic retinopathy C Dry eyes D Glaucoma E Transient ischaemic attack Explanation  The answer is Dry eyes – Rheumatoid arthritis is associated with dry eyes Tear-film integrity on the corneal surface is required both for comfort and to provide an optically smooth surface for refraction Therefore, in dry eye, when the tear film cannot provide adequate wetting of the corneal surface between blinks, grittiness and intermittent blur occurs A reflex response to irritation of the corneal surface is epiphora, or watering Symptoms will be worse when tear-film evaporation is greater, for example in windy or in warm, dry (airconditioned air) environments, or when the blink rate declines (as is likely when concentrating on computer work) The setting and recurrent nature of the intermittent blurring points towards ocular surface dryness as opposed to other forms of transient visual loss, such as transient ischaemic attacks (TIAs)., Cataract (Option A) is incorrect Systemic or topical steroid treatment can cause ocular sideeffects Steroid use is a cause of cataract in young or middle-aged patients A ‘steroid cataract’ is typically posterior subcapsular, and causes constant and gradually progressive blur Cataract does not cause watery eyes, and while visual symptoms can vary, visual impairment is usually constant Diabetic retinopathy (Option B) is incorrect Steroids can cause raised blood glucose levels https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 8/8/2016 MyPastest Fluctuating blood sugar levels can cause osmotic swelling of the lens in the eye, resulting in fluctuations in vision However, diabetic retinopathy will not affect vision unless maculopathy occurs (oedematous, exudative, ischaemic or mixed) or vitreous haemorrhage occurs Furthermore, the visual symptoms with diabetic retinopathy are not usually intermittent Glaucoma (Option D) is incorrect Occasionally, topical or systemic steroid use results in raised intraocular pressure, with subsequent progressive damage to the optic nerve and peripheral vision (secondary open-angle glaucoma) However, any visual symptoms due to peripheral visual field loss would not be intermittent (The rise in intraocular pressure usually reverses when steroid treatment is stopped Any damage to the optic nerve and visual field, however, would not be reversible) Transient ischaemic attack (Option E) is incorrect Loss of vision in a TIA (transient ischaemic attack) results in complete loss rather than a blurring of vision 41804 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 8/8/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 64 of 64 A 32-year-old woman was noted by her GP to have unequal pupils, with the right one more dilated than the left, with absent constriction to light This did not improve after dark adaptation, although the pupil did constrict to accommodation Which one of the following is the most likely diagnosis? A IIIrd nerve palsy B Horner’s syndrome C Adie’s tonic pupil D VIth nerve palsy E Argyll Robertson pupil Explanation Pupil abnormalities The Adie pupil does not constrict to light but does constrict to accommodation (albeit sluggishly) It is usually related to peripheral neuropathy The cause is damage to neurones in the ciliary ganglion The Argyll Robertson pupil is related to syphilis and is usually bilateral It can be caused by selective damage to pathways from the retina to the Edinger–Westphal nucleus 21099 End Session Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 8/8/2016 MyPastest Session Progress Responses Correct: Responses Incorrect: 64 Responses Total: 64 Responses - % Correct: 0% Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 ... (https://www.pastest.com/help) © Pastest 2 016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/8/2 016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 11 of 64 An 82-year-old... (https://www.pastest.com/help) © Pastest 2 016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 8/8/2 016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 64 A 71- year-old man presents... and an https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/ 2 8/8/2 016 MyPastest associated ptosis Mescaline ingestion (Option D) is incorrect Recreational drug use (eg mescaline) can cause