A 59-year-old man presents with severe dyspnoea at rest. He has a past medical history of motor neurone disease which was diagnosed 9 months ago. On examination his chest sounds clear. His respiratory rate is 20 breaths per minute with a shallow depth.
You perform an arterial blood gas which is as follows:
PaO2 7.1 kPa
PCO2 6.3 kPa
pH 7.32
HCO3 38 mmol/l
What is the appropriate management for this patient?
A 72-year-old man presents to the emergency department with limb weakness and speech difficulties. He woke up with these symptoms at 7 am and was last seen by his wife at 9 pm the previous night, when he was feeling well. The patient has a medical history of hypertension and hypercholesterolemia and takes ramipril and atorvastatin. He is a non-smoker and does not consume alcohol. He is an independent individual and holds a non-executive director position in a major multinational organization.
Upon examination, the patient’s heart rate is 88 beats per minute, blood pressure is 128/67 mmHg, respiratory rate is 17/minute, oxygen saturation is 96% on room air, and temperature is 37ºC. Neurological examination reveals expressive dysphasia and 3+/5 power in the right upper and lower limbs with corresponding reduced sensation. Blood glucose testing is normal. An ECG shows atrial fibrillation.
Urgent CT head and CT angiography reveal a proximal occlusion of the anterior circulation and no haemorrhage. The patient undergoes a diffusion-weighted MRI, which shows a limited core infarct volume.
What is the optimal management plan for this patient?
A 35-year-old migrant from Asia is referred for evaluation after a routine health check by her primary care physician. The referral notes ‘possible neurological abnormality’. She has no significant medical history, but reports a past history of working in a factory.
During the examination, you observe that her right pupil is dilated and sluggish responsive to light – both direct and consensual. Ankle reflexes are absent, even with reinforcement. Plantar reflexes are flexor.
What is the probable underlying diagnosis?
A 53-year-old man arrives at the emergency department complaining of a persistent headache that worsens when bending down and in the morning. The headache has been ongoing for a month, and the patient has no medical history or regular medication use.
A CT scan of the head is ordered, revealing a large mass lesion on the right side that is causing displacement of the uncus of the temporal lobe under the tentorium cerebelli.
What is the earliest clinical sign that can be expected to be abnormal based on the patient’s presentation?
A 55-year-old man presents to the Neurology Outpatient Clinic with complaints of memory loss and ataxia. He has lost 10 kg of weight over the past six months and is experiencing fatigue, watery diarrhoea, and abdominal pain. He has a medical history of osteoarthritis and hypertension. On examination, he appears tanned and is wearing loose clothing. A systolic murmur is heard over the left fifth intercostal space during cardiovascular examination. His abdomen is distended, and there is palpable pelvic lymphadenopathy. Neurological examination reveals clonus in the ankles bilaterally, and he has a broad-based stance and sways while walking. Cognitive testing shows an Abbreviated Mental Test Score (AMTS) of 8 out of 10. What is the most likely diagnosis?
An 82-year-old man with a history of congestive cardiac failure presented to accident and emergency with symptoms of an acute ischaemic stroke. He had slurred speech, left sided facial droop, and some loss of fine motor control in the left hand. Upon admission, his blood pressure was 185/70 mmHg and his heart rate was 95 beats per minute in sinus rhythm. The initial CT scan of his brain revealed evidence of chronic small vessel ischaemia but no acute pathology, including no haemorrhage. What combination of investigations should be conducted during his acute admission?
A 65-year-old male with a history of hypercholesterolaemia presents to the emergency department with a 2-hour history of right-sided body weakness and difficulty speaking. The weakness has been gradually worsening since onset.
The patient has a past medical history of peptic ulcer disease due to H.Pylori infection, which was treated with omeprazole, clarithromycin, and amoxicillin-clavulanic acid. A recent upper GI endoscopy performed 3 months ago was unremarkable.
He is currently taking omeprazole 20mg daily, atorvastatin 40 mg daily, and occasionally uses paracetamol for joint pain.
Upon examination, his blood pressure is 140/80 mmHg. He is aphasic, with increased tone on the right side and muscle weakness of 2/5 in the right upper limb proximally and distally, and 1/5 in the lower limb both proximally and distally. There is no evidence of meningeal irritation, and his pupils are normal.
Laboratory investigations reveal:
– Hb 150 g/l
– Platelets 450 * 109/l
– WBC 13.0 * 109/l
– Na+ 138 mmol/l
– K+ 4.4 mmol/l
– Urea 6.9 mmol/l
– Creatinine 118 µmol/l
ECG shows sinus tachycardia with occasional ventricular ectopics.
CT scan of the brain shows no evidence of cerebral hemorrhage but suggests a left middle cerebral artery infarction.
What is the most appropriate course of management for this patient?
A 46-year-old woman presented to the emergency department with sudden onset weakness in both legs and hands, accompanied by reduced sensation in her legs and tingling in her hands and forearms. She also experienced urinary incontinence. She had a medical history of hypertension and diabetes treated with metformin, as well as osteoarthritis in her hands and knees. She worked as a secretary and had been typing when the symptoms began.
During the examination, the patient complained of a generalised headache and exhibited spinal tenderness in her neck. Cranial nerves appeared normal. Peripheral examination of her upper limbs revealed normal tone, brisk triceps jerks, absent biceps and supinator jerks, and positive Hoffman’s sign bilaterally. Handgrip was weak, and there was weakness in wrist and elbow extension/flexion. Pain and temperature sensation were reduced in the thumb, middle, ring, little finger, and medial forearm bilaterally. Vibration and light touch were intact. Lower limb examination revealed a spastic paraparesis with loss of pain and temperature sensation over the entire leg extending to involve the abdominal and chest wall to T1.
An x-ray of the cervical spine showed osteoarthritis affecting vertebrae C7-T1. Based on this information, what is the most likely cause of the patient’s symptoms, pending further tests?
A 35-year-old woman has been admitted with a headache that she first experienced while picking up her 6-week-old baby. She is sensitive to light and feels nauseous. Upon examination, bilateral papilloedema is observed and she reports vision loss on her left side. A CT scan of her head reveals a small bleed in the right occipital region. What is the recommended treatment for her condition?
A 29-year-old male presents to the acute medical unit with confusion. His girlfriend reports that he has been increasingly confused over the past few days. He has a history of epilepsy and is currently taking sodium valproate. On examination, myoclonus is noted and his Glasgow coma score is reduced to 13 (M6, V4, E3).
The following blood results are obtained:
Hb 142 g/l Na+ 138 mmol/l Bilirubin 14 µmol/l
Platelets 388 * 109/l K+ 4.4 mmol/l ALP 82 u/l
WBC 10.8 * 109/l Urea 5.8 mmol/l ALT 24 u/l
Neuts 8.4 * 109/l Creatinine 72 µmol/l γGT 36 u/l
Lymphs 1.2 * 109/l Albumin 42 g/l Plasma ammonia 65 μmol/L (normal range 11–32 μmol/L)
What is the appropriate treatment for this patient?