A 22-year-old male presents with a sudden and severe headache accompanied by disorientation, drowsiness, and neck stiffness. Upon investigation, a subarachnoid haemorrhage is suspected. What is the patient’s grade of illness according to the Hunt and Hess scale?
A 58-year-old male presents with a 4 months history of increasing clumsiness in his hands and arms. He has a complicated past medical history: 23 years ago, he underwent a renal transplant after a progressive deterioration in his renal function following diagnosis with autosomal dominant polycystic kidney disease aged 25. His transplant has functioned well since but the patient has since undergone two resections of squamous cell carcinomas and one serious lengthy hospital admission for a systemic fungal infection. He stopped working 2 years ago as a wine merchant, after complaining that he was no longer able to differentiate ‘the smells of his wines as he got older’.
During examination, he is alert and orientated. Questioning was challenging due to his hearing impairment, despite bilateral hearing aids. He scored 16/30 on a mini-mental examination. Pupils were reactive with a full range of eye movements. Facial power and sensation were normal, with symmetrical palatal elevation and no tongue deviation. He was profoundly deaf bilaterally. Tone, power and sensation were normal, reflexes were present with downgoing plantars. However, you note significant bilateral finger-nose dysmetria and heel-shin mal co-ordination.
Which investigation is likely to lead to a unifying diagnosis?
A 25-year-old white Caucasian left-handed male presents with a 24-hour history of slurred speech. He is a frequent visitor to the Emergency Department with repeated admissions and is known to use intravenous drugs and alcohol. During his adolescence, he was treated for functional neurological symptoms and has a history of depression. He denies having consumed alcohol for the past 2 weeks but used intravenous cocaine yesterday.
Upon examination, the patient appears disheveled and has a lack of prominent veins. An old abscess scar is visible over his right femoral crease. The patient’s speech is markedly slurred, but he remains oriented to time and place. Additionally, there is a significant loss of forehead creasing and facial weakness on both sides of his face, with normal facial sensation. The patient has 4-/5 power in shoulder abduction, shoulder adduction, hip flexion, and hip extension, with 5/5 power on all other movements. Reflexes were present in biceps, supinator, patella, and ankle, with an absent triceps reflex. Both plantar reflexes were downgoing. Sensation to cotton wool, proprioception, and pinprick was normal, and the patient reported no pain.
What is the most likely diagnosis?
A 25-year-old woman presents with a referral to neurology due to progressive weakness in her lower limbs over the past 5 weeks, resulting in difficulty walking. She also reports experiencing bilateral tinnitus for the past 4 months, accompanied by episodes of vertigo. On examination, both lower limbs exhibit reduced power (3/5), increased tone, and hyperreflexia. A single 1 cm tan lesion is observed on her torso, but no other skin lesions are detected. An MRI of her spine is ordered. What is the most probable diagnosis?
A 60-year-old man presents to the neurology outpatient clinic with a six-month history of double vision. He first noticed this when reading before going to bed, but it has been occurring earlier in the day whenever he concentrates on an activity. His wife reports struggling to hear him when he speaks and that his eyelids have drooped late in the day. The patient denies experiencing any weakness in his arms or legs but has limited mobility due to osteoarthritis of both knees. He has a past medical history of hypercholesterolemia, hypertension, and diverticular disease. What is the most sensitive investigation for the likely diagnosis?
A 45-year-old right-handed male accountant has come to your general medical clinic in a state of distress. He has been experiencing difficulty writing for the past 2 weeks. He explains that he wants to write, but his hand stops as soon as he picks up the pen. He has no medical history, lives with his wife, and does not smoke or drink alcohol. During the neurological examination, there were no notable findings. However, when asked to write, his hand and fingers suddenly flex, resulting in illegible handwriting. What is the most probable diagnosis?
A 65-year-old woman presents with constant thoracic back pain that is severely impacting her ability to care for her grandchildren. She has a medical history of breast cancer, which was treated with a mastectomy, reconstruction, radiotherapy, and endocrine therapy. Due to being BRCA1 positive, she also had a hysterectomy with bilateral oophorectomy. On examination, she experiences tenderness over the T4 spine, but there are no neurological abnormalities. What imaging investigation is best suited for her back pain?
A 35-year-old woman presents with difficulty walking and using her hands. She reports struggling to carry her young child.
On examination, bilateral ptosis and a smooth forehead are observed. Fundoscopy is challenging due to bilateral cataracts. The patient’s facial expression is reduced, with wasting of the temporalis muscles, masseters, and sternomastoids. Bilateral hand grip weakness is present, with distal weakness and wasting in the upper limb muscles. There is also bilateral foot drop. Deep tendon reflexes are diminished.
Which of the following best explains the underlying cause of this condition?
A 82-year-old man is brought in by ambulance due to suspected stroke. His wife noticed sudden weakness on his right side. He reports no prior symptoms and describes the onset of weakness as sudden. The patient has a medical history of hypertension, diabetes, and glaucoma. Upon examination, he exhibits pyramidal weakness on the right side of his arm and leg, accompanied by sensory loss and reduced tone. His left side is unaffected. The cranial nerve examination reveals homonymous hemianopia but is otherwise normal. What is the most probable diagnosis?
A 28-year-old man presents to the hospital after feeling unwell at a gathering. Upon arrival, he is found to be lethargic and only responsive to verbal cues. His airway is open, and his lungs are clear. His pupils are reactive to light and measure 4mm. His vital signs are as follows:
– Respiratory rate: 12 breaths per minute
– Oxygen saturation: 95% on room air
– Heart rate: 84 beats per minute
– Blood pressure: 117/65 mmHg
– Temperature: 36.7ºC
Due to his altered mental status, a CT scan of his head is ordered. During the scan, a friend calls the hospital and reports that the patient had taken some pills at the party about 90 minutes ago. Empty packets of diazepam were found at the scene.
After the CT scan, the patient returns to the ward, but his level of consciousness deteriorates, and he begins to make snoring sounds. These sounds improve with a jaw thrust but return when the maneuver is stopped. The rest of the physical examination is unchanged.
What is the most appropriate course of action?