A 59 year old man arrives at the Emergency Room with his wife, expressing concern about his memory. He first noticed a problem when he struggled to prepare breakfast in the morning. When questioned, he cannot recall today’s events and has only fragmented memories of the past week, although his wife confirms that he had no memory issues yesterday. He seems highly anxious about his memory loss and repeatedly asks, Do I have dementia?
A 78-year-old female presents to the emergency department with a history of arm and leg weakness and loss of vision that lasted for approximately 6 hours. She is unsure of the specific limb or visual field affected. The upper and lower neurological examination and cranial nerve examination are normal. The patient has a history of regular migraines, type two diabetes mellitus, and hypertension. Her observations are within normal limits except for a blood pressure of 145/90 mmHg. Given the patient’s symptoms, what is the most appropriate radiological investigation to aid in the diagnosis of a possible transient ischaemic attack?
A 50 year old previously healthy man presents to the emergency department with progressive leg weakness. He works as a construction worker and is usually very active. He reports difficulty walking and describes his gait as like a drunk man. He also mentions having trouble urinating and has not felt the urge to empty his bladder for the past 12 hours. He denies any recent illnesses or injuries.
Upon examination, he has normal muscle mass and no fasciculations. He has symmetrical flaccid paralysis in his lower limbs up to the hips, with symmetrical hyporeflexia. He has a sensory level to T10 and is experiencing urinary retention. His upper limbs and cranial nerves appear normal.
What would be the most useful initial investigation in this case?
A 26 year-old university student presents with a 12 day history of visual disturbance. He reports changes in his visual acuity where he has been experiencing some blurring of his vision which is considerably worse after having been for a run. He thinks it is related to some pain he developed on his right eye prior to the onset of his vision loss. He has no previous history of visual problems and is normally fit and well. He takes no regular medications.
On further questioning he reports that 8 months ago he had some sensory changes on his lower limbs. He felt they were numb and this persisted for a few weeks. He thought it was due to his sporting activities, as he is an avid soccer player.
He drinks 15 units of alcohol at the weekends and does not smoke.
His blood results are shown below:
Hb 130 g/l
Platelets 240 * 109/l
WBC 7.5 * 109/l
Na+ 136 mmol/l
K+ 4.0 mmol/l
Urea 4.5 mmol/l
Creatinine 65 µmol/l
Which investigation below would be most useful to diagnose this patient?
A 65-year-old man presents to the emergency department with a 5-minute episode of slurred speech earlier in the day. His wife noticed that his face was drooping to one side as well. He had no arm weakness and is now completely back to normal. He is normally well and on no regular medication and is not allergic to any medication. He works as a plumber and smokes 10 cigarettes per day for the last 35 years and drinks alcohol socially. On further questioning he mentions that he had a similar episode also lasting 5 minutes four days ago whilst at work.
On examination, his blood pressure is 135/70 mmHg and his heart rate is 58/min. He has no focal neurology and his cardiovascular and respiratory examinations are unremarkable. He has been given 300mg of Aspirin by the paramedics. His blood tests are as follows:
Hb 138 g/l
Platelets 283 * 109/l
WBC 8.1 * 109/l
INR 1.1
PT 13 seconds
Na+ 142 mmol/l
K+ 4.4 mmol/l
Urea 6.4 mmol/l
Creatinine 89 µmol/l
CRP 5 mg/l
Total cholesterol 3.8 mmol/l
HDL 1.3 mmol/l
His ECG shows normal sinus rhythm and rate of 65/min.
What is the most appropriate management for this patient?
A 70 year old woman with Parkinson’s disease is brought to your clinic by her daughter. The daughter is worried because her mother has been expressing concerns that her neighbors are spying on her and have installed wiring in her walls to monitor her movements. The patient has also been experiencing visual hallucinations of animals climbing up her walls. The daughter reports that her mother has become increasingly anxious. The patient is currently taking co-careldopa, ropinirole, and rasagiline. What would be the most appropriate next step?
A 75-year-old man with hypertension and previous myocardial infarction 5 years ago visits his GP complaining of a painful vesicular rash over his left chest and back that has been present for 2 days. The rash is well-defined and limited to the T6 dermatome. The GP diagnoses shingles and prescribes pain relief. The rash gradually disappears over the next 2 weeks.
After 4 weeks, the man experiences stabbing and shooting chest pain on the left side and goes to the Emergency Department. His blood pressure is 154/96 mmHg, and his heart rate is 50/min. His oxygen saturation on room air is 98%.
The following are the results of his investigations:
– Chest x-ray: No abnormalities.
– ECG: 50/min. PR interval 230 milliseconds. QRS interval 110 milliseconds. 5 millimetre Q waves in the inferior leads. Normal T wave and ST segments.
– D-dimer and 12-hour troponin: Normal.
Which analgesic agent should be avoided?
A 78-year-old man with diabetes mellitus has been referred to a specialist memory clinic by his family doctor due to concerns of increased forgetfulness and urinary incontinence. Despite a course of trimethoprim for a suspected urinary tract infection, his symptoms have persisted. On examination, he has a strong odor of urine, an unsteady gait, and suprapubic tenderness. His Mini Mental State Examination score is 22/30 and urinalysis shows white cells and bacteria. MRI of the brain reveals an enlarged ventricular system compared to sulcal atrophy, and LP results are within normal limits. What is the definitive treatment for this patient’s underlying diagnosis?
A 29-year-old woman presents with a gradually worsening headache, nausea and vomiting.
The headache started about 3 days ago coming on over about 3-4 hours and is worse on coughing and lying flat. She has been complaining of some nausea and vomiting which she had attributed to some reheated curry she had the night before.
She is usually fit and well but did suffer a spontaneous below-knee deep vein thrombosis (DVT) 2 years ago which was treated with warfarin for 6 months. She has been taking over-the-counter paracetamol and ibuprofen for the headache and currently has a Mirena intrauterine coil in-situ for contraception. She has no known drug allergies.
She currently works as a sales associate. She smokes 10 cigarettes a day and drink 21 units of alcohol a week.
On examination she looks unwell, pale and nauseated. Her blood pressure was 140/98 mmHg, heart rate 100 bpm, oxygen saturations of 98% on air. Her temperature was 36.1 degrees Celsius.
Heart sounds were normal, and her calves soft and non-tender with no evidence of thromboembolism.
Her chest was clear and her abdominal examination was unremarkable.
On neurological examination there was no cranial nerve abnormalities noted. She had normal tone, power, reflexes and sensation in both her upper and lower limbs. Coordination was intact.
Bloods taken by the Emergency Department were as follows:
Na+ 136 mmol/L
K+ 3.9 mmol/L
Urea 4.8 mmol/L
Creatinine 76 µmol/L
Hb 12.5 g/dL
WBC 11.0 x 10^9/L
Platelets 350 x 10^9/L
INR 0.9
aPTT 30 seconds
LFTs Normal
CT head was performed and reported as normal.
Following this a lumbar puncture was performed:
CSF colour Clear
Opening pressure 250 mmH20
White cell count 5.0 x 10^6/L (all lymphocytes)
Red cell count 15 x 10^6/L
Protein 0.3 g/L
Glucose 4.4mmol/L (Serum glucose 5.3mmol/L)
What is the most likely diagnosis?
You review an 85-year old retired teacher in your clinic who has been experiencing numbness in her arms and difficulty walking. Upon examination, you observe reduced sensation on the lateral aspect of her arms and forearms in the anatomical position. There is no muscle wasting on her hands, but she has reduced biceps and supinator reflexes and reduced power bilaterally. Additionally, she has a wide-based scissoring gait and is unable to stand still without support when asked to close her eyes.
This patient lives independently but has been struggling to cope recently. She has a history of hypertension and high cholesterol. What investigation would be most appropriate to diagnose her condition?