A 58-year-old man presents with slurred speech and difficulty eating. His daughter brought him in by ambulance as she noticed his speech was abnormal. The patient denies any changes, but his daughter has observed drooling and inappropriate laughter during conversations over the past few months. On examination, the patient has mild dysarthria and abnormal tongue movement, but his limbs and other cranial nerves are normal. What is the most probable diagnosis?
A 65 year old man has been referred to you by a psychiatrist for a second opinion. He has been experiencing low mood, apathy and suicidal thoughts for the past 3 months. He was also asked to retire early from his job as an accountant due to poor performance. Additionally, he has been sleeping for an average of 14 hours per day.
During his assessment with the psychiatrist, abnormal jerky movements were noted in his lower limbs and he had a broad based gait. His MMSE score was 15/30, which was confirmed during your examination. You also observed hyperreflexia in his lower limbs and nystagmus. He has no history of cognitive impairment or psychiatric conditions, and there is no family history of neurological or psychiatric disorders. His only past medical history is an appendectomy 20 years ago, which was complicated by a large intraperitoneal bleed.
What investigations are most likely to reveal additional information about his condition?
A 25-year-old woman with a history of epilepsy presents to the Emergency department with worsening generalised headache, vomiting, unsteadiness, and blurred vision over the past three days. She has also experienced slurred speech and a one stone weight loss in the past month. On examination, she has dysarthria, bilateral papilloedema, reduced visual acuity, and a broad-based ataxic gait. Investigations reveal bilateral cerebellar haemangiomas. What is the probable diagnosis for this patient?
A 43-year-old woman presents to neurology clinic for evaluation of her treatment plan for multiple sclerosis. She was diagnosed with multiple sclerosis five years ago after experiencing sensory loss and motor weakness in her left leg. Despite having multiple lesions on MRI suggestive of multiple sclerosis, she initially declined disease modifying therapy. However, one year later, she developed optic neuritis and had progression of her radiographic lesions on repeat MRI. She was then started on interferon beta for two years but discontinued due to intolerable side effects. A trial of glatiramer acetate was also unsuccessful due to severe flushing. Since stopping disease-modifying therapy, she has had multiple relapses, including one requiring hospitalization. She meets criteria for aggressive or highly active multiple sclerosis and is interested in later line therapies. She is a science teacher who has been unable to work for the past year due to her relapses.
At this point, the recommended later line therapy is natalizumab. What is the crucial investigation that must be completed before starting treatment with natalizumab?
An 80-year-old man presents with gradually worsening dyspnoea, without any accompanying cough or chest pain. He has a medical history of Parkinson’s disease, rheumatoid arthritis, type 2 diabetes mellitus, and atrial fibrillation. Peak flow tests reveal a decreased Forced Vital Capacity (FVC), an FEV1:FVC ratio of 90%, and a reduced transfer factor for carbon monoxide (TLCO). A high-resolution CT scan confirms the presence of ground-glass changes. Which medication among his current prescriptions is the most likely cause of his lung changes?
A 28-year-old male presents with sudden left-sided weakness, expressive dysphasia, and dress apraxia. He has a history of progressive cognitive impairment and seizures for the past six years. He lives in a sheltered accommodation and was brought in by his relatives who noticed a change from his baseline. The patient has difficulty recalling the duration of his symptoms. He reports a recent burning sensation while urinating, increased frequency, and reduced oral intake for the past five days. An MRI of the head shows multiple areas of ischemia in the left and right cortex, inconsistent with a single vascular territory. A urine dip test is positive for leukocytes and nitrites but negative for ketones. A venous blood gas test reveals:
pH 7.15
PaCO2 2.4 kPa
Bicarbonate 6 mmol/l
Lactate 18 mmol/l
Anion gap 16 mmol/l
What is the underlying diagnosis that explains all of these symptoms?
A 50-year-old Bangladeshi male presents with a 6-month history of bilateral reduced sensation on the tips of both his feet, which has gradually progressed on both legs to his low shins. His past medical history includes type 2 diabetes, diagnosed 10 years ago and reports good medication compliance with metformin 500mg BD alone, with a HbA1c of 48 mmol/mol (6.5%) two weeks ago. He is also currently in his ninth month of anti-tuberculosis treatment, having initially presented with a chronic cough, night sweats and weight loss. An induced sputum subsequently cultured positive for acid-fast bacilli. He did not bring in his medications but remembers being told they are ‘the standard four then two drugs’. He takes no other medications and has no known drug allergies. On examination, tone, power and gait of his lower limbs are unremarkable. He demonstrates reduced sensation to light touch to his left lower shin and right mid-shin. Ankle jerks are absent bilaterally, plantars are downgoing bilaterally. What is the most likely diagnosis?
A 70-year-old male has been diagnosed with dementia after experiencing a gradual decline in cognitive function over the course of a year. Specifically, he has shown deficits in planning, attention, cognitive flexibility, visual memory, and visuospatial manipulation on detailed neuropsychological assessments. His mini-mental state examination score is 15 out of 30. The patient has a history of Parkinson’s disease and has been taking Madopar for the past 6 years. During a clinic visit, the patient’s son expresses a strong desire to start treatment. What is the most readily available treatment option?
A 79-year-old male visits a Parkinson’s disease clinic complaining of frequent episodes of complete immobility lasting up to 20 minutes, occurring up to four times daily. He has been diagnosed with Parkinson’s disease for the past six years and is currently taking Sinemet 125 as his only medication. What is the most suitable treatment to alleviate his motor fluctuations?
A 23-year-old male presents to the clinic after being referred by his GP. He has been noticing that his eyelids appear to be drooping more and more over the past 10 months, which has been commented on by his friends. He denies experiencing any muscle weakness or double vision. He has no significant medical history and does not smoke or drink alcohol. Upon examination, bilateral abduction and adduction of his eyes are impaired, and there is inconsistent impairment of vertical gaze. His neurological examination of the upper and lower limbs is unremarkable, except for mild finger-nose dysmetria. Blood tests show no abnormalities, and his ECG shows sinus rhythm with a PR interval of 260 ms. Fundoscopy reveals a pigmented retina. What is the likely diagnosis?