A patient presents to the Emergency Department after being assaulted. She tells you that this occurred a few hours ago and she has taken several blows to the head. On examination, there is bruising around the eyes. Clear fluid can be seen discharging from her nose.
Where is the patient’s pathology likely to be?
Which region of the brain is most likely affected in a child displaying hyperactivity, elation, inappropriate conduct, superficial emotional response, juvenile humor with puns and word games (witzelsucht)?
A 64-year-old computer programmer reported experiencing frequent headaches to his GP. Upon examination, the GP observed papilloedema and pupillary dilation and referred the patient for further radiological studies and to a neurologist. The results of the radiological studies revealed a mass causing non-communicating hydrocephalus. Where is the most likely location of the tumour?
A 30-year-old man is brought to the Emergency Department after being involved in an altercation, during which he was stabbed in his lower back. On examination, he has right leg weakness in all muscle groups. Further examination reveals that he has loss of vibration and proprioception on the same side. In his left leg, there is loss of pain and temperature sensation, but preserved motor strength. He has no problems with bladder or bowel retention. His motor strength is preserved in his upper limbs.
With which one of the following spinal cord syndromes is his presentation consistent?
A 28-year-old woman presents with sudden-onset severe and unremitting occipital headache. On examination, she is drowsy and confused, with a blood pressure of 180/95 mmHg. You suspect that she may have had a subarachnoid haemorrhage and arrange a computed tomography (CT) scan. This is normal. She undergoes a lumbar puncture and the results are shown below:
Pot 1: red cells 490 × 109/l, white cells 10 × 109/l, no organisms seen
Pot 2: red cells 154 × 109/l, white cells 8 × 109/l, no organisms seen
Pot 3: red cells 51 × 109/l, white cells <5 × 109/l, no organisms seen
Which of the following is the most likely explanation for these results?
A 49-year-old man with a long history of sarcoidosis presents for review. He has been intermittently treated with varying doses of oral prednisolone and chloroquine. On this occasion, he complains of drooping and weakness affecting the left-hand side of his face, blurred vision, thirst and polyuria. On examination, he has a left facial nerve palsy.
Investigations:
Investigation Result Normal value
Haemoglobin 119 g/l 135–175 g/l
White cell count (WCC) 4.5 × 109/l 4–11 × 109/l
Platelets 195 × 109/l 150–400 × 109/l
Sodium (Na+) 149 mmol/l 135–145 mmol/l
Potassium (K+) 5.4 mmol/l 3.5–5.0 mmol/l
Urea 15.1 mmol/l 2.5–6.5 mmol/l
Creatinine 195 μmol/l 50–120 µmol/l
Ca2+ corrected 2.21 mmol/l 2.20–2.60 mmol/l
Random glucose 5.4 mmol/l 3.5–5.5 mmol/l
Erythrocyte sedimentation rate (ESR) 36 mm/h 0–10mm in the 1st hour
Which of the following diagnoses fit best with this clinical picture?
A 50-year-old patient with diabetes presents to the Emergency department with complaints of dizziness and vomiting. Upon examination, the patient is alert and oriented, with an irregularly irregular pulse of 80 and a blood pressure of 160/90 mmHg. Nystagmus is observed on left lateral gaze, and the patient’s speech is slurred. Intention tremor and past pointing are noted during examination of the limbs, and the patient is ataxic when mobilized. What is the probable diagnosis?
You are requested to evaluate a 15-year-old Caucasian girl who has been feeling unwell for a few days. She has been experiencing intermittent fevers and chills and complains of extreme fatigue. Suddenly, half an hour before her admission to the hospital, she lost all vision in her left eye.
During the examination, the patient appears pale and unwell. Her vital signs are as follows: temperature 38.5°C, pulse 120/minute, regular, blood pressure 100/55 mmHg, and respiratory rate 22/minute. A pansystolic murmur is audible at the apex and lower left sternal border. Both lungs are clear.
The right pupil reacts normally to light, but there is no reaction from the left pupil, which remains fixed and dilated. The patient has complete loss of vision in the left eye, and the left fundus appears paler than the right, without papilloedema. The only additional finding on examination was a paronychia on her right thumb, and light pressure on the nail bed was very uncomfortable.
Investigations reveal the following results: Hb 109 g/L (115-165), WBC 14.1 ×109/L (4-11), Neutrophils 9.0 ×109/L (1.5-7), Lymphocytes 4.8 ×109/L (1.5-4), Monocytes 0.29 ×109/L (0-0.8), Eosinophils 0.01 ×109/L (0.04-0.4), and Platelets 550 ×109/L (150-400).
What is the most crucial investigation to determine the cause of her illness?
A 36-year-old man is brought in by ambulance to the Emergency Department resuscitation area. As the driver of a car, he has been involved in a head-on collision with a lorry. He suffered a 5-min episode of loss of consciousness and now complains of a severe right temporal headache. His right pupil is slightly larger than his left pupil. You notice that his eyes open to speech, he is able to localise pain, and he can talk properly after mildly irritating him, but he appears disorientated. What is his Glasgow Coma Scale (GCS) score?
A 67-year-old woman is on the surgical ward after admission for neurological observations following a head injury. She had fallen on the pavement and banged her head with a moderate laceration. She suffered from no loss of consciousness but now complains of nausea and double vision. You notice that:
her eyes open to speech
she is able to obey commands
she can talk properly but appears disorientated in time and place.
What is her Glasgow Coma Scale (GCS) score?