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  • Question 1 - A 54-year-old man with a history of acromegaly presents for a check-up. He...

    Correct

    • A 54-year-old man with a history of acromegaly presents for a check-up. He reports experiencing pins and needles in his hands in the early morning hours, and a positive Tinel's sign. Which muscle is most likely to be weak?

      Your Answer: Abductor pollicis brevis

      Explanation:

      Carpal Tunnel Syndrome and Median Nerve Innervation

      Carpal tunnel syndrome is a condition that can cause weakness in the abductor pollicis brevis muscle, which is innervated by the median nerve. This muscle, along with the opponens pollicis, is controlled by the median nerve. The flexor pollicis brevis muscle may also be innervated by either the median or ulnar nerve. In this case, the symptoms suggest carpal tunnel syndrome, which is often associated with acromegaly. Early intervention is crucial in treating carpal tunnel syndrome, as permanent nerve damage can occur if decompression is delayed.

    • This question is part of the following fields:

      • Neurology
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  • Question 2 - A 50-year-old man reports experiencing fatigue that worsens towards the end of the...

    Correct

    • A 50-year-old man reports experiencing fatigue that worsens towards the end of the day. He has also been struggling with swallowing and finds repetitive movements challenging. What is the probable cause of these symptoms?

      Your Answer: Antibodies against acetylcholine receptors

      Explanation:

      Autoimmune Conditions and their Mechanisms

      Myasthenia gravis is an autoimmune condition characterized by autoantibodies against acetylcholine receptors of the post-synaptic neuronal membranes of skeletal muscle. This inhibits the binding of acetylcholine, blocking neuronal transmission and resulting in muscle weakness. Diagnosis is made through serum testing for antibodies against the acetylcholine receptor, and treatment involves acetylcholinesterase inhibitors and immunomodulating drugs.

      In Lambert-Eaton myasthenic syndrome, autoantibodies to presynaptic calcium channel blockers are found, often in association with small cell lung cancer. Demyelinating diseases such as multiple sclerosis are caused by the destruction of the myelin sheath surrounding neuronal axons.

      Understanding Autoimmune Conditions and their Mechanisms

    • This question is part of the following fields:

      • Neurology
      35.5
      Seconds
  • Question 3 - A 68-year-old man is admitted to the Emergency Department having been picked up...

    Correct

    • A 68-year-old man is admitted to the Emergency Department having been picked up by a patrolling police car. He was found wandering around a roundabout in his nightgown, and when stopped, had no recollection of where he lived or of his own name. A mini-mental assessment reveals that he is disorientated to time and place and has poor memory. Physical examination is unremarkable. A full history is taken following contact with his wife and she reports that her husband has been suffering from worsening memory and cognition. A differential diagnosis includes dementia. Investigations are requested.
      What is the most common cause of dementia in the United Kingdom?

      Your Answer: Alzheimer’s disease

      Explanation:

      Types of Dementia: Causes, Symptoms, and Management

      Dementia is a progressive loss of cognitive function that affects millions of people worldwide. There are several types of dementia, each with its own causes, symptoms, and management strategies. In this article, we will discuss the most common types of dementia, including Alzheimer’s disease, Huntington’s disease, vascular dementia, dementia with Lewy bodies, and frontotemporal dementia.

      Alzheimer’s Disease
      Alzheimer’s disease is the most common cause of dementia, accounting for approximately 60% of cases in the UK. It is a progressive brain disorder that causes memory loss, disorientation, altered personality, and altered cognition. While there is no cure for Alzheimer’s disease, treatment with antioxidants and certain drugs, such as anticholinesterases, can slow or reduce cognitive decline.

      Huntington’s Disease
      Huntington’s disease is a rare autosomal dominant condition that affects approximately 12 per 100,000 of the UK population. It can cause dementia at any stage of the illness.

      Vascular Dementia
      Vascular dementia is the second most common cause of dementia, accounting for approximately 17% of cases in the UK. It is caused by reduced blood flow to the brain, which can result from conditions such as stroke or high blood pressure.

      Dementia with Lewy Bodies
      Dementia with Lewy bodies is a type of dementia that accounts for approximately 4% of cases. It is characterized by abnormal protein deposits in the brain, which can cause hallucinations, movement disorders, and cognitive decline.

      Frontotemporal Dementia
      Frontotemporal dementia is a rare form of dementia that accounts for around 2% of cases in the UK. It typically causes personality and behavioral changes, such as apathy, disinhibition, and loss of empathy.

      In conclusion, dementia is a complex and challenging condition that can have a significant impact on individuals and their families. While there is no cure for most types of dementia, early diagnosis and management can help to slow the progression of symptoms and improve quality of life.

    • This question is part of the following fields:

      • Neurology
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  • Question 4 - A 50-year-old man, presenting with changes in mood and behavior that have been...

    Incorrect

    • A 50-year-old man, presenting with changes in mood and behavior that have been developing over the past 8 years, is brought to the clinic by his son. The son also reports that his grandfather died from Alzheimer's disease at the age of 52. The patient has recently experienced aphasia, disorientation, and memory loss. He passes away a few weeks later. A brain biopsy shows cortical atrophy with widening of the cerebral sulci.
      What is the most probable mechanism that contributed to the development of this patient's condition?

      Your Answer: Hyper-phosphorylation of tau protein

      Correct Answer: Mutations in amyloid precursor protein

      Explanation:

      The accumulation of Aβ-amyloid in the brain is the main pathology associated with early onset familial Alzheimer’s disease. Aβ-amyloid is derived from amyloid precursor protein (APP), which is processed in two ways. The normal pathway does not result in Aβ-amyloid formation, while the abnormal pathway leads to its formation. Mutations in APP or components of γ-secretase result in an increased rate of Aβ-amyloid accumulation. In the sporadic form of the disease, SORL1 protein deficiency alters the intracellular trafficking of APP, leading to Aβ-amyloid formation. Hyper-phosphorylation of tau protein is another factor that can contribute to the onset of Alzheimer’s disease, but it is not specifically associated with early onset familial Alzheimer’s disease. Increased accumulation of amyloid light protein is also not responsible for the onset of the disease.

    • This question is part of the following fields:

      • Neurology
      43.8
      Seconds
  • Question 5 - A 32-year-old man is brought to the Emergency Department by air ambulance after...

    Incorrect

    • A 32-year-old man is brought to the Emergency Department by air ambulance after being involved in a road traffic accident. According to witnesses this was a high-impact car crash and the other passenger in the car has unfortunately already passed away. The man is unconscious when he arrives, and initial assessment reveals a Glasgow Coma Scale (GCS) score of 9. He has some minor facial injuries and is bleeding from his nose.
      What is the appropriate initial management for traumatic brain injury in this case?

      Your Answer: Fluid resuscitation with saline and albumin

      Correct Answer: Maintain pCO2 4.5 kPa

      Explanation:

      Management of Traumatic Brain Injury: Key Considerations

      Traumatic brain injury (TBI) is a serious condition that requires prompt and appropriate management to prevent secondary injury and improve outcomes. Here are some key considerations for managing TBI:

      Maintain pCO2 4.5 kPa: Sedation and ventilation should be used to maintain a pCO2 of 4.5 kPa to protect the brain. Adequate oxygenation is also essential.

      Permissive hypotension: Hypotension should be treated aggressively to prevent secondary ischaemic injury. Mean arterial pressure should be maintained >75 mmHg.

      Intubation if GCS falls below 6: Patients with a GCS score below 8 should be intubated to maintain their airway. Spinal immobilisation is also essential.

      Head-up tilt to 30 degrees: Head-up tilt to 30 degrees is an accepted measure to minimise rises in intracranial pressure in patients with TBI. Care should be taken if the patient has a cervical spine injury.

      Fluid resuscitation with saline: Initial fluid resuscitation should be with a crystalloid, such as normal saline, and/or blood. Albumin should be avoided.

      By following these key considerations, healthcare professionals can effectively manage TBI and improve patient outcomes.

    • This question is part of the following fields:

      • Neurology
      55.5
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  • Question 6 - A 65-year-old patient complains of back pain that extends to the left leg....

    Incorrect

    • A 65-year-old patient complains of back pain that extends to the left leg. The patient reports decreased sensation on the lateral aspect of the left calf and lateral foot. Which nerve roots are likely to be affected in this case?

      Your Answer: S1-S3

      Correct Answer: L5-S1

      Explanation:

      L5 and S1 Radiculopathy

      L5 radiculopathy is the most common type of radiculopathy that affects the lumbosacral spine. It is characterized by back pain that radiates down the lateral aspect of the leg and into the foot. On the other hand, S1 radiculopathy is identified by pain that radiates down the posterior aspect of the leg and into the foot from the back.

      When examining a patient with S1 radiculopathy, there may be a reduction in leg extension (gluteus maximus), foot eversion, plantar flexion, and toe flexion. Sensation is also generally reduced on the posterior aspect of the leg and the lateral foot.

      It is important to note that both L5 and S1 radiculopathy can cause significant discomfort and affect a patient’s quality of life. Proper diagnosis and management are crucial in addressing these conditions. Patients are advised to seek medical attention if they experience any symptoms related to radiculopathy.

    • This question is part of the following fields:

      • Neurology
      8.9
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  • Question 7 - An anaesthetist administered anaesthesia to a 35-year-old pregnant woman in labour. The anaesthetist...

    Incorrect

    • An anaesthetist administered anaesthesia to a 35-year-old pregnant woman in labour. The anaesthetist palpated the ischial spine transvaginally and then injected a local anaesthetic.
      Injection of a local anaesthetic at this location anaesthetises a nerve that contains fibres from which of the following vertebral segments?

      Your Answer: L5, S1, S2

      Correct Answer: S2, S3, S4

      Explanation:

      Pudendal Nerve Block for Perineal Pain Relief during Childbirth

      During childbirth, perineal pain can be relieved by anaesthetising the pudendal nerve. This nerve contains fibres from the S2, S3, and S4 anterior rami. To locate the nerve, the obstetrician palpates the ischial spine transvaginally as the nerve passes close to this bony feature. It is important to note that the pudendal nerve does not receive fibres from S5 or S1. The superior and inferior gluteal nerves receive fibres from L4 to S1 and L5 to S2, respectively, but they are not the nerves being targeted in this procedure.

    • This question is part of the following fields:

      • Neurology
      13.1
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  • Question 8 - A 9-year-old boy comes to his general practitioner complaining of severe pain in...

    Incorrect

    • A 9-year-old boy comes to his general practitioner complaining of severe pain in his right elbow area. He reports falling off his bike and landing on his outstretched arm.
      During the examination of the affected limb, the radial pulse appears normal. The patient experiences weakness in finger flexion at the proximal interphalangeal joints in all digits, with the index and middle fingers showing particular weakness. The patient has no feeling in the palmar aspect of the thumb, index finger, and middle finger. Finger extension and abduction remain unaffected.
      Which of these findings is most likely to be linked to this injury?

      Your Answer: Loss of flexion at the distal interphalangeal joint of the little finger

      Correct Answer: Persistent extension of the index and middle fingers when the boy attempts to make a fist

      Explanation:

      Understanding Nerve Injuries in the Hand: Symptoms and Causes

      When a child falls on their outstretched hand, it can result in a supracondylar fracture of the humerus. This type of injury can damage the brachial artery and median nerve, leading to symptoms such as persistent extension of the index and middle fingers when attempting to make a fist. Loss of sensation over the palmar aspect of the lateral three digits and weakness of finger flexion at the proximal interphalangeal joints are also common with median nerve injury. Additionally, the inability to flex the metacarpophalangeal joints of the index and middle fingers (known as the ‘hand of benediction’) is caused by loss of innervation of the first and second lumbrical muscles. Other symptoms of nerve injuries in the hand include loss of thumb adduction, loss of sensation over the medial border of the hand, loss of flexion at the distal interphalangeal joint of the little finger, and loss of function of the hypothenar muscles. Understanding these symptoms and their causes can help with early diagnosis and treatment of nerve injuries in the hand.

    • This question is part of the following fields:

      • Neurology
      43.6
      Seconds
  • Question 9 - A 30-year-old man comes to the clinic complaining of urinary symptoms such as...

    Incorrect

    • A 30-year-old man comes to the clinic complaining of urinary symptoms such as hesitancy and incomplete emptying. He lives independently and has primary progressive multiple sclerosis. He recently recovered from a UTI and upon investigation, it was found that he has heavy colonisation of Proteus. An ultrasound bladder scan reveals 400 ml of residual volume. What is the most suitable long-term management for this patient?

      Your Answer: Long-term urethral catheterisation

      Correct Answer: Intermittent self-catheterisation

      Explanation:

      Management of Urinary Symptoms in Multiple Sclerosis

      Multiple sclerosis often leads to a neurogenic bladder, causing urinary retention and associated symptoms such as incomplete bladder emptying, urgency, discomfort, and recurrent UTIs. The following are some management options for urinary symptoms in multiple sclerosis:

      1. Intermittent self-catheterisation: This is the preferred method for ambulant and independent patients. After training, the patient self-catheterises a few times a day to ensure complete bladder emptying, relieving symptoms and reducing the risk of recurrent UTIs. A muscarinic receptor antagonist, such as oxybutynin, can also be used.

      2. Suprapubic catheterisation: This is only indicated when transurethral catheterisation is contraindicated or technically difficult, such as in urethral injury or obstruction, severe benign prostatic hypertrophy or prostatic carcinoma.

      3. Continuous low-dose trimethoprim: There is no current guidance for the use of prophylactic antibiotics to prevent UTIs in multiple sclerosis. The aim is to primarily relieve the retention.

      4. Long-term urethral catheterisation: If symptoms progress and become bothersome for the patient, despite behavioural methods, medication and/or intermittent self-catheterisation, then a long-term catheter can be the next best option. Additionally, in cases where patients are not ambulant or have a disability that would prevent them from being able to self-catheterise, a long-term catheter may be a more desirable choice of management of urinary symptoms.

      5. Muscle relaxant baclofen: Baclofen is not used in the treatment of urinary retention. It is an antispasmodic used in multiple sclerosis to relieve contractures and spasticity.

      Management Options for Urinary Symptoms in Multiple Sclerosis

    • This question is part of the following fields:

      • Neurology
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  • Question 10 - Which of the following characteristics is absent in a corticospinal lesion? ...

    Correct

    • Which of the following characteristics is absent in a corticospinal lesion?

      Your Answer: Cogwheel rigidity

      Explanation:

      Neurological Features of Extrapyramidal and Pyramidal Involvement

      Cogwheel rigidity is a characteristic of extrapyramidal involvement, specifically in the basal ganglia. This type of rigidity is commonly observed in individuals with parkinsonism. On the other hand, pyramidal (corticospinal) involvement is characterized by increased tone, exaggerated spinal reflexes, and extensor plantar responses. These features are distinct from Cogwheel rigidity and are indicative of a different type of neurological involvement. the differences between extrapyramidal and pyramidal involvement can aid in the diagnosis and treatment of various neurological conditions.

    • This question is part of the following fields:

      • Neurology
      6.3
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  • Question 11 - A 70-year-old man presents with symptoms including poor sleep. He reports an itching...

    Incorrect

    • A 70-year-old man presents with symptoms including poor sleep. He reports an itching and crawling sensation affecting his legs with an overwhelming urge to move them. His wife reports that he tosses and turns all night, often pacing the room, and constantly rubs his legs. Things only improve with the break of dawn. He seems tired all day as a consequence of the disturbed sleep at night. The only past medical history of note is diverticular disease, from which he has been troubled by periodic iron deficiency anaemia. Neurological examination is unremarkable.

      Bloods:
      Investigation Result Normal value
      Haemoglobin 101 g/l (microcytic) 135–175 g/l
      White cell count (WCC) 5.1 × 109/l 4–11 × 109/l
      Platelets 285 × 109/l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
      Creatinine 124 μmol/l 50–120 µmol/l
      Fasting glucose 5.8 mmol/l < 7 mmol/l
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer: Primary restless legs syndrome

      Correct Answer: Secondary restless legs syndrome

      Explanation:

      Differential Diagnosis for Restless Legs Syndrome

      Restless legs syndrome (RLS) is a neurological disorder characterized by an irresistible urge to move the legs, often accompanied by unpleasant sensations. Here, we discuss the differential diagnosis for RLS in a patient with iron deficiency anaemia.

      Secondary Restless Legs Syndrome:
      In this case, the patient’s RLS is secondary to iron deficiency anaemia. Iron deficiency can cause RLS, and correcting the anaemia with iron supplementation may improve symptoms. Other causes of secondary RLS include peripheral neuropathy.

      Primary Restless Legs Syndrome:
      Primary RLS is a central nervous system disorder without known underlying cause. However, since this patient has a known precipitant for his RLS, it is more likely to be secondary.

      Alcohol Related Neuropathy:
      Alcohol-related neuropathy typically causes pain and motor loss, which is not seen in this patient.

      Nocturnal Cramps:
      Nocturnal cramps are unlikely to cause problems for the whole night and are typically short-lived.

      Diabetic Neuropathy:
      Diabetic neuropathy can cause burning or stinging sensations, but this patient’s fasting glucose level makes a diagnosis of diabetic neuropathy unlikely.

      In conclusion, RLS can have various causes, and a thorough evaluation is necessary to determine the underlying etiology. Treatment options include medications such as sedatives, anti-epileptic agents, and dopaminergic agents, as well as addressing any underlying conditions.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - A 19-year-old male has recently been diagnosed with schizophrenia. He was prescribed haloperidol,...

    Incorrect

    • A 19-year-old male has recently been diagnosed with schizophrenia. He was prescribed haloperidol, but after two weeks, he was discovered to be confused and drowsy. Upon examination, he was found to have a fever of 40.7°C, rigid muscles, and a blood pressure of 200/100 mmHg. What treatment would you recommend in this situation?

      Your Answer: Diazepam

      Correct Answer: Dantrolene

      Explanation:

      Neuroleptic Malignant Syndrome

      Neuroleptic malignant syndrome (NMS) is a serious medical condition that is commonly caused by potent neuroleptics. Its major features include rigidity, altered mental state, autonomic dysfunction, fever, and high creatinine kinase. The condition can lead to potential complications such as rhabdomyolysis and acute renal failure.

      The treatment of choice for NMS is dantrolene and bromocriptine. However, withdrawal of neuroleptic treatment is mandatory to prevent further complications. It is important to note that NMS can be life-threatening and requires immediate medical attention. Therefore, it is crucial to recognize the symptoms and seek medical help as soon as possible.

    • This question is part of the following fields:

      • Neurology
      20.4
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  • Question 13 - A patient attends the neurology clinic following a referral from the GP due...

    Incorrect

    • A patient attends the neurology clinic following a referral from the GP due to difficulty with eating and chewing food. A neurologist performs a cranial nerve assessment and suspects a lesion of the right trigeminal nerve.
      Which of the following is a clinical feature of a trigeminal nerve palsy in an elderly patient?

      Your Answer: Loss of taste in anterior two-thirds of the tongue

      Correct Answer: Bite weakness on the right

      Explanation:

      Common Symptoms of Cranial Nerve Lesions

      Cranial nerves are responsible for various functions in the head and neck region. Damage to these nerves can result in specific symptoms that can help identify the location and extent of the lesion. Here are some common symptoms of cranial nerve lesions:

      1. Bite weakness on the right: The masticatory muscles are served by the motor branch of the mandibular division of the trigeminal nerve. Therefore, weakness in biting on the right side can indicate damage to this nerve.

      2. Loss of taste in anterior two-thirds of the tongue: The facial nerve carries taste fibers from the anterior two-thirds of the tongue. Damage to this nerve can result in a loss of taste sensation in this region.

      3. Paralysis of the right buccinator muscle: The muscles of facial expression, including the buccinator, are supplied by the motor fibers carried in the facial nerve. Paralysis of this muscle on the right side can indicate damage to the facial nerve.

      4. Hyperacusis: The stapedius muscle, which is innervated by the facial nerve, helps dampen down loud noise by attenuating transmission of the acoustic signal in the middle ear. Damage to the facial nerve can result in hyperacusis, a condition where sounds are perceived as too loud.

      5. Loss of taste in posterior third of the tongue: The glossopharyngeal nerve supplies the posterior third of the tongue. Damage to this nerve can result in a loss of taste sensation in this region.

    • This question is part of the following fields:

      • Neurology
      18.1
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  • Question 14 - What are the possible reasons for having a small pupil? ...

    Incorrect

    • What are the possible reasons for having a small pupil?

      Your Answer: Carbon monoxide poisoning

      Correct Answer: Pontine haemorrhage

      Explanation:

      Causes of Small and Dilated Pupils

      Small pupils can be caused by various factors such as Horner’s syndrome, old age, pontine hemorrhage, Argyll Robertson pupil, drugs, and poisons like opiates and organophosphates. Horner’s syndrome is a condition that affects the nerves in the face and eyes, resulting in a small pupil. Aging can also cause the pupils to become smaller due to changes in the muscles that control the size of the pupils. Pontine hemorrhage, a type of stroke, can also lead to small pupils. Argyll Robertson pupil is a rare condition where the pupils do not respond to light but do constrict when focusing on a near object. Lastly, drugs and poisons like opiates and organophosphates can cause small pupils.

      On the other hand, dilated pupils can also be caused by various factors such as Holmes-Adie (myotonic) pupil, third nerve palsy, drugs, and poisons like atropine, CO, and ethylene glycol. Holmes-Adie pupil is a condition where one pupil is larger than the other and reacts slowly to light. Third nerve palsy is a condition where the nerve that controls the movement of the eye is damaged, resulting in a dilated pupil. Drugs and poisons like atropine, CO, and ethylene glycol can also cause dilated pupils. It is important to identify the cause of small or dilated pupils as it can be a sign of an underlying medical condition or poisoning.

    • This question is part of the following fields:

      • Neurology
      11
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  • Question 15 - A 56-year-old woman visits her doctor with complaints of progressive weakness over the...

    Incorrect

    • A 56-year-old woman visits her doctor with complaints of progressive weakness over the past few months. She reports difficulty getting up from a chair and climbing stairs, which worsens throughout the day and especially with prolonged walking. She has no significant medical history but is a smoker, consuming 15 cigarettes a day. During the review of her systems, she mentions a loss of appetite and weight loss, as well as a worsening cough that led to one episode of haemoptysis two weeks ago. On examination, there are no clear signs of ptosis, diplopia, or dysarthria. The doctor considers a list of differential diagnoses.
      Which antibody is most likely to be involved?

      Your Answer: Antibodies to acetylcholine receptors

      Correct Answer: Antibodies to voltage-gated calcium channels

      Explanation:

      Autoantibodies and their associated conditions

      Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune condition affecting skeletal muscle and can be a paraneoplastic syndrome associated with small cell carcinoma of the lung. The causative autoantibody is against voltage-gated calcium channels. Clinical features include insidious and progressive onset of proximal muscular weakness, particularly in the legs, and autonomic involvement.

      Mixed connective tissue disease (MCTD) is associated with anti-RNP antibodies. Common presenting features include general malaise and lethargy, arthritis, pulmonary involvement, sclerodactyly, Raynaud’s phenomenon, and myositis.

      Myasthenia gravis is a long-term autoimmune disease affecting skeletal muscle associated with antibodies to acetylcholine receptors. It causes fatigable weakness, and oculopharyngeal and ocular muscles are usually prominently affected.

      Granulomatosis with polyangiitis is a vasculitic condition associated with c-ANCA antibodies. It often presents with renal impairment, upper airway disease, and pulmonary haemorrhage and pneumonia-like infiltrates.

      Thyrotropin receptor antibody is an indicator for Graves’ disease, which causes hyperthyroidism.

    • This question is part of the following fields:

      • Neurology
      23.8
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  • Question 16 - A 57-year-old male with diabetes comes to the clinic complaining of weakness in...

    Incorrect

    • A 57-year-old male with diabetes comes to the clinic complaining of weakness in his left foot. He has noticed a dragging sensation when walking for the past two days. The patient has been diabetic for two years and has had no previous abnormalities during annual check-ups.

      During the examination, the patient is unable to dorsiflex his left foot and evert it. However, his right foot is unaffected, and plantar flexion and inversion are normal. What sensory abnormality would you anticipate finding in conjunction with this motor defect?

      Your Answer: Sensory loss over the plantar aspect of the foot

      Correct Answer: Sensory loss over the lateral part of the leg and dorsum of the foot

      Explanation:

      Common Peroneal Nerve Neuropathy in a Diabetic Patient

      A male patient with diabetes has developed a mononeuropathy that is consistent with a common peroneal nerve neuropathy. This condition results in a loss of sensation in the lateral part of the leg and dorsum of the foot, while the fifth toe remains unaffected. Although peripheral neuropathy may be expected in diabetic patients, the sudden onset of this condition and previously normal findings suggest otherwise.

      In summary, this patient’s symptoms are indicative of a common peroneal nerve neuropathy, which is a type of mononeuropathy that affects the peroneal nerve. This condition is commonly seen in diabetic patients and can result in a loss of sensation in specific areas of the leg and foot.

    • This question is part of the following fields:

      • Neurology
      27.2
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  • Question 17 - A 36-year-old man came to the Emergency Department complaining of a severe headache,...

    Incorrect

    • A 36-year-old man came to the Emergency Department complaining of a severe headache, neck stiffness, and photophobia. He had not experienced any recent foreign travel or trauma. Upon examination, he had a fever but no rash or focal neurology. The medical team suspected bacterial meningitis and began treatment. They also requested a lumbar puncture. What is the appropriate spinal level and dural space for the needle to be advanced to during a lumbar puncture?

      Your Answer: Between L3 and L4, advanced to the epidural space

      Correct Answer: Between L3 and L4, advanced to the subarachnoid space

      Explanation:

      Proper Placement for Lumbar Puncture

      The ideal location for a lumbar puncture is between L3 and L4, as this avoids the risk of piercing the spinal cord. To locate this area, a line is drawn across the superior aspect of the posterior iliac crests. The purpose of a lumbar puncture is to obtain a sample of cerebrospinal fluid from the subarachnoid space between the pia mater and the arachnoid mater. However, there are contraindications to this procedure, such as signs of raised intracranial pressure, which can lead to coning and respiratory arrest.

      It is important to note that advancing the needle too high, such as between L1 and L2, can pose a risk to the spinal cord. Additionally, the epidural space is too superficial to obtain a sample of cerebrospinal fluid. Therefore, proper placement between L3 and L4, advanced to the subarachnoid space, is crucial for a safe and successful lumbar puncture.

    • This question is part of the following fields:

      • Neurology
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  • Question 18 - What is the definition of Nissl bodies? ...

    Incorrect

    • What is the definition of Nissl bodies?

      Your Answer: Synaptic vesicles

      Correct Answer: Granules of rough endoplasmic reticulum

      Explanation:

      Nissl Bodies: Stacks of Rough Endoplasmic Reticulum

      Nissl bodies are named after the German neurologist Franz Nissl and are found in neurones following a selective staining method known as Nissl staining. These bodies are composed of stacks of rough endoplasmic reticulum and are a major site of neurotransmitter synthesis, particularly acetylcholine, in the neurone. Therefore, the correct answer is that Nissl bodies are granules of rough endoplasmic reticulum. It is important to note that the other answer options are incorrect as they refer to entirely different organelles.

    • This question is part of the following fields:

      • Neurology
      16.5
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  • Question 19 - A 51-year-old woman sustained a deep posterolateral laceration in her right neck during...

    Correct

    • A 51-year-old woman sustained a deep posterolateral laceration in her right neck during a car crash. Her right shoulder is now lower than the left and she is unable to lift it against resistance. When attempting to shrug her shoulders, there is no rise in muscle tone under the medial upper border of the right shoulder. Which nerve was affected by the injury?

      Your Answer: Spinal accessory nerve

      Explanation:

      Nerves of the Shoulder: Functions and Injuries

      The shoulder is a complex joint that relies on several nerves for proper function. Injuries to these nerves can result in a range of deficits, from isolated muscle weakness to more widespread impairments. Here are some of the key nerves involved in shoulder movement:

      Spinal Accessory Nerve: This nerve innervates the sternocleidomastoid and trapezius muscles. Damage to the spinal accessory nerve can result in trapezius palsy, which can cause difficulty with shoulder elevation.

      Dorsal Scapular Nerve: The dorsal scapular nerve innervates the rhomboid muscles and the levator scapulae. Injury to this nerve can lead to weakness in these muscles, which can affect shoulder blade movement.

      Suprascapular Nerve: The suprascapular nerve innervates the supraspinatus muscle, which is part of the rotator cuff. Damage to this nerve can result in weakness or pain during shoulder abduction.

      Axillary Nerve: The axillary nerve has both anterior and posterior branches that innervate the deltoid muscle and skin over part of the deltoid. Injury to this nerve can cause weakness or numbness in the shoulder.

      Upper Trunk of the Brachial Plexus: The upper trunk of the brachial plexus is a collection of nerves that supply a wider variety of muscles and cutaneous structures. Damage to this area can result in more widespread deficits.

      Understanding the functions and potential injuries of these nerves can help healthcare professionals diagnose and treat shoulder problems more effectively.

    • This question is part of the following fields:

      • Neurology
      13.9
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  • Question 20 - A 28-year-old woman presents to her primary care physician with concerning symptoms that...

    Incorrect

    • A 28-year-old woman presents to her primary care physician with concerning symptoms that have been occurring on and off for the past few months. She reports experiencing episodes of weakness accompanied by rapid, involuntary movements of her arms. Additionally, she has been experiencing persistent tingling sensations, occasional double vision, electric shocks down her arms and trunk when she flexes her neck, and constipation. Based on these symptoms, what would be the most appropriate initial test to diagnose her condition?

      Your Answer: Lumbar puncture

      Correct Answer: MRI

      Explanation:

      Diagnosing Multiple Sclerosis: The Importance of MRI

      Multiple sclerosis (MS) is a debilitating disease that affects many individuals, particularly women. Symptoms can range from spastic weakness to loss of vision, making it difficult to diagnose. However, the first line investigation for somebody with MS is an MRI of the brain and spinal cord. This is because MRI is much more sensitive for picking up inflammation and demyelination than a CT scan, and it does not involve irradiation. Additionally, lumbar puncture can be used to detect IgG oligoclonal bands, which are not present in the serum. While other tests such as antibody testing and slit-lamp examination of the eyes may be useful, they are not first line investigations. It is important to diagnose MS early to prevent further damage to myelin sheaths and improve quality of life.

    • This question is part of the following fields:

      • Neurology
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  • Question 21 - A 28-year-old patient presents with progressive weakness of the arms and legs over...

    Incorrect

    • A 28-year-old patient presents with progressive weakness of the arms and legs over 1 week. Three weeks earlier, she had an episode of diarrhoea lasting 5 days. Examination confirms distal weakness and ‘glove-and-stocking’ sensory loss.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Guillain–Barré syndrome

      Explanation:

      Differential Diagnosis for a Patient with Ascending Paralysis and Glove-and-Stocking Weakness

      The patient presents with acute progressive ascending paralysis and glove-and-stocking weakness, which is typical of Guillain–Barré syndrome. However, cranial nerve palsies can also occur. It is important to consider other potential diagnoses, such as multiple sclerosis, subacute combined degeneration of the cord, diabetic neuropathy, and acute intermittent porphyria. MS is characterised by lesions separated in both space and time, while subacute combined degeneration of the cord is secondary to a deficiency of vitamin B12 and presents with progressive limb weakness, paraesthesiae, and visual disturbances. Diabetic neuropathy usually causes sensory impairment, not motor impairment, and acute intermittent porphyria manifests with a constellation of symptoms, including abdominal pain, peripheral and autonomic neuropathies, and proximal motor weakness. A thorough evaluation and diagnostic workup are necessary to determine the underlying cause of the patient’s symptoms.

    • This question is part of the following fields:

      • Neurology
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  • Question 22 - Which nerve is most commonly injured in conjunction with shoulder dislocation? ...

    Incorrect

    • Which nerve is most commonly injured in conjunction with shoulder dislocation?

      Your Answer:

      Correct Answer: Axillary nerve

      Explanation:

      The Vulnerability of the Shoulder Joint

      The shoulder joint is the most mobile joint in the body, but this comes at a cost of vulnerability. It is prone to dislocation more than any other joint due to its unrestricted movement. The shoulder stability is maintained by the glenohumeral joint capsule, the cartilaginous glenoid labrum, and the muscles of the rotator cuff. Anterior dislocations are the most common, accounting for over 95% of dislocations, while posterior and inferior dislocations are less frequent. Superior and intrathoracic dislocations are extremely rare.

      Injuries to the axillary nerve occur in 5% to 18% of dislocations. The nerve may heal on its own or require surgical exploration and nerve grafting. The shoulder joint vulnerability highlights the importance of proper care and attention to prevent dislocations and other injuries.

    • This question is part of the following fields:

      • Neurology
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  • Question 23 - A 78-year-old man comes to his doctor's office with his daughter. His daughter...

    Incorrect

    • A 78-year-old man comes to his doctor's office with his daughter. His daughter reports that he has been increasingly forgetful, frequently forgetting appointments and sometimes leaving the stove on. He has also experienced a few instances of urinary incontinence. The patient's neurological examination is unremarkable except for a slow gait, reduced step height, and decreased foot clearance. Based on these findings, what is the most probable diagnosis?

      Your Answer:

      Correct Answer: Normal pressure hydrocephalus

      Explanation:

      Distinguishing Normal Pressure Hydrocephalus from Other Conditions: A Guide for Medical Professionals

      Normal pressure hydrocephalus (NPH) is a condition characterized by ventricular dilation without raised cerebrospinal fluid (CSF) levels. Its classic triad of symptoms includes urinary incontinence, gait disturbance, and dementia. While 50% of cases are idiopathic, it is crucial to diagnose NPH as it is a potentially reversible cause of dementia. MRI or CT scans can reveal ventricular enlargement, and treatment typically involves surgical insertion of a CSF shunt.

      When evaluating patients with symptoms similar to NPH, it is important to consider other conditions. Parkinson’s disease, for example, may cause gait disturbance, urinary incontinence, and dementia, but the presence of bradykinesia, tremor, and rigidity would make a Parkinson’s diagnosis unlikely. Multiple sclerosis (MS) may also cause urinary incontinence and gait disturbance, but memory problems are less likely, and additional sensory or motor problems are expected. Guillain-Barré syndrome involves ascending muscle weakness, which is not present in NPH. Cauda equina affects spinal nerves and may cause urinary incontinence and gait disturbance, but memory problems are not a symptom.

      In summary, while NPH shares some symptoms with other conditions, its unique combination of ventricular dilation, absence of raised CSF levels, and classic triad of symptoms make it a distinct diagnosis that requires prompt attention.

    • This question is part of the following fields:

      • Neurology
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  • Question 24 - A 20-year-old female patient with a prolonged history of sinusitis complains of fever...

    Incorrect

    • A 20-year-old female patient with a prolonged history of sinusitis complains of fever and headache accompanied by a change in personality. During fundal examination, papilloedema is observed. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Frontal lobe abscess

      Explanation:

      Sinusitis and Brain Abscess

      A previous occurrence of sinusitis can increase the likelihood of developing a brain abscess. Symptoms of a brain abscess include headache and fever, with papilloedema being present in most cases. Additionally, frontal lobe lesions can cause changes in personality.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A 60-year-old driver is admitted with a left-sided facial droop, dysphasia and dysarthria....

    Incorrect

    • A 60-year-old driver is admitted with a left-sided facial droop, dysphasia and dysarthria. His symptoms slowly improve and he is very keen to get back to work as he is self-employed.
      Following a stroke, what is the minimum time that patients are advised not to drive a car for?

      Your Answer:

      Correct Answer: 4 weeks

      Explanation:

      Driving Restrictions After Stroke or TIA

      After experiencing a transient ischaemic attack (TIA) or stroke, it is important to be aware of the driving restrictions set by the DVLA. For at least 4 weeks, patients should not drive a car or motorbike. If the patient drives a lorry or bus, they must not drive for 1 year and must notify the DVLA. After 1 month of satisfactory clinical recovery, drivers of cars may resume driving, but lorry and bus drivers must wait for 1 year before relicensing may be considered. Functional cardiac testing and medical reports may be required. Following stroke or single TIA, a person may not drive a car for 2 weeks, but can resume driving after 1 month if there has been a satisfactory recovery. It is important to follow these guidelines to ensure safe driving and prevent further health complications.

    • This question is part of the following fields:

      • Neurology
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  • Question 26 - A 22-year-old student is admitted to hospital with symptoms of fever, headache, photophobia...

    Incorrect

    • A 22-year-old student is admitted to hospital with symptoms of fever, headache, photophobia and vomiting. The general practitioner administers 1.2 g of intramuscular benzylpenicillin before transferring the patient to the hospital. On examination, the patient's temperature is 38.0 °C, pulse 100 bpm and blood pressure 150/80 mmHg. No rash is visible, but there is mild neck stiffness. A CT scan of the brain is performed and shows no abnormalities. A lumbar puncture is also performed, and the results are as follows:
      - Opening pressure: 20 cm H2O
      - Appearance: Clear
      - Red cell count: 25/mcl
      - Lymphocytes: 125/mcl
      - Polymorphs: 5/mcl
      - Glucose: 4.5 mmol/l (blood glucose 5.5 mmol/l)
      - Protein: 0.5 g/l
      - Gram stain: No organisms seen
      - Culture: No growth

      What diagnosis is consistent with these findings?

      Your Answer:

      Correct Answer: Viral meningitis

      Explanation:

      Viral meningitis is a serious condition that should be treated as such if a patient presents with a headache, sensitivity to light, and stiffness in the neck. It is important to correctly interpret the results of a lumbar puncture to ensure that the appropriate treatment is administered. The appearance, cell count, protein level, and glucose level of the cerebrospinal fluid can help distinguish between bacterial, viral, and tuberculous meningitis. Bacterial meningitis is characterized by cloudy or purulent fluid with high levels of polymorphs and low levels of lymphocytes, while tuberculous meningitis may have a clear or slightly turbid appearance with a spider web clot and high levels of lymphocytes. Viral meningitis typically has clear or slightly hazy fluid with high levels of lymphocytes and normal protein and glucose levels. A subarachnoid hemorrhage may present with similar symptoms but would not have signs of infection and would show a large number of red blood cells and a color change in the cerebrospinal fluid.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 16-year-old student presents to the Emergency Department with complaints of headache, neck...

    Incorrect

    • A 16-year-old student presents to the Emergency Department with complaints of headache, neck stiffness, and photophobia. During the examination, a purpuric rash is observed on the trunk and limbs.

      What condition is this patient at risk for?

      Your Answer:

      Correct Answer: Waterhouse–Friderichsen syndrome

      Explanation:

      Medical Syndromes and Their Characteristics

      Waterhouse–Friderichsen Syndrome: This syndrome is caused by acute meningococcal sepsis due to Neisseria meningitidis. It can lead to sepsis, disseminated intravascular coagulation (DIC), endotoxic shock, and acute primary adrenal failure.

      Zollinger–Ellison Syndrome: This syndrome results from a gastrinoma, which leads to recurrent peptic ulcers.

      Osler–Weber–Rendu Disease: Also known as hereditary haemorrhagic telangiectasia, this disease results in multiple telangiectasias and arteriovenous shunting of blood.

      Fitz–Hugh–Curtis Syndrome: This is a rare complication of pelvic inflammatory disease, resulting in liver capsule inflammation.

      Cushing Syndrome: This syndrome is due to excess cortisol, which causes hypertension, central obesity, striae, a moon face, and muscle weakness.

    • This question is part of the following fields:

      • Neurology
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  • Question 28 - An 87-year-old woman who lives alone is found wandering in the street, she...

    Incorrect

    • An 87-year-old woman who lives alone is found wandering in the street, she is unable to remember her way home. Past medical history of note includes hypertension for which she takes lisinopril and hydrochlorothiazide. She is known to Social Services having been in trouble for stealing from a local grocery store earlier in the year, and for yelling at a neighbor who complained about her loud music. On examination she is agitated and socially inappropriate, she has been incontinent of urine. During your testing she repeats what you say and appears to be laughing at you. Responses to your questions tend to lack fluency and she has trouble naming simple objects. There is rigidity and increased tone on motor examination.
      Bloods:
      Investigation Result Normal value
      Haemoglobin 130 g/l 135–175 g/l
      White cell count (WCC) 5.2 × 109/l 4–11 × 109/l
      Platelets 250 × 109/l 150–400 × 109/l
      Sodium (Na+) 142 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 190 μmol/l 50–120 µmol/l
      Computed tomography (CT) head scan – evidence of frontal atrophy
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer:

      Correct Answer: Frontotemporal dementia

      Explanation:

      Understanding Frontotemporal Dementia: Symptoms, Diagnosis, and Management

      Frontotemporal dementia, also known as Pick’s disease, is a type of dementia that affects the frontal and temporal lobes of the brain. One of the hallmark symptoms of this condition is a change in personality, often leading to disinhibition, aggression, and inappropriate behavior. Patients may also exhibit echolalia and echopraxia, repeating words and imitating actions of others.

      Unlike Alzheimer’s disease, frontotemporal dementia often presents with early symptoms of behavioral changes and repetitive behavior, rather than memory loss. Incontinence may also be an early symptom. Diagnosis is typically made through brain imaging, which reveals frontotemporal lobe degeneration and the presence of Pick’s bodies, spherical aggregations of tau proteins in neurons.

      Management of frontotemporal dementia focuses on symptomatic treatment of behavior and support for caregivers and patients. Other conditions, such as Shy-Drager syndrome, multi-infarct dementia, and Creutzfeldt-Jakob disease, may present with similar symptoms but can be ruled out through careful evaluation and testing.

    • This question is part of the following fields:

      • Neurology
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  • Question 29 - A 28-year-old woman presents with a 48-hour history of headache and malaise that...

    Incorrect

    • A 28-year-old woman presents with a 48-hour history of headache and malaise that has worsened in the last 6 hours. She has vomited twice and recently had a sore throat. Her general practitioner has been treating her with a topical anti-fungal cream for vaginal thrush. On examination, she is photophobic and has moderate neck stiffness. The Glasgow Coma Score is 15/15, and she has no focal neurological signs. Her temperature is 38.5 °C. A computed tomography (CT) brain scan is reported as ‘Normal intracranial appearances’. A lumbar puncture is performed and CSF results are as follows: CSF protein 0.6 g/l (<0.45), cell count 98 white cells/mm3, mainly lymphocytes (<5), CSF glucose 2.8 mmol/l (2.5 – 4.4 mmol/l), and blood glucose 4.3 mmol/l (3-6 mmol/l). What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Acute viral meningitis

      Explanation:

      Distinguishing Acute Viral Meningitis from Other Neurological Disorders

      Acute viral meningitis is characterized by mild elevation of protein, a mainly lymphocytic cellular reaction, and a CSF: blood glucose ratio of >50%. In contrast, bacterial meningitis presents with a polymorph leukocytosis, lower relative glucose level, and more severe signs of meningism. Tuberculous meningitis typically presents subacutely with very high CSF protein and very low CSF glucose. Fungal meningitis is rare and mainly occurs in immunocompromised individuals. Guillain–Barré syndrome, an autoimmune peripheral nerve disorder causing ascending paralysis, is often triggered by a recent viral illness but presents with focal neurological signs, which are absent in viral meningitis. Accurate diagnosis is crucial for appropriate treatment and management.

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - What is the type of cell that utilizes its Ciliary to assist in...

    Incorrect

    • What is the type of cell that utilizes its Ciliary to assist in the movement of cerebrospinal fluid throughout the central nervous system of vertebrates?

      Your Answer:

      Correct Answer: Ependymal cells

      Explanation:

      The Functions of Cerebrospinal Fluid and the Roles of Different Types of Nervous System Cells

      The cerebrospinal fluid (CSF) is a clear and colourless fluid that circulates in the subarachnoid space, ventricular system of the brain, and central canal of the spinal cord. It provides the brain and spinal cord with mechanical and immunological buoyancy, chemical/temperature protection, and intracranial pressure control. The circulation of CSF within the central nervous system is facilitated by the beating of the Ciliary of ependymal cells, which line the brain ventricles and walls of the central canal. Therefore, ependymal cells are responsible for this function.

      Different types of nervous system cells have distinct roles in supporting the nervous system. Astrocytes provide biochemical support to blood-brain barrier endothelial cells, supply nutrients to nervous tissue, maintain extracellular ion balance, and aid in repairing traumatic injuries. Microglial cells are involved in immune defence of the central nervous system. Oligodendrocytes generate myelin sheaths on neurones of the central nervous system, while Schwann cells generate myelin sheaths on neurones of the peripheral nervous system.

      In summary, the CSF plays crucial roles in protecting and supporting the central nervous system, and ependymal cells are responsible for its circulation. Different types of nervous system cells have distinct functions in supporting the nervous system, including biochemical support, immune defence, and myelin sheath generation.

    • This question is part of the following fields:

      • Neurology
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