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Question 1
Correct
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An 85-year-old man with a history of hypertension, hyperlipidemia, and smoking presents to the Emergency Department with left-sided weakness and numbness. On examination, he has a drooping left face, decreased strength in his left arm and leg (4/5), and reduced sensation on the left side of his body. His pulse is regular at 70 bpm, and his blood pressure is 180/100 mmHg. The initial diagnosis is a possible ischemic stroke.
What proportion of strokes are ischemic rather than hemorrhagic?Your Answer: 80-85%
Explanation:Understanding the Prevalence and Causes of Ischaemic and Haemorrhagic Strokes
Ischaemic strokes are the most common type of stroke, accounting for 80-85% of all cases. They are characterized by a sudden onset of neurological deficits, such as hemiplegia, and are usually caused by thromboembolic disease secondary to atherosclerosis. Risk factors for ischaemic stroke include smoking, diabetes, hyperlipidaemia, heart disease, and previous medical history of myocardial infarction, stroke or embolism.
Haemorrhagic strokes, on the other hand, account for only 10-20% of all strokes and usually result from the rupture of a blood vessel within the brain. While they are less common than ischaemic strokes, they can be more severe and have a higher mortality rate.
It is important to understand the prevalence and causes of both types of strokes in order to prevent and treat them effectively. By addressing risk factors such as smoking and heart disease, we can reduce the incidence of ischaemic strokes. And by recognizing the symptoms of haemorrhagic strokes and seeking immediate medical attention, we can improve outcomes for those affected.
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This question is part of the following fields:
- Neurology
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Question 2
Incorrect
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An 85-year-old man presents with a short history of increasing confusion. Preceding this, he fell four weeks ago in the bathroom. In the afternoon he was examined by his GP and he was alert with a normal physical examination. The patient has a history of hypertension for which he takes bendroflumethiazide.
Four weeks later the patient was visited at home because the dazed state had returned. He is afebrile, has a pulse of 80 per minute regular and blood pressure of 152/86 mmHg. His response to questions is slightly slowed, he is disoriented in time and there is some deficit in recent memory.
The patient moves slowly, but muscle strength is preserved. Neurologic examination shows slight hyperactivity of the tendon reflexes on the right. Plantar responses are unclear because of bilateral withdrawal. That gives him a GCS score of 14.
What would be the most appropriate next investigation for this 85-year-old man?Your Answer: Electromyography and nerve conduction testing
Correct Answer: Computed tomograms of the head
Explanation:Chronic Subdural Haematoma in the Elderly
The confusion and neurological symptoms that developed after a fall in the past suggest that the patient may have chronic subdural haematoma. The best way to investigate this condition is through a CT scan, which is the preferred diagnostic tool. A skull x-ray may also be useful in detecting any fractures.
Chronic subdural haematoma is a condition that commonly affects elderly individuals. It occurs when blood accumulates between the brain and the outermost layer of the brain’s protective covering. This can cause pressure on the brain, leading to a range of symptoms such as confusion, headaches, and difficulty with balance and coordination.
It is important to diagnose and treat chronic subdural haematoma promptly, as it can lead to serious complications if left untreated. Treatment may involve draining the blood from the affected area, and in some cases, surgery may be necessary. Early diagnosis and treatment can greatly improve the patient’s chances of a full recovery.
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This question is part of the following fields:
- Neurology
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Question 3
Incorrect
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A 35-year-old man presents to the doctor’s office with complaints of double vision, drooping eyelids, and difficulty with speaking, chewing, and swallowing. He reports feeling well in the morning without weakness, but as the day progresses, he experiences increasing fatigue and weakness. Additionally, he notes muscle weakness after exercise that improves with rest. On physical examination, there is no muscle fasciculation, atrophy, or spasticity, and all reflexes are normal. Sensation is intact, and his pupils are equal and reactive to light. What autoantibodies are responsible for this patient's condition?
Your Answer: Double-stranded (ds) DNA
Correct Answer: Acetylcholine receptors
Explanation:Autoimmune Diseases and Associated Antibodies
Myasthenia gravis, systemic lupus erythematosus, Becker and Duchenne muscular dystrophy, multiple sclerosis, and Lambert-Eaton syndrome are all autoimmune diseases that involve the production of specific antibodies. Myasthenia gravis is characterised by the presence of acetylcholine receptor antibodies, while SLE is associated with antibodies to double-stranded DNA and anti-Smith antibodies. Antibodies to dystrophin are linked to muscular dystrophy, and those to myelin are involved in multiple sclerosis. Finally, antibodies to the presynaptic calcium receptor are associated with Lambert-Eaton syndrome. Understanding the specific antibodies involved in these diseases can aid in their diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 4
Incorrect
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As a Foundation Year 2 in general practice, you see a 35-year-old diabetic woman who complains of numbness and tingling in some of her fingers in her right hand. During examination, you observe that she has reduced sensation in her thumb, index and middle fingers in this hand. She also has some weakness in these fingers when she tries to flex them and make a fist, and there is some thenar muscle wasting. Her pulse is 80 bpm with a normal volume, and otherwise her skin, joints and bones appear totally normal.
What is the most likely condition that she is suffering from?Your Answer: Radial nerve palsy
Correct Answer: Carpal tunnel syndrome
Explanation:Understanding Hand and Wrist Conditions: Carpal Tunnel Syndrome and Other Possibilities
Carpal tunnel syndrome is a condition where the median nerve is compressed, leading to symptoms such as tingling, numbness, altered sensation, and pain in the thumb, index finger, and half of the middle finger. This condition can be caused by various risk factors, including obesity, overuse of hand and wrist, wrist trauma, and pregnancy. Diagnosis can be made through tests such as Tinel’s and Phalen’s tests, and treatment options range from conservative measures to surgical intervention.
Other possible hand and wrist conditions include radial nerve palsy, peripheral neuropathy, cubital tunnel syndrome, and rheumatoid arthritis. Radial nerve palsy presents with wrist drop and an inability to extend the wrist, while peripheral neuropathy typically affects both upper and lower limbs in a glove and stocking distribution of anesthesia. Cubital tunnel syndrome is caused by entrapment of the ulnar nerve and affects the ring and fifth finger, while rheumatoid arthritis tends to be symmetrical and affects the small joints of the hand. Understanding these conditions and their unique features can aid in proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 29-year-old woman presents to the Emergency Department with a sudden-onset headache that began 12 hours ago. She describes it as ‘an explosion’ and ‘the worst headache of her life’. She denies any vomiting or recent trauma and has not experienced any weight loss. On examination, there are no cranial nerve abnormalities. A CT scan of the head shows no abnormalities. She has no significant past medical history or family history. The pain has subsided with codeine, and she wants to be discharged.
What is the most appropriate course of action for this patient?Your Answer: Discharge home
Correct Answer: Lumbar puncture
Explanation:Management of Suspected Subarachnoid Haemorrhage: Importance of Lumbar Puncture
When a patient presents with signs and symptoms suggestive of subarachnoid haemorrhage (SAH), it is crucial to confirm the diagnosis through appropriate investigations. While a CT scan of the head is often the first-line investigation, it may not always detect an SAH. In such cases, a lumbar puncture can be a valuable tool to confirm the presence of blood in the cerebrospinal fluid.
Xanthochromia analysis, which detects the presence of oxyhaemoglobin and bilirubin in the cerebrospinal fluid, can help differentiate between traumatic and non-traumatic causes of blood in the fluid. To ensure the accuracy of the test, the lumbar puncture should be performed at least 12 hours after the onset of headache, and the third sample should be sent for xanthochromia analysis.
In cases where an SAH is suspected, it is crucial not to discharge the patient without further investigation. Overnight observation may be an option, but it is not ideal as it delays diagnosis and treatment. Similarly, prescribing analgesia may provide symptomatic relief but does not address the underlying issue.
The best course of action in suspected SAH is to perform a lumbar puncture to confirm the diagnosis and initiate appropriate management. Early diagnosis and treatment can prevent further damage and improve outcomes for the patient.
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This question is part of the following fields:
- Neurology
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Question 6
Incorrect
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A 20-year-old female underwent an appendicectomy and was administered an antiemetic for her nausea and vomiting. However, she is now experiencing an oculogyric crisis and has a protruding tongue. Which antiemetic is the most probable cause of her symptoms?
Your Answer: Dexamethasone
Correct Answer: Metoclopramide
Explanation:Extrapyramidal Effects of Antiemetic Drugs
Anti-nausea medications such as metoclopramide, domperidone, and cyclizine can have extrapyramidal effects, which involve involuntary muscle movements. Metoclopramide is known to cause acute dystonic reactions, which can result in facial and skeletal muscle spasms and oculogyric crisis. These effects are more common in young girls and women, as well as the elderly. However, they typically subside within 24 hours of stopping treatment with metoclopramide.
On the other hand, domperidone is less likely to cause extrapyramidal effects because it does not easily cross the blood-brain barrier. Cyclizine is also less likely to cause these effects, making it a safer option for those who are susceptible to extrapyramidal reactions. It is important to discuss any concerns about potential side effects with a healthcare provider before starting any new medication.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 42-year-old male accountant suddenly collapsed at work, complaining of a severe headache and nausea. He had been feeling fine in the days leading up to this incident. He had a medical history of hypertension and took regular medication for it. He did not smoke or drink alcohol.
Upon arrival at the Emergency department, the patient had a Glasgow coma scale score of 12/15 (motor 6, vocal 3, eyes 3) and nuchal rigidity. His blood pressure was 145/85 mmHg, pulse was 90 beats per minute and regular, and temperature was 37.1°C. Heart sounds were normal and the chest appeared clear.
During cranial nerve examination, a left dilated unreactive pupil with oculoparesis of the left medial rectus was observed. Fundoscopy showed no abnormalities. There were no obvious focal neurological signs on examining the peripheral nervous system, although both plantar responses were extensor.
A lumbar puncture was performed, revealing straw-colored fluid with the following results:
- Opening pressure: 15 cmH2O (normal range: 6-18)
- CSF white cell count: 6 cells per ml (normal range: <5)
- CSF red cell count: 1450 cells per ml (normal range: <5)
- CSF protein: 0.46 g/L (normal range: 0.15-0.45)
- Cytospin: Negative for cells
What is the most likely diagnosis for this patient?Your Answer: Cavernous sinus thrombosis
Correct Answer: Posterior communicating artery aneurysm
Explanation:The Oculomotor Nerve and its Effects on Eye Movement and Pupil Size
The oculomotor nerve nucleus complex is located in the midbrain and is responsible for controlling the movement of several eye muscles. Motor neurons from this complex project to the ipsilateral medial rectus, inferior rectus, and inferior oblique muscles, as well as the contralateral superior rectus. Additionally, a central nucleus innervates the levator palpebrae superioris bilaterally, so damage to this area can result in bilateral ptosis.
If the oculomotor nerve is damaged during its course, it can result in ipsilateral ptosis and restrict movement of the eye in certain directions. The effect on the pupil can vary depending on the location of the lesion. However, compression of the nerve, such as by a tumor or aneurysm, can result in an acute total third nerve palsy with a dilated unreactive pupil. This is because the parasympathetic nerve fibers that innervate the iris are carried on the outside of the nerve bundle, causing pupillary dilation early on.
Interestingly, third nerve lesions caused by infarction in patients over 50 years old with diabetes or hypertension often spare the pupil. This means that the pupil remains reactive despite the damage to the nerve. the effects of oculomotor nerve damage can help diagnose and treat various eye conditions.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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A woman presents to Accident and Emergency with a decreased level of consciousness. Her conscious state is formally assessed. She withdraws to a painful stimulus and is mumbling incoherent words randomly, irrespective of people attempting to speak to her in conversation, and her eyes open only in response to painful stimuli.
What is the breakdown of this patient’s Glasgow Coma Scale (GCS) score?Your Answer: Motor response 4/6, verbal response 4/5, eye opens in response 3/4
Correct Answer: Motor response 4/6, verbal response 3/5, eye opening response 2/4
Explanation:Understanding the Glasgow Coma Scale: Interpreting a Patient’s Level of Consciousness
The Glasgow Coma Scale (GCS) is a tool used to assess a patient’s level of consciousness. It consists of three scores: best motor response, best verbal response, and eye opening response. Each score is given a value out of a maximum score, and the total score is used to determine the patient’s level of consciousness.
In this case, the patient’s motor response is a score of 4 out of 6, indicating a withdrawal response to pain. The verbal response is a score of 3 out of 5, indicating mumbling words or nonsense. The eye opening response is a score of 2 out of 4, indicating opening to pain. Therefore, the patient’s total GCS score is 9, indicating a comatose state.
It is important to understand the GCS and how to interpret the scores in order to properly assess a patient’s level of consciousness and provide appropriate medical care.
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This question is part of the following fields:
- Neurology
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Question 9
Correct
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A 42-year-old woman comes to the Neurology Clinic with complaints of painful unilateral visual disturbance, ataxia, and sensory deficit. She is diagnosed with multiple sclerosis (MS) after undergoing magnetic resonance imaging (MRI) and is started on steroid treatment, followed by disease-modifying therapy. Her disease is stable after six months, and she can manage her daily activities without significant problems. She used to drive a car but has not done so since her diagnosis. She is now curious about her driving situation.
What are the most appropriate steps to take regarding her driving circumstances?Your Answer: She must inform the DVLA and may continue to drive
Explanation:Driving with Multiple Sclerosis: Informing the DVLA
Multiple Sclerosis (MS) is a chronic neurological disorder that may affect vehicle control due to impaired coordination and muscle strength. It is essential to inform the Driver and Vehicle Licensing Agency (DVLA) upon diagnosis. The official guidance states that patients with MS may continue to drive as long as safe vehicle control is maintained. However, it is necessary to update the DVLA if circumstances change. There is no arbitrary timeframe for inability to drive, and it is assessed individually based on the state of the patient’s chronic disease. It is not appropriate to base this on relapses as patients may relapse at different time periods and tend not to return to baseline function in relapsing-remitting MS. Failure to inform the DVLA can result in legal consequences. Therefore, it is crucial to inform the DVLA and follow their guidelines to ensure safe driving.
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This question is part of the following fields:
- Neurology
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Question 10
Incorrect
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A 92-year-old woman presents to the Neurology Outpatients with worsening speech difficulties and difficulty swallowing. Upon examination, she exhibits nasal speech, tongue fasciculations, and a lack of gag reflex. The diagnosis given is bulbar palsy. Where is the lesion responsible for this condition typically located?
Your Answer: Substantia nigra
Correct Answer: Cranial nerves IX, X, XI and XII
Explanation:Understanding the Causes of Bulbar Palsy: A Guide to Cranial Nerves and Brain Lesions
Bulbar palsy is a condition that results from lower motor neuron lesions in the medulla oblongata or lesions of cranial nerves IX – XII outside the brainstem. To better understand the causes of bulbar palsy, it is important to know the functions of these cranial nerves.
Cranial nerves IX, X, XI, and XII are responsible for various functions. The glossopharyngeal nerve (IX) provides taste to the posterior third of the tongue and somatic sensation to the middle ear, the posterior third of the tongue, the tonsils, and the pharynx. The vagus nerve (X) innervates muscles of the larynx and palate. The accessory nerve (XI) controls the trapezius and sternocleidomastoid muscles, while the hypoglossal nerve (XII) controls the extrinsic and intrinsic muscles of the tongue.
It is important to note that lesions of cranial nerves V (trigeminal) and VII (facial) are not responsible for the signs and symptoms of bulbar palsy. A lesion of the facial nerve would cause Bell’s palsy, while lesions of the trigeminal nerve can cause lateral medullary syndrome.
A cerebral cortex lesion would cause upper motor neuron signs and symptoms, which are not specific to bulbar palsy. On the other hand, a lesion in the corticobulbar pathways between the cerebral cortex and the brainstem is found in pseudobulbar palsy. This condition typically presents with upper motor neuron signs and symptoms and can occur as a result of demyelination or bilateral corticobulbar lesions.
Lastly, it is important to note that disorders of the substantia nigra are found in Parkinson’s disease, not bulbar palsy. Understanding the various causes of bulbar palsy can help with proper diagnosis and treatment of this condition.
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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A 50-year-old woman is experiencing a difficult separation from her spouse. She presents with a 2-week history of increasing headaches that are affecting her entire head. The headaches worsen when she strains. She is also experiencing more frequent nausea. Although she is neurologically intact, there is slight papilloedema noted on fundoscopy. Other than that, her examination is unremarkable. In her medical history, she had a deep vein thrombosis (DVT) in her calf when she was in her 30s, for which she received 6 months of treatment. She has not taken any significant medications recently. A non-contrast CT scan of her brain is performed and comes back normal. What is the probable diagnosis?
Your Answer: Subarachnoid haemorrhage
Correct Answer: Venous sinus thrombosis
Explanation:Distinguishing Venous Sinus Thrombosis from Other Headache Causes
Venous sinus thrombosis is a condition where one or more dural venous sinuses in the brain become blocked by a blood clot. This can cause a subacute headache with nausea and vomiting, along with signs of increased intracranial pressure. Diagnosis requires a high level of suspicion and imaging with contrast-enhanced CT venogram or MRI with MR venography. Treatment with heparin can improve outcomes, but specialist input is necessary if there has been haemorrhagic infarction. Other conditions that can cause headaches, such as subarachnoid haemorrhage, bacterial meningitis, tension headache, and encephalitis, have different presentations and require different diagnostic approaches.
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This question is part of the following fields:
- Neurology
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Question 12
Correct
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A 45-year-old woman with a history of schizophrenia resulting in multiple hospitalisations is referred to you in a psychiatry ward. She reports feeling generally unwell for several weeks, with increasing stiffness in her jaws and arms. She has been on haloperidol for the past few years with good symptom control. During examination, her temperature is 38.5°C and BP is 175/85 mmHg. What drug treatments would you consider for her condition?
Your Answer: Dantrolene
Explanation:Neuroleptic Malignant Syndrome vs Serotonin Syndrome
Neuroleptic malignant syndrome (NMS) is a potential side effect of antipsychotic medications that can occur at any point during treatment. Concurrent use of lithium or anticholinergics may increase the risk of NMS. Symptoms include fever, rigidity, altered mental status, and autonomic dysfunction. Treatment involves discontinuing the offending medication and using antipyretics to reduce body temperature. Dantrolene, bromocriptine, or levodopa preparations may also be helpful.
Serotonin syndrome is a differential diagnosis for NMS, but the two can be distinguished through a thorough history and examination. NMS develops over days and weeks, while serotonin syndrome can develop within 24 hours. Serotonin syndrome causes neuromuscular hyperreactivity, such as myoclonus, tremors, and hyperreflexia, while NMS involves sluggish neuromuscular response, such as bradyreflexia and rigidity. Hyperreflexia and myoclonus are rare in NMS, and resolution of NMS takes up to nine days, while serotonin syndrome usually resolves within 24 hours.
Despite these differences, both conditions share common symptoms in severe cases, such as hyperthermia, muscle rigidity, leukocytosis, elevated CK, altered hepatic function, and metabolic acidosis. Therefore, a thorough history and physical examination are crucial in distinguishing between the two syndromes.
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This question is part of the following fields:
- Neurology
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Question 13
Incorrect
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What is a lower motor neurone lesion associated with?
Your Answer: Exaggerated stretch reflex
Correct Answer: Flaccid paralysis
Explanation:Characteristics of Lower Motor Neurone Lesions
Lower motor neurone lesions are characterized by flaccid paralysis, downward plantar response, and fasciculations. These lesions result in the inability to elicit reflex contractions and slow muscle atrophy. In contrast, upper motor neurone lesions are associated with a positive Babinski sign.
Flaccid paralysis is a key feature of lower motor neurone lesions, which refers to the loss of muscle tone and strength. Downward plantar response is another characteristic, where the toes point downwards instead of upwards when the sole of the foot is stimulated. Fasciculations, or involuntary muscle twitches, are also commonly observed in lower motor neurone lesions.
Furthermore, reflex contractions cannot be elicited in lower motor neurone lesions, leading to muscle atrophy over time. This is in contrast to upper motor neurone lesions, where a positive Babinski sign is observed. A positive Babinski sign refers to the extension of the big toe and fanning of the other toes when the sole of the foot is stimulated, indicating an upper motor neurone lesion.
In summary, lower motor neurone lesions are characterized by flaccid paralysis, downward plantar response, and fasciculations, while upper motor neurone lesions are associated with a positive Babinski sign.
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This question is part of the following fields:
- Neurology
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Question 14
Incorrect
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A 25-year-old married shop assistant presents to the Emergency Department with a presumed seizure, where her hands and feet shook and she bit her tongue. This is the second such event in the past 6 months and she was due to see a neurologist in a month’s time. Computed tomography (CT) brain was normal. Electroencephalogram (EEG) was normal, albeit not performed during the ‘seizure’ activity. Her doctor believes she has epilepsy and is keen to commence anticonvulsive therapy. She is sexually active and uses only condoms for protection.
Which one of the following drugs would be most suitable for this particular patient?Your Answer: Phenytoin
Correct Answer: Lamotrigine
Explanation:Antiepileptic Medications and Pregnancy: Considerations for Women of Childbearing Age
When it comes to treating epilepsy in women of childbearing age, there are important considerations to keep in mind. Lamotrigine is a good choice for monotherapy, but it can worsen myoclonic seizures. Levetiracetam is preferred for myoclonic seizures, while carbamazepine has an increased risk of birth defects. Sodium valproate is the first-line agent for adults with generalized epilepsy, but it has been linked to neural tube defects in babies. Phenytoin is no longer used as a first-line treatment, but may be used in emergency situations. Clinicians should be aware of these risks and consult resources like the UK Epilepsy and Pregnancy Registry to make informed decisions about treatment.
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This question is part of the following fields:
- Neurology
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Question 15
Incorrect
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A 48-year-old woman presents with sudden-onset severe headache. She complains of pain behind the eyes and photophobia. She has vomited twice since the headache came on. She says it is the worst headache she has ever had by far. There is no past history of migraine. Examination reveals no neurological deficit.
What is the most appropriate initial investigation?Your Answer: Plasma viscosity
Correct Answer: Computerised tomography (CT) scan of the head
Explanation:Diagnostic Tests for Headache: CT Scan, Lumbar Puncture, Plasma Viscosity, MRI, and Angiography
Headaches can have various causes, and it is important to determine the underlying condition to provide appropriate treatment. Here are some diagnostic tests that can help identify the cause of a headache:
1. CT Scan of the Head: This imaging test is the initial investigation of choice when subarachnoid haemorrhage is suspected. It can show the presence of blood in the subarachnoid or intraventricular spaces.
2. Lumbar Puncture: If there is doubt about the presence of subarachnoid haemorrhage, a lumbar puncture may be considered 12 hours after the onset of symptoms. Multiple cerebrospinal fluid samples should be sent for microscopy to look for the persistent presence of red blood cells and xanthochromia.
3. Plasma Viscosity: This test is useful when temporal arthritis is suspected as a cause of headache. It will typically be highly elevated. However, it is not useful in the diagnosis of subarachnoid haemorrhage.
4. MRI of the Head: This imaging test may be considered later in the diagnostic process if other diagnoses are being considered. However, CT scan is a more appropriate first-line test.
5. Angiography: This test is usually performed to identify an aneurysm that may be amenable to intervention, either with open surgery or commonly interventional radiology.
In conclusion, the appropriate diagnostic test for a headache depends on the suspected underlying condition. A thorough evaluation by a healthcare professional is necessary to determine the most appropriate course of action.
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This question is part of the following fields:
- Neurology
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Question 16
Correct
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What is the neurotransmitter that opposes the effects of dopamine in the basal ganglia?
Your Answer: Acetylcholine
Explanation:The Role of Dopamine and Acetylcholine in the Extrapyramidal Motor System
The basal ganglia is a complex structure in the brain that plays a crucial role in regulating and controlling the extrapyramidal motor system. Within the basal ganglia, there are two types of neurons that work together to maintain proper motor function: dopamine-producing neurons and acetylcholine-producing neurons.
The substantia nigra, a structure within the basal ganglia, is rich in dopamine-producing neurons. Dopamine exerts an excitatory effect on the extrapyramidal motor system, facilitating movement. On the other hand, acetylcholine exerts an inhibitory effect on the extrapyramidal motor system.
When both sets of neurons are functioning properly, the extrapyramidal motor system operates normally. However, if either set of neurons is malfunctioning, there can be an excess of inhibition or excitation of the extrapyramidal motor system, resulting in neurological dysfunction.
One example of this is Parkinson’s disease, which is characterized by a loss of dopaminergic activity in the substantia nigra. This leads to bradykinesia and rigidity in patients. the role of dopamine and acetylcholine in the extrapyramidal motor system is crucial for and treating neurological disorders that affect motor function.
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This question is part of the following fields:
- Neurology
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Question 17
Incorrect
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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?Your Answer: Viral meningitis
Correct Answer: Traumatic tap
Explanation:Interpreting Lumbar Puncture Results in Neurological Conditions
Lumbar puncture is a diagnostic procedure used to collect cerebrospinal fluid (CSF) for analysis in various neurological conditions. The results of a lumbar puncture can provide valuable information in diagnosing conditions such as traumatic tap, subarachnoid hemorrhage, bacterial meningitis, and viral meningitis.
Traumatic Tap: A traumatic tap is characterized by a gradation of red cell contamination in sequential samples of CSF. This condition is often accompanied by severe headaches and can be managed with adequate analgesia and reassessment of blood pressure.
Confirmed Recent Subarachnoid Hemorrhage: In cases of subarachnoid hemorrhage, red cells within the CSF are expected to be constant within each bottle. However, a more reliable way to examine for subarachnoid hemorrhage is to look for the presence of xanthochromia in the CSF, which takes several hours to develop.
Bacterial Meningitis: Bacterial meningitis is characterized by a much higher white cell count, mostly polymorphs. CSF protein and glucose, as well as paired blood glucose, are valuable parameters to consider when diagnosing bacterial meningitis.
Viral Meningitis: Viral meningitis is characterized by a much higher white cell count, mostly lymphocytes. Protein and glucose levels in the CSF are also valuable parameters to consider when diagnosing viral meningitis.
Subarachnoid Hemorrhage >1 Week Ago: In cases of subarachnoid hemorrhage that occurred more than a week ago, few red cells would remain in the CSF. In such cases, examining the CSF for xanthochromia in the lab is a more valuable test.
In conclusion, interpreting lumbar puncture results requires careful consideration of various parameters and their respective values in different neurological conditions.
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This question is part of the following fields:
- Neurology
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Question 18
Incorrect
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A 65-year-old man presents to your GP Surgery with worry about an incident that occurred earlier in the day. He vaguely describes experiencing epigastric discomfort, followed by a tingling sensation down his arms and the scent of cooking bacon. Additionally, he reports feeling generally unwell. He did not lose consciousness during the episode. Upon further questioning, he mentions having experienced similar symptoms before. You observe that he has a medical history of ischaemic heart disease and had a stroke four months ago.
What is the most probable diagnosis for this patient?Your Answer: Gastritis
Correct Answer: Focal aware seizure
Explanation:Differential Diagnosis for a Patient with Focal Aware Seizures
Focal aware seizures, also known as simple focal seizures or auras, are a type of seizure that do not result in loss of awareness. Patients may experience vague discomfort, unusual smells or tastes, tingling, or twitching in an arm or leg. It is important to note that these seizures can be a sign of another type of seizure to come. Risk factors include head trauma and previous stroke.
Malingering, or feigning symptoms for secondary gain, should be considered but is a diagnosis of exclusion. It is important to thoroughly investigate the patient’s symptoms before making this diagnosis.
Focal impaired awareness seizures, previously known as complex focal seizures, result in memory loss, loss of awareness, and automatic bodily movements. This is not the case for a patient with focal aware seizures.
Gastritis may be a differential due to the patient’s epigastric pain, but it does not fit with the other neurological symptoms.
Psychotic hallucinations should be considered but are less likely given the patient’s coherent description of events and lack of history or risk factors for mental illness.
In summary, when presented with a patient experiencing focal aware seizures, it is important to consider other neurological conditions before making a diagnosis.
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This question is part of the following fields:
- Neurology
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Question 19
Incorrect
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A 21-year-old woman attends the antenatal clinic, six weeks pregnant with an unplanned pregnancy. She has a history of grand mal epilepsy for two years and is currently taking carbamazepine. She has not had any seizures for the past six months and wishes to continue with the pregnancy if it is safe for her and the baby. She is concerned about the effects of her anticonvulsant therapy on the fetus and seeks advice on how to proceed. What is the most suitable management plan for this patient?
Your Answer: Switch therapy to phenytoin
Correct Answer: Continue with carbamazepine
Explanation:Managing Epilepsy in Pregnancy
During pregnancy, it is important to manage epilepsy carefully to ensure the safety of both the mother and the fetus. Uncontrolled seizures pose a greater risk than any potential teratogenic effect of the therapy. However, total plasma concentrations of anticonvulsants tend to fall during pregnancy, so the dose may need to be increased. It is important to explain the potential teratogenic effects of carbamazepine, particularly neural tube defects, and provide the patient with folate supplements to reduce this risk. Screening with alpha fetoprotein (AFP) and second trimester ultrasound are also required. Vitamin K should be given to the mother prior to delivery. Switching therapies is not recommended as it could precipitate seizures in an otherwise stable patient. It is important to note that both phenytoin and valproate are also associated with teratogenic effects.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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A 68-year-old man comes to the clinic with a 3-year history of postural instability, frequent falls and cognitive decline. He exhibits hypomania, bradykinesia of the right upper limb, brisk reflexes, especially on the right-hand side, occasional myoclonus and a shuffling gait. He is unable to imitate basic hand gestures with his right hand. During the examination, the patient displays some sensory loss and apraxia.
What is the probable diagnosis?Your Answer: Sporadic Creutzfeldt–Jakob disease (CJD)
Correct Answer: Corticobasal syndrome
Explanation:Neurological Disorders and Their Characteristics
Corticobasal Syndrome: This rare progressive neurological disorder is characterized by asymmetrical cortical syndrome, gait unsteadiness, falls, parkinsonism, apraxia, and alien limb syndrome. Unfortunately, there is no known treatment for this disorder, and the prognosis is poor, with a life expectancy of 6-8 years from diagnosis.
Supranuclear Gaze Palsy: This Parkinson’s plus syndrome presents with symmetrical parkinsonism, slow saccades (especially vertical), and a limitation of eye movements.
Idiopathic Parkinson’s Disease: While this disease may present as asymmetrical at onset, it tends to involve both sides after 6 years. The presence of cortical signs such as hyperreflexia, apraxia, and myoclonus would be atypical.
Alzheimer’s Disease: This is the most common pathology in patients with cognitive decline, but it presents with prominent cognitive decline, and basal ganglia features are atypical.
Sporadic Creutzfeldt-Jakob Disease (CJD): This rapidly progressive disorder leads to akinetic mutism and death within a year, with a median of 6 months.
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This question is part of the following fields:
- Neurology
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Question 21
Correct
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What does the term bouton terminaux refer to in an axodendritic chemical synapse?
Your Answer: The synaptic terminal of the presynaptic axon
Explanation:Bouton Terminaux: The Synaptic Terminal of the Presynaptic Axon
A bouton terminaux, also known as a terminal button or end bulb, is a bulge found at the end of a synaptic projection, which can be either an axon or a dendrite. This structure is responsible for releasing neurotransmitters into the synaptic cleft, allowing for communication between neurons. It is important to note that the bouton terminaux specifically refers to the presynaptic cell in the context of a synapse.
It is essential to differentiate the bouton terminaux from other structures involved in synaptic transmission. For instance, synaptic vesicles are membrane-bound packages containing neurotransmitters, but they are not the same as the bouton terminaux. Similarly, axon varicosities are small swellings along the length of an axon that release neurotransmitters directly onto effector organs, such as smooth muscle, and are not the same as the bouton terminaux.
Furthermore, the end bulb on the postsynaptic axon is not the same as the bouton terminaux, even though it is another term for it. This is because the end bulb refers to the postsynaptic cell, whereas the bouton terminaux specifically refers to the presynaptic cell. Finally, fusion pores on the presynaptic axon membrane are structures formed after the presynaptic neurotransmitter vesicles fuse with the presynaptic membrane and are not the same as the bouton terminaux.
In summary, the bouton terminaux is a crucial structure in synaptic transmission, responsible for releasing neurotransmitters into the synaptic cleft. It is specific to the presynaptic cell and should not be confused with other structures involved in synaptic transmission.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 72-year-old woman who has smoked her entire life presents with a complaint of drooping of the left eyelid. Upon examination, there is ptosis of the left eyelid and a small pupil that responds to light but does not dilate. The right eye appears normal.
What is the probable diagnosis?Your Answer: Left seventh cranial nerve palsy
Correct Answer: Left Horner syndrome
Explanation:Common Cranial Nerve Palsies and Horner Syndrome
Horner’s syndrome is a condition that affects the sympathetic trunk and causes ptosis, miosis, and anhidrosis. This syndrome is commonly associated with an apical lung lesion, especially in lifelong smokers. On the other hand, cranial nerve palsies affect the third, fifth, and seventh nerves, each with distinct symptoms.
Third nerve palsy causes ptosis and mydriasis, while trigeminal nerve palsy affects sensation and mastication but leaves the pupil unaffected. Facial nerve palsy, on the other hand, results in facial paralysis and the inability to close the affected eyelid, but it does not affect the pupil.
It is important to differentiate between these conditions as they have different underlying causes and treatments. A thorough neurological examination is necessary to determine the specific cranial nerve affected and the appropriate management plan.
In summary, understanding the differences between Horner’s syndrome and cranial nerve palsies is crucial in making an accurate diagnosis and providing optimal care for patients.
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This question is part of the following fields:
- Neurology
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Question 23
Incorrect
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A 60-year-old man is brought to the Emergency Department by his wife due to sudden onset of incoherent speech. Upon physical examination, he exhibits right-sided weakness in the upper and lower extremities, a right facial droop, and a loss of sensation in the upper and lower extremities. An initial CT scan of the head reveals no acute changes, and treatment with tissue plasminogen activator is initiated. Which arterial territory is most likely affected by this neurological event?
Your Answer: Posterior inferior cerebellar artery
Correct Answer: Middle cerebral artery
Explanation:Cerebral Arteries and Their Effects on the Brain
The brain is supplied with blood by several arteries, each with its own specific distribution and function. The middle cerebral artery (MCA) is the largest and most commonly affected by stroke. It supplies the outer surface of the brain, including the parietal lobe and basal ganglia. Infarctions in this area can result in paralysis and sensory loss on the opposite side of the body, as well as aphasia or hemineglect.
The posterior cerebral artery supplies the thalamus and inferior temporal gyrus, and infarctions here can cause contralateral hemianopia with macular sparing. The anterior cerebral artery supplies the front part of the corpus callosum and superior frontal gyrus, and infarctions can result in paralysis and sensory loss of the lower limb.
The posterior inferior cerebellar artery (PICA) supplies the posterior inferior cerebellum, inferior cerebellar vermis, and lateral medulla. Occlusion of the PICA can cause vertigo, nausea, and truncal ataxia. Finally, the basilar artery supplies the brainstem and thalamus, and acute occlusion can result in sudden and severe neurological impairment.
Understanding the specific functions and distributions of these cerebral arteries can help in diagnosing and treating stroke and other cerebrovascular accidents.
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This question is part of the following fields:
- Neurology
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Question 24
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The on-call consultant is testing the junior members of the team on how to distinguish between the various types of dementia based on symptoms during the medical post-take ward round. What is a typical clinical characteristic of Alzheimer's disease?
Your Answer: Agnosia
Explanation:Common Symptoms of Different Types of Dementia
Dementia is a group of disorders that affect cognitive abilities, including memory, thinking, and communication. While Alzheimer’s disease is the most common form of dementia, there are other types that have distinct symptoms. Here are some common symptoms of different types of dementia:
Agnosia: The inability to perceive and utilize information correctly despite retaining the necessary, correct sensory inputs. It is a common feature of Alzheimer’s disease and leads to patients being unable to recognize friends and family or to use everyday objects, e.g. coins or keys.
Pseudobulbar palsy: This is where people are unable to control their facial movements. This does not typically occur in Alzheimer’s disease and is seen in conditions such as progressive supranuclear palsy, Parkinson’s disease, and multiple sclerosis.
Emotional lability: This is a common feature of fronto-temporal dementia (otherwise known as Pick’s dementia).
Apathetic mood: This is typically a feature of Lewy body disease, but it can also present in other forms of dementia.
Marche à petits pas: It is a short, stepping (often rapid) gait, characteristic of diffuse cerebrovascular disease. It is common to patients with vascular dementia, as is pseudobulbar palsy.
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This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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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: Alzheimer’s disease
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.
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This question is part of the following fields:
- Neurology
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Question 26
Incorrect
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A woman brings her middle-aged husband to see you. She is worried about his recent forgetfulness. She also reveals that he has been experiencing hallucinations of small children playing in the house. On examination, there is nothing significant to note except for a mild resting tremor in the hands (right > left).
What is the most probable diagnosis?Your Answer: Pick’s disease
Correct Answer: Lewy body dementia
Explanation:Differentiating Types of Dementia: Lewy Body Dementia, Korsakoff’s Dementia, Alzheimer’s Disease, Multi-Infarct Dementia, and Pick’s Disease
Lewy Body Dementia: This type of dementia is characterized by memory impairment and parkinsonism. It is caused by the build-up of Lewy bodies in the cerebral cortex and basal ganglia, resulting in a movement disorder similar to Parkinson’s disease and memory problems. Visual hallucinations are common, and symptoms often fluctuate. Treatment involves acetylcholinesterase inhibitors and levodopa, while neuroleptics are contraindicated.
Korsakoff’s Dementia: This type of dementia is typically associated with alcohol misuse. Patients tend to confabulate and make up information they cannot remember.
Alzheimer’s Disease: This is the most common type of dementia. However, visual hallucinations and resting tremor are not typical symptoms of Alzheimer’s disease.
Multi-Infarct Dementia: This type of dementia is caused by problems that interrupt blood supply to the brain, such as multiple minor and major strokes. Risk factors include hypertension, diabetes, smoking, hypercholesterolemia, and cardiovascular disease.
Pick’s Disease: Also known as fronto-temporal dementia, this type of dementia is characterized by the patient sometimes losing their inhibitions.
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This question is part of the following fields:
- Neurology
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Question 27
Incorrect
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A 68-year-old man in-patient on the gastroenterology ward is noted by the consultant on the ward round to have features which raise suspicion of Parkinson’s disease. The consultant proceeds to examine the patient and finds that he exhibits all three symptoms that are commonly associated with the symptomatic triad of Parkinson’s disease.
What are the three symptoms that are most commonly associated with the symptomatic triad of Parkinson’s disease?Your Answer: Shuffling gait, bradykinesia, resting tremor
Correct Answer: Bradykinesia, rigidity, resting tremor
Explanation:Understanding Parkinson’s Disease: Symptoms and Diagnosis
Parkinson’s disease is a neurodegenerative disorder that affects movement. Its classic triad of symptoms includes bradykinesia, resting tremor, and rigidity. Unlike other causes of Parkinsonism, Parkinson’s disease is characterized by asymmetrical distribution of signs, progressive nature, and a good response to levodopa therapy. While there is no cure for Parkinson’s disease, drugs such as levodopa and dopamine agonists can improve symptoms. A thorough history and complete examination are essential for diagnosis, as there is no specific test for Parkinson’s disease. Other features that may be present include shuffling gait, stooped posture, and reduced arm swing, but these are not part of the classic triad. Understanding the symptoms and diagnosis of Parkinson’s disease is crucial for effective management of the condition.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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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: Adductor pollicis
Correct 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.
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This question is part of the following fields:
- Neurology
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Question 29
Incorrect
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A 30-year-old man is referred to a Rapid Access Neurology Service due to severe headache. He gives a history of recurrent rapid-onset severe right-sided headache and eye pain. It sometimes wakes him up at night. He claims the eye itself becomes watery and red during the periods of pain. He also claims that side of his face feels hot and painful during episodes. They normally last 60 minutes. However, he says they can be shorter or longer. There is no significant medical history. He is a smoker. He is pain-free during the consultation and examination is non-contributory.
Which of the following is most likely to be of value in relieving pain?Your Answer: Amitriptyline
Correct Answer: Oxygen
Explanation:Understanding Cluster Headaches and Treatment Options
Cluster headaches are a rare and severe form of headache with an unknown cause, although it is believed to be related to serotonin hyperreactivity in the superficial temporal artery smooth muscle and an autosomal dominant gene. They are more common in young male smokers but can affect any age group. Symptoms include sudden onset of severe unilateral headache, pain around one eye, watery and bloodshot eye, lid swelling, facial flushing, and more. Attacks can occur 1-2 times a day and last 15 minutes to 2 hours. Treatment options include high-flow 100% oxygen, subcutaneous sumatriptan, and verapamil or topiramate for prevention. Other treatments, such as amitriptyline for trigeminal neuralgia or high-dose prednisolone for giant cell arthritis, are not appropriate for cluster headaches.
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This question is part of the following fields:
- Neurology
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Question 30
Incorrect
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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: Multiple sclerosis
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.
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This question is part of the following fields:
- Neurology
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