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Question 1
Correct
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What is the result of a lesion in the occipital lobe?
Your Answer: Cortical blindness
Explanation:The Effects of Brain Lesions on Different Lobes
Brain lesions can have varying effects depending on which lobe of the brain is affected. Lesions in the frontal lobe can result in difficulties with task sequencing and executive skills, as well as expressive aphasia, primitive reflexes, perseveration, anosmia, and changes in personality. On the other hand, lesions in the parietal lobe can cause apraxias, neglect, astereognosis, visual field defects, and acalculia.
Temporal lobe lesions, on the other hand, can lead to visual field defects, Wernicke’s aphasia, auditory agnosia, and memory impairment. Lastly, occipital lobe lesions can result in cortical blindness, homonymous hemianopia, and visual agnosia.
It is important to note that some of these effects may overlap or be present in multiple lobes. However, the specific effects of brain lesions on different lobes can aid in diagnosis and treatment planning for individuals with neurological conditions.
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This question is part of the following fields:
- Neurology
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Question 2
Correct
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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: 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 3
Correct
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A middle-aged homeless alcoholic who frequently attends the Emergency Department is brought by ambulance, having been found unconscious on the street. He had been examined the previous day with head and facial injuries following a fist fight. Examination on admission reveals an unconscious patient smelling strongly of alcohol. He is rousable with painful stimuli, but confused and unco-operative. His pupils are unequal, with the left pupil measuring approximately 8 mm and the right 4 mm. The left pupil is unreactive to both direct and consensual light stimulus, whereas the right pupil constricts normally to direct and consensual light stimulus.
Which cranial nerve(s) is this lesion affecting?Your Answer: The left oculomotor nerve
Explanation:Assessing the Pupillary Light Reflex and Nerve Lesions
The pupillary light reflex involves two cranial nerves, the second and third, and their respective pathways. The optic nerve carries visual stimuli to the brain, while the oculomotor nerve controls the constriction of the pupil. Second-order neurons from the optic tract bypass the thalamus and primary visual cortex to reach the midbrain’s pretectal area. From there, neurons pass to the Edinger-Westphal nuclei, which send preganglionic parasympathetic fibers to both oculomotor nerves en route to the ciliary ganglion and sphincter pupillae.
If a lesion occurs in the left oculomotor nerve, the left pupil will not constrict to light. This can happen due to raised intracranial pressure with a left-sided subdural hematoma, which can impinge on the nerve. However, if the right pupil constricts normally, the right oculomotor nerve and optic nerve must be intact.
If a lesion occurs in the left optic nerve, the left pupil will not constrict to light, and the right pupil will not constrict to consensual light. This is because the optic nerve relays visual stimuli from the retina to the brain, and both eyes must be intact for the reflex to occur.
If a combined lesion occurs in the left oculomotor and optic nerves, the left pupil will not constrict to light, and the right pupil will not constrict to consensual light. However, the right pupil will still constrict to direct light, indicating that the optic nerve is intact bilaterally.
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This question is part of the following fields:
- Neurology
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Question 4
Correct
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A 68-year-old male comes to the clinic complaining of weakness and difficulty moving around. During the examination, it is observed that he has a slow gait with reduced arm movement and a tremor in his right arm. What is the usual frequency of the resting tremor in Parkinson's disease?
Your Answer: 4 Hz
Explanation:the Tremor of Parkinson’s Disease
The tremor associated with Parkinson’s disease is a type of rest tremor that typically has a frequency of 3 to 6 HZ. It usually starts on one side of the body and becomes more severe as the disease progresses. Eventually, the tremor becomes bilateral, affecting both sides of the body.
While the tremor is initially a rest tremor, it may develop into an action tremor over time. Additionally, the severity of the tremor may increase with the use of levodopa. the characteristics of the tremor associated with Parkinson’s disease is important for both patients and healthcare providers in managing the symptoms of the disease. By recognizing the progression of the tremor, appropriate treatment options can be explored to improve quality of life for those living with Parkinson’s disease.
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This question is part of the following fields:
- Neurology
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Question 5
Correct
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A 38-year-old woman attends the Neurological Outpatient Clinic as an urgent referral, with a short, but progressive, history of double vision. It is noted by her husband that her speech is worse last thing in the evening. She is a non-smoker and drinks 18 units a week of alcohol.
Which of the following is the most appropriate diagnostic test?Your Answer: Nerve conduction studies with repetitive nerve stimulation
Explanation:Diagnostic Tests for Myasthenia Gravis
Myasthenia gravis (MG) is a disease characterized by weakness and fatigability due to antibodies against the acetylcholine receptor at the neuromuscular junction. Nerve conduction studies with repetitive nerve stimulation can objectively document the fatigability, showing a decrement in the evoked muscle action after repeat stimulation. A CT brain scan is not useful for MG diagnosis, but CT chest imaging is indicated as thymic hyperplasia or tumors are associated with MG. Autoantibodies to voltage-gated calcium channels are associated with Lambert-Eaton myasthenic syndrome, which is rare. Visually evoked potentials are useful for assessing optic nerve function but not for MG diagnosis.
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This question is part of the following fields:
- Neurology
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Question 6
Correct
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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: 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 7
Correct
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A 35-year-old man complains of severe headaches behind his right eye that last for 1-2 hours at a time. These headaches can occur daily for up to 6 weeks, but then he can go for months without experiencing one. He also experiences eye redness and runny nose alongside his headaches. Despite trying paracetamol and tramadol prescribed by another doctor, he has not found any relief. The pain is so intense that he cannot sleep and if he gets a headache during the day, he is unable to work or socialize. What is the most probable diagnosis?
Your Answer: Cluster headache
Explanation:Cluster headache is a type of headache that mainly affects young men. It is characterized by severe pain behind one eye that can last for up to two hours and occurs repeatedly for a certain period before disappearing for up to a year. Treatment options include inhaled oxygen or sumatriptan, as simple painkillers are usually ineffective.
Tension-type headache, on the other hand, is a headache that feels like a tight band around the head and is not accompanied by sensitivity to light, nausea, or functional impairment. It can be treated with simple painkillers like paracetamol.
Migraine is a recurring headache that may be preceded by an aura and is often accompanied by sensitivity to light, nausea, and functional impairment. Treatment options include simple painkillers and triptans for more severe attacks.
Subarachnoid hemorrhage is a medical emergency that presents as a sudden, severe headache often described as the worst of someone’s life. It requires urgent evaluation with CT brain and possible lumbar puncture to assess the cerebrospinal fluid. A ruptured berry aneurysm is a common cause of subarachnoid hemorrhage.
Meningitis, on the other hand, is associated with fever and systemic symptoms and does not present episodically over a chronic period.
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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 65-year-old male complains of a burning sensation in his feet that has been gradually increasing over the past six months. Upon examination, his cranial nerves and higher mental function appear normal, as do his bulk, tone, power, light touch and pinprick sensation, co-ordination, and reflexes in both his upper and lower limbs. What condition could these clinical findings be indicative of?
Your Answer: Large fibre sensory neuropathy
Correct Answer: Small fibre sensory neuropathy
Explanation:Neuropathy and its Different Types
Neuropathy is a condition that affects the nerves and can cause a burning sensation. This sensation is typical of a neuropathy that affects the small unmyelinated and thinly myelinated nerve fibres. However, a general neurological examination and reflexes are usually normal in this type of neuropathy unless there is coexisting large (myelinated) fibre involvement. On the other hand, neuropathy that affects the large myelinated sensory fibres generally causes glove and stocking sensory loss and loss of reflexes.
There are different types of neuropathy, and conditions in which the small fibres are preferentially affected in the early stages include diabetes and amyloidosis. In the later stages, however, the neuropathy in these conditions also affects large fibres. Another type of neuropathy is associated with Sjögren’s syndrome, which is a pure sensory neuropathy (ganglionopathy). the different types of neuropathy and their symptoms can help in the diagnosis and management of this condition.
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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 52-year-old woman presents to her general practitioner (GP), complaining of bleeding gums every time she brushes her teeth. She reports that this is very concerning to her and has gotten to the point where she has stopped brushing her teeth.
Her past medical history is significant for hypertension, for which she takes lisinopril. She takes no anticoagulants or antiplatelet medication.
Her observations are as follows:
Temperature 37.1°C
Blood pressure 140/90 mmHg
Heart rate 68 bpm
Respiratory rate 16 breaths/min
Oxygen saturation (SpO2) 98% (room air)
Examination of the oral cavity reveals red, swollen gingiva, with bleeding easily provoked with a periodontal probe.
Which of the following is the next best step?Your Answer: Referral to a neurologist
Explanation:Medical Recommendations for Gingival Overgrowth
Gingival overgrowth is a condition where the gum tissues grow excessively, leading to the formation of pockets that can harbor bacteria and cause inflammation. This condition can be caused by certain medications like phenytoin, calcium channel blockers, and ciclosporin. Here are some medical recommendations for managing gingival overgrowth:
Referral to a Neurologist: If the patient is taking antiepileptic medication, a neurologist should review the medication to determine if it is causing the gingival overgrowth.
Avoid Brushing Teeth: Although brushing can exacerbate bleeding, not brushing can lead to poor oral hygiene. The cause of the gingival overgrowth needs to be addressed.
Epstein–Barr Virus Testing: Patients with oral hairy leukoplakia may benefit from Epstein–Barr virus testing.
Pregnancy Test: A pregnancy test is not indicated in patients with gingival overgrowth unless medication is not the likely cause.
Vitamin K: Vitamin K is indicated for patients who require warfarin reversal for supratherapeutic international normalized ratios (INRs). It is not necessary for patients who are clinically stable and not actively bleeding.
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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 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: High-dose prednisolone
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 11
Incorrect
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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: Astrocytes
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.
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This question is part of the following fields:
- Neurology
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Question 12
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: Stooped posture, rigidity, bradykinesia
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 13
Incorrect
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What brain structure is likely affected in a 72-year-old man who suddenly experiences paralysis on the left side of his body and oculomotor nerve dysfunction on the right side?
Your Answer: Lateral medulla
Correct Answer: Midbrain
Explanation:Weber’s Syndrome: A Midbrain Infarction
Weber’s syndrome is a condition that occurs when there is an infarction in the midbrain. This can result in contralateral hemiplegia, which is paralysis on one side of the body, and ipsilateral oculomotor nerve palsy, which affects the eye muscles on the same side as the infarction. Patients with Weber’s syndrome often experience an abnormal level of consciousness and asymmetric hemiparesis or quadriparesis, which is weakness or paralysis in one or more limbs.
In more than 70% of cases, patients also exhibit ipsilateral third nerve palsies with pupillary abnormalities and oculomotor signs. These symptoms can include drooping eyelids, double vision, and difficulty moving the eye in certain directions. Weber’s syndrome can be a serious condition that requires prompt medical attention. Treatment may involve medications to manage symptoms and physical therapy to help patients regain strength and mobility.
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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 55-year-old male patient is admitted with a seizure and reduced conscious level. He had been generally unwell with a fever and headaches over the previous 48 h. Computed tomography (CT) brain scan was normal. Lumbar puncture reveals: protein 0.8 g/l, glucose 3.5 mmol/l (serum glucose 5 mmol/l), WCC (white cell count) 80/mm3, 90% lymphocytes.
Which of the following is the most likely diagnosis?Your Answer: Viral meningitis
Correct Answer: Viral encephalitis
Explanation:Lumbar Puncture Findings for Various Neurological Conditions
Lumbar puncture is a diagnostic procedure used to collect cerebrospinal fluid (CSF) for analysis. The results of the CSF analysis can help diagnose various neurological conditions. Here are some lumbar puncture findings for different neurological conditions:
Viral Encephalitis: This condition is suspected based on clinical features and is initially treated with broad-spectrum antibiotics and antivirals. CSF analysis shows clear and colorless appearance, all lymphocytes (no neutrophils), 10 × 106/l red blood cells, 0.2–0.4 g/l protein, 3.3–4.4 mmol/l glucose, pH of 7.31, and an opening pressure of 70–180 mmH2O.
Acute Bacterial Meningitis: This condition causes neutrophilic CSF.
Viral Meningitis: This condition typically presents with headaches and flu-like symptoms, but seizures and reduced conscious level are not a feature.
Tuberculosis (TB) Meningitis: This condition causes a more protracted illness with headaches, fever, visual symptoms, and focal neurological signs. Investigations reveal raised intracranial pressure.
Stroke: This condition does not have any characteristic lumbar puncture findings, and routine use of lumbar puncture is not recommended.
It is important to note that often no cause is found, and the condition is considered idiopathic.
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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 70-year-old man with a history of cardiovascular disease presents with vertigo, difficulty swallowing, and unsteadiness of gait. Upon neurological assessment, he is found to have nystagmus with the quick phase towards the right side and ataxia of the right upper and lower limbs. He reports no hearing loss. There is a loss of pain and temperature sensation on the right side of the face, and the left side of the limbs and trunk. The patient exhibits drooping of the right side of the palate upon eliciting the gag reflex, as well as right-sided ptosis and miosis.
Which vessel is most likely to be affected by thromboembolism given these clinical findings?Your Answer: The left anterior choroidal artery
Correct Answer: The right posterior inferior cerebellar artery
Explanation:Arterial Territories and Associated Syndromes
The right posterior inferior cerebellar artery is commonly associated with lateral medullary syndrome, which presents with symptoms such as palatal drooping, dysphagia, and dysphonia. The right anterior choroidal artery, which supplies various parts of the brain, can cause contralateral hemiparesis, loss of sensation, and homonymous hemianopia when occluded. Similarly, occlusion of the left anterior choroidal artery can result in similar symptoms. The right labyrinthine artery, a branch of the anterior inferior cerebellar artery, can cause unilateral deafness and vertigo when ischemia occurs. Finally, the right anterior inferior cerebellar artery can lead to ipsilateral facial paresis, vertigo, nystagmus, and hearing loss, as well as facial hemianaesthesia due to trigeminal nerve nucleus involvement. Understanding these arterial territories and associated syndromes can aid in diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 16
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:
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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Question 17
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:
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 18
Incorrect
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A 70-year-old man is admitted at the request of his family due to a 3-month history of increasing confusion and unsteady gait. They have also noted intermittent jerking movements of both upper limbs. He was previously healthy and till the onset of symptoms, had continued to work part-time as a carpenter. On examination, he is not orientated to time, person or place. Myoclonic jerks of both upper limbs are noted together with non-specific cerebellar signs. CT brain and blood work-up for common causes of dementia is normal.
Which of the following tests will help in diagnosis?Your Answer:
Correct Answer: MRI of the brain
Explanation:Diagnostic Procedures for Suspected Sporadic Creutzfeldt-Jakob Disease
Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare and fatal neurological disorder that presents with rapidly progressive dementia and other non-specific neurological symptoms. Here, we discuss the diagnostic procedures that are typically used when sCJD is suspected.
Clinical diagnosis of sCJD is based on a combination of typical history, MRI findings, positive CSF 14-3-3 protein, and characteristic EEG findings. Definitive diagnosis can only be made from biopsy, but this is often not desirable due to the difficulty in sterilizing equipment.
Renal biopsy is not indicated in cases of suspected sCJD, as the signs and symptoms described are not indicative of renal dysfunction. Echocardiography is also not necessary, as sCJD does not affect the heart.
Muscle biopsy may be indicated in suspected myopathic disorders, but is not useful in diagnosing sCJD. Similarly, bone marrow biopsy is not of diagnostic benefit in this case.
Overall, a combination of clinical history, imaging, and laboratory tests are used to diagnose sCJD, with biopsy reserved for cases where definitive diagnosis is necessary. It is important to note that there is currently no curative treatment for sCJD, and the disease is invariably fatal.
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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 60-year-old woman visits her GP with a complaint of hoarseness in her voice for a few weeks. She underwent a thyroidectomy a decade ago. During the examination, the doctor observed decreased breath sounds in the left upper lobe. The patient has a smoking history of 75 pack years and quit five years ago. A chest X-ray revealed an opacity in the left upper lobe. Which cranial nerve is likely to be impacted?
Your Answer:
Correct Answer: Vagus
Explanation:Cranial Nerves and their Functions: Analysis of a Patient’s Symptoms
This patient is experiencing a hoarse voice and change in pitch, which is likely due to a compression of the vagus nerve caused by an apical lung tumor. The vagus nerve is the 10th cranial nerve and provides innervation to the laryngeal muscles. The other cranial nerves, such as the trigeminal, facial, glossopharyngeal, and hypoglossal, have different functions and would not be affected by a left upper lobe opacity. Understanding the functions of each cranial nerve can aid in diagnosing and treating patients with neurological symptoms.
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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 26-year-old female presents to the hospital with a sudden and severe occipital headache while decorating at home. She experienced vomiting and a brief loss of consciousness. Upon examination, her Glasgow coma scale (GCS) score is 15, and she has a normal physical exam except for an abrasion on her right temple. She is afebrile, has a blood pressure of 146/84 mmHg, and a pulse rate of 70 beats/minute. What investigation would be the most beneficial?
Your Answer:
Correct Answer: Computed tomography (CT) brain scan
Explanation:Diagnosis of Subarachnoid Haemorrhage
The sudden onset of a severe headache in a young woman, accompanied by vomiting and loss of consciousness, is indicative of subarachnoid haemorrhage. The most appropriate diagnostic test is a CT scan of the brain to detect any subarachnoid blood. However, if the CT scan is normal, a lumbar puncture should be performed as it can detect approximately 10% of cases of subarachnoid haemorrhage that may have been missed by the CT scan. It is important to diagnose subarachnoid haemorrhage promptly as it can lead to serious complications such as brain damage or death. Therefore, healthcare professionals should be vigilant in identifying the symptoms and conducting the appropriate diagnostic tests to ensure timely treatment.
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This question is part of the following fields:
- Neurology
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Question 21
Incorrect
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A 25-year-old, fit and healthy woman develops severe headache, confusion and nausea on day 5 of climbing Mount Kilimanjaro in her adventure trip. A doctor accompanying the group examines her and finds her to be tachycardic with a raised temperature. They diagnose high-altitude cerebral oedema.
What is the most crucial step in managing this patient?Your Answer:
Correct Answer: Descent
Explanation:Treatment of High-Altitude Cerebral Oedema: The Importance of Rapid Descent
High-altitude cerebral oedema is a serious medical emergency that can be fatal if not treated promptly. It is caused by swelling of the brain at high altitudes and requires immediate action. The most important management for this condition is rapid descent to lower altitudes. In severe cases, patients may need to be air-lifted or carried down as their symptoms prevent them from doing so themselves. While oxygen and steroids like dexamethasone can help improve symptoms, they are secondary to descent.
Acetazolamide is a medication that can be used to prevent acute mountain sickness, but it is not effective in treating high-altitude cerebral oedema. Oxygen can also help reduce symptoms, but it is not a substitute for rapid descent.
Rest is important in preventing acute mountain sickness, but it is not appropriate for a patient with high-altitude cerebral oedema. Adequate time for acclimatisation and following the principles of climb high, sleep low can reduce the risk of developing symptoms.
In summary, rapid descent is the most important treatment for high-altitude cerebral oedema. Other interventions like oxygen and steroids can be helpful, but they are not a substitute for immediate action.
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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 45-year-old patient presents after trauma and exhibits a lack of sensation in the anatomical snuff box. Which nerve is likely responsible for this sensory loss?
Your Answer:
Correct Answer: Radial nerve
Explanation:Common Nerve Injuries and Their Effects
Radial nerve injury causes a condition known as wrist drop, which is characterized by the inability to extend the wrist and fingers. This injury also results in varying degrees of sensory loss, with the anatomical snuffbox being a common area affected.
On the other hand, median nerve injury leads to the loss of sensation in the thumb, index, middle, and lateral half of the ring finger. This condition can also cause weakness in the muscles that control the thumb, leading to difficulty in grasping objects.
Lastly, ulnar nerve injury results in a claw hand deformity, where the fingers are flexed and cannot be straightened. This injury also causes a loss of sensation over the medial half of the ring finger and little finger.
In summary, nerve injuries can have significant effects on the function and sensation of the hand. It is important to seek medical attention if any of these symptoms are experienced to prevent further damage.
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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 76-year-old retired teacher is being evaluated for progressive memory impairment. Based on the information provided by the patient's spouse, the clinician suspects that the patient may have vascular dementia.
What are the typical features of vascular dementia?Your Answer:
Correct Answer: Unsteadiness and falls
Explanation:Understanding the Symptoms of Vascular Dementia
Vascular dementia is a type of dementia that is characterized by a stepwise, step-down progression. This type of dementia is associated with vascular events within the brain and can cause a range of symptoms. One of the early symptoms of vascular dementia is unsteadiness and falls, as well as gait and mobility problems. Other symptoms may include visuospatial problems, motor dysfunction, dysphasia, pseudobulbar palsy, and mood and personality changes.
Vascular dementia is commonly seen in patients with increased vascular risk and may have a cross-over with Alzheimer’s disease. Brain scanning may reveal multiple infarcts within the brain. To manage vascular dementia, it is important to address all vascular risks, including smoking, diabetes, and hypertension. Patients may also be placed on appropriate anti-platelet therapy and a statin.
Compared to Alzheimer’s dementia, vascular dementia has a more stepwise progression. Additionally, it can cause pseudobulbar palsy, which results in a stiff tongue rather than a weak one. However, agnosia, which is the inability to interpret sensations, is not typically seen in vascular dementia. Visual hallucinations are also more characteristic of Lewy body dementia.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A 68-year-old man visits the Elderly Care Clinic with his wife. He has a medical history of Parkinson's disease, which has been under control with various medications. However, his wife is concerned as he has been exhibiting abnormal behavior lately, such as spending a considerable amount of their savings on a car and making inappropriate sexual advances towards his elderly neighbor. Which medication is the probable cause of this man's change in behavior?
Your Answer:
Correct Answer: Ropinirole
Explanation:Parkinson’s Disease Medications and Their Association with Impulsive Behaviours
Parkinson’s disease is a neurodegenerative disorder that affects movement and can lead to tremors, stiffness, and difficulty with coordination. There are several medications available to manage the symptoms of Parkinson’s disease, including dopamine agonists, anticholinergics, NMDA receptor antagonists, levodopa, and monoamine-oxidase-B inhibitors.
Dopamine agonists, such as Ropinirole, are often prescribed alongside levodopa to manage motor complications. However, they are known to be associated with compulsive behaviours, including impulsive spending and sexual disinhibition.
Anticholinergics, like Procyclidine, are sometimes used to manage significant tremor in Parkinson’s disease. However, they are linked to a host of side-effects, including postural hypotension, and are not generally first line. There is no known link to impulsive behaviours.
Amantadine is a weak NMDA receptor antagonist and should be considered if patients develop dyskinesia which is not managed by modifying existing therapy. It is not known to be associated with impulsive behaviours.
Levodopa, the most effective symptomatic treatment for Parkinson’s disease, may be provided in preparations such as Sinemet or Madopar. It is known to feature a weaning-off period and administration should be timed very regularly. However, it is only very rarely associated with abnormal or compulsive behaviours.
Selegiline is a monoamine-oxidase-B inhibitor and can delay the need for levodopa therapy in some patients. However, it is not linked to compulsive behaviours such as sexual inhibition or gambling.
In summary, while some Parkinson’s disease medications are associated with impulsive behaviours, others are not. It is important for healthcare providers to carefully consider the potential side-effects of each medication and monitor patients for any changes in behaviour.
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This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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A 49-year-old man with a long history of sarcoidosis presents for review. He has been intermittently treated with varying doses of oral prednisolone and chloroquine. On this occasion, he complains of drooping and weakness affecting the left-hand side of his face, blurred vision, thirst and polyuria. On examination, he has a left facial nerve palsy.
Investigations:
Investigation Result Normal value
Haemoglobin 119 g/l 135–175 g/l
White cell count (WCC) 4.5 × 109/l 4–11 × 109/l
Platelets 195 × 109/l 150–400 × 109/l
Sodium (Na+) 149 mmol/l 135–145 mmol/l
Potassium (K+) 5.4 mmol/l 3.5–5.0 mmol/l
Urea 15.1 mmol/l 2.5–6.5 mmol/l
Creatinine 195 μmol/l 50–120 µmol/l
Ca2+ corrected 2.21 mmol/l 2.20–2.60 mmol/l
Random glucose 5.4 mmol/l 3.5–5.5 mmol/l
Erythrocyte sedimentation rate (ESR) 36 mm/h 0–10mm in the 1st hour
Which of the following diagnoses fit best with this clinical picture?Your Answer:
Correct Answer: Neurosarcoidosis
Explanation:Differential Diagnosis for a Patient with Neurological Symptoms: Neurosarcoidosis, Bacterial Meningitis, Bell’s Palsy, Viral Meningitis, and Intracerebral Abscess
A man with a history of sarcoidosis presents with neurological symptoms, including polyuria, polydipsia, and blurred vision. These symptoms suggest the possibility of cranial diabetes insipidus, a consequence of neurosarcoidosis. Hypercalcemia and hyperglycemia are ruled out as potential causes based on normal glucose and calcium levels. Treatment for neurosarcoidosis typically involves oral corticosteroids and immunosuppressant agents.
Bacterial meningitis, which presents with headache, neck stiffness, and photophobia, is ruled out as there is no evidence of infection. Bell’s palsy, an isolated facial nerve palsy, does not explain the patient’s other symptoms. Viral meningitis, which also presents with photophobia, neck stiffness, and headache, is unlikely as the patient’s white blood cell count is normal. An intracerebral abscess, which typically presents with headache and fever, is unlikely to produce the other symptoms experienced by the patient.
In summary, the differential diagnosis for this patient’s neurological symptoms includes neurosarcoidosis, bacterial meningitis, Bell’s palsy, viral meningitis, and intracerebral abscess.
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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 50-year-old man has been referred to a neurologist by his GP due to recent concerns with his speech. He has been experiencing difficulty verbalising his thoughts and finds this frustrating. However, there is no evidence to suggest a reduced comprehension of speech.
He struggles to repeat sentences and well-rehearsed lists (such as months of the year and numbers from one to ten). He is also unable to name common household objects presented to him. Additionally, he constructs sentences using the incorrect tense and his grammar is poor.
Imaging studies reveal that the issue is located in the frontotemporal region of the brain.
What is the most likely diagnosis?Your Answer:
Correct Answer: Progressive non-fluent aphasia (PNFA)
Explanation:Different Types of Aphasia and Their Characteristics
Aphasia is a language disorder that affects a person’s ability to communicate effectively. There are different types of aphasia, each with its own set of characteristics. Progressive non-fluent aphasia (PNFA) primarily affects speech and language, causing poor fluency, repetition, grammar, and anomia. Wernicke’s aphasia, on the other hand, is a fluent aphasia that causes impaired comprehension and repetition, nonsensical speech, and neologisms. Broca’s aphasia is a non-fluent aphasia that affects the ability to communicate fluently, but does not affect comprehension. Semantic dementia affects semantic memory, primarily affecting naming of objects, single-word comprehension, and understanding the uses of particular objects. Finally, conductive dysphasia is caused by damage to the arcuate fasciculus, resulting in anomia and poor repetition but preserved comprehension and fluency of speech. Understanding the characteristics of each type of aphasia can help in the diagnosis and treatment of individuals with language disorders.
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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 60-year-old woman is referred by her general practitioner for investigation of a headache. On further questioning, she reports a 2- to 3-week history of worsening left-sided pain which is most noticeable when she brushes her hair. She also reports that, more recently, she has noticed blurred vision in her left eye. On examination, she has stiffness of her upper limbs, as well as tenderness to palpation over her left scalp and earlobe. Her past medical history is notable for hypothyroidism.
Which is the diagnostic test of choice?Your Answer:
Correct Answer: Arterial biopsy
Explanation:Diagnostic Tests for Temporal arthritis: Understanding Their Role in Diagnosis
Temporal arthritis is a condition that affects middle-aged women with a history of autoimmune disease. The most likely diagnostic test for this condition is a biopsy of the temporal artery, which shows granulomatous vasculitis in the artery walls. Treatment involves high-dose steroid therapy to prevent visual loss. Lumbar puncture for cerebrospinal fluid analysis is unlikely to be helpful, while CT brain is useful for acute haemorrhage or mass lesions. MRA of the brain is performed to assess for intracranial aneurysms, while serum ESR supports but does not confirm a diagnosis of temporal arthritis. Understanding the role of these diagnostic tests is crucial in the accurate diagnosis and treatment of temporal arthritis.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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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.
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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 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:
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 30
Incorrect
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A 55-year-old man has been referred to you due to a personality change that has been going on for a year. He has become loud, sexually flirtatious, and inappropriate in social situations. He has also been experiencing difficulties with memory and abstract thinking, but his arithmetic ability remains intact. There is no motor impairment, and his speech is relatively preserved. Which area of the brain is most likely affected?
Your Answer:
Correct Answer: Frontal lobe
Explanation:Pick’s Disease: A Rare Form of Dementia
Pick’s disease is a type of dementia that is not commonly seen. It is characterized by the degeneration of the frontal and temporal lobes of the brain. The symptoms of this disease depend on the location of the lobar atrophy, with patients experiencing either frontal or temporal lobe syndromes. Those with frontal atrophy may exhibit early personality changes, while those with temporal lobe atrophy may experience aphasia and semantic memory impairment.
Pathologically, Pick’s disease is associated with Pick bodies, which are inclusion bodies found in the neuronal cytoplasm. These bodies are argyrophilic, meaning they have an affinity for silver staining. Unlike Alzheimer’s disease, EEG readings for Pick’s disease are relatively normal.
To learn more about Pick’s disease, the National Institute of Neurological Disorders and Stroke provides an information page on frontotemporal dementia. this rare form of dementia can help individuals and their loved ones better manage the symptoms and seek appropriate treatment.
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This question is part of the following fields:
- Neurology
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