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  • Question 1 - Samantha, a 10-year-old girl, visits your clinic with her mother. She reports having...

    Incorrect

    • Samantha, a 10-year-old girl, visits your clinic with her mother. She reports having a constant headache for several weeks. Her mother is extremely worried. However, Samantha is always anxious during medical appointments and refuses to cooperate with a thorough examination.

      As a healthcare provider, you are concerned about Samantha's condition and decide to request an immediate referral. What is the maximum time frame within which she should receive an appointment with a specialist?

      Your Answer: 2 weeks

      Correct Answer: 3 days

      Explanation:

      Referral Guidelines for Children with Suspected Cancer

      When a child presents with symptoms and signs of cancer, it is important to refer them to a paediatrician or a specialist children’s cancer service, if appropriate. If the child experiences headaches and vomiting that cause early morning waking or occur on waking, this could be a sign of raised intracranial pressure, and an immediate referral should be made.

      It is important to note that patients have a legal right to be seen by a specialist within two weeks of being urgently referred for suspected cancer by their GP. If this is not possible, the NHS must do everything it reasonably can to offer them clinically appropriate alternatives. By following these referral guidelines, healthcare professionals can ensure that children with suspected cancer receive timely and appropriate care.

    • This question is part of the following fields:

      • Neurology
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  • Question 2 - A 32-year-old man presents to the local General Practice out-of-hours service after experiencing...

    Incorrect

    • A 32-year-old man presents to the local General Practice out-of-hours service after experiencing a seizure earlier. He has a history of epilepsy since childhood. While waiting to be seen, he has another seizure, which has lasted for more than five minutes.
      What is the most suitable initial pharmacological treatment option for this patient? Choose ONE answer only.

      Your Answer: Intravenous diazepam

      Correct Answer: Buccal midazolam

      Explanation:

      When someone experiences a prolonged or repeated convulsive seizure, immediate emergency care is necessary. The first step is to ensure general protective measures and maintain an open airway. Buccal midazolam is the preferred first-line treatment in the community, administered by placing the medication between the cheek and gum. If this is not effective, rectal diazepam or intravenous lorazepam or diazepam may be used. If the seizure continues despite medication or there is a history of repeated seizures, an ambulance should be called. In the hospital setting, intravenous lorazepam is the first-line treatment, with midazolam or diazepam used as alternatives if necessary. For refractory convulsive status epilepticus, intravenous midazolam or thiopental sodium may be used.

    • This question is part of the following fields:

      • Neurology
      47.7
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  • Question 3 - A 25-year-old woman comes to her General Practitioner complaining of blurred vision in...

    Incorrect

    • A 25-year-old woman comes to her General Practitioner complaining of blurred vision in her right eye and pain on eye movement for the past 6 days. Upon examination, the doctor finds that her acuity is reduced to 6/36, she has impaired colour vision, a relatively afferent pupillary defect, and a swollen, pale optic disc. The doctor diagnoses her with optic neuritis. The patient mentions that she has heard about a connection between optic neuritis and multiple sclerosis (MS) and asks for more information. What is the best advice to give to this patient?

      Your Answer: Most patients will typically develop additional features of MS within two years of diagnosis of optic neuritis

      Correct Answer: Magnetic resonance imaging (MRI) is a useful tool for predicting the risk of developing MS

      Explanation:

      Understanding Acute Demyelinating Optic Neuritis and its Relationship to Multiple Sclerosis

      Acute demyelinating optic neuritis (ADON) is a condition that can be associated with multiple sclerosis (MS). Magnetic resonance imaging (MRI) is a useful tool for predicting the risk of developing MS, as the presence of white matter abnormalities on MRI of the brain increases the risk of MS. The Optic Neuritis Treatment Trial (ONTT) revealed that the risk of developing MS at 15-year follow-up was approximately 25% for patients with no white matter lesions on MRI compared to 75% for those with lesions.

      Interferon-beta treatment can increase the time interval to relapse in MS, particularly in patients with ADON and white matter lesions on MRI. However, it is important to remember that many patients with ADON will not develop MS. Information about their prognosis can help patients to decide whether to undergo MRI scanning and whether to use interferon-beta or other immunomodulators in their treatment.

      While the risk of recurrence of ADON is approximately 35% over ten years, the prognosis for vision retainment in patients with ADON is usually good. The ONTT found that one year after onset, 93% of individuals had visual acuity greater than 6/12 in the affected eye. However, many patients may continue to experience subjective reductions in vision and other visual impairments.

      In summary, understanding the relationship between ADON and MS, as well as the potential benefits and risks of treatment options, can help patients make informed decisions about their care.

    • This question is part of the following fields:

      • Neurology
      179.4
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  • Question 4 - A 35-year-old woman with menstrual migraines presents for evaluation. She experiences a severe...

    Correct

    • A 35-year-old woman with menstrual migraines presents for evaluation. She experiences a severe headache every month just before the onset of her period. According to NICE, what is recommended to prevent the development of these headaches?

      Your Answer: Frovatriptan (2.5 mg twice a day) on the days around the start of menstruation

      Explanation:

      Managing Migraines: Guidelines and Treatment Options

      Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. The National Institute for Health and Care Excellence (NICE) has provided guidelines for the management of migraines.

      For acute treatment, a combination of an oral triptan and an NSAID or paracetamol is recommended as first-line therapy. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective or not tolerated, a non-oral preparation of metoclopramide or prochlorperazine may be offered, along with a non-oral NSAID or triptan.

      Prophylaxis should be considered if patients are experiencing two or more attacks per month. NICE recommends either topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity.

      For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be used as a type of mini-prophylaxis. Specialists may also consider candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, such as erenumab. However, pizotifen is no longer recommended due to common adverse effects such as weight gain and drowsiness.

      It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering the various treatment options available, migraines can be effectively managed and their impact on daily life reduced.

    • This question is part of the following fields:

      • Neurology
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  • Question 5 - A 32-year-old man has suddenly developed left-sided facial weakness and comes to the...

    Incorrect

    • A 32-year-old man has suddenly developed left-sided facial weakness and comes to the clinic on the same day. He is experiencing difficulty in closing his left eye, has lost taste on the front of the tongue, and is sensitive to loud noise. The entire left side of his face is affected, and he cannot wrinkle his forehead on the left side.
      What is the most suitable course of action for managing this patient?

      Your Answer: Aciclovir and prednisolone

      Correct Answer: Prednisolone 25 mg twice a day

      Explanation:

      Facial Nerve Palsy: Causes, Symptoms, and Treatment Options

      Facial nerve palsy is a condition that affects the facial nerve, resulting in the inability to wrinkle the forehead. This indicates a lower motor neurone (LMN) lesion, which is often caused by a viral infection such as herpes simplex type 1 or varicella zoster. In the past, the majority of cases were labelled idiopathic or Bell’s palsy, but recent research has shed light on the underlying causes.

      Other symptoms of facial nerve palsy may include hyperacusis, inability to produce tears, and loss of taste. In an upper motor neurone lesion, the upper facial muscles are partially spared due to alternative pathways in the brain stem.

      Treatment for facial nerve palsy typically involves prednisolone, which should be given within 72 hours of onset and continued for 10 days. Aciclovir is no longer recommended, and there is no evidence supporting the use of steroids in children. Referral to an ophthalmologist may be necessary if the cornea is exposed despite attempts to close the eyelid.

      While most patients recover fully from facial nerve palsy, some may experience permanent nerve damage or severe sequelae. It is important to seek medical attention promptly to ensure the best possible outcome.

    • This question is part of the following fields:

      • Neurology
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  • Question 6 - A 32-year-old woman comes to Neurology Outpatients with complaints of experiencing multiple episodes...

    Incorrect

    • A 32-year-old woman comes to Neurology Outpatients with complaints of experiencing multiple episodes in the past few months where she smells a burning odor followed by twitching in her left arm. These symptoms usually last for a maximum of a few minutes. She remains fully conscious during the episodes and has not experienced any loss of consciousness.
      Which type of seizure do the symptoms of this patient suggest?

      Your Answer: Focal impaired awareness seizure

      Correct Answer: Focal aware seizure

      Explanation:

      Types of Seizures and Their Characteristics

      Seizures can be classified into different types based on their characteristics. Focal onset seizures start in one part of the brain and can spread to both hemispheres, leading to a generalised tonic-clonic seizure. Focal onset seizures can be either aware or impaired awareness, depending on whether the patient has full consciousness and awareness throughout the seizure. Focal seizures may involve motor symptoms or unusual sensations, and there is often an aura such as an abnormal smell or taste.

      Generalised clonic seizures involve sustained rhythmical jerking of the whole body with loss of consciousness. This type of seizure is less common than tonic-clonic seizures, which involve muscle stiffening along with the clonus.

      Absence seizures are a form of generalised seizure that typically involve a transient loss of consciousness, eyelid fluttering, and a blank stare. This type of seizure is more common in children than adults.

      Focal impaired awareness seizures involve an aura and only one part of the body is affected, but the patient is fully aware and alert during the seizure.

      Generalised atonic seizures are often described as drop attacks, as muscle tone is suddenly and transiently lost, resulting in the person falling over and becoming floppy. Focal atonic seizures present when one part of the body becomes limp during a seizure, such as a drooping eyelid. There is usually no aura prior to this type of seizure, and a quick recovery follows.

      Understanding the Different Types of Seizures

    • This question is part of the following fields:

      • Neurology
      70.3
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  • Question 7 - A 25-year-old man comes to his General Practitioner complaining of progressive numbness in...

    Correct

    • A 25-year-old man comes to his General Practitioner complaining of progressive numbness in his feet and weakness in his lower limbs. These symptoms have developed over the past week. He has a broad-based ataxic gait. He has a history of using 'laughing gas' recreationally. His aunt has multiple sclerosis (MS) and he is concerned that he may be experiencing the first signs of the condition. What neurological finding would be most indicative of an alternative diagnosis?

      Your Answer: Absent ankle jerk

      Explanation:

      Distinguishing between Vitamin B12 Deficiency and Multiple Sclerosis: Neurological Manifestations

      Neurological manifestations can help distinguish between vitamin B12 deficiency and multiple sclerosis (MS). Vitamin B12 deficiency causes degeneration of the white matter in the dorsal and lateral columns of the spinal cord, peripheral nerves, optic nerves, and cerebral hemispheres. Chronic inhalation of nitrous oxide is an increasingly common cause of vitamin B12 deficiency. On the other hand, MS is a demyelinating disease that primarily affects the white matter of the brain, spinal cord, and optic nerves.

      Sensory peripheral neuropathy, absent distal tendon reflexes, and distal sensory loss are neurological manifestations of vitamin B12 deficiency. In contrast, sensory loss consistent with peripheral neuropathy and absent ankle jerks are not features of MS. Ataxia, which is the lack of muscle coordination, is a feature of both subacute combined degeneration of the spinal cord and MS.

      Barber’s chair sign, an electrical sensation that runs down the back and into the limbs, can be elicited by bending the head forward or lapping on the posterior cervical spine while the neck is flexed. It is caused by the involvement of the posterior columns and is most commonly associated with MS. However, it may also occur in other lesions of the cervical cord, such as cord compression, syringomyelia, and vitamin B12 deficiency.

      Bilateral up-going plantar responses signify advanced subacute combined degeneration of the cord and pyramidal signs associated with MS. Optic atrophy, the degeneration of the optic nerve, is a common feature of MS and subacute combined degeneration of the cord.

    • This question is part of the following fields:

      • Neurology
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  • Question 8 - An 88-year-old female presents to the Emergency Department with a 24 hours history...

    Incorrect

    • An 88-year-old female presents to the Emergency Department with a 24 hours history of painless loss of vision of her left eye, which has resolved. She described the episode 'like a curtain coming down across my eye'. She has a past medical history of coronary heart disease and diabetes. She is a non-smoker and she doesn't drink. She currently takes no medication and has no past medical history of note. Fundoscopic examination is normal and an MRI is taken which shows volumetric loss of white and grey matter throughout with an area of mild white matter hyperintensity in the left frontal lobe on T2-weighted images.

      What is her most likely diagnosis?

      Your Answer: Multiple sclerosis

      Correct Answer: Transient ischaemic attack

      Explanation:

      A brain tumour can cause local brain invasion, compression of adjacent structures, and increased intracranial pressure (ICP), leading to symptoms such as severe unilateral headache, nausea, and vomiting. However, a sudden onset of weakness that resolves quickly is unlikely to be caused by a brain tumour.

      MS typically presents with temporary vision loss in a woman in her 20s, but a new presentation may be mistaken for a TIA and have longer-lasting neurological deficits. Other symptoms are usually present in a patient of this age.

      While central retinal vein occlusion can cause unilateral vision loss, it usually presents with blurred vision, and the presence of amaurosis fugax or an altitudinal field defect suggests an arterial pathology. A normal fundoscopic examination also makes central retinal vein occlusion unlikely.

      A stroke is characterized by an acute neurological deficit lasting more than 24 hours due to cerebrovascular aetiology. However, in this case, the weakness has resolved, and the MRI shows only age-related changes, making a TIA diagnosis more appropriate.

      A TIA is a transient episode of neurological dysfunction without acute infarction. Given the patient’s presentation of amaurosis fugax, past medical history of coronary artery disease, and normal MRI scan, a TIA is the most likely diagnosis.

      A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

      NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

      Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

      Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

    • This question is part of the following fields:

      • Neurology
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  • Question 9 - How long should a patient cease driving after experiencing a stroke? ...

    Incorrect

    • How long should a patient cease driving after experiencing a stroke?

      Your Answer: 12 months

      Correct Answer: 1 month

      Explanation:

      If you have had a stroke or TIA, the DVLA advises that you should refrain from driving for a period of one month.

      The DVLA has guidelines for individuals with neurological disorders who wish to drive cars or motorcycles. However, the rules for drivers of heavy goods vehicles are much stricter. For individuals with epilepsy or seizures, they must not drive and must inform the DVLA. If an individual has had a first unprovoked or isolated seizure, they must take six months off driving if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met, the time off driving is increased to 12 months. Individuals with established epilepsy or those with multiple unprovoked seizures may qualify for a driving license if they have been free from any seizure for 12 months. If there have been no seizures for five years (with medication if necessary), a ’til 70 license is usually restored. Individuals should not drive while anti-epilepsy medication is being withdrawn and for six months after the last dose.

      For individuals with syncope, a simple faint has no restriction on driving. A single episode that is explained and treated requires four weeks off driving. A single unexplained episode requires six months off driving, while two or more episodes require 12 months off. For individuals with other conditions such as stroke or TIA, they must take one month off driving. They may not need to inform the DVLA if there is no residual neurological deficit. If an individual has had multiple TIAs over a short period of time, they must take three months off driving and inform the DVLA. For individuals who have had a craniotomy, such as for meningioma, they must take one year off driving. If an individual has had a pituitary tumor, a craniotomy requires six months off driving, while trans-sphenoidal surgery allows driving when there is no debarring residual impairment likely to affect safe driving. Individuals with narcolepsy/cataplexy must cease driving on diagnosis but can restart once there is satisfactory control of symptoms. For individuals with chronic neurological disorders such as multiple sclerosis or motor neuron disease, they should inform the DVLA and complete the PK1 form (application for driving license holders’ state of health). If the tumor is a benign meningioma and there is no seizure history, the license can be reconsidered six months after surgery if the individual remains seizure-free.

    • This question is part of the following fields:

      • Neurology
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  • Question 10 - An 81-year-old woman is brought to the clinic by her daughter. She lives...

    Correct

    • An 81-year-old woman is brought to the clinic by her daughter. She lives independently, but her daughter has noticed that she has become increasingly forgetful over the last six months. There are no neurological abnormalities on examination.
      Which of the following additional features would be most suggestive of a diagnosis of mild cognitive impairment (MCI)?

      Your Answer: Difficulty in finding words

      Explanation:

      Understanding the Symptoms of Mild Cognitive Impairment

      Mild cognitive impairment (MCI) is a condition characterized by a decline in cognitive function that is greater than expected for an individual’s age and education level, but doesn’t significantly interfere with daily activities or affect multiple cognitive domains. Here are some common symptoms associated with MCI and how they differ from those of dementia:

      Difficulty in Finding Words: MCI may cause word-finding difficulty without other cognitive deficits, which can be frustrating but doesn’t significantly impact daily life.

      Incontinence: While incontinence can be a sign of autonomic dysfunction in dementia, it is not typically associated with MCI.

      Apathy: Withdrawal or apathy is a common symptom of dementia, but is not typically present in patients with MCI.

      Delusions: Delusions are a sign of psychosis, which can be present in some forms of dementia but are not typically associated with MCI.

      Insomnia: Insomnia can be a symptom of dementia-related sleep disturbances, but is not typically associated with MCI.

      Understanding these symptoms can help healthcare professionals diagnose and manage MCI, as well as differentiate it from more severe forms of cognitive decline.

    • This question is part of the following fields:

      • Neurology
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  • Question 11 - A 65-year-old man presents to his General Practitioner (GP) concerned about his memory....

    Incorrect

    • A 65-year-old man presents to his General Practitioner (GP) concerned about his memory. He has felt more forgetful over the last six months; his wife mentions that he seems to ask the same questions repeatedly.
      The GP decides to conduct a Mini-Mental State Examination (MMSE).
      What is the most appropriate advice to provide the patient before this test?

      Your Answer: The MMSE is useful in assessing patients with affective disorders

      Correct Answer: The MMSE involves tests of immediate and delayed recall

      Explanation:

      The MMSE: A Test of Cognition and Recall

      The Mini-Mental State Examination (MMSE) is a widely used test to assess cognitive function in patients. It consists of 30 items that evaluate various aspects of cognition, including immediate and delayed recall, fine motor skills, calculation, language, and comprehension. One of the tasks involves asking the patient to recall three words immediately and later on in the test. A score of 27 or lower on the MMSE may indicate dementia.

      While the MMSE does test fine motor skills by asking the patient to copy intersecting pentagons, it may not be the best screening tool for general practice. GPs may find other tests, such as the 6-Item Cognitive Impairment Test or the GP Assessment of Cognition Test, more suitable for their needs.

      It’s important to note that the MMSE is not designed to assess affective disorders or delirium. Therefore, it should not be used for this purpose. Overall, the MMSE is a useful tool for clinicians to establish a baseline understanding of a patient’s cognitive state.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - Your next patient is a 50-year-old woman with multiple sclerosis who suffers from...

    Incorrect

    • Your next patient is a 50-year-old woman with multiple sclerosis who suffers from severe spasticity that has failed to respond to conventional treatment.

      Of which of the following would NICE support a trial?

      Your Answer: Methylphenidate

      Correct Answer: Cannabis based product

      Explanation:

      Patients with intractable spasticity in adults with multiple sclerosis may undergo a trial of THC:CBD spray, a medicinal product derived from cannabis. CKS suggests a 4 week trial for those with moderate to severe spasticity who have not found relief from other treatments, under the supervision of a specialist. Other treatments are not recommended.

      Cannabis-Based Medicinal Products: Guidelines and Available Products

      Cannabis-based medicinal products can now be prescribed for therapeutic use under specialist supervision, following a Department of Health review in 2018. These products are defined as medicinal preparations or products that contain cannabis, cannabis resin, cannabinol, or a cannabinol derivative, and are produced for use in humans. Initial prescriptions must be made by a specialist medical practitioner with experience in the condition being treated, and subsequent prescriptions can be issued by another practitioner under a shared care agreement.

      Cannabis-based medicinal products can be used to manage various conditions, including chemotherapy-induced nausea and vomiting, chronic pain, spasticity in adults with multiple sclerosis, and severe-treatment resistant epilepsy. However, current NICE guidance advises against using cannabis-based medicines for chronic pain, except if already initiated and under specialist supervision until appropriate to stop.

      Several cannabis-based products and cannabinoids are available, including Bedrocan, Tilray, Sativex, Epidiolex, Dronabinol, and Nabilone. However, unlicensed cannabis-based products can only be prescribed by doctors on the General Medical Council Specialist Register, and doctors should prescribe products only for disorders within their specialty when there is clear evidence or published guidelines.

      It is important to consider current available evidence, interactions with other prescribed or non-prescribed medication, and the potential for patients to seek or use non-medicinal products lacking safety and quality assurance when considering prescribing cannabis-based products. Patients should also be advised of the risks of impaired driving, as cannabis-based products may impair a patient’s ability to drive safely.

      Common side effects associated with cannabis-based medicines include disorientation, dizziness, euphoria, confusion, dry mouth, nausea, somnolence, fatigue, vomiting, drowsiness, loss of balance, and hallucination. Rare adverse events include psychosis and seizures.

    • This question is part of the following fields:

      • Neurology
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  • Question 13 - A 65-year-old woman with poorly controlled type 2 diabetes presents with burning pains...

    Incorrect

    • A 65-year-old woman with poorly controlled type 2 diabetes presents with burning pains in both feet that have been ongoing for several months. On examination, she has easily palpable pedal pulses but reduced light touch sensation in both feet up to her ankles. Her blood pressure is 130/80 mmHg. Recent blood tests reveal an HbA1c of 76 mmol/mol (9.1%) with normal full blood count, renal and liver function. She is currently taking metformin 500 mg TDS, gliclazide 80 mg OD, aspirin 75 mg OD, ramipril 10 mg OD, and simvastatin 40 mg ON. You discuss the importance of tighter glycemic control and potential medications that may help alleviate her symptoms. What is the most appropriate first-line treatment for her burning foot pain?

      Your Answer: Nortriptyline

      Correct Answer: Lamotrigine

      Explanation:

      NICE Guidelines for Neuropathic Pain Management

      The National Institute for Health and Care Excellence (NICE) has released guidelines for the pharmacological management of neuropathic pain in non-specialist settings. The key points include offering a choice of amitriptyline, duloxetine, gabapentin, or pregabalin as initial treatment for all neuropathic pain (except trigeminal neuralgia). If the initial treatment is not effective or not tolerated, one of the remaining three drugs should be offered, with consideration for switching again if necessary. Tramadol should only be considered for acute rescue therapy, and capsaicin cream may be used for localized neuropathic pain. Nortriptyline is no longer recommended as an alternative to amitriptyline, and lamotrigine and venlafaxine are not recommended in non-specialized settings. It is important to note that there are many plausible options for medication, but the test is to select the one listed in the options.

    • This question is part of the following fields:

      • Neurology
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  • Question 14 - A 55-year-old woman presents following a fall. She reports pain and weakness in...

    Incorrect

    • A 55-year-old woman presents following a fall. She reports pain and weakness in her hands for several months, stiff legs and slurred speech and has bilateral wasting of the small muscles of her hands. Reflexes in the upper limbs are absent. Tongue atrophy and fasciculations are present and both legs show increased tone, pyramidal weakness and hyper-reflexia with extensor plantars. Pain and temperature sensation is impaired in the upper limbs.
      Which of the following is the most likely diagnosis?

      Your Answer: Cervical spondylosis

      Correct Answer: Syringobulbia

      Explanation:

      The patient is showing signs of a spinal cord lesion, with LMN signs in the arms and UMN signs in the legs. There is also a loss of thermal and pain sensation, indicating involvement of the spinothalamic tracts but not the posterior columns. This is typical of a syrinx, which is a fluid-filled hole in the spinal cord. The patient is experiencing dysesthetic pain in the hands, which is a common symptom of syringomyelia/syringobulbia. The presence of twelfth nerve atrophy and slurred speech indicates that the lesion extends into the brainstem, ruling out syringomyelia. Cervical spondylosis can produce similar symptoms, but there should also be neck pain. Motor neurone disease is unlikely due to the sensory involvement, and multiple sclerosis is not a likely explanation given the other clinical features.

    • This question is part of the following fields:

      • Neurology
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  • Question 15 - A 45-year-old man complains of intermittent, unilateral pain above and behind his left...

    Correct

    • A 45-year-old man complains of intermittent, unilateral pain above and behind his left eye, which has been waking him up at night for the past ten days. The pain is described as severe and stabbing, lasting about 20 minutes and causing him to feel restless and agitated. He also experiences tearing from his left eye and nasal congestion. During attacks, he has noticed his left eyelid drooping. He recalls having similar symptoms for a few weeks last year, but they went away on their own and he did not seek medical attention. Physical examination reveals no abnormalities. He has been a smoker for most of his life.
      What is the most likely diagnosis?

      Your Answer: Cluster headache

      Explanation:

      Headache Disorders: Cluster Headache, Migraine, Paroxysmal Hemicrania, Temporal Arteritis, and Trigeminal Neuralgia

      Cluster headache is a type of headache disorder that commonly affects middle-aged men in clusters lasting weeks to months. Verapamil and prednisolone are used for prophylaxis, while sumatriptan and oxygen are the main treatments for the acute attack. Migraine lacks the specific features of cluster headache and tends to have bilateral autonomic symptoms. Paroxysmal hemicrania is another type of trigeminal autonomic cephalgia that occurs multiple times throughout the day but for shorter periods and is more frequently seen in women. It responds to indomethacin and is often used as a diagnostic aid. Temporal arteritis is unusual in this age group and is usually throbbing and continuous with focal tenderness on direct palpation. Trigeminal neuralgia is sometimes mistaken for cluster headache, but the attacks are much shorter and autonomic activation is rare.

    • This question is part of the following fields:

      • Neurology
      44
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  • Question 16 - A 38-year-old woman comes to the General Practitioner for an urgent appointment. She...

    Incorrect

    • A 38-year-old woman comes to the General Practitioner for an urgent appointment. She has a diffuse headache, which she describes as severe. The headache is acute, having developed within the last three hours. She lost consciousness for a brief period. There is no significant past medical history.
      What is the most likely diagnosis?

      Your Answer: Migraine

      Correct Answer: Subarachnoid haemorrhage

      Explanation:

      When a patient presents with a sudden, severe headache, subarachnoid haemorrhage should be considered as a possible cause, with or without loss of consciousness. Menigeal irritation may take some time to appear. In cases of epilepsy, postictal headaches are common, lasting between six and 24 hours. Cluster headaches are characterized by rapid onset and unilateral pain around the eye, temple or forehead, often accompanied by lacrimation or rhinorrhoea. Migraines are also unilateral and may be preceded by an aura, with associated nausea and vomiting. TIAs usually present with focal neurological symptoms, rather than headaches, and loss of consciousness is not typical.

    • This question is part of the following fields:

      • Neurology
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  • Question 17 - A 68-year-old woman presents with a 2-day history of left earache, vertigo and...

    Correct

    • A 68-year-old woman presents with a 2-day history of left earache, vertigo and loss of taste. There is left-sided weakness of both the upper and the lower facial muscles. Facial sensation is normal. There is a vesicular rash on the eardrum, ear canal, earlobe, tongue and roof of the mouth (palate) on the same side as the weakness of the face.
      Select the single most likely diagnosis.

      Your Answer: Ramsay Hunt syndrome

      Explanation:

      Understanding Ramsay Hunt Syndrome and Other Facial Nerve Conditions

      Ramsay Hunt syndrome is a condition caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the facial nerve. This can lead to ear pain, hearing loss, vertigo, facial nerve paralysis, and even involvement of other cranial nerves. The presence of lymphocytes in the cerebrospinal fluid and vesicles on the skin of the ear canal or pinna may also be observed. However, it is important to note that this condition can also occur without a skin rash.

      Bell’s palsy, on the other hand, is the most common cause of unilateral facial nerve paralysis. It may also present with otalgia and pain behind the ear, but vesiculation is absent. Acute otitis media can also lead to facial paralysis, but this usually responds well to antibiotics and corticosteroids.

      Postherpetic neuralgia is a nerve pain that occurs after the herpes zoster vesicles have crusted over and begun to heal. However, the description provided doesn’t suggest that this stage has been reached. Trigeminal neuralgia, on the other hand, is characterised by recurrent episodes of facial pain following the sensory distribution of the trigeminal nerve, but without facial paralysis or rash.

      It is important to understand the differences between these conditions in order to properly diagnose and treat them. While some may share similar symptoms, the underlying causes and treatments can vary greatly.

    • This question is part of the following fields:

      • Neurology
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  • Question 18 - A 35-year-old man has been admitted to the hospital for investigation of worsening...

    Incorrect

    • A 35-year-old man has been admitted to the hospital for investigation of worsening muscle weakness in his upper and lower limbs over the last 10 years. The patient says he had never been interested in sports at school and that his father had problems with his gait for years. On examination, cognition, bulbar function and cranial nerves are all normal. Examination of the limbs shows distal symmetrical wasting and weakness in his arms and legs. There is areflexia. Tone is normal. There are no visible fasciculation. Vibration, pain and temperature are impaired in both hands and feet. There is kyphoscoliosis and bilateral pes cavus.
      Select the single most likely diagnosis.

      Your Answer: Vitamin B12 deficiency

      Correct Answer: Charcot–Marie–Tooth disease

      Explanation:

      Neurological Disorders: A Comparison

      When presented with a patient exhibiting neuromuscular symptoms and signs, it is important to consider various possible diagnoses. In this case, the presence of musculoskeletal deformities and a family history of gait difficulties suggest a hereditary basis for the patient’s condition. The following are some potential diagnoses to consider:

      Charcot-Marie-Tooth Disease (CMT): This is the most common inherited polyneuropathy, affecting approximately 1 in 2500 people. It typically presents with distal limb muscle wasting and sensory loss, with proximal progression over time. However, the disease course can vary greatly.

      Vitamin B12 Deficiency: Neurological features of this deficiency may include peripheral neuropathy and subacute combined degeneration of the spinal cord. However, skeletal defects will be absent.

      Acquired Chronic Inflammatory Demyelinating Polyneuropathy (CIDP): This is a chronically progressive or relapsing symmetric sensorimotor disorder that lacks the skeletal deformities of CMT.

      Motor Neurone Disease (MND): This tends to present with early signs of weakness in an ankle or leg, or a weak grip. It then progresses, leading to problems with slurred speech or swallowing. However, this patient’s relatively young age and symptoms suggest an inherited neurological problem rather than MND.

      Spinal Muscular Atrophy: This is a spectrum of genetically inherited disorders that present with muscle weakness and wasting. It lacks the sensory loss of CMT.

      In conclusion, a thorough evaluation of the patient’s symptoms and medical history is necessary to determine the most likely diagnosis and appropriate treatment plan.

    • This question is part of the following fields:

      • Neurology
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  • Question 19 - A 50-year-old man comes in with weakness in his right upper limb. Upon...

    Incorrect

    • A 50-year-old man comes in with weakness in his right upper limb. Upon examination, there is weakness in the right triceps, brachioradialis, and extensor digitorum profundus. Sensation is normal. The right triceps jerk is absent, and there is some wasting of the dorsum of the forearm. What is the most probable location of the lesion?

      Your Answer: C7 radiculopathy

      Correct Answer: Right radial nerve

      Explanation:

      The radial nerve is responsible for supplying the back part of the upper limb and originates from the brachial plexus, carrying fibers from spinal nerves C5-8 and T1. It supplies the triceps, brachioradialis, and extensor digitorum profundus muscles, with the myotome of the triceps and extensor digitorum being C7 and that of the brachioradialis being C6. Both radial nerve palsy and C7 radiculopathy can result in an absent triceps jerk, and sensory loss in patients with radial nerve palsy is typically at the anatomical snuffbox, although sensation is usually normal. Trauma or entrapment, particularly between muscle heads, can damage the radial nerve, with the extent of muscle power loss depending on the lesion level. The brachioradialis muscle flexes the forearm at the elbow and tends to supinate when the forearm is pronated and pronate when the forearm is supinated. The extensor digitorum muscle extends the medial four digits of the hand. Brachial plexus injuries can cause weak triceps, wrist drop, and possibly median and ulnar nerve involvement. Radiculopathy is a mechanical compression of a nerve root, usually resulting in weakness of elbow flexion and wrist extension, decreased sensation in a dermatomal distribution, and pain in the neck, shoulder, and/or arm. The posterior interosseous nerve is a deep motor branch of the radial nerve that emerges above the elbow between the brachioradialis and brachialis muscles, and compression can result in finger drop, radial wrist deviation on extension, and proximal forearm pain.

    • This question is part of the following fields:

      • Neurology
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  • Question 20 - Which patient is NOT appropriate for urgent referral for suspected brain tumour from...

    Incorrect

    • Which patient is NOT appropriate for urgent referral for suspected brain tumour from the given list?

      Your Answer: A 23-year-old woman who has been previously fit and well complaining of severe headache, worse in the mornings and in certain postures

      Correct Answer: A 17-year-old girl complaining of recurrent episodes of flashing lights in one eye, nausea and headache

      Explanation:

      Differential Diagnosis of Neurological Symptoms

      When a patient presents with neurological symptoms, it is important to consider a range of possible diagnoses. In the case of a patient with migraine, the symptoms may include headache, nausea, and sensitivity to light and sound. However, if the symptoms are more severe or progressive, other conditions may need to be considered.

      One possible diagnosis is a brain tumour, which can cause symptoms of a space-occupying lesion and raised intracranial pressure. Another potential concern is central nervous system cancer, which should be assessed with an MRI or CT scan within two weeks of onset.

      Elderly patients with a first seizure may have underlying factors such as cerebrovascular disease, dementia, or tumours. Therefore, a thorough evaluation is necessary to determine the cause of the symptoms and develop an appropriate treatment plan.

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      • Neurology
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  • Question 21 - A 68-year-old man comes to the clinic for advice after suffering a transient...

    Incorrect

    • A 68-year-old man comes to the clinic for advice after suffering a transient ischaemic attack (TIA) in which he experiences a left hemiparesis. He is found to have a right carotid bruit, and carotid stenosis is suspected.
      What is the most appropriate advice you can provide this patient?

      Your Answer: Surgery should be delayed until he is stable on medical management

      Correct Answer: Surgery reduces the risk of stroke if he has severe carotid stenosis

      Explanation:

      Carotid Endarterectomy and Stenting for Severe Carotid Stenosis

      Carotid endarterectomy is a surgical procedure recommended by NICE for patients with moderate or severe carotid stenosis. It is most beneficial for those with severe stenosis, reducing the risk of stroke by up to 30% over three years. However, the presence of a carotid bruit alone is not enough to confirm or exclude significant stenosis or its severity.

      Carotid endarterectomy is indicated for patients with recent stroke or transient ischaemic attack, but surgery should be carried out within seven days of symptom onset for maximum benefit. While stenting with an emboli protection device may be as effective as endarterectomy, there may be a higher risk of stroke initially post-procedure.

      In addition to surgical intervention, the best medical management includes lowering blood pressure, treatment with statins, and antiplatelet therapy. It is important to start treatment as soon as possible to maximize the benefits of surgery.

    • This question is part of the following fields:

      • Neurology
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  • Question 22 - You assess a 65-year-old male patient who reports frequent episodes of tripping. During...

    Incorrect

    • You assess a 65-year-old male patient who reports frequent episodes of tripping. During your examination, you observe that he has a gait pattern characterized by high-stepping, where he excessively flexes his knees to ensure his feet clear the ground while walking. What is the probable reason for this clinical observation?

      Your Answer: Knee osteoarthritis

      Correct Answer: Peripheral neuropathy

      Explanation:

      When a person develops a high-stepping gait, it is often a compensatory mechanism for foot drop. If foot drop is found on only one side, it is likely that there is a lesion in the common peroneal nerve. However, if foot drop is present on both sides, it is more probable that the cause is peripheral neuropathy.

      Peripheral neuropathy is a condition that can be categorized based on whether it predominantly causes a motor or sensory loss. When the motor function is affected, conditions such as Guillain-Barre syndrome, porphyria, lead poisoning, hereditary sensorimotor neuropathies (HSMN) like Charcot-Marie-Tooth, chronic inflammatory demyelinating polyneuropathy (CIDP), and diphtheria may be the cause. On the other hand, when the sensory function is affected, conditions such as diabetes, uremia, leprosy, alcoholism, vitamin B12 deficiency, and amyloidosis may be the cause.

      Alcoholic neuropathy is a type of peripheral neuropathy that is caused by both direct toxic effects and reduced absorption of B vitamins. Typically, sensory symptoms present before motor symptoms. Vitamin B12 deficiency can lead to subacute combined degeneration of the spinal cord, where the dorsal column is usually affected first, causing joint position and vibration issues before distal paraesthesia. It is important to identify the underlying cause of peripheral neuropathy to provide appropriate treatment and management.

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      • Neurology
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  • Question 23 - A 22-year-old woman visits her General Practitioner with complaints of worsening headaches. She...

    Incorrect

    • A 22-year-old woman visits her General Practitioner with complaints of worsening headaches. She mentions experiencing blurred vision and that her headaches intensify when she bends forward. She is currently taking the combined oral contraceptive pill (COCP) as her only medication. During fundi examination, papilloedema is suspected. Her prolactin level is mildly elevated at 800 mU/l (normal range: < 400 mU/l). She is also obese. What is the most probable diagnosis?

      Your Answer: Microprolactinoma

      Correct Answer: Idiopathic intracranial hypertension (IIH)

      Explanation:

      Neurological Conditions: Causes, Symptoms, and Treatments

      Idiopathic Intracranial Hypertension (IIH)
      IIH is a condition that primarily affects obese young women. It is characterized by papilloedema, headaches, and visual disturbances. The use of combined oral contraceptive pills may worsen the condition. Lumbar puncture reveals elevated cerebrospinal fluid pressure, but there is no associated intracranial mass or ventricular enlargement. If left untreated, IIH can lead to irreversible optic neuropathy. Treatment options include serial lumbar punctures, prednisolone, thiazide diuretics, acetazolamide, weight loss, and surgical decompression or shunting.

      Microprolactinoma and Macroprolactinoma
      Microprolactinoma is a pituitary tumor that is less than 10 mm in size. It can cause amenorrhea, oligomenorrhea, and galactorrhea, accompanied by high prolactin levels. Macroprolactinoma, on the other hand, is larger than 10 mm and can cause headaches and visual field defects. Persistent high prolactin levels may indicate a pathological cause and require further investigation.

      Normal Pressure Hydrocephalus
      Normal pressure hydrocephalus is characterized by ventricular dilation without raised cerebrospinal fluid pressure. It mainly affects the elderly and is characterized by a triad of gait abnormality, urinary incontinence, and dementia. It may be caused by meningitis, head injury, subarachnoid hemorrhage, or a tumor. Normal pressure hydrocephalus is a potentially reversible cause of dementia.

      Superior Sagittal Sinus Thrombosis
      Thrombosis of the cerebral veins or venous sinuses can cause cerebral infarction or hemorrhage. Superior sagittal sinus thrombosis can cause headache, seizures, paralysis, visual disturbances, and neck stiffness. Symptoms are related to the area of thrombosis.

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      • Neurology
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  • Question 24 - A 25-year-old woman with vague symptoms is seen by 4 different GPs over...

    Incorrect

    • A 25-year-old woman with vague symptoms is seen by 4 different GPs over the course of 8 months and is finally diagnosed with multiple sclerosis following an MRI.

      A GP partner reviews her notes to see whether there were any early indicators of this diagnosis. Select ONE statement in her notes that in retrospect, is highly suggestive of multiple sclerosis.

      Your Answer: Unilateral throbbing headache

      Correct Answer: Relative afferent pupillary defect (RAPD) + Pale optic discs

      Explanation:

      Optic neuritis is frequently observed in individuals with multiple sclerosis, often as an initial symptom.

      Migraines are typically associated with unilateral throbbing headaches, while photophobia is a common symptom of both migraines and meningitis.

      Hair loss and sweating are nonspecific symptoms and do not necessarily indicate multiple sclerosis.

      Features of Multiple Sclerosis

      Multiple sclerosis (MS) is a condition that can present with nonspecific features, such as significant lethargy in around 75% of patients. Diagnosis is based on two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion with reasonable historical evidence of a previous relapse.

      MS can affect various parts of the body, leading to different symptoms. Visual symptoms include optic neuritis, optic atrophy, Uhthoff’s phenomenon, and internuclear ophthalmoplegia. Sensory symptoms may include pins and needles, numbness, trigeminal neuralgia, and Lhermitte’s syndrome. Motor symptoms may include spastic weakness, which is most commonly seen in the legs. Cerebellar symptoms may include ataxia and tremor. Other symptoms may include urinary incontinence, sexual dysfunction, and intellectual deterioration.

      It is important to note that MS symptoms can vary greatly between individuals and may change over time. Therefore, it is crucial for patients to work closely with their healthcare providers to manage their symptoms and receive appropriate treatment.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A 42-year-old woman presents with a headache lasting 45 minutes associated with lacrimation...

    Incorrect

    • A 42-year-old woman presents with a headache lasting 45 minutes associated with lacrimation and nasal stuffiness. A similar headache the previous day lasted for 60 minutes.
      Which of the following is the most likely diagnosis?

      Your Answer: Acute glaucoma

      Correct Answer: Cluster headache

      Explanation:

      Differentiating Headache Types: Symptoms and Characteristics

      Cluster Headache
      Cluster headaches are characterized by rapid onset of pain around one eye, accompanied by lacrimation, rhinorrhea, eyelid swelling, ptosis, myosis, facial sweating, and flushing. Attacks are unilateral and occur two to three times in a 24-hour period, lasting from 15 to 180 minutes untreated. Sufferers are restless during attacks, and treatment involves 100% oxygen and/or sumatriptan.

      Intracranial Tumour
      The chronic headache of an intracranial tumour or any other cause of raised intracranial pressure is usually worse in the morning, present on waking, and worse when lying down. The headache of raised intracranial pressure is not usually severe.

      Acute Glaucoma
      Acute glaucoma presents with a decrease in visual acuity, nausea, and a dull ache around the affected eye.

      Maxillary Sinusitis
      Maxillary sinusitis presents as constant dull pain over the maxillary sinus, worse on bending over, and may last up to two weeks.

      Trigeminal Neuralgia
      Trigeminal neuralgia presents with intense stabbing pain, usually lasting only a few seconds. Pain occurs in the distribution of the trigeminal nerve and is often precipitated by contact with the skin over the affected area. Pain is unilateral.

      Understanding the Characteristics of Different Headache Types

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      • Neurology
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  • Question 26 - A 35-year-old truck driver has recently been diagnosed with epilepsy and started on...

    Incorrect

    • A 35-year-old truck driver has recently been diagnosed with epilepsy and started on sodium valproate. What guidance should be given regarding his group 2 license?

      Your Answer: He cannot drive until he is fit-free for 1 year without medication

      Correct Answer: He cannot drive until he is fit-free for 10 years without medication

      Explanation:

      Individuals who possess a group 2 license and have epilepsy are only permitted to operate a vehicle after a period of 10 years without experiencing seizures while not taking medication. This is a more stringent requirement compared to group 1 license holders. If a group 2 license holder is diagnosed with epilepsy, it is advised that they refrain from driving, even if their condition is under control with medication. Only after a decade of being seizure-free without medication can they undergo a reassessment to determine their eligibility to drive.

      The DVLA has guidelines for individuals with neurological disorders who wish to drive cars or motorcycles. However, the rules for drivers of heavy goods vehicles are much stricter. For individuals with epilepsy or seizures, they must not drive and must inform the DVLA. If an individual has had a first unprovoked or isolated seizure, they must take six months off driving if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met, the time off driving is increased to 12 months. Individuals with established epilepsy or those with multiple unprovoked seizures may qualify for a driving license if they have been free from any seizure for 12 months. If there have been no seizures for five years (with medication if necessary), a ’til 70 license is usually restored. Individuals should not drive while anti-epilepsy medication is being withdrawn and for six months after the last dose.

      For individuals with syncope, a simple faint has no restriction on driving. A single episode that is explained and treated requires four weeks off driving. A single unexplained episode requires six months off driving, while two or more episodes require 12 months off. For individuals with other conditions such as stroke or TIA, they must take one month off driving. They may not need to inform the DVLA if there is no residual neurological deficit. If an individual has had multiple TIAs over a short period of time, they must take three months off driving and inform the DVLA. For individuals who have had a craniotomy, such as for meningioma, they must take one year off driving. If an individual has had a pituitary tumor, a craniotomy requires six months off driving, while trans-sphenoidal surgery allows driving when there is no debarring residual impairment likely to affect safe driving. Individuals with narcolepsy/cataplexy must cease driving on diagnosis but can restart once there is satisfactory control of symptoms. For individuals with chronic neurological disorders such as multiple sclerosis or motor neuron disease, they should inform the DVLA and complete the PK1 form (application for driving license holders’ state of health). If the tumor is a benign meningioma and there is no seizure history, the license can be reconsidered six months after surgery if the individual remains seizure-free.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 29-year-old woman began to stumble when walking. Her right leg was slightly...

    Incorrect

    • A 29-year-old woman began to stumble when walking. Her right leg was slightly stiff and weak, especially after exercise and hot showers. These symptoms developed over 3 days and gradually disappeared over 4 weeks. She was on the college swimming team before these symptoms arose. There, she developed a unique and extreme type of fatigue that was different from the usual fatigue she experienced when swimming. This disappeared after several weeks, but reappeared again 6 months before her current presentation.
      Select the single most likely diagnosis.

      Your Answer: Acute disseminated encephalomyelitis

      Correct Answer: Multiple sclerosis

      Explanation:

      Understanding Multiple Sclerosis and its Symptoms

      Multiple sclerosis (MS) is a condition that often presents with symptoms that worsen with exercise and heat, and profound fatigue. These symptoms are not consistent with chronic fatigue syndrome, as MS symptoms are separated by time and can vary in intensity. Acute disseminated encephalomyelitis, Guillain-Barre syndrome, and diabetic neuropathy tend to have symmetrical neurological impairment, which is not typical of MS.

      Fatigue is a common symptom experienced by about 70% of MS patients. It is different from regular tiredness or exhaustion and is often out of proportion to any activity performed. Primary fatigue is caused by MS itself, while secondary fatigue is caused by other factors that affect MS patients more than those without the condition, such as depression, pain, and sleep disturbance. Understanding the symptoms of MS can help patients manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Neurology
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  • Question 28 - A 26-year-old female who is obese visits her GP complaining of headaches and...

    Correct

    • A 26-year-old female who is obese visits her GP complaining of headaches and blurred vision. Upon examination, the GP notes bilateral blurring of the optic discs but no other neurological signs. The patient's blood pressure is 130/74 and she has no fever. What is the probable underlying diagnosis?

      Your Answer: Idiopathic intracranial hypertension

      Explanation:

      When presented with a young female who is obese and experiencing headaches and blurred vision, it is important to consider idiopathic intracranial hypertension as a potential diagnosis, especially if there is evidence of papilloedema but no other neurological abnormalities.

      Understanding Idiopathic Intracranial Hypertension

      Idiopathic intracranial hypertension, also known as pseudotumour cerebri, is a medical condition that is commonly observed in young, overweight females. The condition is characterized by a range of symptoms, including headache, blurred vision, and papilloedema, which is usually present. Other symptoms may include an enlarged blind spot and sixth nerve palsy.

      There are several risk factors associated with idiopathic intracranial hypertension, including obesity, female sex, pregnancy, and certain drugs such as the combined oral contraceptive pill, steroids, tetracyclines, vitamin A, and lithium.

      Management of idiopathic intracranial hypertension may involve weight loss, diuretics such as acetazolamide, and topiramate, which can also cause weight loss in most patients. Repeated lumbar puncture may also be necessary, and surgery may be required to prevent damage to the optic nerve. This may involve optic nerve sheath decompression and fenestration, or a lumboperitoneal or ventriculoperitoneal shunt to reduce intracranial pressure.

      It is important to note that if intracranial hypertension is thought to occur secondary to a known cause, such as medication, it is not considered idiopathic. Understanding the risk factors and symptoms associated with idiopathic intracranial hypertension can help individuals seek appropriate medical attention and management.

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      • Neurology
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  • Question 29 - A 68-year-old man presents to his General Practitioner as the previous night he...

    Incorrect

    • A 68-year-old man presents to his General Practitioner as the previous night he experienced sudden onset of numbness and weakness of the right arm and leg. The symptoms fully resolved after approximately eight hours. Since the last episode, he has had no further symptoms and is usually well. Neurological examination is normal and his blood pressure is 158/92 mmHg. It is found that he has atrial fibrillation with a heart rate of 96 bpm.
      What is the single most appropriate management?

      Your Answer: Refer the patient immediately for specialist assessment within seven days

      Correct Answer: Administer aspirin 300 mg immediately

      Explanation:

      Importance of Immediate Actions for Suspected TIA Patients

      When a patient presents with symptoms of a suspected transient ischaemic attack (TIA), immediate actions are crucial to reduce the risk of stroke. The National Institute for Health and Care Excellence (NICE) guidelines recommend administering aspirin 300 mg immediately, even in cases of unconfirmed TIA. Referral for specialist assessment should also be made immediately, with the patient seen within 24 hours. The ABCD2 score is no longer recommended for risk stratification, as all suspected cases of TIA should be regarded as potentially high risk of stroke. While antihypertensives may be necessary, initiating aspirin is a higher priority. Additionally, patients should be advised not to drive for at least one month after a TIA. Taking these immediate actions can greatly improve outcomes for patients with suspected TIA.

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      • Neurology
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  • Question 30 - A 32-year-old woman comes to her general practice clinic to discuss contraception. Her...

    Incorrect

    • A 32-year-old woman comes to her general practice clinic to discuss contraception. Her father recently had a stroke, and she is worried about the risk of stroke associated with hormonal contraception. She has a history of migraine with aura, but she hasn't had one in almost ten years. She currently smokes 15 cigarettes per day.

      Upon examination, her blood pressure is 110/70 mmHg, and her body mass index is 23 kg/m2.

      What is the most appropriate advice you can give to this patient?

      Your Answer:

      Correct Answer: Combined oral contraceptive pill (COCP) use is contraindicated when there is a history of migraine with aura

      Explanation:

      The Relationship Between Contraceptive Pills, Migraine, and Stroke Risk

      Migraine with aura is a significant risk factor for stroke, and the use of combined oral contraceptive pills (COCPs) can further increase this risk. Smoking also triples the risk of stroke, and the triple combination of migraine, COCP use, and smoking can quadruple the risk. Therefore, COCP use is contraindicated for those with a history of migraine with aura. Additionally, COCPs themselves increase the risk of stroke, so other risk factors such as smoking and arterial risk factors must be taken into account before prescribing them. On the other hand, there is no significant increase in stroke risk for smokers alone. However, for those over 35 who smoke more than 15 cigarettes per day, COCP use is also contraindicated. Women under 45 with migraine, especially with aura, have a statistically significant relationship with ischemic stroke. Finally, it is important to note that progesterone-only contraceptive pills (POPs) do not increase the risk of stroke and may be a better option for those with arterial risk factors.

    • This question is part of the following fields:

      • Neurology
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Neurology (10/29) 34%
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