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Question 1
Incorrect
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You have been requested to visit a 42-year-old woman who has a medical history of multiple sclerosis and is experiencing painful spasticity in both arms. Despite trying various medications such as baclofen, gabapentin, and amitriptyline, none have been successful in managing her symptoms. Recently, it has been suggested by the multiple sclerosis society that cannabis extract spray can effectively treat spasticity and pain. The patient is interested in starting this treatment.
What is the best course of action for managing this patient's symptoms?Your Answer: Initiate a 4-week trial as there is a clear indication for this treatment
Correct Answer: Discuss with the neurologist as you are unable to prescribe this as a GP
Explanation:To prescribe unlicensed cannabis-based products, doctors must be on the General Medical Council Specialist Register and should only do so for disorders within their specialty with clear evidence or published guidelines. As a GP, you are unable to prescribe this for spasticity in multiple sclerosis. It is recommended to discuss with a neurology consultant who would be an appropriate doctor to prescribe this.
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.
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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 70-year-old man presents to the General Practitioner with a left hemiparesis. What sign would indicate that he is more likely to have an ischaemic stroke rather than a haemorrhagic stroke?
Your Answer: Carotid bruit
Explanation:Distinguishing Ischaemic from Haemorrhagic Stroke: The Role of Symptoms and Neuroimaging
Symptoms alone are not enough to differentiate between ischaemic and haemorrhagic stroke. Neuroimaging is necessary for a definitive diagnosis. However, a meta-analysis has shown that the presence of certain incorrect options can increase the likelihood of haemorrhagic stroke. Coma is also more commonly associated with haemorrhagic stroke. Conversely, the probability of haemorrhage is decreased by the presence of cervical bruit and prior transient ischaemic attack. Therefore, a combination of symptoms and neuroimaging is crucial in accurately distinguishing between ischaemic and haemorrhagic stroke.
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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 62-year-old woman presents with complaints of recurrent episodes of dizziness. She has been previously healthy. She reports experiencing repeated episodes of the room spinning around her in a horizontal plane, which occur multiple times a day. Each episode lasts for approximately 10 seconds and seems to happen when she turns in bed, lies down, or sits up from a supine position. There are no other accompanying symptoms, and she is not taking any medication. A standard neurological examination reveals no abnormalities. What is the most likely diagnosis?
Your Answer: Benign positional paroxysmal vertigo
Explanation:Differential Diagnosis for Benign Positional Paroxysmal Vertigo
Benign positional paroxysmal vertigo (BPPV) is a disorder characterized by short episodes of vertigo that are specifically positional in nature. The cause of BPPV is inner ear dysfunction, where otoliths become detached from the maculae and enter the semicircular canals. The diagnosis of BPPV can be confirmed through a Dix-Hallpike test, which involves observing the patient’s eyes for nystagmus after a quick change in head position.
Other potential causes of vertigo were considered and ruled out in this case. Labyrinthitis, which typically presents with hearing changes and nausea/vomiting, was deemed unlikely. Migraine, which can cause vertigo but is usually accompanied by headaches, was also ruled out. Posterior circulation stroke was considered but deemed unlikely due to a normal neurological examination. Postural hypotension was also ruled out as the patient experienced difficulties with turning in bed and lying down as well as standing up.
Overall, the differential diagnosis for BPPV involves ruling out other potential causes of vertigo through a thorough examination and consideration of the patient’s symptoms.
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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 65-year-old woman complains of tingling in her right hand that sometimes disturbs her sleep at night. She usually shakes her hand to alleviate the symptoms, which disappear entirely. She has a history of uncontrolled type 2 diabetes and breast cancer.
During the examination, there is no evidence of deformity or wasting, and she has good strength throughout her hand. The symptoms are reproduced by performing forced wrist flexion.
What is the best initial course of action?Your Answer: Wrist splinting
Explanation:For patients with mild-moderate symptoms of carpal tunnel syndrome, conservative treatment with a wrist splint, with or without a steroid injection, should be attempted first. In this case, the woman’s symptoms suggest carpal tunnel syndrome and therefore, first-line management should involve conservative treatment before symptoms worsen. While amitriptyline may be useful for neuropathic pain, it is not the appropriate treatment in this case. Paracetamol and topical NSAIDs may be suitable for osteoarthritis involving the hands, but this presentation doesn’t suggest osteoarthritis. Surgical decompression may be necessary if symptoms worsen, but it is not the first-line treatment for mild-moderate symptoms. While a steroid injection may be appropriate when used in conjunction with wrist splinting, it is not typically the first-line treatment.
Carpal tunnel syndrome is a condition that occurs when the median nerve in the carpal tunnel is compressed. This can cause pain and pins and needles sensations in the thumb, index, and middle fingers. In some cases, the symptoms may even travel up the arm. Patients may shake their hand to alleviate the discomfort, especially at night. During an examination, weakness in thumb abduction and wasting of the thenar eminence may be observed. Tapping on the affected area may also cause paraesthesia, and flexing the wrist can trigger symptoms.
There are several potential causes of carpal tunnel syndrome, including idiopathic factors, pregnancy, oedema, lunate fractures, and rheumatoid arthritis. Electrophysiology tests may reveal prolongation of the action potential in both motor and sensory nerves. Treatment options may include a six-week trial of conservative measures such as wrist splints at night or corticosteroid injections. If symptoms persist or are severe, surgical decompression may be necessary, which involves dividing the flexor retinaculum.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 58-year-old woman comes to the clinic complaining of a 3-month history of progressive difficulty with speech and swallowing. During examination, she exhibits dysarthria and a brisk gag reflex. There is increased tone in all four limbs, with weakness distributed pyramidally. Sensation is normal.
What is the most probable diagnosis?Your Answer: Brainstem glioma
Correct Answer: Motor neurone disease
Explanation:Neurological Conditions: Types, Symptoms, and Characteristics
Motor neurone disease, also known as amyotrophic lateral sclerosis, is a degenerative condition that affects motor neurones, leading to increasing disability and death. It usually occurs after the age of 50 and has a focal onset, with a particular group of muscles affected first. Rare variants include primary lateral sclerosis and progressive muscular atrophy.
Brainstem gliomas are diagnosed in children and young adults under the age of twenty, with common symptoms including double vision, weakness, unsteady gait, difficulty in swallowing, dysarthria, headache, drowsiness, nausea, and vomiting. Physical examination commonly elicits long tract signs such as spasticity, hyperreflexia, and abnormal reflexes.
Cervical spondylotic myelopathy is a serious consequence of cervical intervertebral disc degeneration, with clinical signs and symptoms depending on which spinal cord level is affected and the extent of the pathology. There may be upper and lower motor neurone signs, sensory changes, and bladder and bowel involvement.
Guillain-Barré syndrome presents within 3 weeks of a respiratory or bowel infection, due to immune damage to the peripheral nervous system. Early symptoms include nerve root type pain and paraesthesia of the legs and feet, followed by proximal muscle weakness of the lower extremities progressing over hours to days. Tendon reflexes are lost but plantar responses remain normal.
Multiple sclerosis is characterized by symptomatic neurological episodes, motor, sensory, or autonomic, that occur months or years apart and affect different anatomical locations.
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This question is part of the following fields:
- Neurology
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Question 6
Correct
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You assess a 28-year-old female patient who reports experiencing frequent migranous headaches that occur only during her menstrual cycle. She has previously attempted propranolol prophylaxis but discontinued it due to adverse effects. Additionally, mefenamic acid and naproxen have not provided relief. Which preventative approach should be considered?
Your Answer: Zolmitriptan bd during menstruation
Explanation:Triptans can serve as a form of preventive treatment for menstrual migraines, known as mini-prophylaxis.
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.
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This question is part of the following fields:
- Neurology
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Question 7
Correct
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You assess a 75-year-old patient who presents with a tremor in their right hand. What are the common symptoms observed in Parkinson's disease?
Your Answer: Resting tremor + bradykinesia + rigidity
Explanation:Parkinson’s disease is a progressive neurodegenerative disorder that occurs due to the degeneration of dopaminergic neurons in the substantia nigra. This leads to a classic triad of symptoms, including bradykinesia, tremor, and rigidity, which are typically asymmetrical. The disease is more common in men and is usually diagnosed around the age of 65. Bradykinesia is characterized by a poverty of movement, shuffling steps, and difficulty initiating movement. Tremors are most noticeable at rest and typically occur in the thumb and index finger. Rigidity can be either lead pipe or cogwheel, and other features include mask-like facies, flexed posture, and drooling of saliva. Psychiatric features such as depression, dementia, and sleep disturbances may also occur. Diagnosis is usually clinical, but if there is difficulty differentiating between essential tremor and Parkinson’s disease, 123I‑FP‑CIT single photon emission computed tomography (SPECT) may be considered.
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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 25-year-old man comes to you with complaints of severe, stabbing pain in his right eye that has been occurring once a day for the past few weeks. The pain lasts for about 30 minutes and he is often seen pacing around and shouting during these episodes. His wife reports that his right eye appears red and he has clear nasal discharge during the episodes.
Based on the probable diagnosis, what advice would you give the patient to prevent future episodes?Your Answer: Opioid medications including codeine
Correct Answer: Alcohol
Explanation:Cluster headaches are often triggered by alcohol, and they typically affect individuals of a certain age and gender.
Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain is typically sharp and stabbing, and it occurs around one eye. Patients may experience redness, lacrimation, lid swelling, nasal stuffiness, and miosis and ptosis in some cases.
To manage cluster headaches, acute treatment options include 100% oxygen or subcutaneous triptan. Prophylaxis involves using verapamil as the drug of choice, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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A 63-year-old man comes in with atrophy of both the thenar and hypothenar eminences of his right hand, along with weakness of thumb abduction, thumb flexion, and finger abduction and adduction. He also reports sensory loss to pinprick over the ulnar border of the hand and forearm. The rest of his neurological exam is unremarkable.
What is the most probable location of the lesion?Your Answer: Median nerve at the wrist
Correct Answer: Lower trunk of the brachial plexus
Explanation:Nerve Supply to the Hand Muscles: An Overview
The muscles of the hand are supplied by different nerves, and lesions to specific nerves can cause distinct symptoms. The thenar eminence, which includes the abductor pollicis, flexor pollicis brevis, and opponens pollicis muscles, is supplied by the median nerve, except for the adductor pollicis, which is supplied by the ulnar nerve. On the other hand, the hypothenar eminence, which includes the abductor, flexor, and opponens digiti minimi muscles, as well as the palmaris brevis, is supplied by the ulnar nerve. The first two lumbrical muscles are supplied by the median nerve.
It is important to note that lesions to the ulnar, median, or anterior interosseous nerve alone cannot cause all the symptoms associated with hand muscle weakness or paralysis. A T1 root lesion, for instance, would primarily affect the intrinsic muscles of the hand, especially the abductor pollicis brevis, and other signs would usually be present, such as Horner syndrome.
In some cases, damage to the lower trunk of the brachial plexus, which can occur due to traction on the arm in an abducted position, can produce combined C8/T1 lesions that mimic a combined median and ulnar nerve lesion in the hand. Understanding the nerve supply to the hand muscles is crucial for accurate diagnosis and treatment of hand muscle disorders.
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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 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: Spinal muscular atrophy
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.
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This question is part of the following fields:
- Neurology
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Question 11
Correct
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A 60-year-old woman visits her General Practitioner with a complaint of proximal upper limb pain that has been bothering her for 6 months. She reports experiencing headaches on the right side and suddenly experiences visual blurring on the right side. Upon examination, her right optic disk is found to be swollen. What is the most probable diagnosis?
Your Answer: Giant cell arteritis (GCA)
Explanation:Differential Diagnosis for Headache with Visual Disturbances
Giant cell arteritis (GCA), carotid artery dissection (CAD), cluster headache, idiopathic intracranial hypertension (IIH), and ophthalmoplegic migraine are all potential causes of headache with visual disturbances. GCA is a systemic vasculitis that primarily affects the aorta and its extracranial branches, presenting with headache, scalp tenderness, jaw claudication, visual disturbances, and fatigue. CAD, which often occurs in the internal carotid artery, can cause headaches and neck and facial pain on the same side as the dissection, followed by signs of stroke. Cluster headaches are characterised by severe, unilateral pain around the eyes, accompanied by ipsilateral autonomic features. IIH, which typically affects obese young women, is characterised by papilloedema, headaches, and visual disturbances, but no associated intracranial mass or ventricular enlargement. Ophthalmoplegic migraine is a rare condition characterised by transient migraine-like headaches accompanied by long-lasting oculomotor, abducens, or trochlear neuropathy with diplopia. Pupillary abnormalities and ptosis may occur if the oculomotor nerve is involved.
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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 61-year-old man presented to his GP with wasting and weakness of the muscles in his left hand.
He had noticed severely impaired hand grip and had noticed problems with writing. He had also developed a tingling sensation over the palm of his hand extending up the forearm.
On examination he appeared alert and orientated. Fundoscopy and cranial nerve examination were all normal and neck movements were full.
On examination of the upper limb, there was significant wasting over the left thenar eminence and fasciculations with a small burn over the left thumb. No other fasciculations could be detected in the proximal limb or other hand. Tone appeared normal and reflexes were intact. There was weakness of thumb abduction and opposition, with loss of pinprick and light touch sensation over the thumb, index and middle finger.
On examination of the lower limb, no abnormalities could be found.
Given the above history and clinical findings, what is the most likely diagnosis?Your Answer: Syringomyelia
Correct Answer: Ulnar nerve palsy
Explanation:Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a condition that occurs when there is pressure on the median nerve in the carpal tunnel. This can result in severe wasting of the muscles in the thenar eminence, abductor pollicis, flexor pollicis brevis, and opponens pollicis, as well as the lateral two lumbricals. Nerve conduction studies can confirm denervation and absent sensory potentials within the median nerve territory.
It is important to note that CTS is not indicative of motor neurone disease, which presents with a combination of upper and lower motor neurone abnormalities without sensory disturbance. Syringomyelia within the cervical cord would cause lower motor neurone signs at the level of the syrinx, with dissociated pain and temperature loss and upper motor neurone signs in the legs. Thoracic inlet syndrome affecting C8, T1 of the brachial plexus would cause additional weakness of hand muscles. An ulnar nerve palsy would cause weakness of small muscles of the hand with preserved thenar muscle function.
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This question is part of the following fields:
- Neurology
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Question 13
Incorrect
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A 72-year-old man presents to his General Practitioner with an episode of memory loss. He had become confused three days earlier while out shopping. His wife led him back to the house where he made himself a cup of tea and then wandered around the house. He appeared confused but remained conscious and able to have some conversation with his wife, though continued to ask similar questions repeatedly. After three hours, he abruptly returned to normal and had no recollection of the events.
What is the single most likely diagnosis?Your Answer: Chronic subdural haematoma
Correct Answer: Transient global amnesia
Explanation:The patient’s symptoms suggest transient global amnesia, which is most common in individuals over 65 years old. This condition causes temporary memory loss, but the patient retains their social skills and ability to perform learned tasks. Repetitive questioning is a common feature, and recovery typically occurs within 24 hours. However, patients are unable to recall the episode once they have recovered. Alcohol-related amnesia is another possibility, but the patient did not exhibit impaired cerebellar function. Chronic subdural haematoma can cause confusion and memory loss, but the patient lacked other symptoms. Complex partial status epilepticus and dissociative fugue state were also ruled out based on the patient’s presentation.
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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 10-year-old boy is reported to have brief staring spells (lasting seconds at a time) accompanied by a blank facial expression. He stops what he is doing during the attack and remains motionless. Several of these can occur during the day.
Which statement correctly describes this condition?Your Answer: Tonic-clonic seizures are uncommon
Correct Answer: Hyperventilation may precipitate an attack
Explanation:Childhood Absence Epilepsy: Diagnosis, Treatment, and Prognosis
Childhood absence epilepsy, also known as petit mal epilepsy, is a type of generalized epilepsy that typically begins between the ages of four and seven. While the seizures associated with this condition are not usually life-threatening, they can have a significant impact on a child’s education, development, and behavior.
Diagnosis of childhood absence epilepsy is typically made through a combination of clinical history and electroencephalogram (EEG) testing. Hyperventilation can be used to trigger an absence seizure, which is characteristic of this type of epilepsy. Neuroimaging is not typically necessary unless there is a suspicion of structural abnormalities.
Treatment for childhood absence epilepsy typically involves medication, with sodium valproate, ethosuximide, and lamotrigine being the drugs of choice. In some cases, a combination of medications may be necessary to fully control seizures. The ketogenic diet may also be effective for some children.
The prognosis for childhood absence epilepsy is generally good, with 80% of patients responding well to medication. However, tonic-clonic seizures may develop in up to 40% of children with this condition, and persistence of seizures is more likely in these cases. Despite the challenges associated with childhood absence epilepsy, educational attainment and behavior are typically not affected.
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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 36-year-old woman has been having occasional pins and needles in her right hand for the last month. During your neurological assessment, you try to elicit the triceps reflex by positioning her arm across her chest and tapping the triceps tendon with a reflex hammer. What nerve (and its corresponding nerve root) are you evaluating?
Your Answer: Radial nerve C6
Correct Answer: Radial nerve C7
Explanation:The triceps reflex arc is formed by the components of the radial nerve, which primarily derives from the C7 nerve root and innervates the triceps muscle. The triceps muscle, with its three heads of origin (long, lateral, and medial), is the chief extensor of the forearm and attaches to the olecranon of the ulna.
Upper limb anatomy is a common topic in examinations, and it is important to know certain facts about the nerves and muscles involved. The musculocutaneous nerve is responsible for elbow flexion and supination, and typically only injured as part of a brachial plexus injury. The axillary nerve controls shoulder abduction and can be damaged in cases of humeral neck fracture or dislocation, resulting in a flattened deltoid. The radial nerve is responsible for extension in the forearm, wrist, fingers, and thumb, and can be damaged in cases of humeral midshaft fracture, resulting in wrist drop. The median nerve controls the LOAF muscles and can be damaged in cases of carpal tunnel syndrome or elbow injury. The ulnar nerve controls wrist flexion and can be damaged in cases of medial epicondyle fracture, resulting in a claw hand. The long thoracic nerve controls the serratus anterior and can be damaged during sports or as a complication of mastectomy, resulting in a winged scapula. The brachial plexus can also be damaged, resulting in Erb-Duchenne palsy or Klumpke injury, which can cause the arm to hang by the side and be internally rotated or associated with Horner’s syndrome, respectively.
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This question is part of the following fields:
- Neurology
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Question 16
Correct
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You assess a 65-year-old patient with a history of chronic obstructive pulmonary disease and epilepsy. The patient's seizure control has deteriorated lately. Which of the following medications is most likely to exacerbate seizure control?
Your Answer: Aminophylline
Explanation:Medications to Avoid in Patients with Epilepsy
Prescribing medications to patients with epilepsy requires careful consideration as some drugs may worsen seizure control. Alcohol, cocaine, and amphetamines are known to have negative effects on seizure control. Antibiotics such as ciprofloxacin and levofloxacin, as well as aminophylline and theophylline, should also be avoided. Bupropion, methylphenidate (used in ADHD), and mefenamic acid are other medications that may worsen seizure control.
It is important to note that some medications, such as benzodiazepines, baclofen, and hydroxyzine, may provoke seizures during withdrawal. Additionally, certain medications may interfere with the metabolism of anti-epileptic drugs, which can worsen seizure control. These medications are known as P450 inducers/inhibitors.
Prescribers should carefully consider the potential risks and benefits of any medication before prescribing it to a patient with epilepsy. Close monitoring and communication with the patient’s healthcare team is essential to ensure optimal seizure control and overall health.
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This question is part of the following fields:
- Neurology
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Question 17
Incorrect
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Which of the following statements about discontinuing anti-epileptic drugs (AED) is the most accurate?
Your Answer: Can be considered if seizure free for > 5 years, with AEDs being stopped over 8-12 months
Correct Answer: Can be considered if seizure free for > 2 years, with AEDs being stopped over 2-3 months
Explanation:The 2004 NICE guidelines recommend that the process be carried out with the assistance of a specialist and that benzodiazepine withdrawal should be conducted over an extended period.
Treatment Options for Epilepsy
Epilepsy is a neurological disorder that affects millions of people worldwide. Treatment for epilepsy typically involves the use of antiepileptic drugs (AEDs) to control seizures. The decision to start AEDs is usually made after a second seizure, but there are certain circumstances where treatment may be initiated after the first seizure. These include the presence of a neurological deficit, structural abnormalities on brain imaging, unequivocal epileptic activity on EEG, or if the patient or their family considers the risk of having another seizure to be unacceptable.
It is important to note that there are specific drug treatments for different types of seizures. For generalized tonic-clonic seizures, males are typically prescribed sodium valproate, while females may be given lamotrigine or levetiracetam. For focal seizures, first-line treatment options include lamotrigine or levetiracetam, with carbamazepine, oxcarbazepine, or zonisamide used as second-line options. Ethosuximide is the first-line treatment for absence seizures, with sodium valproate or lamotrigine/levetiracetam used as second-line options. For myoclonic seizures, males are usually given sodium valproate, while females may be prescribed levetiracetam. Finally, for tonic or atonic seizures, males are typically given sodium valproate, while females may be prescribed lamotrigine.
It is important to work closely with a healthcare provider to determine the best treatment plan for each individual with epilepsy. Additionally, it is important to be aware of potential risks associated with certain AEDs, such as the use of sodium valproate during pregnancy, which has been linked to neurodevelopmental delays in children.
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This question is part of the following fields:
- Neurology
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Question 18
Correct
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What are the two components that the 'Personal Independence Payment' benefit is split into and assessed for a 59-year-old woman named Sarah who has relapsing-remitting multiple sclerosis and is applying for the benefit?
Your Answer: Daily living component and mobility component
Explanation:The Personal Independence Payment is a benefit for those aged 16 to 64 who have long-term ill health or disability that affects their daily living or mobility for at least 3 months and is expected to last for 9 months. The daily living component covers assistance with tasks such as eating, bathing, dressing, communication, medication management, and financial decision-making. The mobility component covers assistance with moving around and going out. There are standard and enhanced levels for each component based on the level of need. Terminally ill patients automatically receive the enhanced level of the daily living component.
Patients who suffer from chronic illnesses or cancer and require assistance with caring for themselves may be eligible for benefits. Those under the age of 65 can claim Personal Independence Payment (PIP), while those aged 65 and over can claim Attendance Allowance (AA). PIP is tax-free and divided into two components: daily living and mobility. Patients must have a long-term health condition or disability and have difficulties with activities related to daily living and/or mobility for at least 3 months, with an expectation that these difficulties will last for at least 9 months. AA is also tax-free and is for those who need help with personal care. Patients should have needed help for at least 6 months to claim AA.
Patients who have a terminal illness and are not expected to live for more than 6 months can be fast-tracked through the system for claiming incapacity benefit (IB), employment support allowance (ESA), DLA or AA. A DS1500 form is completed by a hospital or hospice consultant, which contains questions about the diagnosis, clinical features, treatment, and whether the patient is aware of the condition/prognosis. The form is given directly to the patient and a fee is payable by the Department for Works and Pensions (DWP) for its completion. This ensures that the application is dealt with promptly and that the patient automatically receives the higher rate.
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This question is part of the following fields:
- Neurology
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Question 19
Incorrect
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You see a 36-year-old male who has a past history of alcohol abuse. He is brought in by a friend because he has been more confused over the last few days.
On examination the patient has nystagmus, an abducens nerve palsy and walks with an ataxic gait.
What is the diagnosis?Your Answer: Wernicke's encephalopathy
Correct Answer: Transient ischaemic attack
Explanation:Neuropsychiatric Consequences of Heavy Alcohol Intake
Sustained heavy alcohol intake can lead to several neuropsychiatric consequences. One of these is Wernicke’s encephalopathy, which is characterized by confusion, ophthalmoplegia, and ataxia. However, the classic triad may not always be present, and patients may experience other symptoms such as headache, anorexia, vomiting, and confusion. This condition is caused by thiamine deficiency and requires prompt treatment with parenteral thiamine to prevent progression to Korsakoff’s syndrome.
Korsakoff’s syndrome is a progression from Wernicke’s encephalopathy. Patients with this condition develop memory problems but have good preservation of other cognitive functions. They are unable to consolidate new information and tend to confabulate rather than acknowledge their poor memory. Although treatment with thiamine is necessary, the response is often poor. Therefore, it is important to address alcohol intake and prevent the development of these debilitating conditions.
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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 55-year-old man presents to his general practice surgery as he has started experiencing diarrhoea, especially at night. He has also noticed that he feels dizzy when he stands up; he collapsed while standing at a bus stop a few days ago. On further questioning, he admits to having erectile problems for several years. He has chronic polyneuropathy.
On examination, his blood pressure is 160/88 mmHg when lying down and 136/60 mmHg when standing. He demonstrates signs of reduced knee jerks, absent ankle jerks and reduced pinprick and vibration sense to the knees. These are unchanged from his last examination six months ago.
What is the most likely underlying cause of this patient's symptoms?Your Answer: Charcot-Marie-Tooth (CMT) disease
Correct Answer: Diabetes mellitus
Explanation:The patient is experiencing symptoms of autonomic neuropathy, such as bowel issues, postural hypotension, and erectile dysfunction. The most common cause of this condition is diabetes mellitus, which can also lead to other types of neuropathy. Vitamin E deficiency can also cause peripheral neuropathy, but it is less likely in this case. Charcot-Marie-Tooth disease is an inherited peripheral neuropathy that typically presents in childhood or adolescence. Paraneoplastic neuropathy is a rare syndrome that accompanies malignant disease and would be an unusual pattern of peripheral neuropathy. Vitamin B12 deficiency can also cause peripheral neuropathy and should be checked in this case.
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This question is part of the following fields:
- Neurology
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Question 21
Correct
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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: 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.
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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 26-year-old man has scheduled an appointment at your clinic. He suffered a traumatic head injury in a car accident six months ago and has been recovering well. However, two months ago, he experienced a generalised tonic clonic seizure and was advised by a neurologist to seek further review if he had any more episodes.
Recently, he had another seizure at home and was taken to the emergency department. The on-call neurologist recommended starting levetiracetam and arranged an urgent clinic appointment in the coming weeks. He has been given a short supply of medication and would like to add it to his repeat prescriptions.
During the emergency department visit, he was told by the doctor that he should not drive, but he was not informed for how long. He holds an ordinary car licence and doesn't drive for work.
What advice should you provide to him?Your Answer:
Correct Answer: Must tell the DVLA and must not drive until 12 months seizure free
Explanation:The DVLA has a set of complex rules that drivers should be aware of, including those related to epilepsy. If an individual with epilepsy has experienced more than one seizure resulting in loss of consciousness while awake, they are not permitted to drive until they have been seizure-free for a year. It is crucial that this information is documented clearly.
If an individual has only experienced one generalized seizure, they are prohibited from driving for six months, and their license will only be reinstated at the discretion of the DVLA.
If a known epileptic has a seizure due to a reduction in their medication dosage, they may resume driving once they have been back on their previous dose for six months, provided they have not experienced any further seizures during that time.
There are specific regulations for partial seizures, nocturnal seizures, and those with bus, coach, or lorry licenses. For complete guidance, individuals should refer to the government’s website.
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.
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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 61-year-old man with no previous history of note complains of dribbling and a lopsided smile. On examination, he has lower motor neurone facial nerve palsy.
Select the single correct statement regarding his management.Your Answer:
Correct Answer: He should be prescribed high-dose prednisolone
Explanation:Facial Nerve Palsy: Causes, Treatment, and Prognosis
Facial nerve palsy, also known as Bell’s palsy, is a condition that affects the muscles of the face and can cause drooping, weakness, or paralysis. Lower motor neurone (LMN) facial nerve palsy is the most common type and has a good prognosis, with most cases resolving spontaneously within three weeks. While the cause is often unknown, it is believed to be related to a viral infection. Treatment with high-dose prednisolone has been shown to improve outcomes, with up to half of patients who do not spontaneously recover achieving full resolution with steroids.
Upper motor neurone palsies, on the other hand, are associated with preservation of frowning and should be urgently referred for imaging and possible thrombolysis if a stroke is suspected. In an upper motor neurone lesion, the upper facial muscles are partially spared, allowing the patient to wrinkle their forehead.
It is important to carefully examine the ear in cases of LMN palsy, as it may be a sign of zoster or middle ear infection (Ramsay-Hunt syndrome). In these cases, a combination of prednisolone and acyclovir is typically given.
Overall, while facial nerve palsy can be a concerning condition, the prognosis is generally good for LMN palsy and prompt treatment can improve outcomes.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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For the long-term secondary prevention of stroke, which antiplatelet drug regime is the most appropriate first choice according to current NICE guidelines?
Your Answer:
Correct Answer: Clopidogrel
Explanation:Secondary Prevention after Stroke or Transient Ischaemic Attack
According to the NICE Clinical Knowledge Summaries (2013), the first choice for antiplatelet therapy in secondary prevention after a stroke or transient ischaemic attack is clopidogrel at a daily dose of 75 mg. In cases where clopidogrel is contraindicated or not tolerated, modified-release dipyridamole at a dose of 200 mg twice a day can be used in combination with low dose aspirin. If both clopidogrel and modified-release dipyridamole are not suitable, aspirin alone can be used. And if both clopidogrel and aspirin are contraindicated or not tolerated, modified-release dipyridamole alone can be used. It is important to follow these guidelines to ensure effective secondary prevention after a stroke or transient ischaemic attack.
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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 65-year-old man presents with a 6-month history of personality changes, disinhibition and altered dietary habits with a preference for sweet foods. He lost his job as an accountant because of inappropriate social behaviour. There is no memory deficit. The neurological examination is normal.
Select the single most likely diagnosis.Your Answer:
Correct Answer: Frontotemporal dementia
Explanation:Understanding Frontotemporal Dementia (Pick’s Disease)
Frontotemporal dementia, also known as Pick’s disease, is a type of progressive dementia that primarily affects the frontal and/or temporal lobes of the brain. Unlike other dementias that affect the posterior parietal lobes, frontotemporal dementia is the fourth most common cause of dementia, following Alzheimer’s disease, diffuse Lewy body disease, and vascular or non-neurodegenerative dementia. It typically occurs in individuals aged 55-65 and is characterized by insidious onset of behavioral and cognitive effects.
Early symptoms of frontotemporal dementia include psychiatric problems such as aggression, socially inappropriate behavior, and lack of concern or apathy. Depression may also occur early on, before memory loss. Speech and language problems are common, with difficulty in naming objects and grammatically incorrect speech. Memory problems are less severe in the early stages of the disease. Incontinence may also be an early feature, unlike in Alzheimer’s disease. Parkinsonism may develop but is not as prominent as in Lewy body disease.
On examination, patients with frontotemporal dementia may exhibit inappropriate behavior, echolalia, and echopraxia. Neurological examination may show primitive reflexes and akinesia with plastic rigidity. Visuospatial and visual orientation skills are relatively well preserved.
Full clinical diagnostic features of frontotemporal dementia can be found in the Scottish Intercollegiate Guidelines Network (SIGN) guidance, February 2006. It is important to differentiate frontotemporal dementia from other types of dementia, as the treatment and management strategies may differ.
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This question is part of the following fields:
- Neurology
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Question 26
Incorrect
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What is a common characteristic of pseudoseizures?
Your Answer:
Correct Answer: Incontinence
Explanation:Pseudoseizures: Understanding the Disorder
Pseudoseizure or dissociated non-epileptic attack disorder is a condition that primarily affects disturbed females, with a ratio of 8:1. This disorder is characterized by erratic movements, closed eyes, and resisted eye opening, which are not typical features of epilepsy. However, lateral tongue bite and incontinence may occur, which are common in epilepsy. Patients with pseudoseizures often resist and fight any intervention.
Individuals with pseudoseizures often have a history of abuse or previous illness behavior. These attacks frequently occur in doctors’ surgeries and out-patient departments, and they usually happen in the presence of others. Previous illness behavior is also common in individuals with pseudoseizures.
In summary, pseudoseizures are a disorder that can be challenging to diagnose and treat. Understanding the symptoms and characteristics of this disorder is crucial in providing appropriate care and support to individuals affected by it.
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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 patient in their 60s with Parkinson's disease presents with cognitive symptoms and is diagnosed with mild Parkinson's-related dementia. Is there a licensed medication available to treat their cognitive impairment?
Your Answer:
Correct Answer: Rivastigmine
Explanation:Rivastigmine is the only acetylcholinesterase inhibitor approved for treating mild to moderate Parkinson’s related dementia, while none of the three (donepezil, rivastigmine, and galantamine) are licensed for use in vascular dementia. However, all three are commonly used to alleviate cognitive symptoms in mild to moderate Alzheimer’s dementia.
Understanding the Mechanism of Action of Parkinson’s Drugs
Parkinson’s disease is a complex condition that requires specialized management. The first-line treatment for motor symptoms that affect a patient’s quality of life is levodopa, while dopamine agonists, levodopa, or monoamine oxidase B (MAO-B) inhibitors are recommended for those whose motor symptoms do not affect their quality of life. However, all drugs used to treat Parkinson’s can cause a wide variety of side effects, and it is important to be aware of these when making treatment decisions.
Levodopa is nearly always combined with a decarboxylase inhibitor to prevent the peripheral metabolism of levodopa to dopamine outside of the brain and reduce side effects. Dopamine receptor agonists, such as bromocriptine, ropinirole, cabergoline, and apomorphine, are more likely than levodopa to cause hallucinations in older patients. MAO-B inhibitors, such as selegiline, inhibit the breakdown of dopamine secreted by the dopaminergic neurons. Amantadine’s mechanism is not fully understood, but it probably increases dopamine release and inhibits its uptake at dopaminergic synapses. COMT inhibitors, such as entacapone and tolcapone, are used in conjunction with levodopa in patients with established PD. Antimuscarinics, such as procyclidine, benzotropine, and trihexyphenidyl (benzhexol), block cholinergic receptors and are now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson’s disease.
It is important to note that all drugs used to treat Parkinson’s can cause adverse effects, and clinicians must be aware of these when making treatment decisions. Patients should also be warned about the potential for dopamine receptor agonists to cause impulse control disorders and excessive daytime somnolence. Understanding the mechanism of action of Parkinson’s drugs is crucial in managing the condition effectively.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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A 32-year-old woman presents to her General Practitioner complaining that her vision has become blurred in her right eye over the course of a few days. She has been rubbing the eye a lot, and now she also mentions that there is a dull ache in the eye. She has previously been fit and well. Her only medication is the oral contraceptive pill, which she has been taking for eight years.
What is the most likely diagnosis?
Your Answer:
Correct Answer: Demyelinating optic neuritis
Explanation:Differential Diagnosis for Subacute Onset of Unilateral Blurred Vision with Aching
When presented with a patient experiencing subacute onset of unilateral blurred vision with aching, there are several potential diagnoses to consider. Demyelinating optic neuritis is a likely cause, as it can cause reduced acuity, central scotoma, impaired color appreciation, and a relative afferent pupillary defect. Glaucoma may also be a possibility, but it typically presents with halos around bright lights and may affect both eyes in the case of open-angle glaucoma. Ischaemic optic neuritis and occipital lobe infarction are less likely causes, as they would have a more rapid onset of symptoms. Optic nerve compression may also be a consideration, but it would likely be associated with a space-occupying lesion and a history of headaches. Overall, the presence of aching in the affected eye suggests demyelinating optic neuritis as the most likely diagnosis.
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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 35-year-old man presents to his General Practitioner with a headache over his left eye spreading across his forehead. During the headache, he has difficulty speaking. Three minutes later he has developed clumsiness in his right hand, and two minutes after that he describes his right leg as ‘feeling heavy’. His speech and limb symptoms have disappeared after 20 minutes, but his headache persists for six hours. He suffered from migraines as a teenager but has not had an attack in over 15 years. He smokes 25 cigarettes a day.
What is the most likely diagnosis?Your Answer:
Correct Answer: Migraine
Explanation:Understanding Neurological Symptoms: Differential Diagnosis
When presented with neurological symptoms, it is important to consider various differential diagnoses. In the case of transient symptoms accompanied by a prolonged headache history, migraine with aura is a likely possibility. The aura may be visual, sensory, motor, or a combination of these and typically lasts less than 60 minutes.
While a transient ischaemic attack (TIA) could explain the neurological symptoms, it is unlikely to account for the prolonged headache history. A berry aneurysm, on the other hand, would not cause transient symptoms and would more likely result in a sudden-onset severe headache if ruptured.
Cluster headaches, which are accompanied by autonomic symptoms on the same side of the head as the pain, are more common in smokers but would not explain the transient neurological symptoms.
Finally, a subarachnoid haemorrhage typically presents as a sudden-onset severe headache, which is not consistent with the rapid resolution of the neurological symptoms in this case.
In summary, understanding the differential diagnosis of neurological symptoms is crucial in determining the appropriate course of treatment.
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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 39-year-old man comes to the clinic complaining of a severe, intermittent, daily, left-sided frontotemporal/orbital headache that has been bothering him for the past 6 weeks. The headache seems to occur at the same time every day and lasts for about an hour. The pain makes him feel nauseous, although he has not vomited. Interestingly, he also reports that his right eye sometimes appears red and painful with increased lacrimation.
What is the best immediate treatment to administer?Your Answer:
Correct Answer: Oxygen (100%) + subcutaneous sumatriptan
Explanation:Cluster headaches are a type of headache that is known to be extremely painful. They are called cluster headaches because they tend to occur in clusters that last for several weeks, usually once a year. These headaches are more common in men and smokers, and alcohol and sleep patterns may trigger an attack. The pain is typically sharp and stabbing, and it occurs around one eye. Patients may experience redness, lacrimation, lid swelling, nasal stuffiness, and miosis and ptosis in some cases.
To manage cluster headaches, acute treatment options include 100% oxygen or subcutaneous triptan. Prophylaxis involves using verapamil as the drug of choice, and a tapering dose of prednisolone may also be effective. It is recommended to seek specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging. Some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania, and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Patients with these conditions should be referred for specialist assessment as specific treatment may be required, such as indomethacin for paroxysmal hemicrania.
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This question is part of the following fields:
- Neurology
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