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  • Question 1 - A 42-year-old man has been brought into the Emergency Department, experiencing seizures that...

    Correct

    • A 42-year-old man has been brought into the Emergency Department, experiencing seizures that have lasted for 40 minutes before his arrival. On arrival, he is still having a tonic-clonic seizure. He is a known epileptic and is currently taking lamotrigine for seizure prevention. He has received a single dose of rectal diazepam by the paramedics en route approximately 15 minutes ago. His vital signs are as follows: HR 92, BP 120/70, SaO2 98% on high flow oxygen, temperature is 36.8°C. His blood glucose level is 4.5 mmol/L, and he has an intravenous line in place.
      Which of the following medications would be most appropriate to administer next?

      Your Answer: Intravenous lorazepam

      Explanation:

      Status epilepticus is a condition characterized by continuous seizure activity lasting for 5 minutes or more without the return of consciousness, or recurrent seizures (2 or more) without a period of neurological recovery in between. In such cases, the next step in managing the patient would be to administer a second dose of benzodiazepine. Since the patient already has an intravenous line in place, this would be the most appropriate route to choose.

      The management of status epilepticus involves several general measures, which are outlined in the following table:

      1st stage (Early status, 0-10 minutes):
      – Secure the airway and provide resuscitation
      – Administer oxygen
      – Assess cardiorespiratory function
      – Establish intravenous access

      2nd stage (0-30 minutes):
      – Institute regular monitoring
      – Consider the possibility of non-epileptic status
      – Start emergency antiepileptic drug (AED) therapy
      – Perform emergency investigations
      – Administer glucose (50 ml of 50% solution) and/or intravenous thiamine as Pabrinex if there is any suggestion of alcohol abuse or impaired nutrition
      – Treat severe acidosis if present

      3rd stage (0-60 minutes):
      – Determine the underlying cause of status epilepticus
      – Alert the anaesthetist and intensive care unit (ITU)
      – Identify and treat any medical complications
      – Consider pressor therapy when appropriate

      4th stage (30-90 minutes):
      – Transfer the patient to the intensive care unit
      – Establish intensive care and EEG monitoring
      – Initiate intracranial pressure monitoring if necessary
      – Start initial long-term, maintenance AED therapy

      Emergency investigations for status epilepticus include blood tests for gases, glucose, renal and liver function, calcium and magnesium, full blood count (including platelets), blood clotting, and AED drug levels. Serum and urine samples should be saved for future analysis, including toxicology if the cause of the convulsive status epilepticus is uncertain. A chest radiograph may be performed to evaluate the possibility of aspiration. Additional investigations, such as brain imaging or lumbar puncture, depend on the clinical circumstances.

      Monitoring during the management of status epilepticus involves regular neurological observations and measurements of pulse, blood pressure, and temperature. ECG, biochemistry, blood gases, clotting, and blood count should also be monitored.

    • This question is part of the following fields:

      • Neurology
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  • Question 2 - A 72 year old male comes to the emergency department with complaints of...

    Incorrect

    • A 72 year old male comes to the emergency department with complaints of vertigo. What signs would indicate a central cause?

      Your Answer:

      Correct Answer: Negative head impulse test

      Explanation:

      A patient with central vertigo would typically show a normal head impulse test result, indicating a normal vestibulo-ocular reflex. However, they would likely have an abnormal alternate cover test result, with a slight vertical correction, suggesting a central lesion like a stroke. A positive Romberg’s test can identify instability related to vertigo but cannot differentiate between peripheral and central causes. On the other hand, a positive Unterberger’s test indicates labyrinth dysfunction but does not indicate a central cause.

      Further Reading:

      Vertigo is a symptom characterized by a false sensation of movement, such as spinning or rotation, in the absence of any actual physical movement. It is not a diagnosis itself, but rather a description of the sensation experienced by the individual. Dizziness, on the other hand, refers to a perception of disturbed or impaired spatial orientation without a false sense of motion.

      Vertigo can be classified as either peripheral or central. Peripheral vertigo is more common and is caused by problems in the inner ear that affect the labyrinth or vestibular nerve. Examples of peripheral vertigo include BPPV, vestibular neuritis, labyrinthitis, and Meniere’s disease. Central vertigo, on the other hand, is caused by pathology in the brain, such as in the brainstem or cerebellum. Examples of central vertigo include migraine, TIA and stroke, cerebellar tumor, acoustic neuroma, and multiple sclerosis.

      There are certain features that can help differentiate between peripheral and central vertigo. Peripheral vertigo is often associated with severe nausea and vomiting, hearing loss or tinnitus, and a positive head impulse test. Central vertigo may be characterized by prolonged and severe vertigo, new-onset headache, recent trauma, cardiovascular risk factors, inability to stand or walk with eyes open, focal neurological deficit, and a negative head impulse test.

      Nystagmus, an involuntary eye movement, can also provide clues about the underlying cause of vertigo. Central causes of vertigo often have nystagmus that is direction-changing on lateral gaze, purely vertical or torsional, not suppressed by visual fixation, non-fatigable, and commonly large amplitude. Peripheral causes of vertigo often have horizontal nystagmus with a torsional component that does not change direction with gaze, disappears with fixation of the gaze, and may have large amplitude early in the course of Meniere’s disease or vestibular neuritis.

      There are various causes of vertigo, including viral labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo, Meniere’s disease, vertebrobasilar ischemia, and acoustic neuroma. Each of these disorders has its own unique characteristics and may be associated with other symptoms such as hearing loss, tinnitus, or neurological deficits.

      When assessing a patient with vertigo, it is important to perform a cardiovascular and neurological examination, including assessing cranial nerves, cerebellar signs, eye movements, gait, coordination, and evidence of peripheral neuropathy.

    • This question is part of the following fields:

      • Neurology
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  • Question 3 - A 42-year-old woman comes in with a headache that feels like she has...

    Incorrect

    • A 42-year-old woman comes in with a headache that feels like she has been punched in the head. The headache throbs towards the back of the head and is accompanied by nausea. A CT scan of the head is performed, and it confirms a diagnosis of subarachnoid hemorrhage.
      In which of the following areas will blood have accumulated?

      Your Answer:

      Correct Answer: Between the arachnoid mater and pia mater

      Explanation:

      The meninges refer to the protective tissue layers that surround the brain and spinal cord. These layers, along with the cerebrospinal fluid (CSF), work together to safeguard the central nervous system structures from physical harm and provide support for the blood vessels in the brain and skull.

      The meninges consist of three distinct layers: the outermost layer called the dura mater, the middle layer known as the arachnoid mater, and the innermost layer called the pia mater.

      There are three types of hemorrhage that involve the meninges. The first is extradural (or epidural) hemorrhage, which occurs when blood accumulates between the dura mater and the skull. The second is subdural hemorrhage, where blood gathers between the dura mater and the arachnoid mater. Lastly, subarachnoid hemorrhage happens when blood collects in the subarachnoid space, which is the area between the arachnoid mater and the pia mater.

    • This question is part of the following fields:

      • Neurology
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  • Question 4 - A 35 year old female is brought into the emergency department after being...

    Incorrect

    • A 35 year old female is brought into the emergency department after being hit by a truck that had veered onto the sidewalk where the patient was standing. The patient has a significant bruise on the back of her head and seems lethargic.

      You are worried about increased intracranial pressure (ICP). Which of the following physical signs suggest elevated ICP?

      Your Answer:

      Correct Answer: Vomiting

      Explanation:

      Vomiting after a head injury should raise concerns about increased intracranial pressure (ICP). Signs of elevated ICP include vomiting, changes in pupil size or shape in one eye, decreased cognitive function or consciousness, abnormal findings during fundoscopy (such as blurry optic discs or bleeding in the retina), cranial nerve dysfunction (most commonly affecting CN III and VI), weakness on one side of the body (a late sign), bradycardia (slow heart rate), high blood pressure, and a wide pulse pressure. Irregular breathing that may progress to respiratory distress, focal neurological deficits, and seizures can also be indicative of elevated ICP.

      Further Reading:

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
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  • Question 5 - You are summoned to the resuscitation bay to aid in the care of...

    Incorrect

    • You are summoned to the resuscitation bay to aid in the care of a 45-year-old male who has suffered a traumatic brain injury. What should be included in the initial management of a patient with elevated intracranial pressure (ICP)?

      Your Answer:

      Correct Answer: Maintain systolic blood pressure >90 mmHg

      Explanation:

      Maintaining adequate blood pressure is crucial in managing increased intracranial pressure (ICP). The recommended blood pressure targets may vary depending on the source. The Scottish Intercollegiate Guidelines Network (SIGN) suggests maintaining an adequate blood pressure, while the 4th edition of the Brain Trauma Foundation recommends maintaining a systolic blood pressure (SBP) above 100 mm Hg for individuals aged 50-69 years (or above 110 mm Hg for those aged 15-49 years) to reduce mortality and improve outcomes.

      When managing a patient with increased ICP, the initial steps should include maintaining normal body temperature to prevent fever, positioning the patient with a 30º head-up tilt, and administering analgesia and sedation as needed. It is important to monitor and maintain blood pressure, using inotropes if necessary to achieve the target. Additionally, preparations should be made to use medications such as Mannitol or hypertonic saline to lower ICP if required. Hyperventilation may also be considered, although it carries the risk of inducing ischemia and requires monitoring of carbon dioxide levels.

      Further Reading:

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
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  • Question 6 - A 35 year old female is brought to the emergency department after experiencing...

    Incorrect

    • A 35 year old female is brought to the emergency department after experiencing a sudden and severe headache. CT scan confirms the presence of a subarachnoid hemorrhage. You are currently monitoring the patient for any signs of elevated intracranial pressure (ICP) while awaiting transfer to the neurosurgical unit. What is the typical ICP range for a supine adult?

      Your Answer:

      Correct Answer: 5–15 mmHg

      Explanation:

      The normal intracranial pressure (ICP) for an adult lying down is typically between 5 and 15 mmHg.

      Further Reading:

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
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  • Question 7 - You evaluate a 28-year-old woman who has been experiencing visual difficulties and had...

    Incorrect

    • You evaluate a 28-year-old woman who has been experiencing visual difficulties and had a period where her lower leg felt like 'pins and needles' for a few weeks approximately a year ago. Her sister was diagnosed with multiple sclerosis, and she is concerned about her own health. She has numerous inquiries and wants to know which factors indicate a less favorable prognosis.
      Which ONE factor would NOT be indicative of a positive outcome?

      Your Answer:

      Correct Answer: Older age at time of diagnosis

      Explanation:

      Multiple sclerosis is a condition characterized by the demyelination of nerve cells in the brain and spinal cord. It is an autoimmune disease caused by recurring inflammation, primarily affecting individuals in early adulthood. The condition is more prevalent in females, with a ratio of 3:2 compared to males.

      There are several risk factors associated with multiple sclerosis. These include being of Caucasian race, living at a greater distance from the equator (as the risk tends to increase further away), having a family history of the disease (with approximately 20% of patients having an affected relative), and smoking. Interestingly, the rates of relapse tend to decrease during pregnancy.

      Multiple sclerosis can present in three main patterns. The most common is relapsing and remitting MS, where individuals experience periods without symptoms followed by relapses. This accounts for 80% of cases at the time of diagnosis. Another pattern is primary progressive MS, where symptoms develop and worsen from the beginning with few remissions. This is seen in approximately 10-15% of cases at diagnosis. Lastly, there is secondary progressive MS, which occurs after a relapsing/remitting phase. In this pattern, symptoms worsen with fewer remissions, and it affects around 50% of individuals with relapsing/remitting MS within 10 years of diagnosis.

      Certain factors can indicate a more favorable prognosis for individuals with multiple sclerosis. These include having a relapsing/remitting course of the disease, being female, experiencing sensory symptoms, and having an early age at onset.

    • This question is part of the following fields:

      • Neurology
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  • Question 8 - A 55-year-old man presents with left-sided hemiplegia and loss of joint position sense,...

    Incorrect

    • A 55-year-old man presents with left-sided hemiplegia and loss of joint position sense, vibratory sense, and discriminatory touch. While examining his cranial nerves, you also note that his tongue is deviated to the right-hand side. CT and MRI head scans are undertaken, and he is discovered to have suffered a right-sided stroke. He is subsequently admitted under the stroke team.
      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Medial medullary syndrome

      Explanation:

      Occlusion of branches of the anterior spinal artery leads to the development of the medial medullary syndrome. This condition is characterized by several distinct symptoms. Firstly, there is contralateral hemiplegia, which occurs due to damage to the pyramidal tracts. Additionally, there is contralateral loss of joint position sense, vibratory sense, and discriminatory touch, resulting from damage to the medial lemniscus. Lastly, there is ipsilateral deviation and paralysis of the tongue, which is caused by damage to the hypoglossal nucleus.

    • This question is part of the following fields:

      • Neurology
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  • Question 9 - A 3-year-old boy is brought to the Emergency Department by his parents following...

    Incorrect

    • A 3-year-old boy is brought to the Emergency Department by his parents following a brief self-limiting seizure at home. He was diagnosed with an ear infection by his pediatrician yesterday and started on antibiotics. Despite this, he has been experiencing intermittent high fevers throughout the day. After a thorough evaluation, you determine that he has had a febrile convulsion.
      What is his estimated likelihood of experiencing another convulsion within the next 24 hours?

      Your Answer:

      Correct Answer: 10%

      Explanation:

      Febrile convulsions are harmless, generalized seizures that occur in otherwise healthy children who have a fever due to an infection outside the brain. To diagnose febrile convulsions, the child must be developing normally, the seizure should last less than 20 minutes, have no complex features, and not cause any lasting abnormalities.

      The prognosis for febrile convulsions is generally positive. There is a 30 to 50% chance of experiencing recurrent febrile convulsions, with a 10% risk of recurrence within the first 24 hours. The likelihood of developing long-term epilepsy is around 6%.

      Complex febrile convulsions are characterized by certain factors. These include focal seizures, seizures lasting longer than 15 minutes, experiencing more than one convulsion during a single fever episode, or the child being left with a focal neurological deficit.

      Overall, febrile convulsions are typically harmless and do not cause any lasting damage.

    • This question is part of the following fields:

      • Neurology
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  • Question 10 - A 62-year-old male patient comes in with a recent onset left-sided headache accompanied...

    Incorrect

    • A 62-year-old male patient comes in with a recent onset left-sided headache accompanied by feeling generally under the weather and decreased vision in his left eye. He mentioned that brushing his hair on the side of his headache has been painful. He has also been experiencing discomfort around his shoulder girdle for the past few weeks.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Temporal arteritis

      Explanation:

      This patient presents with a classic case of temporal arteritis, also known as giant cell arteritis (GCA). Temporal arteritis is a chronic condition characterized by inflammation in the walls of medium and large arteries, specifically granulomatous inflammation. It typically affects individuals who are over 50 years old.

      The clinical features of temporal arteritis include headache, tenderness in the scalp, jaw claudication, and episodes of sudden blindness or amaurosis fugax (usually occurring in one eye). Some patients may also experience systemic symptoms such as fever, fatigue, loss of appetite, weight loss, and depression.

      Temporal arteritis is often associated with polymyalgia rheumatica (PMR) in about 50% of cases. PMR is characterized by stiffness, aching, and tenderness in the upper arms (bilateral) and pain in the pelvic girdle.

      Visual loss is an early and significant complication of temporal arteritis, and once it occurs, it rarely improves. Therefore, early treatment with high-dose corticosteroids is crucial to prevent further visual loss and other ischemic complications. If temporal arteritis is suspected, immediate initiation of high-dose glucocorticosteroid treatment (40 – 60 mg prednisolone daily) is necessary. It is also important to arrange an urgent referral for specialist evaluation, including a same-day ophthalmology assessment for those with visual symptoms, and a temporal artery biopsy.

    • This question is part of the following fields:

      • Neurology
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  • Question 11 - A patient in their late 40s has sustained an injury to their right...

    Incorrect

    • A patient in their late 40s has sustained an injury to their right upper limb and is now experiencing peripheral neuropathy as a result. During the examination, it is observed that their hand is clawed, with the metacarpophalangeal joints hyperextended and the distal and proximal interphalangeal joints of the little and ring fingers flexed. Additionally, there is a slight weakness in wrist flexion, which is accompanied by abduction. The patient also reports sensory loss over the anterior and posterior surfaces of the medial one and a half fingers, as well as the corresponding area of the palm.

      Which nerve has been affected in this case?

      Your Answer:

      Correct Answer: Ulnar nerve at the elbow

      Explanation:

      The ulnar nerve originates from the medial cord of the brachial plexus, specifically from the C8-T1 nerve roots. It may also carry fibers from C7 on occasion. This nerve has both motor and sensory functions.

      In terms of motor function, the ulnar nerve innervates the muscles of the hand, excluding the thenar muscles and the lateral two lumbricals (which are supplied by the median nerve). It also innervates two muscles in the anterior forearm: the flexor carpi ulnaris and the medial half of the flexor digitorum profundus.

      Regarding sensory function, the ulnar nerve provides innervation to the anterior and posterior surfaces of the medial one and a half fingers, as well as the associated palm and dorsal hand area. There are three sensory branches responsible for the cutaneous innervation of the ulnar nerve. Two of these branches arise in the forearm and travel into the hand: the palmar cutaneous branch, which innervates the skin of the medial half of the palm, and the dorsal cutaneous branch, which innervates the dorsal skin of the medial one and a half fingers and the associated dorsal hand. The third branch arises in the hand and is called the superficial branch, which innervates the palmar surface of the medial one and a half fingers.

      When the ulnar nerve is damaged at the elbow, the flexor carpi ulnaris and the medial half of the flexor digitorum profundus muscles in the anterior forearm will be spared. However, if the ulnar nerve is injured at the wrist, these muscles will be affected. Additionally, when the ulnar nerve is damaged at the elbow, flexion of the wrist can still occur due to the intact median nerve, but it will be accompanied by abduction as the flexor carpi ulnaris adducts the hand. On the other hand, wrist flexion will be unaffected when the ulnar nerve is damaged at the wrist.

      The sensory function also differs depending on the site of damage. When the ulnar nerve is damaged at the elbow, all three cutaneous branches will be affected, resulting in complete sensory loss in the areas innervated by the ulnar nerve. However, if the damage occurs at the wrist, the two branches that arise in the forearm may be spared.

      Damage to the ulnar nerve at either the elbow or wrist leads to a characteristic claw hand appearance, characterized by hyperextension of the metacarpophalangeal joints and flexion of the distal and proximal interphalangeal joint of the little and ring fingers.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the...

    Incorrect

    • You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the ulnar nerve in his left arm.
      Which of the following muscles is MOST unlikely to be impacted in this individual?

      Your Answer:

      Correct Answer: Lateral two lumbricals

      Explanation:

      The ulnar nerve provides innervation to several muscles in the hand. These include the palmar interossei, dorsal interossei, medial two lumbricals, and the abductor digiti minimi. It is important to note that the lateral two lumbricals are not affected by an ulnar nerve lesion as they are innervated by the median nerve.

    • This question is part of the following fields:

      • Neurology
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  • Question 13 - A 6-year-old boy is brought to the Emergency Department by his parents following...

    Incorrect

    • A 6-year-old boy is brought to the Emergency Department by his parents following a brief self-limiting seizure at home. He was diagnosed with strep throat by his pediatrician yesterday and started on antibiotics. Despite this, he has been experiencing intermittent high fevers throughout the day. After a thorough evaluation, you determine that he has had a febrile seizure.
      What is his estimated risk of developing epilepsy in the long term?

      Your Answer:

      Correct Answer: 6%

      Explanation:

      Febrile convulsions are harmless, generalized seizures that occur in otherwise healthy children who have a fever due to an infection outside the brain. To diagnose febrile convulsions, the child must be developing normally, the seizure should last less than 20 minutes, have no complex features, and not cause any lasting abnormalities.

      The prognosis for febrile convulsions is generally positive. There is a 30 to 50% chance of experiencing recurrent febrile convulsions, with a 10% risk of recurrence within the first 24 hours. The likelihood of developing long-term epilepsy is around 6%.

      Complex febrile convulsions are characterized by certain factors. These include focal seizures, seizures lasting longer than 15 minutes, experiencing more than one convulsion during a single fever episode, or the child being left with a focal neurological deficit.

      Overall, febrile convulsions are typically harmless and do not cause any lasting damage.

    • This question is part of the following fields:

      • Neurology
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  • Question 14 - A 4-year-old boy has been brought into the Emergency Department having seizures that...

    Incorrect

    • A 4-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
      What dose of IV lorazepam is recommended for the treatment of the convulsing child?

      Your Answer:

      Correct Answer: 0.1 mg/kg

      Explanation:

      The recommended dosage of intravenous lorazepam for treating a child experiencing seizures is 0.1 mg per kilogram of body weight.

    • This question is part of the following fields:

      • Neurology
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  • Question 15 - A 70-year-old woman presents with right-sided hemiplegia and right-sided loss of joint position...

    Incorrect

    • A 70-year-old woman presents with right-sided hemiplegia and right-sided loss of joint position sense, vibratory sense and discriminatory touch. She also complains of blurred vision, and on further examination, you notice that she is unable to move her left eye outward and is tilting her head to the left side. A CT head scan is performed, and she is found to have experienced a left-sided stroke. She is subsequently admitted under the care of the stroke team.
      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Medial pontine syndrome

      Explanation:

      When the paramedian branches of the basilar artery are blocked, it leads to a condition known as medial pontine syndrome. This syndrome is characterized by several symptoms. Firstly, there is contralateral hemiplegia, which refers to paralysis on the opposite side of the body due to damage to the pyramidal tracts. Additionally, there is contralateral loss of joint position sense, vibratory sense, and discriminatory touch, which occurs as a result of damage to the medial lemniscus. Lastly, individuals with medial pontine syndrome may experience double vision caused by paralysis of the lateral rectus muscle, which is due to damage to the sixth cranial nerve.

    • This question is part of the following fields:

      • Neurology
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  • Question 16 - A 65-year-old woman presents with right-sided weakness and difficulty speaking. Her ROSIER score...

    Incorrect

    • A 65-year-old woman presents with right-sided weakness and difficulty speaking. Her ROSIER score is 3.
      According to the current NICE guidelines, what is the maximum time frame from the start of symptoms within which thrombolysis can be administered?

      Your Answer:

      Correct Answer: 4.5 hours

      Explanation:

      Alteplase (rt-pA) is a recommended treatment for acute ischaemic stroke in adults if it is initiated within 4.5 hours of the onset of stroke symptoms. It is crucial to exclude intracranial haemorrhage through appropriate imaging techniques before starting the treatment. The initial dose of alteplase is 0.9 mg/kg, with a maximum of 90 mg. This dose is administered intravenously over a period of 60 minutes. The first 10% of the dose is given through intravenous injection, while the remaining amount is administered through intravenous infusion. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals aged 16 and above.

    • This question is part of the following fields:

      • Neurology
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  • Question 17 - A 6-year-old boy has been brought into the Emergency Department having seizures that...

    Incorrect

    • A 6-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
      What dose of rectal diazepam is recommended for the treatment of the convulsing child?

      Your Answer:

      Correct Answer: 0.5 mg/kg

      Explanation:

      The recommended dose of rectal diazepam for treating a child experiencing convulsions is 0.5 mg per kilogram of body weight.

    • This question is part of the following fields:

      • Neurology
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  • Question 18 - A 65-year-old patient who was diagnosed with Parkinson's disease three years ago has...

    Incorrect

    • A 65-year-old patient who was diagnosed with Parkinson's disease three years ago has experienced a rapid deterioration in her overall functioning. She has been experiencing a progressive decline in her cognitive abilities, with severe memory impairment. Additionally, she has been experiencing prominent visual hallucinations and frequent fluctuations in her level of attention and alertness. Although her tremor is relatively mild, it is still present.
      What is the most probable diagnosis for this patient?

      Your Answer:

      Correct Answer: Dementia with Lewy Bodies

      Explanation:

      The Parkinson-plus syndromes are a group of neurodegenerative disorders that share similar features with Parkinson’s disease but also have additional clinical characteristics that set them apart from idiopathic Parkinson’s disease (iPD). These syndromes include Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP), Corticobasal degeneration (CBD), and Dementia with Lewy Bodies (DLB).

      Multiple System Atrophy (MSA) is a less common condition than iPD and PSP. It is characterized by the loss of cells in multiple areas of the nervous system. MSA progresses rapidly, often leading to wheelchair dependence within 3-4 years of diagnosis. Some distinguishing features of MSA include autonomic dysfunction, bladder control problems, erectile dysfunction, blood pressure changes, early-onset balance problems, neck or facial dystonia, and a high-pitched voice.

      To summarize the distinguishing features of the Parkinson-plus syndromes compared to iPD, the following table provides a comparison:

      iPD:
      – Symptom onset: One side of the body affected more than the other
      – Tremor: Typically starts at rest on one side of the body
      – Levodopa response: Excellent response
      – Mental changes: Depression
      – Balance/falls: Late in the disease
      – Common eye abnormalities: Dry eyes, trouble focusing

      MSA:
      – Symptom onset: Both sides equally affected
      – Tremor: Not common but may occur
      – Levodopa response: Minimal response (but often tried in early stages of disease)
      – Mental changes: Depression
      – Balance/falls: Within 1-3 years
      – Common eye abnormalities: Dry eyes, trouble focusing

      PSP:
      – Symptom onset: Both sides equally affected
      – Tremor: Less common, if present affects both sides
      – Levodopa response: Minimal response (but often tried in early stages of disease)
      – Mental changes: Personality changes, depression
      – Balance/falls: Within 1 year
      – Common eye abnormalities: Dry eyes, difficulty in looking downwards

      CBD:
      – Symptom onset: One side of the body affected more than the other
      – Tremor: Not common but may occur
      – Levodopa response: Minimal response (but often tried in early stages of disease)
      – Mental changes: Depression
      – Balance/falls: Within 1-3 years
      – Common eye abnormalities: Dry eyes, trouble focusing

    • This question is part of the following fields:

      • Neurology
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  • Question 19 - A 3-year-old child is brought in by ambulance to the resus area of...

    Incorrect

    • A 3-year-old child is brought in by ambulance to the resus area of your Emergency Department. They have been convulsing for the past 5 minutes. You have been unable to gain IV access and plan to administer a dose of buccal midazolam.
      What is the recommended dose of buccal midazolam for treating seizures in this child?

      Your Answer:

      Correct Answer: 0.5 mg/kg

      Explanation:

      The recommended dosage of buccal midazolam for treating a child experiencing seizures is 0.5 mg per kilogram of body weight.

    • This question is part of the following fields:

      • Neurology
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  • Question 20 - A 65-year-old woman comes in with right-sided weakness and difficulty speaking. Her ROSIER...

    Incorrect

    • A 65-year-old woman comes in with right-sided weakness and difficulty speaking. Her ROSIER score is 3. She weighs 60 kg.
      What is the appropriate dosage of alteplase to give?

      Your Answer:

      Correct Answer: 63mg

      Explanation:

      Alteplase (rt-pA) is recommended for the treatment of acute ischaemic stroke in adults if it is administered as soon as possible within 4.5 hours of the onset of stroke symptoms. It is important to exclude intracranial haemorrhage through appropriate imaging techniques before starting the treatment. The initial dose of alteplase is 0.9 mg/kg, with a maximum dose of 90 mg. This dose should be given intravenously over a period of 60 minutes. The first 10% of the dose should be administered through intravenous injection, while the remaining dose should be given through intravenous infusion. For a patient weighing 70 kg, the recommended dose would be 63 mg. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old.

    • This question is part of the following fields:

      • Neurology
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  • Question 21 - A child arrives at the Emergency Department with a petechial rash, headache, neck...

    Incorrect

    • A child arrives at the Emergency Department with a petechial rash, headache, neck stiffness, and sensitivity to light. You suspect a diagnosis of meningococcal meningitis. The child has a previous history of experiencing anaphylaxis in response to cephalosporin antibiotics.
      Which antibiotic would you administer to this child?

      Your Answer:

      Correct Answer: Chloramphenicol

      Explanation:

      Due to the potentially life-threatening nature of the disease, it is crucial to initiate treatment without waiting for laboratory confirmation. Immediate administration of antibiotics is necessary.

      In a hospital setting, the preferred agents for treatment are IV ceftriaxone (2 g for adults; 80 mg/kg for children) or IV cefotaxime (2 g for adults; 80 mg/kg for children). In the prehospital setting, IM benzylpenicillin can be given as an alternative. If there is a history of anaphylaxis to cephalosporins, chloramphenicol is a suitable alternative.

      It is important to prioritize prompt treatment due to the severity of the disease. The recommended antibiotics should be administered as soon as possible to ensure the best possible outcome for the patient.

    • This question is part of the following fields:

      • Neurology
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  • Question 22 - You evaluate a 38-year-old woman whose son was recently admitted to a Pediatric...

    Incorrect

    • You evaluate a 38-year-old woman whose son was recently admitted to a Pediatric Intensive Care Unit with meningococcal meningitis. She provided close care for her son before his admission and is worried about the potential of contracting the disease herself. She is currently 20 weeks pregnant.
      What is the MOST suitable option for chemoprophylaxis in her situation?

      Your Answer:

      Correct Answer: Ceftriaxone 250 mg IM

      Explanation:

      For individuals who have been in contact with patients diagnosed with Neisseria meningitidis meningitis, the recommended medication to prevent the infection is rifampicin 600 mg taken orally twice a day for two days. Alternatively, a single oral dose of ciprofloxacin 500 mg can also be administered. However, it is important to note that both rifampicin and ciprofloxacin should not be used during pregnancy and are contraindicated in such cases. Therefore, in situations involving pregnant individuals, the preferred option is a single 250 mg dose of ceftriaxone given intramuscularly.

    • This question is part of the following fields:

      • Neurology
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  • Question 23 - A 35-year-old man comes to the clinic complaining of a 3-day history of...

    Incorrect

    • A 35-year-old man comes to the clinic complaining of a 3-day history of increasing numbness and muscle weakness in his legs. The neurological symptoms seem to be spreading up his legs and now affecting his hands as well. He mentions that he had a severe bout of diarrhea two weeks ago, but has no other significant medical history.

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer:

      Correct Answer: Guillain-Barré syndrome

      Explanation:

      This patient’s medical history suggests a diagnosis of Guillain-Barré syndrome (GBS). GBS typically presents with initial symptoms of sensory changes or pain, accompanied by muscle weakness in the hands and/or feet. This weakness often spreads to the arms and upper body, affecting both sides. During the acute phase, GBS can be life-threatening, with around 15% of patients experiencing respiratory muscle weakness and requiring mechanical ventilation.

      The exact cause of GBS is unknown, but it is believed to involve an autoimmune response where the body’s immune system attacks the myelin sheath surrounding the peripheral nerves. In about 75% of cases, there is a preceding infection, commonly affecting the gastrointestinal or respiratory tracts.

      In this particular case, the most likely underlying cause is Campylobacter jejuni, a gastrointestinal pathogen. This is supported by the recent history of a severe diarrheal illness.

    • This question is part of the following fields:

      • Neurology
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  • Question 24 - A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her...

    Incorrect

    • A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her right limbs, difficulty with coordination in her right arm, and difficulty speaking.
      Which of the following blood vessels is most likely to be impacted?

      Your Answer:

      Correct Answer: Anterior cerebral artery

      Explanation:

      The symptoms and signs of strokes can vary depending on which blood vessel is affected. Here is a summary of the main symptoms based on the territory affected:

      Anterior cerebral artery: This can cause weakness on the opposite side of the body, with the leg and shoulder being more affected than the arm, hand, and face. There may also be minimal loss of sensation on the opposite side of the body. Other symptoms can include difficulty speaking (dysarthria), language problems (aphasia), apraxia (difficulty with limb movements), urinary incontinence, and changes in behavior and personality.

      Middle cerebral artery: This can lead to weakness on the opposite side of the body, with the face and arm being more affected than the leg. There may also be a loss of sensation on the opposite side of the body. Depending on the dominant hemisphere of the brain, there may be difficulties with expressive or receptive language (dysphasia). In the non-dominant hemisphere, there may be neglect of the opposite side of the body.

      Posterior cerebral artery: This can cause a loss of vision on the opposite side of both eyes (homonymous hemianopia). There may also be defects in a specific quadrant of the visual field. In some cases, there may be a syndrome affecting the thalamus on the opposite side of the body.

      It’s important to note that these are just general summaries and individual cases may vary. If you suspect a stroke, it’s crucial to seek immediate medical attention.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A 35-year-old woman is brought into the emergency department after being hit by...

    Incorrect

    • A 35-year-old woman is brought into the emergency department after being hit by a car while riding her bike. The patient was not wearing a helmet and suffered a head injury from hitting the pavement. She has a significant scalp contusion and appears drowsy. There is a suspicion of increased intracranial pressure. How does intracranial pressure affect cerebral perfusion pressure?

      Your Answer:

      Correct Answer: Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure (ICP)

      Explanation:

      Cerebral perfusion pressure (CPP) is calculated by adding the intracranial pressure (ICP) to the diastolic blood pressure (DBP).

      Further Reading:

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
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  • Question 26 - A 40-year-old man presents with a history of a headache, fever and increasing...

    Incorrect

    • A 40-year-old man presents with a history of a headache, fever and increasing fatigue. He has had a recent flu-like illness but deteriorated this morning. He has marked neck stiffness and sensitivity to light. On examination, you note a petechial rash on his abdomen.
      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Neisseria meningitidis group B

      Explanation:

      This woman is displaying symptoms and signs that are in line with a diagnosis of meningococcal septicaemia. In the United Kingdom, the majority of cases of meningococcal septicaemia are caused by Neisseria meningitidis group B.

      The implementation of a vaccination program for Neisseria meningitidis group C has significantly reduced the prevalence of this particular type. However, a vaccine for group B disease is currently undergoing clinical trials and is not yet accessible for widespread use.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - After managing a patient with frontotemporal dementia, your consultant believes that the foundation...

    Incorrect

    • After managing a patient with frontotemporal dementia, your consultant believes that the foundation doctors would benefit from additional education on the topic. They request you to prepare a teaching session for the junior doctors. Which of the following statements is accurate?

      Your Answer:

      Correct Answer: Personality change, speech disturbance and behavioural change are predominant features in frontotemporal dementia

      Explanation:

      In the UK, not all dementia cases are suitable for treatment with acetylcholinesterase inhibitors and memantine. Specifically, patients with frontotemporal dementia should not be prescribed these medications. If a patient experiences visual hallucinations, it may indicate that they have dementia with Lewy bodies.

      Further Reading:

      Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.

      To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.

      The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.

      There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.

      Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.

      Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.

      Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.

      In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.

    • This question is part of the following fields:

      • Neurology
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  • Question 28 - A 35-year-old woman has experienced a fracture of the left humerus. During examination,...

    Incorrect

    • A 35-year-old woman has experienced a fracture of the left humerus. During examination, it is found that she has weakness in extending her wrist and metacarpophalangeal joints, leading to wrist drop and an inability to grip with her left hand. However, she still has preserved extension of the elbow. Additionally, there is a loss of sensation over the dorsal aspect of the forearm from below the elbow to the 1st dorsal interosseous.
      Which nerve has been damaged in this particular case?

      Your Answer:

      Correct Answer: Radial nerve

      Explanation:

      Radial nerve injuries often occur in conjunction with fractures of the humerus. The most common cause of a radial nerve palsy is external compression or trauma to the radial nerve as it passes through the spiral groove in the middle of the humerus.

      There are several factors that can lead to damage of the radial nerve in the spiral groove. These include trauma, such as a fracture in the middle of the humerus, compression known as Saturday night palsy, and iatrogenic causes like injections.

      When the radial nerve is injured within the spiral groove, it results in weakness of the wrist and metacarpophalangeal joints. However, elbow extension is not affected because the branches to the triceps and anconeus muscles originate before the spiral groove. The interphalangeal joints remain unaffected as well, as they are supplied by the median and ulnar nerves. Sensory loss will be experienced over the dorsal aspect of the forearm, extending from below the elbow to the 1st dorsal interosseous.

      In contrast, injury to the radial nerve in the axilla will also cause weakness of elbow extension and sensory loss in the distribution of the more proximal cutaneous branches. This helps distinguish it from injury in the spiral groove.

      In the forearm, the posterior interosseous branch of the radial nerve can also be damaged. This can occur due to injury to the radial head or entrapment in the supinator muscle under the arcade of Frohse. However, this type of injury can be easily distinguished from injury in the spiral groove because there is no sensory involvement and no wrist drop, thanks to the preservation of the extensor carpi radialis longus. Nonetheless, there will still be weakness in the wrist and fingers.

    • This question is part of the following fields:

      • Neurology
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  • Question 29 - A 32-year-old woman presents with a diagnosis of cluster headache.
    Which SINGLE clinical feature...

    Incorrect

    • A 32-year-old woman presents with a diagnosis of cluster headache.
      Which SINGLE clinical feature would be inconsistent with this diagnosis?

      Your Answer:

      Correct Answer: Ipsilateral mydriasis

      Explanation:

      Cluster headaches primarily affect men in their 20s, with a male to female ratio of 6:1. Smoking is also a contributing factor to the development of cluster headaches. These headaches typically occur in clusters, hence the name, lasting for a few weeks every year or two. The pain experienced is intense and localized, often felt around or behind the eye. It tends to occur at the same time each day and can lead to restlessness, with some patients resorting to hitting their head against a wall or the floor in an attempt to distract themselves from the pain.

      In addition to the severe pain, cluster headaches also involve autonomic symptoms. These symptoms include redness and inflammation of the conjunctiva on the same side as the headache, as well as a runny nose and excessive tearing on the affected side. The pupil on the same side may also constrict, and there may be drooping of the eyelid on that side as well.

      Overall, cluster headaches are a debilitating condition that predominantly affects young men. The pain experienced is excruciating and can lead to extreme measures to alleviate it. The associated autonomic symptoms further contribute to the discomfort and distress caused by these headaches.

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      • Neurology
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  • Question 30 - A 25-year-old hairdresser is brought into the emergency department after collapsing at work....

    Incorrect

    • A 25-year-old hairdresser is brought into the emergency department after collapsing at work. The patient's coworker presents you with security camera footage of the incident, where the patient is observed falling to the floor just before experiencing involuntary jerking movements in all four limbs. The patient remained unconscious for approximately one minute and also lost control of their bladder during the episode. A diagnosis of tonic-clonic seizure is made, and there is no prior history of seizures or epilepsy. Despite no identifiable cause, what advice should be given to this patient regarding their ability to drive a car?

      Your Answer:

      Correct Answer: Must not drive for 6 months

      Explanation:

      Patients who experience a seizure(s) should be informed about their ability to drive. There are two important instructions to follow in this regard. Firstly, they must refrain from driving for a period of 6 months. Secondly, they must notify the appropriate authority, such as the DVLA or DVA in Northern Ireland. In the case of a single seizure, driving should be suspended for 6 months from the date of the seizure. However, if an underlying cause that increases the risk of seizures is identified, driving should be halted for 12 months. In the case of multiple seizures or epilepsy, driving should be ceased for 12 months from the most recent seizure.

      Further Reading:

      Blackouts are a common occurrence in the emergency department and can have serious consequences if they happen while a person is driving. It is crucial for doctors in the ED to be familiar with the guidelines set by the DVLA (Driver and Vehicle Licensing Agency) regarding driving restrictions for patients who have experienced a blackout.

      The DVLA has specific rules for different types of conditions that may cause syncope (loss of consciousness). For group 1 license holders (car/motorcycle use), if a person has had a first unprovoked isolated seizure, they must refrain from driving for 6 months or 12 months if there is an underlying causative factor that may increase the risk. They must also notify the DVLA. For group 2 license holders (bus and heavy goods vehicles), the restrictions are more stringent, with a requirement of 12 months off driving for a first unprovoked isolated seizure and 5 years off driving if there is an underlying causative factor.

      For epilepsy or multiple seizures, both group 1 and group 2 license holders must remain seizure-free for 12 months before their license can be considered. They must also notify the DVLA. In the case of a stroke or isolated transient ischemic attack (TIA), group 1 license holders need to refrain from driving for 1 month, while group 2 license holders must wait for 12 months before being re-licensed subject to medical evaluation. Multiple TIAs require 3 months off driving for both groups.

      Isolated vasovagal syncope requires no driving restriction for group 1 license holders, but group 2 license holders must refrain from driving for 3 months. Both groups must notify the DVLA. If syncope is caused by a reversible and treated condition, group 1 license holders need 4 weeks off driving, while group 2 license holders require 3 months. In the case of an isolated syncopal episode with an unknown cause, group 1 license holders must refrain from driving for 6 months, while group 2 license holders will have their license refused or revoked for 12 months.

      For patients who continue to drive against medical advice, the GMC (General Medical Council) has provided guidance on how doctors should manage the situation. Doctors should explain to the patient why they are not allowed to drive and inform them of their legal duty to notify the DVLA or DVA (Driver and Vehicle Agency in Northern Ireland). Doctors should also record the advice given to the patient in their medical record

    • This question is part of the following fields:

      • Neurology
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