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Question 1
Incorrect
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A 65-year-old man comes in with a sudden onset of right-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage and he is being prepared for thrombolysis. His blood pressure is currently elevated at 190/100 mmHg.
What would be the most suitable next course of action in managing his condition?Your Answer: Furosemide 40 mg IV
Correct Answer: Labetalol 10 mg IV
Explanation:Severe hypertension, defined as blood pressure greater than 180/120 mmHg, is a condition that prevents the use of thrombolysis. In order to proceed with thrombolysis, it is necessary to lower the patient’s blood pressure to below this level within the designated time frame. Oral medications are unlikely to work quickly enough, so an intravenous antihypertensive agent is required.
One commonly used agent in these situations is labetalol, which is administered intravenously at a dose of 10 mg over 1-2 minutes. This dose can be repeated if necessary, or an infusion can be set up to deliver a continuous dose of 2-8 mg per minute. Once the blood pressure is reduced to less than 180/105 mmHg, thrombolysis can be safely performed.
Alternatively, a nitrate infusion, such as Isoket, can be used in patients who cannot tolerate beta-blockers due to contraindications like asthma, heart block, or cardiac failure. This provides an alternative option for lowering blood pressure in these individuals.
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This question is part of the following fields:
- Neurology
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Question 2
Incorrect
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A 27 year old male is brought to the emergency department by his partner due to increasing drowsiness. The patient's partner informs you that the patient was involved in a physical altercation approximately 40 minutes ago. The patient was struck in the temple and experienced a brief loss of consciousness for around 20 seconds. Initially, the patient appeared to be fine, but after about 20 minutes, he started becoming progressively more drowsy. A CT scan reveals the presence of an extradural hematoma. Which cranial nerve palsy is most commonly observed in this condition?
Your Answer: Oculomotor nerve
Correct Answer: Abducens nerve
Explanation:Abducens nerve palsy is often linked to extradural hematoma. When there is a mass effect, downward brain herniation can occur, leading to the involvement of the 6th cranial nerve (abducens nerve, CN VI). This nerve controls the lateral rectus muscle, which is responsible for eye abduction. When the abducens nerve is affected, the lateral rectus muscle is unable to function properly, resulting in an inward turning of the affected eye towards the nose (esotropia).
Further Reading:
Extradural haematoma (EDH) is a collection of blood that forms between the inner surface of the skull and the outer layer of the dura, the dura mater. It is typically caused by head trauma and is often associated with a skull fracture, with the pterion being the most common site of injury. The middle meningeal artery is the most common source of bleeding in EDH.
Clinical features of EDH include a history of head injury with transient loss of consciousness, followed by a lucid interval and gradual loss of consciousness. Other symptoms may include severe headache, sixth cranial nerve palsies, nausea and vomiting, seizures, signs of raised intracranial pressure, and focal neurological deficits.
Imaging of EDH typically shows a biconvex shape and may cause mass effect with brain herniation. It can be differentiated from subdural haematoma by its appearance on imaging.
Management of EDH involves prompt referral to neurosurgery for evacuation of the haematoma. In some cases with a small EDH, conservative management may be considered. With prompt evacuation, the prognosis for EDH is generally good.
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This question is part of the following fields:
- Neurology
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Question 3
Incorrect
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You have been tasked with arranging a case-based teaching session for the junior doctors in the emergency department regarding vertigo. Which of the subsequent clinical features aligns with a central origin of vertigo?
Your Answer:
Correct Answer: Inability to stand up with the eyes open
Explanation:If a person is unable to stand up or walk, even with their eyes open, it is likely that the cause of their vertigo is central in nature. Additional features that increase suspicion of a central cause include focal neurology, prolonged and severe vertigo (although this can also be seen in vestibular neuronitis or Meniere’s disease), new-onset headache or recent trauma, a normal head impulse test, and the presence of cardiovascular risk factors.
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
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This question is part of the following fields:
- Neurology
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Question 4
Incorrect
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A 62-year-old woman presents with left-sided loss of pain and temperature sense on the body and right-sided loss of pain and temperature sense on the face. While examining her cranial nerves, you note the presence of Horner’s syndrome. She is also complaining of dizziness, vomiting, and ringing in the ears. CT and MRI head scans are performed, and she is found to have experienced a right-sided stroke. She is subsequently admitted under the care of the stroke team.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Lateral medullary syndrome
Explanation:Occlusion of the posterior inferior cerebellar artery leads to the development of lateral medullary syndrome, also known as Wallenberg’s syndrome. This condition is characterized by several distinct symptoms. Firstly, there is a loss of pain and temperature sensation on the opposite side of the body, which occurs due to damage to the spinothalamic tracts. Additionally, there is a loss of pain and temperature sensation on the same side of the face, resulting from damage to the fifth cranial nerve (CN V).
Furthermore, individuals with lateral medullary syndrome may experience vertigo, nystagmus, tinnitus, deafness, and vomiting. These symptoms arise from damage to the eighth cranial nerve (CN VIII). Lastly, the syndrome may also present with Horner’s syndrome, which is caused by damage to the descending hypothalamospinal tract.
In summary, occlusion of the posterior inferior cerebellar artery causes lateral medullary syndrome, leading to a combination of symptoms including sensory loss, vertigo, tinnitus, and Horner’s syndrome.
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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 toddler is brought in with a non-blanching rash and a high fever. You suspect a potential diagnosis of meningococcal disease.
Based on the current NICE guidelines, which of the following features is MOST indicative of this diagnosis?Your Answer:
Correct Answer: Capillary refill time >3 seconds or longer
Explanation:NICE has emphasized that certain symptoms and signs can indicate specific diseases as the underlying cause of a fever. In the case of meningococcal disease, the presence of a rash that does not fade when pressed upon (non-blanching rash) is particularly suggestive, especially if the child appears unwell, the lesions are larger than 2 mm in diameter (purpura), the capillary refill time is 3 seconds or longer, or there is neck stiffness. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Neurology
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Question 6
Incorrect
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A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her right limbs, particularly affecting her face and arm more than her leg, as well as sensory loss on the right side. Additionally, she has receptive dysphasia.
Which blood vessel is most likely to be impacted?Your Answer:
Correct Answer: Middle 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.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 65-year-old woman comes in with right-sided weakness and difficulty speaking. Her ROSIER score is 3. She is noticeably overweight and weighs 90 kg.
What is the appropriate dosage of alteplase to administer?Your Answer:
Correct Answer: 90mg
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 60 minutes, with the initial 10% administered by intravenous injection and the remainder by intravenous infusion. In the case of a patient weighing 120 kg, the maximum dose of 90 mg should be administered. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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A 65-year-old 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.
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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 32-year-old man presents with a range of neurological symptoms. He has been experiencing painless double vision over the past day and is becoming worried. Approximately six months ago, he also recalled a two-week period where he had no feeling in his right arm. When directly asked, he also confesses to feeling tired and quite depressed.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Multiple sclerosis
Explanation:Multiple sclerosis is a condition characterized by the demyelination of nerve cells in the brain and spinal cord. It is an autoimmune disease mediated by cells and is caused by recurring inflammation. Typically, it presents in early adulthood, with a female to male ratio of 3:2.
There are several risk factors associated with multiple sclerosis, including being of Caucasian race, living at a greater distance from the equator (as the risk tends to be higher), having a family history of the disease (with 20% of MS patients having an affected relative), and smoking. Interestingly, the rates of relapse tend to decrease during pregnancy.
There are three main patterns of multiple sclerosis. The most common is relapsing and remitting MS, which is characterized by periods of no symptoms followed by relapses (this is seen in 80% of patients at the time of diagnosis). Another pattern is primary progressive MS, where symptoms develop and worsen from the beginning with few remissions (seen in 10-15% of patients at diagnosis). Lastly, there is secondary progressive MS, which occurs after relapsing/remitting MS. In this pattern, symptoms worsen with fewer remissions, and approximately 50% of those with relapsing/remitting MS will develop this within 10 years of diagnosis.
The key to diagnosing MS lies in the history of neurological symptoms that are discrete in time and location of the affected body. Patients often experience fatigue and low mood, particularly during a relapse.
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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 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 15 minutes. IV access is established and his blood sugar level is 4.5. He weighs 20 kg.
According to the latest APLS guidelines, what would be the most suitable next course of action in managing his condition?Your Answer:
Correct Answer: IV lorazepam 2 mg
Explanation:The current algorithm for the treatment of a convulsing child, known as APLS, is as follows:
Step 1 (5 minutes after the start of convulsion):
If a child has been convulsing for 5 minutes or more, the initial dose of benzodiazepine should be administered. This can be done by giving Lorazepam at a dose of 0.1 mg/kg intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam at a dose of 0.5 mg/kg or rectal diazepam at a dose of 0.5 mg/kg can be given if vascular access is not available.Step 2 (10 minutes after the start of Step 1):
If the convulsion continues for a further 10 minutes, a second dose of benzodiazepine should be given. It is also important to summon senior help at this point.Step 3 (10 minutes after the start of Step 2):
At this stage, it is necessary to involve senior help to reassess the child and provide guidance on further management. The recommended approach is as follows:
– If the child is not already on phenytoin, a phenytoin infusion should be initiated. This involves administering 20 mg/kg of phenytoin intravenously over a period of 20 minutes.
– If the child is already taking phenytoin, phenobarbitone can be used as an alternative. The recommended dose is 20 mg/kg administered intravenously over 20 minutes.
– In the meantime, rectal paraldehyde can be considered at a dose of 0.8 ml/kg of the 50:50 mixture while preparing the infusion.Step 4 (20 minutes after the start of Step 3):
If the child is still experiencing convulsions at this stage, it is crucial to have an anaesthetist present. A rapid sequence induction with thiopental is recommended for further management.Please note that this algorithm is subject to change based on individual patient circumstances and the guidance of medical professionals.
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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A 72 year old female arrives at the emergency department after speaking with her primary care physician over the phone. She explains that while she was shopping, her right arm and right leg suddenly felt weak and became a bit difficult to move. The patient is otherwise alert, oriented, feels well, and has normal speech. A brain CT scan reveals a focal area of ischemia consistent with an acute stroke. You arrange for her transfer to the stroke unit. The patient inquires if she can drive her car before going to the ward. What advice would you give her regarding driving?
Your Answer:
Correct Answer: Advise them, they must not drive a car for at least 1 month following a confirmed stroke
Explanation:Patients who have experienced a stroke should be aware that they are not allowed to drive for at least one month if they have a type 1 license. If there are no neurological issues after this time period, they may not need to inform the DVLA (Driver and Vehicle Licensing Agency). However, they must inform the DVLA if any of the following conditions apply: they have had more than one stroke or transient ischemic attack (TIA), they have a Group 2 license, a medical practitioner has expressed concerns about their ability to drive, they still have residual deficits one month after the stroke (such as weakness in the limbs, visual problems, coordination difficulties, memory or understanding issues), the stroke required neurosurgical treatment, or if they experienced a seizure (unless it was an isolated seizure within 24 hours of the stroke and there is no history of prior seizures).
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
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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 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.
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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 45-year-old woman with no permanent address sustains a head injury after falling. As part of her evaluation, you order a complete set of blood tests and a CT scan of the head. The blood tests reveal abnormal liver function and macrocytic anemia. The CT scan of the head appears normal, but an MRI performed later shows small petechial hemorrhages in the mamillary bodies.
During her hospital stay, she receives a treatment that worsens her condition, leading to acute confusion. Upon examination, you observe an unsteady gait, peripheral neuropathy, and bilateral abducens nerve palsies.
Which medication should be urgently administered to this patient?Your Answer:
Correct Answer: Intravenous Pabrinex
Explanation:This patient has developed Wernicke’s encephalopathy, a condition that is associated with alcohol abuse and other causes of thiamine deficiency. It is important to note that the infusion of glucose-containing intravenous fluids without thiamine in a patient with chronic thiamine deficiency can trigger Wernicke’s encephalopathy. In this particular case, it seems that this is what has occurred.
Wernicke’s encephalopathy is typically characterized by a triad of symptoms, which include acute confusion, ophthalmoplegia, and ataxia. Additionally, other possible features of this condition may include papilloedema, hearing loss, apathy, dysphagia, memory impairment, and hypothermia. It is also common for peripheral neuropathy, primarily affecting the legs, to occur in the majority of cases.
This condition is characterized by the presence of acute capillary haemorrhages, astrocytosis, and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized through MRI scanning, although CT scanning is not very useful for diagnosis.
If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia, an inability to form new memories, disordered time perception, and confabulation.
Patients who are suspected to have Wernicke’s encephalopathy should be promptly treated with parenteral thiamine (such as Pabrinex) for a minimum of 5 days. Following the parenteral therapy, oral thiamine should be administered.
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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 32-year-old woman has been brought into the Emergency Department, experiencing seizures that have lasted for 15 minutes before her arrival. On arrival, she is still having a tonic-clonic seizure. She is known to be homeless and has a long history of alcohol abuse. The paramedics administered a single dose of rectal diazepam on the way, approximately 12 minutes ago. Her vital signs are as follows: HR 110, BP 100/60, SaO2 98% on high flow oxygen, temperature is 37.2°C.
Which of the following medications would be most appropriate to administer next?Your Answer:
Correct Answer: Intravenous thiamine
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 this particular patient’s case, his history of chronic alcohol abuse, homelessness, and likely impaired nutrition necessitates the administration of intravenous thiamine in the form of Pabrinex. Additionally, a second dose of benzodiazepine should be given, and his blood glucose levels should be urgently checked.
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 access2nd stage (0-30 minutes):
– Implement regular monitoring
– Consider the possibility of non-epileptic status
– Initiate emergency antiepileptic drug (AED) therapy
– Perform emergency investigations
– Administer glucose (50 ml of 50% solution) and/or intravenous thiamine as Pabrinex if there are indications of alcohol abuse or impaired nutrition
– Treat severe acidosis if present3rd stage (0-60 minutes):
– Determine the underlying cause of status epilepticus
– Notify the anaesthetist and intensive care unit (ITU)
– Identify and treat any medical complications
– Consider pressor therapy when appropriate4th 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 therapyEmergency investigations include blood tests for gases, glucose, renal and liver function, calcium and magnesium levels, 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 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.
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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 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 focusingMSA:
– 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 focusingPSP:
– 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 downwardsCBD:
– 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 16
Incorrect
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A 45-year-old woman presents with a severe headache that has been ongoing for the past 3 hours. She describes it as the 'most intense headache she has ever experienced'. She also complains of sensitivity to light and stiffness in her neck. There is no history of any head injury. Initially, she was treated conservatively and her symptoms improved. However, on the third day, she had a seizure and lost the ability to move her left arm. Physical examination reveals weakness in the left arm but normal sensation. A CT scan of her head shows a localized area of decreased density in the right frontal lobe, with a loss of distinction between grey and white matter and surrounding swelling.
What is the most likely cause of her current condition?Your Answer:
Correct Answer: Cerebral vasospasm
Explanation:Intracranial hemorrhages can be categorized based on their location into epidural, subdural, subarachnoid, or intracerebral hemorrhages. The patient in this case is experiencing a severe headache accompanied by signs of meningismus, which strongly suggests a diagnosis of subarachnoid hemorrhage. Additionally, there is no history of trauma, and most cases of subarachnoid hemorrhage are caused by the rupture of a berry aneurysm located in the circle of Willis. Hypertension is a significant risk factor for the rupture of an aneurysm.
During the patient’s hospital stay, they develop an ischemic stroke, which is confirmed by a CT scan. This is most likely a result of cerebral vasospasm secondary to the subarachnoid hemorrhage. To prevent this complication, patients are often treated with the cerebral selective calcium channel blocker Nimodipine.
Another potential complication of this condition is rebleeding, with the highest risk occurring in the first few days. Rebleeding can be potentially fatal, so it is crucial to repair the aneurysm as soon as possible. The presence of blood in the subarachnoid space can also disrupt the production and drainage of cerebrospinal fluid, leading to hydrocephalus.
Long-term complications of subarachnoid hemorrhage include epilepsy, with most patients experiencing their first seizure within a year after the hemorrhage. However, the risk of epilepsy decreases over time. Cognitive dysfunction is also a common long-term complication and can manifest as memory loss, difficulty concentrating, or challenges in performing regular tasks. Emotional problems, such as depression and anxiety, are frequently observed as well.
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This question is part of the following fields:
- Neurology
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Question 17
Incorrect
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A 45-year-old female patient is known to have Parkinson’s disease. She complains of recent excessive sleepiness, increased anxiety, and uncontrolled jerky movements in her lower limbs.
Which SINGLE medication is most likely responsible for these symptoms?Your Answer:
Correct Answer: Co-beneldopa
Explanation:Co-beneldopa, such as Madopar®, is a medication that combines levodopa and benserazide, a dopa-decarboxylase inhibitor. Levodopa is a precursor of dopamine and has been the primary treatment for Parkinson’s disease since the 1970s. To minimize the side effects of levodopa, it is administered with a dopa-decarboxylase inhibitor (DDI) to reduce its availability in the peripheral system. However, patients may still experience adverse effects like nausea, dizziness, sleepiness, dyskinesia, mood changes, confusion, hallucinations, and delusions.
None of the other combination medications mentioned in this question cause the listed side effects.
Co-dydramol is a pain reliever that contains dihydrocodeine tartrate and paracetamol.
Co-flumactone is a medication that combines spironolactone, a potassium-sparing diuretic, and hydroflumethiazide, a type of thiazide diuretic used for managing congestive cardiac failure.
Co-tenidone is a combination of atenolol and chlorthalidone, primarily used for treating hypertension.
Co-simalcite, also known as Altacite plus, is an antacid that contains two main ingredients: hydrotalcite and activated dimeticone.
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This question is part of the following fields:
- Neurology
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Question 18
Incorrect
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A 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.
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This question is part of the following fields:
- Neurology
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Question 19
Incorrect
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A 35 year old male comes to the emergency department with sudden onset of facial weakness on one side that has occurred within the last 72 hours. You are considering the possible causes for this condition. What would assist in differentiating between an upper motor neuron and lower motor neuron lesion?
Your Answer:
Correct Answer: Forehead sparing
Explanation:When there is damage to the facial nerve in the LMN, the patient will experience paralysis in the forehead and will be unable to wrinkle their brow. However, in an upper motor neuron lesion, the frontalis muscle is not affected, so the patient can still furrow their brow normally and their ability to close their eyes and blink is not affected. Lower motor neuron lesions affect the final part of the nerve pathway to all branches of the facial nerve, resulting in paralysis of the forehead and the rest of the face on that side. It is important to note that the speed of onset may provide some clues about the cause of the lesion, but it does not help determine the specific location of the damage.
Further Reading:
Bell’s palsy is a condition characterized by sudden weakness or paralysis of the facial nerve, resulting in facial muscle weakness or drooping. The exact cause is unknown, but it is believed to be related to viral infections such as herpes simplex or varicella zoster. It is more common in individuals aged 15-45 years and those with diabetes, obesity, hypertension, or upper respiratory conditions. Pregnancy is also a risk factor.
Diagnosis of Bell’s palsy is typically based on clinical symptoms and ruling out other possible causes of facial weakness. Symptoms include rapid onset of unilateral facial muscle weakness, drooping of the eyebrow and corner of the mouth, loss of the nasolabial fold, otalgia, difficulty chewing or dry mouth, taste disturbance, eye symptoms such as inability to close the eye completely, dry eye, eye pain, and excessive tearing, numbness or tingling of the cheek and mouth, speech articulation problems, and hyperacusis.
When assessing a patient with facial weakness, it is important to consider other possible differentials such as stroke, facial nerve tumors, Lyme disease, granulomatous diseases, Ramsay Hunt syndrome, mastoiditis, and chronic otitis media. Red flags for these conditions include insidious and painful onset, duration of symptoms longer than 3 months with frequent relapses, pre-existing risk factors, systemic illness or fever, vestibular or hearing abnormalities, and other cranial nerve involvement.
Management of Bell’s palsy involves the use of steroids, eye care advice, and reassurance. Steroids, such as prednisolone, are recommended for individuals presenting within 72 hours of symptom onset. Eye care includes the use of lubricating eye drops, eye ointment at night, eye taping if unable to close the eye at night, wearing sunglasses, and avoiding dusty environments. Reassurance is important as the majority of patients make a complete recovery within 3-4 months. However, some individuals may experience sequelae such as facial asymmetry, gustatory lacrimation, inadequate lid closure, brow ptosis, drooling, and hemifacial spasms.
Antiviral treatments are not currently recommended as a standalone treatment for Bell’s palsy, but they may be given in combination with corticosteroids on specialist advice. Referral to an ophthalmologist is necessary if the patient has eye symptoms such as pain, irritation, or itch.
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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 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Wernicke's encephalopathy. You have been requested to examine the patient and arrange an investigation to assist in confirming the diagnosis.
Which of the following investigations is MOST LIKELY to be beneficial in establishing the diagnosis?Your Answer:
Correct Answer: MRI scan of brain
Explanation:Wernicke’s encephalopathy is a condition that is linked to alcohol abuse and other causes of thiamine deficiency. It is commonly identified by the presence of three main symptoms: acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional signs may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. Most cases also involve peripheral neuropathy, primarily affecting the legs.
This condition is characterized by the occurrence of acute capillary hemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be detected through MRI scanning, while CT scanning is not very useful for diagnosis.
If left untreated, most patients with Wernicke’s encephalopathy will develop a condition known as Korsakoff psychosis. This condition is characterized by retrograde amnesia (loss of memory for events that occurred before the onset of amnesia), an inability to form new memories, disordered perception of time, and confabulation (fabrication of false memories).
When Wernicke’s encephalopathy is suspected, it is crucial to administer parenteral thiamine (such as Pabrinex) for at least 5 days. Following the parenteral therapy, oral thiamine should be continued.
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This question is part of the following fields:
- Neurology
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Question 21
Incorrect
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A 65-year-old woman comes to the clinic after a fall. You observe that she has a tremor in her left hand that is most noticeable when she is sitting and at rest. Additionally, you notice that it took her quite a while to walk towards you and unbutton her coat before sitting down. When you shake her hand, you notice that her left forearm feels stiff.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Parkinson’s disease
Explanation:Parkinson’s disease (PD) is a progressive neurodegenerative condition that occurs when the dopamine-containing cells in the substantia nigra die. It is estimated that PD affects around 100-180 individuals per 100,000 of the population, which translates to approximately 6-11 people per 6,000 individuals in the general population of the UK. The annual incidence of PD is between 4-20 cases per 100,000 people. The prevalence of PD increases with age, with approximately 0.5% of individuals aged 65 to 74 being affected and 1-2% of individuals aged 75 and older. Additionally, PD is more prevalent and has a higher incidence in males.
The classic clinical features of Parkinson’s disease include hypokinesia, which refers to a poverty of movement, and bradykinesia, which is characterized by slowness of movement. Rest tremor, typically occurring at a rate of 4-6 cycles per second, is also commonly observed in PD patients. Another clinical feature is rigidity, which is characterized by increased muscle tone and a phenomenon known as cogwheel rigidity.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 45-year-old man presents with a tremor and difficulty with movement. After being referred to a specialist, he is diagnosed with Parkinson's disease. Currently, he is in the early stages of the condition.
Which of the following clinical features is most likely to be present as well?Your Answer:
Correct Answer: Cogwheel rigidity
Explanation:Patients with Parkinson’s disease (PD) typically exhibit the following clinical features:
– Hypokinesia (reduced movement)
– Bradykinesia (slow movement)
– Rest tremor (usually occurring at a rate of 4-6 cycles per second)
– Rigidity (increased muscle tone and ‘cogwheel rigidity’)Other commonly observed clinical features include:
– Gait disturbance (characterized by a shuffling gait and loss of arm swing)
– Loss of facial expression
– Monotonous, slurred speech
– Micrographia (small, cramped handwriting)
– Increased salivation and dribbling
– Difficulty with fine movementsInitially, these signs are typically seen on one side of the body at the time of diagnosis, but they progressively worsen and may eventually affect both sides. In later stages of the disease, additional clinical features may become evident, including:
– Postural instability
– Cognitive impairment
– Orthostatic hypotensionAlthough PD primarily affects movement, patients often experience psychiatric issues such as depression and dementia. Autonomic disturbances and pain can also occur, leading to significant disability and reduced quality of life for the affected individual. Additionally, family members and caregivers may also be indirectly affected by the disease.
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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 toddler is brought in with a severe headache and a high fever. You suspect a potential diagnosis of herpes simplex encephalitis.
Based on the current NICE guidelines, which of the following symptoms is MOST indicative of this condition?Your Answer:
Correct Answer: Focal neurological signs
Explanation:NICE has emphasized that there are particular symptoms and indications that may indicate specific diseases as the underlying cause of a fever. In the case of herpes simplex encephalitis, the following symptoms and signs may suggest its presence: the presence of a focal neurological sign, focal seizures, and a decreased level of consciousness. For more information on this topic, you may refer to the NICE guidelines on the assessment and initial management of fever in children under the age of 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A toddler is brought in with a rash and a high fever. You suspect a potential diagnosis of bacterial meningitis.
Based on the current NICE guidelines, which of the following features is LEAST indicative of this condition?Your Answer:
Correct Answer: Focal seizures
Explanation:NICE has emphasized that certain indications and manifestations may indicate specific diseases as the underlying cause of fever. For instance, symptoms such as neck stiffness, bulging fontanelle, decreased level of consciousness, and convulsive status epilepticus are suggestive of bacterial meningitis. On the other hand, NICE has identified focal seizures and focal neurological signs as the most indicative of herpes simplex encephalitis. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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You are summoned to the resuscitation area to assist with a patient experiencing status epilepticus.
Which ONE statement about the utilization of benzodiazepines in status epilepticus is accurate?Your Answer:
Correct Answer: Diazepam can be given by the intravenous route
Explanation:Between 60 and 80% of individuals who experience seizures will have their seizure stopped by a single dose of intravenous benzodiazepine. Benzodiazepines have a high solubility in lipids and can quickly pass through the blood-brain barrier. This is why they have a fast onset of action.
As the initial treatment, intravenous lorazepam should be administered. If intravenous lorazepam is not accessible, intravenous diazepam can be used instead. In cases where it is not possible to establish intravenous access promptly, buccal midazolam can be utilized.
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This question is part of the following fields:
- Neurology
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Question 26
Incorrect
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A 65-year-old patient who was diagnosed with Parkinson's disease five years ago has experienced a sudden and severe deterioration in her functioning and is now reliant on a wheelchair. Her motor symptoms affect both sides of her body, and she does not exhibit any noticeable tremors. Additionally, she experiences significant fluctuations in blood pressure, urinary incontinence, and has a high-pitched voice.
What is the MOST LIKELY diagnosis for this patient?Your Answer:
Correct Answer: Multiple System Atrophy
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 focusingMSA:
– 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 focusingPSP:
– 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 downwardsCBD:
– 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 27
Incorrect
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A 52-year-old man presents with ataxia, left-sided loss of pain and temperature sense on the face, left-sided paralysis of the facial muscles and right-sided sensory loss to the body. He is also complaining of severe vertigo, nausea and tinnitus. CT and MRI head scans are undertaken, and he is discovered to have suffered a left-sided stroke. He is subsequently admitted under the stroke team.
What is the SINGLE most likely diagnosis?Your Answer:
Correct Answer: Lateral pontine syndrome
Explanation:Obstruction of the long circumferential branches of the basilar artery leads to the lateral pontine syndrome. This condition is characterized by several symptoms. Firstly, there is ataxia, which is caused by damage to the cerebral peduncles. Additionally, there is ipsilateral loss of pain and temperature sense on the face, resulting from damage to CN V. Another symptom is ipsilateral paralysis of the upper and lower face, which occurs due to damage to CN VII. Furthermore, vertigo, nystagmus, tinnitus, deafness, and vomiting are present, all of which are caused by damage to CN VIII. Lastly, there is contralateral sensory loss to the body, which is a result of damage to the spinothalamic tracts.
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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 35-year-old woman comes in with her husband. She is extremely concerned about his frequent headaches and recent changes in his behavior. He complains of experiencing intense pain behind his left eye in the late evenings for the past two weeks. The pain typically lasts for about half an hour, and his wife mentions that he occasionally bangs his head against the wall due to the severity of the pain. Additionally, his left eye becomes watery during these episodes. A thorough neurological examination reveals no abnormalities.
What is the most probable diagnosis in this case?Your Answer:
Correct Answer: Cluster headache
Explanation:Cluster headaches are a type of headache that is commonly seen in young men in their 20s. The male to female ratio for this condition is 6:1. Smoking is also known to increase the risk of developing cluster headaches. These headaches occur in clusters, usually lasting for a few weeks every year or two. The pain experienced is severe and typically affects one side of the head, often around or behind the eye. It tends to occur at the same time each day and can cause the patient to become agitated, sometimes resorting to hitting their head against a wall or the floor in an attempt to distract from the pain.
In addition to the intense pain, cluster headaches are also associated with autonomic involvement. This can manifest as various symptoms on the same side as the headache, including conjunctival injection (redness of the eye), rhinorrhea (runny nose), lacrimation (tearing of the eye), miosis (constriction of the pupil), and ptosis (drooping of the eyelid).
On the other hand, migraine with typical aura presents with temporary visual disturbances, such as hemianopia (loss of vision in half of the visual field) or scintillating scotoma (a visual aura that appears as a shimmering or flashing area of distorted vision). Migraine without aura, on the other hand, needs to meet specific criteria set by the International Headache Society. These criteria include having at least five headache attacks lasting between 4 to 72 hours, with the headache having at least two of the following characteristics: unilateral location, pulsating quality, moderate to severe pain intensity, and aggravation by routine physical activity.
During a migraine headache, the patient may also experience symptoms such as nausea and/or vomiting, as well as sensitivity to light (photophobia) and sound (phonophobia). It is important to note that these symptoms should not be attributed to another underlying disorder.
If a patient over the age of 50 presents with a new-onset headache, it raises the possibility of giant cell arteritis (temporal arteritis). Other symptoms and signs that may be associated with this condition include jaw claudication (pain in the jaw when chewing), systemic upset, scalp tenderness, and an elevated erythrocyte sedimentation rate (ESR).
Medication overuse headache is a condition that is suspected when a patient is using multiple medications, often at low doses, without experiencing any relief from their headaches.
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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 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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This question is part of the following fields:
- Neurology
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Question 30
Incorrect
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A 6-year-old boy comes in with a headache, stiffness in his neck, and sensitivity to light. He has a known allergy to penicillin and had to spend some time in the ICU because of it. He has also recently developed a rash of small red or purple spots on his arms and legs.
What is the MOST suitable next course of action in managing his condition?Your Answer:
Correct Answer: Chloramphenicol
Explanation:This girl is displaying symptoms and signs that are consistent with a diagnosis of meningococcal septicaemia. It is crucial that she receives urgent antibiotic treatment. If a patient has a penicillin allergy, but not anaphylaxis, a third-generation cephalosporin like cefotaxime may be administered. However, in this particular case, the girl has a documented history of anaphylaxis to penicillin. It is important to note that up to 10% of patients who are allergic to penicillin may experience an adverse reaction to cephalosporins. In situations where there is a true anaphylactic reaction to penicillins, the British National Formulary (BNF) recommends the use of chloramphenicol as an alternative treatment option.
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This question is part of the following fields:
- Neurology
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