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  • Question 1 - A 35-year-old accountant presents with a headache. Since she woke up this morning,...

    Incorrect

    • A 35-year-old accountant presents with a headache. Since she woke up this morning, she describes a right-sided, severe, throbbing headache. She has had similar symptoms previously but feels that this is the worst she has ever had. Her work is very stressful at the moment. She has also vomited this morning. Her husband is with her and is anxious as his mother has recently been diagnosed with a brain tumor. He is really worried that his wife might have the same. On examination, the patient is normotensive with a heart rate of 72 beats per minute, regular. Her cranial nerve examination, including fundoscopy, is normal, as is the examination of her peripheral nervous system. She has no scalp tenderness.
      What is the SINGLE most likely diagnosis?

      Your Answer: Temporal arteritis

      Correct Answer: Migraine

      Explanation:

      Migraine without aura typically needs to meet the specific criteria set by the International Headache Society. These criteria include experiencing at least five attacks that meet the requirements outlined in criteria 2-4. The duration of these headache attacks should last between 4 to 72 hours. Additionally, the headache should exhibit at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation or avoidance of routine physical activity. Furthermore, during the headache, individuals should experience at least one of the following symptoms: nausea and/or vomiting, photophobia, and phonophobia. For more detailed information, you can refer to the guidelines provided by The British Association for the Study of Headache.

    • This question is part of the following fields:

      • Neurology
      18.1
      Seconds
  • Question 2 - You are evaluating a 30-year-old individual who has suffered a severe head injury...

    Incorrect

    • You are evaluating a 30-year-old individual who has suffered a severe head injury after being attacked with a baseball bat. There are indications that the patient may be experiencing elevated intracranial pressure. In a person with normal physiological conditions, what percentage of the intracranial volume is typically occupied by cerebrospinal fluid (CSF)?

      Your Answer: 80%

      Correct Answer: 10%

      Explanation:

      The intracranial volume refers to the total space inside the skull. The main component of this volume is the brain parenchyma or neural tissue, which makes up the majority of the intracranial volume.

      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
      180.9
      Seconds
  • Question 3 - A toddler develops a palsy of his left leg following a fall. On...

    Incorrect

    • A toddler develops a palsy of his left leg following a fall. On examination, there is a loss of hip abduction, external rotation and knee flexion. The leg is noticeably dragging with the knee extended and the foot turned inward.
      What is the SINGLE most likely diagnosis?

      Your Answer: Radial nerve palsy

      Correct Answer: Erb’s palsy

      Explanation:

      Erb’s palsy, also known as Erb-Duchenne palsy, is a condition where the arm becomes paralyzed due to an injury to the upper roots of the brachial plexus. The primary root affected is usually C5, although C6 may also be involved in some cases. The main cause of Erb’s palsy is when the arm experiences excessive force during a difficult childbirth, but it can also occur in adults as a result of shoulder trauma.

      Clinically, the affected arm will hang by the side with the elbow extended and the forearm turned inward (known as the waiter’s tip sign). Upon examination, there will be a loss of certain movements:

      – Shoulder abduction (involving the deltoid and supraspinatus muscles)
      – Shoulder external rotation (infraspinatus muscle)
      – Elbow flexion (biceps and brachialis muscles)

      It is important to differentiate Erb’s palsy from Klumpke’s palsy, which affects the lower roots of the brachial plexus (C8 and T1). Klumpke’s palsy presents with a claw hand due to paralysis of the intrinsic hand muscles, along with sensory loss along the ulnar side of the forearm and hand. If T1 is affected, there may also be the presence of Horner’s syndrome.

    • This question is part of the following fields:

      • Neurology
      135.2
      Seconds
  • Question 4 - A 40-year-old man presents with a history of a headache, fever and increasing...

    Correct

    • 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: 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
      1500.5
      Seconds
  • Question 5 - A 55-year-old man presents with left-sided hemiplegia and loss of joint position sense,...

    Correct

    • 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: 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
      154.1
      Seconds
  • Question 6 - A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with...

    Incorrect

    • A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Wernicke's encephalopathy. You have been requested to assess the patient.
      Which of the following symptoms is MOST LIKELY to be observed?

      Your Answer: Confabulation

      Correct Answer: Ataxia

      Explanation:

      Wernicke’s encephalopathy is a condition that is commonly associated with alcohol abuse and other causes of thiamine deficiency. It is characterized by a classic triad of symptoms, including acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional possible features of this condition may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. The majority of cases also experience peripheral neuropathy, which typically affects the legs.

      The condition is marked by acute capillary haemorrhages, astrocytosis (increase in the number of astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized using MRI scanning, while 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 (loss of memory for events that occurred before the onset of amnesia), an inability to form new memories, disordered time perception, 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.

    • This question is part of the following fields:

      • Neurology
      263.2
      Seconds
  • Question 7 - A 35 year old female is brought to the emergency department after experiencing...

    Correct

    • 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: 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
      9
      Seconds
  • Question 8 - A 4-year-old child is brought in by ambulance. He has been experiencing seizures...

    Incorrect

    • A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 20 minutes. He has already received one dose of rectal diazepam from the ambulance crew while on the way. Intravenous access has been established, his bowel movement is 4.5, and he weighs 25 kg.

      Based on the current APLS guidelines, what would be the most suitable next course of action in managing his condition?

      Your Answer: Buccal midazolam 12.5 mg

      Correct Answer: IV lorazepam 2.5 mg

      Explanation:

      The current algorithm for treating 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, they should be given an initial dose of benzodiazepine. This can be administered intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam or rectal diazepam can be given if vascular access is not available.

      Step 2 (10 minutes after the start of step 1):
      If the convulsion continues for another 10 minutes, a second dose of benzodiazepine should be given. It is also important to seek senior help at this point.

      Step 3 (10 minutes after the start of step 2):
      At this stage, it is necessary to involve senior medical personnel to reassess the child and provide guidance on further management. The recommended approach is as follows:
      – If the child is not already receiving 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 instead. The recommended dosage 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.

      In the case of this specific child who weighs 25 kg and has already received a dose of lorazepam, they should receive a second dose of 0.1 mg/kg, which amounts to 2.5 mg.

    • This question is part of the following fields:

      • Neurology
      200.3
      Seconds
  • Question 9 - A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with...

    Correct

    • A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Wernicke's encephalopathy. You have been requested to assess the patient and initiate her treatment.
      What condition will she develop if she goes untreated?

      Your Answer: Korsakoff psychosis

      Explanation:

      Wernicke’s encephalopathy is a condition that is commonly associated with alcohol abuse and other causes of thiamine deficiency. It is characterized by a triad of symptoms, including acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional features may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. Most cases also involve peripheral neuropathy, which typically affects the legs.

      The condition is caused by capillary hemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These changes can be visualized using MRI scanning, although CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will develop 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 time perception, and confabulation (fabrication of false memories).

      Patients suspected of having Wernicke’s encephalopathy should receive parenteral thiamine (such as Pabrinex) for at least 5 days. Oral thiamine should be administered after the parenteral therapy.

      It is important to note that in patients with chronic thiamine deficiency, the infusion of glucose-containing intravenous fluids without thiamine can trigger the development of Wernicke’s encephalopathy.

    • This question is part of the following fields:

      • Neurology
      10
      Seconds
  • Question 10 - A toddler develops a palsy of his left leg following a fall. On...

    Incorrect

    • A toddler develops a palsy of his left leg following a fall. On examination, there is a 'foot drop' deformity and sensory loss of the lateral side of the foot and lower leg. There is also evidence of a left sided Horner's syndrome.
      Which nerve roots have most likely been affected in this case?

      Your Answer: C5 and C6

      Correct Answer: C8 and T1

      Explanation:

      Klumpke’s palsy, also known as Dejerine-Klumpke palsy, is a condition where the arm becomes paralyzed due to an injury to the lower roots of the brachial plexus. The most commonly affected root is C8, but T1 can also be involved. The main cause of Klumpke’s palsy is when the arm is pulled forcefully in an outward position during a difficult childbirth. It can also occur in adults with apical lung carcinoma (Pancoast’s syndrome).

      Clinically, Klumpke’s palsy is characterized by a deformity known as ‘claw hand’, which is caused by the paralysis of the intrinsic hand muscles. There is also a loss of sensation along the ulnar side of the forearm and hand. In some cases where T1 is affected, a condition called Horner’s syndrome may also be present.

      Klumpke’s palsy can be distinguished from Erb’s palsy, which affects the upper roots of the brachial plexus (C5 and sometimes C6). In Erb’s palsy, the arm hangs by the side with the elbow extended and the forearm turned inward (known as the ‘waiter’s tip sign’). Additionally, there is a loss of shoulder abduction, external rotation, and elbow flexion.

    • This question is part of the following fields:

      • Neurology
      64
      Seconds
  • Question 11 - A 32-year-old woman experiences a fracture-dislocation of her forearm after tripping and landing...

    Incorrect

    • A 32-year-old woman experiences a fracture-dislocation of her forearm after tripping and landing on her outstretched hand. As a result, she has developed weakness in her wrist and finger extensors and experiences pain in her proximal forearm. The weakness in her wrist extensors is only partial, but it is observed that wrist extension causes radial deviation of the wrist. There are no sensory abnormalities.
      Which nerve has been affected in this case?

      Your Answer: Anterior interosseous nerve

      Correct Answer: Posterior interosseous nerve

      Explanation:

      The posterior interosseous nerve (PIN) is a motor branch of the radial nerve that is located deep within the body. It emerges above the elbow, between the brachioradialis and brachialis muscles, and then divides into two branches: the superficial radial nerve and the PIN. This division occurs at the lateral epicondyle level. As it travels through the forearm, the PIN passes through the supinator muscle, moving from the front to the back surface. In about 30% of individuals, it also passes through a fibrotendinous structure called the arcade of Frohse, which is located below the supinator muscle. The PIN is responsible for supplying all of the extrinsic wrist extensors, with the exception of the extensor carpi radialis longus muscle.

      There are several potential causes of damage to the PIN. Fractures, such as a Monteggia fracture, can lead to injury. Inflammation of the radiocapitellar joint, known as radiocapitellar joint synovitis, can also be a contributing factor. Tumors, such as lipomas, may cause damage as well. Additionally, entrapment of the PIN within the arcade of Frohse can result in a condition known as PIN syndrome.

      It is important to note that injury to the PIN can be easily distinguished from injury to the radial nerve in other areas of the arm, such as the spiral groove. This is because there will be no sensory involvement and no wrist drop, as the extensor carpi radialis longus muscle remains unaffected.

      The anterior interosseous nerve (AIN) is a branch of the median nerve. It primarily functions as a motor nerve, supplying the flexor pollicis longus muscle, the lateral half of the flexor digitorum profundus muscle, and the pronator quadratus muscle. Damage to the AIN can result in weakness and difficulty moving the index and middle fingers.

    • This question is part of the following fields:

      • Neurology
      6.7
      Seconds
  • Question 12 - A 65 year old male is brought to the emergency department by a...

    Incorrect

    • A 65 year old male is brought to the emergency department by a family member. The family member informs you that the patient experiences episodes of cognitive decline that last for a few days. During these episodes, the patient struggles to remember the names of friends or family members and often forgets what he is doing. The family member also mentions that the patient seems to have hallucinations, frequently asking about animals in the house and people in the garden who are not actually there. Upon examination, you observe muscle rigidity and a tremor. What is the most likely diagnosis?

      Your Answer: Normal pressure hydrocephalus

      Correct Answer: Dementia with Lewy bodies

      Explanation:

      Dementia with Lewy bodies (DLB) is characterized by several key features, including spontaneous fluctuations in cognitive abilities, visual hallucinations, and Parkinsonism. Visual hallucinations are particularly prevalent in DLB and Parkinson’s disease dementia, which are considered to be part of the same spectrum. While visual hallucinations can occur in other forms of dementia, they are less frequently observed.

      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
      11.6
      Seconds
  • Question 13 - A patient who was diagnosed with Parkinson's disease five years ago has experienced...

    Incorrect

    • A patient who was diagnosed with Parkinson's disease five years ago has experienced a sudden and significant deterioration in her functioning. Her motor symptoms are limited to her right arm and leg. She has lost nearly all functionality in her right hand, but there is no noticeable tremor. Additionally, her right arm frequently exhibits involuntary jerking movements and is held in a contracted position. The patient also reports a decline in her memory abilities.

      What is the most probable diagnosis in this case?

      Your Answer: Progressive Supranuclear Palsy

      Correct Answer: Corticobasal degeneration

      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
      174.9
      Seconds
  • Question 14 - A 68-year-old individual experiences a stroke. The primary symptoms include weakness in the...

    Incorrect

    • A 68-year-old individual experiences a stroke. The primary symptoms include weakness in the limbs on the right side, particularly affecting the right leg and right shoulder, as well as dysarthria.

      Which blood vessel is most likely to be impacted in this case?

      Your Answer: Superior cerebellar artery

      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
      167.1
      Seconds
  • Question 15 - 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: Posterior inferior cerebellar artery

      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
      122.5
      Seconds
  • Question 16 - 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: Posterior interosseous nerve

      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 17 - 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: 0.1 mg/kg

      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 18 - A fourth-year medical student is studying subarachnoid hemorrhage (SAH) and has some questions...

    Incorrect

    • A fourth-year medical student is studying subarachnoid hemorrhage (SAH) and has some questions about the topic. What is the ONE accurate statement about SAH?

      Your Answer: SAH is caused by rupture saccular aneurysms in 15% of cases

      Correct Answer: SAH is associated with polycystic kidneys

      Explanation:

      A subarachnoid haemorrhage (SAH) occurs when there is spontaneous bleeding into the subarachnoid space and is often a catastrophic event. The incidence of SAH is 9 cases per 100,000 people per year, and it typically affects individuals between the ages of 35 and 65.

      Approximately 80% of SAH cases are caused by the rupture of berry (saccular) aneurysms, while 15% are caused by arteriovenous malformations (AVM). In less than 5% of cases, no specific cause can be identified. Berry aneurysms are commonly associated with polycystic kidneys, Ehlers-Danlos Syndrome, and coarctation of the aorta.

      There are several risk factors for SAH, including smoking, hypertension, bleeding disorders, alcohol misuse, and mycotic aneurysm. Additionally, a family history of SAH can increase the likelihood of developing the condition.

      Patients with SAH typically experience a sudden and severe occipital headache, often described as the worst headache of my life. This may be accompanied by symptoms such as vomiting, collapse, seizures, and coma. Clinical signs of SAH include neck stiffness, a positive Kernig’s sign, and focal neurological abnormalities. Fundoscopy may reveal subhyaloid retinal haemorrhages in approximately 25% of patients.

      Re-bleeding occurs in 30-40% of patients who survive the initial episode, with the highest risk occurring between 7 and 14 days after the initial bleed. If left untreated, SAH has a mortality rate of nearly 50% within the first eight weeks following presentation. Prolonged coma is associated with a 100% mortality rate.

      The first-line investigation for SAH is a CT head scan, which can detect over 95% of cases if performed within the first 24 hours. The sensitivity of the CT scan increases to nearly 100% if performed within 6 hours of symptom onset. If the CT scan is negative, a lumbar puncture (LP) should be performed to diagnose SAH. The LP should be conducted at least 12 hours after the onset of headache, unless there are contraindications. Approximately 3% of patients with a negative CT scan will be confirmed to have had a SAH following an LP.

    • This question is part of the following fields:

      • Neurology
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  • Question 19 - A 35-year-old woman was diagnosed two years ago with multiple sclerosis (MS). She...

    Correct

    • A 35-year-old woman was diagnosed two years ago with multiple sclerosis (MS). She has had three relapses in that time, and with each relapse, her symptoms are getting worse. She does have periods of remission, but they don't last long.
      Which SINGLE pattern of MS is she experiencing?

      Your Answer: Primary progressive MS

      Explanation:

      Multiple sclerosis (MS) 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 ratio of affected females to males is 3:2.

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

      MS can present in three main patterns. The most common is relapsing and remitting MS, characterized by periods of no symptoms followed by relapses (present in 80% of patients at diagnosis). Primary progressive MS is less common, with symptoms developing and worsening from the beginning and few remissions (present in 10-15% of patients at diagnosis). Secondary progressive MS follows relapsing/remitting MS, with worsening symptoms and fewer remissions (approximately 50% of those with relapsing/remitting MS will develop this within 10 years of diagnosis). Progressive relapsing MS is rare and involves a steady decline in neurological function from the onset of the disease, with superimposed attacks also occurring.

      Certain factors can indicate a more favorable prognosis for individuals with MS. These include having a relapsing/remitting course, 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 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: 35mg

      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 - 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: Chloramphenicol 250 mg PO BD for 2 days

      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 22 - You review a middle-aged man on the Clinical Decision Unit (CDU) who is...

    Incorrect

    • You review a middle-aged man on the Clinical Decision Unit (CDU) who is known to have Parkinson’s disease. Currently, he takes a combination of levodopa and selegiline, and his symptoms are reasonably well controlled. He has recently been diagnosed with a different condition, and he wonders if this could be related to his Parkinson’s disease.

      Which of the following conditions is most likely to be associated with Parkinson’s disease?

      Your Answer: Mononeuritis multiplex

      Correct Answer: Depression

      Explanation:

      Parkinson’s disease is often accompanied by two prevalent diseases, namely dementia and depression. Dementia is observed in approximately 20 to 40% of individuals diagnosed with Parkinson’s disease. On the other hand, depression is experienced by around 45% of patients with Parkinson’s disease.

    • This question is part of the following fields:

      • Neurology
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  • Question 23 - A 42-year-old woman is brought to the emergency department after experiencing a sudden...

    Incorrect

    • A 42-year-old woman is brought to the emergency department after experiencing a sudden and severe headache, which has caused confusion and drowsiness. A CT scan confirms the presence of a subarachnoid hemorrhage. Your consultant instructs you to closely observe for indications of increasing intracranial pressure, such as third cranial nerve palsy. What is the initial manifestation of third cranial nerve palsy in patients with this particular injury?

      Your Answer: Pupil constriction

      Correct Answer: Pupil dilatation

      Explanation:

      The initial indication of progressive compression on the oculomotor nerve is the dilation of the pupil. In cases where the oculomotor nerve is being compressed, the outer parasympathetic fibers are typically affected before the inner motor fibers. These parasympathetic fibers are responsible for stimulating the constriction of the pupil. When they are disrupted, the sympathetic stimulation of the pupil is unopposed, leading to the dilation of the pupil (known as mydriasis or blown pupil). This symptom is usually observed before the drooping of the eyelid (lid ptosis) and the downward and outward positioning of the eye.

      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 24 - 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: Weber’s syndrome

      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 25 - A 65-year-old patient who was diagnosed with Parkinson's disease five years ago has...

    Incorrect

    • 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: Dementia with Lewy Bodies

      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 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 26 - 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: Ipsilateral rhinorrhoea

      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.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the...

    Correct

    • 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 hand muscles is MOST likely to be impacted in this individual?

      Your Answer: Medial 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 abductor digiti minimi. On the other hand, the median nerve innervates the opponens pollicis, lateral two lumbricals, and flexor pollicis brevis. Lastly, the radial nerve is responsible for innervating the extensor digitorum muscle.

    • This question is part of the following fields:

      • Neurology
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  • Question 28 - A 62-year-old man presents with right-sided hemiplegia of the limbs, face, and tongue...

    Incorrect

    • A 62-year-old man presents with right-sided hemiplegia of the limbs, face, and tongue and left-sided deficits in motor eye activity. He has a past medical history of hypertension, diabetes, and a previous ischemic stroke. A CT head scan is 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: Lateral pontine syndrome

      Correct Answer: Weber’s syndrome

      Explanation:

      Occlusion of the branches of the basilar artery that supply the midbrain leads to the development of Weber’s syndrome. This condition is characterized by contralateral hemiplegia, which affects the limbs, face, and tongue due to damage to the descending motor tracts within the crus cerebri. Additionally, there are ipsilateral deficits in eye motor activity caused by damage to cranial nerve III.

    • This question is part of the following fields:

      • Neurology
      190.3
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  • Question 29 - A 67-year-old right-handed woman experiences a stroke. During examination, it is observed that...

    Correct

    • A 67-year-old right-handed woman experiences a stroke. During examination, it is observed that she has weakness in her left arm and neglect on the left side of her body. Which blood vessel is most likely to be affected?

      Your 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - A 4-year-old child is brought in by ambulance. He has been experiencing seizures...

    Incorrect

    • A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 35 minutes. He has received two doses of IV lorazepam. His bowel movement is normal, and he is not taking any medication.

      According to the current APLS guidelines, what would be the most suitable next course of action in managing his condition?

      Your Answer: Give a third dose of lorazepam

      Correct Answer: Set up phenytoin infusion

      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.

    • This question is part of the following fields:

      • Neurology
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