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  • Question 1 - A 35-year-old man comes to the clinic complaining of a 3-day history of...

    Incorrect

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

      What is the MOST LIKELY diagnosis for this patient?

      Your Answer: Peripheral neuropathy

      Correct Answer: Guillain-Barré syndrome

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Neurology
      189.1
      Seconds
  • Question 2 - A 25-year-old man comes in with a complaint of headache, fever, and growing...

    Incorrect

    • A 25-year-old man comes in with a complaint of headache, fever, and growing drowsiness. He recently had a flu-like illness but his condition worsened this morning, prompting his partner to call for the GP. He exhibits significant neck stiffness and sensitivity to light. During the examination, you observe a petechial rash on his abdomen.

      What is the SINGLE most probable diagnosis?

      Your Answer: Subarachnoid haemorrhage

      Correct Answer: Meningococcal septicaemia

      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
      324.5
      Seconds
  • Question 3 - A 65 year old is brought into the emergency department by a coworker...

    Incorrect

    • A 65 year old is brought into the emergency department by a coworker who is concerned about the patient being disoriented. The coworker says he overheard the patient talking to someone in the break room but when he looked over to join the conversation, there was no one there. Despite there being no one present, the patient continued to have a dialogue with thin air. The coworker informs you that he has noticed the patient being a bit confused at times before, but the confusion usually resolves within a day or two. During the examination, you observe a shuffling gait and resting tremor. What is the most likely diagnosis?

      Your Answer: Alzheimer's disease

      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
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  • Question 4 - 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 evaluate the patient and initiate her treatment.

      Which of the following is the most suitable INITIAL treatment?

      Your Answer: Intravenous thiamine

      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
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  • Question 5 - A 35 year old male comes to the emergency department with sudden onset...

    Incorrect

    • 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: Pupil reaction to light

      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.

    • This question is part of the following fields:

      • Neurology
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  • Question 6 - A middle-aged man presents with visual difficulties. Upon examination, it is discovered that...

    Incorrect

    • A middle-aged man presents with visual difficulties. Upon examination, it is discovered that he has a quadrantic visual field defect. He is subsequently taken to the hospital for a CT head scan, which confirms a diagnosis of a cerebrovascular accident.
      Which of the following blood vessels is most likely to be impacted?

      Your Answer: Anterior cerebral artery

      Correct Answer: Posterior 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
      91.7
      Seconds
  • Question 7 - A 35-year-old man comes to the clinic complaining of increasing numbness and weakness...

    Incorrect

    • A 35-year-old man comes to the clinic complaining of increasing numbness and weakness in his legs over the past 4 days. The symptoms seem to be spreading upwards towards his thighs, and he has also noticed some weakness in his hands. He mentions that he had a bad bout of diarrhea about three weeks ago, but otherwise, he has been healthy. What is the most likely organism responsible for his symptoms?

      Your Answer: Clostridium difficile

      Correct Answer: Campylobacter jejuni

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Neurology
      184.9
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  • Question 8 - A 42-year-old woman presents with a history of progressively worsening weakness in her...

    Correct

    • A 42-year-old woman presents with a history of progressively worsening weakness in her right arm. She denies any history of speech difficulties, neck pain, or issues with hand coordination. On examination, there is noticeable muscle wasting in her right upper limb with an upward plantar response. Fasciculations are also observed in her right forearm. There is no apparent sensory loss.
      What is the SINGLE most probable diagnosis?

      Your Answer: Amyotrophic Lateral Sclerosis (ALS)

      Explanation:

      Motor Neuron Disease (MND) is a group of degenerative diseases that primarily involve the loss of specific neurons in the motor cortex, cranial nerve nuclei, and anterior horn cells. Both upper and lower motor neurons are affected in this condition. It is important to note that MND does not cause any sensory or sphincter disturbances, and it does not affect eye movements.

      MND is relatively uncommon, with a prevalence of approximately 5-7 cases per 100,000 individuals. The median age of onset in the United Kingdom is 60 years, and unfortunately, it often leads to fatality within 2 to 4 years of diagnosis. The treatment for MND mainly focuses on providing supportive care through a multidisciplinary approach.

      There are four distinct clinical patterns observed in MND. The first pattern, known as Amyotrophic Lateral Sclerosis (ALS), accounts for up to 50% of MND cases. It involves the loss of motor neurons in both the motor cortex and the anterior horn of the spinal cord. Clinically, individuals with ALS experience weakness and exhibit signs of both upper and lower motor neuron involvement.

      The second pattern, called Progressive Bulbar Palsy, occurs in up to 10% of MND cases. This condition specifically affects cranial nerves IX-XII, resulting in Bulbar and pseudobulbar palsy.

      Progressive Muscular Atrophy is the third pattern, also seen in up to 10% of MND cases. It primarily affects the anterior horn cells, leading to the presence of only lower motor neuron signs.

      Lastly, Primary Lateral Sclerosis involves the loss of Betz cells in the motor cortex. Clinically, individuals with this pattern exhibit upper motor neuron signs, including marked spastic leg weakness and pseudobulbar palsy.

    • This question is part of the following fields:

      • Neurology
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  • Question 9 - A child develops a palsy of their right arm following a difficult birth....

    Incorrect

    • A child develops a palsy of their right arm following a difficult birth. During the examination, it is observed that there is a lack of shoulder abduction, external rotation, and elbow flexion. The arm is visibly hanging with the elbow extended and the forearm pronated.
      Which nerve root is most likely to have been affected in this situation?

      Your Answer: C2

      Correct Answer: C5

      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
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  • Question 10 - A 65 year old is brought into the emergency department (ED) after experiencing...

    Incorrect

    • A 65 year old is brought into the emergency department (ED) after experiencing a head injury. As part of the initial assessment, you evaluate the patient's Glasgow Coma Scale (GCS) score. In an adult patient, what is the minimum GCS score that necessitates an urgent CT scan of the head?

      Your Answer: 9

      Correct Answer: 13

      Explanation:

      In an adult patient, a Glasgow Coma Scale (GCS) score of 13 or lower necessitates an urgent CT scan of the head. The GCS is a neurological assessment tool that evaluates a patient’s level of consciousness and neurological functioning. It consists of three components: eye opening, verbal response, and motor response. Each component is assigned a score ranging from 1 to 4 or 5, with a higher score indicating a higher level of consciousness.

      A GCS score of 15 is considered normal and indicates that the patient is fully conscious. A score of 14 or 13 suggests a mild impairment in consciousness, but it may not necessarily require an urgent CT scan unless there are other concerning symptoms or signs. However, a GCS score of 11 or 9 indicates a moderate to severe impairment in consciousness, which raises concerns for a potentially serious head injury. In these cases, an urgent CT scan of the head is necessary to assess for any structural brain abnormalities or bleeding that may require immediate intervention.

      Therefore, in this case, the minimum GCS score that necessitates an urgent CT scan of the head is 13.

      Further Reading:

      Indications for CT Scanning in Head Injuries (Adults):
      – CT head scan should be performed within 1 hour if any of the following features are present:
      – GCS < 13 on initial assessment in the ED
      – GCS < 15 at 2 hours after the injury on assessment in the ED
      – Suspected open or depressed skull fracture
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – Post-traumatic seizure
      – New focal neurological deficit
      – > 1 episode of vomiting

      Indications for CT Scanning in Head Injuries (Children):
      – CT head scan should be performed within 1 hour if any of the features in List 1 are present:
      – Suspicion of non-accidental injury
      – Post-traumatic seizure but no history of epilepsy
      – GCS < 14 on initial assessment in the ED for children more than 1 year of age
      – Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
      – At 2 hours after the injury, GCS < 15
      – Suspected open or depressed skull fracture or tense fontanelle
      – Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
      – New focal neurological deficit
      – For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

      – CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
      – Loss of consciousness lasting more than 5 minutes (witnessed)
      – Abnormal drowsiness
      – Three or more discrete episodes of vomiting
      – Dangerous mechanism of injury (high-speed road traffic accident, fall from a height of

    • This question is part of the following fields:

      • Neurology
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  • Question 11 - A 68-year-old individual presents with rest tremor, rigidity, and bradykinesia. A diagnosis of...

    Incorrect

    • A 68-year-old individual presents with rest tremor, rigidity, and bradykinesia. A diagnosis of Parkinson's disease is determined.
      Parkinson's disease primarily occurs due to a loss of dopaminergic cells in which anatomical regions?

      Your Answer: Pons

      Correct Answer: Midbrain

      Explanation:

      Parkinson’s disease is primarily characterized by the degeneration of cells in the substantia nigra, a region located in the midbrain. The most severely affected part is the pars compacta, which plays a crucial role in motor control. As a result, there is a significant decrease in the activity of cells that secrete dopamine.

      The main symptoms of Parkinson’s disease include tremors that occur when the body is at rest, rigidity in the muscles, and bradykinesia, which refers to a slowness in movement. These symptoms can greatly impact a person’s ability to perform everyday tasks and can progressively worsen over time.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - A 42-year-old man has been brought into the Emergency Department (ED) experiencing seizures...

    Incorrect

    • A 42-year-old man has been brought into the Emergency Department (ED) experiencing seizures that have lasted for 40 minutes before his arrival. On arrival, he is still having a tonic-clonic seizure. He is a known epileptic and is currently taking phenobarbital for seizure prevention. He has received a single dose of rectal diazepam by the paramedics on the way to the hospital approximately 15 minutes ago. Upon arrival in the ED, intravenous access is established, and a dose of IV lorazepam is administered. After an additional 15 minutes, a fosphenytoin infusion is started. Another 25 minutes have passed, and he has not responded to the previous treatment.

      Which of the following medications would be most appropriate to administer next?

      Your Answer: Lamotrigine infusion

      Correct Answer: Thiopental sodium bolus

      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 case, the patient has already received two doses of benzodiazepine and is currently on a phenytoin infusion. However, despite these treatments, the seizures persist, and it has been 20 minutes since the infusion started. At this point, the preferred treatment option is to induce general anesthesia. The induction agents that can be considered include thiopental sodium, propofol, and midazolam. There is no need to administer intravenous thiamine in this situation.

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

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

      2nd stage (0-30 minutes):
      – Implement regular monitoring
      – Consider the possibility of non-epileptic status
      – Initiate emergency antiepileptic drug (AED) therapy
      – Perform emergency investigations
      – Administer glucose or intravenous thiamine if alcohol abuse or impaired nutrition is suspected
      – Treat severe acidosis if present

      3rd stage (0-60 minutes):
      – Determine the underlying cause of status epilepticus
      – Notify the anesthetist and intensive care unit (ITU)
      – Identify and treat any medical complications
      – Consider pressor therapy if necessary

      4th stage (30-90 minutes):
      – Transfer the patient to the intensive care unit
      – Establish intensive care and EEG monitoring
      – Initiate long-term maintenance AED therapy
      – Perform further investigations as needed, such as brain imaging or lumbar puncture

      Emergency 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 done to evaluate the possibility of aspiration. Additional investigations depend on the clinical circumstances and may include brain imaging or lumbar puncture.

      Monitoring during the management of status epilepticus involves regular neurological observations and measurements of pulse, blood pressure, and temperature.

    • This question is part of the following fields:

      • Neurology
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  • Question 13 - A middle-aged man is brought to the hospital with slurred speech and unusual...

    Correct

    • A middle-aged man is brought to the hospital with slurred speech and unusual behavior. He has been experiencing urinary incontinence and has also noticed weakness in his right arm. A CT scan is conducted, which confirms the diagnosis of a stroke.
      Which of the following blood vessels is most likely to be affected?

      Your Answer: Anterior cerebral artery

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Neurology
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  • Question 14 - You assess a patient who has a confirmed diagnosis of Parkinson's disease. She...

    Incorrect

    • You assess a patient who has a confirmed diagnosis of Parkinson's disease. She has been living with the disease for several years and is currently in the advanced stages of the condition.
      Which of the following clinical manifestations is typically observed only in the later stages of Parkinson's disease?

      Your Answer: Bradykinesia

      Correct Answer: Cognitive impairment

      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 movements

      Initially, 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 hypotension

      Although 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 15 - A patient who was diagnosed with Parkinson's disease two years ago has experienced...

    Incorrect

    • A patient who was diagnosed with Parkinson's disease two years ago has experienced a sudden decline in her functioning and is experiencing significant issues with balance. She is at a high risk of falling and recently fractured her wrist. She complains of severe dryness in her eyes and struggles to look downwards. Her husband reports that she is currently feeling very down and has been displaying uncharacteristic episodes of anger. Additionally, you observe that her speech is slurred today.

      What is the most probable diagnosis in this case?

      Your Answer: Corticobasal degeneration

      Correct Answer: Progressive Supranuclear Palsy

      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 16 - You evaluate a 32-year-old woman with grip weakness. During your examination, you find...

    Incorrect

    • You evaluate a 32-year-old woman with grip weakness. During your examination, you find that 'Froment's sign' is positive.
      Which nerve is most likely to be affected in this scenario?

      Your Answer:

      Correct Answer: Ulnar nerve

      Explanation:

      Ulnar nerve lesions can be assessed using Froment’s sign. To perform this test, a piece of paper is placed between the patient’s thumb and index finger. The examiner then tries to pull the paper out of the patient’s pinched grip. If the patient has an ulnar nerve palsy, they will struggle to maintain the grip and may compensate by flexing the flexor pollicis longus muscle of the thumb to maintain pressure. This compensation is evident when the patient’s interphalangeal joint of the thumb flexes. Froment’s sign is a useful indicator of ulnar nerve dysfunction.

    • This question is part of the following fields:

      • Neurology
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  • Question 17 - A 32-year-old man presents with a range of neurological symptoms. He has been...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 18 - A toddler is brought in with a non-blanching rash and a high fever....

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 19 - 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 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 20 - A middle-aged patient experiences a stroke that leads to impairment in Wernicke’s area.
    What...

    Incorrect

    • A middle-aged patient experiences a stroke that leads to impairment in Wernicke’s area.
      What consequences can be expected from damage to Wernicke’s area?

      Your Answer:

      Correct Answer: Receptive aphasia

      Explanation:

      Wernicke’s area is situated in the dominant cerebral hemisphere temporal lobe. Specifically, it can be found in the posterior section of the superior temporal gyrus.

      This area is responsible for comprehending both written and spoken language. It allows individuals to read a sentence, understand its meaning, and articulate it verbally.

      When Wernicke’s area is damaged, patients may be able to string words together fluently, but the resulting phrases lack coherence and meaning. This condition is known as receptive aphasia or Wernicke’s aphasia.

    • This question is part of the following fields:

      • Neurology
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  • Question 21 - A 25-year-old male is admitted to the emergency department with severe head injuries...

    Incorrect

    • A 25-year-old male is admitted to the emergency department with severe head injuries after jumping from a bridge in a suicide attempt. The following neurological deficits are observed:

      - Contralateral lower limb motor deficit
      - Bladder incontinence
      - Ipsilateral motor and sensory deficits
      - Dysarthria

      Which brain herniation syndrome is most consistent with these findings?

      Your Answer:

      Correct Answer: Subfalcine herniation

      Explanation:

      Subfalcine herniation occurs when a mass in one side of the brain causes the cingulate gyrus to be pushed under the falx cerebri. This condition often leads to specific neurological symptoms. These symptoms include a motor deficit in the lower limb on the opposite side of the body, bladder incontinence, motor and sensory deficits on the same side of the body as the herniation, and difficulty with speech (dysarthria).

      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 22 - A 45-year-old woman with no permanent address sustains a head injury after falling....

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 23 - A 72 year old female arrives at the emergency department after speaking with...

    Incorrect

    • 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

    • This question is part of the following fields:

      • Neurology
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  • Question 24 - A toddler is brought in with a rash and a high fever. You...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A 45-year-old man presents with complaints of headaches. He recently started a new...

    Incorrect

    • A 45-year-old man presents with complaints of headaches. He recently started a new job and spends a significant amount of time on a computer. He admits to feeling more stressed than usual lately. He describes his headaches as a tight band around his head that sometimes extends into his neck. The headaches are more severe towards the end of the day and typically last for a couple of hours. He does not experience any aura, sensitivity to light, or nausea during an episode. The headaches occur approximately 4-5 days per month and are relieved by over-the-counter pain medication.

      What is the most likely diagnosis for this patient?

      Your Answer:

      Correct Answer: Episodic tension-type headache

      Explanation:

      This patient’s history is indicative of episodic tension-type headache. Chronic tension-type headache is defined as experiencing headaches on more than 15 days per month.

      Migraine with typical aura presents with temporary visual disturbances such as hemianopia or scintillating scotoma that spreads. Migraine without aura must meet the criteria set by the International Headache Society, which are outlined below:

      1. The patient must have at least five attacks that meet criteria 2-4.
      2. The duration of each headache attack should be between 4 and 72 hours.
      3. The headache must have at least two of the following characteristics:
      – Located on one side of the head
      – Pulsating quality
      – Moderate or severe pain intensity
      – Aggravation or avoidance of routine physical activity (e.g., walking or climbing stairs)
      4. During the headache, the patient must experience at least one of the following:
      – Nausea and/or vomiting
      – Sensitivity to light (photophobia) and sound (phonophobia)
      5. The headache should not be attributed to another disorder.

      Medication overuse headache is suspected when a patient uses multiple medications, often at low doses, without experiencing any relief from their headaches. Combination medications containing barbiturates, codeine, and caffeine are frequently involved. The diagnosis can only be confirmed when the symptoms improve after discontinuing the medication.

    • This question is part of the following fields:

      • Neurology
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  • Question 26 - A 55-year-old woman with no permanent residence experiences a head injury after a...

    Incorrect

    • A 55-year-old woman with no permanent residence experiences a head injury after a fall. 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 treatment is most likely responsible for causing these symptoms?

      Your Answer:

      Correct Answer: Intravenous glucose

      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.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 3-year-old boy is brought to the Emergency Department by his parents following...

    Incorrect

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

      Your Answer:

      Correct Answer: 10%

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
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  • Question 28 - You have been tasked with arranging a case-based teaching session for the junior...

    Incorrect

    • 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

    • This question is part of the following fields:

      • Neurology
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  • Question 29 - You evaluate a 40-year-old man with a sudden onset entrapment neuropathy involving the...

    Incorrect

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

      Your Answer:

      Correct Answer: Lateral two lumbricals

      Explanation:

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

    • This question is part of the following fields:

      • Neurology
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  • Question 30 - A 38-year-old man comes in after experiencing a seizure. His wife was present...

    Incorrect

    • A 38-year-old man comes in after experiencing a seizure. His wife was present during the episode and reported that his eyes rolled upwards before he became rigid. He felt extremely tired afterwards. Following that, he had shaking movements in all four limbs for approximately 3 minutes and lost control of his bladder. He has no other medical conditions and is generally healthy.
      What type of seizure did he have?

      Your Answer:

      Correct Answer: Generalised, tonic-clonic

      Explanation:

      The patient’s history aligns with a generalized tonic-clonic seizure. The observer of the incident provided a detailed description, which is crucial in diagnosing epilepsy.

      Diagnosing epilepsy can sometimes rely solely on the patient’s history. It is common to ask the patient to maintain a seizure diary to identify patterns and potential triggers. Additionally, EEG tests, along with an MRI scan or CT scan of the brain, can provide further insight into the type and possible cause of the seizures.

    • This question is part of the following fields:

      • Neurology
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