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Question 1
Incorrect
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A 35-year-old woman comes in with her husband. She is extremely concerned about his frequent headaches and recent changes in his behavior. He complains of experiencing intense pain behind his left eye in the late evenings for the past two weeks. The pain typically lasts for about half an hour, and his wife mentions that he occasionally bangs his head against the wall due to the severity of the pain. Additionally, his left eye becomes watery during these episodes. A thorough neurological examination reveals no abnormalities.
What is the most probable diagnosis in this case?Your Answer: Medication overuse headache
Correct Answer: Cluster headache
Explanation:Cluster headaches are a type of headache that is commonly seen in young men in their 20s. The male to female ratio for this condition is 6:1. Smoking is also known to increase the risk of developing cluster headaches. These headaches occur in clusters, usually lasting for a few weeks every year or two. The pain experienced is severe and typically affects one side of the head, often around or behind the eye. It tends to occur at the same time each day and can cause the patient to become agitated, sometimes resorting to hitting their head against a wall or the floor in an attempt to distract from the pain.
In addition to the intense pain, cluster headaches are also associated with autonomic involvement. This can manifest as various symptoms on the same side as the headache, including conjunctival injection (redness of the eye), rhinorrhea (runny nose), lacrimation (tearing of the eye), miosis (constriction of the pupil), and ptosis (drooping of the eyelid).
On the other hand, migraine with typical aura presents with temporary visual disturbances, such as hemianopia (loss of vision in half of the visual field) or scintillating scotoma (a visual aura that appears as a shimmering or flashing area of distorted vision). Migraine without aura, on the other hand, needs to meet specific criteria set by the International Headache Society. These criteria include having at least five headache attacks lasting between 4 to 72 hours, with the headache having at least two of the following characteristics: unilateral location, pulsating quality, moderate to severe pain intensity, and aggravation by routine physical activity.
During a migraine headache, the patient may also experience symptoms such as nausea and/or vomiting, as well as sensitivity to light (photophobia) and sound (phonophobia). It is important to note that these symptoms should not be attributed to another underlying disorder.
If a patient over the age of 50 presents with a new-onset headache, it raises the possibility of giant cell arteritis (temporal arteritis). Other symptoms and signs that may be associated with this condition include jaw claudication (pain in the jaw when chewing), systemic upset, scalp tenderness, and an elevated erythrocyte sedimentation rate (ESR).
Medication overuse headache is a condition that is suspected when a patient is using multiple medications, often at low doses, without experiencing any relief from their headaches.
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This question is part of the following fields:
- Neurology
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Question 2
Incorrect
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A 32-year-old woman has been brought into the Emergency Department, experiencing seizures that have lasted for 15 minutes before her arrival. On arrival, she is still having a tonic-clonic seizure. She is known to be homeless and has a long history of alcohol abuse. The paramedics administered a single dose of rectal diazepam on the way, approximately 12 minutes ago. Her vital signs are as follows: HR 110, BP 100/60, SaO2 98% on high flow oxygen, temperature is 37.2°C.
Which of the following medications would be most appropriate to administer next?Your Answer: Propofol bolus
Correct Answer: Intravenous thiamine
Explanation:Status epilepticus is a condition characterized by continuous seizure activity lasting for 5 minutes or more without the return of consciousness, or recurrent seizures (2 or more) without a period of neurological recovery in between. In this particular patient’s case, his history of chronic alcohol abuse, homelessness, and likely impaired nutrition necessitates the administration of intravenous thiamine in the form of Pabrinex. Additionally, a second dose of benzodiazepine should be given, and his blood glucose levels should be urgently checked.
The management of status epilepticus involves several general measures, which are outlined in the following table:
1st stage (Early status, 0-10 minutes):
– Secure the airway and provide resuscitation
– Administer oxygen
– Assess cardiorespiratory function
– Establish intravenous access2nd stage (0-30 minutes):
– Implement regular monitoring
– Consider the possibility of non-epileptic status
– Initiate emergency antiepileptic drug (AED) therapy
– Perform emergency investigations
– Administer glucose (50 ml of 50% solution) and/or intravenous thiamine as Pabrinex if there are indications of alcohol abuse or impaired nutrition
– Treat severe acidosis if present3rd stage (0-60 minutes):
– Determine the underlying cause of status epilepticus
– Notify the anaesthetist and intensive care unit (ITU)
– Identify and treat any medical complications
– Consider pressor therapy when appropriate4th stage (30-90 minutes):
– Transfer the patient to the intensive care unit
– Establish intensive care and EEG monitoring
– Initiate intracranial pressure monitoring if necessary
– Start initial long-term, maintenance AED therapyEmergency investigations include blood tests for gases, glucose, renal and liver function, calcium and magnesium levels, full blood count (including platelets), blood clotting, and AED drug levels. Serum and urine samples should be saved for future analysis, including toxicology if the cause of convulsive status epilepticus is uncertain. A chest radiograph may be performed to evaluate the possibility of aspiration. Additional investigations, such as brain imaging or lumbar puncture, depend on the clinical circumstances.
Monitoring during the management of status epilepticus involves regular neurological observations and measurements of pulse, blood pressure, and temperature.
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This question is part of the following fields:
- Neurology
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Question 3
Correct
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A 42-year-old woman comes in with complaints of migraines and feeling nauseous. After undergoing an MRI, it is revealed that she has a tumor on the left side of her cerebellum that shows minimal contrast enhancement.
Which of the following is NOT expected to be impacted the most?Your Answer: Spontaneous facial expression
Explanation:The cerebellum, also known as the ‘little brain’ in Latin, is a structure within the central nervous system. It is situated at the posterior part of the brain, beneath the occipital and temporal lobes of the cerebral cortex. Despite its relatively small size, the cerebellum houses more than half of the total number of neurons in the brain, accounting for about 10% of its volume.
The cerebellum serves several crucial functions. It is responsible for maintaining balance and posture, ensuring that we stay upright and steady. Additionally, it plays a vital role in coordinating voluntary movements, allowing us to perform tasks that require precise and synchronized actions. The cerebellum is also involved in motor learning, enabling us to acquire new skills and improve our motor abilities over time. Furthermore, it contributes to cognitive function, supporting various mental processes.
It is important to note that spontaneous facial expression is controlled by the frontal lobes and is unlikely to be impacted by a tumor located in the cerebellum.
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This question is part of the following fields:
- Neurology
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Question 4
Incorrect
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A 42-year-old man has been brought into the Emergency Department, experiencing seizures that have lasted for 40 minutes before his arrival. On arrival, he is still having a tonic-clonic seizure. He is a known epileptic and is currently taking lamotrigine for seizure prevention. He has received a single dose of rectal diazepam by the paramedics en route approximately 15 minutes ago. His vital signs are as follows: HR 92, BP 120/70, SaO2 98% on high flow oxygen, temperature is 36.8°C. His blood glucose level is 1.5 mmol/L, and he has an intravenous line in place.
Which of the following medications would be most appropriate to administer next?Your Answer: Phenytoin infusion
Correct Answer: Intravenous glucose
Explanation:Status epilepticus is a condition characterized by continuous seizure activity lasting for 5 minutes or more without the return of consciousness, or recurrent seizures (2 or more) without a period of neurological recovery in between. In such cases, it is important to address any low blood glucose levels urgently by administering intravenous glucose. While the patient may require additional antiepileptic drug (AED) therapy, the management of status epilepticus involves several general measures.
During the early stage of status epilepticus (0-10 minutes), the airway should be secured and resuscitation measures should be taken. Oxygen should be administered and the cardiorespiratory function should be assessed. It is also important to establish intravenous access. In the second stage (0-30 minutes), regular monitoring should be instituted and the possibility of non-epileptic status should be considered. Emergency AED therapy should be initiated and emergency investigations should be conducted. If there are indications of alcohol abuse or impaired nutrition, glucose and/or intravenous thiamine may be administered. Acidosis should be treated if severe.
In the third stage (0-60 minutes), the underlying cause of status epilepticus should be identified. The anaesthetist and intensive care unit (ITU) should be alerted. Any medical complications should be identified and treated, and pressor therapy may be considered if appropriate. In the fourth stage (30-90 minutes), the patient should be transferred to intensive care. Intensive care and EEG monitoring should be established, and intracranial pressure monitoring may be initiated if necessary. Initial long-term, maintenance AED therapy should also be initiated.
Emergency investigations for status epilepticus include blood tests for blood gases, glucose, renal and liver function, calcium and magnesium, full blood count (including platelets), blood clotting, and AED drug levels. Serum and urine samples should be saved for future analysis, including toxicology if the cause of the convulsive status epilepticus is uncertain. A chest radiograph may be taken to evaluate the possibility of aspiration. Additional investigations, such as brain imaging or lumbar puncture, may be conducted depending on the clinical circumstances.
Monitoring during the management of status epilepticus involves regular neurological observations and measurements of pulse, blood pressure, and temperature.
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This question is part of the following fields:
- Neurology
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Question 5
Correct
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A fourth-year medical student is studying subarachnoid hemorrhages (SAH).
Which of the following statements is accurate regarding subarachnoid hemorrhage?Your 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.
The majority of SAH cases (80%) 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 found. Berry aneurysms are 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, mycotic aneurysm, and a family history of 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 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 event.
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 and there are no contraindications, a lumbar puncture (LP) should be performed at least 12 hours after the onset of headache to diagnose SAH. Approximately 3% of patients with a negative CT scan will be confirmed to have had an SAH following an LP.
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This question is part of the following fields:
- Neurology
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Question 6
Correct
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A 68 year old is brought into the emergency department by his worried husband. The patient's husband informs you that the patient appears to be more disoriented than usual and is experiencing excessive daytime sleepiness. He mentions that the patient was diagnosed with Alzheimer's disease approximately half a year ago. What is the most accurate description of the underlying pathology in Alzheimer's disease?
Your Answer: Beta-amyloid plaques and neurofibrillary tangles
Explanation:Alzheimer’s disease, the leading cause of dementia, is characterized by the presence of beta-amyloid plaques and neurofibrillary tangles in the brain. These plaques are formed due to an excessive buildup of amyloid, which can be caused by either overproduction or impaired clearance of beta-amyloid. The accumulation of amyloid plaques leads to inflammation in the surrounding brain tissue, resulting in damage to neurons. Additionally, the abnormal phosphorylation of tau protein causes it to aggregate into neurofibrillary tangles within neurons. It is important to note that Lewy bodies, composed mainly of alpha-synuclein, are associated with diseases like Parkinson’s disease and dementia with Lewy bodies. Autoimmune diseases often involve the activation of autoreactive T-cells.
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.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 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 lamotrigine for seizure prevention. He has received a single dose of rectal diazepam by the paramedics en route approximately 15 minutes ago. Upon arrival in the ED, intravenous access is established, and a dose of IV lorazepam is administered. His blood glucose level is checked and is 4.5 mmol/L.
He continues to have seizures for the next 15 minutes. Which medication should be administered next?Your Answer: Thiopental sodium bolus
Correct Answer: Phenytoin infusion
Explanation:Status epilepticus is a condition characterized by continuous seizure activity lasting for 5 minutes or more without the return of consciousness, or the occurrence of recurrent seizures (2 or more) without any intervening period of neurological recovery.
In the management of a patient with status epilepticus, if the patient has already received two doses of benzodiazepine and is still experiencing seizures, the next step should be to initiate a phenytoin infusion. This involves administering a dose of 15-18 mg/kg at a rate of 50 mg/minute. Alternatively, fosphenytoin can be used as an alternative, and a phenobarbital bolus of 10-15 mg/kg at a rate of 100 mg/minute can also be considered. It is important to note that there is no indication for the administration of intravenous glucose or thiamine in this situation.
The management of status epilepticus involves several general measures. In the early stage (0-10 minutes), the airway should be secured and resuscitation should be performed. Oxygen should be administered and the patient’s cardiorespiratory function should be assessed. Intravenous access should also be established.
In the second stage (0-30 minutes), regular monitoring should be instituted. It is important to consider the possibility of non-epileptic status and commence emergency antiepileptic drug (AED) therapy. Emergency investigations should be conducted, including the administration of glucose (50 ml of 50% solution) and/or intravenous thiamine if there is any suggestion of alcohol abuse or impaired nutrition. Acidosis should be treated if it is severe.
In the third stage (0-60 minutes), the underlying cause of the status epilepticus should be identified. The anaesthetist and intensive care unit (ITU) should be alerted, and any medical complications should be identified and treated. Pressor therapy may be appropriate in certain cases.
In the fourth stage (30-90 minutes), the patient should be transferred to the intensive care unit. Intensive care and EEG monitoring should be established, and intracranial pressure monitoring may be necessary in certain cases. Initial long-term, maintenance AED therapy should also be initiated.
Emergency investigations should include blood tests for blood gases, glucose, renal and liver function, calcium and magnesium, full blood count (including platelets), blood clotting, and AED drug levels.
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This question is part of the following fields:
- Neurology
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Question 8
Correct
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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: 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.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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A 42-year-old woman comes in with a headache that feels like she has been punched in the head. The headache throbs towards the back of the head and is accompanied by nausea. A CT scan of the head is performed, and it confirms a diagnosis of subarachnoid hemorrhage.
In which of the following areas will blood have accumulated?Your Answer: Between the endosteal layer and the meningeal layer of the dura mater
Correct Answer: Between the arachnoid mater and pia mater
Explanation:The meninges refer to the protective tissue layers that surround the brain and spinal cord. These layers, along with the cerebrospinal fluid (CSF), work together to safeguard the central nervous system structures from physical harm and provide support for the blood vessels in the brain and skull.
The meninges consist of three distinct layers: the outermost layer called the dura mater, the middle layer known as the arachnoid mater, and the innermost layer called the pia mater.
There are three types of hemorrhage that involve the meninges. The first is extradural (or epidural) hemorrhage, which occurs when blood accumulates between the dura mater and the skull. The second is subdural hemorrhage, where blood gathers between the dura mater and the arachnoid mater. Lastly, subarachnoid hemorrhage happens when blood collects in the subarachnoid space, which is the area between the arachnoid mater and the pia mater.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 25 year old third year medical student is brought into the emergency department for a check up after fainting while observing a prolonged delivery that required an emergency C-section. The patient complains of feeling warm and sweaty for a couple of minutes before becoming lightheaded and losing consciousness. There were no reports of loss of bladder or bowel control, and no tongue biting was observed. Physical examination reveals no focal neurological deficits and a normal cardiovascular examination. Blood pressure is 122/74 mmHg when lying down and 120/72 mmHg when standing.
What is the probable cause of the fainting episode?Your Answer: Vasovagal syncope
Explanation:The most likely cause of the fainting episode in this 25-year-old third year medical student is vasovagal syncope. Vasovagal syncope is a common type of fainting that occurs in response to certain triggers, such as emotional stress, pain, or seeing blood. In this case, the prolonged delivery and emergency C-section likely triggered the patient’s vasovagal response.
The patient’s symptoms of feeling warm and sweaty before fainting are consistent with vasovagal syncope. During a vasovagal episode, there is a sudden drop in blood pressure and heart rate, leading to a temporary loss of consciousness. The absence of loss of bladder or bowel control and tongue biting further support this diagnosis.
The physical examination findings of no focal neurological deficits and a normal cardiovascular examination also align with vasovagal syncope. Additionally, the blood pressure measurements of 122/74 mmHg when lying down and 120/72 mmHg when standing suggest orthostatic hypotension, which is commonly seen in vasovagal syncope.
Further Reading:
Blackouts, also known as syncope, are defined as a spontaneous transient loss of consciousness with complete recovery. They are most commonly caused by transient inadequate cerebral blood flow, although epileptic seizures can also result in blackouts. There are several different causes of blackouts, including neurally-mediated reflex syncope (such as vasovagal syncope or fainting), orthostatic hypotension (a drop in blood pressure upon standing), cardiovascular abnormalities, and epilepsy.
When evaluating a patient with blackouts, several key investigations should be performed. These include an electrocardiogram (ECG), heart auscultation, neurological examination, vital signs assessment, lying and standing blood pressure measurements, and blood tests such as a full blood count and glucose level. Additional investigations may be necessary depending on the suspected cause, such as ultrasound or CT scans for aortic dissection or other abdominal and thoracic pathology, chest X-ray for heart failure or pneumothorax, and CT pulmonary angiography for pulmonary embolism.
During the assessment, it is important to screen for red flags and signs of any underlying serious life-threatening condition. Red flags for blackouts include ECG abnormalities, clinical signs of heart failure, a heart murmur, blackouts occurring during exertion, a family history of sudden cardiac death at a young age, an inherited cardiac condition, new or unexplained breathlessness, and blackouts in individuals over the age of 65 without a prodrome. These red flags indicate the need for urgent assessment by an appropriate specialist.
There are several serious conditions that may be suggested by certain features. For example, myocardial infarction or ischemia may be indicated by a history of coronary artery disease, preceding chest pain, and ECG signs such as ST elevation or arrhythmia. Pulmonary embolism may be suggested by dizziness, acute shortness of breath, pleuritic chest pain, and risk factors for venous thromboembolism. Aortic dissection may be indicated by chest and back pain, abnormal ECG findings, and signs of cardiac tamponade include low systolic blood pressure, elevated jugular venous pressure, and muffled heart sounds. Other conditions that may cause blackouts include severe hypoglycemia, Addisonian crisis, and electrolyte abnormalities.
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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A child arrives at the Emergency Department with a petechial rash, headache, neck stiffness, and sensitivity to light. You suspect a diagnosis of meningococcal meningitis. The child has a previous history of experiencing anaphylaxis in response to cephalosporin antibiotics.
Which antibiotic would you administer to this child?Your Answer: Doxycycline
Correct Answer: Chloramphenicol
Explanation:Due to the potentially life-threatening nature of the disease, it is crucial to initiate treatment without waiting for laboratory confirmation. Immediate administration of antibiotics is necessary.
In a hospital setting, the preferred agents for treatment are IV ceftriaxone (2 g for adults; 80 mg/kg for children) or IV cefotaxime (2 g for adults; 80 mg/kg for children). In the prehospital setting, IM benzylpenicillin can be given as an alternative. If there is a history of anaphylaxis to cephalosporins, chloramphenicol is a suitable alternative.
It is important to prioritize prompt treatment due to the severity of the disease. The recommended antibiotics should be administered as soon as possible to ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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You evaluate a 50-year-old woman with recent-onset carpal tunnel syndrome after injuring her wrist.
Which of the following hand muscles is the LEAST likely to be impacted in this patient?Your Answer: Lateral two lumbricals
Correct Answer: Abductor digiti minimi
Explanation:Carpal tunnel syndrome is a condition where the median nerve becomes trapped, resulting in nerve damage. This can lead to weakness and abnormal sensations in the areas supplied by the median nerve. To remember the muscles that are innervated by the median nerve, you can use the acronym ‘LOAF’: L for the lateral two lumbricals, O for the Opponens pollicis, A for the Abductor pollicis, and F for the Flexor pollicis brevis. It’s important to note that the abductor digiti minimi is not affected by carpal tunnel syndrome as it is innervated by the deep branch of the ulnar nerve.
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This question is part of the following fields:
- Neurology
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Question 13
Incorrect
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A 45-year-old man presents with rigidity and slowness of movement. Following a referral to a specialist, a diagnosis of Parkinson’s disease is made. The patient is in the early stages of the disease at present.
Which of the following clinical features is most likely to also be present?Your Answer: Bilateral rest tremor
Correct Answer: Hypokinesia
Explanation:Patients with Parkinson’s disease (PD) typically exhibit the following clinical features:
– Hypokinesia (reduced movement)
– Bradykinesia (slow movement)
– Rest tremor (usually occurring at a rate of 4-6 cycles per second)
– Rigidity (increased muscle tone and ‘cogwheel rigidity’)Other commonly observed clinical features include:
– Gait disturbance (characterized by a shuffling gait and loss of arm swing)
– Loss of facial expression
– Monotonous, slurred speech
– Micrographia (small, cramped handwriting)
– Increased salivation and dribbling
– Difficulty with fine movementsInitially, these signs are typically seen on one side of the body at the time of diagnosis, but they progressively worsen and may eventually affect both sides. In later stages of the disease, additional clinical features may become evident, including:
– Postural instability
– Cognitive impairment
– Orthostatic hypotensionAlthough PD primarily affects movement, patients often experience psychiatric issues such as depression and dementia. Autonomic disturbances and pain can also occur, leading to significant disability and reduced quality of life for the affected individual. Additionally, family members and caregivers may also be indirectly affected by the disease.
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This question is part of the following fields:
- Neurology
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Question 14
Correct
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You are summoned to the resuscitation bay to aid in the care of a 45-year-old male who has suffered a traumatic brain injury. What should be included in the initial management of a patient with elevated intracranial pressure (ICP)?
Your Answer: Maintain systolic blood pressure >90 mmHg
Explanation:Maintaining adequate blood pressure is crucial in managing increased intracranial pressure (ICP). The recommended blood pressure targets may vary depending on the source. The Scottish Intercollegiate Guidelines Network (SIGN) suggests maintaining an adequate blood pressure, while the 4th edition of the Brain Trauma Foundation recommends maintaining a systolic blood pressure (SBP) above 100 mm Hg for individuals aged 50-69 years (or above 110 mm Hg for those aged 15-49 years) to reduce mortality and improve outcomes.
When managing a patient with increased ICP, the initial steps should include maintaining normal body temperature to prevent fever, positioning the patient with a 30º head-up tilt, and administering analgesia and sedation as needed. It is important to monitor and maintain blood pressure, using inotropes if necessary to achieve the target. Additionally, preparations should be made to use medications such as Mannitol or hypertonic saline to lower ICP if required. Hyperventilation may also be considered, although it carries the risk of inducing ischemia and requires monitoring of carbon dioxide levels.
Further Reading:
Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.
The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.
There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.
Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.
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This question is part of the following fields:
- Neurology
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Question 15
Correct
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A 65-year-old woman presents with right-sided weakness and difficulty speaking. Her ROSIER score is 3.
According to the current NICE guidelines, what is the maximum time frame from the start of symptoms within which thrombolysis can be administered?Your Answer: 4.5 hours
Explanation:Alteplase (rt-pA) is a recommended treatment for acute ischaemic stroke in adults if it is initiated within 4.5 hours of the onset of stroke symptoms. It is crucial to exclude intracranial haemorrhage through appropriate imaging techniques before starting the treatment. The initial dose of alteplase is 0.9 mg/kg, with a maximum of 90 mg. This dose is administered intravenously over a period of 60 minutes. The first 10% of the dose is given through intravenous injection, while the remaining amount is administered through intravenous infusion. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals aged 16 and above.
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This question is part of the following fields:
- Neurology
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Question 16
Incorrect
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A 5-year-old boy has had multiple observed instances of momentary pauses that lasted only a few seconds each. He ceases his activities and gazes emptily during these occurrences. The results of his brain scan indicated no abnormalities.
What kind of seizure has he encountered?Your Answer: Grand mal seizure
Correct Answer: Absence seizure
Explanation:This patient has been experiencing absence seizures, which are a form of primary generalized epilepsy that is frequently observed in children.
The defining characteristic of absence seizures is a sudden and immediate loss of consciousness, causing a disruption in ongoing activities. During these episodes, individuals may exhibit a vacant stare and occasionally a brief upward movement of the eyes.
While an EEG cannot definitively confirm or rule out an epilepsy diagnosis, it does provide valuable information in the diagnostic process. In the case of absence seizures, EEG results typically reveal generalized spike-and-slow wave complexes occurring at a frequency of 3-4 Hz.
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This question is part of the following fields:
- Neurology
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Question 17
Incorrect
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A 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: Loss of awareness of sound
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.
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This question is part of the following fields:
- Neurology
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Question 18
Incorrect
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You are requested to aid the team in resuscitating a 42-year-old male who has been admitted to the emergency department with various injuries, including a head injury resulting from a severe assault. The patient shows signs of increased intracranial pressure and has been intubated. The specialist registrar is contemplating the use of hyperventilation. What is the impact of hyperventilation on ICP, and what is its underlying mechanism?
Your Answer: Increases blood p02 which results in venous vasoconstriction and reduced cerebral blood flow
Correct Answer: Increases blood pH which results in arterial vasoconstriction and reduced cerebral blood flow
Explanation:Hyperventilation leads to the constriction of blood vessels in the brain, which in turn reduces the flow and volume of blood in the brain, ultimately decreasing intracranial pressure (ICP). This is because hyperventilation lowers the levels of carbon dioxide (PaCO2) in the blood, resulting in an increase in pH and causing the arteries in the brain to constrict and reduce blood flow. As a result, cerebral blood volume and ICP decrease. The effects of hyperventilation are immediate, but they gradually diminish over a period of 6-24 hours as the brain adjusts its bicarbonate levels to normalize pH. However, caution must be exercised when discontinuing hyperventilation after a prolonged period, as the sudden increase in PaCO2 can lead to a rapid rise in cerebral blood flow and a detrimental increase in ICP.
Further Reading:
Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.
The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.
There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.
Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.
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This question is part of the following fields:
- Neurology
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Question 19
Incorrect
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A 68-year-old man presents with a right-sided headache that has been present for a few days. He also has stiffness and an aching sensation around his neck. He generally feels tired and fatigued and complains that turning his head has been painful.
His observations are as follows: GCS 15/15, temperature 37.2°C, pulse 72/min (regular) and BP 130/78 mmHg. On examination, there is some tenderness over the right occipital area of his scalp with restricted movements to his neck.
What is the SINGLE most appropriate treatment to initiate for him?Your Answer: Intramuscular diclofenac
Correct Answer: High-dose prednisolone tablets
Explanation:This patient presents with a classic case of temporal arteritis, also known as giant cell arteritis (GCA). Temporal arteritis is a chronic condition characterized by inflammation in the walls of medium and large arteries, specifically granulomatous inflammation. It typically affects individuals who are over 50 years old.
The clinical features of temporal arteritis include headache, tenderness in the scalp, jaw claudication, and episodes of sudden blindness or amaurosis fugax (usually occurring in one eye). Some patients may also experience systemic symptoms such as fever, fatigue, loss of appetite, weight loss, and depression.
Temporal arteritis is often associated with polymyalgia rheumatica (PMR) in about 50% of cases. PMR is characterized by stiffness, aching, and tenderness in the upper arms (bilateral) and pain in the pelvic girdle.
Visual loss is an early and significant complication of temporal arteritis, and once it occurs, it rarely improves. Therefore, early treatment with high-dose corticosteroids is crucial to prevent further visual loss and other ischemic complications. If temporal arteritis is suspected, immediate initiation of high-dose glucocorticosteroid treatment (40 – 60 mg prednisolone daily) is necessary. It is also important to arrange an urgent referral for specialist evaluation, including a same-day ophthalmology assessment for those with visual symptoms, and a temporal artery biopsy.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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A 68 year old female is brought into the emergency department by her son due to a two day history of increased confusion and restlessness. The son informs you that the patient had a similar episode 8 months ago that was caused by a urinary tract infection. The son also mentions that the patient is generally in good health but was diagnosed with Parkinson's disease approximately 4 months ago after experiencing a tremor and difficulties with balance. While in the ED, the patient becomes verbally aggressive towards staff and other patients. You decide to administer medication to manage her acute behavior. What is the most suitable choice?
Your Answer: Haloperidol
Correct Answer: Lorazepam
Explanation:Haloperidol should not be used in patients with Parkinson’s, Lewy body dementia, or prolonged QT syndrome. It is the first choice for controlling aggressive behavior in most patients with delirium, but lorazepam is preferred for patients with Parkinson’s, Lewy body dementia, prolonged QT syndrome, extrapyramidal side effects, or delirium due to alcohol withdrawal. Haloperidol can reduce the effectiveness of levodopa in Parkinson’s disease by blocking dopamine receptors in the corpus striatum, which can lead to worsened motor function, psychosis, or a combination of both.
Further Reading:
Delirium is an acute syndrome that causes disturbances in consciousness, attention, cognition, and perception. It is also known as an acute confusional state. The DSM-IV criteria for diagnosing delirium include recent onset of fluctuating awareness, impairment of memory and attention, and disorganized thinking. Delirium typically develops over hours to days and may be accompanied by behavioral changes, personality changes, and psychotic features. It often occurs in individuals with predisposing factors, such as advanced age or multiple comorbidities, when exposed to new precipitating factors, such as medications or infection. Symptoms of delirium fluctuate throughout the day, with lucid intervals occurring during the day and worse disturbances at night. Falling and loss of appetite are often warning signs of delirium.
Delirium can be classified into three subtypes based on the person’s symptoms. Hyperactive delirium is characterized by inappropriate behavior, hallucinations, and agitation. Restlessness and wandering are common in this subtype. Hypoactive delirium is characterized by lethargy, reduced concentration, and appetite. The person may appear quiet or withdrawn. Mixed delirium presents with signs and symptoms of both hyperactive and hypoactive subtypes.
The exact pathophysiology of delirium is not fully understood, but it is believed to involve multiple mechanisms, including cholinergic deficiency, dopaminergic excess, and inflammation. The cause of delirium is usually multifactorial, with predisposing factors and precipitating factors playing a role. Predisposing factors include older age, cognitive impairment, frailty, significant injuries, and iatrogenic events. Precipitating factors include infection, metabolic or electrolyte disturbances, cardiovascular disorders, respiratory disorders, neurological disorders, endocrine disorders, urological disorders, gastrointestinal disorders, severe uncontrolled pain, alcohol intoxication or withdrawal, medication use, and psychosocial factors.
Delirium is highly prevalent in hospital settings, affecting up to 50% of inpatients aged over 65 and occurring in 30% of people aged over 65 presenting to the emergency department. Complications of delirium include increased risk of death, high in-hospital mortality rates, higher mortality rates following hospital discharge, increased length of stay in hospital, nosocomial infections, increased risk of admission to long-term care or re-admission to hospital, increased incidence of dementia, increased risk of falls and associated injuries and pressure sores.
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This question is part of the following fields:
- Neurology
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Question 21
Incorrect
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A middle-aged man presents with homonymous hemianopia. He is brought to the hospital, where a CT head scan is conducted. The CT scan confirms a diagnosis of a stroke.
Which of the following blood vessels is most likely to be impacted?Your Answer: Middle 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.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 78 year old female is brought from her nursing home to the emergency department with heightened confusion after a fall earlier today. A CT head scan is conducted and reveals a subdural hematoma. Which anatomical structure is most likely injured as a result?
Your Answer: Marginal meningeal artery
Correct Answer: Cortical bridging veins
Explanation:Subdural hematoma (SDH) occurs when the bridging veins in the cortex of the brain tear and cause bleeding in the space between the brain and the outermost protective layer. This is different from extradural hematoma (EDH), which is usually caused by a rupture in the middle meningeal artery.
Further Reading:
A subdural hematoma (SDH) is a condition where there is a collection of blood between the dura mater and the arachnoid mater of the brain. It occurs when the cortical bridging veins tear and bleed into the subdural space. Risk factors for SDH include head trauma, cerebral atrophy, advancing age, alcohol misuse, and certain medications or bleeding disorders. SDH can be classified as acute, subacute, or chronic depending on its age or speed of onset. Acute SDH is typically the result of head trauma and can progress to become chronic if left untreated.
The clinical presentation of SDH can vary depending on the nature of the condition. In acute SDH, patients may initially feel well after a head injury but develop more serious neurological symptoms later on. Chronic SDH may be detected after a CT scan is ordered to investigate confusion or cognitive decline. Symptoms of SDH can include increasing confusion, progressive decline in neurological function, seizures, headache, loss of consciousness, and even death.
Management of SDH involves an ABCDE approach, seizure management, confirming the diagnosis with CT or MRI, checking clotting and correcting coagulation abnormalities, managing raised intracranial pressure, and seeking neurosurgical opinion. Some SDHs may be managed conservatively if they are small, chronic, the patient is not a good surgical candidate, and there are no neurological symptoms. Neurosurgical intervention typically involves a burr hole craniotomy to decompress the hematoma. In severe cases with high intracranial pressure and significant brain swelling, a craniectomy may be performed, where a larger section of the skull is removed and replaced in a separate cranioplasty procedure.
CT imaging can help differentiate between subdural hematoma and other conditions like extradural hematoma. SDH appears as a crescent-shaped lesion on CT scans.
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This question is part of the following fields:
- Neurology
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Question 23
Incorrect
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A patient in their late 40s has sustained an injury to their right upper limb and is now experiencing peripheral neuropathy as a result. During the examination, it is observed that their hand is clawed, with the metacarpophalangeal joints hyperextended and the distal and proximal interphalangeal joints of the little and ring fingers flexed. Additionally, there is a slight weakness in wrist flexion, which is accompanied by abduction. The patient also reports sensory loss over the anterior and posterior surfaces of the medial one and a half fingers, as well as the corresponding area of the palm.
Which nerve has been affected in this case?Your Answer: Median nerve at the elbow
Correct Answer: Ulnar nerve at the elbow
Explanation:The ulnar nerve originates from the medial cord of the brachial plexus, specifically from the C8-T1 nerve roots. It may also carry fibers from C7 on occasion. This nerve has both motor and sensory functions.
In terms of motor function, the ulnar nerve innervates the muscles of the hand, excluding the thenar muscles and the lateral two lumbricals (which are supplied by the median nerve). It also innervates two muscles in the anterior forearm: the flexor carpi ulnaris and the medial half of the flexor digitorum profundus.
Regarding sensory function, the ulnar nerve provides innervation to the anterior and posterior surfaces of the medial one and a half fingers, as well as the associated palm and dorsal hand area. There are three sensory branches responsible for the cutaneous innervation of the ulnar nerve. Two of these branches arise in the forearm and travel into the hand: the palmar cutaneous branch, which innervates the skin of the medial half of the palm, and the dorsal cutaneous branch, which innervates the dorsal skin of the medial one and a half fingers and the associated dorsal hand. The third branch arises in the hand and is called the superficial branch, which innervates the palmar surface of the medial one and a half fingers.
When the ulnar nerve is damaged at the elbow, the flexor carpi ulnaris and the medial half of the flexor digitorum profundus muscles in the anterior forearm will be spared. However, if the ulnar nerve is injured at the wrist, these muscles will be affected. Additionally, when the ulnar nerve is damaged at the elbow, flexion of the wrist can still occur due to the intact median nerve, but it will be accompanied by abduction as the flexor carpi ulnaris adducts the hand. On the other hand, wrist flexion will be unaffected when the ulnar nerve is damaged at the wrist.
The sensory function also differs depending on the site of damage. When the ulnar nerve is damaged at the elbow, all three cutaneous branches will be affected, resulting in complete sensory loss in the areas innervated by the ulnar nerve. However, if the damage occurs at the wrist, the two branches that arise in the forearm may be spared.
Damage to the ulnar nerve at either the elbow or wrist leads to a characteristic claw hand appearance, characterized by hyperextension of the metacarpophalangeal joints and flexion of the distal and proximal interphalangeal joint of the little and ring fingers.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A 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: 77mg
Correct Answer: 90mg
Explanation:Alteplase (rt-pA) is recommended for the treatment of acute ischaemic stroke in adults if it is administered as soon as possible within 4.5 hours of the onset of stroke symptoms. It is important to exclude intracranial haemorrhage through appropriate imaging techniques before starting the treatment. The initial dose of alteplase is 0.9 mg/kg, with a maximum dose of 90 mg. This dose should be given intravenously over 60 minutes, with the initial 10% administered by intravenous injection and the remainder by intravenous infusion. In the case of a patient weighing 120 kg, the maximum dose of 90 mg should be administered. For more information, please refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old.
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This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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A 45-year-old woman presents with a history of severe migraines. This morning's episode was similar to previous ones in that it occurred around her right temple and was so intense that she felt like hitting her head to try and distract from the pain. Further questioning and examination lead you to conclude that she is suffering from cluster headaches.
Which of the following is NOT an effective treatment for cluster headaches?Your Answer: Zolmitriptan nasal spray
Correct Answer: Oral codeine phosphate
Explanation:Standard pain relievers are generally not effective in treating cluster headaches. They take too long to work, and by the time they start to relieve the pain, the headache has usually already gone away. It is not recommended to use opioids for cluster headaches as they may actually make the headaches worse, and using them for a long time can lead to dependency.
However, there are other options that can be effective in treating cluster headaches. One option is to use subcutaneous sumatriptan, which is a medication that works by stimulating a specific receptor in the brain. This can help reduce the inflammation in the blood vessels that is associated with migraines and cluster headaches. Most people find that subcutaneous sumatriptan starts to work within 10-15 minutes of being administered.
Another option is to use zolmitriptan nasal spray, which is also a medication that works in a similar way to sumatriptan. However, it may take a bit longer for the nasal spray to start working compared to the subcutaneous injection.
In addition to medication, high-flow oxygen can also be used as an alternative therapy for cluster headaches. This involves breathing in oxygen at a high flow rate, which can help relieve the pain and other symptoms of a cluster headache.
Lastly, octreotide can be administered subcutaneously and has been shown to be more effective than a placebo in treating acute cluster headache attacks.
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This question is part of the following fields:
- Neurology
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Question 26
Correct
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A 65 year old female is brought into the emergency department by her husband following a fall. The patient seems unsure about how the fall occurred. The patient's husband takes you aside to express his growing concern about the patient's memory and overall functioning in the past year. He has previously suggested visiting the doctor about it, but the patient has consistently refused, claiming to be perfectly fine. The patient's husband is worried that the patient might be suffering from dementia. What is the leading cause of dementia?
Your Answer: Alzheimer's disease
Explanation:Dementia is a condition characterized by a decline in cognitive abilities, such as memory, thinking, and reasoning, that is severe enough to interfere with daily functioning. There are several different causes of dementia, but the leading cause is Alzheimer’s disease. Alzheimer’s disease is a progressive brain disorder that affects memory, thinking, and behavior. It is the most common cause of dementia, accounting for approximately 60-80% of cases.
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.
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This question is part of the following fields:
- Neurology
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Question 27
Incorrect
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A 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: Chlordiazepoxide
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.
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This question is part of the following fields:
- Neurology
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Question 28
Incorrect
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A 6-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
What dose of rectal diazepam is recommended for the treatment of the convulsing child?Your Answer: 0.4 mg/kg
Correct Answer: 0.5 mg/kg
Explanation:The recommended dose of rectal diazepam for treating a child experiencing convulsions is 0.5 mg per kilogram of body weight.
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This question is part of the following fields:
- Neurology
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Question 29
Incorrect
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A 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 symptoms is MOST indicative of this condition?Your Answer: Focal seizures
Correct Answer: Decreased level of consciousness
Explanation:NICE has emphasized that there are particular symptoms and signs that may indicate specific diseases as the underlying cause of a fever. For instance, bacterial meningitis may be suggested if the following symptoms and signs are present: neck stiffness, bulging fontanelle, decreased level of consciousness, and convulsive status epilepticus. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.
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This question is part of the following fields:
- Neurology
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Question 30
Incorrect
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A 45-year-old man has been experiencing progressive weakness and numbness in his legs for the past several days. Additionally, he has been feeling breathless during walking. He recently went on a vacation where he had diarrhea, and a stool culture confirmed an infection with Campylobacter jejuni.
What is the SINGLE most probable diagnosis?Your Answer:
Correct Answer: Guillain-Barré syndrome
Explanation:Guillain-Barré syndrome (GBS) affects approximately 1-2 individuals per 100,000 annually and is a condition that primarily affects the peripheral nervous system, including the autonomic system. The most common initial symptom is weakness in the hands or feet, often accompanied by pain and tingling sensations as the paralysis spreads. Miller Fisher syndrome, a variant of GBS, is characterized by a triad of symptoms: ataxia, areflexia, and ophthalmoplegia.
Due to the potential serious consequences of autonomic involvement, such as fluctuations in blood pressure and cardiac arrhythmias, patients with GBS are typically hospitalized. As the diaphragm becomes paralyzed and swallowing becomes difficult, patients may require ventilation and nasogastric feeding.
GBS is an autoimmune disease that usually develops within three weeks of an infection. The leading cause is Campylobacter jejuni, followed by Epstein-Barr virus, cytomegalovirus, and Mycoplasma pneumoniae. While the patient’s immune response effectively targets the initial infection, it also mistakenly attacks the host tissue.
Symptoms of GBS typically peak around four weeks and then gradually improve. Diagnosis is based on clinical examination, which confirms the presence of areflexia and progressive weakness in the legs (and sometimes arms). Nerve conduction studies and lumbar puncture can also aid in diagnosis, with the latter often showing elevated protein levels and few white blood cells.
Treatment for GBS is primarily supportive, with the use of immunoglobulins to shorten the duration of the illness being common. Plasma exchange may also be utilized, although it has become less common since the introduction of immunoglobulin therapy.
Approximately 80% of patients with GBS make a full recovery, although this often requires a lengthy hospital stay. The mortality rate is around 5%, depending on the availability of necessary facilities such as ventilatory support during the acute phase. Additionally, about 15% of patients may experience some permanent disability, such as weakness or pain.
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This question is part of the following fields:
- Neurology
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