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Question 1
Incorrect
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A 62-year-old male patient comes in with a recent onset left-sided headache accompanied by feeling generally under the weather and decreased vision in his left eye. He mentioned that brushing his hair on the side of his headache has been painful. He has also been experiencing discomfort around his shoulder girdle for the past few weeks.
What is the SINGLE most probable diagnosis?Your Answer: Tension headache
Correct Answer: Temporal arteritis
Explanation:This patient presents with a classic case of temporal arteritis, also known as giant cell arteritis (GCA). Temporal arteritis is a chronic condition characterized by inflammation in the walls of medium and large arteries, specifically granulomatous inflammation. It typically affects individuals who are over 50 years old.
The clinical features of temporal arteritis include headache, tenderness in the scalp, jaw claudication, and episodes of sudden blindness or amaurosis fugax (usually occurring in one eye). Some patients may also experience systemic symptoms such as fever, fatigue, loss of appetite, weight loss, and depression.
Temporal arteritis is often associated with polymyalgia rheumatica (PMR) in about 50% of cases. PMR is characterized by stiffness, aching, and tenderness in the upper arms (bilateral) and pain in the pelvic girdle.
Visual loss is an early and significant complication of temporal arteritis, and once it occurs, it rarely improves. Therefore, early treatment with high-dose corticosteroids is crucial to prevent further visual loss and other ischemic complications. If temporal arteritis is suspected, immediate initiation of high-dose glucocorticosteroid treatment (40 – 60 mg prednisolone daily) is necessary. It is also important to arrange an urgent referral for specialist evaluation, including a same-day ophthalmology assessment for those with visual symptoms, and a temporal artery biopsy.
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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 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: Generalised, clonic
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.
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This question is part of the following fields:
- Neurology
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Question 3
Incorrect
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A 2-year-old toddler has been experiencing convulsions for 20 minutes. He has been given two doses of lorazepam. He is on phenytoin for ongoing treatment and you prepare a phenobarbitone infusion.
What is the recommended dosage of phenobarbitone for the management of the convulsing toddler who has reached that stage of the APLS algorithm?Your Answer: 5 mg/kg over 30-60 minutes
Correct Answer: 20 mg/kg over 30-60 minutes
Explanation:If a child who is experiencing convulsions reaches step 3 of the APLS algorithm and has already been given phenytoin as part of their ongoing treatment, it is recommended to initiate a phenobarbitone infusion. This infusion should be administered at a dosage of 20 mg/kg over a period of 30 to 60 minutes.
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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 3-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 phenytoin is recommended in the treatment of the convulsing child that reaches that stage of the APLS algorithm?Your Answer: 5 mg/kg over 20 minutes
Correct Answer: 20 mg/kg over 20 minutes
Explanation:If a child who is experiencing convulsions reaches step 3 of the APLS algorithm, it is recommended to prepare a phenytoin infusion. This infusion should be administered at a dosage of 20 mg/kg over a period of 20 minutes.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 45-year-old patient has sustained an injury to their right forearm and wrist, resulting in a peripheral neuropathy. Upon examination, they exhibit a lack of abduction and opposition of the right thumb. However, wrist and finger flexion remain unaffected, although there is noticeable atrophy of the thenar eminence. The patient is able to form a fist adequately. Additionally, there is a loss of sensation over the radial three and a half fingers.
What specific nerve damage is present in this particular case?Your Answer: Median nerve at the elbow
Correct Answer: Median nerve at the wrist
Explanation:The median nerve originates from the lateral and medial cords of the brachial plexus and receives contributions from the ventral roots of C5-C7 (lateral cord) and C8 and T1 (medial cord). It serves both motor and sensory functions.
In terms of motor function, the median nerve innervates the flexor muscles in the anterior compartment of the forearm, excluding the flexor carpi ulnaris and a portion of the flexor digitorum profundus, which are instead innervated by the ulnar nerve. Additionally, it innervates the thenar muscles and the lateral two lumbricals.
Regarding sensory function, the median nerve gives rise to the palmar cutaneous branch, which provides innervation to the lateral part of the palm. It also gives rise to the digital cutaneous branch, which innervates the lateral three and a half fingers on the palmar surface of the hand.
Within the forearm, the median nerve branches into two major branches. The first is the anterior interosseous nerve (AIN), which supplies the flexor pollicis longus, pronator quadratus, and the lateral half of the flexor digitorum profundus. The second is the palmar cutaneous branch, which provides sensory innervation to the skin of the radial palm.
Differentiating between damage to the median nerve at the elbow and wrist can be done by considering these two branches. Injury at the elbow affects these branches, while injury at the wrist spares them. It is important to note that the palmar cutaneous branch travels superficially to the flexor retinaculum and therefore remains functional in carpal tunnel syndrome. However, it can be damaged by laceration at the wrist.
A comparison of median nerve lesions at the wrist and elbow is presented below:
Median nerve at elbow:
– Motor loss: Weak wrist flexion and abduction, loss of thumb abduction and opposition, loss of flexion of index and middle fingers
– Sensory loss: Lateral 3 and ½ fingers and nail beds, lateral side of palm
– Hand deformity: Ulnar deviation of wrist, thenar wasting, papal benediction on flexing fingersMedian nerve at wrist:
– Motor loss: Loss of thumb abduction and opposition, wrist and finger flexion intact (due to intact AIN)
– Sensory loss: Lateral 3 and ½ fingers and nail beds, lateral side of palm (but can be preserved depending upon palmar cutaneous branch)
– Hand deformity: Thenar wasting, no ulnar deviation of wrist or papal benediction (due to intact AIN) -
This question is part of the following fields:
- Neurology
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Question 6
Incorrect
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A 35-year-old woman presents to the Emergency Department with a brief history of headaches, which are more severe in the morning, and blurred vision and ringing in the ears. Her headache is worse than usual today, and she has vomited multiple times. She has no significant medical history but does take the combined oral contraceptive pill. On examination, you find her to be overweight, and her neurological system examination reveals a sixth cranial nerve palsy, but no other focal neurology and fundoscopy reveals bilateral papilloedema.
What is the SINGLE most likely diagnosis?Your Answer: Glioblastoma
Correct Answer: Idiopathic intracranial hypertension
Explanation:The most probable diagnosis in this case is idiopathic intracranial hypertension, also known as benign intracranial hypertension or pseudotumour cerebri. This condition typically affects overweight women in their 20s and 30s.
The clinical features of idiopathic intracranial hypertension include:
– Headache: The headache is usually worse in the morning and evenings, relieved by standing, and worsened when lying down. It can also be aggravated by coughing and sneezing. Some patients may experience pain around the shoulder girdle.
– Nausea and vomiting
– Visual field defects: These develop gradually over time.
– 6th nerve palsy and diplopia
– Bilateral papilloedemaTo investigate this condition, the patient should undergo a CT scan and/or MRI of the brain, as well as a lumbar puncture to measure the opening pressure and analyze the cerebrospinal fluid (CSF).
The primary treatment goal for idiopathic intracranial hypertension is to prevent visual loss. This can be achieved through one of the following strategies:
– Repeated lumbar puncture to control intracranial pressure (ICP)
– Medical treatment with acetazolamide
– Surgical decompression of the optic nerve sheath -
This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 72 year old female arrives at the emergency department after speaking with her primary care physician over the phone. She explains that while she was shopping, her right arm and right leg suddenly felt weak and became a bit difficult to move. The patient is otherwise alert, oriented, feels well, and has normal speech. A brain CT scan reveals a focal area of ischemia consistent with an acute stroke. You arrange for her transfer to the stroke unit. The patient inquires if she can drive her car before going to the ward. What advice would you give her regarding driving?
Your Answer: They can move their car once they have taken their prescribed dose of aspirin
Correct Answer: Advise them, they must not drive a car for at least 1 month following a confirmed stroke
Explanation:Patients who have experienced a stroke should be aware that they are not allowed to drive for at least one month if they have a type 1 license. If there are no neurological issues after this time period, they may not need to inform the DVLA (Driver and Vehicle Licensing Agency). However, they must inform the DVLA if any of the following conditions apply: they have had more than one stroke or transient ischemic attack (TIA), they have a Group 2 license, a medical practitioner has expressed concerns about their ability to drive, they still have residual deficits one month after the stroke (such as weakness in the limbs, visual problems, coordination difficulties, memory or understanding issues), the stroke required neurosurgical treatment, or if they experienced a seizure (unless it was an isolated seizure within 24 hours of the stroke and there is no history of prior seizures).
Further Reading:
Blackouts are a common occurrence in the emergency department and can have serious consequences if they happen while a person is driving. It is crucial for doctors in the ED to be familiar with the guidelines set by the DVLA (Driver and Vehicle Licensing Agency) regarding driving restrictions for patients who have experienced a blackout.
The DVLA has specific rules for different types of conditions that may cause syncope (loss of consciousness). For group 1 license holders (car/motorcycle use), if a person has had a first unprovoked isolated seizure, they must refrain from driving for 6 months or 12 months if there is an underlying causative factor that may increase the risk. They must also notify the DVLA. For group 2 license holders (bus and heavy goods vehicles), the restrictions are more stringent, with a requirement of 12 months off driving for a first unprovoked isolated seizure and 5 years off driving if there is an underlying causative factor.
For epilepsy or multiple seizures, both group 1 and group 2 license holders must remain seizure-free for 12 months before their license can be considered. They must also notify the DVLA. In the case of a stroke or isolated transient ischemic attack (TIA), group 1 license holders need to refrain from driving for 1 month, while group 2 license holders must wait for 12 months before being re-licensed subject to medical evaluation. Multiple TIAs require 3 months off driving for both groups.
Isolated vasovagal syncope requires no driving restriction for group 1 license holders, but group 2 license holders must refrain from driving for 3 months. Both groups must notify the DVLA. If syncope is caused by a reversible and treated condition, group 1 license holders need 4 weeks off driving, while group 2 license holders require 3 months. In the case of an isolated syncopal episode with an unknown cause, group 1 license holders must refrain from driving for 6 months, while group 2 license holders will have their license refused or revoked for 12 months.
For patients who continue to drive against medical advice, the GMC (General Medical Council) has provided guidance on how doctors should manage the situation. Doctors should explain to the patient why they are not allowed to drive and inform them of their legal duty to notify the DVLA or DVA (Driver and Vehicle Agency in Northern Ireland). Doctors should also record the advice given to the patient in their medical record
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This question is part of the following fields:
- Neurology
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Question 8
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: Motor neurone disease
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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Question 9
Incorrect
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You have been tasked with arranging a case-based teaching session for the junior doctors in the emergency department regarding vertigo. Which of the subsequent clinical features aligns with a central origin of vertigo?
Your Answer: Positive head impulse test
Correct Answer: Inability to stand up with the eyes open
Explanation:If a person is unable to stand up or walk, even with their eyes open, it is likely that the cause of their vertigo is central in nature. Additional features that increase suspicion of a central cause include focal neurology, prolonged and severe vertigo (although this can also be seen in vestibular neuronitis or Meniere’s disease), new-onset headache or recent trauma, a normal head impulse test, and the presence of cardiovascular risk factors.
Further Reading:
Vertigo is a symptom characterized by a false sensation of movement, such as spinning or rotation, in the absence of any actual physical movement. It is not a diagnosis itself, but rather a description of the sensation experienced by the individual. Dizziness, on the other hand, refers to a perception of disturbed or impaired spatial orientation without a false sense of motion.
Vertigo can be classified as either peripheral or central. Peripheral vertigo is more common and is caused by problems in the inner ear that affect the labyrinth or vestibular nerve. Examples of peripheral vertigo include BPPV, vestibular neuritis, labyrinthitis, and Meniere’s disease. Central vertigo, on the other hand, is caused by pathology in the brain, such as in the brainstem or cerebellum. Examples of central vertigo include migraine, TIA and stroke, cerebellar tumor, acoustic neuroma, and multiple sclerosis.
There are certain features that can help differentiate between peripheral and central vertigo. Peripheral vertigo is often associated with severe nausea and vomiting, hearing loss or tinnitus, and a positive head impulse test. Central vertigo may be characterized by prolonged and severe vertigo, new-onset headache, recent trauma, cardiovascular risk factors, inability to stand or walk with eyes open, focal neurological deficit, and a negative head impulse test.
Nystagmus, an involuntary eye movement, can also provide clues about the underlying cause of vertigo. Central causes of vertigo often have nystagmus that is direction-changing on lateral gaze, purely vertical or torsional, not suppressed by visual fixation, non-fatigable, and commonly large amplitude. Peripheral causes of vertigo often have horizontal nystagmus with a torsional component that does not change direction with gaze, disappears with fixation of the gaze, and may have large amplitude early in the course of Meniere’s disease or vestibular neuritis.
There are various causes of vertigo, including viral labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo, Meniere’s disease, vertebrobasilar ischemia, and acoustic neuroma. Each of these disorders has its own unique characteristics and may be associated with other symptoms such as hearing loss, tinnitus, or neurological deficits.
When assessing a patient with vertigo, it is important to perform a cardiovascular and neurological examination, including assessing cranial nerves, cerebellar signs, eye movements, gait, coordination, and evidence of peripheral
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This question is part of the following fields:
- Neurology
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Question 10
Incorrect
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A child develops a palsy of their right arm following a traumatic birth. During the examination, there is a deformity known as 'claw hand' and sensory loss on the ulnar side of the forearm and hand.
What is the SINGLE most probable diagnosis?Your Answer: Erb’s palsy
Correct Answer: Klumpke’s palsy
Explanation:Klumpke’s palsy, also known as Dejerine-Klumpke palsy, is a condition where the arm becomes paralyzed due to an injury to the lower roots of the brachial plexus. The most commonly affected root is C8, but T1 can also be involved. The main cause of Klumpke’s palsy is when the arm is pulled forcefully in an outward position during a difficult childbirth. It can also occur in adults with apical lung carcinoma (Pancoast’s syndrome).
Clinically, Klumpke’s palsy is characterized by a deformity known as ‘claw hand’, which is caused by the paralysis of the intrinsic hand muscles. There is also a loss of sensation along the ulnar side of the forearm and hand. In some cases where T1 is affected, a condition called Horner’s syndrome may also be present.
Klumpke’s palsy can be distinguished from Erb’s palsy, which affects the upper roots of the brachial plexus (C5 and sometimes C6). In Erb’s palsy, the arm hangs by the side with the elbow extended and the forearm turned inward (known as the ‘waiter’s tip sign’). Additionally, there is a loss of shoulder abduction, external rotation, and elbow flexion.
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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 65-year-old woman presents to the Emergency Department with her husband. After lunch this afternoon, she noticed some difficulty ‘finding the right words’ and her husband said that her speech was slurred. The episode lasted for about 2 hours, and she now feels back to normal. When you examine her, she has a blood pressure of 140/90; her speech is normal and cranial nerves are intact. A thorough peripheral neurological examination reveals no deficit. She has no previous history of diabetes.
What is the SINGLE most appropriate next step in her management?Your Answer: Give 300 mg aspirin immediately and seen by a specialist for assessment within 24 hours of onset of symptoms
Correct Answer:
Explanation:This individual has a typical history for a transient ischaemic attack (TIA). According to the NICE recommendations, it is advised to offer aspirin (300 mg daily) to individuals who have experienced a suspected TIA, unless there are contraindications. This treatment should be started immediately. It is also important to refer individuals who have had a suspected TIA for specialist assessment and investigation, with the aim of being seen within 24 hours of symptom onset. Scoring systems, such as ABCD2, should not be used to assess the risk of subsequent stroke or determine the urgency of referral for individuals with a suspected or confirmed TIA. Secondary prevention measures, in addition to aspirin, should be offered as soon as possible after the diagnosis of TIA is confirmed.
In terms of imaging, it is not recommended to offer CT brain scanning to individuals with a suspected TIA, unless there is clinical suspicion of an alternative diagnosis that CT could detect. After a specialist assessment in the TIA clinic, MRI (including diffusion-weighted and blood-sensitive sequences) may be considered to determine the area of ischaemia, detect haemorrhage, or identify alternative pathologies. If an MRI is performed, it should ideally be done on the same day as the assessment. Carotid imaging is also important for everyone with a TIA who is considered a candidate for carotid endarterectomy, and this should be done urgently.
to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old: diagnosis and initial management.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 55-year-old man with a history of hypertension presented to the emergency department with a sudden onset severe occipital headache accompanied by vomiting and neck stiffness. There is no reported history of head injury. Upon clinical examination, his temperature is recorded as 37ºC, respiratory rate at 18 per minute, pulse at 88 beats per minute, and blood pressure at 160/100. It is observed that his right eye is laterally and inferiorly deviated, with a dilated pupil and drooping of the right upper eyelid.
Which of the following would be the most appropriate initial investigation?Your Answer: MRI brain scan
Correct Answer: CT head scan
Explanation:The most probable diagnosis in this case is a subarachnoid haemorrhage (SAH).
When assessing patients who present with an SAH, there may be focal neurological signs that can indicate the potential location of the aneurysm. Common sites for aneurysms include the bifurcation of the middle cerebral artery, the junction of the anterior communicating cerebral artery, and the junction of the posterior communicating artery with the internal carotid artery. If there is complete or partial palsy of the oculomotor nerve, it suggests the rupture of a posterior communicating artery aneurysm.
While hypertension is a risk factor for SAH, a significant increase in blood pressure may occur as a reflex response following the haemorrhage.
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 scan increases to nearly 100% if done within 6 hours of symptom onset. If the CT head scan is negative and there are no contraindications, a lumbar puncture (LP) should be performed to diagnose SAH. It is recommended to perform the LP at least 12 hours after the onset of headache. It is important to note that approximately 3% of patients with a negative CT scan will be confirmed to have had an SAH after undergoing an LP.
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This question is part of the following fields:
- Neurology
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Question 13
Incorrect
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A 45-year-old woman presents with symptoms of confusion. An MRI scan is performed, which reveals a temporal lobe infarct.
Which SINGLE clinical feature would you NOT anticipate to observe during the examination of this patient?Your Answer: Impaired musical perception
Correct Answer: Expressive dysphasia
Explanation:The temporal lobes play a crucial role in various functions such as processing visual and auditory information, storing memories, and helping us categorize objects. However, if this area of the brain is affected by a stroke, a space-occupying lesion, or trauma, it can lead to several issues. These include problems with understanding and producing language (known as receptive dysphasia), difficulty recognizing faces (prosopagnosia), an inability to categorize objects, difficulty understanding auditory information (auditory agnosia), and impaired perception of music.
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This question is part of the following fields:
- Neurology
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Question 14
Incorrect
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You evaluate a 28-year-old woman who has been experiencing visual difficulties and had a period where her lower leg felt like 'pins and needles' for a few weeks approximately a year ago. Her sister was diagnosed with multiple sclerosis, and she is concerned about her own health. She has numerous inquiries and wants to know which factors indicate a less favorable prognosis.
Which ONE factor would NOT be indicative of a positive outcome?Your Answer: Younger age at time of diagnosis
Correct Answer: Older age at time of diagnosis
Explanation:Multiple sclerosis is a condition characterized by the demyelination of nerve cells in the brain and spinal cord. It is an autoimmune disease caused by recurring inflammation, primarily affecting individuals in early adulthood. The condition is more prevalent in females, with a ratio of 3:2 compared to males.
There are several risk factors associated with multiple sclerosis. These include being of Caucasian race, living at a greater distance from the equator (as the risk tends to increase further away), having a family history of the disease (with approximately 20% of patients having an affected relative), and smoking. Interestingly, the rates of relapse tend to decrease during pregnancy.
Multiple sclerosis can present in three main patterns. The most common is relapsing and remitting MS, where individuals experience periods without symptoms followed by relapses. This accounts for 80% of cases at the time of diagnosis. Another pattern is primary progressive MS, where symptoms develop and worsen from the beginning with few remissions. This is seen in approximately 10-15% of cases at diagnosis. Lastly, there is secondary progressive MS, which occurs after a relapsing/remitting phase. In this pattern, symptoms worsen with fewer remissions, and it affects around 50% of individuals with relapsing/remitting MS within 10 years of diagnosis.
Certain factors can indicate a more favorable prognosis for individuals with multiple sclerosis. These include having a relapsing/remitting course of the disease, being female, experiencing sensory symptoms, and having an early age at onset.
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This question is part of the following fields:
- Neurology
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Question 15
Incorrect
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A 72 year old is brought to the emergency department by ambulance due to sudden onset of confusion. The patient's spouse is concerned the sudden decrease in consciousness is due to a hemorrhage as the patient is on blood thinners. Neurological examination reveals flaccid paralysis. Cardiopulmonary resuscitation is initiated before CT scan as the patient experiences a respiratory arrest. Which of the following syndromes is this patient most likely suffering from?
Your Answer: Central herniation
Correct Answer: Tonsillar herniation
Explanation:Tonsillar herniation occurs when the cerebellar tonsils are pushed through the foramen magnum. This condition is characterized by a decrease in consciousness, respiratory arrest, and flaccid paralysis.
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 16
Correct
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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: 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.
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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 65-year-old woman comes to the clinic after a fall. You observe that she has a tremor in her left hand that is most noticeable when she is sitting and at rest. Additionally, you notice that it took her quite a while to walk towards you and unbutton her coat before sitting down. When you shake her hand, you notice that her left forearm feels stiff.
What is the SINGLE most probable diagnosis?Your Answer: Right hemispheric cerebrovascular accident
Correct Answer: Parkinson’s disease
Explanation:Parkinson’s disease (PD) is a progressive neurodegenerative condition that occurs when the dopamine-containing cells in the substantia nigra die. It is estimated that PD affects around 100-180 individuals per 100,000 of the population, which translates to approximately 6-11 people per 6,000 individuals in the general population of the UK. The annual incidence of PD is between 4-20 cases per 100,000 people. The prevalence of PD increases with age, with approximately 0.5% of individuals aged 65 to 74 being affected and 1-2% of individuals aged 75 and older. Additionally, PD is more prevalent and has a higher incidence in males.
The classic clinical features of Parkinson’s disease include hypokinesia, which refers to a poverty of movement, and bradykinesia, which is characterized by slowness of movement. Rest tremor, typically occurring at a rate of 4-6 cycles per second, is also commonly observed in PD patients. Another clinical feature is rigidity, which is characterized by increased muscle tone and a phenomenon known as cogwheel rigidity.
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This question is part of the following fields:
- Neurology
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Question 18
Incorrect
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A 65-year-old patient who was diagnosed with Parkinson's disease three years ago has experienced a rapid deterioration in her overall functioning. She has been experiencing a progressive decline in her cognitive abilities, with severe memory impairment. Additionally, she has been experiencing prominent visual hallucinations and frequent fluctuations in her level of attention and alertness. Although her tremor is relatively mild, it is still present.
What is the most probable diagnosis for this patient?Your Answer: Idiopathic Parkinson's disease
Correct Answer: Dementia with Lewy Bodies
Explanation:The Parkinson-plus syndromes are a group of neurodegenerative disorders that share similar features with Parkinson’s disease but also have additional clinical characteristics that set them apart from idiopathic Parkinson’s disease (iPD). These syndromes include Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP), Corticobasal degeneration (CBD), and Dementia with Lewy Bodies (DLB).
Multiple System Atrophy (MSA) is a less common condition than iPD and PSP. It is characterized by the loss of cells in multiple areas of the nervous system. MSA progresses rapidly, often leading to wheelchair dependence within 3-4 years of diagnosis. Some distinguishing features of MSA include autonomic dysfunction, bladder control problems, erectile dysfunction, blood pressure changes, early-onset balance problems, neck or facial dystonia, and a high-pitched voice.
To summarize the distinguishing features of the Parkinson-plus syndromes compared to iPD, the following table provides a comparison:
iPD:
– Symptom onset: One side of the body affected more than the other
– Tremor: Typically starts at rest on one side of the body
– Levodopa response: Excellent response
– Mental changes: Depression
– Balance/falls: Late in the disease
– Common eye abnormalities: Dry eyes, trouble focusingMSA:
– Symptom onset: Both sides equally affected
– Tremor: Not common but may occur
– Levodopa response: Minimal response (but often tried in early stages of disease)
– Mental changes: Depression
– Balance/falls: Within 1-3 years
– Common eye abnormalities: Dry eyes, trouble focusingPSP:
– Symptom onset: Both sides equally affected
– Tremor: Less common, if present affects both sides
– Levodopa response: Minimal response (but often tried in early stages of disease)
– Mental changes: Personality changes, depression
– Balance/falls: Within 1 year
– Common eye abnormalities: Dry eyes, difficulty in looking downwardsCBD:
– Symptom onset: One side of the body affected more than the other
– Tremor: Not common but may occur
– Levodopa response: Minimal response (but often tried in early stages of disease)
– Mental changes: Depression
– Balance/falls: Within 1-3 years
– Common eye abnormalities: Dry eyes, trouble focusing -
This question is part of the following fields:
- Neurology
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Question 19
Incorrect
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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: 5%
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.
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This question is part of the following fields:
- Neurology
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Question 20
Correct
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A 6-year-old boy is brought to the Emergency Department by his parents following a brief self-limiting seizure at home. He was diagnosed with strep throat by his pediatrician yesterday and started on antibiotics. Despite this, he has been experiencing intermittent high fevers throughout the day. After a thorough evaluation, you determine that he has had a febrile seizure.
What is his estimated risk of developing epilepsy in the long term?Your Answer: 6%
Explanation:Febrile convulsions are harmless, generalized seizures that occur in otherwise healthy children who have a fever due to an infection outside the brain. To diagnose febrile convulsions, the child must be developing normally, the seizure should last less than 20 minutes, have no complex features, and not cause any lasting abnormalities.
The prognosis for febrile convulsions is generally positive. There is a 30 to 50% chance of experiencing recurrent febrile convulsions, with a 10% risk of recurrence within the first 24 hours. The likelihood of developing long-term epilepsy is around 6%.
Complex febrile convulsions are characterized by certain factors. These include focal seizures, seizures lasting longer than 15 minutes, experiencing more than one convulsion during a single fever episode, or the child being left with a focal neurological deficit.
Overall, febrile convulsions are typically harmless and do not cause any lasting damage.
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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 52-year-old man presents with ataxia, left-sided loss of pain and temperature sense on the face, left-sided paralysis of the facial muscles and right-sided sensory loss to the body. He is also complaining of severe vertigo, nausea and tinnitus. CT and MRI head scans are undertaken, and he is discovered to have suffered a left-sided stroke. He is subsequently admitted under the stroke team.
What is the SINGLE most likely diagnosis?Your Answer: Weber’s syndrome
Correct Answer: Lateral pontine syndrome
Explanation:Obstruction of the long circumferential branches of the basilar artery leads to the lateral pontine syndrome. This condition is characterized by several symptoms. Firstly, there is ataxia, which is caused by damage to the cerebral peduncles. Additionally, there is ipsilateral loss of pain and temperature sense on the face, resulting from damage to CN V. Another symptom is ipsilateral paralysis of the upper and lower face, which occurs due to damage to CN VII. Furthermore, vertigo, nystagmus, tinnitus, deafness, and vomiting are present, all of which are caused by damage to CN VIII. Lastly, there is contralateral sensory loss to the body, which is a result of damage to the spinothalamic tracts.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 4-year-old boy has been brought into the Emergency Department having seizures that have lasted for 25 minutes prior to his arrival. On arrival, he is continuing to have a tonic-clonic seizure.
What dose of IV lorazepam is recommended for the treatment of the convulsing child?Your Answer: 0.3 mg/kg
Correct Answer: 0.1 mg/kg
Explanation:The recommended dosage of intravenous lorazepam for treating a child experiencing seizures is 0.1 mg per kilogram of body weight.
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This question is part of the following fields:
- Neurology
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Question 23
Incorrect
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A 27 year old male is brought to the emergency department by his partner due to increasing drowsiness. The patient's partner informs you that the patient was involved in a physical altercation approximately 40 minutes ago. The patient was struck in the temple and experienced a brief loss of consciousness for around 20 seconds. Initially, the patient appeared to be fine, but after about 20 minutes, he started becoming progressively more drowsy. A CT scan reveals the presence of an extradural hematoma. Which cranial nerve palsy is most commonly observed in this condition?
Your Answer: Trigeminal nerve
Correct Answer: Abducens nerve
Explanation:Abducens nerve palsy is often linked to extradural hematoma. When there is a mass effect, downward brain herniation can occur, leading to the involvement of the 6th cranial nerve (abducens nerve, CN VI). This nerve controls the lateral rectus muscle, which is responsible for eye abduction. When the abducens nerve is affected, the lateral rectus muscle is unable to function properly, resulting in an inward turning of the affected eye towards the nose (esotropia).
Further Reading:
Extradural haematoma (EDH) is a collection of blood that forms between the inner surface of the skull and the outer layer of the dura, the dura mater. It is typically caused by head trauma and is often associated with a skull fracture, with the pterion being the most common site of injury. The middle meningeal artery is the most common source of bleeding in EDH.
Clinical features of EDH include a history of head injury with transient loss of consciousness, followed by a lucid interval and gradual loss of consciousness. Other symptoms may include severe headache, sixth cranial nerve palsies, nausea and vomiting, seizures, signs of raised intracranial pressure, and focal neurological deficits.
Imaging of EDH typically shows a biconvex shape and may cause mass effect with brain herniation. It can be differentiated from subdural haematoma by its appearance on imaging.
Management of EDH involves prompt referral to neurosurgery for evacuation of the haematoma. In some cases with a small EDH, conservative management may be considered. With prompt evacuation, the prognosis for EDH is generally good.
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This question is part of the following fields:
- Neurology
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Question 24
Incorrect
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A 65-year-old man is brought in to see you by his wife. She is concerned that he may have had a 'mini-stroke.' After conducting a comprehensive history and examination, you conclude that it is highly probable that he has experienced a transient ischemic attack (TIA). You decide to refer him to the nearby specialist TIA clinic.
What imaging procedure is most likely to be arranged at the TIA clinic?Your Answer: Positron emission tomography (PET) scan
Correct Answer: Carotid imaging
Explanation:The NICE recommendations for managing patients with suspected TIA are as follows:
– Offer aspirin (300 mg daily) to individuals who have experienced a suspected TIA, unless there are contraindications. This treatment should be started immediately.
– Immediately refer individuals who have had a suspected TIA for specialist assessment and investigation. They should be seen within 24 hours of the onset of symptoms.
– Avoid using scoring systems, such as ABCD2, to assess the risk of subsequent stroke or determine the urgency of referral for individuals with suspected or confirmed TIA.
– Provide secondary prevention measures, in addition to aspirin, as soon as possible after confirming the diagnosis of TIA.The NICE recommendations for imaging in individuals with suspected TIA or acute non-disabling stroke are as follows:
– Do not offer CT brain scanning to individuals with suspected TIA, unless there is clinical suspicion of an alternative diagnosis that CT could detect.
– After a specialist assessment in the TIA clinic, consider performing an MRI (including diffusion-weighted and blood-sensitive sequences) to determine the area of ischemia, detect hemorrhage, or identify alternative pathologies. If an MRI is conducted, it should be done on the same day as the assessment.
– Carotid imaging is necessary for all individuals with TIA who, after specialist assessment, are considered candidates for carotid endarterectomy. This imaging should be done urgently.For more information, refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over 16 years old: diagnosis and initial management.
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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 65 year old female is brought to the emergency department as her husband is concerned about increasing confusion and unsteadiness. The patient's husband tells you over the past two to three months the patient doesn't seem to be able to remember anything, often appearing confused, and unable to concentrate on things such as books or conversations. The patient has also been urinating more frequently and has had a few accidents where she has wet herself. The patient's husband has also noticed she walks differently, taking slow short steps as if she has lost her confidence. The patient tells you she feels fine. There is no significant medical history. On examination you note the patient has a broad based stance with delay in initiating movement and a shuffling gait where the patient freezes after 3 or 4 steps. What is the most likely diagnosis?
Your Answer: Alzheimer's disease
Correct Answer: Normal pressure hydrocephalus
Explanation:Normal pressure hydrocephalus is a condition characterized by the classic triad of symptoms: gait instability, urinary incontinence, and dementia. Gait apraxia, which is a common feature, presents as a slow and cautious gait, difficulty initiating movement, unsteadiness, a widened standing base, reduced stride length, shuffling gait, falls, and freezing. The onset of symptoms typically occurs over a period of 3-6 months. This condition is a form of communicating hydrocephalus, where there is a gradual buildup of cerebrospinal fluid (CSF) due to impaired CSF absorption. As a result, the ventricles in the brain enlarge and intracranial pressure increases, leading to compression of brain tissue and neurological complications. Normal pressure hydrocephalus is more commonly seen in individuals over the age of 65, and a CT head or MRI is usually the initial diagnostic test.
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 26
Incorrect
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A 42-year-old left-handed history teacher presents with a sudden onset of difficulty in recalling historical facts. A CT scan of her head reveals a right parietal lobe infarct.
Which SINGLE clinical feature is most likely to also be present?Your Answer: Difficulty recognizing faces
Correct Answer: Agraphia
Explanation:The parietal lobes can be divided into two functional areas. One area is responsible for sensation and perception, while the other integrates sensory input primarily from the visual pathways. These lobes play a crucial role in cognition and spatial awareness.
Typically, the left parietal lobe is dominant, and if there are lesions in this area, it can lead to a condition known as Gerstmann’s Syndrome. This syndrome encompasses several difficulties, including problems with writing (agraphia or dysgraphia), arithmetic (acalculia or dyscalculia), and identifying fingers (finger agnosia). Additionally, individuals may experience left-right disorientation and some form of aphasia or dysphasia, affecting their ability to express themselves or understand others.
On the other hand, lesions in the right parietal lobe, which is the non-dominant side, can result in neglecting a part of the body. This can make tasks like dressing and washing challenging.
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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 35-year-old woman is brought into the emergency department after being hit by a car while riding her bike. The patient was not wearing a helmet and suffered a head injury from hitting the pavement. She has a significant scalp contusion and appears drowsy. There is a suspicion of increased intracranial pressure. How does intracranial pressure affect cerebral perfusion pressure?
Your Answer: Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) + intracranial pressure (ICP)
Correct Answer: Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure (ICP)
Explanation:Cerebral perfusion pressure (CPP) is calculated by adding the intracranial pressure (ICP) to the diastolic blood pressure (DBP).
Further Reading:
Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.
The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.
There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.
Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.
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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 child arrives at the Emergency Department with a petechial rash, headache, neck stiffness, and sensitivity to light. You suspect a diagnosis of meningococcal meningitis.
What is the most suitable initial approach to management?Your Answer: Give benzylpenicillin 1.2 g IM
Correct Answer: Give ceftriaxone 2 g IV
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 29
Incorrect
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After managing a patient with frontotemporal dementia, your consultant believes that the foundation doctors would benefit from additional education on the topic. They request you to prepare a teaching session for the junior doctors. Which of the following statements is accurate?
Your Answer: Frontotemporal dementia accounts for approximately 10-15% of all dementia cases in the UK
Correct Answer: Personality change, speech disturbance and behavioural change are predominant features in frontotemporal dementia
Explanation:In the UK, not all dementia cases are suitable for treatment with acetylcholinesterase inhibitors and memantine. Specifically, patients with frontotemporal dementia should not be prescribed these medications. If a patient experiences visual hallucinations, it may indicate that they have dementia with Lewy bodies.
Further Reading:
Dementia is a progressive and irreversible clinical syndrome characterized by cognitive and behavioral symptoms. These symptoms include memory loss, impaired reasoning and communication, personality changes, and reduced ability to carry out daily activities. The decline in cognition affects multiple domains of intellectual functioning and is not solely due to normal aging.
To diagnose dementia, a person must have impairment in at least two cognitive domains that significantly impact their daily activities. This impairment cannot be explained by delirium or other major psychiatric disorders. Early-onset dementia refers to dementia that develops before the age of 65.
The most common cause of dementia is Alzheimer’s disease, accounting for 50-75% of cases. Other causes include vascular dementia, dementia with Lewy bodies, and frontotemporal dementia. Less common causes include Parkinson’s disease dementia, Huntington’s disease, prion disease, and metabolic and endocrine disorders.
There are several risk factors for dementia, including age, mild cognitive impairment, genetic predisposition, excess alcohol intake, head injury, depression, learning difficulties, diabetes, obesity, hypertension, smoking, Parkinson’s disease, low social engagement, low physical activity, low educational attainment, hearing impairment, and air pollution.
Assessment of dementia involves taking a history from the patient and ideally a family member or close friend. The person’s current level of cognition and functional capabilities should be compared to their baseline level. Physical examination, blood tests, and cognitive assessment tools can also aid in the diagnosis.
Differential diagnosis for dementia includes normal age-related memory changes, mild cognitive impairment, depression, delirium, vitamin deficiencies, hypothyroidism, adverse drug effects, normal pressure hydrocephalus, and sensory deficits.
Management of dementia involves a multi-disciplinary approach that includes non-pharmacological and pharmacological measures. Non-pharmacological interventions may include driving assessment, modifiable risk factor management, and non-pharmacological therapies to promote cognition and independence. Drug treatments for dementia should be initiated by specialists and may include acetylcholinesterase inhibitors, memantine, and antipsychotics in certain cases.
In summary, dementia is a progressive and irreversible syndrome characterized by cognitive and behavioral symptoms. It has various causes and risk factors, and its management involves a multi-disciplinary approach.
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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 presents with a tremor and difficulty with movement. After being referred to a specialist, he is diagnosed with Parkinson's disease. Currently, he is in the early stages of the condition.
Which of the following clinical features is most likely to be present as well?Your Answer: Cognitive impairment
Correct Answer: Cogwheel rigidity
Explanation:Patients with Parkinson’s disease (PD) typically exhibit the following clinical features:
– Hypokinesia (reduced movement)
– Bradykinesia (slow movement)
– Rest tremor (usually occurring at a rate of 4-6 cycles per second)
– Rigidity (increased muscle tone and ‘cogwheel rigidity’)Other commonly observed clinical features include:
– Gait disturbance (characterized by a shuffling gait and loss of arm swing)
– Loss of facial expression
– Monotonous, slurred speech
– Micrographia (small, cramped handwriting)
– Increased salivation and dribbling
– Difficulty with fine movementsInitially, these signs are typically seen on one side of the body at the time of diagnosis, but they progressively worsen and may eventually affect both sides. In later stages of the disease, additional clinical features may become evident, including:
– Postural instability
– Cognitive impairment
– Orthostatic hypotensionAlthough PD primarily affects movement, patients often experience psychiatric issues such as depression and dementia. Autonomic disturbances and pain can also occur, leading to significant disability and reduced quality of life for the affected individual. Additionally, family members and caregivers may also be indirectly affected by the disease.
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This question is part of the following fields:
- Neurology
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