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  • Question 1 - A toddler is brought in with a severe headache and a high fever....

    Correct

    • A toddler is brought in with a severe headache and a high fever. You suspect a potential diagnosis of herpes simplex encephalitis.
      Based on the current NICE guidelines, which of the following symptoms is MOST indicative of this condition?

      Your Answer: Focal neurological signs

      Explanation:

      NICE has emphasized that there are particular symptoms and indications that may indicate specific diseases as the underlying cause of a fever. In the case of herpes simplex encephalitis, the following symptoms and signs may suggest its presence: the presence of a focal neurological sign, focal seizures, and a decreased level of consciousness. For more information on this topic, you may refer to the NICE guidelines on the assessment and initial management of fever in children under the age of 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Neurology
      16.2
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  • Question 2 - You evaluate a 32-year-old woman with grip weakness. During your examination, you find...

    Incorrect

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

      Your Answer: Musculocutaneous nerve

      Correct Answer: Ulnar nerve

      Explanation:

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

    • This question is part of the following fields:

      • Neurology
      30.3
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  • Question 3 - A 62-year-old woman presents with left-sided loss of pain and temperature sense on...

    Correct

    • A 62-year-old woman presents with left-sided loss of pain and temperature sense on the body and right-sided loss of pain and temperature sense on the face. While examining her cranial nerves, you note the presence of Horner’s syndrome. She is also complaining of dizziness, vomiting, and ringing in the ears. CT and MRI head scans are performed, and she is found to have experienced a right-sided stroke. She is subsequently admitted under the care of the stroke team.
      What is the SINGLE most probable diagnosis?

      Your Answer: Lateral medullary syndrome

      Explanation:

      Occlusion of the posterior inferior cerebellar artery leads to the development of lateral medullary syndrome, also known as Wallenberg’s syndrome. This condition is characterized by several distinct symptoms. Firstly, there is a loss of pain and temperature sensation on the opposite side of the body, which occurs due to damage to the spinothalamic tracts. Additionally, there is a loss of pain and temperature sensation on the same side of the face, resulting from damage to the fifth cranial nerve (CN V).

      Furthermore, individuals with lateral medullary syndrome may experience vertigo, nystagmus, tinnitus, deafness, and vomiting. These symptoms arise from damage to the eighth cranial nerve (CN VIII). Lastly, the syndrome may also present with Horner’s syndrome, which is caused by damage to the descending hypothalamospinal tract.

      In summary, occlusion of the posterior inferior cerebellar artery causes lateral medullary syndrome, leading to a combination of symptoms including sensory loss, vertigo, tinnitus, and Horner’s syndrome.

    • This question is part of the following fields:

      • Neurology
      43.2
      Seconds
  • Question 4 - A 65-year-old man comes in with a 2-hour history of left-sided weakness and...

    Correct

    • A 65-year-old man comes in with a 2-hour history of left-sided weakness and difficulty speaking. A CT scan has ruled out a primary intracerebral hemorrhage, and he is being prepared for thrombolysis. According to the current NICE guidelines, which thrombolytic agent is recommended for the treatment of acute ischemic stroke?

      Your Answer: Alteplase

      Explanation:

      According to the current guidelines from NICE, alteplase is recommended as a thrombolysis treatment for acute ischaemic stroke. For more information, you can refer to the NICE guidelines on stroke and transient ischaemic attack in individuals over the age of 16.

    • This question is part of the following fields:

      • Neurology
      72.6
      Seconds
  • Question 5 - You are tasked with organizing a teaching session for the senior residents on...

    Correct

    • You are tasked with organizing a teaching session for the senior residents on head injuries & increased intracranial pressure. What is the intracranial volume of a typical adult?

      Your Answer: 1400ml

      Explanation:

      On average, the intracranial volume in adults is around 1400ml.

      Intracranial pressure (ICP) refers to the pressure within the craniospinal compartment, which includes neural tissue, blood, and cerebrospinal fluid (CSF). Normal ICP for a supine adult is 5-15 mmHg. The body maintains ICP within a narrow range through shifts in CSF production and absorption. If ICP rises, it can lead to decreased cerebral perfusion pressure, resulting in cerebral hypoperfusion, ischemia, and potentially brain herniation.

      The cranium, which houses the brain, is a closed rigid box in adults and cannot expand. It is made up of 8 bones and contains three main components: brain tissue, cerebral blood, and CSF. Brain tissue accounts for about 80% of the intracranial volume, while CSF and blood each account for about 10%. The Monro-Kellie doctrine states that the sum of intracranial volumes is constant, so an increase in one component must be offset by a decrease in the others.

      There are various causes of raised ICP, including hematomas, neoplasms, brain abscesses, edema, CSF circulation disorders, venous sinus obstruction, and accelerated hypertension. Symptoms of raised ICP include headache, vomiting, pupillary changes, reduced cognition and consciousness, neurological signs, abnormal fundoscopy, cranial nerve palsy, hemiparesis, bradycardia, high blood pressure, irregular breathing, focal neurological deficits, seizures, stupor, coma, and death.

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30º head up tilt, maintaining normal blood pressure, providing analgesia, using drugs to lower ICP (such as mannitol or saline), and inducing hypocapnoeic vasoconstriction through hyperventilation. If these measures are ineffective, second-line therapies like barbiturate coma, optimised hyperventilation, controlled hypothermia, or decompressive craniectomy may be considered.

    • This question is part of the following fields:

      • Neurology
      44.6
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  • Question 6 - A middle-aged patient experiences a stroke that leads to impairment in Broca's area....

    Incorrect

    • A middle-aged patient experiences a stroke that leads to impairment in Broca's area. What will be the consequences of the damage to Broca's area?

      Your Answer: Loss of awareness of sound

      Correct Answer: Expressive aphasia

      Explanation:

      Broca’s area is situated in the frontal lobe of the dominant cerebral hemisphere. Specifically, it can be located in the posterior section of the inferior frontal gyrus, and it comprises of the pars opercularis and the pars triangularis.

      Broca’s area is responsible for regulating the motor functions involved in speech production. It facilitates the creation of words through its connections with neighboring motor areas, which stimulate the muscles of the larynx, mouth, tongue, and soft palate.

      If there is damage to Broca’s area, it will lead to speech paralysis and expressive aphasia, commonly referred to as Broca’s aphasia.

    • This question is part of the following fields:

      • Neurology
      10.6
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  • Question 7 - A 45-year-old woman with no permanent address sustains a head injury after falling....

    Incorrect

    • A 45-year-old woman with no permanent address sustains a head injury after falling. As part of her evaluation, you order a complete set of blood tests and a CT scan of the head. The blood tests reveal abnormal liver function and macrocytic anemia. The CT scan of the head appears normal, but an MRI performed later shows small petechial hemorrhages in the mamillary bodies.

      During her hospital stay, she receives a treatment that worsens her condition, leading to acute confusion. Upon examination, you observe an unsteady gait, peripheral neuropathy, and bilateral abducens nerve palsies.

      Which medication should be urgently administered to this patient?

      Your Answer:

      Correct Answer: Intravenous Pabrinex

      Explanation:

      This patient has developed Wernicke’s encephalopathy, a condition that is associated with alcohol abuse and other causes of thiamine deficiency. It is important to note that the infusion of glucose-containing intravenous fluids without thiamine in a patient with chronic thiamine deficiency can trigger Wernicke’s encephalopathy. In this particular case, it seems that this is what has occurred.

      Wernicke’s encephalopathy is typically characterized by a triad of symptoms, which include acute confusion, ophthalmoplegia, and ataxia. Additionally, other possible features of this condition may include papilloedema, hearing loss, apathy, dysphagia, memory impairment, and hypothermia. It is also common for peripheral neuropathy, primarily affecting the legs, to occur in the majority of cases.

      This condition is characterized by the presence of acute capillary haemorrhages, astrocytosis, and neuronal death in the upper brainstem and diencephalon. These abnormalities can be visualized through MRI scanning, although CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will go on to develop a Korsakoff psychosis. This condition is characterized by retrograde amnesia, an inability to form new memories, disordered time perception, and confabulation.

      Patients who are suspected to have Wernicke’s encephalopathy should be promptly treated with parenteral thiamine (such as Pabrinex) for a minimum of 5 days. Following the parenteral therapy, oral thiamine should be administered.

    • This question is part of the following fields:

      • Neurology
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  • Question 8 - A toddler is brought in with a non-blanching rash and a high fever....

    Incorrect

    • A toddler is brought in with a non-blanching rash and a high fever. You suspect a potential diagnosis of meningococcal disease.
      Based on the current NICE guidelines, which of the following features is MOST indicative of this diagnosis?

      Your Answer:

      Correct Answer: Capillary refill time >3 seconds or longer

      Explanation:

      NICE has emphasized that certain symptoms and signs can indicate specific diseases as the underlying cause of a fever. In the case of meningococcal disease, the presence of a rash that does not fade when pressed upon (non-blanching rash) is particularly suggestive, especially if the child appears unwell, the lesions are larger than 2 mm in diameter (purpura), the capillary refill time is 3 seconds or longer, or there is neck stiffness. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Neurology
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  • Question 9 - A 32-year-old man presents with a range of neurological symptoms. He has been...

    Incorrect

    • A 32-year-old man presents with a range of neurological symptoms. He has been experiencing painless double vision over the past day and is becoming worried. Approximately six months ago, he also recalled a two-week period where he had no feeling in his right arm. When directly asked, he also confesses to feeling tired and quite depressed.

      What is the SINGLE most probable diagnosis?

      Your Answer:

      Correct Answer: Multiple sclerosis

      Explanation:

      Multiple sclerosis is a condition characterized by the demyelination of nerve cells in the brain and spinal cord. It is an autoimmune disease mediated by cells and is caused by recurring inflammation. Typically, it presents in early adulthood, with a female to male ratio of 3:2.

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

      There are three main patterns of multiple sclerosis. The most common is relapsing and remitting MS, which is characterized by periods of no symptoms followed by relapses (this is seen in 80% of patients at the time of diagnosis). Another pattern is primary progressive MS, where symptoms develop and worsen from the beginning with few remissions (seen in 10-15% of patients at diagnosis). Lastly, there is secondary progressive MS, which occurs after relapsing/remitting MS. In this pattern, symptoms worsen with fewer remissions, and approximately 50% of those with relapsing/remitting MS will develop this within 10 years of diagnosis.

      The key to diagnosing MS lies in the history of neurological symptoms that are discrete in time and location of the affected body. Patients often experience fatigue and low mood, particularly during a relapse.

    • This question is part of the following fields:

      • Neurology
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  • Question 10 - A 45-year-old woman presents with a severe headache that has been ongoing for...

    Incorrect

    • A 45-year-old woman presents with a severe headache that has been ongoing for the past 3 hours. She describes it as the 'most intense headache she has ever experienced'. She also complains of sensitivity to light and stiffness in her neck. There is no history of any head injury. Initially, she was treated conservatively and her symptoms improved. However, on the third day, she had a seizure and lost the ability to move her left arm. Physical examination reveals weakness in the left arm but normal sensation. A CT scan of her head shows a localized area of decreased density in the right frontal lobe, with a loss of distinction between grey and white matter and surrounding swelling.

      What is the most likely cause of her current condition?

      Your Answer:

      Correct Answer: Cerebral vasospasm

      Explanation:

      Intracranial hemorrhages can be categorized based on their location into epidural, subdural, subarachnoid, or intracerebral hemorrhages. The patient in this case is experiencing a severe headache accompanied by signs of meningismus, which strongly suggests a diagnosis of subarachnoid hemorrhage. Additionally, there is no history of trauma, and most cases of subarachnoid hemorrhage are caused by the rupture of a berry aneurysm located in the circle of Willis. Hypertension is a significant risk factor for the rupture of an aneurysm.

      During the patient’s hospital stay, they develop an ischemic stroke, which is confirmed by a CT scan. This is most likely a result of cerebral vasospasm secondary to the subarachnoid hemorrhage. To prevent this complication, patients are often treated with the cerebral selective calcium channel blocker Nimodipine.

      Another potential complication of this condition is rebleeding, with the highest risk occurring in the first few days. Rebleeding can be potentially fatal, so it is crucial to repair the aneurysm as soon as possible. The presence of blood in the subarachnoid space can also disrupt the production and drainage of cerebrospinal fluid, leading to hydrocephalus.

      Long-term complications of subarachnoid hemorrhage include epilepsy, with most patients experiencing their first seizure within a year after the hemorrhage. However, the risk of epilepsy decreases over time. Cognitive dysfunction is also a common long-term complication and can manifest as memory loss, difficulty concentrating, or challenges in performing regular tasks. Emotional problems, such as depression and anxiety, are frequently observed as well.

    • This question is part of the following fields:

      • Neurology
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  • Question 11 - A 78 year old male is brought into the emergency department from a...

    Incorrect

    • A 78 year old male is brought into the emergency department from a retirement home due to increasing disorientation and drowsiness. Blood tests reveal a serum sodium level of 117 mmol/L and the patient is administered Intravenous 3% sodium chloride solution. The patient initially demonstrates some improvement, becoming more awake and less confused, but after approximately 90 minutes, he becomes lethargic and experiences difficulty speaking with noticeable dysarthria.

      What is the probable underlying reason?

      Your Answer:

      Correct Answer: Central pontine myelinolysis

      Explanation:

      The probable underlying reason for the patient’s symptoms is central pontine myelinolysis. This condition is characterized by the destruction of the myelin sheath in the pons, a region of the brainstem. It is often caused by a rapid correction of hyponatremia, which is a low level of sodium in the blood. In this case, the patient’s serum sodium level was initially low at 117 mmol/L, and the administration of intravenous 3% sodium chloride solution caused a rapid increase in sodium levels. This sudden change in sodium concentration can lead to the development of central pontine myelinolysis. The initial improvement in the patient’s symptoms may have been due to the correction of hyponatremia, but the subsequent development of lethargy and dysarthria suggests the onset of central pontine myelinolysis.

      Further Reading:

      Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition characterized by low sodium levels in the blood due to excessive secretion of antidiuretic hormone (ADH). ADH, also known as arginine vasopressin (AVP), is responsible for promoting water and sodium reabsorption in the body. SIADH occurs when there is impaired free water excretion, leading to euvolemic (normal fluid volume) hypotonic hyponatremia.

      There are various causes of SIADH, including malignancies such as small cell lung cancer, stomach cancer, and prostate cancer, as well as neurological conditions like stroke, subarachnoid hemorrhage, and meningitis. Infections such as tuberculosis and pneumonia, as well as certain medications like thiazide diuretics and selective serotonin reuptake inhibitors (SSRIs), can also contribute to SIADH.

      The diagnostic features of SIADH include low plasma osmolality, inappropriately elevated urine osmolality, urinary sodium levels above 30 mmol/L, and euvolemic. Symptoms of hyponatremia, which is a common consequence of SIADH, include nausea, vomiting, headache, confusion, lethargy, muscle weakness, seizures, and coma.

      Management of SIADH involves correcting hyponatremia slowly to avoid complications such as central pontine myelinolysis. The underlying cause of SIADH should be treated if possible, such as discontinuing causative medications. Fluid restriction is typically recommended, with a daily limit of around 1000 ml for adults. In severe cases with neurological symptoms, intravenous hypertonic saline may be used. Medications like demeclocycline, which blocks ADH receptors, or ADH receptor antagonists like tolvaptan may also be considered.

      It is important to monitor serum sodium levels closely during treatment, especially if using hypertonic saline, to prevent rapid correction that can lead to central pontine myelinolysis. Osmolality abnormalities can help determine the underlying cause of hyponatremia, with increased urine osmolality indicating dehydration or renal disease, and decreased urine osmolality suggesting SIADH or overhydration.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with...

    Incorrect

    • A 65-year-old woman with a history of chronic alcohol abuse is diagnosed with Wernicke's encephalopathy. You have been requested to examine the patient and arrange an investigation to assist in confirming the diagnosis.

      Which of the following investigations is MOST LIKELY to be beneficial in establishing the diagnosis?

      Your Answer:

      Correct Answer: MRI scan of brain

      Explanation:

      Wernicke’s encephalopathy is a condition that is linked to alcohol abuse and other causes of thiamine deficiency. It is commonly identified by the presence of three main symptoms: acute confusion, ophthalmoplegia (paralysis or weakness of the eye muscles), and ataxia (loss of coordination). Additional signs may include papilloedema (swelling of the optic disc), hearing loss, apathy, dysphagia (difficulty swallowing), memory impairment, and hypothermia. Most cases also involve peripheral neuropathy, primarily affecting the legs.

      This condition is characterized by the occurrence of acute capillary hemorrhages, astrocytosis (abnormal increase in astrocytes, a type of brain cell), and neuronal death in the upper brainstem and diencephalon. These abnormalities can be detected through MRI scanning, while CT scanning is not very useful for diagnosis.

      If left untreated, most patients with Wernicke’s encephalopathy will develop a condition known as Korsakoff psychosis. This condition is characterized by retrograde amnesia (loss of memory for events that occurred before the onset of amnesia), an inability to form new memories, disordered perception of time, and confabulation (fabrication of false memories).

      When Wernicke’s encephalopathy is suspected, it is crucial to administer parenteral thiamine (such as Pabrinex) for at least 5 days. Following the parenteral therapy, oral thiamine should be continued.

    • This question is part of the following fields:

      • Neurology
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  • Question 13 - A 28 year old male is brought to the emergency department by his...

    Incorrect

    • A 28 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 about 20 seconds. Initially, the patient appeared to be fine, but after approximately 20 minutes, he started to become progressively more drowsy. A CT scan reveals the presence of an extradural hematoma.

      Which vascular structure is typically injured as the underlying cause of an extradural hematoma?

      Your Answer:

      Correct Answer: Middle meningeal artery

      Explanation:

      Extradural hematoma is most frequently caused by injury to the middle meningeal artery. This artery is particularly susceptible to damage as it passes behind the pterion.

      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.

    • This question is part of the following fields:

      • Neurology
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  • Question 14 - A 55-year-old man with a history of hypertension arrived at the emergency department...

    Incorrect

    • A 55-year-old man with a history of hypertension arrived at the emergency department with a sudden and severe occipital headache accompanied by vomiting and neck stiffness. There is no reported head injury. Upon clinical examination, the patient has a temperature of 37ºC, a respiratory rate of 18 per minute, a pulse of 88 beats per minute, and a blood pressure of 160/100. The physician observes a lateral and inferior deviation of the left eye with a dilated pupil and drooping of the left upper eyelid.

      What is the SINGLE most likely diagnosis?

      Your Answer:

      Correct Answer: Subarachnoid haemorrhage

      Explanation:

      The most probable diagnosis in this case is a subarachnoid haemorrhage (SAH).

      When assessing patients who present with an SAH, they may exhibit focal neurological signs, which can indicate the potential location of the aneurysm. Common areas where aneurysms occur 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 paralysis 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.

    • This question is part of the following fields:

      • Neurology
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  • Question 15 - A 45-year-old man presents with complaints of headaches. He recently started a new...

    Incorrect

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

      What is the most likely diagnosis for this patient?

      Your Answer:

      Correct Answer: Episodic tension-type headache

      Explanation:

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

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

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

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

    • This question is part of the following fields:

      • Neurology
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  • Question 16 - A toddler is brought in with a rash and a high fever. You...

    Incorrect

    • A toddler is brought in with a rash and a high fever. You suspect a potential diagnosis of bacterial meningitis.
      Based on the current NICE guidelines, which of the following features is LEAST indicative of this condition?

      Your Answer:

      Correct Answer: Focal seizures

      Explanation:

      NICE has emphasized that certain indications and manifestations may indicate specific diseases as the underlying cause of fever. For instance, symptoms such as neck stiffness, bulging fontanelle, decreased level of consciousness, and convulsive status epilepticus are suggestive of bacterial meningitis. On the other hand, NICE has identified focal seizures and focal neurological signs as the most indicative of herpes simplex encephalitis. For more information, you can refer to the NICE guidelines on the assessment and initial management of fever in children under 5, as well as the NICE Clinical Knowledge Summary on the management of feverish children.

    • This question is part of the following fields:

      • Neurology
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  • Question 17 - A 25-year-old hairdresser is brought into the emergency department after collapsing at work....

    Incorrect

    • A 25-year-old hairdresser is brought into the emergency department after collapsing at work. The patient's coworker presents you with security camera footage of the incident, where the patient is observed falling to the floor just before experiencing involuntary jerking movements in all four limbs. The patient remained unconscious for approximately one minute and also lost control of their bladder during the episode. A diagnosis of tonic-clonic seizure is made, and there is no prior history of seizures or epilepsy. Despite no identifiable cause, what advice should be given to this patient regarding their ability to drive a car?

      Your Answer:

      Correct Answer: Must not drive for 6 months

      Explanation:

      Patients who experience a seizure(s) should be informed about their ability to drive. There are two important instructions to follow in this regard. Firstly, they must refrain from driving for a period of 6 months. Secondly, they must notify the appropriate authority, such as the DVLA or DVA in Northern Ireland. In the case of a single seizure, driving should be suspended for 6 months from the date of the seizure. However, if an underlying cause that increases the risk of seizures is identified, driving should be halted for 12 months. In the case of multiple seizures or epilepsy, driving should be ceased for 12 months from the most recent seizure.

      Further Reading:

      Blackouts are a common occurrence in the emergency department and can have serious consequences if they happen while a person is driving. It is crucial for doctors in the ED to be familiar with the guidelines set by the DVLA (Driver and Vehicle Licensing Agency) regarding driving restrictions for patients who have experienced a blackout.

      The DVLA has specific rules for different types of conditions that may cause syncope (loss of consciousness). For group 1 license holders (car/motorcycle use), if a person has had a first unprovoked isolated seizure, they must refrain from driving for 6 months or 12 months if there is an underlying causative factor that may increase the risk. They must also notify the DVLA. For group 2 license holders (bus and heavy goods vehicles), the restrictions are more stringent, with a requirement of 12 months off driving for a first unprovoked isolated seizure and 5 years off driving if there is an underlying causative factor.

      For epilepsy or multiple seizures, both group 1 and group 2 license holders must remain seizure-free for 12 months before their license can be considered. They must also notify the DVLA. In the case of a stroke or isolated transient ischemic attack (TIA), group 1 license holders need to refrain from driving for 1 month, while group 2 license holders must wait for 12 months before being re-licensed subject to medical evaluation. Multiple TIAs require 3 months off driving for both groups.

      Isolated vasovagal syncope requires no driving restriction for group 1 license holders, but group 2 license holders must refrain from driving for 3 months. Both groups must notify the DVLA. If syncope is caused by a reversible and treated condition, group 1 license holders need 4 weeks off driving, while group 2 license holders require 3 months. In the case of an isolated syncopal episode with an unknown cause, group 1 license holders must refrain from driving for 6 months, while group 2 license holders will have their license refused or revoked for 12 months.

      For patients who continue to drive against medical advice, the GMC (General Medical Council) has provided guidance on how doctors should manage the situation. Doctors should explain to the patient why they are not allowed to drive and inform them of their legal duty to notify the DVLA or DVA (Driver and Vehicle Agency in Northern Ireland). Doctors should also record the advice given to the patient in their medical record

    • This question is part of the following fields:

      • Neurology
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  • Question 18 - A 45-year-old patient has sustained an injury to their left upper limb, resulting...

    Incorrect

    • A 45-year-old patient has sustained an injury to their left upper limb, resulting in a peripheral neuropathy. Upon examination, the patient presents with clawing of their hand, with hyperextension of the metacarpophalangeal joints and flexion of the distal and proximal interphalangeal joints of the little and ring fingers. However, their wrist flexion remains normal. Sensory loss is observed over the palmar surface of the medial one and a half fingers, while sensation in the rest of the hand and forearm, including the palm and dorsal aspect of all fingers, is normal. Additionally, Froment's sign is positive.

      Which specific nerve has been affected in this case?

      Your Answer:

      Correct Answer: Ulnar nerve at the wrist

      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.

    • This question is part of the following fields:

      • Neurology
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  • Question 19 - A 45-year-old female patient is known to have Parkinson’s disease. She complains of...

    Incorrect

    • A 45-year-old female patient is known to have Parkinson’s disease. She complains of recent excessive sleepiness, increased anxiety, and uncontrolled jerky movements in her lower limbs.
      Which SINGLE medication is most likely responsible for these symptoms?

      Your Answer:

      Correct Answer: Co-beneldopa

      Explanation:

      Co-beneldopa, such as Madopar®, is a medication that combines levodopa and benserazide, a dopa-decarboxylase inhibitor. Levodopa is a precursor of dopamine and has been the primary treatment for Parkinson’s disease since the 1970s. To minimize the side effects of levodopa, it is administered with a dopa-decarboxylase inhibitor (DDI) to reduce its availability in the peripheral system. However, patients may still experience adverse effects like nausea, dizziness, sleepiness, dyskinesia, mood changes, confusion, hallucinations, and delusions.

      None of the other combination medications mentioned in this question cause the listed side effects.

      Co-dydramol is a pain reliever that contains dihydrocodeine tartrate and paracetamol.

      Co-flumactone is a medication that combines spironolactone, a potassium-sparing diuretic, and hydroflumethiazide, a type of thiazide diuretic used for managing congestive cardiac failure.

      Co-tenidone is a combination of atenolol and chlorthalidone, primarily used for treating hypertension.

      Co-simalcite, also known as Altacite plus, is an antacid that contains two main ingredients: hydrotalcite and activated dimeticone.

    • This question is part of the following fields:

      • Neurology
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  • Question 20 - A 42-year-old male patient with an injury to his right arm develops peripheral...

    Incorrect

    • A 42-year-old male patient with an injury to his right arm develops peripheral neuropathy. Examination reveals weakened wrist flexion, inability to abduct or oppose the thumb, and difficulty flexing the index and middle fingers. Ulnar deviation at the wrist and noticeable thenar wasting are observed, along with sensory loss over the radial side of the palm and the radial three and a half fingers. The patient exhibits 'papal benediction' upon flexing his fingers. Which nerve lesion is likely responsible for these findings?

      Your Answer:

      Correct Answer: Median nerve at the elbow

      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 anterior interosseous nerve (AIN) and the palmar cutaneous branch. The AIN supplies the flexor pollicis longus, pronator quadratus, and the lateral half of the flexor digitorum profundus. On the other hand, the palmar cutaneous branch 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 remains functional in carpal tunnel syndrome as it travels superficial to the flexor retinaculum. However, it can be damaged by laceration at the wrist.

      A comparison of median nerve lesions at the wrist and elbow is presented in the table 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 fingers

      Median 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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