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  • Question 1 - A 45-year-old female patient is known to have Parkinson’s disease. She complains of...

    Correct

    • 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: Co-beneldopa

      Explanation:

      Co-beneldopa, such as MadoparÂź, 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
      19.9
      Seconds
  • Question 2 - 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: Focal seizures

      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
      26.7
      Seconds
  • Question 3 - A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her...

    Incorrect

    • A 67-year-old woman experiences a stroke. Her primary symptoms include weakness in her right limbs, particularly affecting her face and arm more than her leg, as well as sensory loss on the right side. Additionally, she has receptive dysphasia.
      Which blood vessel is most likely to be impacted?

      Your Answer: Posterior cerebral artery

      Correct Answer: Middle cerebral artery

      Explanation:

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

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

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

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

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

    • This question is part of the following fields:

      • Neurology
      18.2
      Seconds
  • Question 4 - 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: Ulnar nerve at the wrist

      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 Âœ 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 Âœ 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
      58.3
      Seconds
  • Question 5 - A 35 year old female is brought into the emergency department after being...

    Correct

    • A 35 year old female is brought into the emergency department after being hit by a truck that had veered onto the sidewalk where the patient was standing. The patient has a significant bruise on the back of her head and seems lethargic.

      You are worried about increased intracranial pressure (ICP). Which of the following physical signs suggest elevated ICP?

      Your Answer: Vomiting

      Explanation:

      Vomiting after a head injury should raise concerns about increased intracranial pressure (ICP). Signs of elevated ICP include vomiting, changes in pupil size or shape in one eye, decreased cognitive function or consciousness, abnormal findings during fundoscopy (such as blurry optic discs or bleeding in the retina), cranial nerve dysfunction (most commonly affecting CN III and VI), weakness on one side of the body (a late sign), bradycardia (slow heart rate), high blood pressure, and a wide pulse pressure. Irregular breathing that may progress to respiratory distress, focal neurological deficits, and seizures can also be indicative of elevated ICP.

      Further Reading:

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

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

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

      Measuring ICP typically requires invasive procedures, such as inserting a sensor through the skull. Management of raised ICP involves a multi-faceted approach, including antipyretics to maintain normothermia, seizure control, positioning the patient with a 30Âș 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
      38.5
      Seconds
  • Question 6 - A 45-year-old is brought to the emergency department by her hiking guide following...

    Incorrect

    • A 45-year-old is brought to the emergency department by her hiking guide following a mountain hike. The guide informs you that the patient had been resting for a few minutes when the left side of her face drooped and her speech became incomprehensible. On examination, you observe dysphasia, a left-sided facial droop, and weakness of the left arm. The patient's vital signs are as follows:

      Pulse: 92 bpm
      Blood pressure: 128/80 mmHg
      Respiratory rate: 18 bpm
      Oxygen saturations: 97% on air
      Temperature: 36.9°C

      What is the most appropriate definitive treatment for this patient?

      Your Answer: Thrombolysis following CT exclusion of cerebral haemorrhage

      Correct Answer: Recompression therapy in a hyperbaric oxygen chamber

      Explanation:

      Henry’s law describes the correlation between the quantity of dissolved gas in a liquid and its partial pressure above the liquid. According to Henry’s law, the amount of gas dissolved in a liquid is directly proportional to the partial pressure of that gas above the liquid. In the case of nitrogen narcosis, as the patient descends deeper into the water, the pressure increases, causing more nitrogen to dissolve in the bloodstream. As the patient ascends, the pressure decreases, leading to a decrease in the amount of dissolved nitrogen and improvement in symptoms.

      Further Reading:

      Decompression illness (DCI) is a term that encompasses both decompression sickness (DCS) and arterial gas embolism (AGE). When diving underwater, the increasing pressure causes gases to become more soluble and reduces the size of gas bubbles. As a diver ascends, nitrogen can come out of solution and form gas bubbles, leading to decompression sickness or the bends. Boyle’s and Henry’s gas laws help explain the changes in gases during changing pressure.

      Henry’s law states that the amount of gas that dissolves in a liquid is proportional to the partial pressure of the gas. Divers often use atmospheres (ATM) as a measure of pressure, with 1 ATM being the pressure at sea level. Boyle’s law states that the volume of gas is inversely proportional to the pressure. As pressure increases, volume decreases.

      Decompression sickness occurs when nitrogen comes out of solution as a diver ascends. The evolved gas can physically damage tissue by stretching or tearing it as bubbles expand, or by provoking an inflammatory response. Joints and spinal nervous tissue are commonly affected. Symptoms of primary damage usually appear immediately or soon after a dive, while secondary damage may present hours or days later.

      Arterial gas embolism occurs when nitrogen bubbles escape into the arterial circulation and cause distal ischemia. The consequences depend on where the embolism lodges, ranging from tissue ischemia to stroke if it lodges in the cerebral arterial circulation. Mechanisms for distal embolism include pulmonary barotrauma, right to left shunt, and pulmonary filter overload.

      Clinical features of decompression illness vary, but symptoms often appear within six hours of a dive. These can include joint pain, neurological symptoms, chest pain or breathing difficulties, rash, vestibular problems, and constitutional symptoms. Factors that increase the risk of DCI include diving at greater depth, longer duration, multiple dives close together, problems with ascent, closed rebreather circuits, flying shortly after diving, exercise shortly after diving, dehydration, and alcohol use.

      Diagnosis of DCI is clinical, and investigations depend on the presentation. All patients should receive high flow oxygen, and a low threshold for ordering a chest X-ray should be maintained. Hydration is important, and IV fluids may be necessary. Definitive treatment is recompression therapy in a hyperbaric oxygen chamber, which should be arranged as soon as possible. Entonox should not be given, as it will increase the pressure effect in air spaces.

    • This question is part of the following fields:

      • Neurology
      40.1
      Seconds
  • Question 7 - 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: Superficial temporal artery

      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
      6.5
      Seconds
  • Question 8 - A 45-year-old woman with no permanent residence sustains a head injury after a...

    Correct

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

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

      Which medication has caused the onset of this condition?

      Your Answer: Wernicke’s encephalopathy

      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
      66.2
      Seconds
  • Question 9 - 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: Obstructive hydrocephalus

      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
      40.3
      Seconds
  • Question 10 - A 72 year old male comes to the emergency department with complaints of...

    Incorrect

    • A 72 year old male comes to the emergency department with complaints of vertigo. What signs would indicate a central cause?

      Your Answer: Positive Romberg's test

      Correct Answer: Negative head impulse test

      Explanation:

      A patient with central vertigo would typically show a normal head impulse test result, indicating a normal vestibulo-ocular reflex. However, they would likely have an abnormal alternate cover test result, with a slight vertical correction, suggesting a central lesion like a stroke. A positive Romberg’s test can identify instability related to vertigo but cannot differentiate between peripheral and central causes. On the other hand, a positive Unterberger’s test indicates labyrinth dysfunction but does not indicate a central cause.

      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 neuropathy.

    • This question is part of the following fields:

      • Neurology
      18.1
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  • Question 11 - 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: Medication overuse headache

      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
      38
      Seconds
  • Question 12 - You are summoned to the resuscitation area to assist with a patient experiencing...

    Incorrect

    • You are summoned to the resuscitation area to assist with a patient experiencing status epilepticus.
      Which ONE statement about the utilization of benzodiazepines in status epilepticus is accurate?

      Your Answer: Benzodiazepines have low lipid solubility

      Correct Answer: Diazepam can be given by the intravenous route

      Explanation:

      Between 60 and 80% of individuals who experience seizures will have their seizure stopped by a single dose of intravenous benzodiazepine. Benzodiazepines have a high solubility in lipids and can quickly pass through the blood-brain barrier. This is why they have a fast onset of action.

      As the initial treatment, intravenous lorazepam should be administered. If intravenous lorazepam is not accessible, intravenous diazepam can be used instead. In cases where it is not possible to establish intravenous access promptly, buccal midazolam can be utilized.

    • This question is part of the following fields:

      • Neurology
      57.7
      Seconds
  • Question 13 - 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: Nerve conduction studies

      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
      44.3
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  • Question 14 - A 45-year-old patient has sustained an injury to their left upper limb, resulting...

    Correct

    • 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: 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
      9.8
      Seconds
  • Question 15 - 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: Intramuscular vitamin B12

      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 16 - A 55-year-old man with a history of hypertension arrived at the emergency department...

    Correct

    • 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 37ÂșC, 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: 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 17 - A 4-year-old child is brought in by ambulance. He has been experiencing seizures...

    Correct

    • A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 35 minutes. So far, he has received two doses of IV lorazepam. His bowel movement is normal. He has a history of epilepsy and is on phenytoin as maintenance therapy.

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

      Your Answer: Set up phenobarbitone infusion

      Explanation:

      The current algorithm for the treatment of a convulsing child, known as APLS, is as follows:

      Step 1 (5 minutes after the start of convulsion):
      If a child has been convulsing for 5 minutes or more, the initial dose of benzodiazepine should be administered. This can be done by giving Lorazepam at a dose of 0.1 mg/kg intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam at a dose of 0.5 mg/kg or rectal diazepam at a dose of 0.5 mg/kg can be given if vascular access is not available.

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

      Step 3 (10 minutes after the start of Step 2):
      At this stage, it is necessary to involve senior help to reassess the child and provide guidance on further management. The recommended approach is as follows:
      – If the child is not already on phenytoin, a phenytoin infusion should be initiated. This involves administering 20 mg/kg of phenytoin intravenously over a period of 20 minutes.
      – If the child is already taking phenytoin, phenobarbitone can be used as an alternative. The recommended dose is 20 mg/kg administered intravenously over 20 minutes.
      – In the meantime, rectal paraldehyde can be considered at a dose of 0.8 ml/kg of the 50:50 mixture while preparing the infusion.

      Step 4 (20 minutes after the start of Step 3):
      If the child is still experiencing convulsions at this stage, it is crucial to have an anaesthetist present. A rapid sequence induction with thiopental is recommended for further management.

      Please note that this algorithm is subject to change based on individual patient circumstances and the guidance of medical professionals.

    • This question is part of the following fields:

      • Neurology
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  • Question 18 - A 78 year old male is brought into the emergency department from a...

    Correct

    • 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: 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 19 - 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: Convulsive status epilepticus

      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
      34.7
      Seconds
  • Question 20 - A 4-year-old child is brought in by ambulance. He has been experiencing seizures...

    Incorrect

    • A 4-year-old child is brought in by ambulance. He has been experiencing seizures for the past 15 minutes. IV access is established and his blood sugar level is 4.5. He weighs 20 kg.

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

      Your Answer: Buccal midazolam 5 mg

      Correct Answer: IV lorazepam 2 mg

      Explanation:

      The current algorithm for the treatment of a convulsing child, known as APLS, is as follows:

      Step 1 (5 minutes after the start of convulsion):
      If a child has been convulsing for 5 minutes or more, the initial dose of benzodiazepine should be administered. This can be done by giving Lorazepam at a dose of 0.1 mg/kg intravenously (IV) or intraosseously (IO) if vascular access is available. Alternatively, buccal midazolam at a dose of 0.5 mg/kg or rectal diazepam at a dose of 0.5 mg/kg can be given if vascular access is not available.

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

      Step 3 (10 minutes after the start of Step 2):
      At this stage, it is necessary to involve senior help to reassess the child and provide guidance on further management. The recommended approach is as follows:
      – If the child is not already on phenytoin, a phenytoin infusion should be initiated. This involves administering 20 mg/kg of phenytoin intravenously over a period of 20 minutes.
      – If the child is already taking phenytoin, phenobarbitone can be used as an alternative. The recommended dose is 20 mg/kg administered intravenously over 20 minutes.
      – In the meantime, rectal paraldehyde can be considered at a dose of 0.8 ml/kg of the 50:50 mixture while preparing the infusion.

      Step 4 (20 minutes after the start of Step 3):
      If the child is still experiencing convulsions at this stage, it is crucial to have an anaesthetist present. A rapid sequence induction with thiopental is recommended for further management.

      Please note that this algorithm is subject to change based on individual patient circumstances and the guidance of medical professionals.

    • This question is part of the following fields:

      • Neurology
      62.4
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