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  • Question 1 - You are requested to evaluate a 15-year-old Caucasian girl who has been feeling...

    Incorrect

    • You are requested to evaluate a 15-year-old Caucasian girl who has been feeling unwell for a few days. She has been experiencing intermittent fevers and chills and complains of extreme fatigue. Suddenly, half an hour before her admission to the hospital, she lost all vision in her left eye.

      During the examination, the patient appears pale and unwell. Her vital signs are as follows: temperature 38.5°C, pulse 120/minute, regular, blood pressure 100/55 mmHg, and respiratory rate 22/minute. A pansystolic murmur is audible at the apex and lower left sternal border. Both lungs are clear.

      The right pupil reacts normally to light, but there is no reaction from the left pupil, which remains fixed and dilated. The patient has complete loss of vision in the left eye, and the left fundus appears paler than the right, without papilloedema. The only additional finding on examination was a paronychia on her right thumb, and light pressure on the nail bed was very uncomfortable.

      Investigations reveal the following results: Hb 109 g/L (115-165), WBC 14.1 ×109/L (4-11), Neutrophils 9.0 ×109/L (1.5-7), Lymphocytes 4.8 ×109/L (1.5-4), Monocytes 0.29 ×109/L (0-0.8), Eosinophils 0.01 ×109/L (0.04-0.4), and Platelets 550 ×109/L (150-400).

      What is the most crucial investigation to determine the cause of her illness?

      Your Answer: CT head

      Correct Answer: Blood cultures

      Explanation:

      Complications of Chronic Paronychia

      Chronic paronychia can lead to serious complications such as osteomyelitis and endocarditis. The most common causative organism for these complications is Staphylococcus aureus. Endocarditis can cause emboli, which are fragments of vegetation that can block or damage blood vessels in any part of the body. This can result in severe consequences such as blindness, stroke, or paralysis.

      To properly assess and manage a patient with chronic paronychia and its complications, several investigations may be necessary. However, the most crucial immediate investigations are blood cultures and echocardiography. These tests can help identify the causative organism and determine the extent of damage to the heart valves. Early diagnosis and treatment are essential to prevent further complications and improve the patient’s prognosis.

    • This question is part of the following fields:

      • Neurology
      25.2
      Seconds
  • Question 2 - Which statement about the facial nerve is accurate in terms of its paragraph...

    Correct

    • Which statement about the facial nerve is accurate in terms of its paragraph structure?

      Your Answer: Is secretomotor to the lacrimal gland

      Explanation:

      Functions of the Facial Nerve

      The facial nerve, also known as the seventh cranial nerve, has several important functions. It carries secretomotor fibers to the lacrimal gland through the greater petrosal nerve and is secretomotor to the submandibular and sublingual glands. It also supplies the muscles of facial expression and is associated developmentally with the second branchial arch. The facial nerve carries special taste sensation to the anterior two-thirds of the tongue via the chorda tympani nerve and somatic sensation to the external auditory meatus. However, it does not innervate the levator palpebrae superioris or the principal muscles of mastication, which are supplied by other nerves.

    • This question is part of the following fields:

      • Neurology
      10
      Seconds
  • Question 3 - What type of receptor utilizes G protein for downstream signaling? ...

    Incorrect

    • What type of receptor utilizes G protein for downstream signaling?

      Your Answer: Neuromodulating

      Correct Answer: Metabotropic

      Explanation:

      Classification of Receptors Based on Downstream Signalling Mechanisms

      Receptors are classified based on their mechanism for downstream signalling. There are two main types of receptors: inotropic and metabotropic. Inotropic receptors, such as glutamate receptors, are ion channel receptors that bind to neurotransmitters and cause a direct change in ion flow. On the other hand, metabotropic receptors, such as adrenoreceptors, are coupled to G proteins or enzymes and cause a cascade of intracellular events.

      Metabotropic receptors can be further subdivided into G-protein coupled receptors or enzyme-associated receptors. Some neurotransmitters, like acetylcholine, can bind to both inotropic and metabotropic receptors. However, only metabotropic receptors are used in receptor classification.

      Examples of inotropic receptors include glutamate receptors, GABA-A receptors, 5-HT3 receptors, nicotinic acetylcholine receptors, AMPA receptors, and glycine receptors. Examples of metabotropic receptors include adrenoreceptors, GABA-B receptors, 5-HT1 receptors, muscarinic acetylcholine receptors, dopaminergic receptors, and histaminergic receptors.

      In summary, receptors are classified based on their downstream signalling mechanisms. Inotropic receptors cause a direct change in ion flow, while metabotropic receptors cause a cascade of intracellular events. Only metabotropic receptors are used in receptor classification, and they can be further subdivided into G-protein coupled receptors or enzyme-associated receptors.

    • This question is part of the following fields:

      • Neurology
      4.6
      Seconds
  • Question 4 - A 65-year-old female presents with a three month history of headaches, shoulder pain...

    Incorrect

    • A 65-year-old female presents with a three month history of headaches, shoulder pain and weight loss. Over this time she has lost approximately 6 kg in weight.

      She describes early morning stiffness of the shoulders. Also, she has become aware of frontal headaches and has noticed tenderness of the scalp particularly when she combs her hair. She has little in her past medical history, she is a lifelong non-smoker and takes no medication.

      During examination, she appears to be in good health with a blood pressure of 126/88 mmHg and a BMI of 23.4. Neurological examination is normal though she is tender over the shoulders and scalp.

      Which of the following investigations would you select for this patient?

      Your Answer: CT head scan

      Correct Answer: Erythrocyte sedimentation rate (ESR)

      Explanation:

      Temporal arthritis/Polymyalgia Rheumatica: A Condition of Unknown Aetiology

      This condition, which is of unknown aetiology, typically affects the elderly and is associated with inflammation of the extracranial arteries. It is characterized by weight loss, proximal muscle stiffness and tenderness, headaches, and scalp tenderness. Elevated inflammatory markers, particularly erythrocyte sedimentation rate (ESR) and C reactive protein, are usually associated with it. Temporal arthritis may also be diagnosed through biopsy of the inflamed temporal artery, although false negatives may occur as the disease may patchily affect the artery.

      It is important to recognize and treat the disease early to reduce morbidity and prevent blindness due to involvement of the optic arteries with retinal ischemia. The condition usually rapidly improves with steroid therapy, and the disease may be monitored through reduction of ESR.

    • This question is part of the following fields:

      • Neurology
      17.5
      Seconds
  • Question 5 - A middle-aged homeless alcoholic who frequently attends the Emergency Department is brought by...

    Incorrect

    • A middle-aged homeless alcoholic who frequently attends the Emergency Department is brought by ambulance, having been found unconscious on the street. He had been examined the previous day with head and facial injuries following a fist fight. Examination on admission reveals an unconscious patient smelling strongly of alcohol. He is rousable with painful stimuli, but confused and unco-operative. His pupils are unequal, with the left pupil measuring approximately 8 mm and the right 4 mm. The left pupil is unreactive to both direct and consensual light stimulus, whereas the right pupil constricts normally to direct and consensual light stimulus.
      Which cranial nerve(s) is this lesion affecting?

      Your Answer: The left optic nerve

      Correct Answer: The left oculomotor nerve

      Explanation:

      Assessing the Pupillary Light Reflex and Nerve Lesions

      The pupillary light reflex involves two cranial nerves, the second and third, and their respective pathways. The optic nerve carries visual stimuli to the brain, while the oculomotor nerve controls the constriction of the pupil. Second-order neurons from the optic tract bypass the thalamus and primary visual cortex to reach the midbrain’s pretectal area. From there, neurons pass to the Edinger-Westphal nuclei, which send preganglionic parasympathetic fibers to both oculomotor nerves en route to the ciliary ganglion and sphincter pupillae.

      If a lesion occurs in the left oculomotor nerve, the left pupil will not constrict to light. This can happen due to raised intracranial pressure with a left-sided subdural hematoma, which can impinge on the nerve. However, if the right pupil constricts normally, the right oculomotor nerve and optic nerve must be intact.

      If a lesion occurs in the left optic nerve, the left pupil will not constrict to light, and the right pupil will not constrict to consensual light. This is because the optic nerve relays visual stimuli from the retina to the brain, and both eyes must be intact for the reflex to occur.

      If a combined lesion occurs in the left oculomotor and optic nerves, the left pupil will not constrict to light, and the right pupil will not constrict to consensual light. However, the right pupil will still constrict to direct light, indicating that the optic nerve is intact bilaterally.

    • This question is part of the following fields:

      • Neurology
      29.3
      Seconds
  • Question 6 - You are asked to give a presentation to a group of third-year medical...

    Correct

    • You are asked to give a presentation to a group of third-year medical students about the different types of dementia and how they may present.
      Which of the following is characteristic of frontotemporal dementia?

      Your Answer: Confabulation and repetition

      Explanation:

      Understanding Fronto-Temporal Dementia: Symptoms and Features

      Fronto-temporal dementia is a complex disorder that affects both the frontal and temporal lobes of the brain. Its diagnosis can be challenging, especially in the early stages of the disease. To better understand this condition, it is helpful to examine its symptoms and features based on the affected brain regions.

      Frontal lobe dysfunction is characterized by changes in personality and behavior, such as loss of tact and concern for others, disinhibition, emotional instability, distractibility, impulsivity, and fixed attitudes. However, some patients may exhibit opposite behaviors and become increasingly withdrawn.

      Temporal lobe dysfunction, on the other hand, affects speech and language abilities, leading to dysphasia, confabulation, repetition, and difficulty finding words and names (semantic dementia).

      Other features of fronto-temporal dementia include earlier onset (typically between 40-60 years old), slow and insidious progression, relatively preserved memory in the early stages, and loss of executive function as the disease advances. Unlike Alzheimer’s disease, hallucinations, paranoia, and delusions are rare, and personality and mood remain largely unaffected.

      It is important to note that fronto-temporal dementia can present differently in late onset cases (70-80 years old) and does not typically involve bradykinesia, a hallmark symptom of Parkinson’s disease. Rapid progressive loss of memory and cognitive abilities is also not typical of fronto-temporal dementia, as the disease tends to progress slowly over time.

      In summary, understanding the symptoms and features of fronto-temporal dementia can aid in its early detection and management.

    • This question is part of the following fields:

      • Neurology
      13.4
      Seconds
  • Question 7 - A 28-year-old patient presents with progressive weakness of the arms and legs over...

    Incorrect

    • A 28-year-old patient presents with progressive weakness of the arms and legs over 1 week. Three weeks earlier, she had an episode of diarrhoea lasting 5 days. Examination confirms distal weakness and ‘glove-and-stocking’ sensory loss.
      What is the most likely diagnosis?

      Your Answer: Subacute combined degeneration of the cord

      Correct Answer: Guillain–Barré syndrome

      Explanation:

      Differential Diagnosis for a Patient with Ascending Paralysis and Glove-and-Stocking Weakness

      The patient presents with acute progressive ascending paralysis and glove-and-stocking weakness, which is typical of Guillain–Barré syndrome. However, cranial nerve palsies can also occur. It is important to consider other potential diagnoses, such as multiple sclerosis, subacute combined degeneration of the cord, diabetic neuropathy, and acute intermittent porphyria. MS is characterised by lesions separated in both space and time, while subacute combined degeneration of the cord is secondary to a deficiency of vitamin B12 and presents with progressive limb weakness, paraesthesiae, and visual disturbances. Diabetic neuropathy usually causes sensory impairment, not motor impairment, and acute intermittent porphyria manifests with a constellation of symptoms, including abdominal pain, peripheral and autonomic neuropathies, and proximal motor weakness. A thorough evaluation and diagnostic workup are necessary to determine the underlying cause of the patient’s symptoms.

    • This question is part of the following fields:

      • Neurology
      16.2
      Seconds
  • Question 8 - You are investigating the genetic implications for developing Alzheimer's disease as a part...

    Correct

    • You are investigating the genetic implications for developing Alzheimer's disease as a part of a research paper.
      Which of the following gene alleles is protective against developing Alzheimer's disease in individuals over the age of 60?

      Your Answer: ApoE-e2

      Explanation:

      Understanding the Role of Apolipoprotein E Gene Alleles in Alzheimer’s Disease and Cardiovascular Risk

      Apolipoprotein E (ApoE) is a crucial component of very low-density lipoprotein (VLDL) and has three common gene alleles: ApoE-e2, e3, and e4. Among these, e3 is the most prevalent, found in 50% of the population. However, the presence of different alleles can have varying effects on an individual’s health.

      ApoE-e2 is considered a protective gene against the development of Alzheimer’s disease. On the other hand, ApoE-e4 is regarded as a positive predictor for developing the disease and is also associated with the development of atheromatous disease, making it a predictor of cardiovascular risk.

      It is important to note that ApoE-e1 and e5 are not significant in terms of their association with Alzheimer’s disease or cardiovascular risk. Therefore, understanding the role of ApoE gene alleles can help in predicting an individual’s susceptibility to these diseases and developing appropriate preventive measures.

    • This question is part of the following fields:

      • Neurology
      9.4
      Seconds
  • Question 9 - A 72-year-old woman who has smoked her entire life presents with a complaint...

    Incorrect

    • A 72-year-old woman who has smoked her entire life presents with a complaint of drooping of the left eyelid. Upon examination, there is ptosis of the left eyelid and a small pupil that responds to light but does not dilate. The right eye appears normal.
      What is the probable diagnosis?

      Your Answer: Left seventh cranial nerve palsy

      Correct Answer: Left Horner syndrome

      Explanation:

      Common Cranial Nerve Palsies and Horner Syndrome

      Horner’s syndrome is a condition that affects the sympathetic trunk and causes ptosis, miosis, and anhidrosis. This syndrome is commonly associated with an apical lung lesion, especially in lifelong smokers. On the other hand, cranial nerve palsies affect the third, fifth, and seventh nerves, each with distinct symptoms.

      Third nerve palsy causes ptosis and mydriasis, while trigeminal nerve palsy affects sensation and mastication but leaves the pupil unaffected. Facial nerve palsy, on the other hand, results in facial paralysis and the inability to close the affected eyelid, but it does not affect the pupil.

      It is important to differentiate between these conditions as they have different underlying causes and treatments. A thorough neurological examination is necessary to determine the specific cranial nerve affected and the appropriate management plan.

      In summary, understanding the differences between Horner’s syndrome and cranial nerve palsies is crucial in making an accurate diagnosis and providing optimal care for patients.

    • This question is part of the following fields:

      • Neurology
      10.8
      Seconds
  • Question 10 - A 25-year-old, fit and healthy woman develops severe headache, confusion and nausea on...

    Incorrect

    • A 25-year-old, fit and healthy woman develops severe headache, confusion and nausea on day 5 of climbing Mount Kilimanjaro in her adventure trip. A doctor accompanying the group examines her and finds her to be tachycardic with a raised temperature. They diagnose high-altitude cerebral oedema.
      What is the most crucial step in managing this patient?

      Your Answer: Dexamethasone

      Correct Answer: Descent

      Explanation:

      Treatment of High-Altitude Cerebral Oedema: The Importance of Rapid Descent

      High-altitude cerebral oedema is a serious medical emergency that can be fatal if not treated promptly. It is caused by swelling of the brain at high altitudes and requires immediate action. The most important management for this condition is rapid descent to lower altitudes. In severe cases, patients may need to be air-lifted or carried down as their symptoms prevent them from doing so themselves. While oxygen and steroids like dexamethasone can help improve symptoms, they are secondary to descent.

      Acetazolamide is a medication that can be used to prevent acute mountain sickness, but it is not effective in treating high-altitude cerebral oedema. Oxygen can also help reduce symptoms, but it is not a substitute for rapid descent.

      Rest is important in preventing acute mountain sickness, but it is not appropriate for a patient with high-altitude cerebral oedema. Adequate time for acclimatisation and following the principles of climb high, sleep low can reduce the risk of developing symptoms.

      In summary, rapid descent is the most important treatment for high-altitude cerebral oedema. Other interventions like oxygen and steroids can be helpful, but they are not a substitute for immediate action.

    • This question is part of the following fields:

      • Neurology
      17.6
      Seconds
  • Question 11 - A 72-year-old woman with a history of rheumatoid arthritis, hypertension and depression has...

    Incorrect

    • A 72-year-old woman with a history of rheumatoid arthritis, hypertension and depression has been experiencing severe pins and needles in her hands upon waking in the morning. The patient has worked as a stenographer for the last 25 years, and this sensation has been increasing in intensity over the past 7 years.
      What would be the anticipated findings for this patient based on her medical history and symptoms?

      Your Answer: Numbness over the medial aspect of the ring finger

      Correct Answer: Flattening of the thenar eminence

      Explanation:

      Understanding the Symptoms of Median Nerve Compression in Carpal Tunnel Syndrome

      Carpal tunnel syndrome is a condition that occurs when the median nerve is compressed within the carpal tunnel of the wrist. This can lead to a variety of symptoms, including numbness, weakness, and pain in the affected hand and fingers. Here are some common symptoms of median nerve compression in carpal tunnel syndrome and what they mean:

      Flattening of the thenar eminence: The thenar eminence is the fleshy area at the base of the thumb. When the median nerve is compressed, the muscles in this area may undergo wasting, leading to a flattened appearance.

      Numbness over the medial aspect of the ring finger: The median nerve supplies sensation to the lateral three and a half digits of the hand, including the ring finger. Numbness in this area may be a sign of median nerve compression.

      Inability to abduct the thumb: The abductor pollicis brevis muscle, which is innervated by the median nerve, is responsible for abducting the thumb. When the median nerve is compressed, this movement may be weakened.

      Numbness over the proximal palm: The median nerve gives off a palmar cutaneous branch before entering the carpal tunnel. This branch supplies sensation to the proximal palm and is therefore unaffected by median nerve compression.

      Normal sensation over the radial aspect of the ring finger: Despite supplying sensation to the lateral three and a half digits of the hand, the median nerve does not supply sensation to the dorsal aspect of the interdigital web between the thumb and index finger or the radial aspect of the ring finger. Therefore, sensation in this area would not be affected by median nerve compression.

      Understanding these symptoms can help individuals recognize the signs of carpal tunnel syndrome and seek appropriate treatment. Treatment options may include medication, wrist splints, and surgery to release the compressed nerve.

    • This question is part of the following fields:

      • Neurology
      18.3
      Seconds
  • Question 12 - What brain structure is likely affected in a 72-year-old man who suddenly experiences...

    Correct

    • What brain structure is likely affected in a 72-year-old man who suddenly experiences paralysis on the left side of his body and oculomotor nerve dysfunction on the right side?

      Your Answer: Midbrain

      Explanation:

      Weber’s Syndrome: A Midbrain Infarction

      Weber’s syndrome is a condition that occurs when there is an infarction in the midbrain. This can result in contralateral hemiplegia, which is paralysis on one side of the body, and ipsilateral oculomotor nerve palsy, which affects the eye muscles on the same side as the infarction. Patients with Weber’s syndrome often experience an abnormal level of consciousness and asymmetric hemiparesis or quadriparesis, which is weakness or paralysis in one or more limbs.

      In more than 70% of cases, patients also exhibit ipsilateral third nerve palsies with pupillary abnormalities and oculomotor signs. These symptoms can include drooping eyelids, double vision, and difficulty moving the eye in certain directions. Weber’s syndrome can be a serious condition that requires prompt medical attention. Treatment may involve medications to manage symptoms and physical therapy to help patients regain strength and mobility.

    • This question is part of the following fields:

      • Neurology
      12.4
      Seconds
  • Question 13 - The ward nurses express concern about a 46-year-old man who was admitted with...

    Incorrect

    • The ward nurses express concern about a 46-year-old man who was admitted with jaundice yesterday. They discovered him in the linen cupboard, disoriented and searching for his luggage so he could check-out before midday. Upon your arrival, he is still confused and unsteady, with a tachycardia of 120 bpm and nystagmus. However, he poses no immediate danger to himself or others. Which medication would be suitable for this patient?

      Your Answer: N-acetylcysteine IV

      Correct Answer: Thiamine IV and chlordiazepoxide orally (PO)

      Explanation:

      Treatment Plan for Wernicke’s Encephalopathy in Alcohol Withdrawal

      Wernicke’s encephalopathy is a disorder caused by thiamine deficiency commonly seen in alcohol withdrawal. The triad of ophthalmoplegia, confusion, and ataxia characterizes it. If left untreated, it can lead to Korsakoff syndrome with lasting memory impairment. The following treatment plan is recommended:

      Treatment Plan for Wernicke’s Encephalopathy in Alcohol Withdrawal

      1. Thiamine IV: Parenteral thiamine (Pabrinex®) is required and should be given in a setting where resuscitation facilities are available due to the risk of anaphylaxis. Thiamine is also given prophylactically in alcohol withdrawal.

      2. Chlordiazepoxide PO: Given orally as required (PRN) to control the symptoms of delirium tremens. The dosage should be adjusted according to symptom severity.

      3. Haloperidol IM: Antipsychotic medication such as haloperidol or IM benzodiazepines are not required in this instance where the patient is not at risk to himself or others.

      4. N-acetylcysteine IV: N-Acetylcysteine is used commonly for the treatment of paracetamol overdose. There is no evidence that this patient has a liver impairment as a result of paracetamol overdose.

      5. Propranolol PO: Propranolol is used for the treatment of portal hypertension and although likely, there is no evidence this patient has portal hypertension.

      6. Thiamine IM and midazolam IM: Thiamine is not given IM. There is no indication for IM benzodiazepines as this patient is co-operating with treatment. A chlordiazepoxide withdrawal regime would be better suited to this patient’s needs. This can be given orally.

    • This question is part of the following fields:

      • Neurology
      21.1
      Seconds
  • Question 14 - A 50-year-old homeless individual is brought to the emergency department after being found...

    Incorrect

    • A 50-year-old homeless individual is brought to the emergency department after being found vomiting. Upon examination, the patient appears confused and disoriented, with unkempt appearance and slurred speech. However, the patient has a Glasgow Coma Scale score of 14. Vital signs include a pulse of 108 bpm, oxygen saturation of 94% on air, and blood pressure of 124/78 mmHg. Cardiovascular and respiratory exams are normal, with mild epigastric tenderness on abdominal exam. The patient has a broad-based gait and bilateral nystagmus with weakness of abduction of the eyes. Reflexes, power, and tone are generally normal with flexor plantar responses. What is the likely diagnosis?

      Your Answer: Acute alcohol intoxication

      Correct Answer: Wernicke’s encephalopathy

      Explanation:

      Wernicke’s Encephalopathy: A Medical Emergency

      Wernicke’s encephalopathy is a condition caused by thiamine deficiency, which can be life-threatening if not treated urgently. This condition is often seen in alcoholics or malnourished individuals and can even occur during pregnancy due to hyperemesis gravidarum. The classic triad of symptoms includes ataxia, confusion, and ophthalmoplegia.

      It is crucial to differentiate Wernicke’s encephalopathy from alcohol intoxication as the former requires immediate thiamine replacement. The recommended treatment is either oral thiamine 300 mg/24h or, preferably, intravenous Pabrinex. If left untreated, the condition can rapidly progress to irreversible Korsakoff’s psychosis due to haemorrhage into the mamillary bodies.

      In summary, Wernicke’s encephalopathy is a medical emergency that requires prompt recognition and treatment to prevent irreversible neurological damage. It is essential to be aware of the classic triad of symptoms and to differentiate it from alcohol intoxication to ensure appropriate management.

    • This question is part of the following fields:

      • Neurology
      39.3
      Seconds
  • Question 15 - A 58-year-old man visits his GP complaining of constant fatigue and frontal hair...

    Incorrect

    • A 58-year-old man visits his GP complaining of constant fatigue and frontal hair loss. He has a medical history of high blood pressure and asthma and takes salbutamol, amlodipine, and simvastatin. He appears to be in good health, and his neurological examination is unremarkable. The auto-antibody screen is negative, and his creatine kinase (CK) level is 1,000 U/l (normal range: 22-198 U/l). What is the most likely cause of this man's symptoms?

      Your Answer: Polymyositis

      Correct Answer: Statin therapy

      Explanation:

      Understanding the Differential Diagnosis of Elevated CK Levels

      Elevated creatine kinase (CK) levels can indicate a variety of underlying conditions. When considering an elevated CK, it is important to take a detailed medication history as statin therapy, which is a common medication, can cause CK levels to rise in up to 5% of patients. Other common causes of mildly elevated CK include hypothyroidism, steroid use, and alcohol excess.

      Polymyositis is a potential differential diagnosis for a patient with elevated CK and fatigue, but it typically presents with objective proximal muscle weakness. The CK levels are often considerably higher than in the scenario described. Dermatomyositis, which features dermatological features alongside myositis, may present with papules on the hands, periorbital edema, flagellate erythema, or nailfold hemorrhages, none of which are present in this history.

      Extensive exercise can cause elevated CK levels, but it does not usually raise levels to the extent seen in this scenario. Rhabdomyolysis, which is a common cause of elevated CK, often occurs in elderly patients who have experienced a fall and long lie. However, there is no such history in this case, and CK levels in these patients are usually significantly higher.

      In summary, understanding the differential diagnosis of elevated CK levels requires a thorough evaluation of the patient’s medical history, medication use, and presenting symptoms.

    • This question is part of the following fields:

      • Neurology
      642.7
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  • Question 16 - An epileptic teenager is seeking advice regarding their ability to drive following a...

    Incorrect

    • An epileptic teenager is seeking advice regarding their ability to drive following a seizure six months ago. On further enquiry, you discover that the seizure was in response to a medication change, which also took place six months ago and since being put back on their original medication, they have been seizure-free.
      What advice is appropriate for this patient?

      Your Answer: She will have to wait another six months before she will be eligible to drive, allowing for 12 months following the seizure

      Correct Answer: She can apply to the DVLA to reinstate her licence now

      Explanation:

      Clarifying Misconceptions about Driving Eligibility for Patients with Epilepsy

      There are several misconceptions about driving eligibility for patients with epilepsy. One common misconception is that a patient must wait another six months before being eligible to drive after a medication-induced seizure. However, according to DVLA guidance, if the patient has been seizure-free for six months on their working medication, they can apply to reinstate their licence.

      Another misconception is that the patient must trial the new medication again to determine if they can drive. This is not true, as reverting back to the previous medication that did not work would not be helpful.

      Additionally, some believe that the patient must wait another 12 months due to the medication change resulting in the seizure. However, the time a patient must be seizure-free is not increased because the seizure was medication-induced.

      It is important to note that if a patient with epilepsy has been seizure-free for a certain period of time, depending on certain circumstances, they will be eligible to drive again in most cases. It is crucial for patients and healthcare professionals to have accurate information about driving eligibility for patients with epilepsy.

    • This question is part of the following fields:

      • Neurology
      14.3
      Seconds
  • Question 17 - A 10-year-old child is brought to the general practitioner by his mother. He...

    Correct

    • A 10-year-old child is brought to the general practitioner by his mother. He complains of loss of sensation over the dorsal aspect of his right forearm and hand for the last few days. His mother also states that he cannot extend his fingers and wrist after she pulled her son’s right hand gently while crossing a street 4 days ago. He had pain in his right elbow at that time but did not see a doctor immediately. On examination, there is loss of sensation and muscle weakness over the extensor surface of his right forearm and hand.
      Which of the following nerves is most likely to be injured in this patient?

      Your Answer: Radial nerve

      Explanation:

      Common Nerve Injuries and their Effects on Movement and Sensation

      Radial nerve: Nursemaid’s elbow is a common injury in children that can cause damage to the deep branch of the radial nerve. This can result in wrist drop due to paralysis of the extensors of the forearm and hand.

      Long thoracic nerve: The long thoracic nerve supplies the serratus anterior muscle, which is used in all reaching and pushing movements. Injury to this nerve causes winging of the scapula.

      Musculocutaneous nerve: Injury to the musculocutaneous nerve causes a loss of elbow flexion, weakness in supination, and sensation loss on the lateral aspect of the forearm.

      Axillary nerve: The axillary nerve supplies the deltoid muscle and teres minor. Injury to this nerve presents with flattening of the deltoid muscle after injury, loss of lateral rotation, abduction of the affected shoulder due to deltoid muscle weakness, and loss of sensation over the lateral aspect of the arm.

      Middle subscapular nerve: The middle subscapular nerve supplies the latissimus dorsi, which adducts and extends the humerus.

    • This question is part of the following fields:

      • Neurology
      17
      Seconds
  • Question 18 - A 68-year-old man presents to the general practitioner (GP) with visual complaints in...

    Incorrect

    • A 68-year-old man presents to the general practitioner (GP) with visual complaints in the right eye. He intermittently loses vision in the right eye, which he describes as a curtain vertically across his visual field. Each episode lasts about two or three minutes. He denies eye pain, eye discharge or headaches.
      His past medical history is significant for poorly controlled type 2 diabetes mellitus, hypertension and hypercholesterolaemia.
      On examination, his pupils are of normal size and reactive to light. There is no scalp tenderness. Blood test results are pending, and his electrocardiogram (ECG) shows normal sinus rhythm, without ischaemic changes.
      A provisional diagnosis of amaurosis fugax (AG) is being considered.
      Given this diagnosis, which of the following is the most appropriate treatment at this time?

      Your Answer: Prednisolone

      Correct Answer: Aspirin

      Explanation:

      Treatment Options for Transient Vision Loss: Aspirin, Prednisolone, Warfarin, High-Flow Oxygen, and Propranolol

      Transient vision loss can be a symptom of various conditions, including giant-cell arthritis (temporal arthritis) and transient retinal ischaemia. The appropriate treatment depends on the underlying cause.

      For transient retinal ischaemia, which is typically caused by atherosclerosis of the ipsilateral carotid artery, antiplatelet therapy with aspirin is recommended. Patients should also be evaluated for cardiovascular risk factors and considered for ultrasound of the carotid arteries.

      Prednisolone is used to treat giant-cell arthritis, which is characterised by sudden mononuclear loss of vision, jaw claudication, and scalp tenderness. However, if the patient does not have scalp tenderness or jaw claudication, oral steroids would not be indicated.

      Warfarin may be considered in patients with underlying atrial fibrillation and a high risk of embolic stroke. However, it should typically be bridged with a heparin derivative to avoid pro-thrombotic effects in the first 48-72 hours of use.

      High-flow oxygen is used to treat conditions like cluster headaches, which present with autonomic manifestations. If the patient does not have any autonomic features, high-flow oxygen would not be indicated.

      Propranolol can be used in the prophylactic management of migraines, which can present with transient visual loss. However, given the patient’s atherosclerotic risk factors and description of visual loss, transient retinal ischaemia is a more likely diagnosis.

      In summary, the appropriate treatment for transient vision loss depends on the underlying cause and should be tailored to the individual patient’s needs.

    • This question is part of the following fields:

      • Neurology
      18.8
      Seconds
  • Question 19 - A patient presents to the General Practice (GP) Clinic, seeking advice regarding driving...

    Incorrect

    • A patient presents to the General Practice (GP) Clinic, seeking advice regarding driving following two unprovoked seizures in 48 hours. What advice do you give the patient regarding their ability to drive their car?

      Your Answer: They are fit to drive, unless they have another seizure, but must inform the DVLA

      Correct Answer: They must inform the DVLA and will be unfit to drive for at least six months

      Explanation:

      If an individual experiences a seizure, they must inform the DVLA. Depending on the circumstances, they may be unfit to drive for six months or up to five years if they drive a bus or lorry. It is important to note that the DVLA must always be informed of any neurological event that could affect driving ability. An assessment by a DVLA medical examiner is not conducted, but a private or NHS neurologist should evaluate the individual’s fitness to drive.

    • This question is part of the following fields:

      • Neurology
      21
      Seconds
  • Question 20 - A 35-year-old motorcyclist was brought to the Emergency Department after being in a...

    Incorrect

    • A 35-year-old motorcyclist was brought to the Emergency Department after being in a road traffic accident and found alone on the road. Upon examination, he seems drowsy and is making grunting sounds, his pupils are equal and reactive to light, his eyes open to pain, and he withdraws his hand when the nurses attempt to insert a cannula. What is his Glasgow Coma Scale (GCS) score?

      Your Answer: 10

      Correct Answer: 8

      Explanation:

      Understanding the Glasgow Coma Scale (GCS)

      The Glasgow Coma Scale (GCS) is a tool used by clinicians to objectively measure a patient’s conscious state, particularly in cases of head injury. It provides a common language for healthcare professionals to discuss a patient’s condition. The GCS score is calculated based on the patient’s best eye, verbal, and motor responses, with a maximum score of 15/15 for a fully conscious and alert patient.

      The calculation for the GCS score is as follows: for eyes, the score ranges from 1 to 4 depending on whether the patient’s eyes open spontaneously, in response to speech, in response to pain, or not at all. For verbal response, the score ranges from 1 to 5 depending on whether the patient is oriented, confused, uses inappropriate words or sounds, or has no verbal response. For motor response, the score ranges from 1 to 6 depending on whether the patient obeys commands, localizes pain, withdraws from pain, exhibits abnormal flexion or extension, or has no response.

      If the GCS score is 8 or below, the patient will require airway protection as they will be unable to protect their own airway. This usually means intubation. Therefore, it is important for healthcare professionals to accurately calculate the GCS score and take appropriate action based on the score.

    • This question is part of the following fields:

      • Neurology
      11.6
      Seconds
  • Question 21 - A 48-year-old woman visits her doctor with complaints of painful tingling over the...

    Incorrect

    • A 48-year-old woman visits her doctor with complaints of painful tingling over the lateral side of her left hand upon awakening in recent weeks. She also reports experiencing clumsiness in her hand. Upon examination, the doctor notes reduced sensation on the palmar aspects of her left thumb, index, and middle and ring fingers, leading to a suspicion of carpal tunnel syndrome. What clinical examination would be most effective in confirming this diagnosis?

      Your Answer: Extension of the thumb with palpation of the anatomical snuffbox

      Correct Answer: Abduction of the thumb with palpation of the thenar eminence

      Explanation:

      Testing for Carpal Tunnel Syndrome: Thumb Abduction and Thenar Eminence Palpation

      When testing for carpal tunnel syndrome, one method involves abducting the thumb and palpating the thenar eminence, where the abductor pollicis brevis muscle is located. If this muscle cannot be palpated while the thumb is abducted, it suggests that the abduction is due to contraction of the abductor pollicis longus muscle only, which is supplied by the radial nerve. This indicates a possible issue with the median nerve, which can be compressed in carpal tunnel syndrome. Symptoms of this condition include pain, numbness, and weakness in the hand. Other testing methods, such as opposition of the thumb or palpation of the dorsal interossei muscle, are not as helpful in diagnosing carpal tunnel syndrome.

    • This question is part of the following fields:

      • Neurology
      16.2
      Seconds
  • Question 22 - A 65-year-old male complains of a burning sensation in his feet that has...

    Incorrect

    • A 65-year-old male complains of a burning sensation in his feet that has been gradually increasing over the past six months. Upon examination, his cranial nerves and higher mental function appear normal, as do his bulk, tone, power, light touch and pinprick sensation, co-ordination, and reflexes in both his upper and lower limbs. What condition could these clinical findings be indicative of?

      Your Answer: Motor neurone disease

      Correct Answer: Small fibre sensory neuropathy

      Explanation:

      Neuropathy and its Different Types

      Neuropathy is a condition that affects the nerves and can cause a burning sensation. This sensation is typical of a neuropathy that affects the small unmyelinated and thinly myelinated nerve fibres. However, a general neurological examination and reflexes are usually normal in this type of neuropathy unless there is coexisting large (myelinated) fibre involvement. On the other hand, neuropathy that affects the large myelinated sensory fibres generally causes glove and stocking sensory loss and loss of reflexes.

      There are different types of neuropathy, and conditions in which the small fibres are preferentially affected in the early stages include diabetes and amyloidosis. In the later stages, however, the neuropathy in these conditions also affects large fibres. Another type of neuropathy is associated with Sjögren’s syndrome, which is a pure sensory neuropathy (ganglionopathy). the different types of neuropathy and their symptoms can help in the diagnosis and management of this condition.

    • This question is part of the following fields:

      • Neurology
      10.8
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  • Question 23 - A 5-year-old girl is brought to a Paediatrician due to learning and behavioural...

    Incorrect

    • A 5-year-old girl is brought to a Paediatrician due to learning and behavioural difficulties. During the examination, the doctor observes symmetrical muscle weakness and notes that the child has only recently learned to walk. The girl requires assistance from her hands to stand up. The Paediatrician suspects that she may have Duchenne muscular dystrophy (DMD) and orders additional tests.
      What is the protein that is missing in DMD?

      Your Answer: Fibrillin

      Correct Answer: Dystrophin

      Explanation:

      Proteins and Genetic Disorders

      Dystrophin, Collagen, Creatine Kinase, Fibrillin, and Sarcoglycan are all proteins that play important roles in the body. However, defects or mutations in these proteins can lead to various genetic disorders.

      Dystrophin is a structural protein in skeletal and cardiac muscle that protects the muscle membrane against the forces of muscular contraction. Lack of dystrophin leads to Duchenne muscular dystrophy (DMD), a debilitating and life-limiting condition.

      Collagen is a protein found in connective tissue and defects in its structure, synthesis, or processing can lead to Ehlers Danlos syndrome, a genetic connective-tissue disorder.

      Creatine kinase is an enzyme released from damaged muscle tissue and elevated levels of it are seen in children with DMD.

      Fibrillin is a protein involved in connective tissue formation and mutations in the genes that code for it are found in Marfan syndrome, a connective tissue disorder.

      Sarcoglycans are transmembrane proteins and mutations in the genes that code for them are involved in limb-girdle muscular dystrophy.

    • This question is part of the following fields:

      • Neurology
      4
      Seconds
  • Question 24 - What does the term bouton terminaux refer to in an axodendritic chemical synapse?...

    Correct

    • What does the term bouton terminaux refer to in an axodendritic chemical synapse?

      Your Answer: The synaptic terminal of the presynaptic axon

      Explanation:

      Bouton Terminaux: The Synaptic Terminal of the Presynaptic Axon

      A bouton terminaux, also known as a terminal button or end bulb, is a bulge found at the end of a synaptic projection, which can be either an axon or a dendrite. This structure is responsible for releasing neurotransmitters into the synaptic cleft, allowing for communication between neurons. It is important to note that the bouton terminaux specifically refers to the presynaptic cell in the context of a synapse.

      It is essential to differentiate the bouton terminaux from other structures involved in synaptic transmission. For instance, synaptic vesicles are membrane-bound packages containing neurotransmitters, but they are not the same as the bouton terminaux. Similarly, axon varicosities are small swellings along the length of an axon that release neurotransmitters directly onto effector organs, such as smooth muscle, and are not the same as the bouton terminaux.

      Furthermore, the end bulb on the postsynaptic axon is not the same as the bouton terminaux, even though it is another term for it. This is because the end bulb refers to the postsynaptic cell, whereas the bouton terminaux specifically refers to the presynaptic cell. Finally, fusion pores on the presynaptic axon membrane are structures formed after the presynaptic neurotransmitter vesicles fuse with the presynaptic membrane and are not the same as the bouton terminaux.

      In summary, the bouton terminaux is a crucial structure in synaptic transmission, responsible for releasing neurotransmitters into the synaptic cleft. It is specific to the presynaptic cell and should not be confused with other structures involved in synaptic transmission.

    • This question is part of the following fields:

      • Neurology
      4.1
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  • Question 25 - A 78-year-old man comes to his doctor's office with his daughter. His daughter...

    Correct

    • A 78-year-old man comes to his doctor's office with his daughter. His daughter reports that he has been increasingly forgetful, frequently forgetting appointments and sometimes leaving the stove on. He has also experienced a few instances of urinary incontinence. The patient's neurological examination is unremarkable except for a slow gait, reduced step height, and decreased foot clearance. Based on these findings, what is the most probable diagnosis?

      Your Answer: Normal pressure hydrocephalus

      Explanation:

      Distinguishing Normal Pressure Hydrocephalus from Other Conditions: A Guide for Medical Professionals

      Normal pressure hydrocephalus (NPH) is a condition characterized by ventricular dilation without raised cerebrospinal fluid (CSF) levels. Its classic triad of symptoms includes urinary incontinence, gait disturbance, and dementia. While 50% of cases are idiopathic, it is crucial to diagnose NPH as it is a potentially reversible cause of dementia. MRI or CT scans can reveal ventricular enlargement, and treatment typically involves surgical insertion of a CSF shunt.

      When evaluating patients with symptoms similar to NPH, it is important to consider other conditions. Parkinson’s disease, for example, may cause gait disturbance, urinary incontinence, and dementia, but the presence of bradykinesia, tremor, and rigidity would make a Parkinson’s diagnosis unlikely. Multiple sclerosis (MS) may also cause urinary incontinence and gait disturbance, but memory problems are less likely, and additional sensory or motor problems are expected. Guillain-Barré syndrome involves ascending muscle weakness, which is not present in NPH. Cauda equina affects spinal nerves and may cause urinary incontinence and gait disturbance, but memory problems are not a symptom.

      In summary, while NPH shares some symptoms with other conditions, its unique combination of ventricular dilation, absence of raised CSF levels, and classic triad of symptoms make it a distinct diagnosis that requires prompt attention.

    • This question is part of the following fields:

      • Neurology
      14.7
      Seconds
  • Question 26 - What distinguishes graded potentials from action potentials? ...

    Incorrect

    • What distinguishes graded potentials from action potentials?

      Your Answer: Action potentials involve voltage-gated sodium channels, while graded potentials involve voltage-gated calcium channels

      Correct Answer: Graded potentials are localised, while action potentials conduct across the entire axon

      Explanation:

      Graded Potentials vs. Action Potentials

      Graded potentials are changes in the transmembrane potential that occur mainly in the dendrites and soma of a neuron. These changes do not cause significant depolarization to spread far from the area surrounding the site of stimulation. Graded potentials may or may not lead to an action potential, depending on the magnitude of depolarization. On the other hand, action potentials exhibit a refractory phase and are not subject to either temporal or spatial summation.

      Graded potentials involve chemical, mechanical, or light-gated channels that allow for an influx of sodium ions into the cytosol. In contrast, action potentials involve only voltage-gated ion channels, specifically sodium and potassium. Graded potentials typically last from a few milliseconds to even minutes, while action potential duration ranges between 0.5 – 2 milliseconds.

      In summary, graded and action potentials are two distinct phenomena. Graded potentials are subject to modulation by both temporal and spatial summation, while action potentials are not. Graded potentials involve different types of ion channels compared to action potentials. the differences between these two types of potentials is crucial in the complex processes that occur in the nervous system.

    • This question is part of the following fields:

      • Neurology
      10.4
      Seconds
  • Question 27 - A 38-year-old office worker is becoming increasingly worried that she may be experiencing...

    Incorrect

    • A 38-year-old office worker is becoming increasingly worried that she may be experiencing early signs of Alzheimer's disease, which her mother was diagnosed with at a young age. She reports frequently misplacing her phone and struggling to recall names of colleagues she has worked with for years. She wants to learn more about the initial clinical features of the disease to see if they align with her symptoms.

      What is a typical clinical characteristic of the early stage of Alzheimer's disease?

      Your Answer: Episodic confusion

      Correct Answer: Retention of executive function

      Explanation:

      Understanding Different Types of Dementia and Their Symptoms

      Executive function, which involves planning, reasoning, and problem-solving, is typically retained in the early stages of Alzheimer’s disease. However, in subcortical dementias like Lewy body disease (LBD), patients often lose this cognitive skill early on. Frontotemporal dementia, on the other hand, is more commonly associated with impulsivity and disinhibition, as well as personality changes. Episodic confusion is a hallmark of LBD, where patients may have good and bad days. Finally, bradykinesia and rigidity are signs of parkinsonism, which can be seen in both LBD and Parkinson’s disease. Understanding these different symptoms can help with early diagnosis and appropriate treatment.

    • This question is part of the following fields:

      • Neurology
      25.2
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  • Question 28 - A 28-year-old woman presents with a 48-hour history of headache and malaise that...

    Correct

    • A 28-year-old woman presents with a 48-hour history of headache and malaise that has worsened in the last 6 hours. She has vomited twice and recently had a sore throat. Her general practitioner has been treating her with a topical anti-fungal cream for vaginal thrush. On examination, she is photophobic and has moderate neck stiffness. The Glasgow Coma Score is 15/15, and she has no focal neurological signs. Her temperature is 38.5 °C. A computed tomography (CT) brain scan is reported as ‘Normal intracranial appearances’. A lumbar puncture is performed and CSF results are as follows: CSF protein 0.6 g/l (<0.45), cell count 98 white cells/mm3, mainly lymphocytes (<5), CSF glucose 2.8 mmol/l (2.5 – 4.4 mmol/l), and blood glucose 4.3 mmol/l (3-6 mmol/l). What is the most likely diagnosis?

      Your Answer: Acute viral meningitis

      Explanation:

      Distinguishing Acute Viral Meningitis from Other Neurological Disorders

      Acute viral meningitis is characterized by mild elevation of protein, a mainly lymphocytic cellular reaction, and a CSF: blood glucose ratio of >50%. In contrast, bacterial meningitis presents with a polymorph leukocytosis, lower relative glucose level, and more severe signs of meningism. Tuberculous meningitis typically presents subacutely with very high CSF protein and very low CSF glucose. Fungal meningitis is rare and mainly occurs in immunocompromised individuals. Guillain–Barré syndrome, an autoimmune peripheral nerve disorder causing ascending paralysis, is often triggered by a recent viral illness but presents with focal neurological signs, which are absent in viral meningitis. Accurate diagnosis is crucial for appropriate treatment and management.

    • This question is part of the following fields:

      • Neurology
      19.7
      Seconds
  • Question 29 - A 65-year-old woman presents to her general practitioner (GP) with unsteadiness on her...

    Incorrect

    • A 65-year-old woman presents to her general practitioner (GP) with unsteadiness on her feet and frequent falls of two days’ duration.
      On examination, she is noted to have loss of sensation and weakness of the proximal and distal muscles of the left lower limb. Her upper limbs and face have no weakness or sensory deficit.
      Her GP refers her to the nearest Stroke Unit for assessment and management. Computed tomography (CT) scan confirms a thromboembolic cerebrovascular accident.
      Which vessel is most likely to have been involved?

      Your Answer: The right posterior cerebral artery proximal occlusion

      Correct Answer: The left anterior cerebral artery distal to the anterior communicating branch

      Explanation:

      Understanding the Role of Cerebral Arteries in Neurological Symptoms

      When assessing neurological symptoms, it is important to consider the involvement of different cerebral arteries. In the case of right-sided weakness and lower limb involvement without upper limb or facial signs, the left anterior cerebral artery distal to the anterior communicating branch is likely affected. This artery supplies the medial aspect of the frontal and parietal lobes, which includes the primary motor and sensory cortices for the lower limb and distal trunk.

      On the other hand, a left posterior cerebral artery proximal occlusion is unlikely as it would not cause upper limb involvement or visual symptoms. Similarly, a right anterior cerebral artery distal occlusion would result in left-sided weakness and sensory loss in the lower limb.

      A main stem occlusion in the left middle cerebral artery would present with right-sided upper limb and facial weakness, as well as speech and auditory comprehension difficulties due to involvement of Broca’s and Wernicke’s areas.

      Finally, a right posterior cerebral artery proximal occlusion would cause visual field defects and contralateral loss of sensation, but not peripheral weakness on the right-hand side. Understanding the role of cerebral arteries in neurological symptoms can aid in accurate diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
      20.4
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  • Question 30 - What is a true statement about the femoral nerve? ...

    Incorrect

    • What is a true statement about the femoral nerve?

      Your Answer: Lies medial to the femoral artery in the femoral triangle

      Correct Answer: Has a deep branch which becomes the saphenous nerve

      Explanation:

      The Nerves of the Thigh

      The thigh is innervated by several nerves, including the femoral nerve, sciatic nerve, and lateral femoral cutaneous nerve. The femoral nerve is formed within the psoas major muscle and emerges from its lateral border to lie between the psoas and iliacus muscles in the iliac fossa. It then travels beneath the inguinal ligament and lies lateral to the femoral artery in the femoral triangle before entering the thigh.

      As it enters the thigh, the femoral nerve divides into a posterior division, which becomes the saphenous nerve as it enters the adductor canal. The saphenous nerve supplies the skin over the medial aspect of the leg and foot. The anterior division of the femoral nerve supplies the muscles of the anterior thigh, including the quadriceps femoris muscle.

      The sciatic nerve, which is the largest nerve in the body, divides into the tibial and common peroneal nerves in the popliteal fossa. The tibial nerve supplies the muscles of the posterior thigh and leg, while the common peroneal nerve supplies the muscles of the lateral leg.

      Finally, the lateral femoral cutaneous nerve supplies the skin over the lateral thigh. This nerve arises from the lumbar plexus and travels through the pelvis before entering the thigh. It supplies the skin over the lateral aspect of the thigh but does not supply any muscles.

    • This question is part of the following fields:

      • Neurology
      71.7
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  • Question 31 - A 38-year-old woman attends the Neurological Outpatient Clinic as an urgent referral, with...

    Incorrect

    • A 38-year-old woman attends the Neurological Outpatient Clinic as an urgent referral, with a short, but progressive, history of double vision. It is noted by her husband that her speech is worse last thing in the evening. She is a non-smoker and drinks 18 units a week of alcohol.
      Which of the following is the most appropriate diagnostic test?

      Your Answer: Computed tomography brain

      Correct Answer: Nerve conduction studies with repetitive nerve stimulation

      Explanation:

      Diagnostic Tests for Myasthenia Gravis

      Myasthenia gravis (MG) is a disease characterized by weakness and fatigability due to antibodies against the acetylcholine receptor at the neuromuscular junction. Nerve conduction studies with repetitive nerve stimulation can objectively document the fatigability, showing a decrement in the evoked muscle action after repeat stimulation. A CT brain scan is not useful for MG diagnosis, but CT chest imaging is indicated as thymic hyperplasia or tumors are associated with MG. Autoantibodies to voltage-gated calcium channels are associated with Lambert-Eaton myasthenic syndrome, which is rare. Visually evoked potentials are useful for assessing optic nerve function but not for MG diagnosis.

    • This question is part of the following fields:

      • Neurology
      140.5
      Seconds
  • Question 32 - A 68-year-old male presents with a sudden onset of vision loss in his...

    Incorrect

    • A 68-year-old male presents with a sudden onset of vision loss in his right eye that lasted for about half an hour. He experienced initial blurring of vision followed by cloudiness and inability to see out of the eye. The patient has a recent history of hypertension and takes atenolol, but is otherwise generally healthy. He drinks modest amounts of alcohol and smokes five cigarettes per day. On examination, his vision is now normal in both eyes with visual acuities of 6/12 in both eyes. His pulse is regular at 72 beats per minute, blood pressure is 162/88 mmHg, and BMI is 30. Cardiovascular examination, including auscultation over the neck, is otherwise unremarkable. What investigations would you order for this patient?

      Your Answer: CT head scan

      Correct Answer: Carotid Dopplers

      Explanation:

      Amaurosis Fugax

      Amaurosis fugax is a condition that occurs when an embolism blocks the right carotid distribution, resulting in temporary vision loss. To diagnose this condition, doctors should look for an embolic source and scan the carotids for atheromatous disease. It’s important to note that significant carotid disease may still be present even if there is no bruit. If stenosis greater than 70% of diameter are present, carotid endarterectomy is recommended. Additionally, echocardiography may be used to assess for cardiac embolic sources. To better understand this condition, resources such as a diagnostic flow chart and medical articles can be helpful.

    • This question is part of the following fields:

      • Neurology
      8.4
      Seconds
  • Question 33 - What is the type of cell that utilizes its Ciliary to assist in...

    Incorrect

    • What is the type of cell that utilizes its Ciliary to assist in the movement of cerebrospinal fluid throughout the central nervous system of vertebrates?

      Your Answer: Oligodendrocytes

      Correct Answer: Ependymal cells

      Explanation:

      The Functions of Cerebrospinal Fluid and the Roles of Different Types of Nervous System Cells

      The cerebrospinal fluid (CSF) is a clear and colourless fluid that circulates in the subarachnoid space, ventricular system of the brain, and central canal of the spinal cord. It provides the brain and spinal cord with mechanical and immunological buoyancy, chemical/temperature protection, and intracranial pressure control. The circulation of CSF within the central nervous system is facilitated by the beating of the Ciliary of ependymal cells, which line the brain ventricles and walls of the central canal. Therefore, ependymal cells are responsible for this function.

      Different types of nervous system cells have distinct roles in supporting the nervous system. Astrocytes provide biochemical support to blood-brain barrier endothelial cells, supply nutrients to nervous tissue, maintain extracellular ion balance, and aid in repairing traumatic injuries. Microglial cells are involved in immune defence of the central nervous system. Oligodendrocytes generate myelin sheaths on neurones of the central nervous system, while Schwann cells generate myelin sheaths on neurones of the peripheral nervous system.

      In summary, the CSF plays crucial roles in protecting and supporting the central nervous system, and ependymal cells are responsible for its circulation. Different types of nervous system cells have distinct functions in supporting the nervous system, including biochemical support, immune defence, and myelin sheath generation.

    • This question is part of the following fields:

      • Neurology
      14.4
      Seconds
  • Question 34 - A 35-year-old woman comes to her General Practitioner complaining of sudden onset of...

    Correct

    • A 35-year-old woman comes to her General Practitioner complaining of sudden onset of complete right-sided facial weakness that started yesterday. There are no other neurological symptoms observed during the examination. The patient denies any hearing loss and reports only drooling of saliva. Other than that, she is healthy and has no other complaints. An ear examination reveals no abnormalities.
      What is the probable diagnosis?

      Your Answer: Bell's Palsy

      Explanation:

      Understanding Bell’s Palsy and Differential Diagnoses

      Bell’s palsy is a sudden, unexplained facial nerve paralysis that affects one side of the face. It is more common in individuals with certain risk factors, such as diabetes, obesity, and upper respiratory tract infections. Symptoms include facial muscle weakness, drooling, speech difficulties, dry mouth, numbness, and ear pain. Treatment focuses on preventing complications, such as eye irritation, and can include eye ointment, lubricating drops, sunglasses, and a soft-food diet. Recovery typically occurs within a few weeks to several months.

      Differential diagnoses for Bell’s palsy include stroke, acoustic neuroma, Ramsay-Hunt syndrome, and neurosarcoidosis. Stroke typically spares the forehead muscles, while acoustic neuroma presents with hearing loss, tinnitus, and balance problems. Ramsay-Hunt syndrome is a complication of shingles and includes a vesicular rash, fever, and hearing loss. Neurosarcoidosis is rare and associated with systemic disease. A thorough evaluation is necessary to differentiate these conditions from Bell’s palsy.

    • This question is part of the following fields:

      • Neurology
      12.5
      Seconds
  • Question 35 - What are the reasons for having dilated pupils? ...

    Correct

    • What are the reasons for having dilated pupils?

      Your Answer: Ethylene glycol poisoning

      Explanation:

      Causes of Dilated and Small Pupils

      Dilated pupils can be caused by various factors such as Holmes-Adie (myotonic) pupil, third nerve palsy, and drugs or poisons like atropine, CO, and ethylene glycol. On the other hand, small pupils can be caused by Horner’s syndrome, old age, pontine hemorrhage, Argyll Robertson pupil, and drugs or poisons like opiates and organophosphates.

      Holmes-Adie (myotonic) pupil and third nerve palsy are conditions that affect the muscles that control the size of the pupil. Meanwhile, drugs and poisons like atropine, CO, and ethylene glycol can cause dilation of the pupils as a side effect. On the other hand, Horner’s syndrome, old age, pontine hemorrhage, Argyll Robertson pupil, and drugs or poisons like opiates and organophosphates can cause the pupils to become smaller.

    • This question is part of the following fields:

      • Neurology
      6.4
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  • Question 36 - A 25-year-old university student exhibits involuntary head twitching and flicking of his hands....

    Correct

    • A 25-year-old university student exhibits involuntary head twitching and flicking of his hands. He also says that he suffers from embarrassing grunting which can affect him at almost any time. When he is in lectures at the university he manages to control it, but often when he comes home and relaxes the movements and noises get the better of him. His girlfriend who attends the consultation with him tells you that he seems very easily distracted and often is really very annoying, repeating things which she says to him and mimicking her. On further questioning, it transpires that this has actually been a problem since childhood. On examination his BP is 115/70 mmHg, pulse is 74 beats/min and regular. His heart sounds are normal, respiratory, abdominal and neurological examinations are entirely normal.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 129 g/l 135–175 g/l
      White Cell Count (WCC) 8.0 × 109/l 4–11 × 109/l
      Platelets 193 × 109 /l 150–400 × 109/l
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 95 μmol/l 50–120 µmol/l
      Alanine Aminotransferase (ALT) 23 IU/l 5–30 IU/l
      Which one of the following is the most likely diagnosis?

      Your Answer: Gilles de la Tourette syndrome

      Explanation:

      Distinguishing Movement Disorders: Gilles de la Tourette Syndrome, Congenital Cerebellar Ataxia, Haemochromatosis, Huntington’s Disease, and Wilson’s Disease

      Gilles de la Tourette syndrome is characterized by motor and vocal tics that are preceded by an unwanted premonitory urge. These tics may be suppressible, but with associated tension and mental exhaustion. The diagnosis is based on clinical presentation and history, with an association with attention-deficit hyperactivity disorder, obsessive-compulsive disorder, behavioural problems, and self-mutilation. The pathophysiology is unknown, but treatments include neuroleptics, atypical antipsychotics, and benzodiazepines.

      Congenital cerebellar ataxia typically presents with a broad-based gait and dysmetria, which is not seen in this case. Haemochromatosis has a controversial link to movement disorders. Huntington’s disease primarily presents with chorea, irregular dancing-type movements that are not repetitive or rhythmic and lack the premonitory urge and suppressibility seen in Tourette’s. Wilson’s disease has central nervous system manifestations, particularly parkinsonism and tremor, which are not present in this case. It is important to distinguish between these movement disorders for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Neurology
      11.7
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  • Question 37 - A 78-year-old retired pharmacist is diagnosed with Alzheimer's disease after being investigated for...

    Incorrect

    • A 78-year-old retired pharmacist is diagnosed with Alzheimer's disease after being investigated for worsening memory problems and getting lost on his way home from the shops. What is associated with a diagnosis of Alzheimer's disease?

      Your Answer: Cerebrospinal fluid (CSF) protein = 0.5–1.0 g/l

      Correct Answer: Computed tomography (CT) brain scan = dilation of the sulci and ventricles

      Explanation:

      Diagnostic Tests and Their Relevance in Alzheimer’s Disease

      Computed tomography (CT) brain scan can be used to exclude vascular disease, normal pressure hydrocephalus, and space-occupying lesions in patients with cognitive decline. In pure Alzheimer’s disease, changes consistent with cerebral atrophy, such as dilated sulci and ventricles, are observed.

      Cerebrospinal fluid (CSF) protein levels of 0.5-1.0 g/l are not useful in diagnosing Alzheimer’s disease but may indicate bacterial or viral meningitis.

      An erythrocyte sedimentation rate (ESR) greater than 100 mm/hour is not useful in diagnosing Alzheimer’s disease but may be significant in multiple myeloma or vasculitis.

      Hemoglobin levels of 85 g/l and mean corpuscular volume (MCV) of 112 fl suggest macrocytic anemia, which requires further investigation and is most likely due to B12 or folate deficiency.

      CSF white cells of 100-150 neutrophils/mm3 are not useful in diagnosing Alzheimer’s disease but may indicate meningitis.

      Understanding the Relevance of Diagnostic Tests in Alzheimer’s Disease

    • This question is part of the following fields:

      • Neurology
      13.1
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  • Question 38 - A 32-year-old man presents to the Emergency department with a three-day history of...

    Incorrect

    • A 32-year-old man presents to the Emergency department with a three-day history of paraesthesia in his feet and hands. He has also noticed weakness in his thighs, particularly when walking down stairs, and weakness affecting his shoulders. Prior to this, he had been well, except for a mild case of gastroenteritis after eating Chinese food. On examination, he appears anxious, but cranial nerve examination and fundoscopy are normal. Upper limb examination reveals reduced tone and absent reflexes bilaterally at both wrists. Lower limb examination shows 2/5 power, absent reflexes, and reduced sensation affecting both feet. A lumbar puncture is performed, yielding the following results: opening pressure 14 cmH2O (5-18), CSF protein 0.40 g/L (0.15-0.45), CSF white cell count 4 cells per ml (<5 cells), CSF red cell count 2 cells per ml (<5 cells), and negative CSF oligoclonal bands. What is the diagnosis for this patient?

      Your Answer: Multiple sclerosis

      Correct Answer: Guillain-Barré syndrome

      Explanation:

      Differential Diagnosis for Acute Motor and Sensory Neuropathy

      His symptoms and signs suggest that he may be experiencing an acute motor and sensory neuropathy, which is commonly seen in Guillain-Barré syndrome following an infection. Patients with this condition often experience paraesthesias in their hands and feet, along with weakness. However, sensory abnormalities on examination are usually mild. Brainstem lesions are unlikely due to normal eye movements, and multiple sclerosis is a central demyelinating disorder that does not affect peripheral nerves. Wernicke’s encephalopathy typically presents as acute ataxia and ophthalmoplegia, while spinal cord lesions cause lower motor signs at the level of the lesion with upper motor signs below and a sensory level and bladder involvement. Although neurological complications can occur in systemic lupus erythematosus, including a peripheral neuropathy, the absence of common features such as joint or skin lesions makes this diagnosis unlikely. It is worth noting that cerebrospinal fluid protein is often normal at the onset of symptoms in Guillain-Barré syndrome.

    • This question is part of the following fields:

      • Neurology
      14.1
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  • Question 39 - A 20-year-old female underwent an appendicectomy and was administered an antiemetic for her...

    Correct

    • A 20-year-old female underwent an appendicectomy and was administered an antiemetic for her nausea and vomiting. However, she is now experiencing an oculogyric crisis and has a protruding tongue. Which antiemetic is the most probable cause of her symptoms?

      Your Answer: Metoclopramide

      Explanation:

      Extrapyramidal Effects of Antiemetic Drugs

      Anti-nausea medications such as metoclopramide, domperidone, and cyclizine can have extrapyramidal effects, which involve involuntary muscle movements. Metoclopramide is known to cause acute dystonic reactions, which can result in facial and skeletal muscle spasms and oculogyric crisis. These effects are more common in young girls and women, as well as the elderly. However, they typically subside within 24 hours of stopping treatment with metoclopramide.

      On the other hand, domperidone is less likely to cause extrapyramidal effects because it does not easily cross the blood-brain barrier. Cyclizine is also less likely to cause these effects, making it a safer option for those who are susceptible to extrapyramidal reactions. It is important to discuss any concerns about potential side effects with a healthcare provider before starting any new medication.

    • This question is part of the following fields:

      • Neurology
      10.3
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  • Question 40 - An 87-year-old woman who lives alone is found wandering in the street, she...

    Correct

    • An 87-year-old woman who lives alone is found wandering in the street, she is unable to remember her way home. Past medical history of note includes hypertension for which she takes lisinopril and hydrochlorothiazide. She is known to Social Services having been in trouble for stealing from a local grocery store earlier in the year, and for yelling at a neighbor who complained about her loud music. On examination she is agitated and socially inappropriate, she has been incontinent of urine. During your testing she repeats what you say and appears to be laughing at you. Responses to your questions tend to lack fluency and she has trouble naming simple objects. There is rigidity and increased tone on motor examination.
      Bloods:
      Investigation Result Normal value
      Haemoglobin 130 g/l 135–175 g/l
      White cell count (WCC) 5.2 × 109/l 4–11 × 109/l
      Platelets 250 × 109/l 150–400 × 109/l
      Sodium (Na+) 142 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 190 μmol/l 50–120 µmol/l
      Computed tomography (CT) head scan – evidence of frontal atrophy
      Which of the following diagnoses fits best with this clinical picture?

      Your Answer: Frontotemporal dementia

      Explanation:

      Understanding Frontotemporal Dementia: Symptoms, Diagnosis, and Management

      Frontotemporal dementia, also known as Pick’s disease, is a type of dementia that affects the frontal and temporal lobes of the brain. One of the hallmark symptoms of this condition is a change in personality, often leading to disinhibition, aggression, and inappropriate behavior. Patients may also exhibit echolalia and echopraxia, repeating words and imitating actions of others.

      Unlike Alzheimer’s disease, frontotemporal dementia often presents with early symptoms of behavioral changes and repetitive behavior, rather than memory loss. Incontinence may also be an early symptom. Diagnosis is typically made through brain imaging, which reveals frontotemporal lobe degeneration and the presence of Pick’s bodies, spherical aggregations of tau proteins in neurons.

      Management of frontotemporal dementia focuses on symptomatic treatment of behavior and support for caregivers and patients. Other conditions, such as Shy-Drager syndrome, multi-infarct dementia, and Creutzfeldt-Jakob disease, may present with similar symptoms but can be ruled out through careful evaluation and testing.

    • This question is part of the following fields:

      • Neurology
      10.1
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  • Question 41 - A 32-year-old man is brought to the Emergency Department by air ambulance after...

    Incorrect

    • A 32-year-old man is brought to the Emergency Department by air ambulance after being involved in a road traffic accident. According to witnesses this was a high-impact car crash and the other passenger in the car has unfortunately already passed away. The man is unconscious when he arrives, and initial assessment reveals a Glasgow Coma Scale (GCS) score of 9. He has some minor facial injuries and is bleeding from his nose.
      What is the appropriate initial management for traumatic brain injury in this case?

      Your Answer: Intubation if GCS falls below 6

      Correct Answer: Maintain pCO2 4.5 kPa

      Explanation:

      Management of Traumatic Brain Injury: Key Considerations

      Traumatic brain injury (TBI) is a serious condition that requires prompt and appropriate management to prevent secondary injury and improve outcomes. Here are some key considerations for managing TBI:

      Maintain pCO2 4.5 kPa: Sedation and ventilation should be used to maintain a pCO2 of 4.5 kPa to protect the brain. Adequate oxygenation is also essential.

      Permissive hypotension: Hypotension should be treated aggressively to prevent secondary ischaemic injury. Mean arterial pressure should be maintained >75 mmHg.

      Intubation if GCS falls below 6: Patients with a GCS score below 8 should be intubated to maintain their airway. Spinal immobilisation is also essential.

      Head-up tilt to 30 degrees: Head-up tilt to 30 degrees is an accepted measure to minimise rises in intracranial pressure in patients with TBI. Care should be taken if the patient has a cervical spine injury.

      Fluid resuscitation with saline: Initial fluid resuscitation should be with a crystalloid, such as normal saline, and/or blood. Albumin should be avoided.

      By following these key considerations, healthcare professionals can effectively manage TBI and improve patient outcomes.

    • This question is part of the following fields:

      • Neurology
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  • Question 42 - A 25-year-old man develops a wrist drop after suffering a spiral fracture of...

    Correct

    • A 25-year-old man develops a wrist drop after suffering a spiral fracture of the humerus while playing football. As a result, he is unable to extend his wrist and his hand hangs flaccidly. Which nerve is the most likely to have been damaged?

      Your Answer: Radial

      Explanation:

      The brachial plexus is a network of nerves that originate from the spinal cord in the neck and supply the upper limb. Damage to these nerves can occur due to trauma or compression at various points along their course. The radial nerve, which carries fibres from C5 to C8 and a sensory component from T1, can be injured in the axilla, upper arm, elbow or wrist. A lesion at the spiral groove of the humerus can result in a wrist drop. The musculocutaneous nerve, which arises from the lateral cord of the brachial plexus, can be affected by damage to the shoulder and brachial plexus or compression by the biceps aponeurosis and tendon. The axillary nerve, which supplies the deltoid, teres minor and triceps brachii, can be injured in dislocations of the shoulder joint, compression of the axilla with a crutch or fracture of the surgical neck of the humerus. The median nerve, which innervates all of the flexors in the forearm except the flexor carpi ulnaris and that part of the flexor digitorum profundus that supplies the medial two digits, can be compressed in the carpal tunnel. The ulnar nerve, which supplies the little finger and the adjacent half of the ring finger, can be trapped in the cubital tunnel on the medial side of the elbow. Pinching of the ulnar nerve can cause paraesthesiae in the fourth and fifth digits.

    • This question is part of the following fields:

      • Neurology
      9.3
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  • Question 43 - A 65-year-old woman comes to her GP complaining of frequent falls and unsteadiness...

    Correct

    • A 65-year-old woman comes to her GP complaining of frequent falls and unsteadiness on her feet for the past 2 days. During the examination, the GP observes weakness and loss of sensation in the muscles of her right lower limb, while her upper limbs and face show no sensory deficit or weakness. The GP refers her to the nearest stroke unit for further evaluation and treatment. A CT scan confirms a thromboembolic cerebrovascular accident.

      Which vessel is the most probable culprit?

      Your Answer: The left anterior cerebral artery distal to the anterior communicating branch

      Explanation:

      Identifying the Correct Artery in a Case of Peripheral Weakness

      In cases of peripheral weakness, identifying the correct artery involved is crucial for proper diagnosis and treatment. In this case, the weakness is on the right side, with involvement of the lower limb but not the upper limb or face. This suggests a problem with the left anterior cerebral artery distal to the anterior communicating branch, which supplies the medial aspect of the frontal and parietal lobes, including the primary motor and sensory cortices for the lower limb and distal trunk.

      Other potential arteries that could be involved include the left middle cerebral artery, which would present with right-sided upper limb and facial weakness, as well as speech and auditory comprehension difficulties. The right anterior cerebral artery distal to the anterior communicating branch is unlikely, as it would be associated with left-sided weakness and sensory loss in the lower limb. The right posterior cerebral artery proximal occlusion would result in visual field defects and contralateral weakness in both upper and lower limbs, as well as contralateral loss of sensation, which does not match the current presentation. The left posterior cerebral artery is also unlikely, as the upper limb is spared and there are no visual symptoms.

    • This question is part of the following fields:

      • Neurology
      20.2
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  • Question 44 - A 5-year-old boy is brought to his General Practitioner as his parents are...

    Incorrect

    • A 5-year-old boy is brought to his General Practitioner as his parents are worried about his walking. Up until four months ago, he was developing normally. However, they have now noticed he has difficulty getting up from the floor or climbing stairs. During the examination, the doctor observes Gowers’ sign and the boy has large, bulky calf muscles. His mother remembers having an uncle who died at a young age but cannot recall the cause of death. What is the probable reason for his walking difficulties?

      Your Answer: Myotonic dystrophy

      Correct Answer: Duchenne muscular dystrophy

      Explanation:

      Different Types of Muscular Dystrophy and their Characteristics

      Muscular dystrophy is a group of genetic disorders that cause progressive muscle weakness and wasting. Here are some of the different types of muscular dystrophy and their characteristics:

      1. Duchenne muscular dystrophy: This is an X-linked myopathy that occurs in boys aged 3-5. It can present as delay in motor development or regression of previously obtained motor milestones. Treatment is with steroids and respiratory support. Average life expectancy is around 25 years.

      2. Facioscapulohumeral dystrophy: This is the third most common muscular dystrophy and causes proximal upper limb weakness due to dysfunction of the scapula. Patients may also experience facial muscle weakness and progressive lower limb weakness. It typically presents in the third decade.

      3. Emery-Dreifuss muscular dystrophy: This is a rare muscular dystrophy characterised by weakness and progressive wasting of the lower leg and arm muscles. It is more common in boys, with typical onset in teenage years.

      4. Myotonic dystrophy: This is the most common inherited muscular dystrophy in adults. It is characterised by delayed muscle relaxation after contraction and muscle weakness. Patients may also experience myotonic facies with facial weakness, ptosis and cardiorespiratory complications.

      5. Polymyositis: This is an inflammatory myopathy in which patients experience proximal muscle weakness. It is more common in women in the fifth decade and is associated with underlying malignancy.

      It is important to identify the type of muscular dystrophy a patient has in order to provide appropriate treatment and management.

    • This question is part of the following fields:

      • Neurology
      18.1
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  • Question 45 - A 55-year-old man comes to the doctor complaining of double vision. Upon examination,...

    Incorrect

    • A 55-year-old man comes to the doctor complaining of double vision. Upon examination, his eye is turned down and out, and he has limited adduction, elevation, and depression of the eye, as well as ptosis. Additionally, his pupil is fixed and dilated. What is the probable diagnosis?

      Your Answer: Horner’s syndrome

      Correct Answer: Third nerve palsy

      Explanation:

      Common Cranial Nerve Palsies and Their Symptoms

      Cranial nerve palsies can cause a variety of symptoms depending on which nerve is affected. Here are some common cranial nerve palsies and their associated symptoms:

      Third Nerve Palsy: This affects the oculomotor nerve and causes the eye to be positioned downward and outward, along with ptosis (drooping eyelid) and mydriasis (dilated pupil).

      Sixth Nerve Palsy: This affects the abducens nerve and causes medial deviation of the eye.

      Fourth Nerve Palsy: This affects the trochlear nerve and causes the eye to look out and down, resulting in vertical or oblique diplopia (double vision). Patients may tilt their head away from the affected side to correct this.

      Horner’s Syndrome: This presents with miosis (constricted pupil), ptosis, and ipsilateral anhidrosis (lack of sweating on one side of the face).

      Fifth Nerve Palsy: This affects the trigeminal nerve, which is responsible for facial sensation and some motor functions related to biting and chewing. It does not affect the eye.

    • This question is part of the following fields:

      • Neurology
      10.7
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  • Question 46 - A 67-year-old man comes to the Emergency Department complaining of cough, blood in...

    Incorrect

    • A 67-year-old man comes to the Emergency Department complaining of cough, blood in his sputum, and a 3- to 4-cm right-sided supraclavicular lymph node. During the examination, you observe that the right side of his face is dry, and his right eyelid is drooping. What is the most probable location of the patient's pathology?

      Your Answer: Trigeminal nerve

      Correct Answer: Sympathetic chain

      Explanation:

      Understanding the Nerves Involved in Horner Syndrome

      Horner syndrome is a condition characterized by drooping of the eyelids (ptosis) and dryness of the face (anhidrosis), which is caused by interruption of the sympathetic chain. When a patient presents with these symptoms, an apical lung tumor should always be considered. To better understand this condition, it is important to know which nerves are not involved.

      The phrenic nerve, which supplies the diaphragm and is essential for breathing, does not cause symptoms of Horner syndrome when it is affected. Similarly, injury to the brachial plexus, which supplies the nerves of the upper limbs, does not cause ptosis or anhidrosis. The trigeminal nerve, responsible for sensation and muscles of mastication in the face, and the vagus nerve, which regulates heart rate and digestion, are also not involved in Horner syndrome.

      By ruling out these nerves, healthcare professionals can focus on the sympathetic chain as the likely culprit in cases of Horner syndrome.

    • This question is part of the following fields:

      • Neurology
      17
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  • Question 47 - A 40-year-old woman presents to the Neurology Clinic with a complaint of droopy...

    Incorrect

    • A 40-year-old woman presents to the Neurology Clinic with a complaint of droopy eyelids that have been present for the past 6 months. She reports experiencing intermittent double vision that varies in severity. She has also noticed difficulty swallowing her food at times. Upon examination, she displays mild weakness in eyelid closure bilaterally and mild lower facial weakness. Additionally, there is mild weakness in neck flexion and bilateral shoulder abduction. Reflexes are normal throughout, and the remainder of the examination is unremarkable. Electromyography is performed, revealing a 30% decrease in the compound motor action potential (CMAP) upon repetitive nerve stimulation (right abductor pollicis brevis muscle). Single-fibre electromyography shows normal fibre density and jitter. What is the most likely diagnosis?

      Your Answer: Polymyalgia rheumatica

      Correct Answer: Autoimmune myasthenia gravis

      Explanation:

      Differentiating Myasthenia Gravis from Other Neuromuscular Disorders

      Myasthenia gravis (MG) is an autoimmune disorder that causes muscle weakness and fatigue. It occurs when antibodies block the acetylcholine receptors at the neuromuscular junction, leading to impaired muscle function. This can be detected through electromyographic testing, which measures fatigability. However, other neuromuscular disorders can present with similar symptoms, making diagnosis challenging.

      Congenital myasthenia gravis is a rare form that occurs in infants born to myasthenic mothers. Guillain-Barré syndrome, although typically presenting with ophthalmoplegia, can also cause muscle weakness and reflex abnormalities. Lambert-Eaton myasthenic syndrome is caused by autoantibodies to voltage-gated calcium channels and is characterized by absent reflexes. Polymyalgia rheumatica, an inflammatory disorder of the soft tissues, can cause pain and weakness in the shoulder girdle but does not affect nerve conduction or facial muscles.

      Therefore, a thorough evaluation and diagnostic testing are necessary to differentiate MG from other neuromuscular disorders.

    • This question is part of the following fields:

      • Neurology
      8.9
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  • Question 48 - A 35-year-old female patient, who smokes and is taking the combined oral contraceptive...

    Incorrect

    • A 35-year-old female patient, who smokes and is taking the combined oral contraceptive pill, reports experiencing pain and swelling in her right calf for the past two days. She also presents with sudden onset weakness on her right side. Upon examination, she displays a dense hemiplegia, with upper motor neuron signs and weakness in her right hand. Additionally, evidence of a deep vein thrombosis in her right calf is observed. What is the probable diagnosis?

      Your Answer: Pulmonary embolism

      Correct Answer: Paradoxical embolism

      Explanation:

      Possible Embolic Cerebrovascular Accident in a Patient with History of DVT and Contraceptive Pill Use

      This patient presents with symptoms suggestive of deep vein thrombosis (DVT), including calf pain and swelling, and has a history of using the combined oral contraceptive pill, which increases the risk of DVT. However, the sudden onset of right-sided hemiplegia indicates the possibility of an embolic cerebrovascular accident (CVA) caused by an embolus passing through the heart and crossing over to the systemic side of circulation via an atrial septal defect (ASD) or ventricular septal defect (VSD).

      It is important to note that pulmonary embolism would not occur in this case without an ASD. While an aneurysm or hemorrhagic stroke are possible, they are less likely given the patient’s history of DVT. A tumor would also have a more chronic symptomatology, further supporting the possibility of an embolic CVA in this patient. Further diagnostic testing and treatment are necessary to confirm and address this potential complication.

    • This question is part of the following fields:

      • Neurology
      20.7
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  • Question 49 - A 4-year-old girl without past medical history is brought to the General Practitioner...

    Incorrect

    • A 4-year-old girl without past medical history is brought to the General Practitioner (GP) by her mother with 24 hours of headache and fever. She has also had two episodes of non-bloody vomiting this morning and states that ‘both legs are sore all over’. She is up to date with all of her vaccinations and has never been hospitalised in the past. No one in the child’s social circle has been unwell recently and she has no travel history. She has no drug allergies.
      On examination, discrete lesions of approximately 1–2 mm are visible, present on the trunk and legs. This rash is non-blanching. The mucous membranes are moist without lesions present. Her hands are cool to touch with a capillary refill time of three seconds. She is unable to fully flex her neck. Her observations are shown below:
      Temperature 38.2 °C
      Blood pressure 100/59 mmHg
      Heart rate 107 beats per minute
      Respiratory rate 22 breaths per minute
      Sp(O2) 98% (room air)
      Which of the following is the most appropriate next step in management?

      Your Answer: Discharge with advice for supportive care

      Correct Answer: Intramuscular benzylpenicillin

      Explanation:

      Management of Meningococcal Meningitis: Treatment Options and Considerations

      Meningococcal meningitis is a serious bacterial infection that requires urgent medical attention. In patients presenting with symptoms such as a non-blanching petechial rash, myalgia, and unstable vital signs, immediate transfer to a hospital and treatment with intramuscular benzylpenicillin is imperative. Third-generation cephalosporins can be considered in patients with a penicillin allergy. Early recognition and prompt treatment with antibiotics are associated with improved prognosis. Discharging the patient with supportive care would be inappropriate in this case.

      Fluoroquinolones such as ciprofloxacin are not recommended in the acute management of meningococcal meningitis. Ciprofloxacin is indicated in close contacts of patients with meningococcal infection and should be given as early as possible following exposure. Local health authorities should also be notified.

      Although the effectiveness of steroids in preventing neurological complications following bacterial meningitis has not been conclusively proven in studies, they are often prescribed in the clinical setting. Oral prednisolone, however, is not indicated in these patients.

      Oral rifampicin is not indicated in the acute management of patients with bacterial meningitis, but it can be considered in close contacts who come into contact with the index case.

    • This question is part of the following fields:

      • Neurology
      15.1
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  • Question 50 - A 50-year-old truck driver is admitted with a left-sided facial droop, dysphasia and...

    Incorrect

    • A 50-year-old truck driver is admitted with a left-sided facial droop, dysphasia and dysarthria. His symptoms slowly improve and he is very eager to return to work as he is self-employed. After 3 weeks, he has made a complete clinical recovery and neurological examination is normal. As per the guidelines of the Driver and Vehicle Licensing Agency (DVLA), when can he recommence driving his truck?

      Your Answer: 6 months after onset of symptoms

      Correct Answer: 12 months after onset of symptoms

      Explanation:

      Driving Restrictions Following Stroke or TIA

      After experiencing a stroke or transient ischaemic attack (TIA), there are various restrictions on driving depending on the time elapsed since onset of symptoms and the type of vehicle being driven.

      For car drivers, it is recommended that they do not drive for at least 4 weeks after a TIA or stroke. After 1 month, they may resume driving if there has been satisfactory recovery.

      However, for lorry or bus drivers, licences will be revoked for 1 year following a stroke or TIA. After 12 months, relicensing may be offered subject to satisfactory clinical recovery. Functional cardiac testing and medical reports may be required.

      For car drivers who have had a single TIA or stroke, they may resume driving 1 month after the event following satisfactory clinical recovery.

      Overall, it is important to follow these restrictions to ensure the safety of both the driver and others on the road.

    • This question is part of the following fields:

      • Neurology
      5.5
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