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Question 1
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A 25-year-old man with difficult to control epilepsy is being evaluated by a surgeon, four months after switching his antiepileptic medication. Despite being seizure-free, he has gained 5 kg in weight since his last check-up. Which antiepileptic drug is commonly linked to weight gain?
Your Answer: Sodium valproate
Explanation:Weight gain can be a side effect of taking sodium valproate.
Sodium Valproate: Uses and Adverse Effects
Sodium valproate is a medication commonly used to manage epilepsy, particularly for generalised seizures. Its mechanism of action involves increasing the activity of GABA in the brain. However, the use of sodium valproate during pregnancy is strongly discouraged due to its teratogenic effects, which can lead to neural tube defects and neurodevelopmental delays in children. Women of childbearing age should only use this medication if it is absolutely necessary and under the guidance of a specialist neurological or psychiatric advisor.
Aside from its teratogenic effects, sodium valproate can also inhibit P450 enzymes, leading to gastrointestinal issues such as nausea, increased appetite, and weight gain. Other adverse effects include alopecia, ataxia, tremors, hepatotoxicity, pancreatitis, thrombocytopenia, hyponatremia, and hyperammonemic encephalopathy. In cases where hyperammonemic encephalopathy develops, L-carnitine may be used as a treatment option.
Overall, while sodium valproate can be an effective medication for managing epilepsy, its use should be carefully considered and monitored due to its potential adverse effects, particularly during pregnancy.
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This question is part of the following fields:
- Neurology
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Question 2
Correct
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A 35-year-old man visits the Neurology Clinic after being referred by his General Practitioner for experiencing numbness and tingling in his left arm. He also reports an incident of visual blurring and pain in his left eye about six months ago.
What is the most suitable type of cross-sectional scan to determine the cause of this man's symptoms?
Choose the ONE most appropriate investigation from the options provided.Your Answer: Magnetic resonance imaging (MRI) brain and spine with contrast
Explanation:Imaging Modalities for Multiple Sclerosis Diagnosis
To diagnose multiple sclerosis, imaging modalities are necessary to assess for acute demyelination and anatomical changes in the grey and white matter. The preferred imaging modality is magnetic resonance imaging (MRI) with contrast, which can visualize acute inflammatory changes and demyelinating lesions. Dopamine Active Transfer scan (DaTscan) is not useful for multiple sclerosis diagnosis but can confirm Parkinson’s disease. Computed tomography (CT) with contrast is best for vascular lesions, while CT without contrast is only appropriate for acute trauma. MRI without contrast is the second-best option but cannot differentiate between acute and chronic lesions. Both brain and spine should be imaged to avoid missing the lesion responsible for the patient’s symptoms.
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This question is part of the following fields:
- Neurology
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Question 3
Correct
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A 51-year-old woman was prescribed warfarin due to a pulmonary embolism. During treatment, she has experienced pain, numbness, and tingling in her left anterior thigh that extends to her medial leg. Additionally, she has weakness in knee extension and hip flexion, and her left knee jerk is absent. What is the most probable location of the lesion? Choose ONE option from the list provided.
Your Answer: Left femoral nerve
Explanation:The left femoral nerve originates from L2-L4 in the lumbar plexus and damage to it can cause weakness in the quadriceps and iliopsoas muscles, resulting in difficulty with hip flexion and knee extension. There may also be numbness in the medial thigh and antero-medial calf, and decreased or absent patellar reflex. However, sensation to the anterolateral aspect of the thigh is preserved as it is innervated by a different nerve. The patient’s symptoms are likely due to a retroperitoneal hematoma caused by warfarin use. The left obturator nerve, which also originates from L2-L4, would cause different symptoms such as groin or medial thigh pain and weakness in the adductor muscles. The left common peroneal nerve, a branch of the sciatic nerve, would result in foot drop and sensory loss over the anterior calf and dorsum of the foot, but not above the knee. The left sciatic nerve supplies the hamstrings and all the muscles of the leg and foot, and damage to it would cause loss of power below the knee, loss of ankle jerk, and loss of lateral sensation below the knee. Finally, the left superior gluteal nerve supplies specific muscles in the buttocks and would result in a positive Trendelenburg’s sign, but no sensory loss.
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This question is part of the following fields:
- Neurology
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Question 4
Correct
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A 45-year-old man visits his doctor complaining of difficulty lifting heavy objects and describes a feeling of weakness when climbing stairs. He has noticed occasional muscle twitches and spasms that seem to be increasing in frequency.
Which of the following is the most likely diagnosis?
Your Answer: Polymyositis
Explanation:Based on the patient’s symptoms, the most likely diagnosis is polymyositis. This is a connective tissue disease that affects the striated muscles, causing symmetrical weakness in the proximal muscles. Patients may have difficulty rising from chairs and experience muscle tenderness. Creatine kinase levels are elevated, and a muscle biopsy can confirm the diagnosis. This presentation is not suggestive of Guillain-Barré syndrome, which typically presents with distal weakness that progresses proximally. Mononeuritis multiplex, which involves neuropathy of multiple peripheral and/or cranial nerves, is unlikely given the symmetrical distribution of symptoms affecting proximal muscles. Multiple sclerosis is also unlikely, as it tends to present with distal rather than proximal limb weakness or paraesthesia. Myasthenia gravis, which is associated with antibodies to acetylcholine receptors and causes fatigability, is not suggested by the patient’s symptoms.
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This question is part of the following fields:
- Neurology
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Question 5
Correct
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As the on-call duty doctor, you are in your room when a receptionist rushes in, alarmed that an elderly woman has been hit by a car in the surgery car park. The receptionist calls an ambulance while you quickly assess the patient. The patient's airway is clear, with spontaneous breathing at a rate of 18 breaths per minute and oxygen saturation of 98% on room air. The patient is hemodynamically stable with a heart rate of 70 beats per minute and blood pressure of 138/86 mmHg. The patient is lethargic, but responds to voice and exhibits abnormal flexion in response to pain. The patient mumbles incomprehensible sounds when asked questions. What is the patient's Glasgow Coma Scale (GCS) score based on your assessment?
Your Answer: 8
Explanation:What is the patient’s GCS based on the assessment that he is drowsy, but his eyes open to voice and exhibits abnormal flexion to pain, and mutters incomprehensible sounds in response to questions?
GCS score is 7.Understanding the Glasgow Coma Scale for Adults
The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in adults who have suffered a brain injury or other neurological condition. It is based on three components: motor response, verbal response, and eye opening. Each component is scored on a scale from 1 to 6, with a higher score indicating a better level of consciousness.
The motor response component assesses the patient’s ability to move in response to stimuli. A score of 6 indicates that the patient is able to obey commands, while a score of 1 indicates no movement at all.
The verbal response component assesses the patient’s ability to communicate. A score of 5 indicates that the patient is fully oriented, while a score of 1 indicates no verbal response at all.
The eye opening component assesses the patient’s ability to open their eyes. A score of 4 indicates that the patient is able to open their eyes spontaneously, while a score of 1 indicates no eye opening at all.
The GCS score is expressed as a combination of the scores from each component, with the motor response score listed first, followed by the verbal response score, and then the eye opening score. For example, a GCS score of 13, M5 V4 E4 at 21:30 would indicate that the patient had a motor response score of 5, a verbal response score of 4, and an eye opening score of 4 at 9:30 PM.
Overall, the Glasgow Coma Scale is a useful tool for healthcare professionals to assess the level of consciousness in adults with neurological conditions.
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This question is part of the following fields:
- Neurology
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Question 6
Correct
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A 55-year-old man presents to the General Practice with a 4-week history of pain in his left hand and forearm. The pain is concentrated around the thumb and index finger and is worse at night. There is no history of trauma. Shaking his hand seems to provide some relief. The likely diagnosis conclusion is carpal tunnel syndrome (CTS).
Which of the following would suggest an alternative diagnosis?Your Answer: Wasting of the hypothenar eminence
Explanation:Understanding Carpal Tunnel Syndrome: Symptoms and Examination Findings
Carpal tunnel syndrome (CTS) is a condition caused by compression of the median nerve in the carpal tunnel. One of the symptoms of CTS is the wasting of the thenar eminence, which is innervated by the median nerve. It is important to note that the hypothenar eminence, which is innervated by the ulnar nerve, is not affected by CTS.
During examination, weakness of thumb abduction (abductor pollicis brevis) is a common finding in CTS. Tapping along the problematic nerve causes paraesthesia, which is known as Tinel’s sign. Flexion of the wrist also causes symptoms, which is known as Phalen’s sign.
Treatment for CTS may include a corticosteroid injection, wrist splints at night, and surgical decompression through flexor retinaculum division.
Overall, understanding the symptoms and examination findings of CTS can help with early diagnosis and appropriate treatment.
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This question is part of the following fields:
- Neurology
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Question 7
Correct
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A 75-year-old woman presents with recurrent headaches and confusion for the past week. She has a history of alcohol abuse and a medical history of atrial fibrillation and type 2 diabetes mellitus. Her daughter reports that she has been experiencing frequent episodes of confusion over the past few days. In the previous year, she was evaluated for frequent falls. Her current medications include bisoprolol, metformin, and warfarin. On neurological examination, no abnormalities were found, and her blood sugar level is 6.7 mmol/l. What is the most probable diagnosis?
Your Answer: Subdural haematoma
Explanation:The patient’s age, alcoholism, and use of anticoagulants put them at risk for a subdural hematoma, which can cause confusion and changes in consciousness. Headaches are a common symptom, unlike Korsakoff’s syndrome and Wernicke’s encephalopathy.
Types of Traumatic Brain Injury
Traumatic brain injury can result in primary and secondary brain injury. Primary brain injury can be focal or diffuse. Diffuse axonal injury occurs due to mechanical shearing, which causes disruption and tearing of axons. Intra-cranial haematomas can be extradural, subdural, or intracerebral, while contusions may occur adjacent to or contralateral to the side of impact. Secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia. The Cushings reflex often occurs late and is usually a pre-terminal event.
Extradural haematoma is bleeding into the space between the dura mater and the skull. It often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Subdural haematoma is bleeding into the outermost meningeal layer. It most commonly occurs around the frontal and parietal lobes. Risk factors include old age, alcoholism, and anticoagulation. Subarachnoid haemorrhage classically causes a sudden occipital headache. It usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury. Intracerebral haematoma is a collection of blood within the substance of the brain. Causes/risk factors include hypertension, vascular lesion, cerebral amyloid angiopathy, trauma, brain tumour, or infarct. Patients will present similarly to an ischaemic stroke or with a decrease in consciousness. CT imaging will show a hyperdensity within the substance of the brain. Treatment is often conservative under the care of stroke physicians, but large clots in patients with impaired consciousness may warrant surgical evacuation.
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This question is part of the following fields:
- Neurology
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Question 8
Correct
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A 52-year-old male presents to his GP with a complaint of weakness in his ankles, followed by his knees and hips over the past 3 days. He has no known medical history.
What is the most probable diagnosis?Your Answer: Guillain-Barré syndrome
Explanation:The patient’s symptoms suggest Guillain-Barré syndrome, an acute inflammatory polyneuropathy that often occurs after a viral or bacterial infection. This condition is characterized by progressive, bilateral, ascending weakness that typically starts in the legs and spreads to the arms, respiratory muscles, and bulbar muscles. Areflexia is also present. Treatment may involve respiratory support, intravenous immunoglobulins, and plasma exchange. Most patients recover completely or almost completely, but the mortality rate is around 10%.
Mononeuritis multiplex is a rare condition that affects multiple peripheral and/or cranial nerves. Symptoms are usually asymmetrical and evolve at different times and with different degrees of severity. Diabetes is a common cause, but other systemic disorders can also be implicated. The patient’s symmetrical weakness affecting both legs at the same time is more consistent with a polyneuropathy than mononeuritis multiplex.
The patient’s symptoms do not fit with a diagnosis of multiple sclerosis, which typically presents with relapsing-remitting disease characterized by acute flairs and some improvement between flairs. MS is more common in females and onset peaks between 20 and 40 years. The patient’s symmetrical distribution of symptoms and rapid progression to affect knees and hips make MS unlikely.
Myasthenia gravis is an autoimmune disorder associated with antibodies to acetylcholine receptors at the neuromuscular junction. Patients typically display weakness of the periocular, facial, bulbar, and girdle muscles, with symptoms worsening with prolonged use. The patient’s symmetrical distal weakness is atypical for myasthenia gravis, which tends to affect proximal muscles first.
Polymyositis is a connective tissue disease that affects striated muscle, with symmetrical proximal muscle/limb girdle weakness being a prominent feature. Muscle tenderness and atrophy may also be present. The patient’s distal muscle weakness is not consistent with polymyositis.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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A 70-year-old man presents with sudden onset right-sided weakness and difficulty understanding speech at 9:30 am. It is now 12:15 pm. He has a medical history of hypertension, type 2 diabetes, and hyperlipidemia, and takes lisinopril, metformin, and atorvastatin.
Initial investigations reveal a capillary blood glucose of 5.2 mmol/L (4.0-6.0 mmol/L) and oxygen saturations of 97%. What is the most appropriate next step in his management?Your Answer: Immediate thrombolysis + thrombectomy
Correct Answer: Immediate CT head (non-contrast)
Explanation:The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 10
Correct
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A 68-year-old man with a history of uncontrolled hypertension and diabetes mellitus presents to the ED with acute onset of numbness on the right side of his body. He denies any other symptoms. A CT scan of the head was performed and revealed no evidence of hemorrhage or mass. What is the probable diagnosis?
Your Answer: Lacunar infarct
Explanation:If a patient has a lacunar stroke, they may experience a purely motor, purely sensory, or mixed motor and sensory deficit. A total anterior circulation infarct would cause unilateral weakness in the face, arm, and leg, as well as a homonymous hemianopia and symptoms of higher cerebral dysfunction. A posterior circulation infarct could result in a cerebellar or brainstem syndrome, loss of consciousness, or an isolated homonymous hemianopia. A partial anterior circulation infarct would lead to two of the following: unilateral weakness, homonymous hemianopia, and higher cerebral dysfunction. The absence of hemorrhage on a CT scan suggests that this is most likely a lacunar infarct, as there is only a purely sensory deficit.
Lacunar stroke is a type of ischaemic stroke that accounts for approximately 20-25% of all cases. It occurs when a single penetrating branch of a large cerebral artery becomes blocked, leading to damage in the internal capsule, thalamus, and basal ganglia. The symptoms of lacunar stroke can vary depending on the location of the blockage, but they typically involve either purely motor or purely sensory deficits. Other possible presentations include sensorimotor stroke, ataxic hemiparesis, and dysarthria-clumsy hand syndrome. Unlike other types of stroke, lacunar syndromes tend to lack cortical findings such as aphasia, agnosia, neglect, apraxia, or hemianopsia.
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This question is part of the following fields:
- Neurology
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Question 11
Incorrect
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In the differential diagnosis of cognitive decline, which of the following is the single most appropriate statement?
Your Answer: A multi-infarct aetiology is more common than the Alzheimer disease type
Correct Answer: In Creutzfeldt-Jakob disease an EEG may be characteristic
Explanation:Misconceptions about Dementia: Debunking Common Myths
Dementia is a complex and often misunderstood condition. Here are some common misconceptions about dementia that need to be debunked:
1. In Creutzfeldt-Jakob disease an EEG may be characteristic: An EEG is abnormal in approximately 90% of cases of Creutzfeldt-Jakob disease, showing characteristic changes (i.e. periodic sharp wave complexes).
2. A multi-infarct aetiology is more common than the Alzheimer disease type: Multi-infarct dementia is the second most common type of dementia in people aged over 65 years.
3. A CT scan will reliably distinguish between Alzheimer disease and multi-infarct dementia: The diagnosis of both AD and multi-infarct dementia remains essentially a clinical one (and can only be definitively confirmed at autopsy).
4. In Alzheimer disease a gait disorder is seen at an early stage: Gait disturbances are usually a late sign of AD.
5. Visual hallucinations are typical of Alzheimer’s disease: Visual hallucinations, often very vivid and colourful, are typical of dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD), not of AD.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 63-year-old man presents to you after experiencing his first TIA. He states that he is typically in good health and was surprised to learn that he had suffered a 'mini stroke.' He is eager to resume his normal daily routine and is curious about when he can safely operate his vehicle once more.
What guidance would you offer him?Your Answer: Must inform DVLA immediately and have a medical assessment before a decision is made as to whether she can continue driving
Correct Answer: Can start driving if symptom free after 1 month - no need to inform the DVLA
Explanation:Group 1 drivers do not need to inform the DVLA and can resume driving after being symptom-free for one month following a single TIA.
The DVLA has guidelines for drivers with neurological disorders. Those with epilepsy/seizures must not drive and must inform the DVLA. The length of time off driving varies depending on the type and frequency of seizures. Those with syncope may need time off driving depending on the cause and number of episodes. Those with other conditions such as stroke, craniotomy, pituitary tumor, narcolepsy/cataplexy, and chronic neurological disorders should inform the DVLA and may need time off driving.
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This question is part of the following fields:
- Neurology
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Question 13
Correct
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A 61-year-old man presents to his GP with increasing mild confusion over the past 2 weeks. His husband has also noticed a decline in his mental state. The patient's medical history includes a road traffic accident 8 weeks ago, where he sustained a head injury but was discharged from the emergency department with no significant injuries. He denies any current symptoms of headache, nausea, or changes in vision. On examination, there are no focal neurological deficits, and both ocular and mental state exams are unremarkable. What is the most likely cause of this man's presentation?
Your Answer: Subdural haematoma
Explanation:Understanding Subdural Haemorrhage
A subdural haemorrhage is a condition where blood collects deep to the dural layer of the meninges. This collection of blood is not within the brain substance and is referred to as an ‘extra-axial’ or ‘extrinsic’ lesion. Subdural haematomas can be classified based on their age, which includes acute, subacute, and chronic. Although they occur within the same anatomical compartment, acute and chronic subdurals have significant differences in terms of their mechanisms, associated clinical features, and management.
An acute subdural haematoma is a collection of fresh blood within the subdural space and is commonly caused by high-impact trauma. This type of haematoma is associated with high-impact injuries, and there is often other underlying brain injuries. Symptoms and presentation vary depending on the size of the compressive acute subdural haematoma and the associated injuries. CT imaging is the first-line investigation, and surgical options include monitoring of intracranial pressure and decompressive craniectomy.
On the other hand, a chronic subdural haematoma is a collection of blood within the subdural space that has been present for weeks to months. Elderly and alcoholic patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taut bridging veins. Infants also have fragile bridging veins and can rupture in shaken baby syndrome. If the chronic subdural is an incidental finding or if it is small in size with no associated neurological deficit, it can be managed conservatively. However, if the patient is confused, has an associated neurological deficit, or has severe imaging findings, surgical decompression with burr holes is required.
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This question is part of the following fields:
- Neurology
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Question 14
Correct
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A 78-year-old man is undergoing evaluation for a possible cognitive impairment and movement disorder. Various scans have been ordered to aid in the assessment. The scan results are as follows: MRI head shows normal age-related changes, while the SPECT scan reveals decreased dopaminergic activity in the substantia nigra. Based on this information, what is the probable diagnosis?
Your Answer: Parkinson's disease
Explanation:Neurodegenerative diseases are characterized by the progressive loss of neurons in the brain, leading to a range of symptoms. Parkinson’s disease is a common example, which affects the basal ganglia and causes movement disorders such as bradykinesia, muscle rigidity, tremor, and postural instability. Alzheimer’s dementia, on the other hand, is associated with atrophy of the medial temporal lobe and temporoparietal cortex, but does not typically involve movement disorders. Huntington’s disease primarily affects the striatum, leading to a loss of striatal volume and the characteristic symptom of chorea – jerky, uncontrollable limb movements. Multi-system atrophy is a rare condition that affects both the basal ganglia and cerebellum, leading to autonomic dysfunction, ataxia, and Parkinsonism, but cognitive impairment is not typically seen.
Parkinson’s disease is a progressive neurodegenerative condition that occurs when dopaminergic neurons in the substantia nigra degenerate. This leads to a classic triad of symptoms, including bradykinesia, tremor, and rigidity, which are typically asymmetrical. The disease is more common in men and is usually diagnosed around the age of 65. Bradykinesia is characterized by a poverty of movement, shuffling steps, and difficulty initiating movement. Tremors are most noticeable at rest and typically occur in the thumb and index finger. Rigidity can be either lead pipe or cogwheel, and other characteristic features include mask-like facies, flexed posture, and micrographia. Psychiatric features such as depression, dementia, and sleep disturbances may also occur. Diagnosis is usually clinical, but if there is difficulty differentiating between essential tremor and Parkinson’s disease, 123I‑FP‑CIT single photon emission computed tomography (SPECT) may be considered.
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This question is part of the following fields:
- Neurology
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Question 15
Incorrect
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An 82-year-old woman is diagnosed with Alzheimer’s disease and the next appropriate step is likely starting her on donepezil. She has a past medical history of ischaemic heart diseases, pacemaker insertion for bradyarrhythmias, diabetes mellitus type II, hypercholesterolaemia and general anxiety disorder (GAD).
Which one of the following could be a contraindication to the prescription of donepezil?
Your Answer: General anxiety disorder (GAD)
Correct Answer: Bradycardia
Explanation:Contraindications and Considerations for the Use of Donepezil
Donepezil is a medication used to treat Alzheimer’s disease. However, there are certain contraindications and considerations that healthcare professionals should keep in mind when prescribing this medication.
Bradycardia, a condition where the heart beats too slowly, is a relative contraindication for the use of donepezil. This medication may cause bradycardia and atrioventricular node block, so caution should be taken in patients with other cardiac abnormalities. Additionally, patients with asthma, chronic obstructive pulmonary disease, supraventricular conduction abnormalities, susceptibility to peptic ulcers, and sick-sinus syndrome should also be closely monitored when taking donepezil.
Concurrent use of simvastatin, a medication used to lower cholesterol levels, is not a concern when taking donepezil. General anxiety disorder (GAD) and diabetes mellitus type II are also not contraindications for the use of donepezil.
However, elderly patients with a known history of persistent bradycardia, heart block, recurrent unexplained syncope, or concurrent treatment with drugs that reduce heart rate should avoid donepezil. A history of ischaemic heart diseases alone is not a contraindication for donepezil.
In summary, healthcare professionals should carefully consider a patient’s medical history and current medications before prescribing donepezil. Close monitoring is necessary in patients with certain cardiac abnormalities and caution should be taken in elderly patients with a history of bradycardia or heart block.
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This question is part of the following fields:
- Neurology
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Question 16
Incorrect
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A 50-year-old woman with a history of multiple sclerosis for a few years has been struggling with increased muscle stiffness and trouble with fluid movements. Despite taking baclofen for a year, there has been no improvement. What medication should be considered next to alleviate these symptoms?
Your Answer: Tizanidine
Correct Answer: Gabapentin
Explanation:Spasticity in multiple sclerosis is caused by demyelination along the nerves that control movement, resulting in stiffness that can sometimes be helpful but can also become painful. Physiotherapy exercises are the simplest and most effective treatment, but first-line medications such as baclofen and gabapentin are also recommended. Gabapentin is an anticonvulsant that can be effective against muscle spasms, while diazepam is a muscle relaxant that may be more useful at night due to side effects at higher doses. Botulinum toxin and dantrolene sodium can be considered if conventional treatments prove ineffective, but are not used as first-line for spasticity. The NICE multiple sclerosis guideline recommends gabapentin as one of the first drugs to try in the treatment of spasms and spasticity.
Multiple sclerosis is a condition that cannot be cured, but its treatment aims to reduce the frequency and duration of relapses. In the case of an acute relapse, high-dose steroids may be administered for five days to shorten its length. However, it is important to note that steroids do not affect the degree of recovery. Disease-modifying drugs are used to reduce the risk of relapse in patients with MS. These drugs are typically indicated for patients with relapsing-remitting disease or secondary progressive disease who have had two relapses in the past two years and are able to walk a certain distance unaided. Natalizumab, ocrelizumab, fingolimod, beta-interferon, and glatiramer acetate are some of the drugs used to reduce the risk of relapse in MS.
Fatigue is a common problem in MS patients, and amantadine is recommended by NICE after excluding other potential causes such as anaemia, thyroid problems, or depression. Mindfulness training and CBT are other options for managing fatigue. Spasticity is another issue that can be addressed with first-line drugs such as baclofen and gabapentin, as well as physiotherapy. Cannabis and botox are currently being evaluated for their effectiveness in managing spasticity. Bladder dysfunction is also a common problem in MS patients, and anticholinergics may worsen symptoms in some patients. Ultrasound is recommended to assess bladder emptying, and intermittent self-catheterisation may be necessary if there is significant residual volume. Gabapentin is the first-line treatment for oscillopsia, which is a condition where visual fields appear to oscillate.
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This question is part of the following fields:
- Neurology
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Question 17
Correct
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A 30-year-old female patient complains of vision problems. Upon examination, a left inferior homonymous quadrantanopia is observed. What is the most probable location of the lesion?
Your Answer: Right parietal lobe
Explanation:A visual field defect known as left homonymous hemianopia indicates a loss of vision to the left side, which is caused by a lesion in the right optic tract. Homonymous quadrantanopias, which affect the parietal-inferior and temporal-superior areas, are also a type of visual field defect. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by lesions in the optic radiation or occipital cortex.
Understanding Visual Field Defects
Visual field defects refer to the loss of vision in certain areas of the visual field. One common type of visual field defect is left homonymous hemianopia, which means that there is a visual field defect to the left due to a lesion of the right optic tract. Another type is homonymous quadrantanopias, which can be remembered using the acronym PITS (Parietal-Inferior, Temporal-Superior). Incongruous defects indicate an optic tract lesion, while congruous defects suggest a lesion of the optic radiation or occipital cortex. A congruous defect means complete or symmetrical visual field loss, while an incongruous defect is incomplete or asymmetric.
Homonymous hemianopia can also be caused by a lesion of the optic tract, with macula sparing indicating a lesion of the occipital cortex. Homonymous quadrantanopias can be caused by a lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop) for superior defects, and a lesion of the superior optic radiations in the parietal lobe for inferior defects.
Bitemporal hemianopia, on the other hand, is caused by a lesion of the optic chiasm. An upper quadrant defect that is greater than the lower quadrant defect suggests inferior chiasmal compression, which is commonly caused by a pituitary tumor. Conversely, a lower quadrant defect that is greater than the upper quadrant defect suggests superior chiasmal compression, which is commonly caused by a craniopharyngioma. It is important to note that while this information is useful for exams, actual studies suggest that the majority of quadrantanopias are caused by occipital lobe lesions.
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This question is part of the following fields:
- Neurology
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Question 18
Correct
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A 55-year-old man presents with right-sided hemianopia and is currently undergoing investigations for a possible stroke. The stroke specialist has clinically diagnosed him with a POCI, indicating a posterior circulation infarct. Which specific area of the brain is affected by this type of stroke?
Your Answer: The vertebrobasilar arteries
Explanation:A POCI (posterior circulation infarct) typically affects the vertebrobasilar arteries. In contrast, a TACI involves the middle and anterior cerebral arteries, a PACI affects the smaller arteries of anterior circulation, and a LACI involves the perforating arteries around the internal capsule, thalamus, and basal ganglia.
Stroke can be classified based on the initial symptoms using the Oxford Stroke Classification, also known as the Bamford Classification. The criteria assessed include unilateral hemiparesis and/or hemisensory loss of the face, arm, and leg, homonymous hemianopia, and higher cognitive dysfunction such as dysphasia.
Total anterior circulation infarcts (TACI) involve the middle and anterior cerebral arteries and present with all three criteria mentioned above. Partial anterior circulation infarcts (PACI) involve smaller arteries of the anterior circulation and present with two of the criteria. Lacunar infarcts (LACI) involve perforating arteries around the internal capsule, thalamus, and basal ganglia and present with one of three symptoms: unilateral weakness (and/or sensory deficit) of face and arm, arm and leg, or all three; pure sensory stroke; or ataxic hemiparesis.
Posterior circulation infarcts (POCI) involve vertebrobasilar arteries and present with one of three symptoms: cerebellar or brainstem syndromes, loss of consciousness, or isolated homonymous hemianopia. Other recognized patterns of stroke include lateral medullary syndrome (posterior inferior cerebellar artery), also known as Wallenberg’s syndrome, which presents with ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy (e.g., Horner’s), and contralateral limb sensory loss. Weber’s syndrome presents with ipsilateral III palsy and contralateral weakness.
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This question is part of the following fields:
- Neurology
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Question 19
Correct
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A 20-year-old girl presented at the age of 5 years with progressive ataxia. She is now wheelchair-bound. On examination, she is now dysarthric, with bilateral optic atrophy. There is ataxia in both upper limbs. Reflexes in her lower limbs are absent, with bilateral extensor plantar response. She has absent vibration and impaired joint position in both feet. Bilateral pes cavus is apparent. An electrocardiogram (ECG) shows inverted T waves. Echocardiogram reveals left ventricular hypertrophy.
Which of the following is the most likely diagnosis?
Select the SINGLE most appropriate diagnosis from the list below. Select ONE option only.Your Answer: Friedreich’s ataxia
Explanation:Friedreich’s ataxia is a common inherited progressive ataxia in the UK that typically presents in childhood or adolescence. The earliest symptom is gait ataxia, followed by limb ataxia, absent lower limb reflexes, and later weakness and wasting of the limbs. Other common features include reduced or absent vibration sense and proprioception, spasticity, dysarthria, dysphagia, cardiac abnormalities, scoliosis, pes cavus, equinovarus, sleep apnea, and urinary frequency/urgency. The history is classic for this condition, and the ECG may show left ventricular hypertrophy. Charcot-Marie-Tooth disease, Huntington’s disease, and multiple sclerosis are not consistent with this history, while vitamin B12 deficiency may cause similar symptoms but is generally a condition of adults and does not fit the clinical picture as well as Friedreich’s ataxia.
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This question is part of the following fields:
- Neurology
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Question 20
Correct
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A 58-year-old woman visits her GP urgently, reporting a 10-minute episode where she experienced vision loss in her right eye. The GP suspects a transient ischaemic attack (TIA) and prescribes 300mg aspirin while referring her to the TIA clinic. The diagnosis is amaurosis fugax. Which area of the brain anatomy is impacted by this type of stroke?
Your Answer: Retinal/ophthalmic artery
Explanation:It is unlikely that the patient experienced a stroke as her symptoms resolved completely after 10 minutes and there were no ongoing symptoms. Different types of strokes affect different arteries in the brain. For example, a lesion in the anterior cerebral artery would result in contralateral hemiparesis and sensory loss, with the lower extremities being more affected than the upper. On the other hand, a lesion in the posterior cerebral artery would cause contralateral homonymous hemianopia with macular sparing. If the posterior inferior cerebellar artery is affected, the patient may experience ipsilateral facial pain and temperature loss, as well as contralateral limb and torso pain and temperature loss, along with ataxia and nystagmus. A middle cerebral artery stroke would cause contralateral hemiparesis and sensory loss, with the upper extremity being more affected than the lower, as well as contralateral homonymous hemianopia and aphasia.
When a stroke occurs, the location of the lesion in the brain can determine the specific effects on the body. Depending on which artery is affected, different symptoms may arise. For example, a stroke in the anterior cerebral artery can lead to contralateral hemiparesis and sensory loss, with the lower extremity being more affected than the upper. On the other hand, a stroke in the middle cerebral artery can cause contralateral hemiparesis and sensory loss, with the upper extremity being more affected than the lower, as well as contralateral homonymous hemianopia and aphasia.
If the stroke occurs in the posterior cerebral artery, the individual may experience contralateral homonymous hemianopia with macular sparing and visual agnosia. In the case of Weber’s syndrome, which involves branches of the posterior cerebral artery that supply the midbrain, the person may have an ipsilateral CN III palsy and contralateral weakness of the upper and lower extremities.
Other types of strokes include those affecting the posterior inferior cerebellar artery, which can lead to ipsilateral facial pain and temperature loss and contralateral limb/torso pain and temperature loss, as well as ataxia and nystagmus. A stroke in the anterior inferior cerebellar artery can cause similar symptoms to Wallenberg’s syndrome, but with the addition of ipsilateral facial paralysis and deafness.
Finally, lacunar strokes are small, localized strokes that often occur in individuals with hypertension. They typically present with isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia, and commonly affect the basal ganglia, thalamus, and internal capsule.
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This question is part of the following fields:
- Neurology
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Question 21
Correct
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A 65-year-old man comes to the General Practitioner with his daughter. She reports that her father’s behavior has changed over the past year. He used to be a very sociable and outgoing man but recently he has become withdrawn and uninterested in his hobbies. He has also become forgetful and has difficulty completing tasks that he used to do easily. The patient tells you that he does not think there is anything wrong with him and he is just getting older.
Which of the following is the most likely diagnosis?Your Answer: Frontotemporal dementia
Explanation:Differentiating Types of Dementia: A Brief Overview
Dementia is a broad term used to describe a decline in cognitive function that interferes with daily activities. However, there are different types of dementia, each with unique characteristics. Here are some key features to help differentiate between frontotemporal dementia, Alzheimer’s disease, Huntington’s disease, normal-pressure hydrocephalus (NPH), and Parkinson’s disease.
Frontotemporal Dementia
This type of dementia is rare and typically affects individuals between the ages of 55 and 65. Early personality and behavior changes are core symptoms, while memory impairment is not typical. Other key features include a gradual progression, decline in social conduct, emotional blunting, and loss of insight.Alzheimer’s Disease
Alzheimer’s disease is the most common form of dementia, affecting individuals over the age of 65. Memory loss is a key early symptom, followed by agitation and obsessive behavior later in the disease course.Huntington’s Disease
Huntington’s disease is a neurodegenerative condition that is often inherited. Symptoms include memory impairment, depression, clumsiness, mood swings, and difficulty concentrating. However, this patient’s symptoms are more consistent with early frontotemporal dementia.Normal-Pressure Hydrocephalus (NPH)
NPH is a reversible cause of dementia characterized by gait abnormality, memory impairment, and incontinence. It may be mistaken for Parkinson’s disease, but symptoms will not improve with levodopa.Parkinson’s Disease
While dementia and hallucinations may develop during the course of Parkinson’s disease, it is primarily a movement disorder characterized by tremors, rigidity, and bradykinesia. -
This question is part of the following fields:
- Neurology
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Question 22
Correct
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Which of the following factors indicates true seizures rather than pseudoseizures with the highest certainty?
Your Answer: Tongue biting
Explanation:Understanding Psychogenic Non-Epileptic Seizures
Psychogenic non-epileptic seizures, also known as pseudoseizures, are a type of seizure that is not caused by abnormal electrical activity in the brain. Instead, they are believed to be caused by psychological factors such as stress, trauma, or anxiety. These seizures can be difficult to diagnose as they often mimic true epileptic seizures, but there are certain factors that can help differentiate between the two.
Factors that may indicate pseudoseizures include pelvic thrusting, a family history of epilepsy, a higher incidence in females, crying after the seizure, and the seizures not occurring when the individual is alone. On the other hand, factors that may indicate true epileptic seizures include tongue biting and a raised serum prolactin level.
Video telemetry is a useful tool for differentiating between the two types of seizures. It involves monitoring the individual’s brain activity and behavior during a seizure, which can help determine whether it is caused by abnormal electrical activity in the brain or psychological factors.
It is important to accurately diagnose and treat psychogenic non-epileptic seizures as they can have a significant impact on an individual’s quality of life. Treatment may involve therapy to address underlying psychological factors, as well as medication to manage any associated symptoms such as anxiety or depression.
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This question is part of the following fields:
- Neurology
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Question 23
Incorrect
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A 45-year-old history teacher has contacted his doctor reporting a one-hour episode of weakness in his left arm and leg earlier today, which has since resolved. He denies any facial drooping, residual weakness, or slurred speech. He insists that he feels completely healthy and only called because his wife urged him to. The patient has a previous diagnosis of a pulmonary embolism and is currently taking apixaban. What is the initial approach to managing this patient?
Your Answer: TIA clinic within 24 hours
Correct Answer: Urgent admission to the emergency department for urgent CT head
Explanation:Immediate admission for imaging to rule out a hemorrhage is necessary if a patient with suspected TIA is on warfarin, a DOAC, or has a bleeding disorder.
A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, and sudden transient loss of vision in one eye (amaurosis fugax).
NICE recommends immediate antithrombotic therapy with aspirin 300 mg unless the patient has a bleeding disorder or is taking an anticoagulant. If the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis, specialist review is necessary. Urgent assessment is required within 24 hours for patients who have had a suspected TIA in the last 7 days. Referral for specialist assessment is necessary as soon as possible within 7 days for patients who have had a suspected TIA more than a week previously. Neuroimaging and carotid imaging are recommended, and antithrombotic therapy is necessary. Carotid artery endarterectomy should only be considered if the carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 24
Correct
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A 50-year-old female with multiple sclerosis reports experiencing tingling in her hands when she flexes her neck. What type of symptom is this?
Your Answer: Lhermitte's sign
Explanation:Lhermitte’s sign is a well-known symptom that suggests the presence of an underlying condition in the cervical cord’s dorsal column nuclei. This sign is also observed in cases of subacute combined degeneration of the cord and cervical stenosis.
Multiple Sclerosis: Common Features and Diagnostic Criteria
Multiple sclerosis (MS) is a disease that can present with various non-specific features, such as significant lethargy in around 75% of patients. Diagnosis of MS can be made based on two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion together with reasonable historical evidence of a previous relapse.
MS can affect different parts of the body, leading to a range of symptoms. Visual symptoms are common, with optic neuritis being a frequent presenting feature. Other visual symptoms include optic atrophy, Uhthoff’s phenomenon (worsening of vision following a rise in body temperature), and internuclear ophthalmoplegia. Sensory symptoms may include pins and needles, numbness, trigeminal neuralgia, and Lhermitte’s syndrome (paraesthesiae in limbs on neck flexion). Motor symptoms may include spastic weakness, which is most commonly seen in the legs. Cerebellar symptoms such as ataxia and tremor may also occur.
In addition to these symptoms, MS can also cause urinary incontinence, sexual dysfunction, and intellectual deterioration. It is important to note that not all patients with MS will experience all of these symptoms, and the severity and frequency of symptoms can vary widely between individuals.
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This question is part of the following fields:
- Neurology
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Question 25
Correct
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A 92-year-old male was admitted to the stroke ward with right-sided facial droop and hemiplegia. CT head revealed a significant infarct in the left middle cerebral artery. The patient has finished a 2-week course of high-dose aspirin (300mg) for the management of an acute ischemic stroke. What is the best choice for secondary prevention?
Your Answer: Switch to clopidogrel
Explanation:The preferred antiplatelet for secondary prevention following a stroke is clopidogrel 75mg, as it reduces the risk of major adverse cardiovascular events. It is recommended for patients who have had a transient ischaemic attack or confirmed stroke after two weeks of high-dose aspirin. Low-dose aspirin (75mg) and modified-release dipyridamole can be used as an alternative if clopidogrel is contraindicated. High-dose aspirin (300 mg) is only indicated in the first 2 weeks after an acute ischaemic stroke. Anticoagulants such as DOACs and warfarin are used to prevent clot formation and embolisation in patients with atrial fibrillation (AF) to reduce the risk of stroke. However, since there is no evidence of AF in this patient, these options are not applicable.
The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 26
Correct
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A 63-year-old man comes to the clinic complaining of a sharp, stabbing pain in his right cheekbone that has been ongoing for two weeks. He describes the pain as 'very severe' and 'coming in spasms', lasting for about a minute before subsiding. The pain is triggered by activities such as shaving and eating. Upon examination, there are no abnormalities found in his eyes, cranial nerves, or mouth. What is the most probable diagnosis?
Your Answer: Trigeminal neuralgia
Explanation:The pain experienced by this patient is indicative of trigeminal neuralgia, displaying typical characteristics.
Understanding Trigeminal Neuralgia
Trigeminal neuralgia is a type of pain syndrome that is characterized by severe pain on one side of the face. While most cases are idiopathic, some may be caused by compression of the trigeminal roots due to tumors or vascular problems. According to the International Headache Society, trigeminal neuralgia is defined as a disorder that causes brief electric shock-like pains that are limited to one or more divisions of the trigeminal nerve. The pain is often triggered by light touch, such as washing, shaving, or brushing teeth, and can occur spontaneously. Certain areas of the face, such as the nasolabial fold or chin, may be more susceptible to pain. The pain may also remit for varying periods.
Red flag symptoms and signs that suggest a serious underlying cause include sensory changes, ear problems, a history of skin or oral lesions that could spread perineurally, pain only in the ophthalmic division of the trigeminal nerve, optic neuritis, a family history of multiple sclerosis, and onset before the age of 40.
The first-line treatment for trigeminal neuralgia is carbamazepine. If there is a failure to respond to treatment or atypical features are present, such as onset before the age of 50, referral to neurology is recommended. Understanding the symptoms and management of trigeminal neuralgia is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 27
Correct
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A 45-year-old man visits his General Practitioner complaining of a severely painful headache mainly around his left eye, associated with left-sided eye watering. He has had several similar episodes of pain over the past few months, each lasting about 2–3 hours.
Which of the following is the most likely diagnosis?Your Answer: Cluster headache
Explanation:Distinguishing Cluster Headache from Other Headache Disorders
Cluster headache is a severe headache disorder that primarily affects men between the ages of 20 and 30. The pain is localized around one eye and can last from a few minutes up to three hours. Lacrimation and nasal congestion may occur simultaneously, and symptoms tend to occur frequently for several weeks followed by a symptom-free period lasting months or even years. It is important to distinguish cluster headache from other headache disorders, such as brain tumors, giant cell arteritis (GCA), migraine, and tension headache. Brain tumors may present with signs of raised intracranial pressure, while GCA typically affects those over 50 years old and presents with abrupt-onset headache, scalp pain/tenderness, and jaw claudication. Migraine is characterized by recurrent episodes of headache accompanied by photophobia, phonophobia, nausea, and vomiting, while tension headache is typically bilateral and described as a band-like pain across the forehead. Associated eye watering is not a feature of tension headache.
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This question is part of the following fields:
- Neurology
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Question 28
Correct
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A 67-year-old woman comes to the clinic complaining of experiencing electric shock-like pains on the right side of her face for the past two months. She reports having 10-20 episodes per day, each lasting for 30-60 seconds. She recently had a dental check-up, which was normal. Upon neurological examination, no abnormalities were found. What is the most appropriate initial treatment?
Your Answer: Carbamazepine
Explanation:Carbamazepine is the first-line treatment for trigeminal neuralgia.
Understanding Trigeminal Neuralgia
Trigeminal neuralgia is a type of pain syndrome that is characterized by severe pain on one side of the face. While most cases are idiopathic, some may be caused by compression of the trigeminal roots due to tumors or vascular problems. According to the International Headache Society, trigeminal neuralgia is defined as a disorder that causes brief electric shock-like pains that are limited to one or more divisions of the trigeminal nerve. The pain is often triggered by light touch, such as washing, shaving, or brushing teeth, and can occur spontaneously. Certain areas of the face, such as the nasolabial fold or chin, may be more susceptible to pain. The pain may also remit for varying periods.
Red flag symptoms and signs that suggest a serious underlying cause include sensory changes, ear problems, a history of skin or oral lesions that could spread perineurally, pain only in the ophthalmic division of the trigeminal nerve, optic neuritis, a family history of multiple sclerosis, and onset before the age of 40.
The first-line treatment for trigeminal neuralgia is carbamazepine. If there is a failure to respond to treatment or atypical features are present, such as onset before the age of 50, referral to neurology is recommended. Understanding the symptoms and management of trigeminal neuralgia is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 29
Correct
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A 65-year-old man, who was recently diagnosed with atrial fibrillation but has not yet started any anticoagulant medication, presents with new-onset weakness on the left side of his body. He is also experiencing difficulty speaking and has lost vision on the left side. He contacts emergency services and is transported to the hospital where he undergoes an urgent CT head and MR angiogram. The results confirm a proximal anterior circulation occlusive stroke that occurred approximately 3 hours ago.
What is the most definitive course of action for managing this patient?Your Answer: Arrange thrombectomy AND thrombolysis as soon as possible
Explanation:For patients with an acute ischaemic stroke who present within 4.5 hours, it is recommended to arrange both thrombolysis and thrombectomy as soon as possible. This is in line with NICE guidelines, which suggest offering both treatments to patients diagnosed with an acute proximal anterior circulation occlusive stroke confirmed on CT or MR angiogram. Thrombectomy alone can be offered up to 6 hours post-presentation. Giving a stat dose of aspirin is also part of the acute treatment of ischaemic stroke, but it is not a definitive treatment option. Starting apixaban for atrial fibrillation is not appropriate in the initial management of acute ischaemic stroke, as anticoagulant treatment is usually delayed for at least 2 weeks to reduce the risk of haemorrhagic transformation.
The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 30
Incorrect
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An 80-year-old woman is admitted with acute confusion caused by a urinary tract infection. Despite treatment with antibiotics, environmental changes, and reassurance, she continues to be agitated. You are contemplating prescribing haloperidol. What is one condition that may be significantly exacerbated by the use of haloperidol?
Your Answer: Depression
Correct Answer: Parkinson's disease
Explanation:If possible, antipsychotics should be avoided as they can exacerbate Parkinson’s disease symptoms. Instead, a low dose of oral lorazepam may be considered as an alternative.
Acute confusional state, also known as delirium or acute organic brain syndrome, is a condition that affects up to 30% of elderly patients admitted to hospital. It is more common in patients over the age of 65, those with a background of dementia, significant injury, frailty or multimorbidity, and those taking multiple medications. The condition is often triggered by a combination of factors, such as infection, metabolic imbalances, change of environment, and underlying medical conditions.
The symptoms of acute confusional state can vary widely, but may include memory disturbances, agitation or withdrawal, disorientation, mood changes, visual hallucinations, disturbed sleep, and poor attention. Treatment involves identifying and addressing the underlying cause, modifying the patient’s environment, and using sedatives such as haloperidol or olanzapine. However, managing the condition can be challenging in patients with Parkinson’s disease, as antipsychotics can worsen Parkinsonian symptoms. In such cases, careful reduction of Parkinson medication may be helpful, and atypical antipsychotics such as quetiapine and clozapine may be preferred for urgent treatment.
Overall, acute confusional state is a complex condition that requires careful management and individualized treatment. By addressing the underlying causes and providing appropriate sedation, healthcare professionals can help patients recover from this condition and improve their overall quality of life.
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This question is part of the following fields:
- Neurology
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Question 31
Incorrect
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An 80-year-old man with a known history of mixed type dementia (Alzheimer's and vascular) is evaluated in memory clinic due to a recent decline in his memory and cognition. His mini-mental state score is 12 and he is started on memantine. What is the mechanism of action of memantine?
Your Answer: Butyrylcholinesterase and acetylcholinesterase inhibitor
Correct Answer: NMDA antagonist
Explanation:Memantine is an NMDA receptor antagonist and is not a cholinesterase inhibitor like donepezil and rivastigmine. While memantine does act at the serotonin and dopamine receptors, it acts as an antagonist and agonist respectively, rather than the options given.
Managing Alzheimer’s Disease: Non-Pharmacological and Pharmacological Approaches
Alzheimer’s disease is a type of dementia that progressively affects the brain and is the most common form of dementia in the UK. To manage this condition, there are both non-pharmacological and pharmacological approaches available.
Non-pharmacological management involves offering a range of activities that promote wellbeing and are tailored to the patient’s preferences. Group cognitive stimulation therapy is recommended for patients with mild to moderate dementia, while group reminiscence therapy and cognitive rehabilitation are also options to consider.
Pharmacological management involves the use of medications. The three acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are options for managing mild to moderate Alzheimer’s disease. Memantine, an NMDA receptor antagonist, is considered a second-line treatment and is recommended for patients with moderate Alzheimer’s who are intolerant of or have a contraindication to acetylcholinesterase inhibitors. It can also be used as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s or as monotherapy in severe Alzheimer’s.
When managing non-cognitive symptoms, NICE does not recommend antidepressants for mild to moderate depression in patients with dementia. Antipsychotics should only be used for patients at risk of harming themselves or others or when the agitation, hallucinations, or delusions are causing them severe distress.
It is important to note that donepezil is relatively contraindicated in patients with bradycardia, and adverse effects may include insomnia. By utilizing both non-pharmacological and pharmacological approaches, patients with Alzheimer’s disease can receive comprehensive care and management.
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This question is part of the following fields:
- Neurology
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Question 32
Correct
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A 67-year-old woman presents to the Memory Clinic with a 9-month history of cognitive decline. Her daughter mentions that she has difficulty remembering basic tasks and is becoming more confused and forgetful than usual. Her daughter noticed a change in her personality and has caught her leaving the stove on and wandering outside alone on multiple occasions.
Given the likely diagnosis, which of the following is the most appropriate initial step in this patient’s management?
Select the SINGLE most appropriate management from the list below.
Your Answer: Stop drugs that may be exacerbating memory problems or confusion (anticholinergics, central nervous system drugs)
Explanation:Managing Frontotemporal Dementia: Treatment Options and Referrals
Frontotemporal dementia (FTD) is a progressive neurodegenerative disorder that affects behavior, language, and executive function. While there is no cure for FTD, management strategies can help alleviate symptoms and provide support for patients and their families.
One important step in managing FTD is to stop any drugs that may be exacerbating memory problems or confusion, such as anticholinergics or central nervous system drugs. Multidisciplinary health and social care is also crucial, involving referrals to geriatric medicine, psychiatry, psychology, social work, occupational therapy, speech and language therapy, physiotherapy, and community nursing.
However, certain treatment options should be avoided or used with caution in FTD patients. Benzodiazepines, for example, are associated with cognitive worsening and fall-related injuries. Anticholinesterase inhibitors, typically used in mild to moderate Alzheimer’s disease, have shown disappointing results in FTD patients who do not have cholinergic loss. Memantine, used in moderate to severe Alzheimer’s disease, has not been shown to be effective in FTD and may even have a detrimental effect on cognition in some individuals.
Antipsychotics should only be used cautiously and when other options have failed, as FTD patients are at higher risk of extrapyramidal side effects. Overall, a personalized and coordinated approach to FTD management is essential for optimizing patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 33
Correct
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A 40-year-old patient presents with sudden monocular visual loss on the left, associated with pain behind the eye and alteration of depth perception. Examination on the following day reveals a relative afferent pupillary defect (RAPD) in the left eye.
Which of the following diagnoses is most likely?
Your Answer: Optic neuritis
Explanation:Understanding Optic Neuritis: Symptoms, Causes, and Differential Diagnosis
Optic neuritis is a condition characterized by inflammation, degeneration, or demyelination of the optic nerve. It typically presents with sudden-onset unilateral visual loss, retro-orbital pain, and altered color vision, and is more common in women aged 20-40. Patients with optic neuritis have up to a 50% risk of developing multiple sclerosis (MS) after an episode.
There are three types of optic neuritis: papillitis or anterior optic neuritis, retrobulbar neuritis, and neuroretinitis. Papillitis affects the intraocular portion of the nerve and causes optic disc swelling, while retrobulbar neuritis does not involve the disc and is often associated with MS. Neuroretinitis affects the optic disc and adjacent temporal retina.
The most common cause of retrobulbar neuritis is MS, but it can also be caused by toxic exposure, vitamin deficiency (especially B12), ischaemia (diabetes, giant cell arteritis), or infection. Symptoms include variable loss of central vision, dull aching pain in the eye, and a central scotoma on examination.
Cerebral infarction is an unlikely diagnosis in a young patient without significant risk factors. Optic nerve glioma typically presents with gradual reduction in visual acuity, while migraine aura presents with positive visual phenomena and is associated with unilateral headache. Temporal arteritis, which causes sudden loss of vision associated with ischaemic optic neuropathy, is rare in people under 50 and is associated with polymyalgia rheumatica.
Diagnosis of temporal arteritis requires three of five criteria: >50 years at disease onset, new headache, raised erythrocyte sedimentation rate (ESR), temporal artery abnormality, and abnormal temporal artery biopsy. Understanding the symptoms, causes, and differential diagnosis of optic neuritis is crucial for accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Neurology
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Question 34
Incorrect
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A 35-year-old woman experiences weekly migraines despite making lifestyle changes and avoiding triggers. Her doctor has agreed to prescribe medication for migraine prevention. She is in good health and does not take any regular medications. Her blood pressure measures 130/83 mmHg.
Which medication would be the most appropriate for this patient?Your Answer: Topiramate
Correct Answer: Propranolol
Explanation:For migraine treatment, the recommended acute options are a combination of triptan with NSAID or paracetamol. For prophylaxis, the recommended options are topiramate or propranolol. In a woman of childbearing age with no asthma history and requiring migraine prophylaxis, propranolol is the most appropriate option. Although it should be avoided during pregnancy, it does not carry the high risk of birth defects associated with topiramate. Carbamazepine is not recommended for migraine treatment but is licensed for trigeminal neuralgia. Gabapentin is not effective for migraine prophylaxis and is not recommended by NICE guidelines. Topiramate is an option for migraine prophylaxis, but it is not the most appropriate first-line option for a woman of childbearing age due to its teratogenic effects. Highly effective contraception is required if topiramate is used. The recommended safe options for contraception are the copper intrauterine device, levonorgestrel intrauterine system (Mirena), or Depo-Provera injections plus condoms, as per guidelines from the Faculty of Reproductive and Sexual Health (FSRH).
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.
Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.
Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.
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This question is part of the following fields:
- Neurology
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Question 35
Correct
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A 68-year-old man presents with lower back pain. He has a medical history of prostate cancer, asthma, diabetes, and hypertension. The pain is radiating down his right leg and he is experiencing reduced power in that leg. Additionally, he has a decreased anal tone. Although the lumbar spine x-ray shows no apparent fracture, what would be the most appropriate next investigation to perform?
Your Answer: MRI lumbosacral spine
Explanation:Lower back pain accompanied by lower limb pain, limb weakness, numbness or tingling, and decreased perianal tone are red flags that suggest spinal cord compression. In this case, the patient has a history of prostate cancer, which further raises suspicion. Urgent MRI is necessary to rule out spinal cord compression, and the results should be discussed with the on-call neurosurgical team. Additional x-rays or ultrasound would not be helpful, as MRI is the preferred diagnostic tool.
Neoplastic Spinal Cord Compression: An Oncological Emergency
Neoplastic spinal cord compression is a medical emergency that affects around 5% of cancer patients. The majority of cases are due to vertebral body metastases, resulting in extradural compression. This condition is more common in patients with lung, breast, and prostate cancer.
The earliest and most common symptom of neoplastic spinal cord compression is back pain, which may worsen when lying down or coughing. Other symptoms include lower limb weakness and sensory changes such as numbness and sensory loss. The neurological signs depend on the level of the lesion, with lesions above L1 resulting in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion.
An urgent MRI is recommended within 24 hours of presentation, according to the 2019 NICE guidelines. High-dose oral dexamethasone is used for management, and urgent oncological assessment is necessary for consideration of radiotherapy or surgery.
In summary, neoplastic spinal cord compression is a serious condition that requires prompt diagnosis and management to prevent further neurological damage.
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This question is part of the following fields:
- Neurology
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Question 36
Correct
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A 24-year-old woman presents urgently to the hospital. She is 35 weeks pregnant and reports sudden onset of right-sided numbness and dysphasia. Initially, she experienced tingling in the right side of her face, which then spread to her right hand over a few minutes. Shortly after, she noticed difficulty finding words and her right arm felt clumsy. The entire episode resolved completely within 20-30 minutes. Upon arrival at the hospital, her neurological exam was normal.
What is the most likely diagnosis?Your Answer: Migraine aura without headache
Explanation:Migraine aura without headache is a condition where a person experiences the typical symptoms of a migraine aura, but without the accompanying headache. In some cases, a person may have multiple attacks with only an aura, while in rare cases, they may only experience the aura without a headache. To diagnose this condition, the International Headache Society requires the presence of one or more fully reversible aura symptoms, such as visual, sensory, speech and/or language, motor, brain stem, or retinal symptoms, along with at least two of the following characteristics: gradual spread of symptoms over more than 5 minutes, each symptom lasting between 5-60 minutes, and at least one symptom being unilateral. It can be difficult to distinguish an aura from a transient ischemic attack (TIA) in patients without a history of migraines, but the characteristic slow progression of symptoms is suggestive of migraine aura without headache. This condition is more commonly seen in patients with a previous history of migraines or a positive family history of migraines.
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This question is part of the following fields:
- Neurology
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Question 37
Correct
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A 50-year-old man complains of vertigo and loss of hearing on the left side. Which test is most likely to suggest the presence of an acoustic neuroma?
Your Answer: Absent corneal reflex
Explanation:Consider acoustic neuroma if there is a loss of corneal reflex.
Understanding Vestibular Schwannoma (Acoustic Neuroma)
Vestibular schwannoma, also known as acoustic neuroma, is a type of brain tumor that accounts for 5% of intracranial tumors and 90% of cerebellopontine angle tumors. The condition is characterized by a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. The affected cranial nerves can predict the features of the condition. For instance, cranial nerve VIII can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. On the other hand, cranial nerve V can lead to an absent corneal reflex, while cranial nerve VII can cause facial palsy.
Bilateral vestibular schwannomas are often seen in neurofibromatosis type 2. The diagnosis of vestibular schwannoma is made through an MRI of the cerebellopontine angle, and audiometry is also important since only 5% of patients have a normal audiogram.
The management of vestibular schwannoma involves surgery, radiotherapy, or observation. The choice of treatment depends on the size and location of the tumor, the patient’s age and overall health, and the severity of symptoms. In conclusion, understanding vestibular schwannoma is crucial in managing the condition effectively.
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This question is part of the following fields:
- Neurology
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Question 38
Incorrect
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A 25-year-old man complains of recurring headaches. He experiences these headaches about 2-3 times per month. The headaches are severe and occur on the right side of his head. They are throbbing in nature and last for approximately 8-12 hours. During these episodes, he finds it difficult to continue working and prefers to rest in a dark room. Paracetamol has not been effective in relieving his symptoms. What medication should be prescribed to decrease the frequency of these headaches?
Your Answer: Zolmitriptan
Correct Answer: Propranolol
Explanation:For the acute treatment of migraine, a combination of triptan and NSAID or triptan and paracetamol is recommended. Prophylaxis options include topiramate or propranolol. In this case, the patient’s history is consistent with migraine and prophylaxis with propranolol or topiramate should be considered. Zolmitriptan is not indicated for prophylaxis, but rather for acute treatment of migraine.
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.
Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.
Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.
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This question is part of the following fields:
- Neurology
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Question 39
Correct
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You see a 56-year-old man with a 5-year history of back pain following a work-related injury. He has presented to the clinic due to poor control of his pain. He is experiencing shooting pains down his legs with an associated burning sensation.
Despite intensive physiotherapy, his pain is still poorly controlled and requiring full dose codeine and paracetamol which is failing to control the pain.
His MRI was normal and he has been discharged by the spinal team due to no operable cause identified for his pain.
You're asked to review him due to ongoing pain. The nursing team has asked if he can have morphine sulfate prescribed as required to help with this. He was started by his general practitioner 3 months previously on amitriptyline which he hasn't found of any benefit.
You decide rather than just prescribing morphine that you can try to adjust his chronic pain management as well.
Which of the following options would be best for the management of his chronic pain?Your Answer: Stop amitriptyline and start duloxetine
Explanation:When it comes to managing chronic pain, drugs for neuropathic pain are typically used alone. If they are not effective, it is recommended to switch to a different drug rather than adding another one. This question may also bring attention to poorly controlled acute pain, but it is important to note that morphine sulfate is not ideal for chronic pain management due to its potential side effects, dependence, and worsening of chronic pain. Tramadol is a better option for managing breakthrough pain in neuropathic pain patients, but it does not change the overall management of chronic pain. The recommended drugs for neuropathic pain include duloxetine, gabapentinoids, and amitriptyline (a tricyclic antidepressant).
Understanding Neuropathic Pain and its Management
Neuropathic pain is a type of pain that occurs due to damage or disruption of the nervous system. It is a complex condition that is often difficult to treat and does not respond well to standard painkillers. Examples of neuropathic pain include diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia, and prolapsed intervertebral disc.
To manage neuropathic pain, the National Institute for Health and Care Excellence (NICE) updated their guidance in 2013. The first-line treatment options include amitriptyline, duloxetine, gabapentin, or pregabalin. If the first-line drug treatment does not work, patients may try one of the other three drugs. Unlike standard painkillers, drugs for neuropathic pain are typically used as monotherapy, meaning that if they do not work, patients should switch to a different drug rather than adding another one.
Tramadol may be used as rescue therapy for exacerbations of neuropathic pain, while topical capsaicin may be used for localized neuropathic pain, such as post-herpetic neuralgia. Pain management clinics may also be useful for patients with resistant problems. However, it is important to note that for some specific conditions, such as trigeminal neuralgia, the guidance may vary, and carbamazepine may be used as a first-line treatment. Overall, understanding neuropathic pain and its management is crucial for improving the quality of life for patients suffering from this condition.
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This question is part of the following fields:
- Neurology
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Question 40
Correct
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A 32-year-old man presents to the neurology clinic with primary generalised epilepsy and is currently taking sodium valproate. Despite being on a therapeutic dose, he is still experiencing seizures and has also noticed weight gain since starting the medication. He expresses a desire to discontinue the current drug and try an alternative. What would be the most suitable second-line treatment option?
Your Answer: Lamotrigine
Explanation:Before starting combination therapy, it is advisable to first try monotherapy with a different drug. When combining sodium valproate and lamotrigine, it is important to be cautious as it may lead to the development of severe skin rashes like Steven-Johnson’s syndrome.
Treatment for Epilepsy
Epilepsy is a neurological disorder that affects millions of people worldwide. The condition is characterized by recurrent seizures, which can be debilitating and life-threatening. Treatment for epilepsy typically involves the use of antiepileptic drugs (AEDs) to control seizures and improve quality of life.
According to NICE guidelines, AEDs should be started after the second epileptic seizure. However, if a patient has a neurological deficit, brain imaging shows a structural abnormality, the EEG shows unequivocal epileptic activity, or the patient or their family considers the risk of having a further seizure unacceptable, AEDs may be started after the first seizure. It is important to note that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary due to the risk of neurodevelopmental delay in children.
The choice of AEDs depends on the type of epilepsy. For generalized tonic-clonic seizures, males are typically prescribed sodium valproate, while females are prescribed lamotrigine or levetiracetam. For focal seizures, lamotrigine or levetiracetam are the first-line treatments, with carbamazepine, oxcarbazepine, or zonisamide as second-line options. Ethosuximide is the first-line treatment for absence seizures, with sodium valproate or lamotrigine/levetiracetam as second-line options. For myoclonic seizures, males are prescribed sodium valproate, while females are prescribed levetiracetam. Finally, for tonic or atonic seizures, males are prescribed sodium valproate, while females are prescribed lamotrigine.
In summary, treatment for epilepsy involves the use of AEDs to control seizures and improve quality of life. The choice of AEDs depends on the type of epilepsy, and sodium valproate should be used with caution in women of childbearing age.
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This question is part of the following fields:
- Neurology
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Question 41
Correct
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Migraine can be a debilitating condition that affects many people, but there is no one-size-fits-all solution for managing it. Which of the following is the best statement about migraine.
Your Answer: Over half of all patients have their first attack before the age of 20
Explanation:Understanding Migraines: Facts and Diagnostic Criteria
Migraines are a common neurological disorder that affects people of all ages. Here are some important facts to know about migraines:
– The first attack of migraine often occurs in childhood or teenage years, with over half of all patients experiencing their first attack before the age of 20.
– Migraine attacks can last for a few hours to several days, with the International Headache Society diagnostic criteria requiring at least five episodes of headache lasting 4-72 hours.
– While aura is estimated to accompany headache in only a quarter to a third of patients, over half of all patients experience aura before the headache.
– Migraine is classically described as a unilateral, pulsating headache, but subsequent migraines can affect the same side or be bilateral.
– The release of vasogenic amines from blood vessel walls, accompanied by pulsatile distension, is believed to be responsible for migrainous attacks.
– A good history is important in diagnosing migraines, as patients may self-diagnose and overlook other factors such as combined oral contraception.In summary, migraines are a complex neurological disorder that can have a significant impact on a person’s quality of life. Understanding the facts and diagnostic criteria can help with proper diagnosis and management of this condition.
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This question is part of the following fields:
- Neurology
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Question 42
Correct
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As a junior doctor in the Emergency Department, you are tasked with evaluating an 82-year-old man who has arrived with confusion. The patient has provided little history, but his wife reports that his condition has been deteriorating over the past week. He has also been unusually irritable and not acting like himself. The patient has abstained from alcohol for many years. He is responsive to voice and has an AMT score of 1. The patient appears dehydrated and emits a strong odor of urine. Although neurological examination is challenging, he has normal tone and reflexes, and his pupils are equal and reactive. What is the most probable cause of his symptoms?
Your Answer: Delirium
Explanation:The man is experiencing acute confusion and impaired consciousness, which is indicative of delirium rather than dementia. The presence of dehydration and a smell of urine suggests a possible urinary tract infection as a trigger for the delirium. Korsakoff syndrome is unlikely as it is an amnestic disorder caused by thiamine deficiency associated with prolonged alcohol ingestion. The symptoms described are more likely to be mistaken for Wernicke’s encephalopathy, which can also cause confusion and altered consciousness. There is no evidence to suggest an acute psychotic episode. Treatment for Wernicke’s encephalopathy involves thiamine replacement.
Delirium vs. Dementia: Understanding the Differences
Delirium and dementia are two conditions that are often confused with each other. While both can cause confusion and cognitive impairment, there are some key differences between the two. Delirium is a sudden onset of confusion and disorientation, often accompanied by changes in consciousness and perception. Dementia, on the other hand, is a gradual decline in cognitive function that occurs over time.
Factors that can help distinguish delirium from dementia include the acute onset of symptoms, impairment of consciousness, fluctuation of symptoms (such as being worse at night or having periods of normality), abnormal perception (such as illusions and hallucinations), agitation, fear, and delusions. These symptoms are often more pronounced in delirium than in dementia.
It is important to understand the differences between delirium and dementia, as they require different approaches to treatment. Delirium is often reversible if the underlying cause can be identified and treated, while dementia is a progressive condition that cannot be cured.
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This question is part of the following fields:
- Neurology
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Question 43
Incorrect
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A 47-year-old woman presents to the Stroke Clinic for review after experiencing a transient ischaemic attack (TIA). It is suspected that the patient’s TIA was caused by an issue with her carotid arteries.
A magnetic resonance angiogram (MRA) is requested followed by catheter angiography. The MRA shows a right internal carotid with narrowed eccentric lumen, surrounded by a crescent-shaped mural thrombus and thin annular enhancement. The catheter angiogram shows a ‘string sign’ in the right internal carotid.
What internal carotid abnormality is most likely the cause of this patient’s TIA?
Your Answer: Carotid-artery aneurysm
Correct Answer: Carotid-artery dissection
Explanation:Cervico-cerebral arterial dissections (CADs) are a common cause of strokes in younger patients, accounting for almost 20% of strokes in those under 45 years old. The majority of cases involve the extracranial internal carotid artery, while extracranial vertebral dissections make up about 15% of cases. A high level of suspicion is necessary to diagnose CAD, and confirmation can be obtained through various imaging techniques such as Doppler ultrasonography, magnetic resonance imaging/magnetic resonance angiography (MRA), computed tomography angiography (CTA), or catheter angiography. CTA can reveal several characteristic features of CAD, including an abnormal vessel contour, enlargement of the dissected artery, an intimal flap, and a dissecting aneurysm. The traditional method of diagnosing arterial dissections is catheter angiography, which typically shows a long segment of narrowed lumen known as the string sign. Other conditions such as carotid-artery pseudoaneurysm, carotid-artery aneurysm, carotid-artery occlusion, and carotid-artery stenosis can also be identified through imaging techniques, but they are not evident in this particular angiogram.
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This question is part of the following fields:
- Neurology
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Question 44
Correct
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A 51-year-old man comes to see the GP complaining of leg twitching and cramps that have been going on for a year. He also reports difficulty swallowing both liquids and food. The patient has no prior medical history. During the examination, the GP observes tongue fasciculations and hypophonia. Based on these findings, what conditions should be considered for further investigation?
Your Answer: Motor neuron disease
Explanation:Bulbar onset motor neuron disease can be identified by the presence of tongue fasciculations.
While benign fasciculation syndrome can also cause tongue fasciculations, the overall clinical picture suggests a more serious underlying condition. Other factors may be misleading in making a diagnosis.
Understanding Motor Neuron Disease: Signs and Diagnosis
Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It is a rare condition that usually presents after the age of 40 and can manifest in different patterns such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The diagnosis of motor neuron disease is based on clinical features, including the presence of fasciculations, the absence of sensory signs, and the combination of upper and lower motor neuron signs. Wasting of the small hand muscles and tibialis anterior is also common.
Other features that can help diagnose motor neuron disease include the absence of external ocular muscle involvement, the absence of cerebellar signs, and preserved abdominal reflexes. Sphincter dysfunction, if present, is usually a late feature. While vague sensory symptoms may occur early in the disease, sensory signs are typically absent.
Nerve conduction studies can help exclude a neuropathy, while electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude other conditions such as cervical cord compression and myelopathy. Understanding the signs and diagnosis of motor neuron disease is crucial for early detection and management of the condition.
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This question is part of the following fields:
- Neurology
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Question 45
Incorrect
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You and your consultant are examining a CT head of a middle-aged patient who arrived at the emergency department with decreased consciousness following a fall and hitting the side of their head. Your consultant notes a crescent-shaped lesion on the right frontoparietal region. Which blood vessel is likely to have been affected?
Your Answer: Anterior circulating artery
Correct Answer: Bridging vein
Explanation:The bleeding of damaged bridging veins between the cortex and venous sinuses is the cause of subdural haemorrhage. This condition is the most probable reason for the reduced consciousness in this case. A crescent-shaped lesion is typically seen on CT scans, and it occurs in the subdural space, crossing sutures. Unlike subdural haemorrhage, epidural haemorrhage is linked to the middle meningeal artery, while subarachnoid haemorrhages are associated with vessels of the circle of Willis, such as basilar and anterior circulating arteries.
Understanding Subdural Haemorrhage
A subdural haemorrhage is a condition where blood collects deep to the dural layer of the meninges. This collection of blood is not within the brain substance and is referred to as an ‘extra-axial’ or ‘extrinsic’ lesion. Subdural haematomas can be classified based on their age, which includes acute, subacute, and chronic. Although they occur within the same anatomical compartment, acute and chronic subdurals have significant differences in terms of their mechanisms, associated clinical features, and management.
An acute subdural haematoma is a collection of fresh blood within the subdural space and is commonly caused by high-impact trauma. This type of haematoma is associated with high-impact injuries, and there is often other underlying brain injuries. Symptoms and presentation vary depending on the size of the compressive acute subdural haematoma and the associated injuries. CT imaging is the first-line investigation, and surgical options include monitoring of intracranial pressure and decompressive craniectomy.
On the other hand, a chronic subdural haematoma is a collection of blood within the subdural space that has been present for weeks to months. Elderly and alcoholic patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taut bridging veins. Infants also have fragile bridging veins and can rupture in shaken baby syndrome. If the chronic subdural is an incidental finding or if it is small in size with no associated neurological deficit, it can be managed conservatively. However, if the patient is confused, has an associated neurological deficit, or has severe imaging findings, surgical decompression with burr holes is required.
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This question is part of the following fields:
- Neurology
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Question 46
Incorrect
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A 68-year-old man who has recently had a stroke is here for a follow-up appointment. He explains that he was watching a game with his son when he suddenly lost feeling on the left side of his body. Emergency services were called and he was taken to the hospital where a CT scan confirmed a right-sided ischemic stroke. He has no other medical history. What antiplatelet medication should he be prescribed after the stroke?
Your Answer: Aspirin 300mg and then dipyridamole 200mg twice daily lifelong
Correct Answer: Aspirin 300 mg daily for 2 weeks then clopidogrel 75 mg daily lifelong
Explanation:After a stroke, all patients should receive an antiplatelet medication, unless they require an anticoagulant. As per NICE guidelines, individuals with confirmed ischaemic stroke through brain imaging should be given 300 mg of aspirin daily for two weeks. Afterward, long-term treatment with 75 mg of clopidogrel is recommended, provided it is well-tolerated and not contraindicated. If clopidogrel is not suitable, modified-release dipyridamole with low-dose aspirin should be administered.
Latest Guidance on Antiplatelets
Antiplatelets are medications that prevent blood clots from forming by inhibiting platelet aggregation. The most recent guidelines recommend different antiplatelet regimens depending on the diagnosis. For acute coronary syndrome, aspirin and ticagrelor are recommended for 12 months, followed by lifelong aspirin and clopidogrel if aspirin is contraindicated. For percutaneous coronary intervention, lifelong aspirin and prasugrel or ticagrelor for 12 months are recommended, with lifelong clopidogrel if aspirin is contraindicated. For TIA and ischaemic stroke, lifelong clopidogrel is recommended as first-line treatment, with lifelong aspirin and dipyridamole as second-line treatment. For peripheral arterial disease, lifelong clopidogrel is recommended as first-line treatment, with lifelong aspirin as second-line treatment. It is important to follow these guidelines to ensure the best possible outcomes for patients.
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This question is part of the following fields:
- Neurology
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Question 47
Incorrect
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A 75-year-old man visits the doctor's office accompanied by his wife, who is worried about his well-being. The man has been experiencing episodes of confusion and drowsiness that appear to occur unpredictably for the past five years. Additionally, he has developed a tremor in his right hand on one side of his body. The man's wife reveals that she has slept in a different bed from her husband for the past three decades due to his frequent nightmares. What is the probable diagnosis?
Your Answer: Parkinson's disease dementia
Correct Answer: Dementia with Lewy bodies
Explanation:The correct answer is Dementia with Lewy bodies, which is a type of dementia that is characterized by fluctuating cognition. This can be confusing as there are different types of dementia, especially non-Alzheimer’s disease dementia. In this case, the man’s symptoms and the classification of dementias point towards DLB. Parkinson’s disease dementia is also a type of dementia that falls under the category of Lewy body dementia, but it is characterized by tremors, bradykinesia, and rigidity that develop before dementia. DLB, on the other hand, presents with dementia before these motor symptoms. Other clues that suggest DLB include the man’s periods of confusion and sleepiness that come and go randomly, as well as his wife’s report of him suffering from bad nightmares, which is a distinctive feature of DLB. In contrast, Alzheimer’s disease dementia typically presents with slowly worsening memory loss and forgetfulness, while frontal lobe dementia primarily presents with behavioural changes and reckless behaviour.
Understanding Lewy Body Dementia
Lewy body dementia is a type of dementia that is becoming more recognized as a cause of cognitive impairment, accounting for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions, known as Lewy bodies, in certain areas of the brain. While there is a complicated relationship between Parkinson’s disease and Lewy body dementia, with dementia often seen in Parkinson’s disease, the two conditions are distinct. Additionally, up to 40% of patients with Alzheimer’s disease have Lewy bodies.
The features of Lewy body dementia include progressive cognitive impairment, which typically occurs before parkinsonism, but both features usually occur within a year of each other. Unlike other forms of dementia, cognition may fluctuate, and early impairments in attention and executive function are more common than memory loss. Other features include parkinsonism, visual hallucinations, and sometimes delusions and non-visual hallucinations.
Diagnosis of Lewy body dementia is usually clinical, but single-photon emission computed tomography (SPECT) can be used to confirm the diagnosis. Management of Lewy body dementia involves the use of acetylcholinesterase inhibitors and memantine, similar to Alzheimer’s disease. However, neuroleptics should be avoided as patients with Lewy body dementia are extremely sensitive and may develop irreversible parkinsonism. It is important to carefully consider the use of medication in these patients to avoid worsening their condition.
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This question is part of the following fields:
- Neurology
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Question 48
Incorrect
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You are evaluating a patient who is experiencing double vision. When looking straight ahead, the patient's right eye drifts downward and outward. When attempting to look to the left, the patient cannot move the right eye inward, and the double vision becomes more severe. When looking to the right, the angle of the squint is reduced. What is the probable underlying issue?
Your Answer: Right 6th nerve palsy
Correct Answer: Right 3rd nerve palsy
Explanation:Third Nerve Palsy: Symptoms and Causes
Third nerve palsy is a condition that affects the eye and is characterized by a downward and outward deviation of the eye, ptosis, and sometimes a dilated pupil. The condition can be caused by various factors, including diabetes mellitus, vasculitis such as temporal arteritis and SLE, uncal herniation through tentorium if raised ICP, posterior communicating artery aneurysm, and cavernous sinus thrombosis. In some cases, the condition may be a false localizing sign.
Weber’s syndrome is a type of third nerve palsy that is caused by midbrain strokes and is characterized by an ipsilateral third nerve palsy with contralateral hemiplegia. Other possible causes of third nerve palsy include amyloid and multiple sclerosis. The term false localizing sign is usually associated with sixth nerve palsies, but it may be used for a variety of neurological presentations.
In summary, third nerve palsy is a condition that affects the eye and can be caused by various factors. Weber’s syndrome is a specific type of third nerve palsy that is caused by midbrain strokes and is characterized by an ipsilateral third nerve palsy with contralateral hemiplegia.
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This question is part of the following fields:
- Neurology
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Question 49
Incorrect
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A 10-year-old boy presents to the General Practitioner with his father who reports that he has been falling behind at school. His teachers have noticed that multiple times during lessons he appears to be 'staring into space' for about ten seconds at a time, during which there is twitching of his arms. He does not remember these episodes. He is referred for an electroencephalography (EEG) which shows spike-and-wave complexes during an episode. He is started on a new medication.
Which of the following is the most likely treatment?Your Answer: Lorazepam
Correct Answer: Ethosuximide
Explanation:When it comes to treating absence seizures, ethosuximide is the preferred first-line option for women and girls who may become pregnant. Boys and men can be treated with either ethosuximide or sodium valproate. Absence seizures are most common in children and young people, and are characterized by brief episodes of fixed gaze and possible arm or leg movements. An EEG can confirm the presence of spike-and-wave complexes during an attack. Sodium valproate may be used for boys and men, but should be avoided in women of childbearing potential due to the risk of birth defects. Carbamazepine is not effective for absence seizures, but is the first-line treatment for focal seizures. Lamotrigine may be used as a second-line option if other treatments are not effective or well-tolerated. In cases of status epilepticus, intravenous lorazepam is the preferred treatment in a hospital setting, but buccal midazolam or rectal diazepam can be used if intravenous access is not available.
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This question is part of the following fields:
- Neurology
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Question 50
Incorrect
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A 32-year-old man has, over the course of two days, developed weakness and numbness in his arms. He has no previous medical history of note apart from treated asthma. He smokes cigarettes ‘occasionally’. His father died of a ‘heart problem’ in his early 50s. On examination, the cranial nerves and lower limbs are normal to examination. There is an increased tone in his arms bilaterally, with brisk reflexes. Power is reduced to three-fifths in all modalities above the elbows. Vibration and joint position sense are normal.
Which of the following is the most likely diagnosis?
Your Answer: A lesion at the conus medullaris
Correct Answer: Anterior spinal artery thrombosis
Explanation:The anterior spinal artery supplies the anterior two-thirds of the spinal cord, causing anterior cord syndrome when there is ischaemia/infarct. This results in complete motor paralysis below the lesion, loss of pain/temperature sensation at and below the lesion, and some autonomic and bowel/bladder dysfunction. A lesion at the conus medullaris presents with back pain, saddle anaesthesia, urinary retention, faecal incontinence, lower limb weakness and numbness, and mixed UMN and LMN palsies. Friedreich’s ataxia presents with a slowly progressive gait ataxia, while MND is slowly progressive with combined UMN and LMN signs. Subacute combined degeneration of the spinal cord is due to vitamin B12 deficiency and has a subacute or gradual onset with degeneration of the dorsal and lateral columns of the spinal cord. Syndrome and lesion affected presentations are summarized in a table.
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This question is part of the following fields:
- Neurology
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Question 51
Correct
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An ambulance brings a 70-year-old man to the emergency department with suspected stroke. Upon examination, the man's speech is non-fluent, but his comprehension is intact. He experiences difficulty repeating a phrase. What is the most probable location of the lesion?
Your Answer: Frontal lobe
Explanation:The patient in the scenario has non-fluent speech, normal comprehension, and impaired repetition, which is indicative of Broca’s dysphasia. This type of speech abnormality is associated with a lesion in the frontal lobe affecting Broca’s area. When responding to a conversation, the signal travels from the ear to Wernicke’s area for comprehension, then along the arcuate fasciculus to Broca’s area for speech coordination. A lesion in the cerebellum, occipital lobe, parietal lobe, or temporal lobe would not be associated with Broca’s dysphasia.
Understanding the Different Types of Aphasia
Aphasia is a language disorder that affects a person’s ability to communicate effectively. There are different types of aphasia, each with its own set of symptoms and causes. Wernicke’s aphasia is caused by a lesion in the superior temporal gyrus, which is responsible for forming speech before sending it to Broca’s area. This type of aphasia results in sentences that make no sense, word substitution, and neologisms, but speech remains fluent. On the other hand, Broca’s aphasia is caused by a lesion in the inferior frontal gyrus, resulting in non-fluent, laboured, and halting speech. Repetition is impaired, but comprehension is normal.
Conduction aphasia is caused by a stroke affecting the arcuate fasiculus, the connection between Wernicke’s and Broca’s area. Speech is fluent, but repetition is poor, and the person is aware of the errors they are making. Comprehension is normal. Global aphasia is the most severe type, affecting all three areas and resulting in severe expressive and receptive aphasia. However, the person may still be able to communicate using gestures.
Understanding the different types of aphasia is crucial in providing appropriate treatment and support for individuals with this language disorder. It is important to note that dysarthria is different from aphasia and refers to a motor speech disorder.
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This question is part of the following fields:
- Neurology
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Question 52
Incorrect
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A 42-year-old woman presents with a 2-day history of right-sided neck pain and left-sided sensorimotor disturbance. Shortly after the neck pain had begun, she had noted that her right eyelid was ‘drooping’ and that she had developed weakness and altered sensation in her left arm and leg. She had recently visited a physiotherapist for neck pain after a fall. Examination reveals right Horner syndrome, and weakness and sensory disturbance on the left-hand side, with a left extensor plantar response.
Which of the following is the most likely clinical diagnosis?Your Answer: Lateral medullary infarction
Correct Answer: Carotid artery dissection
Explanation:Differential Diagnosis for a Young Patient with Neck Pain and Stroke Syndrome
Carotid artery dissection, lateral medullary infarction, posterior fossa space-occupying lesion, subarachnoid hemorrhage, and venous sinus thrombosis are all potential causes of neck pain and stroke syndrome in a young patient. Carotid artery dissection is a tear in one of the carotid arteries that can occur spontaneously or following trauma. Symptoms may include vague headache, facial and neck pain, meiosis, ptosis, focal limb weakness, and cranial nerve palsies. Lateral medullary infarction is usually due to occlusion of the intracranial vertebral artery or the posterior inferior cerebellar artery and may present with vestibulocerebellar symptoms, ipsilateral Horner syndrome, sensory symptoms, and ipsilateral bulbar muscle weakness. Posterior fossa space-occupying lesions are more common in children and may cause symptoms due to raised intracranial pressure and brainstem/cerebellum compression. Subarachnoid hemorrhage presents with a sudden-onset, severe headache, while venous sinus thrombosis usually presents with progressive headache, nausea, vomiting, and seizures. Hemiplegia may occur in both posterior fossa space-occupying lesions and venous sinus thrombosis, but Horner syndrome does not occur in either. A thorough evaluation is necessary to determine the underlying cause of neck pain and stroke syndrome in a young patient.
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This question is part of the following fields:
- Neurology
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Question 53
Correct
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An older gentleman patient presents with arthritic pains. At the end of the consultation, he mentions that he recently visited a doctor at the memory clinic who diagnosed him with Alzheimer's dementia. However, he cannot recall why he was not prescribed any medication for this condition.
Which of the following factors would be a potential relative contraindication to prescribing donepezil for this patient?Your Answer: Resting bradycardia
Explanation:Managing Alzheimer’s Disease: Non-Pharmacological and Pharmacological Approaches
Alzheimer’s disease is a type of dementia that progressively affects the brain and is the most common form of dementia in the UK. To manage this condition, there are both non-pharmacological and pharmacological approaches available.
Non-pharmacological management involves offering a range of activities that promote wellbeing and are tailored to the patient’s preferences. Group cognitive stimulation therapy is recommended for patients with mild to moderate dementia, while group reminiscence therapy and cognitive rehabilitation are also options to consider.
Pharmacological management involves the use of medications. The three acetylcholinesterase inhibitors (donepezil, galantamine, and rivastigmine) are options for managing mild to moderate Alzheimer’s disease. Memantine, an NMDA receptor antagonist, is considered a second-line treatment and is recommended for patients with moderate Alzheimer’s who are intolerant of or have a contraindication to acetylcholinesterase inhibitors. It can also be used as an add-on drug to acetylcholinesterase inhibitors for patients with moderate or severe Alzheimer’s or as monotherapy in severe Alzheimer’s.
When managing non-cognitive symptoms, NICE does not recommend antidepressants for mild to moderate depression in patients with dementia. Antipsychotics should only be used for patients at risk of harming themselves or others or when the agitation, hallucinations, or delusions are causing them severe distress.
It is important to note that donepezil is relatively contraindicated in patients with bradycardia, and adverse effects may include insomnia. By utilizing both non-pharmacological and pharmacological approaches, patients with Alzheimer’s disease can receive comprehensive care and management.
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This question is part of the following fields:
- Neurology
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Question 54
Incorrect
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A 67-year-old man presents to his General Practitioner reporting a feeling of weakness in his right arm that occurred about 10 hours ago. He states that the weakness lasted for around one hour and has since disappeared. He has a history of hypertension and takes amlodipine, but is typically healthy.
What is the most suitable course of action for management?Your Answer: Start clopidogrel 75 mg once daily
Correct Answer: Give aspirin 300 mg and refer immediately to be seen in the Stroke Clinic within 24 hours
Explanation:Management of Transient Ischaemic Attack (TIA)
Transient ischaemic attack (TIA) is a medical emergency that requires prompt management to prevent a subsequent stroke. Here are some management strategies for TIA:
Immediate administration of aspirin 300 mg and referral to the Stroke Clinic within 24 hours is recommended, unless contraindicated. Clopidogrel 75 mg once daily is the preferred secondary prevention following a stroke or TIA.
An outpatient magnetic resonance imaging (MRI) head scan may be considered to determine the territory of ischaemia, but only after assessment by a specialist at a TIA clinic.
Patients who have had a suspected TIA within the last week should be offered aspirin 300 mg at once and be seen by a stroke specialist within 24 hours. If the suspected TIA was more than one week ago, patients should be seen by a specialist within the next seven days.
Dual antiplatelet therapy with aspirin and clopidogrel may be considered for the first three months following a TIA or ischaemic stroke if the patient has severe symptomatic intracranial stenosis or for another condition such as acute coronary syndrome.
Management Strategies for Transient Ischaemic Attack (TIA)
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This question is part of the following fields:
- Neurology
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Question 55
Correct
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A 13-year-old boy is presented to the emergency department following an episode of syncope. According to his friends, he was laughing at a joke and suddenly collapsed to the ground. The school teacher called for an ambulance, and he recovered within 15 minutes. His school reports indicate that he often dozes off during classes and was recently disciplined for this behavior. What could be the probable reason for his condition?
Your Answer: Cataplexy
Explanation:It is probable that the patient experienced cataplexy, as indicated by their laughter and history of excessive sleepiness during classes, which suggests a potential diagnosis of narcolepsy. While cardiac syncope is a possibility, further investigations such as an ECG and transthoracic echocardiogram would be necessary to rule it out. Absence seizures are unlikely due to the absence of blank staring, and generalized epilepsy is also improbable as it typically involves longer-lasting tonic-clonic seizures with a slower recovery time.
Understanding Cataplexy
Cataplexy is a condition characterized by a sudden and temporary loss of muscle control triggered by intense emotions such as laughter or fear. It is commonly associated with narcolepsy, with around two-thirds of patients experiencing cataplexy. The symptoms of cataplexy can vary from mild buckling of the knees to complete collapse.
This condition can be debilitating and can significantly impact a person’s quality of life. It can also be challenging to diagnose, as the symptoms can be mistaken for other conditions such as seizures or fainting spells. Treatment options for cataplexy include medication and lifestyle changes, such as avoiding triggers that can cause emotional responses.
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This question is part of the following fields:
- Neurology
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Question 56
Incorrect
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What is a true statement about trigeminal neuralgia? Choose one option from the list provided.
Your Answer: All patients should have a CT scan of the head in suspected trigeminal neuralgia
Correct Answer: Carbamazepine is the first-line treatment
Explanation:Trigeminal Neuralgia: Diagnosis and Treatment
Trigeminal neuralgia is a condition characterized by sharp, shooting pain in the distribution of one or more branches of the trigeminal nerve. While the cause is unknown, it can be due to compression of the nerve as it exits the foramen. The pain is intermittent and often exacerbated by light touch, eating, talking, or exposure to the cold.
Carbamazepine is the first-line treatment for trigeminal neuralgia, with an initial dose of 100 mg up to twice daily. The dosage can be increased in increments of 100-200 mg every 2 weeks until the pain is under control.
Contrary to popular belief, trigeminal neuralgia usually affects the face unilaterally, with only 3% of cases being bilateral. A CT scan of the head is not recommended for all patients with the diagnosis of trigeminal neuralgia, but may be necessary if red flag symptoms are present.
It is important to note that patients with trigeminal neuralgia do not typically experience constant pain, as the pain is episodic in frequency. Tramadol is not the first-line treatment for trigeminal pain, carbamazepine is.
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This question is part of the following fields:
- Neurology
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Question 57
Incorrect
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A 72-year-old man presents to the emergency department with his spouse reporting weakness in his right arm and leg, decreased vision, and difficulty speaking. The symptoms began approximately 30 minutes ago, and his wife promptly called for an ambulance. A CT scan of the head ruled out a hemorrhagic stroke, but a CT contrast angiography revealed a confirmed blockage in the proximal anterior circulation. What is the appropriate acute management for this patient?
Your Answer: Aspirin and clopidogrel
Correct Answer: Alteplase plus thrombectomy
Explanation:For patients with an acute ischaemic stroke who present within 4.5 hours, the recommended treatment is a combination of thrombolysis and thrombectomy. Thrombolysis involves the use of alteplase, a tissue plasminogen activator that breaks down the clot, while thrombectomy physically removes the clot using a specialized device inserted through the femoral artery. In this case, as the patient has confirmed occlusion of the proximal anterior circulation, both thrombolysis and thrombectomy should be performed together for the best possible outcome. While alteplase alone can be considered if thrombectomy is not available, a better prognosis is more likely with the combination treatment. It would not be appropriate to perform thrombectomy alone without considering thrombolysis, as the patient is presenting within the window for thrombolysis and should be considered for both in combination according to the guidelines.
The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 58
Incorrect
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You assess a 27-year-old female patient who experiences intense, one-sided, pulsating headaches. These occur approximately once a month and are not associated with her menstrual cycle. Prior to the onset of the headache, she occasionally experiences momentary 'zig-zags' in her vision. She has no specific preference for treatment and seeks your guidance on the most effective approach to managing acute episodes. Which of the following options would be the most suitable initial treatment?
Your Answer: Oral NSAID
Correct Answer: Oral triptan + oral NSAID
Explanation:Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.
Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.
Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.
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This question is part of the following fields:
- Neurology
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Question 59
Incorrect
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A 67-year-old man presents to the memory clinic with a history of cognitive decline over the past 10 months. His wife reports that he is struggling with basic tasks and becoming increasingly forgetful and confused. She has also noticed a change in his personality, including more frequent swearing and inappropriate behavior such as answering the door naked. Interestingly, his mother had a similar reputation in her later years. The patient reports smoking 20 cigarettes per day and drinking one glass of wine each evening. What is the most probable diagnosis?
Your Answer: Alzheimer’s dementia
Correct Answer: Frontotemporal dementia
Explanation:The patient is likely suffering from frontotemporal dementia, which is also known as Pick’s disease. This type of dementia is characterized by a change in personality and social disinhibition, and it often has a positive family history. In contrast, Alzheimer’s disease typically presents with a decline in episodic memory and visuospatial awareness, while Lewy body dementia is characterized by fluctuating confusion and hallucinations. Creutzfeldt-Jakob disease is a rare condition that causes rapid neurodegeneration and may present with cognitive decline and personality changes, as well as additional symptoms such as abnormal movements and loss of coordination.
Understanding Frontotemporal Lobar Degeneration
Frontotemporal lobar degeneration (FTLD) is a type of cortical dementia that is the third most common after Alzheimer’s and Lewy body dementia. There are three recognized types of FTLD: Frontotemporal dementia (Pick’s disease), Progressive non-fluent aphasia (chronic progressive aphasia, CPA), and Semantic dementia. Common features of frontotemporal lobar dementias include onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems.
Pick’s disease is the most common type of FTLD and is characterized by personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviors. Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease. Macroscopic changes seen in Pick’s disease include atrophy of the frontal and temporal lobes. Microscopic changes include Pick bodies, spherical aggregations of tau protein (silver-staining), gliosis, neurofibrillary tangles, and senile plaques.
In contrast, CPA is characterized by non-fluent speech, with short utterances that are agrammatic. Comprehension is relatively preserved. Semantic dementia, on the other hand, is characterized by fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s, memory is better for recent rather than remote events.
In terms of management, NICE does not recommend the use of AChE inhibitors or memantine in people with frontotemporal dementia. Understanding the different types of FTLD and their characteristics can aid in early diagnosis and appropriate management.
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This question is part of the following fields:
- Neurology
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Question 60
Incorrect
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A 45-year-old patient is found to have a missing ankle reflex. To which nerve root does this correspond?
Your Answer: L2-L3
Correct Answer: S1-S2
Explanation:Understanding Common Reflexes
Reflexes are automatic responses of the body to certain stimuli. These responses are controlled by the nervous system and do not require conscious thought. Common reflexes include the ankle reflex, knee reflex, biceps reflex, and triceps reflex. Each reflex is associated with a specific root in the spinal cord.
The ankle reflex is associated with the S1-S2 root, which is located in the lower part of the spinal cord. This reflex is elicited by tapping the Achilles tendon with a reflex hammer. The resulting contraction of the calf muscle indicates the integrity of the spinal cord and the peripheral nerves.
The knee reflex is associated with the L3-L4 root, which is located in the middle part of the spinal cord. This reflex is elicited by tapping the patellar tendon with a reflex hammer. The resulting contraction of the quadriceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The biceps reflex is associated with the C5-C6 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the biceps tendon with a reflex hammer. The resulting contraction of the biceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The triceps reflex is associated with the C7-C8 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the triceps tendon with a reflex hammer. The resulting contraction of the triceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
Understanding these common reflexes can help healthcare professionals diagnose and treat various neurological conditions. By testing these reflexes, they can determine if there is any damage or dysfunction in the nervous system.
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This question is part of the following fields:
- Neurology
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Question 61
Incorrect
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A 25-year-old comes in for a check-up. Over the last 3 months, he has been experiencing frequent headaches. These headaches are now happening almost every day and can be quite intense. What characteristic in this patient should trigger an investigation for a secondary cause of headaches?
Your Answer: Numbness lasting 30 minutes before the headache
Correct Answer: Headache triggered by coughing
Explanation:When dealing with an older patient, it is important to rule out glaucoma if they are experiencing severe unilateral eye pain. However, for a 23-year-old patient, this is not a top concern. Migraine and cluster headaches are common causes of unilateral eye pain, as well as sinusitis which can cause pain behind the eye.
Red Flags for Headaches
Headaches are a common complaint in clinical practice, but some symptoms may indicate a more serious underlying condition. The National Institute for Health and Care Excellence (NICE) has identified several red flags that should prompt further investigation. These include compromised immunity, a history of malignancy, sudden-onset headache, new-onset neurological deficit, impaired level of consciousness, recent head trauma, and symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma. Other red flags include vomiting without an obvious cause, worsening headache with fever, new-onset cognitive dysfunction, change in personality, orthostatic headache, and a substantial change in the characteristics of the headache. If any of these symptoms are present, it is important to seek medical attention promptly. By identifying these red flags, healthcare providers can ensure that patients receive appropriate care and treatment for their headaches.
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This question is part of the following fields:
- Neurology
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Question 62
Incorrect
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A 32-year-old woman is referred for an evaluation of dysphagia. On examination, she has bilateral ptosis, facial weakness and atrophy of the temporalis. She says that she has difficulties relaxing her grip, especially in cold weather, and that her father had similar problems.
Which of the following is the most likely diagnosis?
Your Answer: Motor neurone disease (MND)
Correct Answer: Myotonia dystrophica
Explanation:Myotonic dystrophy is a genetic disorder that causes muscle stiffness and wasting. It is inherited in an autosomal dominant pattern and typically presents between the ages of 15 and 40. The disease progresses slowly and can lead to cataracts, hypogonadism, frontal balding, and cardiac issues. Patients may experience weakness, wasting, and myotonia in affected muscles, particularly in the face and limbs. Other symptoms include hollowing of the cheeks, swan neck appearance, and difficulty releasing a handshake. This patient’s presentation is consistent with myotonic dystrophy and likely inherited from her father.
Myasthenia gravis is an autoimmune disorder that causes weakness, particularly in the periocular, facial, bulbar, and girdle muscles. Fatigue is a hallmark symptom, and dysphagia may occur in advanced cases. Temporalis atrophy is not a feature.
Motor neurone disease is a rare condition that typically presents with mixed upper and lower motor neuron signs in the same limb. Symptoms may include weakness, wasting, cramps, stiffness, and problems with speech and swallowing. Dysphagia and speech problems become more common as the disease progresses. MND is unlikely in a woman of this age, and there is typically no familial link.
Multiple sclerosis is a more common condition in women that typically presents with transient episodes of optic neuritis or limb weakness/paraesthesiae. Only a small percentage of sufferers have a family history of MS.
Polymyositis is a connective tissue disease that causes proximal muscle weakness and tenderness. Atrophy is a late feature, and patients may have difficulty rising from chairs. Dysphagia may occur in advanced cases, but ptosis and temporalis wasting are not features. Polymyositis is not typically inherited.
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This question is part of the following fields:
- Neurology
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Question 63
Incorrect
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An 85-year-old woman with hypercholesterolaemia, ischaemic heart disease and hypertension complains to her General Practitioner of tingling and numbness in both feet that has been worsening over a period of six months.
Examination reveals that she has an altered pinprick sensation over both feet and absent ankle reflexes. Her urea and electrolyte levels are normal. Her blood glucose is normal and there is no history of alcohol ingestion. She is, however, taking a number of medications for the secondary presentation of her vascular problems.
Which of the following medications is most likely to have caused her symptoms?
Select the SINGLE most appropriate medication from the list below.Your Answer: Bendroflumethiazide
Correct Answer: Simvastatin
Explanation:Medication Analysis for Peripheral Neuropathy: Simvastatin, Bendroflumethiazide, Clopidogrel, Ramipril, and Spironolactone
Peripheral neuropathy is a condition characterized by numbness and tingling in the extremities, often accompanied by a loss of ankle reflexes. Statins, such as simvastatin, are a known risk factor for peripheral neuropathy, with onset ranging from the first dose to years of use. Bendroflumethiazide, on the other hand, is not associated with neuropathy but can cause electrolyte imbalances leading to central neurological disturbances. Clopidogrel, an anti-platelet medication, is unlikely to contribute to peripheral neuropathy. Ramipril, a blood-pressure-lowering medication, can cause cough and dizziness but would not lead to peripheral neuropathy. Spironolactone, a diuretic, can cause hyperkalemia but would not lead to peripheral neuropathy. It is important to consider medication use when evaluating patients with peripheral neuropathy symptoms.
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This question is part of the following fields:
- Neurology
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Question 64
Incorrect
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A 28-year-old woman presents with a history of headache every day for the past three months. She describes that it is worse in the evening. There are no associated symptoms.
Which of the following is the most likely diagnosis?Your Answer: Giant cell arteritis
Correct Answer: Tension headache
Explanation:Understanding Different Types of Headaches
Headaches are a common ailment that can be caused by a variety of factors. Here are some of the different types of headaches and their distinguishing characteristics:
1. Tension headache: This type of headache is often described as a tight, band-like pain across the forehead and is more common in females. It typically worsens towards the end of the day but does not interfere with daily activities. Chronic tension headaches occur at least 15 days of the month for at least three months.
2. Brain tumour: Headaches caused by space-occupying lesions tend to be worse in the morning and when bending forward. They may also be associated with vomiting.
3. Cluster headache: This type of headache is more common in men and presents with intense pain localized around one eye, which can last for a few minutes up to three hours. There may also be simultaneous lacrimation and nasal congestion. Symptoms occur every day or multiple times every day for a number of weeks, followed by a symptom-free period lasting months or even years.
4. Giant cell arteritis: This type of headache typically occurs in those aged over 50 years and is characterized by an abrupt onset and recurrent daily headache. Common symptoms include scalp pain/tenderness, jaw claudication, visual disturbances, fever, weight loss, and lethargy. A diagnosis of GCA requires three out of five specific criteria.
5. Migraine: Migraines can occur daily but are typically accompanied by associated features such as nausea or vomiting, photophobia, or phonophobia. The International Headache Society criteria for migraine without aura include at least five attacks fulfilling specific criteria.
Understanding the different types of headaches and their characteristics can help in proper diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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Question 65
Incorrect
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A 65-year-old man comes to your clinic complaining of progressive slurred speech over the past few months. He is embarrassed because he frequently gives presentations for work and some people have joked that he sounds drunk. Upon examination, there is no droop or drooling in his head and face, but he struggles to articulate certain phrases and has difficulty swallowing. His tongue also appears to fasciculate when he sticks it out. In addition, there is mild weakness and hypotonia in his limbs, but his knees and ankles have slight hyperreflexia. What is the most likely cause of his symptoms?
Your Answer: A 'missed' stroke
Correct Answer: Motor neurone disease
Explanation:The presence of fasciculations, along with upper and lower motor neurone signs, strongly suggests motor neuron disease as the underlying condition. The patient’s difficulty with speech and swallowing may be due to bulbar palsy, which is commonly associated with this disease. A stroke, which typically presents with sudden onset of symptoms, is unlikely to be the cause of the patient’s progressive symptoms over weeks or months. While a cerebellar tumour may cause slurred speech, it would typically be accompanied by other symptoms such as ataxia, vertigo, and difficulty with basic movements. Multiple sclerosis is an uncommon diagnosis in late-middle-aged men and is an upper motor neurone disease, whereas this patient has a combination of upper and lower motor neurone signs. There is no evidence of tremor or bradykinesia in this case.
Understanding Motor Neuron Disease: Signs and Diagnosis
Motor neuron disease is a neurological condition that affects both upper and lower motor neurons. It is a rare condition that usually presents after the age of 40 and can manifest in different patterns such as amyotrophic lateral sclerosis, progressive muscular atrophy, and bulbar palsy. The diagnosis of motor neuron disease is based on clinical features, including the presence of fasciculations, the absence of sensory signs, and the combination of upper and lower motor neuron signs. Wasting of the small hand muscles and tibialis anterior is also common.
Other features that can help diagnose motor neuron disease include the absence of external ocular muscle involvement, the absence of cerebellar signs, and preserved abdominal reflexes. Sphincter dysfunction, if present, is usually a late feature. While vague sensory symptoms may occur early in the disease, sensory signs are typically absent.
Nerve conduction studies can help exclude a neuropathy, while electromyography shows a reduced number of action potentials with increased amplitude. MRI is usually performed to exclude other conditions such as cervical cord compression and myelopathy. Understanding the signs and diagnosis of motor neuron disease is crucial for early detection and management of the condition.
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This question is part of the following fields:
- Neurology
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Question 66
Incorrect
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You are conducting a neurological examination on a thirty-five-year-old patient who presents with recent onset of blurred vision, speech disturbance, pronounced reflexes, and upward plantars upon attempting the Babinski reflex. The patient denies any history of headache and fundoscopy reveals normal findings. What is the probable diagnosis?
Your Answer: Poliomyelitis
Correct Answer: Multiple sclerosis
Explanation:The presence of Babinski sign suggests the presence of a condition affecting the upper motor neurons. When the sole of the foot is stimulated with a blunt object, an atypical reflex is observed where the toes move upwards.
When ankle jerks are absent and extensor plantars are present, it is usually due to a lesion that affects both the upper and lower motor neurons. This can be caused by various conditions such as subacute combined degeneration of the cord, motor neuron disease, Friedreich’s ataxia, syringomyelia, taboparesis (syphilis), or a lesion in the conus medullaris. These conditions can lead to a loss of reflexes in the ankle and a specific type of reflex in the foot that indicates damage to both the upper and lower motor neurons. It is important to identify the underlying cause of these symptoms in order to provide appropriate treatment and management.
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This question is part of the following fields:
- Neurology
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Question 67
Correct
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An 88-year-old woman visits her doctor with her daughter. She was diagnosed with Alzheimer's dementia two years ago and has recently moved in with her daughter for care. Lately, she has become increasingly isolated and has reported seeing animals in the house that are not actually there. She denies any other symptoms. All vital signs are normal and physical examination is unremarkable.
What is the probable cause of her current symptoms?Your Answer: Delirium
Explanation:Cognitively impaired patients can experience delirium when placed in new surroundings. Even minor changes in environment can trigger delirium in individuals with dementia, leading to visual hallucinations. While community-acquired pneumonia and urinary tract infections are common causes of delirium in the elderly, they seem unlikely in this case as there are no other clues in the history or examination. Depression is a common differential for dementia in the elderly, but the acute onset of symptoms in this woman suggests delirium. It is important to note that symptoms of depression in the elderly can be non-specific. While psychosis could explain the visual hallucinations, the absence of other symptoms and the acute onset of the condition suggest delirium.
Acute confusional state, also known as delirium or acute organic brain syndrome, is a condition that affects up to 30% of elderly patients admitted to hospital. It is more common in patients over the age of 65, those with a background of dementia, significant injury, frailty or multimorbidity, and those taking multiple medications. The condition is often triggered by a combination of factors, such as infection, metabolic imbalances, change of environment, and underlying medical conditions.
The symptoms of acute confusional state can vary widely, but may include memory disturbances, agitation or withdrawal, disorientation, mood changes, visual hallucinations, disturbed sleep, and poor attention. Treatment involves identifying and addressing the underlying cause, modifying the patient’s environment, and using sedatives such as haloperidol or olanzapine. However, managing the condition can be challenging in patients with Parkinson’s disease, as antipsychotics can worsen Parkinsonian symptoms. In such cases, careful reduction of Parkinson medication may be helpful, and atypical antipsychotics such as quetiapine and clozapine may be preferred for urgent treatment.
Overall, acute confusional state is a complex condition that requires careful management and individualized treatment. By addressing the underlying causes and providing appropriate sedation, healthcare professionals can help patients recover from this condition and improve their overall quality of life.
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This question is part of the following fields:
- Neurology
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Question 68
Incorrect
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A 50-year-old female patient arrives at the emergency department via ambulance after experiencing a sudden onset of facial droop and speech impairment. Upon examination, she is conscious but displays both expressive and receptive aphasia. The patient's GP summary record indicates that she is only taking tamoxifen. Based on this information, what is the most probable medical condition in her past medical history?
Your Answer: Oestrogen receptor-positive endometrial cancer
Correct Answer: Oestrogen receptor-positive breast cancer
Explanation:Pre-menopausal women with oestrogen receptor-positive breast cancer are managed using Tamoxifen.
Tamoxifen is ineffective in treating oestrogen receptor-negative breast cancer or ovarian cancer.
However, Tamoxifen may increase the risk of endometrial cancer.
Colorectal cancer is not treated with Tamoxifen.Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen can cause adverse effects such as menstrual disturbance, hot flushes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors can cause adverse effects such as osteoporosis, hot flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.
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This question is part of the following fields:
- Neurology
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Question 69
Incorrect
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A 6-year-old girl has a 2-year history of progressive weakness, finding it more difficult to stand from a sitting position at home and climb stairs at school. She had measles when she was 3-years-old and received all her childhood immunisations as normal. Apparently, her maternal grandmother suffered from a similar condition but died in a car accident at the age of 28. On examination, the girl is of normal height and appearance. Cranial nerves and higher mental function are normal. She has normal tone and reflexes in her limbs, with weakness proximally in her arms and legs. On repeated stimulation, there is no change. Cranial nerve and sensory examinations are entirely normal.
Which of the following is the most likely diagnosis?Your Answer: Limb-girdle muscular dystrophy (LGMD)
Correct Answer: Becker’s muscular dystrophy
Explanation:The patient is likely suffering from Becker’s muscular dystrophy, a milder form of the condition compared to Duchenne muscular dystrophy (DMD). Both conditions are caused by mutations in the DMD gene, but Becker’s tends to present later in childhood or adolescence with slower progression of symptoms. The patient’s normal childhood development followed by slow onset of proximal weakness fits the typical picture of Becker’s. Limb-girdle muscular dystrophy (LGMD) is a possibility, but less likely given the patient’s presentation. DMD is unlikely as it typically presents in early childhood with rapid progression of symptoms. Facioscapulohumeral dystrophy is characterized by weakness and wasting of the face, scapula, and upper arms, and would not typically present with gait disturbance or lower limb weakness in childhood. Myasthenia gravis is also unlikely given the patient’s history.
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This question is part of the following fields:
- Neurology
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Question 70
Incorrect
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A 50-year-old woman presents with a two-month history of neck and right arm pain, which is exacerbated by neck flexion. She has a medical history of knee osteoarthritis, obesity, and depression. Upon examination, there is no apparent muscle weakness or atrophy in the right arm, but there is some sensory loss in the middle finger and palm of the hand. Which nerve root is most likely to be affected by the impingement?
Your Answer: C5
Correct Answer: C7
Explanation:Understanding Dermatomes: Major Landmarks and Mnemonics
Dermatomes are areas of skin that are innervated by a single spinal nerve. Understanding dermatomes is important in diagnosing and treating various neurological conditions. The major dermatome landmarks are listed, along with helpful mnemonics to remember them.
Starting from the top of the body, the C2 dermatome covers the posterior half of the skull, resembling a cap. Moving down to C3, it covers the area of a high turtleneck shirt. C4 covers the area of a low-collar shirt. The C5 dermatome runs along the ventral axial line of the upper limb, while C6 covers the thumb and index finger. To remember this, make a 6 with your left hand by touching the tip of the thumb and index finger together.
Moving down to C7, it covers the middle finger and palm of the hand. C8 covers the ring and little finger. The T4 dermatome covers the area of the nipples, while T5 covers the inframammary fold. T6 covers the xiphoid process, and T10 covers the umbilicus. To remember this, think of BellybuT-TEN.
The L1 dermatome covers the inguinal ligament, which can be remembered by thinking of L for ligament, 1 for 1nguinal. L4 covers the knee caps, and to remember this, think of being down on all fours. L5 covers the big toe and dorsum of the foot (except the lateral aspect), and can be remembered by thinking of it as the largest of the five toes. Finally, the S1 dermatome covers the lateral foot and small toe, while S2 and S3 cover the genitalia.
Understanding dermatomes and their landmarks can aid in diagnosing and treating various neurological conditions. The mnemonics provided can help in remembering these important landmarks.
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This question is part of the following fields:
- Neurology
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Question 71
Incorrect
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A 75-year-old male has two episodes of weakness affecting the right arm and leg each lasting ten minutes, both within the space of 2 days. He did not attend the emergency department after the first episode. His only significant past medical history is hypertension, for which he takes amlodipine 5mg OD. He has experienced one similar episode to this one year ago, but did not seek medical attention. His son is present who informs you that the patient has lost a significant amount of weight in the last year. On further questioning, he reports some haemoptysis lately. His blood pressure in the department was 170/90 mmHg initially.
His bloods reveal:
Hb 115 g/l
Platelets 149 * 109/l
WBC 13.1 * 109/l
Na+ 132 mmol/l
K+ 5.3 mmol/l
Creatinine 111 µmol/l
CRP 15 mg/l
ECG: Sinus tachycardia, rate 104/min
What is the most appropriate management for this gentleman?Your Answer: Reassure and discharge
Correct Answer: Admit for CT head + aspirin
Explanation:This question assesses the candidate’s understanding of TIA risk stratification. The individual meets the criteria for crescendo TIAs, having experienced two TIAs within a week. This necessitates prompt evaluation and imaging. Admission is recommended for any patient with a score of more than 4 on the ABCD2 scale or crescendo TIA.
A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, and sudden transient loss of vision in one eye (amaurosis fugax).
NICE recommends immediate antithrombotic therapy with aspirin 300 mg unless the patient has a bleeding disorder or is taking an anticoagulant. If the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis, specialist review is necessary. Urgent assessment is required within 24 hours for patients who have had a suspected TIA in the last 7 days. Referral for specialist assessment is necessary as soon as possible within 7 days for patients who have had a suspected TIA more than a week previously. Neuroimaging and carotid imaging are recommended, and antithrombotic therapy is necessary. Carotid artery endarterectomy should only be considered if the carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 72
Incorrect
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A 32-year-old woman complains of pressure-type headache and brief visual disturbance upon standing.
What is the most indicative feature that supports the diagnosis of idiopathic intracranial hypertension (IIH)?Your Answer: Past history of deep venous thrombosis
Correct Answer: An enlarged blind spot and constriction of the visual field
Explanation:Understanding the Symptoms of Idiopathic Intracranial Hypertension (IIH)
Idiopathic Intracranial Hypertension (IIH) is a headache syndrome that is characterized by raised cerebrospinal fluid pressure in the absence of an intracranial mass lesion or ventricular dilatation. While IIH is associated with visual field defects, reduced visual acuity is not a common presenting feature. Instead, an enlarged blind spot and constriction of the visual field are the classic findings in a patient with papilloedema. Additionally, IIH does not typically present with motor weakness or a raised erythrocyte sedimentation rate (ESR).
It is important to note that a past history of deep venous thrombosis or lateralized motor weakness would raise suspicions about the possibility of cranial venous thrombosis, which can also cause raised intracranial pressure and papilloedema. Reduced visual acuity, on the other hand, is more consistent with an optic nerve lesion such as optic neuritis.
In summary, understanding the symptoms of IIH can help healthcare professionals differentiate it from other conditions and provide appropriate treatment.
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This question is part of the following fields:
- Neurology
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Question 73
Incorrect
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A 62-year-old man has been referred due to a tremor and bradykinesia, leading to a diagnosis of Parkinson's disease. These symptoms are now interfering with his work as an accountant and overall quality of life. What initial treatment is he likely to receive?
Your Answer: Dopamine agonist
Correct Answer: Levodopa
Explanation:Patients with newly diagnosed Parkinson’s who experience motor symptoms that negatively impact their quality of life should be provided with levodopa.
Management of Parkinson’s Disease: Medications and Considerations
Parkinson’s disease is a complex condition that requires specialized expertise in movement disorders for diagnosis and management. However, all healthcare professionals should be familiar with the medications used to treat Parkinson’s disease due to its prevalence. The National Institute for Health and Care Excellence (NICE) published guidelines in 2017 to aid in the management of Parkinson’s disease.
For first-line treatment, levodopa is recommended if motor symptoms are affecting the patient’s quality of life. If motor symptoms are not affecting the patient’s quality of life, dopamine agonists (non-ergot derived), levodopa, or monoamine oxidase B (MAO-B) inhibitors may be used. NICE provides tables to aid in decision-making regarding the use of these medications, taking into account their effects on motor symptoms, activities of daily living, motor complications, and adverse events.
If a patient continues to have symptoms despite optimal levodopa treatment or has developed dyskinesia, NICE recommends the addition of a dopamine agonist, MAO-B inhibitor, or catechol-O-methyl transferase (COMT) inhibitor as an adjunct. Other considerations in Parkinson’s disease management include the risk of acute akinesia or neuroleptic malignant syndrome if medication is not taken or absorbed, the potential for impulse control disorders with dopaminergic therapy, and the need to adjust medication if excessive daytime sleepiness or orthostatic hypotension develops.
Specific medications used in Parkinson’s disease management include levodopa, dopamine receptor agonists, MAO-B inhibitors, amantadine, COMT inhibitors, and antimuscarinics. Each medication has its own set of benefits and potential adverse effects, which should be carefully considered when selecting a treatment plan. Overall, the management of Parkinson’s disease requires a comprehensive approach that takes into account the individual needs and circumstances of each patient.
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This question is part of the following fields:
- Neurology
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Question 74
Incorrect
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A 55 year old male is brought to the emergency department by his wife after falling down a flight of 12 stairs at home and hitting his head. Despite his wife's concerns, the patient does not believe he needs medical attention. He denies experiencing any headache, nausea, vomiting, seizures, or loss of consciousness. He is not taking any regular medications, including anticoagulants, and can recall the entire incident except for a 30-second period after landing at the bottom of the stairs. Upon examination, there is no limb weakness or loss of sensation, and his pupils are equal and reactive bilaterally. What is the most appropriate course of action?
Your Answer: Discharge, outpatient CT head within 72 hours
Correct Answer: CT head within 8 hours of injury
Explanation:The patient experienced a fall caused by a mechanical issue, with a potentially harmful mechanism of injury.
NICE Guidelines for Investigating Head Injuries in Adults
Head injuries can be serious and require prompt medical attention. The National Institute for Health and Care Excellence (NICE) has provided clear guidelines for healthcare professionals to determine which adult patients need further investigation with a CT head scan. Patients who require immediate CT head scans include those with a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment, suspected open or depressed skull fractures, signs of basal skull fractures, post-traumatic seizures, focal neurological deficits, and more than one episode of vomiting.
For patients with any loss of consciousness or amnesia since the injury, a CT head scan within 8 hours is recommended for those who are 65 years or older, have a history of bleeding or clotting disorders, experienced a dangerous mechanism of injury, or have more than 30 minutes of retrograde amnesia of events immediately before the head injury. Additionally, patients on warfarin who have sustained a head injury with no other indications for a CT head scan should also receive a scan within 8 hours of the injury.
It is important for healthcare professionals to follow these guidelines to ensure that patients receive appropriate and timely care for their head injuries. By identifying those who require further investigation, healthcare professionals can provide the necessary treatment and support to prevent further complications and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 75
Incorrect
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A 32-year-old woman presents for follow-up regarding her frequent migraine attacks. Despite taking a combination of paracetamol and ibuprofen, she has not experienced significant relief. Her current medications include as-needed paracetamol and ibuprofen, as well as Cerazette, a progestogen-only pill. What is the most suitable medication to consider for reducing the frequency of her migraines?
Your Answer: Amitriptyline
Correct Answer: Propranolol
Explanation:For women of childbearing age who suffer from migraines, propranolol is a better option than topiramate. This is because NICE recommends both drugs for migraine prophylaxis, but the combined oral contraceptive pill cannot be used due to the patient’s migraine history. While zolmitriptan can be used to stop attacks, it is not effective for prophylaxis.
Managing Migraines: Guidelines and Treatment Options
Migraines can be debilitating and affect a significant portion of the population. To manage migraines, it is important to understand the different treatment options available. According to the National Institute for Health and Care Excellence (NICE) guidelines, acute treatment for migraines involves a combination of an oral triptan and an NSAID or paracetamol. For young people aged 12-17 years, a nasal triptan may be preferred. If these measures are not effective, non-oral preparations of metoclopramide or prochlorperazine may be considered, along with a non-oral NSAID or triptan.
Prophylaxis should be given if patients are experiencing two or more attacks per month. NICE recommends topiramate or propranolol, depending on the patient’s preference, comorbidities, and risk of adverse events. Propranolol is preferred in women of childbearing age as topiramate may be teratogenic and reduce the effectiveness of hormonal contraceptives. Acupuncture and riboflavin may also be effective in reducing migraine frequency and intensity for some people. For women with predictable menstrual migraines, frovatriptan or zolmitriptan may be recommended as a type of mini-prophylaxis.
Specialists may consider other treatment options, such as candesartan or monoclonal antibodies directed against the calcitonin gene-related peptide (CGRP) receptor, like erenumab. However, pizotifen is no longer recommended due to common adverse effects like weight gain and drowsiness. It is important to exercise caution with young patients as acute dystonic reactions may develop. By following these guidelines and considering various treatment options, migraines can be effectively managed.
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This question is part of the following fields:
- Neurology
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Question 76
Correct
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A 42-year-old woman presents with a foot drop after a fall at home. On examination, there is weakness of ankle dorsiflexion and inversion, and weakness of extension of the little toe. She has some sensory loss restricted to the dorsum of her foot and medial side of the affected leg. Other examination is within normal limits.
Which of the following is the most likely site of the lesion?Your Answer: Common peroneal nerve at the head of the fibula
Explanation:Nerve Injuries and Clinical Features: A Guide
The human body is a complex system of nerves and muscles, and injuries to these structures can have a significant impact on daily life. Here is a guide to some common nerve injuries and their associated clinical features.
Common Peroneal Nerve at the Head of the Fibula
The common peroneal nerve is often damaged as it wraps around the fibular head. This can result in foot drop, weak dorsiflexion and eversion of the foot, weak extension of the toes, sensory loss over the dorsum of the foot and lateral side of the leg, and intact reflexes.Common Peroneal Nerve at the Ankle
The common peroneal nerve bifurcates into two terminal branches shortly after passing over the fibular head. Damage to one of these branches can occur at the ankle, but not to the common peroneal nerve itself. Symptoms may include sensory loss and weakness in the affected area.Sciatic Nerve at the Sciatic Notch
Injury to the sciatic nerve at this level can result in pain down the thigh, loss of sensation to the whole leg below the knee (except for a narrow area on the medial leg and medial foot border), widespread motor deficit, and foot drop. The ankle jerk is lost.Tibial Nerve at the Popliteal Fossa
Damage to the tibial nerve at this level can lead to gastrocnemius paralysis, weakened inversion and plantar flexion at the ankle, and loss of the ankle jerk. This type of injury is relatively uncommon.Tibial Nerve at the Ankle
Compression of the tibial nerve at the level of the medial malleolus can result in tarsal tunnel syndrome. Symptoms may include paraesthesiae or numbness affecting the medial ankle and plantar aspect of the foot, weakness to the toe abductors and flexors, and tenderness at the medial malleolus. Foot drop is not a feature.In summary, nerve injuries can have a range of clinical features depending on the location and severity of the damage. It is important to seek medical attention if you suspect you have sustained a nerve injury.
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This question is part of the following fields:
- Neurology
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Question 77
Incorrect
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A 65-year-old woman with suspected dementia is referred by her General Practitioner to the Memory Clinic. A dementia blood screen is performed and is normal.
What is an indication for performing structural neuroimaging (CT or MRI head) in the workup for investigating patients with dementia?
Your Answer: Patient is > 75-years old
Correct Answer: Ruling out reversible causes of cognitive decline
Explanation:The Importance of Neuroimaging in the Diagnosis of Dementia
Neuroimaging plays a crucial role in the diagnosis of dementia and ruling out reversible causes of cognitive decline. Structural imaging should be offered to assist with subtype diagnosis and exclude other reversible conditions unless dementia is well established and the subtype is clear. In primary care, a blood screen is usually sent to exclude reversible causes, while in secondary care, neuroimaging is performed to provide information on aetiology to guide prognosis and management. Focal neurology and cardiovascular abnormalities are not indications for performing structural imaging of the brain. However, neuroimaging is required in the workup of dementia in all age groups, including patients over 75 years old and those under 65 years old with suspected early-onset dementia. The 2011 National Institute for Health and Care Excellence (NICE) guidelines state that structural imaging is essential in the investigation of dementia.
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This question is part of the following fields:
- Neurology
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Question 78
Incorrect
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A 25-year-old man visits his GP with complaints of leg weakness after laughing with his friends. His friends also reported a brief collapse during a similar episode. What is the probable diagnosis?
Your Answer: Absence seizure
Correct Answer: Cataplexy
Explanation:Understanding Cataplexy
Cataplexy is a condition characterized by a sudden and temporary loss of muscle control triggered by intense emotions such as laughter or fear. It is commonly associated with narcolepsy, with around two-thirds of patients experiencing cataplexy. The symptoms of cataplexy can vary from mild buckling of the knees to complete collapse.
This condition can be debilitating and can significantly impact a person’s quality of life. It can also be challenging to diagnose, as the symptoms can be mistaken for other conditions such as seizures or fainting spells. Treatment options for cataplexy include medication and lifestyle changes, such as avoiding triggers that can cause emotional responses.
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This question is part of the following fields:
- Neurology
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Question 79
Incorrect
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A 55-year-old male carpenter visits the GP clinic complaining of right foot drop. He has a medical history of type 2 diabetes mellitus and hypertension. During the examination, the doctor observed weakness in the right foot dorsiflexion and eversion. The patient also reported sensory loss on the dorsum of the right foot and lower lateral part of the right leg. No other neurological deficits were detected. What is the probable diagnosis?
Your Answer: L5 nerve root compression
Correct Answer: Common peroneal nerve palsy
Explanation:The patient is likely suffering from common peroneal nerve palsy, which may be caused by diabetes. This condition can result in weakness of foot dorsiflexion and foot eversion. L5 nerve root compression is a possible cause of foot drop, but it does not lead to weakness of foot eversion, so it is not the correct option. Sciatic nerve palsy can also cause foot drop, but it can also affect other nerves, resulting in weakness of foot plantar flexion and sensory loss of the sole of the foot, which is not present in this case. Stroke is a central cause of foot drop, but the absence of upper motor neuron signs suggests common peroneal nerve pathology is more likely. Polyneuropathy involves multiple nerves, so it is not the correct option.
Understanding Common Peroneal Nerve Lesion
A common peroneal nerve lesion is a type of nerve injury that often occurs at the neck of the fibula. This nerve is a branch of the sciatic nerve, which divides into the tibial and common peroneal nerves. The most notable symptom of this type of nerve damage is foot drop, which is characterized by weakness or paralysis of the muscles that lift the foot.
In addition to foot drop, other symptoms of a common peroneal nerve lesion may include weakness in foot dorsiflexion and eversion, as well as the extensor hallucis longus muscle. Sensory loss may also occur over the dorsum of the foot and the lower lateral part of the leg, and there may be wasting of the anterior tibial and peroneal muscles.
Overall, understanding the symptoms of a common peroneal nerve lesion can help individuals recognize and seek treatment for this type of nerve injury. With proper care and management, it may be possible to improve symptoms and prevent further damage to the affected nerve.
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This question is part of the following fields:
- Neurology
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Question 80
Correct
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A client is observed to have a missing triceps reflex. To which nerve root does this correspond?
Your Answer: C7-C8
Explanation:Understanding Common Reflexes
Reflexes are automatic responses of the body to certain stimuli. These responses are controlled by the nervous system and do not require conscious thought. Common reflexes include the ankle reflex, knee reflex, biceps reflex, and triceps reflex. Each reflex is associated with a specific root in the spinal cord.
The ankle reflex is associated with the S1-S2 root, which is located in the lower part of the spinal cord. This reflex is elicited by tapping the Achilles tendon with a reflex hammer. The resulting contraction of the calf muscle indicates the integrity of the spinal cord and the peripheral nerves.
The knee reflex is associated with the L3-L4 root, which is located in the middle part of the spinal cord. This reflex is elicited by tapping the patellar tendon with a reflex hammer. The resulting contraction of the quadriceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The biceps reflex is associated with the C5-C6 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the biceps tendon with a reflex hammer. The resulting contraction of the biceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
The triceps reflex is associated with the C7-C8 root, which is located in the upper part of the spinal cord. This reflex is elicited by tapping the triceps tendon with a reflex hammer. The resulting contraction of the triceps muscle indicates the integrity of the spinal cord and the peripheral nerves.
Understanding these common reflexes can help healthcare professionals diagnose and treat various neurological conditions. By testing these reflexes, they can determine if there is any damage or dysfunction in the nervous system.
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This question is part of the following fields:
- Neurology
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Question 81
Correct
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A 60-year-old woman comes to the clinic complaining of a gradual loss of hearing and ringing in her right ear for the past 4 weeks. Upon examination, her ear canal and tympanic membrane appear normal. Rinne's test shows air conduction is better than bone conduction on both sides, but Weber's test reveals that the sound is heard best in her left ear. What is the probable diagnosis?
Your Answer: Acoustic neuroma
Explanation:Understanding Vestibular Schwannoma (Acoustic Neuroma)
Vestibular schwannoma, also known as acoustic neuroma, is a type of brain tumor that accounts for 5% of intracranial tumors and 90% of cerebellopontine angle tumors. The condition is characterized by a combination of symptoms such as vertigo, hearing loss, tinnitus, and an absent corneal reflex. The affected cranial nerves can predict the features of the condition. For instance, cranial nerve VIII can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. On the other hand, cranial nerve V can lead to an absent corneal reflex, while cranial nerve VII can cause facial palsy.
Bilateral vestibular schwannomas are often seen in neurofibromatosis type 2. The diagnosis of vestibular schwannoma is made through an MRI of the cerebellopontine angle, and audiometry is also important since only 5% of patients have a normal audiogram.
The management of vestibular schwannoma involves surgery, radiotherapy, or observation. The choice of treatment depends on the size and location of the tumor, the patient’s age and overall health, and the severity of symptoms. In conclusion, understanding vestibular schwannoma is crucial in managing the condition effectively.
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This question is part of the following fields:
- Neurology
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Question 82
Incorrect
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A 60-year-old man presents to his GP with a three month history of intermittent pain and numbness in his fourth and fifth fingers.
Which of the following is the most likely cause of his symptoms?Your Answer: Radial nerve palsy
Correct Answer: Ulnar nerve entrapment
Explanation:Common Hand and Wrist Conditions: Symptoms and Characteristics
Ulnar Nerve Entrapment
Ulnar neuropathy is a common condition where the ulnar nerve is compressed at or near the elbow. Patients experience numbness and tingling in the fifth finger and ulnar half of the fourth finger, along with weakness of grip and potential muscle wasting. In severe cases, a claw hand deformity may occur.De Quervain’s Tenosynovitis
Also known as mother’s wrist, this condition is caused by tendinitis in the tendons of the first dorsal compartment of the wrist. Patients experience pain during thumb and wrist movement, along with tenderness and thickening at the radial styloid. Finkelstein’s test causes sharp pain at the first dorsal compartment, and a prominent radial styloid may be visible. There is no associated sensory loss.Carpal Tunnel Syndrome
This condition occurs when the median nerve is compressed as it passes through the carpal tunnel at the wrist. Symptoms include numbness and tingling in the thumb and radial fingers, aching and pain in the anterior wrist and forearm, and potential weakness and clumsiness in the hand. Risk factors include female sex, pregnancy, hypothyroidism, connective tissue disease, obesity, trauma, dialysis, and repetitive stress.Dupuytren’s Contracture
This progressive fibrous tissue contracture of the palmar fascia mainly affects men over 40 with a family history. Patients experience difficulty with manual dexterity, palmar nodules, and eventually flexion contractures in the fourth and fifth fingers. There is no sensory deficit. Risk factors include smoking, alcohol, heavy manual labor, trauma, and diabetes.Radial Nerve Palsy
Radial nerve palsy results in wrist drop and loss of triceps reflex, along with potential sensory loss in the dorsal thumb and forearm. The radial nerve does not supply sensory innervation to the fourth and fifth fingers. -
This question is part of the following fields:
- Neurology
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Question 83
Incorrect
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A 70-year-old man has been admitted to the stroke ward due to experiencing dense right-sided weakness and facial droop. The stroke team has treated him for an acute stroke, and he has been making good progress with the help of the physiotherapy and occupational therapy team. Although the CT head did not reveal any abnormalities, the team has arranged for an MRI head and a Doppler ultrasound of the carotid arteries. The MRI head has shown a left-sided infarct, and the carotid doppler has revealed severe stenosis of the left carotid artery. What should be the next appropriate plan for the stroke team?
Your Answer: Continue with rehabilitation only
Correct Answer: Refer to the vascular surgeons for consideration of carotid artery endarterectomy
Explanation:If a patient experiences a stroke or TIA in the carotid territory and is not severely disabled, carotid artery endarterectomy may be a viable option. Additionally, if the patient is making positive strides with physiotherapy and has significant carotid stenosis, they should be evaluated by the surgical team for potential endarterectomy. At this time, there is no need for involvement from the cardiology team as it is unclear what cardiac investigations have already been conducted. An MRI of the C-spine would not provide any additional information for the management plan, and there is no indication for repeat blood tests.
The Royal College of Physicians (RCP) and NICE have published guidelines on the diagnosis and management of patients following a stroke. The management of acute stroke includes maintaining normal levels of blood glucose, hydration, oxygen saturation, and temperature. Blood pressure should not be lowered in the acute phase unless there are complications. Aspirin should be given as soon as possible if a haemorrhagic stroke has been excluded. Anticoagulants should not be started until brain imaging has excluded haemorrhage. Thrombolysis with alteplase should only be given if administered within 4.5 hours of onset of stroke symptoms and haemorrhage has been definitively excluded. Mechanical thrombectomy is a new treatment option for patients with an acute ischaemic stroke. NICE recommends thrombectomy for people who have acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography or magnetic resonance angiography. Secondary prevention includes the use of clopidogrel and dipyridamole. Carotid artery endarterectomy should only be considered if carotid stenosis is greater than 70% according to ECST criteria or greater than 50% according to NASCET criteria.
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This question is part of the following fields:
- Neurology
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Question 84
Incorrect
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A 68-year-old woman is brought to her General Practitioner by her daughter who is concerned that she has been experiencing a few falls recently. She reveals that she has been getting confused and forgetful for the past two weeks. She has been complaining of dizziness and has vomited on a couple of occasions in the same time period. Her past medical history includes type 2 diabetes, hypertension and osteoporosis.
Which of the following is the most likely diagnosis?
Your Answer: Extradural haemorrhage
Correct Answer: Chronic subdural haematoma (SDH)
Explanation:Differentiating between types of intracranial hemorrhage
Intracranial hemorrhage can have various causes and presentations. Here are some key points to differentiate between different types of intracranial hemorrhage:
Chronic subdural hematoma (SDH): This type of hemorrhage can be spontaneous or caused by head trauma. Symptoms tend to develop gradually and may fluctuate. They include headache, vomiting, personality changes, memory disturbances, and loss of consciousness. Patients with a history of AF and recurrent falls are at high risk of developing a chronic SDH.
Subarachnoid hemorrhage (SAH): This type of hemorrhage occurs when blood accumulates in the space between the arachnoid and pia mater. The most common cause is rupture of a Berry aneurysm in the Circle of Willis. The classical presentation of SAH is a sudden-onset, severe ‘thunderclap’ headache often accompanied by vomiting and meningism. The presentation is usually acute.
Acute subdural hematoma (SDH): This type of hemorrhage occurs due to tearing of cortical bridging veins leading to bleeding into the subdural space. An acute SDH usually follows a significant head injury. Loss of consciousness may occur immediately or a few hours after the injury.
Extradural hemorrhage: This type of hemorrhage is caused by the rupture of one of the meningeal arteries that run between the dura and the skull. It usually occurs following a significant head injury often in younger patients. There is classically a lucid interval following the injury, followed several hours later by rapid deterioration resulting in loss of consciousness.
Ischemic cerebrovascular accident (CVA): This type of event occurs due to a lack of blood flow to the brain. Patients with risk factors such as AF and hypertension are at higher risk. Classical CVA symptoms include sudden-onset unilateral weakness, speech difficulties, or visual loss which do not resolve within 24 hours. However, the patient’s symptoms in this case are not typical for a CVA.
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This question is part of the following fields:
- Neurology
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Question 85
Correct
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A 32-year-old accountant presents with a sudden onset of a crooked smile. He reports experiencing some discomfort behind his ear but otherwise feels fine. Upon examination, a left-sided facial nerve palsy is observed, affecting the face from forehead to chin. Both tympanic membranes appear normal.
What is the probable cause of this condition?Your Answer: Bell’s palsy
Explanation:Understanding Bell’s Palsy: Symptoms, Diagnosis, and Management
Bell’s palsy is a temporary paralysis of the facial nerve that typically presents with facial weakness, pain behind the ear, earache, aural fullness, or facial palsy. It is caused by a unilateral, lower motor neuron lesion, affecting the muscles controlling facial expression on one side only. The forehead is involved in Bell’s palsy, unlike in upper motor neuron lesions such as a cerebrovascular accident.
Other conditions that may present with similar symptoms include Ramsey Hunt syndrome, which is associated with severe pain and caused by herpes zoster virus, and transient ischaemic attack/stroke, which is the sudden onset of focal neurological signs that completely resolve within 24 hours.
Syphilis and vasculitis are not typically associated with Bell’s palsy. Syphilis has various stages, with primary syphilis presenting with a chancre and secondary syphilis characterized by multi-system involvement. Vasculitis has many different types, including Churg–Strauss syndrome, temporal arteritis, granulomatosis with polyangiitis, Henloch–Schönlein purpura, and polymyalgia rheumatica.
Management of Bell’s palsy includes reassurance and meticulous eye care to prevent complications such as corneal abrasions. Oral corticosteroids, such as prednisolone, are effective if given within 72 hours of onset. Understanding the symptoms, diagnosis, and management of Bell’s palsy is crucial for prompt and effective treatment.
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This question is part of the following fields:
- Neurology
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Question 86
Incorrect
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A 75-year-old man presented to the eye clinic with double vision. He has been experiencing this for the past few weeks. During examination, it was observed that he had horizontal diplopia and slight limitation of one of the extraocular muscles in his left eye. The patient has a medical history of hypertension and prostate cancer. Brain imaging revealed a metastatic lesion in the clivus that surrounds the cavernous sinus and carotid artery. Which cranial nerve palsy is responsible for the diplopia in this patient?
Your Answer: Left third cranial nerve (CN3) palsy
Correct Answer: Left sixth cranial nerve (CN6) palsy
Explanation:Understanding the 12 Cranial Nerves and their Functions
The human body has 12 pairs of cranial nerves that originate from the brainstem and control various functions such as movement, sensation, and reflexes. Each nerve has a specific function and pathway, and damage to any of these nerves can result in various clinical symptoms.
Some of the important functions of these nerves include smell (olfactory nerve), sight (optic nerve), eye movement (oculomotor, trochlear, and abducens nerves), facial sensation and mastication (trigeminal nerve), facial movement and taste (facial nerve), hearing and balance (vestibulocochlear nerve), taste and swallowing (glossopharyngeal nerve), phonation and innervation of viscera (vagus nerve), head and shoulder movement (accessory nerve), and tongue movement (hypoglossal nerve).
In addition to their primary functions, some of these nerves also play a role in various reflexes such as the corneal reflex, jaw jerk reflex, gag reflex, carotid sinus reflex, pupillary light reflex, and lacrimation reflex. Understanding the functions and pathways of these cranial nerves is essential for diagnosing and treating various neurological conditions.
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This question is part of the following fields:
- Neurology
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Question 87
Incorrect
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A 38-year-old woman comes to you with a sudden onset of right-sided facial weakness, which appears to be a lower motor neuron palsy. There are no other neurological symptoms on examination, and her ears appear normal. You diagnose her with Bell's palsy and prescribe prednisolone. What is the crucial next step in managing her condition?
Your Answer: Prescribe aciclovir
Correct Answer: Prescribe artifical tears and advise eye taping at night
Explanation:Understanding Bell’s Palsy
Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It is more common in individuals aged 20-40 years and pregnant women. The condition is characterized by lower motor neuron facial nerve palsy, which affects the forehead. Unlike upper motor neuron lesions, the upper face is spared. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.
The management of Bell’s palsy has been a subject of debate. However, it is now widely accepted that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, but it may be beneficial for severe facial palsy. Eye care is also crucial to prevent exposure keratopathy, and patients should be prescribed artificial tears and eye lubricants. If they are unable to close their eyes at bedtime, they should tape them closed using microporous tape.
If the paralysis shows no sign of improvement after three weeks, an urgent referral to ENT is necessary. Patients with long-standing weakness may require a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within 3-4 months. However, untreated patients may experience permanent moderate to severe weakness in around 15% of cases.
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This question is part of the following fields:
- Neurology
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Question 88
Incorrect
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A mother brings her 8-year-old son into surgery. He has been experiencing recurrent headaches. What is the most common feature of migraine in children?
Your Answer: Good response to metoclopramide
Correct Answer: Gastrointestinal disturbance
Explanation:Children with migraine often experience nausea, vomiting, and abdominal pain.
Diagnostic Criteria for Migraine
Migraine is a neurological disorder that affects millions of people worldwide. The International Headache Society has established diagnostic criteria for migraine without aura, which includes at least five attacks lasting between 4-72 hours and having at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by routine physical activity. During the headache, there must be at least one of the following: nausea and/or vomiting, photophobia, and phonophobia. The headache cannot be attributed to another disorder.
Migraine with aura, which is seen in around 25% of migraine patients, tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma (‘jagged crescent’). Sensory symptoms may also occur. NICE criteria suggest that migraines may be unilateral or bilateral and give more detail about typical auras, which may occur with or without headache and are fully reversible, develop over at least 5 minutes, and last 5-60 minutes. Atypical aura symptoms such as motor weakness, double vision, visual symptoms affecting only one eye, poor balance, and decreased level of consciousness may prompt further investigation or referral.
In summary, the diagnostic criteria for migraine without aura include specific characteristics of the headache and associated symptoms, while migraine with aura is characterized by typical aura symptoms that may occur prior to the headache. It is important to accurately diagnose migraine to provide appropriate treatment and management for those who suffer from this debilitating condition.
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This question is part of the following fields:
- Neurology
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Question 89
Incorrect
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A 24-year-old man presents to his GP with right-sided facial weakness. He complains of weakness on the right side of his face, especially when smiling or chewing. He also reports occasional twitching of his right cheek, which started 3 days ago after a flu-like illness. However, he notes that it is already starting to improve.
During examination, the GP observes mild impairment of the facial muscles on the entire right side of the patient's face, including his forehead. Otoscopy is normal, and examination of the eye is unremarkable. The rest of the cranial nerve exam and upper limb neurological exam is normal.
What is the recommended management for this likely diagnosis?Your Answer: Oral prednisolone, oral aciclovir and artificial tears
Correct Answer: Oral prednisolone and artificial tears
Explanation:Patients with Bell’s palsy should receive oral prednisolone within 72 hours of onset, regardless of the severity of their symptoms or any improvement since onset. This is important to differentiate Bell’s palsy from other conditions such as cerebral events and Ramsay-Hunt syndrome. Eye protection with lid taping or lubricating eye drops should also be considered. Therefore, the correct answer is oral prednisolone and artificial tears. Oral aciclovir alone is not sufficient as it does not provide steroids or eye protection. Reassurance only and advice to return if symptoms persist after 2 weeks is not appropriate as treatment should be offered within the 72-hour window. Urgent referral to ENT is not necessary as the diagnosis can be made and managed in primary care, but non-urgent referral may be necessary in severe or prolonged cases or where the diagnosis is unclear.
Understanding Bell’s Palsy
Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It is more common in individuals aged 20-40 years and pregnant women. The condition is characterized by lower motor neuron facial nerve palsy, which affects the forehead. Unlike upper motor neuron lesions, the upper face is spared. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.
The management of Bell’s palsy has been a subject of debate. However, it is now widely accepted that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, but it may be beneficial for severe facial palsy. Eye care is also crucial to prevent exposure keratopathy, and patients should be prescribed artificial tears and eye lubricants. If they are unable to close their eyes at bedtime, they should tape them closed using microporous tape.
If the paralysis shows no sign of improvement after three weeks, an urgent referral to ENT is necessary. Patients with long-standing weakness may require a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within 3-4 months. However, untreated patients may experience permanent moderate to severe weakness in around 15% of cases.
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This question is part of the following fields:
- Neurology
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Question 90
Incorrect
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A 55-year-old man comes to the clinic with a facial droop. Upon examination, he displays a crooked smile that droops on the left side. He is unable to close his left eye or wrinkle the left side of his forehead. There are no signs of weakness or sensory changes in his upper or lower limbs. What is the probable cause of this presentation?
Your Answer: Lateral medullary syndrome
Correct Answer: Left cranial nerve VII lower motor neuron lesion
Explanation:Bell’s palsy affects the lower motor neurons and results in weakness of the entire side of the face. A left cranial nerve VII lower motor neuron lesion would cause left-sided facial weakness without forehead sparing. However, lateral medullary syndrome, caused by ischemia to the lateral medulla oblongata, would present with vertigo, dizziness, nystagmus, ataxia, nausea and vomiting, and dysphagia. A left cranial nerve VII upper motor neuron lesion would result in right-sided facial weakness with forehead sparing, while a right cranial nerve VII lower motor neuron lesion would cause right-sided facial weakness without forehead sparing.
Understanding Bell’s Palsy
Bell’s palsy is a sudden, one-sided facial nerve paralysis of unknown cause. It is more common in individuals aged 20-40 years and pregnant women. The condition is characterized by lower motor neuron facial nerve palsy, which affects the forehead. Unlike upper motor neuron lesions, the upper face is spared. Patients may also experience post-auricular pain, altered taste, dry eyes, and hyperacusis.
The management of Bell’s palsy has been a subject of debate. However, it is now widely accepted that all patients should receive oral prednisolone within 72 hours of onset. The addition of antiviral medications is still a matter of discussion, but it may be beneficial for severe facial palsy. Eye care is also crucial to prevent exposure keratopathy, and patients should be prescribed artificial tears and eye lubricants. If they are unable to close their eyes at bedtime, they should tape them closed using microporous tape.
If the paralysis shows no sign of improvement after three weeks, an urgent referral to ENT is necessary. Patients with long-standing weakness may require a referral to plastic surgery. The prognosis for Bell’s palsy is generally good, with most patients making a full recovery within 3-4 months. However, untreated patients may experience permanent moderate to severe weakness in around 15% of cases.
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This question is part of the following fields:
- Neurology
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Question 91
Incorrect
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A 60-year-old man had a left mastectomy three years ago for breast cancer. He has now presented with a 4-month history of progressive ataxia and dysarthria. On examination, there is gaze-evoked nystagmus, dysarthria, upper limb ataxia and gait ataxia. Power, tone, reflexes and sensation are normal. Plantar response is flexor bilaterally. Computerised tomography (CT) and magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid (CSF) microscopy are normal.
Which one of the following is the most likely cause of his ataxia?Your Answer: Cerebellar metastasis
Correct Answer: Paraneoplastic cerebellum syndrome
Explanation:Differential diagnosis for a patient with subacute cerebellar dysfunction and normal imaging
Paraneoplastic cerebellum syndrome, multiple sclerosis, cerebellar metastasis, malignant meningitis, and Wernicke’s encephalopathy are among the possible diagnoses for a patient presenting with subacute onset of cerebellar signs and normal imaging.
Paraneoplastic cerebellum syndrome is a rare immune-mediated complication of many cancers, which may be diagnosed before the underlying tumour. Symptoms develop rapidly and include dizziness, nausea, vertigo, nystagmus, ataxia, oscillopsia, dysarthria, tremor, dysphagia, and blurry vision. MRI may be normal, but CSF may show raised protein and anti-neuronal antibodies.
Multiple sclerosis is more common in women and usually presents with transient episodes of visual change or limb weakness/paraesthesiae, as well as bladder and cerebellar dysfunction. MRI may visualise plaques of demyelination, and CSF shows oligoclonal bands.
Cerebellar metastasis could occur in breast cancer, but it would be visualised on MRI.
Malignant meningitis occurs when cancer spreads to the meninges and presents with confusion, headaches, and weakness. Imaging and CSF would be abnormal.
Wernicke’s encephalopathy is due to thiamine deficiency, typically seen in alcoholics, and presents with acute confusional state, ophthalmoplegia, and gait ataxia. Dysarthria is not usually a feature. Thiamine deficiency is not suggested by this patient’s history.
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This question is part of the following fields:
- Neurology
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Question 92
Incorrect
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A 68-year-old man who is a smoker presents with complaints about his left eye. Upon examination, it is found that he has a constricted left pupil with a ptosis and anhidrosis.
What is the most probable diagnosis?Your Answer: Holmes-Adie syndrome
Correct Answer: Horner syndrome
Explanation:Horner syndrome is a rare condition caused by a disruption of the sympathetic nerve supply to the eye. It is characterized by a triad of symptoms including a constricted pupil, partial drooping of the eyelid, and loss of sweating on one side of the face. Possible causes of Horner syndrome include brain-stem stroke or tumor, brachial plexus trauma, lung infections or tumors, carotid artery issues, and migraines. Multiple sclerosis is an autoimmune disease that attacks the central nervous system and can cause optic neuritis, but the symptoms described in the scenario do not match those of MS. Holmes-Adie syndrome is a neurological disorder characterized by a dilated pupil that reacts slowly to light, loss of deep tendon reflexes, and profuse sweating, which is not consistent with the scenario. Myasthenia gravis is an autoimmune disorder that causes muscle weakness, but it typically affects the facial muscles and extraocular muscles, not the pupil. Riley-Day syndrome is a disorder of the autonomic nervous system that affects infants and is characterized by the absence of overflow tears with emotional crying.
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This question is part of the following fields:
- Neurology
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Question 93
Incorrect
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A 40 year old male is brought to the Emergency Department following a severe beating. Upon arrival, his eyes are shut and only open in response to pain. He emits a single groan and withdraws from painful stimuli. What is his Glasgow Coma Scale (GCS) score?
Your Answer: 10
Correct Answer: 8
Explanation:The GCS score for this patient is 654, which can be remembered as MoVE. This scoring system assesses the patient’s level of consciousness by evaluating their eye opening, verbal response, and motor function. In this case, the patient’s eyes are closed but will open in response to pain, earning a score of 2 out of 4. The patient is unable to speak but makes a groaning sound, earning a score of 2 out of 5. The patient also flexes in response to pain, earning a score of 4 out of 6. GCS scores are regularly monitored in patients with head injuries to detect any changes in their neurological status, which could indicate swelling or bleeding.
Understanding the Glasgow Coma Scale for Adults
The Glasgow Coma Scale (GCS) is a tool used to assess the level of consciousness in adults who have suffered a brain injury or other neurological condition. It is based on three components: motor response, verbal response, and eye opening. Each component is scored on a scale from 1 to 6, with a higher score indicating a better level of consciousness.
The motor response component assesses the patient’s ability to move in response to stimuli. A score of 6 indicates that the patient is able to obey commands, while a score of 1 indicates no movement at all.
The verbal response component assesses the patient’s ability to communicate. A score of 5 indicates that the patient is fully oriented, while a score of 1 indicates no verbal response at all.
The eye opening component assesses the patient’s ability to open their eyes. A score of 4 indicates that the patient is able to open their eyes spontaneously, while a score of 1 indicates no eye opening at all.
The GCS score is expressed as a combination of the scores from each component, with the motor response score listed first, followed by the verbal response score, and then the eye opening score. For example, a GCS score of 13, M5 V4 E4 at 21:30 would indicate that the patient had a motor response score of 5, a verbal response score of 4, and an eye opening score of 4 at 9:30 PM.
Overall, the Glasgow Coma Scale is a useful tool for healthcare professionals to assess the level of consciousness in adults with neurological conditions.
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This question is part of the following fields:
- Neurology
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Question 94
Incorrect
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A 35-year-old woman visits her GP complaining of a headache that she describes as worsening over the past three weeks. She reports that the headache wakes her during the night, and is worse when she coughs.
Which of the following is the most likely diagnosis?
Your Answer: Subarachnoid haemorrhage
Correct Answer: Brain tumour
Explanation:The patient’s symptoms suggest a headache caused by increased pressure within the skull, which is often associated with a space-occupying lesion such as a brain tumor. This type of headache is typically worse in the morning and aggravated by bending forward, coughing, or sneezing. As the tumor grows, other symptoms such as vomiting, seizures, and neurological deficits may develop. Brain tumors can be primary or metastatic, with the most common types being astrocytoma, glioblastoma, oligodendroglioma, ependymoma, meningioma, and primary CNS lymphoma.
The patient’s history does not support a diagnosis of giant cell arteritis, which typically affects individuals over 50 years old and presents with an abrupt-onset headache, scalp tenderness, jaw pain, visual disturbances, and constitutional symptoms such as fever and weight loss. The diagnosis of GCA requires specific criteria, including age at onset, new headache, temporal artery abnormality, elevated erythrocyte sedimentation rate, and abnormal artery biopsy.
The patient’s symptoms are also not consistent with cluster headaches, which typically affect younger males and present with severe, unilateral pain around the eye, accompanied by lacrimation and nasal congestion. Cluster headaches have a circadian pattern and occur in episodes, followed by symptom-free periods.
Migraine is another type of headache that is not likely in this case, as the patient’s symptoms do not fit the typical pattern of unilateral, pulsating pain lasting 4-72 hours, accompanied by nausea/vomiting and photophobia.
Finally, subarachnoid hemorrhage is a medical emergency that presents with a sudden, severe headache, often described as the worst headache of one’s life, along with other symptoms such as vomiting, loss of consciousness, seizures, and neurological deficits. However, the patient’s headache has been progressing over weeks, which is not consistent with SAH.
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This question is part of the following fields:
- Neurology
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Question 95
Incorrect
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Neuropathic pain typically does not improve with opioids. Nevertheless, if conventional treatments have been ineffective, which opioid should be considered for initiation in elderly patients?
Your Answer: Codeine
Correct Answer: Tramadol
Explanation:Understanding Neuropathic Pain and its Management
Neuropathic pain is a type of pain that occurs due to damage or disruption of the nervous system. It is a complex condition that is often difficult to treat and does not respond well to standard painkillers. Examples of neuropathic pain include diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia, and prolapsed intervertebral disc.
To manage neuropathic pain, the National Institute for Health and Care Excellence (NICE) updated their guidance in 2013. The first-line treatment options include amitriptyline, duloxetine, gabapentin, or pregabalin. If the first-line drug treatment does not work, patients may try one of the other three drugs. Unlike standard painkillers, drugs for neuropathic pain are typically used as monotherapy, meaning that if they do not work, patients should switch to a different drug rather than adding another one.
Tramadol may be used as rescue therapy for exacerbations of neuropathic pain, while topical capsaicin may be used for localized neuropathic pain, such as post-herpetic neuralgia. Pain management clinics may also be useful for patients with resistant problems. However, it is important to note that for some specific conditions, such as trigeminal neuralgia, the guidance may vary, and carbamazepine may be used as a first-line treatment. Overall, understanding neuropathic pain and its management is crucial for improving the quality of life for patients suffering from this condition.
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This question is part of the following fields:
- Neurology
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Question 96
Incorrect
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An 80-year-old woman is brought to the emergency department by ambulance due to right-sided limb weakness, facial droop, and slurred speech. A CT head scan shows a left-sided infarct but no haemorrhage. Her admission ECG reveals new atrial fibrillation (AF). Aspirin 300mg is given for the acute stroke, and she is recovering well on the ward. After two weeks, what medication should be initiated to lower the risk of future strokes?
Your Answer: Enoxaparin
Correct Answer: Warfarin or a direct thrombin or factor Xa inhibitor
Explanation:For patients with AF who have experienced a stroke or TIA, the recommended anticoagulant is warfarin or a direct thrombin or factor Xa inhibitor. Aspirin/dipyridamole should only be used if necessary for the treatment of other conditions, which is not the case in this scenario. Clopidogrel is typically prescribed for TIA patients without AF, but in this case, the patient had a stroke and would require long-term treatment with a different medication.
Managing Atrial Fibrillation Post-Stroke
Atrial fibrillation is a significant risk factor for ischaemic stroke, making it crucial to identify and treat the condition in patients who have suffered a stroke or transient ischaemic attack (TIA). However, before starting any anticoagulation or antiplatelet therapy, it is important to rule out haemorrhage. For long-term stroke prevention, NICE Clinical Knowledge Summaries recommend warfarin or a direct thrombin or factor Xa inhibitor. The timing of when to start treatment depends on whether it is a TIA or stroke. In the case of a TIA, anticoagulation for AF should begin immediately after imaging has excluded haemorrhage. For acute stroke patients, anticoagulation therapy should be initiated after two weeks in the absence of haemorrhage. Antiplatelet therapy should be given during the intervening period. However, if imaging shows a very large cerebral infarction, the initiation of anticoagulation should be delayed.
Overall, managing atrial fibrillation post-stroke requires careful consideration of the patient’s individual circumstances and imaging results. By following these guidelines, healthcare professionals can help prevent future strokes and improve patient outcomes.
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This question is part of the following fields:
- Neurology
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Question 97
Incorrect
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A 68-year-old woman presents with a 4-month history of heaviness and discomfort in her upper legs, which is present after walking for more than 5 minutes. She used to enjoy walking regularly, but now finds it difficult to participate. However, she is still able to drive to her part-time job as a receptionist. She has a history of hypertension and was recently started on medication. She quit smoking 3 years ago. On examination, her blood pressure is 150/85 mmHg. Her pulse is 64 and regular. Her peripheral pulses are palpable, but the capillary return in her toes is slow. Neurological examination of her arms and legs is normal, except for diminished ankle jerks and reduced vibration sense distally.
Which of the following is the most likely diagnosis?Your Answer: Hypothyroid muscle disease
Correct Answer: Lumbar canal stenosis
Explanation:Differential Diagnosis of Progressive Exertional Leg Pain: A Review of Possible Conditions
Progressive exertional leg pain can be a symptom of various medical conditions. In this article, we will review some of the possible differential diagnoses for this symptom.
Lumbar Canal Stenosis
Lumbar canal stenosis is a degenerative condition associated with the ageing spine, resulting in narrowing of the central spinal canal, lateral recess or neural foramina. It is usually due to progressive hypertrophy of the facet joints and disc degeneration. It is a syndrome of buttock or leg pain, with or without back pain, associated with a narrow space available for the neural and vascular elements in the lumbar spine.Metabolic Muscle Disease
This is a diverse group of hereditary muscle disorders caused by specific enzymatic defects due to defective genes. Disorders of muscle energy metabolism result in skeletal muscle dysfunction. Most metabolic myopathies are considered primary inborn errors of metabolism and are associated with enzymatic defects that affect the ability of muscle fibres to maintain energy and adenosine triphosphate (ATP) concentrations. These include abnormalities of glycogen, lipid, purine or mitochondrial biochemistry.Idiopathic Parkinson’s Disease
Idiopathic Parkinson’s disease (IPD) commonly presents with tremor, stiffness, slowness and balance/gait issues. In addition, PD classically displays a unilateral onset. This patient has no resting symptoms suggestive of IPD.Hypothyroid Muscle Disease
Hypothyroidism is associated with proximal myopathy. There is commonly proximal muscle weakness and raised creatine kinase (CK). Patients may suffer muscle cramping, proximal symmetrical muscle weakness, muscle stiffness and exercise intolerance. Reduced reflexes/ankle reflexes are commonly seen.Abdominal Aortic Stenosis
This refers to narrowing of the aorta during its course in the abdomen. This would produce bilateral vascular claudication symptoms, due to reduced blood flow distal to the stenosis. The progressive exertional leg pain described here could be in keeping with vascular claudication. -
This question is part of the following fields:
- Neurology
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Question 98
Incorrect
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What is the most prevalent form of multiple sclerosis?
Your Answer: Secondary progressive disease
Correct Answer: Relapsing-remitting disease
Explanation:Understanding Multiple Sclerosis
Multiple sclerosis is a chronic autoimmune disorder that affects the central nervous system, causing demyelination. It is more common in women and typically diagnosed in individuals aged 20-40 years. Interestingly, it is much more prevalent in higher latitudes, with a five-fold increase compared to tropical regions. Genetics play a role in the development of multiple sclerosis, with a 30% concordance rate in monozygotic twins and a 2% concordance rate in dizygotic twins.
There are several subtypes of multiple sclerosis, including relapsing-remitting disease, which is the most common form and accounts for around 85% of patients. This subtype is characterized by acute attacks followed by periods of remission. Secondary progressive disease describes relapsing-remitting patients who have deteriorated and developed neurological signs and symptoms between relapses. Gait and bladder disorders are commonly seen in this subtype, and around 65% of patients with relapsing-remitting disease go on to develop secondary progressive disease within 15 years of diagnosis. Finally, primary progressive disease accounts for 10% of patients and is characterized by progressive deterioration from onset, which is more common in older individuals. Understanding the different subtypes of multiple sclerosis is crucial for proper diagnosis and management of the disease.
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This question is part of the following fields:
- Neurology
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Question 99
Incorrect
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A 65-year-old woman is referred to the general medical clinic with a history of about 10 attacks of pins and needles in her right arm and leg over a period of 4 weeks. Her GP is concerned that this patient will soon have a completed stroke despite already being on aspirin. Typical attacks lasted for about 5 min and there were no additional symptoms. On closer enquiry she said that the sensation started in her right foot and then, over a period of about 1 min, spread ‘like water running up my leg’ to involve her whole leg and arm. Each attack was identical. Her past medical history includes hypertension and diabetes, for which she already takes aspirin. There are no abnormalities on neurological examination, but her blood pressure is 180/100 mmHg.
Which of the following is the most likely diagnosis?
Your Answer: Cerebral venous thrombosis
Correct Answer: Partial epileptic seizure affecting the right hemisphere
Explanation:Differential Diagnosis for Recurrent Neurological Symptoms
Recurrent neurological symptoms can be caused by a variety of conditions, and a thorough differential diagnosis is necessary to determine the underlying cause. In the case of a patient experiencing march-like progression of symptoms affecting the left side of the body, several possibilities must be considered.
A partial epileptic seizure affecting the right hemisphere is a likely cause, as the positive sensory symptoms and stereotyped nature of the episodes are typical of epilepsy. The rapid progression of symptoms over seconds to a minute is also characteristic of seizure activity.
Transient ischaemic attacks (TIAs) affecting the right hemisphere are less likely, as the march-like progression of symptoms and positive sensory symptoms are not typical of a vascular cause. TIAs are more likely to present with loss of sensation rather than abnormal sensations.
Recurrent, deep, white-matter microhaemorrhages are a possibility due to the patient’s risk factors, but the stereotyped nature of the attacks and positive sensory symptoms make this diagnosis less likely. Microhaemorrhages would typically present with numbness affecting the entire left side at onset.
Migraine equivalent is a rare possibility, but the rapid progression of symptoms and frequency of episodes make this diagnosis unlikely. Migraine aura without headache typically spreads over 20-30 minutes and is more common in patients with a history of previous migraine.
Cerebral venous thrombosis is also unlikely, as the absence of headache makes this diagnosis less probable. CVT typically presents with headache and other neurological symptoms.
In conclusion, the positive sensory features, stereotyped nature, and march of symptoms suggest epilepsy as the most likely cause of the patient’s recurrent neurological symptoms.
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This question is part of the following fields:
- Neurology
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Question 100
Incorrect
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A 30-year-old male presents with a bilateral high-stepping gait. He is typically healthy, works as a personal trainer, and enjoys rock climbing in his free time. During the examination, there is bilateral weakness of dorsiflexion (3/5) and slightly decreased sensation over the dorsal aspect of his feet. The compression of which nerve do you suspect is responsible for his symptoms, possibly caused by his high rock climbing boots?
Your Answer: Sciatic nerve
Correct Answer: Common fibular nerve
Explanation:Damage to the common peroneal nerve can result in weakened dorsiflexion and eversion of the foot. The nerve runs laterally through the popliteal fossa and over the neck of the fibula before entering the medial compartment of the leg. This area is susceptible to compression or injury, leading to sensory and motor impairments. In this case, the individual’s tight abseiling boots have been compressing their common peroneal nerve.
Understanding Common Peroneal Nerve Lesion
A common peroneal nerve lesion is a type of nerve injury that often occurs at the neck of the fibula. This nerve is a branch of the sciatic nerve, which divides into the tibial and common peroneal nerves. The most notable symptom of this type of nerve damage is foot drop, which is characterized by weakness or paralysis of the muscles that lift the foot.
In addition to foot drop, other symptoms of a common peroneal nerve lesion may include weakness in foot dorsiflexion and eversion, as well as the extensor hallucis longus muscle. Sensory loss may also occur over the dorsum of the foot and the lower lateral part of the leg, and there may be wasting of the anterior tibial and peroneal muscles.
Overall, understanding the symptoms of a common peroneal nerve lesion can help individuals recognize and seek treatment for this type of nerve injury. With proper care and management, it may be possible to improve symptoms and prevent further damage to the affected nerve.
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This question is part of the following fields:
- Neurology
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Question 101
Incorrect
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A 30-year-old male presents with a 3-month history of numbness in his right hand. During examination, you observe a loss of sensation in the palmar and dorsal regions of the 5th digit, while the sensation of the forearm remains intact. What is the probable diagnosis?
Your Answer: Radial nerve neuropathy
Correct Answer: Cubital tunnel syndrome
Explanation:The correct answer is cubital tunnel syndrome. This condition is characterized by ulnar nerve neuropathy, which affects the sensory innervation of the palmar and dorsal aspects of 1.5 fingers medially. It can also cause wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals) and the hypothenar muscles. To test for ulnar neuropathy, Froment’s test can be used to assess the function of the adductor pollicis muscle.
Axillary nerve neuropathy is not the correct answer. The axillary nerve has both motor and sensory functions, innervating the deltoid and teres minor muscles, as well as providing sensory innervation to the skin over the lower two-thirds of the posterior part of the deltoid and the long head of the triceps brachii.
C8/T1 radiculopathy is also not the correct answer. While it can mimic ulnar nerve neuropathy, the preserved sensation of the forearm would suggest cubital tunnel syndrome instead. The medial antebrachial cutaneous nerve (C8 and T1) provides sensation to the medial forearm, not the ulnar nerve.
Carpal tunnel syndrome is also not the correct answer. This condition is caused by median nerve dysfunction, resulting in sensory loss over the lateral 3.5 digits and loss of motor function to the flexor muscles of the forearm and hand, as well as those responsible for thumb movement.
The Ulnar Nerve: Overview, Branches, and Patterns of Damage
The ulnar nerve is a nerve that arises from the medial cord of the brachial plexus, specifically from the C8 and T1 spinal nerves. It provides motor innervation to several muscles in the hand, including the medial two lumbricals, adductor pollicis, interossei, hypothenar muscles (abductor digiti minimi, flexor digiti minimi), and flexor carpi ulnaris. It also provides sensory innervation to the medial 1 1/2 fingers on both the palmar and dorsal aspects.
The ulnar nerve travels through the posteromedial aspect of the upper arm before entering the palm of the hand via the Guyon’s canal, which is located superficial to the flexor retinaculum and lateral to the pisiform bone. The nerve has several branches, including the muscular branch, palmar cutaneous branch, dorsal cutaneous branch, superficial branch, and deep branch. These branches supply various muscles and skin areas in the hand.
Damage to the ulnar nerve can occur at the wrist or elbow. When damaged at the wrist, it can result in a claw hand deformity, which involves hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits. There may also be wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals) and hypothenar muscles, as well as sensory loss to the medial 1 1/2 fingers. When damaged at the elbow, the same symptoms may occur, but with the addition of radial deviation of the wrist. It is important to note that in distal lesions, the clawing may be more severe, which is known as the ulnar paradox.
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This question is part of the following fields:
- Neurology
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Question 102
Incorrect
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A 28-year-old woman is referred to the Neurology Clinic with suspected Guillain–Barré syndrome (GBS). A lumbar puncture (LP) is performed on the patient to rule out any other causes. The results of the LP show normal white blood cells (WBCs) and elevated proteins.
What immediate management should be started for this patient?
Select the SINGLE most appropriate management from the list below.
Your Answer: Intravenous itraconazole
Correct Answer: Intravenous immunoglobulins
Explanation:Guillain-Barré syndrome (GBS) can be treated with either plasma exchange or intravenous immunoglobulin (IVIG), both of which are equally effective. The decision on which treatment to use depends on the institution. Plasma exchange is recommended for ambulatory patients within two weeks of symptom onset and for non-ambulatory patients within four weeks. It is most effective when started within seven days of symptom onset, but improvement can still be seen up to 30 days after onset. Patients receiving plasma exchange should be closely monitored for electrolyte abnormalities and coagulopathies, as well as complications such as infection, blood pressure instability, cardiac arrhythmias, and pulmonary embolus. Compared to IVIG, plasma exchange has a higher risk of pneumonia, atelectasis, thrombosis, and hemodynamic difficulties. Urgent referral to oncology is appropriate if the patient has signs of metastatic spinal cord compression. High-dose dexamethasone is not indicated in this case as there is no history of cancer. Intravenous ceftriaxone is used to treat meningitis, which was ruled out by the LP findings. Intravenous itraconazole would be appropriate if fungal meningitis were suspected based on the patient’s history and LP results.
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This question is part of the following fields:
- Neurology
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Question 103
Incorrect
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An 80-year-old man visits a memory clinic accompanied by his daughter. He has a medical history of hypertension and is a former smoker. The daughter reports that he had been stable for several months before experiencing sudden declines on multiple occasions. The physical examination is normal, and his MoCA score is 18 out of 30. He denies experiencing any visual or auditory hallucinations. What is the probable underlying diagnosis?
Your Answer: Lewy body dementia
Correct Answer: Vascular dementia
Explanation:The gradual decline in cognitive function, along with hypertension and smoking as risk factors for cerebrovascular disease, suggest a diagnosis of vascular dementia. This type of dementia is caused by damage to the brain from reduced blood flow or bleeding due to cerebrovascular disease. In contrast, Alzheimer’s dementia progresses slowly over time, while frontotemporal dementia affects personality, behavior, language, and attention. Lewy body dementia is characterized by hallucinations and Parkinsonian symptoms, while Parkinson’s dementia occurs in patients with Parkinson’s disease and affects their mental function and memory, along with physical signs of PD.
Understanding Vascular Dementia: Causes, Symptoms, and Management
Vascular dementia is a type of cognitive impairment that is caused by different mechanisms resulting from cerebrovascular disease. It is the second most common form of dementia after Alzheimer’s disease. Vascular dementia is often recognized as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment. Early detection and an accurate diagnosis are crucial in preventing vascular dementia.
The prevalence of vascular dementia is estimated to be around 17% of dementia cases in the UK. The incidence of vascular dementia increases with age and is often associated with a history of stroke or transient ischemic attack, atrial fibrillation, hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, coronary heart disease, and a family history of stroke or cardiovascular disease. Rarely, vascular dementia can be inherited as in the case of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.
Patients with vascular dementia typically present with a sudden or stepwise deterioration of cognitive function, focal neurological abnormalities, difficulty with attention and concentration, seizures, memory disturbance, gait disturbance, speech disturbance, and emotional disturbance. Diagnosis is made based on a comprehensive history and physical examination, formal screening for cognitive impairment, medical review to exclude medication cause of cognitive decline, and MRI scan.
Treatment for vascular dementia is mainly symptomatic with the aim to address individual problems and provide support to the patient and carers. It is important to detect and address cardiovascular risk factors to slow down the progression of the disease. Non-pharmacological management is tailored to the individual and may include cognitive stimulation
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