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Question 1
Incorrect
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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: Charcot-Marie-Tooth disease
Correct 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 2
Correct
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A 68-year-old man presents to his GP clinic complaining of confusion and difficulty sleeping for the past 5 months. According to his wife, his confusion varies in severity from day to day, and he has been experiencing visual hallucinations of people and animals in their home. The patient is currently taking apixaban 5 mg, amlodipine 5mg, and atorvastatin 20 mg, and there is no recent history of infection. Physical examination reveals normal vital signs and no motor or speech impairment, but the patient struggles to draw a clock face and count down from 20 to 1 correctly. A urine dip test is unremarkable. What is the most likely diagnosis?
Your Answer: Lewy body dementia
Explanation:Based on the information provided, Lewy body dementia is the most probable diagnosis. Unlike other forms of dementia, it is characterized by fluctuating cognitive abilities, particularly in attention and executive functioning. The patient may also experience sleep disturbances, visual hallucinations, and parkinsonism. To confirm the diagnosis, the patient will need to undergo cognitive testing, blood tests, and a CT head scan to rule out other conditions. SPECT imaging may also be considered if there is still uncertainty, as it is highly sensitive and specific for Lewy body dementia.
Alzheimer’s disease is less likely as memory impairment is typically the first cognitive domain affected, and confusion is not as fluctuating. Visual hallucinations are also less common than in Lewy body dementia.
Chronic subdural hematoma is unlikely as it typically presents with reduced consciousness or neurological deficits rather than cognitive deficits alone. Given the patient’s age and anticoagulation therapy, CT imaging should be performed to rule out any intracranial hemorrhage.
Frontotemporal dementia is unlikely as it typically presents before the age of 65 with personality changes and social conduct problems, while memory and visuospatial skills are relatively preserved.
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 3
Incorrect
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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: Middle cerebral artery
Correct 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 4
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:
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 5
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:
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 6
Incorrect
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A 35-year-old man visits his family doctor complaining of recurrent episodes of severe facial pain that have been occurring for the past 6 months. He reports experiencing sharp shooting pains in his right cheek and teeth, which worsen during the cold winter months and when he brushes his teeth. Despite visiting the dentist multiple times, no abnormality has been found. His neurological and ENT examination is normal.
What is the most suitable primary care treatment for this condition?Your Answer:
Correct Answer: Carbamazepine
Explanation:Comparing Medications for Trigeminal Neuralgia Treatment
Trigeminal neuralgia is a condition characterized by severe facial pain that occurs in one or more branches of the trigeminal nerve. To treat this condition, anticonvulsant medications are often prescribed. Here, we compare five commonly used medications for trigeminal neuralgia treatment.
Carbamazepine is the recommended first-line treatment for trigeminal neuralgia by the National Institute for Health and Care Excellence (NICE). Topiramate is not typically used for trigeminal neuralgia, as it is primarily indicated for migraine prophylaxis. Amitriptyline is recommended for neuropathic pain, but not specifically for trigeminal neuralgia. Duloxetine is also indicated for neuropathic pain, but not for trigeminal neuralgia. Gabapentin is recommended for neuropathic pain, but not for trigeminal neuralgia, as carbamazepine is the preferred first-line treatment for this condition.
In summary, carbamazepine is the recommended first-line treatment for trigeminal neuralgia, while the other medications mentioned may be more appropriate for other conditions.
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This question is part of the following fields:
- Neurology
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Question 7
Incorrect
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A 42-year-old woman presents to the Ear, Nose and Throat Clinic with a 4-month history of right-sided hearing loss. She reports occasional buzzing in her right ear and feeling unsteady. She has no significant medical history and denies any recent infections. On examination, Rinne's test is positive in both ears, with Weber's test lateralizing to her left ear. There is no evidence of nystagmus, and her coordination remains intact. Apart from an absent right-sided corneal reflex, the rest of her cranial-nerve examination is unremarkable. What is the most appropriate investigation to confirm the diagnosis?
Your Answer:
Correct Answer: Magnetic resonance imaging (MRI) of the cerebellopontine angle with contrast
Explanation:Diagnostic Tests for Acoustic Tumours: Importance of MRI with Contrast
Acoustic tumours require accurate diagnosis for effective treatment. The most definitive diagnostic test is gadolinium-enhanced magnetic resonance imaging (MRI) of the cerebellopontine angle. This test can detect tumours as small as 1-2 mm in diameter, while fine-cut computed tomography (CT) scanning may miss tumours as large as 1.5 cm even with intravenous contrast enhancement.
Audiometry is also important, but only 5% of patients with acoustic tumours will have a normal audiogram. If MRI is contraindicated, air-contrast cisternography can detect relatively small intracanalicular tumours with high sensitivity.
Fine-cut CT scanning of the internal auditory canal with contrast can rule out medium to large tumours, but cannot reliably detect tumours smaller than 1-1.5 cm. CT scanning without contrast can rule out medium-sized tumours, but is not reliable for detecting smaller tumours.
It is critical to use gadolinium contrast in MRI of the cerebellopontine angle, as non-enhanced MRI may miss small tumours. Therefore, MRI with contrast is the most important diagnostic test for acoustic tumours.
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This question is part of the following fields:
- Neurology
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Question 8
Incorrect
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A 29-year-old female patient visits her general practitioner complaining of muscle cramps and numbness in her hands and feet for the past 5 days. She also reports a tingling sensation around her mouth. The patient was diagnosed with epilepsy 8 weeks ago and has been prescribed phenytoin. What abnormality is most likely to be observed in her blood test results?
Your Answer:
Correct Answer: Corrected calcium of 1.5 mmol/L
Explanation:The patient is displaying typical symptoms of hypocalcaemia, including perioral paraesthesia, cramps, tetany, and convulsions. This condition can be a side effect of taking phenytoin, and if left untreated, it can lead to seizures due to changes in neuromuscular excitability. Mild cases of hypocalcaemia can be managed with oral supplementation, while more severe cases may require intravenous replacement.
It’s important to note that hypercalcaemia can cause bone pain, renal calculi, constipation, polyuria, fatigue, depression, and confusion. However, the patient does not display any of these symptoms.
Hyperkalaemia can cause muscle weakness and cardiac arrhythmias, but the patient does not have these symptoms. Hypokalaemia can also cause muscle weakness and cardiac arrhythmias, but the patient’s symptoms do not fit this condition.
Finally, hypernatraemia can cause nausea, vomiting, headache, and confusion, but the patient is not experiencing these symptoms.
Hypocalcaemia: Symptoms and Signs
Hypocalcaemia is a condition characterized by low levels of calcium in the blood. Since calcium is essential for proper muscle and nerve function, many of the symptoms and signs of hypocalcaemia are related to neuromuscular excitability. The most common features of hypocalcaemia include muscle twitching, cramping, and spasms, as well as perioral paraesthesia. In chronic cases, patients may experience depression and cataracts.
An electrocardiogram (ECG) may show a prolonged QT interval, while Trousseau’s sign may be present when the brachial artery is occluded by inflating the blood pressure cuff and maintaining pressure above systolic. This causes wrist flexion and fingers to be drawn together, and is seen in around 95% of patients with hypocalcaemia and around 1% of normocalcaemic people. Chvostek’s sign, which is seen in around 70% of patients with hypocalcaemia and around 10% of normocalcaemic people, involves tapping over the parotid gland to cause facial muscles to twitch.
In summary, hypocalcaemia can cause a range of symptoms and signs related to neuromuscular excitability, including muscle twitching, cramping, and spasms, as well as perioral paraesthesia, depression, and cataracts. Trousseau’s sign and Chvostek’s sign are also commonly observed in patients with hypocalcaemia.
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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 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:
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 10
Incorrect
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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:
Correct 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 11
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:
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 12
Incorrect
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A 45-year-old woman with multiple sclerosis comes in for evaluation. She reports experiencing worsening issues with painful spasms in her leg muscles. What is the initial treatment option that should be considered?
Your Answer:
Correct Answer: Baclofen
Explanation:The recommended initial treatments for spasticity in multiple sclerosis are baclofen and gabapentin.
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 13
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:
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 14
Incorrect
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Which one of the following statements regarding migraines is accurate?
Your Answer:
Correct Answer: Typical aura include a spreading scintillating scotoma ('jagged crescent')
Explanation:Caution should be exercised when administering prokinetic agents like metoclopramide to children.
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 15
Incorrect
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A 10-year-old boy is brought to the Emergency Department after being hit on the side of his head by a cricket ball during a match. According to his teacher, he initially fell to the ground and complained of a sore head. However, he got up after two minutes, claimed to feel fine, and resumed playing. Unfortunately, after 30 minutes, he suddenly collapsed and lost consciousness. What kind of injury is he likely to have suffered?
Your Answer:
Correct Answer: Extradural haematoma
Explanation:Extradural (epidural) hematoma – Head injury with a lucid interval
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 16
Incorrect
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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:
Correct 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 17
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:
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 18
Incorrect
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A 25 year old male arrives at the Emergency Department after being struck in the back of the head with a baseball bat. He reports a headache and has a cut on his occiput. He is alert, responsive to commands, and able to provide a detailed description of the incident.
What is his Glasgow coma scale (GCS)?Your Answer:
Correct Answer: 15
Explanation:The GCS score for this patient is 654, which stands for Motor (6 points), Verbal (5 points), and Eye opening (4 points). This scoring system is used to assess a patient’s level of consciousness and is commonly used in cases of head injury to monitor for changes in neurology. The patient in question has a perfect score for eye opening, is fully oriented in time, place, and person, and is able to obey commands, resulting in a motor score of 6.
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 19
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:
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 20
Incorrect
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A 25-year-old male comes to the neurology department with complaints of weakness. He initially experienced weakness in his legs a few days ago, which has now progressed to involve his arms. Additionally, he is experiencing shooting pains in his back and limbs. About four weeks ago, he had a brief episode of vomiting and diarrhea. Upon examination, reduced tendon reflexes and weakness are confirmed.
What test results would you anticipate for this patient?Your Answer:
Correct Answer: Abnormal nerve conduction studies
Explanation:Guillain-Barre syndrome can be diagnosed with the help of nerve conduction studies. The presence of ascending weakness after an infection is a common symptom of this syndrome. Most patients with Guillain-Barre syndrome show abnormal nerve conduction study results. If there are cord signal changes, it may indicate spinal cord compression or a spinal lesion. Inflammatory infiltrates on muscle biopsy are typically observed in patients with myositis. Myasthenia gravis is characterized by the presence of anti-acetylcholine receptor antibodies. In Guillain-Barre syndrome, the CSF protein level is usually elevated, not decreased.
Understanding Guillain-Barre Syndrome: Symptoms and Features
Guillain-Barre syndrome is a condition that affects the peripheral nervous system and is caused by an immune-mediated demyelination. It is often triggered by an infection, with Campylobacter jejuni being a common culprit. The initial symptoms of the illness include back and leg pain, which is experienced by around 65% of patients. The characteristic feature of Guillain-Barre syndrome is a progressive, symmetrical weakness of all the limbs, with the weakness typically starting in the legs and ascending upwards. Reflexes are reduced or absent, and sensory symptoms tend to be mild, with very few sensory signs.
Other features of Guillain-Barre syndrome may include a history of gastroenteritis, respiratory muscle weakness, cranial nerve involvement, diplopia, bilateral facial nerve palsy, oropharyngeal weakness, and autonomic involvement. Autonomic involvement may manifest as urinary retention or diarrhea. Less common findings may include papilloedema, which is thought to be secondary to reduced CSF resorption.
To diagnose Guillain-Barre syndrome, a lumbar puncture may be performed, which can reveal a rise in protein with a normal white blood cell count (albuminocytologic dissociation) in 66% of cases. Nerve conduction studies may also be conducted, which can show decreased motor nerve conduction velocity due to demyelination, prolonged distal motor latency, and increased F wave latency. Understanding the symptoms and features of Guillain-Barre syndrome is crucial for prompt diagnosis and treatment.
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This question is part of the following fields:
- Neurology
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