-
Question 1
Incorrect
-
A 22 year-old university graduate presented with progressive unsteadiness during walking over the last year. She had been otherwise healthy apart from recent difficulty hearing her lecturer in classes. She took no prescription medication but had occasionally taken cocaine during her first year of college. She also admits to drinking up to 30 units of alcohol per week and smoked 10 cigarettes per day. Her parents were both well, but her father's sister had problems with walking before she died. Examination reveals normal tone and power throughout all four limbs. Reflexes were normal in the upper limbs but decreased at the knees and absent at the ankles. Coordination was normal in all four limbs but her gait was ataxic. Sensation in the upper limbs was normal but decreased vibratory sensation and proprioception was noted to the ankles bilaterally. What is the most likely diagnosis?
Your Answer: Dentatorubropallidoluysian atrophy
Correct Answer: Friedreich’s ataxia
Explanation:Friedreich’s ataxia is an autosomal recessive disorder that usually begins before the end of the teens. It has an estimated prevalence in Europe of 1 in 50,000 and life expectancy is around 40–50 years. Neurological features include a progressive ataxia, cerebellar dysarthria, lower limb areflexia, decreased vibratory sensation and proprioception, and pyramidal weakness. Pes cavus and scoliosis are also both seen. Cardiomyopathy occurs in over 70% of cases. Less common features include optic atrophic, diabetes mellitus, and deafness.
-
This question is part of the following fields:
- Neurology
-
-
Question 2
Correct
-
A 23-year-old designer is requesting the combined oral contraceptive pill. During the history taking, she states that in the past she has had migraines with aura. She asks why the combined oral contraceptive pill is contraindicated. Which of the following is the most appropriate response?
Your Answer: Significantly increased risk of ischaemic stroke
Explanation:SIGN produced guidelines in 2008 on the management of migraines. Key points include that if patients have migraines with aura then the combined oral contraceptive (COC) is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72).
-
This question is part of the following fields:
- Neurology
-
-
Question 3
Correct
-
A 14 year-old is brought to the ED after being hit on the head with a cricket ball during a match. His teacher describes that he initially collapsed on the ground and complained of a sore head. Two minutes later, he got up and said he felt OK and continued playing. However, 30 minutes later he suddenly collapsed and lost consciousness. What injury is he most likely to have sustained?
Your Answer: Extradural haematoma
Explanation:A lucid interval, in which the patient portrays a temporary improvement in condition after a traumatic brain injury, is especially indicative of an epidural haematoma.
-
This question is part of the following fields:
- Neurology
-
-
Question 4
Incorrect
-
A 48-year-old hairdresser presents to the GP with loss of sensation over the lateral three and a half fingers of her right hand, tenderness over her right forearm, and inability to make a tight fist. She complains of pain in her right arm when twisting door handles anticlockwise. Phalen’s and Tinel’s tests are negative. She is otherwise neurologically intact. Which of the following is the most likely diagnosis?
Your Answer: Diabetic polyneuropathy
Correct Answer: Pronator teres syndrome
Explanation:Entrapment of the median nerve by pronator teres causes a median nerve neuropathy, which is worse during pronation of the forearm. Examination should involve excluding carpal tunnel syndrome and pronation of the affected forearm against resistance, which brings on the pain. Unlike carpal tunnel syndrome, the median nerve proximal to the wrist may be tender to palpation.
-
This question is part of the following fields:
- Neurology
-
-
Question 5
Correct
-
Which of the following physical findings is least typical on a patient with multiple sclerosis?
Your Answer: Decreased tone
Explanation:Attacks or exacerbations of multiple sclerosis (MS) are characterized by symptoms that reflect central nervous system (CNS) involvement, hence upper motor neuron symptoms are seen.
-
This question is part of the following fields:
- Neurology
-
-
Question 6
Incorrect
-
A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?
Your Answer: Genetic testing
Correct Answer: Phytanic acid
Explanation:The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb). -
This question is part of the following fields:
- Neurology
-
-
Question 7
Incorrect
-
A 53 year-old dancer presents to the ED with increasing weakness. She has no pertinent past medical history aside from a recent diarrhoeal illness, which she attributes to an undercooked chicken meal. Her husband says that she has been unable to get up out of a chair for the past day. Upon examination, there is bilateral limb weakness and areflexia noted, but it is more severe in the lower limbs. You notice that if she lies flat in the bed, her oxygen saturations fall by around 2% on the pulse oximeter and she is unable to perform spirometry. Which of the following represents the most appropriate immediate management of choice in this patient?
Your Answer: Plasma exchange
Correct Answer: ITU review for consideration of ventilation
Explanation:This woman has a history that is suggestive of Guillain– Barré syndrome. This may be precipitated by Campylobacter, and her history of recent diarrhoeal illness is pointing towards that. Certain features point to a poor prognosis, including rapidity of onset, reduced vital capacity or respiratory failure, age >40 and reduced amplitude of compound muscle action potential. Her inability to perform spirometry and desaturating whilst lying flat are suggestive of impending respiratory muscle weakness. Review for consideration of ventilation is recommended. Further management of choice for Guillain-Barre syndrome is IV immunoglobulins. Steroids have no value in the treatment of the condition.
-
This question is part of the following fields:
- Neurology
-
-
Question 8
Incorrect
-
A 41-year-old yoga instructor presents with a 2-month history of left-hand weakness. She has no significant past medical history. On examination, there is mild weakness of the left upper and lower limbs with a right sided facial weakness, which spares the forehead. Which of the following is the most likely location of the lesion?
Your Answer: Right cerebrum
Correct Answer: Right pons
Explanation:The pons is above the level of decussation of the corticospinal tracts so a pontine lesion would cause a contralateral limb weakness.
The facial motor nucleus is located in the pons and supplies the ipsilateral facial muscles.
A right cerebral lesion would give left upper and lower limb weakness. It would also cause a left sided facial weakness.
A left cerebral lesion would give right upper and lower limb weakness with right facial weakness.
Finally, a cervical spinal cord lesion would not cause a facial weakness. -
This question is part of the following fields:
- Neurology
-
-
Question 9
Correct
-
A 71 year-old dentist is seen in clinic with a history of worsening memory problems and confusion. His wife had noted that his sleep was becoming more disturbed and he complains of vivid nightmares and visual hallucinations. Over the past few weeks, he has had increasing difficulty in dressing himself, and his mobility has deteriorated. On examination, he is bradykinesic with a resting tremor and rigidity affecting his arms and legs. His Mini-Mental-State Examination (MMSE) is 18/30. Which of the following is the most likely diagnosis?
Your Answer: Lewy body disease
Explanation:Lewy body dementia is the second most common cause of dementia in the elderly after Alzheimer’s disease. The core feature is a progressive dementia, but other characteristic features include Parkinsonism, visual hallucinations, fluctuating cognitive abilities and executive function, and an increased risk of falls or autonomic failure.
-
This question is part of the following fields:
- Neurology
-
-
Question 10
Correct
-
A 60-year-old lady has been admitted to the stroke ward following a sudden onset of dizziness and visual disturbances, which started yesterday morning. She initially thought she was just dehydrated, however, later realised she was unable to read her own shopping list. On the ward rounds, the consultant examines her and finds she is indeed unable to read. She is, however, able to write. When she writes a sentence it makes perfect sense, although she is again unable to read it out. She has no problems with her speech and is able to converse normally. She has no motor focal neurological deficit. The consultant asks you where the lesion is likely to be?
Your Answer: Corpus callosum
Explanation:The patient presents with sudden onset of alexia (the inability to read) WITHOUT agraphia (inability to write) which is consistent with lesions of the corpus callosum where there is a disconnect syndrome and the patient’s language and visual centres are actually in tact, but are unable to communicate between hemispheres. In this case, the damage due to the stroke is most likely in the left visual cortex, leaving visual processing to the intact right hemisphere which unfortunately cannot communicate the information to the language centres (Broca and Wernicke’s) in the left hemisphere, hence the alexia. Alternatively, the speech and writing are unaffected as the language centres can still communicate with the primary motor cortex.
-
This question is part of the following fields:
- Neurology
-
-
Question 11
Incorrect
-
A 29-year-old physiotherapist with a history of bilateral vitreous haemorrhage is referred due to progressive ataxia. Which of the following is the most likely diagnosis?
Your Answer: Neurofibromatosis type I
Correct Answer: Von Hippel-Lindau syndrome
Explanation:Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage. Von Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3.
-
This question is part of the following fields:
- Neurology
-
-
Question 12
Incorrect
-
A 57-year-old architect presents with weakness of the right hand. You note global wasting of the small hand muscles. There is also sensory loss over the medial border of the forearm around the elbow. Which of the following nerve roots is damaged?
Your Answer:
Correct Answer: T1
Explanation:This patient has Klumpke’s paralysis due to damage to the T1 nerve root. This root eventually supplies the median and ulnar nerves. The ulnar nerve supplies all of the intrinsic hand muscles except for those of the thenar eminence and the first and second lumbricals, which are innervated by the median nerve.
-
This question is part of the following fields:
- Neurology
-
-
Question 13
Incorrect
-
A 40 year-old lawyer suffered a road traffic accident. MRI reveals that he may have hemisection of the spinal cord. Which of the following findings is most likely to occur?
Your Answer:
Correct Answer: Ipsilateral hyperreflexia
Explanation:Spinal cord hemisection, also known as Brown-Sequard syndrome, is associated with symptoms affecting one spinothalamic and one corticospinal tract. Symptoms include ipsilateral paralysis, loss of vibration and position sense, and hyperreflexia below the level of the lesion. Contralateral loss of pain and temperature sensation is also seen, usually beginning 2-3 segments below the level of the lesion.
-
This question is part of the following fields:
- Neurology
-
-
Question 14
Incorrect
-
A 6-year-old boy is referred by his GP to the neurology clinic with abnormal movements. His mother noticed that for the last year, the boy has been falling over more and more frequently. He has also been having increasingly slurred speech. These have been getting progressively worse. He has had recurrent chest infections in his childhood. What is the most likely diagnosis?
Your Answer:
Correct Answer: Ataxic telangiectasia
Explanation:Ataxic telangiectasia is an inherited combined immunodeficiency disorder that is characterised by cerebellar ataxia and telangiectasia as seen in this child, as well as frequent infections as noted in this child’s history. The other differentials would not present with this clinical picture:
Friedreich’s ataxia and Infantile-onset spinocerebellar ataxia do not present with immune problems, whereas Cerebral palsy and Di-George Syndrome do not present with ataxia.
-
This question is part of the following fields:
- Neurology
-
-
Question 15
Incorrect
-
A 71-year old gentleman presents with a subacute history of intermittent difficulty in walking, dry mouth, and variable slurring of speech. When the latter is severe he also has difficulty in swallowing. He has lost 3 kg in weight in the last 2 months. On examination he has bilateral mild ptosis, dysarthria, and proximal weakness of the upper and lower limbs, and he is areflexic. The degree of weakness is variable. Nerve conduction studies confirm the clinical suspicion of a neuromuscular junction disorder. Which of the following autoantibodies is likely to be the underlying cause of his neurological symptoms?
Your Answer:
Correct Answer: Anti-voltage-gated, calcium-channel antibody
Explanation:The clinical picture points to Lambert– Eaton myasthenic syndrome (LEMS) which often presents with weakness of the arms and legs. In LEMS, antibodies against voltage-gated calcium channels (VGCC) decrease the amount of calcium that can enter the nerve ending, causing autonomic symptoms like dry mouth and slurring of speech, as seen in this patient.
-
This question is part of the following fields:
- Neurology
-
-
Question 16
Incorrect
-
A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking and occasional loss of balance. He has a broad-based gait with cogwheel rigidity and intention tremor of his right arm. His blood pressure is 140/80 mmHg sitting and 100/60 mmHg standing. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Multiple system atrophy
Explanation:This patient presents with a combination of akinetic rigid syndrome, cerebellar signs and the suggestion of autonomic features. This is most indicative of a diagnosis of multiple system atrophy.
Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction, tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism) and ataxia.
-
This question is part of the following fields:
- Neurology
-
-
Question 17
Incorrect
-
A 36 year-old accountant presents with a sudden onset of headache which progressed to him collapsing. Upon arrival in A&E, he has a heart rate of 76 bpm, blood pressure 220/140, and Glasgow Coma Score of 9 (E2, M5, V2). Which of the following should be done immediately?
Your Answer:
Correct Answer: Give high flow oxygen via a non-rebreather mask
Explanation:This man is likely suffering from a subarachnoid haemorrhage or intracerebral bleed. The priority is to prevent a secondary brain injury. Important first steps include ensuring a secure airway, normalizing cardiovascular function, and treating seizures. His airway is likely to be protected with a GCS of 9, although he may benefit from a nasal or oral airway, and close attention should be paid to his airway if going for a CT scan. He should receive high flow oxygen and his blood pressure should not be treated acutely, as i is often appropriate to compensate for a rise in intracranial pressure. Nimodipine should be given if a subarachnoid haemorrhage is proven. Attention should also be given to maintaining a normal blood sugar, as hyperglycaemia worsens outcomes.
-
This question is part of the following fields:
- Neurology
-
-
Question 18
Incorrect
-
A 48-year-old hairdresser presented to her GP complaining of tingling in the right palm and right wrist pain. She had intermittently experienced these symptoms; however, recently they had been keeping her awake all night. She had noticed a reduction in grip and was struggling to work at the salon. Otherwise, she felt well in herself and had not noticed any weakness in the other hand or lower limb. Her weight was stable, and she denied any neck problems or swallowing difficulties. She had a past medical history of hypothyroidism and hypertension and took regular thyroxine, Bendroflumethiazide and ibuprofen. She was a non-smoker and rarely drank alcohol. On examination, she appeared alert and orientated. Fundoscopy and cranial nerve examination were all normal and neck movements were full. On examination of the upper limb, there was wasting over the right thenar eminence and fasciculations with a small burn over the right index finger. There was weakness of thumb abduction and opposition, with loss of pinprick and light touch sensation over the thumb, index and middle finger in the right hand. Nerve conduction studies showed absent sensory action potential in right median palmar branches and denervation of the right abductor pollicis brevis. What is the most likely diagnosis?
Your Answer:
Correct Answer: Median nerve palsy
Explanation:The history is consistent with carpal tunnel syndrome (CTS) arising as a result of pressure on the median nerve in the carpal tunnel. The median nerve supplies the muscles of the thenar eminence: the abductor pollicis (C7, C8), flexor pollicis brevis and opponens pollicis, and the lateral two lumbricals. The nerve conduction studies confirm marked denervation and absent sensory potentials within the median nerve territory.
-
This question is part of the following fields:
- Neurology
-
-
Question 19
Incorrect
-
A 46-year-old plumber develops chronic, severe pain after sustaining a brachial plexus injury as a result of a motorbike accident. He has had no benefit from paracetamol or ibuprofen. In addition, he has had an unsuccessful trial of amitriptyline. Following recent NICE guidelines, which of the following is the most appropriate medication to consider?
Your Answer:
Correct Answer: Pregabalin
Explanation:Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesia.
The most recent update to the NICE guidelines for management of neuropathic pain occurred in 2013: first-line treatment* includes amitriptyline. If the first-line drug treatment does not work then move on to one of the other 3 drugs: duloxetine, gabapentin or pregabalin. Tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain. Topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia). Pain management clinics may be useful in patients with resistant problems.*please note that for some specific conditions the guidance may vary. For example carbamazepine is used first-line for trigeminal neuralgia.
-
This question is part of the following fields:
- Neurology
-
-
Question 20
Incorrect
-
Which of the following peripheral neuropathy inducing clinical diagnoses is predominantly associated with sensory loss?
Your Answer:
Correct Answer: Uraemia
Explanation:Diseases that cause predominantly sensory loss include diabetes, uraemia, leprosy, alcoholism, vitamin B12 deficiency, and amyloidosis.
Those that cause predominantly motor loss include Guillain-Barre syndrome, porphyria, lead poisoning, hereditary sensorimotor neuropathies, chronic inflammatory demyelinating polyneuropathy, and diphtheria. -
This question is part of the following fields:
- Neurology
-
-
Question 21
Incorrect
-
A 13-year-old boy complains of several episodes of collapse. He describes the majority of these episodes occurring when he is laughing. He states that he loses power in his legs and falls to the ground. He is alert throughout and recovers quickly. He also describes excessive daytime sleepiness with episodes in the morning of being awake but being unable to move his body. Examination is unremarkable. A diagnosis of narcolepsy is made. Which of the following is the first line treatment for excessive daytime sleepiness?
Your Answer:
Correct Answer: Modafinil
Explanation:Narcolepsy is a rare condition characterised by excessive daytime sleepiness, sleep paralysis, hypnagogic hallucinations, and cataplexy (sudden collapse triggered by emotion such as laughing or crying). There is no cure for narcolepsy. Treatment options include stimulants, such as methylphenidate (Ritalin) or modafinil (Provigil), antidepressants, such as fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), sertraline (Zoloft) and sodium oxybate (Xyrem). Modafinil has replaced methylphenidate and amphetamine as the first-line treatment of excessive daytime sleepiness (EDS).
-
This question is part of the following fields:
- Neurology
-
-
Question 22
Incorrect
-
A 29 year-old new mother presented with a headache that was first noticed as she was picking up her 5 week-old baby. On admission, she was unable to tolerate the lights and complained of feeling sick. Fundoscopy showed bilateral papilledema, and she was complaining that she was unable to see on her left side. CT head showed a small right occipital bleed. Which of the following treatments is most appropriate?
Your Answer:
Correct Answer: Heparin
Explanation:This patient has developed a venous sinus thrombosis peri-partum, resulting in her symptoms. Anticoagulation therapy including Heparin improves outcomes.
-
This question is part of the following fields:
- Neurology
-
-
Question 23
Incorrect
-
A 20-year-old gentleman presents with drop foot following a sports injury. On examination there is weakness of ankle dorsiflexion and eversion, and weakness of extension of the big toe. He has some sensory loss restricted to the dorsum of his foot surrounding the base of his big toe. Other examination is within normal limits. Where is the most likely site of the lesion?
Your Answer:
Correct Answer: Common peroneal nerve at the head of the fibula
Explanation:Peroneal nerve injury is also known as foot drop. The common peroneal nerve supplies the ankle and toe extensor muscle groups as well as sensation over the dorsum of the foot; thus, there is also loss of sensation in these cases.
-
This question is part of the following fields:
- Neurology
-
-
Question 24
Incorrect
-
A 53-year-old cashier with a history of chronic back pain presents for a check-up. He is aware of a dragging feeling affecting his left foot when he tries to walk. This has developed since a minor injury to his left knee. On examination, he has weakness of dorsiflexion and eversion of the left foot. The right is unaffected and plantar flexion and inversion are normal on the left. MRI of the spinal cord shows degenerative disc changes at multiple levels, but no evidence of cord or nerve root impingement. Nerve conduction studies and EMG results are pending. Which of the following sensory loss patterns would you expect to find in association with this motor defect?
Your Answer:
Correct Answer: Sensory loss over the dorsum of the foot and anterolateral leg
Explanation:This patient presentation is unlikely to be an L5 nerve root lesion given the results of the MRI scan. Therefore, the most likely diagnosis is a mononeuritis affecting the left common peroneal nerve. This would lead to sensory loss over the dorsum of the foot and anterolateral leg on the left.
-
This question is part of the following fields:
- Neurology
-
-
Question 25
Incorrect
-
A 69 year-old librarian with motor neuron disease is seen in clinic. Which of the following interventions will have the greatest effect on survival?
Your Answer:
Correct Answer: Non-invasive ventilation
Explanation:Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before age 40 and various patterns of disease are recognised, including amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy.
Non-invasive ventilation (usually BIPAP) is used at night, with studies having shown a survival benefit of around 7 months. Riluzole prevents stimulation of glutamate receptors, used mainly in amyotrophic lateral sclerosis and has been shown to prolong life by about 3 months. -
This question is part of the following fields:
- Neurology
-
-
Question 26
Incorrect
-
An iv-drug abuser sustains an open head injury and is admitted overnight for observation. The next morning she is ok and is discharged. A week later she is re-admitted with fluctuating hard neurological signs. Blood results show neutrophilia and raised C-reactive protein (CRP). Which of the following is the best initial treatment step?
Your Answer:
Correct Answer: Computed tomography (CT) scan with contrast
Explanation:Increased WBC count and CRP suggest infection. But with the fluctuating hard neurological signs, there is suspicion of the presence of a cerebral mass, which is an indication for requesting for a CT scan with contrast, to rule out an abscess or haematoma. The lumbar puncture can be considered after the CT scan.
-
This question is part of the following fields:
- Neurology
-
-
Question 27
Incorrect
-
A 20-year-old gentleman presents to the A&E department complaining of a sudden-onset occipital headache associated with vomiting. His symptoms started 2 hours previously and are continuing. He has a previous history of infrequent migraine without aura, which also causes nausea but not vomiting. He rated his current headache as much more severe than his usual migraine. Examination is unremarkable. In particular, there is no neck stiffness or photophobia. Which of the following management options would be the most appropriate?
Your Answer:
Correct Answer: CT brain scan, followed by lumbar puncture if CT normal
Explanation:The patient presented with sudden-onset headache that is more painful than his usual migraine attacks. This gives a high suspicion of subarachnoid haemorrhage; thus, a CT brain scan should be ordered first to rule this out. However, a normal CT scan is apparent in 30% of patients with subarachnoid haemorrhage and should be referred for lumbar puncture to look for red blood cells.
-
This question is part of the following fields:
- Neurology
-
-
Question 28
Incorrect
-
A 25-year-old athlete presented with a 7-month history of difficulty gripping things. He complained of finding it particularly difficult in cold weather. He remembered his father having similar problems. Upon examination, he had a bilateral ptosis with weakness of the facial muscles. He also had difficulty opening his eyes quickly. Limb examination revealed distal weakness in both hands with difficulty opening and closing both hands quickly. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Myotonic dystrophy
Explanation:Myotonic dystrophy is the most likely diagnosis here.
It is a multisystem disorder causing cognitive impairment, cataracts, cardiac problems and testicular atrophy, as well as affecting the muscles. Patients have muscle weakness, normally worse distally, and/or myotonia (which is worse in cold weather).
On examination, patients may also have frontal balding, a myopathic facies, bilateral ptosis, an ophthalmoplegia and wasting of facial muscles and other limb muscles. Myotonic dystrophy is associated with diabetes mellitus and pituitary dysfunction.
Diagnosis is normally based on clinical features with a characteristic electromyogram (EMG) of myotonic discharges. Creatine kinase is generally normal and muscle biopsy is non-specific. -
This question is part of the following fields:
- Neurology
-
-
Question 29
Incorrect
-
A 66 year-old marketing analyst presents to the respiratory clinic with a 2-month history of progressive weakness and shortness of breath. He finds it difficult to stand from sitting, and struggles climbing stairs. He is an ex-smoker with chronic obstructive pulmonary disease (COPD). He had a recent exacerbation one month ago for which he was treated by the GP with a course of oral prednisolone, during which time his weakness transiently improved. On examination, you note a left-sided monophonic wheeze and reduced breath sounds at the left lung base. Blood tests and a chest x-ray are requested. Hb 145 g/L WCC10.5 109/L, Na+136 mmol/L, K+ 4.3 mmol/L, Urea 6.8 mmol/L, Creatinine 93 mmol/L, Calcium 2.62 mmol/L, Phosphate 1.44 mmol/L, Chest x-ray shows hyperinflated lungs, left lower lobe collapse and a bulky left hilum What is the most likely cause of this patient's weakness?
Your Answer:
Correct Answer: Lambert-Eaton myasthenic syndrome
Explanation:This man has a small-cell lung cancer (SCLC) and associated Lambert-Eaton myasthenic syndrome – a well-recognized paraneoplastic manifestation of SCLC. This classically affects the proximal muscles, especially in the legs, causing difficulty in standing from a seated position and climbing stairs. In contrast to myasthenia gravis, eye involvement is uncommon. Treatment with steroids is often helpful, which explains his transient symptomatic improvement during treatment for his COPD exacerbation. Steroid myopathy does not fit as the symptoms started well before his course of prednisolone. Although the patient is mildly hypercalcaemic, this would not be sufficient to produce his presenting symptoms, although it does reinforce the suspicion of lung malignancy. Motor neurone disease would be unlikely in this context and would not improve with steroids. Myasthenia gravis could produce these symptoms, but in the context of a new lung mass is a less viable diagnosis.
-
This question is part of the following fields:
- Neurology
-
-
Question 30
Incorrect
-
A 30-year-old painter presents with a burning pain in both feet, which has deteriorated over the last six months. He drinks 60 units of alcohol weekly and has a family history of pernicious anaemia. On examination he has impairment of all modalities of sensation in both feet but particularly pain, temperature and absent ankle jerks. What is the most likely diagnosis?
Your Answer:
Correct Answer: Alcoholic peripheral neuropathy
Explanation:Because of the patient’s history of excessive alcohol consumption, there is a strong suspicion of alcoholic peripheral neuropathy. In the UK, alcohol abuse and diabetes are the most common causes of peripheral neuropathy.
-
This question is part of the following fields:
- Neurology
-
SESSION STATS - PERFORMANCE PER SPECIALTY
