Blackboard EMQs Neuro Flashcards
A 30 year old man has been picked up in the street by police. He was initially drowsy but is now agitated & aggressive. His trousers are wet with urine.
For each of the following patients choose the single most likely diagnosis from the list of options. A. Delerium tremens B. Cerebrovascular accident C. Intoxication D. Post-ictal state E. Hypoxia F. Urinary tract infection G. Encephalitis H. Hypothyroidism I. Acute psychosis J. Dementia K. Hypothermia L. Hypoglycaemia
C. Intoxication
This man has had a little too much to drink and is simply intoxicated. He has wet himself. There are no signs or symptoms to suggest this is post-ictal. There is nothing to suggest this patient has had a seizure.
A 75 year old woman has gradually become confused over 3 or 4 years. She forgets the names & birthdays of her family. She gets lost when she goes shopping alone. She sometimes leaves her cooker on all night
For each of the following patients choose the single most likely diagnosis from the list of options. A. Delerium tremens B. Cerebrovascular accident C. Intoxication D. Post-ictal state E. Hypoxia F. Urinary tract infection G. Encephalitis H. Hypothyroidism I. Acute psychosis J. Dementia K. Hypothermia L. Hypoglycaemia
J. Dementia
Dementia is a syndrome with cognitive deterioration. Important differentials are depression, normal ageing and mild cognitive impairment, which need to be considered. It is highly prevalent in the elderly age group, affecting 30-50% by the age of 85. This patient has gradually become confused over 3-4 years, so there is a lower cognitive capability than their premorbid ‘baseline’ level and the progressive slow course suggests a degenerative process. A good history is necessary, from the patient, family, carers and friends to find out what the changes in cognitive function are and whether there are any behavioural, language or personality changes. This may also help you to figure out the exact disease process – for example, the patient may give a history of Parkinson’s, those with vascular dementia may have transient neurological symptoms and patients with NPH may have gait disturbances with urinary incontinence. The MMSE is the most widely used screening test for cognitive function and a score <24 is widely accepted as abnormal. Lab tests cannot diagnose dementia, but are done to find any potentially reversible causes or contributers such as hypothyroidism. A head CT or MRI is also indicated just in case there is a reversible cause like a tumour or hydrocephalus, and to aid diagnosis of the cause of dementia.
A 20 year old man is irritable & confused. He appears disturbed by loud noises. He is also complaining of a headache & has a pyrexia & mild neck stiffness.
For each of the following patients choose the single most likely diagnosis from the list of options. A. Delerium tremens B. Cerebrovascular accident C. Intoxication D. Post-ictal state E. Hypoxia F. Urinary tract infection G. Encephalitis H. Hypothyroidism I. Acute psychosis J. Dementia K. Hypothermia L. Hypoglycaemia
G. Encephalitis
Encephalitis (brain parenchyma inflammation) is not to be confused with meningitis where the meninges is inflammed (although meningoencephalitis can exist). In encephalitis, there is an altered state of consciousness (this patient is confused) and may there also be focal neurology. There is also a fever (exceptions, however, are subacute sclerosing panencephalitis, VZV and HCV). Other typical features include headache and seizures. It is a medical emergency and people are the extremes of age are more at risk. The list of possible causes is massive. If you suspect this diagnosis, empiral IV acyclovir should be started before the results of any investigations are known. A large proportion are caused by HSV and empirical therapy is backed up by RCTs which show improved mortality. You can change the treatment if the cause is known, for instance, ganciclovir for CMV. You should look for a rash which may give a clue to the aetiology. For example, vesicular patterns are seen in VZV, HSV and enteroviruses, EBV causes a maculopapular pattern after ampicillin, Lyme disease pathognomically gives erythema migrans whereas erythema nodosum might make you think of TB. The patient may also have animal/insect bites and a careful and thorough history is important.
A 75 year old woman was found on the floor at home having collapsed. She is drowsy & confused & has been incontinent of urine. She is shaking. Her pulse is 50 beats per min & her ECG shows J waves
For each of the following patients choose the single most likely diagnosis from the list of options. A. Delerium tremens B. Cerebrovascular accident C. Intoxication D. Post-ictal state E. Hypoxia F. Urinary tract infection G. Encephalitis H. Hypothyroidism I. Acute psychosis J. Dementia K. Hypothermia L. Hypoglycaemia
K. Hypothermia
Body temperature <35 degrees Celsius is the defining feature of hypothermia. ECG changes may appear as core temperature hits 32-33, with acute ST elevation and J waves (also called Osborn waves), which are pathognomic. This is an extra deflection at the end of the QRS and I suggest you go look at some images so it sticks. Rectal temperature is the best measure of core body temperature (followed by ear, then mouth). This patient needs to be removed from the cold environment, any wet or cold clothing removed, and then warmed with blankets. The patient will need constant monitoring and warm IV fluids, and the airway needs to be secured. Other signs this patient has include bradycardia, confusion (suggesting very severe hypothermia) and the urinary incontinence may be linked with diuresis induced by the cold, where the kidney effectively loses its concentrating ability. Those at risk of hypothermia include alcoholics and druggies (affects judgement so they fail to respond to the cold and alcohol, as well all know, causes a subjective feeling of warmth when you’re actually cold). Those with altered mental function like dementia, the homeless, elderly and infants/young children are all at increased risk
A 20 year old man, who was picked up by the police, is behaving irrationally & is confused & irritable. He is pale & sweaty & smells of alcohol. He keeps asking for biscuits.
For each of the following patients choose the single most likely diagnosis from the list of options. A. Delerium tremens B. Cerebrovascular accident C. Intoxication D. Post-ictal state E. Hypoxia F. Urinary tract infection G. Encephalitis H. Hypothyroidism I. Acute psychosis J. Dementia K. Hypothermia L. Hypoglycaemia
L. Hypoglycaemia
This patient is hypoglycaemic and has associated signs and symptoms (both sympathoadrenal and neuroglycopenic): he is confused, sweaty, pale, irritable and clearly hungry as he is asking for biscuits. He also smells of alcohol. Alcohol consumption decreases hepatic production of glucose and will contribute to hypoglycaemia. This patient needs glucose and/or glucagon before considering why he has become so hypoglycaemic in the first place. Can you think of some reasons?
A 30 year old man had an appendicectomy 2 days ago & is now agitated & confused. He is sweaty & has a marked tremor of his hands. He claims that his sleep was disturbed by insects in his bed.
For each of the following patients choose the single most likely diagnosis from the list of options. A. Delerium tremens B. Cerebrovascular accident C. Intoxication D. Post-ictal state E. Hypoxia F. Urinary tract infection G. Encephalitis H. Hypothyroidism I. Acute psychosis J. Dementia K. Hypothermia L. Hypoglycaemia
A. Delerium tremens
The Medical Council on Alcohol has a publication called ‘Alcohol and Health’ which is aimed at medical students and newly qualified doctors. I would recommend giving it a read. DT occurs as a result of alcohol withdrawal, although uncommonly (<5%) and usually starts 48-72 hours after cessation. It is characterised by a coarse tremor, agitation, fever, tachycardia, confusion, delusions and hallucinations. This patient also describes formication, which is a symptom that can be seen in alcohol withdrawal.
A 66 year old woman presents with fatigue, breathlessness & paraesthesiae in all limbs. Examination reveals pallor, loss of position sense & impaired vibration sense.
For each patient, choose the most likely diagnosis from the list of options. A. Drug induced B. Porphyria C. Diabetes Mellitus D. Sarcoid E. Trauma F. Amyloid G. Paraneoplastic syndrome H. Alcohol I. Renal failure J. Vitamin B12 deficiency
J. Vitamin B12 deficiency
There is loss of proprioception and vibration indicating degeneration of the dorsal column-medial lemniscus pathway. The patient may also have a positive Romberg as a result. Parasthesias are also common in B12 deficiency indicating peripheral neuropathy. Pallor and signs of frank anaemia are late signs. It is important to remember that hepatic B12 stores last for many years so B12 deficiency depends on chronic deficiency over a long period of time. In general, deficiency is caused by decreased intake, decreased gastric breakdown from food or malabsorption from the GIT. Serum B12 is a useful investigation to initially conduct and will guide further investigations and treatment. You should consider an underlying malabsorptive process such as coeliac or Crohn’s as a possible cause.
A 40 year old man with pulmonary tuberculosis is in the second month of treatment with isoniazid, rifampicin & pyrazinamide. He complains of a burning sensation in his hands & feet. There is impaired sensation to pin prick & light touch.
For each patient, choose the most likely diagnosis from the list of options. A. Drug induced B. Porphyria C. Diabetes Mellitus D. Sarcoid E. Trauma F. Amyloid G. Paraneoplastic syndrome H. Alcohol I. Renal failure J. Vitamin B12 deficiency
A. Drug induced
Pulmonary TB treatment involves 2 months of an intial phase of treatment with 4 months of continuation with just isoniazid and rifampicin. Isoniazid acts only on mycobacteria and inhibits mycolic acid synthesis. Isoniazid can commonly cause peripheral neuropathy (which is why pyridoxine (vitamin B6) 10mg daily is given as prophylaxis, as it is because of deficiency of this substance which leads to CNS and PNS effects). The peripheral neuropathy is more likely to occur if the patient has co-existing risk factors like DM, CRF, pregnancy and HIV, or is malnourished.
An 18 year old woman is admitted with very severe abdominal pain & confusion. She is noted to have bilateral wrist drop. She had recently started the oral contraceptive pill.
For each patient, choose the most likely diagnosis from the list of options. A. Drug induced B. Porphyria C. Diabetes Mellitus D. Sarcoid E. Trauma F. Amyloid G. Paraneoplastic syndrome H. Alcohol I. Renal failure J. Vitamin B12 deficiency
B. Porphyria
There are many types of porphyria. This patient has acute intermittent porphyria, which is characterised by symptoms like the ones this patient describes – abdominal pain, peripheral motor neuropathy, mental symptoms like confusion. These symptoms, certainly in EMQs, can be trigged by the use of certain drugs which are known to provoke AIP attacks. In reality, the list of drugs is pretty vast and include most CYP450 inducers, but in EMQs, alcohol and the OCP are common. Alcohol also induces an enzyme called delta-aminolevulinic acid synthase, which can exacerbate AIP. It is probably not worth learning the pathways unless you plan on sitting USMLE. AIP is a genetic disorder where there is a partial deficiency of PBGD (the third enzyme in the haem biosynthetic pathway). Treatment of acute attacks involves IV haem arginate with adjunctive dextrose IV. The pain is thought to be neuropathic in origin. The patient may complain of red/browny urine due to increased urinary excretion of intermediates in the haem pathway.
A 67 year old overweight Asian woman presents with painful feet. Direct questioning revealed that she has had nocturia for the last 3 months.
For each patient, choose the most likely diagnosis from the list of options. A. Drug induced B. Porphyria C. Diabetes Mellitus D. Sarcoid E. Trauma F. Amyloid G. Paraneoplastic syndrome H. Alcohol I. Renal failure J. Vitamin B12 deficiency
C. Diabetes mellitus
Nocturia with diabetic peripheral neuropathy in an overweight woman (obesity and insulin resistance are linked) point to DM. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. First line intervention in this situation, and in newly diagnosed DM is diet and lifestyle advice and changes.
A 55 year old smoker presents with rapidly progressing weight loss with severe burning pain in his hands & feet. Chest x-ray shows a small round opacity in the right upper lobe.
For each patient, choose the most likely diagnosis from the list of options. A. Drug induced B. Porphyria C. Diabetes Mellitus D. Sarcoid E. Trauma F. Amyloid G. Paraneoplastic syndrome H. Alcohol I. Renal failure J. Vitamin B12 deficiency
G. Paraneoplastic syndrome
Paraneoplastic syndrome, is something which occurs as a result of cancer (but not due to the local cancer cells itself). This patient has lung cancer and paraneoplastic manifestations of sensory neuropathy associated with small cell lung cancer. Small cell lung cancer is treated with chemotherapy and is also associated with SIADH and ectopic ACTH.
A 30 year old woman has developed ear pain & facial weakness. On otoscopy she has an inflamed, bulging tympanic membrane.
For each patient choose the most likely underlying diagnosis from the list of options. A. Stroke B. Trauma C. Sarcoidosis D. Ramsay Hunt syndrome E. Otitis media F. Multiple sclerosis G. Bell’s palsy H. Post-meningitis I. Brainstem tumour J. Parotid tumours K. Cholesteatoma
E. Otitis media
Otitis media is infection of the middle ear and can occur as a result of complicated respiratory illness. The otalgia this patient describes is characteristic, and there may be decreased hearing, vomiting and fever, usually in the presence of a viral respiratory infection. Examination with an otoscope is diagnostic and will reveal an inflammed bulging tympanic membrane with decreased mobility. The membrane may be pink, red, yellow or white. Treatment involves analgesia, and may also include antibiotics. Complications can include the facial weakness this patient has developed in the form of a CNVII palsy, and perforation of the eardrum, mastoiditis and sigmoid sinus thrombosis.
A 35 year old woman has suddenly developed facial palsy. 6 months before this, she had an episode of blurred vision & unsteadiness. On examination, she has mild ataxia and an afferent pupillary defect.
For each patient choose the most likely underlying diagnosis from the list of options. A. Stroke B. Trauma C. Sarcoidosis D. Ramsay Hunt syndrome E. Otitis media F. Multiple sclerosis G. Bell’s palsy H. Post-meningitis I. Brainstem tumour J. Parotid tumours K. Cholesteatoma
F. Multiple sclerosis
MS is a demyelinating CNS condition which is characterised by 2 or more episodes of neurological dysfunction which are separated in both time and space. This person has had blurred vision and now 6 months later has developed facial palsy. A RAPD is seen in a Marcus Gunn pupil which is tested for with the swinging light test in a CN examination and can be caused by any disease affecting the optic nerve. MS classically presents in white women aged 20-40 with temporary visual/sensory loss although any presentation can occur. MRI is a sensitive test but less specific than spinal MRI, however, spinal MRI is abnormal in fewer cases. Treatment aims at treating the attack, preventing future attacks and symptomatic treatment of problems like bladder dysfunction, pain and fatigue.
A 70 year old man has suddenly developed facial weakness, which was preceded by 2 days of severe left ear pain, vertigo & deafness. On examination, he has red vesicles in his ear canal and on the hard palate.
For each patient choose the most likely underlying diagnosis from the list of options. A. Stroke B. Trauma C. Sarcoidosis D. Ramsay Hunt syndrome E. Otitis media F. Multiple sclerosis G. Bell’s palsy H. Post-meningitis I. Brainstem tumour J. Parotid tumours K. Cholesteatoma
D. Ramsay Hunt syndrome
Ramsay Hunt syndrome is reactivation of VZV in the geniculate ganglion and the syndrome consists of CNVII palsy caused by herpes zoster. There is ear pain and an erythematous vesicular rash in the ear canal and on the hard palate which is characteristic of VZV. There is also vertigo in this patient and hearing loss, which is due to CNVIII being affected, due to being in close proximity to the geniculate ganglion. Acyclovir is needed but the damage may well be permanent.
A 50 year old woman has developed complete palsy of the left side of the face including the forehead. She also has mild facial pain & watering of the eye on that side. Her sense of taste is impaired.
For each patient choose the most likely underlying diagnosis from the list of options. A. Stroke B. Trauma C. Sarcoidosis D. Ramsay Hunt syndrome E. Otitis media F. Multiple sclerosis G. Bell’s palsy H. Post-meningitis I. Brainstem tumour J. Parotid tumours K. Cholesteatoma
G. Bell’s palsy
Bell’s palsy is idiopathic unilateral LMN CNVII palsy. It is a diagnosis of exclusion as the aetiology is unknown, so the CNVII palsy of RHS in the previous question is not Bell’s palsy. Corticosteroids are effective and surgical decompression can be considered in severe cases. Eye protection should be considered too. This condition tends to resolve itself by 4-6 months. Think about what you’d expect to find on examination of CNVII. CNVII supplies taste to the anterior 2/3 of the tongue. Think back to anatomy. CNVII supplies all the muscles of facial expression, stapedius and some other muscles (posterior belly of digastric, stylohyoid and occipitofrontalis). It is sensory to the external auditory meatus (via the nervus intermedius). It is parasympathetic via the same nerve, to supply the submandibular and sublingual glands. The same nerve also carries taste sensation in the anterior two thirds of the tongue, and innervates the palate. Do you still remember the branches of the facial nerve?
A 56 year old woman with a history of atrial fibrillation develops sudden weakness of the right side of her face. She is still able to wrinkle both sides of her forehead & her smile is symmetrical. For each patient choose the most likely underlying diagnosis from the list of options. A. Stroke B. Trauma C. Sarcoidosis D. Ramsay Hunt syndrome E. Otitis media F. Multiple sclerosis G. Bell’s palsy H. Post-meningitis I. Brainstem tumour J. Parotid tumours K. Cholesteatoma
A. Stroke
This is an UMN CNVII lesion as the forehead is spared. A stroke is a cause of an UMN lesion (as is a tumour, although both of these in the brainsteam can cause a LMN lesion) and the patient’s history of AF (which can throw off an emboli to cause an ischaemic stroke) and sudden onset of symptoms is highly suggestive. It is important is perform a CT head exclude a haemorrhagic aetiology and consider thrombolysis with tPA if within the 4.5 hour window and there are no contraindications. Thrombolysis is done with alteplase at 10% bolus, 90% infusion at a dose of 0.9 mg/kg. Presentation after the 4.5 hour window is managed with aspirin. The Bamford/Oxford Stroke Classification subtypes ischaemic stroke according to vascular territory of infarction. After initial management, stroke care involves the ethos of an MDT environment with rehabilitation.
A 35 year old man has developed a slowly progressive right-sided facial palsy with deafness & tinnitus. As well as facial asymmetry, he is unable to abduct his right eye. His father had been similarly affected.
For each patient choose the most likely underlying diagnosis from the list of options. A. Stroke B. Trauma C. Sarcoidosis D. Ramsay Hunt syndrome E. Otitis media F. Multiple sclerosis G. Bell’s palsy H. Post-meningitis I. Brainstem tumour J. Parotid tumours K. Cholesteatoma
I. Brainstem tumour
Let us review the nerves that are damaged here – CNVII, CNVIII, CNVI. A cholesteatoma can involve VII (rarely) and tinnitis and hearing loss tends to be what the patient presents with but this will not explain LR dysfunction. Also, there will likely be a purulent discharge from the ear which is malodorous, and examination by a hopefully not incompetent doctor will include otoscopy, where typically, you would see crust in the attic, pars flaccida or tensa and possible perforation of the ear drum. The only thing on the list which would explain all three nerve lesions is a brainstem tumour, which also agrees with the slowly progressive presentation (the tumour is likely growing). The question you might be asking is, where or what is this lesion? Have a think about it and I will tell you what I think it is below. I think this is a lesion at the cerebellopontine angle – a vestibular schwannoma (acoustic neuroma). There is likely to be facial numbness in this patient too i.e. CNV, VII, VIII lesions. And how do you explain the CNVI lesion? Raised intracranial pressure. It helps if you know your anatomy so you can try and figure out the cause of CN lesions. For example, nerves III, IV, Va and VI makes you think of what?
An elderly lady is found collapsed & confused at home by her district nurse. She had been fit & well until 3 days ago when she started behaving oddly & yesterday her neighbour found her wandering around in the road in her dressing gown. On examination, she has a low-grade fever, a tender abdomen & an unpleasant smell.
For each patient choose the most appropriate diagnosis from the list. A. Diabetic ketoacidosis B. Alcohol withdrawal C. Phenytoin toxicity D. Schizophrenia E. Subdural haematoma F. Ecstasy overdose G. Meningitis H. Urinary tract infection I. Dementia J. Hepatic encephalopathy
H. Urinary tract infection
10% of women >70 have a UTI. This is the cause of this elderly lady’s confusion. Her set of symptoms (confusion, fever, abdominal tenderness) are not explained by any of the other conditions given on the list. A UTI, in uncomplicated cases is most commonly caused by E coli. It is diagnosed with a dipstick and urine MC+S from an MSU sample. Have a think about what the dipstick would show. Antibiotic therapy should be guided by local sensitivities and guidelines, or MC+S results. Nitrofurantoin or co-trimoxazole could be used.
A 62 year old hotel owner is in hospital for investigation of his jaundice. When you come to see him in the morning he is slurring his speech & doesn’t seem to know where he is. You can’t help noticing that his abdomen is grossly distended & his breath smells strangely sweet.
For each patient choose the most appropriate diagnosis from the list. A. Diabetic ketoacidosis B. Alcohol withdrawal C. Phenytoin toxicity D. Schizophrenia E. Subdural haematoma F. Ecstasy overdose G. Meningitis H. Urinary tract infection I. Dementia J. Hepatic encephalopathy
J. Hepatic encephalopathy
This patient has decompensated chronic liver disease (he is in liver failure) which has resulted in neurological symptoms associated with hepatic encephalopathy. The brain is exposed to ammonia which bypasses the liver by portosystemic shunting. It is a diagnosis of exclusion and tests will need to be conducted to rule out other potential causes of confusion. The findings of jaundice, ascites and fetor hepaticus (liver failure) are all signs of liver disease. Think about the other signs you might see like spider naevi and palmar erythema. This patient may also have asterixis which is a coarse flapping tremor. HE is likely caused by a host of factors. This patient’s LFTs will be abnormal and he is likely to have coagulopathy too (PT will be elevated).
A 21 year old diabetic student is brought into A&E by his friends. They say he has been acting weirdly all night & wondered if he was on drugs. A couple of hours ago he developed a fever & started vomiting. When you meet him he seems very irritable & is complaining that the lights are too bright. Examination reveals an erythematous rash over his back
For each patient choose the most appropriate diagnosis from the list. A. Diabetic ketoacidosis B. Alcohol withdrawal C. Phenytoin toxicity D. Schizophrenia E. Subdural haematoma F. Ecstasy overdose G. Meningitis H. Urinary tract infection I. Dementia J. Hepatic encephalopathy
G. Meningitis
This patient has meningitis. Universities are common sites of outbreaks due to crowding. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. Kernig’s sign is uncommon but is positive when attempts to extend the leg are met with resistance when the patient is supine with the thigh flexed to 90 degrees. Another uncommon sign is Brudzinski’s sign and a petechial/purpuric rash, typically associated with meningococcal meningitis. CT head should be considered before LP if there is any evidence of raised ICP. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen.
You are called to see a 45 year old man who is known to have suffered a subarachnoid haemorrhage 2 months ago. In hospital he was prescribed an anti-convulsant to reduce the risk of seizure & has continued to take it, despite being discharged a fortnight ago. Over the past week he has become increasingly confused, lethargic & ataxic. On examination, he has nystagmus & an intention tremor & shows past-pointing
For each patient choose the most appropriate diagnosis from the list. A. Diabetic ketoacidosis B. Alcohol withdrawal C. Phenytoin toxicity D. Schizophrenia E. Subdural haematoma F. Ecstasy overdose G. Meningitis H. Urinary tract infection I. Dementia J. Hepatic encephalopathy
C. Phenytoin toxicity
PHT has an unpredictable pharmacokinetic behaviour. It is 80-90% bound to albumin (competitive binding by drugs such as salicylates increase free PHT). It is metabolised by hepatic mixed function oxidase and metabolism can be either induced or inhibited by drugs which share the same hepatic enzymes. It has a narrow therapeutic range of around 40-100 micromol/l and there is a lot of individual variation in the plasma concentration achieved with a fixed dose and unwanted effects tend to occur >100 micromol/l. The symptoms include those seen like nystagmus, confusion, headache, ataxia and vertigo. Chronic use is also associated with unwanted effects like gum hyperplasia and use is associated with fetal malformations like cleft palate (associated with epoxide formation in metabolism).
A 37 year old man has had half his ear bitten off in a fight & is admitted under the plastic surgeons. After being on the ward for a day & a half he becomes extremely agitated, claiming to see spiders & snakes crawling up the walls. Examination shows him to be tachycardic & sweaty but is otherwise unremarkable.
For each patient choose the most appropriate diagnosis from the list. A. Diabetic ketoacidosis B. Alcohol withdrawal C. Phenytoin toxicity D. Schizophrenia E. Subdural haematoma F. Ecstasy overdose G. Meningitis H. Urinary tract infection I. Dementia J. Hepatic encephalopathy
B. Alcohol withdrawl
This is a case of alcohol withdrawal experienced by some 40% of alcohol abusers who subsequently come off alcohol. Scary auditory and visual hallucinations can occur along with the symptoms described including tachycardia, anxiety, sweating, tremor, nausea, retching and a mild pyrexia. Acutely, this should be treated with a BDZ such as chlordiazepoxide. It can progress to delirium tremens with seizures, hallucinations, coma and death.
A 90 year old woman who uses a Zimmer frame because of her OA & general frailty. She has a 3 day weakness of her left arm, which has worsened. Yesterday, she could not walk & became confused & incontinent. You find a flaccid paralysis of her arm & weakness of power in her leg.
Choose the most likely diagnosis A. Food poisoning B. Alzheimer’s disease C. Electrolyte disturbance D. Severe anxiety state E. Urinary tract infection F. Opiate poisoning G. Chronic subdural haematoma H. Alcohol withdrawal I. Multi-infarct dementia J. Digoxin toxicity
G. Chronic subdural haematoma
A subdural occurs due to blood collecting between the dura mater and the arachnoid mater surrounding the brain. It may be arterial or venous although is most often venous. The disease course varies, and in this case this is chronic with confusing, incontinence (both bowel and bladder can occur), and focal neurology. There is neurological deficit evident so surgery will be indicated. The cause is trauma and this frail old lady will most likely have had many falls. Advanced age is associated with chronic subdurals. Chronic subdural haematomas are usually hypodense on head CT. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. This patient is symptomatic and surgical options include twist-drill craniotomy with drainage (a bedside procedure where a hand drill is used to gain access to the subdural space and then a catheter is placed to act as a drain). Standard craniotomy is also an option, as is the creation of a burr hole. Remember that extradural haematomas classically have a ‘lucid interval’ and occur in younger patients, usually with an associated skull fracture, and CT of the haematoma does not cross suture lines.
A very old patient in a nursing home, who has had 3 strokes & who is catheterised. She takes aspirin, & bendrofluazide for her blood pressure. She has become confused with a fever.
Choose the most likely diagnosis A. Food poisoning B. Alzheimer’s disease C. Electrolyte disturbance D. Severe anxiety state E. Urinary tract infection F. Opiate poisoning G. Chronic subdural haematoma H. Alcohol withdrawal I. Multi-infarct dementia J. Digoxin toxicity
E. Urinary tract infection
The indwelling catheter is a significant risk factor for UTI, which can present with a fever and confusion. Other risk factors this patient has: advanced age and post-menopause. It is diagnosed with a dipstick and urine MC+S from an MSU sample. Have a think about what the dipstick would show. Antibiotic therapy should be guided by local sensitivities and guidelines, or MC+S results. Nitrofurantoin is usually effective.
A 30 year old man who lost his job as a publican 3 days ago. He has become confused, sweaty, & his limbs shake. He is very scared by these symptoms. His pulse is 120 & his blood pressure 100/60.
Choose the most likely diagnosis A. Food poisoning B. Alzheimer’s disease C. Electrolyte disturbance D. Severe anxiety state E. Urinary tract infection F. Opiate poisoning G. Chronic subdural haematoma H. Alcohol withdrawal I. Multi-infarct dementia J. Digoxin toxicity
H. Alcohol withdrawal
This is a case of alcohol withdrawal experienced by some 40% of alcohol abusers (this man is a publican) who subsequently come off alcohol. Symptoms include confusion, tachycardia, anxiety, sweating, tremor, nausea, retching and a mild pyrexia. Acutely, this should be treated with a BDZ such as chlordiazepoxide. It can progress to delirium tremens (which this patient may have) with seizures, hallucinations, coma and death.
A 70 year old woman was brought in by her husband. She has become more forgetful over the last few months. Last night she had let a pan of water boil dry & almost burnt the house down.
Choose the most likely diagnosis A. Food poisoning B. Alzheimer’s disease C. Electrolyte disturbance D. Severe anxiety state E. Urinary tract infection F. Opiate poisoning G. Chronic subdural haematoma H. Alcohol withdrawal I. Multi-infarct dementia J. Digoxin toxicity
B. Alzheimer’s disease
This is Alzheimer’s dementia which is a progressive irreversible disorder characterised by memory loss, loss of social function and dimished executive function. The disease runs a deteriorating course and lesions in the brain are characterised by neurofibrillary tangles, plaques of beta amyloid and neurone loss with cortical atrophy. Cholinesterase inhibitors can be used (donepezil, rivastigmine, galantamine). Depression is common in AD and antidepressants may also be indicated. Carer support is crucial and remains the mainstay of treatment with an MDT ethos involving for example, OTs to assess home safety.
A 19 year old girl found collapsed outside a local nightclub. She is drowsy, confused with abdominal cramps & diarrhoea. She is difficult to examine but you notice bilateral small pupils.
Choose the most likely diagnosis A. Food poisoning B. Alzheimer’s disease C. Electrolyte disturbance D. Severe anxiety state E. Urinary tract infection F. Opiate poisoning G. Chronic subdural haematoma H. Alcohol withdrawal I. Multi-infarct dementia J. Digoxin toxicity
F. Opiate poisoning
The history in a nightclub suggests opiate OD. Signs include CNS depression, miosis and apnoea. Opiate use is normally associated with constipation but the history and findings of small constricted pupils are still indicative. Naloxone is indicated both therapeutically and diagnostically. If there is a response, then it is diagnostic. Another diagnosis should be sought if the patient is unresponsive. IV is the preferred route of administration although naloxone can be given IM or SC if IV access cannot be established. Ventilatory support is key with 100% oxygen. You can check out Toxbase for a full database on poisons and treatments.
A 45 year old type 1 diabetic patient presents with a history of feeling light headed. On examination, he is noted to have a blood pressure of 150/90 lying & 125/70 on standing.
Choose the most appropriate diagnosis A. Abducent (VI) nerve palsy B. Amaurosis fugax C. Common peroneal nerve palsy D. Sciatica E. Peripheral neuropathy F. Carpal tunnel syndrome G. Ulnar nerve palsy H. Occulomotor (III) nerve palsy I. Autonomic neuropathy J. Retinopathy K. Diabetic amyotrophy
I. Autonomic neuropathy
Diabetic neuropathy can be autonomic or peripheral. This patient has postural hypotension (measure BP supine and then standing after 1, 2, 3 and sometimes 5 minutes – an abnormal drop when standing is indicative). Other symptoms of autonomic neuropathy include… resting tachycardia (late findings due to vagal impairment), impaired HR variation, erectile dysfunction (affects many diabetic men though is not solely due to autonomic neuropathy), decreased libido, dyspareunia, and urinary symptoms of frequency, urgency, incontinence, nocturia, weak stream and retention. Other symptoms include constipation, faecal incontinence and sweating dysfunction. Fludrocortisone may be helpful.
A 73 year old, previously fit male presents with difficulty ascending stairs. Abnormalities noted on examination are weakness of knee flexion, which is more pronounced on the left with some wasting of the quadriceps & diminished knee reflexes. He is noted to have glycosuria
Choose the most appropriate diagnosis A. Abducent (VI) nerve palsy B. Amaurosis fugax C. Common peroneal nerve palsy D. Sciatica E. Peripheral neuropathy F. Carpal tunnel syndrome G. Ulnar nerve palsy H. Occulomotor (III) nerve palsy I. Autonomic neuropathy J. Retinopathy K. Diabetic amyotrophy
K. Diabetic amyotrophy
Diabetic amyotrophy, more common in T2DM, is an uncommon peripheral diabetic neuropathic complaint. It presents with severe muscle weakness and pain with proximal thigh muscle atrophy. This patient’s glycosuria suggests undiagnosed T2DM, which in any case, you can guess he has given the question stem is called ‘Diabetic Complications’. The weak knee flexion and quadriceps wasting is typical of diabetic amyotrophy. The reduced reflexes are another sign of peripheral neuropathy.
A 62 year old male diabetic presents with a sudden onset of double vision. He is noted to have ptosis and a deviation of the right eye down and to the right. The pupils appear equal in size and are reactive to light.
Choose the most appropriate diagnosis A. Abducent (VI) nerve palsy B. Amaurosis fugax C. Common peroneal nerve palsy D. Sciatica E. Peripheral neuropathy F. Carpal tunnel syndrome G. Ulnar nerve palsy H. Occulomotor (III) nerve palsy I. Autonomic neuropathy J. Retinopathy K. Diabetic amyotrophy
H. Occulomotor (III) nerve palsy
A complete (or surgical) third nerve palsy presents with compete ptosis, a dilated pupil and the eye turned down and out and can be caused by a PCA aneurysm. This is an emergency and the patient needs a neurosurgical opinion with MRI/angiography. A partial pupil-sparing (or medical) third nerve palsy presents with partial ptosis without pupillary signs and can be caused by infarction of the nerve i.e. mononeuritis multiplex, due to possible DM or vasculitis like GCA.
Remember from anatomy that CNIII innvervates all the mucles of the eye except SO and LR. CNIII also supplies levator palpebrae superioris and the sphincter pupillae which causes miosis. If the cause is surgical and compressive, the parasympathetic nerve is affected early on, as it lies at the surface of the third nerve. In an infarctive medical third nerve palsy, the centre infarcts, which is affected more than the surface of the nerve. Hence, the pupil is spared and there is partial ptosis.
A 66 year old male with type 2 diabetes complains of episodes of loss of vision in the right eye that may last up to 2 hours. On examination he is noted to have an irregularly irregular pulse of 70 beats per minute & a blood pressure of 155/95. Fundoscopy is normal.
Choose the most appropriate diagnosis A. Abducent (VI) nerve palsy B. Amaurosis fugax C. Common peroneal nerve palsy D. Sciatica E. Peripheral neuropathy F. Carpal tunnel syndrome G. Ulnar nerve palsy H. Occulomotor (III) nerve palsy I. Autonomic neuropathy J. Retinopathy K. Diabetic amyotrophy
B. Amaurosis fugax
Amaurosis fugax is a transient and painless loss of vision in one eye due to the passage of an embolus into the central retinal artery. The AF has thrown off a cardiac embolus which has passed into the central retinal artery (resulting in a temporary loss of blood flow to the retina and hence loss of vision). This patient needs to be started on aspirin at once while a definitive treatment of the underlying aetiology is sought (treatment of AF). How would you treat AF?
A 56 year old type 2 diabetic female is admitted with pain in the feet that keeps her awake at night. The only abnormality noted on examination is loss of vibration sensation up to the mid-tibia bilaterally
Choose the most appropriate diagnosis A. Abducent (VI) nerve palsy B. Amaurosis fugax C. Common peroneal nerve palsy D. Sciatica E. Peripheral neuropathy F. Carpal tunnel syndrome G. Ulnar nerve palsy H. Occulomotor (III) nerve palsy I. Autonomic neuropathy J. Retinopathy K. Diabetic amyotrophy
E. Peripheral neuropathy
This is a case of diabetic peripheral sensory neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. There tends to be loss of sensation typically occuring in a symmetrical ‘glove and stocking’ distribution. Patient’s may also describe a pain (like this one) or unpleasant sensation which is prickling, burning or sticking. Examination should include peripheral pulses, reflexes and sensation to light touch, vibration (128Hz tuning fork), pinprick and proprioception. Any pain can be treated with medications like gabapentin.
A 25 year old, highly stressed Junior House Officer complains of a headache that has been persistent for weeks. She describes the pain as being “like a tight band around her head”. Over the counter medication has been used to no avail.
Choose the single most likely diagnosis from the list of options. A. Congenital heart disease B. Tension headache C. TIA D. Bacterial meningitis E. Cervical spondylosis F. Stroke G. Trigeminal neuralgia H. Cerebral tumour I. Subarachnoid haemorrhage J. Extradural haemorrhage K. Encephalitis L. Migraine
B. Tension headache
A tension headache is commonly triggered by stress and mental tension (also, fatigure and missing meals), hence the name. It is more common in females and those in middle age, and there is a link with lower socioeconomic status, although this does not necessarily represent causation. Symptoms include a dull, non-pulsatile and constricting bilateral pain, which is often described as a band across the patient’s head. It is not severe or disabling but classically worsens as the day progresses. This headache normally responds well to simple analgesics.
A 40 year old housewife complains of a repeated history of a unilateral throbbing headache lasting several hours for 6 months. The headache is associated with a disturbance of vision. She claims that eating cheese may trigger it.
Choose the single most likely diagnosis from the list of options. A. Congenital heart disease B. Tension headache C. TIA D. Bacterial meningitis E. Cervical spondylosis F. Stroke G. Trigeminal neuralgia H. Cerebral tumour I. Subarachnoid haemorrhage J. Extradural haemorrhage K. Encephalitis L. Migraine
L. Migraine
Migraine is a chronic condition, with genetic determinants, which usually presents in early to mid life. The typical migraine aura this patient describes (which can be visual, sensory or speech symptoms) which can occur during or before the headache, is pathognomic, but is not seen in the majority of patients. The aura can be positive phenomena (for example seeing flashing lights) or negative phenomena (for example visual loss). Nausea, photophobia and disability (the headache gets in the way with the patient’s ability to function) accompanying a headache suggest a migraine diagnosis. The headache of a migraine tends to be prolonged if untreated, and tends to be unilateral and pounding (but does not have to be). Tests aim to rule out other differentials, although if the history is compatible and neurological examination is unremarkable, further testing is not needed. Important red flags which make you think of another dangerous cause can be summed up by the mnemonic SNOOP.
Systemic symptoms: fever, weight loss
Neurological symptoms: confusion, impaired consciousness
Onset: sudden or split-second
Older: new-onset/progressive headache, especially in those >50 (making you think of GCA
PMH: first headache, or something different about this one compared to the usual
Treatment of this chronic condition aims at treating acute attacks to restore function. Triptans can be used in specialist care. These are 5HT1 agonists. Effective initial treatment in a primary care setting can involve NSAIDs, which are available OTC. Treatment should be taken as soon as a patient realises they are having an attack and may need to be repeated after the attack. A few patients who have frequent, severe or disabling headaches may require daily prophylaxis such as anticonvulsants, TCAs and beta blockers.
A 19 year old male 1st year university student complains of a rapidly developing headache & a stiff neck. He has been vomiting & his friends say that he cannot stand to be in bright rooms. Examination reveals a pyrexia of 37.5 degrees Celsius.
Choose the single most likely diagnosis from the list of options. A. Congenital heart disease B. Tension headache C. TIA D. Bacterial meningitis E. Cervical spondylosis F. Stroke G. Trigeminal neuralgia H. Cerebral tumour I. Subarachnoid haemorrhage J. Extradural haemorrhage K. Encephalitis L. Migraine
D. Bacterial meningitis
This patient has meningitis. Universities are common sites of outbreaks due to crowding. Commonly there will be a headache, fever and nuchal rigidity. There may also be an altered mental status, confusion, photophobia and vomiting. Kernig’s sign is uncommon but is positive when attempts to extend the leg are met with resistance when the patient is supine with the thigh flexed to 90 degrees. Another uncommon sign is Brudzinski’s sign and a petechial/purpuric rash, typically associated with meningococcal meningitis.
CT head should be considered before LP if there is any evidence of raised ICP. An LP will confirm the diagnosis with bacterial meningitis showing a low CSF glucose, elevated CSF protein and positive CSF culture/gram stain or meningococcal antigen.
A 70 year old man presents to his GP surgery with repeated episodes left sided hemiparesis. A recent ECG reveals that he is in atrial fibrillation. His symptoms fully resolve within 24 hours.
Choose the single most likely diagnosis from the list of options. A. Congenital heart disease B. Tension headache C. TIA D. Bacterial meningitis E. Cervical spondylosis F. Stroke G. Trigeminal neuralgia H. Cerebral tumour I. Subarachnoid haemorrhage J. Extradural haemorrhage K. Encephalitis L. Migraine
C. TIA
A TIA is colloquially called a ‘mini stroke’ with symptoms typically lasting under an hour. An antiplatelet drug such as aspirin is effective secondary prevention if the patient is not already anticoagulated. The patient will be anticoagulated if they have a likely or known cardioembolic source such as AF. Clopidogrel is an alternative in those who do not tolerate aspirin.
A 55 year old known hypertensive male complains of a sudden devastating occipital headache. He says that he feels as though he had “been kicked in the head” even though he has not experienced any trauma in the last few weeks. He is feeling drowsy & during the examination he loses consciousness.
Choose the single most likely diagnosis from the list of options. A. Congenital heart disease B. Tension headache C. TIA D. Bacterial meningitis E. Cervical spondylosis F. Stroke G. Trigeminal neuralgia H. Cerebral tumour I. Subarachnoid haemorrhage J. Extradural haemorrhage K. Encephalitis L. Migraine
I. Subarachnoid haemorrhage
SAH (bleeding into the subarachnoid space) presents with sudden severe headache patients will often describe as the worst headache of their life, and can often be so bad that they feel like they’ve been kicked in the back of the back. Half of all patients lose consciousness and eye pain with exposure to light can also be seen. Altered mental status is common. SAH occurs most commonly in the 50-55 age group and affects women and black people more than men and white people. The most common cause of non-traumatic SAH is an aneurysm which ruptures. Conditions which predispose to aneurysm formation and SAH include adult PKD, Marfan’s, NF1 and Ehlers-Danlos. Cerebral aneurysms arise around the circle of Willis. A CT scan is indicated, and if unrevealing, this should be followed by an LP. Cerebral angiography can confirm the presence of aneurysms. The patient should be stabilised and this followed by surgical clipping or endovascular coil embolisation, the choice is subject to much current controversy sparked by relatively recent research. Complications can commonly occur and include rebleeding, hydrocephalus and vasospasm.
A 60 year old lady with recent onset unilateral headache made worse by combing her hair. Her thyroid function was in the hypothyroid range & her ESR was 60mm/hr.
Choose the most likely cause of the symptoms from the list of options. A. Analgesic rebound headache B. Temporal arteritis C. Raised intracranial pressure D. Concussive syndrome E. Subarachnoid haemorrhage F. Migraine G. Tension headache H. Sinusitis I. Encephalitis J. Meningitis K. Brain abscess L. Trigeminal neuralgia M. Venous sinus thrombosis N. Severe hypertension
B Temporal arteritis
Temporal arteritis/GCA is a form of vasculitis which commonly affects those >50 and females. The headache typically presents over the temporal/occipital areas and may be accompanied by scalp tenderness – hence made worse by combing her hair. There may additionally be PMR symptoms such as aching and stiffness of the proximal extremities worse after inactivity and with movement. The patient may also have jaw claudication and the artery may be thickened and tender on examination. Systemic symptoms like a low grade fever and fatigue are commonly seen. Treatment is with oral prednisolone which should be started if there is high suspicion of this diagnosis and this should not even be delayed by results of ESR/CRP. IV pulse methylprednisolone is preferred if there are visual or neurological signs/symptoms. The best test to establish a diagnosis is with a temporal artery biopsy, however this should not delay treatment as irreversible blindness is the most common serious consequence of this condition. The arteritis is patchy so an adequate biopsy sample is needed. Histopathology will show a granulomatous inflammatory process, with giant cells present in around half of cases. GCA is unlikely (although 5% occur with normal ESR) if inflammatory markers are normal so an ESR is a quick test and >100 predicts a positive biopsy result (likelihood ratio of 1.9).
A 30 year old nurse presented with frontal headache after an acute viral illness. The pain was constant, affecting the right side of her head only. On examination there was marked tenderness on the right side of her face, over the maxillary area.
Choose the most likely cause of the symptoms from the list of options. A. Analgesic rebound headache B. Temporal arteritis C. Raised intracranial pressure D. Concussive syndrome E. Subarachnoid haemorrhage F. Migraine G. Tension headache H. Sinusitis I. Encephalitis J. Meningitis K. Brain abscess L. Trigeminal neuralgia M. Venous sinus thrombosis N. Severe hypertension
H. Sinusitis
This patient has acute sinusitis (lasting 4 weeks or less) which is most commonly due to a viral aetiology, like this case. If symptoms last >10 days, this would indicate that the cause is bacterial (mainly Streptococcus pneumoniae and Haemophilus influenzae). This condition is normally self limiting and needs only symptomatic treatment. Antibiotics are not usually recommended unless the patient is immunocompromised or has particularly severe disease. There is facial pain here which can manifest as a headache, and is usually associated with a bacterial cause although can occur with an acute viral cause.
A 40 year old man presented with generalised pain in his head, which became progressively worse especially in the mornings. Coughing and bending over made his pain significantly worse. He mentioned that he vomited twice on his way to the surgery.
Choose the most likely cause of the symptoms from the list of options. A. Analgesic rebound headache B. Temporal arteritis C. Raised intracranial pressure D. Concussive syndrome E. Subarachnoid haemorrhage F. Migraine G. Tension headache H. Sinusitis I. Encephalitis J. Meningitis K. Brain abscess L. Trigeminal neuralgia M. Venous sinus thrombosis N. Severe hypertension
C. Raised intracranial pressure
Raised ICP classically presents with symptoms which are worse in the morning. The headache can either awake the patient from sleep or is present on waking up and decreases after being awake for several hours. It is also made worse on exertion/Valsalva such as the coughing and bending over here. This patient will require a CT head to try to find the cause. Raised ICP can also manifest with a CNVI palsy, which is a false localising sign.
Julie is a 20 year old student who is complaining of a pulsatile disabling right sided headache extending over the right eye. She noticed that the pain is worse in the evenings. She experienced a similar episode 3 months previously, which lasted for approximately 4 weeks. Her mother also suffers from headaches. Physical examination was unremarkable. Her BP was 120/80
Choose the most likely cause of the symptoms from the list of options. A. Analgesic rebound headache B. Temporal arteritis C. Raised intracranial pressure D. Concussive syndrome E. Subarachnoid haemorrhage F. Migraine G. Tension headache H. Sinusitis I. Encephalitis J. Meningitis K. Brain abscess L. Trigeminal neuralgia M. Venous sinus thrombosis N. Severe hypertension
F. Migraine
This headache is unilateral, pulsatile in quality and disabling. There is a FH and neurological examination is unremarkable, with normal BP. The patient has had a similar episode previously. Treatment of this chronic condition aims at treating acute attacks to restore function. Triptans can be used in specialist care. These are 5HT1 agonists. Effective initial treatment in a primary care setting can involve NSAIDs, which are available OTC. Treatment should be taken as soon as a patient realises they are having an attack and may need to be repeated after the attack. A few patients who have frequent, severe or disabling headaches may require daily prophylaxis such as anticonvulsants, TCAs and beta blockers.
A 60 year old lady presents with episodes of intense and sharp right sided pain in the mouth, running down to the jaw. She has had these attacks twice daily for 3 weeks now but has had these attacks for a few years now, although sporadically. She says eating sometimes brings on this pain.
Choose the most likely cause of the symptoms from the list of options. A. Analgesic rebound headache B. Temporal arteritis C. Raised intracranial pressure D. Concussive syndrome E. Subarachnoid haemorrhage F. Migraine G. Tension headache H. Sinusitis I. Encephalitis J. Meningitis K. Brain abscess L. Trigeminal neuralgia M. Venous sinus thrombosis N. Severe hypertension
L. Trigeminal neuralgia
Trigeminal neuralgia occurs as episodes of severe unilateral pain in the distribution of CNV, usually lasting seconds, with no pain occuring between these episodes. Examination is often unremarkable. The pain is described as sharp, intense, stabbing or burning. It can be triggered commonly by actions such as eating,tooth brushing, cold and touch. Shaving and eating seem to be common in EMQs. Most people are asymptomatic between attacks although the severity of the pain makes these patients live in constant fear. TN is more common in MS and incidence increases with age. Post-herpetic TN is also possible. The mainstay of treatment is medical, with antiepileptics such as carbamazepine (which is the only medicine which is proven in RCTs and is therefore typically first line). If medical treatment fails, surgical options do exist such as microvascular decompression.
A 50 year old man is stressed from work and has not been sleeping very well. He has had a few headaches and muscle aches in his arms and legs. As a result, he has been taking aspirin and paracetamol for most days of the past 4 months. He has now had a daily headache for the past week which is very painful. OTC drugs do not work, despite upping the dose. Examination is normal.
Choose the most likely cause of the symptoms from the list of options. A. Analgesic rebound headache B. Temporal arteritis C. Raised intracranial pressure D. Concussive syndrome E. Subarachnoid haemorrhage F. Migraine G. Tension headache H. Sinusitis I. Encephalitis J. Meningitis K. Brain abscess L. Trigeminal neuralgia M. Venous sinus thrombosis N. Severe hypertension
A. Analgesic rebound headache
This headache has resulted from medication overuse. There is a history of taking large amounts of over-the-counter analgesics. Examination is normal and the diagnosis is easily made on the history this patient gives. It may be difficult for the patient to accept that the pills he is taking for his sporadic headaches and aches have caused this severe daily headache he is now experiencing. Treatment involves stopping these OTC analgesics. This will often lead to worsening of the patient’s headache before it gets better and the patient needs to be warned about this.
A 67 year old woman suddenly develops a constant aching around her left eye after returning from the cinema. She complains of blurred vision in the affected eye. On examination, the left pupil was fixed & dilated & the entire eye was red. Fundoscopy revealed a cupped optic disc.
For each question choose the diagnosis from the list of options. A. Macular degeneration B. Horner’s syndrome C. Preproliferative retinopathy D. Extradural haematoma E. Migraine F. Diabetic background retinopathy G. Hypercholesterolaemia H. Oculomotor palsy I. Meningitis J. Conjuntivitis K. Paraneoplastic syndrome L. Acute glaucoma M. Subdural haemorrhage
L. Acute glaucoma
Acute closed-angle glaucoma can often present like this, with a change in vision with other severe acute symptoms such as eye pain, headache and N&V. This occurs when the iris comes into contact with the trabecular meshwork, which obstructs aqueous outflow from the eye such that intraocular pressure increases. This damages the optic nerve with loss of axons, leading to loss of visual field, which if untreated can progress to complete blindness. Typical changes that can be seen on fundoscopy include large optic disc cup. Immediate treatment is medical and aims at relieving symptoms and dropping IOP. Carbonic anhydrase inhibitors, topical beta blockers or alpha 2 adrenergic agents may be used, and typically in combination. In terms of pharmacology, CA inhibitors decrease aqueous humour formation. Hyper-osmotic agents are used when pressures are exceedingly high, or the patient is unresponsive to medical treatment. After the acute attack resolves, the patient should receive definitive surgical treatment within 24-48 hours to persistently create an open angle. This can be performed by laser peripheral iridotomy where a laser makes a hole in the iris to allow aqueous to bypass the pupil.
A 10 year old boy wakes to discover he cannot open his eyes because his lids are stuck together. When his mother prises them apart, his eyes are bright red & weeping & he cries that the sunlight is hurting them.
For each question choose the diagnosis from the list of options. A. Macular degeneration B. Horner’s syndrome C. Preproliferative retinopathy D. Extradural haematoma E. Migraine F. Diabetic background retinopathy G. Hypercholesterolaemia H. Oculomotor palsy I. Meningitis J. Conjuntivitis K. Paraneoplastic syndrome L. Acute glaucoma M. Subdural haemorrhage
J. Conjunctivitis
Acute conjunctivitis is most commonly allergic or infectious (bacterial or viral). Allergic is always bilateral and most commonly seasonal and associated with a history of asthma, hay fever, atopic dermatitis etc… Bacterial conjunctivitis is more likely to be bilateral than unilateral. Infectious conjunctivitis is associated with “gluing” of the eyelids. In sexually active young adults, gonorrhoeal and chlamydial conjunctivitis should be considered as a possible diagnosis. A viral cause (mostly adenovirus) typically starts in one eye and spreads to the other eye several days later, and can be associated with recent upper respiratory tract symptoms. Both bacterial and viral conjunctivitis are highly contagious so a contact history may be present. Patients can present with a red eye, itching, burning, a discharge and lymphadenopathy. Bacterial treatment includes topical antibiotics whereas viral conjunctivitis requires symptomatic treatment.
A 57 year old lorry driver attends a regular appointment with his optician. On fundoscopy, dots & blots are noted, in addition to hard exudates around the macula.
For each question choose the diagnosis from the list of options. A. Macular degeneration B. Horner’s syndrome C. Preproliferative retinopathy D. Extradural haematoma E. Migraine F. Diabetic background retinopathy G. Hypercholesterolaemia H. Oculomotor palsy I. Meningitis J. Conjuntivitis K. Paraneoplastic syndrome L. Acute glaucoma M. Subdural haemorrhage
F. Diabetic background retinopathy
This patient has a microvascular complication of diabetes – diabetic retinopathy. His macular involvement is an indication for macular laser therapy. Digital methods for photographing the fundus are preferred over fundoscopy. Microaneurysms, cotton wool spots, haemorrhages, hard/lipid exudates and neovascularisation may all be seen depending on the stage. Young onset T1DM is more associated with retinopathy, and additional risks include a longer duration of DM and poor glycaemic control compounded by renal disease and hypertension. There are also ethnic variations in risk. Background retinopathy initially consists of just microaneurysms, which progresses with small haemorrhages (dots and blots and flames). There may also be hard exudates. However, where these changes occur within the macula, this is maculopathy and is potentially sight-threatening. Maculopathy can be classified, academically, into focal, fissue and ischaemic, though this is of limited clinical relevance. Pre-proliferative is associated with cotton wool spots, typically multiple (arguably, the odd one can be consistent with background). Proliferative is associated with new vessel formation, which can be quite subtle. The patient can also be asymptomatic but is at a risk of vitreous haemorrhage. Diabetic retinopathy needs to be screened for (either dilated fundoscopy in clinic or with retinal photography) at least on an annual basis. Treatment is with photocoagulation where a transpupillary laser is used to burn the retina, which reduces overall oxygen demand lessening the ischaemic stimulus. There are complications, which you can look up. Please have a look at some photographs of retinal images. Reading about it will not help you to identify a cotton wool spot, hard exudate or angiogenesis in real life. There are also variations of normal which you will be able to spot with the more images you look at, like racial pigmentation and drusen in the elderly. What would you expect to see on fundoscopy in a patient with age-related macular degeneration?
An 89 year old male presents with his daughter, who has become worried about his gradual decline in physical & intellectual ability over the past 8 weeks, since a fall at home. She says he complains of headaches & seems sleepy. On examination, he has a left sided hemiparesis & on fundoscopy, papilloedema is present. For each question choose the diagnosis from the list of options. A. Macular degeneration B. Horner’s syndrome C. Preproliferative retinopathy D. Extradural haematoma E. Migraine F. Diabetic background retinopathy G. Hypercholesterolaemia H. Oculomotor palsy I. Meningitis J. Conjuntivitis K. Paraneoplastic syndrome L. Acute glaucoma M. Subdural haemorrhage
M. Subdural haemorrhage
A subdural occurs due to blood collecting between the dura mater and the arachnoid mater surrounding the brain. It may be arterial or venous although is most often venous. The disease course varies but this patient’s presentation fits. The cause is trauma – a fall in this case, most likely due to the patient’s elderly and frail state. Advanced age is associated with chronic subdurals. It is important in the examination to look for signs of trauma such as scalp abrasions and bruises. This patient is symptomatic and surgical options include twist-drill craniotomy with drainage (a bedside procedure where a hand drill is used to gain access to the subdural space and then a catheter is placed to act as a drain). Standard craniotomy is also an option, as is the creation of a burr hole. Remember that extradural haematomas classically have a ‘lucid interval’ and occur in younger patients, usually with an associated skull fracture, and CT of the haematoma does not cross suture lines.
A 46 year old lady, recently diagnosed with Pancoast’s syndrome showed the following facial signs: Miosis, enopthalmos & ptosis in her L eye & an ipsilateral absence of facial sweating.
For each question choose the diagnosis from the list of options. A. Macular degeneration B. Horner’s syndrome C. Preproliferative retinopathy D. Extradural haematoma E. Migraine F. Diabetic background retinopathy G. Hypercholesterolaemia H. Oculomotor palsy I. Meningitis J. Conjuntivitis K. Paraneoplastic syndrome L. Acute glaucoma M. Subdural haemorrhage
B. Horner’s syndrome
The presentation is of a pancoast tumour (most are non-small cell) in the left apex causing ipsilateral Horner’s syndrome (miosis, anhidrosis, ptosis and enophthalmos).
An 84 year old woman in a nursing home has been constipated for a week. Over the past few days she has become increasingly confused & incontinent.
For each presentation below, choose the single most discriminating investigation from the list of options. A. Chest x-ray B. Blood glucose C. Thyroid function tests D. Blood cultures E. Ultrasound abdomen F. Urea & electrolytes G. Mid-stream specimen of urine H. CT scan of head I. Stool culture J. FBC K. ECG
G. Mid-stream specimen of urine
Constipation can be associated with a UTI and with this patient’s history, I would be highly suspicious of this diagnosis. An MSU sample and urine microscopy can confirm the organism type and guide antibiotic selection with culture and sensitivities of urine, which is the most specific and sensitive test for UTI. In real life, a urine dipstick would be the first test to order. Think about what you would expect the dipstick to show.
A previously well 78 year old woman has been noticed by her daughter to be increasingly slow & forgetful over several months. She has gained weight & tends to stay indoors with the heating on even in warm weather.
For each presentation below, choose the single most discriminating investigation from the list of options. A. Chest x-ray B. Blood glucose C. Thyroid function tests D. Blood cultures E. Ultrasound abdomen F. Urea & electrolytes G. Mid-stream specimen of urine H. CT scan of head I. Stool culture J. FBC K. ECG
C. Thyroid function tests
This patient has symptoms of hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Diagnosis is based on measurement of TSH and thyroid hormones (thyroid function tests). Treatment is by replacement of T4 with or without T3 in combination.
A 64 year old man has recently been started on tablets by his GP. He is brought to the Accident & Emergency Department by his wife with sudden onset of aggressive behaviour, confusion & drowsiness. Prior to starting the tablets he was losing weight & complaining of thirst.
For each presentation below, choose the single most discriminating investigation from the list of options. A. Chest x-ray B. Blood glucose C. Thyroid function tests D. Blood cultures E. Ultrasound abdomen F. Urea & electrolytes G. Mid-stream specimen of urine H. CT scan of head I. Stool culture J. FBC K. ECG
B. Blood glucose
This patient’s prior symptoms indicate he was diagnosed with DM and started on an oral hypoglycaemic, which can have the side effect of causing hypoglycaemia. Symptoms present when glucose drops <3mmol/L. Symptoms include sweating, weakness, drowsiness, palpitations and anxiety. This can be managed with oral glucose or sugar, or with IM glucagon. A blood glucose will demonstrate glucose levels consistent with his diagnosis.
A frail 85 year old woman presents with poor mobility & a recent history of falls. She has deteriorated generally over the past 2 weeks with fluctuating confusion. On examination she has a mild right hemiparesis.
For each presentation below, choose the single most discriminating investigation from the list of options. A. Chest x-ray B. Blood glucose C. Thyroid function tests D. Blood cultures E. Ultrasound abdomen F. Urea & electrolytes G. Mid-stream specimen of urine H. CT scan of head I. Stool culture J. FBC K. ECG
H. CT scan of head
This is likely to be a subdural haematoma. A subdural occurs due to blood collecting between the dura mater and the arachnoid mater surrounding the brain. The cause is trauma – a fall in this case. A non-contrast CT will typically show a collection of subdural fluid in a crescenteric shape, which can cross suture lines.
A 75 year old man with known mild Alzheimer’s disease suddenly fainted. When seen in the Accident & Emergency Department, his blood pressure was 90/60 & his pulse rate was 40/min & regular.
For each presentation below, choose the single most discriminating investigation from the list of options. A. Chest x-ray B. Blood glucose C. Thyroid function tests D. Blood cultures E. Ultrasound abdomen F. Urea & electrolytes G. Mid-stream specimen of urine H. CT scan of head I. Stool culture J. FBC K. ECG
K. ECG
This patient is bradycardic and hypotensive. The low blood pressure is a manifestation of low cardiac output due to bradycardia. This patient needs an ECG to investigate the rhythm. The syncope could be due to an arryhthmia of some sort – for example, complete heart block, which resulted in cerebral hypoperfusion. The Alzheimer’s is of no real relevance here.
An unconscious 35 year old man who has a capillary blood glucose of 1.5mmol/l.
For each of the cases below, choose the most appropriate next management option from the list. A. Commence CPR B. Gastric lavage C. CT scan brain D. Inhaled anticholinergic E. Intravenous naloxone F. Precordial thump G. Intravenous dextrose H. DC cardioversion I. Intravenous antibiotics J. Lumbar puncture K. Endotracheal intubation L. IM glucagon
G. Intravenous dextrose
This patient is profoundly hypoglycaemic (symptoms of hypoglycaemia are present when glucose drops <3mmol/L). Patients with either long standing DM or on beta blockers may become unaware of hypoglycaemia and become profoundly hypoglycaemic before symptoms develop. In DM, hypoglycaemia is usually secondary to insulin or oral hypoglycaemics. Non DM causes of hypoglycaemia include insulinomas, alcohol, liver failure and Addison’s disease. Treatment is corrective and for someone this profoundly hypoglycaemic, IV dextrose is needed. Care should be taken when administering such high % dextrose IV due to the risk of skin necrosis if administered incorrectly (if the IV leaks). IM glucagon is only used if IV access cannot be established.
A 55 year old man found collapsed at home who, on arrival at hospital, has no palpable pulse or recordable blood pressure.
For each of the cases below, choose the most appropriate next management option from the list. A. Commence CPR B. Gastric lavage C. CT scan brain D. Inhaled anticholinergic E. Intravenous naloxone F. Precordial thump G. Intravenous dextrose H. DC cardioversion I. Intravenous antibiotics J. Lumbar puncture K. Endotracheal intubation L. IM glucagon
A. Commence CPR
This patient has cardiac arrest and the first thing you need to do is commence CPR. It is thought to work by raising intrathoracic pressure and providing direct cardiac compression. 30 compressions (at 100/min) and 2 breaths for a total of 5 cycles (2 minutes), makes up one cycle of CPR. Compressions are the first priority, breaths may follow but compressions are paramount. Further management depends on whether the patient has a shockable rhythm (pulseless CT or VF) or non-shockable rhythm (PEA or asystole). Do you know when a precordial thump can be used?
An 18 year old woman found unconscious at home. She has needle “track” marks in her arms, a respiratory rate of 10/min & pinpoint pupils.
For each of the cases below, choose the most appropriate next management option from the list. A. Commence CPR B. Gastric lavage C. CT scan brain D. Inhaled anticholinergic E. Intravenous naloxone F. Precordial thump G. Intravenous dextrose H. DC cardioversion I. Intravenous antibiotics J. Lumbar puncture K. Endotracheal intubation L. IM glucagon
E. Intravenous nalaxone
Opiate OD signs include CNS depression, miosis and apnoea. Finding small constricted pupils in someone who is unconscious is highly indicative. Naloxone is indicated both therapeutically and diagnostically. If there is a response, then it is diagnostic. Another diagnosis should be sought if the patient is unresponsive. IV is the preferred route of administration although naloxone can be given IM or SC if IV access cannot be established. Ventilatory support is key with 100% oxygen. You can check out Toxbase for a full database on poisons and treatments.
A 34 year old woman who complained of a severe headache on waking & then collapsed.
For each of the cases below, choose the most appropriate next management option from the list. A. Commence CPR B. Gastric lavage C. CT scan brain D. Inhaled anticholinergic E. Intravenous naloxone F. Precordial thump G. Intravenous dextrose H. DC cardioversion I. Intravenous antibiotics J. Lumbar puncture K. Endotracheal intubation L. IM glucagon
C. CT scan brain
A CT head is indicated here in this possible SAH. This may show hyperdense areas in the basal cisterns, major fissures and sulci.
