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Flashcards in Oxford Handbook Assess and Progress Deck (72)
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1

A 72-year-old woman is recovering from an episode of temporal arteritis. She is due to start gradually reducing her dose of prednisolone tablets and is being counselled on the risks of stopping the tablets suddenly. Which single symptom should this patient be warned to expect if she stops her tablets suddenly?

A Abdominal pain
B Depression
C Dizziness on standing
D Fits
E Weakness in upper arms and thighs

C

  • Feeling faint or dizzy on standing up is suggestive of postural hypotension 
    • It is a feature of hypovolaemia, autonomic dysfunnction and as here adrenal gland dysfunction 
  • After long term steroid use, normal hormone production by the adrenals is suppressed
  • As it will take some time for endogenous production to restart, patients need to be gradually weaned off steroids to avoid a period of 'hypo-adrenialism' and the dangerous symptoms that go along with it. 
  • Other options are features of prolonged steroid use. 

2

An 18-year-old man has recently been diagnosed with idiopathic generalized epilepsy. He lives with his parents who have not witnessed any of his three previous fi ts and are concerned about what to do if he has another one and ask their doctor for advice. Which single course of action should be stressed to the parents?

A Call the emergency services immediately
B Clear local danger and wait for the seizure to pass
C Give diazepam 20mg PR
D Give lorazepam 10mg PR
E Hold him down to prevent injury until the seizure passes

C

A prolonged seizure is one that which lasts 5min or more. Rectal diazepam remains the first-line therapy for seizures occurring outside the hospital setting.

They are usually kept at home by the family in case they are needed. It has very short-acting anticonvulsant properties (20min as opposed to 12h for lorazepam) and can therefore be given again after 15min if status is threatening.

An alternative treatment is buccal midazolam, which may be easier and more socially acceptable to administer. A 10mg dose is given between the cheek and lower gum.

A It may be necessary to contact help if the seizure continues for longer
than 30min or another seizure starts straight after the first.


B It is certainly sensible to move anything out of the path of someone
having a seizure.


D This is not given PR.


E Holding the person down is liable to cause more harm than good and
may result in injury and greater post-ictal muscle fatigue.


NICE (2004). Epilepsy . NICE Clinical Guideline 20.

3

A 60-year-old woman has lost the ability to pick up small objects
with her right hand. She also fi nds it diffi cult to fasten buttons. There
is no other weakness. She is unable to copy one particular movement
made by the doctor examining her (a pinching movement).

Which single nerve is most likely to have been compromised?

A. Anterior interosseous 

B. Median

C. Musculocutaneous

D. Radial

E. Ulnar

A

The anterior interosseous nerve arises from the median nerve about 5cm
above the medial epicondyle supplying the fl exor digitorum profundus
and the fl exor pollicis longus muscles. It can be compromised by direct
trauma or by compression by surrounding muscles (pronator teres), ligaments,
or scar tissue. The result is the inability to pinch the thumb and
forefi nger together (in the way shown in Figure 8.1 ) and thus diffi culty
with fi ne motor pincer movements.

4

A 76-year-old man has collapsed. This has happened increasingly over the past year and tends to happen when he stands from sitting.

This is not associated with any residual ill eff ects, but he also reports mild lower abdominal pain. He has hypertension and type 2 diabetes.

Abdomen: soft with mild suprapubic tenderness that is dull to percussion.

Digital rectal examination: hard impacted stool.

Which is the single most likely underlying cause of this man’s symptoms?

A. Accumulation of CSF with normal intracranial pressure

B. Degeneration of basal gangia

C Disturbance of autonomic nerve function 

D. Permanent loss of cerebral neurones 

E. Temporary loss of local cerebral blood flow

C

There are three symptoms described: postural falls, urinary retention,
and constipation. Whilst they may occur in someone who is cognitively
impaired, dementia itself does not cause them. They are all processes
modulated by the autonomic system and likely to be aff ected by diabetes.
Whilst they can co-exist with Parkinson’s disease in the ‘Parkinson’s plus’
syndrome multisystem atrophy, there is no hint of parkinsonism in this
patient.

5

A 66-year-old woman has awoken to fi nd that the right side of her mouth is sagging and she has difficulty eating on that side, with food getting trapped. She has a very watery right eye, her speech is impaired, and she is hypersensitive to sounds in her right ear. The doctor assessing her feels the cause is almost certainly ‘idiopathic’. Which is the single most likely factor in her history that influenced the doctor’s judgement?

A. Hypersensitivity to sounds

B. Speech impairment

C. Trapping of food 

D. Unilateral sagging of mouth 

E. Watery eye 

A

All the other options can occur in any case of facial nerve palsy. Only A is
seen in Bell’s (idiopathic) palsy due to hyperacusis from stapedius palsy.

6

A 32-year-old man has been dribbling saliva from the right side of his mouth and having diffi culty closing his right eye over the last 48h. His wife has noticed that his face is drooping on the same side. He has normal facial sensation but cannot raise his eyebrow on the right side. Which is the single most appropriate next step?

A No Treatment

B Start oral aciclovir

C Start oral aciclovir and oral prednisolone

D Start oral prednisolone

E Urgent MRI scan

C

In the treatment of Bell’s palsy, there is moderate quality evidence that,
for presentation within 72h of the onset of symptoms, there is improved
function at 4 months if prednisolone is given with aciclovir as opposed to
prednisolone alone.

7

A 68-year-old man has had a worsening tremor of his hands for 9 months. He says his father and brother were troubled with the same problem and that they both noticed improvement after treatment with a beta-blocker. Which single additional feature in the history would be consistent with the most likely diagnosis?

A. He uses two types of inhaler for his asthma

B. His writing seems smaller than it used to be 

C. It disappears when he moves his hands

D. It is only noticeable when his hands are still 

E. It seems to improve with alcohol 

E

This is benign essential tremor, a rhythmic tremor (4–12Hz) that is only present when the aff ected muscle groups are moved. It can be worsened
by stress, demands to perform a task under pressure, the cold, caff eine,
and some drugs. It usually improves following small amounts of alcohol
and beta-blockers.


A This can be a side eff ect of salbutamol, but is more likely to occur
intermittently after overuse of the drug rather than progressively and
constantly.


B and D Micrographia and resting tremor are features of Parkinson’s
disease, which would be more likely to begin in just one hand.


C This is also true of Parkinson’s disease, whilst the opposite is true in
essential tremor.

8

A 24-year-old woman has had a headache and double vision for 2 weeks. She is nauseous and has vomited on two occasions, but finds that her symptoms get better as the day progresses. An MRI scan of her head is normal. A lumbar puncture is performed and has an opening pressure of 260cmH 2 O (normal range: 0–250cmH 2 O). Which single additional feature from her history is most relevant to the likely diagnosis?

A. Her father had chemotherapy 2 years ago for a glioma

B. She drinks five or six cups of strong coffee each day 

C. She has a family history of migraine

D. She smokes 20 cigarettes per day 

E. She takes orlistat 120mg PO three times daily 

E

The gradual presentation together with a ‘normal’ MRI scan of the brain
and raised intracranial pressure suggest a diagnosis of benign intracranial
hypertension. This is associated with obesity in young women and would
be consistent with use of the pancreatic lipase inhibitor orlistat, which is
used as a drug treatment for obesity.

Caffeine ( B ), smoking ( D ), and a strong family history ( C ) would all add
weight to a convincing history of migraine, whilst a family history of a
cerebral tumour at a much older age ( A ) is unlikely to be relevant at this
stage.

9

A 22-year-old man has had a headache increasing in intensity over the past 48h. He has started to feel nauseous and rather drowsy. T 37.8 ° C, HR 100bpm, BP 125/70mmHg. When the junior doctor asks him to lift his head from the pillow, the man
is seen to involuntarily lift both legs in the air. Which is the single most accurate explanation for this finding?

A. Limb girdle weakness

B. Meningeal irritation 

C. Muscle spasm 

D. Raised intracranial pressure

E. Sciatic nerve inflammation 

B

The junior doctor has elicited Brudzin´ski’s neck sign. As with Kernig’s sign, this is a notoriously insensitive marker of meningeal irritation. Even though it is very specific, the fact that it has been absent in 95% of proven cases of meningitis in some studies has led people to question its value in the pre-treatment work-up of meningitis.

It is, however, quick to perform, non-invasive, and may be of use in borderline cases.


Thomas KE, Hasbun R, Jekel J, and Quagliarello VJ (2002). The diagnostic
accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults
with suspected meningitis. Clin Infect Dis 35 :46–52.

10

A 49-year-old woman has weakness in her right arm and her right leg. She has been fi nding it increasingly difficult to find words. These symptoms have developed gradually over a 2-week period. T 37.1 ° C, HR 85bpm, BP 105/70mmHg. She has reduced power on the right with brisk reflexes and upgoing plantars. Which is the single most likely underlying diagnosis?

A. Cerebral infarct

B. Cerebral metastases

C. Hemiplegic migraine

D. Subarachnoid haemorrhage

E. Transient ischaemic attack 

B

  • Difficult to consider a metastatic disease if there is no knowledge of primary.
  • However the gradual onset of neurological symptoms over a 2 week period essentially rules out a vascular process and thus all other options 
  • They would all cause symptoms much more sudden than in this case:
    • A - minutes
    • C - hours 
    • D - seconds 
    • E - minutes to hours (resolving after 24 hours) 
  • The fact that symptoms continue to develop suggests that there is an ongoing process 
  • In this case, it is due to the worsening edema, surrounding the mass.
  • Given the discovery of an intracerebral mass, it would be essential to try and identify a primary (breast, bowel or skin) although the intracerebral mass may itself by the primary

11

A 77-year-old man has felt ‘muddled’ for the last 5 days. He cannot put his fi nger on what is wrong but neighbours say he has been talking and acting inappropriately.
T 37.5 ° C, HR 110bpm, BP 95/70mmHg, RR 26/min, SaO 2 92% on air. He is pale, clammy, and agitated and in an abbreviated mental test he scores 5/10. Which single set of investigations would be the most likely to support the diagnosis?

A. CT of head and carotid Duppler ultrasound scan

B. CT of head, TFTs and MMSE

C. ECG, 12h troponin level and ECG

D. FBC + CXR

E Random venous blood glucose + HbA1C

D

This man presents with confusion. He has a temperature and is tachycardic,
tachypnoeic, and hypoxic. Even before examining his chest, he
should be suspected of having a chest infection causing systemic upset
and an acute confusional state.

A These are used in the work-up after a transient ischaemic attack, which
is unlikely to present with confusion, as, by defi nition, suff erers return
to normal very quickly.


B These are part of a dementia screen; dementia is unlikely to present
so suddenly and should not be suspected until sepsis has been
excluded.


C An acute coronary syndrome can present with delirium but there is no
suggestion of cardiac dysfunction in this case.


E These are used to investigate diabetic ketoacidosis; hypoglycaemia is
more likely to cause delirium.

12

A 50-year-old woman has had an aching pain and numbness in her right hand and arm for 5 months. She fi nds that shaking her arm vigorously relieves the symptoms. She takes levothyroxine, although she admits that she often forgets to take it. Which is the single most appropriate instruction to confirm the diagnosis?

A. Cross your middle finger over the dorsal surface of the index finger 

B. Move your wrists towards the thumb laterally

C. Place the thumb in a closed fist and tilt your hands towards the little finger 

D. Raise your thumbs out vertically out of an open palmar surface

E. Spread your extended fingers open horizontally 

D

This is often weakened in carpal tunnel syndrome and tests abductor pollicis
brevis innervated by the median nerve.


A This tests the dorsal interossei (ulnar nerve).
B This tests the extensor carpi radialis longus (radial nerve).
C This is Finkelstein’s test for De Quervain’s tenosynovitis.
E This tests the dorsal interossei/abductor digiti minimi (ulnar nerve).

13

A 48-year-old man has undergone a 10h intra-abdominal operation. After the operation, he has some numbness in his ring and little finger of his right hand. The doctor thinks he may have damaged a nerve and examines him to confi rm the diagnosis. Which is the single nmost appropriate instruction to confirm the diagnosis?

A Cross your middle finger over the dorsal surface of the index finger 

B Move your thumbs across the palm and touch the base of the little finger 

C. With the palm facing downwards, bend the wrist upwards towards your forearm 

D With the palm facing sideways keep your hand in this position against resistance 

E. With the palm facing upwards, bend the wrist up towards your forearm 

A

This is ‘cubital tunnel syndrome’, which has been caused by intraoperative
compromise and compression of the ulnar nerve at the elbow. The
second commonest entrapment neuropathy to carpal tunnel syndrome,
the ulnar nerve is particularly vulnerable around the elbow.


B This tests the opponens pollicis (median nerve).
C This tests wrist extension (radial nerve).
D This tests the pronator teres (median nerve).
E This tests wrist fl exion (median nerve).
14.

 

14

The junior doctor on-call receives a bleep from a nurse during a busy night shift. A 78-year-old man has been found on the floor.

He did not lose consciousness but was unable to get back on his feet, despite normally being fully independent. He is hoisted back into bed. He has no pain in his hips or wrists. He was admitted 3 days ago with a urinary tract infection and atrial fi brillation. Which is the single most important detail from the nurse, in isolation, that should prompt an immediate review of the patient, i.e. in the next 5min?

A Alcohol dependence

B Headache

C Large swelling over occiput

D Slurred speech 

E Temperature 37.7 

D

The sudden-onset weakness in combination with slurred speech in an
elderly patient who has been admitted with atrial fi brillation should serve
as an alert to a possible stroke.


A This might explain some of the nocturnal delirium.
B and C These are consistent with a fall.
E This is due to the urinary tract infection.

15

A 58-year-old man has double vision, especially while reading. He has hypertension and type 2 diabetes. As he is talking, he tilts his head to the right, but when asked to straighten up, his left eye appears to be slightly higher vertically than the right. Which is the single most likely diagnosis?

A Left inferior oblique palsy 

B Left inferior rectus palsy 

C Left lateral rectus palsy 

D Left superior oblique palsy 

E Left superior rectus palsy 

D

This man’s head tilt is characteristic of a trochlear nerve lesion: patients
usually tilt away from the side of the lesion in order to reduce their
diplopia. The trochlear nerve has three roles: intorsion, depression, and
abduction of the globe. It is most commonly disturbed by head trauma,
but can be aff ected—as here—in microvasculopathies such as diabetes.
The diplopia is worse on downward gaze and gaze away from the
aff ected muscle.


A, B, and E These occur together in palsies of the oculomotor nerve
and result in an eye resting in the ‘down and out’ position.


C Patients with left lateral rectus palsy cannot fully abduct the aff ected
eye and so develop an esotropia (convergent squint) and resulting
diplopia.

16

A 39-year-old man has suffered a seizure while out shopping. He is admitted to hospital where he is drowsy and confused.

This is his third such episode in the past 6 months. He has idiopathic generalized
epilepsy and has been through a variety of treatment regimens. He currently takes phenytoin 300mg PO once daily. Which is the single most appropriate investigation to determine the trigger?

A Blood levels of phenytoin 

B Calcium and phosphate

C FBC

D Random capillary blood glucose 

E Urea and electrolytes 

 

A

In someone with poorly controlled seizures, there should always be rigorous
discussion as to the levels of concordance. If there remain doubts
as to the patient’s adherence to the prescribed medication, then NICE
guidance is that this is an indication for monitoring the blood levels of the
medication. Ideally, this should happen in the outpatient setting with the
aim of preventing admission to hospital.


NICE (2012). Epilepsy . NICE Clinical Guideline 137.
→ http://guidance.nice.org.uk/CG137 .

17

A 26-year-old man lost consciousness 30min ago at work. He was found on the fl oor shaking; this lasted for 10min. He had a similar attack 1 month ago. He drinks only occasional alcohol and takes no medications. T 36.1 ° C, HR 88bpm, BP 142/78mmHg, SaO 2 99% on air. Glasgow Coma Scale (GCS) score 12/15. A CT head scan is reported as ‘normal’. Which is the single most likely diagnosis?

A cataplexy 

B Drop attacks

C Non-epileptiform attack disorder

D Primary generalised epilepsy 

E Vasovagal syncope 

D

This man has had his second tonic–clonic seizure and has presented with
a reduced GCS, in the post-ictal phase.


A This usually occurs against a background of daytime somnolence
(narcolepsy).


B This generally occurs in older people, usually women.


C This was known previously as ‘pseudoseizures’. It is often diffi cult to
tell apart from primary generalized epilepsy, but would not be the case
in a man with a low GCS score following the seizure.


E He would not be as drowsy following a simple faint.

18

A 77-year-old woman has fallen 4.5m from a balcony. Her cervical spine is immobilized and she has a non-rebreather mask on, with 15L/min of oxygen running. She is agitated and groaning and grabs the doctor’s hand and opens her eyes as he rubs her sternum. She is awaiting a CT scan of her head and neck, but within a few minutes she starts to make snoring sounds and her oxygen saturation drops. Which is the single most appropriate next step?

A Head and chin lift manouever

B Jaw thrust

C Larygneal mask airway 

D Oropharyngeal airway 

E Tracheostomy 

B

This woman’s Glasgow Coma Scale score is 9 (E2, V2, M5). Her airway
has become partially obstructed and this simple manoeuvre will help
open it. A head tilt should not be attempted, to protect the cervical spine,
which has not been cleared following a signifi cant fall from height.

19

A 55-year-old man has had a headache for the last 3 days. The pain is over the occipital region and associated with nausea and vomiting. T 36.5 ° C, HR 80bpm, BP 150/80mmHg. He is unable to abduct his right eye on lateral gaze, but otherwise examination of his cranial nerves is unremarkable. He has grade 5/5 power
in his limbs and down-going plantar refl exes. Which single pathological process is most likely to explain these symptoms?

A Demyelination

B Hydrocephalus

C Ischaemic of cerebral arteries

D Ruptured cerebral aneurysm 

E Subdural hematoma 

D

It can be difficult to assess the severity of headaches, especially if there
are no associated symptoms. In this case, however, the continued nausea
and vomiting and the focal neurology suggest a serious cause. The lateral
rectus palsy may suggest the site of the aneurysm (but could also suggest
an intracerebral haematoma).


A This process aff ects the central nervous system in multiple sclerosis;
although this can present with ‘eye signs’, it is unlikely to do so with a
headache and a mononeuropathy in a man in his 60s.


B Normal pressure hydrocephalus is the clinical triad of nystagmus
+ ataxia + urinary incontinence, none of which is a feature of this
case.


C This is the pathological process behind >80% of strokes; it is unlikely
to be accompanied by headache and nausea as in a bleed. An ischaemic
stroke leads to infarction of upper motor neurones and would
be more likely to cause some combination of motor or sensory
loss.


E This can present with a headache but is usually associated with drowsiness
and fluctuating consciousness. Intracerebral haematoma can
cause localizing neurological signs (e.g. sixth nerve palsy), but this tends
to happen long after the injury and onset of the headache.

20

A 38-year-old woman has fractured her right fi bula. She says that she has some numbness on the top of her right foot. The junior doctor thinks she may have damaged a nerve and examines her to confirm the diagnosis. Which is the single most appropriate instruction to confi rm the diagnosis?

A Band your foot up towards your kness

B Make the sole of your foot into a cup 

C Point your toes and place the soles of your feet together 

D Stand up on your tiptoes 

E While I hold your foot, bend the furthermost joints in your toes 

A

This is a common peroneal nerve injury, which runs a course around
the neck of the fi bula and has been damaged by the fracture. The other
movements are all the function of the tibial nerve.


B This tests the small muscles of the foot.
C This tests the tibialis posterior (inverts the foot at the ankle).
D This tests the gastrocnemius.
E This tests the fl exor digitorum longus.

21

A 34-year-old man has been dribbling out of the right side of his mouth for 12h. He thought the television was particularly loud this morning, whilst his wife has commented that his face is lopsided and that he looks like he is grimacing rather than smiling. Which single feature in the examination confirms the most likely diagnosis?

A Asymmetry of oropharynx 

B Difficulty balancing

C Discharge from his ear 

D Ipsilateral limb weakness

E Unilateral eyebrow raise 

E

The scenario describes a Bell’s palsy due to malfunction of all branches of
the facial nerve (CN VII). Lack of frontal sparing would suggest a lower
motor neurone lesion.


A Together with asymmetry of the ipsilateral tonsil, this might suggest a
parotid tumour.
B and C Together with bleeding, headaches, and tinnitus, these might
suggest a cholesteatoma.
D This suggests an upper motor neurone lesion.

22

A 44-year-old man attends pre-assessment clinic prior to the laparoscopic repair of his umbilical hernia. He has epilepsy and has been taking sodium valproate 600mg PO twice daily for the past 5 years. Which single investigation should be performed prior to surgery?

A Blood levels of sodium valproate 

B Clotting profile 

C Fasting venous blood glucose 

D FBC

E Urea and electrolytes 

B

Due to its eff ects on the liver, NICE guidance is that clotting studies should
be performed prior to any surgery in those on sodium valproate.
NICE (2004). Epilepsy . NICE Clinical Guideline 20.

23

A 72-year-old woman, who is normally fit and well, loses the ability to grip and move her right arm for a 12h period. She is assessed overnight in hospital and by the morning she has no residual weakness. Which is the single most appropriate treatment?

A. Aspirin 75 mg PO once daily/dipyridamole modified release (MR) 200mg PO twice daily 

B. Aspirin 300 mg once daily 

C. Clopidogrel 75 mg PO daily 

D. Dipyridamole MR 200mg PO twice daily 

E. Warfarin (variable doses, INR target of 2-3)

B

For the first 2 weeks after a vascular event (stroke/transient ischaemic
attack (TIA)), aspirin 300mg is used. However, ongoing secondary
prophylaxis with anti-platelet therapy after TIAs and ischaemic strokes
has changed. After TIA the recommendation is still aspirin and dipyridamole,
but after an ischaemic stroke, clopidogrel (which is not licensed
in TIA) is used. However, clopidogrel may be preferred in patients who
cannot tolerate dipyridamole such as those with multivascular disease
(e.g. coronary or peripheral vascular disease) or those with overt infarction
on CT of the brain. Dipyridamole may be used alone after stroke
if aspirin and clopidogrel are not tolerated or if aspirin is not tolerated
after a TIA.


A and E Patients who are in atrial fi brillation and suffer either a TIA or an
ischaemic stroke should be off ered anticoagulation therapy.
NICE (2010). Clopidogrel and modifi ed-release dipyridamole for the prevention
of occlusive vascular events. (Review of NICE technology appraisal guidance
90.) NICE technology appraisal guidance 210.

24

An 80-year-old woman’s speech has suddenly become slurred. She can find words without trouble but has difficulty enunciating them. A similar thing happened 2 weeks previously. She takes bendroflumethiazide 2.5mg PO once daily. Which single further detail in the history would be most supportive of the likely diagnosis?

A Concurrent tingling spreading from fingers to face

B Difficulty swallowing

C Photophobia

D Symptoms followed a severe occipital headache

E Symptoms resolved after 1h

E

Recurrent episodes of neurological disturbance in someone with hypertension
are highly suggestive of TIAs. The diagnosis would be clinched by
the rapid resolution of symptoms (<24h). Given the high rates of stroke
in those who suff er TIAs, this woman needs to have an ultrasound scan
of her carotids with a view to an urgent endarterectomy.

25

A 72-year-old woman has had three episodes of left arm weakness in the last week. On each occasion, it began with twitching in her fingers followed by a sudden inability to move her whole arm lasting for around 30min. Her daughter says that during these periods, her speech was noticeably slurred. Which single examination finding would
be most likely to support the diagnosis?

A AF

B Fingers that turn pale, then blue, then red when cold 

C Horizontal nystagmus 

D Tenderness over left temply 

E Weak left radial pulse 

A

A neurological disturbance that lasts <24h is the defi nition of a TIA.
The temporary occlusion of the cerebrovasculature is either due to an
embolus from the carotids or from a heart that has valve disease, a postmyocardial
infarction thrombus, or—as in this case—is fi brillating.

B This describes Raynaud’s phenomenon.
C If >2 beats and not just at the extremities of gaze, this is suggestive of
a cerebellar or vestibular lesion.
D This is found in giant cell arteritis, which can mimic a TIA but only
rarely.
E This is a non-specifi c fi nding, although unilateral pulse weakness has
been described in patients with systemic sclerosis, thoracic outlet syndrome,
and Takayasu’s arteritis.

26

A 66-year-old man has suff ered sudden-onset weakness of his left arm and left leg. An urgent CT scan of his head is performed and is suggestive of an acute ischaemic event. He is admitted to a medical ward where his care is handed over to the on-call junior doctor. T 38.4 ° C, HR 100bpm, BP 195/110mmHg, SaO 2 96% on air. Random capillary blood glucose: 3.4mmol/L. Which single reading listed above warrants the most urgent attention?

A. Blood glucose

B Blood pressure

C Heart rate

D Oxygen saturation 

E Temperature 

 Do not attempt to drop blood pressure acutely (due to the risk of inadequate
cerebral perfusion). Instead, concentrate on diagnosing and treating
fevers and discrepancies in blood sugar.

27

An 81-year-old woman is found groaning and coughing in bed. She was admitted the previous week following a large left middle cerebral artery infarct.
T 39.4 ° C, BP 110/50mmHg, SaO 2 92% on 15L O 2 . Her chest has coarse crepitations bilaterally, her JVP is not seen, and she has no peripheral oedema. Which is the single most likely cause of her sudden deterioration?

A Aspiration pneumonia

B Myocardial infarction 

C Pleural effusion 

D Pulmonary embolism 

E Pulmonary edema 

Aspiration signifies the inhalation of gastric contents into the lower airways,
which then causes an infective process. Most at risk are those who
cannot protect their own airway, as in the early stages after a stroke.
Whilst this patient is at risk of all options after a stroke, her chest signs
and hypoxia are most suggestive of A: the doctor who sees her in this
condition should certainly investigate her with blood cultures and a chest
X-ray and treat her with IV antibiotics to include cover for anaerobes.

28

A 30-year-old woman has had a seizure. Within 15min, she has arrived at the Emergency Department but is still fi tting. The ambulance crew have given diazepam 10mg PR. She is given oxygen 15L via a Hudson TM mask and IV access is secured via a peripheral vein. Which is the single most appropriate next step?

A Arrange electroencephalogram monitoring 

B Contact intensive care for intubation 

C Lorazepam 4mg IV slow bolus 

D Phenytoin 15mg/kg at 50 mg/h IV

E Thiamine 250mg IV over 10 minutes 

C

At 15min, this woman is still in ‘early’ status. According to NICE guidelines,
she therefore needs a bolus of lorazepam along with her usual antiepileptic
drugs (if she is on any). A maximum of two doses of fi rst-line
treament—PR diazepam/buccal midazolam/IV lorazepam or diazepam
(including pre-hospital)—should be administered. If her seizures continue,
then a phenytoin infusion may be started. Fifteen minutes is too
early to contact an anaesthetist, but this may be appropriate if the team
are particularly concerned or lacking in experience.
NICE (2012). Epilepsy . NICE Clinical Guideline 137.
→ http://guidance.nice.org.uk/CG137

29

A 55-year-old man has had muscle pains for about 2 weeks, mainly affecting his thighs and which is particularly bad when he climbs stairs. He has type 2 diabetes and high blood pressure. He started simvastatin 40mg PO once at night a month ago. He has 5/5 power in both legs. Which is the single most appropriate investigation?

A Creatine Kinase 

B Troponin

C UEs

D ESR

E LDH

When starting a statin, patients should be made aware of the risks of
developing a myopathy and advised to report any muscle weakness or
pain as soon as it develops. In this event, it is important to measure the
creatine kinase (CK) promptly. If it is more than fi ve times the upper
limit or if myopathy is suspected on clinical grounds (as in this case), then
treatment should be discontinued. If symptoms resolve and levels of CK
return to normal, then the statin could be tentatively reintroduced, or an
alternative could be considered.

30

A 23-year-old man has pain in his right shoulder after a heavy tackle while playing rugby. He has no neurovascular deficit of the upper limb, but he has some soft-tissue swelling and tenderness over the head of the humerus. His range of movement is slightly reduced globally and he is unable to abduct his right arm without fi rst leaning to the right. Which is the single muscle most likely to have been affected?

A Infraspinatus

B Subscapularis 

C Supraspinatus 

D Teres major 

E Teres minor 

Rupture of supraspinatus is the most common rotator cuff injury. The
supraspinatus muscle arises from the supraspinous fossa on the scapula
and inserts into the greater tubercle of the humerus. The infraspinatus
and teres minor insert here as well, with the subscapularis inserting into
the lesser tubercle.