Oxford Handbook Assess and Progress

Question 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

Answer 1

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.

Question 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

Answer 2

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.

Question 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

Answer 3

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.

Question 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

Answer 4

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.

Question 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

Answer 5

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.

Question 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

Answer 6

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.

Question 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

Answer 7

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.

Question 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

Answer 8

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.

Question 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

Answer 9

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.

Question 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

Answer 10

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

Question 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

Answer 11

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.

Question 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

Answer 12

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).

Question 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

Answer 13

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.

Question 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

Answer 14

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.

Question 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

Answer 15

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.

Question 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

Answer 16

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 .

Question 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

Answer 17

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.

Question 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

Answer 18

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.

Question 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

Answer 19

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.

Question 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

Answer 20

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.

Question 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

Answer 21

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.

Question 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

Answer 22

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.

Question 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)

Answer 23

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.

Question 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

Answer 24

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.

Question 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

Answer 25

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.

Question 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

Answer 26

E 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.

Question 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

Answer 27

A 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.

Question 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

Answer 28

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

Question 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

Answer 29

A 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.

Question 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

Answer 30

C 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.

Question 31

A 48-year-old man has a mid-shaft fracture of the right humerus. He has some numbness on his right hand and forearm. The junior doctor thinks he may have damaged a nerve and examines him to confi rm the diagnosis. Which is the single most appropriate instruction to confirm the diagnosis? A Move your thumb across your palm to the base of the little finger B Resist displacement of a piece of paper between middle and ring finger C Spread your fingers open, increasing the space between them D WIth the palm facing dowards, bend the wrist up towards your forearm E With the palm facing upwards, bend the wrist up towards your forearm

Answer 31

D This is a radial nerve injury which runs a course in a groove around the mid-shaft of the humerus and has been damaged by the fracture. A This tests the opponens pollicis (median nerve). B and C These test the palmar interossei (ADductors) and dorsal interossei (ABductors) (both ulnar nerve). E This tests the forearm fl exors (median nerve).

Question 32

A 22-year-old man has sustained a sports injury. He scuff s the top of his right shoe along the floor as he walks and cannot turn his foot outwards against resistance. Which is the single most likely distribution of sensory compromise? A Dorsum of foot B Lateral calf C Lateral calf and dorsum of foot D Medial calf E Medial calf and dorsum of foot

Answer 32

C This man has a foot drop and weak eversion—symptoms of a common peroneal nerve lesion. The common peroneal nerve is commonly damaged by trauma to the lateral side of the knee. It is here that it winds around the head of the fi bula covered only by skin and subcutaneous tissue. After entering the peroneus longus muscle, it divides into deep and superfi cial branches. It is the superfi cial branch that provides sensory innervation to the skin of the lower lateral calf and dorsum of the foot. The deep branch is primarily a motor nerve.

Question 33

A 66-year-old man has been feeling ‘slowed down’ over a 6-month period. He is struggling to cope around the house and is becoming increasingly reliant on his wife. She has noticed him to be lower in mood and less expressive and eff usive generally. He has a resting tremor and a slow gait of small steps. Which single further feature would be suggestive of Parkinson’s disease rather than parkinsonism? A Asymmetrical symptoms B Inability to look up C Postural dizziness D Short term memory problems E Urinary retention

Answer 33

A C and E suggest the autonomic complications associated with multisystem atrophy, whilst B and D refl ect two symptoms (defective vertical gaze and dementia) common in progressive supranuclear palsy. Parkinsonism is a syndrome of tremor, rigidity, bradykinesis, and loss of postural refl exes. Parkinson’s disease is one cause of parkinsonism.

Question 34

A 74-year-old man visits his family doctor due to increasing difficulty walking over the past 6 months. He has a fixed facial expression and a unilateral tremor of his right hand. Which is the single most appropriate next step? A Check serum dopamine levels B Refer to a neurologist C Request a head CT scan D Start dopamine agonist E Start levodopa

Answer 34

B NICE recommends that if there is any suspicion of a patient having Parkinson’s disease, they should be referred to a neurologist or a physician with an interest in Parkinson’s disease, before drug treatment is initiated. This is to reduce misdiagnosis, unnecessary treatment, and the use of increasingly complex drug regimes.

Question 35

A 30-year-old woman has been reported to have had a seizure. It happened in the standing area at the end of a 2h concert. She remembers feeling nauseous and sweaty beforehand. Her partner describes her falling to the ground where she jerked her limbs for several seconds. She did not bite her tongue and was not incontinent of urine. Two hours later in the Emergency Department, she is lucid although distressed. The junior doctor examines her, refers her for an electroencephalogram (EEG), and sends her home. The registrar feels it is unlikely to be a seizure. Which single detail from the history is most likely to have made the registrar reach this conclusion? A Lack of tongue biting B Lack of urinary incontinence C Nausea beforehand D Prolonged standing E Sweating beforehand

Answer 35

D Both C and E could represent the aura prior to a partial seizure, whilst neither tongue biting ( A ) nor urinary incontinence ( B ) occur in every case of an epileptic seizure. The history certainly suggests a case of vasovagal syncope and, although the brief jerks may have made the junior doctor think of epilepsy, the story as a whole is not concerning for this. In cases of probable syncope, NICE guidelines state that an EEG should not be performed (due to possible false positives). An EEG should only be used to support a diagnosis of epilepsy in those in whom the history is suggestive. NICE (2012). Epilepsy . NICE Clinical Guideline 137. → http://guidance.nice.org.uk/CG137

Question 36

A 31-year-old woman lost consciousness 30min ago. A collateral history describes her falling to the fl oor and jerking for 10min. She had another attack in the ambulance and was given diazepam 10mg PR, but she has three more attacks in the Emergency Department. She has no past medical history of note, drinks minimal alcohol, and takes no medications. The attacks last 2–3min and she feels her fi nger twitch before they start. T 36.1 ° C, HR 88bpm, BP 125/68mmHg, SaO 2 99% on air. Glasgow Coma Scale (GCS) score 15/15. A CT head scan is reported as ‘normal’. Which is the single most likely diagnosis? A Cerebral glioma B Complex partial epilepsy C Drop attacks D Secondary generalized epilepsy E Non-epileptiform attack disorder (NEAD)

Answer 36

E These used to be called ‘pseudoseizures’ and although the diagnosis of NEAD is one of exclusion, this presentation with rapid recovery (GCS 15/15) very soon after the attack is suggestive. It is more common in females and young adults and occurs more often in those who have family members who have seizures or if they suff er from depression or anxiety. Childhood sexual abuse has also been shown to be associated. B and D These would be associated with a much slower recovery and in this age group would be most likely to have happened before (although, of course, fi rst fi ts are possible at any age). A A space-occupying lesion would be likely to have caused some symptoms before this episode. C These are more common in the older population and feature sudden leg weakness and instant recovery.

Question 37

A 42-year-old woman has been feeling more and more tired at the end of her days at work. When she gets home, she struggles to lift anything and is too weak to eat or even use the telephone. She has bilateral ptosis and on counting down from 50 her voice becomes increasingly quiet. Which single pathological process most accurately explains all of this woman’s symptoms? A Demyelination B Mononeuritis multiplex C Myopathy D Neuronal degeneration E Space occupying lesion

Answer 37

C The scenario describes fatiguable weakness aff ecting several muscle groups: extraocular (ptosis), bulbar (‘too tired to eat’), and limb girdle (‘struggles to lift anything’). This pattern is strongly suggestive of myaesthenia gravis, which is above all a disease of muscles.

Question 38

A 30-year-old woman has had diffi culty walking for the past 12h. She fi rst noticed it when she left work the previous night: her walk to the station, which usually takes only a few minutes, on this occasion took over an hour. She has grade 3 power in her lower limbs and an extensor plantar response bilaterally. Her range of eye movements is normal but painful. Which is the single most likely cause of her symptoms? A ALS B GBS C MS D Syphilis E B12 deficiency

Answer 38

C This woman has acute lower limb weakness and what sounds like an optic neuritis. Although MS can present in a variety of ways, these are two of the most common initial symptoms. More commonly, patients present with one symptom that improves, only for another diff erent problem to develop some time later. Anyone in this demographic who gives a history of fl itting, seemingly unlinked (by time and space) neurological problems should raise suspicions and prompt an in-depth history and careful examination. A Amyotrophic lateral sclerosis is a pattern of motor neurone disease. It typically begins with insidious muscle weakness that develops into twitching, cramping, and then stiff ness. The sequence of symptoms varies from person to person, but it would be unlikely that a suff erer would deteriorate as rapidly as the woman in this case. B Guillain–Barr é syndrome could cause such rapid weakness but not with upgoing plantars and it would not aff ect eye movements. It often occurs following a viral illness. D Quaternary syphilis can cause an ataxic gait and numbness but not such rapidly weak legs. E This can give rise to paraesthesia and a peripheral neuropathy, but these are likely to develop gradually and not cause weakness.

Question 39

A 27-year-old woman has been having regular headaches over the last few months. She describes the presence of stripes across her field of vision before the onset of the headache. She is otherwise well and takes only the oral contraceptive pill. Which single additional patient narrative from the history would be consistent with the most likely diagnosis? A I have intense shooting pain around my eye and across my cheek B It's one side of my head. I feel nauseous and the light hurts my eyes C My eye looks blood shot, the eye lid swells and produce more tears D Pain started to wake me up and is worse when I lie down E Work has been very busy recently and I rarely have a chance to relax

Answer 39

B Classical migraine (which can be triggered by the oral contraceptive pill) is associated with an aura, which is often teichopsia (a transient visual sensation of fl ashing lights/colours), usually followed by the headache within the hour. A This indicates trigeminal neuralgia; it can be associated with multiple sclerosis and tumours, usually in older women. C This indicates a cluster headache, occurring once or twice in a 24h period for 4–12 weeks but then followed by sometimes 1–2 years without symptoms. D This indicates raised intracranial pressure; it is also associated with vomiting, personality changes, seizures, and progressive focal neurology. E This indicates a tension headache, ‘like a tight band around the head’, and often provoked by home/work stress and associated with low mood.

Question 40

A 25-year-old woman has had uncontrolled headaches over a period of 6 months. These are unilateral and associated with nausea and photosensitivity. She has tried a number of simple analgesics with no effect. After seeing a neurologist, she unsuccessfully tried an oral triptan. She is having to take large amounts of time off work now and feels increasingly anxious. She asks if she can take anything to prevent the headaches. Which is the single most appropriate prophylaxis? A Amitriptyline B Codeine phosphate C Propanolol D Sodium valproate E Topiramate

Answer 40

C This is appropriate first-line treatment for migraine prophylaxis at a dose of 80–240mg daily and will also help her anxiety. Opioids ( B ) can cause a medication overuse headache and dependence and should not be used. The other options are useful second-line options: tricyclic antidepressants ( A ) and anti-epileptics ( D and E ).

Question 41

A 53-year-old man has had recurrent headaches for 3 weeks. These are accompanied by feelings of nausea and aggravated by lifting heavy boxes at work. His mother suff ered with migraines for many years. A neurological examination is normal. Fundoscopy reveals no evidence of papilloedema. Which is the single most appropriate initial management? A Refer to neurologist within 2 weeks B Send off urine for 5-HIAA levels C Start oral codeine D Start high dose prednisolone E Trial of oral sumatriptan

Answer 41

A This man has headaches of recent onset with features of raised intracranial pressure. A ‘normal’ fundoscopy examination will not be able to defi nitively rule out papilloedema and with this history an urgent referral for investigations is warranted. B This is raised in carcinoid syndrome. C and E These are reasonable treatments for migraines. D This would be indicated if temporal arteritis was suspected.

Question 42

A 24-year-old man has fallen off a 2m-high wall onto grass. He thinks he landed on his head. He has not lost consciousness at any time. His story, however, is unclear as he has drunk over 20 units of alcohol. Aside from the effects of the drinking, he seems well and reports no drowsiness or nausea. The junior doctor is keen to discharge the man home. Which single examination fi nding should prompt the junior doctor to arrange a CT scan first? A Bleeding from scalp B Bruising behind ears C Coarse tremor in hands D Past pointing E Romberg's positive test

Answer 42

B It is diffi cult to assess for neurological defi cits in those who have been drinking. Guidance is therefore that these people should be admitted. Furthermore, if there are any signs of a basal skull fracture, then a CT head scan should be performed. B refers to Battle’s sign (ecchymosis of the mastoid process) and, along with periorbital ecchymosis, cerebrospinal fluid rhino/otorrhoea, and haemotympanum, should prompt urgent imaging. A This is not a signifi cant fi nding in assessment of a head injury. C This might suggest alcohol withdrawal but is unlikely in this situation. D This is a cerebellar sign. E This is positive in conditions causing sensory ataxia.

Question 43

A 30-year-old man has suff ered a head injury. He was hit by a blunt object about 2h prior to coming to the Emergency Department. He remembers the incident well and has not been nauseous or vomited and has no real headache. He was keen to stay at home and sleep it off , but his wife was concerned as she felt he was falling in and out of sleep and was rather confused. Which is the single most appropriate management? A CT scan of head B Discharge home C MRI scan D Observe for 24 hours E Skull X-ray

Answer 43

A It can be difficult to be clear about the management of head injuries, but, broadly summarized, CT scans should be performed on those with normal consciousness but a skull fracture and all those with abnormal consciousness. (Note that it is not just skull fractures that demand imaging in those with a Glasgow Coma Scale score of 15/15; others are persisting severe headache, nausea and vomiting, irritability or altered behaviour, and a seizure.) By this rationale, the patient in this case deserves a CT head scan. This is because the chances of fi nding intracranial pathology in someone with disturbed consciousness is 20%, whilst in someone who is fully conscious and has no other features the chances are \<1%. C This is not used in the acute setting for head injuries. D In those who are drowsy or confused, it might be acceptable to observe them for at most 4h from the time of injury; if they have still failed to recover full consciousness, it would then be appropriate to request a CT head scan. E If a CT is planned, there is no need to carry out a skull X-ray. These are used in those situations where a CT is not planned but there is evidence of skull fracture

Question 44

A 50-year-old man is having increasing diffi culty walking. For the past week, his legs and arms have weakened such that he cannot stand from sitting and is unable to dress himself. His sensation is unaffected. Prior to this episode, he has been well, although he does recall a bout of diarrhoea and vomiting around 6 weeks ago. Which is the single most likely pathological process to have caused his symptoms? A Infection B Inflammation C Malignancy D Metabolic dysfunction E Vasculitis

Answer 44

B The history given is suggestive of Guillain–Barré syndrome, a peripheral neuropathy triggered by infection but actually caused by the infl ammatory response that follows (antibodies attacking nerve cells).

Question 45

A 26-year-old man has had successive seizures without regaining consciousness between them. After arriving at the Emergency Department, he had lorazepam 4mg IV and was started on an infusion of phenytoin 15mg/kg. It is now 40min since the first seizure began. Which is the single most appropriate next step? * Arrange for EEG monitoring * Diazepam 10mg IV * Fast bleep anaesthetist * Second dose of lorazepam 4mg IV * Thiamine 250 mg IV

Answer 45

C This man is now in established status epilepticus. He has received the necessary drug treatments (bolus + subsequent infusion of anti-epileptic drugs) and is heading towards the general anaesthesia phase. Prior to this, an anaesthetist and thus the Intensive Therapy Unit (ITU) should be contacted. An anaesthetist will be needed to protect this man’s airway and oversee the administration of a drug like propofol, whilst the ITU should be preparing itself to accept this man who will need close monitoring and possibly EEG monitoring.

Question 46

A 28-year-old woman lost consciousness at home an hour ago and is brought in to the Emergency Department. She has no previous medical history and this has never happened previously. Her mother is worried that she has had a ‘fit’. Which single feature from the history is most likely to confi rm her mother’s concerns? A Biting the end of her tongue B Feeling tired and wanting to sleep C Incontinence of urine D Still being confused when the ambulance has arrived E Twitching after she fell to the ground

Answer 46

D Although tiredness and fatigue can occur with syncope, confusion lasting more than 2min after regaining consciousness should be regarded as a sign that this woman may well have had a seizure. Urinary incontinence can occur with syncope if the bladder was full at the time of the attack. A deep bite of the lateral border of the tongue is suggestive of a seizure but the tongue can also be bitten during a syncopal episode. Twitching and jerking can occur due to simple hypoxia, but tonic and then clonic movements for more than 1min should be regarded as suspicious of a seizure. McCorry D and McCorry A (2007). Collapse with loss of awareness. BMJ 334 :153.

Question 47

A 20-year-old woman has had one seizure at home. She and her partner, with whom she lives, attend an appointment with an epilepsy specialist 3 weeks later. The decision is made to postpone starting any treatment. The couple remain concerned about the prospect of having another seizure and in particular about when they should contact the emergency services. Which single feature should prompt her partner to call the emergency services? A second fit starts before she has regained consciousness B Experiences an aura prior to seizure C Incontinent of urine D Clonic phase lasts for more than 10 minutes E Evidence of tongue biting

Answer 47

A According to NICE guidelines, there are four circumstances in which the emergency services should be contacted: 1. If seizures develop into status epilepticus. 2 . If there is a high risk of recurrence. 3. If it is a fi rst fi t. 4. If there is diffi culty monitoring the individual’s condition. A second fi t starting before the person has regained consciousness is one of the defi nitions of status epilepticus, the other being seizures lasting \>30min. NICE (2012). Epilepsy . NICE Clinical Guideline 137 → http://guidance.nice.org.uk/CG137

Question 48

A 38-year-old man has been shot in the back of his right thigh. He says that the sole of his right foot feels numb. The junior doctor thinks he has damaged a nerve and examines him to confi rm the diagnosis. Which is the single most appropriate instruction to confi rm the diagnosis? A Lift your foot up towards your knee B Point your toes and place the soles of your feet together C Turn the sole of your foot out to the side D With a straight leg, bury your heel into the couch E With your leg bent at the knee, straighten your leg against resistance

Answer 48

B This man is unable to plantar fl ex or invert his foot due to an injury to the tibial nerve. The tibial nerve supplies a sensory branch to the sole of the foot and a motor branch to the hamstrings, tibialis posterior, gastrocnemius, flexor digitorum longus, and the small muscles of the foot. A and C Both movements—dorsifl exion and eversion of the foot—are powered by the common peroneal nerve. D This tests the gluteus maximus (inferior gluteus nerve). E This tests the quadriceps femoris (femoral nerve).

Question 49

A 36-year-old woman who is 34 weeks pregnant has a strange sensation in her right hand. She has weakness of her abductor pollicis brevis and sensory loss over her radial three and a half fi ngers and palm. Which single anatomical site is most likely to be the source of her symptoms? A Between the brachialis and brachioradialis B Between the two heads of the flexor carpi ulnaris C Deep to the flexor retinaculum D Medial to the brachial artery in the forearm E Posterior to the medial humeral epicondyle

Answer 49

C This is carpal tunnel syndrome and can occur in pregnancy as a result of fl uid retention causing compression of the median nerve in the carpal tunnel below the flexor retinaculum. A This is the radial nerve. B This is the ulnar nerve. D This is the anterior interosseus branch of the median nerve, but if the site of symptoms arose from here, there would be weakness of wrist flexion due to the innervations of the forearm fl exors. E This is the ulnar nerve.

Question 50

A 43-year-old woman has had an increasingly severe headache for the last 6 weeks. She has latterly become nauseated and confi ned to a darkened room. Three months previously, she completed chemo- and radiotherapy for a recurrent breast carcinoma. T 37.6 ° C, HR 100bpm, BP 95/70mmHg. Which single pathological process is most likely to have caused these symptoms? A. Haemorrhage B Infection C Inflammation D Metastasis E Thrombosis

Answer 50

D This is carcinomatous meningitis whereby metastasis has occurred from the primary to the meninges; imaging may show the suggestion of meningeal uptake—an MRI is more likely to do so than a CT scan—but the best way to detect malignant cells in the meninges is via a lumbar puncture. Chamberlain MC and Kormanik PR (1997). Carcinomatous meningitis secondary to breast cancer: predictors of response to combined modality therapy. J Neurooncol 35 :55–64.

Question 51

A 66-year-old man has noticed that one of his eyelids will not open properly. He also complains of pain and tingling in the shoulder and arm on the same side. He has hypertension, gout, and a chronic cough, having quit smoking 5 years previously. The right pupil is constricted and the right side of the face is dry from sweat. Which single pathological process most accurately explains all of this man’s symptoms? A Autonomic neuropathy B Infection C Mononeuritis complex D Paraneoplastic syndrome E Venous sinus thrombosis

Answer 51

D The symptoms and signs (ptosis, miosis, and anhydrosis) described are those of Horner’s syndrome and of nerve impingement (C8–T2). In an ex-smoker who continues to cough, this could be explained by an apical lung tumour (Pancoast’s tumour) that is impacting on both brachial and cervical sympathetic plexuses.

Question 52

A 70-year-old woman has begun dragging her right foot along as she walks. Two weeks previously, her left wrist felt weak such that she could not straighten it. She has had rheumatoid arthritis for 35 years and is currently using methotrexate 12.5mg once weekly. Which is the single most likely neuropathological process to explain her symptoms? A Autonomic neuropathy B Demyelination C Entrapment D Inflammatory peripheral neuropathy E Mononeuritis multiplex

Answer 52

E When two peripheral nerves are compromised, the confusing term mononeuritis multiplex is used. It is rare but is associated with diabetes, some vasculitides, and rheumatoid arthritis. A This does not affect peripheral nerves, rather a range of functions including postural blood pressure, sweating, and bladder and bowel function. B The main example of this is multiple sclerosis. C This would be the most likely cause of an isolated nerve lesion. D The classical inflammatory neuropathy is Guillain–Barré syndrome: an acute, mainly motor demyelinating neuropathy.

Question 53

A 59-year-old woman has been unable to speak for the last 24h. Her daughter has noticed her to be irritable and slightly confused for most of the past week. She has also fallen several times in this period and complained of a headache that is worse in the mornings. Which single management option would be most likely to improve this woman’s symptoms? A Alteplase 0.9mg/ kg IV B Aspirin 300 mg PO once a day C Dexamethasone 8mg PO twice a day D Nimodipine 60 mg PO six times a day E Therapeutic lumbar puncture

Answer 53

C Evolving neurological signs against a background of headache and personality changes are highly suspicious of an intracranial space-occupying lesion. Immediate management should consist of treating the associated cerebral oedema with steroids. A This is used for thrombolysis of those presenting within 4.5h with the symptoms of an ischaemic stroke (see link at end of this answer). B This is used in the acute treatment of transient ischaemic attack and stroke. D This is a calcium-channel blocker used occasionally in the treatment of malignant hypertension. A headache and visual disturbance is possible with a BP \>200/140mmHg, but it is unlikely to be associated with other gross neurological changes. E This can be used to relieve the symptoms of benign intracranial hypertension; this is a key diff erential diagnosis in these cases and may turn out to be the cause if brain imaging is normal. Whilst investigations are pending, however, cases of raised intracranial pressure together with evolving neurology and personality changes need to be treated as if for a space-occupying lesion. → http://www.sign.ac.uk/pdf/qrg108.pdf

Question 54

A 78-year-old woman has a sudden onset of weakness in her right arm and right leg. She also has diffi culty speaking, managing only a few isolated words. There is no discernible visual or sensory loss. The on-call registrar asks the junior doctor to organize an urgent CT head scan, telling her to classify the presumed stroke for the benefi t of the radiologist. Which would be the single most accurate way to classify this woman’s neurological defi cits? A Dominant circulation infarct B Lacunar infarct C Anterior circulation infarct D Posterior circulation infarct E Total anterior circulation

Answer 54

C The registrar wants his junior to use the Bamford classifi cation system. This woman has motor weakness and higher cortical dysfunction (dysphasia), therefore scoring 2/3 (she doesn’t score for hemianopia). Cerebellar or brainstem signs indicate a posterior circulation infarct, whilst A does not exist. The system is quick and easy to use, adds weight to out-of-hours radiology or neurology referrals (‘Hi, I have a 78-yearold who’s having what looks like an acute PACI on the ward . . . ’), and is informative with regard to prognosis. The defi nitions according to the Bamford classifi cation system are: ● Total anterior circulation infarct (TACI). All of the following: • Higher dysfunction (decreased level of consciousness, dysphasia, visuospatial) • Homonymous hemianopia • Motor/sensory defi cit (\>2/3 face/arm/leg). ● Partial anterior circulation infarct (PACI). Any two of the three features of TACI or: • Higher dysfunction alone or • Limited motor sensory deficit. ● Posterior circulation infarct (POCI). Any of the following: • Cranial nerve palsy and CL motor/sensory defi cit • Bilateral motor/sensory defi cit • Conjugate eye movement problems • Cerebellar dysfunction • Isolated homonymous hemianopia. ● Lacunar infarct (LACI). Any of the following (all aff ecting \>2/3 face/ arm/leg): • Pure sensory deficit • Pure motor defi cit • Sensorimotor defi cit • Ataxic hemiparesis. The patient must not have new dysphasia, visuospatial problem, proprioceptive loss, any vertebrobasilar features.

Question 55

A 58-year-old man is confused. He has no recollection of the events that brought him into hospital but says he has never been unwell before. Records show that this is his fi fth admission within a 6-month period. T 35.6 ° C, HR 110bpm, BP 90/55mmHg. His eyes fl icker from side to side and when asked to walk he can only stagger. He scores 0/10 in an abbreviated mental test. Which is the single most appropriate course of action? A Aspirin 300 mg PO once daily B Dexamethasone 8mg PO twice daily C Glucagon 1 mg IM STATE D Donepezil 5mg PO at night E Thiamine IV three times a day

Answer 55

E The acute onset of ophthalmoplegia (nystagmus as here or lateral rectus or conjugate gaze palsies), an ataxic gait, and global confusion is known as Wernicke’s encephalopathy: it results from thiamine defi ciency (which is common in heavy alcohol users) and can proceed to the more serious Korsakoff ’s syndrome (characterized by a retrograde amnesia resulting in confabulation). Untreated, mortality rates are 20% in Wernicke’s and 85% in Korsakoff ’s. Apart from arresting the decline into Korsakoff ’s, thiamine has been shown variously to reverse all three clinical problems within hours. Therefore, in any patient with one or more of the three symptoms and no other more likely cause, give two pairs of thiamine ampoules IV in 50–100mL 0.9% saline over 30min three times a day for 3–7 days before converting to oral thiamine. A Aspirin is started after a transient ischaemic attack or stroke. B This is used to treat cerebral oedema in space-occupying lesions. C Glucagon can be used to treat hypoglycaemia, although it does not work as well in patients who have been drinking alcohol. D This may have a role to play in the treatment of Korsakoff ’s syndrome and also in Alzheimer’s dementia. Day E, Bentham P, Callaghan R, Kuruvilla T, and George S (2009). Thiamine for Wernicke–Korsakoff syndrome in people at risk from alcohol abuse. Cochrane Database Syst Rev 2 :CD004033. → http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/ CD004033/pdf\_standard\_fs.html

Question 56

A 78-year-old woman has had increasingly regular diarrhoea for the last 2 weeks. She has also noticed some blood mixed in with the stool. As she is awaiting a colonoscopy, she develops sudden-onset weakness of her left foot. She fi nds that she cannot pick her foot up properly but drags it behind her, her toes scraping along the fl oor. She is otherwise only treated for asthma, which she developed in her 50s. Which is the single most likely pathological process that would explain this woman’s symptoms? A Immunosuppression B Infection C Inflammation D Malignancy E Vasculitis

Answer 56

E The scenario describes a case of Churg–Strauss syndrome, which is not important: what is important is realizing that a vasculitic process should be considered as an explanation for any multisystem presentation. Churg–Strauss syndrome is a medium- and small-vessel autoimmune vasculitis that often aff ects the lungs, gastrointestinal system, and peripheral nerves.

Question 57

A 24-year-old woman has had 4 months of right-sided parietal headaches with intermittent blurred vision. The headaches are most severe in the morning and get better through the course of the day. Which is the single most likely diagnosis? A Benign ICH B Cluster headache C Giant cell arteritis D Migraine E Tension headache

Answer 57

A Benign intracranial hypertension presents as a mass might: headache and signs of raised intracranial pressure. Because of this, suff erers typically suff er most in the mornings. B A cluster headache can last for this long and the pain is almost always unilateral. However, the pain comes at night more often than the morning and is accompanied by watering of the eye, which can become bloodshot and swollen. C This is not really the right demographic: it should be suspected in those \>50 years who have a persistent headache. D Migraine is often unilateral and is probably the best diff erential here as it does present with strong neurological signs, but it is unlikely to follow such a regular protracted course. E Tension headache is unlikely to present as a unilateral pain: it is classically a ‘tight band around the head’.

Question 58

An 81-year-old man has collapsed. When he comes round, he says he felt dizzy immediately prior to falling but does not remember exactly what happened. He recovers quickly and feels back to his normal self. He has hypertension, asthma, type 2 diabetes, and osteoporosis, and had been started on a new medication the previous day. Which single medication is the most likely cause of the collapse? A Alendronic acid B Doxazosin C Metformin D Rosiglitazone E Salbutamol

Answer 58

B Doxazosin is an α 1 antagonist and is used in the treatment of benign prostatic hypertrophy and hypertension, although it is usually the third- or fourth-line treatment. The most likely cause of the collapse is a postural drop in blood pressure, which can occur after the first dose. A Alendronic acid is associated largely with gastrointestinal side effects. C Metformin cannot cause hypoglycaemic attacks. D Rosiglitazone is associated with fl uid retention and can precipitate heart failure, but not chest pain or shortness of breath in this scenario. E Salbutamol in high doses can cause tremor, tachycardia, and agitation but is unlikely to cause a collapse.

Question 59

A 67-year-old woman had an extended right hemicolectomy with a primary anastomosis 2 days ago. She started eating a light diet today and was recovering well. At 1am, the nursing staff call the junior doctor on call because she is confused and tremulous and has been trying to climb out of bed for 2h. The patient says that she wants to get out of bed ‘ to fi nd her dog, which ran past the end of the bed earlier ’. T 37.4 ° C, HR 90bpm, BP 105/88mmHg, SaO 2 95% on air, capillary blood glucose 5.5mmol/L. Sodium 131mmol/L, potassium 4.1mmol/L, creatinine 88 μ mol/L, Hb 95g/L, MCV 104fL. Which is the single most appropriate next step in management? A Administer 2L of oxygen via nasal cannulae B Cross match for a 2U blood transfusion C Start haloperidol 2.5mg PO D Start a reducing regime of chlordiazepoxide E Start trimethoprim for a presumed urinary tract infection

Answer 59

D Confusion is common following surgery, especially in the elderly. This woman has a few features particular to the diagnosis: alcohol withdrawal. This classically presents between 10 and 72h after admission with hypotension, tachycardia, and visual/tactile hallucinations. She should be given generous amounts of chlordiazepoxide (a benzodiazepine) for the fi rst 3 days, which is then gradually reduced.

Question 60

A 17-year-old woman has had a seizure at home, having felt sick for the preceding 2h. It was witnessed by her father who describes 1min of her stretching her arms and legs out followed by 10min of all four limbs shaking. She was incontinent of urine and bleeding from the side of her tongue. This is her fi rst such episode. No specific trigger can be detected. Twelve hours later, she has recovered well apart from being unable to lift her left arm. The consultant suggests starting sodium valproate 200mg PO twice daily. Which single factor is most likely to have influenced the consultant’s decision? A Lack of a specific trigger B Left arm weakness C Pre-seizure sickness D Tongue biting E Urinary incontinence

Answer 60

B In most cases, anti-epileptic treatment does not start until after a second seizure. However, NICE guidance highlights four situations in which it should be started after the first seizure: 1. The individual has a neurological deficit. 2. The electroencephalogram (EEG) shows unequivocal epileptiform activity. 3. The individual considers risk of further seizures unacceptable. 4. Imaging shows a structural abnormality. Although this woman’s defi cit is likely to be temporary (Todd’s paresis following a seizure involving the motor cortex), it is a sign that the seizure was likely to be epileptic in origin and that the risk of recurrence is high. → http://publications.nice.org.uk/the-epilepsies-the-diagnosis-andmanagement- of-the-epilepsies-in-adults-and-children-in-primary-andcg137/ introduction

Question 61

A 67-year-old man has been brought into the Emergency Department in the early hours of the morning with a head injury following a fall at home 30min ago. All he remembers is fi nding himself on the floor; he is not sure whether he lost consciousness. Which single feature should prompt a request for an urgent CT head scan? A He fell down two flights of stairs B He has vomited twice since the fall C He is more than 5 D Epilepsy sufferer E GCS is 14

Answer 61

B Vomiting more than once should prompt a request for an urgent CT head scan, i.e. within 1h of arrival. Following a head injury but no immediate triggers for an urgent scan, anyone \>65 years, with a dangerous mechanism of injury and amnesia of events \>30min, can wait for up to 8h before the scan if out of hours. NICE (2007). Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults . NICE Clinical Guideline 56. → http://www.nice.

Question 62

A 45-year-old woman has had a headache and has felt increasingly anxious over the last week. Her family report that she has been acting aggressively and saying bizarre things. The on-call junior doctor is called to the medical ward where she has been admitted. The woman is behaving erratically: she has made threatening remarks to staff ,disturbed fellow patients, and now wants to self-discharge. She is due to be reviewed by a psychiatrist in the morning. Which is the single most appropriate next step? A Allow self discharge B Section 5(2) of Mental Heact Act - arranging for her detention C Ask police to detain her under Section 136 D Await review by a psychiatrist in the morning E Sedate her

Answer 62

B The relevant sections of the Mental Health Act 2007 are: ``` Section 5 (2): Doctors’ Holding Power. This allows the doctor in charge of the patient’s care (or an alternative nominated by this doctor) to legally detain a voluntary patient in hospital for 72h. ``` Section 2 : Admission for Assessment. This allows assessment (and treatment) for a period of 28 days. It is often used to detain a patient during their fi rst compulsory mental health admission to hospital. Section 3 : Admission for Treatment. This is used if continued detention and treatment is required for a patient on a Section 2 or a patient who has previously been admitted and has a fi rm treatment plan. Initially it is valid for 6 months, but it can be renewed for another 6 months and then a year at a time. Section 4 : Emergency Admission for Assessment. This requires only one doctor (unlike a Section 2 , which requires two) and should only be used when there is not judged to be enough time to organize a Section 2 . It allows admission for 72h during which time, if warranted, a second doctor can convert it into a Section 2 . Section 136 : Removal of People from Public Places. This allows a police offi cer to take someone who they feel has a mental disorder and is in need of immediate care, or in the interests of the person or others, to a ‘place of safety’. This allows a period of up to 72h to assess the need for an admission under Section 2 . A She might be a danger to herself or others and should not be allowed to self- discharge. C This is not an appropriate Section in this case. D She does not sound like she would be prepared to wait. E Sedating her against her consent would be battery. → http://www.opsi.gov.uk/acts/acts2007/pdf/ukpga\_20070012\_en.pdf

Question 63

A 33-year-old woman has had recurrent spells of tingling in her arms for the past 6 months. The tingling is noticeably worse when she is trying to use her arms and often seems to come on after she has had a hot bath. She has otherwise been well and does not smoke or drink alcohol. Which single investigation or pair of investigations would be the most likely to support the diagnosis? A Anti-acetylcholine receptor antibodies B CT Thoracic Outlet C MRI Brain and Spinal Cord D Nerve Conduction Studies E B12 and folate

Answer 63

C Multiple sclerosis (MS) remains a clinical diagnosis due to an absence of pathognomonic fi ndings. An MRI will detect plaques in the central nervous system but is non-specifi c. Symptoms are often seen to worsen or even present for the fi rst time when body temperature rises, as it is thought that this slows conduction, especially through already demyelinated nerves. A This test is used if myaesthenia gravis is suspected: this would be more likely to present with muscle weakness than paraesthesia. B Thoracic outlet syndrome usually follows neck trauma and presents with paraesthesia and weakness in an arm due to compression of neurovascular structures at the thoracic outlet. It would be unlikely to cause such a fl itting picture that attacks both arms, as in this case. D Guillain–Barr é syndrome, like MS, is a demyelinating disease. Nerve studies therefore show slowing of conduction. It is unlikely to run a course as long as this case—it runs a progressive rather than a fl uctuant pattern and is more likely to aff ect the lower rather than the upper limbs. E Subacute combined degeneration of the spinal cord is a reasonable diff erential diagnosis in cases of lower limb paraesthesia as it causes a peripheral neuropathy. It is, however, progressive rather than relapsing and remitting and unlikely in someone so young.

Question 64

A 78-year-old man has become acutely confused over the last few hours. He is recovering from a lower respiratory tract infection and is awaiting a rehabilitation placement. He has hypertension, chronic obstructive pulmonary disease (COPD), Parkinson’s disease, and type 2 diabetes. He is unsteady on his feet and has increased tone in all four limbs, more so than is usual for him. Which single medication is most likely to have caused his deterioration? A Amoxicillin B Cyclizine C Diazepam D Prenisolone E Rosiglitazone

Answer 64

B Cyclizine will exacerbate the extra-pyramidal symptoms of Parkinson’s disease due to its central anti-cholinergic eff ects. This manifests as confusion, diffi culty walking, and an increase in tone.

Question 65

A 28-year-old woman has had a severe headache for the past 2 weeks. Her family doctor examines her eyes. The left eye constricts directly to light with a consensual response in the right. However, as he swings the torch from the left to the right eye, he notes that both pupils appear to dilate. Which would be the single most accurate explanation of this finding? A Argyll Robertson's pupil on the right B Myotonic right pupil C Normal variation D Raised intracranial pressure E Relative afferent pupillary defect on the right

Answer 65

E The ‘swinging fl ashlight test’ reveals an abnormal response in the right pupil. The fact that the right eye produces less pupillary constriction suggests an aff erent defect on that side. Although it may appear that both pupils are dilating, this is just relative: they are, in fact, both trying to constrict, but failing to do so fully due to the partial aff erent nerve damage that distinguishes this condition. In this case—a young woman with concurrent headache—the damage may have occurred following an optic neuritis and may be indicative of a history of multiple sclerosis. Full dilation and lack of a subsequent response would suggest a total CN II lesion.

Question 66

A 32-year-old man claims he has taken 30 temazepam 20mg tablets 5h ago. He has a long history of depression and recurrent suicide attempts. He smells of alcohol, his speech is slurred, and he has an unsteady gait. RR 12/min, SaO 2 96% on air. Chest: scattered crepitations. Which is the single most appropriate next step? A Activated charcoal B Flumazenil IV C Neurological observations until consciousness level improves D Urgent referral to ITU for intubation and ventilation E Urinary alkalinization

Answer 66

C Treatment of benzodiazepine overdose is supportive with maintenance of the airway, regular assessment of consciousness level, and IV fluids. A This and gastric lavage are no use in pure benzodiazepine overdose. B Although fl umazenil is a benzodiazepine antagonist, it is not used to reverse purposeful overdose because there is no way of being sure how much of the hypnotic has been taken. Flumazenil can trigger seizures via the benzodiazepine receptor as a result of the reduction in the seizure threshold. It is only used if the overdose has been caused during a procedure in the hospital environment. D There is no indication for this at the moment. E This uses sodium bicarbonate to produce urine with a pH between 7.5 and 8. This can enhance elimination of weak acids such as cocaine, tricyclic antidepressants, and salicylates.

Question 67

An 82-year-old woman has rapidly become unable to speak. Her family report that she has been increasingly tired over the last 3 weeks and latterly has been restricted to sitting in a chair. Prior to this, she walked with a stick and was independent with regard to all activities of daily living. She is awake but not able to follow commands and is therefore difficult to examine. T 38.4 ° C, HR 105bpm, BP 100/65mmHg. Tone and reflexes are globally increased with equivocal plantars but no focal neurology. Which single investigation is the most likely to produce a definitive diagnosis? A Blood culture B CT scan of brain C EEG D LP E MRI

Answer 67

D This is viral encephalitis. Cerebrospinal fl uid examination obtained by a lumbar puncture is the most appropriate option. It usually shows a raised protein and lymphocyte count with a normal glucose concentration but can be normal. A This is unlikely to help in the diagnosis. B and E The history is not suggestive of an abscess, space-occupying lesion, or stroke. Although imaging of the brain may aid the diagnosis, it is not the choice that will ‘produce the defi nitive diagnosis’. C Whilst an EEG may show sharp wave activity in one or both temporal lobes of brains with viral encephalitis, it would be used diagnostically less often than a lumbar puncture.

Question 68

A 72-year-old woman describes waking up 3 days ago feeling like she is ‘on a boat’. She has also noticed that after she rolls over in bed, especially to the right, the room spins around her for 15–20s. She has also had to be careful when she has bent down to put on her shoes and getting things out of high cupboards. No nystagmus seen. Romberg’s –ve. The doctor seeing her tries to explain why she is experiencing these symptoms. What is the single most likely explanation for why she is experiencing these symptoms? A benign growth on acoustic nerve B Blockage in the blood supply to the back of the brain C Displaced crystals in the inner part of the ear D Excessive fluid found in the inner ear E Inflammation involving the inner ear

Answer 68

C This is a classic history for benign paroxysmal positional vertigo (BPPV). Displaced otoconia can be relocated by the Epley manoeuvre or Brandt– Daroff exercises and provide a cure in up to 80–90% of cases in some studies. A Acoustic neuroma B Cerebellar stroke D M é ni è re’s disease E Labyrinthitis

Question 69

A 48-year-old man has had a painful neck for the last few months. The doctor examining him thinks he has symptoms consistent with a C8–T1 nerve root compression. Which single test result confi rms this diagnosis? A Numb fifth and ring finger B Numb middle finger C Reduced triceps jerk D Weak biceps and deltoid E Weak triceps and finger extension

Answer 69

A This man has cervical spondylosis associated with a radiculopathy—pain, reduced refl exes, dermatomal sensory disturbance and lower motor neurone (LMN) weakness. B, C, and E These describe the involvement of the C7 nerve root. D This describes the involvement of the C5/6 nerve root.

Question 70

A 52-year-old man has suddenly lost strength in his right arm and leg. He has never experienced anything like this before and his wife is concerned he may be having a stroke and calls an ambulance, but by the time he arrives at the hospital his strength has returned to normal. He asks the doctor assessing him if he can go home. Which single factor should prompt admission for urgent investigation? A BP 180/90 B Type 2 Diabetes C Loss of sensation in his right arm and leg D Strong family history of stroke E Symptoms lasted over an hour

Answer 70

E This man has had a TIA and needs to be assessed to establish his risk for a subsequent stroke. A reliable way of assessing this risk is using the ABCD2 score: A ge \>60 years (1 point), B P \>140/90 mmHg (1 point) C linical features— speech disturbance without unilateral weakness (1 point), unilateral weakness (2 points), D uration 10–59 minutes (1 point), \>60min (2 points), D iabetes (1 point). Notably, the presence of family history and sensory symptoms play no part in his risk assessment for a subsequent stroke. A score of 3 or below: aspirin 300mg daily starting immediately and specialist assessment within 7 days. A score of 4 or more: aspirin 300mg daily starting immediately with specialist assessment within 24h. The man scores 2 for his symptoms and therefore requires 2 further points to trigger an urgent admission, which he would get if his symptoms had lasted for more than 1h. → http://stroke.ahajournals.org/cgi/content/full/strokeaha;40/3/749

Question 71

An 84-year-old man is found unrousable in the bed of his nursing home. He has type 2 diabetes. Sodium 156mmol/L, potassium 5.5mmol/L, urea 33mmol/L, creatinine 288μmol/L. Random venous glucose 55mmol/L. Which is the single most appropriate choice of infusion fluid? A 0.45% saline B 0.9% saline C 5% glucose D 5% glucose/0.9% saline E Sodium bicarbonate

Answer 71

B Reduced consciousness level in a patient with type 2 diabetes is initially suggestive of a hyperosmolar state. This is clearly confi rmed by the laboratory fi ndings which show not only hyperglycaemia but also hypernatraemia, considerable dehydration and a raised serum osmolality (2 × (Na + K) + Ur + glucose). There are several important management steps at this time: 1. Insulin therapy (1U/mL of 0.9% saline at a rate of 6U/h). 2. Anticoagulation therapy: as these patients are at increased risk of venous thrombosis. 3. Fluid replacement: most patients are fl uid depleted by 5L or more. Normal-strength saline is eff ective at rapidly restoring circulating volume and does so without dropping the serum osmolality too quickly, which is a risk for the development of cerebral oedema. If the sodium remains high after 2–3L of infusion fl uids, then half-strength normal saline can be used. Clearly it would be dangerous to use any glucose products, while sodium bicarbonate is usually discouraged unless in the setting of extreme acidosis and under the guidance of experienced renal or intensive care clinicians. Given the amount of fl uid that needs to be replaced, it is worth bearing in mind that these patients—especially if they are over 65 years old and/ or have ischaemic heart disease—will likely need a CVP line and urinary catheter.