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Question 1
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A 32-year-old female has had an episode of a severe occipital headache. This is accompanied by vomiting and unconsciousness. She has been taken to the emergency department, where she is conscious and completely alert. Her pulse is normal and no abnormal neurological signs are found. From the list of options, choose the next step in her treatment.
Your Answer: CT brain
Explanation:Severe headaches and LOC can be caused by basilar migraines (but here the patient has no neurological deficit and becomes completely alert when recovering from unconscious periods). In order to diagnose basilar migraines, there needs to be a history of at least two other migraine attacks with an aura. The diagnostic criteria of a basilar migraine are not fulfilled and so the patient must not be discharged without a CT scan (or MRI).
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This question is part of the following fields:
- Nervous System
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Question 2
Correct
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When considering the anatomical location of intracranial meningiomas, which of the following relations is well recognised?
Your Answer: Parasagittal - spastic paraparesis
Explanation:The localisation of intracranial lesions (based on both history and examination) is crucial. Meningiomas are slow in growth, and its subtle effects are very different from the more aggressive, intrinsic lesions. Olfactory groove lesions affect the sense of smell and may produce ipsilateral optic atrophy. Sphenoid ridge lesions will produce exophthalmos. Chiasmal lesions usually produce bitemporal hemianopia.
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This question is part of the following fields:
- Nervous System
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Question 3
Correct
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Question 4
Correct
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A 43 year-old female artist with no past medical history presents to the emergency department with a 2-day history of pins and needles in the lower limbs, and progressive walking difficulties. She states she had diarrhoea 1 week ago. On examination, there is a loss of pinprick sensation noted to the lower limbs from mid-thigh distally and in the upper limbs from MCP joints distally. There is bilateral weakness of ankle dorsiflexion, noted at 3/5, and knee flexion and extension weakness, noted at 4/5 bilaterally. Power in upper and lower limbs is otherwise normal. Knee and ankle deep tendon reflexes are absent. Which of the following is the most likely diagnosis?
Your Answer: Guillain-Barre syndrome
Explanation:Guillain-Barre syndrome is an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni). Characteristic features include progressive weakness of all four limbs, and it is classically ascending, affecting the lower extremities first. Sensory symptoms tend to be mild.
Functional neurological syndrome can be discounted due to presence of hard neurological signs. Multiple sclerosis can be excluded because of the presence of lower motor neuron signs and absence of upper motor neuron signs. Chronic inflammatory demyelinating polyneuropathy is the chronic form of Guillain-Barre syndrome.
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This question is part of the following fields:
- Nervous System
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Question 5
Correct
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A 51-year-old man speaks fast and does not take enough breaths before speaking again. He ignores interruptions and does not want to pause in between. What best describes this kind of speech?
Your Answer: Pressure of speech
Explanation:A pressured speech is too fast for the listener to understand and is very difficult to interrupt.
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This question is part of the following fields:
- Nervous System
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Question 6
Correct
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Which of the following features is not associated with an oculomotor nerve palsy?
Your Answer: Miosis
Explanation:Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. A complete oculomotor nerve palsy will result in a characteristic down and out position in the affected eye. This is because the lateral rectus (innervated by the sixth cranial nerve) and superior oblique (innervated by the fourth cranial or trochlear nerve), is unantagonized by the paralyzed superior rectus, inferior rectus and inferior oblique. The affected individual will also have a ptosis, or drooping of the eyelid, and mydriasis (pupil dilation), not miosis.
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This question is part of the following fields:
- Nervous System
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Question 7
Correct
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A 51-year-old presents with muscle atrophy. He has a high BMI and finds it difficult to climb stairs. If the patient also has polydipsia and polyuria, what is the most likely diagnosis?
Your Answer: Amyotrophy
Explanation:(Diabetic) Amyotrophy is a condition that presents with muscle wasting and consequent difficulty in climbing stairs. The onset is relatively sudden and symptoms of diabetes are characteristic.
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This question is part of the following fields:
- Nervous System
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Question 8
Incorrect
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A 34-year-old male patient is admitted with hemisection of the spinal cord at the level T5, after being stabbed in the back. Which sign would you expect to see by assessing the patient's sensory function and muscle strength?
Your Answer: Ipsilateral loss of temperature, contralateral loss of fine touch and vibration, ipsilateral spastic paresis
Correct Answer: Contralateral loss of temperature, ipsilateral loss of fine touch and vibration, ipsilateral spastic paresis
Explanation:Depending on the level of SCI, patients experience paraplegia or tetraplegia. Paraplegia is defined as the impairment of sensory or motor function in lower extremities. Patients with incomplete paraplegia generally have a good prognosis in regaining locomotor ability (,76% of patients) within a year. Complete paraplegic patients, however, experience limited recovery of lower limb function if their NLI is above T9. The spinothalamic tract is the one responsible for sensory information such as pain or temperature. However, it decussates at the same level the nerve root enters the spinal cord, meaning that the sensory loss will be contralateral. However, the dorsal column carries sensory fibres for fine touch and vibration and it decussates at the medulla which means that the sensory loss will be ipsilateral. The corticospinal tract is responsible for motor functions and it decussates at the medulla, meaning that the motor function loss will be ipsilateral.
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This question is part of the following fields:
- Nervous System
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Question 9
Incorrect
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A 42-year-old man with a 6 month history of progressive weakness of both lower limbs, complains of lethargy and of difficulties climbing stairs. He also claims he's experienced muscle loss in his lower limbs. History reveals type 2 diabetes mellitus and heavy alcohol use for the last 4 years. Clinical examination reveals marked loss of fine touch and proprioception. The distribution is in a stocking manner and bilateral. However, no evidence of ataxia is present. What is the most probable diagnosis?
Your Answer: Pellagra
Correct Answer: Dry beriberi
Explanation:Hypovitaminosis B1, consistent with dry beriberi is crucially a treatable condition, although sometimes with incomplete recovery, but it is probably under-recognized yet increasingly common given increasing levels of alcohol abuse in the western world. Dry beriberi or ‘acute nutritional polyneuropathy’ is considered to be rare in the western world. Rapid deterioration can occur, typically with weakness, paraesthesia and neuropathic pain. Striking motor nerve involvement can occur, mimicking Guillain-Barre syndrome (GBS). In the context of increasing alcohol abuse in the western world, it is possible that alcoholic neuropathy associated with abrupt deterioration due to concomitant nutritional hypovitaminosis B1 may be seen increasingly often.
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This question is part of the following fields:
- Nervous System
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Question 10
Correct
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A 7-year-old boy was brought to the ED in an unconscious and apnoeic state. What is your immediate management of this case?
Your Answer: Secure airway
Explanation:ABC : Airway, breathing, circulation is the order of assessment in any patient that is unconscious and apnoeic.
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This question is part of the following fields:
- Nervous System
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SESSION STATS - PERFORMANCE PER SPECIALTY
