A 62-year-old man is referred to the neurology clinic with worsening symptoms over the past few months. The neurologist suspects the patient has progressive supranuclear palsy.
Which one of the following features is least likely to be seen in this patient?
Correct Answer B: Progressive supranuclear palsy: parkinsonism, impairment of vertical gaze.
Impairment of vertical gaze is seen in progressive supranuclear palsy. Horizontal gaze impairment is sometimes seen later as the disease progresses, but would be atypical in a newly diagnosed patient.
Overview:
Features:
Management:
A 56-year-old woman comes for review. Around 4 weeks ago she had a blistering rash under her right breast which extended around to the back. A diagnosis of shingles was made. Unfortunately since that time she has been experiencing severe 'shooting' pains. The skin is also very tender to touch. Neither paracetamol nor ibuprofen have helped her symptoms.
What is the most appropriate next step in management?
Correct Answer C: This lady has developed post-herpetic neuralgia. NICE recommend using amitriptyline or pregabalin first-line.
Neuropathic pain:
Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesia.
Examples include:
NICE issued guidance in 2010 on the management of neuropathic pain:
*Please note that for some specific conditions the guidance may vary. For example carbamazepine is used first-line for trigeminal neuralgia, duloxetine for diabetic neuropathy.
A patient is noted to have absent ankle jerks combined with extensor plantars on examination.
Which one of the following is least likely?
Correct Answer A: Multiple sclerosis would not give this combination of physical signs.
Absent ankle jerks, extensor plantars:
Typically caused by lesion producing both upper motor neuron (extensor plantars) and lower motor neuron (absent ankle jerk) signs.
Causes:
A 42-year-old woman presents as she has noticed a 'droop' in the right side of her face since she woke up this morning. There is no associated limb weakness, dysphagia or visual disturbance. On examination you notice right-sided upper and lower facial paralysis.
Which one of the following features would be most consistent with a diagnosis of Bell's palsy?
Correct Answer B: A vesicular rash around the ear would suggest a diagnosis of Ramsey Hunt syndrome. Hyperacusis is seen in around a third of patients.
Bell's palsy:
Bell's palsy may be defined as an acute, unilateral, idiopathic, facial nerve paralysis. The aetiology is unknown although the role of the herpes simplex virus has been investigated previously.
*Upper motor neuron lesion 'spares' upper face.
A 47-year-old man presents to the Emergency Department with a three day history of severe headache associated with vomiting. There is no past medical history of note. On examination blood pressure is 98/62 mmHg, pulse is 108 bpm and temperature is 37.0ºC. There is mild neck stiffness and a partial third nerve palsy of the left eye. Blood rests reveal:
What is the most likely diagnosis?
Correct Answer D: The hypotension, electrolytes and low free T4 point towards hypopituitarism. Clinically, pituitary apoplexy can mimic a subarachnoid haemorrhage.
Pituitary apoplexy:
Sudden enlargement of pituitary tumour secondary to haemorrhage or infarction.
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