A 44-year-old woman presents with pain in her right hand and forearm which has been getting worse for the past few weeks. There is no history of trauma. The pain is concentrated around the thumb and index finger and is often worse at night. Shaking her hand seems to provide some relief. On examination there is weakness of the abductor pollicis brevis and reduced sensation to fine touch at the index finger.
What is the most likely diagnosis?
Correct Answer C: More proximal symptoms would be expected with a C6 entrapment neuropathy e.g. weakness of the biceps muscle or reduced biceps reflex. Patients with carpal tunnel syndrome often get relief from shaking their hands and this may be an important clue in exam questions.
Carpal tunnel syndrome is caused by compression of median nerve in the carpal tunnel.
History:
Examination:
Causes:
Electrophysiology:
Treatment:
You are called to the obstetric ward to see a woman who is fitting. She is 34-weeks pregnant and currently an inpatient for the treatment of severe pre-eclampsia. The anaesthetist has secured the airway and is giving 100% oxygen.
What is the most appropriate next step?
Correct Answer E: Eclampsia - give magnesium sulphate first-line.
Eclampsia:
Eclampsia may be defined as the development of seizures in association pre-eclampsia. To recap, preeclampsia is defined as:
Magnesium sulphate is used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop. Guidelines on its use suggest the following:
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload.
A 56-year-old woman presents with facial asymmetry. Whilst brushing her teeth this morning she noted that the right hand corner of her mouth was drooping. She is generally well but noted some pain behind her right ear yesterday and says her right eye is becoming dry. On examination she has a complete paralysis of the facial nerve on the right side, extending from the forehead to the mouth. Ear, nose and throat examination is normal. Clinical examination of the peripheral nervous system is normal.
Correct Answer B: The pain around the ear raises the possibility of Ramsey-Hunt syndrome but this is actually quite common in Bell's palsy - some studies suggest it is seen in 50% of patients. The normal ear exam also goes against this diagnosis.
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.
Features:
Management:
Prognosis:
*Upper motor neuron lesion 'spares' upper face
A 29-year-old woman with a past history of hypothyroidism presents to the surgery complaining of weakness, particularly of her arms, for the past four months. She has also developed double vision towards the end of the day, despite having a recent normal examination at the opticians.
Correct Answer E: Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. Antibodies to acetylcholine receptors are seen in 90% of cases*. Myasthenia is more common in women (2:1).
The key feature is muscle fatigability - muscles become progressively weaker during periods of activity and slowly improve after periods of rest:
Associations:
Investigations:
Management of myasthenic crisis:
*Antibodies are less commonly seen in disease limited to the ocular muscles.
Which one of the following statements regarding the development of a headache following lumbar puncture is incorrect?
Correct Answer D:
Post-lumbar puncture headache: Headache following lumbar puncture (LP) occurs in approximately one-third of patients. The pathophysiology of is unclear but may relate to a 'leak' of CSF following dural puncture. Post-LP headaches are more common in young females with a low body mass index.
Typical features:
Click to expand