A 34-year-old woman who presents with confusion, headache and fever is admitted to the Emergency Department. Shortly after admission she has a seizure. A MRI scan is performed which shows patchy haemorrhagic changes in the temporal lobe.
Given the likely diagnosis, what is the treatment of choice?
Correct Answer B:
Herpes simplex encephalitis: Herpes simplex (HSV) encephalitis is a common topic in the exam. The virus characteristically affects the temporal lobes - questions may give the result of imaging or describe temporal lobe signs e.g. aphasia.
Features:
Pathophysiology:
Investigation:
Treatment:
A 52-year-old man is reviewed in the neurology clinic. He has been referred due to the development of difficultly in finding the right words whilst speaking. His comprehension of normal conversation has however remained normal.
Where is the likely lesion?
Correct Answer D: This man has expressive aphasia due to a lesion in Broca's area, located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus.
Brain lesions: The following neurological disorders/features may allow localization of a brain lesion:
Gross anatomy: Parietal lobe lesions:
Occipital lobe lesions:
Temporal lobe lesion:
Frontal lobes lesions:
Cerebellum lesions:
More specific areas:
A 34-year-old accountant presents with a one week history of pain around his right eye occurring once or twice a day. They are described as being very severe and lasting between 10-30 minutes each. He also describes a feeling of a blocked nose.
What is the treatment of choice to treat this current episode?
Correct Answer D: Cluster headache - acute treatment: subcutaneous sumatriptan + 100% O2
Standard analgesia is rarely effective in cluster headaches. 100% oxygen may also be used.
Cluster headache:
Cluster headaches* are more common in men (5:1) and smokers.
Management:
*some neurologists use the term trigeminal autonomic cephalgia to group a number of conditions including cluster headache, paroxysmal hemicrania and short-lived unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). It is recommended such patients are referred for specialist assessment as specific treatment may be required, for example it is known paroxysmal hemicrania responds very well to indomethacin.
A 75-year-old man is seen with his family who are concerned about his memory and behaviour over the past six months. A cognitive assessment is performed which seems to confirm the family's concerns. A series of blood tests are performed to exclude reversible causes. A full blood count, urea and electrolytes, liver function tests and bone profile are requested.
Which other blood tests is it most appropriate to request?
Correct Answer B: NICE do not recommend routine testing for syphilis and HIV.
Dementia: Dementia is thought to affect over 700,000 people in the UK and accounts for a large amount of health and social care spending. The most common cause of dementia in the UK is Alzheimer's disease followed by vascular and Lewy body dementia. These conditions may coexist.
*In the 2011 NICE guidelines structural imaging was said to be essential in the investigation of dementia.
A 54-year-old man presents with a persistent tremor. On examination there is 6-8 Hz tremor of the arms which is worse when his arms are outstretched. His father suffered from a similar complaint.
What is the most suitable first-line treatment?
Correct Answer B: Essential tremor is an AD condition that is made worse when arms are outstretched, made better by alcohol and propranolol.
This patient has a typical history of essential tremor. Propranolol is generally considered the first-line treatment.
Essential tremor:
Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs.
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