During a routine cranial nerve examination the following findings are observed: Rinne's test: Air conduction > bone conduction in both ears Weber's test: Localizes to the right side What do these tests imply?
Correct Answer E: In Weber's test if there is a sensorineural problem the sound is localized to the unaffected side (right) indicating a problem on the left side.
Rinne's and Weber's test:
Performing both Rinne's and Weber's test allows differentiation of conductive and sensorineural deafness.
Rinne's test:
Weber's test:
A 40-year-old man undergoes a temporal lobectomy after the discovery of a brain tumour.
Which one of the following consequences would be least likely to develop?
Correct Answer B:
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:
Which one of the following is least associated with the development of chorea?
Correct Answer E: Chorea can be a very rare manifestation of infective endocarditis, following embolization to the basal ganglia. It is however the least likely of the above five options.
Chorea:
Chorea describes involuntaru, rapid, jerky movements which often move from one part of the body to another. Slower, sinuous movement of the limbs is termed athetosis. Chorea is caused by damage to the basal ganglia, especially the caudate nucleus.
Causes of chorea:
A 43-year-old woman with multiple sclerosis presents for review. She is having increasing problems with painful involuntary contractions of the leg muscles.
What is the most appropriate first-line therapy?
Multiple sclerosis: management:
Treatment in multiple sclerosis is focused at reducing the frequency and duration of relapses. There is no cure. High dose steroids (e.g. IV methylprednisolone) may be given for 3-5 days to shorten the length of an acute relapse. Baclofen is helpful in controlling spasticity. Hallucinations are occasionally seen on the withdrawal of baclofen.
Beta-interferon has been shown to reduce the relapse rate by up to 30%. Certain criteria have to be met before it is used:
Other drugs used in the management of multiple sclerosis include:
Symptom control:
A 19-year-old man presents with a two-day history of a diffuse headache and sore throat. He is pyrexial at 37.8ºC and is reluctant to have a fundoscopy due to photophobia. A lumbar puncture is performed:
Lumbar puncture reveals:
What is the most likely diagnosis?
Correct Answer E: There results are consistent with normal CSF - an alternative diagnosis should be considered.
Meningitis: CSF analysis:
The table below summarises the characteristic cerebrospinal fluid (CSF) findings in meningitis:
The Ziehl-Neelsen stain is only 20% sensitive in the detection of tuberculous meningitis and therefore PCR is sometimes used (sensitivity = 75%).
*Mumps is unusual in being associated with a low glucose level in a proportion of cases. A low glucose may also be seen in herpes encephalitis.
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