A 25-year-old female is found to have a left hemiparesis following a deep vein thrombosis. An ECG shows RBBB with right axis deviation.
What is the most likely underlying diagnosis?
Correct Answer D: The ostium secundum in this patient has allowed passage of an embolus from the right-sided circulation to the left causing a stroke.
Atrial septal defects:
Atrial septal defects (ASDs) are the most likely congenital heart defect to be found in adulthood. They carry a significant mortality, with 50% of patients being dead at 50 years. Two types of ASDs are recognized, ostium secundum and ostium primum. Ostium secundum are the most common.
Features:
Ostium secundum (70% of ASDs):
Ostium primum:
You are reviewing a 22-year-old man who has developed headaches.
Which one of the following features is most typical of migraines?
Correct Answer B: Phonophobia occurs in around three-quarters of patients.
Migraine: diagnostic criteria:
The International Headache Society has produced the following diagnostic criteria for migraine without aura:
*In children, attacks may be shorter-lasting, headache is more commonly bilateral, and gastrointestinal disturbance is more prominent.
Migraine with aura (around 1 in 3 migraine patients) tends to be easier to diagnose with a typical aura being progressive in nature and may occur hours prior to the headache. Typical aura include a transient hemianopic disturbance or a spreading scintillating scotoma ('jagged crescent'). Sensory symptoms may also occur.
Which one of the following features is not associated with an oculomotor nerve palsy?
Correct Answer A: Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner's
Oculomotor nerve palsy is typically associated with a dilated pupil.
Third nerve palsy:
Causes:
*This term is usually associated with sixth nerve palsies but it may be used for a variety of neurological presentations.
A 12-year-old boy is brought to the Emergency Department. He was hit on the side the head by a cricket ball during a match. His teacher describes him initially collapsing to the ground and complaining of a sore head. After two minutes he got up, said he felt OK and continued playing. After 30 minutes he suddenly collapsed to the ground and lost consciousness.
What type of injury is he most likely to have sustained?
Correct Answer D: Epidural haematoma - lucid interval.
Head injury:
Types of traumatic brain injury:
A 45-year-old man presents to the Emergency Department following the sudden onset of pain in the right side of his face whilst hammering a nail into the wall. The pain is described as severe and constant. On examination he has a mild right ptosis and small right pupil.
What is the most likely diagnosis?
Correct Answer C: This patient has Horner's syndrome caused by a carotid artery dissection. This may be caused by relatively benign trauma to the neck such as hyperextension whilst doing DIY. Cluster headache would be a differential diagnosis.
Horner's syndrome:
Distinguishing between causes:
*In reality the appearance is due to a narrow palpebral aperture rather than true enophthalmos.
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