A 60-year-old woman presents with a tremor. Which one of the following features would suggest a diagnosis of essential tremor rather than Parkinson's disease?
Correct Answer E: Difficulty in initiating movement (bradykinesia), postural instability and unilateral symptoms (initially) are typical of Parkinson's. Essential tremor symptoms are usually eased by alcohol.
Essential tremor:
Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs.
Features:
Management:
A 24-year-old female presents with a headache. She has a past history of epilepsy and is known to suffer from migraines, but has previously managed attacks with a combination of paracetamol and metoclopramide. This combination is however not working for the current episode.
What second line medication is most appropriate to use?
Correct Answer C: Epilepsy is not a contraindication to the use of triptans. Opioids are not recommended in the management of migraine.
Migraine management:
It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE produced guidelines in 2012 on the management of headache, including migraines.
Acute treatment:
Prophylaxis:
*Caution should be exercised with young patients as acute dystonic reactions may develop
A 45-year-old man presents with dizziness and right-sided hearing loss.
Which one of the following tests would most likely indicate an acoustic neuroma?
Correct Answer E: Loss of corneal reflex - think acoustic neuroma.
Acoustic neuroma: Acoustic neuromas (more correctly called vestibular schwannomas) account for approximately five percent of intracranial tumours and 90 percent of cerebellopontine angle.
Features can be predicted by the affected cranial nerves:
Bilateral acoustic neuromas are seen in neurofibromatosis type 2.
MRI of the cerebellopontine angle is the investigation of choice.
A 57-year-old woman presents with an 8 week history of intermittent dizziness. These episodes typically occur when she suddenly moves her head and are characterized by the sensation that the room is 'spinning'. Most attacks last around one minute before dissipating. Neurological examination is unremarkable.
What is the most likely diagnosis?
Correct Answer A: Viral labyrinthitis typically causes constant symptoms of a shorter duration. Patients with Meniere disease usually have associated hearing loss and tinnitus. Also, the vertigo associated with Meniere disease typically lasts much longer.
Benign paroxysmal positional vertigo Benign: Paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterized by the sudden onset of dizziness and vertigo triggered by changes in head position.
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by:
Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.
Which one of the following is least associated with normal pressure hydrocephalus?
Correct Answer A: Urinary incontinence + gait abnormality + dementia = normal pressure hydrocephalus.
Normal pressure hydrocephalus:
Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be secondary to reduced CSF absorption at the arachnoid villi. These changes may be secondary to head injury, subarachnoid haemorrhage or meningitis.
A classical triad of features is seen:
Imaging:
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