Contents
Dedications
Foreword
Preface
About the Authors
List of Editors and Illustrators
Chapter Editors and Reviewers
Acknowledgments
Disclaimer
Practice Paper 1
Cushing’s triad of raised intracranial pressure
Head trauma
chronic subdural haematoma
Head trauma, GCS of 15 on examination, bruising behind the mastoidprocess and some clear nasal discharge.
a high-speed motor vehicle accident. He was not wearing aseatbelt and he had a GCS of 3 at the scene. His recovery has been slow and he isunable to be taken off the ventilator. A CT head scan shows small punctatecontusions but is otherwise normal.
become more aggressive, been in several bar fights, and lost tenthousand pounds of savings on slot machines. The patient does not appearconcerned, swearing excessively throughout the consultation and demanding thathe be allowed to leave as ‘there is nothing wrong with me’.
markedly loss of inhibition(becoming more aggressive and rude, gambling), and inability to function.
a reducedconsciousness level. He was playing cricket when a wayward ball struck him inthe side of the head. His friend reports that he ‘was out’ for a few minutes butquickly regained consciousness, seemed fine and continued playing, until hecollapsed 30 minutes later. His current GCS is 9.
Headaches
headaches are worse when she gets out of bed, bends over, or coughs. She alsocomplains of reduced visual quality. She has a recent diagnosis of polycystic ovariansyndrome and has gained around 2 stone (13 kg) in the past year — her bodymass index is now 38. On examination you find papilloedema and no other deficits,but her CT head scan results are normal.
The on-call neurologist suspects a subarachnoid haemorrhage. Her CT headscan at 2 hours after onset is reported as normal by a consultant radiologist.
A 28-year-old male with episodes last for 2 hours each time.When he has an episode, it is excruciatingly painful, and he reports having towalk around in circles until the pain subsides. On occasion, he reports excessivetearing from the right eye. Neurological examination is normal, there is no neckstiffness, and ophthalmoscopy is normal.
Alcoholic elderly after a fall GCS of 10. A CT head scanshows a hyperdense, crescent-shaped opacity that crosses suture lines with no skullfractures.
Pregnant woman with a history of asthma presents with medication would you offer her to prevent intense headaches. Theyhappen once every few days and are dull and achy in nature. During an episode,she lies still and tries to go into a dark room, which sometimes helps.
Elderly patient with a 2-week history of troublesome headache presented over a few days and is 8/10 in intensity. She also describes feeling tiredand weak during the same period. She has noticed that the pain is brought on bycombing her hair, and she has had some difficulty chewing foods which she thinksis unrelated.
sudden onset of headache whilst having sexual intercourse with her husband. Thepain is 10/10 in severity, and she describes it as ‘like being hit over the head witha cricket bat’ and it came on suddenly over 2–3 minutes, marked neck stiffness and is in considerable pain.
Cognitive
Gradual decline in memory, reduction in higher functions (likecrossword puzzles), and forgetfulness that is worse at night, Montreal Cognitive Assessment score is 17/30.
facial pain
A 31-year-old female with intense left-sided facial pain. The pain originates fromthe angle of her jaw and travels to the corner of her mouth, and she describes thepain as ‘like little electric shocks’. She has noticed that area of her face is nowextremely sensitive, and the pain can be brought on by touching the area.
the most likely diagnosis?
assuming there are no contraindications, what isthe first line treatment to start the patient on?
Back pain
back pain, altered perianal sensation(‘saddle’ anaesthesia), and sphincter dysfunction (urinary and/or bowel retention and incontinence).
Stroke
altered GCS or reduced consciousness level after thrombolysis
a past medical history of hypertension and type 2diabetes, An acute stroke is suspected. What is the most appropriate initial investigation forthis patient (whilst in the emergency department)?
patient was admitted to their acute medical ward after beingfound unresponsive at home, and he has a significant focal neurological deficit.Based on their CT scan taken 2 hours ago
how long, after symptom onset, are patientseligible to receive thrombolysis and thrombectomy, respectively in acute ischaemic stroke
Unilateral weakness and hemiplegia affectingthe left-hand side of their whole body, and the consultant notes left-sidedhomonymous hemianopia on examination.
neuro-ophthalmology
a dilated pupil which does notreact to light but slowly reacts to accommodation, generalised hyporeflexia.
Recovering from a bad episode of sinusitis presents with painful eye movements and double vision. Significant eyeball protrusion and oedema surrounding both eyes. Loss of forehead sensation bilaterally, and papilloedema.
speech
a left partial anterior circulation stroke, The patient replies, ‘Nice very breakfast my own horsebut then spaceships purple today’.
confusion
the triad for Wernicke’s encephalopathy?
fever, raised intracranial pressure, focal neurological deficits and confusion following a recent episode of sinusitis,
agents should be avoidedwhen treating ‘dull’ and ‘like an electric shock’ bilateral leg pains in a 15-year history of poorly controlled type 2 diabetes and benign prostatichyperplasia.
Glasgow Coma Scale
opens hiseyes when a trapezius squeeze is applied, and he is groaning but not formulating anywords. When you apply a pain stimulus to his shoulder, he pulls his limb away fromthe stimulus.
Horner’s syndrome
lady is presenting with classical symptoms of a subarachnoid haemorrhage, the classical features of this syndrome?
progressive weakness, swallowing difficulties, and general decline. a combination of upper and lower motor neuronsigns, such as wasting, fasciculation coupled with brisk reflexes, and clonus
the patient appears emaciated with widespread muscle wasting, andyou note the presence of fasciculations on his tongue. His reflexes are weak, hehas a positive Babinski sign in both legs, and his sensory function is intact.
normal pressure hydrocephalus
the triad associated with this presentation of symptoms?
brain tumour
the most common primary source of brain metastases in a 57-year-old male?
lumbar puncture
NOT an absolute contraindication to having a lumbarpuncture?
seizures
a 9-month-old baby bring him to a GP. Over the past2 months, they describe the child as having frequent episodes of flexing his armstowards his chest before straightening them out, whilst drawing his knees up tohis chest. On examination, he cannot sit upright, has poor head control, and doesnot babble or say any words.
anti-convulsant medication
anti-convulsant medication is most associated with weight gain?
‘shakingher limbs and then going stiff’ for ten minutes in the morning. The episode resolvedspontaneously, and she had no urinary or faecal incontinence, bit the centre ofher tongue, and was noticeably tearful immediately afterwards. He describes hereyes as being clenched shut during the episode. She has no past medical history,but reports being ‘stressed out’ as her PhD thesis
a 53-year-old male who underwent surgery to remove a brain tumour and hasbeen fitting for the last 10 minutes. The nurse has secured his airway and is givinghigh flow oxygen via a non-rebreathe mask, and the patient is fitting continuously.
Carpal tunnel syndrome
NOT a risk factor for Carpal tunnel syndrome?
the inheritance pattern of the patient appears to havegrossly misshapen feet in a concave appearance, hammer toes, and some evidenceof distal muscle wasting of the leg.
neuroanatomy
dermatome supplies the ventralaspect of the little finger.
region of the brain is the vomitingcentre located?
The neurology registrar holds the patient’s hand andflicks the nail of the middle finger, and you notice the patient’s thumb and indexfinger flex spontaneously.
a feature of an upper motor neuron lesion?
Hydrocephalus
The following examination signs willNOT be present in hydrocephalus?
lying and standing blood pressure measurementsare within normal range, and his 7-day ambulatory ECG reveals 8 ectopic beatsalong with sinus rhythm.
back pain
paraplegia, a sudden onsetof back pain for the last 2 days. He describes having a pain ‘like an elastic band’in his upper abdomen and back for 8 weeks, for the last 2days has found getting about the house difficult. He has no urinary incontinence.He has a past history of prostate cancer, and he underwent radiotherapy 12 monthsago for a recurrence. On examination, he has MRC grade 2/5 power in both lowerlimbs.
Brown-Séquard syndrome
a right-sided stab wound. examination findings would you expect?
cranial nerve
The eyeis deviated in a ‘down and out’ fashion, the pupil is fixed, dilated, and unreactive to light
a patientwhose appearance has slowly changed over time, with increases in shoe and finger size, hypertensionresistant to 3 anti-hypertensive medications and bilateral carpal tunnel syndrome.On examination, you note prognathism and a very large tongue.
Image
CT head scans
the most likely diagnosis?
patient was admitted to their acute medical ward after beingfound unresponsive at home, and he has a significant focal neurological deficit.Based on their CT scan taken 2 hours ago
Gentleman flexing his neck from the bricks falling on him. greater loss of power in the legs compared tothe arms. sensory loss, with loss ofpain and temperature and relative sparing of vibration and proprioception.
movement disorders
young boy has a resting tremor, behavioural disturbance, memory problems, and you note the presence of agolden-brown ring around his eyes.
a 70-year-old male. For the past 6 months, he appears to haveslowed down, taking much longer to get dressed in the morning and return fromthe shops. On further questioning, he trivially reports losing his sense of smell 2years ago, and his handwriting appears much smaller than it used to. Onexamination, you notice a 3–5 Hz tremor that disappears when he moves his arm,and he has a fixed, limited facial expression.
a resting tremor that improves with movement, andshe has slowed significantly. On taking a more detailed history, she reports thatbefore her symptoms started, she began suffering from frequent falls and nowuses a wheelchair to prevent them from happening. On examination, she haslimited eye movements and cannot move them upwards, as well as a fixed facialexpression with the appearance of looking surprised.
Huntington’s
what his son’s chances areof inheriting the disease.
sudden and uncontrollable electric shock-like jerks of his arm that last a secondor two before resolving.
Dementia, stroke at young age, maculopapular rash 20 years ago, myoclonus is present, he has impaired joint proprioceptionand vibration, and his pupils are small and do not react to light from a pen-torch.
Amyotrophic lateral sclerosis
medication known to improve prognosis in patients with motor neurone disease
a gradual onset of left eye pain with associated blurred vision, whichhas now thankfully settled down.
Weakness
The patient cannot raise their arm or leg whenasked to, but there is a flicker of contraction and the patient can flex the arm andleg when both are placed flat on the examination couch.
Young lady with weakness, swallowing difficulty and diplopia towards the end of the day, and weakness that develops after a repetitive movement like making a fist.
limbweakness starting with his legs, which has now moved up to his knee. He is veryworried as the weakness has been getting worse since it started 10 days ago. Otherthan an episode of bad food poisoning 2 weeks ago after a ‘dodgy takeaway’, heis normally fit and well. Examination reveals MRC grade 2/5 power in both lowerlimbs, and reflexes are absent.
difficult todo his buttons up in the morning, and finds it even harder to type up patientnotes on the ward computers. He also says that the strength in his arms is ‘a lotless than it used to be’. On examination, there is reduced power in the upper armsand muscles of the hand, and there is a positive Hoffman’s sign.
back pain, altered perianal sensation(‘saddle’ anaesthesia), and sphincter dysfunction (urinary and/or bowel retention and incontinence).
bumpy lesions occupying a dermatomal pattern inhis upper limbs, strange freckles over his axilla, and a series of light, brown maculeson his lower back.
tumour
a tumour, locatedon the parietal convexity, with no brain invasion. The tumour is spherical andcalcified.
a known diagnosis of glioblastoma, GCS is 8, breathing is regular, right pupilis fixed, dilated and unresponsive to light, and entire left-hand side is affected bya dense hemiparesis.
medication should be given to reduce the oedema in a suspicious mass lesion in the frontal lobe with very prominent oedemaaround the mass.
Practice Paper 2
Practice Paper 3
Practice Paper 4
Practice Paper 5
Answers
Practice Paper 1 — Answers
Practice Paper 2 — Answers
Practice Paper 3 — Answers
Practice Paper 4 — Answers
Practice Paper 5 — Answers
One Sentence Summaries Index (in Alphabetical Order)
Index
