MRCP 2 Masterclass – Neurology

A 48-year-old man presents with unsteadiness of gait and double-vision. The figure below shows the appearance of his eyes when he attempts to look to his left.

What is the diagnosis?

A 78-year-old woman presents on the general medical take with falls, cognitive impairment and failure to cope at home. Her abbreviated mental test score is 2/10 and her gait is very unsteady. A CT scan of her brain is done (see figure below).

What is the diagnosis?

A 58-year-old man presents complaining of unsteadiness.

Which two of the following symptoms or signs would usually be inconsistent with a cerebellar lesion?

A 68-year-old woman is referred having had a ‘funny turn’, the question asked by the general practitioner being ‘was this a transient ischaemic attack (TIA)?’

Which two features listed below would be acceptable to sustain the diagnosis of TIA?

A 16-year-old girl presents with a history of episodes of bizarre behaviour following her parents’ recent divorce.

Her mother describes these attacks to you.

Which two of the following features would suggest a true epileptic seizure rather than a non-epileptic attack?

A 40-year-old man presents with progressive leg weakness.

Which two features would be AGAINST a diagnosis of Guillain-Barré syndrome?

A 19-year-old man presents with a history of a single tonic-clonic seizure that occurred the morning after a party. On direct questioning he also reports the occurrence of occasional blank spells and brief jerking of his upper limbs several times a month.

Which of the following drugs is most suitable?

A 30-year-old man presents with a tremor. He has had this for many years, but it has become worse recently such that he now finds it socially embarrassing. His father had a similar problem. His gait is normal.

The most likely diagnosis is:

An 82-year-old man is admitted following a fall. The physiotherapist thinks he looks Parkinsonian and asks for your opinion.

Which of the following is most supportive of a diagnosis of Parkinson’s disease?

A 29-year-old man presents with a 9-month history of depression, 4-month history of painful sensory disturbance in both legs, and most recently cognitive impairment with myoclonus. His MRI scan reveals thalamic hyperintensity on T2-weighted images. His EEG is normal.

The most likely diagnosis is:

A patient presents with high stepping gait.

Which of the following is the most likely diagnosis?

A 65-year-old man presents with a 3-month history of dysarthria and progressive difficulty in swallowing. Examination reveals a weak, fasciculating, spastic tongue and a brisk gag reflex and jaw jerk.

The likely diagnosis is:

A 56-year-old woman presents with progressive leg weakness over 3 days. She has noted minor urinary incontinence in addition. She has a past medical history of breast cancer treated 10 year ago with lumpectomy and radiotherapy.

Which is the investigation of choice?

A patient presents with weakness of knee extension and ankle inversion.

Which of the following nerve roots is most likely affected?

A 65-year-old man presents with pain and weakness in his left arm.

Which one of the following features is NOT consistent with a C5/C6 radiculopathy?

A 30-year-old man describes recurrent daily attacks of severe constant unilateral orbital pain over the last 2 months. He tends to get bouts of this type of attack once to twice a year, typically lasting six to eight weeks in duration.

Which of the following would be appropriate prophylactic treatment?

A 43-year-old man complains of sensory loss in his left arm and hand. On examination he has subjectively diminished light touch and pinprick sensation in the left hand extending to above the elbow. Joint position sense appears intact. With his eyes closed, he has difficulty distinguishing his cigarette lighter from a pen using the left hand, and his two-point discrimination is 11 mm.

Which investigation is most likely to be diagnostic?

A 36-year-old man presents with a few days of low back pain that radiates to his buttocks and is associated with lower limb parathesiae. He now has difficulty walking, particularly on uneven surfaces. The reflexes are difficult to elicit.

The most likely cause is:

A 58-year-old man presents with back pain that radiates through the knee and down the medial side of the calf to the medial malleolus.

The nerve root involved is:

You are examining the pupils of a 48-year-old woman in whom the diagnosis of multiple sclerosis is suspected.

Which of the following observations would make you conclude that she has a left relative afferent pupillary defect?

A 38-year-old woman has weakness of her right foot. You are trying to decide whether she has a common peroneal nerve lesion or an L5 root lesion.

Which of the following statements is true?

An 84-year-old female was referred to clinic with increasing forgetfulness. Her GP had commenced her on a small dose of haloperidol for agitation eight months ago. According to the staff at the nursing home where she resided, she had become increasingly confused over the past few months and more recently had developed odd movements affecting her face, arms and legs. Her GP had reviewed her two weeks previously and stopped the haloperidol; however, she remained confused and the movement disorder had become much more pronounced. She was not taking any other medication.

On examination, she had a mental test score of 4/10. Her vital parameters were normal. She exhibited intermittent yawning motions of the mouth, with occasional tongue protrusion. There were semi-purposeful movements of her arms and legs. There was also clinical evidence of increased tone and cogwheel rigidity on neurological examination of her limbs.

A CT scan of the brain revealed generalized cerebral atrophy and calcification of the basal ganglia.

What is the cause of her movement disorder?

A 52-year-old man was admitted to the intensive care unit with difficulty in breathing after a coryzal illness. He had a six-week history of rapidly progressive muscular fatigue which was worse at the end of the day. More recently he had had difficulty with speech and chewing food while eating.

On examination he had bilateral ptosis and marked facial muscle weakness. Power in all four limbs was diminished. The heart rate was 90 beats/min and regular. The respiratory rate was 30/min but respiration was shallow. Investigations are shown. His condition deteriorated and he was transferred to the intensive care unit for invasive ventilation.

What is the ideal therapeutic strategy in his immediate management?

An 18-year-old girl presented with a six-month history of daytime somnolence that was causing embarrassment during lecture theatres and while talking to friends. She was apprehensive about driving because she did not have any recollection about how she had driven from one destination to another and felt that she may have fallen asleep while driving on a few occasions. She had vivid frightening dreams just as she fell asleep, which would wake her frequently. On waking she was unable to move for a few minutes. Three months previously the patient underwent cardiac investigations for intermittent episodes of sudden collapse that occurred when she laughed out loud. The episodes were not associated with loss of consciousness.

The patient had a past history of insulin-dependent diabetes mellitus since the age of 7 years that was very well controlled. She had recently commenced the oral contraceptive pill but was not on any other medication.

There was no family history of note. Investigations are shown.

What is the diagnosis?

A 45-year-old man with HIV syndrome presented with weakness affecting the left upper and lower limbs. On examination he was confused and had a temperature of 38°C (100.4°F). He had recently been treated for a Pneumocystis carinii infection. The CD4 count was 150.

CT scan of the brain with contrast revealed subcortical atrophy and multiple contrast-enhancing ring lesions in the cortex and subcortical areas.

What is the most probable diagnosis?

A 22-year-old medical student developed sudden dysphasia and right-sided weakness while on holiday in Australia. She was afebrile. Apart from the neurological abnormality described, there were no other abnormal physical signs.

Investigations are shown.

What is the most probable diagnosis?

A 64-year-old man presented immediately after recovering from a 20-minute episode of dysphasia and weakness of the right side of the face and arm. He had experienced two episodes of transient loss of vision in the left eye in the past three weeks. There was a past medical history of a myocardial infarction two years ago. His medication comprised 75 mg of aspirin daily. He did not smoke.

On examination there was no evidence of residual neurological deficit. Fundoscopy was normal. The pulse rate was 80 beats/min and regular in nature. His blood pressure measured 138/86 mmHg in both arms. Both heart sounds were normal. Auscultation over the carotid arteries revealed a bruit over the left carotid artery.

Investigations are shown.

Which three treatments have been shown to reduce the risk of recurrent stroke in this type of patient?

A 40-year-old woman presented with a five-day history of recurrent falls and an unsteady gait. She had a past history of a stroke causing a right-sided hemiparesis, which resolved spontaneously after a few days. The patient underwent intensive investigation following presentation with the stroke including carotid Doppler studies, transoesophageal echocardiography and CT scan of the brain, which were normal.

On examination she had a broad-based gait. There was evidence of dysdiadochokinesia in both upper limbs and abnormal heel–shin testing. The lower limb reflexes were brisk and the plantar response was extensor. The heart rate was 80 beats/min and regular. The blood pressure was 130/90 mmHg. Both heart sounds were normal.

What is the most probable diagnosis?

A 42-year-old man required ventilation for a prolonged period during an episode of septicaemia. Following this he developed difficulty with walking and required the aid of an assistant to mobilize. On neurological examination there was weakness on dorsiflexion of the toes, as well as ankle eversion. The patient also had reduced sensation, affecting the anterior lateral aspects below the knee and the dorsum of the foot.

What is the neurological diagnosis?

A 66-year-old female patient presented with transient bilateral loss of vision lasting a few seconds. A few days later she developed a right-sided hemiparesis. There was no history of head injury or headaches. She had a four-year history of hypertension. The patient had smoked for 40 years. Physical examination revealed a right-sided hemiparesis but no other abnormality. The heart rate was 80 beats/min and regular. The blood pressure measured 160/100 mmHg.

The following test results were obtained:

What is the investigation of choice to ascertain the cause of her presentation?

A 15-year-old male presented with a four-day history of severe right-sided headaches affecting the orbit and right maxillary area. On examination he had acneform lesions around the nose and cheeks. Shortly after admission he became drowsy and developed a high temperature. He complained of diplopia. Subsequent physical examination revealed swelling of the right eye, a partial ptosis of the right eye and a lateral gaze palsy affecting the same eye.

Fundoscopy revealed papilloedema. There was no evidence of nuchal rigidity.

What is the diagnosis?

A 66-year-old retired school teacher presented with a six-month history of progressive weakness, fatigue and breathlessness which was accompanied by weight loss of 5 kg. He had difficulty climbing stairs because his ‘legs would not carry him’, and had noticed that he had difficulty holding light objects with his left hand without dropping them. Over the past week his wife had noticed that his speech appeared slurred and nasal, and he was having difficulty swallowing his meals. He had a past history of pernicious anaemia for which he was taking regular intramuscular B12 injections. On examination, he was thin. There was no evidence of pallor or clubbing.

The patient had dysarthria. Examination of the cranial nerves revealed normal eye movements, but tongue movement was sluggish and there was reduced palatal movement. The jaw jerk was brisk. On examination of his limbs there was wasting and fasciculation of the small muscles of the left hand. The tone and power in the left upper limb was generally reduced. The upper-limb reflexes were brisk. There was wasting and fasciculation in both thigh muscles. The tone was increased and the power was reduced. The ankle and knee jerks were brisk, and there was obvious clonus at the ankle joint. Sensation was normal and Romberg’s test was negative. Examination of the fundi revealed bitemporal pallor.

Investigations are shown.

What is the diagnosis?

A 66-year-old retired school teacher presented with a six-month history of progressive weakness, fatigue and breathlessness which was accompanied by weight loss of 5 kg. He had difficulty climbing stairs because his ‘legs would not carry him’, and had noticed that he had difficulty holding light objects with his left hand without dropping them. Over the past week his wife had noticed that his speech appeared slurred and nasal, and he was having difficulty swallowing his meals. He had a past history of pernicious anaemia for which he was taking regular intramuscular B12 injections. On examination, he was thin. There was no evidence of pallor or clubbing.

The patient had dysarthria. Examination of the cranial nerves revealed normal eye movements, but tongue movement was sluggish and there was reduced palatal movement. The jaw jerk was brisk. On examination of his limbs there was wasting and fasciculation of the small muscles of the left hand. The tone and power in the left upper limb was generally reduced. The upper-limb reflexes were brisk. There was wasting and fasciculation in both thigh muscles. The tone was increased and the power was reduced. The ankle and knee jerks were brisk, and there was obvious clonus at the ankle joint. Sensation was normal and Romberg’s test was negative. Examination of the fundi revealed bitemporal pallor. Investigations are shown.

What two investigations could be performed to confirm your suspicion?

A 30-year-old woman with a history of epilepsy since childhood was 12 weeks pregnant. Her epilepsy had been very well controlled on carbamazepine 200 mg tds and she had been completely free from epileptic seizures for eight years.

What is the best management of her seizures during pregnancy?

A 20-year-old woman gave birth to a full term baby who was floppy at birth and required resuscitation followed by assisted ventilation. The mother had ptosis, muscle weakness and bilateral cataracts. Her father also had premature cataracts.

What is the baby’s diagnosis?

A 50-year-old woman presented with a two-day history of increasing difficulty with swallowing and regurgitation of food. Over the preceding two to three months she had also experienced difficulty climbing stairs, raising her arms above her head, and arising from a sitting or lying position, with some associated lower back pain.

On examination she was found to have symmetrical proximal muscle weakness with normal tone, sensation and deep tendon reflexes. Cranial nerve examination revealed weakness of the bulbar muscles.

What is the most likely cause of her muscle weakness?

A 23-year-old female student consulted her GP for constant headaches for several weeks, which were worse in the mornings. She also found that her vision had
become blurred recently and she had developed diplopia two days ago. She had no past medical history of note. The patient was taking the oral contraceptive pill.

On examination the blood pressure measured 125/80 mmHg. Her body mass index was 27. Her pupils were equal and reactive to light. Visual field testing
revealed enlarged blind spots bilaterally. She has diplopia on looking to the right and impaired abduction of the right eye. Fundoscopy revealed bilateral papilloedema. All other cranial nerves were normal, as was the examination
of the cerebellar and peripheral nervous system.

Investigations were as follows:

What is the next investigation of choice?

A 23-year-old female student consulted her GP for constant headaches for several weeks, which were worse in the mornings. She also found that her vision had
become blurred recently and she had developed diplopia two days ago. She had no past medical history of note. The patient was taking the oral contraceptive pill.

On examination the blood pressure measured 125/80 mmHg. Her body mass index was 27. Her pupils were equal and reactive to light. Visual field testing
revealed enlarged blind spots bilaterally. She has diplopia on looking to the right and impaired abduction of the right eye. Fundoscopy revealed bilateral papilloedema. All other cranial nerves were normal, as was the examination
of the cerebellar and peripheral nervous system.

Investigations were as follows:

What would your next management step be?

A 23-year-old female student consulted her GP for constant headaches for several weeks, which were worse in the mornings. She also found that her vision had
become blurred recently and she had developed diplopia two days ago. She had no past medical history of note. The patient was taking the oral contraceptive pill.

On examination the blood pressure measured 125/80 mmHg. Her body mass index was 27. Her pupils were equal and reactive to light. Visual field testing
revealed enlarged blind spots bilaterally. She has diplopia on looking to the right and impaired abduction of the right eye. Fundoscopy revealed bilateral papilloedema. All other cranial nerves were normal, as was the examination
of the cerebellar and peripheral nervous system.

Investigations were as follows:

The patient is seen again 48 hours later with significant reduction in visual acuity. What is the best management?

A 31-year-old pregnant woman in her third trimester complained of pain and tingling affecting her right hand, forearm and shoulder. The symptoms were worse at night but were relieved by shaking the hand. Her hand felt weaker than usual. On examination there was no wasting of the hand muscles. Abduction of the right thumb was difficult. There was impaired touch sensation affecting the palmar aspects of the first three digits in the right hand. The biceps, triceps and supinator reflexes were intact.

What is the diagnosis?

A 32-year-old woman, who had recently seen her GP for a chest infection, visited her GP again complaining ofbeing clumsy and dropping things. Her husband had also noticed that her speech was slurred in the evening when he saw her after work. There was no previous medical history or family history of note. She was on no medication. She appeared well and there was nothing to find on general examination. Her pupillary reflexes, visual fields and fundoscopy were normal. She had diplopia on looking left and upwards to the right. All cranial nerves
were normal. Tone, power and reflexes were all normal as were coordination and sensation.

What is the most likely diagnosis?

A 60-year-old male presented with sudden onset of reduced visual acuity in the right eye. Six months prior to the presentation the patient had experienced a three-day episode of ataxia that had resolved spontaneously. The patient had a history of diabetes mellitus that was well controlled on insulin. There was no family history of note. The patient consumed 12 units of alcohol per week.

On examination he was in sinus rhythm. The blood pressure measured 130/80 mmHg. Neurological examination was normal with the exception of markedly
reduced visual acuity in the right eye. Fundoscopy was normal.

What is the most probable diagnosis?

A 60-year-old male presented with sudden onset of reduced visual acuity in the right eye. Six months prior to the presentation the patient had experienced a three-day episode of ataxia that had resolved spontaneously. The patient had a history of diabetes mellitus that was well controlled on insulin. There was no family history of note. The patient consumed 12 units of alcohol per week.

On examination he was in sinus rhythm. The blood pressure measured 130/80 mmHg. Neurological examination was normal with the exception of markedly
reduced visual acuity in the right eye. Fundoscopy was normal.

What is the treatment of choice?

A 20-year-old female is admitted to hospital with a 12-hour history of weakness in her arms and legs. This was accompanied by paraesthesia in her hands and feet. Five days before admission she experienced severe pain between her shoulder blades, and shortly afterwards developed blurred vision. The back pain had persisted but was less severe on admission. There was no history of headaches or nausea, but she had been constipated for two days and had intermittent lower abdominal pain. At the age of eight years she suffered a bout of viral meningitis for which she was in hospital for a week. At the age of 15 years she took an overdose of sleeping tablets while her parents were undergoing a divorce. She had enjoyed good health otherwise.

On examination, the patient was not distressed but had an expressionless face and found it difficult to close her eyes. She was afebrile. Examination of her fundi
demonstrated blurred discs but no haemorrhages. Power in all her limbs was markedly diminished. She found it difficult to raise her arms above her shoulders, and could not move her legs. The tone in the legs was diminished and the reflexes in all her limbs were absent. Abdominal reflexes were present and the plantar response was normal. On examination of the abdomen she had a smooth palpable mass just above the symphysis pubis.

Investigations were as follows:

What two investigations (apart from CSF examination) would affect your immediate management?

A 20-year-old female is admitted to hospital with a 12-hour history of weakness in her arms and legs. This was accompanied by paraesthesia in her hands and feet. Five days before admission she experienced severe pain between her shoulder blades, and shortly afterwards developed blurred vision. The back pain had persisted but was less severe on admission. There was no history of headaches or nausea, but she had been constipated for two days and had intermittent lower abdominal pain. At the age of eight years she suffered a bout of viral meningitis for which she was in hospital for a week. At the age of 15 years she took an overdose of sleeping tablets while her parents were undergoing a divorce. She had enjoyed good health otherwise.

On examination, the patient was not distressed but had an expressionless face and found it difficult to close her eyes. She was afebrile. Examination of her fundi
demonstrated blurred discs but no haemorrhages. Power in all her limbs was markedly diminished. She found it difficult to raise her arms above her shoulders, and could not move her legs. The tone in the legs was diminished and the reflexes in all her limbs were absent. Abdominal reflexes were present and the plantar response was normal. On examination of the abdomen she had a smooth palpable mass just above the symphysis pubis.

Investigations were as follows:

What is the diagnosis?

A 51-year-old dentist presented to his GP because he had difficulty lifting his right arm for over one week. For the past few days he could not hold the razor to his face with his right arm while shaving. About two weeks previously he received a hepatitis B booster vaccine which was associated with pain over his deltoid and shoulder region for almost 48 hours. 

On examination there was wasting over the deltoid region. There was reduced power on abduction, flexion and internal rotation of the right arm and flexion of the right elbow. The right biceps and supinator reflexes were absent. All other examinations were normal.

Investigations are shown.

What is the diagnosis?

A 17-year-old male presented with blurring of vision followed by total loss of vision in the left eye. A few days later he developed total blindness in the other eye. There were no other neurological symptoms. There was no past medical history of significance or any history of alcohol abuse. The patient was not taking any medications. He had a maternal uncle who had become blind before the
age of 18 years. On examination there was evidence of bilateral optic atrophy and a mild tremor.

Investigations are shown.

What is the diagnosis?

A 70-year-old patient was admitted in a drowsy state after being found collapsed by his neighbour. On admission the Glasgow coma score was 9. A CT scan (290) of the brain was performed as an emergency.

What is the diagnosis?

A 44-year-old male presented to his GP with a two-day history of severe boring intermittent pain just below the supraorbital ridge of the right eye. The pain had awoken the patient from his sleep in the early hours of the morning and lasted 3 hours before subsiding. The pain recurred again in the afternoon and persisted for 4 hours despite the patient having taken paracetamol. In 48 hours he had experienced five episodes of similar pain. The patient had also noticed that he had a blocked nose and therefore made a self-diagnosis of sinusitis. He recalled having two similar episodes of pain two and four months previously that he attributed to sinusitis and treated himself with steam inhalations for four days. On examination the patient was distressed with pain. His right eye was red and watering. He had a partial ptosis and miosis affecting the right eye. His blood pressure was 160/90 mmHg. All other physical examination was normal.

What is the most probable diagnosis?

A 44-year-old male presented to his GP with a two-day history of severe boring intermittent pain just below the supraorbital ridge of the right eye. The pain had awoken the patient from his sleep in the early hours of the morning and lasted 3 hours before subsiding. The pain recurred again in the afternoon and persisted for 4 hours despite the patient having taken paracetamol. In 48 hours he had experienced five episodes of similar pain. The patient had also noticed that he had a blocked nose and therefore made a self-diagnosis of sinusitis. He recalled having two similar episodes of pain two and four months previously that he attributed to sinusitis and treated himself with steam inhalations for four days. On examination the patient was distressed with pain. His right eye was red and watering. He had a partial ptosis and miosis affecting the right eye. His blood pressure was 160/90 mmHg. All other physical examination was normal.

Choose two therapeutic steps from the following list for treating his symptom rapidly:

A 70-year-old female presented with sudden onset of expressive dysphasia and a right hemiparesis. She had a long-standing history of hypertension and had been
investigated for an episode of amurosis fugax five years ago. There was no history of diabetes mellitus and the patient was a non-smoker. The patient was taking
bendroflumethiazide 2.5 mg for hypertension. She was not on any other medication.

On examination she had a heart rate of 100 beats/min, which was irregularly irregular. The blood pressure measured 170/100 mmHg. There was clear evidence of an expressive dysphasia and a rightsided hemiparesis. Auscultation of the heart revealed normal heart sounds without any murmurs. There were
no carotid bruits. 

Investigations are shown.

What is the immediate treatment of choice?

A 46-year-old garage mechanic was investigated in a medical clinic for weight loss. Six months previously he had commenced a voluntary diet to reduce weight. He lost 4 kg over two months, following which he stopped his diet. Despite a normal appetite he continued to lose another 4 kg in weight over the next four months. He had also noticed that he tired easily, and was finding it difficult to perform heavy manual work as part of his profession. His arms felt weak. He was breathless on strenuous effort and found heavy lifting increasingly difficult. More recently, he had developed lower back pain which was worse when he sat upright and was associated with pain and numbness of his left calf and left foot. The pain was worsened by movement and he was forced to stop working. His appetite remained good. He had moved his bowels twice daily ever since he could remember. The stool was of normal consistency and did not contain blood. He was married with three children. He stopped smoking 15 years ago after an attack of bronchitis. He consumed 2–3 units of alcohol per week. 

On examination, he was of relative heavy build. There was no evidence of pallor or clubbing. The heart rate was 102 beats/min and irregularly irregular. The blood pressure was 130/80 mmHg. The JVP was not raised. On examination of the upper limbs there was no muscle tenderness, but there was wasting of the proximal muscles of the upper limb with weakness of abduction and adduction. The upper limb reflexes were brisk. Sensory testing was normal. On examination of the lower limbs, there was wasting of the muscles of the thighs. Power testing demonstrated weakness of plantar flexion on the left side. Reflexes were brisk with the exception of the left ankle jerk, which was absent. Plantar responses were normal. Sensory testing demonstrated reduced pinprick sensation affecting the anterolateral aspect of the left foot.

Investigations are shown.

What is the cause of the absent ankle jerk?

A 46-year-old garage mechanic was investigated in a medical clinic for weight loss. Six months previously he had commenced a voluntary diet to reduce weight. He lost 4 kg over two months, following which he stopped his diet. Despite a normal appetite he continued to lose another 4 kg in weight over the next four months. He had also noticed that he tired easily, and was finding it difficult to perform heavy manual work as part of his profession. His arms felt weak. He was breathless on strenuous effort and found heavy lifting increasingly difficult. More recently, he had developed lower back pain which was worse when he sat upright and was associated with pain and numbness of his left calf and left foot. The pain was worsened by movement and he was forced to stop working. His appetite remained good. He had moved his bowels twice daily ever since he could
remember. The stool was of normal consistency and did not contain blood. He was married with three children. He stopped smoking 15 years ago after an attack of bronchitis. He consumed 2–3 units of alcohol per week. 

On examination, he was of relative heavy build. There was no evidence of pallor or clubbing. The heart rate was 102 beats/min and irregularly irregular. The blood pressure was 130/80 mmHg. The JVP was not raised. On examination of the upper limbs there was no muscle tenderness, but there was wasting of the proximal muscles of the upper limb with weakness of abduction and adduction. The upper limb reflexes were brisk. Sensory testing was normal. On examination of the lower limbs, there was wasting of the muscles of the thighs. Power testing demonstrated weakness of plantar flexion on the left side. Reflexes were brisk with the exception of the left ankle jerk, which was absent. Plantar responses
were normal. Sensory testing demonstrated reduced pinprick sensation affecting the anterolateral aspect of the left foot.

Investigations are shown.

What is the diagnosis?.

A 38-year-old male with HIV presented with confusion and ataxia and reduced visual acuity in the left eye. A brain MRI scan is shown (345a).

What is the diagnosis?

A 77-year-old male was seen in the memory clinic owing to progressive deterioration of cognitive function. According to his daughter he had been diagnosed with Parkinson’s disease two years previously, for which he was commenced on L-dopa. Over the past few months he had become intermittently confused and had hallucinations of monkeys in his garden. He had experienced several falls in the house and had been investigated by the cardiologists for recurrent episodes of syncope, but no cause was identified.

On examination he had evidence of bradykinesia, mild tremor and mild cog-wheel rigidity. The mini mental test score was 9. Serial 3 counting was satisfactory. Shortterm memory was impaired.

Investigations are shown.

What is the diagnosis?

A 65-year-old female was referred to a neurologist with a six-month history of progressive weakness and clumsiness of her left hand. She mentioned having particular difficulty in washing the dishes and using the gear stick while driving her car. Her husband noticed that her gait had been unsteady and she had suffered a few falls in the past year. On systemic enquiry there was no history of
headaches, visual disturbance or weight loss, but she had experienced dizziness on turning her head suddenly.

On examination she was thin and had marked kyphoscoliosis. There was evidence of wasting of the small muscles of the hands, which was more prominent on the left side than the right. There was reduced power on flexion and abduction of the arms. The supinator and biceps reflexes on the left side were absent but present on the right. The triceps reflexes were brisk bilaterally. The power in both lower limbs was grade 4 out of 5 in all muscle groups. The tone was increased. The ankle and knee reflexes were brisk bilaterally. The left plantar response was upgoing but the right one was equivocal. Sensation was normal with the exception of vibration sense at both ankle joints.

What is the diagnosis?

A 65-year-old female was referred to a neurologist with a six-month history of progressive weakness and clumsiness of her left hand. She mentioned having particular difficulty in washing the dishes and using the gear stick while driving her car. Her husband noticed that her gait had been unsteady and she had suffered a few falls in the past year. On systemic enquiry there was no history of
headaches, visual disturbance or weight loss, but she had experienced dizziness on turning her head suddenly.

On examination she was thin and had marked kyphoscoliosis. There was evidence of wasting of the small muscles of the hands, which was more prominent on the left side than the right. There was reduced power on flexion and abduction of the arms. The supinator and biceps reflexes on the left side were absent but present on the right. The triceps reflexes were brisk bilaterally. The power in both lower limbs was grade 4 out of 5 in all muscle groups. The tone was increased. The ankle and knee reflexes were brisk bilaterally. The left plantar response was upgoing but the right one was equivocal. Sensation was normal with the exception of vibration sense at both ankle joints.

Which investigation would you perform to confirm the diagnosis?

A 28-year-oldmanpresents to A&Fcomplaining of difficulty swallowing, dry mouth, altered speech and double vision over the last 5 days, and today he had difficulty walking. He has a 10-year history of intravenous heroin use.

On examination he is apyrexial, he has a bilateral ptosis, reduced abduction of both eyes and his pupils are not reactive to light. He has bilateral facial weakness, he is dysarthric and his cough is bovine. Examination of his limbs shows that he is generally thin, there are multiple marks from injection sites, he has a proximal weakness in the upper and lower limbs, his reflexes are reduced but present, plantar reflexes are flexor, sensory examination is normal. His respiratory rate is 20/min; oxygen saturation is 96% on air; forced vital capacity is 900 mL. Creatine kinase (CK) 190 U/l

What is the diagnosis?

A 28-year-oldmanpresents to A&Fcomplaining of difficulty swallowing, dry mouth, altered speech and double vision over the last 5 days, and today he had difficulty walking. He has a 10-year history of intravenous heroin use.

On examination he is apyrexial, he has a bilateral ptosis, reduced abduction of both eyes and his pupils are not reactive to light. He has bilateral facial weakness, he is dysarthric and his cough is bovine. Examination of his limbs shows that he is generally thin, there are multiple marks from injection sites, he has a proximal weakness in the upper and lower limbs, his reflexes are reduced but present, plantar reflexes are flexor, sensory examination is normal. His respiratory rate is
20/min; oxygen saturation is 96% on air; forced vital capacity is 900 mL. Creatine kinase (CK) 190 U/l

Your next management step is to:

You are referred a 70-year-oldright-handedman in the Rapid-Access Stroke Clinic. He describes an episode which occurred2 month sago. He was  eating and developed acute-onset weakness and numbness of his left arm. This lasted 5 minutes and then completely resolved. He is  hypertensive and smokes 10 cigarettes a day. His current medication is aspirin 75 mg and ramipril 5 mg.

On examination his blood pressure is 130/86 mmHg, a carotid bruit is
heard on the right, neurological examination is normal.

He has had a number of investigations:

FBC – Normal 
Renal function – Normal 
Fasting glucose – 3.9 mmol/L
Fasting cholesterol – 5.0 mmol/1L

ECG – Normal sinus rhythm

Echocardiogram – Left ventricular hypertrophy

Carotid Doppler – 55% stenosis of the right carotid artery

The appropriate management is to:

A 20-year-oldman is admitted with a flare of his ulcerative colitis and treated with intravenous hydrocortisone. About 24 hours following admission he becomes increasingly drowsy. His Glasgow Coma Scale (GCS) score drops to 8andhis temperature is 37.5 °C, he has bilateral papilloedema, he is flexing all his limbs to painful stimuli, all his tendon reflexes are present and symmetrical and both plantar reflexes are extensor. He subsequently has a generalised seizure and is intubated and ventilated.

What is the diagnosis?

A 20-year-oldman is admitted with a flare of his ulcerative colitis and treated with intravenous hydrocortisone. About 24 hours following admission he becomes increasingly drowsy. His Glasgow Coma Scale (GCS) score drops to 8andhis temperature is 37.5 °C, he has bilateral papilloedema, he is flexing all his limbs to painful stimuli, all his tendon reflexes are present and symmetrical and both plantar reflexes are extensor. He subsequently has a generalised seizure and is intubated and ventilated.

The correct treatment is:

A 30-year-oldright-handed man attends A&E. Yesterday he went mountain hiking. Today he noticed a pain in his neck and his left arm feels funny.

On examination he has a right partial ptosis and the right pupil is smaller than the left. The remainder of the cranial nerves are normal. You note slight loss of dexterity in the left hand; there is no weakness or ataxia. His reflexes are brisker on the left than on the right, both plantar reflexes are flexor. He has evidence of sensory neglect in the left upper and left lower limbs.

He has had a CT head which is reported as normal.

The best diagnosis is:

A 30-year-oldright-handed man attends A&E. Yesterday he went mountain hiking. Today he noticed a pain in his neck and his left arm feels funny.

On examination he has a right partial ptosis and the right pupil is smaller than the left. The remainder of the cranial nerves are normal. You note slight loss of dexterity in the left hand; there is no weakness or ataxia. His reflexes are brisker on the left than on the right, both plantar reflexes are flexor. He has evidence of sensory neglect in the left upper and left lower limbs.

He has had a CT head which is reported as normal.

The most appropriate next investigation is:

A 30-year-oldright-handed man attends A&E. Yesterday he went mountain hiking. Today he noticed a pain in his neck and his left arm feels funny.

On examination he has a right partial ptosis and the right pupil is smaller than the left. The remainder of the cranial nerves are normal. You note slight loss of dexterity in the left hand; there is no weakness or ataxia. His reflexes are brisker on the left than on the right, both plantar reflexes are flexor. He has evidence of sensory neglect in the left upper and left lower limbs.

He has had a CT head which is reported as normal.

The most appropriate management is:

A 30-year-old lady is brought to hospital by ambulance. The night before, she had complained of nausea and headache to her husband. She had gone to bed and on waking he found that she was confused and irritable.

On admission she was 37.5 °C; GCS was 8; there was neck stiffness; the pupils were equal and reactive; there was no papilledema or haemorrhages; she flexed all four limbs to pain; the reflexes were brisk throughout; and the plantar reflexes were extensor.

The patient is intubated and ventilated and a CT scan (without contrast) is shown.

The diagnosis is:

A 30-year-old lady is brought to hospital by ambulance. The night before, she had complained of nausea and headache to her husband. She had gone to bed and on waking he found that she was confused and irritable.

On admission she was 37.5 °C; GCS was 8; there was neck stiffness; the pupils were equal and reactive; there was no papilledema or haemorrhages; she flexed all four limbs to pain; the reflexes were brisk throughout; and the plantar reflexes were extensor.

The patient is intubated and ventilated and a CT scan (without contrast) is shown.

What complication has occurred?

A 55-year-old Indian lady attends Outpatients complaining of fatigue and muscle pains, particularly affecting her shoulders and thigh muscles. She has difficulty walking upstairs and difficulty rising from a chair. There is no family history of neuromuscular disorders.

On examination, temporal arteries are normal and non-tender; she has normal cranial nerve examination; she has a proximal weakness in both upper and lower limbs and difficulty rising from a squat. Reflexes and sensory examination are normal.

The CP has helpfully performed a number of blood tests:

The diagnosis is:

A 25-year-old Peruvian man, who came to this country a year ago, is referred to you in A&E. He describes abnormal movements of his left arm. These occur without warning: he describes the arm as stiffening and then shaking for 1 to 5 minutes. He is unable to control the arm during the episode and it often feels weak for 30 minutes to an hour afterwards. He does not have any impairment of consciousness during this period. These episodes are occurring approximately once a week and he had a further episode this morning. His GP has started him on carbamazepine.

He complains of painful thigh muscles and on palpation they are tender; otherwise neurological examination is normal. He is afebrile.

He has had a CT scan which is shown below:

Carbamazepine trough level 22 umol/L

The diagnosis is:

A 25-year-old Peruvian man, who came to this country a year ago, is referred to you in A&E. He describes abnormal movements of his left arm. These occur without warning: he describes the arm as stiffening and then shaking for 1 to 5 minutes. He is unable to control the arm during the episode and it often feels weak for 30 minutes to an hour afterwards. He does not have any impairment of consciousness during this period. These episodes are occurring approximately once a week and he had a further episode this morning. His GP has started him on carbamazepine.

He complains of painful thigh muscles and on palpation they are tender; otherwise neurological examination is normal. He is afebrile.

He has had a CT scan which is shown below:

Carbamazepine trough level 22 umol/L

Regarding management of his seizures, you would suggest:

You are asked to review a patient on the ward. He is 35 years old and drinks 80 units of alcohol a week. He was admitted 2 days ago with vomiting and generalised tonic-clonic seizures. He was treated with thiamine, fluid replacement, diazepam and phenytoin. He is now seizure-free but now complains that he can no longer walk. 

On examination he has numerous spider naevi, pupils are equal and reactive and fundoscopy is normal. He has gaze-evoked horizontal nystagmus with reduced eye abduction bilaterally. His speech is slurred but he is lucid and orientated. He has bilateral facial weakness and marked weakness of both upper and lower limbs. His deep tendon reflexes are depressed throughout and both plantar reflexes are extensor.

You review the current blood tests and those performed on admission:

You request a CT brain which is normal.

The diagnosis is:

A 50-year-oldman is referred to the clinic because of unsteadiness on walking. He has also had a number of falls. He first noticed his symptoms 3 months ago and they have been gelling progressively worse; more recently his speech has become slurred. He has a past history of hypertension which is treated with bendroflumethiazide (hendrofluazide) and he smokes 10 cigarettes a day. He drinks 20 units of alcohol a week.

On examination he has sustained horizontal nystagmus in both directions. He is dysarthric and has marked upper and lower limb ataxia bilaterally. Power is normal throughout, and the sensory examination is also normal.

Routine blood tests, including liver function and thyroid function tests are normal. He has had an MRI brain which is reported as normal with no evidence of cerebellar atrophy.

A lumbar puncture is performed:

CSF glucose – 4.0 mmol/L (serum 6.0 mmol/L)
CSF protein – 0.8 g/dL
CSF red cell count – 5/mm3
CSF white cell count I lymphocyte/mm3

Matched oligoclonal bands are positive in CSF and serum.

The most likely diagnosis is:

A 60-year-old right-handed lady complains of severe pain in her right shoulder that started3 weeks ago. This started 1 week alter receiving pneumococcal vaccine, which was administered into her right arm. There was no history of trauma. More recently her pain has improved; however she has noted that she is unable to lift her arm above her head.

On examination there is wasting of the deltoid, which is weak, as is the biceps muscle. The right biceps and supinator jerks are absent; the remainder of the reflexes are normal. On sensory examination she has reduced sensation to pinprick over the right shoulder and the lateral aspect of the arm. Examination of the lower limbs is normal.

The most likely diagnosis is:

An 18-year-oldgirl complains of unusual episodes of collapse. Typically these occur when she laughs. She suddenly feels weak as if she has no power in her legs and drops to the ground. She is completely alert and orientated during this time and makes a rapid recovery. She also describes an unusual experience in the morning of waking and not being able to move. She is anxious about her symptoms; she has not been sleeping well at night and feels tired.

Cardiovascular and neurological examinations are normal.

The diagnosis is:

A 60-year-oldman complains of progressive difficulty with walking over the last 3 months and, more recently, a dry mouth, difficulty swallowing and difficulty passing urine.

On examination he is generally thin; there are no fasciculations. He has clubbing and a fatiguable proximal weakness in both upper and lower limbs. His tendon reflexes are present but depressed, plantar reflexes are flexor. Sensory examination and co-ordination are normal.

A number of blood tests are performed:

The diagnosis is:

A 20-year-old right-handed lady is referred by her CP with unusual episodes. These have occurred since the age of 18 but have recently become more frequent; the last was a week ago. They usually begin with a strange epigastric sensation which rises up. She feels fearful and distant from her surroundings. Her husband describes her as being distant and says that she sometimes picks at objects around her (there may also be chewing movements). She is aware other heart beating strongly. These episodes last for up to 10minutes, although she may be confused for up to an hour afterwards. She had one febrile convulsion as a child.

Neurological and cardiovascular examination is normal.

An EEC is performed which is normal and a CT head is normal.

The most likely diagnosis is:

A 20-year-old right-handed lady is referred by her CP with unusual episodes. These have occurred since the age of 18 but have recently become more frequent; the last was a week ago. They usually begin with a strange epigastric sensation which rises up. She feels fearful and distant from her surroundings. Her husband describes her as being distant and says that she sometimes picks at objects around her (there may also be chewing movements). She is aware other heart beating strongly. These episodes last for up to 10minutes, although she may be confused for up to an hour afterwards. She had one febrile convulsion as a child.

Neurological and cardiovascular examination is normal.

An EEC is performed which is normal and a CT head is normal.

What should the patient be told about driving?

A 40-year-old man attends A&E. He complains of progressive weakness, paraesthesiae and numbness that began in his feet, spreading up both legs and then involved both his hands over 3 days, associated with fever. Today he has had difficulty passing urine. He has a past history of intravenous heroin use.

On examination he is unkempt, he has multiple injection sites, he has a temperature of 38 °C and a soft systolic murmur is heard at the apex. He is alert and orientated. He complains of pain on passive neck movement and neck stiffness is noted. He has a severe flaccid weakness of both upper and lower limbs and his tendon reflexes are absent. Plantar reflexes are extensor. He complains of reduced sensation to pinprick in the lower and upper limbs, and up to just below the level of the clavicle bilaterally and to the same level on the posterior chest wall. Vibration sense and joint-position sense are also reduced in this distribution.

An urgent MRI cervical spine is performed. 

The most likely diagnosis is:

A 40-year-old man attends A&E. He complains of progressive weakness, paraesthesiae and numbness that began in his feet, spreading up both legs and then involved both his hands over 3 days, associated with fever. Today he has had difficulty passing urine. He has a past history of intravenous heroin use.

On examination he is unkempt, he has multiple injection sites, he has a temperature of 38 °C and a soft systolic murmur is heard at the apex. He is alert and orientated. He complains of pain on passive neck movement and neck stiffness is noted. He has a severe flaccid weakness of both upper and lower limbs and his tendon reflexes are absent. Plantar reflexes are extensor. He complains of reduced sensation to pinprick in the lower and upper limbs, and up to just below the level of the clavicle bilaterally and to the same level on the posterior chest wall. Vibration sense and joint-position sense are also reduced in this distribution.

An urgent MRI cervical spine is performed. 

You organise basic blood tests, a septic screen, ECG and chest X-ray.

Your next management step should be:

A 50-year-old Italian man developed a left foot drop 2 months ago and then 2 weeks ago noted reduced grip strength in his right hand associated with pain in the fingers. He describes a fleeting rash on his feet. He has chronic hepatitis C. His current medication is bendroflumethiazide (bendrofluazide) 2.5 mg.

On examination he has weakness of the right first dorsal interosseus and abductor digili minimi, as well as ankle dorsiflexion and eversion on the left. There is a patch of reduced sensation to pinprick on the dorsum of the left foot and on the right little finger and ring finger. Vibration sense and proprioception are preserved. Reflexes are all present.

Urinalysis reveals protein +, blood ++ and no bilirubin. A number of
blood tests are performed:

What is the pattern of the neuropathy?

A 50-year-old Italian man developed a left foot drop 2 months ago and then 2 weeks ago noted reduced grip strength in his right hand associated with pain in the fingers. He describes a fleeting rash on his feet. He has chronic hepatitis C. His current medication is bendroflumethiazide (bendrofluazide) 2.5 mg.

On examination he has weakness of the right first dorsal interosseus and abductor digili minimi, as well as ankle dorsiflexion and eversion on the left. There is a patch of reduced sensation to pinprick on the dorsum of the left foot and on the right little finger and ring finger. Vibration sense and proprioception are preserved. Reflexes are all present.

Urinalysis reveals protein +, blood ++ and no bilirubin. A number of
blood tests are performed:

The most likely diagnosis is:

A 65-year-oldman was diagnosed with idiopathic Parkinson’s disease 5 years ago when he developed a rest tremor and stiffness of the left arm. He was commenced on levodopa therapy 3 years ago when his walking slowed and he says this was helpful. He was admitted to hospital after having a fall and fracturing his hip. This was successfully repaired but the physiotherapists feel that he is much slower to mobilise than they would expect. His current medication is co-careldopa 125mg qds, tramadol 50 mg bd and metoclopramide 10 mg lds.

On examination he has poverty of facial expression, his speech is soft and he has difficulty swallowing. He has marked rigidity in all four limbs a rest tremor, more marked in the left arm, and is very bradykinetic. He is able to stand with difficulty but cannot walk. He has been noted to have a labile blood pressure since admission.

You should:

An 80-year-oldman is admitted from a nursing home. He has a 3-day history of head ache and today has become increasingly confused.

On examination he has a temperature of 38 °C and has neck stillness. He has a CCS of 12 on admission and has a witnessed generalised tonic-clonic seizure.

A CT is performed which is normal. A lumbar puncture is performed. The
opening pressure is 24 cmH2O and the CSF is cloudy:

The treatment of choice is:

The photograph shows the eyes of a 60-year-oldman who developed diplopia, a complete left ptosis over a number of days and then a right hemiparesis.

Where is the lesion?

A 50-year-old man who  lives alone is found collapsed at home; he is in respiratory failure and is intubated by paramedics. His admission bloods are shown below. On ITU he is treated for pneumonia but when his sedation is reduced he is noted to have facial and limb weakness and he is difficult to wean off the ventilator. Neurophysiology is performed on ITU and the figure shows the results of repetitive nerve stimulation.

The diagnosis is:

A 35-year-old lady gives a 2-day history of severe headache, fever and nausea. There is no history of associated neck stiffness or photophobia. On the morning of admission she had also developed ocular pain and swelling bilaterally and diplopia.

On examination she had a temperature of 39 °C; she was alert and orientated. Her face is shown below. Pupillary responses were sluggish. Her visual acuity was 6/6 bilaterally; fundoscopy revealed dilated retinal veins and early papilledema. She had a complete ophthalmoplegia bilaterally. Pinprick sensation was reduced over the forehead.

What is the diagnosis?

A 35-year-old lady gives a 2-day history of severe headache, fever and nausea. There is no history of associated neck stiffness or photophobia. On the morning of admission she had also developed ocular pain and swelling bilaterally and diplopia.

On examination she had a temperature of 39 °C; she was alert and orientated. Her face is shown below. Pupillary responses were sluggish. Her visual acuity was 6/6 bilaterally; fundoscopy revealed dilated retinal veins and early papilledema. She had a complete ophthalmoplegia bilaterally. Pinprick sensation was reduced over the forehead.

Give the two most important steps in the management: