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82 Diagnostic EMQs
3. F. Night eating syndrome
This patient has been having recurrent episodes of night eating which is causing
him distress and affecting his daily function.
4. C. Binge eating disorder
She has recurrent episodes of binge eating in which she eats excessive amounts
of food quickly and feels out of control with her eating habits. She is distressed
by her symptoms and has no obvious inappropriate compensatory behaviour as
seen in bulimia nervosa. She has episodes on average at least one day a week for
more than a year.
Eating disorders 2
1. E. Kleine–Levin syndrome
This is a rare condition which can be associated with excessive periods of sleep,
mood or behaviour changes, hyperphagia and abnormally increased sexual
desire.
2. D. Bulimia nervosa
She has recurrent episodes of binge eating and feels as though she lacks control
over her eating habits. She has inappropriate compensatory behaviours to pre-
vent weight gain such as excessive exercise and potentially self-induced vomit-
ing as evidenced by her enamel erosion. She has concerns about her body image
and her episodes occur at least a couple of days a week for the past six months.
3. G. Orthorexia nervosa
This patient spends a great deal of time preparing his meals, feels he is more
superior than others as a result of his diet and is very rigid with his dietary rules.
His behaviours are affecting his relationships with those close to him.
4. A. Anorexia nervosa
She has restricted her dietary intake which has resulted in a signicantly low
body weight. She has a fear of weight gain despite her low weight and has dis-
turbances in the way in which her body weight is experienced.
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DOI: 10.1201/9781003459941-4 83
4
Neurology
CRANIAL NERVE PATHOLOGY
A. Abducent nerve
B. Accessory spinal nerve
C. Facial nerve
D. Glossopharyngeal nerve
E. Hypoglossal nerve
F. Oculomotor nerve
G. Olfactory nerve
H. Optic nerve
I. Trigeminal nerve
J. Trochlear nerve
K. Vagus nerve
L. Vestibulocochlear nerve
For each of the following, which nerve is MOST likely affected?
1. A 40-year-old plumber presents with a two-week history of shoulder and neck
pain. He explains that his symptoms have become progressively worse and are
now causing him difculty sleeping. On examination he has an asymmetric
neckline, atrophy of the trapezius on the right side, winging of the right scapula
and weakness with forward elevation of the shoulder on the right.
2. A 31-year-old woman attends with a one-week history of left sided facial weak-
ness. She explains that she has been nding it difcult to drink water during her
workouts and is quite embarrassed by the fact that the water dribbles out of her
mouth and down her face. Julie recently had a u like illness a day before her
symptoms started. On examination she has mild left sided facial droop.
3. A 59-year-old diabetic woman presents with a complaint of diplopia. She
explains that her symptoms have been present for the past three days and are
worse when she looks downward or when trying to read a book. On examina-
tion her right eye turns upward and outward when looking forward and elevates
medially when looking left.
4. A 24-year-old presents three days after a high-speed car accident. He suffered
from whiplash injury to his neck and facial injuries. He reports that he has
had neck pain since the accident and over the past two days his sense of smell
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84 Diagnostic EMQs
has decreased. On examination his facial injuries have healed up well. You
arrange for a CT scan of his brain and which reveals a small fracture affecting
the ethmoid bone.
5. A 23-year-old university student presents complaining of numbness in her face
for the past two days. On examination there is reduced sensation in the right
forehead and the corneal reex is absent on the same side.
6. A 16-year-old boy presents for review after tonsillectomy last week. He has not
had any bleeding but explains that he has been suffering from dysgeusia affect-
ing the posterior third of his tongue on the right side.
See page 101 for answers.
DIZZINESS
A. Acoustic neuroma
B. Benign paroxysmal positional vertigo (BPPV)
C. Labyrinthitis
D. Meniere’s disease
E. Panic attack
F. Ramsay Hunt syndrome
G. Stroke
H. Vestibular migraine
I. Vestibular neuritis
For each of the following, what is the MOST likely diagnosis?
1. A 28-year-old woman was at work earlier today when she suddenly felt dizzy,
noticed her heart begin to race, she felt tightness in her chest and reports that
she felt short of breath. She presents at your emergency department where you
review her. She has no signicant medical history. You nd no abnormality on
physical examination.
2. A 37-year-old man presents with a complaint of dizziness. He reports that
he has had a few episodes of dizziness over the past week associated with
headaches. He has a long history of migraine like headaches which he treats
with simple analgesia to good effect but has never had associated dizziness.
He denies hearing loss or tinnitus and there are no signicant examination
ndings.
3. A 26-year-old lady presents with a complaint of gradual onset of imbalance
which has persisted for the past three days. Associated with this she has hori-
zontal nystagmus at rest and left sided unilateral gradual hearing loss and tin-
nitus. One-week prior Louisa reports that she was treated with amoxicillin for
acute otitis media associated with a fever.
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Neurology 85
4. A 72-year-old man presents with a one-day history of nausea and dizziness.
He describes a sensation of “the room spinning around” which was constant
and had left him bed bound last night. You review his patient notes and see
that he had attended your clinic ten days prior for the management of herpes
zoster affecting the right side of his chest, these symptoms have since settled.
On examination he has fast beating horizontal nystagmus towards the right,
the remainder of the neurological examination was unremarkable. He denies
hearing loss.
5. A 78-year-old widow presents complaining of dizziness. She reports that over
the past ve days she has had an intermittent spinning sensation and has been
feeling very nauseated. She reports that she had collapsed to the ground on one
occasion but did not sustain any injuries, she is fearful that she may injure her-
self at home. She explains that the sensation is worse when turning over in the
morning while in bed and when she bends over to pick things up. There is no
associated tinnitus and she examines well.
See page 101 for answers.
EPILEPSY 1
A. Absence seizure
B. Complex partial seizure
C. Dacrystic seizure
D. Dravet syndrome
E. Febrile seizure
F. Gelastic seizure
G. Hypnic myoclonus
H. Juvenile myoclonic epilepsy
I. Meningitis
J. Neonatal seizure
K. Pre-Eclampsia
L. Psychogenic non-epileptic seizures (PNES)
M. Simple partial seizure
N. Tonic-Clonic seizure
O. Tonic reex seizures of early infancy
P. West syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 2-year-old girl is brought in by ambulance with her worried parents. The par-
ents explain that 30 minutes ago she had collapsed to the ground at home and
began to shake uncontrollably, the episode lasted three minutes and she was very
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86 Diagnostic EMQs
tired after this. She has been unwell for the past two days with a cough and runny
nose, she had a temperature of 38.6°C last night which settled with Panadol.
2. A 4-year-old girl presents with her mother who is concerned about episodes of
blanking out that she has been experiencing over the past month. She has epi-
sodes where she has become unresponsive while watching television or playing,
during the episodes her eyes remain wide open, she returns to her activity after
a few seconds and continues on as if she is unaware of what has happened.
3. A 21-year-old student attends with a complaint of ongoing right sided headache
for the past two months. He is due for his nal year examinations next week and
believes his headache may be due to a combination of poor sleep and stress as
he has been spending many hours awake studying. He is most concerned about
jerky motions in his arms that he has been having in the past few days which are
associated with the headaches. You refer him to a neurologist who performs a
partial sleep deprivation EEG which reveals 3–6 Hz generalised poly-spike and
wave discharges associated with myoclonic jerks early in the morning.
4. A 26-year-old student attends your clinic complaining of intermittent episodes
of involuntary right lower limb movements over the past three months, on occa-
sion he reports experiencing a burnt rubber smell associated with this. He has
no history of similar and explains that he has had increasing episodes in the lead
up to his nal year assessments which are causing him much anxiety. He denies
alteration of conscious state and has a full recollection of events.
5. A 24-year-old woman attends your emergency department via ambulance suf-
fering from full body rigors. She was at her local GP clinic an hour ago for an
inuenza vaccination and shortly after the dose she developed full body shakes
which came every ve to ten minutes and each episode lasted for about a min-
ute. She remained awake and conversant during episodes. On examination you
nd no evidence of injury and neurological examination is unremarkable. She
has several episodes in the emergency department and is subsequently admitted
to the neurology ward for observation. On the ward a video EEG demonstrates
no signicant changes prior to, during or after episodes.
6. A 6-month-old infant is brought in by her concerned parents. Over the past two
days she has been having episodes of sudden exion of her body, arms and legs.
Episodes last for about two seconds then settle for about ve seconds before
occurring again. She has about ten to 15 episodes within each cluster and they
occur two times a day. An EEG reveals typical features of hypsarrhythmia –
high amplitude, asynchronous and arrhythmia.
See page 102 for answers.
EPILEPSY 2
A. Absence seizure
B. Complex partial seizure
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Neurology 87
C. Dacrystic seizure
D. Dravet syndrome
E. Febrile seizure
F. Gelastic seizure
G. Hypnic myoclonus
H. Juvenile myoclonic epilepsy
I. Meningitis
J. Neonatal seizure
K. Pre-Eclampsia
L. Psychogenic non-epileptic seizures (PNES)
M. Simple partial seizure
N. Tonic-Clonic seizure
O. Tonic reex seizures of early infancy
P. West syndrome
For each of the following, what is the MOST likely diagnosis?
1. A 32-year-old male was found by a colleague seated in his car outside of his
workplace. His colleague was concerned as she reports James was behaving
quite strangely, apping his arms and hitting his steering wheel quite violently.
She knocked on his window but he did not respond to her. An ambulance was
called and on arrival 15 minutes later he had become responsive but was quite
lethargic. He cannot recall how he had arrived in the car park, the last thing he
remembers was “the smell of burning rubber” after having gotten into his car at
home.
2. A 26-year-old pregnant woman, G1P0, presents with a two-day history of head-
ache, she explains that it is generalised and mildly uncomfortable. Jodie is cur-
rently 26 weeks’ gestation. She took her blood pressure last night at home on her
father’s blood pressure device and had a reading of 164/92 mmHg, she thought
the elevation may have been due to anxiety and the pain of the headache. Jodie
decided to sleep on it and see you in the morning. You take her blood pressure
today which reads 167/93 mmHg. Her last reading two weeks ago was 120/84.
You perform a urine dipstick which reveals proteinuria 2+.
3. A 34-year-old man presents to your clinic with his partner who explains that
she is concerned about him as he has been having sudden jerking motions of
his arms and legs in his bed at night. His symptoms occur shortly after he falls
asleep and have been waking his partner up at night.
4. A 15-day-old child is brought into the emergency department by her worried
mother who explains that she became very stiff in all of her limbs for about
two minutes and had associated jerking motions. Mum noticed her having
small jerking motions while being breastfed since she was born, but not as
bad as they were today. The pregnancy was uneventful and she was born at
term without complication, she is only breastfed and has had no recent illness.
On examination she has a temperature of 36.8°C, weighs 3.1 kg and is in the
50th centile for head circumference and length. Examination is otherwise
unremarkable.
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88 Diagnostic EMQs
5. A 64-year-old man is brought into your emergency department by ambulance
after suffering from a medical episode at home. His daughter tells you that he
was helping her hang a mirror, she left the room to collect a tool when she heard
a loud noise and the sound of glass breaking. Rachel immediately returned to
the room where she found him unresponsive and writhing about on the oor, she
safely removed the shattered mirror from around him and called an ambulance.
The episode lasted for ten minutes and she reports that he was very fatigued
after this. Examination is unremarkable.
See pages 102–103 for answers.
FACIAL PAIN
A. Acute rhinosinusitis
B. Chronic rhinosinusitis with polyps
C. Chronic rhinosinusitis without polyps
D. Eagle’s syndrome
E. Glossopharyngeal neuralgia
F. Greater occipital neuralgia
G. Post-Herpetic trigeminal neuropathy
H. Sialolithiasis
I. Temporal arteritis
J. Temporomandibular joint dysfunction
K. Trigeminal neuralgia
For each of the following, what is the MOST likely diagnosis?
1. A 47-year-old male attends with a two-year history of intermittent left sided sharp
lancinating facial pain affecting his jaw and cheek. He reports that the episodes
last for about 30 seconds and then settle. He reports that episodes are usually trig-
gered by eating. Examination is unremarkable and he is asymptomatic on review.
2. A 31-year-old woman presents with left sided facial pain and swelling. She
explains that her symptoms are worse just before meals and when eating food.
On examination you can palpate a lump in the buccal mucosa on the left side of
the mouth.
3. A 21-year-old male presents with a six-day history of thick green nasal dis-
charge, left sided facial pain and a fever. He explains that his symptoms initially
started with a sore throat and dry cough which resolved after two days, he
improved slightly but his situation then began to deteriorate. On examination
he has a temperature of 38.6
o
C, facial pain on percussion over the left cheek and
pressure in the same location on leaning forward.
4. A 70-year-old man presents with left sided headache and jaw pain associated
with visual impairment. He explains that his pain has been there for the past
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Neurology 89
two weeks and is worse with meals. On examination he is tender on palpation
of the left side of his head.
5. A 24-year-old science student attends with right sided jaw pain, he reports that
he has had this pain for the past two years. He tells you that the pain is occasion-
ally associated with a loud popping sound on the right side when opening his
mouth. On examination there is crepitus palpable anterior to the right ear with
depression of the mandible.
6. A 55-year-old pianist attends with a three-year history of intermittent stabbing
pain on the left occipital area of his head and occasional radiation to the fronto-
orbital area on the left. He reports that the symptoms last for most of the day and
were worse during the night. He reports that when he wears tight tting caps his
symptoms are usually evoked.
See page 103 for answers.
HEADACHE 1
A. Acephalgic migraine
B. Arnold–Chiari malformation
C. Brain abscess
D. Cluster headache
E. Ice pick headache
F. Idiopathic intracranial hypertension
G. Low CSF headache
H. Medication overuse headache
I. Medulloblastoma
J. Meningitis
K. Migraine
L. Migraine with aura
M. Reversible cerebral vasoconstriction syndrome
N. Status migrainosus
O. Subarachnoid haemorrhage
P. Tension headache
For each of the following, what is the MOST likely diagnosis?
1. A 53-year-old presents with a ve-month history of sudden, intensely sharp and
painful stabbing sensations across the top of his head. The sensations last for
a few seconds and have no particular pattern. On some days he will have ten
to 20 similar episodes and on others he will have none, he has no associated
symptoms. Neurological examination is unremarkable so too are investigations
including an MRI brain.
2. A 34-year-old woman reports a six-month history of headaches, she explains
that episodes occur at least three or four times a week and she feels a band like
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90 Diagnostic EMQs
pressure radiating around her whole head. Episodes last for about one hour
before settling with simple analgesia.
3. A 42-year-old man presents with a three-day history of headache. He reports
that his headache is very severe when he is sitting upright or standing, is mostly
at the back of his head and associated with neck pain. He explains that his
symptoms resolve quickly when he lays down at. He has a history of thoracic
spinal stenosis and has had a laminectomy for treatment of this ve days ago.
4. A 31-year-old nurse attends complaining of deep sharp pain around her right
eye, it is associated with drooping of the right upper eyelid, tearing and a run-
ning nose. She explains that she has had ve episodes since this morning and
was awoken by the initial episode.
5. A 22-year-old woman presents with a two-week history of headache associated
with binocular diplopia. On examination she has a BMI of 37 and fundoscopy
reveals papilledema.
See page 103 for answers.
HEADACHE 2
A. Acephalgic migraine
B. Arnold–Chiari malformation
C. Brain abscess
D. Cluster headache
E. Ice pick headache
F. Idiopathic intracranial hypertension
G. Low CSF headache
H. Medication overuse headache
I. Medulloblastoma
J. Meningitis
K. Migraine
L. Migraine with aura
M. Reversible cerebral vasoconstriction syndrome
N. Status migrainosus
O. Subarachnoid haemorrhage
P. Tension headache
For each of the following, what is the MOST likely diagnosis?
1. A 29-year-old accountant attends with pain on the right side of her head for
the past six hours. The pain is sharp, pulsating in nature and is associated with
photophobia. She has a long history of similar such headaches and reports that
she has been having an increased frequency of these over the past four months.
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Neurology 91
She denies visual disturbances, has not had any recent illness, she has a history
of acne for which she is on the oral contraceptive pill and takes no other regular
medication. Examination is unremarkable. She requests a script for Rizatriptan,
she has been using these on a daily basis over this period of time and has found
relief with them.
2. A 54-year-old migraineur attends with sudden onset severe headache. It is the
worst headache he has ever had and not similar to his regular migraine head-
aches. On examination he has neck stiffness and is unable to extend his knee
when his hip and knee are exed to 90 degrees and he is supine. You arrange
for an urgent CT scan of the brain.
3. A 12-year-old boy attends with a headache for the past two hours which is asso-
ciated with a fever, he is covering his eyes as he cannot look into the light. On
examination he has a temperature of 38.9°C, there is a widespread non blanch-
ing maculopapular rash across his body and Kernig’s sign is positive.
4. A 37-year-old male has been in bed for the past four days with a left sided head-
ache, he has had no fevers, no recent illness or recent travel. He reports that he
has had similar such headaches in the past and has been given IM Morphine with
good results. NSAIDs and paracetamol have been ineffective during the current
episode. On examination he has a temperature of 36.5
o
C, no neck stiffness and no
rash. Cranial nerves and neurological examination were unremarkable.
5. A 19-year-old university student presents with a left sided headache for the
past eight hours which was preceded by zigzag shaped bright lights in the
lower visual eld of her left eye, she explains that it is similar to previous
headaches she has had and usually settles with rest. She has no signicant
medical history and takes no regular medication. Neurological examination
is unremarkable.
See page 104 for answers.
HEARING LOSS 1
A. Acute otitis media
B. Barotrauma
C. Cerumen impaction
D. Cholesteatoma
E. Eustachian tube dysfunction
F. Exostosis
G. Glomus tumor
H. Otosclerosis
I. Otitis externa
J. Ototoxicity
K. Vestibular schwannoma
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