And after reading his case, the diagnosis is:

d. Ramsay Hunt Syndrome

Firstly this is a lower motor neuron (LMN) facial (CN VII) palsy: facial weakness of the whole of the face.*

Bell’s is a lower motor neurone lesion which is idiopathic in nature.

The aetiology is probably thought to be a herpes virus and there is some evidence to support the use of short course oral corticosteroids and aciclovir.

• about 50% of people will get better with no treatment
• steroids for approximately 1 week seem to help 50% of cases
• the benefit of aciclovir remains controversial

Read the Bandoleir review here

However: Ramsay Hunt is a facial nerve palsy caused by associated herpes zoster infection (as manifested in this case by the vesicles). When a patient presents with a CNVII weakness, this is one of the key reasons to perform otoscopy, as otherwise you may miss the vesicles.

*Remember in UMN lesions the upper half of the face (highlighted here in yellow) is spared as there is bilateral UMN innervation. You would not expect this in Ramsay hunt as its a LMN lesion. The image below shows a LMN CNVII weakness.

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Well done to those who answered correctly, and comisserations tho those who got caught out… the correct answer to this question was:

g. Guillain Barre Syndrome

See why it was Guillain Barre Syndrome below. Check your hypothesis against the clinical signs:

Remember FVC monitoring in GBS.

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A 44 year old builder presents with weakness over the past 48 hours.

A neurological exam reveals the following (N=normal):

Which of the following is the most likely diagnosis?

a. Polio
b. Motor Neurone disease
c. Myasthenia gravis
d. Stroke
e. Multiple sclerosis
f. Creutzfeldt Jacob disease
g. Guillain Barre Syndrome

Leave your answers as comments, and we will give you the full professional medical answer in a few days!

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And here is is…. the answer to our suspected DVT question:

d. It can be used to discharge patients based on their underlying estimated clinical risk score

D-dimer test can be used to exclude DVT in patients who are assessed to be in the category of “low clinical risk” of DVT.

An individuals pre-test risk can be estimated using a “Wells score”. A patient who is clinically “low risk” with a negative D dimmer can be reassured.

The Wells score is shown below.

The Wells score and an example of its clinical application in terms of planning investigations into a DVT

Although you clearly can’t memorise a wells score its clear from the score itself that patients with numerous risk factors (e.g a man with lung cancer with a swollen right leg with pitting oedema) that a negative D-dimer is not sensitive enough to rule the diagnosis out.

D-dimer is still of some use in patients with a low pre-test probability score.

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An Emergency Department doctor tells you that he feels the patient can be discharged. He tells you this because he shows you the D-Dimer result, which is “negative”. The result is shown below.

Which of the following statements is true about D-Dimer testing in general patients with a suspected DVT?

a. Following a clinical assessment, clinicians should not rely on the test as a basis to ‘discharge’ or ‘investigate’

b. It is of no use in patients who have had recent surgery (e.g. within the last 12 weeks)

c. It is of no clinical use in patients with malignancy and secondary metastases

d. It can be used to discharge patients based on their underlying estimated clinical risk score

e. None of the listed answers are correct.

The answer is of course: e. Skin Pigmentation

Most of the symptoms of adrenal insufficiency (e.g. hypotension, weight loss) result from low cortisol levels and therefore do not distinguish between adrenal or pituitary failure.

This question tests your understanding of the hypothalamic-pituitary-adrenal axis. This is another example where negative feedback is used to control hormone release.

ACTH is released from the pituitary gland. It acts on the adrenal glands stimulating cortisol release.

In primary adrenal failure (Addison’s disease), there is destruction of the adrenal glands and therefore they do not produce cortisol. In an attempt to stimulate the failed adrenal glands, the pituitary gland secretes high levels of ACTH.

ACTH is synthesised within the anterior pituitary gland from pro-opiomelanocortin (POMC). The cleavage of the POMC molecule results in the production of ACTH as well as a number of molecules including forms of MSH (melanocyte stimulating hormone). In fact, alpha-MSH is identical to the start of the ACTH molecule.

High levels of circulating ACTH act as MSH causing increased pigmentation.

Look in the buccal mucosa and at the palmar creases.

If the cause of hypoadrenalism is from pituitary failure, neither ACTH nor MSH will be released, hence there’s no increase in pigmentation.

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Which of these symptoms of hypoadrenalism will distinguish between primary adrenal failure and secondary (pituitary) adrenal insufficiency?

a. Postural Hypotension
b. Weight Loss
c. Fatigue
d. Hypoglycaemia
e. Skin Pigmentation

The chances of transmission are as follows:

The risk is higher with hollow bore needles than with normal needles (e.g. suturing). This data varies widely across specialities. Individuals vaccinated against Hepatitis B have a lower risk of transmission following a needle stick.

The prevalence of needle stick injuries has been estimated to be as high as 33% in a 6 month period for healthcare workers.^[2] A good review on needle stick injuries can be read from Bandolier here.

Hep B is the most transmissible of all 3 conditions. As a healthcare professional with a transmittable disease it may preclude you from working in certain specialities e.g. some surgical specialities.

Remember the prevalence of Hepatitis B, HIV and Hepatitis C in the UK is still low (<1% for each).

[1] The risk of Hep C transmission rate varies from 3-5%. If a person is exposed, the usual practice is to PCR the blood for the hepatits C virus .
^{MS Sulkowski et al. Needlestick transmission of hepatitis C. JAMA 2002 287: 2406-2413.}

[2] A study of 75 medical students and interns in New York
^{F Resnic, MA Noerdlinger. Occupational exposure among medical students and house staff at a New York City medical center. Archives of Internal Medicine 1995 155: 75-80.}

Remember, loads more MCQs are available in the members area – its free to join.

Regarding Hepatitis C which of the following statements is true?

a. Vaccination to hepatitis C is routinely available to healthcare professionals and confers some protection
b. The chance of transmission of hepatitis C is around 3%
c. The chance of transmission is around 0.3%
d. Hepatitis C if transmitted will lead to liver failure in that individual
e. The chance of transmission is around 30%

…answer in a few days!

To recap, here is our 36-year old’s patient clinical cases of history and findings:

“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so from that side I’m pretty happy.”

• Hands Normal.
• Pulse 80.
• No Signs in the face.
• BP 182/92 Pan systolic murmur left sternal edge.
• Otherwise NAD.

Tip 6. Group your thoughts logically every time

a) By the most likely causes
“The differential includes the following:…”

b) By the problem that’s causing the issue:
“Based on the limited information from the history the differential would include infections (viral: T cell disorder seroconversion illness) Bacterial (bacterial endocarditis, bronchopneumonia, abscess etc), fungal (less likely but consider underlying immunosupression), malignancy…”

Tip 7. Let the examiners know you are finished examining the clinical cases every time

Once you’ve finished or exhausted all the possible causes, let your examiner know! “Causes of a pan systolic murmur include… they are the main causes that I know.” This is vital and stops you looking stupid standing around.

Tip 8. Acknowledge what you don’t know

If you’re asked a question you don’t know the answer to, be prepared to tell the examiner in a clear way i.e. “I cant recall that at this time, I don’t know the answer to that question”. This saves valuable time, and is refreshing for examiners to get clear, honest responses, which is what they require from junior doctors.

Tip 9. Have a set way of presenting clinical case examination findings every time

Practice this, it is the same every time. For the above clinical case here would be our example:

“No stigmata of cardiovascular disease in the hands, pulse 80 and regular in terms of rate and volume, hypertensive with a blood pressure of 182/92. No stigmata of CVSD disease in the face. Apex beat palpable 5th intercostal space, mid clavicular line, normal character. The first heart sound is normal. The second heart sound is normal. There is a pan systolic murmur, best heard with the diaphragm, at the left sternal edge that is non-radiating. JVP not elevated, no peripheral oedema.”

If you do this the same every time it will stop you making mistakes.

Tip 10. Thank and ‘look after’ your exam patient (and the examiners).

This is vital. Your duty is first to the patient. When you have finished examining, show the patient the dignity and respect they deserve, cover up exposed areas, and express thanks. The patient has volunteered most likely to do the exam! Thanking both is important, and professional.

We hope this has helped, remember there are over a thousand questions, dozens of videos and downloads to help you with your exams in the student login area.