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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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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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.}

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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 a comment with your answer… we will let you know the correct answer soon!

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So here we go with the likely pathology …

• Symmetrical findings make a central lesion less likely (they would localise).
• The reflexes and sensation are intact, making a cord or peripheral nerve lesion unlikely.
• The absence of fatigability makes a neuromuscular junction lesion less likely (myasthenia etc).
• This sounds like a myopathy: the rash therefore suggests polymyositis (the rash is a heliotropic rash named after the purple heliotrope flower). The CK is likely to be very high (in the thousands, NR <150 iu/l).
• The dysuria and cough are intended as distracters.

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• No Jaundice , anaemia, cyanosis, jaundice or lymphadenopathy
• noted rash under both eyelids.
• BP 134/66
• Pulse 78 regular
• Sats 98% air
• BM 4.5 mmol/l  RR 16
• Normal Cardiovascular Respiratory Gastrointestinal examination.

Neurology as follows:

• Grade 4 power upper and lower limbs symmetrically.
• Normal sensory examination.
• Normal reflexes.
• No clonus
• No fatigability

Where is the likely pathology?

Central Brain Lesion
Brainstem Lesion
Cord Lesion
Peripheral Nerve
Neuromuscular Junction
Acetylcholimesterase enzyme problem
Muscle lesion
None of the above

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The answer is….. b. Warfarin

Based on NICE Guidance 36 (AF) and the CHADS 2 scoring system.

The CHADS2 score is an excellent aide memoir to anticoagulation in AF. It is based on:

SCORE

• 2 or over=Warfarin
• 1= Warfarin or aspirin
• 0=aspirin

This means our chap here will score:

• 1 for being >75
• 1 for being hypertensive

This means he should be treated with warfarin (assuming he has no contraindications)

A link to the original publication citation in circulation is available here. (link will open in a new window)

Get more questions like this in our free trial. ]]> http://medicaleducator.co.uk/answer-to-question-of-the-day-atrial-fibrillation.html/feed 1 http://medicaleducator.co.uk/question-of-the-day-atrial-fibrillation.html http://medicaleducator.co.uk/question-of-the-day-atrial-fibrillation.html#comments Fri, 26 Jun 2009 08:05:10 +0000 admin http://medicaleducator.co.uk/?p=427 A 76 year old man presents with atrial fibrillation which is permanent. He is lucid and has specifically made an appointment with you to discuss the best way of stopping him “dying ” as a result of the AF.

PMHx:
Hypertension (treated), Mild COPD. Nil else of note.

DHx
Verapamil (as treatment for AF)
Amlodipine
Simvastatin
PRN inhalers

SHx
Lives alone. Independent. Can carry out all ADL’s (activities of daily living)

What is the anticoagulation schedule you would recommend to prevent stroke?

a. Clopidrogel
b. Warfarin
c. Aspirin
d. No anticoagulation
e. Warfarin and Aspirin