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!

Remember, for more MCQs check out our free question bank here.

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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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.

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

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.

Look out for our next question of the day coming soon, and remember there are thousands more in the login area!

• 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

Let us know what you think, answer to follow soon. Remember: more questions like these can be found in the free trial area.

Periarticular osteoporosis of the MCP joints
Erosion on the ulnar styloid
Symmetrical distribution of disease
Reduced joint space at the carpal bones

What is the most likely diagnosis?

a. Ankylosing Spondylitis
b. Rheumatoid arthritis
c. Gout
d. Secondary Osteoarthritis
e. Psoriatic Arthritis

The overall average score of medical students on MedicalEducator.

The following weeks will represent the culmination of years of hard work by medical students over the past 1-5 years. Revision patterns have been changing and increasingly medical students are approaching final examinations preparing for them using web based MCQ, OSCE and video guides. For the first time, resources like podcasts and the like have taken a firm footing in the medical students preparation for final examinations.

One technique of sitting mock written papers has long been popular. Short answer questions, EMQ and MCQ format questions help people to prepare.

To quote one of our contributors:

I always felt more comfortable preparing for any exam, and I mean any, by running through exactly what I should know, first from a theoretical perspective, then from a practical perspective. If that meant filling in multiple choice questions, I got a book on multiple choice questions. It was what it was.

Maybe you’d like the opportunity to measure yourself against other medical students across the UK or

The average mark in one of our mock final examinations, which was added to the site in April 09.

across the world. A good example of this is our *(tough) mock medical finals paper. This is designed for students sitting year 1, year 2, year 3 year 4 or final examinations, which have a clinical component.

The average for this exam is 49.6%. Tough. But will it help you learn? A comment from a subscriber:

You keep doing questions where a principle that you didn’t understand is explained in the answer. Thats the value of them.

Overall this is a stressful time for medical students, on behalf of the Medical Educator team, good luck in those examinations.