Nervous System

A 52-year-old woman presents to the emergency department after sudden-onset severe occipital headache that reached maximal intensity within seconds while she was gardening, described as 'the worst headache of my life'. She has associated nausea, vomiting and photophobia. She has no significant past medical history, takes no regular medications and does not smoke. On examination she is alert and orientated (GCS 15), BP 178/102 mmHg, HR 92 beats/min, RR 18, SpO2 98% on room air, afebrile, with mild neck stiffness but no focal neurological deficit or pupillary abnormality. Non-contrast CT brain demonstrates diffuse hyperdensity within the basal cisterns and Sylvian fissures, and CT angiography confirms a 6 mm anterior communicating artery aneurysm. What is the most appropriate next step in her emergency department management?

A 52-year-old man with a long history of alcohol use disorder is brought to the emergency department by his partner after several days of poor oral intake and increasing confusion. He is disorientated to time and place, has a broad-based unsteady gait, and on examination has bilateral horizontal nystagmus with impaired lateral gaze. Vital signs are BP 108/68 mmHg, HR 96 bpm, RR 16/min, temperature 36.8°C, and SpO2 98% on room air. A bedside capillary glucose is 3.2 mmol/L. An intravenous line is inserted. What is the MOST appropriate next step in management?

A 19-year-old man is brought to the emergency department by his parents because of worsening jerking movements over the past two years. He describes brief, shock-like jerks of his arms that are most prominent on waking and are triggered by strobe lighting at nightclubs. His family have noticed he has become progressively clumsier, with several recent falls, slurred speech and difficulty with fine tasks such as buttoning his shirt. He has no history of febrile convulsions or developmental delay in childhood. On examination he has action-induced myoclonus, dysarthria, gait and limb ataxia, and appears to have mild cognitive slowing compared with a year ago. Vital signs are normal. An EEG performed today shows generalised spike-and-wave discharges with a photoparoxysmal response and mild diffuse background slowing; MRI brain is unremarkable. Despite trials of standard anticonvulsants, his myoclonus and ataxia have continued to worsen. Which of the following is the most likely diagnosis?

A 58-year-old woman with a 12-year history of type 2 diabetes presents to the emergency department with a 6-month history of burning, tingling pain in both feet that is worse at night and interferes with her sleep. She describes an unpleasant sensation when the sheets touch her feet. She has no history of foot ulceration and denies chest pain, dyspnoea or trauma. Observations are normal: BP 138/82 mmHg, HR 78 bpm, temperature 36.7°C. Examination reveals reduced sensation to light touch and vibration in a stocking distribution to mid-shin bilaterally, diminished ankle reflexes, and intact pedal pulses with no ulcers or callus. Her HbA1c is 9.0% and renal function is normal. Which of the following is the most appropriate first-line pharmacological agent to target her neuropathic pain?

A 58-year-old man presents to the emergency department with three months of progressive proximal weakness, now unable to rise from a chair without using his arms and struggling to climb stairs. He had been on atorvastatin 40 mg daily for six years for hypercholesterolaemia, which was ceased by his GP four months ago when initial myalgia and a mildly elevated creatine kinase (CK) were noted. Despite statin cessation, his weakness has progressively worsened rather than improved, and he now also reports dysphagia to solids. He denies rash, photosensitivity, joint pains or recent viral illness. On examination there is symmetrical proximal weakness of the shoulder and hip girdles (MRC 3/5), with preserved reflexes and no sensory deficit. Investigations reveal a CK of 9800 U/L (normal <200 U/L), normal renal function and thyroid function, and a negative ANA. Anti-HMGCR antibody testing returns strongly positive. Which of the following is the most likely diagnosis?

A 54-year-old woman with stage II breast cancer is receiving cycle 4 of weekly paclitaxel. She presents to the emergency department with a two-week history of progressive bilateral foot numbness and burning pain that has begun to creep towards her ankles, along with tingling in her fingertips. She denies fever, back pain, bowel or bladder dysfunction, or recent trauma. Observations are unremarkable. On examination there is symmetrical loss of pinprick and vibration sense in a stocking distribution to the mid-shin, absent ankle reflexes, normal power throughout, and a mildly unsteady, sensory-ataxic gait. There are no upper motor neuron signs and no spinal tenderness. Which of the following is the most appropriate next step in management?