Neurology & Psychiatry

A 68-year-old woman develops sudden right-sided weakness and slurred speech. She arrives at hospital 90 minutes after onset and a CT head shows no haemorrhage. What is the most appropriate treatment?

• AAspirin 300 mg and observation
• BIntravenous heparin infusion
• CImmediate carotid endarterectomy
• DIntravenous thrombolysis with alteplase✓

Answer: Acute ischaemic stroke within 4.5 hours of onset, with haemorrhage excluded on imaging, is treated with intravenous alteplase (thrombectomy is considered for large-vessel occlusion). Aspirin is started after thrombolysis is excluded or 24 hours after it.

A 28-year-old woman has recurrent unilateral throbbing headaches with nausea and photophobia that last several hours. What is the most appropriate acute treatment?

• AHigh-dose oral prednisolone for five days to abort the attack
• BAn oral triptan with paracetamol or an NSAID✓
• COpioid analgesia
• DDaily propranolol

Answer: This is migraine without aura. NICE recommends an oral triptan combined with paracetamol or an NSAID for acute attacks. Propranolol is a preventive treatment for frequent attacks, and opioids are avoided because of medication-overuse headache.

A 19-year-old student has fever, headache, neck stiffness and a spreading non-blanching rash. Which drug should be given first in hospital?

• AIntravenous ceftriaxone✓
• BOral amoxicillin
• CIntravenous aciclovir
• DIntravenous vancomycin alone

Answer: Meningococcal septicaemia and bacterial meningitis are treated immediately with an intravenous third-generation cephalosporin such as ceftriaxone (benzylpenicillin is given in the community before transfer). Aciclovir is for suspected viral encephalitis.

A 45-year-old man has a sudden, severe 'worst ever' headache that reached maximum intensity within seconds. He presented late, and his CT head, done ten hours after onset, is normal. What is the next step?

• AStart a triptan for probable migraine
• BLumbar puncture at least 12 hours after onset to look for xanthochromia✓
• CRepeat the CT head in 24 hours to look for blood that was not visible on the first scan
• DReassure and discharge with simple analgesia, since a normal CT at any time after onset excludes a subarachnoid haemorrhage

Answer: A thunderclap headache is subarachnoid haemorrhage until proven otherwise. NICE says a normal CT done within six hours of onset and reported by a radiologist does not routinely need a lumbar puncture, but when the scan is done more than six hours after onset a lumbar puncture, taken at least 12 hours after onset, is needed to look for xanthochromia from broken-down blood.

A 24-year-old woman with moderate depression is started on sertraline. What should she be told about the first weeks of treatment?

• AShe should stop the tablets as soon as she feels better, since continuing them after recovery risks dependence on the medication
• BThe medicine will lift her mood within 24 to 48 hours, and if it has not done so by then the dose should be doubled
• CAny increase in suicidal thoughts or agitation should be reported, and she will be reviewed within a week✓
• DSertraline cannot be combined with talking therapy, so cognitive behavioural therapy should wait until the tablets have been stopped

Answer: Under-25s starting an SSRI have a small increased risk of suicidal thinking in the first weeks and are reviewed within a week of starting. Antidepressants take several weeks to work, are continued for at least six months after recovery, and are usually combined with psychological therapy.

Under the Mental Health Act 1983 in England and Wales, which section allows detention for assessment for up to 28 days?

• ASection 3
• BSection 2✓
• CSection 136
• DSection 5(2)

Answer: Section 2 authorises admission for assessment for up to 28 days. Section 3 is for treatment for up to six months under the Act as currently in force (the Mental Health Act 2025 will shorten the initial period to three months once commenced), Section 5(2) is a doctor's holding power for up to 72 hours for an inpatient, and Section 136 lets the police remove a person from a public place to a place of safety.

An 82-year-old man on a surgical ward becomes acutely confused overnight, with fluctuating attention and visual hallucinations, two days after a hip operation. What is the most likely diagnosis?

• ADementia with Lewy bodies
• BSchizophrenia
• CDepression with psychotic features
• DDelirium✓

Answer: An acute, fluctuating disturbance of attention and cognition in an older inpatient after surgery is delirium, which has a treatable cause such as infection, pain, medication or constipation. Dementia develops over months, and hallucinations alone do not make a psychiatric diagnosis in this setting.

A 38-year-old man wakes with drooping of the whole left side of his face, including the forehead, and cannot close his left eye. There are no other neurological signs. What is the most appropriate treatment?

• AUrgent CT head to exclude a stroke before any treatment is started
• BOral prednisolone within 72 hours and eye protection✓
• CAspirin 300 mg for a presumed stroke
• DOral aciclovir alone

Answer: Weakness involving the forehead indicates a lower motor neurone facial palsy — Bell's palsy — rather than a stroke, which spares the forehead. Prednisolone started within 72 hours improves recovery, and the eye must be protected with lubricants and taping at night.

A 70-year-old man has a resting tremor of one hand, slowness of movement and a shuffling gait. What is the most likely diagnosis?

• AEssential tremor
• BMultiple sclerosis
• CParkinson's disease✓
• DMotor neurone disease

Answer: Bradykinesia with a unilateral resting tremor and rigidity is the classic triad of Parkinson's disease. Essential tremor is bilateral and worse with action, and does not cause slowness.

A 32-year-old woman has a two-day history of blurred vision and pain in one eye on movement. Two years ago she had numbness in her legs that resolved. What is the likely diagnosis?

• AMyasthenia gravis presenting with ocular weakness
• BA transient ischaemic attack affecting the retinal artery
• CMultiple sclerosis presenting with optic neuritis✓
• DMigraine with a prolonged visual aura affecting one eye

Answer: Blurred vision with pain on eye movement in one eye suggests optic neuritis, and a previous separate neurological episode makes multiple sclerosis — lesions disseminated in time and space — the likely diagnosis, confirmed by MRI.

A 40-year-old man with schizophrenia on clozapine develops a sore throat and fever. What must be checked urgently?

• AA clozapine level only, since fever raises the level and causes toxicity
• BLiver function tests, since clozapine causes hepatitis in a third of patients
• CA full blood count for neutropenia or agranulocytosis✓
• DA chest X-ray for pneumonia, since clozapine causes aspiration

Answer: Clozapine causes agranulocytosis in about 1% of patients; any infection symptom requires an urgent neutrophil count, and the drug is stopped if the count is low.

A 25-year-old woman with a history of self-harm presents after taking an overdose. Which is the most important part of the initial assessment once she is medically stable?

• ADischarge with a leaflet on local support services once the blood tests are normal
• BA referral to her GP in two weeks
• CA psychosocial assessment of her risk and needs by a trained professional before discharge✓
• DA prescription for an antidepressant

Answer: NICE requires that everyone who self-harms receives a psychosocial assessment of needs and risk before leaving the emergency department; treating the physical effects alone misses the reason for the presentation.