1. What is the best initial investigation for a patient with suspected malignant
spinal cord compression?
A. Mri brain
B. Mri spine
C. CT chest, abdomen and pelvis
D. Nerve conduction studies
E. Spinal xray
Answer: B
Explanation: Key learning points
Oncology
● An MRI spine is the investigation of choice for malignant spinal cord stenosis.
Explanation
Due to the spine being compressed by a soft tissue lesion MRI gives the best image
quality to identify the site of disease accurately and to allow prompt treatment with
either radiotherapy or surgical decompression.
Urgent treatment with high dose steroids is needed as well as oncology review as to
wheter radiotherapy would be beneficial and neruosurgical review. If the fracture is
unstable bracing or surgical intervention may be needed.
2. Which of the following serious complication can occur when hyponatraemia is
corrected too rapidly?
A. Cerebellar dysarthria
B. Peripheral neuropathy
C. Cerebral demyelination
D. Gait disturbance
E. Postural hypotension
Answer: C
Explanation: Key learning points
Metabolism
● Complications of hyponatraemia
Explanation
,Hyponatraemia, even in mild degrees, is associated with reduced survival and
neurological sequelae.
Even at serum sodium concentrations of 130-135 mmol/l, patients may be at
increased risk of falls, and at increased risk of fracturing. However, it is not clear if
the adverse prognosis of hyponatraemia is due to low serum sodium as such, or if
this just represents a patient group with more comorbidities or polypharmacy.
Hyponatraemia causes:
● fatigue
● muscle weakness
● gait disturbance
● falls
● disorientation
● cerebral oedema
● seizures, and
● death (if untreated).
If hyponatraemia develops gradually (>48 hours), the body can use compensatory
mechanisms. The risk of cerebral oedema is greater in patients with acute onset
(<48 hours) who are unable to use these compensatory mechanisms.
The treatment of hyponatraemia however can also cause problems if it occurs too
rapidly. The consequences include cerebral demyelination at pontine and
extra-pontine sites. Many authorities recommend that increases in serum sodium of
<12 mmol/24 hours are likely to be safe for the majority of patients.
Certain patients with hypokalaemia, liver disease, poor nutritional state or burns are
at higher risk of demyelination and should have a rate of sodium correction of <8
mmol/24 hours.
,3. Which one of the following vaccinations should not be given to patients undergoing
chemotherapy?
A. Rubella
B. Influenza
C. Tetanus
D. Pneumococcus
E. Hepatitis A
Answer: A
Explanation: Key learning points
Oncology
● Live vaccines including the rubella vaccine, should not be given whilst having
chemotherapy and for six months afterwards.
Explanation
Live vaccines should not be given whilst having chemotherapy and for six months
afterwards. These include:
● Rubella
● Mumps
● Measles
● MMR (the triple vaccine for measles, mumps and rubella)
● BCG (for tuberculosis)
● Yellow fever
Non-live vaccines are safe, but until the immune system is back to normal, they may
not give as much protection against infection as they usually would.
Further patient information and resources can be found on the Cancer Help UK
website from Cancer Research UK.
4. A 67-year-old man presents with a severe headache, the worst he has ever had,
affecting the back of his head and his neck.
On admission to the Emergency department he is very agitated and requires opiate
based pain relief for his headache. He has a history of hypertension for which he
takes ramipril, amlodipine and indapamide. His BP is elevated at 185/100 mmHg and
he has a tachycardia of 90 BPM.
, He is severely photophobic and finds it impossible to comply with ophthalmoscopy.
Neurological examination, as far as you can tell, is normal.
Investigations show
Haemoglobin 111 g/L (135-177)
White cell 4.2 ×109/L (4-11)
count
Platelets 231 ×109/L (150-400)
Sodium 143 mmol/L (135-146)
Potassium 4.3 mmol/L (3.5-5)
Creatinine 90 μmol/L (79-118)
CT head Left parietal lobe
haemorrhage
What neurological finding would you most expect?
A. Expressive dysphasia
B. Dysphagia
C. Left hemiplegia
D. Contralateral homonymous superior quadrantanopia
E. Acalculia
Answer: E
Key learning points
Neurology
● Consider a left parietal lobe insult if a patient is found to have difficulty with
perception, interpretation of sensory information and the formation of motor
responses.
Explanation
The dominant parietal lobe (usually the left) is important for perception, interpretation
of sensory information and the formation of motor responses. The non-dominant lobe
spinal cord compression?
A. Mri brain
B. Mri spine
C. CT chest, abdomen and pelvis
D. Nerve conduction studies
E. Spinal xray
Answer: B
Explanation: Key learning points
Oncology
● An MRI spine is the investigation of choice for malignant spinal cord stenosis.
Explanation
Due to the spine being compressed by a soft tissue lesion MRI gives the best image
quality to identify the site of disease accurately and to allow prompt treatment with
either radiotherapy or surgical decompression.
Urgent treatment with high dose steroids is needed as well as oncology review as to
wheter radiotherapy would be beneficial and neruosurgical review. If the fracture is
unstable bracing or surgical intervention may be needed.
2. Which of the following serious complication can occur when hyponatraemia is
corrected too rapidly?
A. Cerebellar dysarthria
B. Peripheral neuropathy
C. Cerebral demyelination
D. Gait disturbance
E. Postural hypotension
Answer: C
Explanation: Key learning points
Metabolism
● Complications of hyponatraemia
Explanation
,Hyponatraemia, even in mild degrees, is associated with reduced survival and
neurological sequelae.
Even at serum sodium concentrations of 130-135 mmol/l, patients may be at
increased risk of falls, and at increased risk of fracturing. However, it is not clear if
the adverse prognosis of hyponatraemia is due to low serum sodium as such, or if
this just represents a patient group with more comorbidities or polypharmacy.
Hyponatraemia causes:
● fatigue
● muscle weakness
● gait disturbance
● falls
● disorientation
● cerebral oedema
● seizures, and
● death (if untreated).
If hyponatraemia develops gradually (>48 hours), the body can use compensatory
mechanisms. The risk of cerebral oedema is greater in patients with acute onset
(<48 hours) who are unable to use these compensatory mechanisms.
The treatment of hyponatraemia however can also cause problems if it occurs too
rapidly. The consequences include cerebral demyelination at pontine and
extra-pontine sites. Many authorities recommend that increases in serum sodium of
<12 mmol/24 hours are likely to be safe for the majority of patients.
Certain patients with hypokalaemia, liver disease, poor nutritional state or burns are
at higher risk of demyelination and should have a rate of sodium correction of <8
mmol/24 hours.
,3. Which one of the following vaccinations should not be given to patients undergoing
chemotherapy?
A. Rubella
B. Influenza
C. Tetanus
D. Pneumococcus
E. Hepatitis A
Answer: A
Explanation: Key learning points
Oncology
● Live vaccines including the rubella vaccine, should not be given whilst having
chemotherapy and for six months afterwards.
Explanation
Live vaccines should not be given whilst having chemotherapy and for six months
afterwards. These include:
● Rubella
● Mumps
● Measles
● MMR (the triple vaccine for measles, mumps and rubella)
● BCG (for tuberculosis)
● Yellow fever
Non-live vaccines are safe, but until the immune system is back to normal, they may
not give as much protection against infection as they usually would.
Further patient information and resources can be found on the Cancer Help UK
website from Cancer Research UK.
4. A 67-year-old man presents with a severe headache, the worst he has ever had,
affecting the back of his head and his neck.
On admission to the Emergency department he is very agitated and requires opiate
based pain relief for his headache. He has a history of hypertension for which he
takes ramipril, amlodipine and indapamide. His BP is elevated at 185/100 mmHg and
he has a tachycardia of 90 BPM.
, He is severely photophobic and finds it impossible to comply with ophthalmoscopy.
Neurological examination, as far as you can tell, is normal.
Investigations show
Haemoglobin 111 g/L (135-177)
White cell 4.2 ×109/L (4-11)
count
Platelets 231 ×109/L (150-400)
Sodium 143 mmol/L (135-146)
Potassium 4.3 mmol/L (3.5-5)
Creatinine 90 μmol/L (79-118)
CT head Left parietal lobe
haemorrhage
What neurological finding would you most expect?
A. Expressive dysphasia
B. Dysphagia
C. Left hemiplegia
D. Contralateral homonymous superior quadrantanopia
E. Acalculia
Answer: E
Key learning points
Neurology
● Consider a left parietal lobe insult if a patient is found to have difficulty with
perception, interpretation of sensory information and the formation of motor
responses.
Explanation
The dominant parietal lobe (usually the left) is important for perception, interpretation
of sensory information and the formation of motor responses. The non-dominant lobe
