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患者出现眼红、角膜和巩膜充血，最可能的诊断是？ (缺图)

Evaluation of a patient with a painful red eye, with corneal and scleral injection, is a common and important problem in primary health care in general practice and in Emergency Departments. Causes include conjunctivitis (infective or allergic), corneal abrasion and foreign body, contact lens overwear, and a number of other conditions. Conditions requiring urgent diagnosis and treatment include acute angle-closure glaucoma, an uncommon but important cause of the 'acute red eye'. Acute glaucoma occurs in eyes with a shallow anterior chamber, and, with the pupil dilated, the peripheral iris blocks aqueduct outflow and an abrupt rise in intraocular pressure occurs, with pain, corneal and scleral injection, corneal oedema, and visual blurring (often with haloes around objects). In some patients, nausea and vomiting accompany the eye symptoms and photophobia can be intense. Symptoms often come on at night and affect older patients. The diagnosis is suggested further, on examination, by irregularity of the pupil with sluggish reaction to light, a hazy and oedematous cornea and elevated intraocular pressure (greater than 20mm), with the globe feeling firm or stony-hard on palpation. In this older patient the scenario and findings suggest that the diagnosis is most likely to be acute angle-closure glaucoma. The hazards of worsening acute angle-closure glaucoma by inducing pupillary dilatation to facilitate retinal examination have probably previously been overstressed, and the facilitation of assessment of the retina probably outweighs any potential for worsening the degree of aqueous obstruction. Primary open angle glaucoma is a chronic and insidious condition, distinct from the 'acute red eye', and presents usually with gradual chronic loss of visual acuity, which can lead to blindness due to an insidious optic neuropathy with chronic elevation of intraocular pressure. The optic nerve disc shrinks and the recessed cup under the disc enlarges ('cupping'). The classic triad of presentation is painless loss of vision and visual field, cupping of the optic disc, and raised intraocular pressure. Acute iritis (iridocyclitis, uveitis) is an inflammatory reaction, sometimes associated with autoimmune disorders, but often without such associations. Diagnosis requires specialist slit-lamp assessment to identify inflammatory cells in the anterior chamber. (缺图)

The clinical picture is classical of a left sixth nerve palsy. The sixth cranial nerve supplies the external (lateral) rectus, paralysis of which causes horizontal diplopia on lateral gaze to the affected side, with failure of abduction of the left eye. The nerve has a long intracranial course from the lower pons in the midline before emerging through the superior orbital fissure, and a sixth nerve palsy not uncommonly complicates a head injury, and is of no particular localising value or guide to severity of injury. Fourth nerve palsies paralyse the superior oblique muscle, giving diplopia on downward gaze. Third nerve palsies paralyse all but two of the ocular muscles, as well as the parasympathetic supply to the pupillary musculature; the typical finding is the 'down and out' eye with an unresponsive dilated pupil. (缺图)

The diagnosis is most likely to be acute angle-closure glaucoma. Atropine will facilitate retinal examination; and the hazards of worsening acute glaucoma by further pupillary dilatation have probably been over-stressed in the past. Adequate diagnosis in this instance, however, can be made by visual acuity and visual field testing and examination of the globe by palpation through the lid, and with the aid of a pencil torch. Treatment of acute angle-closure glaucoma is with immediate topical agents which will inhibit aqueous production, increase aqueous outflow and decrease intraocular pressure. Agents used include carbonic anhydrase inhibitors (acetazolamide), alpha-adrenergic agonists, cholinergic agents (pilocarpine), beta-blockers (timolol) and prostaglandins. Many proprietary preparations exist combining the above agents. Of those listed acetazolamide is the most appropriate and most rapidly active. Physeptone is an opioid analgesic without specific influence on intraocular pressure. Steroids (fluorocortisone) are not effective and antibiotics (chloramphenicol) are similarly ineffective.

Bell Palsy (idiopathic isolated facial nerve palsy) results from a lesion of the facial nerve in the facial canal where the nerve swells and impulse transmission is disrupted. The aetiology is still not known but infection due to herpes simplex virus is considered to be a likely cause. There is a unilateral weakness of all the muscles of facial expression (including frontalis) and the eyelids will not close. Taste may be lost due to involvement of the chorda tympani, which carries sensory fibres from the anterior two-thirds of the tongue. The motor nerve to the stapedius comes from the facial nerve and, when this is involved in Bell palsy, hyperacusis (unpleasantly loud distortion of noise) may result because of paralysis of the stapedius muscle. Sweating is in part controlled by the sympathetic nervous system which, is not involved in seventh nerve palsy. Deviation of the jaw on opening of the mouth occurs in lesions of the trigeminal (fifth) cranial nerve. (缺图)

The history provided suggests a slowly progressive symmetrical peripheral neuropathic process involving predominantly sensory and motor nerves. Which condition fits this description?

The sudden and near-complete loss of vestibular function in a young man of this age is suggestive of which condition?

This question tests localisation of an acute vascular ischaemic stroke, on the basis of a constellation of symptoms and signs, testing knowledge of the vascular distribution of the vertebral artery and its branches compared to the internal carotid artery, applied to the clinical features of a cerebrovascular stroke. Findings of dissociated sensory loss immediately localise the lesion to pons or below, as ascending ipsilateral sensory fibres in posterior columns (touch, postural and vibration sense) and contralateral anterior and lateral column spinothalamic fibres (pain and temperature) remain separate until the run fibres decussate and cross in the pons - so that from this level up all sensory fibres run together and come from the other side of the body. Suprapontine lesions thus cause involvement of all sensory modalities. The vertigo and nystagmus suggest a cerebellar lesion and the left Horner syndrome confirms that the descending cervicosympathetic outflow to the head has been damaged in the lower brain stem - the lesion involves left lower pons and cerebellum - the classic distribution of the left posterior inferior cerebellar artery (PICA syndrome). Which vessel is responsible? (缺图)

Which of the following is the most important diagnostic feature for diagnosing irreversible apnoea in the context of brain death?

患者出现意识混乱，有酗酒史，近期有头部外伤。以下哪项是最可能的诊断？ (缺图)

患者左腕可伸展，但手指和拇指无法伸展，左前臂有刀刺伤史，最可能损伤的神经是？ (缺图)

患者出现单侧听力下降、耳鸣、眩晕，最可能的诊断是？

患者出现单侧T1神经根损伤表现，最可能的病因是？

颅内压增高的典型表现是？ (缺图)

脊髓完全横断后，损伤平面以下会出现？

患者出现眩晕、听力下降、耳鸣，最可能的诊断是？ (缺图)

患者左手小指和无名指麻木，手指无法伸展，最可能的诊断是？ (缺图)

The patient has numbness in the little and ring fingers of the left hand, with sensory loss to light touch and pin prick in either central C8-T1 distribution or peripheral ulnar nerve distribution. There is weakness of abduction of the little finger and of flexion of the terminal joints of little and ring fingers. These signs point to an ulnar nerve lesion at the elbow, the most common cause of which is an entrapment neuropathy as the nerve runs behind the medial epicondyle (B is correct). The ulnar nerve supplies C8-T1 sensation to the hand to little and ring fingers, and supplies the deep long flexors to the little and ring fingers, the interossei and hypothenar muscles of the hand, the lumbricals to ring and little fingers, and the abductor of the thumb. The resultant late deformity is the ulnar 'claw hand' with a clawed deformity of the little and ring fingers and a tendency to catch the little finger when putting the hand in the trouser pocket. As the condition becomes more advanced, weakness and wasting of the above-listed small muscles of the hand occurs. (缺图)

Weakness and wasting of the right hand in a 45-year-old man is least likely to be due to multiple sclerosis (C is correct). (缺图)

Tremor is defined as rhythmic movement resulting from alternating contractions and relaxation of groups of muscles, which produces oscillations about a joint or groups of joints. The pattern most frequently seen is rapid and fine in amplitude and is an exaggeration of physiological tremor. The fine tremor that occurs only on activity, and is not present at rest, is usually either benign essential tremor or exaggerated physiological tremor (D is correct).