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The history given of increasing confusion over some weeks and a major problem with his speech (marked expressive dysphasia) is highly suggestive of a cerebral lesion in the frontoparietal region of the dominant hemisphere. The CT head scan shows a focal relatively homogeneous low attenuation lesion in the left parietal region, surrounded by an area of rim enhancement, extending also into the frontal lobe. There is minimum midline shift. This is highly suggestive of a cerebral tumour (A is correct). The most common cerebral tumours in adults comprise secondary neoplasms, although these are often multiple and do not usually show rim enhancement. With metastatic cerebral neoplasms, the primary site may be occult. The most common primary site is lung, particularly small cell cancer. Malignant melanoma appears to have specific predilection to metastasis to brain; and renal carcinoma is another common primary site, together with breast cancer in women. Appropriate imaging is helpful in identifying occult primary malignancies. The most common primary tumour in adults is the glioblastoma multiforme, which is also the most malignant. Other types of primary brain tumour include the somewhat less aggressive astrocytoma, oligodendroglioma, ependymoma, and (in children) medulloblastoma. Meningiomas, by contrast, arise from the meningeal coverings of the brain - their growth pattern is expansive and not infiltrative. A cerebral embolism usually requires a defined source - from the heart, aorta or carotid artery - associated with a history of sudden onset neurologic deficit. Confirmation of this diagnosis requires demonstrable occlusion within an intracerebral artery, in this case the left middle cerebral artery, by use of CT or MR angiography. Cerebral infarction may occur as a result of embolism or thrombosis with a resultant wedge-shaped defect. Often, irregular haemorrhage into an infarct will show up as higher attenuation area(s) within the lesion or extending from one side. A cerebral haemorrhage presents as a sudden onset of neurological deficit, unlike this presentation. The CT will show a hypodense lesion which may extend irregularly, involve the lateral ventricles, and be associated with surrounding oedema exhibited as low attenuation with effacement of the sulci. A cerebral tuberculoma is usually associated with central caseation and a more heterogeneous appearance. There is nothing in the history to suggest prior tuberculous infection. (缺图)

Life expectancy after C6 tetraplegia (quadriplegia) in a young man as described will be affected by all of the options mentioned, but the effectiveness of continuing management of his neurogenic bladder is the most significant and important of these; and infective complications comprise a potent cause of morbidity and mortality (C is correct).

Diabetes mellitus can be complicated by various forms of peripheral neuropathy, including diabetic proximal neuropathy (diabetic amyotrophy). However, in this instance the motor weakness affects hip flexion (L1, 2), knee extension (L2, 3) and the knee reflex (L3, 4) - a similar distribution to his herpes zoster episode. Herpes zoster can cause motor weakness in up to 3% of patients. This is due to the spread of the virus from the dorsal root ganglia to the anterior root. Around 75% of patients experience gradual recovery. The time course and persisting sensory symptoms fit with this diagnosis (C is correct). Spinal canal stenosis can occur from intervertebral disc bulging or facet joint pathology, but usually presents with pain on walking, and at L4/5 level would not give the unilateral focal motor weakness described. Similarly, prolapse of the L4/5 intervertebral disc gives sensory and/or motor involvement, most usually of the L5 nerve root. A lacunar cerebral vascular accident (small vessel stroke) more commonly presents as a pure motor hemiparesis with upper motor neurone signs.

Sudden or rapid onset of delirium is a common problem in acutely ill patients, particularly the elderly. The delirium may be a manifestation of a pre-existing condition or brought on as a complication or sequel of the illness and its treatment. Pre-existing conditions to consider include chronic medical problems such as cardiorespiratory disease, cerebrovascular disease and myxoedema. Drug usage - including alcohol - must also be taken in account. Many well-defined precipitating factors are associated with the development of delirium in acute illness. These include sepsis (respiratory or urinary infection, cholangitis), hypoxia (chest infection, pulmonary oedema), metabolic disturbances (hyponatraemia, hypoglycaemia), cardiac problems (arrhythmias, congestive cardiac failure), hypotension (haemorrhage, dehydration), narcosis (opiate sedation and consequent hypoenfiliation), and drug withdrawal (alcohol, benzodiazepines). In the case described in the question the woman appeared to be self-sufficient and therefore a pre-existing dementia would be an unlikely cause of the current problem. However, she might have an underlying chronic medical condition and hypothyroidism, B₁₂ deficiency and cirrhosis are all possible contributing factors. The relatively normal liver function tests and absence of a macrocytosis make cirrhosis or pernicious anaemia unlikely aetiological factors in her delirium. The marginal elevation of alkaline phosphatase and gamma glutamyl transferase often occurs with moderate alcohol consumption and would support the hypothesis that this woman's current confusion is related to alcohol withdrawal. Even withdrawal of a small volume

A woman with a history of previous wrist and hand pain presents with spontaneous rupture of the extensor pollicis longus tendon. What is the most likely primary diagnosis?

A 'mallet' deformity of the distal interphalangeal joint of the finger results from a hyperflexion injury, causing rupture of the terminal slip of the extensor tendon of the finger to the distal phalanx. Avulsion of the tendon from the bone may be accompanied by avulsion of a flake of bone. What is the characteristic physical examination finding?

The patient exhibits the typical deformity of a fracture of the left outer clavicle, with elevation of the inner fragment and depression of the outer fragment, associated with a dropped left shoulder. What is the diagnosis? (缺图)

The X-ray shows the typical features of a fractured surgical neck of the humerus. What is the diagnosis? (缺图)

The history of an acute lifting strain, followed by the constellation of clinical features described, is most likely due to a focal left posterolateral disc prolapse affecting the lumbosacral intervertebral disc between L5 and S1. What is the diagnosis?

The aim with open (compound) fractures of bone is to convert them as expeditiously as possible to closed (simple) fractures. What is the most important initial management step?

Motor vehicle crash injuries may include each of the options mentioned. What is the most common injury caused by the knee hitting the dashboard with transmitted violence to the hip? (缺图)

Dislocated acromioclavicular (AC) joint gives a typical step deformity at the top of the right shoulder at the AC joint, as shown in the illustration, due to rupture of the retaining coracoclavicular ligaments. The outer clavicle is seen to be riding higher than the adjacent acromion. What is the diagnosis? (缺图)

The most likely diagnosis with this scenario is a ruptured Achilles tendon, which can be complete or partial, and is frequently provoked by exercise such as squash in patients within this age group. What are the diagnostic findings?

Recurrent anterior glenohumeral shoulder dislocation from minor strain or trauma is often associated with a traumatic Hill-Sachs deformity (flattening or a wedge-shaped defect in the posterolateral humeral head), predisposing to instability and recurrent dislocation. What is the appropriate management for recurrent dislocations?

The X-ray demonstrates an inferior dislocation of the shoulder at the glenohumeral joint (the most common type of dislocation). The axillary nerve runs anteriorly to posteriorly just below the capsule of the joint and is prone to stretching injury in such a dislocation. What is the appropriate initial assessment? (缺图)【试题选项缺失，请补充】

Recurrent anterior glenohumeral shoulder dislocation from minor strain or trauma is often associated with a traumatic Hill-Sachs deformity (flattening or a wedge-shaped defect in the posterolateral humeral head), predisposing to instability and recurrent dislocation. In recurrent dislocations, reduction under intravenous or oral analgesia is usually easy and can be performed immediately in the Emergency Department. Shoulder strapping may help prevent subsequent dislocation but a shoulder orthosis is usually too cumbersome; intra-articular injection of steroids or sclerosants are both inappropriate and potentially hazardous.

The X-ray demonstrates an inferior dislocation of the shoulder at the glenohumeral joint (the most common type of dislocation). The axillary nerve runs anteriorly to posteriorly just below the capsule of the joint and is prone to stretching injury in such a dislocation. Testing for axillary nerve function is essential prior to manipulative reduction (just as testing for integrity of the sciatic nerve is essential with a posterior hip dislocation). The axillary nerve supplies the deltoid muscle, the motor function of which should be tested at once. The patient clearly will be unable to abduct the arm because of the dislocation, so isometric contraction should be tested by asking the patient to tense the deltoid muscle against resistance without active movement. Isometric contraction ('dynamic tension') was the basis of Charles Atlas's ('the world's most perfectly developed man') advertisements for bodybuilding. 'Give me your body for seven days and I will make you a new man!'. Sensory loss should also be checked – a small area of sensory loss on the outer aspect of the upper arm will also occur if the nerve is damaged. Complete recovery from a stretch injury usually occurs within weeks or months. (缺图)

The X-ray shows that the patella has a gap separating two fragments. This is likely to represent a fracture, but the diagnosis of a pre-existing bipartite patella, due to failure of the two primary ossification centres to fuse, should be considered. Such anomalies are not rare and are often bilateral with smooth outlines of the two bony pieces. X-ray of the other uninjured knee may show, in confirmation, similar findings to the affected one. Most cases of bipartite patella, however, are separated by a vertical line whereas fractures, which this turned out to be, occur in the transverse plane from distracting muscular forces. Any of the other options (magnetic resonance imaging (MRI) scan, computed tomogram, arthroscopy, patellectomy) may be required subsequently for diagnosis or therapy. (缺图)

Cervical spine injuries require expert imaging to diagnose or exclude bony fractures and dislocations. Lateral views of the supine patient are needed to show all seven cervical vertebrae, as well as anteroposterior and oblique views to show facet joints and facet joint arthropathy. Oblique views are also required to show intervertebral foraminae. The odontoid peg and any C1-C2 fracture dislocation require additional views, with functional views in flexion and extension to diagnose anterior or posterior ligament damage. These may be performed with active movement by the conscious and cooperative patient, after initial films have demonstrated bone and joint integrity in neutral views. Checking for vertebral alignment, bone and joint integrity, disc spaces, facet joints and soft tissues should be ordered and meticulous. In this single computed tomography (CT) film cervical spondylosis is seen without any obvious evidence of acute bony injury. The film in this single view shows normal alignment of the seven cervical vertebrae and the first thoracic vertebra and no C7 vertebral fracture. C5 and C6 bodies are densely sclerotic and the intervertebral disc markedly narrowed. C4 nerve root compression is diagnosed primarily from clinical assessment. (缺图)

The circumferential plaster cast is too tight and must be completely split to relieve continuing compression and the real risk of Volkmann ischaemic contracture after this severely comminuted distal radial (Colles) fracture. All the other responses are dangerous procrastination. Encouraging active finger exercises, elevation of the limb and support with a sling, further X-ray to check continuing adequacy of reduction, and another review within 24 hours (after splitting the plaster), are all appropriate treatments, but the first step is to ensure relief of compression. (缺图)