Neurology, Older People and Rheumatology for PRES Level 2

Scope and time budget

Nine in every 100 questions is a middle-sized block, but it hides two different skills. Neurology rewards localisation and time-critical thinking: which test, how fast, which treatment window. Care of the older person rewards judgement about risk, function and capacity. Rheumatology and musculoskeletal items reward pattern recognition and drug safety. Expect many stems about older patients in which several problems interact, so the best answer treats the person rather than a single diagnosis.

What is tested

• Acute neurology. Stroke and transient ischaemic attack, subarachnoid haemorrhage and head injury, meningitis and encephalitis, seizures and status epilepticus.
• Chronic neurology. Migraine, tension-type headache and headache red flags, epilepsy, Parkinson's disease and movement disorders, multiple sclerosis and peripheral neuropathy, peripheral nerve injuries.
• Older people. Dementia including frontotemporal dementia, delirium and acute confusion, falls, frailty and polypharmacy.
• Back and spine. Cauda equina syndrome and back pain red flags.
• Rheumatology. Rheumatoid arthritis and inflammatory arthritis, gout, septic arthritis and osteoarthritis, systemic lupus erythematosus, Sjogren's syndrome and vasculitis.
• Bone. Osteoporosis and fragility fractures.

Local guideline points

• Capacity and decisions. Dementia and delirium questions often turn on the Assisted Decision-Making (Capacity) Act 2015: the presumption of capacity, the functional test and support for decision-making. See professionalism, ethics, law and prescribing.
• Restricting liberty. Confused older patients who try to leave raise questions about what a doctor may do. The Medical Council's Guide and the law set the limits.
• Adult safeguarding. Suspected abuse or neglect of an older adult follows HSE safeguarding procedures. Know that there is a duty to act and to document.
• Prescribing. Polypharmacy reviews, anticholinergic burden and drugs that cause falls follow HPRA and formulary advice.

What examiners ask about each group

• Stroke. Recognise the syndrome, decide on the first imaging, know the time-critical treatment logic and the secondary prevention drugs.
• Headache. Separate benign from dangerous with red flags such as sudden onset, fever with neck stiffness, or new headache in an older person.
• Epilepsy. First seizure work-up, drug choice and women of childbearing age, status epilepticus first-line treatment.
• Delirium versus dementia. Acute onset with fluctuation points to delirium, so find the cause: infection, drugs, retention, metabolic.
• Back pain. Identify cauda equina features, which need urgent imaging and referral.
• Inflammatory and crystal arthritis. A hot swollen joint must be treated as infection until proved otherwise.

Three typical traps

1. Treating delirium as dementia. If the change is days old, the answer is to look for a cause, not to start a dementia drug.
2. Missing cauda equina. Saddle numbness, new urinary retention and bilateral leg symptoms change a routine back pain stem into an emergency.
3. Assuming an older patient lacks capacity. Capacity is presumed and judged for a specific decision. An unwise choice is not proof of incapacity.

How to revise it

1. Draw a stroke pathway: recognition, scan, treatment window, prevention.
2. List red flags for headache and for back pain on a single page.
3. Make a delirium checklist of causes you must look for in an acutely confused older person.
4. Create a joint table comparing septic arthritis, gout, pseudogout and rheumatoid arthritis.
5. Review falls prevention as a prescribing topic: which drugs to stop, which to start.

Link this domain with psychiatry for depression and dementia overlap, and with surgery and emergency for head injury and fractures.

Subtopic notes: the decision behind each topic

• Stroke and transient ischaemic attack. Recognition, immediate imaging, the question of whether treatment is possible, and the prevention drugs after a TIA.
• Subarachnoid haemorrhage and head injury. Features of a sudden severe headache, the first scan, and when a lumbar puncture is relevant.
• Headache. Migraine, tension-type and cluster patterns, and the red flags that change the plan.
• Epilepsy and seizures. First-line drugs, the choice for women who may become pregnant, and status epilepticus.
• Parkinson's disease and movement disorders. Diagnosis from signs, drug classes and the dangers of stopping or missing doses.
• Dementia and delirium. Subtypes by pattern, the work-up for reversible causes, and the difference in time course.
• Falls, frailty and polypharmacy. A multifactorial assessment and the drugs that contribute.
• Multiple sclerosis and neuropathy. Patterns of relapse and the work-up for peripheral nerve problems.
• Meningitis and encephalitis. Treat first, then investigate. Know the drugs and the role of steroids.
• Back pain. Red flags and the urgent imaging for suspected cauda equina.
• Inflammatory and crystal arthritis. Joint aspiration, the drugs for flares and the long-term drugs and their monitoring.
• Connective tissue disease and vasculitis. Antibody patterns and the organs at risk.
• Osteoporosis. Who to assess, the drugs and the fracture prevention measures.

Revising across two weeks

Take acute neurology and the older person in the first week, and rheumatology, bone and chronic neurology in the second. For each syndrome, write the clinical clue, the first test and the first treatment. Add a daily set of ten questions that mix capacity and best-interests scenarios with the clinical topics, because older-person items often combine both. In the second week, prepare joint, antibody and bone drug tables. Close the fortnight with a timed mixed block that includes psychiatry and surgery questions to practise switching between systems.