The most recently uploaded E-book from Neurology4MRCP.com is the "MRCP(I) part I Mock test"; a real imitation! Here, you will find paper one and 2, with photographic materials, and at the end there are 2 answer sheet samples to mark. Verify you answers by reading separate chapters.
You may also review the E-book Neurology Themes & Syllables for MRCP(UK)/MRCP(I) , or the notes for clinical examination , or or the neurology questions book , or the book for MRCP part I self-assessment one.
Reaching the no. of five, our publications will continue the journey of knowledge spread, and with out the moral support of our visitors, Neurology4MRCP would not have been continued.
Feel free to dowinload free MRCP books from our official website.
Learning shall be free to all! All the best to all MRCP(UK) and MRCP(I) candidates.
O Amin
We are happy to announce the launching of our new domain www.neurology4mrcp.com , which covers both Neurology and Internal Medicine in 1500 best of five and multiple choice questions for MRCP(UK) and MRCP(I) part I and part II written with photographic materials. Many thanks go to our visitors who supported us all the way while we were in the OrgFree and Ueuo servers. The contiuous input and feedback from MRCPians enlightened and encouraged us about how to make many steps forward and to progress in our job. Tow E-Books are now online, totally free, and without even a simple registration that can be downloaded in zipped PDFs and can be browsed online:
1- "One Year of Hard Work":
2nd edition; a pure neurology book for MRCP(UK) and MRCP(I), part I and part II written. Clinical scenarios, data interpretations, case histories, and photographic materials are included. Best of Fives, Best of Many, MCQs, with papers for MRCP(I) part II written can be seen. This is the only MRCP E-book with 810 questions that can be obtained for free. For example, you may buy a small book with 300 BOFs for 30 Sterlings (i.e. 60 USDs!). You may also browse its chapters online as separate papers. At the end you will find Answer Sheets to fill in and to calculate your scores.
2- "Teaching Best of Five Questions with Clinical Scenarios":
3rd Edition, for MRCP(UK) and MRCP(I) part I. Covers all aspects of internal medicine but neurology. You can download it as a zipped PDF. Again, at the end you will find an answer sheet for you to assess your performance. Needless to say, this is the only MRCP (internal medicine) book that is free.
Within few minutes, you will get 1500 MRCP questions! No need to stay for hours or days "online"!
Thank you for visiting our new website.
Dr. Osama S. M. Amin MBChB MRCPI
Neurologist and Head of Team Neurology4MRCP
Answers:
Q1: Answer D
The sudden occurrence of a partial Brown-Squard syndrome in this young lady should always prompt a search for multiple sclerosis. A compressing metastatic neoplastic tumor (like from a breast cancer) may give a similar picture. Notice the sensory level on lateral aspect of the right arm (C6); an MRI of the cervical cord with gadolinium is the key imaging investigation here.
Q2: Answer D
Severe cervical spondylosis is a well-known risk factor for brain stem stroke due to vertebro-basilar ischemia. Although there is no history of hypertension or diabetes or hyperlipidemia, a carotid Doppler study is worthy to assess the status of the carotids. Aspirin should be given to all patients with ischemic stroke unless contraindicated; this patient's clinical picture clearly indicates that the patient can receive this form of therapy; however, his history is present for about 24 hours, which excludes him from receiving thrombolytics. Always look for and control risk factors like smoking, diabetes, hypertension…etc.
Q3: Answer C
This woman's new generalized seizure should always prompt a search for hematoma expansion or the development of another hematoma that causes cortical irritation. Needless to say, hypo or hypernateremia should not be forgotten. Also, look for other causes like severe hypoxemia, medication side effects and interactions…etc.
Q4: Answer E
Remember that up to 90% of the pyramidal tract decussates in the lower medulla to the contralateral side. However, in a minority of normal population this decussation could be very minor or even absent as in this patient. In those people, a lesion in this tract above the lower medulla will not give a contalateral pyramidal signs, but instead these will be ipsilateral. This patient had a cortical irritating tumor, which causes focal fits at the same side of the tumor. Although other options might be true in real practice, this congenital anomaly should not be forgotten.
Q5: Answer C
He is likely to have been diagnosed with schizophrenia and been given a conventional neuroleptic, after which he developed neuroleptic malignant syndrome. Notice that this syndrome develops over few days and it is not an sudden one.
Q6: Answer A
In Friedreick's ataxia, there is no impairment or only mild impairment in cognition; a marked cognitive impairment should cast a doubt on the diagnosis. An absent family history does not refute the diagnosis; however, its presence is an excellent clue.
Q7: Answer E
The picture is of an acute left sided papillitis, which has a broad differential diagnosis and causes. The pace and severity of the clinical picture, physical findings, and careful investigations and follow up are very important. Vasculitides, infectious agents, sarcoidosis…etc all can produce this picture, and multiple sclerosis (MS) although unlikely it is worthy to exclude it. The visual loss in giant cell arteritis is irreversible, and a rapid spontaneous improvement goes with MS. Foster Kennedy gives a slowly progressive optic atrophy in one side and papilloedema in the other side.
Q8: Answer C
Notice that the overall picture is of a cluster headache-like, but the picture is atypical given the 2 years of non-remission and occurrence during day and night, and there are features of hypogonadism. All of them might indicate an intracranial space-occupying lesion in and around the sella. Actually, MRI of this patient revealed a large sellar mass with supra-sellar extension and impingement upon the left carotid artery, which explains both the hyperprolactinemia and the dysautonomia affecting the left side of the face (eye redness and nasal discharge) by affecting the sympathetic fibers around the left carotid artery. It was a prolactimona by histopathological examination after successful surgical debulking.
Q9: Answer A
These signs indicate that CNS involvement is present, which can be documented by CSF studies (after correcting the platelet count if severely depressed). The duration of steroids is too short to cause such a picture of obesity. Vincristine causes peripheral sensory neuropathy, not a cranial motor one. Those ALL patients with CNS involvement need intrathecal chemotherapy and cranio-spinal irradiation as the prognosis is unfortunately poor.
Q10: Answer C
This patient is immune suppressed because of cyclosporine. Given the presence of impaired consciousness, fever, and neck stiffness, meningitis (or meningoencephalitis) is the most likely diagnosis. We should stop cyclosporine, and start broad-spectrum antibiotics and do CSF examination. Blood cultures can be done, and adding another immune suppressant (azathioprine) would be a silly step.
Q11: Answer E
She has two sites of involvements: spinal cord and optic. Both are of white matter signs. The pace is somewhat rapid, and although she did not report an improvement, B12 deficiency and heredito-familial degenerative conditions are highly unlikely. Instead, one should exclude multiple sclerosis by having this clinical picture and should be differentiated from anti-phospholipid syndrome, SLE, vasculitis...etc. Therefore, Brain imaging would be a reasonable step here.
Q12: Answer A
This is most likely an embolic stroke to the main stem of the left middle cerebral artery. The infracted area is large with mass effect and midline shift. So, measures to reduce the raised intracranial pressure should be instituted without any delay like high concentration O2, mannitol infusion...etc; while anticoagulation is definitely indicated, it is should be omitted for the time being as there is a very high risk of hemorrhagic transformation in this large friable infarcted area, and starting it after 1-2 weeks is reasonable. Her atrial fibrillation is rapid and she needs measures to slow it like giving digoxin, and an echo study is needed to evaluate her heart. A DC shock is not indicated as we don’t know the duration of the AF; besides, given the presence of mitral stenosis, there is a very high risk of recurrence and emboli showering in the presence of no anticoagulation coverage.
Q13: Answer E
Given the presence of such a long history, positive family history, stork-like legs and palpable nerves in the context of little disability and no other system affection, Charcot Marie Tooth disease is the most likely diagnosis.
Q14: Answer D
This is Broca's aphasia in a right-handed man; the posterior part of the lower left frontal gyrus is the culprit site.
Q15: Answer E
Weight gain, not weight loss, is a side effect. Alopecia is seen with valproic acid, while hirsutism is seen with phenytoin.
Q16: Answer C
Kayser-Fleischer ring is due to deposition of copper in the Descement's membrane of the cornea, which is reversible upon successful therapy with copper chelators.
Q17: Answer D
CIDP, not GBS, can be a cause. Notice that CMT type I is a demyelinating disease that produces palpable nerves; type II is an axonal one, with no such finding. Other cause: leprosy.
Q18: Answer C
Notice that both Carbamazepine and phenytoin produce worsening in cases of petit mal (and myoclonic) epilepsy and should be avoided. Valproic acid and Ethosuximide are first line agents for this epilepsy, while lamotrigine and clonazepam are second line agents.
Valproic acid is preferred because of its wide spectrum against many types of epilepsy, which might coexist with petit mal (like myoclonic jerks and GTC seizures).
Q19: Answer E
This is papilloedema! Notice that papillodema is not seen in multiple sclerosis (MS). Papillitis is seen in MS, which is seen as a red optic nerve head swelling with SEVERE reduction in the visual acuity.
Q20: Answer C
The clinical picture is suggestive of pyogenic meningitis in a previously healthy man with no history of head trauma; so staring iv ceftriaxone and vancomycin is the next step while arranging for lumbar puncture.
Q21: Answer E
Dysautonomias are seen in up to 65% of cases and might produce a sudden cardio-respiratory death. Some degree of asymmetry in findings may be seen in up to 9% of cases; however, marked asymmetry should cast a doubt on the diagnosis. Even in the best centers, the mortality rate is around 4-5% of cases. The CSF proteins level (as is the nerve conduction study) might be totally normal in the 1st week of illness; hence normal studies early in the illness are not against the diagnosis. Some patients, around 6%, may experience relapses and which might be associated with certain HLA haplotypes
Q22: Answer C
Mesial temporal or hippocampal atrophy is a common cause of temporal lobe epilepsy (TLE). Notice the prodromal features that are followed by the ictus (for which the patient recollects nothing). Carbamazepine and phenytoin are effective in many patients and should be the first line if no contraindication is present. Refractory TLE patients are the best candidates for surgical treatment for complex focal epilepsies in general. The EEG may show lateralized spikes in one or both temporal lobes.
Q23: Answer C
A meningioma is an extra-axial tumor that is benign in a substantial number of victims. The presence of underlying brain edema indicates that the tumor may be malignant, or the presence of so-called secretary meningioma, or an atypical benign meningioma; hence massive brain edema is seen uncommonly. The tumor may stop growing, but never regresses. The commonest sites are over the cerebral convexities and along the falx cerebri; the infra-tentorial fossa and the spine are uncommon sites. Intra cranial meningiomas are seen more commonly in females with a history of breast cancer, and together with cranial irradiation in the past, are considered a risk factor for meningioma development. Multiple meningiomas should always prompt a search for a diagnosis of neurofibromatosis type II.
Q24: Answer B
Aphasia is a supratentorial sign, that almost always indicates a cortical lesion in the dominant hemisphere; thalamic aphasia is rare and has an excellent prognosis. Certain brainstem lesions might result in anarthria, which can be easily confused with aphasia.
Q25: Answer A
The idiopathic variety is the commonest type; other causes: intracranial venous sinus thrombosis, medications (tetracycline, vitamin A),
Q26: Answer B
CNS involvement in leukemias always portends a grave prognosis, especially when present at the time of the diagnosis. Headache, backache, confusion, cranial palsies, and root signs all might be clues to leukemic meningitis. A single CSF sample may fail to show the blast cells, and repeated samples are required to increase the diagnostic yield. Neck stiffness in leukemias could be due to leukemic meningitis, infectious meningitis, or subarachnoid hemorrhage (due to low platelets). The patient should be put on a certain treatment protocol that entails intrathecal chemotherapy (methotrexate, cytosar and hydrocortisone) and craniospinal irradiation.
Q27: Answer D
Nystagmus is an infratentorial sign, and thus is due to posterior circulation ischemia in stroke patients. Hemiplegia could be due to anterior or posterior circulation strokes.
Seizures are seen in 5-15% of stroke patients because of cortical irritation (mainly in embolic or hemorrhagic strokes).
Q28: D
The concept of dominant and non-dominant hemisphere is important in localization in neurology. All aphasias are due to dominant hemispheric lesions. Hemiplegia is seen in many sites damaged by a pathology (like the cortex, internal capsule, basis pontis…etc). Asteriognosis is a cortical sign, but can be seen in both dominant and non-dominant parietal hemispheric lesions. Constructional apraxia is due to non-dominant parietal lesions. Urinary incontinence is seen in lesions involving both mesial frontal lobes as in normal pressure hydrocephalus.
Q29: Answer B
Most likely, that clarithromycine intake had resulted in enzyme inhibition and carbamazepine toxicity manifesting as ataxia and diplopia.
Q30: Answer D
Motor neuron disease has no autonomic neuropathy as a feature. Other causes: fatal familial insomnia, vasculitides, Fabrey's disease, and multiple system atrophy.
Q31: Answer B
Most likely, he has TB meningitis, and anti TB medications are better to be started while awaiting the CSF culture for TB bacilli. The history is too long for a viral etiology, and the intra cranial pressure is high (normal 5-18 cm H2O). The hydrocephalus in TB meningitis could be both communicating and non-communicating. Even with treatment, many are left with considerable degree of neurological disability.
Q32: Answer C
This man has pseudobulbar palsy. Option C is a cause of bulbar palsy.
Q33: Answer D
Notice that the presence of cerebellar signs, ocular palsies, marked dementia, Parkinsonian features, sensory signs and symptoms, and sphincter disturbances, all are against the diagnosis. The combination of ALS, Dementia, and Parkinsonian features is a very rare distinct clinical syndrome, and should not make you change your answer in the MRCP examination regarding the classical MND features.
Q34: Answer C
Notice that this woman has primary optic atrophy. Any longstanding raised intracranial pressure states with papilloedema (for example from a space-occupying lesion) can produce secondary optic atrophy.
Q35: Answer D
Aphasia is cortical sign; all others are can be caused by white matter demyelination. Noticed that the dementia that is seen in advanced MS is a sub-cortical type.
Q36: Answer B
Oligodendogliomas are primary brain tumors that are usually supratentorially in location, less infiltrative that astrocytomas, and hence most of them are amenable to complete surgical excision, and usually responds well to systemic chemotherapy. Tumor calcification is usually seen in 30% of cases.
Q37: Answer C
Of all gliomas, glioblastoma multiforme is the most aggressive one, and infiltrating the adjacent areas diffusely making complete surgical excision impossible (debulking surgery is used to decrease its size, obtain a tissue diagnosis, and reduce the intracranial pressure). Gliomatosis cerebri is said to be present when there is diffuse infiltration without a clear cut mass or enhancement area on brain MRI. Needless to say, the prognosis is very poor. Metastasis outside the CNS is rare and is usually seen in those who are operated.
Q38: Answer C
Donepezil is a central inhibitor of acetyl cholinesterase, used in early cases of Alzheimer's disease. About 10-20% of patients will show a modest improvement in their cognition. The medication has a long half-life, and is given once per day. Tacarine (central inhibitor of acetyl cholinesterase) is hepatotoxic; donepezil is not. It can cause bradycardia, and thus contraindicated in those with advanced heart blocks.
Q39: Answer A
NPH is a cause of potentially reversible dementia. It is uncommon cause of dementia (Alzheimer's disease comprises up to 50% of cases of dementia in old people). It can be idiopathic, or secondary to head trauma, subarachnoid hemorrhage, or meningitis. Brain MRI will show dilated ventricles (without prominent sulci) with upward bulging of the corpus callosum and widening of the Sylvius aqueduct, in the absence of a mass lesion. The definitive diagnosis is by radionuclide cisternography. Post-shunting, 30-50% of patients will show improvement in their gait and cognition.
Q40: answer C
Huntington's disease (HD) is an autosomal dominant disease, due to trinucleotide (CAG) repeat expansion at the HD gene. Both seizures and Parkinsonian features are more common in juvenile cases, which are fortunately rare. Those who presents with chorea in the context of a positive family history, should be differentiated from benign familial chorea, which has a different prognosis.
Q41: Answer E
Benztropine (like all anticholinergics) is effective at treating tremor, not rigidity; and in those who are above the age of 60-65 years, can produce confusional state. Amantidine can be used in early cases, either alone or with anticholinergics, has a mild short-lived effect that rapidly wears off. L-dopa is the prodrug of dopamine. There are no D6 receptors (only D1-5). Tolcapone (and entacapone) is a COMT inhibitor, and thus enhances the effect of L-dopa therapy.
Q42: Answer A
Hematomyelia is a hematoma in the substance of the cord, can be due to AVMs, coagulation defects, and vasculitis. Decompression into the subarachnoid space can occur. When an AVM is the cause, spinal angiography is done to delineate the AVM together with evacuation of the hematoma; otherwise, the treatment is symptomatic.
Q43: Answer A
Tabes dorsalis is a form of tertiary syphilis. Rombergism is seen in 50% of cases only due to loss of kinesthesia (and hence vibration sense should be impaired also). Loss of bladder sensation causes urinary retention. Extensor planters are seen in Taboparesis or general paresis of insane, not in pure tabes dorsalis. The severe lancinating pains may cause severe abdominal pain (tabetic abdominal crises) that brings the patient as an acute abdomen (but no surgical cause can be found, so-called medical acute abdomen).
Q44: Answer D
The idea of giving Beta INFs in RRMS is to decrease the severity and frequency of relapses (by one third), so the occurrence of 1 relapse after 1 year of therapy is not a reason to stop this form of therapy; instead, 3 or more attacks within 1 year that necessitate steroid pulses, is an indication of treatment failure, and the Beta INF should be stopped. Options a, b, and c are true.
Q45: Answer E
Levitiracetam is an anti-epileptic agent. Also avoid cocaine, quinolones, and chlopromazine.
Q46: Answer C
The precise mode of action of Riluzole is unknown, but it is supposed to have an anti-glutamate action, and thus interfering with excito-toxic mechanisms. It is given orally and has been found to produce a modest improvement in survival figure. It is hepato-toxic, and can cause weight loss.
Q47: Answer B
Dapsone (usually when given in the long term, as in the treatment of leprosy, in which the patient shows a new motor worsening after a period of improvement) can cause a pure motor peripheral neuropathy.
Q48: Answer B
The distinction between demylinating and axonal neuropathy is very important regarding the possible etiology and prognosis. There is no definite clinical test for this discrimination, but a nerve conduction study can answer us. Vitamin B12 deficiency is a cause of subacute/chronic primary peripheral axonopathy.
Q49: Answer D
The anticholinesterases have a symptomatic benefit only, and do not affect the course of illness. Thymectomy has no place in: neonatal myasthenia, congenital myashtenic syndromes, patients above the age of 65 years, myasthenia duration of more than 7 years, and pure ocular myasthenias. Iv Ig is used in myasthenic (not cholinergic) crisis. Although prednisolone is effective in almost all cases, it can produce a dramatic worsening at the start of treatment. Cyclosporine has a modest effect as an immune suppressive agent in MG.
Q50: Answer D
Drug induced myopathy is usually under-diagnosed in clinical practice. The list is long, but paracetamol is not implicated. Zidovudine can cause myopathy with ragged red fibers due to mitochondrial toxicity. The risk of statine-induced myopathy (or myositis) is greatly increased when these agents are used with cyclosporine or gemfibrozil.
Q51: Answer C
IBM is the commonest cause of inflammatory myositis in those above the age of 50 years. Although the EMG may show evidence of denervation, there is no degeneration of anterior horn cells. It is unfortunately resistant to immune suppressive therapy (occasionally, many cases are diagnosed as polymyositis, which comes into light after failure of immune suppressive therapy). The prognosis is poor. Some cases show familial clustering. The presence of rimmed vacuoles on biopsy specimen is highly suggestive of IBM, and there are many other distinctive features on histopathological examination, like deposition of amyloid, presence of eosinophilic cytoplasmic inclusions…etc.
Q52: Answer D
Only facioscapulohumeral muscular dystrophy (MD) is not associated with cardiac involvement (although it may be associated with sensory neural deafness and retinal detachment, and labile hypertension). Limb girdle MD uncommonly associated with cardiac involvement.
Q53: Answer B
Notice that botulism is a disease of motor end plate due to interference of acetylcholine release, and affect acetylcholine release at autonomic ganglia causing various dysautonomias.
Q54: Answer E
Machado-Joseph's disease is a spinocerebellar ataxia type 3, due to CAG repeat expansion.
Q55: Answer C
In 30% of cases, no obvious source of infection can be found, and the surrounding edema is vasogenic. LP is both dangerous and unnecessary. After successful treatment, around 50% are left with seizures.
Q56: Answer A
About 5-10% of PCR-proven cases will have a normal brain MRI (and 33% will have a normal brain CT scan). The virus can not be cultured from the CSF. The negative predicative value of a negative CSF PCR assay for HSV DNA is 98%, and acyclovir should be started without delay when there is a clinical suspicion of HSV encephalitis, as it decreases both morbidity and mortality figures.
Q57: Answer E
Positive CSF protein 14-3-3 in the context of rapidly progressive dementia and myoclonus is highly suggestive (but not diagnostic) of CJD (it can be also positive in HSV encephalitis but negative in Alzheimer's disease). Any fever, high ESR, peripheral blood neutrophilic leukocytosis, or neutrophilic CSF pleocytosis should cast a doubt on the diagnosis.
Q58: Answer C
When the ICP is recorded invasively through ventriculostomy, the CSF can be drained to decrease the pressure. The head of bed should be elevated. Steroids can be used in edemas associated with brain tumors or abscesses (they are useless in edema associated with ischemic stroke or hemorrhagic stroke). Plasma osmolality should be kept BELOW 320 mosmol/Kg when using mannitol.
Q59: Answer B
CPM results from too rapid correction of hyponatremia or hypo-osmolal states. Partial forms are not uncommon, and may present as dysarthria, confusion, or even gaze palsies; thus, the absence of quadriparesis is not against the diagnosis. The usual picture is an acute onset of quadriparesis and pseudobulbar palsy in a chronic alcoholic man who received an aggressive correction of chronic hyponatremia.
Q60: Answer E
Option E is an "inclusion criteria". You should be familiar with both inclusion and exclusion criteria for receiving thrombolytic therapy in this setting.
Q61: Answer E
Hypothyroidism is a cause of slowly progressive ataxia in long standing cases.
Q62: Answer B
Kearns-Sayre syndrome is a sporadic, not inherited cause of SCA.
Q63: Answer C
Enteroviruses are the commonest agents responsible for viral meningitis. All other infectious agents are considered to be uncommon causes.
Q64: Answer D
Not every viral encephalitic process portends a gloomy prognosis.
Q65: Answer D
Status epilepticus is a medical emergency with high mortality rate, the commonest precipitating event is sudden withdrawal (self or iatrogenic) of anti-epileptics. Lactic acidosis is very common but does not warrant any treatment per se. Phenobarbitone infusion should be used as a 3rd step (after lorazepam and phenytoin). Hyperthermia, not hypothermia is seen.
Q66: Answer C
Ischemic stroke in young people (less than 45 years old) should prompt a thorough search for an underlying cause, like atrial fibrillation, SBE, meningovascular syphilis, paradoxical embolism through a patent foramen ovale…etc.
Q67: Answer A
In the absence of chronic hypertension, or in patients younger than 40 years of age, spontaneous "hypertensive" hemorrhage is unlikely. Instead, we should look for other causes like AVM, coagulopathy, drug abuse, head trauma, hemorrhage in tumors…etc. Congophilic angiopathy is seen in old people.
Q68: Answer D
This is a new onset of focal motor seizures in an adult man. Intracranial space occupying lesions should always be excluded.
Q69: Answer A
Aspirin has been shown to decrease stroke related morbidity and mortality, and early stroke recurrence. Heparin is indicated in persistent cardiogenic source of embolization. Heparin is associated with increased risk of CNS (or systemic) hemorrhage which statistically outweighs any benefit. The combination of aspirin and clopidogrel in the acute setting is still controversial.
Q70: Answer D
Ocular and facial muscles in polymyositis are usually spared; while the anterior neck muscles are commonly involved (causing neck drop). Skin rash defines dermatomyositis. Respiratory muscles involvement is fortunately uncommon but dangerous and mainly seen in acute cases.
Q71: Answer C
Cerebellar masses in children are usually malignant brain tumors, and the pilocytic variety of low-grade astrocytomas has an excellent prognosis and complete cure can be achieved if removed completely. In general, infratentorial tumors tend to raise the intracranial pressure early, unlike the supratentorial ones. Neck stiffness, with negative Kerning's sign, indicates an infratentorial mass lesion. The most fearful event is secondary brainstem compression and herniation syndromes.
End
Q41:
A 57-year-old man, presents with 8-month history of resting hand tremor and gait difficulty. Ultimately, he was diagnosed as having idiopathic Parkinson's disease, and you are thinking of prescribing a medication for his illness.
Which one of the following statements is correct regarding medical therapy of this disabling neurological disease?
A 22-year-old man sustained a trauma to the upper spine following a fall from his motor cycle. There are features of acute painful transverse myelopathy at the level of C6,7. Imaging studies confirmed the presence of an acute hematomyelia.
Which one is the correct statement regarding this spinal cord hematoma?
A 54-year-old man presents with repetitive severe lancination pains in his lower limbs and unsteady gait. You found bilateral small pupils with light-near dissociation. He has a history of poorly treated syphilis 20 years ago.
Which one of the followings is true regarding tabes dorsalis?
Q44:
A 26 year old woman, was diagnosed a having relapsing remitting multiple sclerosis (RRMS) since 1 year, and is currently receiving interferon beta therapy.
All of the followings are reasons to stop these medications in RRMS, except?
Q45:
A 16-year-old schoolgirl who is a known case of idiopathic generalized tonic clonic epilepsy, currently receiving valproic acid tablets and is seizure free for the past 3 months, is consulting you about which medications to avoid, because she was surfing the internet and found that some mediations may worsen her epilepsy.
Which one of the following medications does not reduce seizure threshold?
Q46:
A 65 year old man, was diagnosed as having amyotrophic lateral sclerosis (ALS) since 1 month, is referred to you for consideration as whether to start Riluzole or not.
Which one of the followings is true regarding this medication?
Q47:
A 32 year old man, with post primary pulmonary tuberculosis (TB) and is receiving anti TB medications since 5 months, presents with abnormal sensation in his feet. A diagnosis of isoniazide-induced peripheral neuropathy was made.
All of the followings can cause sensory or predominately sensory peripheral neuropathy, except?
Q48:
A 44-year-old woman with history of watery diarrhea before 2 weeks presents with rapidly progressive areflexic weakness in her lower limbs. A diagnosis of Guillain Barre syndrome was made.
The followings can cause demyelinating peripheral neuropathy, but which one is the cause of primary axonal peripheral neuropathy?
Q49:
A 34-year-old woman with generalized myasthenia gravis complains of cramping abdominal pains after the intake of pyridostigmine.
Which one of the followings is true regarding the treatment modalities in myasthenia gravis?
Q50:
A 58-year-old man, with a history of ischemic heart disease, presents with generalized body aches and weakness that interfere with his daily job as a laborer. He is on Aspirin, atenolol, and lovastatin. After 2 weeks of stopping lovastatin, he reported a marked improvement in his weakness and pains.
Which one of the followings is not a cause of drug-induced myopathy?
Q51:
A 62-year-old man presents with slowly progressive distal weakness and wasting in both upper and lower limbs. There is absent knee jerks and flexor planters. EMG and muscle biopsy studies confirmed a diagnosis of inclusion body myositis (IBM).
Which one is the correct statement regarding this form of inflammatory myopathy?
Q52:
A 22-year-old man is consulting you because he has a relative with a muscular dystrophy who died because of cardiac arrest.
Which one of the following muscular dystrophies is not associated with cardiac involvement?
Q53:
A 61-year-old man presents with recurrent orthostasis symptoms. He is hypertensive and is taking captopril and hydrochlorothiaziade tablets. He is afraid that he might have a brain disease causing this picture.
Autonomic dysfunction can be associated with many central and peripheral neurological diseases. Which one of the following autonomic dysfunction-causing diseases is not associated with CNS signs?
Q54:
A 29-year-old new married woman is consulting you about the likelihood of having a child affected by mitochondrial diseases, because she has a relative with one of these diseases.
Which one of the following diseases is not due to mitochondrial cytopathy?
A 22-year-old man presents with 3-week history of progressive somnolence and headache. He has a history of poorly treated frontal sinusitis before 1 month.
Which one of the followings is true regarding brain abscesses?
Q56:
A 34-year-old woman, presents with 3 days history of fever, headache, confusion and seizures. Brain MRI findings were suggestive of herpes simplex encephalitis. Which one is the correct statement regarding this type of viral encephalitis?
a. Bilateral temporal involvement is common.
b. About 50% of PCR-proven cases will have a normal brain MRI.
c. The virus can be cultured from the CSF in 75% of cases.
d. The negative predicative value of a negative CSF PCR assay for HSV DNA is only 2%.
e. Acyclovir should be started only after CSF PCR is done.
Q57:
A 63-year-old woman presents with rapidly progressive dementing illness and myoclonus.
Which one of the followings is not against the diagnosis of Cruetzfeldt-Jakob disease (CJD)?
Q58:
A 57-year-old man presents with 3-week history of confusion, headache, vomiting, and right sided weakness. He is a life long smoker, and recently had a chest X ray showing a large cavitating mass near the upper right hilar area.
Which one of the followings is true regarding treatment of raised intracranial pressure (ICP)?
An elderly vagrant man brought to the A/E department by the ambulance in a severe dehydrated state, and rehydration was started. The next day, he became quadriplegic.
Which one of the followings is true regarding central pontine myelinolysis (CPM)?
Q60:
A 59-year-old man presents with 1-hour history of aphasia and dense right sided weakness.
The presence of all of the followings should exclude him from receiving this mode of therapy, except?
Q61:
A 22-year-old college student brought by his friends to the A/E department with sudden onset of unsteady gait. He is grossly ataxic for stance and gait.
Which one of the followings is not a cause of acute cerebellar ataxia?
Q62:
A 15-year-old male presents with slowly progressive gait unsteadiness and abnormal speech. You detected pes cavus, scoliosis, cardiomyopathy, absent ankles, extensor planters, and nystagmus. Your provisional diagnosis is Friedreick's ataxia.
He has two relatives affected by this disease. Which one of the followings is not inherited as a cause of spinocerebellar ataxia?
Q63:
A 21-year-old woman presents with 2-day history of headache, fever, and mild confusion with neck stiffness. Her CSF revealed elevated opening pressure, lymphocytic pleocytosis, raised protein and normal sugar. Viral meningitis was diagnosed.
Which one of the following infectious viral agents is considered to be a common cause of this type of meningitis?
A 16-year-old boy presents with a 4-day history of fever, headache, and confusion. Further workup disclosed a diagnosis of viral encephalitis.
All of the following viral agents causing encephalitides have a good prognosis in general, except?
A 21-year-old man presents with repeated generalized tonic clonic fits without
regaining consciousness. He is a known cause of epilepsy, and is taking phenytoin, but he stopped taking his medication since 1 week because he was seizure free for seven months and he thought that phenytoin is no more needed, as his roommate said.
Which one of the followings is true regarding status epilepticus?
Q66:
A 34-year-old man presents with sudden onset of aphasia and right sided weakness.
Ischemic stroke in young people is an important subject in neurology. Which one of the followings is true regarding the investigations done to discover the cause of this topic?
A 24-year-old woman, who was completely healthy and reasonably well, presented with sudden severe headache and dense left sided weakness. An urgent non-contrast brain CT scan revealed a small hematoma at the right basal ganglia.
Which one is the wrong statement regarding her illness?
Q68:
A 34-year-old man presents with 3-week history of abnormal jerky movements involving his left hand only, which start and stop suddenly and spontaneously.
Which one of the followings is true regarding his illness?
Q69:
A 63-year-old man presented with an acute onset of right sided weakness and motor aphasia. He is hypertensive and diabetic.
Regarding antiplatelets and anticoagulation use in acute ischemic stroke, which one is the correct statement?
A 54-year-old woman presents with few weeks history of painful proximal muscle weakness. Her CK is markedly elevated, and EMG is of myopathic pattern. A provisional diagnosis of polymyositis is done.
Which one is the correct statement regarding this inflammatory myopahty?
Q71:
A 6-year-old boy presents with progressive gait unsteadiness and right hand clumsiness. His mother said that he frequently vomits in the morning. Brain MRI discloses a right sided cerebellar hemispheric mass. Which one is the correct statement regarding cerebellar tumors in children?
a. Infratentorial tumors tend to raise the intracranial pressure lately.
b. High grade malignant gliomas are the commonest type.
c. A cerebellar pilocytic astrocytoma has an excellent prognosis.
d. Neck stiffness indicates the occurrence of subarachnoid hemorrhage.
e. Brainstem compression never occurs
Continue To Answers.....
Q11:
A 21-year-old woman, who was reasonably well and healthy, presents with 4-month history of progressive unsteadiness in stance and gait. She denied any drug abuse or a back trauma, and there are no risk factors for HIV infection, and no family history of a similar condition. Examination revealed spastic paraparesis with loss of join position and vibration sense in the lower limbs and right-sided primary optic atrophy. No sensory level was detected. What is your next step?
a. Observation only.
b. Give high dose pulse intravenous methylprednisolone.
c. Give vitamin B12 injections.
d. Plain X ray of the lumbosacral spine.
e. Brain MRI with contrast.
Q12:
A 57-year-old woman with a history of mitral stenosis presents with sudden onset of right sided weakness and global aphasia.
Which one is the correct step?
Q13:
A 20-year-old woman presents with long standing history of mild lower limb weakness that is very slowly progressive since the age of 12 years, associated with some sensory numbness. She is not bothered by the weakness, but she is embarrassed by her legs' appearance. Her older sister has a same condition. Examination revealed bilateral pes cavus, hammertoes, and thin stork-like legs. The right common peroneal nerve was palpable. Her past medical history is unremarkable. She refused to be examined further.
What is the most likely diagnosis?
Q14:
A 60-year-old right-handed man has a history of embolic stroke, and he is aphasic. His speech is non-fluent, with impaired repetition and naming, but relatively intact comprehension. Where is the site of the lesion that is likely to be responsible for his aphasia?
a. Upper posterior temporal gyrus, left hemisphere.
b. Left frontal pole.
c. Left mesial temporal lobe.
d. Lower posterior inferior frontal gyrus, left hemisphere.
c. Right occipital pole.
Q15:
A 20-year-old man presents with generalized tonic clonic seizures. He is a know case of idiopathic grand mal epilepsy and he was put on valproic acid tablets since 2 years. All of the followings are well-know side effects of this medication, except:
a. Thrombocytopenia.
b. Pancreatitis.
c. Alopecia.
d. Tremor.
e. Weight loss.
Q16:
An 18-year-old female, was referred to you from the psychiatric department. She was initially diagnosed as having schizophrenia, but investigations revealed impaired liver function tests prior to starting her conventional antipsychotic, and further work up revealed Wilson's disease. An ophthalmologist detected Kayser-Fleischer ring in both eyes. What is the anatomical site of this "ring"?
Q17:
A 47-year-old man with long standing history of acromegally is seen by you in the clinic for a routine follow up visit. Some of his nerves were palpable. All of the following conditions can produce palpable nerves, except?
a. Primary AL Amyloidosis.
b. Charcot Marie Tooth disease type I (CMT I).
c. Rufsum's disease.
d. Guillain Barre syndrome (GBS).
e. Chronic inflammatory demyelinating polyradiculopathy (CIDP).
Q18:
A 7-year-old boy presents with poor school records for the past 2 months. He was cleaver and has no family problems. Examination was otherwise unremarkable. Further work up had revealed petit mal epilepsy. Which one of the following medication can cause worsening of his condition?
a. Valproic acid.
b. Ethosuximide.
c. Carbamazepine.
d. Lamotrigine.
e. Clonazepam.
Q19:
A 28-year-old female presents with an attack of weakness in her lower limbs. She has a history of short-lived numbness and severe blurred vision both of which improved spontaneously. Ultimately, she was diagnosed as having multiple sclerosis. Which one of the following conditions is against the diagnosis of multiple sclerosis?
a. Partial Brown-Squard syndrome.
b. Bilateral trigeminal neuralgia.
c. Rubral type tremor.
d. Dorsal column signs in one limb.
e. Swollen optic nerve heads with visual acuity of 6/6.
Q20:
A 37-year-old man presents with 2-day history of fever and confusion. His brother said that the patient does not have any illness and on no medications or illicit drugs. He has no risk factors for HIV infection, and no history of head trauma. Examination documented a temperature of 38.9 C, global confusion and neck stiffness. What is your immediate action apart from ABC (airway, breathing, circulation)?
a. Order a brain CT scan with contrast.
b. Order a Brain MRI without contrast.
c. Start intravenous Ceftriaxone and Vancomycin.
d. Send a blood sample for HIV testing.
e. Give nimodipine.
Q21:
A 17-year-old male presents with few days history of lower limb weakness in the absence of spinal trauma. There was a bout of diarrhea before 3 weeks. There is flaccid areflexic proximal and distal weakness with no objective sensory signs, and flexor planters. You put a preliminary diagnosis of Guillain Barre syndrome. Which one is the correct statement regarding this syndrome?
a. Dysautonomia is very rare.
b. Marked asymmetric signs are expected in the majority.
c. The mortality rate is around 40%.
d. A normal CSF protein level excludes the diagnosis.
e. Relapses are seen.
Q22:
A 28-year-old man brought by his family to consult you. They said that the patient sometimes stares suddenly with embarrassing picking at clothes movements with funny lip smacking. The patient did admit to feeling of a sudden rising sensation in the upper abdomen with nausea but he did remember the staring or these "embarrassing" movements. A coronal MRI of brain showed left sided mesial temporal lobe atrophy. Which one of the following statements is the correct one regarding his illness?
a. The patient should be referred to a psychiatrist.
b. Carbamazepine is useless.
c. The patient may be selected for anterior temporal lobectomy.
d. Hippocampal atrophy would be unusual in biopsy specimens.
e. EEG usually shows generalized spike and wave activity.
Q23:
A 51-year-old woman, with a cured early breast cancer since 10 years, presents with many months history of generalized headache and early morning vomiting. Examination revealed florid papillodema.
a. There is no association between breast cancer and meningiomas.
b. Underlying massive brain edema is seen in all cases.
c. Multiple meningiomas are seen in neurofibromatosis type 2.
d. The tumor regresses spontaneously in the majority of cases.
e. The spinal cord is the commonest site.
Q24:
A 63-year-old man, with type 2 diabetes and hypertension, presents with one-day history of sudden difficulty in swallowing, vertigo, and vomiting. A diagnosis of brainstem ischemic stroke was made. Which one of the following neurological signs is not an indicative of brainstem pathology?
a. Vertical nystagmus.
b. Aphasia.
c. Internuclear ophthalmoplegia.
d. Horizontal gaze palsy.
e. Onion skin pattern of loss of sensation in the face.
Q25:
A 25-year-old woman presents with few weeks history of generalized headache, vomiting, and blurred vision.
a. The idiopathic variety is the commonest type.
b. Absence of headache should cast a doubt on the diagnosis.
c. Primary optic atrophy is the most fearful complication.
d. Treatment with steroids should be avoided.
e. Optic nerve sheath fenestration protects the operated eye only.
Q26:
A 7-year-old boy with few weeks' history of lethargy and progressive pallor was found to have acute lymphoblastic leukemia L2-subtype. He is complaining of headache and double vision. Non-contrast brain CT scan was normal. Lumbar puncture under platelets infusion showed a CSF filled with blasts and raised protein. Which one of the following statements is true regarding CNS involvement in leukemia?
a. It does not affect he overall prognosis.
b. Neck stiffness is seen in the absence of pyogenic meningitis.
c. A single negative CSF sample excludes leukaemic meningitis.
d. Intrathecal methotrexate should be avoided.
e. The spine, but not the cranium, should be irradiated.
Q27:
A 67-year-old woman with a longstanding type 2 diabetes presents with transient speech defect and right sided weakness. A diagnosis of hemispheric TIA was done. All of the followings can be seen in anterior circulation strokes except?
a. Amaurosis fugax.
b. Motor Aphasia.
c. Transcortical sensory aphasia.
d. Nystagmus.
e Hemiplegia.
Q28:
A 56-year-old man patient is being evaluated after sustaining a stroke with a resultant aphasia. Which one of the followings can result from a dominant hemispheric lesion only?
a. Asteriognosis.
b. Urinary incontinence.
c. Hemiplegia
d. Transcortical motor aphasia.
e. Constructional apraxia.
Q29:
A 58 year old, with post-stroke epilepsy on carbamazepine tablets and is seizure free, presents with few days' history of unsteadiness and double vision following upper respiratory tract infection, which was treated successfully with clarithromycine.
Which one of the followings is responsible for his new presentation?
Q30:
A 22-year-old diabetic man since 10 years is being evaluated for autonomic neuropathy because of orthostasis symptoms and impotence. Autonomic neuropathy is not seen in?
a. Amyloidosis.
b. Alcoholism.
c. Guillain Barre syndrome.
d. Motor neuron disease.
e. HIV infection.
Q31:
A 48-year-old man, who was completely healthy, presents with a 3-week history of headache, fever, anorexia, and a double vision. Examination revealed confusion, fever, neck stiffness, and bilateral abducense palsy with florid papillodema.
His non-contrast brain CT scan showed hydrocephalus but no mass lesion. CSF analysis revealed an opening pressure of 30 cm H2O, cloudy fluid, lymphocytic pleocytosis with 90% lymphocytes, protein 400 mg/dl, and sugar 20 mg/dl (random blood sugar 110 mg/dl). His plain chest x ray showed evidence of old hilar calcifications. He has a family history of a certain chest disease with cough and wasting. Which one is the correct statement regarding his illness?
Q32:
A 67-year-old man presents with an 8 month history of speech difficulty and coughing upon swallowing. Examination revealed dysarthria, small conical tongue, exaggerated gag reflex and jaw jerk. Which one of the followings is not a potential cause of this condition?
a. Motor neuron disease.
b. Bilateral hemispheric lacunar strokes.
c. Myasthenia gravis.
d. Brainstem vasculitis.
e. High brainstem tumors.
Q33:
A 61-year-old man presents with progressive gait difficulty and abnormal speech. Examination revealed wide spread fasciculation and muscle wasting. A preliminary diagnosis of motor neuron disease was made. The presence of which one of the followings is not considered to be against the diagnosis?
a. Parkinsonian features.
b. Ocular palsies.
c. Urinary incontinence.
d. Upper and lower motor neuron signs in one limb.
e. Unilateral cerebellar signs.
Q34:
A 28-year-old woman with a relapsing remitting multiple sclerosis is being evaluated in your clinic. She has bilateral central scotomas, and fundoscopy revealed flat optic nerve heads of whitish color and clear margins. All of the following conditions can cause this optic nerve head picture, except?
a. Vitamin B12 deficiency.
b. Friedreick's ataxia.
c. Surpatentorial meningioma.
d. Tobacco-alcohol amblyopia.
e. Vasculitis.
Q35:
A 31-year-old woman has primary progressive multiple sclerosis since 2 years with no remission at all. Which one of the following features is against the diagnosis of multiple sclerosis?
a. Transverse myelitis.
b. Horner's syndrome.
c. Optic neuritis.
d. Aphasia.
e. Internuclear ophthalmoplegia.
Q36:
A 56-year-old man presents with 6 months history of generalized headache. He was completely healthy and reasonably well, on no medications or illicit drugs . He is a life long non-smoker and non-alcoholic, with no risk factors for HIV infection. His brain MRI is suggestive of a left sided frontal lobe oligodendroglioma.
Which one of the followings is not true regarding this primary brain tumor?
Q37:
A 61-year-old woman, who was reasonably well and enjoyed independent life, presents with 2-month history of depressed mood. Her son stated that his mother is not interested in anything, and she talks very little. She did respond to a trial of fluoxitine tablets prescribed by her general practitioner since 4 weeks. Her brain MRI is consistent with a large right sided frontal lobe glioblastoma multiforme.
Which one of the followings is true regarding this brain tumor?
Q38:
A 68-year-old woman brought by her daughters to consult you regarding the memory status of their mothers. They stated that their mother is becoming gradually forgetful and anxious, while the patient denies this during the interview. She scored 20 on mini mental status examination (MMSE). After an extensive work up, you diagnosed Alzheimer's disease, and you are thinking of giving donepezil to her.
Which one of the followings is true regarding this medication?
Q39:
A 62-year-old man, diagnosed as having idiopathic Parkinson's disease since 5 months, is not responding to Sinemet tablets. Further workup disclosed a diagnosis of normal pressure hydrocephalus (NPH).
Which one of the followings is true regarding this type of hydrocephalus?
Q40:
A 21-year-old man is extremely anxious. He stated that his father died at the age of 45 years because of Huntington's disease (HD), and he is afraid that he might be silently affected. Which one of the followings is true regarding this fatal neurological illness?
a. It is an autosomal recessive disease.
b. There is GGG tri-nucleotide repeat expansion in HD gene.
c. Should be differentiated from benign familial chorea.
d. Seizures are frequent in adult cases.
e. Parkinsonian features are very common in late onset cases.
Preface:
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Dr. Osama Amin
Head of Team Neurology4MRCP
April 2006
All Questions and answers were written by Dr. Osama Amin
Copyright2006. All rights reserved.
http://neurology4mrcp.orgfree.com
Q1:
A 23-year-old housewife presents with 2 day history of numbness and weakness in her left arm to be followed by numbness in her right leg after 1 day. Her past medical history is unremarkable, with no history of spinal trauma or medication abuse.
Examination revealed loss pinprick sensation in her right leg up to the lateral aspect of her right arm and loss of position sense in the left lower and upper limbs, with left sided up-going planter. She reported some spontaneous improvement after 5 days.
All of the following statements are wrong, except:
Q2:
A 67-year-old man presents with one-day history of a sudden onset of difficulty in swallowing and vertigo. Examination revealed impaired gag reflex and sensation in the right pharynx, coarse horizontal nystagmus, and dysarthria. His past medical history is unremarkable. A diagnosis of ischemic brainstem stroke was done. Which one is the correct statement?
a. He dose not need aspirin.
b. Carotid Doppler study should be omitted.
c. Asymptomatic hyperglycemia will not change the management plan.
d. Severe cervical spondylosis can be a risk factor for his stroke.
e. He should receive Thrombolytic therapy.
Q3:
A 62-year-old woman presents with a few hours history of headache and confusion. Her non-contrast brain CT scan showed right basal ganglia hematoma. At day 4, she developed generalized tonic clonic fit. All of the followings are true, except:
a. She needs another brain CT scan.
b. Assessing her serum sodium level is worthy.
c. He fits are likely to represent pseudo-seizures
d. The blood pressure should be monitored.
e. Careful assessment of her fluid status should not be forgotten.Q4:
A 51-year-old woman who was diagnosed as having a right sided frontal lobe meningioma recently, came with a 1-day history of irregular jerky movements of her right arm that is at the side of the tumor. The description is consistent with a focal motor seizure. You reviewed her brain CT scan to be sure of the site of the tumor. How can you explain the site of the seizures?
a. She is lying.
b. The CT scan does not belong to her.
c. There is another left sided cortical tumor that is not seen by the brain CT scan.
d. You are reading the CT scan film in a reversal manner.
e. She might have an uncrossed pyramidal system of fibers.
Q5:A 21-year-old man presents with a 2-day history of impaired consciousness. His mother said that he has recently been diagnosed as having a psychiatric illness and is receiving certain tablets for it. Examination revealed high fever, generalized rigidity, fluctuating blood pressure and pulse rates. What is the likely psychiatric illness?
a. Severe endogenous depression.
b. Panic attacks.
c. Schizophrenia.
d. Hypomania.
e. He has no psychiatric illness at all.
Q6:A 14-year-old girl is being evaluated for an abnormal gait. The final diagnosis was Friedreick's ataxia. However, you noticed something that is against her diagnosis, what is it?
a. Marked cognitive impairment.
b. Hyperglycemia.
c. Retinitis pigmentosa.
d. Scoliosis.
e. Negative family history.
Q7:A 51-year-old woman came with rapid and progressive impairment in her vision affecting her left eye only over a matter of few days. Apart from red swollen left optic disc with severely reduced visual acuity to finger counting and Marcus-Gunn pupil, her examination is totally unremarkable. Few days later while she is in the way of investigations, she said that her vision is better now. Which one is the correct statement?
a. Brain MRI with contrast is not indicated.
b. Auto antibody screen is useless.
c. Her ESR would give no clues.
d. The findings are consistent with Foster Kennedy syndrome.
e. Gradual and excellent improvement is against giant cell arteritis.
A 32-year-old man presents with a 2-year history of left sided headache and ocular pain. The pain seems to occur in severe bouts for about two hours, with eye redness and nasal watering, day and night, with no remission, somewhat responsive to phenacetin. He is non-smoker and non-alcoholic, on no medications or illicit drugs. Examination revealed only gynecomastia and soft testes.Which one is the correct statement?
a. He has migraine without aura.
b. This is malingering.
c. Brain MRI or CT scan should be done.
d. Increasing the dose of phenacetin is helpful.
e. Reassure and discharge him.
A 5-year-old girl is being treated by chemotherapy for acute lymphoblastic leukemia, and she is in the 4th week of remission induction phase, developed partial left sided ptosis with diplopia, generalized headache, and progressive massive weight gain in spite of loss of apatite. All of the followings are wrong, except?
a. Her weight gain is likely to be due to hypothalamic infiltration.
b. CSF examination is contraindicated.
c. Vincristine toxicity is the cause of ptosis.
d. Prednisolone is the cause of her obesity.
e. Cranial irradiation is of no benefit.
Q10:
A 40-year-old man was admitted because of progressive somnolence over few days. He has a history of extensive chronic plaque psoriasis for which he is receiving cyclosporine. Examination revealed fever, neck stiffness and obtundation. Which one is the correct statement regarding his new presentation?
a. We should increase the dose of cyclosporine.
b. CSF examination is unnecessary.
c. Start intravenous cefotaxime and vancomycine.
d. Add azathioprine.
e. Blood cultures should be avoided.
The following MCQs are related to certain basics in neurology. Please read them carefully and review your answers.
Answers:
Q1: Answer: F, F, T, T, F
It is (together with olfactory nerve) located supratentorially. Its lesion can cause varieties of scotomas and unilateral blindness. Leber's optic neuropathy is a form of mitochondrial cytopathy.
Q2: Answer: F, T, F, T, F
It originates from the upper midbrain. A compressive lesion produces pupillary dilatation as the first sign (so-called surgical 3rd nerve palsy); the medical 3rd nerve palsy is pupillary sparing (like the classical diabetic 3rd acute nerve palsy. It supplies the constrictor pupillae and ciliary body with parasympathetic fibers.
Q3: Answer: T, T, F, T, F.
It supplies the superior oblique, horizontal diplopia is seen in 6th nerve palsy.
Q4: Answer: T, T, F, T, F
It is the afferent loop of the corneal reflex. It does not carry parasympathetic fibers to any structure.
Q5: Answer: T, F, F, F, T
It exits from the ponto-medullary junction. It lesion causes horizontal diplopia. It enters the orbit through the superior orbital fissure.
Q6: Answer: T, T, F, F, F
It is attached the lateral portion of the pontomedullary junction (the 5th cranial nerve is attached to the ventral mid portion of the pons), it is a mixed nerve (motor, sensory, and autonomic), and Ramsay Hunt syndrome produces complete palsy of a lower motor neuron type (the upper face is spared in upper motor neuron lesions).
Q7: Answer: T, T, T, F, F
The resulted nystagmus is away from the side of the lesion. It leaves the posterior fossa through the internal auditory meatus and canal.
Q8: Answer: T, T, F, T, F
It carries taste and general somatic sensations from the posterior 1/3rd of the tongue.
Q9: Answer: T, T, T, F, F
The platysma is supplied by the facial nerve, and never involved in motor neuron disease.
Q10: Answer: F, F, F, F, T
The spinal root enters the skull through the foramen magnum afte arising from the 1st 5 cervical cord segements; its lesions cause weakness of ipsilateral trapezius and sternomastoid (has nothing to do with neck extension). It's, rarely if ever, ivloved in upper motor neuron lesion above the medulla.
Q11: Answer: T, F, F, T, T
It causes deviation of the tongue towards the paralyzed side (pushed by the normal side) when damaged, and it arises from the lower medulla.
Q12: Answer: T, T, F, T, T
It is usually examined properly when the clinical picture is suggestive. eg a frontal lobe meningioma beneath the frontal lobe.
Q13: Answer: T, T, T, F, F
It is supplied by the anterior circulation (ie carotid system), a frontal sinus abscess can extend to the frontal lobe. A mastoid abscess usually produces cerebellar or temporal lobe abscesses.
Q14: Answer: T, T, F, F, T
The middle cerebral artery supplies its lateral surface, and positive palmo-mental reflex (a frontal release sign) indicates a frontal lobe lesion.
Q15: Answer: T, T, T, F, F
The hippocampus and amgdala lie in the temporal lobe (both are parts of the limbic system).
Q16: Answer: T, T, T, T, T
Notice that vertigo can be a cortical sign (but very a rare one), and the uncus is responsible for compressing the midbrain and 3rd cranial nerve when it herniates through the tentorial hiatus.
Q17: Answer: F, F, F, F, F
It lies in the middle crania fossa, and its medial surface is supplied by the posterior cerebral artery, and the optic radiation loops back around the tip of the temporal lobe, and can be resected as a mode of treatment of medically refractory complex partial seizures of hippocampal sclerosis. Petit mal epilepsy is a primary generalized epilepsy (not a focal one).
Q18: Answer: F, F, T, T, F
The primary sensory cortex lies in the parietal lobe; formed visual hallucinations indicate a temporal lobe lesion; Dressing and constructional apraxias indicate a non-dominant parietal lobe lesion.
Q19: Answer: T, T, T, F, T
Notice that the limbic lobe is synthetic lobe, not a true lobe, composed of gray matter structures at the medial and basal parts of the hemispheres that form a limbus (border) around the midbrain.
Q20: Answer: T, T, T, T, T
Notice that the limbic system is "the limbic lobe and all cortical and subcortical structures related to it". Besides the mentioned structures, the thalamus (particularly the anterior thalamus) and the brainstem reticular formation are parts of the limbic system.
Q21: Answer: T, T, F, F, F
It plays an important role in: Memory, emotional behavior, sexual behavior, motivation, and integration of homeostatic responses like those related to preservation of species, securing food, fight and flights responses…etc.
Q22: Answer: F, T, F, T, T
It is formed by the choroid plexus, and in cases of choroid plexus papilloma the CSF is formed at a higher rate causing hydrocephalus. The concentration of sodium, chloride, and magnesium ions in the CSF is higher that that of plasma, where its concentration of potassium and calcium ions is lower than that of plasma.
Q23: Answer: T, F, F, T, F
It is also absorbed through perineural spaces.
Q24: Answer: F, T, F, T, T
Cisterna magna (cisterna cerebellomedullaris) is the largest of all cisterns and lies between the medulla oblongata, cerebellum, and occipital bone. Cisterna interpeduncularis lies between the cerebral peduncles of the midbrain. Knowing the exact manes and locations of these cisterns is important in MRI.
Q25: Answer: T, T, F, F, F
The followings occur in the REM sleep (desynchronization sleep, dreaming sleep, and paradoxical sleep):
1- Marked hypotonia.
2- An increase in blood pressure and heart rate with irregular respirations ( all are decreased in non-REM sleep with regular respirations).
3- Erection in males.
4- Teeth grinding.
5- Dreaming (hence the name dreaming sleep).
6- Rapid eye movements (50-60 movements per minutes, hence the name rapid eye movement sleep or REM sleep).
7- Rapid low voltage irregular EEG activity resembling the waking pattern (so-called desynchronization pattern).
8- Increased threshold of arousal, hence the deep sleep.
Q26: Answer: T, T, F, F, F
In non-REM (also synchronized, light, or slow wave) sleep, we see the followings:
1- Hypotonia.
2. A decrease in heart rate, blood pressure, and respiratory rate which regular.
3- A slow EEG activity of high voltage, hence the name slow-wave sleep.
Q27: Answer: T, F, T, F, F
The hippocampus is supplied by the posterior cerebral artery. The spinal cord is also supplied by many local "radicular arteries" at different segments. The micturition center in the mesial frontal lobe is supplied anterior cerebral artery.
Q28: Answer: F, F, F, F, T
The pyramidal system has contribution from the prefrontal motor cortex including area 6 and 8, and also some contribution from the post central gyrus (area 3, 1, 2). It decussates in the lower medulla and occupies the lateral compartment of the cord. Chorea is caused by basal ganglia lesions.
Q29: Answer: F, F, F, T, T
Notice that complete paralysis is not consistent with pyramidal lesions; instead they cause paresis of the muscles not paralysis. Although cord lesions can cause painful flexor or extensor spasms, dysthesic pain indicates sensory system dysfunction. Ill sustained clonus could be a normal finding, especially in anxious people; a pathological clonus (more that 3 sustained beats) is consistent with pyramidal lesions. Clasp knife, not lead pipe rigidity, is an upper motor neuron sign.
Q30: Answer: F, T, T, T, T
Notice that cerebellar lesions cause incoordination of motor movements, not a severe weakness, with pendular knee jerk. Eye signs in cerebellar diseases are almost always overlooked in clinical practice; these are apart from nystagmus: defective saccadic eye movements, impaired pursuit eye movements, transient gaze paresis, inability to maintain an eccentric gaze, failure to suppress the optokinetic nystagmus upon fixation, moderate increase in vestibule-ocular reflexes.
Q31: Answer: T, F, F, F, F
The anterior and lateral spinothalmics occupy the anterior and lateral columns, and convey crude touch, pressure, pain and thermal sensations. They are characteristically spared in vitamin B12 deficiency, and unilateral cord lesions produce contralateral signs, 2-3 segments below the level of the lesion.
Q32: Answer: F, T, T, T, F
It extends from the foramen magnum to the level of lower border of L2 vertebra in adults. It has 2 normal enlargements; the lower cervical and lumbosacral enlargements corresponding to the brachial and lumbosacral plexuses. The upper cervical segments give rise to spinal accessory nerve, which is the only cranial nerve that has a cord contribution.
Q33: Answer: F, T, T, F, T
Lambert Eaton syndrome (like botulism) attacks the nerve terminal (presynaptic) side; while myasthenia gravis attacks the muscle (postsynaptic) side. Acetylcholine is the neurotransmitter which acts on acetylcholine receptors on the postsynaptic side.
Q34: Answer: F, F, T, T, T
Our muscles have 2 types of fibers:
1- Type I: slowly contracting, red, fatigue resistant, rich in oxidative enzymes (and myoglobin, mitochondria, lipids, and local capillary density) but has low phosphorylase and glycogen contents. It has an oxidative metabolism. The erector spinae is an example.
2- Type IIa: Very rare human.
3- Type IIb: Fast twitching and fatigable, white, rich in phosphorylase and glycogen and it has a glycolytic metabolism.
Q35: Answer: F, T, T, T, F
It is preferred to be taken from a muscle that is clinically affected but not severely as we may see only atrophy or fibrosis; however, we can choose other subclinically muscles because the affected muscles might be severely weakened by that disease under investigation. It is generally useless in motor end plate diseases to be examined by light microscope (EM is useful here).
Q36: Answer: T, T, T, T, T
Notice that these "pictures" are commonly seen in the MRCP examination and you should know them.
Q37: Answer: T, T, F, F, F
Notice that the biopsy findings in most neuromuscular diseases are not that pathognomonic or diagnostic. Lymphorrhages are localized collection of lymphocyte (similar to that of Hashimoto's thyroiditis). Fiber type grouping is seen in neurogenic atrophy with re-innervation. Muscle fiber regeneration is against myasthenia gravis, and indicates an ongoing process of fiber necrosis and regeneration due to for example polymyositis. Extensive eosinophilic infiltration is seen in eosinophilic myositis.
Q38: Answer: T, T, F, F, F
Normal brain waves and rhtytms:
1-Alpha rhythm: between 8-13 cps, mainly seen at the posterior hemispheres.
2- Beat rhythm: between 14-30 cps, seen over wide areas of the hemispheres, and accentuated in those taking sedatives.
3- Theta rhythm: between 4-7 cps, normally seen at the temporal lobes mainly in old people.
4- Delta rhythm: between 0.5-3 cps, normally seen in the non-REM sleep. The presence of a focal slowing in a fully alert person always indicates a local lesion like a tumor, and diffuse slowing is usually seen in encephalopathies.
Q39: Answer: T, T, F, F, F
Locus cerulus is found in the lower midbrain; nucleus fastigius is one of the deep cerebellar nuclei; the amygdala is located in the medial temporal lobe.
Q40: Answer: T, F, T, F, F
Hemiballismus is seen in lesions of the nucleus subthalamicus; anomia is a cortical sign.
Q41: Answer: T, T, T, T, T
Notice that the microglial cells proliferate in CNS diseases; the choroidal epithelial cells secrete the CSF; astrocytes provide a supporting framework.
Q42: Answer: T, T, F, T, F
Tanycytes line the floor of the 3rd ventricle; choroidal epithelial cells cover the surface of the choroid plexuses. Notice that the fibrous astrocytes are found in the white matter.
Q43: Answer: T, T, F, F, T
Merkel's disc is related to touch sensation; skin temperature sensation is mediated by free nerve endings; Meissner's corpuscles is related to touch sensation; muscle tension
is mediated neuron-tendinous spindles.
Q44: Answer: T, T, F, T, F
Both 4-aminopyridine and Guanidine hydrochloride increases the release of acetylcholine at the motor end plate, hence their use in Lambert Eaton syndrome.
Q45: Answer: T, T, T, T, T
Also; the substantia nigra, superior colliculi, and the 4th cranial nerve.
Q46: Answer: T, T, F, F, T
The uncus is in the medial temporal lobe; the mammillary bodies are part of the hypothalamus.
Q47: Answer: T, T, F, T, F
Mesencephalic nucleus of trigeminal nerve is found in the midbrain.
Q48: Answer: F, F, F, F, F
The optic nerve passes through the optic foramen and canal. The hypoglossal nerve passes through the hypoglossal foramen. The Abducens passes through the superior orbital fissure. The oculomotor nerve passes through the superior orbital fissure. The trigeminal nerve main trunk does not pass through any foramen.
Q49: Answer: T, F, T, F, F
Wernicke's aphasia is due to lesion in the upper lateral temporal lobe. Conductive aphasia is due to lesion in the in the arcuate fasciculus in the insula. Anomic aphasia is a cortical sign.
Q50: Answer: T, T, T, T, T
Thalamic aphasia has an excellent prognosis; cortical dysarthria is rare and has a better prognosis also. Lacunar strokes are not associated with seizures, impaired consciousness, hemianopia, or aphasia.
End..
The following MCQs are related to certain basics in neurology. Please read them carefully and review your answers.
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Q1: Optic nerve:
a. Is located in the posterior fossa.
b. Optic neuritis causes bitemporal hemianopia.
c. Optic nerve sheath meningioma can produce proptosis of the globe.
d. Originates from the ganglion cells in the retina.
e. Leber's optic neuropathy is a form of tobacco-alcohol amblyopia.
Q2: Oculomotor nerve:
a. Originates from the upper part of pons.
b. Has many subnuclei.
c. Pupillary sparing palsy indicates a compressive lesion.
d. Can be a false localizing sign in herniation syndromes.
e. Responsible for innervating the dilator pupillae.
Q3: Trochlear nerve:
a. Originates from the midbrain.
b. The only cranial nerve that exits from the dorsal surface of the brainstem.
c. Its lesion results in paralysis of the inferior oblique muscle.
d. It supplies only 1 orbital muscle.
e. Its palsy causes horizontal diplopia.
Q4: The trigeminal nerve:
a. It is the largest cranial nerve.
b. It has 2 roots.
c. Carries parasympathetic fibers to the sublingual glands.
d. Its lesion can cause deviation of the jaw.
e. Carries the efferent elements of the corneal reflex.
Q5: The abducens nerve:
a. Can be damaged in pseudotumor cerebri.
b. It exits from the ponto-mesencephalic junction.
c. Its lesion causes vertical diplopia.
d. Enters the orbit through the inferior oblique fissure.
e. Its lesion is a part of Millard Gubler syndrome.
Q6: The facial nerve:
a. Has a long loop inside the pons.
b. Has 2 roots.
c. Attached to the ventral mid-portion of the pons.
d. A pure motor cranial nerve.
e. In Ramsay Hunt syndrome, the upper face is spared.
Q7: The vestibule-cochlear nerve:
a. Is a pure sensory nerve.
b. Its lesions can cause tinnitus.
c. Severe vertigo is seen peripheral nerve lesions.
d. The resulted nystagmus is towards the side of the lesion.
e. It leaves the posterior fossa through the foramen ovale.
Q8: The Glossopharyngeal nerve:
a. Supplies the stylopharyngeus muscle.
b. Mediates the carotid sinus reflex.
c. Carries taste sensation from the posterior 2/3rds of the tongue.
d. Exists the skull through the jugular foramen.
e. Carries general somatic sensation from the anterior 2/3rds of the tongue.
Q9: The vagus nerve:
a. Is the longest cranial nerve.
b. Can be damaged by lesions inside the chest.
c. Its nuclei are involved in lateral medullary syndrome.
d. It supplies motor innervation to platysma muscle.
e. Is damaged early in motor neuron disease.
Q10: The accessory nerve:
a. The spinal root enters the skull through the hypoglossal canal.
b. The spinal root arises for the 1st 2 cervical segments of the cord.
c. Its lesions produce weakness of neck extension.
d. commonly involved in hemispheric strokes.
e. The cranial root supplies the laryngeal muscles.
Q11: The hypoglossal nerve:
a. A pure motor nerve.
b. Its lesions cause deviation of the tongue towards the normal side.
c. Arises from the upper cervical cord.
d. Its nuclei can be involved in motor neuron disease.
e. Is involved in medial medullary syndrome.
Q12: The olfactory nerve:
a. Its sensory nuclei are in the anterior cranial fossa.
b. Can be damaged by tobacco smoke.
c. Commonly properly examined in neurology.
d. It is underneath the frontal lobe.
e. Has connections with the limbic system.
Q13: The Frontal lobe:
a. Has the Broca's area.
b. Disinhibition can be seen in its lesions.
c. The micturition center id found in the medial surface.
d. Supplied by the vertebral artery.
e. A frontal lobe abscess can be a direct complication of a mastoid sinus sepsis.
Q14: The frontal lobe:
a. A focal motor seizure arises from it.
b. Can be damaged by superior sagittal sinus thrombosis.
c. The middle cerebral artery supplies its medial surface.
d. A positive palmo-mental reflex excludes a frontal lobe lesion.
e. Bilateral lesions can cause paraplegia.
Q15: The frontal lobe:
a. Depression can be a presenting feature of its lesions.
b. A large frontal lobe tumor can cause contralateral disc swelling.
c. Is atrophied in Pick's dementia.
d. Has the hippocampus.
e. The amygdala lies in its anterior inferior surface.
Q16: The temporal lobe:
a. Has the secondary auditory association area.
b. Its damage can cause Wernike's aphasia.
c. The uncus herniates in temporal lobe abscess.
d. An episodic isolated vertigo may indicate a temporal lobe seizure.
e. Is atrophied in Pick's dementia.
Q17: The temporal lobe:
a. Lies in the anterior cranial fossa.
b. Its medial surface is supplied by the middle cerebral artery.
c. The optic radiation does not pass through it.
d. Its anterior part can be resected in primary generalized epilepsies.
e. Responsible for petit mal epilepsy generation.
Q18: The parietal lobe:
a. Has a motor cortical strip.
b. Its lesions can cause formed visual hallucinations.
c. The middle cerebral artery supplies its lateral surface.
d. Loss of 2 point discrimination can be a parietal cortical sign.
e. Gait apraxia indicates a parietal lobe dysfunction.
Q19: The followings are parts of the limbic lobe:
a. Subcallosal gyrus.
b. Cingulate gyrus.
c. Parahippocampal gyrus.
d. Upper segments of the cervical cord.
e. Uncus.
Q20: The followings are parts of the limbic system:
a. Septal nuclei.
b. Amygdala.
c. Hippocampal formation.
d. Epithalamus.
e. Hypothalamus.
Q21: The limbic system plays important roles in:
a. Motivation.
b. Sexual behavior.
c. Vision.
d. Hearing.
e. Motor coordination.
Q22: The cerebrospinal fluid:
a. Is formed by the arachnoid granulations.
b. Its volume ranges from 90-150 ml.
c. Choroid plexus papilloma causes low CSF formation.
d. Its sodium concentration is higher than that of plasma.
e. Has a specific gravity of 1.006-0.009
Q23: The CSF is absorbed by the followings:
a. Arachnoid granulations.
b. Choroid plexus.
c. Thalamus.
d. Ependyma.
e. Middle meningeal arteries.
Q24: Subarachnoid cisters:
a. Cisterna magna surrounds the midbrain.
b. Cisterna pontis lies between the pons and cvlivus.
c. Cisterna interpeduncularis lies between the pyramids of the medulla oblongata.
d. The suprasellar cistern is dorsal to the sella turcica.
e. Cisterna ambiens is dorsal and lateral to the mesencephalon.
Q25: The followings are seen in REM-sleep:
a. Erection is males.
b. Teeth grinding.
c. Regular slow respiration.
d. A decline in blood pressure.
e. Increased muscle tone.
Q26: The followings are seen in non-REM sleep:
a. Reduced muscle tone.
b. A decrease in blood pressure.
c. An increase in the heart rate.
d. An increase in the respiratory rate.
e. The presence of low voltage rapid EEG complexes.
Q27: The cerebral circulation:
a. The mid brain is partly supplied by the posterior cerebral artery.
b. The hippocampus is supplied by the anterior cerebral artery.
c. The basilar artery supplies the pons.
d. Spinal cord is supplied by anterior and posterior spinal arteries only.
e. The micturition center in the frontal lobe is supplied by the middle cerebral artery.
Q28: The pyramidal tract:
a. Arises only from the prefrontal cortex.
b. Decussates in the lower pons.
c. It lesion can cause chorea.
d. Lies in the posterior column of the spinal cord.
e. It is concerned with motor control.
Q29: Upper motor neuron signs are:
a. Complete paralysis of involved muscles.
b. Dysthesic pain.
c.
d. Positive finger flexion jerk.
e. Lead pipe rigidity.
Q30: Cerebellar lesions can cause:
a. Severe motor weakness.
b. Positive rebound phenomenon.
c. Defective saccadic eye movements.
d. Impaired pursuit eye movements.
e. Transient gaze paresis.
Q31: The spinothalamic tracts:
a. Are sensory long tracts.
b. Occupy the dorsal columns.
c. Convey Join position and vibration sensations.
d. Unilateral cord lesions produce loss of associated sensations ipsilaterally.
e. Severely involved in vitamin B12 Deficiency.
Q32: The spinal cord:
a. Occupies the whole vertebral canal.
b. It has 2 areas of enlargement.
c. The dorsal cord lesions can cause paraplegia.
d. The subpial areas are particularly involved in multiple sclerosis.
e. The upper cervical segments have a contribution to many cranial nerves.
Q33: The motor end plate:
a. Glutamate is the neurotransmitter.
b. Botulism attacks the nerve terminal side.
c. Lambert Eaton syndrome attacks the muscle side.
d. Acetylcholine receptors are functionless.
e. Wider and simplified in myasthenia gravis.
Q34: Muscle fibers:
a. Fast twitching fibers are highly rich in glycogen.
b. The erector spinae muscle is an example of fast twitching muscle.
c. Myoglobin content is low in white fibers.
d. The red fibers are fatigue resistant.
e. Steroid myopathy attacks type II fibers.
Q35: When choosing a muscle for muscle biopsy for light microscopic examination:
a. The muscle should always be affected.
b. The deltoid, vastus medialis and calf muscles are preferred.
c. Should have a power of at least grade 3.
d. Should not be taken from a muscle recently injected by a medication.
e. Very useful in motor end plate diseases.
Q36: Muscle biopsy results:
a. Ragged red fibers are seen in mitochondrial cytopathy.
b. Ragged red fibers are seen in HIV patients on zidovudin.
c. Perifascicular atrophy is characteristically seen in dermatomyositis.
d. Rimmed vacuoles with myeloid bodies are seen in inclusion body myositis.
e. Fiber type grouping is seen in neurogenic muscular atrophy.
Q37: Muscle biopsy findings in myasthenia gravis:
a. The presence of lymphorrhages.
b. Simplification of the postsynaptic membrane.
c. Fiber type grouping.
d. Muscle fiber regeneration with fasciitis.
e. Extensive eosinophilic infiltration.
Q38: EEG waves and rhythms:
a. Alpha rhythm is normally seen mainly posteriorly.
b. The delta rhythm has a frequency of 0.5-3 cps.
c. Theta preponderance rhythms are seen in normal children.
d. Slow waves are normally seen in a wakeful adult.
e. The Beta rhythm is inhibited by sedatives.
Q39: The medulla oblongata contains the following nuclei:
a. Nucleus ambiguus.
b. Dorsal motor nucleus of vagus nerve.
c. Locus cerulus.
d. Nucleus fastigius.
e. Amygdala.
Q40: Localization in neurology:
a. Chorea is caused by lesions in the caudate nuclei.
b. Hemiballismus is seen in hypothalamic lesions.
c. Myoclonus has no specific localization.
d. Tremor is caused by over activity of the pontine nuclei.
e. Anomia is seen in lesions involving the upper midbrain.
Q41: The neuroglial cells:
a. Protoplasmic astrocytes have a phagocytic function.
b. Microglia is inactive in normal CNS.
c. Ependymocytes can absorb the CSF.
d. Oligodendrocytes from myelin in the CNS.
e. Fibrous astrocytes are electrical insulators.
Q42: Location of the various glial cells:
a. Protoplasmic astrocytes in the gray matter.
b. Ependymocytes line the central canal of the spinal cord.
c. Tanycytes in the gray matter.
d. Microglial cells are scattered through out the CNS.
e. Choroidal epithelial cells in white matter of the spinal cord.
Q43: Type of receptor and its corresponding sensory modality:
a. Pacinian corpuscles and vibration sensation.
b. Ruffini's corpuscles and skin stretching.
c. Merkel's disc and skin temperature sensation.
d. Meissner's corpuscles and muscle tension.
e. Free nerve endings and pain sensation.
Q44: Chemical compounds acting on the motor end plate:
a. Botulinum toxin reduces the release of acetylcholine.
b. d-tubocurarine blocks the acetylcholine receptors.
c. 4-aminopyridine reduces acetylcholine release.
d. Succinylcholine produces depolarization block.
e. Guanidine hydrochloride reduces acetylcholine release.
Q45: The followings are found in midbrain:
a. Oculomotor nerve.
b. Red nuclei.
c. Locus cerulus.
d. Cerebral peduncles.
e. Inferior colliculi.
Q46: The followings are found in the pons:
a. The vestibular nuclei.
b. Trapezoid body.
c. Mammillary bodies.
d. Uncus.
e. Facial nerve fasciculus.
Q47: The followings are found in the medulla oblongata:
a. Inferior olivary nuclear complex.
b. Cerebral peduncles.
c. Pineal body
d. Hypoglossal nucleus.
e. Mesencephalic nucleus of trigeminal nerve:
Q48: Foramena of the skull:
a. The optic nerve passes through the superior orbital fissure.
b. The hypoglossal nerve passes through the jugular foramen.
c. The Abducens passes through the foramen rotundum.
d. The oculomotor nerve passes through the inferior orbital fissure.
e. The trigeminal nerve main trunk passes through foramen ovale.
Q49: Aphasias:
a. Broca's aphasia is due to lesion in the frontal lobe.
b. Wernicke's aphasia is due to lesion in the upper parietal lobe.
c. Trans-cortical motor aphasia is due to lesion in the upper lateral frontal lobe.
d. Conductive aphasia is due to lesion in the medial temporal lobe.
e. Anomic aphasia could be lesion in pons.
Q50: Localization in clinical neurology:
a. Aphasia could be due to thalamic lesion.
b. Dysarthria could be due to cortical lesion.
c. Hemianopia is a supratentorial sign.
d. Lacunar strokes are not associated with impaired consciousness.
e. Barber chair sign indicates a local cervical cord lesion.
Again, a conversion reaction !!!
A 19 year old newly married female referred to us as a case of resistant "hysterical" lower limb weakness. She was completely healthy, reasonably well, self caring, and on no medications or drugs, no such a family condition, no risk factors for HIV, and no history of back trauma ,until 3 months ago when she started to drag her both feet while walking, which was attributed to "simple tiredness" at time. Her husband noticed that her gait became progressively difficult and she looked on to the ground while walking. No complaints regarding back pain, sphincters or sensations.
Her initial examination records documented an anxious young woman, poorly cooperative with the examiner; however, there was bilateral foot drop with absent ankles, equivocal planters, and ?stocking loss of all sensory modalities.
A battery of investigations was carried out including lab tests and EMG. The EMG and nerve conduction studies report was: " completely normal apart from poor recruitment, which could be to upper motor neuron lesion, or hysterical".
Because she was anxious and uncooperative with examiner, together with the neurophysiology report, a diagnosis of a hysterical weakness was made and she was managed as such. Her condition unfortunately progressed to a degree of a total chair bound state.
When we examined her, there was severe atrophy of the lower limbs muscles but no fasciculations, grade 1 distal and grade 3 proximal asymmetric weaknesses, absent knees and ankles, equivocal planters, and stocking loss of all sensory modalities. With assistance to stand and walk, she showed a severe bilateral foot drop; Rombergism was positive.No sensory level at the trunk, and the upper limbs and cranials were normal.
MRI of the lumbosacral area with contrast revealed a large irregular shaped mass inside the vertebral canal, with heterogenous enhancement. She was referred to neurosurgery; the neurosurgeon said that upon exploration, the mass was large, hard, and diffusely infiltrative causing bone destruction and cauda equina involvement; it was debulked only. Biopsy revealed a well differentiated adenocarcinoma of unknown primary site.
We reviewed her general examination records and we repeated the clinical medical examination fully ; they were totally negative. Thorough investigations revealed a very small right-sided deep seated non-palpable breast cancer focus (with negative axillae) in the upper lateral quadrant.
Discussion:
Metastatic tumor-related syndromes are well known to be one of the modes of presentation of a primary cancer. Her breast primary focus was asymptomatic and clinically silent and supple, and the presentation was totally neurological in nature.
This case highlights a common problem in the primary care settings; the over-diagnosis of hysterical conversion reactions. Please notice that a conversion reaction is a diagnosis of exclusion, and in the presence of SOLID signs indicating a RED flag, you should always be careful in the evaluation. Her past history indicates that she was healthy; bilateral foot drop is rarely (if ever) hysterical; and the pace of illness indicates that there is something there, grave and progressing, which definitely prompts a full search for a hidden pathology.
She is now seen by an oncologist and is receiving chemotherapy and radiotherapy for a stage IV estrogen receptor negative breast adenocarcinoma.
Questions related to article No. 12:
a. The clinical findings are usually symmetrical.
b. Sacral anaesthesia is against the diagnosis.
c. Absent ankle reflex indicates a co-existent upper motor lesion.
d. Urinary retention is seen.
e. Back pain is always present.
a. Absent right ankle jerk and left anterior thigh anesthesia are against the diagnosis.
b. Sensory symptoms should be mild or absent.
c. Constipation is suggestive of co-existent pathology.
d. Diarrhea is very common.
e. Sensory araxia is seen.
1) All of the following investigations are of use, except:
a. Complete blood count.
b. Lymph node biopsy.
c. EMG.
d. Brain MRI with contrast.
e. Lumbosacral MRI with contrast.
2) What is the overall diagnosis?
a. Polymyositis and reactive lymphadenopathy.
b. Lumbosacral roots involvement by lymphoma.
c. Systemic lupus erythematosus and cerebral venous sinus thrombosis.
d. Hemispheric glioblastoma multiforme and meningeal drop metastases.
e. Multiple sclerosis and pseudolymphoma.
3) What is your next step?
a. Giving high dose pulse methyl prednisolone for 3 days only.
b. Whole brain irradiation.
c. Oncological consultation.
d. Plasma exchange.
e. Beta interferon injections.
----
Q1:Answer: d
a. false, usually asymmetrical and confusing eg lost pinprick sensation in the right calf and left anterior thigh.
b. false, together with sphincteric problems are highly suggestive in the appropriate clinical setting.
c. false, a co-existent conus medullaris lesion might be seen as extensor planters; absent ankles indicates radicular lesion in cauda equina ( S1) involvement.
d. true. Together with asymmetric lower motor neuron and sensory signs in the lower limbs, should always prompt a search for a cauda equina pathology.
e false.
Q2: Answer: ea. false, remember that the cauda equina is the lumbosacral roots gathered together in a narrow canal; so different roots could be involved.
b. false, could be absent, mild, severe, or the only presenting feature, depending the site of the lesion
c. false, Urinary retention and constipation could be prominent part of the clinical picture.
d. false, should suggest another diagnosis or a co-existent pathology.
e. true, due to involvement of large diameter fibers subserving kinesthesia.
Q3:Answers: d, b, c. End..
Neurology Best of Five Scenarios for MRCP Part II / What is your Next Step?
Q41: A 19 year old male referred to you for further evaluation. He has a history of passing dark urine after exercises since early childhood. He also reported muscle cramps during playing with his friends when he was a child. His older cousin has the same problem. Examination is normal. What would you do next?
Q42: A 56 year old woman presents with 2 months history of headache, early morning nausea, and abnormal repetitive jerking movements involving her left arm that start and stop spontaneously. Examination failed to detect any abnormality apart from early bilateral papillodema. After doing a brain MRI with contrast, what is your next step?
a. Reassure her that every thing is OK.
b. Refer her to neurosurgery.
c. Repeat brain MRI at 2-weekly intervals.
d. EEG.
e. Do mini mental status examination.
Q43: A 43 year old HIV positive homosexual man presented with a 1 month history of impaired vision and left sided weakness. He is on no anti HIV medications. Examination revealed a fully conscious man, afebrile, no neck stiffness, normal speech, but with a left sided homonymous hemianopia and hemiparesis. Brain MRI revealed non enhancing lesions at the parieto-occipital white matter areas with no surrounding edema or mass effect or a midline shift. What would you do next?
Q44: A 78 year old dementic man referred to you as having recurrent intracerebral hemorrhages. He is on a diuretic for a newly diagnosed systolic hypertension which is well controlled, with no orthostasis symptoms. His previous CT scans are consistent with lobar hemorrhages. What would you do next?
Q45: A 63 year old woman with type II diabetes since 6 years on metformin presents with somewhat rapid onset of diplopia before 2 days. Examination revealed a complete right sided ptosis; elevation of the ptotic lid revealed an eye globe in an outward and downward position. The papillary reactions are normal. What would you do next?
c. Order a brain CT scan to exclude a hemorrhagic stroke.
d. Perform lumbar puncture to confirm subarachnoid hemorrhage.
e. Stop metformin.
Q46: A 24 year old man, who is a known case of idiopathic grand mal epilepsy since the age of 15 years, brought to the emergency department with a history of repeated generalized fits without improvement in his consciousness state since 2 hours. Examination revealed an unconscious man with repeated generalized short lived jerking movements, bilateral extensor planters, and high temperature, but no neck stiffness. His mother said that he decided not to take his antiepileptic medications any more before 1 week. His seizures were well controlled with phenytoin 300 mg / day. You started the routine ABC in the emergency department. All of the followings are part of your management plan, except?
Q47: A 59 year old man brought by his friend to the emergency department. The patient's friend said that the patient suddenly became confused about the surroundings and kept saying "where am I?" for the last 4 hours, and he knows that the patient is on aspirin only for an old stroke. Examination revealed a dazed old man, with normal speech, he knew his name and age, but does remember anything about the last 4 hours. No evidence of head trauma, normal ocular movements and gait.
Q48: A 28 year old woman presents with intermittent diplopia since 3 years. Examination revealed bilateral asymmetrical partial ptosis with normal papillary reflexes. Her eye movements are full and intact with no diplopia. Sustained upgaze for 3 minutes reproduced diplopia and made the ptosis worse bilaterally. Her speech is normal with no girdle or limb weakness. All of the followings are useful in your management plan, except?
Q49: An 18 year old woman being treated for severe scarring acne for the last 3 months, presents with generalized headache, vomiting and clouding of vision for the past 3 weeks. Examination revealed bilateral papillodema, left sided abducens palsy, together with severe nodulo-cystic acne and extensive facial scarring. She did admit to the presence of recurrent oral and vulval ulcerations for the last 6 motnhs. What's your next step after doing brain CT scan and CSF opening pressure for her?
a. Blood film.
b. Urea and electrolytes.
c. Brain MRV.
d. Hemoglobin electrophoresis.
e. Pan-retinal LASER photocoagulation.
Q50: A 54 year old chronic heavy alcoholic man is being treated in the emergency department for a severe infective diarrhea-associated profound dehydration. He received several pints of normal saline within 3 hours and made a good improvement initially. Several hours later, he became quadriplegic, and mute. Which one was the wrong step?
a. Not giving thiamin initially.
b. Not giving intravenous potassium initially.
c. Took long time for rehydration to be achieved.
d. To rapid rehydration with normal saline.
e.Not giving intravenous dextrose initially.
Q51: A 60 year old man with a long term history of diabetes and hypertension presets with few hours' history of right sided weakness and speech a defect. Examination revealed a global aphasia and a dense right sided weakness and up going planers. His pulse is rapid and irregular. While doing brain CT scan. What is next investigation?
a. PT and INR.
b. PTT.
c. ECG.
d. Intra-arterial blood pressure monitoring.
e. Swan- Ganz catheter placement.
Q52: A 70 year old woman presented with alternating cognitive dysfunction, well-formed visual hallucinations, rigidity and hypokinesia. He is no medications. What would you do?
a. Start haloperidol for his hallucinations.
b. Give high dose L dopa for his hypokinesia.
c. Avoid giving chlorpromazine.
d. Repeated lumbar punctures.
e. Lumbopreitoneal shunting.
Q53: A 53 year old woman presents with a 4 months history of progressive inability to walk and generalized body aches. Her story started since 4 months ago as burning pain and weakness in her right foot to be followed after 3 weeks by an aching pain and clumsiness in her left hand. After 2 weeks she developed a sudden painful weakness in her left foot. She was dragging her feet while walking, and now she is unable to stand because of pain and severe weakness in her lower limbs. Examination revealed an old thin woman with low grade fever and a blood pressure of 170/105 mmHg, bilateral foot drop and wasting of the left hand muscles. Her ESR is 80, blood urea nitrogen is 80 mg/ dl, serum creatinine 2.7 mg / dl, with many red cell casts in her urine. Which one of the following steps is inappropriate?
a. Doing a renal biopsy.
b. Starting high dose steroids.
c. Requesting EMG and nerve conduction studies.
d. Sending her for anti-GBM antibodies.
e. Sural nerve biopsy.
Q54: A 25 year old woman, who is reasonably well and healthy, presents with 3 months history of progressive inability to stand and walk with difficult urination. She has no history of back trauma, and she is on no medications or drugs, and no family history of a similar problem. Examination revealed bilateral foot drop, flaccid lower limbs, impaired pin prick sensation in the left anterior thigh and perineum, an absent right ankle and left knee jerks and non responsive planters. What is your next step?
a. Cervical spine X ray.
b. Blood film.
c. Muscle biopsy.
d. Serum vitamin B12 level.
e. MRI of the lumbosacral spine with contrast.
Q55: A 24 year old man, who was reasonably well and healthy, presented with headache and progressive clouded consciousness over few hours. His girlfriend said that he took his blood pressure and was 110/80 in the last week. As far as she knows, he is on no medications or illicit drugs, no history of head trauma. Examination revealed a young obtunded man, responds to painful stimuli by withdrawing his right side of the body only, and a left upgoing planter. Non-contrast brain CT scan showed a rounded hyperdense lesion in the right basal ganglia, with mild surrounding edema. Non-contrast brain MRI detected a "flow void" signal in the same area. His lab tests were normal. What is your next step?
a. Carotid Doppler study.
b. Transesophageal echocardiography.
c. 4-vessel cerebral conventional angiography.
d. ECG.
e. Sputum cytology.
Q56: A 21 year old man was brought to the emergency department after having a terrible road traffic accident. Examination revealed a young obtunded man with multiple scalp bruises and lacerations, and unequal pupils. You ordered an emergency non-contrast brain CT scan which revealed a large hyperdense extraaxial lense shaped mass compressing the right hemisphere with prominent midline shift. What would you do?
a. Wait and see.
b. Start thrombolytic therapy.
c. Consult the neurosurgical department.
d. Give subcutaneous heparin.
e. Do emergency EEG.
Q57: A 65 year old diabetic man since 8 years presents with progressive gait difficulty in his feet for the last 7 months. He reposted a sense of numbness parasthesias in his feet for a long time but he was not bothered by them. Examination revealed a spastic gait, inversion of the biceps and supinator jerks bilaterally with loss of pinprick sensation at both lateral arms, exaggerated knee jerks, absent ankle jerks, and upgoing planters. There is a stocking loss of all sensory modalities in the lower limbs. His Fasting blood sugar is 190 mg /dl. What wouldn't you do?
a. MRI of the cervical spine.
b. Control his blood sugar.
c. Refer him for cervical decompressive laminectomy.
d. Assess serum vitamin B12 level.
e. EMG and nerve conduction study of the lower limbs.
Q58: A 10 year old boy presents with a 7 month history of progressive gait difficulty. His story started as a deep aching pain and impairment in handwriting in his right upper limb, to be followed after few weeks by a progressive difficulty in walking and urination. He is now a wheel chair bound. He has no history of a back trauma or similar family history. Examination revealed a well built young boy, with spastic gait, right wrist drop, sensory loss over the right middle finger, and absent right triceps jerk. His lower limbs showed severe spasticity, exaggerated reflexes, ankle and patellar clonus, and extensor planters. His superficial abdominal reflexes are lost bilaterally. What is your next step?
a. EMG of the lower limbs.
b. Serum vitamin B12 level.
c. MRI of the cervical cord with contrast.
d. CSF analysis and opening pressure.
e. Brain MRI.
Q59: A 29 year old refugee Asian female presented with a 4 week history of progressive alteration in her mental state. Her older brother noticed a recent squint. Examination revealed an ill-looking stuporous febrile wasted young lady, with severe neck stiffness and a positive Kerning's sign, right sided abducens palsy. He brain CT scan showed mild hydrocephalus, but no mass lesion. What is your next step?
a. Brain MRI.
b. CSF study.
c. X ray of the lumbosacral spine.
d. Blood culture for pneumococci.
e. Skin biopsy.
Q60: You've been consulted to see this 43 year old man who appears in a coma state. He was completely healthy until 6 days ago when he suddenly collapsed, became quadriplegic, and unresponsive. You noticed that there are no spontaneous limb movements even in response to painful stimuli. There is spontaneous eye opening but he is not responding to your questions regarding his name and age. Till now you suspect something and you asked to move his eyes up and down and did that correctly. There is flaccid quadriparesis and extensor planters, he is unable to say a word and can swallow. His EEG is normal. What is your next step?
a. Repeat the EEG after 2 days.
b. MRI of the brainstem.
c. Give intravenous phenytoin.
d. Chest X ray.
e. Blood culture.
End...
Neurology Best of Five Scenarios for MRCP Part II / What is your Next Step?
Q21: A 34 year old man presents with 3 day history of fever, abnormal behavior, drowsiness, and attacks of staring with picking at clothes movements. Examination revealed Broca's aphasia, right sided weakness, and bilateral upgoing planters, and mild neck stiffness.
Q22: A 63 year old man has a history of diabetes and hypertension since 7 years, presented with dense right sided weakness for 2 days. He is right handed. His speech is totally normal, no visual field defects were detected, and no abnormal sensory or cerebellar signs. You detected a right sided pyramidal weakness of grade 2, with upgoing planter. What is your next step?
Q23: A 55 year old woman with a history of successively treated pyogenic meningitis before 10 years presents with few months history of progressive cognitive decline, mental slowness, apathy, and urinary incontinence. Her daughter said that her mother's illness started as a bizarre inability to walk although she is able to move her legs fully and actively in bed. Examination revealed no papillodema or neck stiffness, or any focal or lateralizing sign. What is your next step?
Q24: A 12 year old boy presented with 3 attacks of lapse of consciousness during the last 4 weeks. His mother said that each attack started suddenly, he became rigid and blue for half a minute, and then his body trembled vigorously for 1 minute to be followed by a phase of drowsiness and headache that lasted for about 10 minutes. The child does remember anything about these attacks. He is on no medications and he denied any illicit drug abuse. His father said that the child's uncle has a similar problem. Examination is totally normal as his lab tests. What is your next step?
Q25: A 60 year old man presents with several months history of involuntary movements in the form of shaking movements of his hands. He said that his problem started in the right arm first to be followed by the left arm after few months. Examination revealed a course slow resting tremor of both hands with no intentional component. His limb tone is increased throughout and his face shows ironed out wrinkles. He is too much concerned about his cosmetic appearance, disabled by his tremor, and he is desperate for help. There were no pyramidal or cerebellar signs. What is your next step?
Q26: A 25 year old woman presents with few days history of progressive inability to stand and walk. She has a band-like burning pain at the level of her umbilicus and urinary retention. She reported a history of visual impairment in her right eye before 9 months ago, with gradual and spontaneous improvement over a period of 2 weeks. Examination revealed a right-sided primary optic atrophy, flaccid weakness of grade 2, hyporeflexia, and bilateral extensor planters. There is severe loss vibration and position sensation in both legs, and a sensory level at the umbilicus. Brain MRI showed multiple oval shaped periventricular lesions, some of which showed enhancement after gadolinium administration. What is your next step?
Q27: A 58 year old woman brought by her husband to see you. He said that his wife's cognitive function is progressively declining, and having a change in her sleep pattern and sexual drive since 3 months. He reported seeing bizarre funny sudden jerking movements, especially when there is a sudden loud noise. Examination revealed gross ataxia, bilateral extensor planters and prominent startle myoclouns. She scored 21 in the mini mental status examination. What is your next step?
Q28: A 59 year old woman with a history of gastric surgery since 8 years for a perforated benign gastric ulcer presents with few month history of gait difficulty and burning feet. Examination revealed severe pallor, a tinge of jaundice, mildly spastic gait, stocking loss of kinesthesia, pinprick and temperature sensations, absent ankle jerks and upgoing planters. Which one of the followings is not a correct step?
Q29: A 39 year old man who was diagnosed as having a cerebellar mass since 7 months, for which he refused any surgical intervention, presents with a 4 week history of repeated vomiting, generalized headache, and speech defect. Examination revealed a drowsy man, with pallor, bilateral papillodema and a vascular looking mass in his right fundus, right-sided non-tender hard loin mass, expressive aphasia, and right sided weakness of grade 4 minus and upogoing planter. A brain CT scan with contrast showed a cerebellar mass and 3 by 5 cm left sided frontal lobe mass with massive surrounding edema and irregular ring enhancement and a midline shift. What is your next step?
Q30: A 46 year old heavy alcoholic man presents with few days history of altered mentation. Examination revealed a middle aged unkempt man, with odor of alcohol, global confusional state, some of his eye movements are absent, and a gait unsteadiness. No fever, neck stiffness, or papillodema. What is your next step?
Q31: A 65 year old man with controlled atrial fibrillation presents with few hours history of clouded consciousness after a trivial fall in the bathroom. Examination revealed no evidence of scalp laceration or hematoma or a skull depression, but he was drowsy, aphasic, and having right sided hemiplegia. No neck stiffness or papillodema was detected. What is your next step?
Q32: A 24 year old man with type I diabetes since 10 years presents with a left sided facial swelling and ptosis over 3 days. Examination revealed an ill looking febrile young man, with a large boil at the left side of his nose, complete left-sided ptosis, facial swelling, and proptosis, and elevation of the left lid showed a complete and total internal and external ophthalmoplegia and severe disc swelling. There is a loss pinprick sensation over the left forehead and cheek. The other eye was totally normal, and apart from dryness, his mouth examination was normal. What would you do?
Q33: A 22 year old woman referred to you as a case of coma. She delivered a healthy term baby vaginally with no complications at that time. At day 6 postpartum, she complained of headache, difficult walking, and repeated vomiting. Examination revealed a young lady in deep coma and a
Q34: A 62 year old hypertensive heavy smoker man presents with few hours history of severe nausea, vomiting and inability to stand. He reported a severe vertigo and oscillopsia. Examination revealed an old man in distress but fully conscious, unable to stand because of severe vertigo, closing his eyes, right sided Horner's syndrome, nystagmus, right upper limb ataxia and impaired finger nose test, uvula deviated to the left side, and impaired gag reflex in the right posterior pharynx, impaired pinprick sensation in the right side of the face and in the left side of rest of the body. Which one of the followings would unreasonable to do next?
Q35: A 54 year old diabetic man on metformin since 5 years presents with few months history of numbness and pins and needles sensation in his hands and feet. Examination revealed a glove and stocking loss of all sensory modalities and absent ankles jerks. What would you do next?
a. Muscle biopsy.
b. Fasting blood sugar.
c. Complete blood count.
d. EMG and nerve conduction study.
e. ESR.
Q36: A 62 year old man living in a nursing home was referred to you because of memory problems and a dysphroic mood. You interviewed him alone, and was uncooperative during the mini mental status examination by responding to your questions by " I don't know" or "I don’t care". He did admit to the presence of early morning insomnia and weight change and loss of sexual drive. What is the most likely cause of his memory problems?
a. Depressive pseudodementia.
b. Alzheimer's type dementia.
c. Pick's dementia.
d. Creutfeldt-Jacob disease.
e. Lewy body dementia.
Q37: A 58 year old woman presents with few months history of sudden severe jabs of pain in her right cheek that is brought about by eating, laughing, and talking. Neurological examination was totally normal. What is would you do next?
Q38: A 56 year old man with a history of ischemic heart disease and an implanted permanent pacemaker for complete heart block, referred to you as having no cognitive functions at all and he is not responding to his family. He sustained a prolonged attack of Stokes
Q39: An 18 year old woman brought to the hospital by her boy friend in an unresponsive state. He said that told her that he is going to leave her for good because he loves someone else, and then she became in deep coma all of a sudden. Examination did not reveal any sign of physical abuse or a head injury. The blood pressure is 120 / 70 mmHg, pulse rate 90 beats per minute and regular, respiratory rate 14 cycles per minute and regular. No focal neurological or lateralizing sings. Her brain CT scan is normal as her lab tests. What is you next step?
Q40: A 68 year old woman referred to you for further evaluation. She has a several month history of recurrent falls, dizziness, and a worsening resting hand tremor and dry mouth. Examination revealed a global cognitive dysfunction, cogwheel rigidity, bilateral extensor planters, and ataxic gait. What is your next step diagnosis?
Neurology Best of Five Scenarios for MRCP Part II / What is your Next Step?
Q1: A 22 year old farmer presents with a 10 month history of spontaneous hand shaking. He is a little bit depressed since that time. He denied alcohol intake or any illicit drug abuse. His cousin has a similar problem. Examination revealed a coarse resting tremor with no intentional component, a dysarthric speech, and down going planters.
His lab tests revealed:
Total serum bilirubin 1.5 mg/ dl
ALT 70 u/L
Alkaline phosphatase 90 u/L
What is your next investigation?
Q2: An 18 year old male brought by his parents for assessing his general conditions. His mother stated that her son's gait is awkward as if he is drunk and progressively impaired since the age of 10 years, and he has difficulty in feeding himself because his hands are too shaky and he seems to be deaf. Examination revealed pes cavus, kyphoscoliosis, a wide based gait, impaired finger nose test, absent ankle jerks and upgoing planters. What is your next step?
a. Doing an echocardiographic study.
b. Measuring serum TSH.
c. CSF opening pressure.
d. Blood film looking for acanthocytes.
e. Muscle biopsy looking for ragged red fibers.
Q3: A 50 year old woman with a history of breast cancer since 1 year which was treated by lumpectomy and local radiotherapy at that time presents with generalized headache that is partially responsive to analgesics since 2 months. She is on no chemotherapy for the timebeing. Examination revealed papilloedema, grade 4 minus pyramidal weakness in both lower limbs with exaggerated reflexes and upgoing planters.
Which one of the following steps would be unreasonable?
a. A brain MRI study with contrast.
b. Liver ultrasonographic study.
c. Bone isotop scan.
d. 24 hours urinary cortisol level.
e. 4-Vessel cerebral conventional angiography.
Q4: A 20 year old single woman presents with an 8 month history of short lived attacks of numbness in her right side of the body that resolved spontaneously after few days. Each attack lasted for about 3 weeks. She denied any sphincteric problems or back pain. She is on medications, no history of illicit drug abuse or alcohol intake, and a negative family history of such a complaint. She stated that she did not practice sex till now. Examination revealed bilateral grade 4 plus pyramidal weakness and upgoing planters in both lower limbs, with prominent disc pallor on right sided fundoscopy. Which one of the following investigations is useless?
a. Brain MRI study with contrast.
b. Cervico-dorsal MRI with contrast.
c. CSF analysis.
d. Visual evoked potentials.
e. Nerve conduction study and EMG for the lower limbs.
Q5: A 6 year old boy brought by his parents because he can not cope with other children while playing with them. His mother said that her son is becoming lazy gradually over a period of 2 years, and his gait is strange like a duck. Examination revealed proximal symmetrical non-tender weakness of grade 4 minus, intact ankle and knee reflexes and downgoing planters in his both lower limbs with a waddling gait; but his calves appeared to be unusually full and doughy.
What is the unreasonable step?
a. Measuring serum CPK level.
b. Doing muscle biopsy.
c. Ordering an ECG.
d. Doing an echocardiographic study.
e. Sending for a nerve conduction study.
Q6: A 68 year old man who was reasonably well and healthy presents with a 4 week history of inability to stand from his low chair and combing his hair. He did admit to some difficulty in swallowing and his body aches as well. He is on medications, nonsmoker and nonalcoholic. Examination revealed symmetrical proximal tender weakness of grade 4 minus in the shoulder and pelvic girdles, intact reflexes throughout and down going planters. No detectable skin rash.
What is your next step?
a. Brain CT scan with contrast.
b. MRI of the lumbosacral spine.
c. EMG.
d. Urea and electrolytes.
e. Anti- centromere antibodies.
Q7: A 40 year old woman presented with a 13 day history of progressive weakness that started in her lower limbs and rapidly involved her upper limbs. She had an attack of diarrhea before 2 weeks and made an uneventful recovery at that time. She did admit to the presence of simultaneous lower back and thigh dull aching pain. There is no history of back trauma and she denied any sphicnteric problems. Examination revealed a flaccid proximal and distal weakness of grade 2, arelfexia throughout with unresponsive planters and intact pinprick and temperature sensations. No sensory level on the trunk.
What is your next step?
Q8: A 64 year old woman presented with a 1 year history of progressive clumsiness in hand writing. She reported a difficulty in swallowing and her husband stated that her speech is somewhat labored. Examination revealed small spastic tongue, sluggish palatal movements, dysarthric speech, wasting in both hand muscles, and spastic lower limbs and upgoing planters. The reflexes are exaggerated in the lower limbs and absent in the upper limbs. No sensory or cerebellar signs, and her eye movements are intact with full range and no diplopia.
What is your next step?
Q9: A 53 year old woman presents with 1 year history of a depressed mood and painful burning feet. Examination of the lower limbs revealed absent ankle jerks, upgoing planters, impaired vibration and join position, and a stocking sensory loss of pin prick and temperature sensations. Her gait is wide based with a positive Rombergism, early bilateral primary optic atrophy, no sensory level at the trunk, and her upper limbs are normal.
Which one of the followings is not used in the assessment?
Q10: A 28 year old man presents with few days history of a terrible headache episodes that start at 2 am at night every day for the last 5 days and each attack lasts for about 1 hour and does not respond to paracetamol. During the attack, the pain is piercing-like behind his right eye, with excessive tearing and nasal discharge. He reported similar attacks when he was 18 years old. What is your next step?
Q11: A 25 year old woman presents with a 3 week history of generalized headache, early morning vomiting, and a double vision. No neck stiffness or fever. Examination revealed only a right sided abducens palsy and a florid bilateral papilloedema with enlargement of the physiological blind spot of a double size of ours.
a- Dorsal spine CT scan.
b- EMG of the facial musculature.
c- CSF opening pressure.
d MRI of the cervical spine with contrast.
e- Intraocular pressure recording.
Q12: A 26 year old woman presents with a 5 week history of easy fatigability and intermittent diplopia and a change in her voice quality. She stated that her symptoms are more prominent in the evening. She did admit to the presence of some difficulty in drinking fluids but she is not bothered by this.
Examination revealed asymmetrical non tender weakness of both proximal upper limbs, with no fasciculation or atrophy, which became more obvious after sustained forward arm abduction for 2 minutes. All other aspects in the clinical examination were normal.
Which on of the followings is not useful in your workup?
a- Tetanic EMG.
b- Anti-actylcholine receptors antibodies.
c- Edrophonium test.
d- Mediastinal CT scan.
e- Nerve conduction study.
Q13: A 38 year old man brought by an ambulance with impaired mentation since 10 hours. His roommate said that the patient developed a sudden severe pain at the back of his head to be followed by a short lived lapse of consciousness. His roommate stated that his friend is on no medications including illicit drug abuse but denied any head trauma. Examination revealed a drowsy middle age man with severe neck stiffness, bilateral papillodema, right sided subhyaloid hemorrhage, and extensor planters. What is your next step?
Q14: A 59 year old life long heavy smoker man, presents with few weeks history of generalized weakness and undue fatigability. He complained of mouth dryness and a poor erection. Examination revealed a prominent postural hypotension, proximal symmetrical non-tender weakness, a hyporeflexia which improves for a while after a sustained muscle contraction, intact ocular movements with sluggish papillary reaction to light. EMG revealed an increamental response of the compound muscle action potential upon repetitive stimulation.
Which one of the followings would be useless in your workup?
Q15: A 20 year old alcoholic man presents with 2 day history of altered mutation. His brother stated that his consciousness gradually deteriorated. Examination revealed a young drowsy man, who is febrile (temperature 39.1 C), with multiple skin bruises, and severe neck stiffness. No papillodema. Non-contrast brain CT scan is normal. What is your next step?
Q16: A 70 year old man presents with vague personality changes and altered mentation during the last 3 eeks. His wife said that her husband complains of headache and infrequent vomiting, and his left arm and leg are not that powerful when compared with the right side. No history of head trauma or a fall, and his past medical history is unremarkable. Examination revealed a drowsy old man, with bilateral papillodema, left sided pyramidal weakness of grade 4 plus and left sided upgoing planter. What is your next step?
Q17: A 60 year old man presents with few months history of abnormal shaking movements involving his arms and head. He said that these movements become less upon drinking alcohol. Examination revealed symmetrical fine tremor of both hands with prominent postural component, somewhat regular head shaking movements but no jaw tremor. What is your next step?
Q18: A 67 year old man was brought by his son to see you. His son said that his father was reasonably well and healthy with no medical illnesses, is now becoming easily forgetful these days, easily irritable, and his mood is low. The patient denied any memory loss. Examination revealed prominent loss of recent memory with relative preservation of immediate recall. Examination of the cranial nerves, upper limbs, lower limbs and gait was normal. He scored 21 on mini mental state examination. What is your reasonable next step?
Q19: A 35 year old man was brought by his brother to consult you. His brother stated that patient has strange irregular involuntary movements involving the head and upper limbs since 1 year, and he has slow thinking, and a depressed mood. He is on no medications. Their father died of a similar illness when he was 40 years old. You noticed variable choreic movements, and he scored 22 in the mini mental status examination. What is your next step?
Q20: A 25 year old woman presents with weakness in her both hands since several months. She feels thirsty most of the times, and passes large amount of urine. Examination revealed a long thin face and neck, with bilateral partial symmetrical ptoses but no frontalis overaction, early cataract, and a dysarthric speech. Percussion of the thenar imminence produced a sustained contraction of that group of muscles for 10 seconds. She is wearing a wig. Her random blood sugar is 290 mg/ dl. What is your next step?
Neurology Best of Five Scenarios for MRCP Part I… "What is the Diagnosis?"
a. Glycogen storage disease.
b. Kernse Sayer Daroff syndrome.
c. Adult dermatomyositis.
d. Duchenne's muscular dystrophy.
e. Werding Hoffman spinal muscular atrophy.
Q42: A 56 year old woman presents with 2 months history of headache and abnormal repetitive jerking movements involving her left arm that start and stop spontaneously. Examination failed to detect any abnormality. Brain MRI revealed a diffusely enhancing semi-rounded extraaxial mass mildly compressing the right hemisphere at the frontal lobe. What is your diagnosis?
a. Hemispheric meningioma.
b. Superior saggittal sinus thrombosis.
c. Massive old hemispheric ischemic infarction.
d. Hemispheric glioblastoma multiforme.
e. Large hemispheric AVM.
Q43: A 43 year old HIV positive homosexual man presented with a 3 month history of impaired vision and left sided weakness. He is on no anti HIV medications. Examination revealed a left sided homonymous hemianopia and hemiparesis. Brain MRI revealed non enhancing lesions at the parieto-occipital white matter areas with no surrounding edema or midline shift. What is the most likely diagnosis?
a. Toxoplasma brain abscesses.
b. Primary CNS lymphoma.
c. Multiple ischemic infarctions.
d. Progressive multifocal leukoencephalopathy.
e. Crypotococcal meningitis.
Q44: A 78 year old dementic man referred to you as having recurrent intracerebral hemorrhages. He is on no medications and no history of repeated falls. His previous CT scans are consistent with lobar hemorrhages. What is the diagnosis?
a. Hemorrhagic metastatic tumors.
b. Congophilic angiopathy.
c. Bleeding AVMs.
d. Large leaking
e. Multiple lacunar strokes.
Q45: A 63 year old woman with type II diabetes since 6 years presents with somewhat rapid onset of diplopia before 2 days. Examination revealed a complete right sided ptosis; elevation of the ptotic lid revealed an eye globe in an outward and downward position. The papillary reactions are normal. What is the diagnosis?
a. Trigeminal neuralgia.
b. Oculomotor nerve palsy.
c. Abducens nerve palsy.
d. Pontine stroke.
e. Cavernous sinus thrombosis.
Q46: A 24 year old man, who is a known case of idiopathic grand mal epilepsy since the age of 15 years, brought to the emergency department with a history of repeated generalized fits without improvement in his consciousness state since 2 hours. Examination revealed an unconscious man with repeated generalized short lived jerking movements, bilateral extensor planters, and high temperature. His mother said that he decided not to take his antiepileptic medications any more before 1 week. His seizures were well controlled with pheytoin 300 mg / day. What is the diagnosis?
a. Pseudo-seizures.
b. Status epilepticus.
c. Phenytoin toxicity.
d. Malingering.
e. Aversive seizures.
Q47: A 59 year old man brought by his friend to the emergency department. The patient's friend said that the patient suddenly became confused about the surroundings and kept saying "where am I?" for the last 4 hours, and he knows that the patient is on aspirin only for an old stroke. Examination revealed a dazed old man, with normal speech, he knew his name and age, but does remember anything about the last 4 hours. No evidence of head trauma, normal ocular movements and gait.
a. Bilateral hippocampal infarction.
b. Transient global amnesia.
c. Wernick'e encephalopathy.
d. Hysterical fugue.
e. Complex partial status.
Q48: A 28 year old woman presents with intermittent diplopia since 3 years. Examination revealed bilateral asymmetrical partial ptosis with normal papillary reflexes. Her eye movements are full and intact with no diplopia. Sustained upgaze for 3 minutes reproduced diplopia and made the ptosis worse bilaterally. Her speech is normal with no girdle or limb weakness. What is the diagnosis?
a. Severe generalized myasthenia gravis.
b. Progressive external ophthalmoplegia.
c. Pure ocular myasthenia.
d. Oculopharyngeal muscular dystrophy.
e. Botulism.
Q49: An 18 year old woman being treated for severe scarring acne for the last 3 months, presents with generalized headache, vomiting and clouding of vision for the past 3 weeks. Examination revealed bilateral papillodema, left sided abducens palsy, together with severe nodulo-cystic acne and extensive facial scarring. What do think that she might have developed during the past 3 weeks?
a. Malignant brain tumor.
b. Pseudo-tumor cerebri.
c. Left-sided hemispheric infarction.
d. Left-sided cavernous sinus thrombosis.
e. Hippocampal sclerosis.
Q50: A 54 year old chronic heavy alcoholic man is being treated in the emergency department for a severe infective diarrhea-associated profound dehydration. He received several pints of normal saline within 3 hours and made a good improvement initially. Several hours later, he became quadriplegic, and mute. What do you think that he might have developed after rehydration?
a. Acute extradural hematoma.
b. Massive brain infarction.
c. Central pontine myelinolysis.
d. Wernicke's encephalopathy.
e. Diarrhea associated Guiallin Barre syndrome.
Q51: A 60 year old man with a long term history of diabetes and hypertension presets with few hours' history of right sided weakness and speech a defect. Examination revealed a global aphasia and a dense right sided weakness and up going planers. His pulse is rapid and irregular. What is the most likely diagnosis?
a. Left-sided transverse sinus thrombosis.
b. Embolic hemispheric stroke.
c. Cerebellar hemorrhage.
d. Left-sided internal capsule lacunar stroke.
e. Pancerebral hypoperfusion.
Q52: A 70 year old woman presented with alternating cognitive dysfunction, well-formed visual hallucinations, rigidity and hypokinesia. He is no medications. What is the diagnosis?
a. Idiopathic Parkinson's disease.
b. Lewy body dementia.
c. Pick's frontotemporal dementia.
d. Shy Dragger syndrome.
e. Normal pressure hydrocephalus.
Q53: A 53 year old woman presents with a 4 months history of progressive inability to walk and generalized body aches. Her story started since 4 months ago as burning pain and weakness in her right foot to be followed after 3 weeks by an aching pain and clumsiness in her left hand. After 2 weeks she developed a sudden painful weakness in her left foot. She was dragging her feet while walking, and now she is unable to stand because of pain and severe weakness in her lower limbs. Examination revealed an old thin woman with low grade fever and a blood pressure of 170/105 mmHg, bilateral foot drop and wasting of the left hand muscles. Her ESR is 80, blood urea nitrogen is 80 mg/ dl, serum creatinine 2.7 mg / dl, with many red cell casts in her urine. What do you think that she might have?
a. Diabetic peripheral sensori-motor polyneuropathy.
b. Systemic vacultitis-associated mononeuritis mutiplex.
c. Foramen magnum meningioma.
d. Malingering.
e. Guillain Barre syndrome.
Q54: A 25 year old woman, who is reasonably well and healthy, presents with 3 months history of progressive inability to stand and walk with difficult urination. She has no history of back trauma, and she is on no medications or drugs, and no family history of a similar problem. Examination revealed bilateral foot drop, flaccid lower limbs, impaired pin prick sensation in the left anterior thigh and perineum, an absent right ankle and left knee jerks and non responsive planters. What do you think that she might have developed?
a. Cervical cord astrocytoma.
b. Cauda equina lesion.
c. Motor neuron disease.
d. Vitamin B12 deficiency.
e. Primary progressive multiple sclerosis.
Q55: A 24 year old man, who was reasonably well and healthy, presented with headache and progressive clouded consciousness over few hours. His girls friend said that he took his blood pressure and was 110/80 in the last week. As far as she knows, he is on no medications or illicit drugs, no history of head trauma. Examination revealed a young obtunded man, responds to painful stimuli by withdrawing his right side of the body only, and a left upgoing planter. Non-contrast brain CT scan showed a rounded hyperdense lesion in the right basal ganglia, with mild surrounding edema. His lab tests were normal. What is you initial impression?
a. Thrombocytopenic intracerebral hemorrhage.
b. Hypertensive hemorrhage.
c. Ruptured arteriovenous malformation.
d. Congophilic angiopathy.
e. Hemorrhagic secondary malignant tumor.
Q56: A 21 year old man was brought to the emergency department after having a terrible road traffic accident. Examination revealed a young obtunded man with multiple scalp bruises and lacerations, and unequal pupils. You ordered an emergency non-contrast brain CT scan which revealed a large hyperdense extraaxial lense shaped mass compressing the right hemisphere with prominent midline shift. What is your diagnosis?
a. Acute subdural hematoma.
b. Acute extradural hematoma.
c. Massive subarachnoid hemorrhage.
d. Ruptured frontal lobe arteriovenous malformation.
e. Hysterical unresponsiveness.
Q57: A 65 year old diabetic man since 8 years presents with progressive gait difficulty in his feet for the last 7 months. He reposted a sense of numbness parasthesias in his feet for a long time but he was not bothered by them. Examination revealed a spastic gait, inversion of the biceps and supinator jerks bilaterally, exaggerated knee jerks, absent ankle jerks, and upgoing planters. There is a stocking loss of all sensory modalities in the lower limbs. What is the diagnosis?
a. Diabetic peripheral sensorimotor polyneuropathy with bilateral carpal tunnel syndrome.
b. Diabetic peripheral sensorimotor polyneuropathy with bilateral brachial plexopathy.
c. Diabetic peripheral sensorimotor polyneuropathy with cervical spondylolytic myelopathy.
d. Diabetic peripheral sensorimotor polyneuropathy with Guillain Barre syndrome.
e. Diabetic peripheral sensorimotor polyneuropathy with a cauda equina lesion.
Q58: A 10 year old boy presents with a 7 month history of progressive gait difficulty. His story started as a deep aching pain and impairment in handwriting in his right upper limb, to be followed after few weeks by a progressive difficulty in walking and urination. He is now a wheel chair bound. He has no history of a back trauma or similar family history. Examination revealed a well built young boy, with spastic gait, right wrist drop, sensory loss over the right middle finger, and absent right triceps jerk. His lower limbs showed severe spasticity, exaggerated reflexes, ankle and patellar clonus, and extensor planters. His superficial abdominal reflexes are lost bilaterally. What do you think that he might have?
a. Hereditary spastic paraparesis.
b. HTLV1- associated myelopathy.
c. Cervical cord compression.
d. Necrotizing cauda equina radiculitis.
e. Para-saggittal menigioma.
Q59: A 29 year old refugee Asian female presented with a 4 week history of progressive alteration in her mental state. Her older brother noticed a recent squint. Examination revealed an ill-looking stuporous febrile wasted young lady, with severe neck stiffness and a positive Kerning's sign, right sided abducens palsy. What do you think that she might have?
a. Psychogenic unresponsiveness.
b. Viral meningitis.
c. Tuberculous meningitis.
d. Brain stem glioblastoma.
e. Massivesubarachnoid hemorrhage.
Q60: You've been consulted to see this 43 year old man who appears in a coma state. He was completely healthy until 6 days ago when he suddenly collapsed, became quadriplegic, and unresponsive. You noticed that there are no spontaneous limb movements even in response to painful stimuli. There is spontaneous eye opening but he is not responding to your questions regarding his name and age. Till now you suspect something and you asked to move his eyes up and down and did that correctly. There is flaccid quadriparesis and extensor planters, he is unable to say a word and can swallow. His EEG is normal. What is the diagnosis?
a. Psychogenic unresponsiveness.
b. High cervical cord trans-section.
c. Non-convulsive status epilepticus.
d. Locked in syndrome.
e. Alpha rhythm coma.
Written By: Dr. Osama Amin
http://neurology4mrcp.orgfree.com/
http://neurology4mrcp.bravejournal.com/
All Rights Reserved. January 2006.
Neurology Best of Five Scenarios For MRCP Part I… "What is the Diagnosis?"
Q22: A 63 year old man has a history of diabetes and hypertension since 7 years, presented with dense right sided weakness for 2 days. He is right handed. His speech is totally normal, no visual field defects were detected, and no abnormal sensory or cerebellar signs. You detected a right sided pyramidal weakness of grade 2, with upgoing planter. What is the likely diagnosis?
a. Pure motor lacunar stroke.
b. Embolic occlusion of the proximal left middle cerebral artery.
c. Tip of the basilar artery occlusion syndrome.
d. Lateral medullary syndrome.
e. Left internal carotid artery dissection.
Q23: A 55 year old woman with a history of successively treated pyogenic meningitis before 10 years presents with few months history of progressive cognitive decline, mental slowness, apathy, and urinary incontinence. Her daughter said that her mother's illness started as a bizarre inability to walk although she is able to move her legs fully and actively in bed. What is your provisional diagnosis?
a. Hereditary spinocerebellar ataxia.
b. Wilson's disease.
c. Normal pressure hydrocephalus.
d. Huntington's disease.
e. Pseudo tumor cerebri.
Q24: A 12 year old boy presented with 3 attacks of lapse of consciousness during the last 4 weeks. His mother said that each attack started suddenly, he became rigid and blue for half a minute, and then his body trembled vigorously for 1 minute to be followed by a phase of drowsiness and headache that lasted for about 10 minutes. The child does remember anything about these attacks. He is on no medications and he denied any illicit drug abuse. His father said that the child's uncle has a similar problem. Examination is totally normal as his lab tests. What is your impression?
a. Pseudo-seizures.
b. Idiopathic grand mal epilepsy.
c. Complex partial seizures.
d. Atypical petit mal absence attacks.
e. Salaam attacks.
Q25: A 60 year old man presents with several months history of involuntary movements in the form of shaking movements of his hands. He said that his problem started in the right arm first to be followed by the left arm after few months. Examination revealed a course slow resting tremor of both hands with no intentional component. His limb tone is increased throughout and his face shows ironed out wrinkles. What is you initial impression?
a. Alcohol withdrawal tremor.
b. Idiopathic Parkinson's disease.
c. Exaggerated essential tremor.
d. Wilson's disease.
e. Paroxysmal chroeathetosis.
Q26: A 25 year old woman presents with few days history of progressive inability to stand and walk. She has a band-like burning pain at the level of her umbilicus and urinary retention. She reported a history of visual impairment in her right eye before 9 months ago, with gradual and spontaneous improvement over a period of 2 weeks. Examination revealed a right-sided primary optic atrophy, flaccid weakness of grade 2, hyporeflexia, and bilateral extensor planters. There is severe loss vibration and position sensation in both legs, and a sensory level at the umbilicus. Brain MRI showed multiple oval shaped periventricular lesions, some of which showed enhancement after gadolinium administration. What is the diagnosis?
a. Anterior spinal artery occlusion.
b. Dorsal meningioma.
c. Multiple sclerosis.
d. Guillain Barre syndrome.
e. Subacute combined degeneration of the cord.
Q27: A 58 year old woman brought by her husband to see you. He said that his wife's cognitive function is progressively declining, and having a change in her sleep pattern and sexual drive since 3 months. He reported seeing bizarre funny sudden jerking movements, especially when there is a sudden loud noise. Examination revealed gross ataxia, bilateral extensor planters and prominent startle myoclouns. She scored 21 in the mini mental status examination. What is your initial impression?
a. Shy Drager syndrome.
b. Picks' frontotemporal dementia.
c. Progressive supranuclear palsy.
d. Creutzfeldt-Jacob disease.
e. Depressive pseudodementia.
Q28: A 59 year old woman with a history of gastric surgery since 8 years for a perforated benign gastric ulcer presents with few month history of gait difficulty and burning feet. Examination revealed severe pallor, a tinge of jaundice, mildly spastic gait, stocking loss of kinesthesia, pinprick and temperature sensations, absent ankle jerks and upgoing planters. What do you think that she might have?
a. Cervical transverse myeltitis.
b. Cervical spondylolytic myelopathy.
c. Subacute combined degeneration of the cord.
d. Osteoporotic dorsal spine compression fracture.
e. Motor neuron disease.
Q29: A 39 year old man who was diagnosed as having a cerebellar mass since 7 months, for which he refused any surgical intervention, presents with a 4 week history of repeated vomiting, generalized headache, and speech defect. Examination revealed a drowsy man, with pallor, bilateral papillodema and a vascular looking mass in his right fundus, right-sided non-tender hard loin mass, expressive aphasia, and right sided weakness of grade 4 minus and upogoing planter. A brain CT scan with contrast showed a cerebellar mass and 3 by 5 cm left sided frontal lobe mass with massive surrounding edema and irregular ring enhancement and a midline shift. What is the overall diagnosis?
a. Turcot's syndrome.
b.
c. Von Hippel Lindau disease.
d. Fanconi's syndrome.
e. Sturge Weber's syndrome.
Q30: A 46 year old heavy alcoholic man presents with few days history of altered mentation. Examination revealed a middle aged unkempt man, with odor of alcohol, global confusional state, some of his eye movements are absent, and a gait unsteadiness. No fever, neck stiffness, or papillodema. What is your first impression?
a. Pyogenic meningitis.
b. Chronic subdural hematoma.
c. Wernicke's encephalopathy.
d. Locked-in syndrome.
e. Alcoholic ketoacidosis.
Q31: A 65 year old man with controlled atrial fibrillation presents with few hours history of clouded consciousness after a ftrivial all in the bathroom. Examination revealed no evidence of scalp laceration or hematoma or a skull depression, but he was drowsy, aphasic, and having right sided hemiplegia. No neck stiffness or papillodema was detected. What do you think that he might have?
a. Viral encephalitis.
b. Pyogenic meinigitis.
c. Acute subdural hematoma.
d. Embolic brain stem stroke.
e. Cardiogenic syncope.
Q32: A 24 year old man with type I diabetes since 10 years presents with a left sided facial swelling and ptosis over 3 days. Examination revealed an ill looking febrile young man, with a large boil at the left side of his nose, complete left-sided ptosis, facial swelling, and proptosis, and elevation of the left lid showed a complete and total internal and external ophthalmoplegia and severe disc swelling. There is a loss pinprick sensation over the left forehead and cheek. The other eye was totally normal, and apart from dryness, his mouth examination was normal. What is the diagnosis?
a. Extensive rhinocerebral mucormycosis.
b. Staph aureus-induced cavernous sinus thrombosis.
c. Wegner's granulomatosis.
d. Nasopharyngeal carcinoma.
e. Orbital pseudotumor.
Q33: A 22 year old woman referred to you as a case of coma. She delivered a healthy term baby vaginally with no complications at that time. At day 6 postpartum, she complained of headache, difficult walking, and repeated vomiting. Examination revealed a young lady in deep coma and a
a. Cavernous sinus thrombosis.
b. Superior saggittal sinus thrombosis.
c. Hemorrhagic falx meningioma.
d. Multiple metastatic chroriocarcinoma.
e. Bilateral subdural hematomas.
Q34: A 62 year old hypertensive heavy smoker man presents with few hours history of severe nausea, vomiting and inability to stand. He reported a severe vertigo and oscillopsia. Examination revealed an old man in distress but fully conscious, unable to stand because of severe vertigo, closing his eyes, right sided Horner's syndrome, nystagmus, right upper limb ataxia and impaired finger nose test, uvula deviated to the left side, and impaired gag reflex in the right posterior pharynx, impaired pinprick sensation in the right side of the face and in the left side of rest of the body. What happed to him?
a. A massive cerebellar hemorrhage.
b. Lateral medullary syndrome.
c. Top of the basilar artery occlusion syndrome.
d. Hemorrhage into a pontine glioma.
e. Acute vestibular neuronitis.
Q35: A 54 year old diabetic man since 5 years presents with few months history of numbness and pins and needles sensation in his hands and feet. Examination revealed a glove and stocking loss of all sensory modalities and absent ankles jerks. What do you think the cause of his presentation is?
a. Diabetic peripheral sensorimotor polyneuropathy.
b. Vasculitic mononeuritis multiplex.
c. Amyloid associated small fiber peripheral neuropathy.
d. Guillain Barre syndrome.
e. Vitamin B12 associated peripheral neuropathy.
Q36: A 62 year old man living in a nursing home was referred to you because of memory problems and a dysphroic mood. You interviewed him alone, and was uncooperative during the mini mental status examination by responding to your questions by " I don't know" or "I don’t care". He did admit to the presence of early morning insomnia and weight change and loss of sexual drive. What is the most likely cause of his memory problems?
a. Depressive pseudodementia.
b. Alzheimer's type dementia.
c. Pick's dementia.
d. Creutfeldt-Jacob disease.
e. Lewy body dementia.
Q37: A 58 year old woman presents with few months history of sudden severe jabs of pain in her right cheek that is brought about by eating, laughing, and talking. Neurological examination was totally normal. What is the diagnosis?
a. Conversion disorder.
b. Trigeminal neuralgia.
c. Large cerebellopontine angle tumor.
d. Brainstem stroke.
e. Cancer of the maxillary sinus.
Q38: A 56 year old man with a history of ischemic heart disease and an implanted permanent pacemaker for complete heart block, referred to you as having no cognitive functions at all and he is not responding to his family. He sustained a prolonged attack of Stokes
a. Locked in syndrome.
b. Persistent vegetative state.
c. Man in a barrel syndrome.
d. Malingering.
e. Hysterical fugue.
Q39: An 18 year old woman brought to the hospital by her boy friend in an unresponsive state. He said that told her that he is going to leave her for good because he loves someone else, and then she became in deep coma all of a sudden. Examination did not reveal any sign of physical abuse or a head injury. The blood pressure is 120 / 70 mmHg, pulse rate 90 beats per minute and regular, respiratory rate 14 cycles per minute and regular. No focal neurological or lateralizing sings. Her brain CT scan is normal as her EEG. What is the diagnosis?
a. Massive spontaneous subarachniod hemorrhage.
b. Psychogenic unresponsiveness.
c. Aspirin overdose.
d. Ruptured intra-cerebral AVM.
e. Malingering.
Q40: A 68 year old woman referred to you for further evaluation. She has a several months history of recurrent falls, dizziness, and a worsening resting hand tremor and dry mouth. Examination revealed a global cognitive dysfunction, cogwheel rigidity, bilateral extensor planters, and ataxic gait. There was a severe postural hypotension. What is you diagnosis?
a. Idiopathic Parkinson's disease.
b. Shy Drager syndrome.
c. Multi infarct dementia.
d. Transient global amnesia.
e. Alzheimer's dementia.
To be continued...
Neurology Best of Five Scenarios For MRCP Part I… "What is the Diagnosis?"
Q1: A 22 year old farmer presents with a 10 month history of spontaneous hand shaking. He is a little bit depressed since that time. He denied alcohol intake or any illicit drug abuse. His cousin has a similar problem. Examination revealed a coarse resting tremor with no intentional component, a dysarthric speech, and down going planters.
His lab tests revealed:
Total serum bilirubin 1.5 mg/ dl
ALT 70 u/L
Alkaline phosphatase 90 u/L
What is the diagnosis?
a. Idiopathic hemochromatosis.
b. Wilson's disease.
c. Shy-Drager syndrome.
d. Multiple sclerosis.
e. Rasmussen's encephalitis.
a. Hemispheric glioblastoma multiforme.
b. Leptomeningeal carcinomatosis.
c. Ataxia telangiectasia.
d. Acquired alcoholic cerebellar degeneration.
e.
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