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.      Gardner's syndrome.

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 Glasgow coma scale of 4, severe florid bilateral papillodema, flaccid paraparesis and upgoing planters. A brain CT scan showed hemorrhagic infarctions involving the frontoparetial lobes at both sides. What do you think she is having?

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 Adams's due to pacemaker failure before 3 weeks, and he was in deep coma but recovered gradually to be in this unresponsive state. You detected normal sleep wake cycles and normal autonomic functions. What complication had occurred?

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...

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