Neurology Best of Five Scenarios for MRCP Part I… "What is the Diagnosis?"

 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. Examination is normal.  Ischemic forearm exercise test was abnormal. 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 Berry aneurysms.

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. Brain CT scan showed an old lacunar stroke only. What is the diagnosis?

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.

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