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?

1. Serum ceruloplasmin.
2. 24 hours urinary calcium level.
3. Complete blood count.
4. CSF analysis.
5. Nerve conduction study.

 

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. Brain CT scan revealed a rounded mass of 3 by 3 cm in the midline fissure with no surrounding edema that enhanced diffusely after contrast administration.     

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?

1. Stool examination and culture for campylobacter.
2. Complete blood count.
3. Nerve conduction study.
4. MRI of the lumbosacral spine.
5. Brain CTscan.

 

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?

1. EMG
2. Nerve conduction study.
3. MRI of the dorsal spine.
4. Visual evoked responses.
5. Sural nerve biopsy.

 

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?

1. MCV.
2. Blood film.
3. Red cell folate.
4. Serum vitamin b12 level.
5. Bone marrow study.

 

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?

 

1. Start high dose prednisolone
2. Continue on same dose paracetamol.
3. Increase the daily doses of paracetamol.
4. Alcohol Gasserian's ganglion ablasion.
5. LASER iridotomy  

 

 

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. Brain CT scan with contrast showed slit like ventricles and no mass lesion or midline shift. What is your next step?

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?

1. Brain MRI with contratst.
2. Non-contrast brain CT scan.
3. Lumbar puncture and CSF analysis.
4. Blood culture.
5. Echocardiography.

 

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?

1. Anti P/Q calcium channel antibodies.
2. Chest CT scan. 
3. Anti-acetylcholine receptors antibodies.
4. Sputum cytology.
5. Bronchoscopy.

 

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?

1. Repeat the brain CT scan with contrast.
2. CSF analysis.
3. Sputum culture.
4. Tuberculin skin testing.
5. MRV.

 

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?

1. Lumabr puncture and CSF opening pressure measurement.
2. Plain lateral skull X ray.
3. Brain CT scan with contrast.
4. Brain CT scan without contrast.
5. Emergency lumboperitoneal shunting.

 

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?

1. Brain CT scan with contrast.
2. 24 hours urinary copper measurement.
3. T3, T4, and TSH blood level.
4. No investigation is needed to confirm the diagnosis.
5. EMG and nerve conduction studies.  

 

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?

1. Serum B12 level.
2. TSH.
3. Brain CT scan.
4. Brain biopsy.
5. CSF protein 14-3-3 level.  

 

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?

1. Brain MRI.
2. Serum ferritin.
3. Visual evoked responses.
4. Urinary toxicology screen.
5. Muscle biopsy for ragged red fibers.

 

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?

 

1. Ischemic forearm exercise test.
2. EMG.
3. Anti-acetylcholine receptors antibodies.
4. Nerve conduction study looking for F-waves.
5. MRI of the brain.

To be continued...

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