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...
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