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www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital20122
NeurologyQ001A55yearoldmanpatientpresentswithan8monthhistoryofprogressivedifficultyinswallowing, and dysarthria. He has lost 6 kg in weight. On examination he has afasciculationonthetongueandabriskjawjerk.Whatisthelikelydiagnosis?
A.AmyotrophiclateralsclerosisB.SubacutecombineddegenerationofthecordC.SeniledementiaD.MultiplesclerosisE.GuillainBarresyndrome
Answer:a)amyotrophiclateralsclerosis.Afifthofpatientswithamyotrophic lateralsclerosishavebulbar involvement.This isaclassicpresentationofapatientwiththisvariantofmotorneurondisease.
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www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital20124
NeurologyQ003A42yearoldmanhasweakness intheextensorsoftheupper limbandflexorsofthelowerlimbmuscles.Hisspeechhasanasalquality.Thereistonguefasciculation.Whatisthelikelydiagnosis?
A.Wilson'sdiseaseB.CreutzfeldtJakobdiseaseC.MotorneurondiseaseD.MyastheniagravisE.Thyrotoxicosis
Answer:c)Motorneurondisease.Inmotorneurondisease,UMNsigns includemusclespasticity,slowed recruitmentofvoluntarymusclestrength,weaknessespecially intheextensorsoftheupper limbandflexorsofthelowerlimbmuscles,pseudobulbarpalsy.LMN features includemusclewastingand fasciculation,depressedreflexesandbulbarpalsy. Onset of the disease is usually in mid to late adult life with the incidenceincreasingwithadvancingage.
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www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital20127
NeurologyQ006A20yearold ladypresentswithahistoryofasingletonicclonicseizure.Shehadnotbeentakinganyillicitdrugs.Shealsoreportstheoccurrenceofoccasionalabsentspellsandbriefjerkingofhisupperlimbs,whenshehasbeenoutlatepartying.WhichoftheFollowingdrugsismostappropriate?
A.LorazepamB.CarbamazepineC.PhenytoinD.GabapentinE.Sodiumvalproate
Answer:e)sodiumvalproate.This patient is likely to have juvenilemyoclonic epilepsy (JME), and valproate is thetreatment of choice. Juvenile myoclonic epilepsy (JME) is an idiopathic generalizedepileptic syndrome characterizedbymyoclonic jerks,generalized tonicclonic seizures(GTCSs),andsometimesabsenceseizures.These can be precipitated when the patient is sleep deprived. Apart from sodiumvalproate,lamotrigineandtopirimatecanalsobeused.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital20128
NeurologyQ007A30yearoldpatienthasrecurrentepisodesofsevere,unilateral,painfeltintheregionoftheeyeandforeheadassociatedwithlacrimation.Themostlikelydiagnosisis:
A.MigraineB.SubarachnoidhaemorrhageC.RetroorbitaltumourD.ClusterheadacheE.Migranousneuralgia
Answer:d)clusterheadache.Clusterheadachecausessevere,usuallyunilateral,painfeltintheregionoftheeyeandforeheadassociatedwith lacrimation,conjunctival injectionandoccasionally transientHornerssyndrome.Oxygen and triptansmay arrest attacks, prophylaxiswith propranolol, pizotifen, andespeciallyverapamilmaypreventfurtherepisodes.
www
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www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201210
NeurologyQ009A50patientisassessedforgraduallyprogressivedementiaoverseveralmonths.Whilsthewasonthewardhewasnoticedtohavemyoclonicjerksofhishands.Whatisthelikelycause?
A.HIVencephalopathyB.ParkinsonsdiseaseC.AlzheimersdiseaseD.PicksdiseaseE.CreutzfeldtJakobdisease
Answer:E)CreutzfeldtJakobdiseaseCreutzfeldt Jakobdisease (CJD)usuallyoccurs in the 4575 year age group andmostcommonlypresentsasarapidlyevolvingmultifocaldementiawithmyoclonicjerksinthelatterstages.NewvariantCJD,whichhasbeenstrongly linked to infection frommeatproducts of cows with BSE, tends to present with behavioural and psychiatricdisturbancesprogressingtoincoordinationanddementiawithmyoclonicjerks.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201211
NeurologyQ010A 45 year old man has presented with lower back pain, radiating to his buttocks,associatedwith lower limbparathesiaoverthe lastfewdays.He isunabletowalkduetolegweakness.Theanklereflexesareabsent.Whatisthediagnosis?
A.DiscprolapseB.TransversemyelitisC.GuillainBarresyndromeD.MultiplesclerosisE.Friedrich'sataxia
Answer:c)GuillainBarresyndrome.Guillain Barr syndrome is preceded by respiratory or gastrointestinal symptoms intwothirds,butnotall,cases.Lowerbackpain,oftenradiatingtothebuttocksoccursinathirdofcases.DifficultywalkinginthiscaseisduetodistalweaknessandabsentdistalreflexessuggestGBS.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201212
NeurologyQ011A62yearoldmanpresentswitharestingtremorofhisrightarm.Hewasfoundtohavecogwheelingandbradykinesia.Hisgaitisshufflinginnature.WhichoneoftheFollowingdrugsismostlikelytohelphertremor?
A.AmantadineB.BenzhexolC.BromocriptineD.CoCareldopaE.Selegiline
Answer:B)Benzhexol.Benzhexol isananticholinergicdrug (usedtoalleviatetremors inparkinsonsdisease).The first line treatment is with Ldopa which is themetabolic precursor of Ldopa.Benzhexolisnoteffectiveagainstbradykinesia.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201213
NeurologyQ012A46yearoldfemalehadatraumaticleftsidedtoothextraction6yearsago.Sincethenshe iscomplainingof facialpainmainlyoverupperpartof left facewith intermittentexacerbation.Occasionallythepainradiatestorightsideoftheface.Whatisthelikelydiagnosis?
A.AtypicalfacialpainB.TrigeminalneuralgiaC.DrysocketcystD.BellspalsyE.Periodontitis
Answer:A)atypicalfacialpain.Complicateddentalproceduresorotherformsoftraumacanleadtoaformofatypicalfacial painswhich is also known as post traumatic facial pain/ neuralgia. The pain isusuallyselflimitingafterseveralyears.
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Dr.KhalidYusufElzohrySohagTeachingHospital201214
NeurologyQ013A25yearoldsecretaryhashadseveralepisodesofbrief jerkingoftherightarmoverthepastfewweeks.Thereisnolossofconsciousness.ACTscanoftheheadisunremarkable.Whichisthebestmedicationtocommence?
A.CarbamazepineB.PhenytoinC.LorazepamD.DiazepamE.Levodopa
Answer:a)carbamazepine.Brief episodes of jerking suggests simple partial seizures. Carbamazepine is first linetherapyforthis.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201215
NeurologyQ014A 63 year old man who has been diagnosed with a glioma is commenced onchemotherapy.4dayslater,hebeginstobehavestrangely,andhassuicidalideation.WhichoneoftheFollowingismostlikely?
A.VincristineencephalitisB.HyponatraemiaC.SteroidpsychosisD.HypoglycaemiaE.Hypocalcaemia
Answer:C)steroidpsychosis.Incidence of steroid associated cognitive changes including psychosis are highparticularlywhenhighdosesteroidsareused(e.g.dexamethaxone).
www
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www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201217
NeurologyQ016A 65 year old man has a history of hypertension. He presents with sudden onsetdysarthria,vomitinghiccupandvertigo.Onexamination,hehasarightsidedHornerssyndrome,rightsidedcerebellarataxia,lossofpainand temperaturesensationontherighthandsideof the face,and lossofpainandtemperaturesensationintheleftupperandlowerlimbs.Whatisthelikelydiagnosis?
A.CerebellarinfarctB.InferiorparietalinfarctC.SuperiortemporalinfarctD.SubthalamicnucleusinfarctE.Lateralmedullaryinfarct
Answer:E)lateralmedullaryinfarct.Inthelateralmedullarysyndrome(inferiorcerebellararteryinvolvement),9thand10thnerveinvolvelementleadstodysphagiaanddysarthria.ThereisalsoipsilateralHornerssyndromeand facialsensory loss,andcontralateralpain/ temperaturesensory loss toupperandlowerlimbs.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201218
NeurologyQ017A60yearoldmanpresentswithdrowsinessandconfusion.Afriendsayshehasbeenconfabulatingabouthavinghiswalletstolen.Onexamination,he isunkempt,hispupilreflexes are normal and eyemovements are normal. Therewere otherwise no focalneurologicaldeficits.ACT scanof thebrain showedmild cerebral atrophy.Hehas aMCVof105fl.Whichdiagnosisismostlikely?
A.TransientglobalamnesiaB.Korsakoff'spsychosisC.Wernicke'sencephalopathyD.Alzheimer'sE.Pick'sdisease
Answer:b)Korsakoff'spsychosis.ThehighMCVsuggestsheavyalcoholdrinking.Heisdelusional(havinghiswalletstolen)and also there are no signs of nystagmus or cerebellar signs to supportWernicke'sencephalopathy.Shorttermmemory loss,amnesiaandpersonalitychangesarealsoseen inKorsakoff'spsychosis.
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Dr.KhalidYusufElzohrySohagTeachingHospital201219
NeurologyQ018A 17 year old boy with mild learning disability presents for assessment. He wasapparentlywell5yearsago,whenhedevelopedjaundicewhichpersistedfor4months.He was found to have difficulty speaking, walking up the stairs and he also hadchoreoathetoidmovementsofthearms.On examination, there was jaundice, but no clubbing, cyanosis or peripherallymphadenopathy. A neurological examination showed weakness and wasting ofmuscles acting on the shoulder and hip joints and brisk deep reflexes. The plantarresponseswere flexor. Therewere no extrapyramidal signs. The patient had KayserFleisherringsconfirmedbyslitlampexamination.Whatisthelikelydiagnosis?
A.NewvariantCJDB.AlzheimersdiseaseC.MotorneurondiseaseD.WilsonsdiseaseE.Picksdisease
Answer:D)Wilsonsdisease.Wilsondisease isarareautosomalrecessive inheriteddisorderofcoppermetabolism.Theconditionischaracterizedbyexcessivedepositionofcopperintheliver,brain,andothertissues.Wilsons disease usually presents at ages less than 40. Hepatic dysfunction is thepresentingfeatureinmorethanhalfofpatients.Apartfromhepatitis,neuropsychiatricpresentation and movement disorders are common presentations. KayserFleischerringsareobservedinupto90%ofindividualswithsymptomaticWilsondisease.Manifestations include dystonia, choreoathetoid movements, spasticity, grand malseizures,rigidity,andflexioncontractures.
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Dr.KhalidYusufElzohrySohagTeachingHospital201220
NeurologyQ019A60yearoldman isonhighdoseprednisolone foradiagnosisofgiantcellarteritis4monthsago.Hecomplainsofaheadache,whichhadworsened forthepastweekanddoublevision.Onexamination,thereisneckstiffness,andrightsided7thnervepalsy.Histemperatureis38degrees.Alumbarpuncturerevealsaproteinof0.8g/l,glucoseof3.5,WCCof30(predominantneutrophils).Whatisthemostlikelycausativeorganism?
A.ListeriamonocytogenesB.MycobacteriumtuberculosisC.MycoplasmapneumoniaeD.BorreliaburgdoferiE.Herpessimplex
Answer:a)listeriamonocytogenes.ThelumbarpuncturefindingsareconsistentwithabacterialmeningitisbuttheglucoseisnotlowenoughtosuggestTB.Listeriamonocytogenesisanaerobicandfacultativelyanaerobicgrampositivebacillus.Theriskoflisteriosisismarkedlyincreasedinimmunocompromised patients, particularly among those undergoing renal transplantation,receivinghighdosesofcorticosteroids,orsufferingwithAIDSorcancer.Ampicillinorpenicillinhasgenerallybeenrecommendedasthetreatmentofchoice.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201221
NeurologyQ020A45yearold ladypresentswithaweek'shistoryofspontaneous,deep,rightshoulderpainradiatingtotheneck.There is also weakness and then wasting of the right deltoid, spinati and tricepsmuscles.Whichisthelikelydiagnosis?
A.SpinobulbardystrophyB.C5andC6myelopathyC.GuillainbarresyndromeD.RotatorcufftendonitisE.Brachialneuritis
Answer:e)brachialneuritis.Idiopathic brachial neuritis is an immunemediated disorder, often preceded by anupperrespiratorytractinfectionorimmunisation.Theinitialfeatureistheabruptonsetofunilateralarmpainorshoulderpain.Thereisalsoevolvingweakness,whichisworst23weeksaftertheonsetofpain.
www.MRCPass.com Neurology
Dr.KhalidYusufElzohrySohagTeachingHospital201222
NeurologyQ021A 60 year oldman presentswith difficultywith hismobility.He has increased tone,bradykinesia,apillrollingtremorandashufflinggait.Whichmedicationshouldbecommencedfirst?
A.BenztropineB.AmantadineC.SelegilineD.ApomorphineE.Cocareldopa
Answer:e)cocareldopa.Cocareldopaisthefirstmedicationusedtoincreasedopaminergicactivityinthebasalganglia. Apomorphine is used for onoff fluctuations. Benztropine is used foranticholinergic side effects. Selegiline is an MAO inhibitor, and Amantadine is anantiviraldrug.Both areused as a second linedrugs.Apomorphine isused foronofffluctuations.
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Dr.KhalidYusufElzohrySohagTeachingHospital201223
NeurologyQ022A50yearoldmanpresentswitha5yearhistoryofheadaches.Thepainhasgraduallyworsenedandisnowpresentdaily,particularlyonwaking.Hedescribesthepainasdull,generalisedandconstant. It isexacerbatedbybright light.Neurologicalexamination isunremarkable.Sheneedstotakeatleasttwoparacetamolandtwotramadoltabletsperday.Whichisthelikelydiagnosis?
A.ClusterheadachesB.AnalgesicinducedheadachesC.MigrainousheadachesD.SpaceoccupyingtumourE.Trigeminalneuralgia
Answer:b)analgesicinducedheadaches.Frequentuseofsomeimmediatereliefmedicationscanresultinrecurringorpersistentheadacheinthosewithpreexistingheadacheandanindividualsusceptibility.Threeormore simple analgesics (aspirin and/ or acetaminophen) a day (more than 1000mg)moreoftenthan5daysaweek.FrequentuseofshortactingNSAIDssuchasibuprofenandalsoopiatebaseddrugscanalsobeacause.
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Dr.KhalidYusufElzohrySohagTeachingHospital201224
NeurologyQ023A60yearoldpatienthasdiplopialookingtotheleft.Whenthelefteyeiscovered,theouterimagedisappears.Whichnerveisinvolved?
A.LeftabducensB.RightabducensC.LefttrochlearD.RighttrochlearE.Leftoculomotor
Answer:a)leftabducens.Covering the affected eye causes the false image (outer image) to disappear. In thiscase,thelefteyeisinvolvedhenceleftlateralrectus(abducensnerve).
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Dr.KhalidYusufElzohrySohagTeachingHospital201225
NeurologyQ024A22yearoldmanhadanaccident3yearsago.DuringthattimehewasdocumentedtohaveaT12lesiononthespinalcord.Henowpresentswithnumbnessonhistrunk.Onexamination,thereisreducedsensationtopinprickfromT6toT10.Whatisthemostlikelycauseofthis?
A.BrownsequardsyndromeB.SubacutecombineddegenerationofthecordC.AnteriorspinalarterythrombosisD.PosttraumaticsyrinxE.Arteriovenousmalformation
Answer:D)posttraumaticsyrinx.Posttraumaticsyringomyelia(PTS)referstothedevelopmentandprogressionofacystfilledwith cerebrospinal fluid (CSF)within the spinal cord. Other symptoms includeincreasedweakness, numbness, increased spasticity, and hyperhidrosis (increased sweating).Ascendingsensorylevelandsensorydissociation(selectivelossofpainandtemperaturesensation) are very sensitive indicators for detecting progressive PTS. MRI is thepreferredinitialimagingstudyforthediagnosisofPTS.
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Dr.KhalidYusufElzohrySohagTeachingHospital201226
NeurologyQ025A42yearoldwomanpresentswithahistoryofheadaches.Shealsoreportsmenstrualirregularities. On examination, she was noted to be obese. Fundoscopy revealedbilateralpapilloedema.Tone,powerandreflexesinthelimbswerenormal.InvestigationsshowanormalCTscanandMRI.EEGnormal.Lumbarpuncture revealselevatedCSFpressurebuttheconstituentsofCSFarenormal.Inthisparticularpatient,whichoftheFollowingwouldsuggestthatacomplicationhasarisen?
A.BitemporalhemianopiaB.LossofcolourvisionC.4thnervepalsyD.VisuallossE.Torticollis
Answer:d)visualloss.Thediagnosisisidiopathicintracranialhypertension(benignintracranialhypertesion).Inthisconditionpapilloedemamayresultinanenlargedblindspot.Uniocularvisual losswouldsuggest infarctionoftheopticnerveconsequentonsevereandlongstandingpapilloedema.
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Dr.KhalidYusufElzohrySohagTeachingHospital201227
NeurologyQ026A 70 year old man presents with sudden onset dysphagia and dysarthria, vomitinghiccupandvertigo.Onexaminationhehasa right sidedHorners syndrome, rightsidedcerebellarataxia,lossofpainand temperaturesensationon the righthandsideof the faceand lossofpainandtemperaturesensationintheleftupperandlowerlimbs.Whereisthelesion?
A.PonsB.LateralmedullaC.CerebellumD.MidbrainE.Tectum
Answer:b)lateralmedulla.Thepatienthasthelateralmedullarysyndrome.Multipleareasare involved :9thand10thnerve dysphagiaanddysarthriaVestibularnuclei vertigo Inferior cerebellar peduncle ipsilateral cerebellar ataxiaDescendingautonomicfibresHornerssyndromeFifthnervenucleuslossofpainandtemperaturesensationover the face (ipsilateral) Lateral leminiscus lossofpain and temperaturesensationinthecontralaterallimbs
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Dr.KhalidYusufElzohrySohagTeachingHospital201228
NeurologyQ027Apatientpresentswithweaknessofkneeextensionandankleinversion.WhichoftheFollowingnerverootscouldbedamaged?
A.L2B.L3C.L4D.L5E.S1
Answer:c)L4.L4 is involved in kneeextension and ankle inversion.The tibialnerve carries L4& L5roots.
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Dr.KhalidYusufElzohrySohagTeachingHospital201230
NeurologyQ029A42yearoldladypresentswithweakness,diplopiaandfatigue.Shehasapastmedicalhistoryofrheumatoidarthritis.Onexamination therewasbilateralpartialptosis andweaknessofabductionofbotheyes.Whatisthelikelydiagnosis?
A.MyastheniagravisB.MononeuritismultiplexC.GuillainBarrsyndromeD.ParaneoplasticsyndromeE.LambertEatonmyasthenicsyndrome
Answer:a)Myastheniagravis.The most likely diagnosis is myasthenia gravis. There is an association betweenmyastheniagravis,perniciousanaemia, systemic lupuserythematosisand rheumatoidarthritis.The condition ismorecommon inwomenwithapeak incidencearound theage of 30. It characterised by fatiguability of the proximal limbmuscles, ocular andbulbarmuscles.Reflexesareinitiallypreservedbutmaybefatiguable.
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Dr.KhalidYusufElzohrySohagTeachingHospital201231
NeurologyQ030A 30 year old man presents with a 6 month history of recurrent episodes alteredbeaviour. During these episodes, he develops amotionless starewith associated lipsmacking,grimacing,chewingmovements,scratchingorgesturing.Hispartnerdescribeshimashavinglabileemotions,hemaygetsuddenoutburstsofaggressionoragitation.WhichoftheFollowingisthelikelydiagnosis?
A.TransientglobalamnesiaB.FrontallobeepilepsyC.TemporallobeepilepsyD.ParietallobelesionE.Migraine
Answer:c)temporallobeepilepsy.The featuresof seizuresbeginning in the temporal lobe canbeextremelyvaried,butcertain patterns are common. In temporal lobe epilepsy, theremaybe amixture ofdifferent feelings, emotions, thoughts, and experiences, which may be familiar orcompletely foreign.Temporal lobeepilepsymay, forexample,causesuddenoutburstsof unexpected aggression or agitation, or it may be characterized by auralikephenomena.Complexpartialseizuresarecharacterizedbyimpairedawareness.Theyloseawarenessand tend to have a motionless stare accompanied by automatisms stereotyped,repetitive, involuntarymovements such as lip smacking, chew ing,picking atobjects,scratching,andgesturing.In some cases, a series of oldmemories resurfaces. Hallucinations of voices,music,people, smells,or tastesmayoccur.These features are called aurasor warnings.Theymaylastforjustafewseconds,ormaycontinueaslongasaminuteortwo.Carbamazepineandphenytoinareusedtotreatthecondition.
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Dr.KhalidYusufElzohrySohagTeachingHospital201232
NeurologyQ031A55yearolddruguserwho ishomelesspresentswith lethargy.Generalexaminationrevealspoorhygieneandasacralsore.Hehasbilateralptosis,anddifficultyswallowing.Thereisalsogeneralweaknessinalllimbs.Hislethargyisworseintheevenings.WhichoftheFollowingisthelikelydiagnosis?
A.MyastheniagravisB.LamberteatonmyasthenicsyndromeC.BotulismD.MotorneurondiseaseE.HIVneuropathy
Answer:c)botulism.Themain differentials aremyasthenia gravis, LEMS and botulism, but in this contextbotulism ismore likely. Botulism is a paralytic disease caused by the neurotoxins ofClostridiumbotulinum.Woundbotulism,causedbysystemicspreadoftoxinproducedbyorganismsinhabitingwounds,trauma,surgeryandsubcutaneousheroininjection.Theneurologicsymptomatologyoftenhasbeendescribedasaprogressive,descendingweaknessorparalysisthataffectsmusclesinnervatedbythecranialnerves.Respiratorydifficulty arises from airway obstruction and diaphragmatic weakness. Diplopia,dysarthria, dry mouth, and generalized weakness are among the most commonpresentingsymptoms.
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Dr.KhalidYusufElzohrySohagTeachingHospital201233
NeurologyQ032A50yearoldteacherdevelopsasidedfacialweakness inassociationwithhearinglossandpainintherightear.On examination, there is a vesicular rash over the right ear, and right lowermotorneuron7thnervepalsy.Whatisthelikelycause?
A.LymediseaseB.HerpeszosterC.DiabetesD.PolyarteritisnodosaE.Syphilis
Answer:b)herpeszoster.ThisisRamsayHuntsyndrome.TheprimarypathophysiologyofRamsayHuntsyndromeislocatedinthegeniculateganglionoftheseventhcranialnerve(CNVII).Classically,RamsayHuntsyndromehasbeenassociatedwithVZV. It isassociatedwith7thnervepalsy,vertigo,ipsilateralhearinglossandtinnitus.
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Dr.KhalidYusufElzohrySohagTeachingHospital201234
NeurologyQ033A55yearoldmanhas leftsidedhearing lossandvertigo.Onexamination,hehasanabsentcornealreflexontheleft.Thereisalsomildleftsidedfacialweakness.WhichoneoftheFollowingismostlikely?
A.FrontallobetumourB.CavernoussinusthrombosisC.RamsayHuntsyndromeD.CerebellopontineangletumourE.Syringomyelia
Answer:D)cerebellopontineangletumour.Cerebellopontine angle (CPA) tumors can cause vertigo,unilateralhearing loss. Largetumors may cause subtle facial weakness, decreased corneal reflex, and facialdysesthesia. If there was opthalmoplegia or chemosis, then a cavernous sinusthrombosiswouldbemorelikely(itcanalsocauseabsentcornealreflexes).
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Dr.KhalidYusufElzohrySohagTeachingHospital201236
NeurologyQ035A35yearoldwomanwakesupwithasuddenonsetseveresharpheadache.Shehasnoneurologicalsigns.CTofherheadisnormal.Whatisthebestnextinvestigation?
A.MRVB.LumbarpunctureC.SerumelectrophoresisD.EEGE.Bonescan
Answer:b)lumbarpuncture.Thediagnosisofsubarachnoidhaemorrhageneedstobeexcludeinapatientwithacutesudden onset severe headache. The CSF sample should be sent for xanthochromia.Lumbarpuncture isrecommended12hoursaftertheeventtoallowxanthochromiatodevelop. It is a yellow ish pigment (subtle and needs spectrophotometry) whichindicatesthepresenceofbilirubinintheCSF.
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Dr.KhalidYusufElzohrySohagTeachingHospital201237
NeurologyQ036A30yearoldmanhasahistoryofepilepsy.HewasfoundonthestreethavingaseizureandwasbroughttoA+E.Rectaldiazepamhadbeengivenbytheambulancecrew.Hisseizurelastsmorethan15minutes.Whatisthebestmanagementstep?
A.IntravenouslorazepamB.IntravenousphenytoinC.OralcarbamazepineD.IntravenousphenobarbitoneE.CTscanofthehead
Answer:b)intravenousphenytoin.Thispatienthasstatusepilepticus.Hehasnotrespondedtoabenzodiazepineandhencethenextstepistoloadwithintravenousphenytoinatadoseof15mg/kg.
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Dr.KhalidYusufElzohrySohagTeachingHospital201239
NeurologyQ038A 45 year oldwoman has sensory loss andwasting of the small handmuscles.Oneexamination, she also has a right sided Horner's syndrome. Her arms demonstratethickeningofthesubcutaneoustissues.ThereisalsoevidenceofCharcotsjointsonthewrists.Whatisthediagnosis?
A.HereditaryspinocerebellarataxiaB.HereditaryspasticparaparesisC.MotorneurondiseaseD.SyringomyeliaE.Multiplesclerosis
Answer:d)Syringomyelia.Syringomyelia is chronicdisorder characterisedby thepresenceof gliallined cavitiessituatedinthecentralpartofthespinalcord.Recognised causes include Chiari type I malformation, central cord tumours, basalarachnoiditisandtrauma.Theremaybesensoryloss,wastingofthesmallhandmuscles,uniorbilateralHornerssyndrome,abnormalitiesofsweating,thickeningofsubcutaneoustissues,atrophyanddecalcificationofbones,developmentofCharcotsjointsandChiariImalformation(duetoarachnoiditis).
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Dr.KhalidYusufElzohrySohagTeachingHospital201240
NeurologyQ039A27yearoldladypresentswithasevereheadache,whichwokeherupfromsleep.Sheis not pregnant and was on no drugs in particular she was not on hormonalcontraception.Onexaminationshewasafebrileandalert.Onexaminationoftheopticfundus the cup of the optic discwas filled and themedialmargins of the discwereblurred.TherewasnootherCNSabnormality,inparticularnoneckstiffness.ACTscanwasasnormal.Whatisthelikelydiagnosis?
A.MeningiomaB.SagittalsinusthrombosisC.BenignintracranialhypertensionD.MigraineE.Meningitis
Answer:b)sagittalsinusthrombosis.Thisisthemostlikelycause,despitenotbeingpregnantorontheOCP.Inonly10%ofcases is cerebral venous thrombosis due to damage to the vesselwall by infection,tumourortrauma.Commonest causes are inherited disorders of coagulation of which factor V Leidenmutation is found in around 20% of cases. Often there is combination of causativefactors:e.g.proteinSdeficiencyandchildbirth,pregnancyandBehcet'sdisease,OCPandfactorVLeidenmutation.
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Dr.KhalidYusufElzohrySohagTeachingHospital201241
NeurologyQ040A 25 year old female patient presents with a 5day history of ascending muscleweaknessinbothhandsandfeet.EMGsconfirmacutedemyelinatingsensoryandmotorneuropathy.Whattreatmentshouldbestarted?
A.PhenytoinB.DiazepamC.AmitriptylineD.IntravenousimmunoglobulinE.Pyridostigmine
Answer:d)intravenousimmunoglobulin.The diagnosis is Guillain Barre syndrome. It is preceded by diarrhea (e.g.campylobacter) and chest infections (e.g. mycoplasma) in two thirds of cases.Autonomic dysfunction and hyporeflexia are associated. Studies have shown thatplasmaexchange and IVIg areequallyeffective in treatingpeoplewithin two to fourweeksofonsetofGBS.
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Dr.KhalidYusufElzohrySohagTeachingHospital201243
NeurologyQ042Apatienthas,onexamination,weakness inplantar flexionand foot inversionon theleft.Healsoisunabletotiptoeonthesamefoot.Anklejerkisabsent.Whichnervelesionismostlikely?
A.CommonperonealnerveB.L4nerverootC.TibialnerveD.SciaticnerveE.Femoralnerve
Answer:c)tibialnerve.Thetibialnervesuppliesthegastrocnemiusmuscleandleadstotheabovefindings.Thecommonperonealnervecausesweaknessofeversionanddorsiflexion.
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Dr.KhalidYusufElzohrySohagTeachingHospital201244
NeurologyQ043A50yearoldmanhassubjectivelydiminishedlighttouchandpinpricksensationinthelefthandextendingtoabovetheelbow.Jointpositionsense is intact.Hehasdifficultydistinguishingacigarettefromapenusingtherighthandwithhiseyesclosed.Histwopointdiscriminationis11mm.Whereisthelesion?
A.AnteriorfrontalB.PosteriorfrontalC.AnteriorparietalD.PosteriorparietalE.Cingulategyrus
Answer:c)anteriorparietal.Thesensorysignsdescribedhereareindicativeofalesionoftheanteriorparietalcortex(mid postcentral gyrus). The cingulate gyrus is part of the limbic system (mood andemotions).
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Dr.KhalidYusufElzohrySohagTeachingHospital201245
NeurologyQ044A55yearoldmanhasbeenprogressivelygettingmoreconfused.Hissymptomsbeganaboutthreeyearsagowhenhenoticedlegstiffness.Atpresenthisentirebodyfeelsstiffandhehasarestingtremorinthelimbs.Hiswritinghasbecomesmall.Overthelastsixmonths,hehasdevelopedhallucinationsand reports seeingghost figures,and isalsobecomingforgetful,ononeoccasionleavingthegascookerfireon.Onexamination,hisminimental scorewas10/30.Hehas increased tone throughoutwhich is spastic and cogw heeling. There is a tremor in all limbs. Cranial nerveexamination revealsmild restrictionofconjugateupgazeeyemovement.Hisgaitwasshufflingwithatendencytofallbackwards.Whatisthemostlikelydiagnosis?
A.Parkinson'sdiseaseB.Pick'sdiseaseC.LewybodydementiaD.Huntington'sdiseaseE.Motorneurondisease
Answer:c)Lewybodydementia.The combination of progressive cognitive decline, fluctuating symptoms, visualhallucinations, extrapyramidal signs (rigidity and bradykinesia more prominent thantremor)suggestLewybodydementia. It isprogressive.Patientsareatriskoffallsandsyncope. Symptoms and signs of lew y body dementia probably result in part fromdisruptionofinformationflowfromthestriatumtotheneocortex,especiallythefrontallobe.Thecauseismultifactorial.Alteredneuromodulatorand/orneurotransmitterlevels(eg,acetylcholine,dopamine)influencethefunctionofmanyneuronalcircuits.
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Dr.KhalidYusufElzohrySohagTeachingHospital201246
NeurologyQ045A35yearoldpatientpresentedtothehospitalwithgeneralisedunsteadinessandlimbweakness. There was a history of ascending weakness, beginning five days beforeadmission. On examination, she had distalweaknesswith decreased reflexes in thelowerlimbs.Shehada lumbarpuncture.TheresultsoftheCSFshowed7x10^9/l lymphocytes,noerythrocytes,and1.2g/lprotein.EMGsshowedreductionofmeanconductionvelocityandprolongeddistallatency(DL)wereobservedinthemedian,ulnar,andtibialnerves.Whatisthediagnosis?
A.MultiplesclerosisB.ViralmeningitisC.SyphilisD.TrigeminalneuralgiaE.GuillainBarresyndrome
Answer:e)GuillainBarresyndrome.Conditionssuchasviralmeningitisandmultiplesclerosiscausemildproteinelevation(above0.5g).However,GuillainBarresyndromecausesmarkedproteinelevation,oftenapproachingormorethan1g.MIn Guillain Barre syndrome, there is acute demyelination of the nerves, leading toreducedconductionvelocitiesontheEMGs.
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Dr.KhalidYusufElzohrySohagTeachingHospital201247
NeurologyQ046A43yearoldmanpresentswithfrequentheadachesandlossoflibido.Hewasfoundtohave hypopituitarism on investigation. The CT scan shows a pituitary tumour withsuprasellarextension.WhichoftheFollowingstructuresislikelybecompressed?
A.AbducensnerveB.HypothalamusC.TrochlearnerveD.OpticchiasmE.3rdVentricle
Answer:D)OpticchiasmSuperior extension (suprasellar) of a pituitary tumour can lead to compression andinvasionoftheopticchiasmandnerve.
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Dr.KhalidYusufElzohrySohagTeachingHospital201248
NeurologyQ047A32yearoldwomanhasknownmigraine.Shegetsperiodicepisodesofheadacheswithassociatedvisualsymptoms.WhichoneoftheFollowingdrugsshouldbeusedfirstinamigraineattack?
A.IbuprofenB.MethysergideC.SubcutaneoussumatriptanD.OralsumatriptanE.Morphine
Answer:a)ibuprofenInacutemigraineattack,thefirstlinetreatmentsaresimpleanalgesicssuchasaspirin,ibuprofenorparacetamol.Second linetreatment inacutemigrainearethetriptans(e.gsumatriptan)whichworkbyselectivelystimulating5hydroxytriptamine1(5HT1)receptors.
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Dr.KhalidYusufElzohrySohagTeachingHospital201249
NeurologyQ048A30yearoldwomanhasan18monthhistoryofunsteadygait,difficultytospeakandto perform finemovementswith the fingers. She has a history ofmoderate alcoholintake.Neurological examination showed scanning dysarthria, horizontal nystagmus in thelateral gaze, severe bilateral dysmetria in the upper and lower limbs, bilateraldysdiadochokinesis,severegaitataxiaandinabilitytomaintainthesitting.Whatisthediagnosis?
A.Parkinson'sdiseaseB.SubacutecombineddegenerationC.CerebellarsyndromeD.MotorneurondiseaseE.Myastheniagravis
Answer:c)cerebellarsyndrome.Amnemonic for cerebellar signs isVANISHD Vertigo,Ataxia,Nystagmus, Intentiontremor,Scanningspeech,HypotoniaandDysdiadochokinesis.Cerebellarsyndromesarecommonlyduetoalcohol,cerebellarspaceoccupyinglesions,multiple sclerosis, and rarely, inherited sydromes such as Friedrich's Ataxia orSpinocerebellarataxia.
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Dr.KhalidYusufElzohrySohagTeachingHospital201250
NeurologyQ049A 30 year oldman presentswith a 5 day history ofweakness in the arms and legs,accompaniedbytingling.Hehadseveralepisodesofbloodydiarrhoeaillnesstwoweeksago.Onexaminationtherewaslegandarmweaknessandflacciddeeptendonreflexes.Whichtestwouldbesthelpconfirmthediagnosis?
A.EMGB.EEGC.MRID.HIVserologyE.AntiAchantibody
Answer:a)EMG.The diagnosis is likely to be Guillain Barre syndrome. The two best tests are EMG(showsacutedemyelinationchanges)andCSF(raisedprotein).Campylobacterserologyshouldalsobesentforthispatient.
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Dr.KhalidYusufElzohrySohagTeachingHospital201251
NeurologyQ050A70yearoldmanwhohadmultipleepisodesofunilateralamaurosisfugax.Hehasriskfactorsofbeingasmokerandhypertension.Heisonatenololandaspirin.AnECGshowsatrialfibrillation.Carotiddopplersshow80%rightcarotidstenosis.Whatisthemostappropriatemanagement?
A.WarfarinB.Carotidendarterectomy,thenwarfariniseC.ClopidogrelD.Highdoseaspirin300mgwithaprotonpumpinhibitorE.Tighthypertensivecontrol
Answer:b)carotidendarterectomy,thenwarfarinise.As there is > 70% carotid artery stenosis and symptoms suggestive of emboli,endarterectomyisrecommended.Thepatientshouldalsobeanticoagulatedafterwardsinviewofatrialfibrillation.
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Dr.KhalidYusufElzohrySohagTeachingHospital201253
NeurologyQ052A 66 year old man has had longstanding tremors in both his hands and forearms.Examinationrevealsnormaltone,powerandreflexesinhisarms.Thetremorsimprovewhenhedrinksalcohol.Whatisthediagnosis?
A.Parkinson'sdiseaseB.MotorneurondiseaseC.BenignessentialtremorD.PrioninfectionE.Hemiballismus
Answer:c)Benignessentialtremor.TheFollowingfeaturessupportadiagnosisofEssentialTremor:(1)bilateralactiontremorofthehandsandforearms(2)absenceofotherneurologicalsigns,exceptthecogwheelphenomenon(3)mayhaveisolatedheadtremorwithnosignsofdystoniaSecondary criteria includea longdiseaseduration (more than threeyears),apositivefamilyhistoryandbeneficialresponsetoalcohol(notanticholinergics).
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Dr.KhalidYusufElzohrySohagTeachingHospital201256
NeurologyQ055A40yearoldpatienthasbeenhavingfevers,neckstiffnessandconfusion.TherewasapastmedicalhistoryofHIVinfectionanddiabetes.A CT scan was normal and lumbar puncture was performed. The opening pressureduringLPwasnormal,andtherewereelevatedCSFlymphocytes(88),andelevatedCSFprotein(5.5g/l),andalowglucose.GramstainingandIndiainkpreparationrevealed47m,roundbuddingyeastswithcapsuleand810lymphocytesperhighpowerfield.Whatisthediagnosis?
A.MumpsmeningitisB.MycobacteriumtuberculosisC.CryptococcalmeningitisD.CarcinomatousmeningitisE.Meningococcalmeningitis
Answer:c)cryptococcalmeningitis.Cryptococcalmeningitis isoftenseen in immunosuppressedpatients.Theorganism isCryptococcus Neoformans. Meningitis manifests with diffuse, nonfocal findings (eg,alteredmentalstatus,vomiting).ACTscanorMRI inpatientswithcryptococcal infectionmayrevealdiffuseatrophyorcerebraledemawithfocal,homogenous,orcontrastenhancedareas.An India inkpreparation is commonlyusedwithCSF to identify theorganism and tosupport a presumptive diagnosis. If performed correctly, 2550% of patients withcryptococcalmeningitisshowcryptococci.InpatientswithAIDS,amphotericinB isgivenfor2weeks,withorwithout2weeksofflucytosine,followedbyfluconazoleat400mg/dforaminimumof10weeks.
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Dr.KhalidYusufElzohrySohagTeachingHospital201257
NeurologyQ056A young lady visits her neurologist complaining of episodes of generalisedweaknessafterargumentswithherpartner.Shealsocomplainsofseeinggoblinsuponwakingup.Atworkasasecretary,shehasdifficultystayingawakeandmayhavesleepattacks.Whatisthelikelydiagnosis?
A.NarcolepsyB.GeneralisedepilepsyC.PetitmalseizuresD.ObstructivesleepapnoeaE.Jacksonianseizures
Answer:a)narcolepsy.Theconditiondescribedisnarcolepsy.Theepisodesdescribedarelikelytobecataplexy.TheHLAassociationisDQB1,Clomipramineisatricyclicantidepressantwhichmayhelp,thereisearlyREMsleepandhypnagogichallucinationsoccur.
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Dr.KhalidYusufElzohrySohagTeachingHospital201258
NeurologyQ057A68yearoldwomanhasneckpainsandoccipitalheadachesfor2years.Sheisreferredtotheneurologyoutpatientsforassessment.InvestigationsshowedanormalCTofthebrain.CervicalXrayshoweddegenerativechangesofnarroweddiscspacesandlossofcervicallordosis.Whatisthelikelydiagnosis?
A.CerebellarhaemorrhageB.TemporalarteritisC.OccipitalneuralgiaD.EpiduralhaemorrhageE.Cervicalspondylosis
Answer:E)cervicalspondylosis.Incervicalspondylosis,severaloverlappingsyndromesareseen:neckandshoulderpain,suboccipital pain and headache, radicular symptoms, and cervical spondyloticmyelopathy.Examinationfindings includeneckpain,radicularsigns,andmyelopathicsigns.Cervicalspine films can demonstrate disk space narrow ing, osteophytosis, loss of cervicallordosis,uncovertebraljointhypertrophy,apophysealjointosteoarthritis,andvertebralcanaldiameter.
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Dr.KhalidYusufElzohrySohagTeachingHospital201259
NeurologyQ58A 45 year oldwoman is referred to you for investigation of headache. She has hadheadachesfor10years.Initially itrespondedtoproprietarypainkillers,butshe iscurrentlyusingthemaximumdoseofparacetamol,tramadolanddiclofenac.Theheadachesarefrequentthroughoutthedayandlastforhours.Therearenoassociatedvisualsymptoms.Whichisthenextbestmanagementstep?
A.IvaspirinB.CaffeineC.WithdrawalofanalgesicsD.PizotifenE.Sumatriptan
Answer:c)withdrawalofanalgesics.The history of chronic use of analgesics and nature of headaches suggests analgesicinducedheadache.Insomepatientstheheadacheswillimprove.
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Dr.KhalidYusufElzohrySohagTeachingHospital201261
NeurologyQ60A18yearoldmale iswheelchairboundandhasdifficultywithrespiration.Healsohasupperlimbweakness.Whenhewasyoungerhedevelopedmarkedhypertrophyofhismuscles.Blood testsrevealaraisedcreatinekinase.Whatisamusclebiopsylikelytoshow?
A.NecroticmusclefibresB.AbsenceofdystrophinC.ExcessivelipidstorageD.MacrophageinfiltrationE.Vasculiticchanges
Answer:b)absenceofdystrophin.Mutation in the dystrophin gene causes deficiency of dystrophin in Duchenne'smusculardystrophy.Patientsdevelopprogressiveupperandlowerlimbweaknesswithpseudohypertrophyofcalvesandquadriceps.
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Dr.KhalidYusufElzohrySohagTeachingHospital201262
NeurologyQ61A 30 year old lady is found to have a left sided posterior communicating arteryaneurysmoncerebralangiography.WhichoftheFollowingwouldyouexpecttofind?
A.FacialnervepalsyB.LeftpupillaryconstrictionC.SensorylosstotheleftsideofthefaceD.DowngazepalsyE.Thirdnervepalsy
Answer:e)thirdnervepalsy.Aposteriorcommunicatingarteryaneurysmwillcausecompressionofthethirdnerve,and therefore pupillary involvement from compressionof the parasympathetic fibresthatrunontheoutsideofthethirdnerve.Thisleadstoadilatedpupil.Otherfeaturesofathirdnervepalsy includeptosis,anda downandouteye.Upgazeandadduction isaffected.
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Dr.KhalidYusufElzohrySohagTeachingHospital201264
NeurologyQ63A75 yearoldmanhasdysphasia and left sided armweakness.He is known tohavehypertension, asthma and rheumatoid arthritis. In addition he suffered from clusterheadaches.Hesmokes20cigarettesaday.On examination, he has some weakness of the left hand. Visual fields, speech andsensationarenormal.Bloodpressureis190/90mmHg.WhichoftheFollowingismostlikely?
A.PartialposteriorcirculationinfarctB.RighthemispherelacunarinfarctC.RightpontinehaemorrhageD.TotalanteriorcirculationinfarctE.Vertebrobasilarinsufficiency
Answer:b)righthemispherelacunarinfarct.Thehistorysuggests thedysarthriaclumsyhandsyndrome,oneof theclassic lacunarsyndromesthatarestrokesinthesubcorticalregions(orbrainstem)secondarytosmallvesseldisease.Theusualsiteofdamageinthedysarthriaclumsyhandsyndromeistheinternalcapsuleorpons.
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Dr.KhalidYusufElzohrySohagTeachingHospital201265
NeurologyQ64A 65 year old lady presents to the hospitalwith an ataxic gait.On examination, thepatienthaddifficulty standingwithout assistance andminormovementsofherheadandbodycausedvertigo.Therewasmildposturaltremorandmarkedhypotoniaoftherightlimbs,mostlythearm.Finger tonose testingelicitedmarked intention tremoranddisdiadochokinesis in therightarm.Speechwasdysarthricbutcomprehensionwasgood.Whereisthelesionlikelytobe?
A.RightponsB.LeftmedullaC.RightcerebellarhemisphereD.CorpuscallosumE.Rightbasalganglia
Answer:c)rightcerebellarhemisphere.Lesions of the cerebellum (intention tremor, disdiadochokinesis) lead tomotor signsipsilateraltothelesion.
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Dr.KhalidYusufElzohrySohagTeachingHospital201266
NeurologyQ65A25yearoldmanisknowntohaveepilepsy.Hehadageneralizedtonicclonicseizuresfor15minutes.Whatdrugshouldbegiven?
A.IVphenytoinB.IVsodiumvalproateC.IVgabapentinD.IVlamotrigineE.IVlorazepam
Answer:E)IVlorazepam.Current consensus is that a benzodiazepine, notably lorazepam (Ativan), is the initialclassofdrugforthetreatmentofstatusepilepticus.Aphenytoin,phenytoinsodiumorfosphenytoinisthenextdrugtobeadministered.
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Dr.KhalidYusufElzohrySohagTeachingHospital201267
NeurologyQ66A 28 year old woman is 30 weeks pregnant. She complains of a sudden onsetgeneralisedheadache.Onexamination,shehaspupilsarewhichreactivebilaterallyandthere isarightsidedthirdnervepalsy.Whichtestismostappropriate?
A.MRAB.MRVC.MRID.CTheadE.Lumbarpuncture
Answer:b)MRV.Aheadacheinapregnantpatient,withassociatedcranialnervepalsysuggestscerebralvenous sinus thrombosis. Treatment is with intravenous or low molecular weightheparin.
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Dr.KhalidYusufElzohrySohagTeachingHospital201268
NeurologyQ67A45yearoldmanhassevereepisodesofdizzinesswithassociatedvomitingandpaininthe right ear. This occurs once or twice a week. During these attacks he feels thesurrounding environment spinning around. He also mentions a high pitched soundfrequentlybeingpresent.On examination, during an attack, he has right horizontal nystagmus. Audiologicaltestingrevealsrightsidedsensorineuraldeafness.Whatisthediagnosis?
A.VestibularnystagmusB.Meniere'sdiseaseC.BenignparoxysmalpositionalvertigoD.AcousticneuromaE.Cerebellopontineangletumour
Answer:b)meniere'sdisease.Meniere'sdisease is causedbydistensionof theendolymphatic compartmentof theinnerear.ThesymptomsofMeniere'sdiseaseincludevertigo,hearinglossandtinnitus.Thedizzinessisdescribedasaspinningorwhirlingfeelingandmaycauseproblemswithbalance.Somepeople feelnauseatedandvomitduringanattack.Tinnitus refers toaringingorroaringsoundintheear.Othersmaynoticesomehearingloss,especiallywithsoundsthathavealowfrequency.Horizontalnystagmus ismorecommonlyseenonexamination,butverticalnystagmusmayalsooccur.
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Dr.KhalidYusufElzohrySohagTeachingHospital201269
NeurologyQ68A30yearoldgynmasthassuddenonsetvertigoanddizziness.Onexamination,thereishorizontalnystagmus,withafullrangeofeyemovements.Herspeechisslurred.Thereisintentiontremoranddisdiadochokinesiswhichisasymmetrical.Shehasanataxicgait.WhichoftheFollowinginvestigationswouldbemostappropriate?
A.CToftheheadB.MRIandMRAofheadandneckC.MRIwithenhancementD.LumbarpunctureE.Otologicaltesting
Answer:b)MRIandMRAofheadandneck.Theclinicalpicture isofanacuteonsetcerebellarsyndrome,whichsuggestavascularcause.Thiswouldinvolvetheposterior(vertebrobasilar)circulation.Ifheadacheorneckpainwereassociated,avertebralarterydissectionwouldbemostimportanttoexclude.AMagneticResonanceAngiography(MRA)willhelptodiagnosedissection,stenosisorthrombosis.
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Dr.KhalidYusufElzohrySohagTeachingHospital201271
NeurologyQ70A40yearoldmanpresentedwithdoublevisionandwasfoundtohavenormalverticaleyemovements.Onleftlateralgaze,therewasabsenceofadductionoftherighteye,andnystagmusintheabductinglefteye.Thiseyemovementdisordercanbeexplainedbyalesioninthe:
A.LeftcerebellopontineangleB.RightparietalareaC.RightmediallongitudinalfasciculusD.LeftmediallongitudinalfasciculusE.Leftlateralmedulla
Answer:c)rightmediallongitudinalfasciculus.Thediagnosis isright internuclearophthalmoplegiaduetoa lesion intherightmediallongitudinalfasciculus.Thelikelyunderlyingpathologyismultiplesclerosis,othercausesofINOincludeagliomaorvascularlesion.
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Dr.KhalidYusufElzohrySohagTeachingHospital201272
NeurologyQ71A70yearoldmanpresentswithahistoryoffalls.Hehasdifficultyreadingandwalkingdown stairs.Hehasdysarthria,akinesiaand rigidity.Powerof themuscles isnormal,reflexesarebrisk.Whatphysicalsignwillhelptoconfirmthediagnosis?
A.GaitB.EyemovementsC.RombergssignD.AbdominalreflexesE.Plantarreflexes
Answer:b)Eyemovements.Thepatienthasprogressivesupranuclearpalsy parkinsonianfeaturesandgazepalsy.Demonstrationofimpairmentofvoluntarygazewillhelpconfirmthediagnosis.
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Dr.KhalidYusufElzohrySohagTeachingHospital201276
NeurologyQ75A45yearoldmanpresentswithasuddenonsetofheadache in theposteriorregion,associatedwithvomiting.Neurological examination, including fundoscopy is unremarkable apart from slightlybriskreflexes.Thereisnoneckstiffnessorphotophobia.WhichoftheFollowingmanagementoptionswouldbethemostappropriate?
A.CToftheheadandlumbarpunctureB.MRIoftheheadC.CToftheheadD.SkullXrayE.Dischargefromhospital
Answer:a)CToftheheadandlumbarpuncture.Asubarachnoidhaemorrhage(SAH)needstobeexcluded.CTbrainscan isnormal inathird of patientswith SAH.A lumbar puncture to look for xanthochromia in the CSFshouldthenbeperformed.
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Dr.KhalidYusufElzohrySohagTeachingHospital201277
NeurologyQ76A40yearoldpatienthaspresentedwithageneralisedtonicclonicseizureforthefirsttime.Thislastedfor10minutes.Whatadviceshouldbegivenregardingdrivingacar?
A.Nodrivingfor1monthB.Nodrivingfor6monthsC.Nodrivingfor1yearD.DrivingisallowedifEEGisnormalE.DrivingisallowedifCTscanisnormal
Answer:c)nodrivingfor1year.For a single seizure, driving is not permitted for 1 year. Also, a medical review isrequiredbeforeone is todo soand it isa requirement for thepatient to inform theDriverandVehicleLicensingAuthority.
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Dr.KhalidYusufElzohrySohagTeachingHospital201278
NeurologyQ77The sisterof apatientwhodied from a subarachnoidhemorrhagedue to a cerebralaneurysm isworriedand isaskingaboutherchancesofhavingthesameproblem.Shementions that there family history of other deaths from subarachnoid haemorrhage.Sheishowever,asymptomatic.Whatshouldbedone?
A.ReassureandnothingelseB.CTscanofheadC.MRIheadscanD.CerebralangiographyE.Lumbarpuncture
Answer:C)MRIheadscan.Thismay be a case of familial subarachnoid haemorrhage. In thosewho have a firstdegreerelativewhogenuinelysufferedaSAH,theirriskofalsosufferingoneis37timesthatofthegeneralpopulation.MRIisbetterthanCTscanforscreening.Angiographyisdiagnosticbuttooinvasiveforscreening.
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Dr.KhalidYusufElzohrySohagTeachingHospital201280
NeurologyQ79A40yearoldladypresentswithdroopingofhereyelidsanddoublevision.Shedoesnothave proptosis. There is no muscle wasting around the face. She has diplopia ondowngazeduringexaminationandalsoproximalmuscleweaknessofherupper limbs.Myastheniagravisisdiagnosed.Whichdrugismostlikelytoimprovehersymptoms?
A.BetainterferonB.IntravenousimmunoglobulinC.BenztropineD.PyridostigmineE.Bromocriptine
Answer:d)pyridostigmine.The condition described is Mysthenia Gravis rather than Grave's eye disease orMyotonic dystrophy (frontal balding). Pyridostigmine is an anticholinesterase whichreduces acetylcholine breakdown and hence improve symptoms of fatiguability inmyastheniagravis.
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Dr.KhalidYusufElzohrySohagTeachingHospital201281
NeurologyQ80A40yearoldbankclerkpresentswithaheadache,nauseaandptosisof the lefteyewithblurredvision.Shedoesnothavefatiguabilityofhereyemovements.Examinationrevealedswellingon the leftsideof face,proptosisandchemosisof the lefteye, leftmastoidswellingandleftophthalmoplegiainvolvingcranialnerves.Thepupilsizeswereequal.ACTofherheadisnormal.Whatisthelikelydiagnosis?
A.ThirdnervepalsyB.MyastheniagravisC.PituitarytumourD.CavernoussinusthrombosisE.Horner'ssyndrome
Answer:d)cavernoussinusthrombosis.Ahistoryofheadacheandnootherobviouscauseofptosis issuggestiveofcavernoussinus thrombosis. Third nerve palsy is associated with dilated pupil and Horner'ssyndromeisassociatedwithmiosis.ACTcanbenormal,anddiagnosisisconfirmedwithMRI.
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Dr.KhalidYusufElzohrySohagTeachingHospital201282
NeurologyQ81A65yearoldmanpresentswithanepisodeofamnesiaforthesecondtime.2daysagohehadanepisodeofconfusion,accordingtohiswife.Hewas,however,abletohaveanormalconversationdespitehavingbeen foundwandering.After2hours,heabruptlyreturnedtonormalandcouldnotrememberwhathappened.Whatisthemostlikelydiagnosis?
A.AlcoholicencephalopathyB.SubarachnoidhaemorrhageC.ComplexpartialseizureD.TransientischaemicattackE.Transientglobalamnesia
Answer:E)tranbsientglobalamnesia.Transientglobalamnesia(TGA) isatemporaryand isolateddisorderofmemorywhichmaylastseveralhours.Heavyexerciseandthecoldareknownprecipitants.
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Dr.KhalidYusufElzohrySohagTeachingHospital201283
NeurologyQ82A40yearoldmanpresentswithfingerweaknesswhichwasdiagnosedasanulnarnervelesion.WhichoftheFollowingmusclesissuppliedbytheulnarnerve?
A.InterosseiB.LateraltwolumbricalsC.OpponenspollicisD.AbductorpollicisbrevisE.Flexorpollicisbrevis
Answer:a)interossei.The interosseimusclesandmedialtwo lumbricalsaresuppliedbytheulnarnerve.Thelateral two lumbricals (anatomicalposition),opponenspollicis,abductorpollicisbrevisandflexorpollicisbrevisaresuppliedbythemediannerve.
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Dr.KhalidYusufElzohrySohagTeachingHospital201284
NeurologyQ83A35yearoldalcoholicpresentswithunsteadinesswhilstwalking.Onexaminationhehasincreasedtoneandbriskreflexesintherightleg.Proprioceptionisabnormalintheright leg.There is lossofvibrationsense intheright leg.There isdecrease inpainandtemperaturesensationintheleftleg.Whichoneofthefollowingconditionsismostlikelytoberesponsibleforhisweakness?
A.SyringomyeliaB.SubacutecombineddegenerationofcordC.Friedrich'sataxiaD.GuillainBarresyndromeE.BrownSequardsyndrome
Answer:e)BrownSequardsyndrome.Brown Sequard syndrome which describes hemisection of the spinal cord, causesipsilateral UMN signs and proprioception loss (corticospinal tract and dorsal columndecussateat themedulla),andcontralateralsensory loss inpainand temprature (thespinothalamic tracts decussate at the same level). The rest of the conditions(syringomyelia,subacutedegenerationofcord,Friedrich'sataxia)cancausecerebellarsignsorpatchysensorylossbutshouldbebilateral.
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Dr.KhalidYusufElzohrySohagTeachingHospital201286
NeurologyQ85A50yearoldalcoholicisadmittedtoA+Ewithunsteadinessandconfusion.BMis7.Whichisthemostappropriatetreatment?
A.GlucoseB.LorazepamC.IVthiamineD.IVvitaminB12E.IVvitaminK
Answer:c)IVthiamine.ThispatientislikelytohaveWernicke'sencephalopathycausingconfusion.IVthiamineshouldgiventoreducetheprogression.ThisiscontainedinPabrinex.
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Dr.KhalidYusufElzohrySohagTeachingHospital201287
NeurologyQ86A man presents with generalised weakness. On examination, fatiguability wasdemonstrated.AdiagnosisofEatonLambertsyndromewasmade.Whatformofantibodyisfoundinthiscondition?
A.AntiPurkinjeB.AnticholinesteraseC.NeuromuscularjunctionD.PotassiumchannelsE.Voltagegatedcalciumchannels
Answer:E)voltagegatedcalciumchannelsEatonLambertsyndromeisfrequentlyassociatedwithamalignancye.g.bronchial.Thedisorderisassociatedwithantibodiesagainstvoltagegatedcalciumchannels.
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Dr.KhalidYusufElzohrySohagTeachingHospital201289
NeurologyQ88An18yearoldwomanisreferredtotheGPbyherteacher.Theteacherwasconcernedabout frequent episodes of day dreaming during class and poor examination resultsoverthepastyear.WhichoneoftheFollowingneedstobeexcluded?
A.VasovasagalsyncopeB.PseudoseizureC.AnxietydisorderD.VisualhallucinationsE.Absenceseizures
Answer:E)Absenceseizures.Daydreaming in children can be easily confused with absence or complex partialseizures, inwhichstaring isaprominentandcommonfeature.However, lipsmacking,eyeblinking,orstiffeningofmusclegroups iscommonduringseizuresbutnotduringdaydreaming.
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Dr.KhalidYusufElzohrySohagTeachingHospital201290
NeurologyQ89A20yearoldmanpresentswitha6monthhistoryofdepressionandpainfulsensorydisturbanceinbothlegs.Hehasalsobecomeveryconfused.Therearemyoclonicjerksobservedinhislegs.HisMRIscanrevealsthalamichyperintensityandEEGisnormal.Themostlikelydiagnosisis:
A.NewvariantCJDB.Huntington'sdiseaseC.Wilson'sdiseaseD.ProgressivemultifocalleucoencephalopathyE.Paraneoplasticsyndrome
Answer:a)newvariantCJD.NewvariantCJDcommonlypresents inyoungadultspainfulsensorysymptoms inthelower limbs and also psychiatric symptoms. Cognitive impairment, pyramidal signs,myoclonusandprimitivereflexesthendevelop.MRI commonly shows high signal on T2w eighted images in the pulvinar (posterioraspectofthalamus).EEGisoftennormal,unlikesporadicCJD,inwhichtriphasicwavesareobserved.
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Dr.KhalidYusufElzohrySohagTeachingHospital201291
NeurologyQ90A 60 year old woman is admitted with a severe headache. CT scan conforms asubarachnoidhaemorrhage.Sheinitiallymakessatisfactoryprogressbut7dayslaterherlevelofconsciousnessbeginstodeteriorate.Themostlikelycauseofthedeteriorationis:
A.CerebraloedemaB.ConingofthemedullaC.MeningitisD.EncephalitisE.Acutehydrocephalus
Answer:e)acutehydrocephalus.Organised blood in the subarachnoid space may cause obstruction to the flow ofcerebrospinal fluid (impaired absorption in the arachnoid villi). 10% of patients willrequireCSFdiversionorshunting.
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Dr.KhalidYusufElzohrySohagTeachingHospital201292
NeurologyQ91A62yearoldwomanhasseveralepisodesofdizzinessparticularlywhensheturnsherhead.2monthsago,shehadanattackofvertigo,withoutdeafnessortinnitus, lastingfor a few minutes. Over the last month, she had five further attacks of vertigo,accompaniedbymoderateheadache and a lefthomonymoushemianopia, lasting forabout a quarter of an hour. After the last episode she developed persistentunsteadinessofgait,andwasadmittedtohospital.Onexaminationtherewasnormalvisualfields.werefull.Therewasrhythmichorizontalnystagmus, slightweaknessof the rightexternal rectusmusclewithoutdiplopia, andataxiaofgait,provokedbyturning.Thebloodpressurewas160/80mmHg.Whatisthediagnosis?
A.ParietallobeCVAB.FrontallobeCVAC.VertebrobasilarinsufficiencyD.SyringomyeliaE.Brownsequardsyndrome
Answer:c)vertebrobasilarinsufficiency.Vertebrobasilar(posterior)circulationconstitutesthearterialsupplytothebrainstem,cerebellum, and occipital cortex. Bilateral visual loss, dizziness, speech disturbances,dropattacksandtransientglobalamnesiaarefeaturesofvertebrobasilar insufficiency.MRI/MRAaregoodinvestigationstoinvestigateforvertebralorbasilararterialdisease.
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Dr.KhalidYusufElzohrySohagTeachingHospital201293
NeurologyQ92A55yearoldmanhasdevelopedweaknessoverthepast3weekswhichhasaffectedhiswalking.Hehasnosignificantpastmedicalhistory.Onexamination,hehaddecreasedsensationperipherallyinthelegsandalsoflaccidreflexesintheankles.ACToftheheadwasnormalandlumbarpuncturewasdone.Resultswere:protein0.75(
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Dr.KhalidYusufElzohrySohagTeachingHospital201295
NeurologyQ94A60yearold ladypresentswithacuteonsetunsteadinessanddizziness.NeurologicalexaminationshowsarightsidedHornerssyndromeandnystagmus.Thereisalsolossofpainandtemperaturesensationontheleftsideofthetrunkandintheleftarmandleg.Hergaitisataxic.Whichisthecorrectdiagnosis?
A.PosteriorinferiorcerebellararteryocclusionB.MedullaryinfarctC.PosteriorcerebralarteryocclusionD.MiddlecerebralarteryocclusionE.Posteriorcommunicatingarteryhaemorrhage
Answer:a)posteriorinferiorcerebellararteryocclusion.There are a complex of symptoms caused by occlusion of the posterior inferiorcerebellararteryoroneof itsbranchessupplyingthe lowerportionofthebrainstem,resultinginsensoryandsympatheticdisturbances,cerebellarandpyramidaltractsigns,and evidence of partial involvement of the fifth, ninth, tenth, and eleventh cranialnerves.Onsetisusuallyacutewithseverevertigo.Nausea,vomiting,ipsilateralataxia,muscularhypertonicity, pastpointing and other cerebellar signs are often present. Horner'ssyndrome isusuallypresent. Sensorydisturbances include ipsilateral lossofpain andtemperature perception of the face and contralateral hypoesthaesia for pain andtemperatureofthetrunkandextremities.Theaffectedpersonshavedifficultyinswallowing.Personswellover40yearsofagearemostoftenaffected.
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Dr.KhalidYusufElzohrySohagTeachingHospital201297
NeurologyQ96A35yearoldman isadmittedwithacuterightsidedweaknessandslurredspeech.Hedoesnothaveahistoryofhypertension,diabetesorhighcholesterol.ThereisnofamilyhistoryofCVA.Hedoesnot smoke.He complainsofheadachesandgeneralised limbweaknessinfrequently.Onexamination,hehashypotoniaandweaknessintheproximalmusclesmorethanthedistalmuscles.Hislaboratorytestsshowahighlactatetopyruvateratio.Whatisthelikelydiagnosis?
A.PolymyositisB.InclusionbodymyositisC.MELASD.PolymorphonuclearleukoencephalopathyE.Neuroacanthocytosis
Answer:c)MELAS.This patient has MELAS (myopathy, encephalopathy, lactic acidosis and stroke likeepisodes).Lacticacidosisisaveryimportantfeatureofthisdisorder,asmeasuredbyahighlactatetopyruvateratio.However,ingeneral,lacticacidosisdoesnotleadtosystemicmetabolicacidosis,anditmaybeabsentinpatientswithimpressiveinvolvementofthecentralnervoussystem.Patientshaveamyopathy causingproximalmuscleweaknessandhypotonia, seizuresandstrokelikeepisodes.Itisamitochondrialinheriteddisorder.
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Dr.KhalidYusufElzohrySohagTeachingHospital201298
NeurologyQ97A75yearoldladycomplainsofaheadachefor2daysintherightsideofthehead.Thepainisworsewhensheischewingortalking.Shehasalsohadmildfeversandsweats.HerESRis80mm/hr.Thevisionintherighteyeis6/18andherlefteyeis6/6.Whatisthebestcourseofaction?
A.StartivmethylprednisoloneB.OrganiseandawaittemporalarterybiopsyC.CToftheheadtoexcludespaceoccupyinglesionD.MRIofthebrainE.Refertoanophthalmologist
Answer:a)startivmethylprednisolone.Thereareearlysignsofvisuallosssohighdosesteroidsshouldbecommencedwiththesuspicionoftemporalarteritis.Althoughalltheotheroptionsarereasonable,theymaytaketimeandthereshouldnotbedelayincommencingsteroids.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012100
NeurologyQ99A65yearoldmanhasmuscleweakness,particularlyaroundthethighsandshoulders.HisCKis2,200U/l.EMGshowsreducedamplitudeanddurationofmotorunits.Whatisthelikelydiagnosis?
A.DermatomyositisB.MyastheniagravisC.MyotonicdystrophyD.PeripheralneuropathyE.Multiplesclerosis
Answer:a)dermatomyositis.TheseEMGchangesareconsistentwithamyositis.Inmotorneurondisease,fibrillationisseen.Inmyasthenia,thereisdiminishedresponsetorepetitivestimulation.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012101
NeurologyQ100A42 yearoldmanpresents toA+E complainingof severe lowerbackpain Followingcarpentrywork.Thepainradiatestohisleftbuttockandthigh.Onexamination,hewasabletostraightlegraiseto45degreesonlyontheleftside.Thesciatic stretch test is positive.He has difficulty plantar flexing his left ankle and hasabnormalsensationontheplantaraspectofthefoot.Whatisthediagnosis?
A.CaudaequinasyndromeB.L2/L3discprolapseC.L4/L5discprolapseD.L5/S1discprolapseE.Commonperonealnerveinjury
Answer:D)L5/S1disease.AnkledorsiflexionisgenerallysuppliedbyL4/L5andplantarflexionsuppliedbyS1/S2.thiscaseislikelytobeduetosciaticnervepalsy.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012102
NeurologyQ101A60yearoldman isbroughttohospitalhavingcollapsedtothegroundsuddenlyandwasunable tomovehis left legorarm.Therewasno lossofconsciousness.Hehasapastmedicalhistoryofhypertensiononly.Theepisodelastedafewsecondsandhehasbeenrelativelywell.Examinationrevealsamildhemiparesisoftheleftarmandleg.Whichisthelikelydiagnosis?
A.PontinehaemorrhageB.PrimaryepilepsyC.MedullaryhaemorrhageD.RightinternalcapsuleinfarctE.Leftinternalcapsuleinfarct
Answer:d)rightinternalcapsuleinfarct.This patient is likely to have a lacunar infarct involving the internal capsule, causingtransientcontralateralhemiparesis.
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Dr.KhalidYusufElzohrySohagTeachingHospital2012103
NeurologyQ102A25yearoldmanhashadbehaviouraldisturbancerecently.Hisparentsmentionedthathisbrotherhasbeeninvestigatedforliverproblemsrecently.Onexamination,hehasaMMSEscoreof28/30.Hehasamasklikefaceandwasnoticedtohavehypersalivation.Wheninvestigationsarecomplete,whichdrugismostlikelytobeusedfortreatment?
A.DesferrioxamineB.CocareldopaC.PenicillamineD.InterferonalphaE.Chlorpromazine