• Personal information

          

    Prof. of Hepatology & Gastroenterology, Cairo University.

    Consultant of Hepatology,Gastroenterology and Endoscopy

    Management Positions: •

    Chief of Hepatology unit El Manial University Hospital (1994-1998).

    • Chief of Gastroentero ICU in Cairo university hospital (1997-2000)

    • President of the board of AlfaScope GI Specialized center (2004-2014).

    • Head of Endoscopy Unit in Cairo University Hospitals (2005-2010).       

     

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    استاذ الكبد و الجهاز الهضمى بكلية الطب جامعة القاهرة

    استشارى الكبد و الجهاز الهضمى و المناظير

    دكتوراه امراض الكبد و الجهاز الهضمى من كلية الطب جامعة القاهرة

    الرئيس السابق لقسم الامراض الباطنية بكلية الطب جامعة ٦ اكتوبر

    الرئيس السابق لوحدة مناظير الجهاز الهضمى و مركز الكبد و الرعاية المركزة بقصر العينى

     

    إقرأ المزيد

     

About Me

Saturday, Nov 18th

Last update10:09:06 AM

        

Neurology

Introduction

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The revision for cardiology is divided into 5 parts:

1. Enumerate

2. Outine & Mention

Those 2 parts are in the first paper of the examination (Short questions)

3. Problem solving

Represents questions of the second paper

4. MCQs part I

5. MCQs part II 

Those 2 are included in paper 3 of examinatin

Introduction

Enumerate

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Enumerate:

1. Causes of hemiplegia.

2. Causes of spastic paraplegia.

3. Causes of polyneuropathy.

4. Causes of subarachnoid haemorrhage.

5. Causes of coma.

6. Causes of headache.

7. Causes of generalized convulsions.

8. Causes of lost ankle with exaggerated knee reflexes.

9. Causes of atrophy of small muscles of the hand.

10. Causes of Nystagmus.

11. Causes of peripheral neuritis.

12. Causes of headache.

13. Types of epilepsy.

14. Clinical features of Wallenburg syndrome.

15. Causes of chorea.

16. Viruses that may cause encephalitis.

17. Types of aphasia.

18. Causes of Tremors.
19. Causes of Dissociated sensory loss.    

Enumerate

Outline & Mention

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Outline:

1. Leveling of hemiplegia.

2. Clinical features of thrombotic hemiplegia.     

3. Clinical picture of spastic paraplegia.

4. Clinical picture & investigations of cervical (Lumbar) spondylosis.

5. Treatment of parkinsosim.

6. Diabetic neuropathy (Pathogenesis, Clinical, Treatment).

8. Diagnosis of subarachnoid hemorrhage.

9. Posterior inferior cerebellar artery thrombosis.

10. Middle cerebral artery occlusion (causes, diagnosis, treatment).

11. Clinical features of Anterior cerebral artery embolism.

12. Vertebro-basilar system affection.

13. Internal carotid artery thrombosis.

14. TIAs, definition, clinical features, DD, and treatment.

15. Diagnosis & treatment of migraine.

16. Bell’s palsy.

17. Clinical picture, investigations & treatment of acute meningitis.

18. Diagnosis of coma.

19. Diagnosis of Trigeminal neuralgia.

Outline & Mention

Problem solving

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Case 1:

A 30 year-old female complains of frequent headaches in the temporal regions for about 5 years. Just prior to an attack, she complains of blind spots and when the attack becomes severe, she gets nauseated and may vomit. The attacks are not relieved by paracetamol. Her entire physical examination is negative.

1. What is your diagnosis?

2. Mention the precipitating factors for this headache.

3. Outline treatment of this patient?

 

Case 2:

A 30 year old female complains of frequent headaches in the temporal regions for the last few months. The attacks are not preceded by any symptoms and are not associated by nausea, vomiting or blurring of vision. They are not related to type of food or time of menstruation. She does not smoke or drink alcohol and she is not under any regular medications. Her temperature, blood pressure, neurological, ophthalmological, ENT and dentist examination were normal.

1. Enumerate causes of headache.

2. What is your diagnosis for this patient?

3. What is her treatment?

 

Case 3:

A 30 year old female complains of frequent severe headaches for the last few months. She had three attacks of convulsions in her right arm during the last two weeks, which occurred and stopped spontaneously. Her physical examination was completely free.

1. You would you instruct this patient to do what?

          a. To take Sumatriptan at the very beginning of headache.

          b. To do MRI.

          c. To do EEG.

2. Mention the manifestations caused by a parietal lobe lesion?

3. Mention the manifestations caused by a frontal lobe lesion?


Case 4:

A 55 year-old diabetic woman developed weakness of the left side of her face as well as of her right arm and leg. Examination revealed typical features of hemiplegia in the right side together with convergent squint of the left eye and paralysis of the whole left side of the face. BP was 160/90 and the cardiac examination was free.

 

1. Mention typical signs of hemiplegia.

2. What is the cause of hemiplegia in this patient?

3. Where is the level of the lesion in this patient?

4. What is the main investigation in this case?

5. Mention other investigations you would ask for and why?

 

Case 5: A patient complained of lack of sensitivity and a tingling in the legs and feet, as well as weakness of the legs. On examination, there is loss of position and vibration sense in the lower limbs up to the iliac crest, weakness and hyper-reflexes of the legs and bilateral Babinski’s sign.

 

1. What is your diagnosis?

2. What is the common cause of this case?

3. What type of anemia would be present in this case?

 

Case 6:

A 40 year old male, complained of sudden, severe, persistent headache,  confusion and repeated vomiting, together with pain in the back of his neck and in the low back area referred to both lower limbs and blurring of vision. He has no history of any previous medical complaints and he denied history of recent travel to foreign countries. His wife showed the doctor the results of a recent check up results which reveal normal blood glucose, serum creatinine, liver functions & enzymes and normal lipids profile.

Examination of the patient revealed:

- The patient was confused.

- Temperature: 37º C.

- Pulse: 110 beats/minute & regular.

- BP: 140/85

- Heart: free.

 

1. What is your diagnosis?

2. What investigations to do and why?

3. What are the causes for this condition?

Case 7:

A 30 year old male was admitted to the hospital for acute onset of weakness which began in lower limbs, followed by upper limbs.

Examination revealed:

- Weakness with flaccidity of both upper and lower limbs.

- Weakness was bilateral & symmetrical.

- Diminished deep reflexes in upper & lower limbs.

- Bilateral stocking & glove hyposthesia.

The patient gave a history of fever, three weeks before, which lasted for 4 days. CSF examination showed elevated protein level and normal number of cells.

 

4. What is your diagnosis?

5. Mention the investigations to be done and the expected results?

6. Outline treatment of this patient?

 

Case 8:

      A male patient presented with right sided cerebellar ataxia. In the past 6 months he complained of severe headache and occasional projectile vomiting. Fundus examinationrevealed papilloedema.

 

1. Enumerate causes of cerebellar ataxia.

2. What is your diagnosis of the case?

3. What are the investigations you would ask for?

 

Case 9:

A 77 year old male presented with weakness of both right upper and lower limbs that developed over few hours. On examination right hemihyposthesia and upper motor neurone facial nerve palsy were found. His BP was 170/120, he was diabetic on oral drugs. He was drowsy. Vision was intact with early diabetic retinal changes.

 

1. What is the diagnosis? where is the site of the lesion?

2. Mention the investigations you will order and their relevance.

3. Outline his treatment on admission.

4. After his discharge from the hospital outline your strategy for his treatment and prevention of recurrence of another stroke?

 


Case 10:

A 63 year old worker was admitted to the hospital 3 hours after the onset of severe chest pain. His blood pressure was 180/115 and the ECG showed extensive anterior myocardial infarction. On the third day of hospitalization he developed sudden complete right hemiplegia.

 

1. What are the most likely causes of his hemiplegia?  

2. How to investigate this case?

 

Case 11:

A middle aged man complained of headache for the last 2 months. On examination there was left cerebellar ataxia. His fundus showed papilloedema. Nystagmus was detected.
1. Enumerate causes of unilateral ataxia.
2. What is your diagnosis of the case?
3. What are the investigatons needed to confirm the diagnosis ?

Case 12:

A 72 year old diabetic male presented to the emergency department with gradual onset of hemiplegia and drowsiness. On examination his blood pressure was 210/120 his pulse was 80/mn and regular. examination revealed a Glasgo coma scale of 8 and he had a complete right hemiplegia.

 

1. What is the likely diagnosis?

2. Mention the investigations you would like to order for him.

3. Outline his at this phase.

 

Two days later he regained consciousness but he was aphasic.

 

4. What was the site of the lesion?

5. What is your long term plan of therapy?

 

Case 13:

A 30 year old female presented with recurrent attacks of hemiplegia.

On examination she had left complete hemiplegia and right cerebellar ataxia. Her fundus showed blurring of the left optic disc.

 

1. What is the likely diagnosis?

2. What are the investigations needed to prove the diagnosis?

3. How would you treat her? 

Problem solving

MCQs part I

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Case 1:

1. You evaluate a 38-year-old man who complains of muscle weakness. His appearance is remarkable for a peri-orbital heliotrope rash with edema and erythema on his upper chest, neck, and face. Which of the following is the most likely diagnosis?

 

(A) Polymyositis

(B) Dermatomyositis

(C) Spino-cerebellar degeneration

(D) Vasculitis

(E) Rheumatoid arthritis

 

2. Which of the following examination findings would this patient most likely have?

(A) Proximal muscle weakness

(B) Distal muscle weakness

(C) Ataxic gait

(D) Hyperactive deep tendon reflexes

(E) Inflamed small joints

 

3. Which of the following blood parameters is likely to be elevated?

(A) Serum creatinine

(B) Serum potassium

(C) Serum sodium

(D) Rheumatoid factor

(E) Creatinine phosphokinase

 

Case 2:

A 70-year-old man presents with shuffling gait, tremor, masked facies, and rigidity which have progressed over the last 9 months. Parkinson’s disease is diagnosed.

 

1. In this patient, which neurotransmitter deficiency primarily is responsible for his symptoms?

(A) Acetylcholine

(B) Epinephrine

(C) Norepinephrine

(D) Dopamine

(E) Cortisol

 

2. Which of the following is not true about Parkinson’s disease?

(A) Over 1 million people in North America have Parkinson’s disease.

(B) Mortality is higher in patients with Parkinson’s disease when compared to age-matched controls.

(C) The classic triad of major signs of Parkinson’s disease is tremors, rigidity, and akinesia.

(D) The tremor in Parkinson’s disease is typically an intention tremor.

(E) Over 90% of patients with Parkinson’s disease have a good initial response to levodopa.

 

Case 3:

A 63-year-old man complains of sudden onset of right-sided headache while at work. He rapidly becomes confused and lethargic. On examination, he is hemiparetic and has bilateral Babinski signs. A CT scan of the head demonstrates a large hemorrhage in the region of the right basal ganglia with a surrounding zone of edema and narrowing of the ventricle.

What is the patient most likely to have?

 

(A) An arterio-venous malformation

(B) A carotid occlusion

(C) Hypertension

(D) An underlying malignancy

(E) Abnormal clotting studies

 


Case 4:

A 44-year-old woman dies as a consequence of a "stroke". At autopsy, she is found to have a large right basal ganglia hemorrhage. She has an enlarged 550 gm heart with predominantly left ventricular hypertrophy. Her kidneys are small, about 80 gm each, with cortical scarring, and microscopically they demonstrate small renal arterioles that have luminal narrowing from concentric intimal thickening. Which of the following is the most likely diagnosis?

A Dominant polycystic kidney disease

B Arterial changes with diabetes mellitus

C Vascular disease with hyperlipidemia

D Malignant hypertension

E Monckeberg's sclerosis

 

Case 5:

A 51-year-old woman has had several syncopal episodes over the past year. Each episode is characterized by sudden but brief loss of consciousness. She has no chest pain. On physical examination her vital signs show T 36.9 C, P 80/minute, RR 20/minute, and BP 110/75 mm Hg. She has no pedal edema. A chest radiograph shows no cardiac enlargement, and her lung fields are normal. Her serum total cholesterol is 165 mg/dL. Which of the following cardiac lesions is she most likely to have?

A Cardiac amyloidosis

B Left atrial myxoma

C Tuberculous pericarditis

D Mitral valve prolapse

E Ischemic cardiomyopathy

 

 


Case 6:

Top of Form

A 70-year-old man has a 2 day history of worsening generalized headache and increasing disturbed conscious. He now complains of stiffness in his neck. On physical examination vital signs include T 38.7 C, pulse 85/minute, respirations 23/minute, and blood pressure 130/85 mm Hg. A CBC reveals a WBC count of 16,850/micro liter. Serum electrolytes include glucose of 88 mg/dL. A lumbar puncture yields cloudy cerebrospinal fluid with a glucose of 32 mg/dL, protein 146 mg/dL, and cell count of 3800 WBCs (95% PMNs and 5 % mononuclears) and 122 RBCs. He receives antibiotic therapy and improves. Which of the following long-term complications is most likely to develop from this man's current disease?

A Cerebral infarction

B Cerebellar tonsillar herniation

C Encephalitis

D Hydrocephalus

E Subdural hematoma

 

Case 7:

A 50-year-old African-American man has had headaches for the past month. On physical examination his blood pressure is 182/108 mm Hg. He cannot afford to take any medications. He is admitted to the hospital after suddenly losing consciousness 2 months later. When he is aroused, he cannot speak and he cannot move his right arm or his right leg. Which of the following intracranial pathologic abnormalities is most likely to be present?

A Middle cerebral artery embolus

B Subfrontal meningioma

C Cerebral venous thrombosis

D Central pontine myelinolysis

E Basal ganglia hemorrhage


Case 8:

A previously healthy 31-year-old woman experiences a severe headache and loses consciousness within an hour. An emergent head CT scan reveals extensive subarachnoid hemorrhage at the base of the brain. She is afebrile. A lumbar puncture yields cerebrospinal fluid with many red blood cells, but no white blood cells. The CSF protein is slightly increased, but the glucose is normal. Which of the following is the most likely diagnosis?

A Acute bacterial meningitis

B Ruptured berry aneurysm

C Progressive multifocal leukoencephalitis

D Tay-Sachs disease

E Parkinson disease

Case 9:

Top of Form

A 48-year-old woman has the sudden onset of a severe headache. On physical examination there are no localizing neurologic signs, but she is minimally responsive. A cerebral angiogram demonstrates marked narrowing of cerebral artery branches near the base of the brain, consistent with vasospasm, but no intra-parenchymal hemorrhage is present. Laboratory studies show serum urea nitrogen of 50 mg/dL. An ultrasound scan of the abdomen shows bilaterally enlarged cystic kidneys. Which of the following is the most likely diagnosis?

A Bacterial meningitis

B Severe atherosclerosis

C Malignant hypertension

D Cerebral edema

E Subarachnoid hemorrhage

Case 10:

A 39-year-old woman with cough and fever for 10 days has had a worsening headache for the past week, along with increasing obtundation. On physical examination her temperature is 38.2 C. A head CT scan reveals a solitary 3 cm diameter lesion with ring enhancement located in the right parietal lobe. A stereotactic biopsy is performed and a frozen section shows granulation tissue with adjacent collagenization, gliosis, and edema. Which of the following is the most likely diagnosis?

A - Chronic brain abscess

B - Aspergillosis

C - Progressive multifocal leukocencephalopathy

D - Toxoplasmosis

E - Rabies virus infection

Case 11:

A 66-year-old man is finding that he has more difficulty moving about for the past year. He is annoyed by a tremor in his hands, but the tremor goes away when he performs routine tasks using his hands. His friends remark that he seems more sullen and doesn't smile at them, but only stares with a fixed expression on his face. He has not suffered any loss of mental ability. Which of the following diseases is he most likely to have?

A Amyotrophic lateral sclerosis (ALS)

B Alzheimer disease

C Parkinson disease

D Niemann-Pick disease

E Tuberous sclerosis

 

 

Case 12:

Top of Form

A 26-year-old previously healthy woman has the sudden onset of mental confusion. She has a seizure and is brought to the hospital. Her vital signs show temperature 37 C, pulse 89/minute, respirations 22/minute, and blood pressure 100/60 mm Hg. A lumbar puncture reveals a normal opening pressure, and clear, colorless cerebrospinal fluid is obtained with 1 RBC and 20 WBC's (all lymphocytes), with normal glucose and protein. MR imaging of her brain reveals swelling of the right temporal lobe with hemorrhagic areas. Which of the following infectious agents is the most likely cause for her findings?

A Herpes simplex virus

B Influenza virus

C Mycobacterium tuberculosis

D Hemophilus influenzae

E Neisseria meningitides

 

Case 13:

A 50-year-old man was involved in a vehicular accident in which he was not wearing any restraint device and struck his head against the windshield of his van. He did not lose consciousness at that time or at any point thereafter. Physical examination showed a minor contusion to his forehead. However, a month later he began complaining of headaches, becoming irritable and acting strangely. Which of the following intracranial vascular abnormalities most likely developed in this man?

A Epidural hematoma

B Chronic subdural hematoma

C Cerebral contusions

D Subarachnoid hemorrhage

E Intracerebral hematoma

 


Case 14:

A previously healthy 42-year-old former football player developed progressive, symmetric muscular weakness of his upper extremities along with fasciculations over the course of 3 years. Then he developed difficulty speaking and swallowing. He did not have myalgias or arthralgias. He remained afebrile. His mental function never became diminished. Which of the following is the most likely diagnosis?

A Amyotrophic lateral sclerosis

B von Recklinghausen disease

C Multiple sclerosis

D Werdnig-Hoffman disease

E Guillain-Barré syndrome

 

Case 15:

A 20-year-old man has recently been inducted into the army. Several weeks into basic training, he experiences a severe headache for an entire day. He had been healthy prior to this, noting only a mild sore throat the prior day. He goes to the base physician, who records vital signs: T 39.2 C, P 90/minute, RR 19/minute, and BP 110/70 mm Hg. A lumbar puncture is performed and examination of the cerebrospinal fluid shows 2 RBC's/microliter, 4,000 WBC's/microliter, glucose of 20 mg/dl (serum 75 mg/dL), and CSF protein of 105 mg/dL. Which of the following additional laboratory tests on the CSF would be the most helpful in reaching a diagnosis in this case?

A Serology for cryptococcal antigen

B Acid fast stain

C India ink preparation

D Serology for Herpes simplex virus

E Gram stain


Case 16:

A 43-year-old woman develops progressive, ascending motor weakness over the past 4 days. She is afebrile. She is hospitalized and requires intubation with mechanical ventilation. A lumbar puncture is performed and normal opening pressure is noted. The CSF is clear and colorless with glucose of 65 mg/dL (serum 100 mg/dL), protein 95 mg/dL, and cell count 5/microliter, all lymphocytes. She gradually recovers over the next month. Which of the following conditions most likely preceded the onset of her neurologic disease?

A Ketoacidosis

B  Guillain-Barré syndrome

C Staphylococcus aureus septicemia

D Systemic lupus erythematosus

E Vitamin B12 deficiency

 

Case 17:

A 50-year-old woman suddenly loses consciousness. On examination in the emergency department, her temperature is 37 C, pulse 79/minute, respirations 18/minute, and blood pressure 160/95 mm Hg. A head CT scan shows a 4 cm area of bright attenuation in the left basal ganglia region. There is effacement of the lateral ventricles and a shift of the midline to the right. Through which of the following mechanisms is death in the patient most likely to occur?

A Cerebellar tonsillar herniation

B Intraventricular hemorrhage

C Widespread metastases

D Septicemia

E Extensive watershed infarction


Case 18:

A 45-year-old woman noticed tinnitus in her left ear which progressed over 5 weeks to unilateral hearing loss. On physical examination she has a marked decrease in hearing on the left, with Rinne test indicating air conduction better than bone conduction. The other cranial nerves I - VII and IX - XII are intact. Brain MR imaging reveals a solitary, circumscribed 3 cm mass located in the region of the left cerebellopontine angle. Which of the following statements is most appropriate to tell the patient regarding these findings?

A You are unlikely to survive for more than a year

B Remissions and exacerbations are likely to occur in coming years

C Other family members should undergo MR imaging of the brain

D The lesion can be resected with a good prognosis

E A test for HIV-1 is likely to be positive

Case 19:

A 53-year-old woman has had transient ischemic attacks (TIAs) for 3 years. She then has the sudden onset of a left hemiparesis. Four months later, brain MR imaging shows a 4 cm diameter cystic area in the right frontal-parietal region. Which of the following underlying conditions is she most likely to have?

A Occlusive coronary atherosclerosis

B Chronic meningitis

C Alzheimer disease

D Glioblastoma multiforme

E Cerebral arterial vasculitis

Case 20:

Top of Form

A 54-year-old woman has noted changes in sensation in her legs for the past 5 months. On physical examination she has a distal, symmetric, primarily sensory polyneuropathy. She also has a non-healing ulceration on the ball of her left foot. She had a myocardial infarction last year but recovered and is doing well following angioplasty. Which of the following laboratory test findings would you most likely expect to be present in this woman?

A CSF protein of 110 mg/dL

B Positive herpes simplex virus serology

C Blood lead of 50 micrograms/dL

D Chromosome analysis with a 47, XX, +21 karyotype

E Serum glucose of 195 mg/dL

 

Case 21:

A 50-year-old man is noted by his wife to have undergone personality changes over the last year. In the past, he was noted to be obsessive-compulsive, but he became careless and now does not appear to take an interest in his work. He has become more forgetful. On physical examination he has frontal release signs (grasping & groping) and memory loss. He appears unconcerned about his illness. MR imaging of the brain is performed and shows a 3 cm diameter left frontal lobe mass with areas of calcification. Which of the following diagnoses is most likely to be made on microscopic examination of this mass?

A Thrombosed berry aneurysm

B Oligodendroglioma

C Schwannoma

D Organizing abscess

E  Remote infarct


Case 22:

A 22-year-old man has recently emigrated from Mexico City. He has the sudden onset of a seizure disorder while working as a chef in a restaurant. On physical examination he is afebrile. No papilledema is noted. MR imaging of his brain reveals a 2 cm rounded cyst in the right temporal lobe cortex and another 1.5 cm cyst in the subarachnoid space over the left parietal lobe. Both lesions are non-enhancing. A lumbar puncture yields colorless CSF under normal pressure. The CSF protein and glucose are normal, and there are 5 WBCs/microliter (4 monos, 1 PMN). Which of the following conditions most likely to cause these findings?

A Metastatic adenocarcinoma

B HIV encephalopathy

C Left atrial mural thrombosis

D Cysticercosis

E Hypertension

 

Case 23:

A 61-year-old man has had a chronic cough for 6 years as a result of smoking 2 packs of cigarettes per day for 45 years. He has noted the onset of headaches over the past 2 weeks. His physician on neurologic exam can find no localizing signs. MR imaging of the brain reveals a solitary 3.5 cm lesion that is located at the grey-white junction in the posterior left frontal lobe. There is no ring enhancement. A stereotactic biopsy of this lesion is performed. Which of the following microscopic appearances is most likely to be present in this biopsy?

A Organizing abscess

B Viral inclusions

C Plaque of demyelination

D Neuronal loss with gliosis

E Metastatic carcinoma

 


Case 24:

A 48-year-old man presents to the emergency room with sudden onset of a severe headache. He is afebrile. He is found to have papilledema on funduscopy. A head CT scan shows a 6 cm mass in the right cerebral hemisphere with a midline shift. He dies before further workup can be performed. At autopsy there are recent hemorrhages in the pons. No other hemorrhages are found in the central nervous system. He does not have hemorrhages elsewhere in the body. Which of the following pathologic findings is most likely to be present at autopsy?

A Severe thrombocytopenia

B Gram negative rods in cerebrospinal fluid

C Fracture of the right parietal bone

D Loss of pigmented neurons in the substantia nigra

E Cerebral edema with uncal herniation

 

Case 25:

A 70-year-old man has had increasing difficulty with movement, starting with his feet and ascending to involve legs, trunk, and now arms, over the past 10 days. On physical examination there are variable sensory changes noted. He is afebrile. He does not lose consciousness and remains mentally alert. He becomes ventilator dependent a week after the onset of this illness. A lumbar puncture is performed and the CSF demonstrates a protein of 86 mg/dL, glucose 63 mg/dL (serum 89 mg/dL), and only 3 mononuclear cells/microliter. He gradually recovers over the ensuing 4 weeks. Which of the following conditions most likely preceded the onset of this man's illness?

A Exposure to a toxin

B Recent viral infection

C Severe hypotension

D Bacterial septicemia

E Radiation therapy


Case 26:

A 70-year-old woman has a history of dyspnea and palpitations for six months. An ECG at that time showed atrial fibrillation. She was given digoxin, diuretics and aspirin. She now presents with two short-lived episodes of altered sensation in the left face, left arm and leg. There is poor coordination of the left hand. ECHO was normal as was a CT head scan.

What is the most appropriate next step in management?

A-  Anticoagulation   

B-   Carotid endarterectomy

C-   Clopidogrel

D-  Corticosteroid treatment

E-   No action

 

Case 27:

A 60-year-old man with a past history of controlled hypertension presents with acute onset weakness of his left arm, that resolved over 12 hours. He had suffered two similar episodes over the last three months. Examination reveals a blood pressure of 132/82 mmHg and he is in atrial fibrillation with a ventricular rate of 85 per minute. CT brain scan is normal.

 

What is the most appropriate management?

A-     Amiodarone

B-  Aspirin

C-   Dipyridamole

D-  Warfarin

E-   Digoxin


Case 28:

A 17-year-old woman loses consciousness whilst out jogging one afternoon. She has had similar blackouts over the last two to three years which have all occured during exertion.  There is no family history of note. She is taken to Accident and Emergency, where a chest X-ray, CT brain scan, FBC, and biochemistry are all normal. Her ECG shows changes of left ventricular hypertrophy and broad Q waves. An echocardiogram reveals left ventricular and septal hypertrophy, small left ventricle, and reduced septal excursion. The septum has a "ground glass" appearance.

 

Which of the following conditions is she most likely to have had?

A-                     Diabetes mellitus        

B-   Hypertrophic cardiomyopathy 

C-   Rheumatic heart disease

D-  Systemic lupus erythematosus

E-   Viral myocarditis

 

Case 29:

A 26-year-old professional footballer collapses while playing football. He is rushed to the Accident and Emergency Department, and is found to be in ventricular tachycardia. He is defibrillated successfully and his 12 lead ECG demonstrates normal sinus rhythm, without ST segment changes. Ventricular tachycardia recurs and despite prolonged resuscitation, he dies.

What is the most likely diagnosis?

A-     Aortic stenosis  

B-   Cocaine intoxication

C-   Hypertrophic cardiomyopathy                                                    

D-  Myocardial infarction

E-   Pulmonary embolism


Case 30:

A 60-year-old man presented with an episode of right sided weakness that lasted 10 minutes and fully resolved. Examination reveals that he is in atrial fibrillation. Assuming he remains in atrial fibrillation which of the following is the most appropriate management regime?

 

A-     Aspirin

B-   No additional drug treatment

C-   Warfarin, INR range 2 - 3 for 6 months then aspirin

D-  Warfarin, INR range 2 - 3      

E-   Warfarin, INR range 3-4 

Case 31:

A 70-year-old woman presented with an acute, severe occipital headache, unsteadiness of her gait and vomiting. She had a history of poorly controlled hypertension. On examination there was nystagmus to the left, ataxia of the left limbs and gait ataxia.

What is the most likely diagnosis?

A-     Acute cerebellar hemorrhage                           

B-   Basal ganglia hemorrhage

C-   Pontine hemorrhage

D-  Subdural hemorrhage

E-   Temporal lobe hemorrhage

Case 32:

A 65 year-old male presents with acute severe headache, ataxia and vomiting. Six hours later he became drowsy. On examination he had left horizontal nystagmus, a partial left sixth cranial nerve palsy and extensor plantar responses. His blood pressure was 188/110 mmHg.

What is the most likely cause for this deterioration?

 

A-     Brain stem herniation                                            

B-   Cerebral edema                                         

C-   Dehydration

D-  Malignant hypertension

E-   Non-convulsive status epilepticus

Case 33:

Which of the following would be expected features of a LEFT Posterior cerebral artery occlusion :

A-     A right homonymous hemianopia                       

B-   Intemuclear ophthalmoplegia

C-   Wernicke's aphasia

D-  Pure aphasia (i.e. without alexia)

E-Decerebrate state

 

Case 34:

A 76 Year old with a recent history of cerebral hemorrhage is admitted with a cough, worsening breathlessness and right pleuritic chest pain. He is also mildly pyrexial. His ventilation-perfusion scan reveals several areas of ventilation/perfusion mismatches in the right lower zone. What is the most appropriate line of management?

A-     Aspirin therapy

B-   Antibiotics

C-   Inferior vena cave filter                                              

D-  Low molecular weight heparin treatment

E-   Warfarin treatment

 


Answers

 

Case 1:

1 (B), 2 (A), 3 (E)

The heliotrope, purple periorbital rash is seen with dermatomyositis and may even precede the muscle involvement. On examination, these patients will usually show proximal muscle weakness and may complain of difficulty getting up from a chair, climbing stairs, and raising the arms over the head. Ataxia may be present with cerebellar lesions. Deep tendon reflexes should be normal and there is no joint inflammation. Polymyalgia rheumatica generally occurs in older people but is not associated with muscle weakness. Spino-cerebellar degeneration, vasculitis, and rheumatoid arthritis are not associated with this rash. Creatine phosphokinase is usually markedly elevated and muscle biopsy will confirm the diagnosis. Serum creatinine, sodium, and potassium should be normal, and the rheumatoid factor should not be elevated.

Case 2:

1 (D), 2 (D)

Deficiency of dopamine primarily is responsible for the signs and symptoms of Parkinson’s disease. Specifically, the loss of dopamine from the substantia nigra is thought to be primarily responsible for the akinesia and rigidity.

Tremor, akinesia, and rigidity are the classic triad of signs seen in Parkinson’s disease. The tremor typically is a resting tremor; often a “pillrolling” tremor is seen in the hand. Well over 90% of patients with Parkinson’s disease do have a good initial response to levodopa.


Case 3:

Answer:  (C)

The history and physical examination of the patient described in the question suggest either an intra-cerebral hemorrhage or a completed ischemic stroke. The CT scan that accompanies the question demonstrates a large hemorrhage in the region of the right basal ganglia with a surrounding zone of edema and narrowing of the ventricle. The basal ganglia include the substantia nigra, striatum (caudate & putamen), globus pallidus, subthalamic nucleus, and thalamus. Patients with intra-cerebral hemorrhage often have a preceding history of hypertension. Putamenal hemorrhage causes hemiplegia, hemianasthesia, homonymous hemianopia, stupor & coma. Thalamic hemorrhage may extend to the internal capsule, to the midbrain, or may rupture into the third ventricle. Symptoms include hemiparesis, hemianasthesia and occasionally homonymous hemianopia. Aphasia may occur if the bleed affects the dominant hemisphere and stuper & coma may occur due to affection of reticular formation. Carotid occlusion, malignancy, Arterio-venous malformation, and coagulopathy all are much less likely causes of this disorder. In general, only cerebellar hemorrhages and cerebral hemorrhages that are easily reached are surgically evacuated. Most intra-cerebral hemorrhages are managed with general supportive care.

Case 4:

(D) CORRECT.

The small arteries of the kidney are affected by hyperplastic arteriolosclerosis. Malignant hypertension is often preceded by chronic hypertension that leads to left ventricular hypertrophy. Hypertension is a risk for CNS hemorrhage.


Case 5:

(B) CORRECT.

Atrial myxomas are more often on the left. Though benign, they can occlude the mitral valve and produce sudden loss of cardiac output. They may embolize small portions of themselves or thrombus forned over their surface.

 

Case 6:

Top of Form

(D) CORRECT.

The scarring following the bacterial meningitis can lead to obstruction of CSF flow at the foramina of Luschka and Magendie with obstructive hydrocephalus, or alternatively scarring at the arachnoid granulations to reduce CSF reabsorption

Case 7:

(E) CORRECT.

The basal ganglia region is the typical location for hypertensive hemorrhages. The hemorrhage can extend to adjacent internal capsule.

Case 8:

(B) CORRECT.

About 1% of the population have such an aneurysm. Berry aneurysms are most likely to involve the Circle of Willis, so that rupture with bleeding occurs into the subarachnoid space at the base of the brain. The blood may cause irritation and spasm of adjacent arteries to cause worsening of symptoms from ischemia. Berry aneurysms can slowly enlarge but rupture suddenly.

Case 9:

Top of Form

(E) CORRECT.

Vasospasm causes symptomatic ischemia & infarction in 20-30% of patients with aneurysmal SAH. It is the leading cause of death & disability after aneurysm rupture. VC begins not earlier than day 3 after hemorrhage, reaching a peak at days 7-8. The onset of clinical vasospasm is characterized by a decline in neurologic status, including the onset of focal neurologic abnormalities. The cause of VC is interaction between the metabolites of blood & Bl.Vs. About 10% of persons with autosomal dominant polycystic kidney disease (ADPKD) develop berry aneurysms.

Case 10:

(A) CORRECT.

Granulation tissue with fibrosis is a typical reaction to a cerebral abscess. Collagen deposition around a ring enhancing lesion is typical for an abscess that organizes. The ring enhancement results from increased vascularity from capillary proliferation and disrupted blood-brain barrier. A common source for such a brain abscess is a lung infection.

Case 11:

(C) CORRECT.

The tremor at rest is typical for Parkinson disease. A 'mask-like' facies is another manifestation of this degenerative disease resulting from loss of pigmented neurons in the substantia

 

Case 12:

Top of Form

(A) CORRECT.

Encephalitis with hemorrhagic lesions of the temporal lobe is typical for Herpes simplex virus infection. Affected persons do not have to be immunocompromised. (Note: when this patient was brought to the ER, the examining physician initially passed the problem off as a 'drug overdose' which was his default diagnosis for any mental problem in a young person, but the family refused to accept that and pressed him for further workup).

Case 13:

(B) CORRECT.

The continued presence of a subdural hematoma leads to the problems described, even if it is relatively small. The trauma led to a rupture of dural bridging veins. Venous bleeding may be slow, so that the hematoma accumulated over time. When the clot begins to organize, it may imbibe additional fluid and increase in size.

Case 14:

(A) CORRECT.

The course is progressive. Bulbar involvement can lead to problems speaking and eating, with risk for aspiration. This disease often goes by the eponym of another baseball player, Lou Gehrig, who could not play first base anymore once the disease became advanced.

Case 15:

(E) CORRECT.

The findings point to an acute bacterial infection. The most likely organism at this age and under these circumstances is Neisseria meningitidis. The portal of infection may be upper respiratory tract, with an initial pharyngitis.


Case 16:

(B) CORRECT.

Guillain-Barré syndrome, an acute idiopathic polyneuritis, is felt to be immunologic. About 75% of cases have a history of a preceding infection, including viral (cytomegalovirus) and bacterial (Campylobacter jejuni) agents.

Case 17:

(A) CORRECT.

She has a hypertensive hemorrhage, and the large collection of blood produces a mass effect with downward pressure to the posterior fossa to produce herniation.

Case 18:

(D) CORRECT.

The findings are characteristic for schwannoma, called an acoustic neuroma when the 8th cranial nerve is involved. These are usually benign neoplasms. A solitary mass with no other lesions is unlikely to be part of neurofibromatosis.

Case 19:

(A) CORRECT.

These findings suggest a 'stroke' from cerebral infarction. Most brain infarcts result from thromboembolism. The most common source for emboli is the heart. Coronary atherosclerosis can result in myocardial infarction with overlying endocardial mural thrombosis. Such mural thrombi can embolize to the systemic circulation.

 

Case 20:

Top of Form

Bottom of Form (E) CORRECT.

Diabetic neuropathy is probably the most common form of peripheral neuropathy in the United States and Europe. She also has a 'diabetic foot' from severe peripheral vascular atherosclerosis, and the MI is consistent with severe occlusive coronary atherosclerosis.


Case 21:

(B) CORRECT.

The location & radiographic changes suggest a glioma, most likely an oligodendroglioma

Case 22:

(D) CORRECT.

This infection results when man becomes the accidental intermediate host for Taenia solium. The larvae may lodge in many organs but in the brain they are primarily found in the subarachnoid space and the cortex. They become encysted and the cysts within the subarachnoid space move around and can obstruct CSF flow leading to life threatening hydrocephalus

Case 23:

(E) CORRECT.

Radiographic features of brain metastases include the following:

  • The presence of multiple lesions.
  • Location at the junction of the grey & white matter.
  • Circumscribed margins.
  • Large amounts of vasogenic edema compared to the size of the lesion

Smoking increases the risk for development of lung & renal carcinomas that are the most common sources for metastases to brain in males.

Case 24:

(E) CORRECT.

The location of the hemorrhages suggests  hemorrhages caused by disruption of perforating arteries from transtentorial  herniation.

Case 25:

(B) CORRECT.

This rapidly ascending paralysis is Guillain-Barré syndrome, or acute idiopathic polyneuritis. About 75% of cases are associated with a history of a prior viral infection. An immunologic mechanism for this disease is suspected. In the case of Campylobacter jejuni infection, this involves molecular mimicry.


Case 26:

A is correct.

This patient is having symptoms of transient ischaemic attacks most likely due to a cardiac source of emboli. A normal ECHO or CT head does not rule out thrombo-embolic events. There is an increased risk of strokes in patients with atrial fibrillation and hence with the given symptoms formal anticoagulation with warfarin should be considered.

 

Case 27:

D is correct.

This patient has had three transient ischaemic attacks due to atrial fibrillation. The most appropriate therapeutic strategy for this patient would be warfarin. Studies reveal that warfarin would be therapeutically superior than aspirin in such a patient's case.

Case 28:

B is correct.

The history of collapses in this young woman with echocardiographic features of hypertrophy are highly suggestive of hypertrophic obstructive cardiomyopathy. Hypertrophic cardiomyopathy is defined as the unexplained, asymmetical or concentric hypertrophy of the undilated left ventricle. There is also hypertrophy of the right ventricle. Incidence is approximately 1 in 500. It is inherited as an autosomal dominant trait but often an inheritance pattern is not found on questioning.

 

Case 29:

C is correct.

The history of sudden arrhythmia in a young previously well individual is suggestive of Hypertrophic cardiomyopathy, relatives should be screened for the condition. There is no history to suggest drug abuse, aortic stenosis is rare in the absence of congenital or Rheumatic heart disease. A myocardial infarction and massive pulmonary embolism would have given ECG changes.

Case 30:

D is correct.

This is a high risk patient for future stroke and should be anticoagulated with warfarin. An initial target range of INR 2 - 3 is the most appropriate.

Case 31:

A is correct.

Cerebellar hemorrhage : The most common symptoms are of severe nausea and vomiting and ataxia. Headache may be severe. Patients with cerebellar hemorrhage can rapidly become comatose within hours after the onset from herniation, because of its limited space in the posterior fossa

Case 32:

A is correct.

 

Case 33:

A is correct.

b- typical of multiple sclerosis. c+d-Middle cerebral artery. e-False? Pontine lesion. Other possible findings in posterior left cerebral artery occlusioir cortical blindness, visual hallucinations, thalamic syndrome, Claude's and Weber's syndromes

Case 34:

C is correct.

This patient has PE following a recent haemorrhagic stroke. The risk of rebleeding into the stroke area is too high with anticoagulation. The best action would be percutaneous insertion of IVC filter which may be as effective as anticoagulation. It is used in cases where anticoagulation is a contraindicated or in those in whom anticoagulation alone fails.

MCQs part I

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