Neuro

Question 1

Meningitis clinical presentation

Answer 1

• Fever
• Meningism: N/V, photophobia, phonophobia, neck stiffness
• Neurological: focal neurological deficits, CN palsies, seizures
• AMS
• +/- purpuric rash (meningococcemia)

Question 2

How to differentiate between bacterial and fungal / parasitic meningitis?

Answer 2

depends on onset:
acute (<4/52) - bacterial
chronic (>4/52) - fungal / parasitic

Question 3

Difference between ischaemic and haemorrhagic stroke (from Hx)

Answer 3

Onset (acute)
- sudden: hemorrhagic
- gradual: ischemic

PMHx
- HTN, HLD, DM, AF, Prosthetic valve replacement: ischemic
- Brain aneurysm, head trauma : hemorrhagic

Question 4

Investigation workup for ischaemic stroke

Answer 4

Biochemical
- Bloods: fasting glucose, HbA1c, Fasting lipids, FBC, GXM, PT/PTT, D-dimer (?), platelet count

• ECG -> note AF

Imaging
- CT cranial angiogram -> localise site of occlusion
- MRI brain -> localise stroke
- CXR -> note prosthetic valve replacement
- Duplex US carotid arteries -> note stenosis

Question 5

Investigation workup for meningitis

Answer 5

Biochemical
- Lumbar puncture - FEME, cytology, PCR, gram stain, biochemistry

• Bloods: FBC, UECr, ABG, CRP, LFT, blood glucose, PT/INR

Imaging
- CT / MRI brain

Question 6

Complications of untreated meningitis

Answer 6

• SIADH
• Hearing loss
• Long term: Epilepsy

Question 7

Management of meningitis

Answer 7

Immediate
- secure ABCs
- monitor vitals + conscious level charting
- obtain blood investigations
- Lumbar puncture

Subsequent
- Empirical IV antibiotics
- bacterial meningitis: IV corticosteroids eg dexamethasone
- viral meningitis: IV antivirals eg acyclovir

Question 8

how to differentiate between Parkinson’s disease and Secondary Parkinsonism ?

Answer 8

STORE
Parkinson’s Disease:
- aSymmetrical
- resting Tremor present
- gradual Onset
- good Response to L-dopa

Secondary Parkinsonism:
- Symmetrical
- resting Tremor absent
- acute Onset
- no / poor Response to L-dopa

Question 10

diagnosis criteria for migraine

Answer 10

at least 5 attacks of (any 2):
- duration 4-72h
- pulsatile
- unilateral
- N/V
- visual disturbance
- triggered by routine physical activity

Question 11

clinical features of cluster headache

Answer 11

• unilateral
• retro-orbital pain; relieved by moving head around; constant, aching, stabbing
• occurs in extreme times of day
• lasts 10min to 2h
• unilateral Horner’s syndrome
• red, watery eye
• nasal congestion

Question 12

What are stroke mimics TRO

Answer 12

Metabolic: hypoglycemia

Neuropathy: Bell’s palsy

Radiculopathy

Seizure: Todd’s paralysis

Migraine

Question 13

Cortical signs for MCA infarct

Answer 13

• Aphasia
• Hemi-neglect
• Gaze deviation

Question 14

Specific signs of cerebellar stroke

Answer 14

• Ataxia
• Vertigo
• N/V
• Nystagmus

Question 15

Specific signs for brain stem stroke

Answer 15

• Cranial nerve palsies
• Cross sign: ipsilateral CN issue + contralateral limb weakness

Question 16

What is the difference between aphasia and dysarthria

Answer 16

Aphasia - unable to understand and/or produce speech -> only moaning sounds

Dysarthria - muscle unable to produce smooth speech eg slurred speech

Question 17

Characteristic features of Myasthenia Gravis

Answer 17

• Muscle fatiguability e.g. ptosis, diplopia, dysarthria, chewing, proximal muscle weakness
• associated with autoimmune thyroid conditions e.g. Graves’ , Hashimoto’s

Question 18

Investigation workup for Myasthenia Gravis

Answer 18

Biochemical
- AChR-Ab
- Muscle-specific Tyrosine Kinase Ab
- FBC -> note TW
- Nerve conduction study, single-fibre EMG

Imaging
- CXR -> note thymoma, aspiration pneumonia

Question 19

Management of Myasthenia Gravis

Answer 19

• Anticholinesterase drugs - PO Pyridostigmine
• Corticosteroids
• Thymectomy

Question 20

Clinical presentation of GBS

Answer 20

• Bilateral weakness ascending from LL
• LL hyporeflexia, flaccid paralysis
• Autonomic dysfunction: cardiac arrhythmia, urinary retention, GI dysfunction
• Cranial nerve involvement: facial diplegia, bulbar dysfunction

Question 22

3 types of seizures

Answer 22

• acute symptomatic / provoked seizure
• reflex seizure
• unprovoked seizure

Question 23

3 types of epilepsies

Answer 23

• reflex epilepsy
• drug-resistant epilepsy
• resolved epilepsy

Question 24

Clinical features of encephalitis

Answer 24

Acute / Subacute (<3/12) onset of:
Prodromal
- fever, headache, nausea

Neurological
- AMS, memory loss
- Seizure
- Focal neurological deficit
- Dysautonomia

Psychiatric
- Hallucination, anxiety, psychosis

Question 25

Investigation workup for encephalitis

Answer 25

Biochemical
- FBC, CRP, ESR, blood culture, LFT, RP, PT/INR, HIV test
- Lumbar puncture - PCR, gram stain, cultures
- Serologic studies - autoAb

Imaging
- MRI brain w/ contrast
- CT brain
- Electroencephalography: non-specific; used in suspected viral etiology

Brain Biopsy (last resort)

Question 26

Conditions a/w autoimmune encephalitis

Answer 26

Malignancies:
- Small cell lung CA
- Breast CA
- Hodgkin Lymphoma
- Prostate CA
- Thymoma

Question 27

Common microB causes of encephalitis

Answer 27

Viral
- Herpes Virus 1-5
- HIV
- Japanese encephalitis virus
- Enterovirus
- Rabies, Measles

Bacterial
- Listeria monocytogenes
- Rickettsia Rickettsia
- Treponema Pallidum