Neuro pathology Flashcards by Kalaryn Fisher

Hemiplegia, common clinical feature of common type of stroke is due to damage to

Thalamus

motor cortex

Globus pallidus

Internal capsule

Putamen

Internal capsule

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Commonest vessel involved in stroke is,

Anterior Cerebral artery

Middle Meningial artery

Posterior Cerebral artery

Middle Cerebral artery

Anterior Meningeal artery.

MCA

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Commonest type of stroke is Hemorrhagic stroke.

True

False

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Compared to ischemic stroke Higher mortality is seen in hemorrahgic stroke.

True

False

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Charcot-Bouchard aneurysms are more common in,

Internal capsule

Brain stem

Caudate nucleus

Thalamus

Putamen

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Lacunar infarcts contain clear fluid in their lumen.

True

False

True

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Slit hemorrhages are typically seen in malignant hypertension.

True

False

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Neck stiffness is typical clinical feature in subarchnoid hemorrhage.

True

False

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EMG in a case of Myasthenia gravis, typically shows

Absence of response on electrical stimulation

Weak response on electrical stimulation

Clonic tonic contractions on electrical stimulation

Fatigue on repeat stimulation

Decreased response on IV edrophonium

Fatigue on repeat stimulation

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Pupillary light reflex in myasthenia gravis is typically

Delayed

Reduced

Increased

Normal

Fatigue on repeat testing

Normal

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What is the reason ESR (Erythrocyte Sedimentation Rate) is typically raised in Myasthenia gravis?

Typically associated with anemia.

Autoantibodies to RBC causing RBC clumping

Anti ACh Receptor antibody in the plasma

Excess fibrinogen & globulins in plasma

Unknown

Excess fibrinogen & globulins in plasma

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62 year old man presents with progressive weakness of both legs since 3 months. His symptoms are worse in the morning but get better by evening. He has lost 3kg weight. What is the most likely pathogenesis of his problem?

Antibody to ACh receptors

Antibody to Ca+ channel

Antibody blocking Ach release

Antibody to Acetylcholinesterase

Endplate damage by antibodies.

Antibody to Ca+ channel

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Typical example of dysmyelinating disorder is “Leukodystrophy”

True
False

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Commonest demyelinating disorder is Multiple sclerosis.

True
False

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Typical example of infective myelinolysis is Central Pontine Myelinolysis.

True
False

F - metabolic

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Typical location of MS Plaque is

Base of Pons
Limbic system
Grey matter
Periventricular
Basal ganglia

Periventricular

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in a stroke region, Inflammation & edema typically start how long after injury.

1 hour

6 hours

24 hours

48 hours

immediately

6 hours

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Cavity formation in stroke starts typically around

6 hours

24 hours

48 hours

2 weeks

4 weeks

2 weeks

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Hematoma in the basal ganglia region extending to ventribles is typically seen in

Subarachnoid hemorrhage

Subdural hemorrahge

ischemic stroke

Hemorrhagic stroke

Ruptured berry aneurysm

Hemorrhagic stroke

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Paradoxical embolism typically occurs in patietns with,

Patent ductus artereosus

Patent foramen ovale

Ventricular Septal defect

Marfan’s syndrome

Patent foramen ovale

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Central pontine hemorrahge typically occurs in patients with

Malignant hypertension

Ruptured berry aneurysm

Charcot-Bouchard aneurysms

Cerebellar herniation

Increased intracranial pressure

Cerebellar herniation

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microscopic Features seen in old healed infarct are

Macrophages & cavity

Inflammation & gliosis

Activated astrocytes

Liqufactive necrosis & macrophages

Cavity surrounded by Gliosis

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“Red Neuron” initial change in damaged neuron is due to loss of

Mitochondria

Micro tubules

Nissl substance

Ribosomes

Na/K pump

Nissl substance

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“Concussion” of brain is characterised by

Tear in the tissue

Superficial small hemorrhages

Haematoma formation

No permanent injury

surface bruise

No permanent injury

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the four major types of Traumatic Intracranial Hemorrahges are Epidural, Subdural, Subarachnoid and Arachnoid Epiarachnoid Extracerebral Intracerebral Ventricular

Intracerebral

Lucid Interval is typically seen in what type of intracranial hemorrhage. Subdural Epidural Subarachnoid Intracerebral Extracerebral

Epidural

Slow development of symptoms over weeks is typical in what type of Intracranial hemorrhage. Epidural Subdural Subarachnoid Intracerebral Extracerebral

Subdural

Subarachnoid Hemorrhage alone is typically caused by Mild trauma Congenital Berry Aneurysm Severe trauma Hypertension Coup injury

Hypertension

Commonest location of CNS tumours in children is, Cerebrum Cerebellum Infratentorial Brain stem

Infratentorial

Commonest primary CNS tumor in both adults and children is, Glioblastoma Meningioma Astrocytoma Medulloblastoma Neurofibroma

Astrocytoma

In adults astrocytomas constitute what percentage of brain tumours. 90% 70% 50% 40% 10%

70%

Commonest genetic mutation & the target of diagnostic test for the common CNS tumor glioma is, p53 10p deletion 9q deletion BFAR IDH

IDH

typical microscopic feature seen in the Glioblastoma multiforme is, Psammoma bodies & epitheloid cells Hemorrhage, Necrosis & Palisading astrocytes with long hairy processes Dark blue cells with rosette formation Pleomorphic cells forming irregular glands.

Hemorrhage, Necrosis & Palisading

Increase in size of CNS tumour during menstrual cycle or pregnancy is typical of, Glioma Ependymoma Glioblastoma Meningioma Neuroma

Meningioma

Cell of origin of Neurofibroma Schwann cells Perineural cells Fibroblasts All of the above Glial cells

All of the above

"Bilateral Acoustic Neuroma" is typically found in Neurofibromatosis Type-1 Neurofibromatosis Type-2 Schwanomatosis Both NF-1 & NF-2 Both NF-2 & SWN

Both NF-2 & SWN

Nodular encapsulated tumor of nerve is typical feature of this, Neurofibroma Schwannoma Plexiform neurofibroma Diffuse NF

Schwannoma

Cafe-Au-Lait spots are typically seen in this type NF-1 NF-2 SWN

NF-1

Multiple meningiomas are typically seen in NF-1 NF-2 SWN

NF-2

Pachymeningitis is infection of Pia mater Dura mater Arachnoid mater Leptomeninges meningitis & encephalitis

Dura mater

Commonest CNS infection is, Acute septi pachymeningitis Septic Meningoencephalitis Acute septic leptomeningitis Chronic aseptic meningitis Fungal chronic leptomeningitis

Acute septic leptomeningitis

Morphologically Meningococci are Gram +ve diplococci Gram -ve diplococci Gram +ve bacilli Gram -ve bacilli Gram -ve bacilli

Gram -ve diplococci

Septic meningitis with hemorragic rash all over body is typical of Pneumococcal meningitis Tuberculous meningitis Viral meningitis Meningococcal meningitis Staphylococcal meningitis

Meningococcal meningitis

Typical Microscopic feature of viral CNS infection is, Glial nodules & giant cells. Granuloma formation Perivascular lymphocyte cuffing Soap bubble lesions Extensive necrosis

Perivascular lymphocyte cuffing

typical clinical feature of Herpes encephalitis is behavioural abnormalities. True False

True

Cobweb formation in the CSF sample is typical of Septic meningitis Aseptic meningitis Tuberculous meningitis Fungal meningitis. Parasitic meningitis

Tuberculous meningitis

CSF findings in Coxsackie meningitis is characterised by high protein and low glucose. True False

False

Epilepsy unlike other seizures, is characterised by Unconsciousness Severe convulsions Stereotypic nature status epilepticus Post Ictal Aura

Stereotypic nature

one of the Pathogenesis of epilespy is, defective GABA neurons. True False

Commonest etiology of epilepsy is, Infections Tumours Congenital CNS trauma Idiopathic

Idiopathic

Normal Cerebral perfusion is <20ml/100g/min 20-50ml/100g/min 5-10ml/100g/min >50ml/100g/min >110ml/100g/min

>50ml/100g/min

Commonest & first cerebral herniation following increased intracranial pressure is, Transtentorial - Central Tonsillar Transtentorial Uncal Subfalcine Transcalvarial

Subfalcine

Dilated pupil with preserved level of consciousness (LOC) is typical of Uncal herniation. True False

Clinical feature of subfalcine herniation is, bilateral constricted but reactive pupils Ipsilateral fixed dialted pupil Contralateral leg weakness Loss of consciousness Cardiorespiratory arrest

Contralateral leg weakness

Stroke, common presentation of AV malformation is commonly due to... Thrombosis Embolism Atherosclerosis Hemorrhage Invasion

Hemorrhage

Typical gross feature in septic meningitis is, Abscess Hemorrhage pus in ventricles cloudy leptomeninges cloudy pachymeninges

cloudy leptomeninges

cyclical pain is typically seen in Low grade glioma Glioblastoma Medulloblastoma Meningioma Metastasis

Meningioma

Common clinical presentation of CNS tumors is, Neurological deficit cloudy consciousness Vision abnormalitis Vomiting Morning headache

Morning headache

Tumor associated with venous sinuses is Glioma ependymoma Glioblastoma Meningioma

Meningioma

Typical microscopic feature of Glioblastoma multiforme is Epithelioid cells in clusters Psammoma bodies Necrosis & Palisading Diffuse infiltration No hemorrahge or necrosis

Necrosis & Palisading

Brain abscess is typically surrounded by, Gliosis scar tissue granuloma necrosis Hemorrhage

scar tissue

A 75 year old male presents to the ED with sudden onset of visual loss in her left eye (like a curtain coming down in front of her eye). This lasted for 2 min and then completely resolved. PMH- glaucoma. On no regular medications. Current smoker (10 a day) with a 20-pack-year smoking history On examination his PR is 72 bpm, regular, BP 142/90 mmHg. Neurological examination shows no deficit. O1. What is the most appropriate next step in the management of this patient? 1. Follow up with GP for BP monitoring and smoking cessation 2. Prescribe an antihypertensive 3. Organise outpatient referral to the TIA clinic 4. Admit for inpatient stroke review (review ABCD2 tool)

Organise outpatient referral to the TIA clinic

Describe the findings seen in the image?

fundus pale - pale retina cherry red spot on the macula narrow artery (central retinal arty obstruction

A 62-year-old male presents to ED with sudden onset of difficulty speaking lasting for 10 minutes. His symptoms are now resolved. He had a similar episode 2 days ago lasting for 2 minutes. PMH: hypertension, hypercholesterolemia Medications: lisinopril, simvastatin Ex- smoker 30 pack years quit 1 year ago On examination: GCS 15, PR 82 bpm, regular; BP 155/92 mmHg. No focal neurological deficits were noted on examination. No carotid bruit. 02. Which of the following features makes a TIA more likely? 1. Seizure 2. Symptoms maximal at onset 3. Presence of accompanying headache 4. Gradual onset of symptoms 5. Loss of consciousness

Symptoms maximal at onset will gradually decrease - lasting only a few minutes

A 62-year-old male presents to ED with sudden onset of difficulty speaking lasting for 10 minutes. His symptoms are now resolved. He had a similar episode 2 days ago lasting for 2 minutes. PMH: hypertension, hypercholesterolemia Medications: lisinopril, simvastatin Ex- smoker 30 pack years quit 1 year ago On examination: GCS 15, PR 82 bpm, regular; BP 155/92 mmHg . No focal neurological deficits. No carotid bruit. CVS- no murmur A TIA is suspected in this instance. He is admitted as an inpatient due to his increased risk of stroke. Table Talk: List 2 investigations you would prioritize for this patient?

ECG- check for AF Lipids profile Coagulation studies CT within 24 hours- CT angiogram Carioted doppler MRI (if other not done) BSL

A 62 year old male presents to ED with sudden onset of difficulty speaking lasting for 10 minutes. His symptoms are now resolved. He had a similar episode 2 days ago lasting for 2 minutes. PMH: hypertension, hyperchloesterolaemia Medications: lisinopril, simvastatin Ex- smoker 30 pack years quit 1 year ago On examination: GCS 15, PR 82 bpm, regular; BP 155/92 mmHg . No focal neurological deficits. No carotid bruit. CVS- no murmur 03. The arterial territory most likely responsible for his symptoms is: 1. Internal carotid 2. Vertebral 3. Basilar

Internal carotid - MCA territory

What feature is most suggestive of a posterior circulation TIA? 1. Hemiparesis 2. Hemianopia 3. Aphasia 4. Vertigo 5. Hemisensory loss

Vertigo - posterior is swallowing and cranial nerves

A 71 year old male presents to ED with sudden onset of right sided limb weakness (arm worse than leg) and difficulty speaking for the past 2 hours. He had a similar episode 2 days ago lasting for 2 minutes. PMH: type 2 diabetes, hypertension, AF Ex- smoker 20 pack years quit 10 years ago On examination: GCS 15, PR 82 bpm, irregular; BP 158/94 mmHg . No carotid bruit. CVS no murmur.He is right handed. Dysphasia is noted on examination.Right upper and lower limb hemiparesis (dense in arm compared to leg). Left arm and leg no motor deficit. Sensory exam both R& L arm and leg normalCranial nerves- Weakness of the right side of the face. All other nerves normal When asked to describe his symptoms that brought him to hospital He says: “Ah ...coffee... cup arm ah…,walk…move leg…ah.. and ah ... sixty minutes .. .and yes ... ah and wife ... hospital. ah, doctors ...” When shown a pen, and asked to name the object, he struggles to name the correct word but he is able to nod in agreement when you correctly name the object. 05. Which of the following best describes his condition? 1. Expressive dysphasia 2. Receptive dysphasia 3. Dysarthria 4. Dysphonia 5. Global dysphasia

Expressive dysphasia dysarthria: muscles wont work Dysphonia: misnames objects

He has expressive dysphagia Which part of the brain is responsible for his speech disturbance? 1. A 2. B 3. C

C - brocas - near motor cortex A is receptive dysphagia B - is parietal - mild dysphagia.

A 71 year old male presents to ED with sudden onset of right sided limb weakness (arm worse than leg) and difficulty speaking for the past 2 hours. He had a similar episode 2 days ago lasting for 2 minutes. PMH: type 2 diabetes, hypertension, AF Ex- smoker 20 pack years quit 10 years ago On examination: GCS 15, PR 82 bpm, irregular; BP 158/94 mmHg . No carotid bruit. CVS no murmur. He is right handed. Dysphasia is noted on examination. Right upper and lower limb hemiparesis (dense in arm compared to leg). Left arm and leg no motor deficit. Sensory exam both R& L arm and leg normal Cranial nerves- Weakness of the right side of the face. All other nerves normal His CT brain is shown. 07. What finding is most likely to be present on neurological examination of the affected side? 1. Muscle wasting 2. Cog wheel rigidity 3. Hyperreflexia 4. Fasciculations 5. Upward pronator drift

UML- hyperreflexia

A: shows area of triangular pinpoint haemorrhages - embolic stroke B: SHowing no evidence of acute change except cavity - internal capsule - chronic hypertensive necrosis leading to lake cystic fluids (lacunar / chronic ) C: haemorrhage CVA

Of an embolic stroke

Pin point Haemorrhages over a triangular area of inflammation, Swelling / Edema. Acute- Swollen /edema L Parietal lobe Compressed L lateral ventricle, Midline shift. (herniation). Loss of demarcation grey & white matter in the affected area. * No Liquefaction (no macrophages). So only edema swelling shift of midline structures to opposite side – herniation. Subacute : Swollen /edema L Parietal lobe Compressed L lateral ventricle, Midline shift. (herniation). Loss of demarcation grey & white matter in the affected area. * No Liquefaction (no macrophages). So only edema swelling shift of midline structures to opposite side – herniation. Inflam, macrophages, clearing / cavity, gliosis around. * Gross: triangular area of left parietal lobe ACA, petechial hemorrhages, cavity (>2wk) with bloody fluid. Area shows mild edema swelling, compressing & shifting lateral ventricle to opposite side - herniation. Late: * Dead cells  inflammation  edema, (umbra & penumbra). * Gross: Right MCA region edema, petechial hemorrhages. Narrow sulci, widened gyri. (severe cerebral edema) Slight mid line shift.

A 60 year old woman presents with sudden onset of weakness and numbness of her right leg. Her CT is shown. 09. What other feature might be noted in this patient? 1. Personality change 2. Bitemporal hemianopia 3. Hemineglect 4. Spatial disorientation 5. Intention tremor

Personality change

What is the commonest site for an ischemic stroke? 1. Anterior cerebral artery 2. MCA superior branches 3. MCA inferior branches 4. MCA deep branches 5. Posterior cerebral artery

MCA deep branches

A 65 year old man is brought in by ambulance to ED with a 3 hour history of confusion, severe headache, vomiting and left sided weakness. His CT is shown. PMH: Hypertension, multiple VTE episodes, hypercholesterolaemia Medications: Apixiban 20mg daily, perindopril 10mg daily, rosuvastatin 40mg daily Social Hx: 6 std alcoholic drinks/day, 30 pack year smoking history Table talk: List 3 possible risk factors from his history that may have contributed to his current presentation

hemorrhagic stroke therefore Anticoagulation medication Hypertension alcohol and smoking status AGE

65 year old man is brought in by ambulance to ED with a 3 hour history of confusion, severe headache, vomiting and left sided weakness. He suffered a hemorrhagic stroke- haematoma is in basal ganglia region. The most likely cause of the pathology in the patient is: 1. Trauma 2. Rupture of a berry aneurysm 3. Charcot –Bouchard aneurysm rupture 4. Arteriovenous malformation

Haematoma is in the basal ganglia region therefore Charcot –Bouchard aneurysm rupture

A 58 year old man presents with rapidly progressive drooping of the left side of his face noticed when he woke up this morning. He has no headache, limb weakness, slurring of speech or vision loss. PMH: chronic low back pain- mechanical cause No regular medications Examination: Vital signs normal Neurological examination no motor or sensory deficit Cranial nerves: left facial weakness. Other nerves normal. A LMN Facial nerve palsy (Bell’s) is suspected. Where is the Facial nerve nucleus located? 1. A 2. B 3. C 4. D 5. E

Presence of what symptom makes an alternative diagnosis more likely than an LMN- Facial nerve palsy? 1. Dry eyes 2. Taste disturbance 3. Hyperacussis 4. Diplopia 5. Dry mouth

Diplopia -

What feature on examination helps distinguish a LMN from an UMN Facial nerve palsy? 1. Inability to wrinkle brow 2. Inability to close eye 3. Inability to puff cheek 4. Drooping of the corner of the mouth 5. Asymmetrical smile

Inability to wrinkle brow

A 62 year old woman presents with a 6 month history of progressively increasing limb weakness and difficulty walking. She now has difficulty standing from a seated position. No PMH of note: No meds Works as an engineer, nonsmoker, 1-2u alcohol/night On examination: she has generalized lower limb weakness more noticeable on the left. Fasciculations and atrophy evident in her calf. She has brisk reflexes in her knees & ankles. Babinski is positive. Sensory examination is unremarkable. 15. What is the most likely diagnosis? 1. Spinal muscular atrophy 2. Guillain Barre syndrome 3. Myasthenia gravis 4. Motor neurone disease 5. Multiple sclerosis

4. MND - degenerative - progressive older 1. young people 2. after viral/ bacterial infection and older 3. MG younger female, pregnancy 5. young female patient, autoimmune

Which pathway is most likely to be affected in this condition? Motor neuron disease 1. Dorsal column 2. Spinothalamic tract 3. Corticospinal tract 4. Spinocerebellar tract 5. Extrapyramidal tract

Corticospinal tract because sensation still intact

A 35 year old woman presents with a 3 day history of blurred vision in the left eye. She has some pain behind the eye and with movement. No redness or discharge. On further questioning she had tingling and pain in both legs 3 months prior which settled spontaneously. PMH: nil, no meds She is a current smoker with a 5 pack year smoking history. 2 wines on the weekend. On examination BMI is 31, vitals normal. Her VA is 6/12 in the LE, no improvement with PH. RE is normal. 17. What sign is most likely to be present on examination? 1. Dilated pupil 2. Positive afferent pupillary defect 3. Limitation of ocular movements 4. Tender temporal artery 5. Normal colour vision

Patient has MS - lower half of optic disc is hazy and disappearing vessels. Positive afferent pupillary defect

What further investigation would be most important in this patient? She has MS 1. CT brain 2. Lumbar puncture 3. ESR 4. Carotid doppler 5. MRI brain

MRI brain

She has MS

A 42 year old man presents with diplopia worsening over the last 2 months. His symptoms worsen as the day progresses. On examination he has a bilateral ptosis. 21. Which of the following tests is appropriate for this patient? 1. CRP 2. Head CT scan 3. Lumbar puncture 4. Thoracic CT scan 5. TFT

Small muscles affected and young - MG Thoracic CT scan- MG linked to thymomas

A 42 year old man presents with diplopia worsening over the last 2 months. His symptoms worsen as the day progresses. On examination he has bilateral ptosis. 22. What is the pathogenesis of his symptoms? 1. Ab blocking Calcium channel 2. Paraneoplastic syndrome due to Thymoma 3. Ab blocking ACH release 4. Ab to ACH receptors 5. Ab to sodium channels

Ab to ACH receptors

Fill in the blank Two classic clinical features of disease identified in his first patient by Dr. Alzheimer were Behavioural abnormality and loss of

Memory

Commonest type of Alzheimer's disease is sporadic / Idiopathic. True False

characteristic intraneuronal abnormality seen in Alzheimer's disease is, Neuritic plaque Amyloid plaque NF tangle Amyloid angiopathy gliosis

NF tangle

Neuritic plaque is abnormal cluster of fibrils formed from, tau protein Microtubules Amyloid Precursor Protein (APP) Cell membrane Neural filaments

Amyloid Precursor Protein (APP)

Earliest clinical symptom of Alzheimer's disease is, Language difficulty decreased cognition Loss of old Memory Loss of recent memory Confusion

Loss of recent memory

Clinical triad of classic Parkinson's disease are Tremor, Rigidity & diminished facial expression Dementia Stooped posture Festinating gait Bradykinesia

Bradykinesia

fill in the blank The three dopaminergic system controls are Movement, Behaviour &

Prolactin

Pigment lost in substantia nigra is, Hemosidern Lipofuscin Nissle granules Lewy body Melanin

Melanin

"Atypical Parkinson" disease is, parkinson's features seen in Early age drugs or toxins. other neurodeg. disorders. Genetic disorders.

early age

Microscopic features of senile degeneration are same as in Alzheimer's disease (NF Tangles & Amyloid plaques). True False

Clinically Pick's disease, the commmonest type of FTLD is characterised by preserved memory till late. True False

Jerking dementia is also known as, Pick's disease Huntington's disease. Demential pugilistica SCDC MND

Huntingtons disease

Both motor and sensory nerves are affected in VitB12 deficiency SCDC. True False

Misfolded protein accumulated in neurons in CJD is, Prion Protein PrP PrPc PrPsc ꞵ-amyloid

PrPsc Normal cytoplasmic PrPc protein transforms from normal “ɑ-helix” to “ꞵ-pleated” PrPsc a non digestible polymer and behaves like a infective organism to covert normal PrP. Accumulation within results in neuronal degeneration.

Typical & distinguishing clinical feature of CJD is Jerky movement Rapidly progressive dementia Behavioural abnormalities Spongiform change Younger age

Rapidly progressive dementia

CJD has 3 different clinical types. This is the commonest type of CJD in clinical practice (90%). Congenital Hereditary Sporadic Familial Infective

Infective/ Sporadic

Classic specimen feature seen in a patient with Tremors, Rigidity and Bradykinesia is, Limbic system atrophy Demyelination Striatonigral atrophy Hippocampus atrophy Caudate & putamen atophy.

Striatonigral atrophy

Cellular inclusions seen in a patient with behavioural changes, aphasia and dementia without significant loss of memory are, NF Tangles Amyloid plaques Picks bodies Lewy bodies α-synuclein

Picks bodies

Characteristic inclusions seen in Parkinson's disease are Lewy bodies. True False

fill in the blank Three classic microscopic features seen in Alzheimer's disease are NF Tangles, Amyloid plaques and

Angiopathy

Case 1: A 37 year old woman presents with a 2 year history of episodic bilateral frontal headache. She describes it as a moderate intensity which normally settles within 2-3 days. 01. The presence of which of the following clinical features would be most consistent with a diagnosis of tension type headache? 1. Vomiting 2. Rhinorrhoea 3. Pericranial tenderness to palpation 4. Visual aura 5. Photophobia & phonophobia

Pericranial tenderness to palpation

Case 2: A 47 year old man presents with a history of episodic pain behind his right eye. He reports the pain comes on quickly and tends to last for around an hour before settling. 02. The presence of which of the following clinical features would be most consistent with a diagnosis of cluster headache? 1. More than 8 attacks of pain per day 2. Onset after exercise 3. Ptosis 4. Reduced visual acuity 5. Scalp tenderness to palpation

Ptosis

Case 3: A 19 Year old university student presents to ED with a 24 hour history of headache associated with vomiting. Group discussion: 1) What differentials would you consider in a patient presenting with headache and vomiting? 2) What red flags would be important to ask about on history?

1. Migraine, tension headache, stress, raised ICP, Idiopathic hyertension, dehydration, heat stroke, TBI, concussion. 2. first/ wrost headache, symptoms of raised ICP, neck stiffness, old person, sudden onset, over 50, personality change, worse with bending or coughing.

Case 3: A 19 Year old university student presents to ED with a 24 hour history of headache associated with vomiting. On further history he report a 2 day history of fevers. He has also noticed increasing neck stiffness today. He is generally well with no significant past medical history. 03. Which of the following examination findings would be most likely to be associated with a diagnosis of bacterial meningitis? 1. Aphasia 2. GCS of 13 3. Hemiparesis 4. Papilloedema 5. Vesicular rash

GCS of 13, potentially papillooedema as well.

Case 3: A 19 Year old university student presents to ED with a 2 day history of fevers. He has experienced a worsening headache over the last 24 hours which has been associated with vomiting. He has no significant past medical history. O/E: Temp 38.3C, HR 128, BP 105/67, RR12, SpO2 97% RA, GCS 13, jolt accentuation test positive, no papilloedema, no focal neurologic deficit on cranial nerve, upper or lower limb examination. 04. Which is the single most important investigation to arrange for your patient? 1. Coagulation studies 2. CSF M/C/S 3. ESR 4. FBC 5. Lactate

CSF M/C/S

Case 3: A 19 Year old university student presents to ED with a 2 history of fevers. He has experienced a worsening headache over the last 24 hours which has been associated with vomiting. He has no significant past medical history. O/E: Temp 38.3C, HR 128, BP 105/67, RR12, SpO2 97% RA, GCS 13, jolt accentuation test positive, no papilloedema, no focal neurologic deficit on cranial nerve upper or lower limb examination. 05. Which of the following is the most single important management step while awaiting investigation results? 1. IV aciclovir 2. IV ceftriaxone 3. IV dexamethasone 4. IV fluids 5. Supplemental oxygen

IV ceftriaxone

Case 3: Antibiotics are commenced according to local clinical guidelines. His CSF biochemistry and M/C/S return the following results: 06. Which pathogen is responsible for his presentation? 1. Cryptococcus gattii 2. Haemophilus influenza 3. Herpes simplex 4. Neisseria meningitides 5. Streptococcus pneumoniae

Neisseria meningitides- gram negative diplococci.

GCS 9 (E2 V3 M4)

Case 4: A 35 year old man is brought in by ambulance to ED after falling from the tray of a moving ute. On initial assessment in the resuscitation bay he is observed to be opening his eyes when his fingernails are squeezed. When asked his name he states ‘Tuesday’. He withdraws from painful stimuli when applied. A witness of the accident states that he struck his head on a rock while falling, he was well initially but over the next 2 hours became more drowsy and confused. His CT brain is shown. 08. What is the cause of his presentation? 1. Acute subdural haematoma 2. Chronic subdural haematoma 3. Extradural haematoma 4. Intracerebral haemorrhage 5. Subarachnoid haemorrhage

Extradural haematoma

Case 4: A 35 year old man is brought in by ambulance to ED after falling from the tray of a moving ute. On reassessment after his CT scan you note that his GCS has decreased and is now 7. He has a developed a dilated and unresponsive right pupil and has left sided hemiparesis. 09. Which brain herniation syndrome is most likely to be causing his new signs and symptoms? 1. Central herniation 2. Subfalcine herniation 3. Tonsillar herniation 4. Uncal / transtentorial herniation

Uncal / transtentorial herniation

Case 5: A 53 year old man presents to ED with a 2 hour history of headache. He describes it as sudden onset and quickly reached a 9/10 severity. He has been vomiting since the headache started. He feels sensitive to light and is wearing sunglasses indoors. There is no history of trauma. He has a 35 pack year history of smoking and has a background of hypertension, taking ramipril 5mg/day. On examination his blood pressure is 193/115, pulse 72 regular, resp rate 12. He is noted to have neck stiffness. 10. Which of the following is the single most important initial investigation for his presentation? 1. CT brain 2. Digital subtraction angiogram 3. EEG 4. Lumbar puncture 5. MRI brain

CT brain

Case 5: A 53 year old man presents to ED with a 2 hour history of headache. He describes it as sudden onset and quickly reached a 9/10 severity. He has been vomiting since the headache started. There is no history of trauma. He feels sensitive to light and is wearing sunglasses indoors. He has a 35 pack year history of smoking and has a background of hypertension, taking ramipril 5mg/day. He has a CT brain (shown below) 11. Which of the following is the most likely cause of his bleeding? 1. Arteriovenous malformation 2. Carotid artery dissection 3. Rupture of Ant comm. artery aneurysm 4. Rupture of Basilar artery aneurysm 5. Rupture of Post comm. artery aneurysm

Rupture of Ant comm. artery aneurysm

Case 6: An 85 year old lady is seen by her GP for increasing confusion and agitation. She has a background of moderate dementia and is a resident of an aged care facility. The nursing staff report that she has developed urinary incontinence, her memory is worse that usual and she has been increasingly aggressive which is out of character. On examination she is noted to have an unsteady gait; neurologic examination is otherwise unremarkable. Her GP arranges a CT brain which is shown. Group discussion: How would you describe the findings of her CT scan?

Subdural bleed - Crescent shape of hematoma. L sided Effacement of the ventricle, compression of ventricle. midline shift

Case 6: An 85 year old lady is seen by her GP for increasing confusion and agitation. She has a background of moderate dementia and is a resident of an aged care facility. The nursing staff report that she has developed urinary incontinence, her memory is worse that usual and she has been increasingly aggressive which is out of character. On examination she is noted to have an unsteady gait; neurologic examination is otherwise unremarkable. 12. Damage to which vessel is most likely to be causing her presentation? 1. Anterior communicating artery 2. Basilar artery 3. Bridging veins 4. Middle meningeal artery 5. Superior sagittal sinus

Bridging veins

Case 7: An 18 year old woman is brought in to ED by ambulance after collapsing at a party. A witness indicates that her limbs stiffened and then began ‘jerking’ uncontrollably. This stopped after 10 minutes while they were waiting for an ambulance. She was drowsy and confused. Another episode started approximately 5 minutes ago while she was in the ambulance and is continuing. 13. What is the single most important initial management step for this patient? 1. Give benzodiazepine 2. Give levetiracetam 3. Give propofol 4. Urgent CT brain 5. Urgent EEG

Give benzodiazepine / urgent EEG

Case 7: An 18 year old woman is brought in to ED by ambulance after collapsing at a party. Her seizure terminates with IV midazolam and when the patient recovers she indicates that she has been experiencing involuntary sudden ‘jerks’ most commonly on waking and lasting for a few seconds. These have been going for some time and she assumed she was ‘just clumsy’. She does not lose consciousness and has never had a generalized seizure before 14. What type of seizure is the patient most likely experiencing? 1. Absence seizure 2. Atonic seizure 3. Clonic seizure 4. Myoclonic seizure 5. Tonic seizure

myoclonic seizure

EEG FBC head CT/ MRI UEC Pregnancy CMP ECG BGL Lactate Toxicology

Case 7: An 18 year old woman is brought in to ED by ambulance after collapsing at a party. Her seizure terminates with IV midazolam and when the patient recovers she indicates that she has been experiencing involuntary sudden ‘jerks’ most commonly on waking and lasting for a few seconds. These have been going for some time and she assumed she was ‘just clumsy’. She does not lose consciousness and has never had a generalized seizure before. After she recovers from her seizure she has a normal neurologic examination. MRI and pathology are unremarkable. EEG shows 4Hz spike and wave discharges. She is diagnosed with juvenile myoclonic epilepsy. Group discussion: Aside from commencing medication what else should be discussed with the patient to improve their safety in the event of another seizure?

discussion with teh family of what to do when they have another seizure, advise the pateint that they cannot drive for 6 months after seizure / 1 year. if it occurs for more than 10 minutes, administer benzos identify triggers safe swimming safe working environments

Case 8: A 57 year old man presents to his GP with a 4 month history of worsening headache. He describes a generalized pain which is present on waking and can be exacerbated by coughing and sneezing. He has also noticed decreased sensation in his right leg. He is right hand dominant. On examination he has a right inferior quadrantanopia. 15. What is the most likely location of his pathology? 1. Left optic nerve 2. Right optic nerve 3. Left parietal lobe 4. Right parietal lobe 5. Left temporal lobe

Left parietal lobe

Case 8: A 57 year old man presents to his GP with a 4 month history of worsening headache. He describes a generalized pain which is present on waking and can be exacerbated by coughing and sneezing. He has also noticed decreased sensation in his right leg. He is right hand dominant. On examination he has a right inferior quadrantanopia. His MRI is shown below. 16. Which of the following clinical features is the patient most likely to experience? 1. Acalculia 2. Hypersalivation 3. Left hemineglect 4. Nystagmus 5. Visual hallucinations

Acalculia

Case 8: A 57 year old man presents to his GP with a 4 month history of worsening headache. He describes a generalized pain which is present on waking and can be exacerbated by coughing and sneezing. He has also noticed decreased sensation in his right leg. He is right hand dominant. On examination he has a right inferior quadrantanopia. His MRI is shown below. 17. What is the most important next step in the management of this patient? 1. Commence antiepileptic medication 2. Provide simple analgesia 3. Neurosurgery referral 4. Ophthalmology referral

Neurosurgery referral - ring enhauncing lesion (surrounding inflammation) - hetrogenous mass in white matter - central necrosis - surroudning oedema

Case 8: A 57 year old man presents to his GP with a 4 month history of worsening headache. He describes a generalized pain which is present on waking and can be exacerbated by coughing and sneezing. He reports being more clumsy than usual and is often walking into things on his left hand side. He undergoes resection of the lesion. Histopathology is shown below. 18. What is the diagnosis? 1. Metastasis 2. Glioblastoma 3. Lymphoma 4. Medullablastoma 5. Meningioma

Glioblastoma a. phleomorphic cells - forming pseudo palidating b. around area of necrosis c. areas of haemorrhage

Case 9: A 74 year old lady presented with progressive depression and headaches worsening over 6 months. Her headache is worse in the morning. More recently she has developed poor short term memory. CT scan image is shown. (Gross image is from a different patient with similar diagnosis) 19. What is the most likely diagnosis? 1. Glioblastoma 2. Pilocytic astrocytoma 3. Medulloblastoma 4. Metastases 5. Meningioma

Meningioma

Case 10: A 28 year old woman presents with a 3 month history of bilateral hearing loss, tinnitus and loss of balance. Examination confirms a sensorineural hearing loss in both ears. Her neurological examination is otherwise normal. You suspect bilateral vestibular schwannomas. 20. Which of the following statements is correct? 1. Bilateral vestibular schwannomas are associated with Neurofibromatosis type 1 2. She is likely to have numerous skin neurofibromas 3. Her children have a 50% chance of developing the same condition 4. She is likely to have numerous café-au-lait spots 5. She is likely to develop malignant peripheral nerve sheath tumours over time

Her children have a 50% chance of developing the same condition It is type NF2

Case 11: A 45 year old man presents with a 6 month history of a slowly growing lump in his upper thigh. On examination an irregular lump is palpated. Following imaging, a biopsy is performed. Microscopy shows highly pleomorphic spindle cells with hyperchromatic nuclei. 21. What is the most likely diagnosis? 1. Liposarcoma 2. Osteosarcoma 3. Lipoma 4. Kaposi’s sarcoma 5. Neurofibroma

Liposarcoma

DDD.

A 79-year-old female presents to ED with confusion. Notes from her nursing home state her confusion has been going on for 3 days. She has been having urinary incontinence for the last 5 days. Her behavior has been worse to manage in the evening with aggression. She is on a number of medications including Targin 5mg BD for OA, ramipril, atorvastatin, rivaroxaban, metoprolol, Panadol osteo, HCTZ. No report of recent falls. FamHx: Mum had Alzheimer’s disease. 01. The presence of which of the following features supports delirium as the most likely diagnosis? A. Dysuria with increased urinary frequency, onset of confusion over a few hours with periods of lucidity, and short term memory impairment B. Sundowning, progressive loss of day to day functions, with long and short term memory impairment C. Insomnia, weeks of low mood, and features of psychosis (delusions and hallucinations) D. Recurrent falls, short term memory impairment, and confabulation

Dysuria with increased urinary frequency, onset of confusion over a few hours with periods of lucidity, and short term memory impairment. b. dementia c. depression d. cerebellar dysfunction

65 yo male is accompanied by his wife for a health check with their GP. He has no PMHx and is not on any meds. Retired from his law practice 2 years ago. The patient’s wife and children have observed increasing episodes of forgetfulness over the last 6-12 months. Specific examples include: repeating the same questions, forgetting tasks he had set out to complete, he’s lost his way driving home from familiar outings, and the other day put some soup on the stove and completely forgot about it! Luckily his wife was home but she’s understandably getting more worried. In addition to asking further history (pt & collateral) and examination –what clinical scoring tool(s) would assist you in the assessment of this patient? Discuss strengths/weaknesses of each

MMSE: out of 30, <24 mild cognitive impairment. is Standardised, quick and easy test, does not take into account education or cultural aspects or language MoCA: more sensitive for MCI, -ve being time taken RUDAS: recommended for culturally linguistic KICA: validated assessment tool for older indigenous austrlaians

65 yo male is accompanied by his wife for a health check with their GP. He has no PMHx and is not on any meds. Retired from his law practice 2 years ago. The patient’s wife and children have observed increasing episodes of forgetfulness over the last 6-12 months. Specific examples include: repeating the same questions, forgetting tasks he had set out to complete, he’s lost his way driving home from familiar outings, and the other day put some soup on the stove and completely forgot about it! Luckily his wife was home but she’s understandably getting more worried. On further questioning, it appears he has been having some word finding difficulties. He also usually enjoys a sudoku puzzle with his morning coffee but has been struggling complete them in the last few months. No mood disturbances. No other symptoms of concern. His MMSE score is 23 today with a normal examination. Case 1 02. What is your most likely diagnosis? A. Lewy Body Dementia B. Frontotemporal Dementia C. Alzheimer’s Dementia D. Parkinson’s Disease

Mild cognitive impairment : deficits seem higher level impairment - alzheimers. A. Lewy Body Dementia - should have parkinsons features B. Frontotemporal Dementia - laguage, intact memory D. Parkinson’s Disease- no cognitive loss

65 yo male is accompanied by his wife for a health check with their GP. He has no PMHx and is not on any meds. Retired from his law practice 2 years ago. The patient’s wife and children have observed increasing episodes of forgetfulness over the last 6-12 months. Specific examples include: repeating the same questions, forgetting tasks he had set out to complete, he’s lost his way driving home from familiar outings, and the other day put some soup on the stove and completely forgot about it! Luckily his wife was home but she’s understandably getting more worried. On further questioning, it appears he has been having some word finding difficulties. He also usually enjoys a sudoku puzzle with his morning coffee but has been struggling complete them in the last few months. No mood disturbances. No other symptoms of concern. His MMSE score is 23 today with a normal examination. 4. 03. For the previous patient, which medication would you consider trialing? A. Risperidone B. Donepezil C. Paroxetine D. Levodopa+Benserazide

Donepezil: dementia drug - ach inhibitor A. Risperidone - seditive C. Paroxetine - antidepressant D. Levodopa+Benserazide - parkinosns disease

Image of features seen in Alzheimers brain. Which of the following feature is shown by arrow B. 1. Neurofibrillary tangle 2. Amyloid plaque 3. Amyloid angiopathy 4. Neuronal atrophy 5. Aꞵ aggregates

Amyloid plaque - made of AB aggregates

40 yo female presents to you in GP clinic with low mood and not enjoying her usual hobbies of running and painting. She reports these symptoms have been ongoing for at least 5 years, although not previously discussed with a doctor. More recently she has found it a struggle to perform her usual work duties as a medical receptionist. No PMHx. No meds.FamHx – Parents divorced when she was young. Didn’t know her dad but he died in his late 40s – was told from “early dementia”.During the consult you notice jerking movements of her hands Case 2 05. What pattern of inheritance is this genetic neurodegenerative disorder? A. Autosomal recessive B. Autosomal dominant C. X-linked recessive D. X-linked dominant E. Mitochondrial

suggested history of huntingtons -Autosomal dominant

40 yo female presents to you in GP clinic with low mood and not enjoying her usual hobbies of running and painting. She reports these symptoms have been ongoing for at least 5 years, although not previously discussed with a doctor. More recently she has found it a struggle to perform her usual work duties as a medical receptionist. No PMHx. No meds.FamHx – Parents divorced when she was young. Didn’t know her dad but he died in his late 40s – was told from “early dementia”.During the consult you notice jerking movements of her hands Huntington’s Disease will likely affect which area of the brain predominantly? A. Thalamus B. Internal capsule C. Substantia nigra D. Motor cortex E. Striatum

Striatum - atrophy of the striatum, enlarged ventricles.

# * A 60 y.o. woman presents as a new patient to your practice. She walks into your room taking small quick steps with her body leaning forwards. On sitting down, you note she has a very apathetic appearance and there is a visible tremor. 07. What are the 3 hallmark signs of her disease? A. Festinating gait, changes to writing, tremor B. Rigidity, bradykinesia, tremor C. Bradykinesia, changes to voice, ataxia D. Facial masking, rigidity, tremor E. Ataxia, tremor, changes to writing

parkinsons B -Rigidity, bradykinesia, tremor. These are the hallmarks.

A 60 y.o. woman presents as a new patient to your practice. She walks into your room taking small quick steps with her body leaning forwards. On sitting down, you note she has a very apathetic appearance and there is a visible tremor. Which of the following tremors is the patient most likely to experience in parkinsons? A. Low frequency tremor of the right hand that is present at rest and diminishes with movement B. High frequency tremor of both hands that is more prominent with movement C. Fine high frequency tremor of the hands triggered by holding her arms outstretched D. Low frequency tremor of the hands that is more apparent as they move towards a target E. Tremor of the legs that is triggered on standing and resolves when sitting

Low frequency tremor of the right hand that is present at rest and diminishes with movement - the only resting tremor.

# [](http://) In parkinsons, the most specific expected macroscopic abnormality is: A. Atrophy of the thalamus B. Posterior cortical thinning and atrophy C. Haemorrhages within the cerebellum D. Depigmented substantia nigra

Depigmented substantia nigra

Which of the following clinical features is the patient most likely to experience in parkinsons? A. Autonomic dysfunction, hypophonia, micrographia B. Ataxic gait, confusion, poor coordination C. Limb weakness, antalgic gait, depression D. Involuntary movements, poor memory, depression

Autonomic dysfunction, hypophonia, micrographia. b. would indictae cerebellum c. structural issue not neurological d. would indicate huntingtons

A 65 yo female was recently diagnosed with Parkinson disease after onset of tremor, increased tone and bradykinesia 10 months ago. She is brought in by family reporting concern that she hasn’t been herself. In the last few weeks, she has appeared inattentive and quite confused at times. They also say that she keeps talking about seeing a black cat in the house, even though they don’t own any pets. 11. What diagnosis should you now consider? A. Lewy Body Dementia B. Frontotemporal dementia C. Wilson’s Disease D. Atypical parkinsonism E. Chronic traumatic encephalopathy

Lewy Body Dementia

A 65 yo female was recently diagnosed with Parkinson disease after onset of tremor, increased tone and bradykinesia 10 months ago. She is brought in by family reporting concern that she hasn’t been herself. In the last few weeks, she has appeared inattentive and quite confused at times. They also say that she keeps talking about seeing a black cat in the house, even though they don’t own any pets. The same patient returns for review 6 months later. You suspect she has developed autonomic dysfunction as a complication of her Parkinson disease. 12. The presence of which of the following feature would support your theory? A. Constipation B. Tinnitus C. Dry mouth D. Hypertension

Constipation

Over the past 2 years, a 57yo male has become more depressed, withdrawn and socially isolated. This has coincided with the development of abrupt mood disturbances and irritability. He has become repetitive in his actions. And now has troubles with his speech – he’s struggling to remember names of simple objects and is speaking with halted sentences. His memory does not appear to be affected. 13. Which diagnosis is he most likely to have? A. Lewy Body Dementia B. Frontotemporal Dementia C. Central pontine myelinolysis D. Huntington’s Disease E. Chronic traumatic encephalopathy

Frontotemporal Dementia

A 55 yo retired boxer has slowly developed headaches, memory loss and tremors over the last few years. During his career, he suffered at least 5 significant head concussions. He has no family history of dementia. 14. What diagnosis does he most likely have? A. Chronic traumatic encephalopathy B. Wernicke’s encephalopathy C. Korsakoff psychosis D. Vascular dementia

Chronic traumatic encephalopathy

A 54 yo female presents to ED with confusion, ataxic gait, and blurry vision. Her memory appears intact and there is no confabulation. She has no PMHx. Smokes 10 cigs/day. EtOH 10+ SD/daily. 15. What is her most likely diagnosis? A. B12 deficiency B. Left sided temporal stroke C. Wernickes encephalopathy D. Korsakoff syndrome

Wernickes encephalopathy - acute

A 54 yo female presents to ED with confusion, ataxic gait, and blurry vision. Her memory appears intact and there is no confabulation. She has no PMHx. Smokes 10 cigs/day. EtOH 5+ SD/daily. 16. Her symptoms are due to which of the following? A. Thiamine deficiency B. B12 deficiency C. Folate deficiency D. Hypoglycaemia

Thiamine deficiency

17. Wernicke’s encephalopathy is associated with haemorrhages in: A. Caudate + 3rd ventricle B. Mamillary body + 3rd ventricle C. Corpus callosum + lateral ventricle D. Putamen + hypothalamus

Mamillary body + 3rd ventricle

43F presents with fatigue, shortness of breath and numbness/tingling in her legs. She reports prior to arriving in Australia from Finland 10 years ago, she was diagnosed with pernicious anaemia. She has not ever received treatment for this condition. 18. Which neurological examination findings would indicate complications from her underlying diagnosis? A. Ataxic gait, nystagmus, dysdiadokinesis B. Impaired vibration sense, hyperreflexia, +ve Rhomberg’s sign C. Café au lait macules, visual loss, polyneuropathy

Impaired vibration sense, hyperreflexia, +ve Rhomberg’s sign - subacute combined degeneration secondary to B12 deficiency.

Etiology of common clinical type of gout is, Genetic defect Excess protein diet Increased cell lysis (Leukemias) Alcohol abuse Renal disease

Genetic defect

Marked hyperuricemia is sufficient to cause clinical Gout. True False

Following inflammatory cells are typically seen in Synovial fluid in Gout. Lymphocytes Macrophages Giant cells All of the above Neutrophils

neutrophils

Crystals seen in Pseudo-Gout are, Calcium Phosphate Oxalic acid Calcium Pyrophosphate Mono-sodium urate Uric acid

Calcium Pyrophosphate

Criteria for diagnosing JIA is children aged less than 16 years with arthritis for more than 8 days 1 week 6 weeks 6 months 6 Years

6 weeks

In majority of JIA laboratory tests show positive Rheumatoid Factor test Anti CCP Antibody test HLA B27 test Anti ds DNA test ANA (Anti Nuclear Antibody) test

ANA (Anti Nuclear Antibody) test

Ankylosing spondylitis typically involves what joint. Knee Sacroiliac Hip Distal Interphalengial Proximal Interphalengial

Sacroiliac

Joint destruction is typically seen in all these arthritis EXCEPT. JIA Ankylosing Spondylitis Lyme disease Gonococcal arthritis Staphylococcal septic arthritis

Gonococcal arthritis

Lymes disease can be trated with oral antibiotics. True False

Ganglion Cyst is a degenerative cyst of peripheral nerve ganglions. True False

90% cases of Ankylosing spondylitis patients are positive for what feature. HLA DRB1 PTPN 22 HLA DR3 HLA B27 Anti CCP

HLA b27

Typical microscopic feature of RA is synovial, Acute inflammation with neutrophils Chronic inflammation Granuloma formation Proliferation with lymphoid follicles. Atrophy with lymphocytes & plasma cells.

Proliferation with lymphoid follicles.

Early involvement of Distal Interphalengial joints (DIP) is typical of Osteoarthritis. True False

What cells are typically only seen in synovial fluid of RA joints. Plasma cells Lymphocytes Neutrophils Macrphages Giant cells

Neutrophils

Typical microscopic feature of OA joints is, Sclerosis Bone cyst Cartilage flaking Cartilage fissuring All of the above

All of the above

In acute gout, Monosodium Urate crystals are typically seen within, Macrophages Giant cells Centre of granuloma Neutrophils Plasma cells.

Neutrophils

Common genetic susceptibility for developing RA is, CD4 Lymphocytes RANK gene Anti CCP HLA DR4 RF

HLA DR4

Rice bodies in RA joints are Necrotic tissue Fibrin clots WBC clumps bone pieces Granulomas

Fibrin clots

Typical microscopic feature seen in Pannus is plenty of Neutrophils Mesothelial cells Lymphocytes Degeneration Inflammation

lymphocytes

In RA injury starts in the articular cartilage and then spreads to synovium True False

False

Tendons & Ligaments have predominantly Type-2 Collagen. True False

Healing in Cartilage is by Type-1 Collagen. True False

Superficial partial thickness injury in articular cartilage is never healed fully. True False

Full thickness injury in articular cartilage is healed by Fibrocartilage True False

Specialized connective tissue bands connecting two bones is called Ligament Tendon Fascia Capsule Periosteum

Ligament

Postural muscles are strong muscles and are actively contracting all the time. True False

F Postural muscles are weak muscles but are active most of the time to keep stable posture, this reduces blood supply causing ischemia. (it is good to move frequently during day time)

Replacement of dead muscle cell is by proliferation of, Myoblasts Surrounding intact muscle cells. Bone marrow stem cells Satellite cells Myocytes

Satellite cells

# ** Among the four stages of healing, third stage is,

* Stages of Healing; (common to all tissues) a) Bleeding b) Inflammation c) Proliferation d) Remodeling

Common myositis in children is, Polymyositis Dermatomyositis Inclusion body myositis Duchenne muscluar dystrophy Becker's muscular dystrophy

Dermatomyositis

# * Amyloid & tau protein deposition is seen in ____________ type of muscular disorder. Polymyositis Rheumatica Dermatomyositis Inclusion body myositis toxoplasma myositis Alzheimer's disease.

Inclusion body myositis

Unlike crush syndrome, Inflammation is the initial trigger in Compartment syndrome. True False

"One slow fat red ox" is the pneumonic to remember type-2 muscle fibre. True False

Dermatomyositis is common in Infants Neonates Children Adults Elcerly

Children

35 year old male presents with pain in his collarbone since a fall on his shoulder with his arm at his side. He now complains of pain +++ in shoulder Q01: How long will it take this fracture to heal? * 3wks * 4-6wks * 6-8wks * 8-10wks * 12 wks

6-8 weeks

The patient with presents five weeks later for review and an Xray reveals a bridge linking the fracture edges Q02: What type of tissue predominates in this bridge? * Organising haematoma * Vascular stage: Granulation tissue * Primary callus: cartilage * Bony callus: woven bone * Mature callus: lamellar bone

Bony callus: woven bone - there is some connection, but it is irregular the first three, there would be no connection at all.

42 year old male patient presents following a motorcycle accident. Q03: What is this type of fracture? * Closed * Open

Open - compound fracture.

Table talk: list factors that delay healing

diabetes infection alignment movement rebreak poor nutrition chronic disease older age

Patient presented with an open fracture Patient presents 6 months later with one month’s history of discharge from skin over fracture site. This is the associated Xray. Q04: What is the most likely diagnosis? * Abscess * Cellulitis * Osteomyelitis * Osteosarcoma

Osteomyelitis

A 52 year old woman presents with severe L upper arm pain after helping her husband move a sofa. On further history, she has had arm pain at night for the last month. Q05: Most likely underlying cause of fracture? * Metastasis * Osteomyelitis * Osteopenia * Osteoporosis

Metastasis

A 52 year old woman presents with severe L upper arm pain after helping her husband move a sofa. On further history, she has had arm pain at night for the last month. Which of the following is the definition of pathological fracture? * Caused by repeated excessive activity * Due to fall from standing height or less * Occurs spontaneously or with minimal trauma

all are suspicious, but occurs spontaneously or with minial trauma is the most correct.

A 52 year old woman presents with severe L upper arm pain after helping her husband move a sofa. On further history, she has had arm pain at night for the last month. What is the most likely source of the metastasis causing her pathological fracture? * Breast * Kidney * Lung * Lymphoma * Thyroid

* Breast - 53 * Kidney - 11 * Lung - 8 * Lymphoma - 5 * Thyroid - 5

A 52 year old woman presents with severe L upper arm pain after helping her husband move a sofa. On further history, she has had arm pain at night for the last month. She had treated breast cancer 8 years ago and had been given the all clear Q08: A biopsy of the lesion is done, what would you expect in the report? * Keratin pearls * Pleomorphic ducts

pleomorphic ducts - irregular ducts kerritin pearls would be rounded sections

68 yo woman Smoker Watches a lot of TV and seldom goes outdoors Depression, on SSRIs Menopause aged 48years Poor nutrition – tea and toast – since death of partner 10 years ago COPD. Several exacerbations. Steroids multiple times this year Diabetes, on metformin Also reflux, PPIs BMI<18 4units alcohol per day Mother had bad osteoporosis and a very crooked spine as an older woman * Table talk: risk factors for osteoporosis * What factors can you identify? * Modifiable vs non modifiable * Diseases and medications

chronic disease menopause smoking malnutrition family hx steriod use lack exercise depression SSRI lack outside diabetes PPIs

68 yo woman Smoker Watches a lot of TV and seldom goes outdoors Depression, on SSRIs Menopause aged 48years Poor nutrition – tea and toast – since death of partner 10 years ago COPD. Several exacerbations. Steroids multiple times this year Diabetes, on metformin Also reflux, PPIs BMI<18 4units alcohol per day Mother had bad osteoporosis and a very crooked spine as an older woman With any of these risk factors, patient undertakes a DXA. Her T score is -2.1. Q09: What is the next step in her management? * Bisphosphonates * Calculate fracture risk * Encourage exercise participation * Oestrogen replacement therapy

osteopenia (-2.5 is osteoperosis) therefore calculate fracture risk

68 yo woman Smoker Watches a lot of TV and seldom goes outdoors Depression, on SSRIs Menopause aged 48years Poor nutrition – tea and toast – since death of partner 10 years ago COPD. Several exacerbations. Steroids multiple times this year Diabetes, on metformin Also reflux, PPIs BMI<18 4units alcohol per day Mother had bad osteoporosis and a very crooked spine as an older woman This patient is suspected of having low Vitamin D. Given the role of Vitamin D in calcium absorption, the patient will have less calcium available in her body. Q10: By what mechanism does her body try to increase her serum calcium levels? * Decrease in osteoclast activity * Increase in PTH * Increase in renal loss

Increase in PTH

Back pain Table talk: What are red and yellow flags for back pain

RED FLAGS TUNAFISH trauma unexplained weightloss neurological symtoms age >50 fever IV drug use steriod use history of cancer YELLOW FLAGS low mood depression social wihdrawal

This is a 74 yo woman. She has a strong family history of osteoporosis and so she was advised to take calcium and vit D and to exercise regularly. She had a DXA at age 55. She presents with a sudden onset of thoracic back pain yesterday. She turned in her chair to get a pen she had dropped on the ground. The pain is severe, continuous and she was unable to sleep comfortably last night, despite Panadol and ibuprofen and this is her MRI. Any red flags? She has been recommended to start denosumab She tells you that at primary school, all children were given free drinks of milk every day for their bone health. Q11: Which of the above is primary prevention for osteoporosis? * Free milk for all children * Regular calcium, Vit D and exercise * Screening with DXA * Treatment with denosumab

red flags: age, bad pain and not sleeping Regular calcium, Vit D and exercise

72 year old female presents with a long standing history of lower back pain. She has had Xrays done and was told it was osteoarthritis and to take extended release paracetamol. Two days ago, she was involved in a mishap where she clumsily caught a heavy box falling off a shelf and she now has a burning and stabbing pain going into her L buttock and down her L leg, which is made worse when coughing. She has also noticed some changes in sensation and power in her left leg since then. Any red flags? You decide to perform a neurological examination on her lower limbs and find the following signs: R side: normal power, sensation and reflexes. L side: Ability to walk on toes and to squat but inability to walk on heel Q12: Where do you expect that there will be loss of sensation? A (light green) B (dark green) C (pale lilac)

A (light green) B (dark green) -L4/5 C (pale lilac)

72 year old female presents with a long standing history of lower back pain. She has had Xrays done and was told it was osteoarthritis and to take extended release paracetamol. Two days ago, she was involved in a mishap where she clumsily caught a heavy box falling off a shelf and she now has a burning and stabbing pain going into her L buttock and down her L leg, which is made worse when coughing. She has also noticed some changes in sensation and power in her left leg since then. Any red flags? You decide to perform a neurological examination on her lower limbs and find the following signs: R side: normal power, sensation and reflexes. L side: Ability to walk on toes and to squat but inability to walk on heel Acute lateral herniation of which disc has led to these symptoms? * L4-L5 * L5-S1 * S1-S2

* L4-L5, but can be a L5 and S1 disk

72 year old male presents with pain in thoracic vertebrae. The pain has been present for 6 weeks and it is worse at night. The patient tired, easily fatigued and has lost weight in last 2 months. O/E Tender on palpation of T8 vertebral body. Any red flags? Therefore, the GP decides to do some investigations. The vertebral Xray demonstrates a lytic lesions in the vertebral bodies, particularly T8. The patient has hypercalcaemia, increased creatinine and normochromic normocytic anaemia. Q14: What is the most likely diagnosis? * Multiple myeloma * Osteoporosis * Prostatic carcinoma metastases

red flags include - weight loss, tender on palpation, timeframe, worse at night therefore, Multiple myeloma

Bone marrow aspirate is done demonstrating: “Normal marrow cells are largely replaced by plasma cells, including atypical forms with multiple nuclei, prominent nucleoli, and cytoplasmic droplets containing immunoglobulin”. Q15: What is the mechanism of the bone pain, fractures and hypercalcemia? * Osteoblast stimulation * Production of cytokine by myeloma cells * Sclerotic lesion in bone that leads to pathological fracture

Production of cytokine by myeloma cells

80 year old male presents with 3 months of worsening back pain. There is some bony tenderness at the lumbar spine. What are the red flags? Investigations are undertaken: FBC is normal, calcium and phosphate are normal but ALP is raised. See Xray of lumbar spine. Q16: What is the underlying pathogenesis of the bone disorder? * Decreased bone vascularity * Increase in size of bone marrow * Increased osteoclastic and osteoblastic activity * Low bone turnover

Increased osteoclastic and osteoblastic activity

A 82 year old male presents after tripping on his cat Now unable to weight bear on his L leg Xray demonstrates subcapital fractured neck of femur. Q17. What is the main reason for surgical repair with hemiarthroplasty/total hip arthroplasty, rather than plaster, immobilsation, or traction? * Avascular necrosis * Osteoporosis

Avascular necrosis - if there is not good traction on the area, the blood supply is compromised.

21 year old male university student presents with 1 month history of pain and tenderness in his R thigh. The pain occurs at night and he is starting to lose sleep due to the pain. However, when he gets up to take ibuprofen, this relieves the pain. Q18: What is the most likely diagnosis? * Osteochondroma * Osteoid osteoma * Osteomyelitis * Osteosarcoma

Osteoid osteoma - pain occurs at night, 5-25 years old, long bone, losing sleep, releived by NSAIDS - common in femur.

A 88 year old female presents with a one year history of R thigh pain, which has worsened in the last month. She was diagnosed with OA of the hip and was started on long acting paracetamol and NSAIDs. She has a past history of distal shaft fracture of femur in a car accident 15 years ago (which was felt to be the likely cause of the OA hip) However, the pain is worsening and is particularly bad at night. There has been an unintentional weight loss of 3kg in the last month. On examination, she has a tender lump deep in her R thigh, above her knee. Review of blood tests done a year ago reveal a random rise in her ALP and the GP was investigating her for Paget’s disease, when this Xray was done, suggesting an additional diagnosis. Q19: From the Xray, what is the most likely cause of the current increase in her thigh pain? * Ewing’s sarcoma * Healed fracture of the femur * Osteomyelitis * Osteosarcoma

Osteosarcoma both osteolytic and osteosclerotic bone shown in the image, you can see the tumor. - only in the metaphysis, also microcalcifications, codmins triangle

1. giant celll tumor 2. osteosarcoma 3. ewing sarcoma 4. Osteoid osteoma

43 year old female, presents with a one year history of a lump at the wrist. It is not painful and she is constitutionally well. On examination, the lump is next the wrist joint and is superficial and hard. It is mobile and not fixed to skin but is fixed to deep tissue Q20: What is the most likely diagnosis? * Ganglion cyst * Lipoma * Osteochondroma * Joint abscess

Ganglion cyst

A 24 year old premier league netball player presents with sudden onset Right knee pain that occurred whilst playing today. PMH/PSH: nil; no medications or allergies On further history: Was changing direction with Right foot firmly planted when the pain was felt Knee feels unstable Difficult to weight bear Knee swollen in an hour On examination Right knee: Swollen Not warm or red Widespread tenderness over knee Inability to fully extend knee Positive Lachman’s test 01.Which structure is most likely affected? 1. A 2. B 3. C 4. D 5. E

B- ACL bc of postives lachmans test

A 24 year old premier league netball player presents with sudden onset Right knee pain that occurred whilst playing today. PMH/PSH: nil; no medications or allergies 02. What investigation of the knee would be most appropriate in this patient? 1. X-ray 2. MRI 3. CT 4. CT arthrography 5. Ultrasound

MRI

What feature on history/examination would make a posterior cruciate ligament injury more likely than an ACL injury? 1. Direct blow to the flexed knee 2. Popping sensation 3. Marked swelling 4. Clicking of the knee

Direct blow to the flexed knee 2. Popping sensation (ACL) 3. Marked swelling (Non-specific) 4. Clicking of the knee (Meniscal)

A 21 year old woman presents to the GP with pain in the left medial knee. She developed pain following a weekend soccer game, when she was tackled by an opponent from the outside and ran into the lateral side of the left knee. The knee was hyperextended and twisted during the tackle. She was unable to play following the injury and limped off the field. She denied any locking or giving way. Overnight she noticed some swelling. On examination: Walks with a limp but has pain, mild swelling of the medial aspect of the knee with some bruising Tenderness on palpation in the pes anserine area, MCL and medial joint line. No neurovascular deficit. AROM-0-130 degrees left knee, 0-135 degrees right knee. PROM 0-135 degrees both knees. Decreased strength left hamstring 4/5. Rest is 5/5 04. An X-ray of the knee is indicated in this patient 1. True 2. False

False

A 21 year old woman presents to the GP with pain in the left medial knee. She developed pain following a weekend soccer game, when she was tackled by an opponent from the outside and ran into the lateral side of the left knee. The knee was hyperextended and twisted during the tackle. She was unable to play following the injury and limped off the field. She denied any locking or giving way. Overnight she noticed some swelling. Special tests: Lachman’s- negative Thessaly's positive- pain on medial knee both at 5 and 20 degrees Valgus stress positive- pain on left with slight laxity An MRI is organised. 05. Considering the history and examination findings which of the following statements is true? 1. The medial meniscus and MCL are affected as they are both extra-articular knee ligaments 2. The medial meniscus is separated from the MCL by the popliteus tendon 3. The medial meniscus is firmly attached to the MCL 4. The medial meniscus and MCL are affected as they are both intra-articular knee ligaments

The medial meniscus is firmly attached to the MCL

R - rest the knee I- Ice applied C - compression and hinge brace E - elevation pain relief physiotherapy for rehabilitation activity modification until they recover

A 13 year old male high school student presents with a 4 month history of bilateral painful knees (R>L). This is worse after exercise and is painful to kneel. Associated swelling right knee. No locking or giving way. No trauma to knee. PMH- no medical problems Social: competitive soccer player On examination: tender++ tibial tubercle Knee X-ray is shown. 06. What is the most likely diagnosis? 1. Popliteal cyst 2. Pre-patellar bursitis 3. Chondramalacia patellae 4. Osgood-Schlatter disease 5. Juvenile chronic arthritis

Osgood-Schlatter disease

Tenderness on the posterior edge of both malleoli

A 52 year old male present to the GP with left ankle pain since his run yesterday. He has just started running training and completed his first 10 km run yesterday. While at the finish line he rolled his ankle and foot inward. This was associated with pain, but he iced it and went home. He complains of pain and swelling today and is concerned he may have a fracture. You perform an examination of his ankle. On examination he has some swelling and tenderness on the lateral aspect of the ankle. There is pain on inversion of the ankle. He can weight bear on the left side but has some pain. No bony tenderness or neurovascular compromise is noted. You decide an X-ray ankle is not indicated and diagnose a sprained ankle. 08. With respect to ligament injury and healing, which of the following statements is correct? 1. Type 2 collagen predominates 2. Are highly vascular 3. Injuries heal quickly (<4 weeks) 4. Tears in ligaments are repaired by fibrovascular scar 5. Return to usual strength is the usual outcome

Tears in ligaments are repaired by fibrovascular scar

A 29 year old man presents to the local health service after being tackled awkwardly during a soccer game in Normanton. This was associated with severe pain in his right shin and inability to weight bear, and he had to be stretchered off the field. On examination of the right leg there is no open wound noted and there is no neurovascular compromise. No other injuries are noted else where and he is haemodynamically stable with a GCS of 15. Xray of the right tibia is shown below. Knee and ankle x-rays are normal. While awaiting further management, he complains of a feeling of tightness in his leg and swelling associated with deep aching burning pain in the front of the lower leg. This is worsened by passive stretching and relieved by rest. This is associated with some numbness on the dorsum of his leg. 09. What is the pathophysiology of the most likely cause of his current symptoms? 1. Myoglobin release following muscle injury 2. Non-necrotizing inflammation of the subcutaneous tissue 3. Elevated pressure in an osteofascial compartment 4. Venous thromboembolism

Elevated pressure in an osteofascial compartment

What sign is most likely to be present on examination that might be suggestive of acute compartment syndrome? 1. Erythema 2. Extensor plantar response 3. Firm wooden feeling on deep palpation 4. Dilated superficial veins 5. Warmth

Firm wooden feeling on deep palpation p's

What limitations need to be considered when managing patients with injuries in remote settings? Table talk:

access to imaging assess to specialists for referrals ability for rehabilitation difficlty and time constraints for followup appointments travel to other places for specialist

bursitis rotator cuff injury osteoarthritis frozen shoulder impingements adhesive capsulitis referred pain inflammatiory arthropathy

A 60 year old woman presents with pain and stiffness in the right shoulder for the past 6 weeks. The pain is located over the outer aspect of her shoulder. She has history of type 2 diabetes on metformin. She is a non-smoker, does not drink alcohol. She swims 4 times a week and plays the violin regularly. On examination: External examination shows no abnormalities. Palpation reveals no tenderness. AROM decreased in all planes and is associated with pain. PROM decreased due to pain and mechanical block. 11. On the basis of these physical examination findings, the most likely cause of her symptoms is 1. Impingement 2. Bursitis 3. Glenohumeral instability 4. Adhesive capsulitis 5. Rotator cuff tear

Adhesive capsulitis

A 60 year old woman presents with pain and stiffness in the right shoulder for the past 6 weeks. The pain is located over the outer aspect of her shoulder. She has history of type 2 diabetes on metformin. She is a non-smoker, does not drink alcohol. She swims 4 times a week and plays the violin regularly. On examination: External examination shows no abnormalities. Palpation reveals no tenderness. AROM decreased in all planes and is associated with pain. PROM decreased due to pain and mechanical block.12. What special tests are indicated in this patient? 1. Hawkins Kennedy 2. Empty can 3. Drop arm 4. Apprehension relocation 5. All 6. None

None

A 60 year old woman presents with pain and stiffness in the right shoulder for the past 6 weeks. The pain is located over the outer aspect of her shoulder. She has history of type 2 diabetes on metformin. She is a non-smoker, does not drink alcohol. She swims 4 times a week and plays the violin regularly. On examination: External examination shows no abnormalities. Palpation reveals no tenderness. AROM decreased in all planes and is associated with pain. PROM decreased due to pain and mechanical block. 13. What is the most appropriate treatment option for this patient? 1. Oral steroids 2. DMARDs 3. Physiotherapy 4. Topical analgesia 5. Intraarticular sodium hyaluronate

Physiotherapy

A 45 year old man presents to his GP with complains of difficulty with overhead activity and paraesthesia in the posterior upper arm. He is recovering from a fractured tibia 3 weeks ago and is currently using crutches to mobilise. He is otherwise well with no other medical problems. Examination confirms sensory loss in the posterior upper arm and weakness and limitation of abduction. 14. What other sign may be present in this patient on examination? 1. Rounded shoulder contour 2. Difficulty with adduction 3. Difficulty with external rotation 4. Difficulty with internal rotation 5. Positive Hawkins Kennedy test

Difficulty with external rotation

A 42 year old woman presents with a 1 month history of numbness, tingling and pain in her left hand. On further history she complains of fatigue and weight gain. Examination confirms sensory loss (highlighted in purple) shown below. 15. Which of the following muscles might be affected in this patient? 1. Extensor pollicis brevis 2. Flexor carpi ulnaris 3. Palmar interossei 4. Abductor pollicis brevis 5. Lumbricals 3 and 4

Abductor pollicis brevis

A 42 year old woman presents with a 1 month history of numbness, tingling and pain in her left hand. On further history she complains of fatigue and weight gain. Examination confirms sensory loss (highlighted in blue) shown below 16. Which of the following tests will assist in determining the most likely underlying cause? 1. FBC 2. ESR 3. IGF-1 4. Anti CCP 5. TFT

TFT

A 27 year old man presents with 1 week history of weakness in his right forearm and wrist. He is recovering from a fracture of the shaft of the humerus sustained 4 weeks ago. He is generally fit and well. On examination he has weakness of his forearm extensors, wrist extensors and brachioradialis. No sensory loss is noted. No vascular compromise. 17. Which of the following images of his hand would best fit in with his clinical presentation?

Hand in the resting position - radial nerve A- ulner B- medial

A 62 year old woman presents to the fracture clinic for removal of her below knee plaster cast in her left leg following her recent left fibular fracture. She complains of sensory loss over her left leg. She has no back pain. No PMH of note. She does not smoke or drink alcohol. On examination you observe a high stepping gait. Examination confirms sensory loss on the lower lateral aspect of her leg and dorsum of her foot. 18. Which nerve is most likely to be affected in this patient? 1. Common peroneal nerve 2. Femoral nerve 3. Tibial nerve 4. Sciatic nerve 5. Sural nerve

Common peroneal nerve

A 62 year old woman presents to the fracture clinic for removal of her below knee plaster cast in her left leg following her recent left fibular fracture. She complains of sensory loss over her left leg. She has no back pain. No PMH of note. She does not smoke or drink alcohol. On examination you observe a high stepping gait. Examination confirms sensory loss on the lower lateral aspect of her leg and dorsum of her foot. 19. What additional abnormality may be seen on motor examination of her left leg? 1. Extensor plantar 2. Weakness on plantar flexion 3. Weakness on ankle eversion 4. Weakness of toe flexion 5. Weakness on knee flexion

Weakness on ankle eversion

Common pathogen causing Epiglottitis is, Rhinovirus Group A Strep pyogenes (GAS) Influenza A H.influenza Parainfluenza

H.influenza

Catarrhal inflammation is characterised by Acute inflammation Excess mucous production Excess Pus formation Serous inflammation Excess eosinophils

Excess mucous production

Common pathogen causing common cold is, Rhinovirus Rotavirus Adenovirus EBV GAS

Rhinovirus

Chronic sinusitis is characterised clinically by presnce of sinusitis for more than, 3 weeks 6 weeks 10 weeks 12 weeks 18 weeks

12 weeks

Bull neck in Diphtheria is due to Swollen, Pharynx Oro-Pharynx Larynx Tonsills & Pharynx Lymphnodes

Lymphnodes

In infectious mononucleosis, Atypical lymphocytes seen in blood film are, EBV infected B lymphocytes Reactive B lymhphocytes Reactive T lymphocytes EBV specific B lymphocytes EBV specific T lymphocytes

EBV infected B lymphocytes

Etiology of Aphthous ulcers is, Tobacco chewing Inflammatory Bowel Disorder (IBD) HPV infection Stress Unknown

Unknown- occurs in Inflammatory Bowel Disorder (IBD)

"Pyogenic granuloma" microscopically is, Granulation tissue Benign fibrous tumor Benign fibrous tumor Pus forming inflammation Scar tissue

Granulation tissue

Leukoplakia (compared to Erythroplakia), has a higher change of becoming cancer. True False

False

27 year old man presents with a painful white patch over the bite line of buccal mucosa on the left side, since a week. Biopsy report said marked acanthosis with hyperkeratosis with submucosal inflammation. what is the most likely chance of him getting squamous cancer? 10% 90% 0% 100% 50%

0 - probably from biting

65 year old man presents with 6 month history of red patch over lateral side of tongue. He has no pain, bleeding or ulceration. Biopsy reports full thickness dysplasia. No invasion of basement membrane noted. What is the most likely chance of him getting cancer? 0% 10% 50% 90% 100%

90%

Parotid gland is what type of salivary gland. Serous Mucinous Mixed like pancreas Unlike pancreas

Serous

Sublingual gland opens on both sides of frenulum through multiple linear openings. True False

True

Commonest tumor of Salivary glands is, Warthins tumor Pleomormphic adenoma Mucoepiderlmoid carcinoma bening Sialoma Carcinoma ex Pleomorphic adenoma

Pleomormphic adenoma

"Pleo" in pleomorphic adenoma denotes that tumor consists of Pleomorphic cells Dysplastic tissue both benign and malignant tissue Malignant tissue Epithelial and Connective tissue

Epithelial and Connective tissue

Quiz 2 2 of 3 Diagnostic findings in Sjogren syndrome are HLA DR2 & 3 HLA DR4 & 6 SS-D & SS-E Anti Ro & La RF & CD4

Anti Ro & La

Mumps virus is typcially of Single serotype. True False

influenza virus has following proteins in its structure. influenza virus has following proteins in its structure. 4 - A,B,C & D 2 - H & N 3 - A, B & Other 29 - 18 H + 11 N 12 - total number

12 - total number

Cause of seasonal epidemics of influenza is "Antigenic shift" Cause of seasonal epidemics of influenza is "Antigenic shift" True False

False

Currently, commonest cause of seasonal flu is by this influenza strain. Currently, commonest cause of seasonal flu is by this influenza strain. H1N1 H2N2 H3N2 H5N1 B Victoria

H1N1

Influenza virus attacks upper respiratory epithelium mainly through Hemagglutinin (H) protein. Influenza virus attacks upper respiratory epithelium mainly through Hemagglutinin (H) protein. True False

True Hemagglutinin (H) is the major antigen that contains the sialic-acid-receptor binding site (abundant in respiratory epithelium) and neuraminidase (N) aids in release of viral particles from infected cells.

The high error rate of the RNA-dependent RNA polymerase (RDRP) and reassortment of RNA segments during co-infections provide influenza A viruses with evolutionary power. True False

Afluria Quad - Flu vaccine has these virus strain components. 3 A & 1 B 2 A & 2 B 1 A & 3 B 1A, 1B, 1C & 1D. 2A & 1B

2 A & 2 B

Spanish Flu was caused by Spanish Flu was caused by H1N1 H3N2 H3N8 SARS-CoV MERS-CoV

H3N8

Olfactory/Gustatory dysfunctions, nausea, vomiting/diarrhoea are more common with COVID. One of the distinguishing symptom of COVID is, Fatigue Myalgia Arthralgia Olfactory dysfunction Arthralgia

Olfactory dysfunction

Name "Corona virus" is because of this feature, Name "Corona virus" is because of this feature, Nucleocapsid protein Spike glycoprotein Hemagglutinin esterase Membrane protein Envelope protein

Spike glycoprotein

Variant B.1.1.7 detected in UK in May 2020 was, Alpha Beta Gamma Delta Omicron

alpha

Scientific name of Omicron variant is Scientific name of Omicron variant is B..1.351 B.1.617.2 B.1.1.529 B.1.1.7 BA.1

B.1.1.529

Likely pathogens of future pandemic are Corona Virus, Dengue virus, Ebola virus, Lassa fever virus and this, Influenza Smallpox Adenoviruses HPV Hepatitis B

Influenza

SICCA Syndrome is a primary autoimmune disorder of salivary glands. True False

True

Leukoplakia is a squamous cell carcinoma seen commonly in smokers. True False

False

Leukoplakia differes from carcinoma in that it has intact basement membrane (lack infiltration) True False

True

Commonest connective tissue element seen within pleomorphic adenoma is, Glands Fibrous tissue Bone Myxoid tissue Cartilage

Cartilage

A 35 year old man presents with nasal discharge with obstruction and facial pain for the past 5 days. The pain is worse on bending forward. No known history of atopy. On examination: Temp 37.2, mucoid nasal discharge and erythema of the nose is noted. Tenderness over both maxillary sinus is noted. Analgesia is prescribed. 01. What is the next step in the management of this patient? 1. Prescribe antibiotics 2. Organise a plain sinus X-ray 3. Organise a CT of the sinuses 4. Nasal saline irrigation 5. Prescribe antihistamines

Nasal saline irrigation

02. What feature on history/examination might suggest progression to from a viral to an acute bacterial rhinosinusitis? 1. Purulent nasal discharge 2. Loss of smell 3. Enlarged turbinates 4. Presence of pruritus 5. Presence of polyps

Purulent nasal discharge

What red flag symptoms should you ask when obtaining a history in this patient?

- visual loss/ disturbances - immunosuppression - neurological symptoms - meningeal signs - unilateral symptoms - bleeding - frontal swelling

A 27year old man presents with a sore throat for the past 3/7 associated with a cough and coryzal symptoms. “I’m just here for some antibiotics doc”. No fevers, rash or dyspnoea. No PMH of note, no meds, no allergies, no travel history On examination: His oral cavity is shown below. No lymphadenopathy 03. What is the most likely diagnosis? A. Bacterial tonsillitis B. Viral tonsillitis C. Difficult to differentiate Tonsils red with discharge

B. Viral tonsillitis C. Difficult to differentiate

What feature on history/examination would make a streptococcal tonsillitis more likely? A. Cough B. Tonsillar exudate C. Presence of fever D. Lymphadenopathy E. Immunosuppression

Immunosuppression

A guy presents with 3/7 day of sore throat and cough. NOW He returns 10 days later with a worsening sore throat “feels like razor blades”, painful to swallow, fevers, voice change and trismus. He has difficulty eating and can only manage liquids. On examination: Temp 38.2, hot potato voice, painful cervical lymphadenopathy R>L. His oral cavity is shown. 06. What is the most likely diagnosis? 1. Bacterial tonsillitis 2. Glandular fever 3. Mumps 4. Peritonsillar abscess 5. Carcinoma tonsil

Peritonsillar abscess

What organism commonly causes peritonsilar abscess 1. Staph Aureus 2. H. Influenzae 3. EBV 4. S. Pyogenes 5. S. Viridans

S. Pyogenes

How do you manage peritonsilar abscess 1. Oral antibiotics 2. IV antibiotics 3. Needle aspiration 4. Swab M/C/S 5. Dexamethasone

Needle aspiration

Which of the following is a non-suppurative complication of Group A Strep? 1. Septicaemia 2. Otitis media 3. Nephrotic syndrome 4. Acute Rheumatic Fever 5. Sinusitis

Acute Rheumatic Fever Nephrotic syndrome

URTI associated with… 1. 2y with a barking cough, stridor, and hoarse voice. 2. 21y with fevers & chills, dry cough, lethargy, myalgia 3. 3y, unvaccinated. Drooling + fever + hyperextension of neck 4. 6y with a blanching sandpaper rash, peri-oral pallor and a strawberry tongue 5. 17y with 1 week cough & coryza, followed by prolonged cough with post-tussive vomiting.

1. croup -parainfluenza 2. Influenza 3. epiglossitis - H influenza 4. Kawasakis disease/ scarlet fever 5. pertussis

A 19 year old woman presents to the GP with a 10 day history of cough, fever and sore throat. On examination tender posterior cervical lymphadenopathy with hepatomegaly and splenomegaly is present. 10. What investigation will confirm your most likely diagnosis? 1. Respiratory viral PCR panel 2. EBV VCA-IgG Ab 3. Throat swab 4. EBV VCA-IgM Ab 5. FBC (Atypical lymphocytes)

EBV VCA-IgM Ab

4 year old boy presents to the GP with a cough, coryza, fevers, myalgia and lethargy. You suspect influenza. His mother disagrees stating, “It can’t be, we’ve had the vaccine. I want Augmentin” 11. What strain does the seasonal influenza vaccine target? 1. A 2. B 3. C 4. A and B 5. A and C

A and B

A 25 year old woman presents with a 1 week history of a painful lesion on the inside of the mouth. She is otherwise well and is on no regular medication. On examination her oral cavity is shown below. No palpable lymph nodes. 12. What is the most likely diagnosis? 1. Hand foot and mouth disease 2. Fixed drug eruption 3. Herpes simplex 4. Aphthous ulcer 5. Herpangina

Aphthous ulcer

A 59 year old man presents with a lesion on his tongue for thepast 6 weeks. It’s “not really painful” but bleeds every now and again when he’s brushing his teeth. He has a 30 pack year smoking history. He undergoes biopsy. 13. Which of the following reports would suggest the most likely diagnosis? 1. Fungal hyphae with inflammation 2. Epithelial dysplasia with inflammation 3. Epithelial dysplasia with hyperkeratosis 4. Granulation tissue with inflammation 5. Infiltrating hyperchromatic, pleomorphic cells

3. Epithelial dysplasia with hyperkeratosis

What is the likely pathogen causing these symptoms? 1. Hemophilus influenzae 2. Rhinovirus 3. Influenza 4. Aspergillus 5. Streptococcus pneumoniae

Streptococcus pneumoniae

Which of the below is an indication for antibiotics in acute otitis media? 1. Fever 2. Child >12months 3. Otorrhea 4. The parent’s asked for them

Otorrhea

Classic PUO is defined as fever of >38°C without diagnosed cause for... > 1 Week > 3 days of investigations > 3 weeks > 4 weeks > 4 weeks as outpatient

> 3 weeks

Example of exogenous pyrogens are, IL-1 IL-6 TNF All of the above LPS

LPS

Mechanism of fever is increase in Prostaglandin synthesis in hypothalamus. True False

True

Important chemical mediators of inflammation & fever are TNF, IL1 and CRP Histamine IFN IL-6 IL-13

IL-6

Melioidosis is contracted through Aedes mosquito Contaminated Urine Contaminated soil Anopheles mosquito Dust inhalation

Contaminated soil

Characteristic clinical feature of Melioidosis is, Fever & Rash Arthralgia Myalgia Pneumonia Multiple Abscesses

Multiple Abscesses

Common tropical infection in NQ farmers presenting with jaundice & hemorrahge is, Q fever Melioidosis Leptospirosis Malaria Dengue

Leptospirosis

Q fever can be caused by a single organism Coxiella burnetii. True False

Chronic phase of Q fever is characterised by, Pneumonia Arthralgia Myalgia Endocarditis skin abscess

Endocarditis

Blackwater fever in Falciparum malaria is, Renal failure BV clogging by parasites Hemoglobinuria Splenomegaly Acidosis

Hemoglobinuria

Most common stage of parasite seen in peripheral blood film of malaria patient is, Gametocyte Sporozoite Trophozoite Schizont Merozoites

Trophozoite

Ross River Virus is a Flavivirus. True False

F- Ross River Virus is a Alpha virus of Arbovirus group.

Zoonotic infections are diseases of animals. True False

Most patients with Ross River Fever recover without treatment usually within, 1 week 2-4 weeks 4-7 weeks 4-7 months 1-2 years

4-7 months

Vector of Dengue fever is, Anopheles Tick Aedes Culex Bird

Aedes

Increased hematocrit in a Dengue Haemorrhagic Fever (DHF) patient is because of, Endothelial damage Thrombocytopenia Capillary leakage Activated T cells Inflammatory rush

Capillary leakage

Ascitis in a DHF patient is because of Thrombocytopenia Endothelial damage T cell activation Serositis Hepatitis

Serositis

Common incubation period in most arboviral infections is, 3 days 3 weeks 1 week 6 weeks 1 month

1 week

Japanese encephalitis is endemic in people of Southeast Asia & Pacific. True False

JE is endemic in Pigs not humans. Once transfered to humans, they cannot spread to others as viremia is low and short.

JE is known to cause epidemics because of this feature. Transfer to humans by mosquitoes Virus carried by water birds Toxicity & infectivity of the Virus RNA mutations giving survival advantage By human to human spread

JEV is a RNA virus which are known to develop rapid mutations. minor mutations may give survival advantage and result in local epidemics. They are NOT known to spread human to humans.

Gold standard test for diagnosis of JE is, MRI - bilateral thalamic inflammation JE specific IgG serum antibodies JE specific IgM antibodies in CSF Viral RNA detection by Rt-PCR Multiple factors. No specific test

JE specific IgM antibodies in CSF

Once infected, this percentage of people become symptomatic. 90% 60% 30% 10% <1%

<1%

Cycles of fever in malaria is due to sudden & massive release of what from infected RBCs. Malarial pigment Malarial toxins Sporozoites Merozoites Gametocytes

Merozoites

Parasitemia is more in the severe form of malaria caused by, vivax falciparum malariae all forms

falciparum

Gold standard for diagnosis of malaria is, Ag detection by RDT PCR molecular diagnosis Blood film Microscopy Serology - ELISA

Blood film Microscopy

Special features of Herpes Infections, Commonest RNA virus infections Common infective cause of Cancers Development of immunity for life LATS & Latency period VZV & Persistency period

LATS & Latency period

Microscopic features of Herpes infections are, Central necrosis with granuloma Large pink eosinophilic cytoplasmic inclusion large double nucleus with owl eye appearance giant cells with Intranuclear inclusions. Pleomorphic large cells with hyperchromatic nucleus

giant cells with Intranuclear inclusions.

Common oropharyngeal cold sores are caused by, Common oropharyngeal cold sores are caused by, VZV HSV-1 HSV-2 HHV-4 HHV-8

HSV-1

Chicken pox is caused by Chicken pox is caused by Reactivation of HSV-1 Primary infection by HSV-1 Primary infection by VZV Reactivation of HSV-2 Reactivation of VZV

Primary infection by VZV

# ** Commonest clinical feature of CMV infection is, Commonest clinical feature of CMV infection is, Bone marrow suppression URTI like Otitis Media Rash & Jaundice Asymptomatic Immunosuppression

Asymptomatic

Reactivation of VZV from spinal dorsal root ganglia results in Oral herpes Genital herpes Herpes zoster Gillian barre syndrome B cell lymphoma

Herpes zoster

Commonest nerve involved in shingles is, Commonest nerve involved in shingles is, Ophthalmic Optic Trigeminal Facial Intercostal

Trigeminal

Characteristic atypical lymphocytes seen in Infectious mononucleosis are, Characteristic atypical lymphocytes seen in Infectious mononucleosis are, B lymphocytes T lymphocytes Monocytes CD4 helper T cells CD8 suppressor T cells

CD8 suppressor T cells

All of the following are differential diagnosis for a 51 year old man with fever, rash and an eschar, EXCEPT All of the following are differential diagnosis for a 51 year old man with fever, rash and an eschar, EXCEPT Anthrax Echthyma Tularemia Tick Typhus Impetigo

Impetigo

Queensland tick typhus is caused by, Queensland tick typhus is caused by, Riskettsia rickettsii Burkholderia pseudomallei Rickettsia australis Orientia tsutsugamushi Borrelia burgdorferi

Rickettsia australis

Typical incubation period for Queensland tick typhus is, Typical incubation period for Queensland tick typhus is, 6 days 14 days 14-21 days 3-30days 1-3 weeks

14 days

Gold standard diagnosis for tick typhus and scrub typhus is, PCR test for Rickettsial DNA Serology for specific antibodies Silver stain of wound scrappings Typical clinical history Gram stain of wound eschar

Serology for specific antibodies

Tissue necrosis resulting in amputation is seen in Tissue necrosis resulting in amputation is seen in Qld tick typhus Scrub typhus Rocky Mountain Spotted Fever Lyme disease Cutaneous Anthrax

Rocky Mountain Spotted Fever

Target or "Bulls eye" lesion is typically seen in, Target or "Bulls eye" lesion is typically seen in, Tularemia Rocky Mountain Spotted Fever Lyme disease Scrub typhus Qld tick typhus

Lyme disease

Although Ixodes ticks are found in Australia, Lyme disease is not endemic in Australia because Australian ticks are not infected by Borrelia burgdorferi. True False