Neuro pathology Flashcards
Hemiplegia, common clinical feature of common type of stroke is due to damage to
Thalamus
motor cortex
Globus pallidus
Internal capsule
Putamen
Internal capsule
Commonest vessel involved in stroke is,
Anterior Cerebral artery
Middle Meningial artery
Posterior Cerebral artery
Middle Cerebral artery
Anterior Meningeal artery.
MCA
Commonest type of stroke is Hemorrhagic stroke.
True
False
False
Compared to ischemic stroke Higher mortality is seen in hemorrahgic stroke.
True
False
T
Charcot-Bouchard aneurysms are more common in,
Internal capsule
Brain stem
Caudate nucleus
Thalamus
Putamen
Putamen
Lacunar infarcts contain clear fluid in their lumen.
True
False
True
Slit hemorrhages are typically seen in malignant hypertension.
True
False
F
Neck stiffness is typical clinical feature in subarchnoid hemorrhage.
True
False
T
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
Pupillary light reflex in myasthenia gravis is typically
Delayed
Reduced
Increased
Normal
Fatigue on repeat testing
Normal
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
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
Typical example of dysmyelinating disorder is “Leukodystrophy”
True
False
T
Commonest demyelinating disorder is Multiple sclerosis.
True
False
T
Typical example of infective myelinolysis is Central Pontine Myelinolysis.
True
False
F - metabolic
Typical location of MS Plaque is
Base of Pons
Limbic system
Grey matter
Periventricular
Basal ganglia
Periventricular
in a stroke region, Inflammation & edema typically start how long after injury.
1 hour
6 hours
24 hours
48 hours
immediately
6 hours
Cavity formation in stroke starts typically around
6 hours
24 hours
48 hours
2 weeks
4 weeks
2 weeks
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
Paradoxical embolism typically occurs in patietns with,
Patent ductus artereosus
Patent foramen ovale
Ventricular Septal defect
Marfan’s syndrome
Patent foramen ovale
Central pontine hemorrahge typically occurs in patients with
Malignant hypertension
Ruptured berry aneurysm
Charcot-Bouchard aneurysms
Cerebellar herniation
Increased intracranial pressure
Cerebellar herniation
microscopic Features seen in old healed infarct are
Macrophages & cavity
Inflammation & gliosis
Activated astrocytes
Liqufactive necrosis & macrophages
Cavity surrounded by Gliosis
Cavity surrounded by Gliosis
“Red Neuron” initial change in damaged neuron is due to loss of
Mitochondria
Micro tubules
Nissl substance
Ribosomes
Na/K pump
Nissl substance
“Concussion” of brain is characterised by
Tear in the tissue
Superficial small hemorrhages
Haematoma formation
No permanent injury
surface bruise
No permanent injury
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
T
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
F
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 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
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
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
- MND - degenerative - progressive older
- young people
- after viral/ bacterial infection and older
- MG younger female, pregnancy
- 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
She has MS
B
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
T
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
T
Clinically Pick’s disease, the commmonest type of FTLD is characterised by preserved memory till late.
True
False
T
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
T
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
T
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?
- Migraine, tension headache, stress, raised ICP, Idiopathic hyertension, dehydration, heat stroke, TBI, concussion.
- 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.
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 pulls his hand away when the nailbed is pinched.
07. What is his GCS score?
1. GCS 8 (E3 V2 M3)
2. GCS 9 (E2 V3 M4)
3. GCS 10 (E3 V3 M4)
4. GCS 11 (E2 V4 M5)
5. GCS 12 (E3 V4 M5)
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
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
Group discussion: What investigations would you arrange for this patient?
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
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.
What differentials are you considering for her presentation?
DDD.
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
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.
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.
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.
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.
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
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
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
- giant celll tumor
- osteosarcoma
- ewing sarcoma
- 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 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
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
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
