Neuro SAQ

Question 1

Young man with acute GE, afterwards present with LL weakness + arreflexia, ascending to affect upper limbs.

1. What is your diagnosis (1)
   2.What tests to support your diagnosis (3)
2. After admission, the patient then developed ataxia + bilateral partial ptosis. Name the condition (1)
3. What antibody is associated with this condition? (1)
4. 2 Complications potentially associated with “this condition that the patient has developed” (2)

Answer 1

1. GBS
2. LP for CSF cytoalbuminologic dissociation, NCS, anti ganglioside ab, EMG
3. Miller fisher syndrome
4. Anti- ganglioside antibodies (GQ1b)
5. Autonomic dysfunction, paralytic ileus, urinary retention, respiratory failure, dysphagia (bulbar dysfunction)
6. IVIG, plasma exchange

Question 2

A middle-aged woman went to Japan, and she had mild flu-like symptoms during the trip. 2 weeks later she developed fever, confusion and speech problems. Physical examination revealed four limbs with normal power, no focal neurological deficits. History of depression, asthma, severe eczema, iatrogenic adrenal insufficiency.
1. Most likely dx and possible ddx
Plain CT show hypodensity over left side, sulcal effacement, obliteration temporal horn of lateral ventricle. Contrast MRI confirm same finding, and an additional area over right side, contrast enhancing over temporal area.
2. What specific investigation and treatment do you want to do. Briefly describe rationale
Suddenly deteriorate, left eye ptosis and abducted, right hemiparesis, CT showed same picture but with more extensive involvement.
3. what happened and what is your management

Answer 2

1. Viral encephalitis, metabolic encephalopathy, autoimmune/post infective encephalitis, addisonian crisis, other infectious causes (bacterial, TB, fungal)
2. Blood for viral PCR
   CSF for differential cell count, protein, glucose
   CSF for PCR HSV1/2, VZV, enterovirus, IgM JE
   NPA x respiratory panel
   EEG
   IV acyclovir
3. Cerebral edema causing raised ICP and uncal herniation, ipsilateral CN3 palsy and contralateral cerebral peduncle compression.
   ICP management: IV acyclovir (if suspect viral), elevate head, optimize BP and ventilation, seizure control, IV mannitol, consult neurosurg

Question 3

An old gentleman presented with tremor that is worse when watching TV, slowing of movement
PE: tremors worsen when he puts his hand on his lap, persistent glabellar tap
1. Most likely dx
2. 4 core features for dx
3. Name 2 classes of drugs that would worsen his symptoms+ cognitive functions
4. Name 2 common ddx for cause

Answer 3

1. Parkinsons disease
2. Tremor, rigidity, bradykinesia, postural instability
3. Anticholinergics, sedatives. 1st gen antipsychotic, antiepileptic, antiemetic, L-dopa
4. Multiple system atrophy, Lewy body dementia, Drug induced Parkinsonism, Vascular parkinsonism

Question 4

A young woman works in the restaurant had a sore throat 2 weeks ago. She developed pins and needle numbness first at feet then at fingers and hands. Lower limbs weakness the morning of admission. Physical examination revealed hyporeflexia of upper limb, lower limb knee jerk and ankle jerk absent. Upper limb normal power, lower limb 4/5 power. ?Mild loss of pin-prick sensation over limbs
1. What is the most likely diagnosis
2. What Ix to do?
3. Describe Mx and 2 mx issues

Answer 4

1. GBS/AIDP
2. LP for protein, glucose, cell count and differential for albuminocytologic dissociation
   Nerve conduction study: demyelinating pattern (low SNAP and CMAP in AIDP)
   Nerve biopsy (differentiate axonal, inflammatory, demyelinating)
   Antiganglioside antibodies: GM1b, GQ1b (Miller Fisher syndrome: opthalmoplegia)
3. Plasmapharesis/IVIG. High dose steroids to start off.
   Autonomic involvement: monitor for dysphagia and respiratory function (FVC), spO2
   Monitor cardiac function: arrhythmia, hypotenesion
   Respiratory support and inotrope support and terminate arrhythmia

Question 5

On steroid, Fever, headache, middle aged woman. CSF shows high protein, lymphocytosis, low glucose.
1. most likely dx
2. 2 diagnostic tests to confirm dx
3. 2 complications

Answer 5

1. Acute TB meningitis
2. CSF culture for AFB, TB PCR. Indian ink, fungal PCR to rule out fungal cause
3. Acute hydrocephalus (basal meninges adhesion preventing reabsorption of CSF), cerebral infarction (tuberculous arteritis: MCA), CN palsies (3,4,6,7,8), tuberculoma, tuberculous brain abscess

Question 6

Answer 6

a) Left ischemic stroke affecting the MCA
b) Yes it is within 4.5 hours of onset of symptoms
c) BP measurement (optimize), random blood glucose (optimize)

Question 7

Answer 7

a) acute tuberculous meningitis
b) culture (ziehl neelson stain), TB PCR
c) hydrocephalus, cerebral infarction, CN palsies (CN 3,4,6,8), tuberculous brain abscess

Question 8

Question 9

Question 10

Answer 10

a) Residual hemiparesis causing uncoordination between leg power.
Parkinsonism features caused by haloperidol (antipsychotic): rigidity, bradykinesia tremor –> susceptible to falls
Oxybutynin is a anticholinesterase (overactive bladder): AE is blurred vision (visual impairment easy to lose balance)
Prochloperazine (dopamine antagonist) used as an antiemetic: produces extrapyramidal symptoms (TRAP), orthostatic hypotension (prone to vasovagal syncope) resulting in falls
b) timed up and go test: patient rises from an arm chair, walks 3m, turns and walks back and sits down again w/o assistance. <10s is normal, >14s increased fall risk, >30s: dependent for ADLs
c) Ondansetron, Dexamethasone (both not dopamine blockers)

Question 11

a. What is the main difference between MCI and mild Alzheimer’s disease?
b. Name 1 drug for mild AD approved by the FDA for Alzheimer’s disease. (1) What is the mechanism?
c. Apart from memory, list two cognitive domains that would be affected in AD.
d. Describe 2 side effects from 2 organ systems
e. Name 1 drug approved by the FDA for moderate to severe AD. (1) What is the mechanism?

Answer 11

a. +/-ADL
b. Rivastigmine: AChE bocker
c. Orientation, attention, language, executive function
d.
e. Memantine: NMDA antagonist

Question 12

A patient was admitted for emergency surgery at night for sigmoid volvulus. He woke up at 11pm after surgery but with dense right sided hemiplegia. Urgent CT brain at midnight showed dense MCA sign.
a. Can you give IV thrombolysis? Why or why not?
His son is a high court lawyer and demands that you perform urgent reperfusion for him.
b. Are there any other revascularization methods? If no, why not? If yes, what is it and what investigation will you do beforehand
The patient was shown to have transient AF, hyperlipidemia and hyperglycemia.
c. Which of the above conditions predisposed to his stroke?
The patient regains some neurological function and you are discussing pharmacological methods to prevent recurrence of stroke
d. After revascularization, will you give antiplatelet or anticoagulant? Name some examples of the antithrombotic drugs you chose

Answer 12

a. No as he woke up with stroke features so is not definite what time was onset of symptoms (time window for tPA may have passed) + recent major surgery
b. Surgical embolectomy, DSA, coagulation profile
c. AF
d. Anticoagulants: DOAC (dabigatran, edoxaban, rivaroxaban)

Question 13

A young 20+ year old lady presents with her mother. Her mother describes several episodes of her staring into the distance with focal twitching of the right upper limb. This lasts for several minutes until the patient returns to her normal state. The patient cannot recall the episode, and only recalls feeling slightly dizzy. She has no history of head injury or trauma. She has no focal neurological signs, fever or neck stiffness.
a. What is the clinical diagnosis?
b. What immediate investigations will you perform? Give 3
The patient is sent home after the investigations and is awaiting the results. However, presents again with generalized stiffening, followed by loss of consciousness and generalized convulsions.
c. What is the diagnosis?
d. What drug can you give to prevent the condition happening again?

Answer 13

a. Complex partial seizure. Focal onset, impaired awareness, motor onset seizure
b. EEG, CT brain, serum glucose
c. Complex seizure (partial seizure –> generalized tonic clonic seizure)
d. Valproate

Question 14

A 25-year-old man with good past health collapsed suddenly after complaining of acute onset, un- precipitated severe headache referred to his occipital and neck regions. He was found to have neck stiff- ness and he was afebrile. He could open his eyes with pain, and localized the source of painful stimuli by withdrawing his limbs to pain. He could only make incomprehensible sounds.
(a) What is the most likely diagnosis?
(b) What is the Glasgow coma scale score by its components?
(c) Name three investigations that would be helpful to confirm this condition.

Answer 14

(a) SAH
(b) E2V2M5 (can localize pain)
(C) NECT for acute blood in sulci/star sign, CTA for aneurysm (spontaneous SAH), LP for blood/xanthochromia

Question 15

An otherwise healthy 25-year-old secretary consulted you for episodic unilateral throbbing headaches. She started to experience on and off headaches when she was 15 years old. The headaches were infre- quent and less severe in the past, and relief was obtained by the use of simple analgesics. Following a recent chance in her job, her headaches have become more frequent, longer-lasting, more severe, and non-responsive to simple analgesics. Her general physical and neurological examinations are normal.
(a) What is the diagnosis of her headaches?
(b) Does she need a computed tomography or magnetic resonance imaging of her brain?
(c) What treatment can be offered to abort the headache?
(d) What treatment can be offered to reduce the frequency and severity of the headache?

Answer 15

(a) migraine without aura
(b) No. Characteristic of headache for migraine. Neuroimaging is reserved for those whose dx is in doubt or a/w focal neurologiacal features
(c) for severe migriane not responsive to simple analgesic,s D2 blocking antiemetics (maxolon) and triptans (sumatriptan) can be used
(d) prophylactic tx can be head BP
Antihypertensives e.g. verapamil
AED e.g. topiramate, valproate
Prophylactic use of analgesic with trigger e.g. stress, menstruation
Antidepressant e.g. amitryptyline, venlaxafine
Pizotifin

Question 16

A previously healthy 20-year-old right-handed truck driver collapsed suddenly and was found to have a GCS score of 12 and right-sided neurological deficits. Urgent plain CT brain revealed a hyperdense lesion of about 6 cm in diameter and height over the left basal ganglia with moderate mass effect.
(a) What is the precise neurological diagnosis?
(b) What neurological deficits may be present?
(c) What are the potential complications in the acute and subacute stages?
(d) What are the possible underlying causes or predisposing factors?


Answer 16

(a) left basal ganglia hemorrhage with mass effect
(b) may affect left internal capsule (right hemiplegia +/-sensory loss)
left basal ganglia: right parkinsonism (unlikely in acute phase)
left thalamus: right hemisensory loss
Increased ICP: bilateral 6th nerve palsy
(c)
Acute:
Neurological: increased ICP with transtentorial or even tonsillar herniation –> coma and death
Systemic: immobilization related (bed sores, DVT, AROU), infection (UTI, pneumonia), metabolic
Subacute
Neurological: residual neurological deficits, post stroke epilepsy
Systemic: musculoskeletal (contractures, shoulder subluxation)
(d) bleeding tendency. HTN. vascular malformation, tumor

Question 17

Answer 17

(a) pneumonia (CAP or aspiration), MG crisis triggered by respiratory infection
(b) pneumonia: consolidation signs (creps, bronchial breathing), lung consolidation on CXR. MGF crisis: generalized muscle weakness, reduced FVC but normral CXR, T2RF pattern on ABG (increased pCO2, normal O2), normal A-a gradient
(c) pyogenic bacteria: s. pneumoniae, mycoplasma pneumonia, klebsiella pneumoniae, viridans streptococci
TB: chronic steroid use
Viral: may just be URTI due to flu
(d) T2RF with respiratory acidosis. High pCo2 suggestive of hypoventilation, suggests MG crisis.

Question 18

Answer 18

(a) GTCS + SIADH due to viral encephalitis
(b) send CSF for PCR (HSV, VZV, EV) and viral culture
CSF TB PCR, AFB smear/culture, cryptococal antigen, indian ink smear
CSF gram stain C/ST
Blood for JEV IgM, blood C/ST
Urine feces, throat swab for viral culture
(c) IV acyclovir +/- meningitic cover (ceftriaxone, vancomycin)
(d) HSV, VZV

Question 19

A 26-year-old lady was seen in outpatient clinic complaining a 2-month history of intermittent double vision with drooping of her left eyelid, worse when looking to her left. She did not have any pain, fever or headaches, and had no previous significant medical history. She was not on any medication. She has no dysarthria, dysphagia, sensory or urinary symptoms. Her symptoms appear to be worse in the evening. On examination, the pupils were symmetrical in size, and there was mild left partial ptosis with mild dysconjugate eye movements, affecting her left eye, when she tried to look to her left.
(a) What is your most likely diagnosis?
(b) What clinical bedside test would help you confirm your diagnosis?
(c) What other tests would you use to support your diagnosis?

Answer 19

(a) ocular MG
(b) tensilon test (2-3 min), sleep test (30 min), ice pack test (2-3 mi)
IV edronophium improves ptosis in 2-3 min (more ACh available)
(c) EMG for RNS >10% decrement in 3Hz repetitive stimulation
Anti AChR and antiMuSK
CT thorax for thymoma, TFT for associated thyroid disorder (young onset), ANA, anti-ENA, RF

Question 20

A 28-year-old woman with good past health complained of one-month history of painless mild double vision & drooping of her left eye lid which is worse in the late afternoon, when compared to the morn- ing. This was associated with mild weakness of her both upper and lower limbs such that she found it more difficult to comb her hair or climb up stairs. There is no sensory disturbance, although she claims that she is more breathless on exertion. Her family also noticed that her speech was slurred in the evenings. She was not on any medication and has no family history. She has no urinary or bowel symp- toms. On examination, there was mild left partial ptosis and diplopia on looking to her left, which worsened with prolonged upward gaze. Her proximal limb power appeared weaker than her distal limb muscles and the limb reflexes were normal. There was slight dysarthria when she was asked to read aloud over a prolonged period.
(a) What is the most likely diagnosis?
(b) What investigations would be helpful to support or confirm your diagnosis?
(c) What other disorders are associated with her illness?
(d) What likely drug treatment options would you use to treat her illness?

Answer 20

(a) generalized MG
ddx:
myopathies: metabolic (endocrine (thyrotoxicosis, hypothyroidism), mitochondrial encephalopathy)
Myasthenic syndrome (lambert eaton syndrome), less likely because eye muscles usually spared in myasthenic syndrome and symptoms improve with ms use

(b) tensilon test (using edrophonium (AChR inhibitor), NPS (repetitive nerve stimulation showing decrement in amplitude of 4th and 5th muscle action potential), sleep test, ice pack test
Others: CT thorax (thymic enlargement), CK (exclude muscle disease), TFT (dysthyroid eye disease and for concomitant thyroid disorders), autoantibodies (ANA, RF, anti thryoid antibodies to detect associated autoimmune conditions)
(c) young onset MG is a/w organ specific autoimmune disease
MG is also a/w thymic pathologies e.g. thymoma (10%) and thymic follicular hyperplasia (70%). Others: autoimmune thyroiditis, autoimmune adrenalitis, DM, RA, IBD etc
(d) 1st line = cholinesterase inhibitor usually pyridostigmine (mestinon) for its longer duration of action (4h)
If inadequate than start immunosuppression with steroids, subsequently tapering for steroid sparing tx (azathioprine, cyclosporineA)
If a/w thymoma or generalized MG + risk < benefit –> consider thymectomy

Question 21

A 20-year-old undergraduate had fever, headache and vomiting for 6 days. Physical examination was normal. Urgent computed tomography of the brain was unremarkable. Lumbar puncture revealed a total cell count of 100 × 106/L (50% lymphocytes and 35% neutrophils), CSF protein of 1.6 g/L, CSF glucose of 2.5 mmol/L (simultaneous blood glucose was 6.4 mmol/L), and CSF Gram smear was nega- tive.
(a) What are your differential diagnoses?
(b) What additional tests on CSF are useful?
(c) Please outline your management.

Answer 21

(a) meningitis (bacterial), TB, cryptococcal, aspetic (SLE, carcinoma)
(b) CSF C/ST, TB PCR, AFB smear/culture, Indian ink smear, cryptococal antigen
(c) ensure ABX
Neuroobs Q4h
Blood Ix
IV access for fluid rehydration
Urgent IV acyclovir, meningitic dose of ceftriaxone/vancomycin
Watch out for Cx e.g. increased ICP, seizure and manage accordingly
Consider further imaging e,g, contrast CT/MRI to r/o any SOL

Question 22

A 63-year-old woman had a slow car crash into a supermarket car park concrete wall. Three witnesses observed her to be unconscious at the wheel before the crash and she recovered consciousness some seconds after they approached the car an opened the door. She was briefly confused, but left soon after with a friend. She consults you next day about this incident.
(a) What is the differential diagnosis for her collapse?
(b) What investigations should be performed?
(c) What other management should you initiate?

Answer 22

(a) Neurology: seizure with post ictal confusion, TIA
Cardiac: syncope,
Systemic: anemia, hypoglycemia
Psych: psychogenic
(b) CBC (Hb for anemia), RFT (electrolytes), hstix, urgent NECT (rule out intracerebral hemorrhage), ECG, holter (underlying clot formation), EEG, consider MRI
(c) stop driving, workup

Question 23

You are called to see a previously well 20-year-old student who has presented to the Accident and Emergency Department with a 24-hour history of increasing headache and myalgia. On examination there is definite neck stiffness and a temperature of 39°C. The neurological examination is otherwise normal, as are the optic fundi. You suspect there are conjunctival petechiae.
(a) What differential diagnosis would you consider?
(b) What immediate investigations would initiate, and would you start any treatment?
Later results from examination of the cerebrospinal fluid show 800 neutrophils/μl, with a CSF glucose 1.7 mM/L (blood glucose 5.6 mM/L), and the Gram stain shows Gram negative intracellular diplococ- ci. You learn two other students have been admitted with an identical illness.
(c) What is now the diagnosis, and what potential complications may occur?
(d) What further action can be taken to protect the student’s roommates and to prevent further
cases in the institution? Can such action fully protect against this disease?

Answer 23

(a) pyogenic meningitis (meningococcus or pneumococcus) as evidenced by acute onset of increasing headahce with neck rigidity, conjunctival petechiae and systemic features such as myalgia, and dever
petechiae on trunk, legs conjunctiva are classic for neisseria meningitis
Other ddx:
infection: systemic infection (meningitism), encephalitis, brain abscess
substance abuse/drug intoxication
b) septic workup (throat and nasal swabs, sputum, blood, CSF)
CBC, ESR, clotting profile, L/RFT
LP for CSF analysis
Urine toxicology screen (potential substance abuse)
(c) meningococcal meningitis as evidenced by CSF analysis of elevated neutrophils, low glucose and gram negative intracellular diplococci and clinically supported by conjunctival petechiae,
Potential complications: local spread of infection (cerebritis, cerebral abscess, subdural effusion), meningeal adhesion: obstructive hydrocephalus, increased ICP, CN palsies), arteritis or thrombophlebitis (cerebral infarction), seizure and epilepsy. Waterhouse friderichsen syndrome (fulminant meningococcemia): septic shock, bilateral hemorrhage into adrenal glands and adrenal insufficiency, abrupt onset of hypotension and tachcyardia, rapidly enlarging petechial skin lesions
(d) contact tracing and chemoprophylaxis: rifampicin or fluoroquinolone prophylaxis for close contacts.

Question 24

A 31-year-old secretary had diplopia and drooping of her eyelids for 4 weeks. Her symptoms worsened after reading or watching television and much improved after sleep or rest. She did not have any prob- lem with her speech, swallowing, breathing sensations or urinary and bowel functions. She has a past history of peptic ulcer, thyroid disease and vitiligo. Her family history is positive for pulmonary tuber- culosis, chronic obstructive pulmonary disease, hypertension, diabetes mellitus and ischaemic heart dis- ease. Three days before admission, she started to have fever, cough and sputum. These symptoms were improved after taking the medications from a general practitioner. On the day of admission, her diplop- ia and drooping of eyelids became much worse. In addition, she had generalized weakness with dysarthria, dysphagia and breathlessness.
(a) What are the differential diagnoses for diplopia plus dropping of the eyelid?
(b) What is the most likely diagnosis for her diplopia plus drooping of the eyelid?
(c) What tests are useful in confirming the most likely diagnosis of question (b)?
(d) What are the related diseases/problems in her past health and family history?
(e) What should be the working neurological diagnosis during her admission?
(f) Please outline the management principles for the neurological diagnosis of question (e).

Answer 24

(a) MG, CN3 palsy
Other less likely ddx
Myopathies. Metabolic (endocrine: thyrotoxicosis, hypothyroidism), mitochondral encephalopathy), polymyositis
Myasthenic syndrome (eaton lambert syndrome) less likely because eye muscles usu spared.
Dysthyroid eye disease, unlikely because no drooping in dysthyroid eye disease
(b) Generalized MG with MG crisis precipitated by respiratory infection
(c) tensilon test, sleep test, ice pack test
(d) thyroid eye disease, vitiligo –> organ specific A/I disease is a/w early onset MG
PUD –> Steroid may be used, therefore need PPI prophylaxis
FHx of pTB –> must screen well for latent TB before starting steroid
FHx of HT, DM, IHD –> steroid has metabolic concerns, should consider early steroid sparing therapy
(e) Generalized MG with crisis
(f) treat underlying cause
Optimize respiration: prop up, clear airway, give O2
Monitor swallowing/FVC. Ventilate if FVC < 15ml/kf or T2RF or cannot protect airway
Start prednisolone 1mg/kg/d
IVIG or plasmapharesis

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Question 25

A 54-year-old man, who had no significant past medical history, complained of developing progressive weakness affecting both his hands over 3 months. He also complained of choking especially when he tried to drink fluids. His family noted that his speech was increasingly slurred. There were no sensory symptoms or sphincter dysfunction. On examination, he was noted to have dysarthria, and wasting and fasciculation of his tongue. He also had weakness and wasting of the muscles of his upper limbs, in- cluding the intrinsic muscles of his hands. His upper and lower limb reflexes were brisk. The muscle bulk and power in his lower limbs appeared spared and the plantar responses were downgoing bilateral- ly. (a) What is the most likely diagnosis? (b) What investigations would be helpful to support your clinical suspicion (and exclude other differential diagnoses)? (c) What is the commonest complication of this illness (causing eventual death)? 
 [2010 SAQ 6] What are common complications of this illness?


Answer 25

(a) motor neuron disease due to a mixture of UMN and LMN signs Other ddx: subacute combined degeneration, DM neuropathy + another CNS pathology (e.g. cervical myelopathy), neurosyphilis (b) * CBC, MCV * VDRL: syphilis infection * EMG * NCS: features of axonal degeneration (reduction in amplitudie of action potential) but preserved conduction velocity * CPK level * Spinal MRI: exclude structural lesion * HbA1c (DM) (c) * Progressive respiratory failure * Cognitive impairment often a/w FTD * Immobilization related (aspiration pneumonia, pressure sore)

Question 26

A perviously well 25-year-old clerk was found wandering in the street with his wallet either lost or stolen. Examination revealed low grade fever, disorientation, mild right sided weakness, moderate apha- sia and dysarthria. Complete blood counts, liver function tests and renal function tests were normal. Urgent plain CT brain revealed hypodense signal with mild mass effect over the left frontal and tempo- ral lobes. Lumbar puncture revealed an opening pressure of 25 cm of water, a total cell count of 60 per microlitre, a differential count of 90% lymphocytes, a protein level of 3.5 g per litre, and a glucose level of 4 mmol per litre. The simultaneous blood glucose was 6 mmol per litre. (a) What is the most likely diagnosis? (b) What is the most likely aetiology? (c) What investigations can confirm the underlying aetiology? (d) What additional investigations are useful in the diagnosis and management? (e) What specific treatment(s) should be considered?

Answer 26

(a) HSV encephalitis (b) HSV-1 (c) CSF viral culture, PCR (d) blood culture/sensitivity Urine toxicology EEG epileptiform activity over temporal region CS for C/ST, TB PCR, AFB smear/culture (e) IV acyclovir

Question 27

A 50-year-old accountant attends a primary care clinic and complains of a frequent headache which comes on several times a week for six months. It began when he was promoted to be the manager of his section. The headaches tend to come on late afternoon. (a) List three likely diagnoses in order of likelihood and give three characteristics for each diagnosis that can differentiate it from the others. (b) What physical examinations would you perform? Please justify them. (c) How would you manage him if the history and physical examination did not find anything positive?

Answer 27

(a) tension type headache: diffuse band like mild persistent headache, increased by stress, relieved by simple analgesics. Migraine: unilateral pounding headache lasting 3-72h, N/V, debilitating +/- aura Intracranial SOL (b) full neurological exam. fundus: papilledema. Systemic PE (c) simple analgesics, reassurance, counselling

Question 28

Mr James, a 42-year-old furniture accountant, is brought to the emergency department by one of his workmates. He was discovered at work an hour previously, collapsed on the floor of the warehouse and was witnessed to be shaking all over. He reluctantly admits that he was incontinent of urine during the episode and his wife also reports that he had collapsed in a similar fashion a few months before at home. On that occasion he went to bed for a few hours and did not seek medical attention. (a) Give 2 possible underlying causes for this presentation. (b) What blood tests are most likely to help you make a diagnosis? (c) Are there any other important investigations that you would consider doing? (d) Whilst in the department the patient loses consciousness and again starts to shake all over. You are asked to see him immediately as the intern doctor on call. What are your immediate ac- tions? (e) The shaking continues for several minutes — what would be an appropriate treatment for the patient at this stage?


Answer 28

(a) seizure, psychogenic non epileptic attack (b) hstix, CBC, R/LFT, blood C/ST, ammonia, CaPO4, CK, neutrophil count high after a true seizure (c) urgent NECT, EEG (d) Recovery position. O2 if possible (e) status epilepticus if > 5 min ABC, administer oxygen, obtain vital signs. Blood test for glucose, hstix, electrolytes, CBC, ABG, urea. Establish EEG monitor. Start IV access: IV diazepam. IV phenytoin if refractory.

Question 29

A 40-year-old bank manager who has developed recurrent headache for three months and presenting to a primary care doctor. (a) List two likely diagnoses and their characteristic features. (b) List two physical examinations which are most worthwhile in ruling out serious conditions. (c) How would you manage each of these two diagnoses?

Answer 29

(a) TTH, migraine (b) fundus, neurological exam (c) TTH = reassurance, simple analgesics +/- prophylactic by amitriptylline or behavioural tx (stress Mx, biofeedback Migraine= avoid trigger, simple analgesics/ triptan/ D2 blocker +/- prophylaxis by head BP

Question 30

A 30-year-old lady with good past health presented with bilateral lower limb pins and needles sensa- tion followed by weakness of both lower limbs that deteriorated over one week. Two weeks prior, she had a bout of severe upper respiratory tract infection. On admission, physical examination of her cranial nerves and upper limbs were normal. There was grade 3/5 weakness of bilateral lower limbs affecting both proximal and distal muscles. The knee and ankle tendon reflexes were symmetrically brisk, com- pared with the upper limb tendon reflexes. The plantar responses were upgoing bilaterally (Babinski’s sign present). Pin-prick sensation was altered in the trunk of her body from T8 dermatome level downwards. (a) Where is the most likely site of lesion that caused her presenting symptoms? (b) What is the most likely nature of this lesion? (c) What urgent investigation would be the most helpful to identify the site and nature of the le- sion? (d) What other investigations would be helpful to identify the cause of this lesion?

Answer 30

(a) spinal cord at T8 (b) transverse myelitis (c) urgent contrast MRI spine showing T2W hyperintensity, contrast enhancement (d) LP: oligoclonal band, lymphocytosis MRI brain for other CNS lesions NM IgG to r/o NMOSD VDRL, HIV Ab, ANA, antiRo/La, TSH for associated autoimmune disorders

Question 31

A 20-year-old man was admitted to hospital in an emergency after he had collapsed on the street out- side a nightclub. Before his arrival in hospital, he developed three tonic-clonic seizures within 40 min- utes, each lasting 60 to 90 seconds. The ambulance crew witnessed one seizure episode, and had noticed a strong smell of alcohol in his vomitus in the ambulance. The patient remained drowsy in between the episodes of seizures. He was found to have a clear airway, breathing spontaneously, and in a sinus rhythm of 120/minute, and BP was 130/69. He had no signs of physical trauma. His friend who ac- companied him had mentioned that the patient had been well before he consumed a large amount of alcohol. He has no history of epilepsy or diabetes mellitus. (a) What immediate measures would you carry out to help this patient? (b) What immediate investigations would you perform? (c) If the seizures continue, how would you further manage this patient?

Answer 31

(a) left lateral position to avoid aspiration, NPO, O2 supplement, IV drip. Assess and monitor: GCS, vitals, continuous cardiac monitor D50 50ml iv +/-thiamine IV AED: IV diazepam. simultaneously IV phenytoin (b) blood test: glucose and hstix, LRFT for electrolytes, CBC, ABG, urea (AED level, toxicology) (c) if refractory to initial AED --> consult iCU. Ventilatory support with phenobarbital IV.

Question 32

A 72-year-old man complained of developing a tremor in his right hand and slowness of movement which had gradually worsening over 4 months. On examination, he has a ‘pill-rolling’ tremor of his right hand at rest with a moderate amount of cogwheel rigidity and stiffness of gait. He has a full range of eye movements and has no cerebellar features or limb weakness. (a) What is the most likely diagnosis? (b) List four disorders or complications that can develop at a later stage of this disease. (c) List three categories of drugs which can help treat this patient’s current clinical features. (d) Within the drug categories mentioned in (c), which drug would you consider most appropriate to help this patient’s symptoms at this stage?

Answer 32

(a) idiopathic parkinsons disease (b) autonomic failure: postural hypotension, constipation, sweating, seborrheic dermatitis PD: dementia DLB like Psychiatric: depression, psychosis REM sleep behavioural disorders, hypersomnolence Sexual problems e.g. ED, loss of libido, hypersexuality (c) L-dopa decarboxylase inhibitor combination e.g. sinemet (carbidopa/L-dopa), madopar Dopamine agonist e,g, pramipexole, rotigotine COMT inhibitor e.g. entacapone Selective MAO-B inhibitor e.g. selegiline (d)L-dopa based tx as motor symptoms already affected ADL

Question 33

A 30-year-old right-handed housewife was admitted because of headache, fever and vomiting for three days. Examination revealed neck stiffness and fever only. Urgent computed tomography of the head revealed no definite abnormality. Urgent lumbar puncture revealed an opening pressure of 27 cm of water, a total cell count of 130 per microlitre, a differential count of 85% lymphocytes, a protein level of 2.0 g per litre, and a glucose level of 1.8 mmol per litre. The simultaneous blood glucose was 6.0 mmol per litre. She was started on some treatment. Two days later, she had sudden onset of left sided weak- ness and slurring of speech. (a) What is your diagnosis of the initial neurological syndrome? (b) What is the standard treatment for the initial neurological syndrome? (c) What is your diagnosis of the subsequent neurological syndrome? (d) What additional investigation should be considered?

Answer 33

(a) acute TB meningitis (b) HREZ3/HR9 (c) acute right sided stroke (d urgent NECT

Question 34

A 48-year-old woman, non-smoker, presented with acute onset of dysarthria and right-sided weakness. Examination showed that he was alert, plethoric, afebrile but spleen tip was palpable. (a) What immediate clinical assessments are needed? (b) What investigations have to be done? Blood tests showed haemoglobin of 20 g/L (12–16 g/dL), leukocyte 13 × 109 /L (4–11 × 109 /L) and platelet counts 450 × 109 /L (150–400 × 109 /L). Serum creatinine 82 μmol/L (< 82). CT scan of the brain showed small cerebral infarction in left internal capsule. (c) What are the immediate management? (d) What other investigations to do?


Answer 34

(a) ABC. vitals, neuro/CVS exam. Swallowing assessment before DAT (oral). Look for features of increased ICP (fundus: papilledema) (b) CBC, L/RFT, Hstix, LP, BG Urgent NECT ECG Echo, carotid doppler, cerebral angiography for underlying cause (c) manage as ucute stroke, admit to ASU Optimize BP, glucose. Adequate hydration, swallowing asessment before DAT Reperfusion by IV rTPA if within 3-4.5h. Not eligable for IA thrombectomy due to small artery involvement. Start aspirin early. (d) peripheral blood smear, blood marrow aspirate/biopsy. Serum peripheral blood/BM aspirate for flow cytometry, molecular study (esp BCR/ABL, JAK2), Serum EPO: low in PV. Serum urate: baseline for TLS if chemotherapy is started.

Question 36

What is the approach to managing a 75-year-old man presenting with an acute stroke?

Answer 36

* Admit to ASU * Initial assessment: vital signs including ABC, consious level and neurological impairment * ix: urgent contrast CT brain, CBP, R/LFT, PT, aPTT (need to reverse coagulopathy if present), blood glucose, lipid, CXR, ECG * Special ix (in selected cases): MRI, MRA, CTA * Supportive Mx: regular monitoring of neurologica land vital signs. Swallowing assessment before feeding, poisitoning * Ensure good hydration, nutrition and oxygenation * Control of blood sugar and pyrexia Control of BP * Lower if systolic BP >220mmg or diastolic BP >120 * BP kept < 180/105mmHg within first 24 hours post thrombolytic therapy * In cases of hypertensive emergency (e.g. hypertensive encephalopathy, aortic dissection, acute renal failure, acute pulmonary edema or acute MI) Specific therapy * Aspirin 80-300mg STAT. High risk DAPT (aspirin +clopidogrel) * Thrombolytic therapy if 3-4.5 hours. * Mechanical thrombectomy if within 6 hours (large to medium sized vessels) Different from intracerebral hemorrhage: urgent reversal of warfarin effect (give vit K1, PPC, FFP) Urgent reversal of anti factor 10a inhibitors (apixiban): give PCC Urgent reversal of dabigatran: give idaruciuzumab Urgent reversal of thrombolytics (alteplase, tenectplase): give cryoprecipitate infusion and a stat dose of transamin

Question 37

A 51-year-old right-handed teacher was admitted because of facial asymmetry. Neurological examina- tion revealed right facial weakness, right hearing impairment and right-sided corneal reflex loss. (a) How should the findings be interpreted? (b) Where is the lesion? (c) What is the aetiology? (d) What are the indicated investigations? (e) What are the recommended treatments?

Answer 37

(a) right sided facial weakness: right CN7 palsy. Right hearing impairment: right CN8 palsy. Right sided corneal reflex loss: right CN5 palsy (b) right pons of brainstem (c) ischemic damage to right pons (d) CBC, random glucose, clotting profile, ECG, plain CT brain (e) neurosurgery. If stroke (acute presentation): antithrombotic agent like aspirin.

Question 38

A 69-year-old gentleman has late-onset asthma for 4 years controlled with regular inhaled steroid, bronchodilators and oral prednisolone 5 mg daily from his family physician. He noticed pain over left forehead and periorbital region 2 weeks ago followed by development of vesicles over left forehead dur- ing a trip to Mainland China with his relatives. He refused immediate medical attention and planned to consult doctors when he returned to Hong Kong. Ten days after the onset of pain, he was noticed to have confused speech and progressive disorientation to time, place and person. He presented to AED when he returned to Hong Kong and was admitted. Physical examination revealed herpes zoster over ophthalmic division of left trigeminal nerve, low grade fever of 37.8°C, GCS 12 (M5, V4, E3) without neck rigidity or focal weakness. He developed an attack of generalized tonic clonic convulsion in the AED, which was stopped with midazolam 5 mg intravenously. (a) Name three important initial investigations that need to be performed. (b) What empirical treatment should be started as soon as possible? (c) The patient developed another attack of generalized tonic-clonic convulsion the next day after admission, what treatment should be initiated to prevent further recurrence of seizures? (d) What is the likely clinical diagnosis? (e) How to confirm the diagnosis?

Answer 38

(a) Bloods: CBC, clotting (reverse coagulopathy prior to doing LP), electrolytes, paired sera for viral titres CT brain LP after CT brain ruled out SOL (prevent herniation) LP direct immunofluorescence, PCR and culture (b) IV acyclovir) (c) Anticonvulsants (d) VZV encephalitis (e) CSF PCR for VZV DNA. Paired sera for viral titres. Direct immunofluoresence, PCR and culture of aspirated vesicular fluid.

Question 39

A 20-year-old man was admitted as an emergency after he was found unconscious on the street. Prior to admission, he had 3 tonic-clonic seizures within 40 minutes, each lasting 60 to 90 seconds. He had a strong smell of alcohol. On examination, the patient remained drowsy in between the episodes of seizures. His airway was clear and he was breathing spontaneously, with a sinus rhythm of 120/minute, and BP 130/69 mmHg. He had no signs of physical trauma. He has no history of epilepsy or diabetes mellitus. What immediate measures would you carry out to help this patient?

Answer 39

* Ensure ABC * Prevent aspiration by putting in recovery position * Monitor spO2 and initiate O2 therapy * VBG or glucose, electrolytes, esp Na (dehydration hypovolemic hyponatremia), Ca, CBC, ABG (respiratory depression), AED level, urine toxicology (concomitant drug abuse) * ECG * CXR * Urgent non contrast CT brain * PR diazepam/IV lorazepam * IV thiamine for suspected wernickes encephalopathy

Question 40

A 53-year-old right-handed teacher was admitted because of generalized weakness and numbness for 2 days. Neurological examination revealed mild bilateral facial weakness, moderate generalized limb weakness and absent tendon reflexes. (a) How should the neurologic findings be interpreted? (b) Where is the lesion? (c) What is the neurological diagnosis? (d) What are the diagnostic investigation and results? (e) What are the specific treatments? (f) What is an essential vital clinical parameter to be monitored?

Answer 40

(a) generalized weakness, LMN type (b) peripheral nerves (c) GBS (d) LP show albuminocytogenic dissociation. NCV show diffuse slowing (demyelinating) or reduced amplitude (axonal). Antiganglioside antibodies e.g. anti GQ1b for MFS, anti GM1, GD1a/b (e) IVIG or plasmapharesis (f) monitor FVC and swallowing function (bulbar involvement)

Question 41

A 45-year-old right-handed secretary was admitted for shortness of breath, drooling of saliva and gen- eralized weakness. She is known to have myasthenia gravis on medical treatment. (a) What is the clinical diagnosis? (b) What are the possible triggers? Please list 5. (c) What are the specific treatment options? (d) What are the supportive treatments?

Answer 41

(a) MG crisis (b) infection Prengnacy, delivery Drugs: aminoglycosides, quinolones, quinine, procainamide, BB, muscle relaxants, phenytoin Poor drug compliance (c) stop anticholinesterase, treat infection, plasmapharesis and IVIG, start prednisolone with small dose (d) ICU admission, maintain airway and breathing with intubation/mechanical ventilation. Establish IV access, strict NPO with IV fluid

Question 42

A 33-year-old Chinese man presented to the emergency department with a 1-day history of progressive muscle weakness and paralysis of the lower extremities. He also gave a history of palpitation and recent weight loss. On physical examination, blood pressure was 116/64 mmHg, heart rate was 92 beats/min, and the patient had symmetrical flaccid paralysis of the lower extremities with areflexia. The remainder of the physical examination was unremarkable. (a) What is the most likely diagnosis? (b) What investigations would you perform and what abnormalities would these investigations show? (c) What is the cause of the paralysis? (d) What is your management plan?

Answer 42

(a) GBS (b) csf albuminocytogologic dissociation, NCV for slowing, anti ganglioside antibodies (c) acute demyelinating neuropathy, leading to generalized LMN type weakness (d) IVIG, plasmapharesis, monitor FVC swallowing. Mechanical ventilation if necessary.

Question 43

A 68-year-old man with type 2 diabetes and hypertension, being treated with metformin, gliclazide (Diamicron®) and a small dose of hydrochlorothiazide, appears to suffer a bout of gastroenteritis (diar- rhoea mainly, slight nausea, and anorexia for 3 days). He feels very weak and can barely walk. Give 7 possible causes (including 3 common causes in this setting) to explain the patient’s weakness

Answer 43

* Hypoglycemia * HypoK from GE and thiazide diuretics * Dehydration with hypo/hyperNa * Hyperglycemic hyperosmolar non ketotic state from infection * Posterior circulation stroke * Subacute combined degeneration of cord from B12 deficency * Lactic acidosis from metformin and prerenal impairment