Part II: Care of Neurosurgical Patient Flashcards
An 84-year-old man has been brought into hospital because of self-neglect. He lives alone in a ground floor flat and has daily carer who have found him to be increasingly suspicious, accusing them of stealing and moving his property and becoming physically aggressive. In the past month he had been refusing to let them in. He also seemed to be experiencing auditory hallucinations and had lost weight. Examination was normal except for BMI 19 and MMSE 18/30. Bloods, CXR, urine, cultures normal. CT is shown. Which one of the following is most likely?
a. Alcoholic hallucinosis
b. Alzheimer’s disease
c. Delirium
d. Paranoid schizophrenia
e. Pick’s disease
B
A 70-year-old gentleman attends outpatient clinic with his wife. She reports that her hus- band’s behavior has changed and that he has become increasingly forgetful over the past year. He has gained 10 kg of weight over the past 6 months. His wife reports that he has an uncontrollable appetite occasionally eating to the point of vomiting. She also states that he has a lack of interest when the grandchildren visit. Over the last 4 weeks she has noticed that her husband has become more unsteady on his feet having had a number of falls. On examining him in clinic he has impaired word comprehension, reduced safety awareness on mobilizing and a positive palmomental reflex. There is no tremor, rigidity or shuffling gait. MMSE is 22/30. CT head is shown. Which one of the following is most likely?
a. Depression
b. Hypomania
c. Pick’s disease
d. Lewy body dementia
e. CJD
C
A 64-year-old man presents with a 6 month history of abnormal behaviors which have been noticed by his wife. He has described seeing vivid visual hallucinations of clowns in his living room which sometimes talk to him and appear very real. He believes that he is the head of a circus and is about to go on a world tour although this is not true. At times he is lucid and is fully independent but at other times he is disorientated in time and place and is unable to perform simple tasks such as preparing food and going to the shops. His wife thinks that his mood is also lower since the onset of symptoms. He presented in A+E today because of having a second fall in 2 weeks. There is no history of infective symptoms. He went to see his GP two days ago who thought that he may have a UTI and prescribed trimethoprim. He has a history of stroke 10 years ago and hypertension and takes warfarin, amlodipine, and enalapril. Physical examination is unremarkable except for slightly increased tone on the left side compared to the right. Which one of the following is most likely?
a. Alzheimer’s disease
b. Semantic dementia
c. Hypothyroidism
d. Lewy body dementia
e. Schizophrenia
D
A 55-year-old man presents with cognitive decline over a 6-month period. He continues to progress and develops myoclonus and a left hemiparesis. On examination, he is alert and orientated to time and place but appears easily startled every time you start a sentence. There is bilateral finger-nose and heel-shin dysme- tria, mild postural tremor and mild speech slurring. Blood tests are normal including thy- roid and liver function. Lumbar puncture: WCC < 1, RBC 16, Protein 0.5 g/l, Glucose 3.4 mmol/l, gram stain negative, and no organisms cultured. An EEG demonstrated brief periodic spikes. A MRI head (FLAIR sequence) is shown. Which one of the follow- ing is most likely?
a. Alzheimer’s disease
b. Creutzfeldt-Jakob disease
c. Carbon monoxide poisoning d. Huntington’s disease
e. Pick’s disease
B
A 81-year-old male experiences progressive cognitive decline over the past 10 years. His wife reports that every 6 months or so she will notice another significant decrease in his functioning. It is now at the point where he is aggressive and has little short-term mem- ory. Past medical history includes hyperten- sion and percutaneous coronary intervention after a myocardial infarction. Examination findings include poor attention and memory, mild left hemiparesis (face, arm, and leg), and brisk reflexes throughout with extensor plan- tar reflex bilaterally and a shuffling gait. Which one of the following is most appropriate?
a. Referral for subthalamic nucleus deep brain stimulation
b. Treat cardiovascular risk factors
c. Carotid endarterectomy
d. Commence carbidopa/levodopa
e. Commence memantine
B
A 55-year-old man presents with a 2-month history of weakness in his right arm. He has also noticed that his voice has become softer. He is finding it hard to use door handles and open jars. On two occasions his wife has noticed him stumbling whilst walking. On examination he has fasciculations over his right deltoid muscle and wasting of the inter- ossei muscles of the right hand. Power is 4/5 in right shoulder abduction with absent reflexes in the right arm but present elsewhere. Coordination and sensation are normal with a negative Romberg’s test. Which one of the following is the most likely diagnosis?
a. Cervical myelopathy
b. Diabetic neuropathy
c. Amyotrophic lateral sclerosis
d. Multiple sclerosis
e. Hereditary sensory motor neuropathy
C
An 18-month-old girl presents with leg weak- ness. Tremors, primarily of the hands, had been noted since 4 months of age. She was crawling by 9 months of age and cruising about the furniture by 12 months. Her lan- guage development was normal. Her 4-year- old sister was developing normally. Cranial nerve examination was normal, and specifically, fasciculations of the tongue were not noted. She was able to sit, crawl, and pull to a stand. She could walk holding onto furniture but could not walk independently. Deep tendon reflexes were absent throughout, and there were no Babinski signs. Sensory examination was normal. Which one of the following is the next appropriate test?
a. Serum ceruloplasmin
b. Electromyography
c. Nerve conduction studies
d. Survival motor neuron gene testing
e. MRI head
D
A 41-year-old man presents with confusion and headaches for the last few weeks. He was diagnosed with HIV 15 years ago and has been stable on highly active antiretroviral treatment. Other past medical history includes an episode of Pneumocystis jirovecii pneumonia 1 year ago. His latest CD4 count is 29 cells/μl. An MRI (T1 C+) is shown. The enhancing lesions on MRI show increased uptake on Thallium-201 Chloride SPECT scan. Which one of the following is likely to be required?
a. Sulfadiazine + pyrimethamine
b. Dexamethasone
c. Methotrexate
d. Amphotericin B
e. Image guided aspiration and intravenous antibiotics.
A 31-year-old man was diagnosed with HIV 5 years ago and had been taking highly active antiretroviral therapy until 8 months ago when he decided to stop. He had been doing well on highly active antiretroviral therapy, but stopped taking his medications 8 months ago because he thought that he would be better off. Two months ago, he was successfully treated for Pneumocystis carinii pneumonia. He now presents with confusion and speech deficit. His CD4 count is 155/ul. MRI appearances are shown below. CSF PCR is positive for JC virus. Which one of the following is most likely?
a. Adrenoleukodystrophy
b. Multiple sclerosis
c. Subacute sclerosing panencephalitis
d. Progressive multifocal leukoencephalopathy
e. AIDS dementia complex
D
A 43-year-old man has been having nightly, unilateral, throbbing headaches with the pain focused at the back of his left eye. They have been occurring daily for the past week. The patient recalls having had a similar headache 5 years ago that lasted for several weeks. The patient has noticed that the headache is asso- ciated with lacrimation and nasal congestion. Which one of the following would be appropriate next in acute management?
a. Dihydroergotamine
b. Glyceryl trinitrate
c. Indometacin
d. Inhaled 100% oxygen
e. Propanolol
D
A 18-year-old female presents with a severe right-sided throbbing headache associated with nausea, vomiting, and photophobia which failed to respond to ibuprofen. There are no other neurological features in the history. She has been having similar headaches 3-4 times per month for the past year. Her mother had a similar problem. Her examination is normal. Which one of the following would be appropriate next in acute management?
a. Amitriptyline
b. Propanolol
c. Sumatriptan
d. Topiramate
e. Verapamil
C
A 45-year-old man is referred urgently to hospital with a severe headache. The pain had started gradually three days before and was now severe. The patient reported the headache was exacerbated by an upright posture with relief obtained by lying flat. Since the headache started the patient had been unable to stand for more than a few minutes at a time but was reasonably comfortable when lying down. The patient denied any focal neurological symptoms and was consti- tutionally well. Clinical examination did not demonstrate any focal neurological signs or features of meningism. CT brain: no evidence of intraaxial or extraaxial bleeding; no space occupying lesion; no hydrocephalus. MRI brain with gadolinium: diffuse pachymeningeal enhancement without leptomeningeal enhancement; subtle downward displacement of brain on sagittal views. Which one of the following would be appropriate next in acute management?
a. Epidural blood patch
b. Flat bed rest
c. Laminectomy dural repair and sealant
d. Lumbar puncture
e. MRI whole spine with STIR
A
A 26-year-old female presents with difficulty walking and complains of problems with her vision in her right eye. She had an episode of diarrhea a week ago, but has no other relevant past medical history apart from problems with her left eye 3 months earlier which had resolved. On examination there is a right rela- tive afferent papillary defect. Visual acuity and color vision are 6/6 (20/20) with 17/17 Ishihara plates on the left, and 6/60 (20/200) with 0/17 Ishihara plates on the right. She reports no dip- lopia with a full range of eye movements, no facial weakness and normal facial sensation. Fundoscopy was unremarkable. Examination revealed 2/5 power on the left arm and leg in all movements; and 4/5 in all movements in right arm and leg, brisk reflexes bilaterally with extensor plantar responses. There is patchy loss of sensation to cotton wool on right lateral wrist and anterior aspect left lateral shin. Anal tone and saddle sensation are intact. MRI brain is normal and MRI spine (Sagittal T2 +T1 with gad) shown below. CSF shows WCC 12/mm3, RBC <1/mm3, Glucose 4.5 mmol/dl, Protein 0.9 g/l, and negative for oligoclonal bands. Which one of the following tests is likely to be positive?
a. Anti-acetylcholine receptor antibody
b. Anti-aquaporin 4 antibody
c. Anti-muscle specific kinase antibody
d. Anti-voltage gated calcium channel antibody
e. Anti-voltage gated potassium channel
antibody
B
A 10-year-old girl presents with subacute mental status change and left arm weakness. She had a viral illness 1 week ago. On examination she appears drowsy. She has a left sided hemiparesis with bilateral nystagmus. Fundoscopy reveals papilledema. There are no skin rashes. MRI head FLAIR sequence is shown. MRI spine showed a longitudinally extensive transverse myelitis. Which one of the following is most likely?
a. Multiple sclerosis
b. Acute disseminating encephalomyelitis
c. Neurosarcoidosis
d. Neuromyelitis optica
e. Systemic lupus erythematosis
f. Lyme disease
B
A 35-year-old female presents with three days of increasing weakness in the right arm and reduced visual acuity in the left eye. She has had a similar episode 2 years ago which she recovered from completely. On examination she has weakness in wrist extension and finger abduction in the left hand and visual acuity in the left eye was measured at 6/24 with an associated reduction in color saturation. Blood tests were unremarkable. Her MRI scan is shown (Axial T1 with contrast and FLAIR). Which one of the following options should be used in acute management?
a. Commence high dose oral prednisone and wean over a month
b. IV methylprednisolone
c. Natalizumab infusion
d. Interferon beta
e. Biopsy
B
A 43-year-old female presents with a second episode of loss of sensation in her left anterior thigh and right foot. This is her second episode within the past 4 months. She had recently reported an episode of left anterior shin numbness 1 year ago, when an MRI with gadolinium demonstrated “spots in her spinal cord” and she was diagnosed with transverse myelitis. Her past medical history also includes ulcera- tive colitis, diagnosed aged 27 years old and pri- mary sclerosing cholangitis. Routine bloods are normal except for mild derangement of liver function tests. Which one of the following is most appropriate?
a. Interferon beta
b. Glatiramer acetate
c. Fingolimod
d. Natalizumab
e. Mitoxanthrone
B
A 43-year-old female presents with a 2 week history of mild left arm weakness and head- ache. MRI was done at presentation (shown). She was discharged on dexamethasone 2 mg twice daily due to her focal neurology with a plan for awake craniotomy and resection. An image guidance scan is repeated one week later but there is no longer any ring-enhancement. Which one of the following is most likely?
a. Cerebral abscess
b. High grade tumor
c. Metastasis
d. Primary CNS lymphoma
e. Demyelination
E
A 31-year-old female suffered multiple cuts and burns to both arms. On examination there is marked wasting of brachioradialis and the small muscles in both hands, with reduced biceps and brachioradialis reflex. She is weak in both arms, distally more than proximally. Her lower limb and cranial nerve examination is unremarkable. On testing upper limb sensation, vibration and proprio- ception are intact but there appears to be reduced pain and temperature sensation over the C3/C4/C5 dermatomes. Which one of the following is most likely?
a. Chiari malformation
b. Chronic inflammatory demyelinating
polyneuropathy
c. Guillain-Barré syndrome
d. Miller Fisher syndrome
e. Multiple sclerosis
A
A 64 Years old man present with sudden onset severe headache while watching televi- sion, followed by confusion and a tonic- clonic seizure. Past medical history included a 20 pack year smoking history, hypertension, hypercholesterolemia and myocardial infarction two years ago requiring stenting. On examination, GCS M5V4E3 but was protecting his own airway. Pupils were equal and reactive. The patient was spontaneously moving all his limbs and had downgoing plantar reflexes. Cardiovascular, respiratory and abdominal examination was unremark- able. Initial observations were blood pressure 220/115 mmHg, heart rate 89 beat/min, O2 sats (15 l O2) 100%, Respiratory rate 19/ min, temperature 37.1°C. CT brain is nor- mal and lumbar puncture shows WCC 3/ mm3, RBC 3, protein 0.6 g/l, glucose 5.4 mmol/l, and no xanthochromia. MRI is shown (FLAIR). Which one of the following is most likely?
a. Acute disseminated encephalomyelitis
b. Herpes simplex virus encephalitis
c. Multiple sclerosis
d. Posterior circulation stroke
e. Posterior reversible encephalopathy syndrome
E
- A 12-year-old boy with Lyme disease and bilateral facial weakness is being treated with a cephalosporin. The child’s facial strength improves, but he notices twitching of the left corner of his mouth whenever he blinks his eye. This involuntary movement disorder is probably an indication of which one of the following?
a. Horner’s syndrome
b. Marcus Gunn phenomenon c. Mononeuritis multiplex
d. Parinaud syndrome
e. Recurrent meningitis
B
A 25-year-old woman has progressive gait disorder. The initial physical examination reveals hepatosplenomegaly and left sided ataxia and abnormal finger-nose test. Urinalysis reveals proteinuria and microscopic hematuria. Which one of the following findings is most likely?
a. Neurofibromas
b. Ash leaf spots
c. Retinal telangiectasia
d. Kayser-Fleisher rings
e. Facial angiofibromas
C
A 62-year-old female has discomfort in her limbs and trouble getting off the toilet. She is unable to climb stairs and has noticed a rash on her face. On examination, she is found to have weakness about the hip and shoulder girdle. She has purplish-red discoloration of the skin around her eyes, erythematous dis- coloration over the finger joints and purplish nodules over the elbows and knees. Which one of the following is the most likely diagnosis?
a. Becker muscular dystrophy b. Dermatomyositis
c. Inclusion body myositis
d. Myotonic dystrophy
e. Polymyositis
B
A 67-year-old male is investigated for chest pain and painful swallowing progressing over the last few months with no response to proton pump inhibitors. There is no history of weight loss or anorexia or smoking. On examination you note a left-sided partial ptosis, and he reports diplopia on testing extrocular muscle movements. Sustained upward gaze exacerbates his ptosis. There is no limb muscle weakness or sensory disturbance. CXR is shown. Which one of the following tests is likely to be helpful?
a. Anti-acteylcholine receptor antibodies
b. Anti-GM1 antibody
c. Anti-GQ1b antibody
d. Anti-muscle specific kinase antibody
e. Anti-voltage gated calcium channel
antibody
A
A 65-year-old presents with a 3 month his- tory of progressive weakness. She had ini- tially noticed difficulty opening jars, but now also has difficulty walking up stairs. She denied any pain or sensory symptoms. Past medical history included osteoporosis, type 2 diabetes mellitus and hypertension.On neurological examination there were no fasciculations, tone was normal and sensation was intact. Power was reduced in finger flex- ion (3/5), wrist flexion (4/5), knee extension (3/5), and hip flexion (4/5) bilaterally. Upper limb reflexes were present but diminished, but the knee jerk was absent and there were flexor plantar responses bilaterally. There was no tenderness over any muscle groups. Cranial nerve examination was unremark- able. Blood results were normal except for CRP 10 mg/l, ESR 41 mm/h, CK 290 u/l. Which one of the following is most likely?
a. Diabetic amyotrophy
b. Inclusion body myositis
c. Polymyalgia rheumatica
d. Polymyositis
e. Chronic inflammatory demyelinating
polyneuropathy
B
A 77-year-old male presents with a 2-day his- tory of right temporal throbbing headache. He has had migraines previously but never this severe and usually occipital. There was no other past medical history of note. On examination, his right scalp is tender and a prominent right temporal artery is noted. He is apyrexic with no skin rashes. His blood tests are as follows: Hb 13.1 g/dl, Plt 450 10- 9/l, WCC 11.5, ESR 85, Na 142, K 4.0., Urea 10, Cr 118 umol/l, CRP 23 mg/l. Which one of the following would you do next?
a. CT angiogram
b. Biopsy
c. Start prednisolone
d. Start azothiaprine
e. Carotid duplex ultrasound
C
A 65-year-old male has been diagnosed with small cell lung cancer and is currently undergo- ing chemotherapy. Over the last few months he has noticed his vision deteriorating and complains of diplopia. He also feels weaker in his upper limbs although his symptoms do fluctu- ate. On examination he has mild ptosis of the eyelids bilaterally and a complex ophthalmoparesis affecting both eyes. He also has reduced power proximally in the upper limbs. Which one of the following may be associated with this clinical picture?
a. Anti-Ro antibody
b. Anti-voltage gated potassium channel
antibody
c. Anti-voltage gated calcium channel
antibody
d. Anti-Hu antibody
e. Anti-GQ1b antibody
C
A 17-year-old girl presents with a second episode on waking earlier in the morning where she could not move at all for 2 h. She reports no loss of consciousness and was aware throughout the episode. There is no other sig- nificant past medical history or epilepsy. Rou- tine systemic and neurological examination is normal. A 12 lead ECG demonstrated a jerky baseline with flat T waves. What one of the fol- lowing is most likely?
a. Andersen-Tawil syndrome
b. Cataplexy
c. Hyperkalemia periodic paralysis
d. Hypokalemic period paralysis
e. Night terror
C
A 10-year-old presents to your neurology clinic reporting 9 months of subtle and gradual onset, progressive lower limb weakness. For the past 18 months, he has noticed a difficulty in keeping up with his peers in PE lessons, which he initially put down to “not being very sporty.” However, he feels weak whenever he walks and has particular difficulty getting up from a chair. His appearance is shown below. Formal examination of power is 4/5 bilaterally in shoulder abduction, adduction and normal 5/5 distally. 4/5 is also noted in hip flexion and extension, 4+/5 in knee flexion and extension, 5/5 in ankle plantar and dorsiflexion. The weaknesses demonstrated are not fatiguable and are persistent. Reflexes are present in all areas, plantars are downgoing. He has no other past medical history. What is the likely diagnosis?
a. Becker muscular dystrophy
b. Duchenne muscular dystrophy
c. Emery-Dreifuss syndrome
d. Facial-scapulo humeral syndrome
e. Limb-girdle dystrophy
B
The horizontal gaze center is formed by which one of the following:
a. Pontine paramedian reticular formation
b. Reticular medial longitudinal fasciculus
c. Preganglionic Erdinger-Westphal nucleus
d. Brodman Area 6
e. Superior colliculus
A
A 25-year-old woman presents with a several week history of diplopia, with an 8 month his- tory of generalized headache which has been particularly bad over the last 2 months. On examination she is obese, has a normal pupillary light reflex and no RAPD. Appearance of fundi are shown. Which one of the following is most likely cause of her complaint?
a. Non-organic disorder
b. Optic nerve drusen
c. Optic neuritis
d. Idiopathic intracranial hypertension
e. Leber’s hereditary optic neuropathy
D
A 50-year-old man complains of 2 days’ dou- ble vision. Has abducting nystagmus in the right eye and vertical gaze is preserved bilat- erally. Which one of the following is most likely?
a. Left internuclear ophthalmoplegia
b. Orbital apex syndrome
c. Left incomplete oculomotor palsy
d. Superior orbital fissure syndrome
e. Left one-and-a-half syndrome
A
