Neurology 4 mrcp answers book - part 8 pptx

a-false, the 1 st division of the trigeminal nerve when involved ,may cause a lost corneal reflex, neuropathic corneal ulcerations, and visual loss. Remember that impaired vision may be due to a previously associated zoster ophthalmitis including: anterior uveitis, chorioditis, optic neuritis. b-true, loss of corneal sensation. c-true, with hypo-pigmentation . d-true, and detected only by carful testing. e-true, due to many reasons mentioned above. Q24: Answer: d a-true, Aciclovir has been shown to reduce the intensity and duration of the zoster rash and associated acute pain but NO effect at reducing the incidence of post herpetic neuralgia. Prednisolone has been shown to reduce the intensity and incidence of the acute pain but NO effect on post herpetic neuralgia. b-true, but usually large dosed are needed ( up to 250 mg/ day ). Carbamazepin , phenytoin , and gabapentin are less effective. c-true , or a xylocain-prilocain cream. d-FALSE, may be very effective by depleting the pain-mediating peptides from the peripheral nerve endings and sensory neurons, but unfortunately it is rarely tolerated. e-true, at weekly intervals. Q25: Answer: d a-true, for which no cause can be found. b-true, and it is not paroxysmal. c-true, and from intracranial extension of squamous cell carcinoma, or an infection at the site of a tooth extraction. d-false, treated by amitryptiline with or without phenelzine. e-true, when tricyclics are not effective. Q26: Answer: d a-true, at least in onset. It may be bilateral or alternating. Cluster headache is always (100%) unilateral. b-true, but not in all cases. c-true, and photo and phnophobias and lassitude. d-false, visual or other neurological abnormalities accompanying headache are seen in up to 10%. e-true, 75% of patients are women. A family history of migraine is seen in 50% of cases( unlike cluster headache where a family history of a similar problem is not seen). Q27: Answer: e a-true, although a consistent mendelian pattern of inheritance has not been found among the collective group of familial migraineurs. b-true, and predicts a significant environmental contribution. c-true, chromosome 19p13( associated with miss-sense mutation in a brain expressed voltage gated P/Q calcium channel gene ) and 2 neighboring loci on chromosome 1q. d-true, an possibly with multiple modes of inheritance and variable degrees of penetrance. e-false, migraine is considered a multi-genetic and multi-factorial disease. Q28: Answer: e a-true, and the commonest are hemianpoic field defects, Chapter XI / Neurology Subchapter E: Q1: Answer: e Apart from sedative drug intoxication, all other items cause confusional state+fever (not hypothermia ) .Alcohol and sedative drug withdrawal cause fever but intoxication with them is the cause of low body temperature Other causes of hypothermia with a confusional state: hypothyroidism, hepatic encephalopathy, hypoglycemia. Q2: Answer: e Bleeding peptic ulcer is the cause of hypotension (not hypertension). Don’t forget hypertensive encephalopathy and sedative drug withdrawal. Q3: Answer: c Apart from opioid intoxication (which produces pinpoint reactive pupils), all others can be the cause of her presentation. Q4: Answer: b Hepatic encephalopathy (and prominent hyperglycemia) can be a cause of hyperventilation not hypoventilation. Q5: Answer: e Wernick's encephalopathy can cause confusional state with ophthalmoplegia and ataxia (not a hemiparesis state) .Keep in mind that metabolic causes of encephalopathy (like hypo or hyperglycemia, hepatic, uremic…etc) can cause focal or multifocal neurological signs that are usually fluctuating or ALTERNATING between the right and left sides of the body. Q6: Answer: e This question highlights the importance of any associated illnesses. a-true, and hence EEG should be done which will reveal an ongoing seizure activity in one of the temporal lobes . b-true, always think of this possibility. A variety of intracranial hemorrhages might occur and can precipitate a catastrophic status epilepticus. c-true. A prolonged post-ictal confusional state is seen in the presence of underlying metabolic or structural encephalopathy. Hence the recovery might be long giving a wrong impression of a continued seizure activity (ie status epilepticus). d-true , either iatrogenic (like adding an enzyme blocking medication like Clarithromycin for a simple chest infection and enhancing phenytoin toxicity) ,or might be self poisoning to suicide. e-False… always take a complete history of any recent or OLD illnesses. Q7: Answer: c a-or a sulphonylurease-induced hypoglycemia b-or post traumatic epilepsy c-false. Alcohol intake can cause: acute intoxication (with alcohol or other materials like methyl alcohol), hypoglycemia, head injury, decompensated hepatic encephalopathy, Wernick's encephalopathy, post-ictal state. Don't forget alcohol withdrawal. d-or may suggest an organic cause like hypothyroidism, Wilson's disease and decompensated cirrhosis, B12 deficiency or a functional state. Don't forget neuroleptic malignant syndrome in those taking conventional neuroleptics like schizophrenic patients. e-it may cause a variety of CNS and extra-CNS causes of confusional state. Q8: Answer: a a-false, think of AIDS-dementia complex. b-true, might be a cause of multi-infarct dementia c-true, like bradycardia in hypothyroidism or atrial fibrillation in multi-infarct dementia . d-true, like hypothermia in hypothyroidism e-true, might be due to brain tumor or subdural hematoma causing a dementing illness. Q9: Answer: c a-true, an acute confusional state which is mainly seen in non-chronic alcoholics. b-true, although the severity and clinical features of encephalopathy correlate roughly with blood ethanol levels. Chronic heavy alcoholics may have a very high blood level although they don't appear to be intoxicated. c-false, it is characteristically raised . The plasma osmolality roughly increases by 22 mOsm/L for every 100 mg/ dl of ethanol presents . d-true. Can be differentiated by presence of ethanol odor, increased plasma osmolality (in ethanol poisoning it is raised), blood and urinary toxicology. e-true. Also predisposes to head injury, lung aspiration, seizures. Chronic alcoholism increases the risk of bacterial meningitis. Remember that the treatment is supportive only. All alcoholics should receive 100 mg of thiamin intravenously to prevent Wernick's encephalopathy. Q10: Answer: d Item d is false because confusion, IF PRESENT, is usually mild. Illusions and hallucinations, usually visual, are seen up to 25% of cases. It usually responds to diazepam 5-20 mg or chlordiazepoxide 20-25 mg orally every 4 hours. Q11: Answer: a a-false. Usually seen within 48hours; however, in 70% of cases they occur within 7- 24 hours of abstinence. b-true, and the interval between the first and last seizure is usually 6-12 hours up to 85% of cases . Up 40 % of patients will have ONE seizure only. c-true. They abate spontaneously; however, diazepam or chlordiazepoxide is given prophylactically because up to 30% of patients will develop delirium tremens. d-unusual and atypical features are: focal fits, prolonged duration of the fits ( > 6-12 hours ), more than 6 fits, status epilepticus or a prolonged post-ictal phase. In these cases, a prompt search for pathology is required. e-true. Always look for such an association. Q12: Answer: c a-true. It is the most aggressive type with a high mortality rate, usually seen with 3-5 of abstinence and may last up to 72 hours. b-true. Also tachycardia and sweating. c-false. The mortality rate is 15% and mostly due to concomitant : infection , pancreatitis, cardiovascular collapse, or trauma . d-true, the total requirement to produce a calm patient may exceed 100 mg/ HOUR. e-true, like atenolol 50-100 mg/ day. Q13: Answer: d a-true, with respiratory depression , hypotension, reactive pupils and hypothermia. b-true, a characteristic feature. However, very large doses of phenobarbitone or glutethimide may result in LARGE FIXED pupils. c-true, with ataxia, dysarthria and hyporeflexia. d-false. The mortality rate is low and mostly due to aspiration pneumonia (with or without systemic sepsis, or due to iatrogenic fluid overload and pulmonary edema ).Despite severe intoxication, a patient who arrives at the hospital with adequate cardio-pulmonary function and support should survive without any sequelae. Remember the treatment is mainly supportive while the drug is being eliminated. e-true, it is mainly used to increase the urinary clearance of Phenobarbital., but in general should be avoided as it can lead to fluid overload. Hemodialysis may be used in severe resistant cases of barbiturate poisoning or when drug elimination is impaied by renal failure. Q14: Answer: d a-true, intermediate or short acting agents are more likely to produce an withdrawal syndrome when stopped abruptly. The syndrome is seen within 1-3 days (for short acting agents ) and may take up to 1 week or even more to appear ( for long acting agents ). b-true, with confusion, agitation, seizures. c-true, if positive , the patient should receive long acting phenobarbital orally to maintain a calm state without signs of intoxication. In most patients it is possible to stop it gradually after progressive decrement in the daily doses within 2 weeks. d-false. Seizures especially the myoclonic ones should be treated aggressively with anticonvulsants. e-true, mainly seen in those taking very high frequent doses. Q15: Answer: d a-true, as an iatrogenic overdose. Also seen as an accidental overdose in addicts, and in suicidal attempts. b-true, and pontine hemorrhage is a differential diagnosis .Although needle tracks and marks might be seen, they are not diagnostic . c-true, the test is positive if the pupils dilates and the patient regains his full consciousness; however, when very large doses of opioids are taken or multiple drug ingestion is present the pupils may slightly dilate. d-false, with appropriate treatment , patients should recover uneventfully . e-true, because nalaxone is a short acting agent. Q16: Answer: d a-true, or with antidepressants and antihistamine overdose. b-true, also flushing, urinary retention and tachycardia. c-true, mainly used in antipsychotics or antidepressants overdose. d-false. Symptoms usually resolve spontaneously. e-true, although rarely needed . Physostigmine can produce severe bradycardia, seizures and hypersalivation. Specific treatment is required when there is life threatening cardiac dysrrythmias. Q17: Answer: d a-true. Their mechanism of action involves a variable combination of inhibiting the reuptake and or increasing the release of noradrenalin and or dopamine and thus producing a central stimulant and peripheral sympathomimetic effects. b-true, and cocaine can produce myocardial infarction. c-true, either due to sudden severe hypertension, drug induced vasculitis, or rupture of AVMs. d-false, should be avoided , especially in cocaine induced myocardial infarctions. Alpha blockers are useful to attack hypertension. e-true, and thus attacking the psychotic manifestations of overdose. Because amphetamines are longer acting than cocaine, amphetamine intoxication is more likely to require treatment. Q18: Answer: c a-true, and prominent insomnia. b-true, changes in the mental status are usually the most striking feature. Alterations in affect and mood may predominate the clinical picture. c-FALSE, very rare. The presence of a prominent seizure activity should prompt a search for another pathology or to revise the diagnosis. d-true, there is prominent sympathetic overactivity. e-true, and when this fails, treatment with diazepam may be of benefit. Q19: Answer: c a-true, unlike other hallucinogens( eg LSD ). b-true, also large or small pupils, horizontal and vertical nystagmus, hypertonia, hyper-reflexia and myoclonus. There may analgesia to a surprising degree. c-false, phenothiazines reduce seizure threshold and may produce severe hypotension. Haloperidol can be used safely in such cases. Diazepam can be used for sedation and treating muscle spasms. d-true, although in some patients it may take days or even weeks. e-true, this is especially seen in poisoning with large doses . Q20: Answer: e a-true, whether accidental or intentional . b-true, thus such patients may be wrongly diagnosed as having a serious CNS illness. c-true, like renal or hepatic failures. d-true. Dementia patients are very susceptible. e-false, one of the prominent causes especially in old people. Q21: Answer: d a-true, and also a "reversible" dementia. b-true, bilateral ptosis is seen up to 65 % of cases due to low sympathetic tone of levators. c-true, also agitation and even frank psychosis is seen. d-false, the most characteristic neurological finding is a delayed relaxation of tendon reflexes, typically seen at the ankles. e-true, and CSF pressure is occasional increased. Q22: Answer: e a-true, so-called " activated crisis ". b-true, so-called " apathetic crisis ". c-true, because of the prominent hyper-adrenergic manifestations. d-true, and exaggerated action tremor and hyper-reflexia are usually seen. e-false, very rare and when prominent should cast a doubt on the diagnosis. Q23: Answer: e a-true, especially in those with recurrent "hypos", or the presence of associated autonomic neuropathy, or concomitant treatment with beta blockers. b-true, flaccid quadriparesis is an advanced feature. Focal , multifocal or generized seizures and myoclonus may be seen. c-true, although a prolonged hypoglycemia at levels of 30 mg/ dl or lower invariably leads to irreversible brain damage. d-true, with coma, bilateral extensor planters and decorticate or decerebrate posturing. e-false, somnolence might be seen. Tachycardia is seen with agitated delirium, but bradycardia is seen with somnolence. Q24: Answer: c a-true, while the degree of systemic acidosis does not. b-true, focal neurological signs, focal or generalized seizures that are not responsive to antiepileptics are commonly seen. c-false, the mortality rate is unfortunately between 40-70% and is largely due to failure to recognize the condition in elderly patients without prior history of diabetes or who present who present with stroke or seizures, and to coexistent diseases. d-true, in contrast to diabetic ketoacidosis. e-true, impairment in consciousness ranges between very mild and subtle drowsiness to deep and profound coma. NB: hypersomolar non-ketotic hyperglycemia is a presenting feature of up to 40% of cases of type II diabetes mellitus. Q25: Answer: d a-true, and hyponatremia may produce focal signs by unmasking preexisting structural brain lesions such as infarcts. b-true, "central pontine myelinolysis syndrome" in which no treatment is available, thus prevention is very important by avoiding rapid correction of hyponatremia. c-true, but the tendon reflexes are usually normal . d-false, they are very rare ( unlike hypocalcemia in which seizures are very common and might be the only presenting feature). e-true, the overall clinical picture is due to calcium-induced increase in the depolarization threshold of nerve and muscle with consequent under-excitability. Q26: Answer: e a-true, thus, hypocalcemic patients demonstrate a positive Chvostek's sign and Trousseau's sign both of which indicate a hyperexcitability state. b-true, this is especially seen in children. Hypocalcemic fits can sometimes be very resistant to anticonvulsants. c-true, also basal ganglia calcification and Parkinsonian features. d-true, or induced by Trousseau's sign. e-false, chorea may be seen. Also, irritability, depression, hallucinations, frank psychosis all might be seen. NB: The following 3 questions highlight the importance of knowing what Wernicke's encephalopathy is. Every few days, the A/E department consults us to see certain patients with a variety of neurological findings, these patients then prove to have Wernicke's, although they give thiamine BLINDLY and the patient usually improves, we noticed that many junior and senior house officers lack much information about Wernicke's. I tried to cover some useful aspects about this VERY COMMON neurological disease (we see it almost every day in the A/E department). You should also know the prognosis if it. Q27: Answer: c a-true, there is also small blood vessel proliferation and small petechial hemorrhages. The most commonly affected areas are: mammilary bodies, periaqueductal grey matter, cerebellar vermis, and occulomotor, abducens and vertibular nuclei. How thiamine deficiency produces these effects is still not clear. b-true, the commonest ocular manifestations are nystagmus and unilateral or bilateral lateral rectus weakness or paralysis. c-FALSE, ataxia primarily affects GAIT, limb ataxia is highly uncommon, as is dysarthria. d-true, up to 80%; remember alcoholism can attack many targets ( some are asymptomatic). e-true, it is uncommon cause of coma, but a very common cause an acute confusion. Mental status examination reveals GLOBAL confusion with a prominent impairment of immediate recall and recent memory. NB: CSF analysis is usually NORMAL, although mild increase in protein (<90 mg/dl) might be seen. An increased opening pressure or pleocytosis or low glucose should prompt a search for other or additional disease. Q28: Answer: d Wernicke's encephalopathy can have many ocular findings which can easily escape detection. Medicine books usually mention " ophthalmoplegia and nystagnmus", but there is no further details regarding these findings. There are 9 ocular findings in general: 1-External rectus weakness or paralysis ( uni- or bilateral ). 2-Nystagmus, horizontal or a combined horizontal and vertical one. 3-Internuclear ophthalmoplegia, a common finding! 4-Conjugate gaze palsy or weakness. 5-Ptopsis. 6-Retinal hemorrhages. 7-Optic neuropathy. 8-Involvement of vestibular focusing mechanisms. 9-Small miotic reactive pupils ( a very rare finding but worthy to mention). Very subtle anisocoria and sluggish pupillary reaction might be seen. However, the pupils are usually spared. Q29: Answer: e a-true, a very important thing tot remember. b-true, together with confusion , should start to improve within 1 week. c-true, they totally disappear in 40% only, others (60%) will be left with residual gait ataxia and horizontal nystagmus. d-true, up to 75 % of cases after recovery from Wernicke's, thus long term follow ups are important. e-FALSE, external ophthalmolegia, VERETICAL nystagmus and confusion SHOULD BE ENTIRELY REVERSIBLE. Failure of these to reverse back to normal should prompt a search for other or additional disease. Q30: Answer: c a-true, can produce confusion, depression ,aggression, agitation, frank psychosis with hallucinations. b-true, but clear cut sensory LEVEL is against the diagnosis. Also, Lhermitte 's sign, distal paresthesias, gait ataxia, all might be the presenting feature. c-FALSE, loss of ankle jerk indicates peripheral neuropathy. Remember both might present together and can cause a combination of exaggerated knee jerks, up going planters with loss of ankle jerks. d-true, any other abnormal profile should cast a doubt on the diagnosis. e-true, vitamin b12 should assessed in the differential diagnosis of any unexplained: cognitive impairment , myelopahty, and peripheral neurpatrhy, whether anemia is present or not. NB: Neurological abnormalities present for more than a year are less likely to correct with treatment. Encephalopathy may begin to clear within 24 hours after the first vitamin B12 injection, but full neurological recovery, when it occurs, may take several months. Q31: Answer: e a-true, that might gradually progress to stupor and coma. b-true, as in other organ failure, asterixis ( which is actually a negative myoclonus) indicates impairment of the parietal postural control mechanism. c-true, and focal or multi-focal neurological signs that might fluctuate in severity and type might occur. d-true, it is the most SPECIFIC CSF finding. Also, an elevated opening pressure, mild pleocytosis, and increased protein all might be seen Xanthochromia is seen when the total serum bilirubin exceeds 4-6 mg/dl. d-false, as in any metabolic encephalopathy, the EEG shows diffuse slowing with triphasic complexes NB: The prognosis in hepatic encephalopathy is most closely correlated with the severity of hepatpocellular damage than neurological dysfunction. Q32: Answer: d a-true. CSF acidosis is rare and cerebral edema is NOT a factor. b-true, adding more confusion to the clinical picture. Motor manifestations are: coarse tremor, asterixis, myoclonus and tetany. Focal or generalized seizures or focal signs all are common. c-true, and this may wrongly suggest an infectious meningitic process. d-false, as in any severe encephalopathy ,and which may be diagnosed as seizures. e-true, should always be kept in mind. The treatment should be directed against the renal failure in its cause. Control of seizures and hypertension is very important. Q33: Answer: d a-true, it may begin during hemodialysis or as long as 24 hours after hemodialysis. It is a rare complication of maintenance hemodialysis in patients with chronic stable renal failure. b-true and a rapid correction of systemic acidosis may also exacerbate CSF acidosis as CO2 diffuses into the CSF. c-true, sometimes before any clinical change has occurred and showing paroxysmal activities with spikes and sharp waves. d-false, fortunately these severe abnormalities are uncommonly seen. [...]... travelers to areas of ongoing epidemics Q43: Answer: d a-true, case fatality rate may exceed 25% b-true, Waterhouse-Friderichsen syndrome c-true, as is a delay at initiating treatment d-false, BAD prognosis e-true Q 44: Answer: a a-false, it is seen within 2 years of a primary syphilitic infections and affects men more than women b-true, it is usually asymptomatic c-true The cranial nerves most frequently... acute psychosis d-false May be seen e-true, reflecting the predilection of HSV for LIMBIC structures Q 48: Answer: c a-true, CSF white cell count usually between 5 0-1 00 cell/ml b-true, it is one of the causes of hemorrhagic CSFs The glucose is usually NORMAL c-FALSE, the virus generally can not be isolated form the CSF but the virus DNA can be detected in the CSF by PCR in some cases d-true, and focal... suppressed state or an over-whelming infections and hence portending a very bad prognosis b-FALSE, fortunately, it can be isolated in 40 -9 0% of cases ( while CSF culture is positive in 80 % of cases only ! ) c-true, indicating a wide spread inflammatory process Granular ependymitis may be seen d-true, and focal changes may indicate the presence of focal cerebritis, brain abscess or scarring e-true, always look... as cause c-true, and may be immeasurably low ie almost ZERO mg/ dl d-FALSE, it is positive in 6 0 -8 0% of cases In TB meningitis , acid fast smears are positive in 20% of cases only e-true, a useful tool CSF culture is positive in 80 % of cases only Q42: Answer: d a-true, and is based upon the patient's age and predisposing factors b-true, although it is suggested to be given to children less than 2 months... pyogenic cause c-false, it may reach very high levels ,especially in those with spinal subarachnoid block d-true, it was used in the past, but nowadays it has been shown that it is too nonspecific e-true, unlike pyogenic meningitis (where the CSF glucose might reach ZERO mg/dl !) Q 38: Answer: c a-true, the inflammatory response is associated with the release of inflammatory cytokines like IL-1, LL-6 and TNF... stroke like pattern within 1 day b-true, it is usually absent in neonates and old people and in those with deep coma Thus its absence is NOT against the diagnosis c-true, and may be easily mistaken for a brain abscess d-FALSE, it is seen in 5 0-6 0% of cases of N meningitidis infections e-true, but in clinical practice the full syndrome is often NOT present Q40: Answer: b a-true, leucopenia may indicate... nerves may be involved as well d-true e-true, even when asymptomatic to prevent the development of more serious CNS complications Q45: Answer: a a-false, although CSF VDRL is positive in 50% of cases only, the blood FTA treponemal tests are almost always positive b-true These are not present in normal CSF c-true, and the opening pressure may be normal or slightly elevated d-true, although acute syphilitic... development of tertiary neurosyphylis e-true, and another course of treatment should be given if the CSF cell count or protein remains elevated Q46: Answer: d a-true, there is no seasonal variation The mortality rate ranges between 40 -7 0% and depends on many factors b-true, the age group is higher than that of other causes of viral encephalitides in general c-true, while HSV type II affects neonates... Q36: Answer: d a-true, surprisingly such history is usually absent, thus the diagnosis needs a high index of suspicion b-true, but ALL might be ABSENT c-true, and can wrongly be attributed to a mass lesion d-false, can be a prominent feature e-true, and thus increasing the already increased morbidity Q37: Answer: c a-true, but may show a clot upon standing due to high protein content b-true, this early... clinical deterioration while systemic acidosis is improving e-true Treatment involves intubation and mechanical ventilation Q35: Answer: e a-true, a very aggressive process b-true, and on the surface of the brain c-true, and their surface may show ependymal exudate or granular ependymitis d-true, and thus focal signs like hemiparesis can be seen e-false, cranial nerve palsies are in general either due to . diazepam 5-2 0 mg or chlordiazepoxide 2 0-2 5 mg orally every 4 hours. Q11: Answer: a a-false. Usually seen within 48 hours; however, in 70% of cases they occur within 7- 24 hours of abstinence. b-true,. Answer: d a-true, case fatality rate may exceed 25%. b-true, Waterhouse-Friderichsen syndrome. c-true, as is a delay at initiating treatment. d-false, BAD prognosis. e-true. Q 44: Answer: a a-false,. patients. e-it may cause a variety of CNS and extra-CNS causes of confusional state. Q8: Answer: a a-false, think of AIDS-dementia complex. b-true, might be a cause of multi-infarct dementia c-true,