neurology PT 1 2016 modif

7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 94 A 45-year-old man with epilepsy who is on carbamazepine has a history of mild and stable hepatic impairment His seizure control is poor and he requires the addition of a second-line agent Which one of the following would be the most appropriate? A Lamotrigine B Levetiracetam C Oxcarbazepine D Phenytoin E Sodium valproate Explanation  The answer is Levetiracetam – In mild to moderate liver failure the pharmacokinetics of levetiractam are unchanged In severe liver failure the dose is usually halved It is therefore a good choice in this setting In addition levetiracetam will not interact with his carbamazepine Lamotrigine (Option A) is incorrect Lamotrigine dose needs to be significantly reduced in patients with liver disease so this option is less correct than levetiracetam Oxcarbazepine (Option C) is incorrect Oxcarbazepine may be safe in mild liver disease, but there is little available data to guide the decision and therefore this answer is less correct than levetiracetam In addition it is not appropriate to add this drug to carbamazepine as a second-line agent as they are very similar in action Phenytoin (Option D) is incorrect Phenytoin is only used with caution in liver disease Sodium valproate (Option E) is incorrect Sodium valproate is avoided in liver disease due to the risk of hepatotoxicity with this drug 44829 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 1/2 7/10/2016 MyPastest Next Question revious Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 94 A 29-year-old woman with temporal lobe epilepsy wishes to have a baby She is currently taking phenytoin 300 mg per day and lamotrigine 50 mg per day in combination Her partial seizures have been controlled for 10 months She has no history of generalised tonic–clonic seizures She is already taking a multivitamin tablet containing folic acid as she has read that this is advised in early pregnancy She is anxious about the risk of fetal malformations What would be the most appropriate advice to suggest regarding her management? A Once she is pregnant, start high-dose folic acid (5 mg per day) B Start high-dose folic acid now C Start high-dose folic acid now and try to withdraw one of her antiepileptic drugs (AEDs) D Try to reduce the dose of each AED and continue taking a multivitamin tablet E Try to reduce the dose of each AED and start high-dose folic acid Explanation  The answer is Start high-dose folic acid now and try to withdraw one of her antiepileptic drugs (AEDs) – Women of child-bearing age with epilepsy should be told in advance of the potential teratogenic effects of AEDs and the desirability of preconception counselling Making decisions about AEDs in this situation depends on many factors, including the type of seizures a patient has, seizure frequency, number of AEDs, type of AED, other risk factors and the individual’s wishes regarding accepting the risk of further seizures versus risk of fetal malformations High-dose folic acid mg daily is advised in view of its effect in diminishing the risk of neural tube defects, and is recommended from the preconception period throughout at least the first trimester If antiepileptic drug treatment is necessary, then monotherapy, at the lowest possible dose that controls seizures, is desirable Out of the two medications decribed here, lamotrogine is associated with a lower rate of fetal malformations so it would be reasonable to aim for monotherapy with that agent (option C) https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest Once she is pregnant, start high-dose folic acid (5 mg per day) (Option A) is incorrect Folic acid is recommended before conception occurs ruling this option out Start high-dose folic acid now (Option B) is incorrect This course of action is only partially correct – high-dose folic acid should be commenced but AED changes ought to be made as well Try to reduce the dose of each AED and continue taking a multivitamin tablet (Option D) is incorrect Reducing the dose of both AEDs would risk a loss of seizure control Try to reduce the dose of each AED and start high-dose folic acid (Option E) is incorrect Reducing the dose of both AEDs whould risk a loss of seizure control 44686 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 94 A 51-year-old man underwent aortic valve replacement, which was uncomplicated Despite his history of alcohol abuse, he was anticoagulated with warfarin After discharge it was noted that he had missed clinic appointments Some months later he was admitted to the Emergency Department with a sudden-onset dense right hemiparesis and moderately severe global dysphasia; he was unkempt and smelling of alcohol His INR was 1.4 There was a systolic murmur at the left sternal edge and during his admission he developed a fever of 37.9 °C Which one of the following is the most likely diagnosis? A Left hemisphere lacunar stroke B Left, middle cerebral territory, infarction secondary to cardioembolism C Left-sided intracerebral haemorrhage D Left-sided subdural haematoma E Thromboembolic stroke secondary to bacterial endocarditis Explanation  The answer is Left, middle cerebral territory, infarction secondary to cardioembolism – The history suggests a large lesion in the left, middle cerebral artery territory involving the cortex This rules out the possibility of a lacunar stroke, which is always subcortical His symptoms are more likely to be the result of cerebral infarction in the left middle cerebral artery territory caused by cardiac embolism from the aortic valve (option B) Left hemisphere lacunar stroke (Option A) is incorrect The history suggests a large lesion in the left, middle cerebral artery territory involving the cortex This rules out the possibility of a lacunar stroke, which is always subcortical Left-sided intracerebral haemorrhage (Option C) is incorrect This syndrome may have been the result of a cerebral haemorrhage as he is on warfarin (although he is not particularly well anti-coagulated), but ischaemic stroke is more common Left-sided subdural haematoma (Option D) is incorrect There is no suggestion of head https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest trauma to suggest subdural haematoma, although that does not exclude the possibility The sudden onset of the symptoms suggests subdural haematoma is not the cause Thromboembolic stroke secondary to bacterial endocarditis (Option E) is incorrect Bacterial endocarditis needs to be excluded, but fever after stroke is more commonly the result of pneumonia or urinary tract infection, which can easily be screened for 44474 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 94 A 16-year-old man presents with acute central abdominal pain and vomiting On examination, his abdomen was tender but there was no guarding, and bowel sounds were normal Power was reduced distally in his lower limbs and ankle and knee reflexes were absent An older sister presented with a similar condition Blood tests showed: Hb, 11 g/dl; mean corpuscular volume (MCV), 72 fl; platelets, 170; bloodfilm, basophilic stippling; Urinary δ-ALA (delta-aminolevulinic acid), 100 mmol/24 hours (normal range 8–53) What is the most likely diagnosis? A Arsenic poisoning B Lead poisoning C Acute intermittent porphyria (AIP) D Guillain–Barré syndrome (GBS) E Diabetic ketoacidosis (DKA) Explanation The patient with abdominal pain and a motor neuropathy Causes of these two symptoms are lead poisoning arsenic poisoning Guillain-Barré syndrome Diabetic ketoacidosis polyarteritis nodosa acute intermittent porphyria (AIP) Both AIP and lead poisoning cause an elevation in urinary delta-aminolevulinic acid However, only lead poisoning causes basophilic stippling This patient’s older sister shared the same environmental lead exposure accounting for https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest her presentation with similar symptoms 202 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question of 94 A patient with HIV presents with gradual and progressive memory loss His magnetic resonance imaging (MRI) scan shows brain atrophy and mild white matter hyperintensity without any other significant changes or contrast enhancement What is the most likely diagnosis? A Cytomegalovirus infection B HIV associated dementia C Lymphoma D Progressive multifocal leukoencephalopathy E Toxoplasmosis Explanation  The answer is HIV associated dementia – HIV associated dementia is thought to be primarily due to the direct effect of HIV on the brain, although other factors, such as cerebrovascular disease, may contribute The typical MRI scan findings are atrophy and hazy white matter signal change Unlike many of the opportunistic infections that can occur in HIV, it is not usual to see discrete lesions or contrast enhancement Cytomegalovirus (CMV) infection (Option A) is incorrect CMV infection of the brain occurs only in very immunosuppressed individuals and is usually rapidly progressive Lymphoma (Option C) is incorrect Lymphoma of the CNS is more common in HIV and may present with cognitive decline Discrete contrast enhancing lesions are normally seen on MRI and atrophy is not an imaging feature of this condition Progressive multifocal leukoencephalopathy (PML) (Option D) is incorrect PML is caused by JC virus and most frequently occurs in very immunosuppressed individuals with HIV, although it can be seen as a complication of certain biologic immunospuppressive drugs https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest White matter signal change is seen on MRI, classically in posterior brain regions It may present with cognitive decline, but there are often accompanying focal neurological signs; it therefore seems less likely to be the correct diagnosis here Toxoplasmosis (Option E) is incorrect Toxoplasmosis can present with cognitive change, although this usually happens subacutely Multiple ring enhancing lesions are classically seen on MRI 45693 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest less likely Multi-infarct dementia (Option D) is incorrect Multi-infarct dementia typically presents with stepwise deterioration, not described here, and may be associated with focal upper motor neurone signs on examination 46455 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 231 of 237 A 78-year-old man presents with left arm weakness and collapse After 24 h he is left with minor weakness affecting his left hand and has a carotid ultrasound scan This reveals a 49% stenosis affecting the right internal carotid artery and a 55% stenosis affecting the left internal carotid artery This is the second event with left-sided symptoms to have occurred within the past months, the first event left him with permanently impaired coordination on his left side Other risk factors of note include smoking 30 cigarettes per day, which he refuses to stop, and hypertension Pre-existing medication includes aspirin 75 mg, ramipril and atorvastatin 10 mg Blood pressure in the clinic is 145/80 mmHg, he is in sinus rhythm and cholesterol is 5.1 mmol/l Which one of the following is the most appropriate management to reduce risk of a further stroke affecting the same territory? A Clopidogrel therapy B High-dose aspirin therapy C Increase statin therapy D Left carotid endarterectomy E Right carotid endarterectomy Explanation  The answer is Clopidogrel therapy – NICE guidance recommends the use of clopidogrel in this situation High-dose aspirin therapy (Option B) is incorrect Although aspirin alone reduces stroke risk, clopidogrel is recommended by NICE guidance, so clopidogrel therapy is more correct than high-dose aspirin therapy Increase statin therapy (Option C) is incorrect Lowering total cholesterol further from this level is unlikely to have an impact on stroke risk to the same extent as optimised antiplatelet therapy Left carotid endarterectomy (Option D) is incorrect The symptoms are not suggestive of left https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest internal carotid artery stroke; carotid endarterectomy is therefore excluded as an option Right carotid endarterectomy (Option E) is incorrect The right carotid artery stenosis is not severe enough to justify surgical intervention; carotid endarterectomy is therefore excluded as an option 46456 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 232 of 237 A 48-year-old woman presents to the Emergency Department with increasing weakness She has no past medical history of note apart from a recent diarrhoeal illness, which she puts down to an undercooked chicken meal Her husband says that she has been unable to get up out of a chair for the past day On examination there is obvious bilateral limb weakness more marked in the lower limbs and areflexia You notice that if she lies flatter in the bed her oxygen saturations fall by around 2% on the pulse oximeter and she is unable to perform spirometry Which of the following represents the most appropriate immediate management of choice in this patient? A Ciprofloxacin 500 mg po bd B High-dose intravenous corticosteroids C ITU review for consideration of ventilation D Lumbar puncture E Plasma exchange Explanation  The answer is ITU review for consideration of ventilation – This woman has a history that is suggestive of Guillain–Barré syndrome (GBS) This may be precipitated by Campylobacter, her history of recent diarrhoeal illness being a pointer Certain features point to a poor prognosis, these include: Rapidity of onset Reduced vital capacity or respiratory failure Age >40 Proven associated bacterial infection Reduced amplitude of compound muscle action potential https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest Her inability to perform spirometry and desaturation on lying flat are pointers to impending respiratory muscle weakness; therefore, the correct answer here is ITU review for consideration of ventilation Ciprofloxacin 500 mg po bd (Option A) is incorrect Ciprofloxacin has no role in treating GBS and she has no current symptoms of bacterial infection High-dose intravenous corticosteroids (Option B) is incorrect High-dose intravenous corticosteroids are ineffective for GBS Lumbar puncture (Option D) is incorrect Lumbar puncture is a useful test in GBS and one expects to see raised CSF protein, but normal CSF white cell count In this case the need for ITU support must come before the lumbar puncture Plasma exchange (Option E) is incorrect Plasma exchange is a possible treatment for GBS, although intravenous immunoglobulin is generally used first line In this case the need for ITU support supercedes the instigation of plasma exchange 46457 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 233 of 237 Multifocal motor neuropathy is most commonly associated with which one of the following? A Anti-GM1 antibodies B Anti-GQ1b antibodies C Anti-myelin-associated glycoprotein antibodies D Antineuronal antibodies E Antinuclear antibodies Explanation  The answer is Anti-GM1 antibodies – Multifocal motor neuropathy with conduction block initially causes progressive, asymmetrical and usually distal upper limb weakness in the majority of cases High titres of IgM antibody to the ganglioside GM1 (option A) are found in 80% of affected patients, but they are not specific for the disease; anti-GM1 antibodies may also be seen in axonal Guillain–Barré syndrome Anti-GQ1b antibodies (Option B) is incorrect Anti-GQ1b antibodies are associated with Miller Fisher syndrome Anti-myelin-associated glycoprotein antibodies (Option C) is incorrect Anti-myelinassociated glycoprotein (MAG) antibodies are seen in association with immune mediated sensory ataxic neuropathy, often with a prominent tremor Antineuronal antibodies (Option D) is incorrect Antineuronal antibodies are also known as ‘paraneoplastic’ antibodies and are seen in conjunction with numerous cancers and neurological syndromes (for example: anti-Hu antibodies associated with small-cell lung cancer and sensory neuronopathy) Antinuclear antibodies (Option E) is incorrect Antinuclear antibodies are associated with systemic lupus erythematosis (SLE) 46460 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 234 of 237 Which one of the following is a characteristic finding in the CSF of patients with Guillain– Barré syndrome? A Atypical lymphocytes on cytology B Low glucose in relation to blood glucose C Oligoclonal bands, unmatched in serum D Raised CSF protein E Raised lactate Explanation  The answer is Raised CSF protein – In Guillain–Barré syndrome (GBS), the CSF classically shows albuminocytological dissociation, ie an acellular CSF with markedly elevated protein However, the CSF may be entirely normal, especially in the early stages Atypical lymphocytes on cytology (Option A) is incorrect Atypical lymphocytes on cytology would suggest the need to look for a haematological malignancy such as lymphoma, which can rarely present with a GBS like illness Low glucose in relation to blood glucose (Option B) is incorrect Low glucose in relation to blood glucose could be seen in bacterial infection or malignancy Oligoclonal bands, unmatched in serum (Option C) is incorrect Oligoclonal bands, unmatched in serum are seen in multiple sclerosis Raised lactate (Option E) is incorrect Raised lactate in the CSF may be seen in mitochondrial cytopathies such as MELAS (mitochondrial encephalopathy with lactic acidosis and strokelike episodes) 46461 Next Question https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 235 of 237 A 50-year-old male presents with a 4-week history of headache and fever He has asymmetrical upper cranial nerve palsies CSF examination reveals: opening pressure 30 cm; 200 white cells/dl (lymphocytic predominance); protein 2.0 g/l; glucose (CSF/plasma) 0.8/6.3 What is the most likely diagnosis? A Brain abscess B Cryptococcal meningitis C Guillain–Barré syndrome D Herpes zoster meningitis E Tuberculous meningitis Explanation  The answer is Tuberculous meningitis – The patient has a subacute–chronic lymphocytic meningitis with multiple cranial neuropathies The CSF glucose is low and the opening pressure is moderately high This is a typical picture for tuberculous meningitis The CSF should be examined with auramine or Ziehl–Neelsen stain to look for myocobacteria Brain abscess (Option A) is incorrect Brain abscess is more likely to present with seizures and focal cortical signs than multiple cranial neuropathies Cryptococcal meningitis (Option B) is incorrect Cryptococcal meningitis also causes a subacute lymphocytic meningitis; it typically occurs in immunosuppressed individuals The CSF opening pressure is often very high (>40 cm) and, although sixth nerve palsies may occur as a false localising sign of raised pressure, multiple cranial neuropathies are not typical Guillain–Barré syndrome (Option C) is incorrect Guillain–Barré syndrome may rarely present with cranial neuropathies, but the CSF picture does not fit, as GBS is associated with normal cells and high protein https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest Herpes zoster meningitis (Option D) is incorrect Herpes zoster meningitis may produce a lymphocytoc CSF, but one would not expect low CSF glucose or a high opening pressure In addition the multiple cranial neuropathies would be unusual 46462 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 236 of 237 A 70-year-old female with a 2-month history of proximal upper limb pain and right-sided headaches develops sudden-onset right-sided visual blurring On examination there is an altitudinal field defect in the right eye What is the most likely diagnosis? A Carotid artery dissection B Cluster headache C Giant cell arteritis D Idiopathic intracranial hypertension E Ophthalmoplegic migraine Explanation  The answer is Giant cell arteritis – The history of proximal limb aching, headache and visual loss is highly suspicious of giant cell arteritis (GCA) Altitudinal field defects are typically seen in ischaemic optic neuropathy, including that caused by GCA Carotid artery dissection (Option A) is incorrect Carotid artery dissection could cause ipsilateral neck pain and headache and can lead to an anterior circulation stroke Cluster headache (Option B) is incorrect Cluster headache is characterised by short-lived spells of severe unilateral pain, often occurring at night Autonomic features such as ptosis, redness of the eye and nasal stuffiness are usually seen It usually presents in men aged 30– 40 Idiopathic intracranial hypertension (Option D) is incorrect Idiopathic intracranial hypertension is usually seen in young, overweight women and causes headache with papilloedema Ophthalmoplegic migraine (Option E) is incorrect Ophthalmoplegic migraine is a rare headache syndrome associated with temporary oculoparesis 46463 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest 46463 Next Question Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7/10/2016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 237 of 237 A 20-year-old male develops seizures Examination reveals short stature, rounded face and shortening of the metacarpal and metatarsal bones CT demonstrates bilateral basal ganglia calcification What is the most likely diagnosis? A Hypoparathyroidism B Juvenile myoclonic epilepsy C Mitochondrial cytopathy D Pseudohypoparathyroidism E Tuberous sclerosis Explanation  The answer is Pseudohypoparathyroidism – Patients with pseudohypoparathyroidism may have short stature and have a characteristic shortening of the fourth and fifth metacarpals The hypocalcaemia may result in generalised seizures Basal ganglia calcification can be seen Hypoparathyroidism (Option A) is incorrect Hypoparathyroidism also causes low calcium and thus could produce siezures (and other neurological symptoms such as tetany), but there would be no abnormal skeletal phenotype Juvenile myoclonic epilepsy (Option B) is incorrect Juvenile myoclonic epilepsy usually presents with generalised seizures, myoclonic jerks and absences No skeletal abnormalities are seen Mitochondrial cytopathy (Option C) is incorrect Mitochondrial cytopathies are associated with seizures and such patients may have short stature A wide range of neurological problems can be encountered, as can basal ganglia calcification The shortened metacarpals are not particularly associated Tuberous sclerosis (Option E) is incorrect Tuberous sclerosis is associated with epilepsy Skin https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 1/2 7/10/2016 MyPastest manifestations of tuberous sclerosis include ungual fibromata, shagreen patches and facial angiomata; brain lesions include cortical tuber glial astrocytomata and subependymal nodules 46464 End Session Previous Question Tag Question Feedback End Review Difficulty: Average Peer Responses Blog (https://www.pastest.com/blog) About Pastest (https://www.pastest.com/about-us) Contact Us (https://www.pastest.com/contact-us) Help (https://www.pastest.com/help) © Pastest 2016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 ... examination is completely normal Investigations: Hb 12 .0 g/dl WCC 5 .1 × 10 9/l PLT 19 1 × 10 9/l ESR 12 mm/h Na+ 13 9 mmol/l K+ 4.5 mmol/l Creatinine 10 5 μmol/l Which one of the following is the best... (https://www.pastest.com/help) © Pastest 2 016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/3 7 /10 /2 016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top MyPastest 3/3 7 /10 /2 016 MyPastest... (https://www.pastest.com/help) © Pastest 2 016 https://mypastest.pastest.com/Secure/TestMe/Browser/429893#Top 2/2 7 /10 /2 016 MyPastest Back to Filters (/Secure/TestMe/Filter/429893/QA) Question 11 of 94 A 25-year-old