Neurology Module 3

A 35-year-old woman presents to the emergency department with a 2-day history of severe headache, nausea, vomiting, and fever. She also reports experiencing transient episodes of confusion and disorientation, which have resolved spontaneously.

Her neurological examination is notable for neck stiffness and photophobia, but no focal neurological deficits are present.

A non-contrast CT scan of the head is performed and reveals no evidence of acute hemorrhage, mass lesion, or structural abnormality. The ventricles and sulci are normal in size, and there is no evidence of midline shift or cerebral edema.

A lumbar puncture is subsequently performed, which reveals a cerebrospinal fluid (CSF) white blood cell count of 150 cells/μL, with a differential count showing 90% lymphocytes and 10% monocytes. The CSF protein level is elevated at 80 mg/dL, while the glucose level is normal at 60 mg/dL. Gram stain and culture of the CSF are negative.

Which of the following is the most likely diagnosis?

A 68-year-old man presents to the emergency department with a sudden onset of left-sided weakness and dysarthria that resolved completely within an hour. His past medical history includes hypertension, hyperlipidemia, and smoking. On examination, his blood pressure is 150/95 mmHg, and a carotid bruit is noted on the right side. An urgent carotid Doppler ultrasound shows significant stenosis on one side.

Based on the clinical presentation, which side is most likely to have significant stenosis?

A 72-year-old female presents with a history of recurrent, transient neurological deficits, including episodes of right-sided weakness and aphasia. Brain MRI shows multiple cerebral microbleeds, predominantly in the cortical and cortico-subcortical regions.

Her cognitive function has been declining over the past year, with memory impairment and executive dysfunction.

Based on her clinical presentation and imaging findings, cerebral amyloid angiopathy (CAA) is suspected.

Which of the following is the most likely long-term complication this patient is at risk of developing?

A 42-year-old man presented with diplopia, dysarthria and difficulty with swallowing. Over the next few days he developed weakness of the upper and lower limbs. On day 4, he was unable to walk unaided. He denied any sensory symptoms or bladder disturbances. His previous medical history is unremarkable. He is a non-smoker, does not drink alcohol excessively. He does not take any drugs On examination he was apyrexial.

His general medical examination was normal. His higher mental function was unremarkable. There were no signs of meningism.

Cranial nerve examination showed bilateral dilated and fixed pupils. He had binocular diplopia but no obvious ophthalmoplegia. He was dysarthric with weak cough.

His vital capacity was 3.15 standing and 2.00 lying flat. He had lower motor neuron tetraparesis of power 3/5. He was hyporeflexic with normal sensation. He was unable to walk unaided.

Blood tests including FBC, U+Es, LFTs, TFTs, Ca, Autoantibody screen, ESR, CRP were normal. ECG and CXR were unremarkable. CT brain was normal. Nerve conduction studies and EMG were normal.

What is the most likely diagnosis?

What is the mechanism of action of Entacapone (COMT inhibitor)?

All of the following medication has anti-dopaminergic activity to some extend. Which one does NOT cross the blood brain barrier?

The etiology of Parkinson’s disease remains unknown.However, there are a few exogenous risk factors that have been associated with the development of Parkinson’s disease.

Which of the following may be protective against Parkinsons?

A patient with Parkinson’s disease presents with gambling problem,compulsive shopping and hypersexuality.

Which medication is likely to have caused this?

Which of the following feature is least consistent with the diagnosis of progressive supranuclear palsy?

A 25 year old nursing student presents with a painless left wrist drop. Where is the lesion?

A 30-year-old man presents with numbness involving the left fifth digit and ulnar border of the hand and distal forearm. On examination there is no evidence of muscle wasting. There is weakness of left finger abduction and adduction (Grade 4/5), abductor pollics brevis (Grade 4/5), flexor pollicis longus (Grade 4/5) and finger extensor (Grade 4/5). Other muscles groups are normal. Sensation is reduced along the ulnar border of the forearm and hand involving the 5th digit. Reflexes are symmetrical and preserved. The remainder of the neurological examination is normal.

What is the most likely diagnosis?

A 55-year-old woman presents with numbness involving her left thumb and index finger, and the first dorsal webspace and dorsoradial forearm. There is no associated neck pain. On examination, power is normal. The biceps and triceps reflexes are normal and symmetrical. The brachioradialis reflex is reduced on the left.

Where is the lesion?

An 18-year-old man wakes after an orthopaedic procedure on his right leg. He is noted to have a right foot drop. Examination shows weakness of the dorsiflexors of the ankle. He has normal plantar flexion at the ankle and normal knee flexion strength. His right ankle jerk is preserved. No sensory abnormality is detected.

Which nerve is most likely affected?

An 80-year-old woman with longstanding rheumatoid arthritis complains of neck pain. X-rays of her cervical spine demonstrate C2 compression.

What is the most likely clinical presentation?

A hemophilia patient presents with a traumatic iliacus hematoma of the right leg.Examination reveals weak knee extension, absent knee jerk and loss of sensory over inner aspect of thigh and right leg.

Which nerve is most likely affected?

A 43-year-old male is found collapsed at home. The next day he is noted to have the following clinical findings:

• Fixed, dilated pupils.
• Absent corneal reflex.
• Absent vestibulo-ocular reflex to cold water.
• No cough reflex.
• No gag reflex.
• No response to central painful stimulus.
• Neurological imaging demonstrates no abnormalities.

What test is required before consideration of testing for brain stem death?

A 28-year-old woman presents with a three month history of numbness of the hands and feet. On examination, upper and lower extremity reflexes are symmetrically brisk with bilaterally down going plantar responses. Upper extremity power is normal with a normal sensory examination.

There is mild weakness of ankle dorsiflexion bilaterally with reduced sensation to pin prick to the level of the ankles. Joint position sense is normal. Vibration sense is impaired to the level of the tibial tuberosity bilaterally.

Her MRI shows the presence of demyelinating lesions in the cervical and thoracic spinal cord. These appear as hyperintense areas on T2-weighted images and are also seen on FLAIR sequences.

The most likely diagnosis is:

A 60 year old woman undergoes a gynaecological surgical procedure.The patient was kept in a lithotomy position for 3 hours and sustained a compression injury to the femoral nerve.

What neurological finding are you most likely to find?

Which one of the following is not consistent with a diagnosis of Guillain Barre syndrome?

An abnormality in which of the following investigation would be most useful in confirming suspected motor neuron disease?

A 57-year-old man with type 2 (non-insulin-dependent) diabetes mellitus presents with a right foot drop. On examination there is mild weakness of right ankle dorsiflexion and toe extension with other muscle groups being normal. Reflexes are symmetrical with bilaterally downgoing plantar responses. Sensory examination is normal. Electromyography (EMG) and nerve conduction studies are shown in the table below.

Needle examination reveals enlarged motor unit potentials in the right tibialis anterior, flexor digitorum longus , and gluteus medius muscles.

The most likely diagnosis is:

A 39-year-old woman presents with a three-month history of numbness, pins and needles and pain in the right hand involving all fingers which wakes her from sleep at night. Nerve conduction studies show marked slowing of the right median motor distal latency, absent median finger sensory potentials, reduced amplitude of the median ascending action potential and normal conduction of the ulnar nerve.

The most appropriate next step in management is:

A 15-year-old girl presents to her doctor with a four month history of progressive weakness. The weakness is diffuse and she complains of inability to run, and climb stairs. She frequently falls.

Her examination shows diffuse 3/5 weakness in her peripheries, absent reflexes with downgoing toes. She has no cranial nerve abnormalities. Sensory examination reveals a symmetrical glove and stocking distribution of altered touch.

Nerve conduction studies show markedly slowed nerve conduction velocities and conduction block.

The most likely diagnosis is:

An 60 year old male has sustained a large cerebral infarct involving most of the left occipital lobe. The remainder of the brain is unaffected. A later neurological examination would be most likely to reveal which one of the following?

A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present.

Which one of the following diagnoses needs to be urgently excluded?

A 60 year old man presents with urinary retention. On examination he has brisk reflexes bilaterally in the lower limbs with up going plantars. Examination of the upper limb is normal.

Where is the lesion?

A 70 year old man with atrial fibrillation presents with sudden onset of visual changes where he is unable to recognize objects in the right lower quadrant of his visual field bilaterally.

Where is the deficit?

A 60 year old man presents to the emergency department with sudden onset of right arm weakness. When you asked him what happened he replied “fudden in a hair, still larging OK”.

Which of the following best describes this man’s speech abnormality?

A 32 year old woman who is currently 20 weeks pregnant, presents to the Emergency department with a new onset of severe headache associated with ptosis on her right eye but without evidence of fatigability on eye movements. Her pupil size are equal and fundoscopy shows mild bilateral papilloedema.

Her CT head is normal.

Which of the following intervention is least likely to be beneficial in this patient’s management?

A patient presents with right sided hemiplegia and left sided facial weakness and is unable to abduct his left eye.

Where is the lesion?

Bilateral posterior cerebral artery infarction will likely present with one of the following:

A 38-year-old man presents complaining that he is no longer able to read his newspaper while commuting on the train. On examination, he has an abnormality of gaze on looking to the right; his right eye develops nystagmus and his left eye is slow to come across to the nasal side. This problem is most likely due to a structural lesion in which area?

A 73 year old lady presents with diplopia on horizontal gaze only with preserved convergence gaze.On examination there is a left adduction weakness and horizontal nystagmus of the right eye.

Where is the lesion?

A patient presents with locked-in syndrome.

Where is the lesion?

A patient presents with right sided weakness of the upper and lower limbs with loss of vibration and proprioception on the right side.

There is also tongue weakness and atrophy on the left.

Where is the lesion?