Case study Neurology

Question 1

1. 33 Female
2. 1 week R-sided weakness
3. L-sided inability to feel temperature & pain
4. R-sided Babinski sign
5. R-sided brisk reflex
6. Diminished sensation over R foot

Dx ?

Answer 1

Brown-Sequard syndrome secondary to viral infection.

Question 2

1.42 Female
2.Insomnia - 3 month
3.Discomfort while lying in bed

Management ???

Answer 2

Serum Fe & Ferritin level

Restless leg syndrome caused by Fe deficiency

Question 3

Restless leg syndrome mnext Management?

Answer 3

D2 agonist

Pramipexole + Ropinirole

Question 4

Restless leg syndrome - increased risk of——————

Answer 4

Parkinson disease

Question 5

1. 58 MALE
2. Shaving-loses consciousness
3. Tilt table test - Normal
   Dx ?

Answer 5

Carotid sinus hypersensitivity

Question 6

1. 58 MALE
2. Shaving-loses consciousness
3. Tilt table test - (+)
   Dx ?

Answer 6

Vasovagal syncope

Question 7

1. 45 Female
2. Fundoscopy-Hard exudates
3. Cotton wool spot
4. Scattered hemorrhage
   Dx ?

Answer 7

Diabetic retinopathy

Question 8

Frontal lobe injury in car accident; NBME asks which deficit is most likely to ensue ?

Answer 8

Conceptual planning

Question 9

1. 56 Male
2. Alcoholism
3. Acutely intoxicated
4. B1 administrated

what Dec later ?

Answer 9

Anterograde amnesia

Question 10

1. 50 FEMALE
2. high ESR
3. high Creatine kinase (CK)
4. Muscle pain
5. Muscle stiffness
6. Proximal muscle weakness

Dx ?

Answer 10

Polymyositis

Question 11

1. 50 FEMALE
2. high ESR
3. [ Normal Creatine kinase (CK) ]
4. Muscle pain
5. Muscle stiffness
6. NO Proximal muscle weakness

Dx ?

Answer 11

Polymyalgia Rheumatica PMR

Question 12

Polymyositis vs Polymyalgia rheumatica ?

Answer 12

Main difference between PMR and polymyositis? à PMR has no proximal muscle weakness + a
normal creatine kinase; polymyositis has high CK and weakness; pain + stiffness of muscles can be
seen in both conditions, but classically PMR. For USMLE vignettes + neuro shelf, focus on whether
there’s weakness or elevated CK.

Question 13

1. 50 FEMALE
2. high ESR
3. high Creatine kinase (CK)
4. Muscle pain
5. Muscle stiffness
6. Proximal muscle weakness

Next best step in Dx ??

Answer 13

“anti-Jo1 / -Mi2 antibodies” or “electromyography and nerve conduction studies”

Polymyositis

After these, do muscle biopsy can be
performed for definitive Dx. In contrast, no specific Dx test is used for PMR.

Question 14

1. 59 Female
2. Temporal headache
3. Muscle pain + Stiffness
4. High ESR

Dx ?

Answer 14

Temporal arteritis + PMR

Next best step ?

= IV methylprednisolone first, followed by temporal artery
biopsy

Question 15

1. 65 FEMALE
2. Breast cancer
3. Neurological findings

Next best step ?

Answer 15

“intravenous
high-dose dexamethasone.”

Question 16

1. 72 MALE
2. Prostate cancer
3. Neurological findings

nEXT best step ?

Answer 16

“epidural spinal cord compression” due
to spinal mets do steroids first (if listed), then MRI.

Question 17

Patient has brain cancer; next best step?

Answer 17

Steroids

Question 18

How to Dx brain cancer?

Answer 18

contrast head CT (done for cancer and abscess).

Question 19

How to Dx brain bleed?

Answer 19

non-contrast CT (always done for intracranial bleeds)

Question 20

Epidural hematoma; next best step after CT confirms?

Answer 20

intubation and hyperventilation
on Neuro NBME. After this is done, craniotomy is the answer

Question 21

Subdural hematoma; next best step after CT?

Answer 21

craniotomy on NBME, not observation.

Question 22

What do you see on non-contrast CT with epidural vs subdural?

Answer 22

epidural hematoma = lens-shaped
bleed;
subdural = crescent-shaped.

Question 23

1. B.P.=220/120
2. Confusion

Dx + Tx ?

Answer 23

Dx-HTN encephalopathy
Tx- IV sodium
nitroprusside

Question 24

BP of 220/120 + sodium nitroprusside administered; now patient has confusion; Dx?

Answer 24

cyanide
toxicity caused by nitroprusside.

Question 25

Drug that can be given to prevent vasospasm after a subarachnoid hemorrhage (SAH)?

Answer 25

nimodipine (dihydropyridine CCB).

Question 26

1. Severe headache 2. Stiff neck Dx ?

Answer 26

Subarachnoid heamorrhage

Question 27

Brain bleed in patient with Alzheimer ?

Answer 27

amyloid angiopathy (intracerebral hemorrhage).

Question 28

1. 87 FEMALE 2. Low grade fever 3. Delirium next best step ?

Answer 28

do urinalysis to look for UTI as cause of delirium.

Question 29

Viral infection + tinnitus + vertigo +/- neurosensory hearing loss

Answer 29

labyrinthitis.

Question 30

Viral infection + vertigo

Answer 30

vestibular neuritis.

Question 31

Tx for acute flare of Multiple sclerosis ?

Answer 31

IV steroids (oral is wrong and can make flares worse)

Question 32

Tx between flares of MS (the patient must by asymptomatic)

Answer 32

IFN-beta (interferon beta)

Question 33

Tx for spasticity in MS ?

Answer 33

baclofen (GABA-B receptor agonist)

Question 34

Incontinence in MS ?

Answer 34

urge (hyperactive detrusor; detrusor instability).

Question 35

Mechanism for MS?

Answer 35

T cell-mediated attack against oligodendrocytes.

Question 36

How to Dx MS?

Answer 36

MRI is gold standard; choose MRI over CSF IgG oligoclonal bands

Question 37

1. 27 FEMALE 2. Intermittent headache 3. Blurry vision

Answer 37

optic neuritis (multiple sclerosis) ## Footnote change in color vision, or Marcus Gunn pupil (relative afferent pupillary defect)

Question 38

Most specific eye finding in MS

Answer 38

medial longitudinal fasciculus (MLF) syndrome à aka internuclear ophthalmoplegia (INO) à when you abduct to one side, you activate CN VI on that side, which requires the contralateral CN III to activate in order to adduct à the side that cannot adduct is the side that’s fucked up; the normal side will have nystagmus.