Medicine solved scenerio based questions (CENTRAL NERVOUS SYSTEM)

Medicine solved scenerio based questions (CENTRAL NERVOUS SYSTEM)

Migraine

1. A 25-year-old lady one year history of episodic unilateral throbbing headache,
associated with nausea, vomiting and photophobia. There is a family history of
similar headaches. On examination, BP 120/80 mm Hg, pulse 80/min, no
neurological physical signs. Fundoscopy is normal. On investigations:
CBC: Hb 12.5 gm/dl, WBC 7×109, Platelets 235, ESR 20, contrast CT scan of head is
normal.
a) What is the most likely diagnosis and four precipitating factors of this type of
headache?
b) How will you manage her headache?
Trigeminal Neuralgia
1. A 50-year-old man presents to his physician with complaints of electric shock like
pain on right side of the face. It is usually triggered in the morning by shaving. Pain
does not occur at night.
a) What is your diagnosis?
b) What treatment options are available?
Third Nerve Palsy
1. A 46-year-old hypertensive, non-diabetic female reports to medical OPD with one
month history of pain in and around the right eye as well as the adjoining part of the
head. For the last two weeks, she is also complaining of double vision. On
examination, she has ptosis of the right eye along with fixed dilated right pupil.
External ocular movements in the left are normal and full while her right eye is facing
downwards and outwards and only abduction and some inward rotation (intorsion)
is possible. On shining light in the right eye, the left pupil constricts but the right fails
to constrict.
a) What is the neurological lesion?
b) What might be causing this neurological lesion?
c) What one investigation may help to confirm the diagnosis?

Epilepsy

1. Parents of 15-year-old girl brought her in emergency immediately after she had an
episode of fall while she was dressing for school and the mother observed the jerk
movements of all her body along with passage of urine. This was her second episode.
This whole episode lasted for 2-3 minutes and the girl has no memory of the event.
a) What do you call this episode?
b) What two investigations you will order initially?
c) What metabolic disorders can cause such kind of symptoms?

2. A 63-year-old female comes with history of single episode of lip smacking associated
with excessive blinking and staring in space with no response to verbal commands
from attendants. After this episode she remained drowsy for almost one hour and
then became normal. No previous history of such attacks. She is smoker and had an
attack of right-sided weakness one month back. On her previous CT scan done at
that time there is a large hypodense area on left side in middle cerebral artery
distribution territory.
a) What is the comprehensive diagnosis?
b) Will you start treatment for this episode and why?
c) If you decide to treat then what is the 1st line and 2nd line drugs for this kind of
episode. Give one name of each.
d) Name three factors in daily life which can trigger the recurrence of these
episodes.

3. A 28-year-old man gets up in the morning and embarrassed to find that he has wet
his bed during sleep. When he went to brush his teeth, he found that his tongue is
sore.
a) What is your most likely diagnosis?
b) What is your differential diagnosis?
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c) Outline plan of management.

Parkinsonism

1. A 70-year-old man presents with a stepwise loss of intellectual function. Prior
episode had been associated with unilateral weakness and difficulty in swallowing.
Unilateral Babinski sign is positive on neurological examination. There is increased
tone in lower limbs and he has a mask like face.
a) What is your diagnosis?
b) Write down reversible causes of this condition.

2. A 72-year-old retired police officer presented with increased difficulty in walking and
falls. On examination, he is hemodynamically stable and has generalized truncal
rigidity with normal deep tendon reflexes and intact sensations.
a) What is the most likely diagnosis?
b) Give three causes of this clinical condition.
c) Enumerate three most important steps in the management of this case.

3. A 70-year-old retired banker presents to OPD with the history of tremors of the right
hand and increased difficulty in walking. He has progressively become physically
incapacitated over the past 18 months.
a) Give most likely diagnosis with three other possibilities.
b) What is the single most pathogenic explanation for this disorder?
c) Give four most appropriate treatment options.

Amyotrophic Lateral Sclerosis

1. A 58-year-old male presented with progressive weakness of all four limbs. His
examination revealed some wasting and power grade 3 in lower limbs and grade 2 in
upper limbs. Fasciculations were noted on thigh muscles during examination. His
tendon reflexes were brisk. The higher mental functions, cranial nerves and sensory
system was normal on examination.
a) What are the different variants of this condition?
b) What are the treatment options?

Multiple Sclerosis

1. A 22-year-old female consulted an ophthalmologist for sudden onset of vision loss in
left eye. Six months ago, she had weakness of right arm and staggering gait which
improved over two months. Two years ago, she felt numbness in limbs and was
thought to be functional as no neurological deficit was detected at that time. On
examination, ophthalmologist noticed afferent pupillary defect and intra-nuclear
ophthalmoplegia. Neurologist also found positive Lhermitte’s sign & ataxia.
a) What is the most likely diagnosis?
b) What investigations would be helpful?
c) How would you treat her?

Meningitis

1. A 35-year-old male presents with complaints of high-grade fever, neck pain and
headache for two days and altered sensorium for 2 hours. On examination, his BP is
100/60 mm Hg, pulse is 120/min, temp is 103 F. GCS is 12/15 and neck is rigid. There
is no focal deficit. Rest of systemic examination is normal.
a) What is your diagnosis?
b) Write down important investigations to confirm diagnosis.
c) Write down empirical treatment for suspected condition.

2. A young man aged 18 has developed low grade fever and severe headaches for the
last two weeks. On examination, he has neck rigidity.
a) How will you further investigate this patient?
b) Which of these investigations is most crucial in diagnosis? Give a sample of
diagnosis.

Guillain-Barre Syndrome

1. A 25-year-old man presented with rapidly progressive paralysis of all four limbs over
days. Examination reveals hypotonia, grade 0/5 power and absent reflexes in all four
limbs. His sensations were normal. CSF examination shows:

a) What is the likely diagnosis?
b) How will you confirm this diagnosis?
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c) How will you manage the case?

2. A 15-year boy is brought to you with progressive weakness of both lower limbs over
a period of 7 days. He was previously normal except mild flu prior to present
condition. On examination, boy is fully alert and febrile. GPE does not reveal any
abnormality except undescended testis on one side. Power in upper limbs is 5/5
whereas in lower limbs is 2/5. Deep tendon reflexes were absent in lower limbs.
a) What is the most likely diagnosis?
b) What investigations are helpful to confirm the diagnosis?
c) What complications can prove fatal and how can you manage them?

Extradural Hematoma

1. Mr. X is known case of valvular heart disease and is taking oral anticoagulants for the
past three months. He fell from motor cycle two days back with an injury to the right
eye and transient loss of consciousness. He developed gradual loss of consciousness
since last night. On examination, he has deeply hemorrhage and dilated pupil of the
right eye. He has generalized hypotonia with an extensor plantar reflex on the left
side.
a) What is your diagnosis?
b) Give four relevant investigations.
c) Outline the management.

STROKE MEDICINE(CVA Infarction)

1. A 28-year-old female, a known case of Rheumatic Heart Disease, on regular
prophylactic monthly injections of Benzathine Penicillin presented in ER with sudden
onset of weakness in right half of the body. On examination, her pulse is irregularly
irregular, rate 130/min, BP 120/80 mm Hg and mild diastolic murmur at mitral area.
a) What is the comprehensive diagnosis?
b) What further investigations are required?
c) Outline the management.

2. A 20-year-old girl who is a known patient of mitral stenosis is admitted in emergency
room with history of sudden weakness of right half of body. On examination, he is
conscious, having irregularly irregular pulse. Her BP is 110/70 mm Hg, and signs of
upper motor neuron lesion on right side are present. CT scan reveals hypodense area
in left parietal region.
a) What is the probable diagnosis?
b) What single most important investigation is needed and why?
c) Give four steps of management.

3. A 45-year-old painter while painting had a mild headache. His painting brush
suddenly dropped from his hand followed by weakness of right upper and lower
limbs. On examination, pulse is 70/min, blood pressure is 130/80 mm Hg. There is
drooping of left upper eye lid. Left pupil is dilated and not reacting to light. Power in
right upper limb is 3/5 and right lower limb is 4/5. Tendon reflexes are brisk on right
upper and right lower limb and right plantar reflex is extensor.
a) What is the most likely diagnosis?
b) Give two investigations to confirm diagnosis.
c) What would be the likely best treatment?

4. A 23-year-old male presents with complete flaccid paralysis of right side. On
examination, his pulse is irregularly irregular. On auscultation of the heart, there is
faint murmur.
a) What do you think is the most likely cause of paralysis?
b) Name one definitive test to confirm the neurological problem.
c) Name one definitive test to establish heart problem.
d) How could you prevent stroke in patients with such heart disease?

Miscellaneous

1. A 63-year-old female is brought by her attendants with complaints of abnormal
behavior, screaming and abnormal limb movements occurring last night. There is no
previous history of similar attacks in past. However, she is smoker and has had an
attack of right-sided weakness 1 month back from which she is almost completely
recovered. On her previous CT scan done at the time there is a large hypodense area
on left anterior cerebral artery distribution.
a) What is the comprehensive diagnosis? Will you start treatment for this episode
and why?
b) What is the first line drug?