Neurology assessment [Unconscious]

A 45 years old male was brought unconscious by family

1) Give six questions you would like to elicit from family member in making diagnosis

2) What investigation you would like to perform

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Clock drawing test

1) What is the function of CDT?
2) Briefly explain it's scoring system
3) Try to score the drawing below

5 different patient was asked to perform the CDT. there are requested to point up to 4. 45

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weakness that resolves after arriving at ER

A 67-year-old man presents with an episode of right face, arm, and leg weakness that resolved on arrival to the emergency room. [Taken and Modified from Question 390, Physical Diagnosis Pretest® Self-Assessment and Review Fourth Editio, Jo-Ann Reteguiz, M.D., Beverly Cornel-Avendaño, M.D, Mcgraw-Hill Medical Publishing Division Pretest® Series]

1)What is the most likely diagnosis?

-Transcient Ischaemic attack
** Episodes of focal neurological symptoms due to inadequate blood supply to the brain. Attack is sudden in onset, resolve within 24 hours. The attack is important as a warning or precursor to cerebral infarction.


2)Outline the pathophysiology

-Reduced flow through vessel
** A fall in perfusion pressure
** Eg: Cardiac dysarhytmia associated with localized cerebrovascular disease
** Hemodynamic explaination


-Blockage of the passage of flow by embolism
** Arising from plagues in aortic arch/ extracranial vessel or from the hearts.
** Embolic explaination


3)What other history that you would like to ask
-Prolong travel (risk of deep vein thrombosis)

-Any cardiac disease
a)Vulvular heart disease
b)Ischaemic heart disease
c)Arrythmias
d)Bacterial endocarditis

-Using of prosthetic joint or device (emboli)
-Any malignant or tumor disease
-History of fracture (fat emboli)


4)What is the drug of choice
-Anticoagulant (Heparin, warfarin)




Generations before you We destroyed when they did wrong: their messengers came to them with clear-signs, but they would not believe! thus do We requite those who sin! [Q10:13]

Wallenberg syndrome

A 61-year-old man with a history of hypertension has been in excellent health until he presents with vertigo and unsteadiness lasting for 2 days. He then develops nausea, vomiting, dysphagia, hoarseness, ataxia, left facial pain, and right-sided sensory loss. There is no weakness. On examination, he is alert, with a normal mental status. He vomits with head movement. There is skew deviation of the eyes, left ptosis, clumsiness of the left arm, and titubation. He has loss of pin and temperature sensation on the right arm and leg and decreased joint position sensation in the left foot. He is unable to walk. Patients admit that he loves to take eat sup gear Box and his cholesterol level being 8 mmol/L. [ Taken and modified from question 49, page 34, Neurology: PreTest® Self-Assessment and Review Fifth Edition, David J. Anschel M.D, The McGraw-Hill Companies, Inc, 2004]

1) Outline the pathophysiology of the disease and signs and symptomps in this patient.

Answer for question 49-51, page 43-44, Neurology: PreTest® Self-Assessment and Review Fifth Edition, David J. Anschel M.D, The McGraw-Hill Companies, Inc, 2004]

Page 153-154, Pathology Recall, Anikar Chhabra MD, Lorne H. Blackbourne MD, Lippincott Williams&Wilkins, 2002

Stroke of left parietal temporal

A 71-year-old woman presents with aphasia and severe right sided hemiparesis greater in the arm than the leg. Her eyes deviate to the left. CT scan shows Ischaemic type of stroke on left parietal temporal region. [Taken and Modified from Question 389, Physical Diagnosis Pretest® Self-Assessment and Review Fourth Editio, Jo-Ann Reteguiz, M.D., Beverly Cornel-Avendaño, M.D, Mcgraw-Hill Medical Publishing Division Pretest® Series]

1)What vessel is most likely involved in this stroke? Justify (4m)
2)What is aphasia and explain the type of aphasia that the patient most likely have (3m)
3)Outline the pharmacological treatment in this patient (3m)


Answer

1)What vessel is most likely involved in this stroke? Justify
-Left Middle Cerebral artery, inferior division.
a)Hemiplegia@ hemiparesis greater in arm and leg
b)Aphasia
c)Eyes deviated to the hemispheric site of lesion

2)What is aphasia and explain the type of aphasia that the patient most likely have
-Acquired loss of of production or comprehension of spoken and/or written language secondary to brain damage.
-Wernicke aphasia (Inability of Patient to understand and give appropriate reply or action. Nonsense words in reply to question)


3)Outline the pharmacological treatment in this patient
-anticoagulants ( Heparin, warfarin)
-fibrinolytic agents (Tissue plasminogen activator) or
-anti platelet agent (Aspirin, Ticlopidine, clopidogrel, dypiridamole)


Tazkirah!!

When trouble toucheth a man, He crieth unto Us (in all postures)- lying down on his side, or sitting, or standing. But when We have solved his trouble, he passeth on his way as if he had never cried to Us for a trouble that touched him! thus do the deeds of transgressors seem fair in their eyes!.[ Q10:12]

Seizure with hemorrhagic temporal lobe

A 32-year-old previously healthy man is brought to the emergency room after having a seizure. A family member states that recently the patient has been complaining of a headache and has been acting bizarre, which is a change in his personality. Physical examination reveals a temperature of 38.3°C. Blood pressure and heart rate are normal. During examination, the patient has a partial complex seizure. CT scan of the head reveals hemorrhagic necrosis of the temporal lobes [Taken and Modified From Question 387, Physical Diagnosis Pretest® Self-Assessment And Review Fourth Editio, Jo-Ann Reteguiz, M.D., Beverly Cornel-Avendaño, M.D, Mcgraw-Hill Medical Publishing Division Pretest® Series]

1) What further question you would like to ask? (3m)
2)What other investigation that you would like to perform? (2m)
3)What is your provisional diagnosis and justify your answer (3)
4)Give one drug of choice and mode of action (2m)



Answer scheme


1)What further question you would like to ask?
-Any family history of seizure?
-Any alcohol or drug abuse?
-Any history of trauma?
-Did patient sexually active ( HSV infection can cause encephalitis)
-History of mumps (can be exclude as mumps usually attack school-age children), herpes zoster
-Any olfactory or gustatory hallucination? (proceed with frontal and temporal lobe involvement especially in HS Encephalitis)


2)What other investigation that you would like to perform?
-CSF Examination (5-500 lymphocytes, mildly elevated protein, normal glucose)
-EEG examination (generalized slowing with burst of periodic high voltage slow wave complex over the involve temporal lobe)
-Polymerase chain reaction on csf (negative in the first 48 hours)
-CSF HSV- specific antibody (immunofluorescence)

3)What is your differential diagnosis and justify your answer
-Herpes simplex encephalitis
a)Sub acute onset seizure
b)Change in personality
c)Fever, headache, seizure.
d)Hemorrhagic necrosis of temporal lobe)

4)Give one drug of choice and mode of action
-Acyclovir
-Antiviral drug that inhibit the DNA synthesis.


Reference: (Page 503, Neurology and Neurosurgery illustrated Fourth Edition, Kenneth W. Lindsay & Ian Bone, Churchill Livingstone, 2004]

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Narated By ‘Abdullah: The Prophet led us in Zuhr prayer and prayer five Rakat. Somebody asked him whether the prayer had been increased." He (the Prophet) said, "And what is that?" They (the people) replied, "You have prayed five Rakat." Then the Prophet offered two prostrations (of Sahu) after he had finished his prayer with the Taslim.[Shahih Bukhari Volumn 009, Book 091, Hadith Number 355]

Pupillary constriction on light and convergence

A 65-year-old woman is seen for evaluation of dementia. On examination, you note that her left pupil does not react well to light. When she follows your finger with her eyes, as you approach the bridge of her nose, you note the left pupil to constrict equally as well as the right one. [Taken and modified from Question 468,Pre Test USMLE Step 1:Pathophysiology, maurice A. Mufson, Mc Graw-Hill, 2002]


1) What nerve control the Constriction and dilation of the pupils?
2) Name the smooth muscle fibres of Iris and innervation in related to pupillary activity.
3) Explain the condition of the pupillary disorder
4) Name one disease synomous with above condition.
5) What labarotary investigation to confirm above disease.
6) What class of drugs use to treat the pupillary condition
7) At which site the lesion could lie which resulting in the pupillary disorder
8) What other disease associated with this pupillary disorder


Answer scheme


Question 1
- Pnemonic: PCP vs PDS (Pupillary constrict-Parasympathetic, Pupillary Dilate-Sympathetic).
- Cranial nerve III


Question 2
- Spinchter pupillae (Circular constrictor innervated by parasympathetic nervous system)
- Dilator pupillae (Radial dilator innervated by sympathetic nervous system)

Question 3
- Small pupils irregular in shape, which unreact to light but react to accomodation.
- Known as Argyl- Robertson Pupil

Question 4
- Syphilitic infection

Question 5
- Rapid Plasma Reagin, RPR ( a non treponemal antibody test)
- Blood Serology- VDRL, Captia G

Question 6
- Parasympathomimetic drugs ( Carbachol, Phenothiazine)
- Opiates producing miosis.

Question 7
- Midbrain (fibres passing to Edingal Westphal nucleus, posterior commisure or ciliary ganglion)

Question 8
- Midbrain lesion- neoplastic, vascular, inflammatory, demylinative.
- Diabetes
- Alcoholic neuropathy
- Infectious mononucleosis.


Reference: (page 140,141,144, Neurology and Neurosurgery illustrated Fourth Edition, Kenneth W. Lindsay & Ian Bone, Churchill Livingstone, 2004]

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But Allah doth call to the Home of Peace: He doth guide whom He pleaseth to a way that is straight. [Q10:25]