NEUROLOGY

18. Lesion in the following brain regions are correctly matched with organized deficita. Left occipital lobe – left homonymus hemianopiab. Left internal capsule – right hemiparesisc. Left cerebellar hemisphere – right dysdiadochokinesiad. Broca’s area – expressive dysphasiae. Left cerebellopontine angle – left lower MOTOR NURON FACIAL PALSY

19. Absolute contraindication in Lumbar Puncture

a. papiloedema b. severe neck stiffnessc. age > 65 yearsd. large cerebellar tumor with surround edemae. abscess of lumbar puncture site

20. The following is/are correct definitiona. dysphasia – inability to enunciate words clearlyb. dysphonia – inability to speak other than in a whisperc. dyslexia – impaired ability to speakd. dysarthria – inability to writee. Dysgraphia – inability to interpret visual information

21. Total paralysis of the 3rd CN causes the same sidea. dilatation of the pupilb. ptosisc. Paralysis of lateral gazed. Absence of facial sweatinge. Absence of the accommodation

22. Recognized features of UMN facial weakness includea. drooping of the angle of the mouthb. inability to wrinkle the foreheadc. preservation of emotional smilingd. weakness of the masseter mse. ptosis

23. The following are recognized findings in the disorder of the cerebellum

a. scanning dysarthriab. increased muscular tone in the limbc. intention tremord. pendular nystagmuse. past pointing

24. Bilateral ptosis can be due toa. parkinsonismb. myasthenia gravisc. grave’s disease

d. dystrophia mytonica e. intraspinal degeneration of the cord

25. The list below are the cause of parkinsonism/ akinetic rigid syndrome a. wilson’s diseaseb. multiple sclerosisc. idiopathic Parkinson diseased. huntington’s diseasee. motor neurone diseasef.

26. In idiopathic Parkinson diseasea. there is strong genetic factor have been identifiedb. the incidence in more in males c. present in elderly people with prevalence rising to 1 in 200 in those over 70 d. result from the depletion of dopamine containing neurons in substantia nigra of basal

ganglia and relative excess of Ach stimulatione. combination of therapy reduces the peripheral side effects principally nausea

27. Statement below about epilepsy is/are truea. a single seizure is already considered as epilepsyb. imaging is a diagnostic methods for epilepsyc. EEG is sensitive for presence / absence epilepsyd. Intercurrent infection and metabolic disturbances are one of the trigger factor e. Phenytion and carbamazepine are not ideal for young woman wishing to use OCP

28. Regarding to myasthenia gravisa. autoa/b in post junctional membrane at NMJ cause reduce no of Ach receptor b. majority of the px have thymomac. men affected more in younger age group and reverse at older aged. tensilon test is a diagnostic teste. thymectomy in early stage lead to overall better prognosis

29. In cerebrovascular diseasea. stroke is a focal neurological deficit lasting longer than 24 hoursb. 85% of strokes due to cerebral hemorrhagesc. Amourosis fugax is one of the TIA featuresd. In 10% case of subarachnoid hemorrhage are due to berry aneurysme. Most cases of cerebral hemorrhage which lead to stroke are due to charcout bouchard

aneurysm

30. causes of proximal myopathya. steroid therapyb. thyroitoxicosisc. hypokalemiad. osteomalaciae. prolonged alcohol abuse

18. Lesion in the following brain regions are correctly matched with organized deficita) F- Left occipital lobe-RIGHT homonymous hemianopia because at the optic chiasm, fibers from

nasal ganglion cells decussate into the contralateral optic tract (Harrison’s Principle of Internal Medicine 16th Edition pg 164) tgk gambo ni btul2 follow kale hijo dan anda jumpa jawapannye…

b) T- Lesion of the LEFT corticospinal tract in the internal capsule (rostral to the pyramidal decussation) results in a RIGHT hemiplegia (involves the right arm, trunk and leg) (http://www.neuroanatomy.wisc.edu/virtualbrain/BrainStem/01Pyramid.html)

c) F- Left cerebellar hemisphere – LEFT dysdiadochokinesia Neurological signs appear on the same side as the lesion since the cerebellum functions largely ipsilaterally (http://isc.temple.edu/neuroanatomy/lab/lesions/36.htm), damage to cerebellar hemisphere always produces signs ipsilateral to the side of the lesion (Neurology & Neurosurgery Illustrated 4th Edition pg 180).

d) T- Broca’s dysphasia=motor/expressive dysphasia (Neurology & Neurosurgery Illustrated 4th Edition pg 122). Broca’s area adelah utk production of language sbb tu dye ade expressive dysphasia dye phm soklan tap nk bgtaw jawapan susah (impaired production of language) whereby Wernicke’s area adelah speech comprehension region, so dye ade receptive dysphasia dye xphm soklan langsung tapi language dye fluent (impaired comprehension) (Harrison’s Principle of Internal Medicine 16th Edition pg 146-147)

e) T- Left cerebellopontine angle – LEFT (ipsilateral) deafness, nystagmus, decrease corneal reflex, facial weakness (LMN), ipsilateral cerebellar signs (Oxford Handbook of Clinical Medicine 8th Edition pg503)

19. Absolute contraindication in Lumbar Puncture

a) True. Papilloedema is a sign of increase intracranial pressure. It is an absolute contraindication for lumbur puncture. Ia kerana, jika lumbar puncture dibuat, ia akan menghasilkan perbezaan pressure antara intracranial CSF pressure dan CSF pressure di spinal cord. Apabila lumbur puncture dilakukan, CSF pressure akan lebih rendah di spinal cord berbanding di intracranial yang mana ia akan meningkatkan risk factor of cerebral herniation through foramen magnum. That cerebellar herniation is very dangerous as it will cause respiratory arrest.

b) False - (from Harrison, volume 2, 17th edition, Meningitis presentation page 2624 )

c) False. There are no age limit especially in older age group for lumbar puncture procedure. Not in the list of absolute contraindication.

d) False. Large cerebellar tumor with surrounding edema (posterior fossa lesion) is not an absolute contraindication for lumbar puncture. As it does not indicate any sign of increased ICP, it is not absolute contraindication. It is relative contraindication as this condition may present certain neurological deficit. Therefore, brain imaging should be performed before doing the LP.

e) True. Local skin infection at the needle track (e.g abscess at the lumbur puncture site) is an absolute contraindication. The reason is it may give rise to infection especially into the CSF and to the brain,

(from EFNS guideline on the management of community-acquired bacterialmeningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults - European Journal of Neurology 2008, 15: 649–659)

20.The following is/are correct definitiona. dysphasia – inability to enunciate words clearlyb. dysphonia – inability to speak other than in a whisperc. dyslexia – impaired ability to speakd. dysarthria – inability to writee. Dysgraphia – inability to interpret visual information

Definition (Doorland)

1. Impairment of speech, consisting lack of coordination and failure to arrange words in their proper order, due to cranial lesion. (F)

2. Difficulty in speaking, voice impairment. (T)3. Impairment of ability to read, spell and write words, despite the ability to see and recognize

letter. (F)4. Imperfect articulation of speech due to disturbances of muscular control resulting from central

or peripheral nervous system damage. (F)5. Difficulty in writing (F)

21. Total paralysis of the 3rd CN causes the same side

A. T – Fixed and dilated pupil(Kumar n Clark, 7th edition, ms: 1105; oculomotor nerve)B. T - jansenkoh.com/Isolated%20Third%20Nerve%20Palsy.docC. F – lateral gaze or abduction action supply by abducens nerve (VI) (Kumar n Clark, 7th edition,

ms: 1106; abducens nerve)

D. F – Absence of facial sweating occur in Horner’s syndrome not in 3rd nerve palsy. The absence of facial sweating depending on level of extend; (i) central lesion = sweating entire half of head, arm and upper trunk, (ii) neck lesion proximal to superior cervical ganglion = diminished facial sweating, (iii) lesion distal to superior cervical ganglion = no affect sweating at all. (Kumar n Clark, 7th edition, ms:1103, Horner’s syndrome)

E. T - Accommodation defines as adjustment, especially of the eye for seeing objects (http://medical-dictionary.thefreedictionary.com/accommodation). So in action of adjustment of pupil, it’s helped by ciliary muscle which a part of 3rd cranial nerve. That why in cranial nerve palsy have fixed and dilated pupil mean that absence of accommodation. (Kumar n Clark, 7th edition, ms:1105, Oculomotor nerve)

22. Recognized features of UMN facial weakness include(Mcleod’s Clinical Examination/Hutchinson)

a. drooping of the angle of the mouth Tb. inability to wrinkle the forehead Fc. preservation of emotional smiling Td. weakness of the masseter ms T

for UMN lesion, the muscle of the upper part receive corticonuclear fibers from both cerebral hemisphere.means that in UMN lesion, only the muscles of the lower face will be paralyzed. (clinical neuroanatomy 355)

e. ptosis - F . X sure of this, cause lack of finding of evidence, but in LMN, such as myasthenia gravis, have ptosis

23. The following are recognized findings in the disorder of the cerebellumCerebellarsigns ( PINARDS)

Past pointing Intention tremor Nystagmus Ataxia Rebound Dysdiadokinesia Slurred speech

a) Scanning dysarthria TDisorders of speech articulation caused by imperfect coordination of pharnyx, larnyx, tongue, or face muscles. This may result from CRANIAL NERVE DISEASES; NEUROMUSCULAR DISEASES; CEREBELLAR DISEASES; BASAL GANGLIA DISEASES; BRAIN STEM diseases; or diseases of the corticobulbar tracts (see PYRAMIDAL TRACTS). The cortical language centers are intact in this condition.

(From Adams et al., Principles of Neurology, 6th ed, p489)

Additional info:Dysarthria in cerebellar lesions is also referred to as speech ataxia characterized by: (1) Slow and slurred speech with prolongation of individual speech sounds (2) Sudden uncontrolled alterations in loudness of voice (3) Consonants become imprecise and vowels are distorted (4) Voice tremor

http://www.medlink.com/medlinkcontent.asp

b) Hypotonia, and not hypertonia, is an important sign of cerebellar disease. It is more obvious in acute lesion than in chronic. It is due to loss of control held by cerebellum normally upon the stretch reflex. F

c) T The most common cause for intention tremors is damage to the cerebellum. The cerebellum is a part of the brain responsible for motor coordination, posture and balance. It is responsible for fine motor movements.The most common site for cerebellar lesions that lead to intention tremors has been reported to be the superior cerebellar peduncle, through which all fibers carrying information to the midbrain pass, and the dentate nucleus, which is also responsible for linking the cerebellum to the rest of the brain (www.wikipedia.com)

d)T Pendularnystagmus is a multivectorialnystagmus (ie, horizontal, vertical, circular, elliptical) with an equal velocity in each direction that may reflect brain stem or cerebellar dysfunction. Often, there is marked asymmetry and dissociation between the eyes. The amplitude of the nystagmus may vary in different positions of gaze (www.emedicine.com)

e)T Cerebellar lesion disturbed fine motor movement. When the cerebellum is damaged, a person has difficulty executing a fine motor movement, such as attempting to touch one's nose with one's finger (www.wikipedia.com)

24. Bilateral ptosis can be due to(a) F rujukan kamus oxford: parkinsonism is a clinical picture characterized by tremor, rigidity,

slowness of movement, postural instability. Xde mention pasal ptosis pun. Google: Tapi ada 1 jenis rare genetic disease called charcot-marie-tooth disease (CMT) characterized by gradual degeneration of nerves in hand and feet associated with parkinsonism and ptosis.so, untuk jawapan soalan ni,sy berpendapat,false.

sumber: ‘making neurological diagnosis at the bedside’ pg 28.

(b) T myasthenia gravis usually cause bilateral ptosis with normal pupil size, rarely it cause unilateral ptosis.

(c) F grave’s disease cause proptosis (bulging of eye ball), not ptosis.

(d) T bilateral ptosis with normal pupil which associated with frontal baldness, sternomastoid/temporal wasting, myotonia.

(e) F xde sumber rujukan,jawab sendiri. Kalau ikut logic, problem in the cord tak effect eyelid because elevator palpabrae superior supplied by CN3.

Extra: other causes of bilateral ptosis: bilateral Horner’s syndrome, bilateral CN3 palsy, midbrain lesion, miller fischer syndrome, congenital, kearns-sayre syndrome.

25. The list below are the cause of parkinsonism/ akinetic rigid syndrome(ARS)

a. T – Excessive copper other than affecting the liver, may also cause damage to brain, present as ARS http://www.annalsofian.org/article.asp?issn=09722327;year=2007;volume=10;issue=1;spage=21;epage=30;aulast=Gupta#Hereditary%20Causes%20of%20Akinetic%20Rigid%20Syndrome

b. T c. T d. T - HD is a autosomal dominant disorder of trinucleotide repeats characterized by chorea,

behavior changes and cognitive impairment http://www.annalsofian.org/article.asp?issn=09722327;year=2007;volume=10;issue=1;spage=21;epage=30;aulast=Gupta#Hereditary%20Causes%20of%20Akinetic%20Rigid%20Syndrome

e. F

26. In idiopathic Parkinson diseasea) there is strong genetic factor have been identifiedb) the incidence in more in males c) present in elderly people with prevalence rising to 1 in 200 in those over 70 d) result from the depletion of dopamine containing neurons in substantia nigra of basal ganglia

and relative excess of Ach stimulatione) combination of therapy reduces the peripheral side effects principally nausea

a) F- The cause is unknown, there is NO STRONG GENETIC FACTOR HAVE BEEN IDENTIFIED (Davidson’s Principle & Practice of Medicine 20th Edition pg 1218), most cases of idiopathic Parkinson disease (IPD) are believed to be due to a combination of genetic and environmental factors. At both ends of the spectrum are rare cases that appear to be due solely to one or the other (http://emedicine.medscape.com/article/1831191-overview)

b) T- sex incidence= male:female-3:2 (Neurology & Neurosurgery Illustrated 4th Edition pg 360), a slight male preponderance is noted (Clinical Neuropathology Text & Colour Atlas pg 101) tp dlm (Davidson’s Principle & Practice of Medicine 20th Edition pg 1218) it stated that sex incidence is about equal. Dlm buku2 len + internet x di stress kn pulak sex incidence. However, I’ve heard it somewhere (sory xengt) Parkinson is a disease of men. Tapi xbley nk clarify la..

c) T- The disease usually presents in elderly people, the prevalence rising to 1 in 200 in those over 70 (Pocket Essential of Kumar & Clerk Clinical Medicine 4th Edition pg 743) sebijik sejabak!

d) T- Ayat sebijik jugak from (Pocket Essential of Kumar & Clerk Clinical Medicine 4th Edition pg 743)e) T- Ayat sebijik jugak from (Pocket Essential of Kumar & Clerk Clinical Medicine 4th Edition pg 744)

27. Statement below about epilepsy is/are truea) False. By definition of epilepsy from Harrison, epilepsy is described as recurrent seizures due to

chronic or underlying process. Secara mudahnya, epilepsy ini boleh dikatakan sebagai tendency for seizure to reoccur manakala seizure ini pula boleh dikatakan sebagai presentation. Sebab itu, presentation (seizure) pelbagai. Tiada presentation epilepsy. Tapi, sebab atau causes of epilepsy banyak tapi tidak diceritakan presentation of epilepsy.

b) False. Imaging is not the the diagnostic tools to diagnose epilepsy. The diagnostic tools to diagnose epilepsy is by clinical history. Details history regarding pre and post event is the most important aspect. Then, physical examination, and blood studies. Imaging (CT, MRI) is used to look for intracranial abnormalities. Based on http://www.epilepsyfoundation.org/about/diagnosis/ ,

c) False. EEG (electroencephalography) not 100% sensitive to presence or absence of any seizures. For example, simpe or complex pressure may originate from a region of the cortex that is not within range of the scalp electrodes.

(from Harrison, 17th edition, page 2505, under Labaratory studies)

d) True. Infection and metabolic disturbance are one of the causes of seizures and epilepsy. Infection is common cause in the late infancy and childhood age. Metabolic disturbace such as hypoglycemia and hypo/hypenatremia may cause seizures and epilepsy.

(from Harrison 17th edition, page 2502, table causes of seizures.)

e) True. Phenytoin and carbamazepine (and phenobarbitol) cause drug interactions with OCP in the sense that these three drugs, reduced the efficacy of OCP. Therefore, kebolehupaya OCP untuk membendung diri dari pregnant berkurang. OCP jadi kurang power. (from Kmar and Clark, 7th edition page 1143 under contraception)

28. .Regarding to myasthenia gravisAnswer (Davidson page 1252-1253)

a. True --- MG is a disease of progressively muscle fatigability, particularly muscle of ocular, neck, facial and bulbar. It is caused by autoantibodies to acetylcholine receptor at postjunctional membrane at NMJ. The AB block neuromuscular transmission and initiate complement mediated inflammatory response --- reduce number of Ach receptor and damages the end plate.

b. False --- only about 15% patient had tyhmoma (usually late onset disease), majority of patient will have thymic follicular hyperplasia.

c. False --- women affected more often at younger age group and the reverse at older age group.

d. False --- http://neuromuscular.wustl.edu/mtime/mgdx.htmltensilon test is a investigative test., but is not that reliable, so it is not a “diagnostic” per say

e. True --- Principle of treatment for MG is to maximize activity of Ach at remaining receptor and to limit or abolish immunological attack on motor end plates. So , drugs given is anticholinesterase (inhibit enzyme yg metabolize Ach), usually pyridostigmine 30-120mg orally 6-Hourly. Thymectomy in early stages lead to better prognosis, whether thymoma is present or not. It should be performed ASAP in antibody positive patient under 45 years old with symptoms not confined to extraocular muscle, unless disease da more than 7 year.

29. In cerebrovascular disease

a) T- Stroke definition: a syndrome of rapid onset of cerebral deficit (usually focal) lasting > 24 hours or leading to death, with no cause apparent other vascular one. (Kumar n Clark, 7th edition, ms 1126: stroke definition)

b) F – Thromboembolic infarction (80%), cerebral and cerebellar haemorrhage (10%) and sub-arachnoid haemorrhage (5%) are main causes. (Kumar n Clark, 7th edition, ms 1126: stroke introduction)

c) T – A TIA causing an episode of amaurosis fugax is often the first clinical evidence of internal carotid artery stenosis and forerunner of a hemipararesis. (Kumar n Clark, 7th edition, ms: 1129: TIA clinical features)

d) F – Causes subarachnoid hemorrhage; saccular (berry) aneurysm = 70%, AVM = 10%, no arterial lesion = 15%, Rare association (<5%) (Kumar n Clark, 7th edition, ms: 1134: SAH causes; table 21.31)

e) T – Intracerebral hemorrhage causes 10% of stroke. One of the cause is rupture microaneurysm (charcot – bouchard aneurysm) (Kumar n Clark, 7th edition, ms: 1133: aetiology intracerebral hemorrhage)

30. Causes of proximal myopathya. steroid therapy Tb. thyroitoxicosis Tc. hypokalemia Td. osteomalacia Te. prolonged alcohol abuse T

Differential Diagnosis For Proximal muscle weaknesshttp://en.diagnosispro.com/differential_diagnosis-for/proximal-muscle-weakness/34521-154.html