Sunteți pe pagina 1din 46

‫الحمد هلل والصالة والسالم على رسول هللا‬

My Study Plan For MRCP II:

→ Not less than 4 months.


→ I solved On Examination nearly 2 times.
→ I had a 3 weeks Vacation before exam (during them I studied most of the pat
papers from 2011 to 2018). half Exam /day (I was not so fast ☺)
→ In the Last week, I had a rapid review of X-rays, ECGs, fundoscopies, GIT
radiology, derma, neuro radiology, very quickly.
→ In the last week, do not solve Questions, only Re-read, Re-read.
→ These notes are recorded also, so you can study them by reading or by listening.
→ I readied these notes & listened to them nearly 3 times.
→ Past papers are uploaded on my telegram channel.
→ The Images, are also uploaded on my telegram channel.
There are 150sample Qs on the website of MRCP Exam, you will find 3 or 4 of them in
the real exam

https://www.mrcpuk.org/mrcpuk-examinations/part-2/part-2-sample-questions

These notes are open source, collected from Onexamination, past papers, spread freely,
if any concern, you can find the “Microsoft Word copy of this PDF document” on my
channel on telegram, you can download the Microsoft word document & add or
remove or edit any part , according to your need.

https://t.me/mrcp_collection

Take chocolate with you in the exam: eat 1 bar of chocolate after 1 hour of the exam
(Total of 6 bars in the 2 papers ☺ , I did so).

☺ .‫وال تنسوني من صالح دعائكم بالمغفرة والرحمة وحسن الخاتمة‬

Dr. Khaled Nabeel Elgohary

If any concern, just mail me: dr.khaled.elgohary@gmail.com


1. In PSP >> MRI >> midbrain atrophy.
2. Vascular parkinsonism presents as lower limb parkinsonism.
3. Ceruloplasmin is normal in approximately 5% of cases of Wilson's disease.
4. NMS >>Rigidity.
5. CSF lactate increases in mitochondrial disorders.
6. DD of ring enhanced lesion:

→ Toxoplasmosis ‫غالبا يكونوا‬multiple.


→ Histoplasmosis
→ Primary brain tumours.
→ Cerebral metastases
→ Abscess.

7. Tropheryma whippelii is a Gram positive organism.


8. HS encephalitis:
Typical findings on presentation include the following:

• Alteration of consciousness (97%)


• Fever (92%)
• Dysphasia (76%)
• Ataxia (40%)
• Seizures (38%): Focal (28%); generalized (10%)
• Hemiparesis (38%)
• Cranial nerve defects (32%)
• Visual field loss (14%)
• Papilledema (14%)

Diagnosis:

→ The MRI (Better than CT) demonstrates a


temporoparietal dense lesion.EXAM2014
→ CSF for HSV PCR

Viral CSF cultures are rarely positive and should not be


relied on to confirm the diagnosis.

HS encephalitis may have normal CT, but MRI will show the charcterisitc temporal lobe
affection EXAM2014
9. CSF analysis:

glucose CSF/serum < 0.6. ‫ بروتين عالي ومعكر‬، ‫ عالي‬pressure :‫بكتيريا‬

glucose CSF/serum > 0.6.‫ بروتين عالي حاجة بسيطة‬، ‫ عالي حاجة بسيطة‬pressure :‫فيروس‬

‫ كله قليل‬glucose CSF/serum < 0.4 ،‫( بروتين قليل‬eg; Cryptococcus neofromans) ‫فطر‬

low CSF glucose ‫ بتعمل‬Listeria

Normal lumbar puncture+meningism → Think about cereberal malaria EXAM2012

Specific Risk Factors for meningitis

• Pneumococcus: (40%) – Otitis media, head injury, pneumonia, immunocompromised


• Meningiococci (30%) – Children and adolescents
• Staphylococcus: Penetrating skull injury, ear or neuro operations
• Fungal: HIV and organ transplant
• Listeria: Extremes of age
• H Influenzae: (3%) – Head trauma with CSF leak, otitis, sinusitis, anatomical defects such
as dermal sinus tracts
• Anaerobes: Consider brain abscess, elderly.

Klippel-Trenaunay-Weber $ : vascular malformation of the spinal cord associated with a


cutaneous naevus and can present with spinal segmental or tract lesions.
Femoral neuropathy → weakness predominantly of the quadriceps. EXAM 2007
10. MRI Brian:
Meningioma
with dural tail

inside the
bone
itself
‫‪calcified‬‬
‫الزقة في ‪mening-‬‬
‫العضمة لكنها مش‬
‫طالعة منه‬
11. CT shows Falx cerebri calcification:

The dura shows higher rates of calcification in


patients who have had shunts or have been
irradiated.

head & neck malignancy ‫ مريض كان عنده‬:‫السيناريو‬

Spastic ‫ دلوقتي جاي عنده‬..‫ قبل كده‬irradiation ‫أخد له‬


‫ في رجليه‬UMNL ‫ يعني‬paraplegaia

12.

Large left subdural haematoma.


→ The haematoma is isodense with the adjacent
brain, which is compressed with complete loss
of the sulci (the sulci are clearly visible on the
right side).
→ There are no areas of high attenuation (white)
blood to suggest an acute haemorrhage.
→ Chronic subdural would cause even lower
attenuation blood (more black).

13. Elderly and falls cay result in SDH, symptoms may be present subacutely.
14. It is quite unusual for systemic lymphoma to metastasise to the brain.
15.

Cereberllar Metastasis:

Scenario:

Old man , smoker , on anti-epileptics,


came with DANISH (= cerebellar
symptoms). Chest auscultataion:
Localized wheezes. + Hypercalcemia.

Idea: SCLC >>Mets to cerebellum.

16.
Chronic subdural haemorrhage (hematoma):
Old Lady, AF, multiple skin bruises.
CT scan image shows a lesion within the right
parietal area and midline shift.

17. Primary CNS lymphoma present with seizures and focal signs, but the lesions are often
confined to the corpus callosum.
18. Paraplegia:
→ UMNL in LL >>>>Spastic paraplegia.
→ LMNL in LL >>>>> Flaccid paraplegia.
Intention (= Kinetic) tremors = Cerebellar tremors (occurs @ the end of purposeful movements.)

Rest tremors = Parkinsonian/ Essential tremors (Both treated with drugs that ↑ dopamine).
19.
Romberg test is a test of the body's sense of positioning (proprioception), which requires
healthy functioning of the posterior columns of the spinal cord.

The Romberg test is used to investigate the cause of loss of motor coordination (ataxia).

→ +ve Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss
of proprioception.
→ If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is
cerebellar in nature >>> & then you should do cerebellar localization test.

20. Criteria for CT brain within the one hour of RTA include:

• GCS <13 when first assessed in ER.


• GCS <15 when assessed in ER two hours after the injury.
• Amnesia > 30 minutes of events before impact.
• Suspected open or depressed skull fracture
• Sign of fracture at skull base (haemotympanum, "panda" eyes, cerebrospinal fluid
leakage from ears or nose, Battle's sign)
• Post-traumatic seizure
• Focal neurological deficit
• >1 episode of vomiting.
• Patient on Warfarin or known coagulopathy.
21.
Autonomic Dysreflexia :

It affects approximately 85% of patients with a lesion above C6 (quadriplegic patients) and may be
triggered by cystitis, retention of urine, blocked catheter or constipation.

↑sympathetic activity →VC →HTN →stimulation of the carotid and aortic baroreceptors→↑vagal
tone → bradycardia.

Vasodilators such as CCBs may be used to treat the hypertension.

22. cortical blindness = X in occipital lobe→ partial or complete loss of vision ± visual
hallucination‫(يخبط في الحاجة‬they have visual anosognosia =‫)عنده مشكلة في النظر وهو مصر إنه زي الفل‬
23. Juvenile myoclonic epilepsy:
The commonest of the idiopathic generalised epilepsies.

Seizures types include

• Absences ‫ شرود‬/‫ذهول‬
• Myoclonic jerks and
• Tonic-clonic seizures which tend to occur within an hour of waking.

Precipitating factors include alcohol, menstruation and sleep deprivation.

The condition is genetically linked to the short arm of chromosome 6.

Prognosis is extremely favourable if the condition is treated correctly.

Treatment options include sodium valproate, lamotrigine and topiramate.

Lifelong drug treatment is usually necessary to avoid relapses in patients who achieve
seizure-free status on medication. ‫وليس لمدة سنتين فقط‬

24. Excessive exposure to the anaesthetic agent nitrous oxide (NO) → sensory neuropathy and
associated myelopathy (leg weakness, increased reflexes and plantar signs) ‫زي مثال لو طبيب‬
.‫أسنان‬
NO→ inhibits vitamin-B -dependent enzyme methionine synthase, which converts
homocysteine to methionine, but not the vitamin-B -dependent conversion of methylmalonyl
coenzyme A to succinyl coenzyme A → homocysteine is raised, but that of methylmalonyl
coenzyme A is not.
neuro signs of Vit.B12 ↓ ‫بيدي صورة شبه الـ‬
25. Headache when standing, that improves with lying flat ? Spontaneous intracranial
hypotension “Hypoooooooooooooooo”.
26. Botulism is caused by a toxin produced by the anaerobic bacterium Clostridium botulinum,
which blocks the release of acetylcholine from the motor nerve terminal.
➢ Early symptoms are blurred vision, dysphagia and dysarthria.
➢ Pupillary responses to light are impaired, tendon reflexes ↓ and typically there is
progressive symmetrical limb weakness.
➢ Most patients have evidence of autonomic dysfunction (such as dry mouth,
constipation or urinary retention). The edrophonium test is falsely positive in about
one-third of cases and does not distinguish botulism from other causes of
neuromuscular blockade.
27. Chemosis= conjunctival injection.
28. Orbital apex syndrome (involvement of cranial nerves II, III, IV and V1) = superior orbital
fissure syndrome (III, IV, V1,VI) +loss of vision (II=optic neuropathy). EXAM 2003
29. Temporal lobe epilepsy: ascending epigastric aura, olfactory and gustatory ‫تذوق‬
hallucinations, ictal fear, oroalimentary automatisms (lip smacking, chewing and swallowing)
and limb automatism (fiddling, picking, tapping) The commonest cause of temporal lobe
epilepsy is hippocampal sclerosis. MRI brain is diagnostic. Surgical treatment has a
complete success rate up to 70% of cases.
30. Listeria meningitis should always be considered in ppl with low immunity (elderly,
diabetics, alcoholics and on immunosuppressive treatment). Brainstem involvement is
common.In CSF ↑WBCs, Protein, ↓Glucose.
31. Jerking of the limbs may occur with cardiac syncope, due to cerebral hypoperfusion.
32. The term ‘lacune’ refers to a small deep infarct resulting from occlusion of a penetrating
branch. Common lacunar strokes include a pure motor hemiparesis, pure hemisensory loss,
ataxic hemiparesis and dysarthria clumsy-hand syndrome.
33. Mononeuritis multiplex: painful, asymmetrical, asynchronous sensory and motor
peripheral neuropathy involving isolated damage to at least 2 separate nerve area. As the
condition worsens, it becomes less multifocal and more symmetrical. Causes are; vasculitis
(CSS)Wagners/PAN, DM, sarcoidosis, paraneoplastic syndrome ,amyloidosis. Nerve biopsy
→ confirm the diagnosis. TTT : prednisolone and cyclophosphamide.
34. Damage to the:
➢ caudate nucleus →chorea
➢ red nucleus → tremor
➢ dentate nucleus →ataxia
➢ hippocampus →memory impairment.
➢ Substantia nigra → Parkinsonism.
➢ Subthalamic nucleus of basal ganglia → Hemiballismus. TTT : tetrabenazin
➢ Medial thalamus & Mamillary bodies of hypothalamus → wernick’s , korsakoff’s
➢ Amygdala →Kluver-Bucy $.
35. Inclusion body myositis (IBM)
• Commonest cause of inflammatory myopathy in patients over 50 years of age.
• Presents with slowly progressive weakness and wasting of the finger flexors and
quadriceps.
• The slow, relentless ‫قاسي‬/‫ متصلب‬progression of muscle weakness in IBM →walking
difficulty, frequent falls and eventual need for mobility aids.
• Dysphagia is a common manifestation of the disease.
Investigations:
➢ CK is either normal or up to fivefold the upper range of normal.
➢ EMG : inflammatory myopathic changes: ↑ insertional and spontaneous activity
+ ↓ amplitude, polyphasic units with short duration.

There is no available treatment.

36. Serum and CSF may contain anti-Purkinje-cell antibodies in paraneoplastic cerebellar $.
37. Lewy body disease is sensitive to neuroleptics. TTT: rivastigmine. Q

38. Carotid endarterectomy is considered if there is significant symptomatic carotid artery


stenosis, that is between 70% - 99% although some centres will accept >50%.
39. Nerve supply in LL:
 The obturator nerve → adductors of the hip.
 The sciatic nerve → hip extensors and all muscle compartments below the knee.
 Femoral nerve →quadriceps.
 L1 root lesion → weakness of hip flexion and knee extension.
40. Progressive muscular atrophy is a rare form of MND → LMNL (fasciculations and
progressive wasting) of upper and lower limbs. best prognosis (PLAB).
41. Treatment of stroke secondary to polycythaemia includes venesection.
Pick’s disease= frontotemporal lobe degeneration ‫ خد بالك إن الـ‬.42
‫ سنة‬65 ‫يجي قبل سن الـ‬
:‫ يعني مثال‬...‫ أكتر من التاني‬lobe affected ‫ بيعتمد على أنهي‬Presentation ‫الـ‬
➢ Predominant frontal atrophy →early personality change.
➢ Predominant temporal lobe atrophy →aphasia and semantic memory impairment.
Semantic= ‫دالالت األلفاظ‬
‫ تبقى مشاكله اكترها في الكالم‬temporal atrophy ‫يعني باختصار مريض الـ‬
43. Kearns-Sayre syndrome (mitochondrial disorder) produces the classic triad of 6 ‫تبدأ في سن‬
‫سنوات‬
 Progressive external ophthalmoplegia.‫عين‬
 Pigmentary degeneration of the retina.‫عين‬
 Heart block.‫قلب‬
(also associated with DM , hypothyroidism,lactic acidosis).
44. Transverse myelitis:

45. Polymyalgia rheumatica → stiffness (not weakness),↑ ESR , Normal CK , muscle biopsy.
46. Eaton-Lambert$ may cause autonomic dysfunction,& the ptn may come with impotence.
47. Thenar wasting (LOAF)
➢ Lateral two lumbricals.
➢ Opponens pollicis.
➢ Abductor pollicis brevis.
➢ Flexor pollicis brevis.

48. Bilateral hemiballismus is rare&indicates metabolic disorder,usually HHS (hyperosmolar)


49. Some $:

Anton's syndrome = infaction in occipital lobe→cortical blindness→ visual anosognosia.

.‫والمريض يخبط في الجدران ومع ذلك يقولك انا كويس وشايف كل حاجة حلو‬

Claude's $ →ipsilateral 3rd nerve palsy + contralateral Cerebellar affection (DANISH).

Weber's $ → ipsilateral 3rd nerve palsy + contralateral hemiplegia.

Foville's $ → ipsilateral Horizontal gaze (6) and facial weakness + contralateral hemiplegia

Parinaud's $ (dorsal midbrain syndrome)→ paralysis of upward gaze and accommodation.

50. Hunt and Hess scale grades SAH

51. Cancer may → inflammatory myositis (= Polymyositis).


52. GBS →subjective sensory symptoms in the absence of objective signs.
53. GBS : may cause back pain
54. Palmomental reflex: primitive reflex consisting of a twitch of the chin muscle elicited by
quick scratch of Thenar eminence It is present in infancy and disappears as the brain matures
during childhood but may reappear due to processes that disrupt the normal cortical
inhibitory pathways. Therefore, it is an example of a frontal release sign.
55. Anatomy of brain ventricles:

Interventricular foramen= Foramen of Monro.

NB: 4th ventricle is located infront of cerebellum

So, in CT:

Dilatation of lateral ventricles. → Tumor in foramen of Monro

Dilatation of both lateral and 3rd ventricles →The Sylvian aqueduct(= cerebral
aqueduct)obstruction

Dilatation of all the ventricles.→ normal pressure hydrocephalus (gait ataxia, mental dysfunction
and urinary incontinence)

Dandy-Walker syndrome is a congenital failure of opening of the foramina of Luschka and


Magendie, resulting in dilatation of the entire ventricular system. ‫تيجي في األطفال‬

56. The ultimate decision to consent a dead relative to organ “harvest” following the brain-stem
death of a patient, rests with the family.
57. Dermatomes of face:

58. Empty Delta sign in Brain CT:

Angle of mandible is supplied by C2

The 'absent =empty delta sign' on CT scan implies a filling


defect in one of the venous sinuses, although often in this
condition the CT scan is normal.

It occurs in cereberal venous sinus thrombosis

(empty delta) ‫شبه دلتا النيل وكأنها فارغة‬

59. Miller-Fisher variant of Guillain-Barré =Triad: of ataxia, areflexia, ophthalmoplegia.


60. Botulism can be food-borne or wound infection or IVdrug injection. Botulism → false
positive tensilon test.
61. Carotid artery territory ischaemia does not cause loss of consciousness.
62. Vertebrobasilar insufficiency =(Basilar migraine)=Migraine with brain-stem aura ‫سؤال هام‬
diplopia , ‫مريض صغير في السن جالها‬
then transient loss of
vision+headache

Patient comes with migrainous


prodrome
(Diplopia/parathesia/unseadiness/
↓ LOC)f ollowed by severe
headache associated with mild
neck stiffness and CSF
abnormalities

‫ بروتين‬،‫ عالي حاجة بسيطة‬Pressure


..‫و مش كدا وبس‬.. ‫عالي حاجة بسيطة‬

CSF ‫دا انت ممكن كمان تالقي‬


pleocytosis

63. Meniere's disease →recurrent attacks of severe vertigo, vomiting, tinnitus and hearing loss.
64. Cerebellar pontine angle tumour →ipsilateral cerebellar dysfunction & Cr n.5,6,7,8 palsy.
65. TTT of MS:

1- B INF: indications: 2- Mito/xan/trone :

 > 18-years-old In high frequency relapse rates unresponsive


 > 2 separate episodes within the last 2 years to beta-interferon.
 Can walk more than 100 metres.
Contraindications:

→ History of severe clinical depression


→ Uncontrolled epilepsy
→ Liver dysfunction, and
→ Myelosupression.
66. separate clinical episodes disseminated through sites and time think about Multiple sclerosis
67. 10% of patients of idiopathic intracranial hypertension are free of headache.
68. In suspected idiopathic intracranial hypertension , you should do Brain MR venography (to
exclude cerebral sinus thrombosis) & CSF analysis.
69. . Aseptic meningitis = -ve CSF culture for organisms:
Causes:

• Viruses - Commonly Enteroviruses, .G. Polio, Coxsackievirus, Echovirus


• Partially Treated Bacterial Meningitis
• Fungal Meningitis
• Parasites
• IV Ig.
• Behcet.
70. Tearing and conjunctival injection are features of cluster headache (migrainous
neuralgia)(Not Migraine) for which acute relief may be achieved by inhaling 100% oxygen
for 10-15 minutes. Or SC sumatriptan EXAM 2005
71. Angiokeratoma: occurs in Fabry disease. XLD.

• Small vessel stroke (eg. Lacunar infarction)


• Painful peripheral neuropathy
• Renal disease
• Skin stigmata ‫ندبات مميزة‬
• Myocardial infarction.
72.
Myelopathy =any neurologic deficit related to the spinal cord.

 If due to trauma, it is known as (acute) spinal cord injury.


 If inflammatory, it is known as myelitis.

The most common form of myelopathy is cervical spondylotic myelopathy (=cervical myopathy), is
caused by arthritic changes (spondylosis) (specially in RA.) of the cervical spine → narrowing of the
spinal canal (spinal stenosis) ultimately causing compression of the spinal cord.

73. Circumflex (=Axillary nerve) neuropathy : → weakness and fasciculations of the deltoid.
74. Inclusion body myositis, an inflammatory myopathy, would present with bilateral often
asymmetrical weakness, which has a tendency to affect distal musculature. The tendon
reflexes would be normal and the creatine kinase would be normal or mildly elevated.
75. Huntington's chorea is a neurodegenerative disorder →incoordination and cognitive
impairment.
76. Mercury poisoning →PN, muscle weakness, problems with coordination and speech.
77. Lead poisoning →insomnia, cognitive impairment, delirium, tremor, hallucinations and
convulsions.
78. Wilson's disease→ extrapyramidal features (tremor, parkinsonism, dystonia), dysarthria,
psychiatric features, liver cirrhosis and Kayser-Fleischer ring.
79. Hereditary spastic paraparesis usually begins with in the lower limbs.
80. periventricular white matter lesions:

Causes are:

 Normal senescent (=aging) changes. ‫علشان كدا لو جابهالك في سؤال والمريض كان سنه كبير بيبقى غالبا عايز‬
‫يوقعك بها‬
 Small strokes.
 MS (patchy, periventricular). PML (extensive): hemiplegia+gait X+dysartheria + cognetiveX,
definitive diagnosis is? Brain biopsy to see asymmetric foci of demyelination &intranuclear
inclusions containing the JC virus
 Vitamin B6 (pyridoxine) deficiency.
81. Cerebellopontine angle tumor: (e.g. acoustic neuroma) →

 5 palsy > loss of corneal reflex V1


 7 palsy > asymmetrical face
 8 vestibulo-cochlear →sensori-neuronal deafness,
tennitus.

Glomus jugulare tumours → pulsatile tinnitus


&conductive deafness. Cranial nerves which run
through the jugular foramen are affected (9,10,11).

82. Patient with ICH & ↑ BP , how to deal ?


Patients with 1ry ICH who present within 6 hours of onset with SBP > 150 , their BP should be
lowered urgently to a SBP 140 for at least 7 days, unless:

• GCS < 6.
• the haematoma is very large and death is expected
• a structural cause for the haematoma is identified
• Immediate surgery to evacuate the haematoma is planned.

ischemic stroke You should lower BP only if SBP >220 or DBP >120. ‫لكن األمر مختلف في الـ‬

In Hgic stroke , when to refer for hematoma evacuation? Low GCS or cerebellar Hge. otherwise
observe. Give measures that↓ ICP(mannitol, sedation, assisted hyperventilation)only if there is brain
edema (i.e Hge per se is not an indication for these measures)

83. Acute disseminated encephalomyelitis:


Vaccination or Viral infection → flu-like symptoms , then neuro signs (auto-immune response).

MRI: multiple hyperintense lesions affecting paraventricular deep white matter within both cerebral
hemispheres. All Lesions enhance with gadolinium contrast (but in MS , some lesions only
enhances).

TTT: IV steroids →failed, IV Ig or plasmaphoresis.


84. Blood supply of brain

The brain has a dual blood supply:

 Anterior circulation arises from the ICA and supplies the front of the brain.
 Posterior circulation arises from the vertebral arteries (branch from subclavian), and
supplies the back of the brain and brainstem. The circulation from the front and the
back join together (anastomise) at the Circle of Willis.

Vertebral artery supply posterior part of brain +brain stem+upper spinal cord.
85. Head and neck pain in a patient with stroke suggests dissection.
86. Carotid artery:
 External: supplies the neck, face and skull.
 Internal: >>> Amurosis fugax
87. Symptoms of posterior circulation ischemia (cerebellar, brainstem signs) =vertebral artery
affection.
88. The recurrent episodes of vomiting and vertigo in a man with DM and a previous MI
represent posterior territory TIAs (=vertebral a.) until proven otherwise. EXAM2012
BPPV ‫ فالناس افتكرت انها‬clinic ‫ وحصلت لما حرك راسه في الـ‬vomiting , vertigo ‫جاب المريض عنده‬
89. sentinel bleed headache is felt posteriorly

90. Meniere’s and acoustic neuroma are associated with tinnitus. BPPV : no tinnitus.
91. Meniere’s = recurrent tinnitus and hearing loss, which occurs in episodes +sense of pressure
inside ear. EXAM 2012
92. Tizanidine = α-2 agonist (centrally acting muscle relaxant), used in TTT of muscle spasm
in MS patients who did not respond well to Baclofen. EXAM 2012 ‫سؤال مكرر‬
93. Tetrabenazine , used in symptomatic treatment of hyperkinetic movement disorders
‫اضطرابات فرط الحركة‬, such as: Huntington's chorea , Hemiballismus,Tourette syndrome
,Tardive dyskinesia,.
94. Young lady, doing Scuba diving , started to complain of migraine attacks . despite
following the decompression tables , think about ASD → paradoxical nitrogen emboli , do
ECHO. EXAM 2012
95. Neurons:
 Sensory (ascending).
 Motor (descending): the cell body is in any place in CNS (motor area /brainstem
/spinal cord), axon may be in spinal cord or even outside it to muscles, glands,…
➢ UMN.
➢ LMN
96. MND =progressive neurodegenerative disease involving the corticospinal =pyramidal /
corticobulbar= extra pyramidal tracts / AHCs.=death of the nerve that controls voluntary
muscles:

MND = PLAB:

 PMA: affects only LMN→ LMNL ‫( سادة‬atrophy, fasciculations, muscle wasting).


 Lateral sclerosis: affects Pyramidal tract only→ UMNL.
 Amyotrophic lateral sclerosis: combined UMNL (Pyramidal) & LMN(AHCs) →fasciculations
. ‫ودي مفتاح الحالة‬
 Bulbar palsy: LMNL of Cr.N 9,10,11,12 (all are in MO) bulbar= MO
→ 9= glossopharyngeal >> loss of sensation in glosso(back of tongue) ,pharyngeal
(oropharynx) , loss of gag reflex.
→ 10=Vagus → loss of parasympathetic to heart >> HTN , tachycardia +X of recurrent
laryngeal nerve → hoarseness of voice, loss of gag reflex
→ 11 accessory /long thoracic n. → shoulder weakness, winging of scapula. EXAM2012
→ 12 Hypoglossal → tongue deviation to side of lesion +tongue wasting, fasciculations.

EMG/NCS →generalised fasciculations in clinically normal and abnormal muscles with preserved
motor conduction and sensory studies.

Fasciulations = think about MND (LMN) or syringomyelia / MMN.


97. Multi-focal motor neuropathy (MMN) Purely motor disease

• Important treatable (IV Ig, cyclophosphamide) differential diagnosis of MND.


• It is an autoimmune neuropathy presenting with progressive weakness +fasciculations
affecting an isolated limb.
• Cranial nerve involvement is rare.
98. Cervical myelopathy at the C3/C4 level →UMNL in the legs and arms.
99. Status epilepiticus>>give lorazepam IV , then repat , if no response>> give fisphenytoin
(IV/IM) faster ,safer ,better than phenytoin (IV only). EXAM 2004
100. Crawling sensation in legs @ night + anemia = Restless leg $ >>TTT correct anemia.
EXAM2003 , 2014
101. Restless leg $ exacerbated by : diuretics, ↓ Mg ,TCA, phenytoin and CCBs
102. Mefloquine (anti-malarial) → ↑ risk of seizures , psychiatric disorders. EXAM2012
103. Combining sodium valproate and lamotrigine →Steven-Johnson's syndrome.stop
Lamotrigine immediately EXAM 2012
104. Spinal manipulation is strongly associated with vertebral artery dissection EXAM2012
105. Caverno-carotid fistula may occur 2ry to trauma , the patient initially okay , then comes
after 1 month with pulsatile proptosis , conjunctival chemosis. EXAM2012
106. Oligoclonal bands (IgG):
 Normally absent from serum, CSF (=-ve).
 If +ve in both serum & CSF = systematic disease (e.g RA).
 IF found in CSF only (but not serum) = MS/sarcoidosis.
107. Kearns-Sayre syndrome produces the classic triad of:
→ Progressive external ophthalmoplegia ‫عين‬

→ Pigmentary degeneration of the retina ‫عين‬

→ Heart block.‫قلب‬

108. Normal pressure hydrocephalus→ dementia, urinary incontinence, gait abnormalityTRIAD.


109. Peripheral nerves lesions:

➢ C5 and C6 roots → Erb's palsy, usually the result of traumatic avulsion (commonly
occurring during delivery at birth) → loss of shoulder abduction and elbow flexion with loss
of biceps and brachioradialis reflexes.
➢ C7,8 → absent triceps reflex.
➢ C8 and T1→ Klumpke's palsy, often the result of a fall that has been stopped by grasping a
fixed object with one hand→weakness of small muscles of the hand and of the long finger
flexors and extensors, and a sensory disturbance affecting the medial half of the ring finger
and little finger.
➢ C8 and T1 also→ medial cord lesion.

110. Patient with soil contaminated wound is its:


→ Clostridium tetani=tetanus: Locked jaw, hyperreflexia. ‫مريض مهيبرفي كله مخشب يعني‬

→ C. botulinum = botulism: Diplopia /Ptosis/Facial weakness/Dysarthria/ Dysphagia.,

hyporeflexia. Then respiratory difficulty , limb weakness after that. ‫مريض واقع في كله‬
111. Pseudo seizures =non-epileptic attack:
Commonly misdiagnosed as true seizures and treated inappropriately with anti-epileptic drugs.

Violent shaking, resistance to passive eye opening and normal vital signs are useful indicators of
pseudoseizures.

Urinary incontinence can also occur in pseudoseizures but tongue biting is rare.

Simple observation is the appropriate management in this case.

112. Parkinson Plus =PSP= PLUS


 P= Parkinsonism, poor response to L-dopa.
 L= Learning difficulties.
 U= up to down (=falls) , Vertical gaze X
 S= slurred speech ‫وبيجيبها كتير علشان يلبخك مع اللي بعدها‬
113. MSA= shy-Dragger $: PAC
→ Parkinsonism.

→ Autonomic X.

→ C= cerebellar signs ‫ وممكن يجيبلك فيها‬slurred speech


114. MG may came with –v Ach. Receptor Ab→ Do Tensilon test.
115. Epilepsy:
 Simple: No LOC
 Complex: there is LOC
116. Sarcoidosis : bilateral LMN facial nerve pasly, oligoclonal bands in CSF (not serum),
uveitis,erythrma nodosum, lymphocytosis in CSF
oligoclonal , nor LMN facial n palsy ‫ ال بيعمل‬Behcet ‫ لكن الـ‬Behcet. ‫الشكل اللي فوق دا ممكن تفتكر انه‬
117. Epilepsy: with 1st episode of seizue DVLA, he can resume driving:
 After 6 months of being seizure free for private car.
 After 5 years of seizure being free for HGV/PSV ‫عربيات النقل أو الباصات الكبيرة‬
118. CT brain:
On CT brain scan:

Infarctions in a non-arterial distribution in the white matter often associated with Hge, should suggest the
possible diagnosis of venous thrombosis.

On contrast-enhanced CT scan, the reverse delta sign (that is, empty triangle sign) can be observed in the
superior sagittal sinus from enhancement of the dural leaves surrounding the comparatively less dense
thrombosed sinus. Look @ item 62

119. Migraine with aura can cause stroke but commonly with posterior circulation S/S.
120. Vertebral artery dissection → head(sever pain behind 1 eye+ brainstem signs+ Horner) &
neck pain + posterior circulation S/S.
121. SAH classically presents with a thunderclap headache and neck stiffness. ‫صداع رهييب‬
122. Internuclear ophthalmoplegia (INO)
‫ يعني ما بين حاجتين‬Inter ‫كلمة‬.. internuclear ‫يعني ايه‬

Internuclear= between 2 nuclei (3rd cr n nucleus & 6th Cr.n nucleus)

The tract in-between the 2 nuclei are called medial longitudinal fasciculus (MLF).

3rd crn → adduction of eye=medial movement of the eye ball

6th crn → abduction of eye= lateral movement of the eye ball

:‫ فلما تيجي تبص يمين هيحصل اآلتي‬3rd&6th ‫ وظيفتها انها بتنسق الحركة مابين الـ‬MLF ‫الـ‬

left 3rd cr ‫ وفي نفس الوقت الـ‬، )‫ فيشد العين اليمين لبرا (يعني الى الجهة اليمنى‬right lateral rectus ms ‫ هيشغل الـ‬right 6th cr n. ‫الـ‬
.‫ فيحرك العين الشمال إلى الجهة اليمنى‬left medial rectus muscle ‫ هيشغل الـ‬n

‫ معناها بصة أو تحديق‬gaze ‫كلمة‬... conjugat gaze ‫اللي فوق دا اسمه‬

conjugate gaze palsy ‫ هيحدث‬MLF ‫لما تحصل مشكلة في الـ‬

...‫بمعنى إنه لما يجي يبص ناحية اليمين‬

:‫يحصل حاجتين‬

abducing eye ‫ والعين السليمة دي اسمها‬.‫ في العين السليمة ألنها اتلخبطت من اللي حصل‬Nystagmus-1

‫ في العين المريضة‬loss of medial rectus muscle movement-2

 Young patient with INO = MS.


 Old patient with INO = stroke

Gaze palsy:
Vertical: (due to X in midbrain) = 3rd Cr.N

➢ X in upward gaze = Parinaud's $


➢ X in downward gaze = PSP.

Horizontal: (due to X in pons) =6th Cr.N


MG → Pseudo INO.
123. Convergence
‫ بيظبطوا‬2 medial recti ‫ الـ‬...‫ أو بتبص على شيء باستمرار‬-‫ معناها إن طول ما انت بتقرأ –مثال‬convergence ‫كلمة‬
‫ على انه صورة واحدة‬fovea ‫ اللي انت شايفه يوصل للـ‬object ‫ علشان الـ‬visual field ‫العين إنها تركز في منتصف الـ‬
...‫فقط‬

supplied by 3rd cr. N ‫ اللي‬medial rectus ms ‫المسئول عن الموضوع دا هو الـ‬

impairment of convergence & diplopia happens ‫ هيحصل فيه‬3rd cr. N ‫إذا لو اضرب الـ‬

3rd Cr n X → horizontal / vertical diplopia

4th Cr n X → Torsional diplopia (Trochlear →Torsional)

6th Cr n X → horizontal diplopia only, no vertical

Remember: “SO4 - LR6 (and the rest are 3)”


124. Nystagmus: any lesion in cerebrum /cerebellum/brainstem/ /inner ear + Wernick’s
encephalopathy may cause nystagmus
 Vertical:
(In vertical);
→ uPbeat nystagmus= Pontine lesion(also common with Phenytoin)
→ downbeat nystagmus= foramen magnum lesions .lesion @ cervico-medullary
junction(e.g; chiari malformation) @ foramen magnum

 Horizontal: patients with a unilateral disease of the cerebral hemispheres, especially


with large, posterior lesions.

125. Arnold-Chiari Malformation is a pathological


condition in which some tissues of cerebellar
tonsils extend into the spinal canal through
foramen magnum (the foramen in the base of
skull).
It may be
❖ congenital in children or
❖ acquired : presents in old age

MRI of Arnold-Chiari malformation, demonstrating


tonsillar herniation.

126. Lower brachial plexus lesion typically will involve muscles supplied by T1, present with ill-
defined pain in the axilla and the sensory disturbance will involve the inner aspect of the
forearm. There may also be diminished brachial and radial pulses.
127. Scenario:
Old Patient with chronic bronchitis suffers few seconds of severe headache , followed by
syncope for seconds. What is this?
Mostly he is having chiari malformation , when he coughs → Sudden pressure headache
→Transient obstructive hydrocephalus → LOC
128. Ulnar neuropathy is a common complication with ill patients in hospital.
129. Mollaret’s meningitis: Rare condition.
 Recurrent meningitis.
 It is a benign condition, caused by HSV, EBV. EXAM2013
 CBC: Atypical monocytosis.

130. Drugs →↑ ICP:


✓ 3 C : Cimetidine, Corticosteroids, Ciclosporin
✓ 2T : Tamoxifen, Tetracycline. EXAM2013
✓ 2N : Nalidixic acid, Nitrofurantoin (Both are Abx , used in TTT of UTI.)
✓ 2L : Levothyroxine, Lithium
✓ DI : Danazol, Isotretinoin.
131. In GBS, Plasma exchange is considered if the patient had significant respiratory
compromise, or was not responding to IV immunoglobulin.
132. Cervical syrinx →pyramidal (UMNL) in the LL, and dissociated sensory loss in a cape-like
distribution in the UL associated with LMN signs in the UL.
133. Brain Hge :
➢ Artery: Tearing of the MMA → EDH ‫= اللي برا خالص‬epidural
➢ Vein: Bridging veins rupture → SDH
➢ Artery: Rupture of the ACA or PCA→ SAH.
➢ Vein: Superior sagittal sinus thrombosis → intracerebral haemorrhage. ً ‫في المخ شخصيا‬

134. Addition of clopidogrel to aspirin in stroke patients is of no benefit and increases GIT side
effects.
‫ ومحتاج‬AF ‫ يعني لو مريض عنده‬warfarin ‫ فيما يخص الـ‬ischemic stroke ‫ ال يعامل مثل الـ‬TIA ‫ الـ‬.135
ASA 300 mg ‫ وتكمل على‬Warfarin‫ هتوقف ال‬stroke ‫إنما لو هو‬... TIA ‫ هتكمل عليه عادي لو هو‬warfarin
for 2 weeks.
136. MG (ocular, bulbar and limb weakness) may be:
 Sero +ve = +ve Anti-acetylcholine receptor antibodies
 Sero –ve : -ve Anti-acetylcholine receptor antibodies. 40% of sero –ve MG have +ve
Anti-muscle specific tyrosine kinase (MuSK) antibodies

TTT in MG:

1- No respiratory involvement:

→ Pyridostigmine 60 mg QDS(4 times /day). If not responding, low dose prednisolone

(10-20 mg) can be cautiously added. High dose prednisolone can lead to
paradoxical worsening of myasthenia gravis.

2- Respiratory involvement/ severe weakness:

→ IV Ig or plasmaphoresis.

3, 4-DAP (diaminopyridine) is a treatment used in Eaton-Lambert $ where ocular and bulbar


weakness is rare and reflexes are generally depressed.

137. Pituitary apoplexy (Hge/infarction): symptoms of ↑ ICP (95% sudden onset


headache)+oculoparesis (Cr. III mainly- 6 can be also affected)
pituitary ‫ الزقة في الـ‬cavernous sinus ‫ألن الـ‬. cavernous sinus thrombosis ‫لحد هنا ممكن تعتقد انها‬
‫ فيها‬apoplexy ‫ لكن الـ‬gland
 ‫دم والدم هيعمل‬
Irritation of meninges → miningism (neck rigidity, intolerance to bright light = photophobia,
↓ LOC).
 Compression on optic chiasm →bitrmporal superior visual field defect, ↓ visual acuity.
 Also you may find endocrinal disturbance (↓Na, ↑ K = Addison….)
MRI pituitary , better than CT(CT may not show Hge/infarction in 50% of ‫والتشخيص‬
patients).
138. Multifocal motor neuropathy (MMN) :
 Purely motor case. NO sensory.
 LMNL in isolated limb , mainly UL (e.g. Right UL only or left UL
only).=asymmetrical
 Affects spinal nerves, no cranial nerve affection (No bulbar symptoms (unlike MND).
 Spinal affection occurs in the form of distribution of spinal segments (rather than
being dermatomal –single nerve- )
 Anti-GM1 ganglioside antibody +ve.
 NCS:
→ Motor nerve: Patchy block.
→ Sensory: intact (the case is purely motor).
‫ في دراع واحد‬LMNL ‫ مريض عنده‬:‫يبقى باختصار‬

139. Anti-parkinsonians:

→ Off time : refers to periods of the day when the medication is not working well, causing

worsening of Parkinsonian symptoms.


→ Do not offer anticholinergics to people with Parkinson's disease who have developed

dyskinesia and/or motor fluctuations.


→ Prioritize non ergot derivatives over ergot derivatives

→ Dopamine agonists:

 Ergot derivatives: Cabergoline (prescribed only in patients who have developed dyskinesia
or motor fluctuations despite optimal levodopa therapy / or/ those not adequately controlled
with a non-ergot-derivatives).
 Non ergot derivatives: Bromocriptine, Apomorphine
140. Bitemporal hemianopia is due to ???? compression on optic chiasm.
141. Ocular apraxia and optic ataxia are both features of larger bilateral parietal lobe lesions.
This is known as "Balint's syndrome".
142. Contralateral neglect is a feature of damage to the right parietal lobe.
143. Occlusion of basilar artery, posterior cerebral artery and vertebral arteries produces signs
and symptoms of posterior and brainstem circulation syndromes.
144. URTI→ followed by affection of upper brachial plexus (C5-6).

Fortnight = 2 W

TTT: conservative

145. CJD:
 NvCJD →young age, psychiatric, sensory disturbances.MRI:changes in post. thalamus
 Sporadic CJD →Memory problems, Myoclonus, cerebellar dysfunction.MRI: changes
in caudate & Putamen
146. Epley and Semont are used in TTT of BPPV.
147. Throat infection → abnormal movements of limbs (think about Sydenham’s chorea).
Speech is affected in 20%. Those who have had several attacks in childhood may develop
chorea in adulthood when exposed to drugs as OCP, phenytoin or digoxin, or pregnancy.

→ Anti DNAse (+ve in patients with recent Streptococcus pyogenes infection).

→ Anti-basal ganglia antibodies: +ve in post-streptococcal neuropsychiatric disorders.

TTT: for chorea with tetrabenazine or sulpiride and for acute infection: course of penicillin for.

148. P Communicating A aneurysm= 3rd Crn N X +opthalmoplegia.


149. Painful 3rd crn N affection = PCA >>do Intra-arterial digital subtraction angiography
150. D.D of painful diplopia (Diplopia+headache):
diplopia ‫ ب ُكم (بكوا من ألم الـ‬PCOM

→ P communicating A aneurysm.
→ Pitutry adenoma.
→ Cavernous s. thrombosis.
→ Ophthalmoplegic migraine (episodic third nerve palsy and headache)
→ Monoueuritis.
151. Subarachnoid blood → (headache, nuchal rigidity and photophobia).
PCA/ ACA‫سواءا كان‬.. Subarachnoid space ‫ في الـ‬artery ‫أي نزف بقى من أي‬
152. decerebrate rigidity

Exaggerated extensor posture of all extremities


due to brainstem lesion.
153. Patients < 60y old who came with ISCHEMIC stroke can be referred for decompressive
hemicraniectomy if they have:
 MCA infarct of > 50% of the MCA territory and have
a. An NIHSS score (software-calculation) > 15 and
b. ↓LOC.
154. Internal capsule stroke due to lesion in??? MCA
155. Supratentorial mass with brain-stem compression → unilateral focal neurology & pupillary
abnormalities namely 3rd nerve compression.
156. Reminder:
Questions about thromolytic therapy are popular, so knowledge of the indications and contraindications to
thrombolytic theory are important.

https://www.patient.info/doctor/thrombolytic-treatment-of-acute-ischaemic-stroke

157. Patient with depression + Migraine came with hyperreflexia, HTN , Hyperpyrexia,
tachycardia , what had happened?
He was receiving Fluxetin (SSerotonin RI) is antidepressant →↑serotonin level+
Sumatriptan (For migraine): ↑ serotonin level → serotonin $ .TTT is? Cyproheptadine or
methesergide.
158. CIDP → Progressive affection of motor , sensory modalities in all 4 limbs+areflexia.
TTT: Steroids, plasmapheresis and IV Ig. Physiotherapy is effective adjunct.
159. Cervical spondylosis → UMNL + sensory level.
160. Patients with syncope can commonly have jerking of the limbs when they are unconscious
and this does not mean they have had a seizure.
161. Vasovagal syncope comes with warning symptoms e.g. feeling hot and blurring of vision.
Tilt table testing is useful to support the diagnosis of vasovagal syncope.
162. Brachial plexus

Ant. Interosseous n injury

MURASL-M -‫مراسل‬M

Median 51(Medial & lat. cords) Ant. Interosseous (from 51


median)
Ulnar 81
Radial 51 (Post. cord),also supplies Post. Interosseous (from 51
triceps Radial)
Axillary 56
SItS 56 (Rotator cuff muscles)
Long 567 (Winged scapula) Musclocutan. (sup.trunk) 567 (Bi, brachialis,
thoracic coracobrachialis)+sensory
to forearm
T1 ‫ إلى‬C5 ‫ نقصد من‬51 ‫لما بنقول مثال‬
High cervical myelopathy C-2 →

UMNL in UL (wasting, clumsiness in small ms of hand) + respiratory involvement


163. Thoracic inlet syndrome involving the lower brachial plexus would cause a
C8/T1 sensory and motor dysfunction and possibly absent brachial or radial pulsation.
164. Sciatic N. = 43 (from L4 to S3).
165. Common peroneal is the smaller terminal branch of the sciatic nerve 42.
166. Common peroneal palsy → X flexion, eversion & sensory disturbance affecting the outer
lower leg and dorsum of the foot. Reflexes are intact.
167. L5 root lesion→ X flexion, inversion & sensory disturbance affecting the outer lower leg
and dorsum of the foot. Reflexes are intact. !!!‫زي اللي فوقه تماما ولكن مين اللي متغير؟‬
168. Jacksonian fits Partial seizures =‫البؤري‬/‫الصرع الجزئي‬
Focus in one cerebral hemispheres → Unilateral fits + No LOC (coz it is partial).

After the fits, there is temporary paralysis for few hours (Todd’s paralysis).

169. Myoclonic seizures → isolated muscle jerking.


170. Leber's optic atrophy usually affects young men. It causes sequential optic neuropathies in
days to weeks. It is typically painless and severe. Visual acuity fails to improve.
.‫ مثال العين اليمين االول ثم بعدها بكم اسبوع العين الشمال‬...‫يعني المريض يفقد عينيه بالتتابع‬
171. Essential tremor : action tremor affect the person's ability to perform activities of daily living.
172. Holme’s tremors (= rubral tremor) :
2ry to a lesion in the red nucleus (=involved in motor coordination. in midbrain),occurs in MS or after stroke in this area.
It classically produces an irregular low frequency tremor which is a combination of a rest, postural & action tremors

Signs of ataxia and weakness can also occur

ataxia. ‫ علشان بيكون معاها هي كمان أحيانا‬cerebellar tremors ‫فمتتخدعش وتفكر انها‬

It is resistant to TTT.
173. Multiple sclerosis is a CNS disorder (not peripheral) and therefore presents UMNL signs
such as brisk reflexes and not LMN signs.
174. Osteomyelitis of the spine → UMNL.
175. Myasthenia gravis does not cause reflex abnormalities (it is a neuromuscular junction
disorder).
176. The CT scan shows evidence of calcified phakomas
in the periventricular white matter.

Phakoma ‫ورم شبه حباية العدس‬

DD of phakoma :

 VHL $.
 NF
 Tuberous sclerosis (TS)
 Sturge-Weber syndrome

Epilepsy and learning difficulty:

 TS.
 Sturge-Weber $.‫ستيرج ويبر‬
Sturge-Weber $.
Port-wine affection in

➢ Skin. ‫كأن حد سكب على وجهه خمرة‬


➢ Ophthalmic division of Trigeminal nerve.
➢ Brain: intracranial leptomeningeal capillary-venous angioma → typical tram-line calcification.
177. Hyperparathyroidism → calcification in basal ganglia.
178. The most common cause of limbic encephalitis is? SCLC
 Acute to subacute onset of short term memory deficits, with relative preservation of
other cognitive functions, is characteristic of limbic encephalitis
 MRI shows hyperintense abnormalities in the medial aspect of the temporal lobes.

‫ هتالقي‬itis ‫ وبيكون معاه‬temporal lobe ‫ اللي هو كمان بيجي في الـ‬HS encephalitis ‫لكن في الـ‬

edema, mass effect, contrast enhancement, and, sometimes, areas of haemorrhage

179. Paraneoplastic neurological syndromes are uncommon but important because they
frequently present before the malignancy.
180. Judu ,Yoga → vertebral artery dissection.
181. What is the target of cerebral perfusion pressure in patients presented with intracerebral
bleed? Ans: 60-80 mmHg.
182. Permanent vegetative state ‫= حالة غيبوبة دائمة‬irreversible damage to the cerebral
hemispheres but the brain stem remains intact EXAM2004
 The patient breathes spontaneously without mechanical support.
 HD stable and has cycles of eye closure and opening that resemble a normal sleeping pattern.
 Patient is inattentive and unaware of his/her surroundings.
 Patients may have spontaneous movements (moaning, grunting, teeth grinding, roving eye
movements) and may also smile, laugh and cry without any apparent reason.
 There is eye movement; the eyes do not track a moving object. Patients may respond to painful
stimuli and may have myoclonus in response to startling stimuli.
 Primitive reflexes may be present. Posture may become decorticate and plantar responses are
commonly extensor.
183. Diagnostically if dementia occurs within 12 months of the onset of parkinsonian features
the patient has Lewy body disease. ☺ cognitive ‫ ملوية‬, -‫ و رؤية ملوية‬lewy = ‫ملوية‬
184. Scenario:
Patient with SAH→ GCS 13/15→ after 2 days→ more ↓ of consciousness or new disability.
Why this happened?
Rebleeding? No.
Vasospasm? Yes.
This is a delayed cerebral ischemia (DCI) due to vasospasm. Typically, the development of
DCI starts on day 3 after the initial SAH and is maximal at days 5-14, resolving on day 21.
How to prevent this? CCBs, Nimodipine
185. Cerebral ischaemia from cerebral vasospasm is the most common cause of death and
disability following aneurysmal subarachnoid hemorrhage (SAH).
186. Hyperchloraemic metabolic acidosis is a documented complication of neobladder
formation.
187. Wilson >> affects parenchymatous organs : Liver, brain , kidney. Gold standard is liver
biopsy , but take care, as those patients have liver affection>>↑ PT , PTT , so in such
condition , depend on Copper studies.
Fasciculations=LMNL ‫ ألن‬MND ‫فكر في‬UMN signs + fasciculations ‫ لما تالقي‬.188
189. When a patient asks many times What am I doing here?This is transient global amnesia.
Subclavian steal phenomenon. ‫ لما يعمل مجهود بايده يبقى دي غالبا‬drop attacks ‫ مريض بيجي له‬.190
191. D.D of autonomic neuropathy: (like postural hypotension)
PARD ‫بارد‬
 PCT.
 AIDS /Amyloid
 R.F
 DM
192. TTT of essential tremors is? .‫بالترتيب‬
 Propranolol , then ً‫أوال‬
 Primidone.
 Topiramate.
 Clozapine in resistant cases.
193. Leptomeninges = arachnoid mater & the pia mater.
194. Common scenario: Sinusitis/mastoiditis/Otitis externa→ Skull base osteomyelitis→affect
nerves passing through Jugular foramen. This is a rare but potentially life threatening
condition affecting people with compromised immunity. Typically, Pseudomonas
aeruginosa is the causative pathogen.
195. Locked in $ =? X in basilar artery→ X Ventral pons EXAM2013
196. Thalamic lesions →contralateral loss of sensation, which can later progress to thalamic
pain syndrome.
197. In adults the presence of any amnesia for patients >65 years of age is an indication for CT
scanning. In adult patients of any age, >30 minutes of retrograde amnesia is an indication of
CT scan. also Fall >1 m or >5 stairs is an indication EXAM2013
198. Autonomic dysreflexia occurs in patients with spinal cord injury above the level of T6.
199. Diabetic amyotrophy starts Unilateral, then becomes Bilateral EXAM2014 Theme.
200. Parkinson patient we recently increased L-Dopa to him>>>started to have visual
hallucinations, how to reat? Clozapine/chlorpromazine? EXAM2017 ‫سؤال مكرر‬
Ans: Clozapine. Chlorpromazine has a bad impact on movement. EXAM2014
EXAM2017 ‫ يبقى اختاره أفضل‬...‫ في السؤال‬Quietapine ‫ولو فيه‬
201. Antipsychotics ‫هتقتل مريض الـ‬ALzehimer dementia.
202. ↑ ICP in pregnancy. Diamox is contraindicated. Steroids will aggravate it .TTT is LP.
203. Lewy body disease is sensitive to neuroleptics. ‫يعني ايه؟‬
worsening of ‫ فحصل له‬dopamine ‫ بدأوه على دوا بيزود الـ‬Parkinsonism or psychosis ‫يعني مريض عنده‬
EXAM2014 Underlying Lewy body dementia. ‫ يبقى ده عندي‬Parkinson disease
204. Normal pressure hydrocephalus→ dementia, urinary incontinence, gait X TRIAD
parkinson ‫ ال يوجد معه‬dementia ‫هذا النوع من الـ‬..Parkinson gait ‫ وليس‬Gait abnormality
205. Lewy body dementia =Dementia+Parkinson+Visual hallucinations+fluctuating cognitions
Normal ‫فخليك عارف ان الـ‬..‫ علشان يلبخك‬urinary incontinence ‫وتالقيه في السؤال يحط لك احيانا فيها‬
Triad ‫ عبارة عن‬pressure hydrocephalus
206. Restless leg $ TTT? Ropinirol /Pramipixole → Pregabalin EXAM2014 EXAM2018
Pixole ‫ أو اديه بوكس‬Rope‫اربط رجله بحبل‬
207. Essential tremors (affects both ULs) TTT: Propranolol/Primidone (Phenobar. analogue).
208. Chiari malformation types:
→ I: Herniation of cerebellar tonsils:

→ II: ------------- MO, 4th ventricle, cerebellum.( ‫وهو دا النوع اللي اسمه‬Arnold Chiari malfo)

→ III: ------------ Cerebellum. + there is spina bifida of cervical part of spinal cord

(syrnix)
209. Syringomyelia:
 1st: affects spinothalamic tract.
 Later: affects ipsilateral pyramidal tract →
LMNL, not UMNL, why? Because the
pyramidal tract decussated from before.

motor ‫ وتكمل‬sensory ‫يعني تبدأ‬

Cape-like due to affection from C4-C6.

If extended to the brain stem , it is


called syringobulbia
210. In CT:
 Extradural Hge → Concave opacity. ‫ الهالل رلبا‬extra
 SDH → Convex opacity ‫الهالل لجوا‬
211.
→ Axillary nerve compression gives deltoid weakness and a patch of sensory disturbance
over the upper outer arm (not hand).

→ Medial trunk compression gives medial forearm pain and ulnar sensory disturbance (not
more lateral hand and no triceps weakness).

→ Median nerve compression would not give triceps weakness.

→ Radial nerve weakness gives wrist drop.

212. CNS abnormalities in HIV:


 toxoplasmosis (ring enhancing).
 Lymphoma (solitary lesion).
 HIV encephalopathy, (PML demylination in advanced HIV, low attenuation lesions)
213. Parkinson patients on L-Dopa, are prone to postural hypotension , In these situations ,
simple measures (as support stockings or raising the head of the bed) are sufficient to reduce
symptoms without need for pharmacological intervention. If no response >> give
Fludrocortisone>> if still no response >>> give Midodrine (α agonist)>> if no response>>
last line pyridostigmine (but it worsens the tremors).
214. Diabetic gastroparesis, which agent to use? Domperidone/ Metoclopramide
/erythromycin?
 Ans: Domperidone >>>Less side effects on long term.
 Metoclopramide: not to be used more than 2 weeks>>Extrapyramidal.
 Erythromycin>>> For short term exacerbations of gasteroparesis.
215. Thrombolysis in stroke, time window is? 4.5 h , not 3.5 h
216.Galatiremer is used in MS, what is the mechanism of action? Competes with Myelin
antigen.
217. Abx that exacerbate MG: Aminoglycoside ,Macolides, Tetracycline, quinolones
EXAM2018
218. Prolonged airplane travel >>hyperextension of the neck (hairdresser’s neck) >>vertebral
artery dissection EXAM2018
219. Restless leg $ TTT? Ropinirol /Pramipixole → Pregabalin EXAM2014 EXAM2018
220. Patient with restless leg $, on Ropinirol, symptoms recurred, what is is? It may be
 Augmentation phenomenon(=worsening of symtpoms while he is on TTT), in this case ,
shift to pregabaline. EXAM2018 OR
 Rebound phenomenon: Symptoms starts to appear , when the effect of drug starts to wear
off ‫يزول‬
. ‫لما الدوا يبدأ يختفي مفعوله من الدم‬..‫بتيجي للمريض الصبح بدري أوي أو آخر اليوم‬
How to treat? Use controlled-release or longer half-life agent at night
221. Antibodies & disease:
→ Anticholinestrase receptor ab = MG.

→ Anti VGCC = Eaton Lambert $. EXAM2018.

→ Anti GM1 =GB$.

→ Anti GQ1b = Miller Fisher $

222. Charcot joint: destructive to hoints ‫سؤال مكرر كثيرا‬


 DM → charcot in foot mainly.
 Syphilis (Tabes dorsalis) → charot in weight bearing joints manily (as knee , lumbar
spines).
 Syringomyelia→ charcot in shoulder joint
223. What symptom is most likely to be prognostic of Parkinson’s disease? REM-sleep
behavior disorder.
224. Cluster headache ‫يحصل كل يوم في نفس الوقت‬
225. Chronic subdural hematoma → fluctuating level of consciousness in elderly.
226.
227.
228.
229.
230.
231.
232.
233.
234.
235.

S-ar putea să vă placă și