Cns scenarios(medicine)

SCENARIO No: 1SCENARIO No: 1
 A young man of 22 years develops weakness of lower limbs withA young man of 22 years develops weakness of lower limbs with
loss of sphincteric control in one week time. The diseaseloss of sphincteric control in one week time. The disease
progressed fast in last couple of hours.progressed fast in last couple of hours.
Neurological examination of lower limbs and trunk revealsNeurological examination of lower limbs and trunk reveals
complete anesthesia in legs reaching up to T11 segments. Powercomplete anesthesia in legs reaching up to T11 segments. Power
1/5 in both lower limbs proximally as well as distally. Increased1/5 in both lower limbs proximally as well as distally. Increased
tone with hyper-reflexia in both lower limbs with up goingtone with hyper-reflexia in both lower limbs with up going
planters. He is having Foly’s catheter in place.planters. He is having Foly’s catheter in place.
Q No 1. What is the diagnosis? (2)Q No 1. What is the diagnosis? (2)
Q No 2. What pertinent investigations you would ask for? (3)Q No 2. What pertinent investigations you would ask for? (3)

Ans No:1. Acute transverse myelitis.Ans No:1. Acute transverse myelitis.
Ans No:2. Investigations:Ans No:2. Investigations:
1.1. MRI thorasic spine.MRI thorasic spine.
2.2. NCS studies.NCS studies.
3.3. CSF for R/ECSF for R/E
Ans No:1. Acute transverse myelitis.Ans No:1. Acute transverse myelitis.
Ans No:2. Investigations:Ans No:2. Investigations:
1.1. MRI thoracic spine.MRI thoracic spine.
3.3. CSF for R/ECSF for R/E

 A 44 years school teacher reports to your clinic with history ofA 44 years school teacher reports to your clinic with history of
weakness in lower limbs starting around ankles of 02 daysweakness in lower limbs starting around ankles of 02 days
duration. Since the previous night he has been unable to moveduration. Since the previous night he has been unable to move
out of bed and has noticed some weakness of upper limbs asout of bed and has noticed some weakness of upper limbs as
well. He has good control on sphincters and apparently hiswell. He has good control on sphincters and apparently his
sensorium remains clear. However he has been experiencingsensorium remains clear. However he has been experiencing
backache all along the spine.backache all along the spine.
 He suffered from an episode of diarrhoea 10 days ago.He suffered from an episode of diarrhoea 10 days ago.
 Clinical examination reveals normal vitals and respiratory rateClinical examination reveals normal vitals and respiratory rate
28/minute. Neurological examination of lower limbs reveals28/minute. Neurological examination of lower limbs reveals
decreased tone, power 2/5 proximally and distally, deep tendondecreased tone, power 2/5 proximally and distally, deep tendon
reflexes markedly decreased ( almost absent) at knees and absentreflexes markedly decreased ( almost absent) at knees and absent
at ankles , planters non elicitable.at ankles , planters non elicitable.
 Mild paraesthesia in lower limbs on sensory system examination.Mild paraesthesia in lower limbs on sensory system examination.

 Neurological examination of upper limbs revealsNeurological examination of upper limbs reveals
normal tone, power 4/5 BIL with reflexesnormal tone, power 4/5 BIL with reflexes
decreased with no sensory loss.decreased with no sensory loss.
 Rest of the examination is unremarkable.Rest of the examination is unremarkable.
Q No 1. What is the likely diagnosis? (1)Q No 1. What is the likely diagnosis? (1)
Q No 2. What are the relevant investigations youQ No 2. What are the relevant investigations you
will do to confirm your diagnosis? (2)will do to confirm your diagnosis? (2)
Q No 3. What are the major steps inQ No 3. What are the major steps in
management? (2)management? (2)

 Ans No 1:Ans No 1:
 Guillain Barre syndrome (Acute post infectiousGuillain Barre syndrome (Acute post infectious
polyradiculoneuropathy), Landy’s ascending paralysis.polyradiculoneuropathy), Landy’s ascending paralysis.
 Investigations:Investigations:
2.2. CSF for routine examination (raised proteins withCSF for routine examination (raised proteins with
little rise in mononuclear cells) – cytoproteiniclittle rise in mononuclear cells) – cytoproteinic
dissociation.dissociation.
3.3. MRI of cervical spine.MRI of cervical spine.

 Ans No 3:Ans No 3: Treatment:Treatment:
1.1. I/V Immunoglobulins 1gm/kg daily for 5 daysI/V Immunoglobulins 1gm/kg daily for 5 days
or Plasmapheresis 500ml/kg per day for 5 days.or Plasmapheresis 500ml/kg per day for 5 days.
2. Assessment of respiratory reserve by doing bed2. Assessment of respiratory reserve by doing bed
side spirometry and preparation of ventilatoryside spirometry and preparation of ventilatory
support if needed and if spirometer not availalesupport if needed and if spirometer not availale
then…...then…...
( Fast counting in one breath)( Fast counting in one breath)

 A 65 years retired factory worker was found unconscious in hisA 65 years retired factory worker was found unconscious in his
bed by his family members early morning. He has been havingbed by his family members early morning. He has been having
cough with hemoptysis since last 4 week and has been loosingcough with hemoptysis since last 4 week and has been loosing
weight. He has been Hukka smoker for over 40 years. No otherweight. He has been Hukka smoker for over 40 years. No other
definite hx is available.definite hx is available.
 Clinical examination reveals grade I clubbing, BP 140/90mmHg,Clinical examination reveals grade I clubbing, BP 140/90mmHg,
with mild pallor and blood in the mouth. CNS examinationwith mild pallor and blood in the mouth. CNS examination
reveals grade 4 coma and increased tone on Rt side with 3+ deepreveals grade 4 coma and increased tone on Rt side with 3+ deep
tendon jerks and Rt planter equivocal while Lt planter downtendon jerks and Rt planter equivocal while Lt planter down
going. Ocular fundi could not be seen due to cataract BIL.going. Ocular fundi could not be seen due to cataract BIL.
 Respiratory system exam shows signs of consolidation in LtRespiratory system exam shows signs of consolidation in Lt
upper chest.upper chest.

 Lab investigations reveal Hb 9.8 gm/dl, serum urea 7.5Lab investigations reveal Hb 9.8 gm/dl, serum urea 7.5
m mol/l, Na 125mmol/l, ESR 55 mm fall in Ist hourm mol/l, Na 125mmol/l, ESR 55 mm fall in Ist hour
and blood glucose 5.1 m mol/l.and blood glucose 5.1 m mol/l.
 X-Ray chest reveals homogenous opacity in Lt upperX-Ray chest reveals homogenous opacity in Lt upper
zone with some widening of mediastinum.zone with some widening of mediastinum.
Q No 1: What is the most likely cause for hisQ No 1: What is the most likely cause for his
unconsciousness? (2)unconsciousness? (2)
Q No 2: What is the differential diagnosis? (2)Q No 2: What is the differential diagnosis? (2)
Q No 3: What appropriate investigations would youQ No 3: What appropriate investigations would you
require to reach the diagnosis? (1)require to reach the diagnosis? (1)

 Post epileptic status of brain due to SOL (metastatic lesion) inPost epileptic status of brain due to SOL (metastatic lesion) in
Lt cerebral hemisphere ( Motor area) from carcinoma lung.Lt cerebral hemisphere ( Motor area) from carcinoma lung.
 Ans No 2 : D/DAns No 2 : D/D
1.1. SOL Brain (Metastatic tuberculoma) in lt cerebral hemispere.SOL Brain (Metastatic tuberculoma) in lt cerebral hemispere.
2.2. CVA ( acute brain attack).CVA ( acute brain attack).
3.3. Inappropriate ADH syndrome leading to brain edema andInappropriate ADH syndrome leading to brain edema and
epilepsy and post ictal status.epilepsy and post ictal status.
4.4. Pulmonary tuberculosis with tuberculoma of brain andPulmonary tuberculosis with tuberculoma of brain and
secondary epilepsy.secondary epilepsy.
5.5. Metabolic changes due to uremia (uremic encephalopathy)Metabolic changes due to uremia (uremic encephalopathy)
leading to convulsions and post ictal status.leading to convulsions and post ictal status.

 Ans No 3 :Ans No 3 :
 Investigations:Investigations:
1.1. CT scan brain with contrast.CT scan brain with contrast.
2.2. CT scan chest with contrast (CT scan abdomenCT scan chest with contrast (CT scan abdomen
to rule out abdominal metastasis and for staging)to rule out abdominal metastasis and for staging)
3.3. FNAC of the lung lesion.FNAC of the lung lesion.
4.4. Full renal functions, electrolytes.Full renal functions, electrolytes.
5.5. Serum and urine osmolality.Serum and urine osmolality.

 A 67 years retired bank officer reports to you forA 67 years retired bank officer reports to you for
sudden onset of weakness of Rt side of body of 6 hrssudden onset of weakness of Rt side of body of 6 hrs
duration. According to his son he had twice lost visionduration. According to his son he had twice lost vision
in eyes in last 1week and each time he regained visionin eyes in last 1week and each time he regained vision
before any remedy could be given. He is known to havebefore any remedy could be given. He is known to have
hypertension for 12 years, Diabetes mellitus since last 6hypertension for 12 years, Diabetes mellitus since last 6
years and heart problem since last 3 years. He has beenyears and heart problem since last 3 years. He has been
regularly attending his physician’s clinic. Last time hisregularly attending his physician’s clinic. Last time his
physician told him that his heart is not having regularphysician told him that his heart is not having regular
beating.beating.

 Clinical assessment reveals BP 170/96 mmHg, pulseClinical assessment reveals BP 170/96 mmHg, pulse
132/ minute irregularly, carotid bruit on Lt, varying132/ minute irregularly, carotid bruit on Lt, varying
intensity of Ist heart sound and normal vesicularintensity of Ist heart sound and normal vesicular
breathing on auscultation of lungs.breathing on auscultation of lungs.
 Neurological exam reveals confusion on rising, aphasiaNeurological exam reveals confusion on rising, aphasia
( expressive- motor) increased tone on Rt with power( expressive- motor) increased tone on Rt with power
2/5 and Rt planter extensor. Motor system exam on Lt2/5 and Rt planter extensor. Motor system exam on Lt
side shows no abnormality.side shows no abnormality.
 Investigations reveal mild hypercholesterolemia, serumInvestigations reveal mild hypercholesterolemia, serum
urea 3.4 mm mol/L with normal electrolytes, X-Rayurea 3.4 mm mol/L with normal electrolytes, X-Ray
chest showing enlarged cardiac shadow.chest showing enlarged cardiac shadow.

Q No 1. What was the cause for his temporaryQ No 1. What was the cause for his temporary
visual loss twice? ( 1 )visual loss twice? ( 1 )
Q No 2 . What is the most likely cause for theQ No 2 . What is the most likely cause for the
weakness of Rt extremities? Explain theweakness of Rt extremities? Explain the
corollary of events. ( 2 )corollary of events. ( 2 )
Q No 3. What are the relevant investigations youQ No 3. What are the relevant investigations you
will order? ( 2 )will order? ( 2 )

 Ans No 1.Ans No 1.
 Amaurosis Fugax.Amaurosis Fugax.
 Hypertension (?IHD) leading to Atrial fibrillationHypertension (?IHD) leading to Atrial fibrillation
leading to formation of clot in Lt atrium whichleading to formation of clot in Lt atrium which
embolises to Lt cerebral hemisphere in territory of Ltembolises to Lt cerebral hemisphere in territory of Lt
middle cerebral artery resulting in drowsiness (due tomiddle cerebral artery resulting in drowsiness (due to
large infarct), aphasia due to dominant hemisphere andlarge infarct), aphasia due to dominant hemisphere and
Rt hemiplegia. The other less likely explanation isRt hemiplegia. The other less likely explanation is
embolic stroke due to Lt carotid artery stenosisembolic stroke due to Lt carotid artery stenosis
depicted by Lt carotid bruit on examination ( This alsodepicted by Lt carotid bruit on examination ( This also
explains the Amaurosis Fugax)explains the Amaurosis Fugax)

 Investigations.Investigations.
 CT Scan Head without contrast (It may remain normal and mayCT Scan Head without contrast (It may remain normal and may
not show infarct up to 12 Hrs, however the hemorrhage will benot show infarct up to 12 Hrs, however the hemorrhage will be
picked up at the earliest).picked up at the earliest).
 ECG (To confirm the atrial fibrillation) and other ischemicECG (To confirm the atrial fibrillation) and other ischemic
changes.changes.
 Echocardiogram ( if possible TEE ) to confirm the presence ofEchocardiogram ( if possible TEE ) to confirm the presence of
Lt atrial clot.Lt atrial clot.
 Carotid doppler studies to document the carotid arterial stenosisCarotid doppler studies to document the carotid arterial stenosis
and if it is severe then to decide about the modality of treatment.and if it is severe then to decide about the modality of treatment.

 A 21 years engineering student has beenA 21 years engineering student has been
admitted in med ward with history of headache,admitted in med ward with history of headache,
vomiting and high grade spiking fever for 2 days.vomiting and high grade spiking fever for 2 days.
He also gives history of cough withHe also gives history of cough with
expectoration of rusty sputum since last 5 days.expectoration of rusty sputum since last 5 days.
There is no history of body rash. He lives inThere is no history of body rash. He lives in
dormitory. He has history of splenectomy 5dormitory. He has history of splenectomy 5
years ago when the spleen was ruptured after ayears ago when the spleen was ruptured after a
blunt injury to abdomen in a foot ball match.blunt injury to abdomen in a foot ball match.
Vaccination history is not available.Vaccination history is not available.

 Clinical examination shows markedly toxic young manClinical examination shows markedly toxic young man
who avoids clinical examination. Temp 103 F, pulsewho avoids clinical examination. Temp 103 F, pulse
82/min, neck rigidity positive, Kerning’s sign positive,82/min, neck rigidity positive, Kerning’s sign positive,
no skin rash, and BP 90/ 60 mmHg with no signs ofno skin rash, and BP 90/ 60 mmHg with no signs of
dehydration. Ocular fundi normal.dehydration. Ocular fundi normal.
 Systemic examination reveals signs of consolidation inSystemic examination reveals signs of consolidation in
Rt upper lung with pleural rub. Liver non palpable.Rt upper lung with pleural rub. Liver non palpable.
Heart sounds normal with no added sounds.Heart sounds normal with no added sounds.

 Q No 1: What is the diagnosis? ( 2 )Q No 1: What is the diagnosis? ( 2 )
 Q No 2: What investigations will you ask for inQ No 2: What investigations will you ask for in
order of preference? ( 2 )order of preference? ( 2 )
 Q No 3: What is the preferred treatment? ( 1 )Q No 3: What is the preferred treatment? ( 1 )

Pneumococcal meningitis and pneumococcal pneumoniaPneumococcal meningitis and pneumococcal pneumonia
(Though structural damage occur less often with(Though structural damage occur less often with
pneumococcal as compared to meningococcal meningitis) .pneumococcal as compared to meningococcal meningitis) .
1.1. Blood culture and drug sensitivity.Blood culture and drug sensitivity.
2.2. CSF for R/E, Gram staining (Gm + diplococci) and C&S.CSF for R/E, Gram staining (Gm + diplococci) and C&S.
3.3. X- chest PA view.X- chest PA view.
4.4. Blood CP.Blood CP.
5.5. Routine investigations.Routine investigations.

 Ans No 3: TreatmentAns No 3: Treatment
1.1. Cefotaxime 2 gm 6 hourly or ceftriaxone 2 gmCefotaxime 2 gm 6 hourly or ceftriaxone 2 gm
12 hourly * 10-14 days and if pneumococcus is12 hourly * 10-14 days and if pneumococcus is
showing resistance to B- Lactam antibiotics thenshowing resistance to B- Lactam antibiotics then
start Vancomycin 1gm 12 hourly or Rafampicinstart Vancomycin 1gm 12 hourly or Rafampicin
1 gm 12 hourly I/V.1 gm 12 hourly I/V.
2.2. For initial 04 days of antibiotics add InjFor initial 04 days of antibiotics add Inj
Dexamethasone 8mg 8 hourly.Dexamethasone 8mg 8 hourly.

 A 65 years diabetic, hypertensive and alcoholicA 65 years diabetic, hypertensive and alcoholic
individual was admitted to the male medical ward withindividual was admitted to the male medical ward with
history of 4 episodes of drowsiness lasting for 15history of 4 episodes of drowsiness lasting for 15
minutes to 2 hrs each followed by complete recoveryminutes to 2 hrs each followed by complete recovery
during last 15 days. He has been having dull globalduring last 15 days. He has been having dull global
headache and occasional episodes of vomiting. He hasheadache and occasional episodes of vomiting. He has
lost interest in surroundings and has been unable tolost interest in surroundings and has been unable to
move around without support. His speech is alsomove around without support. His speech is also
altered and once made to walk his body sways towardsaltered and once made to walk his body sways towards
Rt side. He was found fitting in the morning ofRt side. He was found fitting in the morning of
admission and was found incontinent of urine.admission and was found incontinent of urine.

 Clinical examination reveals BP 170/90 mmHg, pulseClinical examination reveals BP 170/90 mmHg, pulse
53/m, Temp 99 F, respiratory rate 14/m, having Foly’s53/m, Temp 99 F, respiratory rate 14/m, having Foly’s
catheter in place and ocular fundi showing fullness ofcatheter in place and ocular fundi showing fullness of
cup with blurred disc margins.cup with blurred disc margins.
 CNS exam shows a bit confused and lethargicCNS exam shows a bit confused and lethargic
individual who has supple neck. Power 4/5 on Rt sideindividual who has supple neck. Power 4/5 on Rt side
with normal reflexes and up going planter on Rt sidewith normal reflexes and up going planter on Rt side
Lt planter is down going. Rest of systemic exam isLt planter is down going. Rest of systemic exam is
normal.normal.
 Investigations including base line blood chemistries,Investigations including base line blood chemistries,
LFTs, Serum urea, ECG and X-Ray chest are withinLFTs, Serum urea, ECG and X-Ray chest are within
normal limits. Blood glucose 55 mg/dl.normal limits. Blood glucose 55 mg/dl.

 Q No 1: What is the differential diagnosis of hisQ No 1: What is the differential diagnosis of his
ailment? ( 3 )ailment? ( 3 )
 Q No 2: What preferred investigations will youQ No 2: What preferred investigations will you
order? ( 2 )order? ( 2 )

 Ans No 1: Differential diagnosisAns No 1: Differential diagnosis
1.1. Chronic Subdural hematoma.Chronic Subdural hematoma.
2.2. Cerebrovascular accident and secondary epilepsy and post ictalCerebrovascular accident and secondary epilepsy and post ictal
status.status.
3.3. SOL brain (primary or secondary metastatic disease..)SOL brain (primary or secondary metastatic disease..)
4.4. Recurrent hypoglycemia.Recurrent hypoglycemia.
 Ans No 2: Investigations.Ans No 2: Investigations.
1.1. CT brain with contrast.CT brain with contrast.
2.2. Doppler of carotids and vertebral arteries.Doppler of carotids and vertebral arteries.
3.3. Blood glucose fasting.Blood glucose fasting.
4.4. EEG.EEG.

 A 25 years young lady reports to you that for difficulty inA 25 years young lady reports to you that for difficulty in
standing from sitting position especially from floor for the last 2standing from sitting position especially from floor for the last 2
months. The problem started just after her marriage. She hadmonths. The problem started just after her marriage. She had
also noticed difficulty in climbing hills when she had gone foralso noticed difficulty in climbing hills when she had gone for
honey moon in Murree hills in the previous month. There is nohoney moon in Murree hills in the previous month. There is no
history of fever, loss of appetite, difficulty in sleep, change inhistory of fever, loss of appetite, difficulty in sleep, change in
bowel habits, joint pains etc. However she gives history of beingbowel habits, joint pains etc. However she gives history of being
under mental stress because of strained domestic relationship.under mental stress because of strained domestic relationship.
 Her past history is insignificant except for falling on her backHer past history is insignificant except for falling on her back
from motor bike 5 years ago and following that she never hadfrom motor bike 5 years ago and following that she never had
any complaints related to her back.any complaints related to her back.

 Clinical examination reveals normal vitals. NoClinical examination reveals normal vitals. No
abnormality in general physical examination except forabnormality in general physical examination except for
a small goiter in neck with apparently euthyroid status.a small goiter in neck with apparently euthyroid status.
 Neurological examination failed to show anyNeurological examination failed to show any
abnormality. Power was 5/5 in all the four limbsabnormality. Power was 5/5 in all the four limbs
proximally and distally. Reflexes were 2+ BILproximally and distally. Reflexes were 2+ BIL
(Normal).(Normal).
 All relevant investigations were within normal limits.All relevant investigations were within normal limits.
 She was given some vitamin pills and tranquilizers andShe was given some vitamin pills and tranquilizers and
was counseled in regards to her domestic issues.was counseled in regards to her domestic issues.

 She reports again after two weeks complaining ofShe reports again after two weeks complaining of
increasing weakness of hip muscles and difficulty inincreasing weakness of hip muscles and difficulty in
climbing the stairs. She also experiences 2-3 doubleclimbing the stairs. She also experiences 2-3 double
vision in evening which she attributed to excessive usevision in evening which she attributed to excessive use
of tranquilizers. According to her she is having strainedof tranquilizers. According to her she is having strained
relations with her new family members.relations with her new family members.
 Clinical examination again failed to reveal anyClinical examination again failed to reveal any
abnormality. However she had to be supported to getabnormality. However she had to be supported to get
up from floor while being examined and there wasup from floor while being examined and there was
medial squint Rt eye (Paresis of lateral rectus Rt). Themedial squint Rt eye (Paresis of lateral rectus Rt). The
palpebral fissure of Rt eye appeared smaller than Lt.palpebral fissure of Rt eye appeared smaller than Lt.

 Q No 1: What is the likely cause for her ailment? ( 2 )Q No 1: What is the likely cause for her ailment? ( 2 )
 Q No 2: What investigations would you ask for? ( 1 )Q No 2: What investigations would you ask for? ( 1 )
 Q No 3: What treatment would you recommend. ( 2 )Q No 3: What treatment would you recommend. ( 2 )

Myasthenia gravis.Myasthenia gravis.
1.1. Anti Choline receptor antibodies ( IgG) – present in 90%.Anti Choline receptor antibodies ( IgG) – present in 90%.
2.2. NCS and EMGNCS and EMG
3.3. Tensilon test.Tensilon test.
4.4. X-Ray chest and if possible CT scan chest and neckX-Ray chest and if possible CT scan chest and neck
( to find out thymoma)( to find out thymoma)
5.5. Antibodies against skeletal muscles, intrinsic factor, ANA, RAAntibodies against skeletal muscles, intrinsic factor, ANA, RA
factor and atithyroid antibodies.factor and atithyroid antibodies.

 Ans No 4. TreatmentAns No 4. Treatment
1.1. Anticholine – esterase drugs like pyridostigmine.Anticholine – esterase drugs like pyridostigmine.
2.2. Thymectomy for general myasthenia gravis disease. InThymectomy for general myasthenia gravis disease. In
ocular disease it is not beneficial.ocular disease it is not beneficial.
3.3. Immuno - modulatory drugs like corticosteroids andImmuno - modulatory drugs like corticosteroids and
azathioprin if patient responds poorly inspite ofazathioprin if patient responds poorly inspite of
maximum dosage.maximum dosage.
4.4. Immunoglobulin and plasmaphresis in emergency andImmunoglobulin and plasmaphresis in emergency and
as life saving procedure.as life saving procedure.

 A 22 years young girl was admitted last night in med ward withA 22 years young girl was admitted last night in med ward with
history of sudden onset of weakness of Rt lower limb of 2 dayshistory of sudden onset of weakness of Rt lower limb of 2 days
duration. Initially she was found confused but soon she regainedduration. Initially she was found confused but soon she regained
consciousness and power also improved a little.consciousness and power also improved a little.
 Clinical examination reveals apprehensive young lady andClinical examination reveals apprehensive young lady and
examination of precardium revealed loud 1st heart sound andexamination of precardium revealed loud 1st heart sound and
rumbling diastolic murmur at apex with irregular rhythm.rumbling diastolic murmur at apex with irregular rhythm.
 Neurological exam revealed normal higher mental functions.Neurological exam revealed normal higher mental functions.
Power in Rt upper limb 5/5 proximally and distally and 3/5 in RtPower in Rt upper limb 5/5 proximally and distally and 3/5 in Rt
lower limb. Deep tendon reflexes 2+ in Rt upper limb and 3+ inlower limb. Deep tendon reflexes 2+ in Rt upper limb and 3+ in
Rt lower limb. Planters Rt equivocal and Lt down going.Rt lower limb. Planters Rt equivocal and Lt down going.

 Q No 1: What is the diagnosis? ( 2 )Q No 1: What is the diagnosis? ( 2 )
 Q No 2: What investigations would you ask toQ No 2: What investigations would you ask to
confirm your diagnosis? ( 3 )confirm your diagnosis? ( 3 )

Thrombo embolic stroke in Lt anterior cerebral arterialThrombo embolic stroke in Lt anterior cerebral arterial
territory due to clot embolism from dilated Lt Atrium which isterritory due to clot embolism from dilated Lt Atrium which is
fibrillating as a result of Mitral stenosis.fibrillating as a result of Mitral stenosis.
1.1. Echocardiogram trans-esophagial and if not available trans-Echocardiogram trans-esophagial and if not available trans-
thoracic to rule out clot in Lt atrium which is not only helpfulthoracic to rule out clot in Lt atrium which is not only helpful
in diagnosis but in further management of the case. It will alsoin diagnosis but in further management of the case. It will also
diagnose Mitral stenosis and Mitral valve surface area not onlydiagnose Mitral stenosis and Mitral valve surface area not only
to help the diagnosis but also to help in selection of modalityto help the diagnosis but also to help in selection of modality
of treatmentof treatment..

2. CT scan head without contrast to2. CT scan head without contrast to
look for the infarction in territory oflook for the infarction in territory of
Lt anterior cerebral artery.Lt anterior cerebral artery.
3. X-Ray chest.3. X-Ray chest.
4. ECG4. ECG
5. Baseline investigations especially PT,5. Baseline investigations especially PT,
INR, APTT etc.INR, APTT etc.

 A 35 years old lady health worker reports to you forA 35 years old lady health worker reports to you for
weakness in legs of gradual onset over 2 weeks withweakness in legs of gradual onset over 2 weeks with
abnormal pin like sensations in feet. She had vagueabnormal pin like sensations in feet. She had vague
headache and dizziness in the beginning of ailmentheadache and dizziness in the beginning of ailment
which has settled a lot by now. She had similar episodewhich has settled a lot by now. She had similar episode
01 year ago when she had noticed weakness of Rt lower01 year ago when she had noticed weakness of Rt lower
limb from which she had recovered gradually thoughlimb from which she had recovered gradually though
she still has some stiffness and weakness in that limb.she still has some stiffness and weakness in that limb.
Six months ago she noticed rapid deterioration in herSix months ago she noticed rapid deterioration in her
vision Rt more than left. She also had painful eyevision Rt more than left. She also had painful eye
movement. The eye consultants told her that her visionmovement. The eye consultants told her that her vision
is not going to improve much despite treatment.is not going to improve much despite treatment.

 Clinical examination reveals normal higher mentalClinical examination reveals normal higher mental
functions. Examination of lower limbs reveals mildlyfunctions. Examination of lower limbs reveals mildly
increased tone and power 4/5 in proximal and distalincreased tone and power 4/5 in proximal and distal
muscles with 3+ tendon reflexes. Planters - equivocalmuscles with 3+ tendon reflexes. Planters - equivocal
Bil.Bil.
 The Rt lower limb also shows cerebellar signs as well.The Rt lower limb also shows cerebellar signs as well.
 Sensory system examination reveals paresthesia bothSensory system examination reveals paresthesia both
lower limbs.lower limbs.
 Examination of rest of systems show no abnormality.Examination of rest of systems show no abnormality.

 Q No 1: What is the most probable diagnosis?Q No 1: What is the most probable diagnosis?
 Q No 2: What are the investigations you willQ No 2: What are the investigations you will
place in order of priority?place in order of priority?
 Q No 3: What treatment options can youQ No 3: What treatment options can you
promote?promote?

 Multiple sclerosis.Multiple sclerosis.
 Ans No 2: InvestigationsAns No 2: Investigations
1.1. CSF examination showing Lymphocytic pleocytosisCSF examination showing Lymphocytic pleocytosis
and mildly increased proteins and presence of oligo-and mildly increased proteins and presence of oligo-
clonal bands (IgG) on electrophoresis.clonal bands (IgG) on electrophoresis.
2.2. MRI brain with godolinium contrast showingMRI brain with godolinium contrast showing
demylination in different areas, (in spine, posteriordemylination in different areas, (in spine, posterior
columns, cerebellum.columns, cerebellum.
3.3. Evoked potentials (Visual, auditory andEvoked potentials (Visual, auditory and
somatosensory)somatosensory)

Treatment ofTreatment of
complications(26.84Dav)complications(26.84Dav)

 Ans No 3: TreatmentAns No 3: Treatment
1.1. Inj Solu-medral (Methylprednisolone) 1 Gm i/v dailyInj Solu-medral (Methylprednisolone) 1 Gm i/v daily
for three days followed by Tab Prednisolone 1 mg/kgfor three days followed by Tab Prednisolone 1 mg/kg
daily for 3-4 weeks.daily for 3-4 weeks.
2.2. Inj Beta interferon 5millions units s/c on alternateInj Beta interferon 5millions units s/c on alternate
day for 6 months.day for 6 months.
3.3. Int Glatiramer.Int Glatiramer.
4.4. Drugs to relief symptomatic problems like for rigidityDrugs to relief symptomatic problems like for rigidity
Tab Beclofen, for ataxia, Tab isoniazid for fatigue,Tab Beclofen, for ataxia, Tab isoniazid for fatigue,
and Amantidine and amitriptyline for paresthesia etc.and Amantidine and amitriptyline for paresthesia etc.

 A young boy has been brought to medical OPDA young boy has been brought to medical OPD
with history of drowsiness of three dayswith history of drowsiness of three days
duration. He has also been running high gradeduration. He has also been running high grade
fever since last 5 days intermittent in nature. Hefever since last 5 days intermittent in nature. He
has also experienced headache which at timeshas also experienced headache which at times
accompanied vomiting. His appetite has beenaccompanied vomiting. His appetite has been
poor and has been mostly bed bound. Since lastpoor and has been mostly bed bound. Since last
01 day his parents have noticed abnormal01 day his parents have noticed abnormal
position of his Lt eye.position of his Lt eye.

 Clinical examination reveals a young boy ofClinical examination reveals a young boy of
average built, febrile (101F), toxic, pale andaverage built, febrile (101F), toxic, pale and
dehydrated. He is drowsy, rousable withdehydrated. He is drowsy, rousable with
irritability and inability to follow commands. BPirritability and inability to follow commands. BP
102/64 mmHg, Pulse110/ min. No jaundice,102/64 mmHg, Pulse110/ min. No jaundice,
clubbing, cyanosis or dependent edema.clubbing, cyanosis or dependent edema.
 Neck is supple. Lt 6Neck is supple. Lt 6thth
nerve paresis is obviousnerve paresis is obvious
from medial deviation of Lt eye ball.from medial deviation of Lt eye ball.

 The motor and sensory system showed no signsThe motor and sensory system showed no signs
of involvement.of involvement.
 Planters are down going BIL.Planters are down going BIL.
 Other systemic examination failed to reveal anyOther systemic examination failed to reveal any
abnormality.abnormality.
 Q NO 1. What is the likely diagnosis? (2)Q NO 1. What is the likely diagnosis? (2)
 Q NO 2. What is the differential diagnosis? (1)Q NO 2. What is the differential diagnosis? (1)
 Q NO 3. What investigations in priority willQ NO 3. What investigations in priority will
you ask for? (2)you ask for? (2)

 Answer No 1: The likely cause is EncephalitisAnswer No 1: The likely cause is Encephalitis
most probably of viral origin.most probably of viral origin.
 Answer No 2: Differential diagnosis.Answer No 2: Differential diagnosis.
1.1. Viral encephalitis.Viral encephalitis.
2.2. Meningoencephalitis.Meningoencephalitis.
3.3. Cerebral malaria.Cerebral malaria.
4.4. Enteric fever with typhoid state.Enteric fever with typhoid state.

 Answer No 3: Investigations.Answer No 3: Investigations.
1.1. CT scan Head.CT scan Head.
2.2. CSF for R/E.CSF for R/E.
3.3. CSF for C&S.CSF for C&S.
4.4. Blood CP& MP.Blood CP& MP.
5.5. Blood culture.Blood culture.
6.6. Serum urea and electrolytes.Serum urea and electrolytes.

SCENARIOSCENARIO
 A 25 years old lady health worker was admitted withA 25 years old lady health worker was admitted with
history of headache, occasional vomiting and low gradehistory of headache, occasional vomiting and low grade
fever of 01 month duration. She has been sufferingfever of 01 month duration. She has been suffering
from low grade fever and poor appetite for the last 2from low grade fever and poor appetite for the last 2
months or so. She has developed weakness Rt half ofmonths or so. She has developed weakness Rt half of
body since last 3 days with growing confusion. In thebody since last 3 days with growing confusion. In the
morning of admission( 01 day earlier) she was found tomorning of admission( 01 day earlier) she was found to
have jerky movements of Rt arm following which shehave jerky movements of Rt arm following which she
became unresponsive for 2-3 Hrs.became unresponsive for 2-3 Hrs.

SCENARIOSCENARIO
 Clinical examination reveals conscious though a bitClinical examination reveals conscious though a bit
drowsy lady reluctant to be examined. Temp 37.9 C, BPdrowsy lady reluctant to be examined. Temp 37.9 C, BP
138/96 mmHg and pulse 56/minute. Neck rigidity +/-.138/96 mmHg and pulse 56/minute. Neck rigidity +/-.
 Neurological exam reveals tone normal (BIL), PowerNeurological exam reveals tone normal (BIL), Power
-4/5 Rt half of body, Reflexes 3+ on Rt side and Rt-4/5 Rt half of body, Reflexes 3+ on Rt side and Rt
planter up going. Exam of Lt side shows noplanter up going. Exam of Lt side shows no
abnormality. Ocular fundi shows mild papilledema.abnormality. Ocular fundi shows mild papilledema.
 Examination of respiratory system reveals coarse creptsExamination of respiratory system reveals coarse crepts
Rt upper chest.Rt upper chest.
 Abdominal exam shows 2 cms splenomegaly and 4 cmsAbdominal exam shows 2 cms splenomegaly and 4 cms
hepatomegaly.hepatomegaly.

SCENARIOSCENARIO
 Lab reports show Hb 9.0 gm/dl, TLC 4.5 *10Lab reports show Hb 9.0 gm/dl, TLC 4.5 *1099
/L with/L with
normal differential count, serum urea 54mg/dl withnormal differential count, serum urea 54mg/dl with
normal electrolytes.normal electrolytes.
 X-Ray chest films show a heterogenous opacity RtX-Ray chest films show a heterogenous opacity Rt
upper zone and blunting of Rt CP angle.upper zone and blunting of Rt CP angle.
 Q No 1: What is the likely diagnosis? (2)Q No 1: What is the likely diagnosis? (2)
 Q No 2: What investigations you would ask for in orderQ No 2: What investigations you would ask for in order
of preference? (1)of preference? (1)
 Q No 3: What treatment you would recommend andQ No 3: What treatment you would recommend and
for what duration? (2)for what duration? (2)

SCENARIOSCENARIO
 Pulmonary tuberculosis leading to TuberculousPulmonary tuberculosis leading to Tuberculous
meningitis and probably Tuberculoma in Lt cerebralmeningitis and probably Tuberculoma in Lt cerebral
artery territory presenting as SOL brain with signs ofartery territory presenting as SOL brain with signs of
hemiplegia Rt , focal epilepsy and also raising the CSFhemiplegia Rt , focal epilepsy and also raising the CSF
pressure causing papilledema or TBM leading topressure causing papilledema or TBM leading to
obstructive hydrocephalous leading to papilledema.obstructive hydrocephalous leading to papilledema.
 Disseminated tuberculosis may be by some resistantDisseminated tuberculosis may be by some resistant
type of mycobacterium tuberculosis organism as thetype of mycobacterium tuberculosis organism as the
patient is health worker.patient is health worker.

SCENARIOSCENARIO
1.1. CT scan head with contrast ( To look for tuberculomaCT scan head with contrast ( To look for tuberculoma
or other causes of SOL)or other causes of SOL)
2.2. Sputum for AFB for 3 days.Sputum for AFB for 3 days.
3.3. Motoux test.Motoux test.
4.4. Bone marrow biopsy for histopathology.Bone marrow biopsy for histopathology.
5.5. Blood ESR.Blood ESR.
6.6. CSF for R/E if CT scan does not show signs of raisedCSF for R/E if CT scan does not show signs of raised
I/C tension or mass lesion.I/C tension or mass lesion.
7.7. PCR in blood/ CSF for DNA of mycobacteriumPCR in blood/ CSF for DNA of mycobacterium
tuberculosis.tuberculosis.

SCENARIOSCENARIO
 Anti –tuberculosis treatment with 4 drugs andAnti –tuberculosis treatment with 4 drugs and
Streptomycin should be included in place ofStreptomycin should be included in place of
Ethambutal for initial 2 moths and treatment should beEthambutal for initial 2 moths and treatment should be
continued for 9 months with Rifampicin and Isoniazid.continued for 9 months with Rifampicin and Isoniazid.
 Dexamethasone may be given initially to reduce theDexamethasone may be given initially to reduce the
raised I/C tension and brain edema.raised I/C tension and brain edema.
 Antiepileptic treatment should be started.Antiepileptic treatment should be started.
 Other supportive treatment be given.Other supportive treatment be given.

 A 65 years old man has been admitted inA 65 years old man has been admitted in
medical ward with history of gradually increasingmedical ward with history of gradually increasing
difficulty in walking and stiffness in legs of 4difficulty in walking and stiffness in legs of 4
months duration. He has also noticed somemonths duration. He has also noticed some
weakness in upper limbs as well since last 1weakness in upper limbs as well since last 1
month. There is no history of odd sensorymonth. There is no history of odd sensory
symptoms. He does not give history ofsymptoms. He does not give history of
deterioration in higher mental functions, ofdeterioration in higher mental functions, of
painful neck movements and trauma to spine.painful neck movements and trauma to spine.

 Clinical examination reveals normal vital signs. BP160/102Clinical examination reveals normal vital signs. BP160/102
mmHg. No other abnormality is noted in general physical andmmHg. No other abnormality is noted in general physical and
systemic examination.systemic examination.
 Normal non painful movements of cervical spine and otherNormal non painful movements of cervical spine and other
spinal segments.spinal segments.
 However motor system examination in upper limbs shows, flatHowever motor system examination in upper limbs shows, flat
thenar eminence of both hands, loss of muscle mass, decreasedthenar eminence of both hands, loss of muscle mass, decreased
tone, power -4/5 and decreased biceps, triceps and radial jerks.tone, power -4/5 and decreased biceps, triceps and radial jerks.
 Motor system examination in lower limbs shows normal muscleMotor system examination in lower limbs shows normal muscle
mass, increased tone, power 3/5 proximal and distal muscles andmass, increased tone, power 3/5 proximal and distal muscles and
increased deep tendon reflexes. Planters equivocal BIL.increased deep tendon reflexes. Planters equivocal BIL.
 No abnormality of sensory system examination.No abnormality of sensory system examination.
 No signs of incontinence on sphincters.No signs of incontinence on sphincters.

 Laboratory reports show Hb 10.8 gm/dl, normalLaboratory reports show Hb 10.8 gm/dl, normal
TLC and DLC and ESR. Serum urea 4.5TLC and DLC and ESR. Serum urea 4.5
mmol/lt and normal electrolytes, serum calciummmol/lt and normal electrolytes, serum calcium
2.24 mmol/lt, blood glucose 4.3 mmol/lt2.24 mmol/lt, blood glucose 4.3 mmol/lt
( fasting).( fasting).
 X- ray chest PA view shows normal findings andX- ray chest PA view shows normal findings and
Ultra- sound examination shows mildUltra- sound examination shows mild
hepatomegaly.hepatomegaly.

 Q No 1: What is the diagnosis?Q No 1: What is the diagnosis?
 Q No 2: What is the differential diagnosis?Q No 2: What is the differential diagnosis?
 Q No 3: What are the priority investigations youQ No 3: What are the priority investigations you
would ask for?would ask for?

Motor neuron disease ( Amyotrophic lateralMotor neuron disease ( Amyotrophic lateral
sclerosis). (? Other variants - discuss).sclerosis). (? Other variants - discuss).
 Ans No 2: Differential diagnosis.Ans No 2: Differential diagnosis.
1.1. Marked cervical stenosis and compression ofMarked cervical stenosis and compression of
cord.cord.
2.2. SOL cervical spine.SOL cervical spine.
3.3. Sub acute degeneration of cord due toSub acute degeneration of cord due to
pernicious anemia.pernicious anemia.

1.1. X–Ray cervical spine AP and lateral view.X–Ray cervical spine AP and lateral view.
2.2. MRI cervical spine with contrast.MRI cervical spine with contrast.
3.3. NCS and EMG.NCS and EMG.
4.4. Serum Vit B12 level.Serum Vit B12 level.

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