Cns scenarios(medicine)

CNSCNS SCENARIOSSCENARIOS

SCENARIO No: 1SCENARIO No: 1

A young man of 22 years develops weakness of lower limbs with A young man of 22 years develops weakness of lower limbs with loss of sphincteric control in one week time. The disease loss 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 reveals Neurological examination of lower limbs and trunk reveals complete anesthesia in legs reaching up to T11 segments. Power complete anesthesia in legs reaching up to T11 segments. Power 1/5 in both lower limbs proximally as well as distally. Increased 1/5 in both lower limbs proximally as well as distally. Increased tone with hyper-reflexia in both lower limbs with up going tone 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.

2.2. NCS studies.NCS studies.

3.3. CSF for R/ECSF for R/E


A 44 years school teacher reports to your clinic with history of A 44 years school teacher reports to your clinic with history of weakness in lower limbs starting around ankles of 02 days weakness in lower limbs starting around ankles of 02 days duration. Since the previous night he has been unable to move duration. Since the previous night he has been unable to move out of bed and has noticed some weakness of upper limbs as out of bed and has noticed some weakness of upper limbs as well. He has good control on sphincters and apparently his well. He has good control on sphincters and apparently his sensorium remains clear. However he has been experiencing sensorium 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 rate Clinical examination reveals normal vitals and respiratory rate

28/minute. Neurological examination of lower limbs reveals 28/minute. Neurological examination of lower limbs reveals decreased tone, power 2/5 proximally and distally, deep tendon decreased tone, power 2/5 proximally and distally, deep tendon reflexes markedly decreased ( almost absent) at knees and absent reflexes 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 reveals Neurological examination of upper limbs reveals normal tone, power 4/5 BIL with reflexes normal 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 you Q 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 in Q No 3. What are the major steps in

management? (2) management? (2)


Ans No 1: Ans No 1: Guillain Barre syndrome (Acute post infectious Guillain Barre syndrome (Acute post infectious

polyradiculoneuropathy), Landy’s ascending paralysis.polyradiculoneuropathy), Landy’s ascending paralysis. Ans No 2:Ans No 2: Investigations:Investigations:1.1. NCS studies.NCS studies.2.2. CSF for routine examination (raised proteins with CSF for routine examination (raised proteins with

little rise in mononuclear cells) – cytoproteinic little 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 days I/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 bed 2. Assessment of respiratory reserve by doing bed

side spirometry and preparation of ventilatory side spirometry and preparation of ventilatory support if needed and if spirometer not availale support 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 his A 65 years retired factory worker was found unconscious in his bed by his family members early morning. He has been having bed by his family members early morning. He has been having cough with hemoptysis since last 4 week and has been loosing cough with hemoptysis since last 4 week and has been loosing weight. He has been Hukka smoker for over 40 years. No other weight. 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 examination with mild pallor and blood in the mouth. CNS examination reveals grade 4 coma and increased tone on Rt side with 3+ deep reveals grade 4 coma and increased tone on Rt side with 3+ deep tendon jerks and Rt planter equivocal while Lt planter down tendon 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 Lt Respiratory system exam shows signs of consolidation in Lt upper chest.upper chest.


Lab investigations reveal Hb 9.8 gm/dl, serum urea 7.5 Lab investigations reveal Hb 9.8 gm/dl, serum urea 7.5 m mol/l, Na 125mmol/l, ESR 55 mm fall in Ist hour m 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 upper X-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 his Q 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 you Q No 3: What appropriate investigations would you

require to reach the diagnosis? (1)require to reach the diagnosis? (1)


Ans No 1:Ans No 1: Post epileptic status of brain due to SOL (metastatic lesion) in Post 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/D1.1. 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 and Inappropriate 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 and Pulmonary 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 abdomen CT 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 for A 67 years retired bank officer reports to you for sudden onset of weakness of Rt side of body of 6 hrs sudden onset of weakness of Rt side of body of 6 hrs duration. According to his son he had twice lost vision duration. According to his son he had twice lost vision in eyes in last 1week and each time he regained vision in eyes in last 1week and each time he regained vision before any remedy could be given. He is known to have before any remedy could be given. He is known to have hypertension for 12 years, Diabetes mellitus since last 6 hypertension for 12 years, Diabetes mellitus since last 6 years and heart problem since last 3 years. He has been years and heart problem since last 3 years. He has been regularly attending his physician’s clinic. Last time his regularly attending his physician’s clinic. Last time his physician told him that his heart is not having regular physician told him that his heart is not having regular beating. beating.


Clinical assessment reveals BP 170/96 mmHg, pulse Clinical assessment reveals BP 170/96 mmHg, pulse 132/ minute irregularly, carotid bruit on Lt, varying 132/ minute irregularly, carotid bruit on Lt, varying intensity of Ist heart sound and normal vesicular intensity of Ist heart sound and normal vesicular breathing on auscultation of lungs.breathing on auscultation of lungs.

Neurological exam reveals confusion on rising, aphasia Neurological 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 Lt 2/5 and Rt planter extensor. Motor system exam on Lt side shows no abnormality.side shows no abnormality.

Investigations reveal mild hypercholesterolemia, serum Investigations reveal mild hypercholesterolemia, serum urea 3.4 mm mol/L with normal electrolytes, X-Ray urea 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 temporary Q 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 the Q No 2 . What is the most likely cause for the weakness of Rt extremities? Explain the weakness of Rt extremities? Explain the corollary of events. ( 2 )corollary of events. ( 2 )

Q No 3. What are the relevant investigations you Q No 3. What are the relevant investigations you will order? ( 2 )will order? ( 2 )


Ans No 1. Ans No 1. Amaurosis Fugax.Amaurosis Fugax. Ans No 2. Ans No 2. Hypertension (?IHD) leading to Atrial fibrillation Hypertension (?IHD) leading to Atrial fibrillation

leading to formation of clot in Lt atrium which leading to formation of clot in Lt atrium which embolises to Lt cerebral hemisphere in territory of Lt embolises to Lt cerebral hemisphere in territory of Lt middle cerebral artery resulting in drowsiness (due to middle cerebral artery resulting in drowsiness (due to large infarct), aphasia due to dominant hemisphere and large infarct), aphasia due to dominant hemisphere and Rt hemiplegia. The other less likely explanation is Rt hemiplegia. The other less likely explanation is embolic stroke due to Lt carotid artery stenosis embolic stroke due to Lt carotid artery stenosis depicted by Lt carotid bruit on examination ( This also depicted by Lt carotid bruit on examination ( This also explains the Amaurosis Fugax)explains the Amaurosis Fugax)


Ans No 3. Ans No 3. Investigations.Investigations. CT Scan Head without contrast (It may remain normal and may CT Scan Head without contrast (It may remain normal and may

not show infarct up to 12 Hrs, however the hemorrhage will be not 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 ischemic ECG (To confirm the atrial fibrillation) and other ischemic changes.changes.

Echocardiogram ( if possible TEE ) to confirm the presence of Echocardiogram ( if possible TEE ) to confirm the presence of Lt atrial clot. Lt atrial clot.

Carotid doppler studies to document the carotid arterial stenosis Carotid 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 been A 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 with He 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 in There is no history of body rash. He lives in dormitory. He has history of splenectomy 5 dormitory. He has history of splenectomy 5 years ago when the spleen was ruptured after a years 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 man Clinical examination shows markedly toxic young man who avoids clinical examination. Temp 103 F, pulse who 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 of no 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 in Systemic 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 in Q 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 )

SCENARIO No: 6 SCENARIO No: 6

Ans No 1:Ans No 1: Pneumococcal meningitis and pneumococcal pneumonia Pneumococcal 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) .

Ans No 2:Ans No 2:1.1. 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.

SCENARIO No: 6 SCENARIO No: 6

Ans No 3: TreatmentAns No 3: Treatment

1.1. Cefotaxime 2 gm 6 hourly or ceftriaxone 2 gm Cefotaxime 2 gm 6 hourly or ceftriaxone 2 gm 12 hourly * 10-14 days and if pneumococcus is 12 hourly * 10-14 days and if pneumococcus is showing resistance to B- Lactam antibiotics then showing resistance to B- Lactam antibiotics then start Vancomycin 1gm 12 hourly or Rafampicin start 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 Inj For initial 04 days of antibiotics add Inj Dexamethasone 8mg 8 hourly.Dexamethasone 8mg 8 hourly.


A 65 years diabetic, hypertensive and alcoholic A 65 years diabetic, hypertensive and alcoholic individual was admitted to the male medical ward with individual was admitted to the male medical ward with history of 4 episodes of drowsiness lasting for 15 history of 4 episodes of drowsiness lasting for 15 minutes to 2 hrs each followed by complete recovery minutes to 2 hrs each followed by complete recovery during last 15 days. He has been having dull global during last 15 days. He has been having dull global headache and occasional episodes of vomiting. He has headache and occasional episodes of vomiting. He has lost interest in surroundings and has been unable to lost interest in surroundings and has been unable to move around without support. His speech is also move around without support. His speech is also altered and once made to walk his body sways towards altered and once made to walk his body sways towards Rt side. He was found fitting in the morning of Rt 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, pulse Clinical examination reveals BP 170/90 mmHg, pulse 53/m, Temp 99 F, respiratory rate 14/m, having Foly’s 53/m, Temp 99 F, respiratory rate 14/m, having Foly’s catheter in place and ocular fundi showing fullness of catheter 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 lethargic CNS exam shows a bit confused and lethargic individual who has supple neck. Power 4/5 on Rt side individual who has supple neck. Power 4/5 on Rt side with normal reflexes and up going planter on Rt side with normal reflexes and up going planter on Rt side Lt planter is down going. Rest of systemic exam is Lt 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 within LFTs, 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 his Q No 1: What is the differential diagnosis of his ailment? ( 3 )ailment? ( 3 )

Q No 2: What preferred investigations will you Q No 2: What preferred investigations will you order? ( 2 )order? ( 2 )


Ans No 1: Differential diagnosisAns No 1: Differential diagnosis1.1. Chronic Subdural hematoma.Chronic Subdural hematoma.2.2. Cerebrovascular accident and secondary epilepsy and post ictal Cerebrovascular 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 in A 25 years young lady reports to you that for difficulty in standing from sitting position especially from floor for the last 2 standing from sitting position especially from floor for the last 2 months. The problem started just after her marriage. She had months. The problem started just after her marriage. She had also noticed difficulty in climbing hills when she had gone for also noticed difficulty in climbing hills when she had gone for honey moon in Murree hills in the previous month. There is no honey moon in Murree hills in the previous month. There is no history of fever, loss of appetite, difficulty in sleep, change in history of fever, loss of appetite, difficulty in sleep, change in bowel habits, joint pains etc. However she gives history of being bowel 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 back Her past history is insignificant except for falling on her back from motor bike 5 years ago and following that she never had from 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. No Clinical examination reveals normal vitals. No abnormality in general physical examination except for abnormality 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 any Neurological examination failed to show any abnormality. Power was 5/5 in all the four limbs abnormality. Power was 5/5 in all the four limbs proximally and distally. Reflexes were 2+ BIL proximally 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 and She 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 of She reports again after two weeks complaining of increasing weakness of hip muscles and difficulty in increasing weakness of hip muscles and difficulty in climbing the stairs. She also experiences 2-3 double climbing the stairs. She also experiences 2-3 double vision in evening which she attributed to excessive use vision in evening which she attributed to excessive use of tranquilizers. According to her she is having strained of 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 any Clinical examination again failed to reveal any abnormality. However she had to be supported to get abnormality. However she had to be supported to get up from floor while being examined and there was up from floor while being examined and there was medial squint Rt eye (Paresis of lateral rectus Rt). The medial 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 )


Ans No 1: Ans No 1: Myasthenia gravis.Myasthenia gravis.

Ans No 2: Ans No 2: 1.1. Anti Choline receptor antibodies ( IgG) – present in 90%. Anti Choline receptor antibodies ( IgG) – present in 90%. 2.2. NCS and EMGNCS and EMG3.3. Tensilon test.Tensilon test.4.4. X-Ray chest and if possible CT scan chest and neck X-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. Treatment1.1. Anticholine – esterase drugs like pyridostigmine.Anticholine – esterase drugs like pyridostigmine.2.2. Thymectomy for general myasthenia gravis disease. In Thymectomy 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 and Immuno - modulatory drugs like corticosteroids and

azathioprin if patient responds poorly inspite of azathioprin if patient responds poorly inspite of maximum dosage.maximum dosage.

4.4. Immunoglobulin and plasmaphresis in emergency and Immunoglobulin 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 with A 22 years young girl was admitted last night in med ward with history of sudden onset of weakness of Rt lower limb of 2 days history of sudden onset of weakness of Rt lower limb of 2 days duration. Initially she was found confused but soon she regained duration. 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 and Clinical examination reveals apprehensive young lady and examination of precardium revealed loud 1st heart sound and examination 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 Rt Power 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+ in lower 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 to Q No 2: What investigations would you ask to

confirm your diagnosis? ( 3 )confirm your diagnosis? ( 3 )


Ans No 1: Ans No 1: Thrombo embolic stroke in Lt anterior cerebral arterial Thrombo embolic stroke in Lt anterior cerebral arterial

territory due to clot embolism from dilated Lt Atrium which is territory due to clot embolism from dilated Lt Atrium which is fibrillating as a result of Mitral stenosis. fibrillating as a result of Mitral stenosis.

Ans No 2: Investigations.Ans No 2: Investigations.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 helpful thoracic to rule out clot in Lt atrium which is not only helpful in diagnosis but in further management of the case. It will also in diagnosis but in further management of the case. It will also diagnose Mitral stenosis and Mitral valve surface area not only diagnose Mitral stenosis and Mitral valve surface area not only to help the diagnosis but also to help in selection of modality to help the diagnosis but also to help in selection of modality of treatmentof treatment. .


2. CT scan head without contrast to 2. CT scan head without contrast to look for the infarction in territory of look for the infarction in territory of Lt anterior cerebral artery.Lt anterior cerebral artery.

3. X-Ray chest.3. X-Ray chest.4. ECG4. ECG5. 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 for A 35 years old lady health worker reports to you for weakness in legs of gradual onset over 2 weeks with weakness in legs of gradual onset over 2 weeks with abnormal pin like sensations in feet. She had vague abnormal pin like sensations in feet. She had vague headache and dizziness in the beginning of ailment headache and dizziness in the beginning of ailment which has settled a lot by now. She had similar episode which has settled a lot by now. She had similar episode 01 year ago when she had noticed weakness of Rt lower 01 year ago when she had noticed weakness of Rt lower limb from which she had recovered gradually though limb 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 her Six months ago she noticed rapid deterioration in her vision Rt more than left. She also had painful eye vision Rt more than left. She also had painful eye movement. The eye consultants told her that her vision movement. 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 mental Clinical examination reveals normal higher mental functions. Examination of lower limbs reveals mildly functions. Examination of lower limbs reveals mildly increased tone and power 4/5 in proximal and distal increased tone and power 4/5 in proximal and distal muscles with 3+ tendon reflexes. Planters - equivocal muscles 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 both Sensory 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 will Q 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 you Q No 3: What treatment options can you

promote?promote?


Ans No 1:Ans No 1: Multiple sclerosis.Multiple sclerosis. Ans No 2: InvestigationsAns No 2: Investigations1.1. CSF examination showing Lymphocytic pleocytosis CSF 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 showing MRI brain with godolinium contrast showing demylination in different areas, (in spine, posterior demylination in different areas, (in spine, posterior columns, cerebellum.columns, cerebellum.

3.3. Evoked potentials (Visual, auditory and Evoked potentials (Visual, auditory and somatosensory)somatosensory)

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


Ans No 3: TreatmentAns No 3: Treatment1.1. Inj Solu-medral (Methylprednisolone) 1 Gm i/v daily Inj Solu-medral (Methylprednisolone) 1 Gm i/v daily

for three days followed by Tab Prednisolone 1 mg/kg for 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 alternate Inj 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 rigidity Drugs 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 OPD A young boy has been brought to medical OPD with history of drowsiness of three days with history of drowsiness of three days duration. He has also been running high grade duration. He has also been running high grade fever since last 5 days intermittent in nature. He fever since last 5 days intermittent in nature. He has also experienced headache which at times has also experienced headache which at times accompanied vomiting. His appetite has been accompanied vomiting. His appetite has been poor and has been mostly bed bound. Since last poor and has been mostly bed bound. Since last 01 day his parents have noticed abnormal 01 day his parents have noticed abnormal position of his Lt eye.position of his Lt eye.


Clinical examination reveals a young boy of Clinical examination reveals a young boy of average built, febrile (101F), toxic, pale and average built, febrile (101F), toxic, pale and dehydrated. He is drowsy, rousable with dehydrated. He is drowsy, rousable with irritability and inability to follow commands. BP irritability 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 6 thth nerve paresis is obvious nerve paresis is obvious from medial deviation of Lt eye ball.from medial deviation of Lt eye ball.


The motor and sensory system showed no signs The 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 any Other 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 will Q NO 3. What investigations in priority will

you ask for? (2)you ask for? (2)


Answer No 1: The likely cause is Encephalitis Answer 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.



SCENARIO SCENARIO

A 25 years old lady health worker was admitted with A 25 years old lady health worker was admitted with history of headache, occasional vomiting and low grade history of headache, occasional vomiting and low grade fever of 01 month duration. She has been suffering fever of 01 month duration. She has been suffering from low grade fever and poor appetite for the last 2 from low grade fever and poor appetite for the last 2 months or so. She has developed weakness Rt half of months or so. She has developed weakness Rt half of body since last 3 days with growing confusion. In the body since last 3 days with growing confusion. In the morning of admission( 01 day earlier) she was found to morning of admission( 01 day earlier) she was found to have jerky movements of Rt arm following which she have 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 bit Clinical examination reveals conscious though a bit drowsy lady reluctant to be examined. Temp 37.9 C, BP drowsy 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), Power Neurological 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 no planter 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 crepts Examination of respiratory system reveals coarse crepts Rt upper chest.Rt upper chest.

Abdominal exam shows 2 cms splenomegaly and 4 cms Abdominal 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 with normal differential count, serum urea 54mg/dl with normal electrolytes.normal electrolytes.

X-Ray chest films show a heterogenous opacity Rt X-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 order Q No 2: What investigations you would ask for in order

of preference? (1)of preference? (1) Q No 3: What treatment you would recommend and Q No 3: What treatment you would recommend and

for what duration? (2)for what duration? (2)

SCENARIOSCENARIO

Ans No 1:Ans No 1: Pulmonary tuberculosis leading to Tuberculous Pulmonary tuberculosis leading to Tuberculous

meningitis and probably Tuberculoma in Lt cerebral meningitis and probably Tuberculoma in Lt cerebral artery territory presenting as SOL brain with signs of artery territory presenting as SOL brain with signs of hemiplegia Rt , focal epilepsy and also raising the CSF hemiplegia Rt , focal epilepsy and also raising the CSF pressure causing papilledema or TBM leading to pressure causing papilledema or TBM leading to obstructive hydrocephalous leading to papilledema.obstructive hydrocephalous leading to papilledema.

Disseminated tuberculosis may be by some resistant Disseminated tuberculosis may be by some resistant type of mycobacterium tuberculosis organism as the type of mycobacterium tuberculosis organism as the patient is health worker.patient is health worker.

SCENARIOSCENARIO

Ans No 2: Ans No 2: 1.1. CT scan head with contrast ( To look for tuberculoma CT 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 raised CSF 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 mycobacterium PCR in blood/ CSF for DNA of mycobacterium

tuberculosis.tuberculosis.

SCENARIOSCENARIO

Ans No 3: Ans No 3: Anti –tuberculosis treatment with 4 drugs and Anti –tuberculosis treatment with 4 drugs and

Streptomycin should be included in place of Streptomycin should be included in place of Ethambutal for initial 2 moths and treatment should be Ethambutal 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 the Dexamethasone 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 in A 65 years old man has been admitted in medical ward with history of gradually increasing medical ward with history of gradually increasing difficulty in walking and stiffness in legs of 4 difficulty in walking and stiffness in legs of 4 months duration. He has also noticed some months duration. He has also noticed some weakness in upper limbs as well since last 1 weakness in upper limbs as well since last 1 month. There is no history of odd sensory month. There is no history of odd sensory symptoms. He does not give history of symptoms. He does not give history of deterioration in higher mental functions, of deterioration 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. BP160/102 Clinical examination reveals normal vital signs. BP160/102 mmHg. No other abnormality is noted in general physical and mmHg. No other abnormality is noted in general physical and systemic examination. systemic examination.

Normal non painful movements of cervical spine and other Normal non painful movements of cervical spine and other spinal segments.spinal segments.

However motor system examination in upper limbs shows, flat However motor system examination in upper limbs shows, flat thenar eminence of both hands, loss of muscle mass, decreased thenar 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 muscle Motor system examination in lower limbs shows normal muscle mass, increased tone, power 3/5 proximal and distal muscles and mass, 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, normal Laboratory reports show Hb 10.8 gm/dl, normal TLC and DLC and ESR. Serum urea 4.5 TLC and DLC and ESR. Serum urea 4.5 mmol/lt and normal electrolytes, serum calcium mmol/lt and normal electrolytes, serum calcium 2.24 mmol/lt, blood glucose 4.3 mmol/lt 2.24 mmol/lt, blood glucose 4.3 mmol/lt ( fasting).( fasting).

X- ray chest PA view shows normal findings and X- ray chest PA view shows normal findings and Ultra- sound examination shows mild Ultra- 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 you Q No 3: What are the priority investigations you

would ask for?would ask for?


Ans No 1: Ans No 1: Motor neuron disease ( Amyotrophic lateral Motor 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 of Marked cervical stenosis and compression of

cord.cord.2.2. SOL cervical spine.SOL cervical spine.3.3. Sub acute degeneration of cord due to Sub acute degeneration of cord due to

pernicious anemia.pernicious anemia.


Ans No 3: Investigations.Ans No 3: Investigations.

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.

Education

Cns scenarios(medicine)