DISCLAIMER ​

Dear Students, these handouts will help you quickly revise the topics discussed in our lectures
before examination. They shall not replace the lectures as lectures involve detailed explanation
with all important points highlighted for AMC preparation. In order to clear AMC
ACADEMICALLY strongly recommended you re-listen to lectures again and prepare notes and
practice multiple choice questions for AMC examination.

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 Handout ​

MOCK CNS
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A PATIENT had generalized tonic clonic seizures & he is also on warfarin .What to give?

1. Amiodarone
2. sodium valproate
3. carbamazepine
4. phenytoin
5. Topiramate
QUESTION
1
A PATIENT had generalized tonic clonic seizures & he is also on warfarin .What to give?

1. Amiodarone
2. sodium valproate
3. carbamazepine
4. phenytoin
5. topiramate

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Answer inducers-C-GRAPES

Carbemazepines
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylurea

The mnemonic SICKFACES.COM can be used to easily remember

common CYP450 inhibitors.

Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
QUESTION 2
A 14-month-old boy, has been brought into the hospital Emergency Department by his parents following
an episode at home the previous evening. His parent explains that he had beunwell all day with a high
fever (40 °C), and while he was being cuddled, he was staring and did not respond to his name. They
noted that his body twitches all over for several seconds and the whole episode lasted 60 seconds. He
then went off to sleep and slept for the rest of the night. Examination findings he is alert and normal
neurologically. He has a low grade fever and signs of an upper respiratory tract infection. what is likely
diagnosis
1. infantile spasm
2. febrile seizure
3. absence seizure
4. Temporal epilepsy
5. meningitis.
QUESTION
2
A 14-month-old boy, has been brought into the hospital Emergency Department by his parents following
an episode at home the previous evening. His parent explains that he had beunwell all day with a high
fever (40 °C), and while he was being cuddled, he was staring and dId not respond to his name. They
noted that his body twitches all over for several seconds and the whole episode lasted 60 seconds. He
then went off to sleep and slept for the rest of the night. Examination findings he is alert and normal
neurologically. He has a low grade fever and signs of an upper respiratory tract infection. what is likely
diagnosis

1. infantile spasm
2. febrile seizure
3. absence seizure

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4. Temporal epilepsy
5. meningitis.

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 https://www.rch.org.au/clinicalguide/guideline_index/Febrile_seizure/

https://youtu.be/VU6qNLOlU_A

https://www.rch.org.au/clinicalguide/guideline_index/Infantile_Spasms/

https://www.epilepsy.com/what-is-epilepsy/seizure-types/absence-seizures#How-are-
absence-seizures-diagnosed?

https://www.rch.org.au/clinicalguide/guideline_index/Afebrile_seizures/
QUESTION 3

A 4 year old boy presents to your practise by his parents for assessment , the boy has several attacks of blank stares which are
accompanied by Bizarre movements of head and trunk, also mild clonic jerks of the eyelids, corner of the mouth,sometimes leading
to drooping of the head, slumping of the trunk, dropping of the arms, arching of trunk and also features like lip licking and
swallowing to fumbling with clothes and aimless walking. There are 15-20of such episodes each lasting one minute and then resolved.
The boy is confused and drowsy for 2 min after each attack and does not have the memory of the episode.Which of the following is
the treatment option?
1. phenytoin
2. Sodium valproate
3. Ethosuximide
4. Carbamazepine
5. Phenobarbital
A 4 year old boy presents to your practise by his parents for assessment , the boy has several attacks of
blank stares which are accompanied by Bizarre movements of head and trunk, also mild clonic jerks of the
eyelids, corner of the mouth,sometimes leading to drooping of the head, slumping of the trunk, dropping of
the arms, arching of trunk and also features like lip licking and swallowing to fumbling with clothes and
aimless walking. There are 15-20of such episodes each lasting one minute and then resolved. The boy is
confused and drowsy for 2 min after each attack and does not have the memory of the episode.Which of
the following is the treatment option?

1. phenytoin
2. Sodium valproate

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3. Ethosuximide
4. Carbamazepine
5. Phenobarbital

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30 year old man presents complaining of severe headache in the last 2 hours ago. It is
localised to the left side and associated with photophobia. He suffered from a similar
episode a few month ago that had also involved the left side. It had lasted for several
minutes for several times a day for a period of 2 weeks and then subsided spontaneously.
The patient is unable to stand still, agitated and anxious. What is most likely cause

1. SAH
2. Brain tumor
3. Migraine
4. Cluster headache
5. Subdural headache
The previous attacks lasted for several minutes and occurred SEVERAL times a day (which is seen
more commonly in cluster headache).

•Think of cluster headache as a visitor who visits frequently for a month or so and then disappear.
That's why it is called (Cluster). Many frequent back-toback attacks during a limited period, then,
disappear,and re-visit again after a while.

•Remember in migraine, the duration is Longer (4 hours to 72 hours)

The patient is agitated (while in migraine, the patient usually prefers to lay down in a dark room).
A 66 year old lady has developed a severe right sided headache which worsens whenever she
comes to a bright light since the last 3 days. She feels nauseated, but doesn’t vomit. What is
the most likely diagnosis?

1. SAH
2. Brain tumor
3. Migraine
4. Cluster headache
5. Subdural headache
1. SAH
2. Brain tumor
3. Migraine
4. Cluster headache
5. Subdural headache
The symptoms of some types of migraine can mimic stroke, such as hemiplegic migraine, which can cause weakness
down one side.

Migraine auras can be confused with transient ischaemic attack (TIA), where someone has stroke symptoms that
pass in a short time. For instance, a migraine with only a visual aura but no headache may be mistaken for TIA.

Like a stroke, a migraine can be sudden and can lead to mild confusion. However, migraine aura symptoms tend
to develop relatively slowly and then spread and intensify, while the symptoms of a TIA or stroke are sudden.

Migraine can sometimes be mistaken for a stroke caused by bleeding on the brain, called a subarachnoid
haemorrhage (SAH), which is often characterised by a sudden, very severe headache. Unlike SAH, migraine
headache is usually one-sided and throbbing, slow to come on and lasts for a shorter period of time. Vomiting usually
starts after a migraine headache starts, but is likely to happen at the same time as headache during a SAH.

Patients with a SAH also develop neck stiffness, which is uncommon during a migraine attack.

https://www.stroke.org.uk/sites/default/files/migraine_and_stroke.pdf
 QUESTION 5

57 year old male was brought to you by his wife because she noticed that he had been shaving only right side of
face for past 1 day. Assessment suggested ischemic stroke he raises his right hand when asked to raise his left
one . What part of the brain is most likely affected ?
1. Right occipital cortex
2. Right frontal cortex
3. Left temporal cortex
4. Right parietal cortex
5. Left parietal corte
QUESTION
9
57 year old male was brought to you by his wife because she noticed that he had been shaving only right
side of face for past 1 day
Assessment suggested ischemic stroke he raises his right hand when asked to raise his left
one . What part of the brain is most likely affected ?

1. Right occipital cortex

2. Right frontal cortex
3. Left temporal cortex
4. Right parietal cortex
5. Left parietal corte

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A 35 year female presents with a complaint 0f headaches 3-5 days before her periods, it is at the
back of her head and propagates towards temporal area, aggravated by walking and physical
activity.She denies visual auditory or taste disturbances but she cannot tolerate noisy or
crowded places. Every episode lasts 2-7 hours. All physical and systemic examination is normal.
What is the likely diagnosis?

1. Migraine with aura

2. Migraine without aura
3. Cluster headache
4. Tension headache
5. Premenstrual headache
QUESTION
10
A 35 year female presents with a complaint 0f headaches 3-5 days before her periods, it is at the back of
her head and propagates towards temporal area, aggravated by walking and physical activity.She denies
visual auditory or taste disturbances but she cannot tolerate noisy or crowded places. Every episode lasts
2-7 hours. All physical and systemic examination is normal. What is the likely diagnosis?

1. Migraine withaura
2. Migraine without aura
3. Cluster headache
4. Tension headache
5. Premenstrual headache

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https://www.racgp.org.au/afp/2014/march/chronic-headache
Treatment - non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen or mefenamic acid,
oestrogen supplements or triptans.

Frovatriptan tablet (2.5 mg twice daily on the days migraine is expected – generally from two days before
until three days after bleeding starts)

Zolmitriptan tablet (2.5 mg twice or three times a day on the days migraine is expected – generally from
two days before until three days after bleeding starts)

(Taken from the British Association for the Study of Headache’s National Headache Management System
for Adults 2019)
A boy aged five years presented with a new recurrent headache over the past month, associated with
nausea and occasional vomiting, as well as photophobia, phonophobia and pallor. The episodes lasted
up to six hours at a time and occurred 3–4 times per week. They were usually preceded by
approximately 30 minutes of irritable and dysregulated behaviour. They occurred at any time of the
day. The patient had only woken up once with the headache. There was no abdominal pain.
The patient’s history included atopic dermatitis and obstructive sleep apnoea successfully treated with
tonsillectomy. He lived with his mother and sister and attended day care. His immunisations were up
to date and he was developmentally appropriate. His mother reported experiencing classic migraines
with aura. What is the likely cause

Brain tumor
Cerebral venous thrombosis
OSA
Migraine
Medication overuse
a. Brain tumor
b. Cerebral venous thrombosis
c. OSA
d. Migraine
e. Medication overuse
RECURRENT
HEADACHES
Primary headaches are the most common cause of recurrent headaches in children.

The prevalence of paediatric migraines is high in Australia and increases with age, estimated to
be roughly 4% in children aged 5–9 years, 16% in those aged 10–14 years and 20% in
adolescents aged 15–19 years.²

Other primary headaches include tension headaches and, less commonly, trigeminal autonomic
cephalalgias such as cluster headaches.

Secondary causes are less common in recurrent headaches.

Potential causes are extensive and range from rare but sinister causes such as brain tumour and
cerebral venous thrombosis, to other causes, including but not limited to medication overuse
(eg nonsteroidal anti-inflammatory drugs [NSAIDs] and steroids), idiopathic raised
intracranial hypertension, endocrine conditions, obstructive sleep apnoea, dental disease and
psychiatric disorders.³
How should recurrent paediatric headaches be
investigated?
Neuroimaging is not routinely recommended in the absence of red flags, and unscrutinised use can risk
incidental findings, harm from need for procedural sedation and over-reliance on imaging rather than
careful clinical follow-up.

If required, magnetic resonance imaging (MRI) is preferable to computed tomography because of its
superiority in detecting posterior fossa pathology and lower radiation risk.

Referral to an ophthalmologist or skilled optometrist can detect subtle signs of visual disturbance

A lumbar puncture may be considered to measure opening pressure but is usually not required.

In Australia, general practitioners can order MRI under Medicare Benefits Schedule rebates if a child aged
<16 years has unexplained seizures or unexplained headaches with suspected significant pathology.
How do
paediatric
migraines
present
differently to
those in
adults?
Holistic long-term prophylactic management is paramount to prevent recurrent attacks, analgesia overuse
and long-term morbidity.
This should include addressing family factors and using lifestyle, psychological and pharmacological
treatments.
Familial and school stressors, communication issues and relationship conflicts should be considered, as
they can negatively affect the child’s migraine management.
Acute attacks should be treated with ibuprofen as first line or paracetamol as second line, taken as soon as
possible.
Aspirin should be avoided because of the rare risk of Reye’s syndrome.
Ondansetron is the preferred treatment for nausea. Sumatriptan or rizatriptan can be used in children aged
≥6 years.
Rescue therapy should be limited to <10–15 days of NSAIDs and <8 days of triptans per month to prevent
medication overuse headaches.

https://www1.racgp.org.au/ajgp/2021/january-february/a-young-child-with-a-headach
A 28-year-old woman presents to the Emergency Department with a complaint of sudden-onset severe
unilateral headache on the left side. The pain is felt behind the orbit and is associated with nasal stuffiness
and conjunctiva! injection and lacrimation. She has a history of previous similar headaches. Which one of
the following is the treatment of choice to prevent further attacks?

1. 100% oxygen
2. Verapamil
3. Propanol
4. Sumatriptan
5. paracetamol
 QUESTION
11
A 28-year-old woman presents to the Emergency Department with a complaint of sudden-onset severe Q
unilateral headache on the left side. The pain is felt behind the orbit and is associated with nasal stuffiness
and conjunctiva! injection and lacrimation. She has a history of previous similar headaches. Which one of
the following is the treatment of choice to prevent further attacks?

1. 100% oxygen
2. Verapamil
3. Propanol
4. Sumatriptan
5. paracetamol

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Cluster headache

Cluster headache does not merely mean headaches that occur close together and is often
overdiagnosed by family physicians.

Such headaches may have an identifiable precursor, such as occurring in the morning after a ‘big
night out’ or they may be associated with significant alcohol consumption.

They often occur at the same time of day for a finite period, often in the early morning, possibly
waking the patient at the same time each day.

They are often accompanied by suffused red eye with ipsilateral conjunctival injection, lacrimation
and stuffy nose with ipsilateral nasal congestion or rhinorrhea, accompanying unilateral pulsating
pain in the ipsilateral forehead, possibly associated with eyelid oedema, meiosis and ptosis.

Diagnosis dictates at least five attacks, which can occur from one every other day to eight per day,
devoid of an alternative aetiology.

This type of headache should initiate specialist consultation and may be treated with agents such as
verapamil or lithium.
QUESTION
12
A 22-year-old female presented with a 4-week history of headache and blurred vision. She had associated symptoms of
photophobia (FEAR OF LIGHT), diplopia(DOUBLE VISSION) which was binocular, constant transient visual obscurations
(TVOs). She also had tinnitus, nausea and neck pain. The patient had a history of irregular menses for which she was being
managed by the gynaecologists and had been placed on oral contraceptive pills (OCP). The symptoms started around the same
time she commenced the OCPs. On examination her weight was 100kg and height 1.73m, with BMI 33.4. Her blood pressure was
120/72mmHg. The best corrected visual acuity was 6/6 in the right eye and 6/9 in the left eye.
Examination of the optic discs revealed Grade 3 papilloedema. Cranial CT scan showed small ventricles but was otherwise
normal. A lumbar puncture was done but the opening pressure was not measured. Results of her CSF biochemistry and
bacteriology were negative. What is likely diagnosis

a. Migraine with aura

b. Migraine without aura
c. Cerebral tumor
d. Pseudo tumor cerebri
e. Trigeminal neuralgia

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A.migraine with aura
Migraine without aura
Cerebral tumor
Pseudo tumor cerebri
Trigeminal neuralgia

https://www.racgp.org.au/afp/2015/march/papilledema-a-case-of-bilateral-blurred-vision-cau

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idiopathic intracranial hypertension
(IIH) is also called pseudotumor cerebri.

It is a disorder defined by clinical

criteria that include symptoms and
signs isolated to those produced by
increased intracranial pressure (ICP; eg,
headache, papilledema, double vision,
transient visual obscurations, and vision
loss), elevated ICP with normal
cerebrospinal fluid (CSF) composition,
and no other cause of intracranial
hypertension evident on neuroimaging
or other evaluations
Medical management of IIH primarily utilizes carbonic anhydrase
inhibitors including diuretics and antiseizure medication.
A 40 year old patient came to your clinic with complaints of frequent tripping of his right foot He got up in the
morning and face looks funny and paralyzed; cannot feel the left side of the face, no trauma, infection, no
hemiparesis or paralysis, speech problems, or past history of stroke Physical examination showed distressed and
anxious, accumulation of food on left side, sensation intact, drooling of saliva; (+) bell’s reflex left eye/globe
moves up when asking patient to close eyes; cannot wrinkle forehead; change in taste of food, no deviation of
tongue or uvula and hyperacusis of affected side. What is the diagnosis ?

1. Bell palsy
2. CVA (Stroke/TIA)
3. Brain tumor
4. Ramsay-Hunt Syndrome
5. Parotid cancer
 QUESTION
A 40 year old patient came to your clinic with complaints of frequent tripping of his right foot He got up in
the morning and face looks funny and paralyzed; cannot feel the left side of the face, no trauma, infection,
no hemiparesis or paralysis, speech problems, or past history of strokePhysical examination showed
distressed and anxious, accumulation of food on left side, sensation intact, drooling of saliva; (+) bell’s
reflex left eye/globe moves up when asking patient to close eyes; cannot wrinkle forehead; change in
taste of food, no deviation of tongue or uvula and hyperacusis of affected side. What is the diagnosis ?

1. Bell palsy
2. CVA (Stroke/TIA)

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3. Brain tumor
4. Ramsay-Hunt Syndrome
5. Parotid cancer

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Treatment -
1. corticosteroids 60-80mg per day for the first 3 days and
start tapering it.
2. Give artificial tears to protect eyes from drying.
3. Put an adhesive patchor tape over the eye if there is
exposure of the cornea
4. Refer to the physiotherapist for facial exercisesthat is
important to prevent contractures in paralyzed muscles.
5. Prognosis is very good. 70-80% of people recover within 2
months. 5-10% may take a longertime. A few cases do not
recover.

6. CT scan is not required

 A 68-year-old man is in your GP clinic with complaints of weakness and numbness of his legs and unsteady
gait. He also complains of tiredness. started since the last 3 months, weakness in both legs, numbness, unable
to keep balance, tired, headache, pale, no fever, night sweats, weight loss, weather preference; had operation
10 years ago for removal of some part of stomach, alcohol 2 drinks/day for last 20 years) Physical examination
showed pale, normal BMI, decreased power on both sides, loss of sensation on both sides, decreased vibration
and proprioception, and unsteady gait what is most likely Diagnosis ?

1. Stroke
2. ‐Peripheral Neuropathy (Diabetes)
3. ‐ Alcohol

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4. ‐ Brain tumor
5. ‐ Vitamin B 12 deficiency

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1. Stroke
2. ‐Peripheral Neuropathy (Diabetes)
3. ‐ Alcohol
4. ‐ Brain tumor
5. ‐ Vitamin B 12 deficiency

https://www.aafp.org/pubs/afp/issues/1998/0215/p755.html
Causes

o Diet (vegetarian)
o Decreased absorption:
gastrectomy
o Autoimmune:
Pernicious anemia:
Atrophic gastritis
Hypothyroidism,
Diabetes

‐
‐ B12 >220mol pmol/L = deficiency
unlikely
‐ B12 <148 pmol/L = deficiency

‐ Intrinsic factor antibody level is diagnostic

‐ Treatment

o Vitamin B IM injection(1000mcg) Æ body stores are replenished after 10-

14injection given every 2-3 days
o Maintenance with 1000 mcg IM injections every 3rd month
o Co-therapy with oral folate 5mg/day
You are an HMO and a 60-year-oldwoman is in the ED with a complaint of sudden painless blurring of
vision. She remembered the return of vision within 30 minutes. She has a past history of bypass
surgery 2 years ago. She is hypertensive and is on ACE inhibitors.on Physical examination neurologic
and eye examination are normal . No redness, swelling, lacrimation associated.

1. TIA
2. CRAO
3. multiple sclerosis
4. Amaurosis Fugax
5. Papilloedema

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1. TIA
2. crao
3. multiple sclerosis
4. Amaurosis Fugax
5. papilledema
Treatment: It is a surgical procedurewhere the plaque is removed from
the vessel and the normal blood flowto the brain is restored. Second
option is percutaneous transluminalangioplasty that is to put a stent to
prevent further stroke.
- Asymptomatic
o <60% Æ ASA
o 60-70% Æ may or may not undergo carotid endarterectomy
o >70% Æ carotid endarterectomy
Fleeting vision changes—blurred vision, double vision, flickering, or complete loss of
vision—typically lasting seconds are characteristic of papilledema. Other symptoms
may be caused by the elevated pressure in the brain. A pulsating whooshing noise in
the ears, headache, nausea, vomiting, or a combination may occur.
https://www1.racgp.org.au/ajgp/2021/march/blackout-understanding-transient-vision-loss

https://www1.racgp.org.au/ajgp/2021/november/carotid-artery-stenosis
A 65 year old male presents to your GP clinic with his wife Margaret. He
tells you he had funny turn this morning. He has completely recovered and made the
appointment at his wife’s insistence. He says he first noticed something was wrong
when he answered the telephone call from his sister and found it difficult to speak. HiS wife reports that his
words were muddled and he had difficulty making him
understand. She thought she seemed confused at that time.(BMI 27, BP 150/90)
What is the probable diagnosis?

1. Stroke
2. Syncope
3. Seizure

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4. Migraine
5. Cerebral tumour and other SOLs

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1. stroke
2. Syncope
3. Seizure
4. Migraine
5. Cerebral tumour and other SOLs
 Test your knowledge

A 60-year-old female came to the GP clinic with weakness of the right leg. She
has diabetes type I which is well controlled. Physical examination shows B.P- 130/90, normal
fundoscopy, cranial nerves intact, no bruit, tone slightly increased, power 4/5 on left
WHAT SHOULD BE THE NEXT STEP

Refer to ED
Arrange CT
Carotid doppler
Do blood workup
Give asprin

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Refer to ED
Arrange CT
Carotid doppler
Do blood workup
Give asprin
ABCD Stroke Risk Tool
- Age: 60 years (1)
- BP: 140/90 (1)
- Clinical features
o Unilateral limb weakness (2)
o Speech impairment without
weakness (1)

- Duration
o 60 minutes (2)
o 10-59 (1)
- Diabetes: 1
- Maximum: 7 points
- >4 = high risk and should REFER
- <4 = low risk
Is it STROKE? Think Fast
- Face (ask person to smile)
- Arms (raise both arms)
- Speech (speak a simple sentence)
- Time (within 3 hours)

Management
- One of the vessels supplying a part of the brain is blocked by a clot for a brief period of time which causes
a decrease in oxygen supply to that particular area of the brain
temporarily. This is what we call a mini-stroke or TIA. Most symptoms disappear within an hour
althoughthey may last for 24 hours. It might have come from the heart or it is a
clot that is formed from the vessel of the brain. It is due to fat deposits within the vessels called plaques. It is
considered as a medical emergency and taken as a warning sign for future brain attacks.
 Refer to ED or ADMIT to stroke unit ASAP so seen by a neurologist. will.
arrange for urgent CT scan and carotid Doppler
- Need to do FBS, lipid profiles, FBE,UEC, LFTs, ECG, 2d-echo, TFTs,clotting profile,HbA1c

- 20% will get stroke in the next 6 months and 50% of these people areat risk of getting full-blown
strokewithin the next 24-48 hours.-

The specialist might consider starting

clopidogrel or ASA +dipyridamol to decrease the risk ofstroke in the future (30% decrease inthe
risk of future stroke after TIA).
- address- Lifestyle modification.
- If treating as OP:
- In low risk: arrange CT brain and carotid Doppler (for possible
endarterectomy) within the next 24- 48 hours.

- Arrange all basic bloods: FBS, creatinine, cholesterol, TFTs, RFTs, ECG (TEE)
- Refer patient to TIA clinic or neurologist within 7 days
- Management:

o Cessation of smoking and lifestyle modification (weight reduction, exercise, alcohol)

o Start antiplatelet therapy(asprin 100-300mg OD,clopidogrel 75mg OD ordipyridamol + ASA 200/25mg
BD;

o Statins
o Anti-hypertensives: ACE
inhibitors
o Monitor blood sugar
o End-arterectomy >70%

Warfarin
- Indications for carotid duplex ultrasound

o Bruit in the neck

o TIAs
o Crescendo TIAs (2 or more in1 week and longer lasting)
o Internal carotid arterysymptoms
o Hemispheric stroke
o Prior to major vascular surgery

- CHADS SCORE
o major stroke risk factors in people who have atrial fibrillation
o CHF (1)
o Hypertension (1)
o Age >75 (1)
o DM (1)
o Stroke/TIA (2)
‐ 0 – low – aspirin (81-325mg)
‐ 1 – Intermediate – aspirin or
warfarin
‐ >2 – high risk - warfarin
 Test your knowledge

A 61-year-old man is brought the Emergency Department with left-sided weakness of his arm and leg.
His past medical history is significant for myocardial infarction 3 years ago for which he takes aspirin
100 mg daily. Non-contrast brain CT scan excludes intracranial hemorrhage. Doppler ultrasonography
shows bilateral carotid artery stenosis of 50%. Which one of the following would be the
mostappropriate initial management

Add warfarin
Add clopidogrel
Carotid endarcterectomy
Continue aspirin
Give nimodipine

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Add warfarin
Add clopidogrel
Carotid endarcterectomy
Continue aspirin
Give nimodipine
a 40-year-old man who has consulted a general practitioner complaining of the shakes he spilled his drink last night,
he continued saying he had the shakes since early 20’s. It happens to him when he is nervous about something, but it
hasn't been a problem until recently (6-12 months). Sometimes his head shakes and often spills his drink when put a
glass to his mouth. He feels much better after a couple of beers. Recently he heard something about Parkinson's
disease which can cause the shakes, so he thought to see a doctor'.'It doesn't seem to bother him when get up in the
morning and doesn't stop him from going to sleep. It can go away for a few days then comes back. He don't have any
stiffness and no trouble moving from one position to another, nor in walking. he can control the shakes by gripping
things firmly.what is likely diagnosis?

Essential tremor
Parkinsons disease
Thyrotoxicosis
Cerebellar disease
alcoholism

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Essential tremor (ET).
ET is associated with involuntary shaking and difficulty with daily tasks

Alcohol tremors are typically associated with other withdrawal symptoms.

.
Alcohol tremors are caused by alcohol misuse disorder and withdrawal, while ET is
a neurological condition of unknown cause
Parkinson's tremors are present at rest with signs of parkinsonism others, e.g.
bradykinesia,rigidity)

•Essential tremors are absent at rest, do not resolve with distraction.

•Psychogenic tremors are also absent at rest but resolves with distraction.

•Cerebellar tremors are intentional tremors (e.g. when trying to voluntarily catch
something or touch his nose) + other cerebellar features (e.g. nystagmus, ataxia,
dysarthria).

Think of the tremoe as essential (do not resolve even with distraction) as it is essential!
Essential tremor is one of the most common neurological disorders, with prevalence increasingwith age.
An autosomal dominant family history is present in 50-60% of patients and the genetic basis is
unknown.
.
Age of onset is bimodal. with the largest peak in th second decade, and a smaller peak in the fifth
decade.

The characteristic finding is a postural and kinetic tremor of the upper limbs which interferes with fine
manual tasks. Head tremor is also present in 40%. Less commonly legs are involved or there is voice
tremulousness.

With advancing age, the tremor frequency often slows and amplitude increases, leading to a coarse
tremor which can be disabling, although this is uncommon.

Patients with benign essential tremor often drink as a means of controlling the tremor as alcohol has an
ameliorating effect in 50% of cases.

In this case, the patient may also be suffering from the effects of prolonged heavy drinking. Thiswould
require further assessment with the investigations recommended above.
Your next patient in GP practice is an elderly man with a long history of
hypertension and diabetes. He has developed tiredness, confusion, and he’s behaving
strangely for the last 2 days. Investigations show sodium is 120, potassium, chloride,
bicarbonate, Urea and creatinine are all normal. what is likely diagnosis. patient daughter gave
the history of him taking indapamide

Delirium
Fronttemporal Dementia
Acute psychosis
Vascular dementiA
Diabetic coma

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Delirium
FrontOtemporal Dementia
Acute psychosis
Vascular dementiA
Diabetic coma
Acute psychosis can be described as a clinical syndrome that involves hallucinations,
delusions, disorganized thoughts or behaviors, or some combination of these within an acute
timeframe (often less than 1 month).
Specifically, the DSM-5 diagnosis of brief psychotic disorder requires the presence of
psychotic symptoms for between 1 day and 1 month and that these symptoms not be
attributable to other causes.

This timeframe differentiates this condition from schizophreniform disorder, which relies on
the presence of psychotic symptoms for between 1 and 6 months.

In the International Classification of Diseases, Tenth Revision (ICD-10), the diagnosis most
closely corresponding to brief psychotic disorder is acute and transient psychotic disorders
(ATPD).

In ATPD, onset arises within 2 weeks, “changing and variable” psychotic symptoms are
present, and the possibility exists of a recent acute stressor prior to symptom onset.
Ms E, a 28-year-old woman, was brought to the emergency department (ED) by her family because of her
increasingly erratic behavior over the past several weeks. Her family reported that she appeared well until
4 months ago, when she lost her job. Since then, she became quieter and more withdrawn. Over the past
few weeks, she heard her name being called through the walls of her bedroom; however, no one else was in
her apartment. She was also convinced that someone had broken into her apartment and poured gasoline
into her kitchen, as the smell was overpowering; however, others were unable to detect that characteristic
odor. She had called 9-1-1 several times a week to report her concerns, but the police were unable to
identify evidence of a break-in. Her building manager became so concerned about the repeated police calls
that he notified Ms E’s family. In the ED, Ms E was disheveled, confused, and fearful. Her medical and
psychiatric history were unremarkable, and she was taking no prescribed medications or illicit drugs. Her
family history included a maternal uncle with schizophrenia, and her father had a history of bipolar
disorder. A strategy was developed to evaluate her affective, behavioral, and cognitive symptoms so that a
timely and effective intervention could be implemented.
Causes:
- Depression/Drugs/alcohol
- Ears/Eyes
- Metabolic (hyponatreamia, diabetes, hypothyroidism)
- Emotion/encephalopathy
(loneliness)
- Nutrition (Vitamin B12/diet)
- Trauma/tumor
- Infections
- Arteriovascular disease (CVA, MI)

Patient is having hyponatremic encephalopathy.

Symptoms: N/V headaches/
restless/ irritable/ drowsy/ seizure/confusions/coma/death.

Symptoms come with sudden drop of the sodium. Isotonic/hypertonic. If the

sodium drops slowly the fluid becomes hypertonic. Fluid always goes to the higher concentration thus losing the
water which then goes to the cells especially the brain cells. It causes herniation of the brain. If we give the sodium
too quickly, the cells will shrink quickly and the brain is going to die which is called central
pontine myelinolysis. Don’t replace it too quickly 0.5-1 mEq/hr.
QUESTION

MandILY aged 35 years presents to your GP clinic. She tells you that she had
intermittent blurring of vision, also difficulty identifying colours, for the last few weeks. pins and
needles in the left hand and difficulty walking and bladder dysfunction She attributed this to
stress at work and had not asked for help but yesterday evening she had similar episodes.N o
history of headache, no neck stiffness, but retroorbital pain
She is otherwise fit and healthy. Mandy works as secretary in an office and has to
work every day form 8-5 .looks well, BP - 130/80, vitals normal, 80 minutes, regular, BMI 27, VA: R
eye 6/12, L 6/6, visual fields normal, funduscopy blurring of disc margin in right side, no carotid
bruit

Atypical Migraine
TIA
Multiple sclerosis
Neurosyphilis
Trigeminal neuralgia
Atypical Migraine
TIA
Multiple sclerosis
Neurosyphilis
Trigeminal neuralgia
 Test your knowledge

A 56 year-old man presents to the emergency department with complaint of diplopia. On examination,
he has right-sided ptosis. His visual acuity and visual fields are unaffected.1 His right eye is depressed
inferiorly and laterally and he is not able to look at to the left side. The pupillary light reflex of the right
eye is sluggish. The neurological examination is otherwise unremarkable. Which one of the following
can be the most likely cause to this presentation
Midbrain infarct.
Right 6th nerve palsy.
Right 4th nerve palsy.
A lesion in the occipital cortex.
Posterior communicating artery
aneurysm

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Midbrain infarct.
Right 6th nerve palsy.
Right 4th nerve palsy.
A lesion in the occipital cortex.
Posterior communicating artery aneurysm
midbrain infarct.-
Right 6th nerve palsy.-horizontal binocular diplopia no ptosis
Right 4th nerve palsy- binocular vertical diplopia no ptosis.
A lesion in the occipital cortex.-impaired vision field defects
Posterior communicating artery aneurysm
This patient has the classic presentation of a third cranial nerve palsy.
The third cranial nerve supplies the levator muscles of the eyelid and four extraoccular muscles:
(1) the medial rectus (eye adduction),
(2) superior rectus (eye elevation),
(3) inferior rectus (eye depression),
(4) and inferior oblique (eye elevation).

Additionally, the third cranial nerve constricts the pupil through its parasympathetic fibers that supply the smooth muscles of the
ciliary body and the sphincter of the iris. The third nerve begins as a nucleus in the midbrain that consists of several subnuclei
innervating the individual extraoccular muscles, the eyelids, and the pupils.

The etiology of the third cranial nerve palsy is vast and includes conditions such as:

ischemia (e.g. diabetes and midbrain infarcts)

•Compressive effects of aneurysms such as those of the posterior communicating artery, internal carotid artery and basilar
artery.
•Trauma
•Infections
•Infiltrative diseases (e.g. neoplasms)
•Demyelination
•Space occupying tumors
•Meningitis
•Herniation
•Inflammatory diseases
The CN III has both motor (central) and parasympathetic (peripheral)
components.

Which fibers get affected in diabetes?

Which would lead to loss of pupillary light reflex?
Which fibers are compressed first?
Which would cause the down and out pupil?

Motor output
Fibers in the centre of the nerve
Supplies extraocular muscles
Affected in Diabetes mellitus

Parasympathetic output
Fibers on the periphery
Supplies the pupil
Affected by compression (eg, PCom aneurysm, uncal herniation)
A 65-year old woman presents to the emergency department with acute onset of left-sided ptosis
and horizontal diplopia. On examination, there is dilated nonreactive pupil on left side and normal
indirect light reflex of the left side. Which one of the following is the most likely diagnosis?

Optic nerve palsy-

Third cranial nerve
Fourth cranial nerve
Sixth cranial nerve
Seventh cranial nerve

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Optic nerve palsy-
Third cranial nerve
Fourth cranial nerve
Sixth cranial nerve
Seventh cranial nerve