A 72-year-old diabetic man presented to clinic complaining of vertigo and imbalance. On examination, he has right eye ptosis, his right pupil was 2 mm in diameter and his left was 4 mm. He had reduced sensation on the right side of his face and his left side of his body.

Which of the following is the most appropriate investigation?

A 55-year-old hypertensive man presented to casualty 3 hours after he suffered right sided weakness and dysphasia. His blood pressure was 178/90 mmHg, his pulse was 88 beats per minute. He had a GCS of 14/15 and muscle power of 3/5 in his right upper and lower limbs.

What is the most appropriate next step of management?

A 80-year-old diabetic presented to casualty after 4 hours of the onset of right hemiparesis. He had suffered a stroke the year before and was being followed up in the neurology clinic. His pulse was irregularly irregular upon palpation. A brain CT showed a major infarction in the left MCA territory.

A 27-yo man c/o recurrent ‘funny’ experience of nausea and warmth rising through his body followed by twitching of the left side of his face and an inability to speak for several minutes. Afterward he cannot remember what has occurred. Neuroimaging is most likely to show a lesion in which of the following areas?

A 72-year-old man was admitted due to progressive confusion. He claimed to have been visited by his late wife.

On examination, his GCS was 13/15, his blood pressure was 100/60mmHg, pulse was 90 beats per minute, temperature was 38°C. His pupils were equal and reactive and he was moving all limbs equally with normal tone and reflexes. His brain CT showed old lacunar infarcts.

Which of the following is the most appropriate treatment?

A 24-year-old lady was seen in clinic for recurrent episodes of syncope. An eye witness observed that she became unresponsive and noted jerky movement of her limbs which lasted for 5 minutes and was aborted spontaneously.

Which of the following is the most valuable modality in making a diagnosis of seizure?

A 27-year-old man was brought to casualty in status epilepticus. He was given intravenous diazepam on arrival and subsequently commenced on an infusion of phenytoin but continued to seize.

Which of the following is the next best step of management?

A 34-year-old woman has a convulsive seizure that does not stop after 5 min. Upon receiving an intravenous antiepileptics, she suddenly becomes hypotensive and bradycardic.

Which of the following is the likely AED she had received?

A 17-year-old lady was brought to the emergency department after collapsing in class. She was sitting at her desk when she suddenly slumped over. Her classmates noted jerky movements of her limbs with a side to side movement of her head but she was able to verbally respond to their calls. She did not sustain any injuries and was able to converse normally immediately afterwards.

What is the next best step in her management?

A 68-year-old man was brought to casualty after his family noted he was suddenly unable to walk properly and was confused. On examination, he was afebrile, his blood pressure was 96/56mmHg, his pulse was 92 beats per minute. His GCS was 13/15. His pupils were equal and reactive but there was nystagmus and he was unable to abduct both eyes. His muscle tone and reflexes were normal and he was moving all four limbs with an estimated power of at least 4/5.

What is the best treatment for him?

A 21-year-old lady presented with sudden onset monocular visual loss. On examination, he visual acuity was only 60/18 in her left eye and on examination of her fundi, her optic discs were pale. She demonstrated RAPD in the affected eye.

What is the most accurate diagnosis?

A 66-year-old man was admitted to the hospital after he sustained a hip fracture from a fall. He blamed the fall on the fact that he his shaky and slow feet while he was going to the toilet. He also has episodes of urinary incontinence. On examination, his blood pressure was 140/80 mmHg. There was no bradykinesia but fine tremors were present on movement. His gait was broad-based, slow, short-stepped. He scored 22/30 for his MMSE.

What diagnosis is his history suggestive of?

A 55-year-old man presented to casualty with a 3-day history of limb weakness. He spoke with a soft voice and had an expressionless face. On examination, his shoulder and hip flexors and extensors were 3/5, his elbow and knee power were 4/5 and his wrist, finger and ankle power were 5/5. He had normal tone and reflexes.

What is the most likely diagnosis?

A 38-year-old man presented with tremor and falls. He had recently lost his job after several incidences of uncharacteristic disruptive behaviour at work. On examination, he had bilateral rest tremor, bradykinesia and cogwheel rigidity.

Which of the following is the most appropriate treatment?

A 68-year-old man presented to clinic complaining of cramps in his right upper and lower limbs. He claimed he found it difficult to write or put on his buttons. On examination, he was a soft spoken man with paucity of movement. The tone was increased in the affected limbs but power, reflexes and sensation were all normal. All other examination was unremarkable.

What is the most likely diagnosis?

A 61-year-old man presented with giddiness. On examination, his blood pressure was 135/85mmHg lying and 110/60mmHg standing. He was clumsy on both his feet and with both his hands. He was slow in initiating movements.

What is the most likely cause for his symptoms and signs?

A 55-year-old smoker presented with a 3-day history of fever and headache. He had seen several general practitioners for a chronic non-productive cough. A contrasted brain CT was normal. A lumbar puncture was performed which showed an opening pressure of 20cmH2O, protein of 990mg/dL, glucose of 1.3mmol/L and blood sugar of 5.4 mmol/L with 15 lymphocytes/mm3.

Which of the following is the most likely diagnosis?

A 17-year-old student was brought in with fever, headache and altered sensorium. On examination, his GCS was 9/15. His blood pressure was 110/70mmHg, his pulse was 90 beats per minute. A petechial rash was noted on his torso.

Which of the following is the best advice for his contacts?

A 15-year-old boy presented to casualty with a 1 week history of fever, headache and sezures. A lumbar puncture was performed which showed a CSF protein of 1030, glucose of 1.3 mmol/L with 15 lymphocytes.

Which of the following is the most appropriate treatment?

A 25-year-old man was admitted with lower limb weakness. On examination of his lower limbs, the tone was increased as were the reflexes but the power was 3/5. He had anaesthesia from his umbilicus downwards.

Which of the following is the most appropriate investigation?

A 25-year-old man was admitted with lower limb weakness. On examination of his lower limbs, the tone was increased as were the reflexes but the power was 3/5. He had anaesthesia from his umbilicus downwards.

Which of the following is the most appropriate treatment?

A 45- year old teacher presented with a six month history of progressive difficulty in swallowing. He also noticed that his speech became slurred after a few sessions of teaching in class. On examination, there is wasting and fasciculation of his tongue. His jaw jerk is exaggerated and the deep tendon reflexes are diffusely increased with flexor plantar responses. The upper and lower extremities strength was normal.

What is the most likely diagnosis?

A 60-year-old man presented to clinic complaining of marked weight loss of 10 kg over 4 months. He had no constitutional symptoms but noted a change in his voice for the past 2 months. On examination, he had marked muscle wasting and fasciculations. His sensation were normal.

Where is the most likely site of the lesion?

A 73-year-old smoker presented with complaints of bilateral lower limb numbness for the past 3 months. On examination of his lower limbs, the skin was shiny with sparse hair. He had full power with normal tone and absent ankle jerks. His sensation was reduced in both his feet up to mid shin.

What is the most appropriate initial investigation?

A 55-year-old man presented to casualty with a 3-day history of limb weakness. He spoke with a soft voice and had an expressionless face. On examination, his shoulder and hip flexors and extensors were 3/5, his elbow and knee power were 4/5 and his wrist, finger and ankle power were 5/5. He had normal tone and reflexes. He has bilateral eye ptosis which worsen on sustained upward gaze. There is a palpable goitre present as well.

What is the most likely diagnosis?

A 20-year-old lady presented to casualty with sudden onset right sided facial asymmetry. On examination, she was unable to wrinkle her forehead on the right side, shut her right eye tightly or lift the right angle of her mouth.

Which of the following is the most appropriate step in her management?

A 22-year-old lady presented with limb weakness. On examination of her lower limbs, tone was increased, muscle power was 3/5 and reflexes were brisk. She had anaesthesia from T4 downwards with lax anal tone. Her past medical history was unremarkable apart from a transient visual loss in her left eye 6 months ago which has fully resolved. Her serum aquaporin 4 is positive.

What is the most likely diagnosis?

A 70-year-old woman was seen in clinic with her husband for progressive memory loss for 1 year. She would forget where she parked the car and constantly misplaced items. She denied any hallucinations. On examination, her MMSE was 24/30. Her speech was fluent. Her tone, muscle power and reflexes were normal. She was able to write legibly.

A 27-year-old lady presented with progressive lower limb weakness after a bout of the flu. On examination of her lower limbs, tone was normal, muscle power was 2/5 and areflexic. She could not ambulate due to her weakness. Her sensation was intact. All other examination was normal.

What is the best course of management?

A 61-year-old man presents with severe headache and right sided weakness. On examination, his BP was 190/100mmHg and his pulse was 90 beats per minute. He had a right hemiparesis of 3/5. His CT brain was reported as normal.

Which of the following is the most appropriate step in management of his blood pressure?

A 52-year-old oil and gas engineer who worked in the Borneo presented with 8-days history of progressive headache and double vision. For the past one month, his colleagues noted that he was not being himself and had complained of night sweats. On examination, his GCS was E3M5V4 and he had a left third nerve palsy and a right sixth nerve palsy. Lumbar puncture was not performed. His full blood count was unremarkable. His rapid HIV test was negative however the toxoplasma serology was positive.

The below image shows a non enhanced CT and a contrast enhanced CT brain (CT-CE).

State the most likely diagnosis.

A 45-year-old female with a known history of migraine presents with a severe throbbing headache. On examination, she is confused and there is evidence of a 4/5 power on left side with brisk reflexes. She has recently been unwell with sinusitis. A non enhanced CT is performed and shows no significant findings. Which of the following is the most likely diagnosis?

A 64-year old woman is brought to emergency department with feeling generally unwell, fever, low back pain, bilateral leg weakness and urinary retention. She has a history of Type 2 diabetes mellitus and hypertension. Which of the following is the most likely diagnosis?

A 73-year-old man with long-standing diabetes presents with headache and fever. On examination, he has neck stiffness and mild confusion. Brain CT scan is unremarkable. Lumbar puncture is performed, and CSF shows 112 WBCs per mm³, with 89% neutrophils, protein level of 0.6 g/L, and glucose level 30% of plasma glucose. CSF culture is pending. Which empiric antibiotic regimen would you start?

A 35-year-old man suffers and SAH with intraventricular extension and develops hydrocephalus. An external ventricular drain is placed. Over the next several days, he develops fever and his CSF shows 212 WBCs per mm³ (81% neutrophils) and protein level of 0.75 g/. Which of the following is the likely pathogen causing this infection?

A 25-year-old man presents with headache and confusion for the past 3 days. MRI brain shows haemorrhagic changes in the temporal lobes. CSF PCR study comes back positive for HSV. Which of the following is a characteristic EEG finding to support the diagnosis?

A 18-year-old man presented with 2 days history of bilateral face drooping and difficulty fully closing his eyes. There was erythematous rashes at his back. Serum and CSF analysis was positive for B. burgdorgeri.

What is the most appropriate treatment?

A 32-year old pregnant lady with presented with fever, diplopia and facial pain. On examination, she has proptosis of the left eye with periorbital oedema, limited extraocular movements of the left eye, and reduced sensation over her left upper face and cheek. Fundoscopic examination revealed papilloedema and retinal haemorrhages.

What is the likely diagnosis?

A 33-year-old man with who had history of febrile illness last week was brought to emergency with impaired consciousness and seizure. Her vital signs were stable and she was afebrile. Serum IgM and IgG for dengue virus was positive. CSF showed pleocytosis, protein level of 0.4 g/L, and normal glucose level. MRI brain revealed confluent white matter involvement involving bilateral cerebral hemispheres.

What is the likely diagnosis for this patient?

A 53-year-old man with type 2 diabetes presented with 3 weeks of worsening headache, neck stiffness and fever. He recently had shingles in his T10 dermatome. CSF showed 112 WBCs per mm³, with 89% lymphocytes, protein level of 1.6 g/L, and glucose level 30% of plasma glucose. CSF culture is pending.

What is the likely organism?

A 66-year-old man was admitted to the hospital after he developed severe vertigo. He was well in the morning and suddenly had a severe spinning sensation after breakfast associated with vomiting and headache. On examination, his heart rate was 90 bpm and BP 160/90 mmHg. He had non fatiguable horizontal and vertical nystagmus. He is unable to perform neurological exam because of his severe dizziness.

What diagnosis is his history suggestive of?

A 60-year-old man with a history of hypertension presented with vertigo and unsteadiness for 2 days. He then develops nausea, vomiting, dysphagia, hoarseness, ataxia, left facial pain, and right-sided sensory loss. On examination, he is alert and orientated. There is skew deviation of the eyes, left ptosis, clumsiness of the left arm, and titubation. He has loss of pin and temperature sensation on the right arm and leg and decreased joint position sensation in the left foot. Which of the following is the most likely diagnosis?

A 68-year-old woman suddenly developed acute confusion. O/E HR 115bpm, BP 172/86mmHg. She has severe impairment of word fluency, naming, and repetition. There was a left gaze deviation and right hemiparesis. What is the most likely cerebral artery affected?

A 48-year-old man was brought to the emergency room 30 minutes after suddenly developing weakness of the left arm and leg. On examination, his heart rate was 98 beats per min and blood pressure was 162/86 mmHg. Left lower extremity weakness was more profound than the left upper extremity. The right limbs display full antigravity power without drift for 5 seconds.

What is the most likely cerebral artery affected?

A 45 year old man presented with 6 months history of progressive weakness. He first noticed fine motor coordination of the right hand, but this later progressed to involve the right arm and later all extremities. O/E he has dysarthria and reduced gag reflex. There is generalised weakness and atrophy. Deep tendon reflexes are hyperactive in both upper and lower limbs. Fasciculations are seen in the tongue and limbs. Sensory examination is normal. There is no significant family history. Which of the following is the most appropriate treatment?

A 27-year-old lady presented with progressive lower limb weakness after a bout of the flu. On examination of her lower limbs, tone was normal, muscle power was 4/5 and there was areflexia. She could ambulate around with minimal support. Her sensation was reduced as well. All other examination was normal.

A 15-year-old man presented to casualty with a 3 year history of limb weakness. On examination, his shoulder and hip flexors and extensors were 3/5, his elbow and knee power were 4/5 and his wrist, finger and ankle power were 5/5. He had normal tone and reflexes.

What is the most likely diagnosis?