Stroke, seizures, headache and neuromuscular disease

28 NEET-PG practice questions on Stroke, seizures, headache and neuromuscular disease, part of General Medicine. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 62-year-old man is brought to the emergency department with sudden right-sided weakness and difficulty speaking. He was last seen well 2.5 hours ago. Non-contrast CT shows no haemorrhage. BP 176/98 mmHg, capillary glucose 132 mg/dL, and he takes no anticoagulant. What is the next best step?

   1. AIV thrombolysis now
   2. BMRI brain to confirm the infarct first
   3. CAspirin 300 mg and admission for observation
   4. DLower BP below 140/90 mmHg before treatment

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   Answer: A · IV thrombolysis now

   Acute ischaemic stroke within 4.5 hours of last-known-well, with haemorrhage excluded on CT, is treated with IV thrombolysis (alteplase or tenecteplase) as fast as possible, as every minute of delay costs neurons. BP needs to be below 185/110 mmHg before lysis and below 180/105 mmHg for 24 hours after; his already is. Aspirin is withheld for 24 hours after thrombolysis. CT angiography to look for a large-vessel occlusion should not delay the lytic.

   • B: MRI is not needed when CT excludes bleeding, and it wastes time.
   • C: Aspirin alone forgoes a proven treatment within the window and is withheld for 24 hours after lysis.
   • D: The target before lysis is below 185/110 mmHg; aggressive lowering only delays treatment.

2. Question 2 · Medium

   A 34-year-old man with Guillain-Barré syndrome is on day 3 in the ward and the weakness is spreading upward. He now has a weak cough and speaks in short sentences. SpO2 is 97% on room air. Which bedside measure best decides when he needs ICU care and ventilation?

   1. ASerial forced vital capacity
   2. BPeak expiratory flow rate
   3. CArterial PaO2 on blood gas
   4. DContinuous pulse oximetry

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   Answer: A · Serial forced vital capacity

   In GBS the danger is neuromuscular respiratory failure, which shows first as a falling vital capacity while oxygen saturation stays normal until late. FVC (with maximal inspiratory and expiratory pressures) is measured several times a day; a value approaching 20 mL/kg, a fast fall, or bulbar weakness calls for elective intubation. Autonomic instability, with arrhythmias and swings in BP, also needs ICU monitoring.

   • B: Peak flow measures airway obstruction and needs a good seal that weak facial muscles cannot give.
   • C: Hypoxaemia on blood gas is a late sign of ventilatory failure.
   • D: Saturation falls late, when the patient is already close to arrest.

3. Question 3 · Medium

   A 38-year-old man has fatigable ptosis and weakness of the arms; anti-acetylcholine receptor antibody is positive and repetitive nerve stimulation shows a decrement. Pyridostigmine is started. Which investigation should be done next?

   1. AMuscle biopsy
   2. BCSF analysis
   3. CContrast CT of the chest
   4. DMRI of the brain

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   Answer: C · Contrast CT of the chest

   Every new case of myasthenia gravis needs CT or MRI of the anterior mediastinum, because about 10-15% have a thymoma and many others have thymic hyperplasia. A thymoma must be removed. In AChR antibody-positive generalised myasthenia, thymectomy also improves outcome even without a thymoma. Thyroid function is checked too, as autoimmune thyroid disease often coexists.

   • A: Muscle biopsy is for myopathies and does not help here.
   • B: CSF is normal in myasthenia.
   • D: Brain imaging is not needed for a disorder of the neuromuscular junction.

4. Question 4 · Hard

   A 68-year-old man with diabetes has had fever, confusion and neck stiffness for one day. CSF: WBC 1,200/µL (85% neutrophils), protein 180 mg/dL, glucose 22 mg/dL (blood 140 mg/dL); Gram stain shows no organisms. He has no drug allergy. Which empirical regimen is most appropriate, along with dexamethasone?

   1. AAmpicillin and gentamicin only
   2. BCeftriaxone and vancomycin only
   3. CCeftriaxone alone
   4. DCeftriaxone, vancomycin and ampicillin

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   Answer: D · Ceftriaxone, vancomycin and ampicillin

   The CSF is that of bacterial meningitis. In adults over about 50 years, and in those with diabetes, alcohol use or immunosuppression, Listeria monocytogenes is an added cause, and it is intrinsically resistant to cephalosporins, so ampicillin is added. Ceftriaxone covers pneumococcus and meningococcus, and vancomycin is added where penicillin-resistant pneumococci are a concern. Dexamethasone is given with or before the first dose and continued if pneumococcus is found.

   • A: Leaves out good cover for pneumococcus and meningococcus.
   • B: Leaves Listeria uncovered in an older diabetic patient.
   • C: Covers neither Listeria nor resistant pneumococci.

5. Question 5 · Hard

   A 50-year-old man in status epilepticus has received two doses of IV lorazepam and full loading doses of IV levetiracetam and then valproate, but at 55 minutes he is still seizing. SpO2 has fallen to 86% on a face mask and he is cyanosed. What is the next best step?

   1. AAnother loading dose of IV levetiracetam
   2. BIntubate and start a midazolam infusion
   3. CLumbar puncture to look for infection
   4. DOral clobazam by nasogastric tube

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   Answer: B · Intubate and start a midazolam infusion

   Seizures that continue after a benzodiazepine and a second-line drug are refractory status epilepticus. The patient is intubated and ventilated, and an anaesthetic infusion (midazolam, propofol or thiopental) is titrated to stop clinical and electrical seizures, with continuous EEG because seizures may continue without visible movement. The cause (metabolic, infection, drug, structural) is sought in parallel, and an LP is done only once the patient is stable.

   • A: Repeating a failed second-line drug delays control and leaves the hypoxia untreated.
   • C: LP may be needed later, but airway and seizure control come first.
   • D: Oral drugs are too slow and unsafe in a seizing, hypoxic patient.

6. Question 6 · Easy

   An 18-year-old army recruit at a training camp develops fever, vomiting, neck stiffness and a non-blanching purpuric rash. CSF shows a neutrophilic pleocytosis with low glucose, and Gram stain shows Gram-negative diplococci. He is started on IV ceftriaxone. His 12 roommates are well. What is the most appropriate step for the roommates?

   1. ASingle-dose ciprofloxacin chemoprophylaxis
   2. BObserve and treat only if fever develops
   3. COral amoxicillin for 7 days
   4. DThroat swabs before deciding on prophylaxis

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7. Question 7 · Hard

   A 42-year-old woman with myasthenia gravis has been increasing her own pyridostigmine doses over 2 days because she felt weak. She now has worse weakness, muscle twitching, sweating, drooling, abdominal cramps and diarrhoea. Pupils are 2 mm, pulse 52/min, and her FVC is falling. What is the most likely problem and response?

   1. AMyasthenic crisis; double the pyridostigmine
   2. BMyasthenic crisis; start oral prednisolone
   3. CCholinergic crisis; withhold pyridostigmine, support breathing
   4. DOrganophosphate poisoning; give pralidoxime

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8. Question 8 · Medium

   A 66-year-old man reaches a stroke-ready hospital 2 hours after the onset of right hemiparesis and aphasia. Non-contrast CT shows no bleed, glucose is normal and he takes no anticoagulant. His BP is 204/118 mmHg on two readings 10 minutes apart. What is the next best step?

   1. AWithhold thrombolysis because of the high BP
   2. BSublingual nifedipine, then aspirin
   3. CIV labetalol to below 185/110, then thrombolysis
   4. DGive thrombolysis at once without lowering the BP

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9. Question 9 · Medium

   A 45-year-old woman with Guillain-Barré syndrome diagnosed 5 days ago can no longer walk without help. Her breathing and swallowing are normal. Which treatment is most appropriate?

   1. AOral pyridostigmine
   2. BIV methylprednisolone
   3. CIV immunoglobulin
   4. DOral prednisolone

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10. Question 10 · Medium

    A 22-year-old primigravida at 34 weeks is brought to the labour room after a generalised seizure at home. BP 166/112 mmHg, urine protein 3+, and she is drowsy but breathing well. Which drug is best to prevent further seizures?

    1. ADiazepam
    2. BPhenytoin
    3. CMagnesium sulfate
    4. DLevetiracetam

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11. Question 11 · Hard

    A 64-year-old man is brought to a stroke centre 5 hours after he developed right hemiplegia, right gaze palsy and global aphasia. NIHSS is 18. Non-contrast CT shows no haemorrhage and only early changes in a small area (ASPECTS 8). CT angiography shows occlusion of the left middle cerebral artery (M1 segment). What is the next best step?

    1. AMechanical thrombectomy
    2. BDecompressive hemicraniectomy
    3. CAspirin and admission to a stroke unit
    4. DIV alteplase alone

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12. Question 12 · Medium

    A 70-year-old man with type 2 diabetes, on glibenclamide, is found confused at home with weakness of the right arm and leg that began within the last hour. Pulse 96/min, BP 150/90 mmHg, and he is sweating. Capillary glucose is 38 mg/dL. What is the next best step?

    1. ACT angiography for thrombectomy
    2. BIV thrombolysis at once
    3. CIV dextrose and reassess
    4. DAspirin 300 mg by mouth

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13. Question 13 · Medium

    A 40-year-old woman has had progressive weakness of both legs for 10 days, now affecting her arms, with tingling of the hands and feet. Knee and ankle jerks are absent, there is no sensory level and bladder function is normal. Serum K 4.2 mmol/L. CSF: cells 3/µL, protein 180 mg/dL, glucose normal. What is the most likely diagnosis?

    1. AAcute transverse myelitis
    2. BGuillain-Barré syndrome
    3. CHypokalaemic periodic paralysis
    4. DTuberculous meningitis

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14. Question 14 · Easy

    A 35-year-old man who smokes has been woken at night for 5 weeks by attacks of severe pain around his right eye, lasting about 45 minutes. During attacks his right eye waters and reddens, his nose runs and he paces the room. He had a similar bout 2 years ago. Which treatment best aborts an attack?

    1. AOral verapamil
    2. BOral propranolol
    3. COral amitriptyline
    4. DHigh-flow 100% oxygen

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15. Question 15 · Medium

    A 72-year-old man has had a new right-sided headache for 3 weeks, pain in the jaw when chewing and an episode of blurred vision in the right eye yesterday. The right temporal artery is tender and thickened, with a weak pulse. ESR 96 mm/h. What is the next best step?

    1. AHigh-dose prednisolone now, biopsy within days
    2. BTemporal artery biopsy before any treatment
    3. CNSAIDs and review in one week
    4. DOral sumatriptan for the headache

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16. Question 16 · Medium

    A 35-year-old man is still having a generalised seizure 20 minutes after it began, despite two doses of IV lorazepam given 5 minutes apart. His airway is protected and SpO2 is 95% on oxygen. Glucose is normal. What is the next best step?

    1. AIV levetiracetam loading dose
    2. BOral carbamazepine by nasogastric tube
    3. CA third dose of IV lorazepam
    4. DIV magnesium sulfate

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17. Question 17 · Easy

    A 68-year-old woman is brought to a district hospital emergency 1 hour after she suddenly developed weakness of the left arm and leg with slurred speech. Her capillary glucose is 126 mg/dL. Which investigation should be done first?

    1. AElectroencephalography
    2. BCarotid Doppler ultrasound
    3. CNon-contrast CT of the head
    4. DMRI brain with diffusion imaging

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18. Question 18 · Hard

    A 34-year-old man with newly diagnosed HIV (CD4 count 60 cells/µL), not yet on ART, has had headache and fever for 2 weeks. CSF opening pressure 32 cm H2O, cells 20/µL (lymphocytes), protein mildly raised, glucose low; India ink preparation shows encapsulated yeasts and cryptococcal antigen is positive. What is the best plan?

    1. AAmphotericin with flucytosine; ART after 4-6 weeks
    2. BFluconazole alone for 2 weeks, then ART
    3. CAmphotericin plus dexamethasone, with ART started at once
    4. DStart ART at once, with fluconazole

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19. Question 19 · Medium

    A 27-year-old woman has ptosis and double vision worse in the evening. Four statements are made about her likely condition: 1. Weakness increases with repeated use of the muscle. 2. Pupillary responses are normal. 3. Deep tendon reflexes are lost early. 4. An ice pack on the eyelid for 2 minutes improves the ptosis. Which statements are correct?

    1. A1 and 2 only
    2. B1, 2, 3 and 4
    3. C1, 2 and 4 only
    4. D2, 3 and 4 only

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20. Question 20 · Easy

    A 26-year-old man had diarrhoea 2 weeks ago. Over 4 days he has developed tingling of the feet and weakness that started in the legs and has now reached his arms. All deep tendon reflexes are absent and sensation is almost normal. Which preceding infection is most often linked to this illness?

    1. AVibrio cholerae
    2. BShigella dysenteriae
    3. CSalmonella Typhi
    4. DCampylobacter jejuni

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21. Question 21 · Medium

    A 44-year-old woman had a sudden, severe headache while lifting a gas cylinder 14 hours ago, with vomiting and neck pain. She is alert with mild neck stiffness and no focal deficit. Non-contrast CT of the head is normal. What is the next best step?

    1. ADischarge with analgesics
    2. BElectroencephalography
    3. CLumbar puncture for xanthochromia
    4. DRepeat non-contrast CT after 48 hours

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22. Question 22 · Medium

    A 70-year-old woman is receiving IV alteplase for an acute ischaemic stroke. Thirty minutes into the infusion she complains of a severe headache and vomits, and her GCS falls from 14 to 10. BP is 196/104 mmHg. What is the next best step?

    1. AComplete the infusion, then repeat CT
    2. BStop alteplase and get an urgent non-contrast CT
    3. CGive aspirin and start IV heparin
    4. DContinue the alteplase infusion and give IV mannitol

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23. Question 23 · Medium

    A 30-year-old woman from Bihar has had headache, low-grade fever and vomiting for 3 weeks and is now drowsy with a left sixth nerve palsy. CSF: protein 260 mg/dL, glucose 30 mg/dL (blood 100 mg/dL), cells 220/µL with 80% lymphocytes, ADA raised. CT shows basal exudates and mild hydrocephalus. Along with anti-tubercular treatment, which drug should be started?

    1. AAmphotericin B
    2. BMannitol
    3. CDexamethasone
    4. DAcyclovir

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24. Question 24 · Medium

    A 55-year-old woman with myasthenia gravis, stable on pyridostigmine, is admitted with pyelonephritis and started on IV gentamicin and paracetamol. Next day she has worse ptosis, difficulty swallowing and breathlessness. Which drug most likely worsened her myasthenia?

    1. APantoprazole
    2. BGentamicin
    3. CParacetamol
    4. DCeftriaxone

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25. Question 25 · Hard

    A 70-year-old woman reaches the emergency department 2 hours after the onset of left hemiparesis. Non-contrast CT shows no haemorrhage. Her findings: 1. INR 2.1; she takes warfarin for atrial fibrillation. 2. Capillary glucose 190 mg/dL. 3. Platelet count 80,000/µL. 4. BP 178/100 mmHg. Which findings are contraindications to IV thrombolysis?

    1. A1, 2 and 3 only
    2. B1 and 3 only
    3. C1, 2, 3 and 4
    4. D1, 3 and 4 only

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