CASE TASKS FOR THE EXAMINATION

CASE TASKS FOR THE EXAMINATION

1. A 34-year old patient has reported cessation of her menstrual periods and then her eyesight began to worsen. Primary atrophy of optic nerves has been detected as well as bitemporal hemianopia. For 3 years patient has been treated by ophthalmologists in outpatient and inpatient settings but her eyesight was progressively decreasing. At visual acuity of 0.02, 0.03 and prominent primary atrophy of the optic nerves select the supplemental investigation which will make it possible to set the diagnosis. 

A) Ventriculography;

B) CSF analysis;

C) Cranial X-ray;

D) EEG (electroencephalography of the brain);

E) EchoEG (echo-encephalography)

2. A patient has been hospitalized due to closed craniocerebral trauma, fracture of the left temporal bone. 6 hours after trauma patient’s status has abruptly deteriorated, patient is unconscious, respiration disorders have developed, tonic seizures occur periodically, pupils are wide, reaction to light is weak, left pupil is somewhat wider than the right one.

What caused deterioration of patient’s status?

A) Meningoencephalitis;

B) Stroke;

C) Development of epidural hematoma;

D) Development of brain abscess;

E) Peculiarities of clinical course of brain contusion.

3. A 9-year old boy has fallen from the tree and has hit his occipital region; a short loss of consciousness has taken place. Child’s status is satisfactory, patient reports headaches and dizziness. Cranial radiograms have demonstrated an impressed comminuted fracture of the occipital bone.

What treatment is indicated to this patient?

A) Anti-inflammatory therapy;

B) Surgical intervention;

C) Hemostatic therapy;

D) Unloading lumbar punctures;

E) Complex conservative treatment.

4. Patient has a cut wound of the inferior 1/3 of the left shoulder. After the injury left hand has hung down. Patient can not extend his wrist, abduct his thumb and extend his fingers.

Which nerve has been injured?

A) Median nerve;

B) Ulnar nerve;

C) Radial nerve;

D) Brachial plexus;

E) Axillary nerve.

5. Patient has been transported to the specialized traumatological department in the status of alcoholic intoxication. Psychomotor agitation was noted. A subcutaneous hemorrhage has been detected in the left temporal region; hemorrhagic fluid is continuously flowing out of the external acustic meatus. Patient has been diagnosed with alcohol intoxication and therapy has been prescribed. 6 hours after admission patient has developed tonic seizures, anisocoria (left pupil is wider than the right one) and a status of deep spoor.

What is the diagnosis?

A) Alcohol delirium;

B) Brain concussion;

C) Epidural hematoma;

D) Acute disorder of cerebral circulation;

E) Meningoencephalitis.

6. Patient became a victim of traffic accident and has hit his head against pavement. Patient’s status is severe, unconscious state, respiration is intermittent and noisy. A large wound of soft tissues is detected in the frontal region, bone fragments are visualized as well as brain detritus, wound is bleeding.

Indicate management tactics at the pre-hospital stage.

A) Removal of bone fragments;

B) Wound suturing;

C) Hemostasis, aseptic dressing;

D) Removal of brain detritus;

E) Anti-edema therapy.

7. A 42-year old patient was admitted to the clinic with complaints on headache which is worsening in the morning hours and is followed by vomiting, unsteady gait and absent hearing in the right ear. Patient reports “darkening” in her eyes when changing her body position. She has been ill for about 5 years. First, tinnitus in her right ear developed; she has been examined and treated by otorhinolaryngologists with no improvement. Than her hearing in the right ear started to deteriorate. Two years ago deafness of the right ear has occurred. During the last year patient reports headaches in the pre-morning hours. Currently her headache is constant and the abovementioned symptoms have developed.

Determine the type of brain lesion.

A) Otosclerosis;

B) Neuritis of the auditory nerve;

C) Neurinoma of the auditory nerve;

D) Meningoencephalitis;

E) Insufficient circulation in the vertebra-basilar system.

8. Mother of a 9-month old infant has consulted her physician due to recurrent vomiting which has developed a month ago. In the age of 6 months child has fallen off the 60-cm high sofa hitting his head; there was swelling of parietal region and repeated vomiting which lasted one day. One month after the injury cranial part of the head has started to enlarge and the great fontanel has enlarged. Upon examination child is hypotrophic, cranial part of the head is enlarged, skin is thin, transparent, veins on the skin of the head are dilated, the great fontanel is tense.

Establish the preliminary diagnosis.

A) Meningoencephalitis;

B) Rickets;

C) Post-traumatic hydrocephalus;

D) Gastroenterocolitis;

E) Brain abscess.

9. Child was born at term. Parturition was uncomplicated. In the frontal region along the midline there is a tumor-like swelling 4x4x5 cm. Over the swelling skin is unchanged, and the swelling increasing when child is straining. No changes were detected in the neurologic status.

Determine the type of pathology.

A) Cephalohematoma;

B) Craniocerebral hernia;

C) Hydrocephalus;

D) Osteoma;

E) Labor tumor.

10.Patient has fallen down and hit his head; there was a short loss of consciousness. In two hours pulsating noise has developed in his right side of the head, hyperemia of the right eye conjunctiva, right-side exophthalmus which is increasing and weakness in the left extremities.

What caused this clinical presentation?

A) Brain contusion;

B) Intracranial hematoma;

C) Carotid-cavernous fistula;

D) Hydroma;

E) Brain concussion.

11.A 34-year old patient is complaining of constant pain in the interscapular region, predominantly on the left side, which increases in the recumbent position and during abrupt movements. During coughing pain becomes darting and spreads to the left subscapular region. Pain increases during percussion of the spinal process of Th5. A month ago patient developed weakness in his lower extremities, numbness of his feet and shins. Sensitivity disorders have an ascending pattern.

Which is the most possible diagnosis?

A) Multiple sclerosis;

B) Intercostal neuralgia;

C) Spinal cord tumor;

D) Spondyloarthrosis;

E) Syringomyelia.

12.A 32-year old patient has fainted when lifting heavy loads and fell down. Upon admission his status is severe. According to his relatives’ words – until this event he has been practically healthy and had no complaints. No traumatic lesions are detected on the cranium. Focal neurologic symptoms are absent. During lumbar puncture CSF is intensely colored with blood, CSF pressure is 200 mm H20.

What is the most likely cause of the disease;

A) Meningoencephalitis;

B) Rupture of the aneurism;

C) Brain abscess with communication to the ventricle;

D) Brain tumor;

E) Thrombosis of the middle cerebral artery.

13.A 28-year old patient has been hospitalized in a severe status and unconscious. Patient is pale, her pulse is threadlike and frequent, blood pressure 60/0 mm Hg. Focal neurologic symptoms and meningeal signs are absent. In the frontal region there is an abrasion and a small hemorrhage. Emergency team physician has said that patient had been found unconscious.

The most likely cause of the disorder is:

A) Acute disorder of cerebral circulation;

B) Brain contusion;

C) Intraabdominal bleeding;

D) Brain abscess;

E) Viral meningitis.

14.A 62-year old patient is in severe status. Patient reports severe headaches which increase in the morning, vomiting, and limited movements in the left extremities. Patient has been sick for 2 weeks and his status is progressively deteriorating. Patient has been smoking since he was 20 years old. For the last year patient has been reporting constant coughing. Patient is skinny, skin is grayish and dry; signs of intoxication. There are focal symptoms of right hemispheric lesion; on the fundus – edema of the optic nerve disks.

What is the preliminary diagnosis?

A) Atherosclerotic encephalopathy

B) Metastatic tumor of the brain

C) Pneumonia

D) Arachnoencephalitis

E) Ischemic stroke

15.Patient is reporting headache which is more prominent on the right side, fever up to 38ºC, and weakness in the left extremities. From the history it is known that 2 months ago patient has been discharged from the hospital where he has undergone a surgery due to open impressed comminuted of the right parietal bone. During examination there is a 4x4 cm defect of the right parietal bone. Skin over the defect is moderately painful and hyperemic. Anisocoria; tendon reflexes are predominant on the left side, muscle strength is somewhat decreased in the left extremities, hemihypaesthesia on the left side. An 8 mm leftward dislocation of midline echo has been detected.

What preliminary diagnosis is most likely?

A) Chronic subdural hematoma;

B) Meningitis;

C) Meningoencephalitis;

D) Brain abscess;

E) Osteomyelitis.

16.A 30-year old patient has been admitted to the neurosurgical department in a severe status. Profound torporous disorder of consciousness, moderate anisocoria (D>S), hemiparesis and hemihypaesthesia on the left side. From the history it is clear that patient has chronic otitis . Two weeks ago he has undergone a surgery due to right-side otitis media. One week after the surgery patient’s status has deteriorated, he has developed headache and fever up to 38º. During Echo-EG – an 8 mm leftward dislocation of midline echo is detected.

What is the preliminary diagnosis?

A) Brain tumor;

B) Chronic subdural hematoma;

C) Brain abscess;

D) Acute disorder of cerebral circulation;

E) Arachnoencephalitis.

17.A 38-year old patient has developed lumbar pain with irradiation along the posterior surface of his left leg during lifting heavy weights. Pain increases when body position is changed and in the upright position. Positive stretch symptoms were detected during examination.

What is the preliminary diagnosis?

A) Pathology of the intervertebral disks (osteochondrosis);

B) Spinal cord tumor;

C) Arachnomyelitis;

D) Polyneuritis

E) Myelopathy.

18.An 8-year old child has been reporting vomiting for 3 weeks predominantly in the pre-morning hours and during abrupt changes of head position. During examination child has a forced position of his head tilted rightwards, bilateral horizontal positional nystagmus is detected as well as unsteadiness in Romberg’s position. On the ocular fundus – edema of the optic nerve disks.

The most likely diagnosis in this child is:

A) Gastritis

B) Helminthic invasion;

C) Meningoencephalitis;

D) Tumor of the IV ventricle;

E) Chronic cholecystitis.

19.A 40-year old patient is reporting worsening of her eyesight in the right eye, protrusion of her right eye, periodical headache predominantly in the morning, decreased memory. Objectively: right-side exophthalmus, right-side vision acuity 0.05, left-side - 1.0. On the ocular fundus – primary atrophy of the right optic nerve, edema of the left optic nerve disk.

What pathology caused these clinical manifestations:

A) Carotid-cavernous fistula;

B) Aneurism of the cerebral vessels;

C) Orbital tumor;

D) Tumor of the anterior cranial fossa;

E) Thyrotoxicosis;

20.A 36-year old patient has lower spastic paraparesis, conduction hypalgesia from the level of Th4. During lumbar puncture CSF pressure is 80 mm H2O, during liquorodynamic tests - complete liquorodynamic block, CSF hyperalbuminosis.

Which disease is most likely?

A) Syringomyelia;

B) Myelitis;

C) Vascular process (myelopathy);

D) Spinal cord tumor;

E) Multiple sclerosis;

21.A 20-year old patient has undergone an otorhinolaryngological surgery due to left-side purulent otitis. Three days after the procedure patient developed general cerebral symptoms as well as focal symptoms of the left hemispheric lesion. During Echo-EG – a 6 mm rightward dislocation of the midline echo has been detected. On the ocular fundus – veins are dilated, plethoric, increased pulsation of the arteries.

What caused deterioration of patient’s status?

A) Meningitis;

B) Exacerbation of otitis;

C) Encephalitis;

D) Brain abscess;

E) Ischemic stroke.

(21) A child aged 1 year and 10 months has been admitted to the clinic. The dressing on child’s head is overwhelmingly soaked with ichorous liquid. Father has said that the child has fallen on the playground and has hit her head against the board; she did not faint. The dressing has been put which is continuously soaking. During examination child is somnolent, no focal neurologic symptoms are detected, and meningeal signs are absent. In the right parietal region there is a linear skin injury 1 cm long which is constantly excreting ichorous fluid.

What is the preliminary diagnosis?

A) Brain concussion;

B) Meningitis;

C) Open CCT with liquorrhoea;

D) Brain contusion;

E) Closed CCT.

22.A 20-year old patient was admitted to the intensive care unit in a severe status, unconscious, with seizures more prominent in the left extremities, pricking causes intensification of seizures, prominent meningeal syndrome. Parents have said that 7 years ago patient developed seizures in the left extremities which occurred once in 6 months. Three years ago generalized seizures developed with loss of consciousness which repeated every 2 months. Today in the morning patient has developed severe headache, vomiting, weakness in the left extremities, clonic seizures with loss of consciousness. During lumbar puncture patient’s CSF is intensely colored with blood, CSF pressure is 240 mm H2O.

What is the preliminary diagnosis?

A) Brain abscess;

B) Brain tumor;

C) Arteriovenous malformation;

D) Arachnoencephalitis;

E) Craniocerebral trauma.

23.A 36-year old patient two months ago has undergone a radical surgery due to chronic right-side otitis. Patient’s status after the surgery was satisfactory. Three weeks ago patient developed headache, nausea and vomiting t - 39º - 38.5º as well as focal symptoms of the right hemispheric lesion, meningeal syndrome. Patient is hospitalized due to otogenic meningitis. Today patient’s status has worsened, patient is in sopor; anisocoria is detected D>S. Midline M-echo is dislocate leftwards by 8 mm.

What pathology caused deterioration of patient’s status?

A) Arteriovenous malformation;

B) Brain tumor;

C) Hemorrhagic stroke;

D) Brain abscess;

E) Meningitis.

24.A 32-year old patient has reported severe headache and fainted, falling down. Emergency physician has noted patient’s severe status, sopor, and meningeal syndrome. In the inpatient department – during lumbar puncture – CSF is hemorrhagic, CSF pressure is 260 mm H2O

What is the preliminary diagnosis?

A) Brain tumor;

B) Meningoencephalitis;

C) Aneurism, hemorrhagic stroke;

D) Ischemic stroke;

E) Craniocerebral trauma.