Tuesday, May 26, 2009

MRCP PACES Course 2009

The time we feared most and the time we can't wait for it to be over. However, we choose to face it. PACES exam.....
We know that part of it is due to pure luck but if you are better prepared, the chances of passing is much higher.
Once again, Penang General Hospital, Seberang Jaya Hospital and Penang Medical College is planning for a MRCP PACES course the August 29 and 30. This is a soft launch for the course for those whom I am grateful for keeping up this blog. 

Thank you very much for the support. All entries are now closed. 

All the best !!

Friday, May 22, 2009

Neurology Quiz

(Archieves of Neurology Vol 66 (No 4) Apr 2009

What is the diagnosis and what is the differentials for this ?

Thursday, May 21, 2009

Tuberculous meningitis

A 45 year old man was admitted with a 3 day history of coma following 2 weeks of headache and fever. Examination revealed a GCS of 8/15, neck stiffness, and a complete R oculomotor nerve palsy. Examination of the CSF showed an opening pressure of 20 cmH2O, 800 leucocytes.mm3 (30% neutrophils, 70% lymphocytes), protein 180 mg/dl, CSF/ blood glucose 0.18. Gram and Ziehl-Neelsen stains of the CSF were negative. Culture of the CSF on Lowenstein Jensen media grew Mycobacterium tuberculosis.
(Adapted from Practical Neurology 2002)

This type of scenario can come out in the Part 1 or 2a MRCP and medical student exams. Not possible for PACES.

Name 3 complications of TB meningitis that may need neurosurgical intervention.

Sunday, May 10, 2009


Photo taken form www.thereddragonhood.com/ images/rabbit.jpg

Text adapted from Archieves of Neurology (April 2009)

A 21 years old previously healthy man presented with 7 days cough with black and yellowish sputum, fever, chills, myalgia and pleuritic chest pain. 3 days before admission, had progressive worsening headache with neck stiffness and 8 episodes of watery diarrhoea

He had taken amoxycillin for 1 day

He had recently changed job, working as a professional landscaper 7 days before onset of symptoms

He had performed lawn mowing and leaf blowing services and noted he had dead rabbits in the areas he worked

T - 39.6 C, Alert, orientated to time, place, person

Stiff neck, no weakness or numbness

Lungs - bibasal crepts with exp ronchi

No lymphadenopathy,  skin lesions, ulcerations

CT brain - Normal

WBC - 10.4 (78% N) ESR - 40 mm/h

CSF - Cell count 1416/mm3, 19% N 73% L RBC 23, glu 41 mg/dl(glu 123 mg/dl), pro 2660 g/dl

Gm stain CSF -ve


MRI - cerebellar tonsillar herniation consistent with Chiary Type 1 malformation without evidence of brainstem syrinx

Treated with IV Ceftrixone and IV Vancomycin

Day 4 , headache worse and developed diplopia and nausea

Repeated LP -Opening pressure - 49 cmH2O, total nucleated cell count 2590/mm3 32% N 43%L 25% M, glu 28 mg/dL, pro 2950 g/dL (RBS - 128 mg/dL) 

Gram stain negative

What is the diagnosis ?