2-Mark Exam Answers

Q1. Management of Febrile Seizures in Pediatrics

• Place child on their side, protect airway, do not restrain
• Administer rectal/IV diazepam (0.5 mg/kg rectal) for prolonged seizure (>5 min) or status epilepticus
• Antipyretics (paracetamol/ibuprofen) to control fever - treat the underlying cause of fever

• Most simple febrile seizures need NO prophylactic daily medication
• Intermittent oral/rectal diazepam at the time of fever in children with frequent recurrences
• Continuous prophylaxis (phenobarbitone or valproate) only if recurrences are very frequent or complex features are present
• Parental reassurance - condition is benign in the vast majority

Q2. Various Stages of Parkinson's Disease (Hoehn & Yahr Scale)

Q3. Diagnosis of Stroke

• Sudden onset of focal neurological deficits (hemiplegia, aphasia, facial droop, visual loss)
• Use FAST criteria: Face drooping, Arm weakness, Speech difficulty, Time to call help

• Non-contrast CT scan of brain - first line; distinguishes hemorrhagic from ischemic stroke (hemorrhage appears as hyperdense area)
• MRI brain (DWI) - more sensitive for early ischemic stroke
• CBC, PT/INR, APTT, blood glucose, ECG (to detect AF)
• Carotid Doppler/CT angiography - to identify source
• Echocardiography - to identify cardioembolic source

Q4. Classification of Stroke

1. Ischemic stroke (85%) - due to occlusion of a vessel
   • Thrombotic (large vessel atherosclerosis, small vessel lacunar)
   • Embolic (cardioembolic - AF, valve disease; artery-to-artery)
   • Cryptogenic (unknown cause)
2. Hemorrhagic stroke (15%)
   • Intracerebral hemorrhage (ICH) - hypertension most common cause
   • Subarachnoid hemorrhage (SAH) - usually ruptured berry aneurysm

• Anterior circulation (carotid territory): MCA, ACA strokes
• Posterior circulation (vertebrobasilar territory): PCA, basilar, PICA strokes

• TIA (Transient Ischemic Attack): deficits resolve within 24 hours (no infarct on imaging)
• Stroke in evolution: deficits progressing
• Completed stroke: stable deficits

Q5. Benefits of Anticholinesterase Drugs in Alzheimer's Disease (AD)

1. Improved cognition - modest improvement in memory, attention, and orientation (MMSE scores)
2. Improved activities of daily living (ADL) - better functional independence
3. Behavioral improvement - reduced agitation, apathy, and neuropsychiatric symptoms
4. Slowing of disease progression - delay in decline of cognitive function (symptomatic, not curative)
5. Used across all stages - donepezil is approved for mild, moderate, and severe AD; rivastigmine also available as a patch (improves compliance)

Q6. Advantage of Heparin (LMWH) over Warfarin in Stroke

Q7. Patient-Specific Factors to be Considered in EBM (Evidence-Based Medicine)

1. Clinical characteristics - severity of disease, comorbidities, organ function (renal/hepatic), age
2. Patient preferences and values - what outcomes matter most to the patient; willingness to accept risk or side effects
3. Social and cultural factors - literacy, support system, financial status, health beliefs
4. Previous treatment history - what has worked or failed before; allergies
5. Risk-benefit assessment - the evidence may apply differently based on the individual's baseline risk

Q8. Levels of Trust (Hierarchy of Evidence) in EBM

Sources: Bradley and Daroff's Neurology in Clinical Practice; Harrison's Principles of Internal Medicine 22E; Adams and Victor's Principles of Neurology 12E; Washington Manual of Medical Therapeutics.

2-Mark Exam Answers

Q1. Management of Febrile Seizures in Pediatrics

• Place child in lateral (recovery) position, protect from injury, maintain airway
• Diazepam - rectal (0.5 mg/kg) or IV (0.3 mg/kg) for seizure lasting >5 minutes
• Treat fever: paracetamol (15 mg/kg oral/rectal) or ibuprofen
• Identify and treat the underlying cause of fever (e.g., otitis media, URTI)

• Simple febrile seizures - NO daily prophylactic medication needed; parental reassurance
• Recurrent febrile seizures - intermittent oral or rectal diazepam given at onset of fever
• Continuous prophylaxis (phenobarbitone or sodium valproate) only in selected cases with very frequent, complex, or prolonged recurrences

Simple febrile seizure: generalized, <15 min, single episode per illness, age 6 months - 6 years. Complex febrile seizure: >15 min, focal features, OR >1 seizure in 24 hours.

Q2. Various Stages of Parkinson's Disease

Q3. Diagnosis of Stroke

• Sudden onset focal neurological deficit: hemiplegia/hemiparesis, facial droop, aphasia, dysarthria, visual field defect, ataxia
• FAST score: Face drooping, Arm weakness, Speech difficulty, Time to act

Q4. Classification of Stroke

1. Ischemic Stroke (85%)
   • Thrombotic: large vessel (atherosclerosis) or small vessel (lacunar - hypertension/diabetes)
   • Embolic: cardioembolic (AF, valvular disease, LV thrombus) or artery-to-artery
   • Cryptogenic: no identifiable cause
   • Other: vasculitis, hypercoagulable states, dissection
2. Hemorrhagic Stroke (15%)
   • Intracerebral hemorrhage (ICH): hypertension is the most common cause; also amyloid angiopathy
   • Subarachnoid hemorrhage (SAH): ruptured saccular (berry) aneurysm most common

• Anterior circulation (carotid) - MCA, ACA territory
• Posterior circulation (vertebrobasilar) - PCA, basilar, PICA territory

• TIA (Transient Ischemic Attack): deficits resolve <24 hours; no infarct on imaging
• Stroke in evolution: deficits progressing
• Completed stroke: deficits stable

Q5. Benefits of Anticholinesterase Drugs in Alzheimer's Disease (AD)

1. Improved cognition - modest but significant improvement in memory, attention, and orientation (as measured by MMSE and ADAS-Cog)
2. Improved Activities of Daily Living (ADL) - better self-care, reduced dependence on caregivers
3. Reduced behavioral/neuropsychiatric symptoms - less agitation, hallucinations, apathy, and wandering
4. Slows rate of cognitive decline - delays progression (symptomatic benefit, NOT disease-modifying)
5. Available across all stages - Donepezil approved for mild, moderate, and severe AD; Rivastigmine available as transdermal patch (better GI tolerability)

Q6. Advantages of Heparin over Warfarin in Stroke

• Heparin used for bridging therapy (e.g., cardioembolic stroke with AF) when rapid anticoagulation is needed before warfarin takes effect
• LMWH used for DVT prophylaxis in immobile stroke patients
• Routine heparin is NOT recommended in all acute ischemic strokes due to hemorrhagic transformation risk

Q7. Patient-Specific Factors to be Considered in EBM

1. Disease severity and comorbidities - other illnesses that modify treatment choice (e.g., renal failure, hepatic disease)
2. Age and physiological state - pediatric, geriatric, pregnancy, immunocompromised
3. Patient preferences and values - what outcomes the patient prioritizes; willingness to accept adverse effects or invasive procedures
4. Socioeconomic and cultural factors - affordability of treatment, cultural beliefs, health literacy, social support
5. Previous treatment response - history of allergies, drug failures, or successful therapies
6. Baseline risk - the absolute benefit of an intervention depends on the individual's baseline risk; evidence from RCTs may not apply uniformly to all patients

Q8. Levels of Trust / Hierarchy of Evidence in EBM

• Systematic reviews/meta-analyses sit at the apex of the evidence pyramid
• The Cochrane Database of Systematic Reviews is the prototype resource
• Higher levels = less bias, more generalizability
• Expert opinion = lowest trust, most prone to bias
• Systematic reviews are only as good as the underlying trials; they cannot compensate for poor-quality primary evidence

Sources: Bradley and Daroff's Neurology in Clinical Practice | Harrison's Principles of Internal Medicine 22E | Adams and Victor's Principles of Neurology 12E | Washington Manual of Medical Therapeutics