Define the following:
- concussion
- diffuse axonal injury
- lucid interval
- transtentorial herniation
- tonsillar herniation
- whiplash injury
- lumbago
- sciatica
To top
36. A 42 year old man is evaluated for back
pain. This is an aching pain which radiates to his foot. he is uncomfortable
walking and can not find a comfortable position in bed. He consults
his primary care provider and is treated with pain medication, muscle
relaxants and an NSAID. He is no better; percocet proves ineffective.
He reports a tingling sensation over the top of his right foot and
he has tripped on two occasions.
Neuro exam shows
- absent right ankle jerk
- weaknes of dorsiflexion and plantar flexion
- decreased pinprick over the toop of the foot
- Loss of lumbar lordosis
- paraspinal muscle spasm in the lumbar region
- (+) Straight leg raise at 30 degrees on the right
- point tenderness over five lumbar vertebrae
- What structures are involved?
- What are potention mechanisms?
- What diagnostic studies are indicated?
- What are the clinical features of
- Brown-Sequard syndrome
- transverse [thoracic] myelitis
- anterior spinal artery ischemia
- conus medularis symdrome
- cauda equina syndrome?
- cervica syringomyelia
To top
27. "Hurricane" Bill is mugged outside a bar in
the French Quarter. He is unconscious for 15 minutes and has both
anterograde and retrograde amnesia. The neurologic exam is normal
except for abnormal olfaction. Ancillary studies include a skill
roentgenogram which shows a linear parietal skull fraction. CT and
MRI are normal.
Six months later he experiences an episode of lost
awareness. This begins with funny sensation in his stomach which
then rises to his chest. He then smells "burning rubber," and
his wife states he has rhythmical blinking. After three minutes
he is confused and complains of a left temporal headache.
- A. Has the patient suffered a concussion or a contusion?
- B. Interictal EEG is normal. Does this patient has psudo-seizures?
- C. A repeat interictal EEG shows left anterior temporal
spikes. Does this patient have partial complex seizures?
- D. Repeat MRI shows left hippocampal atrophy. What is the
mechanism?
To top
22. A 23 year old injection
drug user develops myalgia, fever and bifrontal headache. One
week ago he had a 3 day episode of diarrhea, which responded to
symptomatic therapy and resolved spontaneously.
On exam BP 140/80 HR 110 temperature 38.4C, respirations
12. The neck is supple and the skin is without rashes. The muscles
are diffusely tender. The neurologic exam is normal.
WBC=10,000, 60% lymph, 40% PMN. ESR=40, U/A and
chest film are normal.
A resident of a different speciality (and who tends
to start patient descriptions with the phrase "this is the guy")
believes "bacterial meningitis" or subarachnoid hemorrhage are
likely possibilities (he does not consult neurology, a service
he regularly belittles) and wants to ensure a nontraumatic tap.
Since he read that the spinal interspaces are bigger higher up
in the cord, he performs the tap at T9-10 instead of L3-4. Following
this LP based on RANDO criteria (Resident Ain't Never Done One)
the patient develops these imprairments:
- paraplegia with hypotonia
- absent patellar and ankle reflexes
- bilateral plantar responses
- a sensory loss to all modalities at T9
- incontinence.
The ER staff asks you to answer the following questions so he
can brief risk management
- A. Explain the post LP neurologic findings
- B. What diagnostic studies are warranted?
- C. Are post-LP findings consistent with anterior spinal
artery ischemia?
- D. Critique the initial handling of the case
- E. Should a CT have been performed prior to performing the
LP?
To top
11. A 35 year old electrician
is involved in an MVA where he is struck from behind. Mild low
back pain resolves completely after two days. Four weeks later
he begins to trip frequently, and three days after that he has
difficulty climbing stairs and opening jars.
The neurologic exam reveals
- weakness of the feet, hips, legs, knees and hands.
- He cannot walk on his toes or heels.
- Reflexes are absent; there are plantar responses.
- Sensation is normal
The physical exam is otherwise normal.
Impairment of which structures explains these findings?
- What diagnostic tests should be done?
- Three days later he develops diplopia and dyspnea. What
might explain this?
- What are the treatment options?
- He shows clinical improvement. Lumbar MRI shows diffuse
spinal and nerve root enhancement. What is the mechanism?
- What is the relationship of trauma to this condition?
To top
17. A 30 year old hockey player
is checked into the boards hard by the Flyers' Eric Lindros, striking
his head and back, and briefly losing consciousness. (The rabid
Philadelphia crowd goes wild.) He complains of occipital pain
which is mild but also severe mid-thoracic back pain. Team physicians
send him to the ER for observation. The following day the occipital
pain is gone but the back pain persists and he reports a band
of numbness on the left chest region extending to his back. He
experiences difficulty urinating.
Neurologic exam reveals mild weakness in both legs;
the arms are normal. Reflexes at the ankle,knee and abdominals
are present but depressed, and there are plantar responses bilaterally.
There is decreased perception of pinprick from the umbilicus downward,
and there is a band of decreased seneation on the left mid thoracic
and back region. There is a reduced anal wink.
- What was the mechanism of the initial injury?
- What condition could cause the symptoms and signs which
developed the following day?
- What neuroimaging studies are warranted?
- Could the neurologic impairment be explained by subdural
hematoma?
To top
4. A 70 year old judge notes deterioration
in his handwriting such that clerks can not read it. (See sample.)
He also has difficulty cutting his food and bringing a cup to
his mouth. He jokes that has always been shaky and that this runs
in his family.
Neurologic exam reveals normal gait and station.
There is a motor sustention and intention arm tremor; mild tremor
of his voice but no rigidity or bradykinesia; Myerson's sign (-).
A drawing of Archimedes spiral is presented.
- What is the differential diagnosis?
- What medication might cause this?
- What is the effect of Sinement (carbidopa/levodopa)?
- Define a treatment strategy for a Parkinson's patient with
tremor.
- Outline a treatment strategy for a Parkinson's patient with
tremor who is functionally impaired.
- List the major side effects for the following medications
- Cogentin (benztropine)
- Sinemet (carbidopa/levodopa)
- Deprenyl (selegiline)
- Parlodel (pergolide)
To top.
15. A 15 year old adolescent
is described as being "nervous and fidgety" (more than appropriate
for age, all things considered). His performance in school and
his behavior become bizarre. Past history is significant for viral
hepatitis 2 years ago and unexplained hemolytic anemia 4 years
ago. Both his parents are diagnosed with schizophrenia.
On exam he is inattentive with motor restlestness.
The gait is broad based with impaired postural reflexes. Motor
exam reveals cogwheel rigidity and intentional tremor. Finger-to-nose
and heel-to-shin testing are impaired. The cranial nerves and
fundi are normal. The physical exam reveals hepatosplenomegaly;
the skin is normal.
- What are the diagnositic possibilities?
- What tests are warranted?
- What are the treatment options?
- What is the natural history of this condition if not treated?
To top.
16. A 70 year old physician
is brought to a neurologist by his family because of "failing
memory." He forgets to pay his bills, has lost his house keys
and gotten lost while driving. Recently, three patients have initiated
malpractice claims due to his failure to diagnose their condition
correctly. He has become depressed and recently locked himself
in the bathrom. He appears to move slowly and has suffered multiple
recent falls.
Neurologic exam reveals a Mini-Mental Status Exam
of 19/30. The gait is slow and he has difficulty initiating movement.
Postural stability is impaired. Strength is normal and coordinated
movements are slow. There is bilateral cogwheel rigidity but no
tremor.
Gaze both up and down is impaired. Myerson's sign
is present (+) and there is neck rigidity.
- What neurological impairments does this patient suffer
from?
- What is the differential diagnosis?
- What studies are warranted?
- following initiation of Sinemet (carbidopa/levodopa) he
become agitated, psychotic and has visual hallucinations.
What should be done?
- Discuss other treatment options.
To top.
20.A 40 year old injection drug
user, while walking down the street minding his own business,
is shot in the left orbit and the bullet damages the left frontal
brain region. He undergoes bifrontal craniotomy for bullet removal
and brain debridement. Following surgery, he is alert and attentive
with no aphasia or memory impairment. He has no motor coordination,
gait, hearing or visual disturbance (other than left eye blindness).
He makes an uneventful recovery but his wife calls the neurosurgeon
very upset. He refuses to return to work or pay any bills, goes
to bars and Harrah's Casino and loses large sums of money, refuses
to go to church and sexually abuses a 6 year old girl and is arrested
for indecent exposure.
Assuming this behavior is a dramatic step down from his life
injecting drugs
- Explain the possible mechanism of this behavior which his
wife says is a dramatic change
- What would neuro-psychiatric testing likely show?
- Who was Phineas Gage?
To top.
19. A 25 year old pregnant woman
goes into active labor. She has a generalized seizure due to eclampsia.
She is treated with fosphenytoin and magnesium sulfate and has
no further seizures. During labor she receives generous amounts
of fluid due to possible dehydration. Four hours later she is
delivers a healthy baby girl by spontaneous vaginal delivery.
In the recovery room she complains of generalized weakness which
progressively worsens. Examination shows both proximal and distal
weakness in her arms and legs, normal sensation and absent reflexes,
normal cranial nerves. Over the next 24 hours this weakness progresses
to quadriplegia with respiratory disturbances.
- What are potential mechanisms of the quadriplegia?
- What laboratory tests should be done?
- What neurodiagnostic tests should be done?
- Explain the significance of the finding of high signal intensity
on MRI in (a)parietal-occipital subcortical region or (b)mid-pons.
To top.
21. An 18 year old man (HM) had
a fall from his bicycle at age 6 and struck his head. He was unconscious
for several hours. Skull roentgenogram showed a left parietal
linear skull fracture. Six months later he had "staring spells"
preceded by olfactory aura. Three months later he had generalized
seizure. Despite treatment with multiple medications seizures
occur on a daily basis. EEG shows bitemporal slow wave activity
and right temporal spikes. MRI shows right temporal lobe atrophy.
He undergoes right temporal lobectomy for seizure control. Following
surgery he has no further seizures, but reports a problem with
his memory. When the patient has breakfast he can not remember
eating 15 minutes later. He talks to the examiner, but cannot
remember the conversation 20 minutes later. His memory is generally
impaired for recent but not remote events.
- What has happened?
- What neural structures account for memory loss in this patient?
- What is the memory circuit?
To top.
12. A 25 year old woman slips
and falls in a shopping mall on a soap sample outside the Body
Shop. She complains of low back pain which does not radiate down
her legs. (Also, the soap smells terrible.) She calls her physician
who calls in a prescription for an NSAID and a muscle relaxant.
Five days later she continues to have severe pain and demands
to see a neurologist.
Neurologic exam reveals a broad based gait with
difficulty standing on her heels. Romberg's sign is present. There
is weakness of dorsiflexion and evertion of the feet. There is
decreased vibration and position sense in the legs. Reflexes are
absent in the ankles. The cranial nerves are normal. The general
exam reveals high arched feet (of which the patient has always
been proud), and hammer toes and pes cavus deformity (of which
she has not), paraspinal muscle spasm, sciatic notch tenderness.
MRI of the lumbar spine shows L4-5 and L5-S1 disc protrusion.
- What is the relationship of the fall to the neurologic findings?
- What diagnostic test should be done next?
- What might you expect to find if you examined the patient's
parents?
- What would you expect the natural history of the back pain
to be?
To top.
23. A 37 year old man develops
polydipsia and polyuria. Lab studies confirm the diagnosis of
diabetes mellitus and treatment with oral hypoglycemic agents
is started. Two months later he complains of an uncomfortable
burning sensation in the soles of his feet, worse at night and
not present when he walks. The neurologic exam reveals absent
vibratory sense in the toes and reduced at the ankles, reduced
pinprick and temperature sensation in the feet, absent ankle reflexes,
and absent response to stimulation of the sole and a normal motor
exam.
- These clinical findings are best explained by what abnormality?
- Describe the different components of this neural structure
and state the location of the lesion.
- What is the initial neurodiagnostic study indicated?
- Is the clinical history in this patient usual and characteristic?
- If parasthesias occurred most commonly when walking or alternatively
when standing, would this raise alternative diagnoses?
- If you were asked to give an lecture on the neurologic complications
of diabetes, what topics would you be sure to cover?
To top.
28. An 18 year old has been weak
since childhod, has never been able to walk normally and has been
convined to a wheelchair for 2 years.As a child he could not run
or climb stairs or arise from a chair without using his hands
to push off. A maternal uncle died at age 20 of progressive neurological
illness, but the parents are normal. He has no siblings.
The neurologic exam reveals scoliosis, winging of
the scapula, flexion contractures of the ankles, knees and hips.
There is marked muscle weakness in the arms and legs (proximal
greater than distal) and marked wasted, except for the calves,
where bulk is preserved. Reflexes are present only in the ankles
and triceps. The cranial nerves are normal.
CPK=3,000. EMG reveals myopathic potentials. Nerve
conduction velocities are normal. A muscle biopsy reveals muscle
atrophy with fat and conective tissue replacing muscle; dystrophin
is shown to be absent by special staining.
- What type of myopathy does the patient have?
- What would genetic studies show?
- Can muscle weakness be avoided?
To top.
29. Harriet is an 18 year college
freshman who develops abdominal pain and vomiting followed by
diarrhea the next day, and a dry mouth. One day later she develops
droopy eyelids, diplopia and difficulty standing and difficulty
lifting heavy objects.
The neurologic exam reveals ptosis, bilateral facial
weakness, pupils are 5mm and poorly reactive, reflexes are absent,
and proximal greater then distal weakness. The sensory exam is
normal. A chest film reveals a left lower lobe pneumonia; an abdominal
film reveals colonic distention.
- What neuro impairments might cause these findings?
- Is a tensilon test warranted?
- What might electromyography/nerve conduction studies show?
- What therapy should be initiated?
- What is the difference between nicotinic and muscarinic
receptor?
- Are these findings consistent with myasthenia gravis?
- Define fatigue.
- What tests are warranted in the patient suspected of having
myasthenia gravis?
To top.
10. A 33 year old woman complains
of blurred vision in her left eye and pain in the left orbital
region (as if she had sand in her eye) especially when she moves
her eyes. She has no headache, double vision, facial parasthesieas,
or numbness. She has recently felt fatigued enough that she has
started working part-time rather than full-time, has had multiple
urinary tract infections and urinary frequency with nocturia.
She complains that her legs become stiff when she walks long distances.
Visual acuity in the left eye is 20/70, in the right
eye 20/20. The fundi are normal. There is a left centro-cecal
scotoma. The left pupil does not react when light is shone into
it; when light is shone into the right pupil both pupils contract,
and when you swing the light in front of the left it dilates (afferent
pupillary defect). The patient is generally hyperreflexic with
plantar responses. Abdominal reflexes are intact and present;
sensory and cerebellar exam are normal.
- Where's the lesion?
- What is the differential diagnosis?
- What diagnostic studies should be done?
- What are the treatment options?
- What is the natural history of this condition?
To top.
5. A 50 year old alcoholic stops
drinking due to severe abdominal pain. That day he has a generalized
seizure and is admitted to the hospital. He is confused, ataxic
and reports double vision. His T-shirt reads "Rehab is for Quitters."
Treatment with Ativan (lorazepam), Librium (chlordiazepoxide)
and phenobarbital is instituted. He becomes increasingly lethargic
and then obtunded.
The physical exam reveals icteric sclerae, multiple
spider angiomas and an enlarged and tender liver. The neurologic
exam reveals a lethargic mental status. There is *asterixis* no
pronator drift and normal strength. He is generally hyperreflexic
with bilateral extensor plantar responses. The sensory exam is
normal. Cranial nerve exam reveals horizontal and vertical nystagmus
and a left lateral rectus palsy. The fundi are normal.
Pertinent laboratory data (from the chem everything
sent by the ER) includes an elevated bilirubin and alkaline phosphatase,
a normal blood glucose, WBC 6000 and Hgb 12.1.
Based on the clinical history and exam findings:
- Explain the mechanism of the neurological and medical disorder.
- What additional diagnostic studies should be done?
To top.
13. A 22 year old man whose roommate
has recently died of AIDS becomes very depresed and suicidal.
He injects himself with a blood of another HIV(+) friend so that
they can "bond." Four weeks later he develops sore throat, fever,
arthralgias and lymph node swellings. He then develops facial
weakness, neck muscle weakness and shoulder weakness.
The neurologic exam reveals weakness of the entire
face bilaterally, neck and proximal arm weakness, absent biceps
and triceps reflexes. The CSF is acellular and has an elevated
protein. Nerve conduction velocities are markedly slowed and electromyography
shows normal muscle potentials.
- What has happened to this patient?
- What is the appropriate treatment?
After complete recovery he reports that his memory is poor and
his thinking is slowed. He can not concentrate or sustain attention.
He has difficulty sleeping and poor appetite. Neurologic exam
reveals a Mini Mental Status Exam score of 27/30, but is otherwise
normal.
- What is wrong with this patient?
- He is HIV (+). Is this AIDS dementia complex?
- What are some of the neurologic complications of HIV?
To top.
14. A 28 year old male with polysubstance
abuse (cocaine, heroin, PCP) develops headache and muscle pain.
He reports night sweats and loss of appetite due to difficulty
swallowing. Two days later he reports back, abdominal and jaw
stiffness. The past history is relevant for bacterial endocarditis
treated with IV antibiotics 3 years ago and chronic schizophrenia
treated with stelazine, haloperidol and clozapine, but the patient
is usually non-compliant with these medications.
BP 200/100, HR 120, RR 22, temp 101. The neurologic
exam reveals an alert, attentive man. His gait is stiff and antalgesic.
Truncal rigidity is present but motor strength is normal. The
reflexes are brisk and symmetrical, with bilateral plantar responses.
Sensation is normal. The cranial nerves reveals orofacial dyskinesias
with facial and jaw spasms and nuchal rigidity. There are multiple
wounds. Laboratory studies reveals WBC 18,000 with a left shift,
normal thyroid studies, CPK 2000, urine negative for myoglobin.
A CT done by the ER is normal, and an LP done in the ER on RANDO
criteria (Resident Ain't Never Done One) is normal as well. ECG
reveals sinus tachycardia only. An EEG is normal.
The ER initially consults psychiatry for effect
of antipsychotics, but he goes to medicine to be "medically cleared."
Neurology is consulted when the patient becomes confused and develops
generalized myoclonic jerks (described to you as seizure activity
by the medicine resident). Respiratory stridor develops, the blood
pressure rises to 220/130 and cardiac arrythmias develop.
- What is the differential, and what is the diagnosis?
- What clues were missed?
- What is the likely course and prognosis?
To top.
8. A 26 year old obese woman develops
headache, double vision and a discharge from her left breast.
Her last menstrual cycle occurred one year ago. She feels tired
all the time and reports that her hair is falling out. The neurologic
exam reveals a left lateral rectus paresis, decreased sensation
on the left side of the uper face. The visual fields are full
and the fundi are normal with spontaneous venous pulsations. The
pupils are equal in size and react normally to accomodation and
light.
- Where's the lesion?
- What diagnostic studies are indicated?
- What imaging should be performed?
- What is the appropriate treatment?
To top.
9. Six months following trans-sphenoidal
hypophysectomy for a prolactin-secreting macroadenoma, headache
and double vision recur. The headache is bi-frontal, episodic,
increases with cough or sneezing and awakens her from sleep. Diplopia
is horizontal and is maximal on far gaze. Neurologic exam now
reveals a right lateral rectus paresis; the fundi are without
spontaneous venous pulsations and there is blurring of the disc
margins with centrally located hemorrhages and exudates. Visual
acuity is 20/50 in the left eye with reduced perception of color
in the left eye; the right eye is normal.
- What is the most likely explanation?
- What would skull roentgenogram, CT or MRI be expected to
show?
- Is an LP indicated or contraindicated? What might it show?
- What is the treatment of this condition?
- If medical treatment fails, is there a surgical option?
(Prospective surgeons note: there is not always a surgical
option.)
- What is the major threat in this condition?
To top.
26. A 32 year old woman has difficulty
understanding what people are saying in telephone conversations
and in noisy crowded rooms. This is a major problem when she holds
the phone to the right ear. She also notes intermittent slurring
of speech and right facial numbness. The neurologic exam reveals
decreased hearing in the right ear, mild right nasolabial flattening,
an unsteady tandem gait, a decreased corneal reflex on the right.
Using a 512Hz tuning fork, hearing is depressed on the right and
air conduction persists when bone conduction terminates. Audiology
reveals a high frequency loss on the right and impaired speech
discrimination, and decreased brain stem auditory evoked potential
on the right. Response to caloric testing on the right is decreased.
- What conditions should be considered?
- Where's the lesion?
- What would CT/MRI be expected to show?
- Why is a skin exam important?
- How would this lesion be treated?
- What neural structures might be injured?
To top.
37. A 52 year old legal secretary
complains of right wrist pain. This is worse with activity and
recurs at night. She has difficulty writing and using tools, and
says she can not work due to tingling numbness in the fingers.
Neurologic exam shows:
- weakness of thumb flexion
- reduced sensation over thumb and index fingers
- absent ankle jerks bilaterally
- reduced strength extending toes
- positive Tinel and Phalen signs bilaterally
Questions
- What neurological condition explains the findings?
- What might EMG show?
- What treatment might be suggested?
- What might neurontin or amitriptyline do?
While driving to work she is struck by the car behind her. Her
head hits the steering wheel. The next day she has neck stiffness
and soreness. Physical exam shows:
- Neck exam shows straightening of the cervical lordosis and
cervical paraspinal muscle spasm
- Increased weakness of thumb flexion
- triceps weakness
- absent triceps reflex
- reduced sensation in thumb, index and middle fingers bilaterally
- What is the mechanism of the new neurological dysfunction
- What is whiplash?
- What tests should be done?
To top.
38. A 10 year old boy falls
on the ice and breaks his left radius and ulna. He is treated
with a cast for 6 weeks. Following removal of the cast, he reports
difficulty opening jars and cans.
Neurologic exam shows
- weakness of wrist flexion and finger adduction
- reduced sensation of fifth finger and ulnar portion of fourth
finger
- normal reflexes
- What is the cause of neural dysfunction?
- What tests should be done?
To top.
39. A 40 year old homeless alcoholic
sleeps on a park bench. When he awakens he has no use of his right
hand. He has no headache, visual symptoms, numbness or difficulty
walking.
Neurologic exam shows:
- weakness of wrist extension
- marked weakness of hand and thumb
- intact biceps and triceps reflex
- normal sensation
- What has happened to this patient?
- What diagnostic studies should be performed?
- The ER has already performed performed a head CT and offers
to write the orders for carotid dopplers, an echo and hypercoagulable
state labs, and the nurse is calling for a bed. Is this helpful?
To top.
40. An 18 year old Tulane co-ed
leaves for Florida by car on spring break. One week previously
she started on an oral contraceptive pill. While sleeping in the
back seat her friends report that she has frequent muscle jerks.
In Florida she has generalized seizure activity after drinking
a six pack of Miller Lite, and is dazed and confused for the next
two hours.
On physical exam
- temp 98.4F, BP 110/80, HR 70 and RR a suspiciously normal
20
- neck supple
- head without trauma
- a detailed neurologic exam is normal
Lab data
- WBC 10, 75% segs, 15% bands, 10% lymphs
- CK 300
- prolactin 100
- Computed tomography normal (your read)
- EEG multifocal spikes
- What is the diagnosis?
- What should her management be?
- Classify the epileptic event.
- Name factors which may trigger seizures?
- Is Miller Lite less filling, or does it taste great?
To top.
41. The student from the previous
question refuses to take any anti-epileptic drug. She has no futher
seizures until the day of last final exam, which occurs after
she stays up all night with the help of No-Doz, Ritalin (given
to her by a friend diagnosed with ADHD) and lots of coffee.
Physical and neurologic exams are normal.
She is started on carbamazepine (Tegretol), 200
mg TID. She compliant with treatment and therapeutic blood levels.
Eight months later she has an episode during which she feels dizzy,
light headed, weak, falls to the ground and is briefly unconscious;
there is no post-ictal confusion.
- What is the likely mechanism?
- What tests should be done?
- List major side effects of antiepileptic drugs.
To top.
33. An 18 year old college
freshman is found apneic and pulseless in her boyfriend's room
after attending a fraternity party after the Tulane-LSU football
game. CPR is initiated by her boyfriend; pulse and blood pressure
are noted when paramedics arrive but she requires assisted ventilation.
She is stabilized.
Exam reveals
- Coma
- No spontaneous respirations
- absent eye movements
- no response to noxious stimuli
- Reflexes are 2+ and symmetrical with plantar responses
The next day respirations are spontaneous, pupils are reactive
but she remains comatose. One week later her eyes are open but
she shows no response to verbal stimulus. Eyes rove spontaneously
but she does not follow objects in her environment and she has
no reponse to auditory stimulus. She has limb movement to noxious
stimulus but no voluntary movements; she continues to require
ventilatory support. CT and MRI are normal, EEG shows low voltage
theta waves.
- What happened to her?
- Define chronic vegetative state
To top.
34. A 35 year old supervisor
of a nuclear energy plant begins to have episodes of falling asleep
on the job. These occur at work and while driving. (Feel free
to hum the theme from 'the Simpsons' now.) He has multiple near
miss accidents and begins to ahve his friends drive him. After
the episodes of excessive daytime sleepiness (each lasting 5 to
10 minutes)he feels better, more alert and refreshed. He is very
concerned because these attacks are increasing in frequency and
now occur multiple times daily. Also, he reports that when he
laughts he feels weak an doccasionally falls to the ground. Family
history is relevant that his mother and brother have epilepsy.
Neurologic exam is normal.
Questions
- What's the diagnosis?
- What would a sleep study show?
- What is a multiple sleep latency study?
- Deliniate the narcolepsy triad
- What is the appropriate treatment of this condition?
To top.
42. A 28 year old man slips and
falls on his buttock. He complains of low back pain which persists
despite bed rest and treatment with naproxen (an NSAID), carisoprodol
(Soma, a muscle relaxant), and tramadol (Ultram, a serotonergic
pain reliever).
Physical exam
- Normal lumbar lordosis
- paraspinal muscle spasm
- right sciatic notch tenderness
- no pain on passive raising of the leg
- detailed neurologic exam is normal
The pain persist and interferes with sleep. Amitriptyline is started
in addition to other medications. One week later he has a generalized
seizure. At this time, neurologic exam and EEG are normal.
- What is the likely mechanism of the seizure?
- What diagnostic tests should be done?
- What should his subsequent management be?
To top.
43. Sally is a 35 year old woman
who has a history of sinus headache. She has strongly positive
family history of headache. She had motion sickness as a child.
At menarche, she develops episodic left temporal throbbing headache
associated with nausea, photophobia and worsened by activity.
Her headache responds to sumatriptan and occurs once per month.
One decade later, she develops chronic daily heacache which is
aching in type, associated with neck pain. She becomes increasingly
depressed and anxious.
One night after 6 days of headache severe enough
cause her to miss work, she goes to the ER with her bag of 23
different medications including hydromorphone (Dilaudid) and codeine/aspirin
(Percodan) for a second opinion (yours).
- Classify her headache pattern.
- What treatment is appropriate?
- Is she an addict by the use of daily narcotics?
To top.
44. A 20 year old college student has an accident
when an ice sculpture strikes her in the left frontal region. She
has no loss of consciousness or amnesia for the event. She has mild
headache and heck pain which resolves spontaneously. Three months
later she has an episode of right facial twitching followed by generalized
tonic-clonic activity, incontinence and post-ictal confusion.
Neurologic exam shows
- a R pronator drift
- R hyper-reflexia and Babinski
- EEG shows L frontal spike discharges
- CT shows a L porencephalic cyst
- What is the mechanism of her episode?
- What is the nature of the episode?
- What is the relationship of trauma to the cyst and episode?
To top.
45. There's a 25 year old nurse in the ER nobody
likes very much. We'll call her Mary. (Actually, everybody calls
her 'that bitch,' but we'll be nice and call her Mary too.) One
day she develops a severe occipital headache after an altercation
with a colleague. The pain is intense and very uncomfortable, and
after trying Aspirin and Tylenol without relief she goes to you
for help. She has no prior headache history, and no history of headache
in her family.
The neurologic exam is normal, as is a computed tomogram of the
head.
- What is the diffential diagnosis?
- Should an LP be done?, other than the fact that you don't
like her either?
- What are the risks of LP?
- What treatment is warranted?
To top.
46. Randy is HIV positive and takes highly active
anti-retroviral therapy. He has a normal CD4 count and an undetectable
viral load. He has no fatigue or weight loss. He reports new onset
heacache, bitemporally, throbbing in nature, building up over 6
hours and ssociated with nausea.
On exam
- Neurologic exam is normal
- Neck is supple and he is afebrile
- CBC and chem everything are normal
- What's the differential diagnosis?
- What is the appropriate management?
- On LP you find
- Opening pressure 18 cm H2O (normal)
- 30 lymphocytes
- protein 80 mg/dl
- glucose 70 mg/dl
- serology cultures and stains are normal
What is the explanation for these findings?
- What are alternative explanations?
To top.
47. Sam is a 67 year old retired CPA. He develops
left temporal aching pain and visual blurring. He has myalgias and
pain on chewing food.
Neurologic exam shows
- left temporal artery tenderness
- biceps muscle tenderness
- left optic atrophy
- when you shine a light in the R eye the L pupil constricts,
but when you shine the light in the L eye it gets bigger again
(afferent pupillary defect)
- visual acuity 20/100 on the L
- What is the mostly likely diagnosis?
- What tests should be done?
- Suppose a temporal artery biopsy is normal. What next?
To top.
48. Immediately following delivery of her third
child, Mary develops severe headache, diplopia and left eye blurring.
On exam
- BP 95/50, taken by you with a manual cuff and HR 110
- L optic atrophy and afferent pupillary defect
- bitemporal hemianopia
- left lateral rectus (VI) palsy
- left ophthalmic branch of trigeminal nerve hypoaesthesia
- nuchal rigidity
- Is this eclampsia?
- Where's the lesion?
- What's the diagnostic study?
- What is appropriate management?
- What is the clinical significance of nuchal rigidity?
To top.
49. harry is a 52 year old math teacher. He has
hypertension and hypercholesteremia. Medications include Accupril
(an ACE inhibitor) and pravastatin (Pravachol). One morning he awakens
with L eye visual blurring as if a shade has been pulled down; he
closes the L eye and his vision is normal in about 15 minutes. He
then develops left sided aching neck pain which resolves with over-the-counter
analgesics. He calls his physician, who makes a diagnosis of "ocular
migraine" over the phone and tells him to make a routine appointment
in 10 days for a checkup. His wife is not pleased with this advice
and insists he see a neurologist (i.e. you).
On exam
- bilateral carotid bruits
- L Hollenhorst plaque in retina
- L superior temporal visual defect
- normal pupillary response and acuity
- What's the diagnosis?
- What is the appropriate management?
- What vessels are involved?
- Why is this not migraine or cluster headache?
- Why is the pupillary response normal?
To top.
50. A 23 year old woman develops episodic headache
lasting 30 minutes associated with diplopia on far gaze while driving.
She has 6 episodes daily and they do not respond to medication.
Other medications include tetracyclinc and tri-orthocycline for
acne. She has gained 40 pounds in the past year.
Neurologic exam shows
- absence of venous pulsations and disc elevation in the eye
- left lateral rectus paresis
- bilateral enlargement of blind spots
- Explain the fundus findings
- outline a management strategy
- Should an LP be done?
- What are potention etiologies?
- The patient develops intermittent visual obscurations lasting
ten minutes and intermittent pulsatile tinnitus. What is the
significance of this?
To top.
51. An 8 year old boy develops intermittent headache
and falls when running. He has intermittent horizontal diplopia
when watching TV.
Neurologic exam shows
- broad based ataxic gait, falling to left
- fundoscopy shows loss of venous pulsations
- bilateral lateral rectus paresis
- left sided dysmetria
- Where's the lesion?
- What are potention pathologic processes?
- What studies should be done?
- He suddenly vomits and becomes dazed, his respirations become
labored, pulse slows and blood pressure becomes elevated. What
has happened?
- What management is appropriate now?
To top.
52. A 24 year old man has 3 generalized major motor seizures.
He has preceeding aura. EEG shows frequent bilateral symmetrical spikes. Treatment
is intiated with depakote and he becomes seizure free. One year
later, EEG is normal. Neuro exam and CT are both normal. Question:
- Patient asks "can I now drive"?
- "Do I need to continue medication"?
- Assume you permit him to drive and he drives 100 miles per
day and he has an accident 3 years later but has no seizure
related to the accident and medication does not make him drowsy.
Despite this you and MD are named as a defendant in law suit
because "patients with epilepsy should not drive". Defend your
decision!
To top.
1a. A 26 year old female graduate student was conducting
a philosophy seminar when she suddenly started stuttering and then
became incoherent. She seemed confused, and her mouth was twisted.
One arm hung limply and she walked unsteadily. She had a past history
of theumatic heart disease and took no meds except for birth control
pills.
- What type of neurologic problem is this?
- Where's the lesion?
- What is the arterial supply?
- What is the most likely etiology?
To top.
2a. A 68 year white female presents complaining
of inability to walk. Upon further questioning you find that this
has progressed over a month or two and is not associated with back
pain. On exam she is slightly inattentive and sometiems inappropriate.
Language is intact. She has no cranail nerve deficits, and good
strength in the upper extremities. Her legs are diffusely weak,
3-4 of 5, proximally and distally. Sensory exam reveals questionable
mild loss of light touch and pinprick distally over the legs, without
a level. Reflexes are brisk in the legs and a Babinski sign is present
bilaterally.
- Where's the lesion?
- What is the pathophysiology?
To top.
3a. A 55 year old black female with a history of
diabetes and hypertension states that while drinking her morning
coffee she suddenly experienced "heviness" of the right arm. She
fumbled with her cup until she spilled the coffee, and when the
symptoms did not resolve within half an hour she came to the ER.
Examination reveals an alert woman with normal mental status, and
decreased light touch, pinprick, vibratory sense over the right
arm and leg. Strength is normal.
- Where's the lesion?
- What is the vascular supply?
- What is the pathophysiology?
- You complete your evaluation 2 hours and 30 minutes after
the onset of symptoms, and a chem everything, CT head, CBC,
PT/PTT are all normal. The ER resident is extremely excited
and is holding a bottle of recombinant Tissue Plasminogen Activator
(Alteplase) in his hands. Should you give it?
To top.
4a. While working out at Reily uptown with free
weights, your friend complains of sudden back pain and inability
to walk. Your exam shows bilateral leg weakness, absent ankle reflexes
(assume you have a reflex hammer in your gym bag), and decreased
tone in the legs. He feels parasthesias running down the back of
both legs, and doesn't notice you sticking his skin with a clean
pin until the mid-thigh. Pressure on the lumbar spine is painful,
and there is paralumbar muscle spasm.
- What happened?
- Where's the lesion?
- Is this upper or lower motor neuron?
To top.
5a. A 35 year old black male is seen in clinic
with a 3 month history of weakness and muscle cramps, first felt
in the left arm but progressing to both legs. His voice is not as
loud as it used to be, and is a little horse. Sometimes food gets
"stuck" on one side of his mouth and he has to move it with his
finger. He has no sensory loss. Reflexes are brisk, including a
jaw jerk. The toes are equivocal. Fasciculations are present in
the tongue at rest, and in all four proximal extremities. He is
lost to follow up, but returns a year later complaining of trouble
swallowing, shortness of breath and appears emaciated.
- Where's the lesion?
- What has happened in the time he was lost to follow up?
- Was it a particularly big mistake for the patient not to return?
- What will you do now?
To top.
6a. A 62 year old woman complains of painand numbness
of the hand. She has been dropping objects from the hand, but the
discomfort is worse at night.
- What further history would help you localize the lesion?
- How can you tell mononeuropathy from myelopathy from diffuse
peripheral neuropathy?
On examination you also find a loss of pinprick at the toes, and
vibrations with a 128 Hz fork are felt for 10-5 seconds at the toes.
- What do you suspect now?
- What other findings might be present?
To top.
7a. A 26 year old woman is referred to you by
her psychiatrist. For the last year she has complained of weakness
which came on after the death of her father. The weakness seems
to come and go depending on her family situation and her depression.
She also complains of a vague tightness of throat (?globus hystericus),
leg aching and frequent headaches. Sometimes she is fine, and other
times she just lays on the couch, or will suddenly fall walking
off a curb. She admits she doesn't know how to "pull herself out
of this."
- How will you proceed?
- Where's the lesion?
- What is causing her headaches and lump in the throat?
To top.
8a. A 30 year old white female has difficulty
climbing stairs. She cannot lift objects but has no problems writing
or buttoning her shirt. Her gait is waddling. She has been followed
for 8 months in rheumatology clinic for "arthritis" not otherwise
specified, and a visit to the walk-in clinic prompted her appointment
with neurology. The joints seem normal to your exam, but the thigh
muscles are tender to palpation?
- Where's the lesion?
- What will be your lab workup?
To top.
9a. A 28 year old white female complains of headaches
for one year, recently daily. They are often throbbing, usually
bitemporal and do not usually cause too much nausea, although she
has vomited once or twice. She also says her vision has changed,
but she went to get her glasses checked and was told they were fine.
Other pertinent history is obtained that she had a child 9 months
ago and gained 80 pounds during the pregnancy, of which she has
lost 30.
On physical exam, she is obese. Vital signs are normal. Funduscopic
exam shows bilateral disc margin blurring with a flame hemorrhage
on the right. Pupils are equally reactive, and visual fields are
full to confrontation. There is a question of mild lateral rectus
weakness on the right. The remainer of the cranial nerve exam
is normal, as is stength, sensation and reflexes, and gait.
CT of the head is normal, as is an EEG. On lumbar puncture,
the opening pressure is 41 cm H20.
- What is this syndrome?
- What severe disability is she at risk for?
- What would visual field testing be likely to show?
To top.
