Cohen CIS: Clinical Neuro

Question 1

case: 32 y/o dragging leg, generally healthy, hypothyroidism. right leg stiff last week, has tried to rest but its getting worse. No back pain, no injuries. Neuro exams shows weakness in both legs and brisk reflexes in both legs. B/l babinski sign - can’t distinguish sharp on leg.
1. where is disease suspected?
2. Order an MRI of?
3. MRI shows T3-4 abnormality of demyelination… whats most likely?
4. 4 mos. later she c/o double vision - physician seen b/l internuclear opthalmoplegia? ddx?
5. confirm the ddx?

Answer 1

1. Suspected disease in spinal cord
2. Spinal cord ends at L1/2: Do Thoracic MRI (note: brachial plexus goes C5-T1)
3. Clinically isolated syndrome (can’t yet ddx MS if has no neuro hx)
4. this is her second episode in time and place = MS!
5. confirm this ddx? Brain MRI or LP

Question 2

case: Mr. James is 42 y/o male who fell down last night and couldn’t get up for 45 minutes. had nausea and vomiting - felt room swirl around him. feels better this morning. had similar episode 1 week prior. Did not loose consciousness.
1. which of following referrals will yield the most useful ddx info to Mr. James?
2. you order an MRI which shows two small round abnormalities in each cerebral hemispheres, you make a tentative ddx of?
3. tx is discussed at length for mennier’s after pt. has three more episodes, what to recommend?

Answer 2

1. Menier’s disease - so refer to the audiologist for hearing test (the number one loss is hearing in this disease)
2. Could have Vestibular Schwannoma or Menier’s
3. low salt diet along w/ consultation w/ ENT specialist

Question 3

case: Ms. peters is 53 y/o with tremors of arms, and has difficulty using cell phone and feeding herself. no falls. her neuro exam is obvious for tremors more in right hand than left hand, primarily when she rests her hands.
1. important next step is?
2. pt. starts tx with pramipexole. 4 mos later she returns with what sx?

Answer 3

1. look for other signs of PD - possibly start her on PD medication
2. this is a dopamine agonist - however she said that it did her no good. it is wise to try which of the following? could reconsider ddx, or try a higher dose

Question 4

case: Mr. Simms is a 60 y/o male in Marines who finds it difficult to give orders - finds it frustrating. He forgets to solute, and he is wearing sandals. When this is pointed out he starts calling colonel obscene names. He has no tremors, speaks slowly, can barely read a paragraph, seems weak when asked to walk across the room.
1. The psychiatrist suspects?
2. partial aphasia, poor executive fn, good visual spatial, the short and long term memory tests are normal. which tx would the psychiatrist chose?

Answer 4

1. Most likely Frontotemporal dementia, though could be LBD or AD
2. the is FTD - give them antidepressants, there are no other txs

Question 5

what two diseases benefit from AD drugs?

Answer 5

AD and LBD