LE 5 Flashcards
1 64 y/o female consulted for 2 day history of facial asymmetry. On physical examination, he was unable to raise the right eyebrow, was unable to fully close the right eye and there was shallow right nasolabial fold. His smile was also noted to be asymmetric. This type of facial palsy is documented as:
A. Left peripheral facial palsy
B. Right central facial palsy
C. Right peripheral facial palsy
D. Left central facial palsy
C. right peripheral facial palsy
Rationalization: The symptoms described (inability to raise the right eyebrow, inability to fully close the right eye, shallow right nasolabial fold, and asymmetric smile) are indicative of a peripheral facial nerve palsy affecting the right side of the face. Peripheral facial palsy affects all branches of the facial nerve on the involved side, leading to the inability to move facial muscles on that side. Central facial palsy, in contrast, typically spares the forehead muscles due to bilateral upper motor neuron innervation.
64 y/o female consulted for 2 day history of facial asymmetry. On physical examination, he was unable to raise the right eyebrow, was unable to fully close the right eye and there was shallow right nasolabial fold. His smile was also noted to be asymmetric.
- in the above case, where is the lesion?
A. Left facial nerve nucleus
B. Right facial nerve
C. Right corticobulbar tract
D. Left corticobulbar tract
B. right facial nerve
Rationalization: Given this is a case of right peripheral facial palsy, the lesion is located in the right facial nerve. The facial nerve (cranial nerve VII) is responsible for innervating the muscles of facial expression. A lesion in the facial nerve nucleus would not present as a unilateral peripheral facial palsy but could potentially cause bilateral symptoms due to its central location.
- Which of the following neural structures is most likely affected given the following neurologic deficit?
a. Right temporal
b. Left frontal
c. Right parietal
d. Left parietal
B. left frontal
Rationalization: Assuming this question is related to the first case, the left frontal area is not directly implicated in right peripheral facial palsy. However, if this question is intended to be independent and focuses on a neurologic deficit not specified here, the answer cannot be accurately determined without more context. Typically, the frontal lobe, especially on the right side, would not be responsible for facial palsy. Facial palsy is related to damage to the facial nerve or its pathways, not typically associated with the frontal lobe regions specified in the options.
- The following statements about pattern of weakness is/are true except
A. Acute paraparesis may be due to bilateral anterior cerebral artery infarction
B. Crossed paralysis consisting of ipsilateral cranial nerve signs and contralateral hemiparesis is usually due to brainstem lesions
C. Symmetric weakness, beginning distally, with accompanying numbness is usually secondary to anterior horn cell disease
D. Ascending weakness with numbness associated with hyporeflexia may be due to disease of peripheral nerves
C. Symmetric weakness, beginning distally, with accompanying numbness is usually secondary to anterior horn cell disease
Rationalization: This statement is false because symmetric weakness beginning distally with accompanying numbness is more characteristic of peripheral neuropathies or polyneuropathies rather than anterior horn cell disease. Anterior horn cell disease, such as amyotrophic lateral sclerosis (ALS), typically presents with a combination of upper and lower motor neuron signs without sensory deficits.
- The following statements are true about the extensor toe sign except
A. There are several ways to elicit the extensor toe sign
B. It is a normal finding among children under 2 years old
C. It indicates a lesion in the vestibulospinal tract which controls the distal lower extremities
D. It indicates an upper motor neuron lesion
C. It indicates a lesion in the vestibulospinal tract which controls the distal lower extremities
Rationalization: This statement is false. The extensor toe sign, also known as Babinski’s sign, indicates an upper motor neuron lesion and is not specifically related to the vestibulospinal tract. It reflects dysfunction in the corticospinal tract rather than the vestibulospinal tract.
8.A patient comes in the er due to bilateral lower extremity weakness. Upon Examination, the last normal sensory level is at the level of the umbilicus. Which Level is likely the spinal cord lesion?
A. T9-T10
B. T7-T8
C. T5-76
D. T3-T4
A. T9-T10
Rationalization: The umbilicus is innervated by the T10 dermatome. A lesion affecting sensory levels at the umbilicus would likely involve the spinal cord around the T9-T10 levels.
- Test for coordination?
A. None
B. Rapid alternating movement
C. Both
D. Heel to shin test
C. Both
Rationalization: Tests for coordination include both rapid alternating movements (to assess cerebellar function related to coordination and precision of movements) and the heel to shin test (to assess lower limb coordination and proprioception).
- 55/female has a tumor compressing the left trigeminal nerve. She may experience
The following signs and symptoms except
A. Difficulty in moving the jaw to the left
B. Numbness of the left side of the face excluding the angle of the jaw
C. Flattened left nasolabial fold
D. Decreased corneal reflex on the left eye
C, “Flattened left nasolabial fold,”
can also be a sign of dysfunction of the facial nerve (cranial nerve VII), which innervates the muscles responsible for facial expression, including the nasolabial fold.
- A simple bedside test used to determine the mental status examination of a
Patient which consists of a 30-points score.
A. Mini mental status examination
B. Clinical dementia rating scale
C. Montreal cognitive exam (MoCA)
A. Mini Mental Status Examination
Rationalization: The Mini Mental Status Examination (MMSE) is a simple bedside test used to assess cognitive function and screen for cognitive impairment. It consists of a 30-point score that evaluates various cognitive domains, including orientation, recall, attention, calculation, language processing, and spatial skills.
- If a patient is complaining of dizziness when turning to the left, and you have diagnosed this case as Benign Positional Paroxysmal Vertigo (BPPV), which direction would you rotate his head when you want to perform Epley maneuver?
A. Right
B. Left
C. Midline
D. Either side
B. Left
Rationalization: When performing the Epley maneuver for a patient with Benign Paroxysmal Positional Vertigo (BPPV) who experiences dizziness when turning to the left, you would start by rotating the patient’s head towards the affected side, which is the left side in this case. The Epley maneuver is designed to move the otoliths out of the semicircular canals back into the vestibule where they won’t cause vertigo.
- A 25-year-old woman with depression present with a daily headache for the past 2 years. The headache began suddenly on November 15, 2016. She recalls it was on her birthday, but otherwise nothing out of ordinary had happened. She reports being healthy, other than mild sore throat the day before the onset of the headache, which is describes as a daily, pressing, moderate, holocephalic pain. There is photophobia, when the headache is exacerbated, but no visual or other neurologic symptoms. There is no postural component of the headache. She has had MRI but was normal. On the basis of the history, how would you classify the headache?
A. Migraine without aura
B. Psychogenic headache disorder
C. New daily persistent headache
D. Tension-type headache
B. Psychogenic headache disorder
This classification is based on the lack of specific characteristics typical of primary headache disorders like migraine or tension-type headache, as well as the absence of neurological symptoms or abnormalities on MRI. The presence of depression and the absence of clear physical triggers for the headache suggest a possible psychogenic origin.
- Which of the following statements is incorrect regarding aphasia?
A. None, all are correct
B. Conduction aphasia is due to a lesion in the internal arcuate fasciculus lesion
C. Broca’s aphasia is due to a dominant hemisphere inferior frontal gyrus
D. Wernicke’s aphasia is due to a nondominant hemisphere superior temporal gyrus lesion
D. Wernicke’s aphasia is due to a nondominant hemisphere superior temporal gyrus lesion
Rationalization: This statement is incorrect. Wernicke’s aphasia is typically due to a lesion in the dominant hemisphere’s superior temporal gyrus, not the nondominant hemisphere. Wernicke’s area is involved in the comprehension of speech, and lesions here cause difficulties in understanding language but often leave the ability to produce fluent, though meaningless, speech.
- All are components of Balint’s syndrome, except:
A. None, all are correct
B. deficit in orderly visuomotor scanning of the environment
C. deficit in accurate manual reaching toward visual targets
D. inability to recognize familiar faces
D. inability to recognize familiar faces
Rationalization: The inability to recognize familiar faces, known as prosopagnosia, is not a component of Balint’s syndrome. Balint’s syndrome is characterized by a triad of symptoms:
- optic ataxia (deficit in accurate manual reaching toward visual targets),
- ocular apraxia (deficit in orderly visuomotor scanning of the environment),
- simultanagnosia (inability to perceive the visual field as a whole).
- This is mainly a test to identify cerebellar ataxia:
A. True
B. False
B. False
The Romberg test primarily assesses proprioception and the vestibular system rather than cerebellar function. It evaluates a person’s ability to maintain balance while standing still with eyes closed, relying on proprioceptive feedback. However, it can be part of a broader assessment that includes testing for cerebellar ataxia, which involves coordination and balance issues due to cerebellar dysfunction.
17..Which is the afferent nerve of the pupillary light reflex
A. cranial nerve Ill
B. cranial nerve VII
C. cranial nerve Il
D. cranial nerve V
C. cranial nerve II
Rationalization: The afferent nerve of the pupillary light reflex is cranial nerve II, the optic nerve. It carries the sensory input from the retina to the brain. The efferent pathway, which constricts the pupil, involves cranial nerve III, the oculomotor nerve.
- Central facial palsy denotes which type of motor involvement?
A. mixed type of upper and lower motor neuron lesion
B. Lower motor neuron lesion
C. upper motor neuron lesion
C. upper motor neuron lesion
Rationalization: Central facial palsy is indicative of an upper motor neuron lesion. It typically affects the contralateral lower half of the face because the upper half of the face receives bilateral innervation from the cerebral cortex. In contrast, a lower motor neuron lesion would affect all branches of the facial nerve on the same side, leading to a complete facial droop.
19.Inability to perform rapid alternating movements:
A. Dyssynergia
B. Dystaxia
C. Dysdiadochokinesia
D. Dysmetria
C. Dysdiadochokinesia
Rationalization: Dysdiadochokinesia is the inability to perform rapid alternating movements, a sign of cerebellar dysfunction. It reflects the inability to coordinate agonist and antagonist muscles smoothly.
- The following may present with acute weakness except
A. Tumor
B. Subdural hematoma
C. Guillain barre syndrome
D. Cerebrovascular disease
A. Tumor
Rationalization: While tumors can cause weakness over time as they grow and exert pressure on surrounding brain structures, the other options listed (subdural hematoma, Guillain-Barré syndrome, and cerebrovascular disease) are more typically associated with acute onset of weakness. Tumors generally lead to a more gradual onset of symptoms.
- In normal individuals, pooling of blood in the lower parts of reflex acceleration of the heart by means of aortic the body is prevented by:
A. Both
B. None
C. Reflex acceleration of the heart by means of aortic and carotid reflexes
D. Pressor reflexes induce dilatation of peripheral arterioles and venules
C. Reflex acceleration of the heart by means of aortic and carotid reflexes
Rationalization: In normal individuals, pooling of blood in the lower parts of the body is prevented by reflex mechanisms, including reflex acceleration of the heart and vasoconstriction through aortic and carotid reflexes. These reflexes help maintain blood pressure and blood flow to vital organs during changes in body position.
- Which of the following tests for language in the mini mental state examination?
A. Serial 7s
B. Asking for the month and date
C. Spelling the word WORLD backwards
D. Following a 3 step command
D. Following a 3-step command
This option tests the ability to understand and process language by following verbal instructions, which is a key component of the language section in the Mini-Mental State Examination (MMSE).
- Characteristic of cerebellar ataxic gait:
A. Intermittent, irregular movement disrupting the smooth flow of normal gait
B. Both legs move in a slow, stiff manner with circumduction
C. Broad-based gait with speed and length of stride which vary irregularly each step
D. All are incorrect
C. Broad-based gait with speed and length of stride which vary irregularly each step
Rationalization: A characteristic of cerebellar ataxic gait is a broad-based stance with irregularities in the speed and length of stride. This type of gait is often unsteady and can involve veering to one side.
- Vestibular neuritis:
A. Due to over-accumulation of endolymph within inner ear
B. Rotatory vertigo lasting minutes to hours
C. Associated with low-frequency sensorineural hearing loss
D. No otological symptoms
D. No otological symptoms
Rationalization: Vestibular neuritis is characterized by acute onset of severe, persistent vertigo that is not accompanied by hearing loss or other otological symptoms. It is thought to be caused by inflammation of the vestibular nerve.
- True of Romberg’s test, EXCEPT:
A. Test to differentiate cerebellar ataxia from sensory ataxia
B. Patient’s eyes should be closed with feet together
C. None, all are correct
D. Tests both the dorsal column pathway and anterolateral pathway
D. Tests both the dorsal column pathway and anterolateral pathway
Rationalization: This statement is incorrect regarding Romberg’s test. Romberg’s test primarily assesses the function of the dorsal columns of the spinal cord, which are responsible for proprioception. It does not directly test the anterolateral pathway, which is involved in pain and temperature sensation.
- “When assessing a patient in the ER who came in with decreased sensorium, you noted the patient assumed a specific position when you applied a painful stimulus. How will you record the motor response?”
A. M2
B. M3
C. M4
D. M5
B. M3
Rationalization: In the context of the Glasgow Coma Scale (GCS), motor responses are graded from M1 to M6, with M1 indicating no motor response and M6 indicating obeys commands. If a patient assumes a specific position in response to pain, it suggests a purposeful response to pain but not necessarily obeying commands, which might be categorized under flexion withdrawal from pain (M4). However, without specific details on the “specific position,” the best approximation given the options would be M3, which typically indicates abnormal flexion to pain (decorticate response). This is a bit of a nuanced interpretation since the exact description of the response is not provided.
- 53/F rushed to the emergency room after being involved in A vehicular crash. On assessment, she would only open her eyes when pressure is applied on her nailbed. She would moan some sounds in response to pain and would briskly withdraw her arm. What is the her GCS score?
A. E2V3M5
B. E3V1M5
C. E2V2M4
D. E3V2M4
Answer: C. E2V2M4
*E4V5M6
Rationalization: Based on the Glasgow Coma Scale (GCS):
E2 indicates eye opening in response to pain.
V2 indicates incomprehensible sounds, which is consistent with moaning in response to pain.
M4 indicates withdrawal from pain, which is a purposeful movement away from a painful stimulus.
A. This is decerebrate posturing which denotes a lesion above the red nucleus
B. This is decerebrate posturing which denotes a lesion below the red nucleus
C. This is decorticate posturing which denotes a lesion above the red nucleus
D. This posturing is given a grade of M3
B. This is decerebrate posturing which denotes a lesion below the red nucleus
Decerebrate posturing is a type of abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. This posture indicates that there may be damage in the area of the brainstem. Specifically, it is associated with dysfunction or damage to the brain at or below the level of the red nucleus in the midbrain. The red nucleus is an area of the midbrain that is involved in motor coordination.
- Most common cause of primary headache
A. Idiopathic
B. Systemic infection
C. Migraine
D. Tension type
D. Tension type
Rationalization: Tension-type headaches are the most common type of primary headache disorder, characterized by a pressing or tightening feeling, of mild to moderate intensity, occurring on both sides of the head and not worsened by routine physical activity. Migraines are also common but not as prevalent as tension-type headaches.
Primary headaches:
1. Migraine 2. Tension-type headache 3. Cluster headache
Secondary headaches:
1. Headache due to a head injury 2. Headache due to sinusitis 3. Headache due to medication overuse 4. Headache due to meningitis 5. Headache due to brain tumor
- 65 y/o female presenting with sudden onset right peripheral facial palsy and Weakness of the left arm and leg. Which of the following tests will you order?
A. Spinal MRI
B. Spinal CT scan
C. Cranial MRI
D. Nerve conduction studies
C. Cranial MRI
Rationalization: Given the sudden onset of right peripheral facial palsy combined with weakness of the left arm and leg, the symptoms suggest a central nervous system pathology that could involve the brainstem or cerebral hemispheres. A cranial MRI is the most appropriate test to order as it can provide detailed images of the brain’s structures to help identify the cause of these symptoms, such as a stroke.
- True of Central Vertigo:
A. Duration of dizziness persists
B. Visual fixation suppresses vertigo
C. Acute onset
D. All are incorrect
A. Duration of dizziness persists
Rationalization: Central vertigo is characterized by vertigo that may have a longer duration, and its intensity is not typically altered by changes in head position. Unlike peripheral vertigo, visual fixation does not suppress central vertigo, and its onset may not always be as acute or associated with specific triggers.
- The Epley Maneuver is both diagnostic and therapeutic for Benign Paroxysmal
Positional Vertigo (BPPV).
A. False
B. True
A. False
Rationalization: The Epley maneuver is therapeutic for Benign Paroxysmal Positional Vertigo (BPPV) but not diagnostic. The diagnosis of BPPV is typically made using the Dix-Hallpike test, which can provoke the characteristic vertigo and nystagmus associated with BPPV.
- Asking a patient to spell the word WORLD backwards tests for which cognitive domain?
a. Fund of knowledge
b. Insight
c. Planning
d. Attention
d. Attention
Rationalization: Asking a patient to spell the word “WORLD” backwards tests the cognitive domain of attention and working memory, as it requires the patient to focus, manipulate information in reverse order, and control their response.
What sensory information does the Dorsal column-medial lemniscus pathway convey?
a. Light touch
b. Proprioception and vibration
c. Light touch, proprioception and vibration
d. Pain and temperature
c. Light touch, proprioception and vibration
Rationalization: The dorsal column-medial lemniscus pathway conveys sensations of fine touch, proprioception, and vibration from the body to the brain. This pathway is critical for the perception of detailed touch and the spatial position of body parts.
- A woman with Alzheimer’s disease stopped being able to recognize her son after he shaved his moustache. She could recognize her husband only when she heard his voice. The term used to describe this type of agnosia is:
A. Topographagnosia
B. Prosopagnosia
C. Misoplegia
D. Asomatognosia
B. Prosopagnosia
Rationalization: Prosopagnosia, also known as face blindness, is the inability to recognize familiar faces. The woman’s inability to recognize her son without his moustache and her husband only by his voice indicates prosopagnosia.
- A 50/M presented with sudden onset difficulty in speaking. On physical examination, he can follow commands and speech seem fluent but had difficulty in naming simple objects and was unable to repeat the phrase “no ifs ands or buts”. What type of aphasia does he have?
A. Transcortical sensory
B. Broca’s transcortical motor
C. Global aphasia
D. Wernicke’s conduction
D. Wernicke’s conduction
Conduction Aphasia is characterized by the disconnection between speech comprehension and speech production areas, leading to fluent aphasia with good comprehension, but impaired repetition and naming.
- Asking the patient to tell you the similarity of a bicycle and train tests for which of the following higher cortical functions?
A. fund of information
B. abstract thinking
C. apraxia
D. registration
B. abstract thinking
Rationalization: Asking a patient to explain the similarity between a bicycle and a train tests abstract thinking, a higher cortical function. This task requires the patient to conceptualize and articulate the abstract relationship or category that both items share.
- Which of the following statements is incorrect regarding the pathophysiology of migraine headache
A. CGRP acts as principal mediator of migraine
B. The trigeminovascular system is involved in the regulation of cranial vasculature and a key element in the transmission of pain
C. The release of calcitonin gene-related peptide from peripheral terminals results in meningeal vasodilation
D. None, all are correct
D. None, all are correct
Rationalization: All the statements provided regarding the pathophysiology of migraine headaches are correct. CGRP (Calcitonin Gene-Related Peptide) is a principal mediator, the trigeminovascular system is involved in pain transmission, and the release of CGRP leads to meningeal vasodilation, contributing to migraine pathophysiology.
- A 67-year-old woman is seen in the medical ICU, where she is being treated for sepsis with profound hypotension. On examination, she is speaking fluently but nonsensically, and comprehension is markedly impaired. However, she can repeat, and exhibits significant echolalia throughout examination. Which language disturbance best explains the clinical picture?
A. Global aphasia
B. Wernicke’s aphasia
C. Broca’s aphasia
D. Transcortical motor aphasia
E. Transcortical sensory aphasia
E. Transcortical sensory aphasia
Rationalization: The clinical picture of fluent but nonsensical speech, markedly impaired comprehension, preserved repetition ability, and significant echolalia is characteristic of transcortical sensory aphasia. This condition is similar to Wernicke’s aphasia but with the preservation of repetition ability.
- Detects Linear acceleration:
A. Semicircular canals
B. None
C. Otolithic organs
D. Otolithic organs and semicircular canals
C. Otolithic organs
Rationalization: The otolithic organs (utricle and saccule) in the inner ear are responsible for detecting linear acceleration and gravity, helping to sense changes in head position relative to linear movements. The semicircular canals, on the other hand, detect angular acceleration or rotational movements.
- The following statements are TRUE regarding amnesia, except:
A. In retrograde amnesia, remote events are more vulnerable than recent events
B. None, all are true
C. Patients with anterograde amnesia have the tendency to confabulate to fill their memory gaps
D. Anterograde amnesia is often seen in Wernicke-Korsakoff syndrome
A. In retrograde amnesia, remote events are more vulnerable than recent events
Rationalization: This statement is incorrect. In retrograde amnesia, recent events are typically more vulnerable or more likely to be forgotten than remote (older) events. This is due to the consolidation process, where recent memories are not as firmly established as older ones.
- Association area of the cerebral cortex responsible for spatial orientation:
A. Prefrontal
B. Parietotemporal
C. Left-dominant perisylvian
D. Right-dominant parietofrontal
B. Parietotemporal
Rationalization: The parietotemporal association area of the cerebral cortex is responsible for integrating sensory information for spatial orientation, including the understanding of maps and the spatial relationship between objects.
- Hyperpathia:
A. Pain from stimuli that is not normally painful
B. Extreme over-response to pain
C. Multiple, very severe, electric shock-like pains that radiate into a specific root or nerve distribution
D. Unbearable, burning, relentless hyperesthesia and hyperalgesia that ensue after injury to a peripheral nerve
B. Extreme over-response to pain
Rationalization: Hyperpathia is characterized by an extreme, exaggerated response to pain. It is a condition where there is an abnormally increased sensitivity to stimuli, especially to painful stimuli, which is not the definition provided in option B. Option A (Pain from stimuli that is not normally painful) describes allodynia.
- Frontal abulic syndrome is caused by a lesion in
A. Orbitofrontal cortex
B. Ventrolateral cortex
C. Ventromedial cortex
D. Dorsomedial prefrontal cortex
D. Dorsomedial prefrontal cortex
Rationalization: Frontal abulic syndrome, characterized by apathy, lack of initiative, and reduced interest in activities, is often associated with lesions in the dorsomedial prefrontal cortex. This area is involved in motivation, decision-making, and social behavior.
- The following tests for the facial nerve except
A. Raising the eyebrows
B. None of the choices (all the given choices tests for facial nerve)
C. Smiling
D. Clenching the teeth
E. Blowing the candle
D. Clenching the teeth
Rationalization: Clenching the teeth primarily tests the trigeminal nerve (cranial nerve V), which is responsible for the muscles involved in mastication, not the facial nerve (cranial nerve VII). The facial nerve is tested by assessing facial expressions such as raising the eyebrows, smiling, and blowing out a candle.
- Cilia of hair cells are embedded in a gelatinous mass known as -
A. Utricle
B. Ampulla
C. Crista
D. Cupula
D. Cupula
Rationalization: The cilia of hair cells in the semicircular canals of the inner ear are embedded in a gelatinous mass known as the cupula. The cupula moves in response to head rotations, leading to stimulation of the hair cells and the sensation of angular motion.
52 The following reflex tests which spinal segments?
A. C6-C7
B. C7-C8
C. С4-С5
D. C5-C6
A. C6-C7
Biceps 5-6
Triceps 6-7
Brachioradialis 5-6
Finger flexor c8-t1
- Which of the statements about motor examination is/are true?
A. All the statements are true
B. Tone is assessed by passive movement of the extremities
C. When doing the reflex testing the extremity must be placed in the fully flexed position
D. Pronator drift tests for mild weakness of the lower extremities
E. Achilles tendon reflex tests for L4-L5 spinal segments
B. Tone is assessed by passive movement of the extremities
Rationalization: Tone is indeed assessed by passive movement of the extremities, observing for any resistance to movement that might indicate hypotonia or hypertonia. The other statements are incorrect: Reflex testing does not require the extremity to be fully flexed, pronator drift tests for mild weakness of the upper extremities (not lower), and the Achilles tendon reflex tests the S1-S2 spinal segments (not L4-L5).
- The following are part of Gerstman syndrome except
A. Number agnosia
B. Agraphia
C. Inability to calculate
D. None of the choices
E. Right left confusion
A. Number agnosia
This is because the classical quartet of symptoms does not include number agnosia as a component of Gerstmann syndrome. However, clinical presentations can vary and overlap among different cognitive syndromes is common.
- A 60-year-old male with a history of myocardial infarction of myocardial Infarction awakens with a dense right-sided hemiplegia. His eyes are tonically Deviated to the left, and he does not respond to threat on the right side of his Visual field. He appears to be alert and responds to pain on the left side of the Body. His speech is unintelligible and non-fluent, and he follows cannot follow Instructions. Efforts to get him to repeat simple phrases consistently fail. Which Language disturbance best explains the clinical picture?
A. Transcortical sensory aphasia
B. Global aphasia
C. Wernicke’s aphasia
D. Transcortical motor aphasia
E. Broca’s aphasia
B. Global aphasia
Rationalization: The clinical picture of dense right-sided hemiplegia, non-fluent unintelligible speech, inability to follow instructions or repeat phrases, and neglect of one side of the visual field suggests global aphasia. This condition typically results from extensive damage to the dominant hemisphere affecting both the language comprehension areas (Wernicke’s area) and the speech production areas (Broca’s area).
- Hyperreflexia with clonus is recorded as:
A. +
B. ++
C. +++
D. ++++
D. ++++
Rationalization: Hyperreflexia with clonus is a sign of upper motor neuron disease and is typically recorded as ++++ (4+), indicating very brisk reflexes, often associated with pathological reflexes like clonus.
79 The following visual field cut indicates a lesion in which of the following structures?
A. right occipital lobe
B. left geniculocalcarine radiation
C. left optic nerve
D. right optic chiasm
B. Left geniculocalcarine radiation: Lesions in the left geniculocalcarine tract, which carries visual information from the right half of the visual field, would result in right homonymous hemianopia.
- Inability to perform this test is called
A. Dysdiadochokinesia
B. Dysmetria
C. Dyssynergia
D. Dysarthria
B. Dysmetria- finger to nose test (ratio)
This is a common neurological exam to assess coordination and is part of testing for cerebellar function. During this test, a person is asked to touch their nose with their finger and then to touch the examiner’s finger, with the examiner changing the position of their finger periodically.
The inability to perform this test due to lack of coordination is known as dysmetria, specifically when the person consistently undershoots (hypometria) or overshoots (hypermetria) the target. Dysmetria is indeed characterized by the inability to control the range of movement and is often seen in cerebellar disorders.
A. Chaddock
B. Babinski
C. Oppenheim
D. Schaeffer
D. Schaeffer
Schaeffer’s Sign: For this test, the examiner squeezes the Achilles tendon, and a positive sign is the same as a positive Babinski.
Babinski Reflex Test: This is the most well-known test where the examiner strokes the lateral aspect of the sole of the foot with a blunt object, usually from the heel toward the toes. A positive Babinski sign, which is abnormal, is indicated by dorsiflexion of the big toe and fanning of the other toes, suggesting an upper motor neuron lesion.
Chaddock’s Sign: Instead of the sole of the foot, the examiner strokes the lateral malleolus or the lateral aspect of the foot. A positive Chaddock’s sign is the same response as a positive Babinski sign and can be used when the sole of the foot is not accessible or the Babinski test is negative in the presence of other signs of an upper motor neuron lesion.
Oppenheim’s Sign: This involves applying pressure to the anterior surface of the tibia, causing the same response as the Babinski sign if positive.
CASE#1. A 53 y/o female, smoker, known hypertensive and diabetic, non-compliant with medications, came to the ER for sudden onset of diplopia and right sided weakness. On PE, pt was awake, with intact higher cortical function. On cranial nerve assessment there was note of ptosis on the left eye, and the left eye was deviated outwards. There was no note of facial numbness or facial palsy. Tongue was midline. The right upper and lower extremities were graded 2/5 while the left upper and lower extremities were 5/5. There was no note of nystagmus, dysmetria. Neck was supple.
Based on the clinical presentation, where is the most likely location of the lesion in this patient?
A) Right cerebrum, frontal lobe
B) Left cerebrum, occipital lobe
C) Brainstem, specifically the left midbrain area
D) Spinal cord, cervical level
C) Brainstem, specifically the left midbrain area
The clinical presentation suggests a lesion in the brainstem, specifically in the region affecting the cranial nerves responsible for eye movement and possibly the corticospinal tract.
CASE#1. A 53 y/o female, smoker, known hypertensive and diabetic, non-compliant with medications, came to the ER for sudden onset of diplopia and right sided weakness. On PE, pt was awake, with intact higher cortical function. On cranial nerve assessment there was note of ptosis on the left eye, and the left eye was deviated outwards. There was no note of facial numbness or facial palsy. Tongue was midline. The right upper and lower extremities were graded 2/5 while the left upper and lower extremities were 5/5. There was no note of nystagmus, dysmetria. Neck was supple.
The patient’s ptosis and outward deviation of the left eye suggest involvement of which cranial nerve?
A) Cranial Nerve II (Optic Nerve)
B) Cranial Nerve III (Oculomotor Nerve)
C) Cranial Nerve IV (Trochlear Nerve)
D) Cranial Nerve VI (Abducens Nerve)
B) Cranial Nerve III (Oculomotor Nerve)
Diplopia and ptosis on the left eye, along with the left eye being deviated outwards, suggest involvement of the cranial nerve III (oculomotor nerve) on the left side, which controls most of the eye’s movements, including constriction of the pupil and maintaining an open eyelid.
CASE #2. A 60 y/o female with known history of breast cancer was brought to the ER for a 3-month history of back pain and progressive lower extremity weakness. She also noted difficulty in urination. On PE, pt was GCS15, with intact cranial nerves. Both upper extremities were graded 5/5, normotonic and normorefexic. Both lower extremities were spastic and hyperreflexic (+4). Hip flexors, knee extensors, ankle dorsi and plantarflexors were graded 0/5. Bilateral babinski and clonus were noted. On sensory testing, last normal sensory level to pain was at the level of the nipple. Both upper extremities had intact proprioception while both lower extremities had impaired proprioception and vibration sense. No dysmetria or nystagmus were noted.
Based on the clinical presentation, where is the most likely location of the lesion in this patient?
A) Cervical spinal cord
B) Thoracic spinal cord at the level of the nipples (T4-T5)
C) Lumbar spinal cord
D) Brainstem
B) Thoracic spinal cord at the level of the nipples (T4-T5
Impaired proprioception and vibration sense in both lower extremities, along with the last normal sensory level to pain at the level of the nipple, suggest a lesion at or above the thoracic level of the spinal cord, around the T4-T5 vertebrae, given the nipple line is typically at the dermatome level of T4.
CASE #2. A 60 y/o female with known history of breast cancer was brought to the ER for a 3-month history of back pain and progressive lower extremity weakness. She also noted difficulty in urination. On PE, pt was GCS15, with intact cranial nerves. Both upper extremities were graded 5/5, normotonic and normorefexic. Both lower extremities were spastic and hyperreflexic (+4). Hip flexors, knee extensors, ankle dorsi and plantarflexors were graded 0/5. Bilateral babinski and clonus were noted. On sensory testing, last normal sensory level to pain was at the level of the nipple. Both upper extremities had intact proprioception while both lower extremities had impaired proprioception and vibration sense. No dysmetria or nystagmus were noted.
The presence of bilateral Babinski sign and clonus in this patient suggests:
A) Lower motor neuron lesion
B) Upper motor neuron lesion
C) Peripheral neuropathy
D) Myasthenia gravis
B) Upper motor neuron lesion
Progressive lower extremity weakness, spasticity, hyperreflexia, bilateral Babinski sign, and clonus are all signs of an upper motor neuron lesion affecting the spinal cord.
CASE #2. A 60 y/o female with known history of breast cancer was brought to the ER for a 3-month history of back pain and progressive lower extremity weakness. She also noted difficulty in urination. On PE, pt was GCS15, with intact cranial nerves. Both upper extremities were graded 5/5, normotonic and normorefexic. Both lower extremities were spastic and hyperreflexic (+4). Hip flexors, knee extensors, ankle dorsi and plantarflexors were graded 0/5. Bilateral babinski and clonus were noted. On sensory testing, last normal sensory level to pain was at the level of the nipple. Both upper extremities had intact proprioception while both lower extremities had impaired proprioception and vibration sense. No dysmetria or nystagmus were noted.
The last normal sensory level to pain at the level of the nipple indicates a lesion at which vertebral level?
A) C5
B) T4-T5
C) L1
D) S1
B) T4-T5
