LE 5

Question 1

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

Answer 1

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.

Question 2

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.

2. 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

Answer 2

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.

Question 3

3. 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

Answer 3

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.

Question 4

4. 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

Answer 4

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.

Question 5

7. 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

Answer 5

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.

Question 6

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

Answer 6

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.

Question 7

9. Test for coordination?
   A. None
   B. Rapid alternating movement
   C. Both
   D. Heel to shin test

Answer 7

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).

Question 8

10. 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

Answer 8

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.

Question 9

11. 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)

Answer 9

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.

Question 10

12. 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

Answer 10

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.

Question 11

13. 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

Answer 11

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.

Question 12

14. 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

Answer 12

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.

Question 13

15. 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

Answer 13

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).

Question 14

16. This is mainly a test to identify cerebellar ataxia:
    A. True
    B. False

Answer 14

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.

Question 15

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

Answer 15

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.

Question 16

18. 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

Answer 16

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.

Question 17

19.Inability to perform rapid alternating movements:
A. Dyssynergia
B. Dystaxia
C. Dysdiadochokinesia
D. Dysmetria

Answer 17

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.

Question 18

20. The following may present with acute weakness except
    A. Tumor
    B. Subdural hematoma
    C. Guillain barre syndrome
    D. Cerebrovascular disease

Answer 18

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.

Question 19

21. 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

Answer 19

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.

Question 20

22. 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

Answer 20

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).

Question 21

23. 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

Answer 21

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.

Question 22

24. 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

Answer 22

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.

Question 23

25. 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

Answer 23

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.

Question 24

26. “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

Answer 24

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.

Question 25

28. 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 25

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.

Question 26

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

Answer 26

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.

Question 27

30. Most common cause of primary headache A. Idiopathic B. Systemic infection C. Migraine D. Tension type

Answer 27

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

Question 28

31. 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

Answer 28

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.

Question 29

32. True of Central Vertigo: A. Duration of dizziness persists B. Visual fixation suppresses vertigo C. Acute onset D. All are incorrect

Answer 29

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.

Question 30

33. The Epley Maneuver is both diagnostic and therapeutic for Benign Paroxysmal Positional Vertigo (BPPV). A. False B. True

Answer 30

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.

Question 31

34. Asking a patient to spell the word WORLD backwards tests for which cognitive domain? a. Fund of knowledge b. Insight c. Planning d. Attention

Answer 31

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.

Question 32

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

Answer 32

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.

Question 33

36. 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

Answer 33

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.

Question 34

37. 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

Answer 34

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.

Question 35

38. 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

Answer 35

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.

Question 36

39. 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

Answer 36

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.

Question 37

40. 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

Answer 37

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.

Question 38

41. Detects Linear acceleration: A. Semicircular canals B. None C. Otolithic organs D. Otolithic organs and semicircular canals

Answer 38

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.

Question 39

42. 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

Answer 39

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.

Question 40

44. Association area of the cerebral cortex responsible for spatial orientation: A. Prefrontal B. Parietotemporal C. Left-dominant perisylvian D. Right-dominant parietofrontal

Answer 40

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.

Question 41

45. 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

Answer 41

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.

Question 42

43. Frontal abulic syndrome is caused by a lesion in A. Orbitofrontal cortex B. Ventrolateral cortex C. Ventromedial cortex D. Dorsomedial prefrontal cortex

Answer 42

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.

Question 43

46. 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

Answer 43

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.

Question 44

47. Cilia of hair cells are embedded in a gelatinous mass known as - A. Utricle B. Ampulla C. Crista D. Cupula

Answer 44

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.

Question 45

48. All of the following are true regarding Syncope, EXCEPT: A. Any interference in venous return may lead to a reduction in cardiac output B. May be due to decreased cerebral vascular resistance C. It may be benign or serious D. It often occurs in the setting of increased peripheral sympathetic activity and venous pooling

Answer 45

B. May be due to decreased cerebral vascular resistance Syncope is typically due to a transient decrease in cerebral blood flow, leading to a brief loss of consciousness. Decreased cerebral vascular resistance would theoretically increase cerebral blood flow, not decrease it. Syncope often results from factors that reduce blood flow to the brain, such as reduced cardiac output or abrupt drops in blood pressure, not from decreased resistance in cerebral vessels.

Question 46

49. Pain from stimuli that is not normally painful Extreme over-response to pain Multiple, very severe, electric shock-like pains that radiate into a specific root or nerve distribution Unbearable, burning, relentless hyperesthesia and hyperalgesia that ensue after injury to a peripheral nerve A. Patient has left hemineglect B. Patient has right hemianopia C. Patient has left apraxia D. Patient has right hemineglect

Answer 46

D. Patient has left hemineglect Rationalization: Pain from stimuli that is not normally painful describes allodynia, not the options provided. However, if this question is intended to match the descriptions with the conditions, none of the options directly describe allodynia. It seems there might be a mismatch in the question's structure.

Question 47

50. A 62-year-old man is brought to the emergency department by his wife because He was acting "funny". He had been paying bills that morning and could not Seem to calculate simple sums. He as also having trouble writing. On Examination, he had right-left confusion and finger agnosia. This man's Syndrome localizes to the: A. Nondominant dorsolateral prefrontal cortex B. Dominant superior temporal cortex C. Nondominant parietal lobule D. Dominant inferior parietal lobule

Answer 47

D. Dominant inferior parietal lobule Rationalization: The symptoms described, including difficulty with calculation (acalculia), writing (agraphia), right-left confusion, and finger agnosia, are characteristic of Gerstmann syndrome, which is associated with a lesion in the dominant inferior parietal lobule.

Question 48

51 A 24-year-old woman abruptly loses all speech during the third trimester of an Otherwise uncomplicated pregnancy. She has a history of severe migraines During which she occasionally develops a transient right hemiplegia. Her Comprehension is good, and she is frustrated by her inability to speak or write, And inability to repeat simple phrases. Which language disturbance best explains the clinical picture? A. Transcortical sensory aphasia B. Wernicke's aphasia C. Global aphasia D. Transcortical motor aphasia E. Broca's aphasia

Answer 48

E. Broca's aphasia Rationalization: The clinical picture of abrupt loss of speech, good comprehension, frustration with the inability to speak or write, and inability to repeat simple phrases is indicative of Broca's aphasia. This condition is characterized by impaired speech production with preserved comprehension, often resulting from a lesion in the posterior inferior frontal gyrus of the dominant hemisphere.

Question 49

52 The following reflex tests which spinal segments? A. C6-C7 B. C7-C8 C. С4-С5 D. C5-C6

Answer 49

A. C6-C7 Biceps 5-6 Triceps 6-7 Brachioradialis 5-6 Finger flexor c8-t1

Question 50

53. Allows eyes to closely follow a moving target A. Smooth pursuit B. Visual fixation C. Saccades D. Oculomotor reflex

Answer 50

A. Smooth pursuit Rationalization: Smooth pursuit allows the eyes to closely follow a moving target. This eye movement is slow and steady, enabling the eyes to maintain visual focus on a moving object, distinguishing it from saccades, which are rapid eye movements used to shift gaze between stationary objects.

Question 51

54. 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

Answer 51

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).

Question 52

55. Allows eyes to closely follow a moving target: A. Smooth pursuit B. Visual fixation C. Saccades D. Oculomotor reflex

Answer 52

A. Smooth pursuit Rationalization: Smooth pursuit allows the eyes to closely follow a moving target, enabling the tracking of objects moving across the visual field with smooth, continuous eye movements.

Question 53

57. 55 y/o male presenting with headache, gradual onset spastic weakness of both legs, memory lapses and urinary incontinence. Which of the following diagnostic tests will you order? A. Electroencephalogram B. Nerve conduction studies and electromyography C. Spinal MRI D. Cranial MRI

Answer 53

D. Cranial MRI Rationalization: Given the symptoms of headache, spastic weakness of both legs, memory lapses, and urinary incontinence, a cranial MRI is the most appropriate diagnostic test. These symptoms suggest a central nervous system disorder that could involve the brain, such as a tumor, vascular lesion, or demyelinating disease.

Question 54

58. Which of the following is a pure motor nerve?. A. Trigeminal nerve B. Optic nerve C. Oculomotor nerve (CN III) D. Facial nerve

Answer 54

C. Oculomotor nerve (CN III) Rationalization: The oculomotor nerve is primarily a motor nerve that controls most of the eye's movements, the constriction of the pupil, and maintains an open eyelid. The trigeminal nerve has both sensory and motor functions, the optic nerve is sensory, and the facial nerve has both motor and sensory (taste) components.

Question 55

59. Taste sensation of the posterior 1/3 of the tongue is supplied by which of the following? A. Glossopharyngeal nerve B. Trigeminal nerve C. Hypoglossal nerve D. Facial nerve

Answer 55

A. Glossopharyngeal nerve Rationalization: The glossopharyngeal nerve (cranial nerve IX) supplies taste sensation to the posterior one-third of the tongue. The trigeminal nerve provides general sensation to the face, including the anterior two-thirds of the tongue, the hypoglossal nerve controls tongue movements, and the facial nerve supplies taste to the anterior two-thirds of the tongue.

Question 56

60. 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 patient's sensorium? A. Stuporous B. Comatose C. Awake D. Lethargic

Answer 56

A. Stuporous Rationalization: A stuporous state is characterized by a lack of response to the environment except to repeated or painful stimuli. The patient's behavior—only opening eyes to pain, moaning in response to pain, and withdrawing from pain—indicates a stuporous condition.

Question 57

61 The most medial lamination of the Spinothalamic tract: A. Lumbar B. Sacral C. Cervical D. Thoracic

Answer 57

B. Sacral Rationalization: In the spinothalamic tract, the most medial lamination is sacral, following the somatotopic organization where sacral fibers are positioned medially, and cervical fibers are positioned laterally. This organization allows for the tract to maintain a specific mapping of the body's sensory information as it ascends to the brain.

Question 58

62. Which functional subdivision of the cerebellum controls the muscle tone, axial and limb movements? A. Cerebrocerebellum B. Spinocerebellum C. Vestibulocerebellum D. Pontocerebellum

Answer 58

B. Spinocerebellum Rationalization: The spinocerebellum controls muscle tone and coordinates fine movements of the limbs and axial body. It receives proprioceptive input from the spinal cord to adjust and correct ongoing movements, ensuring posture and gait stability.

Question 59

63. 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

Answer 59

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.

Question 60

64. The following are pain producing structures except: A. Dural sinuses B. Scalp C. Proximal pial arteries D. Pial veins

Answer 60

D. Pial veins Rationalization: Pial veins are not typically considered pain-producing structures within the cranial cavity. Pain-sensitive structures in the head include the dural sinuses, scalp, and proximal parts of the large pial arteries. The brain parenchyma itself and pial veins do not have pain receptors.

Question 61

65. 54/male patient was brought to the emergency room because of sudden onset left sided weakness. When asked to raise his left arm, he was not able to fully move it against gravity. What is the motor strength score? A. 1 B. 5 C. 2 D. 4 E. 3

Answer 61

E. 3 Rationalization: A motor strength score of 3 indicates that the patient can move the limb against gravity but not against resistance. This is consistent with the description of not being able to fully move the left arm against gravity.

Question 62

66. A 69-year-old man was noted to have difficulty looking at objects that were brought into his visual field. He could not reach for objects placed in front of him, though he could see them. When presented with a picture of a complex scene, he could identify items within the picture but could not describe the picture as a whole. This syndrome localizes to: A. Bilateral caudate region B. Bilateral temporo-occipital region C. Bilateral visual cortices D. Bilateral parieto-occipital region

Answer 62

D. Bilateral parieto-occipital region Rationalization: The symptoms described, including difficulty reaching for objects (optic ataxia), inability to describe a complex scene as a whole (simultanagnosia), and issues with visual fixation, are characteristic of Balint's syndrome, which is associated with bilateral lesions in the parieto-occipital region.

Question 63

67. The following are mixed motor and sensory cranial nerves except A. CN VII B. CN X C. CN IX D. CN IV

Answer 63

D. CN IV Rationalization: The trochlear nerve (CN IV) is a pure motor nerve that innervates the superior oblique muscle of the eye. CN VII (Facial nerve), CN IX (Glossopharyngeal nerve), and CN X (Vagus nerve) have both motor and sensory components.

Question 64

68.Ideational apraxia: A. Inability to perform goal-directed movements in sequence B. Clumsiness in use of tools or objects C. Deficit in using common tools in the absence of real object D. Inability to perform specific motor act

Answer 64

A. Inability to perform goal-directed movements in sequence Rationalization: Ideational apraxia is characterized by the inability to conceptualize, plan, and execute the complex sequences of motor actions involved in the use of tools or the performance of goal-directed activities.

Question 65

69. Test for Deep sensation, except: A. Vibration B. Joint position sense C. Pinprick, vibration and position sense D. Pinprick test

Answer 65

D. Pinprick test Rationalization: The pinprick test assesses pain sensation, not deep sensation. Vibration and joint position sense tests are used to assess deep sensations.

Question 66

70.55 y/o female presenting with 5 month history of urinary retention, gradual weakness of lower extremities. On PE, both legs were spastic and hyperreflexive. She also had positive babinski bilateral. There was note of decreased sensation to pain from the nipple area down to the legs. What neurodiagnostic test will you order? A. Spinal MRI B. Nerve conduction studies C. Cranial MRI D. Cranial CT scan

Answer 66

A. Spinal MRI Rationalization: Given the symptoms of urinary retention, gradual weakness of the lower extremities, spasticity, hyperreflexia, positive Babinski sign bilaterally, and decreased sensation to pain from the nipple area down, a spinal MRI is indicated to look for lesions in the spinal cord that could explain these findings.

Question 67

71. Inability to identify an object after careful palpation: A. Astereognosis B. Agraphia C. Agraphesthesia D. Anosognosia

Answer 67

A. Astereognosis Rationalization: Astereognosis is the inability to identify an object by touch alone without the aid of sight.

Question 68

72. Dressing apraxia localizes to the A. Left frontal lobe B. Left parietal lobe C. Right frontal lobe D. Right parietal lobe

Answer 68

D. Right parietal lobe Rationalization: Dressing apraxia is often associated with damage to the right parietal lobe, which is involved in spatial awareness and the integration of sensory information necessary for dressing.

Question 69

73. 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

Answer 69

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).

Question 70

74. Hyperreflexia with clonus is recorded as: A. + B. ++ C. +++ D. ++++

Answer 70

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.

Question 71

75. Which of the following statements about spasticity is incorrect? A. Spasticity is not velocity dependent B. It is usually described as clasp knife phenomenon C. Spasticity predominantly affects the flexor muscles of the upper extremities and the extensor muscles of the lower extremities

Answer 71

A. Spasticity is not velocity dependent Rationalization: This statement is incorrect. Spasticity is indeed velocity-dependent; it increases with the speed of limb movement. It is characterized by the clasp-knife phenomenon and affects muscle groups as described.

Question 72

76. True about weakness due to involvement of upper motor neurons:. A. Spasticity accompanies weakness but may not be present in the acute phase B. It is due to involvement of the anterior horn cells of the spinal cord corticospinal tract C. Fasciculations and fibrillations may be present D. There is usually marked atrophy of the involved muscles

Answer 72

A. Spasticity accompanies weakness but may not be present in the acute phase Rationalization: This statement is true about weakness due to involvement of upper motor neurons. Spasticity is a hallmark of upper motor neuron lesions, but it may not develop immediately after the onset of the lesion. The other options describe features more typical of lower motor neuron lesions.

Question 73

77. Refers to a person's awareness that symptoms or disturbed behaviors are normal or abnormal A. Thought process B. Attention C. Insight D. Mood

Answer 73

C. Insight Rationalization: Insight refers to the awareness and understanding of one's own condition and behaviors, including the ability to recognize that one's symptoms or behaviors are abnormal.

Question 74

78. Features of Peripheral Vertigo, EXCEPT: A. Visual fixation suppresses vertigo B. Severe vertigo C. Fatigable D. Bidirectional nystagmus

Answer 74

D. Bidirectional nystagmus Rationalization: Peripheral vertigo typically presents with unidirectional nystagmus, not bidirectional. Visual fixation often suppresses vertigo, the vertigo can be severe, and the nystagmus is usually fatigable in peripheral vertigo.

Question 75

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

Answer 75

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.

Question 76

80. Componnets of the Mini-Mental Status Examination A. Calculation B. Language C. Orientation D. All are components of MMSE E. Orientation and Language only

Answer 76

D. All are components of MMSE Rationalization: The Mini-Mental Status Examination (MMSE) includes components such as calculation, language, and orientation, among others, to assess cognitive function.

Question 77

81 A patient with agraphesthesia will have the A. Inability to identify an object with palpation B. Inability to recognize object drawn on the palm of his hand C. Inability to recognize affected limb as his own D. Inability to write

Answer 77

B. Inability to recognize object drawn on the palm of his hand Rationalization: Agraphesthesia is the inability to recognize numbers, letters, or shapes drawn on the skin, typically on the palm of the hand, indicating a sensory perceptual disorder.

Question 78

82. A 72-year old woman is brought to a neurology clinic by her family members for memory impairment and a decline in functional abilities. On examination, when she is asked to pantomime brushing her teeth, she uses her finger as the toothbrush, instead of pretending to hold a toothbrush. When asked to show how she would open a letter with a letter opener, she uses her finger as the blade instead of pretending A. Ideational apraxia B. Limb-kinetic apraxia C. Ideomotor apraxia D. Conduction apraxia E. Conceptual apraxia

Answer 78

C. Ideomotor apraxia Rationalization: Ideomotor apraxia is characterized by the inability to perform a task on command despite understanding the task and having the physical ability to perform it. Using the finger as a tool instead of pantomiming the use of the actual tool (like a toothbrush or letter opener) is indicative of ideomotor apraxia.

Question 79

83. 67 y/o female developed sudden onset diplopia and left sided weakness. On PE, there was note of esotropia of the right eye and she cannot abduct her right eye while testing for extraocular muscle movement. Left upper and lower extremities were graded 3/5 while the right upper and lower 5/5. Where will you localize the lesion? A. right pons B. right midbrain C. right corona radiata D. left medulla

Answer 79

A. right pons Rationalization: The presence of esotropia (inward deviation of the eye) and inability to abduct the right eye suggest a lesion involving the abducens nerve (CN VI), which emerges from the pons. The left-sided weakness indicates a crossed pattern of deficits, typical of brainstem lesions, localizing the lesion to the right pons.

Question 80

84. True of Logopenic Primary Progressive Aphasia, except: a. most commonly associated with Alzheimer's disease b. preserved fluency and syntax but poor single-word comprehension and profound 2-way naming impairments -semantic ppa c. preserved syntax and comprehension but frequent and severe word-finding pauses; repetition impaired d. None, all are correct

Answer 80

B. preserved fluency and syntax but poor single-word comprehension and profound 2-way naming impairments -semantic ppa Rationalization: This description is incorrect for logopenic primary progressive aphasia (PPA). Logopenic PPA is characterized by preserved syntax and comprehension but frequent and severe word-finding pauses; repetition is impaired. The description given matches semantic PPA more closely.

Question 81

85. A spinal cord hemisection will have the following pattern of sensory loss: a. Ipsilateral loss of vibration and position sense and contralateral loss of pain and temperature b. Ipsilateral loss of vibration and position sense and ipsilateral loss of pain and temperature c. Cape distribution d. Contralateral loss of vibration and position sense and ipsilateral loss of pain and temperature

Answer 81

A. Ipsilateral loss of vibration and position sense and contralateral loss of pain and temperature Rationalization: A spinal cord hemisection (Brown-Séquard syndrome) results in ipsilateral loss of vibration and position sense (due to damage to the dorsal columns) and contralateral loss of pain and temperature sense (due to damage to the spinothalamic tract) below the level of the lesion.

Question 82

86. The ideal distance of the patient from the Snellen chart during visual acuity testing A. 14 inches B. 20 feet C. 10 feet D. 20 meters

Answer 82

B. 20 feet Rationalization: The ideal distance for a patient from the Snellen chart during visual acuity testing is 20 feet (or 6 meters in countries using the metric system).

Question 83

87. The second- order neuron in the Dorsal column-medial lemniscus pathway is located at -- A. ventral posterior lateral nucleus of thalamus B. nucleus gracilis and nucleus cuneatus C. central gray matter (dorsal horn) D. dorsal root ganglion

Answer 83

B. nucleus gracilis and nucleus cuneatus Rationalization: The second-order neurons in the Dorsal column-medial lemniscus pathway are located in the nucleus gracilis and nucleus cuneatus in the medulla oblongata.

Question 84

88. In mini mental state exam, registration is given a score of A. 5 B. 2 C. 4 D. 3

Answer 84

D. 3 Rationalization: In the Mini-Mental State Examination (MMSE), registration (the ability to repeat named prompts immediately after hearing them) is given a score of 3.

Question 85

89. Inability to perform this test is called A. Dysdiadochokinesia B. Dysmetria C. Dyssynergia D. Dysarthria

Answer 85

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.

Question 86

90. The following tests for optic nerve A. testing for accommodation reflex B. testing for peripheral vision using the snellen chart C. testing for pupillary light reflex D. none of the choices E. testing for corneal reflex

Answer 86

C. testing for pupillary light reflex Rationalization: Testing for the pupillary light reflex assesses the function of the optic nerve (CN II) as it carries sensory input to the brain, and the oculomotor nerve (CN III) as it controls the pupillary response.

Question 87

91. 70 y/o male presented with sudden onset left sided hemiplegia, numbness and left central facial palsy. Which of the following tests will you order? A. electroencephalogram B. spinal MRI C. nerve conduction studies D. cranial CT scan

Answer 87

D. cranial CT scan Rationalization: For sudden onset of left-sided hemiplegia, numbness, and left central facial palsy, a cranial CT scan is the most appropriate initial test to assess for acute stroke or other cerebral pathologies.

Question 88

92. 20 y/o female with a 2 month history of predominantly proximal weakness of the Shoulder and hip muscles. Which of the following tests will you order? A. Spinal mri B. Nerve conduction studies and electromyography C. Cranial mri D. Cranial ct scan

Answer 88

B. Nerve conduction studies and electromyography Rationalization: For a 20-year-old female with a 2-month history of predominantly proximal weakness of the shoulder and hip muscles, nerve conduction studies (NCS) and electromyography (EMG) are appropriate to assess for neuromuscular disorders such as myopathies or neuromuscular junction disorders.

Question 89

93. Lesion in the territory of posterior arteries particularly the occipitotemporal area may result to: A. Simultagnosia B. Prosopagnosia C. Optic apraxia D. Cortical blindness

Answer 89

B. Prosopagnosia Rationalization: Lesions in the territory of the posterior cerebral arteries, particularly affecting the occipitotemporal area, can lead to prosopagnosia, which is the inability to recognize familiar faces.

Question 90

A. Chaddock B. Babinski C. Oppenheim D. Schaeffer

Answer 90

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.

Question 91

95. The following cranial nerves are found in the medulla except A. Abducens B. Hypoglossal C. Glossopharyngeal D. Vagus

Answer 91

A. Abducens Rationalization: The abducens nerve (CN VI) originates from the pons, not the medulla. The hypoglossal (CN XII), glossopharyngeal (CN IX), and vagus (CN X) nerves are found in the medulla.

Question 92

96. Comprehension of written or spoken language is localized at A. dominant superior parietal lobe B. dominant inferior frontal lobe C. non dominant superior frontal lobe D. dominant superior temporal lobe

Answer 92

D. Dominant superior temporal lobe Rationalization: Comprehension of written or spoken language is primarily localized in the dominant superior temporal lobe, specifically in Wernicke's area.

Question 93

97. When you ask the patient to look to the left and down, which cranial nerves are you testing? A. Left abducens and right oculomotor B. Right trochlear and left oculomotor C. Left trochlear and right optic D. Left trochlear and right oculomotor

Answer 93

B. Right trochlear and left oculomotor Rationalization: Looking to the left involves the left abducens (CN VI) for lateral movement, and looking down involves the right trochlear (CN IV) for intorsion and depression of the eye, along with the left oculomotor (CN III) for its role in most eye movements including downward movement.

Question 94

98. You saw a stroke patient in the clinic who was having difficulty in demonstrating how to wave goodbye even if his motor function, sensorium and comprehension are intact. You can say that the patient has: A. Abulia B. Apraxia C. Apathy D. Agnosia E. Hemineglect

Answer 94

B. Apraxia Rationalization: Difficulty in demonstrating how to perform a familiar gesture, such as waving goodbye, despite intact motor function, sensorium, and comprehension, suggests apraxia, which is a disorder of skilled movement not explained by weakness, akinesia, deafferentation, abnormal tone or posture, or intellectual deterioration.

Question 95

99. True of vasovagal syncope: A. Both are correct B. Unconsciousness may be prolonged if individual remains upright C. Both are incorrect D. Like that of seizure, sphincter control is maintained

Answer 95

A. Both are correct Rationalization: In vasovagal syncope, unconsciousness may indeed be prolonged if the individual remains upright due to continued reduced cerebral perfusion, and unlike seizures, sphincter control is typically maintained.

Question 96

100. Confused speech is given a grade of __ in the verbal response part of the GCS A. 3 B. 2 C. 4 D. 1 E. 5 F. 6

Answer 96

C. 4 - Rationalization: In the Glasgow Coma Scale (GCS), confused speech is given a grade of 4 in the verbal response part. This indicates that the patient is disoriented or not making sense but is able to produce speech. The GCS verbal response scores range from 1 to 5, with specific criteria for each score: 5: Oriented 4: Confused 3: Inappropriate words 2: Incomprehensible sounds 1: No verbal response

Question 97

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

Answer 97

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.

Question 98

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)

Answer 98

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.

Question 99

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

Answer 99

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.

Question 100

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

Answer 100

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.

Question 101

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

Answer 101

B) T4-T5

Question 102

CASE #3. A 35 year-old male consulted at the out patient clinic for jerking of his right hand. 2 months prior to consult, he started experiencing intermittent headache partially relieved with intake of paracetamol. 2 days prior, he noted sudden twitching and jerking of his right hand which lasted for 1 minute. He was completely awake during the episode. Few hours prior to consult, the same episode was noted which lasted for 30 seconds. On PE, he was GCS15 with intact higher cortical functions. There was note of mild pronator drift on the right and the rest of the neurologic exam was normal. Where is the most likely location of the lesion in the patient described in CASE#3? A) Right frontal lobe B) Left frontal lobe C) Right parietal lobe D) Left parietal lobe

Answer 102

B) Left frontal lobe. The rationale is that the jerking and twitching of the right hand, described as focal motor seizures, are controlled by the contralateral (opposite side) hemisphere of the brain, specifically in the frontal lobe where the primary motor cortex is located. The left frontal lobe controls the motor functions of the right side of the body. The presence of a mild pronator drift on the right further supports the involvement of the upper motor neuron pathway originating from the left hemisphere.

Question 103

CASE #3. A 35 year-old male consulted at the out patient clinic for jerking of his right hand. 2 months prior to consult, he started experiencing intermittent headache partially relieved with intake of paracetamol. 2 days prior, he noted sudden twitching and jerking of his right hand which lasted for 1 minute. He was completely awake during the episode. Few hours prior to consult, the same episode was noted which lasted for 30 seconds. On PE, he was GCS15 with intact higher cortical functions. There was note of mild pronator drift on the right and the rest of the neurologic exam was normal. The jerking and twitching of the patient's right hand are most indicative of: A) Peripheral nerve damage B) A focal seizure C) A psychogenic movement disorder D) A spinal cord lesion

Answer 103

B) A focal seizure The sudden, brief, and involuntary twitching or jerking of the right hand, with the patient being fully conscious during the episode, is characteristic of a focal seizure. Focal seizures originate in just one area of the brain and can affect muscle control, movement, and sensation without necessarily impairing consciousness.

Question 104

CASE #3. A 35 year-old male consulted at the out patient clinic for jerking of his right hand. 2 months prior to consult, he started experiencing intermittent headache partially relieved with intake of paracetamol. 2 days prior, he noted sudden twitching and jerking of his right hand which lasted for 1 minute. He was completely awake during the episode. Few hours prior to consult, the same episode was noted which lasted for 30 seconds. On PE, he was GCS15 with intact higher cortical functions. There was note of mild pronator drift on the right and the rest of the neurologic exam was normal. The mild pronator drift observed in the patient's right arm suggests: A) Lower motor neuron lesion B) Upper motor neuron lesion C) Normal neurological finding D) Cerebellar dysfunction

Answer 104

B) Upper motor neuron lesion A mild pronator drift is a sign of weakness or subtle motor dysfunction, often indicative of an upper motor neuron lesion. This type of drift occurs when the patient extends their arms in front of them with palms facing upwards, and one arm slowly pronates and descends, reflecting a mild form of weakness.

Question 105

CASE #4. A 70 year-old male, smoker and alcoholic beverage drinker, known hypertensive, with poor compliance to medications, came to the ER for sudden onset left sided weakness. On PE, pt was awake, able to follow simple commands, with left hemineglect and agraphesthesia. Pupils were 3 mm briskly reactive to light, midline, with full EOMs, with left central facial palsy and tongue deviated to the left. Left upper and lower extremities were graded 2/5. There was (+) extensor toe sign on the left but no clonus. 50% sensory deficit was noted on the left upper and lower extremities. No nystagmus or dysmetria. No neck rigidity. Based on the clinical presentation, where is the lesion located in the patient described in CASE#4? A) Left cerebral hemisphere B) Right cerebral hemisphere C) Brainstem D) Cervical spinal cord

Answer 105

B) Right cerebral hemisphere The presentation of left-sided weakness, left hemineglect, and agraphesthesia, along with left central facial palsy, points to a lesion in the right cerebral hemisphere. Hemineglect, where the patient ignores one side of the body and space, is typically associated with damage to the parietal lobe, particularly on the right side, which manages spatial awareness and attention.

Question 106

CASE #4. A 70 year-old male, smoker and alcoholic beverage drinker, known hypertensive, with poor compliance to medications, came to the ER for sudden onset left sided weakness. On PE, pt was awake, able to follow simple commands, with left hemineglect and agraphesthesia. Pupils were 3 mm briskly reactive to light, midline, with full EOMs, with left central facial palsy and tongue deviated to the left. Left upper and lower extremities were graded 2/5. There was (+) extensor toe sign on the left but no clonus. 50% sensory deficit was noted on the left upper and lower extremities. No nystagmus or dysmetria. No neck rigidity. The presence of left hemineglect in this patient is most indicative of damage to which area of the brain? A) Left frontal lobe B) Right parietal lobe C) Left parietal lobe D) Right occipital lobe

Answer 106

B) Right parietal lobe Left hemineglect is a condition where the patient is unaware of objects or even their own limbs on the left side. This condition is most commonly associated with damage to the right parietal lobe, which is involved in processing spatial orientation and directing attention.

Question 107

CASE #4. A 70 year-old male, smoker and alcoholic beverage drinker, known hypertensive, with poor compliance to medications, came to the ER for sudden onset left sided weakness. On PE, pt was awake, able to follow simple commands, with left hemineglect and agraphesthesia. Pupils were 3 mm briskly reactive to light, midline, with full EOMs, with left central facial palsy and tongue deviated to the left. Left upper and lower extremities were graded 2/5. There was (+) extensor toe sign on the left but no clonus. 50% sensory deficit was noted on the left upper and lower extremities. No nystagmus or dysmetria. No neck rigidity. The left central facial palsy and tongue deviation to the left suggest involvement of: A) Cranial nerve VII B) Cranial nerve V C) Cranial nerve XII D) Both A and C

Answer 107

D) Both A and C Central facial palsy, where only the lower half of one side of the face is affected, and tongue deviation (to the lesion's contralateral side) suggest involvement of the facial nerve (Cranial nerve VII) and possibly the hypoglossal nerve (Cranial nerve XII). These symptoms indicate a central lesion affecting the neural pathways that control these cranial nerves, which in this case, would be located in the right hemisphere of the brain, affecting the left side of the body.

Question 108

A patient presents with diplopia, ptosis, and right-sided weakness. Which diagnostic test is most appropriate for identifying potential brainstem lesions in this patient? A) CT Scan of the Brain B) Magnetic Resonance Imaging (MRI) of the Brain focusing on the brainstem C) Electromyography (EMG) and Nerve Conduction Velocity (NCV) D) Spinal MRI

Answer 108

B) Magnetic Resonance Imaging (MRI) of the Brain focusing on the brainstem Rationale: MRI of the brain, particularly focusing on the brainstem, is the most appropriate diagnostic test for identifying potential brainstem lesions due to its high sensitivity and ability to provide detailed images of soft tissue structures. This capability is crucial for diagnosing conditions such as ischemic strokes, hemorrhages, tumors, or demyelinating diseases in the brainstem. MRI's superior soft tissue contrast compared to CT scans makes it more effective in visualizing the detailed structures within the brainstem, which is essential for accurately diagnosing the cause of symptoms like diplopia, ptosis, and hemiparesis.

Question 109

For a patient suspected of having an acute intracranial hemorrhage following a head injury, which diagnostic test is most immediately appropriate? A) CT Scan of the Brain B) Magnetic Resonance Imaging (MRI) of the Brain C) Electromyography (EMG) and Nerve Conduction Velocity (NCV) D) Spinal MRI

Answer 109

A) CT Scan of the Brain Rationale: A CT scan of the brain is the most immediately appropriate diagnostic test for a patient suspected of having an acute intracranial hemorrhage following a head injury. CT scans are highly effective in quickly detecting acute hemorrhages, fractures, or large masses, making them the first choice in emergency settings where rapid diagnosis is critical for timely intervention.

Question 110

Which diagnostic test is best suited for evaluating a patient with suspected carpal tunnel syndrome? A) CT Scan of the Brain B) Magnetic Resonance Imaging (MRI) of the Brain C) Electromyography (EMG) and Nerve Conduction Velocity (NCV) D) Spinal MRI

Answer 110

C) Electromyography (EMG) and Nerve Conduction Velocity (NCV) Rationale: EMG and NCV are diagnostic tests specifically designed to assess the electrical activity of muscles and the speed of nerve conduction, making them particularly suited for diagnosing diseases of the peripheral nervous system. These tests are ideal for evaluating conditions like nerve compressions (e.g., carpal tunnel syndrome), peripheral neuropathies, and muscle disorders, as they provide direct insight into the functional status of muscles and nerves.

Question 111

A patient presents with lower back pain, radiculopathy, and signs of spinal cord compression. Which diagnostic test would be most appropriate to assess for potential spinal cord lesions? A) CT Scan of the Brain B) Magnetic Resonance Imaging (MRI) of the Brain C) Electromyography (EMG) and Nerve Conduction Velocity (NCV) D) Spinal MRI

Answer 111

D) Spinal MRI Rationale: A spinal MRI is the most appropriate diagnostic test for assessing potential spinal cord lesions in patients presenting with symptoms such as lower back pain, radiculopathy, and signs of spinal cord compression. Spinal MRI provides detailed images of the spinal cord and the structures surrounding it, including nerve roots and intervertebral discs. This makes it invaluable for diagnosing spinal cord lesions, nerve root compressions, disc herniations, and other spinal pathologies, offering superior visualization of the spinal anatomy and any associated abnormalities.