Nervous System Practice Questions Flashcards
- You examine a “sleepy” patient. You note that she will open her eyes and look at you but responds slowly and is confused. She does not appear interested in her surroundings. How would you describe her level of consciousness?
A) Lethargic
B) Obtunded
C) Stuporous
D) Comatose
Ans: B
Chapter: 17
Page and Header: 706, Techniques of Examination
Feedback: An obtunded patient is responsive but slow speaking and is less interested in her surroundings. A patient with lethargy opens her eyes to verbal cues and may respond appropriately but promptly falls back to sleep. The stuporous patient responds only to painful stimuli, and when the stimulus is withdrawn lapses into unconsciousness again. Such patients have little awareness of self or the environment. The comatose patient has no obvious response to external stimuli.
- A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen “staring off into space” and not paying attention. If this is a seizure, it most likely represents which type?
A) Pseudoseizure
B) Tonic–clonic seizure
C) Absence
D) Myoclonus
Ans: C
Chapter: 17
Page and Header: 718, Table 17-3
Feedback: This is a common description and scenario for absence seizures. These are generally brief (less than 10 seconds, “petit mal”). These generally occur without warning and generally do not have a post-ictal confused state. Pseudoseizures are difficult to diagnose but generally involve dramatic-appearing movements, similar to tonic–clonic seizures. Myoclonus represents a single brief jerk of the trunk and limbs.
- You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system?
A) Corticospinal tract
B) Spinothalamic tract
C) Thalamus
D) Dorsal root ganglion
Ans: A
Chapter: 17
Page and Header: 689, Techniques of Examination
Feedback: This describes a pronator drift, which signifies decreased position sense involvement of the corticospinal tract. This tract does not travel through the thalamus. This is commonly tested as an early sign of stroke. This would not occur with a dorsal root ganglion problem.
- A 60-year-old retired seamstress comes to your office, complaining of decreased sensation in her hands and feet. She states that she began to have the problems in her feet a year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer’s disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength is decreased and her plantar and dorsiflexion strength is decreased.
Where is the disorder of the peripheral nervous system in this patient?
A) Anterior horn cell
B) Spinal root and nerve
C) Peripheral polyneuropathy
D) Neuromuscular junction
Ans: C
Chapter: 17
Page and Header: 727, Table 17-9
Feedback: With peripheral polyneuropathy there will be distal extremity symptoms before proximal symptoms. There will be weakness and atrophy and decreased sensory sensations. There is often the classic glove-stocking distribution pattern of the lower legs and hands. Causes include diabetic neuropathy, as in this case, alcoholism, and vitamin deficiencies.
- A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands. He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably. He says when he holds them out in front of his body the shaking diminishes, and when he uses his hands the shaking is also better. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister who has arthritis problems. His children are all essentially healthy. On examination you see a fine, pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back toward you. He has almost no “arm swing” with his gait.
What type of tremor is he most likely to have?
A) Resting tremor
B) Postural tremor
C) Intention tremor
Ans: A
Chapter: 17
Page and Header: 720, Table 17-4
Feedback: Resting tremors occur when the hands are literally at rest, such as sitting in the lap. These are slow, fine tremors, such as the pill-rolling seen in Parkinson’s disease, which this patient most likely has. Decreased arm swing with ambulation is one of the earliest objective findings of Parkinson’s disease.
- A patient presents with a daily headache which has worsened over the past several months. On funduscopic examination, you notice that the disk edge is indistinct and the veins do not pulsate. Which is most likely?
A) Migraine
B) Glaucoma
C) Visual acuity problem
D) Increased intracranial pressure
Ans: D
Chapter: 17
Page and Header: 673, Techniques of Examination
Feedback: This is a description of papilledema, which should make you think of increased intracranial pressure. This can be a critical finding. This patient may have a brain tumor or benign intracranial hypertension. These findings cannot be ignored and should be acted upon quickly.
- A young woman comes in today, complaining of fatigue, irregular menses, and polyuria which have gradually increased over the past few months. Which eye findings would be consistent with her condition?
A) An upper quadrantanopsia
B) A lower quadrantanopsia
C) A bitemporal hemianopsia
D) An increased cup-to-disc ratio
Ans: C
Chapter: 17
Page and Header: 673, Techniques of Examination
Feedback: These symptoms are consistent with a pituitary lesion. Enlargement of a tumor in this area would compress the fibers responsible for the lateral visual fields. A quadrantanopsia would usually be caused by a lesion in the optic radiations in the parietal lobe of the cerebrum. Glaucoma would cause a narrowing of the entire visual field, not just the lateral aspects.
- A 28-year-old book editor comes to your clinic, complaining of strange episodes. He states that about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. He says that after a few seconds his whole left arm and then his left leg will also start to jerk. He denies any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm and leg feel tired but otherwise he feels fine. His past medical history is significant for a cyst in his brain that was removed 6 months ago. He is married and has two children. His parents are both healthy. On examination you see a scar over the right side of his head but otherwise his neurologic examination is unremarkable.
What type of seizure disorder is he most likely to have?
A) Generalized tonic–clonic seizure
B) Generalized absence seizure
C) Simple partial seizure (Jacksonian)
D) Complex partial seizure
Ans: C
Chapter: 17
Page and Header: 718, Table 17-3
Feedback: Simple partial seizures start with a unilateral symptom, involve no loss of consciousness, and have a normal postictal state. In a Jacksonian seizure the symptoms start with one body part and “march” along the same side of the body.
- Jim is an HIV-positive patient who complains about back pain in addition to several other problems. On percussion, there is slight tenderness over the T7 vertebrae, and when you flex his thigh to 90 degrees and extend his lower legs, you meet strong resistance at about 45 degrees of extension. What are likely causes of this constellation of symptoms?
A) Fractured vertebrae
B) Malingering
C) Infection
D) Medication side effect
Ans: C
Chapter: 17
Page and Header: 703, Techniques of Examination
Feedback: This represents Kernig’s sign. When present bilaterally it often indicates meningeal irritation. (Kernig was a physician in eastern Europe and treated many children with tuberculous meningitis.) It is useful in cases when there has been chronic inflammation of the meninges, as seen in TB and cryptococcal disease. There was no trauma reported, and these signs are too important to ascribe them to malingering. Such localized physical findings are unlikely to be caused by medication side effects.
- A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements?
A) Tics
B) Dystonia
C) Athetosis
D) Chorea
Ans: D
Chapter: 17
Page and Header: 720, Table 17-4
Feedback: These represent chorea because they are brief, rapid, unpredictable, and irregular. Tics are irregular but tend to be stereotyped and can be vocal (throat-clearing), facial expressions, or shoulder shrugging. Athetosis is a slow, squirming motion usually affecting the face and distal extremities. Dystonia is similar to athetosis but the movements are more coarse and can involve twisted postural changes.
- A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn’t feel particularly nervous when this occurs but she worries that other people will think she has an anxiety disorder or that she’s a drinker. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form she has obvious tremors in her dominant hand.
What type of tremor is she most likely to have?
A) Resting tremor
B) Postural tremor
C) Intention tremor
Ans: C
Chapter: 17
Page and Header: 720, Table 17-4
Feedback: Intention tremors are absent at rest or in a postural position and occur only with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) or in multiple sclerosis. This patient’s tremor, fatigue, bladder problems, and visual problems are suggestive of multiple sclerosis.
- A 48-year-old grocery store manager comes to your clinic, complaining of her head being “stuck” to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. On examination you see a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise her examination is normal.
What form of involuntary movement does she have?
A) Chorea
B) Asbestosis
C) Tic
D) Dystonia
Ans: D
Chapter: 17
Page and Header: 720, Table 17-4
Feedback: Dystonia involves large movements of the body, such as with the head or trunk, leading to grotesque twisted postures. Some medications (such as one commonly used for gastroparesis) often cause dystonia.
