Neuro cases CIS (Cohen)

Question 1

eating at buffet, quit eating suddenly. Only says “OK” or “yeah.” mouth droops on right, cannot raise right arm. 2 hours later- at ER with aphasia and right hemiplegia. Head CT is normal.

What’s up?

Answer 1

Left middle cerebral artery stroke.

Question 2

most strokes happen from

Answer 2

middle cerebral artery (left and right)

Question 3

why with stroke patient in ER is the CT normal?

Answer 3

takes 24 hours to see it on CT

Question 4

stroke patient has BP of 190/100 and an irregular pulse. An ECG shows atrial fib, which the pt has never had before. Since he has made no progress at 2 hours, the ER doc chooses to:

A. Lower BP only
B. Lower BP and give TPA
C. Give aspirin only

Answer 4

B

TPA should be given within the first 3 hours

Question 5

Stroke pt gets TPA. 2 days later pt is speaking a little more, moving the right arm and the right leg. The hospital doctor tells the family that this pt

A. May keep improving for a year or more

B. Must have had only a TIA after all

C. Would never have suffered a stroke if he had not developed a fib

Answer 5

A.

B isn’t great because he’s better, but not ALL better

Question 6

29 y/o female brought in by ambulance- dizzy, difficulty walking. worsened upon awakening.

dysarthria not aphasia, double vision

limited eye movements, an abnormal cerebellar exam in both the left and the right sides. Blood pressure and heart sounds are normal. Likely dx:

a. alcohol intoxication
b. basilar artery stroke
c. benign paroxysmal positional vertigo

Answer 6

B. Basilar artery stroke

Question 7

MRI shows multiple infarcts in the brainstem and both cerebellar hemispheres. The admitting dr takes a more detailed history and discovers that this young pt has a history of:

A. smoking marijuana

b. deep venous thrombosis and a PE
c. migraine headaches

Answer 7

B. One event puts you on blood thinners for 6 months, 2 strikes and you’re out

Question 8

skiing accident, hit head, loses consciousness for 5 minutes. Awakens, feels well, can answer most simple questions. Lethargic and disoriented. Arm and leg strengths seem normal, and he can walk with assistance to the ambulance. At the emergency department 3 hours later he is given a glasgow coma scale score of 12.

ER doc will probably order:

A. head CT now
B. Electroencephalogram
C. brain MRI tomorrow morning

Answer 8

A. looking for epidural hematoma

CT is good for bones and blood, MRI is really not good for either

Question 9

CT of skier shows:

A. cerebral contusions in both hemispheres
B. left sided epidural hematoma
C. chronic subdural hematoma

Answer 9

B. left sided epidural hematoma

damage in both- usually you’d be unconscious

Question 10

79 y/o man been growing deaf in left ear for nearly a year and is increasingly dizzy. Multiple med problems include diabetes, COPD. Exam: severe left ear deafness, only slightly reduced hearing in the right ear, and a peripheral left seventh nerve palsy. Physician suspects:

A. Bell’s palsy
B. Menier’s disease
C. Possible brain tumor

Answer 10

C. vestibular schwannoma

Question 11

Acoustic schwannoma and multiple areas of small infarcts in the cerebral hemispheres. The physician now advises the pt to:

A. see an ear, nose and throat surgeon
B. take an aspirin each day
C. Try corticosteroids for two weeks

Answer 11

likely A.

Question 12

34 y/o female in hospital one day after childbirth. Suddenly loses most of vision in left eye, spreads over a period of fifteen minutes to the right eye. The pt feels there are large lack spots in both eyes. Her BP is 160/90, visual acuity is approximately 20/200 in both eyes, but her exam is o/w normal. Most likely dx:

A. migraine
B. Giant cell arteritis
C. idiopathic intracranial HTN

Answer 12

A, migraine

optic neuritis could be a possibility

Question 13

childbirth migraine pt gets severe headache with nausea. OB orders and imediate injection of:

A. metaclopramide
B. sumatriptan
C. morphine sulfate

Answer 13

sumatriptan, would help confirm suspicion of migraine

the metaclopramide would help nausia
morphine would help but is opiate

Question 14

31 y/o fem has weakness in both legs and numbness from teh waist down, worsening over one week. When seen by her fam doc, pt has loss of sensation from her lower abdomen to her feet on both sides, weakness rated at 3-4/5 throughout both legs, bliateral Babinski signs. She has no neuro history, suffers only from asthma. Admitted to hospital for a:

A. Cervical spine MRI
B. thoracic spine MRI
c. Lumbar spine MRI

Answer 14

B. Is best answer, when you’re weak at the hips as well. Dermatome level at umbilicus is T10

A is possible, although one would often expect issues in the arms as well

c isn’t great because it wouldn’t lead to abdominal sensory issues

Question 15

abnormal thoracic MRI with 3 small lesions, less than one vertebral body in length, in the lower thoracic spinal cord. After 2 days of coricosteroids the pt can walk a little better. Likely dx is:

A. neuromyelitis optica
B. MS
C. clinically isolated syndrome

Answer 15

C. no history of stuff like this

Question 16

Lady w/ clinically isolated syndrome. Best test?

A. lumbar puncture
B. blood tests for aquaphorin-4 antibodies
C. complete eye exam by opthalmologist

Answer 16

lumbar puncture or brain MRI

Question 17

Clinically isolated syndrome lady

aquaphorin-4 antibodies is neg
eye exam is normal
CSF has 30 cells/ cm (normal under 7), elevated protein, oligoclonal bands.

probably:

a. neuromyelitis optica
b. MS
c. Viral meningitis

Answer 17

B. MS

Question 18

63 y/o man with history of well-controlled diabetes has had constant visual hallucinations for 2 days and has become frightened. He physically attacks his wife, and is brought to the hospital. His exam shows orientation only to himself, inability to recall more than one out of three words, and he refusese further mental status testing. Antipsychotic drugs do not help, so he is admitted for observation. The morning after, he is much improved, and apologietic for his behavior. Likely dx is:

A. early alzheimer’s disease
B. early lewy body disease
c. copmlex partial epilepsy

Answer 18

B. Early lewy body disease; likely because of the visual hallucinations, relatively young for alzheimer’s
lewy body is quite variable, very different the next day

Question 19

lewy body guy has been confused and angry before, with brief visual hallucinations occasionally. Pt seems to have a decreased expression on his face, and walks slowly when getting out of bed, with mild arm and leg tremors. His doctor considers treatment with

A. an antidepressant
B. a cholinesterase inhibitor
C. carbidopa/ levodopa

Answer 19

B. would work for both, help behavior and dementia

C is good too, help the movement disorders

Question 20

51 y/o man had first time generalized tonic clonic seizure, lasting 2 minutes. He is brought to ER and seen 20 min later, lethargic but oriented and speaking clearly. Awakens- drinks alcohol every night, but not the last 2 nights. ER physician suspects:

A. status epilepticus
B. alcohol withdrawal seizure
C. pseudoseizures

Answer 20

B.

Question 21

subdural hematoma- small, not operated on

another seizure, daily headaches, mild arm and leg weakness. Repeat CT shows larger hematoma. Neurosurgeon:

A. begins an anticonvulsant
B. drains the subdural hematoma
C. begins an anticonvulsant and drains the subdural hematoma

Answer 21

Probably C, but you could go for any one of these.

Question 22

71 y/o forgetful, misplaces keys, gets lost, poor short term memory and reduced executive function. He also has difficulty:

A. naming coins and reading a newspaper headline
B. drawing a clock
C. giving his full name

Answer 22

B. Testing the right lobe of the brain

Question 23

68 y/o fem sharp pains down right cheek, 2-3 seconds. face goes numb.

exam most helpful:

A. mental status
B. cranial nerve
C. cerebellar examination

Answer 23

B. cranial nerve test; likely trigeminal neuralgia

Question 24

pain med for trigeminal neuralgia?

Answer 24

carbamazepine

side effects: nausea, vomiting, drug interactions. Leads to its own metabolism

Question 25

trigeminal neuralgia patient has been on carbamazepine but now getting worse.

A. needs higher dose of carbamazepine
B. has a lesion not seen by the brain MRI scan
C. may need gamma knife surgery

Answer 25

Any of these are possibilities.

Question 26

after operation cardiac arrest. CPR–> no pulse or BP 15 minutes. Comatose, transferred to ICU. Next morning: neuro exam emphasizing:

A. cranial nerves
b. strengths
C. reflexes

Answer 26

A. Use flashlight for pupillary reaction (2 in 3 out) or cotton for corneal reflex (5 in 7 out)

Question 27

30 days after the cardiac arrest, the comatose pt can open his eyes, pupils react to light. cannot speak or move his eyes. Breathing on own, but cannot move arms or legs.

A. make a full recovery soon
B. brain dead
C. at risk for vegetative state

Answer 27

C. Very poor prognosis

Question 28

71 y/o fem had right carotid endarterectomy which seems to go well. 2 days later she cannot use right hand well. Right hand painful and tender to touch, and she demands that her IV catheter be removed from wrist. PT is too upset to be examined further. Stroke alert called, emergency head CT is ordered, which shows a possible infarct in the left anterior cerebral artery. Hospitalist then:

A. orders TPA
B. order MRI
C. gently encourages pt to undergo a neuro exam

Answer 28

C.

Radial nerve –> wrist drop. If nothing but wrist drop, 98% radial nerve palsy. (was from IV over the wrist)

Question 29

wrist drop lady: no facial weakness, only mild left leg weakness from prior lumbar spine problems. Pt has complete loss of wrist dorsiflexion and loss of fine touch over top of the right hand. dx:

a. radial nerve injury
b. median nerve injury
c. ulnar nerve injury

Answer 29

A. Radial nerve