Neuro lecture (peds+adult) AND quiz questions

Question 1

What are the CN 1-7 tests?

Answer 1

• CNI – Olfactory –test sense of smell
• CNII – Vision, Visual Fields
• CNIII – Check direct and Consensual pupil response to light
• CN III, IV, and VI – Eye movements
• CN V – Test sensation in 3 areas, clinch teeth, move jaw, corneal reflex
• CN VII – Wrinkle forehead, smile, puff cheeks
• CNVIII – Finger Rub, if abnormal, Weber/Rinne (512 Fork)
• CN IX, X, XII – Stick out tongue, say “ahh”, Gag reflex, tongue midline
• CNXII – Turn head against resistance

Question 2

What is the weber-Rinne test?

Answer 2

• Use when the gross hearing test is negative
• Normal: Air is heard longer than bone
• Conductive loss: Bone is heard longer than air

Question 3

What is spasiticity, rigidity, flaccidity, paratonia?

Answer 3

• Spasticity: increased tone and increased with increased rate (stroke)
• Rigidity: increased resistance throughout ROM that is not dependent on rate is called “lead pipe rigidity”. A rachet like jerkiness is called “cogwheel rigidity” (Parkinsonism)
• Flaccidity: loss of tone, loose, floppy – (Guillain-Barre & early Spinal Cord Injury)
• Paratonia: sudden increase or decrease in tone during motion testing (Dementia)

Question 4

How do you grade musclar strength?

Answer 4

• 0 No contraction noted
• 1 Barely detectable contraction
• 2 Active movement when gravity removed
• 3 Active movement against gravity
• 4 Active movement against gravity & some resistance
• 5 Active movement against full resistance – THIS IS NORMAL STRENGTH

Question 5

What are the lumbar motor functions for L2-5 and S1-2?

Answer 5

• L2: Hip flexion
• L3 :knee extension
• L4: Ankle dorsiflexion
• L5: Great toe extension
• S1: Ankle plantar flexion, ankle eversion, hip extension
• S2: Knee flexion

Question 6

What are the different deep tendon reflexes we need to know? (+ their dermatomes)

Answer 6

• Biceps (C5, C6) – thumb just below elbow crease
• Triceps (C6, C7) – lateral upper arm several cm above the olecranon
• Supinator/Brachioradialis (C5, C6) – forearm about 1/3 of distance to elbow from wrist
• Knee (L2, L3, L4) – patella tendon
• Ankle (S1 primarily) – distal Achilles tendon

Question 7

What do you need to test for if reflexes appear to hyperactive?

Answer 7

Test for clonus
* May Indicate Central Nervous System Disease, but also may be present in a very anxious person or someone just post strenuous exercise

Question 8

How do you test coordination? (4)

Answer 8

• Rapid Alternating Movements – sit patient, hands alternate with palms up and down against top of thighs
• Point to Point Movements – patient touch your finger, then his/her nose, moving your finger or patient heel to shin test
• Gait & Related Body Movements – toes, heels, heel to toe
• Standing in Specific Ways

Question 9

What is the romberg test and the pronator drift test?

Answer 9

• Romberg Test – tests position sense – patient stands with feet together, eyes open, then closes eyes – note ability to maintain posture
• Pronator Drift Test – patient stand with arms straight forward, palms up, eyes closed – watch for ability to hold arm position – then firmly tap the arms downward – they should return to previous position

Question 10

What is sterognosis, graphesthesia and two point discrimation?

Answer 10

• Stereognosis (ability to identify objects held in hand)
• Graphesthesia (ability to identify numbers “drawn” in palm of hand)
• Two-point discrimination (use a paper clip bent to give two points – alternate one point with two)

Question 11

What are the abdominal, planter and anal reflex/response?

Answer 11

• Abdominal Reflexes (T8-10) over the umbilicus and (T10-12) under the umbilicus
• Planter Response (L5, S1) – lateral aspect of foot – from heel to the ball of foot – curving medially as you go
• Anal Reflex – use soft cotton/gauze to stroke outward from anus in four directions – watch for reflexive contraction of anal muscult

Question 12

What is the babinski sign? What can cause a positive babinski sign?

Answer 12

Possible Etiology of Positive Babinski’s – Central Nervous System Lesion in Corticospinal Tract, some Coma states, unconscious states secondary to drugs and/or alcohol intoxication

Rememebr: positive Babinski is normal in children under 2

Question 13

Why do we test nuchal rigidity?

Answer 13

Nuchal Rigidity – used frequently in the evaluation of suspected meningitis

Question 14

What is the brudzinski sign, kernig sign and straight leg raise?

Answer 14

• Brudzinski’s Sign – extension of Nuchal rigidity testing – neck flexed, hips and knees may jerk or contract in response
• Kernig’s Sign – with patient on back, flex hip and knee, then straighten leg – should be uncomfortable, but not painful (limited use!)
• Straight leg raise – patient on back, lift leg with knee in extension, dorsiflex the foot

Question 15

What does asterixis help us identify?

Answer 15

Asterixis – helps identify Metabolic Encephalopathy in patients with cognitive changes – common cause: hepatic encephalopathy
* ask patient to extend both arms in a “stop traffic” pose – watch for a couple of minutes for sudden nonrhythmic motion of hands and fingers

Question 16

How do you test the winging of scapula? What can be the cause?

Answer 16

• have patient push against your hand – if scapula “wings” out – may indicate injury to long thoracic nerve – but more likely indicates poor development of serratus anterior muscle.
• Common in patient’s with muscular dystrophy – but ALSO seen in young male athletes with poor shoulder girdle strength – reversible in this population

Question 17

Move NOTHING until what has been cleared?

Answer 17

• Move NOTHING until the C-Spine has been “cleared” – you may check sensation, some reflexes.
• PA’s often “clear” c-spine in ER, but probably best left to a physician secondary to legal issues and the magnitude of possible patient harm.

Question 18

What is lethargic, obtunded, stuporous and comatose?

Answer 18

• Lethargic – sleepy, but easily aroused, responds to questions, then falls back to sleep
• Obtunded – opens eyes, but very slow to respond, appears confused, may be unaware of environment
• Stuporous – arouses only after painful stimuli
• Comatose – unarousable with eyes closed

Question 19

What are three different painful stimuli?

Answer 19

• Sternal Rub – using the knuckles of your hand, firmly rub up and down the sternum
• Tendon Pinch – pick one and pitch
• Pencil across a nail bed – or press pencil into nail bed

Question 20

Describe:
* Cerebellar Ataxia:
* Sensory Ataxia:
* Parkinsonian:
* Scissors Gait:
* Spastic Hemiparesis:

Answer 20

• Cerebellar Ataxia – wide, unsteady gait
• Sensory Ataxia – wide, unsteady gait AND heel strike first, the strike down toes – you can hear a double tap with this gait sometimes
• Parkinsonian – Stooped, slow start, decreased arm swing
• Scissors Gait – Stiff, marching, walking in water (CP and other disease causing Spasticity)
• Spastic Hemiparesis – classic stroke gait

Question 21

What are the newborn reflexes?

Answer 21

Definition: Inborn behavioral patterns that develop in utero

Mediated at the brainstem or spinal cord level and should be present at birth then gradually disappear during the first 3-12 months postnatal

Reflexes help identify normal brain and nerve activity. Some reflexes occur only in specific periods of development.

Question 22

When are newborn reflexes abnormal?

Answer 22

• Absent during the neonatal period
• Asymmetric (suggesting hemiplegia or monoplegia)
• Persist beyond the age by which they should have normally disappeared

Question 23

What is the timing, elicitation and response of the rooting reflex?

Answer 23

• Timing: present at birth, disappears by 4 months
• Elicitation: stroking the cheek with a finger
• Response: infant turns head toward the side being stroked with mouth open

Question 24

What is the timing, elicitation and response to sucking reflex?

Answer 24

• Timing: present at birth, disappears by 5 months
• Elicitation: place finger into infant’s mouth touching lips and gently touch palate
• Response: infant begins to suck

Question 25

What is the timing, elicitation and response to the plantar grasp?

Answer 25

• Timing: present at birth, disappears by 9 months
• Elicitation: stimulation of plantar surface with thumb/object
• Response: curling of toes around thumb/object

Question 26

What is the timing, elicitation and response to the palmar grasp?

Answer 26

• Timing: present at birth, disappears by 6 months
• Elicitation: stroking of palmar surface with finger
• Response: hand will close around finger and tighten

Question 27

What is the timing, elicitation and response to the moro reflex (startle reflex)?

Answer 27

• Timing: present at birth, disappears by 6 months
• Elicitation: while laying supine gently pull up on arms or hold child and gently allow head to fall back about 3cm, can also occur from loud sound or sudden movement
• Response: infant throws back head, extends out the arms and legs, cries, then pulls the arms and legs back in

Question 28

What is the timing, elicitation and response to the stepping reflex?

Answer 28

• Timing: present at birth, disappears by 2 months
• Elicitation: hold infant upright and touch feet to solid surface then bring to a forward leaning position
• Response: one foot will lift up and then step forward in an apparent walking motion

Question 29

What is the timing, elicitation and response to the tonic neck reflex?

Answer 29

• Timing: present at birth, disappears by 7 months
• Elicitation: turn infants head to one side
• Response: the arm on the side the head is turned stretches out and the opposite arm bends up at the elbow, often called the “fencing” position”

Question 30

What is the timing, elicitation and response to the galant reflex?

Answer 30

• Timing: present at birth, disappears by 6 months
• Elicitation: lie infant on stomach and lightly stroke the side
• Response: infant will laterally flex toward the stimulation side

Question 31

What are some causes of abnormal newborn reflexes? (5)

Answer 31

• Low birth weight at birth
• Premature birth (<36 weeks)
• Traumatic birth
• Severe illness in infancy
• Trauma or injury in infancy

Question 32

What are the language skills for a 2, 4, 5, 6, 9, 11,12, 15, 18, 24 month baby?

Answer 32

Question 33

What are the language skills of a 2.5, 3, 4, 5 year old?

Answer 33

Question 34

What are the social skills for a 2, 4, 6, 9, 12, 15, 18, 24 month baby?

Answer 34

Question 35

What are the social skills of a 2.5, 3, 4 and 5 year old?

Answer 35

Question 36

The nurse in the newborn nursery reports that she is concerned about Baby Boy Jones, who was born full-term by cesarean section for failure to progress. The pregnancy was complicated only by a maternal urinary tract infection in the first trimester. He had APGARs of 9 and 10 at 1 and 5 minutes, respectively, and had been doing well. However, now, on the fourth day of life, the infant has developed a tremor. Which of the following factors would cause the most concern about the tremor?

1. The infant also has asymmetric limb movements.
2. There is a history of benign tremor in elderly family members.
3. The infant lies in a symmetric position with limbs flexed when relaxed.
4. The tremor is brief and only present when the infant is crying vigorously.
5. The infant’s vital signs are normal.

Answer 36

1. The infant also has asymmetric limb movements

Question 37

In caring for children, physicians and other clinicians need to understand child development. Of the following, which is a principle of normal child development?

1. Child development proceeds along a predictable pathway in a healthy child.
2. A child’s developmental level can be ignored in conducting an examination.
3. Regression in developmental skills is not a cause for concern.
4. There is minimal variation in when children achieve milestones
5. All delays in development can be explained by one or two risk factors.

Answer 37

1. Child development proceeds along a predictable pathway in a healthy child.

Question 38

A mother brings her 15-month-old toddler to the clinic for his preventive health care visit. The clinician takes the history and observes the child’s interactions and behaviors and is then ready to begin the rest of the examination. Which of the following best describes the general approach to the pediatric examination of the young child?

1. Never examine a young child in the mother’s lap.
2. Always give immunizations prior to beginning the examination.
3. Children age <2 years do not need to be examined.
4. Examine the child in the same order as for an adult patient.
5. Begin with least invasive parts of the examination first.

Answer 38

5.Begin with least invasive parts of the examination first.

Question 39

The parents of a 21-month-old child explain that their son used to speak nearly 50 words and was using 2-word phrases. In the last month or so, the child has not been using as many words and tends to echo what is being said to him rather than use language spontaneously. They want to know if this is normal. After taking a thorough developmental history, the clinician finds that the child makes poor eye contact and does not play with toys in a purposeful manner. The physical examination is normal except for the child’s limited social interactions. There is a family history of autism in two first cousins. Which of the following would be the best response to the parents at this time?

1. Reassure the parents that all toddlers lose skills at some point in development.
2. Refer the parents for mental health counseling.
3. Refer the child to a developmental and behavioral pediatrician.
4. Send the child to the Emergency Department (ED).
5. Reassure the parents that the child is fine as long as he has not lost skills in other domains.

Answer 39

3.Refer the child to a developmental and behavioral pediatrician.

Question 40

A clinician arrives at the hospital several hours after the birth of a full-term infant. The infant is rooming in with her parents and appears to be doing well. There were no problems with the pregnancy, labor, or delivery. The nurse asks if the baby should be taken back to the nursery for examination. What is the best response to the nurse?

1. Note that the infant already had an examination in the delivery room and does not need another examination so soon.
2. Note that the lighting is better in the newborn nursery.
3. State that it will be much more efficient to conduct the examination in the nursery.
4. Refer the parents to a good book on newborns and wheel the infant back to the newborn nursery to conduct the examination.
5. State that the infant should be examined in the presence of the parents so they can be taught about what their newborn can do.

Answer 40

5.State that the infant should be examined in the presence of the parents so they can be taught about what their newborn can do.

Question 41

A clinician is meeting the mother of a 5-year-old with asthma for the first time. The mother notes that the asthma has been poorly controlled and that the child has had multiple hospitalizations. The clinician inquires about family stressors and finds that the parents are divorced, the mother recently lost her job, and the child spent 2 months living with her grandparents who both smoke. Which of the following is the best example of the role of health promotion with this family?

1. Delay immunizations because of the family stressors.
2. Develop a health promotion plan that includes more frequent visits and guidance to assist family with stressors and improve the child’s asthma symptoms.
3. Reassure the parent that the family stressors are not impacting the child’s asthma.
4. Plan less frequent pediatric visits because the family will take too much time.
5. Postpone vision and hearing screening because the child may not pass

Answer 41

2.Develop a health promotion plan that includes more frequent visits and guidance to assist family with stressors and improve the child’s asthma symptoms.

Question 42

An infant is born 4 weeks preterm to a mother with a history of hypertension, severe diabetes, and alcohol abuse. The infant is noted to be small for gestational age (SGA), weighing just 1,500 g. Which of the following is the most important reason for assessing both gestational age and birth weight for any infant?

1. The parents should be informed of these.
2. A premature infant with a weight appropriate for gestational age has a very low risk for neonatal problems.
3. A SGA infant is at low risk for neonatal problems.
4. Full-term, appropriate-for-gestational age (AGA) infants having a high risk of long-term problems.
5. These two factors help to anticipate certain medical and developmental problems.

Answer 42

5.These two factors help to anticipate certain medical and developmental problems.

Question 43

A clinician is reading the chart of a full-term newborn whose mother had an uneventful pregnancy in the hospital for the first time on the day of birth. In reviewing the infant’s chart, the clinician notes that, in the delivery room, at 5 minutes, the infant had a heart rate >100, strong respiratory effort, was crying vigorously, moving actively, and had good color except for some acrocyanosis of the hands and feet. This infant’s APGAR score is closest to which of the following?

Answer 43

9

Question 44

A mother brings her 9-month-old son to the practice for the first time, concerned that he is not yet sitting by himself. After taking a careful history, the physician notes that the infant has good head control and can grasp a rattle but is unable to roll over, crawl, or pull to stand. What should the clinician explain to the mother?

1. As long as the child is babbling, delays in gross motor skills are not a concern.
2. The delay in his physical motor skills is concerning and warrants a more complete developmental history and possible referral for early intervention.
3. Gross motor development proceeds from peripheral skills, such as finger feeding, to central skills, such as sitting.
4. Delays in gross motor skills are usually because of lack of coordination and catch up as the child ages.
5. Her child is progressing normally and does not need further evaluation.

Answer 44

2.The delay in his physical motor skills is concerning and warrants a more complete developmental history and possible referral for early intervention.

Question 45

A newborn who is floppy and limp, blue in color, with a heart rate of 60, and minimal respiratory effort has just been delivered. The infant has no grimace and only a very weak cry. What is the best immediate response to the infant in this situation?

1. Begin neonatal resuscitation.
2. Suction the infant’s mouth while waiting to calculate the 5-minute APGAR score.
3. Order a chest x-ray.
4. Dry the infant off and swaddle him.
5. Discuss the infant’s poor appearance with the parents who are both in the room

Answer 45

1. Begin neonatal resuscitation.

Question 46

A 63‐year‐old practicing attorney makes an appointment with the office urgently for pain in his right leg for 3 days. Since working in the garden moving heavy bags of mulch for his wife this past
weekend, he has had intermittent but excruciating pain shooting down the posterior aspect of his right leg. On examination, sensory loss to light touch in the right leg posteriorly, corresponding to a sacral 1 (S1) dermatome, is noted. Which reflex would be expected to be decreased compared to the other side?

a) Left knee
b) Left plantar (Babinski)
c) Right ankle
d) Right knee
e) Right plantar (Babinski)
f) Left ankle

Answer 46

c) Right ankle

Question 47

An 82‐year‐old grandmother presents to the Emergency Department in the care of her extended family with new‐onset speech impairment. According to family members, the patient awoke with this symptom as well as difficulty in understanding questions or following commands. Her past medical history is remarkable for atrial fibrillation but no other notable conditions. On examination, her speech is verbose but poorly comprehensible and lacks meaning. She is unable to follow simple commands. Which of the following best describes her speech disorder?
a) Broca aphasia
b) Dysphonia with expressive deficit
c) Wernicke aphasia
d) Dysarthria
e) Global aphasia

Answer 47

c) Wernicke aphasia

Question 48

A 35-year-old female patient has had migraines for much of her adult life. Ather regular checkup, she is healthy, takes no medications except oral contraceptive pills (OCPs), exercises, and has a steady job. Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has been waking up at night with headache and also nausea. Which of the following is the best course of action?

a) Take a further history and perform a very careful neurological examination.
b) Prescribe a strong medication for her migraines.
c) Reassure her that this is a common pattern with migraines.
d) Order studies to evaluate potential transient ischemic attacks (TIAs) because she is on OCPs.
e) Treat her for sinusitis.

Answer 48

a) Take a further history and perform a very careful neurological examination

Question 49

Parents bring in their 3-year-old toddler, stating that he has been pulling at his right ear and fussing all day. Examination of the auditory canal shows a small green plastic toy piece partially obstructing the passage. Which cranial nerve (CN) supplies the sensory innervation to that area and is conducting the boy’s pain sensation?

• CN IX
• CN VII
• CN XII
• CN XI
• CN X

Answer 49

CN IX

Question 50

A new mother brings in her 6-month-old baby for not being able to keep his eyes together when looking to the left. On examination, both of his eyes appear in alignment (conjugate) when looking to the right. However, when looking to the left, the baby’s left eye stays in the forward gaze position, while the right continues on with full adduction to the left. The eyes appear to be out of alignment (dysconjugate). Which cranial nerve (CN) is responsible for the dysfunction in looking left?

• Left trochlear nerve (CN IV)
• Right trochlear nerve (CN IV)
• Right abducens nerve (CN VI)
• Left oculomotor nerve (CN III)
• Left abducens nerve (CN VI)
• Right oculomotor nerve (CN III)

Answer 50

The left abducens nerve (CN VI)

Question 51

A 55-year-old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation?

• The patient also has developed fever and night sweats and thinks she lost some weight.
• The patient had a car accident and minor head trauma about 3 months ago.
• The headache comes and goes.
• The headache is similar in nature to prior ones she has had for decades but more severe.
• The patient lost her glasses.

Answer 51

• The patient also has developed fever and night sweats and thinks she lost some weight.

Question 52

In the case of a middle-aged female with a pounding headache, what is an effective question to ask the patient?

• How old is the patient?
• Has she ever seen anyone with a stroke?
• Does she think she is losing her memory?
• Does the patient have any aura prior to the headaches?
• Is she feeling stressed?

Answer 52

• Does the patient have any aura prior to the headaches?

Question 53

In longstanding and poorly controlled hypertension, white matter tracts in the brain are subjected to ateriolosclerotic effects. Which one of the following is most vulnerable to this process?

• Diencephalon
• Basal ganglia
• Internal capsule
• Reticular activating system
• Thalamus

Answer 53

• Internal capsule

Question 54

A 74-year-old bus driver is delivered to the hospital via emergency transport after an astute passenger noted that the patient exhibited drooping facial features and slurred speech. The patient was diagnosed rapidly with ischemic (nonhemorrhagic) stroke, and urgent intervention lead to a near complete recovery from his symptoms. The astute passenger was thanked and congratulated for recognizing the signs of acute stroke; this individual credited this recognition to a public safety awareness campaign that outlined the critical public health need to recognize strokes early. Which of the following statements is true for risks and rapid recognition of suspected strokes?

• Atrial fibrillation is not a risk factor for ischemic stroke in individuals age ≥75 years.
• Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke.
• Obesity with normal glucose tolerance is not a risk factor for stroke.
• Due to increasing public awareness, the median time for arrival to care for suspected stroke is <3 hours.
• Transient ischemic attacks (TIAs) that resolve within in 1 hour confer a 5% risk of death from stroke within the next 12 months.

Answer 54

• Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke.

Question 55

An 82-year-old retired insurance broker complains of difficulty in walking, having to consciously lift up his feet so he does not trip, stumble, or fall. Both feet are affected equally; he has no sensory complaints or pain. This has been worsening over the past 3 years, and he has had to give up his beloved hiking. The symptoms are improved while wearing tall boots and worse when walking around the house with house slippers. What is the likely location of the pathology in this man?

• Lumbar spinal cord
• Frontal motor area of the cerebral cortex
• Distal muscle
• Peripheral nerve
• Brainstem

Answer 55

• Peripheral nerve

Question 56

A 14-year-old student comes with her family to the urgent care center, having been hit in the right eye with a plastic baseball during a family reunion. She complains of a painful, watery, red right eye and sensitivity to light. She has normal visual acuity in both eyes, no diplopia, and can open and close her eyes normally. The pupils are unequal in size, 3 mm in diameter on the left, 5 mm in diameter on the right. Which cranial nerve (CN) would be implicated as the cause of the photosensitivity complaint and the pupillary asymmetry?

• CN II
• CN IV
• CN VI
• CN V
• CN III

Answer 56

• CN III

Question 57

A 45-year-old physician is having increasing difficulty with speech for the past 6 months. She is less precise in pronunciation of words (dysarthria), has found it more effortful to speak, and finds that her voice sounds more nasal than usual. On examination, her articulation is less than precise, especially with rapid repetition of single syllables, such as “ta-ta-ta-ta,” “go-go-go-go,” “la-la-la-la,” and “ba-ba-ba.” Her neurological examination is otherwise normal. Which nervous system pathway is responsible for control of the muscles producing this symptom?

• Corticospinal tract
• Corticobulbar tract
• Cerebellar system
• Posterior column system
• Spinothalamic tract

Answer 57

• Corticobulbar tract

Question 58

A 70-year-old male presents to the Emergency Department accompanied by his wife, who is concerned that he has experienced a stroke. She states that he awoke with drooping of the right side of his mouth. He has a history of hypertension and diet-controlled diabetes, but no history of prior transient ischemic attacks (TIAs), strokes, or neurologic deficits. Physical examination reveals a well-nourished, right-handed male, who has an obvious flattening of the right nasolabial fold at rest. He is unable to close his right eye, wrinkle his forehead, or raise his eyebrows. The remainder of the neurologic examination is symmetric with intact strength and normal deep tendon reflexes. Based on this history and physical examination, which of the following statements is true?

• The patient most likely has a central upper motor neuron lesion involving cranial nerve (CN) VII (the facial nerve).
• The patient most likely has a central process of unclear location; an acute ischemic event must be ruled out with an emergent computed tomography (CT) scan.
• The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve.
• The patient most likely has had an embolic affecting an upper motor neuron (UMN).
• The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) V, the trigeminal nerve.

Answer 58

• The patient most likely has an isolated peripheral lower motor neuron (LMN) lesion involving cranial nerve (CN) VII, the facial nerve.