Neuro Patient Cases

Question 1

Jeremy is an 18 YO male who presents with a CC of syncopal episode that occurred yesterday. He says he was outside coaching his brother’s little league team at a tournament from 9AM - 6PM and he passed out in the at 2 PM during the 2nd game. He says he suddenly felt nauseated, sweaty, and weak, and his vision went spotty, then he collapsed. The kids told him he turned “white as a sheet” and “shook a little bit” right after he fell. He recovered quickly and returned to normal shortly after. It was 90 degrees out and he admits he was too busy coaching to drink or eat much that day. He isn’t on any medications and has a hx of anemia. PE is normal and he has no other sxs, neuro or otherwise. He’s worried that he had some sort of seizure. What do you tell Jeremy? What test do you run and what do you expect to find? How do you tx him?

Answer 1

vasovagal syncopal episode
- get an EKG

Question 2

Clarissa is a 17 YO female who presents w/ dizziness and a headache after a header in her soccer game this evening that knocked her briefly unconscious. Her mother brought her into clinic immediately. She opens her eyes only when you speak to her, and when you ask her what happened she says “hit with the ball,” looks around and asks where her teammates went, but nonetheless climbs onto the exam table when you ask her to. How would you rate Clarissa’s cognitive function and what tool did you use to do so? What is your dx and tx?

Answer 2

Mild TBI/concussion
Tx with APAP for headache + return to play rules

Question 3

Agatha is a 70 YO pt who presents w/ acute confusion. A CNA, Mary, from her nursing home brought her in because she says that Agatha just seemed “off.” Mary says she’s normally very clear-headed but this morning Agatha forgot where to find her toothbrush and was slurring her speech when she asked Mary for help finding it. Mary says that when she went to the bathroom and found it exactly where it always was, she noticed that bathroom had a foul urine odor that she’s never noticed before. PE shows no motor deficits or other neuro sxs, although Agatha seems a bit suspicious of why you’re asking her questions and examining her. What lab would you run? What is your dx for Agatha? What is the underlying cause? What is your tx?

Answer 3

Delirium from a UTI
- UA, urine culture, abx

Question 4

Garrett is a 62 YO male who presents w/ a resting tremor in his right hand and a slowed walk. He said everything is taking longer than it used to and feels more difficult and he’s not sure why. He’s not exactly sure when the sxs started, it’s been at least several months, maybe even a year. They weren’t this bad at first, so he didn’t pay attention to them - the tremor used to just be in his pinkie. He has a hx of encephalitis 5 years ago. You notice his paperwork has a cramped, small signature and his posture is slightly stooped as he walks to the exam table. PE shows he moves slowly and is positive for propulsion and retropulsion. What is your dx and tx for Garrett? What neurotransmitter is involved?

Answer 4

Parkinson’s disease
- refer to neuro for carbidopa-levodopa

Question 5

Kelsey is a 20 YO female who presents w/ a fever, headache, and a sore neck. She says the symptoms started suddenly during her 9 AM class this morning. PE shows confirms she has a fever and she has positive Brudzinski and Kernig signs. You notice that she is slow when speaking and seems unfocused and dazed but she has no other significant neuro symptoms. Bloodwork shows she has an elevated WBC count, increased neutrophils, elevated proteins, and low glucose. What is your dx and tx? What other tests might you order? What is likely causing her condition? If her bloodwork had shown normal WBC, normal proteins, and normal glucose, how would your tx change?

Answer 5

Bacterial meningitis
- culture to confirm S pneumonia
- treat with dexamethasone and IV abx (ceftriaxone and vanco)

Question 6

Mara is a 63 YO female who presents with a headache. She says she has pain behind her left temple that feels like jabbing that she rates a 9. She says she is feeling fatigued and has been experiencing slight jaw pain as well. She has a hx of polymyalgia rheumatica. PE shows she her left temple is TTP and labs show an elevated ESR. How do you dx and tx Mara? What is a complication if this condition goes untreated?

Answer 6

temporal arteritis
- high dose prednisone

Question 7

Colleen is a 67 YO female who presents with a hx of a “strange spell” from the previous evening. She said her face felt numb on one side and she was suddenly dizzy and stumbled to her chair. She said her daughter told her she looked “really dazed.” The episode passed within about 5 minutes and she’s had no residual symptoms, but she wanted to get an evaluation anyways. She has a history of HTN. PE shows no neuro sxs and BP of 135/85. How do you dx and tx?

Answer 7

TIA
- HTN put her at risk for CBA, ASA and follow up for HTN

Question 8

James is a 58 YO male who presents w/ “tingling” in his hands that started a month ago. He said he’s also started feeling some weakness and cramping in his hands. Recently it’s started to extend up his arms so he decided to come get it checked out. Sohx shows that James drinks half a liter of vodka every day and has for the past 10 years since he lost his job. You do you look for w/ labs? What is the likely cause of James’ sxs? How do you tx?

Answer 8

alcoholic neuropathy
- refer for alc and prescribe TCAs

Question 9

Justin is a 35 YO male who presents w/ unexplained weight gain, and decreased libido that have both been worsening over the past two months. Prior he was a relatively healthy individual and he is taking no meds currently. PE shows he has moon face and buffalo hump, as well as some newly developed acne. You note few bruises and scabs, and Justin says he’s been bruising more easily and healing less slowly than normal. You take a CT. What do you see/what is your dx and tx for Justin? What is the underlying cause of his condition and what cell is being affected?

Answer 9

Cushing’s Syndrome secondary to a pituitary adenoma
- CT to confirm and refer to neuro for surgery
- cell: corticotropes in the anterior pituitary (responsible for ACTH production)

Question 10

Elinor is a 48 YO female who presents w/ a tremor in her left arm that started in her fingers and has progressed over the past several years. She has a hx of drinking 4 drinks/day “to help with the shaking.” PE shows the tremor is postural. Labs show no sign of hyperthyroidism and no elevated Cu levels. What is your dx and tx?

Answer 10

essential tremor
- propranolol (B-blocker) and primidone (ASM)

Question 11

Carol is a 57 YO woman who presents with a “bumped head.” She says she feels fine and PE shows no neuro symptoms, but you take a CT scan to be safe. You don’t see any sign of concussion or bleeding, but you do discover a small mass in the concavity of her skull. How do you dx and tx Carol?

Answer 11

Meningioma
- observation and referral for possible excision

Question 12

Dahren is a 40 YO male who presents w/ unrelenting fatigue that’s plagued him for 6 months now. He said recently he also gets hot easily and is always taking his sweaters and jackets off at work.He is still able to attend work but feels exhausted all the time. He says he has no other sxs. He has a hx of EBV. Neuro exam shows he has normal visual acuity but has difficult adducting both eyes during oculomotor testing. You ask him to walk down the walk and notice he is slightly unsteady in his gait. Other components of his PE are normal. You order an MRI - what do you see? How do you dx and tx?

Answer 12

multiple sclerosis
- follow up with neuro
- steroid taper

Question 13

Derek is a 21 YO male who presents w/ headaches and fatigue for the past 3 weeks. He says he was dx’d w/ a mild concussion after taking a hit in football practice and he’s had these symptoms ever since, they’re not getting better or worse. He’s been taking APAP for the pain, but not very successfully. How do you dx and tx?

Answer 13

post concussion syndrome
- TCA for pain since APAP hasn’t been helpful

Question 14

Kurt is a 62 YO male who presents w/ unilateral palsy of his face, difficulty speaking, and a weak left arm. His daughter brought him in when she walked into the kitchen 30 minutes ago and found him like this. He has a hx of DMII, smoking, and HTN. Tx shows the pt is confused, has difficulty walking, but is able to raise both his eyebrows when asked. His current BP is 180/110 mmHg. You take a CT and find no evidence of bleeding. What is your dx? What do you do next? How do you tx?

Answer 14

ischemic CVA
- start on IV TPA to break clot

Question 15

Norm is a 72 YO male who presents w/ memory loss and aphasia. His son brought him in today because he said his dad just isn’t acting the way he normally does. He’s having trouble remembering the names of common objects around the house and he’s become much quieter - he used to be the chattiest member at family gathering, but now he mostly listens and when he does talk, he seems to repeat himself a lot. PE shows general good physical health and no motor deficits. Depression screening is negative. You administer an MMSE. What do you expect the result to be? What other test might you administer? What is your dx and tx?

Answer 15

Alzheimer’s
- cholinesterase inhibitors (Donezepil) rivastigmine

Question 16

Melissa is a 27 YO female who presents with a headache. She says it started yesterday after she got home from wine and cheese night with her friends and it’s continued for the past 18 hours. She says the pain is on the left side of her head and it’s throbbing. She rates it a 7. She hoped going for a run would help her feel better but it just made the pain worse, and she’s even started feeling nauseated now. She tried ibuprofen w/ no relief. She says she gets “attacks” like this once or twice a year, and has for the past 5 years. Her mother “has the same thing” but never went to the doctor because it wasn’t quite as frequent as Melissa’s. How do you dx and tx Melissa?

Answer 16

Common migraine
- try OTCs or prescribe cafergot (vasoconstrictor)
- can try anti-emetics, serotonin agonist, NSAIDs, steroids

Question 17

Connor is a 22 YO male who presents w/ a “jerky” left leg that seizes up. He says it jerks and seizes often during class, always in the same way. It’s worse when he’s taking tests and when he’s been up late studying or working the night before, as he was last night. You observe his leg jerk up and seize during the appointment one time, but otherwise his PE is normal. How do you dx and tx Connor?

Answer 17

Dystonia
- prescribe levodopa

Question 18

Judah is a 62 YO male who presents with a weakness in his left wrist and hand that’s become more noticeable over the past month. He says his wrist feels stiff and he can’t grip things as well anymore - he’s dropped a few mugs of coffee. He says his wrist sometimes feels cramped as well. PE shows his left wrist has reduced strength compared to his right. He is slower with his left hand in rapid alternating movements. Neuroimaging and electrophysiologic testing are all negative. Labs show he has an elevated CK. What is your dx and tx for Judah?

Answer 18

ALS
- treat symptoms
- Riluzole

Question 19

Grant is a 40 YO male who presents w/ a headache. He says he’s not sure what’s causing it. He has a hx of sleep apnea. PE shows he has bilateral pain in his temporomandibular joint and it is TTP. You feel clicking in the joint. You also notice that some of his teeth seem to be worn down. How do you dx and tx Grant?

Answer 19

TMJ
- NSAID for pain and refer to dental

Question 20

Ann is a 74 YO woman who presents with a headache. Her daughter came to check on her this morning and said she seems confused and not as sharp as normal so she brought her in to see you when Ann mentioned she had a worsening headache as well. You notice a bruise on Ann’s leg and ask what it’s from. Ann says she fell up the last stairs two days ago and hit her knee on the stairs and “tapped” her head against the wall. She says it “wasn’t a big deal” and she felt fine after. You take a CT scan. What do you see/how do you dx. How do you tx?

Answer 20

subdural hematoma
- CT shows crescent-shaped pooling of blood
- refer to surg

Question 21

Kyle is a 22 YO male who presents w/ severe headache and weakness. He says the sxs started last night and worsened so he came in this morning. He said he doesn’t feel like himself, he feels slow and foggy. He had surgery on his left ear 2 days ago to remove a benign tumor from his inner ear. PE shows papilledema upon fundoscopic exam, and noticeable hemiparesis on his left side. You order an MRI, what do you expect to see? How do you dx and tx? What is the likely microbial cause of this condition?

Answer 21

brain abscess
- abx: ceftriaxone and metronidazole
- drain and culture
- reduce ICP

Question 22

Daphne is a 30 month-old female who presents w/ irregular movements and failure to walk successfully. You notice her hands making slow, writhing movements during the appointments, and as she attempts to stand her her hands and arms make rapid, irregular contractions trying to push off the ground. Daphne was born 2 months early and weighed only 4 lbs. What is your specific dx for Daphne? How do you tx?

Answer 22

choreoathetosis CP
- Baclofen for spasticity, refer

Question 23

Tony is a 67 YO male who presents w/ confusion and memory loss. His wife brought him in today because he’s “gotten worse again.” She says every few months he seems to decline noticeably more. She says at this point he doesn’t seem able to concentrate or make even small decisions efficiently and he used to be very organized and thoughtful. He has a long hx of HTN. PE shows that he has hemiparesis of his left limbs and reduced vision acuity. You take an MRI. What do you see? How do you dx and tx?

Answer 23

vascular dementia
- manage HTN, possible CI

Question 24

Grace is a 72 YO female who presents with a CC of syncopal episode that occured last night. She said she stood up after finishing dinner and felt “weak and dizzy” and her vision “went blurry” right before she passed out. Nothing like this has ever happened and she’s worried something is terribly wrong with her. She just started taking an ACE inhibitor for her blood pressure and she has a hx of DM. What is your dx for Grace?
What test do you order and what test do you perform to confirm? How do you tx her

Answer 24

orthostatic hypotensive syncopal episode
- EKG, orthostatic BP
- adjust BP med to lower dose

Question 25

Kayla is a 16 YO female who presents w/ a headache that began this morning, 6 hours ago. She says she feels it “pulsing behind her right eye, cheekbone, and right side of my forehead.” Right before her pain started, she says the right side of her face felt “prickly.” She rates her pain a 5. She says she had to leave school because the lights and the noises were “unbearable.” She took Tylenol when she got home but it hasn’t helped. She is not on any meds beside birth control, but she just started drinking coffee. How do you dx and tx Kayla?

Answer 25

classic migraine
- OTCs arent working so prescribe metoclopromide or an ergot, serotonin agonist, NSAID, steroid, if antiemetic doesnt help

Question 26

Nick is a 19 YO who presents w/ speech difficulty and trouble swallowing. He has a resting tremor in his left hand. He said the sxs started several months ago and have slowly gotten worse. PE confirms the tremor and his neuro sxs. You also examine his eyes w/ a slit lamp and find an abnormality. What is it? What is your dx and tx?

Answer 26

Wilson Disease
- slit lamp shows copper rings
- can look for elevated copper on a liver biopsy or UA
- Tx is chelating agent (D-penicillamine)

Question 27

Dick is a 70 YO male who presents w/ numbness in his hands, legs, and feet that started several months ago. He says he first noticed the numbness in his feet, then it started to move up his legs, and most recently into his hands. PE shows his deformity in his feet, though he doesn’t seem bothered by walking. On x-ray, you see a Lisfranc fracture and dislocation. Labs show he his hyperglycemic. Dick has a hx of DMII and HTN. How do you dx and tx?

Answer 27

Diabetic neuropathy
- stocking-glove progression
- lisfranc characteristic of charcot arthropathy
- control HTN, prescribe TCA for neuropathy
- surgery for fracture

Question 28

Jessie is a 30 YO female who presents w/ some difficulty swallowing, proximal muscle weakness in her arms, and ptosis. She said she’s not sure exactly when this all started, probably years ago. Every couple months she notices it’s getting a little worse. PE shows that her ptosis worsens when you have her hold her gaze upward. You ask her to lift her arms above her head and lower them and to repeat until she is too tired to do so and she is only able to repeat the exercise 4 times. What blood test would likely come back positive? What is your dx and tx? What must you monitor in this pt?

Answer 28

myasthenia gravis
- anti-AChR test will be positive
- tx with Cholinesterase inhibitor and corticosteroid

Question 29

Tyler is a 19 YO male who presents to the ED following a minor car crash. His friend was driving and he was in the passenger seat when a pick-up truck rear-ended them. His friends says the crash was pretty minor, they both probably have whiplash, and both slammed their heads back against their headrests after the initial impact, but it wasn’t “super painful.” Cops decided to bring them both in to the ED when they noticed that Tyler seemed dazed. PE shows that Tyler looks stunned and has dilated pupils with reduced eye movement and orientation. Tyler’s friend mentions that he took a lacrosse ball to the back of the head earlier this week at practice and stayed home from school for two days. What is your dx and tx for Tyler?

Answer 29

second impact syndrome
- immediate CT and neuro consult

Question 30

Michael is a 25 YO male who presents w/ a headache that started 4 days ago. He says it’s an aching pain that gets worse when he leans over his desk at work, but resolves when he lays down to sleep at night. Currently he rates the pain a 3. PE shows he has nasal congestion and pain when you tap him lightly over his brows. What is your dx and tx for Michael?

Answer 30

sinusitis
- OTC NSAIDs, decongestants, or nasal corticosteroid

Question 31

Katelyn is a 38 YO female who presents w/ a movement disorder. She makes uncontrollable involuntary, random movements that she cannot control. She said they started happening subtly about 1 year ago. Her husband says they don’t happen when she’s asleep. You notice she has started to develop a stuttering, dancing gait as she walks to the exam table, and you observe her voice sounds raspy. She says she doesn’t think she has a family hx of anything like this, but she does have an uncle who was institutionalized for uncontrollable OCD and personality changes. What is your dx and tx for Katelyn?

Answer 31

Huntington’s
- antichoreic meds (terbenazine)
- refer

Question 32

Kathy is a 45 YO female who presents w/ tingling and pain in her thumb and index finger of her left hand. She said the sxs started a few months ago and have worsened since then. She rates the pain a 5 currently, but says the pain worsens at night. Kathy has been a hairdresser since she was 30. What special tests do you perform? What is your dx and tx?

Answer 32

carpal tunnel
- Tinel and PHalen
- splint, activity mod, NSAIDs, possible surgery

Question 33

Dwayne is a 52 YO male who presents w/ a progressive language problem. His wife says he’s been having trouble “getting the words out” for the past couple of months, and it’s getting more noticeable. She said he’s been “acting out” too. He’s normally a quiet, calm man, but lately he’s been loud and aggressive. He doesn’t seem to listen to her when she talks and he’s very impulsive. She said she took him to a psychiatrist who sent him here for neurological testing. Neuropsych testing confirms he’s having difficulty speaking and he is very brusque in his manner w/ you and seems disinterested in his exam and the questions you’re asking him. PE shows normal motor function. You order an MRI what do you see? What is your dx and tx?

Answer 33

frontotemporal dementia
- MRI shows shrinkage
- Tx of symptoms (antidepressants, neuroleptics, CIs)

Question 34

Mildred is a 68 YO female who presents w/ dizziness, clumsiness, and bad headache for the past 2 hours. She said her sxs started somewhat suddenly and she feels “off.” You notice she has a clumsy gait as she walks to the exam table. She has a hx of HTN. PE shows vertical nystagmus and +Rhomberg sign. What is your dx and tx for Mildred? What/where is the likely cause? What risk are you particularly worried about? If the location were the pontine artery, what condition would you be concerned about?

Answer 34

cerebellar stroke
- locked in syndrome as a possible outcome
- TPA, mannitol to reduce ICP, manage HTN, coumadin for blood thinning

Question 35

Kenneth is a 50 YO male who presents w/ sudden confusion and disorientation. His husband brought him in because he seems suddenly very unaware of his surroundings and can’t seem to remember anything short-term. At first they laughed it off, but it’s gotten worse over the past month and he has also developed some jerking spasms that come on in episodes. Kenneth has no FH of anything similar. Blood work shows no elevated WBC and Kenneth is afebrile. He has normal CSF on LP and has no other neurological findings currently. What is Kenneth’s dx and tx. What causes this condition?

Answer 35

Creutzfeldt-Jakob
- broad spectrum abx, tx of complications, palliative care

Question 36

Kit is an 8 YO male who presents w/ a sudden onset of repetitive, arrhythmic blinking that started 1 year ago and a new habit of repeating the same word over and over. Prior to the blinking, he had a habit of shrugging his shoulders compulsively that has since resolved. His father says the blinking and word-repeating occur multiple times daily. He has a hx of ADHD and is being tx’d currently for that. The tics haven’t been disruptive to Kit’s school life and he continues to participate in his after-school activities: choir and soccer. PE shows a normal neuro exam and no other significant physical exam findings other than an increased rate of blinking. What is the medical name for his vocal habit? What is your dx and tx?

Answer 36

Tourette’s
- focus on fine motor skills, reducing tics, habit reversal training, educate social circles

Question 37

George is a 28 YO male who presents w/ a headache that started this morning. He says this is the 5th headache like this in the past 2 months and he’s finally fed up. He rates his pain a 9 and says its a deep pain behind his right eye. PE shows his right eye is watering and bloodshot. He is not on any medications and he drinks 2-3 beers after work every night. How do you dx and tx George?

Answer 37

cluster headaches
- calcium channel blocker to prevent further attacks
- high flow oxygen for 10 mins
- cut back alcohol as a possible trigger

Question 38

Wilma is a 65 YO female who presents w/ a headache. She says says the pain is intense and around her left eye and rates it a 7. She’s thrown up twice since the headache started this morning. PE shows her left eye is bloodshot and her vision isn’t 20/20. She has no previous hx of vision impairment. What test do you perform? How do you dx and tx Wilma?

Answer 38

acute glaucoma
- test IO eye pressure with tonometry
- refer to ophtho to prescribe prostaglandin eye drops

Question 39

Evelyn is a 23 YO female who presents w/ a “spell” the previous evening. Her roommate witnessed it and accompanied her to the doctor today. Evelyn said she felt nauseated right before the spell started, she doesn’t remember what happened next, but she woke up confused w/ blood in her mouth from biting the side of her tongue. Her roommate said she called out then fell straight to the floor “Like a stiff board” and her whole body jerked w/ her eyes open. Her roommate said it happened at 4 AM - they were studying for finals, and Evelyn had taken 3 5-hour energies in the past 8 hours. She’s never experienced anything like this before. PE shows a normal neuro and physical exam, except for the bruised tongue and a bruise to the arm from her fall. What is your dx and tx? What do you expect to see on an EEG?

Answer 39

provoked generalized epileptic seizure
- EEG will show no abnormalities
- MRI for lesions
- driving restrictions for 3 mos

Question 40

Caleb is a 40 YO male who presents to the ED following head trauma in an MVC. Caleb has no open wounds to his skull but doesn’t seem well oriented. He opens his eyes and withdraws to pain and only groans when you ask him questions. You notice bruising around his eyes and behind his ears. What imaging do you order? How does he score on the GCS? What is your dx and tx?

Answer 40

severe TBI
- GCS 8
- bruising = basilar skull fracture
- CT without contrast
- mannitol to reduce ICP, ASMs as needed

Question 41

Billy is a 21 YO male who presents w/ a headache. His roommate says he got hit in the helmet w/ a hard line drive during their baseball game this evening that “knocked him out” for 5 seconds. Billy said he had an “awful headache” when he came to and seemed ok at first, but then started to seem more and more dazed. You take a CT. What do you see/how do you dx? How do you tx?

Answer 41

Epidural hematoma
- CT characteristic football pooling
- emergency surgery

Question 42

Dylan is a 3 YO male who presents w/ impaired movement and delayed speech. His parents say Dylan walks but has trouble balancing and difficulty with activities that require coordination - picking up his sippy cup, kicking balls. Dylan is one of three triplets. He also barely speaks, and only knows about 50 words. He rarely speaks in sentences. PE shows a wide, unsteady gait, and difficulty picking up the sticker you give him out of your hand. How do you dx and tx Dylan?

Answer 42

ataxic CP
- PT/OT, baclofen for spasticity

Question 43

Tracy is a 19 YO female who presents w/ a headache and fever that she say started last night fairly suddenly after she got back to her dorm from class. She wasn’t able to sleep well because her neck felt stiff. PE confirms her fever (100.0) and also shows a patch of purpura on her posterior arm. What diagnostic test do you perform and what does it show. How do you dx and tx Tracy?

Answer 43

meningitis, likely neisseria meningitidis
- purpura
- LP confirms leukocytosis, refer to ER for IV abx

Question 44

Pat is a 30 YO male who presents w/ restlessness, tremors, and bradykinesia. He said he doesn’t know exactly when the sxs started, probably several years ago, but they’ve finally gotten bad enough that he decided to come in. Pat has a hx of schizophrenia and is currently taking clozapine. His PE shows no additional signs. How do you dx and tx? What neurotransmitter is likely involved?

Answer 44

tardive dyskinesia
- switch antipsychotics, possible Valbenazine to treat syx

Question 45

Brian is a 24 YO male who presents with a prolonged seizure. Brian is epileptic and began having a seizure. His mother said they normally pass within a minute, but once this one continued to 2 minutes she called 911. He has now been seizing for 18 minutes. How do you dx and tx?

Answer 45

status epilepticus
- ABCs and glucose
- benzodiazepines
- IM midazolam
- IV lorazepam

Question 46

Tim is a 40 YO male who presents w/ fever, headache, and confusion. He was rushed here after his wife found him having a seizure in their garage. She said they had just gotten back from their cabin up north and Tim was unpacking the car. PE confirms he is febrile and you find that he is having difficulty speaking as well. He has a positive Babinski reflex. EEG is abnormal and CSF from an LP shows normal proteins and glucose, and low WBC, with a predominant lymphocyte count. His MRI comes back normal. What do you think Tim has? What is the microbial cause? How do you tx?

Answer 46

encephalitis
- mosquito with West Nile Virus
- lab shows viral infection so tx is symptomatic
- ASMs, Mannitol

Question 47

Gerold is a 65 YO male who presents w/ a headache. He says he noticed the ache 2 months ago, but it wasn’t that bad when it started (he rates it a 3 at the time), but it’s persisted and worsened to a 6, so he decided to come see you. You take an MRI. What is your dx and tx for Gerold? What is his prognosis?

Answer 47

Astrocytoma
- Dexamethasone 10mg IV x1 to reduce ICP
- surgery
- gamma knife radiation with possible chemo

Question 48

Linnea is a 17 YO who presents w/ a hx of “spells” that she can’t explain. She said every so often she gets a strange sense of deja vu and she smells buttered popcorn. She thought it was just a weird incident until the 3rd or 4th time it happened, and she realized her family couldn’t smell what she was smelling. What is your next step? How do you dx and tx Linnea? If her sxs spread to full body motor involvement, how would her dx change?

Answer 48

Focal non-motor epileptic seizure
- MRI for lesions and EEG for abnormalities
- start ASMs (levetiracetam)
- no driving 3 mos

Question 49

Terry is a 48 YO male who presents w/ weakness and paresthesia in both of his feet. He says the numbness started 2 days ago and he figured it would “sort itself out” but instead he noticed that it spread to his ankles. Terry said he’s pretty miffed to be back here, he just got over a bad bout of food poisoning and he thought he was “done with this place.” PE shows normal neuro exam except for decreased deep tendon reflexes in his legs. What test do you order and what are you looking for? What specific condition does Terry have? What are the other variants? How do you tx?

Answer 49

Guillain Barre (acute inflammatory demyelinating polyradiculopathy)
- lumbar puncture to look for elevated CSF
- plasmapharesis or IVIG

Question 50

Myrtle is a 65 YO female who presents w/ an “episode” that occurred last night. She said she was watching TV w/ her daughter when she suddenly lost vision in her left eye, “like a curtain just suddenly fell right in front of it.” She says her vision came back slowly within the next two hours until it was completely normal again. She has a hx of HTN and a BMI of 31. PE shows a normal neurological exam, and a BP Of 128/88 mmHg. How do you dx and tx Myrtle? What caused the sxs?

Answer 50

amaurosis fugax
- manage HTN and obesity d/t CVA risk
- ASA daily

Question 51

Dana is a 42 YO female who presents w/ extreme pain in her distal left arm. She said the pain started about 2 weeks ago and is unbearable - she rates it a 10. She said things that didn’t used to hurt - putting on clothes, brushing up against something - are excruciating. And things that would normally be a little painful - e.g. a paper cut - now hurt tremendously. She said she hasn’t been sleeping well and is feeling depressed. She feels like she can’t do anything because she’s worried it will be painful. Dana had surgery on a displaced Colles fracture 1 month ago. PE confirms that she is hypersensitive to touch - a cotton swab and pinpoint both cause 10/10 pain in this pt. You also notice that her distal left arm feels much warmer than her right arm, is slightly swollen, and is erythematous. How do you dx and tx this pt? What might her surgeon have prescribed that could’ve helped her avoid this condition?

Answer 51

complex regional pain syndrome type I
- POT/OT
- pain management (TCA, SNRI)

Question 52

Kevin is a 27 YO male who presents w/ a facial droop on the left side of his face that he woke up with this morning.He says the left side of his face feels numb and breakfast didn’t taste normal. PE shows ptosis of the left eyelid and you notice your tongue depressor sticks to his tongue. He is unable to move any muscles on the left side of his face - he can’t smile, frown, or raise his eyebrow on that side. How do you dx and tx Kevin? If you noticed a vesicle on his nose or near his ear, how might your dx change?

Answer 52

Bell’s Palsy
- prednisone or acyclovir
- will resolve

Question 53

Joseph is a 70 YO male who presents w/ a headache. He says the headache started 3 months ago and has gotten progressively worse, and the nausea started a month ago as the headache worsened. He has a hx of smoking. You take an MRI and see multiple lesions. What did you see in Joseph’s medical hx? What is your dx and tx for Joseph?

Answer 53

cerebral metastases
- CT chest to ID other tumors
- tx targets primary source and brain mets
- mainly palliative for mets
- whole brain radiation therapy, gamma knife, chemo

Question 54

Blake is a 60 YO male who presents w/ a headache. He says his pain is moderate - he rates it a 4. He has a BMI of 28 and drinks 4 beers nightly. He has a hx of prehypertension. PE shows that his diastolic BP is incredibly elevated at 134. How do you dx and tx Blake?

Answer 54

hypertensive headache
- IV blood pressure meds

Question 55

Frank is a 82 YO male who presents w/ trouble sleeping and hallucinations. His wife brought him in because the sxs have worsened over the past month. She said he wakes up several times every night. He was also certain there was someone standing over their bed two night ago. Earlier in the week he swore he saw a bright blue deer in their yard and couldn’t be convince otherwise. He’s also become very suspicious of their daughter: he thinks she’s an imposter when she comes over to visit and refuses to speak with her. PE shows he has a somewhat shuffling gait and has difficulty coming to a halt and turning around on a dime. What is your dx and tx for Frank? What syndrome is characterized by Frank’s interaction w/ his daughter?

Answer 55

Lewy Body dementia
- Tx with CIs, levodopa (could worsen hallucinations)

Question 56

Blake is a 2 YO male who presents w/ delayed motor ability. He hasn’t started successfully walking and has difficulty with fine motor skills - picking up toys, putting his food in his mouth, but only with his left hand. PE shows weakness in both his left arm and leg, but normal strength and function on his right side. You also note a positive Babinski sign on left right foot. All his movements on the left seem very labored and slow. What is your dx and tx for Blake?

Answer 56

spastic hemiplegia CP
- baclofen for spasticity
- PT/OT

Question 57

Marlese is a 40 YO female who presents w/ a headache that has persisted for 5 days now. She says the pain is like a band around her head and she rates it a 4. She hoped exercise might help, but it didn’t get any better (or worse). She’s worried that she’s very sick, given how long her headache has lasted. How do you dx and tx Marlese?

Answer 57

tension headache
- NSAIDs

Question 58

Margery is a 62 YO female who presents w/ a head pain. She says she gets “jolts” of pain in her jaw and cheeks and lips that last for 15-30 seconds then recede. She says all sorts of things trigger the jolts - brushing her teeth, washing her face, putting on makeup, eating, even talking. How do you dx and tx Margery?

Answer 58

trigeminal neuralgia (tic doloureux)
- analgesics, carbamazepime, phenytoin

Question 59

Travis is a 27 YO male who presents with tingling and numbness in his legs and feet that started a few weeks ago. He says the sensation is worsening and making it difficult to walk properly and it’s starting to spread up his shins. He has no other symptoms but says he recently “got over mono.” What tests/labs might you run? How do you dx and tx?

Answer 59

Guillan Barre (acute inflammatory demylinating polyradiculopathy)
- EMG or NCS to diagnose
- refer for plasmapharesis or IVIg

Question 60

Harry is a 35 YO male who presents with a severe headache. He says it’s the “worst headache of his life” and he almost thought someone had clubbed him on the side of the head when it suddenly came on. He rates the pain a ten. Harry has a hx of smoking and hypertension. PE shows he has weakness in his right arm and his neck is stiff. You take a CT scan and see nothing unusual. What do you do next? How do you dx and tx Harry?

Answer 60

subarachnoid hemorrhage
- LP shows xanthochromia
- tx Nicardipine for cerebral vasospasm, phenytoin as ASM, neurosurgical clip or coil for aneurysm

Question 61

Phil is a 20 month-old male who presents w/ irregular motor development. His parents say Phil often has sustained contractions of his muscles causing him to twist into irregular postures. His mother says she had German measles during her pregnancy. PE shows that Phil’s tonic labyrinthine reflexes are still intact. What do you suspect Phil has? How do you tx?

Answer 61

Dystonic cerebral palsy
- baclofen for spasticity
- PT OT

Question 62

Mary is a 50 YO female who presents w/ headache and tinnitus in her left ear that started 1 month ago and has gotten worse. She rates the pain currently at a 4. PE shows a positive finger rub test for her left ear and you notice she seems off balance when she stands and walks to the exam table. You take an MRI. What do you see? How do you dx and tx Mary?

Answer 62

acoustic neuroma
- MRI shows tumor in cerebello pontine angle
- surgical excision to preserve hearing or gamma knife radiation

Question 63

Tina is a 24 YO female who presents w/ numbness in her hands and fingers. She said she hasn’t been feeling well for the past several months but she’s been so busy furnishing and hosting family at her new cabin up north that she wasn’t able to see a doctor until now. She said it started w/ a fever and chills, and later her neck felt a bit stiff. The numbness is the newest symptom, and she noticed it’s making it difficult to pick things up. PE shows a faded bullseye shaped rash on the nape of her neck.What tests might you run? How do you dx and tx Tina?

Answer 63

peripheral neuropathy secondary to untreated lyme disease
- EMG or NCV
- blood serum for antibodies
- IV abx