Neuro presentations Flashcards

1
Q

A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. He was last known to be fully functional 1 hour ago when the family member spoke to him by phone. There is a history of treated hypertension and diabetes.

A

Ischaemic stroke

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2
Q

A 53-year-old black woman presents with a sudden, excruciating headache which started while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker.

A

Subarachnoid haemorrhage

Sudden, severe headache accompanied by loss of consciousness, nausea, and vomiting

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3
Q

A 75-year-old man with a longstanding history of atrial fibrillation on anticoagulation with warfarin is brought into the emergency department by his carer, who states his concern about the patient’s confusion at home. The carer describes frequent falls over the last several months and says that the patient is dropping utensils from his right hand. On neurological examination, his pupils are equal, round, and reactive to light. He has a right-sided pronator drift and is weaker on his right side than on his left. His mental status testing reveals poor concentration and attention, and impaired short- and long-term recall and registration.

A

Stroke - left side lesion

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4
Q

A young man is brought to the emergency department after being involved in a high-speed motor vehicle accident. He was an unrestrained driver, and no airbags were deployed. He has multiple areas of abrasions, lacerations, and ecchymosis on his scalp and face. On neurological examination, he does not open his eyes to painful stimuli; he is intubated, and he withdraws his left side to pain. His right side is plegic. His right pupil is 3 mm and reactive to light and his left pupil is 8 mm and non-reactive.

A

Subdural haemorrhage

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5
Q

A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the accident and emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.

A

Transient ischaemic attack

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6
Q

An 18-year-old male student presents with severe headache and fever that he has had for 3 days. Examination reveals fever, photophobia, and neck stiffness.

A

Meningitis

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7
Q

A 56-year-old man presents to the emergency department with headache, fever, blurred vision, and somnolence followed shortly by unresponsiveness to verbal commands. For the last 2 weeks he had been feeling ill and had decreased appetite and myalgias. Three days prior to presentation he experienced intermittent confusion, severe headache, and fever

A

Meningo/encephalitis

Symptoms include headache, fever, blurred vision, somnolence, and unresponsiveness.
Progression of confusion and neurological symptoms over a few days.
Associated systemic symptoms such as decreased appetite and myalgias.
Blurred vision is a common neurological symptom in encephalitis.
History of feeling ill for 2 weeks, suggesting a prolonged systemic infection.
Encephalitis involves inflammation of the brain, leading to altered mental status and neurological deficits.

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8
Q

A 28-year-old white woman who has smoked 1 pack per day for the last 10 years presents with subacute onset of cloudy vision in one eye, with pain on movement of that eye. She also notes difficulty with colour discrimination, particularly of reds. She was treated for a sinus infection 2 weeks ago and, on further history, recalls that she had a 3-week history of unilateral hemibody paraesthesias during examination week in university 6 years ago. She occasionally has some tingling on that side if she is overly tired, stressed, or hot.

A

Multiple sclerosis

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9
Q

A 20-year-old woman with no significant past medical history presents with lower back pain and bilateral foot and hand tingling. Her symptoms rapidly progress over 4 days. She develops lower extremity weakness, to the point that she is unable to mobilise her legs. She reports coryzal symptoms 2 weeks ago. On examination, she has 0/5 power in her lower extremity with areflexia, but despite the paraesthesias she does not have sensory deficits. Her aminotransferases are elevated, and lumbar puncture reveals mildly elevated protein with no cells and normal glucose.

A

Guillain barre

Preceded by infection (coryzal symptoms)

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10
Q

A 69-year-old man presents with a 1-year history of mild slowness and loss of dexterity. His handwriting has become smaller, and his wife feels his face is less expressive and his voice softer. Over the last few months he has developed a subtle tremor in the right hand, noted while watching television. His symptoms developed insidiously but have mildly progressed. He has no other medical history, but he has noted some mild depression and constipation over the last 2 years. His examination demonstrates hypophonia, masked facies, decreased blink rate, micrographia, and mild right-sided bradykinesia and rigidity. An intermittent right upper extremity resting tremor is noted while he is walking. The rest of his examination and a brain magnetic resonance imaging are normal.

A

Parkinson’s disease

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11
Q

42-year-old school teacher presents with difficulty managing her classroom. She has become increasingly irritable with students and fails to complete assigned tasks on time. Her sister and husband report that she has become restless, pays less attention to her appearance and social obligations, and at times is anxious and upset. She has stumbled unexpectedly. On examination, her speech is somewhat uneven and she is inappropriately flippant. Subtracting serial 7s from 100, while seated with her eyes closed, brings out random ‘piano-playing’ movements of the digits along with other movements of the limbs, torso, and face

A

Huntington’s disease

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12
Q

A 76-year-old white woman is brought to her general practitioner by her children because she is becoming more forgetful. She used to pay her bills independently and enjoyed cooking but has recently received overdue notices from utility companies and found it difficult to prepare a balanced meal. She has lost 3.5 kg in the past 3 months, and left the water running in her bathtub and flooded the bathroom. When her children express their concerns, she becomes irritable and resists their help. Her house has become more cluttered and unkempt.

A

Alzheimer’s disease

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13
Q

A 55-year-old man who worked as a technician developed difficulty finding words 2 years earlier, which has evolved into dysfluency, frequent repetition of remarks and questions, stereotypies (purposeless behaviours or fragments of speech frequently repeated, without regard to context), and echolalia (reflexive repetition of another’s speech). In the past year, he has also become forgetful. His work efficiency deteriorated due to his poor comprehension, reasoning, planning, and completion, resulting in disability leave. He also became unfeeling, intrusive (indiscriminately approaching strangers), child-like, and impulsive.

A

Frontal temporal dementia

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14
Q

A 58-year-old male teacher developed dysnomia, spelling errors, impaired comprehension of reading and conversation, and diminished singing ability. He also has impaired attention, planning, and organisation, along with declining self-care, child-like behaviour, and altered social habits (e.g., eating meals with his fingers). He developed anxiety.

A

Frontotemporal dementia

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15
Q

A 78-year-old woman presents with confusion, agitation, and visual hallucinations. She has become progressively confused over the past 2 years and has had trouble managing her affairs, including shopping and paying bills. It is unclear when her confusion started. Initially, she was having trouble following conversations and got lost on several occasions. Her memory, which was previously good, has begun to deteriorate. At night, she sees children playing in her house and has called the police on several occasions. She gets angry easily and has been paranoid about her relatives and their intentions. Her behaviour tends to fluctuate from day to day. She started to shuffle about 6 months ago and had difficulty getting out of chairs, and getting dressed to go out seemed to take hours. On one occasion, she fell and was taken to the emergency department but was subsequently discharged with no diagnosis given.

A

Lewy body dementia

  • Visual hallucinations
  • Progressive confusion
  • Parkinsonism - Shuffling gait, slow dressing
  • Increased agitation
  • Falls
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16
Q

A 32-year-old woman presents with a 13-year history of 1-3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding. Untreated, they last for 2 days. On four occasions, headaches were preceded by the gradual appearance of a shimmering, zigzag line that enlarged, moved to the peripheral visual field, and then faded away over 45 minutes.

A

Migraine

17
Q

A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a working day. The pain is generalised. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen. Examination reveals tenderness of her scalp and both trapezius muscles.

A

The pain is generalised and described as similar to wearing a tight band around her head

Tension headache

18
Q

A 56-year-old man presents with a 25-year history of constant headache. The onset was insidious and he is certain that the only time he is headache-free is when he sleeps. He states the headache is generalised and his neck and shoulders are always ‘tight’. He denies any associated autonomic symptoms including eye tearing, nasal congestion, light and sound sensitivity, nausea, or vomiting.

A

Tension headache (Chronic)

19
Q

A 44-year-old male smoker presents with a 9-year history of recurrent headache attacks. Headache attacks occurred twice-monthly initially, always in the early hours of the morning (2 a.m. to 3 a.m.). The headache attacks have increased to an average of two per day. The acute attacks can occur at any time, and last between 2 and 4 hours. He always has a nocturnal attack. Attacks are triggered immediately after drinking alcohol or with the smell of strong aftershave or petrol. The pain is excruciating and focused around his right eye. The right eye reddens and tears, the right eyelid droops, and the right nostril runs. He becomes severely agitated during attacks, often pacing the room or rocking back and forth.

A

Cluster headache

20
Q

A middle-aged woman presents with a complaint of frequent (once or twice daily for 3 weeks), brief (lasting several seconds) episodes of intense, sharp left-sided jaw pain. She has experienced these attacks for several years, but they had previously been relatively rare (1 episode daily for several consecutive days followed by months with no attacks). She says that episodes are sometimes brought on by eating but can occur without an apparent stimulus. The patient states that even though the pain is brief, she lives in fear of repeat flares.

A

Trigeminal neuralgia

Maxillary (V2)/mandibular (V3) distribution symptoms occur in the majority of patients. This can present as sharp pain running from the mouth to the jaw (commonly mistaken for dental pain) or less commonly as pain from the upper lip to the orbit. Symptoms in an exclusively ophthalmia (V1) distribution are the least common, and patients typically refer to the pain as headache.

21
Q

A 16-year-old boy presents to the emergency department with a first-time seizure event after attending an all-night party and consuming alcohol. Witnesses described the seizure as beginning abruptly with bilateral limb stiffening, followed by jerking movements in all limbs; the patient has no memory of warning symptoms prior to the seizure. The event seemed to last about 1 minute, and the patient was quite somnolent afterwards. Further review of the history reveals that the patient has been experiencing ‘jerks’ in the morning after awakening, usually involving the arms and shoulders and occasionally causing him to drop things. These ‘jerks’ do not seem to present a problem during the rest of the day.

A

Generalised seizure

22
Q

An 18-year-old girl presents with several episodes of confusion over the past several months. Typically, she experiences a warning signal, which she describes as a rising sensation within her abdomen that travels upwards through her chest. She is usually unaware for a few minutes, but others have told her that during these episodes she smacks her lips, picks at her clothing, and is unable to speak. After the event she feels tired, has a headache, and prefers to lie down. She notes that her memory has not been as good as it was in the past, and her school grades have declined

A

Complex focal seizure

Automatism like lip smacking and Aura is more seen in focal seizure than generalised

23
Q

A 70-year-old man presents with a tonic-clonic seizure. His wife states that during the past month there have been times when he does not respond when spoken to, mumbles words that do not make sense, and stares in a motionless way. After several minutes he is usually responsive. His past medical history includes hypertension and hypercholesterolaemia. He had a stroke during the preceding year, which resulted in weakness of the right extremities and loss of expressive language. Although he recovered most motor and language deficits, he still walks with a limp on the right side and sometimes uses the wrong word.

A

Complex focal seizure

  • Absence seizures are about 15 seconds long this is a few minutes
24
Q

A 60-year-old woman with breast cancer presents with back pain that has gradually increased in severity over the last 3 weeks. The pain is worse when she lies down. She has found walking more difficult in the last few days, with a feeling of numbness in her toes. Loss of tendon reflex is apparent on examination.

A

Malignant spinal cord compression

25
Q

A 44-year-old man presents with low back pain that has become worse over the past few days. He reports having difficulty when trying to urinate, and erectile dysfunction of recent onset. Bladder palpation indicates urinary retention

A

Cauda equina syndrome

Low Back Pain: usually back pain localised to lower back

Urinary Symptoms: Urinary retention, difficulty initiating urination, and changes in urinary function (such as hesitancy or dribbling) are classic symptoms of cauda equina syndrome. Bladder palpation revealing urinary retention further supports this diagnosis.

Erectile Dysfunction: Erectile dysfunction can occur in cauda equina syndrome due to disruption of nerve pathways involved in sexual function.

26
Q

A 23-year-old white woman presents 24 hours after a fall while ice skating. Initially, she was assisted to stand, and reported back pain and right hip pain. She was examined at a local emergency department, with plain film imaging, and discharged. Prior to discharge the patient reported she had ‘trouble’ passing urine. The next day, the back pain had increased, she could not void, and had upper leg pain.

A

Cauda equina syndrome

27
Q

A 60-year-old man presents with right foot drop, which has developed gradually over the last year and progressed to involve more proximal areas in the last 2 months. The patient reports associated muscle twitching and painful muscle cramps involving the same areas. The neurological examination reveals bilateral lower-extremity weakness, more severe on the right, with associated spasticity, atrophy of the right foot intrinsic muscles, diffuse fasciculations, and hyper-reflexia, with deep tendon reflexes being brisker on the right lower extremity.

A

Amyotrophic lateral sclerosis

28
Q

A 40-year-old woman awakens with left-sided facial fullness and a subjective feeling of facial and tongue ‘numbness’ without objective hypoaesthesia. There is complete absence of brow movement, incomplete eye closure with full effort, and loss of smile, snarl, and lip pucker on the affected side. The remainder of the history and physical examination are unremarkable.

A

Bell’s palsy

29
Q

A 25-year-old woman presents with recurrent slurring of speech that worsens when she continues to talk. She has trouble swallowing, which deteriorates when she continues to eat, and has double vision that gets worse when sewing, reading, or watching TV. She reports that her head is heavy and hard to hold up. Her symptoms have progressively deteriorated over the past 6 months. She has intermittent weakness in her legs and arms. She is fearful of falling due to her legs giving way and she has trouble combing her hair or putting on deodorant. She reports a feeling of generalised fatigue and is occasionally short of breath.

A

Myasthenia gravis

30
Q
A