Neuro Review Session - Sheet1

Question 1

lesion location - monocular vision loss

Answer 1

pre chiasm

Question 2

lesion location - homonymous hemianopsia

Answer 2

anywhere behind chiasm, though optic tract lesions often are incongruous

Question 3

lesion location - bitemporal hemianopsia

Answer 3

suprasellar pituitary, craniopharyngioma

Question 4

lesion location - upper quadrant vision loss

Answer 4

meyer’s loop

Question 5

lesion location - lower quadrant vision loss

Answer 5

parietal

Question 6

lesion location - macular sparing

Answer 6

dual mca/pca blood supply to macula

Question 7

visual field in papilledema

Answer 7

peripheral construction, enlarged blind spot

Question 8

visual field in optic neuritis

Answer 8

central scotoma

Question 9

fundus optic neuritis

Answer 9

may be normal (retrobulbar) or sometimes swollen

Question 10

altitudinal deficit

Answer 10

upper or lower half of one eye - ischemic optic neuropathy

Question 11

RPLS/PRES - visual deficit

Answer 11

cortical blindness with bilateral occipital lesions

Question 12

68 yo M c/o blindness for one hour after 4 episodes of decreased vision in the past 8 hours. history of hypertension and emphysema requiring home O2. last Hb 17.5. funduscopic exam showed edema of disc with enlarged retinal veins and several hemorrhages

Answer 12

central retinal vein occlusion - can present with TIA - like episodes. this patient’s blood is likely hyperviscous. causes: sepsis, neoplasia, hypercoagulability; pizza fundus

Question 13

23 yo F with migraine with aura was found to have a small left occipital infarct. her only med is an ocp. she has a patent foramen ovale on TEE with left to right shunting. what is risk of stroke?

Answer 13

OR 2.0-3.0. risk is higher in smokers and those on ocps. some groups consider migraine with aura an absolute contraindication to combined ocps.

Question 14

prevalence of PFO in the general population

Answer 14

25% - PFO is found in a higher percentage of patients with unexplained stroke vs. general population

Question 15

at the nursing facility where he resides, 75 yo M slumps over at the breakfast table is unresponsive. non con CT shows a hyperdense area in the pons.

Answer 15

pontine hemorrhage - rapid unresponsiveness suggests coma of brainstem origin.

Question 16

74 yo F comes to the office 2 weeks s/p TIA involving aphasia and weakness of the hand. normal neuro exam, BP is normal. carotids normal. she was started on ASA. what is the next step in management?

Answer 16

continue current regimen

Question 17

74 yo F arrives in the ER 5 hours after onset of dizziness, numbness of R face, and dysphagia. she sees a chiropractor weekly for cervical manipulation. Head CT nl. Exam: nystagmus on lateral gaze, r palate does not elevate, r face numb, L body hypesthesia, no babinski’s. what treatment?

Answer 17

lateral medullary syndrome on the right (crossed sensory deficit) - most common vessel occluded is the vertebral (more than pica). because of risk of proximal propagation, heparin is used.

Question 18

indications for heparin

Answer 18

lateral medullary syndrome, ventral venous sinus thrombosis, stuttering TIA, basilar artery thrombosis, low EF, mural thrombus, acute large vessel occlusion, dvt

Question 19

brainstem - clues to diagnosis

Answer 19

crossed sensory deficits imply lateral brainstem, crossed motor more medial; consciousness impaired with reticular activating formation involvement; cranial nerves and crossed sensory and/or motor long tract signs

Question 20

spinal cord - clues to diagnosis

Answer 20

deficits usually bilateral, UMN signs from lesions rostral to lumbar spine, may have LMN signs at lesion level and UMN below lesion level, bowel/bladder dysfunction

Question 21

L4/L5 disc herniation

Answer 21

loss

Question 22

38 yo HIV+ patient with lower limb weakness and pain down the back of both legs and incontinence of bowel and bladder. sacral numbness and decreased sphincter tone

Answer 22

cauda equina

Question 23

39 yo F with 2 weeks of severe neck and arm pain, weak triceps, absent triceps reflex, hyperreflexic legs; Sagittal T2 MRI - large C6-C7 disc catching the C7 nerve root

Answer 23

early signs of myelopathy and lots of pain and weakness - needs urgent operation!

Question 24

78 yo M with h/o 6 months of neck pain radiating to his left had with difficulty with balance when walking. he has osteoarthritis, crohn’s disease, and GERD. decreased range of motion of neck, mild weakness/atrophy of hands, increased tone in legs, bilateral babinski’s, gait stiff and broad based

Answer 24

cervical spondylotic myelopathy - the most common cause of myelopathy in older people, results from disk dessection with narrowing of intervertebral space and consequent bony overgrowth with some facet and ligamentum flavum hypertrophy, often at several levels. weakness and atrophy of hands with increased tone in legs puts this lesion in the cervical area. likely this person needs surgery.

Question 25

57 yo M has lost 30 pounds in 3 months. he feels generally weak, but right leg is particularly weak and he cannot climb stairs. he takes sulfonylurea for diabetes. looks depressed, weakness and atrophy of right thigh muscles, no patellar response on right, Hba1c = 15%, glucose 440

Answer 25

diabetic amyotrophy - a patients with poorly controlled DM may develop a syndrome so bad that the clinician often thinks of neoplasia. can include pain, muscle wasting, and by EMG paraspinous muscle involvement, as well as prominent denervation of the gradricepts. treatment - diabetes control.

Question 26

femoral neuropathy

Answer 26

• can come on suddenly as in a nerve infarct with a great deal of pain and numbness in the medial leg (saphenous nerve distribution)

Question 27

top ten causes of neuropathy

Answer 27

diabetes (small fiber, proximal amyotrophy, mononeuropathies single and multiplex, pupil sparing 3rd nerve; AIDP (GBS), CIDP (treated with steroids unlike GBS), mechanical neuropathies (carpal tunnel, ulnar, radial, peroneal), ALS; nutritional (B12, copper); chemotherapy; AIDS neuropathy (CIDP, CMV, VZV, haart related); paraneoplastic (sensory neuropathy anti-Hu, severe imbalance, sometimes pruritus or pain)

Question 28

following a stab wound to the upper arm a patient complains of arm weakness and numbness. exam - weakness of biceps, absence of biceps reflex, sensory loss of the lateral aspect. What nerve is injured?

Answer 28

musculocutaneous nerve - innervates the biceps and terminates as the lateral antebrachial cutaneous nerve with a sensory territory that is consistent with this patient’s exam

Question 29

24 yo used cocaine yesterday and awakened 10 hours later with R arm weakness. after cocaine two weeks earlier he broke his ankle and is using crutches. he was neurologically normal when he fell asleep. stable since then. decreased wrist and finger extension, normal delt, bi, BR

Answer 29

radial nerve injury below the spiral groove. since his triceps are not involved, the crutches are probably not the issue, but falling asleep while intoxicated probably is. thus, below the spiral groove is likely the compressive site

Question 30

patient c/o bilateral hand numbness. symmetric bilateral loss of sensation on the dorsum of the hand from the thumb to the dorsal aspect of digit 2, above the PIP joint. what question should you ask the patient?

Answer 30

were you recently arrested? compression or trauma to the superficial branch of the radial nerve; aka handcuff neuropathy

Question 31

32 yo F has a 3 month h/o weakness and numbness of both legs. muscle strength 4/5, numbness to pain/temp/vibration up to ankles, no reflexes in any limb. CSF: glu 60, protein 120, WOB, nerve conduction velocities very slowed. which is the most likely structure involved?

Answer 31

myelin - this patient has albuminocytologic dissociation and decreased nerve conduction velocities. the course is too slow for GBS, but chronic inflammatory demyelinating polyneuropathy (CIDP) would fit this picture. unlike gbs, this syndrome can respond to steroids. ivig is used as well

Question 32

27 yo M injured his R hand in a machinery accident. following the injury 1 year previously he had extensive ecchymosis and swelling. hand is warm and dry, unable to tolerate light touch or any motion of wrist or finger joints. what is the most likely explanation?

Answer 32

abnormal sympathetic response - this patient has complex regional pain syndrome. bone scan might be positive in this area. treat for neuropathic pain, although often very unsuccessful. sympathetically mediated pain may follow mild blunt trauma, burns, frostbite, or immobility. a regional sympathetic ganglion nerve block is tried as early as possible in the patients course. can also try propranolol, prazosin, AED’s, and TCAs

Question 33

59 yo M c/o four months of progressive leg weakness. he has had a 14kg weight loss, a dry mouth, and constipation. he has smoked 1 pack of ciggs per day for 30 years. exam shows weak hip flexion and knee extension, improving slightly with repetitive activity. reflexes and babinski signs are absent. sensory exam is normal. CXR shows an upper lobe mass. where is the pathology?

Answer 33

NMJ - most likely lambert-eaton syndrome with small cell lung cancer. presynaptic. bulbar muscles usually not involved. classically gets better with repetitive activity unlike MG

Question 34

88 yo M is seen because of increasingly frequent episodes of loud snoring over the past 19 months. he has a 10 year h/o insomnia and mild low back pain. he takes no medications and drinks one glass of wine with dinner. neuro exam - mild loss of vibration sense over the toes, DTRs decreased at the ankles, unable to tandem walk, BP wnl. what is most likely cause?

Answer 34

normal aging - diminished ankle reflexes ok in geriatrics, probably can’t tandem because of milk vibrator loss and some arthritis dz. should at least check a fasting glucose/ HbA1c

Question 35

75 yo F comes to the ER comatose. she had vague dizziness and slurred speech earlier that day. unresponsive, ocular bobbing, pinpoint reactive pupils, absent vestibulo-ocular reflexes, quadriplegic. diagnosis?

Answer 35

basilar artery thrombosis - this patient had some sort of posterior circulation TIA. now she has all signs of basilar artery thrombosis. if she were locked in she would be awake but de-efferented (unable to communicate except by looking up)

Question 36

the declaration of brain death requires

Answer 36

established cause of trauma

Question 37

12 hours after cardiac arrest a patient has unreactive pupils, absent corneals, and no response to caloric testing or purposeful motor activity. his most likely prognosis is …

Answer 37

death or vegetative state

Question 38

43 yo woman comes to the ER 1 hour after losing consciousness. on awakening she has severe HA and photophobia. she is afebrile. normal exam, CT shows no bleeding. next step?

Answer 38

LP, concern for SAH. you will want to do an LP because you can’t trust the CT. however, you may want to admit her. she may need an mra or cta as well. on lp you would look for xanthochromia, evident as early as 12 hours after a bleed

Question 39

intra-axial mass lesion that enhances heterogeneously (necrotic center) + HA

Answer 39

glioblastoma

Question 40

extra-axial mass lesion that enhances homogeneously + HA

Answer 40

meningioma - full of Calcium, so that it would look much the same on an unenhanced CT. meningiomas of the subfrontal region can affect olfactory nerve and present with decreased test + HA

Question 41

45 yo F gives a six month h/o worsening bioccipital throbbing HAs precipitated by running, coughing, sneezing, bending or lifting. she feels slightly unsteady on romberg testing, rest of PE is normal.

Answer 41

chiari malformation and syrinx. she will need decompression of posterior fossa - the syrinx at the moment is asymptomatic. the headache is a cough headache.

Question 42

bacterial meningitis

Answer 42

don’t wait for diagnostic tests. treatment order: dexamethasone, antibiotics, CT, LP (if done within 4 hours of abx, unlikely to lose culture)

Question 43

patient on steroids for lupus develops pain radiating from shoulder into middle finger

Answer 43

C7 dermatome zoster eruption. patient should be treated with iV meds because she is immunocompromised

Question 44

30 yo F with acute onset of severe HA and somnolence 2 hours ago. temp 100.6, BP wnl, lethargic but responds to questions, CT normal, CSF: OP 250, pink, glucose 53, protein 85, WBC 400 65% pmns. likely diagnosis

Answer 44

SAH. the patient is mildly febrile but has WBC commensurate with blood in the CSF. one can also worry about bacterial infection, but it is not offered as an answer

Question 45

63 yo M with colon cancer is treated with 5-FU, leucovorin, oxaliplatin, and bevacizumab. two days later he is unable to see and quite agitated. discs pupils and eye movements are normal but he is NLP OU. MRI - Bilateral occipital abnormalities

Answer 45

PRES 0 the MRI shows bilateral occipital abnormalities and the patient is cortically blind. culprit was probably bevacizumab (avastin), a VEGF receptor inhibitor

Question 46

25 yo F comes to the ED with 12 other victims of an aerial toxic exposure. diplopia, dysphagia, dysphonia, unsteady gait –> flaccid motor paralysis progressing downward from shoulders, sensory exam and LP are normal. explanation?

Answer 46

exposure to soman nerve gas, which inhibits cholinesterase - this patient has cholinergic toxicity. fentanyl was used to anesthetize terrorists who held hostages in a moscow theatre a couple of years ago. unfortunately the opiate killed hostages and captors. they would not have flaccid paralysis

Question 47

45 yo F admitted for cholecystectomy. she has a long h/o alcohol misuse as well as daily use of diazepam and lorazepam. one week after surgery she becomes agitated and a day later has a seizure. explanation?

Answer 47

benzo withdrawal - benzos have a long half-life with the exception of lorazepam. alcohol withdrawal is within the first 24 hours or so. cocaine use doesn’t cause withdrawal seizure

Question 48

19 yo found unresponsive. two days ago he began risperidone treatment. temp 104, CK 1500, urine + for myoglobin, rigidity in all extremities. what neurotransmitter system is most likely responsible for these symptoms?

Answer 48

dopamine - both atypical and typical neuroleptics can cause this dopaminergic system problem, neuroleptic malignant syndrome. both increase sudden cardiac death, probably QR interval

Question 49

which of the following meds is a common cause of action tremor? haldol, lithium, topiramate, cytarabine, atorvastatin

Answer 49

lithium can cause a nasty tremor and cerebellar toxicity. lithium toxicity is treated with hemodialysis . haldol - extrapyramidal signs, topiramate is actually used to treat action tremor, cytarabine produces cerebellar toxicity and atorvastatin can produce a myopathy

Question 50

familial essential tremor - treated with

Answer 50

propranolol or mysoline (very sedating) or topiramate

Question 51

which of the following (gabapentin, nortriptyline, duloxetine, carbamazepine, pregabalin) is used for neuropathic pain and associated with urinary retention in the diabetic male

Answer 51

nortriptyline. although anticholinergic effects are worse with amitriptyline.

Question 52

24 yo F has a single nocturnal GTC seizure from sleep. she has no epilepsy risk factors and normal PE, EEG, and MRI. she is quite upset at being told she can’t drive for 6 months. what is her risk of seizure recurrence over the next two years

Answer 52

20-30%

Question 53

which antiepileptic drug has no drug interactions with ocps: lamotrigine, gabapentin, oxcarbazepine, topiramate, carbamazepine

Answer 53

gabapentin. lamotrigine levels are decreased by ocps. oxcarbazepine, topiramate, carbamazepine are enzyme reducers.

Question 54

major drug associated with seizure

Answer 54

cocaine

Question 55

30 yo M with known epilepsy p/w several GTC seizures. he has been off AEDs for 3 months. he has no other known seizure types. normal PE and head CT, and he is allergic to phenytoin. would like to start an aed that can be rapidly initiated and titrated up to therapeutic dose

Answer 55

valproate - while it has obvious problems in women of childbearing age, this man’s epilepsy syndrome is unclear. therefore a broad spectrum drug would be reasonable. valproate, topiramate, and lamotrigine are all broad spectrum. but of these only valproate can be loaded IV rapidly.

Question 56

75 yo M who lives in a snf comes to the ED because of ams. refuses to eat, refuses to get out of bed. h/o hypertension, bipolar dz, and depression. his meds are risperidone, valproic acid, and hctz. exam - course tremor at both hands, cogwheeling at elbows and wrists, tongue briefly protrudes from mouth when he speaks. mmse 25. next step?

Answer 56

decrease valproate dose - remember valproate can also produce a parkinsonian syndrome. since it isn’t helping his behavior, should d/c it

Question 57

70 yo F found to be seizing and continues to seize in the ED. bp 160/80, P 100, T 37, glu 85. the most likely cause of status epilepticus in the patient is:

Answer 57

cerebrovascular disease - stroke, including remote and acute hemorrhagic and ischemic, account for 60& of all status epilepticus, with other less common causes: encephalitis, metabolic derangement. her bp is not in the hypertensive encephalopathy range

Question 58

8 yo M thought to have ADD has an eeg showing 3hz spike and wave activity. best treatment

Answer 58

ethosuximide. kids with early onset absence epilepsy have the best prognosis, but up to 1/3 may develop gtc seizures in their adolescent or young adult years

Question 59

65 yo m p.w the story that he has fallen out of bed three times and has struck his wife while dreaming that he was defending his home from a burglar. what is the best initial tx?

Answer 59

clonazepam - first line tx for REM behavior disorder. works 90% of patients. 2nd line - amantadine and ropinirole. rem behavior disorder - increased risk of developing PD.

Question 60

64 yo L handed man c/o 6 months of weakness in left arm and LHeadedness when he plays tennis. his arm and hand are cool 15 min. during these episodes. 30 pack year smoker, but stopped 10 years ago. BP right arm 150/90, L arm 134/79. left radial pulse is diminished. next step in diagnosis?

Answer 60

mra - diagnosis is likely subclavian steal syndrome. smoking may contribute to vascular diz. want to look at aortic arch, etc.

Question 61

what condition is associated with cerebral aneurysm?

Answer 61

autosomal dominant polycystic kidney dz

Question 62

7 yo F has HA’s, vomiting, and visual problems. she is 4th percentile in height and weight. bilateral temporal hemianopia, pupils errl, CT cystic and solid mass in sella turcica region. after surgery, long term mgmt?

Answer 62

hormone replacement therapy. likely a craniopharyngioma

Question 63

78 yo M is brought in by his family with a 4 year ho progressive memory loss. he cannot balance his checkbook and has become withdrawn. workup should include

Answer 63

screening questions for depression. this is probably AD, and evaluation should focus on reversible causes of dementia

Question 64

which area of cognition might improve with normal aging?

Answer 64

vocabulary

Question 65

55 yo M p/w personality changes and language changes for 6 months. he spends money recklessly, quit his job, effortful speech consisting of largely stock phrases with poor word retrieval. memory is good. mri shows focal left temporal atrophy

Answer 65

FTD - prominent behavior changes with early preservation of memory

Question 66

65 yo M c/o 4 weeks of being in a fog. got lost on the way to his home. short term memory impaired. remainder of exam wnl. blood work wnl. Mri- bilateral hippocampal abnormalities

Answer 66

paraneoplastic syndrome - the actual antibody could be an anti-nmda receptor (unlikely given gender/age), anti-hu or anti-ma. tumor is likely in lung but could be testicular. point is that the discovery of an antibody should trigger a neoplasia search. PET scan could search the body for a hypermetabolic focus to direct biopsy.

Question 67

61 yo M c/o severe left leg pain and weakness for 3 months. he has had two stem cell transplantations for multiple myeloma. he was on extended prednisone tx at these times but has had none for two years. no known myeloma recurrence. exam wnl except for left leg 4/5 strength. next step

Answer 67

left hip mri -likely avascular necrosis of the hip. refer to ortho

Question 68

55 yo F c/o 6 months progressive right hearing loss. five years ago a left vestibular schwannoma (acoustic neuroma) was removed. general exam is normal. Rinne lateralizes to the left. likely diagnosis?

Answer 68

NF2

Question 69

75 yo M reports that her husband has had six months of urinary incontinence and 4 months of memory loss. he seems to urinate in his pants and doesn’t care. gait slow, shuffling with feet glued to the floor. what is the cause of the patient’s urologic dysfunction?

Answer 69

failure to inhibit voiding reflex. think NPH - with this he would have indifference to the voiding urge. he might well have some prostatic dz as well.

Question 70

13 yo F brought to the ER on a 95 degree day 20 minutes after being hit on the head by a baseball. she got up to run but 10 min later lost consciousness. BP is 154/104, HR 45. likely problem?

Answer 70

increased ICP - she has a cushings signs of increased BP and decreased pulse - significant risk of raised ICP, possibly an epidural hematoma here. acute treatment would be mannitol infusion and emergent operation - no time for dexamethasone infusion to do much acutely.

Question 71

44 yo M develops behavioral changes and odd movements. his mother died at a nursing home from a progressive neuro dz and his uncle is in a mental institution. what will the CT show?

Answer 71

caudate atrophy. this is a family with huntington’s disease. genetic testing for number of CAG repeats on chromosome 4. there is degeneration of striatal gamma aminobutyric acid neurons

Question 72

75 yo F is admitted to the hospital for a broken hip. at 1am on the POD 3 she begins screaming that there are robbers in the room and pulls her out her IB while wandering down the hall. first line management:

Answer 72

reorient patient, encourage family presence.

Question 73

78 yo F with metastatic breast CA involving many vertebral bodies and ribs as well as lungs is on hospice. she asks for more pain medication, even though increasing narcotic doses impairs her respiratory function

Answer 73

give whatever oral dose is necessary, for this patient relief of pain is the main goal

Question 74

30 yo F develops complicated partial seizures. 2 AED’s provide suboptimal control. what is the likelihood that the addition of 3 AEDs will provide adequate seizure control?

Answer 74

less than 5%. this patient should be evaluated early for alternative therapy including epilepsy surgery

Question 75

65 yo M comes to the ED with a 3 day h/o left leg and back pain after lifting a heavy suitcase. numbness in right groin, urinary urgency, incontinence. decreased pp over buttocks, posterior thighs, perineum, decreased anal tone. diagnosis?

Answer 75

cauda equina

Question 76

30 yo F has low back pain radiating down the back of her right leg after moving furniture. pain on flexion of the thigh. DTR and strength normal. decreased sensation along right lateral foot. bowel/bladder normal. next step

Answer 76

analgesic therapy and activity as tolerated. no imaging is needed..

Question 77

50 yo M comes to the ER with 2 hours of confusion and hallucinations. ETOH abuse for 27 years with seizures and traumatic injuries. stopped drinking 3 days ago. fever, tachycardia, htn disheveled/malnourished. resting tremor of hands, uncooperative, disoriented x 3, visual hallucinations

Answer 77

delirium tremens. GIVE SOME THIAMINE while you are thinking. you can’t tell at this point if the patient has korsakoff psychosis and possibly you will prevent it. withdrawal seizures are within the first 24 hours after ETOH cessation. alcoholic hallucinosis is usually earlier.

Question 78

12 yo boy with hemophilia A has headaches. he fell ice skating 2 weeks ago without loss of consciousness and remembers striking his head. CT a the time was normal and was discharged. exam - bilateral papilledema, slight ocular abduction weakness bilaterally, left babinski, hyperreflexia on left

Answer 78

subdural hematoma. there has been a long delay between trauma and presentation. don’t call this a post concussive state - there is evidence of raised ICP

Question 79

54 yo M with alcoholism comes to the ED because of inability to move his leg for the past 4 hours. he was last seen 48 hours earlier. slight bilateral lower extremity swelling, no voluntary movement, oliguria - bladder catheterization yields 40 cc urine + for blood by dipstick. diagnosis?

Answer 79

rhabdomyolysis. the blood and the swelling indicate muscle issues. hyperkalemia associated with rhabdo should be treated acutely when there are EKG changes with calcium.

Question 80

75 yo M consults a physician for 15 month h/o progressive difficulty walking with 3 months of urinary incontinence. oriented X 3, but speaks infrequently. patient has bilateral grasp reflexes and increased muscle tone. seems stuck to the floor - needs assistance to walk. what will you see on CT?

Answer 80

increased ventricular size. NPH.

Question 81

17 yo F brought in by her parents because of a 1 year h/o excessive daytime sleepiness. she falls asleep during class and was involved in a MVC when she fell asleep while driving. occasionally she has fallen to the ground after laughing or being startled. multiple sleep latency tests shows REM episodes at sleep onset. explanation?

Answer 81

narcolepsy + cataplexy - early REM onset after sleep.. treat with provigil or ritalin for excessive daytime sleepiness. cataplexy can be treated with sodium oxybate.

Question 82

58 yo M whose only pmh is for 30 pack year smoking, has increasing problems walking for 4 months, particularly on stairs. he has lost 10 pounds during this period. he has difficulty touching his nose with his eyes closed but can do so with the eyes open. profound loss of vibration and position sense. can’t stand with feet together with eyes closed. diagnosis?

Answer 82

sensory ataxia - patient has + romberg, poor proprioception.this could all be posterior column problems. likely anti-hu antibody associated with small cell lung cancer.

Question 83

35 yo F has noticed a gradual loss of vision in the corners of both eyes. during the same several week period she has been gaining weight, has decreased libido, increased soe size, can’t remove wedding ring. she has been amenorrheic for 8 months. likely diagnosis?

Answer 83

acromegaly - this patient is growing! ACTH secreting adenomas and cushing syndrome can make one gain weight and develop strae. prolactin producing adenomas also produce bitemporal hemianopsia but would cause galactorrhea and be treated with bromocriptine

Question 84

12 yo M arrives to the ED 1 hour s/p MVC. he as a tibial open fracture with severe pain around the fracture site. he has weakness of toe flexion and much pain on passive extension of the toes with hyperesthesia in his sole

Answer 84

compartment syndrome - with acute swelling and fracture there is a risk of compartment syndrome which can cause tissue necrosis that can –> vigorous decompression

Question 85

72 yo M has a two day history of horizontal diplopia. pain behind the R eye and difficulty keeping the eye open. he has a 50 year h/o T1DM with polyneuropathy htn and renal insufficiency. he takes aspirin and insulin. diplopia on L lateral gaze and incomplete elevation and depression of the R eye. prognosis?

Answer 85

good - recovery of right eye movement. this is a diabetic pupil sparing third nerve palsy whose pathophysiology is micro-infarction and whose prognosis is quite good (just like diabetic abducens palsy)

Question 86

48 yo F with secondary progressive MS stops all her medicines because of diarrhea. she had been taking paroxetine, tolterodine, interferon beta, modafinil, levothyroxine, and amantadine. she has continued taking baclofen. one week later she is irritable, anxious, and has labile affect and loose associations with vivid dreams. abrupt cessation of which med caused these symptoms?

Answer 86

paroxetine - ssri withdrawal syndrome. modafinil absence would make the patient sleepy. baclofen should not be d/c’d abruptly from doses in excess of 40 mg per day as seizures may ensue

Question 87

27 year old F comes to you with 3 month h/o HA and blurred vision. she takes no medications. menses are irregular and she has had a 40 lb weight gain in the past 6 months. blurred optic discs, remainder of exam is normal. CT showed small lateral ventricles. LP opening pressure 300. CSF normal studies. what is the diagnosis?

Answer 87

lateral venous sinus thrombosis. although story is also consistent with pseudotumor cerebri, it should be remembered that one of the causes of this problem is cerebral venous sinus thrombosis. next step is mrv. transverse sinus thrombosis contributes to intracranial hypertension via venous hypertension when the stenosis is bilateral and severe enough to compromise cerebral venous outflow.