Neurology - Part 1 of 2 Flashcards
Visual problem in pituitary tumor compressing optic chiasm (10x)
BITEMPORAL HEMIANOPSIA
Unsteady gait, appendicular ataxia in LE only and normal eye movement. Walks with lurching broad-based gait. (8x)
CEREBELLAR DEGENERATION (ALCOHOLIC)
Severe occipital HA, BL papilledema and no other abnormalities. Chronic acne treated with isotretinoin. Lumbar puncture elevated opening pressure with no cells, 62 mg/dl glucose, and 22mg/dl protein. CT is normal. (7x)
PSEUDOTUMOR CEREBRI
66 y/o c/o frequent falls, several-month hx of anxiety, unwillingness to leave home. On exam, mild impairment of vertical gaze on smooth pursuit/ saccades, mild axial rigidity & minimal rigidity of upper extremities, along w mild slowness of movement on finger tapping, hand opening & wrist opposition. Posture nml. Gait tentative/awkward, but w/o shuffling, ataxia, tremor. Pt is slow in arising from a chair. Most likely dx: (7x)
PROGRESSIVE SUPRANUCLEAR PALSY
79 y/o pt with a deteriorating mental state over a 3-week period has an exaggerated startle response with violent myoclonus that is elicited by turning on the room lights, speaking loudly, or touching the pt. Myoclonic jerks are also seen. Diagnosis: (5x)
SPONGIFORM ENCEPHALOPATHY
Pt presents with a slowly progressive gait disorder, followed by impairment of mental function, and sphincteric incontinence. No papilledema or headaches are reported. Likely diagnosis? (4x)
NORMAL PRESSURE HYDROCEPHALUS
65 y/o pt fell several times past 6 mos. MSE nml. Smooth pursuit, saccadic movements impaired. Worse w vertical gaze. Full ROM w doll head maneuver. Mild symmetric rigidity/bradykinesia, no tremor. MRI/CSF/labs unremarkable. Dx? (4x)
PROGRESSIVE SUPRANUCLEAR PALSY
28y/o with emotional lability and impulsivity. LFT’s elevated. Close relative had similar sx and died at 30y/o from hepatic failure. Which blood level would be diagnostic? (3x)
CERULOPLASMIN
Pt w/ acute onset of pain and decreased vision in the R eye. Colors look faded when viewed through the R eye. On exam, has a R afferent pupillary defect and a swollen right optic disc. Pt spontaneously recovers over the next 6 wks. Likely to develop later: (3x)
MULTIPLE SCLEROSIS
9 y/o F has 3 month h/o seemingly unprovoked bouts of laughter. Worse when not sleeping well. Pt does not feel happy during these episodes. Started menstruating 6 months ago, and at Tanner stage 4. Dx? (2x)
HYPOTHALAMIC HAMARTOMA
5 y/o with 4 month history of morning HA, vomiting, and recent problems with gait, falls, and diplopia: (2x)
MEDULLOBLASTOMA
70 y/o develops flaccid paralysis following severe water intoxication. He develops dysphagia and dysarthria without other cranial nerve involvement. Sensory exam is limited but grossly normal, DTR’s are symmetric, and cognition is intact. Likely dx: (2x)
CENTRAL PONTINE MYELINOLYSIS
Young adult gained 70 lbs in last year c/o daily severe headaches sometimes associated with graying out of vision. Papilledema present. CT and MRI brain no abnormalities but ventricles smaller than usual. Goal of treatment in this case: (2x)
PREVENT BLINDNESS
Superior homonymous quadrantic defects in the visual fields result from lesions to which of the following structures? (2x)
TEMPORAL OPTIC RADIATIONS
Tremor with a frequency of around 3 Hz, irregular amplitude, most evident towards the end of reaching movements: (2x)
CEREBELLAR TUMOR
Pt with several days of fever and severe headaches presents to ED b/o generalized seizure. Pt is confused and somnolent. Also reported to have been irritable and has c/o foul smells. T2 MRI displayed (hyperintensity of left temporal): (2x)
HERPES ENCEPHALITIS
Acute onset of fever, sore throat, diplopia, & dysarthria. Exam reveals an inflamed throat, left adductor nerve palsy w/ impairment of vertical pursuit, diffuse hyperreflexia w/ bilateral clonus, lower ext spasticity, & mild right hemiparesis. CT is uninformative. Spinal fluid has protein of 24, 10 mononuclear cells, and glucose of 70. Dx? (2x)
MULTIPLE SCLEROSIS
Which is the most reliable finding from CSF analysis for a pt with multiple sclerosis in the chronic progressive phase of the dz? (2x)
PRESENCE OF OLIGOCLONAL BANDS
Benign intracranial HTN etiology: (2x)
HYPERVITAMINOSIS A
Gait abnormality, slow movement, asymmetric UE rigidity. Difficulty in voluntary vertical upward/downward gaze. Slowness/rigidity improved slightly with levodopa. Later has problems with horizontal & vertical gaze. Oculocephalic reflexes normal. Involuntary saccades. (2x)
PROGRESSIVE SUPRANUCLEAR PALSY
Pt with several days of fever and severe headaches presents to ED b/o generalized seizure. Pt is confused and somnolent. Also reported to have been irritable and has c/o foul smells. T2 MRI displayed (hyperintensity of left temporal): (2x)
HERPES ENCEPHALITIS
Pt presents with personality changes, cognitive difficulties, affective lability, and olfactory and gustatory hallucinations. The most likely medical cause of this presentation is: (2x)
HERPES SIMPLEX VIRUS (HSV) INFECTION
What condition is a forerunner of MS? (2x)
TRANSVERSE MYELITIS
Head injury with personality changes, impulsivity and euphoria. Site of injury?
ORBITOFRONTAL CORTEX
What is the transmissible element that causes progressive decline and myoclonic jerks. Brain biopsy shows spongiform changes?
PRION
Kluver-Bucy syndrome: placisity, hyperorality, hypersexuality and hyperphagia, can be induced in animals with bilateral resection of which structure?
TEMPORAL LOBES
Most common psych complication from TBI
DEPRESSION
Executive dysfxn comes from damage to?
FRONTO-SUBCORTICAL
36 yo pt w/ double vision, vertigo, vomiting, paresis of medial rectus on lateral gaze w/ coarse nystagmus in abducting eye w/ lateral eye movement
MULTIPLE SCLEROSIS
35 yo pt w/ new onset headache, what suggests mass lesion w/ raised ICP?
PAPILLEDEMA ON EYE EXAM
Aphasia secondary to lesion in posterior third of left superior temporal gyrus
WERNICKE
57 y/o has new onset speech difficulty cannot name objects and sometimes cannot say “yes or no” and cannot repeat “no ifs, ands or buts” but can follow verbal and written commands. No problems with chewing/swallowing. What is the condition? (x2)
BROCA’S APHASIA
5 y/o presents w/ sudden onset of slurred speech and gait difficulty. Exam shows truncal ataxia and nystagmus, mild dysarthria and extensor plantar responses. Recent h/o measles. MRI, UA, blood work unremarkable. Dx?
ACUTE CEREBELLITIS
Abulia refers to impairment in ability to:
SPONTANEOUSLY MOVE AND SPEAK (inability to act decisively, absence of willpower)
Prosopagnosia is:
INABILITY TO RECOGNIZE FACES
Inability to recognize objects by touch:
ASTEREOGNOSIS
Which cancer has the highest likelihood of going to brain?
LUNG
Etiology of meningitis assoc with fever, HA, CSF pleocytosis with lymphocyte predominance, slightly elevated CSF protein, and normal CSF glucose
COXSACKIE VIRUS
Most common solid tumor of the CNS in kids
NEUROBLASTOMA
75 yo patient evaluated for progressive gait, urine incontinence, and cognitive decline. After removal of csf, there is improvement in gait and balance. What would CT show?
ENLARGEMENT OF THE FRONTAL HORNS
41 y/o chronic fatigue, cognitive impairment, reduced perceptual motor speed, poor effort maintenance, and irritability (MRI: hyperintensity in frontal lobe and what looks like a finger protrusion)
MULTIPLE SCLEROSIS
25 y/o pt c/o severe HA and vomiting. Pain is dull and mostly in occipital region. Exam: b/l severe papilledema, otherwise WNL. LP: opening pressure: 200mmH2O, no cells, 62mg/dl glucose, 31 mg/dl protein. CT: normal. Dx?
PSEUDOTUMOR CEREBRI
Histology consistent with Jakob-Creutzfeldt disease
CYTOSOLIC VACUOLATION OF NEURONS AND GLIA WITH PRION INCLUSIONS
Dx for 68yo c/o falls. PE shows upright rigid posture, stiff gait, extended knees, and pivoting while turning.
PROGRESSIVE SUPRANUCLEAR PALSY
Diagnosis of 32yo woman w/ vertigo and INO
MULTIPLE SCLEROSIS
A 66 yo complains of frequent falls. ON exam, the pt has difficulty with upward gaze, and has severe axial rigidity which is less apparent in upper or lower extremities. There is mild slowness of movement on finger tapping, hand opening and wrist opposition and the patient’s fingers acquire cramped pastures with the effort of the task. The pt’s neck posture is extended. Gait is somewhat slow, with short steps, and The pt is slow when arising from a chair. What is most likely diagnosis?
PROGRESSIVE SUPRANUCLEAR PALSY
70 y/o pt develops confusion, lethargy, and generalized tonic-clonic seizure. Lab reveals serum sodium of 95mEq/L. This is most likely a complication of excessively rapid correction of which metabolic problem?
CENTRAL PONTINE MYELINOLYSIS
Hippocampal atrophy has been identified in all of the following disorders:
MDD, ALZHEIMER’S DISEASE, PTSD. (NOT DISSOCIATIVE AMNESIA)
Severe occipital HA, BL papilledema and vomiting. Just started birth control pills. Lumbar puncture elevated opening pressure with no cells, 62 mg/dl glucose, and 31mg/dl protein, RBC 400. CT is normal.
SAGITTAL SINUS THROMBOSIS
Condition most likely to account for the presence of cognitive impairment in a pt with untreated Hep C (HCV) infection and normal ammonia level who is HIV sero- negative:
HCV INFECTION OF BRAIN
Delayed neurological deterioration following carbon monoxide-induced coma is most likely manifested by:
PARKINSONISM
Causative agent of progressive multifocal leukoencephalopathy (PML):
JC VIRUS
Location of characteristic lesions seen in CT scans of pt with carbon monoxide poisoning associated comas?
GLOBUS PALLIDUS
68 y/o pt is depressed following a hip surgery. Pt is withdrawn, looks blank, shows dysarthria, weakness, PMR, hyperreflexia, and has trouble swallowing. MRI of the head will show:
PERIVENTRICULAR WHITE MATTER DEMYELINATION
Adult LP with opening pressure 190, protein 110, glucose 27, leukocytes 5,000. Dx?
BACTERIAL MENINGITIS
75 y/o M, Korean war veteran, with gradual development of forgetfulness and cognitive deterioration, presents with very fast /slurred speech and impaired gait. A head CT shows some generalized atrophy, unusual for his age. The LP show 35 WBC, lymphocytosis and the protein level is 110mg/Dl and elevated gamma globulin. Dx:
NEUROSYPHILIS
Inability to carry out motor activites on verbal command despite intact comprehension & motor function indicates?
APRAXIA
80yo pt is unable to blow out match although motor and sensory function are normal. What is this called?
APRAXIA
Most common cause of aseptic meningitis:
ENTERIC VIRUS
25 y/o M w 7 months depression, forgetfulness, weight loss, insomnia, painful tingling in both feet+incoordination. Involuntary choreic movements of B/L UE, apathetic, monosyllabic. Labs normal. EEG: mild diffuse slowing. CT/MRI nml. During admission develops severe akinetic mutism, seizures, dies. Brain autopsy shows:
DIFFUSE AMYLOID PLAQUES, SPONGIFORM NEURONAL DEGENERATION, AND SEVERE ASTROGLIOSIS
52 y/o pt with EtOH dependence present with several days of severe headache, nausea, and low grade fever. Physical exam reveals mild disorientation, nuchal rigidity, and mild spasticity in the lower extremities. A head CT is unrevealing. LP: 55/mm3 leukocytes (mostly lymphocytes), 45 mg/dl glucose, protein: 43 mg/dl, and presence of occasional gram positive spherical cells. The most likely causative organism is:
CRYPTOCOCCUS NEOFORMANS
CT & MRI show ventriculomegaly are out of proportion to sulcal atrophy. This is suggestive of what diagnosis?
NORMAL PRESSURE HYDROCEPHALUS
49 y/o pt with ETOH dependence is brought to the ED with a one-week history of malaise, headache, diplopia, lethargy and confusion. On examination, the pt has a temp of 38.2 C, stiff neck, medical deviation of the right eye with impaired abduction and hoarseness. CSF: 114 leukocytes, predominantly monocytes, a protein of 132mg/dl, and glucose of 29mg/dl. Likely type of meningitis:
TUBERCULOUS
Closed TBI, initially no LOC, then 20 minutes later LOC. Patient recovers in 5 minutes.
VASOVAGAL SYNCOPAL ATTACK
15 y/o pt fell to the ground after being hit in the head while playing soccer. Pt did not lose consciousness, but was confused for following 20min.The next day, pt reported a headache and irritable, neuro exam normal. Best recommendation to family about pt:
SHOULD BE EXAMINED IN 2 WKS BEFORE RESUMING PLAY
In ER following MVA, receives IV dextrose 5%. Experiences confusion, oculomotor paralysis, and dysarthria:
WERNICKE’S ENCEPHALOPATHY
Which of following is invariably the first manifestation of neurosyphilis?
MENINGITIS
14 y/o @ summer camp develops severe headache and fever, drowsiness, stiffness of neck on passive forward flexion, petechial rash and skin pallor. Spinal tap reveals opening pressure 200mm H20, 84%neutrophils (7,000 nucleated cells), glucose level of 128mg/dl, and protein level of 33mg/dl. Most likely causative agent?
MENINGOCOCCUS
Which hormone is secreted in functional pituitary adenoma:
PROLACTIN
Primary characteristic of Wernicke encephalopathy
ACUTE ONSET
52 y/o M presents with a chief complaint of gait difficulties. On exam: mild dysarthria, very mild finger to nose ataxia and minimal heel to shin ataxia. Romberg test: negative, but very unsteady while walking and walks with a broad-based, lurching gait. The plantar reflexes are flexor. Imaging studies are most likely to demonstrate:
CEREBELLAR VERMIS ATROPHY
75 y/o WWII veteran w/ gradual onset forgetfulness, intellectual deterioration, fast/slurred speech, gait impaired, CT with normal atrophy. LP: 35WBCs (most lymph), protein 110, increased gamma globulin. Dx?
NEUROSYPHILIS
41 y/o pt w/o family h/o corticocerebellar degeneration presents with 3-month h/o ataxia of gait/limbs, dysarthria, and progressive nystagmus. MRI and CSF normal. 1) Antibody panel with presence of? 2) What type of tumor is likely present?
1) ANTI-YO 2) OVARIAN CARCINOMA
MRI finding for woman with memory decline, urinary incontinence, and trouble walking
DILATION OF VENTRICLES
Effortful, nonfluent speech with decreased speech output; where is the lesion?
ANTERIOR FRONTAL GYRUS
A 50 yo BIB ED for SA by being in a closed garage with the cars running for several hours. CT brain 2 weeks later would show
LESION IN GLOBUS PALLIDUS
Which of the following tests is recommended by the American Academy of Neurology to establish the diagnosis of brain death?
APNEA TEST
Essential criterion for declaration of brain death prior to organ donation requires?
A POSITIVE APNEA TEST
43 y/o newly AIDS pt has increasing social withdrawal and irritability over several weeks. Can’t remember phone number, unable to do chores, appears distracted. Mild right hemiparesis, left limb ataxia, and bilateral visual field defects. LP: normal cell counts, protein, and glucose. T2 Scan is shown. What is the diagnosis:
PROGRESSIVE MULTIFOCAL LEUKOENCEPHALITIS
Risk factor for depression in MS patients
LESION VOLUME
Right handed pt recently underwent neurosurgery is now unable to name objects in left hand when blind folded. He was able to name them when displayed on a screen. Where was the surgery?
CORPUS CALLOSUM
Bilateral paresis of medial rectus muscle during lateral gaze with course nystagmus in abducting eye characteristic of:
MULTIPLE SCLEROSIS
82 year old with progressive dementia, myoclonus over 3 months. EEG shows periodic sharp waves with 1hz over both hemispheres. Dx?
CREUTZFELDT–JAKOB DISEASE
62 y/o M w/ DM is not making sense, saying “thar szing is phrumper zu stalking”. Normal intonation but no one in the family can understand it. He verbally responds to Qs w similar utterances but fails to successfully execute any instruction. (8x)
WERNICKE’S APHASIA
Chronic A-fib develops aphasia and R hemiparesis at noon. ER exam notes weakness of R extremities and severe dysfluent aphasia, but CT at 1:30 PM has no acute lesion. Most appropriate treatment: (4x)
TPA
Head CT w/ lens-shaped hyperdensity (x2)
EPIDURAL HEMATOMA
A life threatening complication of cerebellar hemorrhage is: (2x)
ACUTE HYDROCEPHALUS
A 72 yo patient had an embolic infarct in the middle cerebral artery territory. ECG shows no structural abnormalities. Doppler studies of the neck arteries reveal less than 50% occlusion on both carotid arteries. An EKG reveals AFib. Which of the following strategies has the best likelihood of reducing recurrent strokes in this patient? (2x)
ANTICOAGULATION WITH WARFARIN
68 y/o pt w/ hypertension develops rapidly progressing right arm and leg weakness, with deviation of the eyes to the left. Within 30 minutes of the onset of this deficit, pt became increasingly sleepy. Two hours after the onset, the patient became unresponsive. On exam: dense right hemiplegia, eyes deviated to the left, pupils: equal and reactive, a right facial weakness to grimace elicited by noxious stimuli. Cough and gag reflexes: present. Which CT finding is most likely? (2x)
LEFT PUTAMINAL HEMORRHAGE
A pt has multiple stroke like symptoms of short duration over several days. And has new onset symptoms for the last 90 minutes. CT scan shows no evidence of stroke or hemorrhage. What is the appropriate treatment? (2x)
INTRAVENOUS THROMBOLYTIC AGENTS
70 y/o pt was hospitalized because of a middle cerebral artery stroke. The psychiatrist was asked to evaluate the pt. The pt has non-fluent aphasia. Which most likely characterized the pt’s interaction with the psychiatrist? (2x)
THE PT WAS ABLE TO FOLLOW THE VERBAL REQUEST, “CLOSE YOUR EYES.”
Most common psychiatric presentation following a stroke? (2x)
DEPRESSION
Chiropractic adjustments are a known precipitant for which of the following acute conditions? (2x)
VERTEBRAL ARTERY DISSECTION
The most common complication of temporal arteritis is caused by occlusion of the: (2x)
OPHTHALMIC ARTERY
The most common possible cause of a posterior cerebral artery infarct in 36 y/o F with hx of migraine: (2x)
ORAL CONTRACEPTIVES
45 y/o with R hemiparesis, CT shows L internal capsule ischemic changes extending to adjacent basal ganglia + old lacunar injury of R caudate head. LP – 65 wbcs (mostly lymphocytes), 78 protein, 63 glucose, + reagin antibodies. Tx?
PCN
CT Head Large hypodensity on R frontal and parietal lobes
MCA STROKE W/ RESIDUAL L SIDED WEAKNESS
Contralateral leg weakness with personality changes is an injury where
ANTERIOR CEREBRAL
61 y/o with left frontal lobe damage secondary to cerebrovascular accident may be predisposed to which psychiatric syndrome?
MDD
72 y/o pt had a lacunar infarct in the middle cerebral artery territory. Echo is normal. Doppler studies of neck arteries reveal less than 50% occlusion on both carotid arteries. EKG is normal. The best strategies to reduce recurrent stroke:
ANTIPLATELET THERAPY WITH ASPIRIN AND DIPYRIDAMOLE
50 y/o pt recently began having VH of children playing. VH are fully formed, colorful and vivid, but with no sound. Pt is not scared or disturbed, but rather amused. On exam, normal language, memory, cranial nerves, no weakness or involuntary movement, no sensory deficits. DTR: symmetric. CSF/UDS nml.
POSTERIOR CEREBRAL ARTERY ISCHEMIA
Why would brains >65 years old or a history of alcoholism more susceptible to chronic subdural hematoma?
CORTICAL ATROPHY (LONGER DISTANCE FOR BRIDGING VEINS TO BE DAMAGED)
What is the most common manifestation of acute neurosyphilis?
STROKE
65 y/o pt wakes up with right-sided hemiparesis and motor aphasia. Pt is immediately brought to the emergency department and an evaluation is completed within 1 hour. Neurological exam: no additional abnormalities. Head CT w/o contrast: no additional abnormalities. Which is the appropriate next step in management?
ASPIRIN
Abnormal elevated metabolic findings associated with increased risk of stroke in patients under 50
PLASMA HOMOCYSTEINE
Acute onset of dense sensorimotor deficit in the contralateral face and arm, with milder involvement of the lower extremity, associated with gaze deviation toward the opposite side of the deficit, likely indicates occlusion of:
SUPERIOR DIVISION OF THE MCA
CT scan with occipital and intraventricular hyper-intensities:
PARENCHYMAL HEMORRHAGE
Which med has secondary prevention against embolic stroke in pts with A-fib?
ORAL WARFARIN
As opposed to strokes caused by arterial embolism or thrombosis, those caused by cerebral vein or venous sinus thrombosis are:
ASSOCIATED WITH SEIZURES AT ONSET
Pt who 5 days ago experienced a ruptured aneurysm located in the left middle cerebral artery develops a fluctuating aphasia and hemiparesis with no significant headaches. Underlying event:
VASOSPASM
63 y/o with new onset aphasia and R hemiparesis, 2 days ago had milder/similar symptoms that resolved in 30 minutes, yesterday had similar episode x 45 minutes. Current Sx started 1.5 hrs ago. CT shows no stroke or hemorrhage. Tx?
INTRAVENOUS THROMBOLYTIC AGENTS
57 y/o diabetic pt =w/ HTN c/o several episodes of visual loss, “curtain falling” over his L eye, transient speech and language disturbance, and mild R hemiparesis that lasted 2 hrs. Suggests presence of what?
EXTRACRANIAL LEFT INTERNAL CAROTID STENOSIS
Head injury, LOC -> lucid interval x hours -> rapid progressing coma. Hemorrhage?
EPIDURAL
Poststroke depression in 80 yo pt (R handed) is assoc w cognitive impairments that:
CORRELATE WITH LEFT HEMISPHERIC INVOLVEMENT
66 y/o M in ED w/ sudden occipital HA, dizziness, vertigo, N/V, unable to stand, mild lethargy, slurred speech. Exam: small reactive pupils, gaze deviated to the R, nystagmus, w/ occasional ocular bobbing, R facial weakness, decreased R corneal reflex, truncal ataxia, b/l hyperreflexia, b/l Babinski. Dx?
CEREBELLAR HEMORRHAGE
50 y/o pt is in the ED for acute onset of neck pain radiating down the left arm, progressive gait difficulty, and urinary incontinence. This test should be administered immediately:
MRI SCAN OF THE CERVICAL SPINE TO EXCLUDE A DIAGNOSIS OF SPINAL CORD COMPRESSION.
In managing acute ischemic stroke, administer this within 48 hrs of onset of stroke for beneficial effect in reducing risk of recurrent stroke, disability and death:
ASPIRIN
70 y/o pt w/ attacks of “whirling sensations” w/n/v, diplopia, dysarthria, tingling of lips. Occurs several times daily for 1 minute, severe that pt collapses and is immobilized when symptoms start. No residual s/s, no tinnitus, hearing impairment, ALOC or association with any particular activity. Dx?
VERTEBROBASILAR INSUFFICIENCY
Vascular lesion most characteristic of sudden severe headache, vomiting, collapse, relative preservation of consciousness, few or no lateralizing neurological signs, and neck stiffness:
SUBARACHNOID HEMORRHAGE
Head CT demonstrates which dx (grainy picture with diffuse speckling in posterior region, unilateral)
SUBARACHNOID HEMORRHAGE
Mental status changes after CABG, fluent speech and excellent comprehension, inability to name fingers and body parts, right and left orientation errors inability to write down thoughts and calculation, but with good reading comprehension:
AN EMBOLIC STROKE AFFECTING LEFT ANGULAR GYRUS
70 y/o F sudden onset paralysis R foot and leg. R arm and hand slightly affected. No aphasia or visual field deficit. Over weeks found with loss of bladder control, abulia and lack of spontaneity. Which vascular area:
ANTERIOR CEREBRAL ARTERY (LEFT)
Pts in a locked in state following basilar artery occlusion typically retain what movement?
EYELIDS AND VERTICAL GAZE
83 yo pt with mild HTN comes in with new onset headache and left hemiparesis. MRI shows right parietal lobe hemorrhage, small occipital hemorrhage and evidence of previous hemorrhage in right temporal and left parietal regions. What is likely etiology for these findings?
AMYLOID ANGIOPATHY
39 y/o pt with hx of multiple miscarriages develops an acute left sided hemiparesis. Work up reveals elevated anticardiolipin titers and no other risk factors for stroke. Appropriate intervention at this point is?
PLASMAPHERESIS
In which arterial area would a stroke resolve in inability to read but preserved ability to write?
POSTERIOR CEREBRAL
71yo pt w/ Parkinson’s x3yrs p/w difficulties getting up, is not motivated to do anything, has no interest in social events, and has “slowness” in thinking; although motor sx well controlled on Sinemet, sx stable throughout day and no sadness, worthlessness, or SI. Cognitive eval shows slow processing. What is most likely explanation?
APATHY
65 y/o M with 6 mo h/o confusion episodes, disorientation, VHs of children playing in his room. Hallucinated images are fully formed, colorful, vivid and pt has little insight into their nature. No AH. Wife says he is normal between episodes. Exam: Normal language, memory, mod diff with trails test, mild diff with serial subtractions, mild symmetric rigidity and bradykinesia. Brain MRI unremarkable. CSF, routine labs and UDS normal. Diagnosis: (7x)
LEWY BODY DEMENTIA
When combined with functional neuroimaging, which of the following biomarkers is most likely to identify those geriatric pts with mild cognitive impairment most at risk for developing Alzheimer’s disease? (7x)
E-4 APOLIPOPROTEIN E ALLELE
80 y/o with VH and worsening gait, episodic confusion, disturbed sleep, fighting in sleep, bilateral rigidity, masked facies. Levodopa/carbidopa improved movement temporarily. Diagnosis? (4x)
DEMENTIA WITH LEWY BODIES
80 y/o pt with Alzheimer’s is brought in for increasingly combative behavior. Daughter would like to keep the pt at home if possible. What interventions would be most helpful in this situation? (3x)
ASSESSING FOR CAREGIVER BURNOUT
91 y/o hospice pt w/ cachexia, end stage dementia, and renal impairment has stopped eating and drinking. What comfort measure would be most appropriate? (3x)
FREQUENT SMALL SIPS OF WATER
Which of the following is the most specific factor for distinguishing delirium from dementia of the Alzheimer type? (2x)
FLUCTUATING AROUSAL
Neurocognitive functions most likely to show decline in people over 65 years of age? (x2)
INFORMATION PROCESSING SPEED
Over the course of several months, a 46 yo pt w no past psych hx becomes emotionally labile/irritable. Pt undergoes personality changes, is observed to laugh inappropriately when neighbor kids taunt stray cat. Within 2 yrs pt is convinced all food has germs. Memory is preserved. Pt is no longer able to work/live independently. Neuropsych testing shows impaired language/attn. (2x)
FRONTOTEMPORAL DEMENTIA
Excess activation of which receptor contributes to cell death in Alzheimer dx?
NMDA
Test that differentiates Alzheimer’s from frontal-temporal dementia
SINGLE PHOTON EMISSION CT SCAN
Neurocog d/o with fluctuating rate of progression, visual spatial impairment and early unilateral resting tremor and increased muscle tone.
DEMENTIA WITH LEWY BODIES
Confabulation is:
UNCONSCIOUS FILLING IN OF MEMORY GAPS
What test is most helpful to distinguish dementia vs delirium
EEG
Suggests delirium rather than dementia:
CLOUDING OF CONSCIOUSNESS
85 yo patient with hx of dementia admitted for agitation becomes more confused and angry. What lab should you get?
UA
Picture of tau staining for pt with progressive dementia. Dx?
ALZHEIMER’S
80yo p/w insidious forgetfulness f/b progressive language impairment 2yr later with difficulty using common tools/appliances. Dx?
ALZHEIMER’S DISEASE
Which cancer treatment may be followed by a subcortical dementia due to a leukoencephalopathy with onset after 6 months post-treatment?
WHOLE BRAIN RADIATION
A pt who has been receiving dialysis tx for years has become more disoriented, has memory loss. Physical exam normal, nursing staff report that pt has begun to have seizures. Blood lab testing shows no obvious etiology, neurodiagnostics show no suggestive findings. What most likely accounts for this presentation?
DIALYSIS DEMENTIA
FTD with mutation in chromosome 17 is assoc with abnormal intraneuronal deposition of which protein?
TAU
A doc meets with a pt and family to discuss treatment of pt’s mild Alzheimer’s disease. There are no other neurological or psychiatric symptoms or findings. The most appropriate course of action would be to:
BEGIN CHOLINESTERASE INHIBITOR TREATMENT
74 y/o, right-handed patient presents with significant memory loss, expressive aphasia, and left plantar extensor response. The most likely diagnosis is:
VASCULAR DEMENTIA
Earliest evidence of cell loss in pts with Alzheimer’s Dz typically occurs in which of the following areas of the brain?
ENTORHINAL CORTEX
74 y/o F suspicious, poor ADLs, personality changes, most likely dx:
PICK’S DISEASE
Protein mutation associated with Alzheimer disease in people younger than 60 yo
AMYLOID PRECURSOR
80 y/o pt w/ no prior psych hx, more forgetful, having difficulty with ADLs. However, pt is able to conduct routine social activities so that casual acquaintances don’t notice abnormalities. What is the dx?
ALZHEIMER DEMENTIA
Neurofibrillary tangles in Alzheimer’s are composed of:
HYPERPHOSPHORYLATED TAU PROTEINS
80 y/o Alzheimer’s with increasingly combative behavior. Family wants to keep at home. Give what medication?
HALDOL
Dementia characterized by personality change, attention deficit, impulsivity, affect lability, indifference, perseveration, and loss of executive function. Assoc. with dysfunction in what area of the brain?
FRONTAL LOBE
Early stage HIV type I associated dementia as compared to early onset dementia has which of the following deficits?
DECREASED PROCESSING SPEED
Which meds have best results for treating agitation in dementia?
ANTIPSYCHOTICS
Amyloid precursor protein in what cognitive disorder?
ALZHEIMER’S DZ
Most common cause of dementia in pts > 65 yrs of age:
ALZHEIMER’S DZ
Characteristic MRI scan finding in Alzheimer disease:
REDUCED HIPPOCAMPAL VOLUMES.
Known risk factors for dementia:
AGE, FAM HX, FEMALE, DOWN’S SYNDROME
Pt with vascular dementia typically has neuropathological changes assoc with:
BASAL GANGLIA
An 82-yo pt has falls, ophthalmoplegia, parkinsonism and progressive dementia. Autopsy shows:
TAU POSITIVE NEUROFIBRILLARY TANGLES
65 y/o is brought to the ED with disorientation and mild agitation, and is experiencing vivid VH of several children playing inside the house. Two similar episodes in the past, normal in between episodes. Normal language and memory, normal CN, mild symmetric rigidity and bradykinesia, no deficits. MRI, drug screen, CSF normal:
DEMENTIA WITH LEWY BODIES
A med that is most likely to slow the progression of vascular dementia:
ASPIRIN
Best rationale for using cholinesterase inhibitors in pts with Alzheimer:
TO REDUCE NEUROPSYCH SYMPTOMS
The most important tool for evaluation of early and moderate dementia:
MMSE
Dementia rather than depression in regards to memory has…
NAMING DEFICITS (RATHER THAN IMPAIRED NONVERBAL INTELLIGENCE)
Bilat loss of neurons in the CA1 segment of the hippocampus is the most common histologic finding in patients with:
ALZHEIMER DEMENTIA
Patient is Alzheimer’s dementia in clinic. Patient’s daughter is frustrated with having to care for her mother more and is considering removing her from her church group because of it. What is the most initial response by the psychiatrist?
TELL HER TO CONTINUE GOING TO HER CHURCH GROUP
PET scan shows bitemporoparietal hypoperfusion in early stages of which dementia?
ALZHEIMERS
65 y/o pt brought in by family for gradual onset and very slow progression of mental confusion with respect to place and time, anomia, slowness of comprehension, neglect of personal hygiene and grooming, apathy, and alterations of personality and behavior, impairment of gait and upright stance, and prominent grasp and suck reflexes. Dx? The clock drawing test is a quickly administered and sensitive screen for:
FRONTOTEMPORAL DEMENTIA OR ALZHEIMER DEMENTIA
65 y/o high school grad has a MMSE score of 23, this score would suggest which of the following:
DEMENTIA, MILD COGNITIVE IMPAIRMENT
Individuals over 40yo with Down’s syndrome frequently develop:
ALZHEIMER’S DZ
HIV+ pt w/ memory loss, inattention, lack of motivation, & poor coordination. Normal LP. CT scan shows atrophy. MRI shows diffuse & confluent white matter changes in T2, w/o any mass effect or gadolinium enhancement. Dx?
HIV- ASSOCIATED DEMENTIA
Binswanger disease has pseudobulbar state, gait disorder, AND:
DEMENTIA
Clock drawing test is quickly administered and sensitive screen for which d/o?
ALZHEIMER’S DZ
Brain of football player who died by suicide has findings typical of chronic traumatic encephalopathy, what is most typical pathology for this behavior?
TAUPATHY
54yr old pt dies from rapidly progressing dementia associated with myoclonus, what is most likely finding at autopsy?
MICROVACUOLATION OF GLIA AND NEURONAL DENDRITES
Psych eval of 82 y/o F with memory loss (mostly working memory): she frequently calls for help with bathroom but will urinate on herself (staff feel pt is doing this to get back at them). Pt frustrated with staff because she feels the sudden need to void without much warning and wishes the staff would arrive sooner because she’s embarrassed about this. MSE significant only for mod memory loss, labs are normal. Which behavioral intervention should be attempted with pt?
SCHEDULE REGULAR VOIDING, INDEPENDENT OF PT REQUESTS, AND SUFFICIENTLY FREQUENT TO ELIMINATE THE ACCIDENTS
Which is important when working w/ family members who are caregivers to pts w/dementia? • There needs only be one caregiver at a time • Grief work w/fam not necessary before pt. dies • All fam to equally share caregiving responsibility • Work w/fam should enhance effectiveness of care to pt. • Fam should explore SNF options as soon as pt is diagnosed
WORK W/ FAMILY SHOULD ENHANCE EFFECTIVENESS OF CARE TO PT
What characterizes executive abilities in healthy individuals >65?
SHOW NO SIGNIFICANT CHANGE
Fluent speech w preserved comprehension, inability to repeat statements is consistent with what type of aphasia?
CONDUCTION
In normal aging, last cognitive abilities to decline
WORD KNOWLEDGE
Medicare pays for hospice care when a physician declares that a patient has a maximum life expectancy of how long?
6 MONTHS
Two days after bowel surgery, 53 y/o is delirious. Correctly draws a square when asked, but then continues to draw squares when asked to draw other shapes. MSE would reveal:
PERSEVERATION
Cancer patient on chemo is disoriented and agitated. Afebrile VSS. Neg neuro exam. Poor attention, cog impairment. Held for observation. CT neg, EEG diffuse slowing. Treat with:
HALDOL
78 y/o pt with Alzheimer’s dementia living with spouse and daughter, starting to accuse the spouse of infidelity. On evaluation, he asserts that the spouse is unfaithful. He is alert and acts congenially with the spouse, he is on donepezil. Labs and medical workup is unrevealing of any disorder outside of dementia. Next?
ARRANGE FOR REGULAR EVALUATIONS OF THE PT AND REASSURE THE FAMILY.
Family of 75 y/o pt is concerned about his safety b/c he has been forgetting to turn off stove. Psych MD suspects an evolving cognitive d/o. What is most likely to be the earliest impairment to occur in the pt?
INABILITY TO RECALL 3 WORDS AFTER A 3 MIN DELAY
85 y/o nursing home pt w/ hx of dementia being more confused and screaming “fire” whenever the light next to the bed is turned on. Next step?
URINALYSIS
Epigenetic drift has been postulated to contribute to what disorder?
LATE ONSET ALZHEIMER’S DISEASE
35 y/o M awakens frequently middle of night with severe HAs, which sometimes occurs nightly and lasts approx 1-2 hrs, so severe that pt is afraid to go to sleep, located around L eye and assoc with lacrimation, ptosis, & miosis. Likely dx is: (12x)
CLUSTER HEADACHES
Abortive treatment of common migraines is best achieved w/ which medication? (8x)
RIZATRIPTAN
Young pt with new onset severe HAs associated with periods of visual obscuration. Neuro exam is normal except for papilledema. MRI: normal and shows no mass effect. Next test? (7x)
LUMBAR PUNCTURE TO MEASURE PRESSURE
Which of the following is characteristic of post lumbar puncture HA? (4x)
HA WORSE W/ SITTING UPRIGHT
35 y/o reports episodes of flashing lights traveling slowly from L to R in the left visual field, symptoms persisting for about 30 minutes, followed by difficulty expressing self and concentrating. After about 30 minutes, these neurologic symptoms seem to subside, and pt develops a pounding headache associated with nausea. Both physical exam and MRI are normal. (3x)
MIGRAINE WITH AURA
25 y/o has HA and vomiting. Pain is dull and in occipital region, worse when lying down. +severe papilledema b/l. LP shows opening pressure of 80 w/ normal CSF chemistry, and 120 RBC’s in last tube. D-dimer, FDP in blood are elevated. CT normal. (3x)
SAGITTAL SINUS THROMBOSIS
24 yo m with nocturnal HA resulting in early am waking. ROS +rhinorrhea, nostril blocking and ipsilateral eye tearing and facial swelling. HA persists 45-60 min. Likely dx: (2x)
CLUSTER HA
30 y/o with intermittent HAs, each attack lasting approx 1 hour. Attacks w/ sharp, stabbing pain around eye, tearing, and nasal congestion. Most effective abortive treatment? (2x)
OXYGEN
The effective treatment for acute migraine: (2x)
SUMATRIPTAN
28 y/o F reports episodes of severe HAs w nausea/vomiting. HAs can be incapacitating, often preceded by flashes of light in the right visual field. During headache, pt sometimes has difficulty expressing herself. Which med would be the appropriate to prevent these episodes? (2x)
TOPIRAMATE
26-year-old obese pt presents to ER with severe headache. Pt is otherwise healthy and does not take any meds. Head CT and brain MRI are unrevealing. The only finding on exam is shown in the fundoscopic images below (blurred optic disk). What is diagnosis? (x2)
IDIOPATHIC INTRACRANIAL HYPERTENSION
35 yo with hx of migraines has daily migraines for past 3 months no longer responding to sumatriptan which she now takes daily. Hx of MDD but reports okay mood. Normal physical exam. Preferred initial approach.
DISCONTINUE SUMATRIPTAN
Triptan drugs should not be given in abortive treatment of migraine in pts with:
CAD
25 y/o w/ VH – similar to the wavy distortions produced by heat rising from asphalt – affecting the whole of both visual fields, + vertigo, dysarthria, tingling in both hands and feet and around both sides of mouth followed by occipital headache. Most likely dx:
BASILAR MIGRAINE
76 y/o pt complains of bilateral, severe, persistent headache w/ loss of vision and scalp tenderness, and stiffness of proximal musculature. Sedimentation rate: 96mm/hr. Which diagnostic procedure:
BIOPSY
26 y/o F w/ 3-day hx of severe continuous non-throbbing headache, has not improved on NSAID, has mild bilateral papilledema. A head CT w and w/o contrast is shown.
SAGITTAL SINUS THROMBOSIS
Pt c/o severe dull and constant headache not associated with N&V. +vision loss in left eye. +pain and stiffness of limbs. MRI shows periventricular white matter hyperintensities on T2. Elevated sed rate. Next step?
HIGH DOSE PREDNISONE
35 pt is evaluated for headache syndrome characterized by paroxysms of sharp pain around the eyes and side of the head lasting 5 min and happening 10x/day. Headaches are accompanied by rhinorrhea and conjunctival erythema. Which med is most likely to give relief?
PROPRANOLOL
Pt recovering from surgery of an intracranial hemorrhage 2/2 arterial aneurysm, develops a sudden onset of headache, vomiting and progressive decline of consciousness. Pupils are miotic, and abducens muscles are weak bilaterally. Etiology:
ACUTE HYDROCEPHALUS
68yo with dull R-sided non-throbbing HA’s worse at night and with prolonged chewing. Best initial tx?
PREDNISONE
Young adult w/ headache behind left ear. 2 days later twisting of face. Impaired taste sensation. Paralysis of forehead, lower face on left, incomplete closure of left eye w/ blinking. No sensory deficit or other cranial nerve deficit. MRI shows:
GADOLINIUM ENHANCEMENT OF LEFT FACIAL NERVE
35 y/o w daily headaches over last several weeks lasting an hour. Sharp, severe, boring pain into right eye. Another element of this headache?
OCCURS DURING REM
25 y/o pt with severe headache, visual loss, vomiting, bilateral babinski, and then becomes drowsy:
EPENDYMOMA OF THE FOURTH VENTRICLE
32 yo has a new onset headache with unilateral stabbing eye pain, also experiences runny nose and conjunctival injection on same side as headache occurring every evening after falling asleep and last 2 hours. Diagnosis?
CLUSTER HA
71 year old patient with thunderclap headache, unilateral eye pain, blurred vision, dilated pupils, conjunctival injection. Which dx test is best to reveal cause of patient’s headache
INTRAOCULAR PRESSURE MEASUREMENT
Role of the hippocampus and parahippocampal gyrus? (4x)
DECLARATIVE MEMORY (FACTS)
On the way to airport for vacation, 58 yo F begins to behave in very strange way. Husband notices when he talks to her she answers appropriately w fluent speech but seems to have no ability to retain any new information. She repeatedly asks where they are going, even after he has told her many times. The episode lasts for about 6 hours. The following day she is back to normal but has no recollection of the prior day events. This episode is most consist with a diagnosis of: (3x)
TRANSIENT GLOBAL AMNESIA
Characteristic of alcohol-induced blackouts (2x)
ANTEROGRADE AMNESIA FOR A TIME WHILE HEAVILY INTOXICATED BUT AWAKE
What characterizes the memory loss in patients with dissociative amnesia? (2x)
EPISODIC
Example of declarative memory (2x)
RETENTION AND RECALL OF FACTS
Pt with hx of herpes simplex and seizure d/o undergoing EEG monitoring that recorded no epileptic activity during, after and before a confused state wherein pt suddenly awoke frightened. The next day pt with baseline demeanor has no memory about that episode. (2x)
AMNESTIC DISORDER
61y/o pt presents to ED with family who report that the pt unable to remember recent events. Memory problems started 2 hours prior; cognitively intact before episode. Pt is alert, anxious, frustrated: “Why am I in the hospital?” Dx: (2x)
TRANSIENT GLOBAL AMNESIA
A 72 year old develops sudden onset memory loss. She didn’t know how she and spouse arrived at supermarket. The spouse noted that she could drive without issues but appeared anxious. The patient was able to appropriately answer questions but forgot the conversation and then returned to baseline. What is the most likely diagnosis?
TRANSIENT GLOBAL AMNESIA
A surgeon unable to describe anatomical parts involved in one of his common surgeries is experiencing what type of memory impairment?
SEMANTIC
Injury of bilateral parahippocampal cortex and hippocampal formation results in what
AMNESIA
55 year old brought to ED disheveled and behaving strange, stares blankly and is mute. Doesn’t know who they are and all studies are negative. Has vague memory of “walking away from something horrible”. Dx?
DISSOCIATIVE AMNESIA
A 40-year-old pt is hospitalized for eval of fever, weight loss and ataxia. Psychiatric consultation is requested as the patient seems depressed, and a family member reports that the pt has been exhibiting progressive memory loss over the last several months. Which of the following lab tests may help explain the patient’s presentation?
HIV
2 months after severe brain injury, pt opens the eyes for prolonged periods but remains inattentive, does not speak, and shows no signs of awareness of the environment or inner need. Pt is capable of some rudimentary behaviors such as following a simple command, gesturing, or producing single words or brief phrases, always in an inconsistent way from one exam to another. Which of the following is the most accurate description of the pt’s condition?
MINIMALLY CONSCIOUS STATE
Memory loss pattern in dissociative amnesia
OCCURS FOR A DISCRETE PERIOD OF TIME
Amnesia characterized by loss of memory of events, occurs after onset of etiologic condition or agent
ANTEROGRADE
What psychoactive drug produces amnesia?
ALCOHOL
55 y/o pt BIB family after episode of amnesia/bewilderment lasting several hrs. CVA ruled out. Pt keeps asking what is happening. What med to administer at this point?
OBSERVATION WITH NO PHARMACOLOGICAL INTERVENTION
Which of the following diagnoses involves a sense of loss of identity, often following a traumatic experience and associated with inability to recall one’s past?
DISSOCIATIVE FUGUE
65yo pt lives alone, increasingly forgetful over the past year, lifelong difficulty recalling names of acquaintances, now has difficulty with phone calls and remembering appts. lives independently, drives, prepares meals, MSE with delayed recall of 4 words, otherwise normal. Pt upset by difficulty and is not depressed. symptoms most consistent with…?
AMNESTIC MILD COGNITIVE IMPAIRMENT
45 y/o with nystagmus and ataxia, short term memory loss and believes wife is possessed by demons. Most appropriate treatment?
THIAMINE
A conscious memory that covers for another memory that is too painful to hold in the consciousness is:
SCREEN MEMORY
In pts with pronounced defects in recent memory, remote memory is:
OFTEN DEFICIENT ON CLOSE EXAMINATION EVEN WHEN IT SEEMS WELL PRESERVED
“My father was very involved in my life. I remember going to football games in the snow with him” is an example of memory associated with what part of the brain?
MEDIAL TEMPORAL LOBE
Working memory requires prefrontal cortex, dorsal thalamus and what other area of the brain to function?
HIPPOCAMPUS
Asking a pt what the pt ate for breakfast yesterday tests:
RECENT MEMORY
Question to evaluate immediate recall?
CAN YOU REPEAT THESE SIX NUMBERS?
Asking pt to remember 3 things and repeat them in a few minutes is testing:
SHORT-TERM MEMORY
34 y/o pt w/ hx of memory impairment dies of unknown cause for autopsy. Pathological exam: diffuse and multifocal rarefaction of cerebral white matter accompanied by scanty perivascular infiltrates of lymphocytes and clusters of a few foamy macrophages, microglial nodules, and multinucleated giant cells. Most likely Dx:
HIV-ASSOCIATED DEMENTIA
Pt brought to ed by family because of concern for pts ability to recognize them since TBI one month ago. Pt had LOC after trauma. Tenderness and swelling over L temporal area. Neuro exam normal. Pt knows own name, but unable to identify family members or events related to family. What is diagnosis?
DISSOCIATIVE AMNESIA
Which test correlates most strongly with pre-morbid functioning in pt w/ early dementia:
WECHSLER ADULT INTELLIGENCE SCALE IV VOCABULARY TEST (WAIS-IV)
Neuropsychological test most useful in the early diagnosis of Alzheimer disease:
10-ITEM WORD LIST LEARNING TASK.
Disorder with degeneration of mammillary bodies and dorsal nucleus of thalamus
WERNICKE-KORSAKOFF SYNDROME
54 y/o pt has several days of low grade fever, malaise and severe pain in the right side of the ribcage. Examination reveals an erythematous rash with clusters of tense vesicles, with clear content, on a belt distribution from the front of the chest to the back under the nipple, limited to the right side. Likely causal viral agent? (4x)
VARICELLA ZOSTER VIRUS
17 y/o pt has an insidious onset of unusual behavior and argumentativeness. Exam, the mouth is held slightly open. Pt has mild dysarthria and hoarseness, generalized slowness, rigidity, and a mild resting tremor of the left arm and head. rule out drug and/or alcohol abuse. Liver function tests show elevated transaminases. An increase in which laboratory test is most likely to confirm Dx? (4x)
URINARY COPPER EXCRETION
45 y/o M, with recurrent episodes of LOC while wearing a shirt with a tight collar, has feeling of faintness accompanied by pallor, followed by collapse and LOC, and several seconds later by a few bilateral jerks of the arms and legs. Entire episode lasted less than one minute. Most likely explanation? (2x)
CAROTID SINUS SYNCOPE
Decreases in men during andropause
PENILE RIGIDITY
Normal changes with motor fxn in aging?
STOOPED POSTURE AND SLOWED WALKING
55 yo diplopia when looking right, drooping of left eyelid, and drooping L eye, symptoms better in the morning
MYASTHENIA GRAVIS
19 y/o F has bouts of motor agitation, often followed by intense, seemingly meaningless writing; also mood lability, tactile & olfactory hallucinations. During the interview, patient abruptly stops paying attention and begins rapidly pacing around the room. What should be the next step?
WAIT 15 MINS, THEN OBTAIN PROLACTIN LEVEL
Immunocompromised patient with confusion and mild headache, b/l papilledema and cerebellar ataxia. CSF stain shows pleocytosis, inc. protein, low glucose? India ink stain shown below. What is diagnosis?
CRYPTOCOCCUS
45 y/o pt has recurrent episodes of LOC. A detailed description by family: pt reporting a feeling of faintness accompanied by pallor, followed by collapse and LOC, and several seconds later by a few bilateral jerks of the arms and legs. Prior to recovery, the pt’s face and chest are flushed. No precipitating factors are identified. Which of the following is the most likely explanation:
CARDIAC SYNCOPE
43 y/o pt w/ memory loss x 8 months associated with abd pain, wt loss, joint distention/pain, fever, lymphadenopathy, hyperpigmentation of skin, decrease hemoglobin, and fat in stool. Which test result is likely to be found in this patient?
CEREBROSPINAL FLUID WITH PAS+ CELLS INFECTED WITH TROPHERYMA
2 y/o child w/ hx of upper respiratory infections, most likely:
HAEMOPHILUS INFLUENZA
22 yo female is hospitalized with paranoia, hallucinations, abdominal pain worse with periods, physical exam shows reduced strength in upper and lower extremities and reduced tendon reflexes. Which of the following lab values is likely to be elevated and explain her symptoms?
PORPHOPBILINOGEN
Component of type A behavior most reliable risk factor for CAD
HOSTILITY
50 y/o pt with myasthenia gravis and a 3-day hx of cough, low-grade fever and chills, presents with great difficulty breathing. The pt appears tired and anxious, and the pt’s skin is clammy and sweaty. Initial management?
MECHANICAL VENTILATION
55 y/o M with changes in his voice, orthostatic hypotension and one immobile vocal cord on inspection suffers from:
SHY-DRAGER SYNDROME
Neoplasms of the thymus are associated with:
MYASTHENIA GRAVIS
A 25 yr old pt develops progressive hearing loss, has acoustic neuromas and café au lait spots, diagnosis?
NEUROFIBROMATOSIS TYPE 2
Pediatric Autoimmune Disorder Associated with Streptococcus (PANDAS) is associated with what disorder?
OCD
Children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) often manifest:
CHOREIFORM MOVEMENTS AND OCD SYMPTOMS
Age that corticospinal tract complete myelination
3 YEARS
Alternative stimuli that can be used to overcome withdrawal response to Babinski reflex:
DOWNWARD SCRAPING OF THE SHIN
This neuropsych symptoms is most commonly seen in mild neurocognititve disorder
DEPRESSION
Myasthenia gravis associated w/ which EMG finding? (10x)
DECREASED AMPLITUDE WITH REPETITIVE MOTOR NERVE STIMULATION
36 y/o pt w pain behind L ear progressing to numbness of L side of face, tearing of L eye, discomfort w low frequency sounds, left facial weakness on exam. Dx? (9x)
IDIOPATHIC BELL’S PALSY
Treatment of Trigeminal Neuralgia: (7x)
GABAPENTIN (BUT MOST EFFECTIVE IS CARBAMAZEPINE)
37 y/o truck driver w numbness of L hand, inc severity in past 2 yrs. Reduced pinprick sensation on L little/ring fingers, atrophy of hypothenar muscle. (6x)
ULNAR NERVE LESION
22 y/o with pain in the right hand that radiates into the forearm and bicep muscle. Paresthesias in the palm of the hand, thumb, index, middle ring finger. Sensory systems in the ring finger split the ringer finger longitudinally. Dx? (6x)
MEDIAN NERVE ENTRAPMENT AT THE WRIST
Atrophy of the intrinsic muscles of the right arm and forearm. Reflexes are generally brisk, plantar reflexes are extensor. Electrophysiology shows widespread fasciculations, fibrillation and sharp waves, normal sensation, muscle spasticity. Positive sharp waves on EMG. (5x)
AMYOTROPHIC LATERAL SCLEROSIS
Stiffness of legs while walking and spasms of LE while sleeping. Stiff legged gait, adducts legs while walking. Increased LE tone/spastic catch, hyperactive knee jerks, ankle jerk clonus. Increased Romberg sway. (5x)
CERVICAL SPONDYLOSIS
Persistent numbness in the L hand, decreased sensation in 4th/5th digits (palmar/dorsal), weak finger abduction/adduction especially 5th digit: (4x)
ULNAR NERVE ENTRAPMENT AT THE ELBOW
Right neck pain, tends to rotate neck to left – touching the chin prevents deviation – prominent right SCM spasm. Tx? (4x)
BOTULINUM TOXIN
Progressive weakness over several days – absent reflexes worse in lower extremities – slow conduction velocity, conduction block A 54-year-old patient had a viral upper respiratory infection 2 weeks ago and now presents with a 3-day episode of progressive, symmetric weakness in the legs, and tingling in the toes and fingers. On exam, Achilles and patellar deep tendon reflexes are diminished. Nerve conduction studies demonstrate decreased conduction velocity and decreased amplitude of action potentials. The most likely Dx: (4x)
ACUTE INFLAMMATORY DEMYELINATING POLYNEUROPATHY
14 y/o pt after a demanding physical test becomes extremely weak and unable to stand. PE is positive for depressed DTR’s. Labs: K=2.8. Hx of similar episodes after strenuous exercises. EKG: minimally prolonged PR, QRS, QT interval. Father and grandfather had similar episodes. Dx? (3x)
PERIODIC PARALYSIS
26 y/o pt w/ sudden onset back pain. Spasms in R paraspinal muscles in the lumbar region. Straight leg raising on the R is limited by sharp pain at 45 degrees. Ankle jerk on L is diminished. No muscle weakness, no sensory deficit. Next step? (3x)
ORDER MRI SCAN OF THE LUMBAR SPINE
Myasthenia gravis can be diagnosed in 80-90% of cases by identification of serum antibodies against what? (3x)
ACETYLCHOLINE RECEPTORS
Mechanism of action of botulinum toxin at neuromuscular junction: (3x)
INHIBITION OF ACETYLCHOLINE FROM PRESYNAPTIC TERMINALS
During 2nd trimester, a pregnant 38 y/o F has numbness in both hands, particularly thumb, forefinger, middle finger bilaterally. Dorsal part of hand unaffected. Arms ache in the morning from shoulders to hands. Diagnosis: (3x)
MEDIAN NEUROPATHY AT THE WRIST
An IV meth user develops severe back pain, followed after several days by bilateral lower extremity weakness/sensory loss, bladder incontinence, low grade fever, tenderness to percussion over the 2nd and 3rd lumbar vertebrae, paraparesis and loss of sensation to light touch and pinprick in both legs, buttocks & sacral region. (3x)
SPINAL EPIDURAL ABSCESS
What chemo agent is most commonly assoc with distal sensory polyneuropathy? (3x)
CISPLATIN
Pt w/ episodes of severe, intermittent, lancinating pain involving the posterior tongue and pharynx, w/ radiation to deep ear structures. Triggered by swallowing of cold liquids and talking. Workup: normal. Dx? (2x)
GLOSSOPHARYNGEAL NEURALGIA
Contralateral loss of pain and temp sensation with motor paralysis and proprioception loss on the other. Dx? (2x)
BROWN-SEQUARD SYNDROME (HEMISECTION)
Subacute combined degeneration of the posterior column of the spinal cord is associated with a deficiency of: (2x)
VITAMIN B12 DEFICIENCY
Which of the following is the most effective treatment of blepharospasm? (2x)
BOTULINUM TOXIN
Pt c/o progressive weakness of several days. Exam + for generalized weakness and absent reflexes. Nerve conduction studies show slowing of velocities. Dx? (2x)
ACUTE POLYNEUROPATHY
65 yo pt with progressive weakness, worse when squatting and standing from a chair. C/o decreased strength in right hand. On exam, prominent weakness of the quadriceps bilaterally and on opposition of the thumb in the right hand. Atrophy of foreman muscles with normal DTRs. No other weakness noted on exam. Sensory exam normal. ROS negative. Labs show normal CK and neg for anti-transfer RNA synthase antibodies (Jo1). What is the most likely dx? (2x)
MYOTONIC DYSTROPHY
30 y/o develops pain behind left ear. The following day pt complains of numbness on the L side of the face, tearing from L eye, and discomfort with low frequency sounds. Exam shows L facial weakness, but no sensory deficit. Likely diagnosis: (2x)
IDIOPATHIC BELL’S PALSY
One month after a MVA, a 21y/o co persistent pain in the left shoulder and arm, with sharp pain radiating into the left thumb. Exam shows weakness of the biceps. The biceps reflex on the left is absent. The most likely diagnosis is? (2x)
C-6 RADICULOPATHY
Pt c/o unpleasant aching and drawing sensations in calves and thighs associated with a crawling feeling, forcing him to move legs, bringing transient relief. Sxs worsened by fatigue. Exam nl. Best med tx? (2x)
PERGOLIDE (FOR RESTLESS LEG SYNDROME)
Severe spasms and rigidity of limbs intermittently and later more persistent/continuous: (2x)
ANTIGLUTAMIC AND ANTIDECARBOXYLASE ANTIBODIES (anti- GAD) ANTIBODIES
Weakness in limbs 2 weeks after a viral gastroenteritis. Weakness in UE/LE, absent DTRs. Spinal fluid shows no cells and elevated protein. EMG shows slow conduction velocity, prolonged distal motor latency, and conduction block. (2x)
ACUTE INFLAMMATORY POLYNEUROPATHY
2 years after MVA with rear-end collision, pt develops BUE weakness with some muscle wasting, loss of DTRs in arms, loss of sensation to pain and temp in neck/arms/shoulders, intact sensation to touch. Most likely cause? (X2)
SYRINGOMYELIA
