Neurology - Part 2 of 2 Flashcards
Which of the following is the most effective treatment of spasmodic torticollis? (x2)
BOTULINUM TOXIN
72 yo with profound sensory ataxia with loss of vibratory sensation and cognitive issues with irritability and somnolence. Nutritional deficiency?
COBALAMIN
Source of pain that is primarily central (non-nocioceptive)?
FIBROMYALGIA
Exam findings suggests L5 radiculopathy in pt with back pain and foot drop?
WEAKNESS OF ANKLE INVERSION
35yo gets blurry vision, drooping eyelids, and difficulty swallowing. Weakness of bulbar muscles. What caused this?
BOTULINUM
Which of the following is most likely to reduce pain in postherpetic neuralgia
CAPSAICIN
53 y/o w/ insidious onset of blurred vision, diplopia x1 day, ptosis, CN6 palsy, unreactive pupils, hoarse voice, dysarthria, weak neck muscles. EMG - inc amp with repetitive nerve stimulation. Dx?
BOTULISM
Dx for 45yo woman w/ pins & needles feeling in hand at night and upon awakening
CARPAL TUNNEL SYNDROME
Pt with chronic muscle wasting in both UE, loss of light touch, pain, and temperature sensation in shoulders, upper arms, and back, and painful paresthesias over the same distribution, diagnosis?
SYRINGOMYELIA
23 y/o Caucasian F in office for f/u after an ER visit 2 days earlier for sudden diplopia, R leg weakness and shaking, difficulty w/ speech which resolved after a few hours. Pt had fever 103.1 F and was tx for UTI. Current exam: normal CN & sensory, minimal R leg weakness, brisk DTR and musculocutaneous reflexes throughout, and equivocal plantar reflex on L. R toe is downgoing. Hx of several episodes of transient neurological deficits that resolved spontaneously after a few days. Her spinal fluid is most likely to show what?
PROTEIN: 50MG, + OLIGOCLONAL BANDS, NUCLEATED CELLS: 10
68 y/o w/ pain in buttocks while walking, shooting down legs, w/ weakness and numbness. Relieved by sitting, pain persists with standing. Dx?
LUMBAR SPINAL STENOSIS
Where is the lesion when a picture of a female patient with ptosis is shown?
SUPERIOR CERVICAL GANGLION
T2 MRI figure in pt with cervical myelopathy. Most consistent with what dx?
DEGENERATIVE CERVICAL SPONDYLOSIS
New-onset back pain after shoveling – left paraspinal muscle spasm, negative straight leg raise, reflexes symmetric, no weakness, no sensory deficit. Management?
CONSERVATIVE (BED REST) WITH NSAIDS
50 y/o M w/ acute neck pain radiating down L arm, gait problems, urinary incontinence. What test should be ordered?
MRI OF C SPINE TO R/O CORD COMPRESSION
Horner’s syndrome is characterized by?
MIOSIS, PTOSIS, AND ANHIDROSIS OF FOREHEAD
First step in the management of acute myasthenic crisis:
MECHANICAL VENTILATION
Pt c/o pain when walking that radiates from lower back and is severe in the calves. Pain relieved by stopping for a couple of minutes, then resuming. No sensory or motor deficits. Test most likely to yield Dx?
VASCULAR EVALUATION OF LOWER EXTREMITIES
Fall from a ladder with persistent back pain and inability to void. B/l leg weakness, decreased pinprick in sacral and perianal area. Dx?
CAUDA EQUINA COMPRESSION
35-year old pt with new onset of numbness and tingling in the legs. The pt complains of a band-like sensation around the mid chest and reports episodes of urinary incontinence. Which of the following tests should be ordered next?
MRI OF THE SPINE
Fluctuating aching pain in lower back, buttocks, and sciatic distribution elicited by standing or walking, and relieved by sitting with numbness in a similar distribution, loss of ankle reflexes: what dx?
SPINAL STENOSIS
A young pt w/ a few days of progressive weakness and numbness of both legs and feet after recovering from a flu-like illness. Exam: weakness and loss of sensation to all sensory modalities below the middle of the thorax. DTR: brisker on the lower extremities, plantar reflexes are extensor. Pt has had several episodes of urinary incontinence. Other neuro exam and vital: normal. LP: 23 mononuclear cells, protein level: 37mg/dl, and normal glucose. Dx:
ACUTE TRANSVERSE MYELITIS
55 y/o M presents w/ hx of weakness and clumsiness. Symptoms began several months earlier with difficulty buttoning his clothes, getting the car keys in the ignition, and performing other fine motor tasks. He noticed that the muscles in his arm and forearm twitched under the surface, and cramped easily. Over the past few months his arms have continued to weaken and lose muscle mass. On exam, he has diffuse wasting and weakness of BUE, fasciculations, slight spasticity on arms and legs, and hyperreflexia with extensor plantar responses. Sensory, coordination, and CN exams are normal. The underlying pathological process affects neuronal bodies in which of the following structures?
ANTERIOR HORN OF THE SPINAL CORD, MEDIAL BRAINSTEM, AND PREROLANDIC CORTEX
13 y/o M w trouble keeping up w P.E. class. On exam: symmetric weakness in legs/ arms, worse in proximal muscles, most prominent in quadriceps/hamstrings. Both calves enlarged, painful w exercise. Serum creatine kinase level is 13,000. Muscle bx reveals abnormalities in dystrophin protein staining. Pattern of inheritance is?
X-LINKED
A hyperextension lesion of the shoulder resulting in weakness of abduction, internal rotation, flexion, and adduction of the extended arm most likely includes which nerve roots?
C5, C6
5 y/o cannot maintain eyes open, attempts to look at person/object results in tonic eyelid closure. Can watch television w/o difficulty. Extraocular movements NML. Dx?
BLEPHAROSPASM
Electrophysiologic signs of denervation:
FIBRILLATION AND POSITIVE SHARP WAVES
Pt s/p surgery develops weakness and wasting of small muscles of the hand and sensory loss of the ulnar border of the hand and inner forearm. Dx?
LOWER BRACHIAL PLEXUS PARALYSIS
3 month progressive limb weakness L>R, problems swallowing. Normal CN, weakness in neck extensor muscles, in distal and proximal muscles (quadriceps, feet dorsal flexors, extensor pollicis longus) and in wrist/finger flexors. DTRs normal. Motor tone/coordination/gait normal. Elevated CK.
INCLUSION BODY MYOSITIS
Spinal fluid of patient w/ acute inflammatory polyneuropathy shows:
HIGH PROTEIN, NORMAL CELL COUNT
Pt with double vision when looking to the left shows her eyes on primary gaze. On left gaze the right eye fails to adduct and there is nystagmus in the left eye. On right gaze and vertical gaze the eyes move normally. Dx?
INTERNUCLEAR OPHTHALMOPLEGIA
Right shoulder weakness on initial abduction and external rotation of the arm at the shoulder joint, after carrying sand bags. Affect nerve:
SUPRASCAPULAR
Acute onset of left facial weakness involving the forehead & perioral musculature. Onset of facial weakness was preceded by pain in left ear and mastoid, and by sensation of discomfort in the left ear w/ loud noises or low pitch sounds. Dx?
BELL’S PALSY
Orbital pain with L eye paralysis of adduction and elevation of the eye but normal pupil function. Dx?
DIABETIC 3RD NERVE PALSY
25 y/o pt with pain in L periorbital region, followed by blurring then loss of vision in left eye. Exam normal but no reaction when light shone on L eye. This is consistent with:
DEMYELINATING LESION OF LEFT OPTIC NERVE
Involuntary set of flowing jerky movements in multiple joints describe:
CHOREA
49 y/o w/ DM2 presents with severe burning of soles of feet and insomnia b/c the touch of the sheet against the feet is painful. Exam shows decreased sensation to pin and touch up to ankle, 50% reduction in vibratory sense at ankle and impaired proprioception at toes. Ankle jerks are absent, but knee jerks present. Dx?
PERIPHERAL NEUROPATHY
Resting, non-intentional tremor
PARKINSON’S DISEASE
25 y/o F with L eye pain which increases with moving the eye. Diminished acuity in L eye, pupils constrict well with light on R eye, but only constrict weakly with light on L eye. Dx?
OPTIC NEURITIS
Recurrent deafness, tinnitus then vertigo:
MENIERE’S DISEASE
49 y/o with gradual hearing loss. A tuning fork used during the Weber test reveals a failure to lateralize, and the woman’s perception of air conduction is better than that of bone conduction. She has trouble discriminating words “fat” “cat” “mat”. Dx?
BILATERAL SENSORINEURAL HEARING LOSS
Viral agents frequently associated with idiopathic unilateral facial nerve palsy:
HERPES SIMPLEX
Tremor decreasing with volitional movements and appears primarily in an attitude of repose:
RESTING TREMOR
Mucosal lesion that heals and then pt has pain in trigeminal nerve area
POST-HERPETIC NEURALGIA
Unilateral foot drop with steppage gait indicates:
PERONEAL NERVE COMPRESSION
Severe jabbing pain, lasts few seconds, triggered by light touch on face
TIC DOULOUREUX
Irregular, unequal, small pupils nonreactive, do not dilate, but do constrict to accommodation:
SYPHILIS
Pt was hit from behind while driving & awoke w/ pain radiating into his left ankle. Weakness of plantar flexion and decreased ankle jerk. Straight leg raising reveals pain beyond 45 degrees on left. Dx?
S-1 RADICULOPATHY
Myasthenia gravis pt with mild respiratory infection develops severe respiratory fatigue, restlessness, and diaphoresis. Pt appears anxious and tremulous. Tx?
MECHANICAL VENTILATION
Pt c/o left foot slapping floor when he walks. He has to step high to avoid tripping. Weakness of dorsiflexion of left foot, w/ small area of numbness in the dorsum of the left foot. Normal ankle and knee jerks, and hamstring reflexes. Dx?
PERONEAL NERVE PALSY
Hyperkalemic periodic paralysis is characterized by episodes of generalized weakness of fairly rapid onset. It is also associated with a rise in serum K, with weakness typically appearing after a period of rest following exercise. Which of the following molecular deficits underlies this disease?
SODIUM CHANNEL INACTIVATION
Weakness of opponens of thumb and adduction of 4th, 5th digit, decreased sensation in 4th, 5th digits extending into palm and ending at crease of wrist, caused by:
ULNAR NERVE LESION
Severely sensitive, lancinating pain on the cheek
TRIGEMINAL NEURALGIA
52 y/o w recurrent stabbing pain over right cheek and jaw forcing him to frown. Stopped shaving or brushing teeth d/t fear of pain. Episodes last less than 1 minute. Only exam abnormality is pain upon repeated touching of pt’s face. Most likely explanation of symptoms?
TRIGEMINAL NEURALGIA
23 y/o develops tingling paresthesias in the lower extremities, followed several days later by progressive weakness, R>L. PE shows sensory level at T10 to pinprick, +3/5 weakness of LE, slightly weaker on R. Knee and ankle jerks are hyperactive, b/l congenit. Pt has difficulty walking with broad-based, stiff-legged gait. Dx?
TRANSVERSE MYELITIS
Unilateral distal weakness in one limb, often associated w/ muscle wasting in the same distribution, the most common Dx:
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
Which neurological disorder has the highest prevalence of pathological laughing and crying
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
A dislocation of shoulder joint resulting in weakness of abduction of arm, wasting of deltoid muscle and slight impairment of sensation on the lateral aspect of shoulder, involves which nerves:
AXILLARY
A 57 yo pt develops drooping of the R eyelid following mild neck trauma. The patient’s neurological exam is remarkable for asymmetric pupils, smaller on the R, mild eyelid ptosis and decreased sweating over the R face. These findings are consistent with which of the following?
HORNER’S SYNDROME
38 y/o F with muscle spasm of the proximal limbs and trunk, lumbar lordosis while walking, w/o EMG abnormality and with serum antiglutamic acid antibodies is suffering from:
STIFF-PERSON SYNDROME
DM pt with creeping paresthesias and burning pain in L anterolateral thigh. DTRs normal, no weakness. Dx?
MERALGIA PARESTHETICA
45 y/o reports lower back pain along w/ pain and numbness in R leg and foot w/ difficulty walking x 4 wks. Exam: limited due to back pain, foot drop on right side. Nerve conduction studies: normal motor and sensory in leg. EMG: decreased recruitment and spontaneous activity in right tibialis anterior and tibialis posterior muscles. Otherwise normal. Dx:
L-5 RADICULOPATHY
A 54yo pt complains of intermittent double vision that has worsened over the last 3wks. The pt’s coworker also noted that at times the patient had a “droopiness” of the eyelids as if sleepy. Examination reveals bilateral ptosis, mild esotropia, and double vision only after the pt is asked to maintain an upward gaze for 2 minutes. There is no dysarthria, but a mild 4/5 weakness is found in the proximal arm muscles bilaterally. What is most appropriate test to perform next to establish the diagnosis?
EDROPHONIUM TEST
Which of the following antibiotics is most likely to cause or precipitate acute myasthenia?
CIPROFLOXACIN
Polyneuropathy can be caused by either deficiency or extreme excess of which of the following B vitamins?
VITAMIN B6
45yo pw gradual progressive weakness for 3-4mo in LUE, atrophy in RUE intrinsic mm, and brisk reflexes and extensor plantar responses. EMG with widespread fasciculations, fibrillations, and +sharp waves. Dx?
ALS
57 y/o office worker w numbness in 4th/5th digit of right hand, which wakes patient in middle of night. Nerve conduction study finding most likely to explain syndrome?
SLOWED CONDUCTION VELOCITY ACROSS THE ELBOW IN THE ULNAR NERVE
Conduction block in NCS indicates what?
FOCAL DEMYELINATION
Female with vertigo and diplopia, when looks left has isolated L eye nystagmus, and cannot adduct R eye. Dx?
MULTIPLE SCLEROSIS
20 y/o occasional double vision when looking to R and normal acuity in each eye alone. L ptosis and difficulty keeping L eye adducted. Pupils round and reactive. Speech nasal and neck flexors weak. No paresis or reflex abnormalities in extremities. Dx?
MYASTHENIA GRAVIS
55 y/o w/ DM and HTN develops R periorbital pain and diplopia. Exam: paralysis of abduction of R eye.
DIABETIC 6TH NERVE PALSY
Shaking hands, increased when using hands/writing/volitional activities. Stress worsens, wine improves. Is familial. DX:
ESSENTIAL TREMOR
55 yo pt complains of numbness in 4th/5th digit R hand. Sxs worse when pt speaks on phone, awakens w paresthesias in same fingers. Test to confirm the dx?
NERVE CONDUCTION STUDIES
55 y/o pt w/ hx of weakness and clumsiness x several months. Difficulty w/ fine motor tasks. Arm muscles twitch and cramp easily, weakening, atrophy. Sensory, coordination, cranial nerve exams wnl. Underlying illness affects neuronal bodies where?
ANTERIOR HORN OF SPINAL CORD, MEDIAL BRAINSTEM AND CORTEX
Prognosis of acute inflammatory demyelinating polyneuropathy is poorest if the disease process involves which of the following?
PROXIMAL AXON
Pt with HTN develops painless vision loss in the left eye. Exam: blindness in L eye and afferent pupillary defect on the left. MRI: several T2 hyperintensities in the white matter periventricularly. No corpus callosum lesions. No enhancement with gadolinium. Dx?
ISCHEMIC OPTIC NEUROPATHY
Chronic peripheral neuropathy of insidious onset, symmetric, more prominent distally in limbs, legs more than arms affected, slowly progressive, with greater sensory than motor involvement, with involvement of peripheral sympathetic nerves, and variable loss of DTR, is most likely caused by agent:
ALCOHOL
The usual target for Deep Brain Stimulation in Essential Tremor:
VENTRAL INTERMEDIATE THALAMUS
72-year-old pt presents with subacute onset of progressive ataxia of gait and limbs. Lab testing reveals the presence of an anti-Yo antibody in serum. Which of the following tests should be ordered next?
CT SCAN OF THE CHEST, ABDOMEN, AND PELVIS
Young pt recovering from flu-like illness w/ progressive weakness and numbness of legs and feet. Weakness and numbness below middle of thorax. Increased LE DTR’s, extensor plantar reflexes. Urinary incontinence. LP 23 mononuclear cells, protein level 37, nml glucose
ACUTE TRANSVERSE MYELITIS
25 y/o pt reports double vision and some difficulty with balance. On right lateral gaze, there is weakness of the left medial rectus, with nystagmus of the right eye. On left lateral gaze, there is weakness of the right medial rectus, with nystagmus of the left eye. There is also mild finger to nose ataxia on the right. Dx:
MULTIPLE SCLEROSIS
50 y/o man w a cut onset of neck pain radiating down left arm, progressing gait difficulty, urinary incontinence. Which test should be administered immediately?
MRI OF HEAD TO EXCLUDE DX OF ACUTE HYDROCEPHALUS
Transcutaneous electrical nerve stimulation (TENS)
FOR PERIPHERAL NEURALGIA
Electrodiagnostic test finding most indicative of a demyelinating neuropathic process?
CONDUCTION BLOCK
Term for burning dysesthesia with shock-like paroxysms:
NEUROPATHIC
Pt displays spastic gait in which legs are stiff, feet scrape against floor, and legs circumduct which each step. Reflexes are increased and plantar responses are extensor bilaterally. Dx?
CERVICAL SPONDYLOSIS
Term for sudden, irrepressible shock-like contraction of a muscle triggered by an event in CNS?
MYOCLONUS
28 y/o with acute urinary incontinence and unsteady gait. Also reports 1 week h/o numbness progressing from both feet up to abdomen. Light touch, temperature, and pinprick are reduced below the mid-thoracic region. Vibration and position sensation in both feet are absent. Muscle bulk and tone are normal. Strength in BLE are reduced, R>L. Brisk DTRs in BLE with + Babinski’s. What’s the Dx?
ACUTE TRANSVERSE MYELITIS
Pt present with progressive weakness of left upper extremity, followed by the right upper extremity. + Muscle wasting of bilateral arms. Upper and lower ext reflexes increased, and plantar response are extensor. Normal nerve conduction studies. EMG: fibrillations in arm and leg muscles. Dx?
AMYOTROPHIC LATERAL SCLEROSIS
The most frequent cause of simultaneous, bilateral facial nerve palsies
BORRELIA BURGDORFERI
Gait pattern in which one side of pelvis is dropped is associated with which neurological condition?
MUSCULAR DYSTROPHY
A 63 y/o pt with insidious onset of neck pain, progressive limb weakness, falls, and urinary incontinence. On exam, pt has decreased neck ROM, mild distal and proximal limb weakness, brisk DTRs with ankle clonus, and upgoing plantar reflexes. Increase muscle tone in legs. Rest of exam is normal. What is most likely dx?
CERVICAL MYELOPATHY
55 y/o pt c/o of mild muscular aches and stiffness for which steroid treatment was previously given. Hx of hypercholesterolemia and hypertriglyceridemia, and was treated with atorvastatin and gemfibrozil with a positive response. Serum creatine kinase level is slightly elevated. Which of the following is the most likely diagnosis?
STATIN-INDUCED MYELOPATHY
45 y/o pt w/weakness of hips and thighs, and lesser extent the shoulder and neck. Also extremely difficult to rise from a squatting or kneeling position, No muscle pain. No tender. DTR: normal. Dx:
POLYMYOSITIS
A lesion in what structure is associated with ptosis, lack of sweating on same side of the face, and conjunctival injection?
SUPERIOR CERVICAL GANGLION
50 y/o otherwise healthy pt who is a secretary notices cramping and stiffening of hands only while writing, stiffness ceases when pt stops writing. Occasionally hands will tremor. Which of the following Is most effective therapy
BOTULINUM TOXIN
R neck pain, usually rotating neck to left. Corrected by touching chin. Spasm of R SCM on PE. Treatment?
BOTOX
70 Y/O pt with confusion, lethargy, fever. Dx of encephalitis is made after CSF analysis. What clinical feature suggests West Nile virus?
MONOPARESIS
60 y/o pt w/ progressive proximal arm and leg weakness, elevated creatine kinase level. MD suspects a myopathy and orders EMG. Which findings on EMG:
SMALL, SHORT DURING MOTOR UNIT ON NEEDLE EXAM
Which finding would you expect if someone is diagnosed with ulnar neuropathy at the elbow?
LOSS OF SENSATION IN THE FOURTH AND FIFTH DIGIT AND WEAKNESS OF INTRINSIC HAND MUSCLES
Pt c/o hearing loss on right side. When tuning fork held at vertex of skull, pt hears sound better on the right. When fork is held in front of the pt’s ears, pt reports hearing it better on the left. Dx?
CONDUCTIVE HEARING LOSS ON THE RIGHT
Progressive LE stiffness & hyperreflexia (ankle clonus) with extensor plantar responses and decreased light-touch & vibration/proprioception in b/l stocking pattern?
COBALAMIN DEFICIENCY
Pt is evaluated for unilateral lower extremity weakness with no apparent physiologic explanation.
THERE IS A RISK THAT RELEVANT NEUROLOGIC ILLNESS WILL BE IDENTIFIED IN THE FUTURE.
24 y/o pt w/ sudden onset stumbling and pain in legs, negative neuro workup – saw a counselor previously for protracted grief after father’s death – increased conflict with husband. Dx?
CONVERSION D/O
27 year old normal patient with intermittent muscle twitching. EMG findings showing spontaneous discharges, fairly constant, representing motor unit firing are typical of?
FASCICULATIONS
54 y/o wakes up with weakness or R hand. he has been drinking at a bar and fell asleep on right arm over the armrest of chair. exam shows weakness of wrist and finger extension with normal grip strength. Which nerve is affected?
RADIAL NERVE
The new onset of pathological gambling, increased libido, and hypersexuality in a patient with Parkinson disease is likely to be secondary to: (3x)
PRAMIPEXOLE
First line treatment of vocal tics in Tourette syndrome: (2x)
ALPHA 2 ADRENERGIC AGONIST
Which drug for the Tx of parkinsonism has been associated with sudden sleep attacks? (2x)
ROPINIROLE
2nd generation with the lowest D2 affinity
QUETIAPINE
What medicine interferes with efficacy of Donepezil?
OXYBUTYNIN
A condition with increased frequency in pts with HIV on long term HAART:
HEPATOTOXICITY
Inhibitors of enzyme catechol-O-methyl transferase are used in Parkinson disease to address which disease-associate problem?
WEARING OFF OF LEVODOPA EFFECT
33 y/o with insomnia, fatigue, nervousness, irritability, and depressed mood. Has scaly dermatitis in sun-exposed areas, apathy, and mild memory impairment. Which vitamin is pt deficient in?
NIACIN
Which medication reduces accumulation of plaques and disability in pt’s with relapsing remitting MS?
INTERFERON BETA-1 A
What cognitive enhancer is an NMDA receptor antagonist?
MEMANTINE
Medication helpful in early HIV dementia but is potentially toxic later in the disease?
METHYLPHENIDATE
Acamprosate works through which neurotransmitter system?
GLUTAMATE
Neuronal enzyme that is the target of drugs to treat Alzheimer’s i.e. galantamine and rivastigmine
ACETYLCHOLINESTERASE
Pharmacologic mechanisms of topiramate include: inhibition of firing of voltage- dependent sodium channels, antagonism of kainite binding to the alpha-amino-3- hydroxy-5-methyl-4- isoxazole propionic acid (AMPA) receptor & potentiation at which receptor?
GABA-A
A medication to treat MS is an integrin antagonist that primarily acts by blocking lymphocytes and monocytes adhesion to the endothelial cells:
NATALIZUMAB
Medication for restless leg syndrome:
BROMOCRIPTINE
