Neurology USMLE** Flashcards
A patient comes to the office for evaluation of headache. What is the most likely diagnosis when a woman with unilateral HA that is throbbing at the time of menses. She is nauseated and sees bright flashing lights. Light hurts her eyes and sounds are painful.
Migraine HA. more often unilateral with autonomic problems such as N&V. Visual problems such as bright flashing lights, zigzags of lights, or visual field defects also occur. There may be photophobia and phonophobia. Migraines can be preciptated by menstruation, physical or emotional stress and loss of sleep.
A patient comes to the office for evaluation of headache. What is the most likely diagnosis when bilateral squeezing pain like a belt tied around her head.
Tension HA are bilateral and “bandlike.” There are no associated neurological problems.
A patient comes to the office for evaluation of headache. What is the most likely diagnosis when a man with unilateral earing and redness of his eye and nasal stuffiness. There are several short HA.
Cluster HA are 10x more common in men. There are multiple short HA in a limited period of time. They are very severe with redness of the eye, lacrimation, rhinorrhea, and nasal stuffiness. Horners syndrome sometimes occurs.
A man comes in with severe facial pain that occured while his wife was gently stroking his face. The pain is extremeley severe, started at one side of his face and is like “a nail being driven into my cheek.” What is the most likely dx, what is the best initial therapy?
Trigeminal neuralgia or “tic douloureux” is an idiopathic disorder of the fifth cranial nerve. There is sudden severe pain of the face brought on by touch, chewing or movement. The pain is lancinating and unilateral. Trigeminal neuralgia is treated with carbameazepine. If medical therapy is not effective, surgical resection of the nerve may be necessary.
An elderly man is brought to the ED with sudden onset of weakness over the right side of his body, dysarthria and loss of his right visual field. His head CT is N. What is the most likely dx when the symptoms began with unilateral loss of vision on the L side. All sx resolve in 6 hrs. MRI is N.
TIA begins with the loss of sensory and motor dunction that resolves in <24h. All imaging studies are N. TIAs often begin with “amaurosis fugax” which is a transient loss of vision. The visual loss is ont he contraleteral side from the other sensory and motor loss. This is from a carotid embolus on the same side as the visual loss.
An elderly man is brought to the ED with sudden onset of weakness over the right side of his body, dysarthria and loss of his right visual field. His head CT is N. What is the most likely dx when the symptoms persist. MRI of the head is abN in 24h
Stroke is a permanent neurologic loss, often from a non hemorrhagic embolic or thrombotic episode of the middle cerebral artery. There is loss of motor and senosry function on the opposite side from the lesion. THis is frequently accompanied by a “homonymous hemianopsia” which is the loss of the optic radiation of fibers through the parietal lobe. A stroke on the left eminates the visual field on the right. patients “look towards the side of the lesion.”
A man presents to the ED with severe vertigo. He is found to have hemifacial anesthesia, dysarthria, dysphagia and sensory loss of his body on the opposite side from the hemifacial anesthesia. He is ataxic and there is a horner’s syndrome present. What is the most likely diagnosis? What is the most accurate diagnostic test?
Wallenburg or lateral medullary syndrome is a stroke of the PICA (posterior inferior cerebellar artery). This results in ipsilateral facial sensory loss, contralateral body sensory loss, vertigo, ataxia, dysarthria, dysphagia, and Horner’s syndrome. MRI of the brain is the most accurate way to assess the cerebellum and brain stem. CT scanning does not effectively look at the posterior fossa or the brain stem.
A patient comes in with sudden onset of weakness. The weakness is unilateral and is worse in the lower extremity compared to the arm. Sensory loss is also present that is worse in the leg. He is confused and there is urinary incontinence. What is the most likely dx? what is the most accurate diagnostic test?
Anterior cerebellar artery stroke presents with unilateral loss of motor and sensory function. These symptoms are worse in the lower extremity compared to the upper extremity. There is also confusion and urinary incontinence. MRI of the brain is the most accurate method of determining the presence of a stroke. Echocardiography and carotid doppler studies are used to determine the etiology of the origin of the stroke, specifically looking for evidence of vegetations or intracardiac thrombus
A man comes to the ED with sudden, extremely severe HA. This is the first such episode he has ever had. What is the most likely diagnosis when there is photophobia, neck stiffness, fever, and a loss of consciousness from which he recovers?
SAH results in a sudden severe HA with meningeal signs such as nuchal rigidity, fever, and photophobia. The two key features are the sudden onset of sx and a loss of consciousness in abotu 50% of patients. CT scan without contrast is 95% sensitive in detection of SAH. LP will detect the rest, showing RBCs and/or Xanthochromia.
A man comes to the ED with sudden, extremely severe HA. This is the first such episode he has ever had. What is the most likely diagnosis when he has unilateral loss of vision which persists
Temporal Arteritis leads to severe unilateral HA associated with loss of vision as well as tenderness of the scalp and the artery. The answer is always to giver steroids rather than wait for a temporal artery biopsy. There may be jaw claudication and onset is in the elderly.
A woman comes in because of severe back pain. What is the most likely diagnosis when there is a history of cancer, spine tenderness, hyperreflexia, urinary incontinence, and loss of sensation in the lower extremities?
Spinal cord compression from metastatic disease is thoguht to be present when back pain is accompanied by tenderness, hyperreflexia, sensory loss below the level of the compression, and sometimes urinary or fecal incontinence. Steroids are critical to prevent worsening.
A woman comes in because of severe back pain. What is the most likely diagnosis when there is no tenderness or facal neuro abnormalities.
Low back pain or lumbosacral strain has no accompanying focal neuro probelms. The straight leg raise may elicit pain suggesting disc herniation. This does not change the answer for initial management, which is to give analgesics and not perform routine imaging testing. Do not advise bedrest.
A woman comes in because of severe back pain. What is the most likely diagnosis when there is spinal tenderness, leukocytosis and fever?
Spinal epidural abscess is the answer when there is fever, leukocytosis, and spinal tenderness. Imaging such as an MRI should be performed if there is spinal tenderness which suggests a compressive mass.
A child is brought for evaluation of mental subnormality and seizures. What is the most likely diagnosis when there is a port wine stain on the face and leptomeningeal angiomas.
Sturge Weber syndrome presents with seizures and mental subnormality in association with a port wine stain and leptomeningeal angiomas.
A child is brought for evaluation of mental subnormality and seizures. What is the most likely diagnosis when facial adenoma sebaceum, renal lesions, and “shagreen patches” are present which are leathery plaques of subepidural fibrosis, usually situated on the trunk. Retinal hamartomas are present. Pale, hypopigemnted “ash leaf” pathces are present.
Tuberous sclerosis gives hamartomas of the retina in association with ash leaf hypopigmented areas. There are also lesions of the heart and kidneys. Adenomas sebaceum is redenned nodules on the face. Shagreen patches are also present which are leathery plaques of subepidermal fibrosis, usually on the trunk.
A patient comes in with loss of pain and temperature sensation of the lower extremities. What is the most likely diagnosis when the loss of pain and temperature is bilateral. There is also loss of bilateral motor function. There is striking sparing of position and vibratory sensation bilaterally.
Anterior spinal artery infarction results in the bilateral loss of all pain, temperature and motor function below the level of the infarction. There is striking preservation of position and vibratory sensation, which has another vascular supply on the posterior portion of the spinal cord.
A patient comes in with loss of pain and temperature sensation of the lower extremities. What is the most likely diagnosis when a knife wound is sustained to the back. The loss of pain and temperature is on the opposite side of the injury. THere is loss of position and vibratory sense on the same side of the injury.
Brown Sequard syndrome is hemisection of the spinal cord. Pain and temperature are lost on the opposite side from the lesion. Position and sense are lost on the same side as the injury.
A patient comes in some time after being involved in a motor vehicle accident. There was spine trauma. The patient has lost pain and temperature sensation in a “capelike” distribution across the neck and down both arms. Touch, position and vibratory sense are intact. Over time there is motoe loss below the level of the injury. What is the most likely diagnosis, what is the most accurate diagnostic test, what is the therapy?
Syringomelia presents with loss of pain and temperature in a capelike distribution across the neck and arms. There is sparing of tactile sensation, position and vibratory sense. Reflexes are los. There may be lower motor neuron manifestations at the level of the lesion with upper motor neuron signs below the lesion as the lesion enlarges. Syringomelia is caused by tumours and trauma. MRI is the most accurate diagnostic tests. Surgery is treatment.
An obese young woman comes in for evaluation of a severe HA and double vision. She has recently started OCPs. On physical exam, she has sixth cranial nerve palsy and papilledema. Head CT is N. What is the most likely dx? what is the msot accurate dx? what is the best initial therapy?
Pseudotumour cerebri is an idiopathic increase in ICP that occurs more often in obese women who are using OCPs or tetracycline abx. The key to the answer is teh presence of a HA in association with diploplia, papilledema, sixth nerve palsy and a normal head CT. LP is the most accurate dx test. Tx is with the loss of weight, combined with acetazolamide and diuretics. Steroids and surgical shunting are somtimes necessary.
Your patient comes in with multiple bruises on her legs. She is accompanied by her husband, whom she insists is kicking her every night. He denies this. He does say his legs are uncomfortable at night and that this discomfort is relieved by moving his leds. His legs feel “creepy and crawly.” He tries to avoid the problem by staying awake with coffe but this hasnt helped. What is the most likely diagnosis? What is the most effective therapy?
Restless leg syndrome is an idiopathic disorder of discomfort in the legs at night that is relieved only by movement. It is worsened by sleeplessness adn caffeine use. The patient describes the sensation as “creepy and crawly” in the leds. The bd partner often brings the patient in becasue of being kicked at night. There is no specific test to confirm the diagnosis. Dopamine agonists such as ropinirole and pramipexole are the treatment of choice.
