Rita's Neuro Questions

Question 1

The important part of the neuro assessment of a 4yo is:

a) history
b) test of motor cranial nerves
c) deep tendon reflexes

Answer 1

a) history

Question 2

Which of the following is a possible diagnosis in a child with a seizure disorder and Mental Retardation?

a) xeroderma pigmentosa
b) tuberous sclerosis
c) neurofibromatosis

Answer 2

b) tuberous sclerosis
- -> tubers in brain –> seizure d/o

xeroderma pigments –> assoc. w/cancers

Question 3

What deficits would you NOT expect in a child with a hx of periventricular leukocalacia?

a) cerebral palsy
b) intellectual impairment
c) visual dysfunction
d) sensory changes

Answer 3

d) sensory changes
- -> is a MOTOR disease: upper motor neuron lesion –> hyperreflexia

periventricular leukocalacia = #1 cause of CP!
–> visual dysfunction: myopia, strabismus

Question 4

A 9 month old already has left hand dominance. What is the next best step in managing this patient?

a) reassurance
b) observation
c) referral to neurology
d) variation of normal

Answer 4

c) referral to neurology

Question 5

What is the most common comorbidity associated with ADHD?

a) depression
b) conduct disorder
c) anxiety disorder
d) oppositional defiant disorder

Answer 5

d) oppositional defiant disorder

Question 6

What is a side effect of Ritalin?

a) arrhythmias
b) increased appetite
c) insomnia
d) vomiting

Answer 6

c) insomnia

• -> decreased appetite
• -> arrhythmias = uncommon side effect
• -> vomiting should not occur

Question 7

A child with a fever of 103 has pain on extension of leg 90 degree to trunk. This is a positive:

a) Brudzinski sign
b) Kerning’s sign
c) Gallant sign

Answer 7

b) Kerning’s sign

–One of the physically demonstrable symptoms of meningitis is Kernig’s sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

Question 8

A child with a fever of 103 has spontaneous flexion of knee/hip by passive flexion neck. This is a positive:

a) Brudzinski sign
b) Kerning’s sign
c) Gallant sign

Answer 8

a) Brudzinski sign
- -> One of the physically demonstrable symptoms of meningitis is Brudzinski’s sign. Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.

Gallant sign –> baby turns toward side when stimulated

Question 9

What would you most likely see in a baby with spina bifida occulta?

a) a tuft of hair over lumbar sacral spine
b) lower extremity weakness
c) nevus flummox over the thoracic spine

Answer 9

a) a tuft of hair over lumbarsacral spine \

…not a lot of sx..maybe neurogenic bladder…

Question 10

A 2 month old’s HC jumps from the 50th percentile at the 1 month visit to the 95th percentile now. The child is developmentally normal. What is the first action to take?

a) refer to neuro
b) measure the parent’s HC
c) follow up in 2 months

Answer 10

b) measure the parent’s HC
- -> …is usually just due to genetics!

• -if 3 month old male, best test would be ultrasound
  
  • -> benign external hydrocephalus

Question 11

What drug interacts with carbamazepine?

a) phenytoin
b) pheno barb
c) Advil
d) Atenolol

Answer 11

b) pheno barb

Question 12

A 6 month old infant cannot hold his head steadily when brought to sitting position. His reflexes are +4 with spread. There is six beats of clonus. What is the most likely dx?

a) muscular dystrophy
b) hypoxia-ischemic encephalopathy
c) cyanotic congenital heart disease
d) spinal muscular atrophy type

Answer 12

b) hypoxia-ischemic encephalopathy
- -> other cause of CP

muscular dystrophy –> normal to hyporeflexia

spinal muscular atrophy type –> hyporeflexia

Question 13

A 7yo presents with acute headache. On examination, there is the new onset of difficulty in upward gaze of both eyes. What is the most likely cause of this problem?

a) Strabismus
b) Increased intracranial pressure
c) congenital paresis of cranial nerve 4
d) migraine headache

Answer 13

b) Increased intracranial pressure
- -> when hydrocephalus develops or a shunt is not working, the 3rd ventricle becomes enlarged and compresses the vertical gaze center

congenital paresis of cranial nerve 4
–> causes inability to look toward the outer aspect of the nose

Question 14

A developmentally normal 6 month old presents with a full but not bulging fontanelle and a progressive increase in head circumference. The MRI shows benign enlargement of subarachnoid space in the frontal area. This is consistent with:

a) Hydrocephalus
b) External hydrocephalus
c) Macrocephaly
d) Neurofibromatosis

Answer 14

b) External hydrocephalus
- -> benign enlargement of subarachnoid space in the frontal or frontoparietal region
- -> normal development, lack of changes in the ventricle

w/macrocephaly only –> MRI will not show fluid collection in the subarachnoid space

Question 15

A previously healthy 11yo presents with a 1 day hx of fever and severe headache. On exam, she has a temperature of 101.4, positive Brudzinski sign, and positive Kernig’s sign,. She is diagnosed with presumptive meningitis. What is a possible long-term complication?

a) Brain abscess
b) Encephalitis
c) Hearing loss
d) Subdural effusions

Answer 15

c) Hearing loss

• -most common neurologic sequelae of meningitis = hearing impairments (up to 35% of patients)
• -also speech impairments, learning disabilities, behavioral problems

Question 16

A 24 month old with a fever of 102.4 had a generalized seizure. Other than a hx of fever, the hx and exam is unremarkable. The child is playing w/a toy during the visit. What is the next best step?

a) parental education and observation
b) referral to ED for septic work-up
c) admission for 24 hrs
d) tx with antiepileptic drugs

Answer 16

a) parental education and observation

• -in the face of a normal neuro exam, child does not need admission to the hospital or a complete septic w/u
• -pts w/a simple febrile seizure and a normal exam do not need CT scan or MRI

Question 17

A 5yo has a normal posture, bluish coloration to the sclera, and looseness of the joints (hypermobility) without weakness. Which is the most likely dx?

a) Ehlers Danlos Syndrome
b) Iron deficiency anemia
c) Spinal Muscular Atrophy, type II
d) Duchenne muscular dystrophy

Answer 17

a) Ehlers Danlos Syndrome
- -> characterized by skin hyperextensibility, joint hypermobility, tissue fragility, easy bruising, bluish color of the sclera, and paper-thin scars

Iron deficiency anemia –> can cause blue sclera, but not joint hypermobility

Question 18

A well-appearing 6 week old has a hx of a fall from a surface 3 feet off the ground one hour earlier. On exam, there is only a small amt of swelling. What is the next best step?

a) Skull xray or CT scan
b) MRI
c) head ultrasound
d) observation

Answer 18

a) Skull xray or CT scan

- -> children

Question 19

What entity is associated with positional plagiocephaly in a 2month old?

a) microcephaly
b) macrocephaly
c) torticollis
d) strabismus

Answer 19

c) torticollis

Question 20

A 7yo child presents w/a 2 year hx of headaches at the end of the day associated with stress. Recently, the headaches are not relieved with acetaminophen, are located in the occipital area, and are worse when the child coughs or is active. The child’s personality has become increasingly irritable. Which is the most likely dx?

a) cluster headache
b) chronic progressive headache
c) tension headache
d) migraine headache

Answer 20

b) chronic progressive headache
- -> occipital headaches are rare and require immediate evaluation: this case warrants immediate imaging

cluster headache: rarely seen before age 10; characterized by one to several attacks recurring each 24 hours, with symptom-free periods from months to years

Question 21

On exam, a 4yo has large calves with lumbar lordosis, and a waddling, clumsy gait. The family hx is unremarkable. Which is the most likely dx?

a) Muscular dystrophy
b) a brain tumor
c) Marie Charcot tooth syndrome
d) essential hypotonia

Answer 21

a) Muscular dystrophy

DMD: normal milestones until walking, clumsiness, saddling gait, weakness in climbing stairs, pseudohypertrophy of calf muscles and contracture of heel cords, an early complaint of leg pain, toe walking, contractures of neck/biceps/Achilles tendon

Marie Charcot Tooth: stork-like legs with high arches; no pseudohypertrophy of calf muscles

Question 22

An 18 month old presents with with lumbar lordosis, delay in walking, and diminished reflexes. Which of the following lab tests will be the most helpful?

a) CBC
b) Lactose Dehydrogenase (LD)
c) Creatinine kinase (CK)
d) ESR

Answer 22

c) Creatinine kinase (CK)

Question 23

A 6yo complains of headaches on arising in the am before school for 2 months. On PE, there is a head tilt, past pointing, and difficulty in performing rapid alternating hand movements. What is the most appropriate next step?

a) CT with contrast
b) MRI with contrast
c) Lumbar puncture
d) Plain radiograph of skull

Answer 23

b) MRI with contrast

–child has signs of posterior fossa tumor

Question 24

A 14yo gymnast complains that her right side feels different from her left side. She also has pain in her neck, which increases with coughing or sneezing. On exam, she has strength different between her biceps but has equal let strength. There is mild tenderness in the lower cervical vertebra. Which of the following is the most likely cause?

a) myopathy
b) neuropathy
c) nerve root compression
d) psychological disturbances

Answer 24

c) nerve root compression
- -> an inflammatory process starts nerve root compression, –> nerve root swelling
- -> compression can occur from disk herniation

neuropathy = distal weakness

Question 25

An 8 week old presents with a 12hour history of moving less and seemingly slipping out of her arms when held. On exam, the infant is disinterested in her environment, has significant head lag, and is quiet. The temp is normal. Which of the following tests should be ordered?

a) neonatal metabolic screen
b) stool sample for Clostridium botulinum
c) thyroid screen
d) LFTs

Answer 25

b) stool sample for Clostridium botulinum
- -> botulism! infants present w/: apathy, listlessness, feeding poorly, decreased head control, weak cry, suck, and hypotonia with an absence of fever

Question 26

A 19month old presents one hour after a fall off of a 3-foot stepladder. His past medical hx is unremarkable. He vomited once after the fall. On exam there is a large right parietal hematoma. He is crying during the entire exam but is quiet when not being examined. What is the most appropriate next step?

a) observation
b) skull xray
c) CT of the head
d) MRI with contrast

Answer 26

c) CT of the head
- -> with child under 2 who has a non-frontal hematoma following a fall, CT would provide a good look at both bone and provide info about intracranial bleeding

Question 27

A 10yo complains of mild late afternoon, non-pulsating pain in the frontal area with minimal photophobia. The PE is normal. Which is the most likely dx?

a) cluster headache
b) common migraine
c) tension headache
d) complicated migraine

Answer 27

c) tension headache
- -> occur later in the day and are generally milder than migraine

migraine: moderate to severe intensity with a pulsating quality

cluster headache: one to several attacks within a 1-day period with several weeks to months of headache-free periods

Question 28

A 9yo presents with complaints of feeling dizzy with nausea, and ringing in the ear. Which of the following tests would be helpful in evaluating this patient?

a) Gower’s Maneuver
b) Kernig’s sign
c) Brudzinski sign
d) Tandem Romberg test

Answer 28

d) Tandem Romberg test
- -> tests for both balance and equilibrium

Gower maneuver = test for weakness of the pelvic girdle

Question 29

A right hand dominant 14yo boy has thirty cafe au lait spots and axillary freckling. He presents with hx of worsening headaches and difficulties with language. What is the most likely cause of the problem?

a) a brain stem tumor
b) a right sided cerebellar tumor
c) a left sided cerebral tumor
d) a right sided cerebral tumor

Answer 29

c) a left sided cerebral tumor

- -> signs localized to to the language on left side of the brain

Question 30

A 7yo has a cerebellar tumor. What set of sx can be expected?

a) intentional tremors, ataxia, head titubations
b) growth retardation, precocious puberty, visual field defect
c) intellectual changes, seizures, and contralateral hemiparesis
d) focal headache, seizures, hyperreflexia, focal signs

Answer 30

c) intellectual changes, seizures, and contralateral hemiparesis
- -> cerebral tumors characterized by these sx!

Question 31

A 15yo has familial essential tremors. He is embarrassed by the problem and wants to be treated. Which of the following tx’s is the most appropriate?

a) stimulants
b) beta blocker
c) SSRI
d) anti-anxiolytic

Answer 31

b) beta blocker
- -> essential tremor should only be treated if there is functional disability or social embarrassment
- -> 1st line drugs = propranolol, primidone

Question 32

A normal 4 week old has very brief, jerky bilateral movements only associated with going to sleep, and stop when the child is awakened. What should be the first course of action?

a) referral to a pediatric neurologist
b) reassurance to the parents
c) referral for MRI
d) referral for a CT scan

Answer 32

b) reassurance to the parents

- -> benign sleep myoclonus of infancy occurs within a few days of birth; generally resolves by 3rd month of life

Question 33

A 14yo presents with hx of 2 months eye blinking as a 4 month old. His parents recently divorced. His cc today is a 1 month hx of intermittent twitch of the upper eyebrow. The exam is normal. What should be the next course of action?

a) reassurance
b) Clonidine
c) neuro referral
d) psych referral

Answer 33

a) reassurance

- -> transient tic d/o: includes multiple motor and/or vocal tics with a total duration of sx of

Question 34

A 6yo has a tumor compressing the brainstem. What set of sx can be expected?

a) word retrieval difficulties, seizures, hemiparesis
b) ocular palsies, diplopia, and nystagmus
c) intellectual changes, seizures, hearing loss
d) visual field defects, precocious puberty, seizure

Answer 34

b) ocular palsies, diplopia, and nystagmus

brainstem tumors = n/v, diplopia, weakness, unsteady gait, headache, drowsiness
–hydrocephalus is common

Question 35

A 9yo presents with paresis of the right side of the face. On PE the corner of the mouth droops, but he is able to close the right eye. Which is the most likely dx?

a) peripheral 8th nerve palsy
b) peripheral 7th nerve palsy
c) central fifth nerve palsy
d) central seventh nerve palsy

Answer 35

d) central seventh nerve palsy