Test

Question 1

75 yr od shows small infarction in the right cortex. Her neurological exam would most likely demonstrate which of the following

focal neurological signs
headache
loss of consciousness
papilledemia

Answer 1

A small infarction is indicative of an ischemic stroke. Ischemic strokes do not usually produce headache. Increased intracranial pressure is also unlikely because there is not an expanding hematoma. Therefore loss of consciousness and papilledema would not be expected. Focal neurological signs would be expected because of the small circumscribed lesion.

Question 2

Give an example of a communicating hydrocephalus

Answer 2

=excess CSF production from the choroid plexus

Question 3

83 yr old has pain in her back on the left side. She often has shooting pain in left leg in front of the thigh and weakness in the left quadriceps muscle. Her deep tendon reflex at the left knee is 1+ and 2+ on the right. Her sensory and motor test are normal below the knee. Based on these findings, the neurologist suspects a lesion in which of the following structures

Answer 3

Spinal nerve

There are both motor and sensory signs so dorsal root, quadriceps, ventral horn is unlikely. If a spinal cord was affected the symptoms would be below the level of the lesion rather than along a dermatome/myotome distribution. The lesion is most likely in the L4 spinal nerve, although it could be L3 too.

Question 4

A 51 yr old was brought to the emergency room by her husband. She was vomiting and confused. According to her husband she returned from taking a run and said she had suddenly experience the “worst headache of my life”. She reported feeling sick. What caused this?

Answer 4

A ruptured berry aneurysm- sudden onset severe headache is a classic sign of subarachnoid hemorrhage. A rupture berry aneurysm is the most common cause of a nontraumatic subarachnoid hemorrhage. `

Question 5

39yr old complains of sharp pain in neck and right arm. She has sensory loss in her right shoulder. During reflex testing, she is found to have a weaker reflex response to a tendon tap to both the biceps and brachioradialis muscle tendons on the right compared to left. Which of the following spinal nerves is most likely to be involved.

Answer 5

right C5 - the brachioradialis and biceps stretch reflexes are mediated by C5-C6 afferents and efferents so these would be weakened by a C5 lesion. The sensory pattern suggests a C5 lesion.

Question 6

23 yr old girl has headaches and later presented with cerebellar ataxia and paralysis. These progressed over a period of 1 year. An MRI of her brain and spinal cord revealed an abnormality in the posterior fossa with cerebellar tonsils herniating through the foramen magnum. There is also a cyst in the cervical spinal cord. She is most likely to be diagnosed with which of the following conditions.

Answer 6

Chiari type 1malformation. Most common symptoms are a syrinx, headache, cerebellar dysfunciton and impaired movement from brain stem compression. Meningomyelocele which was not present in this case is associated with chiari malformation type 2.

Question 7

A 65 yr old man suddenly collapses in home. He has flaccid paralysis on the right side of his body. After several days the flaccid paralysis becomes spastic. He has a Babinski sign, hypertonia of all the limbs on the right and exaggerated stretch reflexes in the upper extremity and lower extremity. Which of the followign would be expected of this man’s facial muscles.

Answer 7

THe right lower facial muscles would be paralyzed the right upper facial muscles would be intact.

Question 8

Electromyography was included in her neurological exam and the report stated she had fibrillation potentials in her finger flexor and extensor muscles.

Answer 8

Fibrillation potentials are msot likely caused by denervation of the muscle. ALS would most likely cause fasciculations or twitching of the muscles.

Question 9

Describe the GABAa receptor.

Answer 9

It is an ionotropic receptor that allows chloride to enter the neuron thereby inhibiting it.

Question 10

A 27 yr old comes to the emergency room after receiving a gunshot wound. The bullet damaged the thoracic spinal cord at T2. Both sensory and motor pathways were affected. After arriving at the emergency room and stabilized, this patient received a neurological examination and it was determined that the entire psinal cord was severed. Which of the following would be expected from the motor examination.
0+ triceps tendon bilaterally
Grade 3 strength in ankle extensor muscles
Grade 0 of the right and left quadriceps muscle

Answer 10

Person would be expected to be experiencing spinal shock in which the entire spinal cord is unresponsive below the level of the lesion. The upper extremity would not be affected since it is above T2

Question 11

A 65 yr old man suddenly collapses in home. He has flaccid paralysis on the right side of his body. After several days the flaccid paralysis becomes spastic. He has a Babinski sign, hypertonia of all the limbs on the right and exaggerated stretch reflexes in the upper extremity and lower extremity. What lesion could produce all these symptoms

Answer 11

The symptoms are upper motor neuron syndrome. So you should remember the course of the corticospinal tract. With symptoms on the right the affected tract would begin in the left motor cortex, descend through the internal capsule and cerebral crus, cross over in the pyramidal decussion.

A: left internal capsule.

Question 12

An MRI performed on a 19 year old girl reveals an intracranial, dural based mass. A dural tial is seen. In addition to the mass, masses are seen on both vestibular nerves. Hearing testing shows mild hearing loss on the right. What predisposition syndrome does she have.

Answer 12

Verocay bodies, Schwannoma, NF2.

NF1 would have more PNS presentation like cutaneous neurofibromas.

Question 13

A 27 yr old person is diagnosed with a tumor in the meninges that is pressing on the spinal cord at C5. The MRI reveals displacement of the tissue in the area of te lateral corticospinal tract on the right side. The most lateral fibers in the tract are affected. These fibers project to….

Answer 13

The right lower limb-
the somatotopic arrangement of the corticospinal tract in the spinal cord is with the upper limb fibers located medial to those going to the motor neurons of the lower limb. This pathway is ipsilateral in the cord so the right lower limb would be affected.

Question 14

When would light headedness be a concern with cholinergic drugs?

Answer 14

Light headedness due to postural hypotension might occur with sympathetic blockade with a ganglion blocker (ganglia have nicotinic receptors)

Question 15

Glutamate:

Answer 15

most commonly used neurotransmitter in the brain, neurotoxic at high concentrations, a nonessential amino acid, often synthesized from glial-synthesized glutamine.

Question 16

What is sacral sparing and why is it useful?

Answer 16

Sacral sparing can detect a incomplete lesion. A complete lesion of the spinal cord would lead to no sacral sparing.

After spinal shock syndrome and the return of the Bulbocavernosus reflex.
The bulbocavernosus reflex (BCR), is a polysynaptic reflex that is useful in testing for spinal shock and gaining information about the state of spinal cord injuries (SCI).
It involves squeezing the penis and monitoring the internal/external anal sphincter.

Able to perceive pinprick stimulation of perianal skin, dorsiflex the toes.

Question 17

What are major differences between warmth sensitive thermoreceptors and temperature sensitive nociceptors.

Answer 17

• nociceptors require higher temperatures to be activated
• within the range of painful temperatures, thermoreceptors fire at a constant right
• over a range of increasingly painful temperatures, nociceptors fire at an increasing rate

Question 18

Patient has bilateral loss of motor and sensory function from about T4 down including the lower extremities. At 36 hours later, the boy is able to dorsiflex his toes, slightly move his right lower extremity at the knee and is able to perceive pinprick stimulation of the perianal skin (sacral sparing). What best describes the spinal cord lesion?

Answer 18

Answer: incomplete
Although this patient initially presented with complete motor and sensory losses, some function had returned by 36 hours in this case, the lesion is classified as an incomplete lesion of the spinal cord.

Patients with no return of function at 24+ hours and no sacral sparing have suffered a lesion classified as complete and it is unlikely that they will recover useful neurological function.

In a central cord and a large syringomyelia, there is generally sparing of posterior column sensations and in a hemisection the loss of motor function is on the side of the lesion and the loss of pinprick is on the opposite side. (pp. 108–109, Haines)

Question 19

Patient has left shoulder pain and numbness that occasionally radiated down the left arm into the thumb and was increased by neck extension. Exam is normal except for 4/5 deltoid power on the left and decreased pinprick sensation in the left shoulder

Answer 19

Bony osteophytes at C4-C5 causing left C5 radiculopathy.

Left shoulder pain and decreased sensation, left deltoid weakness.

Question 20

weakness of left gastrocnemius and hamstrings, with absent left achilles tendon reflex.

Paresthesias and decreased sensation in the left lateral calf, lateral foot, including the small toe and sole.

Answer 20

L5-S1 posterolateral disc herniation causing left S1 radiculopathy.

Question 21

What is the benefit to adding epinephrine to a solution of lidocaine for a peripheral nerve block.

Answer 21

It will increase the duration of anesthetic action (useful if short or medium duration). Vasoconstriction that prolongs duration also means less local anesthetic is needed so risk of toxicity (seizure) is reduced.

Question 22

Which drug blocks the effects of injected heroin for up to 48 hrs and is proposed as a maintenence drug for treatment programs of opiod addicts.

Answer 22

naltrexone - has a much longer half life than naloxone.

Question 23

{Patient said he had a fix. He exhibits dilated pupils, muscle aches, vomiting, hyperthermia, chills and hyperventilation. What is going on?

Answer 23

Opioid abstinence syndrome aka withdrawal. Usually starting 6-10 hours after last dose. Rhinorrhea, lacrimation, piloerection, muscle jerks and yawning.

Question 24

• complaint of numbness and tingling in lower extremities for about 10 months
• notes no weakness
• reduced sensation to light touch, pin prick and vibratory sensation in feet extending up to knees.
• chest abdomen and upper extremities have normal sensation.
• absent achilles reflex bilaterally

Answer 24

Standard presentation for peripheral neuropathy - diabetes

-sensory are more affected than motor.

• mononeuritis does not have a glove and stocking distribution initially
• GBS is acute onset and usually motor findings (most common cause of acute paralysis, rapidly progressing, could cause respiratory failure and fatality)

Question 25

• low back pain two days ago
• numberness and tingling in feet, gradually seem to worsen
• noon, difficulty walking
• no bowel or bladder incontinence
• strength of 5/5 in upper extremities
• 4/5 proximally in lower
• 3/5 distally
• mild decrease in pinprick and light touch in mid-calf.

Reflexes in lower extremities are trace at the knees and absent at achilles

Answer 25

Guillain-Barre syndrome: acute onset of bilateral lower extremity weakness and sensory deficits.

Stroke would not be bilateral.

Question 26

Neurologist is testing a child who had an injury from sledding. The patient closes her eyes and moves her left great toe upwards and downwards. The child is asked to verbally indicate the direction of the toe: “up or down”. This tests sensory afferents and a pathway that lies where? (indicate side)

Answer 26

left dorsal column- fibers carrying this information from the left great toe are large diameter afferents from joint and muscle receptors. They enter the left dorsal root and then go directly into the left dorsal column (fasciculus gracilis to end in the nucleus gracilis.

Question 27

25 year old male is transported by ambulance to the emergency room after a head on collision with another car. The patient was found by paramedics in the car and he was found with a large laceration to the forehead on the left. Which imaging study is the best to assess for intracranial hemorrhage

Answer 27

A noncontrast head CT is the standard for evaluation of acute blood which would be hyperdense. Subtle areas of acute blood may not be seen on MRI. Cather angiography would be appropriate for evaluation of intracranial vasculature.

Question 28

The 45 yr old man is referred for exam after experiencing left sided low back pain that has progressively worsened over the last two years. In the last week his left leg is also weak and stiff. The neurological exam revealed weakness of the muscles around the left knee and ankle with a +4 achilles tendon reflex. He had a positive babinski sign in the left foot as well. There is numbness and tingling in the medial calf. Otherwise his sensory exam is normal in all limbs. The cranial nerves exam is normal.

The most likely location of the lesion causing his symptoms is in the…

What is the likely underlying condition?

Answer 28

left lumbar spinal cord lesion (Corticospinal tract)

Extramedullary tumor: because he is showing both CST symptoms and spinal nerve (L4 symptoms). The symptoms progressed slowly which suggests a tumor or disc rather than a stroke. An extramedullary tumor would affect entering L4 dorsal roots which also compressing the spinal cord in the location of the CSt. Extramedullary tumors are also likely to compress structures that produce pain such as this man reported.
Syringomyelia which can interrupt crossing pain and temperature fibers WOULD NOT produce motor deficits unless it was very large and would be less likely to produce pain. Herpes zoster produces SENSORY, NOT MOTOR deficits

Question 29

An 11 year old boy is brought to the family physician because she has been complaining that her hands feel funny. His mother states that the boy cut his little finger but did not realize it until he saw blood. The examination reveals a bilateral loss of pain and thermal sensations on the upper extremities and shoulder. Which of the following is the most likely cause of this deficit.

Answer 29

Syringomyelia - pain and temperature are affected without any other sensory or motor functions. Syringomyelia affects a dermatomal distribution so a long pathway is not involved. Although peripheral neuropathies like those due to diabetes, it can selectively affect pain and temperature, the pattern of sensory loss usually affects the distal limb rather than an entire dermatome.

Question 30

56 year old man comes to ER. He reports feeling dizzy and also feeling moody and irritable. Patient has a positive Romberg test and reduced vibration sense. Syphilis test was normal. What is the underlying condition

Answer 30

Decreased blood B12 levels
- can produce dorsal column lesions and can also affect the central nervous system.
Diabetes does into affect CNS neurons. A subdural hematoma would not be likely to produce the vibration and proprioceptive losses.

Question 31

85 year old male presents for an irrigation and debridmenet of gangrenous ankle. The surgeon request that the anesthetic onset be as quick as possible. Which LA would be the best suited for this scenario

Answer 31

In this case Mepivacaine was good. pKa 7.8, minimally lipophilic.

The LOWER the pKa and lower the lipophilicity, the faster the onset of blockade. Benzocaine has a very low pKA but it is used only as topical anesthetic. Quick onset also think ester.

Question 32

You perform a spinal anesthetic, what is order for loss of nerve function

Answer 32

autonomic blockade, somatosensory loss, motor loss (proximal > distal)

Question 33

What is buprenorphine used for?

Answer 33

Like methadone it is used in opiate detoxification and could precipitate withdrawal. *the only partial agonist

Question 34

What is the most important factor for why axons in CNS do not regenerate while PNS does

Answer 34

formation of glial scars

Question 35

a 71 yr old woman notices she has red marks in a few areas on her back and has excruciating pain in those regions especially where her bra rub along her back. The paresthesias induced by her condition are most likely the result of firing in primary afferents

Answer 35

Case is most likely herpes zoster. Reactivation of latent varicella-zoster virus in dorsal root ganglia results in a decrease in the threshold of activation for sensory neurons so there is spontaneous firing and persistent pain. The dermatomal region innervated by that DRG>

Question 36

What is the only sure test of demyelination

Answer 36

decreased nerve conduction velocity. Fibrillation only indicates a denervated muscle but will not distinguish if cause is demyelination or other. Romberg test and 2 point discrimination are affected with dorsal column lesions but again the cause might be demyelination or interruption of fibers.

Question 37

61 yr old was seen by a neurologist after ongoing complaints of pain in the right hand which seemed to be getting worse. Patient described pain as being in palm of hand in the right thumb and forefinger. He had numbness in the same region also. To distinguish between a carpal tunnel and spinal nerve problem, the neurologist would most likely perform which of the following tests on the right side.

Answer 37

The thumb and forefinger are both innervated by C6 and the median nerve. One way to distinguish between the two is to determine whether the sensory loss is also in the C6 dermatome above the wrist. The tricpes reflex would not be helpful because it tests C7! and the C5 dermatome is not part of the differential because C5 does not innervate the palmar hand. Grip strenght could be decreased in all conditions and would not be useful.

Question 38

A 48 yr old firefighter suffered closed head injury when the floor of burning building collapsed. MRI revealed near symmetric lesions confined to the ventral aspects of the occipital and temporal lobes. Which visual deficit is this patient most likely to experience

Answer 38

Prosopagnosia and achromatopsia (commonly together). The damage confined to the ventral aspects of the occipital and temporal fields and is bilateral .These regions house the fusiform face area and bilateral damage leads to prosopagnosia. V4 primarily concerned with color processing also resides in this area and damage can lead to ahcromatopsia. Akinetopsia is usually associated with damage to V5 which is on the lateral surface of the brain.

Question 39

Patient has damage to left temporal lobe and the radiations housed there. What is the visual field deficit

Answer 39

Contralateral homonymous superior quadrantanopia and is produced by interruption of Meyer’s loop passing anteriorly through the temporal lobe. This part of the optic radiation contains information from the contralateral upper portion of the visual field as seen by both eyes.

Question 40

Patient with calcified neoplasm compressing the superior aspect of the optic chiasm. Which VF will be most evident.

Answer 40

Inferior bitemporal quadrantanopsia.

Question 41

A lesion to the left optic tract would most likely lead to which of the following visual field effects

Answer 41

right contralateral homonymous hemianopia.

Question 42

Features of a nocontrast CT

Answer 42

1. bone is showing up hyperdense
2. less able to show grey and white matter.
3. The vessels are dark as blood is flowing and non coagulated, I supposed relative to a T2 .

Question 43

your patient has low intraocular pressure, what would you prescribe to increase production of aqueous humor

Answer 43

A beta 2 agonist

Question 44

Patient has sudden onset of severe headaches and nausea. Examination of her retinas shows an enlarged optic disc. You suspect an increase in intracranial pressure. What is the condition called and the likely mechanism?

Answer 44

Increases CSF pressure due to space occupying lesions (tumor and ruptured cerebral artery) can compress the central retinal vein in the optic nerve reducing venous return and causing papilledema. The central retinal artery is not affected due to its higher pressure and thicker wall.

Question 45

What do each of these drugs do?

Tropicamide
Atropine
Phenylephrine
Timolol (beta blocker)
Brinzolamide (carbonic anhydrase inhibitor)

Answer 45

Tropicamide: muscarinic antagonist to induce mydriasis

Atropine: a muscarinic antagonist user to induce cycloplegia. (No accomodation)

Phenylephrine: alpha agonist used to contract dilator muscle to induce mydriasis

Timolol (beta blocker): decreases production of aqueous humor

Brinzolamide (carbonic anhydrase inhibitor): decreases production of aqueous humor.

Question 46

82 year old white male smoker has decreases vision in right eye. Peripheral vision is normal but central vision is significantly reduced. Most likely diagnosis is:

Answer 46

Age related macular degeneration

Question 47

38 yr old woman presents with features of intraretinal hemorrhages in all quadrants and swelling of central macula. Diagnosis correctly as having central vein occlusion. Appropriate workup to get this requires:

Answer 47

Ruling out hypertension

Question 48

A 26 yr old male develops muscle weakness in both legs over the last week. His history included no previous significant illness besides a URTI 3 weeks ago. He was found to have depressed achilles and patellar deep tendon reflexes but the reflexes in his upper arms were normal. There is reduced motor conduction velocity along the nerves supplying the lower limb muscles. Manual muscle testing showed scores of 3-4 through distal legs but hip trunk and arm muscles were 5/5. His sensory tests were normal. The neurologist suspects that this man has what?

Answer 48

Guillain Barre

Question 49

65-year-old white male complains of “seeing wavy lines” or “window blinds” when looking at the doorway with his right eye. He has no pain or other ocular symptoms. His past medical history is significant for hypertension. He has a 40-pack-year smoking history. On examination, his visual acuity is 20/400 in the right eye. He has no RAPD and slit-lamp examination reveals that his anterior segment is normal. Examination of his right fundus reveals a subretinal hemorrhage involving his fovea.
What caused the patient’s vision loss?

Answer 49

Age-related macular degeneration (AMD)

Dry AMD is the non-neovascular form of AMD. It is characterized by drusen (yellow-
white lesions in the outer retinal layers of the macula) or atrophy within the macula.
Dry AMD may lead to wet (neovascular) AMD, which is associated with a choroidal neovascular membrane (CNVM). The CNVM is an abnormal growth of subretinal blood vessels, which grows in the macula or fovea and affects vision due to fluid
leakage.

Question 50

40-year-old white female presents to your ED complaining of seeing “little floating black spots” in her vision in the left eye. She also notes little sparks of light in the temporal periphery of the left eye. On examination, there is no RAPD (she has normal direct and consensual pupillary reflexes). Confrontation visual fields demonstrate peripheral vision loss in the left eye. Dilated peripheral retinal examination reveals billowing gray folds. The macula appears normal, and her vision is 20/20 in that eye. What is she experiencing?

Answer 50

This patient is presenting with urgent ophthalmologic disease. She has classic symptoms of retinal detachment—flashing lights, visual
field disruption, and floaters. Also, the majority of her vision is still intact. In her
current state, she has a high likelihood of retaining good vision. None of the other
treatments offered do anything for retinal detachment

Question 51

55-year-old white male complains of a gradual decrease in vision in both eyes. He notes glare with oncoming headlights while night driving. Despite this, he feels that he is able to read better without his bifocals.
What is going on?

Answer 51

Cataracts

Progressive visual loss and glare from oncoming
headlights while driving at night are common complaints caused by cataracts. The eye examination can confirm the diagnosis, as most significant cataracts are easily
visualized. The red reflex is diminished bilaterally, and a haze of gray is observed over the lens.

Symptoms of retinal detachment (“A”) are more acute. Glaucoma (“C”)
and diabetic retinopathy (“D”) are less likely, but could also be present. Intraocular
pressures and a dilated eye examination should be completed to adequately assess
and diagnose the patient’s condition.

Question 52

Diagnosed with a left L5/S1 posterateral herniated disc. careful motor exam reveals?

Answer 52

Left plantarflexion weakness when asked to stand on toes

Question 53

Riluzole

Answer 53

Drug that can slow down progression of ALS by several months. It does this by blocking glutamate which is implicated in neurodegenerative diseases like ALS, Alzheimers, Parkinsons