Items 393395

A 60-year-old right-handed man underwent heart transplantation 2 weeks ago for severe ischemic cardiomyopathy. He had an uneventful postoperative course and went home after 1 week. He is now readmitted from an outside hospital where he was admitted with headaches, increasing confusion, and a generalized seizure. He relates that he has had difficulty seeing for several days. On exam, he has a blood pressure of 180 100. His pupils are equal and reactive, but he has difficulty reading and finding...

Items 426429

A 35-year-old man injured his thoracic spine in a motor vehicle accident 2 years ago. Initially he had a bilateral spastic paraparesis and urinary urgency, but this has improved. He still has pain and thermal sensation loss on part of his left body and proprioception loss in his right foot. There is still a paralysis of the right lower extremity as well. 426. This patient has which spinal cord condition a. Brown-S quard (hemisection) syndrome 427. In this patient, where would you expect the...

Items 6670

For each clinical scenario, pick the language disturbance that best explains the clinical picture. c. Transcortical sensory aphasia 66. A 62-year-old man with a history of myocardial infarction awakens with a dense right-sided hemiplegia. His eyes are tonically deviated to the left, and he does not respond to threat on the right side of his visual field. He appears to be alert and responds to pain on the left side of his body. His speech is unintelligible and nonfluent, and he follows no...

Answers

The answer is d. (Rowland, pp 708-713.) Motor neuron disease in the anterior horns of the spinal cord and damage to the corticospinal tracts or motor neurons contributing axons to the corticospinal tracts would account for these neurologic signs. Damage to the dorsal spinal root would be expected to produce sensory, rather than motor, deficits and would produce areflexia, rather than hyperreflexia, at the level of the injury. Damage to the ventral spinal roots would produce weakness and...

Items 5356

A 22-year-old male abuser of intravenous heroin complains of severe headache while having sexual intercourse. Within a few minutes of that complaint, he develops right-sided weakness and becomes stuporous. His neurologic examination reveals neck stiffness as well as right arm and face weakness. An unenhanced emergency CT scan reveals a lesion of 3 to 4 cm in the cortex of the left parietal lobe. The addition of contrast enhancement reveals two other smaller lesions in the right frontal lobe but...

Items 1718

A 33-year-old woman has the acute onset of right orbital pain after a tennis match. The following morning, her 10-year-old son comments that her right eye looks funny. On examination, she has a mild right ptosis and aniso-coria. The right pupil is 2 mm smaller than the left, but both react normally to direct light stimulation. Visual acuity, visual fields, and eye movements are normal. The site of injury is due to interruption of fibers from which of the following structures 18. Magnetic...

Items 490494

A 22-year-old woman presents to the emergency room with an episode of acute painful loss of vision in the right eye. On examination, there is right afferent pupillary defect and papillitis on funduscopic examination. She has no history of neurologic symptoms. An MRI shows a few foci of T2 signal increase in a periventricular distribution. 490. Appropriate treatment for presumed optic neuritis in this patient would be b. Intravenous methylprednisolone 491. This patient's chances of eventually...

Items 3337

For each clinical scenario, choose the single study that is most likely to establish the diagnosis and direct further treatment. c. Nerve conduction (NC) studies f. Serum creatine phosphokinase (CPK) h. Myelography of the spinal canal i. Cranial computerized axial tomography (CAT) j. Skull x-ray k. Visual evoked responses (VER) l. Nerve biopsy 33. A 65-year-old man with a history of atrial fibrillation is brought into the emergency room (ER) at 1 00 p.m. because of the acute onset of...

Neurology

PreTest Self-Assessment and Review Fifth Edition Department of Neurology Stanford University School of Medicine Stanford, California McGraw-Hill Medical Publishing Division New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright 2004 by The McGraw-HIll Companies, Inc. All rights reserved. Manufactured in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this...

Contents

The Neurological Examination and Diagnostic Tests Answers, Explanations, and References 18 Answers, Explanations, and References 42 Answers, Explanations, and References 62 Answers, Explanations, and References 75 Answers, Explanations, and References 86 Answers, Explanations, and References 106 Answers, Explanations, and References 125 Copyright 2004 by The McGraw-Hill Companies, Inc. Click Here for Terms of Use.

Questions

DIRECTIONS Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question. 1. An 85-year-old man is being evaluated for gait difficulties. On examination it is found that joint proprioception is absent in his toes. People with impaired position sense will usually fall if they stand with their feet together and do which of the following b. Extend their arms in front of them Copyright 2004 by The McGraw-Hill Companies,...

Items 482486

A 26-year-old man is brought into the emergency room after a motorcycle accident in which he was not wearing a helmet. Computed tomography (CT) scan shows bifrontal hemorrhagic contusions. The Glasgow Coma Scale (GCS) score is 6. He has no verbal response, opens his eyes to painful stimulation only, and shows a flexion response to pinch of the extremities. 482. This patient's head injury may be classified as 483. The presence of periorbital ecchymosis in this patient should be considered a sign...

Bibliography

Bradley W et al (eds) Neurology in Clinical Practice, 4 e. Boston, ButterworthHeinemann, 2000. Braunwald E, et al (eds) Harrison's Principles of Internal Medicine, 15 e. New York, McGraw-Hill, 2001. Greenberg DA, et al Clinical Neurology, 5 e. New York, McGraw-Hill, 2002. Greenberg JO (ed) Neuroimaging, 2 e. New York, McGraw-Hill, 1999. Hauser R, et al Parkinson's Disease Questions and Answers. Coral Springs, FL, Merit, 2000. Kandel ER, et al (eds) Principles of Neural Science, 4 e. New York,...

Items 356360

Choose the toxic substance likely to produce each clinical picture. f. Phencyclidine hydrochloride (PCP) 356. A 45-year-old Portuguese immigrant develops abdominal pain in the early evening after eating grouper for lunch. He later develops fatigue, headache, and paresthesias. He reports on examination that a cold tuning fork feels excessively hot to the touch. (SELECT 1 SUBSTANCE) 357. A 30-year-old refugee from sub-Saharan Africa is malnourished. She has a subacute spastic paraparesis and gait...

Items 396400

For each clinical scenario, select the probable visual field discovered on tangent screen testing as depicted. Reproduced, with permission, from Adams RD Principles of Neurology. New York, McGraw-Hill, 1997. 396. A 30-year-old woman with diabetes mellitus and menstrual irregularities complains of chronic headaches with blurring of vision. On examination, she has a lantern jaw, prominent nose, spade-shaped hands, and prominent supraorbital ridges. She is slightly taller than other members of her...

Items 457460

A 20-year-old ataxic woman with a family history of Friedreich's disease develops polyuria and excessive thirst over the course of a few weeks. She notices that she becomes fatigued easily and has intermittently blurred vision. 457. The most likely explanation for her symptoms is a. Inappropriate antidiuretic hormone d. Progressive adrenal insufficiency 458. The peripheral neuropathy that would be expected to be seen with this patient develops in part because of degeneration in 459. This...

Items 461463

A 17-year-old male presents with 10 days of progressive tingling paresthesias of the hands and feet followed by evolution of weakness of the legs two evenings before admission. He complains of back pain. He has a history of a diarrheal illness 2 weeks prior. On examination, he has moderate leg and mild arm weakness, but respiratory function is normal. There is mild sensory loss in the feet. He is areflexic. Mental status is normal. 461. Spinal fluid analysis in this case is most likely to show...

Items 464467

Match each clinical scenario with the most likely diagnosis. c. Riley-Day disease (familial dysautonomia) d. Parsonage-Turner syndrome (brachial plexopathy) f. Chronic inflammatory demyelinating polyneuropathy (CIDP) g. Acute intermittent porphyria h. Reflex sympathetic dystrophy 464. A 26-year-old woman develops the acute onset of left shoulder pain. Over the following week, she develops weakness in the proximal left arm and mild sensory loss. On examination, she has scapular winging and...

Items 477478

A 32-year-old woman with alcoholism and cocaine use dating back at least 10 years comes to the emergency room after 48 h of recurrent vomiting and hematemesis. She reports abdominal discomfort that preceded the vomiting by a few days. For at least 36 h, she has been unable to keep ethanol in her stomach. Intravenous fluid replacement is started while she is being transported to the emergency room, and while in the emergency room she complains of progressive blurring of vision. Over the course...

Items 487489

A 47-year-old woman begins to have difficulty swallowing food at dinner. Over the following 3 h, she develops diplopia, dysarthria, and ultimately anarthria. She has a history of hypothyroidism and is on thyroid hormone replacement. There is no history of exposure to ticks or recent travel. On exam, she nods her head appropriately to questions, and she can write. Forced vital capacity is 500 mL, and she is intubated. She is afebrile, tachy-cardic, and normotensive. Bilateral ptosis and...

Items 499500

A 56-year-old man is brought into the emergency room after having collapsed at work 30 min ago. He has no medical history and takes no medications. He is alert and speaking but has no awareness of any deficit. He has a right gaze preference, dense left face and arm plegia, and mild left leg weakness. When asked to raise his legs, he lifts only the right leg. He has reduced blink to threat from the left side. 499. The most appropriate initial diagnostic step is 500. A head CT scan shows no...

Nutritional and Metabolic Disorders

Answers, Explanations, and References 143 Answers, Explanations, and References 161 Answers, Explanations, and References 175 Answers, Explanations, and References 191 Developmental and Hereditary Disorders Answers, Explanations, and References 209 Answers, Explanations, and References 228 Answers, Explanations, and References 240 Answers, Explanations, and References 258

Items 430433

A 61-year-old man, who smokes five packs of cigarettes per day and has hypertension, had an abdominal aortic aneurysm repair 8 h ago. The surgery went very well, and there were no reported perioperative complications. Now the patient is unable to move his legs and states that they are numb. On examination, he has a flaccid paresis of both lower extremities and has impaired pinprick sensation to a T9 level bilaterally. Joint proprioception is normal. 430. The most likely diagnosis in this case...

Items 3844

For each clinical scenario, choose the CSF pattern most likely to be found. 38. A 26-year-old woman with a 7-year history of epilepsy develops a generalized convulsion while shopping. She is taken to an ER, but no one accompanying her is aware of the previous history of epilepsy. Because she has a protracted postictal period, numerous investigations are performed over the course of the next hour. CT scan is completely normal, but her arterial blood gases reveal a mild acidosis. (SELECT 1...

Used Class Cglioblastomas

DIRECTIONS Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question. A 65-year-old right-handed woman began having neurological problems about 1 week ago. She began experiencing nausea, vomiting, and numbness in the left hand and left foot. Today she had a generalized convulsion, and since then she has had a throbbing headache that is worse when she bends forward. On examination, the only deficits she has are loss...

Items 479480

A 57-year-old woman with a history of diabetes mellitus and hyperthy-roidism presents to the emergency room with a history of 2 days of vertical and horizontal diplopia. There is moderate orbital pain. On examination, her left eye is deviated downward and outward. It can be passively moved medially and upward. The pupils both react normally. 479. This woman most likely has 480. The etiology of her diplopia is most likely 481. A 33-year-old operating room nurse accidentally has blood splashed in...

Conscientious Pulmonary Toilet

The answer is a. (Victor, p 1484.) Dermatomyositis occurs as a paraneoplastic syndrome in about 15 of cases overall. Among those over age 40, the proportion of paraneoplastic cases increases to 40 for women and 66 for men. Tumors underlying dermatomyositis may develop in the lungs, ovaries, gastrointestinal tract, breasts, or other organs, but the CNS is generally not the site of a tumor associated with dermatomyositis. Because of the higher probability of malignancy in adults with...

Items 447450

A 32-year-old man living along the coast of Massachusetts presents with an acutely evolving left facial weakness. Although he has no facial pain or numbness, he does complain of diffuse headache. He has no history of diabetes mellitus or other systemic illnesses, but does report newly appearing joint pains and a transient rash on his right leg that cleared spontaneously more than 1 month prior to the appearance of the facial weakness. On examination, he has mild neck stiffness and pain on hip...

Items 441446

A 72-year-old man complains of pain about the waist at the level of the umbilicus. The pain is often burning and occasionally shooting. It does not extend down his legs, but he has noticed some weakness in his legs at the time of the pain. With exertion, such as walking, he develops pain in his legs and a tingling sensation in his feet. He has been taking aspirin for the discomfort, but has noticed no substantial change in the sensation. X-rays of his spine reveal no abnormalities. Pain and...

Items 368369

A 19-year-old woman with complaints of headaches and visual blurring has prominent bulging of both optic nerve heads with obscuration of all margins of both optic discs. Her physician is reluctant to pursue neurologic studies because the patient is 8 months pregnant and had similar complaints during the last month of another pregnancy. Her physical and neurologic examination are otherwise unrevealing. 368. If neuroimaging studies were to be performed on this woman, they probably would reveal...