(Test Bank) PaEasy Neuro Test bank question and answers, graded A+. 2022

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PaEasy Neuro Test bank question and answers, graded A+. 2022 A 75 -year -old man is involved in a motor vehicle accident and strikes his forehead on the windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical examination reveals weakness of his upper extremities. What type of spinal cord injury does this patient have? A anterior cord syndrome B central cord syndrome C Brown -Séquard syndrome D complete cord transection E cauda equina syndrome - ✔✔Central Cord Syndrome the central cord syndrome involves loss of motor function that is more severe in the upper extremities than in the lower extremities, and is more severe in the hands. There is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function. Brown -Séquard syndrome consists of weakness and loss of posterior column functio n on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic function one to two levels below the lesion. Complete cord transection would affect motor and sensory function distal to the lesion. Cauda equina syndrome typic ally presents as low back pain with radiculopathy. A 17 -year -old boy develops progressively abnormal muscle fatigability. He is diagnosed as suffering from myasthenia gravis and is admitted into a hospital. In the course of his treatment with pyridostigmi ne, he develops increased weakness, nausea, vomiting, sweating, and bradycardia. What is the best management for this patient? Answer Choices 1 Thymectomy 2 Corticosteroids 3 Plasmapheresis 4 Withdrawal of pyridostigmine 5 Addition of neostigmine - ✔✔Withdrawal of pyridostigmine Explanation The patient is having a cholinergic crisis. The over -dosage of cholinesterase inhibitors, such as pyridostigmine and neostigmine, results in cholinergic crisis; it is characterized by s alivation, lacrimation, urinary incontinence, emesis, and other symptoms like colic, diarrhea, and miosis. These symptoms are similar to myasthenic crisis, and because treatment differs in both, the 2 conditions need to be differentiated. After stabilizing the patient, edrophonium testing should be done in order to distinguish between a myasthenic and a cholinergic crisis. The management of patients with cholinergic crisis involves prompt withdrawal of cholinesterase inhibitors. The immediate administration of atropine is also recommended. Thymectomy is indicated in severe cases of myasthenia gravis. It is especially effective in young women. Steroids sometimes help if immunosuppression is needed for thymoma, which may be associated with myasthenia gravis. Plasmapheresis is a treatment for severe cases of myasthenia gravis with or without thymectomy. Neostigmine is an alternative cholinesterase inhibitor. There is no rationale in switching from pyridostigmine if a cholinergic crisis has already occurred. A 33 -year -old African -American woman presents with a new onset of left facial droop. The droop was present when she awoke this morning, and it has worsened since then. She reports that she had been feeling fine. She denies headaches, visual changes, and w eakness or tingling in the extremities. Exam reveals an anxious, overweight woman. She is afebrile. Cranial nerve exam reveals weakness of the entire left side of the face, including the forehead. The left eye does not close entirely, and there is a widene d palpebral fissure. Sensation is intact. All cranial nerves, other than VII, appear intact. Her tympanic membranes are clear, and there are no skin lesions around the face or head. The rest of her exam is unremarkable. Labs reveal normal CBC, serum electr olytes, thyroid function tests, and liver transaminases. A chest X -ray is clear. Question What is the most likely cause of this patient's facial droop? Answer Choices 1 Bell's palsy 2 Sarcoidosis 3 Ramsay -Hunt syndrome 4 Lyme disease 5 Cerebrovascular accident (CVA) - ✔✔Bell's Palsy Explanation This patient has a classic presentation of Bell's palsy. Bell's palsy is a sudden, unilateral facial weakness and affects about 1 out of every 60 or 70 persons in their lifetime. The etiology is unknown at this time, but herpes simplex virus type 1 has been associated with some cases. The presumed pathogenesis of the palsy is that inflammation of the facial nerve causes swelling then secondary compression, and ischemia occurs where the nerve cour ses through the temporal bone. Pain behind the ear may precede the paralysis by a day or 2. Hyperacusis and loss of taste may occur, if the lesion is proximal enough; lacrimation may be affected as well. Sensation is not affected, although patients may ex perience numbness or heaviness in the face. In some cases, there is a mild lymphocytosis of the CSF. MRI may reveal swelling and uniform enhancement of the geniculate ganglion and facial nerve. Also, in some cases, MRI may reveal a swollen facial nerve en trapped within the temporal bone. Prognosis depends upon the degree of paralysis. Approximately 80% of patients will recover within a few weeks to a month. Of those with an incomplete paralysis in the 1st week, nearly all will experience complete recovery within several months. Of those with a more complete paralysis, like this patient, nerve conduction studies and electromyography can indicate prognosis. The likelihood of completely recovery is 90% if the nerve branches in the face retain normal excitabil ity to supramaximal electrical stimulation; however, the likelihood is only about 20% if electrical excitability is absent. Treatment includes symptomatic care, such as taping the upper eyelid closed during sleep and using lubricating agents in the eye In order to prevent corneal desiccation. Some studies have shown improvement in patients treated with glucocorticoids; other studies showed improvement with prednisone and acyclovir together. Sarcoidosis can cause a form of bilateral facial paralysis (facia l diplegia) called uveoparotid fever (Heerfordt's syndrome). Given this patient's African American background, sarcoidosis should be considered as a possible etiology of her symptoms. However, the unilateral nature of the paralysis, combined with a negativ e chest X -ray, makes sarcoidosis unlikely. A serum angiotensin converting enzyme (ACE) could be drawn if sarcoidosis is a concern. Ramsay -Hunt syndrome is a facial palsy associated with a vesicular eruption in the pharynx, external auditory canal, and oth er surrounding areas of skin. This is thought to be secondary to herpes zoster infection of the geniculate ganglion; often the 8th cranial nerve is affected, as well. This patient did not have any skin lesions around the ear, thus making this diagnosis ver y unlikely. However, this demonstrates the importance of a thorough examination in facial palsy patients, including careful examination inside the ears. Lyme disease is a frequent cause of facial paralysis in areas where Lyme infection is endemic. However , the majority of patients who have facial palsy caused by Lyme disease note an antecedent rash adjacent to the site of a tick bite. Blood tests for Lyme disease can help identify that as an etiology. However, this patient denied any risk factors for tick bites such as camping/ travel, making this diagnosis less likely. The family history of CVA and the fact that she is currently taking oral contraceptives do confer some increased risk for thrombotic events in this patient. However, with a stroke, the fore head is usually spared from facial palsy, since the upper facial muscles (the frontalis and orbicularis oculi muscles) are innervated by corticobulbar pathways from both motor cortices. The lower facial muscles are innervated only by the contra -lateral hem isphere. This patient's facial palsy is complete and includes the forehead because the facial nerve itself is affected in Bell's palsy. A 13 -year -old boy presents with dysmorphic features (e.g., a long face, prominent jaw, and large ears), large testes, a nd intellectual disability (intellectual developmental disorder). History reveals that 2 other family members also have intellectual disability. Question What is the most likely clinical diagnosis in this child? Answer Choices 1 Klinefelter syndrome 2 Noonan syndrome 3 Patau syndrome 4 Fragile X syndrome 5 Prader -Willi syndrome - ✔✔Explanation The most likely clinical diagnosis is fragile X syndrome; it accounts for 3% of cases of intellectual disability (intellectual developmental disorder). Macroorc hidism and hereditary intellectual disability are 2 specific features of this syndrome. Fragile sites are regions of chromosomes that have a tendency for separation, breakage, or attenuation under particular growth conditions. 1 fragile site associated wit h fragile X syndrome is on the distal long arm of chromosome Xq27.3. In Klinefelter syndrome, most children (80%) have a male karyotype with an extra X,47,XXY. The remaining 20% have a higher grade of sex chromosome aneuploidy, (i.e., 48,XXXY; 49XXXXY; 48 ,XXYY). Klinefelter syndrome is the most common cause of hypogonadism and infertility in boys/men; puberty occurs at the normal time, but the testes and penis remain small. Noonan syndrome is an autosomal dominant disorder. Clinical features are similar t o Turner syndrome, but Noonan syndrome affects both sexes, while Turner syndrome occurs only in girls/women. Clinical features include a short stature, a low posterior hairline, a shield -like chest, and a short webbed neck. Pulmonary stenosis due to valve dysplasia is the most common cardiac anomaly in Noonan syndrome. In Turner syndrome, the common cardiac defects are bicuspid aortic valve, coarctation of aorta, aortic stenosis, and mitral valve prolapse. Patau syndrome (trisomy 13) is characterized by in tellectual disability (intellectual developmental disorder), cleft lip and palate, microcephaly, low -set ears, central nervous system malformations (e.g., holoprosencephaly), and microphthalmia. Prader -Willi syndrome manifests with hypotonia, intellectua l disability (intellectual developmental disorder), hypogonadism, and hyperphagia (leading to obesity). Some children with Prader -Willi syndrome have a partial deletion of the paternally derived chromosome 15 and loss of paternally - expressed genes. A 54 -year-old man presents after having a generalized seizure. The patient is HIV positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inquiry, th e patient also notes that he has become short - tempered and hypercritical; at times he seems confused. An MRI of the brain is performed, and it reveals several cortical ring -enhancing lesions. Question What is the most likely diagnosis? Answer Choices 1 AIDS dementia complex 2 Cryptococcal meningitis 3 Cytomegalovirus encephalitis 4 Progressive multifocal leukoencephalopathy 5 Toxoplasma encephalitis - ✔✔Toxoplasma encephalitis Explanation The patient's symptoms and MRI findings are most consistent with the diagnosis of toxoplasma encephalitis. Toxoplasmosis is the most common cerebral mass lesion among HIV -positive patients. Infection with the Toxoplasma gondii parasite is relatively common and usually asymptomatic. Reactivation occurs in HIV -positive p atients due to failing cellular immunity, and it causes a multifocal necrotizing encephalitis. Seizures may be the initial manifestation of central nervous system (CNS) infection; other common clinical manifestations include focal neurologic deficits (e.g. , impaired speech and hemiparesis). Personality change, lethargy, headache, and confusion are also observed. The MRI in patients with toxoplasma encephalitis characteristically reveals multiple, ring -enhancing lesions with surrounding edema; these lesions usually occur bilaterally in the frontal and parietal cortices. AIDS dementia complex describes a constellation of cognitive symptoms seen among HIV -positive patients. The condition occurs when the HIV virus disseminates to the CNS. Within the CNS, the virus tends to concentrate in the basal ganglia and subcortical reg ions. Symptoms include a constellation of cognitive, behavioral, and motor disturbances that cause varying degrees of functional impairment. Characteristic MRI findings include non -enhancing white matter, cerebral atrophy, and ventricular enlargement. The diagnosis requires that other central nervous system infections, carcinoma, general medical conditions, and substance abuse have been excluded. Cryptococcal meningitis is caused by the encapsulated fungus Cryptococcus neoformans. Among HIV - positive patien ts, the illness may be the result of new infection or reactivation of latent infection. Presenting signs are often nonspecific; they include headache, fever, change in mental status, and nausea or vomiting. Nuchal rigidity and photophobia may also be prese nt, and elevated intracranial pressure is not uncommon. MRI findings vary, but they include lesions in the basal ganglia; meningeal enhancement, cerebral edema, and shrunken ventricles may also be seen. Cytomegalovirus (CMV) infection causing encephalitis is usually observed in patients with evidence of CMV infection at other sites. MRI findings vary, but they often show areas of focal necrosis within the brain parenchyma, meninges, or periventricular regions. Symptoms typically reflect progressive dementi a, with episodes of confusion, apathy, and focal neurologic deficits. Progressive multifocal leukoencephalopathy is often a fatal disorder; it is caused by reactivation of a latent JC viral infection. Focal neurologic deficits (e.g., hemiparesis and gait disturbance) are often the initial presenting symptoms; they are followed by progressive cognitive decline, coma, and death. The MRI commonly reveals multiple, non -contrast enhancing foci in the cerebral white matter. A 48 -year -old Caucasian woman with a past medical history of hypertension and hypercholesterolemia was diagnosed recently with a cerebral aneurysm. The treatment plan for the aneurysm is endovascular coiling. Among other complications, this patient has an increased risk of thromboembolism postoperatively. Question What is the initial preventive medication that will be used to help minimize this risk in this patient? Answer Choices 1 Abciximab 2 Heparin 3 Coumadin 4 Eptifibatide 5 Tirofiban - ✔✔Heparin Explanation Complications of endovasc ular coiling can include thromboembolism and intra -procedural aneurysm rupture. A study found the incidence of thromboembolism in up to 12.5 % of patients in their patient population group. For this reason, many providers will choose to administer some typ e of combination of heparin and/or antiplatelet therapy to help minimize this potential complication. Coumadin is not indicated as an appropriate choice for this acute procedure. The medications abciximab, eptifibatide, and tirofiban are all anti -platele t/glycoprotein IIb/IIIa inhibitors. These all have been shown to be safe, but they are currently only recommended for use in percutaneous coronary intervention and the prevention of complications in patients with unstable angina/non -ST-elevation myocardial infarction. A 70 -year -old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed b y unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have became "dull". Over the past month, she has started having ur inary urgency and involuntary leaking of urine. Besides multivitamins and local application of the Timolol for glaucoma, she takes no other medications; there are no other symptoms. Question What is most likely the best method of treating the patient's urinary problems? Answer Choices 1 Antimuscarinic drug (Tolterodine) 2 Antibiotic (Sulfamethoxazole/trimethoprim) 3 Acetylcholinesterase inhibitor (Donepezil) 4 Ventriculoperitoneal shunt 5 Kegel exercises - ✔✔Ventriculoperitoneal shunt Explanation Clini cal triad of slowly progressive gait disorder, followed by impairment of mental function and then sphincteric incontinence strongly suggests the presence of normal -pressure hydrocephalus. Ventricular expansion is the cause of symptoms, and surgical CSF shu nting is the main treatment modality. The potential benefit from surgery is usually evaluated by testing gait, cognition, and micturition before and after CSF drainage. Antimuscarinic Tolterodine is an antispasmodic that is used for symptomatic treatment of urinary incontinence in patients with an overactive bladder (urge incontinence). Antimuscarinic drugs are contraindicated in patients with glaucoma. A urinary tract infection will probably manifest with a strong, persistent urge to urinate, burning sensation when urinating, passing frequent, small amounts of urine that has unusual smell and the appearance. Your patient has no such signs and symptoms; therefore, in this case, antibiotics are not indicated. Donepezil is used to treat dementia, but in the case of normal -pressure hydrocephalus, the problem is anatomic (the distortion of the periventricular limbic system and frontal lobes), and the best treatment is probably surgical. Kegel exercises can prevent or control urinary incontinence and other pel vic floor problems in cases of pelvic sphincter weakness. However, pelvic sphincter weakness will probably manifest as stress incontinence. What is the treatment of choice for primary generalized seizures? Answer Choices 1 Phenytoin 2 Phenobarbital 3 Valproic acid 4 Carbamazepine 5 Gabapentin - ✔✔Valproic acid Explanation Epilepsy is defined as a syndrome characterized by recurrent, unprovoked seizures. A seizure is best defined as a discrete neurologic event caused by abnormal, excessive, spontaneou s discharge of cerebral cortical neurons. The phenomenology of a single seizure is dependent upon the origin and subsequent spread of neuronal discharge. Epileptic seizures, as opposed to symptomatic seizures provoked by acute brain disturbances (e.g. hypo natremia, meningitis, cocaine use), are treated medically with anticonvulsants. Specific anti -epileptic drugs are efficacious for different types of seizure. Primary generalized epilepsy is commonly associated with developmental brain disorders of childho od (congenital and acquired). Types of primary generalized seizures include tonic -clonic, absence, tonic, clonic, myoclonic, and atonic. Anticonvulsants indicated for primary generalized seizures include valproic acid, clonazepam, and ethosuximide. Locali zation -related epilepsy results in partial (focal) seizures with or without secondary generalization. These are best treated with phenytoin, carbamazepine, phenobarbital, and valproic acid. The newer anticonvulsants, gabapentin, felbamate, and lamotrigine are also effective for partial seizures. A 64 -year -old man presents with difficulty speaking, trouble swallowing, and right arm weakness. Physical examination reveals dysarthria, tongue deviation to the right, paralysis of the left soft palate, left facia l droop, left facial sensory loss, and right arm weakness. Question These findings suggest involvement in what area? Answer Choices 1 Medulla 2 Left brain stem 3 Left cerebral hemisphere 4 Pons 5 Right midbrain - ✔✔Left Brain stem Explanation Although precise localization of neurologic deficits is often difficult, certain patterns are important to recognize. Brain stem involvement results in 'crossed findings' (e.g., right facial weakness and left arm weakness) because the lesions affect the brain stem nuclei directly (uncrossed) and the corticospinal tract as it is crossing to the opposite side of the body. Because of the unique anatomic arrangement of the brainstem, a unilateral lesion within the structure can cause 'crossed findings' in which ipsilat eral dysfunction of 1 or more cranial nerves is associated with hemiplegia and hemisensory loss on the contralateral side of the body, as described in this case. Medullary syndromes, such as lateral medullary syndrome, are associated with vertigo, nausea, vomiting, nystagmus as well as hiccups, and diplopia; they were not observed in this patient. Medial medullary syndrome is associated with tongue deviation toward the lesion, which is opposite to what is described in this case. Cerebral (cortical) lesion s produce contralateral motor and sensory findings in the limbs and contralateral cranial nerve deficits (e.g., right arm and right facial paralysis). Pontine lesions result in coma, miosis, gaze paresis, and altered respiratory patterns. Cerebellar lesion s produce nystagmus, dizziness, nausea and vomiting, and the inability to stand or walk if midline cerebellar areas are involved. What is the therapeutic window for using recombinant tissue plasminogen activator in acute ischemic stroke? Answer Choices 1 1 hour 2 2 hours 3 3 hours 4 4 hours 5 6 hours - ✔✔3 hours Explanation Tissue plasminogen activator (TPA) catalyzes the conversion of plasminogen to plasmin, which promotes fibrinolysis. Ischemic stroke is caused by sudden occlusion of a cerebral artery by thrombus or embolus, producing a focal neurologic deficit. Timely reperfusion of ischemic brain tissue has been shown to limit irreversible neuronal injury in both humans and animals. The benefit of TPA in acute ischemic stroke was demonstrated in a la rge, multicentered national study. Patients whose symptoms began within 3 hours of treatment with TPA had significantly less disability at the end of 3 months than those given placebo. Although treated patients had higher incidence of secondary brain hemor rhage (6.4% vs. 0.8 %), there was no difference in mortality between the 2 groups. TPA must be given no later than 3 hours of symptom onset in patients with acute ischemic stroke. Prior to treatment, it is essential to exclude cerebral hemorrhage on a hea d CT scan. The presence of a bleeding diathesis, uncontrolled hypertension, recent prior stroke, and past history of cerebral hemorrhage are important contraindications for using TPA in acute ischemic stroke. TPA given later than 6 hours of stroke onset is associated with unacceptable risk of cerebral hemorrhage; it is not known whether fibrinolytic therapy can be given between 3 and 6 hours of stroke onset. A 19 -year -old woman presents to the Accident and Emergency Department following a road traffic accident 20 minutes prior. She states her car was just lightly bumped from behind, but she is concerned she might have whiplash, as her neck is stiff and sore. She also says she's experiencing tingling in her left arm down to her thumb. On physical examination , her bicep strength is +3/5 on the left and +5/5 on the right. Her bicep tendon reflex is 2+ on the left and 2+ on the right. In addition, her brachioradialis tendon reflex is 1+ on the left and 2+ on the right. The remainder of the physical examination i s normal. Question Based on the above presentation, what cervical nerve root is most likely affected? Answer Choices 1 C4 2 C5 3 C6 4 C7 5 C8 - ✔✔C6 Explanation The most likely nerve affected in this case is the C6 nerve root. Impingement of this nerve can cause numbness and tingling down the arm into the thumb, with weakness in the bicep muscle and diminished brachioradialis tendon reflex in the affected extremity. Impingement of the C4 nerve root may cause neck and upper shoulder numbness and pain. Impingement of C5 nerve root may cause deltoid and shoulder numbness and pain, and bicep tendon reflex may be diminished. Impingement of C7 also causes numbness and pain down the affected arm, but reflex may be diminished into the middle finger and the tr iceps,. Impingement of C8 may cause numbness and tingling primarily on the lateral surface of the arm and into the lateral hand into the fourth and fifth digits. It may also cause dysfunction of the hand as it innervates the small hand muscles. You are o n duty in the ER when a young man is brought in by ambulance. The paramedics report that they were called by this man's roommate who reported the patient was confused and dazed, and obviously very ill. The patient is acutely febrile and delirious; there is evidence of meningeal involvement. Subsequent diagnosis reveals viral encephalitis. What is the most common cause of viral encephalitis worldwide? Answer Choices 1 La Crosse 2 Herpes simplex 3 Japanese B 4 Eastern equine 5 Western equine - ✔✔Japanese B Explanation Viral encephalitis is secondary to viral infection of the brain tissue itself, causing widespread death of nerve cells and glia. Approximately 1,000 -5,000 cases per year are reported in the U.S. Worldwide, Japanese B encephalitis is the most co mmon cause of epidemic encephalitis. However, herpes simplex is the most common cause of sporadic encephalitis in the U.S. Arthropod -borne viral encephalitides are transmitted through mosquitoes (most often), and ticks and are named for the region of the U S affected. These included LaCrosse, St. Louis, Venezuelan equine, Western equine, and Eastern equine encephalitides. LaCrosse, a type of California encephalitis, is the most common arthropod -borne encephalitis in the U.S. Eastern equine encephalitis (EEE) is a summertime disease that affects children in the east, south and on the Gulf Coast. The mortality is 50 -75%, with 80% of patients having neurological deficits. Western equine encephalitis (WEE) occurs also in the summer months in states west of the Mi ssissippi River. The mortality is 5 -15%, with infants being the most susceptible. Venezuelan equine encephalitis (VEE) occurs in the southwestern U.S. and Central and South America and has very low mortality and morbidity rates. This infection has been lin ked to epidemics in tens of thousands of cases, however. St. Louis encephalitis occurs in the central, western and southern U.S. and affects older adults in the autumn months. Headaches may be considered primary in origin (migraine, tension -type, and clus ter) or due to underlying metabolic or organic disease. Primary headaches are not associated with any structural disease, but it is believed they are caused by biochemical dysfunction. What statement correctly describes cluster headaches? Answer Choices 1 Patients usually have a positive family history for cluster headaches 2 The headache lasts an average of 30 minutes to 3 hours 3 Cluster headaches occur approximately with equal frequency in males and females 4 Cluster headache pain is typically a moderat e, bilateral, steady pain 5 Menstruation is an exacerbating factor for cluster headaches - ✔✔The headache lasts an average of 30 minutes to 3 hours Explanation Cluster and migraine headaches are attributable to cerebrovascular imbalances and are both referred to as vascular headaches. The cerebrovascular dysfunction in cluster headaches is likely different from that of migraine headaches. Cluster headaches usuall y last from 30 minutes to 3 hours; they occur in groups of 1 to 3 daily over a period of several weeks to a few months. Headache -free intervals range from several months to several years. Clusters occur more often in the spring. The pain is described as e xcruciating and as seeming to bore from one eye back into the head. Accompanying characteristics include ipsilateral tearing, conjunctival congestion, nasal stuffiness, and a partial Horner's syndrome. Aggravating factors are mostly unknown, but alcohol an d sleep may be triggers. Physical activity is known to ameliorate cluster headaches. There is rarely a positive family history and cluster headaches occur more frequently in males. Migraine headaches occur more often in females. Alcohol, chocolate, menstr uation, weather changes, and physical activity are considered triggering factors. Migraine headaches usually have moderate to severe pain described as a unilateral throbbing, and they can last from several hours to several days. Associated symptoms include nausea, photophobia, phonophobia and, less commonly, aura. Most patients have a family history positive for migraines A 72 -year -old man presents with the inability to comprehend spoken language. His speech is fluent and has a normal cadence and rhythm; h owever, when he talks, it is gibberish. He frequently substitutes one word for another. What is this phenomenon called? Answer Choices 1 Paraphasia 2 Echolalia 3 Alexia 4 Apraxia 5 Agraphia - ✔✔Paraphasia Explanation - Paraphasia is a type of aphasia. The substitution of a similar sounding word for another word is called paraphasia. With paraphasia, the words can also be jumbled. If a patient is able to hear things and repeat them, it is called echolalia. With echolalia, the patient does not understand wha t he has heard. This is also referred to as echophrasia. Alexia is a type of aphasia. An aphasia in which there is a problem with reading is called alexia. Alexia is word blindness or text blindness. Alexia is also called optical aphasia or visual aphasia. Apraxia refers to the condition in which a patient has difficulty performing motor acts, despite having the muscular capacity and coordination to do so. A patient with apraxia cannot execute the intended movement. A writing disturbance is called agraphi a. There are various forms of agraphia. With absolute agraphia, even simple letters cannot be written. This is also referred to as literal agraphia. A 23 -year -old woman was diagnosed with multiple sclerosis approximately 2 years ago; she presents to reque st information regarding her risk of exacerbation should she become pregnant. Question What does current information on the subject indicate? Answer Choices 1 No increased risk of exacerbations during pregnancy or in the post partum period 2 Increased ri sk during pregnancy but not during the post partum period 3 Decreased risk during pregnancy and during the post partum state 4 Major increased risk during pregnancy and post partum state 5 Decreased risk during pregnancy with increased risk during the post partum state 6 Increased risk such that exacerbations occurring during pregnancy will not remit - ✔✔Decreased risk during pregnancy with increased risk during the post partum state Explanation Confavreux et al have reported the exacerbation rate per year to be 0.7 in non -pregnant state, decreased during pregnancy (0.5 during first trimester, 0.6 during the 2nd trimester, and 0.2 during the 3rd trimester), and increased during the 3 -month postpartum state (1.2). However, when calculated over the whole pregnancy and post partum state, the risk of exacerbations is increased very little, if at all. A 37 -year -old man fell from a ladder as he finished hanging the Christmas lights on his house. The right side of his head hit the alley cement, and he lost consciousness for about 1 minute; he woke up with a headache, but he had no other complaints. A few hours later, the patient is brought to the emergency room by his neighbor because of an intens e headache, confusion, and left hand hemiparesis. On examination, the patient has a bruise located over the right temporal region, mydriasis, and right deviation of the right eye, papilledema, and left extensor plantar response. An emergency CT scan of the head without contrast reveals a lens -shaped hyper -density under the right temporal bone with mass effect and edema. What is the most likely diagnosis? Answer Choices 1 Epidural hematoma 2 Subdural hematoma 3 Subarachnoid hemorrhage 4 Intracerebral parenc hymal hemorrhage 5 Acute meningitis - ✔✔Epidural Hematoma Epidural hematoma most often results from a traumatic tear of the middle meningeal artery. Although a lucid interval ranging from minutes to hours followed by altered mental status and focal deficit s is typical for epidural hematoma, this clinical picture is only encountered in up to 1/3 of the patients. The collection of blood between the skull and dura mater causes an evident mass effect with ophthalmic nerve palsy and the contralateral hemiparesis . Surgical evacuation of the clot via burr holes is the treatment of choice. Subdural hematoma results from a traumatic rupture of the bridging veins that connect the cerebrum to the venous sinuses within the dura. This venous hemorrhage will result in a gradual increase of the hematoma, with a progressive clinical picture over days or weeks. The CT scan will show a concave, crescent -shaped hyper -density compared to the convex, lens -shaped hyper -density in epidural hematoma. Subarachnoid hemorrhage is the result of an aneurysm rupture; the most common is the congenital berry aneurysm. The clinical picture is of a sudden, severe headache with meningeal irritation. A CT scan will show blood in the subarachnoid space, and a lumbar puncture will reveal xanthoc hromia CSF. Intracerebral parenchymal hemorrhage is most likely caused by hypertension complicated with Charcot - Bouchard aneurysms. The blood accumulates into the brain substance and most commonly involves the basal ganglia. Acute meningitis is not assoc iated with trauma. Fever and signs of meningeal irritation dominate the clinical picture. Lumbar puncture, indicated if there are no focal neurological signs on clinical examination, will be the diagnostic procedure. The CT scan of the patient presented in this case is characteristic for epidural hematoma, and there is no indication for a lumbar puncture. A 31 -year -old woman presents with a purpural rash covering her arms, legs, and abdomen. She also has fever, chills, nausea, abdominal tenderness, tachyca rdia, and generalized myalgias. Prior to the development of the rash, the patient noted that she had a headache, cough, and sore throat. Laboratory studies were positive for Gram -negative diplococci in the blood, along with thrombocytopenia and an elevatio n in PMNs. Urinalysis showed blood, protein, and casts. Vital signs are as follows: PB 92/66, P 96, RR 14, T 39. The patient denies any foreign travel and does not have any sick contacts. However, she does work part time as a nurse in a local hospital. Question The patient is diagnosed with Meningococcemia; she is admitted to the hospital and placed in respiratory isolation. What major course of therapy should this patient receive? Answer Choices 1 Steroids 2 Supportive care 3 Antibiotics 4 Transfusion 5 Bactericidal/permeability -increasing protein - ✔✔Antibiotics Antibiotics are the treatment of choice for meningococcemia. The preferred drug for active infection is penicillin G. For those allergic to penicillin, chloramphenicol and cephalosporins (ie, cefotaxime, cefuroxime) may be used as alternatives. Patients will also receive supportive care, but antibiotic therapy must be initiated quickly if the patient is to survive. Intensive care placement may be necessary if organ failure is imminent. Ventila tory support, inotropic support, and IV fluids are necessary in some. If adrenal insufficiency occurs, corticosteroid replacement may be considered. A central venous line helps to provide large amounts of volume expanders and inotropic medications for adeq uate tissue perfusion. Steroids have not been shown to play a major role in the treatment of meningococcemia. However, they have been used in addition to antibiotic therapy. In the case of adrenal insufficiency, for example, steroid replacement has been s hown to be beneficial. Transfusion does not generally play a major role in treatment. If the patient suffers from a devastating coagulopathy, blood or blood products may be replaced as necessary. Bactericidal/permeability -increasing protein is a protein stored in the granules of neutrophils. It binds to endotoxin in vitro and neutralizes it. This technique is experimental, and it is not used in everyday treatment of meningococcemia. In myasthenia gravis, weakness is a result of insufficient acetylcholine transmission at the neuromuscular junction; however, weakness can also occur with overdosing of the cholinergic medications used to treat myasthenia. What symptom helps differentiate a myasthenic crisis from a cholinergic crisis? Answer Choices 1 Respira tory failure 2 Bilateral ptosis 3 Muscle fasciculations 4 Diplopia 5 Normal muscle stretch reflexes - ✔✔Muscle Fasiculations Signs of cholinergic overdosage include muscle fasciculation, rhinorrhea, lacrimation, salivation, increased bronchial secretions, nausea, or diarrhea. The presence of any of these suggests that the patient's weakness may be due to cholinergic crisis. The other signs are due to weakness and can occur in either condition. A 54 -year -old man presents after having a generalized seizure. The patient is HIV positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inqui ry, the patient also notes that he has become short - tempered and hypercritical; at times, he seems confused. An MRI of the brain is performed, and it reveals several cortical ring -enhancing lesions. Question What is the most likely diagnosis? Answer C hoices 1 AIDS dementia complex 2 Cryptococcal meningitis 3 Cytomegalovirus encephalitis 4 Progressive multifocal leukoencephalopathy 5 Toxoplasma encephalitis - ✔✔Toxoplasma encephalitis The patient's symptoms and MRI findings are most consistent with the diagnosis of toxoplasma encephalitis. Toxoplasmosis is the most common cerebral mass lesion among HIV -positive patients. Infection with the Toxoplasma gondii parasite is relatively common and usually asymptomatic. Reactivation occurs in HIV positive patien ts due to failing cellular immunity, and it causes a multifocal necrotizing encephalitis. Seizures may be the initial manifestation of central nervous system (CNS) infection; other common clinical manifestations include focal neurologic deficits, such as i mpaired speech and hemiparesis. Personality change, lethargy, headache, and confusion are also observed. The MRI in patients with toxoplasma encephalitis characteristically reveals multiple, ring -enhancing lesions with surrounding edema; these lesions usua lly occur bilaterally in the frontal and parietal cortices. AIDS dementia complex describes a constellation of cognitive symptoms seen among HIV positive patients. The condition occurs when HIV virus disseminates to the CNS. Within the CNS, the virus tend s to concentrate in the basal ganglia and subcortical regions. Symptoms include a constellation of cognitive, behavioral, and motor disturbances that cause varying degrees of functional impairment. Characteristic MRI findings include non -enhancing white ma tter, cerebral atrophy, and ventricular enlargement. The diagnosis requires that other central nervous system infections, carcinoma, as well as general medical conditions and substance abuse have been excluded. Cryptococcal meningitis is caused by the enc apsulated fungus Cryptococcus neoformans. Among HIV positive patients, the illness may be the result of new infection or reactivation of latent infection. Presenting signs are often nonspecific; they include headache, fever, change in mental status, and nausea or vomiting. Nuchal rigidity and photophobia may also be present, and elevated intracranial pressure is not uncommon. MRI findings vary, but they include lesions in the basal ganglia; meningeal enhancement, cerebral edema, and shrunken ventricles may also be seen. Cytomegalovirus (CMV) infection causing encephalitis is usually observed in patients with evidence of CMV infection at other sites. MRI findings vary, but they often show areas of focal necrosis within the brain parenchyma, meninges, or peri ventricular regions. Symptoms typically reflect progressive dementia, with episodes of confusion, apathy, and focal neurologic deficits. Progressive multifocal leukoencephalopathy is often a fatal disorder; it is caused by reactivation of a latent JC vira l infection. Focal neurologic deficits such as hemiparesis and gait disturbance are often the initial presenting symptoms; they are followed by progressive cognitive decline, coma, and death. The MRI commonly reveals multiple, non -contrast enhancing foci i n cerebral white matter. A 1-year -old boy presents with increasing lethargy. He is barely responsive, and his parents deny any trauma or injury. What is the most common cause of nontraumatic altered levels of consciousness? Answer Choices 1 Seizure disor der 2 Diabetic ketoacidosis 3 Inborn errors of metabolism 4 Toxic ingestion 5 Infection - ✔✔infection Awareness of self and the surrounding environment or consciousness may be altered into different abnormal states of consciousness. Consciousness can shift from loss of clear thinking or confusion, usually accompanied by disorientation, to delirium, a succe ssion of confused and unconnected ideas manifested in children as extreme mental and motor excitement, to lethargy, a profound type of slumber where movement or speech is limited, to stupor or deep sleep where arousal is achieved only by repeated vigorous stimuli, finally to coma, unresponsiveness to even painful stimuli. Non -traumatic coma is most common in infants and toddlers with another smaller peak of occurrence in adolescence. The most common cause of non -traumatic altered level of consciousness in c hildren is infection of either the brain (encephalitis), meninges (meningitis), or both; infections account for more than 1/3 of cases. Prolonged seizures, anticonvulsive therapy, and postictal states can also lead to altered levels of consciousness. The most common metabolic cause of alteration of consciousness is diabetic ketoacidosis, which can occur at any age, but is most common in adolescence. Caused by severe insulin deficiency, hyperglycemia and ketogenesis lead initially to polyuria, polydipsia, hyperpnea, vomiting, and abdominal pain. As the process progresses, hyperosmolar dehydration and acid/base and electrolyte disturbances occur. Advanced stages alter level of consciousness and can lead to coma. Alterations of consciousness due to inborn er rors of metabolism that present with electrolyte and glucose abnormalities typically present in infancy. The availability of gluconeogenic precursors or the functions of the enzymes required for production of hepatic glucose are affected. Metabolic defects causing hypoglycemia include glycogen storage disease, galactosemia, fatty acid oxidation defects, carnitine deficiency, several of the amino acidemias, hereditary fructose intolerance, and defects of other gluconeogenic enzymes. Toxic ingestion and expo sure are very common in toddlers and adolescents, with a toddler's ability to explore his environment filled with often brightly colored medications and intentional ingestion by adolescents typically involving over -the-counter medications or psychotropic d rugs such as antidepressants. A 44 -year -old man starts to notice that his eyelids are drooping. Some time afterwards, his jaw becomes weak. He has difficulty swallowing and also experiences weakness in his limbs. He is quite embarrassed when he eats becau se he must use his hand to help support his jaw. His weakness gets progressively worse. Finally, he seeks medical attention. His physical examination demonstrates the weakness in his limbs; however, no sensory defects are present. A Tensilon test is done a nd is positive. His doctor is concerned about an associated malignancy. What is the underlying pathology of this disease? Answer Choices 1 Inhibition of acetylcholine release 2 Blockage of the sodium channels 3 Demyelination 4 Subacute combined degenerati on of the spinal cord 5 Antibodies to the acetylcholine receptor - ✔✔5 Antibodies to the acetylcholine receptor Antibodies directed towards the acetylcholine receptor at the neuromuscular junction are seen with myasthenia gravis. This man has myasthenia g ravis. Ocular muscle weakness, ptosis, dysphagia, and limb weakness can all be seen with myasthenia gravis. When the initial symptom is ocular weakness, Eaton Lambert Syndrome is extremely unlikely. Eaton Lambert Syndrome tends to not involve the extra -ocular muscles or the muscles involving chewing, swallowing, or speech. The Tensilon test is used in the diagnosis of myasthenia gravis. The Tensilon test consists of the administration of edrophonium. Edrophonium is a quick acting anticholinesterase. Thymi c tumors are associated with myasthenia gravis. Thymic tumors are also referred to as thymomas. Approximately 10 - 15% of patients with myasthenia gravis have an associated thymoma. The majority of patients with myasthenia gravis have hyperplasia of their thymus. Botulinum toxin inhibits acetylcholine release. The site of action is at the neuromuscular junction. Botulinum toxin is an enterotoxin produced by Clostridium botulinum. Botulism can result from incorrectly canned foods. Tetrodotoxin is a toxin produced by puffer fish. The sodium channels are blocked by tetrodotoxin. The blockage of the sodium channels interferes with the inflow of sodium. As a result, the propagation of nerve and muscle action potentials is affected. Dem yelination refers to the loss of myelin around the axon. Several disorders result in demyelination. An example of a demyelinating disease is multiple sclerosis. Subacute combined degeneration of the spinal cord is also called combined systems disease. Sub acute combined degeneration of the spinal cord is a neuropathy secondary to B12 deficiency. It is seen in patients with pernicious anemia, especially pernicious anemia that has been present for quite some time. Symptoms include paresthesias and a loss of p roprioception. A 74 -year -old man presents after his wife witnessed him grab his head in pain and fall to the floor. He has not regained consciousness. His current blood pressure is 150/96 mm Hg, and his heart rate is 65 bpm. Emergent head CT shows a subar achnoid hemorrhage. Question In addition to life saving interventions, what prescription medication will most benefit this patient at this time? Answer Choices 1 Furosemide (loop diuretic) 2 Prednisone (glucocorticoid) 3 Tranexamic acid (antifibrinoly tic agent) 4 Labetolol (beta blocker) 5 Nimodipine (calcium channel blocker) - ✔✔Nimodipine (CCB) Nimodipine, a calcium channel blocker, has been shown to improve outcomes in patients following aneurysmal SAH. The mechanism of action is thought to be preve ntion of ischemia. Glucocorticoids (e.g., prednisone) are often utilized in patients with SAH because they offer symptomatic relief of headache and neck pain, but they have not been proved to decrease cerebral edema. Antifibrinolytic agents (e.g., Tranexam ic acid) can be utilized in patients with a diagnosed aneurysm who cannot undergo directed treatment, but they are not routinely used following aneurysmal rupture. Labetalol (a beta blocker) may be utilized to treat elevated BP, but it must be used with ca ution because it can also decrease cerebral perfusion. Diuretics (e.g., furosemide) have no identified role in the treatment of aneurysmal SAH. A 37 -year -old woman presents to her GP surgery with a history of right -sided facial weakness and peri - auricular discomfort since she awoke this morning. She is afebrile. Question What is the most likely diagnosis? Answer Choices 1 Trigeminal neuralgia 2 Bell's Palsy 3 Multiple sclerosis 4 Myasthenia gravis 5 Primary lateral sclerosis - ✔✔Bell's Palsy Explanation The correct answer is Bell's palsy, which is a condition typically with sudden onset that affects the facial nerve, causing unilateral facial weakness. Trigeminal neuralgia presents with sharp pain on one side of the mouth that radiates to the ipsilateral ear, eye, or nostril. Multiple sclerosis is a demyelinating disorder, causing a multitude of symptoms that typically include diplopia or blurred vision early on, then an insidious onset of progressive weakness, numbness, and/or tingling in th e extremities. Myasthenia gravis commonly presents with ptosis and diplopia, as well as difficulty swallowing, fatigue, and muscle weakness. Primary lateral sclerosis is an upper motor neuron disease that causes limb weakness, stiffness, and fasciculatio ns. A 62 -year -old man presents with vision problems and difficulty swallowing. Over the last week, he has had a constellation of symptoms; they began with numbness and tingling in his feet and progressed to weakness that now affects both lower and upper e xtremities. Within the last day, he has started to notice difficulty swallowing and double vision. He also feels it is difficult for him to take a big breath. His past medical history is noncontributory, and he takes no medications. Exam reveals bilateral absence of patellar and ulnar reflexes. A lumbar puncture is performed to confirm the diagnosis. Question What cerebrospinal fluid (CSF) finding is most likely? Answer Choices 1 Decreased CSF glucose content 2 Decreased CSF protein content 3 Elevated CSF polymorphonuclear cell count 4 Elevated CSF protein content 5 Elevated CSF lymphocyte count - ✔✔Elevated CSF proteins Correct response is elevated CSF protein content. Symmetrical ascending paralysis as described in this patient is indicative of Guillain -Barré syndrome (GBS). The cause of GBS is unknown, but it is generally thought to be an inflammatory autoimmune process. More than half of patients with GBS report an an tecedent illness. The antibodies produced in response to antigens present in the infectious agent are thought to cross -react with components of human neurons, prompting an acute postinfectious demyelinating process. Lumbar puncture characteristically reve als elevated CSF protein content. Other results are normal, although the white blood cell count may be somewhat elevated. Decreased CSF glucose and increased polymorphonuclear cell counts are seen in acute bacterial meningitis. Decreased CSF glucose and e levated CSF lymphocyte counts are commonly seen with meningitis caused by fungi. Viral meningitides usually presents with elevated lymphocyte counts, normal CSF glucose, and normal or slightly elevated CSF protein levels. A 70 -year -old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have became "dull". Over the past month, she has started having urinary urgency and involuntary lea king of urine. Besides multivitamins and local application of the Timolol for glaucoma, she takes no other medications; there are no other symptoms.