1
Q
1 64 y/o female consulted for 2 day history of facial asymmetry. On physical examination, he was unable to raise the right eyebrow, was unable to fully close the right eye and there was shallow right nasolabial fold. His smile was also noted to be asymmetric. This type of facial palsy is documented as:
A. Left peripheral facial palsy
B. Right central facial palsy
C. Right peripheral facial palsy
D. Left central facial palsy
A
C. right peripheral facial palsy
Rationalization: The symptoms described (inability to raise the right eyebrow, inability to fully close the right eye, shallow right nasolabial fold, and asymmetric smile) are indicative of a peripheral facial nerve palsy affecting the right side of the face. Peripheral facial palsy affects all branches of the facial nerve on the involved side, leading to the inability to move facial muscles on that side. Central facial palsy, in contrast, typically spares the forehead muscles due to bilateral upper motor neuron innervation.
2
Q
64 y/o female consulted for 2 day history of facial asymmetry. On physical examination, he was unable to raise the right eyebrow, was unable to fully close the right eye and there was shallow right nasolabial fold. His smile was also noted to be asymmetric.
- in the above case, where is the lesion?
A. Left facial nerve nucleus
B. Right facial nerve
C. Right corticobulbar tract
D. Left corticobulbar tract
A
B. right facial nerve
Rationalization: Given this is a case of right peripheral facial palsy, the lesion is located in the right facial nerve. The facial nerve (cranial nerve VII) is responsible for innervating the muscles of facial expression. A lesion in the facial nerve nucleus would not present as a unilateral peripheral facial palsy but could potentially cause bilateral symptoms due to its central location.
3
Q
- Which of the following neural structures is most likely affected given the following neurologic deficit?
a. Right temporal
b. Left frontal
c. Right parietal
d. Left parietal
A
B. left frontal
Rationalization: Assuming this question is related to the first case, the left frontal area is not directly implicated in right peripheral facial palsy. However, if this question is intended to be independent and focuses on a neurologic deficit not specified here, the answer cannot be accurately determined without more context. Typically, the frontal lobe, especially on the right side, would not be responsible for facial palsy. Facial palsy is related to damage to the facial nerve or its pathways, not typically associated with the frontal lobe regions specified in the options.
4
Q
- The following statements about pattern of weakness is/are true except
A. Acute paraparesis may be due to bilateral anterior cerebral artery infarction
B. Crossed paralysis consisting of ipsilateral cranial nerve signs and contralateral hemiparesis is usually due to brainstem lesions
C. Symmetric weakness, beginning distally, with accompanying numbness is usually secondary to anterior horn cell disease
D. Ascending weakness with numbness associated with hyporeflexia may be due to disease of peripheral nerves
A
C. Symmetric weakness, beginning distally, with accompanying numbness is usually secondary to anterior horn cell disease
Rationalization: This statement is false because symmetric weakness beginning distally with accompanying numbness is more characteristic of peripheral neuropathies or polyneuropathies rather than anterior horn cell disease. Anterior horn cell disease, such as amyotrophic lateral sclerosis (ALS), typically presents with a combination of upper and lower motor neuron signs without sensory deficits.
5
Q
- The following statements are true about the extensor toe sign except
A. There are several ways to elicit the extensor toe sign
B. It is a normal finding among children under 2 years old
C. It indicates a lesion in the vestibulospinal tract which controls the distal lower extremities
D. It indicates an upper motor neuron lesion
A
C. It indicates a lesion in the vestibulospinal tract which controls the distal lower extremities
Rationalization: This statement is false. The extensor toe sign, also known as Babinski’s sign, indicates an upper motor neuron lesion and is not specifically related to the vestibulospinal tract. It reflects dysfunction in the corticospinal tract rather than the vestibulospinal tract.
6
Q
8.A patient comes in the er due to bilateral lower extremity weakness. Upon Examination, the last normal sensory level is at the level of the umbilicus. Which Level is likely the spinal cord lesion?
A. T9-T10
B. T7-T8
C. T5-76
D. T3-T4
A
A. T9-T10
Rationalization: The umbilicus is innervated by the T10 dermatome. A lesion affecting sensory levels at the umbilicus would likely involve the spinal cord around the T9-T10 levels.
7
Q
- Test for coordination?
A. None
B. Rapid alternating movement
C. Both
D. Heel to shin test
A
C. Both
Rationalization: Tests for coordination include both rapid alternating movements (to assess cerebellar function related to coordination and precision of movements) and the heel to shin test (to assess lower limb coordination and proprioception).
8
Q
- 55/female has a tumor compressing the left trigeminal nerve. She may experience
The following signs and symptoms except
A. Difficulty in moving the jaw to the left
B. Numbness of the left side of the face excluding the angle of the jaw
C. Flattened left nasolabial fold
D. Decreased corneal reflex on the left eye
A
C, “Flattened left nasolabial fold,”
can also be a sign of dysfunction of the facial nerve (cranial nerve VII), which innervates the muscles responsible for facial expression, including the nasolabial fold.
9
Q
- A simple bedside test used to determine the mental status examination of a
Patient which consists of a 30-points score.
A. Mini mental status examination
B. Clinical dementia rating scale
C. Montreal cognitive exam (MoCA)
A
A. Mini Mental Status Examination
Rationalization: The Mini Mental Status Examination (MMSE) is a simple bedside test used to assess cognitive function and screen for cognitive impairment. It consists of a 30-point score that evaluates various cognitive domains, including orientation, recall, attention, calculation, language processing, and spatial skills.
10
Q
- If a patient is complaining of dizziness when turning to the left, and you have diagnosed this case as Benign Positional Paroxysmal Vertigo (BPPV), which direction would you rotate his head when you want to perform Epley maneuver?
A. Right
B. Left
C. Midline
D. Either side
A
B. Left
Rationalization: When performing the Epley maneuver for a patient with Benign Paroxysmal Positional Vertigo (BPPV) who experiences dizziness when turning to the left, you would start by rotating the patient’s head towards the affected side, which is the left side in this case. The Epley maneuver is designed to move the otoliths out of the semicircular canals back into the vestibule where they won’t cause vertigo.
11
Q
- A 25-year-old woman with depression present with a daily headache for the past 2 years. The headache began suddenly on November 15, 2016. She recalls it was on her birthday, but otherwise nothing out of ordinary had happened. She reports being healthy, other than mild sore throat the day before the onset of the headache, which is describes as a daily, pressing, moderate, holocephalic pain. There is photophobia, when the headache is exacerbated, but no visual or other neurologic symptoms. There is no postural component of the headache. She has had MRI but was normal. On the basis of the history, how would you classify the headache?
A. Migraine without aura
B. Psychogenic headache disorder
C. New daily persistent headache
D. Tension-type headache
A
B. Psychogenic headache disorder
This classification is based on the lack of specific characteristics typical of primary headache disorders like migraine or tension-type headache, as well as the absence of neurological symptoms or abnormalities on MRI. The presence of depression and the absence of clear physical triggers for the headache suggest a possible psychogenic origin.
12
Q
- Which of the following statements is incorrect regarding aphasia?
A. None, all are correct
B. Conduction aphasia is due to a lesion in the internal arcuate fasciculus lesion
C. Broca’s aphasia is due to a dominant hemisphere inferior frontal gyrus
D. Wernicke’s aphasia is due to a nondominant hemisphere superior temporal gyrus lesion
A
D. Wernicke’s aphasia is due to a nondominant hemisphere superior temporal gyrus lesion
Rationalization: This statement is incorrect. Wernicke’s aphasia is typically due to a lesion in the dominant hemisphere’s superior temporal gyrus, not the nondominant hemisphere. Wernicke’s area is involved in the comprehension of speech, and lesions here cause difficulties in understanding language but often leave the ability to produce fluent, though meaningless, speech.
13
Q
- All are components of Balint’s syndrome, except:
A. None, all are correct
B. deficit in orderly visuomotor scanning of the environment
C. deficit in accurate manual reaching toward visual targets
D. inability to recognize familiar faces
A
D. inability to recognize familiar faces
Rationalization: The inability to recognize familiar faces, known as prosopagnosia, is not a component of Balint’s syndrome. Balint’s syndrome is characterized by a triad of symptoms:
- optic ataxia (deficit in accurate manual reaching toward visual targets),
- ocular apraxia (deficit in orderly visuomotor scanning of the environment),
- simultanagnosia (inability to perceive the visual field as a whole).
14
Q
- This is mainly a test to identify cerebellar ataxia:
A. True
B. False
A
B. False
The Romberg test primarily assesses proprioception and the vestibular system rather than cerebellar function. It evaluates a person’s ability to maintain balance while standing still with eyes closed, relying on proprioceptive feedback. However, it can be part of a broader assessment that includes testing for cerebellar ataxia, which involves coordination and balance issues due to cerebellar dysfunction.
15
Q
17..Which is the afferent nerve of the pupillary light reflex
A. cranial nerve Ill
B. cranial nerve VII
C. cranial nerve Il
D. cranial nerve V
A
C. cranial nerve II
Rationalization: The afferent nerve of the pupillary light reflex is cranial nerve II, the optic nerve. It carries the sensory input from the retina to the brain. The efferent pathway, which constricts the pupil, involves cranial nerve III, the oculomotor nerve.
16
Q
- Central facial palsy denotes which type of motor involvement?
A. mixed type of upper and lower motor neuron lesion
B. Lower motor neuron lesion
C. upper motor neuron lesion
A
C. upper motor neuron lesion
Rationalization: Central facial palsy is indicative of an upper motor neuron lesion. It typically affects the contralateral lower half of the face because the upper half of the face receives bilateral innervation from the cerebral cortex. In contrast, a lower motor neuron lesion would affect all branches of the facial nerve on the same side, leading to a complete facial droop.
17
Q
19.Inability to perform rapid alternating movements:
A. Dyssynergia
B. Dystaxia
C. Dysdiadochokinesia
D. Dysmetria
A
C. Dysdiadochokinesia
Rationalization: Dysdiadochokinesia is the inability to perform rapid alternating movements, a sign of cerebellar dysfunction. It reflects the inability to coordinate agonist and antagonist muscles smoothly.
18
Q
- The following may present with acute weakness except
A. Tumor
B. Subdural hematoma
C. Guillain barre syndrome
D. Cerebrovascular disease
A
A. Tumor
Rationalization: While tumors can cause weakness over time as they grow and exert pressure on surrounding brain structures, the other options listed (subdural hematoma, Guillain-Barré syndrome, and cerebrovascular disease) are more typically associated with acute onset of weakness. Tumors generally lead to a more gradual onset of symptoms.
19
Q
- In normal individuals, pooling of blood in the lower parts of reflex acceleration of the heart by means of aortic the body is prevented by:
A. Both
B. None
C. Reflex acceleration of the heart by means of aortic and carotid reflexes
D. Pressor reflexes induce dilatation of peripheral arterioles and venules
A
C. Reflex acceleration of the heart by means of aortic and carotid reflexes
Rationalization: In normal individuals, pooling of blood in the lower parts of the body is prevented by reflex mechanisms, including reflex acceleration of the heart and vasoconstriction through aortic and carotid reflexes. These reflexes help maintain blood pressure and blood flow to vital organs during changes in body position.
20
Q
- Which of the following tests for language in the mini mental state examination?
A. Serial 7s
B. Asking for the month and date
C. Spelling the word WORLD backwards
D. Following a 3 step command
A
D. Following a 3-step command
This option tests the ability to understand and process language by following verbal instructions, which is a key component of the language section in the Mini-Mental State Examination (MMSE).
21
Q
- Characteristic of cerebellar ataxic gait:
A. Intermittent, irregular movement disrupting the smooth flow of normal gait
B. Both legs move in a slow, stiff manner with circumduction
C. Broad-based gait with speed and length of stride which vary irregularly each step
D. All are incorrect
A
C. Broad-based gait with speed and length of stride which vary irregularly each step
Rationalization: A characteristic of cerebellar ataxic gait is a broad-based stance with irregularities in the speed and length of stride. This type of gait is often unsteady and can involve veering to one side.
22
Q
- Vestibular neuritis:
A. Due to over-accumulation of endolymph within inner ear
B. Rotatory vertigo lasting minutes to hours
C. Associated with low-frequency sensorineural hearing loss
D. No otological symptoms
A
D. No otological symptoms
Rationalization: Vestibular neuritis is characterized by acute onset of severe, persistent vertigo that is not accompanied by hearing loss or other otological symptoms. It is thought to be caused by inflammation of the vestibular nerve.
23
Q
- True of Romberg’s test, EXCEPT:
A. Test to differentiate cerebellar ataxia from sensory ataxia
B. Patient’s eyes should be closed with feet together
C. None, all are correct
D. Tests both the dorsal column pathway and anterolateral pathway
A
D. Tests both the dorsal column pathway and anterolateral pathway
Rationalization: This statement is incorrect regarding Romberg’s test. Romberg’s test primarily assesses the function of the dorsal columns of the spinal cord, which are responsible for proprioception. It does not directly test the anterolateral pathway, which is involved in pain and temperature sensation.
24
Q
- “When assessing a patient in the ER who came in with decreased sensorium, you noted the patient assumed a specific position when you applied a painful stimulus. How will you record the motor response?”
A. M2
B. M3
C. M4
D. M5
A
B. M3
Rationalization: In the context of the Glasgow Coma Scale (GCS), motor responses are graded from M1 to M6, with M1 indicating no motor response and M6 indicating obeys commands. If a patient assumes a specific position in response to pain, it suggests a purposeful response to pain but not necessarily obeying commands, which might be categorized under flexion withdrawal from pain (M4). However, without specific details on the “specific position,” the best approximation given the options would be M3, which typically indicates abnormal flexion to pain (decorticate response). This is a bit of a nuanced interpretation since the exact description of the response is not provided.
25
28. 53/F rushed to the emergency room after being involved in A vehicular crash. On assessment, she would only open her eyes when pressure is applied on her nailbed. She would moan some sounds in response to pain and would briskly withdraw her arm. What is the her GCS score?
A. E2V3M5
B. E3V1M5
C. E2V2M4
D. E3V2M4
Answer: C. E2V2M4
*E4V5M6
Rationalization: Based on the Glasgow Coma Scale (GCS):
E2 indicates eye opening in response to pain.
V2 indicates incomprehensible sounds, which is consistent with moaning in response to pain.
M4 indicates withdrawal from pain, which is a purposeful movement away from a painful stimulus.
26
A. This is decerebrate posturing which denotes a lesion above the red nucleus
B. This is decerebrate posturing which denotes a lesion below the red nucleus
C. This is decorticate posturing which denotes a lesion above the red nucleus
D. This posturing is given a grade of M3
B. This is decerebrate posturing which denotes a lesion below the red nucleus
Decerebrate posturing is a type of abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. This posture indicates that there may be damage in the area of the brainstem. Specifically, it is associated with dysfunction or damage to the brain at or below the level of the red nucleus in the midbrain. The red nucleus is an area of the midbrain that is involved in motor coordination.
27
30. Most common cause of primary headache
A. Idiopathic
B. Systemic infection
C. Migraine
D. Tension type
D. Tension type
Rationalization: Tension-type headaches are the most common type of primary headache disorder, characterized by a pressing or tightening feeling, of mild to moderate intensity, occurring on both sides of the head and not worsened by routine physical activity. Migraines are also common but not as prevalent as tension-type headaches.
Primary headaches:
1. Migraine
2. Tension-type headache
3. Cluster headache
Secondary headaches:
1. Headache due to a head injury
2. Headache due to sinusitis
3. Headache due to medication overuse
4. Headache due to meningitis
5. Headache due to brain tumor
28
31. 65 y/o female presenting with sudden onset right peripheral facial palsy and Weakness of the left arm and leg. Which of the following tests will you order?
A. Spinal MRI
B. Spinal CT scan
C. Cranial MRI
D. Nerve conduction studies
C. Cranial MRI
Rationalization: Given the sudden onset of right peripheral facial palsy combined with weakness of the left arm and leg, the symptoms suggest a central nervous system pathology that could involve the brainstem or cerebral hemispheres. A cranial MRI is the most appropriate test to order as it can provide detailed images of the brain's structures to help identify the cause of these symptoms, such as a stroke.
29
32. True of Central Vertigo:
A. Duration of dizziness persists
B. Visual fixation suppresses vertigo
C. Acute onset
D. All are incorrect
A. Duration of dizziness persists
Rationalization: Central vertigo is characterized by vertigo that may have a longer duration, and its intensity is not typically altered by changes in head position. Unlike peripheral vertigo, visual fixation does not suppress central vertigo, and its onset may not always be as acute or associated with specific triggers.
30
33. The Epley Maneuver is both diagnostic and therapeutic for Benign Paroxysmal
Positional Vertigo (BPPV).
A. False
B. True
A. False
Rationalization: The Epley maneuver is therapeutic for Benign Paroxysmal Positional Vertigo (BPPV) but not diagnostic. The diagnosis of BPPV is typically made using the Dix-Hallpike test, which can provoke the characteristic vertigo and nystagmus associated with BPPV.
31
34. Asking a patient to spell the word WORLD backwards tests for which cognitive domain?
a. Fund of knowledge
b. Insight
c. Planning
d. Attention
d. Attention
Rationalization: Asking a patient to spell the word "WORLD" backwards tests the cognitive domain of attention and working memory, as it requires the patient to focus, manipulate information in reverse order, and control their response.
32
What sensory information does the Dorsal column-medial lemniscus pathway convey?
a. Light touch
b. Proprioception and vibration
c. Light touch, proprioception and vibration
d. Pain and temperature
c. Light touch, proprioception and vibration
Rationalization: The dorsal column-medial lemniscus pathway conveys sensations of fine touch, proprioception, and vibration from the body to the brain. This pathway is critical for the perception of detailed touch and the spatial position of body parts.
33
36. A woman with Alzheimer's disease stopped being able to recognize her son after he shaved his moustache. She could recognize her husband only when she heard his voice. The term used to describe this type of agnosia is:
A. Topographagnosia
B. Prosopagnosia
C. Misoplegia
D. Asomatognosia
B. Prosopagnosia
Rationalization: Prosopagnosia, also known as face blindness, is the inability to recognize familiar faces. The woman's inability to recognize her son without his moustache and her husband only by his voice indicates prosopagnosia.
34
37. A 50/M presented with sudden onset difficulty in speaking. On physical examination, he can follow commands and speech seem fluent but had difficulty in naming simple objects and was unable to repeat the phrase "no ifs ands or buts". What type of aphasia does he have?
A. Transcortical sensory
B. Broca's transcortical motor
C. Global aphasia
D. Wernicke's conduction
D. Wernicke's conduction
Conduction Aphasia is characterized by the disconnection between speech comprehension and speech production areas, leading to fluent aphasia with good comprehension, but impaired repetition and naming.
35
38. Asking the patient to tell you the similarity of a bicycle and train tests for which of the following higher cortical functions?
A. fund of information
B. abstract thinking
C. apraxia
D. registration
B. abstract thinking
Rationalization: Asking a patient to explain the similarity between a bicycle and a train tests abstract thinking, a higher cortical function. This task requires the patient to conceptualize and articulate the abstract relationship or category that both items share.
36
39. Which of the following statements is incorrect regarding the pathophysiology of migraine headache
A. CGRP acts as principal mediator of migraine
B. The trigeminovascular system is involved in the regulation of cranial vasculature and a key element in the transmission of pain
C. The release of calcitonin gene-related peptide from peripheral terminals results in meningeal vasodilation
D. None, all are correct
D. None, all are correct
Rationalization: All the statements provided regarding the pathophysiology of migraine headaches are correct. CGRP (Calcitonin Gene-Related Peptide) is a principal mediator, the trigeminovascular system is involved in pain transmission, and the release of CGRP leads to meningeal vasodilation, contributing to migraine pathophysiology.
37
40. A 67-year-old woman is seen in the medical ICU, where she is being treated for sepsis with profound hypotension. On examination, she is speaking fluently but nonsensically, and comprehension is markedly impaired. However, she can repeat, and exhibits significant echolalia throughout examination. Which language disturbance best explains the clinical picture?
A. Global aphasia
B. Wernicke's aphasia
C. Broca's aphasia
D. Transcortical motor aphasia
E. Transcortical sensory aphasia
E. Transcortical sensory aphasia
Rationalization: The clinical picture of fluent but nonsensical speech, markedly impaired comprehension, preserved repetition ability, and significant echolalia is characteristic of transcortical sensory aphasia. This condition is similar to Wernicke's aphasia but with the preservation of repetition ability.
38
41. Detects Linear acceleration:
A. Semicircular canals
B. None
C. Otolithic organs
D. Otolithic organs and semicircular canals
C. Otolithic organs
Rationalization: The otolithic organs (utricle and saccule) in the inner ear are responsible for detecting linear acceleration and gravity, helping to sense changes in head position relative to linear movements. The semicircular canals, on the other hand, detect angular acceleration or rotational movements.
39
42. The following statements are TRUE regarding amnesia, except:
A. In retrograde amnesia, remote events are more vulnerable than recent events
B. None, all are true
C. Patients with anterograde amnesia have the tendency to confabulate to fill their memory gaps
D. Anterograde amnesia is often seen in Wernicke-Korsakoff syndrome
A. In retrograde amnesia, remote events are more vulnerable than recent events
Rationalization: This statement is incorrect. In retrograde amnesia, recent events are typically more vulnerable or more likely to be forgotten than remote (older) events. This is due to the consolidation process, where recent memories are not as firmly established as older ones.
40
44. Association area of the cerebral cortex responsible for spatial orientation:
A. Prefrontal
B. Parietotemporal
C. Left-dominant perisylvian
D. Right-dominant parietofrontal
B. Parietotemporal
Rationalization: The parietotemporal association area of the cerebral cortex is responsible for integrating sensory information for spatial orientation, including the understanding of maps and the spatial relationship between objects.
41
45. Hyperpathia:
A. Pain from stimuli that is not normally painful
B. Extreme over-response to pain
C. Multiple, very severe, electric shock-like pains that radiate into a specific root or nerve distribution
D. Unbearable, burning, relentless hyperesthesia and hyperalgesia that ensue after injury to a peripheral nerve
B. Extreme over-response to pain
Rationalization: Hyperpathia is characterized by an extreme, exaggerated response to pain. It is a condition where there is an abnormally increased sensitivity to stimuli, especially to painful stimuli, which is not the definition provided in option B. Option A (Pain from stimuli that is not normally painful) describes allodynia.
42
43. Frontal abulic syndrome is caused by a lesion in
A. Orbitofrontal cortex
B. Ventrolateral cortex
C. Ventromedial cortex
D. Dorsomedial prefrontal cortex
D. Dorsomedial prefrontal cortex
Rationalization: Frontal abulic syndrome, characterized by apathy, lack of initiative, and reduced interest in activities, is often associated with lesions in the dorsomedial prefrontal cortex. This area is involved in motivation, decision-making, and social behavior.
43
46. The following tests for the facial nerve except
A. Raising the eyebrows
B. None of the choices (all the given choices tests for facial nerve)
C. Smiling
D. Clenching the teeth
E. Blowing the candle
D. Clenching the teeth
Rationalization: Clenching the teeth primarily tests the trigeminal nerve (cranial nerve V), which is responsible for the muscles involved in mastication, not the facial nerve (cranial nerve VII). The facial nerve is tested by assessing facial expressions such as raising the eyebrows, smiling, and blowing out a candle.
44
47. Cilia of hair cells are embedded in a gelatinous mass known as -
A. Utricle
B. Ampulla
C. Crista
D. Cupula
D. Cupula
Rationalization: The cilia of hair cells in the semicircular canals of the inner ear are embedded in a gelatinous mass known as the cupula. The cupula moves in response to head rotations, leading to stimulation of the hair cells and the sensation of angular motion.
45
48. All of the following are true regarding Syncope, EXCEPT:
A. Any interference in venous return may lead to a reduction in cardiac output
B. May be due to decreased cerebral vascular resistance
C. It may be benign or serious
D. It often occurs in the setting of increased peripheral sympathetic activity and venous pooling
B. May be due to decreased cerebral vascular resistance
Syncope is typically due to a transient decrease in cerebral blood flow, leading to a brief loss of consciousness. Decreased cerebral vascular resistance would theoretically increase cerebral blood flow, not decrease it. Syncope often results from factors that reduce blood flow to the brain, such as reduced cardiac output or abrupt drops in blood pressure, not from decreased resistance in cerebral vessels.
46
49. Pain from stimuli that is not normally painful Extreme over-response to pain Multiple, very severe, electric shock-like pains that radiate into a specific root or nerve distribution Unbearable, burning, relentless hyperesthesia and hyperalgesia that ensue after injury to a peripheral nerve
A. Patient has left hemineglect
B. Patient has right hemianopia
C. Patient has left apraxia
D. Patient has right hemineglect
D. Patient has left hemineglect
Rationalization: Pain from stimuli that is not normally painful describes allodynia, not the options provided. However, if this question is intended to match the descriptions with the conditions, none of the options directly describe allodynia. It seems there might be a mismatch in the question's structure.
47
50. A 62-year-old man is brought to the emergency department by his wife because He was acting "funny". He had been paying bills that morning and could not Seem to calculate simple sums. He as also having trouble writing. On Examination, he had right-left confusion and finger agnosia. This man's Syndrome localizes to the:
A. Nondominant dorsolateral prefrontal cortex
B. Dominant superior temporal cortex
C. Nondominant parietal lobule
D. Dominant inferior parietal lobule
D. Dominant inferior parietal lobule
Rationalization: The symptoms described, including difficulty with calculation (acalculia), writing (agraphia), right-left confusion, and finger agnosia, are characteristic of Gerstmann syndrome, which is associated with a lesion in the dominant inferior parietal lobule.
48
51 A 24-year-old woman abruptly loses all speech during the third trimester of an Otherwise uncomplicated pregnancy. She has a history of severe migraines During which she occasionally develops a transient right hemiplegia. Her Comprehension is good, and she is frustrated by her inability to speak or write, And inability to repeat simple phrases. Which language disturbance best explains the clinical picture?
A. Transcortical sensory aphasia
B. Wernicke's aphasia
C. Global aphasia
D. Transcortical motor aphasia
E. Broca's aphasia
E. Broca's aphasia
Rationalization: The clinical picture of abrupt loss of speech, good comprehension, frustration with the inability to speak or write, and inability to repeat simple phrases is indicative of Broca's aphasia. This condition is characterized by impaired speech production with preserved comprehension, often resulting from a lesion in the posterior inferior frontal gyrus of the dominant hemisphere.
49
52 The following reflex tests which spinal segments?
A. C6-C7
B. C7-C8
C. С4-С5
D. C5-C6
A. C6-C7
Biceps 5-6
Triceps 6-7
Brachioradialis 5-6
Finger flexor c8-t1
50
53. Allows eyes to closely follow a moving target
A. Smooth pursuit
B. Visual fixation
C. Saccades
D. Oculomotor reflex
A. Smooth pursuit
Rationalization: Smooth pursuit allows the eyes to closely follow a moving target. This eye movement is slow and steady, enabling the eyes to maintain visual focus on a moving object, distinguishing it from saccades, which are rapid eye movements used to shift gaze between stationary objects.
51
54. Which of the statements about motor examination is/are true?
A. All the statements are true
B. Tone is assessed by passive movement of the extremities
C. When doing the reflex testing the extremity must be placed in the fully flexed position
D. Pronator drift tests for mild weakness of the lower extremities
E. Achilles tendon reflex tests for L4-L5 spinal segments
B. Tone is assessed by passive movement of the extremities
Rationalization: Tone is indeed assessed by passive movement of the extremities, observing for any resistance to movement that might indicate hypotonia or hypertonia. The other statements are incorrect: Reflex testing does not require the extremity to be fully flexed, pronator drift tests for mild weakness of the upper extremities (not lower), and the Achilles tendon reflex tests the S1-S2 spinal segments (not L4-L5).
52
55. Allows eyes to closely follow a moving target:
A. Smooth pursuit
B. Visual fixation
C. Saccades
D. Oculomotor reflex
A. Smooth pursuit
Rationalization: Smooth pursuit allows the eyes to closely follow a moving target, enabling the tracking of objects moving across the visual field with smooth, continuous eye movements.
53
57. 55 y/o male presenting with headache, gradual onset spastic weakness of both legs, memory lapses and urinary incontinence. Which of the following diagnostic tests will you order?
A. Electroencephalogram
B. Nerve conduction studies and electromyography
C. Spinal MRI
D. Cranial MRI
D. Cranial MRI
Rationalization: Given the symptoms of headache, spastic weakness of both legs, memory lapses, and urinary incontinence, a cranial MRI is the most appropriate diagnostic test. These symptoms suggest a central nervous system disorder that could involve the brain, such as a tumor, vascular lesion, or demyelinating disease.
54
58. Which of the following is a pure motor nerve?.
A. Trigeminal nerve
B. Optic nerve
C. Oculomotor nerve (CN III)
D. Facial nerve
C. Oculomotor nerve (CN III)
Rationalization: The oculomotor nerve is primarily a motor nerve that controls most of the eye's movements, the constriction of the pupil, and maintains an open eyelid. The trigeminal nerve has both sensory and motor functions, the optic nerve is sensory, and the facial nerve has both motor and sensory (taste) components.
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59. Taste sensation of the posterior 1/3 of the tongue is supplied by which of the following?
A. Glossopharyngeal nerve
B. Trigeminal nerve
C. Hypoglossal nerve
D. Facial nerve
A. Glossopharyngeal nerve
Rationalization: The glossopharyngeal nerve (cranial nerve IX) supplies taste sensation to the posterior one-third of the tongue. The trigeminal nerve provides general sensation to the face, including the anterior two-thirds of the tongue, the hypoglossal nerve controls tongue movements, and the facial nerve supplies taste to the anterior two-thirds of the tongue.
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60. 53/F rushed to the emergency room after being involved in a vehicular crash. On Assessment, she would only open her eyes when pressure is applied on her Nailbed. She would moan some sounds in response to pain and would briskly Withdraw her arm. What is the patient's sensorium?
A. Stuporous
B. Comatose
C. Awake
D. Lethargic
A. Stuporous
Rationalization: A stuporous state is characterized by a lack of response to the environment except to repeated or painful stimuli. The patient's behavior—only opening eyes to pain, moaning in response to pain, and withdrawing from pain—indicates a stuporous condition.
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61 The most medial lamination of the Spinothalamic tract:
A. Lumbar
B. Sacral
C. Cervical
D. Thoracic
B. Sacral
Rationalization: In the spinothalamic tract, the most medial lamination is sacral, following the somatotopic organization where sacral fibers are positioned medially, and cervical fibers are positioned laterally. This organization allows for the tract to maintain a specific mapping of the body's sensory information as it ascends to the brain.
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62. Which functional subdivision of the cerebellum controls the muscle tone, axial and limb movements?
A. Cerebrocerebellum
B. Spinocerebellum
C. Vestibulocerebellum
D. Pontocerebellum
B. Spinocerebellum
Rationalization: The spinocerebellum controls muscle tone and coordinates fine movements of the limbs and axial body. It receives proprioceptive input from the spinal cord to adjust and correct ongoing movements, ensuring posture and gait stability.
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63. The following are part of Gerstman syndrome except
A. Number agnosia
B. Agraphia
C. Inability to calculate
D. None of the choices
E. Right left confusion
A. Number agnosia
This is because the classical quartet of symptoms does not include number agnosia as a component of Gerstmann syndrome. However, clinical presentations can vary and overlap among different cognitive syndromes is common.
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64. The following are pain producing structures except:
A. Dural sinuses
B. Scalp
C. Proximal pial arteries
D. Pial veins
D. Pial veins
Rationalization: Pial veins are not typically considered pain-producing structures within the cranial cavity. Pain-sensitive structures in the head include the dural sinuses, scalp, and proximal parts of the large pial arteries. The brain parenchyma itself and pial veins do not have pain receptors.
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65. 54/male patient was brought to the emergency room because of sudden onset left sided weakness. When asked to raise his left arm, he was not able to fully move it against gravity. What is the motor strength score?
A. 1
B. 5
C. 2
D. 4
E. 3
E. 3
Rationalization: A motor strength score of 3 indicates that the patient can move the limb against gravity but not against resistance. This is consistent with the description of not being able to fully move the left arm against gravity.
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66. A 69-year-old man was noted to have difficulty looking at objects that were brought into his visual field. He could not reach for objects placed in front of him, though he could see them. When presented with a picture of a complex scene, he could identify items within the picture but could not describe the picture as a whole. This syndrome localizes to:
A. Bilateral caudate region
B. Bilateral temporo-occipital region
C. Bilateral visual cortices
D. Bilateral parieto-occipital region
D. Bilateral parieto-occipital region
Rationalization: The symptoms described, including difficulty reaching for objects (optic ataxia), inability to describe a complex scene as a whole (simultanagnosia), and issues with visual fixation, are characteristic of Balint's syndrome, which is associated with bilateral lesions in the parieto-occipital region.
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67. The following are mixed motor and sensory cranial nerves except
A. CN VII
B. CN X
C. CN IX
D. CN IV
D. CN IV
Rationalization: The trochlear nerve (CN IV) is a pure motor nerve that innervates the superior oblique muscle of the eye. CN VII (Facial nerve), CN IX (Glossopharyngeal nerve), and CN X (Vagus nerve) have both motor and sensory components.
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68.Ideational apraxia:
A. Inability to perform goal-directed movements in sequence
B. Clumsiness in use of tools or objects
C. Deficit in using common tools in the absence of real object
D. Inability to perform specific motor act
A. Inability to perform goal-directed movements in sequence
Rationalization: Ideational apraxia is characterized by the inability to conceptualize, plan, and execute the complex sequences of motor actions involved in the use of tools or the performance of goal-directed activities.
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69. Test for Deep sensation, except:
A. Vibration
B. Joint position sense
C. Pinprick, vibration and position sense
D. Pinprick test
D. Pinprick test
Rationalization: The pinprick test assesses pain sensation, not deep sensation. Vibration and joint position sense tests are used to assess deep sensations.
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70.55 y/o female presenting with 5 month history of urinary retention, gradual weakness of lower extremities. On PE, both legs were spastic and hyperreflexive. She also had positive babinski bilateral. There was note of decreased sensation to pain from the nipple area down to the legs. What neurodiagnostic test will you order?
A. Spinal MRI
B. Nerve conduction studies
C. Cranial MRI
D. Cranial CT scan
A. Spinal MRI
Rationalization: Given the symptoms of urinary retention, gradual weakness of the lower extremities, spasticity, hyperreflexia, positive Babinski sign bilaterally, and decreased sensation to pain from the nipple area down, a spinal MRI is indicated to look for lesions in the spinal cord that could explain these findings.
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71. Inability to identify an object after careful palpation:
A. Astereognosis
B. Agraphia
C. Agraphesthesia
D. Anosognosia
A. Astereognosis
Rationalization: Astereognosis is the inability to identify an object by touch alone without the aid of sight.
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72. Dressing apraxia localizes to the
A. Left frontal lobe
B. Left parietal lobe
C. Right frontal lobe
D. Right parietal lobe
D. Right parietal lobe
Rationalization: Dressing apraxia is often associated with damage to the right parietal lobe, which is involved in spatial awareness and the integration of sensory information necessary for dressing.
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73. A 60-year-old male with a history of myocardial infarction 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 the Body. His speech is unintelligible and non-fluent, and he follows cannot follow Instructions. Efforts to get him to repeat simple phrases consistently fail. Which Language disturbance best explains the clinical picture?
A. Transcortical sensory aphasia
B. Global aphasia
C. Wernicke's aphasia
D. Transcortical motor aphasia
E. Broca's aphasia
B. Global aphasia
Rationalization: The clinical picture of dense right-sided hemiplegia, non-fluent unintelligible speech, inability to follow instructions or repeat phrases, and neglect of one side of the visual field suggests global aphasia. This condition typically results from extensive damage to the dominant hemisphere affecting both the language comprehension areas (Wernicke's area) and the speech production areas (Broca's area).
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74. Hyperreflexia with clonus is recorded as:
A. +
B. ++
C. +++
D. ++++
D. ++++
Rationalization: Hyperreflexia with clonus is a sign of upper motor neuron disease and is typically recorded as ++++ (4+), indicating very brisk reflexes, often associated with pathological reflexes like clonus.
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75. Which of the following statements about spasticity is incorrect?
A. Spasticity is not velocity dependent
B. It is usually described as clasp knife phenomenon
C. Spasticity predominantly affects the flexor muscles of the upper extremities and the extensor muscles of the lower extremities
A. Spasticity is not velocity dependent
Rationalization: This statement is incorrect. Spasticity is indeed velocity-dependent; it increases with the speed of limb movement. It is characterized by the clasp-knife phenomenon and affects muscle groups as described.
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76. True about weakness due to involvement of upper motor neurons:.
A. Spasticity accompanies weakness but may not be present in the acute phase
B. It is due to involvement of the anterior horn cells of the spinal cord corticospinal tract
C. Fasciculations and fibrillations may be present
D. There is usually marked atrophy of the involved muscles
A. Spasticity accompanies weakness but may not be present in the acute phase
Rationalization: This statement is true about weakness due to involvement of upper motor neurons. Spasticity is a hallmark of upper motor neuron lesions, but it may not develop immediately after the onset of the lesion. The other options describe features more typical of lower motor neuron lesions.
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77. Refers to a person's awareness that symptoms or disturbed behaviors are normal or abnormal
A. Thought process
B. Attention
C. Insight
D. Mood
C. Insight
Rationalization: Insight refers to the awareness and understanding of one's own condition and behaviors, including the ability to recognize that one's symptoms or behaviors are abnormal.
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78. Features of Peripheral Vertigo, EXCEPT:
A. Visual fixation suppresses vertigo
B. Severe vertigo
C. Fatigable
D. Bidirectional nystagmus
D. Bidirectional nystagmus
Rationalization: Peripheral vertigo typically presents with unidirectional nystagmus, not bidirectional. Visual fixation often suppresses vertigo, the vertigo can be severe, and the nystagmus is usually fatigable in peripheral vertigo.
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79 The following visual field cut indicates a lesion in which of the following structures?
A. right occipital lobe
B. left geniculocalcarine radiation
C. left optic nerve
D. right optic chiasm
B. Left geniculocalcarine radiation: Lesions in the left geniculocalcarine tract, which carries visual information from the right half of the visual field, would result in right homonymous hemianopia.
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80. Componnets of the Mini-Mental Status Examination
A. Calculation
B. Language
C. Orientation
D. All are components of MMSE
E. Orientation and Language only
D. All are components of MMSE
Rationalization: The Mini-Mental Status Examination (MMSE) includes components such as calculation, language, and orientation, among others, to assess cognitive function.
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81 A patient with agraphesthesia will have the
A. Inability to identify an object with palpation
B. Inability to recognize object drawn on the palm of his hand
C. Inability to recognize affected limb as his own
D. Inability to write
B. Inability to recognize object drawn on the palm of his hand
Rationalization: Agraphesthesia is the inability to recognize numbers, letters, or shapes drawn on the skin, typically on the palm of the hand, indicating a sensory perceptual disorder.
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82. A 72-year old woman is brought to a neurology clinic by her family members for memory impairment and a decline in functional abilities. On examination, when she is asked to pantomime brushing her teeth, she uses her finger as the toothbrush, instead of pretending to hold a toothbrush. When asked to show how she would open a letter with a letter opener, she uses her finger as the blade instead of pretending
A. Ideational apraxia
B. Limb-kinetic apraxia
C. Ideomotor apraxia
D. Conduction apraxia
E. Conceptual apraxia
C. Ideomotor apraxia
Rationalization: Ideomotor apraxia is characterized by the inability to perform a task on command despite understanding the task and having the physical ability to perform it. Using the finger as a tool instead of pantomiming the use of the actual tool (like a toothbrush or letter opener) is indicative of ideomotor apraxia.
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83. 67 y/o female developed sudden onset diplopia and left sided weakness. On PE, there was note of esotropia of the right eye and she cannot abduct her right eye while testing for extraocular muscle movement. Left upper and lower extremities were graded 3/5 while the right upper and lower 5/5. Where will you localize the lesion?
A. right pons
B. right midbrain
C. right corona radiata
D. left medulla
A. right pons
Rationalization: The presence of esotropia (inward deviation of the eye) and inability to abduct the right eye suggest a lesion involving the abducens nerve (CN VI), which emerges from the pons. The left-sided weakness indicates a crossed pattern of deficits, typical of brainstem lesions, localizing the lesion to the right pons.
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84. True of Logopenic Primary Progressive Aphasia, except:
a. most commonly associated with Alzheimer's disease
b. preserved fluency and syntax but poor single-word comprehension and profound 2-way naming impairments -semantic ppa
c. preserved syntax and comprehension but frequent and severe word-finding pauses; repetition impaired
d. None, all are correct
B. preserved fluency and syntax but poor single-word comprehension and profound 2-way naming impairments -semantic ppa
Rationalization: This description is incorrect for logopenic primary progressive aphasia (PPA). Logopenic PPA is characterized by preserved syntax and comprehension but frequent and severe word-finding pauses; repetition is impaired. The description given matches semantic PPA more closely.
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85. A spinal cord hemisection will have the following pattern of sensory loss:
a. Ipsilateral loss of vibration and position sense and contralateral loss of pain and temperature
b. Ipsilateral loss of vibration and position sense and ipsilateral loss of pain and temperature
c. Cape distribution
d. Contralateral loss of vibration and position sense and ipsilateral loss of pain and temperature
A. Ipsilateral loss of vibration and position sense and contralateral loss of pain and temperature
Rationalization: A spinal cord hemisection (Brown-Séquard syndrome) results in ipsilateral loss of vibration and position sense (due to damage to the dorsal columns) and contralateral loss of pain and temperature sense (due to damage to the spinothalamic tract) below the level of the lesion.
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86. The ideal distance of the patient from the Snellen chart during visual acuity testing
A. 14 inches
B. 20 feet
C. 10 feet
D. 20 meters
B. 20 feet
Rationalization: The ideal distance for a patient from the Snellen chart during visual acuity testing is 20 feet (or 6 meters in countries using the metric system).
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87. The second- order neuron in the Dorsal column-medial lemniscus pathway is located at --
A. ventral posterior lateral nucleus of thalamus
B. nucleus gracilis and nucleus cuneatus
C. central gray matter (dorsal horn)
D. dorsal root ganglion
B. nucleus gracilis and nucleus cuneatus
Rationalization: The second-order neurons in the Dorsal column-medial lemniscus pathway are located in the nucleus gracilis and nucleus cuneatus in the medulla oblongata.
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88. In mini mental state exam, registration is given a score of
A. 5
B. 2
C. 4
D. 3
D. 3
Rationalization: In the Mini-Mental State Examination (MMSE), registration (the ability to repeat named prompts immediately after hearing them) is given a score of 3.
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89. Inability to perform this test is called
A. Dysdiadochokinesia
B. Dysmetria
C. Dyssynergia
D. Dysarthria
B. Dysmetria- finger to nose test (ratio)
This is a common neurological exam to assess coordination and is part of testing for cerebellar function. During this test, a person is asked to touch their nose with their finger and then to touch the examiner's finger, with the examiner changing the position of their finger periodically.
The inability to perform this test due to lack of coordination is known as dysmetria, specifically when the person consistently undershoots (hypometria) or overshoots (hypermetria) the target. Dysmetria is indeed characterized by the inability to control the range of movement and is often seen in cerebellar disorders.
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90. The following tests for optic nerve
A. testing for accommodation reflex
B. testing for peripheral vision using the snellen chart
C. testing for pupillary light reflex
D. none of the choices
E. testing for corneal reflex
C. testing for pupillary light reflex
Rationalization: Testing for the pupillary light reflex assesses the function of the optic nerve (CN II) as it carries sensory input to the brain, and the oculomotor nerve (CN III) as it controls the pupillary response.
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91. 70 y/o male presented with sudden onset left sided hemiplegia, numbness and
left central facial palsy. Which of the following tests will you order?
A. electroencephalogram
B. spinal MRI
C. nerve conduction studies
D. cranial CT scan
D. cranial CT scan
Rationalization: For sudden onset of left-sided hemiplegia, numbness, and left central facial palsy, a cranial CT scan is the most appropriate initial test to assess for acute stroke or other cerebral pathologies.
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92. 20 y/o female with a 2 month history of predominantly proximal weakness of the
Shoulder and hip muscles. Which of the following tests will you order?
A. Spinal mri
B. Nerve conduction studies and electromyography
C. Cranial mri
D. Cranial ct scan
B. Nerve conduction studies and electromyography
Rationalization: For a 20-year-old female with a 2-month history of predominantly proximal weakness of the shoulder and hip muscles, nerve conduction studies (NCS) and electromyography (EMG) are appropriate to assess for neuromuscular disorders such as myopathies or neuromuscular junction disorders.
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93. Lesion in the territory of posterior arteries particularly the occipitotemporal area may result to:
A. Simultagnosia
B. Prosopagnosia
C. Optic apraxia
D. Cortical blindness
B. Prosopagnosia
Rationalization: Lesions in the territory of the posterior cerebral arteries, particularly affecting the occipitotemporal area, can lead to prosopagnosia, which is the inability to recognize familiar faces.
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A. Chaddock
B. Babinski
C. Oppenheim
D. Schaeffer
D. Schaeffer
Schaeffer's Sign: For this test, the examiner squeezes the Achilles tendon, and a positive sign is the same as a positive Babinski.
Babinski Reflex Test: This is the most well-known test where the examiner strokes the lateral aspect of the sole of the foot with a blunt object, usually from the heel toward the toes. A positive Babinski sign, which is abnormal, is indicated by dorsiflexion of the big toe and fanning of the other toes, suggesting an upper motor neuron lesion.
Chaddock's Sign: Instead of the sole of the foot, the examiner strokes the lateral malleolus or the lateral aspect of the foot. A positive Chaddock's sign is the same response as a positive Babinski sign and can be used when the sole of the foot is not accessible or the Babinski test is negative in the presence of other signs of an upper motor neuron lesion.
Oppenheim's Sign: This involves applying pressure to the anterior surface of the tibia, causing the same response as the Babinski sign if positive.
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95. The following cranial nerves are found in the medulla except
A. Abducens
B. Hypoglossal
C. Glossopharyngeal
D. Vagus
A. Abducens
Rationalization: The abducens nerve (CN VI) originates from the pons, not the medulla. The hypoglossal (CN XII), glossopharyngeal (CN IX), and vagus (CN X) nerves are found in the medulla.
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96. Comprehension of written or spoken language is localized at
A. dominant superior parietal lobe
B. dominant inferior frontal lobe
C. non dominant superior frontal lobe
D. dominant superior temporal lobe
D. Dominant superior temporal lobe
Rationalization: Comprehension of written or spoken language is primarily localized in the dominant superior temporal lobe, specifically in Wernicke's area.
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97. When you ask the patient to look to the left and down, which cranial nerves are you testing?
A. Left abducens and right oculomotor
B. Right trochlear and left oculomotor
C. Left trochlear and right optic
D. Left trochlear and right oculomotor
B. Right trochlear and left oculomotor
Rationalization: Looking to the left involves the left abducens (CN VI) for lateral movement, and looking down involves the right trochlear (CN IV) for intorsion and depression of the eye, along with the left oculomotor (CN III) for its role in most eye movements including downward movement.
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98. You saw a stroke patient in the clinic who was having difficulty in demonstrating how to wave goodbye even if his motor function, sensorium and comprehension are intact. You can say that the patient has:
A. Abulia
B. Apraxia
C. Apathy
D. Agnosia
E. Hemineglect
B. Apraxia
Rationalization: Difficulty in demonstrating how to perform a familiar gesture, such as waving goodbye, despite intact motor function, sensorium, and comprehension, suggests apraxia, which is a disorder of skilled movement not explained by weakness, akinesia, deafferentation, abnormal tone or posture, or intellectual deterioration.
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99. True of vasovagal syncope:
A. Both are correct
B. Unconsciousness may be prolonged if individual remains upright
C. Both are incorrect
D. Like that of seizure, sphincter control is maintained
A. Both are correct
Rationalization: In vasovagal syncope, unconsciousness may indeed be prolonged if the individual remains upright due to continued reduced cerebral perfusion, and unlike seizures, sphincter control is typically maintained.
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100. Confused speech is given a grade of __ in the verbal response part of the GCS
A. 3
B. 2
C. 4
D. 1
E. 5
F. 6
C. 4
- Rationalization: In the Glasgow Coma Scale (GCS), confused speech is given a grade of 4 in the verbal response part. This indicates that the patient is disoriented or not making sense but is able to produce speech.
The GCS verbal response scores range from 1 to 5, with specific criteria for each score:
5: Oriented
4: Confused
3: Inappropriate words
2: Incomprehensible sounds
1: No verbal response
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CASE#1. A 53 y/o female, smoker, known hypertensive and diabetic, non-compliant with medications, came to the ER for sudden onset of diplopia and right sided weakness. On PE, pt was awake, with intact higher cortical function. On cranial nerve assessment there was note of ptosis on the left eye, and the left eye was deviated outwards. There was no note of facial numbness or facial palsy. Tongue was midline. The right upper and lower extremities were graded 2/5 while the left upper and lower extremities were 5/5. There was no note of nystagmus, dysmetria. Neck was supple.
Based on the clinical presentation, where is the most likely location of the lesion in this patient?
A) Right cerebrum, frontal lobe
B) Left cerebrum, occipital lobe
C) Brainstem, specifically the left midbrain area
D) Spinal cord, cervical level
C) Brainstem, specifically the left midbrain area
The clinical presentation suggests a lesion in the brainstem, specifically in the region affecting the cranial nerves responsible for eye movement and possibly the corticospinal tract.
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CASE#1. A 53 y/o female, smoker, known hypertensive and diabetic, non-compliant with medications, came to the ER for sudden onset of diplopia and right sided weakness. On PE, pt was awake, with intact higher cortical function. On cranial nerve assessment there was note of ptosis on the left eye, and the left eye was deviated outwards. There was no note of facial numbness or facial palsy. Tongue was midline. The right upper and lower extremities were graded 2/5 while the left upper and lower extremities were 5/5. There was no note of nystagmus, dysmetria. Neck was supple.
The patient's ptosis and outward deviation of the left eye suggest involvement of which cranial nerve?
A) Cranial Nerve II (Optic Nerve)
B) Cranial Nerve III (Oculomotor Nerve)
C) Cranial Nerve IV (Trochlear Nerve)
D) Cranial Nerve VI (Abducens Nerve)
B) Cranial Nerve III (Oculomotor Nerve)
Diplopia and ptosis on the left eye, along with the left eye being deviated outwards, suggest involvement of the cranial nerve III (oculomotor nerve) on the left side, which controls most of the eye's movements, including constriction of the pupil and maintaining an open eyelid.
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CASE #2. A 60 y/o female with known history of breast cancer was brought to the ER for a 3-month history of back pain and progressive lower extremity weakness. She also noted difficulty in urination. On PE, pt was GCS15, with intact cranial nerves. Both upper extremities were graded 5/5, normotonic and normorefexic. Both lower extremities were spastic and hyperreflexic (+4). Hip flexors, knee extensors, ankle dorsi and plantarflexors were graded 0/5. Bilateral babinski and clonus were noted. On sensory testing, last normal sensory level to pain was at the level of the nipple. Both upper extremities had intact proprioception while both lower extremities had impaired proprioception and vibration sense. No dysmetria or nystagmus were noted.
Based on the clinical presentation, where is the most likely location of the lesion in this patient?
A) Cervical spinal cord
B) Thoracic spinal cord at the level of the nipples (T4-T5)
C) Lumbar spinal cord
D) Brainstem
B) Thoracic spinal cord at the level of the nipples (T4-T5
Impaired proprioception and vibration sense in both lower extremities, along with the last normal sensory level to pain at the level of the nipple, suggest a lesion at or above the thoracic level of the spinal cord, around the T4-T5 vertebrae, given the nipple line is typically at the dermatome level of T4.
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CASE #2. A 60 y/o female with known history of breast cancer was brought to the ER for a 3-month history of back pain and progressive lower extremity weakness. She also noted difficulty in urination. On PE, pt was GCS15, with intact cranial nerves. Both upper extremities were graded 5/5, normotonic and normorefexic. Both lower extremities were spastic and hyperreflexic (+4). Hip flexors, knee extensors, ankle dorsi and plantarflexors were graded 0/5. Bilateral babinski and clonus were noted. On sensory testing, last normal sensory level to pain was at the level of the nipple. Both upper extremities had intact proprioception while both lower extremities had impaired proprioception and vibration sense. No dysmetria or nystagmus were noted.
The presence of bilateral Babinski sign and clonus in this patient suggests:
A) Lower motor neuron lesion
B) Upper motor neuron lesion
C) Peripheral neuropathy
D) Myasthenia gravis
B) Upper motor neuron lesion
Progressive lower extremity weakness, spasticity, hyperreflexia, bilateral Babinski sign, and clonus are all signs of an upper motor neuron lesion affecting the spinal cord.
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CASE #2. A 60 y/o female with known history of breast cancer was brought to the ER for a 3-month history of back pain and progressive lower extremity weakness. She also noted difficulty in urination. On PE, pt was GCS15, with intact cranial nerves. Both upper extremities were graded 5/5, normotonic and normorefexic. Both lower extremities were spastic and hyperreflexic (+4). Hip flexors, knee extensors, ankle dorsi and plantarflexors were graded 0/5. Bilateral babinski and clonus were noted. On sensory testing, last normal sensory level to pain was at the level of the nipple. Both upper extremities had intact proprioception while both lower extremities had impaired proprioception and vibration sense. No dysmetria or nystagmus were noted.
The last normal sensory level to pain at the level of the nipple indicates a lesion at which vertebral level?
A) C5
B) T4-T5
C) L1
D) S1
B) T4-T5
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CASE #3. A 35 year-old male consulted at the out patient clinic for jerking of his right hand. 2 months prior to consult, he started experiencing intermittent headache partially relieved with intake of paracetamol. 2 days prior, he noted sudden twitching and jerking of his right hand which lasted for 1 minute. He was completely awake during the episode. Few hours prior to consult, the same episode was noted which lasted for 30 seconds. On PE, he was GCS15 with intact higher cortical functions.
There was note of mild pronator drift on the right and the rest of the neurologic exam was normal.
Where is the most likely location of the lesion in the patient described in CASE#3?
A) Right frontal lobe
B) Left frontal lobe
C) Right parietal lobe
D) Left parietal lobe
B) Left frontal lobe.
The rationale is that the jerking and twitching of the right hand, described as focal motor seizures, are controlled by the contralateral (opposite side) hemisphere of the brain, specifically in the frontal lobe where the primary motor cortex is located. The left frontal lobe controls the motor functions of the right side of the body. The presence of a mild pronator drift on the right further supports the involvement of the upper motor neuron pathway originating from the left hemisphere.
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CASE #3. A 35 year-old male consulted at the out patient clinic for jerking of his right hand. 2 months prior to consult, he started experiencing intermittent headache partially relieved with intake of paracetamol. 2 days prior, he noted sudden twitching and jerking of his right hand which lasted for 1 minute. He was completely awake during the episode. Few hours prior to consult, the same episode was noted which lasted for 30 seconds. On PE, he was GCS15 with intact higher cortical functions.
There was note of mild pronator drift on the right and the rest of the neurologic exam was normal.
The jerking and twitching of the patient's right hand are most indicative of:
A) Peripheral nerve damage
B) A focal seizure
C) A psychogenic movement disorder
D) A spinal cord lesion
B) A focal seizure
The sudden, brief, and involuntary twitching or jerking of the right hand, with the patient being fully conscious during the episode, is characteristic of a focal seizure. Focal seizures originate in just one area of the brain and can affect muscle control, movement, and sensation without necessarily impairing consciousness.
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CASE #3. A 35 year-old male consulted at the out patient clinic for jerking of his right hand. 2 months prior to consult, he started experiencing intermittent headache partially relieved with intake of paracetamol. 2 days prior, he noted sudden twitching and jerking of his right hand which lasted for 1 minute. He was completely awake during the episode. Few hours prior to consult, the same episode was noted which lasted for 30 seconds. On PE, he was GCS15 with intact higher cortical functions.
There was note of mild pronator drift on the right and the rest of the neurologic exam was normal.
The mild pronator drift observed in the patient's right arm suggests:
A) Lower motor neuron lesion
B) Upper motor neuron lesion
C) Normal neurological finding
D) Cerebellar dysfunction
B) Upper motor neuron lesion
A mild pronator drift is a sign of weakness or subtle motor dysfunction, often indicative of an upper motor neuron lesion. This type of drift occurs when the patient extends their arms in front of them with palms facing upwards, and one arm slowly pronates and descends, reflecting a mild form of weakness.
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CASE #4. A 70 year-old male, smoker and alcoholic beverage drinker, known hypertensive, with poor compliance to medications, came to the ER for sudden onset left sided weakness. On PE, pt was awake, able to follow simple commands, with left hemineglect and agraphesthesia. Pupils were 3 mm briskly reactive to light, midline, with full EOMs, with left central facial palsy and tongue deviated to the left. Left upper and lower extremities were graded 2/5. There was (+) extensor toe sign on the left but no clonus. 50% sensory deficit was noted on the left upper and lower extremities. No nystagmus or dysmetria. No neck rigidity.
Based on the clinical presentation, where is the lesion located in the patient described in CASE#4?
A) Left cerebral hemisphere
B) Right cerebral hemisphere
C) Brainstem
D) Cervical spinal cord
B) Right cerebral hemisphere
The presentation of left-sided weakness, left hemineglect, and agraphesthesia, along with left central facial palsy, points to a lesion in the right cerebral hemisphere. Hemineglect, where the patient ignores one side of the body and space, is typically associated with damage to the parietal lobe, particularly on the right side, which manages spatial awareness and attention.
106
CASE #4. A 70 year-old male, smoker and alcoholic beverage drinker, known hypertensive, with poor compliance to medications, came to the ER for sudden onset left sided weakness. On PE, pt was awake, able to follow simple commands, with left hemineglect and agraphesthesia. Pupils were 3 mm briskly reactive to light, midline, with full EOMs, with left central facial palsy and tongue deviated to the left. Left upper and lower extremities were graded 2/5. There was (+) extensor toe sign on the left but no clonus. 50% sensory deficit was noted on the left upper and lower extremities. No nystagmus or dysmetria. No neck rigidity.
The presence of left hemineglect in this patient is most indicative of damage to which area of the brain?
A) Left frontal lobe
B) Right parietal lobe
C) Left parietal lobe
D) Right occipital lobe
B) Right parietal lobe
Left hemineglect is a condition where the patient is unaware of objects or even their own limbs on the left side. This condition is most commonly associated with damage to the right parietal lobe, which is involved in processing spatial orientation and directing attention.
107
CASE #4. A 70 year-old male, smoker and alcoholic beverage drinker, known hypertensive, with poor compliance to medications, came to the ER for sudden onset left sided weakness. On PE, pt was awake, able to follow simple commands, with left hemineglect and agraphesthesia. Pupils were 3 mm briskly reactive to light, midline, with full EOMs, with left central facial palsy and tongue deviated to the left. Left upper and lower extremities were graded 2/5. There was (+) extensor toe sign on the left but no clonus. 50% sensory deficit was noted on the left upper and lower extremities. No nystagmus or dysmetria. No neck rigidity.
The left central facial palsy and tongue deviation to the left suggest involvement of:
A) Cranial nerve VII
B) Cranial nerve V
C) Cranial nerve XII
D) Both A and C
D) Both A and C
Central facial palsy, where only the lower half of one side of the face is affected, and tongue deviation (to the lesion's contralateral side) suggest involvement of the facial nerve (Cranial nerve VII) and possibly the hypoglossal nerve (Cranial nerve XII). These symptoms indicate a central lesion affecting the neural pathways that control these cranial nerves, which in this case, would be located in the right hemisphere of the brain, affecting the left side of the body.
108
A patient presents with diplopia, ptosis, and right-sided weakness. Which diagnostic test is most appropriate for identifying potential brainstem lesions in this patient?
A) CT Scan of the Brain
B) Magnetic Resonance Imaging (MRI) of the Brain focusing on the brainstem
C) Electromyography (EMG) and Nerve Conduction Velocity (NCV)
D) Spinal MRI
B) Magnetic Resonance Imaging (MRI) of the Brain focusing on the brainstem
Rationale: MRI of the brain, particularly focusing on the brainstem, is the most appropriate diagnostic test for identifying potential brainstem lesions due to its high sensitivity and ability to provide detailed images of soft tissue structures. This capability is crucial for diagnosing conditions such as ischemic strokes, hemorrhages, tumors, or demyelinating diseases in the brainstem. MRI's superior soft tissue contrast compared to CT scans makes it more effective in visualizing the detailed structures within the brainstem, which is essential for accurately diagnosing the cause of symptoms like diplopia, ptosis, and hemiparesis.
109
For a patient suspected of having an acute intracranial hemorrhage following a head injury, which diagnostic test is most immediately appropriate?
A) CT Scan of the Brain
B) Magnetic Resonance Imaging (MRI) of the Brain
C) Electromyography (EMG) and Nerve Conduction Velocity (NCV)
D) Spinal MRI
A) CT Scan of the Brain
Rationale: A CT scan of the brain is the most immediately appropriate diagnostic test for a patient suspected of having an acute intracranial hemorrhage following a head injury. CT scans are highly effective in quickly detecting acute hemorrhages, fractures, or large masses, making them the first choice in emergency settings where rapid diagnosis is critical for timely intervention.
110
Which diagnostic test is best suited for evaluating a patient with suspected carpal tunnel syndrome?
A) CT Scan of the Brain
B) Magnetic Resonance Imaging (MRI) of the Brain
C) Electromyography (EMG) and Nerve Conduction Velocity (NCV)
D) Spinal MRI
C) Electromyography (EMG) and Nerve Conduction Velocity (NCV)
Rationale: EMG and NCV are diagnostic tests specifically designed to assess the electrical activity of muscles and the speed of nerve conduction, making them particularly suited for diagnosing diseases of the peripheral nervous system. These tests are ideal for evaluating conditions like nerve compressions (e.g., carpal tunnel syndrome), peripheral neuropathies, and muscle disorders, as they provide direct insight into the functional status of muscles and nerves.
111
A patient presents with lower back pain, radiculopathy, and signs of spinal cord compression. Which diagnostic test would be most appropriate to assess for potential spinal cord lesions?
A) CT Scan of the Brain
B) Magnetic Resonance Imaging (MRI) of the Brain
C) Electromyography (EMG) and Nerve Conduction Velocity (NCV)
D) Spinal MRI
D) Spinal MRI
Rationale: A spinal MRI is the most appropriate diagnostic test for assessing potential spinal cord lesions in patients presenting with symptoms such as lower back pain, radiculopathy, and signs of spinal cord compression. Spinal MRI provides detailed images of the spinal cord and the structures surrounding it, including nerve roots and intervertebral discs. This makes it invaluable for diagnosing spinal cord lesions, nerve root compressions, disc herniations, and other spinal pathologies, offering superior visualization of the spinal anatomy and any associated abnormalities.
MED 1
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