soal 80 -120 Flashcards by anugrahonie widhiatmo

A 54-year-old man was in excellent health until 1 month prior hospital admission when he developed acute severe neck pain after bending over to pick up a newspaper. He went to the emergency room where plain x-rays showed only mild arthritic changes. Over the next 4 weeks he saw multiple physicians from different fields and had various therapies including rest, analgesics, and physical therapy, without relief. One week prior to admission he noticed the gradual onset weakness of both upper extremities as well as slowly progressive involuntary neck flexion. At this point, a bone scan revealed increased uptake of the fourth, fifth, and sixth cervical vertebrae. Magnetic resonance imaging demonstrated severe cord compression at the midcervical level. Physical examination at the time of admission indicated a middle-aged man who was ambulatory with a spastic gait. His neck was held in complete flexion and he was unable to extend it. He was afebrile with stable vital signs. There was marked tenderness of the midcervical spine. Neurologic examination demonstrated pronounced weakness with 0/5 strength in
the biceps and 1/5 strength in the deltoids bilaterally. Lower extremity examination showed minimal weakness and increased tone. Upper extremity reflexes were diminished bilaterally; the lower extremities had significant hyper-reflexia with sustained clonus. Toes were upgoing. Sensation was intact and rectal tone was normal. Lab data showed a moderately elevated white blood cell count with a normal differential. Chest xray was normal and lateral cervical spine x-rays demonstrated complete collapse of the fourth and fifth cervical vertebrae, with angulation at that level. The MOST likely diagnosis is:

A. pyogenic vertebral osteomyelitis
B. metastatic prostate cancer
C. epidural hematoma
D. nasopharyngeal carcinoma with contiguous spread
E. osteoblastama

A. pyogenic vertebral osteomyelitis

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A 54-year-old man was in excellent health until 1 month prior hospital admission when he developed acute severe neck pain after bending over to pick up a newspaper. He went to the emergency room where plain x-rays showed only mild arthritic changes. Over the next 4 weeks he saw multiple physicians from different fields and had various therapies including rest, analgesics, and physical therapy, without relief. One week prior to admission he noticed the gradual onset weakness of both upper extremities as well as slowly progressive involuntary neck flexion. At this point, a bone scan revealed increased uptake of the fourth, fifth, and sixth cervical vertebrae. Magnetic resonance imaging demonstrated severe cord compression at the midcervical level. Physical examination at the time of admission indicated a middle-aged man who was ambulatory with a spastic gait. His neck was held in complete flexion and he was unable to extend it. He was afebrile with stable vital signs. There was marked tenderness of the midcervical spine. Neurologic examination demonstrated pronounced weakness with 0/5 strength in
the biceps and 1/5 strength in the deltoids bilaterally. Lower extremity examination showed minimal weakness and increased tone. Upper extremity reflexes were diminished bilaterally; the lower extremities had significant hyper-reflexia with sustained clonus. Toes were upgoing. Sensation was intact and rectal tone was normal. Lab data showed a moderately elevated white blood cell count with a normal differential. Chest xray was normal and lateral cervical spine x-rays demonstrated complete collapse of the fourth and fifth cervical vertebrae, with angulation at that level.
The BEST initial therapy would be:
A. Gardner-Wells tongs followed by a computed tomography-guided biopsy
B. Gardner-Wells tongs followed by elective surgery
C. immediate operative decompression with methylmethacrylate reconstruction
D. immediate operative decompression with autologous bone reconstruction
E. high-dose methylprednisolone and radiation therapy

D. immediate operative decompression with autologous bone reconstruction

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In degenerative lumbar spondylosis, stenosis of the lateral recess is most to be caused by:
A. the inferior medial aspect of the inferior facet of the vertebral body above the disc
B. hypertrophied ligamentum flavum
C. a deficient pars interarticularis
D. the superior medial aspect of the superior facet of the vertebral body below the disc
E. a laterally bulging intervertebral disc

D. the superior medial aspect of the superior facet of the vertebral body below the disc

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A 12-year-old boy presented with a history of generalized headache and a 3-month history of episodic unresponsiveness. The episodes were often preceded by a sense of anxiety and lasted several minutes each. His neurologic examination was normal. The magnetic resonance image shown in Figure 84A was obtained. Which of the following statements is TRUE?
A. Cyst peritoneal shunting is not an acceptable treatment.
B. The primary abnormality is failure of the temporal lobe to develop.
C. The most likely diagnosis is arachnoid cyst.
D. Craniotomy for complete removal of the mass and epileptic focus is indicated.
E. The most likely diagnosis is epidermoid tumor.

C. The most likely diagnosis is arachnoid cyst.

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A 25-year-old man presents with interscapular pain, hypalgesia below T6 and a spastic paraparesis that has progressed in severity for 1.5 years. The magnetic resonance image shown in Figure 85 was obtained. Which of the following treatments is indicated?
A. biopsy and chemotherapy if high-grade astrocytoma is found
B. syrinx to pleural shunt
C. gross removal ependymoma or low-grade glioma if found
D. gross removal and radiation if ependymoma if found
E. empiric radiation

C. gross removal ependymoma or low-grade glioma is found

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A 54-year-old man with chronic hypertension requiring medication presents with a 6-year history of involuntary twitching on the left side of his face and a 2-month history of left facial pain. The facial movements had evolved from twitching of the palpebral part orbicularis oculi into spasmodic contractions of most of the muscles about the left eye and cheek. His facial pain is lancinating in nature, precipitated by touching a trigger zone in the orbital temporal region, and radiating superolaterally from above his left eye in the distribution of the supraorbital nerve. Except for mild weakness of the facial
muscles, his neurologic exam is normal. A magnetic resonance image is obtained (seeFigure 86). Which of the following statements is TRUE?
A. Tic convulsive may antecede more extensive facial dystonias
B. Endovascular treatment may improve the patient’s symptoms.
C. An attempt at microvascular decompression is contraindicated
D. A trial of carbamazepine is warranted.
E. The mass is best approached by a transoral transclival route.

D. A trial of carbamazepine is warranted.

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A 54-year-old man with severe rheumatoid arthritis presents with a 1-week history of progressively increasing midthoracic back pain. He also complains of occasional paresthesia in both anterior thighs with ambulation. His only medication is prednisone, 10 mg/day, which has been taking for 15 years. Examination reveals pain to percussion over the spinous processes of T5-9, associated with paraspinal spasm in the same distribution. Neurologic exam is completely normal, including rectal tone and perianal sensation. Plain radiographs show osteoporosis with compression fractures at T6 and T8 and approximately 30%loss of vertebral body height at both levels. A computed tomographic is obtained and shows an extradural mass extending from T4-10. There is anterior displacement of the spinal cord. Attenuation numbers of the mass suggest fat. The most appropriate and treatment would be:
A. blood, urine, and sputum cultures followed by emergent thoracic laminectomy and initiation of broad spectrum antibiotics
B. mri with gadolinium enhancement, pancultures, urgent thoracic larninectomy,and broad spectrum anti biotics
C. Thoracolumbar sacral orthosis bracing, short-term increase in prednisone dosage for cord compression
D. MRI with gadolinium,tapering dose of steroids, and rheumatology consult
E. urgent thoracic vertebrectomy T6-8 with sturt grafting followed by thoracic laminectomy with spinal instrumentation

D. MRI with gadolinium,tapering dose of steroids, and rheumatology consult

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A 62-year-old man with a 3-month history of progressive spastic cervical myelopathy had a metrizamide computed tomographic scan (Figure 83). All scan slices from C3-5, have the same appearance. Which the following statements is TRUE ?
A. The tumor is most likely an osteochondroma
B. A chest CT scan is indicated to rule out metastatic spread
C. Postoperative radiation, but not chemotherapy, is indicated
D. Multilevel medial corpectomy and interbody fusion are indicated
E. Calcification of an extrude disc fragment is seen.

D. Multilevel medial corpectomy and interbody fusion are indicated

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There are myriad etiologies of lesions in the pediatric and young adult population. Match each disease or lesion in questions 88-92, with the most appropriate clinical, pathologic, or radiographic feature listed in A-E. Some answers may be used more than once:
A. colonic polyposis, epidermal inclusion cysts
B. “pearlyt” cysts
C. Birbeck granule
D. radiating spicules of bone
E. midline predisposition
88. Hand-Schuller-Christian disease

C. Birbeck granule

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There are myriad etiologies of lesions in the pediatric and young adult population.
A. colonic polyposis, epidermal inclusion cysts
B. “pearlyt” cysts
C. Birbeck granule
D. radiating spicules of bone
E. midline predisposition

osteomas

A. colonic polyposis, epidermal inclusion cysts

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Metastatic neuroblastoma

D. radiating spicules of bone

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Hemangioma

D. radiating spicules of bone

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Epidermoid

B. “pearlyt” cysts

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A 60-year-old woman with non-Hodgkin lymphoma is diagnosed as having lymphomatous meningitis following a lumbar puncture. Which of the following are associated with this complication of her disease?
L5 radiculopathy
. focal seizures, ataxia
. facial nerve palsy
. decreased CSF levels of B-2 microglobulin

a. 1,2,3
L5 radiculopathy
focal seizures, ataxia
facial nerve palsy

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Which of the following statements regarding brain stem auditory evoked potentials
(BAEPs) are TRUE (Figure 94 A) ?
Waves I and II generated in the vestibulocochlear (VIII) nerve.
Signal averaging computers must be used to detect this signal.
BAEPs are useful in preventing deafness as a complication of posterior fossa surgery.
BAEPs are very resistant to general anesthesia

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Which of the following statements regarding Creutzfeldt-Jakob disease are m e ?
It is rapidly progressive and death usually occurs within year of onset.
The recognition of spongiform degeneration is central to the pathologic process.
Distinct changes in the EEG sharacterize the disease
The agent responsible for transmission can be inactivated by autoclaving or formalin fixation.

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A 34-year-old man presents to the emergency room with a complaint of acute visual loss in his right eye. It is thought that he has retrobulbar optic neuritis. Which of the following would cast doubt on that diagnosis?
a.periocular pain
b. a Marcus Gunn pupil
c . normal optic nerve head
d. constriction of the visual field in the affected eye

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Bukan semua

A 19-year-old man presents with complaints of unquenchable thirst. Physical examination remarkable bitemporal hemianopia, and evidence of panhypopituitarism. A complete craniospinal MRI is obtained which demonstrates a densely enhancing mass in the suprasellar region. A stereotactic biopsy is performed. Frozen sections are remarkable for large, round, neoplastic cells intermixed with smaller lymphocytes. The following statements regarding this tumor are TRUE:
Complete craniospinal radiation is usually required.
Serum levels of placental alkaline may be elevated.
This is the most common site of origin for this tumor.
The biopsy specimen may have contained noncaseating granulomas

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Which of the following statements BEST characterize neurosarcoidosis?
Evidence of systemic involvement is found in the vast majority of patients.
Cerebrospinal fluid findings are specific and all patients with suspected neurosarcoidosis should have a lumbar puncture performed.
A facial nerve palsy is the most frequent manifestation.
Seizures are a common occurrence.

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99. A 30-year-old cosmetician presents with a complaint of unequal pupils. She noted the asymmetry at work today, but cannot be certain how long it has been present. There are no complaints of headache or facial pain. Examination of the globe and fundus are normal. The right pupil measures 7 mm,has no direct or consensual reaction to light. The left pupil measures 7 mm and has no direct or consensual reaction to light. Visual acuity is 20/20 OU. Visual fields and color vision are normal. The right eye shows an incomplete and slow constriction while fixating on a near object. It dilates to 7mm upon changing fixation to a distant object, but this too is slow. response of the left eye to near-far fixation is normal. When is instilled into the right eye, the pupil responds after 15-30 minutes. The remainder of the neurologic exam is normal. The MOST likely diagnosis in this case is:
A. deaffereanted pupil
B. toxic pupil
C. paralytic pupil
D. Adie’s pupil
E. Argyll Robertson pupil

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D. Adie’s pupil

Which of the following statements regarding the diencephalic syndrome is FALSE?
A. The responsible lesion is usually a tumor of the anterior hypothalamus and/or the optic chiasm
B. Soft tissue x-rays show a complete absence of subcutaneous fat.
C. Other signs of hypothalamic or visual system disease are often absent.
D. Serum levels of growth hormone are depressed.
E. Nystagmus may be the first sign of the neurologic nature of the syndrome.

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D. Serum levels of growth hormone are depressed.

A 3-year-old child presents visual loss in the right eye. She has acuity of less than 20/100 ODand 20/20 OS. Visual fields on the left are normal. She has no hydrocephalus,no diabetes insipidus, and no endocrine abnormalities. Magnetic resonance imaging shows a 2,5cm irregular lesion in the suprasellar region extending into the anterior third. Portions enhance with gadolinium. There is no calcification on computed scan, At surgery, under microscope left optic nerve and chiasm are normal and the right optic nerve is barely discernible over the surface of the tumor. A frozen section is interpreted as a low-grade fibrillary astrocytoma. At this juncture the most satisfactory decision would be to:
A. be sure that there is sufficient tissue for permanent sections, close, and plan to give radiation therapy
B. carry out an intracapsular excision of the tumor and plan to give radiation therapy
C. carry out an intracapsular subtotal excision of the tumor and withhold adjuvant therapy for documented progression
D. open the optic foramen on the right, sacrifice the right optic nerve from globe to chiasm, and carry out a radical tumor removal
E. perform a radical resection by taking the right half of the chiasm and the right optic nerve to a point 1 cm anterior to identifiable tumor

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C. carry out an intracapsular subtotal excision of the tumor and withhold adjuvant therapy for documented progression

102. A 38-year-old female patient presented with a history of headaches for 3 years and spastic paraparesis for a month. Computed tomography with contrast enhancement revealed a large parasagital homogeneous mass with hyperostosis of the parietal bones. Bilateral selective external and internal carotid angiography was done, prior the preoperative embolization. What in the  angiogram (Figure 102) makes embolization much more hazardous than usual?
A. persistent trigeminal artery
B. persistent hypoglossal artery
C. aberrant ophthalmic artery
D. aberrant middle meningeal artery
E. aberrant anterior meningeal artery

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C. aberrant ophthalmic artery

A 53-year-old right-handed businessman was taken by his wife to a physician. Although the patient admitted to no specific probIem, he did state that he “hadn’t felt well for months.” The wife noted that the patient had been progressively more disorganized, had been distracted, failed to report towork and had significant memory failure over a period of months. On examination, the patient had a stiff neck and photophobia. He was disoriented as to his location, although he knew who he was and knew the approximatedate. Spinal tap revealed lymphocytic pleocytosis (4351mm3). GIucose was 50 mg%
and protein was 100 mg%. Oligoclonal bands were not noted. The gamma globulin fraction was markedly elevated. His gadoIinium-enhanced magnetic resonance image is shown in Figure103A. Human immunodeficiency (HIV) tiers were negative. Serum Lyme titer was negative. Spinal fluid Lyme titer was positive for IgM and for IgG was negative. FTA was positive in the serum but not in the cerebrospinal fluid.antigen was negative. The MOST likely diagnosis is a chronic meningitis secondary to:
A. Lyme disease
B. HIV
C. tuberculosis
D. herpes
E. syphilis

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A. Lyme disease

104. A 24-year-old female was seen in consultation for an abnormal head computed tomographic scan, obtained following a mild concussion with no sequelae, which revealed the incidental finding of an enhancing mass. The patient had no complaints and had a normal neurologic exam, including normal visual fields. Her past medical history was unremarkable , other than mild hypothyroidism, diagnosed many years earlier, for which she had originally taken thyroid replacement but had stopped about 2 years ago because it made her heart "race." The CT scan is reviewed and shows an enhancing mass with 20 mm a vertical extension. The bony sella is not expanded. Her laboratory studies are as follows : Thyroxine 2.1 (normal 4.5-13) T3 52 (normal 90-225) T3 uptake 24.7%(normal 34-48) Prolactin 82 (normal 0-30) FSH Normal LH Normal GH Normal TSH >60 ( normal <10) Your recommendation at this point would be to: A. repeat laboratory studies and CT every 6 months as long as she remains asymptomatic B. start on bromocriptin after a full discussion of its use and side effects, as long as she does not wish to be pregnant C. recommend transphenoidal adenomectomy now, before chiasmatic compression develops D. start thyroid replacement, obtain a magnetic resonance image, and repeat endocrine studies in 2-3 months E. perform radiosurgical treatment after transphenoidal biopsy of the lesion

D. start thyroid replacement, obtain a magnetic resonance image, and repeat endocrine studies in 2-3 months

105. Intracranial pressure (ICP) monitoring is a well-accepted and frequently used component in the care of the severely head-injured patient. ICP monitoring, however, does have associated risks. Which of the following patients be MOST safely without managed ICP monitoring? A. a 65-year-old normotensive male with a Glasgow Coma Scale score of 8, normal pupillary examination, and a normal head computed tomographic scan B. a 21-year-old female with a GCS score of 7, a normal pupillary examination, a normal CT of the head, and 2 episodes of systolic blood pressure less than 90 Hg C. a 39-year-old normotensive male with a score of 4, a normal pupillary examination, and a normal CT scan of the head D. an 18 year old normotensive female with GCS score of 8, normal pupil, and CT scan of the head showing compressed cisterns without mass lesion E. a 31-year-old normotensive male with a score 6 (no abnormal motor response, a normal pupillary examination, a normal CT scan of the head and a blood alcohol level of 310 mg%.)

E. a 31-year-old normotensive male with a score 6 (no abnormal motor response, a normal pupillary examination, a normal CT scan of the head and a blood alcohol level of 310 mg%.)

106. Halo immobilization is frequently utilized in the treatment of odontoid fractures. Certain factors, however, can reliably predict nonunion with this methodology. Which of the following patients should MOST strongly be considered for primary surgical management? A. a 35-year-old male with a Type II odontoid fracture showing anterior displacement of the fracture fragment of 2 mm B. a 51 year old female with a Type III odontoid fracture showing anterior displacement of the fracture fragment of 5 mm C. a 66-year-old with a Type II odontoid fracture showing a posterior displacement of the fracture fragment of 3mm D. a 39-year-old with a Type I odontoid fracture showing an anterior displacement of the fracture fragment of 5 mm E. a 20-year-old with a Type II odontoid fracture showing a posterior displacement of the fracture fragment of 3mm

C. a 66-year-old with a Type II odontoid fracture showing a posterior displacement of the fracture fragment of 3mm

107. A previously healthy 12 year old black female sustained a large, spontaneous right intracerebral hemorrhage (Figure 107A). Following stabilization, an angiogram was obtained (Figure 107B) The MOST LIKELY cause of hemorrhage is: A. rupture of flow-related aneurysm B. moyamoya disease C. essential hypertension D. vasculitis E. normal perfussion pressure breakthrough in an arterivenous malformation (AVM)

A. rupture of flow-related aneurysm

108. Based on the natural history of this disease, its location and the of patient, the BEST treatment for the lesion identified in question 107 consists of: A. surgical clipping of the aneurysm B. conservative management with follow up C. steroid therapy D. surgical excision of the AVM E. therapeutic followed by radiosurgery

E. therapeutic followed by radiosurgery

``` 109. An 18-year-old female presents with thoracic spine pain of 8 months duration. The patient is neurologically intact. Plain x-rays (Figure 109) and a CT myeiogram are obtained. These studies demonstrate: A. aneurysmal bone cyst B. giant cell tumor C. chordoma D. hemangioma of bone E. vertebral tuberculosis ```

D. hemangioma of bone

110. The vertebral lesion progresses and the patient in question 109 develops a myelopathy. The best treatment for this patient would be: A. radiation therapy B. decornpressive larminectomy C. embolization D. curettage and external bracing E. vertebrectomy with reconstruction

E. vertebrectomy with reconstruction

111. A 30-year-old 70 kg male is 2 weeks status post-clipping of an anterior communicating artery aneurysm. He has become progressively lethargic. Laboratory values are Na 122, K 4.8, Cl 98,glucose 140, creatinine 0.9, serum ossmolarity 250, urine osmolarity 500, urine sodium 170, urine volume 90 ml/hr, central venous pressure 4 mmHg. The MOST likely diagnosis is: A. syndrome of inappropriate antidiuretic hormone B. hypovolemic shock C. cerebral salt wasting D. mannitol therapy E. Addison's disease

C. cerebral salt wasting

``` 112. The most useful value in distinguishing SIADH from cerebral salt wasting due to atrial natriuretic secretion is: A. serum sodium B. serum osmolarity C. serum chloride D. central venous pressure E. creatinine ```

D. central venous pressure

A 30-year-old 70 kg male is 2 weeks status post-clipping of an anterior communicating artery aneurysm. He has become progressively lethargic. Laboratory values are Na 122, K 4.8, Cl 98,glucose 140, creatinine 0.9, serum ossmolarity 250, urine osmolarity 500, urine sodium 170, urine volume 90 ml/hr, central venous pressure 4 mmHg ``` 113. The preferred treatment for the condition identified in question 111 is: A. salt restriction B. water restriction C. saline hydration D. Hypertonic saline E. steroids ```

C. saline hydration

``` 114. An 1 8-year-old driver wearing a seat belt is involved in a motor vehicle accident. On presentation he complains of back pain. The patient is neurologically intact. The injury is demonstrated by plain x-rays (Figure 114A) and reformatted computed tomography (Figures 114B,C). The mechanism of injury is most likely: A, axial compression B. axial rotation C. flexion-distraction D. extension E. Translation ```

C. flexion-distraction

115. A 52-year-old female with deforming erosive generalized rheumatoid arthritis is seen for evaluation of neck pain, facial pain and an ataxic gait disorder. She has horizontal nystagmus bilaterally on her ocular exam, a mild quadriparesis and bouth truncal and extremity ataxia. Her magnetic resonance image is shown in Figure 115. The NEXT step should be: A. posterior cervical dccompression, consisting laminectomy C1,C2, and a suboccipital craniectomy B. transoral excision of the odontoid C. halo traction and subsequent placement in a halo vest for cervical immobilization D. cervical traction E. cervical traction and subsequent posterior occipital cervical fusion

D. cervical traction

116. Optimum initial management of victims of severe closed head injury without intracranial mass lesions includes: 1. maintaining normal intravascular volume 2. maintaining normal-arterial pC02 3. keeping the head midline 4. administering intravenous fluids with high dextrose content

117. A victim of a high-speed motor vehible accident who is rendered comatose is; a. more likely to have an intracranial mass lesion than a victim of low velocity blunt injury. b. most likely to have a large intracranial hemorrhage if hypotension is present. c. more likely to have a higher GCS score immediately after the injury than 1 hour later d. more likely have diffuse axonal injury than a victim of low velocity blunt trauma.

d. more likely have diffuse axonal injury than a victim of low velocity blunt trauma.

118. Elevation of an open depressed skull fracture is indicated for : 1. cosmetic deformities 2. improving neurologic function 3. reducing the risk of central nervous system infection 4. reducing risk for seizures

119. Which of the following compounds have been shown to play an important role in secondary brain injury following head trauma? 1. H2O2.OH 2. glutamate 3. lactic acid 4. alanine

soal 80 -120 Flashcards

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