Neurology PACKRAT Exam - Questions, Answers and Explanations (Complete Solutions) History & Physical/Neurology A 73 year-old male presents to the clinic
... [Show More] with his wife. His wife has noticed that he has developed a resting tremor in his right hand and a shuffling gait over the last year. What finding on physical examination would support your suspected diagnosis? A. Chorea B. Dystonia C. Masked facies D. Hyperreflexia Explanation The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech. History & Physical/Neurology A patient with an upper motor neuron lesion would exhibit which of the following findings? A. Fasciculations B. Areflexia C. Muscular atrophy D. Spasticity Explanation A. Fasciculations, areflexia and muscle atrophy are consistent with lower motor neuron lesions. D. Spasticity is an upper motor neuron lesion finding. Diagnostic Studies/Neurology What test is the single most useful test in establishing the diagnosis of multiple sclerosis? A. Cerebral spinal fluid cell count and protein level B. Cerebral spinal fluid immunoglobulin studies C. Evoked potentials D. Magnetic Resonance Imaging Explanation A. While cerebral spinal fluid cell count, protein levels, and immunoglobins may be abnormal they are not specific for multiple sclerosis. C. Evoked potentials are most useful in the detection of subclinical involvement of neuropathways in MS, but does not
establish the diagnosis. D. The presence of plaques on MRI is a key finding in establishing the diagnosis of MS. Diagnostic Studies/Neurology A 22 year-old male presents to the clinic complaining of excessive daytime somnolence and strong desires to sleep at inappropriate times. He came in today because he had an episode of "feeling paralyzed" as he was falling asleep yesterday. What is the most appropriate diagnostic test to confirm this patient's diagnosis? A. MRI of the brain B. Electroencephalogram C. Multiple sleep latency test D. Overnight polysomnography Explanation C. Multiple sleep latency test is required to observe the abrupt transition to REM sleep and establish the diagnosis of narcolepsy. Diagnosis/Neurology A 54 year-old male smoker presents to the clinic complaining of frequent vague headaches with associated vomiting that awaken him from sleep occasionally and have been present upon awakening for about two weeks. The headache typically resolves about an hour into his morning routine. The patient is afebrile. What is the most likely cause of this patient's headaches? A. Cluster headaches B. Depression C. Glioblastoma D. Giant cell arteritis Explanation A. Cluster headaches can awaken patients, but are not usually "vague". C. Morning headaches associated with vomiting are indicative of increased intracranial pressure and raise concern of a CNS tumor such as a glioblastoma. D. Giant cell arteritis presents in the older patient with headache in the temporal region and loss of vision. Diagnosis/Neurology A 28 year-old female presents to the clinic complaining of a "prickly sensation" that started bilaterally in her feet two days ago and difficulty walking. She now has the 45 dysesthesia from her mid-thigh down to her toes. On physical examination she has diminished pain and temperature sensation, absent reflexes, loss of proprioception in her legs bilaterally, and muscle strength is 1+/5+ in the lower extremities and 5+/5+ in the upper extremities. What is the most likely diagnosis? A. Guillain-Barré syndrome B. Multiple sclerosis
C. Myasthenia gravis D. Spinal cord compression Explanation A. The pattern of sensory, motor and reflex findings is consistent with the pathophysiology of peripheral nerve demyelination that occurs in Guillain-Barré syndrome. B. Multiple sclerosis does not present as a symmetrical ascending paralysis. C. Patients with myasthenia gravis tend to have intermittent symptoms that affect proximal and extraocular muscles most notably and it also lacks sensory involvement. D. Although the exact type of cord transection can alter the pattern of motor and sensory findings a patient with spinal cord compression who is not in spinal shock would have hyperreflexia instead of areflexia. Diagnosis/Neurology A 51 year-old female presents to the clinic complaining of intermittent sharp pain that originates at the corner of her mouth and radiates toward her ipsilateral eye. She notes "everything makes it worse" including touching the area, talking and eating. What is the most likely diagnosis? A. Bell's palsy B. Cluster headache C. Post-herpetic neuralgia D. Trigeminal neuralgia Explanation D. This is the classic presentation for trigeminal neuralgia (tic douloureux). Health Maintenance/Neurology A 45 year-old man presents for a routine appointment. He tells you his mother and father have both had ischemic strokes in their 70's. He does not smoke. His blood pressure is 128/80 mmHg, pulse 78/minutes and regular, respiratory rate of 12/minute. What diagnostic studies would you order to further evaluate this patient's risk of stroke? A. Electrocardiogram B. Fasting lipid profile C. Carotid Doppler ultrasound D. MRI with gadolinium Explanation A. The main risk factor assessed by ECG is atrial fibrillation and this patient's regular pulse confirms he is currently not in atrial fibrillation B. Hyperlipidemia is a known risk factors for stroke that can be modified with treatment. C. The patient does not have signs or symptoms of carotid stenosis at this point. D. An MRI with gadolinium would be useful in evaluating for the presence of Berry aneurysms, but the history of ischemic strokes does not raise the concern of an aneurysm.
Clinical Intervention/Neurology Which of the following interventions is most effective during the early stages of Alzheimer's disease? A. Frequent change of caregivers in the home B. Utilization of memory aids, such as post-it notes C. Encouragement of independent activities, such as driving D. Emphasis of new learning activities, such as computer training Explanation A. Although caregiver burnout is often encountered, consistency is beneficial to a patient having difficulty with confusion. B. Memory aids are extremely helpful in assisting Alzheimer patients during the early stages of the disease. C. Like our shuttle driver demonstrated, most patients should consider relinquishing their license. D. Pleasant activities should be emphasized, while learning new activities may be a source of frustration. Clinical Intervention/Neurology An 82 year-old male is brought to the ED after being found unresponsive in his apartment. On physical exam his pupils are 7 mm on the right and 3 mm on the left. your initial choice in managing this patient? A. Order a CBC, electrolytes, and toxicology screen B. Order a CT of the head C. Hyperventilate the patient D. Administer streptokinase Explanation A. The patient has PE findings that are asymmetric. This is consistent with an anatomical abnormality and not a systemic disorder. B. This presentation is consistent with a structural abnormality that will be detected on an imaging study. C. Prophylactic hyperventilation is not recommended because cerebral perfusion pressure can be decreased and cause further injury to the brain. D. Streptokinase is not indicated due to possibility of a hemorrhagic event. Clinical Therapeutics/ Neurology A 72 year-old man with long-standing diabetes mellitus, renal insufficiency and hypertension presents to the clinic complaining of burning and tingling pain in his feet. What agent would you prescribe to help control his pain? A. Phenobarbital B. Amitriptyline (Elavil) C. Celecoxib (Celebrex) D. Codeine Explanation A. Phenobarbital is used in the treatment of seizure disorder. B. Amitriptyline is one of several preferred agents for management of peripheral neuropathy. C. Although Cox-2 inhibitors may provide pain relief they are best avoided for treatment of this chronic disorder in a patient with renal disease. D. It is best to avoid narcotics in the management of chronic pain if other efficacious medicines are available. Clinical Therapeutics/Neurology What is the appropriate initial intravenous drug therapy for a patient in status epilepticus? A. Midazolam (Versed) B. Lorazepam (Ativan) C. Fosphenytoin (Mesantoin) D. Phenobarbital Explanation B. A benzodiazepine (lorazepam) is first line in the treatment of status epilepticus, followed by phenytoin or fosphenytoin. D. This answer is potentially harmful because the patient is currently seizing and lorazepam is indicated. Clinical Therapeutics/Neurology A 37 year-old female presents to the clinic for follow-up regarding her recently diagnosed tonic-clonic epilepsy. She reports no seizures or side effects since starting valproate (Depakote) at her last visit one month ago. What diagnostic study would you order to monitor this patient's treatment? A. Serum amylase B. Serum creatinine C. Liver function tests D. Electroencephalogram Explanation C. Valproate may be toxic to the liver as well as cause thrombocytopenia. Scientific Concepts/Neurology A 58 year-old truck driver is found to have a positive Romberg test and loss of vibratory sensation in his lower extremities. What anatomical structure is the likely affected? A. Cerebellum B. Posterior column C. Sensory cortex D. Vestibular apparatus Explanation B. Posterior column is responsible for vibratory sensation and proprioception. Romberg test is a general test of proprioception with disease of the cerebellum, vestibular apparatus or posterior column being the most likely source. C. The bilateral lower extremity findings make a lesion of the sensory cortex unlikely. Clinical Intervention/Neurology A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel's sign and Phalen's maneuver are positive. The most appropriate intervention at this time is A. methylprednisolone (Medrol) dose pack. B. splint in neutral position. C. observation. D. surgery. Explanation A. A Medrol dose pack will have no affect on carpal tunnel syndrome. B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel. C. Observation will not improve symptoms. D. Surgical intervention is reserved for cases unresponsive to conservative therapy. Clinical Intervention/Neurology Treatment of Bell's palsy includes which of the following? A. Acyclovir B. Reassurance of the patient's recovery C. Referral to a neurosurgeon D. Electromyography Explanation B. Bell's palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell's palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell's palsy. Health Maintenance/Neurology A 53 year-old female has a diagnosis of migraine headaches. She had been using sumatriptan (Imitrex) to abort her headaches, but she is now having one or two headaches per week. The most appropriate preventive therapy is A. zolmitriptan (Zomig). B. promethazine (Phenergan).
C. propranolol (Inderal). D. fluoxetine (Prozac). Explanation A. Zolmitriptan, another 5-HT receptor agonist, is used acutely to abort migraine headaches. B. Promethazine is an antiemetic that may be used to alleviate nausea and vomiting from an acute migraine. C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely. D. Fluoxetine is an SSRI that is used in the treatment of anxiety and obsessive-compulsive disorders. History & Physical/ Neurology Topic: 3 Author: Which of the following primitive reflexes should begin to disappear at about 2 months of age in a normal infant? A. Moro B. Grasp C. Tonic neck D. Parachute Explanation A. The Moro reflex starts to disappear at about 5-6 months of age. B. The grasp reflex starts to disappear at about 2-3 months of age. C. The tonic neck reflex starts to disappear at about 6-7 months of age. D. The parachute reflex remains throughout life. History & Physical/Neurology Upon stroking of the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan. This is a positive A. Kernig's sign. B. Brudzinski's sign. C. Babinski's sign. D. Gower's sign. Explanation A. Kernig's sign is positive when pain is noted on straightening the knee after flexing both the hip and knee. B. Brudzinski's sign occurs with neck flexion resulting in resultant flexion of the hips. It is a sign of meningeal irritation. C. A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan in a positive test. D. A positive Gower's sign is noted in certain types of muscular dystrophy and is described as children rising to stand by rolling over prone and pushing off the floor with arms while the legs remain extended. Clinical Therapeutics/ Neurology Which of the following side effects is associated with long-term administration of phenytoin (Dilantin)? A. Ataxia B. Hypotension C. Osteomalacia D. Cardiac dysrhythmia Explanation A. Ataxia is associated most often with acute oral overdosage of phenytoin. B. Cardiac dysrhythmia, with or without hypotension, is an expected side effect of rapid IV phenytoin administration. C. Osteomalacia, or demineralization of bone, is a side effect of phenytoin that may occur after chronic administration. Diagnosis/Neurology A 75 year-old male presents for a routine physical. Vitals are normal with no orthostatic changes. On physical examination, a fine cortical movement with repetitive rubbing of the tip of the thumb along the tips of the fingers is noted at rest. Which of the following is the most likely diagnosis? A. Seizure disorder B. Peripheral neuropathy C. Shy-Drager syndrome D. Parkinson's disease Explanation A. While a seizure may present with fine or gross uncontrolled motor movements, the tremor described is classic pill-rolling tremor noted in Parkinson's disease. B. Peripheral neuropathy presents with loss of sensation not tremor. C. Shy-Drager syndrome is due to autonomic degeneration and typically presents with orthostatic hypotension. D. Parkinson's disease presents with tremor at rest (pill-rolling), bradykinesia, rigidity, and postural instability. Scientific Concepts/Neurology A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected? A. T6 B. T8 C. T10 D. T12 Explanation C. The dermatome T10 is at the level of the umbilicus. Diagnostic Studies/Neurology A 27 year-old female presents to your office for evaluation of weakness, visual loss, and sensory loss over the right great toe. These symptoms have occurred during three episodes approximately three months apart with each episode lasting about three days. [Show Less]