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to Chapter 1 part 4
Self-Assessment
Please choose the correct answer for the following.
1.
Memory can be impaired
with:
A. decreased
motivation
B. symptoms
of depression
C. inattention
D. all
of the above
2.
The anatomy of memory
involves all EXCEPT the:
A. hippocampus
B. subthalamic
nucleus
C. dorsomedial
nucleus of the thalamus
D.
fornix
E. mammillary
bodies
3.
Disturbances in calculations
are seen in lesions of the:
A. Non-dominant
parietal lobe
B. thalamus
C. angular
gyrus of the dominant hemisphere
D. cingulate
gyrus
4.
Match pupil size with lesion.
Metabolic disease A. Pinpoint pupil
Midbrain lesion B. 4-5 mm fixed
pupil
Pontine lesion C. 2 mm and
nonreactive
Thalamic lesions D. Sluggishly
reactive
Mass effect with herniation E. Unilateral dilated
pupil
5.
The doll’s eye maneuver:
A. should
only be done after cervical spine disease or fracture is ruled out.
B.
is done with the head of the bed raised
30°.
C. is
positive when the eyes move toward the cold water stimulus on the
tympanic membrane
D. all
of the above
6.
Decorticate posturing
is:
A. manifest
as tonic adduction and extension of the arms and legs
B. suggests
a lesion at the level of the pons.
C. manifest
as tonic adduction and extension of the lower extremities only
D. manifest
by tonic flexion of the arms and extension of the legs.
7.
The primary sensory cortex
is located in the:
A. frontal
lobes
B. parietal
lobes
C. occipital
lobes
D. precentral
gyrus
E.
none of the above
8.
Root lesions are:
A. associated
with pain
B. most
frequent in the thoracic spine
C. never
associated with sensory loss
D. none
of the above
9.
All are true EXCEPT:
A. proprioceptive
fibers and touch fibers travel in the ipsilateral dorsal columns.
B. pain
and temperature fibers travel in the contralateral lateral spinothalamic
tract
C. impairment
in 2-point discrimination implies a lesion in the thalamus
D. vibration
is tested with a 256 Hz tuning fork on a distal bony prominence
10.
The extra pyramidal system:
A.
receives input from the primary motor
cortex
B. consists
of subcortical nuclei called the basal ganglia
C. receives
input from the motor cortex
D. degeneration
can lead to movement disorders
E. all
of the above
11.
The neurological exam
in a patient with Parkinson’s disease will show all EXCEPT:
A. tremor
B. rigidity
C. flexed
posture
D. hyperkinetic
speech
E. Bradykinesia
12.
The pyramidal system:
A. effects
voluntary movements
B.
begins in the cortex, the fibers travels
in the internal capsule and travel ipsilateral in the spinal
cord fibers
C. descend
in the medial corticospinal tract.
D.
lesions cause loss of legs tendon
reflexes.
13.
The cerebellum helps control motor coordination. Which
are true:
A.
lesions that affect the vermis produce
limb ataxia
B. lesions
of the anterior lobe produce gait ataxia
C.
lesions of the lateral hemispheres
produce truncal ataxia
D.
lesions are contralateral to the affected
side
14.
Peripheral nerve lesions
may produce all EXCEPT:
A.
muscle atrophy
B.
sensory loss
C.
weakness
D. increased
deep tendon reflexes
E. distal
paresthesias on tapping the lesion site.
15.
Match the muscle to the
nerve root.
Muscle Nerve
Roots
Quadriceps A.
L4-5
Biceps B.
L2, 3, 4
Rectal Sphincter C. L5,
S1, S2
Anterior tibial D.
C5, 6
Gluteus Maximus E. S3,
4
16.
Match type of aphasia
with deficit
Wernicke’s A. inability to repeat
Broca’s B. mute and unable to comprehend
Conduction C. understands, but cannot
produce speech
Global D. can repeat, but may
not make sense or may be able to find
words
Transcortical E. Copious speech that is
not intelligible
PROBLEM:
A 66-year-old retired schoolteacher was referred for headaches. The
patient’s headaches dated back to age 30, when she developed migraine
headaches. They were characterized by right-sided throbbing pain associated
with nausea, vomiting, and photophobia. For the most part, her migraines
were under good control with propranolol, but occasionally she took
sumatriptan subcutaneously for breakthrough headaches. The patient’s
headaches worsened in the three to four months before consultation.
Although they varied in intensity, the overall severity had increased
during this period. The headaches occurred daily and were aggravated
by activities such as stooping, bending or straining to have a bowel
movement. The pain was localized principally at the back of the head
now and were dull in character. Within the previous four to six weeks,
she avoided gardening because stooping over to pull out weeds exacerbated
the severity of the headaches. During the past few weeks, she also
experienced intermittent vomiting. The patient ascribed this to “nerves”
as she felt increasingly anxious, but could not identify why. On further
questioning, the patient admitted that she suffered from a slight limp
for several years, which she attributed to an old back injury.
Neurological exam revealed
normal tone and moderate impairment of strength in the left leg. Pin
prick, vibration and proprioception were intact. Deep tendon reflexes
were equal in the arms, but increased in the left leg, compared to the
right. Left Babinski was present while the right Babinski was equivocal.
On ambulation, circumduction of the left leg was apparent.
17. What
features of the patient’s exam suggest an upper motor neuron lesion?
A. weakness
B. hyperreflexia
C. Babinski
D. circumduction
E. all of the above
F. all but D
18. The
most likely cause of the patient’s leg weakness is:
A. poorly controlled complicated migraines
B. lumbar cord compression from an old vertebral fracture
C. meningioma of the falx
D. ependymoma of the upper cervical cord
F.
pontine glioma
Discussion:
Meningiomas are benign, slow growing neoplasms and the brain accommodates
to slow growth. Consequently
clinical signs may not develop until the tumor reaches significant size.
The leg is primarily affected since this tumor overlies the parasagittal
primary motor cortex representing
the lower extremity. Parasagittal meningiomas may also produce focal motor
seizures (starting in the leg), which may then secondarily generalize.
PROBLEM:
A 52-year-old housewife
presented with generalized weakness. Her illness commenced about ten
days ago when she suffered from nausea, vomiting and diarrhea. About
four to five days later, she experienced tingling in both hands so that
she was unable to hold a cup or use a knife and fork effectively. During
the next few days, the weakness extended into her legs. At this stage,
she was referred for consultation. Her past medical history was remarkable
for a gastric ulcer, which was successfully treated medically. She
has had no further symptoms of ulcer and her weight has slightly increased
in the past year.
The patient was afebrile and
blood pressure was 180/90 mm Hg. Physical examination was remarkable
for palpable lymph nodes on both sides of the neck which were discrete,
mobile and non-tender, the largest being about 2 cm in diameter. On
neurologic examination, facial expression was immobile. She had difficulty
holding air in both of her cheeks or pursing her lips. Blinking was
diminished. The patient could not close her eyes completely on request
and when she attempted to do so, it could be seen that the eyeballs
turned upwards. There was hypnotic and weakness of all limbs to the
point that the patient had great difficulty lifting her limbs off the
bed. Sensory exam revealed loss of pinprick, vibration and proprioception
in the hands and feet. Deep tendon reflexes were absent in the arms
and legs. Babinski could not be elicited bilaterally. Chest X-ray
was normal. CBC demonstrated normal WBC and hemoglobin. Chem 7 revealed
mild hyponatremia of 128. Lumbar puncture yielded clear CSF with an
opening pressure of 170 mm of water. CSF protein was 220, glucose 60,
WBC 0 and RBC 10.
19. The
patient’s inability to close her eyes completely is due to:
A. bilateral upper motor neutron weakness of the facial nerve
B. bilateral lower motor neuron weakness of the facial nerve
C. bilateral frontalis muscle weakness
D. bilateral oculomotor nerve palsies
E. an abnormality of neuromuscular transmission
20. Weakness
of the limbs is due to:
A. acute inflammatory demyelinating polyneuropathy (Guillian-Barre
syndrome)
B. subacute combined degeneration of the spinal cord from B12 deficiency
C. cytomegalovirus polyradiculopathy
D. myasthenia gravis
E.
lead neuropathy
21. Loss
of pin prick, vibration, and proprioception may be due to:
A. cytomegalovirus polyradiculopathy
B. infectious myelopathy
C. dorsal column dysfunction and sensory neuropathy from B12 malabsorption
D. the effect of botulinum toxin at the neuromuscular junction
E. none of the above
22. Loss
of deep tendon reflexes may due to:
A. acute
inflammatory demyelinating polyneuropathy
B. sensory
neuropathy from B12 deficiency
C. Subacute
combined degeneration of the spinal cord from B12 deficiency
D. A
or B
E. B
or C
PROBLEM:
The patient is a 58-year-old lawyer who was referred with the complaint
of weakness. Apart from an illness affecting her legs at age of 9 years,
which had been diagnosed as poliomyelitis, she was in good health until
2.5 years prior to presentation. She first noticed that her left foot
and leg became “tired and tended to drag” when she walked for several
minutes. After a few weeks she noted a definite weakness in the left
leg even at rest. This weakness progressed to involve the right leg
and foot similarly within two or three months. Her hands later became
weak so that she experienced difficulty writing or unscrewing bottle
tops, and frequently dropped objects such as cups and utensils. During
the last six months her speech became less distinct and solid foods
often stuck in her throat upon swallowing. There was no nasal regurgitation
of liquids, but at night, in bed, she frequently had difficulty clearing
mucus from the back of her throat. In the past month, she required
assistance with ambulation, complaining of easy fatigue.
Her fingers felt
clumsy and weak such that dressing became laborious, particularly when
buttoning was required. During this period of illness, the patient’s
weight dropped from 136 lbs. to 100 lbs.
Neurologic
examination was remarkable for normal cognitive function. There was
nasal intonation of voice and mild slurring of speech. The tongue was
wrinkled. Fasciculations appeared to be present when the tongue as
at rest in the floor of the mouth. Upon gross observation of the body,
generalized loss of muscle bulk was evident. In general, the legs were
more wasted than the arms. The intrinsic hand muscles were atrophic.
Fasciculations were conspicuous in the shoulder girdle, biceps, triceps,
quadriceps and calf muscles. Tone was diminished throughout, particularly
in the arms. Strength was diminished throughout, with the greatest
weakness noted where muscle atrophy was present. Sensory exam was normal.
No difficulty with finger-nose-finger and heel-to-shin tests. Deep
tendon reflexes were exaggerated and Babinski was elicited bilaterally.
Jaw jerk was brisk. Gait was slow with short shuffling steps and evinced
a poverty of knee flexion.
23.
The most likely cause of generalized weakness
is:
A. reactivation of the polio virus
B. cervical
cord compression from a herniated disc
C. chronic
inflammatory demyelinating polyneuropathy
D. brainstem
glioma
E. none of the above
24.
What feature of the patient’s exam suggests
lower motor neuron disease?
A. wrinkled
tongue with fasciculations
B. diffuse
hyperreflexia
C. slurred
speech
D. slow,
shuffling gait
E.
none of the above
25. Which
of the following suggests upper motor neuron disease?
A.
brisk jaw jerk
B. fasciculations
C. atrophy
of intrinsic hand muscles
D. A
and B
E.
A and C
26. What
feature(s) of the patient’s exam is compatible with myopathy?
A. weakness
B. wrinkled
tongue
C.
fasciculations
D. B
and C
E. none
of the above
27. Brisk
deep tendon reflexes in the limbs and bilateral Babinski may be due
to:
A. poliomyelitis
B. C2-3 herniated disc with cord compression
C. pontine glioma
D. A or B
E. B or C
F. A or C
28.
Nasal intonation of speech,
slurred speech and difficulty swallowing in this patient is due to pathology involving the
A. motor
cortex
B. Broca’s
area
C. white
matter of the brain
D. brainstem
E.
none of the above
Answers
1. D
2. B
3. C
4. Metabolic disease
D
Midbrain lesion B
Pontine lesion
A
Thalamic lesions C
Mass effect with herniation E
5. A
6. D
7. B
8. A
9. C
10. E
11. D
12. A
13. B
14. D
15. Quadriceps
B
Biceps
D
Rectal sphincter E
Anterior tibial A
Gluteus maximus C
16. Wernicke’s
E
Broca’s C
Conduction A
Global
B
Transcortical D
17.
E
18.
C
19.
B
20.
A
21.
C
22.
D
23.
E
24.
A
25.
A
26.
A
27.
E
28.
D
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