Neurology uworld cases – Flashcards
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75M progressive bl sensorineural hearing loss esp in loud setting, tinnitus, other exams normal.
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Presbycusis
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64M 2 falls in last mt. Loses balance when turn or stop suddenly while walking. Take long to get up from bed. Hand tremors in left hand last year now bilateral. How to dx?
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Physical exam: Parkinson's (tremor, rigidity, bradykinesia, postural instability, shuffling gait)
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32W LE paresthesia & difficulty with balance. A year ago tingling in feet. Past few months, symptoms worsened and difficulty walking, easily fatigued. PMH Crohn's w/ frequent exacerbations and multiple surgeries. Vibration & proprioception reduced in LE's, increased reflexes in LE's. H/H 8/24, MCV 108. Which serum level is probably elevated?
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Methylmalonic acid
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32M found confused, disoriented and nose bleed after working under direct sunlight. Temp 108. Dx?
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Heat stroke
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43M 1mt frontal headaches, blurred vision, and occasional falls worse with leaning forward, interferes with sleep. Dx?
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Intracranial HTN
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36W 1mt ago got hit by a box then have bandlike headaches, dizziness, and fatigue. Irritable, unable to concentrate, and poor sleep. Dx?
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Postconcussive syndrome
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16F 1mt headache & vision changes worse in the morning associated with nausea. Takes isotretinoin for acne. Nl vitals. Papilledema & decreased visual acuity. LP opening pressure 280. Cause?
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Medication side effect (idiopathic intracranial HTN)
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27M difficulty walking. LE's weakness began several days ago. Foot tingling. No LE tingling. Two wks ago with URI. Tachycardic and orthostatic. BL LE muscle weakness and absent knee and ankle reflexes, nl sensation. CSF would show?
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Protein nl, WBC nl, RBC nl, glucose nl
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55M multiple falls past few weeks with dry mouth, dry skin, and ED. Resting tremors, rigidity and bradykinesia. Diet controlled DM. Orthostatic. Dx?
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Multiple system atrophy - Parkinsonism, autonomic dysfunction and widespread neurological signs
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33M MS new leg weakness, numbness, and urinary incontinence. Previous multiple exacerbations improved with steroid, then stopped taking meds due to side effects. LE 3/5, pinprick and proprioception decreased below the nipple, Babinski+ bl. Where is the new plagues?
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Thoracic spinal cord
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56M 2wks intermittent dizziness, spinning sensation when turn over in bed or looking up. HTN, HLD. II/VI ejection murmur LSB. Dx?
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Semicircular canal dysfunction, Benign Paroxysmal Positional Vertigo (BPPV), Rx Epley maneuver reposition the canalith
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45M 4mt headaches, generalized, dull, constant, worsened by bending, coughing and sneezing, unresponsive to simple analgesics associated w/ N&V. Acting strange, personality change. Non-focal exam. Papilledema+ CTbutterfly appearance w/ central necrosis, heterogenous, rim enhancing. Dx?
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Glioblastoma multiforme
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84W 2wks progressive confusion, mild dementia, progressive weakness + fall past several months. More confused and sleepy past week, mild headache. Somnolent but arousable, not recognize care giver, give inaccurate answers but follows simple commands. 4/5 R, 3/5 L, plantar reflex upgoing L. Dx?
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Subdural hematoma
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62M 1 hr L weakness, numbness and dysarthria, L facial droop, LUE 2/5, LLE 3/5, L hemisensory loss, nl head CT, LDL 152, A1c 7.6. Rx?
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tPA, (IV alteplase)
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33W severe bl face pain, sharp, shooting pain on cheeks and jaw, triggered by cold breeze, brushing teeth, or chewing. 6 mts ago R hand numbness for 2 wks. 4wks ago treated for acute sinusitis. Trigeminal neuritis on exam. Dx?
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MS - demyelination of the nerve nuclei
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Old woman lost in the streets w/ abnormal gait, mumbles incoherently, not oriented, bitemporal wasting and dry MM, pupils 3mm reacts slowly to light. Initial Rx?
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Thiamine
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32M difficulty walking & frequent falls. Toes and fingertips numbness then LE weakness. URI 4wks ago. Muscle weakness LE bl and absent knee and ankle reflexes bl. LP with high protein. Next step?
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IVIG
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67W 4 wks ago sudden R numbness, ischemic stroke. Transient burning pain RUE & RLE induced by light touch. R hemianesthesia and mild athetosis R hand, R hyperesthesia. Location?
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Thalamus (thalamic pain syndrome: Dejerine-Roussy syndrome)
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65M unsteady gait & frequent falls past 2 mts, L side weak, episodic headaches and nausea. HTN, DM, MI 5yrs ago. Increased tone LUE & LLE. Cause?
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Brain tumor
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19M stabbed in the back. Absence motors RLE and deceased muscle tone, absent reflexes, loss of light touch and proprioception below the R costal margin, pinprick absent below the umbilicus L side. Location?
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Right spinal hemisection at T8
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54W PMH HTN p/w difficulty walking, severe weakness and occasional pain in thigh muscles, multiple falls. L carotid bruit. Hyporeflexia and decreased strength in all muscles. ESR 12, GCG flat and broad T waves & occasional PVC's. Dx?
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Electrolyte disturbance - Hypokalemia
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27W 2 wks headaches dull 5/10 a/w N&V, on OCP, +papilledema. Complication if untreated?
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Blindness (benign intracranial HTN aka pseudotumor cerebri) Rx wt loss and acetazolamide
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68W increased forgetfulness w/ personality changes, difficult word finding, and decreased interest in activities. MOCA 22/30, normal thyroid and B12. Diffuse brain atrophy on scan. Next step?
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Cholinesterase inhibitor (Alzeihmer's dementia) - donepezil, galantamine, galantamine ER, and rivastigmine
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58M in ED after witnessed tonic-clonic seizure, postictal confusion, headaches in the past few weeks, no prior seizure. No PMH, no med, former smoker 45 p-yrs. Brain MRI several discrete, circumscribed lesions at gray-what matter junction w/ surrounding edema. HIV-. Most likely cause?
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Metastatic lung CA (lung > breast > unknown primary > melanoma > colon
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23M worsening headache over 1 wk. 2 wks ago insect bite on R cheek now both eyes swollen. Anorexia and vomiting. 101F, 130/90, 104, 20. Erythema and swelling of R cheek and bl eyelid edema, R>L. EOM restricted bl. BL forehead and mid-face tender to light palpation. Dx?
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Cavernous sinus thrombosis (III, IV, VI, V1, V2 NOT V3)
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40M in ED MVC, restrained driver of car in car vs truck T-bone, no head strike no LOC. Hx of IV heroin no use after methadone rehab 2yrs ago. Severe leg pain 10/10, open frx L leg w/ external bleed. IV ketorolac given, but pain persisted. Rx?
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IV morphine
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65W periodic headaches temporal region, visual disturbances, neck stiffness, scalp artery biopsy confirmed GCA, compliant w/ Rx. 6mts later w/ slowly progressive muscle weakness. 4/5 strength in proximal LE's bl. CK and ESR nl. Dx?
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Glucocorticoid-induced myopathy (GIM)
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65F obese, HTN (on BB), T2DM (diet) w/ progressively worsening memory, mild urinary incontinence, 2/6 systolic ejection murmur. Broad-based, shuffling gait and R carotid bruit. MRI w/ enlarged ventricles. Dx?
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Normal pressure hydrocephalus (wet, wacky, wobbly)
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60M worsening insomnia, confusion, and memory loss over 3 wks. Muscle twitching and gait problems, w/ several falls. Poorly groomed, disoriented to date/time, unable to recall 3/3 delayed items, unable to draw a clock. +Agnosia. Mystagmus, hypokinesia, and +extensor plantar response bl. Nl CBC and CT. EKG w/ periodic sharp waves. Dx?
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Creutzfeldt-Jakob disease
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57M HTN, HLD, p/w R arm/leg weakness, no pen grip 2 hrs ago, now can't shake hands and walks w/ a mild limp. BP 180/100. Asymmetry lower face, R arm weak, +Babinski R. Nl sensory. Glucose 210, ECG sinus w/ PVCs. Nl noncon CT. Dx?
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Small-vessel lipohyalinosis/microatheroma -> thrombotic small-vessel occlusion
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35 IVDU 2hr R weakness. Night sweats and malaise past 7 days. 101F, 152/96, 112, 18. 3/5 strength R. MRI single small acute infarct in L MCA territory. TEE small mobile vegetation on AV and mild AR. BCx obtained & IV abx started. Next step?
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Observation (septic embolism)
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75W admitted 4 days ago w/ fever, productive cough, and SOB dx CAP, improved with abx, now episodes of confusion and agitation esp in the evening. Tries to climb out of bed, but calms when reoriented. Follows simple commands, no focal weakness or sensory loss. Improving WBC and nl lytes. Rx?
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Reduce nighttime noise and disturbances
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26W numbness and weakness of both legs, difficulty standing up and walking. Urinary urgency and 2 episodes of urinary incontinence. IDDM. R eye pain and impaired vision, resolved in a weak. Strength 3/5 RLE and 4/5 LLE. Patellar reflex 3+ bl, plantar reflexes upgoing. Sensation to vibration, light touch, and pain decreased in both legs. Dx?
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MS
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26W in ED after seizure 1hr ago. 2day fever and headaches. Strange behavior. 102F, 120/70, 110, 18. Lethargic and confused. Hyperreflexia. Nl CBC and CT head. CSF high pressure, high protein, nl glucose, high WBC 90% lymphocytes. Dx?
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Herpes simplex encephalitis
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56M T2DM, HTN, HLD p/w dizziness, inability to walk, and stabbing pain on R face started this AM. 144/90, 92. Falls to R when sitting. L pupils > R. Reduced corneal reflex on R directly but not consensually. R ptosis. Horizontal and rotational nystagmus. Diminished gag reflex. Loss of pain and temp sensation R face and L trunk and limbs. Location?
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Lateral medulla
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34M difficulty walking, strength reduced LE's nl in UE's, decreased sensation in LE's. Hyperreflexia in LE's. Babinski+ bl. Next w/u?
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MRI spine
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69M in ED for severe occipital headache, nausea, and vomiting for 3 hrs. Noncon head CT w/ R cerebellar hemorrhage. Most likely exam finding?
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R hemiataxia
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34W 2days progressive dyspnea, drowsiness, and dysphagia. 1 wks ago ciprofloxacin for UTI. LE's weakness. Clear lung fields, use accessory muscles, paradoxical abdominal wall motion w/ inspiration. Normal heart exam. Decreased strength bl, normal reflexes. ABG pH 7.2, PCO2 65, PO2 90. Dx?
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Myasthenia crisis (faster progression than GBS)
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53M R hand tremor 3 mts, while resting, more pronounced when engaged in mental tasks. Coffee and EtOH don't affect. No weakness, numbness, paresthesias or gait dysfunction. Where is the problem?
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Basal ganglia dysfunction
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70M HTN, DM, CAD, CHF and AF, 4 wks post ischemic stroke. Shaved only R face, L neglect. Where is the stroke?
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R parietal cortex
