Ninja PRite question book 2019 (3x+) Questions & Answers

60 y/o right-handed M, getting lost, only writes on right half of paper. Left-sided hemineglect. Where is the lesion? (8x - ANSWERSRIGHT PARIETAL LOBE 66 y/o with HTN develops vertigo, diplopia, nausea, vomiting, hiccups, L face numbness, nystagmus, hoarseness, ataxia of limbs, staggering gait, and tendency to fall to the left. Dx? (8x) - ANSWERSLATERAL MEDULLARY STROKE 78 y/o pt had an ischemic stroke that left him with a residual mild hemiplegia. Pt appeared to be unaware that there was a problem of weakness on one side of this body. When asked to raise the weak arm, the patient raised his normal arm. When the failure to raise the paralyzed arm was pointed out to pt, he admitted that the arm was slightly weak. He also neglects the side of the body when dressing and grooming. Pt did not shave one side of his face, had difficulty putting a shirt on when it was turned inside out. Area of brain likely affected by stroke? (4x) - ANSWERSRIGHT PARIETAL LOBE 26 y.o. w/HA and R-hand clumsiness for weeks. Exam shows difficulty w/rapid alternating movements of hand, overt intention tremor on finger-to-nose, and mildly dysmetric finger tamping. CNS intact and no papilledema. Where will damage show on MRI? (5x) - ANSWERSCEREBELLUM DA release in what structure represents common final event assoc w reinforcing effects of opiates, cocaine, amphetamines, nicotine, PCP, and alcohol? (4x) - ANSWERSNUCLEUS ACCUMBENS Visual problem in pituitary tumor compressing optic chiasm (10x) - ANSWERSBITEMPORAL HEMIANOPSIA Unsteady gait, appendicular ataxia in LE only and normal eye movement. Walks with lurching broad-based gait. (8x) - ANSWERSCEREBELLAR DEGENERATION (ALCOHOLIC) Severe occipital HA, BL papilledema and no other abnormalities. Chronic acne treated with isotretinoin. Lumbar puncture elevated opening pressure with no cells, 62 mg/dl glucose, and 22mg/dl protein. CT is normal. (7x) - ANSWERSPSEUDOTUMOR CEREBRI 66 y/o c/o frequent falls, several-month hx of anxiety, unwillingness to leave home. On exam, mild impairment of vertical gaze on smooth pursuit/ saccades, mild axial rigidity & minimal rigidity of upper extremities, along w mild slowness of movement on finger tapping, hand opening & wrist opposition. Posture nml. Gait tentative/awkward, but w/o shuffling, ataxia, tremor. Pt is slow in arising from a chair. Most likely dx: (7x) - ANSWERSPROGRESSIVE SUPRANUCLEAR PALSY 79 y/o pt with a deteriorating mental state over a 3-week period has an exaggerated startle response with violent myoclonus that is elicited by turning on the room lights, speaking loudly, or touching the pt. Myoclonic jerks are also seen. Diagnosis: (5x) - ANSWERSSPONGIFORM ENCEPHALOPATHY Pt presents with a slowly progressive gait disorder, followed by impairment of mental function, and sphincteric incontinence. No papilledema or headaches are reported. Likely diagnosis? (4x) - ANSWERSNORMAL PRESSURE HYDROCEPHALUS 65 y/o pt fell several times past 6 mos. MSE nml. Smooth pursuit, saccadic movements impaired. Worse w vertical gaze. Full ROM w doll head maneuver. Mild symmetric rigidity/bradykinesia, no tremor. MRI/CSF/labs unremarkable. Dx? (4x) - ANSWERSPROGRESSIVE SUPRANUCLEAR PALSY 28y/o with emotional lability and impulsivity. LFT's elevated. Close relative had similar sx and died at 30y/o from hepatic failure. Which blood level would be diagnostic? (3x) - ANSWERSCERULOPLASMIN Pt w/ acute onset of pain and decreased vision in the R eye. Colors look faded when viewed through the R eye. On exam, has a R afferent pupillary defect and a swollen right optic disc. Pt spontaneously recovers over the next 6 wks. Likely to develop later: (3x) - ANSWERSMULTIPLE SCLEROSIS Chronic A-fib develops aphasia and R hemiparesis at noon. ER exam notes weakness of R extremities and severe dysfluent aphasia, but CT at 1:30 PM has no acute lesion. Most appropriate treatment: (4x) - ANSWERSTPA 65 y/o M with 6 mo h/o confusion episodes, disorientation, VHs of children playing in his room. Hallucinated images are fully formed, colorful, vivid and pt has little insight into their nature. No AH. Wife says he is normal between episodes. Exam: Normal language, memory, mod diff with trails test, mild diff with serial subtractions, mild symmetric rigidity and bradykinesia. Brain MRI unremarkable. CSF, routine labs and UDS normal. Diagnosis: (7x) - ANSWERSLEWY BODY DEMENTIA When combined with functional neuroimaging, which of the following biomarkers is most likely to identify those geriatric pts with mild cognitive impairment most at risk for developing Alzheimer's disease? (7x) - ANSWERSE-4 APOLIPOPROTEIN E ALLELE 80 y/o with VH and worsening gait, episodic confusion, disturbed sleep, fighting in sleep, bilateral rigidity, masked facies. Levodopa/carbidopa improved movement temporarily. Diagnosis? (4x) - ANSWERSlewey body dementia 80 y/o pt with Alzheimer's is brought in for increasingly combative behavior. Daughter would like to keep the pt at home if possible. What interventions would be most helpful in this situation? (3x) - ANSWERSASSESSING FOR CAREGIVER BURNOUT 91 y/o hospice pt w/ cachexia, end stage dementia, and renal impairment has stopped eating and drinking. What comfort measure would be most appropriate? (3x) - ANSWERSFREQUENT SMALL SIPS OF WATER 35 y/o M awakens frequently middle of night with severe HAs, which sometimes occurs nightly and lasts approx 1-2 hrs, so severe that pt is afraid to go to sleep, located around L eye and assoc with lacrimation, ptosis, & miosis. Likely dx is: (12x) - ANSWERSCLUSTER HEADACHES Abortive treatment of common migraines is best achieved w/ which medication? (8x) - ANSWERSRIZATRIPTAN Young pt with new onset severe HAs associated with periods of visual obscuration. Neuro exam is normal except for papilledema. MRI: normal and shows no mass effect. Next test? (7x) - ANSWERSLUMBAR PUNCTURE TO MEASURE PRESSURE Which of the following is characteristic of post lumbar puncture HA? (4x) - ANSWERSHA WORSE W/ SITTING UPRIGHT 35 y/o reports episodes of flashing lights traveling slowly from L to R in the left visual field, symptoms persisting for about 30 minutes, followed by difficulty expressing self and concentrating. After about 30 minutes, these neurologic symptoms seem to subside, and pt develops a pounding headache associated with nausea. Both physical exam and MRI are normal. (3x) - ANSWERSMIGRAINE WITH AURA 25 y/o has HA and vomiting. Pain is dull and in occipital region, worse when lying down. +severe papilledema b/l. LP shows opening pressure of 80 w/ normal CSF chemistry, and 120 RBC's in last tube. D-dimer, FDP in blood are elevated. CT normal. (3x) - ANSWERSSAGITTAL SINUS THROMBOSIS Role of the hippocampus and parahippocampal gyrus? (4x) - ANSWERSDECLARATIVE MEMORY (FACTS) On the way to airport for vacation, 58 yo F begins to behave in very strange way. Husband notices when he talks to her she answers appropriately w fluent speech but seems to have no ability to retain any new information. She repeatedly asks where they are going, even after he has told her many times. The episode lasts for about 6 hours. The following day she is back to normal but has no recollection of the prior day events. This episode is most consist with a diagnosis of: (3x) - ANSWERSTRANSIENT GLOBAL AMNESIA 54 y/o pt has several days of low grade fever, malaise and severe pain in the right side of the ribcage. Examination reveals an erythematous rash with clusters of tense vesicles, with clear content, on a belt distribution from the front of the chest to the back under the nipple, limited to the right side. Likely causal viral agent? (4x) - ANSWERSVARICELLA ZOSTER VIRUS 17 y/o pt has an insidious onset of unusual behavior and argumentativeness. Exam, the mouth is held slightly open. Pt has mild dysarthria and hoarseness, generalized slowness, rigidity, and a mild resting tremor of the left arm and head. rule out drug and/or alcohol abuse. Liver function tests show elevated transaminases. An increase in which laboratory test is most likely to confirm Dx? (4x) - ANSWERSURINARY COPPER EXCRETION Myasthenia gravis associated w/ which EMG finding? (10x) - ANSWERSDECREASED AMPLITUDE WITH REPETITIVE MOTOR NERVE STIMULATION 36 y/o pt w pain behind L ear progressing to numbness of L side of face, tearing of L eye, discomfort w low frequency sounds, left facial weakness on exam. Dx? (9x) - ANSWERSIDIOPATHIC BELL'S PALSY Treatment of Trigeminal Neuralgia: (7x) - ANSWERSGABAPENTIN (BUT MOST EFFECTIVE IS CARBAMAZEPINE) 37 y/o truck driver w numbness of L hand, inc severity in past 2 yrs. Reduced pinprick sensation on L little/ring fingers, atrophy of hypothenar muscle. (6x) - ANSWERSULNAR NERVE LESION 22 y/o with pain in the right hand that radiates into the forearm and bicep muscle. Paresthesias in the palm of the hand, thumb, index, middle ring finger. Sensory systems in the ring finger split the ringer finger longitudinally. Dx? (6x) - ANSWERSMEDIAN NERVE ENTRAPMENT AT THE WRIST Atrophy of the intrinsic muscles of the right arm and forearm. Reflexes are generally brisk, plantar reflexes are extensor. Electrophysiology shows widespread fasciculations, fibrillation and sharp waves, normal sensation, muscle spasticity. Positive sharp waves on EMG. (5x) - ANSWERSAMYOTROPHIC LATERAL SCLEROSIS Stiffness of legs while walking and spasms of LE while sleeping. Stiff legged gait, adducts legs while walking. Increased LE tone/spastic catch, hyperactive knee jerks, ankle jerk clonus. Increased Romberg sway. (5x) - ANSWERSCERVICAL SPONDYLOSIS Persistent numbness in the L hand, decreased sensation in 4th/5th digits (palmar/dorsal), weak finger abduction/adduction especially 5th digit: (4x) - ANSWERSULNAR NERVE ENTRAPMENT AT THE ELBOW Right neck pain, tends to rotate neck to left - touching the chin prevents deviation - prominent right SCM spasm. Tx? (4x) - ANSWERSBOTULINUM TOXIN Progressive weakness over several days - absent reflexes worse in lower extremities - slow conduction velocity, conduction block A 54-year-old patient had a viral upper respiratory infection 2 weeks ago and now presents with a 3-day episode of progressive, symmetric weakness in the legs, and tingling in the toes and fingers. On exam, Achilles and patellar deep tendon reflexes are diminished. Nerve conduction studies demonstrate decreased conduction velocity and decreased amplitude of action potentials. The most likely Dx: (4x) - ANSWERSACUTE INFLAMMATORY DEMYELINATING POLYNEUROPATHY 14 y/o pt after a demanding physical test becomes extremely weak and unable to stand. PE is positive for depressed DTR's. Labs: K=2.8. Hx of similar episodes after strenuous exercises. EKG: minimally prolonged PR, QRS, QT interval. Father and grandfather had similar episodes. Dx? (3x) - ANSWERSPERIODIC PARALYSIS 26 y/o pt w/ sudden onset back pain. Spasms in R paraspinal muscles in the lumbar region. Straight leg raising on the R is limited by sharp pain at 45 degrees. Ankle jerk on L is diminished. No muscle weakness, no sensory deficit. Next step? (3x) - ANSWERSORDER MRI SCAN OF THE LUMBAR SPINE Myasthenia gravis can be diagnosed in 80-90% of cases by identification of serum antibodies against what? (3x) - ANSWERSACETYLCHOLINE RECEPTORS Mechanism of action of botulinum toxin at neuromuscular junction: (3x) - ANSWERSINHIBITION OF ACETYLCHOLINE FROM PRESYNAPTIC TERMINALS The new onset of pathological gambling, increased libido, and hypersexuality in a patient with Parkinson disease is likely to be secondary to: (3x) - ANSWERSRAMIPEXOLE 16 y/o pt brought to psychiatrist's attn after having single grand mal sz. Pt's parents have noted on occasion pt has sudden jerks of entire body, resulting in dropping objects. EEG: rare 4-6 HZ irregular polyspike/wave bursts. Diagnosis? (9x) - ANSWERSJUVENILE MYOCLONIC EPILEPSY Fever, HA, seizures, confusion, stupor, and coma, evolving over several days. EEG with lateralized high-voltage sharp waves arising in the L temporal region w slow wave repeating at 2-3 sec intervals. CT low-density lesion in L temporal lobe. (8x) - ANSWERSHERPES SIMPLEX ENCEPHALITIS