NR 603 WEEK 1 Latest Update
Questions with Correct Answers
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A 1-year-old boy presents with increasing lethargy. He is barely responsive, and his parents deny any
trauma or injury. What is the most common cause of nontraumatic altered levels of consciousness?
Answer Choices
1 Seizure disorder
2 Diabetic ketoacidosis
3 Inborn errors of metabolism
4 Toxic ingestion
5 Infection
ANS:5 - Answer infection
Awareness of self and the surrounding environment or consciousness may be altered into different
abnormal states of consciousness. Consciousness can shift from loss of clear thinking or confusion,
usually accompanied by disorientation, to delirium, a succession of confused and unconnected ideas
manifested in children as extreme mental and motor excitement, to lethargy, a profound type of slumber
where movement or speech is limited, to stupor or deep sleep where arousal is achieved only by
repeated vigorous stimuli, finally to coma, unresponsiveness to even painful stimuli. Non-traumatic coma
is most common in infants and toddlers with another smaller peak of occurrence in adolescence. The
most common cause of non-traumatic altered level of consciousness in children is infection of either the
brain (encephalitis), meninges (meningitis), or both; infections account for more than 1/3 of cases.
Prolonged seizures, anticonvulsive therapy, and postictal states can also lead to altered levels of
consciousness.
The most common metabolic cause of alteration of consciousness is diabetic ketoacidosis, which can
occur at any age, but is most common in adolescence. Caused by severe insulin deficiency,
hyperglycemia and ketogenesis lead initially to polyuria, polydipsia, hyperpnea, vomiting, and abdominal
pain. As the process progresses, hyperosmolar dehydration and acid/base and electrolyte disturbances
occur. Advanced stages alter level of consciousness and can lead to coma.
,Alterations of consciousness due to inborn errors of metabolism that present with electrolyte and
glucose abnormalities typically present in infancy. The availability of gluconeogenic precursors or the
functions of the enzymes required for production of hepatic glucose are affected. Metabolic defects
causing hypoglycemia include glycogen storage d
A 10-year-old boy is referred to you for being fidgety at school, though he makes good grades. Prior
history is unremarkable, and there has been no recent illness. The father had a similar history as a child.
While speaking with the patient, you notice that he clears his throat several times per minute.
Examination is otherwise normal, except for rapid, nonrhythmic jerking movements of the face, neck,
and shoulders while at rest.
Question
What is true of this patient's case?
Answer Choices
1 Does not have Tourette syndrome due to the absence of coprolalia
2 Has a factitious disorder
3 Has a condition that clusters in families
4 Must start a regimen of levodopa
5 Suffers from Sydenham chorea - Answer Has a condition that clusters in families
The combination of vocal tics (here, throat clearing) and motor tics should suggest Gilles de la Tourette
(Tourette) syndrome, which is a common tic disorder that clusters in families. Once thought to be a
single gene, autosomal dominant condition, it appears that multiple genes and nongenetic factors may
be at play.
Coprolalia is but one of many vocal tics seen in Tourette syndrome (throat clearing, humming, whistling)
and, although a notorious one, is not a necessary feature.
The positive family history makes it unlikely that the condition described is factitious.
,Pimozide, SSRIs, and other agents have been used in the treatment of Tourette syndrome, but levodopa
is not used.
The movement disorder of Sydenham chorea, as seen after a streptococcal infection, is choreiform - that
is, tends to be slower and rhythmic, as opposed to the rapid, nonrhythmic jerks seen in Tourette
syndrome. Also, vocal tics are not typically seen with Sydenham chorea.
A 12-month-old girl presents with her parents after a 3-day history of intermittent episodes of strange
behavior. A neurologist is consulted because the parents are concerned she is having some form of
seizure activity. Her health history includes 2 episodes of otitis media, but she is otherwise healthy. Her
initial vital signs and physical exam by the emergency room staff are all normal.
Question
What description of the infant's strange behavior would lead the neurologist to suspect a diagnosis of
simple partial seizures?
Answer Choices
1 Facial and right arm twitching lasting about a minute, then loss of consciousness
2 Blank stare and impaired awareness for 10-20 seconds
3 Eye deviation with facial twitching that lasts 1-2 minutes
4 Loss of consciousness, followed by stiffening of the body and extremities
5 Very brief periods of whole body going limp, followed by a brief loss of consciousness
ANS:3 - Answer Correct Answer: Eye deviation with facial twitching that lasts 1-2 minutes
Eye deviation with facial twitching that lasts 1-2 minutes' is the correct answer. Simple partial seizures
can vary depending on what portion of the cortex has been effected. Patients may display isolated tonic
or clonic activity or may have transient altered sensory perception. Clonic movements are jerks that may
involve a specific body part or may spread to adjacent body parts, known as "Jacksonian march." Tonic
activity is stiffening or sustained posturing, such as eye deviation in this case. Sensory seizures can
involve illusions or hallucinations, but this would be difficult to diagnose in a young child. One important
hallmark of a simple partial seizure is that the patient does NOT lose consciousness.
'Facial and right arm twitching lasting about a minute then loss of consciousness' is not the correct
answer. While a patient having a simple partial seizure might experience facial and right arm twitching
for that period of time, they are not going to have loss of consciousness. The type of seizure involved in
this answer choice best describes a complex partial seizure.
'Blank stare and impaired awareness for 10-20 seconds' is not the correct answer. This description is best
used to describe a patient who is having a nonconvulsive generalized seizure, otherwise known as an
, absence seizure. Patients having an absence seizure will rarely have any movement during the seizure. At
most, they may have some minor motor activity, such as blinking. In an older child or adult, these
episodes will leave the patient feeling as though they have short periods of time that they do not
remember.
'Loss of consciousness followed by stiffening of the body and extremities' is not the correct answer. The
fact that this description includes loss of consciousne
A 12-year-old girl presents with a 3-day history of progressive dysarthria, dysphagia, and weakness. The
patient was well until 3 days ago, when she developed the onset and subsequent gradual worsening of
dysarthria. She attributed this to a sore throat, which she had about 2 weeks before. Three days prior to
presentation, she had the onset of mild dysphagia, which occurred primarily with liquids. 24 hours prior
to presentation, she developed weakness in both upper extremities; the weakness worsened and began
to involve the lower extremities. This limb weakness was not worsened by activity, but it was not
improved by rest. She developed tingling in her toes 24 hours prior to presentation. When she became
unable to walk without assistance (on the day of presentation), she decided to seek medical care.
Past medical history is significant for measles and mumps. Because of family religious beliefs, she has not
had any i - Answer GBS
Guillain-Barre is the most common cause of acute and subacute generalized paralysis. In 60% of cases, it
is preceded by mild respiratory or gastrointestinal infection 1-3 weeks before the onset of paralysis (1).
Although it more typically begins distally and spreads proximally, the pattern seen here is a well-known
variant. While classically described as a motor neuropathy, varying degrees of sensory neuropathy can
be seen, as evidenced here by her paresthesias and decreased position and vibration sensation. Reduced
or absent deep tendon reflexes are usual findings. Oculomotor nerves are paralyzed in only the most
severe of cases; even the pupils may be unreactive.
Diphtheria of the faucial-pharyngeal type produces an inflammatory exudate in the throat and trachea.
Neurological sequelae usually begin after about 5-12 days, however, and usually with soft palate
paralysis, which may produce dysphagia but also regurgitation and nasal (dysphonic) speech (1). Soon,
trigeminal, facial, vagus, and hypoglossal nerves become involved. Loss of accommodation and blurring
of vision (with preserved light reaction) usually appears by weeks 2-3. External ocular muscles are rarely
involved. While cranial nerve findings may resolve around this time, the patient may go on to develop a
mixed sensorimotor peripheral neuropathy at 5-8 weeks into the clinical course. Although this peripheral
neuropathy may resemble Guillain-Barre, the other symptoms mentioned above and this long time
delay, are not seen in this patient.
Botulism is a rare form of blood borne illness caused by the exotoxin of C. botulinum (1). This exotoxin
acts at the presynaptic endings of neuromuscular junctions, interfering with acetylcholine release.
Questions with Correct Answers
Guaranteed Pass 100%
A 1-year-old boy presents with increasing lethargy. He is barely responsive, and his parents deny any
trauma or injury. What is the most common cause of nontraumatic altered levels of consciousness?
Answer Choices
1 Seizure disorder
2 Diabetic ketoacidosis
3 Inborn errors of metabolism
4 Toxic ingestion
5 Infection
ANS:5 - Answer infection
Awareness of self and the surrounding environment or consciousness may be altered into different
abnormal states of consciousness. Consciousness can shift from loss of clear thinking or confusion,
usually accompanied by disorientation, to delirium, a succession of confused and unconnected ideas
manifested in children as extreme mental and motor excitement, to lethargy, a profound type of slumber
where movement or speech is limited, to stupor or deep sleep where arousal is achieved only by
repeated vigorous stimuli, finally to coma, unresponsiveness to even painful stimuli. Non-traumatic coma
is most common in infants and toddlers with another smaller peak of occurrence in adolescence. The
most common cause of non-traumatic altered level of consciousness in children is infection of either the
brain (encephalitis), meninges (meningitis), or both; infections account for more than 1/3 of cases.
Prolonged seizures, anticonvulsive therapy, and postictal states can also lead to altered levels of
consciousness.
The most common metabolic cause of alteration of consciousness is diabetic ketoacidosis, which can
occur at any age, but is most common in adolescence. Caused by severe insulin deficiency,
hyperglycemia and ketogenesis lead initially to polyuria, polydipsia, hyperpnea, vomiting, and abdominal
pain. As the process progresses, hyperosmolar dehydration and acid/base and electrolyte disturbances
occur. Advanced stages alter level of consciousness and can lead to coma.
,Alterations of consciousness due to inborn errors of metabolism that present with electrolyte and
glucose abnormalities typically present in infancy. The availability of gluconeogenic precursors or the
functions of the enzymes required for production of hepatic glucose are affected. Metabolic defects
causing hypoglycemia include glycogen storage d
A 10-year-old boy is referred to you for being fidgety at school, though he makes good grades. Prior
history is unremarkable, and there has been no recent illness. The father had a similar history as a child.
While speaking with the patient, you notice that he clears his throat several times per minute.
Examination is otherwise normal, except for rapid, nonrhythmic jerking movements of the face, neck,
and shoulders while at rest.
Question
What is true of this patient's case?
Answer Choices
1 Does not have Tourette syndrome due to the absence of coprolalia
2 Has a factitious disorder
3 Has a condition that clusters in families
4 Must start a regimen of levodopa
5 Suffers from Sydenham chorea - Answer Has a condition that clusters in families
The combination of vocal tics (here, throat clearing) and motor tics should suggest Gilles de la Tourette
(Tourette) syndrome, which is a common tic disorder that clusters in families. Once thought to be a
single gene, autosomal dominant condition, it appears that multiple genes and nongenetic factors may
be at play.
Coprolalia is but one of many vocal tics seen in Tourette syndrome (throat clearing, humming, whistling)
and, although a notorious one, is not a necessary feature.
The positive family history makes it unlikely that the condition described is factitious.
,Pimozide, SSRIs, and other agents have been used in the treatment of Tourette syndrome, but levodopa
is not used.
The movement disorder of Sydenham chorea, as seen after a streptococcal infection, is choreiform - that
is, tends to be slower and rhythmic, as opposed to the rapid, nonrhythmic jerks seen in Tourette
syndrome. Also, vocal tics are not typically seen with Sydenham chorea.
A 12-month-old girl presents with her parents after a 3-day history of intermittent episodes of strange
behavior. A neurologist is consulted because the parents are concerned she is having some form of
seizure activity. Her health history includes 2 episodes of otitis media, but she is otherwise healthy. Her
initial vital signs and physical exam by the emergency room staff are all normal.
Question
What description of the infant's strange behavior would lead the neurologist to suspect a diagnosis of
simple partial seizures?
Answer Choices
1 Facial and right arm twitching lasting about a minute, then loss of consciousness
2 Blank stare and impaired awareness for 10-20 seconds
3 Eye deviation with facial twitching that lasts 1-2 minutes
4 Loss of consciousness, followed by stiffening of the body and extremities
5 Very brief periods of whole body going limp, followed by a brief loss of consciousness
ANS:3 - Answer Correct Answer: Eye deviation with facial twitching that lasts 1-2 minutes
Eye deviation with facial twitching that lasts 1-2 minutes' is the correct answer. Simple partial seizures
can vary depending on what portion of the cortex has been effected. Patients may display isolated tonic
or clonic activity or may have transient altered sensory perception. Clonic movements are jerks that may
involve a specific body part or may spread to adjacent body parts, known as "Jacksonian march." Tonic
activity is stiffening or sustained posturing, such as eye deviation in this case. Sensory seizures can
involve illusions or hallucinations, but this would be difficult to diagnose in a young child. One important
hallmark of a simple partial seizure is that the patient does NOT lose consciousness.
'Facial and right arm twitching lasting about a minute then loss of consciousness' is not the correct
answer. While a patient having a simple partial seizure might experience facial and right arm twitching
for that period of time, they are not going to have loss of consciousness. The type of seizure involved in
this answer choice best describes a complex partial seizure.
'Blank stare and impaired awareness for 10-20 seconds' is not the correct answer. This description is best
used to describe a patient who is having a nonconvulsive generalized seizure, otherwise known as an
, absence seizure. Patients having an absence seizure will rarely have any movement during the seizure. At
most, they may have some minor motor activity, such as blinking. In an older child or adult, these
episodes will leave the patient feeling as though they have short periods of time that they do not
remember.
'Loss of consciousness followed by stiffening of the body and extremities' is not the correct answer. The
fact that this description includes loss of consciousne
A 12-year-old girl presents with a 3-day history of progressive dysarthria, dysphagia, and weakness. The
patient was well until 3 days ago, when she developed the onset and subsequent gradual worsening of
dysarthria. She attributed this to a sore throat, which she had about 2 weeks before. Three days prior to
presentation, she had the onset of mild dysphagia, which occurred primarily with liquids. 24 hours prior
to presentation, she developed weakness in both upper extremities; the weakness worsened and began
to involve the lower extremities. This limb weakness was not worsened by activity, but it was not
improved by rest. She developed tingling in her toes 24 hours prior to presentation. When she became
unable to walk without assistance (on the day of presentation), she decided to seek medical care.
Past medical history is significant for measles and mumps. Because of family religious beliefs, she has not
had any i - Answer GBS
Guillain-Barre is the most common cause of acute and subacute generalized paralysis. In 60% of cases, it
is preceded by mild respiratory or gastrointestinal infection 1-3 weeks before the onset of paralysis (1).
Although it more typically begins distally and spreads proximally, the pattern seen here is a well-known
variant. While classically described as a motor neuropathy, varying degrees of sensory neuropathy can
be seen, as evidenced here by her paresthesias and decreased position and vibration sensation. Reduced
or absent deep tendon reflexes are usual findings. Oculomotor nerves are paralyzed in only the most
severe of cases; even the pupils may be unreactive.
Diphtheria of the faucial-pharyngeal type produces an inflammatory exudate in the throat and trachea.
Neurological sequelae usually begin after about 5-12 days, however, and usually with soft palate
paralysis, which may produce dysphagia but also regurgitation and nasal (dysphonic) speech (1). Soon,
trigeminal, facial, vagus, and hypoglossal nerves become involved. Loss of accommodation and blurring
of vision (with preserved light reaction) usually appears by weeks 2-3. External ocular muscles are rarely
involved. While cranial nerve findings may resolve around this time, the patient may go on to develop a
mixed sensorimotor peripheral neuropathy at 5-8 weeks into the clinical course. Although this peripheral
neuropathy may resemble Guillain-Barre, the other symptoms mentioned above and this long time
delay, are not seen in this patient.
Botulism is a rare form of blood borne illness caused by the exotoxin of C. botulinum (1). This exotoxin
acts at the presynaptic endings of neuromuscular junctions, interfering with acetylcholine release.
