PRITE Clinical Neurology
10 yo boy has episodes of being unresponsive and having weakness on one side or the
other of his body. The episodes began about 1 year before the visit, occur approximately
once a month and last several hours. He agrees with his parents description and adds that
during episodes, his head hurts and he is nauseated. Between episodes, he is normal in
every respect. Of the following, which is the most likely diagnosis? - ANS-Migraine
14-3-3 protein in CSF. Diagnosis? - ANS-Creutzfeld Jakob Diseasee
16 yo rural boy loses interest in school, farm work, friends. Parents bring him for evaluation.
Neurologist detects mild but definite cognitive impairment and subtle myoclonus. EEG shows
periodic sharp-wave complexes and the CSF contains markedly elevated level of Abs to
measles, but no cells and no 14-3-3 protein. Which illness does the eval indicate? -
ANS-Subacute sclerosing panencephalitis
19 yo w/ deterioration in personality, cognitive impairment, painful burning sensation in feet,
myoclonic jerks. No family history neuro/psych illness. Lab work-up negative. EEG shows
disorganized and slow background but no distinctive abnormal features. Neurosurgeon
performs biopsy. Cortex shows microscopic vacuoles. Diagnosis? - ANS-Prion infection
23 yo gets eval for sensation of falling with sudden contraction in his leg and back muscles
upon falling asleep. Felt as if he were preventing the fall. This sequence occurs 2x/month.
Most apt to occur after exhausting day. Frightens him and prevents him from sleeping
another 30 minutes. Strategy? - ANS-Reassure him that he is experiencing a benign
condition
(called hypnic jerks)
23 yo med student experimenting with Marijuana. Experienced anxiety and fear. Brought to
ER with hallucinations, agitation, fever, and nystagmus. Increasing agitation developed,
culminating in a seizure. What is most likely culprit? - ANS-PCP
25 yo woman w/ epilepsy that iw well controlled with carbamazepine developed pharyngitis.
Physician prescribed erythromycin. Rapidly developed ataxia, nystagmus, diplopia. In
retrospect, what caused her symtoms? - ANS-Carbamazepine toxicity
25 yo woman with anxiety reports frequent episodes of frightening thoughts that jar her
awake from sleep. Can recall her fears and is oriented and coherent upon awakening.
Remains awake for an hour before returning to sleep. PSG shows that episodes arise from
NREM sleep and the EEG electrodes do not show paroxysmal discharges. Most likely
diagnosis? - ANS-nocturnal panic attacks
28 yo man has several seizures. Previous evals contributed these to congenital cerebral
injury. He is enrolled in a methadone program for narcotic addiction. After stabilization with
IV BZD, physician change AED to phenytoin and continue methadone. Several days later,
agitation, anxiety to the point of incoherence, diaphoresis, and tachycardia develop. What
should be prescribed? - ANS-an increase in daily methadone dose
(phenytoin induces)
28 yo man with mild generalized headache has had a 3 day history of increasing left arm
weakness and clumsiness. Examination reveals only mild left arm weakness and
hyperactive DTRs. Routine medical evaluation reveals no abnormalities. Both CTs and MRIs
,show five large ring-enhancing cerebral lesions. Of the following, which is the most likely
cause of his neurologic difficulties? - ANS-toxoplasmosis
3 months after surviving a drug overdose, a 3 yo man lies in his hospital bed, quadriparetic
and almost mute. However, he has regained enough strength to reach for his food and with
some assistance feed himself with a spoon. He looks directly at examiners and appears to
watch televised sports events. He usually says, "No, no" when someone begins to change
the channel. His EEG when he is alert shows slow backgrounds activity and PET shows
markedly decreased cerebral cortical metabolism. Which of the following diagnoses most
accurately describes his condition? - ANS-Minimal conscious state
30 yo woman admitted for cocaine intoxication has incessant movements of her feet. She
claims that she "must" walk constantly. When forced to sit, she continually abducts and
adducts her legs and shuffles her feet. She is belligerent, but alert and without cognitive
impairment. Which of the following is the most likely cause of her leg movements and
walking? - ANS-d. persistent cocaine effect
34 yo woman develops uncomfortable sensation in her feet which she cannot describe.
Forces her to rub her feet and calves at night and cannot sleep. Only able to relieve by
pacing for 1-2 hours. No ongoing medical illnesses and no medications. Neuro exam normal.
Which lab study is inappropriate?
a. serum ferritin
b. pregnancy
c. BUN or creatinine
d. PSG - ANS-d. PSG (polysomnogram)
Patient is awake. She has RLS.
34 yo woman reports tossing and turning. Lies in bed at 1030. Falls asleep at MN, wakes
refreshed at 645. Productive day, pleasant evening. Which approach should prudent
physician take? - ANS-Suggest CBT
35 yo with HIV w/ CD4 <200 presents with left hemiparesis and bilateral ataxia that has
evolved over past several weeks. Cognitive function WNL. MRI shows several large areas of
demyelination, w/o mass effect, in the cerebral hemispheres. Which test would most likely
indicate the diagnosis? - ANS-A. CSF analysis for JC virus
4 yo boy develops sudden aphasia and right sided hemiparesis. No indication of trauma. CT
confirms L MCA stroke. Blood tests reveal marked lactic acidosis. Results of sickle cell
testing and homocysteine levels are normal. WHich of the following would be the most
appropriate diagnostic test? - ANS-genetic testing
40 yo woman develops sudden paresis of L upper and lower face. Diagnosed with lyme
disease and receives two rounds of antibiotics without resolution of symptoms. Will an
additional course of antibiotics provide relief moreso than placebo? - ANS-NO
45 yo w/ AIDS and CD4 of 50 develops generalized dull headache and inability to
concentrate. Temp of 101. No focal findings or indication of increased ICP. An MRI shows no
intracranial pathology. Which of the following would be the best diagnostic test? -
ANS-lumbar puncture
5 yo boy with brief, completely unprovoked episodes of laughter over past 6 months. Last
about 30 seconds. Cannot communicate with him during episodes. Seems to be saying
"Hee, hee, hee." Boy was developmentally and physically normal. EEG shows generalized
spike and wave discharges during the events that it captured. MRI reveals hypothalamic
hamartoma. Which is most accurate diagnosis? - ANS-Gelastic seizures
50 yo man struggles to stay awake during the day. Has restless nighttime sleep and
according to his girlfriend snores loudly. His PSG shows decreases in the blood oxygen
, concentration followed by brief arousals. What is the best treatment for excessive daytime
sleepiness? - ANS-CPAP
50 yo systems analyst has been taking SSRIs for 10 years. She states that her face pulls to
the left and her left eyelid closes. The movements are more intense during anxiety and
appear in bursts lasting several seconds to a few minutes, but they are not painful. The
eyelid closure interferes with her driving her car. Which of the following conditions is
probably responsible for her movements? - ANS-a. an aberrant blood vessel at the
cerebellopontine angle
50 yo with Fatal familial insomnia undergoes further evaluation. Which of the following
features is likely to be present? - ANS-C. Spongiform cerebra cortical changes (this is a
prion illness)
52 yo woman with treatment refractory seizures undergoes lobectomy, but she has
developed postoperative anxiety, fearfulness, dysphoria, and "moodiness." How to restore
preoperative mental status? - ANS-reinstitute AED, such as VPA
58 yo female depressed, gave up job. dresses inappropriate to weather. Reluctant to
participate in conversation. 24 on MMSE. Neuro exam normal. CT shows atrophy of frontal
lobes. Father had same problem at similar age. Diagnosis? - ANS-FTD
58 yo man has RLS. Wife reports once he falls asleep, his legs jerk in flurries at
approximately 30 second intervals. A polysomnogram (PSG) confirms the periodic bursts of
muscle activity and leg movement. What is the name of these movements? - ANS-C.
Periodic limb movements
59 yo banker has lost ability to complete financial arrangements. Knows individual facts of
each deal, fails to follow the sequence of established procedures. Wife reported that he has
begun to tell off-color jokes (change of character). Otherwise apathetic and speaks only
when prodded. MMSE was 25. General neuro exam normal. Cause? - ANS-FTD
6 signs of phenytoin intoxication - ANS-ataxia of gait
nystagmus
dysarthria
lethargy or stupor
dysmetria on heel shin testing
tremor on finger nose testing
70 yo retired teacher experiences visual hallucinations and parkinsonism - ANS-Dementia
with lewy bodies
70 yo with mild cognitive impairment and parkinsonism experiences hallucinations and
capgras delusion. Diagnosis? - ANS-Dementia w/ lewy bodies
77 yo telling off color jokes, ignoring prompts, urinates on himself. What area of brain is
responsible for such behavior? - ANS-frontal lobe
80 yo has mild forgetfulness and score of 19 on MMSE. Neuro exam normal. Blood tests
and CTH negative. ApoE test shows E4 allele. Which statement is most valid in this case? -
ANS-Little or no education and ApoE4 alleles are each risk factors for Alzheimer's disease.
85 yo man can't move legs after surgery. Has clear sensorium, good memory and
judgement, intact cranial nerves, and normal strength and DTRs in his arms and hands.
Flaccid areflexic paraplegia, hypalgesia to pin below the umbilicus, and urinary retention that
he did not appreciate. In contrast, position and vibration sensation were preserved in his legs
and feet. Where is the lesion? - ANS-Thoracic spinal cord
A 27 yo patient is seen for intermittent muscle twitching. Examination demonstrates full
strength with normal muscle bulk. An EMG demonstrates spontaneous discharges which are
relatively constant and represent firing of the motor unit. These findings are typical of:
10 yo boy has episodes of being unresponsive and having weakness on one side or the
other of his body. The episodes began about 1 year before the visit, occur approximately
once a month and last several hours. He agrees with his parents description and adds that
during episodes, his head hurts and he is nauseated. Between episodes, he is normal in
every respect. Of the following, which is the most likely diagnosis? - ANS-Migraine
14-3-3 protein in CSF. Diagnosis? - ANS-Creutzfeld Jakob Diseasee
16 yo rural boy loses interest in school, farm work, friends. Parents bring him for evaluation.
Neurologist detects mild but definite cognitive impairment and subtle myoclonus. EEG shows
periodic sharp-wave complexes and the CSF contains markedly elevated level of Abs to
measles, but no cells and no 14-3-3 protein. Which illness does the eval indicate? -
ANS-Subacute sclerosing panencephalitis
19 yo w/ deterioration in personality, cognitive impairment, painful burning sensation in feet,
myoclonic jerks. No family history neuro/psych illness. Lab work-up negative. EEG shows
disorganized and slow background but no distinctive abnormal features. Neurosurgeon
performs biopsy. Cortex shows microscopic vacuoles. Diagnosis? - ANS-Prion infection
23 yo gets eval for sensation of falling with sudden contraction in his leg and back muscles
upon falling asleep. Felt as if he were preventing the fall. This sequence occurs 2x/month.
Most apt to occur after exhausting day. Frightens him and prevents him from sleeping
another 30 minutes. Strategy? - ANS-Reassure him that he is experiencing a benign
condition
(called hypnic jerks)
23 yo med student experimenting with Marijuana. Experienced anxiety and fear. Brought to
ER with hallucinations, agitation, fever, and nystagmus. Increasing agitation developed,
culminating in a seizure. What is most likely culprit? - ANS-PCP
25 yo woman w/ epilepsy that iw well controlled with carbamazepine developed pharyngitis.
Physician prescribed erythromycin. Rapidly developed ataxia, nystagmus, diplopia. In
retrospect, what caused her symtoms? - ANS-Carbamazepine toxicity
25 yo woman with anxiety reports frequent episodes of frightening thoughts that jar her
awake from sleep. Can recall her fears and is oriented and coherent upon awakening.
Remains awake for an hour before returning to sleep. PSG shows that episodes arise from
NREM sleep and the EEG electrodes do not show paroxysmal discharges. Most likely
diagnosis? - ANS-nocturnal panic attacks
28 yo man has several seizures. Previous evals contributed these to congenital cerebral
injury. He is enrolled in a methadone program for narcotic addiction. After stabilization with
IV BZD, physician change AED to phenytoin and continue methadone. Several days later,
agitation, anxiety to the point of incoherence, diaphoresis, and tachycardia develop. What
should be prescribed? - ANS-an increase in daily methadone dose
(phenytoin induces)
28 yo man with mild generalized headache has had a 3 day history of increasing left arm
weakness and clumsiness. Examination reveals only mild left arm weakness and
hyperactive DTRs. Routine medical evaluation reveals no abnormalities. Both CTs and MRIs
,show five large ring-enhancing cerebral lesions. Of the following, which is the most likely
cause of his neurologic difficulties? - ANS-toxoplasmosis
3 months after surviving a drug overdose, a 3 yo man lies in his hospital bed, quadriparetic
and almost mute. However, he has regained enough strength to reach for his food and with
some assistance feed himself with a spoon. He looks directly at examiners and appears to
watch televised sports events. He usually says, "No, no" when someone begins to change
the channel. His EEG when he is alert shows slow backgrounds activity and PET shows
markedly decreased cerebral cortical metabolism. Which of the following diagnoses most
accurately describes his condition? - ANS-Minimal conscious state
30 yo woman admitted for cocaine intoxication has incessant movements of her feet. She
claims that she "must" walk constantly. When forced to sit, she continually abducts and
adducts her legs and shuffles her feet. She is belligerent, but alert and without cognitive
impairment. Which of the following is the most likely cause of her leg movements and
walking? - ANS-d. persistent cocaine effect
34 yo woman develops uncomfortable sensation in her feet which she cannot describe.
Forces her to rub her feet and calves at night and cannot sleep. Only able to relieve by
pacing for 1-2 hours. No ongoing medical illnesses and no medications. Neuro exam normal.
Which lab study is inappropriate?
a. serum ferritin
b. pregnancy
c. BUN or creatinine
d. PSG - ANS-d. PSG (polysomnogram)
Patient is awake. She has RLS.
34 yo woman reports tossing and turning. Lies in bed at 1030. Falls asleep at MN, wakes
refreshed at 645. Productive day, pleasant evening. Which approach should prudent
physician take? - ANS-Suggest CBT
35 yo with HIV w/ CD4 <200 presents with left hemiparesis and bilateral ataxia that has
evolved over past several weeks. Cognitive function WNL. MRI shows several large areas of
demyelination, w/o mass effect, in the cerebral hemispheres. Which test would most likely
indicate the diagnosis? - ANS-A. CSF analysis for JC virus
4 yo boy develops sudden aphasia and right sided hemiparesis. No indication of trauma. CT
confirms L MCA stroke. Blood tests reveal marked lactic acidosis. Results of sickle cell
testing and homocysteine levels are normal. WHich of the following would be the most
appropriate diagnostic test? - ANS-genetic testing
40 yo woman develops sudden paresis of L upper and lower face. Diagnosed with lyme
disease and receives two rounds of antibiotics without resolution of symptoms. Will an
additional course of antibiotics provide relief moreso than placebo? - ANS-NO
45 yo w/ AIDS and CD4 of 50 develops generalized dull headache and inability to
concentrate. Temp of 101. No focal findings or indication of increased ICP. An MRI shows no
intracranial pathology. Which of the following would be the best diagnostic test? -
ANS-lumbar puncture
5 yo boy with brief, completely unprovoked episodes of laughter over past 6 months. Last
about 30 seconds. Cannot communicate with him during episodes. Seems to be saying
"Hee, hee, hee." Boy was developmentally and physically normal. EEG shows generalized
spike and wave discharges during the events that it captured. MRI reveals hypothalamic
hamartoma. Which is most accurate diagnosis? - ANS-Gelastic seizures
50 yo man struggles to stay awake during the day. Has restless nighttime sleep and
according to his girlfriend snores loudly. His PSG shows decreases in the blood oxygen
, concentration followed by brief arousals. What is the best treatment for excessive daytime
sleepiness? - ANS-CPAP
50 yo systems analyst has been taking SSRIs for 10 years. She states that her face pulls to
the left and her left eyelid closes. The movements are more intense during anxiety and
appear in bursts lasting several seconds to a few minutes, but they are not painful. The
eyelid closure interferes with her driving her car. Which of the following conditions is
probably responsible for her movements? - ANS-a. an aberrant blood vessel at the
cerebellopontine angle
50 yo with Fatal familial insomnia undergoes further evaluation. Which of the following
features is likely to be present? - ANS-C. Spongiform cerebra cortical changes (this is a
prion illness)
52 yo woman with treatment refractory seizures undergoes lobectomy, but she has
developed postoperative anxiety, fearfulness, dysphoria, and "moodiness." How to restore
preoperative mental status? - ANS-reinstitute AED, such as VPA
58 yo female depressed, gave up job. dresses inappropriate to weather. Reluctant to
participate in conversation. 24 on MMSE. Neuro exam normal. CT shows atrophy of frontal
lobes. Father had same problem at similar age. Diagnosis? - ANS-FTD
58 yo man has RLS. Wife reports once he falls asleep, his legs jerk in flurries at
approximately 30 second intervals. A polysomnogram (PSG) confirms the periodic bursts of
muscle activity and leg movement. What is the name of these movements? - ANS-C.
Periodic limb movements
59 yo banker has lost ability to complete financial arrangements. Knows individual facts of
each deal, fails to follow the sequence of established procedures. Wife reported that he has
begun to tell off-color jokes (change of character). Otherwise apathetic and speaks only
when prodded. MMSE was 25. General neuro exam normal. Cause? - ANS-FTD
6 signs of phenytoin intoxication - ANS-ataxia of gait
nystagmus
dysarthria
lethargy or stupor
dysmetria on heel shin testing
tremor on finger nose testing
70 yo retired teacher experiences visual hallucinations and parkinsonism - ANS-Dementia
with lewy bodies
70 yo with mild cognitive impairment and parkinsonism experiences hallucinations and
capgras delusion. Diagnosis? - ANS-Dementia w/ lewy bodies
77 yo telling off color jokes, ignoring prompts, urinates on himself. What area of brain is
responsible for such behavior? - ANS-frontal lobe
80 yo has mild forgetfulness and score of 19 on MMSE. Neuro exam normal. Blood tests
and CTH negative. ApoE test shows E4 allele. Which statement is most valid in this case? -
ANS-Little or no education and ApoE4 alleles are each risk factors for Alzheimer's disease.
85 yo man can't move legs after surgery. Has clear sensorium, good memory and
judgement, intact cranial nerves, and normal strength and DTRs in his arms and hands.
Flaccid areflexic paraplegia, hypalgesia to pin below the umbilicus, and urinary retention that
he did not appreciate. In contrast, position and vibration sensation were preserved in his legs
and feet. Where is the lesion? - ANS-Thoracic spinal cord
A 27 yo patient is seen for intermittent muscle twitching. Examination demonstrates full
strength with normal muscle bulk. An EMG demonstrates spontaneous discharges which are
relatively constant and represent firing of the motor unit. These findings are typical of:
