Neuro exam master
A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on
the windshield. He complains of neck pain and severe burning in his shoulders and
arms. His physical examination reveals weakness of his upper extremities. What type of
spinal cord injury does this patient have?
A anterior cord syndrome
B central cord syndrome
C Brown-Sequard syndrome
D complete cord transection
E cauda equina syndrome - Central Cord Syndrome
the central cord syndrome involves loss of motor function that is more severe in the
upper extremities than in the lower extremities, and is more severe in the hands. There
is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome
presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with
preservation of posterior column function. Brown-Sequard syndrome consists of
weakness and loss of posterior column function on one side of the body distal to the
lesion with contralateral loss of lateral spinothalamic function one to two levels below
the lesion. Complete cord transection would affect motor and sensory function distal to
the lesion. Cauda equina syndrome typically presents as low back pain with
radiculopathy.
A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his
house. The right side of his head hit the alley cement, and he lost consciousness for
about 1 minute; he woke up with a headache, but he had no other complaints. A few
hours later, the patient is brought to the emergency room by his neighbor because of an
intense headache, confusion, and left hand hemiparesis. On examination, the patient
has a bruise located over the right temporal region, mydriasis, and right deviation of the
right eye, papilledema, and left extensor plantar response. An emergency CT scan of
the head without contrast reveals a lens-shaped hyper-density under the right temporal
bone with mass effect and edema. What is the most likely diagnosis?
Answer Choices
1 Epidural hematoma
2 Subdural hematoma
3 Subarachnoid hemorrhage
4 Intracerebral parenchymal hemorrhage
5 Acute meningitis - Epidural Hematoma
Epidural hematoma most often results from a traumatic tear of the middle meningeal
artery. Although a lucid interval ranging from minutes to hours followed by altered
mental status and focal deficits is typical for epidural hematoma, this clinical picture is
only encountered in up to 1/3 of the patients. The collection of blood between the skull
and dura mater causes an evident mass effect with ophthalmic nerve palsy and the
contralateral hemiparesis. Surgical evacuation of the clot via burr holes is the treatment
of choice.
,Subdural hematoma results from a traumatic rupture of the bridging veins that connect
the cerebrum to the venous sinuses within the dura. This venous hemorrhage will result
in a gradual increase of the hematoma, with a progressive clinical picture over days or
weeks. The CT scan will show a concave, crescent-shaped hyper-density compared to
the convex, lens-shaped hyper-density in epidural hematoma.
Subarachnoid hemorrhage is the result of an aneurysm rupture; the most common is
the congenital berry aneurysm. The clinical picture is of a sudden, severe headache
with meningeal irritation. A CT scan will show blood in the subarachnoid space, and a
lumbar puncture will reveal xanthochromia CSF.
Intracerebral parenchymal hemorrhage is most likely caused by hypertension
complicated with Charcot-Bouchard aneurysms. The blood accumulates into the brain
substance and most commonly involves the basal ganglia.
Acute meningitis is not associated with trauma. Fever and signs of meningeal irritation
dominate the clinical picture. Lumbar puncture, indicated if there are no focal
neurological signs on clinical examination, will be the diagnostic procedure. The CT
scan of the patient presented in this case is characteristic for epidural hematoma, and
there is no indication for a lumbar puncture.
A 31-year-old woman presents with a purpural rash covering her arms, legs, and
abdomen. She also has fever, chills, nausea, abdominal tenderness, tachycardia, and
generalized myalgias. Prior to the development of the rash, the patient noted that she
had a headache, cough, and sore throat. Laboratory studies were positive for Gram-
negative diplococci in the blood, along with thrombocytopenia and an elevation in
PMNs. Urinalysis showed blood, protein, and casts. Vital signs are as follows: PB 92/66,
P 96, RR 14, T 39. The patient denies any foreign travel and does not have any sick
contacts. However, she does work part time as a nurse in a local hospital.
Question
The patient is diagnosed with Meningococcemia; she is admitted to the hospital and
placed in respiratory isolation. What major course of therapy should this patient
receive?
Answer Choices
1 Steroids
2 Supportive care
3 Antibiotics
4 Transfusion
5 Bactericidal/permeability-increasing protein - Antibiotics
,Antibiotics are the treatment of choice for meningococcemia. The preferred drug for
active infection is penicillin G. For those allergic to penicillin, chloramphenicol and
cephalosporins (ie, cefotaxime, cefuroxime) may be used as alternatives.
Patients will also receive supportive care, but antibiotic therapy must be initiated quickly
if the patient is to survive. Intensive care placement may be necessary if organ failure is
imminent. Ventilatory support, inotropic support, and IV fluids are necessary in some. If
adrenal insufficiency occurs, corticosteroid replacement may be considered. A central
venous line helps to provide large amounts of volume expanders and inotropic
medications for adequate tissue perfusion.
Steroids have not been shown to play a major role in the treatment of
meningococcemia. However, they have been used in addition to antibiotic therapy. In
the case of adrenal insufficiency, for example, steroid replacement has been shown to
be beneficial.
Transfusion does not generally play a major role in treatment. If the patient suffers from
a devastating coagulopathy, blood or blood products may be replaced as necessary.
Bactericidal/permeability-increasing protein is a protein stored in the granules of
neutrophils. It binds to endotoxin in vitro and neutralizes it. This technique is
experimental, and it is not used in everyday treatment of meningococcemia.
In myasthenia gravis, weakness is a result of insufficient acetylcholine transmission at
the neuromuscular junction; however, weakness can also occur with overdosing of the
cholinergic medications used to treat myasthenia. What symptom helps differentiate a
myasthenic crisis from a cholinergic crisis?
Answer Choices
1 Respiratory failure
2 Bilateral ptosis
3 Muscle fasciculations
4 Diplopia
5 Normal muscle stretch reflexes - Muscle Fasiculations
Signs of cholinergic overdosage include muscle fasciculation, rhinorrhea, lacrimation,
salivation, increased bronchial secretions, nausea, or diarrhea. The presence of any of
these suggests that the patient's weakness may be due to cholinergic crisis. The other
signs are due to weakness and can occur in either condition.
A 54-year-old man presents after having a generalized seizure. The patient is HIV
positive, but he has been unable to afford antiretroviral therapy since losing his job 2
years ago. Other than cachexia, the physical exam is unremarkable. Upon further
inquiry, the patient also notes that he has become short-tempered and hypercritical; at
times, he seems confused. An MRI of the brain is performed, and it reveals several
cortical ring-enhancing lesions.
, Question
What is the most likely diagnosis?
Answer Choices
1 AIDS dementia complex
2 Cryptococcal meningitis
3 Cytomegalovirus encephalitis
4 Progressive multifocal leukoencephalopathy
5 Toxoplasma encephalitis - Toxoplasma encephalitis
The patient's symptoms and MRI findings are most consistent with the diagnosis of
toxoplasma encephalitis. Toxoplasmosis is the most common cerebral mass lesion
among HIV-positive patients. Infection with the Toxoplasma gondii parasite is relatively
common and usually asymptomatic. Reactivation occurs in HIV positive patients due to
failing cellular immunity, and it causes a multifocal necrotizing encephalitis. Seizures
may be the initial manifestation of central nervous system (CNS) infection; other
common clinical manifestations include focal neurologic deficits, such as impaired
speech and hemiparesis. Personality change, lethargy, headache, and confusion are
also observed. The MRI in patients with toxoplasma encephalitis characteristically
reveals multiple, ring-enhancing lesions with surrounding edema; these lesions usually
occur bilaterally in the frontal and parietal cortices.
AIDS dementia complex describes a constellation of cognitive symptoms seen among
HIV positive patients. The condition occurs when HIV virus disseminates to the CNS.
Within the CNS, the virus tends to concentrate in the basal ganglia and subcortical
regions. Symptoms include a constellation of cognitive, behavioral, and motor
disturbances that cause varying degrees of functional impairment. Characteristic MRI
findings include non-enhancing white matter, cerebral atrophy, and ventricular
enlargement. The diagnosis requires that other central nervous system infections,
carcinoma, as well as general medical conditions and substance abuse have been
excluded.
Cryptococcal meningitis is caused by the encapsulated fungus Cryptococcus
neoformans. Among HIV positive patients, the illness may be the result of new infection
or reactivation of latent infection. Presenting signs are often nonspecific; they include
headache, fever, change in mental status, and nausea or vomiting. Nuchal rigidity and
photophobia may also be present, and elevated intracranial pressure is not uncommon.
MRI findings vary, but they include lesions in the basal ganglia; meningeal
enhancement, cerebral edema, and shrunken ventricles may also be seen.
Cytomegalovirus (CMV) infection causing encephalitis is usually observed in patients
with evidence of CMV infection at other sites. MRI findings vary, but they often show
areas of focal necrosis within the brain parenchyma, meninges, or periventricular
regions. Symptoms typically reflect progressive dementia, with episodes of confusion,
apathy, and focal neurologic deficits.
