Chapter 17: The Nervous System

A 28-year-old book editor comes to your clinic, complaining of strange episodes. He states

that about once a week for the last 3 months his left hand and arm will stiffen and then start jerking. He says that after a few seconds his whole left arm and then his left leg will also start to jerk. He denies any loss of consciousness or loss of bowel or bladder control. When the symptoms resolve, his arm and leg feel tired but otherwise he feels fine. His past medical history is significant for a cyst in his brain that was removed 6 months ago. He is married and has two children. His parents are both healthy. On examination you see a scar over the right side of his

head but otherwise his neurologic examination is unremarkable. What type of seizure disorder is he most likely to have?

A) Generalized tonic-clonic seizure

B) Generalized absence seizure

C) Simple partial seizure (Jacksonian)

D) Complex partial seizure

Simple partial seizure (Jacksonian)

A 7-year-old child is brought to your clinic by her mother. The mother states that her daughter is doing poorly in school because she has some kind of "ADD" (attention deficit disorder). You ask the mother what makes her think the child has ADD. The mother tells you that both at home and at school her daughter will just zone out for several seconds and lick her lips. She states it happens at least four to six times an hour. She says this has been happening for about a year. After several seconds of lip-licking her daughter seems normal again. She states her daughter has been generally healthy with just normal childhood colds and ear infections. The patient's parents are both healthy and no other family members have had these symptoms.

What type of seizure disorder is she most likely to have?

A) Generalized tonic-clonic seizure

B) Generalized absence seizure

C) Simple partial seizure (Jacksonian)

D) Complex partial seizure

Generalized absence seizure

A 37-year-old insurance agent comes to your office, complaining of trembling hands. She says that for the past 3 months when she tries to use her hands to fix her hair or cook they shake badly. She says she doesn't feel particularly nervous when this occurs but she worries that other people will think she has an anxiety disorder or that she's a drinker. She admits to having some recent fatigue, trouble with vision, and difficulty maintaining bladder control. Her past medical history is remarkable for hypothyroidism. Her mother has lupus and her father is healthy. She has an older brother with type 1 diabetes. She is married and has three children. She denies tobacco, alcohol, or drug use. On examination, when she tries to reach for a pencil to fill out the health form she has obvious tremors in her dominant hand. What type of tremor is she most likely to have?

A) Resting tremor

B) Postural tremor

C) Intention tremor

Intention tremor

A 77-year-old retired school superintendent comes to your office, complaining of unsteady hands. He says that for the past 6 months, when his hands are resting in his lap they shake uncontrollably. He says when he holds them out in front of his body the shaking diminishes, and when he uses his hands the shaking is also better. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for over 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister who has arthritis problems. His children are all essentially healthy. On examination you see a fine, pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back toward you. He has almost no "arm swing" with his gait. Wha

Resting tremor

A 48-year-old grocery store manager comes to your clinic, complaining of her head being "stuck" to one side. She says that today she was doing her normal routine when it suddenly felt like her head was being moved to her left and then it just stuck that way. She says it is somewhat painful because she cannot get it moved back to normal. She denies any recent neck trauma. Her past medical history consists of type 2 diabetes and gastroparesis (slow-moving peristalsis in the digestive tract, seen in diabetes). She is on oral medication for each. She is married and has three children. She denies tobacco, alcohol, or drug use. Her father has diabetes and her mother passed away from breast cancer. Her children are healthy. On examination you see a slightly overweight Hispanic woman appearing her stated age. Her head is twisted grotesquely to her left but otherwise her examination is normal. What form of involuntary movement does she have?

A) Chorea

B) Asbestosis

C) Tic

D) Dystonia

Dystonia

A 41-year-old real estate agent comes to your office, complaining that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy and as the day progressed he was unable to close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. His past medical history is unremarkable. He is divorced and has one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination you ask him to close his eyes. He is unable to close his left eye. You ask him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. You then ask him to give you a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. What type of facial paralysis does he have?

A) Peripheral CN VII paralysis

B) Central CN VII paralysis

Peripheral CN VII paralysis

A 60-year-old retired seamstress comes to your office, complaining of decreased sensation in her hands and feet. She states that she began to have the problems in her feet a year ago but now it has started in her hands also. She also complains of some weakness in her grip. She has had no recent illnesses or injuries. Her past medical history consists of having type 2 diabetes for 20 years. She now takes insulin and oral medications for her diabetes. She has been married for 40 years. She has two healthy children. Her mother has Alzheimer's disease and coronary artery disease. Her father died of a stroke and also had diabetes. She denies any tobacco, alcohol, or drug use. On examination she has decreased deep tendon reflexes in the patellar and Achilles tendons. She has decreased sensation of fine touch, pressure, and vibration on both feet. She has decreased two-point discrimination on her hands. Her grip strength is decreased and her plantar and dorsiflexion strength is decreased. Where is the disorder of the peripheral nervous system in this patient?

A) Anterior horn cell

B) Spinal root and nerve

C) Peripheral polyneuropathy

D) Neuromuscular junction

Peripheral polyneuropathy

A 21-year-old engineering student comes to your office, complaining of leg and back pain and of tripping when he walks. He states this started 3 months ago with back and buttock pain but has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. He can think of no specific traumatic incidences but he was a defensive lineman in high school and junior college. His past medical history is unremarkable. He denies tobacco use or alcohol or drug abuse. His parents are both healthy. On examination he is tender over the lumbar spine and he has a positive straight-leg raise on the left. His Achilles tendon deep reflex is decreased on the left. While watching his gait you notice he has to pick his left foot up high in order not to trip. What abnormality of gait does he most likely have?

A) Sensory ataxia

B) Parkinsonian gait

C) Steppage gait

D) Spastic hemiparesis

Steppage gait

A 17-year-old high school student is brought in to your emergency room in a comatose state. His friends have accompanied him and tell you that they have been shooting up heroin tonight and they think their friend may have had too much. The patient is unconscious and cannot protect his airway, so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. Preparing to finish the neurologic examination, you get a penlight. What size pupils do you expect to see in this comatose patient?

A) Pinpoint pupils

B) Large pupils

C) Asymmetric pupils

D) Irregularly shaped pupils

Pinpoint pupils

A 37-year-old woman is brought into your emergency room comatose. The paramedics say her husband found her unconscious in her home. Her past medical history consists of type 1 diabetes and she is on insulin. In the ambulance the paramedics obtained a glucose check and her sugar was 15 (normal is 70 to 105). They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts, she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed.

What type of posturing is she showing?

A) Decorticate rigidity

B) Decerebrate rigidity

C) Hemiplegia

D) Chorea

Decerebrate rigidity

A patient presents with left-sided facial droop. On further testing, you note that he is unable to wrinkle his forehead on the left and has decreased taste. Which of the following is true?

A) This represents a central lesion

B) This resents a CN IV lesion.

C) This may be related to travel.

D) This most likely represents a stroke.

This may be related to travel.

Which is true of examination of the olfactory nerve?

A) It is not tested for laterality

B) The smell must be identified to declare a normal response

C) Abnormal responses may been seen in otherwise normal elderly

D) Allergies are unrelated to testing of this nerve

Abnormal responses may been seen in otherwise normal elderly

Steve has had a stroke and comes to you for follow-up today. On examination you find that he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the

following?

A) The corticospinal tract

B) The cerebellum

C) The cerebrum

D) The basal ganglia

The basal ganglia

You are conducting a mental status examination and note impairment of speech and judgment, but the rest of the examination is intact. Where is the most likely location of the problem?

A) Cerebrum

B) Cerbellum

C) Brainstem

D) Basal ganglia

Cerebrum

A patient presents with a daily headache which has worsened over the past several months. On funduscopic examination, you notice that the disk edge is indistinct and the veins do not pulsate. Which is most likely?

A) Migraine

B) Glaucoma

C) Visual acuity problem

D) Increased intracranial pressure

Increased intracranial pressure

A young woman comes in today, complaining of fatigue, irregular menses, and polyuria which have gradually increased over the past few months. Which eye findings would be consistent with her condition?

A) An upper quadrantanopsia

B) A lower quadrantanopsia

C) A bitemporal hemianopsia

D) An increased cup-to-disc ratio

A bitemporal hemianopsia

A patient with a history of seizure disorder and on several seizure medications says a friend noted "jumping eye movements." The patient describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. On examination you note that the eyes both slowly move to the right and then quickly jump to the left. Which of the following is true?

A) This is called nystagmus to the left

B) This is called saccadic eye movement

C) This resents a sub clinical seizure

D) This most likely has an ominous cause

This is called nystagmus to the left

You are testing the biceps strength in a young man following a spinal trauma from a motor vehicle accident. He cannot lift his hand upward, but if the arm is abducted to 90 degrees, he can then move his forearm side to side. This would represent which muscle strength grading?

A) I

B) II

C) III

D) IV

II

You ask a patient to hold her arms up, with her palms up, and then to close her eyes. The right arm begins to move downward after a few seconds and her thumb rotates upward. This is most likely a problem with which part of the nervous system?

A) Corticospinal tract

B) Spinothalamic tract

C) Thalamus

D) Dorsal root ganglion

corticospinal tract

You are examining a child with severe cerebral palsy. When you suddenly move his foot dorsally, aa sustained "beating" of the foot against your hand ensues. What does this represent?

A) A focal seizure

B) Clonus

C) Extinction

D) Reinforcement

Clonus

Jim is an HIV-positive patient who complains about back pain in addition to several other problems. On percussion, there is slight tenderness over the T7 vertebrae, and when you flex his thigh to 90 degrees and extend his lower legs, you meet strong resistance at about 45 degrees of extension. What are likely causes of this constellation of symptoms?

A) Fractured vertebrae

B) Malingering

C) Infection

D) Medication side effect

Infection

A patient with alcoholism is brought in with confusion. You ask him to "stop traffic" with his palms and notice that every few seconds his palms suddenly move toward the floor. What does this indicate?

A) Stroke

B) Metabolic problems

C) Carpal tunnel syndrome

D) Severe fatigue and weakness

Metabolic problems

You examine a "sleepy" patient. You note that she will open her eyes and look at you but responds slowly and is confused. She does not appear interested in her surroundings. How would you describe her level of consciousness?

A) Lethargic

B) Obtunded

C) Stuporous

D) Comatose

Obtunded

A woman experiences syncope after hearing that her son was severely injured. She becomes pale and collapses to the ground without injuring herself. On waking, she states that she feels very warm. She denies any other symptoms. There are no findings on examination. What caused her loss of consciousness?

A) Micturition syncope

B) Postural hypotension

C) Cardiac arrhythmia

D) Vasovagal syncope

Vasovagal syncope

A 7-year-old boy is performing poorly in school. His teacher is frustrated because he is frequently seen "staring off into space" and not paying attention. If this is a seizure, it most likely represents which type?

A) Pseudoseizure

B) Tonic-clonic seizure

C) Absence

D) Myoclonus

Absence

A patient comes to you because she is experiencing a tremor only when she reaches for things. This becomes worse as she nears the "target." When you ask her to hold out her hands, no tremor is apparent. What type of tremor does this most likely represent?

A) Intention tremor

B) Postural tremor

C) Resting tremor

D) Nervous tremor

Intention tremor

A young woman comes in with brief, rapid, jerky, irregular movements. They can occur at rest or during other intentional movements and involve mostly her face, head, lower arms, and hands. How would you describe these movements?

A) Tics

B) Dystonia

C) Athetosis

D) Chorea

Chorea

An 18 year-old college freshman presents to the emergency room for evaluation of fever, headache, and neck stiffness. On physical examination, the patient is resting quietly and has a flushed face. His vital signs are as follows: temperature, 104 F; pulse, 110 bpm; and BP, 105/70. He has no rashes. During the physical examination, you flex the patient's neck and his hips and knees flex in response, indicating a meningeal irritation. The name of this positive sign is:

-Kernig's sign

-Brudzinski's sign

-Babinski's sign

Brudzinski's sign

Which of the following signs or symptoms are associated with the lower motor neuron disease of peripheral neuropathy?

-Spastic tone, increased DTR's, sensory loss on same side of motor deficits

-Paresthesia, loss of position and vibratory sense, decrease or loss of DTR's, and motor weakness of extremities

-Slowness of movement (bradykinesia), rigidity, and tremor

-Hypotonia, ataxia and other abnormal movements including nystagmus

Paresthesia loss of position and vibratory sense decrease or loss of DTR's and motor weakness of extremities