Casos clínicos Neurología

Question 1

A 23-year-old man comes to the clinic because of a 5-day history of nausea, vomiting, decreased appetite, and insomnia. His temperature is 37.0°C (98.6°F), pulse is 102/min, respirations are 18/min, and blood pressure is 110/72 mm Hg. Physical examination shows red eyes with no discharge. Complete blood count and liver function tests are normal. Tetrahydrocannabinol is found in his urine. Which of the following is the most likely diagnosis?

1. Alcohol use disorder
2. Cocaine dependence
3. Amphetamine dependence
4. Cannabis dependence
5. Nicotine dependence

Answer 1

Cannabis dependence

Cannabis dependence is a psychological desire to use cannabis because it provides a feeling of increased relaxation. Insomnia, red eyes, and decreased appetite are the main withdrawal symptoms. Psychotherapy is primarily used to treat cannabis use disorder.

Question 2

An 58-year-old woman comes to the emergency department because of double vision, and weakness in her arms and legs. She says the symptoms improve with rest and worsen throughout the day, especially after intensive exercise. Physical examination shows a right-sided eyelid droop and mild respiratory depression. Which of the following pharmacotherapies is most appropriate for this patient?

1. Pyridostigmine
2. Pralidoxime
3. Atropine
4. Ipratropium
5. Methacoline

Answer 2

Pyrydistigmine

Myasthenia gravis is a rare autoimmune neuromuscular disorder against nicotinic acetylcholine receptors. It is diagnosed and treated using acetylcholinesterase inhibitors.

Question 3

A 29-year-old female comes to the office because of intermittent muscle cramps and weakness of her left leg for 3 months. She says these episodes usually last a week, and then completely resolve. Other symptoms she has intermittently experienced are blurred vision, difficulty in maintaining balance, as well as urinary urgency and incontinence. Visual examination is normal. There is decreased muscular power in her left leg, and an up-going left-sided plantar reflex. Which of the following medications would most likely reduce this patients muscle cramps?

1. Acetaminophen
2. Baclofen
3. Donepezil
4. Propranolol
5. Sildenafil

Answer 3

Baclofen

Multiple sclerosis is a demyelinating disease in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This damage disrupts the ability of parts of the nervous system to communicate, resulting in a range of signs and symptoms, including physical, mental, and sometimes psychiatric problems.

Spasticity is treated when it interferes with function, mobility, positioning, hygiene, or activities of daily living.

Question 4

A 25-year-old woman comes to the emergency department because of unilateral drooping of the right side of her face for the past half hour. She admits to experiencing ear pain for the past few days as well. Physical examination shows small, red vesicles in the right external meatus. Which of the following additional symptoms is most likely to be found in this patient?

1. Anosmia
2. Hyperacusis
3. Ophtalmoplegia on the right eye on abduction
4. Presbycusis
5. Voice hoarness

Answer 4

Hyperacusis

Ramsay Hunt syndrome is a complication of shingles that is associated with Bell’s palsy. Ramsay Hunt syndrome is characterized by ear pain, ipsilateral facial paralysis, and erythematous vesicles in the ear.

Question 5

A 53-year-old man is brought to the clinic because of a severe headache and decreased mental status. 20 minutes later patient is obtunded. Medical history is contributory for hypertension for the past 14 years. Ophthalmic examination shows anisocoria and a blown pupil. CT findings contraindicate the use of thrombolytics. Which of the following is the most likely diagnosis?

1. Cerebellar tonsillar herniation
2. Cingulate herniation
3. Dandy-Walker malformation
4. Type II Arnold Chiari malformation
5. Uncar herniation

Answer 5

Huncal herniation

Uncal herniation occurs when the uncus of the medial temporal lobe herniate through the tentorium and compress the midbrain.

This patient is likely experiencing a subarachnoid hemorrhage leading to increased intracranial pressure. This increase in intracranial pressure can cause parts of the brain to herniate under or through different parts of the meninges. This patient’s aniscoria is indicative of an uncal herniation.

Question 6

A 5-year-old boy comes to the office because of enuresis for the past 2 weeks. His mother says he stopped wetting the bed at age 3 but has now wet the bed 12 out of the last 14 days. He had a recent positive urinalysis and was treated for a UTI which has resolved, but the enuresis persists. A focused history and physical reveals the patient has a history of excessive snoring and daytime tiredness. His BMI is 31 kg/m2 ,and his neck circumference is 40.6 cm (16 inches). What of the following is the most appropriate next step in management?

1. CBC with differential
2. Fluid intake, stool and voiding diaryHemoglobin electrophoresis
3. Polysomnography
4. rine culture

Answer 6

Polysomnography

Polysomnography is the best test for establishing a diagnosis of obstructive sleep apnea. An obese patient with history of snoring and daytime somnolence should raise suspicion for obstructive sleep apnea. Children with sleep apnea have a noticeably increased prevalenceof enuresis.

Question 7

A 70-year-old woman comes to the hospital because of pneumonia. The patient had normal mental status upon admission, and throughout the course of the day. In the evening, the patient appears to be agitated with an altered mental status. The patient is combative with nursing staff, and makes violent gestures while trying to be examined. She is making comments about a small animal being in her room. There is no history of drug or alcohol abuse. A blood glucose is obtained, and is 98 mg/dL. Which of the following is the next best step in management in this patient?

1. Physical restraints
2. Haloperidol
3. Diphenhydramine
4. Chlordiazepoxide
5. Diazepam

Answer 7

Haloperidol

The first step in management of a patient with delirium and psychomotor agitation is a typical antipsychotic. Physical restraints may be a useful adjunct.

Question 8

A 45-year-old female comes to the emergency department because of a severe headache for 20 minutes. She states that she often gets headaches, but that this one feels different. Medical history includes hypertension. CT-scan is obtained. Lumbar puncture shows xanthochromia. Which of the following is the most likely vasculature associated with her condition?

1. Anterior communicating artery and anterior cerebral artery junction
2. Middle cerebral artery and internal carotid artery junction
3. Middle meningeal artery
4. Posterior cerebral artery and basilar artery junction
5. Posterior cerebral artery and posterior communicating artery junction

Answer 8

Anterior communicating artery and anterior cerebral artery junction

Subarachnoid hemorrhages are most commonly caused by ruptured berry aneurysms (sacular) and bleeding arteriovenous malformations. The most common location for a ruptured berry aneurysm is the junction of the anterior communicating artery and anterior cerebral artery.

When the aneurysmruptures, blood is released into the subarachnoid space. This blood can be broken down into bilirubin pigments in the CSF which imparts a yellow color to the CSF called xanthochromia.

Question 9

A 65-year-old man comes to the urgent care clinic with his wife who describes dramatic changes in the personality of her husband over the past two years. Specifically, she mentions that he has become increasingly aggressive, hypersexual, and easily agitated. As part of the initial workup, a non-contrast head CT is ordered which shows focal, severe atrophy most predominantly affecting the frontal and temporal lobes. The clinical and imaging findings most likely represent which of the following diagnosis?

1. Alzheimer Disease
2. Creutzfeldt-Jakob disease
3. Normal pressure hydrocephalus
4. Pick´s Disease
5. Vascular dementia

Answer 9

Pick´s Disease

Frontotemporal dementia is a rare, progressive form of dementia with no cure. The most common variant is behavioral which is characterized by loss of social inhibition, ritualized behaviors, apathy, aggression, and lack of insight. CT and MRI of the head will show focal atrophy in the frontal and temporal lobes.

Question 10

A 33-year-old woman with intractable hiccups is in severe discomfort in the emergency department. Attempts to extinguish the hiccups have included holding her breath, bearing down, sipping ice water, gargling the same water, swallowing a sugar cube, pressing on her closed eyes, getting into the fetal position, and leaning forward, all to no avail. What can be given to arrest the hiccups?

1. Amantadine
2. Chlorpromazine
3. Metoclopramide
4. Amitryptiline
5. Baclofen

Answer 10

Chlorpromazine

If physical maneuvers fail and there is no clear etiology for the hiccups within another disease or condition, then Chlorpromazine should be considered the first line treatment for intractable hiccups.

Metoclopramide and Baclofen are second line options

Question 11

A 23-year-old woman comes to the psychiatric outpatient clinic because of a tremor for the past 2 weeks. Her past medical history is significant for bipolar I disorder recently started on maintenance therapy with lithium 2 weeks ago. She reports that she developed the tremors ever since starting lithium. After discontinuing the lithium, which of the following is the next best step in management?

1. Quetiapine
2. Buspirone
3. Sertraline
4. Electrical convulsion therapy

Answer 11

Quetiapina

Bipolar I disorder is diagnosed by the presence of a manic episode. The mainstay of treatment for bipolar I is a mood stabilizer such as lithium, carbamazepine, or valproic acid. Atypical antipsychotics can also be utilized.

Question 12

A 70-year-old man is brought to the emergency department because of left-sided weakness. The weakness began an hour ago, while at home, when he noticed that he was suddenly unable to move his left leg. Medical history is contributory for hypercholesterolemia, hypertension, and tobacco-dependence. Physical examination shows 0/5 strength in the left lower extremity and 5/5 strength in the left upper extremity. The left leg and foot also have decreased sensation. A CT scan of the brain shows no hemorrhage. Which of the following arteries is most likely affected by this patient’s condition?

1. Internal thoracic artery
2. Lenticulostriate artery
3. Middle cerebral artery
4. Posterior inferior cerebellar artery
5. RIght anterior cerebral artery

Answer 12

Right anterior cerebral artery

The right anterior cerebral artery is the blood supply to the right medial parietal lobe of the brain, and an ischemic stroke here leads to left-leg weakness and sensation deficit.

Question 13

A 35-year-old male comes to the emergency department because of a stiff neck, severe headache, and vomiting. He states that these symptoms developed suddenly, while he was out for his daily run. Medical history is noncontributory. His temperature is 37.3°C (99°F), pulse is 87/min, respirations are 18/min, and blood pressure is 117/78 mm Hg. Examination shows a fit appearing man. A non-contrast CT-scan is obtained. Which of the following is the most likely diagnosis?

1. Contusion
2. Epidural hematoma
3. Subaracnoid hemorrage
4. Subdural hematoma
5. Meningitis

Answer 13

Subaracnoid hemorrage

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space, the area between the arachnoid membrane and the pia matersurrounding the brain. While SAH commonly occurs in older people, it can affect people of any age.

Question 14

A 25-year-old man comes to the clinic because of several months of intermittent, unilateral, severe headaches that occur suddenly and typically resolve within 1-2 hours. He explains that the pain is greatest around his left eye and can be associated with a watery eye and running nose on the ipsilateral side. Vital signs show his temperature is 37.1°C (98.8° F), pulse is 66/min, and blood pressure is 122/76 mm Hg. Basic ophthalmologic examination is unremarkable. A non-contrast CT head examination is within normal limits. In light of the patient’s presentation and negative imaging study, which of the following is the most likely diagnosis?

1. Cavernous sinus thrombosis
2. Cluster headaches
3. Migraine headaches
4. Subaracnoid hemorrage
5. Tension-type headaches

Answer 14

Cluster headaches

Cluster headaches are characterized by recurrent severe, unilateral, periorbital headaches with associated ipsilateral lacrimation, nasal congestion, and Horner’s syndrome. They are most often seen in younger males and can cause significant distress and disruption to daily life.

Question 15

A 46-year-old woman is brought to the emergency department by her husband because she had a seizure this morning. She has also noticed several intense headaches over the last two months. Last week, when she was talking with her husband, he noticed that she started confusing the meaning of words and could not find the appropriate words to express herself. Computed tomography performed after stabilization shows a mass lesion. A subsequent MRI is shown below. The radiologist’s report describes this as a high-grade lesion that is hypointense on T1-weighted images and enhances heterogeneously following contrast infusion. It can be distinguished from the surrounding hypointense signal of edema. Which of the following is the most likely diagnosis?

1. Central nervous system lymphoma
2. Cerebral abscess
3. Gliobastoma multiforme
4. Grado II astrocytoma
5. Meningioma

Answer 15

Glioblastoma multiforme

Glioblastoma multiforme is the most common and most malignant tumor of the cerebral hemispheres. It usually arises in patients between the ages of 40-60 years. It is characterized as a ‘ring-enhancing’ lesion on neuroimaging.

Question 16

A 70-year-old man is brought to the emergency department because of slurred speech, confusion, and weakness in his right side for the past hour. He has complete hemiparesis of his right upper and lower extremities. Patient’s medical history is significant for hypertension, atrial fibrillation, and diabetes for the past 26 years. His temperature is 37.8°C (100°F), pulse is 100/min, respirations are 14/min, and blood pressure is 150/92 mm Hg. Oxygen saturation is 94% in room air. Physical examination shows a right-sided facial droop to the lower portion of his face, symmetric forehead wrinkles, and symmetric eyebrow elevation. Which of the following is the most likely diagnosis?

1. Acute hemorragic stroke
2. Acute ischemic stroke
3. Bell´s palsy
4. Complex hemiplegic migraine
5. Subaracnoid hemorrage

Answer 16

Acute ischemic stroke

Acute ischemic stroke (AIS) accounts for 80% of all cerebrovascular accidents. AIS is from embolism or local thrombosis and is characterized by an acute onset of any focal neurological findings. Brain CT scan, for evaluating hemorrhagic infarct or subarachnoid hemorrhage, is necessary.

Question 17

A 65-year-old man comes to the emergency department because of a rash for the past 2 days. Seven days prior, he had noticed itching and burning pain around his left shoulder blade which was followed by the development of a painful, vesicular rash. The rash was treated appropriately. He returns to the office six months later complaining of a persistent, lancet-like, burning pain in the same area previously covered by the rash. Physical examination shows no cutaneous abnormalities. Which of the following is the most appropriate treatment option?

1. Acetaminophen
2. Carbamazepine
3. Sertraline
4. Nortryptiline
5. Morphine

Answer 17

Nortryptiline

Post-herpetic neuralgia (PHN) is a complication of herpes zoster characterized by lingering nerve pain at the site of a previous infection. It is treated with tricyclic antidepressants.

Question 18

A 27-year-old woman comes to the clinic because of recurrent headaches over the past 4 days. She describes the headache as diffusely bitemporal, worse when standing up and increasing in severity during the course of the day. There has been no benefit from acetominophen or ibuprofen but the headaches improve dramatically when lying down. She also states that her neck has felt stiff and she has felt mild nausea. Vital signs show that she is afebrile, her pulse is 66/min, and her blood pressure is 120/80 mmHg. Her neurologicexamination is normal. Lumbar puncture shows a protein level of 41 mg/dl, a glucose level of 70 mg/dl, no cells, and an opening pressure of 40 mmH2O. Which of the following diagnoses most completely accounts for her symptoms and signs?

1. Brain tumor
2. Spontaneous intracranial hypotension
3. Orthostatic hypotension
4. Meningitis
5. Cluster headaches

Answer 18

Spontaneous intracranial hypotension

Spontaneous intracranial hypotension typically presents with orthostatic headache with or without nausea, vomiting, neck pain, and vertigo. The symptoms are due to a reduction in CSF resulting from leaks in the cranial or spinal dura.

Remember normal Cerebrospinal fluid pressure is 70-180 mmH2O

Question 19

A 33-year-old man comes to the clinic because he woke up with intense dizziness upon getting out of bed. He says his feelings of dizziness come and go in spells, lasting only a few seconds. He cannot identify a trigger. When asked to described the spells in more detail, he describes them as “feeling like the room is spinning around him”. He denies loss of consciousness, feeling like his vision blacks out during the spells, or feeling weak or like he is going to collapse during the spells. His vital signs are normal. Neurological exam shows no abnormalities. Which of the following is themost appropriate next step in management?

1. Dix Hallpike maneuver
2. Electrocardiogram
3. Head CT
4. Rinne and Weber tests
5. Tympanometry

Answer 19

Dix Hallpike maneuver

Vertigo, the sensation of the room spinning around the patient, has a variety of causes and is distinct from syncope and pre-syncope. Benign paroxysmal positional vertigo (BPPV) is caused by the abnormal shifting of calciumcrystals within the semicircular canals of the inner ear and can be diagnosed using the Dix-Hallpike maneuver.

Then, using the Epley maneuver, you can force the crystals out of the patient’s semicircular canals, thereby preventing recurrence.

Question 20

A 70-year-old woman comes to the emergency department because of painful decreased vision in her right eye for 1 hour. She says that en-route to hospital she vomited once and that she noticed the ‘street lights had halos.’ She has no memory of a traumatic injury or photophobia, and she does not wear contact lenses. Ophthalmicexamination shows the conjunctival vessels of the right eye are dilated and the cornea is slightly hazy. The pupil of the right eye is also slightly dilated in comparison to the left eye and is sluggishly reactive to light. Visual acuity is decreased in the right eye. Which of the following is the most appropriate initial management?

1. Acyclovir
2. Ciprofloxacin
3. Timolol
4. Tropicamida
5. Methylprednisolone

Answer 20

Timolol

Acute angle closure glaucoma is characterized by vomiting in response to intense unilateral eye pain, which is accompanied by halos around lights and decreased vision in the affect eye. Treatment focuses on decreasing aqueous humorsecretion (timolol, carbonic anhydrase inhibitors, apraclonidine) and preventing pupillary dilation.