Susan Bones, a 16-year-old student complains of headaches. She states that her headaches are unilateral, intense, and throbbing. She states that she always gets a funny feeling before a headache. While experiencing these headaches, she notices that bright light and loud sounds make the headache worse. Please answer questions 1–4 based upon this presentation.
- Which type of headache is described as unilateral, throbbing, and coupled with photophobia and phonophobia? (intolerance to light and sound)
A. Tension headache
B. Migraine headache
C. Increased intracranial pressure headache
D. Temporal arteritis headache
2. What is the cause of a headache described as unilateral and throbbing? A. Myospasm B. Vascular C. Increased intracranial pressure D. Decrease intracranial pressure
B. Migraine headache
B. Vascular
3. In addition to appropriate chiropractic care, what is recommended for this patient? A. Emergency room visit B. Go to sleep C. MRI to reveal neural scarring D. Spinal tap
B. Go to sleep
4. Which factors should vascular headache sufferers avoid? A. Gluten B. Citrus C. Red wine D. Meat
C. Red wine
*side note: vascular headache sufferers should avoid any alcohol. Stress would be also be an acceptable answer.
George Weasley, a 16-year-old athlete, complains of loss of feeling in both hands and forearms only. He does have conscious proprioception and vibration sense in both hands, but no ability for point localization or reaction to a pinprick. He states that he has had multiple collisions and has been diagnosed with whiplash injury on four separate occasions. Please answer questions 5-7 based upon this presentation.
5. The shawl-like distribution suggests a lesion of the... A. Central spinal cord B. The cerebellum C. The lateral spinal cord D. The precentral gyrus
A. Central spinal cord
*side note: A posterior cord lesion would take away light touch, proprioception, and vibration.
6. What is the most likely cause of a lesion involving a suspended bilateral sensory loss for pain and crude touch only? A. Multiple sclerosis B. Syringomyelia C. Parietal lobe tumor D. Anemia affecting the spinal tracts
B. Syringomyelia
*side note: this is describing “central cord syndrome.” A syringomyelia is a fluid filled cyst into the spinal cord caused by repetitive head and neck trauma. Other acceptable answers would include a spinal cord tumor and spinal cord contusion (bruise)
7. What is the most likely cause of the lesion in the previous question? A. Intracranial hemorrhage B. Post concussive syndrome C. Motor neuron degeneration D. Repetitive of head and neck trauma
D. Repetitive of head and neck trauma
Neville Longbottom, a 14 year old boy, was hit on the head while fighting with Vincent Crabbe and Gregory Goyle. He complains of headache and some slight confusion. Over the next couple of hours the headache dissipates and the confusion clears up. Please answer questions 8-12 based upon this presentation.
8. Based on the resolution of the patient's symptoms, what is the most likely diagnosis? A. Concussion B. Contusion C. Laceration D. Intracerebral hemorrhage
A. Concussion
- What is the most likely prognosis for this case?
A. Permanent neurological deficit
B. Death within a few hours
C. Complete resolution
D. Slow steady demyelination of the spinal cord
C. Complete resolution
10. If this patient reports several head traumas in the last three months and is now experiencing chronic headache, general weakness, and fatigue, what is the likely diagnosis? A. Cerebral abscess B. Amyotrophic lateral sclerosis C. Intracranial tumor D. Post concussive syndrome
D. Post concussive syndrome
Which of these best describes the ImPACT test? A. Sensory and motor examination B. A mental status exam C. Motor coordination testing D. Reflex testing
B. A mental status exam
*i think
- Which is the best management for this patient?
A. A step-by-step gradual return to activity
B. A rigorous training schedule to get back to normal activity
C. Immediate resumption of activity level
D. Immediate and long-term rest and immobilization
A. The step-by-step gradual return to activity
Victor Crum, an 18 year old man, reports long-standing headache, fatigue, swollen lymph nodes, and joint pain and now is experiencing a fever and neck pain as well. Physical exam reveals a very low fever, 100.2°F, and history of multiple target rashes (erythema multiformans) acquired six months ago following a survival competition held in the woods. Please answer questions 13-15 based upon this presentation.
13. What is the most likely diagnosis for a patient with a minimal fever, joint pain, and a target rash? A. MS B. Lyme disease C. Amyotrophic lateral sclerosis D. Subdural hematoma
B. Lyme disease
14. What is the cause of the patient's condition? A. Inflammatory demyelination B. Deer tick bite C. Motor neuron degeneration D. Middle meningeal artery rupture
B. Deer tick bite
15. This patient is experiencing neck stiffness and neurological deficits six months after the initial exposure. Which stage of the infection is indicated? A. Stage I B. Stage II C. Stage III D. Stage IV
C. Stage III
*side note: stage I is days to about one week after infection causing fatigue, chills, fever, headache, and the target rash. Stage II occurs weeks to months after infection causing signs similar to mild meningitis (fever, headache, neck stiffness). Stage III occurs months to years after infection (this is called “Chronic Lyme Arthritis”) causing neurological deficits including difficulty concentrating and memory loss.
Albus Dumbledore, A 65-year-old high school principal, presents with a complaint of headache. He states that his headache hurts so much that brushing his hair causes intense pain. Palpation of the scalp causes him to wince in pain. Please answer question 16-18 based upon this presentation.
- Which is suggested by a headache in an elderly patient causing scalp pain?
A. Tension headache
B. Migraine headache
C. Increased intracranial pressure headache
D. Temporal arteritis headache
D. Temporal arteritis headache
*side note: aka giant cell arteritis. “Scalp pain” is the buzz word. This is when there is inflammation of the tunica media which causes closure of the lumen. Can cause other blood vessels to be inflamed , the most dangerous of which is the ophthalmic artery which would cause loss of vision
17. What other findings may this patient exhibit. A. Tender, enlarged temporal artery B. Decreased heart rate C. Elevation in blood pressure D. Irregular respiration
A. Tender, enlarged temporal artery
- What is the clinical concern in this patient’s presentation?
A. Inflammation of the ophthalmic artery leading to vision loss
B. Tumor growth within the cranium
C. Degeneration of all the motor neurons
D. Inflammatory demyelinization and scarring of the neuron
A. Inflammation of the ophthalmic artery leading to vision loss
Quirinius Quirrel, a 35 year old high school teacher, presents with a complaint of headache that has gotten steadily worse for the last two months. The patient reports difficulty hearing and understanding people speaking, additionally there is difficulty with concentration and memory. He reports no head trauma and has no fever. Vital signs are: blood pressure of 170\125, a pulse of 54, and 14 respirations per minute, but irregular. Mental status examination reveals the patient has difficulty with memory. Cranial nerve examination reveals decreased hearing in the right ear. Ophthalmoscopic exam reveals papilledema. Please answer questions 19-22 based upon this presentation.
19. In the absence of trauma, considering the neurological deficit, what is the cause of this headache and neurological signs? A. ALS B. Temporal arteritis C. Brain tumor D. Brown Sequard Syndrome
C. Brain tumor
*side note: Brown Sequard Syndrome is where there is damage to 1/2 of the spinal cord resulting in paralysis and loss of proprioception on the same side of the injury, and loss of pain and temperature sensation on the opposite side of the injury.
- Decreased hearing and memory deficits is suggestive of a lesion in the…
A. The right frontal lobe along the precentral gyrus
B. The brainstem and cerebellum
C. The left temporal lobe and the lower parietal lobe
D. The left hemisphere affecting the pre and post central gyri
C. The left temporal lobe and the lower parietal lobe
*side note: this is associated with damage to Heschi’s gyrus, the primary, secondary, and tertiary hearing area in the temporal lobe.
21. Increased blood pressure, decreased heart rate, and irregular respiration is called... A. Cushing's Triad B. Setting sun sign C. Babinski sign D. Lou Gehrig's sign
A. Cushing’s Triad
*side note: The “setting sun sign” is seen in hydrocephalus (water in the brain) and is where the eyes are turned downward and the white of the eye is visible above the iris. The Cushing’s triad is also seen in hydrocephalus. Babinski sign is an upper motor neuron lesion characterized by the toes pointing upward when the soul of the foot is stimulated.
22. Increased blood pressure, decreased heart rate, and your regular respiration result from... A. Inflammatory demyelination B. Increased intracranial pressure C. Motor neuron degeneration D. Central spinal cord lesion
B. Increased intracranial pressure
Lucius Malfoy, A 42-year-old man, complains of weakness in all four extremities. Neurological examination reveals no sensory loss, but the patient exhibits spasticity in both legs and flaccidity in both arms on passive motion. Reflex testing reveals a hyperreflexia with clonus in the patellar and Achilles reflexes, but a 0 or 1+ in the bicep and triceps. Both feet demonstrate an upgoing toe upon stroking the plantar surface of the foot. Please answer questions 23-27 based upon this presentation.
23. General weakness with spasticity and hyperreflexia of the lower extremity, and flaccidity and hyporeflexia of the upper extremity is suggestive of... A. Multiple sclerosis B. Amyotrophic lateral sclerosis (ALS) C. Parietal lobe tumor D. Hydrocephalus
B. Amyotrophic lateral sclerosis (ALS)
*side note: keywords are weakness in all four extremities. In order for ALS to be diagnosed, there must be symptoms of both upper and lower motor neuron damage. Also, The fact that there were no sensory loss also indicates ALS (there would be sensory loss with multiple sclerosis)
- What is one of the earliest signs of this condition?
A. Small, distill muscle weakness with cramping
B. Large, proximal muscle weakness
C. Multiple unrelated neurological deficits
D. Exacerbating and remitting neurological deficits
A. Small, distill muscle weakness with cramping
- What process is involved in this patient’s presentation?
A. Inflammatory demyelination of neurons
B. Degeneration and death of both upper and a lower motor neurons
C. Complete demyelination of the peripheral nervous system
D. Anemia leading to ischemia of spinal cord tracts
B. Degeneration and death of both upper and a lower motor neurons
- What is the most likely progression of this case?
A. Death in 3-5 years from respiratory failure or infection
B. Periods of exacerbation and remission
C. Complete demyelination of the peripheral nervous system
D. Worsening headache from increased intracranial pressure
A. Death in 3-5 years from respiratory failure or infection
27. What sensory signs are associated with this condition? A. Loss of joint proprioception B. Loss of crude and light touch C. Loss of pain sensation D. No associated sensory loss
D. No associated sensory loss
*side note: all the others describe MS signs
Arthur Weasley, a 45-year-old man, complains of a unilateral headache behind his right eye. The headaches are exacerbated by stress or alcohol use. He states that the headaches tend to happen several times per day for 10-20 minutes. These headaches last 1-2 weeks then disappear for months at a time. Please answer questions 28-30 based upon this presentation.
28. Which type of headache is described by the case above? A. Tension headache B. Migraine headache C. Cluster headache D. Temporal arteritis headache
C. Cluster headache
29. What is the cause of a headache described above? A. Myospasm B. Vascular C. Increased intracranial pressure D. Decreased intracranial pressure
B. Vascular
30. Which factor should patients prone to this headache avoid? A. Gluten B. Citrus C. Alcohol D. Meat
C. Alcohol
Collin Creavey, an 11-year-old student, reports to the school nurse with an intense headache and neck stiffness. When the nurse takes his temperature, he is running in 104°F fever. He demonstrates reflexive knee flexion on cervical flexion testing (Brudzinski sign). Please answer questions 31-34 based upon this presentation.
31. What is the first suspicion for this patient's diagnosis? A. Meningitis B. Hydrocephalus C. Concussion D. Migraine
A. Meningitis
32. Which is the most life-threatening cause possible for this diagnosis? A. Bacterial infection B. Cerebrospinal fluid blockage C. Viral infection D. Demyelination
A. Bacterial infection
33. Which of these physical exam procedures will result in increased neck pain in this patient? A. Wrist flexion B. Straight leg raising tests C. Cervical extension D. Valgus stress on the joints
B. Straight leg raising tests
*side note: any cervical flexion tests also (I.e. Brudzinski Sign and L’Hermitte Sign)
- Which lab test will aid in the diagnosis of this case?
A. Cerebrospinal fluid with pus
B. Red blood cell morphology revealing macrocytes
C. Urine and blood sugar testing
D. Genetic testing
A. Cerebrospinal fluid with pus
Fabian Pruitt, a 35-year-old man, presents with left sided weakness following a blow to the neck while being attacked as he walked home one night. Radiographic examination revealed a fracture on the left pedicle of C4 with medial displacement of the fragment. MRI reveals compression of the C5 nerve root on the left. Neurological examination revealed weakness, spasticity, and increased tendon reflexes in both extremities on the left. The patient also exhibits insensitivity to pain in the right arm and leg. Please answer questions 35-37 based upon this presentation.
35. Weakness on one side of the body with loss of pain on the opposite side results from a... A. Anterior spinal cord lesion B. Lateral spinal cord lesion C. Posterior spinal cord lesion D. Central spinal cord lesion
B. Lateral spinal cord lesion
*side note: posterior spinal cord lesion would cause loss of light touch, proprioception, and vibration only
36. Weakness on one side of the body with loss of pain on the opposite side is called... A. Multiple sclerosis B. Brown Sequard syndrome C. Syringomyelia D. Tabes dorsalis
B. Brown Sequard syndrome
37. Which sign would you expect this patient to exhibit? A. Decreased left triceps reflex B. Left pathological reflexes C. Increased right vibration sense D. Right side increased tendon reflexes
B. Left pathological reflexes
Sybill Trelawney, a 48 year old high school teacher, presents with a complaint of a blind spot in the right eye. She states that in the past year has experienced tingling in her legs and weakness in the left arm which has not completely resolved. She also experiences periods of vertigo and weakness, especially when taking a hot bath. Please answer questions 38-43 based upon this case.
38. Multiple unrelated neurological deficit is highly suggestive of... A. Meningitis B. Encephalitis C. Amyotrophic lateral sclerosis (ALS) D. Multiple sclerosis (MS)
D. Multiple sclerosis (MS)
*side note: optic neuritis is a hallmark sign of multiple sclerosis when the optic disc is visualized during an ophthalmologic exam as a bright white swollen area indicating inflammation
39. Which part of the nervous system is affected in this patient? A. The peripheral nervous system B. The motor neurons only C. The central nervous system D. The sympathetic nervous system
C. The central nervous system
- What is the pathology associated with this condition?
A. Degeneration of motor neurons
B. Wasting of proximal, then distal muscles
C. Lymphocyte sensitization to central nervous system myelin
D. Anemia leading to ischemia of spinal cord tracts
C. Lymphocyte sensitization to central nervous system myelin
- What is the likely progression of this case?
A. Death in 3-5 years from respiratory failure or infection
B. Periods of exacerbation and remission
C. Complete demyelination of the peripheral nervous system
D. Worsening headache from increased intracranial pressure
B. Periods of exacerbation and remission
- Why is the hot shower or bath bad for the patient?
A. Increased blood pressure makes the patient light headed
B. Increased body temperature increases the dispersion of nerve impulses
C. Increased body temperature will lower cerebrospinal fluid pressure
D. Increased body heat reduces the strength of the muscles
B. Increased body temperature increases the dispersion of nerve impulses
43. What imaging study will aid in the diagnosis of this case? A. MRI B. CT scan C. Plain film x-ray D. Angiogram
A. MRI
Dudley Dursley, a six month old infant, is brought to your office because he has a high-pitched constant cry. Physical examination reveals spasticity in all extremities and poor head control. Measurement of the head reveals that it is somewhat enlarged with tense fontanelles. Not only is the head control poor, but the infant seems to look down all the time. Please answer questions 44-47 based upon this presentation.
44. Why does infant have a constant cry? A. Migraine headache B. Intracranial pressure headache C. Limb pain from spasticity D. Poor vision, eyestrain headache
B. Intracranial pressure headache
What is the infant's problem? A. Muscular dystrophy B. Infection C. Hydrocephalus D. Encephalitis
C. Hydrocephalus
What is the nature of this patient's problem? A. Blockage of cerebrospinal fluid B. Demyelination C. Infection D. ALS
A. Blockage of cerebrospinal fluid
*side note: The infant’s skull will balloon out because the fontanelles haven’t fused. The infant will have poor head control and headaches along with Cushing’s Triad. The infant will also present with transillumination of the head where light will pass through the head quite easily. Lastly, the patient will present with “setting sun sign,” where the eyes turn downward and the white of the eye is visible.
What is the term form turned down eyes? A. Iritis B. Setting sun sign C. Oculomotor palsy D. Papilledema
B. Setting sun sign
Draco Malfoy, A 12-year-old boy, has a complaint of hip and shoulder weakness. The weakness has been progressing and now affects some of the elbow and knee muscles. When standing, the patient must hold on to something or climb up himself. He walks with a cane due to muscular weakness. The patient exhibits weakness but no loss of sensation. Deep tendon reflexes are decreased and pathological reflexes are absent. Family history is not possible since the patient was adopted as an infant. Please answer questions 48-50 upon this presentation?
48. Proximal, progressive muscular weakness is a sign of which condition? A. Brain tumor B. Multiple sclerosis C. Muscular dystrophy D. Upper motor neuron lesion
C. Muscular dystrophy
49. A patient who must hold on to something or climb up himself demonstrates... A. Setting sun sign B. Babinski sign C. Gower sign D. Cushing sign
C. Gower sign
50. What is the cause of the patient's condition? A. Demyelination B. Inflammation C. Neuron inflammation D. Genetic muscular degeneration
D. Genetic muscular degeneration
