• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/125

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

125 Cards in this Set

  • Front
  • Back
Antalgic gait & posture
• Assoc w/ lumbar disc lesion
• Assoc w/ Facet syndrome
o Lateral HNP
“away”
o Medial HNP
“toward”
• Assoc w/ unilateral UMN disease- i.e. stroke. (Cerebral vascular lesion)
Spastic Hemiparesis Swinging gait
unilateral UMN disease- i.e. stroke. (Cerebral vascular lesion)
what does it interrupt, and is it ipsi or contra?
• Lesion interrupts pyramidal innervation to 1/2 of body
• Spastic hemiparesis contralateral to lesion
• Assoc w/ bilateral spastic paresis (Spastic Paraplegia)
• Congenital spastic diplegia - Little’s disease
• Corticospinal lesion, assoc w/ Cerebral Palsy
Scissors Gait
• Assoc w/ foot drop
• LMN disease
• Motor neuropathy
• Weakness of dorsiflexion of foot - tibialis anterior
• Pressure palsy of peroneal nerve
• Assoc w/: poliomyelitis, progressive spinal muscular atrophy, ALS, charcot-marie-tooth & peripheral neuritis
Steppage Gait (Equine gait)
• Assoc w/loss of position sense in legs (polyneuropathy or posterior column damage, M.S., Tabes dosalis)
• Gait is unsteady & wide-based, double tapping, watches feet
• Romberg +
Sensory Ataxia “Gait of spinal ataxia”
• Assoc w/ cerebellum or assoc tracts disease
• gait = staggering, unsteady, wide-based, w/ exaggerated difficulty on the turns
• Cannot stand with feet together with eyes open or closed, Romberg +
• “Compass deviation”
Cerebellar Ataxia
Cerebellar tests/Gait
• Proximal weakness can produce wavering when pt puts a finger to their nose
• Patient will fall...
o Towards side of lesion in lateral lobe
o Away from in anterior lobe – (AA)anterior - away
o Indiscriminately - lesion in vermis (midline)
Finger to finger w/ eyes closed exhibit what?
action tremor & past pointing
• Assoc w/ basal ganglia defect of Parkinson’s disease
• pt adopts flexed, stooping posture
• Steps - short, rigid & shuffling
• pt turns stiffly- “all in one piece” “En- bloc”
Parkinsonian Gait – aka Festinating
• Speed, balance, & grace decreased
• Steps short, uncertain, & even shuffling.
Gait of Old Age
• Indicates bilateral diffuse cortical dysfunction
Marche ‘a petit pas
• Common causes of Marche ‘a petit pas
diffuse cerebrovascular disease ‘lacunar state’
• Indicative of various myopathies in which there is weakness of hip girdle muscles.
• Most characteristic of muscular dystrophy.
• pt stands & walks with pronounced lordosis
• walking - marked waddling b/c of difficulty in fixing pelvis
• rolls or throws hips from side to side w/ every step to shift weight of body.
Dystrophic Gait – aka Waddling
• basically normal walking gait- can have NS “challenged” via tandem gait.
• Intoxication
• Polyneuropathy
• UMN disease leading to spasticity. Cerebellar, Vestibular, Dorsal col →may cause pt to fall to lesion
Tandem Gait – aka heel-toe walk
1. Progressive gait disturbance – Magnetic
2. Dementia - Apathy
3. Urinary incontinence – Cognitive impairment
Triad of Normal-Pressure Hydrocephalus
• Heel walk tests?
L5
• Toe walk tests?
S1
• Romberg’s (Feet together, eyes closed) positive if pt loses balance
o Examples of positive:
Intoxication, Dorsal column pathology, Polyneuropathy, Vestibular dysfunction
o If Cerebellar disease- pt will...
not stand w/ eyes open or closed.
• Finger to Nose Cerebellar
unilateral deficit
• Finger to Nose Vestibular
bilateral deficit
unilateral wild flail-like, writhing, twisting, or rolling movements-
• may be intense & lead to exhaustion
• Isolated lesion- usually vascular in origin, of contralateral subthalamic nucleus
• Hemiballismus
slower, twisting & writhing of face & distal extremities (spasticity).
• Ex: Cerebral palsy (globus pallidus or putamen)
• Athetosis
brief, rapid, jerky, irregular moves. (St. Vitus’ dance) (caudate & putamen)
• Chorea
: co-contraction of agonist & antagonist →may lead to intermittent or persistent maintenance of abnormal posture.
o Dystonia
o Dystonia
• Chorea
• Athetosis
Hemiballismus
are examples of what type of movement disorders?
Basal Ganglia
jaw jerk tests what?
- Pons
Finger flexors test what?
C8
• Pronator Drift Sign indicates what?
o infarct of right cerebral peduncle.
• Barre’s Sign indicates what?
o infarct of right cerebral peduncle.
Hoffman's sign • Tests integrity of lateral corticospinal tract with lesion at or above C5 or C6
• If positive - may be indicative of what?
UMNL or frontal lobe damage
o pt w/ lower limb paralysis or paresis is recumbent, w/ legs hanging over edge of table→Told to cough
o If coughing produces flexion of thigh & extension of knee in affected limb
o Paralysis due to UMN
• Huntington’s Sign
o Left cerebellum drives what?
right side cortex
o Right cerebellum drives what?
left side cortex
o Combined unilateral IX, X, XI – jugular foramen syndrome
Vernet syndrome)
Left optic nerve
total blindness (monocular loss)
Left junction
scotoma with a right upper quadrantanopia
Optic chiasm
Bi- temporal hemianopia
Left optic tract
Lt nasal hemianopia & Rt temporal hemianopia
Left temporal lobe
right homonymous upper quadrantanopia
Left parietal lobe
right homonymous lower quadrantanopia
Left occipital lobe
(left nasal hemianopia & right temporal hemianopia) macular sparing
visual Pathway
optic nerve → optic chiasm → optic tract → pretectal nucleus (mesencephalon) → Edinger-
Westphal nucleus→ciliary ganglion → short ciliary nerve
small pupil
• Cormiosis
large pupil
• Corectasia
• pupil dilates & becomes “fixed to light”
Marcus Gunn pupil
eye lid movement impaired
• Complete ptosis
• Parasympathetic component of CN III nerve via what?
Edinger-Westphal nuclei (circular constrictors) constricts in bright light
pupil dilated and eyeball deviated laterally
• Nerve paralysis
– leads to ptosis (denervation of superior tarsal muscle), anhydrosis, and cormiosis (loss of ciliary mm innervation
• Horner syndrome
pathway of eye dilation
• Hypothalamus→brain stem→C8/T1→superior cervical ganglion→internal carotid artery→ophthalmic division of CN V→ciliary ganglion→long ciliary nerves→radial fibers of ciliary muscle
• Smooth muscle dilator
weakness in eye muscle
• abnormal deviation of eye
• Tropia
eye does not accommodate
• cortical problem
• Phoria
strabismus where visual axes diverge
• Exotropia
tendency of eyes to deviate outward when fusion is suspended (Maddox rod)
• Exophoria
blending of slightly different images from each eye into a single perception
• Fusion
opk Pursuit
- parietal brain, ipsi•
opk - Saccade
frontal brain, ipsi coming back to other side
opk-• Ocular reflex
vestibular
opk-• Cerebellum
arrest at midline, contra
Cranial nerve V – trigeminal nerve• Main sensory nucleus
touch & pressure
Cranial nerve V – trigeminal nerve
• Spinal nucleus
pain & temperature
Cranial nerve V – trigeminal nerve
• Mesencephalic nucleus
proprioception
Cranial nerve V – trigeminal nerve
• Motor nucleus
mastication, tensor tympani, tensor veli palatini, mylohyoid, anterior digastric
• Corneal reflex what is afferent portion
CN V
• Corneal reflex what is efferent portion
CN VII
peripheral facial nerve palsy
• Bell’s palsy
• Lesion in stylomastoid foramen, inability to close eye, complete ipsi facial weakness, platysma weakness hyperacusis, loss of 2/3 of taste of tongue, excessive tearing due to cornea drying
• Bell’s palsy
unilateral UMNL
• Central or supranuclear lesion of right frontal lobe affecting corticobulbar tracts at any point above facial nucleus leads to facial paresis on left
• Paresis of lower quadrant of face only
• Cortex lesion
in hemiparesis, contraction of platysma muscle is less vigorous on affected side; sign could be present in facial weakness of peripheral origin
• Babinski’s platysma sign
– involuntary blinking (constant closing or screwing up of eyes) or constant forceful prolonged tight eye closure
• Blepharospasm
otosclerosis, Ménière’s disease, drug-induced, noise-induced
o Lesions of the cochlea
o Fatigable with delay with Dix-Hallpike’s maneuver
peripheral vestibular syndrome, benign positional vertigo
o Non-fatigable without delay with Dix-Hallpike’s maneuver
central vestibular syndrome
• Dizziness is due to debris that has collected within a part of the inner ear
o Benign paroxysmal positional vertigo (BPPV)
• Vocal cord paresis
CN X lesion
Sensory
Gag reflex
CN IX
Motor
Gag reflex
CN X; rising of soft palate, Ipsilateral
• Uvula moves to one side
upper or lower motor lesion of vagus on the other side (side of muscle paresis)
• Uvula does not move on saying ahh or on gag
bilateral palatal muscle paresis
• Uvula moves on saying ahh but not on gag, with reduced sensation of pharynx
CN IX palsy (rare)
lesion within jugular foramen affecting CN IX, X, and XI
o Vernet’s syndrome
• Ipsilateral loss of taste and depressed sensation over the posterior 1/3 of tongue
• Ipsilateral depressed gag reflex and palatal weakness
• Ipsilateral vocal cord paresis
• Ipsilateral weakness of the sternocleidomastoid and trapezius
o Vernet’s syndrome
rare; protruded tongue deviates towards side of lesion
• LMNL
common; tongue will have full bulk; if the lesion is in the cortical nuclear fibers, there will be no atrophy, fibrillation, or protrusion; tongue will deviate away from the side of the lesion
• UMNL
• Aids in the diagnosis of lumbar instability
Torsion Testing
o A 60 year old woman suddenly developed double vision. She was watching TV when it occurred. She had no other symptoms. On examination, it was found that her right eye, when at rest, was turned medially and she was unable to turn it laterally.
o Can you explain the problem in her right eye?
Paresthesia in lateral rectus muscle (LMNL)
What strabismus does she have?
o A 60 year old woman suddenly developed double vision. She was watching TV when it occurred. She had no other symptoms. On examination, it was found that her right eye, when at rest, was turned medially and she was unable to turn it laterally.
Esotropia
o A 60 year old woman suddenly developed double vision. She was watching TV when it occurred. She had no other symptoms. On examination, it was found that her right eye, when at rest, was turned medially and she was unable to turn it laterally.
What cranial nerve is affected?
CN VI
o Answer – the medial strabismus of her right eye, the diplopia, and the inability to turn the right eye laterally are due to paralysis of the right lateral rectus muscle caused by a lesion of the abducent nerve (CN VI)
o A 72 year old man with a known history of cerebrovascular problems came to see you because 3 days previously he had started to have trouble reading the paper. He said the print started to tilt and he began to see double. He also said that he found it difficult to see the steps when he descended the staircase to the office. On exam, the patient had weakness of movement of the right eye downward and you noticed that laterally flexing his head to the right produced a hypertropia.
o Name the cranial nerve, the muscle involved, and the site of the lesion with the proper side noted
This patient has a paralysis of the right superior oblique muscle resulting form a lesion of the trochlear nerve (CN IV). Since the trochlear nerves decussate on the emergence from the midbrain, the left trochlear nucleus is the site of the lesion. This patient had a thrombosis of the small artery supplying the left trochlear nucleus
o The patient enters your office for examination and treatment because of a severe left sided facial pain of 3 months duration. She describes the pain to be under the left eye and behind the eye. The pain is constant, except when asleep, and sharp in nature. She is a 69 year old white female who suffered a stroke 6 months earlier and recovered well. Two months later after the stroke, she fell and struck her left superior orbit on the bathroom sink. The pain began a month later starting as previously described. The patient has been to 9 different doctors with various treatments that have not helped. CT and MRI reveal normal findings.
o Can you help her?
No; get someone to do percutaneous radio frequency thermocoagulation
o The patient enters your office for examination and treatment because of a severe left sided facial pain of 3 months duration. She describes the pain to be under the left eye and behind the eye. The pain is constant, except when asleep, and sharp in nature. She is a 69 year old white female who suffered a stroke 6 months earlier and recovered well. Two months later after the stroke, she fell and struck her left superior orbit on the bathroom sink. The pain began a month later starting as previously described. The patient has been to 9 different doctors with various treatments that have not helped. CT and MRI reveal normal findings.
What is your diagnosis?
V2 LMNL; tic douloureux (trigeminal neuralgia)
o A 32 year old female with syringomyelia was found on physical examination to have impairment of appreciation of pain and temperature of the face, but preservation of light touch. Using your knowledge of neuroanatomy explain this dissociated sensory loss in the face
o Spinal nucleus of trigeminal, C1-C2, center of cord
o A 10 year old girl presents with an awkward gait. Six months previously the child complained that her right arm was clumsy & she had inadvertently knocked a glass of water off the table. You noticed that her hand movements were jerky when she was asked to write her name on a sheet of paper. The patient had a right club foot, & scoliosis. Two other family members had similar signs & symptoms.
o On examination, the child was found to have a lurching gait with a tendency to reel over to the right. Intention tremor was present in the right arm and leg. Weakness was noted in the right leg, & hypotonic muscles of the right arm & lower leg were found. She had severe pes cavus of the right foot, and kyphoscoliosis of the upper thoracic spine.
o On examination of her sensory system, she was found to have loss of muscle joint sense and vibratory sense of both legs. She also had loss of two-point discrimination of the skin of both legs. Her knee DTR’s were exaggerated, but her ankle DTR’s were absent. The biceps & triceps were normal. She had bilateral Babinski responses. Slight nystagmus present in both eyes.
1. What major areas of the nervous system are affected?
Cerebellum causes dysmetria and hypotonia (right side) and lateral parts of the spinal cord
o A 10 year old girl presents with an awkward gait. Six months previously the child complained that her right arm was clumsy & she had inadvertently knocked a glass of water off the table. You noticed that her hand movements were jerky when she was asked to write her name on a sheet of paper. The patient had a right club foot, & scoliosis. Two other family members had similar signs & symptoms.
o On examination, the child was found to have a lurching gait with a tendency to reel over to the right. Intention tremor was present in the right arm and leg. Weakness was noted in the right leg, & hypotonic muscles of the right arm & lower leg were found. She had severe pes cavus of the right foot, and kyphoscoliosis of the upper thoracic spine.
o On examination of her sensory system, she was found to have loss of muscle joint sense and vibratory sense of both legs. She also had loss of two-point discrimination of the skin of both legs. Her knee DTR’s were exaggerated, but her ankle DTR’s were absent. The biceps & triceps were normal. She had bilateral Babinski responses. Slight nystagmus present in both eyes.
What produces altered gait, clumsy movements, and nystagmus?
Degeneration of the cerebellum
o A 10 year old girl presents with an awkward gait. Six months previously the child complained that her right arm was clumsy & she had inadvertently knocked a glass of water off the table. You noticed that her hand movements were jerky when she was asked to write her name on a sheet of paper. The patient had a right club foot, & scoliosis. Two other family members had similar signs & symptoms.
o On examination, the child was found to have a lurching gait with a tendency to reel over to the right. Intention tremor was present in the right arm and leg. Weakness was noted in the right leg, & hypotonic muscles of the right arm & lower leg were found. She had severe pes cavus of the right foot, and kyphoscoliosis of the upper thoracic spine.
o On examination of her sensory system, she was found to have loss of muscle joint sense and vibratory sense of both legs. She also had loss of two-point discrimination of the skin of both legs. Her knee DTR’s were exaggerated, but her ankle DTR’s were absent. The biceps & triceps were normal. She had bilateral Babinski responses. Slight nystagmus present in both eyes.
. What tracts are involved?
Dorsal column, corticospinal tract degeneration resulted in weakness of legs and presence of Babinski
o A 10 year old girl presents with an awkward gait. Six months previously the child complained that her right arm was clumsy & she had inadvertently knocked a glass of water off the table. You noticed that her hand movements were jerky when she was asked to write her name on a sheet of paper. The patient had a right club foot, & scoliosis. Two other family members had similar signs & symptoms.
o On examination, the child was found to have a lurching gait with a tendency to reel over to the right. Intention tremor was present in the right arm and leg. Weakness was noted in the right leg, & hypotonic muscles of the right arm & lower leg were found. She had severe pes cavus of the right foot, and kyphoscoliosis of the upper thoracic spine.
o On examination of her sensory system, she was found to have loss of muscle joint sense and vibratory sense of both legs. She also had loss of two-point discrimination of the skin of both legs. Her knee DTR’s were exaggerated, but her ankle DTR’s were absent. The biceps & triceps were normal. She had bilateral Babinski responses. Slight nystagmus present in both eyes.
Explain the DTR grades
Increased DTR’s due to UMN other than corticospinal tract. Loss of S1 reflex due to degenerative process breaking reflex arc
o A 62 year old man with symptoms of neurosyphillis enters your office. You notice that both of his pupils are small and fixed and were not altered by shining a light in the eyes or shading them. You did notice that his pupils narrowed when he focused on the tip of his nose after looking at a distant object, then dilated when he looked in the distance again.
o Where is the lesion
Bilateral lesion of pretectal nucleus after the optic tract; Argyll-Robertson (prostitute’s) pupil
o Lesion is located where the pretectal fibers pass to the oculomotor nuclei on both sides of the midbrain, frontal eye fields have direct access to oculomotor, this is true also with MLF & consensual gaze, the lesion effectively destroys the direct and consensual light reflexes of both eyes but leaves the pathway for the accommodation reflex intact
o Accomodation afferent: impulses travel to optic nerve→optic chiasma→optic radiation to visial cortex frontal cortex, cortical fibers to oculomotor nuclei in midbrain, medial recti muscle
o Carpenter (56) walks into the ER, with only the head of the 3-inch nail visible against the red inside surface of his lower eyelid. The eyelid was pinned open. The nail punched through two sinuses headed toward the pituitary gland.
o The nail narrowly missed the eye, tear ducts, ocular muscles, main artery of the eye, the carotid artery to the brain, the optic nerve, the pituitary gland, ocular nerves, and trigeminal sensory & motor nerves.
o What adjustment?
none
o A patient is observed with a bilateral neuron lesion of some sort. You notice that all DTR’s are increased, even jaw jerk. On examination of their tongue you should notice:
Small tongue with reduced range of motion and normal bulk
o A 37 year old male noticed clumsiness of his right arm. The symptoms started 6 months previously and are getting worse. He also noticed that his right hand had a tremor when he attempted fine movements or tried to insert a key in a lock. When he walks, he notices that now and again he tends to reel over to the right. His speech was normal and nystagmus was not present.
o Where is the lesion?
Cerebellar problem on the right (astrocytoma of the right cerebellar hemisphere) Compass deviation=cerebellum, Romberg’s Test, cerebellum=intention tremor, Basal Ganglia =resting tremor, ex. Parkinson’s
o A 55 year old man enters your office experiencing severe stabbing pains in the abdomen and legs for the least 6 months. You noticed while he was walking, his gait was broad based, and there was a slapping of his feet on the ground. On examination he was not able to feel vibration or postural sensibility in his lower extremities.
o What tract or tracts cold be involved and what is your diagnosis?
Sensory ataxia (dorsal column lesion)
o A 60 year old man was asked to walk in a straight line in your examination room. You observed that the patient had head and shoulders stooped forward, his arms slightly abducted, the elbows partly flexed, and the wrists slightly extended. As he walked he leaned forward and shuffled his feet. The farther he leaned forward the more quickly he moved his legs.
o What is his gait called and his diagnosis?
Festinating gait; Parkinson’s disease, en bloc turn
o A 58 year old male enters the office displaying akinetic-rigid movements with reduced facial expression. You notice an increased tremor of the upper extremities during his gait and bradykinesia on fast repeating movements. Your initial diagnosis would be:
• Parkinson’s
o On examining your patient, you notice that when performing Weber’s test, the patient said he could hear the sound louder in his right ear. On completing Rinne’s the patient was able to hear the tuning fork longer by air in his left ear. This patient is suffering from:
• Conductive deafness of the right ear
o A patient enters your office complaining of dizziness, monaural fullness, and a loud buzzing sound in the right ear. Hallpike’s resulted in no nystagmus (Peripheral vs. Central). This patient is most likely suffering from:
• Ménière’s disease: dizziness and tinnitus and progressive hearing loss, usually in one ear. It is caused by lymphatic channel dilation, affecting the drainage of endolymph
A patient enters your office complaining of dizziness, monaural fullness, and a loud buzzing sound in the right ear. Hallpike’s resulted in no nystagmus (Peripheral vs. Central).
o This patient is also suffering from:
• Sensorineural deafness: Ménière’s causes sensorineural deafness
A patient enters your office complaining of dizziness, monaural fullness, and a loud buzzing sound in the right ear. Hallpike’s resulted in no nystagmus (Peripheral vs. Central).
o The lesion is most likely located
• In the cochlea: Ménière’s occurs in the cochlea, ↑ endolymph
o Patient enters office with small pupil that reacts to light; however, you also notice ptosis and enophthalmos (eye appears sunk in).
o What is the diagnosis?
• Horner’s syndrome: ligaments of Muller=symp to eyelid, no symp=small pupil
o Patient enters office unable to smile fully, and closed right eye. When asked to whistle patient was not able to produce sounds. On testing muscle strength you notice forehead strength equaled the lower face on right. Diagnosis is:
• Unilateral LMNL: Bell’s Palsy
o Patient enters office for exam and treatment. On exam, notice that DTR’s increased bilaterally. Some pain and temperature loss noted bilaterally on the face and head retraction reflex was positive (tap upper lip & jerk away). Diagnosis?
• Supranuclear lesion (UMNL):
o Explanation: Supranuclear involvement of trigeminal due to vascular lesions, neoplasms, degen changes or inflamm rxn affecting the cerebral center, internal capsule, basal ganglia, cerebral peduncle or pons above the nuclear areas, predominantly affecting motor
o If patient enters your office complaining of facial problems. Hearing difficulties, loss of taste, and dry eyes. You would start examining what CN?
• VII Taste, Facial Problem, Dry Eyes
o 55 year old female with involuntary rapid blinking of both eyes. Returned from ophthalmologist with no sign of eye infection or object in eye. On exam, notice constant forceful contractions of eyelid and excessive squinting
• Blepharospasm
o Your patient presents with a right corectasia (lg pupil), left upper extremity dysmetria, right limb flexion, OPK saccades improper, termination failure testing left to right, and a right exophoria on challenged convergence (cortical). Also: Gaze breakdown on L, UpL DnR, weak convergence R, sway left eyes closed, R pupil brisk & fail (couldn’t hold in allotted time), R pyramidal weakness, L paraspinal fail, VA Ratio 3:1 R, Pulse Ox low R
o You would expect this patient to have a:
• Very large left blind spot L (R cortex, parietal (bottom)/temporal (top))
• Case 20
o Your patient presents with a right corectasia (lg pupil), left upper extremity dysmetria, right limb flexion, OPK saccades improper, termination failure testing left to right, and a right exophoria on challenged convergence (cortical). Also: Gaze breakdown on L, UpL DnR, weak convergence R, sway left eyes closed, R pupil brisk & fail (couldn’t hold in allotted time), R pyramidal weakness, L paraspinal fail, VA Ratio 3:1 R, Pulse Ox low R
o This patient is suffering from:
• Left cerebella and right cortical dysfunction
o Your patient presents with a right corectasia (lg pupil), left upper extremity dysmetria, right limb flexion, OPK saccades improper, termination failure testing left to right, and a right exophoria on challenged convergence (cortical). Also: Gaze breakdown on L, UpL DnR, weak convergence R, sway left eyes closed, R pupil brisk & fail (couldn’t hold in allotted time), R pyramidal weakness, L paraspinal fail, VA Ratio 3:1 R, Pulse Ox low R
o If you were to adjust this patient and they could tolerate the afferentation, the correct treatment would be:
• CMT left cervical spine (afferent to bad cerebellum)
o A 65 year old woman presents with a history of dizziness for the last 2 weeks. She describes the dizziness as a whirling sensation that lasts 10 to 20 seconds at a time. Looking upwards exacerbates the condition and the environment moves to the left. These spells are incapacitating and she is afraid to move. She reports no ringing in her ears, visual, hearing, or speech problems. She gait is normal except during the dizzy spells.
o What is your diagnosis?
• BPPV - R Horizontal Canal, Modified Epley’s
o A 32 year old woman describes visual loss in the right eye. She first noticed its onset a week ago, and since then it has become progressively worse over the course of 2 days. There is pain in the right eye when she moves her eyes. She sees well out of her left eye. Examination shows 20/20 in left, the right is unable to read the largest print on the chart, but is able to count fingers that are presented to her. Pupillary constriction to light in the left is normal, while reaction on the right is present but less brisk.
o Funduscope exam shows papilledema of the right optic disc while the left is normal. Eye movements are intact, although she complains of pain on movement of the right eye. The rest of the neurologic exam is normal.
• Optic Neuritis MLF moves eyes, MS attacks the MLF
o A 39 year old man has had abnormal and uncontrollable movements for the past 6 months, as well as forgetfulness, obsessions, and compulsions. He has become somewhat more irritable and withdrawn. These movements are spontaneous, unpredictable, and have become almost continuous.
o The patients problem is in the:
• B. Caudate of the Basal ganglia Possible Huntington’s
o A 72 year old woman developed sudden severe vertigo about 5 hours prior to presentation in the ER. The vertigo has persisted and remained severe. She became nauseated and vomited a few times. She cannot walk or even sit without falling over. There was initially some double vision but this has resolved. She complains that her left arm is “weak” and heavy. Her speech is mildly slurred. She feels that she is being pulled to the left.
o Examination showed mild dysarthria, but language function is normal. Bilateral end gaze nystagmus is present, which is much more prominent toward the left. Facial strength and sensation is normal. Muscle testing throughout is 5/5 for patients age. Sensation is intact throughout.
o Using your knowledge of neuroanatomy what is the patient’s problem?
• Left posterior inferior cerebellar infarct - PICA event
o A patient reveals loss of sensation of pain and temperature on the entire right side of the body, except for the face, where the loss of these modalities is on the left side. Touch on the left side is normal. There is difficulty in swallowing, difficulty in phonation with drawing of the palate toward the right, inability to initiate a gag reflex from the left side of the pharynx, and hoarseness due to paralysis of the vocal cords on the left side.
o symptom complex of difficulty in swallowing and lack of gag reflex is mainly due to involvement of
• D. left glossopharyngeal nerve
• A 22-year-old woman with sudden headache, blurred vision and binocular diplopia. Two weeks previous, she had developed headache after a neck massage in a public bath. The headache was initially severe and generalized including the posterior neck. The next day, the headache improved mildly but persisted without a specific pattern of positional modulation or diurnal fluctuation. One week later, she began to have binocular horizontal diplopia which was more severe on distant viewing. She denied fever, chills, nausea, vomiting, photophobia, phonophobia, tinnitus, transient visual blurring on standing, or sensorimotor symptoms. Her family history was noncontributory except for hypertension in her father.
o Questions: What is the differential diagnosis? What features of the history help make certain entities more or less likely
↑ICP, Idiopathic intracranial hypertension, aneurysmal rupture/subarachnoid hemorrhage, meningitis, traumatic vertebral artery dissection, ophthalmoplegic migraine, neoplasm
o RAPD Relative Afferent Pupil Defect