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38 Cards in this Set
- Front
- Back
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An 81-year-old right-handed Caucasian man is found on the floor at home unable to speak or move the right side of his body. The patient lives alone and was last seen by family members two days previously.
On examination vital signs were blood pressure 80/50, pulse regularly irregular at 110, afebrile with a respiratory rate of 16. He was alert but unable to speak spontaneously or to repeat or to follow commands. He was heard to cuss when the IV was started. Pupils were equal, round and reactive to light, and the extraocular movements were intact. There was a right homonymous superior quadrantanopia to threat. There was weakness of the right side of the face affecting the lower face more than the upper face. The right side extremities were flaccid with 0/5 strength, with 4/5 strength on the left. He reacted to light touch and pinprick on the left but not on the right. Tendon reflexes were decreased on the right and there was a right Babinski's sign. |
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A 34-year-old right-handed Caucasian woman comes to the
emergency room complaining of double vision for three days. The onset has been gradual, and there were no precipitating factors. She has no other symptoms. Her only previous visual difficulty was an episode of optic neuritis in the left eye approximately 10 years ago. On examination vital signs were unremarkable. Examination of the extraocular movements showed that each eye failed to adduct when the gaze was directed to the opposite side. There was a left afferent pupillary defect on swinging light test. The remainder of the neurologic examination was unremarkable. Where is the new lesion? |
Bilateral MLF (INO)
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A 34-year-old right-handed Caucasian woman comes to the
emergency room complaining of double vision for three days. The onset has been gradual, and there were no precipitating factors. She has no other symptoms. Her only previous visual difficulty was an episode of optic neuritis in the left eye approximately 10 years ago. On examination vital signs were unremarkable. Examination of the extraocular movements showed that each eye failed to adduct when the gaze was directed to the opposite side. There was a left afferent pupillary defect on swinging light test. The remainder of the neurologic examination was unremarkable. Where is the old lesion? |
Optic nerve
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A 34-year-old right-handed Caucasian woman comes to the
emergency room complaining of double vision for three days. The onset has been gradual, and there were no precipitating factors. She has no other symptoms. Her only previous visual difficulty was an episode of optic neuritis in the left eye approximately 10 years ago. On examination vital signs were unremarkable. Examination of the extraocular movements showed that each eye failed to adduct when the gaze was directed to the opposite side. There was a left afferent pupillary defect on swinging light test. The remainder of the neurologic examination was unremarkable. What is the disease? |
Multiple Sclerosis
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A 34-year-old right-handed Caucasian woman comes to the
emergency room complaining of double vision for three days. The onset has been gradual, and there were no precipitating factors. She has no other symptoms. Her only previous visual difficulty was an episode of optic neuritis in the left eye approximately 10 years ago. On examination vital signs were unremarkable. Examination of the extraocular movements showed that each eye failed to adduct when the gaze was directed to the opposite side. There was a left afferent pupillary defect on swinging light test. The remainder of the neurologic examination was unremarkable. What cell type is involved? |
Oligodendrocyte
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A 74-year-old African-American man with a history of hypertension comes to the emergency room complaining of weakness in his right hand and slurred speech. He states he was well until he woke up
this morning with the symptoms. On examination vital signs are unremarkable. He is awake and his speech his mildly dysarthric but fluent and appropriate. There is mild weakness in the lower half of the right side of his face. The remainder of cranial nerves are all intact. He has normal muscle bulk and tone. Strength is 4/5 in the right arm and hand, with greater weakness in the extensors than the flexors and marked clumsiness in fine finger movements. The strength is 5/5 everywhere else. Sensation is intact throughout to all modalities. Coordination and gait are intact except as affected by weakness. Tendon reflexes are 2+ throughout and there is no Babinski's sign. |
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Lost vision in the left
visual field of both eyes |
Homonymous hemianopia
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Can see a little further
to the left in his central vision |
Macular sparing
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A 46-year-old right-handed Hispanic man fell from a ladder and was brought to the hospital unconscious. A large subdural hematoma was drained from the right side. On awakening from surgery, he has left sided weakness which gradually improves, but
he states that he cannot see out of his left eye. You examine his visual fields and discover that he has lost vision in the left visual field of both eyes, although he can see a little further to the left in his central vision. |
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A 17-year-old African-American male who was stabbed in the back
presents with inability to use his left leg. The stab wound occurred at the level of L1 just to the left of the spinous process. Since the injury he has been unable to move his left leg and he also complains of tingling in the distal left leg. On examination is vital signs are normal, and his mental status and cranial nerves are unremarkable. He has 5/5 strength with normal tone in both upper extremities and the right lower extremity. He has 0/5 strength in the left lower extremity with increased tone. There is diminished proprioception and vibration sense in the left lower extremity and loss of pain and temperature sense in the right lower extremity. Tendon reflexes are 3+ at the patella and Achille’s tendon on the left and 2+ elsewhere. The Babinski's sign is present on the left. |
Brown-Sequard Syndrome
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disease?
• 0/5 strength in the left lower extremity with increased tone • Diminished proprioception and vibration sense in the left lower extremity • Loss of pain and temperature sense in the right lower extremity • Tendon reflexes are 3+ in the left lower extremity with Babinski's sign |
Brown-Sequard Syndrome
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A 37-year-old right-handed Caucasian man with a history of seizures comes to clinic and reports that he awakened to find himself slumped in a kitchen chair two weeks ago. He last remembered sitting down at the kitchen table after dinner, and when he awakened the experienced the grogginess and dull
headache he typically experiences after a seizure. Assuming he had had a seizure, he went to bed. He complains that since then he has had a "floppy" wrist and numbness in his hand. Examination of the right upper extremity shows a right wrist drop with a weakness of all the wrist and finger extensors. Fasciculations were seen over the dorsal surface of the forearm, and there was loss of sensation over the lateral dorsum of the hand. The rest of the examination is unremarkable. |
Saturday Night Palsy:
Radial Nerve Lesion in the Spiral Groove |
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• Weakness of all the wrist and finger extensors
• Fasciculations were seen over the dorsal surface of the forearm • Loss of sensation over the lateral dorsum of the hand |
Saturday Night Palsy:
Radial Nerve Lesion in the Spiral Groove |
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A 63-year-old right-handed Asian man is brought to the emergency room by family members. He had awakened in the morning complaining of vertigo and nausea, and was noted to have slurred speech and was unable to walk.
On examination his vital signs are unremarkable. He is alert and oriented but his speech is dysarthric. The left pupil is constricted, and there is left ptosis. There is spontaneous nystagmus with the slow phases towards the left (right beating). There is decreased sensation to pinprick and touch on the left face, and the left palate does not elevate. There is normal muscle bulk tone and strength throughout. There is decreased sensation to pinprick and temperature on the right. There is dysmetria on finger-to-nose and heel-to-shin on the left. The reflexes are unremarkable. |
Wallenberg's Syndrome
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what disease has the following sx?
– Ipsilateral • Lateropulsion • Ataxia • Loss of pain & temperature sensation in the face • Paralysis of soft palate, posterior pharynx and vocal cord • Horner's syndrome – Contralateral • Loss of pain & temperature sensation in the body |
Wallenberg's Syndrome
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On examination of the vital signs are unremarkable. She
is unable to adduct the eyes on lateral gaze bilaterally. Fundoscopic examination shows a swollen right optic nerve head with blurred disk margins. Visual acuity is 20/400 in the right eye and 20/20 in the left eye. The remainder cranial nerves are unremarkable. The motor examination shows normal bulk and power throughout with increased tone in the left lower extremity. Sensation and coordination are intact, and the gait is unremarkable. The tendon reflexes are hyperactive throughout, brisker on the left. Superficial abdominal reflexes are absent, and the patient feels "electric shock" sensations down her spine with neck flexion. Her CSF shows lymphocytic pleocytosis, oligoclonal bands, elevated myelin basic protein, and negative Lyme titer. Visual evoked responses, auditory evoked responses, and somatosensory evoked responses are all abnormal. MRI of the brain shows multiple periventricular white matter lesions which are bright on T-2 weighted images. |
MS
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The patient is a 50-year-old, right-handed, married, white male who works as a professional photographer. He first came to medical attention in 2000 when
his wife complained that he had some short-term memory problems. He reported that he had not noticed any ifficulties, but agreed with specific instances she pointed out when he had forgotten to order supplies and had forgotten scheduled appointments. His wife had noted no other difficulties, and he had no complaints. He is a high school graduate, and had been successfully running his own photography business for approximately 18 years. There was no history of serious head injury, CNS infection, alcohol or drug use. Initial evaluation by his primary care physician included normal laboratory values without evidence of renal or hepatic dysfunction, a normal TSH, and an unremarkable CT scan of the head. |
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A 21-year-old woman presents with a history of
intermittent, severe headaches for the last three years. She gets headaches approximately six times per year. The headaches begin with jagged flashing lights seen in the right visual field which continue for 15 to 20 minutes. Approximately 10 minutes after that a unilateral left temporal throbbing pain begins. The pain increases in severity and lasts for five to ten hours. Occasionally the headaches are associated with nausea and vomiting. In addition, the patient cannot bear light, movement or noise during the headaches. She has a family history of migraine. Vital signs are unremarkable. Neurologic exam is unremarkable. |
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A 26-year-old right-handed white man complains of
having "terrible headaches" for the past five years. The headaches usually occur at night and generally start with a burning in the right eye that, within minutes, involves the right orbit and right temple. The pain feels like an "hot poker" behind the right eye, and then the right eye starts tearing and the right nostril begins to run. The pain lasts for 45 minutes. The patient generally has three to four attacks with a 24-hour period for two months every year. He states that the symptoms usually occur after consumption of alcohol. Vital signs are unremarkable. Neurologic exam is unremarkable. During an acute episodes there is lacrimation from the right eye with ptosis, miosis and anhidrosis in the right eye. |
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A 62-year-old woman complains of recurrent episodes
of headache that she has experienced since the age of 40. The headaches consist of a squeezing pain and bilaterally in the frontal area. The headaches initially occur twice monthly and were relieved by Tylenol. For the last two years the headaches have occurred three to four times a week with accompanying nausea. She has not had photophobia or phonophobia. The vital signs are unremarkable. The neurologic exam is unremarkable. |
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A 74-year-old African-American man with a history of hypertension comes to the emergency room complaining of weakness in his right hand and slurred speech. He states he was well until he woke up
this morning with the symptoms. On examination vital signs are unremarkable. He is awake and his speech his mildly dysarthric but fluent and appropriate. There is mild weakness in the lower half of the right side of his face. The remainder of cranial nerves are all intact. He has normal muscle bulk and tone. Strength is 4/5 in the right arm and hand, with greater weakness in the extensors than the flexors and marked clumsiness in fine finger movements. The strength is 5/5 everywhere else. Sensation is intact throughout to all modalities. Coordination and gait are intact except as affected by weakness. Tendon reflexes are 2+ throughout and there is no Babinski's sign. |
?
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Lost vision in the left
visual field of both eyes |
Homonymous hemianopia
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|
Can see a little further
to the left in his central vision |
Macular sparing
|
|
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A 46-year-old right-handed Hispanic man fell from a ladder and was brought to the hospital unconscious. A large subdural hematoma was drained from the right side. On awakening from surgery, he has left sided weakness which gradually improves, but
he states that he cannot see out of his left eye. You examine his visual fields and discover that he has lost vision in the left visual field of both eyes, although he can see a little further to the left in his central vision. |
?
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A 17-year-old African-American male who was stabbed in the back
presents with inability to use his left leg. The stab wound occurred at the level of L1 just to the left of the spinous process. Since the injury he has been unable to move his left leg and he also complains of tingling in the distal left leg. On examination is vital signs are normal, and his mental status and cranial nerves are unremarkable. He has 5/5 strength with normal tone in both upper extremities and the right lower extremity. He has 0/5 strength in the left lower extremity with increased tone. There is diminished proprioception and vibration sense in the left lower extremity and loss of pain and temperature sense in the right lower extremity. Tendon reflexes are 3+ at the patella and Achille’s tendon on the left and 2+ elsewhere. The Babinski's sign is present on the left. |
Brown-Sequard Syndrome
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disease?
• 0/5 strength in the left lower extremity with increased tone • Diminished proprioception and vibration sense in the left lower extremity • Loss of pain and temperature sense in the right lower extremity • Tendon reflexes are 3+ in the left lower extremity with Babinski's sign |
Brown-Sequard Syndrome
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A 37-year-old right-handed Caucasian man with a history of seizures comes to clinic and reports that he awakened to find himself slumped in a kitchen chair two weeks ago. He last remembered sitting down at the kitchen table after dinner, and when he awakened the experienced the grogginess and dull
headache he typically experiences after a seizure. Assuming he had had a seizure, he went to bed. He complains that since then he has had a "floppy" wrist and numbness in his hand. Examination of the right upper extremity shows a right wrist drop with a weakness of all the wrist and finger extensors. Fasciculations were seen over the dorsal surface of the forearm, and there was loss of sensation over the lateral dorsum of the hand. The rest of the examination is unremarkable. |
Saturday Night Palsy:
Radial Nerve Lesion in the Spiral Groove |
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|
• Weakness of all the wrist and finger extensors
• Fasciculations were seen over the dorsal surface of the forearm • Loss of sensation over the lateral dorsum of the hand |
Saturday Night Palsy:
Radial Nerve Lesion in the Spiral Groove |
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|
A 63-year-old right-handed Asian man is brought to the emergency room by family members. He had awakened in the morning complaining of vertigo and nausea, and was noted to have slurred speech and was unable to walk.
On examination his vital signs are unremarkable. He is alert and oriented but his speech is dysarthric. The left pupil is constricted, and there is left ptosis. There is spontaneous nystagmus with the slow phases towards the left (right beating). There is decreased sensation to pinprick and touch on the left face, and the left palate does not elevate. There is normal muscle bulk tone and strength throughout. There is decreased sensation to pinprick and temperature on the right. There is dysmetria on finger-to-nose and heel-to-shin on the left. The reflexes are unremarkable. |
Wallenberg's Syndrome
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|
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what disease has the following sx?
– Ipsilateral • Lateropulsion • Ataxia • Loss of pain & temperature sensation in the face • Paralysis of soft palate, posterior pharynx and vocal cord • Horner's syndrome – Contralateral • Loss of pain & temperature sensation in the body |
Wallenberg's Syndrome
|
|
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On examination of the vital signs are unremarkable. She
is unable to adduct the eyes on lateral gaze bilaterally. Fundoscopic examination shows a swollen right optic nerve head with blurred disk margins. Visual acuity is 20/400 in the right eye and 20/20 in the left eye. The remainder cranial nerves are unremarkable. The motor examination shows normal bulk and power throughout with increased tone in the left lower extremity. Sensation and coordination are intact, and the gait is unremarkable. The tendon reflexes are hyperactive throughout, brisker on the left. Superficial abdominal reflexes are absent, and the patient feels "electric shock" sensations down her spine with neck flexion. Her CSF shows lymphocytic pleocytosis, oligoclonal bands, elevated myelin basic protein, and negative Lyme titer. Visual evoked responses, auditory evoked responses, and somatosensory evoked responses are all abnormal. MRI of the brain shows multiple periventricular white matter lesions which are bright on T-2 weighted images. |
MS
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The patient is a 50-year-old, right-handed, married, white male who works as a professional photographer. He first came to medical attention in 2000 when
his wife complained that he had some short-term memory problems. He reported that he had not noticed any ifficulties, but agreed with specific instances she pointed out when he had forgotten to order supplies and had forgotten scheduled appointments. His wife had noted no other difficulties, and he had no complaints. He is a high school graduate, and had been successfully running his own photography business for approximately 18 years. There was no history of serious head injury, CNS infection, alcohol or drug use. Initial evaluation by his primary care physician included normal laboratory values without evidence of renal or hepatic dysfunction, a normal TSH, and an unremarkable CT scan of the head. |
?
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A 21-year-old woman presents with a history of
intermittent, severe headaches for the last three years. She gets headaches approximately six times per year. The headaches begin with jagged flashing lights seen in the right visual field which continue for 15 to 20 minutes. Approximately 10 minutes after that a unilateral left temporal throbbing pain begins. The pain increases in severity and lasts for five to ten hours. Occasionally the headaches are associated with nausea and vomiting. In addition, the patient cannot bear light, movement or noise during the headaches. She has a family history of migraine. Vital signs are unremarkable. Neurologic exam is unremarkable. |
?
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A 26-year-old right-handed white man complains of
having "terrible headaches" for the past five years. The headaches usually occur at night and generally start with a burning in the right eye that, within minutes, involves the right orbit and right temple. The pain feels like an "hot poker" behind the right eye, and then the right eye starts tearing and the right nostril begins to run. The pain lasts for 45 minutes. The patient generally has three to four attacks with a 24-hour period for two months every year. He states that the symptoms usually occur after consumption of alcohol. Vital signs are unremarkable. Neurologic exam is unremarkable. During an acute episodes there is lacrimation from the right eye with ptosis, miosis and anhidrosis in the right eye. |
?
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A 62-year-old woman complains of recurrent episodes
of headache that she has experienced since the age of 40. The headaches consist of a squeezing pain and bilaterally in the frontal area. The headaches initially occur twice monthly and were relieved by Tylenol. For the last two years the headaches have occurred three to four times a week with accompanying nausea. She has not had photophobia or phonophobia. The vital signs are unremarkable. The neurologic exam is unremarkable. |
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An 18-year-old woman complains a headache,
vomiting, and blurred vision for the past two to three weeks. She experiences a headache with a "pressurelike" feeling in the parietal region bilaterally. She also experiences intermittent brief loss of vision while bending. She denies any associated photophobia or phonophobia. Vital signs are unremarkable. On examination and she is obese and has bilateral papilledema. Neurologic exam is otherwise unremarkable. CT scan of the brain shows small slit like ventricles with no mass, hemorrhage or midline shift. Lumbar puncture shows an opening pressure of 34 cm of water. There are no white or red cells and there is normal protein and glucose. |
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A 53-year-old right-handed man complains of episodes
of severe, sharp pain in the right cheek for the last three months. The pain most often occurs when he is shaving or when he is eating, and lasts for only a minute. The pain occurs every day. Vital signs are unremarkable. Light touch on the right cheek elicits his pain, but the remainder of the neurologic exam is unremarkable. |
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A 69-year-old right-handed man presents with severe,
intermittent right temporal headache of two months duration. He has had blurred vision in the right eye for the last two days. The headache is neither relieved or aggravated by changes in position or by activity. There has been no associated nausea, vomiting, photophobia, or phonophobia. He has lost 10 pounds over the last two months and notes that he has had pain in the right jaw when chewing. He reports that Tylenol will temporarily relieve the headache, but it always returns. Vital signs are unremarkable except for a temperature of 38 o C. On physical exam there is normal visual acuity with swelling of the right optic disk, and there is tenderness in the area of the right temporal artery. ESR is elevated. |
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