Absolute
Case-Based
Neurology Review An
Essential Q & A Study
Guide Test Bank A+
Neuroanatomy
1
Questions
• You are asked to consult on a woman with altered mental status and weakness. In the ER, she is found to
have hyponatremia to 112. Over the next 24 hours, her sodium level becomes 140. On examination, she
has normal vital signs. She is moaning and incoherent. Eye movements seem full. She has significant
quadri- paresis and does not move any extremity to painful stimuli. Her reflexes are increased. Which
of the following diagnostic studies would be most helpful in ascertaining the etiology of change in her
motor examination?
• Repeat BMP as her motor symptoms may be related to her sodium level dropping again to 112
• CT head without contrast stat to evaluate for new onset bilateral lobarhemorrhage
• MRI brain without contrast with attention to the brainstem to evaluate for demyelination in the
corticospinal tract
• Electrodiagnostic studies (electromyography (EMG) and nerve conduction studies) to assess for
critical illness polyneuropathy/myopathy
• A 33 year-old woman presents to your office with difficulty walking. She reports that 10 years ago, she
underwent a gastric bypass procedure (Roux en Y) and lost 150 pounds since that time. She has not
been compliant with post- operative visits with her bariatric surgeons. She reports that she is not
currently taking any medications. Her vital signs are stable. Her neurologic examination shows normal
strength except for mild weakness in distal bilateral lower extremities: dorsiflexion, plantar
flexion, toe flexion and toe extension. Reflexes are brisk in the upper extremities with crossed
adductors in the patella and absent at the ankles. Sensory examination shows reduced vibration and
proprioception up to the knees bilaterally. Her gait reveals reduced hip flexion
and knee flexion movements with some steppage. Which of the following find-ings might be seen on a
pathologic level to explain her symptoms?
, • Loss of myelin in the corticospinal and dorsal column tracts in the spinal cord
• Abnormality in the corticospinal tract and degeneration of the anterior horn cells
• Multifocal demyelinating plaques located throughout the brain and spinal cord affecting multiple
different long tracts
• Degeneration of the spinocerebellar tracts and dorsal column tracts in thespinal cord
• A 70 year-old man presents to your clinic with imbalance. This has been slowly progressive over at least
5–6 years, but he cannot really tell a date of onset. His social history reveals that he drinks about “a
fifth” of liquor per day since his 30s. He has been cutting down. On examination, he has normal cranial
nerves without nystagmus. Strength and reflexes are normal. Sensation shows some reduced pinprick
and temperature distal to the ankles. His finger to nose, rapid alternating movements and heel to shin are
normal. He has significant difficulty with tandem gait and can only perform 2 or 3 steps before lurching.
Which of the following alcohol related findings may explain his primary complaint of imbalance?
• Alcohol is directly toxic to the small nerve fibers
• Alcohol can lead to vitamin deficiencies that cause a sensory-motor polyneuropathy
• Alcohol can lead to degeneration in the cerebellum, particularly the cere-bellar lobes
• Alcohol can lead to degeneration in the cerebellum, particularly the cere-bellar vermis
• A 30 year-old woman presents for evaluation of headache for 3–4 months. She reports constant
progressive headache that have not responded to over the coun- ter ibuprofen or acetaminophen. She also
reports visual loss that occurs in her “peripheral vision”. She denies improvement with rest and
sometimes awakens in the middle of the night with her headache. Her neurologic examination shows
normal strength, reflexes, coordination and sensation. On visual field testing, you notice that she has
difficulty making out fingers in her bitemporal fields. Which of the following etiologies could explain
her symptoms?
• Intractable status migrainosus with scotoma
• Pituitary adenoma compressing on the optic chiasm
• Idiopathic intracranial hypertension (pseudotumor)
• Bilateral occipital lobe hemorrhage
• An 80 year-old woman with known cerebral amyloid angiopathy presents for a follow up visit. She
reports new onset of visual changes. Her neurologic exami- nation shows normal strength, sensation,
reflexes and coordination. However, visual field confrontational testing shows reduced detection of
finger move- ments in the patient’s left superior quadrant of both eyes (left homonymous superior
quandrantanopia). The examining physician orders an MRI and calls the radiologist to discuss her
concerns. She tells the radiologist to look for an abnormality (bleed) in which of the following areas?
• Right temporal lobe
• Right optic nerve
• Optic chiasm
• Right parietal lobe
• You receive a consult for a 45 year-old woman who was involved in a motor vehicle accident leading
to whiplash and left vertebral artery dissection. Brain imaging (MRI) has already been performed and
shows a classic, left, lateral medullary infarct secondary to her vascular injury. Which of the following
find-ings, if present on your examination, would NOT be explained by her Wallenberg’s syndrome?
• Left ptosis, miosis, anhidrosis
• Reduced sensation in the left face to pinprick and temperature
• Vertigo
, • Left tongue weakness leading to deviation of tongue to the left
• A 48 year-old man is admitted for acute myocardial infarction and undergoes cardiac catheterization
(through right femoral artery) and stenting. The follow- ing day, he reports acute onset of severe
weakness, numbness and pain in his right lower extremity. Examination shows weakness in right hip
flexion, knee extension and adduction with reduced sensation in the right medial thigh and medial calf.
His reflexes are normal except for absent right patella reflex. Which of the following would be the
next diagnostic step?
• Electromyography and nerve conduction studies
• Magnetic Resonance Imaging (MRI) of the lumbar spine with and without contrast
• Computed Tomography (CT) abdomen and pelvis without contrast
• Lumbar puncture
• A 56 year-old diabetic man presents with recent good diabetic control. He reports recent unintentional
weight loss of 30 pounds in the last few months. However, he also reports severe pain, weakness and
numbness in his left lower extremity. He denies back pain or any recent trauma. His examination shows
weakness and atrophy of his left quadriceps with significant weakness in hip
flexion, knee extension, and milder weakness in dorsiflexion and gastrocnemius. His examination shows a
stocking-glove distribution sensory loss but with loss of sensation in the anterior medial thigh on the
left as well. Ankle jerks are absent bilaterally, present in the right patella and absent in the left patella.
Whichof the following is the likely localization of his new symptoms?
• Diabetic, symmetric, sensorimotor, polyneuropathy
• Left lumbosacral root lesion, acutely at S1
• Motor neuron disease, such as ALS
• Left lumbosacral radiculoplexus neuropathy
• A 38 year-old woman presents to the emergency room with acute onset of dou- ble vision and left facial
weakness. Her initial blood pressure is 176/115 and pulse is 80. She has limited abduction of the left
eye on left lateral gaze and weakness in eye closure and facial droop on the left. You also notice that
her right arm and leg drift down after 8 seconds of antigravity movement. Which of the following is the
most likely neuroanatomic site for her symptoms?
• Left lateral medulla
• Left ventral pons
• Left medial midbrain
• This is likely a functional disorder as her symptoms cannot be explained bya single neuroanatomic
site.
• A 14 year-old ice skater, fell on her buttocks during a practice free skate. She presents to your clinic
with right face, arm and leg weakness, numbness and pain. Her examination shows reduced sensation
on the right face in V1, V2 and V3 regions which stops and becomes normal at the nasal ridge line. For
her right arm and leg numbness, the sensation becomes normal at the umbilicus line. On her
examination, she does not lift up her right leg at all and when you place your hand under her left ankle,
she does not exert much pressure when trying to lift up the right leg. Despite manual strength testing,
you encourage her to walk. She is able to stand by herself and lurches to both the right and left without
falling. She will occasionally buckle one leg or the other. Her reflexes are normal. Which of the
following is the next best step for this patient?
• MRI brain with and without contrast
• Electromyography and nerve conduction studies
, • MRI lumbosacral spine without contrast
• Referral to psychology for therapy
• A 25 year-old woman with relapsing remitting multiple sclerosis presents to the ER with 10 days of
diplopia. On your examination, you note normal and equally reactive to pupils. Fundoscopic examination
is normal. On left lateral gaze, you note that the patient’s left eye reveals nystagmus and the right eye
does not completely adduct. Upward gaze, right lateral gaze and downward gaze are
normal. Which of the following would be the most likely concerning site for anew MS relapse in this
patient?
• Left occipital cortex
• Left medial longitudinal fasciculus
• Right medial longitudinal fasciculus
• Left cranial nerve V1 nucleus
• A 57 year-old man with 20 pack year tobacco use, hyperlipidemia, hyperten- sion and prior right
middle cerebral artery stroke presents with new onset sei- zures. His wife reports that seizures start
with gaze to the left, followed by version of the neck and body to the left, loss of awareness and
generalized tonic-clonic activity. These have occurred on at least 3 occasions since his stroke 1 year
ago. All events are similar. Which of the following areas is the most likely site of onset of the clinical
seizures?
• Right occipital lobe
• Right lateral geniculate nucleus
• Right frontal eye field
• Right supplementary motor area
• A 40 year-old woman with Ehler’s Danlos syndrome presents with a severe, acute headache on the left.
On your examination, you notice that the patient’s right pupil is 3 mm and reactive and left pupil is 1
mm and pinpoint. She also has ptosis on the left eyelid. Her sweating on both sides of the face seem
nor- mal. Otherwise, her cranial nerve examination, sensory examination, reflexes, cerebellar
examination and strength are normal. Which of the following would be the next best diagnostic step for
this patient?
• MRI of the brain with special attention to the cavernous sinus
• CT angiogram of the neck
• CT of the chest
• Cocaine test in the eyes
• A 22 year-old man was in his usual state of health until this morning. He noticed upon awakening that he
had difficulty closing his right eyelid and moving his right mouth. He also noticed that his breakfast
did not taste right. He went to school, but his teacher advised that he go to the emergency room when
he saw him. On examination, he had weakness of orbicularis oris and orbicularis oculi with reduced taste
sensation. You do not note any other cranial nerve, sensory, strength or reflex abnormalities. What is
the next best step?
• Oral valacyclovir 14 day course
• Oral steroids, high dose course
• MRI brain with and without contrast
• Electromyography and nerve conduction study of the right facial nerve
Case-Based
Neurology Review An
Essential Q & A Study
Guide Test Bank A+
Neuroanatomy
1
Questions
• You are asked to consult on a woman with altered mental status and weakness. In the ER, she is found to
have hyponatremia to 112. Over the next 24 hours, her sodium level becomes 140. On examination, she
has normal vital signs. She is moaning and incoherent. Eye movements seem full. She has significant
quadri- paresis and does not move any extremity to painful stimuli. Her reflexes are increased. Which
of the following diagnostic studies would be most helpful in ascertaining the etiology of change in her
motor examination?
• Repeat BMP as her motor symptoms may be related to her sodium level dropping again to 112
• CT head without contrast stat to evaluate for new onset bilateral lobarhemorrhage
• MRI brain without contrast with attention to the brainstem to evaluate for demyelination in the
corticospinal tract
• Electrodiagnostic studies (electromyography (EMG) and nerve conduction studies) to assess for
critical illness polyneuropathy/myopathy
• A 33 year-old woman presents to your office with difficulty walking. She reports that 10 years ago, she
underwent a gastric bypass procedure (Roux en Y) and lost 150 pounds since that time. She has not
been compliant with post- operative visits with her bariatric surgeons. She reports that she is not
currently taking any medications. Her vital signs are stable. Her neurologic examination shows normal
strength except for mild weakness in distal bilateral lower extremities: dorsiflexion, plantar
flexion, toe flexion and toe extension. Reflexes are brisk in the upper extremities with crossed
adductors in the patella and absent at the ankles. Sensory examination shows reduced vibration and
proprioception up to the knees bilaterally. Her gait reveals reduced hip flexion
and knee flexion movements with some steppage. Which of the following find-ings might be seen on a
pathologic level to explain her symptoms?
, • Loss of myelin in the corticospinal and dorsal column tracts in the spinal cord
• Abnormality in the corticospinal tract and degeneration of the anterior horn cells
• Multifocal demyelinating plaques located throughout the brain and spinal cord affecting multiple
different long tracts
• Degeneration of the spinocerebellar tracts and dorsal column tracts in thespinal cord
• A 70 year-old man presents to your clinic with imbalance. This has been slowly progressive over at least
5–6 years, but he cannot really tell a date of onset. His social history reveals that he drinks about “a
fifth” of liquor per day since his 30s. He has been cutting down. On examination, he has normal cranial
nerves without nystagmus. Strength and reflexes are normal. Sensation shows some reduced pinprick
and temperature distal to the ankles. His finger to nose, rapid alternating movements and heel to shin are
normal. He has significant difficulty with tandem gait and can only perform 2 or 3 steps before lurching.
Which of the following alcohol related findings may explain his primary complaint of imbalance?
• Alcohol is directly toxic to the small nerve fibers
• Alcohol can lead to vitamin deficiencies that cause a sensory-motor polyneuropathy
• Alcohol can lead to degeneration in the cerebellum, particularly the cere-bellar lobes
• Alcohol can lead to degeneration in the cerebellum, particularly the cere-bellar vermis
• A 30 year-old woman presents for evaluation of headache for 3–4 months. She reports constant
progressive headache that have not responded to over the coun- ter ibuprofen or acetaminophen. She also
reports visual loss that occurs in her “peripheral vision”. She denies improvement with rest and
sometimes awakens in the middle of the night with her headache. Her neurologic examination shows
normal strength, reflexes, coordination and sensation. On visual field testing, you notice that she has
difficulty making out fingers in her bitemporal fields. Which of the following etiologies could explain
her symptoms?
• Intractable status migrainosus with scotoma
• Pituitary adenoma compressing on the optic chiasm
• Idiopathic intracranial hypertension (pseudotumor)
• Bilateral occipital lobe hemorrhage
• An 80 year-old woman with known cerebral amyloid angiopathy presents for a follow up visit. She
reports new onset of visual changes. Her neurologic exami- nation shows normal strength, sensation,
reflexes and coordination. However, visual field confrontational testing shows reduced detection of
finger move- ments in the patient’s left superior quadrant of both eyes (left homonymous superior
quandrantanopia). The examining physician orders an MRI and calls the radiologist to discuss her
concerns. She tells the radiologist to look for an abnormality (bleed) in which of the following areas?
• Right temporal lobe
• Right optic nerve
• Optic chiasm
• Right parietal lobe
• You receive a consult for a 45 year-old woman who was involved in a motor vehicle accident leading
to whiplash and left vertebral artery dissection. Brain imaging (MRI) has already been performed and
shows a classic, left, lateral medullary infarct secondary to her vascular injury. Which of the following
find-ings, if present on your examination, would NOT be explained by her Wallenberg’s syndrome?
• Left ptosis, miosis, anhidrosis
• Reduced sensation in the left face to pinprick and temperature
• Vertigo
, • Left tongue weakness leading to deviation of tongue to the left
• A 48 year-old man is admitted for acute myocardial infarction and undergoes cardiac catheterization
(through right femoral artery) and stenting. The follow- ing day, he reports acute onset of severe
weakness, numbness and pain in his right lower extremity. Examination shows weakness in right hip
flexion, knee extension and adduction with reduced sensation in the right medial thigh and medial calf.
His reflexes are normal except for absent right patella reflex. Which of the following would be the
next diagnostic step?
• Electromyography and nerve conduction studies
• Magnetic Resonance Imaging (MRI) of the lumbar spine with and without contrast
• Computed Tomography (CT) abdomen and pelvis without contrast
• Lumbar puncture
• A 56 year-old diabetic man presents with recent good diabetic control. He reports recent unintentional
weight loss of 30 pounds in the last few months. However, he also reports severe pain, weakness and
numbness in his left lower extremity. He denies back pain or any recent trauma. His examination shows
weakness and atrophy of his left quadriceps with significant weakness in hip
flexion, knee extension, and milder weakness in dorsiflexion and gastrocnemius. His examination shows a
stocking-glove distribution sensory loss but with loss of sensation in the anterior medial thigh on the
left as well. Ankle jerks are absent bilaterally, present in the right patella and absent in the left patella.
Whichof the following is the likely localization of his new symptoms?
• Diabetic, symmetric, sensorimotor, polyneuropathy
• Left lumbosacral root lesion, acutely at S1
• Motor neuron disease, such as ALS
• Left lumbosacral radiculoplexus neuropathy
• A 38 year-old woman presents to the emergency room with acute onset of dou- ble vision and left facial
weakness. Her initial blood pressure is 176/115 and pulse is 80. She has limited abduction of the left
eye on left lateral gaze and weakness in eye closure and facial droop on the left. You also notice that
her right arm and leg drift down after 8 seconds of antigravity movement. Which of the following is the
most likely neuroanatomic site for her symptoms?
• Left lateral medulla
• Left ventral pons
• Left medial midbrain
• This is likely a functional disorder as her symptoms cannot be explained bya single neuroanatomic
site.
• A 14 year-old ice skater, fell on her buttocks during a practice free skate. She presents to your clinic
with right face, arm and leg weakness, numbness and pain. Her examination shows reduced sensation
on the right face in V1, V2 and V3 regions which stops and becomes normal at the nasal ridge line. For
her right arm and leg numbness, the sensation becomes normal at the umbilicus line. On her
examination, she does not lift up her right leg at all and when you place your hand under her left ankle,
she does not exert much pressure when trying to lift up the right leg. Despite manual strength testing,
you encourage her to walk. She is able to stand by herself and lurches to both the right and left without
falling. She will occasionally buckle one leg or the other. Her reflexes are normal. Which of the
following is the next best step for this patient?
• MRI brain with and without contrast
• Electromyography and nerve conduction studies
, • MRI lumbosacral spine without contrast
• Referral to psychology for therapy
• A 25 year-old woman with relapsing remitting multiple sclerosis presents to the ER with 10 days of
diplopia. On your examination, you note normal and equally reactive to pupils. Fundoscopic examination
is normal. On left lateral gaze, you note that the patient’s left eye reveals nystagmus and the right eye
does not completely adduct. Upward gaze, right lateral gaze and downward gaze are
normal. Which of the following would be the most likely concerning site for anew MS relapse in this
patient?
• Left occipital cortex
• Left medial longitudinal fasciculus
• Right medial longitudinal fasciculus
• Left cranial nerve V1 nucleus
• A 57 year-old man with 20 pack year tobacco use, hyperlipidemia, hyperten- sion and prior right
middle cerebral artery stroke presents with new onset sei- zures. His wife reports that seizures start
with gaze to the left, followed by version of the neck and body to the left, loss of awareness and
generalized tonic-clonic activity. These have occurred on at least 3 occasions since his stroke 1 year
ago. All events are similar. Which of the following areas is the most likely site of onset of the clinical
seizures?
• Right occipital lobe
• Right lateral geniculate nucleus
• Right frontal eye field
• Right supplementary motor area
• A 40 year-old woman with Ehler’s Danlos syndrome presents with a severe, acute headache on the left.
On your examination, you notice that the patient’s right pupil is 3 mm and reactive and left pupil is 1
mm and pinpoint. She also has ptosis on the left eyelid. Her sweating on both sides of the face seem
nor- mal. Otherwise, her cranial nerve examination, sensory examination, reflexes, cerebellar
examination and strength are normal. Which of the following would be the next best diagnostic step for
this patient?
• MRI of the brain with special attention to the cavernous sinus
• CT angiogram of the neck
• CT of the chest
• Cocaine test in the eyes
• A 22 year-old man was in his usual state of health until this morning. He noticed upon awakening that he
had difficulty closing his right eyelid and moving his right mouth. He also noticed that his breakfast
did not taste right. He went to school, but his teacher advised that he go to the emergency room when
he saw him. On examination, he had weakness of orbicularis oris and orbicularis oculi with reduced taste
sensation. You do not note any other cranial nerve, sensory, strength or reflex abnormalities. What is
the next best step?
• Oral valacyclovir 14 day course
• Oral steroids, high dose course
• MRI brain with and without contrast
• Electromyography and nerve conduction study of the right facial nerve
