A 15 yo boy is brought by his mother for weakness. The 9 mom states her son has always had trouble keeping with the other kids while they were playing. The boy notes that he has had more and more trouble climbing stairs.
No facial weakness is present. You note hypertrophied calf muscles. A 35 year old male presents for weakness. He states he 0 has weakness mainly in his neck, hands and feet. He also complains of muscle stiffness. On exam, you note frontal balding, temporal wasting and cataracts in his eyes. After you have him close his eyes tight, there is a considerable lag time to opening them. He has noticeable ankle dorsiflexor weakness on exam with a foot drop appearance.
Reflexes are normal. When you hit his thenar eminence with your reflex hammer, his thumb involuntarily abducts and then slowly relaxes. Serum CK is normal. EKG shows first-degree AV block. A 35 yo female complains of muscle weakness and aches 1 for the past month. She states she has had difficulty combing her hair and climbing stairs. She also endorses a 10 lb weight gain, feeling cold and constipation over the past month. On exam, the patient has weakness of her proximal muscles. In reflex testing, you notice the relaxation phase is prolonged.
Sensation is normal. Serum CK is 5X normal. A 68 yo M presents for follow up of muscle weakness. He 2 had initially presented with weakness and muscle twitching of his right arm that was gradually progressing over the past 3 months. He had also noticed a change in the timbre of his voice. Since that time, the patient had a normal LP and serum protein electrophoresis. His swallowing has worsened and he now has stiffness and weakness in his right more than left leg.
On exam today, he has atrophy of his right upper extremity. Fasciculations are noted in the extremities and tongue. Plantars are upgoing. A 30 yo female presents with sudden onset of pain and 3 blurry vision in her left eye. The pain is worse with eye movement. The patient denies ever having similar symptoms or any weakness, numbness, tingling in the past.
On exam, pupillary constriction is decreased when light is presented to the left pupil compared to the right. EOMI are intact but elicit pain. No periorbital swelling. IV steroids or supportive care. A 30 yo female presents with sudden onset of pain and 4 blurry vision in her left eye. The patient denies ever having similar symptoms in the past. Babinski is positive on the left. MRI - periventricular, corpus callosum, infratentorial lesions LP - oligoclonal bands. IV steroids for acute flare.
Maintenance therapy — INF-beta or glatiramer acetate. A 50 year old male presents with increased difficulty walking. He also reports gradually worsening numbness and tingling for the past 3 years. He states his symptoms are especially bad when taking a hot shower or after physical exertion. He denies visual changes or back pain. On exam, there is a mild relative afferent pupillary defect.
There is decreased strength in the lower extremities. Plantar response is upgoing. There is moderate deficit on finger to nose pointing and heel to shin testing. Primary progressive multiple sclerosis older patients. A 30 yo female presents with sudden onset of pain and blurry 6 vision in her left eye. Her right eye already has had some decreased vision as well. Strength and sensation are fully intact. MRI of the brain is normal.
MRI of the spine reveals a focal nonenhancing lesion from T9-L2. CSF is negative for oligoclonal bands. Serum is positive for antibodies against aquaporin IV steroids for the acute flare. Immunosuppressants or rituximab may be used.
A 30 year old female presents with fever, headache and 7 paralysis. She had been recovering from a viral illness when her fevers started to recur, she developed headache, neck stiffness and became progressively more sleepy and confused over the period of six hours.
She was noted to have a seizure on transport to the hospital. On exam, the patient is unable to move her upper or lower extremities. LP is performed and shows lymphocytic pleocytosis. A 20 year old male presents with fever, headache and neck 8 stiffness.
Labs show an elevated WBC and sodium of Hypertonic saline is started. LP is performed and patient has a neutrophilic pleocytosis with gram positive lancet shaped diplococci. He is started on ceftriaxone. The next day, the patient wakes up paralyzed, except for his eyes and eyelids. Stat labs are drawn and show an mildly improved WBC and sodium of Brain MRI - symmetric high signal in the basis pontis.
Stop sodium correction immediately! A 67 year old male with heavy smoking history reports the 9 development of midback pain for the past two weeks that is worsening in severity. The pain is relatively constant but worsens with movement and often awakens him at night. MRI with contrast to evaluate for compressive etiology. A 33 year old male IV drug abuser reports the development 0 of mid- back pain for the past two weeks that is worsening in severity.
The pain is relatively constant but worsens with movement. He reports a low-grade fever for the past few weeks as well. The patient just noticed weakness in his lower extremities this morning.
A 75 year old male reports the development of neck and 1 shoulder pain for the past few years that is worsening in severity. He also reports pain over his upper outer arms bilaterally. He has stiffness in his legs for over a year but more recently, the man has had trouble walking and some imbalance. On exam, the man has point tenderness at the neck, shooting pains down his arm with neck rotation, and some atrophy of his hand muscles.
Vibratory sensation is diminished in his feet. His legs are mildly weak, right greater than left. Toes are upgoing bilaterally. A 33 year old female reports the development of bilateral 2 lower extremity weakness and numbness over the past six hours. She also reports a painful band of skin involving the T7-T9 dermatomes. She has had flu-like symptoms for the past couple days. She is incontinent with absent rectal tone. MRI to rule out a compressive cause. A 70 year old patient undergoes repair of an abdominal 3 aortic aneurysm.
On exam, the patient cannot move his legs and has diminished light touch, pain, and temperature sensation up to T8. Vibration and proprioception are intact throughout.
A 25 year old female presents to the ED after burning her 4 hands in the kitchen at work. On exam, her hands reveal second degree burns. She has diminished pain and temperature sensation over her shoulders and upper extremities. Her grip strength and intrinsic hand muscles are weak. Lower extremity sensation and strength are intact.
A 16 year old male loses control of his car and slams into a 5 tree. The ED physician performs an exam and notes the patient has decreased vibration, proprioception, and 2-point discrimination on the right side below the nipples.
He has decreased pin prick and temperature sensation on the left side two levels below the nipples. He has trace movement of his right lower extremity. Right T4 Brown-Sequard Syndrome spinal cord hemitransection. Reflexes can absent despite an UMN lesion in the acute phase due to spinal shock.
An 80 year old female complains of chronic, progressive 6 lower back pain that radiates to her legs. She also complains of leg weakness and numbness in a saddle-like distribution between her thighs. She is incontinent of urine. A 65 year old male presents 10 months after gastric bypass 7 with complaints of weakness, confusion and numbness in his feet.
On exam, the patient has distally decreased proprioception and vibration sense. He has a broad-based gait and appears unsteady. He is able to stand on his own, but starts to fall when he closes his eyes. It is often relieved with rest but more reliably relieved by flexing at the waist. Ankle-Brachial Index is 0. Neurosurgical consultation for decompression. An 18 year old suffered a C5 complete traumatic spinal 9 cord injury one year ago.
In addition, the patient is sweating profusely and complains of an intense headache. Autonomic dysreflexia A response to a noxious stimulus below lesion level that will activate sympathetic tone. This can lead to life-threatening hypertension. A 35 year old female presents with complaints of difficulty 0 sleeping. A 50 year old obese male presents with excessive daytime 1 sleepiness. He will often doze off on the bus or while sitting at his desk at work.
He reports hours of sleep each night but wakes up twice to use the restroom. His wife complains that he has always been a snorer. He denies nighttime caffeine, trouble falling asleep, cataplexy, or hallucinations. On exam, he has hypertrophied tonsils. CBC reveals a hemoglobin of A 17 year old female presents with excessive daytime 2 sleepiness with frequent brief naps. She states she gets approximately hours of sleep with occasional awakenings.
She decided to see a doctor after awakening yesterday morning and not being able to move any of her limbs. Upon questioning, she has noticed a similar phenomenon of paralysis when she has been tickled in the past. A 23 year old college student complains of difficulty sleeping.
He states he has difficulty falling asleep until 3 or 4 am and then has difficulty arising in the morning, leading him to sleep until around 11 am.
He denies naps, snoring, episodic paralysis or abnormal leg movements. A 35 year old female presents with vertigo. She also complains of difficulty hearing out of her left ear. She is nauseated and has vomited twice. The vertigo is worse with head movement. On exam, her tympanic membrane is slightly erythematous on the left, she has nasal erythema, no meningismus. All other cranial nerves are intact.
There is some horizontal nystagmus to the right. MRI would rule out central cause. Supportive with antiemetics and hydration. She has been 5 suffering severe constant vertigo for the past six hours. She denies hearing loss.
Vertigo is worse with head movement. On exam, her tympanic membrane is normal on the left, no meningismus. Electronystagmogram shows caloric hypofunctioning. A 65 year old female presents with vertigo. She has had 6 retroauricular pain for the last couple days and has been suffering severe constant vertigo for the past six hours. On exam, you note vesicular lesions in the left ear canal and around the pinna. She has no meningismus. A 35 year old female presents with recurrent vertigo.
She 7 has been suffering severe constant vertigo for the past six hours. She also complains of difficulty hearing out of her left ear with a sense or aural fullness and tinnitus. She states she has had two similar episodes in the past. On exam, her tympanic membranes are clear. Audiogram - distinctive feature of low tone hearing loss.
A 35 year old female with history of migraine headaches 8 presents with recurrent vertigo. She has been suffering severe constant vertigo for the past six hours. Migraine prevention. A 55 yo male is being treated in the hospital for Klebsiella 9 pneumoniae with IV gentamicin. Four days into his hospital stay he complains of decreased hearing.
He denies nausea or vomiting. No nystagmus. Gait exam reveals a wide-based gait. Stop the offending drug. A 48 year old female presents with vertigo. She states she is 0 having frequent attacks of vertigo that last approximately 20 seconds and tend to occur at night when she rolls over in bed.
She denies hearing loss, nausea or vomiting. On exam, you have her sit with her head rotated 45 degrees and then lay her down with her neck slightly extended. This maneuver brings on the vertigo and you note rotatory nystagmus. A 65 yo male presents with gradually progressive unilateral 1 hearing loss on the right.
He also states he has a mild chronic headache and some ringing in his right ear. When prompted, he reveals a very mild disturbance in his balance. The Rinne test shows depreciation of air more than bone conduction on the right, and the Weber test is heard best in the left ear. Tympanic membranes appear normal.
Surgical removal vs. A 22 yo male presents with gradually progressive unilateral 2 hearing loss on the right.
Audiometry is performed and shows diminished hearing in both ears, right greater than left. An MRI with gadolinium enhancement shows bilateral enhancing lesions at the cerebellopontine angles. A 69 year old female with history of hypertension and 3 atrial fibrillation reports sudden onset diplopia and vertigo since yesterday.
She states the vertigo is mild and is not worse with head movement. She reports no hearing loss. She is not nauseated or vomiting. On exam, she is mildly dysarthric. She is unable to deviate her right eye laterally and reports diplopia on rightward gaze. Both vertical and horizontal nystagmus are noted. Palatal elevation is asymmetric. Her tympanic membranes are clear. A 65 yo male presents with difficulty hearing. His wife 4 states he has trouble hearing her, especially in public places like a shopping mall.
She states the problem has progressively gotten worse over the years. He reports no imbalance, headache or tinnitus.
Weber test shows no laterality. Rinne test shows air over bone conduction bilaterally. Audiometry shows bilateral sensorineural hearing loss in the high frequency range. An 11 year old boy presents with progressive imbalance, 5 headache and vomiting. The boy has had more difficulty walking for the past few weeks. His headaches are worse in the morning and have woken him from sleep. On exam, he has unilateral ataxia and a positive Romberg sign.
MRI shows an enhancing mass in the cerebellum with little surrounding edema. Pilocytic astrocytoma - low-grade astrocytoma typically occurs in the cerebellum. A 5 year old boy presents with progressive headache and 6 vomiting for the past 3 months of unclear etiology and recent onset of imbalance. Exam shows papilledema, ataxia and a positive Romberg.
MRI shows a large enhancing midline cerebellar mass with compression of the fourth ventricle. A 60 year old male presents for seizures. He has had two 7 secondarily generalized seizures in the past week. He also reports a three month history of diffuse, progressive headache. Exam shows papilledema and mild LE weakness with increased reflexes and upgoing toes on the right. MRI shows a mass with heterogenous contrast enhancement and surrounding vasogenic edema of the left side of the brain extending across the corpus callosum.
Biopsy shows focal necrosis with pseudopalisading of malignant nuclei and endothelial proliferation, resembling a glomerulus in structure. A 40 year old female presents with new onset seizures. MRI shows a well-defined calcified mass near in the right temporal lobe. A 35 year old with HIV reports right-sided progressive 9 hemiparesis for the past few months and complaints of progressive headache worse with lying down.
An 8 year old boy presents with growth delay. The boy had 0 been growing normally but has sharply fallen off the growth curve over the past year.
The parents state the boy has been eating normally. ROS reveals a chronic headache for the past six months. On exam, you note decreased peripheral vision.
Lab investigation shows low IGF-1 and Growth Hormone levels show negligible rise after insulin administration. A 65 year old female smoker presents with progressive R 1 sided weakness, headache and seizure.
She also complains of fatigue, weight loss and fevers for the past 2 months. An MRI shows multiple enhancing spherical lesions at the gray-white junction, one in the left frontal lobe, one in the left temporal lobe and one periventricular. Brain metastases with unknown primary Hematogenous seeding. An 8 year old female presents with painless slowly 2 progressive vision loss and proptosis of the right eye. She has optic atrophy on fundoscopic examination. She has inguinal and axillary freckling with multiple rubbery subcutaneous nodules presents on her back and extremities and also hyperpigmented macules on her trunk.
Her mother has similar nodules. Optic nerve glioma in Neurofibromatosis, type I Presents with gradually progressive vision loss, proptosis and possibly strabismus. A 65 year old male with Neurofibromatosis type II presents 3 with progressive weakness and numbness in her right leg over the past couple months. She also complains of a headache with nausea and vomiting. Exam shows hyperreflexia and spasticity on the right with an upgoing Babinski. MRI shows a large uniformly enhancing dural-based mass along the sagittal sinus compressing the temporal lobe.
A 2 year old male with mild mental retardation and 4 epilepsy presents for continued seizures despite treatment with levitiracetam. You perform an MRI, which shows subependymal nodules. At this point, you question the father, who reveals he also has seizures. You note he has numerous papules on his face concentrated around the bridge of his nose and medial cheeks.
Tuberous sclerosis - adenoma sebaceum facial angiofibromas. A 25 year old female presents with progressive 5 imbalance. She states she difficulty walking and tends to fall to the left. She has no other complaints. On fundoscopic exam, you note a dilated artery leading from the optic disc to a peripheral tumor with an engorged vein.
You note difficulty with finger-to- nose and heel-to-shin testing on the left. Her gait is ataxic. MRI reveals a well-defined hypervascular enhancing mass in the left cerebellum. A 1 yo male presents for management of seizures. The 6 child has had seizures since shortly after birth that are poorly controlled on carbamazepine.
On exam, the child has a maroon patch of skin in the V1 and V2 distribution on the right side of his face. CT scan shows calcifications in the right temporoparietal lobe. Seizures, MR, stroke-like episodes, glaucoma.
A 5 year old female presents for difficulty walking. The 7 parents state she has had an abnormal gait since starting to walk and the diagnosis of cerebral palsy had been considered. On exam, you note dilated conjunctival vessels against a white conjunctival background.
The patient has dysarthric speech. She walks with a broad-based unsteady gait. She is equally off balance with her eyes open or closed. Lab results show a low lymphocyte count and low IgA levels. An MRI shows cerebellar atrophy and a dilated fourth ventricle. On exam, you note leukocoria in the right eye. Fundoscopic exam reveals a white retinal mass. CT scan reveals a retinal-based intraocular mass with calcifications. A 24 year old female with presents headache, 9 amenorrhea and milky breast discharge for the past few months Exam reveals decreased peripheral vision.
Lab testing reveals elevated prolactin and calcium levels. PTH is high. A 12 year old female presents with chronic headache and 0 neck pain. The headache is worse with coughing. On exam you note papilledema and diminished pain and temperature sensation in the bilateral upper extremities. Back exam is normal. An MRI reveals no mass lesions, no meningeal enhancement, but the inferior portion of the cerebellar tonsils lie below the level of the foramen magnum.
A one month old male presents with progressive head 1 enlargement. The head circumference is greater than the 99th percentile. He has had poor feeding and vomiting for the past few days. On exam, you noted dysjunction of the sutures, a tense fontanelle, and dilated scalp veins.
A 15 year old male presents after having a generalized seizure 2 with LOC. This is his first seizure. Further history reveals he has had quick occasional bilateral arm jerks when he wakes up in the morning for the past two years. He retains consciousness during those jerking episodes.
A 7 year old male presents for management of seizures. The 3 boy has had two seizures, one was noted while he was sleeping at a sleep over. The other seizure occurred during wakefulness.
He retained consciousness during the episode. Interictal EEG reveals high voltage centrotemporal spikes. A 4 year old female with developmental delay presents for 4 management of seizures.
She has multiple types of seizures: generalized, atonic, and atypical absence seizures. EEG is notable for 2 Hz spike-and-wave discharges. The parents note that the child will suddenly flex his trunk, bringing his head toward his knees, and then slowly relax back over a few seconds.
This is then repeated times during his typical attacks. He typically has attacks per day. Interictal EEG shows chaotic disorganized rhythms with superimposed multifocal spikes, termed hypsarrhythmia. A 20 month old male presents for developmental delay.
The 6 boy was born prematurely at 30 weeks. The boy began to sit at 10 months and is unable to walk. MRI shows periventricular leukomalacia. Cerebral palsy Nonprogressive movement and postural disorder Spastic paresis most common.
A 30 year old female with history of bipolar disorder gives birth to a healthy male at 40 weeks gestation. The child is asymptomatic but a small tuft of hair is noted in the midline lumbosacral area. An x-ray reveals bony deficits at L5 and S1.
A 10 year old child presents for learning difficulty. He has 7 never done well in school and deficits are noted across all subject areas. On exam, you note he has a long narrow face with large ears and a prominent jaw. Testicular exam reveals macroorchidism. A 6 month old male of Ashkenazi Jewish ancestry presents for developmental delay. On exam you note a cherry red macula. No hepatosplenomegaly is present. A 6 month old male of Ashkenazi Jewish ancestry presents 8 for developmental delay.
Hepatosplenomegaly is present. A 5 year old female presents for developmental delay. The parents report a prominent speech delay with minimal use of words. The child had motor delays growing up and now has an ataxic gait. A 5 year old male presents for developmental delay. The 9 parents report a prominent speech delay with minimal use of words. The child had hypotonia at birth and now is generally uncoordinated. A 1 yo female presents with regression of developmental milestones.
She had been developing normally until approximately 10 months of age. You note hand- wringing and teeth grinding on exam. A 40 year old female gives birth to a male at 38 weeks 0 gestation. The child is noted to have brachycephaly, bilateral epicanthal folds, small ears, and a heart murmur. A 24 year old female gives birth to a female at 35 weeks 1 gestation.
The child is noted to have microcephaly, a smooth philthrum, a thin upper lip, and microophthalmia. A 2 year old male presents for evaluation of language delay.
The child has minimal use of words. On exam, the child avoids eye contact and does not exhibit a social smile. A 7 year old male presents for abnormal behavior.
She states he rarely engages conversation unless it is about trains. Step Up to Medicine- Neurology chapter- the bread and butter topics for neurology but by no High yield PDF that is a good last minute review.
UWorld medicine questions. Finseth Neurology Review — amazing! American Academy of Neurology, its affiliates, and the Publisher disclaim any liability to any party A H1N1 infection: European case series and review.
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