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Focused Neurological Evaluation

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Acute Neuro Care

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Abstract

An 18-year-old boy is struck on the side of the head by a ball during a cricket match. He appears dazed for about 30 s, but is lucid for several minutes before he abruptly becomes stuporous. His limbs on the side opposite the site of the blow are more flaccid than those on the same side as the injury. On arrival in the emergency room 25 min after the accident, he is unresponsive to painful stimuli. His pulse is 40 beats per minute, with an electrocardiography (ECG) revealing no arrhythmias. His blood pressure in both arms is 170/110 mmHg. You are called upon to assess the neurological status. How to proceed?

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Author information

Authors and Affiliations

  1. Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, India

    Ajay Prasad Hrishi & Manikandan Sethuraman

Authors
  1. Ajay Prasad Hrishi
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  2. Manikandan Sethuraman
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Editor information

Editors and Affiliations

  1. Division of Neuroanaesthesiology, Department of Anaesthesiology and critical care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

    Prasanna Udupi Bidkar

  2. Senior consultant and Head, Neuroanaesthesiology & Neurocritical care, MGM Healthcare Pvt Ltd, Chennai, Tamil Nadu, India

    Ponniah Vanamoorthy

Multiple Choice Questions

Multiple Choice Questions

  1. 1.

    A 60-year-old right-handed man has presented with gradually progressive hearing loss of the right ear. No h/o worsening balance or ringing in his ears and not associated with pain. A vibrating tuning fork is applied to the center of his forehead. The sound is louder in his left ear. This finding suggests which of the following?

    1. (a)

      Bilateral sensorineural hearing loss

    2. (b)

      Bilateral conductive hearing loss

    3. (c)

      Right ear conductive hearing loss

    4. (d)

      Left ear sensorineural hearing loss

    5. (e)

      Right ear sensorineural hearing loss

  2. 2.

    A 51-year-old woman is being evaluated for gait difficulties. On examination, it is found that her ability to walk along a straight line touching the heel of one foot to the toe of the other is impaired. This finding is most common with which of the following?

    1. (a)

      Cerebellar dysfunction

    2. (b)

      Parietal lobe damage

    3. (c)

      Temporal lobe damage

    4. (d)

      Ocular motor disturbances

    5. (e)

      Dysesthesias in the feet

  3. 3.

    A 32-year-old biker lower back pain radiating down the posterior aspect of his left leg and paresthesias in the lateral aspect of his left foot for the past 6 months. Motor power, bowel and bladder function is normal. Examination would be most likely to show which of the following?

    1. (a)

      Left Babinski sign

    2. (b)

      Loss of pinprick sensation over the web space between the first and second digits of the left foot

    3. (c)

      Hyperreflexia at the left knee jerk

    4. (d)

      Hyporeflexia in the left Achilles tendon reflex

    5. (e)

      Decreased rectal tone

  4. 4.

    A 22-year-old man sustained multiple injuries in an automobile accident. After orthopedic surgery, he is not awakening. If his brainstem function is intact, when he is lying supine with his head slightly elevated (30°) and one external auditory meatus is irrigated with warm water, which of the following would be expected?

    1. (a)

      Tonic deviation of the eyes toward the ear that is stimulated

    2. (b)

      Nystagmus in both eyes toward the ear that is stimulated

    3. (c)

      Tonic deviation of the ipsilateral eye toward the ear that is stimulated

    4. (d)

      Nystagmus in both eyes away from the ear that is stimulated

    5. (e)

      Tonic deviation of both eyes away from the ear that is stimulated

  5. 5.

    Following cardiac catheterization, a 60-year-old right-handed man acutely develops a loss of sensation involving the entire left side of his body (face, arm, and leg). Which of the following structures has most likely been damaged?

    1. (a)

      Internal capsule

    2. (b)

      Thalamus

    3. (c)

      Hippocampus

    4. (d)

      Globus pallidus

    5. (e)

      Pons

  6. 6.

    A 65-year-old diabetic man with h/o cerebellar stroke 5 years back says that he has now fully recovered. His medical records state that he presented with left-sided dysdiadochokinesia. Which of the following was most likely impaired?

    1. (a)

      Successive finger movements

    2. (b)

      Heel-to-toe walking

    3. (c)

      Rapid alternating movements

    4. (d)

      Tremor suppression

    5. (e)

      Conjugate eye movements

  7. 7.

    A 33-year-old woman has an acute onset of headache with blurring of vision. On examination, she has a right ptosis and anisocoria. This could be due to the insult to which of the following structures?

    1. (a)

      Optic tract

    2. (b)

      Optic chiasm

    3. (c)

      CN III

    4. (d)

      T1 nerve root

    5. (e)

      Superior cervical ganglion

  8. 8.

    A 35-year-old woman is being examined and the clinician notices the presence of fine twitching movements beneath the surface of the tongue and wasting of one side of the tongue. This finding suggests which of the following?

    1. (a)

      Pseudobulbar affect

    2. (b)

      Aberrant reinnervation of muscles from CN X

    3. (c)

      Denervation of muscles from CN X

    4. (d)

      Denervation of muscles from CN XII

  9. 9.

    An 85-year-old man is being evaluated for gait difficulties. He says that he frequently trips walking upstairs or on uneven surfaces. On examination, it is found that joint proprioception is absent in his toes. People with impaired position sense will usually fall if they simultaneously stand with their feet together and do which of the following?

    1. (a)

      Flex the neck

    2. (b)

      Extend their arms in front of them

    3. (c)

      Flex the knees

    4. (d)

      Turn the head

    5. (e)

      Close their eyes

  10. 10.

    A 60-year-old woman with diabetes awakens with weakness of the right side. On examination upper motor neuron pattern of weakness involving the face, arm, and leg of right side with no sensory abnormalities and language is preserved. A stroke associated with this presentation is most likely with damage to which of the following?

    1. (a)

      Internal capsule

    2. (b)

      Cerebellum

    3. (c)

      Putamen

    4. (d)

      Caudate

    5. (e)

      Amygdala

Answers: 1. (e), 2. (a), 3. (d), 4. (b), 5. (b), 6. (c), 7. (c), 8. (d), 9. (e), 10. (a).

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Hrishi, A.P., Sethuraman, M. (2020). Focused Neurological Evaluation. In: Bidkar, P., Vanamoorthy, P. (eds) Acute Neuro Care. Springer, Singapore. https://doi.org/10.1007/978-981-15-4071-4_3

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  • DOI: https://doi.org/10.1007/978-981-15-4071-4_3

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  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-15-4070-7

  • Online ISBN: 978-981-15-4071-4

  • eBook Packages: MedicineMedicine (R0)

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