Question 1

Spina bifida is a disorder that is associated with a headache syndrome caused by:

Accepted Answer

Chiari malformation is often associated with spina bifida and can lead to a headache syndrome due to the structural abnormalities at the base of the skull and upper spinal area.

Question 2

A 44-year-old male presents to the emergency room with the "worst headache of my life." He is holding his head and appears severely distressed. This is a patient symptom that should prompt a clinician to look for signs of a:

Accepted Answer

The description of the "worst headache of my life" is a classic presentation for a subarachnoid hemorrhage, which is a medical emergency. This type of headache is often described as sudden in onset and extremely severe, warranting immediate investigation.

Question 3

When carrying out a mental status examination on a non-English speaking patient, it is important to have a(n):

Accepted Answer

Having an objective interpreter, ideally a professional one, ensures that the interpretation is accurate and unbiased, which is crucial for a mental status examination. Family members or friends might unintentionally misinterpret or alter the patient's responses due to their personal relationship or lack of professional interpreting skills.

Question 4

A 77-year-old male is brought into the emergency department accompanied by his daughter. She reports that her father has been complaining of right-handed weakness for 2 to 3 hours and that she has noticed him slurring his speech. On physical examination, the right hand grip strength is 1/5 compared to the left hand grip of 5/5. A facial droop is noted on the right side of the face. Cranial nerve dysfunction is noted in the right-sided cranial nerves VII, V, IX, X, XI, and XII. The clinician should request the following diagnostic test immediately:

Accepted Answer

The patient's symptoms of right-handed weakness, slurred speech, and cranial nerve dysfunction suggest an acute stroke, which is a medical emergency. A computed tomography (CT) scan of the head is the most appropriate initial diagnostic test to differentiate between an ischemic stroke and a hemorrhagic stroke, as it can quickly identify hemorrhages, which is crucial for determining the appropriate treatment plan. Magnetic resonance imaging (MRI) may be used later for further evaluation, but it is not the first choice in an acute setting due to longer acquisition times. Lumbar puncture and electrocardiogram are not indicated based on the presented symptoms and the need for immediate stroke identification.

Question 5

An 8-year-old child presents to the emergency room with a severe unilateral, throbbing headache. She is lying on the gurney with her eyes closed while holding her head. She denies ever having this kind of headache in the past. She complains of sensitivity to light and noise. An appropriate history question to ask the parent would be:

Accepted Answer

The child's symptoms are suggestive of a migraine headache, which can be influenced by family history and can sometimes be associated with systemic symptoms like fever. Asking about potential triggers is also relevant but less directly related to the immediate medical history needed for diagnosis.

Question 6

A female patient presents to the clinic with complaints of a severe, throbbing, unilateral headache. She complains of seeing flashes of light prior to the headache. She complains of sound and light sensitivity, as well as nausea. The clinician should recognize these as symptoms of:

Accepted Answer

The symptoms described by the patient, including severe, throbbing, unilateral headache, seeing flashes of light (aura) prior to the headache, sound and light sensitivity, and nausea, are classic for a migraine headache.

Question 7

On a history and physical examination of a 34-year-old patient, during the review of systems, he reports occasional episodes of headache. He describes the headache pain as a "band around my head" and tightness in the neck and shoulders. The clinician should recognize these symptoms as:

Accepted Answer

The description of the headache as a "band around my head" along with tightness in the neck and shoulders is characteristic of a tension headache. This type of headache is often described as a constant, dull ache on both sides of the head, which matches the patient's symptoms.

Question 8

A 43-year-old male presents to the emergency department in a stupor, accompanied by his wife. She called the ambulance because her husband was difficult to awaken this morning. She reports that for the last 3 days he has had a fever and an upper respiratory infection. Yesterday he had a headache. He has had no medical treatment. On physical examination, the patient demonstrates 103°F fever, sluggish pupil response, and nuchal rigidity. Which of the following should the clinician attempt to elicit next?

Accepted Answer

Given the patient's symptoms of fever, upper respiratory infection, headache, stupor, and nuchal rigidity, the clinician should suspect meningitis. Kernig's sign is a clinical sign that can help support the diagnosis of meningitis. It involves resistance or pain in the lower back or hamstring when the knee is extended after flexing the hip. This sign, along with the other symptoms, suggests inflammation of the meninges, warranting further investigation and management for meningitis.

Question 9

Your patient with a cervical herniated disc presents with a weakened biceps reflex. The biceps reflex is a test of the following spinal nerves:

Accepted Answer

The biceps reflex tests the integrity of the C5 to C6 spinal nerves.

Question 10

An 85-year-old female patient arrives by ambulance to the emergency department accompanied by her husband. He reports that his wife had been ill with pneumonia and, 2 days ago, went to the family physician who prescribed azithromycin twice a day. The husband reports that he is making sure she gets the medicine. His wife has been staying in bed and resting. She awoke from sleep last night and was extremely agitated, left the house, and was walking outside. She did not recognize her husband and wanted to call the police. Which of the following is an appropriate question for the history?

Accepted Answer

BAsking if the patient has dementia or frequent episodes of confusion (A) and if she has been running a fever (B) are appropriate questions. The patient's symptoms could be due to delirium, which can be caused by infections such as pneumonia or adverse reactions to medications. Fever can indicate an ongoing infection, and a history of dementia or confusion could suggest a predisposition to delirium or other cognitive impairments.

Question 11

Which of the following is a common trigger of migraine headache?

Accepted Answer

All of the above options are recognized triggers for migraine headaches. Missed meals can lead to low blood sugar, which can trigger migraines. Hormonal changes during menses are known to trigger migraines in some women, and alcohol, especially red wine, is a well-documented trigger for migraines in many individuals.

Question 12

In order to test abstract thought on the mental status examination, the clinician can ask the patient:

Accepted Answer

Abstract thought is the ability to think about things that are not present or concrete. The question "How is your brother-in-law related to you?" requires the patient to think about the relationship between two people who are not present and to understand the abstract concept of "brother-in-law."

Question 13

A 65-year-old woman is accompanied by her daughter for a physical examination. She has mild heart failure and takes digitalis and an ACE inhibitor. As you examine the patient, you note flat affect, hand tremor, and slowed movements. The tremor is worsened at rest. There are no neurological deficits. Hand grip, sensation of face and extremities, and lower extremity muscle strength are within normal limits and bilaterally equal. Deep tendon reflexes are equal bilaterally. Cranial nerves II to XII are intact. The mental status examination is normal. These are key signs of:

Accepted Answer

The symptoms described, such as flat affect, hand tremor, and slowed movements with the tremor worsening at rest, are classic signs of Parkinson's disease. These features align with the cardinal signs of Parkinsonism, which include tremor, bradykinesia (slowed movement), rigidity, and postural instability.

Question 14

When examining the carotid arteries, the clinician should:

Accepted Answer

All of the options provided are correct practices when examining the carotid arteries. Holding the breath minimizes respiratory sounds, using the bell of the stethoscope helps in detecting low-pitched sounds like bruits, and palpating one artery at a time prevents compromising blood flow to the brain.

Question 15

Ménière's disease presents with the following triad of symptoms:

Accepted Answer

Ménière's disease is characterized by a triad of symptoms: vertigo (a sensation of spinning), tinnitus (ringing in the ears), and hearing loss. This combination of symptoms distinguishes it from other conditions that may present with similar individual symptoms.

Question 16

A 41-year-old male patient presents to the emergency department complaining of severe headache pain. He describes it as a piercing, right-sided head pain that occurred earlier in the day for about 1 hour and now is recurring. You note lacrimation and rhinorrhea on the right side of the face. Which of the following types of headache is the patient describing?

Accepted Answer

The patient's symptoms of severe, unilateral headache pain accompanied by lacrimation and rhinorrhea are characteristic of a cluster headache. Cluster headaches are known for their extreme pain and autonomic symptoms such as tearing and nasal congestion on the side of the headache.

Question 17

An 81-year-old patient with heart failure comes into the emergency room accompanied by his daughter. The daughter reports that her father banged his head as he was getting out of the car 4 days ago. He did not complain of headache pain, so she did not obtain medical advice. She reports that she noticed a mild facial droop, slurring of speech, and gait disturbance in her father today. She reports that her father takes Coumadin, digoxin, and an ACE inhibitor. On physical examination, there is decreased right hand grip 2/5 strength and decreased right quadriceps strength 2/5 compared to the left side 5/5. Computed tomography scan shows an intracranial bleed. Which of the following is the most probable diagnosis?

Accepted Answer

The most probable diagnosis is a subdural hematoma, which is common in elderly patients, especially those on anticoagulation therapy like Coumadin. The symptoms developed gradually over days, which is typical for subdural hematomas, as they can slowly accumulate blood between the dura mater and the brain.

Question 18

A 60-year-old female complains of several episodes of dizziness and nausea that started this morning. She denies trauma, falling, or loss of consciousness. She has a 5-year history of hypertension and takes a beta blocker daily. On physical examination, there are no neurological deficits or any abnormal findings, and electrocardiogram is normal. Which of the following tests should be performed?

Accepted Answer

The patient's symptoms of dizziness and nausea without neurological deficits or abnormal findings suggest a possible benign paroxysmal positional vertigo (BPPV). The Hallpike maneuver (also known as the Dix-Hallpike test) is used to diagnose BPPV, making it the appropriate test in this scenario.

Question 19

Which of the following microorganisms is a common cause of meningitis?

Accepted Answer

Haemophilus influenzae is a common cause of bacterial meningitis, especially in children.

Question 20

A 56-year-old woman brings her 78-year-old father to the emergency room. The patient complains that sometimes he can't think straight. His daughter reports that her father has been tripping over his own feet and has become incontinent of urine in the last few days. The patient's medications include an ACE inhibitor and beta blocker. On physical examination, vital signs are within normal limits, heart and lungs show no abnormalities, cranial nerves are intact, and sensation and muscle strength are normal. A mental status examination is normal. Imbalanced gait and a positive Romberg test are apparent. Which of the following are possible disorders?

Accepted Answer

The patient's symptoms of difficulty thinking, gait imbalance, and urinary incontinence, along with a normal mental status examination and positive Romberg test, suggest normal pressure hydrocephalus (NPH) and could also be indicative of cerebellar dysfunction. Early dementia typically does not present with the acute onset of these specific symptoms, especially not with a normal mental status exam and the described physical findings.

Quiz 15: Neurological System