112. A 35-year-old woman works as a keyboard operator and must type for 6 hours per day. Over the course of a few months she has developed pain in her wrists (right worse than left), as well as some paresthesias into the lateral palmar aspect of her hands. There is no atrophy. Conservative treatment for her condition consists of which of the following?
a. Exploratory surgery
b. Wrist splints
c. Hydrocodone
d. Shoulder sling
e. Back brace
113. A 28-year-old police officer has been generally healthy except for mild, easily controlled hypertension. He sustains a gunshot wound to the upper arm. This type of trauma may cause partial damage to the median nerve that may leave the patient with which of the following?
a. Easily provoked pain in the hand
b. Weakness on wrist extension
c. Atrophy in the first dorsal interosseous muscle
d. Numbness over the fifth digit
e. Radial deviation of the hand
114. A 19-year-old man is involved in a street fight in which he is viciously attacked with a lead pipe. A particularly forceful blow hits his left elbow. Blunt trauma to the elbow may lead to the development of which of the following?
a. Wristdrop
b. Weakness of the abductor pollicis brevis
c. Clawhand or benediction sign (impaired extension of digits 4 and 5)
d. Ulnar deviation of the hand
e. Poor pronation of the forearm
115. A 21-year-old right-handed woman works at an airport as a luggage handler. She is usually on the tarmac working in an environment in which loud noises are routine. Ear protection must be worn to protect against loss of hearing and the development of which of the following?
a. Vertigo
b. Tinnitus
c. Ataxia
d. Diplopia
e. Oscillopsia
116. A young man fractures his humerus in an automobile accident. As the pain from the injury subsides, he notices weakness on attempted flexion at the elbow. He develops paresthesias over the radial and volar aspects of the forearm. During the accident, he probably injured which one of the following nerves?
a. Suprascapular nerve
b. Long thoracic nerve
c. Musculocutaneous nerve
d. Radial nerve
e. Median nerve
117. A 37-year-old alcoholic man awakes with clumsiness of his right hand. Neurologic examination reveals poor extension of the hand at the wrist. He most likely has injured which one of the following nerves?
a. Median nerve
b. Brachioradialis nerve
c. Musculocutaneous nerve
d. Radial nerve
e. Ulnar nerve
118. A 72-year-old man slipped and fell in the bathroom 1 week ago. He hit the right side of his head, but did not think it was necessary to seek medical attention. He finally goes to his doctor because his son thinks his balance is off. Computed tomography (CT) of the brain may fail to reveal a small subdural hematoma in this patient for which of the following reasons?
a. The lesion is subacute
b. The hematoma extends into the brain from the subdural space
c. The resolution of the CT machine is greater than 2 mm
d. The subdural hematoma is less than 4 hours old
e. The patient has extensive cerebral atrophy
119. A 16-year-old boy is struck on the side of the head by a bottle thrown by a friend involved in a prank. He appears dazed for about 30 seconds, 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 minutes 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 mm Hg. Although papilledema is not evident in his fundi, he has venous distention and absent pulsations of the retinal vasculature. Which of the following is the best explanation for this young man’s evolving clinical signs?
a. A seizure disorder
b. A cardiac conduction defect
c. Increased intracranial pressure
d. Sick sinus syndrome
e. Communicating hydrocephalus
120. A 52-year-old patient presents with headache and sudden onset of mania. Her head CT is shown below. Two hours later her blood pressure is 225/110 mm Hg, her heart rate is 40 beats per minute, and her consciousness is fluctuating. Which of the following is the best management over the next 4 hours for this patient?
a. Craniotomy
b. Antihypertensive medication
c. Transvenous pacemaker placement
d. Ventriculoperitoneal shunt
e. Antiepileptic medication
121. A 64-year-old woman slips and falls on an icy sidewalk. She hits the side of her head on the curb. After a momentary loss of consciousness she recovers, but is in some pain. Fifteen minutes later her level of consciousness begins to fluctuate and she is brought to the emergency room comatose. Magnetic resonance imaging (MRI) of the patient’s head within the first few hours of injury will most likely reveal which of the following?
a. A normal brain
b. Intracerebral hematoma
c. Temporal lobe contusion
d. Subarachnoid hemorrhage
e. Epidural hematoma
122. CT scanning of a patient’s head within 2 hours of a newly acquired epidural hematoma should reveal which of the following?
a. A normal brain
b. A lens-shaped density over the frontal lobe
c. Increased cerebrospinal fluid (CSF) density with a fluid-fluid level
d. Multifocal attenuation of cortical tissue
e. Bilateral sickle-shaped densities over the hemispheres
123. An elderly patient suffers from a relatively mild head trauma but then subsequently develops a progressive dementia over the course of several weeks. He is most likely to have sustained which of the following?
a. An acute subdural hematoma
b. An acute epidural hematoma
c. A chronic subdural hematoma
d. An intracerebral hematoma
e. An intracerebellar hematoma
124. A 42-year-old woman is involved in a head-on collision with a lamp-post at 50 mph. Her head hits the windshield. She is highly likely to have an intracranial hemorrhage in which one of the following structures?
a. Occipital lobe
b. Thalamus
c. Putamen
d. Parietal lobe
e. Temporal lobe
125. A 57-year-old woman is involved in a motor vehicle accident in which she strikes the windshield and is briefly unconscious. She makes a full recovery, except that 3 months later she notices that she cannot taste the food she is eating. This is most likely caused by which of the following?
a. Medullary infarction
b. Temporal lobe contusion
c. Sphenoid sinus hemorrhage
d. Phenytoin use to prevent seizures
e. Avulsion of olfactory rootlets
126. An 18-year-old boy is brought into the emergency room after diving into a shallow pool. He is awake and alert, has intact cranial nerves (CNs), and is able to move his shoulders, but he cannot move his arms or legs. He is flaccid and has a sensory level at C5. Appropriate management includes which of the following?
a. Naloxone hydrochloride
b. Intravenous methylprednisolone
c. Oral dexamethasone
d. Intubation and preparation for immediate surgery
e. Hyperbaric chamber therapy
127. A 53-year-old office worker presents to clinic stating, “My hands are numb.” Upon questioning she says that both of her hands have a sensation like “a shot at the dentist.” She also believes that her hands are weaker than they used to be. It fluctuates during the course of the day, but is worst at the end of the work day and during the early morning hours. The symptoms have been progressively worsening over the past 1-to-2 years. On examination the abductor pollicus brevis is weak bilaterally, and there is decreased sensation to pinprick over the anterior portions of digits 1-to-3. Which of the following will most likely be positive?
a. Tinel sign
b. Brudzinski sign
c. Kernig sign
d. Monrad-Krohn test
e. Babinski sign
112. The answer is b. (Ropper, pp 1314-1315.) Pressure on the volar aspect of the wrist may produce recurrent injuries to the carpal tunnel through which the median nerve runs. The injury characteristically produces pain and paresthesias in the hand over the distribution of the sensory component of the median nerve. This sensory distribution extends over the palmar surface of the thumb and first four digits, with the fourth digit supplied on one side by the median nerve and on the other side by the ulnar nerve. Median nerve injuries are consequently said to split the fourth digit on sensory examinations. With carpal tunnel compression of the median nerve, the sensory disturbance may be incapacitating. Subsequently, weakness and atrophy may develop in the muscles that are innervated by the median nerve. The abductor pollicis brevis may be severely involved late in the progression of the disorder. Treatment options for carpal tunnel syndrome include avoiding aggravating factors, splints, and surgical procedures. The role of surgery is not clearly defined, but many experts agree that progressive cases or those with motor involvement should often consider surgical nerve release.
113. The answer is a. (Ropper, pp 137-138.) Trauma to nerves in the extremities may give rise to causalgia, a disturbance in sensory perception characterized by hypesthesia, dysesthesia, and allodynia. Hypesthesia is a decrease in the accurate perception of stimuli. Dysesthesia is persistent discomfort, which in the situation described is likely to be an unremitting burning pain. Allodynia is the perception of pain with the application of nonpainful stimuli. Bullets and other high-velocity missiles need not hit the nerve to cause damage. Enough energy is transmitted as the missile passes through adjacent tissues to produce substantial damage to the nerve. Choices b through d involve motor or sensory findings due to either ulnar or radial nerve damage.
114. The answer is c. (Ropper, p 1315.) The ulnar nerve runs superficially at the elbow in the ulnar groove. It continues forward under the aponeurosis of the flexor carpi ulnaris in the cubital tunnel. Damage to the nerve at this site may produce weakness in the interosseous and ulnar lumbrical muscles of the hand. With lumbrical weakness, the extensor sheaths of the digits are not properly positioned, and a claw deformity with impaired extension of the ulnar two digits develops when the patient tries to straighten his or her fingers.
115. The answer is b. (Ropper, pp 282-283.) Acoustic trauma may produce severe tinnitus in persons who have relatively little hearing loss. Although the initial injury with acoustic trauma is sustained by the cochlear sensory cells, tinnitus may persist even after the acoustic nerve is cut. Tinnitus may take any one of several forms, ranging from a hissing sound to a high-pitched screaming noise.
116. The answer is c. (Ropper, p 1314.) The musculocutaneous nerve is often damaged with fractures of the humerus. This nerve supplies the biceps brachii, brachialis, and coracobrachialis muscles and carries sensory information from the lateral cutaneous nerve of the forearm. Flexion at the elbow with damage to this nerve is most impaired with the forearm supinated. The suprascapular and long thoracic are motor nerves. The radial nerve provides sensation to the dorsal-radial aspect of the forearm. The median nerve does not provide sensation to the forearm.
117. The answer is d. (Ropper, p 1314.) Radial nerve injuries are fairly common in alcoholic persons who may have lost consciousness in awkward positions. These are sometimes referred to as Saturday night palsies. The injury is usually a pressure palsy and produces a wristdrop. The nerve is injured as it courses near the spiral groove of the humerus.
118. The answer is a. (Osborn, pp I[2]:26-27.) Initially subdural blood will be denser than brain and thus readily apparent on CT scan. Within a few days of formation, the contents of a subdural hematoma are degraded into less dense fluid. This fluid is transiently similar in density to the cerebral cortex and may be difficult to distinguish by CT. Eventually it will be hypodense to brain. If the fluid collection is too small to produce substantial deformation of the underlying hemisphere, identification of the subdural collection may be difficult. Angiogram will reveal displacement of the cerebrocortical vessels, but more rapid and less invasive assessment of the patient is feasible with MRI.
119. The answer is c. (Ropper, p 858.) Something has abruptly caused increasing intracranial pressure in this young man after his head trauma. Consequently, he is at risk for herniation of the brain transfalcially (across the falx cerebri) or transtentorially (across the tentorium cerebelli). The head trauma produced an intracranial lesion, which is expanding very rapidly. The slowing of his pulse and increase in his blood pressure are due to the Cushing effect of a rapidly expanding intracranial mass. The history is typical for that of an epidural hematoma.
120. The answer is a. (Ropper, pp 805-808.) Without emergency surgery, the patient will die. Her blood pressure and pulse abnormalities will correct themselves when the intracranial mass is removed. Her loss of consciousness will not correct itself with antiepileptics. Shunt placement will not likely prevent brain herniation and may in fact accelerate it. The hematoma must be evacuated, and the bleeding giving rise to the hematoma must be stopped. Immediate treatment should include elevation of head and hyperventilation.
121. The answer is e. (Ropper, p 858.) The history is typical for an epidural hematoma. Damage to the middle meningeal artery allows blood at arterial pressures to dissect in the potential space that exists between the dura mater and the periosteum of the skull. With MRI, the epidural hematoma should be evident soon after the injury and will certainly be evident by the time the patient is symptomatic.
122. The answer is b. (Ropper, p 858.) The typical shape of an epidural hematoma is that of a biconvex mass that displaces normal brain tissue. Parts of the ventricular system may be dilated as obstructive hydrocephalus develops in parts of the system. Transfalcial herniation with displacement of frontal lobe tissue across the midline and under the falx cerebri is likely with an epidural hematoma on one side of the head. Although subdural hematomas are often bilateral, epidural hematomas are invariably unilateral.
123. The answer is c. (Ropper, p 835.) Chronic subdural hematoma is relatively common in the elderly and in patients receiving renal dialysis. The subdural fluid becomes isodense with the brain after several days or weeks and may be overlooked on CT scanning. MRI will identify the lesion, even if it is present bilaterally and produces no shift of brain structures from the midline.
124. The answer is e. (Ropper, pp 858-862.) The temporal lobes and inferior frontal lobes are frequently involved in traumatic brain injuries. The continued forward movement of the brain within the bony cranial vault, which has suddenly decelerated at impact, leads to these anterior brain structures striking the inside of the skull with great force, creating contusions in these areas. The rough surfaces of the cribriform plate and the middle cranial fossa also lead to injury in these locations. These injuries are referred to as the coup injuries because they reflect the direct blow to the brain. So-called contrecoup injury may also occur at the diametrically opposed region of the brain (generally, the occipital lobes) when there is rebound movement into the overlying skull there. Damage to the temporal lobe may produce symptoms and signs by virtue of compression of adjacent brain structures. As a hematoma expands, uncal herniation may crush the brainstem. Less progressive injuries may disturb memory or even language comprehension. Wernicke area, which is important in language comprehension, is sufficiently posterior on the temporal lobe to escape injury in most cases of frontal head trauma.
125. The answer is e. (Ropper, p 219.) Anosmia is one of the more common long-term cranial nerve deficits after head injury, though it is present in only 6% in one series. It is often associated with ageusia (loss of taste). It can be very disabling and discouraging to patients. Approximately one-third of patients recover. It is caused by avulsion of olfactory nerve rootlets due to acceleration–deceleration injury at the cribriform plate. Damage may be unilateral or bilateral.
126. The answer is b. (Ropper, pp 1187-1188.) High-dose intravenous methylprednisolone (Medrol) (30 mg/kg intravenous bolus followed by 5.4 mg/[kg-h] for 23 hours) has been shown to have a statistically significant, if clinically modest, benefit on the outcome after spinal cord injury when given within 8 hours of the injury. Naloxone hydrochloride and other agents, such as GM1 ganglioside, have not been shown to be of benefit. The role of surgical decompression, removal of hemorrhage, and correction of bone displacement is controversial. Hyperbaric chamber therapy may be useful for treatment of decompression illness (the bends).
127. The answer is a. (Biller, pp 394-396.) The patient presentation is typical for carpal tunnel syndrome. Tinel sign is the sensation of “tingling” radiating away from the percutaneous percussion of a peripheral nerve. For carpal tunnel syndrome Tinel sign of the median nerve at the wrist has ~60% sensitivity and ~67% specificity. Brudzinski and Kernig signs are indications of meningeal irritation. Monrad-Krohn test is used to confirm psychogenic upper extremity monoparesis. Babinski sign is an indication of upper motor neuron damage.