Characteristic feature of Argyll Robertson pupil include all of the following EXCEPT:
E. Argyll Robertson pupil (ARP) is characteristically associated with neurosyphilis. It refers to bilaterally irregular and miotic pupils with variable iris atrophy. It is also characterized by light near dissociation in which light refl ex is absent but accommodation refl ex is intact. The site of the lesion causing ARP is the rostral midbrain. There are a number of conditions, including longstanding diabetes, that can cause light near dissociation. Normally, pupils dilate in darkness. In Flynn phenomenon, paradoxically, pupils constrict in darkness. This is seen in congenital achromatopsia, dominant optic atrophy, and in some cases with congenital nystagmus.
Reference:
Thunderclap headache is highly suggestive of which one of the following?
A. Thunderclap headaches are sudden onset, severe headaches radiating behind the occiput with some degree of associated neck stiffness. Very rarely a thunderclap variant of migraine may be seen. This needs to be differentiated from an intracranial bleed. Tension headache is suggested by generalized or bilateral, continuous, tight band-like pain which worsens as the day progresses. It is associated with stress and is often aggravated by eye movement. It is usually relieved by simple analgesics or antidepressants. Migraine is suggested by a typically unilateral, throbbing headache associated with vomiting, prodromal aura, and visual disturbances. Migraine is often precipitated by a set of well-known precipitating factors such as chocolates, menstruation, etc, which most patients will learn during the course of their illness. A cluster headache is suggested by episodic, typically nocturnal pain in one eye associated with congestion and lacrimation for weeks. This cyclically recurs every year at around the same time. Temporal arteritis is suggested by scalp tenderness, jaw claudication, loss of temporal arterial pulsation, sudden loss of vision, and a raised ESR. It is confirmed by temporal artery biopsy.
Waddling gait is characteristic of which of the following neurological diffi culties?
A. Waddling gait is seen with severe proximal muscle weakness. Weakness of gluteus medius results in an excessive drop of the hip bone towards the side opposite to the foot placement. Corticospinal tract lesions give rise to a spastic gait. This can be hemiparetic when the lesion is unilateral and paraparetic when the lesion is bilateral. Cerebellar lesions cause a complex gait disturbance according to the area affected. Unsteadiness on standing with eyes open is suggestive of cerebellar lesion. Cerebellar dysfunction leads to a broad-based, unsteady (drunken or ataxic) gait. Postural instability that becomes prominent on closure of eyes is indicative of proprioceptive sensory loss, referred to as sensory ataxia. In order to maintain a stable posture, at least two out of three sources of sensory information regarding one’s posture should be normal, that is visual input, vestibular input, and joint position sense. When joint position sense is lost due to posterior column lesion, closing one’s eyes will prevent the visual input from compensating for the deficit, leading to loss of balance. ‘Astasia abasia’ is a conversion disorder where the gait does not confirm to any known neurological deficits. Sometimes such a patient can walk normally but cannot stand and balance herself without support.
A 59-year-old man has a small, spastic tongue with significant difficulty in pronouncing consonants. On neurological examination, he has a brisk jaw jerk.
Which of the following is the most likely explanation for the above presentation?
B. Bilateral upper motor neurone lesions of the corticobulbar tract result in pseudobulbar or spastic dysarthria. This is characterized by a small, spastic tongue and diffi culty pronouncing consonants. It is associated with pathological laughing and crying. Bulbar palsy is the result of lower motor neurone lesions affecting the nuclei of cranial nerves. The extent of speech disturbance in bulbar palsy depends on the specifi c cranial nerves involved. Extrapyramidal dysarthria is characterized by a loss in prosody as seen in Parkinson’s disease, while cerebellar dysarthria refers to slurred drunken-like speech in patients with cerebellar ataxia. Myasthenia gravis is associated with speech that deteriorates in tone and strength during a discourse secondary to muscular fatigue.
When mimicking the use of a screwdriver a patient rotates his arm at the shoulder but fixes his elbow.
Which of the following could be diagnosed with the above presentation?
B. Apraxia is defined as the inability to carry out a motor act despite the absence of sensory or motor deficits. Here the muscular power and tone will be intact and the patient can fully comprehend the instruction. There are many classifications of apraxia according to region affected, for example oculomotor, orofacial, limb-kinetic apraxia. Apraxia is also classified according to specific functional defect, for example dressing apraxia, constructional apraxia, etc. With the exception of dressing and constructional apraxia, apraxic abnormalities are usually secondary to left hemisphere damage. In particular, this includes injuries involving the left frontal and inferior parietal lobes. Ideomotor apraxia (IMA) is the most common type of apraxia. Patients with ideomotor apraxia usually struggle with imitation and copying of skilled movements and falter when using tools. When pantomiming the use of a screwdriver, patients with ideomotor apraxia may rotate their arm at the shoulder and fi x their elbow.
Click to expand