Internal-Medicine

150 7: Diseases of the Nervous System
18. (B) The combination of symptoms is typical of
chronic alcohol abuse. The mental symptoms
are suggestive of Wernicke-Korsakoff syndrome.
A distal limb sensory-motor neuropathy
is also typical of alcoholism. Confusion, tremulousness,
and disorientation are typical for acute
alcohol intoxication. Wernicke’s encephalopathy
is a symptom complex of ophthalmoplegia,
ataxia, nystagmus, and acute confusional state.
(Ropper, p. 984)
19. (D) These signs and symptoms develop in a
fairly large percentage of patients with diabetes
mellitus. Loss of proprioceptive sensation
together with absent reflexes superficially
resembles tabes dorsalis. If sensory loss is severe,
Charcot’s joints can develop. (Ropper, pp. 1134–1135)
20. (A) A subdural hematoma is almost always of
venous origin and secondary to a minor or
severe injury to the head, but may occur in
blood dyscrasias or cachexia in the absence of
trauma. Acute subdural hematomas commonly
present with a fluctuating level of consciousness
and significant cerebral damage. Chronic
subdurals may also present with seizures or
papilledema. (Ropper, pp. 758–759)
21. (C) An acoustic neuroma is most likely to lead
to a palsy of the eighth cranial nerve. Deafness,
headache, ataxia, tinnitus, and diplopia are
seen, as well as facial paresthesias. Acoustic
neuromas represent 5–10% of all intracranial
tumors. They develop from Schwann cells and
generally grow very slowly. They may be very
large before symptoms develop. (Ropper, p. 572)
22. (D) Visual loss in multiple sclerosis varies from
slight blurring to no light perception. Other
eye symptoms include diplopia and pain. The
classic syndrome of optic or retrobulbar neuritis
occurs commonly at some point in the disease,
and it is the presenting symptom in 25%
of cases. (Ropper, p. 777)
23. (B) The early age of onset and otherwise good
health suggest a diagnosis of narcolepsy, which
is usually accompanied by other symptomatology.
Hypnagogic hallucinations are almost
always visual. They occur most frequently at
the onset of sleep, either during the day or at
night. They are generally very vivid. Cataplexy
is a brief loss of muscle power without loss of
consciousness. The patient is fully aware of what
is going on. The paralysis may be complete or
partial. Automatic behavior with amnesia is
a common manifestation of the narcolepsycataplexy
syndromes, occurring in 50% of cases.
Automatic behavior can be confused with complex
partial seizures. Paresthesias are not part of
narcolepsy syndrome. Snoring, restless sleep,
and morning headache suggest sleep apnea.
(Ropper, p. 510)
24. (C) In hyperthyroidism, neurologic symptoms
include tremors of the hands, exophthalmos,
lid lag, stare, and muscle weakness. Muscle
weakness of hyperthyroidism affects the pelvic
girdle and, to a lesser extent, the shoulder
girdle. Reflexes are normal or increased, and
sensation is normal. It must be differentiated
from myasthenia gravis, which may also
accompany thyrotoxicosis. (Ropper, p. 80)
25. (A) This young man has Friedreich’s ataxia,
associated with a gene defect on chromosome
9. The pathologic changes are found in the
spinal cord tracts. Degeneration is seen in the
posterior columns, the lateral corticospinal
tract, and the spinocerebellar tracts. Ataxia, sensory
loss, nystagmus, reflex changes, clubfeet,
and kyphoscoliosis are the characteristic findings.
The heart is frequently involved, and cardiac
disease is a common cause of death. (Ropper,
pp. 931–934)
26. (E) In Wilson’s disease, there is usually a reduction
of the serum ceruloplasmin content. Signs
and symptoms of injury to the basal ganglia are
accompanied by cirrhosis of the liver. Renal
involvement is characterized by persistent
aminoaciduria. The most common neurologic
finding is tremor. The corneal pigmentation
(Kayser-Fleischer ring) is the most important
diagnostic finding on physical examination. If
it is absent, any neurologic findings cannot be
ascribed to Wilson’s disease. (Ropper, pp. 830–831)