Ascending sensory pathways in brainstem — MCQs

A 63-year-old woman comes to the office because of a 2-year history of upper and lower extremity weakness and neck pain that is worse with sneezing. She has had difficulty swallowing and speaking for the past 8 months. Musculoskeletal examination shows spasticity and decreased muscle strength in all extremities. There is bilateral atrophy of the trapezius and sternocleidomastoid muscles. Neurologic examination shows an ataxic gait and dysarthria. Deep tendon reflexes are 4+ bilaterally. Babinski sign is positive. Sensation is decreased below the C5 dermatome bilaterally. An MRI of the neck and base of the skull is shown. Which of the following is the most likely cause of this patient's symptoms?

A 45-year-old patient presents with difficulty speaking and swallowing following a stroke. MRI reveals an infarct in the medulla. Which of the following cranial nerve nuclei is most likely affected?

A patient with a known spinal cord ependymoma presents to his neurologist for a check up. He complains that he has had difficulty walking, which he attributes to left leg weakness. On exam, he is noted to have 1/5 strength in his left lower extremity, as well as decreased vibration and position sensation in the left lower extremity and decreased pain and temperature sensation in the right lower extremity. Which of the following spinal cord lesions is most consistent with his presentation?

A 72-year-old woman is brought in to the emergency department after her husband noticed that she appeared to be choking on her dinner. He performed a Heimlich maneuver but was concerned that she may have aspirated something. The patient reports a lack of pain and temperature on the right half of her face, as well as the same lack of sensation on the left side of her body. She also states that she has been feeling "unsteady" on her feet. On physical exam you note a slight ptosis on the right side. She is sent for an emergent head CT. Where is the most likely location of the neurological lesion?

A 22-year-old man is brought to the physician by his mother because of concerns about his recent behavior. Three months ago, the patient first reported hearing loud voices coming from the ceiling of his room. During this time, he has also become increasingly worried that visitors to the house were placing secret surveillance cameras. Mental status examination shows tangential speech with paranoid thoughts. Treatment for this patient's condition predominantly targets which of the following dopaminergic pathways?

A 55-year-old man is brought to the emergency department by his wife after falling down. About 90 minutes ago, they were standing in their kitchen making lunch and chatting when he suddenly complained that he could not see as well, felt weak, and was getting dizzy. He began to lean to 1 side, and he eventually fell to the ground. He did not hit his head. In the emergency department, he is swaying while seated, generally leaning to the right. The general physical exam is unremarkable. The neurologic exam is notable for horizontal nystagmus, 3/5 strength in the right arm, ataxia of the right arm, and absent pinprick sensation in the left arm and left leg. The computed tomography (CT) scan of the head is unremarkable. Which of the following is the most likely single location of this patient's central nervous system lesion?

A 22-year-old man is brought to the emergency department after he was impaled by a metal rod during a work accident. The rod went into his back around the level of T9 but was removed before arrival. He has no past medical history and does not take any medications. On physical examination, he has significant muscle weakness in his entire left lower body. He also exhibits impaired vibration and proprioception in his left leg as well as loss of pain and temperature sensation in his right leg. Which of the following sections of the spinal cord was most likely damaged in this patient?

A 61-year-old man is found dead in his home after his neighbors became concerned when they did not see him for several days. The man was described as a "recluse" who lived alone and mostly kept to himself. Medical records reveal that he had not seen a physician in over a decade. He had a known history of vascular disease including hypertension, hyperlipidemia, and diabetes mellitus. He did not take any medications for these conditions. An autopsy is performed to identify the cause of death. Although it is determined that the patient suffered from a massive cerebrovascular accident as the cause of death, an incidental finding of a tumor arising from the spinal cord meninges is noted. The tumor significantly compresses the left anterolateral lower thoracic spinal cord. The right side of the spinal cord and the posterior spinal cord appear normal. Which of the following would most likely be impaired due to this lesion?

A man appearing to be in his mid-50s is brought in by ambulance after he was seen walking on railroad tracks. On further questioning, the patient does not recall being on railroad tracks and is only able to provide his name. Later on, he states that he is a railroad worker, but this is known to be false. On exam, his temperature is 99.9°F (37.7°C), blood pressure is 128/86 mmHg, pulse is 82/min, and respirations are 14/min. He appears disheveled, and his clothes smell of alcohol. The patient is alert, is only oriented to person, and is found to have abnormal eye movements and imbalanced gait when attempting to walk. Which of the following structures in the brain likely has the greatest reduction in the number of neurons?

A 63-year-old man presents to the clinic concerned about numbness and weakness in his bilateral shoulders and arms for the past 8 weeks. The symptoms started when he fell from scaffolding at work and landed on his back. Initial workup was benign and he returned to normal duty. However, his symptoms have progressively worsened since the fall. He denies fever, back pain, preceding vomiting, and diarrhea. He has a history of type 2 diabetes mellitus, hypertension, hypercholesterolemia, ischemic heart disease, and a 48-pack-year cigarette smoking history. He takes atorvastatin, hydrochlorothiazide, lisinopril, labetalol, and metformin. His blood pressure is 132/82 mm Hg, the pulse is 72/min, and the respiratory rate is 15/min. All cranial nerves are intact. Muscle strength is reduced in the upper limbs (4/5 bilaterally) but normal in the lower limbs. Perception of sharp stimuli and temperature is reduced on his shoulders and upper arms. The vibratory sense is preserved. Sensory examination is normal in the lower limbs. What is the most likely diagnosis?