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Self-Assessment Questions


Rapidly Progressive Paralytic Syndrome: Review Questions

Lawrence M. Samkoff, MD

Dr. Samkoff is an Associate Professor, Department of Neurology, Rochester General Hospital, University of Rochester School of Medicine and Dentistry, Rochester, NY; and an Attending Neurologist, Rochester Multiple Sclerosis Clinic, Rochester, NY.

Choose the single best answer for each question.

Questions 1 through 5 refer to the following case study.

A 37-year-old man comes to the emergency department for evaluation because of paresthesias in both feet radiating to the ankles. He reports that he woke up yesterday with a tingling sensation in both feet, had some unsteadiness in walking and a feeling of heaviness in his feet that afternoon, and noted a wobbly sensation in his knees that evening; he began to have dull, aching pain in the lower back without radiation but had no difficulty with bladder or bowel function. Earlier this morning, the patient had increased difficulty ambulating and required assistance to walk. He reports no speech difficulty, swallowing disturbance, vertigo, diplopia, or upper-extremity symptoms and no urinary hesitancy or incontinence. The patient has no significant medical history. He had a viral upper respiratory infection 3 weeks ago. He does not take medication, smoke cigarettes, or use alcohol in excess. He reports no use of recreational drugs. Review of systems is otherwise unrevealing. General physical examination is unremarkable, except for mild lower lumbar tenderness to percussion. Neurologic examination reveals normal mental status. Cranial nerve examination shows no abnormalities, but there is mild weakness of eye closure. Motor testing reveals grade 4/5 weakness of the intrinsic hand muscles (ie, dorsal interossei, flexor pollicis brevis, flexor digitorum profundi) bilaterally. Lower extremity strength is 3/5 bilaterally in the iliopsoas, quadriceps, hamstrings, tibialis anterior, and gastrocnemius. The patient has diminished sensation to vibration in the legs bilaterally, to the midcalves. His gait is paraparetic, and he requires assistance to take more than a few steps. Results of cerebellar testing involving the upper extremities are normal. Deep tendon reflexes are diffusely absent; plantar responses are flexor.

1. This patient’s disorder is most likely localized to which of the following structures?
  1. Cerebellum
  2. Muscle
  3. Neuromuscular junction
  4. Peripheral nerves
  5. Spinal cord
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2. Which of the following is the most likely diagnosis?
  1. Cerebellar hemorrhage
  2. Guillain-Barré syndrome
  3. Myasthenia gravis
  4. Polymyositis
  5. Transverse myelitis
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3. Which of the following tests would be most useful to diagnose the patient’s condition?

  1. Computed tomography scan of the brain
  2. Magnetic resonance imaging of the spine
  3. Lumbar puncture
  4. Measurement of the serum creatine kinase level
  5. Tensilon test
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4. Which of the following parameters should be most closely monitored in this patient?

  1. Arterial blood gases
  2. Blood pressure
  3. Forced vital capacity
  4. Mental status
  5. Pupillary size and reactivity
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5. Administration of which of the following substances is most appropriate?

  1. Antibiotic agents
  2. Corticosteroids
  3. Immunoglobulin, intravenously
  4. Interferon beta
  5. Pyridostigmine
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