Nbme 7 block 3 qsn confusion - happy_studying

[ArchivalUser]

A previously healthy 82-year-old woman comes to the physician because she is concerned that she has Parkinson disease. Over the past 6 months, she has had occasional difficulty finding the word that she wants to use, and her ability to distinguish smells has decreased. She reports that her reaction time to shifts in posture seems slow, and she needs to use a hand rail to steady herself while walking on stairs. She lives alone and is able to manage her own finances.T he pupils are 3 mm. There is mild reduction of upward gaze and brisk rotatory nystagmus on left lateral gaze. Audiometry shows mild high-frequency hearing loss. There are no tremors or rigidity. Her gait is normal. Her Mini-Mental State Examination score is 29/30.
Which of the following neurologic findings warrants further evaluation?
A) Brisk rotatory nystagmus on left lateral gaze
B) Decreased sense of smell
C) Decreased upward gaze
D) High-pitched tone hearing loss
E) Small symmetric pupils

A is the right answer???
Why???

[ArchivalUser]

A

BPPV

Epley maneuver

Meclizine

difficulty finding the word -- normal even in younger ones
B. decreased smell -- probably normal in elderly (not sure though), but it is a sign for Parkinson
reaction to time shifts in posture !!! slow !!! -- the equilibrium center (ear , cerebellum , peripheral nerves)
handrail on stairs - same as above (vertigo)
and plus the ROTARY NYSTAGMUS -- so probably BPPV

no tremors, gait normal -- parkinson out.

C. mild upward gaze -- PARINAUD SYNDROME, but it says is mild. (may be normal in elderly)
D. h/p tone hearing loss -- normal in elderly
E normal



please, give ideas, etc...

[ArchivalUser]

Diagnosis isn't as important here as just recognizing which findings are age related and which are pathological.

Nystagmus is almost always pathological unless congenital. Especially gaze evoked nystagmus is almost always pathological.

BPPV btw is head movement induced nystagmus, which isn't the same as gaze evoked. Gaze just means moving eyes whereas bppv usually the nystagmus comes from moving the entire head.

The rest are normal findings for age, except e, which could be normal pupil size for any age.

I think it's interesting they didn't use the memory complaint as an answer choice, maybe too easy of a distractor...

[ArchivalUser]

Thanx both of you !!
Yeah b,c,d,e can be ruled out !!
I was wondering what the dx could be!!
And yeah it's not BPPV (like mastarizh mentioned-- i agree)!!
May be we just need to go with age related pathological finding in this vignette !...

[ArchivalUser]

yes , it is not BPPV

probably MS or a tumor......



https://www.youtube.com/watch?v=9LsHp-tgx8w

[ArchivalUser]

http://www.dizziness-and-balance.com/pra...ional.html


ROTATORY same as TORSIONAL nystagmus.


Primary position pendular torsion:
It is seen in disorders of the medulla such as syringomyelia, in degenerative disorders of the nervous system, in persons with palatal myoclonus, in multiple sclerosis, and in persons with midbrain lesions

Jerk torsion
Jerk Torsional nystagmus is much more common, especially when it is positional. Jerk torsion is commonly elicited by positional maneuvers such as the Dix-Hallpike test. In that context, the nystagmus is transient, and not continuous. Torsional nystagmus in this context is generally attributed to benign paroxysmal positional vertigo (BPPV)