Stupor and Coma
QUESTIONS
1. A 76-year-old male presents with the inability to maintain attention. He is easily distracted, fidgety, and occasionally mistakes the wires in the room for snakes. This has been going on for 2 days, but there are periods when he is completely alert. Which of the following describes this patient’s disease?
A. Frontotemporal dementia
B. Dementia with Lewy bodies
C. Delirium
D. Transient global amnesia
E. None of the above
View Answer
1. Answer: C. Delirium is distinguished from dementia, which is a nonacute progressive process and is not associated with psychomotor, autonomic, and level of consciousness alterations that characterize delirium.
2. Which of the following has not been associated with delirium?
A. Cobalamin
B. Niacin
C. Thiamine
D. Thyroxine
E. All of the above are associated with delirium.
View Answer
2. Answer: E. All of the above have been associated with causing or being associated with delirium.
3. A 67-year-old woman presents with an acute confusional state. She is diagnosed with a stroke. Which of the following is most likely the location of the stroke?
A. Basal forebrain
B. Anterior inferior cerebellar artery territory infarct
C. Left lateral geniculate
D. Subthalamic nucleus
View Answer
3. Answer: A. Basal forebrain strokes have been implicated in confusion/delirium. Other locations that have been associated with delirium are caudate nucleus, thalamic lesions (that include the Papez circuit), and the hippocampus.
4. A 65-year-old man presents in an acute comatose state. Magnetic resonance imaging (MRI) is performed and shows a stroke affecting his ascending reticular activating system. Which of the following areas would correspond with this lesion?
A. Right parietal lobe
B. Left occipital lobe
C. Cerebral peduncle
D. Tegmentum of the upper pons
E. Basal ganglia
View Answer
4. Answer: D. The ascending reticular activating system is a group of neurons that originate in the tegmentum of the upper pons and midbrain. They project their axons to the diencephalons and then on to the cortex. These neurons are thought to be integral in maintaining alertness.
5. A 40-year-old man presents to the intensive care unit in a comatose state. He is hyperventilating, on arterial blood gas, and there is a metabolic acidosis. Which of the following is probably not the cause of his coma?
A. Diabetic ketoacidosis
B. Acetaminophen overdose
C. Ethylene glycol ingestion
D. Excessive vomiting
View Answer
5. Answer: D. All of the above except excessive vomiting could cause hyperventilation with a metabolic acidosis. Excessive vomiting would cause a metabolic alkalosis with hypoventilation, and usually, there should be no impairment of consciousness; if present, suspect psychogenic coma or some other etiology.
6. A 35-year-old female who recently ran a marathon in the summer presents in a comatose state. Her core body temperature is 41°C. She is diagnosed with heat stroke. What are other possible causes for her hyperthermia?
A. Wernicke’s encephalopathy
B. Adrenal failure
C. Hypothyroidism
D. Anticholinergic intoxication
E. None of the above
View Answer
6. Answer: D. Besides heat stroke, anticholinergic intoxication could cause a hyperthermic coma as well as infection. All the other etiologies listed could cause hypothermic coma.
7. An 87-year-old man is found unresponsive in his home. On presentation, he has ataxic breathing, fixed pinpoint pupils, absent vestibuloocular reflexes, and has no movement of his extremities. Which of the following is a possible etiology for his coma?
A. Tumor compressing the lower pons
B. Stroke to the midbrain
C. Herpes encephalitis
D. Bilateral thalamic infarcts
E. None of the above
View Answer
7. Answer: A. Based on the clinical picture, the most likely location for ataxic breathing and fixed pinpoint pupils is a lesion to the lower pons or upper medulla.
8. A 76-year-old man presents to the emergency department (ED) with Cheyne-Stokes respiration, which started acutely. On computed tomography (CT) scan of his head, bilateral parietal lobe infarcts are seen in the middle cerebral artery (MCA) distribution. Which of the following could also cause a similar breathing pattern?
A. Right posterior cerebral artery infarct
B. Alcohol intoxication
C. Cardiomyopathy
D. Opiate overdose
E. None of the above
View Answer
8. Answer: C. Cheyne-Stokes respiration (a crescendo-decrescendo pattern of breathing with apneic episodes) may occur with impaired cardiac output, bilateral cerebral dysfunction, and also in the elderly during sleep.
9. A 34-year-old female presents to the ED in a deep coma. Which of the following skin lesions would support that she had severe head trauma?
A. Hypermelanosis
B. Icterus
C. Battle’s sign
D. Ecthyma gangrenosum
E. None of the above
View Answer
9. Answer: C. Bruises can often indicate head trauma, especially periorbital ecchymosis, also known as “raccoon eyes” and Battle’s sign, which is bruising over the mastoid. All of the above are skin lesions but are do not indicate head trauma.
10. A 19-year-old female presents to the ED with severe head injury due to a recent motor vehicle accident. Her Glasgow coma scale is 4. Which of the following is not possible for her to be performing?
A. Extension response to pain
B. Incomprehensible sounds
C. Eyes open in response to pain
D. Inappropriate words
E. None of the above
View Answer
10. Answer: D. Inappropriate words gives her a score of 3 with best verbal response and therefore a minimum score of 5. The scale ranges between 3 and 15. A Glasgow coma scale score of 3 means no eye opening, no verbal response, or no motor response. The scale is used more as a prognostic indicator than used in the diagnosis of coma.
11. A 56-year-old female found unresponsive is brought to the ED. On examination, she is found to have decorticate posturing. Which of the following is consistent with this condition?
A. Flexion at the elbow, plantar lower extremity extension
B. Upper extremity extension, lower extremity extension
C. Flexion at the wrist and fingers, lower extremity flexion
D. All of the above
E. None of the above
View Answer
11. Answer: A. Decorticate posturing consists of upper extremity adduction and flexion at the elbow, wrists, and fingers along with lower extremity extension. Decerebrate posturing consists of upper extremity extension, adduction, and pronation along with lower extremity extension.
12. Which of the following is most likely the location of the lesion that may cause decerebrate posturing?
A. Thalamus
B. Caudate
C. Red nucleus
D. Cerebellar peduncle
E. Medial longitudinal fasciculus
View Answer
12. Answer: C. A lesion below or at the red nucleus has been traditionally associated with decerebrate posturing, therefore allowing the vestibulospinal tract to dominate.
13. A 56-year-old male with a history of multiple psychiatric hospitalizations was recently admitted to the psychiatric ward with acute psychosis. He was given multiple doses of haloperidol. On the third day of admission, he developed a fever, increased bilateral muscle rigidity, and then went into a coma. Which of the following is the best next step?
A. Place cooling blankets
B. Start dantrolene
C. Check creatine phosphokinase level
D. Stop the neuroleptics
E. None of the above
View Answer
13. Answer: D. All of the above are good options and are part of the management of neuroleptic malignant syndrome. However, stopping the neuroleptics is the first and foremost step in the management.
14. A 42-year-old female with a history of chronic alcohol abuse and hepatitis C presents with a decreased level of consciousness. She is found on examination to have a tremor in her extremities and elevated ammonia levels in her blood. Which of the following describes the type of tremor she most likely has?
A. Transient increase in postural tone
B. Transient decrease in postural tone
C. Occasional twitches of her face
D. A and C
E. None of the above
View Answer
14. Answer: B. The patient most likely has hepatic encephalopathy, which is a type of metabolic coma. With elevated ammonia levels, the type of tremor she most likely has is asterixis, which is defined as transient loss of postural tone and therefore occasionally falling transiently when the tone is decreased.
15. A 32-year-old man with a history of berry aneurysm that was partially coiled 1 week ago presents in a coma and is completely unresponsive. What physical finding would be pathognomonic for a subarachnoid hemorrhage?
A. Elevated blood pressure
B. Loss of the vestibule-ocular reflex
C. Pinpoint pupils
D. Roth spots
E. Subhyaloid hemorrhage
View Answer
15. Answer: E. A subhyaloid hemorrhage is pathognomonic for subarachnoid hemorrhage in a comatose patient. Although all the others can be present except Roth spots (which are often seen with bacterial endocarditis, leukemia, vasculitis, and diabetic retinopathy), none are diagnostic in a comatose patient for a subarachnoid hemorrhage.
16. A 65-year-old man presents after a stroke in the brain stem, and on examination, you find that his pupillary light reflex is impaired and he has an oculomotor palsy. Which of the following could also have caused this?
A. Syphilis
B. Low vitamin B12
C. Herniation of medial temporal structures from an expanding supratentorial mass
D. Thiamine deficiency
E. None of the above
View Answer
16. Answer: C. Disruption of the papillary light reflex in a comatose patient (excluding medication effect) typically implies downward herniation of medial temporal structures due to an expanding supratentorial mass or a brain stem lesion. Usually, the third cranial nerve or the nuclei in the midbrain have been injured.
17. A 36-year-old male presents with pinpoint pupils bilaterally and feels drowsy and nauseated. His sister comes in later and states that he took an overdose of oxycodone. Which of the following could also cause his pupillary changes?
A. Lesion in the pontine tegmentum
B. Bilateral retinal artery occlusion
C. Pilocarpine drops
D. Left carotid artery dissection
E. All of the above
View Answer
17. Answer: A. Lesions in the pontine tegmentum, which selectively interfere with sympathetic outflow, can produce pinpoint pupils (sometimes known as pontine pupils). Opiate overdose is also a common cause.
18. A 76-year-old male presents to the ED with left-sided hemiparesis (worse in the leg than arm) and eye deviation to the left. He has some nystagmus to the left as well and is unresponsive. Which of the following is possible?
A. Large left frontal lobe lesion
B. Seizure
C. Right occipital lobe infarct
D. Tumor in the brain stem
E. None of the above
View Answer
18. Answer: B. Persistent eye deviation especially to the same side as the hemiparesis in an unresponsive patient is possibly due to a seizure. The lesion most likely is in the right frontal lobe (contralateral to the hemiparesis).
19. A 19-year-old man presents in a coma after a major motorcycle accident. His cervical spine is cleared of any fracture. You attempt the oculocephalic maneuver. If the patient has a positive doll’s eye reflex, which of the following would be seen?
A. The eyes do not turn with the head but in the opposite direction
B. The eyes turn with the head in the same direction
C. The left eye turns with the head while the right eye does not turn
D. Both eyes move upward
E. None of the above
View Answer
19. Answer: A. If the oculocephalic reflex is present or positive (or positive doll’s eye reflex), the eyes do not turn with the head but move in the opposite direction, as if the person is trying to maintain a visual fix on a single point (for example, one tile on the ceiling).
20. Which of the following is required for caloric testing of the doll’s eye reflex?
A. One milliliter of ice cold water
B. Three liters of lukewarm water
C. Fifty milliliters of ice cold water
D. Thirty milliliters of lukewarm water
E. None of the above
View Answer
20. Answer: C. Caloric testing requires the head to be in a 30-degree position from horizontal and at least 50 mL of ice cold water. You must first verify there is no obstruction in the ear as well as no perforated eardrum. You should also wait 5 minutes before testing the opposite ear.
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