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Autonomic Nervous System Practice Questions

Semesters 4X and 05
Neuroscience 2 Module
Nancy Selfridge, MD

1) An infant is noted to have unilateral ptosis during a well-child examination. Additional


findings are also noted. A photo of this child at age 3 is shown. What is the etiology of this
condition?

A) Ophthalmic nerve damage


B) Cranial nerve 3 lesion
C) Sympathetic enervation damage
D) Facial nerve lesion

2) A newborn infant fails to pass meconium in the first 48 hours and her abdomen becomes
distended. A barium study shows the following appearance. What is the etiology of this
condition?
A) An ileus
B) Imperforate anus
C) Distal colonic obstruction
D) Aganglionosis of the distal colon

3) A 33-year-old woman complains of paresthesias and pain that have gradually increased over
a 3 year period. These symptoms seem to have gradually spread over her shoulders, upper
arms, upper back and upper chest. Sometimes her arms seem to get hot and sweaty and
appear flushed not associated with being in a hot environment. Which spinal cord anomaly is
most often associated with these findings?

A) Lateral recess stenosis


B) Central canal stenosis
C) A syrinx
D) A central herniated disk

4) A 28-year-old woman complains of problems with color changes in her hands that are
diagnosed as Raynaud’s disease. What is the order of color changes associated with Raynaud’s
disease?

A) Red, white, blue


B) White, blue, red
C) Blue, white, red
D) White, red, blue

5) A newborn is noted to have hypotonia during his first neonatal exam. Later he is noted to
have no tears when he cries and he passes stool only once weekly. Which of the following
conditions is consistent with this presentation?
A) Hirschsprung’s disease
B) Riley-Day syndrome
C) Syringomyelia
D) Reflex sympathetic dystrophy

6) An elderly man has gradually progressive dementia consistent with Alzheimer’s disease. His
wife is able to take care of him at home until he becomes incontinent. Keeping an adult diaper
or condom catheter on him becomes impossible for her to manage. Reluctantly, she has him
admitted to an extended care facility. Where is the likely lesion creating this patient’s
incontinence problem?

A) Forebrain micturition control center


B) Pontine micturition control center
C) Sympathetic hypogastric nerves
D) Parasympathetic pelvic nerves

7) A 65-year-old man experiences increasing pain in his legs and buttocks with walking; this is
relieved with rest and then recurs when he starts walking again. He has also noted problems
with urge incontinence: his bladder feels suddenly very full and he leaks urine before he has a
chance to make it to the bathroom. What problem is likely present to explain his pain
symptoms and his incontinence problem?

A) Dementia
B) Stroke
C) Traumatic spinal cord injury
D) Spinal stenosis

Answers and Discussion:


1) Sympathetic enervation damage (C): Recognized Horner syndrome as unilateral ptosis,
miosis and anhidrosis and that it is an automonic (sympathetic) lesion.

2) Aganglionosis of the distal colon (D): This question requires you to associate symptoms of
Hirschprung disease (no passage of meconium within 48 hours in a newborn), with the
radiographic presentation, and with the pathophysiology of the disorder. Make sure that you
know all of the medical terminology that is commonly used to describe Hirschprung disease:
aganglionosis, aganglionic megacolon.

3) A syrinx (C): The distribution of sensory symptoms should be recognized here as a “cape
distribution” and should make you think immediately of syringomyelia, which can also cause
autonomic symptoms in the same distribution. It is important to link syringomyelia in your
mind with the commonly associated Chiari I malformation.
4) White, blue red (B): You either have to memorize this forever or remember that
vasoconstriction comes first, causing blanching; then venous blood accumulates and looks blue;
then arterial blood flow is restored in a rush and the hands become warm and rosy appearing
again!

5) Riley-Day syndrome (B): The neonatal and early newborn physical examination always
includes a check for muscle tone. Hypotonia is abnormal. This question tests your association
of the buzzwords “neonatal hypotonia” along with autonomic symptoms (no lacrimation and a
“pooping problem”) with Riley-Day syndrome.

6) Forebrain micturition center (A): You need to know a bit of general information about
micturition control, but even if you did not, you should be able to reason through this one.
Alzheimer disease is a brain disorder. As such, the effect on micturition control has to be
localized in the brain. Of the choices given only the pontine center and the forebrain center are
in the brain. Alzheimer disease affects higher center functioning (memory, reasoning) which
are forebrain, not pontine, functions.

7) Spinal stenosis (D): This patient exhibits symptoms of “intermittent claudication” which is
pain that develops in the buttocks and lower extremities upon exercising that resolve with rest.
Intermittent claudication may be due to arterial insufficiency or to spinal stenosis (you learned
about the latter in the Musculoskeletal Pain lecture last semester). Spinal stenosis causes
compression of cauda equina nerves, including the pelvic nerves enervating the bladder,
resulting in a variable degree of parasympathetic bladder stimulation and urge incontinence.