Download neurology mcqs: If you think neurology is difficult then the best way to cope with it is by solving mcqs: http://www.filesonic.com/file/241545504/Neurology_question_and_answers.doc
Neurology:Question 1
A 39-year-old executive comes to the office for a follow-up visit. She had a generalized tonic-clonic seizure 1 week ago, witnessed by her husband, who reports that the seizure started suddenly. She had tonic extension and stiffening of her whole body followed by rhythmic jerking movements of her arms, trunk, and legs. The patient had no warning prior to the seizure, and afterward fell into a deep sleep. She was hospitalized. Wake and sleep electroencephalography and magnetic resonance imaging of the brain with contrast were normal, and she was sent home on a maintenance dose of phenytoin. The patient states that, for the 4 nights prior to the seizure, she slept no more than 2 hours a night in order to finish an assignment. There is no personal or family history of seizures. Neurologic examination is normal.
Which of the following is the most appropriate next step in management?
A. Continue phenytoin
B. Discontinue phenytoin
C. Discontinue phenytoin and begin carbamazepine
D. Discontinue phenytoin and begin valproic acid
E. Discontinue phenytoin and begin gabapentin
Neurology:Question 1
A 39-year-old executive comes to the office for a follow-up visit. She had a generalized tonic-clonic seizure 1 week ago, witnessed by her husband, who reports that the seizure started suddenly. She had tonic extension and stiffening of her whole body followed by rhythmic jerking movements of her arms, trunk, and legs. The patient had no warning prior to the seizure, and afterward fell into a deep sleep. She was hospitalized. Wake and sleep electroencephalography and magnetic resonance imaging of the brain with contrast were normal, and she was sent home on a maintenance dose of phenytoin. The patient states that, for the 4 nights prior to the seizure, she slept no more than 2 hours a night in order to finish an assignment. There is no personal or family history of seizures. Neurologic examination is normal.
Which of the following is the most appropriate next step in management?
A. Continue phenytoin
B. Discontinue phenytoin
C. Discontinue phenytoin and begin carbamazepine
D. Discontinue phenytoin and begin valproic acid
E. Discontinue phenytoin and begin gabapentin
Neurology:Question 2
A 73-year-old woman has transient left hemiparesis lasting 20 minutes and calls your office that same day to inform you. She has a history of intermittent nonvalvular atrial fibrillation, angina pectoris, and hypertension. At the time of her call, she is completely asymptomatic. Her only antithrombotic therapy is aspirin, 81 mg daily.
What is the optimal initial management for this patient?
A. Schedule an office appointment within 1 week.
B. Schedule transesophageal echocardiography.
C. Schedule Holter monitoring.
D. Schedule outpatient carotid duplex ultrasonography.
E. Obtain emergency computed tomography.
A 73-year-old woman has transient left hemiparesis lasting 20 minutes and calls your office that same day to inform you. She has a history of intermittent nonvalvular atrial fibrillation, angina pectoris, and hypertension. At the time of her call, she is completely asymptomatic. Her only antithrombotic therapy is aspirin, 81 mg daily.
What is the optimal initial management for this patient?
A. Schedule an office appointment within 1 week.
B. Schedule transesophageal echocardiography.
C. Schedule Holter monitoring.
D. Schedule outpatient carotid duplex ultrasonography.
E. Obtain emergency computed tomography.
Neurology:Question 3
A 35-year-old woman comes to the office with a 1-day history of blurred vision and retro-orbital pain with movement of the right eye. Past medical history is unremarkable. On examination, she has a right afferent pupillary defect. Visual acuity is 20/200 in the right eye with a dense central scotoma, and 20/25 in the left eye. Funduscopic examination is normal bilaterally. The rest of the neurologic examination is normal. Magnetic resonance imaging of the brain shows one nonenhancing periventricular white matter lesion. The patient refuses lumbar puncture for examination of cerebrospinal fluid. Treatment with intravenous methylprednisolone improves her optic neuritis.
Which of the following should be done to monitor for development of multiple sclerosis?
A. Repeat examination only when patient has a new neurologic symptom
B. Serial visual evoked potential studies in 6 months
C. Formal visual field studies in 6 months
D. Follow-up magnetic resonance imaging of the brain with gadolinium in 6 months
E. Serial nerve conduction velocity examinations in 6 months
A 35-year-old woman comes to the office with a 1-day history of blurred vision and retro-orbital pain with movement of the right eye. Past medical history is unremarkable. On examination, she has a right afferent pupillary defect. Visual acuity is 20/200 in the right eye with a dense central scotoma, and 20/25 in the left eye. Funduscopic examination is normal bilaterally. The rest of the neurologic examination is normal. Magnetic resonance imaging of the brain shows one nonenhancing periventricular white matter lesion. The patient refuses lumbar puncture for examination of cerebrospinal fluid. Treatment with intravenous methylprednisolone improves her optic neuritis.
Which of the following should be done to monitor for development of multiple sclerosis?
A. Repeat examination only when patient has a new neurologic symptom
B. Serial visual evoked potential studies in 6 months
C. Formal visual field studies in 6 months
D. Follow-up magnetic resonance imaging of the brain with gadolinium in 6 months
E. Serial nerve conduction velocity examinations in 6 months
Neurology:Question 5
A 36-year-old woman with a 15-year history of headaches comes to the office for a follow-up visit. Initially, she had moderate to severe bilateral pulsatile, frontal headaches accompanied by nausea, light and noise sensitivity, and occasional vomiting. They occurred one to two times each month and lasted 24 to 36 hours. In the last 2 years, she has developed a daily mild to moderate bilateral frontal headache that is present when she awakens and lasts all day. Approximately once per week she has a headache that is similar to her previous episodic headaches but less severe. She takes amitriptyline, 75 mg at bedtime, as a prophylactic agent. She takes acetaminophen/caffeine/butalbital, 4 tablets/d, and rizatriptan, 10 to 20 mg, one to two days per week for more severe headaches. Physical and neurologic examinations are normal.
What is the most appropriate next step in managing this patients headache disorder?
A. Discontinue amitriptyline and initiate treatment with divalproex sodium.
B. Discontinue acetaminophen/caffeine/butalbital.
C. Discontinue rizatriptan.
D. Increase dose of amitriptyline.
A 36-year-old woman with a 15-year history of headaches comes to the office for a follow-up visit. Initially, she had moderate to severe bilateral pulsatile, frontal headaches accompanied by nausea, light and noise sensitivity, and occasional vomiting. They occurred one to two times each month and lasted 24 to 36 hours. In the last 2 years, she has developed a daily mild to moderate bilateral frontal headache that is present when she awakens and lasts all day. Approximately once per week she has a headache that is similar to her previous episodic headaches but less severe. She takes amitriptyline, 75 mg at bedtime, as a prophylactic agent. She takes acetaminophen/caffeine/butalbital, 4 tablets/d, and rizatriptan, 10 to 20 mg, one to two days per week for more severe headaches. Physical and neurologic examinations are normal.
What is the most appropriate next step in managing this patients headache disorder?
A. Discontinue amitriptyline and initiate treatment with divalproex sodium.
B. Discontinue acetaminophen/caffeine/butalbital.
C. Discontinue rizatriptan.
D. Increase dose of amitriptyline.
Neurology:Question 6
A 65-year-old man has weakness and wasting of his left hand and muscle twitching involving his arms
and thighs. The symptoms have progressed over 5 months. There is no associated pain or paresthesia. Neurologic examination reveals severe weakness and atrophy of the left thenar and hypothenar muscles, and mild weakness of left foot dorsiflexion. Muscle stretch reflexes are hyperactive and symmetric. Sensation is normal. Magnetic resonance imaging of the cervical spine was obtained by an orthopedic surgeon 2 weeks earlier and is normal.
Which of the following is the most appropriate next step?
A. Muscle biopsy
B. Nerve biopsy
C. Serum creatine kinase determination
D. Electromyography
E. Genetic testing
A 65-year-old man has weakness and wasting of his left hand and muscle twitching involving his arms
and thighs. The symptoms have progressed over 5 months. There is no associated pain or paresthesia. Neurologic examination reveals severe weakness and atrophy of the left thenar and hypothenar muscles, and mild weakness of left foot dorsiflexion. Muscle stretch reflexes are hyperactive and symmetric. Sensation is normal. Magnetic resonance imaging of the cervical spine was obtained by an orthopedic surgeon 2 weeks earlier and is normal.
Which of the following is the most appropriate next step?
A. Muscle biopsy
B. Nerve biopsy
C. Serum creatine kinase determination
D. Electromyography
E. Genetic testing
Neurology:Question 7
A 46-year-old woman comes to the office for management of a 4-mm left middle cerebral artery aneurysm. The aneurysm was found when the patient had magnetic resonance angiography and imaging for evaluation of a chronic headache disorder. Medical history is limited to chronic migraine headaches and smoking. Neurologic examination is normal.
Which of the following is the most appropriate next step in this patient’s management?
A. Arteriography
B. Computed tomographic angiography
C. Follow-up magnetic resonance angiography in 6 months
D. Aneurysm clipping
A 46-year-old woman comes to the office for management of a 4-mm left middle cerebral artery aneurysm. The aneurysm was found when the patient had magnetic resonance angiography and imaging for evaluation of a chronic headache disorder. Medical history is limited to chronic migraine headaches and smoking. Neurologic examination is normal.
Which of the following is the most appropriate next step in this patient’s management?
A. Arteriography
B. Computed tomographic angiography
C. Follow-up magnetic resonance angiography in 6 months
D. Aneurysm clipping
Neurology:Question 8
A 71-year-old man comes to the office because of slowness, tremor, stiffness, and difficulty with dexterity, such as buttoning clothes. The problems developed insidiously over the last few years, and have caused him to curtail his activities severely. On examination, he has a shuffling gait, tremor of one hand while walking, and reduced arm swing (right more than left). Rapid alternating movements are very slow, especially in the right limbs. Passive movement of his limbs reveals rigidity. Neurologic examination is otherwise normal.
Which of the following is the most appropriate management for this patient?
A. No treatment
B. Selegiline
C. Amantadine
D. Carbidopa/levodopa
E. Entacapone
A 71-year-old man comes to the office because of slowness, tremor, stiffness, and difficulty with dexterity, such as buttoning clothes. The problems developed insidiously over the last few years, and have caused him to curtail his activities severely. On examination, he has a shuffling gait, tremor of one hand while walking, and reduced arm swing (right more than left). Rapid alternating movements are very slow, especially in the right limbs. Passive movement of his limbs reveals rigidity. Neurologic examination is otherwise normal.
Which of the following is the most appropriate management for this patient?
A. No treatment
B. Selegiline
C. Amantadine
D. Carbidopa/levodopa
E. Entacapone
Neurology:Question 9
A 68-year-old man is under evaluation for memory difficulty that, according to his wife, began insidiously 3 or 4 years earlier. He has difficulty remembering recent events. For example, he forgets appointments and recent conversations, and forgot that a close relative had recently died. He is no longer able to manage his own checkbook or operate his car without getting lost. Medical history is unremarkable. Physical examination is normal. Mental status examination shows prominent memory loss and difficulty drawing a complex figure. Magnetic resonance imaging of the brain shows only mild cerebral atrophy.
Which of the following is the most likely diagnosis?
A. Alzheimer’s disease
B. Dementia with Lewy bodies
C. Vascular dementia
D. Frontotemporal dementia
E. Creutzfeldt-Jakob disease
A 68-year-old man is under evaluation for memory difficulty that, according to his wife, began insidiously 3 or 4 years earlier. He has difficulty remembering recent events. For example, he forgets appointments and recent conversations, and forgot that a close relative had recently died. He is no longer able to manage his own checkbook or operate his car without getting lost. Medical history is unremarkable. Physical examination is normal. Mental status examination shows prominent memory loss and difficulty drawing a complex figure. Magnetic resonance imaging of the brain shows only mild cerebral atrophy.
Which of the following is the most likely diagnosis?
A. Alzheimer’s disease
B. Dementia with Lewy bodies
C. Vascular dementia
D. Frontotemporal dementia
E. Creutzfeldt-Jakob disease
Neurology:Question 10
A 23-year-old woman comes to the office with her husband for evaluation of recent onset of unusual behavior. While providing the clinical history, the patient begins to cry. Shortly after that the patients arms start shaking. Gradually, the shaking becomes more pronounced and involves her legs and head. The patients breathing becomes deep and fast. This continues on and off for several minutes. The shaking stops gradually. The patient opens her eyes and states that she has a headache and is very tired and dizzy. Family history is positive for seizures in the patients cousin. There has been a significant amount of family stress recently.
Which of the following is the most likely diagnosis?
A. Syncope
B. Nonepileptic event (pseudoseizure)
C. Partial seizure with secondary generalization
D. Generalized tonic-clonic seizure
E. Basilar migraine
A 23-year-old woman comes to the office with her husband for evaluation of recent onset of unusual behavior. While providing the clinical history, the patient begins to cry. Shortly after that the patients arms start shaking. Gradually, the shaking becomes more pronounced and involves her legs and head. The patients breathing becomes deep and fast. This continues on and off for several minutes. The shaking stops gradually. The patient opens her eyes and states that she has a headache and is very tired and dizzy. Family history is positive for seizures in the patients cousin. There has been a significant amount of family stress recently.
Which of the following is the most likely diagnosis?
A. Syncope
B. Nonepileptic event (pseudoseizure)
C. Partial seizure with secondary generalization
D. Generalized tonic-clonic seizure
E. Basilar migraine
Neurology:Question 11
A 65-year-old woman comes to the emergency department because of mild left hem iparesis and mild left-sided sensory deficit that began suddenly 2 days earlier. She has a history of myocardial infarction and takes aspirin, 81 mg daily.
Which of the following is the most appropriate next step in the management of this patient?
A. Increase the aspirin dose to 325 mg daily.
B. Discontinue aspirin and begin clopidogrel, 75 mg daily.
C. Change aspirin to combined low-dose aspirin/extended-release dipyridamole.
D. Discontinue aspirin and begin warfarin (target international normalized ratio, 2.0 to 3.0).
E. Initiate inpatient diagnostic evaluation.
A 65-year-old woman comes to the emergency department because of mild left hem iparesis and mild left-sided sensory deficit that began suddenly 2 days earlier. She has a history of myocardial infarction and takes aspirin, 81 mg daily.
Which of the following is the most appropriate next step in the management of this patient?
A. Increase the aspirin dose to 325 mg daily.
B. Discontinue aspirin and begin clopidogrel, 75 mg daily.
C. Change aspirin to combined low-dose aspirin/extended-release dipyridamole.
D. Discontinue aspirin and begin warfarin (target international normalized ratio, 2.0 to 3.0).
E. Initiate inpatient diagnostic evaluation.
Neurology:Question 12
A 74-year-old man with a history of hypertension is brought to the emergency department after being found unresponsive by his wife in bed. He is intubated for airway protection. Blood pressure is 210/90 mm Hg; pulse, 80/min; and temperature, 37 C (98.6 F). When his eyes are opened by the examiner, there are intermittent spontaneous downward eye movements. There are no spontaneous horizontal eye movements, nor are there horizontal movements in response to the doll’s head maneuver. The pupils are very small but reactive. He does not move any extremities on command. There is occasional spontaneous extensor posturing in his arms and legs, and Babinski’s signs are present bilaterally. He blinks his eyes three times in a row on command.
Which of the following is the most likely cause of this patient’s condition?
A. Anoxic encephalopathy
B. Left middle cerebral artery stroke
C. Pontine infarct
D. Cerebellar infarct
A 74-year-old man with a history of hypertension is brought to the emergency department after being found unresponsive by his wife in bed. He is intubated for airway protection. Blood pressure is 210/90 mm Hg; pulse, 80/min; and temperature, 37 C (98.6 F). When his eyes are opened by the examiner, there are intermittent spontaneous downward eye movements. There are no spontaneous horizontal eye movements, nor are there horizontal movements in response to the doll’s head maneuver. The pupils are very small but reactive. He does not move any extremities on command. There is occasional spontaneous extensor posturing in his arms and legs, and Babinski’s signs are present bilaterally. He blinks his eyes three times in a row on command.
Which of the following is the most likely cause of this patient’s condition?
A. Anoxic encephalopathy
B. Left middle cerebral artery stroke
C. Pontine infarct
D. Cerebellar infarct
Neurology:Question 13
A 42-year-old man with secondary progressive multiple sclerosis comes to the local urgent care facility because of increased weakness and spasticity of the legs, with increased hip flexor tone. Over the past 3 days he has also noted an increase in urinary urgency and frequency. Until 3 days ago, he had been fairly stable, with a slowly progressive course, and could walk at least 500 feet with one cane; spasticity had been well controlled with baclofen, 20 mg three times a day orally. On examination, blood pressure is 110/70mm Hg; pulse, 92/min; and temperature, 38.2 C (100.8 F). He has bilateral internuclear ophthalmoplegia. Hip flexion is weak bilaterally. Spasticity is severe in the legs, with sustained clonus at both ankles. Urinalysis shows 50 to 100 leukocytes/hpf, and 2+ leukocyte esterase.
In addition to treatment of the urinary tract infection, which of the following is the most appropriate treatment?
A. Acetaminophen
B. Oral prednisone
C. Intravenous methyiprednisolone
D. Interferon beta
E. Glatiramer acetate
A 42-year-old man with secondary progressive multiple sclerosis comes to the local urgent care facility because of increased weakness and spasticity of the legs, with increased hip flexor tone. Over the past 3 days he has also noted an increase in urinary urgency and frequency. Until 3 days ago, he had been fairly stable, with a slowly progressive course, and could walk at least 500 feet with one cane; spasticity had been well controlled with baclofen, 20 mg three times a day orally. On examination, blood pressure is 110/70mm Hg; pulse, 92/min; and temperature, 38.2 C (100.8 F). He has bilateral internuclear ophthalmoplegia. Hip flexion is weak bilaterally. Spasticity is severe in the legs, with sustained clonus at both ankles. Urinalysis shows 50 to 100 leukocytes/hpf, and 2+ leukocyte esterase.
In addition to treatment of the urinary tract infection, which of the following is the most appropriate treatment?
A. Acetaminophen
B. Oral prednisone
C. Intravenous methyiprednisolone
D. Interferon beta
Neurology:Question 14
A 34-year-old woman comes to the office because of a 2-year history of bifrontal, throbbing headaches that occur two to four times per month and last 8 to 16 hours. During a headache, she tolerates noise and sound poorly and prefers to lie down. She sometimes has associated blurred vision, eye tearing, and rhinorrhea, and she is occasionally unable to work during a headache. The headache worsens with physical activity, such as brisk walking. Physical and neurologic examinations, including funduscopic examination, are normal.
Which of the following is the most likely diagnosis?
A. Episodic tension-type headache
B. Cluster headache
C. Idiopathic intracranial hypertension
D. Migraine without aura
E. Sinus headache
A 34-year-old woman comes to the office because of a 2-year history of bifrontal, throbbing headaches that occur two to four times per month and last 8 to 16 hours. During a headache, she tolerates noise and sound poorly and prefers to lie down. She sometimes has associated blurred vision, eye tearing, and rhinorrhea, and she is occasionally unable to work during a headache. The headache worsens with physical activity, such as brisk walking. Physical and neurologic examinations, including funduscopic examination, are normal.
Which of the following is the most likely diagnosis?
A. Episodic tension-type headache
B. Cluster headache
C. Idiopathic intracranial hypertension
D. Migraine without aura
E. Sinus headache
Neurology:Question 15
A 55-year-old woman presents to her physician with a 4-week history of occipital headache with morning vomiting and a 1-week history of difficulty with peripheral vision to the left. She reports no other neurologic symptoms. The patient has a history of node-positive breast cancer. Neurologic examination reveals papilledema, left homonymous hemianopia, mild left hemiparesis, and subtle gait ataxia. Chest radiograph shows multiple nodules.
Which of the following is the most likely cause of this patient’s findings?
A. Parenchymal brain metastases
B. Leptomeningeal metastases
C. Paraneoplastic encephalitis
D. Cerebral infarction
A 55-year-old woman presents to her physician with a 4-week history of occipital headache with morning vomiting and a 1-week history of difficulty with peripheral vision to the left. She reports no other neurologic symptoms. The patient has a history of node-positive breast cancer. Neurologic examination reveals papilledema, left homonymous hemianopia, mild left hemiparesis, and subtle gait ataxia. Chest radiograph shows multiple nodules.
Which of the following is the most likely cause of this patient’s findings?
A. Parenchymal brain metastases
B. Leptomeningeal metastases
C. Paraneoplastic encephalitis
D. Cerebral infarction
Neurology:Question 16
A 25-year-old woman comes to the office for a follow-up visit. She has a 10-year history of complex partial seizures with occasional secondary generalization. The patient reports that she is 14 weeks pregnant and that she has had no seizures since her last visit more than 1 year ago. Currently, she is on carbamazepine monotherapy, 200 mg three times daily. Her carbamazepine blood level today is 8.2 μglmL (therapeutic range, 8 to 12 μglmL).
Which of the following is the most appropriate next step in management?
A. Continue carbamazepine at the current dose
B. Increase the carbamazepine dose
C. Add another antiepileptic agent
D. Change carbamazepine to lamotrigine
E. Discontinue carbamazepine
A 25-year-old woman comes to the office for a follow-up visit. She has a 10-year history of complex partial seizures with occasional secondary generalization. The patient reports that she is 14 weeks pregnant and that she has had no seizures since her last visit more than 1 year ago. Currently, she is on carbamazepine monotherapy, 200 mg three times daily. Her carbamazepine blood level today is 8.2 μglmL (therapeutic range, 8 to 12 μglmL).
Which of the following is the most appropriate next step in management?
A. Continue carbamazepine at the current dose
B. Increase the carbamazepine dose
C. Add another antiepileptic agent
D. Change carbamazepine to lamotrigine
E. Discontinue carbamazepine
Neurology:Question 17
A 67-year-old man comes to the emergency department because of sudden onset of severe vertigo, headache, nausea, vomiting, and inability to walk. He has a history of hypertension. On examination, his blood pressure is 190/110 mm Hg; pulse, 100/min, respiratory rate, 18/mm, and temperature, 36.7 C (98 F). He is in distress from severe headache and nausea. He has dysarthria, prominent nystagmus on lateral gaze, and clumsiness of the left arm on finger-to-nose maneuver, and he falls to the left when he tries to sit up.
Which of the following is the most likely cause of this patient’s presentation?
A. Menieres disease
B. Vestibular neuronitis
C. Cerebellar hemorrhage
D. Benign positional vertigo
A 67-year-old man comes to the emergency department because of sudden onset of severe vertigo, headache, nausea, vomiting, and inability to walk. He has a history of hypertension. On examination, his blood pressure is 190/110 mm Hg; pulse, 100/min, respiratory rate, 18/mm, and temperature, 36.7 C (98 F). He is in distress from severe headache and nausea. He has dysarthria, prominent nystagmus on lateral gaze, and clumsiness of the left arm on finger-to-nose maneuver, and he falls to the left when he tries to sit up.
Which of the following is the most likely cause of this patient’s presentation?
A. Menieres disease
B. Vestibular neuronitis
C. Cerebellar hemorrhage
D. Benign positional vertigo
Neurology:Question 18
A 38-year-old man comes to the office because of paresthesias in his feet that began approximately 8 months ago. He now also has bilateral foot drop and weakness of the right hand. On examination, he has severe weakness in the foot dorsiflexors bilaterally and moderate weakness of foot eversion, inversion, and plantar flexion. He has mild weakness of hip flexion and is unable to rise from a chair without using his arms. There is also weakness in the ulnar-innervated hand muscles, slightly more pronounced on the right than on the left. There are no obtainable reflexes, and he has moderate proprioceptive loss in the toes.
Which of the following is the most likely diagnosis?
A. Guillain-Barré syndrome
B. Chronic inflammatory demyelinating polyneuropathy
C. Polymyositis
D. Myasthenia gravis
A 38-year-old man comes to the office because of paresthesias in his feet that began approximately 8 months ago. He now also has bilateral foot drop and weakness of the right hand. On examination, he has severe weakness in the foot dorsiflexors bilaterally and moderate weakness of foot eversion, inversion, and plantar flexion. He has mild weakness of hip flexion and is unable to rise from a chair without using his arms. There is also weakness in the ulnar-innervated hand muscles, slightly more pronounced on the right than on the left. There are no obtainable reflexes, and he has moderate proprioceptive loss in the toes.
Which of the following is the most likely diagnosis?
A. Guillain-Barré syndrome
B. Chronic inflammatory demyelinating polyneuropathy
C. Polymyositis
D. Myasthenia gravis
Neurology:Question 19
An 85-year-old man arrives in the emergency department within 30 minutes of sudden-onset left
hemiparesis. Blood pressure is 240/124 mm Hg on arrival and 2 hours after the onset of his symptoms.
He has severe left hemiparesis, neglect (left hemi-inattention), and a left hemisensory deficit.
Electrocardiography, laboratory tests, and cerebral computed tomography are normal.
Which of the following is the most appropriate management for this patient?
A. Give intravenous labetalol to achieve blood pressure below 185/110 mm Hg and then give intravenous tissue plasminogen activator (t-PA).
B. Give intravenous nitroprusside to achieve blood pressure below 185/110 mm Hg and then give intravenous t-PA.
C. Do not give antihypertensive medication or intravenous t-PA.
D. Do not give antihypertensive medication but do give intravenous t-PA.
E. Give antihypertensive medication to achieve blood pressure below 185/110 mm Hg and then give intra-arterial t-PA.
An 85-year-old man arrives in the emergency department within 30 minutes of sudden-onset left
hemiparesis. Blood pressure is 240/124 mm Hg on arrival and 2 hours after the onset of his symptoms.
He has severe left hemiparesis, neglect (left hemi-inattention), and a left hemisensory deficit.
Electrocardiography, laboratory tests, and cerebral computed tomography are normal.
Which of the following is the most appropriate management for this patient?
A. Give intravenous labetalol to achieve blood pressure below 185/110 mm Hg and then give intravenous tissue plasminogen activator (t-PA).
B. Give intravenous nitroprusside to achieve blood pressure below 185/110 mm Hg and then give intravenous t-PA.
C. Do not give antihypertensive medication or intravenous t-PA.
D. Do not give antihypertensive medication but do give intravenous t-PA.
E. Give antihypertensive medication to achieve blood pressure below 185/110 mm Hg and then give intra-arterial t-PA.
Neurology:Question 20
A 23-year-old woman comes to the office for re-evaluation of migraine headaches. She was seen 2 weeks earlier because of recurrent generalized, moderate to severe pulsatile headaches associated with nausea and light and noise sensitivity. The headaches typically last 1 to 2 days, and she was having approximately 10 headache days per month. Amitriptyline was begun at a dose of 10 mg at bedtime, with instructions to increase the dose in 10-mg increments every week toward an initial target dose of 50 mg. The current dose is 30 mg at bedtime. She tolerates the amitriptyline well. Today she has developed a typical attack that is treated with subcutaneous sumatriptan in the office.
What plan should be pursued for prophylactic treatment?
A. Continue amitriptyline at the current dose.
B. Continue increasing amitriptyline as planned.
C. Discontinue all prophylaxis.
D. Discontinue amitriptyline and begin propranolol.
E. Discontinue amitriptyline and begin divalproex sodium.
A 23-year-old woman comes to the office for re-evaluation of migraine headaches. She was seen 2 weeks earlier because of recurrent generalized, moderate to severe pulsatile headaches associated with nausea and light and noise sensitivity. The headaches typically last 1 to 2 days, and she was having approximately 10 headache days per month. Amitriptyline was begun at a dose of 10 mg at bedtime, with instructions to increase the dose in 10-mg increments every week toward an initial target dose of 50 mg. The current dose is 30 mg at bedtime. She tolerates the amitriptyline well. Today she has developed a typical attack that is treated with subcutaneous sumatriptan in the office.
What plan should be pursued for prophylactic treatment?
A. Continue amitriptyline at the current dose.
B. Continue increasing amitriptyline as planned.
C. Discontinue all prophylaxis.
D. Discontinue amitriptyline and begin propranolol.
E. Discontinue amitriptyline and begin divalproex sodium.
Neurology:Question 21
A 55-year-old man reports that his handwriting has been getting smaller, and his wife states that he has been walking with a slow, shuffling gait for about 2 years. He otherwise feels well. He has diabetes, diabetic gastroparesis, a 3-year history of celiac disease responsive to medications and a gluten-free diet, and depression. Daily medications are glyburide, ranitidine, metoclopramide, and bupropion. On examination, he has facial masking, a slightly shuffling gait, bilateral reduced arm swing, mild diffuse limb rigidity, and reduced speed when performing rapid alternating movements.
What is the most appropriate management of his current symptoms?
A. Discontinue metoclopramide.
B. Discontinue ranitidine.
C. Discontinue bupropion.
D. Begin carbidopa/levodopa.
E. Begin pramipexole.
A 55-year-old man reports that his handwriting has been getting smaller, and his wife states that he has been walking with a slow, shuffling gait for about 2 years. He otherwise feels well. He has diabetes, diabetic gastroparesis, a 3-year history of celiac disease responsive to medications and a gluten-free diet, and depression. Daily medications are glyburide, ranitidine, metoclopramide, and bupropion. On examination, he has facial masking, a slightly shuffling gait, bilateral reduced arm swing, mild diffuse limb rigidity, and reduced speed when performing rapid alternating movements.
What is the most appropriate management of his current symptoms?
A. Discontinue metoclopramide.
B. Discontinue ranitidine.
C. Discontinue bupropion.
D. Begin carbidopa/levodopa.
E. Begin pramipexole.
Neurology:Question 22
A 60-year-old woman with a history of adenocarcinoma of the lung presents to her physician with a 3-week history of horizontal diplopia, dysphagia, and right leg pain with foot drop. Examination reveals weakness of right eye abduction, left facial weakness, reduced gag reflex, and weakness of the right leg muscles supplied by the L5 nerve root. Computed tomography of the head with contrast shows only enlargement of the entire ventricular system (communicating hydrocephalus).
Which of the following is the most likely cause of this patient’s findings?
A. Parenchymal brain metastases
B. Venous sinus thrombosis
C. Paraneoplastic encephalitis
D. Leptomeningeal metastases
E. Herpes zoster infection of the central nervous system
A 60-year-old woman with a history of adenocarcinoma of the lung presents to her physician with a 3-week history of horizontal diplopia, dysphagia, and right leg pain with foot drop. Examination reveals weakness of right eye abduction, left facial weakness, reduced gag reflex, and weakness of the right leg muscles supplied by the L5 nerve root. Computed tomography of the head with contrast shows only enlargement of the entire ventricular system (communicating hydrocephalus).
Which of the following is the most likely cause of this patient’s findings?
A. Parenchymal brain metastases
B. Venous sinus thrombosis
C. Paraneoplastic encephalitis
D. Leptomeningeal metastases
E. Herpes zoster infection of the central nervous system
Neurology:Question 23
A 21-year-old woman comes to the office with her mother because of recurrent blackouts. The patient has had five episodes in her life, the last one a week ago. She describes feeling dizzy, lightheaded, nauseated, and warm prior to blacking out. According to her mother, the patient becomes pale, then falls suddenly to the ground and has several jerks of her limbs. Her mother states that the patient recovers consciousness almost immediately, without any confusion or disorientation. During one event, the patient was incontinent of urine, and did not recover for at least 30 seconds. Most episodes have occurred in church after prolonged standing; the latest occurred when the patient witnessed a medical procedure while visiting a relative in the hospital.
Which of the following is the most likely diagnosis?
A. Juvenile myoclonic epilepsy
B. Complex partial seizures with secondary generalization
C. Syncope
D. Nonepileptic events (pseudoseizures)
E. Atonic seizures
A 21-year-old woman comes to the office with her mother because of recurrent blackouts. The patient has had five episodes in her life, the last one a week ago. She describes feeling dizzy, lightheaded, nauseated, and warm prior to blacking out. According to her mother, the patient becomes pale, then falls suddenly to the ground and has several jerks of her limbs. Her mother states that the patient recovers consciousness almost immediately, without any confusion or disorientation. During one event, the patient was incontinent of urine, and did not recover for at least 30 seconds. Most episodes have occurred in church after prolonged standing; the latest occurred when the patient witnessed a medical procedure while visiting a relative in the hospital.
Which of the following is the most likely diagnosis?
A. Juvenile myoclonic epilepsy
B. Complex partial seizures with secondary generalization
C. Syncope
D. Nonepileptic events (pseudoseizures)
E. Atonic seizures
Neurology:Question 24
A 29-year-old woman with multiple sclerosis comes to the office because of overwhelming fatigue. She has had three exacerbations of multiple sclerosis in the past 8 years and is now in remission. Her fatigue is particularly severe in mid afternoon; she often naps if possible or finds it difficult to concentrate on work. She has no problem falling asleep at night and does not wake up before she wishes. She sleeps 10 hours a day. She has no symptoms to suggest depression. Neurologic examination and thyroid function studies are normal.
Which of the following would be a reasonable medication to prescribe for her pathologic fatigue?
A. Thyroid supplement
B. Amphetamine
C. Amantadine
D. Fluoxetine
E. Pemoline
A 29-year-old woman with multiple sclerosis comes to the office because of overwhelming fatigue. She has had three exacerbations of multiple sclerosis in the past 8 years and is now in remission. Her fatigue is particularly severe in mid afternoon; she often naps if possible or finds it difficult to concentrate on work. She has no problem falling asleep at night and does not wake up before she wishes. She sleeps 10 hours a day. She has no symptoms to suggest depression. Neurologic examination and thyroid function studies are normal.
Which of the following would be a reasonable medication to prescribe for her pathologic fatigue?
A. Thyroid supplement
B. Amphetamine
C. Amantadine
D. Fluoxetine
E. Pemoline
Neurology:Question 25
A 78-year-old man is evaluated in the office for progressive impairment of memory and other aspects of intellect, which has developed insidiously over 3 years. The patient recalls none of three words after a 3-minute delay, and has a Mini-Mental State Examination score of 22 of 30. There are no other
significant findings on physical examination.
Which of the following is most likely to improve this patient’s symptoms?
A. Galantamine
B. Gingko biloba
C. Vitamin E
D. Selegiline
A 78-year-old man is evaluated in the office for progressive impairment of memory and other aspects of intellect, which has developed insidiously over 3 years. The patient recalls none of three words after a 3-minute delay, and has a Mini-Mental State Examination score of 22 of 30. There are no other
significant findings on physical examination.
Which of the following is most likely to improve this patient’s symptoms?
A. Galantamine
B. Gingko biloba
C. Vitamin E
D. Selegiline
Neurology:Question 26
A 67-year-old man who lives alone is found on the floor of his home by his son and is brought to the emergency department within 30 minutes. When last seen by his son 3 days earlier, the patient was in full health. In the emergency department, his blood pressure is 180/100 mm Hg. He is mildly lethargic and has global aphasia, a dense right visual field deficit, right hemiplegia, and no response to painful stimuli on the right side. Computed tomography of the head shows that much of the left hemisphere is dark (hypodense) with mass effect (compression of sulci and the left lateral ventricle).
Which of the following is the most appropriate next step in management of this patient?
A. Do not give acute therapy.
B. Give intravenous tissue plasminogen activator.
C. Give intra-arterial tissue plasminogen activator.
D. Give intravenous corticosteroids.
E. Give intravenous heparin.
A 67-year-old man who lives alone is found on the floor of his home by his son and is brought to the emergency department within 30 minutes. When last seen by his son 3 days earlier, the patient was in full health. In the emergency department, his blood pressure is 180/100 mm Hg. He is mildly lethargic and has global aphasia, a dense right visual field deficit, right hemiplegia, and no response to painful stimuli on the right side. Computed tomography of the head shows that much of the left hemisphere is dark (hypodense) with mass effect (compression of sulci and the left lateral ventricle).
Which of the following is the most appropriate next step in management of this patient?
A. Do not give acute therapy.
B. Give intravenous tissue plasminogen activator.
C. Give intra-arterial tissue plasminogen activator.
D. Give intravenous corticosteroids.
E. Give intravenous heparin.
Neurology:Question 27
A 60-year-old woman comes to the office for evaluation of fainting episodes. She feels lightheaded when she stands, and she has fainted three times within the past 2 months. She has imbalance and a shuffling gait that developed slowly over the past 2 years. She is sleepy during the day, and her husband describes high-pitched snoring (screeching’) while she sleeps. She has urinary incontinence. Her medical history is otherwise unremarkable. She takes no medications. Her older sister has a gait disorder. On examination, blood pressure is 120/80 mm Hg while sitting and 80/50 mm Hg when standing; pulse is 80 beats/min in both positions. Eye movements are normal. Finger-to-nose and heel-to-shin movements are uncoordinated, but there is no tremor. Movements are slow and there is limb rigidity. Deep tendon reflexes are brisk, and Babinski’s sign is present.
Which of the following is the most likely diagnosis?
A. Parkinson’s disease
B. Creutzfeldt-Jakob disease
C. Spinocerebellar degeneration
D. Progressive supranuclear palsy
E. Multiple system atrophy
A 60-year-old woman comes to the office for evaluation of fainting episodes. She feels lightheaded when she stands, and she has fainted three times within the past 2 months. She has imbalance and a shuffling gait that developed slowly over the past 2 years. She is sleepy during the day, and her husband describes high-pitched snoring (screeching’) while she sleeps. She has urinary incontinence. Her medical history is otherwise unremarkable. She takes no medications. Her older sister has a gait disorder. On examination, blood pressure is 120/80 mm Hg while sitting and 80/50 mm Hg when standing; pulse is 80 beats/min in both positions. Eye movements are normal. Finger-to-nose and heel-to-shin movements are uncoordinated, but there is no tremor. Movements are slow and there is limb rigidity. Deep tendon reflexes are brisk, and Babinski’s sign is present.
Which of the following is the most likely diagnosis?
A. Parkinson’s disease
B. Creutzfeldt-Jakob disease
C. Spinocerebellar degeneration
D. Progressive supranuclear palsy
E. Multiple system atrophy
Neurology:Question 28
A 46-year-old man comes to the office because of a 1-year history of a slowly progressive gait disorder. He describes his legs as heavy, and he tires quickly when walking. He has spasms in his legs especially when they are tired or when he tries to sleep at night, On examination, he has mild weakness in both hip flexors and ankle dorsiflexors, diffuse hyperreflexia, and bilateral extensor plantar responses. He has severe loss of proprioception and vibration sense in the legs. Pinprick sensation is normal throughout. Magnetic resonance imaging of the cervical and thoracic spine is normal; cerebrospinal fluid is normal, and there are no oligoclonal bands.
Which of the following is the most likely diagnosis?
A. Diabetic neuropathy
B. Polymyositis
C. Vitamin B 12 deficiency
D. Chronic inflammatory demyelinating polyradiculopathy
E. Lambert-Eaton myasthenic syndrome
A 46-year-old man comes to the office because of a 1-year history of a slowly progressive gait disorder. He describes his legs as heavy, and he tires quickly when walking. He has spasms in his legs especially when they are tired or when he tries to sleep at night, On examination, he has mild weakness in both hip flexors and ankle dorsiflexors, diffuse hyperreflexia, and bilateral extensor plantar responses. He has severe loss of proprioception and vibration sense in the legs. Pinprick sensation is normal throughout. Magnetic resonance imaging of the cervical and thoracic spine is normal; cerebrospinal fluid is normal, and there are no oligoclonal bands.
Which of the following is the most likely diagnosis?
A. Diabetic neuropathy
B. Polymyositis
C. Vitamin B 12 deficiency
D. Chronic inflammatory demyelinating polyradiculopathy
E. Lambert-Eaton myasthenic syndrome
Neurology:Question 29
A 29-year-old computer programmer is brought to the emergency department by friends after he suddenly falls to the ground at a party. He has severe headache, photophobia, and vomiting. He has no significant medical history. On examination, blood pressure is 210/110 mm Hg; pulse rate, 110/min; respiratory rate, 22/min; and temperature, 37.2 C (99 F). He is in moderate distress from headache. He has moderate meningismus but no focal neurologic findings. Routine laboratory tests are normal. Urine drug screen is positive for cocaine. Computed tomography of the brain shows a moderate-sized left thalamic hemorrhage with some intraventricular extension of blood. The patient is stabilized and his blood pressure is controlled with intravenous nicardipine. He is admitted to the intensive care unit for monitoring.
What additional diagnostic testing is most appropriate?
A. None
B. Electroencephalography
C. Echocardiography
D. Cerebral angiography
A 29-year-old computer programmer is brought to the emergency department by friends after he suddenly falls to the ground at a party. He has severe headache, photophobia, and vomiting. He has no significant medical history. On examination, blood pressure is 210/110 mm Hg; pulse rate, 110/min; respiratory rate, 22/min; and temperature, 37.2 C (99 F). He is in moderate distress from headache. He has moderate meningismus but no focal neurologic findings. Routine laboratory tests are normal. Urine drug screen is positive for cocaine. Computed tomography of the brain shows a moderate-sized left thalamic hemorrhage with some intraventricular extension of blood. The patient is stabilized and his blood pressure is controlled with intravenous nicardipine. He is admitted to the intensive care unit for monitoring.
What additional diagnostic testing is most appropriate?
A. None
B. Electroencephalography
C. Echocardiography
D. Cerebral angiography
Neurology:Question 30
An obese 66-year-old man has had increasing pain and numbness of the right anterior thigh over the past 3 weeks. He has not seen a physician in more than 20 years. On examination, he has moderate weakness of right knee extension, thigh adduction, and hip flexion. The right knee jerk reflex is absent; the left knee jerk is 1+. Achilles reflexes are absent bilaterally. He has sensory loss in the right anterior thigh region and a stocking-glove distribution of sensory loss in the distal legs. Magnetic resonance imaging of the lumbosacral spine and lumbosacral plexus is normal.
Which of the following studies is most likely to be diagnostic?
A. Creatine kinase level
B. Hemoglobin A 10 level
C. Thyroid function
D. Lumbar puncture
E. Erythrocyte sedimentation rate
An obese 66-year-old man has had increasing pain and numbness of the right anterior thigh over the past 3 weeks. He has not seen a physician in more than 20 years. On examination, he has moderate weakness of right knee extension, thigh adduction, and hip flexion. The right knee jerk reflex is absent; the left knee jerk is 1+. Achilles reflexes are absent bilaterally. He has sensory loss in the right anterior thigh region and a stocking-glove distribution of sensory loss in the distal legs. Magnetic resonance imaging of the lumbosacral spine and lumbosacral plexus is normal.
Which of the following studies is most likely to be diagnostic?
A. Creatine kinase level
B. Hemoglobin A 10 level
C. Thyroid function
D. Lumbar puncture
E. Erythrocyte sedimentation rate
Neurology:Question 31
A 68-year-old woman comes to the office because of a 2-year history of falls and imbalance that has progressed insidiously. She also has trouble reading and doing needlework because of poor vision. Family history is negative for neurologic disease. She has a staring facial expression. Visual acuity and visual fields are normal, but she has impaired upward/downward gaze. She moves stiffly and slowly, and nearly falls over while walking. Her neck and, to a lesser degree, limbs are rigid. Rapid alternating movements are markedly slowed.
Which of the following is the most likely diagnosis?
A. Parkinson’s disease
B. Generalized dystonia
C. Multiple system atrophy
D. Progressive supranuclear palsy
E. Cerebellar degeneration
A 68-year-old woman comes to the office because of a 2-year history of falls and imbalance that has progressed insidiously. She also has trouble reading and doing needlework because of poor vision. Family history is negative for neurologic disease. She has a staring facial expression. Visual acuity and visual fields are normal, but she has impaired upward/downward gaze. She moves stiffly and slowly, and nearly falls over while walking. Her neck and, to a lesser degree, limbs are rigid. Rapid alternating movements are markedly slowed.
Which of the following is the most likely diagnosis?
A. Parkinson’s disease
B. Generalized dystonia
C. Multiple system atrophy
D. Progressive supranuclear palsy
E. Cerebellar degeneration
Neurology:Question 32
A 57-year-old man with a clerical job is brought to the office by his wife for evaluation of changes in memory, personality, and behavior. Over the past 3 years, he has become progressively insensitive to his wife’s concerns, to the point that she has considered separation. He makes loud, inappropriate comments in public, and recently received a poor review from his work supervisor. Past medical history is unremarkable; he takes no medications. His mother, a maternal uncle, and the maternal grandfather had dementia. Physical examination is normal. The Mini-Mental State Examination score is 28 of 30.
Which of the following is the most likely diagnosis?
A. Mild cognitive impairment
B. Alzheimer’s disease
C. Dementia with Lewy bodies
D. Frontotemporal dementia
E. Creutzfeldt-Jakob disease
A 57-year-old man with a clerical job is brought to the office by his wife for evaluation of changes in memory, personality, and behavior. Over the past 3 years, he has become progressively insensitive to his wife’s concerns, to the point that she has considered separation. He makes loud, inappropriate comments in public, and recently received a poor review from his work supervisor. Past medical history is unremarkable; he takes no medications. His mother, a maternal uncle, and the maternal grandfather had dementia. Physical examination is normal. The Mini-Mental State Examination score is 28 of 30.
Which of the following is the most likely diagnosis?
A. Mild cognitive impairment
B. Alzheimer’s disease
C. Dementia with Lewy bodies
D. Frontotemporal dementia
E. Creutzfeldt-Jakob disease
Neurology:Question 33
A 70-year-old man presents to his physician with a 2-month history of progressive cognitive abnormalities and right-sided weakness. He has difficulty dressing and bathing himself and is frequently disoriented with respect to time and place. For the last week he is dragging his right foot when walking. On examination, he is alert but inattentive. He is disoriented with respect to time and place. Papilledema is present. There is a mild right hemiparesis affecting the right face, arm, and leg. Computed tomography of the head with contrast shows multiple, homogeneously enhancing lesions in the periventricular white matter of both cerebral hemispheres (left more than right) with surrounding edema and mass effect. A biopsy of one of the lesions is performed. Postoperatively, dexamethasone, 4 mg three times daily, is administered; after 2 days, the patient is alert and fully oriented, and his right-sided strength is normal. Computed tomography of the head is repeated and shows marked improvement in all lesions with reduced enhancement and mass effect.
Which of the following is the most likely cause of this patient’s findings?
A. Metastatic carcinoma
B. Multiple sclerosis
C. Glioblastoma multiforme
D. Central nervous system vasculitis
E. Primary central nervous system lymphoma
A 70-year-old man presents to his physician with a 2-month history of progressive cognitive abnormalities and right-sided weakness. He has difficulty dressing and bathing himself and is frequently disoriented with respect to time and place. For the last week he is dragging his right foot when walking. On examination, he is alert but inattentive. He is disoriented with respect to time and place. Papilledema is present. There is a mild right hemiparesis affecting the right face, arm, and leg. Computed tomography of the head with contrast shows multiple, homogeneously enhancing lesions in the periventricular white matter of both cerebral hemispheres (left more than right) with surrounding edema and mass effect. A biopsy of one of the lesions is performed. Postoperatively, dexamethasone, 4 mg three times daily, is administered; after 2 days, the patient is alert and fully oriented, and his right-sided strength is normal. Computed tomography of the head is repeated and shows marked improvement in all lesions with reduced enhancement and mass effect.
Which of the following is the most likely cause of this patient’s findings?
A. Metastatic carcinoma
B. Multiple sclerosis
C. Glioblastoma multiforme
D. Central nervous system vasculitis
E. Primary central nervous system lymphoma
Neurology:Question 34
A 40-year-old woman with secondary progressive multiple sclerosis continues to have a gradual decline in neurologic status despite treatment with interferon beta. Two years ago she could walk 200 meters without a cane or rest. She has recently worsened to the point that she can walk no further than 25 meters with a walker. On examination, she has bilateral lower-extremity weakness and hyperreflexia. Magnetic resonance imaging of the brain shows multiple white matter lesions in a periventricular distribution.
Which of the following treatments would be most appropriate instead of interferon beta?
A. Chronic oral prednisone
B. Bone marrow transplantation
C. Glatiramer acetate
D. Plasmapheresis
E. Mitoxantrone
A 40-year-old woman with secondary progressive multiple sclerosis continues to have a gradual decline in neurologic status despite treatment with interferon beta. Two years ago she could walk 200 meters without a cane or rest. She has recently worsened to the point that she can walk no further than 25 meters with a walker. On examination, she has bilateral lower-extremity weakness and hyperreflexia. Magnetic resonance imaging of the brain shows multiple white matter lesions in a periventricular distribution.
Which of the following treatments would be most appropriate instead of interferon beta?
A. Chronic oral prednisone
B. Bone marrow transplantation
C. Glatiramer acetate
D. Plasmapheresis
E. Mitoxantrone
Neurology:Question 35
A 24-year-old woman comes to the office because of severe generalized, throbbing headaches associated with nausea, occasional vomiting, and light and noise sensitivity. The headaches occur two to three times weekly and last 12 to 24 hours. She misses approximately 1 workday each month. She has been taking zolmitriptan, 5 mg orally, for acute attacks, with good benefit approximately two thirds of the time. She has insomnia and a past history of childhood asthma.
Which of the following medications is most appropriate to prevent the headaches?
A. Amitriptyline
B. Nadolol
C. Naratriptan
D. Propranolol
E. Sertraline
A 24-year-old woman comes to the office because of severe generalized, throbbing headaches associated with nausea, occasional vomiting, and light and noise sensitivity. The headaches occur two to three times weekly and last 12 to 24 hours. She misses approximately 1 workday each month. She has been taking zolmitriptan, 5 mg orally, for acute attacks, with good benefit approximately two thirds of the time. She has insomnia and a past history of childhood asthma.
Which of the following medications is most appropriate to prevent the headaches?
A. Amitriptyline
B. Nadolol
C. Naratriptan
D. Propranolol
Neurology:Question 36
A 38-year-old man comes for a follow-up visit. Four years earlier, he had three complex partial seizures and began treatment with phenytoin. He has had no seizures since beginning treatment and tolerates the medication well. He has no previous personal or family history of seizures or other neurologic illness. Neurologic examination is normal. The patients electroencephalograms (EEGs) consistently show right temporal spikes and sharp waves; his last EEG was 3 months ago. Magnetic resonance imaging (MRI) of the brain is normal. He asks whether he still needs to take phenytoin.
Which of the following would you recommend for this patient?
A. Taper phenytoin
B. Continue phenytoin at current dose
C. Change phenytoin to carbamazepine
D. Obtain single photon emission computed tomography (SPECT)
E. Repeat EEG and MRI of brain
A 38-year-old man comes for a follow-up visit. Four years earlier, he had three complex partial seizures and began treatment with phenytoin. He has had no seizures since beginning treatment and tolerates the medication well. He has no previous personal or family history of seizures or other neurologic illness. Neurologic examination is normal. The patients electroencephalograms (EEGs) consistently show right temporal spikes and sharp waves; his last EEG was 3 months ago. Magnetic resonance imaging (MRI) of the brain is normal. He asks whether he still needs to take phenytoin.
Which of the following would you recommend for this patient?
A. Taper phenytoin
B. Continue phenytoin at current dose
C. Change phenytoin to carbamazepine
D. Obtain single photon emission computed tomography (SPECT)
E. Repeat EEG and MRI of brain
Neurology:Question 37
A 50-year-old woman presents to her physician with a 4-month history of progressive right-sided headache that sometimes awakens her from sleep. She has noted a non-tender swelling over the right side of her head for the past year. This is mostly apparent to her when she combs her hair. Neurologic examination is normal except for hyperreflexia of her left upper arm. There is asymmetry of the head, with a fullness of the right side of the skull. Computed tomography of the head reveals a dural-based, calcified, enhancing mass measuring 6 cm along the right cerebral convexity. There is hyperostosis of the skull contiguous with the lesion.
Which of the following is most likely responsible for the clinical and radiographic findings?
A. Low-grade glioma
B. Glioblastoma multiforme
C. Meningioma
D. Subdural hematoma
E. Dural metastasis
A 50-year-old woman presents to her physician with a 4-month history of progressive right-sided headache that sometimes awakens her from sleep. She has noted a non-tender swelling over the right side of her head for the past year. This is mostly apparent to her when she combs her hair. Neurologic examination is normal except for hyperreflexia of her left upper arm. There is asymmetry of the head, with a fullness of the right side of the skull. Computed tomography of the head reveals a dural-based, calcified, enhancing mass measuring 6 cm along the right cerebral convexity. There is hyperostosis of the skull contiguous with the lesion.
Which of the following is most likely responsible for the clinical and radiographic findings?
A. Low-grade glioma
B. Glioblastoma multiforme
C. Meningioma
D. Subdural hematoma
E. Dural metastasis
Neurology:Question 38
An 87-year-old previously healthy woman awakens at 5:00 a.m., makes coffee, and then falls to the kitchen floor unable to speak or move her right side, as witnessed by her daughter. In the emergency department, her blood pressure is 174/70 mm Hg. She has a dense global aphasia, right visual field deficit, right hemiplegia, and right hemisensory loss. Electrocardiography, routine laboratory tests, and computed tomography of the head are normal. At 6:15 a.m., the patients daughter asks about whether the patient should receive intravenous tissue plasminogen activator (t-PA).
Which of the following is the most appropriate response?
A. Intravenous t-PA is contraindicated because of the patients age and size of stroke.
B. Intravenous t-PA offers the patient the best chance of recovery.
C. Intra-arterial t-PA is safer than intravenous t-PA.
D. Intravenous t-PA and oral aspirin given simultaneously offer the best chance for recovery.
An 87-year-old previously healthy woman awakens at 5:00 a.m., makes coffee, and then falls to the kitchen floor unable to speak or move her right side, as witnessed by her daughter. In the emergency department, her blood pressure is 174/70 mm Hg. She has a dense global aphasia, right visual field deficit, right hemiplegia, and right hemisensory loss. Electrocardiography, routine laboratory tests, and computed tomography of the head are normal. At 6:15 a.m., the patients daughter asks about whether the patient should receive intravenous tissue plasminogen activator (t-PA).
Which of the following is the most appropriate response?
A. Intravenous t-PA is contraindicated because of the patients age and size of stroke.
B. Intravenous t-PA offers the patient the best chance of recovery.
C. Intra-arterial t-PA is safer than intravenous t-PA.
D. Intravenous t-PA and oral aspirin given simultaneously offer the best chance for recovery.
Neurology:Question 39
A 33-year-old man is brought to the emergency department by ambulance after having three generalized tonic-clonic seizures over 30 minutes without recovering consciousness between seizures. His friend states that the patient has a history of epilepsy but is not compliant with his medications. During examination, the patient has another generalized seizure. He becomes cyanotic despite oxygen supplementation. His pulse is 110/min and blood pressure is 150/90 mm Hg. He continues to have seizures despite receiving 8 mg of intravenous lorazepam en route to the hospital. The patient weighs approximately 80 kg (176 Ib).
Which of the following intravenous medications should be administered next?
A. Fosphenytoin 1600 mg phenytoin-equivalent
B. Phenobarbital 1600 mg
C. Phenytoin 1000 mg
D. Valproic acid 1600 mg
A 33-year-old man is brought to the emergency department by ambulance after having three generalized tonic-clonic seizures over 30 minutes without recovering consciousness between seizures. His friend states that the patient has a history of epilepsy but is not compliant with his medications. During examination, the patient has another generalized seizure. He becomes cyanotic despite oxygen supplementation. His pulse is 110/min and blood pressure is 150/90 mm Hg. He continues to have seizures despite receiving 8 mg of intravenous lorazepam en route to the hospital. The patient weighs approximately 80 kg (176 Ib).
Which of the following intravenous medications should be administered next?
A. Fosphenytoin 1600 mg phenytoin-equivalent
B. Phenobarbital 1600 mg
C. Phenytoin 1000 mg
D. Valproic acid 1600 mg
Neurology:Question 40
A 75-year-old man is brought to the office because he is confused on a regular basis, particularly at night, and sometimes moment to moment during the day. He woke up thinking he was tied to the bed. He hallucinates that people are in the house, and sometimes believes his wife has been replaced by a look-alike. On some days he needs help with basic activities. Medical history is significant for a confusional episode due to prescription of meclizine for acute peripheral vestibulopathy 2 years earlier. Meclizine was discontinued, and at a follow-up office visit 1 month later the confusion was much improved. He currently takes no medications. There is no family history of dementia or parkinsonism. Masked facies, mild bradykinesia, and rigidity are evident. His score on the Mini-Mental State Examination is 20 of 30. The remainder of the examination is normal.
Which of the following is the most likely diagnosis?
A. Mild cognitive impairment
B. Alzheimer’s disease
C. Frontotemporal dementia
D. Dementia with Lewy bodies
A 75-year-old man is brought to the office because he is confused on a regular basis, particularly at night, and sometimes moment to moment during the day. He woke up thinking he was tied to the bed. He hallucinates that people are in the house, and sometimes believes his wife has been replaced by a look-alike. On some days he needs help with basic activities. Medical history is significant for a confusional episode due to prescription of meclizine for acute peripheral vestibulopathy 2 years earlier. Meclizine was discontinued, and at a follow-up office visit 1 month later the confusion was much improved. He currently takes no medications. There is no family history of dementia or parkinsonism. Masked facies, mild bradykinesia, and rigidity are evident. His score on the Mini-Mental State Examination is 20 of 30. The remainder of the examination is normal.
Which of the following is the most likely diagnosis?
A. Mild cognitive impairment
B. Alzheimer’s disease
C. Frontotemporal dementia
D. Dementia with Lewy bodies
Neurology:Question 41
A 35-year-old man comes to the office for evaluation of almost constant, involuntary movement of his hands and, to a lesser extent, his feet. The movements have developed insidiously over the past 3 years. He denies feeling nervous, and perceives that he has little control over the movements. He takes no medications and has otherwise been in excellent health. His wife mentions recent personality change.
Abnormal involuntary movements are seen throughout the examination. There is no pattern to the movements. His hands move continuously in rapidly flowing gyrations; he tends to sit on them when talking to prevent them from moving. He walks with dancing movements that sometimes cause him to misstep. He has an abnormal cognitive score on the office mental status examination.
Which of the following is the most likely cause of the movements?
A. Huntington’s chorea
B. Parkinson’s disease
C. Creutzfeldt-Jakob disease
D. Tourette’s syndrome
A 35-year-old man comes to the office for evaluation of almost constant, involuntary movement of his hands and, to a lesser extent, his feet. The movements have developed insidiously over the past 3 years. He denies feeling nervous, and perceives that he has little control over the movements. He takes no medications and has otherwise been in excellent health. His wife mentions recent personality change.
Abnormal involuntary movements are seen throughout the examination. There is no pattern to the movements. His hands move continuously in rapidly flowing gyrations; he tends to sit on them when talking to prevent them from moving. He walks with dancing movements that sometimes cause him to misstep. He has an abnormal cognitive score on the office mental status examination.
Which of the following is the most likely cause of the movements?
A. Huntington’s chorea
B. Parkinson’s disease
C. Creutzfeldt-Jakob disease
D. Tourette’s syndrome
Neurology:Question 42
A 45-year-old woman with multiple sclerosis comes to the office as a new patient. Her disease began 15 years ago with an attack of optic neuritis that resolved after 4 months. She was asymptomatic until 6 years ago, when she had weakness of the right leg that responded to treatment with intravenous corticosteroids. Over the next 5 years she had a series of exacerbations that were less responsive to treatment with intravenous corticosteroids and left her with residual neurologic deficits. In the past year, she has had gradual bilateral deterioration in leg strength, such that she now requires a walker.
Which of the following best describes this patient’s course of multiple sclerosis?
A. Monosymptomatic demyelination
B. Relapsing-remitting
C. Primary progressive
D. Secondary progressive
E. Benign
A 45-year-old woman with multiple sclerosis comes to the office as a new patient. Her disease began 15 years ago with an attack of optic neuritis that resolved after 4 months. She was asymptomatic until 6 years ago, when she had weakness of the right leg that responded to treatment with intravenous corticosteroids. Over the next 5 years she had a series of exacerbations that were less responsive to treatment with intravenous corticosteroids and left her with residual neurologic deficits. In the past year, she has had gradual bilateral deterioration in leg strength, such that she now requires a walker.
Which of the following best describes this patient’s course of multiple sclerosis?
A. Monosymptomatic demyelination
B. Relapsing-remitting
C. Primary progressive
D. Secondary progressive
E. Benign
Neurology:Question 43
A 75-year-old man comes to the emergency department because he has an ischemic stroke manifested by mild expressive aphasia and a mild right hemiparesis especially involving his face and arm. He has a history of hypertension, hypercholesterolemia, and cigarette smoking. Noninvasive cardiac evaluation reveals no cardioembolic source. Carotid duplex ultrasonography shows 80% to 99% stenosis of the left internal carotid artery (LICA) just above the carotid bifurcation. Catheter angiography reveals 70% stenosis of the extracranial LICA and no other extracranial or intracranial stenosis.
Which of the following is the most appropriate management for this patient?
A. Intravenous heparin
B. Aspirin
C. Aspirin plus dipyridamole
D. Left carotid endarterectomy
E. Clopidogrel
A 75-year-old man comes to the emergency department because he has an ischemic stroke manifested by mild expressive aphasia and a mild right hemiparesis especially involving his face and arm. He has a history of hypertension, hypercholesterolemia, and cigarette smoking. Noninvasive cardiac evaluation reveals no cardioembolic source. Carotid duplex ultrasonography shows 80% to 99% stenosis of the left internal carotid artery (LICA) just above the carotid bifurcation. Catheter angiography reveals 70% stenosis of the extracranial LICA and no other extracranial or intracranial stenosis.
Which of the following is the most appropriate management for this patient?
A. Intravenous heparin
B. Aspirin
C. Aspirin plus dipyridamole
D. Left carotid endarterectomy
Neurology:Question 44
A 75-year-old woman presents to the emergency department after a fall at home. She struck her head and was briefly unconscious. She is now alert and fully oriented. Neurologic examination is normal. Computed tomography of the head is negative for hemorrhage, but shows a 1-cm dural-based, calcifed, enhancing lesion over her left cerebral convexity.
Which of the following is the most appropriate management of this patients lesion?
A. Gross total resection
B. Biopsy
C. Gamma-knife radiosurgery
D. Observation
A 75-year-old woman presents to the emergency department after a fall at home. She struck her head and was briefly unconscious. She is now alert and fully oriented. Neurologic examination is normal. Computed tomography of the head is negative for hemorrhage, but shows a 1-cm dural-based, calcifed, enhancing lesion over her left cerebral convexity.
Which of the following is the most appropriate management of this patients lesion?
A. Gross total resection
B. Biopsy
C. Gamma-knife radiosurgery
D. Observation
Neurology:Question 45
A 72-year-old woman is admitted to the hospital after a cardiac arrest at home. Minutes after the event, paramedics discern no heartbeat, but she regains sinus rhythm after a 30-minute resuscitative effort. An acute myocardial infarction is diagnosed on admission. Five weeks after the cardiac arrest, she remains unresponsive to voice and does not follow any commands. Her pupillary responses are intact, she has full lateral eye movements to the doll’s head maneuver, and she triggers the ventilator with spontaneous respirations. Her eyes are open some of the time, and she appears to have sleep-wake cycles. There is no evidence of purposeful or voluntary response to visual, auditory, tactile, or noxious stimuli, but she flexes her arms to noxious stimuli.
Which of the following is the most appropriate description of this patients neurologic condition?
A. Brain death
B. Locked-in syndrome
C. Minimally conscious state
D. Persistent vegetative state
A 72-year-old woman is admitted to the hospital after a cardiac arrest at home. Minutes after the event, paramedics discern no heartbeat, but she regains sinus rhythm after a 30-minute resuscitative effort. An acute myocardial infarction is diagnosed on admission. Five weeks after the cardiac arrest, she remains unresponsive to voice and does not follow any commands. Her pupillary responses are intact, she has full lateral eye movements to the doll’s head maneuver, and she triggers the ventilator with spontaneous respirations. Her eyes are open some of the time, and she appears to have sleep-wake cycles. There is no evidence of purposeful or voluntary response to visual, auditory, tactile, or noxious stimuli, but she flexes her arms to noxious stimuli.
Which of the following is the most appropriate description of this patients neurologic condition?
A. Brain death
B. Locked-in syndrome
C. Minimally conscious state
D. Persistent vegetative state
Neurology:Question 46
A 29-year-old woman comes to the office because of gradual loss of vision in her left eye over 5 days. The problem started as a “smudge” in her central visual field and gradually worsened such that she cannot read with her left eye. She has pain with left eye movements, and she is finding it difficult to work because of the impairment.
Neurologic examination is unremarkable except for eye findings. Visual acuity is 20/20 in the right eye and 20/400 in the left eye. Visual field testing shows a dense central scotoma on the left. Funduscopic examination is normal. There is a left afferent pupillary defect. Magnetic resonance imaging of the brain is normal.
What is the best course of treatment?
A. Intravenous methylprednisolone
B. Interferon beta
C. Glatiramer acetate
D. Aspirin
E. Oral prednisone
A 29-year-old woman comes to the office because of gradual loss of vision in her left eye over 5 days. The problem started as a “smudge” in her central visual field and gradually worsened such that she cannot read with her left eye. She has pain with left eye movements, and she is finding it difficult to work because of the impairment.
Neurologic examination is unremarkable except for eye findings. Visual acuity is 20/20 in the right eye and 20/400 in the left eye. Visual field testing shows a dense central scotoma on the left. Funduscopic examination is normal. There is a left afferent pupillary defect. Magnetic resonance imaging of the brain is normal.
What is the best course of treatment?
A. Intravenous methylprednisolone
B. Interferon beta
C. Glatiramer acetate
D. Aspirin
E. Oral prednisone
Neurology:Question 47
A 26-year-old woman comes to the office with her husband, who provides the clinical history. According to him, for the last couple of months the patient has been having episodes of sudden “freezing and looking around, during which she is unresponsive if people talk to her. The episodes last between 5 and 15 seconds, and occur 3 to 6 times a week. The patient does not recall these events and accuses her husband of making them up. Physical examination is normal.
Which one of the following medications should be started while diagnostic work-up is in progress?
A. Lamotrigine
B. Phenobarbital
C. Gabapentin
D. Carbamazepine
E. Ethosuximide
A 26-year-old woman comes to the office with her husband, who provides the clinical history. According to him, for the last couple of months the patient has been having episodes of sudden “freezing and looking around, during which she is unresponsive if people talk to her. The episodes last between 5 and 15 seconds, and occur 3 to 6 times a week. The patient does not recall these events and accuses her husband of making them up. Physical examination is normal.
Which one of the following medications should be started while diagnostic work-up is in progress?
A. Lamotrigine
B. Phenobarbital
C. Gabapentin
D. Carbamazepine
E. Ethosuximide
Neurology:Question 48
A 55-year-old woman has noticed a tremor of her hands for the past 2 to 3 years. Initially, it was apparent when she held a cup of coffee or wrote, but it now also interferes with her use of eating utensils and computer keyboarding. She requests treatment. Medical and family history is negative and she takes no medications. Examination is remarkable only for a moderately severe, bilateral postural and action tremor of both hands. Routine blood studies, including thyroid-stimulating hormone, are normal.
Which of the following would be appropriate therapy?
A. Atenolol
B. Carbidopa/levodopa
C. Primidone
D. Valproic acid
E. Pramipexole
A 55-year-old woman has noticed a tremor of her hands for the past 2 to 3 years. Initially, it was apparent when she held a cup of coffee or wrote, but it now also interferes with her use of eating utensils and computer keyboarding. She requests treatment. Medical and family history is negative and she takes no medications. Examination is remarkable only for a moderately severe, bilateral postural and action tremor of both hands. Routine blood studies, including thyroid-stimulating hormone, are normal.
Which of the following would be appropriate therapy?
A. Atenolol
B. Carbidopa/levodopa
C. Primidone
D. Valproic acid
E. Pramipexole
Neurology:Question 49
A 73-year-old woman is brought to the emergency department because of sudden onset of moderate right hemiparesis and hemisensory deficit involving her face, arm, and leg equally. The patient has no relevant medical history and takes no medications. She has no other signs or symptoms. She is admitted for inpatient etiologic evaluation. Her average blood pressure during hospitalization is 138/82 mm Hg. Carotid duplex ultrasonography shows nonstenotic plaque bilaterally. Transthoracic echocardiography shows diastolic dysfunction but no potential cardioembolic source.
Which of the following should be recommended to the patient for blood pressure management?
A. Begin angiotensin-converting enzyme inhibitor in 2 weeks.
B. Begin oral β-blocker immediately.
C. Begin oral calcium channel blocker immediately.
D. Recommend diet and lifestyle changes only.
A 73-year-old woman is brought to the emergency department because of sudden onset of moderate right hemiparesis and hemisensory deficit involving her face, arm, and leg equally. The patient has no relevant medical history and takes no medications. She has no other signs or symptoms. She is admitted for inpatient etiologic evaluation. Her average blood pressure during hospitalization is 138/82 mm Hg. Carotid duplex ultrasonography shows nonstenotic plaque bilaterally. Transthoracic echocardiography shows diastolic dysfunction but no potential cardioembolic source.
Which of the following should be recommended to the patient for blood pressure management?
A. Begin angiotensin-converting enzyme inhibitor in 2 weeks.
B. Begin oral β-blocker immediately.
C. Begin oral calcium channel blocker immediately.
D. Recommend diet and lifestyle changes only.
Neurology:Question 50
A 37-year-old woman comes to the office because of recurrent headaches for 5 years. Initially, the headaches were of moderate intensity and occurred approximately four times per year. In the past year, she has had right-sided severe, pulsatile pain associated with light and noise sensitivity and nausea without vomiting; the headaches last 12 to 16 hours and occur once or twice monthly. The headaches cause her to miss work and other activities occasionally. She uses acetaminophen without benefit. Physical and neurologic examinations are normal.
Which of the following is most likely to be effective for acute treatment of this patients headaches?
A. Acetaminophen/ASA/caffeine combination
B. Acetaminophen/butalbital/caffeine combination
C. Aspirin
D. Naproxen
E. Zolmitriptan
A 37-year-old woman comes to the office because of recurrent headaches for 5 years. Initially, the headaches were of moderate intensity and occurred approximately four times per year. In the past year, she has had right-sided severe, pulsatile pain associated with light and noise sensitivity and nausea without vomiting; the headaches last 12 to 16 hours and occur once or twice monthly. The headaches cause her to miss work and other activities occasionally. She uses acetaminophen without benefit. Physical and neurologic examinations are normal.
Which of the following is most likely to be effective for acute treatment of this patients headaches?
A. Acetaminophen/ASA/caffeine combination
B. Acetaminophen/butalbital/caffeine combination
C. Aspirin
D. Naproxen
E. Zolmitriptan
Neurology:Question 51
A 30-year-old right-handed man with known HIV infection presents to the emergency department with a 3-day history of progressive right hemiparesis and aphasia. Magnetic resonance imaging of the brain reveals a homogeneously enhancing left frontal lesion. There is central necrosis and mass effect in the white matter of the left cerebral hemisphere. A biopsy is performed and reveals diffuse B-cell lymphoma.
Genomic information from which of the following viruses is most likely to be found in this patients tumor cells?
A. Cytomegalovirus
B. Epstein-Barr virus
C. Herpes simplex virus
D. Herpes zoster virus
A 30-year-old right-handed man with known HIV infection presents to the emergency department with a 3-day history of progressive right hemiparesis and aphasia. Magnetic resonance imaging of the brain reveals a homogeneously enhancing left frontal lesion. There is central necrosis and mass effect in the white matter of the left cerebral hemisphere. A biopsy is performed and reveals diffuse B-cell lymphoma.
Genomic information from which of the following viruses is most likely to be found in this patients tumor cells?
A. Cytomegalovirus
B. Epstein-Barr virus
C. Herpes simplex virus
D. Herpes zoster virus
Neurology:Question 52
A 44-year-old woman with a history of hypertension presents to the emergency department after sudden onset of the “worst headache” of her life. On examination, blood pressure is 190/95 mm Hg; pulse, 112/min ; respiratory rate, 24/mm; and temperature, 36.8 C (98.2 F). She is mildly drowsy but arouses easily and is cooperative. She has meningismus but no focal neurologic deficits. Computed tomography of the brain shows a moderate amount of subarachnoid blood.
After basic medical care, which of the following is the most important acute treatment at this time?
A. Oral nimodipine
B. Intravenous labetalol
C. Intravenous dexamethasone
D. Intravenous enalapril
A 44-year-old woman with a history of hypertension presents to the emergency department after sudden onset of the “worst headache” of her life. On examination, blood pressure is 190/95 mm Hg; pulse, 112/min ; respiratory rate, 24/mm; and temperature, 36.8 C (98.2 F). She is mildly drowsy but arouses easily and is cooperative. She has meningismus but no focal neurologic deficits. Computed tomography of the brain shows a moderate amount of subarachnoid blood.
After basic medical care, which of the following is the most important acute treatment at this time?
A. Oral nimodipine
B. Intravenous labetalol
C. Intravenous dexamethasone
D. Intravenous enalapril
Neurology:Question 53
A previously healthy 38-year-old man has numbness in the right anterolateral leg that began 3 weeks ago and is associated with a deep aching pain in the thigh. Ten days ago, he started to drag his right foot. Yesterday, he became aware of numbness in the fourth and fifth digits of the left hand. He has lost 10 lb in the past month, and has noted frequent night sweats. On examination, there is evidence of a right peroneal mononeuropathy and left ulnar mononeuropathy. Serum chemistries, including fasting blood glucose level, are normal.
Which of the following is the most likely diagnosis?
A. Amyloid polyneuropathy
B. Vasculitic neuropathy
C. Guillain-Barré syndrome
D. Diabetic neuropathy
A previously healthy 38-year-old man has numbness in the right anterolateral leg that began 3 weeks ago and is associated with a deep aching pain in the thigh. Ten days ago, he started to drag his right foot. Yesterday, he became aware of numbness in the fourth and fifth digits of the left hand. He has lost 10 lb in the past month, and has noted frequent night sweats. On examination, there is evidence of a right peroneal mononeuropathy and left ulnar mononeuropathy. Serum chemistries, including fasting blood glucose level, are normal.
Which of the following is the most likely diagnosis?
A. Amyloid polyneuropathy
B. Vasculitic neuropathy
C. Guillain-Barré syndrome
D. Diabetic neuropathy
Neurology:Question 54
An 18-year-old college student comes to the emergency department because of a seizure that occurred at 8:30 this morning. According to her roommate, the patient woke up at her usual time and had several episodes of brief arm jerks before she fell and lost consciousness. Her whole body stiffened for 5 to 10 seconds, and then she had rhythmic clonic jerking of her arms, legs, and trunk for about 2 to 3 minutes. She remained unresponsive for 10 minutes and then gradually regained complete consciousness over the next hour. The patient remembers the arm jerks but has no recollection of the seizure. She states that she has been having arm jerks in the morning for several months and that this has become worse recently. She has been staying up late every night for the last week studying for final examinations. Neurologic examination is normal.
Which of the following is the most likely diagnosis?
A. Partial seizure with secondary generalization
B. Absence epilepsy
C. Syncope
D. Juvenile myoclonic epilepsy
E. Nonepileptic event (pseudoseizure)
An 18-year-old college student comes to the emergency department because of a seizure that occurred at 8:30 this morning. According to her roommate, the patient woke up at her usual time and had several episodes of brief arm jerks before she fell and lost consciousness. Her whole body stiffened for 5 to 10 seconds, and then she had rhythmic clonic jerking of her arms, legs, and trunk for about 2 to 3 minutes. She remained unresponsive for 10 minutes and then gradually regained complete consciousness over the next hour. The patient remembers the arm jerks but has no recollection of the seizure. She states that she has been having arm jerks in the morning for several months and that this has become worse recently. She has been staying up late every night for the last week studying for final examinations. Neurologic examination is normal.
Which of the following is the most likely diagnosis?
A. Partial seizure with secondary generalization
B. Absence epilepsy
C. Syncope
D. Juvenile myoclonic epilepsy
E. Nonepileptic event (pseudoseizure)
Neurology:Question 55
A 26-year-old woman with clinically definite multiple sclerosis comes to the office because she is unexpectedly pregnant and wants to discuss how to proceed with disease management. She is maintained on interferon beta 1a. She has had one acute exacerbation in the past 2 years. Neurologic examination shows right afferent pupillary defect with mild weakness of the right leg and mild right-sided hyperreflexia. She asks how her multiple sclerosis and treatment will affect the pregnancy.
Which of the following is the most appropriate counsel to share with her?
A. Continue interferon
B. Discontinue interferon beta
C. Change to glatiramer acetate
D. Recommend therapeutic abortion
A 26-year-old woman with clinically definite multiple sclerosis comes to the office because she is unexpectedly pregnant and wants to discuss how to proceed with disease management. She is maintained on interferon beta 1a. She has had one acute exacerbation in the past 2 years. Neurologic examination shows right afferent pupillary defect with mild weakness of the right leg and mild right-sided hyperreflexia. She asks how her multiple sclerosis and treatment will affect the pregnancy.
Which of the following is the most appropriate counsel to share with her?
A. Continue interferon
B. Discontinue interferon beta
C. Change to glatiramer acetate
D. Recommend therapeutic abortion
A 42-year-old woman comes to the office because of a 3-year history of daily headaches that involve the left retro-orbital, temporal, and parietal areas. The headaches begin when she awakens and persist all day. The pain fluctuates from mild to moderate; at its most intense, she has left eye lacrimation and left-sided nasal congestion and rhinorrhea. She occasionally has nausea. The patient takes propranolol 160 mg/d without benefit. Physical and neurologic examinations are normal.
What is the most likely diagnosis?
A. Chronic tension-type headache
B. Chronic migraine
C. Cluster headache
D. Hemicrania continua
Neurology:Question 57
A 68-year-old woman comes for a routine physical examination. She describes a 2-year history of insomnia, which she attributes to an inability to get comfortable in bed because of a “creepy-crawly” sensation in her lower limbs. The sensation is absent during most of the day, but it has begun to bother her in the evening when she sits and is especially troublesome in bed. Walking relieves the sensation. Physical examination, including neurologic examination, is normal.
Which of the following studies should be done next?
A. Serum ceruloplasmin level
B. Serum ferritin level
C. Urine porphyrin level
D. Nerve conduction study
E. Magnetic resonance imaging of the brain
A 68-year-old woman comes for a routine physical examination. She describes a 2-year history of insomnia, which she attributes to an inability to get comfortable in bed because of a “creepy-crawly” sensation in her lower limbs. The sensation is absent during most of the day, but it has begun to bother her in the evening when she sits and is especially troublesome in bed. Walking relieves the sensation. Physical examination, including neurologic examination, is normal.
Which of the following studies should be done next?
A. Serum ceruloplasmin level
B. Serum ferritin level
C. Urine porphyrin level
D. Nerve conduction study
E. Magnetic resonance imaging of the brain
Neurology:Question 58
A 60-year-old woman is brought to the emergency department for evaluation of word-finding difficulty. She called her husband’s attention to the problem 3 weeks ago. Two weeks ago, the difficulty became apparent to others, and she began to have difficulty finding her way around the offices at work. One week ago she had difficulty navigating in her own home, confusing the garage, closet, and basement doors, and had difficulty with arithmetic calculations and vision. Past medical and family history is unremarkable. On examination, she has occasional myoclonic jerks of the upper extremities and facial musculature, worse on the right side. Her score is 15 of 30 on the Mini-Mental State Examination. Electroencephalography shows mild diffuse slowing. Magnetic resonance imaging of the brain is normal.
What is the next step in testing?
A. Lumbar puncture
B. Presenilin-1 test
C. Positron emission tomography/single photon emission computed tomography
D. Repeat electroencephalography in 1 week
E. Brain and leptomeningeal biopsy
A 60-year-old woman is brought to the emergency department for evaluation of word-finding difficulty. She called her husband’s attention to the problem 3 weeks ago. Two weeks ago, the difficulty became apparent to others, and she began to have difficulty finding her way around the offices at work. One week ago she had difficulty navigating in her own home, confusing the garage, closet, and basement doors, and had difficulty with arithmetic calculations and vision. Past medical and family history is unremarkable. On examination, she has occasional myoclonic jerks of the upper extremities and facial musculature, worse on the right side. Her score is 15 of 30 on the Mini-Mental State Examination. Electroencephalography shows mild diffuse slowing. Magnetic resonance imaging of the brain is normal.
What is the next step in testing?
A. Lumbar puncture
B. Presenilin-1 test
C. Positron emission tomography/single photon emission computed tomography
D. Repeat electroencephalography in 1 week
E. Brain and leptomeningeal biopsy
Neurology:Question 59
A 50-year-old previously healthy woman presents to her physician with a 3-week history of progressive gait and limb ataxia, dysarthria, and blurred vision. Examination reveals nystagmus, dysarthria, and severe gait and limb ataxia. The remainder of the neurologic examination is normal. Magnetic resonance imaging of the head with contrast is normal. A blood test reveals positive serology for anti-Yo antibodies (anti-Purkinje cell antibody).
Which of the following malignancies is most likely present in this patient?
A. Non-Hodgkin’s lymphoma
B. Small cell lung cancer
C. Ovarian cancer
D. Melanoma
A 50-year-old previously healthy woman presents to her physician with a 3-week history of progressive gait and limb ataxia, dysarthria, and blurred vision. Examination reveals nystagmus, dysarthria, and severe gait and limb ataxia. The remainder of the neurologic examination is normal. Magnetic resonance imaging of the head with contrast is normal. A blood test reveals positive serology for anti-Yo antibodies (anti-Purkinje cell antibody).
Which of the following malignancies is most likely present in this patient?
A. Non-Hodgkin’s lymphoma
B. Small cell lung cancer
C. Ovarian cancer
D. Melanoma
Neurology:Question 60
A 34-year-old man comes to the office because of a 1-month history of episodes during which he is suddenly unable to speak. The episodes last between 20 and 30 seconds. During some episodes, the patient has twitching of the right side of his face; on one occasion the twitching progressed to involve his right arm. He has had five events, the last three during the past week. No warning precedes the spells. The patient states that he is fully aware of his surroundings during the episodes and has no other symptoms. Neurologic examination is normal.
Which of the following is the most likely diagnosis?
A. Transient ischemic attack
B. Anxiety attack
C. Frontal lobe seizure
D. Hemiplegic migraine
E. Hypoglycemia
A 34-year-old man comes to the office because of a 1-month history of episodes during which he is suddenly unable to speak. The episodes last between 20 and 30 seconds. During some episodes, the patient has twitching of the right side of his face; on one occasion the twitching progressed to involve his right arm. He has had five events, the last three during the past week. No warning precedes the spells. The patient states that he is fully aware of his surroundings during the episodes and has no other symptoms. Neurologic examination is normal.
Which of the following is the most likely diagnosis?
A. Transient ischemic attack
B. Anxiety attack
C. Frontal lobe seizure
D. Hemiplegic migraine
E. Hypoglycemia
Neurology:Question 61
A 24-year-old woman comes to the emergency department because of a 3-day history of severe headache. She states that while she was at work she had sudden onset of excruciating, diffuse headache associated with nausea and vomiting. She was unable to continue working, and a colleague drove her home. Over the next 2 days the headache remained too severe for her to go to work. She has no significant past medical history except tobacco use. On examination, blood pressure is 144/90 mm Hg; pulse, 104/min; respiratory rate, 18/mm; and temperature, 37.2 C (98.9 F). She is mildly agitated and has photophobia and minimal neck stiffness. There are no focal neurologic deficits. Computed tomography of the brain is normal.
What is the most appropriate next step in the management of this patient?
A. Emergent magnetic resonance imaging
B. Lumbar puncture
C. Cerebral arteriography
D. Treatment with sumatriptan
E. Treatment with ketorolac
A 24-year-old woman comes to the emergency department because of a 3-day history of severe headache. She states that while she was at work she had sudden onset of excruciating, diffuse headache associated with nausea and vomiting. She was unable to continue working, and a colleague drove her home. Over the next 2 days the headache remained too severe for her to go to work. She has no significant past medical history except tobacco use. On examination, blood pressure is 144/90 mm Hg; pulse, 104/min; respiratory rate, 18/mm; and temperature, 37.2 C (98.9 F). She is mildly agitated and has photophobia and minimal neck stiffness. There are no focal neurologic deficits. Computed tomography of the brain is normal.
What is the most appropriate next step in the management of this patient?
A. Emergent magnetic resonance imaging
B. Lumbar puncture
C. Cerebral arteriography
D. Treatment with sumatriptan
E. Treatment with ketorolac
Neurology:Question 62
A 35-year-old woman comes to the office because of episodic, severe headaches with left retro-orbital and temporal pain and light and noise sensitivity; they are typically accompanied by severe nausea and vomiting shortly after onset. The headaches most commonly awaken her from sleep in the early morning and last 16 to 24 hours. They have occurred approximately one or two times per month for the past 4 years. There are no headache triggers. She has used over-the-counter medications and oral naratriptan without benefit. Physical and neurologic examinations are normal.
Which of the following is the most appropriate acute treatment for this patients headaches?
A. Oral almotriptan
B. Oral rizatriptan
C. Intravenous dihydroergotamine
D. Subcutaneous sumatriptan
A 35-year-old woman comes to the office because of episodic, severe headaches with left retro-orbital and temporal pain and light and noise sensitivity; they are typically accompanied by severe nausea and vomiting shortly after onset. The headaches most commonly awaken her from sleep in the early morning and last 16 to 24 hours. They have occurred approximately one or two times per month for the past 4 years. There are no headache triggers. She has used over-the-counter medications and oral naratriptan without benefit. Physical and neurologic examinations are normal.
Which of the following is the most appropriate acute treatment for this patients headaches?
A. Oral almotriptan
B. Oral rizatriptan
C. Intravenous dihydroergotamine
D. Subcutaneous sumatriptan
Neurology:Question 63
A 75-year-old man comes for an office visit because he is concerned about memory loss. He reports a family history of Alzheimers disease, with dementia affecting three first-degree relatives in their 50s. His difficulties are not apparent to his spouse or close friends, and have not affected his ability to perform his daily activities. He is an active and successful financial officer. Past medical history is remarkable for treated hypertension and osteoarthritis. There is no evidence of depression. Physical examination is normal. Mental status examination discloses mild to moderate memory impairment and no abnormalities in other areas of cognition. Levels of thyroid-stimulating hormone and vitamin B12 are normal, as is magnetic resonance imaging of the brain.
Which of the following is the most appropriate next step?
A. Presenilin-1 test
B. Follow-up evaluation in 1 year
C. Positron emission tomography/single photon emission computed tomography
D. Lumbar puncture
E. Diffusion-weighted magnetic resonance imaging
A 75-year-old man comes for an office visit because he is concerned about memory loss. He reports a family history of Alzheimers disease, with dementia affecting three first-degree relatives in their 50s. His difficulties are not apparent to his spouse or close friends, and have not affected his ability to perform his daily activities. He is an active and successful financial officer. Past medical history is remarkable for treated hypertension and osteoarthritis. There is no evidence of depression. Physical examination is normal. Mental status examination discloses mild to moderate memory impairment and no abnormalities in other areas of cognition. Levels of thyroid-stimulating hormone and vitamin B12 are normal, as is magnetic resonance imaging of the brain.
Which of the following is the most appropriate next step?
A. Presenilin-1 test
B. Follow-up evaluation in 1 year
C. Positron emission tomography/single photon emission computed tomography
D. Lumbar puncture
E. Diffusion-weighted magnetic resonance imaging
Neurology:Question 65
A 35-year-old woman comes to the office because she cannot prevent her neck from turning to the right. The condition developed insidiously over 2 years and is very painful. She is the secretary for a small law firm and is under pressure at work. She recalls no trauma and is otherwise in good health. On examination, she sits with her head turned 45 degrees to the right; walking exacerbates the condition. She is unable to rotate her head to the left. Cervical paraspinal muscles are tense. The remainder of the examination is normal.
Which of the following is most likely to be helpful?
A. Diazepam
B. Botulinum toxin injections
C. Carbidopa/levodopa
D. Cyclobenzaprine
E. Psychiatry referral
A 35-year-old woman comes to the office because she cannot prevent her neck from turning to the right. The condition developed insidiously over 2 years and is very painful. She is the secretary for a small law firm and is under pressure at work. She recalls no trauma and is otherwise in good health. On examination, she sits with her head turned 45 degrees to the right; walking exacerbates the condition. She is unable to rotate her head to the left. Cervical paraspinal muscles are tense. The remainder of the examination is normal.
Which of the following is most likely to be helpful?
A. Diazepam
B. Botulinum toxin injections
C. Carbidopa/levodopa
D. Cyclobenzaprine
E. Psychiatry referral
Neurology:Question 66
A 26-year-old woman comes to the office because of recurrent episodes of unusual behavior. She usually has a warning—a “weird” feeling in her stomach —prior to the episodes. Her husband has witnessed most of the events, and states that the patient suddenly freezes, looks around, smacks her lips, and moves her fingers repetitively. The episodes usually last between 30 seconds and 2 minutes. She has no recollection of the events after the warning. Afterward, the patient is confused and disoriented for as long as 10 minutes. The patient has had at least 10 episodes over the last 2 years.
Which of the following is the most likely diagnosis?
A. Complex partial seizures
B. Absence seizures
C. Nonepileptic events (pseudoseizures)
D. Migraine
E. Transient global amnesia
A 26-year-old woman comes to the office because of recurrent episodes of unusual behavior. She usually has a warning—a “weird” feeling in her stomach —prior to the episodes. Her husband has witnessed most of the events, and states that the patient suddenly freezes, looks around, smacks her lips, and moves her fingers repetitively. The episodes usually last between 30 seconds and 2 minutes. She has no recollection of the events after the warning. Afterward, the patient is confused and disoriented for as long as 10 minutes. The patient has had at least 10 episodes over the last 2 years.
Which of the following is the most likely diagnosis?
A. Complex partial seizures
B. Absence seizures
C. Nonepileptic events (pseudoseizures)
D. Migraine
E. Transient global amnesia
Neurology:Question 67
A65-year-oldwoman presentsto herphysicianwith a 1-month historyof proximal muscleweakness, with difficulty lifting her arms above her head and rising from a low chair. She also notes dry mouth and eyes and postural light-headedness. She has recently completed chemotherapy for small cell lung cancer. Examination reveals symmetric proximal muscle weakness that improves with repeated effort. Deep tendon reflexes are absent. The remainder of the neurologic examination is normal. Blood pressure in the right arm is 125/80 mm Hg lying down and 100/50 mm Hg standing. Pulse rate remains 70/min in either position.
Which of the following is the most likely diagnosis?
A. Metastatic spinal cord compression
B. Myasthenic syndrome
C. Polymyositis
D. Polyneuropathy
A65-year-oldwoman presentsto herphysicianwith a 1-month historyof proximal muscleweakness, with difficulty lifting her arms above her head and rising from a low chair. She also notes dry mouth and eyes and postural light-headedness. She has recently completed chemotherapy for small cell lung cancer. Examination reveals symmetric proximal muscle weakness that improves with repeated effort. Deep tendon reflexes are absent. The remainder of the neurologic examination is normal. Blood pressure in the right arm is 125/80 mm Hg lying down and 100/50 mm Hg standing. Pulse rate remains 70/min in either position.
Which of the following is the most likely diagnosis?
A. Metastatic spinal cord compression
B. Myasthenic syndrome
C. Polymyositis
D. Polyneuropathy
Neurology:Question 68
A 52-year-old woman comes to the emergency department because of a severe generalized, pulsatile headache accompanied by light and noise sensitivity, nausea, and repeated vomiting. The headache began 16 hours earlier. She has a 25-year history of recurrent migraine headaches. She takes amitriptyline for migraine prophylaxis and has used oral rizatriptan today. Pulse rate is 120/min and regular; brachial blood pressure is 160/94 mm Hg. Physical and neurologic examinations are otherwise normal.
In addition to intravenous fluid and electrolyte replacement, what is the most appropriate next step in management?
A. Intravenous dihydroergotamine
B. Intravenous dihydroergotamine and metoclopramide
C. Intravenous chlorpromazine
D. Oral codeine
E. Subcutaneous sumatriptan
A 52-year-old woman comes to the emergency department because of a severe generalized, pulsatile headache accompanied by light and noise sensitivity, nausea, and repeated vomiting. The headache began 16 hours earlier. She has a 25-year history of recurrent migraine headaches. She takes amitriptyline for migraine prophylaxis and has used oral rizatriptan today. Pulse rate is 120/min and regular; brachial blood pressure is 160/94 mm Hg. Physical and neurologic examinations are otherwise normal.
In addition to intravenous fluid and electrolyte replacement, what is the most appropriate next step in management?
A. Intravenous dihydroergotamine
B. Intravenous dihydroergotamine and metoclopramide
C. Intravenous chlorpromazine
D. Oral codeine
E. Subcutaneous sumatriptan
Neurology:Question 69
A 73-year-old man has sudden onset of right hem iparesis and expressive aphasia that improves nearly to baseline by the time he arrives in the emergency department. He is admitted to the hospital for rapid etiologic evaluation. Laboratory studies are normal except for a low-density lipoprotein level of 110 mg/dL. Carotid duplex ultrasonography shows left carotid stenosis of 50%.
Which of the following is the most appropriate management for this patient’s serum cholesterol?
A. Begin pravastatin.
B. Begin niacin.
C. Recommend diet and lifestyle changes only.
D. Recommend no further intervention.
A 73-year-old man has sudden onset of right hem iparesis and expressive aphasia that improves nearly to baseline by the time he arrives in the emergency department. He is admitted to the hospital for rapid etiologic evaluation. Laboratory studies are normal except for a low-density lipoprotein level of 110 mg/dL. Carotid duplex ultrasonography shows left carotid stenosis of 50%.
Which of the following is the most appropriate management for this patient’s serum cholesterol?
A. Begin pravastatin.
B. Begin niacin.
C. Recommend diet and lifestyle changes only.
D. Recommend no further intervention.
Neurology:Question 70
A 25-year-old man with a 15-year history of seizures comes to the office for routine follow-up. He has never been seizure free for more than a few weeks. A feeling of déjà vu precedes the seizures. He then has lip smacking and repetitive movements of his left fingers that continue for less than a minute and are followed by a generalized tonic-clonic seizure. He has had many injuries due to seizures. The patient has tried several combinations of antiepileptic drugs with varying success. Currently, he takes a combination of valproic acid and lamotrigine. Serum levels are in the therapeutic range. The patient has had several electroencephalograms showing focal right temporal lobe epileptiform activity. Magnetic resonance imaging of the brain performed 6 months ago is consistent with right mesial temporal sclerosis.
Which of the following is the most appropriate next management step?
A. Repeat magnetic resonance imaging of the brain
B. Refer for consideration of temporal lobe surgery
C. Order positron emission tomography
D. Treat with vagal nerve stimulation
E. Add a third antiepileptic drug
A 25-year-old man with a 15-year history of seizures comes to the office for routine follow-up. He has never been seizure free for more than a few weeks. A feeling of déjà vu precedes the seizures. He then has lip smacking and repetitive movements of his left fingers that continue for less than a minute and are followed by a generalized tonic-clonic seizure. He has had many injuries due to seizures. The patient has tried several combinations of antiepileptic drugs with varying success. Currently, he takes a combination of valproic acid and lamotrigine. Serum levels are in the therapeutic range. The patient has had several electroencephalograms showing focal right temporal lobe epileptiform activity. Magnetic resonance imaging of the brain performed 6 months ago is consistent with right mesial temporal sclerosis.
Which of the following is the most appropriate next management step?
A. Repeat magnetic resonance imaging of the brain
B. Refer for consideration of temporal lobe surgery
C. Order positron emission tomography
D. Treat with vagal nerve stimulation
E. Add a third antiepileptic drug
Neurology:Question 72
A 27-year-old man comes to the office for advice about treatment of his recently diagnosed multiple sclerosis. Three years ago he had an episode of diplopia that resolved entirely after 2 months. Six months ago, he had mild weakness and numbness of the right leg. Magnetic resonance imaging of the brain at that time showed multiple cerebral white matter lesions in a periventricular distribution classic for multiple sclerosis. His leg weakness resolved without treatment. He is now asymptomatic and has a normal neurologic examination.
Which of the following is the best treatment recommendation at this point?
A. High-dose intravenous methylprednisolone
B. Chronic oral prednisone
C. Azathioprine
D. Interferon beta
E. Observation
A 27-year-old man comes to the office for advice about treatment of his recently diagnosed multiple sclerosis. Three years ago he had an episode of diplopia that resolved entirely after 2 months. Six months ago, he had mild weakness and numbness of the right leg. Magnetic resonance imaging of the brain at that time showed multiple cerebral white matter lesions in a periventricular distribution classic for multiple sclerosis. His leg weakness resolved without treatment. He is now asymptomatic and has a normal neurologic examination.
Which of the following is the best treatment recommendation at this point?
A. High-dose intravenous methylprednisolone
B. Chronic oral prednisone
C. Azathioprine
D. Interferon beta
E. Observation
Neurology:Question 73
A 25-year-old woman comes to the office because of a 4-month history of generalized, nonpulsatile headaches of moderate severity. The headaches are associated with intermittent nausea and episodes during which the vision in her right eye fades for several seconds. She takes naproxen sodium 3 days per week. Physical examination is normal exceptfora body mass index of 32.1. Neurologic examination shows bilateral swelling of the optic discs. Magnetic resonance imaging of the brain and magnetic resonance venography are normal. Examination of CSF shows an opening pressure of 35 cm H2O, total protein of 35 mg/dL, glucose of 64 mg/dL, and 2 leukocytes/μL; the fluid is negative for VDRL. What is the most likely diagnosis?
A. Hydrocephalus
B. Chronic migraine
C. Borrelia burgdorferi meningitis
D. Idiopathic intracranial hypertension
E. Medication overuse headache
A 25-year-old woman comes to the office because of a 4-month history of generalized, nonpulsatile headaches of moderate severity. The headaches are associated with intermittent nausea and episodes during which the vision in her right eye fades for several seconds. She takes naproxen sodium 3 days per week. Physical examination is normal exceptfora body mass index of 32.1. Neurologic examination shows bilateral swelling of the optic discs. Magnetic resonance imaging of the brain and magnetic resonance venography are normal. Examination of CSF shows an opening pressure of 35 cm H2O, total protein of 35 mg/dL, glucose of 64 mg/dL, and 2 leukocytes/μL; the fluid is negative for VDRL. What is the most likely diagnosis?
A. Hydrocephalus
B. Chronic migraine
C. Borrelia burgdorferi meningitis
D. Idiopathic intracranial hypertension
E. Medication overuse headache
Neurology:Question 74
A 72-year-old woman is brought to the office by her daughter for evaluation of mental status changes. The patient had a stroke 1 month earlier, with mild residual left-sided weakness. She had one seizure while in the hospital; the seizure was considered grand mal, and she was treated with phenytoin. According to the daughter, the patient’s left face and arm twitch frequently, and her left side is weaker than when she left the hospital. For the last few days the patient has been confused and disoriented, “like in a daze.” Her current medications include phenytoin and aspirin. On examination, vital signs are normal. The patient is somewhat lethargic and has frequent twitching of her left face and arm. There is left facial weakness and left hemiparesis involving the face, arm, and leg. Complete blood count, serum electrolytes, and urinalysis are normal.
Which of the following is the most likely diagnosis?
A. Stroke in evolution
B. Partial status epilepticus
C. Phenytoin toxicity
D. Creutzfeldt-Jakob disease
Neurology:Question 75 A 72-year-old woman is brought to the office by her daughter for evaluation of mental status changes. The patient had a stroke 1 month earlier, with mild residual left-sided weakness. She had one seizure while in the hospital; the seizure was considered grand mal, and she was treated with phenytoin. According to the daughter, the patient’s left face and arm twitch frequently, and her left side is weaker than when she left the hospital. For the last few days the patient has been confused and disoriented, “like in a daze.” Her current medications include phenytoin and aspirin. On examination, vital signs are normal. The patient is somewhat lethargic and has frequent twitching of her left face and arm. There is left facial weakness and left hemiparesis involving the face, arm, and leg. Complete blood count, serum electrolytes, and urinalysis are normal.
Which of the following is the most likely diagnosis?
A. Stroke in evolution
B. Partial status epilepticus
C. Phenytoin toxicity
D. Creutzfeldt-Jakob disease
A 78-year-old man is brought to the office by his family because of memory decline and confusion. The family reports progressive confusion over 6 months. The family noticed his symptoms at first mainly in the morning, but they now seem to occur throughout the day. He does not recognize his spouse at times, and thinks someone is chasing him. He wanders from the house, has visual hallucinations, and has difficulty using household appliances. Medical history is significant for diabetes with painful peripheral neuropathy, coronary artery disease, and congestive heart failure. Medications include glyburide, nortriptyline, digoxin, lorazepam, diltiazem, and lisinopril. There is no family history of neurologic disease. On examination, the patient has mild asterixis and findings consistent with peripheral neuropathy. He is mildly lethargic and inattentive, and not oriented to time or place. He recalls two of three words after a delay. The Mini-Mental State Examination score is 13 of 30. Electrolyte levels, oxygen saturation, liver function, and renal function are normal. Computed tomography of the head without contrast is normal.
Which of the following conditions is most likely to account for his cognitive impairment?
A. Adverse effect of medication
B. Dementia with Lewy bodies
C. Cerebrovascular disease
D. Depression
