Neurology packrat Flashcards
1
Q
A 7 year-old is evaluated for episodes of unresponsiveness in which she stares, blinking into space. Episodes last only 10-20 seconds but may happen several times daily. There are no abnormal movements, sensory loss or headaches reported. Which of the following is considered first-line therapy for this disorder? A. Carbamazepine (Tegretol) B. Ethosuximide (Zarontin) C. Gabepentin (Neurontin) D. Topiramate (Topamax)
A
(c) B. Absence seizures are usually treated successfully with Ethosuximide. The other agents listed are not
indicated and may actually worsen this type of seizure.
2
Q
A 45 year-old female presents complaining of the worst headache of her life. Which of the following is the most appropriate initial diagnostic study? A. Magnetic resonance imaging (MRI) B. Computed tomography (CT) C. Electroencephalogram (EEG) D. Lumbar puncture (LP)
A
(c) B. A CT scan is more sensitive in detecting cerebral hemorrhage in the first 24 to 48 hours.
3
Q
A 37 year-old right-handed male presents with daily headaches for the past 2 months. They are worse in the morning and awaken him from sleep. In the past week, he has noticed a tendency to drop things. Neurologic examination reveals upper extremity strength of 4/5 on the right and 5/5 on the left. Which of the following is the most appropriate next step in the evaluation of this patient? A. Lumbar puncture (LP) B. Electroencephalogram (EEG) C. Magnetic resonance imaging (MRI) D. Electromyelogram (EMG)
A
(c) C. MRI is the most appropriate diagnostic study in the evaluation of a suspected intracranial neoplasm.
4
Q
Household contacts of a patient with bacterial meningitis are best treated with which of the following? A. Amoxicillin B. Ciprofloxin (Cipro) C. Tetracycline (Sumycin) D. Vancomycin
A
(c) B. Rifampin, Cipro, Levaquin, Zithromax and Rocephin are the drugs of choice.
5
Q
A 22 year-old female presents with onset of right eye vision loss 24 hours ago which has partially improved. She has experienced various widespread paresthesias, regional weakness and fatigue over the past six months. Episodes vary in location, severity and duration but invariably lead to recovery. Her exam is completely normal but MRI reveals numerous areas of periventricular gadolinium uptake. For this condition, what treatment has shown the greatest benefit with long term use? A. Interferon beta 1a (Avonex) B. Ethosuximide C. Methylprednisolone (Solumedrol) D. Pyridostigmine (Mestinon)
A
(c) A. The interferon agents have been the longest used and best studied medications that provide the best long
term benefits in multiple sclerosis. Steroids do play a role in acute exacerbations but not as long term agents.
6
Q
A 50 year-old female has a history of severe, stabbing pains, lasting only seconds, over the cheek and chin areas. She also experiences intense pain in these areas with chewing, washing her face and even with smiling. Examination reveals no sensory or motor deficits. Head computer tomography (CT) and erythrocyte sedimentation rate (ESR) are normal. She has been unresponsive to maximum doses of carbamazepine. What is the next best option for this patient?
A. Combination simvastatin (Zocor) and sertraline (Zoloft)
B. Bilateral deep brain stimulation
C. Stereotactic (Gamma knife) radiosurgery
D. High dose corticosteroid therapy
A
(c) C. Trigeminal neuralgia is generally responsive to Carbamazepine however, for those who fail to respond to
medicinal therapy surgery is the next valid option. Though there are various procedures, Stereotactic (Gamma knife) radiosurgery has provided the best results.
7
Q
What term is given to an ocular examination finding where small, irregular pupils are seen that react with near vision but not to light? A. Amaurosis fugax B. Argyll-Robertson C. Anisocoria D. Optic neuritis
A
(c) B. This finding may be seen in diabetes or in cases of neurosyphilis whereas amaurosis fugax is vision loss due
to a central lesion, anisocoria has unequal sized pupils, unilateral loss of vision due to multiple sclerosis.
8
Q
A patient describes a history of intermittent and uncontrollable twitching of his right hand that spreads to involve the entire arm after a few minutes. Afterward, the arm is extremely weak. There are no other areas of involvement, sensory deficit or altered consciousness. What is the most likely seizure diagnosis? A. Absence B. Complex-partial C. Simple-partial D. Myoclonic Explanations
A
(c) C. The lack of altered consciousness and focal motor symptoms are strongly indicative of this type of seizure.
9
Q
A 73 year-old male presents to the clinic with his wife. His wife has noticed that he has developed a resting tremor in his right hand and a shuffling gait over the last year. What finding on physical examination would support your suspected diagnosis? Answers A. Chorea B. Dystonia C. Masked facies D. Hyperreflexia
A
(c) C. The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech.
10
Q
A patient with an upper motor neuron lesion would exhibit which of the following findings? Answers A. Fasciculations B. Areflexia C. Muscular atrophy D. Spasticity
A
(c) D. Spasticity is an upper motor neuron lesion finding.
11
Q
What test is the single most useful test in establishing the diagnosis of multiple sclerosis?
Answers
A. Cerebral spinal fluid cell count and protein level
B. Cerebral spinal fluid immunoglobulin studies
C. Evoked potentials
D. Magnetic Resonance Imaging
A
(c) D. The presence of plaques on MRI is a key finding in establishing the diagnosis of MS.
12
Q
A 22 year-old male presents to the clinic complaining of excessive daytime somnolence and strong desires to sleep at inappropriate times. He came in today because he had an episode of "feeling paralyzed" as he was falling asleep yesterday. What is the most appropriate diagnostic test to confirm this patient’s diagnosis? Answers A. MRI of the brain B. Electroencephalogram C. Multiple sleep latency test D. Overnight polysomnography
A
(c) C. Multiple sleep latency test is required to observe the abrupt transition to REM sleep and establish the diagnosis of narcolepsy.
13
Q
A 54 year-old male smoker presents to the clinic complaining of frequent vague headaches with associated vomiting that awaken him from sleep occasionally and have been present upon awakening for about two weeks. The headache typically resolves about an hour into his morning routine. The patient is afebrile. What is the most likely cause of this patient’s headaches? Answers A. Cluster headaches B. Depression C. Glioblastoma D. Giant cell arteritis
A
(c) C. Morning headaches associated with vomiting are indicative of increased intracranial pressure and raise concern of a CNS tumor such as a glioblastoma.
14
Q
A 28 year-old female presents to the clinic complaining of a “prickly sensation” that started bilaterally in her feet two days ago and difficulty walking. She now has the dysesthesia from her mid-thigh down to her toes. On physical examination she has diminished pain and temperature sensation, absent reflexes, loss of proprioception in her legs bilaterally, and muscle strength is 1+/5+ in the lower extremities and 5+/5+ in the upper extremities. What is the most likely diagnosis? Answers A. Guillain-Barré syndrome B. Multiple sclerosis C. Myasthenia gravis D. Spinal cord compression
A
(c) A. The pattern of sensory, motor and reflex findings is consistent with the pathophysiology of peripheral nerve demyelination that occurs in Guillain-Barré syndrome.
15
Q
A 51 year-old female presents to the clinic complaining of intermittent sharp pain that originates at the corner of her mouth and radiates toward her ipsilateral eye. She notes "everything makes it worse" including touching the area, talking and eating. What is the most likely diagnosis? Answers A. Bell's palsy B. Cluster headache C. Post-herpetic neuralgia D. Trigeminal neuralgia
A
(c) D. This is the classic presentation for trigeminal neuralgia (tic douloureux).
16
Q
A 45 year-old man presents for a routine appointment. He tells you his mother and father have both had ischemic strokes in their 70’s. He does not smoke. His blood pressure is 128/80 mmHg, pulse 78/minutes and regular, respiratory rate of 12/minute. What diagnostic studies would you order to further evaluate this patient’s risk of stroke? Answers A. Electrocardiogram B. Fasting lipid profile C. Carotid Doppler ultrasound D. MRI with gadolinium
A
(c) B. Hyperlipidemia is a known risk factors for stroke that can be modified with treatment.
17
Q
Which of the following interventions is most effective during the early stages of Alzheimer’s disease?
Answers
A. Frequent change of caregivers in the home
B. Utilization of memory aids, such as post-it notes
C. Encouragement of independent activities, such as driving
D. Emphasis of new learning activities, such as computer training
A
(c) B. Memory aids are extremely helpful in assisting Alzheimer patients during the early stages of the disease.
18
Q
An 82 year-old male is brought to the ED after being found unresponsive in his apartment.
On physical exam his pupils are 7 mm on the right and 3 mm on the left. your initial choice in managing this patient?
Answers
A. Order a CBC, electrolytes, and toxicology screen
B. Order a CT of the head
C. Hyperventilate the patient
D. Administer streptokinase
What would be
A
(c) B. This presentation is consistent with a structural abnormality that will be detected on an imaging study.
19
Q
A 72 year-old man with long-standing diabetes mellitus, renal insufficiency and hypertension presents to the clinic complaining of burning and tingling pain in his feet. What agent would you prescribe to help control his pain? Answers A. Phenobarbital B. Amitriptyline (Elavil) C. Celecoxib (Celebrex) D. Codeine
A
(c) B. Amitriptyline is one of several preferred agents for management of peripheral neuropathy.
20
Q
A 37 year-old female presents to the clinic for follow-up regarding her recently diagnosed tonic-clonic epilepsy. She reports no seizures or side effects since starting valproate (Depakote) at her last visit one month ago. What diagnostic study would you order to monitor this patient's treatment? Answers A. Serum amylase B. Serum creatinine C. Liver function tests D. Electroencephalogram
A
(c) C. Valproate may be toxic to the liver as well as cause thrombocytopenia.
21
Q
A 58 year-old truck driver is found to have a positive Romberg test and loss of vibratory sensation in his lower extremities. What anatomical structure is the likely affected? Answers A. Cerebellum B. Posterior column C. Sensory cortex D. Vestibular apparatus
A
(c) B. Posterior column is responsible for vibratory sensation and proprioception. Romberg test is a general test of proprioception with disease of the cerebellum, vestibular apparatus or posterior column being the most likely source.
22
Q
During EOM testing, the patient is noted to have delayed adduction of the left eye. The rest of the examination is normal. Which of the following is the most likely underlying cause for this abnormality? A. Muscular dystrophy B. Multiple sclerosis C. Myasthenia gravis D. Polymyalgia rheumatica
A
(c) B. Internuclear ophthalmoplegia results from damage to the medial longitudinal fasciculus ascending from the abducens nucleus in the pons to the oculomotor nucleus in the midbrain and results in slow or absent adduction of the eye. It is most commonly seen with multiple sclerosis.
23
Q
Which of the following is the earliest manifestation of dementia of the Alzheimer's type? A. Incontinence B. Memory deficit C. Aggressiveness D. Motor disturbances
A
(c) B. A primary characteristic of dementia is memory impairment. A major component of the presenting symptoms is subjective complaints of memory difficulty.
24
Q
A 12 month-old presents with possible viral meningitis. Which of the following laboratory results is most consistent with this diagnosis? A. Decreased CSF glucose level B. Decreased CSF total protein level C. Increased CSF mononuclear cells D. Increased CSF C-reactive protein
A
(c) C. Increased CSF mononuclear cells are noted in viral meningitis.
25
```
Which of the following tests measures cerebellar function?
A. Finger-to-nose testing
B. Stereognosis
C. Graphesthesia
D. Two-point discrimination
```
(c) A. Cerebellar function is tested by finger-to-nose, heel-to-knee, rapid alternating movements, and gait.
26
```
A 10 year-old male has abrupt, brief episodes of impaired consciousness and rhythmic blinking. Which of the following is the most likely type of seizure?
A. Focal
B. Absence
C. Tonic-clonic
D. Complex partial
```
(c) B. Absence seizures are generalized seizures characterized by abrupt, brief episodes of impaired consciousness, staring, and rhythmic blinking.
27
```
A 73 year-old female patient was diagnosed 3 years ago with Alzheimer's disease. Her 80 year-old husband can no longer help feed and bathe her. Which of the following support services is most appropriate for this patient?
A. Hospice care
B. Senior center
C. Adult day care
D. Skilled nursing facility
```
(c) D. A skilled nursing facility is appropriate for patients requiring assistance with activities of daily living (i.e., feeding and bathing) and a higher level of safety assurance.
28
```
Which of the following is considered to be the gold standard in making the diagnosis of multiple sclerosis?
A. Gadolinium-enhanced MRI
B. MRA of the brain
C. Positron emission testing
D. CT brain scan
```
(c) A. Gadolinium-enhanced MRI studies can help to characterize and delineate intramedullary disease and are able to characterize various lesions in time and space.
29
```
A 5 year-old child has just been hospitalized with meningococcemia. Family members and close contacts should be given which of the following as prophylaxis?
A. Rifampin orally
B. Penicillin orally
C. Erythromycin orally
D. No chemoprophylaxis
```
(c) A. Exposed household, school, or day-care contacts of children with meningococcemia should receive chemoprophylaxis to eliminate the organism from the nasopharynx. The drug of choice is rifampin (10 mg/kg, up to 600 mg) every 12 hours for 48 hours. Sulfisoxazole, ceftriaxone, and ciprofloxacin are alternative choices for prophylaxis.
30
```
A 42 year-old female has a diagnosis of migraine headaches. She had been using ergotamine to abort her headaches, but she is now having one or two headaches per week that are interfering with work. Of the following, the most appropriate preventive therapy is
A. sumatriptan (Imitrex).
B. promethazine (Phenergan).
C. propranolol (Inderal).
D. ketorolac (Toradol).
```
(c) C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely.
31
A 30 year-old male has a history of weakness without pain on the left side of his face for the past 4 days. Physical examination of the face reveals unilateral weakness to the left side, but not complete paralysis. The left eye does not close completely. The most appropriate initial treatment is to
A. reassure the patient and provide patient education.
B. recommend a nonsteroidal anti-inflammatory medication.
C. recommend tricyclic antidepressants.
D. recommend physical therapy.
(c) A. Bell's palsy will resolve completely without treatment in approximately 60% of all cases.
32
```
Of the following drugs, the appropriate treatment of myasthenia gravis is
A. donepezil (Aricept).
B. quinidine (Quinidex).
C. neostigmine (Prostigmin).
D. edrophonium (Tensilon).
```
(c) C. Neostigmine is useful in the treatment of myasthenia gravis.
33
```
A 68 year-old male who is obese has a 50 pack-year history of smoking. He experienced a sudden and total loss of vision in his right eye, which resolved after 20 minutes. Which of the following is the most likely diagnosis?
A. Optic neuritis
B. Retinal detachment
C. Macular degeneration
D. Transient ischemic attack
```
(c) D. This history of sudden onset of a unilateral neurological deficit in a patient with risk factors for vascular disease suggests vascular ischemia. By definition, a transient ischemic attack is a neurological deficit that resolves quickly.
34
```
Bradykinesia is most commonly associated with
A. Wernicke's syndrome.
B. Hashimoto's thyroiditis.
C. Cushing's disease.
D. Parkinson's disease.
```
(c) D. Patients with Parkinson's disease have resting tremor, bradykinesia, lack of facial expression, and micrographia.
35
A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel's sign and Phalen's maneuver are positive. The most appropriate intervention at this time is
A. methylprednisolone (Medrol) dose pack.
B. splint in neutral position.
C. observation.
D. surgery.
(c) B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal
tunnel.
36
Treatment of Bell's palsy includes which of the following?
A. Acyclovir
B. Reassurance of the patient's recovery
C. Referral to a neurosurgeon
D. Electromyography
(c) B. Bell's palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell's palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell's palsy.
37
```
A 53 year-old female has a diagnosis of migraine headaches. She had been using sumatriptan (Imitrex) to abort her headaches, but she is now having one or two headaches per week. The most appropriate preventive therapy is
A. zolmitriptan (Zomig).
B. promethazine (Phenergan).
C. propranolol (Inderal).
D. fluoxetine (Prozac).
```
(c) C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely.
38
```
Which of the following primitive reflexes should begin to disappear at about 2 months of age in a normal infant?
A. Moro
B. Grasp
C. Tonic neck
D. Parachute
```
(c) B. The grasp reflex starts to disappear at about 2-3 months of age.
39
```
Upon stroking of the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan. This is a positive
A. Kernig's sign.
B. Brudzinski's sign.
C. Babinski's sign.
D. Gower's sign.
```
(c) C. A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the
great toe dorsiflexes and the other toes fan in a positive test.
40
```
Which of the following side effects is associated with long-term administration of phenytoin (Dilantin)?
A. Ataxia
B. Hypotension
C. Osteomalacia
D. Cardiac dysrhythmia
```
(c) C. Osteomalacia, or demineralization of bone, is a side effect of phenytoin that may occur after chronic
administration.
41
```
A 75 year-old male presents for a routine physical. Vitals are normal with no orthostatic changes. On physical examination, a fine cortical movement with repetitive rubbing of the tip of the thumb along the tips of the fingers is noted at rest. Which of the following is the most likely diagnosis?
A. Seizure disorder
B. Peripheral neuropathy
C. Shy-Drager syndrome
D. Parkinson's disease
```
(c) D. Parkinson's disease presents with tremor at rest (pill-rolling), bradykinesia, rigidity, and postural instability.
42
```
A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected?
A. T6
B. T8
C. T10
D. T12
```
(c) C. The dermatome T10 is at the level of the umbilicus.
43
```
A 27 year-old female presents to your office for evaluation of weakness, visual loss, and sensory loss over the right great toe. These symptoms have occurred during three episodes approximately three months apart with each episode lasting about three days. Which of the following tests would be most useful in further evaluating this patient?
A. MRI of the brain
B. Electromyograph
C. Glucose tolerance test
D. Electroencephalograph
```
(c) A. Multiple sclerosis typically presents with relapsing weakness of the limbs, sensory loss, paresthesias, and visual changes. Diagnosis is based on history and either abnormal brain or spinal cord MRI, or visual, auditory, or somatosensory evoked electrical response.
44
```
Which of the following drugs is the first choice for insomnia in an elderly patient?
A. Barbiturates
B. Cholinesterase inhibitors
C. Benzodiazepines
D. Beta-blockers
```
(c) C. Benzodiazepines are the drugs of choice for insomnia in the elderly population.
45
```
A 72 year-old patient with a history of hypertension and atrial fibrillation presents with episodes of weakness, numbness, and paresthesias in the right arm. At the same time, she notes speech difficulty and loss of vision in her left eye. These symptoms come on abruptly and clear within minutes. Physical examination is normal except for the previously known arrhythmia. Which of the following is the most likely diagnosis?
A. Focal seizure
B. Migraine headache
C. Hypoglycemic episodes
D. Transient ischemic attack
```
(c) D. This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.
46
A 70 year-old presents with headache and neck stiffness. On physical exam, the patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL, and glucose 35 mg/dL. Which of the following is the most appropriate treatment?
A. Acyclovir (Zovirax)
B. Fluconazole (Diflucan)
C. Ampicillin and ceftriaxone (Rocephin)
D. Penicillin and chloramphenicol (Chloromycetin)
(c) C. Ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes , which is common in the elderly. Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia
47
```
Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes?
A. Cerebrovascular disease
B. Encephalitis
C. Tumor
D. Idiopathic epilepsy
```
(c) C. Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.
48
```
A 37 year-old male presents with headaches for the past 2 months. They occur daily and are worse in the morning. In the past week, he has noticed a tendency to drop things from his right hand. On examination, vital signs are normal, and general examination is unremarkable. Neurologic examination reveals mild weakness of the right upper extremity compared to the left. Which of the following is the most likely diagnosis?
A. focal seizure disorder
B. intracerebral neoplasm
C. transient ischemic attack
D. amyotrophic lateral sclerosis
```
(c) B. Intracerebral neoplasms may present with headaches that are worse in the morning, with improvement during the day. Focal motor or sensory loss depends upon the tumor's location.
49
```
During an influenza epidemic, a 6 year-old child is seen with fever and a severe sore throat. A throat swab is taken for culture and the child is sent home. The next day, he is reported to have persistent vomiting and increased lethargy. On examination, he is delirious and disoriented. No rash is noted. His reflexes are hyperactive. The liver edge is 3 cm below the right costal margin in the midclavicular line. Which of the following is the most likely diagnosis?
A. acute bacterial meningitis
B. Guillain Barré syndrome
C. Reye syndrome
D. measles encephalitis
```
(c) C. Reye syndrome is typically post-influenza or URI. The patient develops lethargy, drowsiness, and vomiting. Babinski reflex is positive and hyperreflexia is noted. The liver is normal or enlarged.
50
A 30 year-old male has a history of weakness without pain on the left side of his face for the past 4 days. Physical examination of the face reveals unilateral weakness to the left side, but not complete paralysis. The left eye does not close completely. The most appropriate initial treatment is to
A. begin physical therapy.
B. refer for surgical ablation.
C. reassure patient and provide patient education.
D. initiate high dose steroids and recheck in 24 hours.
(c) C. Bell's palsy is usually a self-limited condition and typically resolves within a few weeks.
51
```
The most frequent finding in a person presenting with a brain abscess is
A. nuchal rigidity.
B. headache.
C. seizures.
D. vomiting.
```
(c) B. Headache occurs in over 70% of patients with a brain abscess.
52
```
Which of the following is a milestone usually achieved by a 15-month old infant?
A. walks alone
B. puts three words together
C. feeds self well with spoon
D. builds tower of seven cubes
```
(c) A. A 15-month-old infant should be able to walk alone.
53
```
A patient involved in a minor motor vehicle crash is brought to the emergency department by a family member who was riding in the car, but was unhurt. The family member states that the patient was unconscious for about 2 minutes, but seems "okay" now. What diagnostic procedure would be most helpful in assessing this patient?
A. head CT scan
B. lumbar puncture
C. skull radiographs
D. electroencephalogram
```
(c) A. A head CT scan would provide evidence of fractures and demonstrate intracranial hemorrhage and cerebral edema if present.
54
A 2 month-old infant has had a single, generalized tonic-clonic convulsion lasting 4 to 5 minutes. There is no history of trauma and the infant had been well previously. Physical findings include a temperature of 39.6 degrees C (103.2 degrees F), a bulging tympanic membrane on the right, and an inflamed pharynx. The next most appropriate step is to
A. perform a lumbar puncture.
B. order x-ray studies of the skull.
C. obtain an electroencephalogram.
D. send home with antibiotics and an anticonvulsant.
(c) A. Febrile convulsions are uncommon under the age of 3 months. The physical findings suggest the possibility of meningitis, so lumbar puncture with CSF analysis is indicated.
55
```
A 37 year-old male presents with daytime fatigue and drowsiness. He states that he does not sleep well, with frequent awakenings during the night. He has gained 8 pounds over the past six months, and he complains of palpitations. His wife states that he snores at night. A home nocturnal pulse oximetry indicates that his saturation drops 6% intermittently throughout the night. Which of the following is the most likely diagnosis?
A. depression
B. narcolepsy
C. hypothyroidism
D. obstructive sleep apnea
```
(c) D. Obstructive sleep apnea is associated with obesity, nighttime wakening and snoring, hypertension, cardiac dysrhythmias, and oxyhemoglobin desaturation of greater than 4% during hypopnea or apnea.
56
```
A 53 year-old woman recently diagnosed with Parkinson's disease has a moderate tremor. She has no other signs of disease at this time. Which of the following is the most appropriate initial treatment?
A. lorazepam (Ativan)
B. haloperidol (Haldol)
C. ramatidine (Flumadine)
D. levodopa/carbidopa (Sinemet)
```
(c) D. Levodopa/carbidopa is first-line therapy for the treatment of Parkinson's disease.
57
```
Cognitive loss in Alzheimer's dementia may be delayed with which of the following medications?
A. donepezil (Aricept)
B. haloperidol (Haldol)
C. risperidone (Risperdal)
D. zolpidem (Ambien)
```
(c) A. Donepezil is a reversible cholinesterase inhibitor that leads to increased acetylcholine, which is necessary for learning and memory.
58
```
Which of the following is the most common finding of multiple sclerosis?
A. facial palsy
B. hearing loss
C. seizures
D. diplopia
```
(c) D. Diplopia due to ophthalmoplegia is the most common presenting complaint in patients with multiple sclerosis.
59
```
A 28 year-old female presents with complaint of headaches for the past several months. They typically begin behind her right eye, which she describes as a combination of stabbing and pressure. She states that noise bothers her, and she experiences nausea but no vomiting. She has occasionally awakened with the pain. She admits to being under a lot of stress. Aspirin or acetaminophen does not relieve the pain. Which of the following is the best choice for initial treatment of the acute headache?
A. topiramate (Topamax)
B. gabapentin (Neurontin)
C. propranolol (Inderal)
D. sumatriptan (Imitrex)
```
(c) D. 5HT-receptor agonists and ergot alkaloids are effective for the acute treatment of migraine headaches if acetaminophen or nonsteroidal anti-inflammatory drugs are not effective.
60
```
Which of the following animals is the major cause of human rabies in the United States and, therefore, poses the highest risk?
A. bats
B. rabbits
C. rodents
D. dogs
```
(c) A. Bat rabies is found in practically every state and is the most common cause of human rabies in the U.S.
61
In addition to tremor, which of the following are cardinal symptoms of Parkinson disease?
A. Cognitive decline and rigidity
B. Personality change and bradycardia
C. Eye movement abnormalities and hyperkinesias
D. Rigidity and bradykinesia
(c) D. Tremor, rigidity, bradykinesia and postural instability are the cardinal features of Parkinsonism and may be present in any combination.
62
```
During an influenza epidemic, a 6 year-old male is seen with fever and a severe sore throat. The parents report that his symptoms have not improved despite administration of aspirin. The next day, the parent calls to report that the child has persistent vomiting and increased lethargy. On examination, he is found to be delirious and disoriented with hyperactive reflexes. The liver edge is 3 cm below the right costal margin in the midclavicular line. Which of the following is the most likely diagnosis?
A. Reye's syndrome
B. Measles encephalitis
C. Guillain-Barre syndrome
D. Acute bacterial meningitis
```
(c) A. The suspected influenza associated with development of vomiting, progressive mental status changes, hyperreflexia, and hepatomegaly are consistent with a diagnosis of Reye's syndrome.
63
```
The source of pain experienced during a migraine headache is a result of activation of which nerve?
A. Trigeminal
B. Vagus
C. Optic
D. Occulomotor
```
(c) A. Headache may result in release of neuropeptides acting as neurotransmitters at trigeminal nerve branches.
64
```
A 67 year-old female with history of hypertension, diabetes mellitus, and smoking presents to the emergency department with mild expressive aphasia, right facial weakness and mild right arm weakness. She had awakened 60 minutes ago and was speaking to her husband when her speech suddenly became difficult to understand and weakness was noted. Physical examination reveals a blood pressure of 165/85 mm Hg. A CT of the head shows no intracranial hemorrhage. Which of the following is the most appropriate intervention?
A. Aspirin
B. Warfarin (Coumadin)
C. Tissue plasminogen activator (rt-PA)
D. Clopidogrel (Plavix)
```
(c) C. IV thrombolytic therapy with recombinant tissue plasminogen activator is effective in reducing the neurological deficit in selected patient without CT evidence of intracranial hemorrhage and when administered within 3 hours after onset of ischemic stroke.
65
```
A 38 year-old female has a 10 year diagnosis of migraine headaches. She had been using ergotamine to abort her headaches, but is now having one or two headaches per week that are interfering with work. Which of the following is the most appropriate preventive therapy?
A. Sumatriptan (Imitrex)
B. Promethazine (Phenergan)
C. Propranolol (Inderal)
D. Ketorolac (Toradol)
```
(c) C. Propanolol is one beta blocker that is frequently used as a first-line prophylaxis for migraines.
66
```
A 45 year-old male presents for a routine physical. His mother and father both had ischemic strokes in their 70's. He does not smoke. His blood pressure is 128/80 mmHg, pulse 78/minutes and regular, respiratory rate of 12/minute. He has no bruits on examination. Which of the following studies should be ordered to further evaluate this patient's risk of stroke?
A. Electrocardiogram
B. Fasting lipid profile
C. Carotid Doppler ultrasound
D. MRI with gadolinium
```
(c) B. This patient has a genetic risk for stroke secondary to family history. Having an elevated LDL cholesterol and low HDL cholesterol puts him at a greater risk for stroke.
67
```
A 72 year-old man with a long-standing history of diabetes mellitus, renal insufficiency, and hypertension presents to the clinic complaining of burning and tingling pain in his feet. Which of the following medications would help control pain in this patient?
A. Phenobarbital
B. Amitriptyline (Elavil)
C. Celecoxib (Celebrex)
D. Codeine
```
(c) B. Amitriptyline has been recommended for pain associated with diabetic neuropathy.
68
```
A 53 year-old female with sudden onset "of the worst headache she has ever had" presents to the emergency department. She has a history of migraines but states that the current headache is not like her usual headaches. Results of her physical examination are unremarkable. Which of the following is the next best step in the evaluation of this patient?
A. Angiogram
B. CT scan
C. Transcranial Doppler
D. MRI
```
(c) B. This patient's history is highly suggestive of subarachnoid hemorrhage. CT is best to screen for intracranial hemorrhage. It is faster than MRI and more sensitive in the first 24 hours.
69
```
A 32 year-old female presents with a seven month history of recurrent, brief episodes of weakness and tingling in the extremities, diplopia, and vertigo. Which of the following is the most likely diagnosis?
A. Guillain-Barre syndrome
B. Myasthenia gravis
C. Multiple sclerosis
D. Amyotrophic lateral sclerosis
```
(c) C. Multiple sclerosis is most frequently seen in patients in their twenties and presents with episodes of weakness, paresthesias, and diplopia.
70
```
A mother brings in her 4 year-old son with complaints that he falls frequently and he "stands funny". The mother also notes that he has lost the ability to easily stand from a seated position. She reports that he met developmental milestones as an infant. Which of the following is the most likely cause?
A. Developmental hip dysplasia
B. Myasthenia gravis
C. Cerebral palsy
D. Muscular dystrophy
```
(c) D. Muscular dystrophy age of onset is by age 5, and begins in the pelvic girdle.
71
A 23 year-old patient presents with two days of fatigue, headache, fever and pain around the area in which she was bitten by a stray baby raccoon in an unprovoked attack 10 days ago. She cleaned the small wound thoroughly. Which of the following is the most appropriate intervention in this patient?
A. Do nothing and treat her symptoms
B. Human diploid cell rabies vaccine, 5 injections given all at once now
C. Rabies immunoglobulin only
D. Rabies immunoglobulins and human diploid cell rabies vaccine given 5 times in a 1-month period
(c) D. Bites by bats, skunks, and raccoons always require this regimen if the animal is not caught and tested.
72
A 12 month-old in the emergency department is diagnosed with possible viral meningitis. Which of the following cerebral spinal fluid (CSF) laboratory results is most consistent with this diagnosis?
A. Decreased CSF glucose level and increased protein
B. Decreased CSF total protein level and very few neutrophils
C. Increased CSF mononuclear cells and normal glucose
D. Increased CSF C-reactive protein and normal glucose
(c) C. In aseptic meningitis, CSF shows mainly mononuclear cells within 6-8 hours, glucose is normal and there is normal to lower protein.
73
```
An 8 year-old male presents with episodes described as 20-second lapses of awareness during which he blinks his eyes. After these attacks, he resumes his previous activity. Which of the following is the most likely diagnosis?
A. Tonic-clonic seizure
B. Myoclonic seizure
C. Absence seizure
D. Focal seizure
```
(c) C. Absence seizures are characterized by lapses of consciousness associated with postictal confusion.
74
```
Which of the following is first-line treatment for acute inflammatory demyelinating polyneuropathy variant of Guillain- Barre?
A. Neostigmine
B. IV Solu-Medrol
C. Phenytoin
D. IV immunoglobulin
```
(c) D. IV immunoglobulin is effective in patients with Guillain-Barre.
75
```
An 18 year-old male is involved in a motor vehicle accident with a question of cervical spine fracture. What is the imaging test of choice to initially evaluate this patient and clear his cervical c-spine?
A. Positron emission tomography
B. Magnetic resonance imaging
C. Computed tomography
D. Lateral radiograph
```
(c) D. Cervical spine x-rays are most commonly used as the initial screen for cervical spine injury. A cervical spine series consists of a lateral view, anteroposterior (AP) view, and an odontoid view. The lateral view detects up to 80% of traumatic spine injuries.
76
```
A patient with known relapsing-remitting multiple sclerosis (MS) presents to the hospital with an exacerbation of MS symptoms. What is the recommended treatment?
A. Baclofen (Lioresal)
B. Interferon
C. Glatiramer acetate (Copaxone)
D. Methylprednisolone
```
(c) D. Acute relapses of MS are treated with a short course of IV methylprednisolone followed by oral prednisone. This regimen reduces the severity and shortens the duration of attacks. All other drugs listed are used to reduce the attack rate of relapsing remitting multiple sclerosis.
77
```
What is the recommendation for primary prevention of stoke in a patient under sixty years of age with atrial fibrillation?
A. No therapy is needed
B. Aspirin
C. Warfarin
D. Maze procedure
```
(c) A. No therapy is recommended for primary stroke prevention in this patient.
78
```
A 30 year-old female presents to the office complaining of generalized weakness and reduced exercise tolerance that improves with rest. On physical examination you note the presence of bilateral eyelid ptosis, proximal muscle weakness and normal reflexes. What is the most likely diagnosis?
A. Lambert-Eaton syndrome
B. Organophosphate intoxication
C. Multiple sclerosis
D. Myasthenia gravis
```
(c) D. Common symptoms of myasthenia gravis are fatigable weakness, ptosis, diplopia, and proximal muscle weakness. The disease is more common in women in the 2nd and 3rd decade and in men older than 60.
79
```
A 50 year-old male presents to the ER with a complaint of severe headaches. These headaches are unilateral and he describes the headache pain as steady and non-throbbing. He also complains of nasal congestion and rhinorrhea. He also mentions that alcohol often triggers these headaches. What do you recommend for this patient?
A. High flow oxygen
B. Massage
C. Ibuprofen
D. Propranolol
```
(c) A. This a description of a cluster headache (migrainous neuralgia), these headaches respond to oxygen by mask 7-10 L/min for 15 minutes.
80
```
A 21 year-old male college student is admitted to the hospital with suspected meningitis. A lumbar puncture is performed. The results of the cerebrospinal fluid (CSF) analysis reveals an elevated white blood cell count of 5,000/mcL with over 90% neutrophils, a decreased glucose level of 35 mg/dL, and elevated protein level of 150 mg/dL. What is the most likely diagnosis based on these results?
A. Bacterial meningitis
B. Viral meningitis
C. Fungal meningitis
D. Tuberculous meningitis
```
(c) A. CSF results with bacterial meningitis reveal an elevated white count with predominance of neutrophils, a low glucose, and an elevated protein level.
81
```
A 75 year-old male presents to the ER with the following stroke findings: right-sided hemiparesis (face and hand more affected than leg), homonymous hemianopsia of the right half of both visual fields, and aphasia. Where is the location of his stroke?
A. Anterior cerebral artery
B. Middle cerebral artery
C. Posterior cerebral artery
D. Internal carotid artery
```
(c) B. This case is a description of a middle cerebral artery stroke.
82
```
What is the recommended treatment for absence (petit mal) seizures?
A. Phenytoin (Dilantin)
B. Carbamazepine (Tegretol)
C. Ethosuximide (Zarontin)
D. Gabapentin (Neurontin)
```
(c) C. Ethosuximide, valproic acid, and clonazepam are recommended treatments for absence seizures.
83
```
You are examining a patient with right-sided extremity weakness and left-sided weakness of the face. Where is the lesion?
A. Brainstem
B. Cerebral hemisphere
C. Cerebellum
D. Basal ganglia
```
(c) A. A patient with a unilateral sensory or weakness finding on one side of the body and contralateral finding of weakness or sensory loss of the face has a brainstem lesion.
84
You have just stuck yourself with a sharp needle. In order for you to be able to interpret this sensation, which of the following areas must be intact?
A. Anterior spinothalamic tract, basal ganglia, and sensory cortex
B. Corticospinal tract, medulla, and basal ganglia
C. Pyramidal tract, hypothalamus, and sensory cortex
D. Lateral spinothalamic tract, thalamus, and sensory cortex
(c) D. Sensory impulses reach the sensory cortex from the spinothalamic tract or the posterior columns. Fibers transmit this to the thalamus which sends impulses to the sensory cortex of the brain
85
A 64 year-old right-handed woman presents to the emergency room. The patient is pleasant and cooperative, but you note that the left side of her mouth has little movement as she talks, resulting in some dysarthric speech. On physical examination, the left side of her mouth droops, eyebrows raise symmetrically, frown is symmetric, and eyes close but left offers little resistance to opening. You suspect which of the following?
A. Upper motor neuron damage to CN VII (central facial palsy) in left hemisphere
B. Upper motor neuron damage to CN VII (central facial palsy) in right hemisphere
C. Lower motor neuron damage to CN VII (Bell's palsy) on the left
D. Lower motor neuron damage to CN VII (Bell's palsy) on the right
(c) B. The upper face is controlled by pathways from both sides of the face. Upper motor neuron lesions cross, findings on the left are due to lesions on the right. Lower motor neuron lesions of the face are ipsilateral.
86
```
A 50 year-old female with a history of coronary artery disease presents to the office requesting medication for an exacerbation of her migraine headaches. She complains of migraines approximately once a month. What medication is contraindicated in this patient?
A. Sumatriptan (Imitrex)
B. Propranolol (Inderal)
C. Droperidol(Inapsine)
D. Naproxensodium(Anaprox)
```
(c) A. The triptans are contraindicated in patients with coronary artery disease or peripheral vascular disease and should be avoided in patients with an increased risk for stroke. All other drugs listed are not contraindicated.
87
```
A 45 year-old male patient presents to the office with a complaint of dizziness and vertigo that occurs suddenly when he rolls out of bed in the morning. He denies previous illness or any medical problems. On physical exam you note the presence of lateral nystagmus after a few second latency period. What is your recommendation for this patient?
A. Low dose diazepam
B. Repositioning maneuvers
C. Diuretics and a low salt diet
D. MRI of the brain
```
(c) B. This patient has benign paroxysmal positional vertigo (BPPV) and repositioning maneuvers are recommended to move endolymphatic debris out of the posterior semicircular canal.
88
```
A 70 year-old male is brought to the office by his wife. She is complaining that her husband has been having great difficulty remembering things, however remains alert. She also complains that he is having difficulty getting to the bathroom on time. On physical examination you notice that the patient's gait is wide-based and slow and he walks without lifting his feet off the floor. You also notice a tremor in his right hand. What is the most likely diagnosis?
A. Lewy body dementia
B. Parkinson's disease
C. Normal pressure hydrocephalus
D. Frontotemporal dementia
```
(c) B. Patients with Parkinson's disease have clinical features such as bradykinesia, rest tremor, rigidity, postural instability, autonomic dysfunction and behavioral changes. Of the diseases listed, Parkinson's is the most common.
89
```
A 7 year-old is evaluated for episodes of unresponsiveness in which she stares, blinking into space. Episodes last only 10-20 seconds but may happen several times daily. There are no abnormal movements, sensory loss or headaches reported. Which of the following is considered first-line therapy for this disorder?
A. Carbamazepine (Tegretol)
B. Ethosuximide (Zarontin)
C. Gabepentin (Neurontin)
D. Topiramate (Topamax)
```
(c) B. Absence seizures are usually treated successfully with Ethosuximide. The other agents listed are not indicated and may actually worsen this type of seizure.
90
```
A 45 year-old female presents complaining of the worst headache of her life. Which of the following is the most appropriate initial diagnostic study?
A. Magnetic resonance imaging (MRI)
B. Computed tomography (CT)
C. Electroencephalogram (EEG)
D. Lumbar puncture (LP)
```
(c) B. A CT scan is more sensitive in detecting cerebral hemorrhage in the first 24 to 48 hours.
91
```
A 37 year-old right-handed male presents with daily headaches for the past 2 months. They are worse in the morning and awaken him from sleep. In the past week, he has noticed a tendency to drop things. Neurologic examination reveals upper extremity strength of 4/5 on the right and 5/5 on the left. Which of the following is the most appropriate next step in the evaluation of this patient?
A. Lumbar puncture (LP)
B. Electroencephalogram (EEG)
C. Magnetic resonance imaging (MRI)
D. Electromyelogram (EMG)
```
(c) C. MRI is the most appropriate diagnostic study in the evaluation of a suspected intracranial neoplasm.
92
```
Household contacts of a patient with bacterial meningitis are best treated with which of the following?
A. Amoxicillin (Amoxil)
B. Ciprofloxin (Cipro)
C. Tetracycline (Sumycin)
D. Vancomycin (Vancocin)
```
(c) B. Rifampin, Cipro, Levaquin, Zithromax and Rocephin are the drugs of choice.
93
```
A 22 year-old female presents with onset of right eye vision loss 24 hours ago which has partially improved. She has experienced various widespread paresthesias, regional weakness and fatigue over the past six months. Episodes vary in location, severity and duration but invariably lead to recovery. Her exam is completely normal but MRI reveals numerous areas of periventricular gadolinium uptake. For this condition, what treatment has shown the greatest benefit with long term use?
A. Interferon beta 1a (Avonex)
B. Ethosuximide (Zarontin)
C. Methylprednisolone (Solumedrol)
D. Pyridostigmine (Mestinon)
```
(c) A. The interferon agents have been the longest used and best studied medications that provide the best long term benefits in multiple sclerosis. Steroids do play a role in acute exacerbations but not as long term agents.
94
A 50 year-old female has a history of severe, stabbing pains, lasting only seconds, over the cheek and chin areas. She also experiences intense pain in these areas with chewing, washing her face and even with smiling. Examination reveals no sensory or motor deficits. Head computer tomography (CT) and erythrocyte sedimentation rate (ESR) are normal. She has been unresponsive to maximum doses of carbamazepine. What is the next best option for this patient?
A. Combination simvastatin (Zocor) and sertraline (Zoloft)
B. Bilateral deep brain stimulation
C. Stereotactic (Gamma knife) radiosurgery
D. High dose corticosteroid therapy
(c) C. Trigeminal neuralgia is generally responsive to Carbamazepine however, for those who fail to respond to medicinal therapy surgery is the next valid option. Though there are various procedures, Stereotactic (Gamma knife) radiosurgery has provided the best results.
95
```
What term is given to an ocular examination finding where small, irregular pupils are seen that react with near vision but not to light?
A. Amaurosis fugax
B. Argyll-Robertson
C. Anisocoria
D. Optic neuritis
```
(c) B. This finding may be seen in diabetes or in cases of neurosyphilis whereas amaurosis fugax is vision loss due to a central lesion, anisocoria has unequal sized pupils, unilateral loss of vision due to multiple sclerosis.
96
```
A patient describes a history of intermittent and uncontrollable twitching of his right hand that spreads to involve the entire arm after a few minutes. Afterward, the arm is extremely weak. There are no other areas of involvement, sensory deficit or altered consciousness. What is the most likely seizure diagnosis?
A. Absence
B. Complex-partial
C. Simple-partial
D. Myoclonic
```
(c) C. The lack of altered consciousness and focal motor symptoms are strongly indicative of this type of seizure.
97
A 26 year-old female reports progressive distal to proximal spread of extremity weakness over the last 36 hours without fever, headache or syncope. Examination reveals symmetrical, paresis of the hands and feet with loss of the brachioradialis and Achillis reflexes. Biceps and knee reflexes are present but diminished. Sensory exam is normal. What are the most likely findings on cerebral spinal fluid (CSF) analysis?
A. Decreased glucose, increased WBC count and decreased protein
B. Increased glucose, normal WBC count and normal protein
C. Normal glucose, decreased WBC count and elevated protein
D. Normal glucose, normal WBC count and elevated protein
(c) D. Guillain-Barre syndrome is typified by progressive symmetrical, distal to proximal spread of weakness and areflexia without fever or sensory deficits. CSF analysis shows elevated protein due to axonal demyelination but no glucose disturbances and no significant or sustained pleocytosis.
98
```
What spinal nerve root is most likely affected in a patient with weak wrist extension, thumb and index finger paresthesias and diminished triceps reflex?
A. Cervical 4
B. Cervical 5
C. Cervical 6
D. Cervical 7
```
(c) C. In contrast, cervical 5 would be associated with deltoid and biceps weakness and diminished biceps reflex while cervical 7 would result in triceps weakness and paresthesias in the middle finger and diminished brachioradialis reflex.
99
```
A 27 year-old female presents with 5-6 headaches monthly for the past year that are described as severe, throbbing and initially unilateral. They is associated with nausea, photophobia and phonophobia. There have been no concomitant sensory or motor deficits. Her physical examination and brain MRI are normal. What treatment would be best to reduce the frequency of the headaches?
A. Sumatriptan (Imitrex)
B. Isometheptene (Midrin)
C. Propranolol (Inderal)
D. Hydrocodone (Vicodin)
```
(c) C. Each medication listed can be used in the management of migraine headaches, however only propranolol is indicated for reducing the frequency of migraine headaches.
100
```
A 55 year-old male presents with a three month history of progressive weakness in the extremities without associated sensory changes or deficits. Examination reveals widespread muscle atrophy, fasciculations and bilateral hyperactive reflexes with Babinski sign. Which of the following is the most likely diagnosis?
A. Amyotrophic lateral sclerosis
B. Polymyalgia rheumatica
C. Myasthenia gravis
D. Multiple sclerosis
```
(c) A. Though some variability in presentation does occur the characteristic progressive weakness without sensory changes and upper and lower motor nerve dysfunction is a hallmark of amyotrophic lateral sclerosis (ALS).
101
```
A 57 year-old male presents with episodic diplopia over the past two months. Symptoms progressed over the last two days with the onset of bilateral facial weakness made worse with repetitive use. Weakness improves somewhat with rest. He denies fever, headache or areas of pain. Exam reveals a nasal voice, drooping eyelids and a normal sensory exam. Which of the following is the most likely diagnosis?
A. Multiple sclerosis
B. Guillain-Barre syndrome
C. Lambert-Eatonsyndrome
D. Myasthenia gravis
```
(c) D. Episodic diplopia progressing to proximal weakness worsened by repetition and lacking sensory deficits is typical of myasthenia gravis. In Lambert-Eaton syndrome muscular responses actually improve with repetition and the weakness in Guillain-Barre syndrome always begins peripherally.
102
```
Which of the following neurotransmitters is decreased in early Parkinson's disease?
A. Dopamine
B. Serotonin
C. Norepinephrine
D. Acetylcholine
```
(c) A. Decreased dopamine levels are typical of Parkinson's disease even early in the course of the disease.
103
```
A 48 year-old male presents with a mild tremor that seems to increase with stressful situations and subsides when he has a glass of wine with dinner. The patient does not demonstrate the tremor at rest but it reappears when he reaches for a pen. Which of the following is most likely the cause of this patient's symptoms?
A. Parkinson disease
B. Essential tremor
C. Huntington disease
D. Focal torsion dystonia
```
(c) B. Essential tremor can be familial and cause action related hand tremor, head tremor, or voice tremor. The lower extremities are spared and generally no further neurologic findings are present.
104
```
Which of the following is the initial treatment of choice for status epilepticus?
A. Phenobarbital
B. Valproic Acid (Depakene)
C. Lorazepam (Ativan)
D. Propofol (Diprivan)
```
(c) C. Lorazepam is the most appropriate initial medication in the management of status epilepticus.
105
```
A 58 year-old male presents with a 4 month history of instability upon ambulation. Examination reveals resistance to passive movements, mild tremor of the lips and a shuffling gait. Which of the following medications is most appropriate for this patient?
A. Levadopa/carbidopa (Sinemet)
B. Benztropine mesylate (Cogentin)
C. Clozapine (Clozaril)
D. Risperidone (Risperdal)
```
(c) A. Levodopa/carbidopa generally helps reduce many symptoms associated with Parkinsonism, including bradykinesia
106
```
A 58 year-old truck driver is found to have a positive Romberg test and loss of vibratory sensation in his lower extremities. What anatomical structure is the most likely affected?
A. Cerebellum
B. Posterior column
C. Sensory cortex
D. Vestibular apparatus
```
(c) B. Posterior column is responsible for vibratory sensation and proprioception. The Romberg test is a general test of proprioception with disease of the cerebellum, vestibular apparatus or posterior column being the most likely source.
107
```
Which of the following medications is most appropriate for migraine headache prophylaxis?
A. Lisinopril (Zestril)
B. Ergotamine tartrate (Cafergot)
C. Metoclopromide (Reglan)
D. Propanolol (Inderal)
```
(c) D. Propanolol is used as a preventative medication for migraine headaches.
108
A 24 year-old pregnant female presents with an abrupt onset of facial weakness and mild disturbance of taste this morning upon awaking. She denies drug use and other neurological complaints. Examination findings include a loss of forehead markings on right. Which of the following additional exam findings would likely be present?
A. Agitation and word searching
B. Contralateral unequal and dilated pupil
C. Ipsilateral restriction of eye closure
D. Deviated tongue upon protrusion
(c) C. The patient has signs and symptoms of Bell's palsy. With Bell's palsy, it is common to have cranial nerve VII paralysis which will not allow the patient to completely blink the eye on the affected side.
109
```
A 30 year-old male presents with a 1 week history of intermittent left orbital headache. He states that his episodes occur at night and last approximately 1 hour. Examination reveals ptosis, miosis and dyshidrosis. Which of the following would most likely be present in this patient?
A. Loss of vision
B. Scotoma
C. Nasal lacrimation
D. Facial muscle spasm
```
(c) C. This patient is exhibiting signs and symptoms of cluster headache which often includes nasal lacrimation.
110
```
A 58 year-old male presents with a 3 month history of spastic paresis in his legs. Today, he has experienced diplopia on lateral gaze and scotoma in his right eye. Examination reveals decreased visual acuity of the right eye. Which of the following MRI findings is most likely in this patient?
A. Multifocal white matter disease
B. Chiari malformation
C. Cerebral atrophy
D. Intracranial hemorrhage
```
(c) A. The patient is experiencing symptoms of multiple sclerosis (MS). MRI findings demonstrate multifocal white matter disease.
111
```
A 74 year-old female with mild hypertension is brought to the ED with right hemiparesis after a fall two days ago. The family reports that the patient has had some confusion this morning. Examination reveals left pupillary dilation and decreased strength of the upper and lower extremity. Which of the following diagnostic studies should be ordered first?
A. MRI of the brain
B. CT scan of the brain
C. Radiograph of the head
D. Lumbar puncture
```
(c) B. This patient presents with a history of minor trauma and progressive neurological abnormalities consistent with subdural hematoma. The diagnosis would be confirmed by CT scan, which is less expensive and more sensitive for blood than an MRI.
112
```
A 58 year-old female with a history of controlled hypertension is brought to the office after becoming incoherent during lunch 30 minutes ago. Examination reveals a right facial droop and right extremity weakness. A noncontrast head CT is negative for acute hemorrhage and an electrocardiogram reveals normal sinus rhythm. Which of the following is the most appropriate next step in the management of this patient?
A. rtPA bolus and IV infusion
B. Heparin bolus and IV infusion
C. MRI of the brain
D. lumbar puncture
```
(c) A. This patient meets the qualifications for rtPA according to the NIH stroke scale. While Heparin is a good choice in the acute setting, the most effective treatment choice would be thrombolytics. A noncontrast CT scan already defined no bleed or obvious mass. Lumbar puncture is ideal in cases where the diagnosis is uncertain. The window of time is appropriate for acute treatment.
113
```
A 33 year-old male presents to the emergency department reporting progressive distal-to-proximal upper and lower extremity weakness over the past 24 hours. Examination reveals no muscular atrophy, but absent patellar and biceps reflexes. Sensory examination over the same area is intact. Which of the following is the most likely diagnosis?
A. Muscular dystrophy
B. Guillain-Barre syndrome
C. Charcot-Marie-Tooth disease
D. Myasthenia gravis
```
(c) B. Guillain-Barre is an acute inflammatory demyelinating disorder characterized by rapidly progressive distal-to- proximal muscle weakness that is generally first noticed by gait abnormalities and can progress to affect respiration and swallowing
114
```
A 79 year-old nursing home resident with a history of diabetes mellitus and hypertension is transferred to the ED following an episode of confusion and right arm weakness which resolved after 8 hours. The staff recorded a fingerstick glucose of 102 at the onset of symptoms. Vital signs were BP 120/80mmHg, HR 78bpm, RR 18, TEMP 98.8 F. Which of the following is the most likely diagnosis in this patient?
A. Subclavian steal syndrome
B. Cerebral vascular accident
C. Giantcellarteritis
D. Transientischemicattack
```
(c) D. This patient has symptoms of TIA, which are transient and generally resolve within 24 hours. CVA is determined by the extended duration of the above symptoms. Subclavian steal syndrome is demonstrated by a subclavian bruit, unequal radial pulses and unequal blood pressure readings.
115
```
The developmental milestone of speaking 1-3 words should be reached by which of the following ages?
A. 9 months
B. 12 months
C. 18 months
D. 24 months
```
(c) B. Infants should be able to speak 1 to 3 words by 1 year of age.
