Practice Exam

Question 1

A 45 year-old woman was brought to the ED after being found collapsed on the floor by her
daughter. When the woman was examined, her deficits included weakness of the left upper
and lower limb with increased tone and increased deep tendon reflexes. Further examination
revealed a decreased nasolabial fold and drooping mouth on the left although she blinked
both eyes and raised both eye brows normally. Tactile and pin prick sensation were normal
and no other symptoms were observed. What is the most likely blood vessel causing these
symptoms
A. Anterior cerebral artery
B. Middle cerebral artery
C. Posterior cerebral artery
D. internal carotid artery
E. Basilar artery

Answer 1

B

Question 2

An 80 year-old woman presented with a right homonymous hemianopsia with macular
sparing. The vessel most likely to cause this deficit is:
A. posterior cerebral artery
B. middle cerebral artery
C. anterior cerebral artery
D. anterior choroidal artery
E. superior cerebellar artery

Answer 2

A

Question 3

A 50 year-old woman saw her physician with symptoms of hearing loss on the left side,
tinnitus, unsteadiness, and nausea. The most likely cause for these symptoms is:
A. circumscribed astrocytoma
B. medulloblastoma
C. oligodendroglioma
D. schwannoma
E. ependymoma

Answer 3

D

Question 4

Which other deficit could the above woman also have:
A. weakness on one side of body
B. weakness of tongue muscles on one side
C. loss of smell
D. visual field deficit
E. weakness of facial muscles on one side

Answer 4

E

Question 5

A patient presented with a dilated right pupil. Light shone into the right eye produced a
consensual response but not a direct response. Light shone into the left eye produced a direct
response but not a consensual response. These symptoms could be caused by an aneurysm of
A. middle cerebral artery
B. AICA
C. posterior communicating artery
D. anterior cerebral artery
E. anterior choroidal artery

Answer 5

C

Question 6

A 29 year-old man who collapsed while jogging was brought to the ED unconscious. A CT
indicated a ruptured aneurysm was the cause of the man’s condition. A lumbar puncture
revealed RBCs in his CSF. Which of the following would be associated most closely with this
condition?
A. epidural hemorrhage
B. subdural hemorrhage
C. aneurysm of the circle of Willis
D. brainstem infarct
E. intraparenchymal hemorrhage

Answer 6

C

Question 7

A 38 year-old man sees his physician because he has had trouble chewing. Examination
reveals weakness of masticatory muscles on the right side and a CT image shows a small
tumor in a related CNS area. Which blood vessel would be responsible for this symptom?
A. vertebral artery
B. PICA
C. posterior cerebral artery
D. AICA
E. basilar artery

Answer 7

E

Question 8

A 60 year-old woman suddenly felt ill at home, became weak, and
collapsed. An angiogram in the anterior/posterior view obtained in the ED
is shown in the figure where an occluded vessel was found. What
symptom could this woman have developed as a consequence of the
location of her blocked vessel.
A. contralateral lower limb weakness with hyper-reflexia
B. contralateral upper limb weakness with hyper-reflexia
C. contralateral upper/lower limb weakness with hyper-reflexia
D. contralateral lower limb weakness with hypo-reflexia
E. contralateral homonymous hemianopsia

Answer 8

A

Question 9

A 63 year-old patient is seen in a clinic with a tremor in the left hand. Which of the following
would indicate that the patient’s tremor was a symptom of cerebellar disease rather than
basal ganglia disease.
A. the tremor occurs when the patient’s arm is at rest
B. the tremor occurs when the patient begins to move the arm but not while at rest
C. the tremor occurs when the patient’s arm is at rest and during movement
D. the tremor occurs only during rapid, alternating movements
E. the tremor does not occur during sustained muscle contraction

Answer 9

B

Question 10

A 63 year-old patient is seen in a clinic with a tremor in the left hand. Which of the following
would indicate that the patient’s tremor was a symptom of cerebellar disease rather than
basal ganglia disease.
A. the tremor occurs when the patient’s arm is at rest
B. the tremor occurs when the patient begins to move the arm but not while at rest
C. the tremor occurs when the patient’s arm is at rest and during movement
D. the tremor occurs only during rapid, alternating movements
E. the tremor does not occur during sustained muscle contraction

Answer 10

C

Question 11

The pathology specimen (myelin stain) in the
figure was obtained from a 35 year old woman
who died from a neurodegenerative disease.
Which symptom would she have displayed as a
result of the lesioned areas indicated in the
figure?
A. ataxia
B. suspended sensory loss for pain
C. spontaneous tremor
D. choreiform movements
E. muscle atrophy

Answer 11

A

Question 12

A 20 year-old man sees his physician because he has had trouble
hearing. He also says he hears a ringing sound in both ears most of the
time. On exam he loses his balance easily and hearing loss is evident in
both ears. An MRI taken several days later is shown. Examination also
reveals several small menigiomas at various locations. The condition this
man has is known as:
A. tuberous sclerosis
B. Von Hippel-Lindau Disease
C. Sturge Weber Disease
D. NF-1
E. NF-2

Answer 12

E

Question 13

After his wife had a stroke, a husband noticed that his wife’s hair was always tangled and
uncombed on the left side of her head, although on the right her hair was straightened and
orderly. The left side of her face was usually dirty from food remaining there, but the right
face was always clean. She stopped putting her ring and watch on her left hand. When eating,
she never used her fork on the left side of her plate and, surprisingly, she often asked why she
was not given a fork to eat with. This woman’s stroke most likely damaged the:
A. parietal lobe
B. temporal lobe
C. occipital lobe
D. premotor cortex of frontal lobe
E. orbitomedial cortex of frontal lobe

Answer 13

A

Question 14

A 50 year old man who had a history of long term alcohol abuse was seen in a clinic for his
unsteadiness. The ataxic gait displayed by this man when he was asked to walk is most likely
caused by damage to:
A. flocculus and nodulus
B. subthalamic nucleus
C. cerebellar vermis
D. vestibular nuclei
E. spinal motoneurons

Answer 14

C

Question 15

A patient arrived in the ED with symptoms of a stroke. His
symptoms subsided with time, but an MRI the next day revealed
an infarct affecting the structure in the figure. Branches of which
vessel supply the indicated structure:
A. anterior choroidal artery
B. middle cerebral artery
C. posterior cerebral artery
D. internal carotid artery
E. basilar artery

Answer 15

B

Question 16

A patient who has not been sleeping well presents to your sleep clinic. During a sleep trial
you notice that the patient has multiple hypnic myoclonic episodes, which disrupt the
patients sleep. This patient is experiencing difficulty during which sleep stage:
A. stage 1
B. stage 2
C. stage 3
D. REM

Answer 16

A

Question 17

An infant is born with a red mark on its face described as a port wine
stain over her left eyelid and forehead. At 3 months of age, she
develops seizures and her further cognitive development is slow. An
MRI shown here indicates the reason for a homonymous hemianopia
that is now evident in the child. The condition shown in the MRI is
due to:
A. epidural hemorrhage
B. subdural hemorrhage
C. angioma of pia mater
D. subarachnoid hemorrhage
E. intraparenchymal hemorrhage

Answer 17

C

Question 18

A 50 year-old woman developed difficulty with eyesight, which was followed months later
by difficulties at work. She was easily distracted by things around her, she wasn’t as good
multi-tasking, and her problem-solving skills were diminished. An MRI was taken, which
showed a large periventricular lesion and several smaller lesions in the white matter. The
cognitive deficits in this woman most likely result from lesions involving:
A. hippocampus
B. cortex in the frontal lobe
C. thalamus
D. basal ganglia
E. long association fibers

Answer 18

E

Question 19

A 40 year-old man sees his physician because he says he has been “jumpy” lately. His
physician notices that as the man sits in his chair he makes nervous, fidgety movements with
his hands, his tongue protrudes and retracts periodically, and his legs jerk as if he is restless.
His wife says she has noticed that he has been irritable and keeps to himself most of the time
whereas he was very outgoing and easy to get along with previously. This man likely has a
disorder that involves
A. alpha synuclein
B. inclusions in oligodendrocytes
C. frataxin
D. atrophy of the caudate nucleus
E. Lewy bodies

Answer 19

D

Question 20

A healthy 58 year-old women suddenly collapsed in her home with
her body jerking uncontrollably. Her husband rushed over to help
her. He tried to ask her what happened but she was unable to
respond for several minutes. Eventually she recovered and she was
able to answer him. He took her to the ED where a CT was done as
shown here. A biopsy of the abnormal region shown in the CT
would likely show:
A. perivascular pseudo-rosettes
B. psammoma bodies
C. verocay bodies
D. areas of necrosis with pseudopalisading
E. chicken-wire vascular pattern

Answer 20

B

Question 21

A 65 year-old hypertensive woman had a stroke damaging her right motor cortex. Which
symptom would this woman be expected to have:
A. weakness or paralysis of right jaw muscles
B. weakness or paralysis of left jaw muscles
C. difficulty closing the right eye
D. difficulty closing the left eye
E. none of the above

Answer 21

E

Question 22

A 58-year-old male office manager was brought to the clinic by his
wife. Six years ago, he began to believe, without any conclusive
evidence, that his wife was cheating on him. The couple went into
marriage counseling, but without much success. One year ago, he
started to think that one of his coworkers was stealing money from
him. He confronted the coworker over and over, appearing
increasingly aggressive and agitated. Six months ago, the patient
was fired from his job because of lack of restraint in his social
behavior with staff. His wife stated that more recently her husband
was depressed most of the time. His MMSE score was 22. After
examining a recent CT (figure), his physician most likely made a
diagnosis of:
A. dementia with Lewy bodies
B. frontotemporal lobe dementia
C. Alzheimer’s disease
D. chronic traumatic encephalopathy

Answer 22

B

Question 23

A 68-year-old man visits his doctor complaining about a tremor in his hands, which is
particularly bad when he tries to perform a task. He demonstrates past-pointing when asked
to perform a finger to nose test, and has difficulty producing rapidly alternating supination and pro-nation movements of the hands. The doctor also notes a wide, awkward gait. Based
on these clinical findings alone, in which part of the motor system is a dysfunction expected?
A Basal ganglia
B Cerebellum
C Supplementary motor area
D Primary motor cortex
E Spinal motor pathways

Answer 23

B

Question 24

Occlusion of the posterior inferior cerebellar artery results in which of the following
patterns of sensory loss?
A. Loss of pain on the ipsilateral body and ipsilateral face
B. Loss of pain on the contralateral body and contralateral face
C. Loss of pain on the ipsilateral body and contralateral face
D. Loss of pain on the contralateral body and ipsilateral face
E. There would be no change in pain

Answer 24

D

Question 25

A 54-year-old man collapsed at work after complaining of the sudden onset of a severe
headache. At the ER, his vital signs include temperature 36.7°C, pulse 110 bpm, respirations
28 per minute, and blood pressure 220/110 mmHg. He is awake but drowsy and disoriented.
His family reported that he had not been compliant with his hypertension medications for
several years. A non-contrast CT scan is shown in Figure 22-54. Which brain area is most likely
to be affected by a large spontaneous hypertensive brain hemorrhage?
A Cerebral cortex
B Deep cerebral nuclei (basal ganglia/thalamus)
C Brainstem
D Cerebellum

Answer 25

B

Question 26

A 34-year-old woman presents with new-onset left lower extremity
weakness that came on over a period of a week. She recounts an
episode of “blurry vision” and “discomfort” affecting one eye 2 years
ago, and her visual symptoms resolved over several weeks.
Examination reveals profound weakness of her left leg. Her CSF has an
elevated protein, high levels of IgG, and six oligoclonal bands. Brain
MRI with and without contrast, and total spine MRI with and without
contrast are ordered. On brain MRI (Figure) the neuroradiologist notes
multiple periventricular lesions, some showing contrast enhancement
(arrow). In a patient with this clinical history and MR findings, these
lesions most likely represent:
A ADEM
B Age-related ischemic lesions in the cerebral periventricular
white matter
C MS
D PML

Answer 26

C

Question 27

You are evaluating a 39-year-old woman in the hospital for a new event of transverse
myelitis that has resulted in her inability to walk and severe bladder and bowel dysfunction.
When reviewing her images, you note that her lesion extends through most of her thoracic
spinal cord and into her lower cervical spinal cord with patchy enhancement in the central
portion. The fact that this lesion is longitudinally extensive—defined as being longer than 3
vertebral body heights—makes which of the following diagnoses less likely?
A Multiple sclerosis
B Idiopathic transverse myelitis
C Neuromyelitis optica spectrum disorder

Answer 27

A

Question 28

A patient presents to your clinic with a 2-year history of worsening gait trouble. He reports
that he is not sure when it began but that he now has trouble walking short distances and has
noticed increasing difficulty feeling where his feet are placed and controlling his bladder and
bowel functioning. You suspect a diagnosis of progressive multiple sclerosis (MS). Which of
the following findings would not help you fulfill the diagnostic criteria for progressive MS?
A Brain magnetic resonance imaging (MRI) with 1 or more lesions suggestive of
demyelination
B Spinal fluid with elevated immunoglobulin G (IgG) index or oligoclonal bands
C Abnormal somatosensory evoked potentials of the lower extremities
D Spinal cord MRI showing 2 lesions typical of MS

Answer 28

C

Question 29

A 50-year-old man is diagnosed with a malignant brain tumor. Which of the following is the
most likely cause of malignant brain tumors in this age group?
A Malignant meningioma
B Glioblastoma
C Oligodendroglioma
D Anaplastic astrocytoma
E Pilocytic astrocytoma

Answer 29

B

Question 30

Which of the following finding is one of the features used to distinguish glioblastoma (GBM)
from lower-grade astrocytomas?
A Nuclear atypia
B Cellular density
C Necrosis
D GFAP staining

Answer 30

C

Question 31

A 9-year-old girl presents with headache and is found by imaging to have a cystic lesion with
a protruding nodule in the cerebellum. On biopsy, the tumor is glial in origin, does not have
brisk mitotic activity, and has bright eosinophilic fibers. What type of tumor is this?
A Glioblastoma multiforme
B Meningioma
C Medulloblastoma
D Pilocytic astrocytoma
E Oligodendroglioma

Answer 31

D

Question 32

A patient presents with a tumor in the cerebellopontine angle. On biopsy, the pathology
shows a biphasic histology with dense and loose areas and Verocay bodies. What type of
tumor is this?
A Glioblastoma
B Meningioma
C Pilocytic Astrocytoma
D Neurofibroma
E Schwannoma

Answer 32

E

Question 33

A 32-year-old woman with complex partial epilepsy is seen in the emergency department
for a breakthrough seizure. Her phenytoin dose is increased from 300 mg/d to 400 mg/d. A
few days later, she comes to your office complaining of constant ataxia, nystagmus, and
confusion. What is the most likely cause of her new symptoms?
A She continues to have frequent complex partial seizures.
B She has developed cerebellar ataxia.
C She has phenytoin toxicity.
D She has opioid intoxication.

Answer 33

C

Question 34

An 85-year-old man with a history of well-controlled hypertension presents to primary care
clinic with his daughter to discuss memory loss. They have both noticed that he is increasingly
forgetful. He has forgotten some doctors’ appointments and forgot to pay his electric bill. He
is able to perform all of his activities of daily living (ADLs), and has no trouble with swallowing
or language. What is the most likely diagnosis?
A Normal aging
B Mild cognitive impairment
C Alzheimer disease
D Vascular dementia

Answer 34

B

Question 35

Which of the following medications has been shown to slow cognitive deterioration in
patients with mild to moderate Alzheimer disease?
A Donepezil
B Pyridostigmine
C Levodopa
D Verapamil

Answer 35

A

Question 36

You are seeing a patient with a recent diagnosis of Creutzfeldt-Jakob disease (CJD). Which of
the following is true regarding the pathogen responsible for CJD?
A It is caused by a bacterial pathogen.
B It is caused by a DNA virus.
C It is caused by a transmissible pathogen devoid of nucleic acid.
D It is caused by an environmental toxin.
E It is caused by an RNA virus.

Answer 36

C

Question 37

A 35 year old woman recovering from an upper respiratory infection noticed some
weakness in her legs. By the next day, the weakness spread to her upper limbs and she began
to have difficulty breathing. She was brought to the ED where a physical exam indicated
mostly normal sensation, but significant motor weakness and hyporeflexia. The most likely
agent causing this disorder is
A Neisseria meningitidis
B Streptococcus pneumoniae
C Campylobacter jejuni
D E coli
E Herpes simplex virus-1

Answer 37

C

Question 38

A 31-year-old white woman is evaluated for symptoms of blurred vision and weakness. She
is not really sure how long the symptoms have been occurring. She has had intermittent
blurring of her vision for the last 2 months, although it has been more persistent for the last 2
weeks. She states that she also notes that colors seem less vivid and that her symptoms are
worse in the right eye. Three months ago, she did notice some sharp pains in the right eye
that were worse when she looked around. They subsided after about a week, and since then,
her vision has worsened. At the same time, she feels as though she is stiff in her legs and also
feels that her left leg is weak. She sometimes feels as if her left leg will give out on her if she
stands on it for a prolonged period. Her past medical history is significant for type 1 diabetes
mellitus for which she uses an insulin pump. She has smoked one pack of cigarettes daily
since the age of 18. On physical examination, there is spasticity in both of her lower
extremities with passive motion. Deep tendon reflexes are 3+ bilaterally with strength at the
quadriceps on the right at 4/5. All other strength in the lower extremity is 5/5 bilaterally.
Sensation to light touch and pinprick is decreased in the lower extremities. A dilated
funduscopic examination shows swelling of the optic disc. Which of the following findings is
most likely to be demonstrated?
A Hyperintensity on T1-weight images consistent with a mass lesion in cortex
B Elevated levels of leukocytes in the cerebrospinal fluid
C Periventricular hyperintensity in T2-weighted MRI images
D Cortical infarct involving the middle cerebral artery
E Presence of 15 polymorphonuclear cells per microliter in the cerebrospinal fluid

Answer 38

C

Question 39

A 57-year-old woman was being seen by a neurologist after reporting several episodes of
abnormal hand and arm movements that lasted for less than 2 min. She reports that she first
experiences an unusual feeling that has served as a warning that something is about to
happen. This is followed by jerking movements in the fingers of her right hand and then her
entire arm begins to shake. She indicates that she does not lose consciousness during these
episodes, but they frighten her. This description is consistent with
A a complex partial seizure.
B a simple partial seizure.
C tonic-clonic seizure.
D absence epilepsy.
E temporal lobe epilepsy.

Answer 39

B

Question 40

A 21-year-old woman was talking with her friends when she suddenly experienced the
onset of strong contraction of her left and right limb muscles that lasted about 30 s which was
accompanied by a grunting sound and momentary loss of consciousness causing her to
collapse; this was immediately followed by jerking of her limbs that lasted for about 2 min.
This description is consistent with
A a complex partial seizure.
B a simple partial seizure.
C tonic-clonic seizure.
D tonic seizure
E absence seizure

Answer 40

C

Question 41

A healthy 23-year-old male medical student volunteered to have his EEG recorded as part of
a class demonstration of cortical activity patterns. An electrode was placed over his occipital
lobes and the activity was recorded initially while awake, sitting restfully with his eyes closed
and then after opening his eyes and he is alert. The dominant EEG patterns observed during
these two behaviors is expected to be
A beta (18–30 Hz) rhythm and then alpha (8–13 Hz) rhythm, respectively.
B delta (0.5–4 Hz) rhythm and then beta (18–30 Hz) rhythm, respectively.
C alpha (8–13 Hz) and then beta (18–30 Hz) rhythm, respectively.
D delta (0.5–4 Hz) rhythm and then fast, irregular low-voltage activity, respectively.
E beta (18–30 Hz) rhythm and then fast, irregular low-voltage activity, respectively.

Answer 41

C

Question 42

Childhood absence epilepsy was diagnosed in a 10-year-old boy. His EEG showed a bilateral
synchronous, symmetric 3-Hz spike-and-wave discharge. He began treatment with an
antiepileptic drug. What is the mechanism of action by which this drug works?
A It is a GABA analog that decreases Ca2+ entry into cells.
B It blocks voltage-gated Na+ channels associated with glutamate receptors.
C It potentiates GABA transmission.
D It is a dopamine receptor agonist.
E It inhibits T-type Ca2+ channels.

Answer 42

E

Question 43

A 35-year-old man with a history of epilepsy was brought to the emergency department by
a family member who found him on the ground shaking. Typically his seizures would last no
more than a few minutes, but this episode of rhythmic shaking has persisted for the past 30
min. It was determined that he was experiencing a tonic-clonic seizure. Blood was dripping
from his mouth because he bit his tongue during the convulsion. After making certain his
airway was patent, the physician requested that an intravenous dose of phenytoin be
administered to the patient. What is the mechanism of action of phenytoin?
A Blocks Na+ channels and decreases synaptic release of glutamate
B Blocks N-type voltage-gated Ca2+ channels and decreases glutamate release
C Blocks Na+ channels, inhibits T-type Ca2+ channels, and enhances GABA transmission
D A GABA analog, blocks N-type voltage-gated Ca2+ channels, and reduces synaptic
release of glutamate
E Potentiates GABA transmission, decreases glutamate receptor activity, and blocks Na+
channels

Answer 43

A

Question 44

A 64-year-old patient presents with the sudden onset of impaired vision. On examination,
you find a right homonymous hemianopia without any other neurologic deficits. What is the
most likely vascular territory involved?
A Left middle cerebral artery (MCA)
B Right MCA
C Left posterior cerebral artery (PCA)
D Right PCA

Answer 44

C

Question 45

A 48-year-old man is brought to the emergency department after collapsing at home with
left hemiparesis. Computed tomography reveals an intraparenchymal hemorrhage in the right
basal ganglia with intraventricular extension. What is the most likely etiology for his
hemorrhage?
A Hypertensive hemorrhage
B Amyloid angiopathy
C Superior sagittal sinus thrombosis
D Herpes simplex virus encephalitis

Answer 45

A

Question 46

A 24-year-old woman presents with 3 days of headache and blurred vision to the
emergency department. She has papilledema on examination, and magnetic resonance
venography demonstrates a parietal infarction with loss of flow in the superior sagittal sinus.
What is the best acute therapy for this condition?
A Start oral aspirin daily
B Start a therapeutic heparin drip and transition to warfarin
C Start dexamethasone, scheduled 4 times per day
D Administer intravenous tissue plasminogen activator (tPA)

Answer 46

B

Question 47

Which of the following reversible causes of cognitive impairment should you screen for in a
patient with mild cognitive impairment?
A Depression
B Hypothyroidism
C Vitamin B12 deficiency
D All of the above

Answer 47

D

Question 48

A patient experiences a strong toxic effect after the administration of a large intravenous
dose of lidocaine. He is then quickly treated with intravenous diazepam. Which toxicity is this
patient most likely experiencing?
A Bronchoconstriction
B Methemoglobinemia
C Renal failure
D Seizures
E Tachycardia

Answer 48

D

Question 49

The mechanism of antiseizure activity of carbamazepine is
A Block of sodium ion channels
B Block of calcium ion channels
C Facilitation of GABA actions on chloride ion channels
D Glutamate receptor antagonism
E Inhibition of GABA-transaminase

Answer 49

A

Question 50

A 30 year old woman was being treated with a single anti epileptic drug for complex partial
seizures for the past 5 years. She recently saw her neurologist because she noticed a gradual
increase in hairiness and thickening of her gums that made her self-conscious about smiling.
These changes are most likely associated with adverse effects of
A Carbamazepine
B Ethosuximide
C Phenytoin
D Tiagabine

Answer 50

C

Question 51

A 9-year-old child is having learning difficulties at school. He has brief lapses of awareness
with eyelid fluttering that occur every 5–10 min. Electroencephalogram (EEG) studies reveal
brief 3-Hz spike and wave discharges appearing synchronously in all leads. Which drug would
be effective in this child without the disadvantages of excessive sedation or tolerance
development?
A Clonazepam
B Diazepam
C Ethosuximide
D Gabapentin
E Phenobarbital

Answer 51

C

Question 52

Which statement about phenytoin is most accurate?
A Displaces sulfonamides from plasma proteins
B Drug of choice in myoclonic seizures
C Half-life is increased if used with phenobarbital
D Isoniazid (INH) decreases steady-state blood levels of phenytoin
E Toxic effects may occur with only small increments in dose

Answer 52

E

Question 53

Which drug used in management of seizure disorders is most likely to elevate the plasma
concentration of other drugs administered concomitantly?
A Carbamazepine
B Clonazepam
C Phenobarbital
D Phenytoin
E Valproate

Answer 53

E

Question 54

A young man suffers from a seizure disorder characterized by tonic rigidity of the
extremities initially, followed in 15–30 s by tremor progressing to massive jerking of the body.
This clonic phase lasts for 1 or 2 min, leaving the patient in a stuporous state. Of the following
drugs, which is most suitable for long-term management of this patient?
A Clonazepam
B Ethosuximide
C Felbamate
D Phenytoin

Answer 54

D

Question 55

A 32-year-old man had medial temporal lobe epilepsy for over 10 years. This caused
bilateral loss of hippocampal function. As a result, this individual might be expected to
experience a
A disappearance of remote memories.
B loss of working memory.
C loss of the ability to encode events of the recent past into long-term memory.
D loss of the ability to recall faces and forms but not the ability to recall printed or
spoken words.
E production of inappropriate emotional responses when recalling events of the recent
past

Answer 55

C

Question 56

A 70-year-old woman fell down a flight of stairs, hitting her head on the concrete sidewalk.
The trauma caused a severe intracranial hemorrhage resulting in brain damage. Following this
injury, she seemed to ignore her left side; for example, she would only wash the right side of
her body or only put a shoe on her right foot. What area of the brain was most likely damaged
as a result of this fall down the stairs?
A Parietal lobe of the right hemisphere
B Frontal lobe of the right hemisphere
C Mammillary bodies
D Temporal lobe in the right hemisphere
E Occipital lobe of the right hemisphere

Answer 56

A

Question 57

A 67-year-old woman suffered a stroke that damaged the posterior end of the superior
temporal gyrus on the left side of her brain. A lesion of this area will likely cause her to
A lose the ability to remember recent events.
B experience nonfluent aphasia in which she speaks in a slow, halting voice.
C experience déjà vu.
D talk rapidly but make little sense, which is characteristic of fluent aphasia.
E lose the ability to recognize faces, which is called prosopagnosia.

Answer 57

D

Question 58

A 79-year-old woman has been experiencing difficulty finding her way back home after her
morning walks. Her husband has also noted that she takes much longer to do routine chores
around the home and often appears to be confused. He is hoping that this is just due to “old
age”. Which of the following would be definitive signs of Alzheimer disease in this woman?
A Difficulty with calculations, depression, emotional lability
B The presence of intracellular neurofibrillary tangles and extracellular neuritic plaques
with a core of β-amyloid peptides and brain atrophy
C A mutation in genes for amyloid precursor protein (APP) on chromosome 21 and the
presence of intracellular neurofibrillary tangles and extracellular amyloid plaques
D The inability to form new long-term memories, rapid reversal of all symptoms with the
use of acetylcholinesterase inhibitors, and brain atrophy
E A loss of cholinergic neurons in the nucleus basalis of Meynert, rapid reversal of
symptoms with the use of acetylcholinesterase inhibitors, and brain atrophy

Answer 58

B

Question 59

Which of the following is the target of the autoantibody found in 70% of patients with a
clinical diagnosis of neuromyelitis optica?
A Aquaporin-4
B Cyclic citrullinated peptides
C frataxin
D alpha synuclein
E peripheral myelin protein 22

Answer 59

A

Question 60

Ms. Weiwadell presents to you in the emergency department with acute-onset dysarthria
and confusion. You make the diagnosis of stroke clinically. What is the next appropriate step?
A Aspirin 81 mg by mouth
B CT of the brain
C Heparin IV drip
D Tissue plasminogen activator
E None of the above

Answer 60

B

Question 61

You are evaluating a 53-year-old woman with neurologic complaints reminiscent of a
demyelinating disease. Which of the following evaluative modalities is recommended for
further workup of demyelinating disease?
A CT angiography
B CT
C Electroencephalogram
D MRI
E Transcranial Dopplers

Answer 61

D

Question 62

You are seeing a patient with progressive dementia and apathy, disinhibition, compulsivity,
loss of empathy, and overeating. Brain MRI shows marked atrophy in anterior cingulate,
prefrontal cortex and frontoinsular region. Which of the following is an effective therapy to
improve this patient’s dementia?
A Memantine
B Phenytoin
C Trazadone
D Donepezil
E None of the above

Answer 62

E

Question 63

In evaluating a patient with a new focal neurologic deficit, which of the following should be
the first diagnostic priority?
A Obtaining an echocardiogram to evaluate for possible etiology of emboli
B Obtaining an electroencephalogram to rule out seizures
C Obtaining laboratory studies to rule out a metabolic reason for the supposed
neurologic complaint
D Obtaining rapid MRI with and without contrast
E Obtaining the history and examination to identify the region of the nervous system
that is likely to be responsible for the symptoms

Answer 63

E

Question 64

A 52-year-old man presents to the emergency department complaining of weakness that
has developed over the last 2 days. He first noticed that he had generalized fatigue and felt
like he was having a hard time moving his feet. Over the last 24 hours, the weakness has
progressed to the point that he can barely stand with assistance. He was brought into the
emergency department in a wheelchair. He is beginning to feel that it is difficult to lift his
arms. He also complains of a sharp pain in his shoulders and along his spine. Both his hands
and feet are tingling. On physical examination, his initial blood pressure is 138/82. On repeat
1 hour later, it is 92/50. His heart rate is 108 beats/min, respiratory rate is 24 breaths/min,
temperature is 37.0°C (98.6°F), and SaO2 is 96% on room air. He appears anxious and weak.
Deep tendon reflexes are absent at the knee, ankle, and wrist. The brachioradialis reflex is 1+.
Strength throughout the lower extremities is diminished as the patient is unable to lift either
leg against gravity. In the arms, strength is 4/5 in the deltoids, biceps, and triceps. However,
he is unable to maintain a grip, and wrist flexion and extension are 3/5. Which of the
following features would most commonly accompany this patient’s history?
A A diagnosis of “walking pneumonia” that was treated with azithromycin 2 weeks prior
to presentation
B An acute diarrheal illness 2 weeks prior to presentation
C Presence of a massive mediastinal lymphadenopathy on chest radiograph
D Presence of a monoclonal gammopathy of unknown significance on laboratory testing
E Recent immunization with the covid vaccine

Answer 64

B

Question 65

Which of the following statements is true regarding the treatment of the above patient?
A Glucocorticoids are first-line therapy.
B Combination IVIg and plasma exchange has better efficacy than either treatment
alone.
C Effective therapy is equally effective regardless of how quickly it is given after first
motor symptoms.
D IVIg and plasma exchange are both effective and either can be used as first-line
therapy.
E No therapy reduces the likelihood of mechanical ventilation.

Answer 65

D

Question 66

You are seeing Mr. Williams today in the clinic. You note a tremor, which he says is new.
Which of the following pathologies is matched CORRECTLY with the tremor type below:
A Essential tremor: resting tremor.
B Parkinson disease: intension tremor.
C Cerebellar dysfunction: resting tremor.
D Enhanced physiologic tremor: occurs with caffeine ingestion.

Answer 66

D

Question 67

A 24-year-old man presents for evaluation of foot drop. He has noted that for the last
several months he has had difficulty picking his feet up to walk upstairs and over thresholds.
His right leg is more affected than his left leg. He has not noted any sensory changes. His
father and paternal aunt each have had some weakness in their lower extremities; however,
his father is currently 50 years of age and only began to develop some weakness in the last 2
years. His paternal aunt has always had a limp for as long as he can recall. He does not
remember his grandparents having any symptoms, although his paternal grandfather died in
a car accident at the age of 46 prior to his birth. The patient’s examination is notable for distal
leg weakness with reduced sensation to light touch in both lower extremities. Knee and ankle
jerk reflexes are unobtainable. Calves are reduced in size bilaterally. Upper extremity
examination is normal. Which of the following is the most likely diagnosis?
A Charcot-Marie-Tooth Disease
B Fabry disease
C Guillain-Barré syndrome
D Multiple sclerosis
E Hereditary sensory and autonomic neuropathy

Answer 67

A

Question 68

A 62-year-old man presents with memory and behavior problems. Until 1 year ago, he had
worked as a senior account manager at a local bank, but he had to retire after he had an
angry outburst with a client. He then was inappropriate with a female colleague in a
departmental meeting. His family reports that this behavior was entirely out of character for
him and since then, he is increasingly brusque and easily angered. He also has been overly
sexual and has said many inappropriate things within the hearing of his teenage
grandchildren. He has been gaining weight due to overeating and he has been hoarding food
in his bedroom. He has an MBA degree, but his wife has recently began managing the money
after he could no longer be relied on to do this. The financial records were highly disorganized
when she began to look into them. On examination, he is gruff and says that he does not
want to do “this damn thing.” He needs to “get the hell out of here.” He was quite rude and
insulting to his wife several times. He has a positive glabellar reflex. Recent memory as well as
long term memory are intact. Mini-Mental State Examination is 22/30. There is no rigidity.
Gait is normal. Deep tendon reflexes are 2+ and symmetric. Strength is 5/5 throughout and
there are no sensory deficits. Cerebellar function is normal. Which of the following is the most
likely diagnosis?
A Alzheimer’s disease
B Dementia with Lewy bodies
C Frontotemporal dementia
D Progressive supranuclear palsy
E Vascular dementia

Answer 68

C

Question 69

A 68-year-old man presents to the emergency room with right-sided face, arm, and leg
weakness that began abruptly 1 hour prior to arrival. The patient is accompanied by his wife.
He exhibits Broca aphasia and dysarthria. Physical examination confirms a dense hemiparesis
of the right face, arm, and leg with decreased sensation. In addition, there is a gaze
preference to the left. The patient’s initial blood pressure on presentation to the emergency
room is 220/140 and, despite treatment with IV antihypertensives, remains at 195/120. An
emergent noncontrast head CT shows no evidence of intracranial hemorrhage or edema with
only mild loss of gray–white matter differentiation. On further review of the patient’s medical
history, he has had a prior embolic stroke affecting the posterior circulation 12 months ago.
He also has a history of colon cancer that was diagnosed 3 months ago when he presented
with a lower gastrointestinal (GI) bleed requiring transfusion of 4 units of packed red blood
cells. He successfully underwent left hemicolectomy of a stage I adenocarcinoma. Which of
the following factors is a contraindication to use for IV recombinant tissue plasminogen
activator in this patient?
A Age >65
B Blood pressure elevation >185/110
C GI bleeding within the last 3 months
D Major surgery within the last 3 months
E Prior embolic stroke

Answer 69

B

Question 70

You are seeing Mr. DeWinter, a 71-year-old man, for changes in mental status and
cognition. His wife reports that he has slowly been worsening over the last year or two. He
has frequent visual hallucinations, sleeps heavily during the daytime but not well at night, and
has delusions of persecution. He was noted to have some parkinsonian features previously
and was started on L-dopa, but quickly developed a hallucinatory delirium requiring cessation
of L-dopa. He does not have orthostatic hypotension or syncope. Which of the following
diseases best fits his dementia syndrome?
A Alzheimer’s disease
B Delirium
C Dementia with Lewy bodies
D Multiple systems atrophy with parkinsonism
E Normal aging

Answer 70

C

Question 71

A 72-year-old woman is evaluated for memory problems. She and her husband first noticed
some mild problems about 2 or 3 years ago, but attributed her symptoms to “old age.” They
decided to seek an evaluation when she became lost while returning home from the grocery
store last week. She had driven back and forth from this same store weekly for the last 20
years, and this incident frightened them both. She does not know what happened and had to
call her husband for help. She has shown no changes to her personality. Her medical history is
significant for hypertension and stage 2 breast cancer treated 10 years ago. She is taking
ramipril 5 mg bid. She smoked one pack of tobacco daily from the age of 20 until she was 64.
She drinks a glass of wine nightly. She retired from her position as an accountant at the age of
60. On examination, she appears well groomed and pleasant. Her blood pressure is 158/90
and heart rate is 82 beats/min. Her neurologic examination is normal without focal defect.
Gait is normal. No rigidity is present. Neuropsychological testing shows impairment 1.5
standard deviations below the norm. Which of the following would be the most likely
pathologic finding in the brain?
A Deposition of amyloid within cerebral blood vessels
B Loss of cortical serotonergic innervation with atrophy of the frontal, insular, and/or
temporal cortex
C Neuritic plaques and neurofibrillary tangles in the medial temporal lobes
D Presence of intraneuronal cytoplasmic inclusions that stain with periodic acid–Schiff
and ubiquitin in the substantia nigra, amygdala, cingulate gyrus, and neocortex

Answer 71

C

Question 72

You are seeing Mrs. Fajedo, a 74-year-old woman with a recently worsening tremor. She
notes that it predominantly affects her hands and is worse with action such as trying to eat. It
is not present at rest. It is improved by drinking 1–2 beers. She has no other symptoms. On
examination, her resting heart rate is 52 beats/min (she is an avid runner and physically fit)
with normal vital signs otherwise. Mrs. Fajedo’s condition is best diagnosed as
A. Parkinson Disease
B. Essential tremor
C. Huntington Disease
D. Lewy Body Dementia

Answer 72

B

Question 73

A 31-year-old white woman is evaluated for symptoms of blurred vision and weakness. She
is not really sure how long the symptoms have been occurring. She has had intermittent
blurring of her vision for the last 2 months, although it has been more persistent for the last 2
weeks. She states that she also notes that colors seem less vivid and that her symptoms are
worse in the right eye. Three months ago, she did notice some sharp pains in the right eye
that were worse when she looked around. They subsided after about a week, and since then,
her vision has worsened. At the same time, she feels as though she is stiff in her legs and also
feels that her left leg is weak. She sometimes feels as if her left leg will give out on her if she
stands on it for a prolonged period. Her past medical history is significant for type 1 diabetes
mellitus for which she uses an insulin pump. She has smoked one pack of cigarettes daily
since the age of 18. On physical examination, there is spasticity in both of her lower
extremities with passive motion. Deep tendon reflexes are 3+ bilaterally with strength at the
quadriceps on the right at 4/5. All other strength in the lower extremity is 5/5 bilaterally.
Sensation to light touch and pinprick is decreased in the lower extremities. A dilated
funduscopic examination shows swelling of the optic disc. On further historical review, the
patient reports that she had one prior episode of blurred vision that resolved spontaneously
about 8 months ago. She never sought treatment for it, although it lasted for about 2 weeks.
All of the following are epidemiologic risks factors for her disease EXCEPT:
A Age between 20 and 40
B Cigarette smoking
C Female sex
D History of an autoimmune disorder (type 1 diabetes mellitus)
E Caucasian ethnicity

Answer 73

D

Question 74

A 38-year-old man with a history of seizure disorder presents with generalized convulsive
status epilepticus. He had been having persistent seizure activity for 20 minutes when
emergency medical services was activated. He was given paralytic agents in the field to allow
for intubation as well as lorazepam 8 mg IV. On arrival in the emergency department 20
minutes later, the neuromuscular blockade had worn off and generalized seizure activity was
again apparent. His initial temperature is 39.2°C (102.5°F) with blood pressure 182/92, heart
rate 158 beats/min, respiratory rate 38 breaths/min, and SaO2 95% on mechanical ventilation
with an assist control mode with a set rate of 15, tidal volume of 420 mL, PEEP of 5 cm H2O,
and FiO2 of 0.6. Which of the following is the next step in the management of this patient?
A Additional dosing of neuromuscular blockers
B Isoflurane anesthesia
C Fosphenytoin
D Carbamazepine
E Propofol

Answer 74

C

Question 75

Mr. Gabrielle is a 74-year-old who presents with CT findings of pontine intracerebral
hemorrhage. Which of the following is the most common clinical finding in pontine
hemorrhage?
A Bilateral hypo-reflexia
B Deep coma with quadriplegia
C Homonymous hemianopsia
D Loss of balance
E Severe headache

Answer 75

B

Question 76

A patient presents with decreased visual acuity and weakness of the left upper and lower
limbs. Which of the following can distinguish neuromyelitis optica (NMO) clinically from
multiple sclerosis (MS) in this patient?
A Attacks of optic neuritis can be bilateral and produce severe vision loss more
commonly in NMO than in MS.
B Brain MRIs are more abnormal in NMO.
C Myelitis is typically more severe in MS compared to NMO.
D NMO is more common in men, whereas MS is more common in women.

Answer 76

A

Question 77

A 78-year-old man has been diagnosed with mild cognitive impairment after complaining of
decreased memory. He asks you to prescribe something that will decrease his likelihood to
progress to Alzheimer’s disease. Which of the following treatments do you recommend?
A Brain training exercises
B Donepezil
C Ginkgo biloba
D Memantine
E No treatment at this time has been demonstrated to delay the progression of mild
cognitive impairment to Alzheimer disease

Answer 77

E

Question 78

You are seeing a patient with a recent diagnosis of Creutzfeldt-Jakob disease (CJD). Which of
the following is true regarding the pathogen responsible for CJD?
A It is caused by a bacterial pathogen.
B It is caused by a DNA virus.
C It is caused by a transmissible pathogen devoid of nucleic acid.
D It is caused by an environmental toxin.
E It is caused by an RNA virus.

Answer 78

C

Question 79

All of the following are usually associated with absence seizures EXCEPT:
A Lip smacking
B Postictal confusion
C Provocation with hyperventilating
D Rapid blinking
E Small amplitude clonic movements of the hands

Answer 79

B

Question 80

A 45-year-old homeless man who is hospitalized on a mental illness warrant is having
difficulty with speech and walking. On physical examination, he appears confused and has
nystagmus, bilateral lateral rectus palsies, and a broad-based ataxic gait. Most of his
symptoms resolve over the course of hospitalization, but he has a permanent footdrop. What
is the most likely diagnosis?
A Korsakoff psychosis
B Wernicke encephalopathy
C Herpes encephalitis
D Bacterial meningitis

Answer 80

B

Question 81

A 72-year-old man suddenly developed weakness of his left leg, causing him to fall to the
ground while shopping with his wife. An ambulance is called, and he is rushed to the hospital.
He spends 4 days in the hospital, but the weakness in his left leg does not resolve. Which of
the following is the most likely diagnosis?
A Global hypoxic ischemic encephalopathy
B Transient ischemic attack
C Acute infarct in the distribution of the right middle cerebral artery
D Acute infarct in the distribution of the right anterior cerebral artery

Answer 81

D

Question 82

A 28-year-old woman presents to her physician because of complaints of a mass on her left
shoulder that has grown rapidly in size over the past several months. The nodule is
nontender, and the patient is afebrile. She has multiple large (> 2 cm) hyperpigmented
macules on her skin, and small brown dome-shaped elevations on her irises. Which of the
following conditions is the most likely diagnosis for her rapidly growing mass?
A A malignant peripheral nerve sheath tumor
B A hamartoma composed of smooth muscle
C A benign tumor of Schwann cells
D An angiomyolipoma

Answer 82

A

Question 83

A 73-year-old woman sustains an infarct of her right parietal lobe due to an embolic
occlusion of the right middle cerebral artery due to atherosclerosis of the internal carotid
artery. She dies 1 year later, and an autopsy is performed. Examination of the brain will most
likely reveal
A a 4.5 cm cavity in the right parietal lobe
B an ill-defined softening of the right parietal lobe
C a well-defined friable area in the right parietal lobe
D a tiny (< 1.0 cm) cavity in the pons

Answer 83

A

Question 84

. A brain autopsy specimen from a patient who recently died is shown in the figure below.
The patient’s family indicated that the patient had difficulty following conversations,
remembering where things were put, and getting lost during car trips. What type of pathology
is shown in the figure?
A neurofibrillary tangle
B senile plaque
C Lewy body
D TGP-43 deposit

Answer 84

A

Question 85

A 30 year old woman presented to the ED with a recent onset, first seizure. Radiology
indicates a mass lesion in the frontal lobe. A neuropathologist is summoned to the pathology
gross room by the neurosurgical team to perform a frozen section on a surgical specimen of
the lesion. The specimen is found to show GFAP positive staining, hypercellularity, and low
mitotic activity Based on these findings, which of the following tumors would be most likely?
A Infiltrating low-grade astrocytoma
B Glioblastoma multiforme
C Oligodendroglioma
D Meningioma

Answer 85

A

Question 86

A patient experiences a strong toxic effect after the administration of a large intravenous
dose of lidocaine. He is then quickly treated with intravenous diazepam. Which toxicity is this
patient most likely experiencing?
A Bronchoconstriction
B Methemoglobinemia
C Renal failure
D Seizures
E Tachycardia

Answer 86

D

Question 87

35-year-old woman presents with weakness and spasticity in the lower left extremity,
visual impairment and throbbing in the left eye, and difficulties with balance, fatigue, and
malaise. There is an increase in CSF protein, elevated gamma globulin, and moderate
pleocytosis. MRI confirms areas of demyelination in the anterior corpus callosum. Imaging
identifies plaques that are hyperintense on T2-weighted and fluid-attenuated inversion
recovery (FLAIR) images, and hypointense on T1-weighted scans. Which of the following cells
are specifically targeted in her condition?
A Microglia
B Oligodendrocytes
C Astrocytes
D Schwann cells
E Multipolar neurons

Answer 87

B

Question 88

A 54-year-old man collapsed at work after complaining of the
sudden onset of a severe headache. At the ER, his vital signs
include temperature 36.7°C, pulse 110 bpm, respirations 28 per
minute, and blood pressure 220/110 mmHg. He is awake but
drowsy and disoriented. His family reported that he had not
been compliant with his hypertension medications for several
years. Noncontrast CT scan is shown in the Figure. The CT scan
reveals:

A Acute ischemic infarct
B Acute intracerebral hematoma
C Diffuse subarachnoid hemorrhage
D Epidural intracranial hematoma

Answer 88

B

Question 89

A 85-year-old man who has Alzheimer’s disease was prescribed donepezil (Aricept) in an
attempt to improve his memory. Which one of the following is the most likely side effect of
the drug?
a. Mydriasis
b. Abdominal cramping and diarrhea
c. Muscle weakness
d. Hypertension
e. Tachycardia

Answer 89

B

Question 90

A patient presents with weakness and hyper-reflexia affecting the left hand and leg and loss
of ability to move the right eye inward or vertically. The most likely locus of the lesion is the:
a. Medial aspect of the precentral gyrus
b. Genu of the internal capsule
c. Posterior limb of the internal capsule
d. Medial half of the ventral midbrain
e. Basilar pons

Answer 90

D

Question 91

Which blood vessel and location is involved:
A. A beleaguered 39-year-old handball player with a drooping right eyelid, laterally deviated
right eye, dilated right pupil, weak left arm and leg, and left Babinski sign
B. A patient with a weak right arm and leg, right Babinski sign, and impaired touch and position
sense in the right arm and leg. The tongue deviates to the left when protruded.
C. A patient with a weak left arm and leg, left Babinski sign, and impaired touch and position
sense in the left arm and leg. His right eye is deviated medially, and his tongue deviates
slightly to the left when protruded.
D. A patient with diminished pain and temperature sensation over the right arm and leg and the
left side of the face, ataxic left arm and leg, and a palate whose left side does not elevate
when he says “Ahhhhh.”
E. A patient presents with protrusion of the jaw to the right when opened, loss of tactile
sensation over the right face, intention tremor of the right arm with dysmetria and
overshooting in finger-nose-finger testing and tremor of the right leg in the hell-shin test.

Answer 91

A. PCA/ Rostral Midbrain
B. Anterior spinal Artery/ rostral medulla
C. Basilar branch/ caudal pons
D. PICA/ Rostral Medulla
E. Basilar Branch/ Mid pons

Question 92

A patient with a brain tumor was seen in the ED. The tumor damaged the patient’s
flocculus. Which of the following symptoms would this patient have exhibited.
a. akinesia
b. ataxia
c. dyskinesia
d. dystonia
e. nystagmus

Answer 92

E

Question 93

A patient presents with a wide, ataxic, and unsteady gait. Physical exam indicated no tremor
during arm reaching or one leg sliding against the other. Eye movements were normal.
Strength and reflexes were normal. Which of the following structures could be responsible for
this patient’s symptoms?
a. dentate nucleus of cerebellum
b. cerebellar nodulus
c. corticospinal tract
d. cerebellar vermis
e. middle cerebellar peduncle

Answer 93

D

Question 94

A 17-year-old boy was brought to a psychologist for psychological testing because he was
unable to express any feelings of fear. He was also unable to recognize fear in pictures
presented to him. Further analysis confirmed this impression and indicated that other
emotions were quite normal. A subsequent MRI revealed calcification in a region of the brain.
Where in the brain was the lesion found?
a. Amygdala
b. Hippocampus
c. Anterior cingulate gyrus
d. Prefrontal cortex
e. insula

Answer 94

A

Question 95

A patient with long-standing hypertension that was mostly untreated due to poor access to
health care was seen in the ED with stroke symptoms. A CT indicated that the patient had a
lacunar stroke. Which area would have been involved in this patient.
a. cerebellum
b. basal ganglia
c. hippocampus
d. amygdala
e. frontal lobe

Answer 95

B

Question 96

A 34-year-old female with a history of high blood pressure and smoking was brought into
the ED complaining of having the worst headache ever. She had complained of nausea and a
stiff neck to her spouse and was lethargic by the time she reached the ED. The most likely
structure responsible for this woman’s condition is
A. lenticulostritate arteries
B. internal carotid artery
C. circle of Willis
D. vertebral artery
E. middle meningeal artery

Answer 96

C

Question 97

Which of the following is the best choice for initial management of a patient with mild
Alzheimer disease (AD)?
A N-methyl-D-aspartate (NMDA) receptor antagonist (eg, memantine)
B Peripherally acting cholinesterase inhibitor (eg, pyridostigmine)
C Ginkgo biloba
D Centrally acting cholinesterase inhibitor (eg, donepezil)
E Selective serotonin reuptake inhibitor (eg, fluoxetine)

Answer 97

D

Question 98

A 64-year-old woman presents with a reduction in fluency of speech with a serious
deficiency in naming of objects and repetition of words when requested to do so. The
patient’s writing is poor, and she also displays a hemiparesis. Comprehension of speech
appears to be preserved. A magnetic resonance imaging (MRI) scan and overall neurologic
examination reveal that the patient has a lesion. Which of the following regions is likely to
contain the lesion?
A Medial aspect of the premotor cortex
B Posterior inferior frontal lobe (Frontal operculum)
C Supramarginal gyrus
D Angular gyrus
E Posterior region of superior temporal gyrus

Answer 98

B

Question 99

A 67-year-old woman is brought to a local hospital following complaints by her family
because of recent difficulties that the patient has experienced in communicating with others.
In particular, the patient has great difficulty in comprehending words and understanding
simple commands. A neurologic examination confirms that the patient experiences difficulties
in language comprehension, and an MRI reveals a cortical lesion. Which of the following
regions was observed to be the locus of the lesion?
A Medial portion of the premotor cortex
B Posterior inferior frontal lobe (Frontal operculum)
C Medial aspect of occipital cortex
D Superior posterior parietal lobule
E Posterior aspect of superior temporal lobe

Answer 99

E

Question 100

. A 75-year-old man, who is right handed, was told in the past by his internist that he has an
irregular heartbeat. The patient decides that he does not wish to learn anything further about
this condition, so he does not return to this physician, and it remains untreated. One morning,
he awakes to find that his face droops on the right side and that he cannot move his right arm
or right leg. When he tries to call an ambulance for help, he has a great deal of difficulty
communicating with the operator because his speech is slurred, nonfluent, and missing some
pronouns. The call is traced by the police; an ambulance arrives at his house and takes him to
an emergency room. A neurologist is called to see the patient in the emergency room. When
he listens to the patient’s heart, he detects an irregular heartbeat. It is very difficult to
understand his speech because it is halting, with a tendency to repeat the same phrases over
and over. He has difficulty repeating specific sentences given to him by the neurologist, but
he is able to follow simple commands such as, “Touch your right ear with your left hand.” His
mouth droops on the right when he attempts to smile, but his forehead remains symmetric
when he wrinkles it. He cannot move his right arm at all, but he is able to wiggle his right leg a
little bit. Which of the following language problems does this patient have?
A Dysarthria
B Wernicke aphasia
C Broca aphasia
D Alexia
E Pure word deafness

Answer 100

C

Question 101

The hippocampus is required for the formation of new _________ memories.
A semantic, episodic, and spatial
B explicit and implicit
C declarative and nondeclarative
D procedural and spatial
E short-term working

Answer 101

A

Question 102

A 50 year old man who was in an automobile accident hit his head on the windshield and
was in coma in hospital for 2 weeks. He recovered over the next several months, but he
complained several deficits. He found it difficult to manipulate numbers mentally, like adding
a few numbers or making change from his cash register at his store. He also had difficulty
remembering phone numbers that were told to him by customers. The man’s memories of
people he know and his life before the accident remained intact. Which brain areas are
involved in the deficits this man had?
A frontal and temporal lobes
B frontal and parietal lobes
C parietal and occipital lobes
D temporal and occipital lobes
E frontal and occipital lobes

Answer 102

B

Question 103

A patient is described as being socially disinhibited and displaying severe impairments in
judgment, foresight, and insight. An MRI revealed the presence of a brain lesion. Where is the
likely location of this lesion?
A Premotor cortex
B Superior parietal lobule
C Prefrontal cortex
D Hippocampal formation
E Amygdala

Answer 103

C

Question 104

A 40-year-old man noticed that he had an almost complete loss of vision in his right eye. A
funduscopic examination of his eye indicated a loss of blood supply to the right eye. An
embolus from which one of the following arteries may have caused this condition?
a. Posterior communicating artery
b. Anterior cerebral artery
c. Posterior cerebral artery
d. Internal carotid artery
e. Middle cerebral artery

Answer 104

D

Question 105

A neurologic examination of a 55-year-old woman indicated that she had weakness on the
left side of her body. In addition, there was hyper-reflexia and Babinski sign on the left side
along with loss of discriminative touch, vibratory sense, and proprioception. When she
attempted to protrude her tongue, it deviated to the right. Which one of the following
arteries may be occluded in this patient?
a. Basilar artery
b. Branches of the anterior spinal artery
c. Branches of the superior cerebellar artery
d. Posterior spinal artery
e. Anterior inferior cerebellar artery

Answer 105

B

Question 106

A patient was seen in the ED with symptoms of a stroke. Imaging
revealed the area of the stroke localized to the region shown in the
adjacent figure. Which of the following symptoms would be expected in
the patient?
A Loss of tactile and proprioceptive sense on the right body
B Deviation of the tongue to the right
C Weakness with hyper-reflexia on the right body
D Limb ataxia of the limbs on the right
E Loss of pain sensation on the left side of face
F. Drooping of the mouth on the right side

Answer 106

E

Question 107

Which artery is responsible for the infarcted are in the above case?
A Anterior spinal artery
B Posterior inferior cerebellar artery
C Basilar artery
D Anterior inferior cerebellar artery
E Posterior spinal artery

Answer 107

B

Question 108

A 65 year-old man was found confused and unable
to see following a cardiac arrest. On exam he had
prominent weakness of the shoulder and hip girdle
muscles on the right side with hyper-reflexia and
spasticity. He had complete blindness in both eyes.
Imaging of the patient is shown in the figure. Which of
the following accurately explains the reason for this
patient’s symptoms.
A ischemia in brain areas located between the
distal ends of two or more major arteries
B ischemia in brain areas supplied by vessels with small branches
C ischemia related to occlusion of venous drainage involving the superior sagittal sinus
D occlusion of the Circle of Willis
E Symmetrical infarct involving the middle cerebral artery bilaterally

Answer 108

A

Question 109

A patient presents with symptoms of a stroke in the region of
the brainstem shown in the figure. Imaging indicates that the
stroke was caused by occlusion of a long circumferential branch
of the major artery supplying that area. Which of the following
symptoms would be expected from this lesion.
A Weakness with hyper-reflexia and spasticity
B loss of tactile sensation on the opposite side of body
C loss of tactile sensation on the same side of the face
D loss of pain sensation on the same side of the face
E medial deviation of the ipsilateral eye

Answer 109

C

Question 110

A 25 year old woman presented to the ED with recent onset of
confusion, headache, and fever. An MRI is shown in the figure. CSF
analysis indicates increased lymphocytes and presence of red blood
cells. What symptoms might be expected in this patient considering the
location of the lesion?
A Loss of tactile sensation on the opposite side of body
B weakness with hyper-reflexia and spasticity on opposite side
C contralateral hemianopsia
D Wernicke aphasia
E spatial neglect syndrome

Answer 110

D

Question 111

In the above patient, what pathological features might be expected?
A cowdry type A intranuclear inclusions
B negri body intranuclear inclusions
C neurofibrillary tangles
D abscess
E white matter demyelination

Answer 111

A

Question 112

A 40 year old man presented to the ED with confusion and
difficulty understanding commands. His partner said that his
speech hadn’t made sense during the past few days and that his
answers to questions were unintelligible. The patient had a 4
year history of HIV. An MRI from the patient is shown in the
figure. What is the most likely diagnosis?
A multiple sclerosis
B progressive multifocal leukoencephalopathy
C neuromyelitis optica
D toxoplasmosis
E meningitis

Answer 112

B

Question 113

A 35 year old female patient presented to the ED with malaise,
headache and left-sided weakness. Physical exam indicated hyper-reflexia
and spasticity of the left upper and lower limbs. The patient had an 8 year
history of HIV. Her MRI is shown in the figure. What is he most likely
diagnosis.
A Creutzfeldt-Jacob disease
B PML
C rabies
D HSV-1 encephalitis
E toxoplasmosis

Answer 113

E

Question 114

A wife noticed changes in the behavior of her 50 year old husband over
the previous year. His wife said he was a very sociable, caring, and frugal person previously.
The man became obsessed with audiobooks, insisting that they listen to them while cooking
eating, or driving. He impulsively bought items they could not afford. He made mistakes at
work and was eventually fired for consistent careless, poor workmanship. He did not have
urinary incontinence, but more recently he would urinate anywhere and anytime at home
even in the presence of other family members. He became more reserved, communicated
poorly with family members and at times was found to be non-responsive to questions. He
did not have any visual hallucinations and he his memory was recent and past memory was
intact. What pathological changes would be expected in this man?
A neurofibrillary tangles
B neuritic plaques
C Lewy bodies
D Bunina bodies

Answer 114

A

Question 115

A 28 year old woman had a 5 year history of deficits that varied. Initially
she saw her physician because of blurry visual that made reading difficult.
They she experienced weakness of her left upper and lower limbs with
stiffness. Recently, she saw her physician because she had trouble holding
objects with her right hand, feeling like her hand was numb. A recent MRI is
shown in the figure. What other finding would be expected in this woman.
A presence of amyloid plaques in gray matter
B presence of oligoclonal bands in CSF analysis
C a disorder associated with the JC virus
D presence of neurofibrillary tangles in cortical neurons
E presence of Lewy bodies in the cortex and brainstem

Answer 115

B

Question 116

In the above case concerning the 28 year old woman, what aspects seen in the MRI are
characteristic for this disease.
A. cortical atrophy
B. enlarged ventricles
C. periventricular hyperintensity
D. cortical ribboning
E. midline shift

Answer 116

C