Neuro
A 16-year-old boy is brought to the emergency department after being hit by a car while riding his bike. He is somnolent, opens his eyes to pain, responds to questions with inappropriate words, and uses his left hand to stop the physician attempting to start an IV in his right arm. What is the patient's Glasgow coma score? A10 B11 C12 D9
A
A 17-year-old boy experiences involuntary contractions of the facial and neck muscles after administration of haloperidol. The patient has arching of the back, deviation of the head to the left, and protrusion of the tongue. What management is indicated? ABenztropine BCyproheptadine CDantrolene DDiazepam
A
A 20-year-old woman presents with numbness in the left arm, left eye pain and blurry vision, and generalized weakness. She states she has had similar episodes in the past. Physical examination reveals a visual acuity of 20/20 in the right eye and 20/100 in the left eye. She also has decreased sensation in the left arm. Which of the following lumbar puncture findings is most likely? ACerebrospinal fluid pleocytosis and elevated IgG BIncreased opening pressure CPositive India ink stain DXanthochromia
A
A 22-year-old man with a recent diagnosis of schizophrenia is brought by his parents for evaluation of abnormal behavior. His mother notes that he has been very restless and has been pacing around the house constantly. On examination, his vital signs are unremarkable. He is noted to be mildly agitated and rocking back and forth on the examining table. What is the likely diagnosis? AAkathisia BDystonic reaction CParkinsonian sydrome DTardive dyskinesia
A
Which of the following patients in the setting of a known subarachnoid hemorrhage has the worst prognosis? AA 39-year-old woman who is confused and has mild right lower extremity weakness BA 55-year-old man with a severe headache and oculomotor nerve palsy CA 65-year-old man with a mild headache, nausea, and an episode of vomiting DA 70-year-old woman with headache, neck stiffness, and an episode of vomiting
A
A 38-year-old man presents with the worst headache of his life. A magnetic resonance angiogram is obtained which demonstrates a large unruptured cerebral aneurysm of the posterior communicating artery. Which of the following are you most likely to find on physical examination? ACranial nerve III palsy BCranial nerve V palsy CCranial nerve VI palsy DCranial nerve VII palsy
A Cranial nerve III palsy is a likely physical examination finding in a patient presenting with a subarachnoid hemorrhage due to a cerebral aneurysm. A subarachnoid hemorrhage is bleeding within the subarachnoid space of the brain and is most commonly caused by a cerebral aneurysm or an arteriovenous malformation. A cerebral aneurysm is a ballooning of the blood vessels of the brain that when under continued pressure can rupture. This is a medical emergency which requires immediate intervention. An unruptured cerebral aneurysm is often incidentally found on brain imaging or when screening for a cerebral aneurysm if a patient has a strong family history. Patients are typically asymptomatic with an unruptured aneurysm but may become symptomatic if increased pressure on the aneurysm continues. Characteristic findings of both unruptured and ruptured cerebral aneurysms include headache, often the worst headache of life, cranial nerve III deficit, and visual loss. Cranial nerve III is the oculomotor nerve which can become compressed when a cerebral aneurysm is present at the junction of the internal carotid artery and posterior communicating artery, causing a unilateral strict downward gaze, ptosis, anisocoria, and blurred vision. When a cerebral aneurysm causes a cranial nerve III deficit with no other neurological symptoms, the aneurysm is likely to be unruptured, but is large enough to compress the nerve
A 56-year-old man underwent a prolonged pelvic surgery. Two weeks later, he reports frequent tripping over his right foot. Strength examination of the right foot reveals: 5/5 plantar flexion, 5/5 ankle inversion, 3/5 ankle eversion, and 2/5 dorsiflexion. Light touch sensation is diminished over the lateral but not medial shin. Ankle and knee reflexes are intact. Injury to which one of the following nerves is most likely causative? ACommon peroneal BFemoral CSciatic DTibial
A PE will show foot drop, numbness in web space between first and second toes Most commonly caused by proximal fibula injury Treatment is an ankle splin
A 67-year-old woman presents with severe unilateral pain in her face. She characterizes the symptoms as lasting only a few seconds and denies any associated nausea, vomiting, dizziness, or blurry vision. Her HEENT exam and neurologic exam are normal. Which of the following statements is correct regarding this patient's condition? AFacial droop is associated with this condition BPain is most commonly located in the V2 and V3 cranial nerve distribution CPain is usually bilateral in the elderly population DPoor dentition is associated with this condition EThe typical pain attack lasts 30-60 minutes then resolves spontaneously
B
A patient presents with nausea, vomiting, right-sided hemiplegia, and non-occipital headache. His gaze is deviated to the left. Thirty minutes later, he becomes stuporous and progresses into coma. The pupils are now fixed and dilated. Abnormal posturing is absent. A brain CT scan is ordered. In which of the following sites would you expect to find intracerebral hemorrhage? ALeft pons BLeft putamen CRight cerebellum DRight thalamus
B
A patient presents with right-sided homonymous hemianopia. Which of the following is the location of the suspected lesion? ALeft optic nerve BLeft optic tract COptic chiasm DRight optic tract
B
A patient with a right-sided cranial nerve VI palsy would have which of the following findings on physical examination? AHead turned toward unaffected side BInability to look laterally with the right eye CInability to look medially with the right eye DPtosis, dilated pupil, and displacement of right eye downward and laterally
B
What effect does hyperbaric oxygen therapy have on carbon monoxide poisoning? AIt reduces mortality BIt reduces risk of neurologic sequelae CIt reduces the risk of dysrhythmia DIt reduces the risk of myocardial infarction
B
A 26-year-old man was involved in an automobile collision and sustained a pelvic fracture. He complains of medial ankle paresthesias, which radiate into the arch of his foot. Which of the following nerves is most likely involved? AObturator BSaphenous CSuperficial peroneal DSural
B Nerve exclusively sensory ↓ sensation in medial lower leg, medial ankle, foot arch
A 47-year-old man presents to the emergency department with active tonic-clonic seizure activity. Initial vital signs include T 97.5°F, BP 125/80 mm Hg, HR 110 beats/minute. Intravenous access is established and the administration of anticonvulsant therapy is initiated. The seizure activity ceases. Repeat vital signs include T 98°F, BP 80/40 mm Hg, HR 45 beats/minute, RR 12 breaths/minute. Which of the following anticonvulsant agents was most likely administered and is responsible for these physiologic changes? ACarbamazepine BPhenytoin CTopiramate DValproic acid
B Phenytoin Toxicity Delayed GI absorption Dizziness, gastrointestinal disturbances, headache, nystagmus, somnolence Parenteral: hypotension, bradycardia, cardiac toxicity (due to propylene glycol diluent) Multiple-dose activated charcoal
A 14-year-old boy presents with headache, fever, and altered mental status. He was recently seen and evaluated for sinusitis one week ago but was not given antibiotic treatment at that time. A CT scan of the head is performed. What management is indicated? ACeftriaxone, metronidazole, and admit BCeftriaxone, metronidazole, and neurosurgery consultation CCeftriaxone, vancomycin, and neurosurgery consultation DPyramethamine, sulfadiazine, and admit
B This patient presents with signs, symptoms, and imaging consistent with an intracranial abscess. Immediate management involves administration of antibiotics covering the most likely pathogens and neurosurgical consultation. CNS abscess is unusual in immunocompetent hosts but can result from direct spread from other infections. The most common causes from direct spread are dental infections, otitis media, and sinus infections. Patients with multiple abscesses should raise suspicion for endocarditis. Streptococcus species and anaerobic bacteria are the predominant causative agents. Patients with a history of trauma or intracranial surgery are also at risk for MRSA. CT scan is the diagnostic modality of choice and is typically followed by a lumbar puncture (unless there are signs of increased intracranial pressure), which aids in determining the etiologic agent. Location, size, and number of abscesses dictate management. Patients with a single abscess are more readily treated with neurosurgical intervention while those with multiple abscesses are usually treated with antibiotics alone. Initial antibiotics in patients without a history of neurosurgery should be with a third-generation cephalosporin and an agent covering anaerobic bacteria like metronidazole.
Which of the following is an indication for emergent hemodialysis following an acute ethylene glycol overdose? AAnion gap greater than 10 mmol/L BEthylene glycol level greater than 25 mg/dL CGlycolic acid level greater than 8 mmol/L DSerum pH greater than 7.5
C A glycolic acid level greater than 8 mmol/L is an indication for emergent hemodialysis following an acute ethylene glycol overdose. Ethylene glycol is found in automobile coolants, antifreeze, hydraulic brake fluid, de-icing agents, and industrial solvents. Symptoms progress through 4 stages: inebriation and intoxication, cardiopulmonary symptoms (tachycardia, hypertension, pulmonary edema), renal symptoms (acute renal failure), and delayed neurologic symptoms (cranial neuropathy). Treatment includes 1.) Alcohol dehydrogenase (ADH) enzyme blockade with fomepizole or ethanol to prevent toxic and acidic metabolite production, 2.) Correction of the metabolic acidosis with sodium bicarbonate, and 3.) Hemodialysis for removal of the parent compound and toxic metabolites. Although somewhat controversial with the advent of fomepizole, other indications for hemodialysis following ethylene glycol ingestion include severe metabolic acidosis, renal failure, deterioration despite intensive care, and electrolyte disturbances. Ethylene Glycol Intoxication History of ingestion of antifreeze, solvents, windshield wiper fluid, cleaners, fuels, deicing solutions Flank pain, hematuria, and oliguria Labs will show anion gap metabolic acidosis, ↑ osmol gap, hypocalcemia, acute kidney injury, envelope- or Maltese cross-shaped crystals in urine, fluorescent urine under Wood lamp Symptoms caused by the accumulation of the toxic byproduct oxalic acid Treatment is fomepizole
A 68-year-old man presents with complaints of a progressive, constant headache for the last three weeks. He was involved in a low speed motor vehicle collision a few days before the headaches began, but did not seek medical attention at the time because of a lack of symptoms immediately following the event. He takes aspirin and lisinopril daily. He denies a prior history of headaches. Noncontrast computed tomography of the head reveals a thin, crescent-shaped collection that is hypodense relative to the adjacent parenchyma. The lesion extends from the right frontal lobe to the ipsilateral falx cerebri, without crossing the midline. Which of the following is the most likely diagnosis? AAcute epidural hematoma BAcute subdural hematoma CChronic subdural hematoma DSubarachnoid hemorrhage
C An acute subdural hematoma (B) is generally described as occurring within three days of presentation.
A substrate is a medication that is metabolized by CYP450 isoenzymes in the gastrointestinal tract and liver. Substrates are subject to drug interactions with agents that inhibit or induce the enzyme. Substrate inhibition may result in drug toxicity while induction may result in lack of efficacy. Which of the following benzodiazepines is the best choice for use in the presence of liver failure or concomitant CYP450 interacting drugs? AChlordiazepoxide BDiazepam CLorazepam DMidazolam
C Lorazepam undergoes phase II hepatic metabolism via glucuronidation and is therefore not subject to the potential for CYP450 isoenzyme drug interactions. Since lorazepam does not undergo CYP450 metabolism in the liver and has an intermediate duration of action with a half-life of approximately 12 hours, it is preferred with hepatic failure when a benzodiazepine is needed, such as in alcohol withdrawal syndrome. Longer-acting benzodiazepines, such as diazepam and chlordiazepoxide, that undergo phase I CYP450 hepatic metabolism may accumulate with liver failure. Lorazepam has no known active metabolites and is primarily eliminated in the urine.
Which of the following tests for function of the median nerve? AAbduction of the index finger against resistance BExtension of the wrist against resistance CPincer function of the thumb and index finger DSensation of the dorsum of the first webspace
C Motor and Sensory Hand Function Testing Median Motor: OK sign Sensory: two-point discrimination of tip of index finger Ulnar Motor: abduct index finger (scissors motion) Sensory: two-point discrimination over tip of fifth finger Radial Motor: wrist and finger extension Sensory: dorsal thumb-index finger web space
A 17-year-old girl presents to your office with a complaint of worsening headaches. The headaches occur most days of the week, worsen with activity, and are sometimes associated with vomiting. She denies a family history of headaches. She is taking ibuprofen for her headaches and doxycycline for acne. Exam is significant for papilledema. A brain MRI is normal, and on lumbar tap the opening pressure is elevated. What is the best next step in treatment? AStart acetazolamide BStart rizatriptan CStop doxycycline DStop ibuprofen
C The patient has idiopathic intracranial hypertension (formally known as pseudotumor cerebri) as evidenced by papilledema, normal imaging and elevated opening CSF pressure. Idiopathic intracranial hypertension should be suspected in any older child or adolescent with headaches and papilledema. Patients typically describe diffuse headaches that may worsen on straining. It is often associated with visual loss or diplopia, transient visual obscurations, pulsatile tinnitus, limited abduction of one or both eyes, and rarely a decreased level of consciousness. The disorder typically affects obese, hirsute-appearing young women. Idiopathic intracranial hypertension has many drug-induced etiologies as well, including tetracyclines, oral contraceptives, sulfonamides, hypervitaminosis A, phenytoin, corticosteroids and nitrofurantoin. It is appropriate to stop doxycycline to determine if that is the underlying cause of her headaches
A 33-year-old man with schizophrenia treated with haloperidol presents with involuntary, writhing movements of the tongue and face. Additionally, the patient has choreoathetoid movements of the trunk and arms. What management is indicated? ABenztropine BDiphenhydramine CLorazepam DStop haloperidol
D Extrapyramidal Symptoms Typical > atypical antipsychotics Acute dystonia: muscle spasms, stiffness, oculogyric crisisRx: benztropine, diphenhydramine Akathisia: restlessnessRx: benztropine, diphenhydramine Bradykinesia: parkinsonismRx: benztropine Tardive dyskinesia: orofacial involuntary movements
What is the most common cause of nontraumatic intracerebral hemorrhage in adults? ACerebral amyloid angiopathy BHypertensive vasculopathy CMalignant hypertension DVascular malformations
B
Which of the following is recommended for secondary stroke prevention for non-cardioembolic transient ischemic attack and ischemic stroke? AAspirin BAspirin plus clopidogrel CCilostazol DIndomethacin
A
A 24-year-old woman presents to Urgent Care after tripping over her backpack and hitting her head at home. A friend noted brief period of unconsciousness lasting less than 3 seconds. Prior to arrival to urgent care, she vomits once. On your physical exam, she is noted to have a normal physical exam with normal vital signs. According to the Canadian CT Head Rule, which of the following is the most appropriate next step in management? AObservation BTransfer to emergency department for a CT scan of the head with contrast CTransfer to emergency department for a CT scan of the head without contrast DTransfer to emergency department for an MRI scan of the head
A
A 32-year-old man who works as a carpenter presents with leg numbness. On physical exam, he has decreased light touch and pinprick sensation only in an area around his front pants pocket. Distal leg sensation, strength, and reflexes are intact. Which of the following nerves is most likely involved? ALateral femoral cutaneous BPudendal CSaphenous DSural
A
A 33-year-old woman presents with intermittent, intense shooting pain to the left side of the face. She states the pain begins near her ear and radiates to her chin. The pain is often brought on by chewing and brushing her teeth. Which of the following managements is most likely indicated? ACarbamazepine BDental X-rays CMandible CT scan DPrednisone
A
A 34-year-old man presents with complaints of progressive lower extremity weakness over the past two days associated with two weeks of diarrhea that has since resolved. Vital signs are HR 89 bpm, BP 160/95 mm Hg, and RR 12/min. On exam, you note symmetric lower extremity weakness with intact sensation and absent ankle reflexes. Which of the following would help to support the most likely diagnosis? AAlbuminocytologic dissociation BImprovement with steroids CIncreased forced vital capacity DSelective enhancement of the dorsal root ganglion on MRI
A
A 40-year-old man presents to ED with the chief complaint of headache for two days. The headache is right frontal, constant, and severe. He has tried ibuprofen and acetaminophen without relief of the pain. He denies history of headaches, recent trauma, nausea, vomiting, and syncope. He has a past medical history of cervical disk protrusion, for which he takes ibuprofen and gets manipulation by a chiropractor. His vital signs are T 36.6°C, BP 142/90 mm Hg, HR 82 bpm, RR 16/min, and oxygen saturation 99%. On examination, his right pupil is 3 mm and reactive, and his left pupil is 6 mm and reactive. Extraocular movements are intact. He is unable to keep his right eyelid open against resistance. Visual acuity is 20/30 in both eyes with glasses. Funduscopic exam is normal. His neck is supple. Strength is 5/5 in all extremities, gait is normal, and Romberg is negative. Which of the following is the most likely diagnosis? ACarotid artery dissection BCluster headache CRetinal artery occlusion DTemporal arteritis EVertebral artery dissection
A
A 55-year-old woman with a history of hypertension and diabetes mellitus presents to the emergency department after becoming incoherent during a work meeting 45 minutes prior to arrival. Examination reveals a right facial droop and right upper extremity weakness. It is decided to proceed with thrombolysis with recombinant tissue-type plasminogen activator. Which of the following is an exclusion criterion for using reperfusion therapy? ACurrent warfarin use with INR > 1.7 BLack of intracranial hemorrhage on computed tomographic imaging CMyocardial infarction 6 months prior DSignificant head trauma one year prior
A
A 63-year-old right-handed man presents to the emergency department with a sudden onset of numbness on the right side of his face, arm, and leg, as well as right arm and leg weakness. His symptoms started fifteen minutes prior to presentation. On exam, the patient has mild aphasia, mild dysarthria, a pronator drift of his right arm, diminished strength of his right arm and leg, and diminished sensation on the right side. Computed tomography of the brain and computed tomography angiography of his brain and neck were performed and by the time the scans were finished the patient had complete resolution of his symptoms. The computed tomography angiography of the neck revealed a 90% stenotic atherosclerotic lesion of the left internal carotid artery. Carotid endarterectomy was scheduled. The most appropriate next step is administration of which of the following? AAspirin BClopidogrel CDual antiplatelet therapy DWarfarin sodium
A
A 77-year-old man presents with left sided weakness. The patient woke this morning with difficulty moving his left side. On examination, his leg is weaker than his arm. Which vascular structure is likely responsible for this stroke? AAnterior cerebral artery BBasilar artery CMiddle cerebral artery DPosterior cerebral artery
A
A patient is diagnosed with multiple sclerosis. Imaging shows that the majority of plaques are located in the cerebellum. Examination is positive for dysmetria and ataxia. Which of the following types of tremor would most commonly occur in this patient? AIntention BPill-rolling CPostural DRubral
A
A previously healthy 10-year-old girl presents to your office with a complaint of repetitive, intermittent shoulder shrugging that began one year ago. She says that she can sense when the movement is going to occur, then feels relief after doing it. Her mother says that her daughter is becoming more socially withdrawn because she is embarrassed about these movements. She denies any other complaints. Which of the following is the most appropriate therapy? AClonidine BFluoxetine CMethylphenidate DPimozide
A
During an exam, passive flexion of a patient's neck causes a reflexive flexion of his hips and knees. What is this finding called? ABrudzinski sign BGriesinger sign CKernig sign DLevine sign
A
In the initial diagnostic evaluation of a patient with undifferentiated polyneuropathy, which of the following approaches is most appropriate? AElectrodiagnostics, then laboratory testing BElectrodiagnostics, then nerve biopsy CLaboratory testing, then electrodiagnostics DLaboratory testing, then nerve biopsy
A
What is the genetic basis of Huntington disease? AExpansion of the cytosine-adenine-guanine trinucleotide repeats in the HTT gene BHemizygous deletion of up to 28 genes on chromosome 7q11.23 CMutations in the fibrillin gene DMutations in the gene encoding phenylalanine hydroxylase
A
What level does the spinal cord terminate in adults? AL1-L2 BL2-L3 CL3-L4 DL4-L5
A
Which of the following antiepileptic medications prevents seizures by blocking neuronal sodium channels to prolong the refractory period and inhibit action potential propagation? ACarbamazepine BDiazepam CEthosuximide DLevetiracetam
A
Which of the following statements is true regarding the local anesthetic lidocaine? AIt is a member of the class of ester anesthetics BSymptoms of overdose include seizures and cardiac dysrhythmia CThe maximum dose is 3-5 mg/kg when prepared with epinephrine DThe mechanism of action is via calcium channel blockade
B
A previously healthy 32-year-old man presents to your office with a complaint of tingling in both feet. He says that the tingling sensation started 3 days ago and now his lower legs feel weak and he is having difficulty walking. In addition, he is having trouble chewing his food. Physical exam shows absent patellar and Achilles reflexes. Which of the following is the most likely diagnosis? ADiabetic neuropathy BGuillain-Barré syndrome CMultiple sclerosis DMyasthenia Gravis
B
What is a significant adverse effect related to the use of dexmedetomidine? AAdrenal suppression BBradycardia CHypertriglyceridemia DUrticaria
B
A 14-year-old treated for sinusitis two weeks ago presents to your ED with worsening headache and fevers over the last week. His mother states that he has been sleeping most of the day and brought him in because he was having trouble walking. He has had no vomiting, vision changes, photophobia, neck pain, or trauma. His vital signs are within normal limits for his age. Your examination shows a pale appearing, somnolent male who wakes and answers questions appropriately. He has a normal cranial nerve exam, negative Kernig and Brudzinski signs, but is unable to heel-to-toe walk and has a foot drop on the left. Of the following, what is the next best step to establish the diagnosis? ABlood culture BBrain CT scan with contrast CElectroencephalogram DLumbar puncture
B
A 16-year-old boy presents to the office with a complaint of 10 headaches over the last 3 months. These headaches last 8-10 hours, are unilateral, pulsatile, worse with physical activity, and often accompanied by nausea with emesis. The headaches have caused him to miss school. Ibuprofen has given minimal relief. Which one of the following is the most likely diagnosis? ACluster headache BMigraine headache CRebound headache DTension headache
B
A 24-year-old man presents to the emergency department via ambulance after having two witnessed seizures at home. The patient received two doses of intravenous lorazepam en route but is still exhibiting seizure-like activity. You decide to administer 1,500 mg of intravenous phenytoin. Over how many minutes should the medication be infused? A10 minutes B30 minutes C5 minutes D60 minutes
B
A 28-year-old woman with myasthenia gravis presents with progressive shortness of breath that started several hours ago. She takes pyridostigmine every six hours and has not missed any doses. Yesterday she was prescribed an unknown antibiotic for sinusitis at an urgent care clinic. On exam, her vital signs are within normal limits, and she does not appear in respiratory distress. What is the next immediate step in management? ABegin intravenous immunoglobulin BMeasure negative inspiratory force CObtain a chest X-ray DStart corticosteroids
B
A 35-year-old woman presents to clinic three hours after the onset of a recurrent right frontal pulsatile headache that starts roughly one hour after experiencing visual loss which has since resolved. You suspect migraine headache with aura. What are you likely to find on physical examination? ABitemporal hemianopsia BNormal visual fields CRight homonymous hemianopsia DRight temporal field loss
B
A 35-year-old woman with a known history of seizure disorder is actively seizing in the ED. Which of the following is the first-line medication and route to treat her seizure? AIntramuscular fosphenytoin BIntravenous midazolam COral lorazepam DRectal diazepam
B
A 40-year-old man with HIV presents with two weeks of progressive headache, malaise, and fever. On examination, he has mild nuchal rigidity, confusion, and a temperature of 38.2°C. Cerebrospinal fluid analysis shows a white blood cell count 360 cells/mL with a mononuclear predominance, glucose 28 mg/dL, and protein 220 mg/dL. What is the treatment of choice? AAcyclovir BAmphotericin B CCeftriaxone DVancomycin
B
A 43-year-old woman being treated for non small cell lung cancer is experiencing severe chemotherapy-related nausea and vomiting after receiving cisplatin. The patient normally responds well to high-dose metoclopramide but has recently developed a resting tremor and tongue protrusions after receiving the medication. Which medication would be most appropriate to manage this patient's chemotherapy-related nausea and vomiting? ADroperidol BOndansetron CProchlorperazine DPromethazine
B
A 44-year-old woman presents with a bilateral throbbing headache and nausea that was preceded by vision changes of flashing lights and blind spots. Her past medical history is significant for poorly controlled hypertension. Currently, her blood pressure is 182/100 and neurological examination is normal. CT scanning reveals no intracranial pathology. Which of the following is the most appropriate headache treatment at this time? AHigh flow oxygen BIbuprofen CSumatriptan alone DSumatriptan plus ergotamine
B
A 55-year-old woman with a history of hypertension and diabetes mellitus presents to the emergency department after becoming incoherent during a work meeting 45 minutes prior to arrival. On examination, a right facial droop and right upper extremity weakness is appreciated. Vital signs are within normal limits. Her serum blood glucose is within normal limits. A non-contrast head computed tomography scan is normal. Electrocardiogram reveals normal sinus rhythm. Which of the following is the next appropriate step in management? AIntravenous heparin bolus and infusion BIntravenous recombinant tissue-type plasminogen activator bolus and infusion CMagnetic resonance imaging of the brain DWatchful waiting
B
A 57-year-old man diagnosed with Parkinson's disease two years ago presents to a routine clinic visit with complaints of increased tremors and slowed muscle movements despite being on amantadine for one year. The nurse practitioner discontinues the amantadine and prescribes carbidopa-levodopa. What is the function of carbidopa when combined with levodopa? ATo act as a dopamine receptor agonist BTo inhibit decarboxylase from converting levodopa to dopamine in the systemic circulation CTo inhibit monoamine oxidase B from metabolizing dopamine DTo prevent dyskinesia that is a side effect of chronic levodopa therapy
B
A 59-year-old woman with a history of poorly controlled hypertension presents to the emergency room for a sudden, very severe headache that began 50 minutes ago. She is disoriented and vomiting. A CT of her head showed no acute abnormalities. Which of the following is the next best step in her management? AElectroencephalogram BLumbar puncture CMRI head DSupportive care
B
A 65-year-old man presents to the ED after a fall. He says he has had trouble walking "for a while." His examination is significant for normal cranial nerve function, normal strength, a resting tremor, and difficulty stopping when he is walking. What is the cellular pathology associated with this condition? ADemyelination BLewy bodies CLoss of anterior horn cells DNeurofibrillary tangles
B
A 65-year-old man presents to the ED complaining of persistent dizziness. He complains of nausea and feels like the room is spinning. He has a history of hypertension. Vital signs are within normal limits. Which of the following physical exam findings supports a central cause of his dizziness? AHearing loss BLimb ataxia CPatient remains steady when eyes are open and closed, when performing the Romberg test DSpontaneous nystagmus that is suppressed by visual fixation ESudden onset of intense, intermittent episodes of disequilibrium
B
A 20-year-old woman presents with weakness in her left wrist. She states that she fell asleep in a chair after a night of heavy drinking. On physical examination, she is unable to extend her wrist. What nerve is compromised? AAxillary nerve BMedian nerve CRadial nerve DUlnar nerve
C
A 27-year-old woman presents with a complaint of transient vision loss in her right eye. She states that she has had multiple similar episodes in the past six months. She also complains of incomplete bladder emptying, intermittent tremors, and intermittent weakness in her left arm. Which of the following is the best diagnostic test for the suspected diagnosis? ACSF testing for myelin basic protein BCT scan of the brain and spine CMRI of the brain and spine DSerum oligoclonal bands
C
A 49-year-old woman with a history of osteoarthritis presents to the emergency department stating that she feels like the room around her is spinning. She reports a similar episode three weeks ago and, since then, has had an intermittent ringing sound in her ears. Her husband adds that, over the same time frame, she also has developed some difficulty hearing from the left ear. During your exam, the patient has an episode of nonbilious vomiting and states that the room is spinning again. Vital signs are normal. Which of the following is the most likely diagnosis? ABenign paroxysmal positional vertigo BCerumen impaction CMénière disease DSalicylate toxicity EVestibular neuronitis
C
A 57-year-old woman is brought by ambulance to the emergency room. Three hours ago she began having a headache with nausea and noticed a loss of sensation on most of the right side of her body. A non-contrast computed tomography scan of her head shows a 2 cm area of enhancement in the brain parenchyma. Which of the following is the most likely location of the patient's lesion? ACerebellum BFrontal lobe CTemporal lobe DThalamus
C
A 58-year-old woman who works on an assembly line complains of bilateral wrist pain for the last several months. She describes pain, numbness, and paresthesias in her thumb, index, and long fingers. Which of the following tests is most likely to be positive? AAdson's test BFinkelstein's test CPhalen's test DTinel's sign
C
An 80-year-old man who does not have housing is found in his riverside tent with confusion and fever in July. On physical examination, the patient is disoriented with T 38.2°C, HR 122 bpm, BP 106/84 mm Hg, and oxygen saturation 99% on room air. You note splenomegaly, flaccid paralysis, and multiple mosquito bites. Which lab abnormality would lead you to suspect West Nile encephalitis in this patient? ADecreased cerebrospinal fluid glucose level BLeukocytosis CLymphopenia DMarkedly increased serum ALT and AST
C
Chronic use of which of the following medications would most likely cause gingival hyperplasia? AClonazepam BClozapine CPhenytoin DPromethazine
C
In which of the following ways does essential tremor differ from the tremor of Parkinson disease? AEssential tremor can be treated with dopamine agonists BEssential tremor is a pill-rolling tremor CEssential tremor is exacerbated by action DEssential tremor is unilateral
C
What is the most common cause of an intracranial neoplasm? AAstrocytoma BMeningioma CMetastases DPituitary adenoma
C
Which of the following is characteristic of myasthenia gravis? ADescending paralysis BImprovement of muscle strength with repeated stimulation CPositive ice bag test DPtosis worse in the morning
C
Which of the following is the most common type of migraine headache? ABasilar-type migraine BMigraine with aura CMigraine without aura DOphthalmoplegic migraine
C
Which of the following medications helps prevent cerebral vasospasm in patients with spontaneous subarachnoid hemorrhage? ALisinopril BMetoprolol CNimodipine DVerapamil
C
Which of the following medications is considered first line therapy for absence seizure? ACarbamazepine BDiazepam CEthosuximide DPhenytoin
C
Which of the following, based upon current literature, best defines a transient ischemic attack? AA focal neurologic deficit lasting for less than 30 minutes, caused by reversible cerebral ischemia BA focal neurologic sign or symptom lasting for at least 30 minutes, but less than 24 hours, caused by reversible central nervous system ischemia CAn episode of neurologic dysfunction caused by cerebral, spinal, or retinal ischemia, without acute tissue infarction DAn episode of neurologic dysfunction that resolves without residual functional deficit, but with evidence of acute tissue infarction on diffusion-weighted MRI studies
C
You are caring for a 60 kg patient who has been seizing for 30 minutes. You have already administered 4 mg of IV lorazepam and 1,200 mg of phenytoin without termination of seizure activity. Which of the following should most likely be your next step? AAdminister another bolus of IV phenytoin BAdminister IV fosphenytoin CAdminister IV pentobarbital DAdminister IV sodium bicarbonate
C
You are evaluating a patient with polyneuropathy. His nerve conduction study reveals a predominantly demyelinating injury process. Which of the following serum laboratory tests would best delineate this patient's diagnosis? ACreatinine BHemoglobin A1C CHepatitis B panel DThyroid function studies
C
A 10-year-old boy presents to the emergency department with nausea, vomiting, perioral numbness, blurry vision, and feeling his tactile sensation of hot temperature seems off. He reports eating out and having grouper at a local restaurant. No other family members report illness. Which of the following is the most appropriate treatment? AActivated charcoal BAntihistamine CHemodialysis DIntravenous fluids and antiemetics
D
A 10-year-old girl presents to the Emergency Department with weakness in her legs. It began yesterday and since has progressed up her legs. Reflexes are diminished in her bilateral lower extremities and are normal in her upper extremities. Sensation is intact throughout. She denies recent illness or sick contacts. Her family returned from a camping trip at a national park last week, but otherwise she has not traveled. During the camping trip, the child ate canned and boxed foods that the family had packed, as well as fish that the family caught and cooked. They also went hiking and swam in a freshwater stream. What intervention is most likely to improve the child's symptoms? ABotulism immune globulin BIntravenous Immunoglobulin CPyridostigmine DRemoval of a tick from the child
D
A 16-year-old girl presents to the ED complaining she cannot walk up steps. She has been well recently except for an episode of gastroenteritis two weeks ago. On exam, she has decreased strength in her bilateral lower extremities with absent patellar and ankle jerk reflexes. What is the most important next test to perform? AElectromyography BLumbar puncture CMRI lumbar spine DVital capacity
D
A 19-year-old woman at 34 weeks gestation presents with a one-day history of progressive left-sided facial weakness. She notes a recent history of an upper respiratory infection. On exam, she is unable to raise her left eyebrow, close her left eye, or smile on her left side. She also reports decreased taste sensation. Her neurologic exam is otherwise unremarkable. Which of the following complications is most commonly associated with the patient's diagnosis? ACavernous sinus thrombosis BDescending paralysis CHearing loss DKeratitis
D
A 24-year-old woman presents to the emergency department with a headache and receives a lumbar puncture. She is eventually discharged home in improved condition, but returns 24 hours later with a worsened headache, now throbbing in nature, which is worse in the standing position and relieved in the supine position. Which of the following reduces the risk of post-lumbar puncture headache? AInserting the needle bevel perpendicular to the spine BLying supine for one hour after the lumbar puncture is completed CUsing a higher gauge needle DUsing a Quincke needle
D
A 28-year-old woman complains of onset of lower back pain that began two days ago. The pain radiates down both legs. On exam, she has 3/5 strength bilaterally, decreased sensation from her waist distally, decreased patellar reflexes, and a distended urinary bladder. An MRI of her spine reveals no masses. Which of the following is the most likely diagnosis? AGuillain-Barré syndrome BSpinal epidural abscess CSyringomyelia DTransverse myelitis
D
A 32-year-old man presents after falling off a porch onto the driveway an hour ago. His family reports that he did not lose consciousness, but has become progressively more drowsy since the accident. He has vomited twice. His non-contrast head computed tomography scan is shown above. What is the most likely etiology of this condition? ATear of a bridging vein BTear of a dural sinus CTear of the anterior cerebral artery DTear of the middle meningeal artery
D
A 40-year-old woman presents to her primary care provider's office with complaints of droopy eyelids and difficulty chewing. She has difficulty keeping her eyes open as the day goes on. Throughout a meal, she has progressive difficulty chewing. She holds her jaw up at the end of the meal. Which of the following physical exam findings would this woman most likely exhibit? ADecreased sensation to light touch in extremities BDiminished or absent deep tendon reflexes CHyperreflexive deep tendon reflexes DNormal deep tendon reflexes
D
A 42-year-old man presents to your office with complaints of uncontrollable fidgeting, irritability and difficulty with short-term memory. He tells you that his father had similar symptoms and died at a young age. Which of the following is the most appropriate next step in management? ADiscussion of end-of-life issues BMagnetic resonance imaging CPositron emission tomography scan DReferral for genetic testing
D
A 52-year-old man presents with decreased sensation in the upper extremities and chronic neck pain. He states that the loss of sensation has been progressive for months. On physical examination, he has decreased sensation to pain over the upper back, shoulders and arms with intact proprioception and light touch. What is the likely diagnosis? AAnterior cord syndrome BBrown-Séquard syndrome CCentral cord syndrome DSyringomyelia
D
A 64-year-old man presents to the emergency department with acute onset of left arm and left leg weakness approximately one hour ago. He has slurred speech and is difficult to understand while obtaining the history. Vital signs are HR 80, BP 192/100, RR 12, T 37.0°C. Examination shows facial asymmetry with left upper and lower extremity weakness. What is the most important bedside diagnostic test to perform at this time? AChest radiograph BEchocardiogram CElectrocardiogram DFingerstick glucose
D
A 68-year-old man presents to the ED after a fall down twelve stairs. On physical exam, you note a large parietal scalp hematoma. His non-contrast computed tomography scan of the head is shown above. Which of the following is the most likely diagnosis? ABasilar skull fracture BEpidural hematoma CSubarachnoid hemorrhage DSubdural hematoma
D
A 75-year-old woman is brought to your office by her daughter, who tells you that her mother has recently been exhibiting short-term memory loss and confusion over the recent months. The patient's medical problems include type 2 diabetes mellitus, hypertension, hypercholesterolemia, and osteoarthritis. She had a stroke last year and has residual mild hemiparesis. On cognitive testing she is able to recall only one of three words, and all the numbers are on one side on the clock-drawing test. Which of the following is the most likely diagnosis? AAlzheimer's disease BDementia with Lewy bodies CFrontotemporal dementia DVascular dementia
D
A previously healthy 48-year-old man presents with fever, headache, and signs of meningeal irritation. He has no significant past medical history. He has no rash and has not had any recent medical procedures. Which of the following is the most common bacteria responsible for the suspected diagnosis? AHaemophilus influenzae BNeisseria meningitidis CStaphylococcus aureus DStreptococcus pneumoniae
D
Which antiepileptic medication requires a dosing adjustment for patients with hypoalbuminemia? ACarbamazepine BLacosamide CLevetiracetam DPhenytoin
D
You refer a 45 year old man with a movement disorder to a neurologist. She obtains a brain MRI which shows significant atrophy of the basal ganglia. She also comments on finding significant choreiform movements and ballism, as well as dementia. She initiates drug therapy with the specific goal of addressing the chorea since the patient states it is interfering with his function, but asks you to follow-up for medication monitoring. Which of the following class of medications will you most likely be titrating? ADopamine-agonist BErgotamine-derivative CTricyclic antidepressant DVesicular monoamine transporter type 2 (VMAT2) inhibitor
D
A 67-year-old man presents after being in a motor vehicle collision 20 minutes ago. His wife reports that there was a brief period of unconsciousness followed by a lucid interval. Past medical history is significant for cardiac stents to the left anterior descending coronary artery, and the patient has been on warfarin ever since stent placement. Vital signs include temperature 98.6°F, respiratory rate 18 breaths/minute, blood pressure 120/65 mm Hg, heart rate 90 beats/minute, and oxygen saturation 98% on room air. Physical examination shows no neurological deficits. Glasgow Coma Scale score is 12. Complete blood count shows white blood cell count 5.8/L, hemoglobin 15 mg/dL, hematocrit 45%, and platelet count 265,000. The comprehensive metabolic panel reveals no abnormalities. Prothrombin time is 16 seconds, and international normalized ratio is 4.0. Computed tomography shows a 15 cm3 lens-shaped pattern with clot thickness of 8 mm and no midline shift. Which of the following is the most appropriate next step in management? ACraniotomy BMannitol CProtamine DProthrombin complex concentrate
D Epidural hematoma is due to head trauma by a motor vehicle collision, fall, or assault, causing injuries to the middle meningeal artery. Nontraumatic acute epidural hematoma is rare and is usually caused by infection, coagulopathy, congenital anomaly, epidural abscess, surgical complications, pregnancy, lupus, sickle cell disease, or Paget disease of the skull. Patients typically present with a brief loss of consciousness followed by a lucid interval. In the setting of continued arterial bleeding, deterioration in mental status continues and is often associated with headache, vomiting, drowsiness, confusion, aphasia, seizures, and hemiparesis. Herniation may develop and is usually heralded by the triad of coma, fixed and dilated pupils, and decerebrate posturing. Initial diagnosis of epidural hematoma is made by a noncontrast computed tomography (CT) of the head and brain. Epidural bleeding produces a lens-shaped or biconvex pattern on head CT. Lumbar puncture is contraindicated in any patient suspected of having a space-occupying lesion, such as epidural hematoma, due to the risk of brain herniation. Magnetic resonance imaging is more sensitive than CT for detecting epidural hematoma at the vertex of the head. In the setting of vertex epidural hematoma suspected to originate from a dural arteriovenous fistula of the middle meningeal artery, cerebral angiography is indicated. An emergent craniotomy is required for acute symptomatic epidural hematoma. Indications for emergent surgery include hematoma volume > 30 cm3, regardless of Glasgow Coma Scale, or acute epidural hematoma with a GCS score < 9 in the presence of anisocoria. Patients with stable and small epidural hematoma with mild symptoms who have epidural hematoma volume < 30 cm3 with clot thickness < 15 mm on head CT and midline shift of < 5 mm, no coma (GCS score > 8), and no neurological deficits can be managed nonoperatively. Reversal of anticoagulation in patients taking anticoagulants (warfarin) must be done before surgical intervention. The approach to warfarin reversal includes immediate cessation of further warfarin therapy, slow infusion of vitamin K, and infusion of prothrombin concentrate complex. If prothrombin concentrate complex is not available, fresh frozen plasma may be used instead. International normalized ratio (INR) goal in this setting is typically less than 1.2. Once the required INR level is achieved, surgical intervention may proceed. Epidural hematoma often results in increased intracranial pressure, requiring hematoma evacuation. In stable patients with elevated intracranial pressure, head elevation, hyperventilation, and osmotic diuresis using intravenous mannitol or hypertonic solution can be used to decrease intracranial pressure.
An 89-year-old woman presents to the emergency department after sustaining a fall. Her vital signs are within appropriate limits for her age, the Glasgow Coma Scale assessment is 7, and a CT scan reveals an intracranial hemorrhage. After obtaining labs, her estimated creatinine clearance (CrCl) is calculated to be 35 mL/min. She does not require surgical intervention and the neurotrauma team decides to initiate levetiracetam for one week to prevent seizure. What is the maximum levetiracetam dose this patient may receive? ALevetiracetam 1,000 mg IV every 12 hours BLevetiracetam 1,500 mg IV every 12 hours CLevetiracetam 500 mg IV every 12 hours DLevetiracetam 750 mg IV every 12 hours
D Levetiracetam is eliminated primarily through the kidney and the clearance is reduced in patients with renal impairment, including the elderly. Other dosing adjustment considerations may include the patient's weight and use of other agents that may contribute to oversedation. Levetiracetam 750 mg IV every 12 hours represents the maximum dose for patients with moderate renal impairment defined as an estimated CrCl of 30-50 mL/min. Levetiracetam 1,000 mg IV every 12 hours (A) is the maximum recommended dosing regimen for those with mild renal impairment defined by an estimated CrCl of 51-80 mL/min. Levetiracetam 1,500 mg IV every 12 hours (D) represents the maximum dosing regimen in those with normal renal function defined by an estimated CrCl ≥ 80 mL/min. Levetiracetam 500 mg IV every 12 hours (C) is an appropriate dosing regimen to initiate and represents the maximum dosing regimen with severe renal impairment defined as an estimated CrCl < 30 mL/min.
A 79-year-old woman with Parkinson's disease is being treated with three-times-a-day carbidopa/levodopa for the past 5 years. She recently developed cervical dystonia and involuntary tongue movements, both of which have caused feeding impairments. She does not report problems with tremor or rigidity. Her medical history is significant for constipation and hypotensive episodes. Which of the following pharmacologic interventions is recommended at this time? AAdd benztropine, and switch to five-times-a-day dosing of carbidopa/levodopa BAdd nothing, but switch any immediate-release carbidopa/levodopa to a controlled-release formulation CAdd ropinirole, and switch to once-a-day dosing of carbidopa/levodopa DContinue the current carbidopa/levodopa dosing, but add pramipexole
D Parkinson's disease is mainly characterized by its impairment on voluntary movement, leading to gait, balance and fine motor abnormalities which significantly affects functionality. Carbidopa/levodopa (immediate-release) is the most effective medication for this disease, and is the mainstay first-line medication used, especially early in the disease course (<5 years). Unfortunately, long-term use of carbidopa/levodopa can cause tardive dyskinesia and further motor control complications, which may cause further functional limitations, in up to 40% of patients treated with this drug for >5 years. As disease progresses, increasing the dose of carbidopa/levodopa is common practice. Dopamine agonists, such as bromocriptine, pramipexole and ropinirole, are also considered first-line treatment of motor abnormalities, albeit they have less benefit than carbidopa/levodopa, but fortunately have less motor side effects than levodopa. Overall, when carbidopa/levodopa has reached its end usefulness, there are several options to consider. Some clinicians will split up the total daily carbidopa/levodopa dose into 5 smaller doses a day. Others will decrease the carbidopa/levodopa dose, and some will convert any controlled-release preparations into immediate-release preparations. Another viable option is to add, or switch to adjuvant medications like dopamine-agonists (pramipexole). Other adjuvants include monoamine oxidase-B inhibitors like selegiline, catechol-O-methyltransferase inhibitors like tolcapone and entacapone, and anticholinergics like benztropine. The most sensible option above is to add an adjuvant medication.
A previously healthy, 60-year-old man presents to your office with a complaint of hand tremor. He tells you that the tremor started in his right hand and over the past few months began affecting both hands. He denies any other symptoms. Which of the following is the most appropriate therapy? AClonidine BLorazepam CNifedipine DPropranolol
D Tremor is defined as a rhythmic, wavelike movement of a part of the body that occurs consistently and varies in severity. It is caused by muscle contractions and is the most common movement disorder. The most common type of action or postural tremor is an essential tremor. The cause of essential tremor is unknown and there are no pathological findings associated with the condition; however, there is a familial connection. Essential tremor affects men and women equally, however men often have more symptoms with the hands and women have more symptoms with the head. Patients generally present with a complaint of tremor as the only symptom. It usually starts in one upper extremity before progressing to involvement of both upper extremities. The tremor symptom is often intermittent at first, then becomes more persistent. In most cases the tremor will be exacerbated by voluntary activity like drinking from a glass. There are no specific laboratory or diagnostic markers for essential tremor. If the personal and family history and physical exam point to essential tremor, no additional workup is needed. The most common treatment and first-line therapy for essential tremor is with the beta-blocker propranolol. Primidone, an anticonvulsant agent, is also indicated for use in the treatment of essential tremor.
A 45-year-old man is brought to the emergency department after being the unrestrained passenger in a motor vehicle collision. His vital signs on arrival are T 37.3°C, HR 90, BP 140/94, RR 23. His physical exam is significant for a GCS of E3V4M5 and a large left temporal scalp laceration from hitting the windshield. CT imaging of his head reveals a left temporal linear skull fracture under the area of the laceration with no signs of intracranial hematoma formation. Which of the following therapies is indicated in this patient? AHypertonic saline BIntravenous antibiotics CMannitol DNicardipine
b
A 20-year-old man is seen in the emergency department for sudden onset left-sided severe headache with associated syncope, nausea, and vomiting. He has a history of migraines but states this feels different from his usual headaches. A non-contrast CT scan of his head today is negative for hemorrhage. What is the most appropriate next step in management? AEmergent MRI BNeurosurgery consult for aneurysm clipping CPerform a lumbar puncture DRepeat a CT scan with contrast
c
A 32-year-old man is brought to the emergency department after being the unrestrained passenger in a motor vehicle collision. His Glasgow coma score on scene was 6 and he was intubated for airway protection. On arrival, his vital signs are T 36.5°C, HR 40, BP 180/110. His physical exam is notable for a fixed and dilated left pupil. Which of the following is the most likely cause of this patient's physical exam findings? ACentral transtentorial herniation BTonsillar herniation CUncal transtentorial herniation DUpward posterior fossa herniation
c
A 36-year-old woman presents to the emergency department with progressive lower back pain. She denies history of fever or trauma, but the pain worsened acutely when she bent over to pick up a box earlier today. Which of the following features is most concerning for cauda equina syndrome? ADecreased patellar reflex on the right BDecreased sensation of the lateral foot CPain radiating down both legs DPositive straight leg raise
c History of trauma, malignancy, epidural abscess, or hematoma Acute onset of lower back pain with weakness and numbness PE will show urinary retention, saddle anesthesia, decreased rectal tone Diagnosis is made by MRI or CT myelogram Most commonly caused by a herniated disc Treatment is operative decompression
A 32-year-old woman with history of migraine headaches presents for evaluation of increased frequency of headaches. She takes abortive medication for migraines 2-4 times weekly and misses several days of work a month. You decide to start topiramate daily for migraine prophylaxis. Of the following, which one is the most common side effect of this medication? ABronchospasm BDry mouth CParesthesias DSeizure
c Topiramate is an anticonvulsant used for migraine prevention and treatment of epilepsy. Central nervous system side effects are the most common and include paresthesias, nervousness, fatigue, ataxia, drowsiness, lack of concentration, dizziness and confusion. Topiramate should be initiated at a low dose and gradually titrated to the recommended dose to reduce the risk of these side effects. Also, topiramate should not be discontinued abruptly, but instead decreased gradually over weeks, as sudden cessation may increase the risk for seizure. In addition to anticonvulsants, antihypertensive agents and antidepressants are sometimes used for migraine prophylaxis. Beta-blockers and tricyclic antidepressants are commonly used. Patients with a history of bronchospastic disease should avoid nonselective beta-blockers, such as propranolol, due to the possible side effect of bronchospasm (B). Tricyclic antidepressants antagonize muscarinic receptors leading to dry mouth (A), constipation, urinary retention, and sometimes blurred vision. Topiramate is used in the prevention of seizures (D) as well as migraines, and seizure is also a potential side effect of abrupt discontinuation of topiramate.