Neuro 1

The _________________nerve is another branch of the lumbosacral plexus. It innervates the thigh adductors and only has a small sensory contribution to the medial thigh, superior to the knee.

obturator (A)

First-line pharmacologic management for an actively seizing patient is a

parenteral benzodiazepine The intravenous route is the preferred route to administer an antiepileptic because this has the quickest onset of action. Therefore, intravenous midazolam is the preferred agent from the choices listed above

What treatments may improve recovery time for Guillain-Barre syndrome

Plasmapheresis or IVIG

This Intracerebral Hemorrhage area presents with deep coma, paralysis and pinpoint pupils

Pontine

What imaging modality can show abnormalities in patients with concussion in the acute setting?

Positron emission tomography (PET) scan.

The Cushing reflex is a sign of_______ __________ ___________, a fatal complication of increased ICP.

The Cushing reflex is a sign of impending brain herniation, a fatal complication of increased ICP.

This Intracerebral Hemorrhage area presents with contralateral pleia or paresis or leg

Frontal lobe

______________ dementia (C) is a type of cortical dementia characterized by behavioral and personality disorders more than cognitive issues.

Frontotemporal

Pick's disease is characterized by which type of dementia?

Frontotemporal.

most common malignant brain tumpr

Glioma

MCC of encephalitis

HSV

Increased RBC when suspecting encephalitis suggests

HSV encephalitis

________________ is an autosomal dominant inherited, neurologic disorder characterized by choreiform movements, dementia and psychiatric disturbances.

Huntington disease (HD)

Which cranial nerve is responsible for smell

I Olfactory

Which cranial nerve is responsible for Ability to see

II Optic nerve

Which cranial nerve is responsible for ability to move and blink eyes

III Oculomotor

Which cranial nerve is responsible for Ability to move eyes up and down and back and forth

IV Trochlear

Which cranial nerve is responsible for ability to taste and swallow

IX Glossopharyngeal

CSF analysis in patients with encephalitis demonstrates

Inreased WBC, Elevated Protein, Normal-Low glucose

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

BAmphotericin B Cryptococcal meningoencephalitis is an opportunistic infection that occurs primarily in patients with advanced AIDS, although it can be seen in immunocompromised transplant patients as well. The majority of HIV-related cases occur when the CD4 count is < 100 cells/mm3. Patients present with progressive headache, nausea, malaise, and fever over the course of 1 - 2 weeks.

A 30-year-old woman is pregnant with her third child. Her medical history is significant for cocaine use disorder. She delivered her first and second low-birth-weight children preterm. Both of these children have congenital abnormalities. Which of the following diseases is this third fetus most at risk of developing? ACerebellar ataxia BCerebral palsy CCharcot-Marie-Tooth disease DCystic fibrosis

BCerebral palsy Risk factors include birth weights <2,000 grams, sibling history of congenital malformations, maternal intellectual disability or substance use disorder (cocaine causes intrauterine ischemia) and birth injury.

A 50-year old woman presents to her primary care provider's office with complaints of difficulty walking and balancing. The weakness started in both of her feet, but has now progressed to her knees and hips. She has an unremarkable past medical history except for a recent gastrointestinal infection with Campylobacter jejuni. Which of the following exam findings would this woman most exhibit? AChoreiform movements and dyskinesia BDiminished or absent deep tendon reflexes CHyperreflexia of the patellar reflex DResting tremor and immobile faces

BDiminished or absent deep tendon reflexes Patients with Guillain-Barré syndrome would most likely have diminished or absent deep tendon reflexes. Guillain-Barré syndrome (GBS) encompasses a heterogeneous group of acute immune-related polyneuropathies. GBS most commonly presents following a preceding respiratory or gastrointestinal infection, which is thought to trigger an autoimmune response against axons. Campylobacter jejuni is the most commonly recognized precipitant of GBS. The hallmark symptoms of GBS are bilateral, progressive, symmetrical muscle weakness and paralysis, accompanied by diminished to absent deep tendon reflexes.

A 21-year-old woman presents with progressive headaches for 1 month. She also reports intermittent blurred vision bilaterally and increased headache with coughing. Direct ophthalmoscopy findings show papillaedema. What abnormality is typically found on lumbar puncture in patients with this presentation? ADecreased glucose BElevated opening pressure CElevated red blood cell count DElevated white blood cell count

BElevated opening pressure This patient presents with signs and symptoms consistent with a diagnosis of idiopathic intracranial hypertension (IIH), which can be diagnosed by an increased opening pressure on lumbar puncture

This Intracerebral Hemorrhage area presents with contralateral homonymous hemianpsia

Occiptal Lobe

Which form of sumatriptan was found not to be an effective treatment for cluster headache?

Oral sumatriptan.

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

A lesion of the left optic tract results in dysfunction of the left temporal and right nasal visual fields, or right homonymous hemianopia.

Which of the following patients is most likely suffering from dementia? AA confused 65-year-old man brought from a house fire who exhibits good long-term recall, no recall of immediate events, normal vital signs, and carboxyhemoglobin level of 7 BA confused 65-year-old man brought from a house fire who exhibits poor long-term recall, no recall of immediate events, normal vital signs, and carboxyhemoglobin level of 25 CA confused 80-year-old man brought from home with fever, back pain, and urinary retention DA confused 80-year-old man brought from home with fever, cough, and hypoxia EA confused 80-year-old man brought from home with increased thirst, increased urination, and blood sugar monitor that reads high

AA confused 65-year-old man brought from a house fire who exhibits good long-term recall, no recall of immediate events, normal vital signs, and carboxyhemoglobin level of 7 ementia results from a gradual loss of mental capacity with preservation of motor and speech. Dementia generally occurs in the elderly. Remote memories are often preserved. The most common types of dementia are Alzheimer disease and vascular dementia, both insidious in onset. Symptoms may worsen acutely because of a concurrent medical condition. Physical exam and laboratory workup are generally unrevealing. Of the choices, a confused 65-year-old man brought from a house fire who exhibits good long-term recall, no recall of immediate events, normal vital signs, and carboxyhemoglobin level of 7 is most likely to have dementia.

A 26-year-old woman presents to the clinic reporting intermittent right-sided throbbing headaches for the past month. She has had no recent illnesses. The patient states that she is 34 weeks pregnant and that she had similar headaches prior to her pregnancy that resolved with ibuprofen and rest. The headaches have a gradual onset and are exacerbated by light and sound. Vital signs include a heart rate of 92 bpm, blood pressure of 120/80 mm Hg, respiratory rate of 20/min, oxygen saturation of 98% on room air, and temperature of 98.6°F. Physical examination reveals the patient to be in moderate distress due to the pain but with no nuchal rigidity or lower extremity edema. The patient has intact sensory and motor function, a normal cranial nerve exam, a steady gait, and intact finger-to-nose testing. Which of the following is the recommended initial treatment for the patient's symptoms? AAcetaminophen BAcetaminophen-butalbital-caffeine CNaproxen DOxycodone ESumatriptan

AAcetaminophen mended treatment is different in pregnant patients because of concern regarding adverse fetal drug effects. Acetaminophen is recommended initially because it is effective and has the best maternal-fetal safety profile. However, migraine headaches that are not relieved with acetaminophen alone can be treated with acetaminophen combination therapy, such as acetaminophen and metoclopramide, acetaminophen and codeine, and butalbital-acetaminophen-caffeine

A 65-year-old woman with a history of mixed hyperlipidemia presents to your office with her daughter for concerns of memory loss and changes in mood. The daughter explains that for the past 5 years she has noticed that her mother has had progressively worsening memory impairment. At first, the patient mainly forgot recent events and had a hard time with recall. She then began to notice her mother having a hard time completing simple tasks at home. In the past 6 months, she states her mother has been very irritable and gets agitated very easily. On exam, the patient is calm with reassuring vital signs. HR is 80 bpm, RR is 18/min, BP is 120/82 mm Hg, and oxygen saturation is 98% SpO2 room air. She is able to answer your questions and recognizes that she sometimes has a hard time remembering certain words when talking, but she does not feel she has any significant loss of memory. You perform a Mini-Mental State Exam, and the patient is unable to recall three objects and cannot draw a clock correctly. What is the most likely diagnosis of the patient? AAlzheimer disease BDementia with Lewy bodies CFrontotemporal dementia DParkinson disease dementia EPrimary progressive aphasia

AAlzheimer disease Dementia is defined as a decline in various areas of mental function that causes difficulty in performing activities of daily living. Alzheimer disease is the most common cause of dementia. It is a neurodegenerative disorder that most commonly affects people 60 years old or older. The most common early symptom of Alzheimer disease is loss of memory or memory impairment. Memory, which allows recall of events, is usually the first change, with vocabulary recall and motor learning being affected later in the disease. People with Alzheimer disease will have variable impairment in executive functioning in the early stages, but they commonly have poor insight into their disease progression. Insight from a friend or family member is very important, and they are often the ones to have concerns. As the disease progresses, the patient can develop neuropsychiatric symptoms such as irritability, apathy, aggression, and psychosis

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

ABenztropine This patient presents with a dystonic reaction after administration of a neuroleptic agent and should be given benztropine. Acute dystonia is the most common adverse effect seen after the administration of neuroleptic agents and occurs in up to 5% of patients

A 70-year-old man presents after a fall down twelve stairs at home. He complains of a headache. There is a large parietal scalp hematoma. His non-contrast computed tomography scan of the head shows subdural hematoma. Which of the following is the most likely source of bleeding? ABridging veins BMeningeal veins CMiddle meningeal artery DSuperior sagittal sinus

ABridging veins Meningeal veins (B) course through the dura mater while bridging veins drain the underlying neural tissue and puncture through the dura mater, making these more prone to shearing and causing a subdural hematoma than meningeal veins. The middle meningeal artery (C) is the vessel most commonly injured in epidural hematomas. The superior sagittal sinus (D) is where the meningeal veins and bridging veins drain into, and is typically not involved in causing a subdural hematoma.

A 15-year-old boy presents to the emergency department with his parents. The patient states he fell off his bike 30 minutes ago and hit his head on the concrete. He was not wearing a helmet. His parents witnessed his fall and stated that he lost consciousness for 1 minute. They also report he has vomited twice since his fall. Vital signs are BP 134/82 mm Hg, HR 89 bpm, RR 16 breaths/minute, T 98.2°F, and oxygen saturation 99% on room air. The patient has a Glasgow Coma Scale score of 14. On physical exam, you note a 4 cm by 5 cm hematoma over his left temporal bone. You also notice that he has been slow to respond to questions, and his parents report that he seems "sleepier" than usual. What is the most appropriate next step in management of this patient's condition? ACT head without contrast BDischarge home with follow-up instructions CObserve for 4-6 hours and discharge home DUrgent neurosurgical consult EX-ray of skull

ACT head without contrast This patient had loss of consciousness, vomiting, and altered mental status, thus he is at high risk for clinically important traumatic brain injury, and neuroimaging is the next step in management. CT head without contrast is the most appropriate neuroimaging for this patient.

A 30-year-old woman presents to the ED reporting pain in the right side of her face for the last 2 days. The pain is sharp, severe, and lasts several seconds. The pain is associated with an involuntary movement of the side of her mouth. Between episodes, there is no pain. She has no medical history. Her vital signs include a T of 36.6°C, BP of 122/78 mm Hg, HR of 80 bpm, and RR of 20/min. Her exam is normal. Which of the following medications has been shown to relieve this condition and is the first-line treatment? ACarbamazepine 100 mg twice daily BGabapentin 100 mg three times daily CPhenytoin 100 mg three times daily DPrednisone 60 mg once daily

ACarbamazepine 100 mg twice daily This patient has trigeminal neuralgia (tic douloureux), a disorder of the trigeminal nerve (cranial nerve V). Trigeminal neuralgia is characterized by paroxysms of severe unilateral pain in the trigeminal nerve distribution, sometimes described as recurrent bursts of an electric shock. The pain lasts only a few seconds and most commonly occurs on the right side of the face.The first-line treatment is carbamazepine 100 mg twice daily

A 56-year-old woman is brought to the emergency department by her coworker with reports of sudden-onset dizziness. The patient describes the dizziness as "feeling off balance." She reports that she was walking to a meeting approximately 1 hour ago when she suddenly became nauseous and was unable to walk without falling. She reports a coworker wheeled her to a car in a desk chair to bring her to the hospital. She has vomited twice in the emergency department since arrival. She reports a headache that is predominantly located over the back of her head. She reports no head injury or recent illness. She has a history of high blood pressure for which she is prescribed losartan, but she says she has been out of her medication for the past 3 months. She smokes two to five cigarettes on weekends socially with friends. Vital signs reveal blood pressure 184/108 mm Hg, heart rate 96 bpm, respiratory rate 22/min, and oxygen saturation 98%. She is afebrile. Neurologic examination reveals bidirectional nystagmus, skew deviation of the eyes, and a positive Romberg test result. What is the most likely diagnosis? ACerebellar hemorrhage BHeat stroke CPosterior cerebral artery occlusion DPosterior fossa tumor EVestibular neuritis

ACerebellar hemorrhage

Which of the following diagnostic criteria differentiate Tourette syndrome from other neurological disorders? AChildhood onset BComorbid symptoms of depression CDevelopmental delay DObservation of tics on physical exam

AChildhood onset

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

AClonidine Tourette syndrome (TS) is a neurologic disorder that presents during childhood, generally before age 11. Clinical manifestations of TS include motor or vocal tics. TS is known to be a genetic disorder, although non-genetic cases have been documented and are believed to be related to brain trauma or streptococcal infection Tics may be treated with alpha adrenergic agonists like clonidine and is also helpful with patients that have comorbid ADHD. Botulinum toxin injections are also used in the treatment of TS.

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

ACurrent warfarin use with INR > 1.7

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

AExpansion of the cytosine-adenine-guanine trinucleotide repeats in the HTT gene Huntington disease (HD) is an autosomal dominant inherited, neurologic disorder characterized by choreiform movements, dementia and psychiatric disturbances. Genetic testing in individuals with HD will show expansion of the cytosine-adenine-guanine trinucleotide repeats in the HTT gene. There is no cure and no disease-modifying treatment available at this time. Treatment focuses on supportive care for the patient and family along with management of symptoms. HD is progressive with the end stages of the disease being severe disability and then death.

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

AIntention Tremor is classified into three main types: postural, intention, and resting. An intention tremor is a tremor that occurs during movement that increases as a target is approached. The tremor is associated with cerebellar signs. The tremor is not seen at rest. Causes of intention tremor include cerebellar or brain stem disease, Wilson's disease, and drug toxicity.

Patients with ______________ dementia (A) have early language and visuospatial deficits. Deficits in short-term memory are severe, and clues do not help in retrieving information. The onset of the disease is gradual, with a slow progression.

Alzheimer's

______________ is a neurodegenerative disorder characterized by progressive muscle weakness, muscle atrophy, and cognitive decline. Patients with this conditon may present with reduced dexterity, foot or wrist drop, extremity weakness, slurred speech, or difficulty swallowing.

Amyotrophic lateral sclerosis (A)

What is a good drug for prevention of daily tension headache

Amytriptyline

An 18-year-old woman presents to the clinic reporting several episodes that she describes as blackouts. She reports feeling a fluttering in her stomach and a sense of anxiety and approaching doom, then does not remember anything for a few seconds to a few minutes. Her mother states when her daughter has these episodes, she stares into space, tilts her head to the left, and smacks her lips repetitively, although the patient has no recollection of this. The patient reports having no prior illness, trauma, or surgery and does not take any medications or illicit drugs. Her vital signs are within normal limits. Her physical exam, including the neurologic exam, is normal. CBC and CMP results are normal, and her urine drug screen is negative. Which of the following is the most likely diagnosis? AAcute dystonia BFocal onset seizure CGeneralized tonic-clonic seizure DPsychogenic nonepileptic seizure ETourette syndrome

BFocal onset seizure Common signs and symptoms of focal onset seizures are an aura, automatisms, and dystonic posturing, while uncommon signs and symptoms are affective disordered behavior, vocalizations, or hypermotor behavior. Examples of auras encountered in focal onset seizures include a feeling of impending doom, anxiety, fear, nausea, or deja vu. Examples of automatisms include lip-smacking, chewing, fumbling, picking, or fidgeting.

What is the most common cause of nontraumatic intracerebral hemorrhage in adults? ACerebral amyloid angiopathy BHypertensive vasculopathy CMalignant hypertension DVascular malformations

BHypertensive vasculopathy Nontraumatic intracerebral hemorrhages (ICH), while significantly less common than ischemic strokes, have an in-hospital mortality rate of up to 60%. Hypertensive vasculopathy, the result of long-standing hypertension, is the leading cause of intracerebral hemorrhage. The result of degenerative changes and eventual rupture of small penetrating arteries that branch off major intracerebral arteries, hypertensive intracranial hemorrhage occurs most frequently in deep cerebral locations such as in the putamen. Hemorrhage in this area can result in hemiplegia, hemisensory loss, homonymous hemianopsia, gaze palsy and coma.

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

BIbuprofen Triptan medications (C and D) have adrenergic-agonistic properties. Therefore, they should not be used in patients with cardiovascular or cerebrovascular disease, angina, severe hypertension and peripheral vascular disease. Clinicians must never combine ergot-derivatives with triptan medications. Abortive treatment consists of acetaminophen-aspirin-caffeine, NSAIDs (ibuprofen), antiemetics, ergotamine and triptan medications. Preventive treatment of migraine consists of tricyclic antidepressants, beta-blockers, anticonvulsants, ergot-derivatives, tizanidine, occipital nerve blocks, botulinum toxin injection and calcium channel blockers.

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

BIntravenous midazolam In an actively seizing patient, attention is always directed to the airway first. A patient having a generalized tonic-clonic seizure has a suppressed gag reflex and is prone to aspiration of gastric contents. Therefore, patients should be placed in the left lateral decubitus position. First-line pharmacologic management for an actively seizing patient is a parenteral benzodiazepine

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

BIt reduces risk of neurologic sequelae Hyperbaric oxygen therapy has been shown to decrease the risk for developing delayed neurologic sequelae in patients with carbon monoxide (CO) poisoning.

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

BLeft putamen A large putamen hemorrhage results in a rapid progression of hemiplegia, nausea, vomiting and headache over 30 minutes, which is quickly followed by ipsilateral deviation of the eyes, stupor, coma and mydriatic pupils ("blown-pupil", associated with brainstem compression and oculomotor nerve palsy). Acute management includes controlling intracranial pressure and hypertension. Surgical removal of clots is seldom successful. However, some neurologic function may be salvaged in those without coma or those with lobar clots.

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

BLewy bodies This patient is showing signs of Parkinson disease, a chronic neurologic condition. It is characterized by intracellular cytoplasmic inclusions called Lewy bodies, dopaminergic neuron loss in the substantia nigra, and depigmentation along with gliosis of pigmented areas in the midbrain.

28-year-old woman with myasthenia gravis presents with progressive shortness of breath that started several hours ago. She takes pyridostigmine every 6 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

BMeasure negative inspiratory force This patient is experiencing a myasthenic crisis, which is impending respiratory failure with an associated need for mechanical ventilation. Myasthenic crisis may be precipitated by a variety of factors, most often a concurrent infection. It can also follow a surgical intervention, pregnancy, childbirth, or tapering of immunosuppressive medications.

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

BSaphenous The saphenous nerve, is a pure sensory nerve that transmits sensation from the medial lower leg, medial ankle, and arch of the foot. The main contribution to the saphenous nerve is from the L4 root. The lumbosacral plexus lies anterior to the sacroiliac joints within the pelvis and can be damaged post pelvic trauma, especially from an anterior-to-posterior force that results in sacroiliac joint disruption. A proximal femoral nerve injury may result in distal saphenous symptoms.

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

CChronic subdural hematoma Chronic subdural hemorrhage occurs because of rupture of the bridging veins between the dural sinuses and the surface of the brain. Subdural hemorrhage is described as chronic if it is at least three weeks old, and often follows so-called 'trivial' head trauma that may not be readily recalled by the patient

Which of the following medications is considered first line therapy for absence seizure ACarbamazepine BDiazepam CEthosuximide DPhenytoin

CEthosuximide Electroencephalography (EEG) shows generalized spike-and-slow wave discharges. The traditional treatment of absence seizures is with ethosuximide. An alternative agent is valproic acid.

A 60-year-old man is admitted to the general medicine floor. He presented to the emergency department 1 week ago with bilateral leg weakness that had worsened to include bilateral arm and hand weakness after recovering from a recent gastrointestinal infection. You are performing your daily rounds. The patient reports feeling well this morning. On exam, he has a T of 97°F, RR of 18/min, oxygen saturation of 99% on room air, HR of 85 bpm, and BP of 117/77 mm Hg. The patient has not had trouble breathing independently. Based on the suspected diagnosis, what is the most likely exam finding? ABilateral papilledema BCogwheel rigidity CHyporeflexia DParesthesias EUrinary retention

CHyporeflexia Guillain-Barré syndrome is an immune-mediated polyneuropathy that is triggered from an event such as recent illness, commonly gastrointestinal illness or influenza. It can also be triggered by vaccinations, although the risk is very low. Gastrointestinal illness is the most common preceding event. It will present with symmetric, ascending, progressive muscle weakness, and up to 90% of patients will have diminished or absent deep tendon reflexes on initial exam and hyporeflexia will be present at the nadir of the disease.

A 54-year-old woman presents with bilateral lower extremity weakness. She has no achilles or patellar reflexes. Her sensation appears intact. Her strength is 3 out of 5. An MRI of the thoracolumbar spine is normal. Which of the following is the most appropriate next step in making the diagnosis? ACT myelogram BEdrophonium test CLumbar puncture DPulmonary function tests

CLumbar puncture Guillain-Barré syndrome (GBS) is a polyneuropathy characterized by symmetric weakness typically beginning distally and spreading proximally. Sensory abnormalities may also occur although motor weakness predominates. Some patients present days to weeks after an antecedent upper respiratory or gastrointestinal illness. GBS is diagnosed clinically with the assistance of some additional tests including a lumbar puncture. The results of the lumbar puncture demonstrate a markedly elevated protein and mild pleocytosis.

An 82-year-old man presents with slurred speech and unilateral arm weakness that have resolved. His non-contrast head CT is negative and he is given aspirin. Which of the following is the most appropriate management plan? ADischarge home with PCP follow-up BLow molecular weight heparin CMRI and MRA of the head and neck DTranscranial dopplers

CMRI and MRA of the head and neck Patients who have a TIA are at high risk for stroke in the period immediately following a TIA and therefore further testing is warranted in a timely fashion. In most cases, patients should be admitted to an observation unit or hospital in order to rule out any reversible causes of the TIA. Testing includes vascular imaging to identify any critical stenosis. The MRI will also identify the subset of patients with TIA symptoms who ultimately have an infarct on MRI.

What is the most common cause of an intracranial neoplasm? AAstrocytoma BMeningioma CMetastases DPituitary adenoma

CMetastases Metastatic disease (primarily from lung cancer) is the most common cause of an intracranial neoplasm. Other cancers that commonly metastasize to the brain include breast and renal cell carcinoma.

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

CMénière disease The common triad is tinnitus, vertigo, and unilateral hearing loss (sensorineural). A key finding in Ménière disease is fluctuating hearing loss. Episodes are abrupt in onset and associated with nausea and vomiting. There are often long, symptom-free intervals between attacks.

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

CParesthesias 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.

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

CPhalen's test

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

CPincer function of the thumb and index finger

Which of the following medications should be used in the treatment of cluster headache if high-flow oxygen is ineffective? AAspirin BCaffeine CSumatriptan DVerapamil

CSumatriptan Sumatriptan is a selective serotonin receptor agonist used as first-line pharmacotherapy to treat migraine headaches with or without aura and cluster headaches in addition to oxygen therapy or when oxygen treatment is ineffective. Cluster headache is characterized by severe orbital, supraorbital, or temporal head pain accompanied by unilateral sweating, conjunctival injection, lacrimation, miosis, ptosis, rhinorrhea, agitation, or restlessness.

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

CUsing a higher gauge needle (smaller) odern evidence-based strategies for prevention include the use of a higher gauge spinal needle (which corresponds to a smaller caliber needle), orientation of the needle's bevel parallel to the spine, use of a noncutting needle like the pencil-point Whitacre or Sprotte models, and reinsertion of the stylet prior to needle removal.

This Intracerebral Hemorrhage area presents with ataxia, headache, vomiting, neck stiffness, gaze palsy, facial weakness. No hemiparesis

Cerebellar

is a childhood disease caused by previous infection with varicella-zoster virus, Epstein-Barr virus and echovirus.

Cerebellar ataxia

the most common inherited neurologic disorder, is characterized by myelin and axonal abnormalities that cause distal > proximal weakness and atrophy.

Charcot-Marie-Tooth disease

____________ is defined as excessive, spontaneous and abrupt movements or irregular frequency and random distribution.

Chorea

Which chromosome is the huntingtin gene located on?

Chromosome 4.

What bedside screening tool is useful for suspected delirium

Confusion Assessment Method

__________________ is spongiform encephalopathy caused by prions. It can be inherited or, more commonly, acquired from eating infected meat. A family history is usually absent in this condition and it manifests with rapidly progressive dementia and mental status changes.

Creutzfeldt-Jakob disease (B)

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

DContinue the current carbidopa/levodopa dosing, but add pramipexole 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 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 13-year-old boy with no significant medical history presents to urgent care with a headache 3 days after a closed head injury. The patient states that he stood up from a kneeling position and hit the top of his head on a wood cabinet. There was no loss of consciousness or evidence of seizure activity. In addition to the headache, he reports difficulty concentrating at school and dizziness. His physical examination is unremarkable. What management is indicated? ACT scan of the head with contrast BCT scan of the head without contrast CMRI of the brain DReferral to primary care physician

DReferral to primary care physician The patient presents with minor head trauma and concerns consistent with a concussion and should have follow-up arranged with their primary care provider or concussion specialist. A concussion is a minor traumatic brain injury (TBI) that is often seen in MVCs and collision sports (e.g., football, hockey). It is typically caused by a rotational or acceleration-deceleration injury.

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

DRemoval of a tick from the child The child's ascending weakness and lower extremity hyporeflexia are concerning for Guillain-Barré syndrome or tick paralysis. In light of the child's recent camping trip, as well as no recent illnesses, tick paralysis is most likely.

A 33-year-old man presents to the clinic reporting chronic headaches. The headaches are preceded by a visual aura and cause nausea, vomiting, and photosensitivity. His medical history is positive only for a tonsillectomy. The patient takes no medications except ibuprofen as needed for headaches. His vital signs are within normal limits. CMP, CBC, and TSH are all within normal limits. An MRI of the head shows av malformation. Which of the following is likely to occur in the future if this patient's findings on head imaging are left untreated? ABlindness BFlaccid paralysis CGrowth into several other cranial regions DSpontaneous hemorrhage ESpontaneous resolution

DSpontaneous hemorrhage They may regress over time, but most do not. The majority (40-60%) of patients present with the most serious complication: intracranial hemorrhage, which is generally intraparenchymal but may also be intraventricular or subarachnoid. The second most frequent presenting symptom is seizure activity.

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

DThalamus A thalamic hemorrhage classically presents with contralateral hemisensory loss. Other symptoms such as hemiparesis and ocular symptoms can also occur when the internal capsule and other nuclei are involved.

A 45-year-old woman presents to the ED reporting 1 day of vision loss in her left eye associated with a left retro-orbital headache. She reports no trauma or preceding illness. On exam, her vital signs are T 36.8°C, BP 112/80 mm Hg, and HR 74 bpm. Visual acuity is 20/20 in the right eye, 20/400 in the left eye, and 20/40 using both eyes. She has a left-sided afferent pupillary defect. Visual field testing reveals left-sided central vision loss. Which of the following is most accurate regarding her condition? AStrict blood glucose control reduces the likelihood for future recurrences BThe diagnosis is confirmed by measurement of an intraocular pressure > 20 mm Hg CThe diagnosis is made by magnetic resonance venography DThe syndrome is associated with multiple sclerosis ETherapy should be aimed at removing the acute obstruction of the ophthalmic artery

DThe syndrome is associated with multiple sclerosis he patient's exam is consistent with optic neuritis, an acute monocular loss of vision caused by focal demyelination of the optic nerve. Most cases are retrobulbar and do not involve any visible changes on funduscopy (especially during an acute episode). But on occasion and with more protracted cases, optic disk pallor may be seen. However, an afferent pupillary defect is always present. Approximately 30% of patients presenting with acute optic neuritis develop multiple sclerosis (MS) within 5 years. The classic clinical syndrome of MS consists of recurring episodes of neurologic symptoms that rapidly evolve over days and slowly resolve.

A woman presents with 30 minutes of double vision, vertigo, difficulty swallowing, and difficulty speaking. During her initial evaluation, these symptoms resolve and her neurologic exam returns to normal. Which of the following is the most appropriate diagnosis and the most likely affected artery? AEmbolic ischemia - anterior cerebral artery BThrombotic stroke - left anterior descending artery CTransient ischemic attack - middle cerebral artery DTransient ischemic attack - vertebrobasilar arteries

DTransient ischemic attack - vertebrobasilar arteries . Vertebrobasilar insufficiency leads to TIAs marked by hemiplegia or quadriplegia, varying sensory changes, blindness, hemianopsia, diplopia, vertigo, dysarthria, dysphagia, and facial, motor, and sensory change.

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

DTransverse myelitis Transverse myelitis is an acute spinal cord disorder characterized by paraplegia, a transverse level of sensory impairment, and sphincter disturbance. The specific etiology is unknown, although it is noted to follow a viral infection in 30% of patients and is commonly referred to as postinfectious myelitis. Patients often complain of back pain and may have a low-grade fever, raising the concern for an epidural abscess. An MRI is usually performed to rule out compressive lesions of the spine. Despite the absence of evidence, most sources still recommend high-dose steroids as first-line treatment.

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

DVascular dementia Vascular dementia is a common type of dementia that is seen in patients with risk factors such as hyperlipidemia, hypertension and diabetes. Patients with vascular dementia have patchy cognitive impairment, often with focal neurologic signs and symptoms. Onset may be abrupt, with a stepwise decline. Patients who have had a stroke are at increased risk for vascular dementia

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

DVesicular monoamine transporter type 2 (VMAT2) inhibitor - tetrabenazine and deutetrabenazine. Huntington's disease is an autosomal dominant genetic disorder with gradual onset and progression of chorea and dementia, usually starting at 35-50 years of age.. The major pathology exists as neuronal loss, astrogliosis and eventual atrophy of the caudate nucleus and putamen of the basal ganglia, and the cerebral cortex. Three main symptoms exist: movement disorder (characterized by chorea, ballism, dystonia and parkinsonian features), cognitive disorder (mostly dementia) and mood or behavior disorder

A 72-year-old woman with hypertension, hyperlipidemia, and diabetes mellitus presents to the emergency department with left-sided numbness and weakness for the past 1 hour. The patient reports taking amlodipine, atorvastatin, and metformin daily. Vital signs include a HR of 103 bpm, BP of 142/95 mm Hg, RR of 20/min, SpO2 of 98% on room air, and T of 98.6°F. Physical examination reveals intact facial expression and 2/5 strength in the left upper and lower extremities. Sensation and motor function are intact on the right side. Head CT reveals no hemorrhage. Which of the following risk factors is most strongly associated with the patient's condition? ACigarette smoking BDiabetes mellitus CFamily history of ischemic stroke DHyperlipidemia EHypertension

EHypertension The major modifiable risk factors associated with ischemic stroke include hypertension, dyslipidemia, diabetes mellitus, smoking, and physical inactivity. Of these risk factors, hypertension is the most significant and is present in about 80% of individuals with ischemic stroke.

A 23-year-old man presents to the emergency department reporting his first-ever seizure. He is drowsy, but his roommate accompanies him and was a witness to the seizure. The roommate reports the patient cried out, fell to the floor, and began to shake his entire body. His eyes were open during the episode, but he did not talk or respond, and the duration of the episode was < 3 min. Afterward, the patient went immediately to sleep. The patient has no history of illness, reports no head trauma, has no family history of epilepsy, takes no medications, and reports no substance use. Vital signs are within normal limits. Physical exam reveals contusions to the right elbow and right hip and a normal neurologic exam. Which of the following is the best next step in evaluation of this patient? AComputed tomography of brain BElectroencephalogram CLumbar puncture DMagnetic resonance imaging of brain EUrine toxicology screen

EUrine toxicology screen irst nonfebrile seizures may indicate new-onset epilepsy but may also be indicative of other, systemic diseases or toxins. Seizures may be provoked by drug use, drug withdrawal, fever, intracranial surgery, head trauma, stroke, infection, hyperglycemia, hypoglycemia, porphyria, electrolyte imbalance, or tumors. These are called acute symptomatic seizures. The evaluation of a patient with a first-ever nonfebrile seizure should begin with a thorough history of what events led to the seizure and a thorough physical exam. Urine toxicology should always be evaluated, along with serum analysis for electrolyte or glucose imbalance and for signs of infection.

Which motor symptoms may traumatic femoral neuropathy result in?

Knee extension (quadriceps) weakness.

What level does the spinal cord terminate in adults?

L1-L2

__________ dementia (B) is progressive degenerative dementia of unknown etiology. It is a clinical diagnosis that includes memory deficits, reduced alertness as well as visual hallucinations and parkinsonian motor features.

Lewy body

What intracerebral hemorrhage area is associated with higher incidence of seizures

Lobar

Dx for guillain-barre

Lumbar Puncture

Most common metastatic brain tumor orign locations

Lung, Melanoma, Renal, Breast, Colorectal

Most common primary brain tumor

Meningioma

T2 lesions are due to

Multiple Sclerosis

This Intracerebral Hemorrhage area presents with hemiplegia, hemisensory loss, homonymous hemianipsia, gaze palsy, stpor, coma

Putaminal

What serologic test can be ordered 10 to 20 min after a seizure-like event to determine if the event was likely a clonic-tonic seizure?

Serum prolactin level, which will be elevated at least two times normal after a tonic-clonic seizure.

Parkinson's disease is a disease of the central nervous system that affects movement and mood. It is due to loss of the ____________ ____________with resultant depletion of ______________

Substantia nigra dopamine

This Intracerebral Hemorrhage area presents with hemiparesis, hemisensory loss, transient homynymous hemianopsia, upward gaze palsy, miotic pupils

Thalamic

Which cranial nerve is responsible for moving of eyes

VI Abducens

Which cranial nerve is responsible for Facial expressions and sense of taste

VII Facial

Which cranial nerve is responsible for hearing and balance

VIII Auditory/Vestibular

_____________ insufficiency leads to TIAs marked by hemiplegia or quadriplegia, varying sensory changes, blindness, hemianopsia, diplopia, vertigo, dysarthria, dysphagia, and facial, motor, and sensory change.

Vertebrobasilar

Clinical manifestations of __________ _________ include cardiac anomalies, impaired cognition, friendly personality, "elfin" facies and genitourinary abnormalities.

Williams syndrome

Hemizygous deletion of up to 28 genes on chromosome 7q11.23 (B) is found in

Williams syndrome

Which cranial nerve is responsible for Digestion and heart rat

X Vagus

Which cranial nerve is responsible for Shoulder and neck muscle movement

XI Accessory

Which cranial nerve is responsible for Ability to move tongue

XII Hypoglossal

The risk of hepatotoxicity (B) is a black box warning for

acetaminophen Over 90% of acetaminophen is metabolized in the liver before being excreted in the urine. When acetaminophen is ingested in excessive amounts or when ingested while also ingesting drugs that utilize the CYP2E1 enzyme, hepatotoxicity can occur.

What is the cushing triad, and what is it a result of

bradycardia, hypertension, and irregular breathing and results from increased intracranial pressure (ICP) hypertension occurs in an attempt to increase the MAP to maintain CPP in the setting of increased ICP. This arterial hypertension stimulates the baroreceptors in the carotid bodies, leading to increased parasympathetic tone to the heart and bradycardia. Irregular respirations occur as a result of poor perfusion of the brainstem. The Cushing reflex is a sign of impending brain herniation, a fatal complication of increased ICP.

Tx for Acute Multiple Sclerosis Attack

corticosteroids are the treatment of choice. The initial drug therapy for acute episodes, whether CIS or a subsequent acute episode, is intravenous corticosteroids. Corticosteroids decrease T-cell response to antigens, production of cytokines, secretion of immunoglobulins, and levels of myelin basic protein in cerebrospinal fluid. Treatment with high-dose intravenous methylprednisolone (more than 500 mg/day for at least 3 days) is a typical recommended treatment.

The biggest risk factor for cystic fibrosis is

family history

Mutations in the ____________ gene are seen in Marfan syndrome, an autosomal dominant connective tissue disorder.

fibrillin gene (C)

This patient is showing symptoms of benign essential (familial) tremor, for which the best initial treatment option in lifestyle-limiting disease is

propranolol

The __________ nerve is also a distal lower extremity sensory nerve, but it supplies sensory innervation to the posterolateral lower leg, lateral ankle, and lateral foot.

sural (D)

A ________________ hemorrhage classically presents with contralateral hemisensory loss

thalamic