Lange--Neurology
A 25-year-old female presents with complaints of double vision and fatigue. These symptoms are generally better in the morning and progress throughout the day. She notes reading and watching television tend to bring on the double vision. She works long hours and states toward the end of her shift she is extremely fatigued and has difficulty completing her tasks. Which of the following is the most likely etiology? (A) Antibodies to acetylcholine receptors (B) Blockage of sodium-gated ion channels (C) Demyelination of peripheral nerves (D) Genetic defect of chromosomes (E) Inhibition of acetylcholine release
(A) Antibodies to acetylcholine receptors
Which of the following patient profiles would be most likely to present with a chronic subdural hematoma? (A) 12-year-old male gymnast with hemophilia A (B) 20-year-old male suffering a head injury 2 hours ago (C) 36-year-old female with head injury 30 minutes ago (D) 55-year-old female with a cerebral aneurysm (E) 78-year-old male with long-standing alcoholism
(E) 78-year-old male with long-standing alcoholism
During physical examination, a 58-year-old man is instructed to hold his hands up as if he was attempting to stop traffic. After about 20 seconds of observation his wrists demonstrate an intermittent sudden loss of postural tone that is translated into a flapping movement of flexion and return to extension. This physical examination sign is known as: (A) Asterixis (B) Brudzinski sign (C) Clonus (D) Stereognosis (E) Hyperekplexia
(A) Asterixis
Huntington disease follows which of the following patterns of genetic inheritance? (A) Autosomal dominant (B) Autosomal recessive (C) X-linked dominant (D) X-linked recessive (E) Y-linked
(A) Autosomal dominant
Which of the following is the most appropriate initial disease-modifying treatment for a patient diagnosed with multiple sclerosis? (A) Beta-interferon (B) Methylprednisone (C) Methotrexate (D) Natalizumab
(A) Beta-interferon
Which of the following physical examination findings is most likely present in a patient with extraocular muscle entrapment following facial trauma? (A) Binocular double vision (B) Binocular loss of vision (C) Monocular double vision (D) Monocular loss of vision (E) Tear drop-shaped pupil
(A) Binocular double vision
A 78-year-old woman with a medical history of diabetes and hypertension presents to the emergency department complaining of left hand weakness and slurred speech. Which of the following tests is most likely to determine the source of an arterial thrombus? (A) Carotid ultrasound (B) CT of the brain (C) Erythrocyte sedimentation rate (D) Magnetic resonance angiography (MRA) of the vertebral arteries
(A) Carotid ultrasound
A 3-year-old girl is being followed by the neurologist to evaluate her motor spasticity that resulted from anoxia during labor and delivery. Which of the following is the most likely cause of this patient's spasticity? (A) Cerebral palsy (B) Congenital hypothyroidism (C) Meningitis (D) Multiple sclerosis
(A) Cerebral palsy
A 35-year-old male with a history of type I diabetes complains of a 4-week history of severe headaches that occur every evening. The headaches are sharp in nature and affect the left eye. He reports profuse watery discharge from the left nostril and the left eye with each headache. Eye examination is negative for myosis, ptosis, conjunctival injection, and papilledema. Which of the following is the most likely diagnosis? (A) Cluster headache (B) Horner syndrome (C) Intracranial tumor (D) Migraine with aura (E) Pseudotumor cerebri
(A) Cluster headache
A patient with myasthenia gravis would most likely experience symptomatic benefit with which of the following? (A) Acetylcholinesterase inhibitors (B) α1-Blockers (C) β-Blockers (D) Dopamine agonists (E) Muscarinic antagonists
(A) Acetylcholinesterase inhibitors
Drugs such as donepezil and rivastigmine that are used for Alzheimer disease exert their effects by which of the following mechanisms? (A) Acetylcholinesterase inhibitors (B) Muscarinic agonists (C) Muscarinic antagonists (D) Serotonin agonists (E) Serotonin antagonists
(A) Acetylcholinesterase inhibitors
A 61-year-old male arrives at the emergency department (ED) and is determined to be suffering from an ischemic stroke. Which of the following agents should be administered as quickly as possible to induce thrombolysis? (A) Alteplase (B) Clopidogrel (C) Eptifibatide (D) Heparin (E) Warfarin
(A) Alteplase
A 63-year-old woman with a medical history of type II diabetes, hypertension, obesity, and hyperlipidemia presents to the clinic complaining of burning pain in her feet bilaterally (dysautonomia). Neurologic examination is normal except for hyperesthesia and loss of vibratory sensation bilaterally in her feet. Which of the following may be the preferred initial treatment for managing this patient's pain? (A) Amitriptyline (B) Cetuximab (Erbitux) (C) Oxycodone (OxyContin) (D) Edrophonium (Tensilon) (E) Vitamin D
(A) Amitriptyline
Both rifampin and certain antiepileptics such as phenytoin and carbamazepine have been shown to reduce the effectiveness of which of the following? (A) Combined oral hormonal contraceptives (B) Nicotine replacement therapy (C) Nonsteroidal anti-inflammatory drugs (D) Proton pump inhibitors (E) Statins
(A) Combined oral hormonal contraceptives
A 30-year-old male presents to the ED with headache, fever, nuchal rigidity, and altered mental status. Lumbar puncture reveals: an opening pressure of 25 mm H2O, CSF protein of 400, CSF glucose of 25, and pleocytes of 4,000 (mostly neutrophilic). Appropriate IV antibiotics have been started immediately. What adjunct treatment in addition to the antibiotics has been shown to reduce mortality and improve overall outcomes? (A) Acyclovir (B) Dexamethasone (C) Mannitol (D) Phenytoin (E) Solumedrol
(B) Dexamethasone
Which of the following is the most common etiology for a subarachnoid hemorrhage? (A) Trauma (B) Ruptured aneurysm (C) Bleeding arteriovenous malformation (D) Embolic stroke (E) Primary intracerebral hemorrhage
(B) Ruptured aneurysm
A 62-year-old man presents to the emergency department with aphasia and right lower extremity weakness that started about 4 hours ago. He now has progressive right upper extremity weakness, worsening right lower extremity weakness, and decreased sensation throughout his right side. This cerebral ischemia is best characterized as: (A) Transient ischemic attack (B) Stroke in evolution (C) Completed stroke (D) Subarachnoid hemorrhage (E) Global cerebral ischemia
(B) Stroke in evolution
A 47-year-old male presents with a 3-month history of progressive bilateral leg weakness. Symptoms began in the left leg and eventually progressed to the right leg. The patient also reports associated muscle twitching and painful muscle cramps. He denies vision changes and any recent illnesses or immunizations. Physical examination reveals intact sensation bilaterally and a decrease in muscle strength of the lower extremities, more prominent on the left side than the right. Electromyography (EMG) testing reveals diffuse degenerative signs with normal nerve conduction. Which of the following is the most likely diagnosis? (A) Amyotrophic lateral sclerosis (B) Guillain-Barré syndrome (C) Multiple sclerosis (D) Myasthenia gravis (E) Nonparalytic poliomyelitis
(A) Amyotrophic lateral sclerosis
A 55-year-old female suffered a fracture of her right wrist after a fall. Two months after the cast was removed she presents with a burning pain over the radial aspect of her wrist and sharp shooting pains into her palm, which increase with movements of the wrist. One month later, she returns complaining of continued pain over the volar and lateral wrist, now with mild swelling and discoloration of her hand. Several months after her injury, symptoms worsen and she develops limitations in range of motion of the right shoulder and right wrist, and contractures of the digits. Repeat radiographs show demineralization. This scenario best describes which of the following? (A) Complex regional pain syndrome (B) de Quervain's tenosynovitis (C) Thoracic outlet syndrome (D) Ulnar nerve entrapment (E) Median nerve entrapment
(A) Complex regional pain syndrome
A 62-year-old obese woman presents with progressive numbness and tingling in her feet for the past 3 months. On physical examination, the patient is found to have decreased sensation to pinprick and vibration, absence of ankle reflexes, and difficulty with tandem walking. Which is the most common etiology of her symptoms? (A) Diabetes mellitus (B) Alcoholism (C) Vitamin B12 deficiency (D) Spinal cord tumor (E) Rheumatoid arthritis
(A) Diabetes mellitus
A 45-year-old woman with a known seizure disorder has been noncompliant with her anticonvulsant medication due to side effects she has been experiencing. While in your office, she starts to seize, and continues to convulse for longer than 5 continuous minutes. Which of the following is the most appropriate initial drug treatment? (A) Lorazepam (B) Phenytoin (C) Phenobarbital (D) Valproic acid
(A) Lorazepam
A 36-year-old auto mechanic presents to the emergency department after hurting his back on the job. While lifting an object, he experienced sudden pain in his lower back with radiation to the right buttock. He was initially treated for muscle strain with a nonsteroidal anti-inflammatory drug (NSAID) after x-rays of his lumbosacral spine demonstrated no pathology. He continued to complain of this low back pain now radiating posteriorly down his left leg to the midthigh. Physical examination is unremarkable. The most likely diagnosis is: (A) Mechanical low back pain (B) Left S1 radiculopathy (C) Cauda equina syndrome (D) L5-S1 disc herniation (E) Lateral femoral cutaneous neuropathy
(A) Mechanical low back pain
A 45-year-old man presents to the office with a 24-hour history of right facial droop, decreased tearing in the right eye, poor right eyelid closure, hyperacusis, dysgeusia, and drooling from the right side of his mouth. On examination, the patient is found to have a right facial droop, and he is unable to close his right eye and raise his right eyebrow. The remainder of the physical examination is completely normal. His vision is not affected. What would be the most appropriate therapy at this time? (A) Prednisone for 1 week and re-evaluate in office (B) Stat CT scan of the head and neurology consult (C) Obtain Lyme disease titers (D) Aspirin
(A) Prednisone for 1 week and re-evaluate in office
A patient is diagnosed with a transient ischemic attack. What is the risk of having a stroke within the next 90 days? (A) 2% to 7% (B) 10% to 15% (C) 20% to 25% (D) 30% to 45%
(B) 10% to 15%
Serotonin 1b/1d agonists, or triptans, are most effective for the acute treatment of which of the following? (A) Absence seizures (B) Acute migraine (C) Chemotherapy-induced nausea and vomiting (CINV) (D) Myoclonic seizures (E) Nocturia
(B) Acute migraine
A cerebrospinal fluid analysis reveals the following results: opalescent color, increased protein, decreased glucose, and increased polymorphonuclear white blood cells (WBCs). The most likely diagnosis would be: (A) Subarachnoid hemorrhage (B) Bacterial meningitis (C) Viral meningitis (D) Multiple sclerosis (E) Encephalitis
(B) Bacterial meningitis
A 68-year-old woman presents to the ED with an exacerbation of chronic low-back pain. Which of the following indicates the patient has developed cauda equina syndrome? (A) Anesthesia to entire leg, bilateral leg weakness, and loss of deep tendon reflexes (B) Bilateral leg pain, saddle anesthesia, urinary incontinence, and fecal incontinence (C) Bilateral leg weakness, loss of peripheral pulses, and incontinence (D) Loss of deep tendon reflexes bilaterally and urinary retention (E) Lower leg weakness, paresthesias to both legs, and incontinence
(B) Bilateral leg pain, saddle anesthesia, urinary incontinence, and fecal incontinence
A 42-year-old automobile mechanic presents complaining of neck pain that radiates down the lateral aspect of his arm and into his left hand. The patient states that the pain has become progressively more constant over the past 3 weeks. He feels that he is "loosing strength" in his left arm and that parts of his left hand are feeling numb. He states that his symptoms seem to lessen when he places his hand on top of his head. Physical examination reveals vital signs that are within normal limits; no muscle atrophy or spasm is noted in the neck or upper extremities bilaterally. Sensory ability is diminished in the dorsolateral aspect of the thumb and index finger left hand. Biceps muscle strength is 5/5 on the right and 4/5 on the left. Wrist extension strength is 5/5 on the right and 4/5 on the left. Tricep strength is 5/5 bilaterally. Tricep reflexes are +2 bilaterally, right-sided biceps and brachioradialis reflexes are 2+, and left-sided biceps and brachioradialis reflexes are 1+. On the basis of this presentation, what spinal root is most likely involved? (A) C5 (B) C6 (C) C7 (D) C8 (E) T1
(B) C6
A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on the windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical examination reveals weakness of his upper extremities. What type of spinal cord injury does this patient have? (A) Anterior cord syndrome (B) Central cord syndrome (C) Brown-Séquard syndrome (D) Complete cord transection (E) Cauda equina syndrome
(B) Central cord syndrome
A 12-year-old boy presents to the clinic for follow- up regarding his recently diagnosed partial seizures. Neither the parent nor the patient reports any interval seizures or side effects since he started taking carbamazepine (Tegretol) 1 month ago. What study should be ordered to monitor this patient's treatment? (A) Blood glucose (B) Complete blood cell count, liver function tests, sodium (C) Electroencephalogram (D) Vitamin B12 (E) Urinalysis
(B) Complete blood cell count, liver function tests, sodium
A 69-year-old male is brought to your clinic by his wife. She states that his handwriting has become smaller and he has been progressively dropping things over the last year. He also has developed a mild shaking of the right hand over the last few months that is worse when he sits down to rest. Examination is significant for masked facies, hypophonia, and right-sided bradykinesia and rigidity. Which of the following class of drugs is most commonly used for treatment? (A) Cholinesterase inhibitor (B) Dopamine agonist (C) Monoamine oxidase inhibitors (D) Opioid agonist (E) Serotonin reuptake inhibitor
(B) Dopamine agonist
A 12-year-old boy presents to the urgent care center complaining of burning pain in his lower extremities with weakness. On examination, the clinician notes symmetric weakness with severely decreased active range of motion of the lower extremities. In addition, there is decreased position and vibratory sensation in the distal portions bilaterally. Upon further questioning, the patient admits to being diagnosed with mononucleosis 2 weeks ago. Which of the following is the most likely diagnosis? (A) Botulism (B) Guillain-Barré syndrome (C) Poliomyelitis (D) Tick-bite paralysis (E) Transverse myelitis
(B) Guillain-Barré syndrome
A 43-year-old woman presents complaining of a "pins and needles" sensation that started bilaterally in her feet 2 days ago. Ten days prior she ate "on the road" and developed 4 days of nausea, vomiting, and diarrhea. The sensation now extends up to her midthighs. On physical examination, she is noted to have mild sensory loss, increasing difficulty with gait, and absent reflexes bilaterally in her legs. Which of the following is the most likely diagnosis? (A) Diabetic peripheral neuropathy (B) Guillain-Barré syndrome (C) Multiple sclerosis (D) Myasthenia gravis (E) Hypothyroidism
(B) Guillain-Barré syndrome
Recent vaccination is associated with the development of which of the following conditions? (A) Benign essential tremor (B) Guillain-Barré syndrome (C) Multiple sclerosis (D) Huntington disease (E) Parkinson disease
(B) Guillain-Barré syndrome
Which of the following is the most common finding in a person presenting with a brain abscess? (A) Fever (B) Headache (C) Nuchal rigidity (D) Papilledema (E) Vomiting
(B) Headache
Which of the following findings is an independent risk factor for mortality in patients suffering a head injury? (A) Absence of gag reflex (B) Hypoxia (C) Mandibular fracture (D) Scalp laceration (E) Unconsciousness
(B) Hypoxia
While performing a routine history and physical examination on a 70-year-old man, you note a right carotid bruit. He denies any symptoms suggestive of a transient ischemic attack (TIA) or cerebrovascular accident. A carotid Doppler ultrasound shows a 40% stenosis of the right common carotid artery. The next most appropriate step would be: (A) STAT carotid arteriogram (B) Initiate antiplatelet aggregating therapy with aspirin (C) Anticoagulate with warfarin, or other direct Xa inhibitor (D) Intra-arterial tissue plasminogen activator (tPA) (E) Carotid endarterectomy
(B) Initiate antiplatelet aggregating therapy with aspirin
A 64-year-old woman presents to the ED with complaints of left-sided headache, low-grade fever, malaise, pain with chewing, and decreased vision in her left eye. Which of the following would be the most appropriate measure in managing this patient? (A) Aspirin therapy (B) Intravenous steroids (C) Lumbar puncture (D) Muscle relaxants (E) Oxygen (O2) therapy
(B) Intravenous steroids
A 30-year-old man presents complaining of back pain radiating down his right leg. On examination, you note that his knee jerk reflex is absent on the right. This finding suggests compression of which spinal nerve root? (A) L1-L2 (B) L3-L4 (C) S1-S2 (D) T11-T12 (E) C5-C6
(B) L3-L4
An 11-year-old male recently had soft tissue surgery performed in the upper and anterior part of his neck. Three weeks after the operation, deviation of the tongue to the left side was noted upon sticking it out. The left side of the tongue was also observed to have marked atrophy. Which of the following was most likely injured during the operation? (A) Left glossopharyngeal nerve (B) Left hypoglossal nerve (C) Right accessory nerve (D) Right glossopharyngeal nerve (E) Right hypoglossal nerve
(B) Left hypoglossal nerve
A 35-year-old male is brought to the emergency department with unremitting, generalized convulsive status epilepticus. The initial, preferred treatment is intravenous administration of which of the following? (A) Donepezil (B) Lorazepam (C) Phenobarbital (D) Phenytoin (E) Valproate
(B) Lorazepam
A 19-year-old woman presents to the emergency department complaining of headache. The headaches are generalized and increasing in intensity. They have not responded to over-the-counter (OTC) medications. She complains of approximately 1 week of blurred vision, intermittent diplopia, and vague dizziness. Her medical history includes obesity and acne. She takes accutane and oral contraceptives. She is found to have bilateral papilledema, visual acuity of 20/30 on physical examination, and a normal MRI of the brain. The next most appropriate step would be (A) CT scan of the head (B) Lumbar puncture (C) Therapy with high-dose prednisone (D) Stat cerebral arteriogram (E) Reassurance and follow-up in the office in 6 months
(B) Lumbar puncture
Which of the following regions best describes the location of a Le Fort fracture? (A) Mandible (B) Midfacial (C) Occipital (D) Temporal (E) Zygoma
(B) Midfacial
A 16-year-old girl presents to the clinic complaining of strong desires to sleep at inappropriate times. She is very concerned because she "felt paralyzed" while falling asleep on the couch last night. Which of the following is the best diagnostic test to confirm this patient's diagnosis? (A) CT of the head (B) Multiple sleep latency test (C) Tensilon test (D) Thyroid stimulating hormone (E) Polysomnography
(B) Multiple sleep latency test
A 53-year-old man presents to the emergency department because of fever, headache, and confusion. On physical examination, you note an obtunded man who appears acutely ill with temperature of 104°F, blood pressure of 128/76 mm Hg, pulse of 98, and respiratory rate of 20. The patient has stomatitis, nuchal rigidity, and a positive Kernig sign. CSF examination shows increased opening pressure, 80 WBC/mL (normal <10/mL), mildly elevated protein, and normal glucose. Which of the following tests would confirm the most likely causative organism? (A) CT of the head (B) Polymerase chain reaction test for herpes simplex virus (PCR) (C) Blood culture for herpes simplex virus (D) Serum IgG for herpes simplex virus (E) MRI of the head
(B) Polymerase chain reaction test for herpes simplex virus (PCR)
A 6-year-old boy is struck by a car while riding his bicycle. He reportedly was wearing no helmet sustaining a soft tissue injury to the R temporal area of the head. He was reported to be unconscious for 2 minutes following the accident. He is conscious and alert upon arrival to the emergency department by EMS reporting anisocoria. Within 45 minutes of his ED arrival he begins to vomit and shortly thereafter he becomes completely unresponsive. Which of the following most likely explains this child's injury? (A) Spinal cord transection (B) Chronic subdural hematoma (C) Acute epidural hematoma (D) Acute subarachnoid hemorrhage (E) Grade III concussion
(C) Acute epidural hematoma
Which of the following is the recommended treatment for a 4-year-old child with presumed bacterial meningitis? (A) Ampicillin plus chloramphenicol (B) Cefotaxime (Claforan) or ceftriaxone (Rocephin) plus ampicillin (C) Cefotaxime (Claforan) or ceftriaxone (Rocephin) plus vancomycin (Vancocin) (D) Gentamicin plus ampicillin (E) Rifampin (Rifadin) plus dexamethasone (Decadron)
(C) Cefotaxime (Claforan) or ceftriaxone (Rocephin) plus vancomycin (Vancocin)
A 35-year-old female with a history of chronic hepatitis develops progressive personality changes, clumsiness, and stuttering speech to the point of near incoherence over a 6-month period. On physical examination, you notice dysarthria, muscular rigidity in the lower extremities, and spasm of the arms. Slit-lamp examination reveals gold-brown rings that encircle the iris in both eyes. Which of the following is most likely to be decreased in the serum of this patient? (A) Ammonia (B) Calcium (C) Ceruloplasmin (D) Glucose (E) Lactate
(C) Ceruloplasmin
A 21-year-old male is observed by his girlfriend to have episodes during which he seems inattentive and unresponsive to stimulation. During these episodes he typically will pull on his shirt and make smacking noises with his mouth. The episodes last for 30 to 60 seconds. Afterward, he is confused and denies any recollection of the event. This scenario best describes which type of seizure disorder? (A) Absence (B) Atonic (C) Complex partial (D) Psychogenic (E) Simple partial
(C) Complex partial
An otherwise healthy 40-year-old female presents to the emergency department with a severe headache, nausea, and vomiting. Physical examination is significant for bilateral papilledema. The remainder of the physical examination is completely normal. Which of the following interventions is indicated first? (A) Carotid ultrasound (B) Lumbar puncture (C) Computed tomography of the head (D) Temporal artery biopsy (E) Visual field testing
(C) Computed tomography of the head
For the past 4 days, a 77-year-old female has been crying easily, confused, and rambling incoherently. Her medical history is remarkable for mild dementia and well-controlled hypertension. She has never had anything like this in the past and she has not had any recent changes to her medications. When questioned, she has no difficulty articulating a sentence but difficulty remembering what she was asked. Laboratory testing is significant for leukocytosis. What is the most likely diagnosis? (A) Alzheimer disease (B) Depression (C) Delirium (D) Sundowning (E) Wernicke aphasia
(C) Delirium
A 73-year-old man is brought into your office by his adult children with a concern of memory loss. They report their father's memory has been declining since the death of their mother a few months ago but are now concerned because he is losing weight, sleeping during the daytime, and is not keeping up with current events like he usually does. This type of behavior is most associated with which of the following? (A) Pick disease (B) Creutzfeldt-Jakob disease (C) Depression (D) Alzheimer disease (E) Vitamin B12 deficiency
(C) Depression
A 2-year-old is brought to the emergency department by her parent for evaluation of jerking motions that lasted for about 2 minutes. Her temperature is 39°C rectal; pulse 120/min; respirations 32/min; blood pressure 110/64 mm Hg. On physical examination, she is sleepy but arousable with negative Kernig and Brudzinski signs. Which of the following seizures did this patient most likely experience? (A) Absence (B) Complex partial (C) Febrile (D) Psychogenic nonepileptic (E) Simple partial
(C) Febrile
Which of the following pairs of medications are antiepileptics approved by the Food and Drug Administration (FDA) for the treatment of neuropathic pain? (A) Aripiprazole and topiramate (B) Duloxetine and venlafaxine (C) Gabapentin and pregabalin (D) Modafinil and tolterodine (E) Quetiapine and risperidone
(C) Gabapentin and pregabalin
A patient is involved in an MVA and suffered a fractured neck. The fracture lines extend through the pedicles of C2. Which of the following describes this unstable hyperextension fracture to the cervical spine? (A) Clay-shoveler fracture (B) Extension teardrop fracture (C) Hangman fracture (D) Jefferson fracture (E) Johnson fracture
(C) Hangman fracture
A 78-year-old woman presents to the office complaining of a constant left-sided headache for 2 months. She has tried various over-the-counter (OTC) medications without relief. The patient admits to vision loss of her left eye last night for 10 minutes. The patient states that her vision then returned to normal. She denies pain in her eye. On review of systems, she relates several months of muscle aches and weight loss. On physical examination, she is found to have a tender, nonpulsatile superficial temporal artery. Her sedimentation rate is elevated at 90 mm/h. What is the next most appropriate step in the evaluation of this patient? (A) Stat MRI/MRA of the brain and cranial vessels (B) Aspirin therapy (C) High-dose prednisone (D) Lumbar puncture (E) Sumatriptan (Imitrex) injection
(C) High-dose prednisone
After a carotid endarterectomy, a patient experienced a unilateral small pupil, mild ptosis with normal response to light and accommodation. This abnormality is called: (A) Adie pupil (B) Argyll Robertson pupil (C) Horner syndrome (D) Marcus Gunn pupil (E) Light-near dissociation
(C) Horner syndrome
A 46-year-old HIV positive male is brought to the emergency department by his partner. Over the past few weeks, the patient has been having unexplainable headaches and episodes of confusion. This evening he became agitated and then suddenly dropped to the floor and began convulsing. This went on for 30 to 60 seconds. His partner reports that the patient has been unable to afford antiretroviral drugs since he quit his job over a year ago. Diagnostic testing reveals a CD4 count of 160/mm3, and a CT scan of the brain demonstrates ring-enhancing lesions. Which of the following is the most likely diagnosis? (A) Bacterial meningitis (B) Ischemic stroke (C) Infectious encephalitis (D) Status epilepticus (E) Subarachnoid hemorrhage
(C) Infectious encephalitis
A 62-year-old man complains of low back pain that radiates from his back down into his buttock and into his right leg. On physical examination, you note sensory loss on the first dorsal web space between the first and second toes and decreased ability to dorsiflex (extend) the first toe on the right side. The straight-leg raise test elicits pain at 45 degrees of elevation. Based on the information contained in this scenario, between which pairing of vertebrae is the disc herniation most likely to have occurred? (A) L2-L3 (B) L3-L4 (C) L4-L5 (D) L5-S1 (E) S1-S2
(C) L4-L5
A 62-year-old man is brought to the emergency department after being found unresponsive in his car. On physical examination, his pupils are noted to be 7 mm on the right and 3 mm on the left. Which of the following diagnostic tests is most likely to identify the cause of the patient's signs and symptoms? (A) Straight catheter obtained urine drug screen (B) STAT serum electrolytes (C) MRI with contrast (D) STAT liver function tests (E) STAT skull x-rays
(C) MRI with contrast
A 75-year-old male is brought to your clinic by his daughter for evaluation of forgetfulness. The patient reports that he is doing well and, aside from occasional difficulty sleeping and hypertension, he does not have any other health problems. According to his daughter, over the last year his memory seems to be getting worse; he has difficulties finding words and remembering recent events. What is the next most appropriate step? (A) Electroencephalogram (B) Intelligence quotient testing (C) Mini-mental status examination (D) Noncontrast head CT (E) Rapid plasma reagin (RPR)
(C) Mini-mental status examination
Midday, an 18-year-old woman is transferred to your emergency department from a local college infirmary. She presented to the infirmary complaining of headache beginning late the night before. At the infirmary her headache had worsened and she became confused. On examination, she was found to be febrile with a petechial rash. A lumbar puncture is done and the cerebrospinal fluid comes back with increased WBCs, increased protein, and decreased glucose. What is the most likely organism responsible for her meningitis? (A) Haemophilus influenzae (B) Cytomegalovirus (C) Neisseria meningitidis (D) Mycobacterium tuberculosis (E) Coxsackievirus B
(C) Neisseria meningitidis
Which of the following functions is controlled by the frontal lobe? (A) Gait (B) Writing (C) Planning (D) Smell (E) Vision
(C) Planning
A 40-year-old man slips on the ice, injuring his left arm. He complains of pain and swelling to the midshaft humeral region. The physical examination reveals a wrist drop on the injured side. Which nerve is most likely injured? (A) Axillary (B) Median (C) Radial (D) Subclavian (E) Ulnar
(C) Radial
A 52-year-old female bus driver presents to the clinic with a chief complaint of intense, shooting pains in her right cheek, each lasting for only a few seconds she avoids touching certain parts of her face and has started to chew food only on the right side of her mouth because she is afraid she will set off an attack of pain. In between attacks, the patient feels well. What is the most likely diagnosis? (A) Cluster headache (B) Tension-type headache (C) Trigeminal neuralgia (D) Giant cell arteritis (E) Dental abscess
(C) Trigeminal neuralgia
Which of the following motor, sensory, and reflex findings are most likely to be found in a patient with lumbar radiculopathy of the L4-L5 disc? (A) Weakness of the anterior tibialis, numbness of the shin, and an asymmetric knee reflex (B) Weakness of the great toe flexor and gastrocsoleus, inability to sustain tiptoe walking, and an asymmetrical ankle reflex (C) Weakness of the great toe extensor, numbness on the top of the foot and first web space, no reflex findings (D) Perianal numbness, urinary and bowel incontinence (E) Ankle clonus
(C) Weakness of the great toe extensor, numbness on the top of the foot and first web space, no reflex findings
Which of the following patient populations is at the greatest risk for an epidural hematoma following head trauma? (A) Elderly patients (B) Infants (C) Young adults (D) Young children
(C) Young adults
While doing an eye examination, it is noted that patient's left eye will not move lateral of the midline. Which cranial nerve is implicated? (A) CN II (B) CN III (C) CN IV (D) CN VI (E) CN VII
(D) CN VI
A 10-month-old girl is brought to your facility with a history of fever and a rash. The parents report she was in good health until this morning, when she developed poor feeding, fever, and irritability. In the afternoon her parents noticed bruises on her legs and trunk. On examination, she appears acutely ill with fever, tachycardia, cool hands and feet, and petechiae on her legs and trunk. Which of the following is the diagnostic test of choice? (A) Blood cultures (B) CBC with differential (C) Coagulation profile (D) CSF analysis (E) Serum electrolytes
(D) CSF analysis
A 37-year-old woman presents to your office with the complaint of bouts of pain and tingling in dominant right hand most severe during hours of sleep. Sensation in the radial palm has been recurrent. On your examination, she demonstrates a positive Phalen sign, and positive Tinel sign with paresthesias consistently in the distribution of the median nerve. She states that the pain can sometimes wake her up at night and feels as if her thumb is falling asleep. What disease might be associated with this onset of symptoms? (A) Myasthenia gravis (B) Radial nerve compression (C) Thoracic outlet syndrome (D) Carpal tunnel syndrome (E) Recent injury to the medial cord of the right brachial plexus
(D) Carpal tunnel syndrome
A 12-year-old, left-hand dominant girl is being evaluated for "spells" that she has been experiencing. According to her parents, she was born following an uncomplicated pregnancy and was a healthy child until last year when she was struck by a drunk driver while walking home from a friend's house. The episodes begin by her complaining of an upset stomach and then she appears confused, turns her head to the left, and raises her left arm in the air. Each episode lasts for about 30 to 60 seconds, after which she is very tired for another hour. This scenario best describes which type of seizure disorder? (A) Absence (B) Tonic-clonic (C) Simple partial (D) Complex partial (E) Pseudoseizures
(D) Complex partial
Which of the following HLA haplotypes is strongly associated with rheumatoid arthritis? (A) HLA-B8 (B) HLA-B27 (C) HLA-B51 (D) HLA-DR4 (E) HLA-DRB3
(D) HLA-DR4
A 66-year-old male is diagnosed with idiopathic Parkinson disease (IPD) and is suffering from tremor and bradykinesia that has become troublesome in his job-related activities as a teacher. The patient has expressed that he would like to continue working for another 3 to 4 years and is seeking the most effective medication to control his symptoms. Which of the following would be most appropriate to prescribe to this patient? (A) Amantadine (B) Benztropine (C) Entacapone (D) Levodopa/carbidopa (E) Selegiline
(D) Levodopa/carbidopa
A 41-year-old woman presents to the emergency department complaining of a sudden "thunderclap" onset of the "worst headache of my life." She denies taking anticoagulants, oral contraceptives, or estrogen replacement therapy. There is no family history of brain aneurysm. A noncontrast, computed tomography (CT) scan of her brain was obtained and is read "normal." The next appropriate step in the diagnosis of this patient would be (A) Outpatient magnetic resonance imaging (MRI) of the brain (B) Complete blood cell count (CBC) with differential (C) Injection of sumatriptan (Imitrex) (D) Lumbar puncture (E) Repeat CT scan in 48 hours
(D) Lumbar puncture
An otherwise healthy 16-year-old girl presents to your office with a complaint of headache that began when getting ready for school today. Her mother, who has a history of migraine headaches herself, reports that her daughter had a similar headache a month ago lasting about 2 days. The pain continues to worsen on a pain scale of 9-10/10. It is generalized headache, throbs, and worsens when she moves. She is likely to vomit if she does not stop what she is doing and go lay down in a dark, quiet room. No over-the-counter medications that she tried have ever worked. The mother has migraines as well as the maternal grandmother. She is not on oral contraceptives, denies sudden "thunderclap" headache, and there is no family history of cerebral aneurysm. Her history is consistent with which of the following? (A) Migraine with aura (B) Cluster headache (C) Tension-type headache (D) Migraine without aura (E) Medication withdrawal headache
(D) Migraine without aura
A patient presents with progressive visual changes over the past 2 years. On physical examination, bitemporal hemianopsia is noted. A lesion in which of the following anatomic locations is most likely to cause these findings? (A) Optic tract (B) Optic nerve (C) Occipital cortex (D) Optic chiasm
(D) Optic chiasm
A 58-year-old man presents to your office with a complaint of tremor in his right hand at rest. Upon questioning, you discover that the tremor is getting worse and now seems to be in both arms especially when at his sides. He also complains that food doesn't smell as good now and he is having trouble eating with a fork and buttoning his shirt. On your physical examination, you notice a resting tremor, bradykinesia, rigidity, and a shuffling gait. What is your initial assessment? (A) Essential tremor (B) Wilson disease (C) Huntington disease (D) Parkinson disease (E) Progressive supranuclear palsy
(D) Parkinson disease
Which of the following seizure medications is associated with gingival hyperplasia? (A) Carbamazepine (Tegretol) (B) Clonazepam (Klonopin) (C) Ethosuximide (Zarontin) (D) Phenytoin (Dilantin) (E) Valproic acid (Depakote)
(D) Phenytoin (Dilantin)
A postural tremor that occurs at rest and may be exacerbated by fear, anxiety, excessive physical activity, or sleep deprivation is consistent with which of the following? (A) Wilson disease (B) Intention tremor (C) Asterixis (D) Physiologic tremor (E) Hemiballismus
(D) Physiologic tremor
A 10-year-old female presents with complaints of recurrent, episodic migraine headaches. They occur about two to three times a month and have started to interfere with schoolwork when they occur. Which of the treatments is FDA approved for abortive therapy for this patient? (A) Almotriptan (Axert) (B) Coenzyme Q10 (C) Dihydroergotamine (Migranal) (D) Rizatriptan (Maxalt) (E) Topiramate (Topamax)
(D) Rizatriptan (Maxalt)
A 22-year-old woman, with no previous medical problems, suddenly cried out, fell to the ground, extended her legs, flexed her arms, and jerked her extremities for 30 seconds. There was associated tongue biting and urinary incontinence. She awoke slowly over a 10-minute period and recalled nothing about the episode. She remained lethargic for several hours but the rest of her neurologic examination was normal. What is the most likely etiology for this episode? (A) Epilepsy (B) Hyperventilation (C) Cardiac arrhythmia (D) Seizure (E) Stroke
(D) Seizure
A 60-year-old patient presents with new-onset localized headache. The erythrocyte sedimentation rate is 55 mm/h. Which of the following is the most likely diagnosis? (A) Cluster headache (B) Migraine (C) Subarachnoid hemorrhage (D) Temporal arteritis (E) Trigeminal neuralgia
(D) Temporal arteritis
A 35-year-old woman presents with a history of a self-limited upper respiratory illness 3 weeks prior to this visit. She now complains of persistent weakness, difficulty chewing and malaise which worsen at the end of the day. She complains that she has difficulty keeping her right eye open toward the latter part of the day. Taking a nap usually helps to alleviate the patient's symptoms. Upon examination, you notice that the right eyelid covers the top part of her pupil. Pupillary reactions are normal. A complete neurological evaluation is otherwise negative Which evaluation is most likely to confirm your suspected diagnosis? (A) CT scan of the brain (B) Lumbar puncture (C) Fundoscopic examination (D) Tensilon test (E) Psychiatric evaluation
(D) Tensilon test
A 65-year-old chronic alcoholic is found disoriented and stumbling. On examination, he is somnolent and confused. Neurologic examination reveals a horizontal gaze palsy and ataxia but normal extremity motor strength. Deficiency of which of the following vitamins is the most likely cause? (A) Biotin (B) Niacin (C) Riboflavin (D) Thiamine (E) Vitamin C
(D) Thiamine
A 45-year-old male is diagnosed with myasthenia gravis. He complains of some dysphagia and has a CT scan of the chest performed which reveals a large mediastinal mass in the anterior portion of the anterior/superior mediastinum. This mass most likely represents a/an: (A) Esophageal tumor (B) Neuroblastoma (C) Thoracic aneurysm (D) Thymoma
(D) Thymoma
Which of the following findings is consistent with a lower motor neuron deficit? (A) Aphasia (B) Dysdiadochokinesia (C) Sensory loss (D) Weakness (E) Hyperreflexia
(D) Weakness
A 65-year-old man is brought to the clinic by his family noting increasing short-term memory loss, intermittent confusion, trouble handling money, and increased anxiety over the last 6 months. In the last couple weeks he seems to have an occasional problem recognizing people he should know, and a new unfamiliarity with performing tasks he normally would be accustomed to performing like simple use of the kitchen toaster. Recently, his decline has accelerated. This patient is most likely experiencing: (A) Depression (B) Delirium (C) Hypothyroidism (D) Normal pressure hydrocephalus (E) Alzheimer dementia
(E) Alzheimer dementia
It is not uncommon for premonitory symptoms of an impending cerebral aneurysm rupture to begin 10 to 20 days earlier to the event. The following lists are likely signs and symptoms that occur in order of prevalence, the first being the most common. Select the correct order of symptoms that can be found. (A) Headache, sensory and motor disturbance, dizziness, diplopia, orbital pain (B) Dizziness, headache, sensory and motor disturbance, diplopia, orbital pain (C) Sensory and motor disturbance, diplopia, headache, dizziness, orbital pain (D) Sensory and motor disturbance, dizziness, headache, orbital pain, diplopia (E) Headache, dizziness, orbital pain, sensory and motor disturbance, diplopia
(E) Headache, dizziness, orbital pain, sensory and motor disturbance, diplopia
Which of the following is the primary mechanism by which benzodiazepines exert their sedative and anxiolytic effects? (A) Acting as dopamine receptor agonists (B) Acting as NMDA receptor antagonists (C) Acting as serotonin receptor antagonists (D) Decreasing reuptake of serotonin and norepinephrine (E) Increasing GABAA receptor-mediated chloride conductance
(E) Increasing GABAA receptor-mediated chloride conductance
A 21-year-old female presents with blurred vision and pain with movement in one eye. In addition, she is concerned about an episode of numbness and tingling she had in both feet 6 weeks ago. Review of systems is positive for constipation, fatigue, and nocturnal leg cramps. She denies extremity weakness or urinary frequency. Which of the following is the test of choice in evaluation of this patient? (A) Serum antimyelin antibodies (B) Cerebrospinal fluid analysis (C) Computed tomography (D) Evoked potentials (E) Magnetic resonance imaging
(E) Magnetic resonance imaging
A 65-year-old man presents to the emergency department with an acute ischemic stroke. His CT scan is normal. His blood pressure is 180/100 mm Hg. What is the most appropriate treatment for his hypertension? (A) Labetalol (Normodyne) 20 mg IV (B) Nifedipine (Procardia) 10 mg po (C) Nitroprusside (Nipride) drip at 1 mg/kg/min (D) Clonidine (Catapres) 0.1 mg po (E) No antihypertensive at this time
(E) No antihypertensive at this time
A 46-year-old female reports feeling an uncomfortable deep crawling and aching sensation in her legs. The patient notes that she typically experiences this sensation at night when she gets into bed. Also associated is a strong urge to move her legs and she has to get up several times each night to relieve the feeling. She denies associated low back pain or recent blood donation. Neurologic and vascular examination is normal. Which of the following is the most likely diagnosis? (A) Lumbosacral radiculopathy (B) Nocturnal leg cramps (C) Periodic limb movements of sleep (D) Peripheral neuropathy (E) Restless leg syndrome
(E) Restless leg syndrome
A 59-year-old, right-handed African-American male with a 20-year history of type 2 diabetes mellitus is found on the floor by his wife. She asks him what's wrong and his only complaint is a headache. Examination reveals an alert, awake patient with anosognosia, left hemineglect, and right gaze preferences. There are also signs of left hemiparesis (upper extremity substantially weaker than lower extremity) and left hemisensory deficits in the upper extremity and face. Which of the following arterial vessels was most likely affected? (A) Left anterior cerebral (B) Left middle cerebral (C) Right anterior cerebral (D) Right anterior inferior cerebellar (E) Right middle cerebral
(E) Right middle cerebral
A patient develops pain, numbness, and tingling in both the hands and feet 1 year after undergoing gastrectomy. She denies joint swelling and extremity weakness. Which of the following tests would be best for determining the etiology of her presenting symptoms? (A) Antinuclear antibody (B) Electromyography (C) Lumbar puncture (D) Nerve biopsy (E) Serum B12 level
(E) Serum B12 level
Which of the following is the most common etiologic agent of bacterial meningitis in the pediatric population of the United States? (A) Haemophilus influenzae type B (B) Listeria monocytogenes (C) Neisseria meningitidis (D) Staphylococcus aureus (E) Streptococcus pneumoniae
(E) Streptococcus pneumoniae
A 46-year-old female presents with a long history of headaches. She describes the pain as a generalized squeezing and tightness. The headaches occur almost daily. No over-the-counter medications that she has tried have helped. She denies nausea, vomiting, eye tearing, and nasal congestion. On examination, there is mild tenderness of her scalp and both trapezius muscles. Which of the following precipitants is most common with this type of headache? (A) Foods (B) Menstruation (C) Odors (D) Smoking (E) Stress
(E) Stress
Which of the following seizures is associated with incontinence? (A) Atonic (B) Complex partial (C) Psychogenic (D) Simple partial (E) Tonic-clonic
(E) Tonic-clonic
A 10-year-old male is brought to the pediatrician by his parents. The parents are concerned about frequent symptoms of facial twitches and sudden uncontrollable outbursts of sounds. These symptoms have been going on since he was in kindergarten and he has become reluctant to go to school for fear of ridicule by his peers. Which of the following is the most likely diagnosis? (A) Complex partial seizures (B) Conduct disorder (C) Huntington disease (D) Myoclonic seizures (E) Tourette disorder
(E) Tourette disorder
The risk of extrapyramidal side effects (pseudoparkinsonism) and tardive dyskinesia is associated with which class of medications? (A) Amphetamines (B) Benzodiazepines (C) Monoamine oxidase inhibitors (MAOIs) (D) Tricyclic antidepressants (TCAs) (E) Typical (first-generation) antipsychotics
(E) Typical (first-generation) antipsychotics
A 39-year-old woman presents to the ED with agitation, tremors, visual hallucinations, fever, and tachycardia. The eye examination reveals nystagmus and a sixth cranial nerve palsy. Which of the following conditions best describes this clinical scenario? (A) Acute cocaine toxicity (B) Acute dystonia (C) Korsakoff psychosis (D) Trigeminal neuralgia (E) Wernicke encephalopathy
(E) Wernicke encephalopathy