Lange PA Questions

(C) Delirium is the most likely diagnosis. Delirious individuals have cognitive and perceptual problems, including memory loss, disorientation, and difficulty with language and speech. Delirium may be the only finding suggesting acute illness in older demented patients. Infections are common precipitators of delirium and the underlying leukocytosis in this patient is key. In contrast to delirium, cognitive change in Alzheimer disease is typically insidious, progressive, without much fluctuation, and occurs over a much longer time. Delirium is commonly misdiagnosed as depression. Both are associated with poor sleep and difficulty with attention or concentration but depression will not cause a leukocytosis. Sundowning presents as behavioral deterioration seen in the evening hours, typically in demented, institutionalized patients. Patients with Wernicke aphasia may appear delirious in that they do not comprehend or obey and seem confused. However, the problem is restricted to language, while other aspects of mental function are intact.

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

(E) In order of prevalence, headache (48%) is most common, followed by dizziness (10%), orbital pain (7%), sensory and motor disturbance (6%), and diplopia (4%). The collections of prodromal signs and symptoms are sentinel leaks, mass effect, and possible emboli. Sentinel leaks are usually small amounts of blood loss from the aneurysm occurring in 30% to 50% of subarachnoid headaches (SAHs). A sentinel leak produces a sudden focal or generalized head pain and is usually severe. This may occur a few hours to a few months with an average of 2 weeks before discovery of the SAH. The mass effect occurs from the expanding aneurysm size and its location within the brain vascular. Emboli are the result of the formation of intra-aneurysmal thrombus leading to transient ischemic attacks (TIA).

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

(D) Weakness is one potential finding of a lower motor neuron process. When these axons are damaged, the innervated muscles will show some combination of the following signs: weakness or paralysis of the involved muscles, flaccidity, hypotonia, diminished or absent muscle stretch reflexes (hypo or areflexia), and eventually atrophy. Aphasia results from injury to the speech pathways within the brain. Sensory loss arises from many causes, but it is not a motor issue. Dysdiadochokinesia (impaired performance of rapidly alternating movements) is consistent with cerebellar pathology. Hyperreflexia is typically a signal of upper motor neuron disease.

Which of the following findings is consistent with a lower motor neuron deficit? (A) Aphasia (B) Dysdiadochokinesia (C) Sensory loss (D) Weakness (E) Hyperreflexia

(C) Functions of the frontal lobe include planning and initiating of activity, reasoning and abstraction, monitoring and shaping of behavior to ensure adaptive actions, prioritizing and sequencing actions, and problem solving. Function of the parietal lobe includes integrating sensory information from various senses, and in the manipulation of objects; portions of the parietal lobe are involved with visuospatial processing. Function of the occipital lobe includes sense of sight. Function of the temporal lobe includes sense of smell and sound, as well as processing of complex stimuli like faces and scenes. The cerebellum is involved in motor control.

Which of the following functions is controlled by the frontal lobe? (A) Gait (B) Writing (C) Planning (D) Smell (E) Vision

(A) The goal of the treatment of multiple sclerosis is to reduce the frequency and severity of recurrent attacks. Most data agree that the use of beta- interferons as early as possible in the diagnosis of multiple sclerosis is the treatment of choice for attaining this goal. Corticosteroids may be used to lessen the severity of an acute attack but have not been shown to be effective in suppressing further attacks. Methotrexate and natalizumab are not first-line agents. The use of amantadine and physical therapy can help with energy and mobility issues.

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

(B) Up to 80% of subarachnoid hemorrhages can be attributed to the rupture of saccular or berry aneurysms in nontraumatic subarachnoid hemorrhages. Most of these aneurysms arise from the anterior circulation. Most are in the anterior communicating artery. Twenty-five percent of patients will have more than one aneurysm. Because of cerebrovascular anatomy, the blood is usually confined to the subarachnoid space. Blood from a ruptured arteriovenous malformation can be intraparenchymal and cause focal neurologic symptoms. Trauma is more likely to cause epidural or subdural hematoma.

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) Headache is the most common symptom of a brain abscess occurring in 69% of patients. The pain is usually localized to the side of the abscess, and its onset can be gradual or sudden. The pain tends to be severe and not relieved by over-the-counter pain medications. Neck stiffness occurs in 15% of patients. Fever is not a reliable indicator of brain abscess since only 45% to 53% of patients have this sign. Vomiting generally develops in association with increased intracranial pressure. Papilledema is found in 25% of patients with a brain abscess as a late manifestation of cerebral edema and usually takes days to develop.

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

(D) Phenytoin is associated with gingival hyperplasia, anemia, and hirsutism. Carbamazepine is associated with aplastic anemia, hyponatremia, and leukopenia. Clonazepam is associated with ataxia, sedation, and slowed thinking. Ethosuximide is associated with hepatotoxicity, neutropenia, and rash. Valproic acid is associated with hepatotoxicity, osteoporosis, and pancreatitis.

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)

(E) Tonic-clonic seizures are associated with cessation of breathing and incontinence. Atonic seizures are typically associated with loss of muscle tone and collapse to the ground. In complex partial seizures (focal seizure with loss of consciousness) there are focal motor or autonomic symptoms, or subjective sensory or psychic symptoms that may precede, accompany, or follow the period of altered responsiveness. Psychogenic nonepileptic seizures (PNES) resemble tonic-clonic seizures, but there may be obvious preparation before a PNES occurs. Moreover, there is usually no tonic phase. Simple partial seizures (focal seizure with no loss of consciousness) present with focal motor, sensory, psychic and/or autonomic symptoms but the patient does not lose consciousness.

Which of the following seizures is associated with incontinence? (A) Atonic (B) Complex partial (C) Psychogenic (D) Simple partial (E) Tonic-clonic

(D) A lumbar puncture will establish the diagnosis of meningitis and should be performed on any child in whom meningitis is suspected, unless specific contraindications to lumbar puncture are present. Isolation of a bacterial pathogen from the cerebrospinal fluid (CSF) confirms the diagnosis of bacterial meningitis. Blood tests are helpful in evaluation of bacterial meningitis but are nonspecific. Tests should include a complete blood count with differential and platelet count and two aerobic blood cultures. Serum electrolytes and glucose, blood urea nitrogen, and creatinine concentrations are helpful in determining the cerebrospinal fluid-to-blood glucose ratio, and in planning fluid administration. Evaluation of clotting function is indicated if petechiae or purpuric lesions are noted. (Kaplan,

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

(E) Tourette disorder is most likely. Motor tics are the initial manifestation in 80% of cases and most commonly involve the face, whereas in the remaining 20%, the initial symptoms are phonic tics; ultimately a combination of different motor and phonic tics develop in all patients. These are noted first in childhood, generally between the ages of 2 and 15. Complex partial seizures involve impaired consciousness. Myoclonic seizures consist of single or multiple muscle jerks and are not associated with vocal outbursts. Huntington disease is characterized by onset of chorea and dementia between 30 and 50 years of age. The disease is progressive and usually leads to a fatal outcome within 15 to 20 years.

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

(B) Carbamazepine is an antiepileptic drug that potentially causes aplastic anemia, agranulocytosis, or hyponatremia. Therefore, baseline and periodic CBC, LFT, and Na testing are required. Disorders of carbohydrate metabolism, vitamin B12 deficiency, or renal toxicity are not commonly reported. EEG is used to help establish a diagnosis of a seizure disorder.

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

(D) Complex partial seizures are often preceded by some type of sensory aura. This is followed by an impairment of consciousness (but not total loss of consciousness) along with an involuntary motor activity. The seizure will resolve in about 30 minutes and is followed by postictal confusion. Simple partial seizures have no alteration of consciousness. Absence and tonic-clonic seizures are generalized seizure disorders in which consciousness is lost. Absence seizures are characterized by staring spells without motor involvement, whereas tonic-clonic seizures involve strong muscle extension and contraction in many major muscle groups. Pseudoseizures are a diagnosis of exclusion. All tests results including an electroencephalogram (EEG) are normal, and the seizures may be a manifestation of an underlying psychiatric disturbance.

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

(B) Narcolepsy is characterized by hypersomnolence, loss of muscle tone prior to sleep, hallucinations upon initiating or arising from sleep, and episodes of sleep paralysis. The diagnostic test that is used in conjunction with clinical history to establish the diagnosis is the multiple sleep latency test. The tensilon test is utilized to assess for the presence of myasthenia gravis. Polysomnography can be useful in excluding other sleep disorders, but it does not assess sleep latency time necessary to support the diagnosis of narcolepsy.

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) The presence of headache associated with papilledema raises the concern for a brain tumor. The MRI excluded a mass lesion, raising a strong suspicion of pseudotumor cerebri. This is also known as benign intracranial hypertension. It is not a benign condition, however, since it causes severe headache and may result in visual loss. It is particularly frequent in obese adolescent girls and young women. The etiology is unknown but may be associated with the use of oral contraceptives, vitamin A, and tetracycline. The presentation consists of headaches caused by an increase in intracranial pressure and blurring of vision. There may be diplopia, but the remainder of the neurologic examination is unremarkable. Papilledema is virtually always part of the presentation. The mental status examination is normal. The differential diagnosis includes venous sinus thrombosis, sarcoidosis, and tuberculosis or carcinomatous meningitis. The last two are excluded by lumbar puncture. An abnormal cerebrospinal fluid is not consistent with pseudotumor cerebri. The diagnosis is made by excluding mass lesions with CT scan or MRI and demonstrating markedly increased intracranial pressure by lumbar puncture. The treatment involves weight loss, diuretics, and steroids. Repeat lumbar punctures to remove cerebrospinal fluid and decrease intracranial pressure are usually effective. In cases that are unresponsive to these measures, lumbarperitoneal shunting is effective, as is unilateral optic nerve sheath fenestration. Effective treatment can improve headaches and prevent vision loss.

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

(C) Approximately 80% to 90% of patients with Wilson disease have low serum ceruloplasmin levels and a serum ceruloplasmin concentration less than the laboratory lower limit for normal. Decreased levels of ammonia are seen with essential or malignant hypertension and hyperornithinemia. Hypocalcemia is seen in multiple diseases but commonly with hypoparathyroidism and renal failure. Hypoglycemia is seen with diseases such as insulinoma. A decreased lactate dehydrogenase is not clinically significant but can be caused by drugs such as ascorbic acid.

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

(E) Multiple sclerosis (MS) can present in a myriad of ways but the most common presenting signs are optic neuritis and transverse myelitis. MRI is the test of choice to support the clinical diagnosis of MS. The McDonald diagnostic criteria include specific clinical and MRI findings needed for the demonstration of lesion dissemination in time and space. Current evidence suggests antimyelin antibodies are not associated with an increased risk of progression to MS or with MS disease activity. CSF analysis is not a requirement for the diagnosis of MS in patients with classic MS symptoms and brain MRI appearance, but it can be used to help rule out the diagnosis in equivocal cases. MRI detects many more MS lesions than CT, and it is able to detect plaques in regions that are rarely abnormal on CT such as the brainstem, cerebellum, and spinal cord. Evoked potentials may help with subclinical disease detection. Evoked potentials also may help define the anatomical site of the lesion in tracts not easily visualized by imaging, such as the optic nerve.

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

(C) The scenario describes a complex partial seizure (focal seizure with loss of consciousness). Observable focal motor or autonomic symptoms, or subjective sensory or psychic symptoms may precede, accompany, or follow the period of altered responsiveness. Atonic seizures are typically associated with loss of muscle tone and collapse to the ground. Clinically, psychogenic nonepileptic seizures (PNES), resemble tonic-clonic seizures, but there may be obvious preparation before a PNES occurs. Moreover, there is usually no tonic phase; instead, there may be an asynchronous thrashing of the limbs, which increases if restraints are imposed and rarely leads to injury. Postictally, there are no changes in behavior or neurologic findings. Simple partial (focal seizure with no loss of consciousness) present with focal motor or autonomic symptoms, or subjective sensory or psychic symptoms but the patient does not lose consciousness.

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

(D) This event represents a well-demarcated episode affecting some combination of consciousness, motor, and/or sensory function consequent to abnormal electrical discharges in the brain. This is consistent with the definition of a seizure. Epilepsy refers to multiple, recurrent seizures. This history is not consistent with hyperventilation, stroke, or cardiac arrhythmia, which would typically include chest pain, shortness of breath, dyspnea on exertion, or focal neurologic deficits.

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

(A) Myasthenia gravis is due to antibodies directed at acetylcholine receptors. Demyelination of peripheral nerves is seen with multiple sclerosis. Inhibition of acetylcholine release is seen with botulism. A variety of disorders affecting muscle contraction and nerve function are due to chromosomal causes and/or gene mutations that affect sodium-gated ion channels.

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) Cerebral palsy is caused by perinatal injury to the nervous system and results in motor spasticity. The history of perinatal anoxia is consistent with cerebral palsy. Congenital hypothyroidism is typically asymptomatic at birth and diagnosed through routine screening tests. Neonatal meningitis may result in anoxia, but this patient's anoxia is attributed to the birthing process. Multiple sclerosis is caused by inflammation, demyelination, and scarring.

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

(B) The absence of the knee jerk reflex suggests compression of the L3-L4 spinal nerve root. The four most commonly tested deep tendon reflexes are the Achilles (ankle jerk) reflex, quadriceps (knee jerk) reflex, triceps reflex, and biceps reflex. The nerve roots that each tests in ascending order are S 1 and 2, L3 and 4, C 5 and 6 (biceps), and C 7 and 8 (triceps). One only needs to remember that the ankle jerk is a sacral nerve root, the knee jerk is a lumbar nerve root, and the biceps and triceps are cervical nerve roots.

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

(C) The patient's unilateral symptoms are best explained by a local anatomical cause (e.g., tumor) that would be detected with an imaging study (MRI). An MRI is preferred over skull x-rays to assess directly for intracranial pathology. CNS abnormalities arising from systemic causes are more likely to be symmetric.

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

(A) The diagnosis is cluster headache as signified by episodes of severe unilateral periorbital pain accompanied by one or more of the following: ipsilateral nasal congestion, rhinorrhea, lacrimation, and redness of the eye. Horner syndrome presents with ptosis of the eyelid, meiosis or constriction of the pupil, and anhidrosis or reduced sweat secretion. Headaches associated with tumors may be worsened by exertion or postural change and may be associated with nausea and vomiting, but this is also true of migraine. Migrainous headaches generally are lateralized, may be dull or throbbing, and are sometimes associated with nausea, vomiting, photophobia, phonophobia, and blurring of vision. Migraine with aura denotes a migraine headache preceded by an abnormal sensory experience. Pseudotumor cerebri is suggested by headache, diplopia, and other visual disturbances due to papilledema and abducens nerve dysfunction.

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) Low back pain is one of the more common presenting neurologic complaints to a primary care provider. Most acute pain syndromes are benign, self-limiting conditions, with pain arising from myofascial sources. Patients with back pain and normal neurologic examinations are unlikely to have any serious underlying pathology and further diagnostic testing is usually unrevealing.

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

(D) Carpal syndrome is composed of four major components including bouts of pain in the affected wrist/hand especially prevalent during sleep hours, paresis and atrophy of the abductor pollicis brevis muscles, etc., sensory loss in the affected radial palm, and often positive Tinel/Phalen (flexion and extension of the wrist testing). Myasthenia gravis is characterized by weakness then recovery with rest. Radial nerve compression usually occurs as a result of entrapment following a crush or twisting injury to the wrist and forearm as occurs with certain jobs. And, a medial cord injury to the right brachial plexus is consistent with an ulnar nerve anomaly. Thoracic outlet syndrome may be purely vascular, purely neuropathic, or, rarely, mixed.

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) The hallmark of a subarachnoid hemorrhage is the very sudden onset of a severe headache. The headache is often described as the "worst headache of my life." A CT scan will detect a subarachnoid hemorrhage in about 93% to 100% of cases within 24 hours if a fifth-generation CT scanner is used. Studies show that small bleeds may not be found on CT scan. Furthermore, the accuracy of CT scanning finding a bleed may reduce to approximately 58% by 5 days from initial bleed. When the history suggests SAH and the CT scan fails to detect a bleed, a lumbar puncture is mandatory. The lumbar puncture may yield bloody cerebrospinal fluid indicating a subarachnoid hemorrhage, or possibly, a bloody tap. Cell counts in tubes #1 and #4 often help to clarify this point. Following neurologic consultation, admission most often occurs to allow for additional workup and management. CBC with differential, chemistries, and PT/PTT/INR may be ordered. Treatment with Imitrex is contraindicated in the presence of a potential cerebrovascular syndrome.

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

(B) The pattern of sensory, motor, and reflex findings occurring over an acute time period is consistent with Guillain-Barré Syndrome. Campylobacter jejuni bacterial infection often precedes the development of this syndrome. Diffuse diabetic peripheral neuropathy develops more insidiously than this case scenario. Multiple sclerosis presents with central nervous system (CNS) lesions that are unlikely to occur in this pattern. Myasthenia gravis causes intermittent motor symptoms without sensory involvement. Hypothyroidism may cause weakness and delayed reflexes, but is not the single best answer for this question.

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 dif iculty 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

(A) This is a typical presentation of Bell's palsy. Bell's palsy is an idiopathic facial nerve palsy that results in unilateral weakness or paralysis of the facial muscles. This results in facial drooping, decreased tearing, aching in the ear or mastoid of the affected side, taste alteration, tingling or numbness involving the cheek/mouth of the affected side, and, an inability to close the eye and to raise the affected eyebrow. Facial weakness caused by a stroke does not affect the ability to close the affected eye or to move the forehead. This weakness is characteristic of peripheral seventh nerve palsy. In a stroke, there are often other abnormalities beyond the facial nerve. Bell's palsy is often preceded or accompanied by pain around the ear. It is more common in pregnancy and in diabetics. It is believed that starting prednisone within 5 days of the onset of symptoms increases the number of patients who recover completely. The weakness or paralysis is usually maximal between 2 and 5 days. Eighty percent of patients recover in several weeks. In some cases, it may take up to 2 months to resolve. Improvement in facial motor function within the first 5 to 7 days is the most favorable prognostic sign. A CT scan of the head and neurologic consult are not indicated in this patient. Lyme disease would be a rare cause of facial nerve paralysis and is not part of the routine evaluation. Aspirin is not indicated, since this is not caused by cerebrovascular disease.

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) Status epilepticus is defined as a continuous seizure or repeated seizures for longer than 5 minutes without the patient regaining consciousness. This is a medical emergency that calls for prompt intervention to stop the seizure activity. An intravenous infusion of a longer acting benzodiazepine, such as lorazepam, has been shown to be effective in terminating a seizure. If the seizures persist, then other potential agents to use after the initial lorazepam infusion include fosphenytoin (phenytoin), phenobarbital, or valproic acid (depakote).

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

(C) The diagnosis is infectious encephalitis. Considering the advanced immunosuppression, an opportunistic infection is most likely. Toxoplasma is suggested by ring enhancement on CT. Bacterial meningitis typically presents with fever, headache, stiff neck, or altered mental status. Ischemic stroke would likely present with focal neurologic deficits and hemiplegia. Status epilepticus presents as prolonged seizure activity and is a medical emergency. Subarachnoid hemorrhage presents with sudden onset of the worst headache of life, which may lead rapidly to loss of consciousness. This would also be identified on a CT.

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

(E) Stress and mental tension are reported to be the most common precipitants for tension headache. Foods, hunger, menstruation, and odor are significantly more common triggers in patients with migraine headache.

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) The symptoms of voluntary leg movement prompted by an urge to move that is maximal at rest, worsens at night, and is relieved by movement is classic for restless legs syndrome (RLS). Although symptoms of neuropathy and RLS can be partially overlapping, the discomfort of peripheral neuropathy is more commonly associated with sensory paresthesias and sensitivity to touching of the skin and typically not relieved by movement. Lumbosacral radiculopathy, unlike RLS, is often asymmetrical and associated with lower back pain and sensory paresthesias. Nocturnal leg cramps are typically a more localized pain characterized by sudden muscle tightness that is relieved by forceful muscle stretching rather than simple movement of the legs.

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

(B) During a stroke in evolution, symptoms will worsen or new symptoms will appear. A completed stroke is one in which neurologic symptoms have stabilized, whereas a transient ischemic attack produces deficits that resolve over time. This patient's symptoms do not match those of an acute subarachnoid hemorrhage. Global cerebral ischemia as seen in sudden cardiac arrest would involve loss of consciousness. (Aminof

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

(A) The diagnosis is amyotrophic lateral sclerosis. This is a degenerative motor neuron disease that is marked by weakness and wasting of affected muscles without accompanying sensory changes. Guillain-Barré syndrome most commonly follows infective illness, inoculations, or surgical procedures. It also typically involves lower extremity weakness but will have an ascending pattern and is associated with sensory changes. Multiple sclerosis will present with episodic weakness, numbness, tingling, or unsteadiness in a limb; optic neuritis and diplopia are also common. Myasthenia gravis presents with any combination of ptosis, diplopia, difficulty in chewing or swallowing, respiratory difficulties, and limb weakness. Nonparalytic poliomyelitis presents with fever, headache, and vomiting. Signs of meningeal irritation and muscle spasm occur in the absence of frank paralysis.

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

(C) Trigeminal neuralgia is characterized by sharp, brief pain often described as "shooting, jabbing, electric shock, or stabbing." It occurs more frequently in women than men, with advancing age, and more likely on the right than left. The history given for cluster headache (typically ipsilateral ocular headaches with tearing, and lasting for 2 hours) and tension-type headache is unlike this patient's complaints. The history for temporal arteritis is generally includes ocular symptoms, but a sedimentation rate may be justified. This pain pattern is different than that of a focal dental problem.

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

(B) The patient's presentation is consistent with viral meningitis with potential encephalitis. The presence of active stomatitis indicates herpes simplex virus as the most likely causative organism. A CT of the head could be considered prior to performing a lumbar puncture and may show temporal lobe abnormalities that support a diagnosis of herpes virus encephalitis, but like an MRI will not identify the causative organism and has limited sensitivity. Of the three herpes tests described, the PCR technique is the most likely to identify the herpes simplex virus as the causative organism in the CSF due to its high sensitivity and specificity. Serum IgG indicates prior infection from herpes simplex virus but does not confirm the causative organism of the patient's encephalitis. Viral blood cultures for herpes simplex would likely show no growth even in the presence of herpes simplex virus encephalitis.

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

(A) Complex regional pain syndrome (formerly called reflex sympathetic dystrophy) is a rare disorder of the extremities characterized by autonomic and vasomotor instability. The cardinal symptoms and signs are pain localized to an arm or leg, swelling of the involved extremity, disturbances of color and temperature in the affected limb, dystrophic changes in the overlying skin and nails, and limited range of motion. Most cases are preceded by direct physical trauma, often of relatively minor nature, to the soft tissues, bone, or nerve. Radiographs eventually reveal severe generalized osteopenia. Compression of the ulnar nerve is the second most common entrapment neuropathy after carpal tunnel syndrome. The most frequent site of compression is at the elbow. Symptoms usually begin with tingling in the fourth and fifth digits of the hand. Patients suffering from thoracic outlet syndrome have pain that radiates from the point of compression to the base of the neck, axilla, arm, forearm, and hand. Paresthesias are common and distributed to the volar aspect of the fourth and fifth digits. Sensory symptoms may be aggravated at night or by prolonged use of the extremities. Weakness and muscle atrophy are the principal motor abnormalities. Vascular symptoms consist of arterial ischemia characterized by pallor of the fingers on elevation of the extremity. There is no associated osteopenia in thoracic outlet syndrome. With de Quervain's tenosynovitis, patients experience pain on grasping with their thumb. Swelling and tenderness are often present over the radial styloid process. The usual cause is repetitive twisting of the wrist.

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

(D) The symptoms of a resting tremor, bradykinesia or hypokinesia, postural instability, and rigidity are the cardinal symptoms for Parkinson disease. Difficulty with activities of daily living will usually prompt a patient to seek medical attention. Essential tremor and Wilson disease are postural tremors with different characteristics than the tremor seen in Parkinson disease. Huntington disease produces choreiform movements and has a much earlier age of onset. Progressive supranuclear palsy is characterized by an ophthalmoplegia in addition to tremor.

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

(C) This is the classic history of an epidural hematoma. The typical presentation is that of a child who sustains a blow to the head and experiences a brief loss of consciousness, followed by a lucid interval, when the child is awake and alert. As the hematoma expands, the patient experiences a headache followed by vomiting, lethargy, ipsilateral anisocoria, and contralateral hemiparesis. This condition may progress to coma and/or death if left untreated. This injury usually results from a temporal bone fracture with a laceration of the middle meningeal artery or vein and less often a tear in a dural venous sinus. Intracranial epidural hematoma may be acute (58%), subacute (31%), or chronic (11%). Epidural hematomas are treated with surgical evacuation of the clot and ligation of the bleeding vessel. Spinal cord transection should not present initially as a loss of consciousness and will affect distal motor and sensory function. Chronic subdural hematomas present more than 20 days after the trauma. Subarachnoid hemorrhage typically presents as a generalized headache without associated trauma. A grade III concussion usually involves continued improvement after consciousness is gained. The lucid period followed by worsening symptoms in this question is worrisome of more severe intracranial pathology.

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

(A) Peripheral neuropathy is a syndrome that is manifested by muscle weakness, paresthesias, decreased deep tendon reflexes, and autonomic disturbances most commonly in the hands and feet, such as coldness and sweating. There are many causes of peripheral neuropathy ranging from metabolic conditions to malignant neoplasm, rheumatoid arthritis, and drug and alcohol use. The increase in non-insulin-dependent diabetes mellitus due to obesity in the American population has increased the incidence of associated disease states.

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) The patient most likely is suffering from diabetic peripheral neuropathy (pending further testing to rule out other causes). Amitriptyline is one of several medications that may be effective in some cases of diabetic neuropathy. Cetuximab is a chemotherapeutic drug for metastatic colorectal carcinoma. Oxycodone would not be used as initial treatment of this likely chronic condition especially because of increasing drug dependence and increasing fall risk. Edrophonium is a drug used for the evaluation of myasthenia gravis. And, vitamin D is not closely associated with peripheral neuropathy.

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

(D) Wernicke-Korsakoff syndrome is the best known neurologic complication of thiamine (vitamin B1 ) deficiency. Nystagmus, ophthalmoplegia, and ataxia, along with confusion are common presenting signs and symptoms. This combination of symptoms is almost exclusively described in chronic alcoholics with thiamine deficiency. Symptoms of biotin deficiency are nonspecific and may include changes in mental status, myalgia, dysesthesias, anorexia, and nausea. Niacin deficiency, also known as pellagra, causes a symmetric hyperpigmented rash, similar in color to a sunburn. Other clinical findings are a red tongue and many nonspecific symptoms, such as diarrhea and vomiting. Neurologic symptoms include insomnia, anxiety, disorientation, delusions, dementia, and encephalopathy. Riboflavin deficiency is characterized by sore throat, hyperemia of pharyngeal mucous membranes, cheilitis, stomatitis, glossitis, normocytic-normochromic anemia, and seborrheic dermatitis. Scurvy (vitamin C deficiency) is characterized by ecchymoses, bleeding gums, petechiae, hyperkeratosis, arthralgias, and impaired wound healing.

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

(E) This presentation is classic for Alzheimer dementia. Increasing short-term memory loss, anomia, apraxia are all significant components to the constellation of progressive symptoms. There is no history of urinary incontinence, which would suggest normal pressure hydrocephalus. Depression is a possibility along with his any dementia, however, dementia would be the primary suspect to account for these symptoms. There are no other historical or examination findings suggestive of hypothyroidism.

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) Blood pressure is typically elevated at the time of presentation in acute ischemic stroke. It will decline without medication in the first few hours to days. Aggressively lowering blood pressure in an acute ischemic stroke may decrease the blood flow to the ischemic but salvageable brain tissue. This potentially salvageable brain tissue is referred to as the penumbra. Decreasing blood flow to the ischemic penumbra by acutely lowering blood pressure may result in eventual infarction of this brain tissue. Treatment of previously undiagnosed hypertension should be deferred for several days. Blood pressure should be treated if there are other indications, such as angina or heart failure. Control of blood pressure is appropriate in patients who are receiving tissue plasminogen activator (tPa) for their stroke. Blood pressure should be lowered cautiously to a systolic of less than 185 mm Hg and a diastolic of less than 110 mm Hg. This is thought to decrease the incidence of intracerebral hemorrhage in these patients.

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

(B) Pharmacologic options for Parkinson disease include dopamine agonists, anticholinergics, amantadine, monoamine oxidase type B inhibitors, levodopa/carbidopa, and catechol-O-methyltransferase inhibitors. The American Academy of Neurology determined that is reasonable to start treatment with levodopa, a dopamine precursor, or a dopamine agonist. Cholinesterase inhibitors are used in treating Alzheimer disease and glaucoma. Opioid agonists are used in opioid dependence treatment. Monoamine oxidase inhibitors and selective serotonin reuptake inhibitors are used, in general, to treat depression and anxiety. (Chisholm-Burns

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

(C) This patient's symptoms are most consistent with situational depression over the loss of his spouse. Transient memory problems can be a component of depression as a result of decreased attention and interest. Dementia is a progressive impairment of higher cognitive function, and initially, the patient's social graces are preserved. It has many causes, of which Pick disease, Creutzfeldt-Jakob disease, and Alzheimer disease are irreversible. Vitamin B12 deficiency can cause reversible form of cognitive impairment, in which the elderly are susceptible, so serum analysis of vitamin B12 should be performed in diagnostic evaluations of dementia in this population.

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) The mini-mental status examination is a useful screening test for dementia. Electroencephalogram is primarily utilized in the evaluation of seizure activity. Intelligence quotient (IQ) testing is not used in the diagnosis of dementia, although, estimating the premorbid mental ability may be useful to assess the extent of dementia present. Structural neuroimaging with a head CT or MRI scan is important for patients with acute onset of cognitive impairment and rapid neurologic deterioration. Screening for neurosyphilis with RPR is not recommended unless there is a high clinical suspicion.

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)

(B) The central cord syndrome involves loss of motor function that is more severe in the upper extremities than in the lower extremities, and is more severe in the hands. There is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function. Brown-Séquard syndrome consists of weakness and loss of posterior column function on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic function one to two levels below the lesion. Complete cord transection would affect motor and sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain with radiculopathy.

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

(C) The diagnosis is temporal arteritis. This is an arteritis of the temporal branch of the external carotid artery characterized by unilateral or bilateral headaches that may be localized to a tender temporal artery. The temporal artery may be thickened and tender and may be thrombosed and nonpulsatile late in the disease. Many patients present with malaise and have anemia and a low-grade fever. Fifty percent of patients report generalized muscle aches consistent with polymyalgia rheumatica. The most severe complication of temporal arteritis is blindness resulting from thrombosis of the ophthalmic artery. In some cases, this may be preceded by previous episodes of amaurosis fugax before the blindness becomes irreversible. Once blindness occurs in one eye, it may be prevented in the other by initiating treatment. The diagnosis is based on recognizing the clinical picture and obtaining a temporal artery biopsy. Treatment should not be delayed pending the biopsy. Early treatment with prednisone may prevent irreversible blindness. The efficacy of treatment can be measured with serial sedimentation rates. MRI and MRA have no value in establishing the diagnosis of temporal arteritis. Antiplatelet aggregating therapy would not be inappropriate but is inadequate for this diagnosis. The potentially unilateral headache should not be confused with a migraine for which Imitrex therapy would be appropriate. Lumbar puncture has no role in establishing this diagnosis.

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

(A) The patient's symptoms are consistent with pathology arising from the anterior cerebral circulation including the carotid arteries. A CT should be ordered to rule out acute hemorrhage and an erythrocyte sedimentation rate may be useful if giant cell arteritis was suspected. An MRA of the vertebral arteries would likely show deficits but is not likely to demonstrate the etiologic location of this stroke.

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

(B) The cerebrospinal fluid (CSF) analysis in bacterial meningitis includes a cloudy appearance with a markedly elevated protein and white cell content. The white cells are predominantly polymorphonuclear (PMN) leukocytes. Bacterial utilization of CSF glucose causes it to be low. Gram stain may or may not be positive for bacteria. The diagnosis of bacterial meningitis requires a culture of the CSF. CSF pressures at the time of the lumbar puncture are elevated in 90% of cases. In viral meningitis, the CSF white count is usually 1,000/mL. The cell types are lymphocytes or monocytes but early in the disease PMN leukocytes may predominate. CSF glucose is normal in viral meningitis and protein is elevated. Gram stain will be negative and the culture will show no growth. The CSF in multiple sclerosis may have a mild lymphocytosis with an increased protein concentration. CSF protein electrophoresis in multiple sclerosis shows discrete bands of IgG called oligoclonal bands. These oligoclonal bands are present in 90% of patients with multiple sclerosis. The CSF in subarachnoid hemorrhage may be grossly bloody. Because bleeding can be caused by a traumatic puncture, the red blood cell (RBC) count should be done on the first and last tubes and the counts compared. In subarachnoid hemorrhage, the RBC count will be the same, whereas in a traumatic lumbar puncture, the RBCs will not be present, or, may be markedly diminished in the last tube that is collected. The CSF in subarachnoid hemorrhage may reveal xanthochromia. This is a yellow appearance in the centrifuged CSF supernatant caused by the degradation of RBCs in the CSF. The CSF becomes xanthochromic after it has been exposed to blood for several hours.

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

(E) Gastrectomy can produce vitamin B12 deficiency which subsequently can cause a distal neuropathy. Laboratory tests with the highest yield for detecting abnormalities in patients with polyneuropathy are blood glucose and serum B12 level. Antinuclear antibodies are used to diagnose autoimmune disease which is unlikely with this presentation. Electromyography and/or nerve conduction is useful when there is no clear etiology or when symptoms are severe or rapidly progressive. Nerve biopsy is occasionally useful for diagnosing the underlying etiology of polyneuropathy. Nerve biopsy generally is reserved for patients in whom it is difficult to define whether the process is predominantly axonal or demyelinating. Lumbar puncture is helpful in identifying patients with inflammatory demyelinating polyneuropathies.

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

(D) Bitemporal hemianopsia is caused by a chiasmatic lesion. An optic nerve lesion results in complete blindness in the eye affected. A homonymous hemianopia can result from lesions in multiple areas specifically the optic tract or occipital cortex.

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) Physiologic tremor is a postural tremor that may be exacerbated by the factors outlined in this question. Both asterixis and intention tremor are also postural tremors; however, asterixis is seen in the context of metabolic encephalopathy and intention tremor during activity. Wilson disease occurs with other abnormal cerebellar findings. Hemiballismus is a choreiform movement disorder and not an oscillatory movement.

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

(C) Horner syndrome is defined by a unilateral, small pupil with mild ptosis in which pupillary response to light and accommodation is preserved. It may also be associated with ipsilateral anhydrosis. It is usually caused by some interruption in the oculosympathetic pathway. An Adie pupil is characterized by a unilateral-dilated pupil that is sluggish to direct light stimuli. An Argyll Robertson pupil usually affects both eyes, is irregular in shape, and is poorly reactive to light. A Marcus Gunn pupil constricts slower to direct light stimulation than to the consensual stimulation. Light- near dissociation is usually bilateral and consists of preserved constriction to accommodation but impaired response to light.

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

(D) The history is consistent with migraine without aura. Migraine is a headache that is defined by a pain that is usually unilateral, is pounding or will take on a pounding quality with activity, can be made worse with physical activity, and may be associated, nausea, vomiting, photophobia, and phonophobia. If the headache is preceded by an abnormal sensory experience such as a visual disturbance that lasts no longer than 60 minutes and totally remits, it is classified as a migraine with aura. Cluster headaches are usually unilateral as well but tend to be periorbital and are of shorter duration but greater intensity, often described as a stabbing pain. In addition, patients may experience ipsilateral autonomic symptoms such as epiphora, rhinorrhea, and ptosis. Tension-type headaches are mostly due to contraction of cranial and cervical muscles and are described as bilateral, tight, or squeezing in nature, and are sometimes relieved by physical activity. Medication withdrawal headaches typically present as daily, constant headaches.

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

(C) The first step in the evaluation of papilledema should be a neuroimaging study; although a brain MRI is preferred, a CT scan should be done if an MRI is not available, like in the emergency department. Lumbar puncture with measurement of opening pressure and analysis of cerebrospinal fluid should follow a normal neuroimaging study. Measurements of visual acuity and visual field testing are important while following the course of papilledema and response to treatment. Carotid ultrasound is recommended in patients with neurologic symptoms, hemiparesis, paresthesia, and acute speech and visual field defects. Temporal artery biopsy is used in the evaluation of headache associated with giant cell arteritis.

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

(A) The test described is known as asterixis, and is a finding associated with metabolic encephalopathy specifically af ecting the thalamus. Brudzinski sign is performed by passively flexing the neck of a supine patient and is more specific for ruling in/out meningeal irritation. Clonus is assessed by rapid passive plantar-dorsiflexion of the ankle followed by sustained dorsiflexion. A positive test indicates an upper motor neuron lesion. Stereognosis is assessed by having the patients recognize a familiar object placed in their hand. Hyperekplexia is the sudden loss of postural tone following a startling stimuli as may be exacerbated in thalamic lesions.

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

(C) Neisseria meningitidis and Streptococcus pneumoniae are the most common etiologic agents for bacterial meningitis in this patient's age group. So much so that many colleges and universities require a vaccine for students who live in dormitories. Her fever and the cerebrospinal fluid values are consistent with a bacterial and not a viral infectious source for the meningeal irritation.

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

(B) Recent vaccination is one potential cause of Guillain-Barré syndrome (GBS). Patients can also develop GBS after another triggering event such as infection, surgery, trauma, or bone marrow transplantation. The cause of benign essential tremor is uncertain, but it is sometimes inherited in an autosomal dominant manner. Multiple sclerosis is likely autoimmune in nature and is more common in western Europeans who live in temperate zones. Huntington disease is caused by an inherited defect in a single gene on chromosome 4. Idiopathic Parkinson disease is due to dopamine depletion in the nigrostriatal system. Although, in contrast, parkinsonism has been linked to environmental triggers such as certain toxins and carbon monoxide.

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

(D) Three cranial nerves provide efferent control of the extraocular muscles. The abducens nerve (CN VI) controls the lateral rectus. The trochlear nerve (CN IV) controls the superior oblique. The oculomotor nerve controls the superior rectus, inferior rectus, and medial rectus. This can be summarized as SO4, LR6, and the remainder 3 which means that superior oblique muscle is innervated by the trochlear nerve, the lateral rectus muscle is innervated by the abducens nerve, and the remainder of the eye muscles is innervated by the oculomotor nerve.

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

(B) The patient exhibits an asymptomatic carotid bruit. The most appropriate step would be to initiate antiplatelet aggregating therapy with daily aspirin. Arteriography would not be indicated for an asymptomatic carotid bruit. Anticoagulation with warfarin (coumadin), or any Xa inhibitor drug should be limited to symptomatic bruits manifested as multiple TIAs. Carotid endarterectomy is reserved for carotid artery stenosis that is greater than 50% to 70% in patients who have had recurrent TIAs on medical therapy. (Aminof

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