Neurology Practice Questions

Health Maintenance/Neurology Which of the following is a milestone usually achieved by a 15-month old infant? A. walks alone B. puts three words together C. feeds self well with spoon D. builds tower of seven cubes

Explanations (c) A. A 15-month-old infant should be able to walk alone. (u) B. The ability to put three words together, feed oneself well with a spoon and build a tower of seven cubes does not occur until 24 months. (u) C. See B for explanation. (u) D. See B for explanation.

Diagnostic Studies/Neurology A patient involved in a minor motor vehicle crash is brought to the emergency department by a family member who was riding in the car, but was unhurt. The family member states that the patient was unconscious for about 2 minutes, but seems "okay" now. What diagnostic procedure would be most helpful in assessing this patient? A. head CT scan B. lumbar puncture C. skull radiographs D. electroencephalogram

Explanations (c) A. A head CT scan would provide evidence of fractures and demonstrate intracranial hemorrhage and cerebral edema if present. (u) B. A lumbar puncture would not be immediately indicated, but if the patient worsens it might be a consideration. (u) C. Skull radiographs would only reveal skull fracture and not any potentially lethal intracranial injuries. (u) D. An electroencephalogram is not needed because there is no history of seizures.

Diagnosis/Neurology You are examining a patient with right-sided extremity weakness and left-sided weakness of the face. Where is the lesion? A. Brainstem B. Cerebral hemisphere C. Cerebellum D. Basal ganglia

Explanations (c) A. A patient with a unilateral sensory or weakness finding on one side of the body and contralateral finding of weakness or sensory loss of the face has a brainstem lesion. (u) B. Patients with cerebral hemisphere lesions may present with motor, sensory, visual or auditory findings depending on the lesion. (u) C. Patients with cerebellum lesions present with ataxia, intention tremor, and dysmetria. (u) D. Patients with basal ganglia lesions present with bradykinesia, akinesia, and loss of postural reflexes.

Scientific Concepts/Neurology Which of the following animals is the major cause of human rabies in the United States and, therefore, poses the highest risk? A. bats B. rabbits C. rodents D. dogs

Explanations (c) A. Bat rabies is found in practically every state and is the most common cause of human rabies in the U.S. (u) B. Rabbits, rodents, and dogs are uncommon causes of human rabies in the United States. (u) C. See B for explanation. (u) D. See B for explanation.

Diagnostic Studies/Neurology A 21 year-old male college student is admitted to the hospital with suspected meningitis. A lumbar puncture is performed. The results of the cerebrospinal fluid (CSF) analysis reveals an elevated white blood cell count of 5,000/mcL with over 90% neutrophils, a decreased glucose level of 35 mg/dL, and elevated protein level of 150 mg/dL. What is the most likely diagnosis based on these results? A. Bacterial meningitis B. Viral meningitis C. Fungal meningitis D. Tuberculous meningitis

Explanations (c) A. CSF results with bacterial meningitis reveal an elevated white count with predominance of neutrophils, a low glucose, and an elevated protein level. (u) B. CSF values in patients with viral meningitis are lymphocytic pleocytosis with normal glucose and normal or slightly elevated protein. (u) C. CSF findings in fungal meningitis include lymphocytic pleocytosis, elevated protein, and decreased glucose. (u) D. CSF findings with TB meningitis reveals elevated pressure, lymphocytic pleocytosis, elevated protein, and decreased glucose. Ref: (1)

Scientific Concepts/Neurology Which of the following neurotransmitters is decreased in early Parkinson's disease? A. Dopamine B. Serotonin C. Norepinephrine D. Acetylcholine

Explanations (c) A. Decreased dopamine levels are typical of Parkinson's disease even early in the course of the disease. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Therapeutics/Neurology Cognitive loss in Alzheimer's dementia may be delayed with which of the following medications? A. donepezil (Aricept) B. haloperidol (Haldol) C. risperidone (Risperdal) D. zolpidem (Ambien)

Explanations (c) A. Donepezil is a reversible cholinesterase inhibitor that leads to increased acetylcholine, which is necessary for learning and memory. (u) B. Haloperidol, risperidone, and other antipsychotics may be used to treat the agitation and behavioral symptoms in patients with dementia, but have significant side effects. (u) C. See B for explanation. (u) D. Zolpidem is used to treat insomnia.

Diagnostic Studies/Neurology A 2 month-old infant has had a single, generalized tonic-clonic convulsion lasting 4 to 5 minutes. There is no history of trauma and the infant had been well previously. Physical findings include a temperature of 39.6 degrees C (103.2 degrees F), a bulging tympanic membrane on the right, and an inflamed pharynx. The next most appropriate step is to A. perform a lumbar puncture. B. order x-ray studies of the skull. C. obtain an electroencephalogram. D. send home with antibiotics and an anticonvulsant.

Explanations (c) A. Febrile convulsions are uncommon under the age of 3 months. The physical findings suggest the possibility of meningitis, so lumbar puncture with CSF analysis is indicated. (u) B. See A for explanation. (u) C. See A for explanation. (h) D. See A for explanation. In addition, anticonvulsant therapy is not indicated for febrile seizures.

Scientific Concepts/Neurology The source of pain experienced during a migraine headache is a result of activation of which nerve? A. Trigeminal B. Vagus C. Optic D. Occulomotor

Explanations (c) A. Headache may result in release of neuropeptides acting as neurotransmitters at trigeminal nerve branches. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Diagnostic Studies/Neurology A 27 year-old female presents to your office for evaluation of weakness, visual loss, and sensory loss over the right great toe. These symptoms have occurred during three episodes approximately three months apart with each episode lasting about three days. Which of the following tests would be most useful in further evaluating this patient? A. MRI of the brain B. Electromyograph C. Glucose tolerance test D. Electroencephalograph

Explanations (c) A. Multiple sclerosis typically presents with relapsing weakness of the limbs, sensory loss, paresthesias, and visual changes. Diagnosis is based on history and either abnormal brain or spinal cord MRI, or visual, auditory, or somatosensory evoked electrical response. (u) B. See A for explanation. (u) C. Glucose tolerance test is used in the evaluation of diabetes mellitus. (u) D. Electroencephalograph is used to evaluate patients for possible seizure disorder.

52. Health Maintenance/Neurology What is the recommendation for primary prevention of stroke in a patient under sixty years of age with atrial fibrillation? A. No therapy is needed B. Aspirin C. Warfarin D. Maze procedure

Explanations (c) A. No therapy is recommended for primary stroke prevention in this patient. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Therapeutics/Neurology A 37 year-old female presents to the clinic for follow-up regarding her recently diagnosed tonic-clonic epilepsy. She reports no seizures or side effects since starting valproate (Depakote) at her last visit one month ago. What diagnostic study would you order to monitor this patient's treatment? Answers A. Serum amylase B. Serum creatinine C. Liver function tests D. Electroencephalogram

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Valproate may be toxic to the liver as well as cause thrombocytopenia. (u) D. See C for explanation.

Clinical Therapeutics/Neurology A 22 year-old female presents with onset of right eye vision loss 24 hours ago which has partially improved. She has experienced various widespread paresthesias, regional weakness and fatigue over the past six months. Episodes vary in location, severity and duration but invariably lead to recovery. Her exam is completely normal but MRI reveals numerous areas of periventricular gadolinium uptake. For this condition, what treatment has shown the greatest benefit with long term use? A. Interferon beta 1a (Avonex) B. Ethosuximide (Zarontin) C. Methylprednisolone (Solumedrol) D. Pyridostigmine (Mestinon)

Explanations (c) A. The interferon agents have been the longest used and best studied medications that provide the best long term benefits in multiple sclerosis. Steroids do play a role in acute exacerbations but not as long term agents. (u) B. See A for explanation. (u) C. See A for explanation. u) D. See A for explanation.

Diagnosis/Neurology A 28 year-old female presents to the clinic complaining of a "prickly sensation" that started bilaterally in her feet two days ago and difficulty walking. She now has the dysesthesia from her mid-thigh down to her toes. On physical examination she has diminished pain and temperature sensation, absent reflexes, loss of proprioception in her legs bilaterally, and muscle strength is 1+/5+ in the lower extremities and 5+/5+ in the upper extremities. What is the most likely diagnosis? A. Guillain-Barré syndrome B. Multiple sclerosis C. Myasthenia gravis D. Spinal cord compression

Explanations (c) A. The pattern of sensory, motor and reflex findings is consistent with the pathophysiology of peripheral nerve demyelination that occurs in Guillain-Barré syndrome. (u) B. Multiple sclerosis does not present as a symmetrical ascending paralysis. (u) C. Patients with myasthenia gravis tend to have intermittent symptoms that affect proximal and extraocular muscles most notably and it also lacks sensory involvement. (u) D. Although the exact type of cord transection can alter the pattern of motor and sensory findings a patient with spinal cord compression who is not in spinal shock would have hyperreflexia instead of areflexia.

Clinical Therapeutics/Neurology A 50 year-old female with a history of coronary artery disease presents to the office requesting medication for an exacerbation of her migraine headaches. She complains of migraines approximately once a month. What medication is contraindicated in this patient? A. Sumatriptan (Imitrex) B. Propranolol (Inderal) C. Droperidol(Inapsine) D. Naproxensodium(Anaprox)

Explanations (c) A. The triptans are contraindicated in patients with coronary artery disease or peripheral vascular disease and should be avoided in patients with an increased risk for stroke. All other drugs listed are not contraindicated. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Clinical Intervention/Neurology A 50 year-old male presents to the ER with a complaint of severe headaches. These headaches are unilateral and he describes the headache pain as steady and non-throbbing. He also complains of nasal congestion and rhinorrhea. He also mentions that alcohol often triggers these headaches. What do you recommend for this patient? A. High flow oxygen B. Massage C. Ibuprofen D. Propranolol

Explanations (c) A. This a description of a cluster headache (migrainous neuralgia), these headaches respond to oxygen by mask 7-10 L/min for 15 minutes. (u) B. Massage may be effective for patients with tension headaches. (u) C. Ibuprofen is helpful for the treatment of tension type headaches. (u) D. Propranolol is a preventative medication used for migraine headaches.

Diagnosis/Neurology A 55 year-old male presents with a three month history of progressive weakness in the extremities without associated sensory changes or deficits. Examination reveals widespread muscle atrophy, fasciculations and bilateral hyperactive reflexes with Babinski sign. Which of the following is the most likely diagnosis? A. Amyotrophic lateral sclerosis B. Polymyalgia rheumatica C. Myasthenia gravis D. Multiple sclerosis

Explanations (c) A. Though some variability in presentation does occur the characteristic progressive weakness without sensory changes and upper and lower motor nerve dysfunction is a hallmark of amyotrophic lateral sclerosis (ALS). (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.

Diagnostic Studies/Neurology A 37 year-old right-handed male presents with daily headaches for the past 2 months. They are worse in the morning and awaken him from sleep. In the past week, he has noticed a tendency to drop things. Neurologic examination reveals upper extremity strength of 4/5 on the right and 5/5 on the left. Which of the following is the most appropriate next step in the evaluation of this patient? A. Lumbar puncture (LP) B. Electroencephalogram (EEG) C. Magnetic resonance imaging (MRI) D. Electromyelogram (EMG)

Explanations (h) A. Lumbar puncture results would give information on the cerebrospinal fluid. In the presence of focal neurologic findings, a lumbar puncture would be contraindicated prior to an MRI. (u) B. An EEG is used in the evaluation of seizure disorders. (c) C. MRI is the most appropriate diagnostic study in the evaluation of a suspected intracranial neoplasm. (u) D. EMG is not indicated in the evaluation of a suspected intracranial neoplasm.

Clinical Intervention/Neurology A 43 year-old data entry clerk presents with a one-month history of pain and tingling in the right thumb, index finger, and middle finger. Tinel's sign and Phalen's maneuver are positive. The most appropriate intervention at this time is A. methylprednisolone (Medrol) dose pack. B. splint in neutral position. C. observation. D. surgery.

Explanations (u) A. A Medrol dose pack will have no affect on carpal tunnel syndrome. (c) B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel. (u) C. Observation will not improve symptoms. (u) D. Surgical intervention is reserved for cases unresponsive to conservative therapy.

Diagnosis/Neurology During an influenza epidemic, a 6 year-old child is seen with fever and a severe sore throat. A throat swab is taken for culture and the child is sent home. The next day, he is reported to have persistent vomiting and increased lethargy. On examination, he is delirious and disoriented. No rash is noted. His reflexes are hyperactive. The liver edge is 3 cm below the right costal margin in the midclavicular line. Which of the following is the most likely diagnosis? A. acute bacterial meningitis B. Guillain Barré syndrome C. Reye syndrome D. measles encephalitis

Explanations (u) A. Acute bacterial meningitis presents with fever, malaise, and neck stiffness. The liver is typically normal. (u) B. Guillain Barré syndrome typically presents post-Campylobacter enteritis. Signs and symptoms include an ascending weakness. No hepatomegaly is noted and reflexes are diminished. (c) C. Reye syndrome is typically post-influenza or URI. The patient develops lethargy, drowsiness, and vomiting. Babinski reflex is positive and hyperreflexia is noted. The liver is normal or enlarged. (u) D. Measles encephalitis typically presents one week after the measles rash with ataxia, vomiting, and seizures.

Clinical Therapeutics/Neurology A 70 year-old presents with headache and neck stiffness. On physical exam, the patient is febrile, Kernig's sign is present, and no rash is noted. A spinal tap reveals a white count of 250/cm3 with 100% neutrophils, total protein 250 mg/dL, and glucose 35 mg/dL. Which of the following is the most appropriate treatment? A. Acyclovir (Zovirax) B. Fluconazole (Diflucan) C. Ampicillin and ceftriaxone (Rocephin) D. Penicillin and chloramphenicol (Chloromycetin)

Explanations (u) A. Acyclovir is used to treat meningitis secondary to herpes. Viral meningitis presents with increase number of lymphocytes and elevated glucose in the CSF . (u) B. Fluconazole is used to treat fungal meningitis. Fungal meningitis, typically noted in immunocompromised hosts, presents with increase number of lymphocytes in the CSF. (c) C. Ampicillin and ceftriaxone is used to treat bacterial meningitis, secondary to Listeria monocytogenes , which is common in the elderly. Ceftriaxone will cover other common etiologic agents such as Streptococcal pneumonia (u) D. Penicillin and chloramphenicol is used to treat bacterial meningitis, secondary to Neisseria meningitidis. Bacterial meningitis due to N

Clinical Intervention/Neurology Which of the following interventions is most effective during the early stages of Alzheimer's disease? Answers A. Frequent change of caregivers in the home B. Utilization of memory aids, such as post-it notes C. Encouragement of independent activities, such as driving D. Emphasis of new learning activities, such as computer training

Explanations (u) A. Although caregiver burnout is often encountered, consistency is beneficial to a patient having difficulty with confusion. (c) B. Memory aids are extremely helpful in assisting Alzheimer patients during the early stages of the disease. (u) C. Like our shuttle driver demonstrated, most patients should consider relinquishing their license. (u) D. Pleasant activities should be emphasized, while learning new activities may be a source of frustration.

Diagnostic Studies/Neurology A 45 year-old female presents complaining of the worst headache of her life. Which of the following is the most appropriate initial diagnostic study? A. Magnetic resonance imaging (MRI) B. Computed tomography (CT) C. Electroencephalogram (EEG) D. Lumbar puncture (LP)

Explanations (u) A. An MRI is not as sensitive in detecting an acute cerebral bleed as a CT scan. (c) B. A CT scan is more sensitive in detecting cerebral hemorrhage in the first 24 to 48 hours. (u) C. Electroencephalogram (EEG) is used in the evaluation of seizures and will not assess the presence of cerebral hemorrhage. (u) D. A lumbar puncture is indicated in evaluation of suspected subarachnoid hemorrhage only if the CT scan does not establish the diagnosis.

History & Physical/Neurology What spinal nerve root is most likely affected in a patient with weak wrist extension, thumb and index finger paresthesias and diminished triceps reflex? A. Cervical 4 B. Cervical 5 C. Cervical 6 D. Cervical 7

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. In contrast, cervical 5 would be associated with deltoid and biceps weakness and diminished biceps reflex while cervical 7 would result in triceps weakness and paresthesias in the middle finger and diminished brachioradialis reflex. (u) D. See C for explanation.

Diagnostic Studies/Neurology A 53 year-old female with sudden onset "of the worst headache she has ever had" presents to the emergency department. She has a history of migraines but states that the current headache is not like her usual headaches. Results of her physical examination are unremarkable. Which of the following is the next best step in the evaluation of this patient? A. Angiogram B. CT scan C. Transcranial Doppler D. MRI

Explanations (u) A. Angiogram is necessary to define details of aneurysm and anatomic configuration, but not as an initial diagnostic study. (c) B. This patient's history is highly suggestive of subarachnoid hemorrhage. CT is best to screen for intracranial hemorrhage. It is faster than MRI and more sensitive in the first 24 hours. (u) C. Transcranial Doppler can detect cerebral artery vasospasm but cannot detect aneurysm. (u) D. MRI is not as sensitive for an acute bleed, but is appropriate for old bleeds.

Clinical Intervention/Neurology A 67 year-old female with history of hypertension, diabetes mellitus, and smoking presents to the emergency department with mild expressive aphasia, right facial weakness and mild right arm weakness. She had awakened 60 minutes ago and was speaking to her husband when her speech suddenly became difficult to understand and weakness was noted. Physical examination reveals a blood pressure of 165/85 mm Hg. A CT of the head shows no intracranial hemorrhage. Which of the following is the most appropriate intervention? A. Aspirin B. Warfarin (Coumadin) C. Tissue plasminogen activator (rt-PA) D. Clopidogrel (Plavix)

Explanations (u) A. Aspirin is used for preventative purposes and will not resolve a current embolism. (u) B. Warfarin is a preventative medicine that will not help the current situation. (c) C. IV thrombolytic therapy with recombinant tissue plasminogen activator is effective in reducing the neurological deficit in selected patient without CT evidence of intracranial hemorrhage and when administered within 3 hours after onset of ischemic stroke. (u) D. Plavix is a platelet aggregation inhibitor and used for preventative measures.

Clinical Therapeutics/Neurology Which of the following side effects is associated with long-term administration of phenytoin (Dilantin)? A. Ataxia B. Hypotension C. Osteomalacia D. Cardiac dysrhythmia

Explanations (u) A. Ataxia is associated most often with acute oral overdosage of phenytoin. (u) B. Cardiac dysrhythmia, with or without hypotension, is an expected side effect of rapid IV phenytoin administration. (c) C. Osteomalacia, or demineralization of bone, is a side effect of phenytoin that may occur after chronic administration. (u) D. See B for explanation.

Clinical Therapeutics/Neurology A 53 year-old woman recently diagnosed with Parkinson's disease has a moderate tremor. She has no other signs of disease at this time. Which of the following is the most appropriate initial treatment? A. lorazepam (Ativan) B. haloperidol (Haldol) C. ramatidine (Flumadine) D. levodopa/carbidopa (Sinemet)

Explanations (u) A. Benzodiazepines are used to treat anxiety and insomnia, but are not used to treat Parkinson's disease. (u) B. Haloperidol is used for the treatment of Tourette's syndrome, but is not indicated for the treatment of Parkinson's disease. (u) C. Ramatidine is used in the treatment of viral infections and has no role in the treatment of Parkinson's disease. (c) D. Levodopa/carbidopa is first-line therapy for the treatment of Parkinson's disease.

Clinical Therapeutics/Neurology A 28 year-old female presents with complaint of headaches for the past several months. They typically begin behind her right eye, which she describes as a combination of stabbing and pressure. She states that noise bothers her, and she experiences nausea but no vomiting. She has occasionally awakened with the pain. She admits to being under a lot of stress. Aspirin or acetaminophen does not relieve the pain. Which of the following is the best choice for initial treatment of the acute headache? A. topiramate (Topamax) B. gabapentin (Neurontin) C. propranolol (Inderal) D. sumatriptan (Imitrex)

Explanations (u) A. Beta blockers, calcium channel blockers, antiepileptic drugs, and tricyclic antidepressants have been used for the prevention of migraine headaches, but not for the acute treatment. (u) B. See A for explanation. (u) C. See A for explanation. (c) D. 5HT-receptor agonists and ergot alkaloids are effective for the acute treatment of migraine headaches if acetaminophen or nonsteroidal anti-inflammatory drugs are not effective.

Diagnosis/Neurology A 54 year-old male smoker presents to the clinic complaining of frequent vague headaches with associated vomiting that awaken him from sleep occasionally and have been present upon awakening for about two weeks. The headache typically resolves about an hour into his morning routine. The patient is afebrile. What is the most likely cause of this patient's headaches? Answers A. Cluster headaches B. Depression C. Glioblastoma D. Giant cell arteritis

Explanations (u) A. Cluster headaches can awaken patients, but are not usually "vague". (u) B. See C for explanation. (c) C. Morning headaches associated with vomiting are indicative of increased intracranial pressure and raise concern of a CNS tumor such as a glioblastoma. (u) D. Giant cell arteritis presents in the older patient with headache in the temporal region and loss of vision.

Diagnosis/Neurology A 30 year-old female presents to the office complaining of generalized weakness and reduced exercise tolerance that improves with rest. On physical examination you note the presence of bilateral eyelid ptosis, proximal muscle weakness and normal reflexes. What is the most likely diagnosis? A. Lambert-Eaton syndrome B. Organophosphate intoxication C. Multiple sclerosis D. Myasthenia gravis

Explanations (u) A. Common symptoms of Lambert-Eaton syndrome are proximal muscle weakness of lower limbs, cranial nerve findings, and depressed or absent reflexes. Patients commonly have a malignancy. (u) B. Patients with organophosphate intoxication have seizures, excessive secretions, wheezing and diaphoresis. (u) C. Patients with multiple sclerosis have multiple lesions in time and space. (c) D.Common symptoms of myasthenia gravis are fatigable weakness, ptosis, diplopia, and proximal muscle weakness. The disease is more common in women in the 2nd and 3rd decade and in men older than 60.

Diagnostic Studies/Neurology A 12 month-old in the emergency department is diagnosed with possible viral meningitis. Which of the following cerebral spinal fluid (CSF) laboratory results is most consistent with this diagnosis? A. Decreased CSF glucose level and increased protein B. Decreased CSF total protein level and very few neutrophils C. Increased CSF mononuclear cells and normal glucose D. Increased CSF C-reactive protein and normal glucose

Explanations (u) A. Decreased CSF glucose level and increased protein is consistent with bacterial meningitis. (u) B. Decreased CSF total protein level and very few neutrophils is a finding in syphilitic meningitis. (c) C. In aseptic meningitis, CSF shows mainly mononuclear cells within 6-8 hours, glucose is normal and there is normal to lower protein. (u) D. Increased CSF C-reactive protein and normal glucose is found in any inflammatory process affecting the CSF.

History & Physical/Neurology Which of the following is the most common finding of multiple sclerosis? A. facial palsy B. hearing loss C. seizures D. diplopia

Explanations (u) A. Facial palsy, hearing loss, and seizures are rare with multiple sclerosis. (u) B. See A for explanation. (u) C. See A for explanation. (c) D. Diplopia due to ophthalmoplegia is the most common presenting complaint in patients with multiple sclerosis.

History & Physical/Neurology A patient with an upper motor neuron lesion would exhibit which of the following findings? Answers A. Fasciculations B. Areflexia C. Muscular atrophy D. Spasticity

Explanations (u) A. Fasciculations, areflexia and muscle atrophy are consistent with lower motor neuron lesions. (u) B. See A for explanations. (u) C. See A for explanation. (c) D. Spasticity is an upper motor neuron lesion finding.

Diagnosis/Neurology A 37 year-old male presents with headaches for the past 2 months. They occur daily and are worse in the morning. In the past week, he has noticed a tendency to drop things from his right hand. On examination, vital signs are normal, and general examination is unremarkable. Neurologic examination reveals mild weakness of the right upper extremity compared to the left. Which of the following is the most likely diagnosis? A. focal seizure disorder B. intracerebral neoplasm C. transient ischemic attack D. amyotrophic lateral sclerosis

Explanations (u) A. Focal seizure disorder is not associated with morning headaches. (c) B. Intracerebral neoplasms may present with headaches that are worse in the morning, with improvement during the day. Focal motor or sensory loss depends upon the tumor's location. (u) C. A TIA is characterized by focal findings that resolve completely and spontaneously within 24 hours. (u) D. Amyotrophic lateral sclerosis is a degenerative disorder characterized by motor weakness, but is not associated with morning headaches.

Diagnosis/Neurology A 72 year-old patient with a history of hypertension and atrial fibrillation presents with episodes of weakness, numbness, and paresthesias in the right arm. At the same time, she notes speech difficulty and loss of vision in her left eye. These symptoms come on abruptly and clear within minutes. Physical examination is normal except for the previously known arrhythmia. Which of the following is the most likely diagnosis? A. Focal seizure B. Migraine headache C. Hypoglycemic episodes D. Transient ischemic attack

Explanations (u) A. Focal seizures usually cause abnormal motor movement rather than weakness or loss of feeling. (u) B. Patients with migraines commonly have a history of episodes since adolescence. (u) C. Hypoglycemic episodes do not present with focal neurological findings. (c) D. This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.

Diagnosis/Neurology A 32 year-old female presents with a seven month history of recurrent, brief episodes of weakness and tingling in the extremities, diplopia, and vertigo. Which of the following is the most likely diagnosis? A. Guillain-Barre syndrome B. Myasthenia gravis C. Multiple sclerosis D. Amyotrophic lateral sclerosis

Explanations (u) A. Guillain-Barre syndrome typically presents with progressive weakness that starts peripherally and proceeds centrally over a brief period of time. (u) B. Myasthenia gravis presents with weakness and fatigue in the upper limbs, cranial, and/or trunk musculature. Blurry vision and diplopia are common visual complaints and dysphagia is common. (c) C. Multiple sclerosis is most frequently seen in patients in their twenties and presents with episodes of weakness, paresthesias, and diplopia. (u) D. Amyotrophic lateral sclerosis presents with progressive weakness, fasciculations, and loss of muscle mass.

Clinical Intervention/Neurology A 73 year-old female patient was diagnosed 3 years ago with Alzheimer's disease and heart failure. Her 80 year-old husband can no longer help feed and bathe her or manage her medications. Which of the following support services is most appropriate for this patient? A. hospice care B. senior center C. adult day care D. skilled nursing facility

Explanations (u) A. Hospice care is a program to provide palliative care to individuals who are terminally ill and projected to die within 6 months. (u) B. Senior centers are community-based facilities that provide recreational activities and mid-day meals for functional adults. (u) C. Adult day health care is designed to meet the needs of functionally impaired adults in a community setting, but does not usually provide for the higher level of care that is required to feed or bathe a patient. (c) D. A skilled nursing facility is appropriate for patients requiring assistance with activities of daily living (i.e., feeding and bathing) and a higher level of safety assurance.

Diagnosis/Neurology A 37 year-old male presents with daytime fatigue and drowsiness. He states that he does not sleep well, with frequent awakenings during the night. He has gained 8 pounds over the past six months, and he complains of palpitations. His wife states that he snores at night. A home nocturnal pulse oximetry indicates that his saturation drops 6% intermittently throughout the night. Which of the following is the most likely diagnosis? A. depression B. narcolepsy C. hypothyroidism D. obstructive sleep apnea

Explanations (u) A. Hypothyroidism, narcolepsy, and depression are not associated with oxyhemoglobin desaturation or snoring. (u) B. See A for Explanation. (u) C. See A for Explanation. (c) D. Obstructive sleep apnea is associated with obesity, nighttime wakening and snoring, hypertension, cardiac dysrhythmias, and oxyhemoglobin desaturation of greater than 4% during hypopnea or apnea.

Clinical Therapeutics/Neurology A 38 year-old female has a 10 year diagnosis of migraine headaches. She had been using ergotamine to abort her headaches, but is now having one or two headaches per week that are interfering with work. Which of the following is the most appropriate preventive therapy? A. Sumatriptan (Imitrex) B. Promethazine (Phenergan) C. Propranolol (Inderal) D. Ketorolac (Toradol)

Explanations (u) A. Imitrex is not approved for preventive therapy but is used as abortive therapy. (u) B. Phenergan is an antiemetic that helps with nausea and vomiting for people who get migraines. It is not a preventive medication. (c) C. Propanolol is one beta blocker that is frequently used as a first-line prophylaxis for migraines. (u) D. Ketorolac is not indicated for scheduled, daily use as a preventive for migraines.

Diagnosis/Neurology A patient describes a history of intermittent and uncontrollable twitching of his right hand that spreads to involve the entire arm after a few minutes. Afterward, the arm is extremely weak. There are no other areas of involvement, sensory deficit or altered consciousness. What is the most likely seizure diagnosis? A. Absence B. Complex-partial C. Simple-partial D. Myoclonic

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. The lack of altered consciousness and focal motor symptoms are strongly indicative of this type of seizure. (u) D. See C for explanation.

History & Physical/Neurology Upon stroking of the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan. This is a positive A. Kernig's sign. B. Brudzinski's sign. C. Babinski's sign. D. Gower's sign.

Explanations (u) A. Kernig's sign is positive when pain is noted on straightening the knee after flexing both the hip and knee. (u) B. Brudzinski's sign occurs with neck flexion resulting in resultant flexion of the hips. It is a sign of meningeal irritation. (c) C. A Babinski test is performed by stroking the lateral aspect of the sole from the heel to the ball of the foot, the great toe dorsiflexes and the other toes fan in a positive test. (u) D. A positive Gower's sign is noted in certain types of muscular dystrophy and is described as children rising to stand by rolling over prone and pushing off the floor with arms while the legs remain extended.

Clinical Intervention/Neurology A 45 year-old male patient presents to the office with a complaint of dizziness and vertigo that occurs suddenly when he rolls out of bed in the morning. He denies previous illness or any medical problems. On physical exam you note the presence of lateral nystagmus after a few second latency period. What is your recommendation for this patient? A. Low dose diazepam B. Repositioning maneuvers C. Diuretics and a low salt diet D. MRI of the brain

Explanations (u) A. Low dose diazepam is used to treat acute vertigo. (c) B. This patient has benign paroxysmal positional vertigo (BPPV) and repositioning maneuvers are recommended to move endolymphatic debris out of the posterior semicircular canal. (u) C. Diuretics and a low salt diet are used to treat Meniere's disease. (u) D. An MRI of the brain should be ordered in a patient in whom a central etiology of vertigo is suspected.

Clinical Therapeutics/Neurology Which of the following is first-line treatment for acute inflammatory demyelinating polyneuropathy variant of Guillain- Barre? A. Neostigmine B. IV Solu-Medrol C. Phenytoin D. IV immunoglobulin

Explanations (u) A. Neostigmine may be used for a more chronic variant for symptoms, but not in acute inflammatory variant. (u) B. Treatment with corticosteroids is ineffective and may prolong recovery time. (u) C. Phenytoin may be used for ongoing neuropathic pain, but is not useful in any type of acute neuropathy. (c) D. IV immunoglobulin is effective in patients with Guillain-Barre.

History & Physical/Neurology The most frequent finding in a person presenting with a brain abscess is A. nuchal rigidity. B. headache. C. seizures. D. vomiting.

Explanations (u) A. Nuchal rigidity occurs in approximately 35% of patients with a brain abscess. (c) B. Headache occurs in over 70% of patients with a brain abscess. (u) C. Seizures occur in approximately 35% of patients with a brain abscess. (u) D. Vomiting occurs in approximately 35% of patients with a brain abscess.

Diagnosis/Neurology A 70 year-old male is brought to the office by his wife. She is complaining that her husband has been having great difficulty remembering things, however remains alert. She also complains that he is having difficulty getting to the bathroom on time. On physical examination you notice that the patient's gait is wide-based and slow and he walks without lifting his feet off the floor. You also notice a tremor in his right hand. What is the most likely diagnosis? A. Lewy body dementia B. Parkinson's disease C. Normal pressure hydrocephalus D. Frontotemporal dementia

Explanations (u) A. Patients with Lewy body dementia have hallucination, Parkinsonism, fluctuating alertness, and falls. (c) B. Patients with Parkinson's disease have clinical features such as bradykinesia, rest tremor, rigidity, postural instability, autonomic dysfunction and behavioral changes. Of the diseases listed, Parkinson's is the most common. (u) C. Patients with normal pressure hydrocephalus have an abnormal gait (apraxic or ataxic), dementia, and urinary incontinence. (u) D. Patients with frontotemporal dementia have predominant behavioral symptoms, dementia, apraxia, Parkinsonism, and motor neuron disease.

History & Physical/Neurology A 75 year-old male presents to the ER with the following stroke findings: right-sided hemiparesis (face and hand more affected than leg), homonymous hemianopsia of the right half of both visual fields, and aphasia. Where is the location of his stroke? A. Anterior cerebral artery B. Middle cerebral artery C. Posterior cerebral artery D. Internal carotid artery

Explanations (u) A. Patients with anterior cerebral artery stroke will have findings greater in the legs than hands. (c) B. This case is a description of a middle cerebral artery stroke. (u) C. Posterior cerebral artery stroke patients will have midbrain and thalamic or sensory findings. (u) D. Internal carotid artery stroke patients will have amaurosis fugax, visual disturbances and crossed symptoms.

Clinical Therapeutics/Neurology A 72 year-old man with long-standing diabetes mellitus, renal insufficiency and hypertension presents to the clinic complaining of burning and tingling pain in his feet. What agent would you prescribe to help control his pain? Answers A. Phenobarbital B. Amitriptyline (Elavil) C. Celecoxib (Celebrex) D. Codeine

Explanations (u) A. Phenobarbital is used in the treatment of seizure disorder. (c) B. Amitriptyline is one of several preferred agents for management of peripheral neuropathy. (u) C. Although Cox-2 inhibitors may provide pain relief they are best avoided for treatment of this chronic disorder in a patient with renal disease. (h) D. It is best to avoid narcotics in the management of chronic pain if other efficacious medicines are available.

Clinical Therapeutics/Neurology What is the recommended treatment for absence (petit mal) seizures? A. Phenytoin (Dilantin) B. Carbamazepine (Tegretol) C. Ethosuximide (Zarontin) D. Gabapentin (Neurontin)

Explanations (u) A. Phenytoin is used to treat tonic clonic and partial seizures. (u) B. Carbamazepine is used to treat tonic clonic and partial seizures. (c) C. Ethosuximide, valproic acid, and clonazepam are recommended treatments for absence seizures. (u) D. Gabapentin is used to treat partial seizures.

Clinical Intervention/Neurology A 30 year-old male has a history of weakness without pain on the left side of his face for the past 4 days. Physical examination of the face reveals unilateral weakness to the left side, but not complete paralysis. The left eye does not close completely. The most appropriate initial treatment is to A. begin physical therapy. B. refer for surgical ablation. C. reassure patient and provide patient education. D. initiate high dose steroids and recheck in 24 hours.

Explanations (u) A. Physical therapy is not indicated for Bell's palsy (u) B. Surgery has not been shown to provide any significant benefit in the treatment of Bell's palsy. (c) C. Bell's palsy is usually a self-limited condition and typically resolves within a few weeks. (u) D. Corticosteroids may be used if paralysis is complete or there is significant pain, but are not first-line.

Clinical Therapeutics/Neurology What is the appropriate initial intravenous drug therapy for a patient in status epilepticus? Answers A. Midazolam (Versed) B. Lorazepam (Ativan) C. Fosphenytoin (Mesantoin) D. Phenobarbital

Explanations (u) A. See B for explanation. (c) B. A benzodiazepine (lorazepam) is first line in the treatment of status epilepticus, followed by phenytoin or fosphenytoin. (h) C. See B for explanation. (h) D. This answer is potentially harmful because the patient is currently seizing and lorazepam is indicated.

Clinical Therapeutics/Neurology A 7 year-old is evaluated for episodes of unresponsiveness in which she stares, blinking into space. Episodes last only 10-20 seconds but may happen several times daily. There are no abnormal movements, sensory loss or headaches reported. Which of the following is considered first-line therapy for this disorder? A. Carbamazepine (Tegretol) B. Ethosuximide (Zarontin) C. Gabepentin (Neurontin) D. Topiramate (Topamax)

Explanations (u) A. See B for explanation. (c) B. Absence seizures are usually treated successfully with Ethosuximide. The other agents listed are not indicated and may actually worsen this type of seizure. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Intervention/Neurology Treatment of Bell's palsy includes which of the following? A. Acyclovir B. Reassurance of the patient's recovery C. Referral to a neurosurgeon D. Electromyography

Explanations (u) A. See B for explanation. (c) B. Bell's palsy is a peripheral neuropathy of cranial nerve VII. Although it has been suggested it may be related to an activation of herpes simplex virus, there is little empiric evidence for this. Approximately 60% of cases of Bell's palsy recover without treatment and patient reassurance of this is advised. Electromyography may provide aid in the prognosis, but not as a treatment option. A neurosurgeon has no role in the management of Bell's palsy. (u) C. See B for explanation. (u) D. See B for explanation.

Scientific Concepts/Neurology A 58 year-old truck driver is found to have a positive Romberg test and loss of vibratory sensation in his lower extremities. What anatomical structure is the likely affected? Answers A. Cerebellum B. Posterior column C. Sensory cortex D. Vestibular apparatus

Explanations (u) A. See B for explanation. (c) B. Posterior column is responsible for vibratory sensation and proprioception. Romberg test is a general test of proprioception with disease of the cerebellum, vestibular apparatus or posterior column being the most likely source. (u) C. The bilateral lower extremity findings make a lesion of the sensory cortex unlikely. (u) D. See B for explanation.

History & Physical/Neurology A 64 year-old right-handed woman presents to the emergency room. The patient is pleasant and cooperative, but you note that the left side of her mouth has little movement as she talks, resulting in some dysarthric speech. On physical examination, the left side of her mouth droops, eyebrows raise symmetrically, frown is symmetric, and eyes close but left offers little resistance to opening. You suspect which of the following? A. Upper motor neuron damage to CN VII (central facial palsy) in left hemisphere B. Upper motor neuron damage to CN VII (central facial palsy) in right hemisphere C. Lower motor neuron damage to CN VII (Bell's palsy) on the left D. Lower motor neuron damage to CN VII (Bell's palsy) on the right

Explanations (u) A. See B for explanation. (c) B. The upper face is controlled by pathways from both sides of the face. Upper motor neuron lesions cross, findings on the left are due to lesions on the right. Lower motor neuron lesions of the face are ipsilateral. (u) C. See B for explanation. (u) D. See B for explanation.

History & Physical/Neurology What term is given to an ocular examination finding where small, irregular pupils are seen that react with near vision but not to light? A. Amaurosis fugax B. Argyll-Robertson C. Anisocoria D. Optic neuritis

Explanations (u) A. See B for explanation. (c) B. This finding may be seen in diabetes or in cases of neurosyphilis whereas amaurosis fugax is vision loss due to a central lesion, anisocoria has unequal sized pupils, unilateral loss of vision due to multiple sclerosis. (u) C. See B for explanation. (u) D. See B for explanation.

Diagnostic Studies/Neurology A 74 year-old female is being treated for mild hypertension. She is found at home with right hemiparesis and brought to the emergency department. Her daughter states that the patient fell in her kitchen 2 days ago, but had no complaints at that time. She did state that her mother sounded a little confused this morning. The patient's left pupil is dilated. Which of the following diagnostic studies should be ordered first? A. MRI of the brain B. CT scan of the brain C. Skull x-ray D. Lumbar puncture

Explanations (u) A. See B for explanation. (c) B. This patient presents with a history of minor trauma and progressive neurological abnormalities consistent with subdural hematoma. Diagnosis would be confirmed by CT scan, which is less expensive and more sensitive for blood than an MRI. (u) C. Skull x-rays would not be helpful because they evaluate bony, not soft tissue, injury. (h) D. A lumbar puncture is contraindicated because of the potential for brain herniation.

Health Maintenance/Neurology Household contacts of a patient with bacterial meningitis are best treated with which of the following? A. Amoxicillin (Amoxil) B. Ciprofloxin (Cipro) C. Tetracycline (Sumycin) D. Vancomycin (Vancocin)

Explanations (u) A. See B for explanation. (c) B. Rifampin, Cipro, Levaquin, Zithromax and Rocephin are the drugs of choice. (u) C. See B for explanation. (u) D. See B for explanation.

Clinical Therapeutics/Neurology A 27 year-old female presents with 5-6 headaches monthly for the past year that are described as severe, throbbing and initially unilateral. They is associated with nausea, photophobia and phonophobia. There have been no concomitant sensory or motor deficits. Her physical examination and brain MRI are normal. What treatment would be best to reduce the frequency of the headaches? A. Sumatriptan (Imitrex) B. Isometheptene (Midrin) C. Propranolol (Inderal) D. Hydrocodone (Vicodin)

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Each medication listed can be used in the management of migraine headaches, however only propranolol is indicated for reducing the frequency of migraine headaches. (u) D. See C for explanation.

Diagnostic Studies/Neurology A 22 year-old male presents to the clinic complaining of excessive daytime somnolence and strong desires to sleep at inappropriate times. He came in today because he had an episode of "feeling paralyzed" as he was falling asleep yesterday. What is the most appropriate diagnostic test to confirm this patient's diagnosis? Answers A. MRI of the brain B. Electroencephalogram C. Multiple sleep latency test D. Overnight polysomnography

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Multiple sleep latency test is required to observe the abrupt transition to REM sleep and establish the diagnosis of narcolepsy. (u) D. See C for explanation.

Diagnosis/Neurology Seizures that first manifest in early to middle adult life should be considered suspicious of which of the following causes? A. Cerebrovascular disease B. Encephalitis C. Tumor D. Idiopathic epilepsy

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal. (u) D. See C for explanation.

Scientific Concepts/Neurology A patient complains of loss of sensation at the level of the umbilicus. Which of the following dermatomes is affected? A. T6 B. T8 C. T10 D. T12

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. The dermatome T10 is at the level of the umbilicus. (u) D. See C for explanation.

History & Physical/Neurology A 73 year-old male presents to the clinic with his wife. His wife has noticed that he has developed a resting tremor in his right hand and a shuffling gait over the last year. What finding on physical examination would support your suspected diagnosis? Answers A. Chorea B. Dystonia C. Masked facies D. Hyperreflexia

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech. (u) D. See C for explanation.

Clinical Intervention/Neurology A 50 year-old female has a history of severe, stabbing pains, lasting only seconds, over the cheek and chin areas. She also experiences intense pain in these areas with chewing, washing her face and even with smiling. Examination reveals no sensory or motor deficits. Head computer tomography (CT) and erythrocyte sedimentation rate (ESR) are normal. She has been unresponsive to maximum doses of carbamazepine. What is the next best option for this patient? A. Combination simvastatin (Zocor) and sertraline (Zoloft) B. Bilateral deep brain stimulation C. Stereotactic (Gamma knife) radiosurgery D. High dose corticosteroid therapy

Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Trigeminal neuralgia is generally responsive to Carbamazepine however, for those who fail to respond to medicinal therapy surgery is the next valid option. Though there are various procedures, Stereotactic (Gamma knife) radiosurgery has provided the best results. (u) D. See C for explanation.

Clinical Intervention/Neurology A 23 year-old patient presents with two days of fatigue, headache, fever and pain around the area in which she was bitten by a stray baby raccoon in an unprovoked attack 10 days ago. She cleaned the small wound thoroughly. Which of the following is the most appropriate intervention in this patient? A. Do nothing and treat her symptoms B. Human diploid cell rabies vaccine, 5 injections given all at once now C. Rabies immunoglobulin only D. Rabies immunoglobulins and human diploid cell rabies vaccine given 5 times in a 1-month period

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Bites by bats, skunks, and raccoons always require this regimen if the animal is not caught and tested.

Scientific Concepts/Neurology You have just stuck yourself with a sharp needle. In order for you to be able to interpret this sensation, which of the following areas must be intact? A. Anterior spinothalamic tract, basal ganglia, and sensory cortex B. Corticospinal tract, medulla, and basal ganglia C. Pyramidal tract, hypothalamus, and sensory cortex D. Lateral spinothalamic tract, thalamus, and sensory cortex

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Sensory impulses reach the sensory cortex from the spinothalamic tract or the posterior columns. Fibers transmit this to the thalamus which sends impulses to the sensory cortex of the brain

Diagnosis/Neurology A 51 year-old female presents to the clinic complaining of intermittent sharp pain that originates at the corner of her mouth and radiates toward her ipsilateral eye. She notes "everything makes it worse" including touching the area, talking and eating. What is the most likely diagnosis? Answers A. Bell's palsy B. Cluster headache C. Post-herpetic neuralgia D. Trigeminal neuralgia

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. This is the classic presentation for trigeminal neuralgia (tic douloureux).

History & Physical/Neurology In addition to tremor, which of the following are cardinal symptoms of Parkinson disease? A. Cognitive decline and rigidity B. Personality change and bradycardia C. Eye movement abnormalities and hyperkinesias D. Rigidity and bradykinesia

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Tremor, rigidity, bradykinesia and postural instability are the cardinal features of Parkinsonism and may be present in any combination.

Clinical Intervention/Neurology A 26 year-old female reports progressive distal to proximal spread of extremity weakness over the last 36 hours without fever, headache or syncope. Examination reveals symmetrical, paresis of the hands and feet with loss of the brachioradialis and Achillis reflexes. Biceps and knee reflexes are present but diminished. Sensory exam is normal. What are the most likely findings on cerebral spinal fluid (CSF) analysis? A. Decreased glucose, increased WBC count and decreased protein B. Increased glucose, normal WBC count and normal protein C. Normal glucose, decreased WBC count and elevated protein D. Normal glucose, normal WBC count and elevated protein

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Guillain-Barre syndrome is typified by progressive symmetrical, distal to proximal spread of weakness and areflexia without fever or sensory deficits. CSF analysis shows elevated protein due to axonal demyelination but no glucose disturbances and no significant or sustained pleocytosis.

Diagnosis/Neurology An 8 year-old male presents with episodes described as 20-second lapses of awareness during which he blinks his eyes. After these attacks, he resumes his previous activity. Which of the following is the most likely diagnosis? A. Tonic-clonic seizure B. Myoclonic seizure C. Absence seizure D. Focal seizure

Explanations (u) A. Tonic-clonic seizures are associated with a loss of consciousness, tonic-clonic movements, and postictal confusion or sleep. (u) B. Myoclonic seizures are associated with mild myoclonic jerks of the neck and shoulder flexor muscles when falling asleep. (c) C. Absence seizures are characterized by lapses of consciousness associated with postictal confusion. (u) D. Focal seizures are associated with motor or sensory symptoms involving any portion of the body.

Clinical Therapeutics/Neurology A patient with known relapsing-remitting multiple sclerosis (MS) presents to the hospital with an exacerbation of MS symptoms. What is the recommended treatment? A. Baclofen (Lioresal) B. Interferon C. Glatiramer acetate (Copaxone) D. Methylprednisolone

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Acute relapses of MS are treated with a short course of IV methylprednisolone followed by oral prednisone. This regimen reduces the severity and shortens the duration of attacks. All other drugs listed are used to reduce the attack rate of relapsing remitting multiple sclerosis.

Diagnosis/Neurology A 57 year-old male presents with episodic diplopia over the past two months. Symptoms progressed over the last two days with the onset of bilateral facial weakness made worse with repetitive use. Weakness improves somewhat with rest. He denies fever, headache or areas of pain. Exam reveals a nasal voice, drooping eyelids and a normal sensory exam. Which of the following is the most likely diagnosis? A. Multiple sclerosis B. Guillain-Barre syndrome C. Lambert-Eatonsyndrome D. Myastheniagravis

Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Episodic diplopia progressing to proximal weakness worsened by repetition and lacking sensory deficits is typical of myasthenia gravis. In Lambert-Eaton syndrome muscular responses actually improve with repetition and the weakness in Guillain-Barre syndrome always begins peripherally.

History & Physical/Neurology A mother brings in her 4 year-old son with complaints that he falls frequently and he "stands funny". The mother also notes that he has lost the ability to easily stand from a seated position. She reports that he met developmental milestones as an infant. Which of the following is the most likely cause? A. Developmental hip dysplasia B. Myasthenia gravis C. Cerebral palsy D. Muscular dystrophy

Explanations (u) A. Signs and symptoms of developmental hip dysplasia would have been present more at birth and when beginning to crawl and walk. (u) B. Myasthenia gravis (MG) is less likely due to age and MG typically affects the ocular, pharyngeal and respiratory muscles. (u) C. Cerebral palsy (CP) typically presents with ataxia, spasticity or tightness, and uncoordination. Patients with CP typically do not meet developmental milestones. (c) D. Muscular dystrophy age of onset is by age 5, and begins in the pelvic girdle.

History & Physical/Neurology Topic: 3 Author: Which of the following primitive reflexes should begin to disappear at about 2 months of age in a normal infant? A. Moro B. Grasp C. Tonic neck D. Parachute

Explanations (u) A. The Moro reflex starts to disappear at about 5-6 months of age. (c) B. The grasp reflex starts to disappear at about 2-3 months of age. (u) C. The tonic neck reflex starts to disappear at about 6-7 months of age. (u) D. The parachute reflex remains throughout life.

Health Maintenance/Neurology A 45 year-old man presents for a routine appointment. He tells you his mother and father have both had ischemic strokes in their 70's. He does not smoke. His blood pressure is 128/80 mmHg, pulse 78/minutes and regular, respiratory rate of 12/minute. What diagnostic studies would you order to further evaluate this patient's risk of stroke? Answers A. Electrocardiogram B. Fasting lipid profile C. Carotid Doppler ultrasound D. MRI with gadolinium

Explanations (u) A. The main risk factor assessed by ECG is atrial fibrillation and this patient's regular pulse confirms he is currently not in atrial fibrillation (c) B. Hyperlipidemia is a known risk factors for stroke that can be modified with treatment. (u) C. The patient does not have signs or symptoms of carotid stenosis at this point. (u) D. An MRI with gadolinium would be useful in evaluating for the presence of Berry aneurysms, but the history of ischemic strokes does not raise the concern of an aneurysm.

Clinical Intervention/Neurology An 82 year-old male is brought to the ED after being found unresponsive in his apartment. On physical exam his pupils are 7 mm on the right and 3 mm on the left. your initial choice in managing this patient? Answers A. Order a CBC, electrolytes, and toxicology screen B. Order a CT of the head C. Hyperventilate the patient D. Administer streptokinase

Explanations (u) A. The patient has PE findings that are asymmetric. This is consistent with an anatomical abnormality and not a systemic disorder. (c) B. This presentation is consistent with a structural abnormality that will be detected on an imaging study. (h) C. Prophylactic hyperventilation is not recommended because cerebral perfusion pressure can be decreased and cause further injury to the brain. (h) D. Streptokinase is not indicated due to possibility of a hemorrhagic event.

Clinical Therapeutics/Neurology Which of the following drugs is the first choice for insomnia in an elderly patient? A. Barbiturates B. Cholinesterase inhibitors C. Benzodiazepines D. Beta-blockers

Explanations (u) A. The use of barbiturates is obsolete and these agents may actually disrupt the sleep cycle. (u) B. Cholinesterase inhibitors are used in the treatment of Alzheimer's, but have no effect on insomnia. (c) C. Benzodiazepines are the drugs of choice for insomnia in the elderly population. (u) D. Beta-blockers have no use in the treatment of insomnia.

iagnostic Studies/Neurology An 18 year-old male is involved in a motor vehicle accident with a question of cervical spine fracture. What is the imaging test of choice to initially evaluate this patient and clear his cervical c-spine? A. Positron emission tomography B. Magnetic resonance imaging C. Computed tomography D. Lateral radiograph

Explanations (u) A. There is no role for positron emission tomography in suspected cervical spine injury. (u) B. MRI and CT of the spine may be performed in the setting of acute cervical spine injury when a major fracture or dislocation is identified. (u) C. See B for explanation. (c) D. Cervical spine x-rays are most commonly used as the initial screen for cervical spine injury. A cervical spine series consists of a lateral view, anteroposterior (AP) view, and an odontoid view. The lateral view detects up to 80% of traumatic spine injuries.

Diagnosis/Neurology A 75 year-old male presents for a routine physical. Vitals are normal with no orthostatic changes. On physical examination, a fine cortical movement with repetitive rubbing of the tip of the thumb along the tips of the fingers is noted at rest. Which of the following is the most likely diagnosis? A. Seizure disorder B. Peripheral neuropathy C. Shy-Drager syndrome D. Parkinson's disease

Explanations (u) A. While a seizure may present with fine or gross uncontrolled motor movements, the tremor described is classic pill-rolling tremor noted in Parkinson's disease. (u) B. Peripheral neuropathy presents with loss of sensation not tremor. (u) C. Shy-Drager syndrome is due to autonomic degeneration and typically presents with orthostatic hypotension. (c) D. Parkinson's disease presents with tremor at rest (pill-rolling), bradykinesia, rigidity, and postural instability.

Diagnostic Studies/Neurology What test is the single most useful test in establishing the diagnosis of multiple sclerosis? Answers A. Cerebral spinal fluid cell count and protein level B. Cerebral spinal fluid immunoglobulin studies C. Evoked potentials D. Magnetic Resonance Imaging

Explanations (u) A. While cerebral spinal fluid cell count, protein levels, and immunoglobins may be abnormal they are not specific for multiple sclerosis. (u) B. See A for explanation. (u) C. Evoked potentials are most useful in the detection of subclinical involvement of neuropathways in MS, but does not establish the diagnosis. (c) D. The presence of plaques on MRI is a key finding in establishing the diagnosis of MS.

Health Maintenance/Neurology A 53 year-old female has a diagnosis of migraine headaches. She had been using sumatriptan (Imitrex) to abort her headaches, but she is now having one or two headaches per week. The most appropriate preventive therapy is A. zolmitriptan (Zomig). B. promethazine (Phenergan). C. propranolol (Inderal). D. fluoxetine (Prozac).

Explanations (u) A. Zolmitriptan, another 5-HT receptor agonist, is used acutely to abort migraine headaches. (u) B. Promethazine is an antiemetic that may be used to alleviate nausea and vomiting from an acute migraine. (c) C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely. (u) D. Fluoxetine is an SSRI that is used in the treatment of anxiety and obsessive-compulsive disorders.