Neurology SMARTY PANCE
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
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.
A 28-year-old female presents with complaints 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 the initial treatment of the acute headache? A topiramate (Topamax) B gabapentin (Neurontin) C propranolol (Inderal) D sumatriptan (Imitrex)
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.
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
A 15-month-old infant should be able to walk alone.
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.
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.
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)
A CT scan is more sensitive in detecting cerebral hemorrhage in the first 24 to 48 hours.
What is the appropriate initial intravenous drug therapy for a patient in status epilepticus? A Midazolam (Versed) B Lorazepam (Ativan) C Fosphenytoin (Mesantoin) D Phenobarbital
A benzodiazepine (lorazepam) is first line in the treatment of status epilepticus, followed by phenytoin or fosphenytoin.
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
A head CT scan would provide evidence of fractures and demonstrate intracranial hemorrhage and cerebral edema if present.
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
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.
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
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.
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
Absence seizures are characterized by lapses of consciousness associated with postictal confusion
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)\
Absence seizures are usually treated successfully with Ethosuximide. The other agents listed are not indicated and may actually worsen this type of seizure.
A 72-year-old man with a long-standing history of diabetes mellitus, renal insufficiency, and hypertension presents to the clinic complaining of burning and tingling pain in his feet. Which of the following medications would help control pain in this patient? A Phenobarbital B Amitriptyline (Elavil) C Celecoxib (Celebrex) D Codeine
Amitriptyline has been recommended for pain associated with diabetic neuropathy.
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? A Phenobarbital B Amitriptyline (Elavil) C Celecoxib (Celebrex) D Codeine
Amitriptyline is one of several preferred agents for management of peripheral neuropathy.
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)
Ampicillin and ceftriaxone are 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
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
Bat rabies is found in practically every state and is the most common cause of human rabies in the U.S.
Treatment of Bell's palsy must include which of the following? A Acyclovir B Reassurance of the patient's recovery C Referral to a neurosurgeon D Electromyography
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.
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.
Bell's palsy is usually a self-limited condition and typically resolves within a few weeks.
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
Benzodiazepines are the drugs of choice for insomnia in the elderly population.
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 four times in a 1-month period
Bites by bats, skunks, and raccoons always require this regimen if the animal is not caught and tested. It is given in four doses on days 0,3,7, and 14.
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
CSF results with bacterial meningitis reveal an elevated white count with predominance of neutrophils, a low glucose, and an elevated protein level.
An 18-year-old male is involved in a motor vehicle accident with a question of a 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
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.
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
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.
Which of the following neurotransmitters is decreased in early Parkinson's disease? A Dopamine B Serotonin C Norepinephrine D AcetylcholineHint: See answer for explanation.
Decreased dopamine levels are typical of Parkinson's disease even early in the course of the disease.
Which of the following is the most common finding of multiple sclerosis? A facial palsy B hearing loss C seizures D diplopia
Diplopia due to ophthalmoplegia is the most common presenting complaint in patients with multiple sclerosis.
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)
Donepezil is a reversible cholinesterase inhibitor that leads to increased acetylcholine, which is necessary for learning and memory.
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)
Each medication listed can be used in the management of migraine headaches, however only propranolol is indicated for reducing the frequency of migraine headaches.
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
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.
What is the recommended treatment for absence (petit mal) seizures? A Phenytoin (Dilantin) B Carbamazepine (Tegretol) C Ethosuximide (Zarontin) D Gabapentin (Neurontin)
Ethosuximide, valproic acid, and clonazepam are recommended treatments for absence seizures.
A patient with an upper motor neuron lesion would exhibit which of the following findings? A Fasciculations B Areflexia C Muscular atrophy D Spasticity
Explanation: Spasticity is an upper motor neuron lesion finding.
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
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.
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 the loss of the brachioradialis and Achilles reflexes. Biceps and knee reflexes are present but diminished. The 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
Guillain-Barre syndrome is typified by progressive symmetrical, distal to the 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.
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
Headache may result in the release of neuropeptides acting as neurotransmitters at trigeminal nerve branches.
The most frequent finding in a person presenting with a brain abscess is A nuchal rigidity. B headache. C seizures. D vomiting.
Headache occurs in over 70% of patients with a brain abscess.
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? A Electrocardiogram B Fasting lipid profile C Carotid Doppler ultrasound D MRI with gadolinium
Hyperlipidemia is a known risk factors for stroke that can be modified with treatment.
Which of the following is a first-line treatment for acute inflammatory demyelinating polyneuropathy variant of Guillain- Barre? A Neostigmine B IV Solu-Medrol C Phenytoin D IV immunoglobulin
IV immunoglobulin is effective in patients with Guillain-Barre
A 67-year-old female with a 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)
IV thrombolytic therapy with recombinant tissue plasminogen activator is effective in reducing the neurological deficit in select patients without CT evidence of intracranial hemorrhage and when administered within 3 hours after onset of ischemic stroke.
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
In aseptic meningitis, CSF shows mainly mononuclear cells within 6-8 hours, glucose is normal and there is normal to lower protein.
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
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.
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
Parkinson's disease presents with tremor at rest (pill-rolling), bradykinesia, rigidity, and postural instability.
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
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.
A 67-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)
Levodopa/carbidopa is first-line therapy for the treatment of Parkinson's disease
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)
MRI is the most appropriate diagnostic study in the evaluation of a suspected intracranial neoplasm.
Which of the following interventions is most effective during the early stages of Alzheimer's disease? 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
Memory aids are extremely helpful in assisting Alzheimer patients during the early stages of the disease.
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? A Cluster headaches B Depression C Glioblastoma D Giant cell arteritis
Morning headaches associated with vomiting are indicative of increased intracranial pressure and raise concern of a CNS tumor such as a glioblastoma.
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
Multiple sclerosis is most frequently seen in patients in their twenties and presents with episodes of weakness, paresthesias, and diplopia
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
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.
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? A MRI of the brain B Electroencephalogram C Multiple sleep latency test D Overnight polysomnography
Multiple sleep latency test is required to observe the abrupt transition to REM sleep and establish the diagnosis of narcolepsy.
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
Muscular dystrophy age of onset is by age 5, and begins in the pelvic girdle.
What is the recommendation for primary prevention of stroke in a patient under sixty years of age with atrial fibrillation? The patient has no prior history of stroke, MI, hypertension, vascular disease, or diabetes. A No therapy is needed B Aspirin C Warfarin D Maze procedure
No therapy is recommended for primary stroke prevention in this patient.
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
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.
Which of the following side effects is associated with long-term administration of phenytoin (Dilantin)? A Ataxia B Hypotension C Osteomalacia D Cardiac dysrhythmia
Osteomalacia, or demineralization of bone, is a side effect of phenytoin that may occur after chronic administration.
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? A Cerebellum B Posterior column C Sensory cortex D Vestibular apparatus
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.
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)
Propanolol is one beta-blocker that is frequently used as a first-line prophylaxis for migraines.
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).
Propanolol is useful in preventing migraine headaches and may be maintained indefinitely.
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
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.
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)
Rifampin, Cipro, Levaquin, Zithromax and Rocephin are the drugs of choice.
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
Seizures that develop during adolescence and adult life are predominantly due to tumor, trauma, drug use, or alcohol withdrawal.
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? A Bell's palsy B Cluster headache C Post-herpetic neuralgia D Trigeminal neuralgia
This is the classic presentation for trigeminal neuralgia (tic douloureux)
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
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
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.
Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal tunnel.
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
The dermatome T10 is at the level of the umbilicus.
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
The grasp reflex starts to disappear at about 2-3 months of age
A 22-year-old female presents with the 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)
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.
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
The lack of altered consciousness and focal motor symptoms are strongly indicative of this type of seizure.
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? A Chorea B Dystonia C Masked facies D Hyperreflexia
The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech.
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
The pattern of sensory, motor and reflex findings is consistent with the pathophysiology of peripheral nerve demyelination that occurs in Guillain-Barré syndrome.
What test is the single most useful test in establishing the diagnosis of multiple sclerosis? A Cerebral spinal fluid cell count and protein level B Cerebral spinal fluid immunoglobulin studies C Evoked potentials D Magnetic Resonance Imaging
The presence of plaques on MRI is a key finding in establishing the diagnosis of MS.
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
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 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)
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.
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
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.
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
This a description of a cluster headache (migrainous neuralgia), these headaches respond to oxygen by mask 7-10 L/min for 15 minutes.
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
This case is a description of a middle cerebral artery stroke.
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
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.
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 periods. 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
This patient has benign paroxysmal positional vertigo (BPPV) and repositioning maneuvers are recommended to move endolymphatic debris out of the posterior semicircular canal.
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
This patient presents with a history of minor trauma and progressive neurological abnormalities consistent with subdural hematoma. Diagnosis would be confirmed by a CT scan, which is less expensive and more sensitive for blood than an MRI.
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
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.
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
This patient's symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.
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? A Order a CBC, electrolytes, and toxicology screen B Order a CT of the head C Hyperventilate the patient D Administer streptokinase
This presentation is consistent with a structural abnormality that will be detected on an imaging study.
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
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).
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? A Serum amylase B Serum creatinine C Liver function tests D Electroencephalogram
Valproate may be toxic to the liver as well as cause thrombocytopenia.
In addition to tremor, which of the following are cardinal symptoms of Parkinson's disease? A Cognitive decline and rigidity B Personality change and bradycardia C Eye movement abnormalities and hyperkinesias D Rigidity and bradykinesia
Tremor, rigidity, bradykinesia, and postural instability are the cardinal features of Parkinsonism and may be present in any combination.
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 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
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.
