A
A 25-year-old man is evaluated for a 1-year history of headaches. He recently returned from active military duty where he sustained a mild traumatic brain injury (TBI). A CT scan obtained after injury was normal. Headaches, which started soon after the TBI, typically occur three times weekly, last 24 hours, and are bifrontal, dull, and moderate in intensity. The patient also reports occasional photosensitivity accompanying the headaches but has had no nausea, phonophobia, visual disturbances, or neurologic symptoms. He takes ibuprofen as needed to relieve the pain.
On physical examination, vital signs and all other physical examination findings are normal.
Results of standard laboratory studies are normal.
Which of the following is the most appropriate diagnostic test to perform next?
Brain MRI
Depression screening
Electroencephalography
Erythrocyte sedimentation rate
Montreal Cognitive Assessment
A 25-year-old woman is evaluated for a 3-month history of headaches that previously occurred weekly but now occur daily. She describes the headaches as holocranial, dull, and vice-like, and worsened by the Valsalva maneuver. The patient reports associated neck stiffness, intermittent visual blurring without diplopia, and nocturnal pulsatile tinnitus. She has had no other symptoms. She also has a history of acne and vitamin D deficiency. Medications are topical benzoyl peroxide, oral doxycycline, and vitamin D.
On physical examination, vital signs and BMI are within normal limits. Neurologic examination reveals bilateral papilledema. Physical examination findings are otherwise unremarkable.
Cerebral spinal fluid analysis shows an opening pressure of 280 mm H2O. Other laboratory studies are within normal limits.
A contrast-enhanced brain MRI shows a partially empty sella and widened optic nerve sheaths. Results of magnetic resonance venography are normal.
Which of the following is the most appropriate next step in treatment?
Administer prednisone
Administer topiramate
Discontinue doxycycline
Discontinue vitamin D
A 26-year-old man is evaluated for spells that began 4 months ago and occur twice monthly. He has no memory of the episodes, but family members report that he suddenly stops talking and sometimes has twitching of the right arm. He will not look at them, will not speak, and does not follow verbal commands. Family members also report stiffness and clenching of his right hand toward the end of an episode, which typically lasts 30 to 90 seconds. After he regains speech and the twitching stops, he usually has slurred speech, right-arm weakness, and mild confusion for up to 30 minutes. He has no other medical problems and takes no medications.
On physical examination, vital signs are normal. All other examination findings, including those from a neurologic examination, are unremarkable.
Which of the following is the most likely diagnosis?
Focal aware seizures
Focal impaired awareness
Generalized absence seizures
Generalized myoclonic seizures
A 78-year-old man is evaluated for a 4-month history of increasing forgetfulness. He lives alone and maintains independence in all of his instrumental and basic activities of daily living. His daughter reports that he forgets appointments and his home is less organized than before with more clutter, including unopened bills on the dining room table. He does not drink alcohol. There is no history of high-risk sexual behavior. He is otherwise well and takes no medications.
On physical examination, vital signs, general screening, and neurologic examination findings are normal.
He can recall two of three items on the Mini-Cog test but cannot correctly draw a clock face.
Which of the following is the most appropriate test to perform next?
Cerebrospinal fluid analysis for tau protein
Depression screening
Genetic testing
Serum VDRL testing
A 56-year-old woman is evaluated for recent difficulty with tasks at her job as a paralegal, especially those involving short-term memory and multitasking. She has multiple sclerosis. She has had previous major depressive episodes, which are currently managed with venlafaxine. Other medications are glatiramer acetate and a vitamin D supplement.
On physical examination, vital signs are normal. On neurologic examination, the patient can recall only one of three objects at 3 minutes and recites “d-r-l-o-w” when asked to spell “world” backward.
Her score on the Patient Health Questionnaire 9 for depression is 4 because of difficulties with concentration and sleep.
Which of the following is the most appropriate management?
Increase venlafaxine dose
Refer for cognitive rehab
Start memantine
Start methylphenidate
A 44-year-old man is evaluated for a 15-year history of headaches that have become increasingly frequent over the past 6 months, now occurring between 15 and 20 days per month. He describes the headache pain as a global feeling of heaviness or tightness that seems to improve with exercise or distraction. Headaches are often preceded and accompanied by neck tightness. He has had no photophobia, phonophobia, nausea, aura, or neurologic symptoms. Acetaminophen, relaxation training, and cognitive behavioral therapy have been ineffective. NSAIDs caused gastroesophageal reflux symptoms.
All physical examination findings, including vital signs, are normal.
Which of the following is the most appropriate preventive treatment?
Amitriptyline
Butalbital
Cyclobenzaprine
Botulinum toxin
Topiramate
A 35-year-old woman is evaluated for a 5-year history of right- or occasionally left-sided throbbing headache with photophobia, phonophobia, and nausea. Recently, her headaches have been associated with right-arm tingling lasting 30 minutes. The headaches occur twice a month and last 6 to 8 hours each. The patient is otherwise asymptomatic, and she has had no other neurologic symptoms.
On physical examination, vital signs are normal. All other examination findings, including those from a neurologic examination, are unremarkable.
MRI of the brain with contrast shows a homogenously enhancing, dural-based lesion that has well-demarcated borders and appears to be outside the brain parenchyma in the right hemisphere. No mass effect, hemorrhage, or cerebral edema is noted.
Which of the following is the most appropriate next step in management?
Brain biopsy
Dexamethasone
Levetiracetam
Serial brain MRI
Surgical resection
A 47-year-old man is evaluated in the emergency department for a prolonged seizure. According to the family, the initial seizure lasted for 3 minutes and stopped, but the patient did not regain consciousness and a second generalized tonic-clonic seizure started within 5 minutes and has continued. The patient received 4 mg intravenous lorazepam in the ambulance on the way to the hospital. In the emergency department, the seizure continues and he receives an additional 4 mg of intravenous lorazepam followed by another 2 mg 10 minutes later without benefit. The patient has a history of generalized tonic-clonic seizures treated with levetiracetam.
On physical examination, blood pressure is 147/92 mm Hg, pulse rate is 122/min, and respiration rate is 18/min. Oxygen saturation with the patient breathing ambient air is 90%. Pupils are reactive. Clonic seizure activity persists.
Twenty minutes have elapsed since admission to the emergency department. The patient is intubated, an intravenous line is placed, a blood specimen is obtained, and fingerstick glucose is obtained (126 mg/dL [7.0 mmol/L]).
Which of the following is the most appropriate additional management?
Head CT
Immediate continuous electroencephalography
Intravenous fosphenytoin
Rectal administration of diazepam
A 65-year-old man is evaluated in the emergency department for a 24-hour history of difficulty walking and inability to urinate. He has hypertension treated with amlodipine.
On physical examination, vital signs are normal. Muscle strength is 4/5 for both hip flexors. Patellar reflexes are 3+ bilaterally. There are bilateral extensor plantar responses in the toes, decreased sensation to pinprick below the nipple line bilaterally, and a palpable bladder. Upper extremity reflexes are 2+ in both biceps. Arm strength is normal. Gait is ataxic.
Which of the following is the most appropriate diagnostic test to perform next?
CT myelography
BMRI of the brain
MRI of the lumbosacral spine
MRI of the thoracic spine
A 38-year-old woman is hospitalized with a subarachnoid hemorrhage. The patient's medical history is otherwise unremarkable, and she takes no medications or illicit drugs.
On physical examination, blood pressure is 142/82 mm Hg; the remaining vital signs are normal. Nuchal rigidity is present. The right pupil is 2 mm larger than the left; both pupils are reactive to light. Mental status examination shows somnolence but is otherwise normal.
CT scan of the head shows subarachnoid hemorrhage in the basal cisterns with intraventricular hemorrhage. Digital subtraction angiogram shows an 8-mm aneurysm in the right posterior communicating artery; during angiography, this aneurysm was successfully treated with coiling.
Which of the following is the most appropriate treatment?
Intravenous dexamethasone
Intravenous labetalol
Oral nimodipine
Oral verapamil
A 70-year-old woman is hospitalized for progression of cognitive impairment to dementia and ataxia over the past 6 months. She has developed myoclonus, gait problems, and interruption of circadian rhythm.
On physical examination, vital signs are normal. She is alert but has difficulty with orientation to place and time. Cranial nerves and motor strength are normal. There are occasional myoclonic jerks of the trunk. Sensation is intact throughout; cerebellar ataxia is seen on finger-nose-finger, heel-to-shin, and gait testing. Deep tendon reflexes are increased throughout.
Diffusion-weighted MRI of the brain shows hyperintensity in the basal ganglia and several regions of the cortex.
A lumbar puncture is performed.
Which of the following is the most appropriate diagnostic test to perform on the cerebrospinal fluid?
14-3-3 Protein assay
Polymerase chain reaction for herpes simplex virus
Real-time quaking-induced conversion assay
Total tau protein measurement
A 29-year-old man is evaluated in the emergency department for pain and discomfort with movement of his left eye that began yesterday morning. He awoke this morning with blurry vision and a dark spot in the center of the visual field of his left eye. He has no other medical problems and takes no medications.
On physical examination, vital signs are normal. Funduscopic examination is normal. Pupils are reactive, with an afferent pupillary defect in the left eye. Visual acuity is 20/20 in the right eye and 20/100 in the left eye with a central scotoma. There is no proptosis, conjunctival erythema, or pain on palpation of the orbit.
Results of laboratory studies show a normal leukocyte count and erythrocyte sedimentation rate.
Which of the following is the most likely diagnosis?
Central retinal artery occlusion
Giant cell arteritis
Optic neuritis
Orbital cellulitis
A 27-year-old man is evaluated in the emergency department after three episodes of loss of consciousness and falling down that started 2 weeks ago. He has no memory of the events. The third event was witnessed by a coworker who noted that the patient cried out, had whole-body stiffening, and fell backward off his chair. While on the ground, the patient's whole body shook with synchronous limb jerking for 2 minutes. Afterward, the patient was very sleepy and had slow, snoring-like breathing. He remained in a state of impaired alertness for 8 minutes. He gradually awoke by the time he reached the emergency department 20 minutes later, and now has recovered to normal.
On physical examination, vital signs are normal. All other examination findings, including those from a neurologic examination, are unremarkable.
Which of the following is the most likely diagnosis?
Generalized convulsive status epilepticus
Generalized tonic-clonic
Psychogenic nonepileptic spells/events
A 52-year-old man is evaluated for 4-week history of left lower extremity weakness that began with tripping on the left foot. He now must lift his knee to clear his foot off the ground. He reports no pain but has mild tingling on the lateral border of his left foot. He has no history of trauma or low back pain. He takes simvastatin for dyslipidemia.
On physical examination, vital signs are normal. BMI is 27. Weakness on dorsiflexion, eversion of the left foot, and extension of the left big toe are observed. There is mild sensory loss on the lateral border of the left foot. Result of a straight-leg-raise test is negative. Plantar responses are flexor. The rest of the neurologic examination is normal.
Serum creatine kinase level is normal.
An electromyogram reveals slow velocity of peroneal nerve conduction around the fibular neck. Other lower extremity motor and sensory nerve conduction measurements and needle examination results are normal.
Which of the following is the most appropriate next step in management?
Avoid leg crossing
Avoid prolonged standing
Discontinue simvastatin
Pursue weight loss
A 48-year-old man is evaluated for a 25-year history of headaches that have become increasingly frequent. Headaches previously occurred four to five times per month but now occur 16 to 20 times per month and last 12 to 24 hours. The headaches are bilateral, throbbing, moderate in intensity, aggravated by physical activity, and accompanied by photophobia and phonophobia. He has had no other associated symptoms. The patient takes amitriptyline and sumatriptan for the headaches and has been taking sumatriptan four to five times weekly for the past 3 months.
Physical examination findings, including vital signs, are all normal.
A brain MRI with contrast is normal.
Which of the following is the most appropriate next step in treatment?
Begin butalbital
Begin verapamil
Discontinue amitriptyline
Discontinue sumatriptan
A 60-year-old man is evaluated for a 3-year history of gradual, progressive decline in his cognition, behavior, and motor skills. Both he and his wife have noticed these changes. He becomes agitated easily, and his wife reports that his personality is much more subdued than it used to be. He no longer enjoys socializing. Memory loss is not a prominent symptom. The patient played professional football for 5 years after college graduation. He has hypertension and hyperlipidemia. His medications are lisinopril, hydrochlorothiazide, and atorvastatin.
On physical examination, vital signs are normal. There is slightly increased tone in the bilateral upper extremities. He has a slow, shuffling gait.
MRI of the brain reveals global atrophy.
Neuropsychological testing shows marked cognitive slowing and a disorganized thought process.
Which of the following is the most likely diagnosis?
Alzheimer disease
Behavioral-variant frontotemporal dementia
Traumatic encephalopathy syndrome
Vascular cognitive impairment