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General Neurology
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100
A 34-year-old man is referred for psychiatric evaluation 5 years after sustaining a head injury at work. Prior to the accident, he was a stable, happily married man. Since the accident, he has been described as overly talkative and restless. His wife divorced him because he was acting irresponsibly, which also resulted in termination from his job. Psychometric testing reveals that the man has average intelligence and no detectable memory deficits. The patient’s clinical presentation is most consistent with damage to which of the following brain areas?
A. Thalamus
B. Frontal lobe
C. Corpus striatum
D. Amygdaloid body
E. Nucleus accumbens
What is B: Frontal lobe?
100
A 65-year-old patient has a stroke which causes him to fall. On examination, the patient is found to have weakness of the right leg with only minor weakness of the right hand, and no weakness of the face. There is no sensory deficit. Speech is not affected, but the patient seems unusually quiet and passive. The stroke most likely involves the:
A. right vertebral artery.
B. mainstem left middle cerebral artery.
C. left anterior cerebral artery.
D. posterior division left middle cerebral artery.
What is C: left anterior cerebral artery?
100
A 65-year-old patient wakes up with right-sided hemiparesis and motor aphasia. The patient is immediately brought to the emergency department, and an evaluation is completed within 1 hour. Neurological examination shows no additional abnormalities. Head computed tomography (CT) scan without contrast shows no abnormality. Which of the following is the most appropriate next management step?
A. Aspirin
B. Warfarin
C. Heparin
D. Tissue plasminogen activator
What is A: Aspirin?
100
A 16-year-old patient is brought to the psychiatrist’s attention after having a single grand mal seizure. The patient’s parents have noted that on occasion the patient has sudden jerks of the entire body, which have resulted in dropping objects and being labeled as clumsy. The electroencephalograph (EEG) shows rare 4-6 Hz irregular polyspike and wave bursts. The most likely diagnosis is:
A. Dysrhythmia with drop attacks.
B. Juvenile myoclonic epilepsy.
C. Non-complex partial seizures.
D. Complex partial seizures.
E. Peitit mal epilepsy.
What is B: Juvenile myoclonic epilepsy?
100
Which of the following magnetic resonance imaging (MRI) scan findings is most characteristic of Alzheimer disease?
A. Frontal lobe atrophy.
B. Occipital lobe atrophy.
C. Caudate nucleus atrophy.
D. Reduced hippocampal volumes.
E. Periventricular white matter lesions.
What is D: Reduced hippocampal volumes?
200
A 78-year-old patient had an ischemic stroke that left him with a residual mild hemiplegia. The patient appeared to be unaware that there was a problem of weakness on one side of his body. When asked to raise the weak arm, the patient raised his normal arm. When the failure to raise the paralyzed arm was pointed out to the patient, he admitted that the arm was slightly weak. He also was found to neglect that side of the body when dressing and grooming. The patient did not shave one side of his face and found it difficult to put a shirt on when it was turned inside out. Which of the following is likely to have been affected by the stroke?
A. Right frontal lobe
B. Right parietal lobe
C. Right temporal lobe
D. Right somatosensory cortex
E. Deep thalamic nuclei
What is B: Right Parietal Lobe?
200
A 25-year-old patient reports double vision and some difficulty with balance. On right lateral gaze, there is weakness of the left medial rectus, with nystagmus of the right eye. On left lateral gaze, there is weakness of the right medial rectus, with nystagmus of the left eye. There is also mild finger to nose ataxia on the right. The most likely diagnosis is:
A. multiple sclerosis.
B. myasthenia gravis.
C. diabetic third nerve palsies.
D. posterior communicating artery aneurysm.
E. conversion disorder.
What is A: multiple sclerosis?
200
A 13-year-old boy has trouble keeping up with physical education classes. On examination he has symmetric weakness in legs and arms, which is worse in the proximal muscles, and most prominent in quadriceps or hamstrings. Both calves are enlarged, and are painful with exercise. A serum creatine kinase level is 13,000 mg/dL, and a muscle biopsy reveals abnormalities in dystrophin protein staining. The pattern of inheritance of this disease is which of the following?
A. Autosomal dominant
B. Autosomal recessive
C. X-linked
D. Mitochondrial
What is D: X-linked?
200
A 61-year-old patient presents to the emergency department (ED) accompanied by family who report that the patient is unable to remember recent events. The patient’s memory problems began 2 hours prior, and the patient was cognitively intact before this episode. The patient is alert, slightly anxious and frustrated, and repeatedly asks, “Why am I in the hospital? Is someone sick?” This presentation is most consistent with a diagnosis of:
A. Korsakoff dementia.
B. Temporal lobe epilepsy.
C. Transient global amnesia.
D. Midline cerebellar tumor.
E. Middle cerebral artery occlusion.
What is C:Transient global amnesia?
200
A 27- year-old patient with a disabling major anergic depression is treated with 60 mg of tranylcypromine and 1.5 gm of 5-hydroxytryptophan (5-HT). The patient develops colorful visual hallucinations, mild confusion, and myoclonic jerks. A likely diagnosis is:
A. Serotonin syndrome.
B. Noradrenergic crisis.
C. Hypertensive crisis.
D. Dopaminergic syndrome.
E. Anticholinergic syndrome.
What is A: Serotonin syndrome?
300
A 44-year-old man, found wandering aimlessly, is brought to the emergency department by police. Blood pressure is 200/132 and heart rate is 112 and regular. The patient is belligerent, picking at his skin, and reporting feeling crawling insects on his skin. The patient is oriented only to name, is tremulous and is unable to cooperate with a thorough neurological examination. The patient is diaphoretic and his pupils are dilated. The patient has palmar erythema and spider angiomata on the chest. Which of the following is the most likely explanation for the patient’s symptoms?
A. Opioid withdrawal
B. Psilocybin intoxication
C. Phencyclidine intoxication
D. Schizophrenia, paranoid type
E. Delirium tremens
What is E: delirium tremens?
300
A 68-year-old patient with hypertension develops rapidly progressing right arm and leg weakness, with deviation of the eyes to the left. Within 30 minutes of the onset of this deficit, the patient became increasingly sleepy. Two hours after the onset the patient became unresponsive. On examination, the patient has dense right hemiplegia, eyes deviated to the left. The pupils are equal and reactive. There is right facial weakness to grimace elicited by noxious stimuli. Cough and gag reflexes absent. Which of the following computed tomography (CT) findings is most likely?
A. Basilar artery thrombosis
B. Left thalamic hemorrhage
C. Acute infarct in left pons
D. Acute infarct in right cerebellum
E. Left putaminal hemorrhage
What is E: The left putaminal hemorrhage?
300
A 54-year-old patient complains of intermittent double vision that has worsened over the last 3 weeks. The patient’s coworker also noted that at times the patient had a "droopiness" of the eyelids as if sleepy. Examination reveals bilateral ptosis, mild esotropia, and double vision only after the patient is asked to maintain an upward gaze for 2 minutes. There is no dysarthria, but a mild 4/5 weakness is found in the proximal arm muscles bilaterally. Which of the following is the most appropriate test to perform next to establish the diagnosis?
A. Edrophonium test
B. Nuclear bone scan
C. Spinal fluid electrophoresis
D. Computed tomography (CT) scan of the thorax
What is A: Edrophonium test?
300
A 38-year-old patient complains of difficulty talking, and reports a history of diffuse muscular aching and stiffness. The physical examination reveals an enlarged tongue and percussion myoedema. Which of the following is the most likely diagnosis?
A. Polymyositis.
B. Fibromyalgia.
C. Congestive heart failure.
D. Somatoform pain disorder.
E. Hypothyroidism.
What is E: Hypothyroidism?
300
Which of the following symptoms makes a diagnosis of neuroleptic malignant syndrome more likely than other neurological and general medical conditions?
A. Tachycardia and tachypnea.
B. Fever and severe muscle rigidity.
C. Status epilepticus and hypertension.
D. Myoclonus, hyperreflexia and diarrhea.
E. At least 2 extrapyramidal symptoms including choreiform movements.
What is B: Fever and severe muscle rigidity?
400
Which of the following findings on a magnetic resonance imaging (MRI) scan would most specifically indicate a diagnosis of Huntington’s disease?
A. Cerebellar atrophy
B. Frontal lobe atrophy
C. Temporal lobe atrophy
D. Caudate head atrophy
E. Dilatation of the 4th ventricle
What is D: Caudate head atrophy?
400
A 30-year-old patient develops pain behind the left ear. The following day the patient complains of numbness in the left side of the face, tearing from the left eye and discomfort with low frequency sounds. Examination shows left facial weakness, but no sensory deficit. The most likely diagnosis is:
A. Herpes zoster.
B. Brain stem stroke.
C. Trigeminal neuralgia.
D. Idiopathic Bell’s palsy.
What is D: Idiopathic Bell’s palsy?
400
A 26-year-old male reports that he is sometimes awakened by headache in the early morning hours. The headache can be excruciating and usually lasts about 60 to 90 minutes. Sometimes during the day he gets similar headaches, beginning with a sharp stabbing sensation in the left nostril and followed by severe retro-orbital pain, tearing of the left eye, and rhinorrhea. He indicates that his wife has noted some swelling of is face during the headache. The neurologic examination is normal. The most likely diagnosis is:
A. Temporal arteritis.
B. Trigeminal neuralgia.
C. Cluster headache.
D. Chronic tension headache.
E. Sentinel bleeds from berry aneurysm.
What is C: Cluster headache?
400
A 25-year-old patient reports having visual hallucinations described as similar to the wavy distortions produced by heat rising from asphalt and affecting the whole of bot visual fields. These episodes of visual disturbance are accompanied by vertigo, dysarthia, and tingling in both hands and feet, sometimes around both sides of the mouth followed by occipital headache. Which of the following is the most likely explanation for this patient’s symptoms?
A. Parasinusitis.
B. Basilar migraine.
C. Cerebellar tumor.
D. Vertebrobasilar ischemia.
E. Ependymoma of the fourth ventricle.
What is B: Basilar migraine?
400
A 70-year-old patient was hospitalized because of a middle cerebral artery stroke. The psychiatrist as asked to evaluate the patient. The patient has nonfluent aphasia. Which of the following most likely characterized the patient’s interaction with the psychiatrist?
A. The patient spoke at a normal rate.
B. The patient’s interpretation of proverbs was concrete.
C. The patient was able to repeat, “No ands, ifs, or buts.”
D. The patient was able to follow the verbal request, “Close your eyes.”
E. The patient was able to explain to the psychiatrist why the patient was in the hospital.
What is D: The patient was able to follow the verbal request, “Close your eyes”?
500
A 65-year-old patient is brought to the emergency department with disorientation and mild agitation, and is experiencing vivid visual hallucinations of several children playing inside the house. The patient’s family reports that the patient had two similar episodes in recent months, but between them, seemed fine. On examination, the patient has normal language and memory, normal cranial nerves, mild symmetric rigidity and bradykinesia, but no weakness or involuntary movements and no sensory deficits. Deep tendon reflexes are symmetric. A brain magnetic resonance imaging (MRI) scan is unremarkable, as are the results of cerebrospinal fluid (CSF) and routine laboratories including toxic drugs screen. Which of the following is the most likely diagnosis?
A. Major Depressive disorder with psychotic features.
B. Progressive supranuclear palsy.
C. Dementia with Lewy bodies.
D. Late onset schizophrenia.
E. Alzheimer dementia.
What is C: dementia with Lewy bodies?
500
A 72-year-old patient complains of leg weakness and frequent falls. The patient has a several-month history of forgetfulness, urinary urgency and frequency, but no incontinence. The patient walks with shuffling steps and a stooped posture, but the motor examination is otherwise normal. A bedside cognitive assessment reveals short-term memory problems, but no other difficulties. The most likely diagnosis is:
A. normal pressure hydrocephalus.
B. Parkinson disease.
C. chronic subdural hematoma.
D. Alzheimer’s disease.
What is A: normal pressure hydrocephalus?
500
A 55-year-old male patient presents with a history of weakness and clumsiness. Symptoms began several months earlier with difficulty buttoning his clothes, getting the car keys in the ignition, and performing other fine movements. He noticed that the muscles in his arm and forearm twitched under the surface, and cramped easily. Over the past few months is arms have continued to weaken and lose muscle mass. On examination he has diffuse wasting and weakness on both upper extremities, fasciculations, slight spasticity on arms and legs, and hyperreflexia with extensor plantar responses. The sensory, coordination, and cranial nerve examinations are normal. The underlying pathological process affects neuronal bodies in which of the following structures?
A. Anterior horn of the spinal cord, medial brainstem, and prerolandic cortex
B. Posterior horn of the spinal cord, lateral brainstem, and postrolandic cortex
C. Intermediolateral column of the spinal cord, dorsal brainstem and intralaminar thalamus
D. Clarke’s column of the spinal cord, dorsal pons, and cerebellar cortex
What is A: Anterior horn of the spinal cord, medial brainstem, and prerolandic cortex?
500
A 50-year-old man is examined in the emergency department for acute onset of neck pain radiating down the left arm, progressive gait difficulty, and urinary incontinence. Which of the following tests should be administered immediately?
A. A spinal tap to measure gamma-globulin levels.
B. A magnetic resonance imagining (MRI) scan of the head to exclude a diagnosis of acute hydrocephalus.
C. A MRI scan of the cervical spine to exclude a diagnosis of spinal cord compression.
D. X-ray films of the cervical spine to exclude a diagnosis of cervical trauma.
E. Urodynamic studies to establish the pathophysiology of his incontinence.
What is C: A MRI scan of the cervical spine to exclude a diagnosis of spinal cord compression?
500
A 66-year-old patient complains of frequent falls. The patient has a several-month history of anxiety and unwillingness to leave home. On the examination, the patient has mild axial rigidity and minimal rigidity of the upper extremities, along with mild slowness of movement on finger tapping, hand opening and wrist opposition. Posture is normal. Gait is tentative and awkward, but without shuffling, ataxia or tremor. The patient is slow arising from a chair. Which of the following is the most likely diagnosis?
A. Alzheimer disease.
B. Parkinson disease.
C. Chronic subdural hematoma.
D. Progressive supranuclear palsy.
What is D: Progressive supranuclear palsy?