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A 49-year-old woman is evaluated in the emergency department for sudden-onset severe headache of 24 hours' duration. The headache reached its peak intensity within 1 minute. She is otherwise well and takes no medications.
On physical examination, vital signs are normal. Nuchal rigidity is present. Findings on mental status and funduscopic examinations are normal. There are no cranial nerve deficits.
A CT scan of the head is normal.
Which of the following is the most appropriate next step in management?
LP
MRV of brain
oral sumatriptan
cerebral catheter angio
An 82-year-old woman is evaluated for an 18-month history of progressively worsening repetitive questioning, one episode of getting lost while driving on a familiar route, and repeated instances of losing her cell phone. She lives alone and is independent in all of her basic activities of daily living, except that her daughter has automated her finances because of some errors.
On physical examination, vital signs are normal and other findings are unremarkable. The Mini–Mental State Examination score is 23.
An MRI of the brain shows significant hippocampal atrophy bilaterally with minimal white matter hyperintensities.
Which of the following is the most appropriate treatment?
Donepezil
Gingko-bilboa
High dose vit E
Memantine
A 66-year-old man is evaluated for abnormal behavior during sleep. His wife reports he has a prolonged history of nocturnal flailing and jerking movements and of shouting, punching, and jumping out of bed. The patient does not recall these movements and reports no discomfort. He also has a history of urinary incontinence and falls. He takes no medications.
On physical examination, vital signs are normal. He has reduced facial expression and bilateral rigidity. His gait is unsteady, with postural imbalance during turns, and he cannot walk in tandem. Other neurologic examination findings are unremarkable.
A polysomnogram reveals complex movements associated with preserved muscle tone during rapid-eye-movement sleep.
Which of the following is the most likely diagnosis?
Rapid eye movement sleep behavior disorder
Hypnic myoclonus
Periodic limb movement disorder
RLS
Vivid dreams
A 62-year-old man is evaluated in the emergency department for right arm weakness that lasted 20 minutes and occurred 6 hours ago. He has hypertension and type 2 diabetes mellitus. Current medications are metformin, lisinopril, and hydrochlorothiazide.
On physical examination, blood pressure is 142/82 mm Hg; the remainder of the vital signs and neurologic examination are normal.
Hemoglobin A1c value is 6.5%, and LDL cholesterol level is 120 mg/dL (3.1 mmol/L). Basic metabolic profile and aminotransferase levels are normal.
CT scan of the head shows no acute ischemic changes. Carotid duplex ultrasound shows less than 40% stenosis in both carotid arteries and normal flow in the vertebral arteries.
High-intensity rosuvastatin is initiated.
Which of the following is the most appropriate additional treatment?
ASA/plavix
ASA, plavix, dipyridamole
ASA, apixaban
Ticagrelor
An 18-year-old woman is evaluated for a 5-year history of recurrent headaches. Headaches occur approximately 12 days per month; three of these episodes are severe, occurring without a trigger or premonitory symptoms, and last for a full day, followed by profound fatigue the next day. She describes the pain as bilateral, frontotemporal, steady and throbbing, associated with sensitivities to light and noise, worsening with movement, and causing her to miss 2 or 3 days of school per month. The severe headaches have not responded to ibuprofen or naproxen. The patient also has seasonal allergies. Other medications are fexofenadine and a combination estrogen-progestin oral contraceptive.
All physical examination findings, including vital signs, are normal.
Which of the following is the most appropriate next step in management?
Triptan
Dc OCP
MRI brain
Switch loratadine to fexofenadine
A 68-year-old woman is evaluated for a diffuse pruritic rash that began 2 days ago and initially involved the torso. Today the rash has spread to the upper and lower extremities and back. She began lamotrigine therapy 6 weeks ago for epilepsy and discontinued it yesterday. She denies ocular symptoms, sores in her mouth, or fever. She is minimally symptomatic. She has no other medical problems and takes no other medications.
On physical examination, vital signs are normal. There is a patchy, erythematous maculopapular rash on the upper and lower extremities, torso, and back. There is no involvement of the mucosa, palms, or soles. The remainder of the examination is normal.
Complete blood count with differential and a comprehensive metabolic panel are normal.
Diphenhydramine is prescribed.
Which of the following is the most appropriate seizure management?
Gabapentin
Phenobarb
Phenytoin
Carbamazepine
A 54-year-old man is evaluated for difficulty swallowing of 6 months' duration. He initially had occasional choking with liquids, which has progressed to dysphagia with both liquids and solids. His voice has become hoarse. He reports no changes in extremity strength but sometimes finds it hard to lift his head. He takes no medications.
On physical examination, vital signs are normal. Lower facial muscles are weak. Tongue is atrophied and moves slowly; fasciculations are present. Neck flexion and right-hand finger flexion are mildly weak. Jaw jerk and patellar reflexes are brisk, and right ankle clonus is present. Extraocular movements are intact.
Creatine kinase level is 250 U/L.
MRI of the brain and cervical spine and chest radiograph are normal.
Which of the following is the most likely diagnosis?
ALS
MG
NMO
Inclusion body myositis
Chronic inflammatory demyelinating polyradic
A 34-year-old woman is hospitalized for right-sided visual loss of 2 days' duration. She has no headache, eye pain, or neck pain. She has had two prior pregnancies without complications. She has no other symptoms and is otherwise well.
On physical examination, vital signs are normal. Right visual field deficit in both eyes is observed. Pupils are equal in size and are reactive to light; she has full eye movements.
Complete blood count, coagulation profile, and C-reactive protein level are normal.
CT scan of the head shows a left occipital infarct. Magnetic resonance angiogram of the head and neck and ECG are normal.
Which of the following is the most appropriate diagnostic test to perform next?
ECHO with bubble study
TEE
Spinal tap
Cath
A 70-year-old woman is evaluated in the hospital for the recent onset of severe back pain and gait ataxia. Extensive-stage small cell lung cancer was diagnosed 1 month ago. Metastases to brain, liver, and adrenal glands were noted. She has decided to forego active therapy and has opted for comfort care. Until the past week she has experienced only modest pain. Her other medical problems include chronic kidney disease, diabetes mellitus, hypertension, and oxygen-dependent COPD. Medications are oral morphine, losartan, hydrochlorothiazide, metformin, albuterol, and tiotropium inhalers. Her predicted life expectancy is 3 months.
On physical examination, vital signs are normal. She has a wide-based gait and poor vibratory and position sense in the feet. Muscle strength testing shows 4/5 bilateral hip flexion.
MRI of the thoracic spine reveals two contrast-enhancing masses involving the posterior vertebra and dura at T3 and T8. Both lesions cause cord compression with increased T2 signal in the cord.
Which of the following is the most appropriate treatment?
Steroids + radiation
Steroids + surgical decompression
Steroids + surgical decompression + radiation
Radiation + surgical decompression
A 55-year-old man is evaluated for a 1-year history of worsening personality and behavioral changes, compulsive tendencies, a loss of empathy, and poor insight. Although he previously was neither a drinker nor a smoker, he now drinks heavily and smokes two packs of cigarettes daily. According to his son, the patient lost more than half of his retirement savings in the past month while gambling, and 2 weeks ago, he was arrested for breaking into a neighbor's house. Results of recent cognitive screening have been normal. He has no other medical problems and takes no medication.
All physical examination findings, including vital signs, are unremarkable.
An MRI of the brain shows atrophy of the right frontal lobe.
Which of the following classes of drugs is most appropriate for the pharmacologic treatment of this patient?
SSRI
Antipsychotics
Acetylcholinesterase inhibitors
NMDA receptor antagonists
A 72-year-old man is evaluated for dementia with fluctuations in attentiveness, visual hallucinations, and slowness of movements over the past year. He has also acted out his dreams in his sleep a few times over the last 2 years.
On physical examination, vital signs are normal. Mild hypomimia, symmetrically increased tone in bilateral upper extremities, and bradykinesia on rapid alternating movements are observed.
What is the diagnosis?
Lewy body dementia - dementia and motor sxs occur within 1-2 yrs of one another
Parkinson's - dementia after motor sxs
A 78-year-old woman is evaluated in the hospital following treatment with intravenous alteplase 8 hours ago for acute ischemic stroke. CT angiogram showed no large vessel occlusion. The National Institutes of Health Stroke Scale (NIHSS) score before and 1 hour after treatment was 9. She has atrial fibrillation and hypertension. Outpatient medications were warfarin, enalapril, and amlodipine. At the time of hospital admission the INR was 1.0.
On physical examination, vital signs are normal. Oxygen saturation is 97% with the patient breathing ambient air. She has left facial weakness and dysarthria. The raised left arm and leg have a downward drift that contacts the bed, and there is a decreased sensitivity to pinprick on the left side. Heart rhythm is irregularly irregular.
Which of the following is the most appropriate next step in management?
Swallow eval
IV heparin
Atorvastatin
Oxygen by NC
Repeat CTH
A 48-year-old man is taken to the emergency department with a 3-month history of progressive headaches, double vision, and slurred speech. On arrival, he has a sudden decline in mentation, becomes comatose, and is emergently intubated.
On physical examination, blood pressure is 188/96 mm Hg, pulse rate is 48/min, and respiration rate is 10/min. The patient is comatose, with large unreactive pupils bilaterally, has no spontaneous movements, and withdraws his upper and lower limbs from noxious stimuli.
Head CT shows a midline thalamic mass extending downward into the upper brainstem with associated parenchymal and intraventricular hemorrhage. There is associated edema and mass effect on the brainstem, leading to compression of brainstem and crowding of the foramen magnum.
The patient's head of the bed is elevated to 30 degrees, hyperventilation with mechanical ventilation in initiated, and intravenous dexamethasone is administered.
Which of the following is the most appropriate additional emergent management?
IV Mannitol
Normal saline
Bevacizumab
Decompressive craniotomy
A 67-year-old man comes to the office for a follow-up evaluation of secondary progressive multiple sclerosis (MS). He was diagnosed with relapsing-remitting MS 20 years ago and had his last relapse 6 years ago. His disease converted to a secondary progressive course 4 years ago, and 2.5 years ago, he became nonambulatory. His only medication is interferon-beta 1b.
On physical examination, all vital signs are normal. Marked spasticity is noted in the lower extremities. Muscle strength is grade 1/5 with hip and knee flexion, bilaterally, and grade 2/5 with ankle dorsiflexion, bilaterally. An indwelling suprapubic catheter is noted.
A recent MRI of the brain shows multiple lesions consistent with MS that are unchanged from 2 years ago; gadolinium does not enhance the lesions.
Which of the following changes to the patient's immunomodulatory therapy is most appropriate?
Discontinue interferon-beta 1b
Change interferon-beta 1b for natalizumab
Change interferon-beta 1b for ocrelizumab
IV steroids
A 27-year-old woman is evaluated for a 10-day history of involuntary movements involving the face, arms, and trunk. Symptoms began as occasional twitching of the limbs and then became more generalized and persistent to the point that now she has difficulty sitting still. She cannot suppress the movements voluntarily. The patient has no personal or family medical history of involuntary movements. She is otherwise well and takes no medications.
On physical examination, vital signs are normal. Variable and random movements that flow from one body part to another are noted; the movements are not distractible. Gait has a prancing quality with flailing arms. Cognition is intact and motor strength and deep tendon reflexes are normal.
A complete blood count and comprehensive metabolic profile are normal.
Which of the following is the most appropriate diagnostic test?
UPT
Genetic testing for Huntington's
Spinal fluid analysis
Serum ceruloplasmin
Peripheral blood smear
A 57-year-old woman is evaluated in the emergency department for a 70-minute history of right-sided weakness involving the face, arm, and leg. She has had no surgeries or recent gastrointestinal or genitourinary bleeding. Medical history is significant for hypertension and type 2 diabetes mellitus. Medications are metformin and lisinopril.
On physical examination, blood pressure is 192/122 mm Hg; the remaining vital signs are normal. She has right facial weakness, dysarthria, and right arm and leg weakness with a downward drift, with the leg not touching the examination table.
ECG is normal. CT of the head shows no sign of hemorrhage or early infarcts.
Which of the following is the most appropriate initial intravenous treatment?
Labetolol
Nitroprusside
Alteplase
Abciximab