Geriatric/Neurology Flashcards
During EOM testing, the patient is noted to have delayed adduction of the left eye. Rest of exam is normal. What is most likely to be the underlying cause of this abnormality?
a) Muscular dystrophy
b) MS
c) Myasthenia gravis
d) Polymyalgia rheumatica
Multiple sclerosis. These lesions love to affect the oculomotor nucleus, which results in slow or absent adduction of the eye.
Which of the following is the earliest manifestation of alzheimer’s dementia
a) incontinence
b) memory deficit
c) aggressiveness
d) motor disturbances
Memory impairment.
Aggressiveness is a late finding, incontinence doesn’t happen and motor disturbances are a parkinsons thing.
45 yo woman presents with sharp, burning pain that radiates from her mouth towards her right ear. Pain is intermittent, excrutiating, lasting for a few seconds and is worse with eating/touching her face, Drug of choice for long term tx?
a) Carbamazepine
b) Propanolol
c) Valium
d) Phenobarbitol
Carbamezapine is helpful for the tx of trigeminal neuralgia
12 month old presents with possible viral meningitis. Which lab result is most consistent with this diagnosis?
a) Dec CSF glucose
b) Dec CSF protein
c) Inc CSF mononuclear cells
d) Inc CSF C-reactive protein
Increased CSF mononuclear cells are noted in viral meningitis. Elevated proteins are seen in viral meningitis.
The other two findings are seen in bacterial meningitis.
10yo male has abrupt, brief episodes of impaired consciousness and rhythmic blinking. Which of the following is the most likely type of seizure?
a) Focal
b) absence
c) tonic clonic
d) complex partial
Absence seizures are generalized seizures characterized by abrupt, brief episodes of impaired consciousness, staring and rhythmic blinking.
73yo female was diagnosed with alzheimers 3 years ago. Her 80 yo husband can no longer help feed and bathe her. Which of the following support services is most appropriate for this patient?
a) Hospice
b) Senior center
c) Adult day care
d) Skilled nursing facility
Skilled nursing facility is appropriate for patients who require assistance for ADL
Which of the following is considered to be the gold standard in making the diagnosis of MS?
a) Gadolinium enhanced MRI
B) MRA of the brain
c) positron emission testing
d) CT brain scan
Gadolinium enhanced MRI studies can help to characterize and delineate intramedullary disease and are able to characterize various lesions in time and space
5yo child has just been hospitalized with meningococcemia. Family members and close contacts should be given what as ppx
a) Rifampin PO
b) PCN PO
c) Erythromycin
d) no ppx needed
Everybody exposed should get rifampin to eliminate the organism from the nasopharynx
42yo has chronic migraine HA. Has been using ergotamine, but is now having 2 HA per week. Interfering with work. Appropriate preventative tx?
a) Sumatriptan (imitrex)
b) Promethazine
c) Propranolol
d) Ketorolac
C) Propanolol. Rad for preventing migraine HA and may be maintained indefinitely
Sumatriptan and ketorolac are used for acute HA, not preventative
Appropriate tx of myasthenia gravis
a) donepezil (Aricept)
b) quinidine (quinidex)
c) neostigmine (prostigmin)
d) edrophonium (tensilon)
Neostigmine.
Edrophonium is used for diagnosing MG but is too short acting to be used therapeutically.
68yo obese man w/ 58 PY hx. Has experienced sudden and total LOV in right eye, which resolved after 20 minutes. Which is the most likely diagnosis?
a) Optic neuritis
b) Retinal detachment
c) macular degeneration
d) TIA
TIA. Sudden onset unilateral neuro defecit and RF for vascular disease suggests vascular ischemia. The short duration of symptoms suggests TIA specifically.
Bradykinesia is most commonly associated with:
a) Wernicke’s syndrome
b) Hashimoto thyroiditis
c) Cushing’s disease
d) Parkinsons
Parkinsons. Have a resting tremor, bradykinesia, lack of facial expression and micrographia.
43 yo receptionist has 1 mo hx of pain and tingling in R thumb, index and middle finger. + Tinel + PHalen. Most appropriate intervention at this time is:
a) methylprednisone
b) neutral splint
c) observation
d) Surg
Neutral splint. Relieves impingement of median nerve
Tx of Bell’s palsy involves which of the following?
a) acyclovir
b) reassurance of pt recovery
c) referral to neurosurg
d) electromyography
Reassurance. Bells is a peripheral neuropathy of CN VII. 60% of cases recover spontaneously.
Which reflexes should begin to disappear at 2mo in a normal infant?
a) moro
b) grasp
c) tonic neck
d) parachute
Grasp should start to disappear at 2 mo.
Moro @ 5-6
Tonic neck @6-7
Parachute life
Upon stroking lateral aspect of sole from heel to ball, great toe dorsiflexes and the other toes fan. This is a positive:
a) Kernig’s sign
b) Brudzinski
c) Babinksi
d) Gower
Babinski. `
Which is a LONG TERM SE of phenytoin
a) ataxia
b) hypotension
c) osteomalacia
d) dysrhythmia
Osteomalacia (demineralization of bone) is a SE of chronic administration.
Ataxia is pheny OD
Cardiac dysrhythmia w/w/o hypotension is an expected SE of a pheny IV push
75yo male presents for routine physical. On PE fine cortical movement with repetitive rubbing of the tip of the thumb along the tips of the fingers is noted at rest. Most likely diagnosis?
a) Seizure
b) peripheral neuropathy
c) Shy-Drager
d) PD
Parkinsons presents with a tremor at rest (pill rolling), bradykinesia, rigidity and postural instability
A patient complains of loss of sensation at umbilicus level. Which dermatome is affected?
a) T6
b) T8
c) T10
d) T12
T10
27 yo female presents w/ weakness, visual loss, and sensory loss over the R great toe. These symptoms have occurred during 3 episodes approximately 3 mo apart w/ each episode lasting 3 days. Which testing is more useful for evaluation of this patient?
a) MRI of brain
b) electromyography
c) glucose tolerance test
d) Electroencephalograph
MRI. MS typically presents with relapsing weakness of the limbs, sensory loss, paresthesias, and visual changes.
Which of the following drugs is 1st choice for insomnia in an elderly pt?
a) Barbiturates
b) cholinesterase inhib
c) BZD
d) BB
BZD are the drug of choice for insomnia in the elderly population
72 yo pt w/ hx of HTN and Afib presents w/ episodes of weakness, numbness and paresthesias in the R arm. Also has speech difficulty & LOV in L eye. Symptoms come on abruptly and clear in minutes. Most likely diagnosis?
a) Focal seizure
b) Migraine HA
c) Hypoglycemic episode
d) TIA
TIA. Afib is a big risk factor for a cardiacemboli
70 yo presents w/ HA and neck stiffness. Febrile. + kernig. No rash. CSF has a white count of 250, 100% neutrophils, protein 250 and glu of 35. Most appropriate tx?
a) Acyclovir
b) fluconazole
c) Ampi and ceftriaxone
d) PCN and chloarmphenicol
Ampicillin and ceftriaxone are the go-to tx for bacterial meningitis caused by listeria, which is the most common cause in the elderly. Ceftriaxone will also cover other common causes of bacterial meningitis, like strep pneumonia.
74 yo female being txed for mild HTN. Found @ home w/ R hemiparesis. Pt fell in kitchen 2 days ago. Mildly confused. L pupil dilated. What to order first?
a) MRI of brain
b) CT of brain
c) Skull xray
d) LP
CT. Pt presents with hx of minor trauma nad progressive neurological abnormalities consistent w/ subdural hematoma. Diagnosis can be confirmed with CT
Seizures that first manifest in early/middle adult life should be considered suspicious of which of the following causes?
a) Cerebrovascular disease
b) encephalitis
c) Tumor
d) idiopathic epilepsy
Tumor. Seizures that dvlp during adolescence/adult life are usually due to tumor, trauma, drugs or etOH withdrawal
37yo male presents w/ HA for past two months. Occur daily, worse in morning. Past week tendency to drop things from R hand. Neuro exam reveals RUE weakness. Most likely diagnosis?
a) Focal seizure disorder
b) intracerebral neoplasm
c) TIA
d) ALS
Intracerebral neoplasms. These guys will present with HA that are worse in the morning and will improve during the day. Focal/motor sensory loss depends on tumor’s location.
During an influenza epidemic, 6yo is seen w/ fever and severe sore throat. Next day child is reported to have persistent vomiting and inc lethargy. Delirious and disoriented. No rash. Hyperactive reflexes. Liver edge is 3cm below the right costal margin in the mid clavicular line. Most likely diagnosis?
a) acute bacterial meningitis
b) Guillain barre
c) Reye syndrome
d) Measles encephalitis
Reye syndrome. Typically post influenza or URI. pt develops lethargy, drowsiness, vomiting. Babinksi and hyperreflexia noted. Liver is normal/enlarged.
30 yo male has a hx of weakness w/o pain on left side of face for 4 days. PE reveals unilateral weakness to L side, but not complete paralysis. Left eye does not close completely. Most appropriate initial tx?
a) PT
b) Surgical ablation
c) Reassurance & education
d) High dose steroids, recheck in 24 hours
Reassurance and education. Bell’s palsy is typically self limiting.
Most frequent finding in a person presenting w/ a brain abscess is
a) Nuchal rigidity
b) HA
c) seizures
d) vomiting
HA. In >70% of patients with a brain abscess.
The rest are much less common
Pt in a MVA brought to ER. Was unconscious for 2 min but is “OK” now. What to order?
a) Head CT
b) LP
c) Skull radiographs
d) EEG
Head CT. Provides evidence of fractures and shows ICH or edema.
2 mo infant has had a single tonic-conic for 4-5 min. No hx of trauma. Temp of 103.2 degrees, bulging T membrane on right and an inflamed pharynx. Most appropriate next step?
a) Do an LP
b) XR studies of the skull
c) EEG
d) Send home with abx and anticonvulsant
LP. Febrile convulsions are uncommon <3mo old. PE findings suggest possible meningitis, do an LP.
37 yo male presents w/ daytime fatigue and drowsiness. Freq awakenings overnight. gained 8lbs over last 6 mo and complains of palps. Snores at night. Nocturnal pulse ox shows drop of 6%. Most likely diagnosis?
a) Depression
b) narcolepsy
c) Hypothyroidism
d) obstructive sleep apnea
Obstructive sleep apnea. Associated w/ obestiy, nighttime wakening, snoring, cardiac dysrhytthmias, and O2 drop of >4% overnight
53 yo woman diagnosed with PD and has a mod tremor. No other sx of disease. Most appropriate inital tx?
a) Lorazepam
b) Haloperidol
c) Ramatidine
d) Levodopa/carbidopa
Levodopa/carbidopa is first line therapy for PD
Cognitive loss in AD may be delayed with which of the following Rx?
a) Donepezil
b) Haloperidol
c) Risperidone
d) Zolpidem
Donepezil is a reversible cholinesterase inhibitor, which leads to inc Ach. Ach is necessary for learning and memory.
Haloperidol/risperidone and other antipsych may be used for agitation and behavioral symptoms but have huge SE
28yo female presents with HA for the past several mmonths. Begin behind R eye, combo of stabbing and pressure. Phonophobia, nausea, no vomiting. Occasionally awakened with pain. Under a lot of stress. Aspirin/APAP do not alleviate. Best choice for initial tx of acute HA?
a) Topiramate
b) gapapentin
c) propranolol
d) sumatriptan
Sumatriptan are effective for acute abortion of a migraine HA. 5HT receptor agonists and ergot alkaloids are rad for acute
Cardinal features of PD?
a) cognitive decline and rigidity
b) personnality change and brady
c) eye movement abnormalities and hyperkinesias
d) rigidity and brady
Tremor, rigidity, bradykinesia and postural instability are the cardinal features of PD and may be present in any combination
Influenza season. 6yo male is seen w/ fever and severe sore throat. Sx have not improved despite ASA. Next day parent calls to report that the child has persistent vomiting and inc lethargy. On exam, found to be delirious and disoriented w/ hyperactive reflexes. Liver edge is 3cm below the right costal margin in the midclavicular line. Which is the most likely diagnosis?
a) Reye
b) Measles encephalitis
c) Guillain Barre
d) ABM
a) Suspected influenza with the development of vomiting, mental status changes, hyperreflexia, and hepatomegaly are consistent with a diagnosis of reyes.
(hepatomegaly is not usually seen in ABM)
Pain experienced during a migraine HA is a result of which nerve activation?
a) Trigeminal
b) Vagus
c) Optic
d) Occulomotor
Trigemintal. HA may be a result of a release of neuropeptides acting as neurotransmitters at trigeminal nerve branches
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67 yo female with hx of HTN, DM, smoking presents w/ mild expressive aphasia, right facial weakness and RA weakness. Awakened 60 minutes ago and was speaking to her husband when she became difficult to understand and weakness was noted. BP of 165/85. Head CT showed no ICH. Most appropriate intervention?
a) Aspirin
b) Warfarin
c) TPA
d) Clopidogrel
TPA. Can be used in relatively normotensive pts w/ CT evidence of NO ICH. Must be administered within 3 hours after onset of the stroke
38 yo female has a 10 year diagnosis of migraine HA. She had been using ergotamine to abort her HA but is now having 1-2 per week and it is interfering with work. Which is best preventative tx?
a) sumatriptan
b) promethazine
c) propranolol
d) ketorolac
Propranolol is one BB that is freq used as first line ppx for migraines
72 yo man w/ hx of DM, CKD, HTN presents w/ burning/tingling in his feet. Which Rx for pain?
a) Phenobarb
b) amytriptuline
c) celecoxib
d) codeine
Amitriptyline for diabetic neuropathy
30yo female presents w/ 7 month hx of recurrent, brief hx of weakness and tingling in the extremities, diplopia and vertigo. Most likely diagnosis?
a) Guillain Barre
b) MG
c) MS
d) ALS
Multiple sclerosis is most freq seen in patient in their 20’s and presents with episodes of weakness, paresthesias and diplopia
Rabies ppx protocol post bite.
Rabies immunoglobulins and human diploid cell rabies vaccine given 5 times in a 1 mo period
12 mo old in the ER is diagnosed with possible viral meningitis. Which of the following CSF results is most consistent with this diag?
a) Decreased CSF glucose lvls and inc protein
b) Decreased CSF total protein and very few neutrophils
c) Inc CSF mononuclear cells and normal glucose
d) Inc CSF CRP and normal glucose
Inc CSF mononuclear cells and normal glucose. Either normal or lower glucose
pt in a MVA w questionable C spine fx. What is the imaging test of choice to intitialy eval and clear his c spice
a) positiron emission topography
b) MRI
c) CT
d) lateral radiograph
Lateral radiograph. MRI/CT is used for major fractures or dislocations
Tx for exacerbation of MS symptoms
a) Baclofen
b) INF
c) Glatiramer acetate
d) methylprednisone
Acute relapses of MS are txed w/ a short course of IV methylprednisolone and followed by oral prednisone. All the other drugs mentioned are for reducing attack rate of MS
Reommendation for primary prevention of a stroke in a pt <60yo w/ afib
a) No tx
b) ASA
c) Warfarin
d) Maze procedure
No tx is recommended for primary stroke prevention in this patient
30 yo female presents to the office complaining of generalized weakness and reduced exercise tolerance that improves with rest. On PE you notice bilateral eyelid ptosis, proximal muscle weakness and normal reflexes. Most likely diagnosis?
a) Lambert Eaton Syndrome
b) Organophosphate intoxication
c) MS
d) MG
MG/ Common symptoms are fatigable weakness, ptosis, diplopia and proximal muscle weakness. Disease is more common in women in the 2nd and 3rd decade and in men older than 60.
50 yo male presents to the ER w/ unilateral HA. Pain is steady and non throbbing. Also has nasal congestion and rhinorrhea. Mentions that EtOH triggers these HA. What do we recommend for this pt?
a) High flow O2
b) Massage
c) Ibuprofen
d) propranolol
O2 is rad for cluster HA, which this is.
Massage and IBU is good for tension, propranolol is good for migraine.
CSF with elevated WBC (>5,000), Dec glucose (35) and elevated protein lvl (>150)
Acute bacterial meningitis
Tx for abscence seizures
a) Phenytoin
b) carbamazepine
c) Ethosuximide
d) gabapentin
Ethosuximide, valproic acid and clonazepam are all used for absence seizures.
Phenytoin/carbamazepine is used for TC and partial seizures, gabapentin is used for partial seizures
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