Neurology packrat Flashcards
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)
(c) B. Absence seizures are usually treated successfully with Ethosuximide. The other agents listed are not
indicated and may actually worsen this type of seizure.
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)
(c) B. A CT scan is more sensitive in detecting cerebral hemorrhage in the first 24 to 48 hours.
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)
(c) C. MRI is the most appropriate diagnostic study in the evaluation of a suspected intracranial neoplasm.
Household contacts of a patient with bacterial meningitis are best treated with which of the following? A. Amoxicillin B. Ciprofloxin (Cipro) C. Tetracycline (Sumycin) D. Vancomycin
(c) B. Rifampin, Cipro, Levaquin, Zithromax and Rocephin are the drugs of choice.
A 22 year-old female presents with 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 C. Methylprednisolone (Solumedrol) D. Pyridostigmine (Mestinon)
(c) A. 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 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 with 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
(c) C. 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.
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
(c) B. 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 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 Explanations
(c) C. 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? Answers A. Chorea B. Dystonia C. Masked facies D. Hyperreflexia
(c) C. The patient symptoms are consistent with Parkinsonism. Physical exam findings include masked facies, micrographia, decreased arm swing, and monotonous speech.
A patient with an upper motor neuron lesion would exhibit which of the following findings? Answers A. Fasciculations B. Areflexia C. Muscular atrophy D. Spasticity
(c) D. Spasticity is an upper motor neuron lesion finding.
What test is the single most useful test in establishing the diagnosis of multiple sclerosis?
Answers
A. Cerebral spinal fluid cell count and protein level
B. Cerebral spinal fluid immunoglobulin studies
C. Evoked potentials
D. Magnetic Resonance Imaging
(c) D. The presence of plaques on MRI is a key finding in establishing the diagnosis of MS.
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? Answers A. MRI of the brain B. Electroencephalogram C. Multiple sleep latency test D. Overnight polysomnography
(c) C. Multiple sleep latency test is required to observe the abrupt transition to REM sleep and establish the diagnosis of narcolepsy.
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? Answers A. Cluster headaches B. Depression C. Glioblastoma D. Giant cell arteritis
(c) C. Morning headaches associated with vomiting are indicative of increased intracranial pressure and raise concern of a CNS tumor such as a glioblastoma.
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? Answers A. Guillain-Barré syndrome B. Multiple sclerosis C. Myasthenia gravis D. Spinal cord compression
(c) A. The pattern of sensory, motor and reflex findings is consistent with the pathophysiology of peripheral nerve demyelination that occurs in Guillain-Barré syndrome.
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? Answers A. Bell's palsy B. Cluster headache C. Post-herpetic neuralgia D. Trigeminal neuralgia
(c) D. This is the classic presentation for trigeminal neuralgia (tic douloureux).
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? Answers A. Electrocardiogram B. Fasting lipid profile C. Carotid Doppler ultrasound D. MRI with gadolinium
(c) B. Hyperlipidemia is a known risk factors for stroke that can be modified with treatment.
Which of the following interventions is most effective during the early stages of Alzheimer’s disease?
Answers
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
(c) B. Memory aids are extremely helpful in assisting Alzheimer patients during the early stages of the disease.
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?
Answers
A. Order a CBC, electrolytes, and toxicology screen
B. Order a CT of the head
C. Hyperventilate the patient
D. Administer streptokinase
What would be
(c) B. This presentation is consistent with a structural abnormality that will be detected on an imaging study.
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? Answers A. Phenobarbital B. Amitriptyline (Elavil) C. Celecoxib (Celebrex) D. Codeine
(c) B. Amitriptyline is one of several preferred agents for management of peripheral neuropathy.
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? Answers A. Serum amylase B. Serum creatinine C. Liver function tests D. Electroencephalogram
(c) C. Valproate may be toxic to the liver as well as cause thrombocytopenia.
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? Answers A. Cerebellum B. Posterior column C. Sensory cortex D. Vestibular apparatus
(c) B. 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.
During EOM testing, the patient is noted to have delayed adduction of the left eye. The rest of the examination is normal. Which of the following is the most likely underlying cause for this abnormality? A. Muscular dystrophy B. Multiple sclerosis C. Myasthenia gravis D. Polymyalgia rheumatica
(c) B. Internuclear ophthalmoplegia results from damage to the medial longitudinal fasciculus ascending from the abducens nucleus in the pons to the oculomotor nucleus in the midbrain and results in slow or absent adduction of the eye. It is most commonly seen with multiple sclerosis.
Which of the following is the earliest manifestation of dementia of the Alzheimer's type? A. Incontinence B. Memory deficit C. Aggressiveness D. Motor disturbances
(c) B. A primary characteristic of dementia is memory impairment. A major component of the presenting symptoms is subjective complaints of memory difficulty.
A 12 month-old presents with possible viral meningitis. Which of the following laboratory results is most consistent with this diagnosis? A. Decreased CSF glucose level B. Decreased CSF total protein level C. Increased CSF mononuclear cells D. Increased CSF C-reactive protein
(c) C. Increased CSF mononuclear cells are noted in viral meningitis.
Which of the following tests measures cerebellar function? A. Finger-to-nose testing B. Stereognosis C. Graphesthesia D. Two-point discrimination
(c) A. Cerebellar function is tested by finger-to-nose, heel-to-knee, rapid alternating movements, and gait.
A 10 year-old 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
(c) B. Absence seizures are generalized seizures characterized by abrupt, brief episodes of impaired consciousness, staring, and rhythmic blinking.
A 73 year-old female patient was diagnosed 3 years ago with Alzheimer's disease. Her 80 year-old husband can no longer help feed and bathe her. 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
(c) D. 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.
Which of the following is considered to be the gold standard in making the diagnosis of multiple sclerosis? A. Gadolinium-enhanced MRI B. MRA of the brain C. Positron emission testing D. CT brain scan
(c) A. Gadolinium-enhanced MRI studies can help to characterize and delineate intramedullary disease and are able to characterize various lesions in time and space.
A 5 year-old child has just been hospitalized with meningococcemia. Family members and close contacts should be given which of the following as prophylaxis? A. Rifampin orally B. Penicillin orally C. Erythromycin orally D. No chemoprophylaxis
(c) A. Exposed household, school, or day-care contacts of children with meningococcemia should receive chemoprophylaxis to eliminate the organism from the nasopharynx. The drug of choice is rifampin (10 mg/kg, up to 600 mg) every 12 hours for 48 hours. Sulfisoxazole, ceftriaxone, and ciprofloxacin are alternative choices for prophylaxis.
A 42 year-old female has a diagnosis of migraine headaches. She had been using ergotamine to abort her headaches, but she is now having one or two headaches per week that are interfering with work. Of the following, the most appropriate preventive therapy is A. sumatriptan (Imitrex). B. promethazine (Phenergan). C. propranolol (Inderal). D. ketorolac (Toradol).
(c) C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely.
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. reassure the patient and provide patient education.
B. recommend a nonsteroidal anti-inflammatory medication.
C. recommend tricyclic antidepressants.
D. recommend physical therapy.
(c) A. Bell’s palsy will resolve completely without treatment in approximately 60% of all cases.
Of the following drugs, the appropriate treatment of myasthenia gravis is A. donepezil (Aricept). B. quinidine (Quinidex). C. neostigmine (Prostigmin). D. edrophonium (Tensilon).
(c) C. Neostigmine is useful in the treatment of myasthenia gravis.
A 68 year-old male who is obese has a 50 pack-year history of smoking. He experienced a sudden and total loss of vision in his right eye, which resolved after 20 minutes. Which of the following is the most likely diagnosis? A. Optic neuritis B. Retinal detachment C. Macular degeneration D. Transient ischemic attack
(c) D. This history of sudden onset of a unilateral neurological deficit in a patient with risk factors for vascular disease suggests vascular ischemia. By definition, a transient ischemic attack is a neurological deficit that resolves quickly.
Bradykinesia is most commonly associated with A. Wernicke's syndrome. B. Hashimoto's thyroiditis. C. Cushing's disease. D. Parkinson's disease.
(c) D. Patients with Parkinson’s disease have resting tremor, bradykinesia, lack of facial expression, and micrographia.
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.
(c) B. Splinting in neutral position relieves impingement of the median nerve, thus improving symptoms of carpal
tunnel.
Treatment of Bell’s palsy includes which of the following?
A. Acyclovir
B. Reassurance of the patient’s recovery
C. Referral to a neurosurgeon
D. Electromyography
(c) B. 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 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).
(c) C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely.
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
(c) B. The grasp reflex starts to disappear at about 2-3 months of age.
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.
(c) C. 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.
Which of the following side effects is associated with long-term administration of phenytoin (Dilantin)? A. Ataxia B. Hypotension C. Osteomalacia D. Cardiac dysrhythmia
(c) C. Osteomalacia, or demineralization of bone, is a side effect of phenytoin that may occur after chronic
administration.
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
(c) D. Parkinson’s disease presents with tremor at rest (pill-rolling), bradykinesia, rigidity, and postural instability.
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
(c) C. The dermatome T10 is at the level of the umbilicus.
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
(c) A. 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.
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
(c) C. Benzodiazepines are the drugs of choice for insomnia in the elderly population.
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
(c) D. This patient’s symptoms are consistent with transient ischemia in the carotid territory. Atrial fibrillation is a risk factor for cerebral emboli.
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)
(c) C. Ampicillin and ceftriaxone is 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
