Vignette Questions Flashcards
A 75-year-old male with a history of hypertension and dementia is admitted to the hospital for pneumonia. Two days after admission, the nurses note that he is increasingly confused, disoriented, and agitated, particularly in the evening. He has been pulling at his IV lines and trying to get out of bed. He has no fever, and his vital signs are stable. His medications include levofloxacin and lisinopril. His CAM score is positive for delirium.
Question: What is the most likely cause of this patient’s delirium?
A) Urinary tract infection
B) Sepsis
C) Medication side effect
D) Pneumonia combined with dementia
Pneumonia combined with dementia
The combination of acute illness (pneumonia) and underlying dementia is a common cause of delirium in elderly patients. While medications and infections such as a UTI can also cause delirium, pneumonia in the presence of pre-existing cognitive impairment is the most likely factor here.
A 70-year-old male with a history of atrial fibrillation and chronic obstructive pulmonary disease (COPD) is brought to the ER by his family due to confusion, disorganized speech, and visual hallucinations over the past day. He was recently started on a new medication for his COPD. His vital signs are stable, and there are no signs of infection.
Question: Which of the following medications is most likely causing the delirium?
A) Albuterol
B) Tiotropium
C) Prednisone
D) Theophylline
Prednisone
Prednisone, a corticosteroid, is known to cause neuropsychiatric side effects, including delirium, especially in older adults. The acute onset of confusion and hallucinations after starting a new medication suggests corticosteroid-induced delirium.
An 85-year-old woman with advanced dementia is admitted to the hospital for a hip fracture. Two days post-op, she becomes agitated, refuses to eat, and is unable to maintain attention during conversations. Her vital signs are stable, and she is afebrile. She has no new medications.
Question: What is the most appropriate next step in managing this patient’s delirium?
A) Restrain the patient
B) Administer haloperidol
C) Ensure adequate hydration and reorient the patient frequently
D) Discharge the patient
Ensure adequate hydration and reorient
Non-pharmacologic interventions are the first-line treatment for delirium. Ensuring hydration, frequent reorientation, and a calm environment are essential for managing delirium, especially in patients with dementia. Restraints and antipsychotics should only be used if absolutely necessary.
An 80-year-old woman presents with her daughter, who reports a 2-year history of memory problems. The patient frequently forgets recent conversations, misplaces items, and has become disoriented in familiar environments. Her past medical history is significant for hypertension, type 2 diabetes, and osteoarthritis. On examination, she has difficulty recalling three words after five minutes and struggles with complex tasks. Her MMSE (Mini-Mental State Examination) score is 21/30.
Question: What is the most likely diagnosis?
A) Mild cognitive impairment (MCI)
B) Major depressive disorder
C) Alzheimer’s disease
D) Vascular dementia
Alzheimer’s Disease
This patient’s progressive memory decline over two years, especially her difficulty with recent memory and disorientation, is characteristic of Alzheimer’s disease, the most common form of dementia. Mild cognitive impairment (MCI) does not usually involve functional impairment to this degree, and vascular dementia typically presents with a stepwise decline in function.
A 75-year-old man with a history of stroke presents with gradual worsening of his memory and difficulty performing daily tasks over the last year. His wife reports that his memory loss is often abrupt and seems to get worse in “steps.” He also has occasional focal neurological symptoms like weakness in his right arm. His brain MRI shows multiple small infarcts in both hemispheres.
Question: What is the most likely diagnosis?
A) Alzheimer’s disease
B) Frontotemporal dementia
C) Vascular dementia
D) Lewy body dementia
Vascular Dementia
The patient’s history of stroke, stepwise decline in memory, and focal neurological deficits, along with evidence of infarcts on imaging, suggest vascular dementia, which is commonly caused by cerebrovascular disease. This differentiates it from the more gradual decline seen in Alzheimer’s disease.
A 70-year-old woman is brought to the clinic by her family for increasing episodes of forgetfulness and visual hallucinations. They report that she sometimes sees people who are not there and has episodes of acting out her dreams at night. On examination, she has mild parkinsonism with a shuffling gait and bradykinesia. Her MMSE score is 24/30.
Question: What is the most likely diagnosis?
A) Parkinson’s disease dementia
B) Alzheimer’s disease
C) Lewy body dementia
D) Vascular dementia
Lewy Body Dementia
The combination of visual hallucinations, cognitive decline, and parkinsonism suggests Lewy body dementia. Additionally, REM sleep behavior disorder (acting out dreams) is often seen in this condition. Parkinson’s disease dementia typically appears later in the course of established Parkinson’s disease, whereas Lewy body dementia has early cognitive symptoms.
A 58-year-old male is brought in by his wife due to a 6-month history of increasingly inappropriate behavior and personality changes. He has become socially withdrawn, has lost interest in work, and exhibits impulsive behavior. His memory appears intact, but he has difficulty planning and organizing his day. His neurological exam is unremarkable.
Question: What is the most likely diagnosis?
A) Alzheimer’s disease
B) Frontotemporal dementia
C) Lewy body dementia
D) Depression
Frontotemporal Dementia
Frontotemporal dementia (FTD) typically presents with early personality changes, disinhibition, and poor executive function (difficulty with planning and organization), which differentiates it from Alzheimer’s disease, where memory loss is more prominent. The patient’s relatively preserved memory supports FTD.
A 72-year-old male presents to your clinic with memory problems. His wife states that he has been repeating questions, losing items, and missing appointments over the past year. His medical history includes hypertension and poorly controlled diabetes. Neurological examination is normal, and his MMSE score is 25/30. An MRI of the brain reveals moderate atrophy, predominantly in the hippocampal region.
Question: What is the most likely diagnosis?
A) Vascular dementia
B) Frontotemporal dementia
C) Alzheimer’s disease
D) Normal pressure hydrocephalus
Alzheimer’s Disease
The MRI findings of hippocampal atrophy, along with the memory deficits and gradual decline in cognitive function, point towards Alzheimer’s disease. The hippocampus is particularly affected in Alzheimer’s, leading to early and significant memory impairment.
A 22-year-old man presents to your office after experiencing a head injury while playing football 3 days ago. He lost consciousness for less than 5 seconds after hitting his head during a tackle. Upon regaining consciousness, he was taken to the hospital for evaluation due to experiencing symptoms of headache, nausea, and mild confusion. Computed tomography of the head was negative for any acute findings. The patient now has questions about return to activity and ongoing health maintenance after a concussion. Which of the following is the most appropriate guidance?
A) Annual brain imaging
B) Cognitive rehabilitation
C) Immediate return to activity
D) Stepwise return to activity
Stepwise return to activity
A 35-year-old woman presents with sudden onset right-sided facial weakness. She is unable to raise her right eyebrow or close her right eye. She denies limb weakness or speech difficulties. Physical examination reveals complete right-sided facial paralysis, including the forehead. Which of the following is the most likely diagnosis?
A) Stroke
B) Bell’s Palsy
C) Myasthenia gravis
D) Multiple sclerosis
Bell’s Palsy
Bell’s Palsy causes peripheral facial paralysis, affecting both the upper and lower face. The inability to raise the eyebrow and close the eye suggests a lower motor neuron lesion of the facial nerve.
A 45-year-old man presents with sudden onset left-sided facial weakness. He reports difficulty closing his left eye and raising his left eyebrow. He was recently treated for a cold sore. What is the most appropriate initial treatment for this patient?
A) Antibiotics
B) Antiviral therapy alone
C) High-dose corticosteroids
D) Low-dose corticosteroids and antiviral therapy
Low-dose corticosteroids and antiviral therapy
The recommended treatment for Bell’s Palsy includes corticosteroids to reduce inflammation, and antivirals may be considered, especially if there is evidence of a viral trigger such as herpes simplex.
A 50-year-old woman presents with sudden right-sided facial paralysis and difficulty closing her right eye. She also reports dry eyes and decreased tear production on the affected side. What is the most important next step in managing her dry eyes?
A) Oral corticosteroids
B) Surgical intervention
C) Artificial tears and eye patching
D) Antiviral therapy
Artificial tears and eye patching
Bell’s Palsy can impair the ability to close the eye, leading to dry eyes and potential corneal damage. Artificial tears and eye patching are necessary to protect the eye from drying and injury.
A 40-year-old male presents with right-sided facial paralysis that began 2 days ago. He cannot close his right eye or smile on the right side. He has no history of trauma or previous neurological deficits. Examination reveals right-sided lower motor neuron facial weakness. Which of the following clinical signs helps distinguish Bell’s Palsy from a stroke?
A) Facial droop involving the entire face, including the forehead
B) Sudden onset of symptoms
C) Absence of headache or altered mental status
D) Involvement of the upper extremities
Facial droop involving the entire face, including the forehead
A 34-year-old man presents with acute onset left-sided facial paralysis. He is diagnosed with Bell’s Palsy. Which of the following best describes the pathophysiology of this condition?
A) Demyelination of the facial nerve
B) Inflammation and edema of the facial nerve
C) Autoimmune destruction of the facial nerve
D) Ischemia of the facial nerve
Inflammation and edema of the facial nerve
A 45-year-old man presents with involuntary jerking movements, irritability, and difficulty with memory and concentration. His father had a similar condition and died at age 55. On physical exam, he has choreiform movements of the upper extremities. Which of the following is the most likely diagnosis?
A) Parkinson’s disease
B) Huntington disease
C) Amyotrophic lateral sclerosis (ALS)
D) Multiple sclerosis
Huntington’s Disease
The patient presents with chorea, cognitive decline, and a family history consistent with Huntington disease, an autosomal dominant neurodegenerative disorder.
A 40-year-old woman with a family history of Huntington disease is experiencing mood swings, irritability, and mild memory problems. She is worried she may have inherited the condition. Which of the following tests would confirm the diagnosis?
A) MRI of the brain
B) Serum C-reactive protein
C) Genetic testing for CAG repeat expansion
D) Electromyography (EMG)
Genetic testing for CAG repeat expansion
Genetic testing is the definitive method for diagnosing Huntington disease by detecting the CAG repeat expansion in the HTT gene.
A 50-year-old man with Huntington disease presents with worsening motor symptoms, including involuntary movements and gait instability. He also reports increased irritability and difficulty concentrating. What is the best treatment option for managing his chorea?
A) Levodopa
B) Tetrabenazine
C) Donepezil
D) Carbamazepine
Tetrabenazine
Tetrabenazine is commonly used to manage the chorea associated with Huntington disease by depleting dopamine and reducing involuntary movements.
A 46-year-old man with Huntington disease presents with progressive difficulty walking and frequent falls. MRI of the brain reveals atrophy of the caudate nucleus. Which of the following best explains the pathophysiology of Huntington disease?
A) Degeneration of dopaminergic neurons in the substantia nigra
B) Loss of lower motor neurons in the anterior horn of the spinal cord
C) Atrophy of the caudate nucleus and putamen in the basal ganglia
D) Demyelination of white matter in the central nervous system
Atrophy of the caudate nucleus and putamen in the basal ganglia
A 30-year-old male presents to the emergency department with intense, right-sided orbital pain, tearing, and nasal congestion. The pain started 45 minutes ago and is unbearable. He has had similar episodes over the past few days. Which of the following findings is typically associated with this condition?
A) Bilateral eye tearing
B) Mydriasis (pupil dilation)
C) Horner’s syndrome (ptosis, miosis, anhidrosis)
D) Vision loss
Horner’s Syndrome (ptosis, miosis, anhidrosis)
Cluster headaches are associated with autonomic symptoms on the affected side, including Horner’s syndrome, which involves ptosis (drooping eyelid), miosis (constricted pupil), and anhidrosis (loss of sweating).
A 32-year-old woman presents with sudden onset of vision loss in her right eye, associated with pain when moving her eye. She also reports tingling in her legs and difficulty with balance. MRI of the brain shows multiple hyperintense lesions in the periventricular area. What is the most likely diagnosis?
A) Guillain-Barré syndrome
B) Multiple sclerosis
C) Myasthenia gravis
D) Transverse myelitis
Multiple Sclerosis
A 34-year-old man with a diagnosis of relapsing-remitting multiple sclerosis presents with a new onset of leg weakness and difficulty walking. MRI shows new lesions in the spinal cord. Which of the following is the most appropriate treatment for his acute exacerbation?
A) Methotrexate
B) High-dose intravenous corticosteroids
C) Plasma exchange
D) Intravenous immunoglobulin (IVIG)
High-dose intravenous corticosteroids
A 36-year-old woman with multiple sclerosis presents with worsening muscle spasticity in her legs. Her walking has become more difficult, and she has increased stiffness and spasms. Which of the following is the most appropriate treatment for managing her spasticity?
A) Diazepam
B) Baclofen
C) Gabapentin
D) Prednisone
Baclofen
Baclofen is a muscle relaxant commonly used to manage spasticity in patients with multiple sclerosis, helping to reduce muscle stiffness and improve mobility.
A 29-year-old woman presents with blurred vision, double vision, and sensory disturbances in her legs. She is diagnosed with multiple sclerosis. Which of the following best describes the underlying pathophysiology of multiple sclerosis?
A) Autoimmune destruction of peripheral nerves
B) Immune-mediated demyelination of the central nervous system
C) Accumulation of amyloid plaques in the brain
D) Degeneration of motor neurons in the spinal cord
Immune-mediated demyelination of the central nervous system
A 65-year-old man presents to the emergency department with sudden onset of left-sided weakness and slurred speech that resolved spontaneously after 30 minutes. He has a history of hypertension and smoking. Physical exam is now normal. CT scan of the head shows no acute abnormalities. What is the most likely diagnosis?
A) Stroke
B) Transient ischemic attack (TIA)
C) Migraine with aura
D) Bell’s palsy
TIA
