food for the brain

7/26/2019 food for the brain

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Neurology Questions & AnswersNeurology:Question 1A 39-year-old executive comes to the office for a follow-up visit. She had a generalied tonic-clonic seiure !wee" ago# witnessed $y her hus$and# who reports that the seiure started suddenly. She had tonic extensionand stiffening of her whole $ody followed $y rhythmic %er"ing movements of her arms# trun"# and legs. hepatient had no warning prior to the seiure# and afterward fell into a deep sleep. She was hospitalied. 'a"e

and sleep electroencephalography and magnetic resonance imaging of the $rain with contrast were normal# andshe was sent home on a maintenance dose of phenytoin. he patient states that# for the ( nights prior to theseiure# she slept no more than ) hours a night in order to finish an assignment. here is no personal or familyhistory of seiures. Neurologic examination is normal.'hich of the following is the most appropriate next step in management*A. +ontinue phenytoin,. iscontinue phenytoin+. iscontinue phenytoin and $egin car$amaepine. iscontinue phenytoin and $egin valproic acid. iscontinue phenytoin and $egin ga$apentin

Neurology:Question 2A /3-year-old woman has transient left hemiparesis lasting )0 minutes and calls your office that same day toinform you. She has a history of intermittent nonvalvular atrial fi$rillation# angina pectoris# and hypertension.At the time of her call# she is completely asymptomatic. 1er only antithrom$otic therapy is aspirin# 2! mg daily.'hat is the optimal initial management for this patient*A. Schedule an office appointment within ! wee".,. Schedule transesophageal echocardiography.+. Schedule 1olter monitoring.. Schedule outpatient carotid duplex ultrasonography.. $tain emergency computed tomography.Neurology:Question 3A 34-year-old woman comes to the office with a !-day history of $lurred vision and retro-or$ital pain withmovement of the right eye. 5ast medical history is unremar"a$le. n examination# she has a right afferentpupillary defect. 6isual acuity is )07)00 in the right eye with a dense central scotoma# and )07)4 in the left eye.8unduscopic examination is normal $ilaterally. he rest of the neurologic examination is normal. agneticresonance imaging of the $rain shows one nonenhancing periventricular white matter lesion. he patientrefuses lum$ar puncture for examination of cere$rospinal fluid. reatment with intravenousmethylprednisolone improves her optic neuritis.

'hich of the following should $e done to monitor for development of multiple sclerosis*A. :epeat examination only when patient has a new neurologic symptom,. Serial visual evo"ed potential studies in ; months+. 8ormal visual field studies in ; months. 8ollow-up magnetic resonance imaging of the $rain with gadolinium in ; months. Serial nerve conduction velocity examinations in ; months

Neurology:Question 5A 3;-year-old woman with a !4-year history of headaches comes to the office for a follow-up visit.


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Neurologic examination reveals severe wea"ness and atrophy of the left thenar and hypothenar muscles# andmild wea"ness of left foot dorsiflexion. uscle stretch reflexes are hyperactive and symmetric. Sensation isnormal. agnetic resonance imaging of the cervical spine was o$tained $y an orthopedic surgeon ) wee"searlier and is normal.'hich of the following is the most appropriate next step*A. uscle $iopsy,. Nerve $iopsy

+. Serum creatine "inase determination. lectromyography. =enetic testingNeurology:Question 7A (;-year-old woman comes to the office for management of a (-mm left middle cere$ral artery aneurysm. heaneurysm was found when the patient had magnetic resonance angiography and imaging for evaluation of achronic headache disorder. edical history is limited to chronic migraine headaches and smo"ing. Neurologicexamination is normal.'hich of the following is the most appropriate next step in this patient>s management*A. Arteriography,. +omputed tomographic angiography+. 8ollow-up magnetic resonance angiography in ; months. Aneurysm clippingNeurology:Question 8

A /!-year-old man comes to the office $ecause of slowness# tremor# stiffness# and difficulty with dexterity# suchas $uttoning clothes. he pro$lems developed insidiously over the last few years# and have caused him to curtailhis activities severely. n examination# he has a shuffling gait# tremor of one hand while wal"ing# and reducedarm swing ?right more than left@. :apid alternating movements are very slow# especially in the right lim$s.5assive movement of his lim$s reveals rigidity. Neurologic examination is otherwise normal.'hich of the following is the most appropriate management for this patient*A. No treatment,. Selegiline+. Amantadine. +ar$idopa7levodopa. ntacaponeNeurology:Question 9A ;2-year-old man is under evaluation for memory difficulty that# according to his wife# $egan insidiously 3 or( years earlier. 1e has difficulty remem$ering recent events. 8or example# he forgets appointments and recent

conversations# and forgot that a close relative had recently died. 1e is no longer a$le to manage his ownchec"$oo" or operate his car without getting lost. edical history is unremar"a$le. 5hysical examination isnormal. ental status examination shows prominent memory loss and difficulty drawing a complex figure.agnetic resonance imaging of the $rain shows only mild cere$ral atrophy.'hich of the following is the most li"ely diagnosis*A. Alheimer>s disease,. ementia with ewy $odies+. 6ascular dementia. 8rontotemporal dementia. +reutfeldt-Ba"o$ diseaseNeurology:Question 10A )3-year-old woman comes to the office with her hus$and for evaluation of recent onset of unusual $ehavior.'hile providing the clinical history# the patient $egins to cry. Shortly after that the patients arms start sha"ing.=radually# the sha"ing $ecomes more pronounced and involves her legs and head. he patients $reathing

$ecomes deep and fast. his continues on and off for several minutes. he sha"ing stops gradually. he patientopens her eyes and states that she has a headache and is very tired and diy. 8amily history is positive forseiures in the patients cousin. here has $een a significant amount of family stress recently.'hich of the following is the most li"ely diagnosis*A. Syncope,. Nonepileptic event ?pseudoseiure@+. 5artial seiure with secondary generaliation. =eneralied tonic-clonic seiure. ,asilar migraineNeurology:Question 11A ;4-year-old woman comes to the emergency department $ecause of mild left hem iparesis and mild left-sided


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sensory deficit that $egan suddenly ) days earlier. She has a history of myocardial infarction and ta"es aspirin#2! mg daily.'hich of the following is the most appropriate next step in the management of this patient*A.


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Neurology:Question 16A )4-year-old woman comes to the office for a follow-up visit. She has a !0-year history of complex partialseiures with occasional secondary generaliation. he patient reports that she is !( wee"s pregnant and thatshe has had no seiures since her last visit more than ! year ago. +urrently# she is on car$amaepinemonotherapy# )00 mg three times daily. 1er car$amaepine $lood level today is 2.) Gglm ?therapeutic range#2 to !) Gglm@.'hich of the following is the most appropriate next step in management*

A. +ontinue car$amaepine at the current dose,. s presentation*A. enieres disease,. 6esti$ular neuronitis

+. +ere$ellar hemorrhage. ,enign positional vertigoNeurology:Question 18A 32-year-old man comes to the office $ecause of paresthesias in his feet that $egan approximately 2 monthsago. 1e now also has $ilateral foot drop and wea"ness of the right hand. n examination# he has severewea"ness in the foot dorsiflexors $ilaterally and moderate wea"ness of foot eversion# inversion# and plantarflexion. 1e has mild wea"ness of hip flexion and is una$le to rise from a chair without using his arms. here isalso wea"ness in the ulnar-innervated hand muscles# slightly more pronounced on the right than on the left.here are no o$taina$le reflexes# and he has moderate proprioceptive loss in the toes.'hich of the following is the most li"ely diagnosis*A. =uillain-,arrH syndrome,. +hronic inflammatory demyelinating polyneuropathy+. 5olymyositis. yasthenia gravis

Neurology:Question 19An 24-year-old man arrives in the emergency department within 30 minutes of sudden-onset lefthemiparesis. ,lood pressure is )(07!)( mm 1g on arrival and ) hours after the onset of his symptoms.1e has severe left hemiparesis# neglect ?left hemi-inattention@# and a left hemisensory deficit.lectrocardiography# la$oratory tests# and cere$ral computed tomography are normal.'hich of the following is the most appropriate management for this patient*A. =ive intravenous la$etalol to achieve $lood pressure $elow !247!!0 mm 1g and then give intravenous tissueplasminogen activator ?t-5A@.,. =ive intravenous nitroprusside to achieve $lood pressure $elow !247!!0 mm 1g and then give intravenous t-5A.+. o not give antihypertensive medication or intravenous t-5A.. o not give antihypertensive medication $ut do give intravenous t-5A.. =ive antihypertensive medication to achieve $lood pressure $elow !247!!0 mm 1g and then give intra-arterial t-5A.

Neurology:Question 20A )3-year-old woman comes to the office for re-evaluation of migraine headaches. She was seen ) wee"s earlier$ecause of recurrent generalied# moderate to severe pulsatile headaches associated with nausea and light andnoise sensitivity. he headaches typically last ! to ) days# and she was having approximately !0 headache daysper month. Amitriptyline was $egun at a dose of !0 mg at $edtime# with instructions to increase the dose in !0-mg increments every wee" toward an initial target dose of 40 mg. he current dose is 30 mg at $edtime. Shetolerates the amitriptyline well. oday she has developed a typical attac" that is treated with su$cutaneoussumatriptan in the office.'hat plan should $e pursued for prophylactic treatment*A. +ontinue amitriptyline at the current dose.,. +ontinue increasing amitriptyline as planned.


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+. iscontinue all prophylaxis.. iscontinue amitriptyline and $egin propranolol.. iscontinue amitriptyline and $egin divalproex sodium.Neurology:Question 21A 44-year-old man reports that his handwriting has $een getting smaller# and his wife states that he has $eenwal"ing with a slow# shuffling gait for a$out ) years. 1e otherwise feels well. 1e has dia$etes# dia$eticgastroparesis# a 3-year history of celiac disease responsive to medications and a gluten-free diet# and

depression. aily medications are gly$uride# ranitidine# metoclopramide# and $upropion. n examination# hehas facial mas"ing# a slightly shuffling gait# $ilateral reduced arm swing# mild diffuse lim$ rigidity# and reducedspeed when performing rapid alternating movements.'hat is the most appropriate management of his current symptoms*A. iscontinue metoclopramide.,. iscontinue ranitidine.+. iscontinue $upropion.. ,egin car$idopa7levodopa.. ,egin pramipexole.Neurology:Question 22A ;0-year-old woman with a history of adenocarcinoma of the lung presents to her physician with a 3-wee"history of horiontal diplopia# dysphagia# and right leg pain with foot drop. xamination reveals wea"ness ofright eye a$duction# left facial wea"ness# reduced gag reflex# and wea"ness of the right leg muscles supplied $ythe 4 nerve root. +omputed tomography of the head with contrast shows only enlargement of the entire

ventricular system ?communicating hydrocephalus@.'hich of the following is the most li"ely cause of this patient>s findings*A. 5arenchymal $rain metastases,. 6enous sinus throm$osis+. 5araneoplastic encephalitis. eptomeningeal metastases. 1erpes oster infection of the central nervous systemNeurology:Question 23A )!-year-old woman comes to the office with her mother $ecause of recurrent $lac"outs. he patient has hadfive episodes in her life# the last one a wee" ago. She descri$es feeling diy# lightheaded# nauseated# and warmprior to $lac"ing out. According to her mother# the patient $ecomes pale# then falls suddenly to the ground andhas several %er"s of her lim$s. 1er mother states that the patient recovers consciousness almost immediately#without any confusion or disorientation. uring one event# the patient was incontinent of urine# and did notrecover for at least 30 seconds. ost episodes have occurred in church after prolonged standingC the latest

occurred when the patient witnessed a medical procedure while visiting a relative in the hospital.'hich of the following is the most li"ely diagnosis*A. Buvenile myoclonic epilepsy,. +omplex partial seiures with secondary generaliation+. Syncope. Nonepileptic events ?pseudoseiures@. Atonic seiuresNeurology:Question 24A )9-year-old woman with multiple sclerosis comes to the office $ecause of overwhelming fatigue. She has hadthree exacer$ations of multiple sclerosis in the past 2 years and is now in remission. 1er fatigue is particularlysevere in mid afternoonC she often naps if possi$le or finds it difficult to concentrate on wor". She has nopro$lem falling asleep at night and does not wa"e up $efore she wishes. She sleeps !0 hours a day. She has nosymptoms to suggest depression. Neurologic examination and thyroid function studies are normal.'hich of the following would $e a reasona$le medication to prescri$e for her pathologic fatigue*

A. hyroid supplement,. Amphetamine+. Amantadine. 8luoxetine. 5emolineNeurology:Question 25A /2-year-old man is evaluated in the office for progressive impairment of memory and other aspects ofintellect# which has developed insidiously over 3 years. he patient recalls none of three words after a 3-minutedelay# and has a ini-ental State xamination score of )) of 30. here are no othersignificant findings on physical examination.'hich of the following is most li"ely to improve this patient>s symptoms*


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A. =alantamine,. =ing"o $ilo$a+. 6itamin . SelegilineNeurology:Question 26A ;/-year-old man who lives alone is found on the floor of his home $y his son and is $rought to the emergencydepartment within 30 minutes. 'hen last seen $y his son 3 days earlier# the patient was in full health.


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Neurology:Question 30An o$ese ;;-year-old man has had increasing pain and num$ness of the right anterior thigh over the past 3wee"s. 1e has not seen a physician in more than )0 years. n examination# he has moderate wea"ness of right"nee extension# thigh adduction# and hip flexion. he right "nee %er" reflex is a$sentC the left "nee %er" is !F.Achilles reflexes are a$sent $ilaterally. 1e has sensory loss in the right anterior thigh region and a stoc"ing-glove distri$ution of sensory loss in the distal legs. agnetic resonance imaging of the lum$osacral spine andlum$osacral plexus is normal.

'hich of the following studies is most li"ely to $e diagnostic*A. +reatine "inase level,. 1emoglo$in A !0 level+. hyroid function. um$ar puncture. rythrocyte sedimentation rateNeurology:Question 31A ;2-year-old woman comes to the office $ecause of a )-year history of falls and im$alance that has progressedinsidiously. She also has trou$le reading and doing needlewor" $ecause of poor vision. 8amily history isnegative for neurologic disease. She has a staring facial expression. 6isual acuity and visual fields are normal#$ut she has impaired upward7downward gae. She moves stiffly and slowly# and nearly falls over while wal"ing.1er nec" and# to a lesser degree# lim$s are rigid. :apid alternating movements are mar"edly slowed.'hich of the following is the most li"ely diagnosis*A. 5ar"inson>s disease

,. =eneralied dystonia+. ultiple system atrophy. 5rogressive supranuclear palsy. +ere$ellar degenerationNeurology:Question 32A 4/-year-old man with a clerical %o$ is $rought to the office $y his wife for evaluation of changes in memory#personality# and $ehavior. ver the past 3 years# he has $ecome progressively insensitive to his wife>s concerns#to the point that she has considered separation. 1e ma"es loud# inappropriate comments in pu$lic# and recentlyreceived a poor review from his wor" supervisor. 5ast medical history is unremar"a$leC he ta"es nomedications. 1is mother# a maternal uncle# and the maternal grandfather had dementia. 5hysical examinationis normal. he ini-ental State xamination score is )2 of 30.'hich of the following is the most li"ely diagnosis*A. ild cognitive impairment,. Alheimer>s disease

+. ementia with ewy $odies. 8rontotemporal dementia. +reutfeldt-Ba"o$ diseaseNeurology:Question 33A /0-year-old man presents to his physician with a )-month history of progressive cognitive a$normalities andright-sided wea"ness. 1e has difficulty dressing and $athing himself and is freDuently disoriented with respectto time and place. 8or the last wee" he is dragging his right foot when wal"ing. n examination# he is alert $utinattentive. 1e is disoriented with respect to time and place. 5apilledema is present. here is a mild righthemiparesis affecting the right face# arm# and leg. +omputed tomography of the head with contrast showsmultiple# homogeneously enhancing lesions in the periventricular white matter of $oth cere$ral hemispheres?left more than right@ with surrounding edema and mass effect. A $iopsy of one of the lesions is performed.5ostoperatively# dexamethasone# ( mg three times daily# is administeredC after ) days# the patient is alert andfully oriented# and his right-sided strength is normal. +omputed tomography of the head is repeated and showsmar"ed improvement in all lesions with reduced enhancement and mass effect.

'hich of the following is the most li"ely cause of this patient>s findings*A. etastatic carcinoma,. ultiple sclerosis+. =lio$lastoma multiforme. +entral nervous system vasculitis. 5rimary central nervous system lymphomaNeurology:Question 34A (0-year-old woman with secondary progressive multiple sclerosis continues to have a gradual decline inneurologic status despite treatment with interferon $eta. wo years ago she could wal" )00 meters without acane or rest. She has recently worsened to the point that she can wal" no further than )4 meters with a wal"er.n examination# she has $ilateral lower-extremity wea"ness and hyperreflexia. agnetic resonance imaging of


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the $rain shows multiple white matter lesions in a periventricular distri$ution.'hich of the following treatments would $e most appropriate instead of interferon $eta*A. +hronic oral prednisone,. ,one marrow transplantation+. =latiramer acetate. 5lasmapheresis. itoxantrone

Neurology:Question 35A )(-year-old woman comes to the office $ecause of severe generalied# thro$$ing headaches associated withnausea# occasional vomiting# and light and noise sensitivity. he headaches occur two to three times wee"ly andlast !) to )( hours. She misses approximately ! wor"day each month. She has $een ta"ing olmitriptan# 4 mgorally# for acute attac"s# with good $enefit approximately two thirds of the time. She has insomnia and a pasthistory of childhood asthma.'hich of the following medications is most appropriate to prevent the headaches*A. Amitriptyline,. Nadolol+. Naratriptan. 5ropranolol. SertralineNeurology:Question 36A 32-year-old man comes for a follow-up visit. 8our years earlier# he had three complex partial seiures and

$egan treatment with phenytoin. 1e has had no seiures since $eginning treatment and tolerates themedication well. 1e has no previous personal or family history of seiures or other neurologic illness.Neurologic examination is normal. he patients electroencephalograms ?=s@ consistently show righttemporal spi"es and sharp wavesC his last = was 3 months ago. agnetic resonance imaging ?:


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patient has a history of epilepsy $ut is not compliant with his medications. uring examination# the patient hasanother generalied seiure. 1e $ecomes cyanotic despite oxygen supplementation. 1is pulse is !!07min and$lood pressure is !40790 mm 1g. 1e continues to have seiures despite receiving 2 mg of intravenousloraepam en route to the hospital. he patient weighs approximately 20 "g ?!/; s course of multiple sclerosis*A. onosymptomatic demyelination,. :elapsing-remitting+. 5rimary progressive. Secondary progressive

. ,enignNeurology:Question 43A /4-year-old man comes to the emergency department $ecause he has an ischemic stro"e manifested $y mildexpressive aphasia and a mild right hemiparesis especially involving his face and arm. 1e has a history ofhypertension# hypercholesterolemia# and cigarette smo"ing. Noninvasive cardiac evaluation reveals nocardioem$olic source. +arotid duplex ultrasonography shows 20J to 99J stenosis of the left internal carotidartery ?


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+. Aspirin plus dipyridamole. eft carotid endarterectomy. +lopidogrelNeurology:Question 44A /4-year-old woman presents to the emergency department after a fall at home. She struc" her head and was$riefly unconscious. She is now alert and fully oriented. Neurologic examination is normal. +omputedtomography of the head is negative for hemorrhage# $ut shows a !-cm dural-$ased# calcifed# enhancing lesion

over her left cere$ral convexity.'hich of the following is the most appropriate management of this patients lesion*A. =ross total resection,. ,iopsy+. =amma-"nife radiosurgery. $servationNeurology:Question 45A /)-year-old woman is admitted to the hospital after a cardiac arrest at home. inutes after the event#paramedics discern no heart$eat# $ut she regains sinus rhythm after a 30-minute resuscitative effort. An acutemyocardial infarction is diagnosed on admission. 8ive wee"s after the cardiac arrest# she remains unresponsiveto voice and does not follow any commands. 1er pupillary responses are intact# she has full lateral eyemovements to the doll>s head maneuver# and she triggers the ventilator with spontaneous respirations. 1er eyesare open some of the time# and she appears to have sleep-wa"e cycles. here is no evidence of purposeful orvoluntary response to visual# auditory# tactile# or noxious stimuli# $ut she flexes her arms to noxious stimuli.

'hich of the following is the most appropriate description of this patients neurologic condition*A. ,rain death,. oc"ed-in syndrome+. inimally conscious state. 5ersistent vegetative stateNeurology:Question 46A )9-year-old woman comes to the office $ecause of gradual loss of vision in her left eye over 4 days. hepro$lem started as a KsmudgeL in her central visual field and gradually worsened such that she cannot read withher left eye. She has pain with left eye movements# and she is finding it difficult to wor" $ecause of theimpairment.Neurologic examination is unremar"a$le except for eye findings. 6isual acuity is )07)0 in the right eye and)07(00 in the left eye. 6isual field testing shows a dense central scotoma on the left. 8unduscopic examinationis normal. here is a left afferent pupillary defect. agnetic resonance imaging of the $rain is normal.'hat is the $est course of treatment*

A.


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,. +ar$idopa7levodopa+. 5rimidone. 6alproic acid. 5ramipexoleNeurology:Question 49A /3-year-old woman is $rought to the emergency department $ecause of sudden onset of moderate righthemiparesis and hemisensory deficit involving her face# arm# and leg eDually. he patient has no relevant

medical history and ta"es no medications. She has no other signs or symptoms. She is admitted for inpatientetiologic evaluation. 1er average $lood pressure during hospitaliation is !3272) mm 1g. +arotid duplexultrasonography shows nonstenotic plaDue $ilaterally. ransthoracic echocardiography shows diastolicdysfunction $ut no potential cardioem$olic source.'hich of the following should $e recommended to the patient for $lood pressure management*A. ,egin angiotensin-converting enyme inhi$itor in ) wee"s.,. ,egin oral M-$loc"er immediately.+. ,egin oral calcium channel $loc"er immediately.. :ecommend diet and lifestyle changes only.Neurology:Question 50A 3/-year-old woman comes to the office $ecause of recurrent headaches for 4 years.


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+. =uillain-,arrH syndrome. ia$etic neuropathyNeurology:Question 54An !2-year-old college student comes to the emergency department $ecause of a seiure that occurred at 2I30this morning. According to her roommate# the patient wo"e up at her usual time and had several episodes of$rief arm %er"s $efore she fell and lost consciousness. 1er whole $ody stiffened for 4 to !0 seconds# and thenshe had rhythmic clonic %er"ing of her arms# legs# and trun" for a$out ) to 3 minutes. She remained

unresponsive for !0 minutes and then gradually regained complete consciousness over the next hour. hepatient remem$ers the arm %er"s $ut has no recollection of the seiure. She states that she has $een having arm%er"s in the morning for several months and that this has $ecome worse recently. She has $een staying up lateevery night for the last wee" studying for final examinations. Neurologic examination is normal.'hich of the following is the most li"ely diagnosis*A. 5artial seiure with secondary generaliation,. A$sence epilepsy+. Syncope. Buvenile myoclonic epilepsy. Nonepileptic event ?pseudoseiure@Neurology:Question 55A );-year-old woman with clinically definite multiple sclerosis comes to the office $ecause she is unexpectedlypregnant and wants to discuss how to proceed with disease management. She is maintained on interferon $eta!a. She has had one acute exacer$ation in the past ) years. Neurologic examination shows right afferent

pupillary defect with mild wea"ness of the right leg and mild right-sided hyperreflexia. She as"s how hermultiple sclerosis and treatment will affect the pregnancy.'hich of the following is the most appropriate counsel to share with her*A. +ontinue interferon,. iscontinue interferon $eta+. +hange to glatiramer acetate. :ecommend therapeutic a$ortionNeurology:Question 56A ()-year-old woman comes to the office $ecause of a 3-year history of daily headaches that involve the leftretro-or$ital# temporal# and parietal areas. he headaches $egin when she awa"ens and persist all day. he painfluctuates from mild to moderateC at its most intense# she has left eye lacrimation and left-sided nasalcongestion and rhinorrhea. She occasionally has nausea. he patient ta"es propranolol !;0 mg7d without$enefit. 5hysical and neurologic examinations are normal.'hat is the most li"ely diagnosis*

A. +hronic tension-type headache,. +hronic migraine+. +luster headache. 1emicrania continua

Neurology:Question 57A ;2-year-old woman comes for a routine physical examination. She descri$es a )-year history of insomnia#which she attri$utes to an ina$ility to get comforta$le in $ed $ecause of a Kcreepy-crawlyL sensation in her

lower lim$s. he sensation is a$sent during most of the day# $ut it has $egun to $other her in the evening whenshe sits and is especially trou$lesome in $ed. 'al"ing relieves the sensation. 5hysical examination# includingneurologic examination# is normal.'hich of the following studies should $e done next*A. Serum ceruloplasmin level,. Serum ferritin level+. Erine porphyrin level. Nerve conduction study. agnetic resonance imaging of the $rain


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Neurology:Question 58A ;0-year-old woman is $rought to the emergency department for evaluation of word-finding difficulty. Shecalled her hus$and>s attention to the pro$lem 3 wee"s ago. wo wee"s ago# the difficulty $ecame apparent toothers# and she $egan to have difficulty finding her way around the offices at wor". ne wee" ago she haddifficulty navigating in her own home# confusing the garage# closet# and $asement doors# and had difficulty witharithmetic calculations and vision. 5ast medical and family history is unremar"a$le. n examination# she hasoccasional myoclonic %er"s of the upper extremities and facial musculature# worse on the right side. 1er score is

!4 of 30 on the ini-ental State xamination. lectroencephalography shows mild diffuse slowing. agneticresonance imaging of the $rain is normal.'hat is the next step in testing*A. um$ar puncture,. 5resenilin-! test+. 5ositron emission tomography7single photon emission computed tomography. :epeat electroencephalography in ! wee". ,rain and leptomeningeal $iopsyNeurology:Question 59A 40-year-old previously healthy woman presents to her physician with a 3-wee" history of progressive gait andlim$ ataxia# dysarthria# and $lurred vision. xamination reveals nystagmus# dysarthria# and severe gait andlim$ ataxia. he remainder of the neurologic examination is normal. agnetic resonance imaging of the headwith contrast is normal. A $lood test reveals positive serology for anti-Oo anti$odies ?anti-5ur"in%e cellanti$ody@.

'hich of the following malignancies is most li"ely present in this patient*A. Non-1odg"in>s lymphoma,. Small cell lung cancer+. varian cancer. elanomaNeurology:Question 60A 3(-year-old man comes to the office $ecause of a !-month history of episodes during which he is suddenlyuna$le to spea". he episodes last $etween )0 and 30 seconds. uring some episodes# the patient has twitchingof the right side of his faceC on one occasion the twitching progressed to involve his right arm. 1e has had fiveevents# the last three during the past wee". No warning precedes the spells. he patient states that he is fullyaware of his surroundings during the episodes and has no other symptoms. Neurologic examination is normal.'hich of the following is the most li"ely diagnosis*A. ransient ischemic attac",. Anxiety attac"

+. 8rontal lo$e seiure. 1emiplegic migraine. 1ypoglycemiaNeurology:Question 61A )(-year-old woman comes to the emergency department $ecause of a 3-day history of severe headache. Shestates that while she was at wor" she had sudden onset of excruciating# diffuse headache associated with nauseaand vomiting. She was una$le to continue wor"ing# and a colleague drove her home. ver the next ) days theheadache remained too severe for her to go to wor". She has no significant past medical history except to$accouse. n examination# $lood pressure is !((790 mm 1gC pulse# !0(7minC respiratory rate# !27mmC andtemperature# 3/.) + ?92.9 8@. She is mildly agitated and has photopho$ia and minimal nec" stiffness. here areno focal neurologic deficits. +omputed tomography of the $rain is normal.'hat is the most appropriate next step in the management of this patient*A. mergent magnetic resonance imaging,. um$ar puncture

+. +ere$ral arteriography. reatment with sumatriptan. reatment with "etorolacNeurology:Question 62A 34-year-old woman comes to the office $ecause of episodic# severe headaches with left retro-or$ital andtemporal pain and light and noise sensitivityC they are typically accompanied $y severe nausea and vomitingshortly after onset. he headaches most commonly awa"en her from sleep in the early morning and last !; to)( hours. hey have occurred approximately one or two times per month for the past ( years. here are noheadache triggers. She has used over-the-counter medications and oral naratriptan without $enefit. 5hysicaland neurologic examinations are normal.'hich of the following is the most appropriate acute treatment for this patients headaches*


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A. ral almotriptan,. ral riatriptan+.


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prophylaxis and has used oral riatriptan today. 5ulse rate is !)07min and regularC $rachial $lood pressure is!;079( mm 1g. 5hysical and neurologic examinations are otherwise normal.


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Neurology:Question 74A /)-year-old woman is $rought to the office $y her daughter for evaluation of mental status changes. hepatient had a stro"e ! month earlier# with mild residual left-sided wea"ness. She had one seiure while in thehospitalC the seiure was considered grand mal# and she was treated with phenytoin. According to the daughter#the patient>s left face and arm twitch freDuently# and her left side is wea"er than when she left the hospital. 8orthe last few days the patient has $een confused and disoriented# Kli"e in a dae.L 1er current medicationsinclude phenytoin and aspirin. n examination# vital signs are normal. he patient is somewhat lethargic and

has freDuent twitching of her left face and arm. here is left facial wea"ness and left hemiparesis involving theface# arm# and leg. +omplete $lood count# serum electrolytes# and urinalysis are normal.'hich of the following is the most li"ely diagnosis*A. Stro"e in evolution,. 5artial status epilepticus+. 5henytoin toxicity. +reutfeldt-Ba"o$ diseaseNeurology:Question 75A /2-year-old man is $rought to the office $y his family $ecause of memory decline and confusion. he familyreports progressive confusion over ; months. he family noticed his symptoms at first mainly in the morning#$ut they now seem to occur throughout the day. 1e does not recognie his spouse at times# and thin"s someoneis chasing him. 1e wanders from the house# has visual hallucinations# and has difficulty using householdappliances. edical history is significant for dia$etes with painful peripheral neuropathy# coronary arterydisease# and congestive heart failure. edications include gly$uride# nortriptyline# digoxin# loraepam#

diltiaem# and lisinopril. here is no family history of neurologic disease. n examination# the patient has mildasterixis and findings consistent with peripheral neuropathy. 1e is mildly lethargic and inattentive# and notoriented to time or place. 1e recalls two of three words after a delay. he ini-ental State xamination scoreis !3 of 30. lectrolyte levels# oxygen saturation# liver function# and renal function are normal. +omputedtomography of the head without contrast is normal.'hich of the following conditions is most li"ely to account for his cognitive impairment*A. Adverse effect of medication,. ementia with ewy $odies+. +ere$rovascular disease. epression

ANSWERSANSWERSNeurology:Question 1Te !orre!t "ns#er is $

E%u!"tion"l &'(e!ti)esanage a patient with a single seiure.*riti+ueost neurologists would not start antiepileptic drug therapy after a single seiure unless the patient has one ormore ris" factors associated with seiure recurrenceI a$normal neurologic examination# a$normalelectroencephalography or magnetic resonance imaging of the $rain# partial onset# a history of neurologicin%ury ?such as stro"e# hemorrhage# or tumor@# family history of seiures# or postictal motor paralysis. hispatient has no ris" factor for recurrence of seiures. 1er seiure was provo"ed $y sleep deprivation. Seiurescaused $y external events ?drug toxicity# drug withdrawal# sleep deprivation# hypoglycemia# hypoxia#hyponatremia@ are considered provo"ed and do not reDuire chronic antiepileptic drug treatment. 5atients witha single provo"ed seiure should have electroencephalography and magnetic resonance imaging to rule outunderlying focal pathology that could lower the seiure threshold and precipitate a seiure. Not ordering anytests and %ust treating the patient with an antiepileptic drug can lead to missing an early diagnosis of $raintumor# small stro"e# hemorrhage# or other focal cortical a$normality.

Neurology:Question 2Te !orre!t "ns#er is EE%u!"tion"l &'(e!ti)es


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anticoagulation should $e initiated urgently. 'arfarin $enefits patients with chronic or intermittent atrialfi$rillation regardless of left atrium sie# so findings on 1olter monitoring and transesophagealechocardiography would not affect initial management.


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Neurology:Question 8Te !orre!t "ns#er is ,E%u!"tion"l &'(e!ti)ess disease# that are causing him torestrict his lifestyle. reatment is indicated to "eep him engaged in activities appropriate for his age.

+ar$idopa7levodopa is the appropriate first choice of medication. opamine agonist medications# such aspramipexole# ropinirole# pergolide# or $romocriptine# are not as effective as car$idopa7levodopa and may $einsufficient to counter his increasing par"insonian symptoms. Selegiline and amantadine are unli"ely to have ama%or impact upon his symptoms. ntacapone is ineffective in the a$sence of levodopa treatment and hencehas no role in initial treatment.Neurology:Question 9Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)es:ecognie Alheimer>s disease.*riti+uehis patients progressive cognitive impairment affects $oth multiple aspects of intellect and his a$ility toperform daily tas"s. he findings are consistent with a progressive dementia. 5rominent recent memory losssuggests early involvement of the temporal lo$es. he lac" of other neurologic signs suggests sparing of the$asal ganglia and primary motor and sensory areas. he findings are most compati$le with dementia due to

Alheimer>s disease. 8rontotemporal dementia may cause a similar profile# $ut usually has more prominentearly personality change and less visuospatial impairment.


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his patient is not comatose# $ut is in a Kloc"ed-inL state. 5atients in a loc"ed-in state are Duadriplegic# haveparalysis of horiontal eye movements# and are una$le to spea" $ecause of paralysis of $ul$ar musclesCcommunication is possi$le only through the patient>s a$ility to move the eyes vertically and $lin". he loc"ed-insyndrome occurs with lesions of the $ase of the pons# usually infarction ?such as from $asilar artery occlusion@or hemorrhage. he finding of $ris" downward eye movements is consistent with ocular $o$$ing# a "ind ofspontaneous eye movement that can $e seen in large pontine lesions. Although not entirely specific# anotherclue to a $rainstem localiation of this patient>s findings is the presence of $ilateral extensor ?decere$rate@

posturing. he $ilaterally small pupils are also commonly associated with pontine lesions. A left middlecere$ral artery stro"e would cause aphasia and a right hemiparesis# not the $ilateral signs or the eye findingsseen in this patient. An anoxic encephalopathy would cause diffuse cere$ral# and sometimes $rainstem#dysfunction $ut would not explain this patient>s eye movements or the intact alertness in the presence ofDuadriplegia. he typical findings of a cere$ellar infarct are headache# nausea# vomiting# and ataxiaC $rainstem?including pontine@ dysfunction can occur as a secondary phenomenon due to mass effect from infarct-relatededema# which is why neurosurgical consultation is important for large cere$ellar infarcts as well as forcere$ellar hemorrhages.Neurology:Question 13Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)es:ecognie effect of fever on multiple sclerosis.*riti+ueNeurologic function often deteriorates when patients with multiple sclerosis are exposed to am$ient heat or

fever# $ecause raised temperature decreases conduction through demyelinated nerves. his is considered apseudoexacer$ation and is not necessarily evidence of a new exacer$ation. Sudden worsening of lower-extremity strength and increased spasticity in any patient with multiple sclerosis# especially if associated withfever# should prompt investigation for urinary tract infection# decu$itus ulcer# cellulitis# arthritis# or otherirritative conditions. Any painful or irritating stimulus can worsen spasticity. ften the course improves overseveral days with hydration# appropriate anti$iotic therapy# and aggressive reduction of fever. he othertreatment options will not directly address this patient>s deterioration due to fever.Neurology:Question 14Te !orre!t "ns#er is ,E%u!"tion"l &'(e!ti)es:ecognie the clinical features of migraine headaches.*riti+uehis patients symptoms fulfill the criteria for migraine without aura# despite the $ilateral pain and a$sence ofnausea. :hinorrhea and tearing are autonomic symptoms that freDuently accompany migraine and do not

usually represent sinus disease. ost patients with a diagnosis of sinus headache in fact have migraine. Acutesinusitis is accompanied $y fever and purulent nasal discharge. pisodic tension-type headaches are notpulsatile# do not worsen with physical activity# and are not associated with photopho$ia and phonopho$ia.+luster headaches are unilateral ?most commonly retro-or$ital@# last ! to ) hours# and occur in TclustersL ofrecurrent attac"s lasting wee"s to months. ost patients are agitated and prefer not to lie down during a clusterheadache. his patient has no signs or symptoms# such as visual o$scurations# that suggest a diagnosis ofidiopathic intracranial hypertension# and there is no papilledema on funduscopic examination.Neurology:Question 15Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)es:ecognie $rain metastases.*riti+uehis patients history of node-positive $reast cancer places her at high ris" for development of recurrent andmetastatic tumor. She presents with progressive signs and symptoms of focal neurologic deficit and raised

intracranial pressure. She most li"ely has multiple $rain metastases. agnetic resonance imaging of the headwith contrast would $e the most appropriate diagnostic test for this patient. 5arenchymal $rain metastases are$y far the most common neurologic complication of systemic cancer# occurring in )0J to (0J of patients.eptomeningeal and su$dural metastases are less common. 5atients with leptomeningeal metastases typicallypresent with headache# multiple cranial nerve palsies# and multiple spinal radiculopathies. 5atients withsu$dural metastases and dural sinus throm$osis primarily present with headache# hemiparesis# and sometimesdrowsiness. 1emianopia would $e distinctly unusual with a lesion not directly involving $rain parenchyma.5araneoplastic encephalitis is rare.


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Neurology:Question 16Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)esanage antiepileptic drug therapy in a pregnant patient.*riti+ueuring pregnancy# seiure freDuency increases in approximately one third of women with epilepsy. his is aresult of increased hepatic meta$olism of most antiepileptic drugs and an increased volume of distri$ution.

herefore# drug levels should $e monitored during pregnancy to ma"e sure they remain therapeutic. hispatient appears to have good seiure control on the current dose of car$amaepine. here is no need to changethe dose or add or switch to another antiepileptic drug at the present time.


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s symptoms are most compati$le with vasovagal syncope. here is usually a $rief prodrome thatmay include lightheadedness# warmth# diaphoresis# nausea# pallor# and $lurred vision. A$normal movements

?mainly myoclonic %er"s or tonic posturing@ and urinary incontinence may occur during unconsciousness. ncerecum$ent# the patient usually recovers consciousness rapidly $ut may $e confused for up to 30 seconds.Buvenile myoclonic epilepsy is a genetic syndrome characteried $y myoclonic %er"s and a$sence andgeneralied tonic-clonic seiures. Affected patients have no warning prior to the generalied tonic-clonicseiure. Afterward# the patient falls into a deep sleep or is tired and confused for minutes to hours. +omplexpartial seiures with secondary generaliation are associated with auras# $ut patients are not li"ely to $e pale ordiaphoretic or to feel warm. 5ostictal confusion lasts minutes to hours. 5seudoseiures are not stereotypical inpresentation and usually last longer. Atonic seiures consist of sudden loss of postural tone without anyprodrome or warning and without loss of consciousness.Neurology:Question 24Te !orre!t "ns#er is *


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E%u!"tion"l &'(e!ti)esreat pathologic fatigue of multiple sclerosis.*riti+ueAmantadine is the first-line pharmacologic agent for treatment of multiple sclerosis fatigue# which is commonand disa$ling. Amantadine affects several neurotransmitter systems and enhances neurotransmitter releaseChowever# the exact mechanism $y which it improves fatigue of multiple sclerosis is not "nown. s dementia. +linicaltrials consistently demonstrate modest efficacy of cholinesterase inhi$itors# including galantamine# tacrine#donepeil# and rivastigmine# in mild to moderate Alheimers disease# on $oth cognitive and glo$al functionscales. s disease. =ing"o $ilo$a pro$a$ly exerts modest effects on cognitive symptoms# $ut has not $eenshown to improve glo$al or psychiatric function. Although some studies suggest that vitamin and selegilinedelay the progression of Alheimer>s disease# they do not directly relieve cognitive or psychiatric symptoms.Neurology:Question 26Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)es

Administer intravenous tissue plasminogen activator ?t-5A@to ischemic stro"e patients only within 3hours of stro"e onset.*riti+ue


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atrophy. he KscreechingL sounds during the night are worrisome for nocturnal stridor# which is highlysuggestive of multiple system atrophy. 5olysomnography should $e o$tained to confirm nocturnal stridor$ecause patients with multiple system atrophy and stridor may die during the night# presuma$ly fromdysfunction of the $rainstem $reathing center. Stridor can $e treated with tracheostomy or possi$ly withcontinuous positive airway pressure. Although 5ar"inson>s disease is often associated with dysautonomia# thepronounced autonomic symptoms# including symptomatic orthostatic hypotension# are atypical. 8urther#corticospinal tract signs and ataxia are not expected in 5ar"inson>s disease. +reutfeldt-Ba"o$ disease is

unli"ely# given the clinical picture and the )-year course.Although spinocere$ellar degenerations may manifest with par"insonism# corticospinal tract signs# and ataxia#they do not include prominent dysautonomia. 5rogressive supranuclear palsy manifests with par"insonism andoften corticospinal tract signs# $ut not with severe dysautonomia with symptomatic orthostatic hypotension.Also# the patient does not have the vertical ?downward@ gae palsy suggesting progressive supranuclear palsy.Neurology:Question 28Te !orre!t "ns#er is *E%u!"tion"l &'(e!ti)es:ecognie vitamin ,!) deficiency.*riti+uehis man has signs and symptoms of progressive spinal cord dysfunction. 1e has dense posterior columndysfunction ?vi$ration and proprioception@ as well as corticospinal tract motor signs and deficits. hiscom$ination suggests su$acute com$ined degeneration# as seen in vitamin ,!) deficiency. he normalmagnetic resonance image of the spinal cord rules out cord compression. 1owever# other causes of progressive

myelopathy should $e considered.he other options are not upper motor neuron syndromes and are not associated with hyperreflexia or extensorplantar responses.Neurology:Question 29Te !orre!t "ns#er is ,E%u!"tion"l &'(e!ti)esvaluate intracranial hemorrhage.*riti+uehis patient has an intracere$ral hemorrhage with intraventricular extension. Although the location of thehemorrhage is typical for a hypertensive $leed# patients younger than (4 years who have no prior history ofhypertension are at much higher ris" for a potential vascular anomaly underlying the hemorrhage. +ocaine usecould $e solely responsi$le for the stro"eC however# patients with cocaine-related hemorrhage are also moreli"ely to have a vascular anomaly. his patient needs aggressive evaluation for a possi$le underlying vascularmalformation# and the definitive test is cere$ral angiography. lectroencephalography is not indicated unless

the history raises the possi$ility of seiure. chocardiography would provide information a$out the possi$ilityof chronic hypertension in this patient# $ut patients younger than (4 years should have vascular imaging afterintracranial hemorrhage# even if they have "nown hypertension.Neurology:Question 30Te !orre!t "ns#er is $E%u!"tion"l &'(e!ti)esiagnose acute dia$etic proximal neuropathy.*riti+uehis patients signs and symptoms are consistent with a lesion of the right upper lum$ar root or right lum$arplexus. he normal findings on magnetic resonance imaging argue against a structural or compressive cause.he most li"ely noncompressive cause of right upper lum$ar radiculoneuropathy is dia$etes. ia$etic proximalneuropathy ?dia$etic amyotrophy@ may $e symmetric or asymmetric# and presents with su$acute proximal legmuscle wea"ness associated with severe pain. Symptoms usually $egin after longstanding uncontrolledhyperglycemia and weight loss. he pathogenesis is unclearC nerve $iopsy studies have shown a vasculitic

inflammatory infiltrate in involved nerves.$taining a creatine "inase level would $e appropriate if primary muscle disease were suspected# $ut this is notli"ely given the presence of neuropathic pain and sensory loss. hyroid function tests are often o$tained incases of peripheral neuropathy# $ut thyroid derangement would not cause a lum$ar radiculopathy orplexopathy. um$ar puncture may help confirm an inflammatory process in the cere$rospinal fluid# $ut wouldnot result in a specific diagnosis. Similarly# elevations of the erythrocyte sedimentation rate are nonspecific.Neurology:Question 31Te !orre!t "ns#er is ,E%u!"tion"l &'(e!ti)esiagnose progressive supranuclear palsy.*riti+ue


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his patient>s early falls and vertical gae paresis ma"e progressive supranuclear palsy the li"ely diagnosis.5atients with progressive supranuclear palsy often have vision complaints# yet their optometrists are una$le todocument pro$lems with either visual acuity or peripheral vision.


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*riti+uehis patient has freDuent attac"s of migraine without aura. She is at ris" for developing re$ound headachesfrom overuse of acute medication. Accordingly# a preventive medication is indicated. Amitriptyline is a first-lineagent for migraine prophylaxisC its sedating effect may also help her insomnia. Nadolol and propranolol arecontraindicated $ecause they may trigger her asthma. Naratriptan is used for treatment of acute migraine andis not approved for prophylactic therapy. Selective serotonin reupta"e inhi$itors have limited effectiveness inmigraine prophylaxis.

Neurology:Question 36Te !orre!t "ns#er is $E%u!"tion"l &'(e!ti)esetermine when to withdraw antiepileptic drug treatment.*riti+ueAccording to recent studies of adult patients who are seiure free for more than ) years# approximately onethird relapse following termination of antiepileptic drugs. :is" factors associated with recurrence of seiuresinclude prolonged duration and high freDuency of seiures $efore they were controlled# a$normal neurologicexamination# a$normal magnetic resonance imaging ?:


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faster than phenytoin and has a lower incidence of hypotension and local throm$ophle$itis at the site ofadministration ?Kpurple glove syndrome>@. s course $egan with acute exacer$ations followed $y remissions of varia$le duration# so her diseasewas initially relapsing-remitting. 1owever# in the past year# she has had progression of neurologic deficits$etween acute relapses.


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Sudden right hemiparesis with expressive aphasia suggests a left cortical infarction in the territory of the leftmiddle cere$ral artery# which is supplied $y the left internal carotid artery. +arotid stenosis of 40J or more thatis ipsilateral to the infarction implies that the stro"e is due to large artery disease. +arotid endarterectomydecreases ris" of future stro"e in patients with symptomatic stenosis of 40J or more# and especially in patientswith /0J to 99J stenosis# as compared with antiplatelet agents alone. Aspirin# 2! or 3)4 mg daily# decreasesthe ris" of stro"e after endarterectomy. here is no evidence that intravenous heparin is safe and effective inpatients with acute ischemic stro"e.

Neurology:Question 44Te !orre!t "ns#er is ,E%u!"tion"l &'(e!ti)esanage small# asymptomatic meningiomas.*riti+uehis /4-year-old woman has what is most pro$a$ly a small# asymptomatic convexity meningioma. hecalcification suggests that the meningioma has $een present for months or years. +alcified meningiomas areless li"ely to progress than noncalcified lesions.


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his patients episodes are most li"ely complex partial seiures of frontal lo$e origin. 8rontal lo$eseiures are $rief# usually occur in clusters# and usually are not associated with aura or postictal confusion.Appropriate anticonvulsant management should $e initiated# even during the diagnostic wor"-up.+ar$amaepine is approved $y the E.S. 8ood and rug Administration ?8A@ for treatment of partial seiuresand is an appropriate initial choice. 5heno$ar$ital is not a first-line agent $ecause of possi$le associatedsedation and cognitive impairment.=a$apentin is approved for ad%unctive treatment of partial seiures $ut should not $e used in monotherapy.

thosuximide is used to treat a$sence seiures# which this patient does not have. amotrigine is 8A approvedfor ad%unctive treatment of partial seiuresC many neurologists use it with success as second-line monotherapy.Neurology:Question 48Te !orre!t "ns#er is *E%u!"tion"l &'(e!ti)esreat essential tremor.*riti+uehis patient has a postural and action tremor ?essential tremor@# rather than a resting tremor typical of5ar"inson>s disease. 8irst-line drugs include primidone or a nonselective M-adrenergic $loc"er# such aspropranolol. Selective M!$loc"ers# such as atenolol# are not effective against tremor# at least in the lower doseswhere the M!effect is predominant. As the clinical description is not that of par"insonian tremor#car$idopa7levodopa or pramipexole would not $e helpful. 6aiproic acid may induce tremor and is not used totreat it.Neurology:Question 49

Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)es5rescri$e an angiotensin-converting enyme ?A+@ inhi$itor and a diuretic for patients who have had stro"e ortransient ischemic attac"# regardless of $aseline $lood pressure.*riti+ue


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Enfortunately# treatment of primary +NS lymphoma in patients with 1


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1owever# the transmission of increased suscepti$ility is $elieved to $e multigenicC no simple one-gene pattern#such as autosomal-recessive transmission# is o$served. here is no medical indication for therapeutic a$ortionin this patient.Neurology:Question 56Te !orre!t "ns#er is ,E%u!"tion"l &'(e!ti)esiagnose hemicrania continua.

*riti+ue1emicrania continua is a primary headache disorder characteried $y chronic# daily unilateral headache withsome autonomic phenomena.


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degeneration in the setting of ovarian# uterine# fallopian tu$e# or $reast cancer. Anti-1u ?anti-neuronalanti$ody type


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Neurology:Question 65Te !orre!t "ns#er is $E%u!"tion"l &'(e!ti)esEse $otulinum toxin to treat adult-onset focal dystonia.*riti+uehe patient has cervical dystonia ?spasmodic torticollis@# an idiopathic focal dystonia of adulthood. Although itsorigins are presumed to $e within the $rain# imaging studies of the $rain are negative# as are studies of the

cervical spine. ral medications for cervical dystonia# including muscle relaxants ?diaepam# cyclo$enaprine@#are mildly effective at $est. Analgesics may $e necessary to relieve pain from muscle contraction. he mostconsistently effective medical treatment is $otulinum toxin in%ected into appropriate nec" muscles# sometimesunder electromyographic guidance. 'ithin a few days# the in%ected muscles wea"en# tending to release thespasm. ,enefits persist for ) to ( months# and rein%ection every 3 or more months maintains the $enefits.xcessive wea"ness of the in%ected muscles is rarely a pro$lem.Although car$idopa7levodopa may improve the dystonia of 5ar"inson>s disease# it is ineffective in treatingprimary idiopathic focal dystonias# such as cervical dystonia. 5sychiatry referral may improve stressmanagement# $ut is unli"ely to have a ma%or impact on the motor manifestations of cervical dystonia.Neurology:Question 66Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)es:ecognie complex partial seiures of temporal lo$e origin.*riti+ue

his is a typical description of complex partial seiure of temporal lo$e origin. he symptoms of complex partialseiures vary# $ut they are stereotypical for each patient. 5atients may have a warning ?aura@ prior to theseiure. he most common warning is a rising epigastric sensationC other auras may include affective ?such asfear@# cognitive ?such as dH% vu@# and sensory symptoms ?such as olfactory hallucinations@. +omplex partialseiures typically last less than 3 minutes. uring that time the patient appears awa"e# $ut loses contact withthe environment and does not respond normally to instructions or Duestions. 5atients usually stare and remainmotionless# or engage in repetitive# semi-purposeful $ehavior ?automatisms@# such as gesturing# chewing# lipsmac"ing# repeating words or phrases# wal"ing# running# or undressing. 5atients do not recall these $ehaviors.After the seiure the patient is confused or sleepy for minutes to hours.A$sence seiures occur primarily in children# are not preceded $y aura# and are not followed $y postictalconfusion. hey last 4 to !0 seconds and occur primarily in clusters. Nonepileptic events ?pseudoseiures@ arecharacteristically varia$le ?not stereotypical@ in presentation and last longer. igraine can $e associated withneurologic symptoms# including confusion# $ut there is usually a history of headache or other o$vious symptom?for example# visual phenomena@. ransient glo$al amnesia is a syndrome of acute memory loss of un"nown

etiologyC it can last for minutes to hours. here is no alteration or loss of consciousness during transient glo$alamnesia.Neurology:Question 67Te !orre!t "ns#er is $E%u!"tion"l &'(e!ti)es:ecognie the clinical presentation of am$ert-aton myasthenic syndrome.*riti+uehis patient has am$ert-aton myasthenic syndrome ?S@# which in ;0J of cases occurs in patientshar$oring small cell lung cancer. S is a disorder of nicotinic and muscarinic cholinergic synapses resultingin impaired acetylcholine release# with muscle wea"ness and autonomic dysfunction. Affected patients produceanti$ody to the voltage-gated calcium channel ?6=++@# thus impairing calcium influx into the nerve terminaland reducing acetylcholine release. he circulating anti-6=++ anti$ody is detecta$le in some $ut not allpatients. Spinal cord compression presents with spine and radicular pain and evidence of myelopathy ?signs ofupper motor neuron wea"ness# spasticity# ,a$ins"i signs# and sensory loss typically with a defined level@.

5olymyositis generally produces muscle pain and wea"ness without symptoms of autonomic nervous systemdysfunction. 5olyneuropathy is a possi$ility# although it usually would produce distal more than proximalwea"nessC the wea"ness would not improve with repeated effort. Autonomic dysfunction is less commonlyassociated with polyneu ropathy.Neurology:Question 68Te !orre!t "ns#er is *E%u!"tion"l &'(e!ti)esreat acute migraine in the emergency department.*riti+uehis patient needs parenteral treatment for her prolonged# severe migraine headache that is accompanied $yrepeated vomiting. he neuroleptic agent chlorpromaine is effective for such a situation. Although


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dihydroergotamine may $e useful when administered intravenously during a severe migraine attac"# it shouldnot $e used in this situation $ecause the patient has already used riatriptan within the past )( hours and $othmedications have vasoconstrictive effects. ihydroergotamine may cause nausea and vomiting# so when it can$e used intravenously# an antiemetic such as metoclopramide must $e administered first. ral codeine ?or anyoral agent@ is a poor choice since the patient is nauseated and vomiting. 8inally# sumatriptan should not $e used$ecause the patient has already used riatriptan within the past )( hours.Neurology:Question 69

Te !orre!t "ns#er is AE%u!"tion"l &'(e!ti)es5rescri$e cholesterol-lowering therapy for secondary prevention of stro"e.*riti+ueAmong patients with "nown coronary artery disease# statin drugs decrease the ris" of ischemic stro"e as well asmyocardial infarction. he evidence is strongest for pravastatin# (0 mg7d# and simvastatin# )0 to (0 mg7d.5revious studies of lipid-lowering therapy other than statins did not show a decrease in stro"e ris" ?and showedlesser decreases in cholesterol levels@. $servational studies suggest that a low-density lipoprotein ?@ level$elow /0 mg7d may increase the ris" of hemorrhagic stro"e. 5atients with dia$etes or a history of stro"e#coronary artery disease# or peripheral artery disease should ta"e a statin# if at all possi$le# to achieve a target value $etween /0 and !00 mg7d. cholesterol levels decrease in the first )( to (2 hours after anischemic event and do not return to $aseline for several wee"s.


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$y an unremitting headacheC there may $e associated visual o$scurations. he neurologic examination istypically normal except for papilledema and enlarged $lind spots. s altered level of consciousness and asterixis suggest a toxic7meta$olic etiology of the impairment.he patient is on several medications that might impair cognition. Nortriptyline has anticholinergic properties#and is especially li"ely to cause impairment in patients with latent cholinergic deficiency ?for example# patientswith early dementia or 5ar"inson>s disease@. he sedative-hypnotic loraepam and digoxin may also contri$uteto cognitive impairment.ementia with ewy $odies is also associated with fluctuation of cognitive status and visual hallucinations# $utis less li"ely given the medication history# a$sence of par"insonism# and presence of asterixis. 6asculardementia# particularly that due to small-vessel cere$rovascular disease# is unli"ely given the a$sence of a

stepwise course and a$sence of stro"e on computed tomography. epression may cause chronic cognitiveimpairment ?pseudodementia@# $ut not asterixis and an altered level of consciousness.

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