1 >>A 25-year-old man is being evaluated. Rhythmic jerk nystagmus is elicited by having the patient look at a rotating drum with stripes on it. This finding suggests which of the following? ?
- (A) Drug toxicity
- (B) No pathologic lesion in the brain
- (C) Unilateral parietal lobe damage
- (D) Parinaud syndrome
2 >>A 36-year-old man abruptly loses vision in one eye. His retina appears cloudy and grayish yellow with narrowed arterioles. The fovea appears cherry red, and the vessels that are obvious appear to have segmented columns of blood. Which of the following is the most likely diagnosis? ?
- (A) Chorioretinitis
- (B) Occlusion of the central retinal vein
- (C) Occlusion of the central retinal artery
- (D) Optic neuritis
3 >>A 62-year-old man with hypertension has an episode in which he suddenly loses vision in his left eye. He is outside walking up the street, as he does every day, when suddenly the vision in his left eye goes black. When he closes his right eye, he can barely see at all. Within 2 hours, his vision is back to normal. What is the best next step to assess the patient’s risk of having another attack of this kind? ?
- (A) Transthoracic echocardiogram
- (B) Brain MRI
- (C) Brain CT
- (D) Carotid ultrasound
4 >>A 5-year-old girl sustains a cut on her face from broken glass. Initially, the injury appears superficial except for a small area of deeper penetration just above the right eyebrow. Within 4 days, the child develops periorbital pain and double vision. The tissues about the eye are erythematous, and the eye appears to bulge slightly. The optic disc is sharp, and no afferent pupillary defect is apparent. Visual acuity in the affected eye is preserved. Which of the following is the most likely diagnosis? ?
- (A) Orbital cellulitis
- (B) Cavernous sinus thrombosis
- (C) Transverse sinus thrombosis
- (D) Optic neuritis
5 >>An otherwise healthy young woman has poorly responsive pupils that are dilated. Visual acuity is normal. A careful neurological examination reveals bilaterally absent Achilles tendon jerks. Which of the following is the most likely diagnosis? ?
- (A) A cervical spinal cord tumor
- (B) A brainstem glioma
- (C) MS
- (D) Benign tonic pupillary dilatation
6 >>A 32-year-old man from a rural area of southern Africa was recently brought to the United States by some of his family members who had emigrated previously. His family says that he was diagnosed with syphilis at age 16 and has taken penicillin off and on over the years, but he never completed the prescribed course. Assuming that he has neurosyphilis, which of the following is true with regard to the classic pupillary defect most likely to be observed? ?
- (A) Completely normal (no defect)
- (B) Reacts poorly to light but accommodates well
- (C) Accommodates poorly but reacts well to light
- (D) Is pinpoint and regular in shape
7 >>A 60-year-old, right-handed man underwent heart transplantation 2 weeks ago for severe ischemic cardiomyopathy. He had an uneventful postoperative course and went home after 1 week. He is now readmitted from an outside hospital where he was admitted with headaches, increasing confusion, and a generalized seizure. He relates that he has had difficulty seeing for several days. On examination, he has a blood pressure of 180/100 mm Hg. His pupils are equal and reactive, but he has difficulty reading and finding objects presented to him. Motor and sensory functions are normal. An MRI shows several areas of T2 signal abnormality in the occipital and parietal lobe white matter bilaterally. A diffusion-weighted MRI sequence, sensitive to the changes of acute infarction, is negative. This patient’s history, examination, and laboratory findings are most consistent with which of the following diagnoses? ?
- (A) Cyclosporine toxicity
- (B) Steroid psychosis
- (C) Occipital lobe infarction
- (D) Ischemic optic neuropathies
8 >>A 60-year-old, right-handed man presents with visual loss. About 2 weeks before, he began to notice difficulty seeing the television. Within 1 week, he noticed that the inferior field of vision in the right eye was much worse than the top of his vision. Within a few more days, he noticed the bottom of the vision in his left eye worsen as well. This has been painless. He has otherwise felt well, without headaches or cognitive changes. An ophthalmologist saw bilateral papillitis with white exudates of the nasal part of the discs. There is no history of alcohol use, and the patient has stopped smoking since his heart transplant. On examination, he appears well. Blood pressure is 160/80 mm Hg; pulse is 100 beats per minute and regular. There are no carotid bruits. Pupils are equal and reactive. Visual acuity is 20/400 OU, with central-inferior scotomas (left larger than right). Neurological examination is otherwise normal. An MRI scan with and without gadolinium contrast agent, including orbital cuts, is negative, as is cerebrospinal fluid (CSF) examination. This patient’s history, examination, and laboratory findings are now most consistent with which of the following diagnoses? ?
- (A) Cyclosporine toxicity
- (B) Occipital lobe lymphoma
- (C) Tobacco-alcohol amblyopia
- (D) Ischemic optic neuropathies
9 >>Three months after an episode of anterior ischemic optic neuropathy, a patient’s vision is essentially unchanged. He is able to see in his superior fields, but cannot drive. Funduscopic examination at this time is likely to show which of the following? ?
- (A) Papilledema
- (B) Optic disc pallor
- (C) Retinal exudates
- (D) Retinal vein enlargement
10 >>An 89-year-old man has noticed that his hearing has gradually worsened with aging. The examining physician applies a vibrating tuning fork to his right mastoid process. The moment the sound can no longer be heard, the fork is held near the auditory meatus and the patient can again hear it. His deafness has probably developed because of which of the following? ?
- (A) Neuronal degeneration
- (B) Calcification of ligaments stabilizing the ossicles
- (C) Weakness of the tensor tympani
- (D) Weakness of the stapedius muscle
11 >>A 65-year-old diabetic woman has aphasia secondary to a stroke involving the inferior division of the left middle cerebral artery. Her hearing is intact. Which of the following correctly reflects why dominant temporal lobe infarction will not produce complete deafness? ?
- (A) There is no temporal lobe representation for hearing.
- (B) Each cochlear nucleus projects to both temporal lobes.
- (C) Deafness results with nondominant hemisphere damage.
- (D) Both thalamic and temporal lobe damage must occur.
12 >>A 72-year-old man is having difficulty hearing. He is being tested with a tuning fork. If he has disease of the middle ear, sound transmitted strictly by air conduction will be perceived as which of the following? ?
- (A) Louder than that transmitted by bone conduction
- (B) Quieter than that transmitted by bone conduction
- (C) Lower pitched than that transmitted by bone conduction
- (D) Higher pitched than that transmitted by bone conduction
13 >>A 13-year-old girl has a severe case of mastoiditis. Despite treatment, she develops a fluent aphasia. Her aphasia is most likely the result of extension of the infection into which portion of the brain? ?
- (A) Frontal lobe
- (B) Parietal lobe
- (C) Temporal lobe
- (D) Occipital lobe
14 >>A 19-year-old soldier stationed in Iraq was exposed to an exceptionally loud nearby explosion. There was an initial severe loss of hearing followed by partial recovery. Which of the following best describes her hearing loss? ?
- (A) High-tone sensorineural loss
- (B) Low-tone sensorineural loss
- (C) High-tone conductive loss
- (D) Low-tone conductive loss
15 >>A 79-year-old woman is brushing her teeth when she has an intense sensation that the room is moving as if she were on a ship. Examination and testing reveal a cerebellar stroke. Cerebellar damage may be associated with severe vertigo if the tissue damaged is in the distribution of which of the following arteries? ?
- (A) Superior cerebellar artery
- (B) Posterior inferior cerebellar artery (PICA)
- (C) Anterior inferior cerebellar artery (AICA)
- (D) Anterior spinal artery
16 >>A 62-year-old man has started getting a haircut every week. Whenever he lays his head back to have his hair washed, he has the sensation of spinning. With vertigo that develops on extreme extension or rotation of the head, the patient probably has insufficiency in which of the following? ?
- (A) Left subclavian artery
- (B) Internal carotid arteries bilaterally
- (C) Vertebrobasilar system
- (D) Internal maxillary artery
17 >>A 45-year-old left-handed man has had recurrent attacks of “dizziness.” He describes the sensation of feeling the room spinning. The episodes occur abruptly and usually last for approximately 45 minutes. The dizziness occurs about once per month, but may happen more frequently. There is often accompanying ringing and decreased hearing in one ear. Which of the following most accurately describes the early hearing loss in this disease? ?
- (A) Overall frequencies
- (B) Primarily over high frequencies
- (C) Primarily over middle frequencies
- (D) Primarily over low frequencies
18 >>A 52-year-old diabetic man on multiple medications develops vertigo. Which of the following may cause a toxic labyrinthitis? ?
- (A) Promethazine
- (B) Penicillin
- (C) Dimenhydrinate
- (D) Acetylsalicylic acid
19 >>A 50-year-old man is being evaluated for tinnitus. It is worse on some days than others. Which of the following should he be told may exacerbate the tinnitus? ?
- (A) Alcohol
- (B) Aspirin
- (C) Glucose
- (D) Diazepam
20 >>A 26-year-old man has multiple hyperpigmented lesions, each over 1.5 cm. Which of the following tumors is most likely to occur in this patient? ?
- (A) Medulloblastoma
- (B) Acoustic schwannoma
- (C) Neurofibroma
- (D) Ependymoma
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