1 >>A 17-year-old girl presents with subacute mental status change and left arm weakness. She had a viral illness 1 week ago, and now a diagnosis of acute disseminated encephalomyelitis (ADEM) is made. ADEM is a white matter disease that is distinguishable from multiple sclerosis (MS) by its being which of the following? ?
- (A) Monophasic
- (B) Rapidly lethal
- (C) Associated with brainstem and spinal cord disease
- (D) Associated with magnetic resonance imaging (MRI) lesions, which may resolve
2 >>A 26-year-old woman with low back pain is seen in the clinic. She states that her pain began acutely 2 weeks ago while lifting a couch. An MRI was performed in the emergency room and she was told that she has a “slipped disk” and sent home. The patient wants to know why surgery was not done immediately to correct the problem. Acute herniation of an intervertebral disk will require emergency surgery in which of the following circumstances? ?
- (A) The disk is laterally herniated at C7.
- (B) The disk is causing radicular pain.
- (C) The cauda equina is being crushed.
- (D) A thoracic disk is involved.
3 >>A 57-year-old man has been having nightly, unilateral, throbbing headaches. They have been occurring daily for the past week. The patient recalls having had a similar headache 5 years ago that lasted for several weeks. The patient has noticed that the headache is associated with lacrimation and a “stuffy nose.” Ergotamine prophylaxis has been partially successful. Which of the following is the most effective means of aborting this type of headache? ?
- (A) Inhaled 100% oxygen
- (B) Sublingual nitroglycerin
- (C) Oral methysergide
- (D) Oral propranolol
4 >>A 32-year-old woman with alcoholism and cocaine use dating back at least 10 years comes to the emergency room after 48 hours of recurrent vomiting and hematemesis. She reports abdominal discomfort that preceded the vomiting by a few days. For at least 36 hours, she has been unable to keep ethanol in her stomach. Intravenous fluid replacement is started while she is being transported to the emergency room, and while in the emergency room she describes progressive blurring of vision. Over the course of 1 hour, she becomes increasingly disoriented, ataxic, and dysarthric. Which of the following is the most likely explanation for her rapid deterioration? ?
- (A) Dehydration
- (B) Hypomagnesemia
- (C) Wernicke encephalopathy
- (D) Hypoglycemia
5 >>A 27-year-old man undergoes general anesthesia for a hernia repair. As the anesthesia begins, his jaw muscles tense and he becomes generally rigid. He becomes febrile, tachycardic, and tachypneic. Intravenous administration of which of the following agents may be lifesaving? ?
- (A) Suxamethonium
- (B) Nitrous oxide
- (C) Succinylcholine
- (D) Dantrolene
6 >>A 57-year-old woman with a history of diabetes mellitus and hyper-thyroidism presents to the emergency room with a history of 2 days of vertical and horizontal diplopia. There is moderate orbital pain. On examination, her left eye is deviated downward and outward. It can be passively moved medially and upward. The pupils both react normally. Which of the following is the most likely etiology of her diplopia? ?
- (A) Hyperthyroidism
- (B) Diabetes mellitus
- (C) Cerebral aneurysm
- (D) Orbital pseudotumor
7 >>A 33-year-old operating room nurse accidentally has blood splashed in her eyes during a procedure. The surgical resident who examines her immediately afterward notices that she has 2-mm anisocoria and sends her to the emergency room. She feels well, is alert and talkative, and has no motor dysfunction. On examination, the emergency room physician recognizes that the iris of the eye with the smaller pupil is pale blue, whereas that of the other eye is brown. Which of the following is the most likely etiology of the woman’s anisocoria? ?
- (A) Conjunctivitis
- (B) Congenital
- (C) Pupillary sphincter injury
- (D) Carotid artery dissection
8 >>A 26-year-old man is brought into the emergency room after a motorcycle accident in which he was not wearing a helmet. The computed tomography (CT) scan shows bifrontal hemorrhagic contusions. The Glasgow Coma Scale (GCS) score is 6. He has no verbal response, opens his eyes to painful stimulation only, and shows a flexion response to pinch of the extremities. Which of the following is the most appropriate classification of this patient’s head injury? ?
- (A) Minimal
- (B) Mild
- (C) Moderate
- (D) Severe
9 >>Two days after a motor vehicle accident, you are examining a 19-year-old right-handed man. He has a severe headache and “raccoon eyes.” The presence of periorbital ecchymosis in a patient with traumatic head injury should be considered a sign of which of the following? ?
- (A) Subdural hemorrhage
- (B) Basilar skull fracture
- (C) Parenchymal hematoma
- (D) Ocular injury
10 >>MRI scan of a 19-year-old woman after a motor vehicle accident shows multiple foci of punctate hemorrhage. These are most likely indicative of which of the following? ?
- (A) Diffuse axonal injury
- (B) Uncontrolled hypertension
- (C) Amyloid angiopathy
- (D) Coagulopathy
11 >>Which of the following treatments should be recommended to improve the outcome of a patient with a severe traumatic head injury? ?
- (A) Corticosteroids
- (B) Hyperthermia
- (C) Prophylactic hyperventilation
- (D) Hypothermi
12 >>A 47-year-old woman begins to have difficulty swallowing food at dinner. Over the following 3 hours, she develops diplopia, dysarthria, and ultimately anarthria. She has a history of hypothyroidism and is on thyroid hormone replacement. There is no history of exposure to ticks or recent travel. On examination, she nods her head appropriately to questions, and she can write. Forced vital capacity is 500 mL, and she is intubated. She is afebrile, tachycardic, and normotensive. Bilateral ptosis and ophthalmoparesis are present; pupils are 6 mm in diameter and minimally reactive. Facial sensation is intact. Bifacial paresis is present, and the tongue is weak. Extremity muscle bulk and tone are normal, and proximal strength is 4/5 in her arms and legs. Finger and toe movements are rapid and symmetric. Plantar responses are flexor. Blood tests are normal. Motor nerve conduction studies (NCS) show low-amplitude compound muscle action potentials with normal velocities. Sensory nerve action potentials are normal. Which of the following organisms is most likely responsible for this woman’s syndrome? ?
- (A) Cytomegalovirus (CMV)
- (B) Treponema pallidum
- (C) Chlamydia pneumoniae
- (D) Clostridium botulinum
13 >>A 66-year-old woman presents with fever and a generalized convulsion. MRI shows high T2 signal in the medial temporal lobes (R > L). Lumbar puncture is performed and routine CSF analysis indicates 100 lymphocytes/?L, 15 red blood cells (RBCs), xanthochromia, and a mildly elevated pressure. Which of the following is the most appropriate treatment for this patient? ?
- (A) Dexamethasone
- (B) Amphotericin B
- (C) Gamma globulin
- (D) Acyclovir
14 >>A 41-year-old right-handed woman has had 1 day of progressive weakness. The symptoms began in her extraocular muscles and then spread quickly to involve other muscles in her face before her entire body felt weak. The history is significant for the recent ingestion of home-canned fruit. The underlying mechanism of this disease is which of the following? ?
- (A) Antibodies to the acetylcholine receptor
- (B) Impaired formation of acetylcholine-laden vesicles
- (C) Depolarizing blockade of the potassium channel
- (D) Antibodies to the calcium receptor
15 >>A 22-year-old woman presents to the emergency room with an episode of acute painful loss of vision in the right eye. On examination, there is a right afferent pupillary defect and papillitis on funduscopic examination. She has no history of neurological symptoms. An MRI shows a few foci of T2 signal increase in a periventricular distribution. Which of the following is the most appropriate treatment for presumed optic neuritis in this patient? ?
- (A) Oral prednisone
- (B) Intravenous methylprednisolone
- (C) Cyclophosphamide
- (D) Plasma exchange
16 >>A previously healthy 23-year-old woman has had 2 weeks of blurry vision in her left eye. Multiple tests, including visual evoked potentials, are performed. The diagnosis of optic neuritis is made. What is the approximate likelihood that this patient will eventually develop MS? ?
- (A) 0
- (B) 0.05
- (C) 0.25
- (D) 0.75
17 >>A 27-year-old man, who 6 months ago had optic neuritis, presents to the emergency room describing a brief, sharp pain radiating into the left side of his face. The vision in his eye has largely recovered, and there is no evidence of sensory loss on the right side of his face. He describes the pain as ice pick-like and grimaces with each attack. He is most likely to have symptomatic relief from his facial pain if he is managed with which of the following drugs? ?
- (A) Aspirin
- (B) Acetaminophen
- (C) Ibuprofen
- (D) Carbamazepine
18 >>A patient who has been diagnosed with MS has had recurrent episodes of bed wetting (enuresis) over the preceding month. This should decrease with the administration of which of the following drugs? ?
- (A) Oxybutynin
- (B) Phenytoin
- (C) Carbamazepine
- (D) Baclofen
19 >>Over the course of a few months, a patient with MS develops painful spasticity in her left leg that interferes with extension of her leg. The spasticity progresses to the point of interfering with her sleep. Which of the following is the most appropriate treatment for this patient? ?
- (A) Imipramine
- (B) Phenytoin
- (C) Baclofen
- (D) Carbamazepine
20 >>A 47-year-old man arrives at the emergency room in a coma. His wife reports that he developed shaking movements and abnormal breathing sounds in the middle of the night. His shaking and the sounds woke her, but she was unable to wake him. He has been somewhat forgetful over the prior 3 months, but has seemed well otherwise. Examination in the emergency room reveals an unresponsive man who exhibits generalized convulsions every 10 minutes. He is afebrile and incontinent of urine. The physician on call believes the patient is in status epilepticus and should consequently immediately order which of the following? ?
- (A) An intraventricular drain to monitor intracranial pressure
- (B) Lorazepam for intravenous administration
- (C) Carbamazepine by nasogastric tube
- (D) Phenytoin by nasogastric tube
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