NEUROLOGY Diagnosis/Neurology Bradykinesia is most commonly associated with A. Wernicke's syndrome. B. Hashimoto's thyroiditis. C. Cushing's disease. D. Parkinson's disease. Explanations (u) A. Patients with Wernicke's syndrome demonstrate confabulation and difficulty understanding normal speech. (u) B. Hashimoto's thyroiditis (hypothyroidism) can cause puffiness of the face and eyelids and thinning of the outer halves of the eyebrows. (u) C. Cushing's disease causes a moon-like facies. (c) D. Patients with Parkinson's disease have resting tremor, bradykinesia, lack of facial expression, and micrographia. Diagnosis/Neurology A 68 year-old male who is obese has a 50 pack-year history of smoking. He experienced a sudden and total loss of vision in his right eye, which resolved after 20 minutes. Which of the following is the most likely diagnosis? A. Optic neuritis B. Retinal detachment C. Macular degeneration D. Transient ischemic attack Explanations (u) A. Optic neuritis usually has a more insidious onset. (u) B. Retinal detachment most often presents with a history of sudden onset of flashing lights, floaters, or blurred vision in one eye, quickly becoming progressively worse. (u) C. Macular degeneration is a slowly progressive disease leading to blindness and is most often bilateral. (c) D. This history of sudden onset of a unilateral neurological deficit in a patient with risk factors for vascular disease suggests vascular ischemia. By definition, a transient ischemic attack is a neurological deficit that resolves quickly. Clinical Therapeutics/Neurology Of the following drugs, the appropriate treatment of myasthenia gravis is A. donepezil (Aricept). B. quinidine (Quinidex). C. neostigmine (Prostigmin). D. edrophonium (Tensilon). Explanations (u) A. Donepezil is an acetylcholinesterase inhibitor and used in the treatment of Alzheimer's disease. (u) B. Quinidine is an antidysrhythmic agent and has no place in the treatment of myasthenia gravis. (c) C. Neostigmine is useful in the treatment of myasthenia gravis. (u) D. Edrophonium is useful in diagnosing myasthenia gravis but is too short acting for the treatment of the disorder.
Clinical Intervention/Neurology A 30 year-old male has a history of weakness without pain on the left side of his face for the past 4 days. Physical examination of the face reveals unilateral weakness to the left side, but not complete paralysis. The left eye does not close completely. The most appropriate initial treatment is to A. reassure the patient and provide patient education. B. recommend a nonsteroidal anti-inflammatory medication. C. recommend tricyclic antidepressants. D. recommend physical therapy. Explanations (c) A. Bell's palsy will resolve completely without treatment in approximately 60% of all cases. (u) B. Nonsteroidal anti-inflammatory medications can be used to relieve pain only. (u) C. Tricyclic antidepressants are indicated in post-herpetic neuralgia, not Bell's palsy. (u) D. Physical therapy would not provide any benefit. Health Maintenance/Neurology A 42 year-old female has a diagnosis of migraine headaches. She had been using ergotamine to abort her headaches, but she is now having one or two headaches per week that are interfering with work. Of the following, the most appropriate preventive therapy is A. sumatriptan (Imitrex). B. promethazine (Phenergan). C. propranolol (Inderal). D. ketorolac (Toradol). Explanations (u) A. Sumatriptan is used acutely to abort a migraine headache. (u) B. Promethazine is an antiemetic that may be used to alleviate nausea and vomiting from an acute migraine. (c) C. Propanolol is useful in preventing migraine headaches and may be maintained indefinitely. (u) D. Ketorolac is an NSAID that may help relieve an acute migraine. Clinical Therapeutics/Neurology A 5 year-old child has just been hospitalized with meningococcemia. Family members and close contacts should be given which of the following as prophylaxis? A. Rifampin orally B. Penicillin orally C. Erythromycin orally D. No chemoprophylaxis Explanations (c) A. Exposed household, school, or day-care contacts of children with meningococcemia should receive chemoprophylaxis to eliminate the organism from the nasopharynx. The drug of choice is rifampin (10 mg/kg, up to 600 mg) every 12 hours for 48 hours. Sulfisoxazole, ceftriaxone, and ciprofloxacin are alternative choices Diagnostic Studies/Neurology Which of the following is considered to be the gold standard in making the diagnosis of multiple sclerosis? A. Gadolinium-enhanced MRI B. MRA of the brain
- Positron emission testing D. CT brain scan Explanations (c) A. Gadolinium-enhanced MRI studies can help to characterize and delineate intramedullary disease and are able to characterize various lesions in time and space. (u) B. MRA of the brain primarily is used to assess the vascular integrity of the brain rather than plaque formation or denervation. (u) C. PET scanning is used to assess the metabolism of the brain and is primarily used in the assessment of Alzheimer's disease. (u) D. CT brain scan is used to assess for metastatic lesions to the brain. It is rarely used today. Clinical Intervention/Neurology A 73 year-old female patient was diagnosed 3 years ago with Alzheimer's disease. Her 80 year-old husband can no longer help feed and bathe her. Which of the following support services is most appropriate for this patient? A. Hospice care B. Senior center C. Adult day care D. Skilled nursing facility Explanations (u) A. Hospice care is a program to provide palliative care to individuals who are terminally ill and projected to die within 6 months. (u) B. Senior centers are community-based facilities that provide recreational activities and mid-day meals for functional adults. (u) C. Adult day health care is designed to meet the needs of functionally impaired adults in a community setting, but does not usually provide for the higher level of care that is required to feed or bathe a patient. (c) D. A skilled nursing facility is appropriate for patients requiring assistance with activities of daily living (i.e., feeding and bathing) and a higher level of safety assurance. Diagnosis/Neurology A 10 year-old male has abrupt, brief episodes of impaired consciousness and rhythmic blinking. Which of the following is the most likely type of seizure? A. Focal B. Absence C. Tonic-clonic D. Complex partial Explanations (u) A. Focal seizures affect only part of the brain and usually produce focal motor symptoms of a limb. (c) B. Absence seizures are generalized seizures characterized by abrupt, brief episodes of impaired consciousness, staring, and rhythmic blinking. (u) C. Tonic-clonic seizures present with sudden loss of consciousness with generalized jerking of muscles. (u) D. Complex partial seizures involve impaired consciousness and automatisms. History & Physical/Neurology Which of the following tests measures cerebellar function? A. Finger-to-nose testing
- Stereognosis C. Graphesthesia D. Two-point discrimination Explanations (c) A. Cerebellar function is tested by finger-to-nose, heel-to-knee, rapid alternating movements, and gait. (u) B. Discriminative sensory tests include two-point discrimination, stereognosis, graphesthesia, and point localization. Diagnostic Studies/Neurology A 12 month-old presents with possible viral meningitis. Which of the following laboratory results is most consistent with this diagnosis? A. Decreased CSF glucose level B. Decreased CSF total protein level C. Increased CSF mononuclear cells D. Increased CSF C-reactive protein Explanations (u) A. A decreased CSF glucose level is noted in bacterial meningitis. (u) B. In viral meningitis an elevated CSF total protein would be noted. (c) C. Increased CSF mononuclear cells are noted in viral meningitis. (u) D. An increased C-reactive protein is noted in bacterial meningitis. Clinical Therapeutics/Neurology A 45 year-old woman presents with sharp, burning pain that radiates from her mouth toward her right ear. The pain is intermittent, excruciating, lasting for a few seconds, and is worse with eating or touching her face. Which of the following is the drug of choice for long term treatment? A. Carbamazepine B. Propranolol C. Valium D. Phenobarbital Explanations (c) A. Carbamazepine may be helpful in the treatment of trigeminal neuralgia. (u) B. Propranolol, valium, and phenobarbital are not indicated for treatment of trigeminal neuralgia. History & Physical/Neurology Which of the following is the earliest manifestation of dementia of the Alzheimer's type? A. Incontinence B. Memory deficit C. Aggressiveness D. Motor disturbances Explanations (u) A. Incontinence is not an early manifestation of Alzheimer's disease. (c) B. A primary characteristic of dementia is memory impairment. A major component of the presenting symptoms is subjective complaints of memory difficulty. (a) C. Aggressiveness may be seen, but is a later finding. (u) D. Motor disturbances, such as akinesia/bradykinesia, postural/gait abnormalities, rigidity, and tremor, are signs and symptoms of Parkinson's.
