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Old 03-27-2016
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Default CLINICAL MASTERY NEURO please help!

41. A previously healthy 67-year-old man comes to the physician because of a 2-month history of back pain that awakens him at night. Physical examination, including rectal examination, shows no abnormalities. X-rays of the spine show multiple osteoblastic lesions; a biopsy specimen of the lesions shows well-differentiated adenocarcinoma. Which of the following is the most appropriate next step to establish the origin of cancer in this patient?
A) Measurement of serum a-fetoprotein concentration
B) Measurement of serum prostate-specific antigen concentration
C) Urine immunoelectrophoresis
WRONG• D) X-ray of the chest
E) Colonoscopy

17. An 18-year-old man comes to the physician because of difficulty walking for 1 week. Examination shows visual fields that are constricted equally in both eyes on close and distant testing. He has collapsing effort on muscle strength testing in the left extremities. He staggers from side to side when walking but does not fall. On Romberg testing, he abruptly falls to the left. There is hemisensory loss to light touch, pinprick, vibration, and proprioception on the left that stops exactly at the midline. Which of the following is the most likely diagnosis?
A) Cerebellar degeneration
B) Cervical spinal cord compression
C) Conversion disorder
D) Guillain-Barre syndrome
E) Multiple sclerosis
F) Sensory neuropathy
G) Tabes dorsalis
WRONG• H) Vitamin 8 12 (cobalamin) deficiency

25. An 82-year-old woman comes to the physician because of a 1-year history of neck stiffness, pain radiating from her neck to her left hand, urinary incontinence, and unsteadiness when walking. Medical history includes osteoarthritis, peptic ulcer disease, and hyperlipidemia. Current medications are naproxen, ranitidine, and lovastatin. She has a history of alcohol abuse but has abstained from drinking for 5 years. Neurologic examination shows atrophy of the left upper extremity and increased tone in both lower extremities. Muscle strength in the left upper extremity is 3/5. Deep tendon reflexes are 2+ at the biceps and brachioradialis bilaterally, absent at the left triceps, and 3+ at the knees and ankles. Babinski sign is present bilaterally. Sensation to pinprick and temperature is decreased over the left dorsal forearm and hand. Proprioception and sensation to vibration are markedly decreased at the ankles and toes. She has a stiff, wide-based gait. Which of the following is the most likely diagnosis?
A) Bilateral brachia! plexopathy
B) Epidural cord compression
WRONG• C) Parasagittal meningioma
D) Peripheral neuropathy
E) Spondylotic cervical myelopathy

49. A 67-year-old woman is brought to the emergency department by her husband 1 hour after the sudden onset of incomprehensible speech that began shortly after breakfast. Her husband describes her speech during the episode as fluent and well articulated but full of illogical word combinations, making it impossible for her to be understood. He says that she also did not seem to understand him or follow commands. She has hypertension, hyperlipidemia, and asthma. Current medications include lovastatin and lisinopril. She is allergic to aspirin. On arrival, her language function is normal. Her pulse is 80/min and regular, and blood pressure is 152/88 mm Hg. Physical and neurologic examinations show no abnormalities. Echocardiography shows no abnormalities. Carotid duplex ultrasonography shows 30% stenosis of the left common carotid artery; the right is normal. Which of the following is the most appropriate intervention to decrease this patient's risk for future episodes?
A) Clopidogrel therapy
B) Estrogen replacement therapy
WRONG• C) Propranolol therapy
D) Warfarin therapy
E) Left carotid endarterectomy

50. A previously healthy 27-year-old man comes to the physician because of a 2-week history of pain in his neck and left shoulder radiating through the lateral surface of his left arm to his thumb and index finger. Examination shows a decreased biceps reflex on the left. Muscle strength is 4/5 on extension of the left wrist. Sensation to light touch is decreased over the left thumb and index finger. The remainder of the examination, including neurologic examination, shows no abnormalities. Which of the following is the most likely diagnosis?
A) C4 radiculopathy
B) C5 radiculopathy
C) C6 radiculopathy
D) C? radiculopathy
WRONG• E) C8 radiculopathy
F) Carpal tunnel syndrome
G) Cubital tunnel syndrome

17. A 62-year-old woman comes to the physician because of right-sided facial pain for 3 days and a facial rash for 1 day. She describes the pain as a burning uncomfortable feeling in her cheek. She had cold symptoms 1 week ago that have now resolved. She has hypertension treated with hydrochlorothiazide but is otherwise healthy. She cares for her two grandchildren, ages 1 and 3 years, every weekday after school. Examination shows a vesicular rash over the face. Neurologic examination shows no abnormalities. Which of the following is the most appropriate measure to prevent transmission to the unvaccinated grandchildren?
A) Avoid contact with the grandmother until the rash has resolved
WRONG• B) Administration of varicella vaccine to the children
C) Acyclovir therapy for the children
D) Acyclovir therapy for the grandmother
E) No preventive measures available

22. A previously healthy 18-year-old man is brought to the emergency department because of facial weakness and ear pain that began this morning. When he awoke this morning, he looked in the mirror and noticed that his face appeared twisted. While he was eating breakfast, milk drooled from the left side of his mouth. The ear pain has not been relieved by acetaminophen. Examination shows weakness of both the upper and lower face on the left. Sensation over the face is normal. Which of the following is the most likely location of the abnormality?
A) Anterior horn cell
B) Muscle
C) Myoneural junction
D) Nerve
WRONG• E) Nerve root

27. A 57-year-old woman with metastatic breast cancer comes to the physician for a follow-up examination. She reports that her pain is poorly controlled with her current dosage of oral sustained-release morphine. One month ago, she reported the same problem and the dosage of morphine was increased. On examination today, she is agitated and tearful and insists on another increase in her morphine dosage. Which of the following is the most likely explanation for this patient's request?
A) Inadequate pain control
B) Intent to attempt suicide
WRONG• C) Major depressive disorder
D) Substance abuse
E) Surreptitious use of morphine by family

38. A 72-year-old woman is brought to the physician because of increasing clumsiness, restlessness, and confusion over the past 3 weeks. She currently lives with her daughter. She can no longer remember how to make coffee or button her clothes. She has urinary incontinence. Her medications include digoxin, furosemide, potassium, ibuprofen, ranitidine, and diphenhydramine. One month ago, she began taking meperidine for a rotator cuff injury. Examination shows disorientation, memory loss, and dyspraxia. A CT scan of the head shows mild cortical atrophy. Which of the following is the most appropriate next step in management?
A) Discontinue anticholinergic medications
B) Discuss obtaining durable power of attorney
D) Fluorescent treponemal antibody assay
E) Prescribe an antidepressant
WRONG• F) Recommend 24-hour in-home nursing assistance
G) Suggest labeling the drawers and cabinets for contents

49. A 47-year-old woman is brought to the emergency department 1 hour after the sudden onset of headache. She says that she was walking from work to her car when she felt an explosion in her head causing her to fall to the ground. She is not sure if she lost consciousness. Since then, she has had a severe headache characterized by double vision and throbbing pain exacerbated by head movement. She has hypertension treated with atenolol. She has smoked two packs of cigarettes daily for 20 years. Her pulse is 80/min, respirations are 16/min, and blood pressure is 148/82 mm Hg. Examination shows left ptosis. The left pupil is 6.5 mm, and the right pupil is 4.5 mm. Upward gaze and adduction of the left eye are limited. A CT scan of the head shows diffuse subarachnoid blood. A lumbar puncture yields grossly bloody cerebrospinal fluid. Cerebral angiography is most likely to show a saccular aneurysm in which of the following locations?
A) Basilar artery
B) Bifurcation of the left middle cerebral artery
C) Left posterior communicating artery
WRONG• D) Origin of left anterior cerebral artery
E) Origin of left ophthalmic artery
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