Quiz 07/26/2022

A 20-year-old man with a history of poorly controlled schizophrenia was admitted to the hospital by his parents for severe bizarre hallucinations. He informed the nursing staff that there were toxins in his body that needed to be flushed out and continuously asked for water. There was a concern for psychogenic polydipsia. Over the next two days, the patient was started on haloperidol, a fluid-restricted diet, and normal saline infusions. On the second day of hospitalization, the patient developed progressive confusion and gait instability. A brain MRI was performed and is shown below. Which of the following is the most likely etiology of his symptoms?

A 56-year-old male with a past medical history of smoking presents to the clinic with the chief complaint of a 1-month history of progressive muscle weakness. Interestingly, he notes that his strength seems to improve with repeated use. The physical examination is notable for proximal muscle weakness of the bilateral lower extremities and areflexia in all extremities. Serology and electrodiagnostic testing confirm the diagnosis. What is the first-line therapy for symptomatic management?

Parents bring their 3-year-old son to the clinic for difficulty walking. On examination, the patient has a waddling gait and enlarged calf muscles. When rising from a seated position he has to rely extensively on his arms to stand up. Which of the following is the most likely inheritance pattern of the genetic disorder affecting this patient?

An abnormal breathing pattern described as an initial prolonged inspiratory phase, inspiratory pause, and then incomplete expiration can localize to damage of which of the following regions along the neuraxis?

A 76-year-old man with a five-year history of idiopathic Parkinson’s disease presents to your office accompanied by his daughter. She remarks that he has started talking to his wife who passed away 5 years ago. She also frequently finds him frightened, looking around the room at “small people” who are not there. Which of the following is a treatment of choice that is correctly paired with its associated monitoring parameters?

A 57-year-old teacher presents to the clinic with reading difficulties. His first symptoms developed 12 months ago when he had trouble marking students’ homework. He progressively also lost the ability to write and had to retire from his profession. Now he needs help tying his shoes and buttoning his clothes. His visual acuity is 20/20. Funduscopic examination and the rest of the neurological examination are unremarkable. Which of the following is the most likely diagnosis?

Which of the following cranial nerve(s) transverses through the structure (blue arrow) shown below?

A 67-year-old man presents urgently to the emergency room with an acute onset of left-sided weakness and numbness. A CT head was performed and shown below. What is the most likely etiology of the patient’s symptoms?

A 36-year-old female with a history of renal cell carcinoma with headaches and slight right arm/leg ataxia had an MRI of the brain that showed a contrast-enhancing lesion in the right cerebellum. Surgical resection was completed and histology of the lesion is shown below. This patient most likely has which of the following diagnoses?

According to Practice Parameters by the American Academy of Neurology, Which of the following is not recognized as a reliable assistive device in accurately predicting a poor outcome in comatose patients after cardiopulmonary resuscitation for cardiac arrest?

A 4-year-old male is brought to your clinic by his father who states that he has been experiencing random jerky movements of his arms and his neck for the past year. His father states that the jerky movements have not gotten worse over time but tend to appear more when the boy is agitated or under stress. The movements cease when he is asleep. The patient has otherwise been meeting all of his developmental milestones. Genetic testing reveals a mutation in TITF1, a thyroid transcription factor. What is the diagnosis?

What are the 3 most common causes of bacterial meningitis in neonates (0-1 months)?

A 35-year-old male presents to the neurology clinic for the management of seizures. The patient reports having focal to bilateral tonic-clonic seizures (FTBTC) since the age of 15. His seizures are usually preceded by the smell of burning rubber. He will then have left hand automatisms followed by whole-body tonic-clonic activity. Levetiracetam monotherapy was initially effective. However, 1 year ago seizures returned, occurring once every two months. Lacosamide was added 6 months ago but there has been no significant improvement in his seizure frequency. Levels of these two anti-seizure medications (ASMs) are therapeutic and there have been no concerns regarding medication adherence. What is the most appropriate next step in management?

Which is the following findings on EMG is suggestive of a chronic neurogenic lesion?

A 66-year-old patient with bradykinesia, hypomimia, dementia, postural instability, cogwheel rigidity, shuffling gait, and resting tremor presents to your clinic. He has been on carbidopa/levodopa for several years, which has helped, but now his wearing-off phenomenon is becoming more frequent despite attempted medication adjustments. He asks about deep brain stimulation (DBS).

Which of the following is a contraindication for DBS in Parkinson’s disease (PD)?

The PET scan shown is most consistent with which of the following diseases?

A patient with a history of focal to bilateral tonic-clonic seizures has an EEG performed to see if they have responded to levetiracetam. Based on the EEG below, from which region of the brain does epileptiform activity arise?

A 38-year-old man visiting from India presents to your clinic as a new patient for months of weakness in bilateral ankles to dorsiflexion and plantar flexion. On exam, he has diminished reflexes. He had an EMG done recently, showing axonal neuropathy in the lower extremities. He does not have his medication list with him, but he states he has taken a medication prescribed in India for “a cough” for several months. Which of the following labs would provide the highest yield?

A 16-year-old girl is seen in the clinic for episodes concerning for seizures. Episodes are characterized by staring off, unresponsiveness, and licking her lips for 30 to 60 seconds. Two weeks ago one of these episodes developed into a generalized tonic-clonic seizure. That day she went to the emergency room and had an MRI performed. The associated images are shown below. Based on the clinical history and imaging what is the most likely diagnosis?

Which of the following can be appreciated on histopathologic analysis of ischemic tissue five hours after an ischemic injury to the cortex?

A 7-day-old infant is in the hospital since birth when he starts having seizures. He has been feeding poorly thus far. On examination, he has hypotonia, as well as distinctive facial features of midface hypoplasia, hypoplastic supraorbital ridges, and a prominent high forehead. The metabolic testing panel returns with elevated very-long-chain fatty acids. What is the physiology of this disorder?

A 40-year-old woman with a history of neurofibromatosis type 2 is presenting to the clinic with chronic anosmia and progressive left eye vision loss. Visual acuity testing reveals 20/200 OS and 20/20 OD. There is a left eye afferent pupillary defect. Funduscopic examination shows pallor of the left optic disc and blurring of the disc margins of the right optic disc. An MRI brain is ordered to localize the lesion. Based on the clinical examination, where will the pathologic lesion most likely be found?

A 74-year-old male with a past medical history of hypertension and hyperlipidemia is brought to the physician by his daughter who states that he has been exhibiting abnormal shaking of his hands and difficulty walking for the past year. On exam, the patient exhibits a shuffling gait, a tremor of his left hand at rest, and difficulty initiating movements. Which of the following is the most appropriate first-line therapy?

A 70-year-old male presents to your clinic with the chief complaint of leg discomfort. He states that he has difficulty sleeping at night due to these symptoms. Movement of his limbs gives transient relief. Serum ferritin levels were within normal limits. Which of the following therapeutic options is the most appropriate treatment for his disorder?

Nursing staff in the neonatal intensive care unit noticed that a 32-week gestational age newborn with a complicated delivery and low initial Apgar scores and intracranial hemorrhage developed abnormal movements on the 2nd day of life. The movements were described as rhythmic, high-frequency movements of the left limb. There were no associated autonomic changes appreciated with events. The child was placed on continuous EEG recording and an event was captured which had no EEG correlate. What is the most likely diagnosis?

A 30-year-old male presents to the clinic with a fifteen-year history of progressive weakness and sensory loss in his lower extremities. Examination shows hammertoes, high arches on his feet, 4/5 ankle dorsiflexion strength, and a mild decrease in sensation to pinprick in the 1st toes bilaterally. Upon questioning he mentions that his father had similar-looking feet and started to use a cane in his fifties. What is the most likely diagnosis for his symptoms?

A patient with newly-diagnosed early state amyotrophic lateralized sclerosis (ALS) presents to your multidisciplinary clinic for the first time. After discussing the effectiveness and side effects of riluzole and endavarone, the patient informs you that he doesn’t want to start either medication. Which of the following basic principles of medical ethics could be best applied to this scenario?

Which of the following identifies the straight sinus?

A two-month-old boy is brought to the Emergency Room by his mother because of lethargy for the past 3 hours. His mother states that earlier today the child rolled off the couch and hit his head on the hardwood floor. Physical exam shows excessive somnolence, tense anterior fontanelle, and fundoscopic exam shows bilateral retinal hemorrhages. A non-contrast CT of the head shows subdural hematomas of varying ages. A CT head is ordered and pending. Otherwise, what is the next most appropriate step in the management of this patient?

Which of the following is the relay center for hearing?

A 58-year-old male presents with a few months of progressive symptoms. He reports limb rigidity, left greater than right, as well as neck stiffness. On exam, you note bradykinesia and cervical dystonia. He does not have a tremor. Speech is hesitant, and there is evidence of speech apraxia. You also note that the patient has trouble controlling the location of his left hand in space, and he grabs for your stethoscope without realizing it.

What is the most likely diagnosis?

Which of the following genetic abnormalities is most common in the pathology shown in the image below?

Which of the anti-seizure medications (ASMs) listed operates under zero-order kinetics at high doses?

A 68-year-old man with an unknown past medical history presents with language difficulties. His spontaneous speech is non-fluent. He has anomia and difficulty following complex tasks, but intact repetition. A solitary lesion in which of the following regions can present with these symptoms?

A 43-year-old man with obesity and hypertension presents with complaints of excessive daytime sleepiness, gasping awakenings, and witnessed periods of not breathing during sleep. A polysomnogram is performed and confirms the presence of sleep-disordered breathing. What feature would point to a central rather than obstructive cause?

The EEG pattern on this bipolar EEG recording is most consistent with which of the following epilepsy syndromes?

A 65-year-old man presents to the emergency room with progressive weakness over the course of several months. Examination shows pure motor weakness with no sensory involvement, decreased reflexes, and diffuse fasciculations. An EMG shows a conduction block of motor neurons outside of compression sites and normal sensory conduction velocities. Which of the following of most appropriate for treatment?

A 67-year-old man with a past medical history of obstructive sleep apnea is being evaluated for bilateral arm tremors. His symptoms started insidiously 5 years ago. It is best appreciated when the patient brushes his teeth or eats with a fork. Oddly, he has noticed that a glass of wine at night can help with his symptoms. What is the most appropriate therapy for his movement disorder?

Identify the electrographic pattern appreciated at electrode P3 in the EEG below:

A 32-year-old female comes into the clinic with a continuous, throbbing headache for 5 months. The pain is unilateral near the temple. The headache is constant but there are periods of pain exacerbations that can last from minutes to days and are debilitating. There is associated lacrimation and rhinorrhea on the ipsilateral side. What is the most likely diagnosis?

Charcot Marie Tooth disease (CMT) is associated with which of the following pathologic findings?

The pathology shown in the image below is likely due to which of the following?

A 38-year-old man with long-standing migraines was recently hospitalized for an unprovoked seizure. Upon further questioning, the patient admits to a strong family history of headaches and early strokes. A brain MRI is completed and a T2 sequence image is shown below. This patient likely has a mutation in which of the following genes?

Which of the following medications is the most effective in the management of PTSD-associated nightmares?

A 20-year-old female presents to the clinic with weakness and numbness in the right leg. She states that earlier in the day she was taking a long nap on her right side, and when she awoke, her entire leg felt like pins and needles. When she got up, she felt that she was dragging her right leg on the floor. She has had similar experiences in other limbs over the years but symptoms would slowly improve over weeks. Nerve conduction studies showed a right common peroneal nerve conduction block and mildly decreased conduction velocities of all nerves tested. Her mother reports that her father had similar episodes before he passed away from an unrelated illness. Which of the following is the most likely diagnosis?

A 32-year-old man with a 4-week history of painful swelling on his right forehead presents to the emergency room. A CT scan of the head was performed and is shown below. What is the most likely diagnosis?

A 68-year-old male with a 10-year history of Parkinson’s disease comes to the clinic for routine follow-up. He currently is taking levodopa/carbidopa, entacapone, and ropinirole. The patient is complaining of significant dyskinesias and unpredictable motor fluctuations between doses of levodopa/carbidopa. What is the most appropriate next best step in management?

Aquaporin-4 (AQP4) channels are found on which cell type?

A 68-year-old male presents with complaints of insomnia for 2 years. On further questioning, he also endorses a 2 years period of feelings of guilt about his sleeping, considerably low appetite (current BMI = 17), and low energy. He used to enjoy checkers but has lost interest in most activities these days. He denies suicidal ideation. He has previously declined medications to help with this, but he says he is ready to try something. Which of the following medications is most appropriate?

The MR angiogram shown below demonstrates which of the following?