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A 78-year-old male with a past medical history of diabetes presents to the clinic with a 2-year history of progressive lower extremity numbness and pain. He describes the pain as “pins and needles”. Physical examination reveals loss of pinprick sensation to the ankles bilaterally, mute Achilles reflexes, and moderate difficulty with tandem gait. A diagnosis is made based on examination and clinical history. What is the mechanism of action of the most appropriate first-line therapeutic agent?
A 35-year-old male with a history of intravenous drug use was found unresponsive with a used syringe at his side. After 30 minutes of CPR, there was a return of spontaneous circulation. A CTH was performed (shown below). Which of the following is appreciated on imaging?
A 62-year-old woman presents to your clinic with complaints of dizziness. She states that about 2 weeks ago she had some dental work done including a root canal, and ever since then has had spells of extreme dizziness. She describes that the room spins and she becomes sick to her stomach. The sensation is improved by sitting very still. It completely resolves in between episodes, and episodes happen about once or twice a day. She noticed that it happens consistently when she tries to back out of the driveway in the early morning. She had a CT head one day ago that was read as normal. On exam, she has inducible nystagmus. The otoscopic exam is normal. Which of the following is the most accurate statement?
Which of the following is an absolute contraindication for the use of tPA?
A 32-year-old obese and pregnant female in her third trimester presents to the clinic with pain and tingling of the lateral thigh with occasional aching in the groin. It is worsened by moving to a standing or sitting position and by wearing tight underwear. She has numbness on the right anterolateral thigh up to the level of the hip. The strength exam is normal. Which nerve is likely affected?
A 14-year-old male is referred to the neurology clinic by his PCP with the complaint of bilateral hearing loss. Neurological examination shows a sensorineural hearing loss. Multiple hyperpigmented lesions on the chest and back were also appreciated. An MRI of the brain was ordered that showed bilateral posterior fossa lesions. Genetic testing would reveal a mutation on which chromosome?
Which of the following nerve conduction study abnormalities is least likely to be seen during the initial phase of acute inflammatory demyelinating polyneuropathy (AIDP)?
An unresponsive patient with an ischemic stroke is transferred to the intensive care unit. On physical exam, the patient has flexion of the bilateral elbows, wrists, and fingers, but extension of the legs. Where is the stroke most likely located?
A 14-year-old female presents to the clinic with frequent falls, clumsiness, and stumbling on her feet. She also reports progressive difficulty with simple tasks such as buttoning her shirts and a loss of feeling in her feet. On physical exam, she has high-arched feet and loss of position and vibration sensation of her great toe. Thoracolumbar MRI shows atrophy of the cervical cord. This condition is associated with which genetic mutation?
A 55-year-old female with a past medical history of coronary artery disease and ischemic stroke with residual mild left arm weakness presents with headaches for a year. Episodes occur two to three times a month. The pain is unilateral and is associated with nausea and photophobia. During this episode, she is unable to go to work and over-the-counter anti-inflammatories have been ineffective. Physical exam and vitals are normal. Which abortive therapy is the most appropriate next step in management?
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 conduction block of motor neurons outside of compression sites and normal sensory conduction velocities. Which of the following antibodies is associated with this disease?
A 65-year-old male is brought in by his daughter due to progressive headache and memory difficulties. MRI of the brain was ordered and is shown below (Left: T2 FLAIR, Right: T1 with contrast). A biopsy of the lesion would most likely reveal which of the following?
A 38-year-old man with a prolonged history of intravenous drug use, HIV, and poor compliance with HAART therapy is brought to the hospital by police after being seen wandering across a busy street intersection. His last CD4 count was 180 cells/microliter 8 months ago. Vitals appear within normal limits on arrival. Neurological examination shows inattention, poor short-term memory, and difficulties with abstract thought. An MRI is performed and shown below. What is the likely etiology of his symptoms?
A 15-year-old male is brought to his primary care doctor by his parents because of learning difficulties in school. Examination revealed several pigmented skin lesions (see below). Which of the following additional findings may be present on examination?
A 39-year-old male presents to the clinic for hallucinations. His medical history is only remarkable for a chemical accident at his job resulting in severe corneal scarring bilaterally, for which he now requires a seeing-eye dog.
His hallucinations are usually of tall figures dressed in black with long fingers. He is not frightened by this because he knows they are not real. He denies other neurologic deficits, denies auditory hallucinations and describes his mood as “good”. The rest of his exam is normal.
You are familiar with the underlying syndrome the patient is experiencing. You inform the patient that in the rest of the population the most common cause of this syndrome is actually…
A patient with a recent history of ischemic stroke with almost no residual focal deficits except for a mild right-sided facial droop presents to the emergency room with altered mental status. Vital signs are only impressive for a low-grade fever. CT head and CTA show no acute changes when compared to imaging completed for his initial stroke. Blood work shows thrombocytopenia, anemia, and renal failure. A severe drug reaction is suspected. Which of the following medications is most likely the cause of this clinical presentation?
A 19-year-old female who was admitted to the epilepsy monitoring unit for medically refractory epilepsy had one of her typical seizures captured during recording (see below). Which of the following symptoms did the patient most likely experience at the time of this recording?
A 42-week gestational age female was born vaginally to a mother with a history of type 2 diabetes. Delivery was complicated by shoulder dystocia and required assistance with forceps. Apgar scores at 1 and 5 minutes were seven and nine, respectively. Her birth weight was 9 pounds and 6 ounces. Examination after birth showed there was no appreciable left arm bicep or deltoid function. What is the most likely etiology for this finding?
A 30-year-old male comes into the clinic with a 3-month history of scalp tenderness. His MRI brain is shown below (Left: T1, Middle: T2, Right: T1 with contrast). Which of the following is the most likely diagnosis?
A 16-year-old male is brought to the emergency room by his parents for generalized weakness. The patient states that he woke up in the morning that day with flaccid paralysis of his arms and legs which was so significant that he couldn’t get out of bed. In typical teenage boy fashion, he wasn’t very worried about this at the time and went back to bed. It wasn’t until 4 hours later when he woke up again with the same degree of weakness that he became concerned and screamed for his parents to help. The patient denies any recent drug or alcohol use. The only interesting thing from the previous night was that he partook in and won a pizza-eating contest with his friends. The patient’s father admits to having had similar episodes to this when he was younger. If the patient’s symptoms are due to a genetic disorder, a mutation in which of the following genes is most likely responsible?
Which of the following findings is depicted in the catheter angiogram shown?
A 34-year-old woman comes to the emergency room with complaints of neck stiffness, headaches that are worse on standing, and diplopia. An MRI brain with contrast shows diffuse dural enhancement. Which of the following findings is also likely to be present in this case?
A 26-year-old female presents with unilateral vision loss. She says that she noticed symptoms upon awakening yesterday morning and it has gotten progressively worse since then. On neurological examination, she has 20/70 visual acuity of the left eye and 20/20 of the right. There is a left afferent pupillary defect (APD). Extraocular movements are intact but cause pain. What is the most likely etiology of her symptoms?
A 56-year-old right-handed man is brought to the emergency room for new-onset aphasia. On exam, he cannot write, perform simple calculations, name his own fingers, and cannot distinguish with accuracy between his right and left sides. A lesion in which area can explain his symptoms?