Old Q&A – Neurology

The correct answer is C. The diagnosis of headache is often a challenge. This patient has many classical signs and symptoms of migraine. However, her associated visual loss, which is not described as an “aura” is troubling and should trigger concern for a possibly different and more severe diagnosis. This pattern is suggestive, if not worrisome, for temporal arteritis. Since she is having no current symptoms, the first step in evaluating for this condition is to order an ESR. Prednisone should be considered to prevent blindness if you strongly believe that this diagnosis is possible.

Believing that no action is indicated at this time (choice A) is a common mistake that is made by young physicians because the tendency is to think that patients such as this are somewhat hypochondriacal.

Having the patient increase the dose of her migraine therapy regimen (choice B) is not appropriate because she is having new symptoms that are not clearly related to a migraine. Specifically, visual “aura” is common with migraine, but loss of vision is not and therefore prompts additional investigation.

Referring the patient for a CT scan of her head (choice D) is not indicated, as there is no evidence from this patients’ history that warrants an evaluation for any intracranial process.

Referring the patient for a temporal artery biopsy (choice E) would be more sensitive and specific for the diagnosis of TA, but as a screening tool for disease it is too invasive.

The correct answer is D. This is a typical presentation for analgesic withdrawal headache. She must be weaned off the daily use of analgesics for her headaches. There may be an underlying condition such as migraine or tension type headache, but the analgesics must first be stopped to determine this.

If a headache of intracranial hypertension were suspected a lumbar puncture (choice A) might be indicated, but this case seems to be analgesic withdrawal headaches.

Both analgesics must be stopped so stopping the acetaminophen and increasing the dose of ibuprofen (choice E) is incorrect.

Amitriptyline (choice B) may be used for migraine prophylaxis, but she must be off the daily analgesics before we make that diagnosis.

Sumatriptan (choice C) may be used for acute treatment of migraine, but she must be off the daily analgesics before we make that diagnosis.

The correct answer is B. As part of the widely accepted University of Pittsburgh criteria for brain death, the presence of either posturing or brain stem function (e.g., pupillary reflexes or corneal reflexes), as is present in this case, violates the brain criteria for the formal definition of brain death. That said, the fact that the patient has no purposeful activity one week after an anoxic brain injury bodes poorly for a meaningful neurological recovery.

Although stating that more time is required to pronounce brain death (choice A), the passing of time often aids in the prognosticating of likely neurological recovery, but the diagnosis of brain death can be made at any time and is not time-dependent

MRI (choice C) may help assess the extent of brain injury but has no role in the formal diagnosis of brain death.

The EEG, even when suggestive of minimal or no cortical function (choice D), does not exclude brainstem activity and therefore cannot be used in isolation to make the diagnosis of brain death.

Neurologists are often asked in consultation to help predict neurological recovery and diagnose brain death (choice E) but any physician who is trained to diagnose brain death (e.g. critical care physicians) may do so.

The correct answer is A. The differential diagnosis is rather broad at this point. You should look for an infectious or malignant mass with a contrast enhanced CT or MRI.

A non-contrast head CT (choice B) is less sensitive for abscess or tumor.

A lumbar puncture (choice C) should only be done after you are sure that there is not significant mass effect.

This patient has an acute problem which should be addressed now. Antiretroviral therapy (choice D) will help him in the long term, but does not need to be initiated in the emergency department.

Intravenous heparin (choice E) is a treatment for embolic stroke. Embolic stroke is unlikely in this case and he needs further evaluation before considering treatment with intravenous heparin.

The correct answer is C. The immediate concern is that she has bacterial meningitis and she should be treated with intravenous ceftriaxone. A lumbar puncture should be performed, however the treatment should not be delayed until the results return.

Doing a lumbar puncture and blood draw to obtain cultures should be done (choices A and E), however it can take a few days for the results to come back and it may be too late for her by then. An MRI before the lumbar puncture is recommended if the patient has papilledema, to rule out a mass that may herniate if a lumbar puncture is performed. This is not necessary in this case because the patient has a normal ophthalmologic exam.

Oral azithromycin (choice B) is not the proper treatment for bacterial meningitis.

Intravenous acyclovir (choice D) would be used to treat herpes encephalitis.

The correct answer is E. In these difficult situations where the patient is not able to make their own decisions and when there is disparate views among family members, the most important directing factor should be what the patient would have decided were they able to speak for themselves. Therefore, previously expressed views on what the patient would want if faced with a similar situation could prove invaluable in helping to direct care in the direction that the patient would have wanted.

Court appointed legal guardians (choice A) are utilized when a patient has no family or has family members who are not competent to help make medical decisions on behalf of the incapacitated patient.

If the patient has a clearly expressed view, this view would supercede any sentiments by the medical team (choice B), the husband (choice C), or a hospital ethics committee (choice D).

The correct answer is A. This patient is postictal. Poor compliance is one of the leading causes of “breakthrough” seizures. In this case, blood should have been sent for a carbamazepine level almost immediately on arrival to the emergency room.

Since she has not yet been fully evaluated for the cause of the present seizure, there is no reason to start a new medication and she should not be discharged yet (choice B).

A brain MRI (choice C) is unlikely to be helpful in this case.

Intravenous lorazepam (choice D) or phenytoin (choice E) would be indicated if she were in status epilepticus. She is not seizing right now and probably could even take oral medications if needed.

The correct answer is A. This is a typical history for multiple sclerosis (MS). This is a sometimes a difficult diagnosis to make and the management can be complicated. The patient should be referred to a neurologist. However, it is not emergent (choice E) in this case, particularly since her most recent episode has resolved.

Daily aspirin (choice B) is a treatment for cerebrovascular disease. This patient’s history and examination are more consistent with multiple sclerosis than with cerebrovascular disease.

Intravenous corticosteroids (choice C) are a treatment for acute MS attacks. Presently, she is asymptomatic and should be sent for evaluation by a neurologist.

Warfarin (choice D) is a treatment for cerebrovascular disease, which she probably does not have.

The correct answer is E. In any patient with a new headache that is associated with nausea and vomiting and exacerbated by exertion or positional changes, a brain tumor should be suspected. This is the typical presentation of a posterior fossa brain tumor. Weight loss, systemic symptoms, and an elevated erythrocyte sedimentation rate are not typically associated with a primary brain tumor. Papilledema, caused by increased intracranial pressure, is rarely found in patients over 55 years old with an intracranial mass. An MRI or CT scan of the head will establish the diagnosis.

Administration of glucocorticoids, intravenously (choice A) is the appropriate treatment to prevent blindness in a suspected case of temporal arteritis. Temporal arteritis typically presents with a unilateral headache, myalgias, jaw pain, fever, and weight loss. A tender, reddened temporal artery is often found. Visual changes may occur and blindness is a feared complication. This patient does not have any of the usual systemic symptoms associated with temporal arteritis. The diagnosis of temporal arteritis is established with a temporal artery biopsy (choice D). The erythrocyte sedimentation rate is typically elevated in temporal arteritis

Administration of sumatriptan, intramuscularly (choice B) is the treatment for a migraine headache which typically presents with a throbbing headache, nausea, vomiting, photophobia, and functional impairment. An aura consisting of hallucinations and scotomas sometimes occurs before the headache. An intermittent headache that becomes constant is not the typical pattern of a migraine. The sublingual ergotamine and oral sumatriptan that this patient was taking are typically effective in treating a migraine.

Oxygen inhalation therapy (choice C) is the treatment for a cluster headache. A cluster headache is an episodic headache that typically presents with a few short headaches a day for a few weeks that is associated with periorbital pain, reddening of the eye, and lacrimation. This patient’s history is inconsistent with a cluster headache.

A lumbar puncture (choice F) should be performed in a suspected case of meningitis and possibly in a suspected intracranial hemorrhage, if the CT scan fails to show the bleed. Meningitis often presents with a headache, nuchal rigidity, and photophobia. Fever and a rash may be present. An intracranial hemorrhage may present with a headache and nuchal rigidity, seizures, and confusion. A CT scan of the head usually establishes the diagnosis. The patient’s history is inconsistent with meningitis and is more consistent with a brain tumor than an intracranial bleed. A lumbar puncture should not be performed in this patient or any patient with a suspected brain tumor because it may cause brain herniation.

The correct answer is D. Sulfadiazine and pyrimethamine is proper treatment for T. gondii infection.

Intravenous acyclovir (choice A) is used to treat herpes encephalitis.

Neurosurgical removal of the lesions (choice B) is not indicated.

Oral fluconazole (choice C) is a treatment for fungal infections.

Thiabendazole (choice E) is used to treat helminth infections.

The correct answer is E. This presentation is concerning for venous sinus thrombosis. MRV is the best noninvasive test to confirm this diagnosis. If the MRI/MRV is negative, then she should have a lumbar puncture to rule out idiopathic intracranial hypertension (pseudotumor cerebri).

Intravenous heparin (choice A) is the usual treatment for a venous sinus thrombosis, however, the diagnosis should be confirmed first if possible. Therefore, a brain MRI and MRV is the most appropriate next step in management.

A neurosurgical consult (choice B) is not indicated in this case.

Naratriptan (choice C) is used for the acute treatment of migraine headaches. This is atypical for a migraine, but she should be further evaluated before she is discharged and treated.

Soft cervical collar and metaxalone (choice D) are used to treat headaches from cervical muscle spasms. There was no neck muscle spasms noted on exam, and she should be further evaluated before she is discharged.

The correct answer is D. This patient with altered mental status, a rapid neurological decline, and skin lesions all point to fulminant infection with Neisseria meningitidis.

E. coli (choice A) is generally not a disease that, when it becomes blood-born, produces anything other than the sepsis syndrome. A petechial or purpuric rash is not such a feature.

The same holds true for Haemophilus influenza (choice B) that is most often seen in young children, but has been decreasing in incidence since wide-spread effective vaccination programs have been implemented.

Listeria monocytogenes (choice C) is often a disease of newborns and neonates and again, does not present with characteristic skin lesions.

Streptococcus pneumoniae meningitis (choice E) is a common etiologic agent for pneumonia in adults. It can also be associated with significant morbidity and mortality but is not associated with a rapid (<12 hour) neurological decline, nor with purpuric skin lesions. The skin lesions on this patient are believed to be the result of an immune complex deposition in the skin capillaries.

The correct answer is D. This patient is presenting with signs and symptoms of temporal arteritis, also known as giant cell arteritis. This disease is caused by inflammation of the large vessels off of the aortic arch, most commonly manifesting in the temporal artery. Biopsy will show mononuclear and giant multinucleated cells in the intima and media of the vessel. Classic symptoms are new onset temporal headaches in a patient over 60 years of age, jaw claudication as he describes, and an ESR that is markedly elevated. Patients often have pain to palpation over the temporal artery itself. There is also a high association with polymyalgia rheumatica (PMR), which causes limb girdle pain and stiffness as this patient describes. Progressive visual loss, due to the effect of the disease on the ophthalmic artery can befall up to 50%, in untreated patients.

Intracranial hemorrhage (choice A) is also very unlikely in this case. Longer-term headache can be seen with chronic subdural hematomas. However, this patient also has jaw claudication, symptoms of PMR, and an elevated ESR, which go along more with temporal arteritis.

Death from metastatic tumor (choice B) or herniation of the uncal region of the brain (choice C) would be of concern in the setting of a brain tumor. Although headache can be an initial symptom in patients with central nervous system malignancies, it is not a likely consideration in this case.

There is nothing to suggest from the case presentation that he is at high risk for an embolic stroke (choice E).

The correct answer is C. The history and exam are typical for idiopathic intracranial hypertension (pseudotumor cerebri). The exact cause is unknown, but it is probably due to impaired reabsorption of cerebrospinal fluid leading to raised intracranial pressure. It usually occurs in obese, young women. Lumbar puncture shows an elevated opening pressure and normal CSF. Acetazolamide may be used to lower intracranial pressure. Weight reduction is important.

Obtaining an electroencephalogram (choice A) will not help with the diagnosis.

There is no reason for a neurosurgical consult (choice B).

Since nothing has changed since last week and she has the exact same symptoms, a repeat MRI of the head (choice D) is not indicated. It would be appropriate if she had different symptoms.

Propranolol (choice E) is used for migraine prophylaxis and is not indicated here, as this patient’s condition is consistent with idiopathic intracranial hypertension, and further evaluation is indicated.

The correct answer is A. This patient has suffered a devastating subarachnoid bleed. The most common non-traumatic cause of SAH is rupture of a preexisting aneurysm. The mortality rate of these bleeds is high, but in managing these patients much has been learned about how to minimize morbidity in the first post-bleed weeks. This patient had a vasospasm. This is a nearly universal event after a SAH since the blood in the CSF is an irritant. The treatment shown to have fairly good benefit is the calcium channel blocker nimodipine. No other blocker, including verapamil (choice C), has been shown to be beneficial.

Starting intravenous pressors (choice B) in these patients is the next management step after nimodipine. This is done to maximize cerebral perfusion pressure (mean arterial pressure minus ICP) in an attempt to maintain cerebral perfusion.

Not more than a few years ago, vasospasm was not treated since, many thought that the deterioration after bleeding was the natural history of the disease. Not initiating therapy (choice D) is no longer the standard of care.

Since there is no sign of new blood on the CT scan, there is no reason to return to the operating room (choice E).

The correct answer is A. You should reverse the warfarin. The risk of him having a stroke from atrial fibrillation is far outweighed by the immediate goal of stopping the intracranial bleeding.

This patient requires a high blood pressure to maintain cerebral perfusion. If you drop his blood pressure with labetalol (choice B) this will cause his brain to lose oxygen. Also, subdural bleeds are venous, so the high arterial blood pressure would not be expected to increase the bleeding.

A brain MRI (choice C) will not provide additional useful information at this time.

Heparin (choice D) is contraindicated during an intracranial bleed. The goal is to reverse anticoagulation.

It is too early to predict outcome. You should not tell the family that he will die and do nothing further (choice E).

The correct answer is G. This patient has Bell’s palsy, an idiopathic inflammatory neuropathy of the facial nerve usually following a viral upper respiratory infection. Over 90% of patients recover without residual symptoms in 1 month. Oral prednisone with or without acyclovir is sometimes used to shorten the recovery period and possibly improve the outcome. However, this is based on a limited amount of studies.

Prednisolone therapy (choice A) is not indicated. High-potency intravenous steroids are not used in Bell’s palsy as they have no proven benefit and many side effects. Low-potency oral steroids are used anecdotally, although they have no proven benefit.

Aspirin (choice B) has no direct role in the treatment of Bell’s palsy.

A CT of the head (choice C) is not necessary in the evaluation of Bell’s palsy. Focal facial nerve neuropathy following an upper respiratory infection is the classic presentation of Bell’s palsy. The presence of other neurologic symptoms or signs would point to a primary neurologic process and would then warrant some type of neuroimaging.

An MRI of the brain (choice D) is not necessary in the evaluation of Bell’s palsy. Focal facial nerve neuropathy following an upper respiratory infection is the classic presentation of Bell’s palsy. The presence of other neurologic symptoms or signs would point to a primary neurologic process and would then warrant some type of neuroimaging.

Nerve conduction studies (choice E) are not necessary in the evaluation of Bell’s palsy.

Ampicillin (choice F) is not indicated because a facial nerve neuropathy is not due to a bacterial infection. The patient should be managed conservatively for Bell’s palsy.

The correct answer is A. The patient has myasthenia gravis, which is characterized by fluctuating weakness in a characteristic distribution, usually causing diplopia, ptosis, and proximal muscle weakness. It is caused by an autoimmune response that produces an antibody to acetylcholine receptor. The diagnosis is based on clinical suspicion and confirmed by the acetylcholine receptor antibody test or by an EMG that shows decremental response to repetitive stimulation. One can also perform a single fiber EMG, which is possibly the most specific test, but not required for the diagnosis. In patients with confirmed MG, it is important to look for other autoimmune disease such as RA, SLE, thyroiditis, and Graves disease, which have a higher incidence in patients with MG and their first degree relatives. After the diagnosis is confirmed, it is important to look for evidence of thymoma, especially in patients younger than age 60. The reason is that thymectomy is recommended for most patients with MG, the best responses to it are in young patients with evidence of thymoma. The response to thymectomy is variable and may not be noticed until 2-5 years after the surgery.

Lumbar puncture (choice B) is incorrect. Based on the clinical history, physical exam, and labs, the patient has myasthenia gravis and there is no role for examining the cerebrospinal fluid.

MRI (choice C) is incorrect. MRI of the brain is a good test to evaluate for structural abnormalities of the central nervous system. Myasthenia gravis does not affect the central nervous system and therefore, there is no role for MRI.

Muscle biopsy (choice D) is incorrect. The patient has complaints of weakness that are characteristic for myasthenia gravis. However, myopathy should remain in the differential diagnosis until confirmatory tests are done. In this case, the labs and EMG did confirm MG. If they did not confirm MG and one wanted to pursue a diagnosis of myopathy, muscle biopsy would still not be the first test to perform. Instead, one would begin with serum CK and aldolase levels.

Tensilon test (choice E) is incorrect. A Tensilon test is a simple but subjective test that may be performed in the office or at the bedside. It may be used to clinically corroborate a suspected diagnosis of MG, but may be positive in diseases other than MG, such as motor neuron disease. Thus, it does not replace the acetylcholine receptor antibody test or the EMG in the diagnosis of MG. Furthermore, in this case, MG has already been diagnosed by the above tests and no additional information will be obtained by doing a Tensilon test.

The correct answer is D. A number of studies have conclusively established that the risk of stroke for patients over the age of 65 with atrial fibrillation (AF) is significant and warrants therapy in all cases. The magnitude of this risk depends on the underlying etiology. Most patients with AF have a significantly increased risk of embolic stroke. Patients with rheumatic heart disease (RHD) have a 17-fold higher risk than the general population and patients with non-RHD have an estimated 5-fold increased risk.

The risk of stroke depends on the presence of coronary artery disease (choice A) is true, but only for non-RHD patients. The risk for these patients is not uniform and is instead based on the presence or absence of a number of risk factors, coronary artery disease being one of them. However, for RHD patients, the risk for stroke is almost uniformly determined by the magnitude of the valvular lesion and the size of the atrium.

The risk of stroke is greater than the general population, but less than with lone atrial fibrillation (choice B) is incorrect. Lone AF is AF with no underlying risk factors, such that occurs after cardiac surgery or below the age of 65. These patients have a very low annual risk for embolic events. These patients are usually treated with aspirin.

The risk of stroke is greater than the general population, but less than with congestive heart failure and atrial fibrillation (choice C) comprises the so-called non-RHD group of AF patients, and as mentioned above, has a 5-fold increased risk of stroke compared to 17-fold for RHD patients.

The risk for stroke is not different from the general population (choice E) is clearly incorrect because it is the greatest of any population.

The correct answer is C. This young, healthy, athletic patient had a syncopal episode, which can be cardiogenic or neurogenic in origin. After the history and physical, blood work is usually sent to rule out anemia, infections, hypocalcemia, or hypomagnesemia and an EKG must be performed. An EKG may show evidence of cardiac abnormalities such as Wolf-Parkinson-White syndrome (r wave slurring), idiopathic hypertrophic subaortic stenosis, or congenital prolonged QT syndrome.

It is inappropriate to admit him for cardiac monitoring (choice A) before even performing an EKG. You need to first try to distinguish the etiology of this syncopal episode, therefore an EKG and other studies should be done in the emergency department. Cardiac monitoring may be necessary if an arrhythmia is found.

An echocardiogram (choice B) may be necessary to evaluate cardiac abnormalities, however this should not be done until an EKG is performed.

An electroencephalogram (choice D) may be performed if a seizure is suspected. However this should not be performed at this time in this patient because it does not seem like he had a seizure.

A neurology consultation (choice E) is not necessary at this time because you must first try to determine whether this syncopal episode was cardiogenic or neurogenic in etiology. An electrocardiogram is an easy test to perform in the emergency department to assess for cardiac abnormalities.

A tilt-table test (choice F) is useful in establishing the diagnosis of vasovagal/neurocardiogenic syncope, which is caused by venous pooling, decreased venous return, inappropriate vasodilatation, hypotension, and relative bradycardia. A positive test will show hypotension and bradycardia, and syncope. This test is not part of the initial evaluation of a single syncopal episode in a young, healthy, athletic patient. It is usually used in patients with multiple unexplained syncopal episodes. An electrocardiogram is easier to perform and is more likely to help establish a diagnosis in this patient at this time.

The correct answer is D. In this patient, you should perform lumbar puncture with CSF analysis for suspected subarachnoid hemorrhage (SAH). The CT scan can be normal in 5% of patients with a subarachnoid hemorrhage within the first 12 hours of headache onset. Between 24 and 72 hours from onset of headache, up to 25% of CT scans can be normal. Therefore, if one suspects a subarachnoid hemorrhage from the patient’s history, it is imperative to perform a lumbar puncture to evaluate the CSF for xanthochromia and red blood cells. Xanthochromia is not seen in a traumatic tap and may be more specific than RBC analysis. A lumbar puncture will also help to rule out meningitis, although this is unlikely in this patient given his presentation.

Giving pain medication (choice A) is acceptable, but the patient should have a more thorough evaluation.

Giving a 5-HT agonist (choice B) is a bad idea in this patient because it may lead to vascular spasm and worsen the subarachnoid bleeding.

Neurosurgical evaluation and cerebral angiography (choice C) may be necessary, but further evaluation is needed to justify this consult.

Prior to psychiatric evaluation (choice E), one must first rule out life threatening causes of headache.

The correct answer is D. The tremor is of a Parkinsonian type and he should be examined by a neurologist.

Electromyography and nerve conduction studies would not be useful in diagnosing the tremor (choice A).

His Parkinsonian features are very mild and do not interfere with his daily activities, so treatment with carbidopa/levodopa (choice B) is not indicated at this time.

Propranolol (choice C) may be effective for kinetic and postural tremors, but is not a treatment for a Parkinsonian type tremor.

This patient has a Parkinsonian tremor that should be evaluated by a neurologist, but there is nothing to suggest that it be done emergently (choice E).

The correct answer is B. This patient gives a typical history for temporal lobe epilepsy. Seizures are often exacerbated by estrogen, which is a neuroexcitatory hormone. The neurological examination, including mental status exam, is often normal in these cases. This is a complicated case and should be managed at least initially by a neurologist.

There is no acute issue that would warrant sending this patient to the emergency department (choice A).

There is no history suggestive of mental illness. A psychological etiology for her symptoms must be a diagnosis of exclusion, so a psychiatric consult is not necessary (choice C).

A brain MRI (choice D) might detect an abnormality contributing to her seizures. However, a neurologist would probably order specific MRI sequences based on his evaluation and the test would need to be repeated anyways. Additionally, the neurologist may want to order other tests.

A rising discomfort in the stomach followed immediately by feelings of rage is highly suggestive of temporal lobe epilepsy. However, further evaluation should be done before starting phenytoin (choice E). Additionally, she will need to be closely followed and phenytoin is often a poor first choice anti-seizure medication for a young woman.

The correct answer is B. This is a neurosurgical emergency and a neurosurgical consult needs to be called. There is no age that is an absolute contraindication for surgery and it would be wrong to tell the family he is too old for any treatment and send him back to the nursing home (choice E).

A cerebral angiogram (choice A) would be indicated if you had strong suspicion for an aneurysm or vascular malformation. This is not the usual cause of a subdural hematoma.

Since his coagulation studies were already normal, there is no reason to give fresh frozen plasma (choice C).

A brain MRI (choice D) will not provide any further useful diagnostic information right now.

The correct answer is B. This history is typical of a simple partial seizure. A focal brain lesion must be ruled out with an MRI or CT scan.

It would be wrong to discharge the patient to follow up in clinic in 2 weeks (choice A) without at least a CT scan and preferably an MRI.

Although he probably had a seizure, obtaining an electroencephalogram (choice C) at this point will not be as helpful as an MRI.

This is unlikely to be a peripheral nerve problem and an orthopedic consult (choice D) or electromyography and nerve conduction studies (choice E) are not indicated.

The correct answer is C. This question asks about clinical efficacy. In the presented study, 120 of the 200 patients given the drug did not report migraines in the measurement period (120/200 = 60%).

Expressing enthusiasm (choice A and D) about a prescribed treatment does help to engender confidence in the treatment on the part of the patient. However, this response does not answer the patient’s question.

Of course, individual patients may be the exception to the rule (choice B), but this research tells us that the drug is likely to be effective. The probability is that the drug will work for this patient.

Statistical significance is high, less than one per 1,000 chance of Type I error. However, statistical significance tells us little about clinical significance. Knowing the “p-value” tells us nothing about the number of patients who get better or the chance that an actual patient will get better (choice E).

The treatment group did report half the migraines compared with the placebo group, but this is a misuse of this ratio. The study did not measure the reduction in migraines within each person. Rather, it examined the presence/absence of migraines between the treatment and control groups. In short, this study does not tell us what sort of reduction in migraines an individual patient might expect, therefore (choice F) is incorrect.

Inquiring after a patient’s concerns over treatment (choice G) is a reasonable tack, but does not answer the question posed by the patient. If the patient asks a question, you should try to answer it.

The correct answer is C. This patient is presenting with a fairly classic history for multiple sclerosis (MS), which is characterized by multiple neurologic symptoms separated in space and time. That is to say, a single central nervous system lesion could not explain the signs and symptoms that she has manifested over the past several months. Her ocular symptoms are very characteristic of optic neuritis, which is one of the most common manifestations of MS. Furthermore, she has the classic MRI findings of multiple sclerosis showing multiple plaques on white matter tracts. One of the mainstays of treatment in MS is corticosteroid therapy, and it is particularly useful in the acute setting with optic neuritis.

Intravenous acyclovir therapy (choice A) is often used in herpetic encephalitis that classically affects the temporal lobes of the brain in younger patients and often presents with seizures.

Intravenous ceftriaxone (choice B) is good initial therapy for acute community acquired bacterial meningitis. This clinical presentation is not consistent with meningitis.

No therapy (choice D) is clearly not appropriate for the reasons discussed previously.

Radiation therapy (choice E) is not used in the treatment of MS, and moreover, this clinical scenario is not consistent with any form of malignancy.

The correct answer is B. The headache is typical of that caused by intracranial hypertension. Additionally, she has focal neurological symptoms and signs. This is particularly concerning for a brain tumor or hemorrhage. This should be evaluated as soon as possible. An appointment next month (choice D) is too late.

Intravenous prochlorperazine (choice A) is a good treatment for status migrainous, however this history is atypical for such a diagnosis and more serious problems should be ruled out first in the emergency department.

Zolmitriptan (choice C) is a treatment for migraines. This history is not typical for migraine and zolmitriptan is relatively contraindicated in patients with complex migraine.

This history is very atypical for seizures and an electroencephalogram (choice E) is not likely to provide useful information in this case.

The correct answer is A. For the elderly, the risks of surgery and anesthesia are often heightened and much of this increased risk stems for comorbid conditions more present in the elderly. This patient is a high aspiration risk even while awake. After general anesthesia however, his risk is dramatically elevated such that aspiration of significant quantities of stomach contents are possible leading to pneumonitis. If the pneumonitis progressed to pneumonia, a patient such as this, debilitated and moderately demented, would certainly need a tracheostomy (choice E). The patient’s risk however is for the aspiration, not necessarily the pneumonia or prolonged intubation.

All postoperative patients are at risk for deep venous thrombosis (choice B). This patient’s risk is no greater because of his comorbid conditions and his surgical procedure is at the low risk end of the spectrum since his ambulation should not be limited by the incision in his neck.

Delirium (choice C) is certainly troublesome for the patient and family, but is not serious. Elderly patients are more likely to be confused in hospital settings (so-called sundowning) as well as postoperatively. This patient is at high risk for both given his dementia but again, these concerns are not serious compared to the possibility of aspiration. The aspiration can be guarded against, the delirium cannot.

This patient is at low-risk for a perioperative myocardial infarction (choice D) based upon American Heart Association stratification guidelines that all medical house officers carry in their jacket pockets. The surgical procedure is classified as low risk. Given the patient’s lack of prior coronary history, he is also classified as low risk. The combination of the two, make this patient for this procedure a very low-risk candidate for a possible myocardial ischemic event.

The correct answer is A. This patient probably has a subarachnoid hemorrhage. She must be evaluated for an aneurysm and a neurosurgical consult must be obtained.

Sumatriptan (choice B) is a treatment for migraine. The history and cerebrospinal fluid results do not support a diagnosis of migraine.

Intravenous acyclovir (choice C) would be used to treat herpes encephalitis. Although there are often red blood cells in the spinal fluid of such patients, the overall history is more consistent with a subarachnoid hemorrhage than herpes encephalitis.

This does not appear to be bacterial meningitis. It is not emergent that ceftriaxone (choice D) be given in this case.

Repeating the lumbar puncture (choice E) is not going to help with the diagnosis or treatment.

The correct answer is C. Whenever a patient arrives with a history of a syncopal episode, especially in a teenager, drug exposure must be considered. In this case, it is most likely that the syncope was secondary to exposure to a recreational drug such as cocaine, hallucinogens, or marijuana. Drug exposure should be considered with young children as well because they can accidentally ingest a parents’ medications if left within reach.

This history is not consistent with that of orthostatic hypotension. If the patient had a syncopal episode because of orthostatic hypotension one would expect to hear about a history of lightheadedness, palpitations, prolonged standing, fainting upon rising, and dehydration. He should be evaluated for the cause of the episode and therefore, observation in the emergency department and performing serial measurements of orthostatic blood pressure and heart rate (choice A) is incorrect. Since this history wasn’t obtained it makes the diagnosis of postural/orthostatic hypotension unlikely.

There is no evidence that this episode of syncope was in any way related to an infectious cause and therefore a CBC and blood culture (choice B) is unnecessary.

Whenever a patient has syncope from a sitting or recumbent position it is worrisome. An arrhythmia must be considered, such as long QT, Wolff-Parkinson-White, AV block, atrial fibrillation/flutter, and ventricular fibrillation/flutter. An electrocardiogram was done in this case which was negative. This does not rule out an arrhythmia as the primary cause because a baseline electrocardiogram might be normal. Secondary to the history in this case, it is more likely that a toxicology screen would be helpful first. If the tox screen turns out to be negative then a consult with a pediatric cardiologist would be indicated. But an echocardiogram (choice D) is not necessary at this time.

As apparent by the discussion here, a work up for the syncope is reasonable and therefore sending the patient home (choice E) is not proper management of this case.

The correct answer is C. NSAIDs are first-line therapy against migraine headaches. Even if a patient tells you that that they have tried NSAIDs without relief, you must first inquire if they have taken an appropriate dose prior to providing other therapy. For example, no headache relief with 200 mg of ibuprofen is not a treatment failure. First-line therapy for migraines is a trial of moderate to high-dose NSAIDs along with environmental controls such as placing the patient in a darkened, quiet room until symptoms resolve. All of the other agents mentioned below can be effective for migraines but they are definitely second-line agents or used for migraine prophylaxis.

Amitriptyline (choice A) is a tricyclic antidepressant, which has a role in prophylaxis of tension and migraine headache but is not useful in acute treatment.

Dihydroergotamine (choice B) is a potent vasoconstrictor with less peripheral vasoconstriction than the above. Its advantages are that it comes in IV/IM or intranasal form. It should also be used with caution in patients with coronary artery or peripheral vascular disease.

Sumatriptan (choice D) is another potent vasoconstrictor which can be delivered intranasally or subcutaneously. It should not be used in patients with CAD or uncontrolled hypertension. It acts by binding to 5-HT1 receptors selectively.

Verapamil (choice E) is a calcium channel blocker which can be used as prophylactic treatment. They have been shown to decrease the frequency of migraines but they do not affect the severity or duration of attacks.

The correct answer is B. For all patients requiring an LP for any reason, the paramount concern is the presence of increased intracranial pressure. The importance of this lies with the theoretical possibility that withdrawing CSF can precipitate herniation. Therefore, for many patients in many institutions, a head CT scan without contrast will be obtained to look for signs of increased ICP such as flattening of the sulci, shrunken ventricles, or a midline shift.

A dural tear (choice A) is common during LP procedures and relates to both the gauge of the needle and the type of tip. The smaller the needle gauge, the less likely it is to tear the dura. It is the dural tears that are believed to be the cause of postdural puncture headaches. In order to minimize this, anesthesiologists and emergency room physicians will use 22 or 25 gauge needles for LP procedures.

Pain during neck flexion for the procedure (choice C) is uncomfortable for the patient, but is of no genuine concern from a medical perspective. This pain should not prevent an LP from being performed.

Possible bacterial meningitis (choice D), other causes of meningitis, and a subarachnoid hemorrhage are all indications for an LP. Possible meningitis is not the most important consideration prior to beginning the procedure, increased intracranial pressure is.

While the presence of bacteremia (choice E) is often a contraindication to performing other procedures such as indwelling line placements or epidural catheters, since the CSF is also infected, there is no contraindication to bacteremia for an LP. In patients where the only source of infection is the blood, introducing blood into the CSF (for example by performing an epidural) is a risk that patients should not be exposed to for the pain relief benefits of an epidural catheter.

The correct answer is A. Aphasia is a disorder of language that is acquired from a lesion in the brain. Aphasia must be differentiated from delirium, dysarthria, and psychosis. Expressive aphasia is caused by a lesion involving Broca’s area, the posterior part of the inferior frontal gyrus. Broca’s aphasia, as it is also known is characterized by intact auditory and written comprehension, but impairment of fluency, naming, repetition, and writing. Patients frequently produce paraphasic speech, which is characterized by substitutions of words or sounds, such as “dog” for “cat” and “band” for “hand”, respectively. This type of aphasia is frequently associated with right hemiparesis or hemisensory loss and sometimes with apraxia of the left limbs. Aphasia is frequently caused by stroke, as was the case in this clinical scenario. The patient has many stroke risk factors (age, gender, hypertension, coronary artery disease, smoking, alcohol use, family history of early coronary artery disease) and his deficit is new, suggesting a sudden onset, which is what characterizes stroke.

Delirium (choice B) is incorrect. Delirium is an acute confusional state characterized by fluctuating levels of wakefulness and attention as well as psychomotor overactivity and hallucinations. Aphasia is not a component of delirium.

Dysarthria (choice C) is incorrect. Dysarthria is a disorder of speech, the articulation and phonation of sounds. This is different than aphasia, which is a disturbance of language.

Wernicke aphasia (choice D) is incorrect. Receptive, or Wernicke aphasia, is caused by a lesion in the posterior part of the dominant superior temporal gyrus. It is characterized by fluent speech with impaired naming and repetition. This speech is sometimes described as “word salad” because it is fluent but devoid of meaning. Comprehension is impaired, which is the most important distinction from Broca aphasics, who are able to comprehend.

Wernicke encephalopathy (choice E) is incorrect. Wernicke encephalopathy is a clinical triad of encephalopathy, ataxia, and ocular motor disturbance that is caused by thiamine deficiency in alcoholics. Aphasia is not a component of Wernicke encephalopathy.

The correct answer is C. This is a good history for cardioembolic stroke — sudden onset, cortical symptoms, atrial fibrillation, subtherapeutic INR. The immediate goal should be to rule out an intracranial hemorrhage and confirm the diagnosis.

Tissue plasminogen activator (choice A) is the treatment for acute stroke in specific circumstances. We are not sure yet that this is a stroke. It may be an intracranial hemorrhage which would be a contraindication for tissue plasminogen activator. Additionally, an elevated INR in a patient on warfarin is a contraindication for tissue plasminogen activator.

Carotid endarterectomy (choice B) is indicated for some cases when a transient ischemic attack or stroke is believed to be caused by carotid artery narrowing. We do not know what caused her event and this procedure would rarely be done emergently.

A cerebral angiogram (choice D) would be indicated if you had strong suspicion for an aneurysm or vascular malformation. There is no reason to believe one of these is causing her symptoms.

Heparin (choice E) may be indicated if there is not an intracranial hemorrhage. This must first be established by CT or MRI.

The correct answer is B. This patient’s symptoms are consistent with a facial nerve palsy that may be caused by Lyme disease (from his camping trip). To test the facial nerve, you should ask the patient to show you his teeth. If the left side of his face is drawn to the right, he most likely has a left-sided facial palsy. Other facial nerve tests include asking him to wrinkle his forehead, puff out his cheeks, and hold his eyes shut as tightly as possible as you try to carefully pry them open.

If this patient had a trigeminal nerve palsy, you should ask him to clench his teeth while you palpate the masseter muscle (choice A). During this maneuver, his jaw would deviate to the same side as the lesion. Also, he would complain of sensory abnormalities on his forehead, cheek, and jaw and paroxysms of pain on his chin, lips, cheeks, and gums.

Sensory abnormalities can be elicited by having him close his eyes and tell you when you are touching his cheek with gauze (choice C). He does not have these sensory symptoms.

If he had a left-sided spinal accessory nerve palsy, you should have him turn his head to the right against your hand (choice D). The dysfunction would manifest with the patient being unable to do this, or weakness on this side as opposed to the other side. He does not complain of weakness in the head, neck, or shoulder.

The gag reflex of the glossopharyngeal nerve is tested by touch the posterior pharyngeal wall with an applicator stick (choice E). Symptoms of glossopharyngeal nerve lesions are sensory dysfunction of the pharynx, loss of taste on the posterior third of the tongue, and a partially dry mouth.

The correct answer is A. Although it is clear that you are ethically bound to follow the patient’s wishes, which in this care appears to be the withdrawal of care, it is always better to do so with the resolve of the family. Often times, feelings such as guilt will drive family members to insist on seemingly unreasonable or inappropriate action. A thoughtful discussion, whereby the family members are allowed to express their reservations in a supportive setting, often will produce a resolution among previous disparate views.

While withdrawing care (choice B) appears to be what ultimately is the most appropriate action, it is worth trying first to have all of the interested parties “on the same page” before preceding if this resolution can be achieved in a timely manner without causing suffering on the patient’s part.

Whereas consult services such as psychiatry (choice C) may be helpful on selected occasions, the first attempts to resolve the conflict should fall on the primary medical team and primary care physicians.

While physicians have the positive duty to report suspected abuse, there is no indication from the information present that the wife has abused her husband (choice D).

Ethics committees (choice E) may be helpful in resolving conflict, but, again, the primary medical providers should first attempt to resolve conflict in order to respect the patient’s wishes in a thoughtful and timely manner.

The correct answer is A. Patients with new intracranial bleeds, especially epidural hematomas, must be watched closely for 24-48 hours. Epidural bleeds are notorious for worsening quickly following an apparent recovery from the original trauma.

If she had subarachnoid blood, which was not obviously caused by trauma, you would arrange for a cerebral angiogram (choice B) to look for an aneurysm or vascular malformation.

This patient has an epidural hematoma, which can quickly worsen and therefore she needs to be admitted for observation. It would be completely inappropriate to discharge her home from the emergency department (choice C).

A brain MRI (choice D) would not give you any further useful information because we already know from the CT scan that she has an epidural hematoma.

A lumbar puncture (choice E) is used to look for subarachnoid blood not seen on CT, but still suspected clinically. This patient has evidence of an epidural hematoma and there is no reason to suspect that she also has a subarachnoid hemorrhage.

The correct answer is A. The history is good for a transient ischemic attack. She should have a full cerebrovascular evaluation. This potentially could be done as an outpatient, however this was not a choice and it is preferable to do as an inpatient.

Carotid endarterectomy (choice B) is indicated for some cases when a transient ischemic attack or stroke is believed to be caused by carotid artery narrowing. We do not know what caused her event.

Sumatriptan (choice C) is a treatment for migraine. We do not know if this was a migraine and she has 2 significant risk factors for cerebrovascular disease. Additionally, sumatriptan is relatively contraindicated in patients with complex migraine.

Warfarin (choice D) may be used for secondary prevention of stroke following a transient ischemic attack in certain cases, particularly if a cardiac embolus is to blame. However, we do not yet know what caused her event.

Although she appears to have fully recovered from the episode, this may have been a transient ischemic attack, putting her at higher risk for a stroke. She should have a full cerebrovascular evaluation and possibly begin secondary prevention. You should not send her home and tell her that she has fully recovered (choice E).

The correct answer is D. MRI of the pituitary gland would likely reveal an adenoma, which is likely secreting TSH. This patient is obviously hyperthyroid by history. She reports anxiety, weight loss, difficulty sleeping, hot flashes, and diarrhea. Her exam reveals a nervous woman with a goiter, moist skin, tachycardia, and hyperreflexia. She lacks the exophthalmos seen in Graves disease. The “mild decrease in peripheral vision” suggest a pituitary mass. Her thyroid function tests reveal inappropriate secretion of TSH by the pituitary despite an elevated T3 and T4. This suggests that the pituitary gland is functioning autonomously without the proper feedback from T3 and T4. Normally, high levels of thyroid hormone would be expected to suppress TSH. It is important to recognize that the TSH in this patient could have been within normal range, but in the presence of elevated thyroid hormone this would be inappropriate as well. An MRI of the pituitary gland would probably reveal a macroadenoma.

Factious disorders (choice A) are an important cause of illness and the USMLE likes to ask questions about them. A case with multiple laboratory inconsistencies, especially if the patient is a health care worker, might make you suspect a factious disorder. In this case, ingestion of levothyroxine would lead to elevated thyroid hormone levels but would suppress TSH. Remember that this is a diagnosis of exclusion.

Antithyroglobulin and antithyroid peroxidase (choice B) antibodies are helpful in confirming a diagnosis of Hashimoto thyroiditis (hypothyroidism). They can also be elevated in Graves disease. These antibodies are elevated in a small percentage of euthyroid patients as well.

TSH receptor antibodies (choice C) are positive in approximately 80% of patients with Graves disease. They are a reasonable test to order if you suspect Graves disease but a negative test certainly wouldn’t exclude Graves as your diagnosis.

Radioactive uptake scans (choice E) can be part of the workup for Graves disease because it not only helps confirm the diagnosis by showing a diffuse increase in uptake, but later it is useful to determine the dose of radioactive iodine that would be necessary if the patient were to opt for radioactive ablation as their form of therapy. In this patient, one would likely see a diffuse uptake of radioactive iodine because the gland is actively producing excess thyroid hormone. It would not help in ruling out a pituitary etiology.

The correct answer is C. The most common etiologies of rim-enhancing brain lesions in AIDS patients are primary CNS lymphoma (PCNSL) and Toxoplasma gondii infection. Other etiologies such as bacterial or fungal abscess are also possible. CSF EBV PCR test is highly sensitive and specific for PCNSL.

A cerebral angiogram (choice A) should be done if you suspect an aneurysm or vascular malformation. These are unlikely in this case.

Since there is no mass effect it is safe to do a lumbar puncture. Therefore, a ventricular cerebrospinal fluid (CSF) aspiration (choice B) is not necessary.

There is no reason to stop all antiretroviral therapy (choice D).

Intravenous acyclovir (choice E) is used to treat herpes encephalitis, which is unlikely in this case.

The correct answer is C. One of the most common causes of neurological deficit in elderly patients is a toxic or metabolic disturbance. Hypoglycemia is particularly common in patients who are being treated for diabetes. These problems are often easily correctable if caught early. While this patient may have had a stroke, the first step is to correct his hypoglycemia. Orange juice (choice B) may also work, but it will not work as quickly and is not the best choice because he is having difficulty swallowing and so he is at risk for aspiration.

Tissue plasminogen activator (choice A) is the treatment for acute stroke in specific circumstances. We do not know that he had a stroke and since his symptoms are relatively mild and over 3-hours old, tissue plasminogen activator is not an appropriate treatment.

Stroke is a possibility in this case. Brain MRI (choice D) would be the best test for this, however it can take a while to get this done and you should first correct the toxic/metabolic disturbances.

Prednisone and acyclovir (choice E) are the treatment for Bell palsy. His facial weakness is not the pattern of Bell palsy and Bell palsy does not cause sensory impairments.

The correct answer is B. This patient has complex partial seizures, which are characterized by automatisms (“picking” movements with hands, chewing, swallowing), that are preceded by an aura. The sequence of events is as follows: aura, behavioral arrest or a motionless stare, automatisms, and postictal confusion. The patient has an impairment of consciousness. These seizures occur in a focal region of the brain, often the temporal lobe.

Absence seizures (choice A), also called petit mal seizures, are generalized seizures that consist of a brief loss of consciousness and automatisms. Postural control is a maintained. There is no postictal confusion.

Generalized tonic-clonic seizures (choice C) are characterized by a sudden contraction of the muscles followed by periods of contraction and relaxation, and finally, relaxation. There is postictal unresponsiveness, excess salivation, and bowel and bladder incontinence.

Myoclonic seizures (choice D) consist of the sudden contraction of one part of the body or may involve the entire body. It is caused by cortical dysfunction.

Simple partial seizures (choice E) are characterized by motor, autonomic, sensory, or psychic symptoms. An aura may precede the seizure. Consciousness is maintained.

The correct answer is D. This patient with optic neuritis needs a more thorough evaluation, including special CSF studies and a spine MRI. Optic neuritis may progress to multiple sclerosis (MS), but does not always. This patient should be further evaluated and followed by a neurologist.

Glatiramer (choice A), interferon beta-1B (choice B), and interferon beta-1A (choice C) are all treatments for MS. They are primarily used for relapsing-remitting MS. However, their use is still evolving and they are best prescribed by a specialist.

Daily aspirin (choice E) is a treatment for cerebrovascular disease which she probably does not have.

The correct answer is A. This is the presentation for a headache caused by intracranial hypotension. It is often caused by a dural tear during physical exertion. The initial management is conservative and includes bed rest and hydration for 1-2 weeks.

It is not necessary to get a brain MRI (choice B).

Intravenous prochlorperazine (choice C) is a treatment for acute migraine headache.

Observation in the hospital (choice D) is not necessary. This can be managed conservatively as an outpatient with rest and fluids.

There is no indication for a psychiatry consult (choice E) as it seems like this patient has a headache consistent with intracranial hypotension, not a psychiatric disorder.