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Question 1 of 40
A 38-year-old woman comes to the emergency department due to 2 hours of left leg weakness and numbness. Over the last 3 months, the patient has had several similar episodes in which her left foot tingles and becomes numb and her entire left foot becomes limp, causing her to trip. The symptoms resolve spontaneously within a few hours. Her right leg has never displayed similar symptoms. The patient has no significant medical history but does have a family history of multiple sclerosis. She does not use tobacco, alcohol, or illicit drugs. The patient has experienced major psychosocial stress after losing her job 6 months ago, but this has tempered somewhat since she joined a meditation group. Vital signs are within normal limits. Physical examination shows diminished pinprick sensation over the dorsum of the left foot and weakness of the left big toe on extension. The patient is able to walk on her left toes but not on her left heel. Which of the following is the most likely cause of this patient’s current symptoms?
Question 2 of 40
A 76-year-old woman is brought to the emergency department by her son with several days of confusion, disorientation, and decreased oral intake. Her other medical problems include mild dementia, hypertension, and type 2 diabetes mellitus. The son says that the patient has been talking to people who are not there and wandering around the house in the middle of the night. She has no history of recent falls. Her medications include metoprolol, valsartan, and metformin. Temperature is 37.2° C (99° F). blood pressure is 100/60 mm Hg, and pulse is 100/min and regular. The fingerstick glucose level is 156 mg/dL. Which of the following initial evaluations is most likely to indicate the precipitating cause of this patient’s condition?
Question 3 of 40
A 32-year-old man is brought to the emergency department with progressive ascending paralysis that began 18 hours earlier. He initially noticed paresthesias in his lower extremities, followed by a sense of fatigue and weakness that was more pronounced in his left leg. He has no history of headache, fever, or recent infection or illness. He had just returned from a hiking trip to Colorado. His blood pressure is 122/81 mm Hg, pulse is 86/min, respirations are 16/min, and temperature is 37.3 C (99.2 F). Physical examination reveals intact cranial nerves, absent deep tendon reflexes in the left lower extremity and 1 + in the right lower extremity, and a normal sensory examination. Both lower extremities show weakness, with no motor activity in his left leg. Laboratory results show a normal WBC count. No abnormalities are noted on CSF examination. What is the most appropriate next step in the management of this patient?
Question 4 of 40
A 21-year-old man with a prior history of seizures is brought to the emergency department by ambulance during a tonic-clonic seizure. His mother, who accompanied him, found him on the floor seizing. She says that he has not been compliant with his medications. The patient received intravenous lorazepam, thiamine, and glucose en route but continued seizing. In the emergency department, he is unresponsive and cyanotic. His blood pressure is 96/54 mm Hg and his pulse is 152/min and regular. His pupils are mid-size and reactive to light. Clonic jerks of all extremities are observed. The patient is at highest risk for which of the following?
Question 5 of 40
A 32-year-old construction worker is brought to the emergency department after his coworkers found him confused, disoriented, and bleeding from the nose. His past medical history is unknown. According to his friends, he had been in his normal state of health this morning when he came to work. He then spent the morning moving heavy packages under direct sunlight for several hours. Temperature is 42 C (108 F), blood pressure is 110/70 mm Hg, and pulse is 120/min and regular. His skin is warm and dry and his neck is supple with no stiffness. His pupils are symmetric, mid-size and reactive to light. Deep tendon reflexes are symmetric. No Babinski is present. He moves all 4 extremities but is unable to speak or follow simple commands. There is active bleeding from the right nostril. Which of the following is the most likely diagnosis?
Question 6 of 40
A 28-year-old woman comes to the emergency department due to left-sided headache and neck pain after a fall while skiing the day prior. She took ibuprofen and rested but the symptoms persisted, and today, she also had transient leg weakness. The patient has no prior medical conditions. She occasionally drinks alcohol but does not use tobacco or illicit drugs. Family history is significant for stroke in her father. Temperature is 37.2 C (99 F), blood pressure is 134/86 mm Hg. and pulse is 90/min. Physical examination shows mild ptosis and miosis of the left eye. There is no excessive lacrimation or rhinorrhea. Funduscopic examination is normal. No carotid bruit is present. Heart and lung sounds are normal. Neurological examination shows normal motor strength, deep tendon reflexes, and sensation in bilateral upper and lower extremities. Which of the following is the most likely cause of this patient’s current condition?
Question 7 of 40
A 60-year-old man complains of 3 days of gait imbalance. He was hospitalized 2 weeks ago for a complicated enterococcal wound infection on his left leg. He was started on ampicillin and gentamicin, which he has continued via home intravenous antibiotic therapy. The patient subsequently developed a constant sensation of objects moving around in his visual field when looking in any direction, which has caused him to feel unsteady in his gait. He has no associated nausea or vomiting. The patient has a history of type 2 diabetes mellitus, hypertension, and early-stage chronic kidney disease. His other medications include lisinopril and high-dose insulin therapy due to poor diabetic control. His temperature is 36.7 C (98 F), blood pressure is 120/76 mm Hg, pulse is 80/min. and respirations are 16/min. His body mass index is 34 kg/m2. Neurologic examination shows 5/6 muscle strength and 2+ reflexes in all extremities. Hearing is decreased in the right ear on whisper test. Rapid head movement away from a fixed target causes eye movement away from the target followed by horizontal saccade back toward it. Which of the following is the most likely cause of his current condition?
Question 8 of 40
A 56-year-old man is brought to the emergency department due to difficulty speaking and paralysis of the right side of his body since he awoke this morning. The patient has not seen a primary care physician for many years and takes no medications. Two years ago, he was told that his blood pressure was elevated during a visit to the dentist. He has a 30-pack-year smoking history and drinks 1 or 2 cans of beer daily. The patient has a sedentary lifestyle and a diet consisting mostly of fast food. His father had a stroke at age 60. Blood pressure is 170/95 mm Hg and pulse is 94/min. BMI is 34 kg/m2. The patient’s speech is dysarthric. Weakness of the right lower face and right upper and lower extremities is present. There is decreased pinprick sensation on the right side of the lower face and body. Right-sided deep tendon reflexes are brisk, and Babinski sign is present on the right. Noncontrast CT scan of the head reveals no hemorrhage. Serum LDL is 190 mg/dL and HbA1c is 8%. Which of the following is most strongly associated with this patient’s current neurological condition?
Question 9 of 40
A 44-year-old woman comes to the office with muscle weakness over the past several months. She has difficulty combing her hair and, occasionally, difficulty holding up her head, particularly after prolonged sitting or standing. The patient has had no difficulty walking or getting up from a chair. She has also had 2 episodes of double vision while driving home from work. The patient takes rosuvastatin for hyperlipidemia and lisinopril for hypertension. Blood pressure is 142/84 mm Hg and pulse is 76/min. Neurologic examination shows mild right ptosis, symmetric proximal muscle weakness in the upper extremities, and weakness in the head extensors. Muscle bulk and tone are normal and there is no muscle tenderness. Which of the following is the most likely site of the pathology in this patient?
Question 10 of 40
A 55-year-old man comes to the office because of numerous falls for the past few weeks. Yesterday, he felt so dizzy that he fell on the ground and hurt his knees. He has also noticed dry mouth, dry skin, and erectile dysfunction over this period. His medical history is significant for the recent onset of resting tremors. He was diagnosed with diabetes 6 months ago, which is controlled with diet. Blood pressure is 121/84 mm Hg supine, and 92/61 mm Hg standing. Physical examination reveals rigidity and bradykinesia. What is the most likely diagnosis of this patient?
Question 11 of 40
A 56-year-old man with a prolonged history of hypertension and medication nonadherence comes to the emergency department with abrupt-onset, severe, tearing back pain. Blood pressure is 240/130 mm Hg, and CT angiography reveals descending aortic dissection originating at the left subclavian artery takeoff and extending to the iliac arteries. Intravenous infusion of labetalol and nitroprusside are initiated, and the patient is admitted for further management. In the intensive care unit, the patient states that the pain has improved, but he is unable to move the lower extremities. Blood pressure is now 110/60 mm Hg, and pulse is 56/min. Physical examination shows normal heart and lung sounds and a distended urinary bladder. Neurological examination shows normal cranial nerves and upper extremity examination. There is weakness of bilateral lower extremities with decreased deep tendon reflexes. The patient is unable to sense crude touch and pain in the lower extremities, but vibration sensation is intact. Which of the following is the most likely cause of this patient’s current neurological findings?
Question 12 of 40
A 67-year-old woman is brought to the office by her son. He reports that his mother has had periodic confusion, memory loss, and poor sleep and seems “kind of out of it sometimes.” These symptoms have gradually worsened over the past 1-2 years. The patient occasionally sees “strangers in the backyard,” who are not there when her son looks for them. More recently, she has begun walking more slowly and has fallen twice in the past month without any significant injuries. The patient has a history of hypertension and depression. She does not drink alcohol or use illicit drugs. On physical examination, she walks slowly and has mild bilateral hand tremors and mild bilateral lower limb rigidity. On cognitive examination, the patient appears to be oriented to person and place, and can recall 1 of 3 items in 5 minutes; she can state the days of the week forward but does not cooperate with stating them backward. Chemistries, complete blood count, vitamin B12, and thyroid function tests are normal. Serum treponemal test is nonreactive. MRI of the brain shows mild generalized cortical atrophy. Which of the following is the most likely diagnosis in this patient?
Question 13 of 40
A 70-year-old man comes to the office 4 weeks after experiencing an ischemic stroke. His medical history is significant for a long history of hypertension, diabetes, coronary artery disease, congestive heart failure, and atrial fibrillation. Vital signs are unremarkable. BMI is 23.8 kg/m2. Cardiovascular examination reveals an irregularly irregular rhythm. The patient is right-handed. Only the right side of his face is shaved. When asked to raise his left arm, he raises his right arm. When asked to fill in the numbers of a clock, he puts numbers only on the right side. Which of the following areas is most likely affected by the stroke in this patient?
Question 14 of 40
A 29-year-old man comes to the emergency department due to a week of progressive bilateral lower extremity weakness. He has no history of trauma or back pain. The patient had trigeminal neuralgia 3 months ago and a self-limited upper respiratory illness 2 weeks ago. His temperature is 37 C (98.6 F), blood pressure is 122/76 mm Hg, and pulse is 82/min. Physical examination shows increased resistance to passive flexion and extension of the lower limbs. Deep tendon reflexes are 3+ and plantar reflexes are upgoing bilaterally. There is decreased vibratory and positional sensation in his left upper extremity but no other sensory loss. A lumbar puncture is performed. Which of the following is most likely found on the cerebrospinal fluid analysis in this patient?
Question 15 of 40
A 65-year-old woman comes to the office due to deteriorating memory. She used to pride herself on her sharp memory and is very concerned about its loss, saying, “Over the last 6 months I have been forgetting the most trivial things.” The patient has had to delegate tasks such as household chores and cooking to her husband because of her poor memory and “cloudy thinking.” “I have been feeling useless and worthless since retiring last year. Now I just watch TV all day and barely have enough energy to eat. I haven’t felt like gardening in over a year—I used to love it!” Both the patient’s mother and father died of complications of Alzheimer disease. She’s lost 5 kg (11 lb) over the last 2 months but her physical examination is within normal limits. On testing with the Montreal Cognitive Assessment, she scores 24/30 (normal >26) with deficits in delayed recall and attention. Laboratory results, including thyroid function, are unremarkable. MRI of the head is normal. Which of the following is the best next step in management of this patient?
Question 16 of 40
A 43-y0ar-old man presents to your office complaining of periodic involuntary head turning and head fixation to the right side. Physical examination reveals a hypertrophied left sternocleidomastoid muscle. What is the most likely diagnosis?
Question 17 of 40
A 52-year-old man is brought to the emergency department by his daughter due to a fall while climbing stairs. He has mild pain in his right arm but no other obvious injuries. The patient has had frequent stumbling and near-falls over the last 2 months. He has also had significant fatigue, chronic abdominal paint constipation, and recurrent headaches as well as a “pins-and-needles sensation” in his palms and soles. His daughter notes he has been more forgetful recently. The patient has smoked a pack of cigarettes daily for 20 years and drinks beer on weekends. A year agoT he started work as a janitorial custodian at a battery manufacturing plant and finds his job moderately stressful. The patient has not had regular medical follow-ups. Blood pressure is 160/90 mm Hg, and pulse is 84/min. The abdomen is soft and nontender, and no masses are palpable. There is mild tenderness over the right middle ulna with normal range of motion at the wrist and elbow. Neurological evaluation shows reduced pinprick sensation bilaterally in hands and feet. There is weakness of adduction and abduction of the fingers and of bilateral thigh and knee extensors. The patient has a wide-based gait and is unable to tandem walk. Laboratory results are as follows:
Complete blood count:
Mean corpuscular volume 66fL
Glucose 100 mg/dL
Aspartate aminotransferase 12 U/L
Alanine aminotransferase 24 U/L
Uric acidr serum 13 mg/dL
Which of the following is the most likely diagnosis for this patient’s clinical presentation?
Question 18 of 40
A 23-year-old woman is brought to the emergency department after a seizure episode. The seizure occurred at work and was not preceded by any prodromal symptoms or aura. The patient’s coworkers reported that she became unresponsive with generalized tonic-clonic movements lasting 1-2 minutes followed by several minutes of confusion. She experienced urinary incontinence but no tongue biting. The patient has no medical problems and takes no prescription medications. She has no prior head trauma and no family history of epilepsy. Vital signs and neurologic examination are normal. Serum electrolytes, glucose, calcium, magnesium, complete blood count, renal function tests, and liver function tests are unremarkable. A non-contrast head CT scan is normal. Which of the following is the most appropriate next step in management?
Question 19 of 40
A 62-year-old man comes to the emergency department for evaluation of weakness. Six hours ago, he had weakness in his right arm and leg that resolved within 30 minutes. He has never had similar symptoms before and has no chest pain, palpitations, shortness of breath, dizziness, or syncope.
The patient’s past medical history is significant for hypertension, hyperlipidemia, and osteoarthritis. He takes no medications. He has a 25-pack-year smoking history but quit 5 years ago. Family history is significant for hypertension and type 2 diabetes mellitus.
His blood pressure is 145/76 mm Hg and pulse is 69/min and regular. There are no carotid bruits. An S4 is heard on cardiac auscultation. Neurologic examination shows mild right-sided pronator drift. Electrocardiogram shows sinus rhythm with increased voltage and T-wave inversion in leads I and V6. Computed tomography of the brain without contrast shows no abnormalities, and magnetic resonance imaging is pending. Which of the following is the best next step in management of this patient?
Question 20 of 40
A 72-year-old woman is brought to the emergency department by her husband due to sudden-onset, right-sided weakness and numbness. The patient’s husband reports that her symptoms progressed over several minutes and were iater accompanied by vomiting and headache. He also notes that she is now excessively somnolent. The patient has hypertension and persistent atrial fibrillation as well as myelodysplasia that has not required treatment. She takes amlodipine, metoprolol. warfarin, and multivitamins. In the past couple of days, she has also used over- the-counter medications for cold symptoms. Temperature is 37 C (98.6 F). blood pressure is 172/90 mm Hg. pulse is 68/min, and respirations are 16/min. Her laboratory results and CT scan of the head without contrast are as follows:
Activated partial thromboplastin time 30S
Which of the following is the best immediate step in management of this patient?
Question 21 of 40
A 57-year-old man comes to the emergency department with right arm and leg weakness, first noticed about 2 hours ago when he could not grip a pen. He is now unable to shake hands and walks with a mild limp. The patient has also had a mild, constant headache the past several days that he attributes to stress from a new project at work. His past medical history is significant for hypertension and hyperlipidemia, and he does not smoke or consume alcohol. His blood pressure is 180/100 mm Hg, and pulse is 80/min. There is mild asymmetry of the lower face, decreased muscle strength in the right arm, and positive Babinski sign on the right side. Sensory examination is normal. Blood glucose is 210 mg/dl_. ECG shows sinus rhythm with occasional premature ventricular beats. Noncontrast CT scan of the head reveals no abnormalities. Which of the following is the most likely cause of this patient’s symptoms?
Question 22 of 40
A 32-year-old man comes to the physician after a day of blurred vision in his right eye. He has no pain, ocular discharge, or gritty sensation. On examination, visual acuity is slightly reduced in the right eye. Fluorescein examination shows a large geographic corneal staining defect. Which of the following nerve dysfunctions is most likely responsible for this patient’s impaired corneal sensation?
Question 23 of 40
A 72-year-old man is hospitalized for a right femoral fracture following a motor vehicle collision. Six days after undergoing surgical repair, he is found to be lethargic. The patient has hypertension and osteoarthritis. His medications include hydrochlorothiazide, lisinopril, and naproxen, which were continued in the hospital. On examination, the patient is drowsy but awakens briefly when addressed by name. Temperature is 36.7 C (98 F), blood pressure is 144/76 mm Hgf pulse is 88/min, and respirations are 16/min. Pulse oximetry is 95% on room air. Multiple contusions are present in the anterior abdominal wall and thighs. Physical examination findings are shown in the video clip. Laboratory results are as follows:
Hemoglobin 8.4 g/dL
Blood urea nitrogen 78 mg/dl
Albumin 3.8 g/dL
Total bilirubin 0.4 mg/dL
Aspartate aminotransferase 112 U/L
Alanine aminotransferase 42 U/L
Creatine kinase, serum 32,000 U/L
Which of the following is the most appropriate next step in management of this patient?
Question 24 of 40
A 58-year-old man is brought to the emergency department after a witnessed tonic-clonic seizure. The patient was at work when he suddenly collapsed and convulsed for approximately a minute. His coworker says that the patient was confused immediately afterward; however he is now awake and cooperative. He has been having headaches for the past several weeks and has never before had a seizure. He has no prior medical problems and takes no medications. The patient is a former smoker with a 45-pack-year history. He occasionally drinks alcohol but does not use illicit drugs. The patient has lived most of his life in Texas and has never traveled outside of the country. Temperature is 36.7 C (98.1 F)f blood pressure is 122/70 mm Hgf and pulse is 77/min. Cardiopulmonary auscultation is normal, and no masses are present on abdominal examination. Cranial nerves are intact, and there is no muscle weakness or sensory loss. MRI of the brain reveals several discrete, circumscribed lesions at the junction of the gray and white matter with surrounding edema. Rapid HIV testing is negative. Which of the following is the most likely cause of this patient’s seizure?
Question 25 of 40
A 36-year-old woman comes to the emergency department due to left-sided facial droop. The patient woke up 4 hours ago and noticed that the left side of her face was sagging and that she was drooling from a corner of the mouth. She has had no facial numbness but has noticed an increased sensitivity to noise. The patient has a history of migraines, seasonal allergies, and gestational diabetes. Temperature is 36.5 C (97.7 F), blood pressure is 120/70 mm Hgf and pulse is 78/min. BMI is 32 kg/m2. The face appears asymmetric with loss of the left nasolabial fold. When the patient is asked to smile, the left side of her face does not move. She is unable to raise her left eyebrow or completely close her left eye. Facial sensation to touch and pain is normal bilaterally. There are no skin or mucous membrane lesions. Which of the following is the most likely cause of this patient’s current condition?
Question 26 of 40
A 65-y0ar-old woman comes to the office with several months of progressive cough and generalized weakness. The patient has limited mobility and shortness of breath due to osteoarthritis and chronic obstructive pulmonary disease, respectively. She also has difficulty standing from a chair, combing her hair, and putting dishes in overhead cabinets. The patient’s medical history includes hypertension and hyperlipidemia. She quit smoking cigarettes 2 years ago but previously smoked 3 packs daily since age 20. Blood pressure is 112/70 mm Hg, and pulse is 92/min. BMI is 17 kg/m2. Physical examination shows moderate weakness in the proximal muscles of her upper and lower limbs and loss of deep tendon reflexes. CT scan of the chest is shown below.
Which of the following is the most likely cause of this patient’s weakness?
Question 27 of 40
A 30-year-old man comes to the office with fatigue and lethargy that has worsened over the last 2 weeks. He has been forgetful lately and feels “exhausted” at the end of the day. The patient works as a contractor and is currently renovating old houses for sale. He describes feeling “clumsy11 and dropping things at work, as well as tripping multiple times while climbing stairs. He also has abdominal pain that he attributes to constipation. The patient drinks 1 or 2 beers each weekend and does not use tobacco or illicit drugs. His mother was diagnosed with lupus and his older sister had thyroid surgery. Blood pressure is 120/80 mm Hg, and pulse is 76/min. Examination shows normal jugular venous pressure, no thyromegaly. clear lung fields, and normal first and second heart sounds. The abdomen is soft and nontender. There is no hepatomegaly or splenomegaly. There is weakness on dorsifiexion of bilateral wrists and feet. Upper and lower limb deep tendon reflexes are 1+. Laboratory results are as follows:
Blood urea nitrogen 12mg/dL
Uric acid, serum 11 mg/dL
Creatine phosphokinase levels are normal. Which of the following is most likely to improve this patient’s symptoms?
Question 28 of 40
A 62-year-old man is brought to the emergency department due to left-sided weakness, numbness, and difficulty speaking. He was walking his dog about an hour ago and fell after developing sudden-onset weakness of his left upper and lower limbs. The patient did not lose consciousness. He has hypertension and type 2 diabetes mellitus but no other medical or surgical history. The patient’s blood pressure is 170/96 mm Hg and pulse is 76/min and regular. On examination, his speech is dysarthric and he has left facial droop. The patient’s left upper extremity muscle strength is 2/5 and left lower extremity strength is 3/5. Left hemisensory loss is present. His finger-stick blood glucose level is 190 mg/dLf and a noncontrast head CT scan reveals no abnormalities. Recent laboratory studies performed at the patient’s primary care provider’s office show his serum LDL is 152 rng/dL and hemoglobin A1c is 7.6%. Which of the following therapies is most likely to reverse this patient’s acute neurologic deficits?
Question 29 of 40
A 56-year-old right-handed man comes to the physician with right-sided weakness and speech difficulty. He speaks in short sentences with considerable effort. He fully follows written and verbal commands but has difficulty writing and repeating. Which of the following lesion locations is most likely responsible for the observed findings?
Question 30 of 40
A 75-year-old man comes to the office for progressive hearing loss and ringing in his ears. The patient states that over the last 5 years he has noticed a decline in his ability to hear social conversations, especially when there is competing background noise. He has difficulty tolerating loud sounds that others in the room are able to handle. The patient has also experienced subjective continuous high-pitched ringing in both ears over the past year. He has no history of head trauma, headache, vertigo, visual changes, disequilibrium, slurred speech, difficulty swallowing, weakness, or numbness. His medical problems include diabetes mellitus and hypertension. He takes atorvastatin, metformin, and lisinopril. The patient has been a chronic smoker for many years. Vital signs are normal. Weber and Rinne tests suggest the presence of bilateral sensorineural hearing loss. Otoscopic examination and auscultation over both periauricular areas are unremarkable. The remainder of his neurologic examination is normal. Which of the following is the most likely diagnosis?
Question 31 of 40
A 47-year-old woman is brought to the emergency department after being found unresponsive in her garage. The patient has a history of chronic pain, depression, and prior suicide attempts. Temperature is 35 C (95 F), blood pressure is 106/64 mm Fig, pulse is 108/min, and respirations are 22/min. Pulse oximetry is 96% on room air. The patient withdraws all extremities to painful stimuli but does not follow commands. Bilateral pupils are equal and reactive, and funduscopy shows no papilledema. Lung auscultation shows occasional wheezes. No heart murmurs are present. The abdomen is soft and nontender with decreased bowel sounds. There is no extremity edema. Laboratory results are as follows:
Creatinine 0.8 mg/dL
Glucose 120 mg/dL
Endotracheal intubation followed by mechanical ventilation and other supportive measures are begun. A brain MRI obtained several days later is shown in the exhibit. Which of the following is the most likely cause of this patient’s current condition?
Question 32 of 40
A 33-year-old woman comes to the office with severe bilateral facial pain for the past several days. She reports sharp, shooting pain that is confined to her cheeks and jaw, lasts several seconds, and occurs 10-20 times a day. The pain is sometimes triggered by a cold breeze, brushing of her teeth, or chewing. The patient has been taking ibuprofen for the pain without much relief. She has never experienced this condition before, but 6 months ago she had numbness of her right hand that lasted about 2 weeks. Four weeks ago, she was treated for acute sinusitis. The patient is a primary school teacher and does not use tobacco, alcohol, or illicit drugs. Her temperature is 36.7 C (98 F), blood pressure is 118/82 mm Hg, pulse is 72/min, and respirations are 14/min. On physical examination, a similar pain is elicited by lightly touching the patient’s cheeks. Otherwise, neurologic examination demonstrates no focal deficits. Which of the following is the most likely cause of this patient’s symptoms?
Question 33 of 40
A 54-year-old woman presents to your office complaining of difficulty walking. She describes severe weakness and occasional pain in her thigh muscles. She has stumbled and fallen several times over the last week. Her past medical history is significant for hypertension treated with hydrochlorothiazide and metoprolol. She consumes two to three cans of beer on weekends. Her younger brother died of a neurological disease when he was 20 years old. Her mother suffers from hypertension and diabetes mellitus. Her heart rate is 90/min and blood pressure is 170/100 mmHg. Chest examination is within normal limits. A bruit is heard over the left carotid artery. Neurologic examination reveals hyporeflexia and decreased strength in all muscle groups. Her ESR is 12 mm/hr. EGG shows flat and broad T waves with occasional premature ventricular contractions. Which of the following is the most likely cause of this patient’s current complaints?
Question 34 of 40
A 56-year-old man comes to the office for evaluation of right leg pain and numbness. The pain started 2 days ago during an 8-hour car ride during which the patient was the backseat passenger in a small car. Midway through the car ride, he began to have numbness and burning pain over the lateral aspect of his right thigh. The patient has tried stretching to relieve the pain but it only worsened, and he is now unable to wear a belt due to the discomfort. He has type 2 diabetes mellitus and has gained 11.3 kg (25 lb) over the past year. BMI is 42 kg/m2. On examination, lower extremity strength is 5/5 bilaterally. The right leg has a large area of numbness over the upper lateral thigh. Straight leg raise is negative. Reflexes are symmetrical and intact. Pain is reproduced on hip extension and with palpation immediately below the anterior superior iliac spine. Compression of which of the following nerves is the most likely cause of this patient’s presentation?
Question 35 of 40
A 34-year-old woman is brought to the emergency department due to a 2-day history of progressive dyspnea and drowsiness. According to her husband, she had difficulty swallowing food and almost choked while having dinner yesterday. One week ago, she was treated with ciprofloxacin for a urinary tract infection. The patient volunteers in a local library and for the past several months has had to reduce her work hours due to difficulty lifting books and placing them on shelves. She drinks alcohol socially and does not smoke. Her blood pressure is 142/90 mm Hg, pulse is 92/min, and respirations are 20/min and shallow. Pulse oximetry shows 93% on room air. The patient’s BMI is 32 kg/m2. Her speech sounds nasal. Physical examination demonstrates clear lung fields with the use of accessory muscles of respiration and paradoxical abdominal wall motion with inspiration. Heart sounds are normal without a murmur. Muscle strength is bilaterally decreased with normal deep tendon reflexes. Babinski reflex is absent bilaterally. Arterial blood gas shows pH 7.2, pC02 65 mm Hg. and p02 90 mm Hg. Which of the following is the most likely diagnosis?
Question 36 of 40
A 63-year-old man comes to the office for follow-up after a recent hospitalization. One week ago, he was evaluated in the emergency department for sudden-onset right-sided weakness that resolved spontaneously within 30 minutes. An MRI of the head was normal and the patient was admitted to the hospital for 24-hour observation. He has had no symptom recurrence since then and feels well. Medical history includes hypertension and anxiety. The patient takes lisinopril and has also taken aspirin and atorvastatin since the hospitalization. He has a 20-pack- year smoking history and quit 10 years ago. Blood pressure is 128/70 mm Hg and pulse is 74/min. Neurological examination is normal. ECG performed in the hospital showed sinus rhythm. Doppler ultrasonography revealed a 76% stenosis of the proximal left internal carotid artery. Echocardiography was unremarkable. Which of the following interventions is most appropriate for this patient?
Question 37 of 40
A 25-year-old. HIV-positive male presents to the office with an altered mental status. He is disoriented, lethargic, and has loss of recent memory. These symptoms have been present for the last month. His current medications include combination antiretroviral therapy, trimethoprim-sulfamethoxazole and azithromycin. His temperature is 37.7° C (99.8° F), pulse is 78/min, blood pressure is 130/80mm Hgf and respirations are 16/min. The neurological examination is non-focal. His CD4 count is 40/microL and viral load is 25,000 copies/mL by PCR. MRI scan reveals a solitary, irregular, weakly ring-enhancing mass in the periventricular area. The serology for Toxoplasma is positive. PCR of CSF shows EBV DNA. What is the most likely diagnosis?
Question 38 of 40
A 73-year-old Caucasian man is brought to the office by his daughter, who is concerned that he might be depressed. He is a retired surgeon, and has lived alone ever since his wife died a year ago. His daughter visits him every 6 months; she feels bad about not being able to visit him more frequently because her job and family keep her very busy. He denies having any feelings of sadness, guilt, weight loss, loss of appetite, suicidal ideation, deafness, vertigo, and decreased or blurred vision. His medical problems include hypertension, diabetes mellitus- type 2 and a myocardial infarction 10 years ago. His current medications are glyburide. aspirin and enalapril. He denies the use of tobacco, alcohol, or drugs. His vital signs are within normal limits. He appears withdrawn, less energetic than usual, and walks stiffly. He sits with a stooped posture. He has a fixed facial expression, and his voice sounds monotonous. His deep tendon reflexes are 2+. Sensations and motor strength are normal. There is increased resistance to passive flexion. Which of the following types of gait is most likely to be present in this patient?
Question 39 of 40
A 35-year-old intravenous drug user comes to the emergency department due to right-sided weakness that started 2 hours ago. He has also been experiencing night sweats and malaise for the last 7 days. His temperature is 38.9 C (102 F). blood pressure is 152/96 mm Hg, pulse is 112/min and regular, and respirations are 18/min. Neurologic examination shows 3/5 strength on the right side. MRI of the brain with diffusion demonstrates a single small acute infarct in the left middle cerebral artery territory. Transesophageal echocardiogram shows a small mobile vegetation on the aortic valve and mild aortic regurgitation. Blood cultures are obtained and intravenous antibiotic therapy is initiated. Which of the following is the most appropriate next step in management of this patient?
Question 40 of 40
A 29-year-old woman comes to the office due to frequent episodes of headache. She has moderate to severe, left¬sided, throbbing pain associated with nausea and occasional vomiting. Her headache is often preceded by a tingling sensation in the right hand that gradually involves the right arm and face and is followed by numbness lasting <1 hour. She feels irritable while experiencing the headaches. The pain typically improves following several hours of rest in a dark and quiet room. The patient has had these episodes every 1-2 months for the past 5 years. She has taken as-needed sumatriptan with some relief, but the symptoms have caused her to miss several days of work. She has no other medical history and does not use tobacco, alcohol, or recreational drugs. There is a family history of depression. Vital signs are within normal limits and physical examination is normal. Which of the following is most likely to be helpful in preventing this patient’s headaches?
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