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Question 1 of 40
A 64-year-old woman comes to the emergency department due to sudden-onset headache associated with nausea and vomiting and a sensation that the “room is spinning.” The patient first noticed the symptoms yesterday when she awoke, and they have not improved. She has had no ear painr hearing loss, fever, or chills. The patient had an upper respiratory infection a week ago that has since resolved. She also has a history of type 2 diabetes mellitus and hyperlipidemia. She was recently started on hydrochlorothiazide and lisinopril for hypertension. She does not use tobacco or alcohol. Blood pressure is 124/76 mm Hg and pulse is 86/min. Neurologic examination with the patient lying still and eyes closed shows pure rotatory nystagmus but no extremity weakness or sensory loss. Walking causes worsening symptoms, and the patient falls toward the left side. Fingerstick glucose is 145 mg/dl. Complete blood count and serum electrolytes are unremarkable. Which of the following is the best next step in management of this patient?
Question 2 of 40
A 35-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unconscious. Blood pressure is 100/50 mm Hg, pulse is 100/min, and respirations are 19/min. Examination shows bilaterally reactive and nondilated pupils. He does not follow commands and makes inappropriate sounds. A CT scan of the head shows numerous minute punctate hemorrhages with blurring of the gray-white matter interface. Which of the following is the most likely diagnosis?
Question 3 of 40
A 16-year-old girl comes to the physician with headache and vision changes for the past month. The headaches are worse in the morning and are associated with nausea. She takes oral isotretinoin for severe acne. Her temperature is 36.7 C (98 F), blood pressure is 130/80 mm Hg, pulse is 70/min, and respirations are 15/min. Eye examination shows papilledema and decreased visual acuity. There is no neck stiffness. Motor examination shows 5/5 strength, 2+ deep-tendon reflexes, and a normal plantar response. Sensory examination is unremarkable. Computed tomography scan of the head is within normal limits.
Lumbar puncture shows the following:
Opening pressure 280 mm H2O
Cerebrospinal fluid glucose 40 mg/dL
Cerebrospinal fluid protein 40 mg/dL
White blood cells 3/mm2
Which of the following is the most likely cause of this patient’s symptoms?
Question 4 of 40
A 62-year-old woman comes to the office due to progressive gait unsteadiness. The patient’s legs feel stiff, and she frequently stumbles and has to hold handrails while descending stairs. She also has had tingling and numbness in the hands and an occasional electric shock-like sensation in the spine. She has had no bowel or bladder incontinence. The patient has fibromyalgia and continues to have shoulder and neck pain despite a recent dosage increase in duloxetine. Other medical conditions include depression and hypothyroidism. She does not use tobacco, alcohol, or illicit drugs. Examination of the cranial nerves is normal. Upper extremity muscle strength is decreased, with mild wasting of intrinsic hand muscles. Lower extremity tone and reflexes are increased bilaterally. Sensation is grossly intact. Which of the following is the most likely cause of this patient’s current condition?
Question 5 of 40
A 24-year-old woman comes to the office due to headaches that she has had every few months for the past 6-7 years. She describes these as left-sided and throbbing; they are associated with mild nausea, last for 12-18 hours, and improve after she rests in a dark and quiet room or takes ibuprofen. For the past month, she has been waking up almost daily with bifrontal headaches often accompanied by nausea and vomiting. She also has occasional blurry vision. The patient attributes these headaches to increased stress at work after being promoted to a supervisor position. She has had no fevers, focal weakness, or numbness. She has no other medical history and does not use tobacco, alcohol, or recreational drugs. Her mother and sister have migraine headaches. Temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 72/min. Bilateral pupils are equal and reactive to light. She has a normal examination of the cranial nerves, motor strength, sensation, and deep tendon reflexes. Which of the following is the most appropriate next step in management of this patient?
Question 6 of 40
A 67-year-old woman comes to the office for follow-up. Four weeks ago. she experienced sudden-onset right side numbness, and evaluation revealed an ischemic stroke. The patient feels like some of her sensation is returning but experiences transient burning pain in the right upper and lower limbs that can be induced even by a light touch. Her medical history is significant for hypertension and type 2 diabetes mellitus. She smoked a half-pack of cigarettes daily for 30 years but stopped after her stroke. Blood pressure is 125/70 mm Hgf and pulse is 74/min and regular. Neurologic examination shows right side hemianesthesia and mild athetosis of the right hand. There is hyperesthesia on the right side of the body demonstrated by exaggerated pain on light touch. Motor strength is normal in all 4 extremities. Which of the following is the most probable location of the stroke experienced 4 weeks ago by this patient?
Question 7 of 40
A 70-year-old right-handed man is brought to the emergency department due to sudden onset of right-sided weakness and urinary incontinence that began about 10 hours ago. He has had type 2 diabetes mellitus for the last 20 years and hypertension for the last 28 years. On examination, there is 4/5 strength in the right upper extremity, 1/5 strength in the right lower extremity, and a Babinski sign on the right side. Sensation is decreased throughout the right foot and leg. Visual fields are full with no deficits. Which of the following is the most likely diagnosis of this patient?
Question 8 of 40
An 86-year-old woman is brought to the emergency department due to progressive confusion and lethargy for the past several hours. The patient has a history of Alzheimer dementia and her family reports that she has been gradually declining in mental and physical capacity over the last 6 months. She also has had several falls and requires assistance with daily activities. Her other medical problems include hypertension, myocardial infarction, chronic atrial fibrillation, and osteoarthritis. Her medications include aspirin, losartan, metoprolol, simvastatin, and donepezil. The patient’s anticoagulation therapy was stopped 6 months ago after an episode of rectal bleeding. Temperature is 38 C (100.4 F). blood pressure is 170/100 mm Hg, and pulse is 70/min and irregularly irregular. On physical examination, the patient is somnolent but arousable. She withdraws from painful stimuli applied to her right side but not to her left. ECG shows atrial fibrillation. Noncontrast CT scan of the head is shown in the image below.
Which of the following is the most likely cause of this patient’s current condition?
Question 9 of 40
An 84-year-old woman is brought to the emergency department due to 2 weeks of progressive confusion. She has a history of mild dementia and lives in an assisted living facility. Her caregiver reports that during the past several months she has become progressively weaker, and she has fallen down on several occasions and is now using a walker. In her usual state, the patient recognizes most of the staff, converses appropriately, and performs daily activities with minimal assistance; however, for the past week, she has been more confused and sleeping most of the time. She has also developed a mild headache. The patient has had no fever, vomiting, or urinary symptoms. Her other medical problems include hypertension and osteoarthritis. Blood pressure is 138/76 mm Hg and pulse is 74/min and regular. She is somnolent but arousable. The patient does not recognize her caregiver and gives several inaccurate answers but is able to follow simple instructions. Muscle strength is 4/5 on the right side and 3/5 on the left. Plantar reflex is upgoing on the left. Which of the following is the most likely diagnosis?
Question 10 of 40
A 46-year-old man is being evaluated for a gait disorder. He was referred to the community health center by social workers at the local emergency department due to frequent falls. His symptoms began gradually about a year ago and have become progressively worse. The patient’s history is notable for chronic alcoholism, and he is currently homeless with sporadic stays in a nearby shelter. On examination, he has a broad-based, unsteady gait. A single tap on his patellar tendon elicits persistent, slow, back-and-forth swinging of the leg. Nystagmus and truncal ataxia are also present. Which of the following additional findings would most likely be seen in this patient?
Question 11 of 40
A 74-year-old woman is brought to the emergency department due to worsening weakness and gait unsteadiness. The patient has a history of ischemic stroke causing right-sided weakness and uses a cane to ambulate. Over the past several days, she has been feeling weak and unsteady, and this morning she fell while getting out of bed.
She did not lose consciousness and has had no headache, vomiting, or vision loss. The patient recently has had dysuria and urinary urgency, which have improved after taking trimethoprim-sulfamethoxazole. Other medical conditions include hypertension, type 2 diabetes mellitus, and seizure disorder controlled with phenytoin. Temperature is 37.1 C (98.8 F), blood pressure is 140/86 mm Hg, and pulse is 84/min. Pupils are equal and briskly reactive, and extraocular movements are intact. There is bilateral nystagmus on lateral gaze. Muscle strength is diffusely decreased but more pronounced in the right extremities. Deep tendon reflexes are increased throughout. Dysmetria is present on finger-nose testing, and the gait is wide-based. Which of the following is the most likely cause of this patient’s current condition?
Question 12 of 40
A 55-year-old man comes to the office due to progressive difficulty walking and frequent falls over the past year. Initially the patient had difficulty with balance when walking up and down the stairs. Now he has to brace himself against a wall even when walking on flat surfaces. He has had no urinary incontinence, slurred speech, or headaches. The patient was diagnosed with type 2 diabetes mellitus and hypertension several years ago but is not compliant with medications. He also has a history of long-term, heavy alcohol and tobacco use. Blood pressure is 170/96 mm Hg and pulse is 84/min. The patient is alert and oriented. Bilateral pupils are equal and reactive. Extraocular movements are normal. Muscle bulk, tone, and strength are normal. Proprioception and vibration sensation are normal in the lower extremities. The patient exhibits a wide-based gait and is unable to perform tandem walking. Heel-knee-shin testing is abnormal but finger-nose testing is normal. Which of the following is the most likely cause of his ambulatory dysfunction?
Question 13 of 40
A 35-year-old man is brought to the emergency department after crashing his motorcycle into a guardrail at high speed. He was riding without a helmet and briefly lost consciousness, but he is now awake and alert in the emergency department. Blood pressure is 120/70 mm Hg and pulse is 96/min. The patient is wearing a cervical collar and his breath smells of alcohol. Bilateral pupils are equal and reactive. There is chest wall bruising and tenderness. Heart and breath sounds are normal. The abdomen is soft and nontender. There is an obvious deformity of the right leg. Neurological examination shows bilateral lower extremity weakness. Light touch and vibratory sensation is present in both legs, but there is loss of pain and temperature sensation. Bilateral upper extremity motor and sensory examination is normal. Injury at which of the following sites is the most likely cause of this patient’s neurological deficits?
Question 14 of 40
A 36-year-old woman comes to the office after a month of almost daily, bandlike headaches, dizziness, and fatigue. She has experienced irritability, inability to concentrate, and poor sleep of the same duration. Prior to the onset, she had an accident at work; a box fell on her head, and she lost consciousness briefly. The patient was taken to an emergency department and all tests were normal, so she was discharged. She has had no nightmares or flashbacks of the event. She has no known medical problems. She drinks 1-2 glasses of wine every evening but does not use tobacco or illicit drugs. The patient is afebrile. Blood pressure is 125/85 mm Hg and pulse is 76/min. Cardiopulmonary and abdominal examinations are unremarkable. She appears anxious but her neurologic evaluation including attention and memory is normal. Which of the following is the most likely diagnosis?
Question 15 of 40
A 65-year-old man is being evaluated for new-onset ptosis. Earlier in the day, the patient underwent right total knee arthroplasty for advanced osteoarthritis with no operative complications. While in the postoperative recovery unit, he had difficulty opening his left eye and developed slurred speech. The patient has never had these symptoms, and his preoperative neurologic examination was unremarkable. He has no prior history of double vision, difficulty swallowing, or limb weakness. Medical history includes ischemic stroke with no residual deficits, type 2 diabetes mellitus, hypertension, and a 20-pack-year smoking history. Temperature is 36.7 C (98.1 F), blood pressure is 150/90 mm Hg, pulse is 92/min, and respirations are 12/min. Neurologic examination reveals bilateral ptosis, left greater than right. Pupils are equal in size and reactive to light. An ice pack is placed over the closed eyelids for 2 minutes, leading to improvement of the ptosis. Which of the following is the most likely cause of this patient’s current symptoms?
Question 16 of 40
A 68-year-old man with myasthenia gravis is evaluated for progressive weakness while hospitalized. The patient was admitted 2 days prior due to fever, productive cough, and pleuritic chest pain. Chest x-ray demonstrated a right lower lobe consolidation for which the patient has been receiving intravenous ceftriaxone and azithromycin.
He also has been receiving his outpatient dose of pyridostigmine. In the past several hours, he has experienced progressive generalized weakness and an inability to cough out sputum. His temperature is 37.6 C (99.8 F), blood pressure is 130/70 mm Hg. pulse is 110/m in. and respiratory rate is 25/min. Oxygen saturation is 89% on 4 L/min oxygen by nasal cannula. The patient appears to be in distress, and his breathing pattern is rapid and shallow with occasional gurgling sounds. Lung auscultation reveals coarse crackles throughout. There is mild weakness of the extremities, but deep tendon reflexes are normal. His vital capacity is now 1.0 L compared to 1.5 L at the time of admission, and arterial blood gas shows pH 7.27, pC02 55 mm Hg. and p02 60 mm Hg. The patient is intubated and moved to the intensive care unit. Which of the following is the best next step in management of this patient?
Question 17 of 40
A 27-year-old woman comes to the office for follow-up. She was last seen 2 months ago for generalized musculoskeletal pain and several months of fatigue. Evaluation revealed multiple soft-tissue tender points, negative inflammatory and serological markers, and normal thyroid studies. The patient was diagnosed with fibromyalgia and prescribed a low-impact exercise program and pharmacotherapy. Her pain and fatigue have subsequently improved, but she now notes intermittent episodes of dizziness. Most of the episodes are short¬lived, but she occasionally needs to brace herself against a wall or sit until the dizziness resolves. There have been no associated falls or loss of consciousness. She also notes worsened lethargy and frequent dry mouth. Other medical history includes migraines and irritable bowel syndrome. The patient currently takes daily amitriptyline for fibromyalgia, occasional acetaminophen for muscular pains, and polyethylene glycol as needed for constipation. She does not use tobacco, alcohol, or illicit drugs and has no known drug allergies. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 14/min. BMI is 21 kg/m2. Mucous membranes are pink and moist and there is no jugular venous distention. Cardiopulmonary auscultation is normal. The abdomen is soft and nontender. Neurologic examination reveals intact cranial nerves and normal muscle strength in all extremities. Which of the following would be most helpful in determining the cause of this patient’s dizziness?
Question 18 of 40
A 56-year-old man comes to the emergency department with severe dizziness, inability to walk, and stabbing pain on the right side of his face that started this morning. He has a history of diet-controlled type 2 diabetes mellitus. hypertension, and hyperlipidemia. His blood pressure is 144/90 mm Hg and pulse is 92/min. The patient topples to the right when sitting without support. The left pupil is larger than the right, and there is reduced corneal reflex on the right directly but not consensually. There is partial ptosis of the right eye. Horizontal and rotational nystagmus is present. His gag reflex is diminished. There is loss of pain and temperature sensation in the right face and the left trunk and limbs. Which of the following is the most likely location of this patient’s brain lesion?
Question 19 of 40
A 68-year-old man comes to the emergency department due to severe dizziness while playing tennis an hour ago. He says that he had a spinning sensation accompanied by nausea and vomiting; the symptoms have now subsided. The patient has had brief episodes of dizziness in the past, especially when performing vigorous work with his arms. He has also experienced heaviness and fatigue of the left arm with exertion. The patient has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. Blood pressure is 140/90 mm Hg on the right arm and 100/74 mm Hg on the left, and pulse is 82/min and regular A systolic bruit is present at the base of the neck just above the clavicle on the left side. Cardiac auscultation discloses a fourth heart sound. There is no extremity weakness or sensory loss. Which of the following is the most likely cause of this patient’s symptoms?
Question 20 of 40
A 36-year-old woman comes to the office due to headaches. Over the past 3 months the patient has had constant, bilateral headaches almost every day shortly after awakening. She has had intermittent episodes of migraines since adolescence, but her current headaches are more frequent though milder. The patient has been taking over- the-counter analgesics several times a day. She has had no focal weakness, numbness, or vision changes. The patient has no other medical conditions and does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. BMI is 24 kg/m2. Physical examination, including funduscopy and neurological examination, shows no abnormalities. Blood cell counts and serum chemistry studies are within normal limits. Which of the following is the most appropriate next step in management of this patient?
Question 21 of 40
A 65-year-old woman comes to the physician complaining of periodic headaches in the temporal region, visual disturbances, and neck stiffness. Appropriate empiric medical therapy is initiated, and biopsy of a scalp artery confirms giant cell arteritis. The patient is very compliant with treatment. She comes to the physician 6 months later with slowly progressive muscle weakness. Her headaches have resolved, but she has difficulty climbing stairs and getting up from a chair. Her blood pressure is 120/70 mm Hg, pulse is 82/min, and respirations are 12/min. Physical examination shows 4/5 muscle power in her proximal lower extremities bilaterally. Her serum creatine kinase level and erythrocyte sedimentation rate are normal. Which of the following is the most likely cause of this patient’s current complaints?
Question 22 of 40
A 19-year-old man is brought to the emergency department due to a seizure. The patient’s roommate was awakened by a noise 30 minutes ago and found him “convulsing11 on the bed. Emergency medical services were called, and the patient had another brief seizure episode in the ambulance. He has no history of seizure or other medical conditions. The roommate says the patient went to bed late last night after a fraternity party. Temperature is 37.2 C (99 F), blood pressure is 148/90 mm Hg, and pulse is 94/min. On physical examination, the patient is somnolent, groans to painful physical stimuli, and does not follow instructions. There is a small tongue laceration. While being examined, the patient has another generalized tonic-clonic seizure, which terminates after administration of intravenous lorazepam. Which of the following is the most appropriate next step in the management of this patient?
Question 23 of 40
A 30-year-old Caucasian male comes to the office due to symmetric weakness of his lower extremities. He also has paresthesias in his toes and fingers, and lower back pain. The neurological examination shows symmetric weakness, diminished reflexes, and intact sensation in his lower extremities. Orthostatic hypotension is also noted. Electrophysiological studies show slowed nerve conduction velocities. Lumbar puncture reveals normal opening pressure. CSF examination shows few cells, and a protein concentration of 90 mg/dL. Which of the following organisms is involved in the pathogenesis of this disorder?
Question 24 of 40
A 48-year-old man comes to the emergency department due to facial drooping. The patient says he had mild left ear discomfort in the morning, and while driving to work he had difficulty closing the left eye against the light. Four hours later, he was unable to sip drinks through a straw, and a colleague remarked that his face appeared droopy. He has had no upper or lower limb weakness or numbness, headache, fever, dizziness, or hearing loss. The patient was recently diagnosed with hypertension and hyperlipidemia, which he is managing with lifestyle modification. He smokes cigarettes and drinks alcohol daily, and says he is trying to cut down on both. Temperature is 37 C (98.6 F), blood pressure is 142/86 mm Hg, and pulse is 84/min. On physical examination, there is left facial asymmetry with drooping of the left corner of the mouth and flattening of the nasolabial fold. He is unable to fully close the left eye. Extraocular movements are intact, and pupils are briskly reactive. Bilateral hand grips are equal, and there is no pronator drift. The patient is able to lift his lower extremities against resistance, and gait is normal. Sensation to light touch and pain is intact on the left side of the face. Which of the following is the most appropriate pharmacotherapy for this patient?
Question 25 of 40
A 58-year-old right-handed man is brought to the emergency department with sudden onset of severe difficulty speaking and weakness that developed over a few seconds while he was at work. His other medical problems include hypertension, hyperlipidemia, severe left atrial enlargement (seen on previous echocardiogram), mild bilateral carotid disease with recent carotid ultrasound showing <30% stenosis, type 2 diabetes mellitus. and autosomal dominant polycystic kidney disease. He is not compliant with his medication regimen. The patient smokes a pack of cigarettes a day and drinks alcohol occasionally. His blood pressure is 156/96 mm Hg and pulse is 124/min and irregularly irregular. His body mass index is 35 kg/m2. There are no carotid bruits. The patient speaks in very short sentences and has difficulty finding words while trying to speak. He is awake and alert but has difficulty following simple commands. There is a forced conjugate gaze preference to the left, neglect of the right visual field, and severe right lower facial droop. He has marked weakness and sensory loss in the right arm and mild weakness and sensory loss in the right leg. His fingerstick glucose value is 345 mg/dL. Which of the following is the most likely cause of this patient’s current condition?
Question 26 of 40
A 38-year-old man is brought to the emergency department due to confusion and double vision. His family reports that the patient did not feel well for the past several days due to headaches, nausea, and vomiting. Yesterday, he became progressively confused and experienced double vision. He has a history of HIV and does not take antiretroviral therapy consistently. Temperature is 38.2 C (100.7 F), blood pressure is 122/80 mm Hg, and pulse is 90/min. On physical examination, the patient appears lethargic and disoriented. Pupils are equal and reactive, but the left eye does not move laterally with leftward gaze. The rest of the neurologic examination is unremarkable. Skin examination shows scattered, small, umbilicated papules with surrounding erythema. CT scan of the head reveals mildly enlarged ventricles but no hemorrhage, infarction, or mass lesions. Which of the following is the best next step in evaluation of this patient?
Question 27 of 40
A 32-year-old man is brought to the emergency department due to difficulty walking and frequent falls. One week ago he had numbness in his toes and fingertips that progressed to lower-extremity weakness. He had an upper respiratory tract infection 4 weeks ago that resolved spontaneously. The patient has no bowel or bladder complaints. His past medical history is unremarkable. His temperature is 36.9° C (98.5° F), blood pressure is 130/70 mm Hg supine and 100/62 mm Hg standing, pulse is 102/min, and respirations are 18/min. Physical examination shows muscle weakness in both lower extremities and absent knee and ankle reflexes bilaterally. The sensory examination is unremarkable. Lumbar puncture is performed and cerebrospinal fluid analysis results are as follows:
Glucose 70 mg/dL
Protein 120 mg/dL
Gram stain No organisms
What is the most appropriate next step in management of this patient?
Question 28 of 40
A 60-year-old man comes to the office due to right-sided neck and shoulder pain. The pain worsens with neck movement and is associated with numbness in his forearm. Over the past 2 years, he has had several episodes of similar symptoms that improved with rest and ibuprofen. The patient has no history of neck or shoulder trauma.
He smokes a pack of cigarettes daily and has used injection drugs in the past. Vital signs are within normal limits. Physical examination shows limited neck rotation and lateral bending. There is decreased pinprick sensation on the posterior aspect of the right forearm but no muscle weakness. Triceps reflex is normal. Left upper and bilateral lower extremity examination show no other abnormalities. A plain radiograph of the cervical spine is ordered. This patient’s symptoms are most likely associated with which of the following radiographic findings?
Question 29 of 40
A 69-year-old man comes to the emergency department due to severe occipital headache, nausea, and vomiting for the last 3 hours. He has never had a headache like this before and has otherwise been in good physical condition. The patient was told several years ago that he has high blood pressure, but he has not been taking any medications or seen any health care providers. He has smoked half a pack of cigarettes daily for 40 years and drinks 1 or 2 cans of beer every evening. Both of his parents died of natural causes. Blood pressure is 160/90 mm Hg and pulse is 86/min and regular. His noncontrast head CT scan is shown in the image below.
Which of the following physical examination findings is most likely to be seen in this patient?
Question 30 of 40
A 54-year-old man comes to the office due to recurrent falls. During ambulation, the patient prominently flexes his right hip and knee and the right foot slaps to the floor with each step. Romberg sign is absent. Which of the following is the most likely cause of this gait abnormality?
Question 31 of 40
A 32-year-old woman comes to the office with several days of tingling and numbness in both hands. She moved to Arizona in June to care for her ailing mother who died 2 weeks ago of metastatic lung cancer. Since moving, she has had occasional headaches, dizziness, fatigue, poor sleep, and blurry vision. She has had no fevers, weight loss, or anorexia. Her medical history is unremarkable. The patient drinks 1 or 2 glasses of wine daily but does not use tobacco or illicit drugs. Her blood pressure is 132/70 mm Hg and pulse is 78/min. Sensation to light touch and pain is decreased distally in the bilateral upper extremities. Muscle strength is 5/5 in the upper and lower extremities and deep tendon reflexes are normal. On funduscopic examination, the right optic disc appears hyperemic and swollen. Which of the following is the best next step in management of this patient?
Question 32 of 40
A 36-year-old woman comes to the office for follow-up of bipolar I disorder. The patient was diagnosed at age 20 following a manic episode and has a history of 2 hospitalizations at age 24 and 33 for major depressive episodes. Her mood has been stable on valproate for the past 2 years; she takes no other medications. The patient recently got married and has been functioning well. She hopes to become pregnant and would like to stop her oral contraceptive in the next few months. She says, “I do not want to risk having another hospitalization, so I would like to keep taking medication during my pregnancy.” After discussion of treatment options, the patient decides to stop the valproate and switch to a different medication. Which of the following is the most appropriate treatment option for this patient?
Question 33 of 40
A 69-year-old man is brought to the office by his wife due to recent changes in behavior. Despite years of managing the family’s finances, over the previous 12 months the patient has failed to pay a number of important bills. He has become more withdrawn and no longer enjoys social gatherings. When he does socialize now. he is often irritable and offensive. The patient used to smoke a quarter pack of cigarettes a day but has increased to a pack a day over the previous 12 months. He also now insists on eating the same thing for breakfast every morning and gets very upset if a different meal is prepared. The patient denies having any problems and seems indifferent to his wife’s concern. Medical history includes hypertension and type 2 diabetes mellitus. There is a family history of Alzheimer disease. Temperature is 36.7 C (98 F), blood pressure is 144/86 mm Hg, pulse is 62/min, and respirations are 14/min. The patient scores a 24 out of 30 on the Montreal Cognitive Assessment (normal >26). Which of the following is the most likely diagnosis in this patient?
Question 34 of 40
A 62-year-old man is brought to the office by his wife due to recent personality changes and cognitive impairment. The symptoms began 4 months ago with abrupt-onset depression and profound sleepiness. Soon after, the patient began having difficultly remembering names and events. He now cannot prepare his own meals or care for himself. The patient has a history of herpes simplex type 1 for which he occasionally takes acyclovir for symptomatic recurrence. He has no history of psychiatric disease but has a family history of dementia from his father. The patient smoked a pack of cigarettes daily for 40 years. Temperature is 37.7 C (99.9 F), blood pressure is 118/79 mm Hg, pulse is 72/min, and respirations are 14/min. The patient is oriented only to self. Montreal Cognitive Assessment yields a score of 10 on a scale of 30 (normal: >26). Near the end of the examination, the patient startles and jerks his arms when a door closes loudly. A lumbar puncture is recommended. Which of the following findings would be expected in this patient’s cerebrospinal fluid?
Question 35 of 40
A 4-year-old boy is brought to the emergency department by his parents for evaluation of a fever and headache. Two days ago, the boy began to have low-grade fever, cough, and congestion. Last night, his fever became higher, and he became fussy, more difficult to console, and less active. He slept poorly and woke up with a headache unrelieved with over the counter pain medications. The patient vomited twice prior to arrival. He has no medical conditions but has not received regular health maintenance or vaccinations. Temperature is 39.4 C (102.9 F), pulse is 110/min, and respirations are 20/min. Physical examination shows an irritable child. Pupils are equal and reactive; funduscopic examination is limited by photophobia. The oropharynx is erythematous. Nuchal rigidity is present and bilateral lower extremities flex when the neck is flexed. The remainder of the physical examination is normal. Cerebrospinal fluid results are shown below:
Which of the following pathogens is most likely responsible for this patient’s presentation?
Question 36 of 40
An 18-month-old boy is brought to the emergency department by his parents due to fever, vomiting, and lethargy. This morning he developed a fever that initially responded to treatment with acetaminophen. Throughout the day. the patient became increasingly lethargic and developed a rash on the lower extremities that has worsened over the past few hours. The child’s immunizations are up to date. He was treated with antibiotics for acute otitis media last year but is otherwise healthy. He lives with his parents and 3-year-old brother. Both he and his brother attend day care. Temperature is 40.2 C (104.4 F) and pulse is 124/min. On examination the patient is lethargic. He flexes his hips when his neck is flexed. He also has an erythematous, nonblanching pinpoint rash on the trunk and lower extremities. Which of the following is the most likely organism causing this patient’s symptoms?
Question 37 of 40
A 6-day-old boy is brought to the emergency department due to spasms involving the whole body. The infant has had 3 days of difficulty latching on the breast, and this morning he was unable to nurse. The parents have been supplementing breastfeeding with a mixture of honey and goat milk. The infant lives in a religious commune with his parents, 3 older siblings, and 2 dogs. The members of the community do not accept vaccinations. The mother did not receive prenatal care and delivered vaginally with the assistance of her sister. The umbilical cord was cut with a pair of kitchen scissors. Temperature is 38.8 C (101.8 F). Examination shows an irritable infant with marked hypertonicity, neck stiffness, and inspiratory stridor. Auscultation of the heart and lungs is normal. The umbilical stump is swollen and has a small amount of purulent drainage. Cerebrospinal fluid analysis shows the following:
Cultures of the blood, cerebrospinal fluid, and umbilical stump are pending. Which of the following is the most likely diagnosis?
Question 38 of 40
A 6-year-old boy is brought to the emergency department after falling out of bed. He ate dinner an hour earlier and had been asleep for 30 minutes when his mother heard him fall out of bed onto a hardwood floor. She immediately went to his room and found him unconscious on the floor with a blue discoloration around his lips that resolved after a few seconds. He regained consciousness after a few minutes but seemed sleepier than normal. He has slowly become more awake over the past 30 minutes and is now alert and interactive, but he does not remember anything about the event. Which of the following is the most likely diagnosis?
Question 39 of 40
A 6-year-old boy is brought to the emergency department due to difficulty moving his right arm and leg. He was playing in his room at home when his mother heard him fall. When she checked on the boy. she found him unresponsive on the floor. The child regained consciousness after 3 minutes; however, he was confused and unable to move his right side. The patient has no known medical conditions and takes no medications. He has had normal development. His mother has a history of migraines, and his maternal uncle died from a hemorrhagic stroke last month. Physical examination reveals an alert boy with normal speech and behavior and no complaints of pain. Cranial nerves ll-XII are intact. Heart sounds are normal. Right upper and lower extremities are flaccid, and right-sided strength is 0/5. Left-sided strength is 5/5 in upper and lower extremities. Sensation to light touch is intact in all extremities. A CT scan of the head and MRI of the brain are normal. The boy gradually regains complete motor function in his right arm and leg over the next 4 hours. Which of the following is the most likely cause of this patient’s hemiplegia?
Question 40 of 40
A 4-year-old girl is brought to the office due to behavioral concerns. Over the last 2 months, her parents and preschool teacher have noticed that she frequently does not respond to their questions, and they often need to repeat themselves several times to get a response. Three months ago. the patient was hospitalized due to high fever, headache, nuchal rigidity, and recurrent seizures. Cerebrospinal fluid culture grew Streptococcus pneumoniae, and she was given parenteral antibiotics. The seizures were initially difficult to control but resolved after 72 hours of antibiotic therapy. A repeat cerebrospinal fluid culture was sterile, and the patient completed the course of antibiotics. She has had no fever or headache since then and has not followed up until today’s visit. Vital signs and growth parameters are normal for age. In the office, the child is alert and can hop on 1 foot. She can copy a cross and square on paper. Which of the following is the most likely cause of this patient’s current symptoms?
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