Clinical Neurology Test

Question 1

A 39-year-old man is admitted to the hospital by his brother for evaluation of increasing forgetfulness and confusion during the past month.
His brother reports that the patient has been drinking heavily and eating very little, and has been slightly nauseated and tremulous.
He wanders at night because he cannot sleep.
On admission to the hospital, intravenous administration of 5% dextrose in water is initiated.
Two hours later, the patient has ophthalmoplegia and is completely confused.
Which of the following is the most appropriate next step in management?

Accepted Answer

Administration of large doses of vitamin B1 (thiamine), intravenously

Answer

Administration of an anticoagulant

Answer

Administration of diazepam

Answer

Administration of large doses of vitamin C,

Answer

Continued administration of intravenous fluids with magnesium

Question 2

A 47-year-old man comes to the physician because of a 2-year history of fatigue. He has had progressive difficulty with daytime sleepiness and has intermittently fallen asleep at work. He has no difficulty falling asleep or staying asleep at night but awakens in the morning not feeling well rested. His vital signs are within normal limits. Examination of the throat shows no abnormalities except for hypertrophied tonsils. His hemoglobin concentration is 17.9 g/dL, leukocyte count is 8700/mm3 , and platelet count is 170,000/mm3 . Which of the following is the most likely cause of this patient’s symptoms?

Accepted Answer

Sleep apnea

Answer

Chronic Epstein-Barr virus infection

Answer

Chronic fatigue syndrome

Answer

Erythroleukemia

Answer

Polycythemia vera

Question 3

A 45-year-old man has had a 1-week history of increasing neck pain when he turns his head to the right. He also has had a pins-and-needles sensation starting in the neck and radiating down the right arm into the thumb. His symptoms began 3 months ago when he developed severe pain in the neck and right shoulder. Neurologic examination shows limitation of motion on turning the neck to the right. There is 4+/5 weakness of the right biceps and decreased pinprick over the right thumb. Deep tendon reflexes are 1+ in the right biceps and brachioradialis; all others are 2+. Which of the following is the most likely diagnosis?

Accepted Answer

Cervical root compression

Answer

Carpal tunnel syndrome

Answer

Multiple sclerosis

Answer

Thoracic outlet syndrome

Answer

Ulnar nerve compression

Question 4

A 29-year-old man is brought to the emergency department because he has a severe bilateral headache and irritability. His pulse is 120/min, respirations are 30/min, and blood pressure is 200/120 mm Hg. Ophthalmoscopic examination shows blurring of the optic discs. Deep tendon reflexes are 3+ and symmetric. Which of the following is the most likely diagnosis?

Accepted Answer

Hypertensive encephalopathy

Answer

Alcohol intoxication

Answer

Heavy metal poisoning

Answer

Hyperthyroidism

Answer

Panic disorder

Question 5

A 65-year-old man has had increasingly severe headaches and diffuse muscle aches during the past 3 months. He also has a 1-month history of jaw pain when chewing food and decreasing visual acuity in his left eye. His temperature is 38°C (100.4°F). Visual acuity in his left eye is 20/100, and the left optic disc is slightly atrophic. His muscle strength is normal. Which of the following tests should be obtained next?

Accepted Answer

Measurement of erythrocyte sedimentation rate

Answer

Antinuclear antibody assay

Answer

Examination of cerebrospinal fluid

Answer

CT scan of the head

Answer

Electroencephalography

Question 6

A 19-year-old woman comes to the physician because of a 3-month history of intermittent drooping of her left eyelid each evening and occasional difficulty chewing and swallowing. She also has had two episodes of double vision that occurred in the evening and resolved by the following morning. Examination shows no abnormalities except for slight ptosis on the right. Which of the following is the most likely diagnosis?

Accepted Answer

Myasthenia gravis

Answer

Acute intermittent porphyria

Answer

Brain stem glioma

Answer

Complex partial seizures

Answer

Guillain-Barré syndrome

Question 7

A 21-year-old college student comes to student health services requesting medication to help her sleep. Four days ago, she returned from a 1-year trip to India where she studied comparative religions. Since her return, she has been unable to fall asleep until 4 or 5 AM and has difficulty awakening before noon. She constantly feels tired, has difficulty concentrating, and does not feel ready to begin classes. Her appetite has not decreased, but she has an aversion to eating meat since following a vegetarian diet in India. She has no history of medical or psychiatric illness. She takes no medications and does not drink alcohol. She appears sleepy. She is 173 cm (5 ft 8 in) tall and weighs 54 kg (120 lb); BMI is 18 kg/m2 . Her pulse is 60/min, and blood pressure is 115/70 mm Hg. She is alert and oriented to person, place, and time. When asked to subtract serial sevens from 100, she begins accurately but then repeatedly loses track of the sequence. Which of the following is the most likely diagnosis?

Accepted Answer

Circadian rhythm sleep disorder

Answer

Adjustment disorder with depressed mood

Answer

Bipolar disorder

Answer

Major depressive disorder

Answer

Malingering

Answer

Primary insomnia

Question 8

A 67-year-old woman comes to the physician for a follow-up examination. She had a pulmonary embolism and required treatment in the hospital for 3 weeks. She had a retroperitoneal hemorrhage; anticoagulant therapy was temporarily discontinued, and she underwent placement of an inferior vena cava (IVC) filter. She had a hematoma that was resolving on discharge from the hospital 2 weeks ago. Today, she says she has had a persistent sensation of tingling and numbness of her left thigh that she did not report in the hospital because she thought it would go away; the sensation has improved somewhat during the past week. Her only medication is warfarin. Vital signs are within normal limits. Examination of the skin shows no abnormalities. Muscle strength is normal. Sensation to light touch is decreased over a 5 × 5-cm area on the lateral aspect of the left anterior thigh. Which of the following is the most likely cause of this patient’s decreased sensation?

Accepted Answer

Compression of the lateral femoral cutaneous nerve

Answer

Cerebral infarction during the hospitalization

Answer

Complication of the IVC filter placement

Answer

Hematoma of the left thigh

Answer

Spinal cord infarct

Answer

Vitamin B12 (cobalamin) deficiency

Question 9

An 82-year-old man is admitted to the hospital because nursing staff in his skilled nursing care facility report that he has appeared sad and depressed during the past 2 months. It is reported that he has a history of psychiatric illness, but details are not provided. He has been taking olanzapine, paroxetine, and haloperidol for 2 years. He does not appear to be in acute distress. He is 160 cm (5 ft 3 in) tall and weighs 48 kg (105 lb); BMI is 19 kg/m2 . Physical examination shows 2+ cogwheel rigidity of the upper extremities. Neurologic examination shows psychomotor retardation. On mental status examination, he is alert and generally pleasant and cooperative. His affect has little intensity or range. He says he does not feel depressed or anxious. Laboratory findings are within the reference range. Which of the following is the most likely cause of this patient’s current symptoms?

Accepted Answer

Drug-induced parkinsonism

Answer

Adjustment disorder

Answer

Akathisia

Answer

Dementia, Alzheimer type

Answer

Major depressive disorder

Question 10

A 25-year-old butcher has had severe episodic pain in his right thumb and right second and third digits for 2 months. The pain frequently awakens him from sleep. He has decreased sensation over the palmar surface of the thumb and index and long fingers of the right hand and atrophy of the thenar muscle mass. Compression of which of the following nerves is the most likely cause?

Accepted Answer

Median

Answer

Musculocutaneous

Answer

Posterior interosseous

Answer

Radial

Answer

Ulnar