ITE Neurology

Question 1

A 68-year-old man with atrial fibrillation and hypertension presents 90 minutes after sudden onset right-sided weakness and aphasia. CT head is negative for hemorrhage. His INR is 1.1 (not on anticoagulation). What is the most appropriate immediate intervention?

Accepted Answer

IV alteplase (tPA) if no contraindications

Answer

IV tPA within 4.5 hours of ischemic stroke symptom onset is the standard of care when contraindications are absent. Aspirin is appropriate but is secondary to thrombolysis in the acute window. Carotid endarterectomy is for symptomatic carotid stenosis, not acute treatment. IV heparin is not recommended in acute ischemic stroke.

Question 2

A 22-year-old woman presents with her second unprovoked tonic-clonic seizure. MRI brain is normal. EEG shows 3 Hz spike-and-wave discharges. She is of childbearing age. Which antiepileptic drug is MOST appropriate as initial monotherapy?

Accepted Answer

Lamotrigine

Answer

Lamotrigine is appropriate for generalized epilepsy (consistent with 3 Hz spike-wave = absence/generalized epilepsy) and carries a lower teratogenic risk compared to valproate, making it preferable for women of childbearing potential. Valproate is highly effective but is a known teratogen (neural tube defects). Phenytoin and carbamazepine can worsen absence seizures.

Question 3

A 52-year-old woman presents with sudden-onset 'thunderclap' headache that she describes as the worst headache of her life, reaching peak intensity in seconds. CT head is negative. What is the next most appropriate diagnostic step?

Accepted Answer

Lumbar puncture for xanthochromia and RBC count

Answer

A thunderclap headache with normal CT requires lumbar puncture to rule out subarachnoid hemorrhage (SAH), which can be CT-negative in up to 2–5% of cases in the first 6–12 hours but positive for xanthochromia on LP. MRI is less sensitive than LP for early SAH. Delaying CTA or treating empirically without LP risks missing a potentially fatal condition.

Question 4

A 65-year-old man with type 2 diabetes presents with burning pain, numbness, and tingling in both feet in a 'stocking' distribution. Nerve conduction studies show reduced amplitude and slowed conduction velocity in distal sensory nerves bilaterally. Which of the following is MOST appropriate for neuropathic pain control?

Accepted Answer

Duloxetine or pregabalin

Answer

Duloxetine and pregabalin are FDA-approved first-line agents for diabetic peripheral neuropathic pain with strong evidence and favorable risk profiles. Opioids are not first-line. High-dose amitriptyline (150 mg) carries significant anticholinergic and cardiac risk; low doses may be used but are not first-line. NSAIDs do not address neuropathic pain mechanisms.

Question 5

A 72-year-old man presents with a 1-year history of resting tremor of the right hand, reduced arm swing while walking, a shuffling gait, and difficulty initiating movement. Cognitive function is intact. Which of the following is the most appropriate initial pharmacologic treatment?

Accepted Answer

Carbidopa-levodopa

Answer

Carbidopa-levodopa is the most effective symptomatic treatment for Parkinson's disease and is appropriate for an elderly patient with significant motor disability. Haloperidol is a dopamine antagonist that worsens parkinsonism. Trihexyphenidyl (anticholinergic) may be used for tremor but is poorly tolerated in the elderly due to cognitive side effects. Memantine is used for dementia, not Parkinson's motor symptoms.

ITE - Internal Medicine In-Training Exam Practice Test

ITE - Internal Medicine In-Training Exam Practice Test

ITE Neurology