Site MapHelpFeedbackQuiz for Practitioners
Quiz for Practitioners
(See related pages)



1

For the past 5 weeks a 35-year-old woman has had episodes of intense vertigo lasting several hours. Each episode is associated with tinnitus and a sense of fullness in the right ear; during the attacks, she prefers to lie on her left side. Examination during an attack shows that she has fine rotary nystagmus, which is maximal on gaze to the left. There are no ocular palsies, cranial-nerve signs, or long-tract signs. An audiogram shows high-tone hearing loss in the right ear, with recruitment but no tone decay. The most likely diagnosis in this case is
A)labyrinthitis
B)Ménière's disease
C)vertebral-basilar insufficiency
D)acoustic neuroma
E)multiple sclerosis
2

A 25-year-old woman presents to the emergency department with a severe, throbbing headache of the right supraorbital area for the past hour. She also complains of nausea and photophobia. She has had similar attacks in the past, often brought on by menstruation. About 45 min ago she took 400 mg of ibuprofen. Which of the following would be the best therapeutic choice at this time?
A)Meperidine, 50 mg intramuscularly
B)Codeine, 60 mg orally
C)Naproxen, 750 mg orally
D)Sumatriptan, 6 mg subcutaneously
E)Verapamil, 300 mg orally
3

A 29-year-old woman who uses oral contraceptives comes to the emergency room because when she looked in the mirror this morning, her face was twisted. It felt numb and swollen. While eating breakfast, she found that her food tasted different and she drooled out of the right side of her mouth when swallowing. Neurologic examination discloses only a dense right facial paresis equally involving the frontalis, orbicularis oculi, and orbicularis oris. Finger rubbing is appreciated as louder in the right ear than in the left. The physician should
A)instruct the patient in using a patch over the right eye during sleep
B)recommend that she discontinue the use of oral contraceptives
C)order brainstem auditory evoked potentials to assess her hearing asymmetry
D)inform her that her chances of substantial improvement within several weeks are only about 40%
E)order an echocardiogram to rule out mitral valve prolapse as a source of emboli
4

A 78-year-old woman with metastatic breast cancer arrives in your clinic for evaluation. She is currently receiving palliative chemotherapy. The patient lives with her husband and her 40-year-old son. Over the past several months she has fractured two vertebral bodies and has been hospitalized for a deep venous thrombosis. Both she and her family have sought aggressive treatment. Her husband is ill from advanced coronary artery disease, and the patient is his primary caregiver. Unfortunately, as her disease has progressed she has become too sick to care for her husband. Her pain remains poorly controlled, and she is receiving naproxen and morphine, in both the long- acting as well as immediate-release form. She has lost ~11.5 kg (25 lb) over the past 3 months, and her appetite is described as poor. On further questioning the patient volunteers that she feels her future is over and that only pain and suffering lie ahead. The patient is gravely worried about the care her husband will receive in the future with her loss. She feels she is no longer able to serve as his caregiver and feels saddened by this. She is focused on the suffering she is putting both her husband and friends and family through with her physical and emotional decline. She states that she is sad and nervous about the future and has been unable to focus on anything else. Which of the following diagnoses best describes the mental status of this patient?
A)Grief
B)Adjustment disorder
C)Depression
D)Posttraumatic stress disorder (PTSD)
E)Dysthymic disorder
5

A 45-year-old man presents with a daily headache. He describes two attacks per day over the past 3 weeks. Each attack lasts about an hour and awakens the patient from sleep. The patient has noted associated tearing and reddening of his right eye as well as nasal stuffiness. The pain is deep, excruciating, and limited to the right side of the head. The neurologic examination is nonfocal. The most likely diagnosis of this patient's headache is
A)migraine headache
B)cluster headache
C)tension headache
D)brain tumor
E)giant cell arteritis
6

A 25-year-old woman who was the driver of a car struck in the rear by another car while she was stopped at a red light presents to the emergency department with neck pain as well as discomfort in the axilla, upper arm, elbow, dorsal forearm, and index and middle fingers. Coughing exacerbates the pain. Neurologic examination reveals weakness in the right second and third fingers, forearm, and wrist. The right triceps reflex is diminished. The most likely diagnosis in this case is
A)syringomyelia
B)cervical sprain
C)thoracic outlet syndrome
D)cervical disk herniation
E)brachial plexopathy
7

A patient with previous spells of diplopia, ataxia, dysarthria, and dizziness becomes acutely comatose. The most likely cause is
A)basilar artery thrombosis
B)subarachnoid hemorrhage
C)carotid occlusion
D)cerebellar hemorrhage
E)pontine hemorrhage
8

A 75-year-old woman complains of dizziness and lightheadedness while walking. The patient has had long- standing diabetes and is taking an oral hypoglycemic agent. She has no other medical problems and lives alone. Physical examination reveals visual acuity of 20/80 in both eyes and sensory neuropathy in a stocking-glove distribution. On close questioning, she denies any symptoms of "herself spinning or the world spinning." She has no apparent anxiety or depression. Orthostatic vital signs are normal. A head-tilt maneuver reveals no nystagmus. The most likely diagnosis in this case is
A)dysequilibrium of aging
B)benign positional vertigo
C)Ménière's disease
D)brainstem stroke
E)neoplasm of the central nervous system
9

A 35-year-old woman complaining of trouble with her "peripheral vision" is subjected to visual field examination. While one eye is tested at a time, she is asked to focus on a central target while the examiner's fingers are moved in from various directions. She is unable to distinguish objects brought laterally toward the midline, encompassing about half the visual field in each eye. Which of the following lesions would most likely account for these findings?
A)Open-angle glaucoma
B)Closed-angle glaucoma
C)Multiple sclerosis
D)Pituitary tumor
E)Embolic occlusion of the posterior cerebral artery
10

Evoked-potential testing is most useful in diagnosing
A)brainstem involvement in stroke
B)a clinically occult lesion in multiple sclerosis
C)large hemispheral strokes
D)spinal cord compression
E)shearing of white matter tracts after head injury
11

A 25-year-old weight lifter comes to the emergency department frightened by recent headaches. He recently read a newspaper article about cerebral aneurysms. He reports 5 to 10 sudden, severe headaches, all occurring during coitus, with each lasting about 1 h. The physician should
A)recommend that the patient seek psychiatric help for his sexual dysfunction
B)perform a CT scan with contrast and schedule four-vessel cerebral angiography to search for an aneurysm or arteriovenous malformation
C)inform the patient that coital headache is a benign clinical syndrome that may be helped by the administration of propranolol, 20 mg three times a day
D)(D) tell the patient to report back to the emergency department for a cerebrospinal fluid (CSF) examination and CT scan without contrast to search for subarachnoid blood
E)determine whether other members of his family have a history of migraine
12

A 60-year-old male diabetic patient complains of the acute onset of diplopia. He denies headache, fever, stiff neck, or other symptoms. The only abnormality on neurologic examination pertains to eye movements. The patient's right eyelid is ptotic. The pupil is deviated downward and outward. The patient cannot move the eye upward, downward, or inward. There is, however, no anisocoria, and normal pupillary responses are present bilaterally. The appropriate course of action at this time is
A)administration of high-dose steroids
B)administration of a topical ophthalmic -adrenergic blocker
C)cerebral angiography
D)visual field testing
E)reexamination in 1 month
13

Presbycusis, the hearing loss associated with aging, may affect 33% of people age 75 or older. The most common cause of this problem is
A)fixation of middle ear bones
B)tympanic membrane failure
C)loss of neuroepithelial cells
D)vascular lesions in central auditory pathways
E)exposure to ototoxins such as furosemide
14

Bradykinesia, a decreased ability to initiate volitional movements, as well as constant impedance to the examiner's efforts to extend the arm would most likely be due to lesions in which of the following structures?
A)Anterior horn cell of the spinal cord
B)Descending corticospinal fibers
C)Basal ganglia
D)Internal capsule
E)Cerebral cortex
15

A 70-year-old man complains of pain and stiffness in both shoulders and hips. Examination reveals atrophic shoulder girdle and gluteal musculature. Reflexes and cerebellar function are intact. There is no sensory loss. The serum creatine kinase level is normal. Temporal artery biopsy is negative. The most appropriate therapeutic strategy at this time is
A)prednisone, 60 mg daily
B)prednisone, 10 mg daily
C)potassium repletion
D)naproxen, 750 mg twice daily
E)reassurance; no treatment is required
16

A 65-year-old man with advanced pancreatic cancer complains of increasing abdominal pain. He is taking codeine 60 mg every 4 h. Examination reveals an alert man with a benign abdomen and normal neurologic function. The best step at this point would be to
A)add phenytoin
B)add indomethacin
C)increase the dose of codeine
D)add sustained-release morphine sulfate and use the codeine as circumstances require (prn)
E)refer the patient for a celiac block
17

A 55-year-old woman presents because of intermittent, brief, extreme stabbing pains in her lips and right cheek. The pain can be brought on by touching her face. The results of an examination of the structures of the face and cranial nerves are entirely normal. Appropriate initial treatment for this condition would consist of
A)ergotamine
B)amitriptyline
C)propranolol
D)carbamazepine
E)referral to an otolaryngologist for nerve block
18

During the evaluation of a patient with a gait disorder, it is noted that the patient is unable to identify accurately the direction of examiner-initiated movement of the great toe. Pain and temperature sense in the same distribution are intact. This abnormality reflects a lesion in which of the following structures?
A)Posterior column on the same side as the affected toe
B)Spinothalamic tract on the same side as the affected toe
C)Thalamic nucleus on the same side as the affected toe
D)Lower sensory neuron on the same side as the affected toe
E)Frontal cortex on the opposite side from the affected toe
19

A patient being evaluated for aphasia is unable to repeat sentences correctly or name objects properly. However, the patient's speech is effortless and melodic. There are frequent errors in word choice and obvious difficulties in comprehension. The remainder of the patient's neurologic examination is normal. Damage in which area of the brain would account for this type of aphasia?
A)Posterior temporal and parietal lobes, dominant hemisphere
B)Frontal and parietal lobes, dominant hemisphere
C)Prefrontal and frontal regions, dominant hemisphere
D)Posterior parietal and temporal lobes, nondominant hemisphere
E)Parietal and occipital lobes, nondominant hemisphere
20

A patient is evaluated for anisocoria. The right pupil is small and round compared with the left pupil in room light; this difference is magnified when the room is darkened. The right pupil responds briskly to light, constricts when pilocarpine is placed in the eye, and dilates when atropine is placed in the eye. Minimal dilation is produced by 4% cocaine. This patient has a lesion in the
A)right optic nerve
B)right iris
C)right third nerve
D)right sympathetic chain
E)left occipital lobe
21

Which of the following would help exclude the diagnosis of seizure in a patient with sudden loss of consciousness?
A)A brief period of tonic-clonic movements at the time of falling
B)An aura of a strange odor before falling
C)Sudden return to normal mental function upon awakening, though with a feeling of physical weakness
D)Urinary incontinence
E)Laceration of the tongue
22

A 55-year-old man who lost his job approximately 5 months ago complains of profound difficulty sleeping at night. He recently found a new job but has continued to experience difficulty sleeping. He notes that he falls asleep more easily while watching television early in the evening and feels sleepy outside the house. He is preoccupied with his inability to sleep at night. General physical examination and routine laboratory screening are unremarkable. He denies the use of alcohol, coffee, and other drugs. What is the most appropriate approach?
A)Administration of a benzodiazepine
B)Administration of stimulants
C)Administration of estrogen
D)Administration of tricyclic antidepressants
E)No therapy
23

A 65-year-old man presents with severe right- sided eye and facial pain, nausea, vomiting, colored halos around lights, and loss of visual acuity. His right eye is quite red, and that pupil is dilated and fixed. Which of the following diagnostic tests would confirm the diagnosis?
A)CT of the head
B)MRI of the head
C)Cerebral angiography
D)Tonometry
E)Slit-lamp examination
24

A 35-year-old woman presents with an apparent seizure. She was feeling well when she noted that her right thumb began suddenly to retract repetitively, followed by right hand movements. Within 1 min her right arm and the right side of her face also began to contract. About 2 min later the patient developed diffuse convulsive motor activity and loss of consciousness lasting about 5 min. After her recovery of consciousness the patient was amnestic for the event and also had about 6 h of weakness in her right arm. Which of the following is the most likely cause of this type of seizure?
A)Herpes encephalitis
B)Temporal lobe epilepsy
C)Juvenile myoclonic epilepsy
D)Abscess or tumor in the left motor strip
E)Cerebral embolism
25

A 19-year-old man has had an 8-year history of recurrent episodes of loss of conscious activity that last for seconds to several minutes. Sometimes he has as many as 100 of these lapses. The patient regains awareness of his environment very quickly. There is no major motor manifestation during the episodes or a period of confusion afterward. The patient's neurologic examination is totally normal. Which of the following drugs would be the most effective for this patient's problem?
A)Phenytoin
B)Carbamazepine
C)Phenobarbital
D)Ethosuximide
E)Primidone
26

A patient who complains of imbalance is found to walk with a wide-based gait and to sway forward and backward upon standing. Balance cannot be maintained when the patient is standing with the feet together and with the eyes open or closed. No limb ataxia or nystagmus can be elicited. These findings are most consistent with a lesion or lesions in the
A)vestibular apparatus
B)midline cerebellar zone
C)intermediate cerebellar zone
D)lateral cerebellar zone
E)left frontal cortex
27

Which of the following brain tumors tends to occur in immunosuppressed persons, arise in periventricular regions, and respond both clinically and radiographically to glucocorticoid therapy?
A)Glioblastoma
B)Ependymoma
C)Meningioma
D)Medulloblastoma
E)B cell lymphoma
28

A 59-year-old chronic alcoholic has loss of consciousness and shaking of his entire body for approximately 5 min. He is somewhat confused after this episode and is brought to the emergency department, where another episode occurs. The patient develops incontinence during the event and again is confused afterward. CT of the brain and a lumbar puncture are negative. No major metabolic abnormalities were detected on blood testing. Appropriate therapy for this condition consists of
A)phenytoin, 1000 mg given in a slow IV push
B)diazepam, 10 mg IV bolus
C)phenobarbital, 400 mg given over 30 min
D)carbamazepine, 600 mg orally daily
E)no specific anticonvulsant therapy
29

A patient who is being treated for temporal lobe epilepsy (complex partial seizures) and is having recurrent seizures on his chronic regimen of carbamazepine is given phenobarbital as a second drug. However, the seizures increase in frequency. What is the probable reason for the apparently deleterious effect of adding phenobarbital?
A)Intracerebral bleeding from worsening bone marrow suppression
B)Decreased carbamazepine level
C)Decreased stability of CNS neuronal membranes
D)Hypokalemia
E)Increased intracranial pressure
30

Which of the following statements regarding glaucoma is true?
A)If recognized early, the optic neuropathy of glaucoma is reversible.
B)Primary closed-angle glaucoma is the most common type in the United States.
C)Topical -adrenergic antagonists have few if any side effects due to low systemic absorption.
D)The Schiøtz indentation tonometer is the most frequently used device to measure interocular pressure in both hospitals and clinics.
E)The initial symptom of optic neuropathy due to glaucoma is loss of central vision.







Harrisons Internal MedicineOnline Learning Center

Home > 15. Neurologic > Quiz for Practitioners