Neuro 6 - Answers PDF

Exam Section: Item 1 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 1. A ?-year-old girl is brought to the physician because of progressive sll...

Exam Section: Item 1 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 1. A ?-year-old girl is brought to the physician because of progressive slleepiness, ataxia, and double vision over the past 2 days. She has a 2-year history of complex partial seizures treated with carbamazepine. One week ago, she developed fever and received erythromycin for pharyngitis. Her brother has attention-deficit/hyperactivity disorder treated with methyllphen idate. Her temperature is 37°C (98.6°F). She appears sleepy. Ocular movements appear full. She has no weakness, but is moderately ataxic. Wh ich of the following is the most likely cause of her current symptoms? A) Carbamazepine-erythromycin interaction B) Cerebellar astrocytoma C) Erythromyci n allergy D) Methylphenidate ingestion E) Viral encephalitis Correct Answer: A. Carbamazepine is a common antiepileptic medication. It has been shown to interact with other medications and caution shou ld be exercised when choosing concomitant medications for treating patients. It is a CYP450 inducer, which may increase hepatic clearance of some medications (eg, warfarin, phenytoin, valproic acid), leading to subtherapeutic concentrations in the serum. Other drugs, such as erythromycin, can interfere with the hepatic metabolism of carbamazepine by inhibiting CYP450 enzymes, leading to decreased carbamazepine clearance, increased serum concentration, and toxicity. Carbamazepine toxicity typically presents with altered mental status, drowsiness, ataxia, nystagmus, nausea, and vomiting. Diagnosis can be made by measuring a serum carbamazepine concentration above therapeutic levels, and there is a dose-dependent effect on neurologic depression. Treatment is supportive, with benzodiazepines for seizures or agitation, and involves discontinuation of offending medications. Incorrect Answer: B, C, D, and E. Cerebellar astrocytomas (Choice B) are slow-growing and typically benign tumors in children and young adults. Children with astrocytomas can present with headache, nausea, vomiting, irritability, behavioral changes, impaired coordination, and visual impairment, depending on the size and location of the astrocytoma. Typical allergic reactions to medications, including erythromycin (Choice C), would present with rash, urticaria, and, if severe, signs and symptoms of anaphylaxis such as oropharyngeal, lip, or tongue swel ling; voice changes; wheezing; shortness of breath; vomiting; or other gastrointestinal disturbances. Methylphenidate (Choice D) is a central nervous system stimulant used to treat attention-deficit/hyperactivity disorder by blocking norepinephrine and dopamine reuptake in neuronal synapses. The inappropriate ingestion of methylphenidate can present with agitation, anxiety, palpitations, decreased appetite, tremors, hyperreflexia, delirium, hyperthermia, tachycardia, hypertension, and.... -- - -- - ~, https://t.me/USMLENBME2CK ~ ~ r, Next Score Report Lab Values Calculator Help Pause  Exam Section: Item 1 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment Please Walt E) Viral encephalitis... Correct Answer: A. Carbamazepine is a common antiepileptic medication. It has been shown to interact with other medications and caution shou ld be exercised when choosing concomitant medications for treating patients. It is a CYP450 inducer, which may increase hepatic clearance of some medications (eg, warfarin, phenytoin, valproic acid), leading to subtherapeutic concentrations in the serum. Other drugs, such as erythromycin, can interfere with the hepatic metabolism of carbamazepine by inhibiting CYP450 enzymes, leading to decreased carbamazepine clearance, increased serum concentration, and toxicity. Carbamazepine toxicity typically presents with altered mental status, drowsiness, ataxia, nystagmus, nausea, and vomiting. Diagnosis can be made by measuring a serum carbamazepine concentration above therapeutic levels, and there is a dose-dependent effect on neurologic depression. Treatment is supportive, with benzodiazepines for seizures or agitation, and involves discontinuation of offending medications. Incorrect Answer: B, C, D, and E. Cerebellar astrocytomas (Choice B) are slow-growing and typically benign tumors in children and young adults. Children with astrocytomas can present with headache, nausea, vomiting, irritability, behavioral changes, impaired coordination, and visual impairment, depending on the size and location of the astrocytoma. Typical allergic reactions to medications, including erythromycin (Choice C), would present with rash, urticaria, and, if severe, signs and symptoms of anaphylaxis such as oropharyngeal, lip, or tongue swel ling; voice changes; wheezing; shortness of breath; vomiting; or other gastrointestinal disturbances. Methylphenidate (Choice D) is a central nervous system stimulant used to treat attention-deficit/hyperactivity disorder by blocking norepinephrine and dopamine reuptake in neuronal synapses. The inappropriate ingestion of methylphenidate can present with agitation, anxiety, palpitations, decreased appetite, tremors, hyperreflexia, delirium, hyperthermia, tachycardia, hypertension, and mydriasis. Viral encephalitis (Choice E) typically presents with fever, headache, altered mental status, and neurologic abnormalities such as seizure, aphasia, hemiparesis, or cranial nerve deficits. This patient does not demonstrate a fever and a carbamazepine-erythromycin interaction is a more likely cause of this patient's altered mental status. Educational Objective: Erythromycin can interfere with the hepatic metabolism of carbamazepine by inhibiting CYP450 enzymes, leading to decreased carbamazepine clearance, increased serum concentration, and toxicity. Carbamazepine toxicity typically presents with altered mental status, drowsiness, ataxia, nystagmus, nausea, and vomiting..,. ~, https://t.me/USMLENBME2CK ~ ~ r, Waiting for www.starttest.co~.:. · - - · Lab Values Calculator Help Pause Exam Section: Item 2 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 2. A 52-year-old man comes to the physician because of progressive billateral leg pain over the past year. The pain is located on the posterior aspect of the th ighs and calves, occurs only when he is standing, and resolv,es within 30 seconds of sitting or lying down. He has noticed that the pain is less intense if he leans on something as he walks, such as a grocery cart. He can still ride an exercise bicycle without developing any pain. He has hypertension, hyperlipidemia, and a small abdominal aortic aneurysm. He had a left carotid endarterectomy 3 years ago after several transient ischemic attacks in the left hemisphere. Medications include lisinopril, lovastatin, and aspirin. He has smoked one pack of cigarettes daily for 30 years. He is 180 cm (5 ft 11 in) tall and weighs 110 kg (242 lb); BMI is 34 kg/m 2. His temperature is 37°C (98.6°F), pulse is 70/min, respirations are 12/m in, and blood pressure is 150/90 mm Hg. Examination shows a rig ht femoral bruit and diminished pedal pulses. Which of the following is the most likely cause of this patient's lower extremity pain? A) Cerebrovascular disease B) Lumbar spinal stenosis C) Lumbosacral plexopathy D) Peripheral vascular disease E) Trochanteric bursitis Correct Answer: B. The patient's symptoms are most consistent with neurogenic claudication caused by lumbar spinal stenosis. Spinal stenosis describes narrowing of the central canal, neural foramen, or lateral recesses of the spine with consequent nerve compression. Common causes include degenerative arthritis, spondyloarthropathies, degenerative disc disease, hypertrophy of the ligamentum flavum, and osteophyte formation in the facet joints. Neurogenic claudication describes lower back pain with radiation to the buttocks and lower extremities that results from increased nerve compression, as may occur with extension of the spine during standing and walking downhill. Lengthening the spinal column with spinal flexion as during sitting, walking uphill, or leaning against a grocery cart, tends to relieve the pain. Diagnostic evaluation involves x-rays followed by MRI of the lumbar spine to evaluate the degree of spinal stenosis and whether surgical management is necessary. Incorrect Answers: A, C, D, and E. Cerebrovascular disease (Choice A) is a concern in this patient with multiple risk factors and a history of transient ischemic attacks; however, progressive bi lateral leg pain that is worsened or relieved by postural changes is more consistent with lumbar spinal stenosis. Persistent or new motor or sensory deficits wou ld be more concerning for cerebrovascular disease. Lumbosacral plexopathy (Choice C) describes a diverse range of motor and sensory disturbances to the lower extremities, including weakness, paresis, pain, numbness, and tingling, resulting from lesions of the lumbosacral plexus. Patients typically display abnormalities along mu ltiple contiguous nerve root distributions. Diagnostic evaluation includes a thorough neurologic and.... -- - - -- - - - - - -- - - - - -- - - - - - - - -- - - -- -- - -- - -- - - - - - --- -- - -- -- - -- - - - - r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 2 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment E) Trochanteric bursitis... Correct Answer: B. The patient's symptoms are most consistent with neurogenic claudication caused by lumbar spinal stenosis. Spinal stenosis describes narrowing of the central canal, neural foramen, or lateral recesses of the spine with consequent nerve compression. Common causes include degenerative arthritis, spondyloarthropathies, degenerative disc disease, hypertrophy of the ligamentum flavum, and osteophyte formation in the facet joints. Neurogenic claudication describes lower back pain with radiation to the buttocks and lower extremities that results from increased nerve compression, as may occur with extension of the spine during standing and walking downhill. Lengthening the spinal column with spinal flexion as during sitting, walking uphill, or leaning against a grocery cart, tends to relieve the pain. Diagnostic evaluation involves x-rays followed by MRI of the lumbar spine to evaluate the degree of spinal stenosis and whether surgical management is necessary. Incorrect Answers: A, C, D, and E. Cerebrovascular disease (Choice A) is a concern in this patient with multiple risk factors and a history of transient ischemic attacks; however, progressive bilateral leg pain that is worsened or relieved by postural changes is more consistent with lumbar spinal stenosis. Persistent or new motor or sensory deficits would be more concerning for cerebrovascular disease. Lumbosacral plexopathy (Choice C) describes a diverse range of motor and sensory disturbances to the lower extremities, including weakness, paresis, pain, numbness, and tingling, resulting from lesions of the lumbosacral plexus. Patients typically display abnormalities along multiple contiguous nerve root distributions. Diagnostic evaluation includes a thorough neurologic and musculoskeletal examination, imaging of the lumbar spine, electromyography, and nerve conduction studies. Peripheral vascular disease (Choice D) is also a common cause of claudication, and this patient has multiple risk factors including tobacco use, hypertension, hyperlipidemia, and obesity. His physical examination findings support the presence of peripheral vascular disease with a right femoral bruit and diminished pedal pulses. However, claudication caused by peripheral vascular disease is commonly relieved by rest rather than postural changes. His symptoms are more likely caused by lumbar spinal stenosis. Trochanteric bursitis (Choice E) classically presents with lateral! hip pain that is exacerbated by activity. Physical examination shows point tenderness over the greater trochanter and increased pain with external rotation of the hip as a result of compression of the bursa. Bilateral, posterior leg pain is not consistent with a diagnosis of trochanteric bursitis. Educational Objective: Lower extremity pain that is exacerbated by extension of the spinal column and relieved by flexion is suggestive of neurogenic claudication resulting from lumbar spinal stenosis..,. r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 3 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 3. A 57-year-old woman comes to the physician because of a 2-day history of dribbling fluid from her mouth every time she drinks. She has not had difficulty swallowing or any other symptoms. She has no history of serious illness and takes no medications. She has an active lifestyle. Vital signs are within normal limits. Exam ination shows drooping of the lower lip on the left. The left forehead does not wrinkle on upward gaze. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management? A) Echocardiography B) MRI of the brain C) Doxycycline therapy D) Prednisone therapYi E) Lumbar puncture Correct Answer: D. Bel l palsy refers to a facial nerve palsy that leads to unilateral facial paralysis. It is most commonly caused by viral-mediated inflammation or immune reaction in the setting of a herpes simplex or herpes zoster infection, although it can also be idiopathic or caused by other viral infections. It presents acutely with unilateral facial paralysis that includes the forehead, consistent with its lower motoneuron pathologic involvement. It can also be associated with loss of taste on the anterior two-thirds of the tongue and decreased lacrimation. Symptoms typically peak around 3 weeks, with slow recovery beginning within 6 months. Diagnosis is most commonly based on clinical symptoms, but electrodiagnostic tests, such as EMG, and imaging of the face and head can be utilized if the diagnosis is unclear. Initial treatment consists of oral glucocorticoids, such as prednisone, and antiviral therapy in severe cases. Incorrect Answers: A, B, C, and E. Echocardiography (Choice A) is useful in the evaluation of embolic stroke, since an intracardiac thrombus or patent foramen ovale cou ld explain its cause. However, a stroke that affects the facial muscu lature would spare the forehead. Additionally, this patient has no risk factors for stroke or symptoms such as extremity weakness or numbness to suggest this as an underlying diagnosis. MRI of the brain (Choice B) is useful in the evaluation of stroke, especially early in the course of the disease, before it may be evident on CT scan. This patient's symptoms are not consistent with stroke. Doxycycline therapy (Choice C) can be used in the treatment of Lyme disease, which may present with Bell palsy in disseminated Lyme disease. Lyme disease also typically presents with erythema migrans, fatigue, headache, myalgias, arthralgias, and lymphadenopathy, as well as myocarditis, abnormal liver function tests, and kidney injury. This patient has no other signs or symptoms to suggest Lyme disease..... -- - - - -- - -- -- - --- - -- - - - -- - -- - - - - - - - - - -- - - - - - - - - - - - - - - - - -- - - - - - --- - r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 3 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment... C) Doxycycline therapy D) Prednisone therapYi E) Lum bar pu nctu re Correct Answer: D. Bel l palsy refers to a facial nerve palsy that leads to unilateral facial paralysis. It is most commonly caused by viral-mediated inflammation or immune reaction in the setting of a herpes simplex or herpes zoster infection, although it can also be idiopathic or caused by other viral infections. It presents acutely with unilateral facial paralysis that includes the forehead, consistent with its lower motoneuron pathologic involvement. It can also be associated with loss of taste on the anterior two-thirds of the tongue and decreased lacrimation. Symptoms typically peak around 3 weeks, with slow recovery beginning within 6 months. Diagnosis is most commonly based on clinical symptoms, but electrodiagnostic tests, such as EMG, and imaging of the face and head can be utilized if the diagnosis is unclear. Initial treatment consists of oral glucocorticoids, such as prednisone, and antiviral therapy in severe cases. Incorrect Answers: A, B, C, and E. Echocardiography (Choice A) is useful in the evaluation of embolic stroke, since an intracardiac thrombus or patent foramen ovale cou ld explain its cause. However, a stroke that affects the facial muscu lature would spare the forehead. Additionally, this patient has no risk factors for stroke or symptoms such as extremity weakness or numbness to suggest this as an underlying diagnosis. MRI of the brain (Choice B) is useful in the evaluation of stroke, especially early in the course of the disease, before it may be evident on CT scan. This patient's symptoms are not consistent with stroke. Doxycycline therapy (Choice C) can be used in the treatment of Lyme disease, which may present with Bell palsy in disseminated Lyme disease. Lyme disease also typically presents with erythema migrans, fatigue, headache, myalgias, arthralgias, and lymphadenopathy, as well as myocarditis, abnormal liver function tests, and kidney injury. This patient has no other signs or symptoms to suggest Lyme disease. Lumbar puncture (Choice E) is used in the evaluation of central nervous system infections, such as bacterial meningitis and viral meningitis. While these infections can present with focal neurologic deficits, they are commonly associated with fever, nuchal rigidity, headache, and altered mental status. Educational Objective: Bel l palsy is a unilateral, viral-mediated or idiopathic facial nerve palsy that causes facial paralysis that does not spare the forehead. Treatment utilizes glucocorticoids, and occasional ly, antiviral therapy..,. r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 4 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 4. A 72-year-old man comes to the physician because of a 1-week history of imbalance and leg weakness and a 3-day history of difficulty initiati ng urination. He also has had mild midthoracic back pain for 5 months, but during the past 2 weeks, the pain has worsened and frequently awakens him. He has had a 9-kg (20-lb) weight loss since an episode of bronchitis 6 months ago. He has smoked one pack of cigarettes daily for 50 years. He is cachectic and appears chron ically ill. Examination shows scleral icterus. Muscle strength in the lower extrem ities is decreased in the proximal and distal muscles bi laterally. There is no muscle atrophy, but tone is increased. Deep tendon reflexes are hyperactive, and Babinski sign is present bilaterally. Sensation is decreased to pinprick to the umbilicus. Muscle strength, sensation, and reflexes in the upper extrem ities are normal. Which of the following is the most likely diagnosis? A) Epidural spinal cord compression B) Myasthenic (Lambert-Eaton) syndrome C) Spinal cord infarction D) Syringomyelia E) Transverse myelitis Correct Answer: A. This patient's presenting signs and symptoms of focal back pain, upper motoneuron signs, and weight loss are suggestive of epidural spinal cord compression caused by metastatic carcinoma. Metastatic disease frequently affects the vertebral column and may cause compression of the spinal cord by extending into the epidural space or by causing bony destruction and fracture of the vertebral bodies. Patients present with back pain, lower extremity weakness, loss of balance, urinary or bowel incontinence, or complete paralysis of the lower extremities. Early detection and treatment are crucial to prevent permanent spinal cord damage and myelopathy. Patients may benefit from short-term treatment with intravenous dexamethasone to decrease spinal cord edema, although definitive treatment often requires a combination of surgical decompression, chemotherapy, and/or radiotherapy. Incorrect Answers: B, C, D, and E. Myasthenic (Lambert-Eaton) syndrome (Choice B) is characterized by the formation of autoantibodies against presynaptic calcium channels, resulting in the impairment of acetylcholine release at the neuromuscular junction. It presents with progressive proximal muscle weakness that improves with exercise and does not typically present with upper motoneuron signs. Spinal cord infarction (Choice C) may result from occlusion of the anterior or posterior spinal arteries and presents with abrupt onset myelopathy. Neuroimaging may be required to distinguish this entity from compressive spinal cord lesions. This patient's history of subacute onset and weight loss is more suggestive of a compressive epidural malignant lesion. Syringomyelia (Choice D) features a cystic cavity in the central cervical or thoracic spinal cord, which affects mid line structures such as.... - - -- - - - - - - -- -- - - - - - - --- - - - - - - - - - - - - -- - -- - --- - -- --- -- -- -- - - -- -- -- --- -- - - - r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 4 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment... Correct Answer: A. This patient's presenting signs and symptoms of focal back pain, upper motoneuron signs, and weight loss are suggestive of epidural spinal cord compression caused by metastatic carcinoma. Metastatic disease frequently affects the vertebral column and may cause compression of the spinal cord by extending into the epidural space or by causing bony destruction and fracture of the vertebral bodies. Patients present with back pain, lower extremity weakness, loss of balance, urinary or bowel incontinence, or complete paralysis of the lower extremities. Early detection and treatment are crucial to prevent permanent spinal cord damage and myelopathy. Patients may benefit from short-term treatment with intravenous dexamethasone to decrease spinal cord edema, although definitive treatment often requires a combination of surgical decompression, chemotherapy, and/or radiotherapy. Incorrect Answers: B, C, D, and E. Myasthenic (Lambert-Eaton) syndrome (Choice B) is characterized by the formation of autoantibodies against presynaptic calcium channels, resulting in the impairment of acetylcholine release at the neuromuscular junction. It presents with progressive proximal muscle weakness that improves with exercise and does not typically present with upper motoneuron signs. Spinal cord infarction (Choice C) may result from occlusion of the anterior or posterior spinal arteries and presents with abrupt onset myelopathy. Neuroimaging may be required to distinguish this entity from compressive spinal cord lesions. This patient's history of subacute onset and weight loss is more suggestive of a compressive epidural malignant lesion. Syringomyelia (Choice D) features a cystic cavity in the central cervical or thoracic spinal cord, which affects midline structures such as the anterior white commissure (decussation of the spinothalamic tracts) and, if large enough, the anterior horns (cell bodies of lower motoneurons). Patients present with deficits in pain and temperature sensation and a potential lower motoneuron pattern of dysfunction in the bilateral upper extremities and torso. The syrinx may progressively expand to affect the lateral corticospinal tract as well, which would result in an upper motoneuron pattern of dysfunction in the lower body. Transverse myelitis (Choice E) refers to inflammation that extends transversely across the spinal cord, leading to bilateral sensory, motor, and/or autonomic dysfunction, often with a clearly identifiable spinal level below which normal function is decreased or absent. It is associated with multiple sclerosis and neuromyelitis optica, the latter of which is associated with the presence of anti-aquaporin-4 antibodies. Educational Objective: Patients with epidural spinal cord compression present with back pain, lower extremity weakness, loss of balance, urinary or bowel incontinence, or complete paralysis of the lower extremities. Metastatic disease is a frequent cause of epidural spinal cord compression..,. r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 5 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 5. A 67-year-old woman comes to the physician because of a 6-month history of buttock and leg pain. The pain occurs when she walks for more than two blocks or stands for more than 10 minutes; sitting or bending forward provides relief within 1 minute. She has not had weakness or loss of sensation. Bladder fun ction has been normal. She has a 20-year history of lower back pain relieved with rest. She has type 2 diabetes mellitus well controlled with metformin. Muscle strength is full. Deep tendon reflexes are 2+ except for absent ankle reflexes. Sensation is intact. There is decreased lumbar lordosis; lumbar flexion is fu ll and extension is limited. Straight-leg raising is negative. Peripheral pulses are intact. Which of the following is the most likely diagnosis? A) Femoropopliteal arterial stenosis B) Lumbar spinal stenosis C) Piriform is syndrome D) Sacroiliac arthritis E) Trochanteric bursitis Correct Answer: B. The patient's symptoms are best explained by lumbar spinal stenosis. Spinal stenosis describes narrowing of the central canal, neural foramen, or lateral recesses of the spine with consequent nerve compression. Common causes include degenerative arthritis, spondyloarthropathies, degenerative disc disease, hypertrophy of the ligamentum flavum, and osteophyte formation in the facet joints. Lower back pain with radiation to the buttocks and lower extremities that results from increased nerve compression is called neurogenic claudication. It is exacerbated by extension of the spine during standing and walking downhill. Lengthening the spinal column with spinal flexion as during sitting, walking uphill, or bending forward tends to relieve the pain. The absence of ankle reflexes suggests involvement of the S 1 nerve root. Incorrect Answers: A, C, D, and E. Femoropopliteal arterial stenosis (Choice A) is a common complication of atherosclerosis and peripheral vascular disease. Patients may present with vascular claudication, which is more commonly provoked by exertion and relieved by rest. Severe stenosis may result in limb ischemia. A bruit may be appreciated over the femoral artery, and peripheral pulses would be diminished in the affected extremity. Piriformis syndrome (Choice C) results from compression of the sciatic nerve as it exits the pelvis. Patients typically present with neuropathic pain in the posterior gluteal region that radiates down the back of the leg. The pain is reproduced by flexion, adduction, and internal rotation of the hip, which tenses the piriformis muscle. A negative straight-leg test is less suggestive of the diagnosis. r ~, ----- -- - --- - -- --- - - - --- -- - - -- - -- - - - - - - - -- --. Sacroiliac arthritis (Choice D) is a common cause of low back pain that radiates down the leg, and may result from prior trauma, - - - - ~ -- - -- ~ --- - -- -- r, - - - -- - -.... Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section : Item 5 of 50 National Board of Medical Examiners Clinical Neurology Self-Assessment Please Walt Mark I ·~ t -. t - C) Piriformis syndrome D) Sacroiliac arthritis E) Trochanteric bu rsitis Correct Answer: B. The patient's symptoms are best explained by lumbar spinal stenosis. Spinal stenosis describes narrowing of the central canal, neural foramen, or lateral recesses of the spine with consequent nerve compression. Common causes include degenerative arthritis, spondyloarthropathies, degenerative disc disease, hypertrophy of the ligamentum flavum, and osteophyte formation in the facet joints. Lower back pain with radiation to the buttocks and lower extremities that results from increased nerve compression is called neurogenic claudication. It is exacerbated by extension of the spine during standing and walking downhill. Lengthening the spinal column with spinal flexion as during sitting, walking uphill, or bending forward tends to relieve the pain. The absence of ankle reflexes suggests involvement of the S 1 nerve root. Incorrect Answers: A, C, D, and E. Femoropopliteal arterial stenosis (Choice A) is a common complication of atherosclerosis and peripheral vascular disease. Patients may present with vascular claudication, which is more commonly provoked by exertion and relieved by rest. Severe stenosis may result in limb ischemia. A bruit may be appreciated over the femoral artery, and peripheral pu lses would be diminished in the affected extremity. Piriformis syndrome (Choice C) results from compression of the sciatic nerve as it exits the pelvis. Patients typically present with neuropathic pain in the posterior gluteal region that radiates down the back of the leg. The pain is reproduced by flexion, adduction, and internal rotation of the hip, which tenses the piriformis muscle. A negative straight-leg test is less suggestive of the diagnosis. Sacroiliac arthritis (Choice D) is a common cause of low back pain that radiates down the leg, and may result from prior trauma, spondyloarthropathy, osteoarthritis, or scoliosis and other spinal deformities. Pain is typically worse when sitting down or walking uphill. Physical examination wou ld show localized tenderness over the sacroiliac joint. Trochanteric bursitis (Choice E) classically presents with lateral! hip pain that is exacerbated by activity. Physical examination shows point tenderness over the greater trochanter and increased pain with external rotation of the hip as a result of compression of the bursa. Educational Objective: Lower extremity pain that is exacerbated by extension of the spinal column and relieved by flexion is suggestive of neurogenic claudication resu lting from lumbar spinal stenosis..,. r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 6 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 6. An otherwise healthy 77-year-old woman comes to the physician because of a 1-month history of severe dizziness. Several times every day she has the sudden onset of a spinning sensation and loss of equilibrium that lasts for 20 to 30 seconds. The episodes beg in most frequently after she rolls over in bed or turns her head to the right. Her pu lse is 76/min, and blood pressure is 140/80 mm Hg. Neurolog ic examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis? A) Positional oculovestibu lar testing B) Tilt table test C) Holter monitoring D) Doppler ultrasonography of the carotid arteries E) EEG F) Electronystagmography G) Magnetic resonance angiography Correct Answer: A. Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo and is best diagnosed with positional oculovestibular testing. BPPV occurs when an otolith becomes dislodged from the utricle and enters the semicircular canals. Changes in head posture then cause the malpositioned otolith to move within the semicircular canals, stimulating abnormal movements in endolymph and causing a sensation of vertigo. Patients typically report symptoms of intense, brief episodes of vertigo that occur after changes in position (such as after rolling over or rising from bed), accompanied by visual disturbances (caused by nystagmus), nausea, and vomiting. Positional oculovestibular testing, such as the Dix-Hallpike test, allows the examiner to reproduce the patient's symptoms by repositioning the otolith. Further positional maneuvers, such as the Epley maneuver, can be used to move the malpositioned otolith to its proper position within the utricle. Patients with refractory symptoms may benefit from medical management including scopolamine or meclizine. Incorrect Answers: B, C, D, E, F, and G. Tilt table testing (Choice B), or tilt testing, is useful for the diagnosis of orthostasis. While orthostasis may cause position-dependent symptoms of vertigo, presyncope, or syncope, these symptoms are more likely to occur upon suddenly standing, rather than while rolling in bed or turning one's head. Holter monitoring (Choice C), or ambulatory ECG monitoring (24-hour), is useful for the diagnosis of cardiac arrhythmia. Cardiac arrhythmia is unlikely to produce paroxysmal symptoms with a positional component that is dependent on rolling in bed or turning one's head..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 6 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment... Correct Answer: A. Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo and is best diagnosed with positional oculovestibular testing. BPPV occurs when an otolith becomes dislodged from the utricle and enters the semicircular canals. Changes in head posture then cause the malpositioned otolith to move within the semicircular canals, stimulating abnormal movements in endolymph and causing a sensation of vertigo. Patients typically report symptoms of intense, brief episodes of vertigo that occur after changes in position (such as after rolling over or rising from bed), accompanied by visual disturbances (caused by nystagmus), nausea, and vomiting. Positional oculovestibular testing, such as the Dix-Hallpike test, allows the examiner to reproduce the patient's symptoms by repositioning the otolith. Further positional maneuvers, such as the Epley maneuver, can be used to move the malpositioned otolith to its proper position within the utricle. Patients with refractory symptoms may benefit from medical management including scopolamine or meclizine. Incorrect Answers: B, C, D, E, F, and G. Tilt table testing (Choice B), or tilt testing, is useful for the diagnosis of orthostasis. While orthostasis may cause position-dependent symptoms of vertigo, presyncope, or syncope, these symptoms are more likely to occur upon suddenly standing, rather than while rolling in bed or turning one's head. Holter monitoring (Choice C), or ambulatory ECG monitoring (24-hour), is useful for the diagnosis of cardiac arrhythmia. Cardiac arrhythmia is unlikely to produce paroxysmal symptoms with a positional component that is dependent on rolling in bed or turning one's head. Doppler ultrasonography of the carotid arteries (Choice D) is useful for the diagnosis of carotid stenosis, which may produce position- dependent symptoms of presyncope or syncope. However, these symptoms would be more likely to occur upon suddenly standing, rather than while rolling in bed or turning one's head. EEG (Choice E) is useful for the diagnosis of epilepsy. This patient's lack of postictal symptoms or other suggestive symptoms, such as premonitory aura, generalized muscle spasms, or loss of bladder or bowel control, render this a less likely diagnosis. Electronystagmography (Choice F) evaluates nystagmus as a method of diagnosing disorders of the vestibular system. While this technique may be indicated for patients with refractory symptoms, it is not necessary for the initial evaluation or treatment of BPPV. Magnetic resonance angiography (Choice G) is useful for the diagnosis of vertebrobasilar insufficiency, which may cause position- dependent symptoms of vertigo. Similar to blood pressure-dependent causes of presyncope, such as orthostasis or carotid stenosis, these symptoms would be expected to occur upon suddenly standing, rather than while rolling in bed or turning one's head. Educational Objective: Benign paroxysmal positional vertigo occurs when an otolith becomes dislodged from the utricle and enters the semicircular canals. Patients report symptoms of intense, brief, position-dependent episodes of vertigo accompanied by visual.... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 6 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment testing. BPPV occurs when an otolith becomes dislodged from the utricle and enters the semicircular canals. Changes in head posture... then cause the malpositioned otolith to move within the semicircular canals, stimulating abnormal movements in endolymph and causing a sensation of vertigo. Patients typically report symptoms of intense, brief episodes of vertigo that occur after changes in position (such as after rolling over or rising from bed), accompanied by visual disturbances (caused by nystagmus), nausea, and vomiting. Positional oculovestibular testing, such as the Dix-Hallpike test, allows the examiner to reproduce the patient's symptoms by repositioning the otolith. Further positional maneuvers, such as the Epley maneuver, can be used to move the malpositioned otolith to its proper position within the utricle. Patients with refractory symptoms may benefit from medical management including scopolamine or meclizine. Incorrect Answers: B, C, D, E, F, and G. Tilt table testing (Choice B), or tilt testing, is useful for the diagnosis of orthostasis. While orthostasis may cause position-dependent symptoms of vertigo, presyncope, or syncope, these symptoms are more likely to occur upon suddenly standing, rather than while rolling in bed or turning one's head. Holter monitoring (Choice C), or ambulatory ECG monitoring (24-hour), is useful for the diagnosis of cardiac arrhythmia. Cardiac arrhythmia is unlikely to produce paroxysmal symptoms with a positional component that is dependent on rolling in bed or turning one's head. Doppler ultrasonography of the carotid arteries (Choice D) is useful for the diagnosis of carotid stenosis, which may produce position- dependent symptoms of presyncope or syncope. However, these symptoms would be more likely to occur upon suddenly standing, rather than while rolling in bed or turning one's head. EEG (Choice E) is useful for the diagnosis of epilepsy. This patient's lack of postictal symptoms or other suggestive symptoms, such as premonitory aura, generalized muscle spasms, or loss of bladder or bowel control, render this a less likely diagnosis. Electronystagmography (Choice F) evaluates nystagmus as a method of diagnosing disorders of the vestibular system. While this technique may be indicated for patients with refractory symptoms, it is not necessary for the initial evaluation or treatment of BPPV. Magnetic resonance angiography (Choice G) is useful for the diagnosis of vertebrobasilar insufficiency, which may cause position- dependent symptoms of vertigo. Similar to blood pressure-dependent causes of presyncope, such as orthostasis or carotid stenosis, these symptoms would be expected to occur upon suddenly standing, rather than while rolling in bed or turning one's head. Educational Objective: Benign paroxysmal positional vertigo occurs when an otolith becomes dislodged from the utricle and enters the semicircular canals. Patients report symptoms of intense, brief, position-dependent episodes of vertigo accompanied by visual disturbances (caused by nystagmus), nausea, and vomiting. Positional oculovestibular testing, such as the Dix-Hallpike test, allow the examiner to reproduce the patient's symptoms by moving the otolith..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 7 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 7. A 35-year-old woman has had constant burni ng pain in her right hand since closing her hand in a car door 1 year ago. Exam ination immediately following the injury showed extensive ecchymosis and swel ling. No fractu res were identified, but the hand was placed in a cast for 1 month. She is unable to tolerate light touch or any motion of the wrist or finger joints during the current exam ination. Wh ich of the following is the most likely explanation for these findings? A) Abnormal sympathetic neural response B) Increased intracarpal canal pressu re C) Median nerve fibrosis D) Post-traumatic arth ritis E) Radial artery th rombosis Correct Answer: A. Abnormal sympathetic neural response, also known as reflex sympathetic dystrophy or complex regional pain syndrome, can potentially occur after traumatic injuries and has a variety of clinical characteristics. Commonly, patients will develop pain out of proportion to the degree of injury in a distinct anatomic location that does not correspond to a single nerve or dermatome. The exact pathophysiology is unknown but is thought to involve either changes in central pain processing or aberrant stimulation of damaged peripheral nerves that release inflammatory substances such as neuropeptide Y and substance P. Common clinical manifestations include pain out of proportion to the injury with severe allodynia, impaired muscle strength in the location of injury, autonomic changes including increased sweating and color or temperature changes, and occasionally atrophy or fibrosis. Incorrect Answers: B, C, D, and E. Increased intracarpal canal pressure (Choice B) leads to carpal tunnel syndrome as a result of compression of the median nerve at the wrist. Symptoms include paresthesias in the palmar aspect of the first two or three digits. Median nerve fibrosis (Choice C) can sometimes occur following a bone fracture with injury to the nerve or after surgical intervention. Symptoms include sensory and motor disturbances in the distribution of the median nerve and depend upon the location at which the median nerve is affected. Post-traumatic arthritis (Choice D) describes joint pain that occurs following a traumatic injury to the articular cartilage of a joint. Like most cases of osteoarthritis, pain is localized to the affected joint and worsens with activity but improves with rest. Temperature changes and sensory changes of the skin are not seen unless the traumatic injury also resulted in trauma to local tissues or nerves. r ~, - Radial artery thrombosis (Choice E) can occur following trauma or instrumentation, as might occur with the placement of a radial artery -- - - - -- -- -- - - - - - -- - - - - - -- - - - - - - - - - -- - - - - - - - - -- - -- ~ ~ -- -- - - -- -- - r, -- - --.... Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 7 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment Please Walt i.., t...., I..., ·.. I I C) Median nerve fibrosis D) Post-traumatic arthritis E) Radial artery th rombosis Correct Answer: A. Abnormal sympathetic neural response, also known as reflex sympathetic dystrophy or complex regional pain syndrome, can potentially occur after traumatic injuries and has a variety of clinical characteristics. Common ly, patients will develop pain out of proportion to the degree of injury in a distinct anatomic location that does not correspond to a single nerve or dermatome. The exact pathophysiology is unknown but is thought to involve either changes in central pain processing or aberrant stimulation of damaged peripheral nerves that release inflammatory substances such as neuropeptide Y and substance P. Common clinical manifestations include pain out of proportion to the injury with severe allodynia, impaired muscle strength in the location of injury, autonomic changes including increased sweating and color or temperature changes, and occasionally atrophy or fibrosis. Incorrect Answers: B, C, D, and E. Increased intracarpal canal pressure (Choice B) leads to carpal tunnel syndrome as a result of compression of the median nerve at the wrist. Symptoms include paresthesias in the palmar aspect of the first two or three digits. Median nerve fibrosis (Choice C) can sometimes occur following a bone fracture with injury to the nerve or after surgical intervention. Symptoms include sensory and motor disturbances in the distribution of the median nerve and depend upon the location at which the median nerve is affected. Post-traumatic arthritis (Choice D) describes joint pain that occurs following a traumatic injury to the articular carti lage of a joint. Like most cases of osteoarthritis, pain is localized to the affected joint and worsens with activity but improves with rest. Temperature changes and sensory changes of the skin are not seen unless the traumatic injury also resulted in trauma to local tissues or nerves. Radial artery thrombosis (Choice E) can occur following trauma or instrumentation, as might occur with the placement of a radial artery catheter. Often, the ulnar artery provides enough collateral blood flow to maintain perfusion to the hand, but in patients where the palmar arch is incomplete, thrombosis can lead to ischemia of the hand. Educational Objective: Reflex sympathetic dystrophy can occur following traumatic injury to a limb and presents with allodynia and color or temperature changes in the area of injury that do not fol low a typical nerve or dermatomal distribution..,. r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 8 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 8. A 25-year-old woman has had generalized weakness for 2 days. On question ing, she reports numerous hospital adm issions for abdom inal pain. One episode occurred after treatment of a urinary tract infection with a su lfonamide. Examination shows global weakness and areflexia; Babinski sign is absent. Sensation to pinprick is mildly decreased in a stocking-glove distribution, and sensation to vibration is decreased over the feet. She has tachycardia that does not slow w ith carotid massage. Which of the following is the most likely diagnosis? A ) Acute intermittent porphyri B) Alcoholic neuropathy C) Charcot-Marie-Tooth disease D) Diabetic radiculopathy E) Guillain-Barre syndrome F) Leprosy G) Paraneoplastic neuropathy Correct Answer: A. Acute intermittent porphyria is the most likely diagnosis in this patient with episodic abdominal pain and peripheral neuropathy in a stocking-glove distribution, which is caused by an autosomal dominant mutation in the porphobilinogen deaminase gene (PBGD). This enzyme catalyzes the third step in heme synthesis, which combines four porphobilinogen (PBG) molecules into hydroxymethylbilane, which is subsequently converted to uroporphyrinogen Ill. Loss of this enzyme leads to the accumulation of PBG, which is toxic to the nervous system. Additionally, increased activity of the upstream enzyme, delta-aminolevulinic acid synthase (ALAS1) leads to accumulation of ALA, which is also toxic. The mutation affects both erythroid cells and hepatocytes. The disease's manifestations are primarily neurologic and include peripheral neuropathy, bladder dysfunction, and autonomic dysfunction. Abdominal pain is classic and results often from ileus. The penetrance is low, so a fami ly history is not often present, which can delay the diagnosis. Disease flares can occur after exposure to certain triggers such as certain medications, tobacco and alcohol, stress, and starvation. Incorrect Answers: B, C, D, E, F, and G. Alcoholic neuropathy (Choice B) presents with a primary sensory neuropathy that starts in the feet and progresses proximally. A history of chronic alcohol intake is requ ired for this diagnosis. Other nutritional deficiencies are often present as well. Charcot-Marie-Tooth disease (Choice C) is a genetic disorder that presents with slowly progressive peripheral neuropathy often in association with foot deformities such as hammertoes and pes cavus. A fami ly history is typical. Diabetic radiculopathy (Choice D) occurs most commonly in patients with recently diagnosed or uncontrolled diabetes mellitus, and is.... r -- - , ~ - -- -- -- - - -- - - -- -- - - -- - - -- - - -- --~- - -- ~-- r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 8 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment... Correct Answer: A. Acute intermittent porphyria is the most likely diagnosis in this patient with episodic abdominal pain and peripheral neuropathy in a stocking-glove distribution, which is caused by an autosomal dominant mutation in the porphobilinogen deaminase gene (PBGD). This enzyme catalyzes the third step in heme synthesis, which combines four porphobilinogen (PBG) molecu les into hydroxymethylbilane, which is subsequently converted to uroporphyrinogen Ill. Loss of this enzyme leads to the accumulation of PBG, which is toxic to the nervous system. Additionally, increased activity of the upstream enzyme, delta-aminolevulinic acid synthase (ALAS1) leads to accumulation of ALA, which is also toxic. The mutation affects both erythroid cells and hepatocytes. The disease's manifestations are primarily neurologic and include peripheral neuropathy, bladder dysfunction, and autonomic dysfunction. Abdominal pain is classic and resu lts often from ileus. The penetrance is low, so a fami ly history is not often present, which can delay the diagnosis. Disease flares can occur after exposure to certain triggers such as certain medications, tobacco and alcohol, stress, and starvation. Incorrect Answers: B, C, D, E, F, and G. Alcoholic neuropathy (Choice B) presents with a primary sensory neuropathy that starts in the feet and progresses proximally. A history of chronic alcohol intake is required for this diagnosis. Other nutritional deficiencies are often present as well. Charcot-Marie-Tooth disease (Choice C) is a genetic disorder that presents with slowly progressive peripheral neuropathy often in association with foot deformities such as hammertoes and pes cavus. A fami ly history is typical. Diabetic radiculopathy (Choice D) occurs most common ly in patients with recently diagnosed or uncontrolled diabetes mellitus, and is most commonly characterized by acute, asymmetric radicu lar symptoms involving the proximal leg. Guil lain-Barre syndrome (Choice E) manifests as rapid ly progressive, ascending weakness and areflexia that often follows a viral or diarrheal illness. It does not affect the arms at the same time as the legs. Patients can develop respiratory insufficiency, which can occasionally require mechanical ventilation. Leprosy (Choice F) is caused by infection with Mycobacterium leprae and is exceedingly rare in the developed world. It presents with characteristic skin findings in conjunction with peripheral sensory neuropathy commonly involving the ulnar, median, radial, or peroneal nerves. Paraneoplastic neuropathy (Choice G) is most commonly a peripheral sensory neuropathy that is related to an underlying systemic malignancy and is often secondary to the production of autoantibodies. This patient has no evidence of cancer. Educational Objective: Acute intermittent porphyria is an autosomal dominant disease with low penetrance caused by deficiencies in the PBGD gene leading to the accumulation of hepatically synthesized heme intermediates, which are toxic to the nervous system. Typical findings include episodic abdominal pain, sensory neuropathy, and autonomic dysfunction that occurs after certain triggers..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 9 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 9. A 62-year-old woman comes to the physician because of a 6-week history of stiffness and pain of her neck, shoulders, and hips. She has difficulty dressing herself and combing her hair in the morn ing. She also has had generalized weakness, malaise, and a low-grade fever. She has had a 2.3-kg (5-lb) weight loss during the past month despite no changes in diet. She has no history of serious illness. Her only med ication is occasional acetaminophen for pain. Vital signs are within normal limits. Exam ination shows pitting edema of the hands and the dorsal aspects of the feet. Range of motion of the neck, shoulders, and hips is limited. Her erythrocyte sedimentation rate is 110 mm/h. Additional laboratory fi ndings, incl uding her serum thyroid-stim ulating hormone concentration, are within the reference ranges. X-rays of the shou lders and feet show no abnormalities. Which of the following is the most likely diagnosis? A) Bursitis B) Dermatomyositis C) Fibromyalgia D) Polymyalgia rheumatica E) Polymyositis F) Rheumatoid arthritis Correct Answer: D. Polymyalgia rheumatica (PMR) is an inflammatory condition in which aching and stiffness develop in the shoulders, hip, and neck. The most common risk factors are age (older than 50 years) and being female. It is also frequently associated with giant cell, or temporal arteritis, which presents with unilateral headache and vision loss, if untreated. Other inflammatory signs, such as malaise and fever, are often present, though localized muscle weakness is not typically seen. Laboratory evaluation demonstrates increased inflammatory markers, including erythrocyte sedimentation rate (ESR) and C-reactive protein, and thrombocytosis. Polymyalgia rheumatica is responsive to glucocorticoids, which are the first-line therapy for the disease. Low-dose prednisone is the treatment of choice. Incorrect Answers: A, B, C, E, and F. Bursitis (Choice A) is inflammation of one or more bursae and is manifested by pain and swelling over a single joint. Some examples include the subacromial bursa which can cause pain in the shoulder, the trochanteric bursa which can cause pain over the lateral aspect of the hip, and the olecranon bursa which can cause pain and swel ling posterior to the elbow. When inflamed or injured, fluid can collect inside the potential space of the bursa causing swelling, which can be appreciated on examination as a fluctuant, tender, circumscribed mass. Muscle stiffness is not a typical feature. Dermatomyositis (Choice B) and polymyositis (Choice E) are autoimmune inflammatory myopathies characterized by muscle weakness, rather than stiffness, of the proximal muscles. Dermatomyositis additionally demonstrates cutaneous findings including a Ii ht ink- or heliotro e-colored rash on the e elids and Gottron a ules on the dorsal fin ers. Previous Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section: Item 9 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment Please Walt... B) Dermatomyositis C) Fibromyalgia D) Polymyalgia rheumatica E) Polymyositis F) Rheumatoid arthritis Correct Answer: D. Polymyalgia rheumatica (PMR) is an inflammatory condition in which aching and stiffness develop in the shoulders, hip, and neck. The most common risk factors are age (older than 50 years) and being female. It is also frequently associated with giant cell, or temporal arteritis, which presents with unilateral headache and vision loss, if untreated. Other inflammatory signs, such as malaise and fever, are often present, though localized muscle weakness is not typically seen. Laboratory evaluation demonstrates increased inflammatory markers, including erythrocyte sedimentation rate (ESR) and C-reactive protein, and thrombocytosis. Polymyalgia rheumatica is responsive to glucocorticoids, which are the first-line therapy for the disease. Low-dose prednisone is the treatment of choice. Incorrect Answers: A, B, C, E, and F. Bursitis (Choice A) is inflammation of one or more bursae and is manifested by pain and swelling over a single joint. Some examples include the subacromial bursa which can cause pain in the shoulder, the trochanteric bursa which can cause pain over the lateral aspect of the hip, and the olecranon bursa which can cause pain and swel ling posterior to the elbow. When inflamed or injured, fluid can collect inside the potential space of the bursa causing swelling, which can be appreciated on examination as a fluctuant, tender, circumscribed mass. Muscle stiffness is not a typical feature. Dermatomyositis (Choice B) and polymyositis (Choice E) are autoimmune inflammatory myopathies characterized by muscle weakness, rather than stiffness, of the proximal muscles. Dermatomyositis additionally demonstrates cutaneous findings including a light pink- or heliotrope-colored rash on the eyelids and Gottron papules on the dorsal fingers. Unlike PMR, fibromyalgia (Choice C) affects middle-aged women at various anatomical sites in conjunction with anxiety, stress, and point tenderness. ESR is normal. This patient's limited involvement to the pelvic and hip girdles along with other inflammatory symptoms including generalized weakness, malaise, and fever suggest a diagnosis of PMR over fibromyalgia. Rheumatoid arthritis (Choice F) is a common autoimmune disease characterized by joint destruction, pain, and upregulation of immunomodulatory cytokines. Muscle pain and stiffness are not typical features. Educational Objective: Polymyalgia rheumatica (PMR) is an inflammatory condition in which aching and stiffness develop in the muscles of the hip and shoulder girdles. Low-dose prednisone is the treatment of choice..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section : Item 10 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment... 'f 10. A 57-year-old woman comes to the physician because of daily headaches for 8 months. The headaches are localized to the right temple and usually worsen throughout the day. At times, the headaches are exacerbated by chewing. She has a history of migraines but has not had one since menopause 6 years ago. She recently divorced and is under a great deal of stress at work. She has smoked one-half pack of cigarettes daily for 25 years. Her temperature is 37°C (98.6°F), pulse is 82/min, and blood pressure is 144/86 mm Hg. Examination shows pain with movement of the jaw and tenderness under the right zygomatic arch. The nasal mucosa is normal. Erythrocyte sedimentation rate is 20 mm/h. Which of the following is the most likely diagnosis? A) Bacterial meningitis B) Cluster headache C) Migraine D) Sinusitis E) Temporal arteritis F) Temporomandibular joint syndrome G) Tension-type headache H) Trigeminal neuralgia Correct Answer: F. The temporomandibu lar joint (TMJ) forms the articulation between the mandibular condyle and the glenoid fossa of the temporal bone. TMJ syndrome occurs because of a combination of structural damage to the TMJ and a variety of neurologic and psychological factors related to pain and stress. Patients usually present with unilateral, dull, occasionally sharp or stabbing pain near the TMJ or anterior to the auricle that is exacerbated by chewing or jaw clenching. Patients may also experience popping or clicking sensations associated with movement of the jaw and a decreased range of jaw motion. Treatment includes physical therapy, cognitive behavior therapy or biofeedback therapy to treat underlying stress, and pharmacologic therapy including nonsteroidal anti-inflammatory drugs or tricyclic antidepressants. Incorrect Answers: A, B, C, D, E, G, and H. Bacterial meningitis (Choice A) presents with fever and signs of meningeal irritation (nausea, irritability, confusion, anorexia, headache, and nuchal rigidity). This patient's absence of fever and meningismus renders this diagnosis unlikely. Cluster headache (Choice B) are primary headaches that typically present with short-lived, unilateral, severe, often lancinating pain in the orbital, supraorbital, or temporal region of the head and are accompanied by ipsilateral autonomic symptoms (eg, lacrimation, mydriasis, perspiration, nasal congestion)..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section : Item 10 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment... Correct Answer: F. The temporomandibu lar joint (TMJ) forms the articulation between the mandibular condyle and the glenoid fossa of the temporal bone. TMJ syndrome occurs because of a combination of structural damage to the TMJ and a variety of neurologic and psychological factors related to pain and stress. Patients usually present with unilateral, dull, occasionally sharp or stabbing pain near the TMJ or anterior to the auricle that is exacerbated by chewing or jaw clenching. Patients may also experience popping or clicking sensations associated with movement of the jaw and a decreased range of jaw motion. Treatment includes physical therapy, cognitive behavior therapy or biofeedback therapy to treat underlying stress, and pharmacologic therapy including nonsteroidal anti-inflammatory drugs or tricyclic antidepressants. Incorrect Answers: A, B, C, D, E, G, and H. Bacterial meningitis (Choice A) presents with fever and signs of meningeal irritation (nausea, irritability, confusion, anorexia, headache, and nuchal rigidity). This patient's absence of fever and meningismus renders this diagnosis unlikely. Cluster headache (Choice B) are primary headaches that typically present with short-lived, unilateral, severe, often lancinating pain in the orbital, supraorbital, or temporal region of the head and are accompanied by ipsilateral autonomic symptoms (eg, lacrimation, mydriasis, perspiration, nasal congestion). Migraines (Choice C) are a common cause of headache in adult patients. They may present with visual aura of scintillating scotoma or fortification spectra but are not associated with focal tenderness of the jaw or pain with chewing. Sinusitis (Choice D) may be associated with bilateral, pressure-like, periorbital headaches and nasal congestion. Patients may experience focal tenderness and tenderness to percussion overlying the affected sinus (typically overlying the brow or maxilla) but rarely experience focal jaw tenderness overlying the TMJ. Temporal arteritis (Choice E), also known as giant cell arteritis, is a vasculitis of medium and large vessels in elderly patients and commonly presents with systemic symptoms, headache, jaw claudication, proximal muscle stiffness, and sudden, irreversible vision loss. This patient's chronic course, lack of associated systemic symptoms, and normal erythrocyte sedimentation rate render this diagnosis less likely. Tension-type headache (Choice G) typically presents with bilateral dull, pressure-like or band-like pain across the bilateral frontal and temporal areas. It does not tend to present with focal tenderness of the jaw or pain with chewing. Trigeminal neuralgia (Choice H), also known as tic douloureux, presents with brief, recurrent, sudden episodes of pain in the distribution of the trigeminal nerve. This is typically triggered by minor stimulation to the affected area, such as light touch, cold air, talking, or brushing one's teeth. Patients often describe the pain as sharp, stabbing, or electric..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section : Item 10 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment Please Walt I I. I I J. i, I I ,, t - J. e · t t e t t t e t e e t with movement of the jaw and a decreased range of jaw motion. Treatment includes physical therapy, cognitive behavior therapy or biofeedback therapy to treat underlying stress, and pharmacologic therapy including nonsteroidal anti-inflammatory drugs or tricyclic antidepressants. Incorrect Answers: A, B, C, D, E, G, and H. Bacterial meningitis (Choice A) presents with fever and signs of meningeal irritation (nausea, irritability, confusion, anorexia, headache, and nuchal rigidity). This patient's absence of fever and meningismus renders this diagnosis unlikely. Cluster headache (Choice B) are primary headaches that typically present with short-lived, unilateral, severe, often lancinating pain in the orbital, supraorbital, or temporal region of the head and are accompanied by ipsilateral autonomic symptoms (eg, lacrimation, mydriasis, perspiration, nasal congestion). Migraines (Choice C) are a common cause of headache in adult patients. They may present with visual aura of scintillating scotoma or fortification spectra but are not associated with focal tenderness of the jaw or pain with chewing. Sinusitis (Choice D) may be associated with bilateral, pressure-like, periorbital headaches and nasal congestion. Patients may experience focal tenderness and tenderness to percussion overlying the affected sinus (typically overlying the brow or maxilla) but rarely experience focal jaw tenderness overlying the TMJ. Temporal arteritis (Choice E), also known as giant cell arteritis, is a vasculitis of medium and large vessels in elderly patients and commonly presents with systemic symptoms, headache, jaw claudication, proximal muscle stiffness, and sudden, irreversible vision loss. This patient's chronic course, lack of associated systemic symptoms, and normal erythrocyte sedimentation rate render this diagnosis less likely. Tension-type headache (Choice G) typically presents with bilateral dull, pressure-like or band-like pain across the bilateral frontal and temporal areas. It does not tend to present with focal tenderness of the jaw or pain with chewing. Trigeminal neuralgia (Choice H), also known as tic douloureux, presents with brief, recurrent, sudden episodes of pain in the distribution of the trigeminal nerve. This is typically triggered by minor stimulation to the affected area, such as light touch, cold air, talking, or brushing one's teeth. Patients often describe the pain as sharp, stabbing, or electric. Educational Objective: Temporomandibular joint syndrome occurs because of a combination of structural damage to the temporomandibular joint and a variety of neurologic and psychological factors related to pain and stress. Patients present with unilateral preauricular pain exacerbated by chewing or jaw clenching, decreased jaw range of motion, and popping or clicking sensations associated with jaw movement. Treatment includes physical therapy, cognitive behavior therapy or biofeedback therapy to treat underlying stress, and pharmacologic therapy including nonsteroidal anti-inflammatory drugs or tricyclic antidepressants..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section : Item 11 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 11. A 42-year-old man comes to the physician with his wife because of a 6-month history of increasing cl umsiness and a 1-month history of irritability. His wife has noticed jerkiness of his limbs when he walks down stairs or walks quickly. During the past month, he has had the same involuntary movements at rest after stressful days at work. He has not had fever, chills, or night sweats. He does not smoke cigarettes, drink alcohol, or use illicit drugs. He goes camping several times yearly. He does not appear to be in distress. Exam ination shows involuntary movements of the right upper extremity, which the patient is able to suppress when made aware of them. His gait is ataxic. Additional testing is most likely to show which of the following abnormalities? A) Atrophy of the caudate nucleus on brain imaging B) Decreased serum methylmalonic acid concentration C) Dilated ventricles on brain imaging D) Increased oligoclonal bands in cerebrospinal fluid E) Increased serum acetylcholine esterase inhibitor concentration F) Positive serum lgM Lyme titer Correct Answer: A. Atrophy of the caudate nucleus on brain imaging would be expected in this patient who most likely has Huntington disease, a progressive neurodegenerative condition that arises from misfolded proteins as the result of a trinucleotide expansion in the Huntington gene. Patients develop choreiform movements, which are characterized by involuntary flailing motions of the upper extremities. Eventually, these motor disturbances and others, including ataxic gait, greatly interfere with daily life. Concomitant psychiatric disturbances such as emotional !ability, anxiety, depression, and psychosis may also occur in the later stages of the disease. Many patients exhibit a family history of similar symptoms, but the disease can also arise de novo. Since this is an autosomal dominant disease, there is a 50% chance that an affected individual will pass it on to offspring. Anticipation, whereby symptoms manifest at progressively earlier ages and/or more severely in subsequent generations, is also typical of this disease. Incorrect Answers: B, C, D, E, and F. Decreased serum methylmalonic acid (MMA) concentration (Choice B) is not correct. High concentrations of MMA are seen in vitamin B 12 (cobalamin) deficiency, which can lead to subacute combined degeneration of the spine. Dilated ventricles on brain imaging (Choice C) are seen in patients with hydrocephalus, which can either be communicating or noncommunicating. Patients can present with headaches, nausea, vomiting, or gait instability but would not typically exhibit choreiform movements.......... - -..... -.- -... Previous Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section : Item 11 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment..... J..... D) Increased oligoclonal bands in cerebrospinal fluid E) Increased serum acetylcholine esterase inhibitor concentration F) Positive serum lgM Lyme titer Correct Answer: A. Atrophy of the caudate nucleus on brain imaging would be expected in this patient who most likely has Huntington disease, a progressive neurodegenerative condition that arises from misfolded proteins as the result of a trinucleotide expansion in the Huntington gene. Patients develop choreiform movements, which are characterized by involuntary flai ling motions of the upper extremities. Eventually, these motor disturbances and others, including ataxic gait, greatly interfere with daily life. Concomitant psychiatric disturbances such as emotional !ability, anxiety, depression, and psychosis may also occur in the later stages of the disease. Many patients exhibit a fami ly history of similar symptoms, but the disease can also arise de novo. Since this is an autosomal dominant disease, there is a 50% chance that an affected individual wil l pass it on to offspring. Anticipation, whereby symptoms manifest at progressively earlier ages and/or more severely in subsequent generations, is also typical of this disease. Incorrect Answers: B, C, D, E, and F. Decreased serum methylmalonic acid (MMA) concentration (Choice B) is not correct. High concentrations of MMA are seen in vitamin B 12 (cobalamin) deficiency, which can lead to subacute combined degeneration of the spine. Di lated ventricles on brain imaging (Choice C) are seen in patients with hydrocephalus, which can either be communicating or noncommunicating. Patients can present with headaches, nausea, vomiting, or gait instability but would not typical ly exhibit choreiform movements. Increased oligoclonal bands in cerebrospinal fluid (Choice D) is characteristic of multiple sclerosis (MS). Patients can develop a variety of sensory and motor symptoms but characteristical ly present with internuclear ophthalmoplegia. They do not exhibit choreiform movements. Increased serum acetylcholine esterase inhibitor concentration (Choice E) is seen in patients with organophosphate poisoning. Cholinergic toxicity presents with excess salivation, bradycardia, emesis, and central nervous system depression. Positive serum lgM Lyme titer (Choice F) can be seen in acute Lyme disease, which presents with erythema migrans following a tick bite. Late neurologic manifestations of Lyme disease include cranial nerve palsies, but choreiform movements would not be expected. Educational Objective: Huntington disease presents with progressive neurodegeneration leading to choreiform movement, ataxia, and neuropsychiatric decline. On MRI, the caudate nucleus often appears atrophic..... r ~, ~ ~ r, Previous Next Score Report https://t.me/USMLENBME2CK Lab Values Calculator Help Pause Exam Section : Item 12 of 50 National Board of Medical Examiners Mark Clinical Neurology Self-Assessment 12. A previously healthy 82-year-old man is brought to the emergency department because of a 3-hour history of difficulty communicating. His wife reports that when he awoke this morn ing, he seemed slightly confused and "d id not make sense." He has hyperlipidemia treated with simvastatin. He does not appear