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Category: Medicine--->Neurology
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Question 1# Print Question

A 30-year-old man complains of unilateral headaches. He was diagnosed with migraine headaches at age 24. The headaches did not respond to triptan therapy at that time, but after 6 weeks the headaches resolved. He has had three or four spells of severe headaches since then. Currently his headaches have been present for the past 2 weeks. The headaches start with a stabbing pain just below the right eye. Usually the affected eye feels “irritated” (reddened with increased lacrimation). He saw an optometrist during one of the episodes and a miotic pupil was noted. Each pain lasts from 60 to 90 minutes, but he may have several discrete episodes each day. The neurological examination, including cranial nerve examination, is now normal.

What is your best approach to treatment at this time? 

A. Prescribe oral sumatriptan for use at the onset of headache
B. Prednisone 60 mg daily for 2 to 4 weeks
C. Obtain MRI scan of the head with gadolinium contrast
D. Begin propranolol 20 mg bid
E. Refer for neuropsychiatric testing

Question 2# Print Question

A 47-year-old dentist consults you because of tremor, which is interfering with his work. The tremor has come on gradually over the past several years and seems more prominent after the ingestion of caffeine; he notices that, in the evening after work, an alcoholic beverage will decrease the tremor. No one in his family has a similar tremor. He is otherwise healthy and takes no medications. On examination his vital signs are normal. Except for the tremor, his neurological examination is normal; in particular there is no focal weakness, rigidity, or bradykinesia. When he holds out his arms and extends his fingers, you detect a rapid fine tremor of both hands; the tremor goes away when he rests his arms at his side.

What is the best next step in the management of this patient?

A. MRI scan to visualize the basal ganglia
B. Electromyogram and nerve conduction studies to more fully characterize the tremor
C. Therapeutic trial of propranolol
D. Therapeutic trial of primidone
E. Neurology referral to rule out motor neuron disease

Question 3# Print Question

A 35-year-old previously healthy woman suddenly develops a severe headache while lifting weights. A minute later she has transient loss of consciousness. She awakes with vomiting and a continued headache. She describes the headache as “the worst headache of my life.” She appears uncomfortable and vomits during your physical examination. Blood pressure is 140/85, pulse rate is 100/minute, respirations are 18/minute, and temperature is 36.8°C (98.2°F). There is neck stiffness. Physical examination, including careful cranial nerve and deep tendon reflex testing, is otherwise normal.

Which of the following is the best next step in evaluation? 

A. CT scan without contrast
B. CT scan with contrast
C. Cerebral angiogram
D. Holter monitor
E. Lumbar puncture

Question 4# Print Question

A 58-year-old man complains of the sudden onset of syncope. It occurs without warning and with no sweating, dizziness, or light-headedness. He believes episodes tend to occur when he turns his head too quickly or sometimes when he is shaving. Physical examination is unremarkable. He has no carotid bruits, and cardiac examination is normal.

Which of the following is the best way to make a definitive diagnosis in this patient? 

B. Carotid massage with ECG monitoring
C. Holter monitor
D. Electrophysiologic study to evaluate the AV node
E. Carotid duplex ultrasonogram

Question 5# Print Question

An 82-year-old woman is evaluated for progressive dementia. She is on no medications; the family has not noticed urinary incontinence or seizure activity. Her MMSE score is 21 out of 30; she has no focal weakness or reflex asymmetry on physical examination. MR scan shows a 2.4-cm partly calcified, densely enhancing mass near the falx (shown below). There is no surrounding edema or mass effect. 

What is the best approach to this patient’s management?

A. Neurosurgical resection of the mass
B. Radiation therapy to the mass
C. Serial CT scans and cholinergic treatment for the dementia if indicated
D. Ventriculoperitoneal shunting
E. Phenytoin and watchful waiting

Category: Medicine--->Neurology
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