QCM/DES/USMLE/NEUROLOGY

1. A 54-year-old woman presents to your office complaining of difficulty walking. She describes severe weakness and occasional pain in her thigh muscles. She has stumbled and fallen several times over the last week. Her past medical history is significant for hypertension treated with hydrochlorothiazide and metoprolol. She consumes two to three cans of beer on weekends. Her younger brother died of a neurological disease when he was 20 years old. Her mother suffers from hypertension and diabetes mellitus. Her heart rate is 90/min and blood pressure is 170/100 mmHg. Chest examination is within normal limits. A bruit is heard over the left carotid artery. Neurologic examination reveals hyporeflexia and decreased strength in all muscle groups. Her ESR is 12 mm/hr. ECG shows flat and broad T waves with occasional premature ventricular contractions. Which of the following is the most likely cause of this patient's current complaints?

2. A 34-year-old Mexican male comes to the emergency department and complains of severe episodic headache, especially at night, for the past month. He also complains of unilateral, sharp, stabbing pain in the eye, which wakes him from sleep. The pain often starts suddenly just behind the right eye, and spreads to his face and temple region. It is not associated with nausea or visual disturbances, but is associated with watering of the eyes and nose, and with red eye. He had a similar episode one year ago, and it lasted for 2 months. Which of the following is the best treatment regimen for aborting the patient's pain during an acute attack

3. A 27-year-old man complains of difficulty in walking. He noticed leg weakness several days ago, and now he is barely able to walk. He also complains of mild back pain and foot numbness. Two weeks ago, he had an upper respiratory tract infection. Physical examination reveals lower extremity muscle weakness, absent knee and ankle reflexes, and minimal sensory loss. Spinal MRI shows no abnormalities. Which of the following findings would you expect on CSF analysis in this patient? (Protein, WBC, count RBC, count Glucose)

4. A 21-year-old female comes to the office for the evaluation of fatigue and weakness. She first noticed these symptoms nine months ago. She says, "I can't exercise a lot anymore because I get fatigued very easily, but after resting for a while, I feel better, and my fatigue disappears." She then describes a recent episode of weakness while swimming in a pool, where she experienced double vision (especially when she did not look straight ahead), difficulty raising her eyelids, and swallowing problems. What is the most likely diagnosis?

6. A 27-year-old woman presents to the ER with severe vomiting and abdominal pain that started several hours ago. She describes her emesis as "yellowish." She has a history of alcohol and cocaine use. Her temperature is 36.7C (98F), pulse is 98/min, respirations are 16/min, and blood pressure is 140/86 mmHg. Physical examination reveals dryness of the oral mucosa. Her abdomen is soft, nondistended, and without hepatosplenomegaly. Mild epigastric tenderness is present on deep palpation. Bowel sounds are increased. No rebound or rigidity is noted. She is treated with intravenous normal saline and metoclopramide. Several hours later she complains of neck pain and her neck muscles are noted to be stiff and tender. Which of the following best explains this patient's current complaints?

7. A 63-year-old man presents to the emergency department with a 6-hour history of slurred speech and right hand weakness. His past medical history is significant for chronic hypertension and a myocardial infarction 2 years ago. His current medications include enalapril and aspirin. He smokes 2 packs of cigarettes daily and consumes alcohol occasionally. His blood pressure is 165/95 mmHg, pulse is 80/min, and respirations are 14/min. Physical examination reveals right hand weakness and mild motor aphasia without sensory abnormalities Which of the following is the most probable cause of this patient's condition?

8. A 73-year-old Caucasian man is brought to the office by his daughter, who is concerned that he might be depressed. He is a retired surgeon, and has lived alone ever since his wife died a year ago. His daughter visits him every 6 months; she feels bad about not being able to visit him more frequently because her job and family keep her very busy. He denies having any feelings of sadness, guilt, weight loss, loss of appetite, suicidal ideation, deafness, vertigo, and decreased or blurred vision. His medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10 years ago. His current medications are glyburide, aspirin and enalapril. He denies the use of tobacco, alcohol, or drugs. His vital signs are within normal limits. He appears withdrawn, less energetic than usual, and walks stiffly. He sits with a stooped posture. He has a fixed facial expression, and his voice sounds monotonous. His deep tendon reflexes are 2+. Sensations and motor strength are normal. There is increased resistance to passive flexion. Which of the following types of gait is most likely to be present in this patient?

9. A 50-year-old male patient comes to the office because he is concerned about the marked tremors of his hands. His tremors disappear with voluntary activity and worsen with emotional stress. He finds it mild difficult to initiate movements. He does not have a family history of tremors. Physical examination reveals tremors that occur at a frequency of 3-4 cycles/sec. There is rigidity of his limb musculature. His gait and posture is minimally disturbed. His higher mental functions are intact. Which of the following is the most appropriate treatment for this patient?

10. A 55-year-old Caucasian male comes to the office because of numerous falls for the past few weeks. Yesterday, he felt so dizzy that he fell on the ground and hurt his knees. He has also noticed dry mouth, dry skin, and erectile dysfunction over this period. His past medical history is significant for the recent onset of resting tremors. He was diagnosed with diabetes six months ago, which is controlled with diet. His blood pressure is 120/80 mmHg supine, and 90/60 mmHg standing. Physical examination reveals rigidity and bradykinesia. What is the most likely diagnosis of this patient?

11. A 65-year-old, obese, white female comes to the office for the evaluation of her progressively worsening memory. She considers herself "very independent," and lives alone; however, the development of her new symptoms is causing her some distress, as she often forgets to pay her bills. A detailed review of systems reveals no other symptoms, except for mild urinary incontinence. She has hypertension controlled with a beta-blocker and type 2 diabetes mellitus controlled with diet. She does not use tobacco, alcohol or drugs. Her blood pressure is 130/90 mmHg, pulse is 72/min, temperature is 36.7C (98F) and respirations are 14/min. Lungs are clear to auscultation and percussion. A grade 2/6, systolic ejection murmur is heard. Abdominal examination shows no tenderness or masses. Neurological examination shows broad-based, shuffling gait and a right-sided carotid bruit. Complete blood count and serum chemistry panel are within normal limits MRI shows enlarged ventricles. What is the most likely diagnosis?

12. A 67-year-old male presents with a six-month history of rigidity, gait problems, tremor and slowness of movements. His condition has progressively worsened over the last few months, and he is now unable to perform his routine daily activities due to the slowness of his movements. He is not taking any medications. On examination, he is alert and conscious. His face is without expression. There is a resting tremor of his hands. He has a stooped posture and shuffling gate. There is rigidity of his limb muscles. Which of the following is the most appropriate initial treatment for this patient?

13. A 58-year-old woman presents to the emergency department with severe headache and agitation. She describes her pain as right-sided and retro-orbital, and also reports blurred vision, constipation, and vomiting. Her medical history is significant for Parkinson's disease, hypothyroidism, hypertension and chronic hepatitis C. Work-up reveals that her current condition is medication-induced. Which of the following agents is most likely responsible

14. A 37-year-old white female with myasthenia gravis presents to the office with a fever and cough productive of yellow-green sputum. She has been on pyridostigmine for the past few months. She refuses to have a thymectomy. Her pulse is 90/min, blood pressure is 120/76 mm Hg, respirations are 18/min, and temperature is 38.9C (102F). Her respiratory effort is weak. Pulse oximetry reveals 86% oxygen saturation on room air. There is a consistent decline on serial measurement of vital capacity. Which of the following is the most appropriate next step in management?

17. A 12-year-old boy is brought to the clinic for a routine health maintenance exam. He has no complaints, but mentions some spots on his back, which he noticed during his physical education class. He does not know how long they have been there. He denies any allergies. He remembers having a few seizures some years ago, which have not recurred since. He does not take any medication. The physical examination reveals several white spots and nodules measuring 2x3 cm on his back. There are freckles on his face and axilla. Closer examination reveals some nodules on his iris. What is the concerning complication that this boy is prone to?

18. A 25-year-old woman comes to the office and complains of intermittent dizziness and an unsteady gait for the last few days. Her symptoms worsen with exercise. Her past medical history is significant for tingling and numbness of her right foot that lasted 3-4 days (1 year ago), and visual loss in her right eye which spontaneously resolved (3 years ago). She is currently nursing her 2-month-old baby. Her obstetrical history was uncomplicated. Her neurological examination shows right hyperactive deep tendon reflexes. On attempted left gaze, her left eye abducts and exhibits horizontal jerk nystagmus, but her right eye remains stationary. When she attempts to look to the right, her right eye abducts and exhibits horizontal jerk nystagmus, but her left eye remains stationary. The patient is able to converge both eyes together, without any associated nystagmus. The facial muscles show no signs of weakness. Where is the most likely site of this patient's lesion?

15. A 27-year-old man complains of poor appetite, loss of interest in his daily activities, and impaired sleep. He has lost 10 pounds over the last two months. He says that he feels regretful about IV drug abuse in his past, but denies having suicidal or homicidal thoughts. He drinks alcohol occasionally but denies regular alcohol consumption or early morning drinking. He is sexually active with one partner and she uses oral contraceptives. On physical examination, his pulse is 76/min and his blood pressure is 110/70 mm Hg. His heart and lung exams are unremarkable and his abdomen is soft and non-tender. The liver span is 9 cm and the spleen is not palpable. He is fully oriented to person, place and time but performs poorly on memory tests. Which of the following is the best next step in managing this patient?

16. A 23-year-old white man is brought to the emergency department (ED) by an ambulance due to an epileptic seizure. He fell on the sidewalk while going home from a pub, where he had two beers. A witness noted tonic-clonic movements of all four extremities for about one minute. This seizure was his first episode, and lasted 30 minutes. In the ED, he is in a state of partial confusion and disoriented to time, place and person. The physical examination does not reveal any focal neurologic pathology. His eye exam does not show any papilledema. His airway is secured, and his breathing is normal. CBC, serum electrolytes, EKG and chest x-ray are normal. Urine toxicology screen is ordered, and lorazepam is given. What is the most appropriate next step in the management of this patient?

19. A 65-year-old woman complains of periodic headaches in the temporal region, visual disturbances, and neck stiffness. Treatment is initiated early and biopsy of a scalp artery is consistent with arteritis. Two months later, the patient presents to your office with weakness. She says that her headaches are gone but she has difficulty climbing stairs and getting up from a chair. Her serum CK level and ESR are normal. Which of the following is the most likely cause of this patient's current complaints?

20. A 60-year-old male complains of recent onset gait imbalance and visual illusion of to-and-fro environmental motion. The symptoms are constant. He has no associated nausea or vomiting. His past medical history includes diabetes, hypertension, and chronic renal failure, and recent enterococcal endocarditis for which he is taking ampicillin and gentamicin. On physical examination, his temperature is 36.7C (98.F), blood pressure is 120/76 mm Hg, pulse is 80/min, and respirations are 16/min. Neurologic examination shows 5/5 power and 2+ reflexes in all four extremities. Cranial nerve examination is normal. There is no nystagmus. Which of the following is the most likely cause of his current condition?

21. A 35-year-old bank executive is brought to the emergency department after the sudden onset of a severe (10/10) headache, followed by a brief period of unconsciousness. His headache started while he was at a meeting and shortly thereafter, he vomited and lost consciousness. He regained consciousness soon afterwards, but was quite confused and irritable. His blood pressure is 160/100 mm Hg, pulse is 90/min, temperature is 37.2C(99F), and respirations are 16/min. The physical examination reveals a normal pupil size, no congestion or inflammation of the eye, and no focal neurological deficits. The ECG reveals nonspecific ST and T wave changes. The CT scan shows a subarachnoid hemorrhage. What is the most likely expected electrolyte abnormality with the patient's disease?

22. A 63-year-old accountant is brought to the emergency department after suddenly collapsing at his desk at work. He is unconscious upon arrival but regains consciousness within several minutes. His medical history is significant for stable angina, hypertension, and hypercholesterolemia. He has had no surgeries. His medications include atenolol, simvastatin, aspirin, and a multivitamin. Physical examination is remarkable for paralysis of the upper and lower extremities on the right side. Vibration and position sense are absent on the right side. When the flat of the right foot is stroked with a pen, the right great toe is up going and the other toes fan out. The patient's tongue deviates to the left upon protrusion. Given these findings, a lesion in which region of the brain is most likely?

23. A 60-year-old white male is brought to the physician's office for the evaluation of worsening confusion and memory loss for the past three weeks. His other complaints are muscle twitching and gait problems. He denies any fever, headache or urinary problems. He does not drink nor smoke. His pulse is 82/min, blood pressure is 130/76 mm Hg, and temperature is 37.1C (98.7F). He displays poor grooming and is disoriented. The pertinent physical findings are nystagmus and positive extensor plantar response bilaterally. The laboratory studies are as follows: Hematocrit 40% WBC 6,000/microl Platelets 160,000/microl A non-contrast head CT scan is normal. The EEG shows periodic sharp waves. What is the most likely diagnosis of this patient?

24. A 70-year-old retired engineer is brought to the office by his son for a routine check-up. He believes that his son is too greedy and wants all his property. He is accusing his son of "kicking him out of the house to get all of his property." He has been getting more forgetful over the past few years. His younger sibling has the same problem. He has no significant past medical history, except a history of smoking for 6 years when he was young. His blood pressure is 138/78 mm Hg, pulse is 86/min, respirations are 14/min and temperature is 37.0 C (98.6F). He cannot remember current events, such as the name of the current American president; however, he can still remember past political history. He is unable to concentrate, but is oriented to time, place and person. The neurological examination is nonfocal. CT scan reveals mild generalized atrophy. His HIV and RPR tests are negative. The serum electrolytes and thyroid function tests are normal. What is the most likely diagnosis of this patient?

25. A 54-year-old man comes to your office complaining of recurrent headaches. While observing his gait as part of your neurologic examination, you notice that he very prominently flexes his right hip and knee and his right foot slaps to the floor with each step. Which of the following is the most likely cause of this gait abnormality?

26. A 33-year-old female presents to the office for the evaluation of a one-week history of lightning-like pain on the left side of her face. The pain is very sharp and feels like a burn. An episode lasts for 10 seconds, occurs 10-20 times a day, and keeps her from sleeping, eating, or working. She denies any history of trauma; medication use or recent surgery Vital signs are within normal limits. What is the most likely diagnosis?

27. A 68-year-old white male comes to the emergency department due to a sudden onset of right-sided hemiplegia, headache and impaired consciousness. There is no prior history of transient ischemic attacks. His medical problems include hypertension, obesity, hypercholesterolemia, tobacco abuse, benign essential tremor, gout, and benign prostatic hyperplasia. His medications include amlodipine, simvastatin, colchicine, propranolol, and doxazosin. The neurological exam shows right-sided weakness and hemi-sensory loss. There is a carotid bruit on his left side. Which of the following is the most appropriate next step in management?

28. A 54-year-old female complains of muscle weakness. She describes difficulty getting up from a chair and combing her hair. She does not use tobacco, alcohol or drugs. She takes no medication. Her vital signs are within normal limits. Physical examination reveals bilateral ptosis. Which of the following is the most likely cause of this patient's complaints?

29. A 56-year-old male complains of occasional dizziness. He gets a brief spinning sensation while getting out of bed. He sometimes feels dizzy while turning in bed or looking up. He denies any nausea, diaphoresis, chest pain or tinnitus. His past medical history is significant for long-standing hypertension, which is being treated with hydrochlorothiazide, and hyperlipidemia, which is being treated with simvastatin. His father died of a stroke at the age of 62 years. His blood pressure is 130/80 mmHg while supine, and 135/85 mmHg while standing. His heart rate is 77/min. A grade IINI ejection murmur is heard over the aortic area. ECG reveals left ventricular hypertrophy and premature ventricular contractions. Which of the following is the most likely cause of this patient's complaints?

30. A 67-year-old male comes to the office for a routine physical exam. He retired this year and wants "a clean bill of health." He has no complaints. He stopped smoking 10 years ago, but smoked for 40 years prior to that. He only takes a "water pill" for hypertension. His vital signs are normal. The physical examination reveals a bruit in his neck. His chest x-ray, EKG, and blood work have normal results. Duplex ultrasonography of his neck reveals a 70% irregular lesion at the right common carotid artery bifurcation. The left common carotid artery has a 40% lesion. What is the best next step in the management of this patient?

31. A middle-aged woman is found wandering the streets with an abnormal gait. Police officers bring her to the hospital. She mumbles when asked for her name and age. She is not oriented to time or place. Her blood pressure is 160/100 mmHg and her heart rate is 100/min. She is afebrile. Mucous membranes are moist and the pupils are dilated and reactive to light. She moves all of her extremities, and her deep tendon reflexes are symmetric. Which of the following is the best initial treatment for this patient?

32. A 72-year-old woman complains of difficulty "finding the right word" when she is speaking. Her daughter notes that she also frequently complains that her neighbor is stealing her newspapers when this is not the case in actuality. Recently, the patient has been having difficulty balancing her checkbook as well. On physical examination, her blood pressure is 160/100 mmHg and her heart rate is 90/min. The exam is otherwise unremarkable. Over the course of the next three years, the patient develops a severe memory deficit, and suffers from poor sleep, slowness of movement, shuffling gait and urinary incontinence. Which of the following is the most likely diagnosis?

33. A 32-year-old man presents to your office with blurred vision in his right eye. He denies any pain, ocular discharge, or gritting sensation. Physical examination findings include anisocoria, right-sided ciliary injection, mild ptosis, and impaired right eye adduction. Fluorescein examination reveals a large geographic corneal staining defect. Dysfunction of which of the following nerves is most likely responsible for this patient's impaired corneal sensation?

34. A 61-year-old Caucasian male presents with ptosis, diplopia and limb weakness. These symptoms worsen in the evening and with exercise, and improve with rest. He also has fatigue, which is worse in the evening. He denies any tingling or numbness. On examination, he cannot sustain an upward gaze, and his eyelids tend to drift downward. Injection of edrophonium quickly restores power, and allows him to maintain an upward gaze. Which of the following is the best initial treatment for this patient?

35. A 7-year-old boy is brought to the office by his mother because, "he is always daydreaming." Sometimes, he stares for a few seconds and rolls his eyes for unknown reasons. His teacher has noted a recent decline in his school performance. He has no family history of any seizure disorder, and his psychomotor development is normal. His neurological examination is unremarkable. EEG during hyperventilation shows generalized, symmetrical 3-Hz spike-and-wave activity on a normal background. Which of the following medications is the most appropriate to treat the boy's disorder?

37. A 76-year-old male with a history of mild dementia, hypertension and diabetes mellitus is brought to the emergency department by his daughter because of two days of confusion, disorientation and decreased oral intake. She says that he has been talking to people who are not there and wandering around the house in the middle of the night. His current medications are metoprolol, valsartan and metformin. On physical examination, his blood pressure is 100/60 mmHg and his heart rate is 70/min. Which of the following initial evaluations is most important for this patient?

39. A 40-year-old man is brought to the emergency room because of altered mental status and gait instability. He has had two falls in the last two days. He drinks one pint of vodka daily and smokes one pack of cigarettes daily. His temperature is 35.0 C (95.0 F), blood pressure is 100/70 mm Hg, pulse is 90/min, and respirations are 14/min. He is disoriented, but not in acute distress. You note prominent horizontal nystagmus and conjugate gaze palsy in both eyes and absent ankle reflexes in both legs. His chest is clear to auscultation. Which of the following is the most likely cause of his symptoms?

40. A 16-year-old boy is recommended for admission to the neurology department for rapidly deteriorating clinical symptoms. He is a college student, living in a dormitory. During past week, he was sick. He did not recover fully and during last 3 days, his condition deteriorated. He started to have high fever, terrible headaches. His roommate said he talked about "some foolish happenings" during his high fever, and did not remember what he said later. This morning, he vomited repeatedly and his condition deteriorated rapidly. You examined him and found: febrile man in acute distress with cyanotic pallor, petechiae on his trunk and legs, purpura on his back bilaterally, with cold extremities. He is still alert, but has clammy skin, rapid pulse and labored respiration. His meningeal signs are positive. You diagnose this patient with meningococcal meningitis with systemic progression and you fear that he can develop the Waterhouse-Friderichsen syndrome. What characterizes this syndrome?

41. A 67-year-old Caucasian female presents to your office three weeks after having an ischemic stroke. She complains of transient pain in the right upper and lower limbs that can be induced even by light touch. Her past medical history is significant for hypertension and diabetes mellitus, type 2. Her current medications include enalapril, amlodipine, aspirin, and glyburide. She has right hemianesthesia due to the stroke and mild athetosis of the right hand. The strength is preserved in all four extremities. Hypersensitivity to all kinds of stimuli that induce severe pain reaction is present over the right extremities. Which of the following is the most probable location of the stroke experienced by this patient three weeks ago?

42. A 43-year-old man is being evaluated for one month of blurred vision, frontal headaches and occasional falls. He reports that the blurry vision is worse when he leans forward. He relates his symptoms to a recent break-up with his girlfriend. On physical examination, his blood pressure is 160/100 mmHg and his heart rate is 60/min. Which of the following is most likely responsible?

43. A 43-year-old man presents to your office complaining of periodic involuntary head turning and head fixation to the right side. Physical examination reveals a hypertrophied right sternocleidomastoid muscle. What is the most likely diagnosis?

44. A 57-year-old man presents to the emergency department complaining of right arm weakness. He says that he first noticed the weakness two hours ago when he was unable to grip a pen. He is now unable to shake hands and walks with a mild limp. His past medical history is significant for hypertension, diabetes mellitus, and mild headaches over the past several days. He does not smoke or consume alcohol. His blood pressure is 180/100 mmHg, heart rate is 80/min and regular. There is mild asymmetry of the lower face, decreased muscle strength in the right arm, and an extensor plantar reflex on the right side. Sensory examination is normal. Blood glucose level is 210mg/dL. ECG shows sinus rhythm with occasional ventricular premature beats. His urine is negative for ketones and protein. Non-contrast CT scan of the head does not reveal any abnormalities. Which of the following is the most likely cause of this patient's symptoms?

45. A 32-year-old Caucasian male comes to the emergency department due to progressive ascending paralysis, which began 18 hours ago. He initially noticed paresthesias in his lower limbs, followed by a sense of fatigue and weakness. He denies any history of headache, fever, and recent infection or illness. His blood pressure is 120/80 mm Hg, pulse is 80/min, respirations are 16/min, and temperature is 37.3C (99.2F). The physical examination reveals intact cranial nerves, absent deep tendon reflexes, and a normal sensory exam. Laboratory studies reveal a normal WBC count. No abnormalities are noted on CSF examination. While evaluating the patient in the hospital, he quickly deteriorates. What is the most appropriate next step in the management of this patient?

46. A 30-year-old, HIV-positive male, presents with left-sided paralysis of recent onset. His temperature is 37.1 C (98.9F), pulse is 78/min, blood pressure is 130/80, and respirations are 16/min. The neurological examination reveals loss of recent memory, expressive aphasia, hyperreflexia, hypertonia, and up going plantars on the left side. His current medications include zidovudine, didanosine, indinavir and trimethoprim-sulfamethoxazole. His CD4 count is 70/dl and viral load is 90,000 copies/ml by PCR. The serology is positive for Toxoplasma. CT scan shows multiple, hypodense, non-enhancing lesions with no mass effect in the cerebral white matter. What is the most likely diagnosis?

47. A 19-year-old man is brought in to the emergency department after being stabbed in the back. He has no past medical history and takes no medications. Muscle strength is absent and tone is decreased in the right leg. The right patellar and Achilles reflexes are absent. Babinski sign is present on the right. There is a loss of vibratory sense and toe joint position on the right. There is a loss of pain and temperature sensation below T12 on the left. Which of the following will cause a loss of pain and temperature sensation on the left side, beginning at T12?

48. A 64-year-old Caucasian male presents to your office because he has had two falls within the last month. He states that he loses his balance when he tries to turn or stop suddenly while walking. Recently, he says, it has been taking him quite a while to get himself out of bed. He also complains of hand tremors that started last year in his left hand, but that now have been affecting both hands. Which of the following is the best tool to confirm his diagnosis?

49. A 36-year-old Caucasian male is brought to the emergency department due to weakness of his upper and lower extremities. Neurological examination reveals weakness, atrophy, fasciculations, spasticity and hyperreflexia of the involved muscles. His sensory, bowel, bladder and cognitive functions are intact. Serum creatine kinase is normal. Cerebrospinal fluid examination is within normal limits. Electromyography shows chronic partial denervation. The patient is subsequently diagnosed with amyotrophic lateral sclerosis. Which of the following has been approved for use in patients with amyotrophic lateral sclerosis?

50. A 69-year-old patient is brought to the office by his daughter because his behavior changed progressively for the past several months. He roams in the apartment at night, and forgets his grandchildren's names. Three days ago, he was found by the doorman urinating by the building's gates. His wife died three years ago. He insists that there is nothing wrong with him, and tries to give excuses for what his daughter is reporting. He does not feel particularly fatigued and has a good appetite. He does not smoke, has no history of alcohol abuse, and no history of diabetes. His blood pressure is 155/85 mm Hg, pulse is 90 /min, and respirations are 15/min. Although the neurologic exam was difficult to assess, there were no abnormalities found. The Babinski sign is negative bilaterally. There is no evidence of rectal or bladder incontinence. The mini-mental state examination (MMSE) score is 15/30 (normal > 24). The laboratory studies show: Hb 13.5 g/dl RBC 4.5 million/mm3 Hct 45% Leukocyte count 4,500/mm3 Platelet count 230,000/mm3 MCV 83 um3 MCHC 32% Hb/cell S. calcium 9.0 mg/dl S. sodium 137 mEq/dL S. potassium 4.0 mEq/dL S. creatinine 1.1 mg/dl S. glucose 100 mg/dl TSH 3 uU/mL Total cholesterol 180 mg/dl CT scan is done. Which of the following abnormalities would you expect to see on the CT scan?

51. A 64-year-old woman presents to your office after falling in the grocery store earlier today. She says she was doing her usual shopping when she felt weak in her legs and fell down. She denies hitting her head, headache, or loss of consciousness, but does complain of low back pain. Her past medical history is significant for diabetes mellitus, hypertension, severe osteoporosis, chronic neck pain and congestive heart failure. She has had three transient ischemic attacks, each lasting 15-20 minutes and characterized by slurred speech, in the past. Her medications include insulin, lisinopril, carvedilol, alendronate, aspirin, and acetaminophen. Her blood pressure is 160/90 mmHg and her heart rate is 73/min. Physical exam reveals muscular weakness, increased deep tendon reflexes, and mildly decreased pinprick sensation in both lower extremities. Which of the following is most likely responsible?

52. A 60-year-old male presents to the office and complains of muscle weakness in his extremities. Other accompanying symptoms include progressive difficulty in performing weight-carrying tasks, and a 7 kg (15 lb) weight loss during the last three months. His past medical history is insignificant. He smokes 2 packs of cigarettes daily, and consumes alcohol occasionally. His muscle strength is 3/5 in the proximal muscle groups symmetrically. His reflexes are normal. No sensory abnormality is present. Chest x-ray reveals a right lower lobe ill-defined mass. Which of the following is the most likely localization of the pathologic process in this patient?

53. A 47-year-old obese female comes to the office for the evaluation of recent episodes of mood instability. Her mood varies between sad and irritable. She denies any other symptoms, except for some mild forgetfulness. She tearfully shares that she is convinced that she is going to die, as her father also developed similar symptoms around the same age and died subsequently. On physical examination, writhing movements of the extremities are prominent. This patient's clinical presentation is most consistent with:

54. A 34-year-old Caucasian man presents to your office with a several day history of difficulty walking. He also describes some "funny" sensations in his feet. He denies any recent skin rash, diarrhea, or joint pain. His past medical history is significant only for a recent mild respiratory infection. He visited his friends in Connecticut one month ago. He smokes one pack of cigarettes a day and admits to occasional IV drug use. He is not sexually active. His temperature is 36.C (98.F), heart rate is 90/min, respirations are 20/min, and blood pressure is 160/100 mmHg. Chest examination is unremarkable. Abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Cranial nerves II-XII are intact. Muscle strength is reduced in the lower extremities but well preserved in the upper extremities. Lower extremity sensation is decreased. Stroking the soles of the feet elicits extension of the great toe. Which of the following is most likely to diagnose this patient's condition?

55. A 70-year-old Caucasian male is brought to the emergency department due to a sudden onset of right-sided weakness and urinary incontinence about ten hours ago. His past medical history is significant for type 2 diabetes for the last 20 years and hypertension for the last 28 years. On examination, there is 3/5 power in the right upper extremity and 1/5 power in the right lower extremity. Babinski's sign is positive on the right side. The sensations are decreased on the right side of the body, more so in the right lower limb than the right upper limb. Which of the following is the most likely diagnosis?

56. A 32-year-old woman describes five episodes of intractable vomiting over the last year. The episodes last several hours and are associated with a sensation that the room is spinning or tilting. At these times, it is difficult for her to walk because she loses her balance. She cannot relate the timing of the episodes to any particular inciting event. Physical examination reveals stability in the Romberg position and during tandem walk. Proprioception is intact. Dysfunction of which of the following structures best explains this patient's symptoms?

58. A 35-year-old Caucasian man comes to the emergency department at 2 am because of severe pain 'behind the left eye' which woke him up in the middle of the night. The pain is intense and has a stabbing quality. He took ibuprofen at home but didn't get any relief. He denies fever, chills, decreased or blurred vision, cough, nausea or vomiting. He has no other medical problems. He drinks 3-4 bottles of beer daily. He has no known drug allergies. His temperature is 36.7 C (98 F), blood pressure is 120/80 mm Hg, pulse is 88/min and respirations are 14/min. The examination is unremarkable, except for left-sided ptosis and miosis. Which of the following is the most likely diagnosis?

59. A 38-year-old female presents with one week of "shakiness" in her right arm, right leg weakness and unsteady gait. An MRI of her brain is shown below: Which of the following is the best treatment for this patient?

60. A 36-year-old white female is brought to the emergency department due to paraplegia and bladder incontinence. She immediately tells you that she has, "multiple sclerosis in remission." She has a history of optic neuritis and internuclear ophthalmoplegia, and both resolved with treatment. At that time, MRI showed plaques in the periventricular region. She is currently not taking any medications. Which of the following is the most appropriate next step in the management of this patient?

61. A 63-year-old Asian-American woman presents to the ER with a severe right-sided headache that started one hour ago. The pain is located "all around my eye." She has vomited once since the pain began. She also says that bright light aggravates the pain and she complains of seeing "halos" around light. She has never had a headache like this before. Her only medication is trimethoprimsulfamethoxazole, which she has been taking for the last two days for a urinary tract infection. Her mother has a history of migraine headaches. She does not use tobacco, alcohol, or illicit drugs. On exam, she is afebrile with a pulse of 90/min. Physical exam reveals a non-reactive, dilated right pupil and erythematous right eye. There is lacrimation present. The remainder of examination is unremarkable. Laboratory studies reveal an ESR of 40 mm/hr. Which of the following is the most likely diagnosis?

62. A previously healthy 8-year-old boy is brought to the office by his mother because he has multiple staring episodes. During these episodes, he is unresponsive to verbal or tactile stimuli, and produces lip-smacking movements. Each episode lasts for a few minutes, after which he remains confused for some time. He has no family history of any seizure disorder. His neurological examination is unremarkable. EEG performed before and after hyperventilation is normal. Which of the following is the most likely diagnosis?

63. An 18-year-old girl comes to the office due to a three-week history of headaches that has been disturbing her daily activities, including her sleep. She describes these headaches as pulsatile, diffuse, and occasionally results in vomiting. Her school grades have deteriorated over the past 3 months. She complains of double vision when she looks sideways. Her family history is significant for migraine. She is afebrile. Her neurologic examination is significant for sixth cranial nerve palsy. The pupils are equal, and reactive to light and accommodation. There is no sinus tenderness. Fundoscopy reveals bilateral papilledema. MRI of the brain reveals an empty sella. What is the most appropriate next step in the management of this patient?

64. A 30-year-old white female presents with an attack of common migraine. This is her fourth attack of migraine over the last 4 months. Her attacks previously responded well to aspirin and ibuprofen; however, her current headache is very severe and not relieved by NSAIDs. She has been trying to conceive for the past 2 months. Six years ago, she was treated with isoniazid due to a positive PPD test. Her father died at the age of 45 from an acute myocardial infarction. Before starting therapy with serotonin agonists (e.g., sumatriptan), which of the following tests should be performed in this patient?

66. A 76-year-old man presents with several months of urinary incontinence. He denies associated dysuria, nocturia, or penile discharge, and has otherwise been feeling well aside from moderate left arm pain following a fall three days ago. He denies headache or head trauma. His medical history is significant for osteoarthritis and glaucoma, which are controlled with medications. On exam, his vital signs are within normal limits. His heart, lungs, and prostate are unremarkable. The cranial nerves are all intact, fundoscopic exam is normal, and there is no tremor. His gait is wide-based and shuffling, and he scores 24/30 on the Folstein mini-mental status exam. His muscle power is 5/5 in all four extremities and the deep tendon reflexes are normal. What is the most likely cause of his current condition?

67. A 1-year-old female infant is brought to the clinic by his 30-year-old mother due to feeding problems since birth. She still cannot walk nor speak. She began to sit when she was 8 months old. Her weight is in the 15th percentile, height is in the 20th percentile, and head circumference is in the 100th percentile for her age. She has multiple freckles in her armpit and groin area. She has cafe-au-lait spots on her skin, and the diameter of at least 20 of these spots is greater than 1.5mm. What is the most likely diagnosis?

68. A 33-year-old Caucasian female comes to the office and complains of occasional diplopia and ptosis. These symptoms become especially prominent when she looks above her head for some time. She also complains of fatigue in her hands and leg muscles after exercising, such as swimming. Her muscle strength and double vision returns to normal after resting for some time. On examination, lid lag is observed after she is asked to look above her head for some time. No pupillary involvement is seen. The rest of the examination is normal. What is the level of the lesion in the disease that is being described?

69. A 62-year-old Caucasian man with hypertension and chronic kidney disease complains of poor sleep. He describes a sensation of spiders crawling over both legs about 15-20 minutes after going to bed. Sometimes he has to sit up in bed and massage his legs. His wife's sleep has deteriorated as her husband's leg movements have gotten worse. Pharmacotherapy for this patient's disease is typically directed at which of the following?

70. A 33-year-old white female comes to the office for the evaluation of weakness in her upper extremities. She thinks she is unable to feel pain or heat, because she recently noted some burn wounds on her fingertips, and does not know how she got them. She denies weakness in her lower limbs, as well as any history of trauma, headache, bowel or bladder problems, neck pain or facial pain. Examination reveals absent reflexes in her upper limbs. There is absent pain and temperature sensation on the nape of neck, shoulders and upper arms in a 'cape' distribution. Vibration and position sensations are preserved. Which of the following is the most likely pathology of the patient's condition?

71. A 25-year-old, HIV-positive male presents to the office with an altered mental status. He is disoriented, lethargic, and has loss of recent memory. These symptoms have been present for the last month. His current medications include zidovudine, didanosine, indinavir, trimethoprimsulfamethoxazole and azithromycin. His temperature is 37.7C (99.8F), pulse is 78/min, blood pressure is 130/80mm Hg, and respirations are 16/min. The neurological examination is non-focal. His CD4 count is 40/microl and viral load is 25,000 copies/ml by PCR. MRI scan reveals a solitary, irregular, weakly ring-enhancing mass in the periventricular area. The serology for Toxoplasma is positive. PCR of CSF shows EBV DNA. What is the most likely diagnosis?

72. A 33-year-old Canadian female presents to the office with severe, bilateral, lightning-like pain on her face. The pain is burning and sharp in nature, occurs 20-30 times a day, and each episode lasts a few seconds. She is completely incapacitated by this pain. Prior to this event, she had weakness in her left arm, which gradually improved. She denies any history of trauma or drug use. She has no other medical problems. She does not use tobacco, alcohol or drugs. Her blood pressure is 120/80 mmHg, pulse is 72/min, temperature is 36.7C (98F) and respirations are 14/min. Complete neurologic examination shows no focal deficits. This type of disorder is most commonly seen in which of the following?

73. A 67-year-old woman is being evaluated for periodic confusion, insomnia, and frequent falls as well as episodes of decreased alertness and visual hallucinations. On physical examination, she has increased lower extremity muscle tone but downgoing Babinski reflexes bilaterally. Which of the following pathologic findings most likely underlies her condition?

74. A 22-year-old white obese female presents with headache for the last few weeks. Headache is worse at night and wakes her from sleep. Headache is pulsating in quality and is also associated with nausea and vomiting. She denies any weakness, sensory abnormalities or visual problems. She denies any history of trauma. She does not take any medication. Neurological examination is unremarkable. Fundoscopy shows papilledema. CT scan of head does not show any abnormality. Lumbar puncture is performed and CSF examination is normal except increased CSF pressure. Weight loss fails to control her symptoms. Which of the following is the most appropriate next step in the management of this patient?

75. A 65-year-old man was brought to the emergency department after his wife and son were unable to wake him up this morning. His past medical history is significant for hypertension for the past 7 years. For the past year, he has had several episodes of chest pain, which was triggered by physical activity and relieved by rest. His current medications are nitrates and "baby aspirin." His blood pressure is 140/80 mm Hg, heart rate is 85/min, and respirations are 15/min. The physical examination reveals an obese man with impaired consciousness. He has a Glasgow score of 6, asymmetric pupils, and brisk deep tendon reflexes in the left extremities. Plantar stimulation provokes extension of the left great toe. The EKG shows no abnormalities. His CK-MB serum levels are within the normal range, and his LDL cholesterol level is 150 mg/dl. What is the most likely etiopathology of this patient's symptoms?

76. A 72-year-old male comes to the emergency department (ED) due to a sudden onset of right-sided weakness, aphasia and incontinence. He did not lose consciousness. All his symptoms started suddenly, 1 hour ago. He was previously diagnosed with hyperlipidemia, and is on simvastatin. He is a known smoker and alcoholic. He is taking aspirin as prophylaxis for heart attacks and strokes. His family history is not significant. His blood pressure is 160/88 mm Hg, pulse is 78/min, respirations are 18/min, and temperature is 37.8C (100F). He is admitted to the ED, and a patent airway is secured. The cardiac examination and EKG findings are normal. CT of the brain shows no acute hemorrhage. Which of the following interventions will result in the best outcome in this patient?

77. A 33-year-old white man with a 9-year-history of progressive-relapsing multiple sclerosis is brought to the emergency department (ED) due to a severe flare-up. He has had several attacks before, and has recovered every time with some residual damage. The last physical examination in his medical records revealed cerebellar symptomatology, a visual defect, and central hemiparesis on the right side. MRI showed multiple, bright, signal abnormalities in the white matter supratentorially on the left side, in the cerebellum, and the left optic nerve. CSF examination revealed an increased synthesis of oligoclonal bands. In the ED, the physical examination reveals paraplegia, bladder and fecal incontinency, and absent sensation from the nipples down. What is the most likely location of this patient's new plaque?

78. A 52-year-old Caucasian male comes to the office for the evaluation of tremors. He has been having tremors in both hands and head over the past several months. He does not experience any tremors at rest, or any problem with his legs. He has a history of alcohol abuse. He is currently not on any medication. His father had essential tremors, and his paternal uncle has Parkinsonism. The physical examination reveals tremors, which increase in amplitude when he tries to reach for an object. Which of the following is the most appropriate next step in the management of this patient?

79. A 32-year-old Caucasian male is admitted to the hospital due to a 1-week history of progressive paralysis of his upper and lower extremities. He had a flu-like illness 3 weeks ago, followed by paresthesias in his fingertips and toes. The weakness initially started in his lower extremities. He denies any changes in bowel and bladder functions. His blood pressure (supine) is 130/70mm Hg, heart rate is 82/min, respirations are 18/min, and temperature is 36.9C(98.5F). Physical examination reveals bilateral facial paralysis, orthostatic hypotension, areflexia in all four extremities, and distal paresthesias. His CSF analysis shows: Total WBC 10/cmm Protein 120 mg/dl Glucose 70 mg/dl Gram stain No organisms What is the most appropriate next step in the management of this patient?

80. A 37-year-old homeless man complains of weakness in his right arm. He says that he was smoking a cigarette when the weakness developed, causing the cigarette to fall from his hand. He also reports having mild headaches, fatigue, and chills over the last week. He admits to regular intravenous heroin use and binge drinking. On physical examination, his blood pressure is 120/70 mmHg and his heart rate is 80/min. There is asymmetry of the lower face, decreased muscle strength in the right arm, and an extensor plantar reflex on the right side. He has multiple needle tracks on his arms. ECG shows sinus rhythm with occasional ventricular premature beats. Urinalysis shows 2+ proteins. Which of the following is the most likely cause of this patient's symptoms?

81. 17-year-old girl is brought to the office by her mother due to weakness of her hands and legs. The weakness has been progressively worsening over the past 24 hours, and she now feels that the weakness is affecting her hips. Her mother says she was a bit unwell a couple of weeks ago, but otherwise her past medical history is unremarkable. The physical examination reveals 1/5 power in ankle and knee flexion/extension and 2/5 power in hip flexion. Reflexes are absent in her lower extremities bilaterally. She is admitted to the hospital. Spinal fluid analysis shows albumino-cytologic dissociation. Which of the following tests is the most appropriate for monitoring her respiratory function?

82. An 84-year-old female is hospitalized with right-sided hemiplegia secondary to an ischemic stroke. She has a complex past medical history including hypertension, diabetes mellitus, hypercholesterolemia and mild Alzheimer disease. Her current medications include lisinopril, metoprolol, insulin glargine, simvastatin and aspirin. On physical examination, her blood pressure is 140/60 mm Hg and her heart rate is 62/min. Her neck is supple and without jugular venous distension. Her lungs are clear to auscultation and her abdomen is soft and non-distended. She cannot move her right arm or right leg. There is a partial thickness ulcer on her right heel. Her wound is most likely the result of which of the following?

83. A 45-year-old man comes to the office for the evaluation of excessive wasting of his extremity muscles, which is more apparent on the extensor side. The weakness began distally and asymmetrically. He recently started to have difficulties with swallowing, chewing, and speaking. He feels some movements in his face and tongue. He also has muscle stiffness. His bowel, bladder, cognitive, and sensory functions are intact. The physical examination reveals excessive wasting of his muscles, which is more prominent in the lower extremities. Fasciculation and hyperreflexia of all extremities are noted. His bulbar reflexes are decreased. What neural pathway is most likely damaged?

85. A 67-year-old Asian male comes to the clinic for the first time. He walks very slowly as he enters the room. His chief complaint is "extreme forgetfulness" for the past 6 months. He tearfully shares that he has been "losing sleep." He used to be a very "bright and sharp" person, but is now unable to focus on his daily activities and feels "really extremely low and useless." His past medical history is significant for hypertension, hypercholesterolemia, diabetes, benign prostatic hyperplasia, and TIA. His family history is insignificant, except for Alzheimer's dementia in his father. He does not smoke, and drinks wine only occasionally. He has been living alone for the last 6 months, after his son moved out. His physical exam is normal, except for markedly slow movements. A CT scan of the head is normal. Which of the following is the most likely diagnosis?

86. A 24-year-old male is brought to the emergency room after he fainted while practicing football on a bright sunny day. He complained of dizziness and headache before he collapsed. He was in his usual state of health until today and has no medical problems. He takes no medication. On arrival to the emergency room, his temperature is 41 C (105.8F), blood pressure is 90/60 mm Hg, pulse is 140/min, and respirations are 22/min. He is not oriented. Skin is dry and hot. Neck is supple. Auscultation of the chest is unremarkable. Abdomen is soft and non-tender. Muscle tone and reflexes are within normal limits. Intravenous hydration is started. Which of the following is the most appropriate next step in management?

87. A 29-year-old female is brought to the emergency department due to paraplegia, urinary incontinence and urgency. She denies any trauma. She has a history of trigeminal neuralgia. The neurological examination shows spasticity and hyperreflexia in the lower extremities, and impaired vibration and proprioception in her left forearm. Which of the following is the most likely finding in this patient's cerebrospinal fluid (CSF) examination?

88. A 54-year-old construction worker presents to your office complaining of a "funny sensation" in his right arm. He has no significant past medical history. His diet consists of mainly fast food and he drinks one to two litters of soda per day. He does not exercise regularly. He smokes 1½ pack of cigarettes per day. His BMI is 28.5 kg/m2. You ask the patient to stretch out his arms with the palms facing up and close his eyes. Five seconds later you observe the right palm turning inward and downward. Which of the following best explains the observed findings in this patient?

89. A 53-year-old man complains of "shaking" of his right hand. He first noticed this shaking while resting in an armchair and watching TV. He reports that the shaking stopped when he reached for the remote to change the channel. On physical examination, his vital signs are within normal limits and all other organ systems appear normal. Which of the following is most likely responsible?

90. A 60-year-old Hispanic female is brought to the emergency department due to a sudden onset of worsening, left-sided hemiplegia, which was followed by a headache and altered mental status. She was taking her regular morning walk when she developed these symptoms. Her past medical history is remarkable for uncontrolled essential hypertension. She has been a chronic smoker for the last 30 years. The neurological examination shows flaccid paralysis on the left side, and deviation of eyes towards the right side. The CT scan is consistent with a hemorrhagic stroke. Which of the following is the most likely diagnosis?

92. A 23-year-old male with a history of drug abuse is brought to the emergency department (ED) by an ambulance while having a tonic-clonic seizure. His mother soon arrives at the ED and says that she found him on the floor, where "he must have fallen." She says his seizure has lasted for more than 30 minutes now, and that he never regained consciousness since she found him. In the ED, he is unresponsive and cyanotic. He is biting his tongue and is incontinent. Despite resuscitation and administration of intravenous lorazepam, phenytoin, and glucose, the seizures continue. What is the best next step in the management of this patient?

93. A 28-year-old Caucasian female presents to the emergency department (ED) appearing very anxious. She is accompanied by her boyfriend. She woke up this morning with severe weakness over the right side of her body. The weakness came on all of a sudden, but gradually resolved during the day. She denies any sensory symptoms. Her boyfriend reports that her speech was "weird, almost as if she was stuttering or struggling to get her words out." This too has resolved. The patient denies any other symptoms. The only other history of note is that she returned from a holiday in Italy 2 days ago. Vitals signs are unremarkable. The neurological examination is normal. Her chest x-ray is within normal limits. EKG shows normal sinus rhythm with a rate of 82/min. An urgent head CT scan is within normal limits. Which of the following investigations is most likely to reveal the underlying cause of this episode?

94. A 59-year-old white male comes to the office for the evaluation of a brief episode of right arm and leg weakness. The episode lasted for a few minutes, and was followed by a complete recovery. He had a similar episode one month ago. He has a 30 pack-year history of cigarette smoking. He has hypercholesterolemia, which is being treated with diet and exercise. His pulse is 76/min, regular, and blood pressure is 130/80 mmHg. His laboratory test results are: Hb 14.2 g/dl WBC 7,000/cmm Platelets 230,000/cmm Blood Glucose 118 mg/dl Serum Na 138 mEq/L Serum K 4.5 mEq/L BUN 16 mg/dl Serum Creatinine 1.0 mg/dl EKG shows normal sinus rhythm. CT scan of the head is unremarkable. MRI angiography of the head and neck fails to show any abnormality. Transesophageal echocardiography (TEE) is unremarkable. Which of the following is the most appropriate next step in management?

95. A 70-year-old Caucasian male comes to your office four weeks after experiencing an ischemic stroke. His past medical history is significant for a long history of hypertension, diabetes, coronary artery disease, congestive heart failure, and atrial fibrillation. You noticed that the patient has shaved only the right side of his face. When you ask him to raise his left arm, he raises his right arm. You ask him to fill in the numbers of a clock, and he puts numbers only on the right side. Which of the following areas is most likely affected by the stroke in this patient?

96. A 59-year-old male presents to the ER with diplopia that started several hours ago. He has no other complaints. His past medical history is significant for long-standing diabetes with poor glycemic control, right knee osteoarthritis, and peptic ulcer disease. Physical examination reveals right-sided ptosis with the right eye looking down and out. Pupils are equal and reactive to light. This patient's condition is most likely due to which of the following?

97. A 10-year-old boy is brought to the office by his mother after having a seizure this morning. All he can recall before the episode is "seeing funny little lights." According to his mother, his body went stiff; he lost consciousness, and then had jerky movements of the entire body. He bit his tongue, and started to drool. The seizure lasted for about one minute. After the seizure, he appeared confused for several minutes, and passed urine. He has been complaining of a headache for the past two hours. The neurological examination is normal. What type of seizure did this patient experience?

98. A 76-year-old Caucasian female is brought to the hospital with a one-hour history of confusion. Her husband says that she started to complain of occipital headaches two hours ago and took some acetaminophen; an hour later, he found her confused on the couch and called an ambulance. She has no recent history of fever, chills, ear pain, or upper respiratory infection. Her past medical history is significant for coronary artery disease, diabetes mellitus, hypertension and atrial fibrillation. She had triple vessel coronary artery bypass five years ago. Her current medications include warfarin, metoprolol, diltiazem and lisinopril, plus 25 units of long-acting insulin at bedtime. She lives with her husband and is independent in her activities of daily living. On examination, her blood pressure is 160/90 mmHg and her heart rate is 80/min and irregular. She is unable to follow simple commands or speak. She moves all four extremities. Deep tendon reflexes are symmetric and Babinski reflexes are downgoing bilaterally. Which of the following is the best next step in evaluating this patient?

99. A 56-year-old Hispanic male presents with right-sided arm weakness and speech difficulty. He expresses words slowly and with difficulty. His speech is agrammatic and the melody of speech is abnormal. He is able to comprehend words spoken to him. Which of the following is the most likely site of lesion in the above patient

100. 52-year-old male is referred to the neurology clinic for the evaluation of EEG abnormalities. He presented with rapidly increasing memory impairment, and denied any history of seizures or head trauma. The physical examination revealed no abnormalities, except a myoclonus. An extensive work-up ruled out the presence of any medical illness; however, the EEG report revealed sharp, triphasic and synchronous discharges Which of the following abnormalities is most likely in this patient?

101. A 69-year-old man presents to the emergency department with a severe occipital headache, nausea and vomiting for several hours. His medical history is significant for poorly controlled essential hypertension for the last 7 years. The neurologic examination shows ataxia, right-sided facial weakness and deviation of the eyes to the left side. His CT scan is consistent with a hemorrhagic stroke. Which of the following is the most likely diagnosis?

102. A 27 -year-old white female comes to the office and complains of a headache for the last two weeks. She characterizes the headache as intermittent, "feels like a dull ache", 5/10 in severity, and associated with nausea and vomiting. She is afebrile and never had such a headache before. She has no visual complaints. She is a non-smoker and drinks alcohol only on weekends. Her only drugs are oral contraceptive pills (OCPs). Her menses are regular, and she has never conceived. She has no family history of similar problem. Her pulse is 80/min, temperature is 37.1 C, blood pressure is 120/75mmHg and respirations are 15/min. She is 5 feet 10 inches tall, and her weight is 210 lbs. The neurological examination is non-focal, and there are no signs of meningeal irritation. Funduscopy reveals papilledema. MRI of the brain is normal. Which of the following complications is likely to develop if this patient is left untreated?

103. A 76-year-old woman presents for a routine medical check-up. Her medical history is significant for hypertension, type 2 diabetes mellitus, and hypothyroidism that are controlled with oral agents. She had a stroke one year ago and has mild residual right arm weakness. Otherwise she has no physical complaints. She is widowed and lives alone. Regarding her memory, she sometimes forgets to return phone calls and take her blood pressure pills. Occasionally during conversations, she has difficulties finding the right word. She drives herself to the grocery market weekly to do her shopping, and has no difficulty managing her finances. She describes her mood as good. She visits her close friends on occasion and often has difficulty falling asleep. Her blood pressure is 135/76 mmHg and her heart rate is 65/min. Finger stick glucose and TSH levels are normal. Which of the following is the most likely diagnosis in this patient?

104. A 64-year-old male is brought to the emergency department (ED) due to a sudden onset of lower extremity weakness. He was swimming in the pool, when he suddenly felt his legs become weak. He then felt that his legs had no more strength, and he was not able to move them. He struggled out of the pool, called EMS, and was rushed to the ED. He denies any trauma, loss of consciousness, visual or speech problems. He cannot pass urine. He has a long history of back problems. The physical examination reveals significant motor weakness in both legs, and numbness from the buttocks to the soles of the feet. He has no sensation in the perineal area. The rectal tone is absent. A Foley catheter is placed, and 800 cc of urine is collected. What is the best treatment for this patient?

105. A 59-year-old man is brought to the office by his family due to attitude problems over the last year. He has a history of memory loss and word-finding problems. He has lost interest in golf, which used to be one of his favorite sports. Recently, he has become promiscuous and has started using "dirty language," which he has never used before. He is a non-smoker. He has no significant past medical or surgical history. His uncle had similar features, for which he was admitted into a nursing home, but died soon after admission. The physical examination reveals intact visuospatial functions, intact cranial nerves, and prominent snout and grasp reflexes. What is the most likely diagnosis?

106. A 26-year-old white female presents with worsening weakness of her right upper extremity, left lower extremity and ataxia. She also complains of unilateral eye pain and visual loss. The eye pain is worsened by ocular movements. On eye examination, there is a central visual field defect in her right eye. Fundoscopy is normal. Neurological examination shows spastic paraparesis in the right upper extremity and the left lower extremity. What is the most appropriate next step in this patient's management?

107. A 67 -year-old male presents to the emergency department with severe dizziness and the inability to walk. He complains of repetitive vomiting and occipital headache. The symptoms started two hours ago when he was playing golf in sunny weather with his friends. His past medical history is significant for hypertension and diabetes. He underwent coronary stenting two years ago for recurrent chest pain. His current medications are aspirin, glipizide, enalapril and metoprolol. His blood pressure is 210/110 mmHg, heart rate is 78/min, temperature is 37.8°C (100°F), and respirations are 18/min. Muscle strength is preserved in all four extremities, and there are no sensory abnormalities. Which of the following is the most likely cause of this patient's symptoms?

108. A 65-year-old lady comes to the office for the evaluation of her deteriorating memory. She has become increasingly forgetful over the last several months, and now appears very concerned about her memory loss. She used to pride herself for her sharp memory, but has been forgetting the most trivial things and has become "extremely inefficient." She also complains of easy fatigability, poor appetite, and frequent awakening at night. She feels worthless and has lost interest in her favorite hobby, which is gardening. On coughing or laughing, she loses urine involuntarily, and this is adding to her misery. She lives with her husband, who says that she has become very "cranky and irritable" lately. Her medical history is significant for hypercholesterolemia, for which she refuses to take medication. She is presently not on any hormonal therapy. The physical examination is completely normal. Laboratory studies are unremarkable. CT scan of the head is normal. What is the best next step in the management of this patient?

109. A 65-year-old man comes to the physician's office because of frequent falls. For the past 2 months, he has been having increasing difficulty in maintaining balance when walking or standing. He tends to lose his balance on the left side, and feels that his "left body has become weak." He also complains of occasional headaches and nausea for the past 3 months. His other medical problems include hypertension, diabetes mellitus-type 2 and a myocardial infarction 10 years ago. He denies the use of tobacco, alcohol, or drugs. His medications include glyburide, aspirin and enalapril. His vital signs are within normal limits. When asked to get up from the chair and stand with his feet together, he tends to sway to the left, even with his eyes open. When asked to walk a few steps, he walks cautiously and lurches to the left. There is decreased resistance to passive flexion. Which of the following is the most likely diagnosis?

110. 27-year-old Caucasian female with multiple sclerosis (MS) comes to the office for a follow-up visit. Six months ago, she experienced monocular vision impairment and clumsiness of the right hand, and both symptoms resolved completely. Three weeks ago, she experienced incoordination, weakness and spasticity in the right extremities. She was admitted in the hospital for treatment of an acute MS flare, and rapidly improved thereafter. Physical examination currently demonstrates slight weakness of the right leg with a hyperactive knee jerk. Which of the following medications may slow the long-term progression of this patient's disease?

111. A 52-year-old male comes to the office due to a sudden onset of photophobia, redness around the eye and pain in his right eye. He also has nausea and a terrible headache, which has not responded to ibuprofen. He denies any trauma, and has never had such an episode before. He was watching TV when the event started. The physical examination reveals a non-reactive mid-dilated pupil. The eye appears red with conjunctival flushing. What is the best diagnostic test for this patient's condition?

112. A 32-year-old female is brought to the clinic by her husband because he believes she is a malingerer and is "just being difficult." Sometimes, she appears confused and disoriented. Over the past year, she has complained of visual loss, eye pain and inability to do any household chores. Two months ago, she claimed to have lost control of her bladder. Interestingly, she is "her normal self" when it is time to go for summer trips. The wife insists that she does not understand what is happening to her, and adds that she occasionally loses the ability to move her right hand. The physical examination is basically normal. The patient appears, alert, oriented, and is in no distress. Which of the following is the most appropriate next step in management?

113. A 45-year-old man is brought to the emergency department following a serious motor vehicle collision. Despite heroic attempts to save him, the physician caring for him believes he is brain dead. Unfortunately, the patient does not have an advanced directive or durable medical power of attorney. What step is necessary in order to remove the patient from the ventilator?

114. A 32-year-old female is crying as she approaches the office. She has had severe, unbearable pain in her face for the past five days. She describes the pain as knife-like, comes in paroxysms, occurs 1020 times a day, and lasts a few seconds. She does not know what precipitates the attacks, but she has been unable to sleep, eat or go to work because of her symptoms. She has tried numerous pain medications, but nothing seems to relieve the pain. She denies any history of trauma, medication use or recent surgery. Vital signs are within normal limits. Physical examination is within normal limits. Which of the following agents will best benefit this patient?

115. A 23-year-old white female presents with an acute onset of headache for the last eight hours. Her headache is severe, unilateral, pulsating in quality, associated with photophobia, worsens with physical activity, and does not respond to acetaminophen or ibuprofen. This is her 6th episode of similar headache over the last 2 months, and it is her first time to seek medical attention. Her neurological examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

116. A 26-year-old previously healthy white female is brought to the emergency department after having an episode of seizures one hour ago. She has a two-day history of fever and headaches, for which she has been taking acetaminophen and ibuprofen without much relief. She has no family history of seizures. Her temperature is 38.9 C (102 F), blood pressure is 120/70 mmHg, pulse is 110/min, and respirations are 18/min. Complete blood count and CT scan of the head are unremarkable. Her cerebral spinal fluid study shows: Opening pressure 220 mm H2O Protein 200 mg/dl Glucose 55 mg/dl WBC 150/mm3 Lymphocytes 90% Polymorphs 10% RBC 200/cmm What is the most likely diagnosis of this patient?

117. A 24-year-old athlete was running a marathon on a bright sunny and humid day, when he suddenly collapsed. He was disoriented at the scene. He has no medical history and takes no medication. He does not use tobacco, alcohol or drugs. Family history is insignificant. On arrival to the emergency room, his temperature is 41C (105.8F), blood pressure is 90/60mm Hg, pulse is 140/min, and respirations are 22/min. Mucous membranes and skin are dry. Neck is supple. Auscultation of the chest is unremarkable. Abdomen is soft and non-tender. Muscle tone and reflexes are within normal limits. Labs show a hematocrit of 52%. Chest x-ray is within normal limits. Urinalysis shows large blood but no red blood cells. Which of the following is the most likely underlying pathophysiology of his current condition?

118. A 45-year-old Caucasian male presents in the office with a movement disorder and behavioral disturbance. For the past month, he has been having frequent, sudden, jerky and irregular movements of his upper extremities. He has become irritable, and does not visit his family or friends. He is a business executive, and co-workers have commented on the serious decline in his performance. His father had similar problems and died in a nursing home CT scan is ordered. Which of the following is a typical CT finding in such patients?

119. A 54-year-old male presents to the office with several months history of hand tremors that are unresponsive to over-the-counter medication. The tremors always become worse when he is in public places. Sometimes, the hand tremors are so bad that he is unable to grasp. He denies trauma, fever, loss of muscle function or any prior stroke. His past medical history is significant for vague abdominal pains, the cause of which was never found. He is given some medication. A month later, he comes back and says, "The tremor is gone, but now I have colicky abdominal pain, confusion, headaches, hallucinations and dizziness." What is the drug that caused this patient's new symptoms?

120. A 78-year-old woman is brought to the emergency department with agitation and insomnia. She screams out loudly and tries to run away while being examined. She is a nursing home resident and has a recent medical history that includes severe memory loss, gait disturbance and urinary incontinence. Her chronic medical issues include hypertension, diabetes mellitus, atrial fibrillation, peptic ulcer disease and chronic pyelonephritis. Her blood pressure is 160/100 mmHg and heart rate is 95/min and irregular. ECG reveals atrial fibrillation but no acute ischemic changes. Laboratory investigations reveal the following: Hematocrit 41% WBC count 9,000/mm3 Platelets 160,000/mm3 Sodium 137 meq/L Potassium 5.5 meq/L Chloride 95 meq/L Creatinine 1.4 mg/dl BUN 25 mg/dl Urinalysis shows trace protein, numerous leukocytes and occasional erythrocytes. Which of the following is the best initial treatment for this patient?

121. A 44-year-old male has been abusing drugs for many years. Recently he started using the agent MPTP and he now presents to you in the ER. He says that he is not feeling well and wonders what is going on. He says he has a persistent tremor in his fingers and his body has become rigid. At times has had difficulty in walking. The CT scan of his brain is normal and all the blood work is within normal limits. You decide to treat him. Two years later you see him and he tells you that his symptoms have improved. He also noticed that he had a significant relief from the recurrent and persistent upper respiratory tract viral infections that he was so prone to. The agent you gave him was?

122. A 64-year-old man presents to the ER with back pain and frequent falls. He also describes difficulty initiating urination. The symptoms started one week ago and have progressed gradually. He was diagnosed with prostate cancer one year ago and treated with radiation therapy. Physical examination reveals weakness of knee and hip extension that is more pronounced on the right. Knee and ankle reflexes are absent bilaterally. Babinski sign is negative. Perianal skin is insensitive to touch but sensation in the anterolateral thigh is preserved. Which of the following is the most likely lesion location in this patient?

123. A 62-year-old Caucasian woman complains of difficulty remembering important dates and appointments. She also describes poor concentration, daytime sleepiness and easy fatigability. She is concerned about her forgetfulness because her mother suffered from recurrent strokes and had severe memory loss. Her father died of chronic leukemia. Her daughter's recent job loss has caused her a lot of stress. She does not smoke or consume alcohol. Her appetite is decreased but she has gained 4 pounds over the last three months. She visited an otolaryngologist for hoarseness of recent onset. She takes over- the-counter laxatives for constipation and occasional aspirin for knee pain. She denies any other medication use. Which of the following is the most likely diagnosis in this patient?

124. A 69-year-old comatose man is brought to the emergency department by an ambulance. His wife says that he has been hypertensive for the past twenty years, and he is not compliant with his medication. His pulse is 80/min and blood pressure is 240/140 mm Hg. The physical examination reveals reactive pupils, no oculocephalic reflexes, no nystagmus, positive conjugate gaze deviation to the left, and reflexes of 3/4 on the right and 2/4 on the left side. Which of the following is most likely to be seen on computed tomography?

125. A 21 -year-old male has been experiencing severe headaches for the past week. He also describes difficulty grasping objects in his right hand and difficulty getting dressed, which both started today. CT scan of the head shows a ring-enhancing lesion in the left frontal lobe and a fluid collection in the left maxillary sinus. Tissue biopsy of the brain lesion is most likely to demonstrate which of the following?

126. A 30-year-old Caucasian male comes to the office due to symmetric weakness of his lower extremities. He also has paresthesias in his toes and fingers, and lower back pain. The neurological examination shows symmetric weakness, diminished reflexes, and intact sensation in his lower extremities. Orthostatic hypotension is also noted. Electrophysiological studies show slowed nerve conduction velocities. Lumbar puncture reveals normal opening pressure. CSF examination shows few cells, and a protein concentration of 90 mg/dL. Which of the following organisms is involved in the pathogenesis of this disorder?

127. A 65-year-old Caucasian male presents to your office complaining of an episode of slurred speech and clumsiness of his right hand. The episode lasted 15 minutes and resolved spontaneously. He had a similar episode one week ago. His past medical history is significant for moderate hypertension, diabetes mellitus (OM) type 2 and osteoarthritis of the right knee. He has smoked one pack of cigarettes daily for 35 years, and drinks 1-2 glasses of wine daily. His current medications include metoprolol, glyburide and naproxen. His blood pressure is 160/95 mmHg, pulse is 65/min, respirations are 16/min, and temperature is 36.7C (98F). The physical findings are within normal limits. The lab studies show Fasting blood glucose 200 mg/dl Total cholesterol 240 mg/dl LDL cholesterol 140 mg/dl HDL cholesterol 76 mg/dl What is the most important risk factor for a stroke in this patient?

128. A 65-year-old bedridden woman is brought in with complaints of weight loss, weakness and malaise. Her past medical history includes chronic obstructive pulmonary disease (diagnosed fifteen years ago) and hypertension of ten years' duration. She quit smoking two years ago, but previously smoked three packs of cigarettes daily since she was 20 years of age. Her vital signs are stable. Her physical examination reveals severe weakness in her proximal muscles, and loss of deep tendon reflexes. Chest x-ray shows a right upper lung mass with mediastinal lymphadenopathy. Which of the following is the most likely cause of her weakness?

129. A 46-year-old homeless man is being evaluated for frequent falls and a broad-based gait. A single tap on his patellar tendon elicits several to-and-fro leg movements. There is also nystagmus on physical examination. Which of the following additional findings would you expect most in this patient?

130. A 5-year-old boy is brought to the office by his frustrated mother because, "he just can't seem to concentrate!" He has episodes that are characterized by frequent blinking and indifference to his surroundings. He does not remember anything after an episode. An episode does not last long, but he usually has 50-80 "daydreaming accidents" daily. His school performance has deteriorated lately, and his teacher has complained about his decreased concentration. Which of the following is the drug of choice for this patient's condition?

131. A 75-year-old male comes to the office for the evaluation of a two-month history of intermittent right eye visual loss. Each episode is "painless, lasts a few seconds, and feels like a curtain coming over the eye." He denies any other symptoms. He has never had any trauma to his eye, and does not use any medications. His past medical history is significant for hypertension. He quit smoking 20 years ago, but had smoked for 25 years. On examination, the patient is alert and without neurologic findings. His blood work and chest x-ray are normal. What is the best next step in the management of this patient?

132. A 79-year-old woman is brought to the emergency department due to a suspected cerebrovascular accident on her right side. She complains of diffuse paresthesias and tingling in her right hand. She did not lose consciousness. The physical examination reveals normal speech, symmetric deep tendon reflexes (2/4 on both upper extremities, 2/4 both patellar reflexes, and 0/4 both Achilles reflexes), a cold right hand, and undetectable arterial radial pulse. Tinel and Phalen's signs are negative. The rest of the examination is normal. What is the most appropriate next step in the management of this patient?

133. A 66-year-old female is brought to the office by her concerned son due to increasing confusion, loss of mobility and stiff limbs. She tends to cry out for no reason. She often screams and sees, "a lion roaring in the backyard." She often sees cats in her room, even though her son does not see any. She has significant memory loss. She never had "joint problems" before. She was previously treated with haloperidol, but this only aggravated her rigidity. She is a non-smoker. She has no significant past psychiatric history. In the office, she appears alert, but disoriented and quite agitated. Her blood pressure is 136/72 mm Hg, pulse is 98/min, and respirations are 16/min. Physical examination reveals impaired visuospatial abilities, increased tone, normal reflexes, and coarse resting tremors in the extremities. Her CBC, electrolytes, creatinine, glucose, LFTs, TSH and B 12 levels are within normal range. The serology for syphilis is negative. What is the most likely diagnosis?

134. A 59-year-old obese man comes to the office "to make sure everything is okay." Yesterday after lunch, he experienced weakness in his right upper arm and right lower extremity. He was limping, and his right hand was not strong enough to hold some heavy things. His speech was "somewhat faulty”, and he had a light diffuse headache. By dinnertime, his symptoms were resolving, and when he woke up this morning, his weakness was gone. His past medical history is significant for hypertension, for which he takes atenolol. He has been smoking 1 pack of cigarettes a day for the past 40 yrs. His blood pressure is 150/95 mm of Hg and heart rate is 78/min. The neurological examination is normal. There is a mild carotid bruit on his left side. What is the most likely diagnosis?

135. A 27-year-old white female comes to the office and complains of ptosis, diplopia and difficulty in chewing. Her symptoms worsen in the evening. She is asymptomatic when she wakes up in the morning. She denies any sensory complaints or limb weakness. The Tensilon test is positive. Serological testing shows positive acetylcholine receptor antibodies. Which of the following is the best treatment to induce remission and provide long-term benefits in this patient?

136. A 68-year-old woman comes to the office due to the inability to move the right half of her face for the past 24 hours. Her blood pressure is 135/90 mm Hg and heart rate is 76/min. The physical examination is performed. Which of the following signs will exclude the diagnosis of central facial paresis?

137. A 60-year-old, obese, diabetic woman comes to the office and complains of "balance problems while walking." She also has tingling and paresthesias in her feet, decreased sensation below the knees, and burning and aching sensations in both legs. She has been very fatigued lately. The neurological examination reveals diminished proprioception peripherally on her feet, "stocking" distribution of hypesthesia from her knees distally, and positive signs of spinal ataxia. What is the best diagnostic test for this patient's condition?

138. A 12-year-old male child comes to the office after being referred for a medical evaluation. His schoolteacher says that he has a problem concentrating during class. He stares in space for a few seconds several times a day, and appears totally absorbed in his thoughts. He is not disruptive in class, but appears forgetful. There is no history of trauma, infection or problems at birth. On examination, the child is alert with stable vital signs. There is no loss of motor or sensory perception. Which of the following can confirm the patient's diagnosis?

139. A 32-year-old construction worker is brought to the emergency room after his co-workers found him confused, disoriented, and bleeding from the nose. His past medical history is unknown. According to his friends, he had been in his normal state of health this morning when he came to work. He then spent the morning moving heavy packages under direct sunlight for several hours. Presently, his blood pressure is 130/90 mmHg, heart rate is 120/min and regular, and temperature is 42°C (108°F). His skin is warm and dry and his neck is supple with no stiffness. His pupils are symmetric, mid-size and reactive to light. Deep tendon reflexes are symmetric and Babinski reflexes are downgoing bilaterally. He moves all four extremities but is unable to speak or follow simple commands. There is active bleeding from the right nostril. Which of the following is the most likely diagnosis?

140. A 16-year-old female complains of headaches and visual impairment for the past month. She says that the headaches are worst in the morning and are associated with nausea. Her medical history is also significant for severe acne for which she takes oral isotretinoin. On physical examination, her temperature is 36.7C (98.F), blood pressure is 130/80 mm Hg, pulse is 70/min, and respirations are 15/min. She has papilledema and decreased visual acuity. There is no neck stiffness. Motor examination shows 5/5 power, 2+ deep tendon reflexes, and a normal plantar response. Sensory examination is unremarkable. CT scan of the head is within normal limits. Lumbar puncture reveals the following: Opening pressure 250 cm H20 CSF glucose 40 mg/dL CSF protein 40 mg/dL WBC 3/mm3 Which of the following is the most likely cause of her symptoms?

141. A 62-year-old male is brought to the emergency department with a chief complaint of weakness. He says that he was walking his dog 1 hour ago when he began to limp and noticed some weakness in his left arm. His past medical history is significant for hypertension treated with hydrochlorothiazide, and type II diabetes mellitus managed with metformin. He denies nausea, vomiting, chest pain, fever or chills. He does note occasional palpitations and tension headaches at baseline. On physical examination, his blood pressure is 170/95 mmHg and his heart rate is 76/min and regular. His blood glucose level is 190 mg/dl and his HbA1c is 7.6%. The neurological examination is significant for profound left-sided weakness and an upgoing Babinski reflex on the left. Non-contrast head CT is negative for any intracranial bleed. Which of the following is most likely to affect his chance of neurological recovery?

142. A 65-year-old Caucasian male presents to the emergency department with sudden onset of weakness in his right arm and right leg. He has had episodes of transitory weakness and numbness in his right extremities over the last month, but those episodes used to resolve quickly. He denies headache, nausea, vomiting and loss of consciousness. His past medical history is significant for hypertension, diabetes mellitus, type 2 and myocardial infarction experienced 2 years ago. His current medications are aspirin, metoprolol, enalapril, simvastatin, and glyburide. He does not smoke or consume alcohol. His blood pressure is 160/80 mmHg, pulse is 65/min, temperature is 36.7C (98F) and respirations are 14/min. The physical examination reveals right-sided hemiplegia and facial paresis. His speech and praxis do not seem to be impaired. He correctly names his left and right arms. Bedside visual field testing is normal. Head CT without contrast shows no intracranial bleeding Where is the most likely location of the lesion responsible for this patient's condition?

143. A 20-year-old Caucasian male is on mechanical ventilation after sustaining a severe head trauma in a car accident. He is unresponsive to various stimuli. His blood pressure is 100/60mmHg and heart rate is 110/min. After monitoring the patient for six hours, the physician decides to do a bedside assessment of brain death. Which of the following can be observed in a patient with brain death?

144. A 26-year-old man comes to the emergency department because he is "suffering from the worst headache of his life." He feels nauseated and is photosensitive. His blood pressure is 160/90 mm Hg, heart rate is 88/min, and temperature is 36.5C (97.7F). The physical examination reveals no focal neurological symptoms, except for some meningismus and vertigo, which is not localized to either side. CSF examination reveals the presence of xanthochromia. What is the major cause of morbidity and mortality in a patient with the above condition?

145. A 22-year-old white male comes to the office and complains of a noise in his right ear. The noise has been intermittently present for several months, but recently became "very annoying." He also complains of decreased hearing on his right side while using the telephone. His past medical history is insignificant. The physical examination reveals numerous cafe-au-lait spots. What is the best next step in the management of this patient?

146. A 74-year-old woman comes to your office with her husband for a routine check-up. Her husband complains that she often forgets to take her blood pressure pills. He feels that her speech has changed because she occasionally struggles to find appropriate words. Two days ago, she drove to the nearby grocery store and did not find her way back. She has difficulty falling asleep and she always wakes up early in the morning. Her appetite is good. Which of the following is the best indicator of dementia in this patient?