NR 603 APEA Predictor 2024/2025: Latest Exam Questions and Solutions, Exams of Nursing

Download NR 603 APEA Predictor 2024/2025: Latest Exam Questions and Solutions and more Exams Nursing in PDF only on Docsity! NR 603 APEA PREDICTOR 2024/2025 LATEST EXAM WITH ALL POSSIBLE QUESTIONS AND VERIFIED CORRECT SOLUTIONS (RATIONALES PROVIDED)/GRADED A+ Question In addition to life saving interventions, what prescription medication will most benefit this patient at this time? Answer Choices 1 Furosemide (loop diuretic) 2 Prednisone (glucocorticoid) 3 Tranexamic acid (antifibrinolytic agent) 4 Labetolol (beta blocker) 5 Nimodipine (calcium channel blocker) ANS: 5 Nimodipine (CCB) Nimodipine, a calcium channel blocker, has been shown to improve outcomes in patients following aneurysmal SAH. The mechanism of action is thought to be prevention of ischemia. Glucocorticoids (e.g., prednisone) are often utilized in patients with SAH because they offer symptomatic relief of headache and neck pain, but they have not been proved to decrease cerebral edema. Antifibrinolytic agents (e.g., Tranexamic acid) can be utilized in patients with a diagnosed aneurysm who cannot undergo directed treatment, but they are not routinely used following aneurysmal rupture. Labetalol (a beta blocker) may be utilized to treat elevated BP, but it must be used with caution because it can also decrease cerebral perfusion. Diuretics (e.g., furosemide) have no identified role in the treatment of aneurysmal SAH. A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on the windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical examination reveals weakness of his upper extremities. What type of spinal cord injury does this patient have? A anterior cord syndrome B central cord syndrome C Brown-Séquard syndrome D complete cord transection E cauda equina syndrome ANS: B Central Cord Syndrome the central cord syndrome involves loss of motor function that is more severe in the upper extremities than in the lower extremities, and is more severe in the hands. There is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function. Brown-Séquard syndrome consists of weakness and loss of posterior column function on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic function one to two levels below the lesion. Complete cord transection would affect motor and sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain with radiculopathy. A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his house. The right side of his head hit the alley cement, and he lost consciousness for about 1 minute; he woke up with a headache, but he had no other complaints. A few hours later, the patient is brought to the emergency room by his neighbor because of an intense headache, confusion, and left hand hemiparesis. On examination, the patient has a bruise located over the right temporal region, mydriasis, and right deviation of the right eye, papilledema, and left extensor plantar response. An emergency CT scan of the head without contrast reveals a lens-shaped hyper-density under the right temporal bone with mass effect and edema. What is the most likely diagnosis? Answer Choices 1 Epidural hematoma 2 Subdural hematoma 5 ingestion 5 Infectio n ANS:5 infection Awareness of self and the surrounding environment or consciousness may be altered into different abnormal states of consciousness. Consciousness can shift from loss of clear thinking or confusion, usually accompanied by disorientation, to delirium, a succession of confused and unconnected ideas manifested in children as extreme mental and motor excitement, to lethargy, a profound type of slumber where movement or speech is limited, to stupor or deep sleep where arousal is achieved only by repeated vigorous stimuli, finally to coma, unresponsiveness to even painful stimuli. Non-traumatic coma is most common in infants and toddlers with another smaller peak of occurrence in adolescence. The most common cause of non-traumatic altered level of consciousness in children is infection of either the brain (encephalitis), meninges (meningitis), or both; infections account for more than 1/3 of cases. Prolonged seizures, anticonvulsive therapy, and postictal states can also lead to altered levels of consciousness. The most common metabolic cause of alteration of consciousness is diabetic ketoacidosis, which can occur at any age, but is most common in adolescence. Caused by severe insulin deficiency, hyperglycemia and ketogenesis lead initially to polyuria, polydipsia, hyperpnea, vomiting, and abdominal pain. As the process progresses, hyperosmolar dehydration and acid/base and electrolyte disturbances occur. Advanced stages alter level of consciousness and can lead to coma. Alterations of consciousness due to inborn errors of metabolism that present with electrolyte and glucose abnormalities typically present in infancy. The availability of gluconeogenic precursors or the functions of the enzymes required for production of hepatic glucose are affected. Metabolic defects causing hypoglycemia include glycogen storage disease, galactosemia, fatty acid oxidation defects, 6 carnitine deficiency, several of the amino acidemias, hereditary fructose intolerance, and defects of other gluconeogenic enzymes. Toxic ingestion and exposure are very common in toddlers and adolescents, with a toddler's ability to explore his environment filled with often brightly colored medications and intentional ingestion by adolescents typically involving over-the-counter medications or psychotropic drugs such as antidepressants. A 44-year-old man starts to notice that his eyelids are drooping. Some time afterwards, his jaw becomes weak. He has difficulty swallowing and also experiences weakness in his limbs. He is quite embarrassed when he eats because he must use his hand to help support his jaw. His weakness gets progressively worse. Finally, he seeks medical attention. His physical examination demonstrates the weakness in his limbs; however, no sensory defects are present. A Tensilon test is done and is positive. His doctor is concerned about an associated malignancy. What is the underlying pathology of this disease? Answer Choices 1 Inhibition of acetylcholine release 2 Blockage of the sodium channels 3 Demyelination 4 Subacute combined degeneration of the spinal cord 5 Antibodies to the acetylcholine receptor ANS: 5 5 Antibodies to the acetylcholine receptor Antibodies directed towards the acetylcholine receptor at the neuromuscular junction are seen with myasthenia gravis. This man has myasthenia gravis. Ocular muscle weakness, ptosis, dysphagia, and limb weakness can all be seen with myasthenia gravis. When the initial symptom is ocular weakness, Eaton Lambert Syndrome is extremely unlikely. Eaton Lambert Syndrome tends to not involve the extra-ocular muscles or the muscles involving chewing, swallowing, or speech. 7 The Tensilon test is used in the diagnosis of myasthenia gravis. The Tensilon test consists of the administration of edrophonium. Edrophonium is a quick acting anticholinesterase. Thymic tumors are associated with myasthenia gravis. Thymic tumors are also referred to as thymomas. Approximately 10 - 15% of patients with myasthenia gravis have an associated thymoma. The majority of patients with myasthenia gravis have hyperplasia of their thymus. Botulinum toxin inhibits acetylcholine release. The site of action is at the neuromuscular junction. Botulinum toxin is an enterotoxin produced by Clostridium botulinum. Botulism can result from incorrectly canned foods. Antibiotics Antibiotics are the treatment of choice for meningococcemia. The preferred drug for active infection is penicillin G. For those allergic to penicillin, chloramphenicol and cephalosporins (ie, cefotaxime, cefuroxime) may be used as alternatives. Patients will also receive supportive care, but antibiotic therapy must be initiated quickly if the patient is to survive. Intensive care placement may be necessary if organ failure is imminent. Ventilatory support, inotropic support, and IV fluids are necessary in some. If adrenal insufficiency occurs, corticosteroid replacement may be considered. A central venous line helps to provide large amounts of volume expanders and inotropic medications for adequate tissue perfusion. Steroids have not been shown to play a major role in the treatment of meningococcemia. However, they have been used in addition to antibiotic therapy. In the case of adrenal insufficiency, for example, steroid replacement has been shown to be beneficial. Transfusion does not generally play a major role in treatment. If the patient suffers from a devastating coagulopathy, blood or blood products may be replaced as necessary. Bactericidal/permeability-increasing protein is a protein stored in the granules of neutrophils. It binds to endotoxin in vitro and neutralizes it. This technique is experimental, and it is not used in everyday treatment of meningococcemia. In myasthenia gravis, weakness is a result of insufficient acetylcholine transmission at the neuromuscular junction; however, weakness can also occur with overdosing of the cholinergic medications used to treat myasthenia. What symptom helps differentiate a myasthenic crisis from a cholinergic crisis? Answer Choices 1 Respiratory failure 2 Bilateral ptosis 3 Muscle fasciculations 4 Diplopia 5 Normal muscle stretch reflexes ANS: 3 Muscle Fasiculations Signs of cholinergic overdosage include muscle fasciculation, rhinorrhea, lacrimation, salivation, increased bronchial secretions, nausea, or diarrhea. The presence of any of these suggests that the patient's weakness may be due to cholinergic crisis. The other signs are due to weakness and can occur in either condition. A 54-year-old man presents after having a generalized seizure. The patient is HIV positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inquiry, the patient also notes that he has become short- tempered and hypercritical; at times, he seems confused. An MRI of the brain is performed, and it reveals several cortical ring-enhancing lesions. Question What is the most likely diagnosis? Answer Choices 1 AIDS dementia complex 2 Cryptococcal meningitis 3 Cytomegalovirus encephalitis 4 Progressive multifocal leukoencephalopathy 5 Toxoplasma encephalitis ANS:5 Toxoplasma encephalitis The patient's symptoms and MRI findings are most consistent with the diagnosis of toxoplasma encephalitis. Toxoplasmosis is the most common cerebral mass lesion among HIV-positive patients. Infection with the Toxoplasma gondii parasite is relatively common and usually asymptomatic. Reactivation occurs in HIV positive patients due to failing cellular immunity, and it causes a multifocal necrotizing encephalitis. Seizures may be the initial manifestation of central nervous system (CNS) infection; other common clinical manifestations include focal neurologic deficits, such as impaired speech and hemiparesis. Personality change, lethargy, headache, and confusion are also observed. The MRI in patients with toxoplasma encephalitis characteristically reveals multiple, ring-enhancing lesions with surrounding edema; these lesions usually occur bilaterally in the frontal and parietal cortices. AIDS dementia complex describes a constellation of cognitive symptoms Answer Choices 1 Trigeminal neuralgia 2 Bell's Palsy 3 Multiple sclerosis 4 Myasthenia gravis 5 Primary lateral sclerosis ANS: 2 Bell's Palsy Explanation The correct answer is Bell's palsy, which is a condition typically with sudden onset that affects the facial nerve, causing unilateral facial weakness. Trigeminal neuralgia presents with sharp pain on one side of the mouth that radiates to the ipsilateral ear, eye, or nostril. Multiple sclerosis is a demyelinating disorder, causing a multitude of symptoms that typically include diplopia or blurred vision early on, then an insidious onset of progressive weakness, numbness, and/or tingling in the extremities. Myasthenia gravis commonly presents with ptosis and diplopia, as well as difficulty swallowing, fatigue, and muscle weakness. Primary lateral sclerosis is an upper motor neuron disease that causes limb weakness, stiffness, and fasciculations. A 62-year-old man presents with vision problems and difficulty swallowing. Over the last week, he has had a constellation of symptoms; they began with numbness and tingling in his feet and progressed to weakness that now affects both lower and upper extremities. Within the last day, he has started to notice difficulty swallowing and double vision. He also feels it is difficult for him to take a big breath. His past medical history is noncontributory, and he takes no medications. Exam reveals bilateral absence of patellar and ulnar reflexes. A lumbar puncture is performed to confirm the diagnosis. Question What cerebrospinal fluid (CSF) finding is most likely? Answer Choices 1 Decreased CSF glucose content 2 Decreased CSF protein content 3 Elevated CSF polymorphonuclear cell count 4 Elevated CSF protein content 5 Elevated CSF lymphocyte count Elevated CSF proteins Correct response is elevated CSF protein content. Symmetrical ascending paralysis as described in this patient is indicative of Guillain-Barré syndrome (GBS). The cause of GBS is unknown, but it is generally thought to be an inflammatory autoimmune process. More than half of patients with GBS report an antecedent illness. The antibodies produced in response to antigens present in the infectious agent are thought to cross-react with components of human neurons, prompting an acute postinfectious demyelinating process. Lumbar puncture characteristically reveals elevated CSF protein content. Other results are normal, although the white blood cell count may be somewhat elevated. Decreased CSF glucose and increased polymorphonuclear cell counts are seen in acute bacterial meningitis. Decreased CSF glucose and elevated CSF lymphocyte counts are commonly seen with meningitis caused by fungi. Viral meningitides usually presents with elevated lymphocyte counts, normal CSF glucose, and normal or slightly elevated CSF protein levels. A 70-year-old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have became "dull". Over the past month, she has started having urinary urgency and involuntary leaking of urine. Besides multivitamins and local application of the Timolol for glaucoma, she takes no other medications; there are no other symptoms. Question What is most likely the best method of treating the patient's urinary problems? Answer Choices 1 Antimuscarinic drug (Tolterodine) 2 Antibiotic (Sulfamethoxazole/trimethoprim ) 3 Acetylcholinesterase inhibitor approach to the patient should be the "ABCs." After assessing and stabilizing the patient's airway and obtaining IV access, intravenous antibiotics should be given immediately. As bacterial meningitis is associated with high morbidity and mortality, prompt initiation of empirical antibiotics is crucial for better prognosis. The choice of antibiotics is dependent on the patient's age and specific predisposing conditions. Use of broad-spectrum cephalosporins, such as ceftriaxone or cefotaxime with vancomycin, may be used in infants more than 1 month old. Ideally, serum glucose, blood culture, complete blood count, and serum chemistries should be drawn when IV access is obtained; however, drawing labs should not delay beginning antibiotics. Intravenous glucose is necessary if the patient is found to be hypoglycemic; bedside serum glucose is mandatory in any patient that presents with a seizure. Intravenous phenytoin and an MRI of the head might also be necessary for a patient such as the one in the vignette, but would not emergently precede antibiotics. The diagnosis of bacterial meningitis rests on CSF examination performed after lumbar puncture. However, LP is deferred in patients with evidence of increased intracranial pressure, new onset seizure, cardiorespiratory compromise, or focal neurological deficits. Antibiotics should be given, and CT scan of the head should be performed. If CT scan is negative, LP can be performed. A 12-year-old girl presents with a 3-day history of progressive dysarthria, dysphagia, and weakness. The patient was well until 3 days prior to admission to the hospital; at that time, she developed the onset and subsequent gradual worsening of dysarthria. She attributed the dysarthria to a sore throat that she had had about 2 weeks earlier. 3 days prior to admission, she also had the onset of mild dysphagia; it mostly occurred with liquids. 24 hours prior to admission, she developed weakness in both upper extremities, which increased and began to involve the lower extremities. This limb weakness was neither worsened by activity nor improved by rest. She also developed tingling in her toes 24 hours prior to presentation. When she became unable to walk without assistance on the day of admission, she decided to seek medical attention and was admitted to the hospital. Past medical history is significant for measles and mumps. Because of family religious beliefs, she has not had any immunizations. She is very athletic, and frequently plays soccer with friends and siblings in the fields on her grandfather's horse farm. Physical examination reveals a well-developed, well- nourished girl. She is awake, alert, cooperative, and in no acute distress. Temperature is 98.7 F by mouth, blood pressure of 140/80 mm Hg, heart rate is 84/min and regular, and respirations are 22/min and unlabored. There are multiple scratches and abrasions in varying stages of healing over most of her extremities. Her speech is moderately dysarthric. She experiences some mild choking when she tries to drink a glass of water. She can smile weakly, but she cannot raise her eyebrows against resistance. She shows mild bilateral weakness of eye adduction. Pupillary responses are normal. There is mild to moderate upper extremity and mild lower extremity weakness, greater distally than proximally. Her motor strength is sustained over at least 30 seconds without fatigue. Her gait is ataxic, and she cannot walk without assistance. Reflexes are hypoactive to absent, and the response to plantar stimulation is downgoing bilaterally. Sensation is intact, except for mildly impaired position and vibratory sensation in both feet. A complete blood count, chemistry profile, chest X-ray, and EKG are all normal. Computed tomography of the brain, with and without contrast, is negative. A nerve conduction study reveals a moderate degree of mostly motor demyelinating peripheral neuropathy, highly suggestive of Guillain- Barre. Question What statement best describes the patient's prognosis? Answer Choices 1 With a predominantly demyelinating rather than axonal neuropathy, her prognosis is especially bad Sumatriptan The correct response is sumatriptan. This patient's most likely diagnosis is most likely a cluster headache. Pharmacologic management of cluster headache may be divided into abortive/symptomatic and preventive/prophylactic strategies. Abortive agents are used to stop or reduce the severity of an acute attack, and include oxygen, triptans, ergot alkaloids, and anesthetics. Inhalation of high-flow concentrated oxygen is extremely effective for aborting attacks. 5- Hydroxytryptamine-1 (5-HT1) receptor agonists, such as triptans or ergot alkaloids with metoclopramide, are often the first line of treatment. Stimulation of 5-HT1 receptors produces a direct vasoconstrictive effect and may abort the attack. Subcutaneous injection of sumatriptan can be effective, in large part because of the rapidity of onset. Studies have indicated that intranasal administration is more effective than placebo but not as effective as injections. Prophylactic agents are used to reduce the frequency and intensity of individual headache exacerbations. Preventive and prophylactic medications include calcium channel blockers, mood stabilizers, and anticonvulsants. Verpamil is the most effective calcium channel blocker for prophylaxis. It inhibits calcium ions from entering slow channels, select voltage-sensitive areas, or vascular smooth muscle, thereby producing vasodilation and preventing the initial vasoconstrictive phase of cluster headaches. It can be combined with ergotamine or lithium. Preliminary evidence suggests that prophylactic lithium may interfere with substance P and vasoactive intestinal peptide (VIP)-induced arterial relaxation. Anticonvulsants such as Divalproex and Topiramate are preventative medications whose mechanism of action may involve regulation of central sensitization. Prednisone is very effective for aborting the cluster headache cycle or providing intermediate prophylaxis as bridging therapy between acute and prophylactic agents. It is effective for treatment that does not respond to lithium. A 48-year-old woman presents after a seizure. Prior to the seizure, she experienced confusion and disorientation preceded by nausea, vomiting, and blurred vision. Symptoms appeared after working for several hours in the garden under the sun. Her medical history is significant for the presence of schizophrenia, for which she takes chlorpromazine at bedtime. Her temperature is 41 C; BUN and creatinine are elevated; and there is neutrophilia, hemoconcentration, and lactic acidosis. You think that the event is possibly drug-related. Question What is the most likely diagnosis? Answer Choices 1 Heat cramps 2 Neuroleptic malignant syndrome 3 Heat stroke 4 Malignant hyperthermia 5 Heat exhaustion ANS:5 Heat stroke Heat disorders can be exertional and nonexertional. Both can be drug- related. Neuroleptics (e.g., phenothiazines, thioxanthenes) may impair thermoregulation due to both anticholinergic and antidopaminergics effects. Anticholinergics inhibit sweating, therefore disturbing thermoregulation during exercise or under conditions of environmental heat stress. Antidopaminergics elevate the set point of the temperature regulation center in hypothalamus. Your patient most probably suffered heat stroke. It is a life-threatening condition characterized by elevated body temperature with nausea, blurred vision, confusion, disorientation, and seizures. Hemoconcentration, anuria, rhabdomyolysis, kidney dysfunction, lactic acidosis, and even disseminated intravascular coagulation may result. Heat cramps are a mild disorder characterized by painful muscle contractions due to temporary fluids and electrolytes depletion. There are no signs and symptoms of neurological dysfunction, and body temperature is normal. Neuroleptic malignant syndrome is an idiosyncratic reaction to neuroleptics, most commonly phenothiazines and butyrophenones, and it is characterized by rigidity, fever, and autonomic instability. It is not connected with the exposure to heat and exertion. Men under 40 are at greatest risk. Malignant hyperthermia is a nonexertional idiosyncratic reaction to the anesthetic. Heat exhaustion is a condition with a severity that lies between heat cramps and heat stroke. Body temperature might be slightly elevated, and there may be neurological signs like headache, but there will be neither fevers, pain in other areas, and new trauma. She denies polyuria and polydipsia. Her past medical history is unremarkable; she is a menopausal woman, with no known medical conditions, no history of surgeries, no regular medications and no allergies. She lives with her husband, and she is a homemaker. She denies drug, alcohol, and tobacco use. On physical exam, she is a small, thin, pleasant woman, and she is fully oriented. Vitals are normal. No gait or balance abnormalities are noted when she walks or gets onto the exam table. Her left forearm has some mild edema and erythema, as well as tenderness with even light touch. Distribution of findings includes the region from the elbow to wrist, both the anterior and posterior surfaces. Left wrist strength and range of motion are decreased compared to the right. Distal pulses, capillary refill, and reflexes are normal. The remainder of the exam, including mental status, is normal. Question What medication would be most appropriate for this patient's likely diagnosis? Answer Choices 1 Gabapentin 2 Heparin 3 Methadone 4 Probenecid 5 Vancom ycin ANS:1 Gabapentin This patient's diagnosis is most likely a complex regional pain syndrome (CRPS). CRPS most often develops after a minor trauma and classic characteristics include pain out of proportion with findings and history, allodynia (pain sensation with normally non-painful stimuli) and motor and sensory disturbances in the affected extremity. The mechanism for CRPS development is not well understood. Prolonged immobilization following injury is a risk factor for development of CRPS. Diagnosis is clinical, and testing is done to rule out other disorders. Treatment is multi-modal and primarily consists of physical therapy, focusing on mobilization and desensitization. Other treatments are often off-label and targeted at chronic pain relief; they include corticosteroids, bisphosphonates, tricyclic antidepressants, anticonvulsants, and topical anesthetics. Gabapentin would be a reasonable choice for this patient. Heparin would be used if this patient's symptoms were attributed to a deep venous thrombosis (DVT). DVT is rare in the upper extremities; it is not associated with the hyperesthesia and allodynia shown in this patient. Methadone, a longer-acting opioid medication, can be used for chronic pain. However, for several reasons, this is not the most appropriate medication to use in CRPS. Opiates carry addiction potential and increase fall risk in the elderly. CRPS is often categorized as early (<6 months' duration) versus late (>6 months). For early CRPS, opiates should be avoided and even with late CRPS, other medications options should be utilized before initiating opiates. Probenecid is a medication which inhibits urate resorption. It is used for gout, a painful inflammatory condition which may cause acute pain, erythema and swelling in the affected joint(s). Gout tends to be more acute and affect joints (not the forearm, as with this patient). Vancomycin is an IV glycopeptide antibiotic; it is used for severe bacterial infections, including cellulitis. Cellulitis, which commonly presents with erythema, edema and tenderness in an extremity, may be considered on the differential for this patient. Cellulitis tends to occur more acutely. This patient had a normal 8 week exam with symptoms of CRPS, but no findings of cellulitis at that time. A 46-year-old man recently recovered from a bout of influenza, and he now presents due to an 8-hour history of right-sided facial paralysis. He is having trouble closing his right eye, cannot raise his right eyebrow, and cannot smile with the right side of his mouth. Question What medication(s) should this patient be started on? 1 CBC 2 Urinalysis 3 Chemistry panel 4 Serum glucose 5 CSF analysis ANS: 5 CSF analysis The clinical picture is suggestive of meningitis, which is diagnosed after obtaining and evaluating the cerebrospinal fluid (CSF). Although a bulging fontanelle is an indication of increased intracranial pressure (ICP), it is not an automatic contraindication for a lumbar puncture (LP) unless the patient displays additional signs of increased ICP. Tonic seizures would be an example of an indication of increased ICP. Even though this child has had seizures, an LP to run a CSF evaluation is still the best answer. This will be the most important study and diagnostic tool for this child. It is likely that a CT or MRI would be done to look at the level of swelling in the brain, and possibly determine the level of ICP. It would be likely for either of these tests to be done prior to a lumbar puncture. Normally, meningitis causes fever, inactivity, and mental status changes; however, these symptoms are often hard to detect in young children. In infants, signs and symptoms may include appearing to be slow or inactive (lack of alertness), irritable, vomiting, or feeding poorly. When CSF infections are suspected, blood should be obtained for a CBC, general chemistry panel, and culture. However, obtaining CSF analysis is the most important. A 46-year-old man presents with severe insomnia and anxiety. While hospitalized, an overnight polysomnogram was performed over 2 consecutive nights. Sleep latency was 60 minutes; REM latency was 45 minutes. He reports feeling paresthesias deep within his legs while lying in bed, especially while falling asleep. He denies recent illness or illicit drug use. His physical exam and lab work were within normal limits. Question What is the most likely cause of the patient's symptoms? Answer Choices 1 Deep vein thrombosis 2 Peripheral neuropathy 3 Restless legs syndrome 4 Alcoholic peripheral neuropathy 5 Periodic limb movements in sleep ANS:3 Restless leg syndrome Restless legs syndrome (RLS) is a neurological disorder with symptoms of an unpleasant sensations in the legs, such as insects crawling inside the legs, burning, tugging, or creeping. There is an uncontrollable urge to move the limb when at rest (lying down and trying to relax activates the symptoms). Most people with RLS have difficulty falling asleep and staying asleep. Women may be slightly more affected than men. Symptoms may begin at any stage of life, although the disorder is more common with increasing age. The severity of the disorder appears to increase with age. In some patients, symptoms will improve over a period of weeks or months. In most cases, the cause of RLS is idiopathic. A family history of the condition is seen in many cases, suggesting a genetic component. People with familial RLS tend to be younger when symptoms start, and they have a slower progression of the condition. Hypoglycemia can worsen the condition. The disorder is diagnosed clinically by evaluating the patient's history and symptoms. Needle electromyography and nerve conduction studies should be considered if polyneuropathy is suspected on clinical grounds, even if results of neurologic examination are apparently normal. Ropinirole is approved for the treatment of moderate-to-severe RLS. Benzodiazepines may be prescribed for patients who have mild or intermittent symptoms. These drugs help patients obtain a more restful sleep, but they do not fully alleviate the symptoms and can cause daytime drowsiness. For more severe symptoms, opioids may be prescribed since they can cause relaxation and decrease pain. Anticonvulsants, such as carbamazepine and gabapentin, are also useful for some patients; they can decrease the creeping and crawling sensations. There may be no symptoms associated with deep vein thrombosis (DVT), but the classical symptoms of DVT include pain, swelling, redness of the leg, and dilation of the surface veins. Peripheral neuropathy, of which alcoholic peripheral neuropathy is a type, causes tingling or burning pain in the feet. At times, it may be so severe that it interferes with walking, which is a result of injury to sensory fibers. As the condition worsens, the pain typically decreases and numbness increases. Periodic limb movements in sleep are associated with periodic episodes of highly repetitive limb movements during sleep. These repetitive episodes The reactivation of the varicella zoster virus (shingles) can produce severe throbbing, stinging, or other pain symptoms along the affected dermatome. Shingles would be a disorder to consider on this patient's differential, but the patient's young age, lack of skin lesions, and the episodic nature of the attacks fit much better with a diagnosis of cluster headaches. A 73-year-old man presents after a 15-minute episode of right eye vision loss, which he described as being "like a shade being pulled down". What diagnostic test is most likely to be abnormal? Answer Choices 1 Carotid ultrasound 2 Computed tomography 3 Electrocardiogram 4 Erythrocyte sedimentation rate 5 Electroencephalogram ANS:1 carotid u/s The case described above is a classic example of amaurosis fugax, which is caused by transient occlusion of the ophthalmic artery, a branch of the internal carotid artery. This occurs most often in the setting of internal carotid artery stenosis. Like other transient ischemic attacks, it is often a harbinger of an impending stroke. A 42-year-old man presents to the emergency department with a severe headache. He has been getting several of these headaches recently and has tried all over-the-counter pain relievers and headache medicines with no relief. His current headache started 15 minutes ago. He describes the pain as located next to and behind his left eye and "stabbing/excruciating" in nature. He feels like his left eye tears up profusely with these headaches. He reports he has been healthy otherwise, with no chronic medical conditions, no history of surgery, no medications, and no drug allergies. He denies recent stressors that may have caused his headaches. On physical exam, the patient appears slightly agitated and appears uncomfortable. His left eye's conjunctiva is mildly injected, and lacrimation is noted. His right eye is normal. Cranial nerves II-VII are intact, although the patient expresses discomfort when the light is shown in his left eye. Speech, gait, coordination, and reflexes are all normal. The remainder of his exam is normal. Head MRI is performed and reported as normal. Question Which of the following aspects of patient history would be most consistent with this patient's suspected condition? Answer Choices 1 Head injury prior to onset of headaches 2 Periodic episodes of aphasia and gait disturbances 3 Recent exposure to outdoor pollens 4 Rhinorrhea associated with headaches 5 2 to 3-day duration of each headache ANS:4 Rhinorrhea associated with HA This patient is suffering from cluster headaches. Cluster headaches are classified as trigeminal autonomic cephalalgias and are most common in men. Cluster headaches may be triggered by alcohol, histamine, and nitroglycerin, but often no cause is identified. There may be a genetic component. Classic presentation of cluster headache includes episodic, unilateral, severe headache, usually located in the temporal and/or orbital region, along with associated lacrimation, injection, eyelid edema, miosis or ptosis of the ipsilateral eye, and nasal congestion and rhinorrhea associated with the headaches. Imaging studies, such as head MRI, should be performed to rule out other primary causes of headache, A writing disturbance is called agraphia. There are various forms of agraphia. With absolute agraphia, even simple letters cannot be written. This is also referred to as literal agraphia. A 35-year-old man presents with unusual sensations in his legs. He states that his symptoms began in college and were mild, but they have been steadily worsening over the last 4 years. His symptoms begin whenever he is lying down attempting to go to sleep. He describes the sensation as an uncomfortable crawly sensation deep within his legs. If he tries to ignore them, the feeling worsens. He has brief relief with movement, but the feelings return as soon as he is still again. He was given a trial of a benzodiazepine to take at bedtime, but it did not really help. In addition, he complains of being sleepy during the day as a result of the medication. He also tried leg massages and exercise without much relief. His past medical history is significant for depression and anxiety. The patient denies snoring, vivid dreams, or cataplexy. He states that he has a depressed mood and reduced energy and concentration, but he denies suicidal ideation. His physical exam is normal. Complete blood cell count and chemistry panels are normal. Question What is true regarding the patient's condition? Answer Choices 1 Men are affected more than women 2 Opioids are the drug of choice for this condition 3 The condition is caused by a deficiency in calcium 4 Symptoms usually resolve when underlying depression is successfully treated 5 An abnormal electrical impulse conduction study is frequently seen ANS:5 5 An abnormal electrical impulse conduction study is frequently seen An abnormal electrical impulse conduction study is frequently seen in restless legs syndrome (RLS), which is a neurological disorder characterized by unpleasant sensations in the legs and an uncontrollable urge to move when at rest in an effort to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs. Often called paresthesias or dysesthesias, the sensations range in severity from uncomfortable to painful. Needle electromyography and nerve conduction studies should be considered if polyneuropathy is suspected on clinical grounds, even if results of the neurologic examination are apparently normal. The most distinctive aspect of the condition is that lying down and trying to relax activates the symptoms. Many patients with RLS have difficulty falling asleep and staying asleep. The disorder is diagnosed clinically by evaluating the patient's history and symptoms. Women may be slightly more affected than men. Calcium deficiency causes mainly muscle spasm and twitching, and is usually associated with other symptoms of arm and leg numbness, numbness around the mouth, nervousness, heart palpitations, and an inability to sleep, which are all not found in this case. In most cases, the cause of RLS is not known; in some cases, it may be caused by iron deficiency, folic acid deficiency, vitamin B12 deficiency, or arthritis. Sometimes, RLS can be associated with the use of antidepressant medications, necessitating the use of an alternative treatment. A 70-year-old man presents with memory loss that has been worsening over the past few months. He also has history of slurred speech and walking difficulty. There is a history of getting lost in familiar surroundings. His history is also significant for a stroke 2 years ago. On examination, there are focal neurological signs including plantar response, gait abnormalities, exaggeration of deep tendon reflexes, and weakness of the right lower limb. Brain imaging studies show multiple large-vessel infarcts and extensive periventricular white matter lesion. What is indicated by evidence of relevant cerebrovascular disease on brain imaging and by focal signs, along with temporal relationship of stroke and dementia, or abrupt cognitive deterioration and stepwise progression? Answer Choices 1 Lewy body dementia 2 Vascular Dementia 3 Dementia of the Alzheimer's Type 4 Dementia Due to Parkinson's disease 5 Delirium ANS;2 Vascular dementia Dementia is defined as a multifaceted decline in cognitive functioning that causes impaired functioning in daily life. Memory impairment is generally regarded as a necessary aspect, but decline in one or more other cognitive domains (such as language, praxis, gnosis, visuoconstructive function, frontal- executive functions) also should be demonstrated. Vascular dementia is the second most common cause of dementia after Alzheimer's. Multi-infarct dementia is the most common type of vascular dementia. The criteria for the diagnosis of vascular dementia includes evidence of relevant cerebrovascular disease on brain imaging (brain imaging must show infarcts. Vascular dementia may also include behavioral disturbances in the patient. In patients with a delirium, there are usually rapid fluctuations in cognitive functioning, brief durations of normalcy, and disturbances in the sleep-wake cycle. In addition, deliriums come on acutely and rapidly. Deliriums are somewhat common in older patients who have had heart surgery and in those who have experienced a change of environments, such as a hospital intensive unit. Clients with substance-induced dementia have cognitive deficits related to a drug or alcohol use or abuse and/or toxicity of prescription drugs; the toxicity can be accidental or intentional. This appears to be more common in the elderly than once thought. Many elderly take prescription drugs incorrectly or mix them with contraindicated over-the-counter drugs. Also, patients may suffer side effects and not report them to their physicians. Dementia of the Alzheimer's type involves gradual loss of memory and other cognitive functioning, which results in the inability to accomplish activities of daily living. Before a diagnosis is made, all other physiological causes should be ruled out. A 9-year-old boy presents to a neurologist's office accompanied by his mother. She reports that he has had 3 episodes of what she thinks are seizures. She describes these episodes in detail to the neurologist. Question What would lead the neurologist to consider the diagnosis of tonic-clonic seizures? Answer Choices 1 Sudden loss of consciousness with convulsions that do not cease without medical attention and recur on a semi-regular basis 2 Sudden loss of consciousness with convulsions and confusion that lasts about 15 minutes each time, then resolves spontaneously 3 Sudden episodes of staring into space lasting 2-4 seconds each time and occurring 3-6 times per day 4 Alternating jerking of each of his extremities while maintaining consciousness in episodes that last several minutes 5 Episodes of blank staring that last a few minutes, during which he walks the same pattern in the room and does not remember it afterwards ANS:2 Sudden loss of consciousness with convulsions and confusion that lasts about 15 minutes each time, then resolves spontaneously The correct answer is the type of seizure that involves a sudden loss of consciousness with convulsions and confusion that lasts about 15 minutes each time, then resolves spontaneously. These types of seizures are also known as generalized convulsive seizures, or tonic-clonic seizures. They are associated with loss of consciousness, convulsions, and muscle rigidity lasting minutes to hours. Sudden loss of consciousness with convulsions that do not cease without medical attention and recur regularly is not the correct answer because this description is closest to status epilepticus given the recurrent and severe nature. Epilepsy is a condition during which a person has recurrent seizures that typically need medical attention. Any seizure that lasts longer than 5 minutes should be treated medically. Episodes of starting into space that last only a few seconds occur in patients with absence seizures. Absence seizures are a type of generalized seizure known as a generalized non-convulsive seizure. Tonic- clonic seizures involve loss of consciousness and some sort of convulsion, so this type of seizure is not a tonic-clonic seizure. Alternating jerking of each of his extremities while maintaining consciousness in episodes that last several minutes is not the correct answer, as this description closest describes simple partial seizures. Patients with simple partial seizures do not experience loss of consciousness. Question What is the most likely cause of the patient's syncope? Answer Choices 1 Hypoglycemic episode 2 Arrhythmia 3 Neurogenic shock 4 Vasovagal episode 5 Orthostatic hypotension ANS:4 vasovagal episode This patient is having syncope due to a vasovagal episode. This reaction is common in patients who are exposed to blood or are having their blood drawn. In fact, vasovagal episodes are the most common cause of syncope. These individuals typically present with loss of consciousness when exposed to a certain trigger. The trigger leads to an activation of the nucleus tract solitarius of the brainstem, which results in a surge of parasympathetic response, leading to the cardioinhibitory and vasodepressor effects. Although this patient has a history of diabetes mellitus, is not currently hypoglycemic. Hypoglycemia, if severe, can potentially lead to a loss of consciousness. However, diabetics who are hypoglycemic typically have a sympathetic response. Arrhythmia is not the correct answer choice. This patient does not have any cardiac history of arrhythmia. As the patient had the syncopal episode during the blood draw, and there were no ECG changes, this answer choice is unlikely. Orthostatic hypotension is a reasonable answer choice. However, this patient's acute syncopal episode in response to the blood draw makes a vasovagal reaction more likely. In addition, this patient has no history of dehydration or any other cause that would lead to this condition. A 6-year-old girl presents because her teacher is concerned about behaviors at school. The teacher has noticed the girl "staring off into space" frequently throughout the day, and the teacher is able to get her attention only occasionally. There are also periods when she appears to be talking to herself, but there is no sound coming from her mouth. The girl's mother states that there are times when the patient does not seem to be paying attention to what the mother is saying. Shortly after these "episodes", the child engages in conversation without any problem; therefore, the mother did not think the episodes were an issue. There is no concern about other abnormal behavior or discipline issues at home or at school. Question What is the most likely diagnosis? Answer Choices 1 Attention-deficit disorder (ADD) 2 Syncopal episodes 3 Petit mal (absence seizures) 4 Narcolepsy 5 Childhood disintegration disorder (CDD) ANS:3 Petit mal (absence) seizures The patient is probably experiencing petit mal (absence) seizures. Absence seizures are a form of generalized seizures seen in children, and they usually cease by age 20. They are characterized by abrupt onset of impaired consciousness and can be associated with enuresis or automatisms. Patients often appear as though they are "staring off into space" during the seizure, and the episodes often terminate as quickly as they came. These children are often categorized as "being in their own world", leading to a delay in diagnosis or a misdiagnosis of attention deficit disorder. These types of seizures are diagnosed using an electroencephalogram (EEG), showing crusts of bilaterally synchronous and symmetric 3-Hz spike-and-wave activity. Attention-deficit disorder (ADD) is a form of Attention-deficit hyperactivity disorder (ADHD) that is characterized more by inattentiveness without the presence of restless or impulsive behavior. This is the most common emotional, cognitive, and behavioral disorder treated in children/adolescents. The diagnosis is made by careful clinical history, revealing a significant level of inattentiveness and distractibility, plus-or-minus impulsivity, and hyperactivity that is inappropriate for the developmental stage of the child. These patients often change activities frequently, have a hard time with organizational skills, and are commonly caught daydreaming. The symptoms of ADD are usually pervasive, even though they may not occur in all settings. ADD/ADHD also does not involve any impairment of consciousness. Syncopal episodes are better known as "fainting spells." These are episodes of diminished or complete loss of consciousness accompanied by flaccidity that usually occur in relation to postural change, emotional stress, instrumentation, pain, straining, cardiac arrhythmias, or other physiologic disturbance. Associated signs/symptoms include pallor, sweating, nausea, and malaise. While this could be in the differential diagnosis for our patient, the cause of the syncopal episode would still need to be determined by wrist. Occupational injury is most often located in the elbow because of the nerve's proximity to the bony surfaces; therefore, it is susceptible to external compression (e.g., in persons who lean their elbow against a hard surface). In addition, work-related repetitive flexion and extension of the elbow causes narrowing of the ulnar groove, and it results in ulnar nerve entrapment. The diagnosis can be made by radiographs of the elbow, neck, chest, and wrist. Definitive diagnosis is made by electromyography and nerve conduction tests. Conservative treatment can be tried; it should consist of elbow rest and padding, non-steroidal anti-inflammatory drugs (NSAIDs), and vitamin B-6 supplements. If the paresthesias worsen, surgical decompression coupled with transposition can be performed, depending on the site of entrapment. Median neuropathy (carpal tunnel syndrome) characteristically produces a sensory disturbance of the palmar aspect of the hand, thumb, 2nd and 3rd fingers, and the lateral aspect of the 4th finger. Radial neuropathy produces weakness of wrist extension. A C8-radiculopathy produces weakness of all intrinsic hand muscles and does not cause splitting sensory loss of the 4th finger. Radial neuropathy does not cause weakness of the abductor digiti minimi. When there is axillary nerve entrapment, the patient complains of weakness and numbness of the shoulder, with signs of deltoid atrophy. A 52-year-old woman presents with a 1-year history of bilateral shaking in her hands. The shaking tends to worsen when she is using her hands, and her symptoms improve when she drinks a glass of wine on the weekends. Her 82- year-old mother also has a similar shaking in her hands which developed when she was in her 50s. Question What is the most likely diagnosis? Answer Choices 1 Alcohol withdrawal 2 Parkinson's disease 3 Essential tremor 4 Huntington's disease 5 Multiple sclerosis ANS:3 Essential tremor (or benign tremor) typically involves the hands or head, but it spares the legs. The cause is unknown, but it may be inherited. Patients note that the tremor develops when moving the hands. The symptoms may worsen in times of stress, and they may be alleviated by alcohol intake. Alcohol withdrawal may be associated with a tremor, but is unlikely given the duration of the tremor. The tremor of Parkinson's disease is typically a resting tremor; this patient is not experiencing other symptoms of Parkinson's disease (e.g., rigidity, bradykinesia, and postural instability). Huntington's disease may be associated with abnormal movements and is inherited in a familial matter; however, Huntington's disease is typically fatal within 20 years of onset. This patient notes that her mother has been suffering from her tremor for close to 30 years. Multiple sclerosis is not typically associated with tremor. A 32-year-old woman presents due to "I'm feeling odd." Further questioning reveals the patient experiencing a significant amount of involuntary movements and a severe lack of coordination; she recently had a significant decrease in cognitive abilities. Because she is an established patient, you recall that the patient got married about a year ago; past family history is unknown due to the fact that the patient was adopted as a child. Physical examination reveals rapid, involuntary movements of fingers bilaterally, impaired ability to concentrate, minor slurred and disorganized speech, as well as difficulty responding with the appropriate words or phrases when prompted. Answer Choices 1 Traumatic Brain Injury 2 Dysthymia 3 Complex partial seizures 4 Post Concussion Syndrome 5 Subdural hemorrhage ANS:4 Post concussion syndrome This adolescent displays the characteristic features of post-concussion syndrome, which is usually diagnosed on the basis of presence of 3 out of the following 8 features after a significant injury event: 1) headache; 2) dizziness; 3) fatigue; 4) irritability; 5) insomnia; 6) concentration or 7) memory dif?culty; and 8) intolerance of stress, emotion, or alcohol. It is unlikely to be a traumatic brain injury because he had a short duration of loss of consciousness, normal head CT, and his current neurologic exam is normal. Symptoms of dysthymia or depression can seem to overlap with those of PCS, but he had no such symptoms prior to the traumatic event. Complex partial seizures are unlikely; they are usually associated with focal seizure activity in the form of tonic/tonic-clonic movements. Subdural hemorrhage is usually evident on head CT, but delayed subdural hemorrhages are rarely seen. In those situations, they are associated with abnormalities on neurologic examination. A 22-year-old man presents after being hit on the right temple by a baseball 1 hour ago. He lost consciousness for 2 minutes after the impact, but he did not seek immediate medical attention. He has no other significant medical problems and family history is unremarkable. On presentation, he is comatose, with no response to painful stimuli. There is anisocoria with fixed dilatation of the right pupil. Vital signs are as follows: BP 100 / 66 mm Hg, RR 14 rpm, HR 62 bpm, temperature 36.6 °C (97.9 F). What is the most appropriate next step to confirm the suspected diagnosis? Answer Choices 1 MRI of the brain 2 Perform a lumbar puncture 3 Burr hole craniotomy 4 Computed tomography of the brain 5 Observation only ANS:4 CT The signs and symptoms described in this clinical scenario are consistent with an acute epidural hematoma. This lesion's pathophysiology is a dural tear with laceration of an artery or, less commonly, a vein. The most commonly injured vessel is the middle meningeal artery (66% of cases), but lesions of the anterior ethmoidal artery and the dural sinuses may also occur. About 85- 95% of these cases are associated with a fracture of the skull. However, there is little injury to the underlying intracranial components; because of this, the prognosis is good. Other findings, such as intracranial air or vascular malformations, may also be present. Due to the progressiveness of this pathology if not treated, immediate diagnosis and surgical intervention is required. The most commonly used method to make this diagnosis to date is a non- contrast CT of the head. Not only will this help locate the hematoma, this will also help visualize any other abnormalities that may be present, such as skull fractures. A CT scan would also enable the patient to be observed during the entirety of the procedure to ensure his stability and safety. MRI of the brain may be considered appropriate, however should not be used in any patients who are unstable. Due to the patient being comatosed with no response to painful stimuli, this would not be an acceptable choice. Burr hole craniotomy is used primarily in the treatment approach in a rapidly deteriorating patients with signs of imminent herniation. Although the patient is in a comatose state, his vitals are acceptable. Knowing if there is indeed an epidural hematoma as well as where it is located will both be accomplished via a CT of the head. A lumbar puncture would not be an acceptable choice in this patient scenario and in fact may result in detrimental results. Observation only would also most likely have devastating circumstances A 74-year-old woman presents for management of an ischemic stroke. She reports difficulty seeing objects on her right side. You perform confrontational visual field testing as part of your neurological examination, and you discover she has a right inferior homonymous quadrantanopsia. This lesion localizes to what part of the body? Answer Choices 1 Left optic tract 2 Optic chiasm 3 Left optic nerve 4 Left parietal lobe 5 Right optic tract ANS:4 Left parietal lobe Quadrantanopsia (visual loss in a quadrant of the visual field) may result What is the most likely cause of this patient's facial droop? Answer Choices 1 Bell's palsy 2 Sarcoidosis 3 Ramsay-Hunt syndrome 4 Lyme disease 5 Cerebrovascular accident (CVA) ANS:1 bell's palsy This patient has a classic presentation of Bell's palsy. Bell's palsy is a sudden, unilateral facial weakness and affects about 1 out of every 60 or 70 persons in their lifetime. The etiology is unknown at this time, but herpes simplex virus type 1 has been associated with some cases. The presumed pathogenesis of the palsy is that inflammation of the facial nerve causes swelling then secondary compression, and ischemia occurs where the nerve courses through the temporal bone. Pain behind the ear may precede the paralysis by a day or 2. Hyperacusis and loss of taste may occur, if the lesion is proximal enough; lacrimation may be affected as well. Sensation is not affected, although patients may experience numbness or heaviness in the face. In some cases, there is a mild lymphocytosis of the CSF. MRI may reveal swelling and uniform enhancement of the geniculate ganglion and facial nerve. Also, in some cases, MRI may reveal a swollen facial nerve entrapped within the temporal bone. Prognosis depends upon the degree of paralysis. Approximately 80% of patients will recover within a few weeks to a month. Of those with an incomplete paralysis in the 1st week, nearly all will experience complete recovery within several months. Of those with a more complete paralysis, like this patient, nerve conduction studies and electromyography can indicate prognosis. The likelihood of completely recovery is 90% if the nerve branches in the face retain normal excitability to supramaximal electrical stimulation; however, the likelihood is only about 20% if electrical excitability is absent. Treatment includes symptomatic care, such as taping the upper eyelid closed during sleep and using lubricating agents in the eye In order to prevent corneal desiccation. Some studies have shown improvement in patients treated with glucocorticoids; other studies showed improvement with prednisone and acyclovir together. Sarcoidosis can cause a form of bilateral facial paralysis (facial diplegia) called uveoparotid fever (Heerfordt's syndrome). Given this patient's African American background, sarcoidosis should be considered as a possible etiology of her symptoms. However, the unilateral nature of the paralysis, combined with a negative chest X-ray, makes sarcoidosis unlikely. A serum angiotensin converting enzyme (ACE) could be drawn if sarcoidosis is a concern. Ramsay-Hunt syndrome is a facial palsy associated with a vesicular eruption in the pharynx, external auditory canal, and other surrounding areas of skin. This is thought to be secondary to herpes zoster infection of the geniculate ganglion; often the 8th cranial nerve is affected, as well. This patient did not have any skin lesions around the ear, thus making this diagnosis very unlikely. However, this demonstrates the importance of a thorough examination in facial palsy patients, including careful examination inside the ears. Lyme disease is a frequent cause of facial paralysis in areas where Lyme infection is endemic. However, the majority of patients who have facial palsy caused by Lyme disease note an antecedent rash adjacent to the site of a tick bite. Blood tests for Lyme disease can help identify that as an etiology. However, this patient denied any risk factors for tick bites such as camping/ travel, making this diagnosis less likely. The family history of CVA and the fact that she is currently taking oral contraceptives do confer some A 16-year-old girl is brought to the emergency room for evaluation of continuous seizures. The patient was first diagnosed with idiopathic epilepsy at age 10. She was started on valproic acid. Phenobarbital and carbamazepine (Tegretol) have been tried without success, and the phenobarbital resulted in transient severe personality changes. 2 previous EEG's have been normal. This spell occurred abruptly at the family dinner table without apparent warning. Past medical history has been normal except for the usual childhood diseases without complications. 2 days prior to presentation, she saw her primary physician for nausea and vomiting; as he believed she had the flu, he started her on prochlorperazine (Compazine), which relieved her nausea. Physical exam reveals a well-developed, well-nourished young woman lying on a gurney; there is continuous but variable motor jerking of all 4 extremities. The jerking varies in intensity from side to side. The head intermittently turns from side to side. Eyes are closed tightly and cannot be passively opened. Old cutdown sites in the right antecubital fossa and left supraclavicular regions are noted. Deep tendon reflexes cannot be assessed. The response to plantar stimulation is withdrawal bilaterally. There are no signs of trauma to the head or elsewhere. Skin is warm and dry with normal color, and vitals are normal. The general medical exam is otherwise normal. Labs are done stat, and they include normal complete blood count and differential, normal chest X-ray, normal urinalysis on cathed specimen, normal chemistry profile, and normal arterial blood gases. Question Pseudoseizure (psychological rather than epileptic event) is suspected. What test would be of greatest value in this acute clinical setting in differentiating pseudoseizures from true epileptiform seizures? Answer Choices 1 Stat electroencephalogram (EEG) 2 Stat serum prolactin level 3 Stat creatine kinase (CK) 4 Stat referral to a comprehensive epilepsy center 5 Stat psychiatric referral ANS:1 stat EEG If an electroencephalogram can be obtained on a stat basis, it can be of immeasurable help in differentiating pseudoseizures from true seizures. During a spell suggesting generalized tonic-clonic seizure, the electroencephalogram should show generalized spike and wave activity; after the spell, it should show generalized slowing and disorganization lasting 30- 90 minutes. Even if the active phase of the spell were over before the electroencephalogram, if done in this 30-90 minutes post-event time frame, it could be compared with a later electroencephalogram, which would probably be normal in case of pseudoseizure (5). If an electroencephalogram is normal during or immediately after this event, it is major evidence against epilepsy and for pseudoseizures. In view of the above, and with a history of 2 previous normal electroencephalograms, obtaining an outpatient electroencephalogram or one during subsequent admission would most likely be a waste of time and money. If a video camera were available, video recording the patient during a spell, especially during electroencephalography, may provide excellent evidence or even lead to a definitive diagnosis. A serum prolactin level is a very good test in differentiating seizure from pseudoseizure; most generalized seizures, and many complex partial seizures, result in elevated levels during this initial 30- minute period following the event (1). It should be done but the results may not be back for several days. In a study by Holtkamp et al., serum creatine kinase (CK) in psychogenic status had a mean of 39 U/L (range 16-90), but in true epileptic status the mean was 699 with a range of 57-2,625 (1). In this study, creatine kinase began to rise after a delay of 3 hours and peaked after more than 36 hours. Therefore, it will not help in an emergency room setting, but it should be done and repeated (e.g., at 12, 24, and 36 hours after the event), as it can provide good evidence later on for true seizures (levels will rise) or against seizures, and for pseudoseizures if levels do not rise or rise only minimally. Through the use of 24-hour electroencephalography and video monitoring, comprehensive epilepsy centers can be extremely valuable and even definitive in differentiating pseudoseizures from true epileptic seizures. However, they are tertiary centers for evaluation of patients who have not received definitive diagnoses or have not responded to treatment for either. Also, these centers are not that common, and referral can be prolonged and complicated. As valuable as psychiatric referral could be if the patient is having pseudoseizures, a consult at this time would not be helpful. The patient's condition would preclude any meaningful interview. Also, pseudoseizure is a diagnosis of exclusion, and a full evaluation for other causes of her spells has not yet been done. Furthermore, premature referral could negatively impact cooperation from the patient and family. Psychiatric referral should be considered only after a firm diagnosis of pseudoseizures has been made, or where it becomes apparent that behavioral input is necessary to help in this differential. Summary of objective diagnostic testing that can be done to differentiate seizures from pseudoseizures: and ancillary lab testing do not define the subtype. The patient is best subtyped at this time as Relapsing Remitting MS. Subtyping may change over time with new clinical events. This patient might later develop persistent clinical disability (e.g., severe ataxia, persistent urinary incontinence, extremity weakness, diplopia, etc.). She would then best be reclassified as Secondary Progressive MS, whether these occurred as residua of discrete relapses or as an independent progressive deterioration independent of relapses. Unlike the classic Relapsing/Remitting presentation of MS, some patients present with a progression of neurological disability with no clear relapses, per se. These are subtyped as Primary Progressive MS. Some patients may initially rate a Primary Progressive MS rating, yet later develop episodes of superimposed relapses and remissions. These patients are then reclassified as Progressive Relapsing MS. A 31-year-old man with a known generalized seizure disorder is brought to your emergency department. His friends tell you that the patient had a seizure and did not wake up. When he did not wake up after 30 minutes, his friends called 911. On examination, he is breathing and his heart is beating. He is warm, dry, and pink. His basic laboratory values are within normal limits, and the computerized axial tomography (C.A.T.) scan of his brain is unremarkable. An emergency electroencephalogram (E.E.G.) is not available. His only medications are phenytoin and phenobarbital. What is the best initial treatment in this case? Answer Choices 1 Glucose 2 Lorazepam (Ativan) 3 Phenytoin (Dilantin) 4 Phenobarbital 5 Craniotomy with burr hole placement by a neurosurgeon ANS:2 lorazepam (Ativan) According to consulting neurologist Wade S. Smith, Audio-Digest Family Practice, Vol. 49, 2001, "Consciousness is usually regained in a few minutes following a generalized seizure. When consciousness is not promptly regained following a seizure, then the diagnosis of status epilepticus becomes a reasonable consideration." When the emergency electroencephalogram (E.E.G.) is not readily available on a 24-hour basis, Professor Smith recommends that empiric pharmacotherapy for a working diagnosis of status epilepticus be provided. The first pharmacotherapy recommended for status epilepticus is lorazepam (Ativan). The second line pharmacotherapy for status epilepticus is phenytoin (Dilantin). The third line pharmacotherapy for status epilepticus is phenobarbital. Note that the absence of tonic-clonic movements does not exclude the diagnosis of status epilepticus, as it is possible that it will present with the solitary manifestation of persistent loss of consciousness. With his normal laboratory values, glucose would not be of value for this patient. Additionally, with the normal computerized axial tomography (C.A.T.) scan, the neurosurgical placement of burr holes by craniotomy would be nonfunctional A 60-year old woman has a history of stress related migraine headaches. Many conventional treatments have failed. What treatment would you now try on this client? Answer Choices 1 Aversion therapy 2 Biofeedback 3 Flooding roommate of stealing his food from their shared refrigerator. He complained that he could not smell his food. Several times, he was noted to be having staring spells and lip smacking; during these episodes, he did not respond to his roommate. The spells lasted less than 1 minute. On the day of presentation, the roommate returned to the dorm to find the patient standing naked in the hallway outside their room; he was screaming "We're going to settle this now!" He then fell to the floor and sustained a major motor seizure. The patient's mother denies a history of major illness, but reveals he had measles and chicken pox as a child. The roommate states that the patient drinks a lot of beer at weekend parties and smokes marijuana occasionally, but he denies knowledge of other drug use. There is no history of seizures. Exam shows a well-developed, lean, muscular young man. He is lying on a gurney and fighting his restraints. He is alert but mute, and he is unresponsive to the spoken word. Temperature is 101.2 F (taken rectally). Heart rate is 110 and regular; respirations are 22 and unlabored. Blood pressure is 140/85 mm Hg. Neurological exam is limited by patient agitation and lack of cooperation, but it reveals normal pupils and eye movements, full symmetric facial movements, a mild right hemiparesis, and right extensor plantar response. Labs include complete blood count with a white blood cell count of 8,500; there is a normal differential. The chemistry profile, chest X- ray, and electrocardiogram are normal. Stat computed tomography of the head with contrast reveals left inferomedial temporal and frontal confluent areas of hypointensity with surrounding edema as well as scattered areas of hemorrhage in the same regions. These areas enhance densely. Cerebrospinal fluid exam reveals moderately elevated pressure, mildly elevated protein, and 267 white blood cells (80% lymphs, 20% polymorphs). Glucose is normal. Question What is the most likely cause of this patient's illness? Answer Choices 1 Herpes simplex encephalitis 2 Acute hemorrhagic leukoencephalitis 3 Subdural empyema 4 Cerebral abscess 5 Cerebral venous thrombosis 6 Septic embolism 7 Ruptured saccular aneurysm ANS:1 HSv encephalitis This is a rather classic presentation for focal encephalitic form of herpes simplex encephalitis. A prodrome of fever and headache is common. Anosmia, apparent temporal lobe seizures, and personality changes point to the inferomedial temporal and frontal regions. A convulsion is frequently the event that precipitates admission. The computed tomogram is classic. The cerebrospinal fluid is typical, but it can be normal early in the clinical course. This is the most common and serious of the acute encephalitides. This is a very grave illness, and it must be recognized and treated with antiviral agents (acyclovir) as soon as possible. Acute hemorrhagic leukoencephalitis is seen mostly in children, but it can also be seen in young adults. However, it is almost always preceded by symptoms of respiratory infection of 1 - 14 days duration. These patients may also develop headache and confusion, but neck pain and signs of meningeal irritation are more common and pronounced. Anosmia and temporal lobe seizures would be less common or pronounced. In this condition, white blood cell counts as high as 20,000 - 30.000 can be an important point of differential. Cerebrospinal fluid may be identical, but pleocytosis of up to 3,000 can help to differentiate it from herpes simplex encephalitis. The most helpful information at this point in differentiating this condition is the computed tomogram and magnetic resonance imaging scan, which would be expected to show diffuse asymmetric, large, and confluent edematous lesions in the white matter, with multiple small hemorrhages in both white and gray matter. Subdural empyema is a suppurative condition between the inner surface of the dura and the outer surface of the arachnoid. Since it occurs in a preformed space, it is properly termed an empyema, although it is frequently and erroneously called subdural abscess. It most commonly follows a worsening of chronic sinusitis, in which cases it most commonly involves adolescent and young men. There is usually a history of worsening of brow or mastoid pain and nose or outer ear canal purulent discharge. Fever, malaise, and headache appear. The headache pain worsens, and then becomes generalized; vomiting is frequent. Focal neurological signs may appear, and stupor and coma may ensue. Fever, leukocytosis, and stiff neck are almost universal. Cerebrospinal fluid is rather similar to that seen in herpes simplex encephalopathy. However, computed tomography scan of the head shows ear or sinus lesions and possible bone erosion. Enhanced meninges around the pus may be seen. Magnetic resonance imaging is more likely to visualize the empyema. About 40% of cerebral abscesses are related to diseases of the paranasal sinuses, middle ear, and mastoid air cells. Other conditions include bronchiectasis, lung abscess, acute bacterial endocarditis, congenital heart disease, pulmonary arterial venous malformation (AVM), abscessed teeth, osteomyelitis, or other sites of bacterial infection. The clinical course may be as seen in this patient, but onset and progression are much more variable depending on where the abscess is and the stage of development it has identifiable cause, within 7 days of giving a dose of DTaP or DTP), it is a contraindication for subsequent doses of DTaP. Acute neurological illness after receiving DPT can have chronic neurological sequelae. The National Childhood Encephalopathy Study (NCES) data also are consistent with a possibility that some children with underlying brain or metabolic abnormality can have acute neurologic illness triggered by DPT, which might go to chronic nervous system dysfunction, which further affects the physical, social, behavioral, and educational outcome of children. Therefore, encephalopathy is a contraindication for subsequent doses of DTaP. If the infant has progressive or unstable neurologic disorder, including infantile spasms, uncontrolled seizures, or progressive encephalopathy, defer vaccination with DTaP or TdaP until the condition is stabilized. If the infant develops a fever of 105º or above following a dose of DTaP, it is not a contraindication for subsequent dose of DTaP. Risk and benefits of the vaccine should be carefully considered. Consider giving acetaminophen before and every 4 hours thereafter for 24 hours after giving the vaccine. Collapse or shock-like state, i.e., hypotonic hyporesponsive episode, within 48 hours after receiving a previous dose of DTP or DTaP is not a contraindication, but it is important to consider the benefits and the risks. If the benefits are believed to outweigh the risk (e.g., during an outbreak or foreign travel), give the vaccine under careful observation in a facility where anaphylaxis can be recognized and managed. Seizure within 3 days of a dose of DTaP is not a contraindication, but needs precaution and a consideration of the risks and the benefits. If the benefits outweigh the risk (e.g., during an outbreak or foreign travel), the vaccine should be given under observation. Persistent inconsolable crying lasting for 3 or more hours occurring within 48 hours of dose is not a contraindication, but it is important consider the benefits and the risks of this vaccine under the circumstances. If the benefits outweigh the risk (e.g., during an outbreak or foreign travel), give the vaccine. A 40-year-old man presents with drooping of eyelids and difficulty getting up from a sitting position. He also gives a history of impotence and frequent dryness of his mouth. On examination, he is found to have ptosis, depressed reflexes, and loss of power in the proximal muscle groups of the lower extremity. On electrodiagnostic testing, he is found to have incremental response on repetitive nerve stimulation. What is the likely diagnosis in this patient? Answer Choices 1 Neurasthen ia 2 Botulism 3 Lambert Eaton syndrome 4 Progressive external ophthalmoplegia 5 Myasthenia gravis ANS:3 Lambert eaton syndrome The above history and findings are suggestive of Lambert-Eaton syndrome. Lambert-Eaton myasthenic syndrome (LEMS) is a presynaptic neuromuscular disorder that causes weakness of the muscles. LEMS is caused by antibodies directed against the calcium channel on the motor nerve terminal, leading to the decreased release of acetylcholine. 1/2 of the patients have an autoimmune form, the other half have a tumor-associated form (usually small-cell lung cancer) of the disease. Hence a thorough investigation has to be done to detect occult malignancy. Clinical features include: Weakness of proximal muscle groups initially (especially the lower limb) and later other muscles. ibuprofen for shoulder pain, he does not take any medications. Question The patient's symptoms are most consistent with what disorder? Answer Choices 1 Central sleep apnea 2 Insomnia 3 Medication side effect 4 Narcolepsy 5 Obstructive sleep apnea ANS:4 Narcolepsy Based on the symptoms described, the patient is most likely to have narcolepsy. Narcolepsy is marked by 4 major symptoms: 1) excessive daytime sleepiness; 2) cataplexy; 3) sleep-related hallucinations;and 4) sleep paralysis. It is a central sleep disorder that is attributed to abnormal neurotransmission in the brain's sleep centers. Daytime sleepiness can be so severe that it results in involuntary somnolence during activities such as driving or talking. Cataplexy describes the brief loss of muscle tone that can occur sporadically during waking hours. Patients also may suffer from visual, auditory, or tactile hallucinations at the onset of or upon awakening from sleep. In addition, they may experience inability to move on falling to or emerging from sleep (sleep paralysis). Obstructive sleep apnea is defined as partial or complete upper airway obstruction caused by anatomic collapse of pharyngeal structures. Patency of the upper airway is partially (hypopnea) or completely (apnea) lost during sleep. This results in the development of progressively increasing inspiratory effort against an obstructed glottic opening, leading to the build-up of increasingly negative intrathoracic pressure. At some point, brain stem reflexes result in an altered sleep state that prompts reopening of the airway. This may awaken the patient or be observed as a "gasping" respiratory effort by an onlooker. Snoring is indicative of obstructed airflow, and daytime somnolence is a function of disrupted sleep. Central sleep apnea is an uncommon neurological condition that involves impairment of a patient's normal spontaneous cue to breathe based on changes in blood oxygen and carbon dioxide levels. The symptoms are similar to those of obstructive sleep apnea. Insomnia is a generic condition marked by difficulty falling asleep or inability to remain sleeping for extended periods of time. It is a symptom, not a diagnosis in and of itself. Sleep derangement is a common medication side effect; it is especially observed with psychotropic medications. There is no reason to suspect medication-related sleep impairment in this patient because he reports no medication use. A 55-year-old man starts to develop behavioral and mental changes. In addition, he is having coarse, spasmodic, involuntary movements that involve his face and his extremities. What is the classification of this abnormal movement? Answer Choices 1 Chorea 2 Athetosis 3 Ballism 4 Asterixis 5 Dysto nia ANS:1 chorea Chorea is a spasmodic involuntary movement that involves the face and limbs. Chorea can be seen with Huntington's disease (Huntington's chorea). Athetosis is slow, writhing, twisting involuntary movement. Almost all parts of the body can be affected by athetosis. Speech can also be affected when the athetosis is affecting the tongue. Depending on the characteristic of the movements that are seen, it is sometimes modified and called choreoathetosis or athetotic dystonia. Athetosis can be seen with cerebral palsy and some other conditions. Ballism is a flailing, jerky movement of the limbs. It affects the proximal muscles. If the abnormal movement is on one side, it is called hemiballism. Asterixis is also called "liver flap". It is a flapping movement of the hands or arms. During the physical examination to test for asterixis, have the patient hold up his hands (dorsiflex) and spread his fingers. Asterixis is seen with metabolic encephalopathies. Dystonia is an abnormal movement where there is abnormal contraction of muscles. Dystonia can be divided into primary and secondary. Spasmodic torticollis is a form of dystonia. A colleague asks you to provide a neurosurgical consultation on a 75-year-old man. The consultation request form informs you that, "This man is having difficulty tolerating his medications as well as difficulty with his day-to-day activities". Your colleague wants to know if neurosurgery could help the