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Self-Assessment Test pet Which of the following is the most appropriate preventive ® Item 82 — oad measure? < A 36-year-old woman is evaluated for left-sided facial a (A) Citalopram weakness. Over the last 10 days she has developed pro- = wn gressive weakness on the left side of her face, which is (B) Gabapentin wn <8) apparent with eye closure, smiling, and chewing. She has wn (C) Indomethacin wn also reduced tearing and diplopia. She is otherwise well and (D) Lamotrigine = takes no medications. ees ao (E) Venlafaxine On physical examination, vital signs are normal. Left "2) upper and lower facial muscles and muscles of mastication are weak. She has difficulty closing her left eye and dimin- Item 80 ished leftward gaze. Left corneal reflex is impaired. Facial A 22-year-old woman is evaluated for a 5-year history sensation is preserved. The rest of the neurologic examina- of seizures that occur twice monthly, last 2 minutes, and tion is unremarkable. are characterized by staring, lip smacking, and confusion. Which of the following is the most appropriate next step in These seizures have continued despite treatment with two management? adequately dosed antiepileptic medications (carbamaze- pine, followed by levetiracetam, both of which have been (A) Electromyography of face muscles discontinued owing to insufficient ability to control sei- (B) MRI of brain zures). Her current medication is lamotrigine at maximum (C) Oral acyclovir dose, which she tolerates well with no adverse effects. On physical examination, vital signs are normal. All (D) Prednisone other examination findings, including those from a neuro- (E) No further testing or intervention logic examination, are unremarkable. Results of outpatient routine electroencephalography (EEG) are normal. Item 83

Which of the following is the most appropriate preventive ® Item 82 — oad measure? < A 36-year-old woman is evaluated for left-sided facial a (A) Citalopram weakness. Over the last 10 days she has developed pro- = wn gressive weakness on the left side of her face, which is (B) Gabapentin wn <8) apparent with eye closure, smiling, and chewing. She has wn (C) Indomethacin wn also reduced tearing and diplopia. She is otherwise well and (D) Lamotrigine = takes no medications. ees ao (E) Venlafaxine On physical examination, vital signs are normal. Left "2) upper and lower facial muscles and muscles of mastication are weak. She has difficulty closing her left eye and dimin- Item 80 ished leftward gaze. Left corneal reflex is impaired. Facial A 22-year-old woman is evaluated for a 5-year history sensation is preserved. The rest of the neurologic examina- of seizures that occur twice monthly, last 2 minutes, and tion is unremarkable. are characterized by staring, lip smacking, and confusion. Which of the following is the most appropriate next step in These seizures have continued despite treatment with two management? adequately dosed antiepileptic medications (carbamaze- pine, followed by levetiracetam, both of which have been (A) Electromyography of face muscles discontinued owing to insufficient ability to control sei- (B) MRI of brain zures). Her current medication is lamotrigine at maximum (C) Oral acyclovir dose, which she tolerates well with no adverse effects. On physical examination, vital signs are normal. All (D) Prednisone other examination findings, including those from a neuro- (E) No further testing or intervention logic examination, are unremarkable. Results of outpatient routine electroencephalography (EEG) are normal. Item 83 Which of the following is the next most appropriate man- A 75-year-old man is evaluated for progressive cognitive impairment over the past year that has led to loss of daily agement? function. He loses his train of thought and misplaces items (A) Phenytoin at home. His gait has slowed, and his behavior has changed. (B) Temporal lobectomy He has hypertension, hyperlipidemia, type 2 diabetes mel- (C) Vagus nerve stimulator litus, and coronary artery disease. Current medications are lisinopril, carvedilol, atorvastatin, metformin, canagliflozin, (D) Video EEG monitoring and aspirin. On physical examination, blood pressure is 153/85 mm Item 81 Hg and pulse rate is 65/min. Deep tendon reflexes are normal; gait is slowed. No hypomimia, hypophonia, A 62-year-old woman is evaluated in the emergency depart- tremor, rigidity, or shuffling gait is observed. He demon- ment for a 1-hour history of left-sided weakness. The patient strates slowed processing speed when generating word also has hypertension. Medications are amlodipine, chlor- lists. thalidone, and low-dose aspirin. MRI of the brain shows diffuse, confluent white matter On physical examination, blood pressure is 190/105 mm hyperintensities and no significant hippocampal atrophy. Hg; all other vital signs are normal. The patient is awake and attentive. The pupils are 2 mm in diameter and reactive to Which of the following is the most likely diagnosis? light. A left visual field defect, left-sided hemineglect, left facial weakness, and left arm and leg paralysis on the left are noted. (A) Alzheimer disease (B) Dementia with Lewy bodies Laboratory studies: Hemoglobin 12 g/dL (120 g/L) (C) Frontotemporal dementia, behavioral-variant type INR 14 (D) Vascular cognitive impairment Platelet count 320,000/uL (320 x 10°/L) Activated partial Normal thromboplastin time Item 84 Prothrombin time Normal A 74-year-old man is evaluated for fatigue and lack of energy. He had a pontine infarction 2 months ago. He has A CT scan reveals an intracerebral hemorrhage in the hypertension, diabetes mellitus, and dyslipidemia. Current right basal ganglia with a 1-mm midline shift and no intra medications are aspirin, hydrochlorothiazide, atorvastatin, ventricular extension. and metformin. Which of the following is the most appropriate treatment? On physical examination, vital signs are normal. BMI is 26. He has left facial weakness, slurred speech, left arm (A) Intravenous nicardipine and leg weakness (grade 4+/5 muscle strength) with slower (B) Intravenous nitroprusside finger and toe tapping, and a wide-based gait using a cane. (C) Platelet transfusion The remainder of the neurologic and medical examinations ( D) Prothrombin complex concentrate is normal.

Which of the following is the next most appropriate man- A 75-year-old man is evaluated for progressive cognitive impairment over the past year that has led to loss of daily agement? function. He loses his train of thought and misplaces items (A) Phenytoin at home. His gait has slowed, and his behavior has changed. (B) Temporal lobectomy He has hypertension, hyperlipidemia, type 2 diabetes mel- (C) Vagus nerve stimulator litus, and coronary artery disease. Current medications are lisinopril, carvedilol, atorvastatin, metformin, canagliflozin, (D) Video EEG monitoring and aspirin. On physical examination, blood pressure is 153/85 mm Item 81 Hg and pulse rate is 65/min. Deep tendon reflexes are normal; gait is slowed. No hypomimia, hypophonia, A 62-year-old woman is evaluated in the emergency depart- tremor, rigidity, or shuffling gait is observed. He demon- ment for a 1-hour history of left-sided weakness. The patient strates slowed processing speed when generating word also has hypertension. Medications are amlodipine, chlor- lists. thalidone, and low-dose aspirin. MRI of the brain shows diffuse, confluent white matter On physical examination, blood pressure is 190/105 mm hyperintensities and no significant hippocampal atrophy. Hg; all other vital signs are normal. The patient is awake and attentive. The pupils are 2 mm in diameter and reactive to Which of the following is the most likely diagnosis? light. A left visual field defect, left-sided hemineglect, left facial weakness, and left arm and leg paralysis on the left are noted. (A) Alzheimer disease (B) Dementia with Lewy bodies Laboratory studies: Hemoglobin 12 g/dL (120 g/L) (C) Frontotemporal dementia, behavioral-variant type INR 14 (D) Vascular cognitive impairment Platelet count 320,000/uL (320 x 10°/L) Activated partial Normal thromboplastin time Item 84 Prothrombin time Normal A 74-year-old man is evaluated for fatigue and lack of energy. He had a pontine infarction 2 months ago. He has A CT scan reveals an intracerebral hemorrhage in the hypertension, diabetes mellitus, and dyslipidemia. Current right basal ganglia with a 1-mm midline shift and no intra medications are aspirin, hydrochlorothiazide, atorvastatin, ventricular extension. and metformin. Which of the following is the most appropriate treatment? On physical examination, vital signs are normal. BMI is 26. He has left facial weakness, slurred speech, left arm (A) Intravenous nicardipine and leg weakness (grade 4+/5 muscle strength) with slower (B) Intravenous nitroprusside finger and toe tapping, and a wide-based gait using a cane. (C) Platelet transfusion The remainder of the neurologic and medical examinations ( D) Prothrombin complex concentrate is normal. 113

Self-Assessment Test rn 2. Which of the following is the most appropriate initial step = Depression screening with the PHQ-9 survey is > normal. in management? 7) wn © wn Which of the following is the most appropriate manage- (A) Cerebrospinal fluid analysis and culture wn ment? (B) CT myelography = @o > ( ) Bupropion & (C) Lumbar spine radiography (D) MRI of the entire spine ~~

rn 2. Which of the following is the most appropriate initial step = Depression screening with the PHQ-9 survey is > normal. in management? 7) wn © wn Which of the following is the most appropriate manage- (A) Cerebrospinal fluid analysis and culture wn ment? (B) CT myelography = @o > ( ) Bupropion & (C) Lumbar spine radiography (D) MRI of the entire spine ~~ o (B Fluoxetine wn Coal (Cc Methylphenidate ( Gok MRI Item 87 (E — Polysomnography A 33-year-old woman is evaluated during a routine primary care visit. She has multiple sclerosis treated with dimethyl fumarate. She works as an accountant. Item 85 On physical examination, vital signs are normal. All other examination findings, including those from a neuro- A 74-year-old woman has a follow-up evaluation of left logic examination, are unremarkable. arm weakness due a right frontal cerebral infarct that occurred 2 weeks ago. She has hypertension and dyslip- Which of the following is the most appropriate immunization? idemia. Current medications are aspirin, chlorthalidone, (A) Annual influenza vaccine and atorvastatin. On physical examination, vital signs are normal. Left (B) Measles, mumps, and rubella vaccine arm shows 4/5 muscle strength throughout, with increased (C) Meningococcal vaccination tone in the elbow and finger flexors. Cardiac and peripheral (D) Recombinant herpes zoster vaccine vascular examinations are normal. LDL cholesterol level is 68 mg/dL (1.76 mmol/L). Serum creatinine level, basic metabolic profile, and aminotransfer- Item 88 ase levels are normal. A 65-year-old man is evaluated for a 3-year history of mild CT scan of the head shows a right frontal lobe dementia with fluctuations in attentiveness and visual hal- infarct involving the cortical surface compatible with lucinations. He has also acted out his dreams in his sleep a an embolic stroke. ECG shows sinus rhythm, left atrial few times over the last 2 years. He has no history of tremor. enlargement, and left ventricular hypertrophy. Trans- On physical examination, vital signs and the remainder thoracic echocardiogram shows an ejection fraction of of the physical examination are normal with the exception 50% with no wall motion abnormalities, left atrial dila- of mild rigidity of bilateral upper extremities. tion, valvular regurgitation, or stenosis. Carotid duplex MRI of the brain shows no significant vascular disease ultrasound shows less than 40% stenosis in both carotid or hippocampal atrophy. arteries and normal flow in the vertebral arteries. Mag- Which of the following is the most likely diagnosis? netic resonance angiogram of the brain shows no major arterial stenoses. (A) Alzheimer disease dementia

o (B Fluoxetine wn Coal (Cc Methylphenidate ( Gok MRI Item 87 (E — Polysomnography A 33-year-old woman is evaluated during a routine primary care visit. She has multiple sclerosis treated with dimethyl fumarate. She works as an accountant. Item 85 On physical examination, vital signs are normal. All other examination findings, including those from a neuro- A 74-year-old woman has a follow-up evaluation of left logic examination, are unremarkable. arm weakness due a right frontal cerebral infarct that occurred 2 weeks ago. She has hypertension and dyslip- Which of the following is the most appropriate immunization? idemia. Current medications are aspirin, chlorthalidone, (A) Annual influenza vaccine and atorvastatin. On physical examination, vital signs are normal. Left (B) Measles, mumps, and rubella vaccine arm shows 4/5 muscle strength throughout, with increased (C) Meningococcal vaccination tone in the elbow and finger flexors. Cardiac and peripheral (D) Recombinant herpes zoster vaccine vascular examinations are normal. LDL cholesterol level is 68 mg/dL (1.76 mmol/L). Serum creatinine level, basic metabolic profile, and aminotransfer- Item 88 ase levels are normal. A 65-year-old man is evaluated for a 3-year history of mild CT scan of the head shows a right frontal lobe dementia with fluctuations in attentiveness and visual hal- infarct involving the cortical surface compatible with lucinations. He has also acted out his dreams in his sleep a an embolic stroke. ECG shows sinus rhythm, left atrial few times over the last 2 years. He has no history of tremor. enlargement, and left ventricular hypertrophy. Trans- On physical examination, vital signs and the remainder thoracic echocardiogram shows an ejection fraction of of the physical examination are normal with the exception 50% with no wall motion abnormalities, left atrial dila- of mild rigidity of bilateral upper extremities. tion, valvular regurgitation, or stenosis. Carotid duplex MRI of the brain shows no significant vascular disease ultrasound shows less than 40% stenosis in both carotid or hippocampal atrophy. arteries and normal flow in the vertebral arteries. Mag- Which of the following is the most likely diagnosis? netic resonance angiogram of the brain shows no major arterial stenoses. (A) Alzheimer disease dementia Which of the following is the most appropriate manage- (B) Dementia with Lewy bodies ment? (C) Frontotemporal dementia (D) Parkinson disease dementia (A) Adding clopidogrel to aspirin (B) Changing aspirin to rivaroxaban (C) Prolonged ambulatory ECG Item 89 (D) Transesophageal echocardiography An 82-year-old man is seen for presyncope symptoms and a recent fall. He has never fallen before, and the fall was not associated with injury. He was diagnosed with moderate Alzheimer disease two weeks ago, and drug therapy was Item 86 initiated. His other medical conditions are hypertension A 29-year-old man is evaluated in the emergency depart and osteoarthritis of the knees. His current medications are ment for fever and subacute onset of lumbar back pain hydrochlorothiazide, topical diclofenac, and donepezil. that radiates down his legs. with numbness and weak On physical examination, blood pressure is 125/74 mm ness. Symptoms began 3 days ago and have progres Hg and pulse rate is 42/min; other vital signs and the sively worsened. He has type 1 diabetes and a history of remainder of the physical examination are normal. intravenous drug use. Medications are basal and prandial ECG reveals sinus bradycardia without other abnor- insulin. malities. On physical examination, temperature is 38.6 °C (101.5 °F); the remaining vital signs are normal. There is Which of the following is the most appropriate next step in spinal tenderness in the lumbar region on palpation. The management? lower extremities have decreased sensation to touch, dimin- (A) Echocardiography ished reflexes, and 3/5 muscle strength. Laboratory studies show a leukocyte count of 12,.150/uL (B) 24-Hour ambulatory electrocardiography (12.2 x 10°/L). Blood cultures are pending. (C) Pacemaker insertion

Which of the following is the most appropriate manage- (B) Dementia with Lewy bodies ment? (C) Frontotemporal dementia (D) Parkinson disease dementia (A) Adding clopidogrel to aspirin (B) Changing aspirin to rivaroxaban (C) Prolonged ambulatory ECG Item 89 (D) Transesophageal echocardiography An 82-year-old man is seen for presyncope symptoms and a recent fall. He has never fallen before, and the fall was not associated with injury. He was diagnosed with moderate Alzheimer disease two weeks ago, and drug therapy was Item 86 initiated. His other medical conditions are hypertension A 29-year-old man is evaluated in the emergency depart and osteoarthritis of the knees. His current medications are ment for fever and subacute onset of lumbar back pain hydrochlorothiazide, topical diclofenac, and donepezil. that radiates down his legs. with numbness and weak On physical examination, blood pressure is 125/74 mm ness. Symptoms began 3 days ago and have progres Hg and pulse rate is 42/min; other vital signs and the sively worsened. He has type 1 diabetes and a history of remainder of the physical examination are normal. intravenous drug use. Medications are basal and prandial ECG reveals sinus bradycardia without other abnor- insulin. malities. On physical examination, temperature is 38.6 °C (101.5 °F); the remaining vital signs are normal. There is Which of the following is the most appropriate next step in spinal tenderness in the lumbar region on palpation. The management? lower extremities have decreased sensation to touch, dimin- (A) Echocardiography ished reflexes, and 3/5 muscle strength. Laboratory studies show a leukocyte count of 12,.150/uL (B) 24-Hour ambulatory electrocardiography (12.2 x 10°/L). Blood cultures are pending. (C) Pacemaker insertion 114

Self-Assessment Test ed a (D) Stopping donepezil accompanied by nausea and nasal congestion but no visual ke heat (E) Stopping hydrochlorothiazide or neurologic symptoms. Combined naproxen-pseudo- <= c+) ephedrine provides partial symptom relief. = All physical examination findings, including vital signs, wn wn Item 90 are normal. aw wn nn A 20-year-old woman is evaluated in the emergency depart Which of the following is the most likely diagnosis? <= ment after sustaining a brief loss of consciousness follow- = (A) Cluster headache @ ing a head-to-head collision in a soccer match. Immediate rn

(E) Stopping hydrochlorothiazide or neurologic symptoms. Combined naproxen-pseudo- <= c+) ephedrine provides partial symptom relief. = All physical examination findings, including vital signs, wn wn Item 90 are normal. aw wn nn A 20-year-old woman is evaluated in the emergency depart Which of the following is the most likely diagnosis? <= ment after sustaining a brief loss of consciousness follow- = (A) Cluster headache @ ing a head-to-head collision in a soccer match. Immediate rn examination on the sidelines revealed gait unsteadiness and (B) Migraine headache amnesia for recent events; she had an isolated 20-second (C) Primary stabbing headache seizure en route to the emergency department. The patient (D) Tension-type headache now reports dizziness and headache but no vomiting or visual or neurologic symptoms. She takes no medication. On physical examination, blood pressure is 98/54 mm Item 93 Hg and pulse rate is 88/min; all other vital signs are normal. A 19-year-old woman is evaluated for a 1 year history of She is alert and oriented. Funduscopic examination shows recurrent stereotyped episodes of loss of consciousness and normal findings. Unsteadiness of tandem gait is noted, as is subsequent shaking, most of which have been precipitated retrograde amnesia for the past 4 hours. All other physical by standing for prolonged periods in hot weather. She typ- examination findings are unremarkable. ically has a warning symptom of tunnel vision followed by Which of the following is the most appropriate next step in diminished hearing, nausea, pallor, and a fall associated management? with loss of consciousness. Witnesses of these events have noted intermittent twitching of all four limbs, with each (A) Brain MRI limb shaking independently. Within 45 seconds, the patient (B) Head CT awakens feeling alert, oriented, and able to continue normal (C) Levetiracetam conversation. All physical examination findings, including vital signs, (D) Mannitol are unremarkable. (E) Norepinephrine Which of the following is the most likely diagnosis?

examination on the sidelines revealed gait unsteadiness and (B) Migraine headache amnesia for recent events; she had an isolated 20-second (C) Primary stabbing headache seizure en route to the emergency department. The patient (D) Tension-type headache now reports dizziness and headache but no vomiting or visual or neurologic symptoms. She takes no medication. On physical examination, blood pressure is 98/54 mm Item 93 Hg and pulse rate is 88/min; all other vital signs are normal. A 19-year-old woman is evaluated for a 1 year history of She is alert and oriented. Funduscopic examination shows recurrent stereotyped episodes of loss of consciousness and normal findings. Unsteadiness of tandem gait is noted, as is subsequent shaking, most of which have been precipitated retrograde amnesia for the past 4 hours. All other physical by standing for prolonged periods in hot weather. She typ- examination findings are unremarkable. ically has a warning symptom of tunnel vision followed by Which of the following is the most appropriate next step in diminished hearing, nausea, pallor, and a fall associated management? with loss of consciousness. Witnesses of these events have noted intermittent twitching of all four limbs, with each (A) Brain MRI limb shaking independently. Within 45 seconds, the patient (B) Head CT awakens feeling alert, oriented, and able to continue normal (C) Levetiracetam conversation. All physical examination findings, including vital signs, (D) Mannitol are unremarkable. (E) Norepinephrine Which of the following is the most likely diagnosis? Item 91 (A) Atonic seizure (B) Convulsive syncope A 54-year-old woman is evaluated in the emergency depart- ment for a severe, nonpulsatile, bilateral occipital headache (C) Generalized tonic-clonic seizure accompanied by photophobia and vomiting that suddenly (D) Myoclonic seizure began 3 hours ago during sexual intercourse. She describes the headache as being “different” from her usual migraine. Whereas rizatriptan typically is effective in resolving the Item 94 migraine, neither rizatriptan nor ibuprofen has relieved her A 64-year-old woman is evaluated in the emergency current symptoms. department for a 2-day history of worsening lower extrem- On physical examination. blood pressure is 144/94 mm ity weakness, fatigue. and a return of urinary frequency. Hg: all other vital signs are normal. She appears uncomfort- She has secondary progressive multiple sclerosis with gait able and prefers a dark room: the remainder of the physical dysfunction, leg weakness, and poor vision. She uses a examination is unremarkable. walker. She also has an overactive bladder with symptoms Results of laboratory studies are within normal limits. of urgency and frequency previously well controlled on solifenacin. Additional medications are fluoxetine and a Which of the following is the most appropriate next step in vitamin D supplement. management? On physical examination, temperature is 38.4 °C (A) Brain MRI (101.1 °F), blood pressure is 110/50 mm Hg, and pulse rate is 70/min. Muscle strength testing shows normal strength in (B) Head CT the upper extremities and 3/5 strength in the lower extremi- (C) Lumbar puncture ties with increased tone. She is unable to support her weight (D) Sumatriptan independently when she stands from a seated position. The remainder of the examination is normal.

Item 91 (A) Atonic seizure (B) Convulsive syncope A 54-year-old woman is evaluated in the emergency depart- ment for a severe, nonpulsatile, bilateral occipital headache (C) Generalized tonic-clonic seizure accompanied by photophobia and vomiting that suddenly (D) Myoclonic seizure began 3 hours ago during sexual intercourse. She describes the headache as being “different” from her usual migraine. Whereas rizatriptan typically is effective in resolving the Item 94 migraine, neither rizatriptan nor ibuprofen has relieved her A 64-year-old woman is evaluated in the emergency current symptoms. department for a 2-day history of worsening lower extrem- On physical examination. blood pressure is 144/94 mm ity weakness, fatigue. and a return of urinary frequency. Hg: all other vital signs are normal. She appears uncomfort- She has secondary progressive multiple sclerosis with gait able and prefers a dark room: the remainder of the physical dysfunction, leg weakness, and poor vision. She uses a examination is unremarkable. walker. She also has an overactive bladder with symptoms Results of laboratory studies are within normal limits. of urgency and frequency previously well controlled on solifenacin. Additional medications are fluoxetine and a Which of the following is the most appropriate next step in vitamin D supplement. management? On physical examination, temperature is 38.4 °C (A) Brain MRI (101.1 °F), blood pressure is 110/50 mm Hg, and pulse rate is 70/min. Muscle strength testing shows normal strength in (B) Head CT the upper extremities and 3/5 strength in the lower extremi- (C) Lumbar puncture ties with increased tone. She is unable to support her weight (D) Sumatriptan independently when she stands from a seated position. The remainder of the examination is normal. Item 92 Which of the following is the most appropriate next step in management? A 38-year-old woman is evaluated for a 2-year history of headache. Headache episodes occur three times per month, (A) Increase solifenacin dose each lasting approximately 8 hours and sometimes up to ~~ B) Initiate intravenous high-dose glucocorticoids 3 days. She describes midfrontal pressure that spreads bilat- Cc ) Initiate modafinil erally and becomes both stabbing and throbbing over 1 to 2 hours, worsening with her usual activities and becoming o ) Obtain MRI of the cervical and thoracic spines so severe that she must lie down. Headaches are occasionally we E) Obtain urinalysis and urine culture

Item 92 Which of the following is the most appropriate next step in management? A 38-year-old woman is evaluated for a 2-year history of headache. Headache episodes occur three times per month, (A) Increase solifenacin dose each lasting approximately 8 hours and sometimes up to ~~ B) Initiate intravenous high-dose glucocorticoids 3 days. She describes midfrontal pressure that spreads bilat- Cc ) Initiate modafinil erally and becomes both stabbing and throbbing over 1 to 2 hours, worsening with her usual activities and becoming o ) Obtain MRI of the cervical and thoracic spines so severe that she must lie down. Headaches are occasionally we E) Obtain urinalysis and urine culture 115

Self-Assessment Test a) pe = Item 95 her face. The movements are painless, and she does not > experience any unusual sensation or urge before them. She 7) A 67-year-old man is evaluated for a 1-minute episode of right- 7) cannot suppress the movements. She reports no history oO sided weakness and aphasia that occurred yesterday. The patient 7) of involuntary movements or exposure to psychoactive = also has type 2 diabetes mellitus treated with metformin. medications. © On physical examination, blood pressure is 164/100 mm = On physical examination, vital signs are normal. She Hg; all other vital signs are within normal limits. Cardiac exhibits fast and synchronous contraction of the muscles -

a) pe = Item 95 her face. The movements are painless, and she does not > experience any unusual sensation or urge before them. She 7) A 67-year-old man is evaluated for a 1-minute episode of right- 7) cannot suppress the movements. She reports no history oO sided weakness and aphasia that occurred yesterday. The patient 7) of involuntary movements or exposure to psychoactive = also has type 2 diabetes mellitus treated with metformin. medications. © On physical examination, blood pressure is 164/100 mm = On physical examination, vital signs are normal. She Hg; all other vital signs are within normal limits. Cardiac exhibits fast and synchronous contraction of the muscles - examination reveals a regular rhythm; no murmurs or o of facial expression that repeat at irregular intervals. On wv tonal carotid bruits are heard on cardiac auscultation. A neuro- the left side, during each contraction the eye is closed, the logic examination has normal findings. eyebrow is raised, and the corner of the mouth is pulled. Which of the following is the most appropriate next diag- There is no facial weakness or sensory loss. The rest of the nostic test? neurologic examination is normal. MRI of the brain reveals focal compression of left cra- (A) Carotid ultrasonography nial nerve VII at its exit zone from the brainstem. (B) Electroencephalography Which of the following is the most likely diagnosis? (C) Magnetic resonance angiography of the brain (D) Transesophageal echocardiography (A) Chorea (B) Dystonia

examination reveals a regular rhythm; no murmurs or o of facial expression that repeat at irregular intervals. On wv tonal carotid bruits are heard on cardiac auscultation. A neuro- the left side, during each contraction the eye is closed, the logic examination has normal findings. eyebrow is raised, and the corner of the mouth is pulled. Which of the following is the most appropriate next diag- There is no facial weakness or sensory loss. The rest of the nostic test? neurologic examination is normal. MRI of the brain reveals focal compression of left cra- (A) Carotid ultrasonography nial nerve VII at its exit zone from the brainstem. (B) Electroencephalography Which of the following is the most likely diagnosis? (C) Magnetic resonance angiography of the brain (D) Transesophageal echocardiography (A) Chorea (B) Dystonia Item 96 (C) Myoclonus A 48-year-old woman is evaluated for a 3-month history D) Stereotypy of repeated rapid and jerky movements on the left side of =_~a2 E) Tic