Continuum MULTIPLE-CHOICE QUESTIONS

Life Long Learning in Neurology MULTIPLE-CHOICE QUESTIONS Prepared By Neurology Residents Team Medical City Hospitals-Baghdad iraqineurologist@yahoo.com iraqineurologist@yahoogroup.com © 2008 All rights reserved. Continuum Contents CONTENTS Internal medicine 1 Neurogenetics 9 Spinal Cord Disorder 22 Stroke prevention 30 Critical care neurology 41 Infectious disease 49 Muscle disease 61 Neuro-otology 70 Psychiatry for neurologist 79 Headache 88 Movement disorder 99 Dementia 107 Sleep disorder 116 Epilepsy 126 Multiple sclerosis 134 Autonomic Disorders 144 Continuum Contents 1 INTERNAL MEDICINE Feb. 2005 TYPE A QUESTIONS (ONE BEST ANSWER) 1. Most evidence suggests that the major efferent limb of the inflammatory reflex is carried in: A. The sympathetic chain B. The phrenic nerve C. The vagus nerve D. Postganglionic sympathetics arising in the stellate ganglia E. The long thoracic nerve Correct Answer: The correct answer is C. Evidence suggests that information leaving the central nervous system regarding regulation of inflammation is carried mainly in the vagus nerve. The sympathetic chain is the origin of postganglionic fibers for sympathetic innervation of visceral organs. The phrenic nerve carries motor axons for the diaphragm, and the postganglionic sympathetics are destined to provide sympathetic innervation to the heart, lungs, and neighboring structures. 2. Autopsy studies in patients with gluten ataxia have demonstrated within the cerebellum lymphocytic infiltration and loss of: A. Stellate cells B. Mossy fibers C. Granule cells D. Purkinje cells E. Basket cells Correct Answer: The correct answer is D. Hadjivassiliou and colleagues have reported the presence of Purkinje cell loss and lymphocytic infiltration in the cerebellum and posterior columns of the spinal cord in several individuals with gluten ataxia, suggesting the presence of an immune-mediated inflammatory process as the mechanism for the development of gluten ataxia. Hadjivassiliou M, Boscolo S, Davies-Jones GA, et al. The humoral response in the pathogenesis of gluten ataxia. Neurology 2002;58:1221-1226. 3. A 25-year-old primigravida is seen in urgent consultation shortly after experiencing a first generalized tonic-clonic seizure. She is 1 day postpartum after vaginal delivery of a full-term infant. Pregnancy was complicated by early preterm labor treated successfully with magnesium sulfate. Delivery was uncomplicated with stable vital signs and no sign of maternal infection. Examination shows a still somnolent woman who has bitten her tongue. Vital signs show a blood pressure of 150/90 mm Hg. She moves all limbs spontaneously with brisk deep tendon reflexes throughout; Babinski`s sign is present bilaterally. She becomes oriented over the course of the examination and complains of a headache and blurred vision. Magnetic resonance imaging (MRI) imaging of the brain done later that day shows large areas of increased signal in the occipital lobes bilaterally on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences. What is the most important causative factor in this patient`s problem? A. Degree of hypertension B. Rapid rise of blood pressure C. Integrity of collateral circulation D. Postpartum hypercoagulability E. Amniotic fluid emboli Correct Answer: The correct answer is B. This patient has eclampsia with primary endothelial cell dysfunction. In these patients, who were not long-term hypertensives, "rapid rise of blood pressure over time rather than the absolute blood pressure carries the greatest risk" (see chapter 5, "Hyperperfusion Syndromes," p. 99).Collateral circulation is irrelevant. Postpartum hypercoagulability or amniotic fluid emboli is unlikely. 4. 4. Which of the following vasculitic syndromes is most likely to be associated with the presence of serum antineutrophil cytoplasm autoantibodies (ANCA)? A. Polyarteritis nodosa B. Giant cell arteritis C. Takayasu`s arteritis D. Wegener granulomatosis E. Leukocytoclastic skin vasculitis Correct Answer: The correct answer is D. ANCA with a diffuse cytoplasmic staining pattern (cANCA) with specificity for proteinase 3 (PR3) are found in over 90% of patients with untreated Wegener granulomatosis. None of the other vasculitides listed above are commonly associated with ANCA. Microscopic polyangiitis shows 2 considerable overlap with Wegener granulomatosis and is frequently associated with antimyeloperoxidase ANCA or anti-PR3-ANCA. Churg-Strauss angiitis is also associated with ANCA. Seo P, Stone JH. The antineutrophil cytoplasmic antibody-associated vasculitides. Am J Med 2004;117:39-50. 5. The following is a serum marker associated with arterial hypercoagulability: A. D-dimer B. High sensitivity C-reactive protein C. Factor V Leiden mutation D. Protein C deficiency E. Protein S deficiency Correct Answer: The correct answer is A. D-dimer is a marker for both arterial and venous thrombosis. The other choices are all markers of venous thrombosis only. 6. A 70-year-old man with a history of unstable angina and hypertension undergoes coronary artery bypass grafting and is transferred postoperatively to the surgical intensive care unit for further care. On the second postoperative day, he is noted by staff to be disoriented and poorly cooperative with his care. A neurological consultant is called. The patient is afebrile with stable vital signs. He appears distracted and is unable to state where he is or how long he has been there. He looks off to various corners of the room; he moves all four limbs normally. Deep tendon reflexes are symmetric, and plantar responses are flexor. He has been receiving tapering doses of morphine sulfate, along with other medications. The consultant diagnoses encephalopathy. Which of the following is the most likely cause of this condition? A. Microemboli B. Hypoxemia C. Drug withdrawal D. Focal cerebral infarction E. Infection Correct Answer: The correct answer is A. Showers of embolic material to the brain are the most likely cause of postoperative encephalopathy, on the same spectrum as those who suffer definitive strokes after surgery. There is no evidence for poor oxygenation or infection with stable vital signs; drug withdrawal is unlikely with careful tapering of doses. 7. The central nervous system (CNS) regulates inflammation via two mechanisms: a humoral system and a neural system. Stimulation of what nervous structure is known to result in an inhibition of inflammatory cytokine synthesis in all visceral organs? A. Cingulate gyrus B. Amygdala C. Pontine reticular formation D. Superior cervical ganglion E. Vagus nerve Correct Answer: The correct answer is E. Stimulation of the vagus nerve has been shown to inhibit inflammatory cytokine synthesis in all visceral organs, including those that belong to the reticuloendothelial system, via release of acetylcholine, which reacts with macrophage receptors. This direct inhibitory influence does not occur with stimulation of the other structures. 8. A 67-year-old insurance salesman presents to his physician with complaints of chronic cough, unintentional loss of 25 lbs over the past 3 months, andthe development of poor balance, numbness on the lateral aspect of the right leg and foot, and burning in his left foot over the past 2 weeks. Nerve conduction studies/electromyography demonstrate a predominantly sensory neuronopathy with superimposed mononeuritis multiplex polyneuropathy. Blood work includes a normal glycosylated hemoglobin level, an elevated anti-Hu antibody titer, and a negative human immunodeficiency virus serology. Right peroneal nerve biopsy yields pathological evidence of transmural inflammation of epineurial vessels. Which of the following is the most likely diagnosis? A. Wegener granulomatosis B. Polyarteritis nodosa C. Microscopic polyangiitis D. Paraneoplastic vasculitis E. Nonsystemic vasculitic neuropathy Correct Answer: The correct answer is D. Paraneoplastic vasculitis, most likely due tolung neoplasm, is the most likely diagnosis. None of the other options is associated with a positive anti-Hu antibody but could present with weight loss and neuropathy. 9. A 38-year-old male is referred to the neurologist with a 2-year history of gradually progressive deterioration in balance. His past medical history is significant for chronic diarrhea and difficulty maintaining his weight. His ... - tailieumienphi.vn