Question of the Week # 359

359)  A 50 year old woman with history of Diabetes Mellitus presents to your office with complaining of discomfort in her both legs for past few months. She describes unpleasant sensations as well as abnormal sensations such as including tingling, creeping and itching sensations deep in her legs while sitting. Walking a few steps relieves her symptoms. She denies any pain in the legs upon walking or at rest. Physical examination reveals slightly diminished pulses in bilateral lower extremities.  Which of the following is the first step in managing her symptoms?

A) Nerve Conduction Studies

B) Cilostozol

C) Dopamine Agonists

D) Obtain Serum ferritin

E) Gabapentin

Question of the Week # 358

358)  A 36 year old man presents to your office for an annual health examination. During review of systems, he reports  feeling excessively sleepy during the day and forgetful at work. He states no matter how much he slept, it  does not make him feel rested in the morning. He denies snoring at night. He is athletic and maintains his body weight in a healthy range. He denies alcohol consumption, smoking or excessive caffeine use. His girlfriend reports that he abruptly moves his legs often during the night and that disturbs her as well. She has noticed him flexing his leg and extending his great toe repeatedly. The patient is not aware of this and he denies any pain or discomfort in his legs. Physical examination is unremarkable. Laboratory investigations including complete blood count, serum creatinine, electrolytes and a thyroid stimulating hormone are within normal limits. Which of the following is the most likely diagnosis?

A) Complex Partial Seizures

B) Restless leg syndrome

C) Nocturnal Leg Cramps

D) Myoclonus

E) Periodic Limb Movement Disorder

F) Sleep Apnea

Question of the Week # 356

356) A 7 year old boy is evaluated in your office for frequent episodes of “staring spells” while at school. His teacher reports that he does not seem to concentrate during the class and stares blankly in to space. He has had many such episodes in the past six months that got his teacher very concerned. Waving a hand in front of his eyes and calling out his name does not seem to disrupt these episodes. Often he returns to his norm when the boy next to him physically moves him or tickles him. He is otherwise, healthy and plays well with other kids without any issues. His mother also has noticed such episodes while he was watching television at home. On examination, he appears comfortable and healthy. There are no physical abnormalities.  He is attentive to your questions and does not seem to be distracted. Which of the following is the most appropriate next step?

A) Re-assurance

B) Obtain Electro-Encephalogram

C) Refer to Child Psychiatry

D) Start Methylphenidate trial

E) Refer to Neurology

Question of the Week # 355

355)  A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?

A) Attention Deficit Hyperactivity Disorder

B) Absence Seizures

C) Complex Partial Seizures

D) Simple Partial Seizures

E) Generalized Seizures

Question of the Week # 323

323)  A 65 year old man is evaluated in your office for slowly progressing involuntary shaking movements in his hands. He noticed these movements about 10 months ago which have slightly worsened now.  Occasionally, he was told by his wife that his head shakes as well. The movements have led him to feel socially embarrassed because they are worse when he attempts to write or hold a cup of coffee or fasten a shirt button. He denies any tremors in his legs. He denies any problems with his gait or muscle pain or stiffness. He reports drinking wine on daily basis since the tremors have started because he thinks alcohol appears to improve the tremors. He denies using any medications. There is no family history of tremors or seizures. On examination, he appears comfortable. Tremors are visible bilaterally with his arms outstretched and they are increased when asked to hold a cup filled with water. His handwriting is large and tremulous. Gait is normal with normal arm-swing. There are no other neurological deficits. Routine chemistry panels including TSH and Liver function tests are normal. Which of the following is the most appropriate next step in management?

A)  MRI brain with contrast

B) Vitamin B12 level

C) Trial of Dopamine Agonist

D) Initiate Propranolol Therapy

E) Serum Cerulopalsmin level

F) Start oral Primidone

Question of the week # 312

312) A 73 year old man with history of Dementia and well-controlled Parkinson’s disease was admitted to the hospital 3 days ago with fever, hypotension and dysuria. He was diagnosed with sepsis secondary to urinary tract infection and has been on treatment with Ampicillin and Gentamicin. Urine cultures revealed enterococci. Over the past two days, his blood pressure improved and he has been afebrile however, he has become increasingly immobile and excessively tremulous. He is unable to rise from a chair or walk without help.  His home medications include Levodopa, Benserazide and Selegeline. On physical examination, blood pressure is 130/80 mm Hg. He is alert, awake and oriented. He has severe bilateral resting tremor, generalized rigidity and bradykinesia . Results of routine blood tests showed no abnormality and CT of the head is normal.  Which of the following is the most appropriate management at this time?

A) Increase Levodopa

B) Add Carbidopa

C) Discontinue Gentamicin

D) Add Piperacillin-Tazobactam

E) Start Bromocriptine

Question of the week # 311

311) A 3 year old male child is brought to the emergency room by his mother after he fell from his tricycle and sustained an injury to his head  . The child was found to be alert and awake after the fall, however, he reported mild pain on the right side of his head. His mother noted a small bruise and swelling over the right side of his scalp. There is no history of vomiting or nausea. He has no past history of convulsions or epilepsy. Family history is unremarkable. At this time, child is quiet and reports mild headache. On examination, he is alert and awake. He is not in distress. There is small contusion on the fronto-parietal aspect of his scalp. There is no evidence of hematoma. Palpation does not reveal any depressed fracture. Neurological examination is normal with out any deficits.  Rest of the physical exam is normal. Which of the following is the most appropriate management at this time?

A) Contact Child Protection Services

B) Perform Head CT scan

C) Admit to Hospital

D) Observe at home

E) Skull X-rays

Question of the Week # 309

309)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most appropriate management of  his dizziness?

A) Discontinue Hydrochlorthiazide

B) Cervical Collar

C) Cerumen Disimpaction

D) Increase Diuretics and add Meclizine

E) Methylprednisolone

Question of the Week # 308

308)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most likely explanation for his Vertigo?

A) Orthostatic Hypotension

B) Vertebral artery occlusion from cervical spondylosis

C) Cerumen Impaction

D) Meniere’s disease

E) Labyrinthitis

Question of the week # 276

276) A 70 year old obese woman is evaluated in your office during an annual follow up visit. Her other medical problems include hypertension, chronic sinusitis, nasal polyps, asthma, osteoarthritis and a history of transient ischemic attack about 2 months ago. She uses acetaminophen for her arthritis pain because ibuprofen makes her “swell up” and causes severe “breathing problems”. Upon review of her medications, you note that she is not on any antiplatelet therapy.  Physical examination is unremarkable except for nasal polyps. Which of the following recommendations is most appropriate management for this patient?

A) Warfarin

B) Aspirin and Dipyridamole

C) Aspirin

D) Clopidogrel

E) Dipyridamole

F) No anti-platelet therapy

Question of the week # 275

275) A 70 year old obese woman is evaluated in your office during an annual follow up visit. She has a history of moderate osteoarthritis and she takes over the counter ibuprofen for arthritis pain. She was recently hospitalized with one episode of gastro-intestinal bleeding about 6 months ago. She is being maintained on a proton pump inhibitor. Her other medical problems include hypertension and a history of transient ischemic attack about 2 months ago. Upon review of her medications, you note that she is not on any antiplatelet therapy.  Physical examination is unremarkable. Which of the following recommendations is most appropriate management for  this patient?

A) Warfarin

B) Aspirin and Dipyridamole

C) Aspirin

D) Clopidogrel

E) Dipyridamole

F) No anti-platelet therapy

Question of the Week # 267

267 )  A 32 year old woman is evaluated in your office for increasing headaches over the past few months. She has a 5 year history of intermittent headaches. The headaches are throbbing in nature and are localized to frontal area. They are often accompanied by nausea and vomiting. Her episodes are usually preceded by irritability and food craving. She usually takes ibuprofen at the onset of headache which seem to relieve her pain. She recently broke up with her partner and has been under severe emotional stress since then. Lately, her headaches have become more frequent occurring about 4 to 5 times per month. The episodes interfere with her quality of life. She denies any headache at this time.  Physical examination including neurological and ophthalmoscopic exam is normal.  Her last menstrual period was 16 weeks ago and a urine pregnancy test returns positive. Which of the following strategies is most appropriate for this patient?

A) Biofeedback

B) Lumbar puncture

C) Start Propranolol

D) Start Sumatriptan

E) Start Valproic acid

Question of the Week # 211

211 )  A 42 year old woman in otherwise good health presents to the Emergency room for severe headache. She has history of migraines in the past for which she uses sumatriptan at the onset of Headache and usually, she has relief. Though this is not the worst headache of her life, she says that it is very severe and is upset that the headache did not resolve even after injecting herself  with a triptan. She denies any fever.  Her physical and neurological examination is benign. There is no neck stiffness.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid. The specimen was transported to the lab for further evaluation. It was processed in the laboratory 12 hours later and the report indicates “Xanthochromia” Which of the following most likely explains  the CSF findings?

A) Status migranosus

B) Meningitis

C) Sub-arachnoid Hemorrhage

D) Sentinel bleed

E) Delay in CSF processing

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