Transcript Neurology - RCRMC Family Medicine Residency

Neurology
A 60-year-old male complains of recurrent and worsening bouts
of foot drop and difficulty picking up objects. He denies any
trauma or pain but admits to muscle cramps and twitching.
Family members have noticed that he has been forgetful recently
with inappropriate bouts of laughing and crying. A diagnosis of
amyotrophic lateral sclerosis (ALS) is suspected. Which of the
following is TRUE concerning this disease?
• A:
• The process involves the degeneration of both upper and lower motor
neurons.
• B:
• The majority of ALS cases have a familial basis.
• C:
• No treatment has been found to improve survival.
• D:
• The initial symptoms are usually muscle cramps, twitching and
drooling.
• E:
• Extraocular muscles and bladder muscles are usually affected.
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Answer
• A:
• The process involves the degeneration
of both upper and lower motor neurons.
Amyotrophic Lateral Sclerosis
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Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a progressiveneurologic disease of
uncertain etiology. It is comprised of two types, familial and sporadic, with the latter accounting for
approximately 90 percent of the cases. In the familial form, a genetic mutation is usually transmitted in
an autosomal dominant fashion. In the sporadic form, advanced age is the only established risk factor, although
smoking, high fat or glutamate diets, exposures (herbicides, pesticides, heavy metals) and service in the Gulf
War (1990-1991) are being cited as possible risk factors. Annual incidence is 1-3/100,000 with a slight male
predominance.
The pathophysiology consists of the degeneration of both upper motor neurons and lower motor neurons. In
addition, there is sclerosis of the lateral motor column of the spinal cord. This leads to decreased nerve
transmission to the muscles and subsequent muscle weakness and atrophy. The initial manifestation of the
disease is commonly painless muscle weakness in the distal extremities. Weakness is asymmetric in 80 percent
of patients. Patients may complain of a foot drop (slapping gait) or a weak grip (difficulty writing or
manipulating fingers). As the disease progresses, there may be muscle cramps, spasticity, twitching, loss of
voluntary limb movement, drooling, speech and swallowing difficulties and the inability to regulate laughter or
crying (pseudobulbar affect). Anxiety, dementia and Parkinsonism may also accompany ALS. Death usually
occurs when respiratory muscles become too weak to support adequate ventilation. Survival is usually 3-5 years
from the time of diagnosis. Face and neck weakness are rarely the initial symptoms of ALS. Extraocular muscles
and bladder muscles are typically not affected by the disease. Frontotemporal dementia can be seen.
The diagnosis of ALS is made clinically by the findings of both lower (weakness, atrophy,fasciculations) and
upper motor deficits (increased tone and reflexes, presence of any reflexes in muscles that are very weak or
wasted) with a wide distribution. No particular test is confirmatory, but electromyography can be used to
confirm lower motor neuron involvement. The management of ALS consists of a multidisciplinary team (speech
therapist, nutritionist, occupational therapist, physician therapist, physician, etc.) and medications to provide
supportive and symptomatic care. Examples of supportive medicines include atropine for
drooling, fluvoxamine for pseudobulbar affect, lorazepam for anxiety, oxygen for hypoxia,baclofen for muscle
cramps and spasticity and laxatives for constipation. Riluzole 100 mg daily is reasonably safe and
probably prolongs median survival by about 2 to 3 months in patients with amyotrophic lateral
sclerosis (SOR A; Ref. 1). Riluzole (Rilutek®) is a sodium channel blocker and glutamate antagonist. Its use is
limited by its high cost and routine liver function testing requirement.
Selected references:
1. Miller RG, Mitchell JD, Moore DH. Riluzole for amyotrophic lateral sclerosis (ALS)/motor neuron disease
(MND). Cochrane Database Syst Rev 2007 Jan 24;
(1):CD001447.http://www.cochrane.org/reviews/en/ab001447.html Accessed March 2008
2. Strong M, Rosenfeld J. Amyotrophic lateral sclerosis: A review of current
concepts. Amyotroph Lateral SclerOther Motor Neuron Disord 2003; 4(3):136-143.
3. Vanderhoff BT, Delphia M, Pemmering TL. Amyotrophic lateral sclerosis. In: Rake RE, ed, Textbook of Family
Practice. 6th ed. Philadelphia: EB Saunders Co., 2002: electronic version.
4. Wicklund MP. Amyotrophic lateral sclerosis: possible role of environmental influences. Neurol Clin 2005;
23(2):462-484.
A 27-year-old woman with epilepsy comes to the office to
discuss her current contraception needs and also to ask
about the implications of her epilepsy on future
pregnancies. She is currently on carbamazepine (generic,
Tegretol®) 400 mg orally twice daily. All of the following
statements to her are true EXCEPT
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She is not a good candidate for low-dose oral contraceptive pills.
B:
Fetuses exposed to any antiepileptic drugs have higher rates of minor
and major malformations than the general population.
• C:
• Once she decides to become pregnant, she should be switched to
lower doses of 2 antiepileptic drugs because it is safer to keep a
woman on low doses of more than one antiepileptic drug rather than a
higher dose of just one.
• D:
• Folic acid supplementation prior to conception is especially important.
• E:
• Women with epilepsy in their reproductive years may be considered for
withdrawal of their antiepileptic drugs if they have been seizure-free for
2-5 years, have a normal exam, single type of seizure and normalized
electroencephalogram (EEG).
Answer
• C:
• Once she decides to become pregnant,
she should be switched to lower doses
of 2 antiepileptic drugs because it is
safer to keep a woman on low doses of
more than one antiepileptic drug rather
than a higher dose of just one.
Assuming that the patient in the previous question
becomes pregnant and remains on carbamazepine, which
of the following is NOT appropriate management during
her pregnancy?
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She should take oral vitamin K from 36 weeks until delivery.
B:
She should be offered screening for neural tube defects.
C:
Drug levels of her carbamazepine should be monitored
periodically during the pregnancy.
D:
She should be delivered by cesarean section as the stress of the
second stage of labor may precipitate a seizure.
E:
Epidural analgesia can be administered without increased risk.
Answer
• D:
• She should be delivered by cesarean
section as the stress of the second
stage of labor may precipitate a seizure.
Antiepileptic Drugs And Pregnancy
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Up to 1 percent of the population has epilepsy. Therefore, most family physicians will care for women on antiepileptic drugs (AEDs). There
are special considerations when considering the use of oral contraceptive pills (OCPs) in patients taking AEDs. Unfortunately, physicians are
often unaware of decreased efficacy of OCPs when given to patients taking some of the most commonly used AEDs. In one study only 4
percent of neurologists and no obstetrician/gynecologists were aware of the interaction. It is thought that the effect is the result of hepatic
enzyme induction caused by progesterone and estradiol. Contraceptive failure is particularly noted with the lower estrogen-containing pills
commonly prescribed now. In one study the failure rate was 25 times greater than expected. The Table shows which AEDs are associated
with increased OCP failure and those that are not.
Antiepileptic Drugs and Oral Contraceptive Pill Interactions
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Significant InteractionNo Carbamazepine (generic, Tegretol®)
Ethosuximide (generic, Zarontin®)
Oxcarbazepine (Trileptal®)
Phenobarbital
Phenytoin (generic, Dilantin®)
Primidone (generic, Mysoline®)
No Significant Interaction
Gabapentin (generic, Neurontin®)
Lamotrigine (Lamictal®)
Levetiracetam (Keppra®)
Tiagabine (Gabitril®)
Valproic acid (Depakene®)
Vigabatrin (Sabril®)
Physicians must remember that the use of these medications is not limited to the treatment of epilepsy. Some of them are also used for
treatment of migraine headache, pain disorders, bipolar disorder and other disorders. Therefore, women using these medications for these
purposes also must be informed properly about potential contraceptive failure.
Pregnant women with epilepsy may experience a higher seizure frequency and may need higher doses of AEDs. Physiologic increases in
blood volume with resultant lower serum drug levels during pregnancy necessitate frequent measurement of drug levels and higher
medication doses in many women. Women should have drug levels tested at least once a trimester and then within the first two to four
weeks after delivery.
Women with epilepsy have an increased chance of giving birth to a baby with a major malformation compared to women in the general
population (4-11.5 percent vs. 2-4 percent). A substantial part of this risk is due to taking AEDs. Fetal anticonvulsant syndrome is a term
used to describe all of the abnormalities found in babies born to women on anticonvulsant medications. Comparison studies of women with
epilepsy not on any medications compared to women taking AEDs show lower rates of malformation, suggesting that the medication is
responsible for much of the risk. The risk of minor malformations is also higher. Therefore, pregnant women on AEDs for other indications
should also be counseled about the risks.
Therapy with more than one AED has been shown to be related to even higher rates of malformations. The Cochrane Database states
that based on currently available evidence women who are pregnant should continue medication during pregnancy and
that monotherapy at the lowest effective dose. Polypharmacy should be avoided (SORA; Ref: 1). It is not recommended to
change medications once a woman is pregnant because the exposure to multiple medications may further increase the risk of malformations
and changing medications may predispose the patient to seizures.
Various types of anomalies have been described in women on virtually all AEDs. The older anticonvulsants generate free radicals and may
predispose to folic acid deficiency. TheAmerican Academy of Neurology (AAN) recommends that all pregnant women on AEDs should receive
folic acid supplementation. The dose of folic acid is between 0.4 mg to 4 mg per day. Women on valproic acid
(generic, Depakene®, Depakote®) or carbamazepine (generic,Tegretol®) should receive the highest dose of folic acid. As in other pregnant
women, folic acid is most effective in preventing neural tube defects if taken before conception and during the first few weeks of pregnancy.
Women on AEDs should be offered aggressive prenatal diagnostic testing including maternal serum testing and targeted ultrasound at 15-20
weeks.
Many AEDs can inhibit the transport of vitamin K across the placenta. Therefore, it is recommended that all women on AEDs should receive
oral vitamin K (10-20 mg) daily from 36 weeks gestation until delivery. Infants should then also receive intramuscular vitamin K after
delivery. Neonatal hemorrhage and shock from vitamin K deficiency carries a mortality rate of 30 percent.
Selected references:
1. Adab N, Tudur Smith C, Vinten J, et al. Common antiepileptic drugs in pregnancy in women with epilepsy.Cochrane Database of
Systematic Reviews 2004; 3:CD004848. http://www.cochrane.org/reviews/en/ab004848.html Accessed March 2008
Rhabdomyolysis is a potentially life-threatening condition
with a variety of etiologies. Adverse drug reactions can
present with rhabdomyolysis. Antipsychotic medications
can induce rhabdomyolysis and should be considered in the
differential diagnosis of this condition. Which of the
following statements regarding rhabdomyolysis is TRUE?
• A:
• Rhabdomyolysis occurs only with older antipsychotics such as
chlorpromazine (generic, Thorazine®) but has not been associated with
the newer atypical antipsychotics such as olanzapine.
• B:
• Rhabdomyolysis is unlikely to occur with a second exposure to an
antipsychotic that caused rhabdomyolysis in a first exposure.
• C:
• Alcoholism is not considered a risk factor for neuroleptic malignant
syndrome.
• D:
• A patient with antipsychotic-induced rhabdomyolysis would meet
criteria for neuroleptic malignant syndrome if fever, muscle rigidity and
delirium are also present.
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• The primary cause of death associated with rhabdomyolysis is stroke.
Answer
• D:
• A patient with antipsychotic-induced
rhabdomyolysis would meet criteria for
neuroleptic malignant syndrome if fever,
muscle rigidity and delirium are also
present.
Antipsychotic-Induced Rhabdomyolysis
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Antipsychotic drugs represent one of the pharmacologic classes most commonly associated with toxic rhabdomyolysis. Rhabdomyolysis is a
clinical condition of acute muscle injury with evidence of muscle catabolism. This catabolism produces increased levels
of creatinephosphokinase (CPK), myoglobin and other muscle components in the bloodstream and urine. The nephrotoxic effects of these
compounds on the kidney can produce acute renal failure.
A study of more than 400 patients presenting with rhabdomyolysis found that 46 percent has a significant toxic insult from illicit drugs,
alcohol or a variety of pharmacologic agents. Along with antipsychotic agents, statins, zidovudine, colchicine, selective serotonin reuptake
inhibitors (SSRIs) and lithium were contributing agents. In the majority of cases, multiple factors were identified as contributing to
the rhabdomyolysis. This suggests that the risk ofrhabdomyolysis may be increased by the presence of chronic or acute contributing factors
(risk factors). Contributing factors may include systemic infection, dehydration, electrolyte disturbance, alcoholism, rapid antipsychotic dose
escalation, antipsychotic-inducedextrapyramidal symptoms and previous brain injury.
Conventional antipsychotics such as chlorpromazine (generic, Thorazine®) and haloperidol (generic, Haldol®) have been felt to be more
likely to induce rhabdomyolysis than newer agents such as olanzapine (Zyprexa®), risperidone (Risperdal®) and ziprasidone (Geodon®).
However, rhabdomyolysis has been described with many of the newer agents and so these compounds do not represent a completely safe
alternative to the older agents. A previous episode of antipsychotic-induced rhabdomyolysis increases the risk for
recurrentrhabdomyolysis with a second exposure to an offending drug.
Antipsychotic-induced rhabdomyolysis may be part of a broader clinical presentation that has been described as neuroleptic (antipsychotic)
malignant syndrome (NMS). Antipsychotic-induced rhabdomyolysis can meet criteria for NMS when additional signs and symptoms are
clinically present. The diagnostic classification criteria for NMS are listed below.
DSM-IV Diagnostic Criteria for Neuroleptic Malignant Syndrome
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- Severe muscle rigidity and fever associated with use of neuroleptic medication
- Two or more of the following:
Diaphoresis
Dysphagia
Tremor
Incontinence
Fluctuating consciousness (delirium)
Mutism
Tachycardia
Elevated or labile blood pressure
Leucocytosis
Laboratory evidence (e.g., elevated CPK) of muscle injury – rhabdomyolysis
- Symptoms that are not better explained by another medical or psychiatric condition
Acute renal failure from medication-induced rhabdomyolysis (not just antipsychotics) is quite common (approximately 50 percent in one
study). Death can occur and is usually related to renal failure or multisystem organ failure. Other serious complications
of rhabdomyolysis are disseminated intravascular coagulation and compartment syndrome. Effective treatment
forrhabdomyolysis includes removing exposure to the antipsychotic drug, ruling out other treatable causes
for rhabdomyolysis, hydration, electrolyte normalization, dialysis and cardiopulmonary support.
Selected references:
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington,DC: American Psychiatric
Association, 2000.
2. Ananth J, Parameswaran S, Gunatilake S, et al. Neuroleptic malignant syndrome and atypical antipsychotic drugs. J Clin Psychiatry 2004;
65:1722-1723.
3. Gupta S, Nihalani N. Neuroleptic malignant syndrome: a primary care perspective. Prim Care Companion JClin Psychiatry 2004; 6:191184.
4. Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 patients. Medicine 2005; 84:377-385.
5. Rosebraugh CJ, Flockhart DA, Yasuda SU, et al. Olanzapine-induced rhabdomyolysis. Ann Pharmacother2001; 35:1020-1023.
6. Sauret JM, Marindes G, Wang GK. Rhabdomyolysis. Am Fam Physician 2002; 65(5):907912.http://www.aafp.org/afp/20020301/907.html Accessed March 2008
7. Webber MA, Mahmud W, Lightfoot JD, et al. Rhabdomyolysis and compartment syndrome
withcoadministration of risperidone and simvastin. J Psychopharmacol 2004; 18:432-434.
Which one of the following statements
concerning insomnia is correct?
A. There is little correlation between insomnia
and depression
B. Daytime drowsiness, excessive snoring,
and confusion if awakened from sleep are
associated with restless legs syndrome
C. Getting up at the same time every day can
increase the restfulness of sleep
D. Patients must take hypnotic drugs for a
prolonged period to cure insomnia
E. Insomnia rarely occurs in the elderly
Answer
• C. Getting up at the same time every day can
increase the restfulness of sleep
• Explanation: Getting up at the same time every
day stabilizes the sleep-wake schedule and
improves the restfulness of actual sleep in bed.
Insomnia is more prevalent among the elderly and
is associated with depression. Daytime
drowsiness, excessive snoring, and confusion
when awakened are associated with sleep apnea.
Hypnotics should be prescribed only for shortterm use. Ref: Kupfer DJ, Reynolds CF III:
Management of insomnia. N Engl J Med
1997;336(5):341-346.
A 27-year-old female complains of
palpitations. Your clinical evaluation finds no
abnormalities. You recommend that she
discontinue her daily regimen of 3–4 cups of
regular coffee. Which one of the following
symptoms is she most likely to develop?
A. Anxiety
B. Depression
C. Headache
D. Fatigue
E. Flu-like illness
Answer
• C. Headache
• Explanation: In a study of patients with low to
moderate caffeine intake, discontinuing caffeine
resulted in moderate to severe headache in 52%.
About 10% had depression or anxiety, and less
than 10% had fatigue or flu-like symptoms. Ref:
Silverman K, Evans SM, Strain EC, et al:
Withdrawal syndrome after the double-blind
cessation of caffeine consumption. N Engl J Med
1992;327(16):1109-1114. 2) Tierney LM Jr,
McPhee SJ, Papadakis MA (eds): Current Medical
Diagnosis & Treatment, ed 38. Appleton & La
A 27-year-old white male has been in rehabilitation for C6
complete quadriplegia. His health had been good prior to a
diving accident 2 months ago which caused his paralysis. The
patient has been catheterized since admission and his
recovery has been steady. His vital signs have been normal
and stable. The nurse calls and tells you that for the past hour
the patient has experienced sweating, rhinorrhea, and a
pounding headache. His heart rate is 55/min and his blood
pressure is 220/115 mm Hg. His temperature and respirations
are reported as normal. There has been no vomiting and his
neurologic examination is unchanged. The most likely
diagnosis is:
A. Cluster headache
B. Autonomic hyperreflexia
C. Sepsis
D. Intracranial hemorrhage
E. Progression of the spinal cord lesion
Answer
• B. Autonomic hyperreflexia
• Explanation: Autonomic hyperreflexia is characterized by the sudden
onset of headache and hypertension in a patient with a lesion above the
T6 level. There may be associated bradycardia, sweating, dilated
pupils, blurred vision, nasal stuffiness, flushing, or piloerection. It
usually occurs several months after the injury and has an incidence as
high as 85% in quadriplegic patients. Frequently, it subsides within 3
years of injury, but it can recur at any time. Bowel and bladder
distention are common causes. Hypertension is the major concern
because of associated seizures and cerebral hemorrhage. Cluster
headaches have a constant unilateral orbital localization. The pain is
steady (non-throbbing) and lacrimation and rhinorrhea may be part of
the syndrome. Sepsis is usually manifested by chills, fever, nausea, and
vomiting. Common signs include tachycardia and hypotension rather
than bradycardia and hypertension. Signs and symptoms of intracranial
hemorrhage vary depending upon the site of the hemorrhage, but the
unchanged neurologic status and the lack of a history of hypertension
decrease the likelihood of this diagnosis. There are no neurologic
findings or history which suggest progression of the patient’s lesion at
C6. Ref: Braunwald E, Fauci AS, Kasper DL, et al (eds): Harrison’s
Principles of Internal Medicine, ed 15. McGraw-Hill, 2001, pp 70, 78,
799, 2385, 2419.
Contraindications to
thrombolytic therapy in acute
stroke include which one of the
following?
A. Age >80
B. Resolving transient ischemic
attack
C. Blood glucose >200 mg/dL
D. Deficit present for >1 hour
Answer
• B. Resolving transient ischemic attack
• Explanation: Thrombolysis is now an approved
treatment for acute stroke. The critical time frame
is 3 hours after the onset of the deficit. Beyond
that time span, the use of thrombolytic agents is
contraindicated. Advanced age per se is not a
contraindication to thrombolytic therapy.
Contraindications include blood glucose levels
<50 mg/dL or >400 mg/dL, resolving transient
ischemic attack, and hemorrhage visible on a CT
scan. Ref: Rakel RE, Bope ET (eds): Conn’s
Current Therapy 2002. WB Saunders Co, 2002, pp
874-876.
Which one of the following therapeutic
agents is most appropriate for daily use
in the prevention of migraine headache?
A. Dihydroergotamine (D.H.E. 45)
B. Amitriptyline (Elavil)
C. Sumatriptan (Imitrex)
D. Aspirin/caffeine/butalbital (Fiorinal)
E. Acetaminophen/hydrocodone
bitartrate (Vicodin)
Answer
• B. Amitriptyline (Elavil)
• Explanation: Beta-adrenergic blockers,
antidepressants, anticonvulsants, calcium channel
blockers, NSAIDs, and serotonin antagonists are
the major classes of drugs used for preventive
migraine therapy. All of these medications result
in about a 50% reduction in the frequency of
headaches. The other drugs listed are useful for the
treatment of acute migraine, but not for
prevention. Ref: Noble SL, Moore KL: Drug
treatment of migraine: Part II. Preventive therapy.
Am Fam Physician 1997;56(9):2279-2286. 2)
Goadsby PJ, Lipton RB, Ferrari MD: Migraine—
Current understanding and treatment. N Engl J
Med 2002;346(4):257-270.
A 72-year-old woman cuts herself with a
clean knife. The wound is 4 cm long on the
volar surface of the right forearm. A reliable
history of which one of the following would
make tetanus toxoid UNNECESSARY at this
time?
A. Tetanus toxoid 1 year ago
B. Tetanus toxoid 5 years ago
C. Tetanus toxoid 11 years ago
D. Tetanus toxoid 5 years ago and 3 tetanus
toxoid shots over her lifetime
E. Tetanus toxoid 11 years ago and 3 tetanus
toxoid shots over her lifetime
Answer
• D. Tetanus toxoid 5 years ago and 3 tetanus toxoid
shots over her lifetime
• Explanation: The Advisory Committee on
Immunization Practices of the Centers for Disease
Control recommends that for a clean, minor
wound, tetanus toxoid should be given if the
patient has not had a tetanus toxoid shot within 10
years, with a total of at least 3 prior tetanus toxoid
shots. Ref: Tintinalli JE, Kelen GD, Stapczynski
JS (eds): Emergency Medicine: A Comprehensive
Study Guide, ed 5. McGraw-Hill, 2
The physician counseling a 4-year-old child
about the death of a loved one should keep in
mind that children in this age group:
A. Often feel no sense of loss
B. Often believe they are somehow
responsible for the death
C. Should not attend a funeral
D. Should usually be told the loved one is
having a long sleep
E. Usually accept the finality of death with
little question
Answer
• B. Often believe they are somehow responsible for
the death
• Explanation: Children from the ages of 2 to 6
often believe they are somehow responsible for
the death of a loved one. The emotional pain may
be so intense that the child may react by denying
the death, or may somehow feel that the death is
reversible. If children wish to attend a funeral, or
if their parents want them to, they should be
accompanied by an adult who can provide comfort
and support. Telling a child the loved one is asleep
or that he or she “went away” usually creates false
hopes for return, or it may foster a sleep phobia.
Ref: Behrman RE, Kliegman RM, Jenson HB
(eds): Nelson Textbook of Pediatrics, ed 16. WB
Saunders Co, 2000, p 109.
A 40-year-old sedentary white male with a family
history of stroke sees you for a health maintenance
visit. His blood pressure averages 150/100 mm Hg
over several visits. His LDL cholesterol level is 170
mg/dL. Which one of the following would have the
greatest impact on decreasing his future risk of
stroke?
A. Reducing his blood pressure to normal levels
B. Reducing his LDL cholesterol level to <130
mg/dL
C. Aspirin, 81 mg daily
D. A program of regular physical exercise
Answer
• A. Reducing his blood pressure to normal levels
• Explanation: Stroke is the third leading cause of death in
the United States, and hypertension is the most
consistently powerful predictor of stroke. There is strong
and consistent evidence supporting the efficacy of
antihypertensive therapy in reducing stroke risk. Several
other interventions have been shown to lower stroke risk to
a lesser extent, including statin treatment of high
cholesterol, daily aspirin, and regular exercise. Ref:
Bronner LL, Kanter DS, Manson JE: Primary prevention
of stroke. N Engl J Med 1995;333(21):1392, 1395, 1397.
2) Goldman L, Bennett JC (eds): Cecil Textbook of
Medicine, ed 21. WB Saunders Co, 2000, pp 2103-2104.
3) Braunwald E, Fauci AS, Kasper DL, et al (eds):
Harrison’s Principles of Internal Medicine, ed 15.
McGraw-Hill, 2001, p 2383.
A mother gives her 3-year-old
child a cookie whenever he starts
to whine. In behavioral terms, she
is using:
A. Positive reinforcement
B. Negative reinforcement
C. Extinction
D. Bonding
Answer
• A. Positive reinforcement
• Explanation: This situation illustrates a common problem
in the behavioral management of children, namely positive
reinforcement or reward for a negative or undesirable
behavior. By giving the child a cookie, the mother is
actually increasing the likelihood that the child will whine.
Putting a child in time-out for whining would be an
example of negative reinforcement. Letting the child
continue to whine by ignoring the behavior is termed
extinction. Bonding is not a term used in behavioral
management, but it describes the affectional relationship
between parents and infants. Bonding occurs rapidly and
shortly after birth and reflects the feelings of the parents
toward a newborn (unidirectional). Ref: Behrman RE,
Kliegman RM, Jenson HB (eds): Nelson Textbook of
Pediatrics, ed 16. WB Saunders Co, 2000, pp 15-16.
Which one of the following is associated
with an increased risk of developing
Alzheimer’s disease?
A. A positive homozygous genotype for
apolipoprotein E4
B. Elevated serum aluminum
C. Elevated serum alpha-tocopherol
D. Decreased serum beta-carotene
E. A low-fiber diet
Answer
• A. A positive homozygous genotype for apolipoprotein E4
• Explanation: Recent genetic work has demonstrated a high
risk for the development of Alzheimer’s disease in patients
with the apolipoprotein E4 genotype. Other predictors of
the disease have been elusive. Serum aluminum is not
predictive, although higher than normal brain aluminum
levels have been studied for many years. Eating a low-fiber
diet has no known correlation, and serum levels of betacarotene and vitamin E are not useful for predicting the
development of Alzheimer’s disease, although
supplementation is considered helpful by some sources.
Ref: Martinez M, Campion D, Brice A, et al:
Apolipoprotein E epsilon4 allele and familial aggregation
of Alzheimer disease. Arch Neurol 1998;55(6):810-816.
A previously alert, otherwise healthy 74-yearold African-American male has a history of
slowly developing progressive memory loss
and dementia associated with urinary
incontinence and gait disturbance resembling
ataxia. This presentation is most consistent
with:
A. Normal pressure hydrocephalus
B. Alzheimer’s disease
C. Subacute sclerosing panencephalitis
D. Multiple sclerosi
Answer
• A. Normal pressure hydrocephalus
• Explanation: In normal pressure hydrocephalus a mild impairment of
memory typically develops gradually over weeks or months,
accompanied by mental and physical slowness. The condition
progresses insidiously to severe dementia. Patients also develop an
unsteady gait and urinary incontinence, but there are no signs of
increased intracranial pressure. In Alzheimer’s disease the brain very
gradually atrophies. A disturbance in memory for recent events is
usually the first symptom, along with some disorientation to time and
place; otherwise, there are no symptoms for some period of time.
Subacute sclerosing panencephalitis usually occurs in children and
young adults between the ages of 4 and 20 years and is characterized
by deterioration in behavior and work. The most characteristic
neurologic sign is mild clonus. Multiple sclerosis is characteristically
marked by recurrent attacks of demyelinization. The clinical picture is
pleomorphic, but there are usually sufficient typical features of
incoordination, paresthesias, and visual complaints. Mental changes
may occur in the advanced stages of the disease. About two-thirds of
those affected are between the ages of 20 and 40. Ref: Humes HD (ed):
Kelley’s Textbook of Internal Medicine, ed 4. Lippincott Williams &
Wilkins, 2000, pp 2919-2921, 2954-2955. 2) Victor M, Ropper AH:
Adams and Victor’s Principles of Neurology, ed 7. McGraw-Hill,
2001, pp 663-665
When evaluating a patient on
chronic phenytoin (Dilantin)
therapy for a seizure disorder,
which one of the following is a
sign of toxicity?
A. Peripheral neuropathy
B. Ataxia
C. Clonus
D. Ballistic movements
E. Photophobia
Answer
• B. Ataxia
• Explanation: Family physicians often see patients
with seizure disorders well controlled on
phenytoin. However, due to its many side effects
and associated illnesses, careful monitoring is
required. Screening for ataxia, which is often
subtle, must be performed at each visit, even when
following blood levels at regular intervals. Ref:
Victor M, Ropper AH: Adams and Victor’s
Principles of Neurology, ed 7. McGraw-Hill,
2001, pp 356-361.
A 70-year-old white female who has been your patient for 10 years had an
emergency cholecystectomy 2 days ago. When you see her today while
making rounds, she appears to be confused. When you ask her how she is,
she just stares at your stethoscope, and then says, “That snake may bite
you.” When you ask further questions she seems distracted and does not
answer the question asked. At times, she closes her eyes and seems to fall
asleep unless questioned. She does not know her daughter, who is in the
room when you are. Which one of the following additional observations
would help you differentiate delirium from dementia?
A. Her pulse, blood pressure, temperature, and respiratory rate are all
normal
B. She cannot remember today’s date or the day of the month, interpret
proverbs, name the president, or even remember your name
C. Her neurologic examination is normal, except for the noted mental
status changes
D. Her mental status was normal before surgery, and on successive visits it
fluctuates
Answer
• D. Her mental status was normal before surgery, and on
successive visits it fluctuates
• Explanation: An acute onset and fluctuating course, along
with an altered level of consciousness, illusions, and
distractibility are consistent with delirium according to
current diagnostic criteria. A normal neurologic and
general physical examination, as well as memory and
orientation problems, are common to both states. Ref:
Bross MH, Tatum NO: Delirium in the elderly patient. Am
Fam Physician 1994;50(6):1325-1332. 2) Hazzard WR,
Blass JP, Ettinger WH Jr, et al (eds): Principles of Geriatric
Medicine and Gerontology, ed 4. McGraw-Hill, 1999, pp
1229-1237. 3) Rakel RE: Textbook of Family Practice, ed
6. WB Saunders Co, 2002, pp 1365-1367.
You have diagnosed tardive dyskinesia in a 72-yearold white female with schizophrenia. She resides in a
nursing home and has been treated with haloperidol
(Haldol), 1 mg twice a day, for 5 years. She also has
a hiatal hernia. Which one of the following
statements is true regarding this patient?
A. The chances of symptom remission after
withdrawal of the haloperidol are better than for a
younger patient
B. Quickly reducing the dosage of haloperidol will
lead to prompt worsening of her tardive dyskinesia
C. Long-term metoclopramide (Reglan) would be the
best treatment for her hiatal hernia
D. Risperidone (Risperdal) would be more likely
than haloperidol to cause tardive dyskinesia
Answer
• B. Quickly reducing the dosage of haloperidol will lead to
prompt worsening of her tardive dyskinesia
• Explanation: Symptom remission is more likely to occur
after neuroleptic withdrawal in young patients than in the
elderly. Tardive dyskinesia is initially exacerbated by a
reduction in neuroleptic dosage, and dyskinesias decrease
following an increase in the dosage. Metoclopramide has
been shown to cause tardive dyskinesia with long-term
treatment, and therefore would not be the best drug for the
patient’s hiatal hernia. There is no convincing evidence
that any of the traditional antipsychotic drugs is less likely
to produce tardive dyskinesia than any other, but the newer
atypical agents such as clozapine, risperidone, and
olanzapine offer some hope for a reduced incidence. Ref:
Sadock BJ, Sadock VA (eds): Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry, ed 7. Lippincott
Williams & Wilkins, 2000, pp 295-296, 2295-2296, 30753076.
A 38-year-old alcoholic male has successfully
completed outpatient alcohol detoxification
and has plans to participate in Alcoholics
Anonymous. Which one of the following
pharmacologic agents can aid in relapse
prevention?
A. Naltrexone (ReVia)
B. Naloxone (Narcan)
C. Bupropion (Wellbutrin)
D. Mirtazapine (Remeron)
E. Flumazenil (Romazicon)
Answer
• A. Naltrexone (ReVia)
• Explanation: Pharmacologic agents can be a useful
adjunct to counseling in preventing relapse in
patients with alcohol dependence. Naltrexone and
disulfiram are currently approved by the FDA for
the treatment of alcohol-dependent patients.
Bupropion is of value for smoking cessation and
mirtazapine is an antidepressant. Naloxone is used
to treat opioid overdose and flumazenil to treat
benzodiazepine overdose. Ref: Fiellin DA, Reid
MC, O’Connor PG: Outpatient management of
patients with alcohol problems. Ann Intern Med
2000;133(10):815-827.
It would be most appropriate to
WITHHOLD rabies prophylaxis for
which one of the following?
A. A rat bite occurring in the patient’s
basement
B. A bat bite sustained on a hiking trip
C. A dog bite from an unprovoked
cocker spaniel not found for observation
D. A raccoon bite occurring on a hunting
trip
Answer
• A. A rat bite occurring in the patient’s basement
• Explanation: Rabies postexposure prophylaxis (RPEP)
should be given for all bat bites and most raccoon bites
unless brain test results will be available within 48 hours.
Bites from small rodents (e.g., rats, mice, and squirrels)
never require RPEP. RPEP should be given after a
domestic animal bite if it was unprovoked and/or the
animal demonstrated abnormal behavior and is not
available for observation. Ref: Moran GJ, Talan DA,
Mower W, et al: Appropriateness of rabies postexposure
prophylaxis treatment for animal exposures. JAMA
2000;284(8):1001-1007. 2) Human rabies prevention—
United States, 1999: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR
1999;48(
Children typically manifest
anxiety toward strangers at what
age?
A. 3 months
B. 9 months
C. 18 months
D. 24 months
E. 30 months
Answer
• B. 9 months
• Explanation: At 3–4 months of age, a normal term
baby will smile at almost anyone. By 9 months of
age, there is a developmentally normal anxiety
over separation from the mother (or primary
caregiver), as well as anxiety at the sight of an
unfamiliar face. Coincident with the increased
mobility gained by walking (usually at 12–15
months of age), these anxieties normally abate.
Ref: Behrman RE, Kliegman RM, Jenson HB
(eds): Nelson Textbook of Pediatrics, ed 16. WB
Saunders Co, 2000, p 36.
A 30-year-old gravida 3 para 2 at 28 weeks' gestation is a
restrained passenger in a high-speed motor vehicle accident.
After initial stabilization in the field with supplemental
oxygen and intravenous fluids, she is brought into the
emergency department on a backboard and wearing a cervical
collar. Until you are able to rule out a spinal injury, in what
position should the patient be kept?
A. Supine
B. Supine, with the uterus manually deflected laterally
C. Prone
D. Trendelenburg’s position
E. Left lateral decubitu
Answer
• B. Supine, with the uterus manually deflected laterally
• Explanation: In general, it is best to place a woman who is greater than
20 weeks pregnant in the left lateral decubitus position because the
uterus can compress the great vessels, resulting in decreased systolic
blood pressure and uterine blood flow. However, in the case of trauma
where a spinal cord injury cannot be ruled out, the woman needs to be
kept supine on a backboard. The weight of the uterus can be shifted off
the great vessels by either manual deflection laterally or by elevating
the right hip 4–6 inches by placing towels under the backboard. The
Trendelenburg position does not relieve the weight of the uterus on the
great vessels. The prone position does not provide adequate spinal cord
protection, and would be extremely awkward in a large pregnant
woman. Ref: Advanced Trauma Life Support for Doctors, ed 3.
American College of Surgeons, 2001, p 319. 2) Grossman NB: Blunt
trauma in pregnancy. Am Fam Physician 2004;70(7):1303-1310.
Promoting good sleep hygiene is basic in the
treatment of insomnia. Which one of the following
measures will aid in promoting healthy sleep habits?
A. Vigorous evening exercise
B. Taking an enjoyable book or magazine to bed to
read
C. Drinking a glass of wine as a sedative before
retiring
D. Eating the heaviest meal of the day close to
bedtime
E. Maintaining a regular sleep/wake schedule
Answer
• E. Maintaining a regular sleep/wake schedule
• Explanation: Maintaining a regular sleep/wake
schedule helps prevent insomnia. While a light
snack before bed may be sleep inducing, heavy
meals close to bedtime may be counterproductive.
Alcohol should be avoided as a sedative, to
prevent midsleep awakenings. Hours spent reading
or watching television in bed can lead to long
awakenings in the middle of the night. Ref:
Kasper DL, Braunwald E, Fauci AS, et al (eds):
Harrison’s Principles of Internal Medicine, ed 16.
McGraw-Hill, 2005, pp 156-158. 2) Doghramji K,
Kuritzky L: Strategies For Managing Insomnia.
AAFP Video CME Program Monograph, 1999, p
You are asked to perform a preoperative
evaluation on a 75-year-old male
scheduled for a cholecystectomy. Which
one of the following would be most
predictive of postoperative delirium?
A. Anxiety
B. Dementia
C. Depression
D. Psychosis
Answer
• B. Dementia
• Explanation: Older patients have a high incidence
of post-anesthesia delirium and thus should have a
mental status examination before and after
surgery. Although patients with anxiety,
depression, and psychosis may have particular
perioperative problems, patients with dementia are
more likely to develop postoperative delirium.
Ref: Evans JG, Williams TF, Beattie BL, et al:
Oxford Textbook of Geriatric Medicine, ed 2.
Oxford University Press, 2000, p 1037.
. A 75-year-old white male complains of a tremor
which has been progressive over the past 2 years.
The tremor interferes with writing, pouring liquids,
and eating soup. He has no other medical problems.
He abstains from alcohol and tobacco products.
Physical examination is remarkable for an action
tremor of the upper extremities and a head tremor.
No rigidity or gait disorder is noted. Of the following
agents, which one is most appropriate as initial drug
therapy for this problem?
A. Alprazolam (Xanax)
B. Clonazepam (Klonopin)
C. Carbamazepine (Tegretol)
D. Propranolol (Inderal)
E. Theophylline
Answer
• D. Propranolol (Inderal)
• Explanation: Essential tremor is the most likely cause of a
disabling action tremor in this age group. A resting tremor,
rigidity, and other associated problems are seen with
Parkinson’s disease. Propranolol and primidone are the
agents of choice. Alprazolam may have beneficial effects,
but it is not a first-line agent because of the risk of sedation
and habituation. Clonazepam has not been found to be
effective in this disorder. Low doses of theophylline have
been found to be somewhat beneficial, but it is considered
a second-line agent for essential tremor. Selective betablockers such as metoprolol are not as effective as
propranolol. Ref: Duthie EH Jr: Practice of Geriatrics, ed
3. WB Saunders Co, 1998, pp 339-340. 2) Goroll AH:
Primary Care Medicine, ed 4. Lippincott Williams &
Wilkins, 2000, pp 954-955. 3) Louis ED: Essential tremor.
N Engl J Med 2001;345(12):887-891.
The parents of a 20-month-old female bring her to your office
because she has lost consciousness twice recently. They
describe two episodes where the child was crying vigorously
then “turned purple and passed out.” The child is an otherwise
healthy product of a term delivery. There is no history of head
trauma and no family history of seizures or cardiac problems.
The episodes are not associated with fever or other
symptoms. Physical examination of the child is normal.
Which one of the following would be most appropriate at this
point?
A. Reassurance
B. A CT scan of the brain
C. An EKG and chest radiograp
D. Measurement of serum glucose, electrolytes, and
hematocrit
E. Echocardiography
Answer
• A. Reassurance
• Explanation: The parents are describing classic breath-holding spells.
These are a form of autonomic syncope frequently misdiagnosed as
seizures. They occur in early childhood and infancy. They can be of
two forms: cyanotic, as described here, and pallid. The cyanotic form
usually occurs after vigorous crying, while the pallid form commonly
occurs after a sudden fright or minor injury. The history of a prodrome
of injury, vigorous crying, or sudden fright is key to distinguishing a
breath-holding spell from a seizure. Parents can be reassured that no
brain damage occurs and, in the presence of a classic history, no
further workup is necessary. An EKG and chest radiograph would be
indicated if the history or examination suggested cardiac syncope.
Blood testing would be indicated if the history suggested orthostatic
hypotension or diabetes. A head CT scan would be indicated in the
evaluation of seizures. Ref: Tintinalli JE, Kelen GD, Stapczynski JS
(eds): Emergency Medicine: A Comprehensive Study Guide, ed 5.
McGraw-Hill, 2000, p 872.
A 40-year-old male professional consults you about his recent
onset of depression. He generally feels well, but sometimes
feels “high and out of control.” This is followed by significant
depression which usually remits after a long weekend of sleep
at his cabin on the lake. He also complains of persistent nasal
congestion and a 10-lb weight loss. His psychiatric history is
negative, but he is suspicious and feels that people are against
him. His mental status otherwise reveals normal thought
content and processes. His physical examination is normal
except for inflamed nares and enlarged nasal turbinates. The
most likely diagnosis is:
A. Schizophrenia
B. Generalized anxiety disorder
C. Panic disorder
D. Alcohol abuse
E. Cocaine abuse
Answer
• E. Cocaine abuse
• Explanation: A chronic user of cocaine, like the chronic
user of alcohol, does not always fit the classic description
of dependence, and the physician must therefore consider
the diagnosis in all patients with episodic depression and
peculiar mood swings. Organic symptoms are like those of
amphetamine use, mainly hyperpyrexia, tachycardia, and
even cardiac arrhythmias. Routine, continued cocaine
“snorting” often leads to nasal mucosal congestion and
occasional septal perforation. Paranoid ideation is
sometimes seen with the use of cocaine and other
stimulants. The patient’s age and normal mental status
make schizophrenia unlikely. Panic disorder is not
complicated by paranoid behavior. Ref: Sadock BJ, Sadock
VA (eds): Kaplan & Sadock’s Comprehensive Textbook of
Psychiatry, ed 7. Lippincott Williams & Wilkins, 2000, pp
1003-1004.
An 85-year-old white male is brought to you for the
first time by his son. The father has recently seen a
neurologist who performed a workup for dementia
and diagnosed moderate Alzheimer’s disease. Which
one of the following is true regarding the use of a
cholinesterase inhibitor in this patient?
A. It is too late to initiate cholinesterase therapy
B. Agitation is often intensified by these agents
C. Memory is likely to improve significantly
D. If the patient has a vascular dementia rather than
Alzheimer’s dementia the drug will not be useful
E. Nursing-home placement may be delayed a year
or longer
Answer
• E. Nursing-home placement may be delayed a year or longer
• Explanation: Medications for dementia should be prescribed with
caution, and the patient watched closely for side effects. Currently
available cholinesterase inhibitors are at least as effective for vascular
dementia as they are for Alzheimer’s dementia, although they are not
approved for this use by the FDA. These agents include donepezil,
rivastigmine, and galantamine, and they are often helpful in
Alzheimer’s disease patients with agitation. Anticholinesterase therapy
is considered the standard of care for Alzheimer’s disease, and therapy
can begin at any stage in the disease process, although early therapy is
the most beneficial. While the medication will not restore memory, it
does prevent the rapid loss of more memory. Long-term studies on
effectiveness are still in progress, but most evidence at present
indicates that nursing-home placement can be delayed a year and
possibly longer. Ref: Cefalu C, Grossberg GT: Diagnosis and
Management of Dementia. American Family Physician monograph
series, 2001, no 2, pp 13-15. 2) Bonner LT, Peskind ER:
Pharmacologic treatments of dementia. Med Clin North Am
2002;86(3):657-674.
You are treating an 89-year-old white male who has lived
alone since his wife died 5 years ago. His niece found him
helpless in his apartment. The patient is filthy, listless, and
weak, and complains of thirst. He is oriented to self, but he is
sure that you are his pastor and that Nixon is president. His
general physical examination reveals cardiomegaly and
peripheral edema. Findings on neurologic examination
include horizontal and vertical nystagmus, weakness of lateral
recti, ataxia, and peripheral areflexia. Plantar responses are
downpointing. A CBC is pending; electrolyte, BUN, and
glucose levels obtained in the emergency department reveal
hypertonic dehydration for which 5% dextrose in ½-normal
saline is running at 200 cc/hr. The patient’s drowsiness
increases during your examination. You order which one of
the following?
A. Cyanocobalamin (vitamin B12)
B. Thiamine
C. Methylprednisolone sodium succinate (Solu-Medrol)
Answer
• B. Thiamine
• Explanation: Alcoholism, while less frequent in the elderly, is often
masked by isolation. Elderly widowers are in the highest risk group.
Several features of this case, including the long-term inattention to
self, gaze disturbance, cerebellar signs, confabulation (confidence in
the face of confusion), and better past than present memory, all suggest
Wernicke’s encephalopathy. The presence of signs of wet beriberi
related to the same nutritional deficiency support the diagnosis. The
patient is at immediate risk and thiamine should be administered right
away. Other diagnoses are less likely. Pernicious anemia causes no
prominent eye motor signs; temporal arteritis, lupus, and Takayasu’s
vasculitis cause lateralizing signs; lead poisoning doesn’t generally
cause cardiomegaly; and carbon monoxide intoxication is more acute,
causing headache and nonselective confusion. Ref: Braunwald E,
Fauci AS, Kasper DL, et al (eds): Harrison’s Principles of Internal
Medicine, ed 15. McGraw-Hill, 2001, p 2496.
An 18-year-old patient presents with his father for a
pre-college physical examination. The student plans
to attend college in a nearby state and will live in a
university-owned residence hall. A review of his
record shows that he received all of the currently
recommended immunizations on time throughout
childhood. The benefits of vaccination against which
one of the following organisms should be discussed
during this visit?
A. Measles
B. Tetanus
C. Pertussis
D. Meningococcus
E. Polio
Answer
• D. Meningococcus
• Explanation: College freshmen, especially those who live
in dormitories, are at a modestly increased risk for
meningococcal disease compared with other persons of the
same age, and vaccination with the currently available
quadrivalent meningococcal polysaccharide vaccine will
decrease their risk. The Advisory Committee on
Immunization Practices of the Centers for Disease Control
and Prevention recommends that incoming and current
college freshmen, and their parents, be informed about
meningococcal disease and the benefits of vaccination.
This is particularly true for those who live in dormitories
and residence halls. In this case, the patient has received
vaccinations against measles, polio, pertussis, and tetanus
at the recommended times, and booster vaccinations are
not indicated now. Ref: Meningococcal disease and college
students: Recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR 2000;49(RR-
Compared with younger adults,
healthy older adults:
A. Fall asleep more quickly at
bedtime
B. Awaken less frequently during
the night
C. Spend less time awake in bed
D. Spend fewer hours in stages of
deep sleep
Answer
• D. Spend fewer hours in stages of deep sleep
• Explanation: Normal older adults require less total
sleep time. This change begins by the age of 50,
and gradually increases with time. By age 75, total
sleep time is reduced to 6 or 7 hours per night, and
by age 85, 5 to 6 hours of total sleep time is
biologically and physiologically normal. Older
adults take longer to fall asleep, awaken more
frequently at night, spend more time awake in bed,
and spend far less time in stages of deep sleep.
Ref: Lantz MS: Insomnia and sleep complaints:
What is normal in the older adult? Clin Geriatr
2002;10
A 62-year-old male with a previous history of
hypertension, smoking, and hypercholesterolemia
comes to your office after being seen in the
emergency department with an episode of dysarthria
and weakness on the left side of his body. Physical
examination reveals a right carotid bruit. Carotid
ultrasonography shows 70%–80% stenosis of the
right carotid artery, which is confirmed by magnetic
resonance angiography. In addition to management
of risk factors, which one of the following is
appropriate?
A. Long-term aspirin therapy
B. Aspirin plus clopidogrel (Plavix)
C. Warfarin (Coumadin)
D. Carotid endarterectomy
Answer
• D. Carotid endarterectomy
• Explanation: Carotid stenosis is an important cause of
transient ischemic attacks and stroke. For patients with
symptomatic carotid stenosis of more than 70%, the value
of carotid endarterectomy has been firmly established on
the basis of three major randomized trials. Both the North
American Symptomatic Carotid Endarterectomy Trial
(NASET) and the European Carotid Surgery Trial (ECST)
showed that only seven or eight patients would need to
undergo endarterectomy to prevent one stroke in a 5-year
period. The trial by the Veterans Affairs Cooperative
Studies Program also showed that endarterectomy was the
best treatment in this situation. Ref: Sacco RL:
Extracranial carotid stenosis. N Engl J Med
2001;345(15):1113-1118.
An 82-year-old white male has a transient
ischemic attack. A carotid duplex study reveals
an 85% stenosis in the affected carotid artery.
Which one of the following would be the most
appropriate management at this time?
A. Aspirin
B. Aspirin plus extended-release dipyridamole
(Aggrenox)
C. Warfarin (Coumadin)
D. Clopidogrel (Plavix)
E. Surgical referral for carotid endarterectomy
Answer
• E. Surgical referral for carotid endarterectomy
• Explanation: Carotid endarterectomy is beneficial in
patients with internal carotid artery stenosis of 70%–99%
who have had a stroke or a transient ischemic attack
attributable to the stenosis. The short-term risk of stroke is
high among patients with severe stenosis of the internal
carotid artery. Although data are lacking on the optimal
timing of endarterectomy, when infarction is absent or
limited, urgent endarterectomy is probably indicated for
patients with internal carotid artery stenosis of 70%–99%
and in selected patients with stenosis of 50%–69% who
can be treated surgically with a low risk of complications.
Ref: Johnston SC: Transient ischemic attack. N Engl J Med
2002;347(21):1687-1692.
For the past 3 days, an 11-year-old white male has had several
small, circular lesions on the left side of his lower forehead
and nose, extending to the tip of the nose. On examination
you note grouped vesicles, several of which are scabbed. The
patient also complains of burning pain in the area of the
lesions. He had a sore throat with a fever 5 days ago, but is
now improved. His stepfather reports he is up-to-date on
immunizations, but a specific immunization record is not
available. His history and examination are otherwise
unremarkable. The most likely diagnosis is:
A. Herpes zoster
B. Undetected immune deficiency
C. Primary herpes simplex type 1
D. Impetigo
E. Erythema multiforme
Answer
• A. Herpes zoster
• Explanation: Clustered circular lesions with
accompanying dysesthesia in a dermatome are
characteristic of herpes zoster, which may occur
after a stressful event or infection in both children
and adults. For herpes zoster to occur there must
be a previous primary varicella infection or
immunization. Herpes zoster is less likely to be
associated with significant postherpetic neuralgia
in children than in adults. Ref: Behrman RE,
Kliegman RM, Jenson HB (eds): Nelson Textbook
of Pediatrics, ed 16. WB Saunders Co, 2000, pp 9
In differentiating early Parkinson’s
disease from variants such as druginduced parkinsonism, progressive
supranuclear palsy, and multiple system
atrophy, which one of the following is
the most important clue?
A. A resting tremor
B. Bradykinesia
C. Rigidity
D. Gait difficulty
E. Loss of postural reflexes
Answer
• A. A resting tremor
• Explanation: Resting tremor is the most common
presentation of Parkinson’s disease. It is rare in
progressive supranuclear palsy and multiple
system atrophy, and less common in drug-induced
parkinsonism. Ref: Hazzard WR, Blass JP,
Ettinger WH Jr, et al (eds): Principles of Geriatric
Medicine and Gerontology, ed 4. McGraw-Hill,
1999, pp 1272-1274
A 28-year-old female complains of generalized headache, dizziness
(characterized as lightheadedness), and generally not feeling well for 3
days. This started at the same time as her menses and coincided with a
major examination in a college class she is taking. Her review of
symptoms is otherwise negative. Her past medical history includes a
recent acute onset of low back pain related to lifting, and a recent
depressive episode which responded well to medication. Her current
medications include an oral contraceptive which she has taken for 2 years,
a corticosteroid nasal spray, and ibuprofen for the past 2 weeks. She was
on paroxetine (Paxil), 30 mg/day, for 7 months, but this was stopped 5
days ago because of sexual dysfunction. Because of her symptoms she has
not taken any medications for the past 2 days. Since then the headache has
eased substantially, but the feeling of lightheadedness has remained. A
physical examination is unremarkable. Which one of the following is the
most likely cause of her symptoms?
A. Allergic rhinitis
B. Paroxetine withdrawal
C. Serotonin syndrome
D. Viral infection
E. Stress
Answer
• B. Paroxetine withdrawal
• Explanation: The timing of the symptoms (starting
about 2 days after paroxetine was stopped) and the
symptoms (headache, lightheadedness) are
consistent with SSRI discontinuation syndrome.
This syndrome is more likely with abrupt
withdrawal, after prolonged treatment, and at
higher doses. Ref: Rosenbaum JF, Fava M, Hoog
SL, et al: Selective serotonin reuptake inhibitor
discontinuation syndrome: A randomized clinical
trial. Biol Psychiatry 1998;44(2):77-87.
A 66-year-old white female consults you because she has
developed a tremor of her right hand that interferes with her
ability to do needlework. She has noticed that the tremor
improves when she rests her hands in her lap and gets worse
when she holds them up against gravity. She has developed a
slight quiver to her voice as well. Her symptoms started
gradually over 6 months ago and have progressed slowly. She
remembers her mother having similar problems in her later
years. She takes no medications, and her physical
examination corroborates her history. No other abnormalities
are noted. A multiple chemistry screen and TSH level are
normal. Which one of the following is most likely to alleviate
her tremor?
A. Propranolol (Inderal)
B. Paroxetine (Paxil)
C. Carbidopa/levodopa (Sinemet)
D. Bromocriptine (Parlodel)
E. Carbamazepine (Tegretol)
Answer
• A. Propranolol (Inderal)
• Explanation: This patient has essential tremor,
which is frequently a familial condition.
Primidone and propranolol are the drugs most
likely to provide relief of essential tremor. Other
beta-blockers such as atenolol and metroprolol
may not be as effective, although results of trials
are mixed. Antiparkinsonian medications such as
carbidopa and bromocriptine have no effect on
essential tremor. Carbamazepine is occasionally
useful, but is much less likely to be effective than
primidone. Ref: Louis ED: Essential tremor. N
Engl J Med 2001;345(12):887-891
Which one of the following is a
common early side effect of
fluoxetine (Prozac)?
A. Constipation
B. Loss of appetite
C. Orthostatic hypotension
D. Atrioventricular block
E. Skin rash
Answer
• B. Loss of appetite
• Explanation: Fluoxetine, a selective serotonin
reuptake inhibitor, has no effect on the
norepinephrine system; therefore, it does not
produce the side effects common to the tricyclic
antidepressants. These include anticholinergic side
effects (dry mouth, constipation), orthostatic
hypotension, cardiac conduction disturbances, and
drowsiness. Loss of appetite is often seen in
patients who take fluoxetine, and can be especially
troublesome in the elderly. Skin rash is
uncommon. Ref: Tasman A, Kay J, Lieberman JA
(eds): Psychiatry. WB Saunders Co, 1997, pp
1616-1619. 2) Physicians’ Desk Reference, ed 54.
Medical Economics Co, 2000, pp 962-967.
Which one of the following is
useful in migraine prophylaxis?
A. Cyanocobalamin (vitamin
B12)
B. Riboflavin (vitamin B2)
C. Ascorbic acid (vitamin C)
D. Cholecalciferol (vitamin D)
E. Tocopherol (vitamin E)
Answer
• B. Riboflavin (vitamin B2)
• Explanation: A daily oral dose of 400 mg of
riboflavin has been shown to be superior to
placebo for migraine prophylaxis. The effect of
riboflavin begins after 1 month of treatment and is
maximal after 3 months of treatment. Its effect is
most pronounced on attack frequency and the
number of days patients have a headache. Ref:
Schoenen J, Jacquy J, Lenaerts M: Effectiveness
of high-dose riboflavin in migraine prophylaxis: A
randomized controlled trial. Neurology
1998;50(2):466-470.
Which one of the following sleep
disorders is in the general class of
circadian sleep disorders and may
respond to bright-light therapy?
A. Shift-work insomnia
B. Alcohol-dependent sleep
disorder
C. Inadequate sleep hygiene
D. Sleep-related myoclonus
Answer
• A. Shift-work insomnia
• Explanation: Shift-work insomnia is the only circadian
sleep disorder listed. It may respond to bright-light therapy.
Alcoholism is a behavioral disorder that may respond to
gradual discontinuance. Inadequate sleep hygiene (use of
stimulants at night, sleeping other than at bedtime, etc.)
may respond to habit changes. Sleep-related myoclonus is
an intrinsic sleep disorder and can be treated with levodopa
or clonazepam. Ref: Sadock BJ, Sadock VA (eds): Kaplan
& Sadock’s Comprehensive Textbook of Psychiatry, ed 8.
Lippincott Williams & Wilkins, 2005, pp 2023-2030. 2)
Kasper DL, Braunwald E, Fauci AS, et al (eds): Harrison’s
Principles of Internal Medicine, ed 16. McGraw-Hill,
2005, pp 153-162.
Pallidotomy is a surgical therapy
for:
A. Alzheimer’s disease
B. Parkinson’s disease
C. Huntington’s chorea
D. Vascular dementia
E. Temporal lobe epilepsy
Answer
• B. Parkinson’s disease
• Explanation: Thalamotomy and pallidotomy,
contralateral to the side of the body that is most
affected, are most effective for the treatment of
disabling unilateral tremor and dyskinesia from
Parkinson’s disease. Ref: Brownlee HJ, Hubble
JP: Current Approaches to the Management of
Parkinson’s Disease. AAFP Video CME Program
Monographs, 2000, p 13. 2) Victor M, Ropper AH:
Adams and Victor’s Principles of Neurology, ed 7.
McGraw-Hill, 2001, pp 1136-1137.
In healthy adults, performance
on the Folstein Mini-Mental State
Examination is affected by which
one of the following?
A. Educational attainment
B. Socioeconomic status
C. Gender
D. Race
Answer
• A. Educational attainment
• Explanation: The Mini-Mental State Examination,
developed by Folstein in 1975, has become a
standard tool for rapid clinical assessment of
cognitive impairment. The score is known to be
affected by the patient’s educational attainment.
Given the same level of cognitive impairment,
those with higher education levels score somewhat
better than those with less education. Race, sex,
and socioeconomic status per se do not affect
patients’ scores. Ref: Ross GW, Bowen JD: The
diagnosis and differential diagnosis of dementia.
Med Clin North Am 2002;86(3):455-476.
Which one of the following would
support a diagnosis of carpal tunnel
syndrome?
A. Absence of symptoms at night
B. Numbness in the fourth and fifth
digits
C. Wasting of the thenar
compartment
D. Provocation of symptoms by
sustained wrist extension
Answer
• C. Wasting of the thenar compartment
• Explanation: Carpal tunnel syndrome (CTS) is an entrapment
neuropathy of the median nerve at the wrist, producing paresthesias
and weakness of the hands. The syndrome is caused by pressure on the
median nerve where it and the flexor tendons of the fingers pass
through the tunnel formed by the carpal bones and the transverse
carpal ligament. It usually begins with a gradual onset of numbness,
tingling, and pain in the hand and wrist. Symptoms are often present at
night, during sleep, and when the wrists are flexed. The symptoms
occur in the thumb and the index and middle fingers, and occasionally
in part of the fourth finger. The fifth finger is never involved. The
thenar compartment is innervated by the median nerve and may
atrophy as the syndrome progresses. The hypothenar musculature is
not involved. Physical signs of CTS include a positive Phalen’s
maneuver, which is a provocation of symptoms by sustained wrist
flexion. Symptoms can be precipitated by activities which require
repeated flexion, pronation, and supination of the wrist, e.g., sewing,
driving, operating computers and cash registers, and playing golf. Ref:
Goldman L, Bennett JC (eds): Cecil Textbook of Medicine, ed 21. WB
Saunders Co, 2000, p 1559. 2) Victor M, Ropper AH: Adams and
Victor’s Principles of Neurology, ed 7. McGraw-Hill, 2001, pp 14331434.
A 15-month-old male is brought to the emergency department
following a generalized tonic-clonic seizure at home. The
parents report that the seizure lasted 5 minutes, with
confusion for the next 15 minutes. This is the child’s first
seizure. There is no family history of seizures. His medical
history is normal except for a 1-day history of a URI. While
initially lethargic in the emergency department, the child is
now awake and playful, with a temperature of 39.5 degrees C
(103.2 degrees F) and a normal examination. Appropriate
diagnostic tests are performed, including a blood glucose
level, which is 96 mg/dL. Which one of the following would
be most appropriate to administer at this point?
A. Phenytoin (Dilantin) intravenously
B. Ceftriaxone (Rocephin) intravenously
C. Acetaminophen orally
D. Carbamazepine (Tegretol) orally
E. Phenobarbital orally
Answer
• C. Acetaminophen orally
• Explanation: This child has had a simple febrile seizure,
the most common seizure disorder of childhood. Treatment
includes finding a source for the fever; this should include
a lumbar puncture if meningitis is suspected. The most
common infections associated with febrile seizures include
viral upper respiratory infections, otitis media, and roseola.
Antipyretics are the first-line treatment. Antibiotics are
indicated only for appropriate treatment of underlying
infections. Phenytoin and carbamazepine are ineffective
for febrile seizures. Phenobarbital is sometimes used for
prevention of recurrent febrile seizures, but is not indicated
as an initial therapy. Only 30%–50% of children with an
initial febrile seizure will have recurrent seizures. Ref:
Behrman RE, Kliegman RM, Jenson HB (eds): Nelson
Textbook of Pediatrics, ed 17. Saunders, 2004, p 1994.
You evaluate an 80-year-old white male who
is a heavily medicated chronic schizophrenic.
You note constant, involuntary chewing
motions and repetitive movements of his legs.
Which one of the following is the most likely
diagnosis?
A. Neuroleptic malignant syndrome
B. Acute dystonia
C. Huntington’s disease
D. Tardive dyskinesia
E. Oculogyric crisis
Answer
• D. Tardive dyskinesia
• Explanation: The patient has classic signs of tardive
dyskinesia. Repetitive movement of the mouth and legs is
caused by antipsychotic agents such as phenothiazines and
haloperidol. Neuroleptic malignant syndrome consists of
fever, autonomic dysfunction, and movement disorder.
Acute dystonia involves twisting of the neck, trunk, and
limbs into uncomfortable positions. Huntington’s disease
causes choreic movements, which are flowing, not
repetitive. Oculogyric crisis involves the eyes. Ref: Sadock
BJ, Sadock VA (eds): Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry, ed 7. Lippincott Williams &
Wilkins, 2000, pp 295-296. 2) Ross GW, Bowen JD: The
diagnosis and differential diagnosis of dementia. Med Clin
North Am 2002;86(3):455-476.
The most effective way to diagnose
chronic alcoholism is to:
A. Ask the patient directly if he/she is an
alcoholic
B. Obtain a careful history of alcohol
intake from the patient
C. Inquire about problems resulting from
drinking
D. Confront the patient when he/she is
intoxicated
Answer
• C. Inquire about problems resulting from drinking
• Explanation: Because denial is a key aspect of
alcoholism, eliciting examples of loss of control as
a consequence of drinking is an effective interview
strategy. Little can be accomplished when the
patient is intoxicated. Ref: Sadock BJ, Sadock VA
(eds): Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry, ed 7. Lippincott Williams
& Wilkins, 2000, p 959.
A 30-year-old white female returns to your office for
a 6-week follow-up for depression. Six weeks ago
she started fluoxetine (Prozac) and she now
complains that her libido, which was decreased when
she started the drug, has become significantly worse.
Which one of the following is appropriate?
A. Continue fluoxetine and tell her that her libido
will improve
B. Continue fluoxetine but increase the dosage
C. Stop fluoxetine and start imipramine (Tofranil)
D. Stop fluoxetine and start bupropion (Wellbutrin)
E. Stop fluoxetine and start sertraline (Zoloft)
Answer
• D. Stop fluoxetine and start bupropion
(Wellbutrin)
• Explanation: Fluoxetine and other SSRIs (e.g.,
sertraline) can cause or worsen loss of libido. This
is also true with tricyclics such as imipramine.
Bupropion does not inhibit libido. Ref: Phillips RL
Jr, Slaughter JR: Depression and sexual desire.
Am Fam Physician 2000;62(4):782-786.
As a member of the local emergency response
management team you are asked about the
treatment of nerve gas (e.g., sarin) poisoning.
Which one of the following is most effective
in reversing the symptoms of nerve gas
toxicity?
A. Albuterol (Proventil, Ventolin) via
inhalation
B. Ciprofloxacin (Cipro)
C. Atropine
D. Parenteral verapamil (Calan, Isoptin)
E. Parenteral corticosteroids
Answer
• C. Atropine
• Explanation: Nerve gas agents such as sarin resemble
organophosphate insecticides and inactivate
anticholinesterase, leading to the accumulation of
acetylcholine at nerve endings. Respiratory symptoms
include rhinorrhea, bronchorrhea, bronchospasm, and
respiratory muscle paralysis. Gastrointestinal symptoms
include nausea, vomiting, and diarrhea. Central nervous
system symptoms include headache, vertigo, agitation,
seizures, and coma. Exposed patients benefit from
treatment with atropine, which competitively inhibits
acetylcholine. Pralidoxine chloride and diazepam are also
beneficial. Although beta-agonists and corticosteroids are
beneficial in the general treatment of bronchospasm,
atropine is preferred in this situation. Verapamil and
ciprofloxacin have no role in the treatment of nerve gas
exposure. Ref: Prevention and treatment of injury from
chemical warfare agents. Med Lett Drugs Ther 2002;44:14.
Which one of the following is
the most effective drug for the
treatment of alcohol dependence?
A. Disulfiram (Antabuse)
B. Diazepam (Valium)
C. Amitriptyline (Elavil)
D. Fluoxetine (Prozac)
E. Naltrexone (ReVia)
Answer
• E. Naltrexone (ReVia)
• Explanation: Drug therapy should be considered
for all patients with alcohol dependence who do
not have medical contraindications to the use of
the drug and who are willing to take it. Of the
several drugs studied for the treatment of
dependence, the evidence of efficacy is strongest
for naltrexone and acamprosate. Naltrexone is
currently available in the U.S.; acamprosate and
tiapride are currently available in Europe but not
in the U.S. Ref: Swift RM: Drug therapy for
alcohol dependence. N Engl J Med
1999;340(19):1482-1490. 2) Kasper DL,
Braunwald E, Fauci AS, et al (eds): Harrison’s
Principles of Internal Medicine, ed 16. McGrawHill, 2005, pp 1810, 2562-2564.
The Mini-Mental State
Examination (MMSE) tests for:
A. Mood
B. Behavior
C. Intelligence quotient
D. Cognitive function
E. Functional impairment
Answer
• D. Cognitive function
• Explanation: The MMSE is most commonly used
in clinical settings. It is considered valuable
because it assesses a broad range of cognitive
abilities (i.e., memory, language, spatial ability, set
shifting) in a simple and straightforward manner.
In addition, the wide use of the MMSE in
epidemiologic studies has yielded cutoff scores
that facilitate the identification of patients with
cognitive dysfunction. Ref: Geldmacher DS,
Gordon B: Dementia in the elderly: Is it
Alzheimer’s disease? The AD Letter 2000;1(1):14. 2) Cassel CK, Leipzig RM, Cohen HJ, et al
(eds): Geriatric Medicine: An Evidence-Based
Approach, ed 4. Springer, 2003, p 206.
The most common cause of
fainting is:
A. Cardiac dysrhythmia
B. Medications
C. Orthostatic hypotension
D. Psychiatric disorders
E. Vasovagal syncope
Answer
• E. Vasovagal syncope
• Explanation: Neurally mediated syncope (also
termed neurocardiogenic or vasovagal syncope)
comprises the largest group of disorders causing
syncope. These disorders result from reflexmediated changes in vascular tone or heart rate.
Ref: Kapoor WN: Syncope. N Engl J Med
2000;343(25):1856-1862. 2) Kasper DL,
Braunwald E, Fauci AS, et al (eds): Harrison’s
Principles of Internal Medicine, ed 16. McGrawHill, 2005, pp 126-128.
A 15-year-old white male is being evaluated after a fall down
one flight of stairs. He was transported by the local rescue
squad with his cervical spine immobilized. He walked briefly
at the scene and did not lose consciousness. His only
complaint is a mild, generalized headache. One episode of
vomiting occurred shortly after the accident. No weakness or
numbness has been noted. Vital signs, mental status, and
neurologic findings are normal. Radiologic evaluation of the
cervical spine is remarkable only for an air-fluid level in the
sphenoid sinus. Which one of the following abnormalities is
most likely to be associated with this radiologic finding?
A. A basilar skull fracture
B. An orbital floor fracture
C. An epidural hematoma
D. A zygomatic arch fracture
E. A mandible fracture
Answer
• A. A basilar skull fracture
• Explanation: A post-traumatic air-fluid level in the
sphenoid sinus is associated with basilar skull fractures.
This finding is frequently noted on cervical spine films.
Orbital floor fractures may be associated with double
vision, fluid in the maxillary sinus, an air-fluid level in the
maxillary sinus, and diplopia. Epidural hematomas are
more frequently associated with skull fractures in the area
of the meningeal artery. Zygomatic arch fractures are more
visible on Towne’s view. Characteristic swelling and lateral
orbital bruising are typically present. Mandible fractures
may be associated with dental misalignment or bleeding.
Panoramic views are often diagnostic. Ref: Barkin RM,
Rosen P (eds): Emergency Pediatrics: A Guide to
Ambulatory Care, ed 6. Mosby, 2003, pp 428, 433.
An otherwise healthy 72-year-old white male
presents with pain on the right side of his head,
increasing in severity over the past 2 days. Today he
broke out in a rash consisting of grouped vesicles on
an erythematous base in the distribution of the first
division of the fifth cranial nerve. The right eyelid is
involved, but the patient complains of no pain in the
eye itself, or of any visual disturbance. There are no
lesions on any part of the nose. Appropriate
management at this time would include the
administration of which one of the following?
A. Intravenous acyclovir (Zovirax)
B. Oral famciclovir (Famvir)
C. Topical capsaicin (Zostrix)
D. Varicella-zoster immune globulin (VZIG)
E. Idoxuridine (Herplex) eye drops
Answer
•
•
B. Oral famciclovir (Famvir)
Explanation: Herpes zoster, or shingles, is a common condition which results
from the reactivation of varicella virus acquired during an earlier episode of
chickenpox. The distribution of the characteristic rash typically follows a
single dermatome and does not cross the midline. The lesions are typically
painful, and postherpetic neuralgia can become a disabling chronic problem.
When any branch of the opthalmic nerve is involved, the condition is called
herpes zoster ophthalmicus. Vesicles on the side or tip of the nose
(Hutchinson’s sign) that occur during an episode of zoster suggest involvement
of the nasociliary branch, and are associated with the most serious ocular
complications. Involvement of the other sensory branches of the trigeminal
nerve may affect the eyelid but rarely involve the eye itself. Treatment of
uncomplicated herpes zoster ophthalmicus in an immunocompetent patient
includes oral acyclovir, famciclovir, or valacyclovir. Corticosteroids can be
used for acute pain but have no effect on the development of postherpetic
neuralgia. Intravenous antiviral therapy is indicated for immunosuppressed
patients with extensive cutaneous disease, and those at high risk for ocular
complications. Treatment is most effective when started within 48 hours of the
onset of the disease. Capsaicin cream is used in the treatment of postherpetic
neuralgia, and varicella zoster immunoglobulin (VZIG) is used in high-risk
immunocompromised patients to prevent varicella infection. Idoxuridine is
indicated for herpes simplex keratitis. Ref: Habif TP: Clinical Dermatology, ed
3. Mosby-Year Book Inc, 1996, pp 355-359.
A 12-year-old white male is brought to your
office after accidentally cutting his left hand
with a pocketknife. On examination you find a
deep 2-cm laceration at the base of the thenar
eminence. To test for motor injury to the
median nerve you would have the patient:
A. Extend the thumb and fingers
B. Oppose the thumb and little finger
C. Flex the wrist
D. Abduct the thumb and index finge
Answer
• B. Oppose the thumb and little finger
• Explanation: The ability to touch the tip of the
thumb to the tip of the little finger indicates
normal motor function of the median nerve. The
radial nerve controls extension of the thumb and
fingers. The median nerve partially controls
flexion of the wrist, but the site of innervation is
proximal to the wound site at the base of the
thumb. Abduction of the thumb is a function of the
radial nerve. Finger abduction is a function of the
ulnar nerve. Ref: Marx JA (ed): Rosen’s
Emergency Medicine, ed 5. Mosby Inc, 2002, p
505.
A 16-year-old white female is brought to your office because she has been
“passing out.” She tells you that on several occasions while playing in the
high-school band at the end of the half-time show she has “blacked out.”
She describes feeling lightheaded with spots before her eyes and tunnel
vision just prior to falling. Friends in the band have told her that she
appears to be pale and sweaty when these episodes occur. No seizure
activity has ever been observed. In each instance she regains
consciousness almost immediately; there is no postictal state. She has
been seen in the emergency department for this on two occasions with
normal vital signs, physical findings, and neurologic findings. A CBC, a
metabolic profile, and an EKG are also normal. Which one of the
following tests is most likely to yield the correct diagnosis?
A. A sleep-deprived EEG
B. 24-hour Holter monitoring
C. A pulmonary/cardiac stress test
D. An echocardiogram
E. Tilt table testing
Answer
• E. Tilt table testing
• Explanation: Reflex syncope is a strong diagnostic consideration for
episodes of syncope associated with a characteristic precipitating
factor. The major categories of syncope include carotid sinus
hypersensitivity, and neurally mediated and situational syncopes. The
most common and benign forms of syncope are neurally mediated or
vasovagal types with sudden hypotension, frequently accompanied by
bradycardia. Other terms for this include neurocardiogenic, vasomotor,
neurovascular, or vasodepressive syncope. Most patients are young and
otherwise healthy. The mechanism of the syncope seems to be a period
of high sympathetic tone (often induced by pain or fear), followed by
sudden sympathetic withdrawal, which then triggers a paradoxical
vasodilatation and hypotension. Attacks occur with upright posture,
often accompanied by a feeling of warmth or cold sweating,
lightheadedness, yawning, or dimming of vision. If the patient does not
lie down quickly he or she will fall, with the horizontal position
allowing a rapid restoration of central profusion. Recovery is rapid,
with no focal neurologic sense of confusion or headache. The event
can be duplicated with tilt testing, demonstrating hypotension and
bradycardia. Ref: Weimer LH, Williams O: Syncope and orthostatic
intolerance. Med Clin North Am 2003;87(4):835-
A 65-year-old male has recently undergone coronary
artery bypass graft (CABG) surgery. Generally, he
has recovered well from his surgery. However, his
cardiac surgeon referred him back to you because of
symptoms suggestive of depression. Which one of
the following is true in this situation?
A. Patients with chronic cardiac symptoms prior to
surgery are more likely to develop postoperative
depression
B. Postoperative depression increases the risk for
subsequent cardiovascular events
C. Treatment of postoperative depression with
antidepressants decreases the rate of subsequent
cardiovascular events
D. Enrollment in a cardiac rehabilitation program
often worsens depression
Answer
• B. Postoperative depression increases the risk for subsequent
cardiovascular events
• Explanation: In patients who are depressed after coronary artery
bypass graft (CABG) surgery, impaired memory and cognition are
seen more frequently than other depressive symptoms. Patients with
rapid progression of cardiac symptoms before surgery are at particular
risk of depressive symptoms after surgery. Newly depressed patients
are at higher risk than non-depressed patients for long-term
cardiovascular events and death from cardiovascular causes. The
Sertraline AntiDepressant Heart Attack Randomized Trial
(SADHART) showed that antidepressant use was associated with a
slight, but not significant, reduction in the rates of cardiovascular
events. The Enhancing Recovery in Coronary Heart Disease
(ENRICHD) trial showed that although it did not reduce the risk of
cardiac events, participation in a cardiac rehabilitation program
reduced depressive symptoms and increased social ties. Ref: Charlson
ME, Isom OW: Care after coronary-artery bypass surgery. N Engl J
Med 2003;348(15):1456-1463.
A 33-year-old white female has a 12-year
history of headache occurring 3–4 times per
month, accompanied by nausea and vomiting.
She takes over-the-counter analgesics, but
relief is usually obtained only when she falls
asleep. This is her first visit to you for this
problem. You diagnose migraine without aura.
Although the patient is willing to consider
prescription drugs, she says that she would
prefer “something that is natural and without
side effects.” Which one of the following
would be the best recommendation?
Answer
• B. Ma huang
• Explanation: Of the listed options covering the realm of
complementary and alternative medicine, only biofeedback has been
shown to have a therapeutic effect on migraine. Specifically, the
modality that seeks to control physiologic response to skin temperature
and skin conductance appears to be the most successful. It is best
performed in a medical office by caring, supportive staff members
under physician supervision. Oxygen is used to treat cluster headaches.
The Epley maneuver is used for managing benign positional vertigo,
and phototherapy is useful in seasonal affective disorder. Ma huang, a
Chinese herb, has ephedrine properties but is not useful in treating
migraine headaches. Ref: Novey DW (ed): Clinician’s Complete
Reference to Complementary/Alternative Medicine. Mosby, 2000, pp
32-35. 2) Dambro MR (ed): Griffith’s 5 Minute Clinical Consult.
Lippincott Williams & Wilkins, 2002, pp 690-691. 3) Kasper DL,
Braunwald E, Fauci AS, et al (eds): Harrison’s Principles of Internal
Medicine, ed 16. McGraw-Hill, 2005, pp 88-93.
A 27-year-old white male presents to the emergency department 2 hours
after being bitten by a rattlesnake. He complains of weakness, abdominal
cramping, left leg pain, and left leg swelling. His speech is slurred, and his
breath smells of alcohol. Physical Findings Temperature 37.0° C (98.6° F)
Blood pressure 100/60 mm Hg Pulse 122 beats/min Respirations 24/min
Skin diaphoretic; ecchymoses on both forearms; bite puncture site just
above left lateral malleolus Lungs clear to auscultation Cardiac normal
heart tones, 1+ posterior tibial pulses Abdomen flat; hypoactive bowel
sounds; no masses or guarding Extremities visible swelling of left leg and
thigh; skin tightness of left leg Neurologic decreased sensation to light
touch and sharp sensation in left foot Which one of the following
therapeutic interventions is indicated?
A. Antivenin administration
B. Venom extractor use
C. Tourniquet application at the upper thigh
D. Surgical consultation for decompression fasciotomy
E. Administration of platelets and fresh frozen plasma
Answer
•
•
A. Antivenin administration
Explanation: This patient presents with a history of snakebite, swelling of an
entire extremity, weakness, and ecchymosis. This is consistent with a grade III
envenomation and merits antivenin therapy. Production of equine-derived
antivenin has stopped, but may still be indicated where available. The ovine
product, CroFab, is less allergenic but still scarce due to limited production.
Venom extractors are thought to be useful only in the first few minutes after a
bite. Two hours is too late to be of any use. Tourniquets are thought to be
contraindicated when used to compress an artery. Low-pressure constriction of
lymphatic and venous vessels is controversial. Fasciotomy has not proved
useful. Antivenin is indicated before any consideration of compartment
syndrome. Pressure measurements would be required because of the clinical
similarities between envenomation injury and compartment syndrome.
Coagulation factors and blood products are rapidly inactivated. They are
indicated only in the presence of exsanguination. Ref: Walter FG, Bilden EF,
Gibly RL: Envenomations. Crit Care Clin 1999;15(2):353-386. 2) Juckett G,
Hancox JG: Venomous snakebites in the United States: Management review
and update. Am Fam Physician 2002;65(7):1367-1374, 1377. 3) Marx JA (ed):
Rosen’s Emergency Medicine, ed 5. Mosby Inc, 2002, pp 786-793. 4) Rakel
RE, Bope ET (eds): Conn’s Current Therapy 2004. Saunders, 2004, pp 11921193.
A 66-year-old white male is brought to your office for
evaluation of progressive memory loss over the last several
months. The problem seems to wax and wane significantly
over the course of days and weeks. At times when he is more
confused, he tends to have visual and auditory hallucinations
that he is back fighting in Vietnam, thinking a ringing
telephone is calling in fighter jets. He has also been falling
occasionally. On physical examination, he has a resting
tremor in his left leg, and rigidity of his upper body and face.
A full medical workup, including standard blood work and a
CT scan, shows no abnormalities that suggest delirium,
stroke, or other primary etiologies. Which one of the
following is the most likely diagnosis?
A. Alzheimer’s disease
B. Dementia with Lewy bodies
C. Fronto-temporal dementia
D. Multi-infarct dementia
E. Pseudodementia
Answer
• B. Dementia with Lewy bodies
• Explanation: Dementia with Lewy bodies is currently considered one
of the most common etiologies of dementia in elderly patients,
representing up to 20%-30% of those with significant memory loss.
The clinical presentation consists of parkinsonian symptoms (rigidity,
tremor), fluctuating levels of alertness and cognitive abilities, and
behavior sometimes mimicking acute delirium. Significant visual
hallucinations are common, and delusions and auditory hallucinations
are seen to a lesser degree. On pathologic examination, Lewy bodies
(seen in the substantia nigra in patients with Parkinson’s disease) are
present diffusely in the cortex. There is currently no specific treatment.
Ref: Galvin JE: Dementia with Lewy bodies. Arch Neurol
2003;60(9):1332-1335. 2) Kasper DL, Braunwald E, Fauci AS, et al
(eds): Harrison’s Principles of Internal Medicine, ed 16. McGraw-Hill,
2005, pp 2402-2403.
An 87-year-old African-American female is admitted to your
hospital with a hip fracture. She lives alone and has been selfsufficient. She has been able to drive, go to the grocery, and
balance her own checkbook. She does well in the hospital
until the second postoperative day, when she develops
agitated behavior, tremor, and disorientation. She attempts to
remove her Foley catheter repeatedly. She exhibits alternating
periods of somnolence and agitation, and describes seeing
things in the room that are not there. Which one of the
following is the most likely diagnosis?
A. Delirium
B. Alzheimer’s disease
C. Senile dementia
D. Schizophrenia
E. Psychosis
Answer
• A. Delirium
• Explanation: This individual is exhibiting symptoms of delirium.
Diagnostic criteria for delirium, according to the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR), include the
following: A. Disturbance of consciousness (i.e., reduced clarity of
awareness about the environment) with reduced ability to focus,
sustain, or shift awareness. B. A change in cognition (e.g., memory
deficit, disorientation, language disturbance) or development of a
perceptual disturbance that is not better accounted for by a preexisting,
established, or evolving dementia. C. Development over a short period
of time (usually hours to days) with a tendency to fluctuate during the
course of a day. D. Evidence from the history, physical examination, or
laboratory findings that indicates the disturbance is caused by direct
physiologic consequences of a general medical condition. In the case
described, the patient’s history does not indicate preexisting problems
and she had a relatively abrupt onset of disturbance of consciousness
and change in cognition, related to the hospitalization for hip fracture.
Ref: American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, ed 4. American Psychiatric Association,
1994, pp 132-133. 2) Gleason OC: Delirium. Am Fam Physician
2003;67(5):1025-1034.
A 75-year-old male has not seen a
physician in 25 years and presents
with advanced Parkinson’s disease.
The best initial treatment would be:
A. Referral to a neurosurgeon for
thalamotomy
B. Amantadine (Symmetrel)
C. Benztropine (Cogentin)
D. Pramipexole (Mirapex)
E. Carbidopa/levodopa (Sinemet)
Answer
• E. Carbidopa/levodopa (Sinemet)
• Explanation: While anticholinergics such as benztropine and
amantadine may provide some improvement of symptoms, these
effects wane within a few months. Such medications are not a good
option in this patient with advanced disease. Dopamine agonists
provide some improvement in motor complications, but are mainly
used to delay the introduction of levodopa in younger patients, to avoid
levodopa-related adverse reactions. Carbidopa/levodopa is better for
initial therapy in older patients, and those who present with more
severe symptoms. Slow-release versions of this combination may
decrease motor fluctuations. Stereotactic thalamotomy is used to
ameliorate tremors that have become disabling. This procedure has
been replaced by other surgical options such as pallidotomy and highfrequency, deep-brain stimulation of specific nuclei. Ref: Siderowf A,
Stern M: Update on Parkinson disease. Ann Intern Med
2003;138(8):651-658. 2) Goldman L, Ausiello D (eds): Cecil Textbook
of Medicine, ed 22. Saunders, 2004, pp 2306-2310.
Which one of the following
should be avoided in the
treatment and prophylaxis of
migraine during early pregnancy?
A. Calcium channel blockers
B. Beta-blockers
C. Triptans
D. NSAIDS
Answer
• C. Triptans
• Explanation: Headaches, and migraines in particular, are very common
in women of childbearing age. Migraine sufferers usually have
improvement of symptoms in pregnancy and many have complete
remission. Most medications used for prophylaxis and abortive
treatment of migraines in the nonpregnant patient can also be used in
pregnant patients. Most beta-blockers and calcium channel blockers
are safe. Acetaminophen and narcotics can be used for acute pain.
Ibuprofen can also be used but should be avoided late in pregnancy
because it is associated with premature closure of the ductus arteriosus
and oligohydramnios. Ergotamines should be avoided as they are
uterotonic and have abortifacient properties. They have also been
associated with case reports of fetal birth defects. Triptans have the
potential to cause vasoconstriction of the placental and uterine vessels
and should be used only if the benefit clearly outweighs the harm. Ref:
Gabbe SG, Niebyl JR, Simpson JL (eds): Obstetrics: Normal and
Problem Pregnancies, ed 4. Churchill Livingstone, 2002, pp 12441246.
Which one of the following side
effects induced by traditional
neuroleptic agents responds to
treatment with beta-blockers?
A. Akathisia
B. Rigidity
C. Dystonia
D. Sialorrhea
E. Stooped posture
Answer
• A. Akathisia
• Explanation: Rigidity, sialorrhea, and stooped
posture are parkinsonian side effects of
neuroleptic drugs. These are treated with
anticholinergic drugs such as benztropine or
amantadine. Dystonia, often manifested as an
acute spasm of the muscles of the head and neck,
also responds to anticholinergics. Akathisia (motor
restlessness and an inability to sit still) can be
treated with either anticholinergic drugs or betablockers. Ref: Sadock JB, Sadock VA (eds):
Kaplan & Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry, ed 9.
Lippincott Williams & Wilkins, 2003, pp 1009,
1012-1015.
. A case of meningococcal meningitis has just
been confirmed at a day-care center. The
susceptibility of the microorganism is not yet
known. At this point, you should do which
one of the following for the day-care center
contacts?
A. Culture their nasopharyngeal secretions
B. Administer meningococcal vaccine
C. Prescribe sulfadiazine
D. Prescribe chloramphenicol
(Chloromycetin)
E. Prescribe rifampin (Rifadin)
Answer
• E. Prescribe rifampin (Rifadin)
• Explanation: Rifampin, in the absence of major contraindications, is
the drug of choice for preventing the spread of meningococcal disease
when the susceptibility of the organism is not known. In this situation,
meningococcal vaccines are of no value because their protective
effects take a few days to develop, and because they do not protect
against group B meningococci, the most prevalent strain for
meningococcal disease. Sulfadiazine is the drug of choice if the
meningococcus is known to be susceptible to it. Chloramphenicol and
penicillin, which are effective in treating the disease, are ineffective in
eliminating nasopharyngeal carriers of meningococci, possibly because
they do not appear in high concentrations in saliva. Culturing contacts
for meningococcal carriage in the nasopharynx has no value for
identifying those at risk for meningococcal disease. Ref: Pickering LK
(ed): 2003 Red Book: Report of the Committee on Infectious Diseases,
ed 26. American Academy of Pediatrics, 2003, pp 123-137, 430-436
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DIRECTIONS: The following series of questions concern
two diseases ? babesiosis and Lyme disease. For the
following questions, select the answer most closely
associated with the statement.
There are documented cases of transmission via blood
transfusion.
A:
if babesiosis is associated with the statement
B:
if Lyme disease is associated with the
statement
C:
if BOTH babesiosis AND Lyme disease are
associated with the statement
D:
if NEITHER babesiosis NOR Lyme disease is
associated with the statement