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Question 1 of 25
1. Question
A 45-year-old man comes to the clinic due to a 2-month history of progressive left arm clumsiness and weakness. The patient initially attributed his symptoms to a left rotator cuff injury he sustained several years ago; however, he has recently developed problems with his gait. The patient’s symptoms have interfered with daily activities such as bathing and dressing. He has had no recent injury, headaches, or bowel/bladder symptoms. On physical examination, there is reduced muscle strength in the left upper extremity. Further evaluation with brain MRI reveals a lesion involving the corticospinal tract. Which of the following additional signs is most likely to been seen in this patient?
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Question 2 of 25
2. Question
A 4-year-old boy is evaluated for difficulty walking. Past medical history includes frequent respiratory infections. Cultured cells from this patient demonstrate a high rate of radiation-induced genetic mutation. This patient is most likely to experience which of the following?
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Question 3 of 25
3. Question
A 5-year-old boy is brought to the office due to concerns about his speech and motor skills. The patient has a history of speech delay, and his parents say that his speech has become more slurred lately. He also has an unsteady, staggering gait that has progressively worsened over the past year. In addition, the mother states that the patient’s eyes and head “do not move smoothly” when he looks at moving objects. Medical history is significant for recurrent ear and pulmonary infections. Vital signs are normal. Physical examination reveals numerous superficial nests of distended capillaries on the face and ears that blanch with pressure. This patient’s condition is most likely due to a genetic defect affecting which of the following processes?
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Question 4 of 25
4. Question
A 60-year-old woman is enrolled in a longitudinal research study for individuals with a family history of Parkinson disease. The patient’s mother died from complications of idiopathic Parkinson disease 2 years ago. The study consists of symptom questionnaires, serial neurologic examinations, and brain imaging. Review of systems is notable for chronic constipation, which is progressively worsening. The patient also recently began having difficulty double-clicking her mouse. Vital signs show orthostatic hypotension. Neurologic examination reveals normal muscle bulk, tone, and strength with no abnormal movements. Postural stability is maintained. Gait speed and stride length are normal. Advanced brain imaging reveals 50% loss of nigrostriatal volume. Compared to an age-matched healthy individual, which of the following is most likely present in this patient’s remaining nigrostriatal neurons?
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Question 5 of 25
5. Question
A 55-year-old man comes to the clinic due to gradual, progressive weakness of the right upper extremity over the past 6 months. Over the last month, he has also noticed weakness in the left upper extremity. Vital signs are normal. Physical examination shows fasciculations and atrophy of the intrinsic muscles of the right hand and the muscles of the forearm. Reflexes are brisk in the upper extremities, and the plantar responses are extensor. Mild gait ataxia is present. Over the course of his illness, this patient will most likely develop which of the following?
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Question 6 of 25
6. Question
A 20-year-old man comes to the office for evaluation of abnormal behavior. Over the past 4 months, the patient has had several episodes of unresponsiveness, during which he would stare blankly while smacking his lips. He spontaneously becomes responsive after about 2 minutes and has no recollection of the event. The patient says these episodes are often preceded by an uneasy sensation in his upper abdomen and the pungent smell of something burning. He has had no falls or jerky movements of the extremities. The patient has no history of recent fever, headaches, head trauma, nausea, vomiting, or focal neurologic deficit. He had seizures in early childhood precipitated by high fevers but has had none since then and reports no other medical conditions. Cranial nerve examination reveals no abnormalities. Motor strength, sensation, and deep tendon reflexes are normal throughout. Neuroimaging is most likely to reveal an abnormality in which of the following locations in the brain?
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Question 7 of 25
7. Question
A 65-year-old man is found dead at his home due to a suspected suicide. The family reports that the patient has been having difficulty swallowing, dyspnea on exertion, and arm and leg weakness for the past several months and had undergone a medical workup. They suspect the physician may have given bad news and the patient ended his life so he would not have to live with the diagnosed condition. External examination shows atrophy of the muscles of the right lower and left upper extremities. Autopsy would most likely reveal which of the following additional findings?
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Question 8 of 25
8. Question
A 40-year-old man comes to the office due to a 6-month history of sleep abnormalities, constipation, and generalized slowing of activity. In addition, he has difficulty rising from a seated position. Medical history is significant for a traumatic head injury 3 years ago, which required a prolonged hospital stay. The patient has no other medical conditions and takes no medication. He does not use tobacco, alcohol, or recreational drugs. Vital signs are normal. Examination shows resistance to passive movement in the upper extremities, which is slightly greater on the left than on the right. Left hand tremor and decreased arm swing occur during walking. Which of the following is the most likely explanation for this patient’s current condition?
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Question 9 of 25
9. Question
A 55-year-old man comes to the clinic due to headache and progressive facial weakness. The patient’s headaches began 2 months ago and are characterized as throbbing. They are typically worse in the morning and when he bears down or coughs. He has had no recent head trauma or loss of consciousness. The patient has a history of hypertension for which he takes lisinopril. He does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. On physical examination, there is flattening of the left nasolabial fold and drooping of the left lower lip. The patient cannot fully close his left eye. MRI of the brain reveals a well-circumscribed homogenously enhancing mass in the posterior fossa that is compressing the left facial nerve root. Which of the following additional findings is most likely present on this patient’s neurologic examination?
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Question 10 of 25
10. Question
A 65-year-old homeless man is brought to the hospital after he is found wandering the streets during a cold winter day. The patient appears confused and has slurred speech. He has no chronic medical conditions and takes no medications. On examination, his temperature is 32 C (89.6 F). Cardiopulmonary examination is normal. No focal neurologic deficits are present. Toxicology screen is negative for any substances. Which of the following physiologic adaptations is most likely occurring in this patient to help maintain homeostasis?
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Question 11 of 25
11. Question
A 21-year old man is brought to the emergency department due to head trauma sustained during a boxing match. During the fight, he had a brief loss of consciousness after a hard hit to the right side of his face. He has a headache and muffled hearing in his right ear. On examination, the patient is alert and oriented. Palpation of the head does not reveal any step-offs. Cervical spine examination is normal. Otoscopic examination reveals hemotympanum in the right ear. This patient is at greatest risk for injury involving which of the following cranial nerves?
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Question 12 of 25
12. Question
A 3-year-old boy is rushed to the emergency department after he is found underwater in the bathtub. His parents say the patient was left alone for 5 minutes. On physical examination, he does not respond to painful stimuli and is pulseless and not breathing. Cardiac rhythm is asystole and spontaneously returns after several minutes of resuscitation. While performing endotracheal intubation, stimulation of the posterior pharyngeal wall with laryngoscope elicits no soft palate movements or gagging. This patient’s findings during intubation most likely indicate dysfunction of which of the following neural structures?
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Question 13 of 25
13. Question
A 58-year-old man undergoes operative repair of a descending thoracic aortic aneurysm. There are no intraoperative complications, but postoperatively the patient is found to have new-onset neurologic deficits. Imaging of the brain is normal, but MRI of the lower thoracic spinal cord reveals ischemic infarct of the areas shown in the exhibit below:
Lower extremity examination of this patient is most likely to show which of the following neurologic findings?
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Question 14 of 25
14. Question
A 76-year-old woman is brought to the emergency department due to sudden-onset vertigo and difficulty swallowing for an hour. Her only other medical condition is hypertension. Blood pressure is 160/90 mm Hg and pulse is 80/min and regular. The patient is alert, awake, and oriented. Examination shows decreased pain and temperature sensation on the left side of the face and right side of the body. The gag reflex is absent on the left side. Muscle strength is 5/5 in all 4 extremities. This patient’s lesion is most likely located in which of the following areas?
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Question 15 of 25
15. Question
A 25-year-old woman comes to the office due to right ear pain that has worsened over the past 2 months. The pain is dull and constant and waxes and wanes. It is worse when she chews hard foods such as steak or almonds. In addition to ear pain, her ear feels stuffy and has some ringing. The patient grinds her teeth at night and previously wore a dental guard, but it broke several months ago. Ear examination is normal. Which of the following nerves is most likely responsible for this patient’s ear pain?
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Question 16 of 25
16. Question
A 66-year-old, right-handed man is brought to the emergency department due to possible stroke. This morning, his wife noticed that the patient’s face appeared drooped and he was not moving his left arm. On physical examination, the patient is awake and alert and preferentially looks toward the right. Muscle strength is decreased in the left lower face and left upper and lower extremities. When asked to draw an analog clock face to show 3 o’clock, the patient places the numbers and hands on the right half, leaving an empty space on the left. Occlusion of which of the following labeled arteries in the image below is the most likely cause of this patient’s current condition?
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Question 17 of 25
17. Question
A 26-year-old woman is evaluated for increasing discomfort in the right posterior mandible. The patient has no prior medical conditions and takes no medications. Physical examination is unremarkable with the exception of a partially erupted right mandibular third molar tooth. Radiographs reveal impaction of the molar tooth. Surgical tooth extraction under general anesthesia is performed. During the surgery, the inferior alveolar nerve that is close to the tooth is inadvertently injured. Which of the following is the most likely to be observed on the injured side?
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Question 18 of 25
18. Question
A 65-year-old man with a history of hypertension is brought to the hospital due to sudden-onset vertigo and dizziness that started an hour ago. On physical examination, there is ptosis and pupillary constriction in the left eye. Extraocular movements are normal in both eyes. Pain and temperature sensations are decreased over the left side of the face, and the direct corneal reflex is absent on the left. Pain and temperature are also decreased over the right side of the body. Muscle strength is 5/5 in all 4 extremities with normal deep tendon reflexes. Which of the following is the most likely cause of this patient’s asymmetrical pupils?
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Question 19 of 25
19. Question
A 49-year-old woman comes to the office due to muscle weakness. For the past 3 months, the patient has had worsening weakness in her right hand. She has also been tripping. The patient experiences twitching and cramping in her arms and legs. She has no sensory deficits. On examination, there is increased tone and fasciculations in the lower extremity muscles. Atrophy of the interosseus muscles of the right hand and the bilateral intrinsic muscles of the feet is present. When the physician taps on the chin while the mouth is slightly open, the jaw jerks upward briskly. Which of the following cranial nerves mediate this reflex?
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Question 20 of 25
20. Question
A 64-year-old woman is brought to the emergency department due to stroke-like symptoms. The patient has a history of transient ischemic attacks as well as other risk factors for cerebrovascular disease, including hypertension, type 2 diabetes mellitus, and hyperlipidemia. Urgent brain imaging reveals occlusion of a vessel indicated by the arrow in the exhibit. Which of the following findings is most likely to be observed in this patient?
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Question 21 of 25
21. Question
A 70-year-old man is brought to the emergency department due to sudden-onset weakness in his right arm and leg. Although he can speak, he cannot pronounce words clearly. Blood pressure is 170/96 mm Hg and pulse is 80/min. The patient is alert and oriented. Neurologic examination shows 3/5 strength in both right upper and lower extremities. When the patient is asked to stick out his tongue, it deviates to the left. Sensory examination shows no abnormalities. Which of the following is the most likely location of this patient’s brain injury?
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Question 22 of 25
22. Question
A 65-year-old woman is brought to the emergency department due to abnormal behavior. The patient was in her usual state of health until 3 hours ago, when she suddenly became confused and kept asking repetitive questions. She has had no headache, abnormal motor activity, or focal weakness or numbness. Medical history is significant for hypertension and migraine. Blood pressure is 136/84 mm Hg and pulse is 80/min. On physical examination, the patient is awake and alert but keeps asking, “What happened?” She can state her date of birth and address correctly, recognizes her family members, and is aware of current events. The patient recalls 0 of 3 objects after several minutes and cannot retain the physician’s name despite many repetitions. Speech is fluent without dysarthria or aphasia. Cranial nerve examination shows no abnormalities. Motor strength, reflexes, and sensation are normal throughout. Blood cell count and serum chemistry panel are within normal limits. Urine drug screen is negative. CT scan of the head shows no hemorrhage. Two hours later, the patient spontaneously returns to normal. Temporary dysfunction of which of the following neural structures best explains this patient’s symptoms?
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Question 23 of 25
23. Question
A 59-year-old man comes to the office for evaluation of a facial skin lesion. The lesion is a mole-like spot that has been on the patient’s face for the past several months and has slowly enlarged. He reports no pain or bleeding from the lesion. Family medical history is positive for skin cancer. Physical examination findings are shown in the exhibit. Biopsy of the lesion with a local nerve block for anesthesia is planned. Which of the following injection sites is most likely to provide adequate anesthesia for the procedure?
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Question 24 of 25
24. Question
A 62-year-old man comes to the emergency department due to acute-onset constipation. His last bowel movement was 4 days ago; before that time, his stools were always regular. Review of systems is positive for dry cough, increasing low back pain, a 9-kg (20-lb) weight loss in the past month, and increasing difficulty with urination. He has smoked 2 packs of cigarettes daily for 30 years. Vital signs are within normal limits. Point tenderness is elicited with palpation over the lower spine. Bilateral lower extremity weakness is present, and sensation is impaired in the perineal region. Chest x-ray reveals a right lung mass. Dysfunction of which of the following nerves best explains this patient’s constipation?
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Question 25 of 25
25. Question
A 54-year-old woman comes to the clinic due to difficulty hearing for the past few weeks. During the neurologic examination, the physician assesses her hearing using a vibrating tuning fork. The handle of the tuning fork is placed on her left mastoid process until the sound is no longer audible. The tines are then quickly placed near the patient’s left auditory meatus, and she reports hearing no sound. When the handle of the vibrating fork is placed on the middle of her forehead, she hears the vibration more strongly in her left ear than her right. This patient is most likely experiencing which of the following types of hearing loss?
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