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Question 1 of 40
1. Question
A researcher is exploring various methods to decrease neuronal loss after ischemic injury. During an experiment, the researcher induces focal cerebral ischemia in rodents; after a short time, there is ATP depletion and subsequent ionic derangements in cells within the infarction core. Increased release and impaired clearance of extracellular neurotransmitters is also noted. One particular neurotransmitter leads to sustained calcium influx in exposed neurons, initiating a toxic cascade that result in rapid cell death. Blockade of a receptor for which of the following neurotransmitters is most likely to decrease this type of neuronal injury?
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Question 2 of 40
2. Question
A 45-year-old woman is brought to the hospital after she collapsed during an airshow on a hot summer day. The patient has a history of fibromyalgia and takes amitriptyline. Temperature is 40.5 C (104.9 F), blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 22/min. The skin is warm and red. She is disoriented. Neurologic examination shows no focal findings. If this patient’s medication contributed to her current condition, which of the following mechanisms is most likely responsible?
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Question 3 of 40
3. Question
A 62-year-old hospitalized woman is evaluated for muscle weakness. The patient was admitted 2 weeks ago due to septic shock from acute pyelonephritis. She was treated in the intensive care unit with intravenous fluids, vasopressors, and broad-spectrum antibiotics. The patient was also mechanically ventilated due to respiratory failure. Her hemodynamic status and infection gradually improved, but she has had difficulty being taken off the ventilator due to respiratory muscle weakness. She is also noted to have significant extremity weakness. Physical examination shows diffuse mild atrophy of the extremity muscles. Bilateral upper and lower extremity deep tendon reflexes are decreased. Which of the following is the most likely cause of this patient’s current condition?
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Question 4 of 40
4. Question
A 40-year-old man comes to the emergency department 30 minutes after experiencing a seizure. Over the past 3 months, the patient has had several episodes of brief twitching of the right hand, but today the abnormal movement gradually progressed to involve the entire right upper extremity, followed by shaking of the whole body for about a minute. He also lost consciousness and urinated involuntarily during the event. The patient feels groggy and has a mild headache. He has no other medical conditions but reports several concussions from playing football in college. Vital signs are within normal limits. Physical examination shows mild weakness of right hand grip but is otherwise normal. This patient’s seizure presentation is most suggestive of which of the following etiologic processes?
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Question 5 of 40
5. Question
A 14-year-old, previously healthy girl is brought to the office due to recurrent headaches. The patient has had 4 episodes of severe, throbbing pain on the right side of her head over the last 2 months, with the most recent occurring a week ago. The headaches are often associated with nausea, and the patient has had occasional vomiting. Lying in a dark room and taking acetaminophen improve the pain. The episodes resolve after 4-5 hours. The patient has had no visual disturbances or focal weakness but has tingling and numbness on the right upper extremity prior to the headaches. Vital signs are within normal limits. Physical examination, including funduscopic and neurologic examination, shows no abnormalities. Which of the following is most likely involved in the pathogenesis of this patient’s current condition?
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Question 6 of 40
6. Question
A 74-year-old woman comes to the office due to progressive forgetfulness over the past 2 years. Her family states that the patient asks the same questions repeatedly over the course of a day and often forgets what she is doing in the middle of chores. The patient has also been more irritable but has had no movement or gait abnormalities, feelings of depression, hallucinations, or delusions. Medical conditions include hypertension and renal artery stenosis. Vital signs are within normal limits. Mini-Mental State Examination score is 21 out of 30 and she recalls 1 out of 3 objects after 5 minutes. There are no focal neurologic deficits. Which of the following is most likely involved in the pathogenesis of this patient’s condition?
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Question 7 of 40
7. Question
A 28-year-old woman comes to the office due to pain at a previous surgery site. The patient underwent cesarean delivery a year ago and had no issues with wound healing. However, over the past 2 months, she has had intermittent sharp and burning pain at the incision site. Physical examination reveals a well-healed, low, transverse scar. There is a small knot palpable at the left end of the scar, light touch of which elicits severe pain. Cutaneous sensory nerve injury and abnormal axonal regeneration are suspected. Which of the following ion channels is most likely upregulated within the affected axons?
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Question 8 of 40
8. Question
A 67-year-old man has recurrent witnessed episodes of loss of consciousness while shaving. The episodes are characterized by a feeling of faintness followed by loss of consciousness, and each episode resolves after less than a minute. Blood pressure is 130/80 mm Hg and pulse is 80/min and regular; there are no significant changes in blood pressure or heart rate with supine and standing positions. Cardiac auscultation is normal with no murmurs or extra sounds. There are no neck bruits and the lungs are clear to auscultation. Which of the following factors is most likely contributing to this patient’s symptomatic episodes?
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Question 9 of 40
9. Question
A 68-year-old woman comes to the emergency department for evaluation of stroke-like symptoms. The patient says her face appeared “twisted” this morning but was normal when she went to bed last night. Her brother recently had a stroke, and she was worried that she may also be having a stroke. The patient has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. Vital signs are within normal limits. Physical examination shows facial asymmetry with drooping of the left corner of the mouth and loss of the left nasolabial fold. Which of the following additional examination findings on the affected side would be most suggestive of central nervous system involvement?
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Question 10 of 40
10. Question
A 67-year-old man is brought to the hospital after he developed sudden-onset altered mental status. The patient was taking care of some yardwork alongside his 17-year-old grandson during a hot summer day. The grandson does not have any symptoms. On examination, the patient’s temperature is 41 C (105.8 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination shows warm and dry skin. The patient is not oriented to time, place, or person. Deep tendon reflexes and muscle tone are normal. Which of the following findings in this patient most likely explains why the patient developed symptoms while his grandson remained asymptomatic?
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Question 11 of 40
11. Question
A 54-year-old man is brought to the office by his friend because of worsening memory impairment over the past several months. The patient is also withdrawn and not focused during conversations. He is slow to answer questions or carry out instructions. The patient has a prolonged history of HIV infection and has had several opportunistic infections due to inconsistent antiretroviral medication use. On physical examination, he is alert and oriented. Muscle strength, deep tendon reflexes, and sensation are normal. MRI of the head shows diffuse cerebral atrophy with no focal mass lesions or areas of demyelination. Viral proliferation in which of the following central nervous system cells is most likely involved in this patient’s disease process?
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Question 12 of 40
12. Question
A 24-year-old previously healthy man is brought to the emergency department after a motorcycle collision. The patient was intubated in the field. On arrival, Glasgow Coma Scale is 3/15. CT scan of the head shows left temporoparietal skull fractures, a large subdural hematoma, and diffuse cerebral edema. The patient undergoes hematoma evacuation and decompressive craniotomy. He is admitted in the neurocritical care unit, and supportive measures are provided. His clinical status gradually improves, and the patient is extubated on day 9. Over the next 15 months the patient opens his eyes spontaneously, gazing randomly around the room, but does not visually track moving objects. Bilateral pupils are equally responsive to light. He does not vocalize or follow instructions. The patient moves all 4 extremities, but the movements are not purposeful and there is no withdrawal to painful stimuli. The patient tolerates feeding via a percutaneous gastrostomy tube but has urinary and fecal incontinence. Which of the following is the most likely diagnosis?
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Question 13 of 40
13. Question
A 70-year-old man is brought to the emergency department due to left-sided weakness and slurred speech upon awakening 30 minutes ago. The patient was asymptomatic when he went to bed last night. Medical history includes type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient is a former smoker with a 30-pack-year history. Physical examination shows a right gaze preference, left lower facial droop, and hemiplegia and hemisensory loss on the left. CT scan of the brain reveals early infarction in the right middle cerebral artery territory with no acute hemorrhage. The patient is hospitalized for further management. Several hours later, he becomes progressively obtunded with elevated intracranial pressure. A repeat CT scan reveals edema in the region of acute infarction causing mass effect. Which of the following is the primary contributor to the pathogenesis of this patient’s raised intracranial pressure?
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Question 14 of 40
14. Question
A 55-year-old woman comes to the physician due to a 4-month history of progressive hearing loss in her right ear. Vital signs are within normal limits. Inspection of the external ear canals and tympanic membranes shows no abnormalities. Neurologic examination shows decreased hearing in the right ear; hearing in the left ear is normal. MRI of the head with contrast is shown in the image below:
Which of the following is the most likely diagnosis?
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Question 15 of 40
15. Question
A 9-month-old boy is brought to the clinic by his parents for a well-child check. The mother says that he cannot roll over, sit without support, or crawl. The patient can reach for toys with his left hand but not with his right. He was born at 28 weeks gestation, and Apgar scores were 5 and 6 at 1 and 5 minutes, respectively. The patient’s birth weight was 1.2 kg (2 lb 10 oz), and he was admitted to the neonatal intensive care unit for 3 months. Head circumference and length are at the 50th percentile; weight is at the 15th percentile. Vital signs are normal. On examination, the patient keeps his right hand fisted shut. Muscle tone and deep tendon reflexes are increased in the right arm and leg. Which of the following is the most likely cause of this patient’s condition?
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Question 16 of 40
16. Question
A 65-year-old woman comes to the office due to progressively worsening weakness of the legs for 5 months. Examination shows increased muscle tone, brisk deep tendon reflexes, and decreased muscle strength in the lower extremities. The Babinski sign is positive in both legs. Upper extremities are normal. MRI of the spine reveals a 2-cm, round lesion with homogeneous, intense contrast enhancement compressing the spinal cord at the T12 level; the lesion is extramedullary but is surrounded by cerebrospinal fluid, as shown in the exhibit. Which of the following is the most likely cell of origin of the lesion?
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Question 17 of 40
17. Question
A 15-year-old boy is evaluated for progressive lower extremity weakness. The patient has had difficulty running and keeping up with peers for the past several years and has sprained his ankles on multiple occasions. His father also experienced similar symptoms beginning at the same age and became wheelchair bound. Physical examination shows weakness and atrophy of the distal lower extremity muscles. There is bilateral pes cavus deformity. Ankle reflexes are absent, and sensation to vibration is also absent in the feet. Abnormal function of which of the following is the most likely cause of this patient’s condition?
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Question 18 of 40
18. Question
A 3-year-old boy is being evaluated for recurrent generalized seizures and developmental delay. Physical examination is notable for scattered hypopigmented skin patches. MRI of the head reveals multiple masses, most of which line the ependymal surfaces of the lateral ventricles, and some are calcified, as shown in the below image.
Which of the following is the most likely underlying cause of this patient’s brain lesions?
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Question 19 of 40
19. Question
A 45-year-old woman comes to the emergency department due to sudden-onset, severe headache. On arrival, the patient is alert and oriented and has no focal neurological deficits. CT scan of the head reveals subarachnoid hemorrhage, and she is admitted to the critical care unit. Over the next several hours, the patient gradually becomes somnolent and less responsive. She opens her eyes to painful stimuli only and does not follow commands. Repeat imaging of the brain shows no new hemorrhage, but there is enlargement of the entire ventricular system compared to the previous CT scan. Which of the following is the most likely cause of this patient’s neurologic deterioration in the hospital?
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Question 20 of 40
20. Question
A 55-year-old woman is brought to the office by her husband for evaluation of strange behavior. She has been spending large amounts of money to buy expensive clothes and jewelry. The patient has also offered sex to unknown men in the neighborhood and has become increasingly indifferent toward her family, about whom she used to care deeply. She usually drinks 1 or 2 glasses of wine on weekends but lately has been drinking 2 or 3 glasses almost every day. When asked about these changes during the interview, the patient states that she has not noticed any change in her behavior. Vital signs are normal. The general physical and neurologic examinations are normal. This patient’s condition is most likely due to abnormal accumulation of which of the following?
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Question 21 of 40
21. Question
A 41-year-old woman is undergoing evaluation for progressively worsening headaches. The patient has a history of hypertension and hyperlipidemia. She drinks a glass of wine daily and does not use tobacco or recreational drugs. Sagittal MRI is shown in the image below:
Item 1 of 2
Which of the following physical examination findings is most likely to be found in this patient?CorrectIncorrect -
Question 22 of 40
22. Question
Item 2 of 2
The MR findings are discussed with the patient, and a blood sample is drawn for laboratory testing. Which of the following hormones is most likely to be increased in this patient?CorrectIncorrect -
Question 23 of 40
23. Question
A 38-year-old woman comes to the emergency department due to severe headache. An hour ago, she experienced a sudden, explosive headache followed by a brief loss of consciousness. Since regaining consciousness spontaneously, she has had persistent global headache and nausea. Head movement or bright light worsens the pain. Temperature is 37.2 C (99 F), blood pressure is 142/90 mm Hg, and pulse is 98/min. The patient is somnolent but easily rouses to voice. She is well oriented to time, place, and person. There is increased resistance to neck flexion, which elicits pain. The pupils are equal and reactive to light. Deep tendon reflexes and sensory examination are normal. Brain imaging would most likely reveal which of the following?
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Question 24 of 40
24. Question
A 17-year-old right-handed boy is brought to the emergency department due to brief loss of consciousness after colliding with another player during a football game. The patient reports “fogginess” but has had no headache, vomiting, focal weakness or numbness, or seizures. He has no other medical conditions and takes no medications. Vital signs are within normal limits. On physical examination, the patient demonstrates retrograde amnesia about the game but no focal neurologic deficits. CT angiography of the head reveals no skull fractures or intracranial bleeding, but a small lesion in the left temporoparietal region composed of abnormal vascular channels is noted and is shown in the exhibit. Without treatment of this abnormality, which of the following will most likely occur in this patient?
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Question 25 of 40
25. Question
A 22-year-old woman comes to the emergency department due to a severe left frontal headache for the past 30 minutes. The patient has had similar pain every day for the past 3 days, and the episodes resolve spontaneously after about an hour. She has no other medical conditions and takes no medications. On physical examination, the patient appears restless and in pain. There is ptosis on the left side. Which of the following findings is most suggestive of cluster headache in this patient?
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Question 26 of 40
26. Question
A 23-year-old man who notes recurrent severe nosebleeds is found to have pink spider-like lesions on his oral and nasal mucosa, face, and arms. The patient most likely suffers from:
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Question 27 of 40
27. Question
An 8-year-old boy is being evaluated due to drug-resistant epilepsy. The patient has had recurrent seizures since age 2, which have remained uncontrolled despite multiple antiepileptic medications. He has no history of head trauma, meningitis, or encephalitis. There is no family history of seizure disorder. Electroencephalography reveals epileptic foci originating from the left temporal lobe, and neuroimaging reveals an abnormality of the left hippocampus. Surgical resection of the cortical region from which the seizure originates is performed. Histopathological examination of the removed brain tissue is most likely to reveal which of the following findings?
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Question 28 of 40
28. Question
A 66-year-old man comes to the office after his employer urged him to undergo medical evaluation for repeated mistakes at work. The patient was a highly successful accountant until 6 months ago when he started making uncharacteristic errors and turning in projects late. He says, “I don’t know why, but it’s suddenly really hard for me to organize and plan for these projects.” His wife has had to take over managing their finances at home. The patient is also having difficulty shopping for groceries and preparing meals. He has not seen a physician in many years and takes no medications. Blood pressure is 159/96 mm Hg and pulse is 72/min. Physical examination shows impaired executive neurocognitive function. Reflexes are 2+ in the right lower extremity and 3+ in the left. Strength is 5/5 on the right side and 4/5 in the left lower extremity. He has an unsteady gait. Which of the following is the most likely pathophysiologic process underlying this patient’s condition?
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Question 29 of 40
29. Question
A 59-year-old woman comes to the office due to recurrent facial pain for the past month. The pain occurs only on the left side. It starts just in front of the ear as a shock-like sensation that quickly radiates down the jaw over 4-8 seconds, then resolves. It is most commonly triggered by chewing, so the patient sometimes skips meals to avoid the pain. Vital signs are normal. The patient has lost 4.5 kg (10 lb) since she was last seen 6 months ago. Physical examination of the oral cavity shows no dental caries. Severe pain is reproduced with light touch of the left cheek. Neurologic examination is otherwise normal. Which of the following is the most likely cause of this patient’s condition?
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Question 30 of 40
30. Question
A 10-year-old girl is brought to clinic for laboratory follow-up. Her mother was recently diagnosed with von Hippel-Lindau (VHL) disease, and the patient received genetic testing. Examination is unremarkable. Laboratory evaluation reveals a missense mutation in the VHL gene. Periodic surveillance with which of the following is most likely to be of benefit in this patient?
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Question 31 of 40
31. Question
A 55-year-old man with HIV comes to the emergency department due to 3 weeks of increasing headache, fever, and vomiting. Examination shows low blood pressure and neck stiffness. The patient’s condition quickly deteriorates, and he dies in the hospital despite appropriate treatment. Autopsy of the brain shows a diffuse gelatinous exudate covering the base of the brain. Cut sections of the brain show marked ventriculomegaly and frontal lobe infarcts but no intraparenchymal mass lesions. Which of the following is the most likely diagnosis?
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Question 32 of 40
32. Question
Researchers are testing various modalities to reduce glutamate-induced excitotoxic neuronal injury after ischemic stroke. The investigators record the postsynaptic potential of cortical neurons under various conditions. The neurons are exposed to glutamate, which causes them to depolarize; excessive depolarization triggers cell death. The experiment is repeated after altering the electrolyte composition of the extracellular fluid. When the extracellular magnesium concentration is increased, glutamate-induced neuron depolarization and cell death are decreased. Which of the following changes in ion conductance explains the improved neuron survival in response to magnesium?
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Question 33 of 40
33. Question
A 12-year-old boy is being evaluated for worsening headaches for the past several months. He also has had paresthesia, weakness, and stiffness of the extremities. MRI of the brain reveals an expansile mass in the lower pons, as shown in the image below:
Which of the following is most likely to be observed in this patient due to direct involvement of nerve nuclei by the brain lesion?
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Question 34 of 40
34. Question
A 30-year-old woman comes to the emergency department after a seizure. The patient reports pain on the left side of her face and is unable to fully open or close her mouth. She is drooling. On examination, the jaw deviates to the right and the left mandibular condyle is very prominent with a palpable depression posterior to it. The patient is diagnosed with an anterior dislocation of the left temporomandibular joint. The jaw is most likely maintained in a dislocated position due to continued spasm of which of the following muscles?
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Question 35 of 40
35. Question
A 62-year-old, right-handed man is evaluated for an episode of left leg weakness that spontaneously resolved within 30 minutes of onset. The patient also has had transient vision loss in the right eye. Medical history is significant for hypertension and diabetes mellitus. Evaluation reveals an atherosclerotic plaque in the extracranial portion of the supplying artery. During percutaneous stenting of the lesion, the vascular catheter is inserted into the right common femoral artery and gradually advanced to the level of the aortic arch. Which of the following is the most likely path of the catheter before stenting of the culprit lesion can be performed?
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Question 36 of 40
36. Question
A 6-year-old girl with cerebral palsy undergoes selective dorsal rhizotomy surgery. The patient was born prematurely with a very low birth weight and had experienced periventricular cerebral white matter injury. During the procedure, dorsal rootlets of lumbosacral spinal nerves are selectively severed, as shown in the image below:
Which of the following is the most likely effect of this intervention in this patient’s lower extremities?
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Question 37 of 40
37. Question
A 56-year-old man is brought to the emergency department due to weakness and difficulty speaking. He has a history of hypertension, cigarette smoking, and polysubstance use. The patient experienced a headache while smoking crack cocaine the previous night. This morning, he was found on the bed unable to move or speak. On physical examination, the patient is awake with normal pupillary responses. Vertical eye movements are intact, but horizontal eye movements are impaired. There is loss of motor strength in the upper and lower extremities bilaterally. Ischemic infarction from cocaine-induced vasospasm is suspected. A lesion involving which of the brain regions is the most likely cause of this patient’s current condition?
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Question 38 of 40
38. Question
A 74-year-old woman is brought to the emergency department by her son after he found her acting strangely. She was asking to open the window blinds, even though the blinds were already open and was bumping into objects when walking around her home. The patient insists that her vision is fine and came to the hospital upon her son’s insistence. On physical examination, the patient is alert and oriented but lacks appropriate eye contact. Bilateral direct and consensual pupillary reflexes are normal. On confrontation visual field testing, she reports the wrong number of fingers in all 4 visual quadrants. The patient indicates the wrong direction when asked to point to the door and gives an incorrect visual description when asked to describe the physician. This patient most likely has an infarction involving the brain regions supplied by which of the following arteries?
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Question 39 of 40
39. Question
A 15-year-old girl is evaluated for recurrent episodes of focal onset seizures evolving to bilateral tonic-clonic seizures over the past several months. She has also had headaches that are severe enough to keep her home from school. The patient has no prior medical conditions. MRI of the brain is shown in the exhibit. Which of the following histopathological findings are most likely present in the abnormal lesion?
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Question 40 of 40
40. Question
A 65-year-old man with a history of atrial fibrillation comes to the office due to numbness of his left hand for the past 3 weeks. When the eyes are closed, he is unable to recognize the letters written on his left hand with a stylus. Muscle strength is normal in all extremities. Deep tendon reflexes are 2+. Gait is normal. This patient most likely has a lesion in which of the following locations of the brain?
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