A 79-year-old man comes to the physician with his daughter for memory loss over the last 8-12 months.  She initially noticed that he had trouble with forgetfulness, followed by distractibility and difficulty with word finding and object recognition.  The patient is currently dependent on her for most independent activities of daily living, including transportation and finances.  He is able to dress, bathe, and toilet himself.  His gait has been unstable, and he sometimes seems to get “stuck in a chair.”  On review of systems, he notes urinary urgency, frequency, and incontinence.  He has a history of benign prostatic hyperplasia for which he takes tamsulosin.  The patient has no tremor, problems with sleep, weakness, hallucinations, or sensory disturbances.  On examination, his vital signs are normal.  He is oriented to self only.  On mental status examination, he has impairments in language, visuospatial skills, and executive function.  His cranial nerves are intact.  There is normal bulk and tone of the musculature.  His gait is wide based and magnetic.  He has decreased stride length and a slow turn requiring several steps.  Laboratory results, including TSH and vitamin B12, are normal.  Brain imaging is shown in the image below.

Which of the following is the most appropriate next step in management of this patient?

A 79-year-old man is brought to the office by his daughter.  The patient has been having increasing difficulty caring for himself over the last 2 years.  He is now dependent on his daughter for meal preparation, shopping, and cleaning.  He will frequently go a week without bathing and often has difficulty dressing himself appropriately.  The patient sometimes grows frustrated and shouts at his daughter but has never been physically violent.  On direct questioning, he states that he feels fine, does not see any reason for coming to the office, and is quite suspicious of his daughter’s motives.  The patient has lived alone since his wife died 5 years ago.  He has hypertension, osteoarthritis, and a history of remitted major depressive disorder.  Medications include hydrochlorothiazide and acetaminophen as needed.  Neurologic examination is nonfocal.

Item 1 of 2

Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2

The patient scores 20 out of 30 on the Montreal Cognitive Assessment.  Neuroimaging studies reveal diffuse cortical atrophy.  The laboratory workup is unremarkable.  Which of the following is the most appropriate next step in pharmacotherapy?

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign.

Item 1 of 5

Which of the following is the most appropriate test to confirm the diagnosis in this patient?

Item 2 of 5

Appropriate investigation has confirmed the most likely diagnosis.  Which of the following is the most appropriate next step in management of this patient?

Item 3 of 5

The patient has marked symptomatic improvement within a few days of initial treatment and is scheduled for physical therapy.  Which of the following is the most appropriate long-term pharmacotherapy for this patient?

Item 4 of 5

Four months later, the patient comes to the physician for a routine visit and asks for advice regarding pregnancy.  She has been taking her medication regularly.  Which of the following is the most appropriate response?

Item 5 of 5

The patient returns to the physician due to painful muscle spasms.  She has frequent episodes of pain and stiffness in both legs, especially when rising from her bed.  She has tried home stretching exercise without significant relief.  The patient is afebrile and has no new neurological deficits.  Increased muscle tone is noted in the lower extremities.  Laboratory evaluation, including electrolytes, is normal.  Which of the following is the most appropriate next step in managing this patient’s current symptoms?

A 65-year-old woman comes to the office with several months of progressive cough and generalized weakness.  The patient has limited mobility and shortness of breath due to osteoarthritis and chronic obstructive pulmonary disease, respectively.  She also has difficulty standing from a chair, combing her hair, and putting dishes in overhead cabinets.  The patient’s medical history includes hypertension and hyperlipidemia.  She quit smoking cigarettes 2 years ago but previously smoked 3 packs daily since age 20.  Blood pressure is 112/70 mm Hg, and pulse is 92/min.  BMI is 17 kg/m².  Physical examination shows moderate weakness in the proximal muscles of her upper and lower limbs and loss of deep tendon reflexes.  CT scan of the chest is shown below.

Which of the following is the most likely cause of this patient’s weakness?

A 66-year-old man comes to the emergency department with progressive lower back pain, urinary incontinence, and decreased appetite for the past 2 days.  The patient was recently diagnosed with L4-L5 disc herniation and received an epidural injection for radicular pain 2 weeks ago.  Other medical concerns include type 2 diabetes mellitus and hypertension.  Temperature is 38.3 C (100.9 F), blood pressure is 136/88 mm Hg, pulse is 96/min, and respirations are 14/min.  The patient is alert and oriented.  Physical examination shows poor dentition, tenderness on palpation of the lumbar spine, and absent deep tendon reflexes in both lower extremities.  Rectal examination shows decreased rectal sphincter tone and an enlarged, smooth prostate.  Laboratory results are as follows:

Which of the following is the most appropriate next step in management of this patient?

A 65-year-old man was admitted to the intensive care unit after going into cardiac arrest when alone at home.  Cardiopulmonary resuscitation and advanced cardiac life support were performed extensively in the field, and return of spontaneous circulation was eventually achieved.  Two days later, he remains intubated and is on full ventilator support.  The patient is unresponsive to verbal and tactile stimuli.  His temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 70/min.  The treating physician discusses with the patient’s family the possibility of brain death.

Item 1 of 2

Which of the following is most consistent with the criteria for brain death?

Item 2 of 2

The patient is diagnosed with brain death based on apnea testing and in accordance with local regulations.  The physician explains this finding to the patient’s family and discusses withdrawing of mechanical ventilator support.  Everyone in the family appears to understand and agrees to proceed with withdrawing ventilatory support.  A relative then walks into the patient’s room and notices some movements in the patient’s legs and toes.  The relative believes the patient is not dead and gets angry with the treating physician.  Which of the following is the most appropriate response to the relative’s reaction?

A 62-year-old Caucasian man comes to the physician because of progressive weight loss and right lower extremity weakness for the last two months.  On further questioning, he tells you that he has been having frequent leg cramps in the right leg.  These cramps are most prominent in the morning, after he wakes up.  He also has difficulty with swallowing and chewing.  He denies any problems with bowel or bladder function.  His other medical problems include hypertension and hypercholesterolemia.  He does not use tobacco.  His family history is not significant.  His vital signs are within normal limits.  The physical examination reveals weakness in his right lower leg, atrophy and fasciculation of the thigh and calf muscles, a hyperactive knee jerk, and tongue fasciculations.  The rest of his neurological examination, including the sensory examination, is normal.

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

Which of the following treatment has been shown to be beneficial in these patients?

A 78-year-old woman is brought to the office by her son due to progressive forgetfulness over the last year.  She has been less active than normal and is having some difficulty walking.  The patient has no urinary incontinence.  Medical history is significant for exertional angina and hypertension.  She has recently been depending on her son to manage her medications, which include metoprolol, amlodipine, rosuvastatin, and aspirin.  She does not smoke or consume alcohol.  Her father had hypertension and stroke, and her mother had Alzheimer dementia.  The patient is oriented to person and place, but not time.  She has difficulty with 3-word recall.  Her gait is slightly unstable, and she has problems balancing when she closes her eyes.  Examination of the lower extremities shows decreased vibratory sensation, spastic paresis, and hyperreflexia bilaterally.

Item 1 of 2
What is the most likely cause of this patient’s condition?

Item 2 of 2
Further evaluation of the patient shows mild indirect hyperbilirubinemia.  Which of the following is the most likely explanation of this finding?