Untreated neurological disease may persist for months. Optic neuritis may also appear in association with the chronic meningitis of Lyme disease. A schwannoma may develop on the seventh cranial nerve, but it would produce unilateral Prep for the Shelf Exam, Ace the Clerkship! A neurological examination indicates that speech, sensation, jaw movement, vision, eye movements, Neuroscience PreTest Self-Assessment and Review, 8e provides students with board-style questions, answers, and concise but comprehensive explanations for correct and incorrect answer options.
Hutchison's Clinical methods 18th ed. Hurst , J. Muscular dystrophies cause insidious onset of muscle weakness and wasting and will present with pure motor weakness without other evidence of neurological abnormality. Muscular dystrophy, however, would be uncommon at this age in a It delivers USMLE-style questions and answers that address the clerkship's core competencies along with detailed explanations of both correct and incorrect answers.
The infarct has damaged the left sixth and seventh cranial nerves or nuclei in the left pons with resultant diplopia The differential diagnosis of headaches associated with neurological or visual dysfunction is important because it Prepare Early…Score Higher Completely revised and small enough to fit in a lab coat pocket, this review of Medicine features questions with answers and explanations, including new questions in clinical vignette format.
A year-old man develops bed wetting and transient sexual dys- function that resolves over the course of 6 weeks. One month later, he notices a pins-and-needles sensation in his right leg that never clears com- pletely.
On examination, he has hyperreflexia in both of his legs and past- pointing in his right arm. His gait is slightly ataxic, and he is unable to perform tandem gait. A year-old woman weighing in excess of lb complains of headache and blurred vision that began 2 weeks prior to consulting a physician. She has no vomiting or diplopia. Examination of her eyes reveals florid papilledema but without hemorrhages.
Her neurologic exam- ination is otherwise entirely normal. She had a similar problem while preg- nant with her fourth child. The answer is e. Victor, pp , — Standing with the feet together and the eyes closed is the Romberg test. The person with poor position sense needs visual cues to remain standing. This test was intro- duced as a helpful way to check for deficits associated with tabes dorsalis, a form of neurosyphilis. In tabes dorsalis, the dorsal columns of the spinal cord are damaged.
These dorsal or posterior columns carry the nerve fibers that transmit vibration and position sense to the brain. With the wide- spread use of penicillin, tabes dorsalis has become rare in industrialized nations, and impaired position sense is much more likely to be a conse- quence of diabetes mellitus or alcoholism. In both of these conditions, the impaired position sense is much more likely to be a consequence of dam- age to nerves in the limbs than of damage to the posterior columns of the spinal cord.
In performing the test, it is important to remember that even normal people will tend to sway slightly more when their eyes are closed, and that those with loss of cerebellar function will also sway more with loss of visual cues. The answer is a.
Osborn, pp — Computed tomographic scan- ning measures the density of intracranial as well as extracranial structures. Bone appears much denser than blood, but blood is obvious on the unen- hanced precontrast CT scan precisely because it is much denser than white matter, gray matter, and CSF. The resolution of the CT scan is generally not sufficient to differentiate the pia mater from the gray matter on which it lies.
Other meningeal structures, such as the dura mater, may appear denser than brain, especially if there is some calcification in the membranes. The answer is b. Osborn, p Magnetic resonance imaging looks primarily at the water content of tissues, but it can be customized to look at specific properties of tissues. The T1-weighted image enhanced by gadolinium contrast agent is useful for identifying inflammation and other causes of fluid extravasation into the brain. The T2-weighted image is not specific for demyelination, but it is useful in following changes in plaques of demyelination, an appli- cation that has been used in studies of agents useful in the management of multiple sclerosis.
Magnetization transfer and other more complex tech- niques have been developed to look at demyelination specifically, but they are not generally available. The diffusion—weighted image technique looks at the diffusion coefficients of water molecules in tissues and is proving useful in studies of acute stroke. The CT scan cannot readily distinguish between tissues of similar densities. Positron emission tomography is pri- marily a research tool that is useful in determining what materials are used or are unavailable for use in specific parts of the brain.
The answer is d. The classic triad is asymmetric resting tremor, rigidity, and bradykinesia. The rigidity is generally severe later, not early in the disease. Victor, p Intention or kinetic tremors are most characteristic of damage to the cerebellum. Kinetic tremors of the hand or arms are most common with disease of the cerebellar hemispheres, but they may also develop with damage to the spinocerebellar tracts of the spinal cord.
Damage to the thalamus is more likely to produce a sensory disturbance. Tremors may develop with spinal cord damage, but they do not follow a typical pattern and do not suggest a spinal cord origin.
Hauser, p Paradoxically, this resting tremor ceases when relaxation progresses to sleep. Rowland, p Most rhythmic to-and-fro move- ments of the eyes are called nystagmus. Nystagmus has a fast component in one direction and a slow component in the opposite direction.
Nystagmus with a fast component to the right is called right-beating nystagmus. The eye movements typically appear as a laterally beating nystagmus on gaze to either side; this type of nystagmus is called gaze-evoked. If the patient has nystag- mus on looking directly forward, he or she is said to have nystagmus in the position of primary gaze. Ataxia, dysarthria, impaired judgement, and lethargy may also occur at toxic levels of phenytoin.
Many other drugs also evoke nystagmus. Weakness of abduction of the left eye, or abducens palsy, is due either to injury to the sixth cranial nerve or to increased intracranial pressure. Impaired convergence can occur normally with age or may be a sign of injury to the midbrain. Papilledema is a sign of increased intracranial pressure.
Impaired upward gaze may occur in many conditions, but would not be expected to occur with a toxic phenytoin level. Braunwald, p With primary muscle diseases, such as polymyositis, weakness usually develops in proximal muscle groups much more than in distal groups.
This means that weakness will be most obvious in the hip girdle and shoulder girdle muscles. The hip girdle is usually affected before the shoulder girdle.
To get out of a low seat, the affected person may need to pull him- or herself up using both arms. Per- sons with more generalized weakness or problems with coordination are less likely to report problems with standing from a seated position. Poor rapid alternating movements and poor fine finger movements usually develop with impaired coordination, such as that due to cerebellar damage.
With severe weakness in the limbs, patients will do poorly on these tests of function as well. With proximal muscle weakness, the affected person will usually perform relatively well on these tests of distal limb coordination. The vibrations from a tuning fork placed on top of the head are transmitted through the skull to both ears.
Bone con- duction of sound through the skull should be equal in both ears. With sen- sorineural hearing loss, the patient will hear the midline fork more loudly in the unaffected ear.
Sensorineural hearing loss is the deafness that develops with injury to the receptor cells in the cochlea or to the cochlear division of the auditory nerve. In conductive hearing loss, the vibrations of the tuning fork are perceived as louder in the affected ear.
With this type of hearing loss, the injury is in the system of membranes and ossicles designed to focus the sound on the cochlea. Impairment of the conductive system causes the vibra- tions of the tuning fork to be transmitted to the cochlea directly through the skull. Much like a person with cotton stuffed into the external auditory meati, the patient with the conductive hearing loss has impaired perception of sound coming from around him or her but an enhanced perception of his or her own voice.
This type of tuning fork test is called the Weber test. Bradley, pp — ENG is used primarily to characterize nystagmus and disturbances of eye movements that involve rel- atively fast eye movements. Abnormal patterns of eye movement may help localize disease in the central or peripheral nervous system in patients with vertigo.
The retina is negatively charged in comparison with the cornea, which creates a dipole that is monitored during ENG studies by electrodes placed on the skin about the eyes. Movement of the most posterior elements of the retina toward an electrode is registered as a negative voltage change at that electrode. Damage to the pons may produce characteristic conjugate deviations of the eyes. The conjugate eye movements are rhythmic and directed downward, but they lack the rapid component characteristic of nystagmus.
This type of abnormal eye movement is called ocular bobbing. A lesion at the cervicomedullary junction, such as a meningioma at the fora- men magnum, will produce a down-beating nystagmus with both eyes rhythmically deviating downward, with the rapid component of this nys- tagmus directed downward as well.
Cervicomedullary refers to the cervical spinal cord and the medulla oblongata. Damage to the midbrain, thalamus, or hypothalamus may disturb eye movements, but down-beating nystag- mus would not ordinarily develop with damage to these structures. Victor, pp — The facial nerve innervates the stapedius muscle of the middle ear.
Hyperacusis is an indication that the damage to the facial nerve is close to its origin from the brainstem, because the nerve to the stapedius muscle is one of the first branches of the facial nerve. The tensor tympani is controlled by the motor fibers in the fifth cra- nial nerve.
With damage to this nerve, the tympanic membrane has some inappropriate slack, but the patient does not usually comment on increased sensitivity to sound in the affected ear. Walking along a straight line with the heel of one foot touching the toe of the other foot is called heel-to- toe walking, or tandem gait. It is a routine test for ethanol intoxication because alcohol exposure impairs the coordination of gait as governed by the cerebellum. Tandem gait will be abnormal with many other problems, including weakness, poor position sense, vertigo, and leg tremors, but such abnormality in the absence of these other problems suggests a cerebellar basis for the problem.
The hypoglossal nerve inner- vates the tongue. The fine movements noted under the surface of the tongue with injury to the hypoglossal nerve are called fasciculations and are an indication of denervation.
They are presumed to occur through hypersensi- tivity to acetylcholine acting at the denervated neuromuscular junction. Atrophy and fasciculations are likely to occur together and are highly sug- gestive of denervation of the tongue. This is most often seen with brainstem disease, such as stroke or bulbar amyotrophic lateral sclerosis ALS , or with transection of the hypoglossal nerve. This patient has a history most consistent with a herniated lumbar disk. The most common locations for lumbar disk herniation are between the fifth lumbar and first sacral verte- brae producing S1 nerve root compression and between the fourth and fifth lumbar vertebrae producing L5 root compression.
S1 nerve root compression, or radiculopathy, is associated with pain in the lower back or buttock region, often radiating down the posterior thigh and calf to the lat- eral and plantar surfaces of the foot and affecting the fourth and fifth digits of the foot.
Motor function of the foot and toe flexors, toe abductors, and hamstring muscles may be impaired but more often is not. The loss of the ankle jerk, or Achilles tendon reflex, is often the only objective sign of S1 radiculopathy.
Deep tendon reflexes such as the ankle jerk are diminished or lost when there is damage to the sensory fibers from the tendon stretch organs.
A Babinski sign is an indication of upper motor neuron damage, which is not expected in this case with preserved autonomic and motor function. Loss of pinprick sensation over the web space between first and second toes is found in association with injury to the fifth lumbar nerve root or to the peroneal nerve.
Hyperreflexia of the knee jerk is another sign of an upper motor neuron lesion and would not be expected in this case. This test may be positive on the contralateral side crossed straight-leg raising sign , but it is usually more prominent on the affected side.
Victor, pp —, — The presentation with subacute onset of morning headaches culminating in confusion, right hemiparesis, and seizure in a young person suggests an expanding mass lesion, most likely a tumor. The weakness of eye abduction bilaterally is what may be referred to as a false localizing sign.
Although this suggests injury to the sixth cranial nerves bilaterally, the injury is not restricted to the sixth cranial nerve. The increase in intracranial pressure ICP from the mass causes stretching of the sixth-nerve fibers, which consequently leads to their dysfunction. Diplopia may be appreciated only on lateral gaze, which requires full function of the sixth nerve. Funduscopic exam in such a case would most likely reflect changes of increased ICP.
The first sign of this is usually blurring of the margins of the optic disc and elevation of the disc due to swelling.
Changes in the optic disc—the area in which all the nerve fibers from the retina come together and exit as the optic nerve— occur with problems other than increased ICP such as optic neuritis , but blurring of the margins should be routinely considered a sign of increased ICP. This is especially true if the appearance of the disc has changed in asso- ciation with the development of headache, obtundation, and vomiting.
Pigmentary degeneration of the retina may occur with some infections, such as congenital toxoplasmosis or cytomegalovirus, or as part of a hered- itary metabolic disorder, as in retinitis pigmentosa.
Caloric stimulation of the ear drives the endolymphatic fluid in the inner ear up or down, depending on whether warm or cold water is used. The vestibular organ exposed to warm water sends impulses to the brainstem that indicate that the head is moving to the side that is being warmed. The eyes deviate to the opposite side to maintain fixation on their targets, but the eye movement actually breaks fixation. A reflex nystagmus toward the ear that is being stimulated develops as the brain tries to establish refixation while the vestibular signals repeatedly prompt deviation of the eyes contralateral to the warm stimulus.
Kandel, p The presence of ptosis and miosis indicate oculosympathetic palsy, or Horner syndrome. This indicates injury to the sympathetic supply to the eye. This pathway begins in the hypothalamus, travels down through the lateral aspect of the brain- stem, synapses in the intermediolateral cell column of the spinal cord, exits the spinal cord at the level of T1, and synapses again in the superior cervi- cal ganglion. From there, postganglionic fibers travel along the surface of the common carotid and internal carotid artery until branches leave along the ophthalmic artery to the eye.
Fibers of the sympathetic nervous system, which are destined to serve the sudomotor function of the forehead, travel with the external carotid artery. Thus, diseases affecting the internal carotid artery and the overlying sympathetic plexus do not produce anhidrosis, the third element of Horner syndrome.
In this case, the occurrence of painful Horner syndrome acutely after vigorous activity is virtually diagnostic of carotid artery dissection. Dissections may occur more frequently in mi- graineurs. The preservation of visual fields and acuity excludes significant disease of the optic tract and chiasm, which also would not be expected to cause ptosis. The sympathetic pathway does exit the spinal cord at T1, but injury at this location would not cause orbital pain, which is typical of carotid arterial dissection.
The answer is c. Dissections are caused by a tear in the intimal lining of the vessel with penetration of blood beneath the intimal surface, forming an intramural hematoma blood clot within the wall of the vessel. This may be seen as an area of increased signal within the lining of the vessel on T1-weighted images, on which a blood clot appears bright. Typically, this takes a crescentic pattern, and the lumen of the vessel is displaced eccentrically.
An increased T2 signal in a periventricular distri- bution is typical of the plaques of demyelinating disease seen in multiple sclerosis. Contrast enhancement along the tentorial margin might be seen in inflammatory diseases of the dura mater or meninges.
An enlarged optic nerve might be seen in the setting of optic neuritis or infiltration of the nerve by a tumor or other process, and this would be expected to cause visual impairment. A cavernous sinus aneurysm that is sufficient to produce ocu- losympathetic palsy would be expected to cause other deficits in ocular motility because the cranial nerves subserving oculomotor function course through the cavernous sinus.
After injury to the facial nerve, regen- erating fibers may be misdirected. Aberrant regeneration is possible only if the nerve cell bodies survive the injury and produce axons that find their way to neuromuscular junctions. Fibers intended for the periorbital muscles end up at the perioral muscles, and signals for eye closure induce mouth retraction. With a habit spasm or idiopathic tic, similar movements may occur, but the movement disorder would not be linked to facial weakness.
This patient gives a good his- tory for subarachnoid hemorrhage. A cerebral angiogram could diag- nose the etiology of a subarachnoid hemorrhage, such as an aneurysm. How- ever, it is an invasive test and should not be done without first attempting to confirm the diagnosis with less risky tests. If you suspected seizures an elec- troencephalogram might be useful. As this patient did not have any loss of consciousness, personality changes, hallucinations, or rhythmic movements suggestive of seizures, there is no indication for a psychiatry consult.
However, if no blood is seen, the physician should proceed to a lum- bar puncture. A cerebral an- giogram could diagnose the etiology of a subarachnoid hemorrhage, such as an aneurysm; however, it is an invasive test and should not be done without first attempting to confirm the diagnosis with less risky tests.
An MRI is un- likely to give new useful information in this case. Zolmitriptan is a treatment for migraines. This patient probably has a subarach- noid hemorrhage and must be evaluated for an aneurysm. This does not appear to be bacterial meningitis. It is not emergent that ceftriaxone be given in this case. Repeating the lumbar puncture will not help with the diagnosis or treatment. Intravenous acyclovir would be used to treat herpes encephalitis. Although there are often red blood cells in the spinal fluid of such patients, the overall history makes herpes encephalitis unlikely.
Computed tomographic scan- ning is especially sensitive to intracerebral hemorrhage, but not to aneurysms unless they are more than 5 mm across. Even such relatively large aneurysms may not be revealed by CT scanning unless there is bleeding from the aneurysm or distortion of adjacent structures by the aneurysm. Microscopic aneurysms may be localizable on CT only because of the high signal left near the aneurysm by telltale blood. In most cases of aneurysmal bleeding, angiography is needed to characterize and localize the lesion.
The open black arrow denotes the aqueduct of Sylvius, which connects the third ventricle with the fourth ventricle. This sagittal view of the lower part of the brain provides a high- resolution view of the posterior fossa. What appears to be a connection between the most inferior aspect of the fourth ventricle and the cisterna magna at the straight black arrow is an artifact. This is the obex of the fourth ventricle, and there is a complete roof over this ventricle, which communicates with the subarachnoid space through the foramens of Luschka and Magendie.
Bone has low signal on this T1- weighted image of the head, and so it may not be obvious that this cerebel- lar tonsil is sitting above the opening of the foramen magnum. The white streak just above the curved white arrow is the bone marrow in the occipi- tal bone. With Arnold-Chiari malformations, the tonsil would be expected to sit below the foramen magnum. With Dandy-Walker syndrome or giant cisterna magna, the tonsil would be inapparent or at least sitting much more cephalad.
All five of the tumors listed are common in the posterior fossa. The tentorium cerebelli is a fold of meninges. Consequently, it is a relatively common site for the development of meningiomas. A tumor arising on the tentorium may extend either supe- riorly or inferiorly.
Inferior extension of the tumor may damage cranial nerves and make complete extirpation of this benign neoplasm impossible.
Calcified masses appear hyper- dense without contrast enhancement, whereas highly vascular lesions may appear dense on CT scanning after the patient has received intravenous con- trast material. Tumors, granulomas, and other intracranial lesions enhance because of a breakdown in the blood-brain barrier. More cystic lesions may exhibit enhancement limited to the periphery of the cyst. Bradley, pp , With signs and symptoms that evolve slowly, a neo- plasm is more likely.
Because there was no involvement of the eighth cra- nial nerve and because the lesion on CT scan is calcified, the most probable neoplasm is a meningioma. This tumor also appears to arise from the petrous bone, another indication that it is most likely a meningioma.
Complete resection of this large meningioma is probably impractical because of the damage to cranial nerves that would be sustained with any attempt at complete extirpation. If tumor must be left behind, repeated surgery may be necessary. Chemotherapy is not helpful because these tumors are notoriously insensitive.
Radiation ther- apy is controversial because some tumors may become more anaplastic after radiation, but the current evidence supports irradiating residual tumor. Meningiomas occur with increased frequency in type 2 neurofibromatosis, a dominantly inherited disorder aris- ing with a deletion on the long arm of chromosome Women with breast cancer and other gynecologic cancers are also at increased risk of develop- ing meningiomas, perhaps because of sex steroid receptors on these tumors that enhance their growth when gynecologic disturbances occur.
Estrogen or progesterone antagonists may be useful in the management of these tumors, but tamoxifen, an estrogen inhibitor, paradoxically stimulates the growth of meningioma cells. Victor, pp 93— Dysdiadochokinesia is usually apparent with cerebellar damage.
It is most evident when strength and sen- sation are intact. Alternately tapping one side of the hand and then the other, or tapping the heel and then alternating with the toe of the foot, is the test usually employed to check this aspect of coordination. Multiple sclerosis in adults and cerebellar tumors in children are two of many causes of problems with this part of the neurologic examination.
Focal lesions in the nervous sys- tem may produce highly asymmetric dysdiadochokinesia. A variety of move- ment disorders, such as parkinsonism and choreoathetosis, may interfere with rapid alternating movements and give the false impression that the patient has a lesion in systems solely responsible for coordination.
Victor, pp 27— This brain wave activity should be equally well developed over both sides of the head. The answer is i. Shuaib, p This man has suffered an acute cere- brovascular event. The most important test in the immediate period is a CT scan of the head to establish whether the lesion is hemorrhagic or ischemic. If there is no evidence of hemorrhage on head CT, then the patient is within the 3-h time window permitting therapy with intravenous recombinant tis- sue plasminogen activator r-TPA , which has been shown to improve functional outcome after stroke.
Bradley, p A nerve conduction study should confirm that this woman has a peripheral neuropathy—that is, a distur- bance of sensory and motor nerve function in the limbs. Given her social condition, she is at high risk for a nutritional neuropathy. A glove-and- stocking pattern of sensory disturbance is usually seen with lesions that involve peripheral nerves, specifically the nerves extending out into the limbs.
The meaning of glove-and-stocking is self-evident: sensation is dis- turbed over the hands and the feet with extension up the arms and the legs being quite variable.
With severe neuropathy of the hands or the feet, ulcer- ations and pressure sores will develop over the skin that is innervated by the damaged nerves.
The most severe sensory deficit affects the most terminal elements of the limbs. Metabolic or nutritional problems are the usual causes of a glove-and-stocking pattern of sensory disturbance. Diabetes mellitus, thiamine deficiency, and neurotoxin damage e. Affected persons usually report the sensation of pins and needles in the hands and feet, but with some neuropathies severe pain may develop along with the loss of sensory acuity. This boy is probably having general- ized absence seizures.
The EEG will show the typical 3-Hz spike-and-wave pattern characteristic of this type of seizure disorder. Even if this patient does not have the typical pattern, the character of his episodes suggests epilepsy i. Swaiman, pp — Seizures associated with fever at this age are worrisome and must be aggressively investigated. The neck stiffness, fever, and recurrent seizures necessitate a spinal tap to allow examination of the cerebrospinal fluid.
The fluid should be checked for the opening pressure, Gram staining, protein and glucose content, cell count, bacterial and fungal cultures, acid-fast bacillus AFB staining, and flagel- lated treponemal antigen FTA-ABS.
Antibiotic treatment should be started immediately if there is any indication of an infection. Haemophilus influenzae was commonly responsible for meningitis at this early age prior to the avail- ability of vaccination against it, but infections with a variety of bacteria, including gram-negative bacteria, are also possible causes of the clinical scenario described.
The answer is f. This patient probably has a myopathy. The elevated ESR and periungual telangiectasias suggest an inflammatory myopathy, and specifically dermatomyositis.
Creatine phos- phokinase would help to confirm that this is a primary muscle disease. Addi- tional tests that will be of use are electromyography EMG and muscle biopsy.
Electromyography may show brief, low-voltage action potentials, fib- rillation potentials, positive sharp waves, polyphasic units, and some evi- dence of denervation. Muscle biopsy may show changes characteristic of the particular inflammatory myopathies.
In polymyositis, extensive necrosis of muscle fiber segments is seen with macrophage and lymphocyte infiltration. In dermatomyositis, the picture is quite different: there is perifascicular mus- cle fiber atrophy, and the inflammatory infiltrate occurs in the perimysial connective tissue rather than throughout the muscle fibers themselves.
In addition, electron microscopy shows characteristic tubular aggregates. In the rarer inclusion body myositis, the appearance is similar to that of polymyosi- tis except that rimmed vacuoles are also seen. This CSF profile is essentially nor- mal. With idiopathic seizures, the CSF should be normal.
Seizure activity does not ordinarily drive up the CSF protein content or significantly change the cellular content of the fluid. The acidosis that is observed in this patient is inconsequential and is routinely found during the early postictal period after a generalized tonic-clonic seizure.
This man with fever, generalized seizure, lethargy, cough, headache, blurred vision, and progressive stupor probably has an acute bacterial meningitis. Given his age of 72 and his- tory of probable upper respiratory infection, a pneumococcal meningitis is highly probable. In bacterial meningitis, the CSF typically exhibits an elevated protein content, no or few RBCs, an elevated opening pressure, milky or xanthochromic fluid, and a normal or slightly elevated gamma globulin content.
If there are relatively few white cells and the CSF pro- tein is not greatly elevated, the fluid may appear clear and colorless. A very low CSF glucose content supports the diagnosis of bacterial meningitis.
Tuberculous menin- gitis, however, produces an atypical pattern of CSF changes distinct from that caused by other bacterial pathogens and reminiscent of that caused by fungi.
His CSF is largely normal except for its markedly high protein. The CSF is xanthochromic i. Despite the pattern of weakness, which suggests an ascending myelitis, his CSF reveals a normal cell count.
That a bacterial meningitis is not responsible for his weakness is supported by a normal CSF glucose con- tent. McGraw-Hill has no responsibility for the content of any information accessed through the work. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
They may also be a useful study tool for Step 3. For multiple-choice questions, the one best response to each question should be selected. For matching sets, a group of questions will be pre- ceded by a list of lettered options.
For each question in the matching set, select one lettered option that is most closely associated with the question. Each question in this book has a corresponding answer, a reference to a text that provides background to the answer, and a short discussion of var- ious issues raised by the question and its answer.
A listing of references for the entire book follows the last chapter. To simulate the time constraints imposed by the qualifying examina- tions for which this book is intended as a practice guide, the student or physician should allot about one minute for each question.
After answering all questions in a chapter, as much time as necessary should be spent in reviewing the explanations for each question at the end of the chapter. Attention should be given to all explanations, even if the examinee answered the question correctly.
Those seeking more information on a sub- ject should refer to the reference materials listed or to other standard texts in medicine. Cris Sheffield and Julie Schaef, for secretarial assistance. To the medical students, residents, faculty, and staff of Texas Tech University School of Medicine— in pursuit of excellence.
A year-old male patient complains of fever and sore throat for several days. The patient presents to you today with additional complaints of hoarse- ness, difficulty breathing, and drooling. On examination, the patient is febrile and has inspiratory stridor.
Which of the following is the best course of action? Begin outpatient treatment with ampicillin. Admit to intensive care unit and obtain otolaryngology consultation.
Schedule for chest x-ray. Obtain Epstein-Barr serology. A year-old patient with long-standing type 2 diabetes mellitus presents with complaints of pain in the left ear with purulent drainage. On physical examination, the patient is afebrile.
The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal. Which of the following organisms is most likely to grow from the purulent drainage? Pseudomonas aeruginosa b. Streptococcus pneumoniae c. Candida albicans d.
Haemophilus influenzae e. A year-old male student presents with the chief complaint of rash. Open this PreTest for: a format that simulates the exam; board-type questions; referenced answers and explanations; material reviewed by recent. Moreover Cmecde. If you feel that we have violated your copyrights, then please contact us immediately. Save my name, email, and website in this browser for the next time I comment.
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