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Educational objective: Individuals with features of myasthenia gravis ( eg, fluctuating and fatigable ocularfbulbar weakness) should undergo confirmatory testing with acetylcholine receptor antibodies, which are highly specific. Those with an established diagnosis should subsequently undergo chest imaging (eg, CT scan, MRI) to evaluate for thymoma and for possible surgical planning, as thymectomy is associated with Jong-term clinical improvement in both patients with and without thymoma


Which of the following is the most appropriate next step in evaluation of this patient?
Poll
  •   A. Cerebrospinal fluid analysis
  •   B. Cervical spine imaging
  •   C. CT scan of the chest
  •   D. Echocardiography
  •   E. MRI of the brain
  •   F No additional testing required
  •   G . Slit-lamp ocular examination
309 votes


A 31-year-old woman comes to the office due to vision disturbances. The patient is a software developer and works on a computer most of the time. She first noticed blurry vision 2 months ago. Since then, she has had several episodes of blurry and double vision, especially toward the end of the workday. Two days ago, she experienced neck discomfort and had difficulty holding her head up, which resolved after a night's rest. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. On physical examination, pupils are 3 mm, round, and reactive to light. There is no ptosis, and ocular movements are normal. No neck deformity or tenderness is present. Muscle strength, deep tendon reflexes, and sensation are normal in the bilateral upper and lower extremities. Further evaluation reveals antibodies directed against nicotinic receptors on the motor endplate.


Educational objective: Hemineglect syndrome is characterized by ignoring one side of a space (the left side in right-handed individuals) and involves the nondominant parietal lobe (the right lobe in right-handed individuals).


Which of the following areas is most likely affected by the stroke in this patient?
Poll
  •   A. Left frontal cortex
  •   B. Left temporal cortex
  •   C. Right parietal cortex
  •   D. Right occipital cortex
  •   E. Right frontal cortex
244 votes


A 70-year-old man comes to the ·office 4 weeks after experiencing an ischemic stroke. His medical history is significant for a long history of hypertension, diabetes, coronary artery disease, congestive heart failure, and atrial fibrillation. Vital signs are unremarkable. BMI is 23.8 kg/m2. Cardiovascular examination reveals an irregularly irregular rhythm. The patient is right-handed. Only the right side of his face is shaved. When asked to raise his left arm, he raises his right arm. When asked to fill in the numbers of a clock, he puts numbers only on the right side.


Educational objective: Spontaneous cerebellar hemorrhage is typically caused by poorly controlled hypertension and presents with occipital headache, neck stiffness, nauseafvomiting, nystagmus, and ipsilateral hemiataxia. There is usually no hemiparesis or sensory loss. Early diagnosis with noncontrast head CT scan is important as emergency surgical decompression may be life-saving .


Which of the following physical examination findings is most likely to be seen in this patient?
Poll
  •   A. Homonymous hemianopia
  •   B. Left hemineglect
  •   C. Left hemiplegia
  •   D. Left hemisensory loss
  •   E. Pinpoint pupils
  •   F Right eye vision loss
  •   G. Right hemiataxia
  •   H. Right hemiplegia
  •   I. Right hemisensory loss
190 votes


A 69-year-old man comes to the emergency department due to severe occipital headache, nausea, and vomiting for the last 3 hours. He has never had a headache like this before and has otherwise been in good physical condition. The patient was told several years ago that he has high blood pressure, but he has not been taking any medications or seen any health care providers. He has smoked half a pack of cigarettes daily for 40 years and drinks 1 or 2 cans of beer every evening. Both of his parents died of natural causes. Blood pressure is 160/90 mm Hg and pulse is 86/min and regular. His noncontrast head CT scan is shown in the image below.




Educational objective: Chronic, excessive noise exposure can lead to sensorineural hearing loss due to the irreversible death of hair cells in the cochlea. Hearing screening programs are often mandated in high-risk occupations (eg, manufacturing, transportation).


Which of the following is the most likely cause of this patient's hearing impairment?
Poll
  •   A. Cochlear hair cell damage
  •   B. Decreased ossicular mobility
  •   C. Middle ear barotrauma
  •   D. Ossification of the cochlea
  •   E. Tympanic membrane fibrosis
135 votes


A 34-year-old man comes to the ·office for evaluation of hearing loss. The patient is a military pilot who has flown the past 8 years in noncombat zones. Regular hearing tests administered by the military have been normal until his most recent one. The patient has noticed no change in his hearing and has no ear pain, tinnitus, or vertigo. The results from the remainder of his annual physical, mental, vision, and cardiac tests were normal. The patient has no medical conditions and takes no medications. Aural examination shows clear, intact tympanic membranes bilaterally with no middle ear effusion. Review of the audiometry reveals a mild, bilateral, high-frequency hearing loss.


Educational objective: Alzheimer disease, the most common type of dementia in the United States, is characterized by early and prominent memory impairment The differential includes dementia with Lewy bodies, frontotemporal dementia, and vascular dementia, as well as nondementing syndromes such as normal pressure hydrocephalus.


Which of the following is the most likely diagnosis?
Poll
  •   A. Alzheimer disease
  •   B. Dementia with Lewy bodies
  •   C. Frontotemporal dementia
  •   D. Normal pressure hydrocephalus
  •   E. Vascular dementia
126 votes

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