75. A 9-year-old boy is brought to your clinic by his parents because he has begun to have episodes of eye fluttering lasting several seconds. Sometimes he loses track of his thoughts in the middle of a sentence. There was one fall off a bicycle that may have been related to one of these events. There are no other associated symptoms, and the episodes may occur up to 20 or more times per day. The boy’s development and health have been normal up until this point. He had two head injuries as a young child: the first when he fell off a tricycle onto the ground, and the second when he fell off a playset onto his head. Both episodes resulted in a brief loss of consciousness and he did not think clearly for part of the day afterward, but he had no medical intervention. Which of the following test results is most likely?
a. Electroencephalogram (EEG) showing 1-2 Hz spike wave
b. Brain magnetic resonance imaging (MRI) showing widespread abnormalities
c. EEG showing 2-3 Hz spike wave
d. Lumbar puncture with high white blood cell (WBC) count
e. Conners Rating Scale abnormalities reported by parents, but not teachers
76. A 19-year-old right-handed man who carries the diagnosis of epilepsy is seen in the urgent-care clinic. He had been healthy until about age 12, when he began to have episodes of eye fluttering lasting several seconds. Sometimes he would lose track of his thoughts in the middle of a sentence. There was one fall off of a bicycle that may have been related to one of these events. He has been treated with valproic acid. At one point he was off all medications, but the seizures returned. He is now at the end of his first semester of college and came in today because he had a witnessed generalized tonic-clonic seizure this morning. He had had only about 2 hours of sleep the night before because he was studying for a final examination. Which of the following is the most appropriate thing to tell this patient?
a. “I know that you faked this seizure to avoid taking a test.”
b. “Lack of sleep may have contributed to triggering this seizure.”
c. “You can expect to have tonic-clonic seizures on a regular basis from now on.”
d. “Your seizures are getting worse and there is nothing we can do about it.”
e. “You should take the next semester off to recover and get extensive testing.”
77. A 56-year-old man with epilepsy is brought into the emergency room. He has been having continuous generalized tonic-clonic seizures for the past 30 minutes. He is treated with 2 mg of intravenous lorazepam. Most physicians recommend using a high dose of intravenous benzodiazepine as part of the management of status epilepticus because it has which of the following qualities?
a. Ability to suppress seizure activity for more than 24 hours after one injection
b. Lack of respiratory depressant action
c. Rapid onset of action after intravenous administration
d. Lack of hypotensive effects
e. Lack of dependence on hepatic function for its metabolism and clearance
78. A 34-year-old woman is having her medications tapered in the epilepsy-monitoring unit. She has a convulsive seizure that does not stop after 5 minutes, even after she receives a lorazepam injection. A second intravenous drug is given. Infusing which of the following antiepileptic drugs at more than 50 mg/minute in an adult may evoke a cardiac arrhythmia?
a. Carbamazepine
b. Diazepam
c. Phenobarbital
d. Clonazepam
e. Phenytoin
79. A 44-year-old man presents with left arm shaking. Two days ago, the patient noticed left arm paresthesias along the lateral aspect of his left arm and left fourth and fifth fingers while he was reading. He thinks he may have been leaning on his left arm at the time; the symptoms resolved after 30 seconds. This morning, he noted the same feelings, lasting a few seconds, but then his fourth and fifth fingers started shaking rhythmically, and the shaking then spread to all of his fingers, his hand, and then his arm up to his elbow. This episode lasted a total of 30 seconds. He denies any strange smells or tastes, visual changes, or weakness. Afterward, his fingers felt locked in position for a few seconds. Then he felt as if he did not have control of his hand and had difficulty donning his socks. He and his wife decided to drive to the emergency room, and in the car he had trouble putting his seat belt latch into its socket. Examination and routine labs are normal. Which of the following is the most appropriate next action?
a. Discharge the patient to follow up in clinic in 2 weeks
b. Obtain a brain MRI
c. Obtain an EEG
d. Obtain an orthopedic consult
e. Order electromyography (EMG) and nerve conduction studies (NCS)
80. A 31-year-old right-handed woman has a history of alcohol abuse requiring detox. Currently, she says she is drinking about nine beers 3 days per week. She drank five glasses of wine and three beers 5 days ago. Last night, she had 10 beers. This morning, she awoke feeling well. She was speaking with her fiancé, went to the bathroom, and got back into bed. She had no headache, fever, chills, nausea, vomiting, or pain. Suddenly her body became stiff with arms flexed for a few seconds, followed by rhythmic jerking of both arms. Her legs were shaking, but less so. Her eyes were open, and she was foaming at the mouth. After 1 minute, this stopped, and she initially did not recognize her fiancé or his sister. She slowly returned to a normal level of consciousness over a 10-minute period. She remembers events just prior to the episode, and she remembers being in the car on the way to the hospital. Her only medication is a multivitamin. She denies illicit drugs. Her examination is entirely normal. Routine labs and a brain MRI are normal. Following cessation of drinking, what is the peak time period for alcohol withdrawal seizures?
a. 1-to-2 days
b. 2-to-3 days
c. 3-to-4 days
d. 4-to-5 days
e. 5-to-6 days
81. A 4-year-old boy has the onset of episodes of loss of body tone, with associated falls, as well as generalized tonic-clonic seizures. His cognitive function has been deteriorating. EEG shows 1-to-2 Hz spike-and-wave discharges. Which of the following is the most likely diagnosis?
a. Landau-Kleffner syndrome
b. Lennox-Gastaut syndrome
c. Juvenile myoclonic epilepsy
d. Mitochondrial encephalomyopathy
e. Febrile seizures
82. A 27-year-old man begins to experience infrequent episodes of nausea, warmth rising through his body, and an unusual odor like rotting fish. His girlfriend notices that afterward he may develop twitching of the right side of his face and an inability to speak for several minutes. Afterward the man appears dazed and cannot remember what has occurred. He has otherwise been well. MRI of his brain is most likely to show a lesion in which of the following areas?
a. Left occipital lobe
b. Right frontal lobe
c. Cribriform plate
d. Hippocampus
e. Left parietal lobe
83. An 18-year-old girl riding on the back of her boyfriend’s motorcycle without a helmet is brought in with a left frontal skull fracture and cortical contusion. Her Glasgow Coma Scale (GCS) is 10. She is admitted to the intensive care unit. She has had no seizures. Which of the following is true regarding anticonvulsant therapy in this case?
a. It is contraindicated owing to risk of rash.
b. It is best achieved using phenobarbital.
c. It is likely to cause increased cerebral edema.
d. It is indicated to reduce the incidence of late posttraumatic epilepsy.
e. It is indicated to reduce the incidence of early posttraumatic seizures.
84. A 36-year-old man with intractable complex partial seizures and mesial temporal sclerosis (MTS) undergoes left temporal lobectomy. He is most likely to develop which of the following problems after surgery?
a. Right superior quadrantanopsia
b. Right inferior quadrantanopsia
c. Right homonymous hemianopsia
d. Right hand weakness
e. Aphasia
85. A 29-year-old man with a history of febrile seizures as a child has developed medication-refractory complex partial seizures within the past 2 years. An MRI reveals the abnormality indicated by the arrow. Which of the following is true regarding this condition?
a. This patient may benefit from a neurosurgical procedure.
b. The patient will probably die within 2 years.
c. The seizures will most likely stop with further medication titration.
d. A head computed tomography (CT) should be performed.
e. A cerebral angiogram may confirm the diagnosis.
Questions 86 to 91
For each clinical scenario, choose the seizure type that best explains the patient’s complaints. Each lettered option may be used once, more than once, or not at all.
a. Generalized tonic-clonic
b. Generalized absence
c. Complex partial
d. Epilepsia partialis continua
e. Simple partial sensory
f. Jacksonian march
g. Psychomotor status
h. Tonic-clonic status epilepticus
i. Pseudoseizures
j. Myoclonic
86. A 37-year-old man develops involuntary twitching movements in his left thumb. Within 30 seconds, he notices that the twitching has spread to his entire left hand and that involuntary movements have developed in his left forearm and the left side of his face. He cannot recall what happened subsequently, but his wife reports that he fell down and the entire left side of his body appeared to be twitching. He appeared to be unresponsive for about 3 minutes and confused for another 15 minutes. During the episode, he bit his tongue and wet his pants.
87. A 17-year-old boy reports involuntary jerking movements in his arms when he awakens. This has occurred during the day after a nap as well as in the morning after a full night’s sleep. Over the next few months, he developed similar jerks during the day, even when he had been awake for several hours. He did not lose consciousness with these muscle jerks, but did occasionally fall. On one occasion, jerks in his legs caused a fall that resulted in a fractured wrist.
88. A 21-year-old man reports several episodes over the previous 4 years during which he lost consciousness. He had no warning of the impending episodes, and with each episode he injured himself. Observers told him that he abruptly developed a blank stare and stopped talking. His body became stiff and he arched his back. After several seconds of this type of posturing, his arms and legs started shaking violently. During one of these episodes, he dislocated his right shoulder. He routinely bit his tongue and urinated in his pants during the episodes.
89. A 25-year-old woman was fired from her job after she misplaced papers vital for the company. She had had recurrent episodes for several years during which she performed nonsensical activities such as burying her plates in the backyard, hiding her underwear, and discarding her checkbook. She did not recall what she had done after performing these peculiar activities. She had been referred for psychotherapy, but the episodes became even more frequent after she was started on thioridazine. Her husband observed one episode and noted that she was unresponsive for about 5 minutes and confused for at least 1 hour. She did not fall down or remain immobile during the episodes. As the episodes became more frequent, she noticed that she would develop an unpleasant taste in her mouth, reminiscent of motor oil, just before an episode.
90. A 21-year-old cocaine-abusing man develops seizures that persist for more than 30 minutes before emergency medical attention is available. When examined nearly 1 hour later, he is still exhibiting tonic-clonic movements and has never recovered consciousness.
91. A 16-year-old boy with a history of acute viral myocarditis requires placement of a left ventricular assist device. He has a complicated postoperative course, with fever, bacteremia, and renal failure. On postoperative day 10, he develops continuous rhythmic jerking of the left corner of the mouth, associated with jerking of the left thumb. This persists for 24 hours. He is alert, able to follow commands, and has no gaze deviation. CT shows a small hemorrhagic infarction of the right posterior frontal region.
Questions 92 to 95
For each clinical scenario, choose the medication that is most appropriate in the management of the patient’s problem. Each lettered option may be used once, more than once, or not at all.
a. Lorazepam
b. Magnesium sulfate
c. Clonazepam
d. Felbamate
e. Phenobarbital
f. Levetiracetam
g. Divalproex sodium
h. Primidone
i. Adrenocorticotropic hormone (ACTH)
92. A 19-year-old woman describes recurrent memory problems. Her fiancé reports that she seems to be inattentive for minutes at a time several times a week. She never injures herself during these episodes, but she cannot recall what happened, and, on one occasion, she became lost while walking home. An ambulatory EEG demonstrates evolving spike activity originating in the left temporal lobe during one of the episodes. The EEG pattern does not generalize. CT and MRI scanning of the brain reveal no structural abnormalities. Conversations with the woman’s parents reveal that she had febrile seizures when she was 3 years old, which abated with antipyretic treatment alone.
93. A 7-month-old boy develops generalized limb extension and neck flexion spasms that occur more than 20 times daily and are associated with altered consciousness. EEG reveals diffuse, high-voltage, polyspike-and-slow-wave discharges between spasms and suppression of these bursts during the spasms. A sibling died with a brainstem glioma, and the father has several large areas of hypopigmented skin in the shape of ash leaves. The infant had obvious psychomotor retardation even before the appearance of the spasms.
94. A 5-year-old girl has frequent staring spells and does not respond when her mother calls her name during these episodes. She never falls down or bites her tongue, but she does have occasional lip smacking during episodes. EEG reveals a 3 Hz spike-and-wave pattern that occurs for less than 10 seconds at a time but several times an hour. The child has normal motor and cognitive development.
95. A 35-year-old pregnant woman at term is admitted to the hospital for delivery. She has headaches and visual blurring. Her blood pressure is 180/100. On examination, she is edematous. Reflexes are increased. Protein is found in the urine. She then develops a generalized tonic-clonic convulsion.