A 35-year-old female patient presents to the clinic with complaints of irregular menstrual cycles and a thick yellowish fluid oozing out of her breasts. She is sexually active and has been married for four years, but for no known reason, she is unable to get pregnant. The rest of the physical examination is unremarkable. The thyroid function tests are within a normal range, and the serum prolactin level is 1200 ng/ml (4.8 to 23.3 ng/ml). MRI shows a 2.0 cm pituitary mass. Which of the following drugs is used to treat this pathology?

A 15-year-old boy is brought to the emergency department with complaints of progressive headache and multiple episodes of projectile vomiting 5 months after the revision of a hydrocephalus shunt. The patient has optic disc edema. The shunt chamber does not recoil following its manual compression. There is poor CSF flow during a diagnostic shunt tap. Which of the following is the most likely etiology for the clinical deterioration observed in this patient?

The nurse mishears the order for "2 and 50" and instead gives 250 mcg of fentanyl. Two minutes later the oxygen saturation is 80 percent. What should be administered first?

A 45-year-old man patient presents to the clinic following progressive headache and diminution of vision. Visual field study reveals the presence of bitemporal hemianopia in the patient. MRI reveals giant pituitary macroadenoma with suprasellar extension. An endoscopic endonasal trans-sellar excision of the tumor is planned. Intraoperatively, while trying to remove the tumor on the cavernous wall, there is a sudden jet of blood into the operating field. The operating surgeon controlled the bleeding with rigorous packing with hemostatic agents into the cavernous wall. The remaining portion of the tumor is removed. In the postoperative period, the patient complains of severe headaches. The patient also develops ptosis with ophthalmoplegia. He further develops progressive painful proptosis. Which of the following is the next best step in the management of this patient?

A 45-year-old female is seen in the outpatient clinic due to the incidental finding of a 1.7 cm x 1.9 cm isodense left lateral ventricle mass seen on the head computed tomographic scan with contrast done for workup for chronic sinusitis. On magnetic resonance imaging, the mass is located adjacent to the choroid plexus of the atrium of the left lateral ventricle and is isointense to gray matter on T1/T2 and has homogenous/vividly enhancing on post-contrast images. Also, there is evidence of fine calcified borders on the gradient echo sequence. No evidence of hydrocephalus or parenchymal edema is seen. On the physical exam, the patient is neurologically intact and only complains of a bifrontal headache. What is the best next step in management?

A 17-year-old female, with no comorbidities, is brought to the emergency department with a history of a motor vehicle accident involving a car (which she was driving) and a bus, one hour back. On examination, her pulse rate is 80/minute, blood pressure 130/80 mmHg, respiratory rate 16/minute, and oxygen saturation is 98%. Her airway is clear, and air entry is bilaterally equal in all lung fields. Her Glasgow Coma Scale (GCS) score is E3V4M6, and her pupils are bilaterally 3 mm in size and react to light. A chest X-ray taken shows clear lung parenchyma. A computed tomogram scan of the brain is taken, which shows an undisplaced right frontal bone fracture and an underlying contusion of 15 ml volume. There is no midline shift or mass effect. She is admitted to the neurosurgery intensive care unit. Two hours later, the patient develops tachypnea (respiratory rate of 30/minute), while GCS score and pupils remain the same. Within 2 minutes, her saturation drops down to 80%, and she has to be intubated and ventilated. On chest auscultation, there are bilateral basal crackles. A chest X-ray shows bilateral hyperdense infiltrates in the lung parenchyma. Which part of the brainstem is likely to contribute to the current deterioration in her clinical condition?

A 65-year-old male with a past medical history of atrial fibrillation on warfarin and metoprolol, gastroesophageal disease, and type 2 diabetes on metformin presents to the emergency department after the onset of word slurring and left facial droop 3 hours ago. He is still unable to articulate a complete sentence. After a comprehensive neurologic exam and imaging, an area of decreased perfusion is found in the territory supplied by the middle cerebral artery, and tPA is administered. The patient's symptoms partially improve. Several hours after treatment, the patient develops worsening confusion and arm weakness. Repeat computed tomography scan shows a new large area of increased attenuation in the lateral parietal lobe. What is the appropriate next step?

A 60-year-old male is being evaluated at the emergency department for a frontal right-sided headache. Skull Xrays show mild opacification of the right frontal sinus. Brain magnetic resonance imaging with and without contrast is performed. It shows an incidental 2.0 cm x 1.8 cm homogeneous enhancing mass at the atrium of the left lateral ventricle without evidence of ventricular trapping or edema on adjacent brain parenchyma. The mucosa of the frontal sinus is thickened and enhanced. On the physical exam, the patient is neurologically intact. He is prescribed nasal decongestants. What is the best next step in management for the incidental mass?

A 71-year-old male smoker with a past medical history of right lung adenocarcinoma presents with a small pupil on the right, drooping of the right eyelid, and decreased sweating on the right side of his face. Which of the following conditions would increase the size discrepancy between the pupils?

A 52-year-old female presented to the clinic with a 4-month history of pain and burning in the left hemithorax, initially treated as symptoms of herpes, without a satisfactory result, until it became more acute 13 days ago. Her past medical history is significant for type 2 diabetes mellitus for the past 4 years. She is taking metformin and sitagliptin for diabetes. Her BMI is 36 kg/m2. She underwent laparoscopic cholecystectomy 8 years ago. On physical exam, she has mild paraspinal tenderness, normal patellar reflexes, normal muscle strength in her lower extremities, and a normal gait exam. MRI thoracolumbar spine reveals thoracic disk herniation at T7-T8 interspace. Which of the following is the next best step in the management of this patient?

A 35-year-old man presents with a two-month history of a gradually enlarging, painful scrotal mass. He has a history of acromegaly, for which he underwent transsphenoidal surgery, thyroid nodules, and multiple lentigines. The patient was adopted and does not take any medications. Examination is notable for diffuse blue-black ovoid macules and a firm 4 cm scrotal mass. After further workup consistent with a Leydig cell tumor, the patient undergoes left radical orchiectomy and subsequently is found to have a cardiac myxoma. Given the likely diagnosis, which of the following manifestations of this patient's condition is most associated with mortality?

A 4-year-old boy is brought to the provider with an inability to carry out his daily activities. He has difficulty running, climbing stairs, and falls frequently. His maternal uncle, who died of respiratory failure, had similar problems and was wheelchair-bound by the age of 12 years. What is the diagnostic test for this patient?

A 62-year-old male has a one-week history of nausea, vomiting, and paresthesias of the right hand and foot. On the day of admission, he had a generalized seizure followed by a headache that increases when he bends forward. There is right facial droop and loss of double simultaneous tactile stimulation. MRI shows a left posterior frontal, intraparenchymal, non-enhancing mass with a local mass-effect on the lateral ventricle consistent with a brain tumor. Transformation of which brain cell type is most likely the etiology of the tumor in this patient?

A 28-year-old man presents for preoperative evaluation before elective surgery for a distal ulnar fracture. He injured his arm during a basketball game and has been in a sling since the incident. He reports numbness and tingling. When recording somatosensory evoked potentials (SEPs) from the patient's injured arm, which potential is most likely to show changes from baseline?

A 34-year-old woman with a BMI of 42 kg/m2 presents to the clinic with complaints of numbness and paresthesias in the lateral aspect of the right thigh. The patient says she has tried gabapentin in the past with no relief in symptoms. She had an MRI of the lumbar spine, which was reported normal. What is the most appropriate placement of the peripheral stimulator lead in this patient?

A 50-year-old man presents to the clinic with leftsided facial pain for the past 6 months. He describes it as a sharp stabbing pain along the left forehead, and it appears in short episodes. During the episodes, he experiences lacrimation. He uses carbamazepine but is seeking a permanent solution. Radiofrequency thermocoagulation of the implicated ganglion is planned. What is the most appropriate anatomic location to mark the site for needle entry for this procedure in this patient?

A 35-year-old patient presents with acute onset worst headache of his life. CT head revealed an acute subarachnoid hemorrhage. CT cerebral angiography showed evidence of an ophthalmic artery aneurysm. The treating clinician planned for microsurgical clipping of the aneurysm. He however wants to safeguard from the possible intraoperative rupture of the lesion. Which of the following is the most rational approach to control hemorrhage following the same in the patient?

A 17-year-old male patient with severe neurological injury after a motor vehicle collision requires prolonged mechanical ventilation. He has been intubated for 14 days and remains at a Glasgow coma scale of 6 since his decompressive craniotomy two weeks ago. He has a nasogastric tube in place and has been on stable ventilator settings for the past 48 hours but has failed ventilator weaning multiple times. He initially developed posttraumatic diabetes insipidus after his accident, but his fluid balance has been stable for five days. He is being prepared to be transferred to a neurological care center, which requires a tracheostomy before transportation there. What is the next best step in management?

A 24-year-old woman falls approximately 15 feet from a ladder while cleaning her gutters. At the scene, she is nonresponsive and intubated. She is taken to the local hospital, where imaging shows diffuse axonal injury with numerous microhemorrhages and shear injury. The patient is given multiple medications to manage presumed intracranial hypertension from cerebral edema, and an intracranial pressure monitor is placed. Her intracranial pressure is initially controlled with medical interventions, including intravenous mannitol, but at 36 hours post-injury, her intracranial pressure begins to rise and worsens despite medical intervention. What is the mechanism most likely responsible for her increased intracranial pressure?

A 28-year-old male is shifted to the intensive care unit due to an altered sensorium associated with a high-grade fever. He was diagnosed with acute myeloid leukemia and had undergone 2 cycles of induction chemotherapy with the completion of the last cycle 10 days ago. On the examination, there is erythema and black eschar surrounding the left eye. The left pupil was fixed & dilated. CT revealed enhancing mass in the ethmoidal sinus as well. The periodic acid-Schiff stain of the material obtained following the surgical debridement demonstrated broad hyphae with right-angle branching. What is the best next step in the management of the patent?

A 6-year-old boy is diagnosed with a posterior fossa cystic tumor and is awaiting surgery. The neurosurgeon informs the patient's parents that he could develop acute hydrocephalus if there is bleeding into the tumor. Which of the following would be the last sign to manifest if the patient develops this complication?

A previously healthy 38-year-old male accountant presents to the clinic complaining of lower back pain. The onset of pain was insidious, but the pain intensity has started to affect his work. He recently returned to his hobby, which is weight lifting after 4 months of brake he had to take to recover from his pulled hamstring. The neurological examination is normal. He has slightly limited back extension and is complaining of increased back pain during the both legs extension test while prone. What is the best initial step in the management of this patient?

A 71-year-old woman with a past medical history significant for hypertension, osteoarthritis of the spine, hyperlipidemia, opioid use disorder, and mechanical aortic valve on life prolonged anticoagulation presents to the office for a consultation for spinal cord stimulator implantation. The patient has a history of multiple back surgeries. She complains of low back pain that is burning in nature, persistent, moderate to severe, depending on the time of day. She denies numbness and tingling into her lower extremities. She states that her back pain is causing a significant impact on her quality of life. Her physical exam is unremarkable for any red flags; muscle strength, sensation, and deep tendon reflexes are within normal limits. For which of the following postoperative complications does the patient have the highest risk?

A 26-year-old female presents to the clinic for evaluation of amenorrhea. She denies being sexually active. She has missed her past four menstrual cycles. Her menarche was at 13, and the periods have been consistently 27-28 days apart. She complains of new headaches. Physical examination is unremarkable, and the patient is found to be of normal weight. Laboratory test reveals negative bHCG with a normal thyroid-stimulating hormone and prolactin level. MRI head showed a 2 cm sellar mass. The patient undergoes transsphenoidal surgery. The histological examination of the specimen shows sheets of differentiated nonkeratinizing squamous epithelium with clear cystic fluid and crude papillae around fibrovascular cores. What is the likely mutation associated with this lesion?

A 10-year-old male was brought in by his mother. The mother states that she has noticed recent changes in the behavior of her son. His school grades are dropping, and he has been complaining of tiredness over the past few weeks. Recently he started wetting the bed at night and experiences increased thirst and urination. Complete physical examination is unremarkable. Significant laboratory findings include fasting blood glucose 75 mg/dl, serum sodium 149 mEq/L, plasma osmolality 297 mOsm/liter, urine osmolality 280 mOsm/liter, serum thyroid stimulating hormone (TSH) 0.3 mIU/L, and free T4 0.2 ng/dL. Urine osmolality did not increase after the water deprivation test. Plasma osmolality after desmopressin administration is 285 mOsm/L. Magnetic resonance imaging showed a small, homogenous mass in the suprasellar region of the brain. Tumor oncoproteins were not elevated. He subsequently underwent an endoscopic biopsy of the mass. A dual population of cells comprising of large polygonal cells with vesicular nuclei, prominent nucleoli, and distinct cell borders intermixed with small cells with coarse, dense nuclei and scant cytoplasm was detected on histological examination. Malignant cells were also detected in cerebrospinal fluid (CSF) cytology. What is the most effective treatment modality for this patient?

A 59-year-old woman presents to the clinic with concerns about hand and foot swelling and coarsening facial features. On clinical examination, she is noted to have a prominent supraorbital ridge, broad nose, acne, large lips, overbite, prognathism, tongue enlargement, and coarsening of facial features. Her fasting blood glucose level is 140 mg/dL. An IGF-1 level is obtained, which is high at 504 ng/mL (reference range: 117-321 ng/mL). She is being planned for medical treatment as she is surgically not fit. She has been prescribed a second-generation somatostatin analog. Two weeks later, she presented to the clinic with a fasting blood glucose of 200 mg/dL. Which of the following best describes the mechanism responsible for this patient's increased blood glucose?

A 30-year-old female presents with complaints of amenorrhea and white nipple discharge for the past three months. She also complains of headaches and visual changes. She has no past medical history and currently takes no medications. Her vital signs show an oxygen saturation of 98% on room air, respiratory rate of 14 breaths per minute, heart rate of 82 beats per minute, blood pressure 130/75 mmHg, and temperature of 98.6 F (37 C). Physical examination reveals bitemporal hemianopsia. Neuroimaging reveals a 1.8 cm pituitary mass abutting the optic chiasm. Which of the following is an appropriate treatment strategy?

A 55-year-old female with a past medical history of hypertension and hyperlipidemia presents to the emergency department with a severe headache, which began an hour ago. The patient denies any head trauma. The patient denies headache like this in the past. On physical examination, blood pressure is 180/100 mm Hg, respiratory rate is 20/minute, pulse rate 100/minute, and oxygen saturation is 99% on ambient air. The patient is stuporous, and the neurological exam reveals mild hemiparesis. CT brain without contrast shows subarachnoid hemorrhage (SAH). What is this patient's mortality risk?

A 46-year-old female presented with defective vision in the right eye since the age of 13 years. She has a history of fever and generalized rash over the body at the same time. Anterior segment examination reveals grade 2 nuclear sclerosis in the right eye. Fundus examination reveals mild temporal pallor. Visual acuity is 20/240, improving to 20/40 with -3D spherical correction. Color vision and central fields reveal no defect. Intraocular pressure is within normal limits. What will be the next best step in management?

A 70-year-old man presents with chronic neck pain that radiates into his right arm. These symptoms have been ongoing for the past eight weeks. Examination reveals diminished right brachioradialis reflex, diminished sensation on the right thumb, and right wrist extension weakness. The Spurling test is positive on the right. Hoffman sign is negative bilaterally. The patient has been taking NSAIDs for the past four weeks and attending physical therapy for the past six weeks without any relief of his symptoms. Which of the following is the most appropriate next step in the management for this patient?

A 2-year-old female child presents to the clinic with her mother, with chief complaints of poor feeding, vomiting, and incessant crying over the last few days. The birth, immunization, and developmental histories are unremarkable. There is no significant medical history in any of the family members. The examination reveals an irritable child who tends to hit her head with her fists. On examination, there is a single bruise over the head and one on the chest. The head circumference is 54 cm. The temperature is 38.28 C (100.9 F). On ocular examination, the retina cannot be visualized. The rest of the exam is normal. A CT scan reveals diffuse hyperintensities in both the lateral ventricles. What is the most likely diagnosis?

A 39-year-old man suffers a fall from a horse and hits the occipital area on the ground. He lost consciousness momentarily and had one episode of vomiting. He is brought to the emergency department for evaluation. On arrival, he has a Glasgow coma scale of (GCS) 13/15 but follows instructions. An emergency CT head shows a 3 cm frontal contusion. He is admitted to the intensive care unit for observation. On the second day, he has a GCS of 15/15 and is sent to the ward. On the third day of admission, he becomes disoriented and minimally responsive. Repeat CT head shows the progression of the traumatic contusion. Which of the following is the most significant parameter governing the progression of the lesion observed in the patient?

A 3-year-old boy is being evaluated for a triangular shape of the anterior head. He has a preferred sleeping position. His forehead has a prominent midline forehead ridge. Computed tomography of the head shows that the frontal bone has a triangular shape with a closed metopic suture. There is anterior displacement of the coronal sutures, widening of the posterior parietal regions, pterional constriction, and flattening of the supraorbital ridges with lateral orbital hypoplasia. Hypotelorism is also present. All the other sutures are patent. During which of the following time periods did the involved suture most likely close in this patient?

A 67-year-old man with a past medical history of hypertension, alcohol use disorder, depression, gout, and benign prostatic hyperplasia is admitted to the intensive care unit with a grade 3 subarachnoid hemorrhage (modified Fischer scale). A cerebral aneurysm is identified on angiography, and endovascular coiling is done to reduce the risk of further bleeding. Seven days post-procedure, the patient reports nausea and headache. There is no dizziness on standing, capillary refill time is normal, and vitals show no new increase in the heart rate or fall in the blood pressure. A current set of labs is shown below. CT brain is negative for further findings.

What is the best next step in treatment?

A 65-year-old female with a past medical history significant for osteoporosis and type two diabetes presents to a clinic with back pain. She states that she slipped and fell on her back yesterday while working in the kitchen. She noticed a sharp electrical pain and was unable to get up for 15 minutes. Today, she is ambulating without gait instability but says the pain is not going away with her usual dose of ibuprofen. She denies saddle anesthesia, urinary, and fecal incontinence. On physical examination, she has midline and low back tenderness but no lower extremity weakness. Which of the following is the most rational initial imaging modality to be advised in the patient?

What is the most common reason that adults develop spondylolisthesis?

A 35-year-old man presents for continuous ringing in his right ear for the past few weeks. He also reports a constant decrease in hearing on the affected side and occasional headaches that have been worsening over the past few weeks. The physical examination is normal. His audiogram reveals sensorineural hearing loss in his right ear. MRI brain demonstrates a 2 cm lesion at the cerebellopontine angle that enhances with gadolinium and does not appear to have a "tail." What is the most likely cause of this patient's presentation?

A 49-year-old male patient presents to the hospital for evaluation of hearing difficulty. The patient reports progressively increasing difficulty with hearing. He also complains of an occasional ringing sound in his left ear. Audiometric examination reveals an asymmetric sensorineural hearing loss in the left ear of mild severity. Non-contrast CT scan reveals a mass in the left cerebellopontine angle that is isodense. MRI reveals an avidly enhancing mass following contrast injection. The mass is seen eroding into the left internal auditory canal. A preliminary diagnosis of vestibular schwannoma is made. The patient wants to know the prognosis and available treatment options for his tumor. He makes it very clear that he wants a definitive solution that has minimum effect on his functionality. What is the most suitable option for this patient?

A 35-year-old man with a history of chronic lower back pain presents to the clinic for further evaluation and treatment. The patient reports living an active lifestyle, playing football and soccer with his friends frequently. He also reports having some mild trauma to his back while playing but never had to see a clinician. On physical examination, there are scars on the right lower back. On palpation, the right lumbar muscles are tense and hypertrophic. On the range of motion testing, he is unable to bend laterally to his left side fully and that he feels the most amount of pain towards the end of the movement. According to the McKenzie classification, the patient's condition is most appropriate to be classified as which of the following?

An ash leaf spot is most likely going to be seen in a patient with which condition?

A 59-year-old male has two months of worsening diplopia and a cranial nerve VI palsy on the right is identified. Imaging shows a clival mass which is heterogeneously enhancing on MRI T1 sequencing and hypointense on T1-weighted images without contrast. CT imaging shows a lytic lesion of the clivus with peripheral sclerosis and local invasion and contrast enhancement. Based on the possible differential diagnoses for a clival tumor which of the following is an important consideration prior to biopsy?

A 34-year-old man with traumatic brain edema is managed in the intensive care unit (ICU) with a ventriculotomy guided intracranial pressure (ICP) monitoring. The monitor reveals the onset of waves lasting 10 minutes with an amplitude of 50 mmHg above the baseline. After the wave dissipates, the clinician notes that the baseline intracranial pressure is set to a higher level than when the wave began. Which of the following is the next best step in managing this patient?

An 11-year-old girl with no pertinent medical history is brought to the emergency department with a history of headache, fever, purulent rhinorrhea. The mother mentions, “she has a bump in her forehead that is red and tender since yesterday" after an upper respiratory infection in the past week. On examination, the patient is alert but mildly diaphoretic, and breathing comfortably. Her extraocular movements are intact and there is prominent mucus visible around both nares. Her forehead is edematous, erythematous, and tender to palpation at the root of her left brow. Which of the following is the best initial therapy for this patient?

A 65-year-old woman is found to have a C5-C6 herniated disc causing right C6 radiculopathy. After four weeks of physical therapy, no improvement is noted. A right-sided approach with an anterior cervical discectomy is sought, and fusion is made under general anesthesia with neck hyperextension. No intraoperative complications are observed. However, the patient develops hoarseness with difficulties in speech and swallowing after extubation. The tongue deviates to the left side with protrusion. What is the most appropriate management strategy for this complication?

A 17-year-old male patient is brought to the emergency department following a motor vehicle accident. He is under the influence of alcohol. His pulse rate is 120/minute, and blood pressure is 110/60 mm Hg. In the primary survey, he is found to have a right-sided femur fracture, which is stabilized temporarily. His Glasgow coma scale score is eye-opening, verbal response, motor response (E1V1M5), and his pupils are bilaterally 2 mm in size and reacting to light. A computed tomogram of his brain is done, which shows a right frontal acute subdural hemorrhage with mild mass effect and no midline shift. An intracranial pressure monitor (ICP) bolt is inserted by the neurosurgeon, which shows the pressure as 15 mm Hg. The trauma surgeon suggests fixing the femur fracture, as it is associated with a hematoma and grossly displaced. He is taken to the operating room, where the anesthetist gives succinylcholine just before intubation. What is the likely value in the ICP monitor after this bolus dose?

A 32-year-old man with a history of traumatic brain injury is admitted to the ICU. CT brain reveals multiple contusions with midline shift to right and he required decompressive craniectomy. He undergoes percutaneous tracheostomy in view of poor sensorium and anticipated need for prolonged airway protection. He develops a fever of 101.3 F (38.5 C). Blood, tracheal aspirate, and urine are sent for culture, and he is given IV piperacillin/tazobactam. The cultures show no growth. CSF evaluation is unremarkable. All the obvious sources of infections are ruled out, and all invasive lines and catheters are revised. Procalcitonin is within normal limits. Which of the following is the next best step in the management of this patient?

A 12-year-old boy is brought to the clinic with recurrent effort-induced suboccipital headaches and occasional ataxia. He is an otherwise healthy male with no past medical history or history of birth defects. Which of the following structures is most likely to be abnormal on brain magnetic resonance imaging (MRI) in this patient?

A 45-year-old man suffering from a muscular disorder for the past seven years is seen in the clinic. This disorder includes CAG repeat units, and his father had the same disease that began at age 45. Recently, the patient has experienced worsening depression, mood swings, dysphagia, weight loss, and chorea. He also fell on his left side two weeks ago while walking to the kitchen. A work-up from three months ago included an MRI brain. The enlargement seen on neuroimaging is a well-known sign of atrophy of one of the nuclei of the basal ganglia related to this patient's underlying disease. Which of the following best describes the anatomical relationship of this nucleus to the ventricular system?

A 67-year-old male is brought into the emergency department after the sudden onset of right-sided paralysis 45 minutes ago at home. His initial vital signs include a blood pressure of 160/110 mmHg, a heart rate of 75 beats per minute, a respiratory rate of 12 breaths per minute, and a temperature of 98.7°F (37.1°C). He has a past medical history significant for coronary artery disease, atrial fibrillation, and hypertension. His medications include warfarin, propranolol, tomale, and atorvastatin. While being wheeled to the CT scanner, the patient suddenly loses consciousness, and a rapid response is called. His repeat vital signs include a heart rate of 43 beats per minute, a blood pressure of 170/60 mmHg, and a respiratory rate of 7 breaths per minute. What is the most likely etiology for this patient's sudden decompensation?

A 77-year-old man is admitted to the hospital after a ground-level fall at home due to disorientation. His Glasgow Coma Scale (GCS) score is 13. He is managed conservatively for a small 1.7 cm right basal frontal contusion seen on a head CT. On the third day of admission, he is found lethargic with a GCS score of 11. A repeat CT scan shows progression of the contusion to 2.9 cm with a new area of hemorrhage in the left frontal basal area. Which of the following is most likely responsible for this progression?

A 12-year-old boy was admitted to the emergency department after a motor vehicle collision. His initial Glasgow coma scale was 15, and his only complaint was a moderate to severe headache and several episodes of vomiting. CT of the head revealed a small epidural hematoma and several small cerebral contusions. Transfer to the local trauma center was arranged, and while awaiting transport, the nurse stated that the patient's mental status had decreased. Physical examination of the patient revealed that he was becoming combative and his oxygen saturation was 88% on room air. Which of the following is preferred management?

A 28-year-old overweight female is brought to the emergency department with a history of three episodes of grand mal tonic-clonic seizures. The last event occurred half an hour back, which lasted for one minute. On eliciting the history from the relatives, it is noted that she was normal until 11 PM last night when she started having a mild-moderate holocranial headache. She is nauseated but not having any vomiting, and there is no previous history of seizures. Her drug history reveals that she is on oral contraceptive pills. On examination, she is in the post-ictal phase with a Glasgow Coma Scale score of E3V4M5. The computed tomogram of the brain shows a small (2 ml volume) hematoma in the left temporal lobe. She is managed conservatively, and the next day magnetic resonance imaging of the brain with magnetic resonance venogram is ordered, which shows thrombotic occlusion of the vein of Labbe on the left side. Which of the following venous drainage pathways is impaired due to this thrombus?

A 34-year-old female presents to the labor and delivery unit and delivers a newborn female vaginally. She had no access to prenatal care. She does not have any significant medical history and takes no medications. Her infant was born with an enlarged head, and her eyes are red with excessive tearing. CT brain shows generalized intracranial calcifications. Which of the following is the strongest risk factor for the development of the newborn female’s condition?

A 25-year-old male patient presents to the emergency department after a car accident with a piece of metal sticking out of his head. Imaging shows the piece of metal is piercing a nerve found at the dorsal midbrain. Which of these findings are expected when considering the location of the injury?

On examination, a neonate cannot move the right side of his face when smiling, and the right ear shows malformation. Newborn hearing screening demonstrates reduced hearing in the right ear. During which of the following gestational ages does the complete separation of the affected nerves occur?

A newborn is noted to have a mass in the back, which looks like a sac containing fluids and tissue. You thoroughly examine the neonate. Which of the following finding would be of most concern?

A 6-day-old baby in the nursery has progressively increasing head circumference which is now in the 95th percentile. The patient has a full fontanelle, sunset eyes, and poor sucking. He had repair of a lumbosacral myelomeningocele on day two after birth. CT showed features of communicating hydrocephalus. The cerebrospinal fluid culture was reported negative. What is the most rational approach for the management of this patient?

After a difficult delivery a neonate is noted to have asymmetric Moro reflex. One of the arms is held in adduction, shows internal rotation at the shoulder, is pronated and extended at the elbow, and wrist flexion. Which nerve roots are most likely affected?

A 65-year-old male patient presents to his provider's office due to unsteadiness. He tripped several times in the past month, more often on his left side. His wife also claims that there are times when he is inattentive and does not answer her call, especially when she is on his left side. He has no known medical comorbidities. On examination, vital signs are within normal limits. The cranial nerve examination reveals isochoric pupils, equally reactive to light, and extraocular muscular movements are full and equal on examination. There is decreased forehead crease on the left, weaker eye closure on the left and nasolabial fold is shallow on the left than the right on smiling. Weber exam localizes to the right, Rinne test shows air conduction (AC) is better than bone conduction (BC) on the right, and BC is better than AC on the left. There are no motor or sensory deficits noted. His cerebellar examination shows dysmetria and dysdiadochokinesia on the left. What is the most likely location of this patient's lesion?

A 25-year-old female is brought to the outpatient clinic with the complaint of one episode of focal seizures involving the right side of the body a day back. On examination, she is neurologically intact. She undergoes a magnetic resonance imaging scan of the brain, which shows a T1-hypo and T2-hyperintense lesion involving the left frontal lobe with mild mass effect and blooming on T2-star images. She undergoes craniotomy and decompression of the lesion. Loss of which of the following chromosomes on histopathological examination of the specimen is associated with increased patient survival?

A 50-year-old man arrives at the emergency department after a motor vehicle collision. The bystanders report that he was unresponsive for about 15 minutes, then started to regain consciousness. He is drowsy but able to answer questions appropriately and complains of a severe headache. He takes medication regularly for hypertension and has polycystic kidney disease. He had valvular heart surgery five years ago, his family history is significant for his father with polycystic kidney disease dying of a hemorrhagic stroke, and the patient has a smoking history of 30 pack-years. His blood pressure is 130/84 mmHg in all limbs, pulse 90/min, and respiratory rate 24/min. An examination demonstrates a conscious, well-oriented man who admits to having no memory of the motor vehicle collision. A preliminary neurological examination reveals a dilated pupil in the left eye, about 3 mm larger than the right. Extraocular movements are full and equal on the right, with difficulty of medial, upward, and downward gaze on the left. There is no facial asymmetry, the facial sensation is normal, and there is no ptosis. The motor examination does not reveal any weakness, there is a mild decrease in the vibration sense of the feet, and he ambulates without difficulty. There is an upgoing big toe bilaterally on stimulation of the lateral aspect of the foot. Nuchal rigidity is also present. He seems to have labored breathing, and a first rib fracture is suspected on the right side. Chest x-ray reveals a mass lesion at the apex of the right lung. CT scan reveals hyperdensities around the circle of Willis. Laboratory investigations, including complete blood count, glucose level, liver function tests, and renal function tests, are normal. What is the most likely cause of this patient's pupillary defect?

A 4100-gram (99th percentile) newborn male is delivered at 39 weeks gestation to a 32-year-old gravida 3 para 3 female. The patient was born via normal vaginal delivery, but the second stage of labor was protracted. The baby is examined several hours after delivery, and there is a swollen deformity of the baby’s scalp. The patient is hemodynamically stable and well-appearing. Scalp examination revealed a soft palpable swelling over the right temporoparietal area, has slight discoloration and did not extend past the suture lines. The patient’s physical examination is otherwise unremarkable. His head circumference was noted to be 36 cm (90th percentile), and this finding remained stable throughout the patient’s hospital course. At four weeks of age, the patient presented to the emergency department with decreased feeding and a fever of 38.9 C (102 F). The only clinical symptom apart from the fever was redness and tenderness over the swelling noted during the patient’s nursery stay. Laboratory tests revealed leukocytosis, hemoglobin level of 8.8 g/L, normal platelet count, and a C-reactive protein level above 25 mg/L. Contrast enhancement was seen within the scalp lesion following the CT brain scan. Before initiating broad-spectrum antimicrobial therapy, which of the following best describes the next step in the management of the child?

A 17-year-old high school basketball player has his left forearm impacted after falling and having an opponent landing on him. He complains of pain over the dorsal lateral aspect of the proximal left forearm. He then develops progressive weakness with wrist extension but denies pain or tingling in his wrist or hand. His physical examination is remarkable for tenderness over the proximal supinator muscle with 4/5 strength on wrist extension. There is also 4/5 strength with forearm supination. He has the normal sensation to light touch over radial and median distributions. Radiographs of the left forearm and wrist reveal no fractures or dislocation. Which of the following is the most likely diagnosis?

A 65-year-old male presents to the emergency department with a severe headache. He states it as the worst headache of his life. Neurological examination is unremarkable. A CT scan of the brain shows a hyperdense material filling the subarachnoid space. CT angiography of the brain shows an anterior communicating artery aneurysm. He undergoes a right pterional craniotomy and clipping of the aneurysm. There is an intraoperative rupture, and the procedure becomes complicated. Postoperatively he is found to have weakness of the left upper limb. He undergoes an MRI scan of the brain. Diffusion restriction of which of the following structures shows damage to the recurrent artery of Heubner as opposed to other lenticulostriate vessels?

A 60-year-old female with a history of lower extremity weakness is undergoing spine surgery using motor evoked potential monitoring. Induction of anesthesia with propofol, fentanyl, and succinylcholine was uneventful. Maintenance of anesthesia is performed with propofol and remifentanil. After verifying the full return of muscle strength following succinylcholine administration, - the neurophysiologist notes that the amplitude of baseline motorevoked potential signals is weak. Which of the following medications could be added to increase the amplitude of the motor-evoked potentials?

A 36-year-old woman presents to the clinic for evaluation regarding chronic cluster headaches. She reports that her headaches are frequently associated with rhinorrhea, conjunctival injection, and epiphora. Input from which of the following anatomic structures is most likely contributing to this patient's symptoms?

A 40-year-old male without a significant past medical history presents with a severe headache that started about 14 hours ago. The patient was asleep when his headache started. The patient denies any head trauma and a family history of stroke or sudden death. CT brain without contrast is negative. On physical examination, blood pressure is 200/115 mm Hg, respiratory rate is 25/minute, pulse rate 100/minute, and oxygen saturation is 99% on ambient air. The patient is awake, alert, oriented, and can move all extremities. Which of the following is the best next step in management?

A 30-year-old male boxer presents to the emergency department for recurrent episodes of clear, watery, unilateral otorrhea. He noted the otorrhea after one of his recent fights, in which he was knocked unconscious from a blow to his right ear. It seems to worsen when he bends over to tie his shoe, and better when he turns his head to the left. He denies any fevers, chills, otalgia, tinnitus, vertigo, congestion, or nasal purulence. What is the best initial step in the management of this patient?

A 65-year-old female presents with weakness on her left side that has been ongoing for the past week. The patient is unable to get an MRI scan due to an old pacemaker. On physical examination, the clinician performs a reflex to determine if the etiology is central or peripheral. The clinician taps the distal radius to perform the reflex. Which nerve innervates the muscle used to elicit this reflex?

A 29-year-old female presents to the outpatient department with a complaint of amenorrhea for the past two months. A urine pregnancy test is negative. After gynecological evaluation, she undergoes a magnetic resonance imaging of the brain, which shows a pituitary macroadenoma with para sellar extension bilaterally. Her prolactin level is 510 ng/ml. She is started on bromocriptine, and her menstruation returns two months after initiating therapy. Of the following, which best describes the mechanism of action by which bromocriptine achieves this therapeutic effect in this patient?

A 64-year-old woman is found collapsed near her bed in her nursing home after the staff outside hear a noise. On arrival of the paramedics, she has a GCS of 6 (E1V1M4), which quickly improves to 13 (E3V4M6) while transferring her to the ambulance. On arrival at the emergency department, she undergoes a CT Head, which reveals a hyperdense lesion in the right thalamus extending into the temporal lobe without midline shift. As she is being transferred from the CT scan room, her GCS drops again to 6 (E1V1M4). Her bedside observations reveal a blood pressure of 134/65 mmHg, heart rate of 74/min, and respiratory rate of 17/min. Her pulse oximetry shows an oxygen saturation of 97% on room air, and her pupils remain equal in size. Which of the following is the next best step in the management of this patient?

A 5-year-old child is brought to the clinic with the complaint of diplopia. On examination, he has right lateral rectus palsy and right-sided lower motor neuron type of facial palsy. Computed tomogram shows enlarged pons with mild hydrocephalus. What is the most likely diagnosis?

The patient is having a clinical and radiological diagnosis of intrinsic pontine glioma. Cranial nerves VI and VII arise from the pons. Intrinsic pontine glioma is usually a radiological diagnosis. The prognosis is poor for this type of lesions.

A 42-year-old man presents to the clinic with pain radiating down his right leg and numbness over the dorsum of his right foot. He has no back pain. These symptoms began after helping his friend move three months ago. He also had a successful L4/5 microdiscectomy three years ago. On exam, there is weakness to dorsiflexion of ankle and extension of the hallux. MRI with contrast demonstrates a right-sided paracentral herniation of the L4/5 disc. There is no instability on plain radiographs. The patient has failed conservative management. Which of the following is the next best step in the management of this patient?

A 2-year-old male was recently diagnosed with medulloblastoma. Histologic evaluation revealed sheets of small round cells, possessing a high nuclear-to-cytoplasmic ratio occasionally with neuroblastic differentiation. Although he has a rare form of medulloblastoma, the provider reports with confidence that he has a good prognosis and can have a 5-year survival of over 90% with this subgroup of medulloblastoma. What key protein undergoes constitutive activation leading to this subgroup of medulloblastoma?

A 29-year-old female presents to the clinic with thoracic back pain. Her past medical history is unremarkable, and there has been no trauma, heavy lifting, or repetitive work maneuvers. The pain is sharp and stabbing and worse with motion or bending to unload the car after shopping. There are no other focal neurologic complaints, palpable spine tenderness, or focal neurological signs. What is a possible related clinical breast finding that may be associated with the pain?

A 35-year-old female with a past medical history of hypertension presents to the clinic with a severe headache. She claims that she has a history of migraines; however, for the past three months, she has had a persistent right frontal headache that would decrease in intensity on taking painkillers but would not completely resolve. The headaches are more prominent upon waking up in the morning and are usually accompanied by nausea. There is no photophobia, and the patient can still do daily activities despite the headache. Her vital signs include a blood pressure of 150/80 mmHg, a heart rate of 56/min, and a temperature is 38 C. On examination, pupils were isochoric, equally reactive to light with full extraocular muscle movement. The funduscopic exam reveals papilledema bilaterally. A mild facial droop is noticed on the left when the patient is asked to smile. On motor examination, there is a mild drift of the left upper extremity with no sensory deficits. A contrast CT scan of the head was requested, which showed a homogenous, welldemarcated contrast-enhancing lesion on the right frontal lobe. Which of the following entity is the first to be involved following herniation syndrome in the patient?

A 16-year-old male with bilateral vestibular schwannomas presented with a history of progressive left-sided weakness and paresthesias for the past month. On physical examination, there was decreased sensation and hypertonia in the left upper and lower limbs, with power being 3/5. Bilateral sustained clonus and Babinski's sign were also noted otherwise cranial nerve examination was normal. The parents mentioned a positive family history of first degree relatives with vestibular schwannomas. Which tumor will most likely be present in this patient?

A 3-year-old girl with a past medical history of patent foramen ovale recently is scheduled for cardiac surgery. As part of fast track anesthesia, an intrathecal morphine injection is performed for multimodal pain control. The following day, the child has diminished motor function in her right lower side. At which of the following levels was the spinal needle most likely inserted?

A 77-year-old woman with a past medical history of Alzheimer disease with mild cognitive impairment presents to the clinic with her son for new-onset headaches and confusion. She was recently started on a new medication classified as a monoclonal antibody that targets amyloid-beta plaques in the brain. The clinician expects an adverse effect from therapy. A brain MRI is ordered and confirms the diagnosis. What is the most likely cause of her presenting symptoms?

A 40-year-old man undergoes a diagnostic lumbar facet joint injection for chronic low back pain. After identifying the correct facet joint on fluoroscopy, the physician begins to inject a combination of local anesthetic and corticosteroid. During the injection, the physician encounters resistance after injecting a total of 1 mL. Which of the following is the next most appropriate course of action?

A 12-year-old female presents to a clinic with a 4- month history of worsening intermittent headaches associated with dizziness. MRI shows a small mass occupying the third ventricle with areas of calcification, isointense on T1-weighted images, hyperintense on T2-weighted images. Which of the following features supports the most likely diagnosis?

A 47-year-old man is scheduled for elective laparoscopic cholecystectomy under general anesthesia. Her past surgical history is significant for transsphenoidal hypophysectomy for acromegaly. Which one of the following hormones is most appropriate to be given to this patient in the perioperative period?

A 65-year-old male presents with weakness in his right hand. He is asked to hold a piece of paper between the thumb and index finger with both hands. As the paper is pulled away, the patient can hold the paper in place with his left hand, but in his right hand, he has to flex the interphalangeal joint of the thumb to maintain his grip on the paper. What is the most likely diagnosis for this patient?

A 33-year-old woman is scheduled for elective surgery. The patient is already prepped and draped, and the surgeon has the scalpel in his hand. He is anxious to complete the surgery quickly since this is his fifth surgery of the day. During the time-out, the patient states that she does not want to be resuscitated if an emergency develops, but she has not documented previously this wish. The surgeon should next do which of the following?

A 52-year-old male presents with a slowly growing mass of the hard palate. It is asymptomatic and measures 0.75 x 0.75 cm. No other abnormalities are found. Needle biopsy shows the most common tumor in this location. Select the best management.

A 57-year-old man presents with acute severe back pain. The pain radiated to the left leg and foot after lifting some heavy pots in his garden four days ago. He describes the pain as nine out of ten, and it keeps him up at night. The patient has been taking ibuprofen 800 mg three times a day and acetaminophen over the counter with no relief. He denies weakness, numbness, or tingling. His past medical history includes a spinal fusion of the L1-L2 vertebrae and chronic fatigue syndrome. On examination, the straight leg raise on the left is positive, reproducing his pain. His muscle strength, sensation, and deep tendon reflexes are all within normal limits. What is the most appropriate next step in the management of this patient's pain?

A 16-year-old patient is rushed to the emergency department following a motor vehicle collision. He is complaining of localized neck pain without any radiation towards his upper limbs. His neurological examination did not reveal any sensory or motor deficits. All the deep tendon reflexes are normal. He has a normal single breath count and has no features suggestive of Horner syndrome. The CT of the cervical spine, however, revealed a complete spondyloptosis at the interface of the fifth and sixth cervical spine (C5-6). The patient also had fractures of the bony components of the Denis third columns. What is the preferable method of posterior implant fixation at the subluxated segments of the cervical spine in this patient?

A 29-year-old man presents to the emergency department (ED) with a significant neck injury following a major road traffic accident (RTA). His neurological exam is within normal limits. The rest of his clinical, systemic assessment is also within normal limits. On detailed radiological evaluation (including plain radiographs, CT, and MRI), he is diagnosed with type 3 fracture of odontoid extending onto C2 body, along with C1 arch fracture and C1-2 subluxation. He is scheduled for posterior C1-2 instrumented fusion. Pre-operatively, CT angiography is performed, which revealed complete left vertebral artery disruption. Which of the following intraoperative steps is most likely to minimize the chances of a brainstem stroke in this patient?

A 43-year-old man presents to the healthcare provider after a motor vehicle collision. The patient is unconscious and unresponsive. An x-ray of the head confirms a fracture of the skull through the parietal foramen, while a CT scan reveals a hemorrhage. The vein that passes through the parietal foramen connects which of the following pair of veins?

A 30-year-old female is brought to the emergency department with the complaint of one episode of seizures involving the left side of the body three hours back, which lasted for 2 minutes. She was conscious at that time, and the ictus involved tonic posturing of the left upper and lower limbs. This was the first time she was having seizures in her life. She does not have any comorbidities, and she is a smoker. There is no history of trauma. On examination, she is conscious and oriented with no neurological deficits. She undergoes a computed tomogram of the brain, which shows a 2x1 cm sized hematoma in the right temporal lobe. She is managed conservatively. She undergoes magnetic resonance imaging (MRI) of the brain one month later, in which the gradient echo sequence shows a berry appearance with a rim of signal loss at the hematoma site. She is scheduled for surgery. Before that, a contrast MRI of the brain is ordered. What is its role in preoperative planning?

A baby is born by C-section due to cephalopelvic disproportion. The anterior fontanelle is closed with a palpable coronal suture ridging, hypertelorism, and syndactyly of the hand and feet. What is the most correct in terms of management for this child?

A 50-year-old female presents to the clinic with generalized weakness and difficulty in walking for the past three to four months. She has more difficulty in climbing stairs, combing hair, and standing from the chair. She denies fever, pain, trauma, numbness, paresthesia, urinary, or bowel symptoms. On further inquiry, she reveals that she has constipation, sleeps a lot, and has gained 12 kgs of weight even though her appetite has decreased. On physical examination, her skin seems dry. Muscle strength is 3/5 in proximal muscles and 4/5 in distal muscles of both upper and lower limbs. Deep tendon reflexes are present with delayed relaxation. What is the next step in the diagnosis of this condition?

A 45-year-old woman is undergoing microsurgical clipping of the anterior communicating artery aneurysm. The surgeon wants to prevent complications that can occur from an inadvertent clipping of the perforators. Which of the following modalities can best help in achieving this?

Wernicke syndrome, often seen in patients with chronic alcohol use disorder, typically presents with which of the following symptoms?

A 22-year-old male with a past medical history of high spinal cord injury undergoes laparoscopic direct diaphragmatic pacing for the persistent requirement of mechanical ventilation. On the second-day post-operation patient's temperature is 39 degrees Celsius, heart rate is 120 beats per minute, blood pressure is 70/40 mmHg. He is complaining of generalized abdominal pain. Pertinent examination findings reveal tachycardia, decreased capillary refill, and abdominal tenderness with guarding and rigidity. Which of the following should be immediate management in this patient?

A 32-year-old right-handed female with a past medical history of systemic lupus erythematosus (SLE) presents to the emergency department with nausea, dizziness, headache, confusion, vertigo, dysarthria, and bilateral central vision loss with the onset of symptoms two hours ago. On examination, the temperature is 37 C, pulse rate is 90/min, blood pressure is 165/73 mmHg, and respiratory rate is 36/min breaths per minute. The patient is alert but confused and complaining of a headache. Her blood glucose level is 93 mg/dL, and the National Institute of Health stroke scale is 7. CT scan of the head without contrast is negative for an acute bleed, and subsequent CT angiogram of the head and neck shows a large vessel occlusion (LVO) at the basilar tip. Which of the following steps is recommended at this time?

A 19-year-old G1P0 woman at 19 weeks gestation presents to the emergency department after being assaulted by her partner. She has diffuse ecchymosis around her right zygoma, decreased visual acuity, diplopia, and gross hyphemia. Extraocular movements are asymmetric, and the patient complains of a right-sided throbbing headache. Her GCS is 15. She has no focal deficits and did not lose consciousness. MRI is unavailable, and the patient states she does not want any imaging study that would harm her fetus. An optic nerve sheath ultrasound (ONSUS) is planned for risk stratification. Which of the following is the next best step in managing this patient?

A 65-year-old man with a past medical history significant for hypertension, diabetes mellitus, and smoking is brought to the clinic by his daughter with chief concerns of memory loss. The patient has had a rapid decline in cognitive and memory function, having problems with activities of daily living and paying his bills all within the past year. MRI of the head reveals infarcts in multiple areas, including the posterior hippocampus. What vessel normally provides blood to the posterior hippocampus?