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APEA PRE-PREDICTOR EXAM| 2025 - 2026|ACTUAL 150
QUESTIONS AND CORRECT ANSWERS|GRADED A+
In myasthenia gravis, weakness is a result of insufficient acetylcholine transmission at the neuromuscular junction; however, weakness can also occur with overdosing of the cholinergic medications used to treat myasthenia. What symptom helps differentiate a myasthenic crisis from a cholinergic crisis? Muscle fasciculations A 74-year-old man presents after his wife witnessed him grab his head in pain and fall to the floor. He has not regained consciousness. His current blood pressure is 150/96 mm Hg, and his heart rate is 65 bpm. Emergent head CT shows a subarachnoid hemorrhage. Nimodipine (CCB) A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on the windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical examination reveals weakness of his upper extremities. What type of spinal cord injury does this patient have? Central cord syndrome A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his house. The right side of his head hit the alley cement, and he lost consciousness for about 1 minute; he woke up with a headache, but he had no other complaints. A few hours later, the patient is brought to the emergency room by his neighbor because of an intense headache, confusion, and left hand hemiparesis. On
examination, the patient has a bruise located over the right temporal region, mydriasis, and right deviation of the right eye, papilledema, and left extensor plantar response. An emergency CT scan of the head without contrast reveals a lens-shaped hyper-density under the right temporal bone with mass effect and edema. What is the most likely diagnosis? Epidural hematoma A 1-year-old boy presents with increasing lethargy. He is barely responsive, and his parents deny any trauma or injury. What is the most common cause of nontraumatic altered levels of consciousness? Infection A 44-year-old man starts to notice that his eyelids are drooping. Some time afterwards, his jaw becomes weak. He has difficulty swallowing and also experiences weakness in his limbs. He is quite embarrassed when he eats because he must use his hand to help support his jaw. His weakness gets progressively worse. Finally, he seeks medical attention. His physical examination demonstrates the weakness in his limbs; however, no sensory defects are present. A Tensilon test is done and is positive. His doctor is concerned about an associated malignancy. What is the underlying pathology of this disease? Antibodies to the acetylcholine receptor A 31-year-old woman presents with a purpural rash covering her arms, legs, and abdomen. She also has fever, chills, nausea, abdominal tenderness, tachycardia, and generalized myalgias. Prior to the development of the rash, the patient noted that she had a headache, cough, and sore throat. Laboratory studies were positive for Gram-negative diplococci in the blood, along with thrombocytopenia and an elevation in PMNs. Urinalysis showed blood, protein, and casts. The patient denies any foreign travel and does not have any sick contacts. However, she does work part time as a nurse in a local hospital. The patient is diagnosed with
A 70-year-old woman is brought to your attention by her family because of the slowly progressive gait disorder, the impairment of mental function, and urinary incontinence. About 1 year ago, she started having weakness and tiredness in her legs, followed by unsteadiness; her steps became shorter and shorter, and she also experienced unexplained backward falls. She is becoming emotionally indifferent, inattentive, and her actions and thinking have became "dull". Over the past month, she has started having urinary urgency and involuntary leaking of urine. What is most likely the best method of treating the patient's urinary problems? Ventriculoperitoneal shunt A 5-month-old male infant presents after a seizure involving all 4 limbs. His mother tells you that he was born full term without any complications, and he was well until 2 days ago when he developed a fever. He vomited multiple times yesterday and was irritable. He was given antipyretic medication for his fever. He has no known allergies. On physical exam, his temperature is 102.7 F, and his pulse is 154/min; BP is 90/50 mmHg, and RR is 20/min. He is lethargic, pale, and focal neurological deficits are present. His anterior fontanel is bulging. You suspect that he has bacterial meningitis. After drawing blood samples for investigations, what is the most appropriate next step? Intravenous empirical antibiotics A 12-year-old girl presents with a 3-day history of progressive dysarthria, dysphagia, and weakness. The patient was well until 3 days prior to admission to the hospital; at that time, she developed the onset and subsequent gradual worsening of dysarthria. She attributed the dysarthria to a sore throat that she had had about 2 weeks earlier. 3 days prior to admission, she also had the onset of mild dysphagia; it mostly occurred with liquids. 24 hours prior to admission, she developed weakness in both upper extremities, which increased and began to involve the lower extremities. This limb weakness was neither worsened by activity nor improved by rest. A nerve conduction study reveals a moderate degree of mostly motor demyelinating peripheral neuropathy, highly suggestive of Guillain- Barre. What statement best describes the patient's prognosis?
Her rapidly evolving clinical course indicates a poor prognosis A 45-year-old African American man with no significant past medical history presents with a 1-hour history of left retroorbital headache. It is described as excruciating, stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any preceding infections, nausea, vomiting, photophobia, or osmophobia; he also denies fever, chills, stiff neck, focal weakness, numbness, tingling, vision, hearing, gait, or speech changes. He recalls a similar episode several months ago; it lasted about a week, and it dissipated without complications. His physical exam is remarkable for painful distress, lacrimation with conjunctival injection, nasal congestion, rhinorrhea, left ocular miosis, and left forehead diaphoretic flushing. What pharmacologic agent is the most beneficial for this patient at this time? Sumatriptan A 48-year-old woman presents after a seizure. Prior to the seizure, she experienced confusion and disorientation preceded by nausea, vomiting, and blurred vision. Symptoms appeared after working for several hours in the garden under the sun. Her medical history is significant for the presence of schizophrenia, for which she takes chlorpromazine at bedtime. Her temperature is 41 C; BUN and creatinine are elevated; and there is neutrophilia, hemoconcentration, and lactic acidosis. You think that the event is possibly drug related. What is the most likely diagnosis? Heat stroke A 17-year-old adolescent male presents with unexplained neurological symptoms. His liver is enlarged on palpation, and he has other symptoms of hepatitis. Blood work reveals depressed ceruloplasmin levels. An ophthalmological examination reveals Kayser-Fleischer rings. What is the most likely diagnosis? Wilson's Disease
A 32-year-old man presents with a severe headache; he has had 2 similar headaches within the past week. He describes a burning, 'hot poker'-type of pain located primarily behind his right eye. He notes that his eye waters profusely with the headache; in addition, his nose is initially congested, then it starts running. Only his right side is affected. The headache is so severe that he cannot work or sleep through it, and he is unable to concentrate on anything else. The headaches have been unresponsive to over- the-counter pain medications. The episodes seem to last about 1 hour. He denies any other symptoms. This patient has no chronic medical conditions, and he takes no regular medications. What is the most likely underlying pathophysiology of this patient's condition? Increased trigeminal nerve and parasympathetic activity, leading to vasodilation A 73-year-old man presents after a 15-minute episode of right eye vision loss, which he described as being "like a shade being pulled down". What diagnostic test is most likely to be abnormal? Carotid ultrasound A 42-year-old man presents to the emergency department with a severe headache. He has been getting several of these headaches recently and has tried all over-the- counter pain relievers and headache medicines with no relief. His current headache started 15 minutes ago. He describes the pain as located next to and behind his left eye and "stabbing/excruciating" in nature. He feels like his left eye tears up profusely with these headaches. He denies recent stressors that may have caused his headaches. On physical exam, the patient appears slightly agitated and appears uncomfortable. Which of the following aspects of patient history would be most consistent with this patient's suspected condition? Rhinorrhea associated with HA
A 66-year-old English teacher is in the hospital. Her neurologist gives her a magazine to read, and she is unable to do so. What is this phenomenon called? Alexia A 35-year-old man presents with unusual sensations in his legs. He describes the sensation as an uncomfortable crawly sensation deep within his legs. If he tries to ignore them, the feeling worsens. He has brief relief with movement, but the feelings return as soon as he is still again. He was given a trial of a benzodiazepine to take at bedtime, but it did not really help. In addition, he complains of being sleepy during the day as a result of the medication. He also tried leg massages and exercise without much relief. The patient denies snoring, vivid dreams, or cataplexy. He states that he has a depressed mood and reduced energy and concentration, but he denies suicidal ideation. His physical exam is normal. Complete blood cell count and chemistry panels are normal. Question What is true regarding the patient's condition? An abnormal electrical impulse conduction study is frequently seen A 70-year-old man presents with memory loss that has been worsening over the past few months. He also has history of slurred speech and walking difficulty. There is a history of getting lost in familiar surroundings. His history is also significant for a stroke 2 years ago. On examination, there are focal neurological signs including plantar response, gait abnormalities, exaggeration of deep tendon reflexes, and weakness of the right lower limb. Brain imaging studies show multiple large-vessel infarcts and extensive periventricular white matter lesion. What is indicated by evidence of relevant cerebrovascular disease? Vascular dementia
syncope. The patient never had such an episode before. Vital signs upon presentation are as follows: BP 124/82 mmHg, P 88 beats/min, R14/min. EKG is within normal limits. Cardiovascular examination reveals a normal S1 and S2, with no rubs, murmurs, or gallops. The patient is being treated with atenolol and hydrochlorothiazide for his hypertension. His blood sugar is 96 mg/dl. What is the most likely cause of the patient's syncope? Vasovagal syncope The girl's mother states that there are times when the patient does not seem to be paying attention to what the mother is saying. Shortly after these "episodes", the child engages in conversation without any problem; therefore, the mother did not think the episodes were an issue. There is no concern about other abnormal behavior or discipline issues at home or at school. What is the most likely diagnosis? Petit mal (absence) seizures A 45-year-old secretary presents with a 1-month history of paresthesias on the medial aspect of her right hand. She has no neck pain or shoulder pain, but she has had some difficulty typing with the right hand. Neurological exam reveals diminished sensation to pain and light touch on the medial aspect of the palmar and dorsal surfaces of the hand to the wrist, the 5th finger, and the medial aspect of the ring finger. Mild weakness of the right abductor minimi digiti is present, but the other intrinsic hand muscles are of normal strength. The remainder of the neurological exam is normal. Compressive ulnar neuropathy at the elbow A 52-year-old woman presents with a 1-year history of bilateral shaking in her hands. The shaking tends to worsen when she is using her hands, and her symptoms
improve when she drinks a glass of wine on the weekends. Her 82- year-old mother also has a similar shaking in her hands which developed when she was in her 50s. What is the most likely diagnosis? Essential tremor A 32-year-old woman presents due to "I'm feeling odd." Further questioning reveals the patient experiencing a significant amount of involuntary movements and a severe lack of coordination; she recently had a significant decrease in cognitive abilities. Because she is an established patient, you recall that the patient got married about a year ago; past family history is unknown due to the fact that the patient was adopted as a child. Physical examination reveals rapid, involuntary movements of fingers bilaterally, impaired ability to concentrate, minor slurred and disorganized speech, as well as difficulty responding with the appropriate words or phrases when prompted. What would be the recommended testing at this time to confirm the patient's diagnosis? Genetic testing A 16-year-old previously healthy boy fell on a cemented surface while skateboarding 3 weeks ago, and he lost consciousness for 2 minutes. He was not wearing a helmet. A CT scan showed no abnormalities. He is now back at school and complains of difficulty concentrating in class, frequent spells of dizziness, and headaches. His neurologic exam is normal. What condition should you consider as the likely explanation for his symptoms? Post Concussion Syndrome A 22-year-old man presents after being hit on the right temple by a baseball 1 hour ago. He lost consciousness for 2 minutes after the impact, but he did not seek
Labs reveal normal CBC, serum electrolytes, thyroid function tests, and liver transaminases. A chest X-ray is clear. Bell's palsy A patient with early onset of hypertension, hematuria, and palpable kidneys was diagnosed to have adult polycystic kidney disease, and he is being evaluated for associated berry aneurysms. What investigation is considered the "gold standard" for the detection of aneurysms of the cerebral blood vessels? Angiogram A 16-year-old girl is brought to the emergency room for evaluation of continuous seizures. The patient was first diagnosed with idiopathic epilepsy at age 10. She was started on valproic acid. Phenobarbital and carbamazepine (Tegretol) have been tried without success, and the phenobarbital resulted in transient severe personality changes. 2 previous EEG's have been normal. This spell occurred abruptly at the family dinner table without apparent warning. Past medical history has been normal except for the usual childhood diseases without complications. 2 days prior to presentation, she saw her primary physician for nausea and vomiting; as he believed she had the flu, he started her on prochlorperazine (Compazine), which relieved her nausea. Pseudoseizure is suspected. What test is best in this acute clinical setting in differentiating pseudoseizures from true epileptiform seizures? Stat EEG A 21-year-old woman presents with double vision that occurs only when she looks to her right side. The double vision began when she woke up in the morning. She had an episode of left leg numbness while at summer camp 6 years ago, but it resolved over 3 days and she never told anyone. Also, 3 years ago she saw her private
physician after a 7-day episode of right eye pain and visual blurring. He attributed her symptoms to an ocular migraine. There is no history of head trauma. She hasn't had any infections, fevers, or immunizations recently. She is awake, alert, and in no acute distress. Positive findings include mild pallor and atrophy of the right optic disc. Given this history, how would this patient's condition best be subtyped? RRMS A 31-year-old man with a known generalized seizure disorder is brought to your emergency department. His friends tell you that the patient had a seizure and did not wake up. When he did not wake up after 30 minutes, his friends called 911. On examination, he is breathing and his heart is beating. He is warm, dry, and pink. His basic laboratory values are within normal limits, and the computerized axial tomography (C.A.T.) scan of his brain is unremarkable. An emergency electroencephalogram (E.E.G.) is not available. His only medications are phenytoin and phenobarbital. What is the best initial treatment in this case? Ativan A 60-year old woman has a history of stress related migraine headaches. Many conventional treatments have failed. What treatment would you now try on this client? Biofeedback A 22-year-old engineering student presents after a major motor seizure. The patient was well until 3 days prior to presentation, when he developed generalized headache and a fever of 101.2 F (by mouth), for which he took aspirin. He later
conversation. Upon further questioning, the patient admits that he occasionally experiences nighttime episodes during which he has the sensation of being unable to speak or move. The remainder of the history and physical exam are unremarkable. Aside from the occasional ibuprofen for shoulder pain, he does not take any medications. The patient's symptoms are most consistent with what disorder? Narcolepsy A 55-year-old man starts to develop behavioral and mental changes. In addition, he is having coarse, spasmodic, involuntary movements that involve his face and his extremities. What is the classification of this abnormal movement? chorea A colleague asks you to provide a neurosurgical consultation on a 75-year-old man. The consultation request form informs you that, "This man is having difficulty tolerating his medications as well as difficulty with his day-to-day activities". Your colleague wants to know if neurosurgery could help the patient's neurologic disorder. As a prudent provider, you plan to visit this man prior to recommending or denying definitive surgery. For what disorder may neurosurgery become a reasonable therapeutic option? Parkinson's A 5-year-old girl was hit by a slow moving car when she ran into the street while playing tag. She hit her head and had a brief period of loss of consciousness along with a few superficial scrapes and bruises. She was placed in cervical spine precautions and brought to the ED where cervical spine radiographs were read as
negative. What transient symptoms immediately after injury suggest the presence of spinal cord injury without radiographic abnormality? Lightning sensation down the spine with neck movement A 22-year-old woman presents with an 8-hour history of headache and vomiting. She resides in a college dormitory; she has no remarkable travel history, and reports eating food from a street vendor 24 hours before becoming ill. The patient is lethargic and disoriented. On examination, she is found to have a temperature of 38.5° C and a petechial rash on her legs. Gram stain of exudate from a skin lesion shows Gram-negative diplococci. A lumbar puncture is performed; the cerebral spinal fluid (CSF) reveals a leukocyte count of 5/μL consisting of primarily neutrophils. A Gram stain of CSF is negative for bacteria. What is the most likely diagnosis? Meningococcemia A 45-year-old woman presents with a 1-month history of double vision, tripping, urinary incontinence, and restless legs; the symptoms are accompagnied by weakness, numbness, and tingling sensations. She denies any headaches, difficulty with speech, or memory impairment. Her physical examination does not demonstrate impairments in mental status, speech, or memory. Her muscular strength is 2+ bilaterally in the upper and lower extremities, although it is diminished from a previous exam 1 year ago. Deep tendon reflexes are also diminished compared to 1 year ago. What is the most likely diagnosis? MS
with atrioventricular (AV) conduction abnormality. It is determined that she has Chagas' disease. What is a complication that occurs during the acute phase of this patient's condition? meningoencephalitis A 15-month-old toddler presents with sudden onset of generalized tonic and clonic convulsions for the last 30 minutes. There is no history of trauma, fever, vomiting, or irritability prior to the onset of convulsions. This is the first episode of seizure, and there is no history of convulsions in the family. Birth history, neonatal period, and developmental milestones are normal. Question After initial stabilization by securing the airway, oxygenation, and controlling the acute convulsion, what is the investigation of choice for the above child? CT scan of head A 40-year-old man presents with a 3-week history of a daily headache that awakens him from sleep. The headaches occur around the left eye. He notes that the left eye waters and his left nostril gets stuffy with each headache. What is the most likely diagnosis? Cluster HA A 64-year-old woman presents for evaluation of myxedema. She is experiencing constipation, headaches, weakness, fatigue, lethargy, somnolence, cold intolerance, decreased sweating, paresthesias, arthralgias, and muscle cramps. She has dry,
coarse skin. Her face and extremities are swollen, and her voice is coarse. What gait abnormality would you most likely expect to see in this patient? Myopathic A 28-year-old man presents following a motor vehicle accident 20 minutes prior. He states that it was just a "fender bender," but he feels he might have whiplash. His neck is stiff and sore, and he has developed numbness and tingling on the medial surface of his right arm and into his right fourth and fifth digits. On physical examination, his bicep strength is +5/5 on the left and +5/5 on the right. His biceps tendon reflex is 2+ on the left and 2+ on the right. In addition, his triceps tendon reflex is 2+ on the left and 2+ on the right. His grip strength on the right is diminished as compared to the left. The remainder of the physical exam is normal. Based on the above presentation, what is the cervical nerve root most likely affected? C A 32-year-old woman starts to notice that she is having difficulty brushing her hair. She also notices that her eyes are extremely tired after reading the evening newspaper. One night, her husband comments that she has droopy eyelids. She is relieved the next morning when her eyelids appear normal. Her condition deteriorates, and she has weakness and fatigability to the point that she finally sees her family doctor. On history, she denies pain. Her physical exam demonstrates weakness in her limbs. Her deep tendon reflexes are within normal limits. Her doctor wants to run a diagnostic test by injecting a drug. What is the most likely diagnosis? MG
