Exam Section: Item 1 of 50 National Board of Medical Examiners Time Remaining:

■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 51 sec

1. A 27-year-old man comes to the physician because of a 2-year history of severe muscle cramping and weakness immed iately following calisthenics or after
jogging a short distance. The cramping and weakness resolve within 24 hours. He also has dark urine du ring these episodes. Neurologic exam ination,
performed while he is asymptomatic, shows no abnormalities. Which of the folllowing is the most likely diagnosis?

0 A) Alcoholic rhabdomyolysis

0 B) Hypokalem ic periodic paralysis

0 C) Muscle phosphorylase deficiency (McArdle disease)

0 D) Myasthenic (Lambert-Eaton) syndrome

0 E) Polymyositis

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Exam Section: Item 2 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 51 sec

2. A 77-year-old woman with mild dementia, Alzheimer type, is brought to the emergency department by her daughter 3 hours after the sudden onset of
fearfulness and combativeness. The patient lives with her daughter and son-in-law. She attempted to smash their television screen with her walker and struck
her son-in-law when he tried to stop her. She has hypertension, gastroesophageal reflux disease, and diverticulosis. Her medications are metoprolol,
omeprazole, triamterene-hydrochlorothiazide, and donepezil. On arrival, she is hosti le and accuses the physician of trying to steal her money. Her temperature
is 37.5°C (99.5°F), pulse is 74/min, respirations are 16/min, and blood pressu re is 144/82 mm Hg. Physical examination shows restless movements. Mental
status examination initially shows hypervigilance; the patient later appears drowsy. She mutters under her breath as if respond ing to internal stimuli and picks
at the air. Her Mini-Mental State Examination score is 10/30. Results of which of the following diagnostic studies are most likely to be abnormal in th is patient?

0 A) Liver function tests

Q B) Measurement of serum vitamin B 12 (cobalamin) concentration
Q C) Serum toxicology screening
0 D) Thyroid function tests
Q E) Uri nalysis

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Exam Section: Item 3 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 50 sec

3. A 77-year-old woman is brought to the physician by her son because she recently has become unable to take care of herself or walk independently. Her son
says that her ability to function has declined during the past 4 months, but she has not had any specific complaints. She has hypertension treated with atenolol
and enalapril. Her only other medication is 81-mg aspirin. Six years ago, she had a myocardial infarction. On exam ination, her speech is confused. Her pulse is
72/min, and blood pressure is 145/86 mm Hg. Exam ination shows diffuse muscle weakness. Gait testing shows an inabi lity to ambulate. She can recall one of
three objects after 2 minutes. Results of laboratory studies are with in the reference ranges. An MRI of the brain shows mu ltiple small infarctions throughout
both cortices and a few in the thalamus. In addition to adjustments to her antihypertensive medications, adm inistration of which of the following is the most
appropriate management?

0 A) Enoxaparin

0 B) Hepari n followed by warfarin

0 C) Vitam in E

0 D) Warfarin only

0 E) No additional medication is indicated

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Exam Section: Item 4 of 50 National Board of Medical Examiners
■ Mark Clinical Neurology Self-Assessment Please Walt

The response options for the next 2 items are the same. Select one answer for each item in the set.

For each patient with a visual disturbance, select the most likely site of the lesion.

0 A) Cerebellum

0 B) Cranial nerve II

0 C) Cranial nerve Il l

0 D) Cranial nerve IV

0 E) Cranial nerve VI
Q F) Extraocular muscles
Q G) Medial longitudinal fasciculus
Q H) Neuromuscular junction

0 I) Retina

4. A 62-year-old woman is brought to the emergency department 3 hours after the onset of double vision and left eye pain that she first noted when she awoke.
She describes a horizontal separation of images, which is worse for distant as opposed to near vision. She has an 18-year history of type 2 diabetes mellitus.
Examination of the left eye shows mild adduction on primary gaze with severe weakness of abduction with conjugate gaze to the left. The remainder of the
neurologic examination shows no abnormalities.

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Exam Section: Item 5 of 50 National Board of Medical Examiners
■ Mark Clinical Neurology Self-Assessment Please Wait

For each patient with a visual disturbance, select the most likely site of the lesion.

0 A) Cerebellum

0 B) Cran ial nerve II

0 C) Cran ial nerve Il l

0 D) Cran ial nerve IV

0 E) Cran ial nerve VI

Q F) Extraocular muscles
Q G) Medial longitudinal fascicu lus
Q H) Neuromuscular junction

0 I) Retina

5. A 35-year-old man comes to the physician 1 day after the sudden onset of double vision. He describes seeing two objects side by side that are farthest apart
when he looks to the right. Exam ination shows the eyes move normally when looking to the left. When looking to the right, the left eye does not fully adduct,
and there is nystagmus in the abducting eye. The remainder of the neurologic exam ination shows no abnormalities.

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Exam Section: Item 6 of 50 National Board of Medical Examiners
■ Mark Clinical Neurology Self-Assessment Please Walt

6. A 4 ?-year-old woman with chronic alcoholism is brought to the emergency department acutely intoxicated. Other than her intoxication, physical and neurologic
examinations show no abnormalities. Which of the following complications is most likely to be prevented by immediate administration of vitamin B 1 (thiamine)?

0 A) Acute alcoholic myopathy

0 B) Anterograde amnesia

0 C) Burn ing paresthesias of the feet

0 D) Hallucinations

0 E) Seizures

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Exam Section: Item 7 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 46 sec

7. An 82-year-old woman has had a chronic bitemporal headache and diffuse achiness of the shoulders for 6 months. She has no history of serious illness and
takes no med ications. Her temperature is 37°C (98.6°F), pu lse is 80/min, respirations are 12/min, and blood pressure is 150/85 mm Hg. There is mild deformity
of the distal interphalangeal joints; range of motion is full, and there is no edema or erythema of the joints . Examination shows normal fund i. Neurologic
examination shows no focal find ings. Erythrocyte sedimentation rate is 120 mm/h. Wh ich of the following is the most likely diagnosis?

0 A) Ankylosing spondylitis

0 B) Fibromyositis

0 C) Polymyalg ia rheumatica

0 D) Polymyositis

0 E) Rheumatoid arthritis

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Exam Section: Item a of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 45 sec

8. A 57-year-old man comes to the physician because of a 1-year history of progressive difficulty hearing, especially on the right. He frequently needs to ask
people to repeat what they are saying, especially children. His partner has told him that he has been increasing the volume of their television at home. The
patient does not recall any related trauma or previous problems with his ears. For 20 years, he has managed a nig htclub that features live performances . He
has no history of serious illness. He occasionally takes aspirin, ibuprofen, or acetam inophen for headache or low back pain. There is no fam ily history of
hearing loss. His pulse is 76/min and reg ular, and blood pressure is 124/74 mm Hg. On examination, the external ear canals and tympanic membranes appear
normal. There is a small amount of cerumen in both ears. He has difficu lty hearing whispered voice bilaterally, especially on the right. A vibrating tu ning fork
placed on the forehead is heard better on the left. Air conduction is greater than bone conduction bilateral ly but clearer on the left. Which of the following is the
most likely explanation for these fi ndings?

0 A) Adverse effect of aspirin

0 B) Loss of mobility of the auditory ossicles

0 C) Meniere disease

0 D) Scarring of the tympanic membranes

0 E) Sensorineural hearing loss

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Exam Section: Item 9 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 44 sec

9. A 77-year-old man comes to the physician because of a 3-week history of low-grade fever, fatigue, severe headache, sensitivity to bright light, and pain in the
hips and shoulders. He has also had a 3.2-kg (7-lb) weight loss due to a decreased appetite during this period. He appears ill. His temperatu re is
38.2°C (100.8°F). Exam ination shows mild photophobia but no meningeal signs. There is moderate pain on palpation of the large muscle groups of the
shoulders and hips. The remainder of the examination shows no abnormalities. His hemog lobin concentration is 11.1 g/dl, leukocyte count is 11,600/mm 3 with
a normal differential, and erythrocyte sedimentation rate is 85 mm/h. Which of the following is the most appropriate next step in diagnosis?

0 A) Cerebral angiography

0 B) MRI of the brain

0 C) Lumbar puncture

0 D) Nerve and muscle biopsy

0 E) Temporal artery biopsy

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Exam Section : Item 10 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 43 sec

10. A previously healthy 42-year-old man comes to the physician because of a 1-week history of moderate back pain. The pain originates in his right buttock and
radiates down the posterior th igh and calf to the back of his foot. He has not had any changes in bladder or bowel function. He has no history of trauma to the
back. His pulse is 82/min, respirations are 16/min, and blood pressure is 132/84 mm Hg. Sensation to lig ht touch is decreased over the right posterior leg and
lateral foot. Muscle strength and deep tendon reflexes are normal. Which of the following is the most appropriate next step in management?

0 A) Myelography

0 B) Gabapentin therapy

0 C) Ibuprofen therapy

0 D) Pred nisone therapy

0 E) Nerve conduction studies

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Exam Section : Item 11 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 24 sec

11. A 4?-year-old woman is brought to the physician because of progressive loss of visual acuity
over the past 6 months. Snellen chart testi ng shows a visual acuity of 20/180. A photograph of
the optic fundus is shown. The remainder of the examination shows no abnormalities. Which
of the following is the most likely cause of these fi ndings?
Q A) Acute glaucoma
Q B) Detached reti na
Q C) Diabetic retinopathy
Q D) Macular degeneration
Q E) Optic neuritis

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Exam Section : Item 12 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 21 sec

12. A 42-year-old man, who immigrated to the USA 3 years ago, tells his physician that his hands are numb. He is being treated with isoniazid for tuberculosis.
His featu res are mildly coarsened. Examination shows widespread patches of loss of pinprick and lig ht touch sensations, especially over the tip of the nose
and the ears. The patches are oval or irregular and measure 2 to 3 cm. The common peroneal nerves feel th ickened. Which of the following is the most likely
diagnosis?

0 A) Acute intermittent porphyria

0 B) Alcoholic neuropathy

0 C) Charcot-Marie-Tooth disease

0 D) Diabetic amyotrophy

0 E) Guillain-Barre syndrome
Q F) Leprosy
Q G) Motor neu ropathy with conduction block
Q H) Paraneoplastic neuropathy

0 I) Paraproteinemic neuropathy

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Exam Section : Item 13 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 20 sec

13. A 77-year-old man is brought to the emergency department because of confusion, lethargy, and excessive sleepiness over the past 3 weeks. Three days ago,
he fell and struck his head. On arrival, he has a generalized tonic-clonic seizure that lasts 40 seconds. He has hypertension and type 2 diabetes mellitus and
has a history of frequent urinary tract infections and renal calculi. His medications include losartan, glyburide, and trimethoprim-sulfamethoxazole. He is
lethargic but easily aroused. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 190/ 105 mm Hg. Exam ination
shows an ecchymosis over the left scalp. Pupils are equally round and reactive to light. Doll's eye (oculocephalic) maneuver shows full eye movement.
Cranial nerves are intact. He moves all four extremities in response to painful stimuli. Deep tendon reflexes are absent in the upper and lower extremities.
Babinski sign is absent bilaterally. There is an occasional myoclonic jerk in the lower extremities. He is disoriented to place and time. Laboratory studies
show:
Hemoglobin 9 g/dL
Leukocyte count 7500/mm 3
Serum
Urea nitrogen 105 mg/dL
Creatinine 5.3 mg/dL
Alkaline phosphatase 150 U/L
ALT 47 U/L

Which of the following is the most likely cause of the patient's lethargy?

0 A) Hepatic failure

0 B) Pontine hematoma

0 C) Status epilepticus

0 D) Subdural hematoma

0 E) Urem ic encephalopathy

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Exam Section : Item 14 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 19 sec

14. For 10 days, a 40-year-old man has had pain in his left buttock and posterior th igh that is exacerbated by coughing or sneezing. Deep tendon reflexes are
absent at the left ankle. Passive flexion of the right hip with the knee extended produces pain in the left lower extrem ity. An x-ray and an MRI are shown.
Wh ich of the following is the most likely diagnosis?

0 A) Fracture of the pars interarticularis

Q B) Herniated nucleus pulposus
Q C) Mechanical low back strain
0 D) Metastatic carcinoma

0 E) Spinal stenosis

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Exam Section : Item 15 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 18 sec

15. A 52-year-old man comes to the physician because of a 3-month history of insomnia. He has had difficulty falling asleep because of restlessness and a
feel ing of "ants crawling inside my legs." He notes that he has to constantly move his legs to relieve the sensation. He often has to uncover his legs or hang
them over the side of the bed to get some relief. These symptoms now occur almost nightly. He has milder symptoms during the day but is generally moving
around so the sensation is not as noticeable. Physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 13.5 g/dl
Hemoglobin A 1c 5.6%
Serum ferriti n 15 ng/ml

Thyroid function tests show no abnormalities. Which of the following is the most appropriate pharmacotherapy?

0 A) lm ipram ine

0 B) Paroxetine

0 C) Ropinirole

0 D) Trazodone

0 E) Triazolam

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Exam Section : Item 16 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 16 sec

16. A 57-year-old man comes to the physician because of increasing problems with memory. He reports that he was fired from his job as an accountant recently
because he was no longer able to maintain accurate accounts. He has a 5-year history of fa cial grimacing and involuntary arm and leg spasms that have
become increasingly severe. He has hypertension treated with captopril. There is no family history of neurologic illness. The patient's father died at the age of
28 years of injuries sustained in a motor vehicle collision. The patient has never smoked cigarettes, and he does not drink alcohol or use illicit drugs. His
tem perature is 36.8°C (98.2°F), pulse is 80/min, respirations are 20/min, and blood pressure is 142/82 mm Hg. Neurologic exam ination shows frequent,
asymmetric, involuntary movements of all extrem ities that are random and jerk-like. On mental status examination, the patient recalls zero of three objects
after 5 minutes; he cannot name the current president or recall the mean ing of proverbs. An MRI of the brain is most likely to show which of the following?

0 A) Atrophy of the caudate nucleus

0 B) Atrophy of the substantia nigra

0 C) Atrophy of the thalamus

0 D) Increased T2 signal in the globus pal lidus

0 E) Increased T2 signal in the putamen

0 F) Increased T2 signal in the subthalamic nuclei

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Exam Section : Item 17 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 16 sec

17. A47-year-old woman is brought to the emergency department 1 hour after the sudden onset of headache. She says that she was walking from work to her
car when she felt an explosion in her head causing her to fall to the ground. She is not sure if she lost consciousness. Since then, she has had a severe
headache characterized by double vision and throbbing pain exacerbated by head movement. She has hypertension treated with atenolol. She has smoked
two packs of cigarettes daily for 20 years. Her pulse is 80/min, respirations are 16/min, and blood pressure is 148/82 mm Hg. Exam ination shows left ptosis.
The left pupil is 6.5 mm, and the right pupil is 4.5 mm. Upward gaze and adduction of the left eye are limited. A CT scan of the head shows diffuse
subarachnoid blood. A lumbar puncture yields grossly bloody cerebrospinal fluid. Cerebral angiography is most likely to show a saccu lar aneurysm in wh ich of
the following locations?

0 A) Basilar artery

0 B) Bifurcation of the left middle cerebral artery

0 C) Left posterior communicating artery

0 D) Origin of left anterior cerebral artery

0 E) Origin of left ophthalmic artery

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Exam Section : Item 18 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 14 sec

18. A 72-year-old woman comes to the physician because of a 4-week history of involuntary movements of her tongue and jaw. She has a 3-year history of
intermittent nausea. Medications incl ude psyllium, metoclopram ide, ranitidine, calci um carbonate, and bismuth subsalicylate. Exam ination shows licking
movements of the tongue and side-to-side movements of the jaw. There is mi ld slowness of limb movements. Wh ich of the following drugs is the most likely
cause of these findings?

0 A) Bismuth subsalicylate

0 B) Calcium carbonate

0 C) Metoclopramide

0 D) Psyllium

0 E) Ran itidine

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Exam Section : Item 19 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 14 sec

19. A 22-year-old woman, gravida 2, para 1, aborta 1, comes to the physician because of two episodes of blurred vision in the left eye and one episode of right-
sided weakness during the past 3 years. She also has had urinary urgency and frequency w ith some episodes of incontinence during this time. The first
episode of blurred vision occurred after a motor vehicle collision 3 years ago during which she sustained a fracture of her left humerus and soft-tissue
contusions. She has used an oral contraceptive for the past 2 years. She has smoked one pack of cigarettes daily for 3 years. She is of northern European
descent and has lived in the southern United States for her entire life . Vital signs are w ithin normal limits. Funduscopic examination shows mild pallor of the
left optic disc. Visual acuity is 20/80 on the left and 20/25 on the right. Neuro log ic examination shows mild rig ht hemiparesis and bilateral ataxia on
finger-nose and heel-shin testing. The remainder of the examination shows no abnormalities. An MRI of the brain shows multiple areas of increased T2 signal
in the periventricular white matter and the white matter of the cerebellum . Which of the following is the strongest pred isposing factor for th is patient's
cond ition?

0 A) Ancestry

0 B) History of spontaneous abortion

0 C) History of trauma

0 D) Residence in warm cl imate

0 E) Use of oral contraceptives

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Exam Section : Item 20 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 12 sec

20. Four days after hospitalization for internal fixation of a femoral fracture sustained in a motor vehicle col lision, a 32-year-old man becomes agitated and
disruptive. His temperature is 38°C (100.4 °F), pulse is 124/min, respirations are 24/min, and blood pressure is 180/ 100 mm Hg. He is diaphoretic and picking
at his bedsheets . Funduscopic and motor and sensory exam inations show no abnormalities. Mental status exam ination shows psychomotor agitation and
disorientation. His hematocrit is 40%, and leukocyte count is 7000/mm 3. Which of the following is the most likely diagnosis?

0 A) Cryptococcal men ing itis

0 B) Deliri um tremens

0 C) Fat embolism

0 D) Hypoglycemia

0 E) Subdural hematoma

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Exam Section : Item 21 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 11 sec

21. A 57-year-old woman with metastatic breast cancer comes to the physician for a follow-up examination. She reports that her pain is poorly controlled with her
current dosage of oral sustained-release morphine. One month ago, she reported the same problem and the dosage of morphine was increased . On
examination today, she is agitated and tearful and insists on another increase in her morphine dosage. Which of the following is the most likely explanation for
this patient's request?

0 A) Inadequate pain control

0 B) Intent to attempt suicide

0 C) Major depressive disorder

0 D) Substance abuse

0 E) Surreptitious use of morphine by fam ily

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Exam Section : Item 22 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 10 sec

22. A 62-year-old man comes to the physician because of a 9-month history of weakness in his left arm and light-headedness when he plays tennis. His left hand
and arm are cool to the touch during these episodes, and his symptoms usually resolve after 15 minutes of rest. He plays tennis for 60 minutes three times
weekly, and the episodes occur twice weekly. He is left-handed . He does not recall any trauma to his left arm and has not had any other symptoms. He
smoked one and one-half packs of cigarettes dai ly for 27 years but stopped 10 years ago. He drinks one glass of wine daily. His pulse is 78/min and regular,
and blood pressure is 150/88 mm Hg in the right arm and 136/70 mm Hg in the left arm. The lungs are clear to auscultation. S 1 and S 2 are normal. The left
radial pulse is decreased. The remainder of the exam ination, incl uding neurologic exam ination, shows no abnormalities. Which of the following is the most
appropriate next step in diagnosis?

0 A) Ambu latory ECG monitoring

0 B) Tilt test

0 C) Echocardiography

0 D) Card iac stress scintigraphy

0 E) MR ang iography

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Exam Section: Item 23 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 9 sec

23. A 35-year-old man w ith a 3-year history of dermatomyositis has had progressive weakness for 3 weeks. He had previously responded wel l to high-dose
pred nisone therapy. He appears cush ingoid; serum creatine kinase and aldolase activities are now normal. Which of the following is the most likely
diagnosis?

0 A) Corticosteroid myopathy

0 B) Hypothyroid ism

0 C) Major depressive disorder

0 D) Peripheral neuropathy

0 E) Progressive myositis

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Exam Section : Item 24 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 7 sec

24. A 72-year-old woman is brought to the physician because of increasing clum1siness, restlessness, and confusion over the past 3 weeks. She currently lives
with her daughter. She can no longer remem ber how to make coffee or button her clothes. She has urinary incontinence. Her medications incl ude digoxi n,
furosemide, potassium, ibuprofen, ranitidine, and diphenhydramine. One month ago, she began taking meperidine for a rotator cuff injury. Exam ination shows
disorientation, memory loss, and dyspraxia. A CT scan of the head shows mild cortical atrophy. Which of the following is the most appropriate next step in
management?

Q A) Discontinue anticholinerg ic medications

Q B) Discuss obtain ing durable power of attorney
Q C) EEG
Q D) Fluorescent treponemal antibody assay
0 E) Prescribe an antidepressant
Q F) Recommend 24-hour in-home nursing assistance
Q G) Suggest labeling the drawers and cabinets for contents

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Exam Section: Item 25 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 6 sec

25. A 62-year-old man is brought to the physician by his wife because of progressive behavior changes over the past 8 weeks. His initial symptoms incl uded
anxiety and fatigue that were followed by decreased memory and disorientation. Two weeks later, he developed progressive imbalance that has progressed
to the point where he is unable to walk unassisted. Over the past week, he has had brief body jerks that are precipitated by loud noises. Exam ination shows
disorientation, decreased memory, inability to walk due to marked ataxia, and stimu lus-induced myoclonus. An MRI of the brain shows generalized cerebral
atrophy. Which of the following is the most likely diagnosis?

0 A) Benzodiazepine intoxication

0 B) Creutzfeldt-Jakob disease

0 C) Dementia, Alzheimer type

0 D) Hydrocephalus

0 E) Hypothyroid ism
Q F) Multi-infarct (vascular) dementia
Q G) Prog ressive supranuclear palsy
Q H) Wern icke-Korsakoff syndrome

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Exam Section : Item 26 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 5 sec

26. A 72-year-old man is brought to the emergency department because of a decreased level of consciousness for the past 6 hours . Three days ago, he had
fever, shortness of breath, and productive cough treated with an antibiotic, but his symptoms did not improve. On arrival, his temperature is 39°C (102.2°F),
pulse is 110/min, respirations are 28/min, and blood pressure is 110/75 mm Hg. Breath sounds are decreased over the right midlung field. On neurolog ic
examination, he is unarousable but responds to tactile stimuli by moaning. Cranial nerves are intact. There is resistance to passive flexion of the neck. Which
of the following is the most likely pathogen?

0 A) Herpes simplex virus 1

0 B) Listeria monocytogenes

0 C) Pseudomonas aeruginosa

0 D) Streptococcus pneumoniae

0 E) Toxop/asma gondii

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Exam Section : Item 27 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 4 sec

27. A 37-year-old woman comes to the physician because she has stumbled several times during the past 4 days. She has also noticed intermittent numbness of
her left shin and foot. She has no history of serious illness and takes no medications. She delivered her two children after uncomplicated pregnancies
8 and 10 years ago. Vital signs are within normal limits. Muscle strength is 3/5 on dorsiflexion of the left foot. Range of motion of the hip does not produce any
symptoms. Deep tendon reflexes are normal. Sensation to pinprick is decreased over the lateral aspect of the left shin and the dorsal surface of the left foot.
The remainder of the examination shows no abnormalities. Which of the following is the most appropriate initial recommendation?

0 A) Avoiding sitting with crossed legs

0 B) Starting an exercise program

0 C) Wearing flat shoes that fit comfortably

0 D) Placi ng an orthotic pad in the left shoe

0 E) Taking nonsteroidal anti-inflammatory drugs

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Exam Section: Item 28 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 3 sec

28. An 82-year-old woman with osteoarthritis is brought to the emergency department because of a 4-day history of increasing confusion and progressive
generalized weakness. During the past 2 months, she has fallen several times; there was no loss of consciousness. She has had no difficulty sleeping.
Two weeks ago, hydrochloroth iazide and metoprolol were started for hypertension. Her temperature is 36.7°C (98°F), pulse is 68/min, and blood pressure is
140/86 mm Hg. Exam ination shows a right pronator drift. Babinski sign is present on the rig ht. She is drowsy, inattentive to questions, and gives several
inaccurate answers. Wh ich of the following is the most likely explanation for this patient's mental status changes?

0 A) Adverse effect of metoprolol

0 B) Cerebral infarction

0 C) Herpes encephalitis

0 D) Hypothyroid ism

0 E) Subdural hematoma

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Exam Section : Item 29 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 2 sec

29. A previously healthy 58-year-old man is admitted to the hospital because of three episodes of amaurosis fugax in the right eye and two episodes of temporary
weakness of the left hand and arm over the past 3 weeks. Which of the following is the most likely cause?

0 A) Occlusion of the right common carotid artery

0 B) Occlusion of the left internal carotid artery

0 C) Occlusion of the right vertebral artery

0 D) Ulcerative plaque of the basilar artery

0 E) Ulcerative plaque of the right internal carotid artery

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Exam Section : Item 30 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 45 min 1 sec

30. A previously healthy 18-year-old man is brought to the emergency department because of facial weakness and ear pain that began this morning. When he
awoke this morning, he looked in the mirror and noticed that his face appeared twisted. While he was eating breakfast, milk drooled from the left side of his
mouth. The ear pain has not been relieved by acetaminophen. Exam ination shows weakness of both the upper and lower face on the left. Sensation over the
face is normal. Which of the following is the most likely location of the abnormality?

0 A) Anterior horn cell

0 B) Muscle

0 C) Myoneural junction

0 D) Nerve

0 E) Nerve root

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Exam Section : Item 31 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 34 sec

31. A 22-year-old college student has a 4-year history of severe, throbbing, generalized headaches that occur once weekly. The headaches are preceded by a
20-minute period of seeing bright spots. Which of the following drugs is most likely to be effective in reducing the frequency of th is patient's headaches?

0 A) Anticholinergic drugs

0 B) ~-Adrenergic blocking drugs

0 C) Ergotam ine tartrate

0 D) Salicylates

0 E) Sympathom imetic drugs

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Exam Section: Item 32 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 33 sec

32. A 62-year-old woman comes to the physician because of right-sided facial pain for 3 days and a facial rash for 1 day. She describes the pain as a burning
uncomfortable feeling in her cheek. She had cold symptoms 1 week ago that have now resolved. She has hypertension treated with hydrochlorothiazide but
is otherwise healthy. She cares for her two grandchildren, ages 1 and 3 years, every weekday after school. Examination shows a vesicular rash over the face .
Neurologic exam ination shows no abnormalities. Wh ich of the following is the most appropriate measure to prevent transmission to the unvaccinated
grandchildren?

0 A) Avoid contact with the grandmother until the rash has resolved

0 B) Admin istration of varicella vaccine to the children

0 C) Acyclovir therapy for the children

0 D) Acyclovir therapy for the grandmother

0 E) No preventive measures available

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Exam Section: Item 33 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 31 sec

33 . A 17-year-old girl is brought to the emergency department 30 minutes after striking her forehead on the dashboard in a motor vehicle col lision . Exam ination
shows lethargy and confusion . A CT scan of the head shows a frontal lobe injury. Wh ich of the following is the most likely man ifestation of this injury?

0 A) Dysd iadochoki nesia

0 B) ldeomotor apraxia

0 C) Problems with conceptual planning

0 D) Prosopagnosia

0 E) Spatial disorientation

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Exam Section : Item 34 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 30 sec

34. A 57-year-old woman is brought to the physician because of a 4-week history of progressive ti ngling in her hands and fe et. She says she has also had
decreased sensation in her feet, "like I'm walking on sponges," and a painless ti ngling sensation down her back and legs when she flexes her neck. She has
not had weakness or changes in bowel and bladder function. She was diagnosed with stage Ill ovarian cancer 6 months ago and has been treated with
intravenous cisplatin and etoposide month ly. She has hypothyroidism treated with levothyroxine. Muscle strength is normal. Deep tendon reflexes are absent.
Babinski sign is absent. Sensation to vibration is decreased in the fingertips and absent below the knees, and sensation to pinprick is decreased in a stocking
distribution. Proprioception is decreased in the fingers and toes. Romberg sign is present. Her gait is slightly wide based. Coord ination is normal. Which of
the following is the most likely cause of th is patient's neurolog ic symptoms?

0 A) Gu illain-Barre syndrome

0 B) Hypothyroid ism

0 C) Meningeal carcinoma

0 D) Multiple sclerosis

0 E) Toxic neuropathy

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Exam Section: Item 35 of 50 National Board of Medical Examiners
■ Mark Clinical Neurology Self-Assessment Please Wait

35 . A 6-month-old girl is brought to the physician for a follow-up examination after two audiometry screenings showed hearing loss. She was born at term to a
27-year-old primigravid woman after an uncomplicated preg nancy. Examination of the infant today shows no abnormalities . Audiometry today shows
significant hearing loss bi laterally. Which of the following is the most likely cause of th is infant's condition?

0 A) Cytomegalovirus infection

0 B) Group B ~-streptococcal infection

0 C) Herpes simplex

0 D) Parvovirus infection

0 E) Respiratory syncytial virus

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Exam Section : Item 36 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 28 sec

36. A 57-year-old man is brought to the physician by his wife because of constant fatig ue for 2 weeks. He has consumed 1 pint of vodka daily for 30 years. He
appears drowsy. His temperature is 37°C (98.6°F), pulse is 100/m in, respirations are 20/min, and blood pressure is 120/76 mm Hg. Cardiopu lmonary
examination shows no abnormal ities. Abdominal exam ination shows severe distention with a fluid wave. Rectal examination shows hemorrhoids. Test of the
stool for occu lt blood is positive. On mental status examination, he responds to questions slowly. When asked to write his name, it is an un intellig ible scribble
compared with a clear signature on his medical chart from 1 year ago. Laboratory studies show:
Hemoglobin 12.5 g/dL
Hematocrit 39%
Leukocyte count 7000/mm 3 with a normal differential
Platelet count 200,000/mm 3
Prothrombi n time 18 sec (INR=2)
Partial thromboplastin time 40 sec
Serum
Urea nitrogen 6 mg/dL
Creatinine 0.6 mg/dL
AST 8 U/L
ALT 8 U/L

Wh ich of the following is most likely to improve this patient's mental status?

0 A) Hig h-protein, low-carbohydrate diet

0 B) Admin istration of lactulose

0 C) Infusion of fresh frozen plasma

0 D) Transfusion of packed red blood cells

0 E) Hemodialysis

0 F) Paracentesis

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Exam Section : Item 37 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 27 sec

37. A 32-year-old woman comes to the physician because of weakness of her right arm and leg that began 1 week ago when she awoke in the morning. Six days
ago, when she took a bath, she noticed that she was unable to feel the heat of the water on the left side of her body. She had a mi ld upper respiratory tract
infection 3 weeks ago. Cran ial nerves are intact. There is mild weakness of the right upper and lower extremities. Sensation to pinprick and temperature is
decreased over the left trunk and left upper and lower extremities; sensation to vibration is decreased over the right foot. Reflexes in the upper and lower
extremities are more brisk on the right than the left. Babinski sign is present on the right. Which of the following is the most likely location of th is patient's
lesion?

0 A) Brain stem

0 B) Cauda equina

0 C) Cerebral hemisphere

0 D) Cervical nerve root

0 E) Lumbar nerve root

Q F) Peripheral nerve
Q G) Spinal cord

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Exam Section : Item 38 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 26 sec

38 . A 72-year-old man w ith a 3-year history of Parkinson disease is brought to the physician by his wife for a follow-up examination . Three weeks ago, his dosage
of carbidopa-levodopa was increased . Since then, he has reported seeing people spying on him from across the street. He has no other history of serious
medical or psych iatric illness and takes no other medications. Physical examination shows a resti ng tremor. There is cogwheel rigidity and increased muscle
tone. On mental status examination, he reports seeing people spying on him and says his wife is "one of them ." Addition of which of the following med ications
is the most appropriate next step in pharmacotherapy?

0 A) Haloperidol

0 B) Lorazepam

0 C) Paroxetine

0 D) Quetiapine

0 E) Valproic acid

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Exam Section: Item 39 of 50 National Board of Medical Examiners
■ Mark Clinical Neurology Self-Assessment Please Walt

39. A 72-year-old woman is brought to the physician by her son because of a 1-month history of progressive forgetfulness. During th is period, she has misplaced
her keys and checkbook, and she forgot that she was supposed to meet him for lunch last week. The patient says that she has had progressive fatigue
because of recent difficulty staying asleep at night. She often awakens at 4 or 5 am and is unable to fall back asleep. She takes zolpidem once or twice
weekly to help her sleep, but she has taken it nig htly for the past 2 weeks. She also has had a 4.5-kg (10-lb) weight loss and says that nothing tastes good
anymore. She has a 10-year history of esophageal reflux disease treated with lansoprazole and a 2-year history of arthritis treated with acetam inophen. She
was an English professor at a prom inent university until 1 year ago when she was requi red to retire by university regulations. She maintained an active
schedule of lecturing and writing until 2 months ago. Her hair is unwashed, and she has a mild body odor. She is 168 cm (5 ft 6 in) tall and weighs
50 kg (110 lb); BMI is 18 kg/m 2. Her pulse is 72/min, and blood pressure is 125/70 mm Hg. On mental status examination, she appears distracted and
worried. She says that her mood is "okay." Her speech is slow and monotone, and she answers with single words. She is alert and oriented to person, place,
and time. Her digit span is 6 forward and 2 backward. She can recall zero of three objects after 5 minutes. She refuses to perform simple change calculations
or name past presidents. Which of the following is the most likely diagnosis?

0 A) Adjustment disorder with depressed mood

0 B) Deliri um

0 C) Dementia, Alzheimer type

0 D) Dysthymic disorder

0 E) Major depressive disorder

Q F) Parkinson disease
Q G) Substance-induced persisting amnestic disorder

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Exam Section : Item 40 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 24 sec

40. A 77-year-old man w ith Parkinson disease is brought to the physician by his wife because of a 3-month history of unusual behavior at night. She says that he
yel ls in his sleep and waves his arms as if defending himself. Two nig hts ago, he bit her and tried to push her out of the bed. Current med ications include
carbidopa-levodopa. Examination shows little facial expression, a pill-rolling tremor of both hands, and muscle rigidity. Which of the following is the most
appropriate next step in diagnosis?

0 A) Multiple sleep latency testi ng

0 B) Overnight pulse oximetry testing

0 C) Polysom nog raphy

0 D) Sleeping and waking EEG

0 E) Wrist actigraphy

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Exam Section : Item 41 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 23 sec

41. A 42-year-old woman is brought to the emergency department by her girlfriend 15 minutes after several episodes of staring and blinking whi le eating dinner.
The patient has a history of bipolar disorder wel l control led with daily bupropion and lithium carbonate for the past 5 years. She started taking terbinafine
2 weeks ago for chron ic toenail fung us. During the examination, she is conversant. Her pulse is 64/min, respirations are 16/min, and blood pressure is 140/90
mm Hg. A normal rhythm is heard on cardiac examination. Neurologic examination shows no focal fi ndings. Which of the following is the most likely
explanation for this patient's symptoms?

0 A) Cataton ic episode

0 B) Glioblastoma multiforme

0 C) Rapid cycling bipolar disorder

0 D) Seizure activity

0 E) Transient ischemic attack

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Exam Section : Item 42 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 22 sec

42. A 27-year-old man who is HIV positive comes to the physician because of left arm clumsiness for 1 week. His CD4+ T-lymphocyte count was 78/mm 3
(Normal~500) 8 weeks ago. Medications include zidovudine (AZT), didanosine, ritonavir, and azithromycin. He appears well. His temperature is 37.2°C
(99°F), pulse is 96/min, and respirations are 16/min. Examination shows weakness of the left upper extremity. A CT scan of the head with contrast shows a
ring-enhancing lesion in the right parietal cortex. Which of the following is the most appropriate next step in management?

0 A) Intravenous methylprednisolone therapy

0 B) Oral dapsonetherapy

0 C) Oral sulfadiazine-pyrimethamine therapy

0 D) Oral trimethoprim-sulfamethoxazole therapy

0 E) Lumbar puncture

0 F) Brain biopsy

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Exam Section : Item 43 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 21 sec

43. A previously healthy 32-year-old woman had the acute onset of severe headache followed by somnolence 2 hours ago. Her temperatu re is 38.3°C (101°F),
pulse is 96/min, and blood pressure is 140/92 mm Hg. She is lethargic but oriented and answers questions appropriately. A CT scan of the head shows no
abnormalities except for small ventricles. Laboratory stud ies show:
Serum glucose 90 mg/dL
Cerebrospinal fluid
Color pink
Opening pressure 25 mm H20
Glucose 53 mg/dL
Protein 85 mg/dL
RBC 4000/mm 3
WBC 10/mm 3
Segmented neutrophils 65%
Lymphocytes 35%

Wh ich of the following is the most likely diagnosis?

Q A) Cryptococcal men ing itis

0 B) Enterovirus infection

0 C) Idiopathic intracranial hypertension

0 D) Subarachnoid hemorrhage

0 E) West Nile encephalitis

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Exam Section : Item 44 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 20 sec

44. A 62-year-old woman with metastatic breast cancer is brought to the emergency department because of uri nary incontinence for 24 hours. She has
metastases to the skull, mu ltiple vertebral bodies, ribs, liver, and para-aortic lymph nodes. Medications incl ude tamoxifen, sustained-release morphine, stool
softeners, and fluoxetine. Her tem peratu re is 36. ?°C (98.1 °F), pulse is 84/min, respirations are 14/min, and blood pressure is 128/76 mm Hg. Examination
shows a large suprapubic mass. There is sign ificant pain over the entire lumbar spine on fist percussion. Rectal examination shows decreased sphincter
tone. Wh ich of the following is the most likely cause of the incontinence?

0 A) Anticholinergic effects of fluoxetine

0 B) Hypercalcemia

0 C) Metastases to the bladder

0 D) Metastases to the cauda equina

0 E) Ureth ral spasm

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Exam Section: Item 45 of 50 National Board of Medical Examiners
■ Mark Clinical Neurology Self-Assessment Please Walt

45. A 52-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure . Her husband reports that
she has had a headache and has seemed confused over the past 3 days. She was schedu led to be evaluated by a pulmonolog ist later th is week for the
recent onset of mild hemoptysis. She smoked two packs of cigarettes dai ly for 30 years but quit 5 years ago . She has a 5-year history of type 2 diabetes
mel litus controlled by diet. On arrival, she is postictal. Her temperatu re is 37°C (98.6°F), and blood pressure is 110/60 mm Hg. She is minimally responsive to
painful stimu li. Cardiopu lmonary examination shows no abnormalities. There is no peripheral edema . There are no focal neurologic deficits. Laboratory
studies show:
Serum
Na+ 112 mEq/L
Glucose 150 mg/dl
Creatin ine 0.7 mg/dl
Cholesterol 230 mg/dl
Osmolality 238 mOsmol/kg
Uri ne
Glucose trace
Protein none
RBC 1- 3/hpf
WBC 1- 3/hpf
Osmolality 240 mOsmol/kg
Na+ 25 mEq/L

Wh ich of the following is the most likely diagnosis?

0 A) Bacterial pneumon ia 0 H) lntracranial neoplasm

0 B) Cirrhosis of the liver 0 I) Meningitis

0 C) Decreased solute intake 0 J) Nephrotic syndrome

0 D) Dehydration 0 K) Pseudohyponatrem ia

0 E) Glucocorticoid deficiency Q L) Psychogenic polyd ipsia

Q F) Hyperglycem ia Q M) Renal failure
Q G) Inappropriate secretion of AD H (vasopressin)

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Exam Section : Item 46 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 17 sec

46. A 3-week-old male newborn is brought to the emergency department by his parents because of a 1-day history of increased fussiness and drowsiness.
En route to the emergency department, he had rhythmic jerking movements of all extremities. His mother received minimal prenatal care and was treated for
gonorrheal cervicitis during pregnancy; her Streptococcus aga/actiae (group B) status was unknown . He was born at 38 weeks' gestation. Exam ination at
birth showed no abnormal ities. Today, he is irritable and responds only to painful stimulation. His temperature is 39°C (102.2°F), pulse is 160/min, and
respirations are 32/min. Examination shows no conjunctivitis or cutaneous lesions. The lungs are clear to auscultation. A lumbar puncture is performed, and
cerebrospinal fluid analysis shows:
Glucose 60 mg/dl
Total protein 100 mg/dl
WBC 300/mm 3
RBC 5000/mm 3
Gram stain
WBC 2+
Organisms none

In addition to ceftriaxone and vancomycin , wh ich of the following is the most appropriate pharmacotherapy?

Q A ) Acyclovir
0 B) Dexamethasone

0 C) Ganciclovir

0 D) Ribavirin

0 E) Zidovudine

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Exam Section : Item 47 of 50 National Board of Medical Examiners
■ Mark Clinical Neurology Self-Assessment Please Walt

47. An otherwise healthy 62-year-old man is brought to the emergency department 45 minutes after an episode of loss of consciousness while shaving. Prior to
the episode, he had light-headedness, nausea, and dimming of vision. His wife states that he was unconscious for about 1 minute and lost control of bladder
function. She did not notice any movement during the episode. He had a simi lar episode 1 month ago while shaving. At that time, echocardiography, 24-hour
ambulatory ECG monitoring, and a ti lt test showed no abnormalities; card iac enzyme activities were within the reference range. His current blood pressure is
150/96 mm Hg. A grade 2/6, systolic ejection murmur is heard best at the upper left sternal border. The remainder of the examination shows no abnormalities.
Wh ich of the following is the most likely diagnosis?

0 A) Absence seizure

0 B) Aortic stenosis

0 C) Carotid sinus hypersensitivity

0 D) Generalized tonic-clonic seizure

0 E) Neurocardiogenic (vasovagal) syncope

0 F) Transient ischemic attack

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Exam Section : Item 48 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 15 sec

48. A 32-year-old man is brought to the physician because of a 10-month history of difficu lty walking and decreased grip strength and stiffness of his hands that
are interfering w ith his job as a plum ber. He has no history of serious illness. There is frontal balding. Cran ial nerve exam ination shows bilateral ptosis and
atrophy of the sternocleidomastoid and temporalis muscles. There is distal intrinsic musculature weakness of the hand and bilateral weakness on ankle
dorsiflexion. Percussion of the hypothenar muscles results in slow relaxation. Sensation is intact. Which of the following is the most likely diagnosis?

0 A) Amyotroph ic lateral sclerosis

0 B) Facioscapulohumeral muscular dystrophy

0 C) Myasthenia gravis

0 D) Myotonic dystrophy

0 E) Spinal muscular atrophy

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Exam Section : Item 49 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 14 sec

49. A 57-year-old woman comes to the physician because of persistent numbness of the back of her rig ht hand for 2 weeks. Her symptoms began after operative
treatment of a distal rad ial fracture. Sensation to pinprick is decreased over the dorsal first web, th umb, and index finger. There is no motor deficit. Which of
the following is the most likely site of nerve injury?

0 A) Axillary nerve 0 I) Rad ial nerve above the elbow

0 B) Long thoracic nerve 0 J) Rad ial nerve at the elbow

0 C) Median nerve above the elbow 0 K) Rad ial nerve at the distal forearm

0 D) Median nerve at the elbow Q L) Suprascapu lar nerve

0 E) Median nerve at the wrist Q M) Thoracodorsal nerve

Q F) Musculocutaneous nerve above the elbow Q N) Ulnar nerve above the elbow
Q G) Musculocutaneous nerve at the elbow 0 0) Ulnar nerve at the elbow
Q H) Musculocutaneous nerve at the wrist Q P) Ulnar nerve at the wrist

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Exam Section : Item 50 of 50 National Board of Medical Examiners Time Remaining:
■ Mark Clinical Neurology Self-Assessment 4 hr 44 min 13 sec

50. A 62-year-old woman is brought to the emergency department because of a 3-day history of progressive weakness and numbness. These symptoms first
occurred in her feet and have spread to incl ude her chest. She also has had difficulty emptying her bladder completely. She has moderate midback pain that
began 1 month ago and now rad iates to her chest; it is exacerbated when she coughs. One year ago, she had breast cancer and underwent lumpectomy
followed by radiation and chemotherapy. Her only medication is tamoxifen. Vital signs are within normal limits. Muscle strength is 5/5 in the upper extremities
and 4/5 in the lower extremities with increased tone. Deep tendon reflexes are 2+ in the upper extremities and 4+ in the lower extremities. Babinski sign is
present bilaterally. Sensation to pinprick is decreased below the T4 level. Which of the following is the most likely diagnosis?

0 A) Epid ural spinal cord compression

0 B) Guillain-Barre syndrome

0 C) Leptomen ingeal carcinomatosis

0 D) Paraneoplastic myelopathy

0 E) Transverse myelitis

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