11.

A 65-year-old, obese, white female comes to the office for the evaluation of her progressively
worsening memory. She considers herself "very independent," and lives alone; however, the
development of her new symptoms is causing her some distress, as she often forgets to pay her bills. A
detailed review of systems reveals no other symptoms, except for mild urinary incontinence. She has
hypertension controlled with a beta-blocker and type 2 diabetes mellitus controlled with diet. She does
not use tobacco, alcohol or drugs. Her blood pressure is 130/90 mmHg, pulse is 72/min, temperature is
36.7C (98F) and respirations are 14/min. Lungs are clear to auscultation and percussion. A grade 2/6,
systolic ejection murmur is heard. Abdominal examination shows no tenderness or masses.
Neurological examination shows broad-based, shuffling gait and a right-sided carotid bruit. Complete
blood count and serum chemistry panel are within normal limits MRI shows enlarged ventricles. What
is the most likely diagnosis?
A. Parkinsonism
B. Normal pressure hydrocephalus@
C. Multi-infarct dementia
D. Pick's disease
E. Alzheimer's disease

24. A 70-year-old retired engineer is brought to the office by his son for a routine check-up. He believes
that his son is too greedy and wants all his property. He is accusing his son of "kicking him out of the
house to get all of his property." He has been getting more forgetful over the past few years. His younger
sibling has the same problem. He has no significant past medical history, except a history of smoking
for 6 years when he was young. His blood pressure is 138/78 mm Hg, pulse is 86/min, respirations are
14/min and temperature is 37.0 C (98.6F). He cannot remember current events, such as the name of the
current American president; however, he can still remember past political history. He is unable to
concentrate, but is oriented to time, place and person. The neurological examination is nonfocal. CT
scan reveals mild generalized atrophy. His HIV and RPR tests are negative. The serum electrolytes and
thyroid function tests are normal. What is the most likely diagnosis of this patient?
A Lewy body dementia
B. Alzheimer's dementia@
C. Multi Infarct dementia
D. Neurosyphilis
E. Pick's disease

32. A 72-year-old woman complains of difficulty "finding the right word" when she is speaking. Her
daughter notes that she also frequently complains that her neighbor is stealing her newspapers when
this is not the case in actuality. Recently, the patient has been having difficulty balancing her checkbook
as well. On physical examination, her blood pressure is 160/100 mmHg and her heart rate
is 90/min. The exam is otherwise unremarkable. Over the course of the next three years, the patient
develops a severe memory deficit, and suffers from poor sleep, slowness of movement, shuffling gait
and urinary incontinence. Which of the following is the most likely diagnosis?
A. Alzheimer's dementia@
B. Dementia with Lewy bodies
C. Multiinfarct dementia
D. Vitamin B 12 deficiency
E. Normal pressure hydrocephalus

73. A 67-year-old woman is being evaluated for periodic confusion, insomnia, and frequent falls as well
as episodes of decreased alertness and visual hallucinations. On physical examination, she has increased
lower extremity muscle tone but downgoing Babinski reflexes bilaterally. Which of the following
pathologic findings most likely underlies her condition?
A Neurofibrillary tangle
B. Lewy bodies@
C. Impaired CSF absorption
D. Multiple lacunar strokes
E. Corticospinal tract demyelinization

133. A 66-year-old female is brought to the office by her concerned son due to increasing confusion,
loss of mobility and stiff limbs. She tends to cry out for no reason. She often screams and sees, "a lion
roaring in the backyard." She often sees cats in her room, even though her son does not see any. She
has significant memory loss. She never had "joint problems" before. She was previously treated with
haloperidol, but this only aggravated her rigidity. She is a non-smoker. She has no significant past
psychiatric history. In the office, she appears alert, but disoriented and quite agitated. Her blood pressure
is 136/72 mm Hg, pulse is 98/min, and respirations are 16/min. Physical examination reveals impaired
visuospatial abilities, increased tone, normal reflexes, and coarse resting tremors in the extremities. Her
CBC, electrolytes, creatinine, glucose, LFTs, TSH and B 12 levels are within normal range. The
serology for syphilis is negative. What is the most likely diagnosis?
A Lewy body dementia@
B. Alzheimer's disease
C. Multi infarct dementia
D. Neurosyphilis
E. Pick's disease

85. A 67-year-old Asian male comes to the clinic for the first time. He walks very slowly as he enters
the room. His chief complaint is "extreme forgetfulness" for the past 6 months. He tearfully shares that
he has been "losing sleep." He used to be a very "bright and sharp" person, but is now unable to focus
on his daily activities and feels "really extremely low and useless." His past medical history is
significant for hypertension, hypercholesterolemia, diabetes, benign prostatic hyperplasia, and TIA. His
family history is insignificant, except for Alzheimer's dementia in his father. He does not smoke, and
drinks wine only occasionally. He has been living alone for the last 6 months, after his son moved out.
His physical exam is normal, except for markedly slow movements. A CT scan of the head is normal.
Which of the following is the most likely diagnosis?
A. Parkinson's disease
B. Vascular dementia
C. Alzheimer's dementia
D. Pseudodementia@
E. Normal aging

103. A 76-year-old woman presents for a routine medical check-up. Her medical history is significant
for hypertension, type 2 diabetes mellitus, and hypothyroidism that are controlled with oral agents. She
had a stroke one year ago and has mild residual right arm weakness. Otherwise she has no physical
complaints. She is widowed and lives alone. Regarding her memory, she sometimes forgets to return
phone calls and take her blood pressure pills. Occasionally during conversations, she has difficulties
finding the right word. She drives herself to the grocery market weekly to do her shopping, and has no
difficulty managing her finances. She describes her mood as good. She visits her close friends on
occasion and often has difficulty falling asleep. Her blood pressure is 135/76 mmHg and her heart rate
is 65/min. Finger stick glucose and TSH levels are normal. Which of the following is the most likely
diagnosis in this patient?
A. Alzheimer's dementia
B. Depression
C. Normal pressure hydrocephalus
D. Frontotemporal dementia
E. Normal aging@
105. A 59-year-old man is brought to the office by his family due to attitude problems over the last
year. He has a history of memory loss and word-finding problems. He has lost interest in golf, which
used to be one of his favorite sports. Recently, he has become promiscuous and has started using "dirty
language," which he has never used before. He is a non-smoker. He has no significant past medical or
surgical history. His uncle had similar features, for which he was admitted into a nursing home, but
died soon after admission. The physical examination reveals intact visuospatial functions, intact cranial
nerves, and prominent snout and grasp reflexes. What is the most likely diagnosis?
A Lewy body dementia
B. Alzheimer's disease
C. Multi-infarct dementia
D. Neurosyphilis
E. Pick's disease@

46. A 30-year-old, HIV-positive male, presents with left-sided paralysis of recent onset. His temperature
is 37.1 C (98.9F), pulse is 78/min, blood pressure is 130/80, and respirations are 16/min. The
neurological examination reveals loss of recent memory, expressive aphasia, hyperreflexia, hypertonia,
and up going plantars on the left side. His current medications include zidovudine, didanosine, indinavir
and trimethoprim-sulfamethoxazole. His CD4 count is 70/dl and viral load is 90,000 copies/ml by PCR.
The serology is positive for Toxoplasma. CT scan shows multiple, hypodense, non-enhancing lesions
with no mass effect in the cerebral white matter. What is the most likely diagnosis?
A. Cerebral toxoplasmosis
B. Primary CNS lymphoma
C.Progressive multifocal leukoencephalopathy@
D. AIDS dementia complex
E. Subacute sclerosing panencephalitis

71. A 25-year-old, HIV-positive male presents to the office with an altered mental status. He is
disoriented, lethargic, and has loss of recent memory. These symptoms have been present for the last
month. His current medications include zidovudine, didanosine, indinavir, trimethoprim-
sulfamethoxazole and azithromycin. His temperature is 37.7C (99.8F), pulse is 78/min, blood pressure
is 130/80mm Hg, and respirations are 16/min. The neurological examination is non-focal. His CD4
count is 40/microl and viral load is 25,000 copies/ml by PCR. MRI scan reveals a solitary, irregular,
weakly ring-enhancing mass in the periventricular area. The serology for Toxoplasma is positive. PCR
of CSF shows EBV DNA. What is the most likely diagnosis?
A. Cerebral toxoplasmosis
B. Primary CNS lymphoma@
C. Progressive multifocal leukoencephalopathy
D. AIDS dementia complex
E. Bacterial abscess