BCPS: Neurology Exam Questions With
Answers 100% Correct
T.L. is a 35-year-old man with focal seizures with impaired awarness . He is otherwise
healthy. He was given phenytoin after a seizure about 2 months ago. He currently takes
phenytoin 100 mg (3 capsules) orally every night. During his clinic visit, he continues to
have seizures, and he has no signs of toxicity. He is allergic to sulfa drugs. His phenytoin
serum concentration is 11.2 mcg/mL. What is the best new phenytoin dose for this
patient?
A. 300 mg/day.
B. 350 mg/day.
C. 400 mg/day.
D. 260 mg/day. - ANSWER B. 350 mg/day
The therapeutic range for phenytoin is 10-20 mcg/mL. The patient continues to have
seizures and is not complaining of dose-related adverse effects, so a dose adjustment is
recommended making Answer A incorrect. Phenytoin follows zero-order
pharmacokinetics, resulting in the need for caution in dose adjustments. With a
concentration between 7 and 12 mg/L, a dose adjustment of 50 mg/day is appropriate
(Answer B is correct). Answer C would result in too large of increase in serum
concentrations due to zero-order pharmacokinetics. Answer D is a reduction in dose,
which will likely make seizures worse.
B.V. is a 28-year-old woman brought to your emergency department for treatment of
status epilepticus. She receives lorazepam 4 mg intravenously with subsequent seizure
cessation. What medication is the best next treatment step for B.V.?
A. Topiramate.
B. Levetiracetam.
C. Zonisamide.
D. Clobazam. - ANSWER B. Levetiracetam
In general, medications to treat status epilepticus should be in parenteral formulation to
,facilitate rapid administration. Once the seizures of status epilepticus have been
stopped, a second, long-acting drug should be initiated to prevent seizure recurrence.
Levetiracetam is well tolerated, shows good efficacy as monotherapy, and has less risk
of teratogenicity (Answer B is correct). Topiramate (Answer A) and zonisamide (Answer
C) are possibilities, but have a greater risk of adverse effects and may be associated
with higher risk of birth defects. Clobazam (Answer D) is indicated only for
Lennox-Gastaut syndrome, which would be an unlikely diagnosis for this patient
J.H. is a 42-year-old man with focal seizures with impaired awareness for which he was
prescribed topiramate. He has been increasing the topiramate dose every other day,
according to instructions from his primary care provider. He comes to the pharmacy
where you work, but seems a little confused and has difficulty finding the words to have
a conversation with you. What is the best assessment of J.H.'s condition?
A. Discontinue topiramate; he is having an allergic reaction.
B. Increase the topiramate dose; he is having partial seizures.
C. Slow the rate of topiramate titration; he is having psychomotor slowing.
D. Get a topiramate serum concentration; he is probably supratherapeutic. - ANSWER
C. Slow the rate of topiramate titration; he is having psychomotor slowing.
Psychomotor slowing is a troublesome adverse effect for many patients who start
topiramate (Answer C is correct). It usually manifests as difficulty concentrating,
difficulty thinking, word-finding difficulties, and a feeling of slowness of movement. The
usual dose titration for topiramate calls for increasing the dose every week. This patient
has been increasing the topiramate dose every other day. Because psychomotor
slowing is related to the speed of titration, this makes slowing the titration rate the most
probable answer. Partial seizures could present as confusion; however, they are
unlikely to be a continuous condition (Answer B is incorrect). Allergic reactions would
usually involve rash (Answer A is incorrect). Psychomotor slowing in this situation is
more related to speed of titration rather than supratherapeutic concentrations (Answer
D is incorrect).
R.H. is a 62-year-old man who presents to the emergency department for new-onset
right-sided weakness and slurred speech that began 6 hours ago. He has a history of
hypertension and coronary artery disease. His medication list includes atenolol 50
mg/day orally, hydrochlorothiazide 25 mg/day orally, and aspirin Neurology ACCP
Updates in Therapeutics® 2018: Pharmacotherapy Preparatory Review and
Recertification Course 1-89 81 mg/day orally. His vital signs include blood pressure (BP)
160/92 mm Hg, heart rate 92 beats/minute, respiratory rate 14 breaths/minute, and
,temperature 38°C. The ED physician asks for your opinion on treatment options.
Which reply is best, given this information?
A. R.H. should be treated with alteplase.
B. R.H. should be treated with aspirin 81 mg/day
C. R.H. should be treated with clopidogrel 300 mg as a loading dose and then 75 mg/day
with aspirin 81 mg/day for 90 days.
D. R.H. should b - ANSWER C. R.H. should be treated with clopidogrel 300 mg as a
loading dose and then 75 mg/day with aspirin 81 mg/day for 90 days.
Patients who can be treated within 4.5 hours of stroke symptom onset should be
considered for alteplase, making Answer A incorrect due to the time since onset of
symptoms. Recent studies indicate that dual antiplatelet therapy with aspirin and
clopidogrel for 90 days is more effective than either drug alone in preventing additional
strokes (Answer C is correct). Aspirin alone is less effective than dual antiplatelet
therapy (Answer B is incorrect). Aspirin/dipyridamole has not been extensively studied
in this situation (Answer D is incorrect).
R.H. is a 62-year-old man who presents to the emergency department for new-onset
right-sided weakness and slurred speech that began 6 hours ago. He has a history of
hypertension and coronary artery disease. His medication list includes atenolol 50
mg/day orally, hydrochlorothiazide 25 mg/day orally, and aspirin Neurology ACCP
Updates in Therapeutics® 2018: Pharmacotherapy Preparatory Review and
Recertification Course 1-89 81 mg/day orally. His vital signs include blood pressure (BP)
160/92 mm Hg, heart rate 92 beats/minute, respiratory rate 14 breaths/minute, and
temperature 38°C. The ED physician asks for your opinion on treatment options.
R.H. is treated appropriately and survives his stroke. As part of his discharge treatment
plan from rehabilitation 3 months later, you evaluate his risk factors for a second stroke.
Which medication for secondary stroke prevention is best to initiate?
A. Dipyridamole.
B. Aspirin - ANSWER D. Clopidogrel.
All stroke survivors need secondary stroke prevention drugs. If a patient claims to be
, adherent to aspirin when his first stroke occurred, a different drug is usually
considered. Clopidogrel is more effective than aspirin, making Answer D correct and
Answer B incorrect. Dipyridamole alone is not effective for secondary stroke prevention
(Answer A is incorrect). Warfarin is reserved for patients with atrial fibrillation (Answer
C is incorrect).
C.P. is a 69-year-old man given a diagnosis of Parkinson disease 7 years ago. He states
that he is most bothered by his bradykinesia symptoms. On examination, he also has a
pronounced tremor, postural instability, and masked facial expression. He currently
takes carbidopa/levodopa/entacapone 25 mg/100 mg/200 mg orally four times daily,
ropinirole 1 mg orally three times daily, and selegiline 5 mg orally twice daily. He has no
drug allergies. He also describes a worsening of his Parkinson disease symptoms,
which fluctuate randomly during the day. He has developed a charting system for his
symptoms during the day, and no relationship seems to exist with the time he is
scheduled to take his carbidopa/levodopa/entacapone doses.
Which condition best describes C.P.'s fluctuating Parkinson disease symptoms?
A. Wearing-off.
B. On-off.
C. Dyskinesia.
D. Dystonia. - ANSWER B. On-off.
Wearing off is the return of symptoms before the next dose (Answer A is incorrect). It
has a definite pattern, whereas on-off is unpredictable, consistent with the description
provided by this patient (Answer B is correct). Dyskinesias (Answer C) and dystonias
(Answer D) are long-term adverse effects of carbidopa/levodopa, and are not consistent
with the description provided.
C.P. is a 69-year-old man given a diagnosis of Parkinson disease 7 years ago. He states
that he is most bothered by his bradykinesia symptoms. On examination, he also has a
pronounced tremor, postural instability, and masked facial expression. He currently
takes carbidopa/levodopa/entacapone 25 mg/100 mg/200 mg orally four times daily,
ropinirole 1 mg orally three times daily, and selegiline 5 mg orally twice daily. He has no
drug allergies. He also describes a worsening of his Parkinson disease symptoms,
which fluctuate randomly during the day. He has developed a charting system for his
symptoms during the day, and no relationship seems to exist with the time he is
scheduled to take his carbidopa/levodopa/entacapone doses.
Answers 100% Correct
T.L. is a 35-year-old man with focal seizures with impaired awarness . He is otherwise
healthy. He was given phenytoin after a seizure about 2 months ago. He currently takes
phenytoin 100 mg (3 capsules) orally every night. During his clinic visit, he continues to
have seizures, and he has no signs of toxicity. He is allergic to sulfa drugs. His phenytoin
serum concentration is 11.2 mcg/mL. What is the best new phenytoin dose for this
patient?
A. 300 mg/day.
B. 350 mg/day.
C. 400 mg/day.
D. 260 mg/day. - ANSWER B. 350 mg/day
The therapeutic range for phenytoin is 10-20 mcg/mL. The patient continues to have
seizures and is not complaining of dose-related adverse effects, so a dose adjustment is
recommended making Answer A incorrect. Phenytoin follows zero-order
pharmacokinetics, resulting in the need for caution in dose adjustments. With a
concentration between 7 and 12 mg/L, a dose adjustment of 50 mg/day is appropriate
(Answer B is correct). Answer C would result in too large of increase in serum
concentrations due to zero-order pharmacokinetics. Answer D is a reduction in dose,
which will likely make seizures worse.
B.V. is a 28-year-old woman brought to your emergency department for treatment of
status epilepticus. She receives lorazepam 4 mg intravenously with subsequent seizure
cessation. What medication is the best next treatment step for B.V.?
A. Topiramate.
B. Levetiracetam.
C. Zonisamide.
D. Clobazam. - ANSWER B. Levetiracetam
In general, medications to treat status epilepticus should be in parenteral formulation to
,facilitate rapid administration. Once the seizures of status epilepticus have been
stopped, a second, long-acting drug should be initiated to prevent seizure recurrence.
Levetiracetam is well tolerated, shows good efficacy as monotherapy, and has less risk
of teratogenicity (Answer B is correct). Topiramate (Answer A) and zonisamide (Answer
C) are possibilities, but have a greater risk of adverse effects and may be associated
with higher risk of birth defects. Clobazam (Answer D) is indicated only for
Lennox-Gastaut syndrome, which would be an unlikely diagnosis for this patient
J.H. is a 42-year-old man with focal seizures with impaired awareness for which he was
prescribed topiramate. He has been increasing the topiramate dose every other day,
according to instructions from his primary care provider. He comes to the pharmacy
where you work, but seems a little confused and has difficulty finding the words to have
a conversation with you. What is the best assessment of J.H.'s condition?
A. Discontinue topiramate; he is having an allergic reaction.
B. Increase the topiramate dose; he is having partial seizures.
C. Slow the rate of topiramate titration; he is having psychomotor slowing.
D. Get a topiramate serum concentration; he is probably supratherapeutic. - ANSWER
C. Slow the rate of topiramate titration; he is having psychomotor slowing.
Psychomotor slowing is a troublesome adverse effect for many patients who start
topiramate (Answer C is correct). It usually manifests as difficulty concentrating,
difficulty thinking, word-finding difficulties, and a feeling of slowness of movement. The
usual dose titration for topiramate calls for increasing the dose every week. This patient
has been increasing the topiramate dose every other day. Because psychomotor
slowing is related to the speed of titration, this makes slowing the titration rate the most
probable answer. Partial seizures could present as confusion; however, they are
unlikely to be a continuous condition (Answer B is incorrect). Allergic reactions would
usually involve rash (Answer A is incorrect). Psychomotor slowing in this situation is
more related to speed of titration rather than supratherapeutic concentrations (Answer
D is incorrect).
R.H. is a 62-year-old man who presents to the emergency department for new-onset
right-sided weakness and slurred speech that began 6 hours ago. He has a history of
hypertension and coronary artery disease. His medication list includes atenolol 50
mg/day orally, hydrochlorothiazide 25 mg/day orally, and aspirin Neurology ACCP
Updates in Therapeutics® 2018: Pharmacotherapy Preparatory Review and
Recertification Course 1-89 81 mg/day orally. His vital signs include blood pressure (BP)
160/92 mm Hg, heart rate 92 beats/minute, respiratory rate 14 breaths/minute, and
,temperature 38°C. The ED physician asks for your opinion on treatment options.
Which reply is best, given this information?
A. R.H. should be treated with alteplase.
B. R.H. should be treated with aspirin 81 mg/day
C. R.H. should be treated with clopidogrel 300 mg as a loading dose and then 75 mg/day
with aspirin 81 mg/day for 90 days.
D. R.H. should b - ANSWER C. R.H. should be treated with clopidogrel 300 mg as a
loading dose and then 75 mg/day with aspirin 81 mg/day for 90 days.
Patients who can be treated within 4.5 hours of stroke symptom onset should be
considered for alteplase, making Answer A incorrect due to the time since onset of
symptoms. Recent studies indicate that dual antiplatelet therapy with aspirin and
clopidogrel for 90 days is more effective than either drug alone in preventing additional
strokes (Answer C is correct). Aspirin alone is less effective than dual antiplatelet
therapy (Answer B is incorrect). Aspirin/dipyridamole has not been extensively studied
in this situation (Answer D is incorrect).
R.H. is a 62-year-old man who presents to the emergency department for new-onset
right-sided weakness and slurred speech that began 6 hours ago. He has a history of
hypertension and coronary artery disease. His medication list includes atenolol 50
mg/day orally, hydrochlorothiazide 25 mg/day orally, and aspirin Neurology ACCP
Updates in Therapeutics® 2018: Pharmacotherapy Preparatory Review and
Recertification Course 1-89 81 mg/day orally. His vital signs include blood pressure (BP)
160/92 mm Hg, heart rate 92 beats/minute, respiratory rate 14 breaths/minute, and
temperature 38°C. The ED physician asks for your opinion on treatment options.
R.H. is treated appropriately and survives his stroke. As part of his discharge treatment
plan from rehabilitation 3 months later, you evaluate his risk factors for a second stroke.
Which medication for secondary stroke prevention is best to initiate?
A. Dipyridamole.
B. Aspirin - ANSWER D. Clopidogrel.
All stroke survivors need secondary stroke prevention drugs. If a patient claims to be
, adherent to aspirin when his first stroke occurred, a different drug is usually
considered. Clopidogrel is more effective than aspirin, making Answer D correct and
Answer B incorrect. Dipyridamole alone is not effective for secondary stroke prevention
(Answer A is incorrect). Warfarin is reserved for patients with atrial fibrillation (Answer
C is incorrect).
C.P. is a 69-year-old man given a diagnosis of Parkinson disease 7 years ago. He states
that he is most bothered by his bradykinesia symptoms. On examination, he also has a
pronounced tremor, postural instability, and masked facial expression. He currently
takes carbidopa/levodopa/entacapone 25 mg/100 mg/200 mg orally four times daily,
ropinirole 1 mg orally three times daily, and selegiline 5 mg orally twice daily. He has no
drug allergies. He also describes a worsening of his Parkinson disease symptoms,
which fluctuate randomly during the day. He has developed a charting system for his
symptoms during the day, and no relationship seems to exist with the time he is
scheduled to take his carbidopa/levodopa/entacapone doses.
Which condition best describes C.P.'s fluctuating Parkinson disease symptoms?
A. Wearing-off.
B. On-off.
C. Dyskinesia.
D. Dystonia. - ANSWER B. On-off.
Wearing off is the return of symptoms before the next dose (Answer A is incorrect). It
has a definite pattern, whereas on-off is unpredictable, consistent with the description
provided by this patient (Answer B is correct). Dyskinesias (Answer C) and dystonias
(Answer D) are long-term adverse effects of carbidopa/levodopa, and are not consistent
with the description provided.
C.P. is a 69-year-old man given a diagnosis of Parkinson disease 7 years ago. He states
that he is most bothered by his bradykinesia symptoms. On examination, he also has a
pronounced tremor, postural instability, and masked facial expression. He currently
takes carbidopa/levodopa/entacapone 25 mg/100 mg/200 mg orally four times daily,
ropinirole 1 mg orally three times daily, and selegiline 5 mg orally twice daily. He has no
drug allergies. He also describes a worsening of his Parkinson disease symptoms,
which fluctuate randomly during the day. He has developed a charting system for his
symptoms during the day, and no relationship seems to exist with the time he is
scheduled to take his carbidopa/levodopa/entacapone doses.
