A 65-year-old man comes to the physician because of experiencing episodes of double vision. He says that double vision is intermittent and has been going on for 3 months. The patient is wondering if he has to change his prescription glasses. The patient has not had any headaches or dizziness. Physical examination shows that the patient experiences diplopia, and when he is asked to turn his right eye inward toward his nose and look down, he is able to look inward but not down. Which nerve is most likely involved?

A 44-year-old woman comes to the physician for follow-up examination. She is being treated for Raynaud disease and systemic lupus erythematosus. Her medication regimen contains a sympathetic blocking drug that is administered in high doses. Which of the following conditions will most likely be expected to occur as an adverse effect of the drug?

A 32-year-old woman is brought to the emergency department because of a sudden onset of headaches and dizziness. Physical examination shows that the patient has partial ptosis, miosis, and anhidrosis on the right side of her face. She says this has never happened before. It was her sister that noticed her eyelid was drooping. Which of the following muscles is most likely paralyzed to cause her ptosis?

A 32-year-old man is brought to the emergency department because of difficulties with his vision. Physical examination shows a loss of the lateral halves of the fields of vision in both eyes (bitemporal hemianopia). An MRI of the head shows a tumor of the adenohypophysis. Which of the following structures was most likely compressed by the tumor?

A 57-year-old man is brought to the emergency department because of dizziness and a severe headache. Physical examination shows the patient’s eyeball is fixed in an abducted position, slightly depressed, the pupil is dilated and the upper lid is droopy. When the patient is asked to move the pupil toward the nose, the pupil rotates medially. Consensual corneal reflexes are normal. A CT scan of the head shows a tumor in the superior orbital fissure. Which of the following nerves is most likely affected? 

A 55-year-old woman comes to the physician because of deteriorating vision. Ophthalmologic examination tests the globe, the retina, and the cornea of each eye and all extraocular eye movements are observed to ensure full range of motion, smoothness of movements, and synchronicity bilaterally. Which of the following nerves must be functioning properly if the patient is able to abduct the eye without difficulty and without upward or downward deviation? 

A 12-year-old boy is brought to the emergency department because of fever and fatigue. Physical examination shows neck stiffness and neck tenderness with passive movement. The patient was diagnosed with meningitis and a lumbar puncture is performed to determine the etiology of infection. However, lumbar puncture should not be performed when CSF pressure is elevated. Which of the following conditions would most likely indicate an elevated CSF pressure?

A 65-year-old woman is brought to the emergency department after being diagnosed with cavernous sinus thrombosis. The patient has headaches but is otherwise stable. A CT scan of the head shows an aneurysm of the internal carotid artery within the cavernous sinus. Which of the following will most likely be present during physical examination if nerve compression was suspected within the cavernous sinus? 

A 36-year-old woman is brought to the emergency department after being struck in the left orbital region by a ball. Physical examination of the left eye shows the eye is unable to abduct. An x-ray of the head shows a blow-out fracture of the medial wall of the orbit. Which of the following muscles is most likely injured or trapped? 

A 54-year-old woman is brought to the emergency department because of a severe headache, nausea, and vomiting. Physical examination shows that she is unconscious. When she regains consciousness, her right eye is directed laterally and inferiorly. There is also complete ptosis of her upper eyelid and pupillary dilation of the affected eye. An MRI of the head shows a tumor in her brain producing a transtentorial herniation. Which of the following lobes of the brain is most likely affected by the tumor? 

A 55-year-old woman is brought to the emergency department by her husband after she was found unconscious in their home. She has a history of poorly controlled hypertension. Her temperature is 37.5°C (99.5°F), pulse is 90/min, respirations are 16/min, and blood pressure is 175/100 mm Hg. Physical examination shows ptosis of the right eye and right pupillary mydriasis. The right eye is also deviated inferolaterally. A non-contrast CT scan shows a subarachnoid hemorrhage. Angiography is most likely to show a hematoma compressing which of the following structure structures? 

An 88-year-old man comes to the physician because of blurry vision and headache for the past 6 months. Physical examination shows an inability to abduct his right eye and ipsilateral absence of the corneal reflex. A CT scan of the head shows a dural mass. A growth located in which of the following structures of the skull is most likely responsible for the symptoms of this patient?

During neurological examination of a 27-year-old woman, the physician strokes a wisp of cotton across a patient’s left cornea without a response. The physician then strokes the cotton across the patient’s right cornea and both eyes blink. The most likely explanation of these findings is damage to which of the following cranial nerves on the left?

A 5-year-old girl is brought to the physician by her parents because of fever and cough for the last 2 days. Her mother is concerned she may be having trouble breathing and says that the patient may have decreased hearing. Physical examination shows a tender right ear with a golden-brown fluid that can be observed through the tympanic membrane. Which is the most likely direct route for the spread of an infection from the upper respiratory tract to the middle ear cavity? 

A 55-year-old man is brought to the emergency department because of severe ear pain. He accidentally punctured his tympanic membrane with an ear pick when he was suddenly startled by a loud noise. Physical examination shows the ear pick still in his ear as the patient was afraid to pull it out himself. Which of the following nerves is responsible for the sensory innervation of the inner surface of the tympanic membrane?

A 72-year-old woman comes to the physician because of pain in her left ear. She says that this pain started suddenly 2 days ago and is so severe that she must hold the phone away from her ear because it sounds too loud. Physical examination shows a hyperacusis of the left ear and Bell palsy of the left side of the face. Which cranial nerve is most likely to be affected by the infection to result in hyperacusis? 

A 58-year-old man comes to the physician because of progressive unilateral hearing loss and ringing in the affected ear (tinnitus) of 4 months duration. His vital signs are within normal limits. Physical examination shows hearing loss in the right ear. An MRI of the head shows a tumor at the cerebellopontine angle. Which of the following nerves is most likely affected? 

A 70-year-old man comes to the physician for evaluation of sudden hearing loss in his right ear. Physical examination shows a large amount of cerumen (earwax) in the right external acoustic meatus which is removed to fully evaluate the tympanic membrane. During this process the patient begins to cough. The cough results from stimulation of an area of the meatus that is innervated by which of the following nerves?

A 51-year-old man comes to the office because of hearing loss in his left ear, poor balance, a loss of taste sensation, and drooling from the left side of his mouth. A CT scan of the head shows a tumor on the left side of the posterior cranial fossa. Which of the following locations of the tumor would result in the symptoms observed by this patient?

A 5-year-old boy is brought to the emergency department by his parents because of left ear pain. The patient had a history of recurrent otitis media and this is his fourth episode in 6 months. Otoscopic examination shows a bulging and inflamed tympanic membrane. It is decided to incise the tympanic membrane to relieve the  pressure and drain the fluid. Which of the following is the best location to make an opening (myringotomy) for drainage?

A 40-year-old woman comes to the emergency department because of swelling and pain over the left side of her face. Physical examination shows a tender, warm swelling over the left mandible anterior to the ear. An ultrasound shows a hyperechoic mass within the lumen of the parotid duct, which was distended proximally. What other clinical features are most likely present in this patient?

A 55-year-old woman comes to the physician because of episodes of hearing loss, ringing of the right ear, and feeling of fullness or pressure in her right ear for the past 4 months. Physical examination shows decreased hearing in the right ear. A diagnosis of Ménière disease is made. Which of the following structures is most likely affected by the edema associated with Ménière disease?

A 7-year-old boy was brought to the emergency department by his parents for a complication of otitis media which became a mastoiditis. A mastoidectomy with myringotomy was performed to treat the infection. Five days postoperatively, the boy develops several facial deficits. Physical examination shows that the right corner of his mouth was drooping, he was unable to close his right eye, and there was food collection in his right oral vestibule. Which of the following nerves was most likely injured during the surgery? 

A 3-year-old girl is brought to the emergency department after accidentally inserting a pencil into her ear. The child is crying in pain. Physical examination shows a ruptured tympanic membrane with a few drops of blood in the external acoustic meatus. There is concern that there might have been injury to the nerve that principally innervates the external surface of the tympanic membrane. Which of the following clinical tests can be performed to check for injury to this nerve? 

A 21-year-old man is brought to the emergency department after collapsing on the basketball court because of severe dizziness. Physical Physical examination shows the patient demonstrates lack of equilibrium and memory impairment. A 3-cm wound is noted on his scalp from an injury in a game several weeks earlier. A CT scan of the head shows an intracranial hematoma. A lumbar puncture was also performed that showed no signs of infection or blood in the CSF. Which of the following is the most likely diagnosis?

A 2-month-old girl is brought to the physician because of an enlarged head. The patient is quickly sent to the hospital for an MRI and admitted for further evaluation. The MRI of the head shows a complete dilation of the entire ventricular system. The treatment team is currently evaluating whether to place a shunt or consider surgery. Which of the following conditions most likely led to this type of clinical picture? 

 A 65-year-old man comes to the emergency department 3 weeks after hitting his head. He had the accidental head bump while moving furniture and did not have any significant pain at that time. Currently, the pain has been progressively worsening. Physical examination shows mental confusion and poor physical coordination. A CT scan of the head shows an intracranial thrombus probably due to leakage from a cerebral vein over the right cerebral hemisphere. Which of the following is the most likely diagnosis?

A 42 year old woman is brought to the emergency department because of an acute onset of left facial weakness. She has a history of hypertension and uncontrolled diabetes. Her pulse is 85/min, blood pressure is 185/110 mmHg, and respirations are 17/min. A CT scan of the head confirms an ischemic stroke. She is treated with tissue plasminogen activator (tPA) and her blood pressure is managed. Two weeks following the stroke, the patient began to experience difficulty in speech repetition. Her speech is fluent, and comprehension is intact, but she is unable to repeat sentences. The aphasia is thought to be a secondary complication related to the ischemic stroke. Which of the following anatomic structures is most likely damaged?

A 15-year-old boy is brought to the emergency department because of fever, nausea, vomiting, and abdominal pain. His parents say that their child has been feeling unwell for the past 2 days and has not been able to attend school. History includes type one diabetes mellitus. His blood pressure is 110/75 mm Hg, temperature is 38.3°C (101°F), respirations are 25/min, and SpO2% 97 on room air. Physical examination shows a young man who is somnolent. Respiratory examination shows rapid short breaths. Urine dipstick is positive for ketones. Blood serum studies show hyperglycemia, metabolic acidosis, and severe hyponatremia. The diabetic ketoacidosis protocol is initiated. Two days later the patient develops weakness of the upper and lower extremities, hallucinations, and tremors. Which of the following is where the lesion is located?

A 35-year-old woman is brought to the emergency department by her family because of worsening fever. Her family says that she has had a severe case of sinusitis for the past week that has not gotten better and this morning she seemed confused. Physical examination shows a lethargic woman with fever, tachycardia, and tachypnea. Laboratory studies show leukocytosis and a negative urine dip. A CT scan of the head shows a thrombus within the cavernous sinus. A diagnosis of sepsis secondary to cavernous sinus thrombosis is made. Which of the following is the most direct route for spread of infection from the face to the cavernous sinus?

A 54-year-old man comes to the physician for a recent diagnosis of an aneurysm in the basilar artery, close to the cavernous sinus. Because of the risk of rupture, the vascular surgery team has recommended an endovascular aneurysm repair. An anterior approach to the sella turcica through the nasal cavity is chosen. Through which of the following routes is the surgeon most likely to gain access to the cranial cavity?

A 45-year-old woman is brought to the emergency department after falling down a flight of concrete stairs. The patient has a contusion on her head with bruising of her arms and legs. Physical examination shows weakness of patient’s downward medial gaze. The patient admits she’s been having headaches and vision problems recently. A CT scan of the head shows no intracranial bleeding or fractures. A cerebral arteriography and an MRI show a nerve being compressed by an arterial aneurysm inferior to the tentorium cerebelli. Which of the following arteries is most likely compressing the associated nerve?

A 54-year-old man is brought to the emergency department after being struck by a moving vehicle. On arrival, the patient has a GCS of 10 and stable vital signs. The patient has no obvious signs of bleeding and a Facial drooping, Arm weakness, Speech difficulties and Time (FAST) examination is also negative. A CT scan of the head shows a fracture through the crista galli of the anterior cranial fossa, resulting in slow, local bleeding. Which of the following is the most likely source of bleeding?

A 64-year-old man is brought to the emergency department by his son after being found unconscious at home. The patient has a history of diabetes mellitus and hypertension. A CT scan of the head shows that the patient had a cerebral vascular accident, with a small hematoma produced by the superior cerebellar artery. Which of the following nerves will most likely be affected by the hematoma?

A 34-year-old man is brought to the emergency department because of head injury after falling off his motorbike. The patient was not wearing a helmet. His temperature is 37.1°C (98.78°F), pulse is 97/min, respirations are 25/min, and blood pressure is 100/70 mm Hg. Physical examination shows multiple lacerations over the frontal bone. If his wounds become infected, which of the following veins could most likely provide a pathway of infection transmission from the veins of the scalp to the underlying dural venous sinuses? 

A 59-year-old man comes to the office 2 weeks after undergoing resection of a brainstem tumor. Physical examination shows a well-healing scar on the posterior aspect of his head. A postoperative CT scan of the head shows a nonobstructive (communicating) hydrocephalus. Between which structures is malabsorption most likely to occur?

A 61-year-old man is brought to the emergency department because he was found unconscious by his daughter. Shortly after arriving, he regains consciousness. Physical examination shows that he is unable to shrug his shoulder on the right side and turn his head to the left. A CT scan of the head and neck shows a large aneurysm of an artery compressing the nerve responsible for his symptoms. In which of the following arteries is the aneurysm located? 

A 21-year-old man comes to the emergency department because of severe headache and nausea. Five days ago, he sustained a deep cut on his scalp while shaving his head with a razor blade. The man did not seek medical attention for this injury. His temperature is 39.5°C (103.1°F), pulse is 110/min, respirations are 27/min, and blood pressure is 90/60 mm Hg. Physical examination shows a lethargic man. A CT scan of his head shows an infection of the superior sagittal sinus. Which of the following veins was most likely responsible for this patient’s current infection?

An 8-year-old boy is brought to the emergency department by his parents because of a 3-week history of mild intermittent headaches, vomiting, and fatigue. The headaches and fatigue have progressively worsened over the past week. He appears sluggish and is difficult to arouse. A CT scan of the brain shows the lateral ventricles measure 20 mm in diameter bilaterally (normal range: <10 mm), the third ventricle measures 4 mm (normal range:<5 mm), and the fourth ventricle measures 8 mm (normal range:<9 mm). Which of the following is the most likely source of obstruction in this patient?

A 55-year-old man comes to the emergency department because of progressively severe headaches. His temperature is 38°C (100.4°F), otherwise his vital signs are within normal limits. Physical examination shows neck stiffness and pain on passive movement of the neck. A lumbar puncture is performed and shows traces of blood in the CSF. Which of the following conditions has most likely occurred in this patient? 

A 20-year-old woman delivered a boy at term by cesarean section. The second trimester ultrasound showed enlarged ventricles of the fetal brain. Neonatal physical examination shows a head circumference of 40 cm (normal range, 34 to 36 cm). There is decreased movement of the limbs. A CT scan of the head shows dilatation of all the ventricles. Which of the following is likely to be the cause of the infant’s condition? 

A 58 year old patient is brought to the emergency department because of weakness in their right arm and face and inability to speak. They have a history of alcohol use, cigarette smoking and hypertension. Neurologic examination shows an alert patient. They are able to say a few words, and they can follow simple commands. They have a decreased right nasolabial fold and decreased movements of the right side of their face, sparing the forehead. They have no right arm movement but are able to raise their left leg. Occlusion of which of the following vessels best explains the findings in this patient?

A 3 year old boy is brought to the emergency department because of persistent vomiting, a stiff neck, and decreased responsiveness. An MRI scan of the head shows a posterior fossa tumor filling the fourth ventricle. Which of the following physical findings is most likely present in this patient?

A 25-year-old man comes to the physician because of uncontrollable choreiform movements. He has moderate dementAtrophy of the head of the caudate nucleus ia with a severe gait disturbance as well as agitation and problems with his mood. He has a family history of movement disorders. Which of the following findings will most likely be present on MRI in this condition? 

A 62-year-old man is brought to the emergency department by his wife when she noticed he was having a meaningless conversation with her this morning. She says he was conversing normally the previous night. Physical examination shows fluent speech without comprehension and he is unable to repeat phrases. Which of the following areas correlate with the symptoms presented in this patient?

A 82-year-old man is brought to the emergency department because of headache, vomiting, and impaired consciousness. The patient has a history of chronic hypertension and has no recent history of falls or trauma. His pulse is 85/min, blood pressure is 155/98 mm Hg, and respirations are 18/min. Physical examination shows neck stiffness, an unsteady gait, and bilateral horizontal nystagmus. There is no hemiparesis. A CT scan of the head shows an intracranial hemorrhage. In which of the following anatomic sites is this hemorrhage most likely present?

A 75-year-old woman is brought to the emergency department by her son after a sudden onset of confusion with drooping of the right side of the face this morning. Since this morning, her sense of taste was diminished, and her gait has become unbalanced. Physical examination shows a loss of facial movements and sensation on the right side of the face, ptosis and miosis of the right eye with a diminished corneal reflex, and loss of pain and temperature sensation of the left side upper and lower extremities. The patient’s hearing is also decreased on the right side. Which of the following locations is most likely damaged? 

A 24-year-old man comes to the physician because of worsening headaches for the past 1 month. He has had episodes of nausea and vomiting for the past 2 days. He has had occasional minor headaches for the past year, which resolve after taking over-the-counter acetaminophen. An MRI of the head shows a cystic enhancing lesion measuring 2.0 × 2.5 cm in the right cerebellar hemisphere. At physical examination, which of the following findings is mostly likely expected to be present in this patient?