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Colen Publishing
Colen Publishing, L.L.C. PO Box 36536 Grosse Pointe Woods, MI 48236 Author and Editor: Chaim B. Colen, M.D., Ph.D. Editorial Assistant: Roxanne E. Colen, PA-C COPYRIGHT © 2008 by Colen Publishing, L.L.C. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the author’s consent if illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. Permissions may be sought directly from Colen Publishing, L.L.C. by writing to the above address. Printed in China Colen Flash-Review: Neurology ISBN Volume 1: 0-9788502-4-6 Volume 2: 0-9788502-5-4 2 Volume Set: 0-9788502-9-7 Note: Knowledge in medicine is constantly changing. The author has consulted sources believed to be reliable in the effort to provide information that is complete and in accord with the standards at the time of publication. However, in view of the possibility of human error by the author in preparation of this work, warrants that the information contained herein is in every respect accurate and complete, and that the author is not responsible for any errors or omissions or for the results obtained from use of such information. The reader is advised to confirm the information contained herein with other sources. This is especially important in connection with new or infrequently used drugs. In such instances, the product information sheet included in the package with each drug should be reviewed.

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Glossary
COPYRIGHT-------------------------------------------------PREFACE -----------------------------------------------------HOW TO USE THIS CARD REVIEW-------------------CONTRIBUTORS-------------------------------------------GLOSSARY--------------------------------------------------NEUROSURGERY-----------------------------------------NEUROLOGY -----------------------------------------------NEUROPATHOLOGY-------------------------------------NEUROANATOMY----------------------------------------NEUROCRITICAL CARE---------------------------------NEURORADIOLOGY--------------------------------------NEUROBIOLOGY------------------------------------------BONUS BIOSTATISTICS---------------------------------1 1 1 4 1 110 86 238 57 80 73 64 6

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Preface
• The idea to undertake such a large Flashcard review spawned from watching my wife Roxanne study for her Physician Assistant Boards. Diligently every day she would create a set of 7-10 flashcards from her study material that she would take with her to work. Later on, when I was studying for my written Neurosurgery Board examination, I gleaned information from various texts and other study guides and wrote down the most relevant material on cards for quick review while at work. It was amazing how much time during the day would be available to review these cards. If there was a delay in a OR case, a long lunch-line, a traffic jam (especially the i94 on a Friday afternoon) or waiting for my wife at her OB/GYN appointment -these little cards were specially handy. Always ambitious in life, the thought of giving this study tool to the busy neurosurgery resident was captivating. My expectation is to enable the resident with a quick yet informative review of basic neuroscience principles. With positive encouragement from my fellow residents on the 1st edition, I cautiously proceed here with updating information, adding new images, improved illustrations and clarification of neuroscience concepts. May this endeavor serve to better our wonderful science inherited through the legacy of Harvey Cushing, Neurosurgery. Chaim September 9, 2008
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The Colen Flash-Review
Author and Editor Chaim B. Colen, M.D., Ph.D. Department of Neurological Surgery Wayne State University School of Medicine Detroit, Michigan Assistant Editor Roxanne E. Colen, M.S., PA-C Colen Publishing, LLC Grosse Pointe, Michigan

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Acknowledgements
I would like to give thanks to a great many wonderful persons whose efforts, although not inscribed in these cards, were instrumental in making this monumental task possible. One exceptional individual to whom I owe special thanks is my mother in-in-law, Colleen Johns, who babysat my daughter Emily and son Joshua for hours on end, while my wife and I toiled through hundreds of pages of various textbooks and journal articles, formatted questions, and drew computer illustrations. To my daughter Emily Rivka, who incessantly tugged at my pants trying to get my attention to the squirrel in our backyard ;and that big bright smile from my son Joshua that continually sent me optimism. To Mahmoud and Abhi who spent hours at my home assisting with typing, researching and editing; Naomi whose positive attitude in life is exceptionally brightening and uplifted the group’s 2 am brainstorming sessions when I still had to wake up early to work the next day, all the pathologists, especially Doha, who assisted in taking photographs, Dr. William Kupsky, for allowing us access to his collection of unique neuropathology, and to all the medical students especially Kristyn, whose hard work is admirable. There are those whose names are not here but did assist in some way, thank you. I am forever indebted to my training program, the Wayne State University neurosurgery program, my Chairman Dr. Murali Guthikonda, and Associate Chairman Dr. Setti S. Rengachary whose moral support over the last five years has kept me on this educational drive. For this second edition, there were fellow residents that gave me input and new insight that has helped to improve this edition over the first. To my parents Joseph and Leila, educators of true dedicated quality, and to whom I owe my homeschooling education and self-motivation. Lastly to my wife Roxanne, whose patience with my ambitiousness knows no boundaries. ©™ Thank you All, Chaim September 9, 2008

How to use this Flashcard review
• These cards are intended to cover most of the aspects of the Neurosurgery Board Examination. They are not a COMPLETE review and therefore they are not intended to replace textbooks. We would advise using these cards during the last couple of weeks before your board exam except for the pathology section which you should go through all year to better remember the photographs in it (heavily encountered during the boards!). BOARD FAVORITE questions are of extreme importance and most likely to bump into during the boards, so make you sure you know how to answer them right. Good luck! Chaim B. Colen, M.D., Ph.D.
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Faculty Reviewers
Murali Guthikonda, MD Professor and Chairman Department of Neurological Surgery Wayne State University School of Medicine Detroit, Michigan Setti Rengachary, MD Associate Chairman Department of Neurological Surgery Wayne State University School of Medicine Detroit, Michigan William, J. Kupsky, MD Department of Neuropathology Wayne State University School of Medicine Detroit, Michigan

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Forward
• With ever increasing scope and complexity of knowledge base, the current day trainee or practitioner of neurosurgery finds it difficult to keep up with the explosion of neurosurgical information. This is compounded by a healthy growth in specialization in various branches of neurosurgery. Chaim has made an attempt to make life simpler by incorporating small quanta of knowledge on flashcards accompanied by clear and simple illustrations. The user may review as few or as many cards as his/her time will allow. Although not meant to be substitutes for standard comprehensive texts and atlases, these cards help to refresh the information learned from the bedside, operating room and standard books. Each card represents a mini-examination with instant access to appropriate answers. This is a fun way to recall neurosurgical information especially before an upcoming test. Setti S. Rengachary, M.D. Department of Neurological Surgery
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Physician Contributing Authors
Rivka R. Colen, MD Department of Radiology The Massachusetts General Hospital Harvard Medical School Boston, Massachusetts Doha Itani, MD Department of Pathology WSU School of Medicine Detroit, Michigan Mahmoud Rayes, MD Department of Neurological Surgery WSU School of Medicine Erika Peterson, MD UT Southwestern, Department of Neurological Surgery Dallas, Texas

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Contributing Medical Students
Darmafall, Kristyn Wayne State University School of Medicine Class of 2012 Davis, Naomi Wayne State University School of Medicine Class of 2011 Dub, Larissa Wayne State University School of Medicine Class of 2012 Faulkiner, Rodney Wayne State University School of Medicine Class of 2012 Galinato, Anthony Wayne State University School of Medicine Class of 2012 Gotlib, Dorothy Wayne State University School of Medicine Class of 2009 Kozma, Bonita Wayne State University School of Medicine Class of 2008 Lai, Christopher Wayne State University School of Medicine Class of 2010 Larson, Sarah Wayne State University School of Medicine Class of 2012 Martinez, Derek Wayne State University School of Medicine Class of 2011 Matthew Smith Wayne State University School of Medicine Class of 2011 Matto, Shereen Wayne State University School of Medicine Class of 2012 ©™

Contributing Undergraduates
Jeffrey P. Kallas Wayne State University Class of 2010 Abhinav Krishnan Wayne State University Class of 2010 Peter Paximadis Wayne State University Class of 2008

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Neurobehavioral Section

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Q?

Neurobehavioral

Which of the following types of mental retardation is associated with a maternallyinherited deletion of segment 11-13 of chromosome 15? A. Prader-Willi syndrome B. Rett’s syndrome C. Fragile X syndrome D. Angelman’s syndrome

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The correct answer is D, Angelman’s syndrome. Angelman’s syndrome is classically associated with a maternally-inherited deletion of segment 11-13 on chromosome 15. This syndrome is characterized by mental retardation, abnormal gait, speech impairment, seizures, and inappropriate happy behavior that is often described as “happy puppet syndrome.” Prader-Willi syndrome consists of the same deletion (segment 11-13 of chromosome 15) but is located on the paternal chromosome 15. (Remember: P-P, Paternal-Prader-Willi) Rett’s syndrome is a progressive neurodevelopmental disorder that affects females only. The cause of Rett’s syndrome is the MeCP2 gene, located on the long arm of the X chromosome. Fragile X syndrome is the most common form of inherited mental retardation. It is caused by a CGG repeat on the X chromosome, and effects include long face, enlarged ears, and macroorchidism.
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Fauci A, Braunwald E, et al. Harrison’s Principles of Internal Medicine 17th Edition. New York, NY: McGraw-Hill, Medical Pub. Division 2005. p. 407-14.

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Neurobehavioral

Fragile X syndrome is the most common form of inherited mental retardation. Somatic abnormalities seen commonly in Fragile X patients include a long face, large ears, and macroorchidism. Which of the following genetic abnormalities is the most likely cause of Fragile X syndrome? A. Absence of segment 11-13 on chromosome 5 B. MeCP2 gene on the long arm of the X chromosome C. CGG trinucleotide expansion of an area of the X chromosome D. Inheritance of an extra copy of chromosome 21

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The correct answer is C, CGG trinucleotide expansion of an area of the X chromosome. Fragile X syndrome is the most common form of inherited mental retardation. It is caused by a CGG repeat on the X chromosome, and effects include long face, enlarged ears, and macro-orchidism. It affects males more than females. Angelman’s syndrome is classically associated with a maternally-inherited deletion of segment 11-13 on chromosome 15. This syndrome is characterized by mental retardation, abnormal gait, speech impairment, seizures, and inappropriate happy behavior that is often described as “happy puppet syndrome.” Prader-Willi syndrome consists of the same deletion (segment 11-13 of chromosome 15) but is located on the paternal chromosome 15. Rett’s syndrome is a progressive neurodevelopmental disorder that affects females only. The cause of Rett’s syndrome is the MeCP2 gene, located on the long arm of the X chromosome.
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Sadock B, Sadock V. Kaplan & Sadock’s Synopsis of Psychiatry, 10th Edition. Philadelphia, PA: Lippincott Williams & Wilkins 2007. p. 1143.

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Neurobehavioral

A 6 year-old boy has been sent for evaluation by a psychiatrist for attention deficit hyperactivity disorder (ADHD) because he has not been completing his homework and is constantly interrupting his teacher and classmates. His teacher reports that he has trouble sitting still. Upon questioning his parents, they report that their son’s inattention and hyperactivity started over 6 months ago. With a diagnosis of attention deficit hyperactivity disorder in this child, which of the following would be the first-line treatment? A. Individual psychotherapy B. Selective serotonin reuptake inhibitors & tricyclic antidepressants C. Methylphenidate (Ritalin) D. Monoamine oxidase inhibitor (MAOI)
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The correct answer is C, methylphenidate (Ritalin). Methylphenidate is considered the first line therapy for children diagnosed with attention deficit hyperactivity disorder (ADHD). Significant improvement is seen in roughly 75% of children when taking methylphenidate. Individual psychotherapy with a focus on behavioral modification can be used as adjunctive therapy, but is not considered first-line. Selective serotonin reuptake inhibitor (SSRI) and tricyclic antidepressant (TCA) therapy can be used as adjunctive pharmacologic therapy for ADHD, but is not a first-line treatment. Monoamine oxidase inhibitors (MAOIs) are also antidepressants, but are not used in the treatment of attention deficit hyperactivity disorder. Of note, it is important to recognize that in order for a diagnosis of attention deficit hyperactivity disorder to be made, symptoms must be present for a minimum of 6 months, and the child must have the onset of symptoms before the age of 7.
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Sadock B, Sadock V. Kaplan & Sadock’s Synopsis of Psychiatry, 10th Edition. Philadelphia, PA: Lippincott Williams & Wilkins 2007. p. 1211-14.

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Neurobehavioral

The treatment of attention deficit hyperactivity disorder (ADHD) classically involves the use of stimulants, such as methylphenidate (Ritalin). Which of the following are common adverse effects of methylphenidate? A. Tachycardia, insomnia, and abdominal pain B. Bradycardia and hyperphagia C. Suicidal thoughts, gestures, or ideation D. Increased intracranial pressure (ICP)

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The correct answer is A, tachycardia, insomnia, and abdominal pain. Tachycardia, insomnia, and abdominal pain are all reported side effects of methylphenidate. Bradycardia is not seen. Methylphenidate is also reported to cause a decrease in appetite, not hyperphagia. Increased intracranial pressure is not a side effect of methylphenidate use.

Sadock B, Sadock V. Kaplan & Sadock’s Synopsis of Psychiatry, 10th Edition. Philadelphia, PA: Lippincott Williams & Wilkins 2007. p. 1211-12.

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Q?

Neurobehavioral

At which age are developmental milestones of group play, ability to ride a tricycle, and the ability to copy a line or circle drawing present? A. 2 years B. 3 years C. 4 years D. 5 years

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The correct answer is B, 3 years. The above milestones are classically present at age 3. 4 year-olds, on the other hand, can participate in cooperative play and construct simple drawings (stick figure drawings, for example). Milestones like abstract reasoning and the formation of personality occur during adolescence (age 11 for girls and age 13 for boys).

Bhushan V, Le T, Chandwani R, Ozturk A. First Aid for the USMLE Step 1 2005: A Student to Student Guide. New York, NY: McGraw-Hill 2005. p. 120.

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Q?

Neurobehavioral

A 25 year-old medical student is arrested at school after stealing a laboratory scale. He has a history of multiple childhood arrests, both for abusing his neighbor’s dog and setting fires to houses nearby. His school records show a history of disciplinary action for aggressiveness and fighting with classmates. During questioning, he shows no remorse for his actions. Prior to the age of 18, this individual would most probably have been diagnosed with which of the following? A. Antisocial personality disorder B. Schizotypal personality disorder C. Conduct disorder D. Borderline personality disorder E. Histrionic personality disorder
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The correct answer is C, conduct disorder. Prior to age 18, individuals with the above behavior are classified as having conduct disorder. Currently, as a 25 year-old medical student, he would be classified as having antisocial personality disorder. Borderline personality disorder is characterized by unstable moods and labile, unstable relationships. Histrionic personality disorder is characterized by excessive attention-seeking behavior and emotionality. These individuals are dramatic, sexually provocative, and unable to form long-lasting relationships. Schizotypal personality disorder is characterized by individuals with eccentric behavior and peculiar thought patterns. They commonly exhibit odd beliefs or magical thinking.
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Sadock B, Sadock V. Kaplan & Sadock’s Synopsis of Psychiatry, 10th Edition. Philadelphia, PA: Lippincott Williams & Wilkins 2007. p. 1220-1224.

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Neurobehavioral

Which of the following is a metabolic abnormality associated with anorexia nervosa? A. Hypochloremic hyperkalemic metabolic alkalosis B. Hypochloremic hypokalemic metabolic alkalosis C. Hyperkalemic metabolic acidosis D. Hyponatremia

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The correct answer is B, hypochloremic hypokalemic metabolic alkalosis. Anorexia nervosa is an eating disorder in which body weight is 15% below normal. Additionally, there is an intense fear of gaining weight, disturbed body image, and amenorrhea. The most common metabolic complication resulting from anorexia nervosa is hypochloremic hyperkalemic metabolic alkalosis. Lanugo, or fine body hair, is also commonly seen in the anorexic patient. Hypochloremic hypokalemic metabolic alkalosis is commonly seen in bulimia nervosa (secondary to emesis), not in anorexia. Hyponatremia and hyperkalemic acidosis are usually not seen in anorexia nervosa.

Sadock B, Sadock V. Kaplan & Sadock’s Synopsis of Psychiatry, 10th Edition. Philadelphia, PA: Lippincott Williams & Wilkins 2007. p. 731-2.

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Q?

Neurobehavioral

A 23 year-old female is brought in to your psychiatric clinic by her parents for an eating disorder evaluation. Her parents report that they rarely see her eating and are concerned that she is suffering from anorexia nervosa. You perform a history and physical examination on the patient without her parents present, and find that she is mildly overweight. You notice that she has calloused knuckles on her right hand. When you ask her questions about her body image, she informs you that she is extremely distressed by her inability to achieve a lower body weight. What is the most likely diagnosis? A. Anorexia nervosa B. Bulimia nervosa, purging type C. Bulimia nervosa, non-purging type D. This patient is not suffering from an eating disorder.
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The correct answer is B, bulimia nervosa, purging type. This patient is suffering from bulimia nervosa, purging type. Common findings in a bulimic patient of the purging type include hypochloremic hypokalemic metabolic alkalosis, dental erosion, and calloused knuckles (all as a result of self-induced vomiting). Interestingly, while anorexia nervosa patients have body weight 15% below-average, bulimia nervosa patients often have normal body weights or are slightly overweight. In addition, bulimia is described as ego-dystonic (distressing to the patient). These patients are aware that they have a problem and are distressed by it, making them more likely to seek help than anorexic patients. Anorexia nervosa, on the other hand, is ego-syntonic (not distressing to the patient) and patients suffering from anorexia are less likely to seek help. The purging type of bulimia nervosa involves vomiting, the use of laxatives, or the use of diuretics as a means to lose weight. The non-purging type of bulimia involves excessive exercise or fasting. Note that while anorexia and bulimia can potentially involve excessive fasting, the anorexic will have a low body weight while the bulimic will have a normal body weight or be overweight.

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Sadock B, Sadock V. Kaplan & Sadock’s Synopsis of Psychiatry, 10th Edition. Philadelphia, PA: Lippincott Williams & Wilkins 2007. p. 735-8.

Q?

Neurobehavioral

A 23 year-old female gives birth to a healthy baby girl. However, on further inspection the newborn is noted to be deaf, has congenital cataracts, and has cardiac abnormalities with possible mental retardation. The mother reported having an unremarkable pregnancy except during the first trimester when she reported having a mild illness consisting of a maculopapular rash, arthritis, aching joints, and diffuse swollen lymph nodes lasting 2-3 days. These congenital anomalies could have best been prevented by which of the following? A. Treatment of penicillin prior to pregnancy B. Receiving the measles, mumps, and rubella vaccine prior to pregnancy C. Avoiding uncooked pork and cat litter during the pregnancy D. Maintaining on highly active antiretroviral therapy (HAART) during the pregnancy E. Receiving the varicella zoster vaccine prior to pregnancy
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The correct answer is B, receiving the measles, mumps and rubella vaccine prior to pregnancy. This patient who was not immunized to rubella, contracted the disease during her pregnancy as noted by her classic symptoms and classical congenital defects. Congenital rubella syndrome (CRS) has the highest transference rate during the first trimester. Choice A , refers to syphilis which usually manifests as a late abortion or congenital syphilis with eighth nerve deafness, saber shins, Hutchinson teeth, and a saddle nose Choice C, refers to Toxoplasmosis gondii a common protozoan parasite whose transmission also occurs during the first trimester. However, this parasite often manifests with fevers, seizures, chorioretinitis, hepatosplenomegaly, jaundice, and hydrocephaly or microcephaly. Choice D, refers to HIV infected mothers. Transmission is believed to occur late in pregnancy or during delivery. Choice E, refers to the varicella zoster virus , which can also occur during the first trimester, but in this trimester the effects are often a spontaneous abortion and possible teratogenic effects but not the series of effects listed.
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Charles R. B. Beckmann et al. Obstetrics and Gynecology Fifth Edition. Philadelphia, PA: Lippincott Williams & Wilkins 2006. p. 181- 184.

Q?

Neurobehavioral

A 19 year old women presents to the psychiatrist with her mother. The patient reports having heard voices for the past month. On further questioning the psychiatrist discovers that for the past 2 months the patient has had grossly disorganized behavior and a delusion that someone is following her. Her mother states that she was completely normal until two months ago. What is the most likely diagnosis at this time? A. Schizophrenia B. Brief psychotic disorder C. Schizoaffective disorder D. Schizophreniform E. Schizotypical

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The correct answer is D, schizophreniform. While this patient displays the DSM IV criteria for schizophrenia, her symptoms have only been present for the past 2 months. The DSM IV requires that symptoms be present for the past 6 months in order to diagnose schizophrenia (choice A). If the symptoms last under 1 month then the diagnosis of a brief psychotic disorder is made (choice B). Choice C, schizoaffective disorder is diagnosed when a patient meets both the DSM IV criteria for schizophrenia and a mood disorder. Choice E, schizotypical is a personality disorder where a patient displays odd or magical beliefs, lack of friends, and the criteria for true psychosis is not met.

Benjamin James Sadock, M.D. and Virginia Alcott Sadock, M.D. Kaplan & Sadock’s Synopsis of Psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins 2003. p. 471-511; 520-529; 806-807.

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Q?

Neurobehavioral

A nine year-old boy was adopted when he was one years old. His adopted papers showed that his mother was a recovering alcoholic and admitted to drinking heavily during her pregnancy. Since he started school at age 6, he has been in special education due to learning disabilities and an IQ test of 63. According to his IQ measurements, the boy would be classified as having: A. Borderline intellectual functioning B. Mild mental retardation C. Moderate mental retardation D. Severe mental retardation

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The correct answer is B, mild mental retardation. In mild mental retardation, IQ ranges from 50/55 to approximately 70. In moderate mental retardation, IQ ranges from 35/40 to 50/55 In severe mental retardation, IQ ranges from 20/25 to 35/40. Borderline intellectual function is a term no longer used.

Shaywitz SE, Cohen DJ, Shaywitz BA. Behavior and learning difficulties in children of normal intelligence born to alcoholic mothers. J  Pediatr. Jun 1980;96(6):978‐82

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Q?

Neurobehavioral

A 45 year-old man is brought into the doctor’s office by his wife. She states that her husband has been acting “weird” for the past few months. He does not eat food on the left side of his plate, does not shave the left side of his face, and will deny that he even has a left arm. When the doctor asked the patient to draw a clock, he only drew a right sided clock. Shown here. What is the best diagnosis for this patient? A. Gerstmann’s syndrome B. Agnosia C. Dementia D. Hemineglect E. Homonymous hemianopsia
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The correct answer is D, hemineglect. Neglect is lack of attention to one side, usually the left. Patients with severe neglect may fail to describe objects on the left, dress or shave their left side. They may even deny their left arm as theirs and claim that it is the examiner’s arm. Patients with neglect do not have a hemianopia, or a primary motor or sensory deficit for that side; rather, they have damage to the non-dominant (usually right) hemisphere. Neglect is usually caused by lesions in the right frontal or parietal lobe

Guttmann-Steinmetz S, Crowell JA. Attachment and externalizing disorders: a developmental psychopathology perspective. J Am Acad Child Adolesc Psychiatry. Apr 2006;45(4):440-51.

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Q?

Neurobehavioral

A 26 year-old primigravid female has been admitted to the hospital today due to newonset seizures that reportedly began five days ago. She has a history of rapid-cycling bipolar disorder. She currently complains of depressive symptoms and possible suicidal ideation. The first year resident assigned to the case is interested in administering carbamazepine (Tegretol) as a mood stabilizer for her bipolar disorder. Which of the following adverse effects could carbamazepine potentially have on the developing fetus? A. Growth deficiency and microcephaly B. Neonatal withdrawal syndrome C. Spina bifida and agranulocytosis D. Ebstein’s anomaly and other cardiac defects E. Floppy baby syndrome
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The correct answer is…. To obtain the answer to this question and to view over 250 more comprehensive neurobehavioral questions please purchase the full product here !

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Ebert M, Loosen P, Nurcombe B. Current Diagnosis & Treatment in Psychiatry. New York, NY: McGraw-Hill 2000. p. 320-1.

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