Internal-Medicine

Questions: 59–78 147
For each patient with a pupillary abnormality,
select the most likely diagnosis.
For each patient with muscle weakness, select the
most likely anatomic site for the disorder.
69. A 63-year-old man is noticed to have asymmetric
pupils. He is completely well and has no
symptoms. On examination, the left pupil is
small, round, and has a brisk response to light
and near stimuli (accommodation). There is
also ptosis of the left eyelid, but no other ocular
movement abnormality or symptoms of double
vision. (SELECT ONE)
70. A 23-year-old woman is noticed to have irregular
pupils on routine examination. She has one
large pupil, which has minimal response to light
stimulation, but it does respond to accommodation.
The eye movements are normal and she
experiences no double vision. (SELECT ONE)
71. A 57-year-old woman presents for evaluation
of memory loss. She is noticed to have small,
irregular pupils that respond poorly to light
but pupillary response to accommodation is
normal. (SELECT ONE)
72. A 24-year-old man notices different size pupils.
The left pupil is 1 mm larger than the right.
Both pupils respond normally to light and
accommodation. The discrepancy in the pupils
is still there in low, medium, and bright light
conditions. He reports no other visual symptoms.
(SELECT ONE)
73. A 64-year-old woman is having double vision
and severe headaches. On examination, the left
pupil is dilated compared to the right, and the
light response is diminished. (SELECT ONE)
Questions 74 through 78
(A)
(B)
(C)
(D)
anterior horn cell
peripheral nerve
neuromuscular junction
muscle
74. A 48-year-old man complains of muscle weakness
in his right hand (dominant hand). On
examination, the hand muscles are smaller than
on the left, and the reflexes are decreased out of
proportion to weakness. (SELECT ONE)
75. A 26-year-old woman complains of early
fatigue and weakness in doing strenuous activity.
Her symptoms are worse near the end of
the day. She appears well, muscle bulk, tone,
and reflexes are normal. Handgrip strength
decreases with repetitive testing. (SELECT
ONE)
76. A 63-year-old woman has noticed weakness in
her right hand such that she is having difficulty
writing and doing up buttons. On examination,
there is marked atrophy of the forearm
and hand muscles with fasciculations. Tone is
increased and reflexes are brisk. Sensory testing
in the hand is normal. There are also fasciculations
on her thighs, which she has never
noticed before. (SELECT ONE)
77. A 49-year-old man notices weakness and
numbness in his left hand. He had recently
slipped on a wet floor and injured his elbow.
Examination of the hand reveals predominantly
weakness to abduction and adduction and sensory
loss over the fourth and fifth fingers.
(SELECT ONE)
78. A 67-year-old man with lung cancer notices
symptoms of weakness in his arms and legs.
He describes difficulty in rising out of chair or
going upstairs, but no pain or discomfort. On
examination, proximal muscle strength is four
out of five in the upper and lower limbs, but
the reflexes, tone, and sensation are normal.
He has a colored rash on his eyelids, and raised
papules on his knuckles. (SELECT ONE)