Welcome to your Gp neelima neuro muscular 7-02-17

Name Business Email Phone Number

Headache and horizontal diplopia on far right lateral gaze are the complains of a 17-year-old girl since three weeks. Whilst bending forwards, she noted dimmed vision on two separate occasions. She gained 12Kg in the past year her weight is 96 kg, and height is 163 cms. She also had bilateral papilledema and a partial right sixth cranial nerve palsy. What is the most likely diagnosis?

A 73 year old woman with Alzheimer´s disease falls in the nursing home and hits her head. Skull is not fractured but she complains of a severe headache on the left side of her head and has fluctuating levels of consciousness. Mydriasis is noted in the left pupil. Which one of the following is the most likely diagnosis in this patient?

A 71 year old lady presented with episodic impairment of consciousness. The most likely cause is

A female aged 36 years presents in emergency department because of the sudden onset of severe low back pain 12 hours earlier. Careful physical examination, including a neurologic examination, is normal except for evidence of muscle spasm. She believes she has a herniated disc because 2 years ago her father developed the sudden onset of back pain that required immediate surgery. Three weeks later she returned because of persistent left lower leg pain and weak left ankle-jerk reflex. Which of the following is next appropriate step in addition to pain management?

You see an elderly hospitalized patient with mild obstructive lung disease who roused one morning with difficulty and appeared confused. Drug that is most likely associated with this episode is

A 66 year old male comes to you complaining of mild tremor while at rest. His posture is normal. Slight slowness of movement is noticed by him. The most appropriate therapy in this stage of his Parkinsonism is

A 64 year old woman develops intermittent dizziness. Examination discloses diminished corneal light reflex mild hearing loss in the right ear. What is the most likely diagnosis?

The mechanism of action in organophosphate poisoning is

The mechanism of action in organophosphate poisoning is

A 30-year-old woman has an acute onset of right hemiplegia and aphasia with no such past or family history. On exam, she was confirmed to have right-sided hemiparesis and aphasia. Her pulse was irregular. Diagnose:

A 67 year old man presents with paralysis of the upper extremities and face. Also present are hemisensory loss, hemianopia, and aphasia. He is diagnosed with stroke. Which one of the following arteries is most likely involved in this patient?

Physician of 50-year-old man suffering from cerebral injuries thinks that he can be kept alive by mechanical ventilation, but he is unlikely to regain consciousness. His son presents a document signed by the patient and two witnesses that should this state arise, he would not want to be kept alive by mechanical means. His son states that "I think he wanted to donate organs but did not write anything". His driver´s license shows at the back that he has written about donating organs. His wife states that he would like to keep him on support and not donate his organs after his death. What should the physician do?

An 11 year old girl is brought to a pediatrician because of a newly developed tendency to stumble and fall. Physical examination demonstrates a broad-base, slow clumsy gait with a tendency to lunch from side to side. Several years later, the girl develops upper limb involvement manifested by clumsiness of fine movements and a coarse intention tremor. The patient eventually dies in the fourth decade of life, having experienced slowly progressive symptoms, and eventually becoming bedridden and developing kyphoscoliosis and foot deformities. The most likely finding at autopsy would be

A 55 year old man presents with gradual onset mild dementia, ataxic gait, and startle myoclonus. MRI scan is normal, and his cerebrospinal fluid examination reveals no abnormalities, but the patient´s EEG is remarkable for recurrent bursts of high voltage slow waves. Over the next 6 months the patient´s dementia rapidly worsens, accompanied by general hypertonicity and profound dysarthria. The patient dies shortly thereafter. The mostly likely neuropathological finding on autopsy would be

A 22 year old man with new onset of seizures is evaluated with contrast enhanced CT scan of the head, which demonstrate a mixed parenchymal and subarachnoid hemorrhage. The parenchymal hemorrhage is centered over one cerebral hemisphere. She has no history of hypertension. The most likely source of the hemorrhage is

A 5 year old child is brought to a pediatrician because the child is having chronic, severe headaches. Physical examination demonstrates poor visual tracking with one eye, which had not been present 1 year previously. A CT scan of the head is ordered which demonstrates a cystic 4 cm mass above the pituitary gland. Resection of the tumor reveals a cystic lesion filled with dark, oily fluid containing granular debris. Histological examination of the tumor would most likely demonstrate a tumor with areas resembling which of the following?

A 74 year old man with no known cardiac history flies from California to New York. He collapses and is rushed to the emergency department. The patient is unable to respond to questions or follow instruction. He dies three days later. Examination of the brain at autopsy reveals multiple loosely adherent clots within the distal branching arteries of the left middle cerebral artery. The pathologic condition that would most likely account for these findings is

Which of the following does not characterize electrical activity of the brain?

Bacterial pathogens encroach upon the central nervous system by invading which one of the following structures during meningeal invasion?

A 60 year old man is brought to the Emergency Department by family members after he experienced a seizure. According to them he recently complained of headache and weakness of his hand. The most likely diagnosis is which of the following?

What test is most appropriate for the diagnosis of carpal tunnel syndrome?

The LEAST likely finding in cerebral thrombosis is

The psychiatric finding that is most consistent with neoplastic lesions of the temporal lobe includes which one of the following?

A 45 year old obese male with a history of hypercholesterolemia, hypertension, and coronary artery disease woke up in the morning and collapsed. The patient did not regain consciousness and died 8 hours after arriving in the hospital. Autopsy shows a large amount non clotted blood in the brain. Hemosiderin is absent. The blood had tracked through the brain tissue making the origin of the hemorrhage difficult to detect. The most likely the source of the bleeding is

A 3 year old girl with a history of hydrocephalus presents with a severe headache and fever. She underwent a revision of a ventricular peritoneal shunt one month ago, and the neurologist suspects that an infection has occurred. The most important feature of the most likely organism in this case is

A couple present to the physician because of sleep difficulties. The wife reports that she cannot fall asleep at night because of her obese husband´s loud snoring. He complains of feeling drowsy during the day and falling asleep while driving home from work. The husband most likely has which condition?

A 65-year-old hypertensive maintained on amlodipine and lisinopril has pain in his back for the last several months. It starts in his lower back and radiates to his buttocks as well as to the back of his legs, bilaterally. It worsens on walking or standing and improves on sitting or going uphill. He had an inguinal hernia surgically repaired 3 years ago. There is no other significant past medical or surgical history. It can be elicited by extension of the spine. The patient also has a positive Romberg sign. What is the most likely diagnosis?

A 73 year old man presents with weakness and reduced mobility. On exam he has a slow gait with reduced arm swing and a tremor is noticed in the left arm. The typical frequency of the rest tremor in Parkinsons disease is which one of the following?

A 61 year old woman has headache and vomiting for 1 day. She has been on steroid for temporal arteritis for the last 3 years. Exam shows pyrexia, neck stiffness, photophobia, dysarthria, nystagmus and ataxia. CSF shows neutrophilic pleocytosis, low glucose, elevated protein. The likely diagnosis is

A 29-year-old HIV-positive woman had a seizure. She has been having headaches and fevers over the past couple of months. Her husband says that she "Just has not been herself lately and often seems like she is in another world." Her temperature is 38.5 oC (101.3 °F). Physical examination is unremarkable. A CT scan of the head is shown below.

The lesions respond to a 14-day course of pyrimethamine and sulfadiazine. Which statement is most correct regarding the scenario given:

A 31-year-old male is admitted with severe acute onset headache. He is disoriented and drowsy and has neck stiffness. What grade of SAH does this patient have?

Which of the following statements regarding hiccup is true?

A 36 year old male has been on life support systems for the past 48 hours following blunt head trauma. The most by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199078&Page=3#22395005">IMPORTANT criterion to declare the patient brain dead and to permit removal of life support systems is

Which of the following is not present in a patient with delirium tremens?

A 25 year old female arrives at the Emergency Department in a state of unconsciousness. Her BP is 90/60, heart rate is 60 bpm, she is breathing at 8 breaths per minute and her O2 saturation is 86%. Her eyes remain closed even after pain stimulation and the sounds she makes are incomprehensible. Her elbows and wrists are flexed with her feet extended. Glascow coma score (GCS) of this patient is

A 62 year old man presents with back and leg pain and trouble urinating. On examination, he has decreased sensation over the buttocks, normal motor power, and absent ankle jerks bilaterally. What would be the best investigation for this patient?

A 49-year-old female patient develops an acute, severe and isolated left C6 radiculopathy affecting both the motor and sensory roots. She is examined in an EMG clinic three weeks after the onset of symptoms. Which of the following statement is true?

A 29 year old carpenter dropped his circular saw and severed his lower leg. A severed tibial nerve would be indicated by which of the following?

A 36 year old epileptic patient presents to you complaining of a fuzzy feeling in the head. Examination shows bidirectional horizontal nystagmus. What is the most likely cause of this finding?

A vegetarian woman develops symptoms of fatigue, dizziness and dyspnea. She comes in for evaluation and here CBC shows anemia with a MCV of 104. The most appropriate next step in diagnosis is

A 65 year old diabetic man presents with constriction of the pupil, drooping of the upper lid and enophthalmos on the left. The nerve that is most likely involved is

In differentiating early Parkinson´s disease from variants such as drug induced Parkinsonism, progressive supranuclear palsy, and multiple system atrophy, the most by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199177&Page=8#56909115">IMPORTANT clue is

A 58 year old man with normocytic, normochromic anemia presents with an acute backache after sitting down on the toilet. He is unable to pass his urine and unable to stand up because of weakness in his legs. The most appropriate next investigation is

Which of the following can be associated with optic neuropathy due to nerve compression?

What is a major consequence of severe dermatomyositis in children that rarely seen in adults?

A 63 year old retired salesman is brought to the physician´s office by his wife because of progressive dementia, confusion, and memory loss. The geriatrician suspects Alzheimer´s disease. Which of the following is NOT associated with Alzheimer´s disease?

A 34 year old nurse comes to the emergency department after leaving work early because of a "horrible headache." She has had a "cold" with sinus congestion for the past week, and yesterday she began taking an over the counter combination of diphenydramine and pseudoephedrine. She tells you she has a history of migraines, multiple allergies, premenstrual syndrome and depression, for which she takes phenelzine (a monoamine oxidase inhibitor). Vital signs are: temperature 37.2°C (99.0°F), pulse 90/min, respiration 16/min and blood pressure 210/118 mmHg. The most appropriate action at this time is

A 55 year old man presents with a right sided hemiparesis. The patient seems to comprehend everything, but cannot express his thoughts well. He is diagnosed with Broca´s aphasia. The most likely site of the brain lesion is

Which one of the following findings is consistent with neoplastic lesions of the parietal lobe?

A schizophrenic Chinese male of 25 years age presents with symptoms of rigidity, fever, and a leukocytosis. His creatinine phosphokinase level is elevated. His only medications are haldoperidol and multivitamins. The treatment of choice would be

Which of the following does NOT produce a Parkinsonian syndrome?

A 66 year old man with a history of hypertension and atrial fibrillation was seen in his usual state of health 2 hours ago, and then he was found on the living room sofa in an obtunded state. On exam, he has the signs of middle cerebral artery stroke. Head CT scan does not reveal any acute hemorrhage, but MRI supports ischemic injury to a large portion of his right cerebral cortex. Which is most appropriate in his acute treatment?

A 66 year old man with a history of hypertension and atrial fibrillation was seen in his usual state of health 2 hours ago, and then he was found on the living room sofa in an obtunded state. On exam, he has the signs of middle cerebral artery stroke. Head CT scan does not reveal any acute hemorrhage, but MRI supports ischemic injury to a large portion of his right cerebral cortex. Which is most appropriate in his acute treatment?

A 50 year old woman has rhythmic involuntary shaking of both hands that had been gradually worsening for 10 years. It is worse when she is nervous or upset. On exam, she has a moderate amplitude 8 Hz tremor of the upper extremities that particularly involves flexion and extension at the wrists and lingers. Tremor is mildly accentuated when her arms are outstretched and when she performs the finger-nose maneuver. She also has very low amplitude, similar frequency tremor of her head and voice. Rest of her neurologic examination is normal. Which agent would most likely relieve her symptoms?

A 47 year old male is brought to the ER with hyperpyrexia, muscle rigidity, altered mental status, tachycardia, hypertension, and diaphoresis. He is taking only one medication. Which medication is he most likely taking?

A 28 year old male is brought to a physician following a head injury. According to his wife she and her husband were walking on the sidewalk when he suddenly fell to the ground and hit his head. She said similar episodes had occurred before. An EEG at the appropriate time would probably reveal which type of seizures?

A 56-year-old woman underwent total right mastectomy and chemotherapy for metastatic breast cancer 3 years ago. 2 months ago, she started noticing lower back pain that became progressively worse, and this morning, she went incontinent. Bone scan previously showed positive radioisotope uptake in T10, L5, L3, and the right 5th rib. The pleural tap revealed exudative effusion with cytology positive for adenocarcinoma cells consistent with the patient´s known primary diagnosis. Power is normal except in lower extremity, it is 4/5. In addition to steroid therapy, what is the next correct step?

A 71-year-old gets easily confused and has trouble remembering where he is or with whom he is talking. For last 6 months to a year, his memory is progressively deteriorating. He has also been paranoid, accusing others of trying to steal from him. No other relevant findings exist. His 6 months old CT scan of the head shows diffuse atrophy, but no masses. MMSE score =22 out of 30. Which is necessary to confirm the diagnosis?

A 36-year-old man has gradually progressive decreased sensation and tingling in both upper extremities (with sparing of fine touch and vibration sense) for the last few months. There is no motor weakness or bowel or bladder incontinence. DTRs and CNs are normal. MRI of the head shows downward shift of the cerebellum and medulla through the foramen magnum. Which of the following is the most likely diagnosis?

A 35-year-old man has daily headaches over the past 2 weeks. They begin in the morning and last for the whole day. They feel like a squeezing tightness around his head and is particularly intense in the back of the neck. He drinks many cups of coffee during the day. Which can be the most appropriate next step?

A 69-year-old hypertensive and case of pancreatic cancer suffers a pulmonary embolus. He is started on IV heparin. After the second day of therapy he develops right-sided weakness, and a CT scan of the brain shows an intracerebral hemorrhage. The heparin is stopped. Which of the following is the most appropriate in the management of this patient?

A 69-year-old pediatrician develops headache of sudden onset, slurring of speech, and confusion. He is brought to the emergency department, where he arrives with a Glasgow coma score of 8. An emergency CT scan of the head reveals well-demarcated lobar bleeding involving the left frontal lobe, centered in the cortex and extending into the underlying white mailer. The patient history is negative for hypertension or vascular risk factor. Which of the following is the most probable underlying cause a of the patient´s blooding?

A 69-year-old man has had "out of control" behavior in the past few weeks. He has started cursing and passing flatus loudly in front of others. His mood changes suddenly, and he bursts easily into laughter or tears without an apparent cause. At family meals he grabs food from his plate and the table and shoves it into his mouth as if someone were about to the take it from him. He is slow to arise from a by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199177&Page=28#70456331">CHAIR. No cogwheel rigidity is noted. He has a tremor which increases when reaching for a piece of paper. Brain studies show irreversible changes with prominent frontotemporal atrophy. Which of the following is the most likely diagnosis?

A 29-year-old man has severe eye pain. He has had similar episodes but this one is the worst. It is stabbing, 9/10 in intensity, behind his left eye. He has tearing of the left eye. Visual acuity is normal, the left pupil is smaller than the right pupil, and the left eyelid is slightly drooped. Which of the following is the best initial step in the management of this patient?

A 48 year old woman has a history of migraine. She smokes 20 cigarettes a day. She has found that paracetamol 1 g was not always effective in relieving her pain. The factor that is most likely to account for this problem is which one of the following?

Which of the following statements regarding CADASIL (cerebral Autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is correct?

A 23-year-old male is admitted with acute onset headache and is drowsy. He opens his eyes spontaneously, is disoriented and localizes painful stimuli. He has a normal computed tomography scan. Which of the following is the next most appropriate investigation for this patient?

A 20-year-old boy is brought to the Emergency Department after having taking drugs at a rave. Which of the following suggests that he has taken Ecstasy (MDMA)?

A 70-year-old man presents with Parkinson´s disease. Which of the following is a mechanism underlying the neurodegeneration seen in this condition?

A 73-year-old male has dyspnea, weight loss and lethargy for two months. Past history inculdes a left sided hemiparesis due to stroke. On exam there is residual left sided hemiparesis with a pale and slightly jaundiced appearance. His Hb is 5g/dL, MCV is 109fL, WBC count is 2 x 109/L and platelets are 46 x 109/L. Urinalysis shows increased urobilinogen. Appropriate next investigation is:

Out of the following, which is not a classic sign of basal skull fracture?

A 60 year old woman has demonstrated increasing loss of recent memory over a 5 year period, now associated with reduced affect and nominal dysphasia. She by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199200&Page=7#45891230">DRESSES neatly and social amenities are preserved. No localizing motor or sensory findings are present. The most likely diagnosis is

A 50-year-old man is diagnosed with small cell lung cancer. Despite a normal brain MRI he develops progressive truncal ataxia. Which of the following would be most useful in the diagnosis of his condition?

A 36 year old woman presents with ataxia, weakness of the left side of her body, dysphagia and visual problems. Examination reveals diplopia and nystagmus. The most likely diagnosis is

What is the correct initial dosage and frequency for levodopa in the treatment of Parkinson disease?

A patient on total parenteral nutrition develops proximal neuromuscular weakness. What is the most likely deficiency?

A 20 year old girl is brought to the emergency department unconscious. Her vital signs are within normal limits and she has no focal abnormalities on neurological examination. She has been incontinent. General physical examination is unrevealing save for a nasal septal perforation and thrombosed antecubital veins. The most appropriate diagnosis is

A 70 year old female with insomnia participates in a sleep study. As part of the study protocol, she has EEG leads attached then goes to sleep. At one point during the evening, 12-16 Hz sleep spindles and K-complexes are observed. Out of the following which sleep stage is associated with this patient?

A 44 year old homeless man is brought to the emergency department in a coma. There is no specific odor to his breath. Arterial blood gas studies show a blood pH of 7.32 with bicarbonate level of 20.9 mEq/L. No enzyme elevation is seen on serum chemistries. The man is oliguric; a urine sample is remarkable only for oxalate crystals. The most likely diagnosis is

A 36 year old man complains of having frequent severe headaches. He also has a history of fever and weight loss, for which he had been admitted for an extensive workup. Obtaining IV access was difficult, and a central venous line had been placed. On physical exam today he has a heart murmur and painful indurated areas on his fingers and toes. He is HIV negative and has positive blood cultures. Papilledema is revealed on fundus examination. Brain CT scan demonstrates a ring enhancing lesion. The most likely causative agent involved in this man´s disorder is

Which of the following is NOT a characteristic of melatonin?

The prognosis is best with which etiology of meningitis?

A 25 year old woman presents with severe headache. Which criterion is NOT supportive of a diagnosis of migraine headaches?

A 23 year old man has acute lower back pain without paresthesias or other neurologic signs. No lower extremity weakness is present on examination. The best treatment initially is which of the following?

A 32 year old morbidly obese female presents to the emergency room with headache, nausea, vomiting, and diplopia. Bilateral papilledema is revealed on examination. CNS exam and brain CT scan is normal. The lumbar spinal fluid pressure is elevated to 350 mm. Which is NOT a therapeutic modality for this disease?

An HIV positive 54 year male with a CD4 count of 198/mm3 presents because of a sudden deterioration of mental acuity. He has headache, and at the time of examination, has nuchal rigidity, time place disorientation, and marked contusion. CSF analysis reveals 100 WBCs, 80% lymphocytes, protein = 85 mg/dL, and glucose = 45 mg/dL. Simultaneous blood glucose is 90 mg/dL. After the physician treats a drop of CSF with a particulate dye, microscopy reveals the structures shown below. The diagnosis would most likely be confirmed by

A 34 year old man´s neurologic examination reveals a direct and a consensual by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199200&Page=22#35158517">LIGHT reflex in his left eye, but neither a direct nor a consensual light reflex in his right eye. Which sign is also likely to be found during his examination?

An 89-year-old male has pain in his right arm 1 month after a humeral fracture, and has now been present for 6 months. His arm is in a sling and is wrapped in soft by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199200&Page=23#1846489">CLOTH. He states that even the breeze blowing against the skin of his affected arm causes severe pain. He also states that his arm constantly has a burning or aching sensation. The skin of the distal arm is cool, shiny, and cyanotic. An early flexion contracture of the fingers and wrist is evident. In the course of this condition, the skin on his affected arm was actually sweatier and warmer than his uninjured arm. Which of the following conditions best explains this patient´s symptoms?

A 70-year-old man complains of dizziness. While shopping, he says that the room seemed tilted and spinning. He did not black out, but he became confused and had blurred, double vision. He felt as if his head, arms, and legs were made of lead, and that the floor was rushing up at him. No pain or altered sensation, aside from a by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199200&Page=24#32327995">RINGING in his ears, now resolved, was present. He had slurred speech and difficulty keeping his eyes open. He is admitted for evaluation of TIA. Based on the patient´s history, which of the following was most likely affected?

A 49-year-old man has recurrent attacks of headache, which manifest with a peculiar rhythmic pattern. Each attack begins on awakening, approximately at the same time. He reports severe unilateral pain localized in the right eye and temple, and accompanied by running nose, teary eyes, and sweating on the same side. The attack spontaneously resolves after 2 hours. Ibuprofen and acetaminophen do not help with the acute pain. All examination is normal. Which of the following is the most likely diagnosis?

A 30-year-old woman has urinary incontinence for 6 months. She is being treated for multiple sclerosis, diagnosed 3 years ago. After treatment with methylprednisolone and interferon, the incontinence still remains. Despite restricting fluid to 1800mL /day and scheduled voiding, she continues to have episodes of urinary leakage and a sensation of a full bladder. Urodynamic studies show a flaccid bladder and high post void residual volume. What to start treatment with?

A 55-year-old man has acute onset of back pain over the past couple of days localized to his sacral area. He denies any fever, chills, and by DealXplorer" href="http://www.interface.edu.pk/medical-exams/test.php?u=33509&t=199200&Page=27#59306607">SHORTNESS of breath or trauma. He has had loss of control of his bodily functions. His past medical history is notable for small cell lung carcinoma treated with chemotherapy 5 years ago. Currently he takes no medicines. BP= 180/70 mmHg. Which additional finding would aid in confirming the diagnosis?

A 14-year-old boy has soreness and weakness in his legs for the past day that has slowly spread from his calves to his thighs. He now complains of weakness in his trunk and arms, and double vision. He had a diarrheal episode a week ago. Temperature is 37°C (98.6 °F), pulse is 48/min, and respirations are 22/min. Both legs are diffusely tender with symmetric weakness. Deep tendon reflexes are difficult to elicit in the lower extremities, and sensation is greatly diminished. Which of the following is the best initial test to make the diagnosis?

A 43-year-old HIV-positive man gets a seizure. He is confused, febrile and has headache. Pulse= 116 beats/min, BP= 110/64 mmHg. He is disoriented to time, person, and place. CT is below:

Which of the following is the best next step in management?

Confusion with headaches is complained by a 64-year-old female for 1 day. GCS is 13 and temperature is 39.5°C. She has nuchal rigidity and photophobia. CSF shows glucose of 0.5mmol/L, white cell count of 2500 per mm and Gram-positive cocci in pairs. Which of the following is correct?

A baseball player was struck on the left side of the head with the ball. The player fell to the ground, but was not unconscious. After a few hours he was seen to be confused and irritable. Which one of the following is the most likely diagnosis?

A 24 year old right handed female has recurrent spells during which she seems to be "out of contact" for about 30 seconds. These are associated with a feeling of fear and recollection of memories from the past. For a few minutes following an attack, she has trouble finding words to express herself. The site of origin for these attacks is which of the following?

A 57 year old man with a history of a parathyroidectomy for primary hyperparathyroidism now presents with complains of headaches worse in the AM, made worse by a small MVA he credits to a loss of peripheral vision. You plan to

A 56 year old man with coronary artery disease suffered a cardiac arrest while jogging 10 days ago. He was resuscitated after 45 minutes but has remained unresponsive and on a ventilator since then. To diagnose brain death in this patient which of the following is required?