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Questions and Answers
What is the most likely diagnosis for the 27-year-old man who experiences severe muscle cramping and weakness after exercise?
Which diagnostic study is most likely to be abnormal in a delirious elderly patient?
In the case of the 77-year-old woman with multi-infarct dementia, what is the most appropriate management?
What is the most appropriate next step in the management of a patient with signs and symptoms consistent with a right S1 radiculopathy?
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What is the likely cause of the findings in a patient exhibiting signs of proliferative diabetic retinopathy?
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What are the symptoms of radiculopathy associated with S1 nerve root compression?
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What is the most appropriate management for a patient with silent cerebrovascular disease who is already on aspirin for secondary prevention of myocardial infarction?
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What type of dementia results from acute cerebral infarctions secondary to cerebrovascular disease?
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Which cranial nerve is most commonly affected in microvascular cranial nerve palsy due to diabetes mellitus?
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What is a common cause of internuclear ophthalmoplegia (INO) in younger patients?
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During horizontal eye movements, lesions of the __________ cause internuclear ophthalmoplegia.
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Which of the following is the most likely diagnosis?
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What is the characteristic presentation of leprosy?
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Leprosy is endemic to developed countries.
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What is the treatment for leprosy?
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What is the primary mode of diagnosis for leprosy?
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Which cranial nerve is responsible for motor innervation of the superior oblique muscle?
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What is the presentation of a trochlear nerve deficit?
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Which cranial nerve is responsible for motor innervation of the lateral rectus muscle?
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What condition is characterized by diplopia, ptosis, and weakness that worsens towards the end of the day?
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In what condition does an erythrocyte sedimentation rate (ESR) commonly exceed 100 mm/h?
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What is the primary cause of internuclear ophthalmoplegia (INO)?
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Thiamine supplementation can prevent Wernicke-Korsakoff syndrome.
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What triad is commonly associated with Wernicke encephalopathy?
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Which spinal condition often has a presentation of chronic bitemporal headache and diffuse achiness?
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What is commonly used to treat polymyalgia rheumatica (PMR)?
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Which of the following symptoms should prompt consideration of giant cell arteritis (GCA)?
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What is the typical presentation of sensorineural hearing loss?
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What does the diagnosis of giant cell arteritis typically require?
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What is the most common cause of sensorineural hearing loss?
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What clinical signs are consistent with a diagnosis of giant cell arteritis?
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A vibrating tuning fork placed on the forehead is heard better on the affected side for sensorineural hearing loss.
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What findings on a Rinne test indicate sensorineural hearing loss?
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What should be the next step in diagnosis for a patient suspected of having giant cell arteritis?
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What is the most likely diagnosis for a 35-year-old man with a 3-year history of dermatomyositis and progressive weakness?
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What is the most appropriate next step in management for a 72-year-old woman with confusion and urinary incontinence?
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What is the most likely diagnosis for a 62-year-old man with progressive behavior changes, ataxia, and myoclonus?
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What is the most likely pathogen for a 72-year-old man with decreased consciousness after fever and productive cough?
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What is the most appropriate initial recommendation for a 37-year-old woman with intermittent numbness and foot weakness?
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What is the most likely explanation for the mental status changes in an 82-year-old woman who has been treated with hypertension medications?
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What is the most likely cause of temporary neurological episodes in a previously healthy 58-year-old man?
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What is the most likely location of the abnormality for a previously healthy 18-year-old man with facial weakness?
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Which drug is most likely effective in reducing the frequency of severe throbbing headaches preceded by visual disturbances?
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What is the appropriate measure to prevent transmission of chickenpox to unvaccinated grandchildren from the grandmother with a rash?
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What is the most likely manifestation of frontal lobe injury in a 17-year-old girl after a motor vehicle collision?
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What is the most likely cause of neurological symptoms for a 57-year-old woman with history of ovarian cancer and tingling in her extremities?
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Which of the following is the most likely diagnosis for a 52-year-old woman who had a generalized tonic-clonic seizure and has a sodium level of 112 mEq/L?
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In addition to ceftriaxone and vancomycin, which of the following is the most appropriate pharmacotherapy for a 3-week-old newborn presenting with signs of infection?
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What is the most likely diagnosis for a 62-year-old man who experienced a loss of consciousness while shaving, with a history of light-headedness, nausea, and normal cardiac evaluations?
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What is the most likely diagnosis for a 32-year-old man with difficulty walking, decreased grip strength, and atrophy of facial muscles?
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Which of the following is the most likely site of nerve injury for a patient experiencing numbness in the dorsal first web, thumb, and index finger after radial fracture surgery?
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What is the most likely diagnosis for a 62-year-old woman with a history of breast cancer presenting with progressive weakness and numbness starting in her feet?
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Which of the following is the most likely cause of the patient's lethargy?
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Which of the following is the most likely diagnosis of the 40-year-old man with pain in his left buttock and posterior thigh?
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Which of the following is the most appropriate pharmacotherapy for the 52-year-old man experiencing insomnia and restless legs?
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An MRI of the brain for a 57-year-old man with increasing memory problems is most likely to show which of the following?
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In which of the following locations is a saccular aneurysm most likely to be found in a patient with sudden onset headache and subarachnoid blood?
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Which drug is most likely to cause involuntary movements of the tongue and jaw in a 72-year-old woman?
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Which factor is the strongest predisposing factor for the condition of a 22-year-old woman with multiple neurologic episodes?
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What is the most likely diagnosis for a 32-year-old man who becomes agitated and disoriented four days after hospitalization for internal fixation of a femoral fracture?
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What is the most likely explanation for the increased request for morphine dosage from a 57-year-old woman with metastatic breast cancer?
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What is the most appropriate next step in diagnosis for a 62-year-old man with weakness in his left arm and light-headedness?
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What is the most likely diagnosis for a 27-year-old man with severe muscle cramping and weakness after exercise, resolving within 24 hours and dark urine during episodes?
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In a 77-year-old woman with sudden onset fearfulness and combativeness, which diagnostic study is most likely to be abnormal?
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What is the most appropriate management for a 77-year-old woman with multiple small infarctions and diffuse muscle weakness?
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What is the most likely site of the lesion in a patient with visual disturbance and eye movement deficits?
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What is the most likely cause of a 35-year-old man seeing double and having an eye movement problem?
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Which complication can be prevented in a 49-year-old woman with chronic alcoholism by immediate administration of vitamin B1 (thiamine)?
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What is the most likely diagnosis for an 82-year-old woman with chronic bitemporal headaches and elevated erythrocyte sedimentation rate?
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What is the likely explanation for hearing difficulties in a 57-year-old man with a history of managing a nightclub?
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What is the most appropriate next step in diagnosis for a 77-year-old man with headache, fever, and elevated erythrocyte sedimentation rate?
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What is the most appropriate next step in management for a 42-year-old man with right posterior leg reduced sensation and back pain?
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What is the most likely cause of progressive loss of visual acuity in a 49-year-old woman?
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What is the most likely diagnosis for a 42-year-old man treated with isoniazid, who has numb hands and thicken peroneal nerves?
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What is the most likely cause of the infant's condition with significant bilateral hearing loss?
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Which of the following is most likely to improve this patient's mental status?
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Which of the following is the most likely location of the patient's lesion causing weakness on the right side and sensory loss on the left?
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What is the most appropriate next step in pharmacotherapy for the patient with Parkinson's disease experiencing hallucinations?
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What is the most likely diagnosis for the woman with progressive forgetfulness and changes in sleep patterns?
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What is the most appropriate next step in diagnosis for the patient with unusual behavior and Parkinson's disease?
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What is the most likely explanation for the patient's episodes of staring and blinking while eating?
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What is the most appropriate next step in management for the patient with a ring-enhancing lesion in the right parietal cortex and left arm clumsiness?
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What is the most likely diagnosis for the woman with a severe headache and marked neurological symptoms?
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The woman with urinary incontinence due to metastatic breast cancer has significant pain over the entire lumbar spine on ______.
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Study Notes
Multi-Infarct (Vascular) Dementia
- A type of dementia caused by multiple small strokes
- Typically, patients have a history of clinical strokes that are associated with focal neurological deficits and a stepwise decline in function.
- Diagnosis requires evidence of cerebrovascular disease and cognitive impairment
- Management involves secondary prevention of stroke via blood pressure control
- Anti-platelet therapy with aspirin is required for patients with a history of stroke and for many patients with silent cerebrovascular disease
- This patient already takes aspirin for secondary prevention of myocardial infarction and does not require additional medication
Silent Cerebrovascular Disease:
- Patients experience progressive neurological decline with multiple small infarcts on neuroimaging
- Causes: underlying cerebrovascular or thromboembolic disease
Vascular Dementia
- Results from cognitive impairment caused by acute cerebral infarctions due to underlying cerebrovascular or thromboembolic disease.
- Patients often have a history of clinical strokes with focal neurologic deficits and stepwise decline in function.
- Some patients demonstrate silent cerebrovascular disease with progressive neurologic decline and multiple small infarcts seen on neuroimaging.
- Risk factors for cerebrovascular disease include hypertension and atherosclerotic disease (as evidenced by a prior myocardial infarction).
- Management involves secondary stroke prevention through blood pressure control.
- Antiplatelet therapy with aspirin is generally required in patients with a stroke history or silent cerebrovascular disease.
- Long-term antithrombotic therapy with enoxaparin, heparin followed by warfarin, or warfarin alone are appropriate after acute ischemic stroke related to atrial fibrillation, left ventricular thrombus, or valve replacement.
- Vitamin E supplementation has not been proven effective for preventing cardiovascular or cerebrovascular disease.
Cranial Nerve VI (Abducens) Palsy
- Commonly affected by microvascular damage from diabetes mellitus, resulting in esotropia, unilateral abduction deficit, and diplopia in horizontal gaze.
- Patients may experience ocular or periocular pain.
- Important to exclude other causes, such as stroke, increased intracranial pressure, vasculitis, or optic neuropathy.
- Most patients with microvascular abducens nerve palsy see resolution of symptoms after several months of treating the underlying cause.
Medial Longitudinal Fasciculus (MLF) Lesions
- Cause internuclear ophthalmoplegia (INO), presenting with an ipsilateral adduction deficit and a contralateral abduction saccade.
- INO may be unilateral or bilateral.
- In younger patients, demyelination associated with multiple sclerosis is the most common cause.
- In older patients, ischemic stroke is the most common cause.
Internuclear Ophthalmoplegia (INO)
- INO is a neurological condition that disrupts coordinated horizontal eye movements
- It arises from a lesion of the medial longitudinal fasciculus (MLF)
- MLF connects the oculomotor nucleus with the contralateral paramedian pontine reticular formation and abducens nucleus, enabling coordinated horizontal eye movements
- People with INO experience an ipsilateral adduction deficit, meaning the affected eye cannot cross the midline
- The eye on the opposite side will show an abduction saccade, an involuntary rapid eye movement away from the midline
Wernicke Encephalopathy
- A neurological disorder caused by thiamine (vitamin B1) deficiency
- Frequently occurs in people with chronic alcohol use due to malnutrition, poor thiamine absorption, and impaired cellular thiamine utilization.
- The condition results in damage and atrophy of the mammillary bodies, visible on brain MRI.
- Classic symptoms include:
- Acutely altered mental status
- Ophthalmoplegia (with nystagmus)
- Ataxia
- Treatment involves high-dose parenteral thiamine
- Prompt treatment with thiamine is essential because Wernicke encephalopathy can increase the risk of developing Wernicke-Korsakoff syndrome, an irreversible condition.
Wernicke-Korsakoff Syndrome
- A neurological disorder caused by long-term thiamine deficiency, often associated with chronic alcohol use.
- The syndrome presents with a combination of Wernicke encephalopathy and Korsakoff psychosis.
- Symptoms:
- Psychosis
- Anterograde and retrograde amnesia
- Confabulation (fabricating stories or memories)
- Ataxia
- Ophthalmoplegia
- Wernicke-Korsakoff syndrome is irreversible.
Polymyalgia Rheumatica (PMR)
- An inflammatory disorder that primarily affects older adults
- Often occurs concurrently with giant cell arteritis (GCA)
- Characterized by:
- Proximal muscle and joint pain and stiffness (eg, shoulder and hip girdle)
- Fatigue
- PMR is diagnosed clinically
- Treatment involves low-dose prednisone for up to a year
- Rapid response to prednisone can help confirm the diagnosis.
- Because GCA occurs concurrently in up to 20% of PMR patients, it's essential to watch for symptoms like:
- Throbbing temporal headaches
- Vision changes
- Jaw claudication
- These symptoms necessitate a temporal artery biopsy and high-dose prednisone therapy
Sensorineural Hearing Loss
- A type of hearing loss caused by damage or loss of function of the hair cells in the inner ear
- Common causes include exposure to loud noise and age-related hearing loss (presbycusis)
- Symptoms:
- Difficulty hearing, especially high-frequency sounds
- Normal conduction hearing tests
- Rinne test - normal air conduction with decreased hearing in the affected ear
- Weber test - decreased hearing in the affected ear
Sensorineural Hearing Loss
- Occurs due to damage or loss of function of the hair cells of the organ of Corti within the inner ear.
- Most common cause is presbycusis, which often occurs with prolonged exposure to loud noise.
- Examination findings include:
- High frequency hearing loss
- Normal air conduction and decreased hearing in the affected ear in a Rinne test
- Decreased hearing in the affected ear in a Weber test.
Otosclerosis
- Causes loss of mobility of the auditory ossicles.
- Small bones of the middle ear undergo bony remodeling and loss of mobility.
- Impairs the ability to transmit sounds as mechanical vibrations.
- Presents with low frequency conductive hearing loss and tinnitus.
Meniere Disease
- Characterized by episodic vertigo and sensorineural hearing loss.
- Caused by pressure accumulation in the endolymph of the inner ear.
Giant Cell Arteritis (GCA)
- Autoimmune inflammatory vasculitis of medium and large vessels.
- Presents with systemic symptoms such as:
- Fever
- Chills
- Weight loss
- Headache
- History of transient vision loss (amaurosis fugax)
- Jaw claudication
- Tenderness of the scalp
- Pale optic disc edema.
- Often occurs in association with polymyalgia rheumatica, characterized by stiffness and pain of proximal muscles.
- Laboratory findings include:
- Increased inflammatory markers (ESR and CRP)
- Thrombocytosis.
- Affects vessels of the head and neck, often affecting the ophthalmic artery.
- Inflammatory occlusion of the ophthalmic artery can result in sudden, ischemic damage to the retina.
- Diagnosis is confirmed with a biopsy of the temporal artery demonstrating granulomatous vasculitis.
- Treatment includes immediate high-dose corticosteroids to preserve vision.
Lumbosacral Radiculopathy
- Neurological symptoms secondary to spinal nerve root compression.
- Compression can be due to:
- Herniated intervertebral disc
- Narrow or stenotic neural foramen
- Compression from tumors or infection.
- Presents with pain and weakness in the dermatome and/or myotome supplied by the affected nerve root.
- Most common in the lumbosacral region.
- Often presents with sensory changes in the buttocks, posterior leg, and lateral foot.
- Compression leads to edema and inflammation of the nerve root and surrounding structures, causing pain.
- Treatment involves anti-inflammatory medications such as ibuprofen.
- Most patients will improve with conservative care and graded exercise or physical therapy.
Leprosy
- Leprosy is a mycobacterial disease involving the skin and peripheral nerves
- The bacteria causing the disease has a predilection (preference) for cooler areas of the body
- It is most commonly found in developing countries.
- Patients present with pigmented, hypoesthetic (loss of sensation) skin lesions with associated paresthesia (abnormal sensations)
- Thickened nerves and sensorimotor neuropathy are also common findings
- This is due to an immune response likely leading to segmental demyelination (loss of myelin sheath)
- The most commonly affected nerves are the ulnar, median, common peroneal, facial, and greater auricular nerves
- There are two main variations of leprosy:
- Tuberculoid disease: one to a few well-demarcated skin lesions with associated focal neuropathy
- Lepromatous disease: diffuse skin lesions and neuropathy
- Untreated leprosy can lead to:
- Permanent disability
- Skin lesions becoming nodular and ulcerating
- Coarsened facial features
- Diagnosis is made by means of a skin biopsy that shows acid-fast bacilli within a cutaneous nerve
- Treatment includes a combination of the following:
- Dapsone and rifampin
- Clofazimine in lepromatous disease
- Neuritis is treated with steroids
Acute Intermittent Porphyria
- Refers to the abnormal accumulation of the red blood cell protein porphyrin
- Clinically characterized by episodic abdominal pain, polyneuropathy, and psychological symptoms
- Patients may also have port wine-colored urine
- Polyneuropathy typically presents as acute sensory and motor neuropathy of the extremities
- Skin patches and coarse facial features are considered atypical for this condition
Other Differential Diagnoses
- Diabetic amyotrophy: presents with proximal leg muscle atrophy and weakness
- Guillain-Barré syndrome: characterized by ascending paralysis
- Paraneoplastic neuropathy: associated with malignancy
- Paraproteinemic neuropathy: related to abnormal proteins in the blood
- Motor neuropathy with conduction block: presents with weakness and muscle atrophy
- Charcot-Marie-Tooth disease: a hereditary disorder characterized by muscle weakness, atrophy, and sensory loss
- Alcoholic neuropathy: characterized by sensory and motor neuropathy, often with pain
- Acute glaucoma: presents with eye pain, redness, a fixed, mid-dilated pupil, increased intraocular pressure, and no visible fundus abnormalities.
- Detached retina: presents with decreased visual acuity and a visible region of subretinal fluid
- Macular degeneration: presents with visual distortions, scotoma (blind spot) drusen (yellow deposits) geographic atrophy, and neovascularization
- Optic neuritis: presents with acute onset vision loss, a relative afferent pupillary defect, and pain exacerbated by extraocular movements. It is often caused by demyelination and is potentially associated with the subsequent development of multiple sclerosis. Fundus findings are often normal but may include optic disc edema.
Patient Presentation
- A 77-year-old man, previously healthy, comes to the emergency room, with a history of falling and hitting his head, shows confusion, lethargy, and excessive sleepiness over the past 3 weeks.
- The patient has a history of hypertension, type 2 diabetes mellitus, frequent urinary tract infections, and renal calculi, treated with medications including losartan, glyburide, and trimethoprim-sulfamethoxazole.
- The patient, upon arrival, had a generalized tonic-clonic seizure lasting 40 seconds
- The patient is lethargic but easily aroused.
- Physical Examination:
- temperature is 37°C (98.6°F)
- pulse is 110/min
- respirations are 20/min
- blood pressure is 190/105 mm Hg
- examination shows an ecchymosis over the left scalp.
- Pupils are equally round and reactive to light
- Doll's eye (oculocephalic) maneuver shows full eye movement
- Cranial nerves are intact
- The patient moves all four extremities in response to painful stimuli
- Deep tendon reflexes are absent in the upper and lower extremities
- Babinski sign is absent bilaterally
- There is an occasional myoclonic jerk in the lower extremities
- He is disoriented to place and time.
Diagnosis
- The patient's presentation suggests a possible neurological issue, such as brain injury due to the recent fall, an infection, or a metabolic disturbance related to diabetes.
Next Steps
- The next step is to conduct further investigations to determine the cause of the patient's seizures, confusion, lethargy, and absence of reflexes. These investigations could include imaging studies like a CT scan or MRI of the brain, as well as blood tests to check for signs of infection, metabolic disturbances, and electrolyte imbalances.
- Further Examination:
- Blood tests to check for blood sugar levels and evaluate for infection
- EEG to evaluate brain activity and assess possible seizure activity
- Lumbar Puncture to rule out Meningitis or Encephalitis
- Treatment:
- Anti-seizure medication
- Aggressive hydration to prevent further neurological complications
- Treating any underlying conditions like diabetes or infection
- It is crucial to provide rapid and appropriate management for the patient's condition to ensure the best possible outcome.
Patient with Lethargy and Laboratory Results
- Lethargy is a common symptom that can be caused by several factors, including hepatic failure, pontine hematoma, status epilepticus, subdural hematoma, and uremic encephalopathy.
- The patient's laboratory results reveal elevated urea nitrogen and creatinine levels, suggesting uremic encephalopathy as the most likely cause of their lethargy.
Patient with Left Buttock and Thigh Pain
- A 40-year-old man presents with pain in his left buttock and posterior thigh that is exacerbated by coughing or sneezing.
- Deep tendon reflexes are absent at the left ankle.
- Passive flexion of the right hip with the knee extended produces pain in the left lower extremity.
- The most likely diagnosis is herniated nucleus pulposus, based on the patient's symptoms and the findings on x-ray and MRI.
Patient with Restless Legs Syndrome
- A 52-year-old man presents with a 3-month history of insomnia due to restlessness and a feeling of "ants crawling inside my legs."
- The patient experiences relief by moving his legs, hanging them over the bed, or uncovering them.
- Ropinirole is the most appropriate pharmacotherapy for restless legs syndrome, considering the patient's symptoms and laboratory findings.
Patient with Memory Problems and Involuntary Movements
- A 57-year-old man presents with increasing memory problems, facial grimacing, involuntary arm and leg spasms, and hypertension treated with captopril.
- Mental status examination reveals memory deficits, including inability to recall objects or name the current president.
- The patient experiences frequent, asymmetric, involuntary movements of all extremities, suggesting Huntington's disease.
- The most likely MRI finding would be atrophy of the caudate nucleus.
Patient with Sudden Onset Headache
- A 47-year-old woman presents with sudden onset of a severe headache characterized by double vision, throbbing pain exacerbated by head movement, and left ptosis.
- The patient also has hypertension treated with atenolol.
- The most likely diagnosis is subarachnoid hemorrhage, as confirmed by CT and lumbar puncture.
- Cerebral angiography is likely to show a saccular aneurysm in the left posterior communicating artery.
Patient with Involuntary Tongue and Jaw Movements
- A 72-year-old woman presents with involuntary movements of her tongue and jaw, intermittent nausea, and is currently taking various medications including metoclopramide, ranitidine, calcium carbonate, and bismuth subsalicylate.
- The most likely cause of her involuntary movements is metoclopramide, which is known to induce tardive dyskinesia.
Patient with Blurred Vision and Right-Sided Weakness
- A 22-year-old woman presents with episodes of blurred vision, right-sided weakness, urinary urgency and frequency, and incontinence.
- The patient has a history of a motor vehicle collision with a left humerus fracture, and has been using oral contraceptives for the past two years.
- The most likely diagnosis is multiple sclerosis, supported by the patient's symptoms, MRI findings, and absence of other risk factors.
- While the patient's history of the motor vehicle collision may seem relevant, it's not the strongest predisposing factor for her condition.
Patient with Agitation and Disorientation Following Femoral Fracture Fixation
- A 32-year-old man presents with agitation, disorientation, diaphoresis, picking at his bedsheets, and elevated temperature, pulse, and blood pressure four days after internal fixation of a femoral fracture.
- The patient is also experiencing psychomotor agitation and disorientation.
- The most likely diagnosis is fat embolism, considering the patient's recent surgery, vital signs, and mental status changes.
Patient with Metastatic Breast Cancer and Pain Management
- A 57-year-old woman with metastatic breast cancer presents with poorly controlled pain despite increased dosage of oral sustained-release morphine.
- The patient is agitated and tearful and requests another increase in her morphine dosage.
- The most likely explanation for her requests is inadequate pain control, considering her disease progression and history of increasing morphine dosage.
Patient with Left Arm Weakness and Lightheadedness
- A 62-year-old man presents with weakness in his left arm and lightheadedness during tennis games, accompanied by a cool left hand and arm.
- The patient's symptoms resolve after resting for 15 minutes.
- The most appropriate next step in diagnosing the patient's condition is ambulatory ECG monitoring, considering the potential for cardiac issues.
Patient with Dermatomyositis and Progressive Weakness
- A 35-year-old man presents with progressive weakness three weeks after previously responding well to high-dose prednisone therapy for dermatomyositis.
- The patient has normal serum creatine kinase and aldolase activities, but appears cushingoid.
- The most likely diagnosis is corticosteroid myopathy, due to the patient's history of high-dose prednisone treatment and the development of muscle weakness.
Patient with Confusion, Clumsiness, and Memory Loss
- A 72-year-old woman presents with increasing clumsiness, restlessness, confusion, and memory loss.
- The patient is unable to perform daily activities such as making coffee or buttoning her clothes.
- Her medications include digoxin, furosemide, potassium, ibuprofen, ranitidine, and diphenhydramine.
- The most appropriate next step in management is to discontinue anticholinergic medications, considering the patient's symptoms and the fact that diphenhydramine can cause anticholinergic side effects.
Patient with Behavioral Changes, Imbalance, and Myoclonus
- A 62-year-old man presents with progressive behavioral changes, including anxiety, fatigue, decreased memory, disorientation, imbalance, and brief body jerks.
- The patient's symptoms have progressed over eight weeks, and he is now unable to walk unassisted.
- The most likely diagnosis is Creutzfeldt-Jakob disease, supported by the patient's progressive neurologic decline, including myoclonus, and the absence of other potential causes.
Patient Presentation
- 72-year-old man with a 3-year history of Parkinson's disease
- Brought to the physician by his wife for a follow-up examination
- Three weeks ago, his dosage of carbidopa-levodopa was increased
- Since then, he has reported seeing people spying on him from across the street
Parkinson's Disease
- A chronic and progressive movement disorder
- Characterized by resting tremor, rigidity, bradykinesia, and postural instability
Carbidopa-Levodopa
- Commonly used medication for Parkinson's disease
- Helps to improve motor symptoms
- Can cause side effects, including hallucinations
Hallucinations
- Sensory experiences that seem real but are not
- Can be a side effect of medications, such as carbidopa-levodopa
- Can also be a symptom of other medical conditions
- In this case, the hallucinations may be due to an increase in carbidopa-levodopa dosage
Patient Presentation
- A 72-year-old woman is brought to the physician by her son because of a 1-month history of progressive forgetfulness.
- Patient reports recent difficulty staying asleep, often awakening at 4 or 5 am and unable to fall back asleep.
- Patient also reports a 4.5-kg (10-lb) weight loss and says that nothing tastes good anymore.
- She has a 10-year history of esophageal reflux disease treated with lansoprazole and a 2-year history of arthritis treated with acetaminophen.
- She was an English professor at a prominent university until 1 year ago.
- She maintained an active schedule of lecturing and writing until 2 months ago.
- Patient's hair is unwashed, and she has a mild body odor.
- She is 168 cm (5 ft 6 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2.
- Her pulse is 72/min, and blood pressure is 125/70 mm Hg.
- On mental status examination, she appears distracted and worried.
- She says that her mood is "okay."
- Her speech is slow and monotone, and she answers with single words.
- She is alert and oriented to person, place, and time.
- Her digit span is 6 forward and 2 backward.
- She can recall zero of three objects after 5 minutes.
- She refuses to perform simple change calculations or name past presidents.
Most Likely Diagnosis
- Dementia, Alzheimer type
Patient Presentation
- A 77-year-old man with Parkinson disease is brought to the physician by his wife because of a 3-month history of unusual behavior at night.
- Wife reports he yells in his sleep and waves his arms as if defending himself.
- Two nights ago, he bit her and tried to push her out of the bed.
- Current medications include carbidopa-levodopa.
- Examination shows little facial expression, a pill-rolling tremor of both hands, and muscle rigidity.
Most Appropriate Next Step
- Polysomnography
Patient Presentation
- A 42-year-old woman is brought to the emergency department by her girlfriend 15 minutes after several episodes of staring and blinking while eating dinner.
- Patient has a history of bipolar disorder well-controlled with daily bupropion and lithium carbonate for the past 5 years.
- She started taking terbinafine 2 weeks ago for chronic toenail fungus.
- During the examination, she is conversant.
- Her pulse is 64/min, respirations are 16/min, and blood pressure is 140/90 mm Hg.
- A normal rhythm is heard on cardiac examination.
- Neurologic examination shows no focal findings.
Most Likely Explanation
- Seizure activity
Patient Presentation
- A 27-year-old man who is HIV positive comes to the physician because of left arm clumsiness for 1 week.
- His CD4+ T-lymphocyte count was 78/mm3 (Normal ~500) 8 weeks ago.
- Medications include zidovudine (AZT), didanosine, ritonavir, and azithromycin.
- He appears well.
- His temperature is 37.2°C (99°F), pulse is 96/min, and respirations are 16/min.
- Examination shows weakness of the left upper extremity.
- A CT scan of the head with contrast shows a ring-enhancing lesion in the right parietal cortex.
Most Appropriate Next Step
- Oral sulfadiazine-pyrimethamine therapy
Patient Presentation
- A previously healthy 32-year-old woman had the acute onset of severe headache followed by somnolence 2 hours ago.
- Her temperature is 38.3°C (101°F), pulse is 96/min, and blood pressure is 140/92 mm Hg.
- She is lethargic but oriented and answers questions appropriately.
- A CT scan of the head shows no abnormalities except for small ventricles.
- Laboratory studies show:
- Serum glucose 90 mg/dL
- Cerebrospinal fluid
- Color pink
- Opening pressure 25 mm H20
- Glucose 53 mg/dL
- Protein 85 mg/dL
- RBC 4000/mm3
- WBC 10/mm3
- Segmented neutrophils 65%
- Lymphocytes 35%
Most Likely Diagnosis
- Enterovirus infection
Patient Presentation
- A 62-year-old woman with metastatic breast cancer is brought to the emergency department because of urinary incontinence for 24 hours.
- She has metastases to the skull, multiple vertebral bodies, ribs, liver, and para-aortic lymph nodes.
- Medications include tamoxifen, sustained-release morphine, stool softeners, and fluoxetine.
- Her temperature is 36.?°C (98.1 °F), pulse is 84/min, respirations are 14/min, and blood pressure is 128/76 mm Hg.
- Examination shows a large suprapubic mass.
- There is significant pain over the entire lumbar spine on fist percussion.
- Rectal examination shows decreased sphincter tone.
Most Likely Cause
- Metastases to the cauda equina
Patient Presentation
- A 52-year-old woman is brought to the emergency department by her husband 30 minutes after a generalized tonic-clonic seizure.
- Her husband reports that she has had a headache and has seemed confused over the past 3 days.
- She was scheduled to be evaluated by a pulmonologist later this week for the recent onset of mild hemoptysis.
- She smoked two packs of cigarettes daily for 30 years but quit 5 years ago.
- She has a 5-year history of type 2 diabetes mellitus controlled by diet.
- On arrival, she is postictal.
- Her temperature is 37°C (98.6°F), and blood pressure is 110/60 mm Hg.
- She is minimally responsive to painful stimuli.
- Cardiopulmonary examination shows no abnormalities.
- There is no peripheral edema.
- There are no focal neurologic deficits.
- Laboratory studies show:
- Serum
- Na+ 112 mEq/L
- Glucose 150 mg/dl
- Creatinine 0.7 mg/dl
- Cholesterol 230 mg/dl
- Osmolality 238 mOsmol/kg
- Urine
- Glucose trace
- Protein none
- RBC 1- 3/hpf
- WBC 1- 3/hpf
- Osmolality 240 mOsmol/kg
- Na+ 25 mEq/L
- Serum
Most Likely Diagnosis
- Pseudohyponatremia
Patient Presentation
- A 3-week-old male newborn is brought to the emergency department by his parents because of a 1-day history of increased fussiness and drowsiness.
- En route to the emergency department, he had rhythmic jerking movements of all extremities.
- His mother received minimal prenatal care and was treated for gonorrheal cervicitis during pregnancy; her Streptococcus agalactiae (group B) status was unknown.
- He was born at 38 weeks' gestation.
- Examination at birth showed no abnormalities.
- Today, he is irritable and responds only to painful stimulation.
- His temperature is 39°C (102.2°F), pulse is 160/min, and respirations are 32/min.
- Examination shows no conjunctivitis or cutaneous lesions.
- The lungs are clear to auscultation.
- A lumbar puncture is performed, and cerebrospinal fluid analysis shows:
- Glucose 60 mg/dl
- Total protein 100 mg/dl
- WBC 300/mm3
- RBC 5000/mm3
- Gram stain
- WBC 2+
- Organisms none
Most Appropriate Pharmacotherapy
- Acyclovir
Patient Presentation
- An otherwise healthy 62-year-old man is brought to the emergency department 45 minutes after an episode of loss of consciousness while shaving.
- Prior to the episode, he had light-headedness, nausea, and dimming of vision.
- Wife states that he was unconscious for about 1 minute and lost control of bladder function.
- She did not notice any movement during the episode.
- He had a similar episode 1 month ago while shaving.
- At that time, echocardiography, 24-hour ambulatory ECG monitoring, and a tilt test showed no abnormalities; cardiac enzyme activities were within the reference range.
- His current blood pressure is 150/96 mm Hg.
- A grade 2/6, systolic ejection murmur is heard best at the upper left sternal border.
- The remainder of the examination shows no abnormalities.
Most Likely Diagnosis
- Neurocardiogenic (vasovagal) syncope
Patient Presentation
- A 32-year-old man is brought to the physician because of a 10-month history of difficulty walking and decreased grip strength and stiffness of his hands that are interfering with his job as a plumber.
- He has no history of serious illness.
- There is frontal balding.
- Cranial nerve examination shows bilateral ptosis and atrophy of the sternocleidomastoid and temporalis muscles.
- There is distal intrinsic musculature weakness of the hand and bilateral weakness on ankle dorsiflexion.
- Percussion of the hypothenar muscles results in slow relaxation.
- Sensation is intact.
Nerve Injury
- A 57-year-old woman presents with numbness in the back of her right hand after distal radial fracture surgery.
- Sensation to pinprick is decreased over the dorsal first web, thumb, and index finger.
- There is no motor deficit.
- The most likely site of nerve injury is the radial nerve at the elbow.
Spinal Cord Compression
- A 62-year-old woman presents with progressive weakness and numbness in her feet that has spread to her chest.
- She also has difficulty emptying her bladder completely.
- She has moderate mid-back pain that radiates to her chest, exacerbated by coughing.
- She had breast cancer and received treatment one year prior.
- Muscle strength is 5/5 in the upper extremities and 4/5 in the lower extremities with increased tone.
- Deep tendon reflexes are 2+ in the upper extremities and 4+ in the lower extremities.
- Babinski sign is present bilaterally.
- Sensation to pinprick is decreased below the T4 level.
- The most likely diagnosis is epidural spinal cord compression.
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Description
Test your knowledge on medical diagnoses, particularly focusing on muscle cramping and weakness in young adults, diagnostic studies in delirious elderly patients, and management strategies for multi-infarct dementia. This quiz will challenge your understanding of clinical scenarios and appropriate interventions.
