Question 1

A 50-year-old Caucasian female presents to your office with a six month history of periodic involuntary closure of her right eye.  The closure is provoked by bright light or cigarette smoke.  Her past medical history is significant for osteoarthritis of her left knee.  She takes naproxen occasionally.  The attempt to check the pupillary reaction induces prolonged closure of the right eye.  Otherwise, the neurologic examination is normal.  Which of the following is the next best step in the management of this patient?

Accepted Answer

Explanation: The clinical scenario described is suggestive of blepharospasm, which is a form of focal dystonia. The history of periodic involuntary eye closure that can be provoked by external stimuli (eg, bright light or irritants) is typical. Older women are particularly predisposed to this condition. A potential explanation is that dry eyes in postmenopausal women may serve as a trigger for blepharospasm. Botulinum toxin injections are the mainstay of treatment. They can be used for many years without any loss of efficacy or significant side effects. (Choices A, B, and D) Oral agents such as levodopa, trihexyphenidyl, and carbamazepine are employed in the treatment of more generalized forms of dystonia, and are marginally effective in patients with blepharospasm. (Choice E) Although reactive depression can be associated with blepharospasm, psychotherapy is not the treatment of choice in this case. Educational objective: Botulinum toxin injections are very effective and relatively safe in the treatment of patients with focal dystonia.

Question 2

A 20-month-old boy is brought to the emergency department by ambulance after a single, generalized, tonic-clonic seizure that lasted for approximately 5 minutes.  The seizure was witnessed by his grandmother who immediately placed the child onto the floor and turned him on his side.  The seizure stopped spontaneously a few minutes prior to the arrival of emergency services.  The patient has never had a seizure before.  He has had a cough and runny nose for the last 3 days and developed a fever today.  His appetite has decreased, but he is drinking and voiding adequately.  The patient's vaccinations are up to date, and he takes no daily medications.  Developmentally, the patient walks well, can eat with a spoon, and is able to speak 10-15 words.  Temperature is 38.7 C (101.7 F), blood pressure is 98/66 mm Hg, pulse is 116/min, and respirations are 28/min.  Pulse oximetry is 98% on room air.  The child is well appearing and playing quietly with toys.  The pupils are equal and briskly reactive to light.  Tympanic membranes are clear bilaterally, and posterior pharynx is injected slightly without exudate.  The neck is supple.  Cardiopulmonary examination is normal.  Muscle tone is normal and strength is full bilaterally.  Deep tendon reflexes are 2+ and symmetric in the upper and lower extremities.  There are no rashes or petechiae.  An antipyretic is administered, and his temperature decreases to 37.8 C (100 F).  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bff4_bb15_8f63_2f307a8e35b5_MD0005_00 This child had a febrile seizure, a common complication of high fevers that usually develops from a mild viral infection (eg, common cold). Febrile seizures frequently affect children age 3 months to 6 years. The seizures are typically nonfocal, last <15 minutes, and do not occur more than once per day. Patients with febrile seizures have no previous afebrile seizure, no evidence of metabolic disease (eg, asterixis, depressed sensorium), and no signs of intracranial infection (eg, neck stiffness, bulging fontanelles, photophobia). Febrile seizures are clinically diagnosed and further evaluation is typically not indicated. Parents should be provided reassurance that febrile seizures are common and usually self-resolve without acute or long-term sequelae. Antipyretics are administered for general fever reduction, but parents should be informed that they do not prevent future episodes of febrile seizures. (Choice A) Although this patient has a fever, he appears well and has viral upper respiratory tract infection symptoms (eg, cough, rhinorrhea); therefore, hospitalization and antibiotics are not indicated. (Choice B) An electroencephalogram (EEG) may be indicated in patients with atypical seizures (eg, multiple, focal) or with abnormal neurologic examinations (eg, abnormal reflexes, developmental delay). This child has a normal neurologic examination and no atypical features; therefore, an EEG is not indicated. In addition, EEG results do not alter long-term outcome. (Choice C) This child does not require lumbar puncture as there are no clinical features suggestive of meningitis (eg, meningismus), and vaccinations against Haemophilus influenzae type b and Streptococcus pneumoniae are current. (Choice D) Abortive antiepileptic drugs should be considered for any patients with febrile or afebrile seizures lasting >5 minutes due to the risk of cardiorespiratory compromise. However, most febrile seizures resolve spontaneously, as in this case. In addition, abortive antiepileptic drugs do not alter the outcome of a child who has had a febrile seizure, even with an abnormal EEG. Educational objective: Febrile seizures are benign complications of infection that are diagnosed clinically. Patients with this presentation have a favorable prognosis and no acute or long-term sequelae; therefore, management is typically to provide reassurance. References: Evaluation and management of pediatric febrile seizures in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/21109105) Update on the management of simple febrile seizures: emphasis on minimal intervention. (http://www.ncbi.nlm.nih.gov/pubmed/22327951)

Question 3

A 28-year-old man comes to the office for a health maintenance visit.  He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen.  Occasionally the headaches are severe enough to necessitate taking a sick day from work.  He cannot recall specific triggers but notes that the headaches are usually unilateral.  The patient does not use tobacco or illicit drugs.  He drinks alcohol socially and 2-3 cups of coffee daily.  He is a software engineer and often works at a computer 10-12 hours a day.  His sister has a history of migraines.  Vital signs are within normal limits.  Physical examination, including neurological examination, is normal. The patient comes to the emergency department at 1 AM later that night due to unrelenting headache.  He was awakened 2 hours prior by severe, sharp, periorbital pain on the left side of his head.  He also has had nausea and watering from the left eye.  The patient took ibuprofen and acetaminophen but experienced no relief.  Temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 92/min, and respirations are 16/min.  Pulse oximetry shows 98% while breathing ambient air.  He appears in pain and is restless.  Physical examination shows mild ptosis and miosis of the left eye.  There is clear discharge from the left nostril.  He has no other focal neurological deficits, and the remainder of the physical examination is normal.  Which of the following is the most appropriate intervention at this time?

Accepted Answer

Explanation: This patient comes to the hospital due to severe, acute pain from an ongoing cluster headache. First-line therapy for acute management of cluster headache is 100% oxygen inhalation by nonrebreathing facial mask. This treatment is administered for >15 minutes and provides significant relief in >70% of patients. Patients with partial or no response to oxygen therapy are often given intranasal sumatriptan contralateral to the side of headache. This therapy is considered second-line due to the risk of adverse effects and medication-overuse headaches. Intranasal lidocaine and ergot preparations are also sometimes used. (Choices A and B) Glucocorticoids and verapamil are often used in the preventive treatment of cluster headaches; they are not used for aborting acute headaches. (Choice C) There are no current manifestations (eg, fever, nuchal rigidity) of a central nervous system infectious process; lumbar puncture would not be indicated. This patient with a severe, periorbital, unilateral headache associated with restlessness and autonomic symptoms is likely to have a cluster headache. (Choice D) Subarachnoid hemorrhage is often diagnosed by noncontrast CT scan of the head. Manifestations typically include a sudden, severe headache. However, ipsilateral autonomic signs would be atypical. Educational objective: First-line therapy for acute management of cluster headache is 100% oxygen inhalation. This treatment improves or aborts headaches in >70% of patients.

Question 4

A 9-month-old boy is brought to the emergency department by his parents as he is not "acting like himself." The parents report that he has always been a fussy baby and often awakens multiple times a night. However, yesterday he cried the entire night and seemed more tired than usual this morning. The infant typically eats yogurt and formula for breakfast but refused to eat this morning and vomited 3 times. His mother says, "He may have hit his head on the floor after climbing onto and then rolling off the couch 2 days ago. He recently started crawling and often bumps into furniture around the house." The infant was born at term via an uncomplicated vaginal delivery. He was evaluated several times in the emergency department between ages 3 and 5 months for fussiness and was diagnosed with colic. His mother is currently taking antibiotics for bacterial pharyngitis; otherwise, there are no sick contacts or contributory family history. Temperature is 37 C (98.6 F) and pulse is 125/min. Height and weight are at the 75th and 50th percentiles, respectively. On examination, the infant is lethargic. The lungs are clear to auscultation and there are no murmurs. The abdomen is soft and nondistended. A small bruise is present on the buttocks; there are no additional rashes, lesions, or bruises. Item 1 of 2 Which of the following additional findings is most likely present in this patient?

Accepted Answer

Explanation: This infant's presentation is suspicious for abusive head trauma (AHT) (previously known as "shaken baby syndrome"), which refers to injury from shaking and/or blunt force to the head. Injuries typically result from repeated acceleration-deceleration forces as the brain collides against the inside of the cranium. Young children (age <1) are at greatest risk, particularly if they are "fussy" with frequent crying/colic, as in this patient. An unstable home environment (eg, single-parent home, parental drug/alcohol abuse) is also a risk factor. Delayed presentation to medical care following the alleged injury and a vague and inconsistent history of events is suspicious for AHT. In this case, a 9-month-old infant typically cannot climb onto a couch, and falling from this height is unlikely to cause a head injury severe enough to alter his mental status. In addition, his frequent emergency department visits for fussiness suggest that this may not be the first time he has been abused. Irritability and vomiting are signs of increased intracranial pressure from AHT that may be overlooked, and medical attention is often not sought until the child is apneic, seizing, or comatose. Physical examination may show suspicious bruising patterns, such as this patient's bruise on the buttocks; however, frequently there is no external sign of injury. In the majority of AHT cases, fundoscopy shows retinal hemorrhages, which are often multilayered and bilateral and are a result of shearing forces on the retinal vessels. Abnormal neurological findings are concerning for intracranial bleeds and diffuse brain injury. (Choice A) Costochondral junction enlargement is characteristic of rickets. Vitamin D deficiency is unlikely in an infant eating yogurt and formula, which is typically fortified with vitamin D. (Choice B) Hepatosplenomegaly may occur with significant abdominal trauma but is less likely in this patient without bruising and with a soft, nondistended abdomen. Retinal hemorrhages are more likely, given this patient's neurological status. (Choice D) Intussusception, causing a sausage-shaped abdominal mass on examination, presents with colicky abdominal pain, vomiting, and "currant jelly" stools. This patient's altered mental status and history of trauma inconsistent with his development is more concerning for AHT. (Choice E) Although the patient's mother has pharyngitis, streptococcal pharyngitis with tonsillar exudates is uncommon in infants. In addition, fever is expected with a streptococcal infection. Educational objective: Abusive head trauma, typically caused by repeated acceleration-deceleration forces on the brain, often presents in an infant with a reported mechanism of injury inconsistent with the patient's development. Retinal hemorrhages, intracranial bleeds, and diffuse brain injury are characteristic. References: Retinal hemorrhage in abusive head trauma. (http://www.ncbi.nlm.nih.gov/pubmed/20921069) Abusive head trauma: past, present, and future. (http://www.ncbi.nlm.nih.gov/pubmed/25316728) Accuracy of the history of injury obtained from the caregiver in infantile head trauma. (http://www.ncbi.nlm.nih.gov/pubmed/27422215)

Question 5

A 24-year-old man is brought to the emergency department by his girlfriend due to progressive weakness. They have been on a cross-country road trip for the past month. While traveling through the midwestern United States 2 weeks ago, the patient developed diarrhea, nausea, and vomiting. He rested, drank fluids, and improved spontaneously after 2-3 days. However, the patient had persistent fatigue, and 4 days ago they had to stop traveling as his legs became too weak to press down the brake pedal. He is now unable to get out of bed. The patient has also had tingling of the hands and feet as well as shortness of breath. He has had no fever, chills, abdominal pain, or recurrent diarrhea. The patient has no prior medical problems and takes no medications. He does not use tobacco, alcohol, or illicit drugs. Temperature is 37.7 C (99.8 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 20/min. Pulse oximetry shows 98% on ambient air. The patient is awake, alert, and speaking in full sentences but develops a weak cough after taking a sip of water. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender. Neurologic examination shows symmetric bilateral lower extremity weakness. Deep tendon reflexes are absent at the knees and ankles, and 1+ in the biceps and triceps. Cranial nerve examination and sensation are normal, and he has no neck rigidity. There is no skin rash or lymphadenopathy. Item 1 of 3 Which of the following is the best immediate step in management of this patient?

Accepted Answer

Explanation: This patient had a gastrointestinal illness and developed severe symmetric muscle weakness and absent deep tendon reflexes, indicating likely Guillain-Barré syndrome (GBS). GBS usually occurs after a gastrointestinal (eg, Campylobacter) or respiratory infection generates cross-reacting antibodies to peripheral nerve components. The resultant immune-mediated polyneuropathy causes: Symmetric muscle weakness that usually begins in the legs Paresthesias Dysautonomia (eg, tachycardia, urinary retention) that may be life-threatening Decreased or absent deep tendon reflexes Patients with GBS are at high risk for rapid-onset respiratory failure due to respiratory muscle weakness; frequent measurement of vital capacity and negative inspiratory force is required to monitor respiratory status. Approximately 30% of patients with GBS ultimately require mechanical ventilation. (Choice A) Peak expiratory flow rate is useful in obstructive lung diseases such as asthma and chronic obstructive pulmonary disease. It is not typically used to assess respiratory muscle weakness in GBS. (Choice C) This patient with likely GBS and normal oxygen saturation on pulse oximetry does not require arterial blood gas analysis at this time. A baseline respiratory muscle assessment with tidal volume is required. (Choices D and E) Electrodiagnostic studies and a lumbar puncture with cerebrospinal fluid analysis (elevated protein with normal leukocyte count) are often performed in patients with suspected GBS to help support the diagnosis. However, respiratory status monitoring with tidal volume would be required prior to either of these procedures. Educational objective: Guillain-Barré syndrome is an immune-mediated polyneuropathy that causes symmetric motor weakness and reduced/absent deep tendon reflexes. Patients are at high risk of respiratory failure and require frequent monitoring of tidal volume and negative inspiratory force to assess respiratory status.

Question 6

A 65-year-old man is brought to the office by his daughter due to decreased activity and impaired sleep over the past month.  He was diagnosed with Parkinson disease 2 years ago.  According to his daughter, he displays very few emotions and does not want to do anything.  She says, "He has been slowing down these past few years and I suppose that was to be expected, but I am worried that he's getting worse so quickly.  He just sits in his chair and watches TV with a blank expression.  He has been waking up early in the morning, which is very unusual for him.  When I suggest that he should go out, he says he is too tired or makes excuses.  It's like he doesn't care much about anything."  The patient is quiet during most of the discussion.  He does not disagree with his daughter's comments, but says, "I'm alright.  I manage.  I don't have much to add."  The patient is adherent with his current levodopa/carbidopa treatment.  His other medication is pravastatin for hypercholesterolemia.  He does not use tobacco, alcohol, or illicit drugs.  Physical examination shows masklike facies and slowed movements.  Mild hand tremor and postural instability have improved since his last visit.  Which of the following is the most appropriate next step in pharmacological management of this patient?

Accepted Answer

Explanation: Depression affects up to 50% of patients with Parkinson disease (PD) and can negatively impact quality of life. It can be easily overlooked because some depressive symptoms may be mistakenly attributed to the progression of PD. For example, depressed, blunted affect looks similar to masked facies; psychomotor slowing is similar to bradykinesia. This patient's one-month history of decreased interest, low energy, and early- morning awakening is concerning for depression. Because his other Parkinson symptoms, such as tremor and postural instability, appear to have improved since his last visit, an antidepressant trial would be the most appropriate next step in pharmacological management. Selective serotonin reuptake inhibitors (eg, sertraline) are typically used first due their favorable side effect profile. Nonpharmacological approaches, such as cognitive-behavioral therapy, can also be considered to treat depression. (Choices A, D, and E) These interventions could be considered if the patient's motor symptoms were inadequately controlled. (Choice B) The second-generation antipsychotic quetiapine has been used to treat psychosis, a frequent complication of PD, which is characterized by visual hallucinations and delusions. Educational objective: Identifying underlying depression in patients with Parkinson disease is often difficult as psychomotor slowing and blunted affect can resemble bradykinesia and masked facies, respectively. Pharmacological treatment consists of antidepressant medications, specifically selective serotonin reuptake inhibitors. References: A comprehensive overview of the neuropsychiatry of Parkinson's disease: a review. (http://www.ncbi.nlm.nih.gov/pubmed/28271905) Antidepressive treatments for Parkinson's disease: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26037457)

Question 7

A 9-month-old boy is brought to the office for a well-child visit.  His parents are concerned that he has not been meeting milestones as quickly as his older brother.  The patient has not started crawling and requires support from his parents to sit up.  His mother states, "I think his lack of crawling is because he cannot roll over from his back to his stomach."  The parents say that he sleeps well through the night and is a happy infant overall.  The patient spits up occasionally after bottle feedings but less so than when he was a newborn.  His diet is still primarily infant formula, but he has been self-feeding solid foods since age 6 months with no gagging or coughing.  The patient was born at 35 weeks gestation via an uncomplicated delivery.  Due to gestational age, the infant was observed in the neonatal intensive care unit; however, his stay was uneventful, and he was discharged from the hospital a week after delivery.  Family history is negative for developmental delays or metabolic disorders; his 3-year-old brother is healthy with no chronic medical conditions.  Height, weight, and head circumference are at the 75th percentile.  The infant is alert and smiling and has no dysmorphic facial features.  The anterior fontanelle is open and flat, and gaze is conjugate with no nystagmus.  He reaches for small toys and laughs when they rattle.  Musculoskeletal examination reveals increased tone in the bilateral lower extremities.  When the infant is suspended by the axillae, his legs maintain a scissoring posture.  Patellar reflexes are 3+.  Sustained clonus is also noted in the ankles bilaterally.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfec_a4bc_8f63_b18aba92da30_MD0005_00 Cerebral palsy (CP), a common complication of prematurity (birth at <37 weeks gestation), is characterized by an insult to the central nervous system resulting in nonprogressive motor dysfunction. Spastic CP, as seen in this infant, is the most common subtype. Early signs of CP include the delayed disappearance of neonatal reflexes (eg, tonic neck reflex), persistent or asymmetric fisting, and early hand preference (before age 1). Although infants with CP may initially have normal or low tone at birth, hypertonia (spasticity) develops within a few months and can result in contractures and scissoring of the legs. Hyperreflexia and sustained clonus are also typically present. In addition, infants often have delayed motor milestones based on a corrected gestational age. For instance, this infant with a corrected gestational age around 8 months should be rolling and sitting without support. By age 9 months, infants are expected to pull up to a stand and cruise. When clinical presentation is consistent with CP, MRI of the brain is recommended as the vast majority of patients have abnormal findings (eg, periventricular leukomalacia, brain malformation, ischemia). Comorbid epilepsy is common; but patients with no seizure-like activity do not require electroencephalography (Choice B). Treatment is primarily supportive with physical, occupational, and speech therapies for associated developmental delays. If oromotor dysfunction is severe, gastrostomy feeds may be required for adequate caloric intake and to prevent aspiration. Medications such as botulinum and baclofen can help to reduce spasticity and clonus. (Choice A) MRI is superior to CT scan of the head for identifying the location and timing of central nervous system insults. In addition, CT scan is typically avoided in children due to its associated radiation exposure. (Choice D) A nerve conduction study can diagnose lower motor neuron disorders that present with weakness, hypotonia, and hyporeflexia; they are not beneficial in a patient with an upper motor neuron disorder such as CP. (Choice E) Although children age <2 may have a few beats of clonus and upgoing toes on Babinski reflex, sustained clonus and spasticity with a scissoring posture are never normal. Reassurance and observation are not appropriate. Educational objective: Premature infants are at risk for cerebral palsy, which often presents as hypertonia, hyperreflexia (eg, sustained clonus), and delayed motor milestones. MRI of the brain evaluates for a potential etiology. References: MRI and motor outcomes in children with cerebral palsy. (http://www.ncbi.nlm.nih.gov/pubmed/26933597) MRI classification system (MRICS) for children with cerebral palsy: development, reliability, and recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/27325153)

Question 8

A 28-year-old man comes to the office for a health maintenance visit.  He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen.  Occasionally the headaches are severe enough to necessitate taking a sick day from work.  He cannot recall specific triggers but notes that the headaches are usually unilateral.  The patient does not use tobacco or illicit drugs.  He drinks alcohol socially and 2-3 cups of coffee daily.  He is a software engineer and often works at a computer 10-12 hours a day.  His sister has a history of migraines.  Vital signs are within normal limits.  Physical examination, including neurological examination, is normal. The patient returns to the office 2 weeks later and reports "on and off" headaches almost every day since his last visit.  The headaches are predominantly behind his left eye and are so severe that his left eye becomes watery and his forehead feels sweaty.  The headaches occur at approximately the same time each day and improve after resting in a dark, quiet room for about an hour.  Physical examination shows no abnormalities.  Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: This patient has unilateral, orbital headaches of short duration associated with autonomic symptoms, suggesting cluster headache. Cluster headaches primarily affect men and are characterized by headaches that last <180 minutes and occur 1-8 times a day over a period of weeks. The headaches are orbital, supraorbital, or temporal and always unilateral. The pain during a cluster headache can be so severe as to lead to suicide. Patients also usually experience restless agitation (unable to sit still) and ipsilateral autonomic symptoms such as ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion. (Choice A) Generalized anxiety disorder can be associated with tension-type headaches and generalized autonomic hyperactivity (eg, palpitations, sweating). Focal autonomic hyperactivity in the trigeminal branch associated with unilateral orbital headache is much more likely to indicate cluster headache. (Choice C) Migraine headaches can cause unilateral orbital headaches that improve with resting in a dark, quiet room (to reduce phonophobia and photophobia). However, migraines are typically not associated with trigeminal autonomic hyperactivity. (Choice D) Temporal arteritis is a vasculitis often associated with unilateral headache, vision change, and jaw claudication. Temporal arteritis almost always affects patients age >50; this young patient is unlikely to have temporal arteritis. (Choice E) Tension-type headaches are usually bilateral, band-like, and nonthrobbing. This patient with episodic, unilateral, orbital headaches associated with autonomic symptoms is more likely to have cluster headache. Educational objective: Cluster headaches are primarily seen in men and are characterized by episodic headaches 1-8 times a day occurring over a period of weeks. The pain is typically orbital, supraorbital, or temporal as well as unilateral and severe. Patients usually have restless agitation and autonomic symptoms of the ipsilateral trigeminal branch such as lacrimation, conjunctival injection, rhinorrhea, and nasal congestion.

Question 9

A previously healthy 13-month-old boy is brought to the emergency department by ambulance after an episode of "jerky movements all over" that lasted 2 minutes.  The movements occurred when the patient's father had just put him in his crib at naptime.  The child has had fever, nasal congestion, and "eye redness" for the past day.  Review of systems is otherwise negative.  The patient was born full term, takes no medications, and has received all recommended vaccinations.  His father has a history of a febrile seizure during childhood and a cousin with developmental delays.  Temperature is 39.2 C (102.5 F), pulse is 120/min, and respirations are 22/min.  Examination shows an awake, well-appearing boy resting on his father's lap.  The anterior fontanelle is closed, and there is clear rhinorrhea and nasal congestion.  The neck is supple with full range of motion.  Auscultation reveals no adventitious sounds and no murmurs.  The abdomen is soft and nontender.  The extremities have full range of motion, and deep tendon reflexes are 2+ throughout.  The soles of the feet are firmly stroked, causing the big toe to move upward, and the other toes fan out.  Which of the following is the most accurate statement regarding this patient's prognosis?

Accepted Answer

Explanation: 11ec2b69_bff4_45e4_8f63_718b5f253714_MD0005_00 This child had a febrile seizure, a condition that occurs exclusively in infants and young children, likely due to nervous system immaturity. Patients present between age 3 months and 6 years and often have a family history of febrile seizure. Febrile seizures are a common complication of high fever associated with a viral infection (eg, human herpes virus-6, influenza). These seizures usually occur during the first day of the illness and are frequently the initial manifestation of infection. Febrile seizures are diagnosed clinically. Patients have findings consistent with infection (eg, rhinorrhea, tachycardia, tachypnea); however, they have no history of afebrile seizures and no abnormal neurologic findings (eg, nuchal rigidity, bulging fontanelles). Febrile seizures typically have a benign course, do not require therapy, and have no long-term impact on development (Choice A). However, children who experience a febrile seizure have a ~30% chance of at least one recurrence and are at increased risk for subsequent development of epilepsy (eg, afebrile seizures) (Choice C). (Choice D) This child had a typical febrile seizure (eg, short, generalized, single, minimal postictal lethargy). Workup for febrile seizures is generally unnecessary as it is not cost-effective and is typically normal. Electroencephalography is of limited value in the prediction of future epilepsy and is not predictive of recurrent febrile seizures. (Choice E) Lumbar puncture is not indicated as there is no evidence of intracranial infection (eg, no bulging fontanelles, no neck stiffness) and vaccinations are up to date (eg, Haemophilus influenza type b, Streptococcus pneumoniae). A positive Babinski sign is normal until age 2. Educational objective: Febrile seizures typically occur as a complication of viral infection. Diagnosis is clinical and patients have normal development. However, patients with febrile seizures are at an increased risk of recurrence as well as epilepsy. References: Neurodiagnostic evaluation of the child with a simple febrile seizure. (http://www.ncbi.nlm.nih.gov/pubmed/21285335) Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. (http://www.ncbi.nlm.nih.gov/pubmed/19117854) Update on the management of simple febrile seizures: emphasis on minimal intervention. (http://www.ncbi.nlm.nih.gov/pubmed/22327951)

Question 10

A 66-year-old man comes to the emergency department with progressive lower back pain, urinary incontinence, and decreased appetite for the past 2 days.  He was recently diagnosed with L4-L5 disc herniation and received an epidural injection for radicular pain 2 weeks ago.  His other medical problems include type 2 diabetes mellitus and hypertension.  Temperature is 38.3 C (100.9 F), blood pressure is 136/88 mm Hg, pulse is 96/min, and respirations are 14/min.  The patient is alert and oriented.  Physical examination shows poor dentition, tenderness on palpation of the lumbar spine, and absent deep-tendon reflexes in both lower extremities.  Rectal examination shows decreased rectal sphincter tone and an enlarged, smooth prostate.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bff3_0d63_8f63_65327d3a607d_MD0005_00 This patient's presentation suggests spinal epidural abscess (SEA) and possible cord compression. SEA is more common than intracranial epidural abscess and is caused by hematogenous spread of bacteria from a distant source, contiguous tissue infection (eg, vertebral body osteomyelitis), or direct inoculation (eg, steroid injections, epidural anesthesia). Other risk factors for SEA include intravenous drug use and immunocompromised states such as diabetes mellitus, alcoholism, and HIV. Staphylococcus aureus accounts for about 60% of infections caused by pyogenic bacteria. spinal epidural abscess (SEA) The classic triad of symptoms includes fever (may not be present), severe focal spinal pain, and neurologic deficits. As symptoms progress, patients may develop radiculopathy, motor and sensory deficits, bowel or bladder dysfunction, and eventual paralysis. Initial evaluation includes complete blood count, inflammatory markers (erythrocyte sedimentation rate, and C-reactive protein), blood cultures, and urgent magnetic resonance imaging of the spine with gadolinium (preferred) or computed tomography (CT) with intravenous contrast. Once the diagnosis of SEA is confirmed on imaging, CT-guided aspiration and culture are needed to guide antibiotic therapy. Most patients are treated with immediate surgical decompression (preferably within 24 hours) to avoid complications of cord compression or cauda equina syndrome. magnetic resonance imaging of the spine with gadolinium (Choice A) Intravenous glucocorticoids are indicated for spinal cord compression or cauda equina syndrome due to metastatic malignancy/traumatic injury. They are NOT recommended empirically for patients with fever, back pain, and possible epidural abscess. (Choice B) Lumbar puncture is not recommended for the diagnosis of epidural abscess due to low diagnostic yield (<25% positive cerebral spinal fluid cultures). There is also risk of subdural spread of infection from the procedure. (Choice D) Serum prostate-specific antigen and bone scan are indicated in diagnosing metastatic prostate cancer. However, this patient's prostate examination is normal (no asymmetry or frank nodules). (Choice E) Tagged white blood cell scan is useful for detection of occult infections when preliminary studies fail to localize the source (eg, persistent bacteremia with no identifiable source). This procedure is time-consuming and is not indicated in this patient. Educational objective: Epidural abscess presents with fever, focal spinal tenderness/back pain, and neurologic dysfunction. Evaluation includes urgent magnetic resonance imaging, blood cultures, inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), computed tomography-guided aspiration and culture, and antibiotics. Emergency surgical decompression and drainage of the abscess are recommended for most patients. References: Iatrogenic (para-) spinal abscesses and meningitis following injection therapy for low back pain (http://www.ncbi.nlm.nih.gov/pubmed/15979793) Spinal epidural abscess: a ten-year perspective (http://www.ncbi.nlm.nih.gov/pubmed/2385333)

Question 11

A 65-year-old man comes to the emergency department due to severe headache localized to the left frontal temporal region that began 4 hours ago.  At the onset of the headache, he also had transient vision impairment in the left eye, which has now resolved.  The patient has never had similar symptoms previously.  Medications are acetaminophen for arthritis and metformin for recently diagnosed type 2 diabetes mellitus.  He lives in rural Connecticut, smokes a pack of cigarettes per day, and does not use alcohol or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 152/96 mm Hg, and pulse is 89/min.  Pulse oximetry shows 99% on room air.  Physical examination findings are shown in the exhibit.  Laboratory studies are as follows:  A noncontrast CT scan of the head shows no intracranial hemorrhage or mass lesion.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfed_680e_8f63_fbbe6171d647_MD0005_00 The constellation of unilateral headache and partial left-sided Horner syndrome indicates left carotid artery dissection until proven otherwise. This condition can occur due to trauma (eg, whiplash injury, neck manipulation) but often develops spontaneously; connective tissue disease, hypertension, smoking, and recent infection may be underlying contributors. Relatively young patients are often affected (mean age ~45 years), and cerebral ischemia (eg, transient ischemic attack, ischemic stroke) is a frequent complication. Carotid artery dissection leads to the formation of an intramural hematoma/thrombus; due to the relatively small caliber of the carotid artery, most of the adverse neurologic effects result from luminal obstruction by the intramural blood collection. As sympathetic nerves travel along the carotid artery, dissection may cause Horner syndrome (ie, ptosis, miosis, anhidrosis) due to aneurysmal dilation and compression. However, anhidrosis is typically absent in internal carotid artery dissection as sweat nerve fibers branch off at the superior cervical sympathetic ganglion and follow the course of the external carotid artery. Carotid artery dissection superior cervical sympathetic ganglion Diagnosis is typically by CT angiography or MR angiography; if the results are negative but carotid dissection is still suspected, catheter angiography (gold standard) may be performed. Despite concerns of enlargement of the intramural hematoma, management of acute ischemia due to dissection is similar to other ischemic strokes and consists of thrombolysis if ?4.5 hours from symptom onset (preferably ?3 hours) and antiplatelet therapy (eg, aspirin). Evidence suggests that this approach is safe and offers comparable outcomes to ischemia from other causes. Anticoagulation is given in some settings, but its use is controversial. (Choice B) Cluster headache, which can be treated with 100% oxygen, is an important consideration in patients with severe unilateral headache and autonomic symptoms such as ptosis, miosis, lacrimation, sweating (not anhidrosis), and conjunctival injection. However, the painful attacks are episodic and short (15-180 minutes). (Choice C) Tight blood pressure control (goal systolic blood pressure: 100-120 mm Hg) is indicated in acute aortic dissection. It is not routine therapy for carotid artery dissection. (Choice D) Lyme disease is endemic to the northeastern United States (eg, Connecticut), and early disseminated disease (which is typically associated with positive serologic test results for antibodies against Borrelia burgdorferi) can cause headache and cranial nerve palsies. However, Horner syndrome is a rare presentation, and waiting for the results of serologic testing could unnecessarily delay recognition of a life-threatening disease process. (Choice E) Temporal artery biopsy is the diagnostic test of choice for giant cell (temporal) arteritis. However, the diagnosis is unlikely in the setting of a low erythrocyte sedimentation rate and the absence of jaw claudication, fever, and anemia. Additionally, giant cell arteritis is not commonly associated with Horner syndrome. Educational objective: A unilateral headache with partial Horner syndrome should be considered a carotid artery dissection until proven otherwise. Head and neck vasculature imaging (eg, CT angiography) is the initial diagnostic modality of choice. References: Cervical artery dissection: a review of the epidemiology, pathophysiology, treatment, and outcome. (http://www.ncbi.nlm.nih.gov/pubmed/26478890) Spontaneous cervical artery dissection: an update on clinical and diagnostic aspects. (http://www.ncbi.nlm.nih.gov/pubmed/19099146)

Question 12

A 9-month-old boy is brought to the emergency department by his parents as he is not "acting like himself."  The parents report that he has always been a fussy baby and often awakens multiple times a night.  However, yesterday he cried the entire night and seemed more tired than usual this morning.  The infant typically eats yogurt and formula for breakfast but refused to eat this morning and vomited 3 times.  His mother says, "He may have hit his head on the floor after climbing onto and then rolling off the couch 2 days ago.  He recently started crawling and often bumps into furniture around the house."  The infant was born at term via an uncomplicated vaginal delivery.  He was evaluated several times in the emergency department between ages 3 and 5 months for fussiness and was diagnosed with colic.  His mother is currently taking antibiotics for bacterial pharyngitis; otherwise, there are no sick contacts or contributory family history.  Temperature is 37 C (98.6 F) and pulse is 125/min.  Height and weight are at the 75th and 50th percentiles, respectively.  On examination, the infant is lethargic.  The lungs are clear to auscultation and there are no murmurs.  The abdomen is soft and nondistended.  A small bruise is present on the buttocks; there are no additional rashes, lesions, or bruises. The infant's airway is secured, and his condition is stabilized.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bfef_15bf_8f63_83f02bc7265b_MD0005_00 Infants are particularly prone to abusive head trauma (AHT) as they have a large head-to-body ratio and weak neck muscles, making their heads unstable and vulnerable to coup-contrecoup injuries. In addition, the infant brain is incompletely myelinized, making it more susceptible to shearing forces during shaking. coup-contrecoup CT scan of the head is the preferred method for evaluating suspected AHT in a symptomatic patient (eg, lethargic, vomiting), as it is fast, widely available, and cost-effective. This patient is clinically unstable, and after the primary survey is complete and the airway secured, emergency CT scan of the head is required to determine whether neurosurgical intervention is required. CT scan detects intracranial bleeding in addition to cerebral edema and hypoxic-ischemic changes. Subdural hematomas, caused by shearing of the bridging veins, are the most common bleed seen in this setting and on imaging appear as crescents overlying the brain. They typically have a mixed-density pattern due to varying stages of injury, compared with the homogenous hyperdense pattern seen in accidental head trauma. mixed-density pattern On the other hand, in a situation that is not time sensitive and in which the patient is asymptomatic, MRI may be performed to provide more detail regarding the extent and timing of the injury while avoiding radiation exposure. (Choice B) A lumbar puncture is performed when meningitis is suspected. Although meningitis can cause lethargy and vomiting in an infant, this patient's history of trauma makes an intracranial bleed more likely. (Choice C) This patient is lethargic and vomiting, likely from increased intracranial pressure, and first requires an emergency CT scan of the head. Once his condition is stabilized, a skeletal survey may be performed to evaluate for other injuries suspicious for abuse, such as posterior rib fractures, metaphyseal corner fractures, and fractures in different stages of healing. If a patient is stable with a normal neurological examination, a skeletal survey may be performed first. (Choice D) Although abdominal trauma can be associated with AHT, this patient's vomiting and altered mental status are highly concerning for life-threatening intracranial hemorrhages requiring emergency CT scan of the head. (Choice E) Ultrasound of the head is used primarily to grade intraventricular hemorrhage in preterm infants. It is not as sensitive as CT scan and is not the preferred imaging modality for assessing AHT. Educational objective: CT scan of the head is a fast and cost-effective method for detecting subdural hematomas in infants with abusive head trauma. References: Imaging abusive head trauma: why use both computed tomography and magnetic resonance imaging? (http://www.ncbi.nlm.nih.gov/pubmed/25501731)

Question 13

A 12-month-old girl is brought to the emergency department by ambulance for evaluation of a generalized tonic-clonic seizure.  About 1 hour ago, the mother witnessed rhythmic jerking of the patient's arms and legs and called 911.  By the time the paramedics arrived, the jerking had stopped, lasting a total of 7 minutes.  She was born at 32 weeks gestation but has no chronic medical conditions.  Her maternal uncle had seizures as a child.  Temperature is 40 C (104 F), blood pressure is 100/65 mm Hg, pulse is 150/min, and respirations are 30/min.  The patient appears drowsy but is in no distress.  The anterior fontanelle is open, soft, and flat.  The neck is supple.  Cardiopulmonary examination is normal.  She is difficult to rouse but withdraws from painful stimuli.  Skin examination appears normal.  Which of the following is this patient's indication for lumbar puncture?

Accepted Answer

Explanation: 11ec2b69_bff5_5756_8f63_adac9f617941_MD0005_00 Although convulsions in the setting of fever are common in young children and often benign, concerning history and/or physical examination findings may warrant evaluation for meningitis. Simple febrile seizures are generalized, last <15 minutes, and do not recur within 24 hours. Postictal drowsiness typically lasts up to 10 minutes. Febrile seizures are a clinical diagnosis in children age 6 months to 5 years, and patients do not require diagnostic studies or treatment. Red flag findings on examination that may suggest meningitis should prompt immediate lumbar puncture (LP). These include: Signs of increased intracranial pressure (eg, morning headache, vomiting, bulging fontanelle) Meningeal signs (eg, nuchal rigidity) Prolonged altered mental status (ie, postictal period >10 min) Petechial rash This febrile patient has prolonged altered mental status following a seizure. Her abnormal neurologic examination (ie, responsive only to painful stimuli 1 hour after seizure) warrants LP to assess for CNS infection. (Choice A) Evaluation for meningitis may be also indicated for a seizure in a premature infant with an underlying neurologic condition (eg, ventriculoperitoneal shunt) that increases the risk of CNS infection. Birth history in a patient with no chronic medical problems (as seen here) does not affect the decision to perform LP. (Choice B) Prolonged (>30 min) or recurrent seizures without return to neurologic baseline are associated with a higher risk of an underlying CNS infection. This patient's 7-minute seizure duration does not warrant LP. (Choices C and D) High fever and family history of febrile seizures are risk factors for developing a febrile seizure but do not change management. Educational objective: Most convulsions in the setting of fever in young children are benign (ie, febrile seizure). However, meningitis should be suspected in patients with nuchal rigidity, headache, bulging fontanelle, and/or prolonged altered mental status. Lumbar puncture is warranted in these cases. References: Recovery of consciousness following acute symptomatic seizures due to central nervous system infections in children. (http://www.ncbi.nlm.nih.gov/pubmed/22352298) Neurodiagnostic evaluation of the child with a simple febrile seizure. (http://www.ncbi.nlm.nih.gov/pubmed/21285335)

Question 14

A 24-year-old man is brought to the emergency department by his girlfriend due to progressive weakness.  They have been on a cross-country road trip for the past month.  While traveling through the midwestern United States 2 weeks ago, the patient developed diarrhea, nausea, and vomiting.  He rested, drank fluids, and improved spontaneously after 2-3 days.  However, the patient had persistent fatigue, and 4 days ago they had to stop traveling as his legs became too weak to press down the brake pedal.  He is now unable to get out of bed.  The patient has also had tingling of the hands and feet as well as shortness of breath.  He has had no fever, chills, abdominal pain, or recurrent diarrhea.  The patient has no prior medical problems and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.7 C (99.8 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 20/min.  Pulse oximetry shows 98% on ambient air.  The patient is awake, alert, and speaking in full sentences but develops a weak cough after taking a sip of water.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender.  Neurologic examination shows symmetric bilateral lower extremity weakness.  Deep tendon reflexes are absent at the knees and ankles, and 1+ in the biceps and triceps.  Cranial nerve examination and sensation are normal, and he has no neck rigidity.  There is no skin rash or lymphadenopathy. Which of the following is the best treatment modality for this patient?

Accepted Answer

Explanation: Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy due to cross-reacting antibodies against peripheral nerve components. Disease-modifying treatment with plasma exchange or intravenous immunoglobulin (IVIG) speeds recovery and reduces the need for mechanical ventilation. Patients with GBS should receive plasma exchange or IVIG if: Nonambulatory Within 4 weeks of symptom onset Those who are ambulatory and recovering generally do not require treatment. (Choice A) Botulism is typically treated with equine serum antitoxin and antibiotics. Patients with botulism usually have symmetric descending weakness (starting in the cranial nerves) with no sensory deficits (except blurred vision). This patient with weakness that began in his legs and paresthesias is much more likely to have GBS. (Choice B) Transverse myelitis is typically treated with high-dose glucocorticoids. Manifestations typically include motor weakness, paresthesias, and autonomic dysfunction (eg, bowel/bladder dysfunction). Most patients have a sensory level deficit. This patient with recent gastrointestinal illness who developed symmetric motor weakness, diminished reflexes in the upper and lower extremities, and potential respiratory compromise (weak cough, tachypnea) is more likely to have GBS. (Choice C) Amyotrophic lateral sclerosis is a degenerative motor neuron disease that usually manifests with asymmetric limb weakness of the hand or foot (eg, foot drop) and can be treated with riluzole and supportive care. Most cases arise in those of advanced age (>70). This young patient with symmetric, rapidly progressive weakness after a gastrointestinal illness is more likely to have GBS. (Choice D) A spinal epidural abscess (SEA) is often managed with surgical decompression and antibiotics. SEA usually manifests with slowly progressive back pain, fever, and neurologic deficits (eg, paresthesia, motor weakness, bladder/bowel dysfunction). This patient is afebrile with no back pain, making SEA unlikely. Educational objective: Guillain-Barré syndrome is treated with plasma exchange or intravenous immunoglobulin to speed recovery and reduce risk of respiratory failure. Patients who are nonambulatory should receive treatment if symptoms have been present <4 weeks.

Question 15

A 16-year-old-girl comes to the clinic for follow-up after sustaining a head injury 7 days ago.  The patient was playing soccer and her head collided with another player.  She was seen in the office that day and diagnosed clinically with a concussion.  The patient was instructed to rest for 2 days before beginning a gradual return-to-play program.  She participated in light aerobic activity yesterday and began moderate aerobic activity exercises today.  During training today, she developed nausea and felt dizzy.  The patient has no chronic medical conditions.  Blood pressure is 112/76 mm Hg, pulse is 90/min, and respirations are 16/min.  The patient is alert and oriented.  Cardiopulmonary examination is normal.  Cranial nerves are intact.  Strength is normal.  Sensations and reflexes are equal bilaterally.  Cerebellar examination and gait are normal.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_bff1_d4e1_8f63_47fc461dc1e4_MD0005_00 Concussion is a mild traumatic brain injury caused by axonal shearing from rapid rotational acceleration of the brain during a fall or strike to the head. Children and adolescents playing contact sports (eg, soccer) are at increased risk for concussions. Patients are usually diagnosed clinically based on the presence of a neurologic disturbance (eg, headache, cognitive dysfunction) after head trauma. Neuroimaging is not typically required unless high-risk features for structural intracranial injury are present (ie, altered mental status, loss of consciousness, severe headache/vomiting, severe mechanism of injury, signs of basilar skull fracture). Initial management is physical and cognitive rest for 24-48 hours. Athletes should then follow a gradual return-to-play protocol with progressive intensity of physical exercise (eg, light aerobics → moderate noncontact activity → competitive play) as tolerated. If symptoms worsen at any level of exertion, a 24-hour rest period is recommended before returning to the previous step in the protocol that did not exacerbate symptoms. In this case, the patient tolerated light aerobics but developed dizziness and nausea with moderate exercise; therefore, she should rest for a day and then return to light aerobic activity. (Choice A) Refraining from contact sports for prolonged periods may be appropriate for a patient with persistent neurocognitive deficits due to multiple concussions, which are not seen in this patient. (Choice B) Brain imaging to exclude structural intracranial injury may be considered for worsening symptoms despite appropriate rest and adherence to the gradual return-to-play protocol. In contrast, this patient's symptoms that wax and wane with exertion are typical of a concussion and can be managed by adjusting the activity level. (Choice C) Continuing moderate exercise despite worsening symptoms can lead to chronic postconcussive symptoms and is not recommended. (Choice D) Physical rest for a week prolongs the recovery time and increases the risk of deconditioning. Early return to light exercise is safe as long as the progression of intensity is gradual. Educational objective: Concussion is a mild traumatic brain injury characterized by neurologic disturbance without structural intracranial injury. Management involves a gradual return-to-play protocol with increasing intensity of physical activity. When symptoms develop with progressive exertion, patients should rest and return to the previously tolerated activity level. References: American Medical Society for Sports Medicine position statement: concussion in sport. (http://www.ncbi.nlm.nih.gov/pubmed/23243113)

Question 16

A 28-year-old man comes to the office for a health maintenance visit. He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen. Occasionally the headaches are severe enough to necessitate taking a sick day from work. He cannot recall specific triggers but notes that the headaches are usually unilateral. The patient does not use tobacco or illicit drugs. He drinks alcohol socially and 2-3 cups of coffee daily. He is a software engineer and often works at a computer 10-12 hours a day. His sister has a history of migraines. Vital signs are within normal limits. Physical examination, including neurological examination, is normal. Item 1 of 4 Which of the following is the best next step in management of this patient's headaches?

Accepted Answer

Explanation: This patient has had several years of episodic headaches that occasionally interfere with work. He is otherwise healthy and has a normal neurological examination. These features suggest a benign form of headache such as tension-type, migraine, or cluster. Additional information is now required to differentiate these etiologies; the patient should keep a headache diary to record headache triggers, headache length, associated symptoms, and palliative techniques and then return for follow-up. Although this patient has features consistent with a benign cause of headache, headaches can also indicate a serious underlying condition such as brain mass, infection, or hemorrhage. Danger signs indicating a potentially life-threatening cause of headache include the following: Systemic symptoms (eg, fever) or illness (eg, cancer) Neurological signs/symptoms Onset is new Other associated conditions (eg, head trauma) Previous headaches with change in frequency, severity, or presentation Patients with any of these findings usually require urgent investigation, often including brain imaging (eg, MRI) (Choice B). (Choice A) Patients who take analgesics (eg, acetaminophen) for headaches >10 days/month for >3 months can develop a secondary headache disorder due to medication overuse. Prior to recommending cessation of acetaminophen, this patient should keep a headache diary to clarify the number of headaches per month and associated acetaminophen use. (Choices C and D) Acute migraine headaches can be treated with nonsteroidal anti-inflammatory medication and sumatriptan, and tension-type headaches can be treated with lifestyle modification and reassurance. However, additional information about the headache type, location, timing, and associated symptoms is required prior to making either of these diagnoses. Educational objective: The cause of headache can often be differentiated based on history and physical examination. Headache diaries can help gather data on headache frequency, duration, intensity, associated symptoms, and medications used for treatment. References: Headache diaries and calendars. (http://www.ncbi.nlm.nih.gov/pubmed/20816416)

Question 17

A 28-year-old man comes to the office for a health maintenance visit.  He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen.  Occasionally the headaches are severe enough to necessitate taking a sick day from work.  He cannot recall specific triggers but notes that the headaches are usually unilateral.  The patient does not use tobacco or illicit drugs.  He drinks alcohol socially and 2-3 cups of coffee daily.  He is a software engineer and often works at a computer 10-12 hours a day.  His sister has a history of migraines.  Vital signs are within normal limits.  Physical examination, including neurological examination, is normal. The patient states that the prior headaches were of similar nature and recurred several days in a row before remitting.  Recently, the periods of active headaches have increased in duration with no remission.  Which of the following is the best pharmacotherapy for headache prevention in this patient?

Accepted Answer

Explanation: Patients with cluster headache typically have 1-8 episodes a day over weeks or months. Although several medications are effective for acute treatment of cluster headaches, the repeated use of abortive medications can lead to rebound headaches and toxicity. As such, patients with cluster headache should receive preventive treatment at the onset of a cluster period to mitigate symptoms. The first-line therapy for cluster headaches that typically last >2 months is verapamil. This medication is usually initiated at 240 mg and titrated up as needed. (Choice A) Carbamazepine is an anticonvulsant that can be useful in patients with trigeminal neuralgia but is not typically used in cluster headaches. Topiramate, another anticonvulsant, is sometimes added to verapamil therapy in patients with cluster headaches. (Choice B) Indomethacin is a nonsteroidal anti-inflammatory drug that may be useful for acute treatment of tension-type or migraine headaches, but it is not an effective preventive therapy for cluster headaches. (Choice C) Propranolol can be used to prevent migraine headaches but is not an effective preventive therapy for cluster headaches. This patient with unilateral orbital headache associated with autonomic symptoms is more likely to have a cluster headache than migraine. (Choice D) Sumatriptan is useful for acute treatment of cluster headaches but is not used for chronic prevention. Educational objective: Patients with cluster headache should receive preventive treatment at the onset of a cluster period. Verapamil is considered the agent of choice for the prevention of episodic and chronic cluster headaches. References: Verapamil in the prophylaxis of episodic cluster headache: a double-blind study versus placebo. (http://www.ncbi.nlm.nih.gov/pubmed/10746617) Management of chronic cluster headache. (http://www.ncbi.nlm.nih.gov/pubmed/21107766)

Question 18

A 24-year-old man is brought to the emergency department by his girlfriend due to progressive weakness.  They have been on a cross-country road trip for the past month.  While traveling through the midwestern United States 2 weeks ago, the patient developed diarrhea, nausea, and vomiting.  He rested, drank fluids, and improved spontaneously after 2-3 days.  However, the patient had persistent fatigue, and 4 days ago they had to stop traveling as his legs became too weak to press down the brake pedal.  He is now unable to get out of bed.  The patient has also had tingling of the hands and feet as well as shortness of breath.  He has had no fever, chills, abdominal pain, or recurrent diarrhea.  The patient has no prior medical problems and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.7 C (99.8 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 20/min.  Pulse oximetry shows 98% on ambient air.  The patient is awake, alert, and speaking in full sentences but develops a weak cough after taking a sip of water.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender.  Neurologic examination shows symmetric bilateral lower extremity weakness.  Deep tendon reflexes are absent at the knees and ankles, and 1+ in the biceps and triceps.  Cranial nerve examination and sensation are normal, and he has no neck rigidity.  There is no skin rash or lymphadenopathy. The patient is told that the diarrheal illness may have triggered his current condition, and he becomes upset that he did not seek medical attention earlier.  He inquires about the course and prognosis of his current condition.  Which of the following is the most accurate statement?

Accepted Answer

Explanation: The manifestations of Guillain-Barré syndrome (GBS) tend to evolve as follows: 2 weeks of progressive motor weakness that can lead to paralysis 2-4 weeks of plateaued symptoms Slow, spontaneous recovery over months At a year after symptom onset, 85% of patients with GBS have regained the ability to walk and nearly 60% have had full, spontaneous neurologic recovery. Although patients with GBS typically recover without intervention, treatment with plasma exchange or intravenous immunoglobulin shortens the time to recovery by approximately 50%. (Choice A) Botulism is associated with full recovery after treatment and typically does not recur if the neurotoxin is avoided. Botulism causes a symmetric descending paralysis that usually begins in the cranial nerves. (Choice B) Patients with transverse myelitis typically have incomplete recovery and are at increased risk for multiple sclerosis. Transverse myelitis usually causes a sensory level. (Choice C) Amyotrophic lateral sclerosis typically progresses over 3-5 years and is fatal; patients with this disease have asymmetric (not symmetric) motor weakness and are usually older. (Choice D) Patients with GBS tend to have impaired neurologic recovery if the illness was preceded by a Campylobacter infection, they had severe motor weakness on admission, or required ventilatory support. Educational objective: Patients with Guillain-Barré syndrome tend to worsen over 2 weeks, plateau for 2-4 weeks, and then spontaneously recover over months. Time to recovery is shortened by the use of plasma exchange or intravenous immunoglobulin.

Question 19

An 11-month-old boy is brought to the emergency department following a head injury.  About 45 minutes ago, the patient had pulled himself up to stand on the second step of the staircase at home.  He attempted to take a step to the side and as his mother approached to grab him, lost his footing and tumbled onto the floor, falling from a height of 0.38 m (15 in).  The boy hit his head on the wooden floor and began crying.  He did not lose consciousness and has not vomited.  The patient was born at 33 weeks gestation.  He has no chronic medical conditions.  Vital signs are normal.  Glasgow Coma Scale is 15.  Examination shows a 4 cm hematoma along the right parietal lobe.  The anterior fontanel is closed.  Neurological examination shows a symmetric face with equal and reactive pupils.  The boy reaches out with each hand equally.  When the plantar surface of each foot is stroked with a pointed object, the corresponding big toe dorsiflexes while the remaining toes fan out.  Which of the following is most concerning for an underlying traumatic brain injury in this patient?

Accepted Answer

Explanation: 11ec2b69_bff1_38a0_8f63_01734d0a44a7_MD0005_00 This patient has sustained minor head trauma, which is defined as blunt trauma in an alert patient with a nonfocal neurological examination. Although the trauma is mild, skull fractures and intracranial injury (eg, hemorrhage) can occur. Children age <2 are at the highest risk for skull fractures; however, clinical assessment of a young, nonverbal child is often challenging. In addition, in infants with open fontanels, intracranial hemorrhage is more likely to be asymptomatic. The evaluation of minor head trauma is based on risk for intracranial injury. High-risk features in children age <2 include: Altered mental status Loss of consciousness Severe mechanism of injury (eg, fall >0.9 m [3 ft], high-impact hit, serious motor vehicle collision) Nonfrontal scalp hematoma Palpable skull fracture This patient has a nonfrontal scalp hematoma, which may indicate an underlying skull fracture. Large (ie, >3 cm) parietal and temporal hematomas have the highest risk. CT scan of the head without contrast is the preferred imaging study to assess for skull fracture or intracranial injury when high-risk features are present. Observation for 4-6 hours in the emergency department may be an alternative option for children at intermediate risk (eg, self-limited emesis, small/isolated scalp hematoma). Patients may be discharged with return precautions if the CT scan is normal or if symptoms improve during the observation period. (Choice A) Patients with closed fontanels are more likely to have symptoms of increased intracranial pressure (eg, headache, vomiting) with intracranial injury, but they are not at higher risk for developing traumatic brain injury. This patient's closed anterior fontanel is a normal finding for age. (Choice B) Fall height >3 ft is a risk factor for traumatic brain injury. This patient fell only 15 in. (Choice D) Focal neurological findings after head trauma raise a concern for intracranial injury. This patient's neurological examination is normal, including a Babinski reflex (ie, great toe dorsiflexion with fanning of other digits when the sole is stroked), which can be seen until age 2. (Choice E) The surface on which the patient landed is not a factor in assessing risk for intracranial injury in minor head trauma. Educational objective: The evaluation of a child following minor head trauma is based on risk for intracranial injury. In children age <2, high-risk features include altered mental status, loss of consciousness, severe mechanism of injury, nonfrontal scalp hematoma, and palpable skull fracture. References: Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. (http://www.ncbi.nlm.nih.gov/pubmed/24635991) To scan or not to scan: overutilization of computed tomography for minor head injury at a pediatric trauma center. (http://www.ncbi.nlm.nih.gov/pubmed/30463714)

Question 20

A 68 year old male presents to the emergency room with his wife complaining of falling at his home.  The patient is currently hemodynamically stable and has no other complaints.  The patient takes hydrochlorothiazide and metoprolol for high blood pressure and atorvastatin for hypercholesterolemia.  A head CT reveals no intracranial bleeding or skull fractures and the patient is free of any noticeable injuries.  The patient says he feels fine and wonders if it is okay to go home.  What is the next best step in the management of this patient?

Accepted Answer

Explanation: This patient describes a fall at home, but it is unclear in the given history if it was a mechanical fall (i.e. the patient tripped) or a syncopal episode (transient loss of consciousness with rapid recovery). Syncope can be divided into two broad categories: cardiovascular and noncardiovascular. Cardiovascular causes include arrhythmia and blood flow obstruction (i.e. aortic stenosis). Noncardiovascular causes are extensive including: vasovagal, carotid sinus hypersensitivity, orthostasis, seizures, TIA, etc. Approximately 25% of patients have no known etiology of their syncopal event. The most important part of a syncope work up is the history. Thorough history taking, physical examination (including orthostatics), and EKG will reveal the cause of syncope in about 50% of patients. A high number of episodes in a short time span points towards a more serious etiology, such as arrhythmia. Vasovagal syncope is often associated with a prodrome of tunnel vision, diaphoresis, nausea, and pallor. Associated symptoms may help to point towards the diagnosis as well. (Choice A) It would be inappropriate to discharge this patient without a thorough history and physical with follow up testing if indicated. The patient's age along with his history of hypertension and hyperlipidemia raise the likelihood of an arrhythmia, therefore an inpatient admission may be warranted. (Choice B) An MRI of the brain is not likely to show any abnormalities associated with true syncope, but could be helpful in seizure or stroke. (Choice C)An EEG is also unlikely to reveal a cause for syncope unless suggested by history. Only if there is sufficient evidence for seizures (postictal confusion, tongue biting etc.) is an EEG indicated. (Choice E)An echo would be an appropriate diagnostic test in this patient, but further history should be obtained first. Educational objective: Thorough history taking in a patient with a fall is crucial in order to determine if the underlying cause is syncope, mechanical, or seizure. Additional history taking should clarify number of episodes, presence of a prodrome, surrounding events, associated symptoms, duration of the episode, time until full recovery, witnesses to the event, other medical problems, drug use, and history of seizures.

Exam 1: Advanced Clinical Medicine