Question 1

A 34-year-old, obese, Caucasian male presents to your office with an abnormal sensation over his right thigh. He says, "It gets numb, and sometimes I feel burning over my thigh."  He denies any back pain, muscle weakness, or abnormal sensation below the knee.  His past medical history is insignificant.  He smokes two packs of cigarettes and consumes 1-2 bottles of beer daily.  He is a construction worker.  He frequently works in a squatting position.  Physical examination reveals an area of decreased sensation over the right anterolateral thigh.  There is no muscle weakness.  Deep tendon reflexes are symmetrical.
Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: Meralgia paresthetica is a clinical diagnosis (diagnosed based on the history and physical findings). The classic patient will present with complaints of typical pain in the characteristic location, sensory abnormalities, and absent neurologic abnormalities of the lower leg on examination. Some of the common causes are obesity and the use of tight garments around the waist. Management includes reassurance of the patient (that this is not a serious condition) and conservative measures such as weight loss (in obese patients) and avoidance of tight-fitting garments to reduce the pressure on the nerve entrapment area. (Choices A and B)Plain x-rays of the hip and pelvis, electromyography (EMG), and nerve conduction studies (NCS) are not necessary in a patient with the characteristic history and physical findings. (Choice C)Physical therapy has no role in the management of meralgia paresthetica. (Choice D)Local corticosteroid injection and the use of anticonvulsants (i.e., carbamazepine, phenytoin, or gabapentin) are reserved for patients with persistent symptoms that are refractory to conservative measures. Educational Objective: Meralgia paresthetica is a clinical diagnosis. It is a benign condition, and treatment includes reassurance, weight loss, and the avoidance of tight-fitting garments.

Question 2

A 78-year-old man is brought to the office by his daughter, who states that he has become forgetful.  Over the past year, his responses have become slow, and he has had increasing difficulties in caring for himself.  He was recently seen by another physician, who suspected a "certain type of anemia."  He has no urinary or respiratory problems.  The patient was previously diagnosed with hypertension and coronary artery disease.  He takes lisinopril, metoprolol, and aspirin.  He lives with his daughter and son-in-law.  He does not use tobacco, alcohol, or illicit drugs.  Examination shows an elderly man who is disoriented to time and place and communicates poorly.  He speaks softly and slowly and seems to think too much about his answers.  The mini-mental state examination (MMSE) score is 22 points (normal >24).  The patient's gait is slow and cautious, as if he were expecting to fall.  Laboratory test results are as follows:  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: 11ec2b69_bff7_5328_8f63_a1982f62fd38_MD0005_00 This patient has disordered gait, impaired language, chronic cognitive decline, and abnormal findings on mental status examination; these are typical features of dementia. Even though most cases of dementia are due to Alzheimer's disease, approximately 20% of patients have a potentially reversible cause. For this reason, the American Academy of Neurology (AAN) currently recommends screening for hypothyroidism, vitamin B₁₂ deficiency, and depression as part of the initial evaluation of all patients with suspected dementia. Additional testing may be indicated for individual patients depending on history or examination findings (eg, hepatic function tests in patients with signs of ascites on examination). In this case, hyponatremia, macrocytosis, bradypsychia (slowed thought process), and slowed speech suggest underlying hypothyroidism, which should be ruled out by assessing serum TSH. ₁₂ (Choices A and B) The AAN also recommends cerebral imaging with MRI or head CT for the evaluation of dementia. Imaging may identify signs of chronic vascular disease, subdural hematoma, or normal pressure hydrocephalus (NPH). Patients with NPH may have a shuffling broad-based gait but a "cautious gait" is nonspecific and can be seen in normal elderly patients. Correcting the underlying hypothyroidism may obviate the need for imaging in this case. (Choice C) Screening for syphilis in a patient with dementia is not routinely recommended, though it may be considered if the patient has specific risk factors or evidence of a prior syphilitic infection. (Choice E) Depression is probably the most common cause of reversible dementia; however, it does not explain the hyponatremia or macrocytosis seen in this patient. If depression is suspected, a brief depression screen (eg, Geriatric Depression Scale) would be indicated prior to psychiatry referral. Educational objective: Approximately 20% of cases of dementia are due to potentially reversible conditions. In particular, hypothyroidism, vitamin B₁₂ deficiency, and depression should be ruled out in the initial evaluation of dementia. Hypothyroidism in elderly patients may present with impaired cognition and is often associated with hyponatremia and macrocytosis. ₁₂ References: Cognitive and neuropsychiatric aspects of subclinical hypothyroidism: significance in the elderly (http://www.ncbi.nlm.nih.gov/pubmed/13678560)

Question 3

A 78-year-old woman is brought to the emergency department after her neighbor found her slumped over on her front porch bench, unable to speak or walk.  The neighbor reports that, 2 hours prior, he had seen the patient walking to her mailbox.  He spoke with her for a few minutes, and she seemed normal at that time.  The patient lives alone but has an adult daughter in another town.  Vital signs are normal.  Neurologic examination demonstrates right-sided hemiparesis and aphasia.  The patient is a candidate for thrombolysis but does not appear to understand when the risks and benefits of thrombolysis are discussed.  The daughter could not be reached by phone on the initial attempt.  Which of the following is the most appropriate next step regarding consent for thrombolysis in this patient?

Accepted Answer

Explanation: This patient has symptoms of a debilitating stroke and is a candidate for thrombolysis, a therapy endorsed by evidenced-based guidelines for acute ischemic stroke. Thrombolysis greatly decreases poststroke disability, but its efficacy is time-dependent (ie, "time is brain"). Therefore, thrombolysis administration is urgent, so delays in treatment should be minimized. When possible, the risks and benefits of thrombolysis are briefly discussed with the patient to obtain consent for treatment. However, an exception to informed consent includes treatment of life-threatening emergencies (eg, stroke) when there is inadequate time to obtain consent or when the patient's capacity to give informed consent is impaired, as in this patient with receptive aphasia. Because of the circumstances of emergency stroke care and the safety and efficacy of thrombolysis, consent is not required to administer thrombolysis on an emergency basis. Therefore, this patient should receive tissue plasminogen activator without further delay (Choice D). (Choice B) Most states designate the legal surrogate hierarchy as follows: spouse (unless divorced or legally separated), then adult child, parent, and adult sibling. A few states also give authority to a "close friend"; however, this patient's neighbor is not necessarily a close friend, and it is unlikely that he would know the patient's wishes regarding her medical care. More important, consent for treatment with thrombolysis is not required on an emergency basis. (Choice C) Two-physician consent is often obtained when nonemergency medical decisions (eg, end-of-life care) are required and no one can be identified to act on behalf of an incapacitated patient. However, consent for emergency thrombolysis is unnecessary; in addition, finding a second physician and waiting for the second evaluation may also create a significant (and detrimental) delay. (Choice E) When a patient's capacity to provide consent for emergency care is impaired, a rapid and reasonable attempt is typically made to determine the patient's wishes by consulting a living will or locating a legal surrogate. However, withholding thrombolysis for an indefinite length of time (eg, hours) until the consent of a legal surrogate (eg, patient's daughter) can be obtained is inappropriate and unnecessary; delay reduces thrombolysis efficacy and neurologic recovery, and emergency thrombolysis may be given without consent. Educational objective: Consent for thrombolysis in acute ischemic stroke should be obtained from the patient when possible. However, because time to treatment is critical (ie, "time is brain"), thrombolysis can be given on an emergency basis without consent. References: Getting the gist across is enough for informed consent for acute stroke thrombolytics. (http://www.ncbi.nlm.nih.gov/pubmed/31084320)

Question 4

An 18-year-old man comes to the physician for daytime sleepiness lasting several months. The patient recently started college, has difficulty staying awake during classes, and often falls asleep suddenly even though he "gets a good night's sleep." He typically goes to bed at 2 am and sleeps until at least 9 am, usually later. The patient's sleep pattern at night is fragmented. He wakes frequently but is usually able to go back to sleep within a few minutes. He does not snore or wake up gasping. The patient feels like "someone is in the room with me when I'm just falling asleep and I sometimes hear my name being called." His past medical history is otherwise insignificant. The patient does not use tobacco or alcohol. Blood pressure is 120/70 mm Hg and heart rate is 70/min. His body mass index is 23 kg/m². Item 1 of 3 Which of the following is the best next step in diagnosing the cause of this patient's symptoms?

Accepted Answer

Explanation: 11ec2b69_bffe_cd3d_8f63_7f44f0edd6f7_MD0005_00 Insufficient sleep is the most common cause of excessive daytime sleepiness (EDS). Other common causes can include medication effects, alcohol or illicit drug use, and obstructive sleep apnea. However, in addition to EDS, this patient experiences fragmented sleep, hypnagogic hallucinations, and the sudden onset of sleep during the day, features consistent with narcolepsy. The typical age of onset for narcolepsy is late teens to early 20s. Polysomnography (sleep study) can diagnose narcolepsy; characteristic findings include multiple spontaneous awakenings and reduced sleep efficiency (total sleep time divided by total recording time) and latency of rapid eye movement (REM) sleep. Polysomnography can also exclude other causes of EDS (eg, sleep apnea). (Choice A) CT scan of the head can be useful for identifying signs of increased intracranial pressure (ICP) that can cause EDS. However, this patient lacks other features of increased ICP (eg, headaches, nausea/vomiting, gait disturbances). (Choice B) Absence seizures are characterized by repetitive staring spells and can be documented with electroencephalography. This patient's excessive daytime sleepiness and hypnagogic hallucinations are unlikely to represent absence seizures. (Choice C) Hypnagogic hallucinations (eg, feelings of people walking around, hearing one's name called on falling asleep) are not evidence of psychiatric disease but are characteristic of narcolepsy. They are likely to result from a combination of REM sleep dreaming and wakefulness. (Choice D) A sleep diary can document a patient's sleep pattern over several weeks and is helpful for evaluating circadian rhythm disorders. This patient has a delayed sleep phase (late to bed, late to rise), which is common at his age. This patient seems to get an adequate amount of sleep (at least 7 hours nightly), making a sleep study a more useful diagnostic test. Educational objective: Excessive daytime sleepiness (EDS) is a common symptom and is most commonly caused by insufficient sleep. However, narcolepsy should be considered in a young patient with EDS, especially if the patient also experiences falling asleep suddenly at inappropriate times, hypnagogic hallucinations, or cataplexy. References: Excessive daytime sleepiness. (http://www.ncbi.nlm.nih.gov/pubmed/19275068)

Question 5

A 65-year-old man comes to the office for a follow-up visit. His friend recently died from a massive cerebrovascular event. The patient is worried about his individual risk for stroke. Medical conditions include hypertension, type 2 diabetes mellitus, hypercholesterolemia, and obesity. He is an active smoker with a 40-pack-year history. The patient does not use alcohol or illicit drugs. Family history is not contributory. Medications include low-dose (81-mg) aspirin, metformin, lisinopril, and atorvastatin. Blood pressure is 161/92 mm Hg. BMI is 30 kg/m². Examination shows no abnormalities. Laboratory results are as follows: Which of the following would provide the greatest benefit for decreasing this patient's risk for an ischemic stroke?

Accepted Answer

Explanation: Most ischemic strokes are related to atherosclerotic cerebrovascular disease. Major modifiable risk factors for ischemic stroke include: hypertension. hypercholesterolemia. diabetes mellitus. smoking. Patients at risk for stroke warrant a multifactorial care plan to address all risk factors, in addition to general recommendations regarding healthy habits (eg, regular exercise, weight loss). Of these risk factors, hypertension control has the largest potential benefit in primary prevention of stroke. Stroke risk rises sharply with blood pressure, with an approximate 2-fold increase in risk for every 20/10 mm Hg rise above 130/80 mm Hg. Therefore, all patients with elevated blood pressure should be counseled on lifestyle interventions for blood pressure control (eg, DASH [Dietary Approaches to Stop Hypertension] diet) and antihypertensive medications (as appropriate) to reduce the risk for stroke. Patients with diabetes should have a blood pressure target of 140/90 mm Hg, with many experts recommending a goal of 130/80 mm Hg if tolerated. (Choice A) Heavy drinking can increase stroke risk and should be reduced or stopped. Some studies have found a slightly lower risk for stroke in individuals who consume light to moderate alcohol (eg, 1 or 2 drinks/day for men); risk reduction via initiation of alcohol intake has not been proven and is not recommended. (Choice B) Hypertriglyceridemia's increased risk for stroke is related primarily to the presence of concurrent risk factors (eg, hypercholesterolemia). Fibrates (eg, fenofibrate) have not been shown to reduce stroke risk and are likely unbeneficial in this patient with a small elevation in triglycerides. Statins (eg, atorvastatin) are recommended by most treatment guidelines for patients age >40 with diabetes mellitus and have a modest triglyceride-lowering effect. (Choice C) Aspirin is generally recommended to prevent cardiovascular disease and stroke in patients at high risk for stroke (eg, 10-year risk >10%). However, there is no convincing evidence that risk reduction is greater with a high (325 mg/day) compared to a low (81 mg/day) dose. (Choice E) Although intensive glycemic control (eg, hemoglobin A1c <7.0%) is associated with a lower risk for microvascular complications (eg, nephropathy), its benefits in stroke risk reduction are unclear and likely less than in those with aggressive blood pressure control. Educational objective: The major treatable risk factors for ischemic stroke include hypertension, diabetes mellitus, smoking, and dyslipidemia. Hypertension is the most important modifiable risk factor for stroke. All patients with elevated blood pressure should be counseled on lifestyle interventions for blood pressure control (eg, DASH [Dietary Approaches to Stop Hypertension] diet) and antihypertensive medications (as appropriate) to reduce the risk for stroke. References: Guidelines for the Primary Prevention of Stroke (http://www.ncbi.nlm.nih.gov/pubmed/25355838) Primary and secondary prevention of ischemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/20357456)

Question 6

An 18-year-old man comes to the physician for daytime sleepiness lasting several months. The patient recently started college, has difficulty staying awake during classes, and often falls asleep suddenly even though he "gets a good night's sleep." He typically goes to bed at 2 am and sleeps until at least 9 am, usually later. The patient's sleep pattern at night is fragmented. He wakes frequently but is usually able to go back to sleep within a few minutes. He does not snore or wake up gasping. The patient feels like "someone is in the room with me when I'm just falling asleep and I sometimes hear my name being called." His past medical history is otherwise insignificant. The patient does not use tobacco or alcohol. Blood pressure is 120/70 mm Hg and heart rate is 70/min. His body mass index is 23 kg/m². Which of the following is the best initial therapy for this patient?

Accepted Answer

Explanation: The focus of therapy for patients with narcolepsy is on reducing excessive daytime sleepiness (EDS). Older stimulant medications (eg, methylphenidate, amphetamines) are effective but can be highly addictive and have severe side effects. Modafinil is a novel stimulant that has a better side effect profile and lower abuse potential; it is now the first-line pharmacotherapy for narcolepsy. Nonpharmacologic interventions are equally important in management of EDS. Patients can temporarily stall the powerful sleep drive of narcolepsy by taking scheduled naps during the day. Sleep fragmentation and insomnia are prominent features of narcolepsy, making good sleep hygiene necessary. Patients with narcolepsy do not necessarily need more sleep than normal patients; however they acquire their sleep during several, sometimes involuntary, sleep periods during the day. (Choice A) Therapeutic lumbar puncture is sometimes considered for initial treatment of normal-pressure hydrocephalus. (Choice B) Melatonin and light therapy are useful in patients with circadian rhythm disorders (eg, delayed sleep phase, advanced sleep phase). (Choice D) Hypnagogic/hypnopompic (falling asleep/waking) hallucinations do not require treatment with neuroleptic drugs (eg, quetiapine), and this patient does not exhibit other symptoms of a psychotic disorder (eg, schizophrenia). (Choice E) Valproic acid is effective in patients with absence seizures. Educational objective: Modafinil is generally considered first line pharmacotherapy for narcolepsy, and has good effectiveness with a tolerable side effect profile and low abuse potential. Older stimulants such as methylphenidate may also be useful. Behavioral interventions such as good sleep hygiene and scheduled naps are also recommended. References: Narcolepsy: clinical features, co-morbidities & treatment. (http://www.ncbi.nlm.nih.gov/pubmed/20308759)

Question 7

A 32-year-old Caucasian female presents to your office with a two month history of headaches. Initially, her headaches occurred only in the evening and while she tried to take a nap, but recently they seem to be persistent during the day. She describes them as diffuse throughout her entire head. She also complains of some nausea, occasional numbness of her fingertips, and blurry vision. Over-the-counter ibuprofen provides minimal relief. She denies any fevers, vomiting, imbalance, falls, or neck pain. She used to have migraines as a teenager, but they stopped years ago. Her family history is significant for migraines in her mother and older sister. Current medications include an oral contraceptive pill and a daily multivitamin. She smokes one pack of cigarettes per day and drinks alcohol occasionally. Her blood pressure is 152/90 mmHg and heart rate is 76/min. Her BMI is 35 kg/m². Neurological examination is unremarkable. Which of the following is the best next step in managing this patient?

Accepted Answer

Explanation: The most likely diagnosis in this patient is idiopathic intracranial hypertension, also known as pseudotumor cerebri. This disorder most commonly affects women of childbearing age who are overweight. The underlying cause is not well understood. Headache is the primary symptom in most patients, although the character of the headaches is variable and not distinct from other etiologies of headache such as tension headaches or migraines. Most patients with pseudotumor cerebri also complain of visual disturbances and nausea, although these complaints are often present in patients with migraines as well. Although this patient's personal and family history of migraines should be taken into consideration, it is somewhat atypical for patients to have a recurrence of migraines after they have been symptom free for years. The primary physical examination finding in patients with idiopathic intracranial hypertension is papilledema, so an ophthalmoscopic examination is the most appropriate next step. (Choice A) The presence of headaches and papilledema suggests that there is elevated intracranial pressure that could be secondary to an intracranial mass lesion. Some form of neuroimaging study (MRI) is needed, but this should follow the ophthalmologic examination. (Choice C)A lumbar puncture is frequently performed following a neuroimaging study, but would obviously be contraindicated if a mass lesion was seen intracranially due to the risk of herniation. An opening pressure greater than 20-25 cmH2O can help to confirm the diagnosis of pseudotumor cerebri. (Choice D)While this patient's blood pressure is elevated, hypertension generally does not cause headaches unless the blood pressure is markedly elevated. This patient should have a follow-up blood pressure measurement in the near future to determine the need for initiating antihypertensive therapy. (Choice E)This patient's presentation is more suggestive of intracranial hypertension than either headaches caused by medication overuse or migraines. Educational objective: Idiopathic intracranial hypertension, also known as pseudotumor cerebri, is a potential cause of headaches typically seen in overweight women of childbearing age. Papilledema is classically seen on ophthalmoscopic examination. A negative neuroimaging study (except an empty sella) and an elevated opening pressure on lumbar puncture can help to confirm the diagnosis.

Question 8

A 69-year-old woman underwent thyroidectomy due to thyroid cancer.  The surgery was uncomplicated.  Three hours afterward, the patient developed slurred speech and right-sided weakness.  Temperature is 36.3 C (97.3 F), blood pressure is 140/86 mm Hg, pulse is 90/min, and respirations are 18/min.  On examination, the patient is alert and awake, but her speech is incomprehensible.  Strength is 2/5 in both right upper and lower extremities.  Sensations are decreased on the right side of the body.  The dressing covering the operative site on the neck is dry. There is no stridor.  The extremities are warm with normal capillary refill time.  Neurologic examination prior to the surgery showed no abnormalities.  Serum glucose and calcium concentration are normal.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient's new-onset dysarthria, right-sided weakness, and numbness are concerning for perioperative stroke. Most perioperative strokes are ischemic (vs hemorrhagic) and are caused by an embolism, thrombosis, or hypotensive episode (eg, watershed infarction). Patients with preoperative risk factors (eg, cardiovascular disease, carotid stenosis) have the greatest likelihood of stroke. Patients with symptoms of stroke, such as this one, should receive an emergency CT scan of the head without contrast to rule out hemorrhage. Once intracerebral hemorrhage is excluded, reperfusion therapy (eg, intravenous thrombolysis, mechanical thrombectomy) should be considered. Intravenous thrombolysis is sometimes contraindicated due to the risk of surgical site hemorrhage, but thrombectomy may still be possible, depending on the location of the stroke (eg, large-vessel occlusion). rule out hemorrhage Early recognition of postoperative ischemic stroke can be challenging due to the residual effects of general anesthesia but is essential because perioperative ischemic stroke has a high mortality rate (>40%) and reperfusion therapies are time dependent. Early treatment provides a better chance of neurologic recovery. (Choice A) Postoperative hypercapnia (diagnosed by arterial blood gas) can cause incomprehensible speech. However, hypercapnia of that severity would also lead to depressed mental status; this patient is awake and alert. In addition, focal neurologic deficits (eg, right-sided weakness) are unexpected. (Choice C) Postoperative hemorrhage, which can be visualized on a soft tissue CT scan of the neck, can compress the lymphatics, resulting in airway edema and leading to voice changes that can make speech incomprehensible. However, stridor would also likely be present. An anterior neck hematoma would not explain this patient's right-sided weakness. (Choice D) Subtotal thyroidectomy that releases free T4 from hyperactive thyroid tissue can cause intraoperative or postoperative thyroid storm. However, it typically manifests with hyperthermia, tachycardia, and hypertension (vs the normal vital signs in this patient). Tremor may be present, but focal neurologic deficits do not occur. (Choice E) Serum phosphorus levels can be elevated following thyroidectomy, when parathyroid function is also impaired (parathyroid hormone promotes excretion of phosphorus in the urine). However, elevated phosphorus levels typically cause muscle cramps, bone pain, and pruritus, which are not present in this patient. Educational objective: Perioperative patients with new neurologic deficits should receive a full stroke evaluation, including an emergency noncontrast CT scan of the head. Those with perioperative stroke may be eligible for time-dependent reperfusion therapies. References: Perioperative stroke: pathophysiology and management. (http://www.ncbi.nlm.nih.gov/pubmed/29441169)

Question 9

A 63-year-old woman is brought to the emergency department with left-sided weakness that started an hour ago.  According to family members, the patient dropped her fork while having dinner and subsequently was unable to walk.  Medical history includes hypertension, hyperlipidemia, and type 2 diabetes mellitus.  Examination shows normal S1 and S2 and no carotid bruits.  Neurologic examination shows dense, left-sided hemiplegia.  After initial evaluation, including a noncontrast CT scan of the head that is negative for hemorrhage, tissue plasminogen activator is administered.  The patient is not a candidate for mechanical thrombectomy.  Five hours later, the left-sided weakness is improved.  The patient has no headache, blurred vision, or nausea.  Blood pressure is 198/110 mm Hg and pulse is 87/min and regular.  Finger-stick glucose level is 143 mg/dL.  Which of the following is the most appropriate immediate next step in management?

Accepted Answer

Explanation: 11ec2b69_bffa_877a_8f63_8983ecfb88ce_MD0005_00 This patient with an acute ischemic stroke (eg, acute left-sided hemiplegia, no hemorrhage on CT scan) has received thrombolysis with tissue plasminogen activator (tPA) and experienced improved symptoms. After thrombolysis, she should be admitted to an intensive care or dedicated stroke unit for close monitoring of the following: Neurologic status: Frequent examinations monitor for neurologic deterioration, which may signal intracerebral hemorrhage, the most feared complication of thrombolysis. Blood pressure: Blood pressure is kept at <180/105 mm Hg to decrease the risk of hemorrhagic transformation. This is best achieved using intravenous antihypertensive agents such as labetalol or nicardipine because they have rapid onset and are easily titratable. Hypotension should also be avoided to maintain adequate perfusion to the ischemic penumbra (ie, hypoperfused brain at risk for infarction). Intensive monitoring also facilitates the recognition and treatment of other possible complications of tPA, such as angioedema or systemic bleeding. Because the risk of bleeding increases following thrombolysis, waiting at least 24 hours is recommended before performing any invasive testing or procedures and before beginning antiplatelet therapy or anticoagulation. (Choices A and C) Full-dose anticoagulation with heparin or oral anticoagulant therapy is contraindicated in the first 24 hours following tPA. In addition, there is no indication (eg, atrial fibrillation, intracardiac thrombus) for anticoagulation in this patient. (Choice D) Antiplatelet therapy (eg, aspirin) is eventually administered to most stroke patients. However, it is contraindicated in the first 24 hours after tPA because it increases the risk of bleeding. It is typically started 24-48 hours after tPA if the patient is stable; some institutions also perform a noncontrast CT scan of the head prior to initiation to confirm that no interval intracerebral hemorrhage has occurred. (Choice E) Oral antihypertensive agents (eg, hydrochlorothiazide) will likely be needed for long-term control of this patient's blood pressure to decrease her risk of future stroke. However, in the early period after tPA administration, intravenous antihypertensive agents are preferred; their rapid onset of action and ability to be quickly titrated help keep the blood pressure <180/105 mm Hg while avoiding hypotension. Educational objective: Patients with acute ischemic stroke who are treated with tissue plasminogen activator should have strict blood pressure control. Blood pressure is kept <180/105 mm Hg using intravenous antihypertensive agents to decrease the risk of hemorrhagic transformation. Hypotension is avoided to maintain adequate perfusion to the ischemic penumbra. References: Critical care management of acute ischemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/28466119) Complications associated with recombinant tissue plasminogen activator therapy for acute ischaemic stroke. (http://www.ncbi.nlm.nih.gov/pubmed/23394532)

Question 10

An 18-year-old high school senior is brought to the emergency room after she was involved in a motor vehicle accident.  Upon her arrival to the emergency room, she is minimally responsive, and there is evidence of bleeding from the right side of her head.  Her vital signs are as follows: temperature 37.6C (99.6F), blood pressure 182/98 mmHg, heart rate 52 per minute and respiratory rate 6 per minute.  Her oxygen saturation is 96% on two liters of oxygen.  Her breath smells of alcohol.  Physical examination reveals a right pupillary size of 7 mm with minimal response to light.  The left pupil is 3 mm with normal pupillary light reflex.  The right eye is deviated outwards and downwards.  There is bilateral papilledema on funduscopic examination.  While in the ER, the patient had an episode of generalized body extension, with adduction and pronation of her upper extremities.  There is no evidence of any thoracic or abdominal injuries.  Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

Explanation: The above patient has the typical clinical features of elevated intracranial pressure (ICP), most likely secondary to an intracranial hemorrhage from head trauma sustained in the motor vehicle accident. Other causes of elevated intracranial pressure include an intracranial hemorrhage from ruptured aneurysms, bleeding AV malformations, CNS infections, CNS neoplasm, and hydrocephalus. Patients with intracranial hypertension have been classically described to have bradycardia, hypertension and respiratory depression (Cushing's triad). In the early stages, patients complain of headaches, vomiting, blurred vision, and have papilledema on funduscopic examination. Further elevation in the intracranial pressure leads to transtentorial herniation of brain tissue, causing altered levels of consciousness (stupor progressing to coma), dilation of the ipsilateral pupil, third cranial nerve palsy, hemiparesis, decerebrate posturing, and eventually, respiratory arrest. The patient in the above vignette has signs of marked respiratory depression and intracranial hypertension. The most important next step in the management is to rapidly intubate the patient to protect and maintain her airway, in case of a respiratory arrest. (Choice A) Intravenous thiamine is useful in alcoholic patients with severe malnutrition to prevent the development of Wernicke's encephalopathy. It has no role in the lowering of an elevated intracranial pressure. (Choice B) CT scan of the brain should be done urgently to look for an intracranial hemorrhage or any other potentially reversible causes of elevated intracranial pressure; however, the patient's airway should be secured before sending her for neuroimaging. (Choice C) Intravenous mannitol is an osmotic diuretic which reduces brain volume by drawing water out of the cells. It can be used to acutely lower elevated intracranial pressures in emergent situations; however, securing and maintaining a patent airway should still remain the first priority in the management of such patients. (Choice D) Lowering the PaCO2 by hyperventilating the patient causes cerebral vasoconstriction, which decreases the cerebral blood flow, and reduces intracranial pressure. Hyperventilation is therefore used to decrease the PaCO2 to 25-30 mmHg and to rapidly lower intracranial pressure in emergent situations; however, it is contraindicated in patients with traumatic brain injury and an acute stroke. This is due to the fact that a significant decrease in cerebral blood flow caused by vasoconstriction can lead to worsening of neurological injury in these patients. Educational objective: Securing and maintaining a patent airway is the first priority in the management of trauma patients with symptomatic intracranial hypertension.

Question 11

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. The patient returns to the physician due to painful muscle spasms.  She has frequent episodes of pain and stiffness in both legs, especially when rising from her bed.  She has tried home stretching exercise without significant relief.  The patient is afebrile and has no new neurological deficits.  Increased muscle tone is noted in the lower extremities.  Laboratory evaluation, including electrolytes, is normal.  Which of the following is the most appropriate next step in managing this patient's current symptoms?

Accepted Answer

Explanation: 11ec2b69_bffe_580c_8f63_0f07431b80ad_MD0005_00 Muscle spasticity is one of the most common disabling symptoms associated with multiple sclerosis (MS). It frequently involves the lower extremities and may result in pain/stiffness of the legs, especially when rising out of bed or a chair. First-line treatment for severe spasticity includes oral muscle relaxants such as baclofen or tizanidine, as these have similar efficacy and tolerability. Nonpharmacologic measures such as physical therapy and stretching exercises may also be helpful. (Choice A) Although amantadine may be considered in the treatment of MS-related fatigue, this patient's muscle stiffness and spasms are consistent with spasticity as opposed to fatigue. (Choice C) Benztropine is an anticholinergic medication that can treat drug-induced dystonia. Acute dystonic reactions may occur in patients receiving dopamine antagonist therapy (eg, antipsychotics, metoclopramide) and are characterized by sustained muscle contractions resulting in twisting or abnormal postures (eg, torticollis). Although this patient has increased lower-extremity muscle tone, her history of MS, lack of treatment with dopamine antagonists, and provocation of symptoms when getting out of bed make spasticity more likely. (Choice D) High-dose prednisone should be considered in the treatment of MS flare. The absence of new neurologic deficits in this patient makes the diagnosis less likely. (Choice E) Pyridostigmine is a cholinesterase inhibitor that can treat symptoms of myasthenia gravis. Although myasthenia gravis may be associated with proximal muscle weakness, it usually presents with ocular (eg, ptosis, diplopia) or bulbar (eg, dysarthria, dysphagia) weakness. Increased muscle tone and spasticity are not characteristic. Educational objective: Muscle spasticity is a common disabling symptom in patients with multiple sclerosis and frequently involves the lower extremities. First-line treatment for severe spasticity includes oral baclofen or tizanidine. Physical therapy and stretching exercises may also be helpful. References: Spasticity: pathophysiology, evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/22976059)

Question 12

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. Appropriate investigation has confirmed the most likely diagnosis.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: Treatment of acute multiple sclerosis (MS) exacerbation is indicated when disabling symptoms are present. Oral and intravenous (IV) corticosteroids are considered equally efficacious in hastening recovery. However, this patient has optic neuritis and should initially receive IV corticosteroids as oral corticosteroids are associated with an increased risk of recurrent optic neuritis (Choice D). An oral corticosteroid taper can be considered after IV therapy. Plasmapheresis should be considered in glucocorticoid-refractory patients (Choice A). (Choices B and E) There is not enough compelling evidence to recommend the use of IV immunoglobulins or pulse-dose cyclophosphamide for MS exacerbation. Educational objective: Acute multiple sclerosis exacerbation is treated with corticosteroids. Patients with optic neuritis should receive intravenous corticosteroids as oral agents may be associated with an increased risk of recurrence. Plasmapheresis can be used in refractory cases. References: A randomized, controlled trial of corticosteroids in the treatment of acute optic neuritis. The Optic Neuritis Study Group. (http://www.ncbi.nlm.nih.gov/pubmed/1734247) Oral versus intravenous steroids for treatment of relapses in multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/19588409)

Question 13

A 34-year-old, obese, Caucasian male presents to your office with an abnormal sensation over his right thigh. He says, "It gets numb, and sometimes I feel burning over my thigh." He denies any back pain, muscle weakness, or abnormal sensation below the knee. His past medical history is insignificant. He smokes two packs of cigarettes and consumes 1-2 bottles of beer daily. He is a construction worker. He frequently works in a squatting position. Physical examination reveals an area of decreased sensation over the right anterolateral thigh. There is no muscle weakness. Deep tendon reflexes are symmetrical. Item 1 of 2 Which of the following is the most likely cause of this patient's condition?

Accepted Answer

Explanation: Meralgia paresthetica is a very common syndrome that is caused by the entrapment of the lateral femoral cutaneous nerve, which is a small, purely sensory nerve that is a direct branch of the lumbar plexus. It can be compressed as it courses from the lumbar plexus, through the abdominal cavity, under the inguinal ligament, and into the subcutaneous tissue of the thigh. Physical examination typically reveals an area of decreased sensation over the anterolateral thigh without any muscle weakness or deep tendon reflex abnormalities. (Choice C)A femoral nerve lesion causes anterior and anteromedial thigh paresthesia, but it is uncommon. It is accompanied by quadriceps muscle weakness and decreased knee jerk reflex. (Choices A and B)L5 and S1 radiculopathies are typically accompanied by back pain that radiates down the lateral or posterior aspect of the leg. Weakness of the muscles supplied by the corresponding segment is usually present. (Choice E)An obturator nerve lesion is characterized by sensory loss over the medial thigh and weakness in leg adduction. Educational Objective: Meralgia paresthetica is a very common syndrome that is caused by the entrapment of the lateral femoral cutaneous nerve. Physical examination typically reveals an area of decreased sensation over the anterolateral thigh without any muscle weakness or deep tendon reflex abnormalities.

Question 14

A girl at 39 weeks gestation is born via vaginal delivery to a 25-year-old primigravida.  The patient's mother has no significant medical history and took no medications during pregnancy, but the parents moved several times, making prenatal care inconsistent.  Family history is notable for a paternal cousin with cystic fibrosis and a maternal aunt with iron-deficiency anemia.  Ultrasonography performed at 35 weeks gestation by the mother's current health care provider demonstrated a cystic sac over the infant's lumbar spine.  Group B Streptococcus screening at 36 weeks gestation was negative.  At birth, the infant's Apgar scores are 7 and 8, with a birth weight of 3.5 kg (7 lb 11 oz).  Physical examination shows a red sac with an overlying membrane over the infant's lumbar spine.  The suspected diagnosis is discussed with the infant's parents.  Which of the following is the most common complication of this patient's condition?

Accepted Answer

Explanation: 11ec2b69_bfff_deae_8f63_b94e939b853d_MD0005_00 This patient has a myelomeningocele, or spina bifida, which is a defect of the lower vertebral column that exposes the spinal cord and meninges. The most common neural tube defect (NTD), spina bifida is caused by failure of the caudal neuropore to close properly during fetal development. Most NTDs result from folate deficiency during pregnancy; other risk factors include pregestational diabetes, maternal fever in the first trimester, maternal obesity, and genetic factors. Elevated alpha-fetoprotein on maternal screening is suspicious for NTD, and the diagnosis is confirmed on prenatal ultrasound. Immediately after birth, the defect is wrapped in a moist, sterile dressing and covered with plastic wrap to prevent infection and heat loss. Patients undergo urgent surgical repair, which results in hydrocephalus requiring a ventriculoperitoneal shunt in over half of infants. spina bifida Despite surgical repair, motor, sensory, and autonomic functions below the level of the spinal lesion are typically affected. Neurogenic bladder, presenting with urinary retention/incontinence, recurrent urinary tract infections, and potential renal dysfunction, is almost universal. Treatment with clean intermittent catheterization relieves pressure on the upper urinary tract and helps prevent urinary stasis. Neurogenic bowel is also common, and a scheduled bowel regimen of laxatives, suppositories, and enemas is recommended to treat constipation. (Choice A) Although decubitus ulcers can occur in patients with spina bifida who may be immobile for prolonged periods, they are usually preventable with frequent repositioning. Neurogenic bladder is more common. (Choice B) Feeding difficulties may occur in patients with cerebral palsy due to abnormalities in tone, but they are not common in children with spina bifida. (Choice C) Patients with spina bifida are typically fertile and require counseling on reproductive health. Compared with the general population, these patients carry an increased risk of having a child with spina bifida. (Choice D) Megaloblastic anemia can be caused by folate deficiency; although children with spina bifida are often born to folate-deficient mothers, they are not typically folate deficient. Educational objective: Myelomeningocele, or spina bifida, is a result of the spinal cord and meninges herniating through a defect in the vertebral column. Almost all patients with spina bifida have associated neurogenic bladder due to disruption of spinal cord control of normal urinary function. References: Update on urological management of spina bifida from prenatal diagnosis to adulthood. (http://www.ncbi.nlm.nih.gov/pubmed/25839383)

Question 15

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks. She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days. A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days. She has no other medical problems and does not take any medications. The patient has no significant social or family history. Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min. On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect. She also has a right arm intention tremor. Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. Item 1 of 5 Which of the following is the most appropriate test to confirm the diagnosis in this patient?

Accepted Answer

Explanation: 11ec2b69_bffc_f87b_8f63_1b3705cfb2e9_MD0005_00 This patient likely has multiple sclerosis (MS) as her neurologic deficits are disseminated in time and space. Relapsing-remitting MS is the most common pattern and is characterized by neurologic recovery between episodes of acute exacerbations. Nearly 50% of MS patients develop optic neuritis, which typically presents with monocular visual loss accompanied by eye pain that worsens with eye movement. Patients can also develop transverse myelitis resulting in upper motor neuron signs and sensory loss below the level of spinal involvement. This patient's dizziness and right arm intention tremor are concerning for cerebellar involvement as well. The diagnosis of MS is supported with MRI revealing hyperintense lesions in the brain and/or spinal cord on T2-weighted images. Ovoid-shaped periventricular white matter lesions can be seen in 23%-75% of patients. MRI is superior to CT in evaluating posterior fossa/cerebellar abnormalities and is more sensitive/specific in detecting MS lesions (Choice A). periventricular white matter lesions (Choices B and E) Evoked potentials (eg, visual, auditory, somatosensory) can identify silent central nervous system lesions. Nerve conduction studies and electromyography can be useful in distinguishing neuropathic versus myopathic weakness, respectively. These studies have limited diagnostic utility in the evaluation of MS. (Choice C) Lumbar puncture is not required for the diagnosis of MS and is usually performed in atypical cases to confirm the diagnosis. Oligoclonal bands and elevated IgG index can be seen in >90% of cases. Opening pressure and other cerebrospinal fluid measures are typically normal. Educational objective: MRI is the preferred test to support the diagnosis of multiple sclerosis and typically shows ovoid-shaped periventricular white matter lesions. Lumbar puncture can confirm the diagnosis in equivocal cases and may demonstrate oligoclonal bands and an elevated IgG index. References: Multiple sclerosis: a primary care perspective. (http://www.ncbi.nlm.nih.gov/pubmed/25368924)

Question 16

A 65-year-old man comes to the emergency department 2 hours after the onset of weakness in his left arm and leg. Two months ago, he had a 15-minute episode of left arm weakness that resolved spontaneously. He has had no headache, nausea, vomiting, or difficulty swallowing. His medications include chlorthalidone, lisinopril, and metformin. The patient occasionally takes ibuprofen for muscle cramps and antacids for heartburn. His temperature is 36.7 C (98.0 F), blood pressure is 172/98 mm Hg, and pulse is 83/min with a regular rhythm. Physical examination shows a dense, left-sided hemiparesis. Fingerstick blood glucose is 108 mg/dL. CT scan of the head without contrast shows no signs of intracranial hemorrhage Item 1 of 2 Prior to any further emergency treatment, which of the following should be evaluated in this patient?

Accepted Answer

Explanation: An acute onset of left-sided weakness is highly suspicious for a stroke in the right middle cerebral artery (MCA) distribution. The patient's episode of temporary left-sided weakness 2 months ago may have been a transient ischemic attack, which indicates an increased risk for stroke in the near future. A head CT imaging study is generally the initial test in patients in whom there is concern for acute stroke. Although early changes of acute cerebral ischemia may not be visualized, imaging helps to eliminate the possibility of intracranial hemorrhage, which requires markedly different management. This patient is still within the 3-4.5-hour window after the onset of symptoms, which potentially renders him eligible for fibrinolytic treatment with tissue plasminogen activator (tPA). However, in addition to excluding intracranial hemorrhage, the patient's risk for bleeding must first be assessed more fully before tPA is administered. Contraindications to fibrinolysis with tPA include: Presence of active internal bleeding Bleeding diathesis (eg, platelets <100,000/µL) Hypodensity in >33% of an arterial territory on CT scan Presence of intracranial hemorrhage on CT scan Intracranial surgery in the last 3 months Blood pressure >185/110 mm Hg (Choice B) Cerebral vasospasm is more commonly associated with subarachnoid hemorrhage and vasculitis. The presence of vasospasm does not affect the decision to begin fibrinolytic treatment. (Choice C) Deep venous thrombosis risk assessment is important for hospitalized patients, but an assessment of the risk of bleeding is more crucial at this point as a decision on fibrinolytic therapy must be made quickly. (Choice D) The patient should be evaluated and treated for arrhythmias such as atrial fibrillation that may have led to the stroke, but assessment of bleeding risk takes precedence at this point. (Choice E) Seizures can be associated with cerebral infarcts. However, seizures are a relative contraindication to fibrinolytic therapy only if the patient has postictal impairment, as there may be diagnostic confusion over whether seizure or stroke is the primary problem. Educational objective: Fibrinolytic therapy with tissue plasminogen activator (tPA) should be considered for patients with symptoms of acute stroke that have been present <3-4.5 hours. A rapid assessment must be performed for bleeding risk (and especially for intracranial hemorrhage), which is a serious concern and a common side effect of tPA administration. Several conditions, including the presence of active bleeding and hypodensity in >33% of an arterial territory on CT scan, are absolute contraindications to tPA administration. References: Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/23370205)

Question 17

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. The patient has marked symptomatic improvement within a few days of initial treatment and is scheduled for physical therapy.  Which of the following is the most appropriate long-term pharmacotherapy for this patient?

Accepted Answer

Explanation: Disease-modifying drugs (eg, beta-interferon, glatiramer acetate) are indicated for chronic maintenance therapy in patients with relapsing-remitting multiple sclerosis (MS) as they can decrease the frequency of relapses and reduce the development of brain lesions. (Choice B) Long-term glucocorticoids are generally not recommended due to their potential systemic side effects (eg, osteoporosis, cataracts). (Choice C) Pramipexole is a dopamine agonist used in the long-term treatment of Parkinson disease. The tremor of Parkinson disease may be unilateral at onset but usually occurs at rest. This patient's young age and other neurologic features (eg, optic neuritis, transverse myelitis) also make MS more likely. (Choice D) Rivastigmine is a cholinesterase inhibitor that may be useful in the treatment of mild to moderate Alzheimer dementia. This patient's young age and lack of cognitive dysfunction make Alzheimer dementia highly unlikely. (Choice E) Topiramate is an anticonvulsant that can be used for migraine prophylaxis or seizure disorder; neither is evident in this patient. Educational objective: Beta-interferon or glatiramer can decrease the frequency of exacerbations and reduce the development of brain lesions in patients with relapsing-remitting multiple sclerosis. References: Interferons-beta versus glatiramer acetate for relapsing-remitting multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/25062935) The use of interferon Beta and glatiramer acetate in multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/23709209)

Question 18

An 18-year-old man comes to the physician for daytime sleepiness lasting several months. The patient recently started college, has difficulty staying awake during classes, and often falls asleep suddenly even though he "gets a good night's sleep." He typically goes to bed at 2 am and sleeps until at least 9 am, usually later. The patient's sleep pattern at night is fragmented. He wakes frequently but is usually able to go back to sleep within a few minutes. He does not snore or wake up gasping. The patient feels like "someone is in the room with me when I'm just falling asleep and I sometimes hear my name being called." His past medical history is otherwise insignificant. The patient does not use tobacco or alcohol. Blood pressure is 120/70 mm Hg and heart rate is 70/min. His body mass index is 23 kg/m². The appropriate treatment is initiated, but the patient returns in 4 weeks and says that his symptoms have not improved. He recently had "some little troubles" in his family, and has felt sudden onset of muscle weakness and falls, especially during arguments with his family members. What is the best next step in management of this patient?

Accepted Answer

Explanation: Cataplexy (CP) is the sudden onset of muscle weakness, often triggered by intense emotional episodes (eg, anger, laughing, surprise) and is a common symptom of narcolepsy. CP is a pathognomonic symptom that occurs in roughly 70% of patients with narcolepsy. Although stimulants and behavioral interventions are important initial steps in the treatment of sleepiness associated with narcolepsy, they may be insufficient for management of CP. Patients with CP can be treated with a serotonin-norepinephrine reuptake inhibitor (eg, venlafaxine) or selective serotonin reuptake inhibitor, and a tricyclic antidepressant can also be considered. Sodium oxybate (the salt form of gamma-hydroxybutyrate) can improve nocturnal sleep, relieve excessive daytime sleepiness and has anti-cataplectic properties; however, it is rarely used due to abuse potential and restrictive regulations. (Choice A) Clonazepam can be useful for treating sleep-related parasomnias, but it is not effective for CP. (Choice B) Lamotrigine is less effective than valproic acid for the treatment of absence seizures. (Choice C) Methylphenidate is a second-line stimulant used to treat narcolepsy. Its adrenergic activity may mildly improve CP, but it is usually not more effective than modafinil. (Choice D) Urgent neurosurgical consultation for shunt placement is the primary treatment for normal-pressure hydrocephalus. Educational objective: Cataplexy (CP) is the sudden loss of muscle tone triggered by strong emotions and is a common symptom of narcolepsy. Stimulant medications may mildly improve the symptoms but are often insufficient, especially if there is a significant safety risk. Other medications for CP include serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants, and sodium oxybate. References: Narcolepsy: clinical approach to etiology, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/22249574)

Question 19

A 22-year-old woman comes to the physician with her husband for intermittent dizziness, weakness, and unsteady gait for the last several weeks.  She has also had visual loss and pain in the right eye that worsens with eye movement for the past 2 days.  A year ago, the patient had tingling and numbness of her right hand accompanied by unsteadiness, which improved spontaneously after 3-4 days.  She has no other medical problems and does not take any medications.  The patient has no significant social or family history.  Her temperature is 37.2 C (99 F), blood pressure is 122/80 mm Hg, pulse is 82/min, and respirations are 16/min.  On neurologic examination, her right eye has diminished visual acuity and an afferent pupillary defect.  She also has a right arm intention tremor.  Both lower extremities have spastic paresis, hyperreflexia, and positive Babinski sign. Four months later, the patient comes to the physician for a routine visit and asks for advice regarding pregnancy.  She has been taking her medication regularly.  Which of the following is the most appropriate response?

Accepted Answer

Explanation: The management of pregnantpatients with multiple sclerosis (MS) may be similar to those who are not pregnant; however, there are several unique considerations. Pregnant women with MS have a modest increase in cesarean section and assisted delivery (eg, vacuum, forceps) rates compared to those without MS. As in nonpregnant patients, the preferred treatment for acute MS exacerbations in pregnant patients is short-term intravenous glucocorticoids as they are generally well tolerated and are not associated with teratogenicity (Choice A). (Choices B and D) The majority of disease-modifying agents used for relapsing-remitting MS also have category B (no evidence of risk in available studies) or C (risk cannot be ruled out) pregnancy risk. Teriflunomide and mitoxantrone are exceptions to this rule as they are both known teratogens that are contraindicated in pregnancy. Nonetheless, pregnant women with MS usually have lower disease activity during pregnancy and higher disease activity in the postpartum period. Some experts propose that disease-modifying therapy be discontinued during pregnancy if possible as a result of these observations. (Choice E) Infants born to women with MS also warrant special consideration as they have an increased risk of developing MS (eg, 3%-23% of MS cases are familial) and can be born with lower birth weights. Educational objective: Pregnant women with multiple sclerosis typically have lower disease activity during pregnancy and higher activity in the postpartum period. Acute exacerbations are treated similarly to nonpregnant patients, and most disease- modifying agents have relatively low pregnancy risk. References: Multiple sclerosis in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/24492810) Multiple sclerosis and pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/22011954)

Question 20

A 65-year-old man comes to the emergency department 2 hours after the onset of weakness in his left arm and leg.  Two months ago, he had a 15-minute episode of left arm weakness that resolved spontaneously.  He has had no headache, nausea, vomiting, or difficulty swallowing.  His medications include chlorthalidone, lisinopril, and metformin.  The patient occasionally takes ibuprofen for muscle cramps and antacids for heartburn.  His temperature is 36.7 C (98.0 F), blood pressure is 172/98 mm Hg, and pulse is 83/min with a regular rhythm.  Physical examination shows a dense, left-sided hemiparesis.  Fingerstick blood glucose is 108 mg/dL.  CT scan of the head without contrast shows no signs of intracranial hemorrhage The patient receives appropriate therapy.  The next day, neurologic examination shows some improvement of the left-sided weakness.  Carotid duplex ultrasound scanning shows bilateral atherosclerotic plaques with no significant stenosis, and an electrocardiogram shows normal sinus rhythm.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: After the diagnosis of an acute stroke is made and appropriate treatment is started, further evaluation is necessary to determine the cause of the cerebral infarct: Magnetic resonance or CT angiographycan evaluate the carotids and intracranial vasculature, or duplex ultrasound can evaluate the carotids alone. Electrocardiogram can diagnose myocardial ischemia or arrhythmia that may result in intracardiac thrombus formation and resultant embolus. Transthoracic echocardiogram (TTE)or transesophageal echocardiogram (TEE) can be used to detect intracardiac thrombus. TEE is more sensitive than TTE but is more invasive and therefore difficult to use in patients with acute stroke. Cardiovascular magnetic resonance imaging for evaluation for intracardiac thrombus may be an option for some patients. (Choice B) An electroencephalogram is typically used when there is concern for seizure activity but is not used routinely in acute stroke. (Choice C) Hypercoagulability studies are not indicated in all patients with acute stroke. They should be ordered in those with a personal or family history of hypercoagulable disease, in young patients with no apparent etiology for stroke despite evaluation for vascular and cardiac sources, and in patients with clinical findings that suggest systemic lupus erythematosus. (Choice D) Upper-extremity Doppler studies can detect thrombi but would not be performed routinely in a stroke patient when there is no suspicion for deep vein thrombosis. (Choice E) Lumbar puncture should be considered if there is concern that this patient's neurologic symptoms are secondary to central nervous system infection or multiple sclerosis. Educational objective: All patients with acute stroke should have an evaluation of the heart and neck vessels to rule out possible embolic sources. Ultrasound can be used to evaluate the neck vasculature; CT angiogram or MR angiogram can evaluate both the neck and intracranial vasculature. Electrocardiogram is helpful to evaluate for ischemia and arrhythmia, and a transthoracic echocardiogram is generally recommended to evaluate for the presence of an intracardiac thrombus. References: Transesophageal echocardiography is superior to transthoracic echocardiography in management of patients of any age with transient ischemic attack or stroke. (http://www.ncbi.nlm.nih.gov/pubmed/16946152)

Exam 1: Advanced Clinical Medicine