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NR 603 WEEK 1 APEA PREDICTOR EXAM REVIEW
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES 2025 LATEST UPDATE// ALREADRY
GRADED A+
A .75-year-old .man .is .involved .in .a .motor .vehicle .accident .and .strikes .his .forehead .on .the .windshield. .He .complains .of .neck .pain .and .severe .burning .in .his .shoulders .and .arms. .His .physical .examination .reveals .weakness .of .his .upper .extremities. .What .type .of .spinal .cord .injury .does .this .patient .have?
A .anterior .cord .syndrome B .central .cord .syndrome C .Brown-Séquard .syndrome D .complete .cord .transection E. cauda .equina .syndrome .ANS: .B
Central .Cord .Syndrome the .central .cord .syndrome .involves .loss .of .motor .function .that .is .more .severe .in .the .upper .extremities .than .in .the .lower .extremities, .and .is .more .severe .in .the .hands. .There .is .typically .hyperesthesia .over .the .shoulders .and .arms. .Anterior .cord .syndrome .presents .with .paraplegia .or .quadriplegia, .loss .of .lateral .spinothalamic .function .with .preservation .of .posterior .column .function. .Brown-Séquard .syndrome .consists .of .weakness .and .loss .of .posterior .column .function .on .one .side .of .the .body .distal .to .the .lesion .with .contralateral .loss .of .lateral .spinothalamic .function .one .to .two .levels .below .the .lesion. .Complete .cord .transection .would .affect .motor .and .sensory .function .distal .to .the .lesion. .Cauda .equina .syndrome .typically .presents .as .low .back .pain .with .radiculopathy.
A .37-year-old .man .fell .from .a .ladder .as .he .finished .hanging .the .Christmas .lights .on .his .house. .The .right .side .of .his .head .hit .the .alley .cement, .and .he .lost .consciousness .for .about. 1 .minute; .he .woke .up .with .a .headache, .but .he .had .no .other .complaints. .A .few .hours .later, .the .patient .is .brought .to .the .emergency .room .by .his .neighbor .because .of .an .intense .headache, .confusion, .and .left .hand .hemiparesis. .On .examination, .the .patient .has .a .bruise .located .over .the .right .temporal .region, .mydriasis, .and .right .deviation .of .the .right .eye, .papilledema, .and .left .extensor .plantar .response. .An .emergency .CT .scan .of .the .head .without .contrast .reveals .a .lens-shaped .hyper-density .under .the .right .temporal .bone .with .mass .effect .and .edema. .What .is .the .most .likely .diagnosis?
Answer .Choices 1 Epidural .hematoma 2 Subdural .hematoma 3 Subarachnoid .hemorrhage
4 Intracerebral .parenchymal .hemorrhage 5 Acute .meningitis .ANS:. 1
Epidural .Hematoma Epidural .hematoma .most .often .results .from .a .traumatic .tear .of .the .middle .meningeal .artery. .Although .a .lucid .interval .ranging .from .minutes .to .hours .followed .by .altered .mental .status .and .focal .deficits .is .typical .for .epidural .hematoma, .this .clinical .picture .is .only .encountered .in .up .to .1/ .of .the .patients. .The .collection .of .blood .between .the .skull .and .dura .mater .causes .an .evident .mass .effect .with .ophthalmic .nerve .palsy .and .the .contralateral .hemiparesis. .Surgical .evacuation .of .the .clot .via .burr .holes .is .the .treatment .of .choice.
Subdural .hematoma .results .from .a .traumatic .rupture .of .the .bridging .veins .that .connect .the .cerebrum .to .the .venous .sinuses .within .the .dura. .This .venous .hemorrhage .will .result .in .a .gradual .increase .of .the .hematoma, .with .a .progressive .clinical .picture .over .days .or .weeks. .The .CT .scan .will .show .a .concave, .crescent-shaped .hyper-density .compared .to .the .convex, .lens-shaped .hyper-density .in .epidural .hematoma.
Subarachnoid .hemorrhage .is .the .result .of .an .aneurysm .rupture; .the .most .common .is .the .congenital .berry .aneurysm. .The .clinical .picture .is .of .a .sudden, .severe .headache .with .meningeal .irritation. .A .CT .scan .will .show .blood .in .the .subarachnoid .space, .and .a .lumbar .puncture .will .reveal .xanthochromia .CSF.
Intracerebral .parenchymal .hemorrhage .is .most .likely .caused .by .hypertension .complicated .with .CharcotBouchard .aneurysms. .The .blood .accumulates .into .the .brain .substance .and .most .commonly .involves .the .basal .ganglia.
Acute .meningitis .is .not .associated .with .trauma. .Fever .and .signs .of .meningeal .irritation .dominate .the .clinical .picture. .Lumbar .puncture, .indicated .if .there .are .no .focal .neurological .signs .on .clinical .examination, .will .be .the .diagnostic .procedure. .The .CT .scan .of .the .patient .presented .in .this .case .is .characteristic .for .epidural .hematoma, .and .there .is .no .indication .for .a .lumbar .puncture.
A .31-year-old .woman .presents .with .a .purpural .rash .covering .her .arms, .legs, .and .abdomen. .She .also .has .fever, .chills, .nausea, .abdominal .tenderness, .tachycardia, .and .generalized .myalgias. .Prior .to .the .development .of .the .rash, .the .patient .noted .that .she .had .a .headache, .cough, .and .sore .throat. .Laboratory .studies .were .positive .for .Gram-negative .diplococci .in .the .blood, .along .with .thrombocytopenia .and .an .elevation .in .PMNs. .Urinalysis .showed .blood, .protein, .and .casts. .Vital .signs .are .as .follows: .PB .92/66, .P .96, .RR .14, .T .39. .The .patient .denies .any .foreign .travel .and .does .not .have .any .sick .contacts. .However, .she .does .work .part .time .as .a .nurse .in .a .local .hospital. Question The .patient .is .diagnosed .with .Meningococcemia; .she .is .admitted .to .the .hospital .and .placed .in .respiratory .isolation. .What .major .course .of .therapy .should .this .patient .receive?
Answer .Choices
ANS:. 3
Muscle .Fasiculations Signs .of .cholinergic .overdosage .include .muscle .fasciculation, .rhinorrhea, .lacrimation, .salivation, .increased .bronchial .secretions, .nausea, .or .diarrhea. .The .presence .of .any .of .these .suggests .that .the .patient's .weakness .may .be .due .to .cholinergic .crisis. .The .other .signs .are .due .to .weakness .and .can .occur .in .either .condition.
A .54-year-old .man .presents .after .having .a .generalized .seizure. .The .patient .is .HIV .positive, .but .he .has .been .unable .to .afford .antiretroviral .therapy .since .losing .his .job. 2 .years .ago. .Other .than .cachexia, .the .physical .exam .is .unremarkable. .Upon .further .inquiry, .the .patient .also .notes .that .he .has .become .shorttempered .and .hypercritical; .at .times, .he .seems .confused. .An .MRI .of .the .brain .is .performed, .and .it .reveals .several .cortical .ring-enhancing .lesions. Question What .is .the .most .likely .diagnosis? .Answer .Choices 1 AIDS .dementia .complex 2 Cryptococcal .meningitis 3 Cytomegalovirus .encephalitis 4 Progressive .multifocal .leukoencephalopathy 5 Toxoplasma .encephalitis .ANS:
Toxoplasma .encephalitis The .patient's .symptoms .and .MRI .findings .are .most .consistent .with .the .diagnosis .of .toxoplasma .encephalitis. .Toxoplasmosis .is .the .most .common .cerebral .mass .lesion .among .HIV-positive .patients. .Infection .with .the .Toxoplasma .gondii .parasite .is .relatively .common .and .usually .asymptomatic. Reactivation .occurs .in .HIV .positive .patients .due .to .failing .cellular .immunity, .and .it .causes .a .multifocal .necrotizing .encephalitis. .Seizures .may .be .the .initial .manifestation .of .central .nervous .system .(CNS) .infection; .other .common .clinical .manifestations .include .focal .neurologic .deficits, .such .as .impaired .speech .and .hemiparesis. .Personality .change, .lethargy, .headache, .and .confusion .are .also .observed. .The .MRI .in .patients .with .toxoplasma .encephalitis .characteristically .reveals .multiple, .ring- enhancing .lesions .with .surrounding .edema; .these .lesions .usually .occur .bilaterally .in .the .frontal .and .parietal .cortices.
AIDS .dementia .complex .describes .a .constellation .of .cognitive .symptoms .seen .among .HIV .positive .patients. .The .condition .occurs .when .HIV .virus .disseminates .to .the .CNS. .Within .the .CNS, .the .virus .tends .to .concentrate .in .the .basal .ganglia .and .subcortical .regions. .Symptoms .include .a .constellation .of .cognitive, .behavioral, .and .motor .disturbances .that .cause .varying .degrees .of .functional .impairment. Characteristic .MRI .findings .include .non-enhancing .white .matter, .cerebral .atrophy, .and .ventricular .enlargement. .The .diagnosis .requires .that .other .central .nervous .system .infections, .carcinoma, .as .well .as .general .medical .conditions .and .substance .abuse .have .been .excluded.
Cryptococcal .meningitis .is .caused .by .the .encapsulated .fungus .Cryptococcus .neoformans. .Among .HIV .positive .patients, .the .illness .may .be .the .result .of .new .infection .or .reactivation .of .latent .infection. Presenting .signs .are .often .nonspecific; .they .include .headache, .fever, .change .in .mental .status, .and .nausea .or .vomiting. .Nuchal .rigidity .and .photophobia .may .also .be .present, .and .elevated .intracranial .pressure .is .not .uncommon. .MRI .findings .vary, .but .they .include .lesions .in .the .basal .ganglia; .meningeal .enhancement, .cerebral .edema, .and .shrunken .ventricles .may .also .be .seen.
Cytomegalovirus .(CMV) .infection .causing .encephalitis .is .usually .observed .in .patients .with .evidence .of .CMV .infection .at .other .sites. .MRI .findings .vary, .but .they .often .show .areas .of .focal .necrosis .within .the .brain .parenchyma, .meninges, .or .periventricular .regions. .Symptoms .typically .reflect .progressive .dementia, .with .episodes .of .confusion, .apathy, .and .focal .neurologic .deficits.
Progressive .multifocal .leukoencephalopathy .is .often .a .fatal .disorder; .it .is .caused .by .reactivation .of .a .latent .JC .viral .infection. .Focal .neurologic .deficits .such .as .hemiparesis .and .gait .disturbance .are .often .the .initial .presenting .symptoms; .they .are .followed .by .progressive .cognitive .decline, .coma, .and .death. .The .MRI .commonly .reveals .multiple, .non-contrast .enhancing .foci .in .cerebral .white .matter.
A .1-year-old .boy .presents .with .increasing .lethargy. .He .is .barely .responsive, .and .his .parents .deny .any .trauma .or .injury. .What .is .the .most .common .cause .of .nontraumatic .altered .levels .of .consciousness? .Answer .Choices 1 Seizure .disorder 2 Diabetic .ketoacidosis 3 Inborn .errors .of .metabolism 4 Toxic .ingestion 5 Infection .ANS:
infection Awareness .of .self .and .the .surrounding .environment .or .consciousness .may .be .altered .into .different .abnormal .states .of .consciousness. .Consciousness .can .shift .from .loss .of .clear .thinking .or .confusion, .usually .accompanied .by .disorientation, .to .delirium, .a .succession .of .confused .and .unconnected .ideas .manifested .in .children .as .extreme .mental .and .motor .excitement, .to .lethargy, .a .profound .type .of .slumber .where .movement .or .speech .is .limited, .to .stupor .or .deep .sleep .where .arousal .is .achieved .only .by .repeated .vigorous .stimuli, .finally .to .coma, .unresponsiveness .to .even .painful .stimuli. .Non- traumatic .coma .is .most .common .in .infants .and .toddlers .with .another .smaller .peak .of .occurrence .in .adolescence. .The .most .common .cause .of .non-traumatic .altered .level .of .consciousness .in .children .is .infection .of .either .the .brain .(encephalitis), .meninges .(meningitis), .or .both; .infections .account .for .more .than .1/3 .of .cases.
Prolonged .seizures, .anticonvulsive .therapy, .and .postictal .states .can .also .lead .to .altered .levels .of .consciousness.
The .most .common .metabolic .cause .of .alteration .of .consciousness .is .diabetic .ketoacidosis, .which .can .occur .at .any .age, .but .is .most .common .in .adolescence. .Caused .by .severe .insulin .deficiency,
Thymic .tumors .are .associated .with .myasthenia .gravis. .Thymic .tumors .are .also .referred .to .as .thymomas. .Approximately. 10 .- .15% .of .patients .with .myasthenia .gravis .have .an .associated .thymoma. .The .majority .of .patients .with .myasthenia .gravis .have .hyperplasia .of .their .thymus.
Botulinum .toxin .inhibits .acetylcholine .release. .The .site .of .action .is .at .the .neuromuscular .junction. .Botulinum .toxin .is .an .enterotoxin .produced .by .Clostridium .botulinum. .Botulism .can .result .from .incorrectly .canned .foods.
Tetrodotoxin .is .a .toxin .produced .by .puffer .fish. .The .sodium .channels .are .blocked .by .tetrodotoxin. .The .blockage .of .the .sodium .channels .interferes .with .the .inflow .of .sodium. .As .a .result, .the .propagation .of .nerve .and .muscle .action .potentials .is .affected.
Demyelination .refers .to .the .loss .of .myelin .around .the .axon. .Several .disorders .result .in .demyelination. .An .example .of .a .demyelinating .disease .is .multiple .sclerosis.
Subacute .combined .degeneration .of .the .spinal .cord .is .also .called .combined .systems .disease. .Subacute .combined .degeneration .of .the .spinal .cord .is .a .neuropathy .secondary .to .B12 .deficiency. .It .is .seen .in .patients .with .pernicious .anemia, .especially .pernicious .anemia .that .has .been .present .for .quite .some .time. .Symptoms .include .paresthesias .and .a .loss .of .proprioception.
A .74-year-old .man .presents .after .his .wife .witnessed .him .grab .his .head .in .pain .and .fall .to .the .floor. .He .has .not .regained .consciousness. .His .current .blood .pressure .is .150/96 .mm .Hg, .and .his .heart .rate .is. 65 .bpm. .Emergent .head .CT .shows .a .subarachnoid .hemorrhage.
Question In .addition .to .life .saving .interventions, .what .prescription .medication .will .most .benefit .this .patient .at .this .time?
Answer .Choices 1 Furosemide .(loop .diuretic) 2 Prednisone .(glucocorticoid) 3 Tranexamic .acid .(antifibrinolytic .agent) 4 Labetolol .(beta .blocker) 5 Nimodipine .(calcium .channel .blocker) .ANS:. 5
Nimodipine .(CCB) Nimodipine, .a .calcium .channel .blocker, .has .been .shown .to .improve .outcomes .in .patients .following .aneurysmal .SAH. .The .mechanism .of .action .is .thought .to .be .prevention .of .ischemia. .Glucocorticoids .(e.g., .prednisone) .are .often .utilized .in .patients .with .SAH .because .they .offer .symptomatic .relief .of .headache .and .neck .pain, .but .they .have .not .been .proved .to .decrease .cerebral .edema. .Antifibrinolytic .agents .(e.g., .Tranexamic .acid) .can .be .utilized .in .patients .with .a .diagnosed .aneurysm .who .cannot .undergo .directed .treatment, .but .they .are .not .routinely .used .following .aneurysmal .rupture. .Labetalol .(a .beta .blocker) .may
be .utilized .to .treat .elevated .BP, .but .it .must .be .used .with .caution .because .it .can .also .decrease .cerebral .perfusion. .Diuretics .(e.g., .furosemide) .have .no .identified .role .in .the .treatment .of .aneurysmal .SAH.
A .37-year-old .woman .presents .to .her .GP .surgery .with .a .history .of .right-sided .facial .weakness .and .periauricular .discomfort .since .she .awoke .this .morning. .She .is .afebrile.
Question What .is .the .most .likely .diagnosis? .Answer .Choices 1 Trigeminal .neuralgia 2 Bell's .Palsy 3 Multiple .sclerosis 4 Myasthenia .gravis 5 Primary .lateral .sclerosis .ANS:. 2
Bell's .Palsy Explanation .The .correct .answer .is .Bell's .palsy, .which .is .a .condition .typically .with .sudden .onset .that .affects .the .facial .nerve, .causing .unilateral .facial .weakness.
Trigeminal .neuralgia .presents .with .sharp .pain .on .one .side .of .the .mouth .that .radiates .to .the .ipsilateral .ear, .eye, .or .nostril.
Multiple .sclerosis .is .a .demyelinating .disorder, .causing .a .multitude .of .symptoms .that .typically .include .diplopia .or .blurred .vision .early .on, .then .an .insidious .onset .of .progressive .weakness, .numbness, .and/or .tingling .in .the .extremities.
Myasthenia .gravis .commonly .presents .with .ptosis .and .diplopia, .as .well .as .difficulty .swallowing, .fatigue, .and .muscle .weakness.
Primary .lateral .sclerosis .is .an .upper .motor .neuron .disease .that .causes .limb .weakness, .stiffness, .and .fasciculations.
A .62-year-old .man .presents .with .vision .problems .and .difficulty .swallowing. .Over .the .last .week, .he .has .had .a .constellation .of .symptoms; .they .began .with .numbness .and .tingling .in .his .feet .and .progressed .to .weakness .that .now .affects .both .lower .and .upper .extremities. .Within .the .last .day, .he .has .started .to .notice .difficulty .swallowing .and .double .vision. .He .also .feels .it .is .difficult .for .him .to .take .a .big .breath. .His .past .medical .history .is .noncontributory, .and .he .takes .no .medications. .Exam .reveals .bilateral .absence .of .patellar .and .ulnar .reflexes. .A .lumbar .puncture .is .performed .to .confirm .the .diagnosis.
Question What .cerebrospinal .fluid .(CSF) .finding .is .most .likely?
Clinical .triad .of .slowly .progressive .gait .disorder, .followed .by .impairment .of .mental .function .and .then .sphincteric .incontinence .strongly .suggests .the .presence .of .normal-pressure .hydrocephalus. .Ventricular .expansion .is .the .cause .of .symptoms, .and .surgical .CSF .shunting .is .the .main .treatment .modality. .The .potential .benefit .from .surgery .is .usually .evaluated .by .testing .gait, .cognition, .and .micturition .before .and .after .CSF .drainage.
Antimuscarinic .Tolterodine .is .an .antispasmodic .that .is .used .for .symptomatic .treatment .of .urinary .incontinence .in .patients .with .an .overactive .bladder .(urge .incontinence). .Antimuscarinic .drugs .are .contraindicated .in .patients .with .glaucoma.
A .urinary .tract .infection .will .probably .manifest .with .a .strong, .persistent .urge .to .urinate, .burning .sensation .when .urinating, .passing .frequent, .small .amounts .of .urine .that .has .unusual .smell .and .the .appearance. .Your .patient .has .no .such .signs .and .symptoms; .therefore, .in .this .case, .antibiotics .are .not .indicated.
Donepezil .is .used .to .treat .dementia, .but .in .the .case .of .normal-pressure .hydrocephalus, .the .problem .is .anatomic .(the .distortion .of .the .periventricular .limbic .system .and .frontal .lobes), .and .the .best .treatment .is .probably .surgical.
Kegel .exercises .can .prevent .or .control .urinary .incontinence .and .other .pelvic .floor .problems .in .cases .of .pelvic .sphincter .weakness. .However, .pelvic .sphincter .weakness .will .probably .manifest .as .stress .incontinence.
A .5-month-old .male .infant .presents .after .a .seizure .involving .all. 4 .limbs. .His .mother .tells .you .that .he .was .born .full .term .without .any .complications, .and .he .was .well .until. 2 .days .ago .when .he .developed .a .fever. .He .vomited .multiple .times .yesterday .and .was .irritable. .He .has .not .had .diarrhea .or .a .cough. .He .was .given .antipyretic .medication .for .his .fever. .He .has .no .known .allergies. .His .immunizations .are .up-to-date. .His .developmental .milestones .have .been .in .accordance .with .his .age. .On .physical .exam, .his .temperature .is .102.7 .F, .and .his .pulse .is .154/min; .BP .is .90/50 .mmHg, .and .RR .is .20/min. .He .is .lethargic, .pale, .and .focal .neurological .deficits .are .present. .His .anterior .fontanel .is .bulging. .You .suspect .that .he .has .bacterial .meningitis. .Question After .drawing .blood .samples .for .investigations, .what .is .the .most .appropriate .next .step? .Answer .Choices 1 Intravenous .phenytoin 2 Intravenous .empirical .antibiotics 3 MRI .of .the .head 4 Lumbar .puncture 5 Intravenous .glucose .ANS:
intravenous .emiprical .antibiotics The .infant .in .the .vignette .appears .to .have .bacterial .meningitis. .The .initial .approach .to .the .patient .should .be .the ."ABCs." .After .assessing .and .stabilizing .the .patient's .airway .and .obtaining .IV .access, .intravenous
antibiotics .should .be .given .immediately. .As .bacterial .meningitis .is .associated .with .high .morbidity .and .mortality, .prompt .initiation .of .empirical .antibiotics .is .crucial .for .better .prognosis. .The .choice .of .antibiotics .is .dependent .on .the .patient's .age .and .specific .predisposing .conditions. .Use .of .broad- .spectrum .cephalosporins, .such .as .ceftriaxone .or .cefotaxime .with .vancomycin, .may .be .used .in .infants .more .than. 1 .month .old. .Ideally, .serum .glucose, .blood .culture, .complete .blood .count, .and .serum .chemistries .should .be .drawn .when .IV .access .is .obtained; .however, .drawing .labs .should .not .delay .beginning .antibiotics.
Intravenous .glucose .is .necessary .if .the .patient .is .found .to .be .hypoglycemic; .bedside .serum .glucose .is .mandatory .in .any .patient .that .presents .with .a .seizure. .Intravenous .phenytoin .and .an .MRI .of .the .head .might .also .be .necessary .for .a .patient .such .as .the .one .in .the .vignette, .but .would .not .emergently .precede .antibiotics.
The .diagnosis .of .bacterial .meningitis .rests .on .CSF .examination .performed .after .lumbar .puncture. .However, .LP .is .deferred .in .patients .with .evidence .of .increased .intracranial .pressure, .new .onset .seizure, .cardiorespiratory .compromise, .or .focal .neurological .deficits. .Antibiotics .should .be .given, .and .CT .scan .of .the .head .should .be .performed. .If .CT .scan .is .negative, .LP .can .be .performed.
A .12-year-old .girl .presents .with .a .3-day .history .of .progressive .dysarthria, .dysphagia, .and .weakness. .The .patient .was .well .until. 3 .days .prior .to .admission .to .the .hospital; .at .that .time, .she .developed .the .onset .and .subsequent .gradual .worsening .of .dysarthria. .She .attributed .the .dysarthria .to .a .sore .throat .that .she .had .had .about. 2 .weeks .earlier.. 3 .days .prior .to .admission, .she .also .had .the .onset .of .mild .dysphagia; .it .mostly .occurred .with .liquids.. 24 .hours .prior .to .admission, .she .developed .weakness .in .both .upper .extremities, .which .increased .and .began .to .involve .the .lower .extremities. .This .limb .weakness .was. neither .worsened .by .activity .nor .improved .by .rest. .She .also .developed .tingling .in .her .toes. 24 .hours .prior .to .presentation. .When .she .became .unable .to .walk .without .assistance .on .the .day .of .admission, .she .decided .to .seek .medical .attention .and .was .admitted .to .the .hospital.
Past .medical .history .is .significant .for .measles .and .mumps. .Because .of .family .religious .beliefs, .she .has. not .had .any .immunizations. .She .is .very .athletic, .and .frequently .plays .soccer .with .friends .and .siblings .in .the .fields .on .her .grandfather's .horse .farm. .Physical .examination .reveals .a .well-developed, .wellnourished .girl. .She .is .awake, .alert, .cooperative, .and .in .no .acute .distress. .Temperature .is .98.7 .F .by .mouth, .blood .pressure .of .140/80 .mm .Hg, .heart .rate .is .84/min .and .regular, .and .respirations .are .22/min .and .unlabored. .There .are .multiple .scratches .and .abrasions .in .varying .stages .of .healing .over .most .of .her .extremities. .Her .speech .is .moderately .dysarthric. .She .experiences .some .mild .choking .when .she .tries .to .drink .a .glass .of .water. .She .can .smile .weakly, .but .she .cannot .raise .her .eyebrows .against .resistance. .She .shows .mild .bilateral .weakness .of .eye .adduction. .Pupillary .responses .are .normal. .There .is .mild .to .moderate .upper .extremity .and .mild .lower .extremity .weakness, .greater .distally .than .proximally. .Her .motor .strength .is .sustained .over .at .least. 30 .seconds .without .fatigue. .Her .gait .is .ataxic, .and .she .cannot .walk .without .assistance. .Reflexes .are .hypoactive .to .absent, .and .the .response .to .plantar .stimulation .is .downgoing .bilaterally. .Sensation .is .intact, .except .for .mildly .impaired .position .and .vibratory .sensation .in .both .feet. .A .complete .blood .count, .chemistry .profile, .chest .X-ray, .and .EKG .are .all .normal. .Computed .tomography .of
2 Verapamil 3 Lithium 4 Topiramate 5 Prednisone ANS:. 1 Sumatriptan The .correct .response .is .sumatriptan.
This .patient's .most .likely .diagnosis .is .most .likely .a .cluster .headache. .Pharmacologic .management .of .cluster .headache .may .be .divided .into .abortive/symptomatic .and .preventive/prophylactic .strategies. .Abortive .agents .are .used .to .stop .or .reduce .the .severity .of .an .acute .attack, .and .include .oxygen, .triptans, .ergot .alkaloids, .and .anesthetics. .Inhalation .of .high-flow .concentrated .oxygen .is .extremely .effective .for .aborting .attacks. .5-Hydroxytryptamine-1 .(5-HT1) .receptor .agonists, .such .as .triptans .or .ergot .alkaloids .with .metoclopramide, .are .often .the .first .line .of .treatment. .Stimulation .of .5-HT .receptors .produces .a .direct .vasoconstrictive .effect .and .may .abort .the .attack. .Subcutaneous .injection .of .sumatriptan .can .be .effective, .in .large .part .because .of .the .rapidity .of .onset. .Studies .have .indicated .that .intranasal .administration .is .more .effective .than .placebo .but .not .as .effective .as .injections.
Prophylactic .agents .are .used .to .reduce .the .frequency .and .intensity .of .individual .headache .exacerbations.
Preventive .and .prophylactic .medications .include .calcium .channel .blockers, .mood .stabilizers, .and .anticonvulsants. .Verpamil .is .the .most .effective .calcium .channel .blocker .for .prophylaxis. .It .inhibits .calcium .ions .from .entering .slow .channels, .select .voltage-sensitive .areas, .or .vascular .smooth .muscle, .thereby .producing .vasodilation .and .preventing .the .initial .vasoconstrictive .phase .of .cluster .headaches. .It .can .be .combined .with .ergotamine .or .lithium.
Preliminary .evidence .suggests .that .prophylactic .lithium .may .interfere .with .substance .P .and .vasoactive .intestinal .peptide .(VIP)-induced .arterial .relaxation.
Anticonvulsants .such .as .Divalproex .and .Topiramate .are .preventative .medications .whose .mechanism .of .action .may .involve .regulation .of .central .sensitization.
Prednisone .is .very .effective .for .aborting .the .cluster .headache .cycle .or .providing .intermediate .prophylaxis .as .bridging .therapy .between .acute .and .prophylactic .agents. .It .is .effective .for .treatment .that .does .not .respond .to .lithium.
A .48-year-old .woman .presents .after .a .seizure. .Prior .to .the .seizure, .she .experienced .confusion .and .disorientation .preceded .by .nausea, .vomiting, .and .blurred .vision. .Symptoms .appeared .after .working .for .several .hours .in .the .garden .under .the .sun. .Her .medical .history .is .significant .for .the .presence .of .schizophrenia, .for .which .she .takes .chlorpromazine .at .bedtime. .Her .temperature .is. 41 .C; .BUN .and
creatinine .are .elevated; .and .there .is .neutrophilia, .hemoconcentration, .and .lactic .acidosis. .You .think .that .the .event .is .possibly .drug-related. Question What .is .the .most .likely .diagnosis? .Answer .Choices 1 Heat .cramps 2 Neuroleptic .malignant .syndrome 3 Heat .stroke 4 Malignant .hyperthermia 5 Heat .exhaustion .ANS:
Heat .stroke Heat .disorders .can .be .exertional .and .nonexertional. .Both .can .be .drug-related. .Neuroleptics .(e.g., .phenothiazines, .thioxanthenes) .may .impair .thermoregulation .due .to .both .anticholinergic .and .antidopaminergics .effects. .Anticholinergics .inhibit .sweating, .therefore .disturbing .thermoregulation .during .exercise .or .under .conditions .of .environmental .heat .stress. .Antidopaminergics .elevate .the .set .point .of .the .temperature .regulation .center .in .hypothalamus.
Your .patient .most .probably .suffered .heat .stroke. .It .is .a .life-threatening .condition .characterized .by .elevated .body .temperature .with .nausea, .blurred .vision, .confusion, .disorientation, .and .seizures. Hemoconcentration, .anuria, .rhabdomyolysis, .kidney .dysfunction, .lactic .acidosis, .and .even .disseminated .intravascular .coagulation .may .result.
Heat .cramps .are .a .mild .disorder .characterized .by .painful .muscle .contractions .due .to .temporary .fluids .and .electrolytes .depletion. .There .are .no .signs .and .symptoms .of .neurological .dysfunction, .and .body .temperature .is .normal.
Neuroleptic .malignant .syndrome .is .an .idiosyncratic .reaction .to .neuroleptics, .most .commonly .phenothiazines .and .butyrophenones, .and .it .is .characterized .by .rigidity, .fever, .and .autonomic .instability. .It .is .not .connected .with .the .exposure .to .heat .and .exertion. .Men .under. 40 .are .at .greatest .risk.
Malignant .hyperthermia .is .a .nonexertional .idiosyncratic .reaction .to .the .anesthetic.
Heat .exhaustion .is .a .condition .with .a .severity .that .lies .between .heat .cramps .and .heat .stroke. .Body .temperature .might .be .slightly .elevated, .and .there .may .be .neurological .signs .like .headache, .but .there .will .be .neither .severe .confusion .nor .seizures.
A .17-year-old .adolescent .male .presents .with .unexplained .neurological .symptoms. .His .liver .is .enlarged .on .palpation, .and .he .has .other .symptoms .of .hepatitis. .Blood .work .reveals .depressed .ceruloplasmin .levels. .An .ophthalmological .examination .reveals .Kayser-Fleischer .rings. .What .is .the .most .likely .diagnosis? .Answer .Choices 1 Krabbe .disease
includes .the .region .from .the .elbow .to .wrist, .both .the .anterior .and .posterior .surfaces. .Left .wrist .strength .and .range .of .motion .are .decreased .compared .to .the .right. .Distal .pulses, .capillary .refill, .and .reflexes .are .normal. .The .remainder .of .the .exam, .including .mental .status, .is .normal. Question What .medication .would .be .most .appropriate .for .this .patient's .likely .diagnosis? .Answer .Choices 1 Gabapentin. 2 .Heparin 3 .Methadone 4 .Probenecid 5 .Vancomycin .ANS:
Gabapentin This .patient's .diagnosis .is .most .likely .a .complex .regional .pain .syndrome .(CRPS). .CRPS .most .often .develops .after .a .minor .trauma .and .classic .characteristics .include .pain .out .of .proportion .with .findings .and .history, .allodynia .(pain .sensation .with .normally .non-painful .stimuli) .and .motor .and .sensory .disturbances .in .the .affected .extremity. .The .mechanism .for .CRPS .development .is .not .well .understood. .Prolonged .immobilization .following .injury .is .a .risk .factor .for .development .of .CRPS. .Diagnosis .is .clinical, .and .testing .is .done .to .rule .out .other .disorders. .Treatment .is .multi-modal .and .primarily .consists .of .physical .therapy, .focusing .on .mobilization .and .desensitization. .Other .treatments .are .often .off-label .and .targeted .at .chronic .pain .relief; .they .include .corticosteroids, .bisphosphonates, .tricyclic .antidepressants, .anticonvulsants, .and .topical .anesthetics. .Gabapentin .would .be .a .reasonable .choice .for .this .patient.
Heparin .would .be .used .if .this .patient's .symptoms .were .attributed .to .a .deep .venous .thrombosis .(DVT). .DVT .is .rare .in .the .upper .extremities; .it .is .not .associated .with .the .hyperesthesia .and .allodynia .shown .in .this .patient.
Methadone, .a .longer-acting .opioid .medication, .can .be .used .for .chronic .pain. .However, .for .several .reasons, .this .is .not .the .most .appropriate .medication .to .use .in .CRPS. .Opiates .carry .addiction .potential .and .increase .fall .risk .in .the .elderly. .CRPS .is .often .categorized .as .early .(<6 .months' .duration) .versus .late .(>6 .months). .For .early .CRPS, .opiates .should .be .avoided .and .even .with .late .CRPS, .other .medications .options .should .be .utilized .before .initiating .opiates.
Probenecid .is .a .medication .which .inhibits .urate .resorption. .It .is .used .for .gout, .a .painful .inflammatory .condition .which .may .cause .acute .pain, .erythema .and .swelling .in .the .affected .joint(s). .Gout .tends .to .be .more .acute .and .affect .joints .(not .the .forearm, .as .with .this .patient).
Vancomycin .is .an .IV .glycopeptide .antibiotic; .it .is .used .for .severe .bacterial .infections, .including .cellulitis. .Cellulitis, .which .commonly .presents .with .erythema, .edema .and .tenderness .in .an .extremity, .may .be .considered .on .the .differential .for .this .patient. .Cellulitis .tends .to .occur .more .acutely. .This .patient .had .a .normal. 8 .week .exam .with .symptoms .of .CRPS, .but .no .findings .of .cellulitis .at .that .time.
A .46-year-old .man .recently .recovered .from .a .bout .of .influenza, .and .he .now .presents .due .to .an .8- hour .history .of .right-sided .facial .paralysis. .He .is .having .trouble .closing .his .right .eye, .cannot .raise .his .right .eyebrow, .and .cannot .smile .with .the .right .side .of .his .mouth. Question What .medication(s) .should .this .patient .be .started .on? .Answer .Choices 1 Ibuprofen .800mg .PO .q. 6 .hours .plus .acyclovir .400mg .PO. 5 .times .daily 2 Prednisone .60mg .PO .daily .alone 3 Prednisone. 60 .mg .PO .daily .plus .acyclovir .400mg .PO. 5 .times .daily 4 Acyclovir .400mg .PO. 5 .times .daily .alone 5 Prednisone .60mg .PO .daily .plus .augmentin .500mg .PO. 2 .times .daily
ANS:. 3
3 .Prednisone. 60 .mg .PO .daily .plus .acyclovir .400mg .PO. 5 .times .daily The .correct .answer .is .prednisone .60mg .PO .daily .plus .acyclovir .400mg .PO. 5 .times .daily. .Either .medication .alone .can .be .used .with .fairly .good .results, .but .the .most .recent .research .has .shown .that .patients .treated .within. 3 .days .of .onset .with .both .a .glucocorticoid .and .an .antiviral .have .a .better .outcome .than .patients .treated .with .either .prednisone .or .acyclovir .alone.
Ibuprofen .800mg .PO .q. 6 .hours .plus .acyclovir .400mg .PO. 5 .times .daily .is .not .the .correct .answer. .Acyclovir .is .an .appropriate .choice .for .treatment, .as .it .is .an .antiviral, .and .herpes .simplex .virus .is .the .likely .etiologic .agent .in .the .pathogenesis .of .Bell's .palsy. .However, .a .nonsteroidal .anti-inflammatory .is .not .the .correct .type .of .anti-inflammatory .to .treat .Bell's .palsy, .so .ibuprofen .is .an .incorrect .choice.
Prednisone .60mg .PO .daily .alone .is .not .the .correct .answer. .Prednisone .is .an .appropriate .treatment .choice .for .Bell's .palsy. .It .is .typically .given .1mg/kg .for .5-7 .days .and .then .tapered .over .the .next .5- .days. .This .appears .to .shorten .the .duration .of .symptoms .and .improve .the .functional .outcome. .It .should .be .started .as .early .as .possible, .but .not .at .all .if .it .has .been. 7 .days .or .more .since .the .onset .of .symptoms. However, .outcomes .are .even .better .if .this .treatment .is .used .in .conjunction .with .an .antiviral, .such .as .acyclovir.
Acyclovir .400mg .PO. 5 .times .daily .alone .is .not .the .correct .answer. .Acyclovir .400mg .PO. 5 .times .per .day .for. 10 .days .is .a .good .treatment .option .for .Bell's .palsy. .It .is .best .if .started .within. 72 .hours .of .symptoms, .but .can .be .started .up .to. 7 .days .after .the .onset. .However, .outcomes .are .even .better .if .this .treatment .is .used .in .conjunction .with .a .glucocorticoid, .such .as .prednisone.
Prednisone .60mg .PO .daily .plus .augmentin .500mg .PO. 2 .times .daily .is .not .the .correct .answer. .Prednisone .is .an .appropriate .treatment .choice .for .Bell's .palsy. .It .is .typically .given .1mg/kg .for .5- .days .and .then .tapered .over .the .next .5-7 .days. .This .appears .to .shorten .the .duration .of .symptoms .and .improve .the .functional .outcome. .However, .because .it .is .an .antibiotic .used .to .treat .bacterial .infections, .augmentin
Restless .leg .syndrome Restless .legs .syndrome .(RLS) .is .a .neurological .disorder .with .symptoms .of .an .unpleasant .sensations .in .the .legs, .such .as .insects .crawling .inside .the .legs, .burning, .tugging, .or .creeping. .There .is .an .uncontrollable .urge .to .move .the .limb .when .at .rest .(lying .down .and .trying .to .relax .activates .the .symptoms). .Most .people .with .RLS .have .difficulty .falling .asleep .and .staying .asleep. .Women .may .be .slightly .more .affected .than .men.
Symptoms .may .begin .at .any .stage .of .life, .although .the .disorder .is .more .common .with .increasing .age. .The .severity .of .the .disorder .appears .to .increase .with .age.
In .some .patients, .symptoms .will .improve .over .a .period .of .weeks .or .months.
In .most .cases, .the .cause .of .RLS .is .idiopathic. .A .family .history .of .the .condition .is .seen .in .many .cases, .suggesting .a .genetic .component. .People .with .familial .RLS .tend .to .be .younger .when .symptoms .start, .and .they .have .a .slower .progression .of .the .condition. .Hypoglycemia .can .worsen .the .condition.
The .disorder .is .diagnosed .clinically .by .evaluating .the .patient's .history .and .symptoms. .Needle .electromyography .and .nerve .conduction .studies .should .be .considered .if .polyneuropathy .is .suspected .on .clinical .grounds, .even .if .results .of .neurologic .examination .are .apparently .normal.
Ropinirole .is .approved .for .the .treatment .of .moderate-to-severe .RLS. .Benzodiazepines .may .be .prescribed .for .patients .who .have .mild .or .intermittent .symptoms. .These .drugs .help .patients .obtain .a .more .restful .sleep, .but .they .do .not .fully .alleviate .the .symptoms .and .can .cause .daytime .drowsiness. .For .more .severe .symptoms, .opioids .may .be .prescribed .since .they .can .cause .relaxation .and .decrease .pain. .Anticonvulsants, .such .as .carbamazepine .and .gabapentin, .are .also .useful .for .some .patients; .they .can .decrease .the .creeping .and .crawling .sensations.
There .may .be .no .symptoms .associated .with .deep .vein .thrombosis .(DVT), .but .the .classical .symptoms .of .DVT .include .pain, .swelling, .redness .of .the .leg, .and .dilation .of .the .surface .veins.
Peripheral .neuropathy, .of .which .alcoholic .peripheral .neuropathy .is .a .type, .causes .tingling .or .burning .pain .in .the .feet. .At .times, .it .may .be .so .severe .that .it .interferes .with .walking, .which .is .a .result .of .injury .to .sensory .fibers. .As .the .condition .worsens, .the .pain .typically .decreases .and .numbness .increases.
Periodic .limb .movements .in .sleep .are .associated .with .periodic .episodes .of .highly .repetitive .limb .movements .during .sleep. .These .repetitive .episodes .of .muscle .contractions .are .usually .grouped .into .series.
A .32-year-old .man .presents .with .a .severe .headache; .he .has .had. 2 .similar .headaches .within .the .past .week. .He .describes .a .burning, .'hot .poker'-type .of .pain .located .primarily .behind .his .right .eye. .He .notes .that .his .eye .waters .profusely .with .the .headache; .in .addition, .his .nose .is .initially .congested, .then .it .starts .running. .Only .his .right .side .is .affected. .The .headache .is .so .severe .that .he .cannot .work .or .sleep .through
it, .and .he .is .unable .to .concentrate .on .anything .else. .The .headaches .have .been .unresponsive .to .overthe- .counter .pain .medications. .The .episodes .seem .to .last .about. 1 .hour. .He .denies .any .other .symptoms. .This .patient .has .no .chronic .medical .conditions, .and .he .takes .no .regular .medications. Question What .is .the .most .likely .underlying .pathophysiology .of .this .patient's .condition? .Answer .Choices 1 Antigen .binds .to .IgE, .triggering .the .release .of .histamines .and .other .inflammatory .substances 2 Growth .of .an .intracranial .tumor .near .the .base .of .skull, .leading .to .pressure .on .the .cerebellum 3 Increased .emotional .stress, .leading .to .contractions .of .head .and .neck .musculature 4 Increased .trigeminal .nerve .and .parasympathetic .activity, .leading .to .vasodilation. 5 .Reactivation .of .varicella .zoster .virus, .leading .to .inflammation .in .a .ganglion .ANS:
4 .Increased .trigeminal .nerve .and .parasympathetic .activity, .leading .to .vasodilation This .patient .presents .with .a .history .indicating .cluster .headaches. .While .the .exact .mechanism .is .unclear, .it .is .known .that .there .is .increased .trigeminal .nerve .and .parasympathetic .activity, .leading .to .vasodilation .in .the .intracranial .vasculature. .Key .features .of .cluster .headaches .include .unilateral .pain, .involvement .of .the .eye .and .nose .(autonomic/parasympathetic .system), .an .episodic .pattern .of .attacks, .and .excruciating .pain.
Antigen .binding .to .IgE, .leading .to .release .of .histamines, .leukotrienes, .and .prostaglandins .is .the .typical .type .I .hypersensitivity .reaction .of .allergies. .Seasonal .allergies .could .cause .a .headache, .along .with .nasal .and .ophthalmic .symptoms; .however, .this .patient's .severity .of .headaches .exceeds .a .usual .allergic .sinus .headache. .If .this .patient's .symptoms .had .been .caused .by .an .allergic .response .he .would .have .presented .with .a .history .of .allergies, .chronic .lower-grade .headaches, .and .sinus .symptoms; .he .would .not .have .acute, .episodic .attacks .of .high .intensity.
While .the .growth .of .an .intracranial .tumor .could .present .with .headaches, .this .patient's .history .is .not .suggestive .of .cerebellar .dysfunction. .If .there .were .a .tumor .in .this .patient's .cerebellar .region, .some .motor, .and .possibly .language, .dysfunction .would .be .expected. .Headaches .with .lacrimation .and .rhinitis .are .not .typically .seen .from .a .tumor.
Increased .emotional .stress .and .tight .neck .musculature .is .associated .with .tension-type .headaches, .which .are .the .most .common .form .of .headaches. .Typically, .these .headaches .are .more .chronic; .they .are .associated .with .psychosocial .stressors .and .respond .to .analgesics. .Nasal .and .ophthalmic .symptoms .are .not .seen .with .tension-type .headaches.
The .reactivation .of .the .varicella .zoster .virus .(shingles) .can .produce .severe .throbbing, .stinging, .or .other .pain .symptoms .along .the .affected .dermatome. .Shingles .would .be .a .disorder .to .consider .on .this .patient's .differential, .but .the .patient's .young .age, .lack .of .skin .lesions, .and .the .episodic .nature .of .the .attacks .fit .much .better .with .a .diagnosis .of .cluster .headaches.
