Gertrude is an 85 y/o female who has a 2 year hx of Major Cognitive Impairment of the Alzheimer's type. She is brought to your office today by her daughter because she has has recently become agitated and confused and has been combative towards her caretakers. Which medication would you NOT add to her current regimen
Select the best option for a first line treatment for Alzheimer's Disease
Jackie is a 30 y/o woman who presents to her dentists office due to severe pain. Pt states that she believes she needs another root canal. On history the dentist notes that she is having brief, lancinating pain that has been happening in recurrent attacks several times throughout the day. The pain radiates through the lower two thirds of her face and shoots from her mouth to her ear on the right side. Due to this history he suggests she goes to her PCP's office. Which of the following conditions might Jackie have?
Jackie denies any loss of sensation or paralysis.
Herpes Zoster in the Trigeminal Distribution
Jack is an 85 y/o pt who is brought to your ER by his daughter due to R upper extremity weakness and a R sided facial droop. On exam you note that the facial weakness only effects the face under the eyebrow as the Pt is able to scrunch his forehead. What is your top ddx?
Herpes Zoster in the trigeminal distribution
Bell's palsy is an idiopathic facial paresis of LMN type caused by inflammation of the facial nerve. Facial paralysis comes on abruptly. Pain about the ear precedes the attacks at times. On exam the patient will have unilateral paralysis of the face but will be able to wrinkle their forehead. Face may feel stiff and pulled to one side and may have ipsilateral restriction of eye closure and difficulty w/ eating and fine facial movement
Bob is a 75 year old man who comes into your office due to a painful weeping rash that extends from his forehead to just below the eye on the R side of the face. Upon review of his medical records you note that he has not received the recommended immunizationsfor older adults. What is your top ddx for Bob?
Herpes Zoster in a trigeminal distribution
Sandra is an obese middle-aged woman with a PMHx of Type II DM, HTN, and CAD. Pt "controls" her DM with oral medications, her last HbA1C was 13. Pt comes to your office today because she has noticed that she's been stumbling around lately and tripping over little cracks in the side walks. On exam you note that she has lost vibratory sensation up to her patella B/L and that she cannot feel pain in her feet. What is your top ddx?
Numb foot Disease
All of the following are characteristics of Myasthenia Gravis EXCEPT:
Difficulty chewing, swallowing, talking, and breathing
Sx get better as the day goes on
Larry is an 80 y/o smoker with a 70 pack year history. Pt has not been seen by his PCP for several years but states that he has came in today because he's been coughing up blood. During the exam his wife pipes up and states that he also has had limb weakness in the mornings but that it is usually gone after he has become afternoons. Select which of the following would be your DDX
Amanda is a 30 y/o woman who comes to the ED due to leg weakness which she noticed when trying to get out of a chair at work. Pt states that she was required to use her arms in order to get up and is worried that she is becoming paralyzed. Pt denies any history of prior episodes of this and notes that she has no pertinent PMHx. Two weeks ago she notes she had a URI but has been asymptomatic for a week. Pt denies any other weakness at this time. What does Amanda have?
Pt is a 75 y/o professor who comes to the office stating that he has been having problem writing and notes that his writing is messier and gets smaller as he is writing. Pt's wife also states that he has been moving slower and stumbling more. Pt states that his daily life has not become severely impacted. What is your dx and tx choice at this time?
Parkinson's dz; Cogentine
Parkinson's dz; Sinemet
Benign Essential Tremor; Propranolol
Huntington's Dz; Amantadine
Idiopathic Torsion Dystonia; Diazepam
Jeremy is a 28 year old surgical resident who is having trouble exceeding in his program because of a shaking in his right hand. Pt states that his sx are impacting his performance and states that he does not have shakes when he is resting and that it occurs when he tries to use his surgical instruments. Pt also states that he notes it gets better when he's having a few drinks (not before surgery) and that his grandfather had similar issues. What is your diagnosis and what would the tx be?
Benign Essential Tremor; propranolol
Huntington's Disease; tetrabenazine
Idiopathic Torsion Dystonia; Levodopa
Parkinson's Disease; Amantadine
Juan is a 28 y/o male who comes to the office with his father due to increased irritability and moodiness. Pt's father states that he is nervous because his grandmother had similar sx when he was a kid and she ended up committing suicide due to severe depression and a movement disorder. On exam you note that the patient appears fidgety and restless. Select what dx and the tx you'd select.
Parkinson's Dz; Levodopa
Huntington's Disease; Phenothiazine
Idiopathic Torsion Dystonia; Carbamezepine
Which of the following is not a negative prognostic factor for strokes.
Loss of consciousness
Continued decline after admission
Which of the following is not a contraindication to use tPA or other clot-busting drugs in strokes.
Treatment with anticoagulants
Systolic pressure >160 mm Hg or diastolic pressure >100 mmHg
Pt is a 20 year old college student who lives in the dorms. Pt's roommate states yesterday he was feeling slightly ill and that today he found him laying in bed confused with shaking chills and a high fever. Pt was brought to the ED due and is found to have a petechial rash on his skin and mucous membranes and nuchal rigidity. There are no signs of ICP. What is your ddx and what is the first test you would run?
Bacterial meningitis; Lumbar Puncture
Subarachnoid Hemorrhage; CT (preferably CT angiography)
Ischemic Stroke; CT w/o contrast
Viral Meningitis; Lumbar Puncture
Pt is an 80 y/o woman who is brought in s/p a MVA that she was in a passenger in. Pt has a hx of HTN and DM. Pt bumped her head in the MVA and now states that she has had the worst headache of her life. What is your top ddx and what is the initial test that you would like to perform?
Bacterial Meningitis; CT
Subarachnoid hemorrhage; CT w/o contrast
Ischemic Stroke; MRI w/ diffusion-weighted sequences
Viral Meningitis; LP
Pt comes to the ED c/o a low grade fever, headache, and neck which started 4 days ago and states that it has gotten progressively worse. Pt denies any rashes, altered mental status. Pt has a positive brudzinski's sign and appears uncomfortable but not toxic. Other than a fever of 37.6 pt's vitals are WNL. There are no signs of ICP. You decide to preform a lumbar puncture and find the following:
-Glucose: 50 (normal)
-Protein: 80 (high)
-Opening pressure: slightly elevated
-Cells: 500 lymphocytes.
Pt is a 40 y/o female teacher who comes to your office stating that they have been coming into the office c/o dizziness and increasing hearing loss stating that she cannot tell the voices of her students apart. She states that the dizziness is constant and is a room spinning sensation.
Your next patient is a 75 y/o male with a hx of hyperlipidemia and HTN. You have been seeing this patient for years and note that his hair does not seem to be as neatly maintained as usual. He is just in for a recheck on his BP and the rest of your physical exam is normal. When asking about his ADL to ensure he is still able to take care of himself at home he notes that he hasn't been brushing his hair as much because it causes him pain. This causes you to take a closer look at his face and head. Upon auscultaiton of the temporal arteries you note bruits. What is the likely dx?
Pt is an 18 y/o female who comes to the ED due to loss of vision in her right eye which began as blurred vision this afternoon and steadily worsened. Upon further examination Pt has had a prior history of episodes of numbness in her hands 3 months ago and recently noticed a sharp searing pain when she flipped her head upside down to dry her hair. What is your top differential dx?
Polymyalgia rheumatic includes sx of pain and stiffness of the shoulder and pelvic girdle associated w/ fever, malaise, depression, and weight loss. It causes muscle weakness through primary muscle inflammation or secondary to nerve infarction.
Someone with a migraine HA will be running around the ER trying to bash their head into the wall because the pain is so severe
A 26 y/o physician assistant comes into their PCP's office stating that the have had a headache for the last couple of weeks that is nearly always present. Pt describes the HA as a daily HA that is tight on quality stating that it feels like their head is in a vise. Pt denies any nause or vomiting and states that the headache is constant and not pulsatile. When asked point where the HA is they point to the back of their head. Waht type of HA is this?
Tension type HA
HA d/t intracranial lesion
Pt is a 30 y/o woman who comes to the ED due to an HA which she states is a 9/10 on a pain scale. Pt notes that she often gets these HA and that it has been going on for 5 hours and has not let up when she took ibuprofen. Pt states that prior to the HA beginning she saw flashing lights that appeared to be lightening bolts in the corner of her eyes and noted that they went away when the HA began. Pt noted that the she becomes violently nauseous and vomited on her way here when an ambulance went past with their flashing bright lights and sirens on. Pt describes the headache as a severe throbbing of the right side of her head. What tx might you give this pt?
Zolmitriptan 5 mg Intranasal
Sumatriptan 5 mg PO
Propranolol 25 mg IV
Topiramate 100mg PO
Ned is a 40 y/o man who comes into the ED due to a severe headache stating that he started to have a HA 20 minutes ago and needs to see a practitioner NOW because someone is shoving an icepick in his eye. All of the following except are tx you should try to break this HA.
100% oxygen by Nasal Cannula
Viscous lidocaine intranasally
Pt is a 70 y/o female who comes to the doctor stating that she has had a worsening headache over the past few weeks that is much worse during the day but that it is better once she gets into her routine. Pt states that at first she thought it was just caffeine withdrawal but states that they are getting much worse and occurring each morning. What is your top differential?
Select which of the following is NOT a sx of cluster HA
Ipsilateral Horner's Syndrome (Conjunctival injection, lacrimation, nasal congestion, ptosis, miosis)
B/L stabbing periorbital pain
Triggers can include: alcohol/smoking, stress, NTG, chocolate/foods, glare
Generally occurs at night and can cause restlessness and agitation and spontaneous remission can occur and pt is well for weeks or months before next bout
Tom is a 7 y/o boy who is brought in by his mother because she believes that the he has ADHD. She several episodes a day of staring and not listening to her directions. When he does begin to talk to her again he acts as if he hasn't even heard her instructions. She'd like some adderal or ritalin to fix the problem.
While in the office the Pt has what she describes as an episode and you note that he begins to pick at his clothes. You send him to a pediatric neurologist and they note that an EEG done during "an episode" shows a 3 Hz spike and wave pattern. What does this patient have and what is the tx
simple partial seizure; carbamezopine
absence seizures; ethosuximide
Myoclonic Seizures; Valproic Acid
Select which one of the following descriptions are correct.
Myoclonic seizure-simulates an epileptic seizure, common in conversion disorders or malingering
Grand mal seizures-sudden LOC involves a tonic phase (rigidity, trunk and limb extension, may become apneic) and a clonic phase (rhythmical musculature jerking of limbs and body for at least 30 seconds). Also has a postictal state.
Complex partial seizures-single or multiple myoclonic jerks
Pseudoseizures-automatisms lasting 1-3 minutes-lipsmaking or chewing; olfactory or gustatory hallucinations, Deja vu, dysphagia, person may become aggressive if restraint is attempted.
Which of the following is not appropriate treatment for a first time seizure.
Dx them with epilepsy and start them on high doses of valproic acid
EEG and neuro consult
Check an MRI for any structural lesions
Check blood sugar, tox screen, electrolytes.
Which of the following is not a part of terminating anticonvulsants in an epileptic patient?
Pt should be 2 yrs seizure free
Decrease dose gradually over weeks to months
D/c drugs one at a time if on polytherapy
If seizures re-occur once therapy has been terminated start new regimen.
Which of the following is not a characteristic of Benign positional peripheral vertigo?
15-20 seconds after changing position
Dick Halpike maneuver can reduce sx
Precipitated by changing position of head, usually moving from erect position to supine
Short-lived vertigo lasting 15-60 seconds w/ complete recovery