The answer is E.
EXPLANATION: Diabetic peripheral neuropathy is the diagnosis, and describes any neuropathy in the diabetic patient. This patient is exhibiting a distal symmetric polyneuropathy with the classic associated symptoms, commonly called "pins and needles" by patients. When associated with pain and functional impact, pharmacologic therapy is warranted. There are many agents to choose from, with each of the answer choices being options. However, in a patient with a known seizure disorder, tramadol should be avoided, as it decreases the seizure threshold. Gabapentin, also a seizure medication, may be used, but close monitoring is suggested.
The answer is B.
EXPLANATION: The presence of headache associated with papilledema raises the concern for a brain tumor. The MRI excluded a mass lesion, raising a strong suspicion of pseudotumor cerebri. This is also known as benign intracranial hypertension. It is not a benign condition, however, since it causes severe headache and may result in visual loss. It is particularly frequent in obese adolescent girls and young women. The etiology is unknown but may be associated with the use of oral contraceptives, vitamin A, and tetracycline. The presentation consists of headaches caused by an increase in intracranial pressure and blurring of vision. There may be diplopia, but the remainder of the neurologic examination is unremarkable. Papilledema is virtually always part of the presentation. The mental status is normal. The differential diagnosis includes venous sinus thrombosis, sarcoidosis, and tuberculosis or carcinomatous meningitis. The last two are excluded by lumbar puncture. An abnormal cerebrospinal fluid is not consistent with pseudotumor cerebri. The diagnosis is made by excluding mass lesions with CT scan or MRI and demonstrating markedly increased intracranial pressure by lumbar puncture. The treatment involves weight loss, diuretics, and steroids. Repeat lumbar punctures to remove cerebrospinal fluid and decrease intracranial pressure are effective. In cases that are unresponsive to these measures, lumbar-peritoneal shunting is effective, as is unilateral optic nerve sheath fenestration. Effective treatment can improve headaches and prevent vision loss.
A 21-year-old college student presents with headache, fever, and a stiff neck. You perform a lumbar puncture for suspected meningitis. Which of the following cerebrospinal fluid analysis results is consistent with bacterial meninigitis?
A. Elevated opening pressure, markedly elevated white blood cell count, decreased glucose, increased protein concentration
B. Elevated opening pressure, mildly elevated white blood cell count, markedly elevated red blood cell count with noted xanthochromia
C. Mildly elevated opening pressure, white blood cell count elevated but less than 1000/mL, normal glucose, protein slightly increased
The answer is E.
EXPLANATION: Classic migraines often present with episodic, unilateral, and throbbing headache pain, associated with photophobia and phonophobia. Nausea and vomiting may also be involved. Management of migraines includes nonpharmacologic therapies, such as healthy eating, sleep pattern stabilization, caffeine avoidance, and stress relief. If nonpharmacologic therapies are not sufficient, or if symptoms impact activities of daily living, pharmacologic management is indicated. Medications are available for migraine sufferers and are typically catergorized as abortive or preventive. Abortive therapy for this patient may include nonsteroidal anti-inflammatory medications. Additionally, studies have shown that stimulation of the 5-HT receptors can successfully stop a migraine, and the 5-HT1 receptor agonists, with selective agents (the triptans) often used successfully for headache improvement. Nasal spray formulations are useful for nausea and vomiting. Topiramate, an anticonvulsant, has received FDA approval for migraine prevention therapy in patients with increasing migraine frequency or poor response to abortive therapies. Narcotics are typically avoided for migraine management, and MRI is not warranted without additional clinical signs and symptoms, and other differential diagnoses.
A 53-year-old man presents to the emergency department because of fever, headache, and confusion. On physical examination, you note an obtunded man who appears acutely ill with temperature of 104°F, blood pressure of 128/76 mm Hg, pulse of 98, and respiratory rate of 20. The patient has stomatitis, nuchal rigidity, and a positive Kernig sign. CSF examination shows increased opening pressure, 80 WBC/mL (normal < 10/mL), mildly elevated protein, and normal glucose. Which of the following tests would confirm the most likely causative organism?
A. CT of the head
B. polymerase chain reaction test for herpes simplex virus
C. blood culture for herpes simplex virus
D. serum IgG for herpes simplex virus
The answer is C.
EXPLANATION: The anterior cerebral arteries supply the frontal lobes as well as the medial aspects of the parietal and occipital lobes rostral to the parietooccipital sulcus. The prefrontal cortex of the frontal lobe is concerned with a person's personality, depth of feeling, and initiative. Hence, occlusion of an anterior cerebral artery can cause neuronal injury to this area, leading to feelings of apathy and personality changes. The paracentral lobule represents the medial aspects of the precentral gyrus (frontal lobe) and postcentral gyrus (parietal lobe), which are responsible for motor control and somatosensory perception, respectively, of the leg and foot. Hence, occlusion of an anterior cerebral artery can produce contralateral hemiparesis and hemisensory loss involving the leg and foot. With the 54-year-old patient, the symptoms were occurring on the left side, which points to a right anterior cerebral artery occlusion.