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?

Item 2 of 3

Which of the following is the best initial therapy for this patient?

Item 3 of 3

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?

A 12-year-old boy is brought to the emergency department due to unsteadiness, weakness, and falls.  The patient recently went on a week-long family camping and hiking trip to the mountains in Washington State.  On returning home to California 2 days ago, he experienced a sense of fatigue and a tingling sensation in his fingers.  Yesterday, the patient started having bilateral leg weakness and is now unable to walk without assistance; he sways from side to side when standing and then falls to the floor.  The patient has had no fever, headache, joint pain, or skin rash and has no history of recent respiratory or gastrointestinal illness.  Vital signs are within normal limits.  He is alert and active but can stand only briefly before requiring assistance.  There is no increased resistance to neck flexion.  Cranial nerve examination is normal and sensation is not impaired.  Muscle strength is 4/5 in the upper extremities and 2/5 in the lower extremities.  Deep tendon reflexes are absent at the knees and ankles but are normal elsewhere.  Finger-to-nose testing shows dysmetria of the arms.

Item 1 of 2

Which of the following is the best next diagnostic intervention that should be performed for this patient?

Item 2 of 2

Diagnostic intervention reveals significant findings.  Which of the following is most likely to improve this patient’s condition?

A 56-year-old man is hospitalized due to a 7-hour history of left-sided weakness and difficulty speaking.  Medical history is significant for hypertension and type 2 diabetes mellitus.  He smokes 1.5 packs of cigarettes daily and consumes alcohol occasionally.  Medications include antihypertensives and oral antidiabetic medications.  Blood pressure is 185/111 mm Hg and pulse is 90/min.  Physical examination shows left-sided hemiplegia with hemisensory loss and mild dysarthria.  Cardiac auscultation demonstrates a regular rhythm without murmurs or additional sounds.  There are no carotid bruits.  Finger-stick glucose is 184 mg/dL.  ECG shows left ventricular hypertrophy with secondary repolarization changes.  CT scan of the head without contrast reveals focal hypodensity involving the right posterior limb of the internal capsule.  CT angiography of the head and neck reveals no large vessel occlusion.

Item 1 of 2
Which of the following interventions is most appropriate at present?

Item 2 of 2
Swallow evaluation shows that the patient has normal swallowing capabilities, and he is given aspirin orally.  Five hours after hospital admission, the neurologic examination remains unchanged.  Blood pressure is now 175/95 mm Hg and heart rate is 98/min.  Laboratory results are as follows:

Finger-stick glucose is 138 mg/dL.  Which of the following pharmacotherapies is indicated for this patient?

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?

A 42-year-old woman comes to the office due to 6 months of worsening headaches.  The patient has had occasional headaches in the past, but lately “they seem to be getting out of control” and are often throbbing.  She also has constant, pressure-like headaches localized behind the forehead and eyes.  The patient takes acetaminophen and ibuprofen and recently began taking them on a daily basis.  The medications often make her nauseated, and she has had several episodes of vomiting.  The patient also has blurry vision but no muscle weakness, syncope, or seizures.  She experiences a considerable amount of stress at work and says that she “cannot afford to slow down.”  Medical history is significant for irritable bowel syndrome and chronic back pain.  She smokes a pack of cigarettes daily.  The patient’s mother suffered from migraines and had surgery for a meningioma.  Her father died of a drug overdose.  Blood pressure is 155/98 mm Hg and pulse is 83/min.  BMI is 27 kg/m².  Chest examination is unremarkable.  Abdominal examination shows mild periumbilical tenderness.  There is no muscle weakness, and the deep tendon reflexes are symmetric.  There is no hand tremor.  Romberg test is negative.  Funduscopic findings are shown in the image below.

Which of the following is the most appropriate next step in management of this patient?

A 34-year-old man comes to the office due to an abnormal sensation over his right thigh.  He says, “It gets numb, and, sometimes, I feel burning over my thigh.”  He has no back pain, muscle weakness, or abnormal sensation below the knee.  Medical history is insignificant.  He smokes 2 packs of cigarettes and consumes 1 or 2 bottles of beer daily.  He is a construction worker and frequently works in a squatting position.  Vitals signs are normal.  BMI is 37 kg/m².  Physical examination reveals an area of decreased sensation over the right anterolateral thigh.  There is no muscle weakness.  Deep tendon reflexes are symmetric.

Item 1 of 2
Which of the following is the most likely cause of this patient’s condition?

Item 2 of 2
Which of the following is the most appropriate next step in management of this patient?

A 36-year-old man has had weakness in his right arm and leg as well as difficulty walking over the past 2 weeks.  This was preceded for several days by mild headaches and dizziness that have not recurred.  He is an ex-smoker with a 10-pack-year history.  The patient experimented with cocaine in college although never intravenously, and he has used no illicit drugs in the last 10 years.  He has a history of multiple sexual partners and has been treated twice in the past several years for gonococcal urethritis.  He also reports an ulcerative lesion on his penis “a while ago,” that resolved.  The patient has no history of diabetes or hypertension.  His family history is negative for stroke or premature coronary artery disease.  He is afebrile, his blood pressure is 132/80 mm Hg, and his heart rate is 85/min with a regular rhythm.  There is no murmur on cardiac examination.  His reflexes are hyperactive on the right side.  Electrocardiogram shows normal sinus rhythm.  A urine toxicology screen is negative.  Brain MRI demonstrates a subacute stroke in the left frontal lobe.  HIV test is negative.  Cerebrospinal fluid analysis results are as follows:

Cerebrospinal fluid Gram stain shows no organisms.  Which of the following is most likely to indicate the underlying etiology of this patient’s symptoms?

A 45-year-old Caucasian man comes to see you in the office.  He is accompanied by his wife.  They have noticed that he has shakiness of both hands for the past six months.  The shakiness is limited only to his hands and has not progressed over time.  It becomes much more pronounced when he tries to pick up things or attempts to eat or drink.  On physical examination, you notice a constant tremor in both his hands, which becomes much more pronounced when his arms are outstretched.  There is also a very subtle head tremor present.  There is no rigidity or slowing of voluntary movements in the upper or lower extremities.  His father had a similar problem in his 50s or 60s, but he is not sure what treatment he received at that time.  His wife is extremely anxious and wants to know his prognosis.

Item 1 of 2

Which of the following is the most appropriate response?

Item 2 of 2

The patient works as a carpenter and feels that he is unable to perform the fine motor tasks due to the tremor. Which of the following is the most appropriate next step in the management of this patient?

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

Item 1 of 3

Which of the following is the best immediate step in management of this patient?

Item 2 of 3

Which of the following is the best treatment modality for this patient?

Item 3 of 3

The patient is told that the diarrheal illness may have triggered his current condition, and he becomes upset that he did not seek medical attention earlier.  He inquires about the course and prognosis of his current condition.  Which of the following is the most accurate statement?

A 55-year-old man comes to the emergency department 2 hours after the onset of weakness in his left arm and leg.  Two months ago, the patient had a 15-minute episode of right arm weakness that resolved spontaneously.  He has no headache, nausea, vomiting, or difficulty swallowing.  Temperature is 36.7 C (98.1 F), blood pressure is 172/98 mm Hg, and pulse is 83/min with a regular rhythm.  Physical examination shows left-sided hemiparesis.  Finger-stick blood glucose is 108 mg/dL.  CT scan of the head without contrast reveals no signs of intracranial hemorrhage.  The patient is given thrombolytic therapy.  CT angiography of the head and neck reveals no large-vessel occlusion and no significant arterial stenosis.  The next day, neurologic examination shows marked improvement in left-sided weakness.  Carotid duplex ultrasound reveals 20% stenosis of the right internal carotid artery and 30% stenosis of the left internal carotid; there is no evidence of thrombosis or ulceration.  ECG shows normal sinus rhythm.  Complete blood count and coagulation studies are normal.

Item 1 of 2
Which of the following is the most appropriate next step in management of this patient?

Item 2 of 2
MRI of the head reveals a cortical infarct in the right middle cerebral artery territory.  Echocardiography reveals left ventricular hypertrophy with an ejection fraction of 60% and moderate left atrial dilation.  There are no valvular lesions, wall motion abnormalities, intracardiac thrombi, or intracardiac shunts.  A small (1 mm) atheroma is present in the aortic arch without ulceration.  The patient is observed in the hospital for 48 hours on the telemetry floor; there is no evidence of arrhythmia.  Serum erythrocyte sedimentation rate is normal and rapid plasma reagin is negative.  Which of the following is the most appropriate next step in management of this patient?