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Headache, Weakness, and Dizziness-2
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1. A 37-year-old woman with a history of migraines presents to the ED complaining of crampy lower abdominal pain for 3 Workup reveals an intrauterine pregnancy and early prenatal care is arranged with obstet- rics as an outpatient. You are concerned because her headaches are con- trolled with a significant number of medications. She uses medications for both abortive therapy and for prophylaxis. Which of the following classes of medications do you advise she discontinue while pregnant?
2. A 78-year-old man presents to the ED complaining of left arm weak- ness that started 10 minutes ago in the The patient states that he has a history of hypertension and diabetes but has never had similar symptoms in the past. He is feeling well otherwise. His BP is 157/85 mm Hg, HR is 87 beats per minute, temperature is 98.8°F, and RR is 14 breaths per min- ute. His neurologic examination is unremarkable and the patient embar- rassingly states that his left arm is no longer weak. Which of the following is the most likely diagnosis?
- Thrombotic stroke
- Conversion disorder
- Migraine with focal neurologic deficit
- Transient ischemic attack (TIA)
- Todd paralysis
3. A 56-year-old man presents to the ED complaining of intermittent light-headedness and nausea throughout the He believes it started after eating leftover shrimp salad in the morning. On further questioning, he reports that during the light-headedness episodes the room is spinning around him and the episodes are triggered by turning his head to the right. He denies hearing loss, tinnitus, or other associated symptoms. His BP is 137/85 mm Hg, HR is 67 beats per minute, temperature is 98.5°F, and RR is 14 breaths per minute. The patient reproduces the symptoms by turning his head to the right. Which of the following is the most likely diagnosis?
- Benign positional vertigo (BPV)
- Food poisoning
- Meniere disease
4. A 29-year-old woman presents to the ED complaining of double vision for 3 She states that she has been feeling very tired lately, particularly at the end of the day, when even her eyelids feel heavy. She feels better in the morning and after lunch when she is able to rest for an hour. Her BP is 132/75 mm Hg, HR is 70 beats per minute, temperature is 98.4°F, and RR is 12 breaths per minute. On examination, you find ptosis and proximal muscle weakness. What is the most appropriate diagnostic test to perform?
- Edrophonium test
- Serologic testing for antibodies to acetylcholine receptors
- Head CT scan
- Electrolyte panel
- Lumbar puncture
5. 40-year-old woman is brought to the ED by the paramedics com- plaining of bilateral foot weakness and numbness that started a few hours ago and is progressively She denies similar episodes in the past. On the review of systems, she describes having abdominal cramps with nausea, vomiting, and diarrhea 2 weeks ago that resolved after 2 to 3 days. Her BP is 124/67 mm Hg, HR is 68 beats per minute, temperature is 98.8°F, and RR is 12 breaths per minute. On examination, you elicit 2/5 strength, decreased sensation, and loss of deep tendon reflexes in the lower extremi- ties below the hips. Which of the following is the most likely diagnosis?
- Hypokalemic periodic paralysis
- Guillain-Barré syndrome
- Peripheral vascular disease
- Brain abscess
6. What life-threatening complication is associated with this disease process described in the previous question?
- Permanent paralysis
- Respiratory failure
- Need for surgery
- Kidney failure
7. A 58-year-old man presents to the ED complaining of generalized weakness for the last 2 He states that a few days ago he had abdomi- nal cramps, vomiting, and diarrhea when his whole family got sick after a picnic. These symptoms resolved a day and a half ago, but he has not been eating well and now feels weak all over. The patient has a history of hypertension for which he takes hydrochlorothiazide (HCTZ), which was recently increased. His BP is 144/87 mm Hg, HR is 89 beats per min- ute, temperature is 98.7°F, and RR is 12 breaths per minute. The physical examination reveals hyporeflexia. His electrocardiogram (ECG) is shown below. Which of the following is the most likely diagnosis?
8. A 69-year-old man is brought to the ED by his His son, who states that his father developed left arm and leg weakness this afternoon and now has difficulty walking. The patient states that he has a history of heart palpitations and recently stopped taking his blood-thinning medicine because it was giving him an upset stomach. His BP is 165/90 mm Hg, HR is 97 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. You suspect the patient is having a stroke and rush him to the CT scanner. The result of the head CT is seen below. What percentage of all stroke patients will have this type of stroke?
(Reproduced, with permission, from Brunicardi CF et al. Schwartz’s Principles of Surgery. New York, NY: McGraw-Hill, 2005: 1616.)
9. A 35-year-old woman presents to the ED complaining of left arm weakness and right facial pain for 1 She denies any past medical history but on the review of systems remembers having pain and decreased vision in her left eye approximately 4 months ago that has since resolved. She attributed it to being stressed and tired and did not see a physician at the time. Her BP is 126/75 mm Hg, HR is 76 beats per minute, temperature is 98.8°F, and RR is 12 breaths per minute. The physical examination is unremarkable except for 4/5 strength in the left upper extremity. Which of the following is the most likely diagnosis?
- Myasthenia gravis
- Multiple sclerosis (MS)
- Vertebrobasilar artery occlusion
- Guillain-Barré syndrome
10.Which of the following is the best test to confirm your diagnosis in the previous question?
- Edrophonium test
- Angiogram of the carotid arteries
- LP and CSF analysis
- Head CT
11. A 58-year-old woman is brought to the ED by paramedics complain- ing of worsening left arm and leg She reports a history of hyper- tension, diabetes, and smoking. She denies any past surgeries. Her BP is 165/83 mm Hg, HR is 110 beats per minute, temperature is 98.4°F, RR is 18 breaths per minute, pulse oxymetry is 98% on room air, and capillary glucose is 147 mg/dL. On examination, the patient’s speech is slurred and you notice a left-sided facial droop. Her left arm and leg strength is 2/5 and there is decreased sensation. The patient’s head CT is normal. It has been 130 minutes since the onset of symptoms. Which of the following is the most appropriate next step in management?
- Observation since she is out of the thrombolytic window.
- Administer nitroprusside to lower her BP; then give thrombolytics.
- Administer heparin only since she is out of the thrombolytic window.
- Administer thrombolytic therapy.
- Administer aspirin only since she is out of the thrombolytic window.
12. A 37-year-old woman presents to urgent care complaining of general weakness and blurry vision over the last She states that she feels great in the morning, but by dinner she has trouble cooking and com- plains of double vision. Her husband notices that her eyelids sometimes look droopy in the evening. On physical examination, her cranial nerves are intact, pupils are equal and reactive, extraocular muscles are intact; however, you notice slight ptosis. What is the most likely diagnosis of this patient?
- Lambert-Eaton myasthenic syndrome
- Ophthalmoplegia of the third cranial nerve
- Guillain-Barré syndrome
- Myasthenia gravis
13. A 63-year-old woman accompanied by her husband is brought to the ED by EMS with worsening right arm weakness that started 90 minutes ago at the Her husband states that she has a history of hypertension and long smoking. She has no surgical history. The husband states that his wife was fine when going to the opera. The patient’s BP is 215/118 mm Hg, HR is 97 beats per minute, temperature is 99.3°F, and RR is 14 breaths per minute. On examination, the patient is anxious, mildly aphasic, has 2/5 strength, and diminished sensation in the right upper extremity. An emergent head CT scan is normal. It has been 2 hours since the onset of symptoms. Which of the following is the most appropriate next step in management?
- Administer labetalol.
- Administer fibrinolytic therapy.
- Administer aspirin before fibrinolytic therapy to reduce platelet aggregation.
- Administer phenytoin before fibrinolytic therapy as seizure prophylaxis.
- Administer mannitol to reduce intracranial pressure before fibrinolytic therapy.
14. A 46-year-old woman presents to the ED with her husband com- plaining of flu-like symptoms, headache, vomiting, and She states that she never had similar symptoms in the past and that her husband is getting sick with similar symptoms as well but refuses to see a doctor. She reports feeling well yesterday and even helped her husband set up a home generator in their garage. Her BP is 142/85 mm Hg, HR is 97 beats per minute, temperature is 100.6°F, and RR is 20 breaths per minute. On examination the patient is slow to respond to questions. Which of the fol- lowing is the most appropriate diagnostic test?
- Send blood to check the WBC count.
- Order a head CT scan.
- Send blood to check the carboxyhemoglobin level.
- Perform an LP.
- No testing is necessary at this point.
15. An 82-year-old right-handed woman is brought to the ED by her daughter stating that her mother has not been able to walk after waking up from a nap 30 minutes The patient has a history of hypertension and diabetes. Her BP is 179/76 mm Hg, HR is 91 beats per minute, temperature is 98.9°F, and RR is 14 breaths per minute. On examination, you elicit neu- rologic deficits and emergently bring her to the CT scanner. The radiologist tells you there is an abnormality in the left parietal lobe and a likely middle cerebral artery stroke. Which of the following motor deficits are you likely to find in this patient?
- Right sensorimotor deficit in arm greater than leg and aphasia
- Left sensorimotor deficit in arm greater than leg and aphasia
- Right sensorimotor deficit in leg greater than arm, slowed response to questions, and impaired judgment
- Right motor deficit and left facial droop
- Right leg hemiplegia only
16. A 67-year-old man is brought to the ED by his wife who states that her husband’s face looks different and that he has been nauseated, vomit- ing, and unsteady on his feet since The patient also states that he has been having blurry vision and difficulty swallowing, in addition to feeling like the room is tilting from side to side. The patient attributes this to eating leftover salmon last night. The patient’s past medical history is notable for obesity and hypertension. His BP is 187/89 mm Hg, HR is 86 beats per minute, temperature is 99.3°F, and RR is 13 breaths per minute. On examination, you find a right facial droop, diplopia, vertical nystagmus, and severe ataxia. Which of the following is the most likely diagnosis?
- Lacunar infarct
- Posterior cerebral artery occlusion
- Vertebrobasilar artery occlusion
17. A 45-year-old man presents to the ED complaining of recurrent epi- sodes of light-headedness and nausea He describes the episodes as a room swaying from side to side when he lies on his left side. He reports mild headache now and denies tinnitus, hearing loss, fevers, or vomiting. He has no medical problems and takes no medications except for occa- sional acetaminophen. His BP is 123/65 mm Hg, HR is 69 beats per minute, temperature is 98.5°F, and RR is 12 breaths per minute. The patient is asymptomatic now and the examination is unremarkable. Which of the following is the most appropriate diagnostic test?
- Dix-Hallpike maneuver
- Caloric stimulation testing
- Orthostatic vital signs
- Head CT scan
18. A 23-year-old woman presents to the ED complaining of dizziness and weakness for 2 She complains that she does not have energy to perform her duties at work and even gets short of breath going up the stairs to her third-floor apartment. She denies shortness of breath at rest, fever, nausea, vomiting, diarrhea, chest pain, headache, recent travel, or other associated symptoms. She does not have any medical problems and takes no medications. On further questioning, she reports that she is on day 9 of her menstrual period, which has been heavy. Her periods are regular and last about 10 days. Her BP is 122/75 mm Hg, HR is 108 beats per minute, temperature is 98.7°F, and RR is 12 breaths per minute. Physical examina- tion is unremarkable except for pale conjunctiva and mild tachycardia. Which of the following is the most appropriate initial diagnostic test?
- Basic metabolic panel
- Complete blood count
- Chest x-ray
- Chest CT with contrast
19. A 57-year-old man presents to the ED with generalized weakness and pain, abdominal discomfort, and nausea for 2 On the review of sys- tems, he also admits to recent polydipsia, polyuria, and a 10-lb weight loss. His medical history includes hypertension for which he takes no medica- tions. He has a 20-pack-year smoking history. The vital signs are remarkable for mild tachycardia and hypertension. Laboratory results reveal a serum sodium 131 mEq/L, potassium 3.5 mEq/L, chloride 101 mEq/L, bicarbonate 22 mEq/L, blood urea nitrogen (BUN) 15 mg/dL, creatinine 1.1 mg/dL, glucose 125 mg/dL, and serum calcium level of 12.6 mEq/L. Which of the following is the most appropriate next step in management?
- Administer calcitonin.
- Start 0.9% normal saline intravenous (IV) bolus.
- Administer furosemide.
- Obtain chest radiograph.
- Obtain ECG.
20. A 46-year-old woman presents to the ED with left-sided arm and leg weakness for half an She has no medical problems except for chronic neck pain after a motor vehicle collision 5 years ago. On examination she has right eye miosis, partial ptosis, and 3/5 strength in her left upper and lower extremities. Which of the following is consistent with the patient’s ocular findings?
- Oculomotor nerve palsy
- Bell palsy
- Horner syndrome
- Kehr sign
- Nikolsky sign
21. On further questioning, the patient mentioned in the previous ques- tion states that earlier in the day she saw a chiropractor for her neck After the session she developed severe right-sided neck pain. About an hour later she noticed difficulty using her left side of her body. Which of the following is the most likely diagnosis?
- Internal carotid artery (ICA) dissection
- Cavernous sinus syndrome
- Transverse myelitis
- Spinous process fracture of a cervical vertebra
22. A 64-year-old man presents to the ED complaining of an episode of vertigo he experienced while exercising in the gym He states that he has been having similar episodes with exercise for a week. His routine con- sists of running on a treadmill, lifting weights, and doing leg presses. The vertigo usually occurs mid-routine when he is lifting weights and resolves with cessation of exercise. He also noticed unusual left arm pain during these episodes. He has hypertension for which he takes antihypertensive medication and had a myocardial infarction 6 years ago. He decreased his smoking from one pack per day to five cigarettes per day over the last 6 years. His BP in the right arm is 148/80 mm Hg and in the left arm it is 129/74 mm Hg. Which of the following is the most likely diagnosis?
- Superior vena cava syndrome
- Aortic dissection
- Subclavian steal syndrome
- Angina pectoris
- Vestibular neuronitis
23. A 36-year-old woman presents to the ED complaining of worsening weakness over the past few She states that initially she attributed it to being overworked, but for the last few days she has been having unusual difficulty getting out of chair or walking the steps to her fourth-floor apart- ment. She has no prior medical history and takes no medications. Her vital signs are unremarkable. On examination, she has 5/5 strength in her bilateral upper and lower extremities distally but 3/5 strength proximally. Sensory examination and reflexes are normal. You also notice a red conflu- ent macular rash on her eyelids. Which of the following is the most likely diagnosis?
- Myasthenia gravis
- Disseminated gonococcal infection
24. A 32-year-old woman presents to the ED complaining of sudden onset of left facial weakness that began half an hour ago that was noticed by her She denies having medical problems or taking medica- tions. On the review of systems, she admits to subjective fevers, fatigue, and arthralgias for the last week, which she attributed to the flu. She also reports having a rash on the back of her thigh a month ago, around the time she was hiking in Rhode Island. On examination she has left facial paralysis. Which of the following is the most likely diagnosis?
- Bell palsy
- Lyme disease
- Ramsay Hunt syndrome
- Brain tumor
- Rocky Mountain spotted fever (RMSF)
25. A 24-year-old woman presents to the ED complaining of dizzi- ness and numbness and tingling in her fingertips with decreased range of Her initial vitals include an HR of 100 beats per minute, an RR of 30 breaths per minute, and an oxygen saturation of 100% on room air. The patient denies any other symptoms. Upon physical examination, the patient appears anxious, tachypneic with a clawed appearance to both hands that are difficult to range. An arterial blood gas is drawn that shows a pH of 7.55 with a decreased carbon dioxide level and normal bicarbonate level. Which of the following underlying metabolic disturbances is respon- sible for this patient’s symptoms?
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis