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Old 07-18-2016
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Default Help pls Neuro CMS Form 3

A 23-*year-*old woman with sickle cell disease is brought to the emergency department after becoming obtunded; she has a 2*day history of cough and fever. Her temperature is 39.3C (102.7F), pulse is 128/min, respirations are 28/min, and blood pressure is 98/60 mm Hg. She appears stuporous. She is intubated and mechanically ventilated. There is moderate nuchal rigidity. Right basilar crackles are heard on auscultation. Hematocrit is 21% with many nucleated erythrocytes, and leukocyte count is 24,000/mm . Which of the following is the most appropriate next step in management?

A) Administration of antibiotics
B) Administration of dopamine
C) CT scan of the head (WRONG)
D) Transfusion of 3 units of packed red blood cells
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A 72*-year-*old man comes to the physician because of a 7*day history of increasingly severe pain around the waist. He says that it feels like a burning belt from the left midback to the umbilicus. He has a history of chronic low back pain. He has type 2 diabetes mellitus treated with glyburide and asthma treated with beclomethasone and albuterol inhalers. He completed a 10-*day course of corticosteroids for asthma 3 weeks ago. Examination shows numbness in the left T12 distribution. The remainder of the examination shows no abnormalities. Which of the following is the most likely explanation for these findings?

A) Ankylosing spondylitis
B) Atherosclerotic vascular disease
C) Diabetic radiculopathy
D) Epidural abscess
E) Low back strain
F) Lumbar radiculopathy
G) Lumbar stenosis
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3. A 72*-year-*old man has had episodes of loss of consciousness for the past 2 years. He says that there are no warning symptoms and that he suddenly finds himself on the ground. He has fractured his arm and has bruised himself many times. Bystanders say that he suddenly becomes pale and sweaty and then slumps to the floor like a rag doll. Jerking or twitching movements of the trunk and extremities occur for several seconds during episodes. He recovers completely and is not confused at the end of the episode. He has had two myocardial infarctions.

A) Cataplexy
B) Complex partial seizure
C) Migraine
D) Panic attack
E) Photomyoclonic seizure
F) Primary generalized seizure
G) Simple partial (motor) seizure with generalization
H) Simple partial (motor) seizure without generalization
I) Simple partial (sensory) seizure with generalization
J) Simple partial (sensory) seizure without generalization
K) Syncope
L) Transient ischemic attack
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Old 07-19-2016
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Quote:
Originally Posted by doc2530 View Post
A 23-*year-*old woman with sickle cell disease is brought to the emergency department after becoming obtunded; she has a 2*day history of cough and fever. Her temperature is 39.3C (102.7F), pulse is 128/min, respirations are 28/min, and blood pressure is 98/60 mm Hg. She appears stuporous. She is intubated and mechanically ventilated. There is moderate nuchal rigidity. Right basilar crackles are heard on auscultation. Hematocrit is 21% with many nucleated erythrocytes, and leukocyte count is 24,000/mm . Which of the following is the most appropriate next step in management?

A) Administration of antibiotics
B) Administration of dopamine
C) CT scan of the head (WRONG)
D) Transfusion of 3 units of packed red blood cells
This is a very difficult question. I believe the patient could be experiencing an acute chest syndrome and may have pneumonia and meningitis. Along with supplementary oxygen and fluid management... the patient would also receive antibiotics and a transfusion. I think they would do a transfusion as early as possible.... however, according to the algorithm below (albeit for children), antibiotics would have already been given by that point.

How I treat acute chest syndrome in children with sickle cell disease



However, according to the following guidelines, I think that the transfusion would come immediately. This makes more sense to me since a transfusion has the potential to quickly improve the patient's status.

Guidelines for the Diagnosis and Management of Acute Chest Syndrome in Adults with
Sickle Cell Disease


At any rate, both are given without undue delay.
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Last edited by Kruno; 07-19-2016 at 04:05 AM.
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Originally Posted by doc2530 View Post
3. A 72*-year-*old man has had episodes of loss of consciousness for the past 2 years. He says that there are no warning symptoms and that he suddenly finds himself on the ground. He has fractured his arm and has bruised himself many times. Bystanders say that he suddenly becomes pale and sweaty and then slumps to the floor like a rag doll. Jerking or twitching movements of the trunk and extremities occur for several seconds during episodes. He recovers completely and is not confused at the end of the episode. He has had two myocardial infarctions.
K) Syncope
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Quote:
Originally Posted by doc2530 View Post
A 72*-year-*old man comes to the physician because of a 7*day history of increasingly severe pain around the waist. He says that it feels like a burning belt from the left midback to the umbilicus. He has a history of chronic low back pain. He has type 2 diabetes mellitus treated with glyburide and asthma treated with beclomethasone and albuterol inhalers. He completed a 10-*day course of corticosteroids for asthma 3 weeks ago. Examination shows numbness in the left T12 distribution. The remainder of the examination shows no abnormalities. Which of the following is the most likely explanation for these findings?
C) Diabetic radiculopathy

Typical location and symptoms of monoradiculopathy due to diabetes.

Management of Diabetic Neuropathy
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4. This is tough, how do you differentiate these

Five days after a left hemicolectomy for colon cancer, a 62*-year*-old man is transferred to the intensive care unit because of temperatures to 40.6C (105F), lethargy, diaphoresis, and labile blood pressure for 3 hours. His postoperative course had been complicated by temperatures to 37.8C (100F) and nocturnal agitation since day 2; he has required haloperidol therapy (2 mg nightly). He has a history of bipolar disorder. Medications include morphine by patient*-controlled analgesia pump, lithium carbonate, and clonazepam. He is lying expressionless in a pool of sweat and is drooling. His temperature is 40.6C (105F), pulse is 140/min, and blood pressure is 180/100 mm Hg. Examination shows wet skin and dry mucosa. There is a herpetic lesion on his lower lip. The neck is supple and the intravenous catheter insertion site is nontender with no erythema. Bowel sounds are hyperactive; there is no organomegaly. The wound is clean and dry with no erythema. Neurologic examination shows a masked facies and a marked intention tremor. Deep tendon reflexes are hyperactive and symmetric. Babinski sign is absent. Laboratory studies show:
Hemoglobin 15 g/dL
Leukocyte count 20,000/mm3
Segmented neutrophils 80%
Bands 5%
Lymphocytes 10%
Monocytes 5%

Serum
Urea nitrogen 38 mg/dL
Creatinine 1.6 mg/dL
Creatine kinase 1000 U/L

Urinalysis and an x*-ray of the chest show no abnormalities. Which of the following is the most likely diagnosis?

A) Antibiotic-*related fever
B) Herpes encephalitis
C) Lithium toxicity
D) Malignant hyperthermia
E) Neuroleptic malignant syndrome
F) Postoperative sepsis
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E) Neuroleptic malignant syndrome

History

Medications that could cause nms
  • haloperidol
  • clonazepam
  • lithium --> especially concomitant use with other neuroleptics

symptoms consistent with nms
  • fever
  • lethargy
  • diaphoresis
  • expressionless (possible extrapyramidal side effect)
  • sweating
  • agitation

physical exam

findings consistent with nms
  • temperature is 40.6C
  • blood pressure is 180/100 mm Hg
  • wet skin
  • masked facies
  • intention tremor
  • Deep tendon reflexes are hyperactive and symmetric

laboratory
findings consistent with nms
  • Leukocyte count 20,000/mm3
  • Segmented neutrophils 80%
  • Creatine kinase 1000 U/L --> due to muscle rigidity
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Default help

I cannot distinguish the correct answer on this either

5. A 47*-year*-old woman comes to the physician because of a 6*month history of gradual hearing loss in the left ear. She also has had difficulty maintaining her balance over the past 3 months. Six months ago, she had an episode of nephrolithiasis complicated by a severe urinary tract infection requiring intravenous antibiotic therapy. Examination shows a decrease of the left nasolabial fold and a slight perioral droop when she smiles. The forehead movements are intact bilaterally. Her gait is normal, but she has difficulty with tandem walking. Audiometry shows moderate high*-frequency hearing loss on the left with impaired speech discrimination. Which of the following is the most likely diagnosis?

A) Acoustic neuroma (vestibular schwannoma)
B) Aminoglycoside ototoxicity
C) Brain stem infarction (WRONG)
D) Mastoiditis
E) Meniere disease
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Default last one

6. Over the past year, a 72*-year-*old man has had progressive aching in his lower extremities when he walks in the shopping mall. Initially, the pain began after 15 minutes of walking and resolved after he stopped; now, it starts after 5 or 10 minutes of walking, and it occasionally occurs when he stands up after sleeping all night. The pain radiates from his buttocks to his feet. He describes it as a "terrible" pain. He has mild chronic obstructive pulmonary disease but continues to smoke one pack of cigarettes daily. He has cervical arthritis and often has neck and arm pain. Examination shows decreased breath sounds bilaterally. Strength and sensation are normal in the extremities. Babinski's sign is absent bilaterally. Deep tendon reflexes are 1+ in both knees and ankles and 2+ in the upper extremities. Dorsalis pedis pulses are normal. Which of the following is the most likely diagnosis?

A) Alcoholic rhabdomyolysis
B) Amyotrophic lateral sclerosis
C) Becker muscular dystrophy
D) Botulism
E) Carcinomatous meningitis
F) Cervical spondylosis
G) Epidural metastatic carcinoma
H) Epstein*-Barr virus infection
I) Guillain-*Barré syndrome
J) Hypokalemic periodic
K) Hypothyroid myopathy
L) Lumbar spinal stenosis
M) Multiple sclerosis
N) Myasthenia gravis (WRONG)
O) Polymyositis
P) Sensorimotor peripheral neuropathy
Q) Spinal cord compression
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I think Answer is Lumbar Spinal Stenosis, but can anyone please tell me why in Lumbar Spinal stenosis Babinski's sign is absent bilaterally. Deep tendon reflexes are 1+ in both knees and ankles. I was expecting Positive Babinski and hyperreflexia due to compression of lumbar spine
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