A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on the
windshield. He complains of neck pain and severe burning in his shoulders and arms. His physical
examination reveals weakness of his upper extremities. What type of spinal cord injurydoes this
patient have?
A anterior cord syndrome
B central cord syndrome
C Brown-Séquard syndrome
D complete cord transection
E cauda equina syndrome
ANS: B Central Cord Syndrome
the central cord syndrome involves loss of motor function that is more severe in the upper
extremities than in the lower extremities, and is more severe in the hands. There is typically
hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or
quadriplegia, loss of lateral spinothalamic function with preservation of posterior column
function. Brown-Séquard syndrome consists of weakness and loss of posterior column function
on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic
function one to two levels below the lesion. Complete cord transection would affect motor and
sensory function distal to the lesion. Cauda equina syndrome typically presents as low back pain
with radiculopathy.
A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his house.
The right side of his head hit the alley cement, and he lost consciousness for about 1 minute; he
woke up with a headache, but he had no other complaints. A few hours later, the patient is
brought to the emergency room by his neighbor because of an intense headache, confusion, and
left hand hemiparesis. On examination, the patient has a bruise located over the right temporal
region, mydriasis, and right deviation of the right eye, papilledema, and left extensor plantar
response. An emergency CT scan of the head without contrast reveals a lens-shaped hyper-
density under the right temporal bone with mass effect and edema. What is the most likely
diagnosis?
Answer Choices
1 Epidural hematoma
2 Subdural hematoma
3 Subarachnoid hemorrhage
4 Intracerebral parenchymal hemorrhage
5 Acute meningitis
ANS: 1 Epidural Hematoma
Epidural hematoma most often results from a traumatic tear of the middle meningeal artery.
Although a lucid interval ranging from minutes to hours followed by altered mental status and
focal deficits is typical for epidural hematoma, this clinical picture is only encountered in up to
1/3 of the patients. The collection of blood between the skull and dura mater causes an evident
mass effect with ophthalmic nerve palsy and the contralateral hemiparesis. Surgical evacuation
of the clot via burr holes is the treatment of choice.
Subdural hematoma results from a traumatic rupture of the bridging veins that connect the
,cerebrum to the venous sinuses within the dura. This venous hemorrhage will result in a gradual
,increase of the hematoma, with a progressive clinical picture over days or weeks. The CT scan
will show a concave, crescent-shaped hyper-density compared to the convex, lens-shaped hyper-
density in epidural hematoma.
Subarachnoid hemorrhage is the result of an aneurysm rupture; the most common is the
congenital berry aneurysm. The clinical picture is of a sudden, severe headache with meningeal
irritation. A CT scan will show blood in the subarachnoid space, and a lumbar puncture will
reveal xanthochromia CSF.
Intracerebral parenchymal hemorrhage is most likely caused by hypertension complicated with
Charcot-Bouchard aneurysms. The blood accumulates into the brain substance and most
commonly involves the basal ganglia.
Acute meningitis is not associated with trauma. Fever and signs of meningeal irritation dominate
the clinical picture. Lumbar puncture, indicated if there are no focal neurological signs on
clinical examination, will be the diagnostic procedure. The CT scan of the patient presented in
this case is characteristic for epidural hematoma, and there is no indication for a lumbar
puncture.
A 31-year-old woman presents with a purpural rash covering her arms, legs, and abdomen. She
also has fever, chills, nausea, abdominal tenderness, tachycardia, and generalized myalgias. Prior
to the development of the rash, the patient noted that she had a headache, cough, and sore throat.
Laboratory studies were positive for Gram-negative diplococci in the blood, along with
thrombocytopenia and an elevation in PMNs. Urinalysis showed blood, protein, and casts. Vital
signs are as follows: PB 92/66, P 96, RR 14, T 39. The patient denies any foreign travel and does
not have any sick contacts. However, she does work part time as a nurse in a local hospital.
Question
The patient is diagnosed with Meningococcemia; she is admitted to the hospital and placed in
respiratory isolation. What major course of therapy should this patient receive?
Answer Choices
1 Steroids
2 Supportive care
3 Antibiotics
4 Transfusion
5 Bactericidal/permeability-increasing protein
ANS:3 Antibiotics
Antibiotics are the treatment of choice for meningococcemia. The preferred drug for active
infection is penicillin G. For those allergic to penicillin, chloramphenicol and cephalosporins (ie,
cefotaxime, cefuroxime) may be used as alternatives.
Patients will also receive supportive care, but antibiotic therapy must be initiated quickly if the
patient is to survive. Intensive care placement may be necessary if organ failure is imminent.
Ventilatory support, inotropic support, and IV fluids are necessary in some. If adrenal
insufficiency occurs, corticosteroid replacement may be considered. A central venous line helps
, to provide large amounts of volume expanders and inotropic medications for adequate tissue
perfusion.
Steroids have not been shown to play a major role in the treatment of meningococcemia.
However, they have been used in addition to antibiotic therapy. In the case of adrenal
insufficiency, for example, steroid replacement has been shown to be beneficial.
Transfusion does not generally play a major role in treatment. If the patient suffers from a
devastating coagulopathy, blood or blood products may be replaced as necessary.
Bactericidal/permeability-increasing protein is a protein stored in the granules of neutrophils. It
binds to endotoxin in vitro and neutralizes it. This technique is experimental, and it is not used in
everyday treatment of meningococcemia.
In myasthenia gravis, weakness is a result of insufficient acetylcholine transmission at the
neuromuscular junction; however, weakness can also occur with overdosing of the cholinergic
medications used to treat myasthenia. What symptom helps differentiate a myasthenic crisis from
a cholinergic crisis?
ANS: 3 Muscle Fasiculations
Signs of cholinergic overdosage include muscle fasciculation, rhinorrhea, lacrimation, salivation,
increased bronchial secretions, nausea, or diarrhea. The presence of any of these suggests that the
patient's weakness may be due to cholinergic crisis. The other signs are due to weakness and can
occur in either condition.
A 54-year-old man presents after having a generalized seizure. The patient is HIV positive, but
he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than
cachexia, the physical exam is unremarkable. Upon further inquiry, the patient also notes that he
has become short-tempered and hypercritical; at times, he seems confused. An MRI of the brain
is performed, and it reveals several cortical ring-enhancing lesions.
Question
What is the most likely diagnosis?
Answer Choices
1 AIDS dementia complex
2 Cryptococcal meningitis
3 Cytomegalovirus encephalitis
4 Progressive multifocal leukoencephalopathy
5 Toxoplasma encephalitis
ANS:5 Toxoplasma encephalitis
The patient's symptoms and MRI findings are most consistent with the diagnosis of toxoplasma
encephalitis. Toxoplasmosis is the most common cerebral mass lesion among HIV-positive
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