Uworld | Step 2ck

2022-08-28 08:11:01 A 64-year-old woman is brought to the emergency department due to sudden-onset headache associated with nausea, vomiting, and a sensation that the "room is spinning." The patient first noticed the symptoms yesterday when she awoke, and they have not improved. She has had no ear pain, hearing loss, fever, or chills. She was recently prescribed hydrochlorothiazide and lisinopril for hypertension. Medical history also includes type 2 diabetes mellitus and hyperlipidemia. The patient does not use tobacco or alcohol. Blood pressure is 124/76 mm Hg and pulse is 86/min. Neurologic examination with the patient lying still shows pure rotatory nystagmus but no extremity weakness or sensory loss. Walking causes worsening of symptoms, and the patient falls toward the left side. Finger-stick glucose is 145 mg/dl. Complete blood count and serum electrolytes are within normal limits. Open / Comment

2022-08-27 21:11:01 Educational objective: Syringomyelia is a disorder in which a fluid-filled cavity forms within the spinal cord (usually within the cervical and/or thoracic spine). Patients typically have dissociated sensory loss (ie, loss of pain/temperature sensation but not vibratory/proprioceptive sensation), often in a "cape" distribution, and may develop weakness that disproportionately affects the upper extremities. Open / Comment

2022-08-27 08:11:02 Open / Comment

2022-08-27 08:10:17 A 33-year-old woman comes to the office due to sensory loss in both upper extremities. She recently burned both of her hands while cooking but did not feel any pain. The patient has no history of trauma, headache, or neck pain. She also has no lower extremity weakness or abnormalities of bowel or bladder function. Examination shows diminished strength in the upper limbs. There is loss of pain and temperature sensation on the posterior neck, both shoulders, and both upper extremities. Vibratory and proprioceptive sensation are preserved. Open / Comment

2022-08-26 21:10:41 Educational objective: Essential tremor is an action tremor that tends to worsen at the end of goal-oriented actions (eg, drinking from a cup). Manifestations usually arise in bilateral hands and forearms; the head is also commonly involved. Beta blockers such as propranolol are typically the first-line therapy. Open / Comment

2022-08-26 08:09:01 Open / Comment

2022-08-26 08:08:01 A 62-year-old man comes to the office due to tremors. The patient first noticed them several years ago, but they have progressively worsened and now cause difficulty with daily activities such as drinking tea and buttoning clothing. His wife reports that he also has a mild head tremor. His father had similar symptoms, which worsened as he advanced in age. The patient has a history of osteoarthritis, hypertension, and gastroesophageal reflux disease. He does not drink alcohol. Blood pressure is 144/80 mm Hg and pulse is 82/min. Physical examination shows a mild tremor of the head and a tremor of the bilateral upper extremities when the arms are extended. The tremor worsens during finger-to-nose testing. Muscle tone, deep tendon reflexes, limb coordination, and gait are normal. Open / Comment

2022-08-20 21:31:03 Educational objective: When multiple sclerosis is suspected but clinical examination or MRI is not classic, a lumbar puncture should be performed for cerebrospinal fluid analysis; this analysis shows oligoclonal bands in 85%-95% of patients. Opening pressure, protein, and cell count are generally normal. Open / Comment

2022-08-20 08:31:03 Open / Comment

2022-08-20 08:30:38 A 29-year-old man comes to the emergency department due to a week of progressive bilateral lower extremity weakness. He has no history of trauma or back pain. The patient had trigeminal neuralgia 3 months ago and a self-limited upper respiratory illness 2 weeks ago. His temperature is 37 C (98.6 F), blood pressure is 122176 mm Hg, and pulse is 82/min. Physical examination shows increased resistance to passive flexion and extension of the lower limbs. Deep tendon reflexes are 3+ and plantar reflexes are upgoing bilaterally. There is decreased vibratory and positional sensation in his left upper extremity but no other sensory loss. A lumbar puncture is performed. Open / Comment