A 32-year-old man comes to the office due to right-sided facial weakness for 3 days.  He has had no fever, headache, vision disturbances, or extremity weakness or numbness but has been extremely fatigued over the past several months.  The patient has no prior medical conditions and takes no medications.  He drinks alcohol occasionally and does not use tobacco or illicit drugs.  The patient lives in coastal California and has not traveled recently.  Vital signs are within normal limits.  Physical examination reveals right-sided facial droop with flattening of the nasolabial fold.  He is unable to elevate the right eyebrow or close the right eye completely.  Upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal on both sides.  There is no neck rigidity.  The lungs are clear on auscultation, and heart sounds are normal.  Hepatosplenomegaly is present.  The cervical, axillary, and inguinal lymph nodes are multiple, firm, and nontender.  No skin rash or extremity edema is present.  The joints are not swollen or tender.

Item 1 of 2
Which of the following is the best initial test for this patient?

Item 2 of 2
A week later, the patient returns to the office for follow-up.  His facial weakness is improving with oral glucocorticoids, and he has had no new symptoms.  Laboratory results from the previous visit are as follows:

Chest x-ray reveals bilateral hilar adenopathy and interstitial infiltrates.  Which of the following is most appropriate to confirm the diagnosis?

A 77-year-old woman is brought to the office by her son due to frequent falls and confusion.  The patient began to fall without clear provocation 2 years ago.  Her family didn’t think anything of the falls until she began having episodes of confusion a year ago.  The patient’s son says, “She has good and bad days.  On good days she seems almost like her old self, but on bad days she appears confused and is difficult to understand.”  He adds that she sometimes appears to be distracted and agitated by people or things that he cannot see.  The patient’s medical history includes hypertension and coronary artery disease; her mother died of a stroke and her father had several heart attacks.  Temperature is 37.2 C (98.9 F), blood pressure is 140/86 mm Hg, pulse is 84/min, and respirations are 16/min.  Her movements and speech are slow, she has a short-stepped gait and rigidity in her upper extremities.  Montreal Cognitive Assessment is 20 on a scale of 0-30 (normal: ≥26).

Item 1 of 2

Which of the following is the most likely diagnosis?

Item 2 of 2

The patient is prescribed donepezil, carbidopa levodopa, and risperidone.  Two weeks after the initial office visit, she is brought to the emergency department by her son due to increasing confusion and falls.  Supine blood pressure and pulse are 124/82 mm Hg and 65/min, respectively; standing blood pressure and pulse are 98/74 mm Hg and 87/min.  The patient is not oriented to person, place, or time.  Examination shows cranial nerves are within normal limits.  Rigidity is present in both upper and lower extremities on passive movement.  Upper and lower limb deep tendon reflexes are 2+.  Which of the following is the most likely explanation for this patient’s symptoms?

A 62-year-old woman collapses at home after a period of shortness of breath and foaming at the mouth.  She has no respirations or pulse when the emergency response team arrives 30 minutes later.  ECG shows asystole.  Cardiopulmonary resuscitation with advanced cardiac life support is initiated.  The patient is intubated and given epinephrine with restoration of a pulse.  She is transferred to the emergency department in a comatose state.  ECG shows Q waves in the inferior leads, first-degree atrioventricular block, and a right bundle branch block.  Initial laboratory results are as follows:

The patient is admitted to the intensive care unit.  She remains comatose 48 hours later.  Her blood pressure is 108/60 mm Hg, and core temperature is 36.7 C (98 F).  There is no motor response to firm supraorbital pressure.  Her pupils are fixed and dilated at 8 mm.  Corneal reflexes are absent.  Caloric testing produces no conjugate eye deviation.  Deep tracheal suctioning produces no cough reflex.  A brain CT scan demonstrates loss of the gray/white junction, loss of sulci, and obliterated ventricles.  Which of the following is the most appropriate next step in management of this patient?

A 70-year-old Caucasian male presents to clinic complaining of “some very disturbing whirling attacks.”  He says that on three occasions in this past week, he suddenly began to feel dizzy, nauseated, and found himself unable to walk or speak properly.  During these episodes he also noticed a tingling sensation in his lips and that he had double vision.  The symptoms resolved gradually after lasting approximately eight to ten minutes.  The episodes happened at different times of day, both while at rest and during activity.  His medical history is significant for diabetes mellitus, chronic obstructive pulmonary disease, hypertension, hypercholesterolemia, and a remote myocardial infarction.  His current medications include metformin, enalapril, hydrochlorothiazide, simvastatin, albuterol, and aspirin.  He has a fifty-pack-year smoking history and drinks 1-2 beers per night.  He denies having ever used recreational drugs.  His temperature is 36.7C (98F), blood pressure is 142/88 mm Hg, pulse is 82/min, and respirations are 14/min.  Funduscopic examination shows some neovascularization of the retinal surfaces.  Tympanic membranes are translucent and the light reflex is present.  Heart sounds are normal.  Auscultation of the chest reveals wheezing and diffusely decreased breath sounds.  He is barrel-chested.  Abdomen is nontender and bowel sounds are present.  Mild peripheral edema is evident.  There is a loss of vibratory sensation and altered proprioception and impairment of pain, light touch, and temperature in a bilateral stocking-glove distribution.  Ankle reflexes are decreased.  His most recent laboratory evaluation included the following:

What is the most likely diagnosis?

A 65-year-old man comes to the emergency department due to severe headache localized to the left frontal temporal region that began 4 hours ago.  At the onset of the headache, he also had transient vision impairment in the left eye, which has now resolved.  The patient has never had similar symptoms previously.  Medications are acetaminophen for arthritis and metformin for recently diagnosed type 2 diabetes mellitus.  He lives in rural Connecticut, smokes a pack of cigarettes per day, and does not use alcohol or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 152/96 mm Hg, and pulse is 89/min.  Pulse oximetry shows 99% on room air.  Physical examination findings are shown in the exhibit.

Laboratory studies are as follows:

A noncontrast CT scan of the head shows no intracranial hemorrhage or mass lesion.  Which of the following is the most appropriate next step in management of this patient?

A 54-year-old homeless man is brought to the emergency department by the police after he was found to be confused and disheveled.  The patient is unable to provide a medical history and has no prior hospital record.  Temperature is 36.5 C (97.7 F), blood pressure is 110/60 mm Hg, pulse is 90/min, and respirations are 16/min.  The patient is thin and appears ill, with temporal muscle wasting.  The mucous membranes are dry.  The lungs are clear to auscultation, and heart sounds are normal with no murmur.  The abdomen is soft, nontender, and nondistended.  The patient is disoriented and unable to recognize where he is or state the date.  Bilateral pupils are equal and reactive to light, but extraocular motion is restricted on leftward gaze.  No obvious motor weakness is present.  Deep tendon reflexes are reduced and plantar responses are flexor.  The patient has no neck rigidity, but his gait is markedly ataxic.  Laboratory results are as follows:

Item 1 of 2

Which of the following is the best next step in management of this patient’s confusion?

Item 2 of 2

With treatment, the patient’s gait abnormalities and eye movement gradually improve.  He becomes more oriented, but the nurses report that he is forgetful and tells incongruent stories that seem to have never happened.  Neuroimaging is most likely to reveal abnormalities in which of the following areas of this patient’s brain?

A 65-year-old man comes to the office for a follow-up visit.  His friend recently died from a massive cerebrovascular event.  The patient is worried about his individual risk for stroke.  Medical conditions include hypertension, type 2 diabetes mellitus, hypercholesterolemia, and obesity.  He is an active smoker with a 40-pack-year history.  The patient does not use alcohol or illicit drugs.  Family history is not contributory.  Medications include low-dose (81-mg) aspirin, metformin, lisinopril, and atorvastatin.  Blood pressure is 161/92 mm Hg.  BMI is 30 kg/m².  Examination shows no abnormalities.  Laboratory results are as follows:

Which of the following would provide the greatest benefit for decreasing this patient’s risk for an ischemic stroke?