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A 38-year-old man is brought to the emergency department due to confusion and double vision. His family reports that the patient did not feel well for the past several days due to headaches, nausea, and vomiting. Yesterday, he became progressively confused and experienced double vision. He has a history of HIV and does not take antiretroviral therapy consistently. Temperature is 38.2 C (100.7 F), blood pressure is 122/80 mm Hg, and pulse is 90/min. On physical examination, the patient appears lethargic and disoriented. Pupils are equal and reactive, but the left eye does not move laterally with leftward gaze. The rest of the neurologic examination is unremarkable. Skin examination shows scattered, small, umbilicated papules with surrounding erytherna. CT scan of the head reveals mildly enlarged ventricles but no hemorrhage, infarction, or mass lesions.

Educational objective: The upper face receives input from bilateral motor cortices. Lesions in the central nervous system typically cause unilateral lower facial weakness that spares the forehead whereas peripheral lesions (eg, Bell palsy) cause weakness that affects the entire side of the face. Bell palsy may also result in decreased eye lacrimation, hyperacusis, and reduced taste sensation over the anterior tongue.

A 68-year-old woman comes to the emergency department for evaluation of stroke-like symptoms. The patient says her face appeared "twisted" this morning but was normal when she went to bed last night Her brother recently had a stroke, and the patient was worried that she may also be having a stroke. The patient has a history of hypertension, hypertipidemia, and type 2 diabetes mellitus. Vital signs are within normal limits. Physical examination shows facial asymmetry with drooping of the left corner of the mouth and loss of the left nasolabial fold.

Educational objective: lvlyasthenic crisis is a life-threatening complication of myasthenia gravis that is characterized by severe respiratory muscle weakness leading to respiratory failure. Symptoms are often preceded by increasing generalized or bulbar muscle weakness. The condition may be precipitated by infection, surgery, and certain medications (eg, fluoroquinolones).

A 34-year-old woman is brought to the emergency department due to a 2-day history of progressive dyspnea and drowsiness. According to her husband, she had difficulty swallowing food and almost choked while having dinner yesterday. One week ago, she was treated with ciprofloxacin for a urinary tract infection. The patient volunteers in a local library and for the past several months has had to reduce her work hours due to difficulty lifting books and placing them on shelves. She drinks alcohol socially and does not smoke. Her blood pressure is 142/90 mm Hg, pulse is 92/min, and respirations are 20/min and shallow. Pulse oximetry shows 93o/o on room air. The patient's BMI is 32 kgfm2. Her speech sounds nasal. Physical examination demonstrates clear lung fields with the use of accessory muscles of respiration and paradoxical abdominal wall motion with inspiration. Heart sounds are normal without a murmur. Muscle strength is bilaterally decreased with normal deep tendon reflexes . Babinski reflex is absent bilaterally. Arterial blood gas shows pH 7.2, pC02 65 mm Hg, and p02 90 mm Hg.

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Educational objective: Medication overuse headache is characterized by chronic, near-daily headache in the setting of regular use of acute headache medications in patients with a preexisting headache disorder. Common features include headache that is present upon awakening and brief symptom relief followed by rebound pain. Management involves cessation of the culprit medication.

A 36-year-old woman comes to the office due to headaches. Over the past 3 months the patient has had constant, bilateral headaches almost every day shortly after awakening. She has had intermittent episodes of migraines since adolescence, but her current headaches are more frequent though milder. The patient has been taking over-the-counter analgesics several times a day. She has had no focal weakness, numbness, or vision changes. The patient has no other medical conditions and does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. BMI is 24 kg/m2. Physical examination, including funduscopy and neurological examination, shows no abnormalities. Blood cell counts and serum chemistry studies are within normal limits.

Educational objective: Mild to moderate cancer-related pain can usually be managed with nonopioid analgesics. However, if initial interventions are not effective, intermittent doses of short-acting opioids should be offered. If the pain requires frequent dosing or if bedtime dosing does not provide relief through the night, a long-acting opioid may be added.

A 71-year-old man comes to the ·office due to worsening low back pain. The patient is having significant pain with movement that is limiting his activity, as well as nocturnal pain that is disrupting his sleep. He has had no lower extremity weakness or numbness and no bladder or bowel dysfunction. He is taking ibuprofen 3-4 times a day, and it is not controlling his pain. The patient has a history of prostate cancer and takes leuprolide. He also received palliative radiotherapy for multiple lumbar spine metastases several months ago. Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min. Lower extremity motor strength, deep tendon reflexes, and sensation are normal.

Educational objective: Chemotherapy-induced peripheral neuropathy typically presents as a symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern. Common causative agents include platinum-based medications (eg, cisplatin}, taxanes (eg, paclitaxel), and Vinca alkaloids (eg, vincristine }.

A 58-year-old woman comes to the physician due to difficulty walking. Over the last several weeks she has also experienced bilateral foot numbness and tingling. She was diagnosed with advanced Hodgkin lymphoma 2 months ago and is currently undergoing chemotherapy containing bleomycin, doxorubicin, and vincristine. Her other medical problems include type 2 diabetes and hypertension. Physical examination shows bilateral weakness on dorsiflexion of the feet and loss of pain and temperature sensation affecting both toes. Knee jerk reflexes are 2+ bilaterally but ankle jerk reflexes are absent

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