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A 64-year-old man comes to the ·office because he has had 2 falls within the last month. He states that he loses his balance when he tries to turn or stop suddenly while walking. Recently, it has been taking him quite a while to get himself out of bed. He also has hand tremors that started last year in his left hand, but that now have been affecting both hands.

Educational objective: Amyotrophic lateral sclerosis (ALS) is characterized by the presence of both upper (eg, spasticity, hyperreftexia) and lower (eg, fasciculations, atrophy) motor neuron lesions.

A 45-year-old man comes to the ·office for the evaluation of excessive wasting of his extremity muscles, which is more apparent on the extensor side. The weakness began distally and asymmetrically. He recently started to have difficulties with swallowinq, chewing, and speaking. He feels some movements in his face and tongue. He also has muscle stiffness. His bowel, bladder, cognitive, and sensory functions are intact. The physical examination reveals excessive wasting of his muscles, which is more prominent in the lower extremities. Fasciculations and hyperreflexia are noted. His bulbar reflexes are decreased.

Educational objective: Late neurosyphilis can manifest years after untreated Treponema pal/idum infection with tabes dorsalis (sensory ataxia, lancinating pains, reduced/absent deep tendon reflexes) and Argyll Robertson pupils (normal pupillary constriction with accommodation but not with light). Intravenous penicillin is the treatment of choice.

A 56-year-old previously healthy man comes to the office with progressive difficulty walking due to imbalance for the past 3 months. On several occasions, the patient has lost balance and almost fallen while taking a shower. He also reports episodes of transient, sharp, stabbing pain in his back and lower limbs, as well as involuntary dribbling of urine. He has no history of back injury. The patient has smoked half a pack of cigarettes daily for 30 years and drinks 1 or 2 glasses of wine per day. Physical examination shows that bilateral knee and ankle reflexes are 1 +and vibratory and position sensation is impaired in both feet His gait is broad based. Bilateral pupils are small, irregular, and constrict poorly to light but constrict normally when he is instructed to look at a finger placed near the tip of his nose.

Educational objective: Recent studies have suggested that a brain that has seized for >5 minutes (status epilepticus) is at increased risk of developing permanent injury due to excitatory cytotoxicity. Cortical laminar necrosis is the hallmark of prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures.

A 21-year-old man with a prior history of seizures is brought to the emergency department by ambulance during a tonic-clonic seizure. His mother, who accompanied him, found him on the floor seizing. She says that he has not been compliant with his medications. The patient received intravenous lorazepam, thiamine, and glucose en route but continued seizing.In the emergency department, he is unresponsive and cyanotic. His blood pressure is 96/54 mm Hg and his pulse is 152fmin and regular. His pupils are mid-size and reactive to light Clonic jerks of all extremities are observed.

Educational objective: Management options for acute pain (including opioids) will be similar for all patients regardless of substance use history, although those with a history of opioid addiction who are given opioid analgesics may need close follow-up care to avoid relapse.

A 40-year-old man is brought to the emergency department after a motor vehicle collision. He was the restrained driver when his car was hit on the side by a truck. He did not injure his head or lose consciousness but had severe left leg pain with intensity rated at 10 out of 10. The patient has a history of injection heroin use but has not used any illicit drugs since completing a methadone rehabilitation proqram 2 years ago. Temperature is 37.1 C (98.8 F), blood pressure is 147/86 mm Hg, pulse is 114/min, and respirations are 18/min. There is an open fracture of the left leg with some external bleeding but no other injuries. Wound debridement and external fixation of the fracture are planned. The patient is given a dose of intravenous ketorolac. One hour later, his pain is persistent.

Educational objective: Wernicke encephalopathy is due to thiamine (vitamin B1) deficiency and is most commonly seen in malnourished patients with underlying alcoholism. Features include encephalopathy, ocular dysfunction, and gait ataxia. Patients should be treated empirically with thiamine prior to or along with glucose administration.

A middle-aged woman is found wandering the streets with an abnormal gait She is brought to the hospital by police officers. When asked for identification, the patient mumbles incoherently. She is not oriented to time or place. Her temperature is 36.2 C (97.3 F), blood pressure is 160/100 mm Hg, pulse is 100/min, and respirations are 18/min. Btvll is 17 kg/m2• Head and neck examination shows bitemporal wasting and dry mucous membranes. The pupils are 3 mm bilaterally and react slowly to light Her neck is supple, and she moves all extremities equally. Deeptendon reflexes are symmetrical bilaterally.

Educational objective: Dominant frontal lobe lesions can cause expressive (Broca's) aphasia, contralateral hemiparesis due to involvement of the primary motor cortex, and contralateral apraxia due to involvement of the supplementary motor cortex .

A 56-year-old right-handed man comes to the physician with right-sided weakness and speech difficulty. He speaks in short sentences with considerable effort He fully follows written and verbal commands but has difficulty writinq and repeating.