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A 23-year-old man comes to the physician complaining of worsening headache over the past week. He is "under a lot of stress at school" and having trouble sleeping because the headache is constant Two weeks ago, he had an insect bite on his right cheek and now both of his eyes are swollen. He also has lost his appetite and vomited twice today. His temperature is 38.3° C (101° F), blood pressure is 130/90 mm Hg, pulse is 104/min, and respirations are 20/min. Examination shows erythema and swelling of the right cheek and bilateral eyelid edema, right greater than left Bilateral extraocular movements are restricted. The bilateral forehead and mid-face are extremely tender to light palpation.

Educational objective: Patients with advanced AIDS are at increased risk for malignancy. Primary CNS lymphoma is an AIDS-defining malignancy associated with the expression of Epstein-Barr virus oncogenes, which can often be identified in the cerebrospinal fluid. MRI of the brain generally shows a solitary, irregular, nonhomogenous ring-enhancing mass.

A 25-year-old man is brought to the emergency department due to a generalized tonic-clonic seizure. According to his roommate, the patient has had worsening confusion and lethargy for the last 2 weeks. Today, he had a seizure lasting approximately 3 minutes. The patient has a history of HIV and is not adherent with antiretroviral therapy or other HIV-related medications. He is an active injection drug user. Temperature is 37.7 C (99.9 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 16/min. On physical examination, the patient is somnolent but arousable. There is no focal extremity weakness or sensory loss. CD4 count is 26/mm3 and viral load is 86,000 copies/ml. MRI of the brain with contrast shows a solitary, irregular, nonhomogenous ring-enhancing lesion in the periventricular area. Cerebrospinal fluid PCR is positive for Epstein-Barr virus DNA.

Educational objective: Aspirin is the only antiplatelet agent that is effective in reducing the risk of early recurrence of ischemic stroke. It should be given within 24 hours to all patients presenting with ischemic stroke. Aspirin plus dipyridamole OR clopidogrel is recommended for patients who have recurrent stroke on aspirin therapy.

A 62-year-old man comes to the emergency department for evaluation of weakness. Six hours ago, he had weakness in his right arm and leg that resolved within 30 minutes. He has never had similar symptoms before and has no chest pain, palpitations, shortness of breath, dizziness, or syncope. The patient's past medical history is significant for hypertension, hyperlipidemia, and osteoarthritis. He takes no medications. He has a 25-pack-year smoking history but quit 5 years ago. Family history is significant for hypertension and type 2 diabetes mellitus. His blood pressure is 145/76 mm Hg and pulse is 69/min and regular. There are no carotid bruits. An S4 is heard on cardiac auscultation. Neurologic examination shows mild right-sided pronator drift Electrocardiogram shows sinus rhythm with increased voltage and T-wave inversion in leads I and V6. Computed tomography of the brain without contrast shows no abnormalities, and magnetic resonance imaging is pending.

Educational objective: Pronator drift is a relatively sensitive and specific sign for upper motor neuron or pyramidal tract disease affecting the upper extremities. performed by having the patient outstretch the arms with the palms up and eyes closed. downward and the palm turns (pronates) toward the floor.

A 36-year-old woman is evaluated in the clinic due to left hand clumsiness. The patient works as an office secretary and has been having difficulty typing. Six months ago, she had an episode of vertigo and difficulty walking that improved after several weeks. The patient also has a history of bipolar disorder and takes valproic acid. On physical examination, she is asked to close her eyes and stretch out her arms with the palms facing up. Several seconds later, her left arm involuntarily drifts downward and the palm turns toward the floor.

Educational objective: Dementia with Lewy bodies is characterized by fluctuating cognitive impairment, recurrent visual hallucinations, and parkinsonism.

A 66-year-old woman is brought to the emergency department by her concerned son due to increasing confusion, loss of mobility, and behavioral changes. The patient tends to cry out for no apparent reason and recently exclaimed that "a lion was sleeping in the backyard." She often sees cats in her room when none are present. She has memory loss and frequently gets lost in her neighborhood. The patient is a nonsmoker and does not use alcohol or illicit drugs. She has no significant psychiatric history. She appears alert but disoriented and quite agitated. She is afebrile; blood pressure is 136172 mrn Hg, pulse is 98/min, and respirations are 16/min. Physical examination shows increased muscle tone, normal reflexes, and coarse resting tremors in the extremities. Complete blood count, electrolytes, creatinine, glucose, liver function tests, TSH, and 812 levels are within normal range. Rapid plasma reagin is negative, and fluorescent treponemal antibody absorption is nonreactive. When the patient becomes combative, she is given a small dose of risperidone, which only aggravates her stiffness.

Educational objective: Parkinson disease (PD) should be suspected in patients with a resting tremor of 5-7 Hz that is asymmetric and associated with rigidity. Tremor is often the presenting symptom of PD. Trihexyphenidyls an anticholinergic medication sometimes used in the treatment of PD, generally inyounger patients where tremor is the primary symptom.