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A 31-year-old woman comes to the office due to vision disturbances. The patient is a software developer and works on a computer most of the time. She first noticed blurry vision 2 months ago. Since then, she has had several episodes of blurry and double vision, especially toward the end of the workday. Two days ago, she experienced neck discomfort and had difficulty holding her head up, which resolved after a night's rest. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. On physical examination, pupils are 3 mm, round, and reactive to light. There is no ptosis, and ocular movements are normal. No neck deformity or tenderness is present. Muscle strength, deep tendon reflexes, and sensation are normal in the bilateral upper and lower extremities. Further evaluation reveals antibodies directed against nicotinic receptors on the motor endplate.

Educational objective: Hemineglect syndrome is characterized by ignoring one side of a space (the left side in right-handed individuals) and involves the nondominant parietal lobe (the right lobe in right-handed individuals).

A 70-year-old man comes to the ·office 4 weeks after experiencing an ischemic stroke. His medical history is significant for a long history of hypertension, diabetes, coronary artery disease, congestive heart failure, and atrial fibrillation. Vital signs are unremarkable. BMI is 23.8 kg/m2. Cardiovascular examination reveals an irregularly irregular rhythm. The patient is right-handed. Only the right side of his face is shaved. When asked to raise his left arm, he raises his right arm. When asked to fill in the numbers of a clock, he puts numbers only on the right side.

Educational objective: Spontaneous cerebellar hemorrhage is typically caused by poorly controlled hypertension and presents with occipital headache, neck stiffness, nauseafvomiting, nystagmus, and ipsilateral hemiataxia. There is usually no hemiparesis or sensory loss. Early diagnosis with noncontrast head CT scan is important as emergency surgical decompression may be life-saving .

A 69-year-old man comes to the emergency department due to severe occipital headache, nausea, and vomiting for the last 3 hours. He has never had a headache like this before and has otherwise been in good physical condition. The patient was told several years ago that he has high blood pressure, but he has not been taking any medications or seen any health care providers. He has smoked half a pack of cigarettes daily for 40 years and drinks 1 or 2 cans of beer every evening. Both of his parents died of natural causes. Blood pressure is 160/90 mm Hg and pulse is 86/min and regular. His noncontrast head CT scan is shown in the image below.

Educational objective: Chronic, excessive noise exposure can lead to sensorineural hearing loss due to the irreversible death of hair cells in the cochlea. Hearing screening proqrams are often mandated in high-risk occupations (eg, manufacturing, transportation).

A 34-year-old man comes to the ·office for evaluation of hearing loss. The patient is a military pilot who has flown the past 8 years in noncombat zones. Regular hearing tests administered by the military have been normal until his most recent one. The patient has noticed no change in his hearing and has no ear pain, tinnitus, or vertigo. The results from the remainder of his annual physical, mental, vision, and cardiac tests were normal. The patient has no medical conditions and takes no medications. Aural examination shows clear, intact tympanic membranes bilaterally with no middle ear effusion. Review of the audiometry reveals a mild, bilateral, high-frequency hearing loss.

Educational objective: Alzheimer disease, the most common type of dementia in the United States, is characterized by early and prominent memory impairment The differential includes dementia with Lewy bodies, frontotemporal dementia, and vascular dementia, as well as nondementing syndromes such as normal pressure hydrocephalus.

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A 76-year-old woman is brought to the office by her daughter due to progressively worsening memory and language difficulties. The patient first started having memory problems and word-findinq difficulties 5 years ago. She then began having difficulty balancing her checkbook and buying groceries. The patient became lost while driving to church last year and no longer drives. She is now dependent on her daughter for cooking and cleaning. Over the past 6 months, the patient's personality has changed from seeming apathetic to becoming more paranoid and agitated; she frequently claims to have seen her niece stealing from her purse. The patient recently developed urinary incontinence. She has a history of hyperlipidemia and osteoarthritis of the left hip and both knees. Blood pressure is 130/80 mm Hg and pulse is 90/min. Deep tendon reflexes are 2+ throughout, and she has preserved motor strength. The patient recalls none of 3 objects on memory testing and cannot draw a clock. Laboratory studies show normal electrolytes, lipid panel, TSH, vitamin 812, and complete blood count

Educational objective: Thrombolytic therapy (eg, intravenous alteplase) improves neurologic outcomes in patients with acute ischemic stroke when given within 4.5 hours of symptom onset. Before thrombolytics are administered, a noncontrast head CT should be performed to rule out hemorrhagic stroke, and the patient should be screened for other contraindications to therapy.

A 62-year-old man is brought to the emergency department due to left-sided weakness, numbness, and difficulty speaking. He was walking his dog about an hour ago and fell after developing sudden-onset weakness of his left upper and lower limbs. The patient did not lose consciousness. He has hypertension and type 2 diabetes mellitus but no other medical or surgical history. The patient's blood pressure is 170/96 mm Hg and pulse is 76/min and regular. On examination, his speech is dysarthric and he has left facial droop. The patient's left upper extremity muscle strength is 215 and left lower extremity strength is 3/5. Left hemisensory loss is present. His finger-stick blood glucose level is 190 mg/dl, and a noncontrast head CT scan reveals no abnormalities. Recent laboratory studies performed at the patient's primary care provider's office show his serum LDL is 152 mg/dl and hemoglobin A 1c is 7.6%.