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An 18-year-old woman comes to the clinic due to persistent headaches, which have occurred daily for 3 months. The headaches are holocranial, pulsating, and especially bothersome at night Ibuprofen has not helped the pain. The patient has double vision when looking sideways and blurry vision in both eyes. She has no history of head trauma prior to the onset of symptoms and no fever, vomiting, photophobia, or weakness. The patient has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs. Her mother and sister have migraine headaches. Temperature is 37 C (98.6 F), blood pressure is 130/85 mm Hg, and pulse is 90/min. BMI is 34 kg/m2. Physical examination shows no nuchal rigidity or sinus tenderness. Eye examination reveals optic disc edema and left lateral rectus palsy. CT scan of the head without contrast is normal.

Educational objective: Trigeminal neuralgia is characterized by recurrent severe pain usually along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve (CN V), often triggered by minor stimuli. This condition is usually treated with carbamazepine.

A 52-year-old woman comes to the office due to a week of intermittent pain on the right side of the face. It is intense, sharp pain on the right cheek and lips that lasts several seconds and recurs several times a day. The patient is afraid to brush her teeth or to drink cold water as both trigger the pain. She has a history of hypertension, type 2 diabetes mellitus, and seasonal allergies. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 136/84 mm Hg, and pulse is 80/min. No rash or tenderness is present on palpation of the face. Neurologic examination demonstrates normal facial sensation and muscle strength. Cardiopulmonary examination reveals normal lung and heart sounds.

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Educational objective: Myoclonus is characterized by sudden, involuntary muscle contraction or relaxation that results in movement of limbs or joints. Posthypoxic myoclonus is often seen after cardiac arrest; the acute form (myoclonus status epilepticus [MSE]) occurs while patients are still unconscious and is characterized by generalized (often symmetric) myoclonus that involves the axial, limb, and facial muscles. Prolonged MSE is a marker of poor prognosis.

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A 68-year-old man with chronic obstructive pulmonary disease (COPD) experiences progressive dyspnea, wheezinq, and cough over several days despite using inhaled glucocorticoids and bronchodilators. His shortness of breath rapidly worsens and emergency medical services (EMS) is called. The patient becomes unresponsive prior to EMS arrival and is found to have pulseless electrical activity. Cardiopulmonary resuscitation is begun, and he is endotracheally intubated. The patient regains spontaneous circulation on arrival to the emergency department and is found to have a large pneumothorax and exacerbation of COPD. His other medical conditions include hypertension, type 2 diabetes mellitus, and Parkinson disease. A chest tube is inserted, and the patient is admitted to the intensive care unit for further management Over the next several days, his respiratory status gradually improves, but he remains unresponsive despite not receiving any sedation. The patient is also observed to have recurrent episodes of brief contractions of various muscle groups. Deep tendon reflexes are normal. Serum electrolytes are within normal limits.

Educational objective: The diagnosis of myasthenia gravis can be supported with the bedside ice pack test. In this test, an ice pack is applied over the eyelids for several minutes, leading to an improvement in ptosis. Patients with positive test results should undergo confirmatory testing for acetylcholine receptor antibodies (highly specific).

A 65-year-old man is being evaluated for new-onset ptosis. Earlier in the day, the patient underwent right total knee arthroplasty for advanced osteoarthritis with no operative complications. While in the postoperative recovery unit, he had difficulty opening his left eye and developed slurred speech. The patient has never had these symptoms, and his preoperative neurologic examination was unremarkable. He has no prior history of double vision, difficulty swallowing, or limb weakness. Medical history includes ischemic stroke with no residual deficits, type 2 diabetes mellitus, hypertension, and a 20-pack-year smoking history. Temperature is 36.7 C (98.1 F), blood pressure is 150/90 mm Hg, pulse is 92/min, and respirations are 12/min. Neurologic examination reveals bilateral ptosis, left greater than right Pupils are equal in size and reactive to light An ice pack is placed over the closed eyelids for 2 minutes, leading to improvement of the ptosis.

Educational objective: Amitriptyline is commonly used for depression, insomnia, and pain disorders but is frequently associated with side effects including orthostatic hypotension, lethargy, and anticholinergic symptoms (eg, dry mouth, constipation, urinary retention). Discontinuing the medication usually resolves these symptoms.

A 27-year-old woman comes to the office for follow-up. She was last seen 2 months ago for generalized musculoskeletal pain and several months of fatigue. Evaluation revealed multiple soft-tissue tender points, negative inflammatory and serological markers, and normal thyroid studies. The patient was diagnosed with fibromyalgia and prescribed a low-impact exercise program and pharmacotherapy. Her pain and fatigue have subsequently improved, but she now notes intermittent episodes of dizziness. Most of the episodes are short-lived, but she occasionally needs to brace herself against a wall or sit until the dizziness resolves. There have been no associated falls or loss of consciousness. She also notes worsened lethargy and frequent dry mouth. Other medical history includes migraines and irritable bowel syndrome. The patient currently takes daily amitriptyline for fibromyalgia, occasional acetaminophen for muscular pains, and polyethylene glycol as needed for constipation. She does not use tobacco, alcohol, or illicit drugs and has no known drug allergies. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 14/min. BMI is 21 kg/m2. Mucous membranes are pink and moist and there is no jugular venous distention. Cardiopulmonary auscultation is normal. The abdomen is soft and nontender. Neurologic examination reveals intact cranial nerves and normal muscle strength in all extremities.

Educational objective: Tick-borne paralysis is characterized by rapidly progressive ascending paralysis (which may be asymmetrical), absence of fever and sensory abnormalities, and normal CSF examination. Ticks must feed for 4-7 days and are typically found on patients after meticulous searching . Removal of the tick results in spontaneous improvement in most patients.

A 32-year-old man is brought to the emergency department with progressive ascending paralysis that began 18 hours earlier. He initially noticed paresthesias in his lower extremities, followed by a sense of fatigue and weakness that was more pronounced in his left leg. He has no history of headache, fever, or recent infection or illness. He had just returned from a hiking trip to Colorado. His blood pressure is 122/81 mm Hg, pulse is 86/min, respirations are 16/min, and temperature is 37.3 C (99.2 F). Physical examination reveals intact cranial nerves, absent deep tendon reflexes in the left lower extremity and 1+ in the right lower extremity, and a normal sensory examination. Both lower extremities show weakness, with no motor activity in his left leg. Laboratory results show a normal WBC count No abnormalities are noted on CSF examination.

Educational objective: Vasovagal (neurocardiogenic) syncope occurs due to excessive vagal tone that can be triggered by emotional stress, pain, or prolonged standing. Episodes typically involve a prodrome of nausea, diaphoresis, and pallor.