A 60-year-old male with a history of atrial fibrillation, hypertension and diabetes mellitus presents to the emergency department with sudden onset right upper extremity weakness and facial droop. His wife reports that these symptoms started 2 hours ago. He denies any fevers, chills, nausea, vomiting, unintentional weight loss or night sweats. He denies ever having these symptoms in the past. On exam, the patient is noted to have right-sided facial droop but has normal movement of his forehead, as well as 3/5 strength in his right upper extremity with a 1/4 reflex. He has 5/5 strength in his left upper extremity with 2/4 reflexes and 5/5 strength in his bilateral lower extremities. Which of the following is the most appropriate next step in management? A. administer tPA B. Start unfractionated heparin C. Non-contrast CT scan of the brain D. Contrast CT scan of the brain E. Urgent neurosurgical consultation. F. Administer aspirin, morphine, and oxygen and admit a patient to the hospital.
The answer is C. Non-contrast CT scan of the brain. This patient is having an acute cerebrovascular accident (CVA) or a stroke. The first step in the management of a stroke patient is to determine if the stroke is ischemic or hemorrhagic. This can be achieved using a non-contrast CT scan of the brain. The next step in management will vary greatly depending on if the stroke is hemorrhagic or ischemic. Hemorrhagic strokes require urgent surgical consultation as well as nifedipine to prevent vasospasm. Ischemic strokes require evaluation for possible thrombolysis with tissue plasminogen activator (tPA).
A 46-year-old female with no significant past medical history presents with weakness and fatigue. On exam, her mucous membranes are pale. Labs show that she is anemic with a hemoglobin of 9, with an elevated Mean Corpuscular Volume, indicating a megaloblastic anemia. B12 and Folate levels are pending. You order levels of homocysteine and methionine. What values of these proteins would you expect for a B12 deficiency and a folate deficiency (respectively)?
B12: Elevated homocysteine, low methionine Folate: Elevated homocysteine, normal methionine.
A 50-year-old male presents with 3 months of back pain, which started after lifting a heavy box. He says the back pain is intermittent and "shoots down his right leg". On MRI, a bulging intervertebral disc is seen compressing his L3-L4 nerve root. What additional findings might you expect to find in this patient?
1. Numbness/Sensory loss over the anterior thigh and knee as well as the anteromedial leg 2. Loss of the patellar reflex 3. Possible weakness in knee flexion The overall question is testing whether you know what the L4 nerve root does. You must know the sensory dermatomes, that the patellar reflex is testing L4, and that L4 plays a major role in knee extension (via the femoral nerve). You also must know that intervertebral discs tend to herniate posterolaterally and affect the more inferior nerve root. (e.g. a nerve root that herniates between L3-L4 will be more likely to affect L4 more than L3).