By O. Jorn. Northern Illinois University.

Migraine with or without aura is associated with an tests are necessary before instituting this therapy except increased risk of subclinical posterior circulation in- A order bystolic 5 mg with mastercard blood pressure 120 0. A 76-year-old nursing home resident is brought to Except for a fairly severe upper respiratory tract infection the local emergency room after falling out of bed generic 2.5 mg bystolic with visa high blood pressure medication and xanax. In the last was not witnessed; however, she was suspected to have hit year he has had two self-limited episodes of tinnitus asso- her head. She is not responsive to verbal or light tactile ciated with dizziness and a decrement in his hearing. At baseline she is able to converse but is fre- symptoms are always unilateral on the same side and have quently disoriented to place and time. She has a medical required him to take off from work for a few days each history that includes stable coronary disease, mild em- time. He comes into your office at the outset of his third physema, and multi-infarct dementia. In your office, he has tinnitus and vertigo while following is true regarding head injury and hematomas? Which is the best long-term treatment option mas will experience a lucid interval prior to loss of for the patient at this time? While you are working in the urgent care center, a tracranial pressure and can require arterial ligation. He gives a history of having slipped on the ice and On examination, visual acuity in the right eye is 20/60 and severely contusing his right shoulder approximately 1 in the left eye 20/80. At this time he has sharp knifelike pain in the He has cerebellar ataxia on neurologic examination as well right arm and forearm. His strength is 5 out of 5 in all major right arm that is more moist and hairy than the left arm. When the mother arrives, you find ever, the right arm is clearly more edematous than the out that many relatives on the father’s side of the family, in- left, and the skin appears somewhat atrophic in the af- cluding the father, have been diagnosed with cerebellar fected limb. The patient’s pain most likely is due to ataxia but she does not know more than that. Physical examination demonstrates progressive weak- to find on examination of this patient’s fundi? All the following are associated with a decreased sistance, and the ankle drags for varying distances before sense of smell except being lifted off the bed. The finding is not seen in the other leg nor in the upper extremities when examining the el- A. He has had left a pseudobulbar affect, mildly increased muscle tone, and lower extremity weakness that has been constant for 6 brisk deep tendon reflexes in the right upper extremity and months. The history and ex- pain is intermittent and he uses chronic narcotics on an amination are most consistent with which of the following? All the following are causes of paresthesias in the thumb and the index and middle fin- carpal tunnel syndrome except gers. Delirium often goes unrecognized despite clear evidence that it is often a cognitive manifestation of many medical and neurologic illnesses. Delirium is asso- ciated with a substantial mortality with in-hospital mortality estimates ranging from 25– 33%. Overall estimates of delirium in hospitalized patients range from 15–55% with higher rates in the elderly. Postoperative patients, especially status post hip surgery, have an incidence of delirium that is some- what higher than patients admitted to the medical wards. Because of these associated symptoms, pa- tients may be misdiagnosed as having sinus headache due to allergic rhinitis and treated inappropriately with antihistamine and nasal steroids. A typical presentation of cluster headaches is one of episodic severe headaches that occur at least once daily at about the same time for a period of 8–10 weeks. An attack usually lasts from 15–180 minutes, and 50% of headaches will have nocturnal onset. Men are af- fected three times more commonly with cluster headaches than women, and alcohol in- gestion may trigger cluster headaches. A distinguishing feature between cluster headaches and migraine headaches is that individuals with cluster headaches tend to move about during attacks and frequently rub their head for relief, whereas those with migraines tend to remain motionless during attacks. Interestingly, unilateral phonophobia and photo- phobia can occur with cluster headaches but do not with migraines. Treatment of acute at- tacks of cluster headaches requires a treatment with a fast onset as the headaches reach peak intensity very quickly but are of relatively short duration. High-flow oxygen (10–12 L/min for 15–20 min) has been very effective in relieving the headaches.

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Physical examination is notable tidal volume) >105 for mild diffuse polyphonic expiratory wheezing but no E purchase 5mg bystolic arrhythmia young adults. Exercise physiology testing recalls having an upper respiratory tract infection prior B order bystolic 5 mg fast delivery hypertension unspecified. Skin testing for allergies solved, he states that “the cold moved to my chest” about E. A 46-year-old man is brought to your office by his but these are less frequent now. He is reluctant to admit that he has any health prob- been coughing that awakens him from sleep at night and lems. His wife, on the other hand, is adamant that some- ultimately has resulted in progressive fatigue. Specific triggers for his cough include eating frequently sleepy at work and falls asleep while watching cold foods, especially ice cream. He has no history of television at night, but he attributes this to stress on the asthma or prior history of prolonged cough. She describes loud snoring at night that begins almost symptoms of gastroesophageal reflux disease. He breathes immediately when he falls asleep, punctuated by long peri- easily through his nose and does not have seasonal rhi- ods of no breathing at all. He does not recall his vaccination history, normal oropharynx and has a short, squat neck. His lung but thinks he has not had any vaccinations since gradu- sounds are clear, and he has a protuberant, obese abdo- ating from high school. He is 190 cm amination, the patient’s wife demands to know what is tall and weighs 95. What are the piratory rate of 14 breaths/min, heart rate of 64 beats/ next steps in diagnosis and treatment? He and his wife should be reassured that his symp- nose, and throat examination reveals no enlargement of toms will improve as his work stress lessens. He should be prescribed a therapeutic trial of No forced expiratory wheezes are present. Which test is most likely to establish the diagno- plaint of cough and dyspnea on exertion that has gradu- sis correctly? Before 3 months ago the patient had no limita- systemic lupus erythematosus except tion of exercise tolerance, but now she reports that she A. A 68-year-old man presents to the emergency room has scattered rhonchi and faint expiratory wheezes bilat- with fever and productive cough. There is associated left-sided pleuritic chest chiectasis to explain his recurrent infections. Positive Gram stain or culture of the pleural fluid chiectasis in a patient with this history. A 45-year-old female is seen in the clinic for evalua- the following is the most common cause of mortality? She reports a cough that began in her early twenties that is occasionally productive of yel- A. Bronchiolitis obliterans innumerable courses of antibiotics, all with brief im- C. Posttransplant lymphoproliferative disorder that she has asthma, and her only medications are flutica- E. A 52-year-old alcoholic man presents to a local cal examination is notable for normal vital signs and an emergency room with purulent, productive cough, short- oxygen saturation of 92% on room air. He lungs have dullness in the upper lobes bilaterally and dif- thinks his symptoms started a few days ago. There is multiple positive cultures for Pseudomonas aeruginosa dullness to percussion over the right lower lung field, and and Staphylococcus aureus. A chest radiograph shows eral chest radiography shows bilateral upper lobe infil- a right-sided opacity in the superior portion of the right trates. Which of the following tests is the most important lower lobe with an air-fluid level present. Subsequent management should include scribes the symptoms as “ants crawling in her veins. A 72-year-old male with a long history of tobacco very hot bath to alleviate the symptoms. During sleep, use is seen in the clinic for 3 weeks of progressive dyspnea her husband complains that she kicks him throughout on exertion.

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