7 - The Point
A 70‐year‐old man complains of double vision. Which of the following associated symptoms or signs would be worrying about an underlying neurological problem (as opposed to pathology in the eye)? a) Abnormality in extraocular movements on examination b) Symptoms of flashing lights c) An associated conjunctivitis d) Diplopia persisting in the right eye when the left eye is closed e) Worsening vision bilaterally on examination
a) Abnormality in extraocular movements on examination Paralysis or weakness of extraocular muscles suggests a possible brainstem or cerebellar lesion. Diplopia persisting in the right eye when the left eye is closed is incorrect. Diplopia in one eye while the other eye is closed suggests a problem in the cornea or lens. An associated conjunctivitis is incorrect. Conjunctivitis is an independent problem and generally a minor one. Worsening vision bilaterally on examination is incorrect. Worsening bilateral vision is common among elderly patients. Symptoms of flashing lights is incorrect. Flashing lights suggest vitreous floaters, although it could suggest detached vitreous from the retina.
A 35‐year‐old female patient has had migraines for much of her adult life. Ather regular checkup, she is healthy, takes no medications except oral contraceptive pills (OCPs), exercises, and has a steady job. Her only complaint is that her migraines seem to have become worse, and, for the past few weeks, she has been waking up at night with headache and also nausea. Which of the following is the best course of action? a) Take a further history and perform a very careful neurological examination. b) Prescribe a strong medication for her migraines. c) Reassure her that this is a common pattern with migraines. d) Order studies to evaluate potential transient ischemic attacks (TIAs) because she is on OCPs. e) Treat her for sinusitis.
a) Take a further history and perform a very careful neurological examination. The history of nightly awakening and nausea is concerning for increased intracranial pressure from a tumor or other mass. (Brain tumor is not common in a 35‐year‐old.) A careful neurological examination may uncover deficits. Reassure her that this is a common pattern with migraines is incorrect. The new symptoms are not typical of migraines. Order studies to evaluate potential TIAs because she is on OCPs is incorrect. Despite her being on OCPs, the new symptoms are not typical of TIAs or strokes. Treat her for sinusitis is incorrect. Headaches from sinusitis are typically frontal, worse when leaning forward, and do not typically cause such nighttime nausea. Prescribe a strong medication for her migraines is incorrect. Treatment without further workup is not prudent, particularly since these symptoms are not typical of migraines.
A 65‐year‐old overweight male presents at the clinic with hoarseness which has lasted for around 2 months. He thinks it began along with a cold. He is not feeling badly other than frequent heartburn, and he has continued to work as a bartender (for the past 30 years), but he is having difficulty being heard and understood because of his hoarse voice. A diagnosis that is on the differential list includes which of the following? a) Voice strain from bartending and talking amidst loud ambient noise b) Acid reflux c) Inhalation of fumes d) Viral infection e) Environmental allergies
b) Acid reflux Acid reflux (also known as gastroesophageal reflux disease, or GERD) can cause hoarseness through damage to the laryngeal area due to acid stomach contents being refluxed to the vocal cords. Voice strain from bartending and talking amidst loud ambient noise is incorrect. Voice strain is unlikely to cause these problems right now. Viral infection is incorrect. Viral infections such as parainfluenza virus can certainly cause hoarseness, which can last for several weeks. However,2 months is too long a duration for a viral infection. Inhalation of fumes is incorrect. Inhalation of fumes is unlikely to cause symptoms for 2 months.Environmental allergies is incorrect. Environmental allergies tend to last for only a few weeks as the "season" for these allergies comes and goes.
An 82‐year‐old gentleman seems to be speaking loudly during an examination, suggesting that he may not be hearing well. What is a good question to ask him to help identify whether or not he has hearing loss? a) Does he have vertigo? b) How well does he understand people in a noisy environment such as a restaurant? c) Does he have discharge from his ear? d) Has he been listening to loud music? e) Has he been having an earach
b) How well does he understand people in a noisy environment such as a restaurant? Patients with slowly progressive hearing loss may change their behavior gradually to accommodate—such as watching‐‐ the face of the speaking person, or moving closer to the person. However, in a noisy environment, the patient may have difficulty in understanding others. Has he been listening to loud music is incorrect as this would be very unusual for an elderly person. Does he have vertigo is incorrect. Vertigo can be associated with hearing loss but the question about vertigo by itself does not help identify whether or not the patient has hearing loss. Has he been having an earache is incorrect. An otitis media may result in hearing loss but again it is an associated diagnosis. Does he have discharge from his ear is incorrect. Discharge from ear may suggest wax, otitis externa or even a perforated tympanic membrane, but these are associated diagnoses rather than clues to whether or not the patient has hearing loss.
A patient with cystic fibrosis (CF) has been complaining of fullness in his left nasal cavity. Examination of his nose using an otoscope and a speculum reveals a normal nasal septum, but a pale, saclike growth of inflamed tissue that is obstructing a large part of the nasal cavity. What is the most likely diagnosis? a) Allergic rhinitis b) Deviated nasal septum c) Nasal polyp d) Ulcer e) Viral rhiniti
c) Nasal polyp Nasal polyps are more likely in patients with CF (as well as other conditions such as allergic rhinitis, aspirin sensitivity, and chronic sinusitis). Ulcer is incorrect as an ulcer is not a mass but rather a tender denuded area. Viral rhinitis is incorrect as it should not produce a saclike structure. Allergic rhinitis is incorrect as it produces a pale and boggy mucosa but not a saclike structure. Deviated nasal septumis incorrect. The nasal septum was reported to be normal.
In the case of a middle‐aged female with a pounding headache, what is an effective question to ask the patient? a) Is she feeling stressed? b) Does she think she is losing her memory? c) Has she ever seen anyone with a stroke? d) Does the patient have any aura prior to the headaches? e) How old is the patient?
d) Does the patient have any aura prior to the headaches? An aura or a prodrome of unusual feelings or neurological symptoms may increase the likelihood that this is a migraine. "How old is the patient?" is incorrect. Age of the patient does not produce a useful clue. "Is she feeling stressed?" is incorrect. Most patients report feeling stressed. Also, headaches themselves can stress out a patient. "Does she think she is losing her memory?" is incorrect. Losing memory may be an early symptom of dementia but is not typically linked to headaches. "Has she ever seen anyone with a stroke?" is incorrect. This is unlikely to be a stroke, and asking such a question will only increase the patient's stress.
A 55‐year‐old woman with a headache explains to the clinician that she has had headaches before, but this one is unusual because of some new symptoms. Which of the following symptoms would prompt an immediate investigation? a) The patient lost her glasses. b) The headache comes and goes. c) The headache is similar in nature to prior ones she has had for decades but more severe. d) The patient also has developed fever and night sweats and thinks she lost some weight. e) The patient had a car accident and minor head trauma about 3 months ago.
d) The patient also has developed fever and night sweats and thinks she lost some weight. Concomitant fever, night sweats, and weight loss are concerning systemic symptoms and suggest a serious underlying cause of the headaches. The headache is similar in nature to prior ones she has had for decades but more severe is incorrect. Most headaches follow a classic pattern and even if this one is more severe, the same pattern to prior headaches makes this one likely to be benign. The patient had a car accident and minor head trauma about three months ago is incorrect. Although recent head trauma is a concerning history, trauma 3 months ago is unlikely to have produced changes that lead to a headache at this time. The headache comes and goes is incorrect. Headaches that come and go tend to be benign. For example, migraines come and go. The patient lost her glasses is incorrect. Losing glasses can cause squinting and subsequent development of headache. In any case, this is not a serious concern although she should get new glasses.
A 25‐year‐old construction worker is complaining of a swishing noise in both ears that never goes away and has occurred for about 6 months. He is otherwise healthy, is able to work on his job (operating large, vibrating machinery) without problems, and is not taking any medications. A complete examination reveals an abnormality. Which of the following abnormality is most often associated with tinnitus? a) Headache b) Wax in both ears c) Mild tremor d) Vertigo e) Bilateral earache
d) Vertigo Vertigo and tinnitus together comprise a syndrome called Ménière disease, which may affect young adults. A more common diagnosis in this case would have been tinnitus resulting from the loud noise of the machinery he is working with. Bilateral earache is incorrect. Otitis media can cause pounding in the ear but not tinnitus, and it is rarely bilateral. Wax in both ears is incorrect. Cerumen can push against the tympanic membrane and can cause a dull sound and pressure, but not typically tinnitus. Headache is incorrect as it can be associated with tinnitus in the case of a brain lesion, but this is rare.A mild tremor is incorrect as it would be unusual at this age but it is sometimes a normal variant, and in this case might be associated with his work.
An 87‐year‐old woman who is generally healthy and cognitively sharp complains to the clinician of slow loss of vision, with similar problems in both eyes, particularly when she looks straight ahead. She is having difficulty reading of late. What is a reasonableresponse to her? a) "Are you experiencing depression or stress?" b) "This is a common occurrence with aging and unlikely to have a diagnosis." c) "This is an unusual occurrence, even among elderly, and may be due to a problem within the brain (since it is bilateral)." d) "This is a classic 'floater' and no cause for concern." e) "This may be the onset of macular degeneration, which an ophthalmologist should confirm."
e) "This may be the onset of macular degeneration, which an ophthalmologist should confirm." Macular degeneration is a common disease of the elderly and results in central vision loss. It is often bilateral. This particular patient likely has "dry" macular degeneration. "This is a common occurrence with aging and unlikely to have a diagnosis" is incorrect. Although this is common among elderly patients, there is likely to be a diagnosis. "This is an unusual occurrence, even among elderly, and may be due to a problem within the brain (since it is bilateral)" is incorrect. Although central lesions can cause bilateral visual defects, this will not be central visual loss but rather a particular portion of the visual field. "Are you experiencing depression or stress?" is incorrect. Depression or stress will not by themselves cause central visual loss. "This is a classic 'floater'and no cause for concern" is incorrect. Floaters are transient and unlikely to be bilaterally symmetric.
A 74‐year‐old man is being seen because of a 1‐day history of a painful right eye. He also mentions that he has blurred vision in that eye. He thought something had blown into his eye, but after flushing it out, the pain and blurred vision remains. What is the best course of action? a) Check his blood pressure. b) Perform a complete neurological examination. c) Perform a vision examination. d) Reassure him that pain from a foreign body can remain for a day or two (even after the foreign body is removed). e) Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma.
e) Refer to an ophthalmologist emergently with the possibility of corneal ulcer, uveitis, or acute glaucoma. A unilateral, painful eye may be due to acute glaucoma or corneal pathology (foreign body, ulcer, uveitis, etc.). Reassure him that pain from a foreign body can remain for a day or two (even after the foreign body is removed) is incorrect. The pain from a foreign body tends to resolve rather quickly once it is removed. Perform a vision examination is incorrect. (Visual exam should be performed even if referral to an ophthalmologist is urgently needed. Extra information can be added to this option to make it completely incorrect.) Although a vision examination is always good, unilateral pain/blurriness indicates pathology in a single eye. Perform a complete neurological examination is incorrect. A complete neurological examination is never harmful, but not highest priority for this patient who clearly has single eye pathology. Check his blood pressure is incorrect. Hypertension does not cause these symptoms.
