APEA Predictor
APEA Predictor
In myasthenia gravis, weakness is a result of insufficient acetylcholine transmission at
the neuromuscular junction; however, weakness can also occur with overdosing of the
cholinergic medications used to treat myasthenia. What symptom helps differentiate a
myasthenic crisis from a cholinergic crisis?
Muscle fasciculations
A 74-year-old man presents after his wife witnessed him grab his head in pain and fall to
the floor. He has not regained consciousness. His current blood pressure is 150/96 mm
Hg, and his heart rate is 65 bpm. Emergent head CT shows a subarachnoid hemorrhage.
Nimodipine (CCB)
A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on
the windshield. He complains of neck pain and severe burning in his shoulders and
arms. His physical examination reveals weakness of his upper extremities. What type of
spinal cord injury does this patient have?
central cord syndrome
A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his
house. The right side of his head hit the alley cement, and he lost consciousness for
about 1 minute; he woke up with a headache, but he had no other complaints. A few
hours later, the patient is brought to the emergency room by his neighbor because of an
intense headache, confusion, and left hand hemiparesis. On examination, the patient
has a bruise located over the right temporal region, mydriasis, and right deviation of the
right eye, papilledema, and left extensor plantar response. An emergency CT scan of the
head without contrast reveals a lens-shaped hyper-density under the right temporal
bone with mass effect and edema. What is the most likely diagnosis?
Epidural hematoma
A 1-year-old boy presents with increasing lethargy. He is barely responsive, and his
parents deny any trauma or injury. What is the most common cause of nontraumatic
altered levels of consciousness?
Infection
,A 44-year-old man starts to notice that his eyelids are drooping. Some time afterwards,
his jaw becomes weak. He has difficulty
APEAswallowing
Predictor and also experiences weakness in
his limbs. He is quite embarrassed when he eats because he must use his hand to help
support his jaw. His weakness gets progressively worse. Finally, he seeks medical
attention. His physical examination demonstrates the weakness in his limbs; however,
no sensory defects are present. A Tensilon test is done and is positive. His doctor is
concerned about an associated malignancy. What is the underlying pathology of this
disease?
Antibodies to the acetylcholine receptor
A 31-year-old woman presents with a purpural rash covering her arms, legs, and
abdomen. She also has fever, chills, nausea, abdominal tenderness, tachycardia, and
generalized myalgias. Prior to the development of the rash, the patient noted that she
had a headache, cough, and sore throat. Laboratory studies were positive for Gram-
negative diplococci in the blood, along with thrombocytopenia and an elevation in
PMNs. Urinalysis showed blood, protein, and casts. The patient denies any foreign
travel and does not have any sick contacts. However, she does work part time as a
nurse in a local hospital. The patient is diagnosed with Meningococcemia; she is
admitted to the hospital and placed in respiratory isolation. What major course of
therapy should this patient receive?
Antibiotics
A 54-year-old man presents after having a generalized seizure. The patient is HIV
positive, but he has been unable to afford antiretroviral therapy since losing his job 2
years ago. Other than cachexia, the physical exam is unremarkable. Upon further
inquiry, the patient also notes that he has become short- tempered and hypercritical; at
times, he seems confused. An MRI of the brain is performed, and it reveals several
cortical ring-enhancing lesions.
Toxoplasma encephalitis
A 37-year-old woman presents to her GP surgery with a history of right-sided facial
weakness and peri-auricular discomfort since she awoke this morning. She is afebrile.
What is the most likely diagnosis?
Bell's Palsy
A 62-year-old man presents with vision problems and difficulty swallowing. Over the
last week, he has had a constellation of symptoms; they began with numbness and
tingling in his feet and progressed to weakness that now affects both lower and upper
extremities. Within the last day, he has started to notice difficulty swallowing and
double vision. He also feels it is difficult for him to take a big breath. His past medical
,history is noncontributory, and he takes no medications. Exam reveals bilateral absence
of patellar and ulnar reflexes. A lumbar puncture is performed to confirm the diagnosis.
APEA
What cerebrospinal fluid (CSF) finding Predictor
is most likely?
Elevated CSF proteins
A 70-year-old woman is brought to your attention by her family because of the slowly
progressive gait disorder, the impairment of mental function, and urinary incontinence.
About 1 year ago, she started having weakness and tiredness in her legs, followed by
unsteadiness; her steps became shorter and shorter, and she also experienced
unexplained backward falls. She is becoming emotionally indifferent, inattentive, and
her actions and thinking have became "dull". Over the past month, she has started
having urinary urgency and involuntary leaking of urine. What is most likely the best
method of treating the patient's urinary problems?
Ventriculoperitoneal shunt
A 5-month-old male infant presents after a seizure involving all 4 limbs. His mother tells
you that he was born full term without any complications, and he was well until 2 days
ago when he developed a fever. He vomited multiple times yesterday and was irritable.
He was given antipyretic medication for his fever. He has no known allergies. On
physical exam, his temperature is 102.7 F, and his pulse is 154/min; BP is 90/50 mmHg,
and RR is 20/min. He is lethargic, pale, and focal neurological deficits are present. His
anterior fontanel is bulging. You suspect that he has bacterial meningitis. After drawing
blood samples for investigations, what is the most appropriate next step?
intravenous empirical antibiotics
A 12-year-old girl presents with a 3-day history of progressive dysarthria, dysphagia,
and weakness. The patient was well until 3 days prior to admission to the hospital; at
that time, she developed the onset and subsequent gradual worsening of dysarthria.
She attributed the dysarthria to a sore throat that she had had about 2 weeks earlier. 3
days prior to admission, she also had the onset of mild dysphagia; it mostly occurred
with liquids. 24 hours prior to admission, she developed weakness in both upper
extremities, which increased and began to involve the lower extremities. This limb
weakness was neither worsened by activity nor improved by rest. A nerve conduction
study reveals a moderate degree of mostly motor demyelinating peripheral neuropathy,
highly suggestive of Guillain- Barre. What statement best describes the patient's
prognosis?
Her rapidly evolving clinical course indicates a poor prognosis
A 45-year-old African American man with no significant past medical history presents
with a 1-hour history of left retroorbital headache. It is described as excruciating,
stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any
, preceding infections, nausea, vomiting, photophobia, or osmophobia; he also denies
fever, chills, stiff neck, focal weakness, numbness, tingling, vision, hearing, gait, or
APEA
speech changes. He recalls a similar Predictor
episode several months ago; it lasted about a
week, and it dissipated without complications. His physical exam is remarkable for
painful distress, lacrimation with conjunctival injection, nasal congestion, rhinorrhea,
left ocular miosis, and left forehead diaphoretic flushing. What pharmacologic agent is
the most beneficial for this patient at this time?
Sumatriptan
A 48-year-old woman presents after a seizure. Prior to the seizure, she experienced
confusion and disorientation preceded by nausea, vomiting, and blurred vision.
Symptoms appeared after working for several hours in the garden under the sun. Her
medical history is significant for the presence of schizophrenia, for which she takes
chlorpromazine at bedtime. Her temperature is 41 C; BUN and creatinine are elevated;
and there is neutrophilia, hemoconcentration, and lactic acidosis. You think that the
event is possibly drug related. What is the most likely diagnosis?
Heat stroke
A 17-year-old adolescent male presents with unexplained neurological symptoms. His
liver is enlarged on palpation, and he has other symptoms of hepatitis. Blood work
reveals depressed ceruloplasmin levels. An ophthalmological examination reveals
Kayser-Fleischer rings. What is the most likely diagnosis?
Wilson's Disease
A 62-year-old woman presents with excruciating pain, burning, and swelling in her left
forearm and wrist. She reports that symptoms initially began with a fracture 4 months
ago. The fracture was casted, and the patient was told it had healed well with cast
removal at 8 weeks. She is frustrated because her symptoms have persisted and
worsened, rather than improving, as she was told they would.
What medication would be most appropriate for this patient's likely diagnosis?
Gabapentin
A 46-year-old man recently recovered from a bout of influenza, and he now presents due
to an 8-hour history of right-sided facial paralysis. He is having trouble closing his right
eye, cannot raise his right eyebrow, and cannot smile with the right side of his mouth.
What medication(s) should this patient be started on?
Prednisone 60 mg PO daily plus acyclovir 400mg PO 5 times daily
A 4-month-old febrile infant presents with loss of appetite, irritability, seizures, focal
sensory and motor deficits, and an acute petechial rash. On physical examination, a
APEA Predictor
In myasthenia gravis, weakness is a result of insufficient acetylcholine transmission at
the neuromuscular junction; however, weakness can also occur with overdosing of the
cholinergic medications used to treat myasthenia. What symptom helps differentiate a
myasthenic crisis from a cholinergic crisis?
Muscle fasciculations
A 74-year-old man presents after his wife witnessed him grab his head in pain and fall to
the floor. He has not regained consciousness. His current blood pressure is 150/96 mm
Hg, and his heart rate is 65 bpm. Emergent head CT shows a subarachnoid hemorrhage.
Nimodipine (CCB)
A 75-year-old man is involved in a motor vehicle accident and strikes his forehead on
the windshield. He complains of neck pain and severe burning in his shoulders and
arms. His physical examination reveals weakness of his upper extremities. What type of
spinal cord injury does this patient have?
central cord syndrome
A 37-year-old man fell from a ladder as he finished hanging the Christmas lights on his
house. The right side of his head hit the alley cement, and he lost consciousness for
about 1 minute; he woke up with a headache, but he had no other complaints. A few
hours later, the patient is brought to the emergency room by his neighbor because of an
intense headache, confusion, and left hand hemiparesis. On examination, the patient
has a bruise located over the right temporal region, mydriasis, and right deviation of the
right eye, papilledema, and left extensor plantar response. An emergency CT scan of the
head without contrast reveals a lens-shaped hyper-density under the right temporal
bone with mass effect and edema. What is the most likely diagnosis?
Epidural hematoma
A 1-year-old boy presents with increasing lethargy. He is barely responsive, and his
parents deny any trauma or injury. What is the most common cause of nontraumatic
altered levels of consciousness?
Infection
,A 44-year-old man starts to notice that his eyelids are drooping. Some time afterwards,
his jaw becomes weak. He has difficulty
APEAswallowing
Predictor and also experiences weakness in
his limbs. He is quite embarrassed when he eats because he must use his hand to help
support his jaw. His weakness gets progressively worse. Finally, he seeks medical
attention. His physical examination demonstrates the weakness in his limbs; however,
no sensory defects are present. A Tensilon test is done and is positive. His doctor is
concerned about an associated malignancy. What is the underlying pathology of this
disease?
Antibodies to the acetylcholine receptor
A 31-year-old woman presents with a purpural rash covering her arms, legs, and
abdomen. She also has fever, chills, nausea, abdominal tenderness, tachycardia, and
generalized myalgias. Prior to the development of the rash, the patient noted that she
had a headache, cough, and sore throat. Laboratory studies were positive for Gram-
negative diplococci in the blood, along with thrombocytopenia and an elevation in
PMNs. Urinalysis showed blood, protein, and casts. The patient denies any foreign
travel and does not have any sick contacts. However, she does work part time as a
nurse in a local hospital. The patient is diagnosed with Meningococcemia; she is
admitted to the hospital and placed in respiratory isolation. What major course of
therapy should this patient receive?
Antibiotics
A 54-year-old man presents after having a generalized seizure. The patient is HIV
positive, but he has been unable to afford antiretroviral therapy since losing his job 2
years ago. Other than cachexia, the physical exam is unremarkable. Upon further
inquiry, the patient also notes that he has become short- tempered and hypercritical; at
times, he seems confused. An MRI of the brain is performed, and it reveals several
cortical ring-enhancing lesions.
Toxoplasma encephalitis
A 37-year-old woman presents to her GP surgery with a history of right-sided facial
weakness and peri-auricular discomfort since she awoke this morning. She is afebrile.
What is the most likely diagnosis?
Bell's Palsy
A 62-year-old man presents with vision problems and difficulty swallowing. Over the
last week, he has had a constellation of symptoms; they began with numbness and
tingling in his feet and progressed to weakness that now affects both lower and upper
extremities. Within the last day, he has started to notice difficulty swallowing and
double vision. He also feels it is difficult for him to take a big breath. His past medical
,history is noncontributory, and he takes no medications. Exam reveals bilateral absence
of patellar and ulnar reflexes. A lumbar puncture is performed to confirm the diagnosis.
APEA
What cerebrospinal fluid (CSF) finding Predictor
is most likely?
Elevated CSF proteins
A 70-year-old woman is brought to your attention by her family because of the slowly
progressive gait disorder, the impairment of mental function, and urinary incontinence.
About 1 year ago, she started having weakness and tiredness in her legs, followed by
unsteadiness; her steps became shorter and shorter, and she also experienced
unexplained backward falls. She is becoming emotionally indifferent, inattentive, and
her actions and thinking have became "dull". Over the past month, she has started
having urinary urgency and involuntary leaking of urine. What is most likely the best
method of treating the patient's urinary problems?
Ventriculoperitoneal shunt
A 5-month-old male infant presents after a seizure involving all 4 limbs. His mother tells
you that he was born full term without any complications, and he was well until 2 days
ago when he developed a fever. He vomited multiple times yesterday and was irritable.
He was given antipyretic medication for his fever. He has no known allergies. On
physical exam, his temperature is 102.7 F, and his pulse is 154/min; BP is 90/50 mmHg,
and RR is 20/min. He is lethargic, pale, and focal neurological deficits are present. His
anterior fontanel is bulging. You suspect that he has bacterial meningitis. After drawing
blood samples for investigations, what is the most appropriate next step?
intravenous empirical antibiotics
A 12-year-old girl presents with a 3-day history of progressive dysarthria, dysphagia,
and weakness. The patient was well until 3 days prior to admission to the hospital; at
that time, she developed the onset and subsequent gradual worsening of dysarthria.
She attributed the dysarthria to a sore throat that she had had about 2 weeks earlier. 3
days prior to admission, she also had the onset of mild dysphagia; it mostly occurred
with liquids. 24 hours prior to admission, she developed weakness in both upper
extremities, which increased and began to involve the lower extremities. This limb
weakness was neither worsened by activity nor improved by rest. A nerve conduction
study reveals a moderate degree of mostly motor demyelinating peripheral neuropathy,
highly suggestive of Guillain- Barre. What statement best describes the patient's
prognosis?
Her rapidly evolving clinical course indicates a poor prognosis
A 45-year-old African American man with no significant past medical history presents
with a 1-hour history of left retroorbital headache. It is described as excruciating,
stabbing, sharp, and lancinating; it is rated as severe in intensity. He denies any
, preceding infections, nausea, vomiting, photophobia, or osmophobia; he also denies
fever, chills, stiff neck, focal weakness, numbness, tingling, vision, hearing, gait, or
APEA
speech changes. He recalls a similar Predictor
episode several months ago; it lasted about a
week, and it dissipated without complications. His physical exam is remarkable for
painful distress, lacrimation with conjunctival injection, nasal congestion, rhinorrhea,
left ocular miosis, and left forehead diaphoretic flushing. What pharmacologic agent is
the most beneficial for this patient at this time?
Sumatriptan
A 48-year-old woman presents after a seizure. Prior to the seizure, she experienced
confusion and disorientation preceded by nausea, vomiting, and blurred vision.
Symptoms appeared after working for several hours in the garden under the sun. Her
medical history is significant for the presence of schizophrenia, for which she takes
chlorpromazine at bedtime. Her temperature is 41 C; BUN and creatinine are elevated;
and there is neutrophilia, hemoconcentration, and lactic acidosis. You think that the
event is possibly drug related. What is the most likely diagnosis?
Heat stroke
A 17-year-old adolescent male presents with unexplained neurological symptoms. His
liver is enlarged on palpation, and he has other symptoms of hepatitis. Blood work
reveals depressed ceruloplasmin levels. An ophthalmological examination reveals
Kayser-Fleischer rings. What is the most likely diagnosis?
Wilson's Disease
A 62-year-old woman presents with excruciating pain, burning, and swelling in her left
forearm and wrist. She reports that symptoms initially began with a fracture 4 months
ago. The fracture was casted, and the patient was told it had healed well with cast
removal at 8 weeks. She is frustrated because her symptoms have persisted and
worsened, rather than improving, as she was told they would.
What medication would be most appropriate for this patient's likely diagnosis?
Gabapentin
A 46-year-old man recently recovered from a bout of influenza, and he now presents due
to an 8-hour history of right-sided facial paralysis. He is having trouble closing his right
eye, cannot raise his right eyebrow, and cannot smile with the right side of his mouth.
What medication(s) should this patient be started on?
Prednisone 60 mg PO daily plus acyclovir 400mg PO 5 times daily
A 4-month-old febrile infant presents with loss of appetite, irritability, seizures, focal
sensory and motor deficits, and an acute petechial rash. On physical examination, a
