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Case: Headache and vomiting after fall

A 34-year-old man is evaluated in the emergency department for worsening headache, nausea, and two episodes of vomiting 2 hours after hitting his head in a fall from the top of a 6-foot ladder.

On physical examination, temperature is normal, blood pressure is 128/84 mm Hg, pulse rate is 86/min, and respiration rate is 14/min. The patient's Glasgow Coma Scale score is 15/15.

Which of the following is the most appropriate immediate step in management?

An 18-year-old man is evaluated for recurrent headaches 1 week after falling on his head during a soccer match at his high school. The patient reports being “dazed” for 15 minutes after the fall but never losing consciousness. Findings from a sideline examination were unremarkable, and the patient was removed from play. Given the temporary alteration in consciousness, a follow-up examination with his internist was recommended. He developed headaches the morning after the injury that for 3 days were severe, global, throbbing, and associated with nausea and dizziness; the nausea and dizziness have gradually resolved, and for the past 2 days, the headache pain has been controlled with acetaminophen. He has had no cognitive symptoms but has not yet resumed school or sports activities.

Results of physical examination, including vital signs and neurologic examination findings, are unremarkable.

Which of the following is the most appropriate management?

Case: Blurred vision after assault

A 44-year-old man is evaluated in the emergency department for a severe global headache and blurred vision. Two hours ago, he was struck with a pipe in the right frontotemporal region and anterior neck and knocked to the ground but did not lose consciousness. While describing the assault, the patient becomes stuporous.

On physical examination, blood pressure is 150/100 mm Hg, pulse rate is 50/min, and respiration rate is 10/min. Continued stupor is noted, as are right pupillary dilation, palsy of the oculomotor nerve (cranial nerve III), and an extensor plantar response on the left. The patient withdraws from pain more weakly on the left than the right. No other cranial nerve abnormalities are detected.

Which of the following is the most likely diagnosis?

Case: Former pro football player

A 48-year-old man is evaluated for increasing depression and suicidal ideation. He reports experiencing feelings of hopelessness, lack of initiative, and general disinterest over the past 5 years that recently have worsened and are now accompanied by mood swings, irritability, impatience, verbal abuse, and physical aggression. Thoughts of death and suicide often have been present in the past month. His gait has become slow and shuffling, and his balance is increasingly impaired. His wife says he is more forgetful than ever and unable to perform home repairs that he previously accomplished easily. He has had no hallucinations or delusions. The patient is retired from a 13-year career playing professional football. Other than minor football injuries, he has no significant medical history and has an unremarkable family history, including no neurologic and psychological disorders. The patient takes no medication.

On physical examination, vital signs are normal. Neurologic examination shows slow processing speed, mild dysarthria, slowed rapid alternating movements bilaterally, and a wide-based gait with decreased foot-floor clearance. The patient scores 20/30 on the Montreal Cognitive Assessment, losing points in the visuospatial/executive function, attention, orientation, and delayed recall sections.

Which of the following is the most likely diagnosis?

Case: Car accident

A 32-year-old woman is evaluated in the emergency department 30 minutes after a motor vehicle accident in which she struck her head on the steering wheel. She is awake and conversant and has no major symptoms aside from a mild headache. She is at 23 weeks' gestation of her second pregnancy. She has been receiving routine prenatal care, and her pregnancy has been uncomplicated. Her only medication is a prenatal vitamin.

On physical examination, the patient is in neck immobilization. Temperature is 37.1 °C (98.7 °F), blood pressure is 111/63 mm Hg, pulse rate is 76/min, and respiration rate is 12/min. BMI is 24. There is a contusion on the upper forehead but no other evidence of trauma. The abdomen shows normal changes of pregnancy but is otherwise normal. The remainder of the physical and neurologic examinations is unremarkable.

Initial laboratory studies show a serum sodium level of 131 mEq/L (131 mmol/L); the remainder of the electrolytes, blood urea nitrogen, and serum creatinine are normal.

Which of the following is the most likely cause of this patient's decrease in her serum sodium level?

Which of the following disorders would most likely be caused by a stroke?

Which of the folowing describes the profile of an individual with aphasia who still has preserved abilities in spontaneous speech attributes (e.g., melodic flow)?

During treatment, a client is shown a picture of a sofa, and says "fosa." Which of the following is she demonstrating?

Transcortical motor aphasia presents similarly to Broca's aphasia except that with transcortical motor aphasia:

Electrical injuries are commonly caused by:

Current flow from hand to hand is called:

Most Seizures Last:

A 9-year-old boy is brought to your clinic by his parents because he has begun to have episodes of eye fluttering lasting several seconds. Sometimes he loses track of his thoughts in the middle of a sentence. There was one fall off a bicycle that may have been related to one of these events. There are no other associated symptoms, and the episodes may occur up to 20 or more times per day. The boy’s development and health have been normal up until this point. He had two head injuries as a young child: the first when he fell off a tricycle onto the ground, and the second when he fell off a playset onto his head. Both episodes resulted in a brief loss of consciousness and he did not think clearly for part of the day afterward, but he had no medical intervention. Which of the following test results is most likely?

A 19-year-old right-handed man who carries the diagnosis of epilepsy is seen in the urgent-care clinic. He had been healthy until about age 12, when he began to have episodes of eye fluttering lasting several seconds. Sometimes he would lose track of his thoughts in the middle of a sentence. There was one fall off of a bicycle that may have been related to one of these events. He has been treated with valproic acid. At one point he was off all medications, but the seizures returned. He is now at the end of his first semester of college and came in today because he had a witnessed generalized tonic-clonic seizure this morning. He had had only about 2 hours of sleep the night before because he was studying for a final examination. Which of the following is the most appropriate thing to tell this patient?

A 56-year-old man with epilepsy is brought into the emergency room. He has been having continuous generalized tonic-clonic seizures for the past 30 minutes. He is treated with 2 mg of intravenous lorazepam. Most physicians recommend using a high dose of intravenous benzodiazepine as part of the management of status epilepticus because it has which of the following qualities?