 of stroke occurring during a hypertensive crisis. Which of the following medications could be considered?
A. Acamprosate
B. Disulfiram
C. Naltrexone
D. A and C
E. All of the above
115. What is the most common initial illicit drug of abuse among U.S. adolescents?
A. Benzodiazepines
B. Heroin
C. Marijuana
D. Methamphetamines
E. Prescription narcotics
116. A 32-year-old woman is admitted to the hospital for drainage and treatment of a soft tissue abscess of her left forearm. She uses IV heroin on a daily basis, often spending $100 or more per day on drugs. Upon admission, she has a 4 × 2-cm fluctuant mass in the left forearm associated with fevers to 39.3°C (102.7°F) and tachycardia. The abscess is drained and packed, and the patient is initiated on therapy with IV clindamycin. About 10 hours after admission, you are called to the patient’s bedside for a change in the patient’s condition. You are suspecting narcotic withdrawal. All of the following symptoms are consistent with this diagnosis EXCEPT:
A. Hyperthermia
B. Hypotension
C. Piloerection
D. Sweating
E. Vomiting
117. A 24-year-old man is brought to the emergency department by emergency medical services (EMS) about 2 hours after an intentional overdose of sustained-release oxycodone that was taken in conjunction with alcohol. Upon arrival at the scene, emergency medical technicians found an empty bottle of sustained-release oxycodone tablets with a dose of 20 mg. It is unknown how many pills the patient ingested, but the prescription was written for 60 tablets. The patient was unresponsive with a respiratory rate of 4 breaths/min, blood pressure of 80/56 mmHg, heart rate of 65 beats/min, and oxygen saturation of 86% on room air. The patient was intubated in the field and naloxone 2 mg IM was administered. He is currently intubated and unresponsive without spontaneous respiration above the set ventilator rate. His blood pressure is 82/50 mmHg and heart rate is 70 beats/min. Which of the following is most appropriate at the present time in the evaluation and treatment of this patient?
A. Activated charcoal
B. IV saline bolus 1 L followed by repeated 500–1000 mL boluses to maintain adequate blood pressure
C. Naloxone continuous infusion at a rate of 0.4 mg/h
D. Urine drug screen, acetaminophen levels, and blood alcohol content
E. All of the above
118. Which of the following statements is TRUE with regard to the chronic effects of marijuana use?
A. Chronic use of marijuana is associated with low testosterone levels.
B. Chronic use of marijuana is the primary cause of amotivational syndrome.
C. Marijuana use is associated with an increased risk of psychotic symptoms in individuals with a past history of schizophrenia.
D. Physical and psychological tolerance does not develop in chronic users of marijuana.
E. There is no withdrawal syndrome associated with cessation of marijuana use.
ANSWERS
1 and 2. The answers are D and D, respectively.
(Chap. 1) The ability to perform a thorough neurologic examination is an important skill for all internists to master. A careful neurologic examination can localize the site of the lesion and is important in directing further workup. The components of the neurologic examination include mental status, cranial nerves, motor, sensory, gait, and coordination. The motor examination is further characterized by appearance, tone, strength, and reflexes. Pronator drift is a useful tool for determining if upper extremity weakness is present. In this test, an individual is asked to stand with both arms fully extended and parallel to the floor while closing his or her eyes. If the arms flex at the elbows or fingers or there is pronation of the forearm, this is considered a positive test. Other tests of motor strength include tests of maximal effort in a specific muscle or muscle group. Most commonly this type of strength testing is graded from 0 (no movement) to 5 (full power) with varying degrees of weakness noted against resistance. However, many individuals find it more practical to use qualitative grading of strength, such as paralysis, severe weakness, moderate weakness, mild weakness, or full strength.
Babinski sign is a sign of upper motor neuron disease above the level of the S1 vertebra and is characterized by paradoxical extension of the great toe with fanning and extension of the other toes as well. Dysdiadochokinesis refers to the inability to perform rapid alternating movements and is a sign of cerebellar disease. Lhermitte symptom causes electric shock–like sensations in the extremities associated with neck flexion. It has many causes including cervical spondylosis and multiple sclerosis. Romberg sign is performed with an individual standing with feet together and arms at the side. The individual is then asked to close his or her eyes. If the individual begins to sway or fall, this is considered a positive test and is a sign of abnormal proprioception.
3. The answer is C.
(Chap. 1) This patient likely has metastatic disease to the cervical spinal cord. The patient’s symptoms are bilateral with sparing of the cranial nerves and normal mental status, localizing the lesion below the level of the brainstem and cerebrum. The patient demonstrates mixed upper and lower motor neuron signs with decreased sphincter tone and a positive Babinski sign, placing the lesion at the level of the spinal cord. As the weakness is involving both the arms and legs, this would indicate a lesion in the lower cervical or upper thoracic spine. Symptoms of abnormalities at the level of the neuromuscular junction include bilateral weakness that can include the face having normal sensation.
4. The answer is C.
(Chap. 4) Appropriate and timely evaluation is needed to determine if a subarachnoid hemorrhage is present as it can be rapidly fatal if undetected. The procedure of choice for initial diagnosis is a CT of the head without IV contrast. On the CT, blood in the subarachnoid space would appear whiter compared to the surrounding brain tissue. The CT of the head is most sensitive when it is performed shortly after the onset of symptoms, but declines over several hours. It can also demonstrate the presence of mass effect and midline shift, factors that increase the severity of the underlying hemorrhage. In the situation where the CT head is negative but clinical suspicion is high, a lumbar puncture can be performed. This may demonstrate increased numbers of red blood cells that do not clear with successive aliquots of cerebrospinal fluid. If the lumbar puncture is performed more than 12 hours after a small subarachnoid hemorrhage, then the red blood cells may begin to decompose, leading to xanthochromia—a yellow to pink coloration of cerebrospinal fluid that can be measured spectrographically. A basic CT of the head with IV contrast is rarely useful in subarachnoid hemorrhage, as coiling.
5. The answer is E.
(Chap. 4) Magnetic resonance imaging (MRI) is generated from the interaction between the hydrogen protons in biologic tissues, the magnetic field, and the radiofrequency (Rf) of waves generated by the coil placed next to the body part of interest. The Rf pulses transiently excite the protons of the body with a subsequent return to the equilibrium energy state, a process known as relaxation. During relaxation, the protons release Rf energy creating an echo that is then transformed via Fourier analysis to generate the MR image. The two relaxation rates that influence the signal intensity of the image are T1 and T2. T1 refers to the time in milliseconds that it takes for 63% of protons to return to their baseline state. T2 relaxation is the time for 63% of protons to become dephased owing to interactions among nearby protons. The intensity of the signal is also influenced by the interval between Rf pulses (TR) and the time between the Rf pulse and the signal reception (TE). T1-weighted images are produced by keeping both TR and TE relatively short, while T2-weighted images require long TR and TE times. Fat and subacute hemorrhages have relatively shorted TR and TE times and thus appear more brightly on T1-weighted images. Structures with more water such as cerebrospinal fluid or edema conversely have long T1 and T2 relaxation times, resulting in higher signal intensity on T2-weighted images. T2 images are also more sensitive for detecting demyelination, infarction, or chronic hemorrhage.
FLAIR stands for fluid-attenuated inversion recovery and is a type of T2-weighted image that suppresses the high-intensity signal of CSF. Because of this, images created by the FLAIR technique are more sensitive to detecting water-containing lesions or edema than the standard spin images.
MR angiography refers to several different techniques that are useful for assessing vascular structures, but does not provide details of the underlying brain parenchyma.
6. The answer is E.
(Chap. 4) For many years, MRI imaging was considered the modality of choice for patients with renal insufficiency because it does not lead to acute renal failure. However, gadolinium was recently linked to a rare disorder called nephrogenic systemic fibrosis. This newly described disorder results in widespread fibrosis in skin, skeletal muscle, bone, lungs, pleura, pericardium, myocardium, and many other tissues. Histologically, thickened collagen bundles are seen in the deep dermis of the skin with increased numbers of fibrocytes and elastic fibers. There is no known medical treatment for nephrogenic systemic fibrosis (NSF), although improvement may be seen following kidney transplantation. It