Neurology-Main神经内科-111-120

NeurologyMain111-120Q111A59-year-oldmalepresentstotheERwithdiplopiathatstartedseveralhoursago.Hehasnoothercomplaints.Hispastmedicalhistoryissignificantforlong-standingdiabeteswithpoorglycemiccontrol,rightkneeosteoarthritis,andpepticulcerdisease.Physicalexaminationrevealsright-sidedptosiswiththerighteyelookingdownandout.PupilsareequalandreactivetoSight.Thispatient'sconditionismostlikelyduetowhichofthefollowing?A.NervecompressionB.NerveischemiaC.NerveInflammationD.LacunarstrokeE.MuscleinfiltrationA111Correctanswer:BDiabetesmellituscausesanumberofcomplications:withneuropathybeingverycommon.Diabeticsmostcommonlyhave(symmetric)peripheralneuropathy,mononeuropathy,andautonomicneuropathy.Mononeuropathiesaredividedintocranialandsomatic-amongcranialnerves,.CNIIIisaffectedthemostoften.Indiabetes,oculomotornerve(CNIll)neuropathyisischemic.SomaticandparasympatheticfibersofCNIIIhaveseparatebloodsupplies.Forthisreason,diabeticCNIIIneuropathyaffectsonlysomaticfibers,leavingparasympatheticfibersintactSymptomsareptosisandadownandoutgaze.Accommodationandthepupil'sresponsetolightremainintact.(Alternatively,ifnervecompressioncausesCNIIIneuropathy,bothsomaticandparasympatheticfiberswillbeaffected.Patientswillhaveptosis,arfdownandoufgaze,afixed,dilatedpupil,andnoaccommodationreflex.)CNIII(oculomotornerve)hasthefollowingfunctions:1.Itssomaticcomponentinnervatestheinferior,superior,andmedialrectus,inferiorobliqueandlevatorpalpebraemuscles.Ptosisoccursduetoparalysisofthelevatorpalpebrae;whereas,theunopposedactionofthelateralrectus(CNVI)andsuperioroblique(CNIV)musclesleadtoadownandoutgaze.2.ParasympatheticfibersofCNIIIinnervatethesphincteroftheirisandtheciliarymuscle.Paralysisofparasympatheticfiberscausesafixed,dilatedpupilandcausesaninabilityofthelenstochangeshape(lossofaccommodation).(ChoiceA)CNIllneuropathycanoccurduetonervecompression.Causesincludetranstentorial(uncal)herniationoraneurysmoftheposteriorcommunicatingartery.BothsomaticandparasympatheticfibersofCNII!areequallyaffectedinthiscondition.(ChoiceD)Lacunarstrokeresultsfromobstructionofthepenetratingarteriolesthatsupplywhitematter.Thesestrokesmanifestwithpuremotororpuresensorysyndromes.(ChoicesCandE)Neithernerveinflammationnormuscleinfiltrationcontributestothedevelopmentofdiabeticneuropathy.EducationalObjective:DiabeticmononeuropathyofteninvolvesCNIII.Nervedamageisischemic,andonlysomaticnervefibersareaffected.ParasympatheticfibersofCNIIIretainfunction.Ptosisanda“downandoutgazeinconjunctionwithnormallightandaccommodationreflexesindicatediabeticCNIIIneuropathy.Q112A71-year-oldmancomestotheofficeduetoworseninglowbackpain.Thepatientishavingsignificantpainwithmovementthatislimitinghisactivity,aswellasnocturnalpainthatisdisruptinghissleep.Hehashadnolowerextremityweaknessornumbnessandnobladderorboweldysfunction.Heistakingibuprofen3-4timesaday,anditisnotcontrollinghispain.Thepatienthasahistoryofprostatecancerandtakesleuprolide.Healsoreceivedpalliativeradiotherapyformultiplelumbarspinemetastasesseveralmonthsago.Temperatureis37C(98.6F),bloodpressureis140/86mmHg;andpulseis88/min.Lowerextremitymotorstrength,deeptendonreflexes,andsensationarenormal.Whichofthefollowingisthemostappropriatenextstepinthispatientspainmanagement?A.Extended-releaseopioidB.HeatingpadC.LocalglucocorticoidinjectionD.Short-actingopioidE.SubstitutionofibuprofenwithnaproxenF.SystemicglucocorticoidG.TopicalcapsaicinH.TransdermalfentanylpatchA112Correctanswer:DThispatienthasbonemetastaseswithprogressivepaindespitespecificcancer-directedtreatments(ie,leuprolide,radiotherapy).Metastaticbonediseaseiscommoninadvancedprostatecancer：aswellaslung：breast,andrenalcellcancersandmultiplemyeloma.Mildtomoderatecancer-relatedpaincanusuallybemanagedwithnonopioidanalgesics(eg,acetaminophen,nonsteroidalanti-inflammatorydrugs[NSAIDs]).However,forseverepain,orifinitialinterventionsarenoteffective,short-actingopioids(eg,morphine,hydromorphone,oxycodone)shouldbeoffered.Short-actingopioidsaresafeandwell-toleratediftakenasdirected,andthedoseandschedulecanbevarieddependingonthepatient'spainpattern.Ifthepatienthaspainrequiringfrequentdosingorifbedtimedosingdoesnotprovideadequatereliefthroughthenight,a丨〇ng-actingopioid(eg,sustained-releasemorphine)maybeadded(ChoiceA).(ChoiceB)Nonpharmacologicmeasures(eg;heatrice,massage,splinting)mightbeusefulformildcancer-relatedpainbutareunlikelytobeadequateforthosewithmoresignificantpain.(ChoicesCandF)LocalglucocorticoicHnjectionsaremostusefulforasingleorlimitednumberofpainfulmusculoskeletallesions(eg,bursitis).Systemicglucocorticoids(eg,dexamethasone)areusedurgently:ntreatmentofmalignantneurologiccompromise(egrspinalcordcompression).Theyarealsosometimesusedasadjunctivetherapyinpatientswhohavebonepainwithoutneurologicdeficitsifthereisincompleteimprovementonopioidtherapyalone.(ChoiceE)Naproxenhasalongerdurationofactionthanibuprofenandcanbeusedinpatientswhorequirefrequentdosing.SwitchingfromoneNSAIDtoanothercanbeconsideredforpatientswithmildpain,butthispatient'sactivity-limitingpainwarrantsatrialofanopioid.(Ch