Kamsi
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A 35-year-old man with a history of Addison's disease presents to the emergency department complaining of nausea, vomiting, and generally not feeling well for a week. He began having a cough with brownish sputum and felt feverish, with chills starting about a week ago. Yesterday, the patient began having increasing weakness, abdominal pain, and diarrhea. His wife also adds that at times he gets confused and doesn't realize where he is. His only medication is hydrocortisone 15 mg daily. His temperature is 102.7 F, with a heart rate of 116/min, a blood pressure of 89/53 mm Hg, and a respiratory rate of 25/min. He has dry mucous membranes, and bronchial sounds are heard over the right lung. The abdomen is diffusely tender to palpation, and there is no rebound tenderness. His white cell count is 18,200/mm3, sodium 126 mEq/L, potassium 5.6 mEq/L, bicarbonate 24 mEq/L, BUN 32 mg/dL, creatinine 1.1 mg/dL, and glucose 72 mg/L. The chest x-ray shows a right middle-lobe infiltrate. What is the most urgent initial step in the management of this patient?<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
(A) ACTH stimulation test
(B) Increase his dose of hydrocortisone to 30 mg daily
(C) Start antibiotics
(D) Stat dose of hydrocortisone 100 mg intravenously
(E) CT scan of the chest and abdomen
A 45-year-old man comes to the office complaining of shooting pains in his legs for the past two weeks. He describes these pains as transient and agonizing. He also has had urinary incontinence for the last four to six months. He drinks alcohol heavily. On physical examination, his gait is unsteady and wide-based. The unsteadiness is exacerbated by eye closure. The vibration and position sense in his legs is decreased, and his deep-tendon reflexes are diminished. His pupils are small, slightly irregular, poorly reactive to light, and more responsive to accommodation. What is the most likely cause of his problem?
(A) Wernicke's encephalopathy
(B) Holmes-Adie syndrome
(C) Diabetes mellitus
(D) Multiple sclerosis
(E) Tabes dorsalis
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| Justice
Just signed contract
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D
A
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| peraspera
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1. D. Dose hydrocortisone 100mg IV + volume repletion( Adrenal crisis)
2. A. Wernicke's encephalopathy
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| Kamsi
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I thought Wernicke as well but found the ans to be Tabes dorsalis .this is the expalanation
This patient presents with manifestations of neurosyphilis and tabes dorsalis. The clinical manifestations of neurosyphilis are divided into acute syphilitic meningitis, cerebrovascular disease, dementia (general paresis), and tabes dorsalis. Tabes dorsalis is a myeloneuropathy that involves the proximal dorsal-root entry zones into dorsal-root ganglia. The classic triad includes lightning pains, sensory ataxia, and urinary disturbance. Signs of neurosyphilis include pupillary abnormalities, lower extremity hyporeflexia, and an abnormal Romberg's sign. The pains are most common in the legs but may involve any part of the body. Early loss of vibration and position sense is characteristic, which is attributed to secondary degeneration of the posterior columns of the spinal cord. This produces a wide-based gait, which is exacerbated by the loss of visual input, known as Romberg's sign. Bladder hypotonia with overflow incontinence results from involvement of sacral, sensory nerve roots. Half of the patients with pupillary abnormalities will have the classic Argyll-Robertson pattern, as in our patient. Other pupillary abnormalities will include unilateral mydriatic pupils with loss of the pupillary light reflex.
Wernicke's encephalopathy is a complication of chronic alcoholism, which is characterized by ophthalmoplegia, ataxia, and a confusional state. Pupillary abnormalities include anisocoria and sometimes a sluggish reaction to light. The most common ocular symptoms are nystagmus, abducens nerve palsy, and horizontal or combined horizontal-vertical gaze palsy. <?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
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| starcraftbw
Forum Senior
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D and E
Argyl-Robertson eyes: accommodate but no REACT  ...someone may know what it means
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| usmle-china
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D and E
Good explanation
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