Topic: Cauda Equina Syndrome
Subject: Medicine
A 65-year-old male presents with a 1-month history of problems passing urine. He says that his bladder will feel full when he needs to urinate, but the urine stream is weak and his bladder does not feel as if it has emptied completely. The symptoms have become increasingly severe over the past week. Other symptoms include upper respiratory congestion for 3 days which he has treated with an over-thecounter decongestant with some relief, constipation with no passage of stool in the past 9 days, and increasing low back pain incompletely relieved with ibuprofen, with associated weakness in both legs. Examination shows a healthy-appearing male who is moderately overweight. He is afebrile and vital signs are normal. There is no abdominal tenderness and no masses are detected. A rectal examination reveals a large amount of hard stool in the rectum; a markedly enlarged (4+), boggy, tender prostate gland; laxity of the anal sphincter; and numbness in the perianal area. Urinalysis shows trace protein and 10-20 WBCs/hpf. Ultrasonography shows a post-void residual volume of 250 mL (normal for age <100).
Which one of the following must be done urgently in this patient?
Foley catheterization
Hospitalization for intravenous antibiotics
Digital disimpaction of the rectum, and Fleet enemas until clear
MRI of the lumbosacral spine
Correct Answer :
D. MRI of the lumbosacral spine
The differential diagnosis of urinary retention in the elderly is broad. While most causes are benign and readily treated, the physician must be vigilant in looking for conditions that require urgent intervention.
This patient presents with many possible causes of urinary retention, with the most common being benign prostatic hyperplasia. Acute prostatitis, especially in a male with an enlarged prostate, is another relatively common reason for obstructive symptoms. This patients physical examination and abnormal urinalysis support this diagnosis, but his normal vital signs and lack of fever suggest he can be treated with an oral fluroquinolone and does not require hospital admission for intravenous therapy. Medications such as oral decongestants can contribute to urinary retention in men with enlarged prostate glands, and should be used with caution and discontinued if obstructive symptoms occur. Obstipation (severe constipation caused by intestinal obstruction) with stool impaction is another relatively common reason for urinary retention in the elderly and can be treated with manual disimpaction and enemas. In this patient, the presence of increasing low back pain and leg weakness, and the findings of anal sphincter laxity and numbness in the perianal area on examination, suggest the presence of a serious neurologic etiology such as cauda equina syndrome. Urgent diagnosis and treatment are necessary to reduce morbidity, and MRI should be performed immediately. The presence of a mildly elevated post-void residual is not an indication for urgent decompression with a Foley catheter.
Related Questions
Topic: Diagnostic Investigations
Subject: Medicine
A 52 year old male with a history of psychosis presents with muscle stiffness and resting tremors, associated with difficulty in balance and initiating movements. What is the best diagnostic method for detection of the above condition?
Serum dopamine levels
Computed tomography scan
Positron emission tomography scan
Magnetic resonance imaging
Topic: Guillain-Barr� syndrome
Subject: Medicine
Guillain-Barr� syndrome is not associated with which of the following?
Proximal muscle weakness
Areflexia
Infection with C. jejuni
Treatment with corticosteroids
Topic: Seizure
Subject: Medicine
A 32-year-old female experiences an episode of unresponsiveness associated with jerking movements of her arms and legs. Which one of the following presentations would make a diagnosis of true seizure more likely?
Post-event confusion
Eye closure during the event
A history of fibromyalgia
A history of chronic back pain
Topic: Absence Seizures
Subject: Medicine
The treatment of choice for absence seizures is:
Lamotrigine
Ethosuximide
Phenobarbital
Phenytoin
Topic: Dementia
Subject: Medicine
An 85 year old white male is brought to you for the first time by his son. The father has recently seen a neurologist who performed a workup for dementia and diagnosed moderate Alzheimers disease. Which one of the following is true regarding the use of a cholinesterase inhibitor in this patient?
It is too late to initiate cholinesterase therapy
Agitation is often intensified by these agents
Memory is likely to improve significantly
Nursing-home placement may be delayed a year or longer
Topic: Peripheral Neuropathy
Subject: Medicine
A 68-year-old male presents to your department complaining of a very horrible sensation in his legs that started out 4 weeks ago as pins and needles tickling him but now has progressed and feels like being stabbed in his feet. He has started to use a walker because he feels that when he walks it feels like stepping on eggshells. The pain has not been responsive to acetaminophen and ibuprofen. The patients past medical history is significant for diabetes type II treated with metformin and glimepiride. The patient has not been very compliant with medications, especially metformin because he feels it causes him an upset stomach. His most recent HbA1C level was 9.8%. He also has hypercholesterolemia treated with lovastatin and hypertension treated with Lisinopril and amlodipine. His vital signs are temperature 37.4°C, BP is 125/70 mmHg, pulse 85/min, and respirations 15/min. The dorsalis pedis and posterior tibial pulses are +2 bilaterally. No distal muscles weakness or atrophy is observed. Manual esthesiometer with monofilaments is used and reveals decreased sensation from the midfoot distally on both feet. There is no evidence of erythema, edema, or any wounds on either foot. He has tenderness to light touch on both feet. Labs reveal normal Vitamin B12 and thyroid function.
Which of the following would be the most appropriate treatment for this patients pain?
Daily metformin compliance
Metoclopramide
Pregabalin
Alpha lipoic acid
Topic: Postherpetic Neuralgia
Subject: Medicine
A 78-year-old male comes to your office with a 3- day history of pain in the right side of his chest. The pain is described as burning and intense. Two days ago he noted a rash at that site. Examination reveals groups of vesicles on an erythematous base in a T-5 dermatome distribution on the right.
Which one of the following would be the most appropriate treatment to minimize the chance of post-herpetic neuralgia?
Famiciclovir (Famvir)
Prednisone
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Topic: Heatstroke
Subject: Medicine
A 72-year-old male is brought to your office by a friend because of increasing confusion, irritability, and difficulty walking. This began shortly after the patients car broke down and he had to walk a mile to get to a phone and call the friend. The temperature outdoors has been near 39.5°C (100°F).
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Confusion
Sweating
His temperature
His heart rate
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Subject: Medicine
While performing the Mini-Mental State Exam the PCP asks her patient to copy the following design. What cognitive function is being assessed by this request?
Language
Orientation
Registration
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Topic: Seizure
Subject: Medicine
A 52-year-old male with a history of seizure attacks suffered from loss of consciousness and tonic-clonic muscular contractions. His tongue fell back into his throat and he choked.
What is the medication of choice for the treatment of this patient's condition?
Phenytoin
Valproic acid
Tiagabine
Phenobarbital
Topic: Diagnostic Investigations
Subject: Medicine
A 50-year-old male is brought to the emergency department because of a syncopal episode. Prior to the episode, he felt bad for 30 minutes, then developed nausea followed by vomiting. During a second bout of vomiting he blacked out and fell to the floor. His wife did not observe any seizure activity, and he was unconscious only for a few seconds. His history is otherwise negative, his past medical history is unremarkable, and he currently takes no medications. A physical examination is normal.
Which one of the following would be the most helpful next step?
CT of the head
Carotid ultrasonography
A CBC and complete metabolic profile
An EKG
Topic: MMSE
Subject: Medicine
The Mini-Mental State Examination (MMSE) tests for:
Mood
Behavior
Intelligence quotient
Cognitive function
Topic: Alzheimer's Disease
Subject: Medicine
An 84-year-old black female is brought to your office by her daughter, who is concerned that the mother has memory problems and is neglecting to pay her monthly bills. The mother also is forgetting appointments and asks the same questions repeatedly. This problem has been steadily worsening over the last 1-2 years. The patient has very little insight into her problems, scores 24 out of a possible 30 points on the Mini-Mental State Examination, and has difficulty with short-term recall and visuospatial tasks. Her physical examination and a thorough laboratory workup are normal. A CT scan of the brain reveals diffuse atrophy. Which one of the following is the most likely etiology for the patients memory problem?
Alzheimers disease
Dementia resulting from depression
Lewy body dementia
Multi-infarct dementia
Topic: Essential Tremor
Subject: Medicine
A 66 year old white female consults you because she has developed a tremor of her right hand that interferes with her ability to do needlework. She has noticed that the tremor improves when she rests her hands in her lap and gets worse when she holds them up against gravity. She has developed a slight quiver to her voice as well. Her symptoms started gradually over 6 months ago and have progressed slowly. She remembers her mother having similar problems in her later years. She takes no medications, and her physical examination corroborates her history. No other abnormalities are noted. A multiple chemistry screen and TSH level are normal.
Which one of the following is most likely to alleviate her tremor?
Propranolol (Inderal)
Paroxetine (Paxil)
Carbidopa/levodopa (Sinemet)
Bromocriptine (Parlodel)
Topic: Benign Positional Vertigo
Subject: Medicine
Which one of the following is characteristic of benign positional vertigo?
A duration of 10-15 minutes
Associated hearing loss and tinnitus
Associated diplopia and facial numbness
Being triggered by turning the head
Topic: Korsakoff's Psychosis
Subject: Medicine
In a patient with recent onset of alcohol amnestic disorder, the mental status test most likely to be done poorly is memory of:
Political figures of 10 years ago
Digits (forward)
His own name
Three items for 5 minutes
Topic: Osmotic Demyelination
Subject: Medicine
Osmotic demyelination can result when which one of the following is corrected too rapidly?
Hypocalcemia
Hypoglycemia
Hypomagnesemia
Hyponatremia
Topic: Seizure
Subject: Medicine
A 52-year-old male with a history of seizure attacks suffered from loss of consciousness and tonic and clonic muscular contractions. His tongue fell back into the throat and he choked. What is the most likely diagnosis of this presentation?
Petit mal seizure
Grand mal seizure
Myoclonic seizure
Atonic seizure
Topic: Seizure
Subject: Medicine
A 36-year-old male with a history of a seizure disorder is brought to the emergency department with generalized tonic-clonic activity. Emergency medical personnel report this has been ongoing for 20 minutes.
After initial resuscitative measures, the preferred medication in this situation is:
Phenytoin (Dilantin)
Fosphenytoin (Cerebyx)
Naloxone
Lorazepam (Ativan)
Topic: Subarachnoid Hemorrhage
Subject: Medicine
A 36-year-old female presents with the sudden onset of severe headache, nausea, and photophobia. Her level of consciousness is progressively diminishing. Which one of the following would be the most appropriate next step?
Head CT without contrast
Head CT with contrast
Head MRI
Lumbar puncture
Topic: Temporal Arteritis
Subject: Medicine
A 70-year-old woman returns to the office because of aching and weakness in her arms to the point where she cannot lift her arm to brush her hair. Physical examination shows no muscle tenderness or other evidence of joint disease in both arms. The aching improves when she takes the prescribed nonsteroidal anti-inflammatory drug (NSAID). She also describes tenderness over the right temporal area of her scalp. Physical examination of the scalp shows no lesions.
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Increase the dose of the NSAID
Order determination of erythrocyte sedimentation rate
Order determination of serum rheumatoid factor
Order x-ray films of the cervical spine
Topic: Dementia
Subject: Medicine
A 60-year-old white female presents for her annual physical examination. She tells you that since her last visit she has begun taking ginkgo biloba to improve her memory. She takes no other medications. The evidence supporting a benefit from ginkgo biloba is best for which one of the following?
Tinnitus
Benign prostatic hyperplasia
Dementia
Intermittent claudication
Topic: Alzheimer's Disease
Subject: Medicine
Which one of the following tests is most useful for the initial workup of suspected Alzheimers disease?
Carotid Doppler ultrasonography
An erythrocyte sedimentation rate
A cardiac stress test
A TSH level
Topic: Huntington disease
Subject: Medicine
A 42-year-old white male is brought to your department by his wife because of the progressive loss of his mental abilities, irritability, and some irregular involuntary movements of his hands. She says that she can remember when they were newlyweds, her husbands father had a similar condition at the age of 45 and he died few years later because there was not much doctors could do for him back then. She wants to know if their children may eventually develop a similar condition in the future. None in her family has ever had this type of condition. Which of the following would be the most appropriate answer?
Only their male children are at risk
If one child develops the disease, siblings are not at risk
All their children will inherit the disease
Each child has 50% risk of inheriting the disease
Topic: Trigeminal Neuralgia
Subject: Medicine
A man complains that recently when he shaves he has a shooting type of pain in his face. It happens once in a while and then goes away. You suspect trigeminal neuralgia.
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Fluoxetine
Prednisone
Acyclovir
Carbamazepine
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Subject: Medicine
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T12
L1
L2
L4 - L5
Topic: Seizure
Subject: Medicine
A 52-year-old man with a history of seizure attacks suffered from loss of consciousness and tonic and clonic muscular contractions. His tongue fell back into his throat and he choked. What is the best diagnostic test for assessment of the presenting condition of this patient?
X-rays
CT-Scan
Electroencephalogram
Discography
Topic: Alzheimer's Disease
Subject: Medicine
Which one of the following has NOT been identified as a risk factor for Alzheimer-type dementia (AD)?
Trisomy 18
Head trauma
Advanced age
Obesity and hypertension
Topic: Seizure
Subject: Medicine
A 68-year-old man with a history of urolithiasis, suffered from a seizure attack which involved loss of consciousness with tonic and clonic muscular contractions. His tongue fell back into his throat and he choked.
Which of the following medications is contraindicated in this patient's treatment?
Levetiracetam
Phenytoin
Topiramate
Carbamazepine
Topic: Cauda Equina Syndrome
Subject: Medicine
A 65-year-old male presents with a 1-month history of problems passing urine. He says that his bladder will feel full when he needs to urinate, but the urine stream is weak and his bladder does not feel as if it has emptied completely. The symptoms have become increasingly severe over the past week. Other symptoms include upper respiratory congestion for 3 days which he has treated with an over-thecounter decongestant with some relief, constipation with no passage of stool in the past 9 days, and increasing low back pain incompletely relieved with ibuprofen, with associated weakness in both legs. Examination shows a healthy-appearing male who is moderately overweight. He is afebrile and vital signs are normal. There is no abdominal tenderness and no masses are detected. A rectal examination reveals a large amount of hard stool in the rectum; a markedly enlarged (4+), boggy, tender prostate gland; laxity of the anal sphincter; and numbness in the perianal area. Urinalysis shows trace protein and 10-20 WBCs/hpf. Ultrasonography shows a post-void residual volume of 250 mL (normal for age <100).
Which one of the following must be done urgently in this patient?
Foley catheterization
Hospitalization for intravenous antibiotics
Digital disimpaction of the rectum, and Fleet enemas until clear
MRI of the lumbosacral spine