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
Correct Answer :
C. Pregabalin
This patient presents with complaints of dysesthesias and given his history of uncontrolled diabetes mellitus, this is concerning for diabetic neuropathic pain. Dysesthesias are unpleasant sensations that are often described as electric shock, pins and needles, or feelings as though one is walking on broken glass with barefoot. Diabetic neuropathy is present in at least 50% of diabetes patients and while its primary symptoms are unpleasant, the secondary complications such as falls, foot ulcers, arrhythmias, and ileus are even more serious.
To confirm this diagnosis, it is important to do physical examination in patients who present with its common symptoms, as signs are better predictors of polyneuropathy than symptoms. Moreover, electrodiagnostic studies further increase the accuracy of diagnosis as sensitive, specific and validated measures of the presence of polyneuropathy.
Management of diabetic neuropathy obviously includes endeavors to control blood glucose, but this would not be sufficient for immediate relief of pain in the patient. For neuropathic pain management available oral agents include antidepressants and anticonvulsant drugs. Pregabalin (choice C) has been found to have the same efficacy and safety in older patients and results are comparable to those observed in younger patients with neuropathic pain.
> Daily metformin (choice A) would gradually decrease HbA1C over a period of several months and greatly improve the patients overall condition, but his pain needs immediate attention.
> Metoclopramide (choice B) is used in the treatment of diabetic gastroparesis but it would not be the best choice for treating neuropathic pain.
> Alpha lipoic acid (choice D) has been studied as treatment option for diabetic neuropathy but there have been insufficient evidence to support or refute the usefulness of this drug in the treatment of neuropathic pain.
> Amitriptylline (choice E) is useful as analgesic for neuropathic pain but its benefits in elderly are limited by the increased adverse effects reported in these patients. Generally, tricyclic antidepressants should be avoided in patients who are > 65.
Key point:
The most commonly used oral agents for diabetic neuropathic pain are antidepressants and anticonvulsants. Pregabalin has the same efficacy and safety in older patients and results are comparable to those observed in younger patients with neuropathic pain.
Related Questions
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: Seizure
Subject: Medicine
A 75-year-old male is brought to your office 1 month after a stroke that involved the left anterior cerebral artery, manifested by leg weakness, initial incontinence, and slowness in mentation. He experienced seizure activity on the second day after his stroke, but this was controlled by phenytoin (Dilantin). He has improved significantly and is now ambulatory. His family states that he now has episodic confusion, sleepiness, and clumsiness, which is preceded by paresthesias and dizziness, although no tonicclonic activity has been noted. He remains very drowsy for several hours after these episodes. He was wearing a cardiac monitor during one episode, but it showed nothing remarkable. His phenytoin level is therapeutic, and a CBC, metabolic profile, and magnesium level are all normal.
Which one of the following would be the most appropriate next step?
Discontinue the phenytoin
Add phenobarbital to the phenytoin
Begin bupropion (Wellbutrin)
Begin lamotrigine (Lamictal)
Topic: Guillain-Barrďż˝ syndrome
Subject: Medicine
A 43-year-old man presents 2 weeks after you see him for infectious diarrhea caused by C. jejuni. He has now developed bilateral proximal lower limb weakness and bilateral distal parasthesia and decreased ankle tendon reflex.
What is the most likely diagnosis?
Guillain-Barrďż˝ syndrome
Multiple Sclerosis
Myasthenia Gravis
Systemic Lupus Erythematosus
Topic: Essential Tremor
Subject: Medicine
A 75 year old white male complains of a tremor which has been progressive over the past 2 years. The tremor interferes with writing, pouring liquids, and eating soup. He has no other medical problems. He abstains from alcohol and tobacco products. Physical examination is remarkable for an action tremor of the upper extremities and a head tremor. No rigidity or gait disorder is noted. Of the following agents, which one is most appropriate as initial drug therapy for this problem?
Alprazolam (Xanax)
Clonazepam (Klonopin)
Carbamazepine (Tegretol)
Propranolol (Inderal)
Topic: Normal Pressure Hydrocephalus
Subject: Medicine
An 81-year-old female is brought to your office by her son. He reports a decrease in his mothers memory and prolonged delays in her responses to questions. She also has developed urinary incontinence. MRI shows dilated ventricles, but no other pathology, and a lumbar puncture reveals a normal opening pressure.
Which one of the following would provide additional evidence of normal pressure hydrocephalus?
Monocular visual loss
Internuclear ophthalmoplegia
Headache
Apraxia of gait
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: Organophosphate poisoning
Subject: Medicine
What is the mechanism of action in organophosphate poisoning?
Cholinesterase inhibition
Cholinesterase activation
Catecholamine inhibition
Catecholamine activation
Topic: Adverse Drug Effect
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. He is treated with valproic acid.
What are the most common side effects caused by this medication?
Weight gain
Rash
Nausea and headache
Tardive dyskinesia
Topic: Mini Mental Status Exam (or MMSE)
Subject: Medicine
In healthy adults, performance on the Folstein Mini-Mental State Examination is affected by which one of the following?
Educational attainment
Socioeconomic status
Gender
Race
Topic: Osmotic Demyelination
Subject: Medicine
Osmotic demyelination can result when which one of the following is corrected too rapidly?
Hypocalcemia
Hypoglycemia
Hypomagnesemia
Hyponatremia
Topic: Hepatic Encephalopathy
Subject: Medicine
A 50-year-old man with a history of hemochromatosis presents to the emergency room vomiting up bright red blood. He had his most recent phlebotomy yesterday. His blood pressure is 110/85 mm Hg, his pulse 115/min; his face is flushed, and he is diaphoretic. During the physical examination splenomegaly and a venous pattern on his chest and abdomen are noted. He seems somewhat drowsy and confused but has no focal neurologic signs.
What is the probable source of this patient's confusion?
Severe anemia
Hepatic encephalopathy
Subarachnoid hemorrhage
Vitamin B12 deficiency
Topic: Adverse Drug Effect
Subject: Medicine
During the morning rounds, a second year resident presents a patient as a 58-year-old female who suffers from rigidity and tremors. She has been diagnosed with a neurodegenerative disease involving the depigmentation of substantia nigra and loss of dopaminergic input to basal ganglia. Identify the medication that would worsen rather than improve this patient's condition?
Levodopa
Bromocriptine
Chlorpromazine
Pergolide
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: Seizure
Subject: Medicine
Of the following, which is the most frequent cause of seizures in the elderly?
Alcohol withdrawal
Stroke
Head trauma
Hypoglycemia
Topic: Amnesia
Subject: Medicine
Which of the following medications may cause amnesia as a side effect?
Hydroxyzine
Fluoxetine
Triazolam
Clonidine
Topic: Guillain-Barrďż˝ syndrome
Subject: Medicine
Guillain-Barrďż˝ syndrome is not associated with which of the following?
Proximal muscle weakness
Areflexia
Infection with C. jejuni
Treatment with corticosteroids
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
Capsaicin (Zostrix)
Carbamazepine (Tegretol)
Topic: Dementia
Subject: Medicine
All of the following dementias can benefit from specific treatments, except:
Normal pressure hydrocephalus (NPH)
Alzheimers disease
Sarcoidosis
Creutzfeldt Jakob disease
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: 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: 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: 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: Temporal Arteritis
Subject: Medicine
A 75-year-old female presents with a 2-month history of bilateral headache, diffuse myalgias, and diplopia. On examination she has substantially diminished vision in her left eye, but no other neurologic findings. A moderately tender, cordlike structure is palpable just anterior to her ear and extending up to her lateral scalp. Blood tests show a markedly elevated erythrocyte sedimentation rate.
Which one of the following would be most appropriate at this point?
Clopidogrel (Plavix)
High-dose corticosteroids
NSAIDs
Dipyridamole/aspirin (Aggrenox)
Topic: Status Epilepticus
Subject: Medicine
A 58-year-old male with a history of seizure attacks suffered from a 30min loss of consciousness with repetitive seizures with no recovery of consciousness between attacks. What is the best initial treatment for his condition?
Lorazepam
Phenytoin
Phenobarbital
Carbamazepine
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.
Which of the following is the most appropriate next step?
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: MMSE
Subject: Medicine
The Mini-Mental State Examination (MMSE) tests for:
Mood
Behavior
Intelligence quotient
Cognitive function
Topic: Neurologic pain
Subject: Medicine
A 21-year-old man presented to the emergency hospital with severe abdominal pain. The pain started four hour ago. His medical history reveals Acute Intermittent Porphyria (AIP) and he used to have frequent attacks of abdominal pain and believes that this attack is no different. On examination, the patient is in acute pain and slightly feverish but not pale, jaundiced or cyanosed. However, his blood pressure is found to be high and he has tachycardia.
You should consider a diagnosis other than an AIP attack if the pain is associated with:
Constipation
Tenderness
Abdominal distension
Decreased bowel sounds
Topic: Delirium Tremens
Subject: Medicine
You see a 49-year-old man in the emergency room with a 20-year-history of alcohol abuse. He is agitated and floridly psychotic, with visual hallucinations and persecutory delusions. On examination his blood pressure, heart rate and respiratory rate are all increased. He is disoriented, sweaty, and has abdominal cramps.
What is the most likely diagnosis?
Subdural hematoma
Alcohol intoxication
Hepatic encephalopathy
Delirium tremens
Topic: Brown-Sequard Syndrome
Subject: Medicine
Which of the following would not be expected in a right-sided Brown-S�quard syndrome?
Right-sided hemi-paresis
Right-sided loss of proprioception
Left-sided decreased sensitivity to pinprick
Left-sided decreased vibration sense
Topic: Essential Tremor
Subject: Medicine
Which one of the following is most likely to be of benefit in patients with essential tremor of the hand?
Isoniazid
Diazepam
Primidone
Clonidine