搜索
NeurologyMain51-60Q51A35-year-oldmancomestotheemergencydepartmentduetoseverepainbehindhislefteye.Thepatientreportsthatthepainisintenseandstabbingandthatitwokehimuparoundmidnight.Itimprovedafter30minutesandhewasabouttogobacktosleepwhenthesamepainbeganagain.Hetookibuprofenwithoutrelief.Severalmonthsago,thepatienthadsimilarepisodesofpainthatresolvedspontaneouslyafter2weeks.Hehashadnofevers,blurryvision,nausea,orvomitingbuthashadnasalcongestion.Thepatienthasseasonalallergiesforwhichhetakescetirizine.Heworksasaflightoperationsofficeranddescribeshisjobasprettystressful.”Hedrinks2or3cupsofcoffeedailyanddrinksalcoholoccasionally.Hismotherhasmigraineheadaches.Temperatureis36.7C(98F):bloodpressureis140/90mmHg;andpulseis94/min.Thepatientisrestlessandagitated.Physicalexaminationshowsleft-sidedptosis;miosis,andrhinorrhea.Neurologicexaminationshowsbilateralequalandnormalmotorstrength,sensation,anddeeptendonreflexes.Whichofthefollowingisthemostlikelycauseofthispatient'sheadache?A.AcutemaxillarysinusitisB.AngleclosureglaucomaC.BraintumorD.ClusterheadacheE.LacunarinfarctionF.MigrainewithoutauraG.OrbitalcellulitisH.RetinaldetachmentI.SubarachnoidhemorrhageJ.SubstanceabusedisorderK.Tension-typeheadacheL.TrigeminalneuralgiaA51Correctanswer:DThispatientwithacuteleftretro-orbitalpainthatresolvesandrecursandisaccompaniedbyipsilateralautonomicmanifestations(eg,ptosis[droopyeyelid],miosis[pupillaryconstriction],rhinorrhea)likelyhasclusterheadaches.Theseepisodesaregenerallyseeninyoungmenrareunilateralandcanbeaccompaniedbyrednessoftheipsilateraleyewithtearingbutnovisualchanges,aswellasbyagitationduetotheseverityofthepain.Theparoxysmsofclusterheadacheattacksbeginduringsleep,peakrapidly,lastapproximately90minutes,andoccurupto8timesdailyfor6-8weeksfollowedbyaremissionlastinguptoayear.Becausetheattacksareshortbutsevere：prophylacticmedication(eg;verapamil,lithium)isimportantformanagement.Anacuteattackcanbeabortedwithinhalationof100o/ooxygenandsubcutaneoussumatriptan.(ChoicesAandG)Acutemaxillarysinusitiscanpresentwithfacialpainandrhinorrhea,butthereisusuallyassociatedfeverandanosmia.OrbitalcelJulitisisaninfectionofthefatandextraocularmusclesoftheeye.Patientsusuallyhaveerythema,edema,andtenderness,oftenwithimpairedextraocularmovement.Theseconditionsgenerallydonotcauseparoxysmsofsevereretro-orbitalpainormiosis.(ChoiceB)Angleclosureglaucomausuallypresentswithsudden-onseteyepain,nausea,anddiminishedvisionwithhalosseenaroundlights.Patientstypicallyhaveafixedandmid-dilatedpupilandnotptosisormiosis.(ChoicesC,E,andI)Abraintumortypicallypresentswithprogressiveheadache,morningnausea,andfocalneurologicdeficitsduetomasseffect.Alacunsrinfarctioncanhavearangeofsyndromicpresentations(egrpuremotorhemiparesis,ataxic-hemiparesis:dysarthria/clumsyhand).Asubarachnoidhemorrhageischaracterizedbysudden-onset,persistent,severeheadachethatcanbeassociatedwithvomiting,seizure,andadecreasedlevelofconsciousness.Noneoftheseconditionswouldcauserecurrentsevereretro-orbitalpaininayoungpatient.(ChoicesF,K,andL)Migrainesareusuallyassociatedwithnausea：vomiting,andphotophobia;theseheadachesaretypicallypulsatileandthrobbingratherthansharpandsevere.Tension-typeheadachescanoccurduetostressbutareusuallynon-throbbingandbilateral.Trigeminalneuralgiaischaracterizedbyrecurrentandsudden-onsetstabbingpainalongtheM2(maxillary)andMZ(mandibular)branchesofthetrigeminalnerve.Theepisodeslastafewsecondstominutesandcanbetriggeredbyminorstimuli(eg,wind).Piosis,miosis：andrhinorrheaaremoresuggestiveofclusterheadache.(ChoiceH)Aretinaldetachmenttypicallypresentswithlightflashes,floaters,oracurtainacrossthevisualfieldthatusuallystartsfromtheperipheryandisgenerallynotpainful.(ChoiceJ)Substanceabusedisordercanpresentwithagitationandrestlessness,butitdoesnotusuallypresentwithunilateralptosisandmiosisorwithsudden-onsetandrecurrentretro-orbitaleyepain.Educationalobjective:Clusterheadachesusuallypresentwithacute：unilateral,severeretro-orbitalpainthatawakenspatientsfromsleep.Theseheadachesmaybeaccompaniedbyrednessandtearing,rhinorrhea;andipsilateralptosisandmiosis.Q52A75-year-oldmancomestotheofficeforprogressivehearinglossandringinginhisears.Thepatientstatesthatoverthelast5yearshehasnoticedadeclineinhisabilitytohearsocialconversations：especiallywhenthereiscompetingbackgroundnoise.Hehasdifficultytoleratingloudsoundsthatothersintheroomareabletohandle.Thepatienthasalsoexperiencedsubjectivecontinuoushigh-pitchedringinginbothearsoverthepastyear.Hehasnohistoryofheadtrauma,headache,vertigo,visualchanges,disequilibrium,slurredspeech,difficultyswallowing,weakness,ornumbness.Hismedicalproblemsincludediabetesmellitusandhypertension.Hetakesatorvastatin,metformin,andlisinopril.Thepatienthasbeenachronicsmokerformanyyears.Vitalsignsarenormal,WeberandRinnetestssuggestthepresenceofbilateralsensorineuralhearingloss.Otoscopicexaminationandauscultationoverbothperiauricularareasareunremarkable.Theremainderofhisneurologicexaminationisnormal.Whichofthefollowingisthemostlikelydiagnosis?A.AcousticneuromaB.CholesteatomaC.Drug-induc