Internal Medicine

Educational objective: Surgical resection is recommended for solitary brain metastasis in patients with good performance status and stable extracranial disease. patients with multiple brain metastases, whole brain radiation therapy is typically used.

A 65-year-old man is brought to the emergency department after having a seizure. Past medical history is significant for non-small cell lung carcinoma diagnosed 2 years ago and treated surgically. He continues to work as a college professor and usually walks 1-2 miles daily. MRI of the brain shows a solitary cortical mass (2 cm x 3.5 cm) in the right hemisphere at the grey-white matter junction that is most consistent with metastasis. CT scan of the chest and abdomen shows no evidence of recurrent malignancy. The patient is admitted for further management and started on phenytoin.

Educational objective: Phenytoin is an antiepileptic drug with known teratogenic effects (eg, fetal hydantoin syndrome). Women of childbearing age who have a low risk of seizure recurrence may safely discontinue phenytoin if considering becoming pregnant; however, the medication should be slowly tapered as rapid withdrawal may result in seizure recurrence.

A 29-year-old woman comes to the clinic for routine follow-up. Five years ago, she experienced an unprovoked generalized tonic-clonic seizure. At that time, phenytoin was prescribed, and the patient has been on a stable dose since. She has not experienced seizure recurrence. MRI of the brain performed following the initial episode was normal. She has no other medical problems and is a lifetime nonsmoker. The patient's family history is negative for neurologic disease. She is in a stable relationship and is contemplating pregnancy. Blood pressure is 123/72 mm Hg and pulse is 75/min. Neurologic examination is unremarkable. Serum phenytoin level is 11 mcg/ml (therapeutic range, 10-20 mcg/ml}. Electroencephalogram is normal.

Educational objective: Patients with an intracranial mass often have headache associated with nausea and vomiting andfor focal neurologic deficits. Symptoms are often worse at night and with body positioning that increases intracranial pressure. An MRI of the brain is usually diagnostic .

A 65-year-old man comes to the ·office due to unsteady gait and frequent falls over the past 2 months. His left side feels "weak," which makes it difficult to maintain balance when walking or standing. He has also had headaches and nausea, which are worse in the mornings before he has had coffee. The patient has a history of hypertension and type 2 diabetes mellitus, and he had a myocardial infarction 5 years ago. He takes insulin for diabetes mellitus but does not routinely monitor his blood glucose. The patient is a former smoker and does not use alcohol or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 76/min. Ambulation results in the patient swaying to the left and using the wall to brace himself. There is increased resistance to passive flexion of the left upper and lower extremity.

Educational objective: The management of myasthenic crisis with respiratory failure consists of endotracheal intubation followed by treatment with plasmapheresis (or intravenous immunoglobulins) and corticosteroids.

A 68-year-old man with myasthenia gravis is evaluated for progressive weakness while hospitalized. The patient was admitted 2 days prior due to fever, productive cough, and pleuritic chest pain. Chest x-ray demonstrated a right lower lobe consolidation for which the patient has been receiving intravenous ceftriaxone and azithromycin. He also has been receiving his outpatient dose of pyridostigmine.
In the past several hours,
he has experienced progressive generalized weakness and an inability to cough out sputum. His temperature is 37.6 C (99.8 F), blood pressure is 130170 mm Hg, pulse is 11 Of min, and respiratory rate is 25fmin. Oxygen saturation is 89°/o on 4 Umin oxygen by nasal cannula. The patient appears to be in distress, and his breathing pattern is rapid and shallow with occasional gurgling sounds. Lung auscultation reveals coarse crackles throughout There is mild weakness of the extremities, but deep tendon reflexes are normal. His vital capacity is now 1.0 L compared to 1.5 Lat the time of admission, and arterial blood gas shows pH 7.27, pC02 55 mrn Hg, and p02 60 mm Hg. The patient is intubated and moved to the intensive care unit

Educational objective: Dementia with Lewy bodies causes cognitive fluctuations, visual hallucinations, and parkinsonism. Cognitive symptoms may precede, or appear along with, parkinsonian features.

A 67-year-old woman is brought to the office by her son. He reports that his mother has had periodic confusion, memory loss, and poor sleep and seems "kind of out of it sometimes." These symptoms have gradually worsened over the past 1-2 years. The patient occasionally sees "strangers in the backyard," who are not there when her son looks for them. More recently, she has begun walking more slowly and has fallen twice in the past month without any significant injuries. The patient has a history of hypertension and depression. She does not drink alcohol or use illicit drugs. On physical examination, she walks slowly and has mild bilateral hand tremors and mild bilateral lower limb rigidity. On cognitive examination, the patient appears to be oriented to person and place, and can recall 1 of 3 items in 5 minutes; she can state the days of the week forward but does not cooperate with stating them backward. Chemistries, complete blood count, vitamin B12, and thyroid function tests are normal. Serun1 treponemal test is nonreactive. MRI of the brain shows mild generalized cortical atrophy.