27-year-old woman comes to the office for follow-up. She was last seen 2 months ago for generalized musculoskeletal pain and several months of fatigue. Evaluation revealed multiple soft-tissue tender points, negative inflammatory and serological markers, and normal thyroid studies. The patient was diagnosed with fibromyalgia and prescribed a low-impact exercise program and pharmacotherapy. Her pain and fatigue have
subsequently improved, but she now notes intermittent episodes of dizziness. Most of the episodes are short-lived, but she occasionally needs to brace herself against a wall or sit until the dizziness resolves. There have been no associated falls or loss of consciousness. She also notes worsened lethargy and frequent dry mouth. Other medical history includes migraines and irritable bowel syndrome. The patient currently takes daily amitriptyline for fibromyalgia, occasional acetaminophen for muscular pains, and polyethylene glycol as needed for constipation. She does not use tobacco, alcohol, or illicit drugs and has no known drug allergies. Temperature is 36.8 C (98.2 F), blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 14/min. BMI is 21 kg/m2. Mucous membranes are pink and moist and there is no jugular venous distention.
Cardiopulmonary auscultation is normal. The abdomen is soft and nontender. Neurologic examination reveals intact cranial nerves and normal muscle strength in all extremities. Which of the following would be most helpful in determining the cause of this patient’s dizziness?
- Q A. Carotid sinus massage
- Q B. Dix-Hallpike testing
- Q C. Orthostatic blood pressure measurements
- Q D. Romberg testing with eyes closed
- Q E. Tandem gait testing
17-year-old girt is admitted to the hospital due to lower extremity weakness. Onset of tingling in the patient’s feet began 5 days ago; she then developed weakness 3 days ago, which has been worsening, and now she cannot stand or walk. She had an upper respiratory infection 2 weeks ago; otherwise, medical history is unremarkable. Temperature is 36.7 C (98 F), blood pressure is 110170 mm Hg, pulse is 85/min, and respirations are 18/min. Pulse oximetry is 99% on room air. Physical examination shows an adolescent girl in no acute distress and clear lungs on auscultation. Bilateral ankle and knee flexion/extension strength is 1/5, and hip flexors are 2/5. Reflexes are absent in the lower extremities. The upper extremities have 3/5 strength and 1 + reflexes. The patient can keep her head erect and swallow saliva. Gag reflex is intact. Cerebrospinal
fluid results are as follows:
Red blood cells 0/mm3
Protein 200 mg/dl
Glucose 65 mg/dl
Gram stain No bacteria seen
Which of the following is the most appropriate next step in management of this patient?
- QA Chest x-ray
- 0 B. Elective intubation
- 0 C. Muscle biopsy
- 0 D. Spinal MRI with gadolinium
- 0 E. Spirometry
- 0 F Stool assay for botulism toxin