Doctors In Training ( DIT )

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Educational objective: Diabetic peripheral neuropathy is characterized by numbness and paresthesia in a stocking-and-glove distribution. It results from nonenzymatic glycosylation of proteins, leading to hyalinization of endoneurial arteries and ischemic nerve damage. In addition, accumulation toxic substances within neurons results in deranged metabolism and increased oxidative stress.

A 62-year-old woman comes to the office due to tingling and numbness in her feet over the last several months. The patient has also noticed a small ulcer on her right foot that "doesn't seem to be healing." Medical history is significant for long-term diabetes, hypertension, and gout. Physical examination shows decreased pain sensation over both feet and bilateral absence of ankle reflexes.

Educational objective: Delayed cerebral ischemia due to cerebral vasospasm usually presents 3-12 days after the initial subarachnoid hemorrhage (SAH) with an acute change in mental status and/or new focal neurological deficits. Nimodipine, a selective calcium channel blocker, improves outcomes in patients with cerebral vasospasm by inducing cerebral vasodilation and decreasing calcium-dependent excitotoxicity.

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Educational objective: Creutzfeldt-Jakob disease is a prion disease characterized by rapidly progressive dementia, myoclonus, and death within a year of symptom onset.It is caused by the accumulation of an abnormally folded (ie,beta pleated sheet) protein that is resistant to proteases and can trigger similar conformational changes in other normally folded proteins.

A 57-year-old man is hospitalized for aspiration pneumonia. The patient was healthy and worked as an engineer without difficulty until about 4 months ago. Since that time, he has developed severe confusion, mood changes, and memory impairment and had to take medical leave from work. The patient is now completely dependent on his wife for toileting, feeding, and general self-care. Physical examination shows disorientation and sporadic, jerky extremity movements. During hospitalization, the patient lapses into a coma and dies. Postmortem examination of his brain shows widespread atrophy of the cerebral cortex and cerebellum.

Educational objective: Schwannomas present histologically with a biphasic pattern of cellularity (Antoni A and B areas) and S-100 positivity (indicating neural crest origin). Schwannomas can arise from the peripheral nerves, nerve roots, and cranial nerves (except CN II and CN I). Acoustic neuromas are the most common type of intracranial schwannoma and are located at the cerebellopontine angle at CN VIII.

An intracranial mass is removed from a 33-year-old patient. The mass is composed of cells that have elongated, wavy nuclei. A biphasic pattern of growth is identified, consisting of areas of dense cellularity interspersed with less dense myxoid regions. The cells show diffuse S-100 immunoreactivity.

Educational objective: Lesions of the jugular foramen can result in jugular foramen (Vernet) syndrome, which is characterized by the dysfunction of cranial nerves IX, X, and XI. Symptoms include dysphagia, hoarseness, loss of gag reflex on the ipsilateral side, and deviation of the uvula toward the normal side.

A 67-year-old woman with a known history of lung cancer comes to the office due to hoarseness and difficulty swallowing. She has no disturbances in vision or hearing. On examination, there is loss of the gag reflex on the left side; when the patient is prompted to say "ah," the uvula deviates to the right side. a right lower lobe lung mass and several osteolytic rib lesions. MRI of the head also demonstrates multiple Her left shoulder is drooped and strength is reduced during left shoulder shrug testing. Chest x-ray shows lesions consistent with metastasis.

Educational objective: Germinomas are the most common pineal gland tumor and present with obstructive hydrocephalus and dorsal midbrain (Parinaud) syndrome. Germinomas in the suprasellar region cause endocrinopathies due to pituitary/hypothalamic dysfunction.