A 58-year-old man describes a temporary weakness in his right hand that occurred 3 days ago while driving his truck. He was unable to move his arm for 30 minutes, but he progressively regained his strength. He also had difficulty speaking around the same time with transient loss of vision. All symptoms are resolved now. His temperature is 98.4⁰ F, heart rate is 71 beats per minute, respiratory rate is 16 breaths per minute, oxygen saturation 97%, and blood pressure is 172/101 mm Hg. His past medical history is significant for diabetes, hypertension and coronary artery disease with stable angina. He has been smoking since he was 15 years-old and he currently smokes one pack of cigarettes a day. His current medications include aspirin, insulin, sublingual nitroglycerin, and metoprolol. On examination, bruits can be auscultated over both carotid arteries. The remainder of his physical examination is unremarkable. CT scan of the head is normal. Carotid artery ultrasound revealed 78% occlusion in the left carotid artery and 52% occlusion in the right carotid artery. Which of the following is the most appropriate management for this patient?
A 68-year-old man of African heritage comes to your office complaining of progressive loss of vision over the last four months. First it started with loss of peripheral vision and later his central vision has also worsened. He gets headaches as he tries to see things more clearly than he can. His past medical history is significant for hypertension. He has a 30-pack-year smoking history. Family history is significant for MYOC gene carriers. On examination, his visual acuity is 20/400 both eyes. There does not appear to be a relative afferent pupillary defect (RAPD). Ophthalmoscopy shows symmetrically enlarged cup-to-disk ratio (0.8) and a highly asymmetric cupping in the right eye. Tonometry measures the intraocular pressure of 18 mm Hg in the left eye and 20 mm Hg in the right eye. Pachymetry reveals decreased thinning of the cornea in both eyes. You decided to treat this patient’s disorder with medication. Which of the following medications are considered preferred first-line agents in the management of this disorder?
A 68-year-old man of African heritage comes to your office complaining of progressive loss of vision over the last four months. First it started with loss of peripheral vision and later his central vision has also worsened. He gets headaches as he tries to see things more clearly than he can. His past medical history is significant for hypertension. He has a 30-pack-year smoking history. Family history is significant for MYOC gene carriers. On examination, his visual acuity is 20/400 both eyes. There does not appear to be a relative afferent pupillary defect (RAPD). Ophthalmoscopy shows symmetrically enlarged cup-to-disk ratio (0.8) and a highly asymmetric cupping in the right eye. Tonometry measures the intraocular pressure of 18 mm Hg in the left eye and 20 mm Hg in the right eye. Pachymetry reveals decreased thinning of the cornea in both eyes. You decided to treat this patient’s disorder with medication. Which of the following medications works by increasing aqueous humor outflow through uveoscleral channels?
A 68-year-old man of African heritage comes to your office complaining of progressive loss of vision over the last four months. First it started with loss of peripheral vision and later his central vision has also worsened. He gets headaches as he tries to see things more clearly than he can. His past medical history is significant for hypertension. He has a 30-pack-year smoking history. Family history is significant for MYOC gene carriers. On examination, his visual acuity is 20/400 both eyes. There does not appear to be a relative afferent pupillary defect (RAPD). Ophthalmoscopy shows symmetrically enlarged cup-to-disk ratio (0.8) and a highly asymmetric cupping in the right eye. Tonometry measures the intraocular pressure of 18 mm Hg in the left eye and 20 mm Hg in the right eye. Pachymetry reveals decreased thinning of the cornea in both eyes. Which of the following is the most likely cause of this patient’s vision loss?
A 20 year-old man is brought into the emergency department by his girlfriend. The patient has been unconscious for over twenty minutes. The patient went to a rave party last night and came home in a drunken state. His girlfriend was not able to give any details on what he drank or what he ate at the party. Now, the patient is not communicating. He barely opens his eyes upon painful stimuli. His temperature is 97 ⁰ F, heart rate is 58 beats per minute, respiratory rate is 7 breaths per minute, and blood pressure is 80/55 mm Hg. His heart and lung examinations are unremarkable. Abdomen is nontender with hypoactive bowel sounds. Pupils react to light but constricted and sluggish. Which of the following is the next best step in the management of this patient, after you checked his airway, breathing and circulation?
A 24 year-old male is admitted to the hospital for treatment of endocarditis secondary to intravenous drug use. He was discharged from a methadone clinic 3 weeks ago and he bought some buprenorphine and some other pills off the street. Today his urine drug screen came positive for 6-monoacetylmorphine (6-MAM). Which of the following substances is he most likely abusing at this time?
Anand is a 34 year-old male who presents in the emergency room because he decided to ‘do something about my pill problem before they destroy my life’. He feels guilty that he had to starve this children to buy his ‘goodies’.He reports using hydrocodone and morphine and ‘whatever I can get my hands on’ pills almost on a daily basis, ‘I go bonkers if I don’t feed my habit one way or another’. His last use of morphine was around two hours ago. What is the best way to treat his opioid use disorder?
