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A 36-year-old woman with a 15-year history of headaches comes to the office for a follow-up visit. Initially, she had moderate to severe bilateral pulsatile, frontal headaches accompanied by nausea, light and noise sensitivity, and occasional vomiting. They occurred one to two times each month and lasted 24 to 36 hours. In the last 2 years, she has developed a daily mild to moderate bilateral frontal headache that is present when she awakens and lasts all day. Approximately once per week she has a headache that is similar to her previous episodic headaches but less severe. She takes amitriptyline, 75 mg at bedtime, as a prophylactic agent. She takes acetaminophen/caffeine/butalbital, 4 tablets/d, and rizatriptan, 10 to 20 mg, one to two days per week for more severe headaches. Physical and neurologic examinations are normal.
What is the most appropriate next step in managing this patients headache disorder?
A. Discontinue amitriptyline and initiate treatment with divalproex sodium.
B. Discontinue acetaminophen/caffeine/butalbital.
C. Discontinue rizatriptan.
D. Increase dose of amitriptyline
6
A 65-year-old man has weakness and wasting of his left hand and muscle twitching involving his arms
and thighs. The symptoms have progressed over 5 months. There is no associated pain or paresthesia. Neurologic examination reveals severe weakness and atrophy of the left thenar and hypothenar muscles, and mild weakness of left foot dorsiflexion. Muscle stretch reflexes are hyperactive and symmetric. Sensation is normal. Magnetic resonance imaging of the cervical spine was obtained by an orthopedic surgeon 2 weeks earlier and is normal.
Which of the following is the most appropriate next step?
A. Muscle biopsy
B. Nerve biopsy
C. Serum creatine kinase determination
D. Electromyography
E. Genetic testing

a??
d

_ Q1: BBB

_ Q2: DDD

Q1-B
Q2-D

B
D?

B?
D MND?

B
D - Fasciculations suggesting MND

5b
This patient has developed a form of daily headache known as chronic migraine (transformed migraine). In many patients the change in headache pattern is caused by overuse of analgesics (more than 2 to 3 days per week). Combination analgesics are particularly likely to lead to chronic daily headache. Accordingly, the first intervention is to discontinue use of the combination analgesic. Discontinuing the offending agent usually results in improvement within 1 month, but occasionally takes longer. Patients should be advised that headaches may transiently worsen when the medication is discontinued. Amitriptyline may prove to be an effective preventive agent once the medication overuse headache has been eliminated. Increased amitriptyline or substitution with divalproex sodium is not likely to improve the daily headaches as long as the overuse of analgesics persists. Overuse headache from triptan agents is unlikely to occur when the medication is taken at a frequency of 2 days per week, as in this patient

6d
This patient has progressive, painless weakness and atrophy in the absence of sensory symptoms. He has upper and lower motor neuron signs in the symptomatic left arm, and essentially asymptomatic weakness in the left leg. The presentation suggests motor neuron disease (amyotrophic sclerosis). EMG would most likely confirm the diagnosis with findings of denervation in multiple extremities. As only 5% to 10% of cases of amyotrophic lateral sclerosis are familial, genetic testing at this stage is not indicated. The distribution of weakness is not proximal, as would occur with most myopathies, so muscle biopsy would not be helpful. Although creatine kinase levels may be elevated in rapidly progressive motor neuron disease, it is a nonspecific finding. The absence of sensory symptoms or signs argues against a peripheral neuropathy, so nerve biopsy, while likely showing axonal loss, would not be of high yield.

thanks again.