Educational objective: Because the facialfophthalmic venous system is valveless, uncontrolled infection of the skin can result in cavernous sinus thrombosis. Red-flag symptoms include severe headache; bilateral periorbital edema; and cranial nerve 111, IV, V, and VI deficits .

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A 58-year-old woman comes to the physician due to difficulty walking. Over the last several weeks she has also experienced bilateral foot numbness and tingling. She was diagnosed with advanced Hodgkin lymphoma 2 months ago and is currently undergoing chemotherapy containing bleomycin, doxorubicin, and vincristine. Her other medical problems include type 2 diabetes and hypertension. Physical examination shows bilateral weakness on dorsiflexion of the feet and loss of pain and temperature sensation affecting both toes. Knee jerk reflexes are 2+ bilaterally but ankle jerk reflexes are absent

Educational objective: Chemotherapy-induced peripheral neuropathy typically presents as a symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern. Common causative agents include platinum-based medications (eg, cisplatin}, taxanes (eg, paclitaxel), and Vinca alkaloids (eg, vincristine }.

A 71-year-old man comes to the ·office due to worsening low back pain. The patient is having significant pain with movement that is limiting his activity, as well as nocturnal pain that is disrupting his sleep. He has had no lower extremity weakness or numbness and no bladder or bowel dysfunction. He is taking ibuprofen 3-4 times a day, and it is not controlling his pain. The patient has a history of prostate cancer and takes leuprolide. He also received palliative radiotherapy for multiple lumbar spine metastases several months ago. Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min. Lower extremity motor strength, deep tendon reflexes, and sensation are normal.

Educational objective: Mild to moderate cancer-related pain can usually be managed with nonopioid analgesics. However, if initial interventions are not effective, intermittent doses of short-acting opioids should be offered. If the pain requires frequent dosing or if bedtime dosing does not provide relief through the night, a long-acting opioid may be added.

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A 31-year-old woman comes to the office due to vision disturbances. The patient is a software developer and works on a computer most of the time. She first noticed blurry vision 2 months ago. Since then, she has had several episodes of blurry and double vision, especially toward the end of the workday. Two days ago, she experienced neck discomfort and had difficulty holding her head up, which resolved after a night's rest. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. On physical examination, pupils are 3 mm, round, and reactive to light. There is no ptosis, and ocular movements are normal. No neck deformity or tenderness is present. Muscle strength, deep tendon reflexes, and sensation are normal in the bilateral upper and lower extremities. Further evaluation reveals antibodies directed against nicotinic receptors on the motor endplate.

Educational objective: Individuals with features of myasthenia gravis ( eg, fluctuating and fatigable ocularfbulbar weakness) should undergo confirmatory testing with acetylcholine receptor antibodies, which are highly specific. Those with an established diagnosis should subsequently undergo chest imaging (eg, CT scan, MRI) to evaluate for thymoma and for possible surgical planning, as thymectomy is associated with Jong-term clinical improvement in both patients with and without thymoma

A 44-year-old woman comes to the office with muscle weakness over the past several months. She has difficulty combing her hair and, occasionally, difficulty holding up her head, particularly after prolonged sitting or standing. The patient has had no difficulty \'talking or getting up from a chair. She has also had 2 episodes of double vision while driving home from work. The patient takes rosuvastatin for hyperlipidemia and lisinopril for hypertension. Blood pressure is 142184 mm Hg and pulse is 76fmin. Neurologic examination shows mild right ptosis, symmetric proximal muscle weakness in the upper extremities, and weakness in the head extensors. Muscle bulk and tone are normal and there is no muscle tenderness.