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A 69-year-old man comes to the emergency department due to severe occipital headache, nausea, and vomiting for the last 3 hours. He has never had a headache like this before and has otherwise been in good physical condition. The patient was told several years ago that he has high blood pressure, but he has not been taking any medications or seen any health care providers. He has smoked half a pack of cigarettes daily for 40 years and drinks 1 or 2 cans of beer every evening. Both of his parents died of natural causes. Blood pressure is 160/90 mm Hg and pulse is 86/min and regular. His noncontrast head CT scan is shown in the image below.

Educational objective: Spontaneous cerebellar hemorrhage is typically caused by poorly controlled hypertension and presents with occipital headache, neck stiffness, nauseafvomiting, nystagmus, and ipsilateral hemiataxia. There is usually no hemiparesis or sensory loss. Early diagnosis with noncontrast head CT scan is important as emergency surgical decompression may be life-saving .

A 70-year-old man comes to the ·office 4 weeks after experiencing an ischemic stroke. His medical history is significant for a long history of hypertension, diabetes, coronary artery disease, congestive heart failure, and atrial fibrillation. Vital signs are unremarkable. BMI is 23.8 kg/m2. Cardiovascular examination reveals an irregularly irregular rhythm. The patient is right-handed. Only the right side of his face is shaved. When asked to raise his left arm, he raises his right arm. When asked to fill in the numbers of a clock, he puts numbers only on the right side.

Educational objective: Hemineglect syndrome is characterized by ignoring one side of a space (the left side in right-handed individuals) and involves the nondominant parietal lobe (the right lobe in right-handed individuals).

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

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