A previously healthy 10-year-old boy is brought to the emergency department for the evaluation of one episode of vomiting and severe headache since this morning. His mother says he also had difficulty getting dressed on his own. He has not had any trauma. The patient appears nervous. His temperature is 37°C (98.6°F), pulse is 100/min, and blood pressure is 185/125 mm Hg. He is confused and oriented only to person. Ophthalmic examination shows bilateral optic disc swelling. There is an abdominal bruit that is best heard at the right costovertebral angle. A complete blood count is within normal limits. Which of the following is most likely to confirm the diagnosis?

High-dose dexamethasone suppression test

A 22-year-old man is brought to the emergency department by ambulance 1 hour after a motor vehicle accident. He did not require any circulatory resuscitation at the scene, but he was intubated because he was unresponsive. He has no history of serious illnesses. He is on mechanical ventilation with no sedation. His blood pressure is 121/62 mm Hg, the pulse is 68/min, and the temperature is 36.5°C (97.7°F). His Glasgow coma scale (GCS) is 3. Early laboratory studies show no abnormalities. A search of the state donor registry shows that he has registered as an organ donor. Which of the following is the most appropriate next step in evaluation?

Evaluation of brainstem reflexes

A 74-year-old male is brought to the emergency department 1 hour after he fell from the top of the staircase at home. He reports pain in his neck as well as weakness of his upper extremities. He is alert and immobilized in a cervical collar. He has hypertension treated with hydrochlorothiazide. His pulse is 90/min and regular, respirations are 18/min, and blood pressure is 140/70 mmHg. Examination shows bruising and midline cervical tenderness. Neurologic examination shows diminished strength and sensation to pain and temperature in the upper extremities, particularly in the hands. Upper extremity deep tendon reflexes are absent. Strength, sensation, and reflexes in the lower extremities are intact. Anal sensation and tone are present. Babinski's sign is absent bilaterally. Which of the following is most likely to confirm the cause of this patient's neurologic examination findings?

MRI of the cervical spine without contrast

CT of the cervical spine with contrast

A 37-year-old man is presented to the emergency department by paramedics after being involved in a serious 3-car collision on an interstate highway while he was driving his motorcycle. On physical examination, he is responsive only to painful stimuli and his pupils are not reactive to light. His upper extremities are involuntarily flexed with hands clenched into fists. The vital signs include temperature 36.1°C (97.0°F), blood pressure 80/60 mm Hg, and pulse 102/min. A non-contrast computed tomography (CT) scan of the head shows a massive intracerebral hemorrhage with a midline shift. Arterial blood gas (ABG) analysis shows partial pressure of carbon dioxide in arterial blood (PaCO2) of 68 mm Hg, and the patient is put on mechanical ventilation. His condition continues to decline while in the emergency department and it is suspected that this patient is brain dead. Which of the following results can be used to confirm brain death and legally remove this patient from the ventilator?

Lumbar puncture and CSF culture

Electromyography with nerve conduction studies

A 56-year-old man comes to the physician because of worsening double vision and drooping of the right eyelid for 2 days. He has also had frequent headaches over the past month. Physical examination shows right eye deviation laterally and inferiorly at rest. The right pupil is dilated and does not react to light or with accommodation. The patient's diplopia improves slightly on looking to the right. Which of the following is the most likely cause of this patient’s findings?

Aneurysm of the posterior communicating artery

Demyelination of the medial longitudinal fasciculus

Thrombosis of the cavernous sinus

A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?

Second opinion from a neurologist

Withdraw ventilation support and mark time of death

Repeat examination in several hours

A 27-year-old man presents to the emergency department after being hit by a car while riding his bike. The patient was brought in with his airway intact, vitals stable, and with a C-collar on. Physical exam is notable for bruising over the patient’s head and a confused man with a Glasgow coma scale of 11. It is noticed that the patient has a very irregular pattern of breathing. Repeat vitals demonstrate his temperature is 97.5°F (36.4°C), blood pressure is 172/102 mmHg, pulse is 55/min, respirations are 22/min and irregular, and oxygen saturation is 94% on room air. Which of the following interventions are most likely to improve this patient's vital signs?

Head elevation, sedation, mannitol, hyperventilation

Head elevation, sedation, hypertonic saline, hypoventilation

Lower head, sedation, hypertonic saline, hypoventilation

Head elevation, norepinephrine, mannitol, hyperventilation

Lower head, sedation, hypertonic saline, hyperventilation

A 25-year-old male presents to his primary doctor with difficulty sleeping. On exam, he is noted to have impaired upgaze bilaterally, although the rest of his ocular movements are intact. On pupillary exam, both pupils accommodate, but do not react to light. What is the most likely cause of his symptoms?

Melanoma with temporal lobe metastasis

A 45-year-old female presents to the emergency room as a trauma after a motor vehicle accident. The patient was a restrained passenger who collided with a drunk driver traveling approximately 45 mph. Upon impact, the passenger was able to extricate herself from the crushed car and was sitting on the ground at the scene of the accident. Her vitals are all stable. On physical exam, she is alert and oriented, speaking in complete sentences with a GCS of 15. She has a cervical spine collar in place and endorses exquisite cervical spine tenderness on palpation. Aside from her superficial abrasions on her right lower extremity, the rest of her examination including FAST exam is normal. Rapid hemoglobin testing is within normal limits. What is the next best step in management of this trauma patient?

Remove the patient’s cervical collar immediately

Discharge home and start physical therapy

Initiate rapid sequence intubation.

Consult neurosurgery immediately

Disability assessment (neurological status) — USMLE Lesson

GCS - Scoring the Brain Game

Assesses level of consciousness after brain injury. Sum of best Eye, Verbal, & Motor responses.

Score	Eye Opening (E)	Verbal Response (V)	Motor Response (M)
6	-	-	Obeys commands
5	-	Oriented	Localizes to pain
4	Spontaneous	Confused	Withdraws from pain
3	To speech	Inappropriate words	Abnormal flexion (decorticate)
2	To pain	Incomprehensible sounds	Abnormal extension (decerebrate)
1	None	None	None

Mild: 13-15
Moderate: 9-12
Severe: ≤8

📌 Mnemonic: "EVM 4-5-6" for max scores in each category (Eyes, Verbal, Motor).

⭐ GCS ≤ 8 indicates severe brain injury and is a critical threshold for intubation.

Glasgow Coma Scale Components

Pupils - Windows to the Brain

Assessment: Evaluate size, equality, and reactivity to light (PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation).
Size & Symmetry:
- Normal: 2-4 mm in light, 4-8 mm in dark.
- Anisocoria: Unequal pupil sizes.
Reactivity: A sluggish or absent direct light response suggests ↑ ICP or optic nerve (CN II)/oculomotor nerve (CN III) dysfunction.
⚠️ Unilateral Dilated Pupil ("Blown Pupil"):
- A fixed and dilated pupil is a critical sign of ipsilateral uncal herniation compressing CN III.
- Requires immediate neurosurgical consultation.

⭐ Cushing's Triad: A late sign of severely increased ICP, consisting of hypertension (widening pulse pressure), bradycardia, and irregular respirations.

Uncal Herniation: Causes, Symptoms, and Treatment

Spinal Check - Don't Get on My Nerves

Log-Roll Maneuver: A coordinated effort by 4-5 personnel to turn the patient while maintaining strict spinal immobilization. Allows for inspection and palpation of the entire thoracic and lumbar spine.
Physical Examination:
- Palpate the full length of the spine for tenderness, swelling, or palpable "step-offs" between vertebral bodies.
- Inspect for bruising (e.g., seatbelt sign), penetrating wounds, or deformities.
Key Neurological Signs:
- Digital Rectal Exam (DRE): Essential to test for rectal tone. ↓ tone is a sign of spinal cord injury.
- Priapism: A persistent, painful erection; a sign of complete spinal cord transection.
- Sacral Sparing: Check for intact perianal sensation (S2-S4).

⭐ Prognostic Pearl: The presence of sacral sparing (intact perianal sensation, voluntary rectal sphincter contraction, or great toe flexion) indicates an incomplete spinal cord lesion and is the single most critical factor for a favorable prognosis.

Log-roll maneuver with C-spine stabilization

High‑Yield Points - ⚡ Biggest Takeaways

The Disability assessment's primary goal is to rapidly identify life-threatening central nervous system (CNS) injury.

Use the Glasgow Coma Scale (GCS) to objectively assess consciousness by evaluating eye, verbal, and motor responses.

A GCS score of ≤ 8 signifies severe brain injury and is a critical indication for definitive airway management (intubation).

Assess pupil size, symmetry, and reactivity to light for early signs of brain herniation.

The AVPU scale (Alert, Verbal, Pain, Unresponsive) is a faster, simpler alternative for rapid initial assessment.

Frequent reassessment of GCS and pupils is crucial to detect neurological deterioration.

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