Questions 08/29/2012

Questions 01/10/2013NeurologyQuestion 1A 40-year-old previously healthy female presents with sudden onset of a severe occipital and nuchal headache following a coughing fit. Vital signs and physical examination are normal. Which of the following is indicated?Contrast CT scan of the brain followed by lumbar puncture if negativeNon-contrast CT scan of the brain followed by lumbar puncture if negativeMRI scan of the brainTrial of pain medication and CT scan of the head and lumbar puncture only if headache is unrelievedAnswer 1Subarachnoid hemorrhagePresent in 11-25% of patients who present with thunderclap headache (sudden onset headache whose intensity is severe, aka worst of life or excruciating, and reaches a maximal intensity within seconds to a minute)20% of patients develop symptoms while engaged in activities that raise blood pressure (exercise, intercourse, defecation)Sensitivity of CT in diagnosis greatest after symptom onset and is estimated to be 98% when performed within 12 hours of symptom onset

A sudden, severe onset of an occipitonuchal headache is a common presentation of subarachnoid hemorrhage. Physical exam may be entirely normal, yet 12% of those presenting to the ED with the sudden onset of a severe headache have subarachnoid hemorrhage despite a normal exam. Exertion as minor as coughing or defecating at the onset of a headache is also suggestive of this diagnosis. Noncontrast-enhanced CT scan is the best neuroimaging test for diagnosing subarachnoid hemorrhage, although a negative scan alone does not exclude the diagnosis. Lumbar puncture would be indicated as a follow-up test. Contrast scans are not considered more diagnostic. MRI scanning is equally or less sensitive than CT scanning in the first few days following a bleed, and it can be a more costly and difficult test to obtain. Response to pain medications does not rule out the diagnosis.

3Question 2Which is considered an indication for emergent neuroimaging?Headache after lumbar punctureA cluster headache in a patient with a history of themNew headache in an HIV-positive patientHeadache, isolated fever, stiff neck, and photophobia4Answer 2ACEP Clinical Policy on Acute HeadacheNo level A RecommendationsLevel B RecommendationsPatients presenting to the ED with headache and new abnormal finding in a neurologic examination (focal deficit, altered mental status, altered cognitive function)Patients presenting with a new sudden-onset severe headacheHIV-positive patients with a new type of headacheLevel C RecommendationsPatients older than 50 years and presenting with a new type of headache but with normal neurologic examinationAcute, sudden onset of headache, new headache in HIV-positive patients, and new focal neurologic deficit are considered level B recommendations in the 2002 ACEP Clinical Policy on Acute Headache. (There were no level A recommendations.) Typical headache after lumbar puncture and typical headaches of the migraine, tension, or cluster type generally do not need emergent neuroimaging. In the absence of papilledema, decreased level of consciousness, or focal neurologic findings (evidence of increased intracranial pressure), CT is not required prior to obtaining a lumbar puncture to rule out meningitis. Chapter 237 states, however, that "despite the absence of scientific validation, it has become the standard of care to precede lumbar puncture with non-contrast-enhanced CT of the head."

5Question 3Which of the following is true of cerebrospinal fluid shunts?A lumbar puncture performed by the emergency physician is indicated when shunt infection is suspectedShunt infections are more common the longer the shunt has been in placeStaphylococcus epidermidis is the pathogen responsible for half of all shunt infectionsVomiting is the cardinal sign of a shunt malfunction6Answer 3Shunt infectionIn adults, the most commonly culture agent is Staphylococcus epidermidisAccounts for 50% of shunt infections50% of shunt infections present within the first two weeks, 70% within the first two months, 80% within 6 months10% present at > 1 year after placementTo exclude CSF shunt infection, a shunt tap is required. Lumbar puncture often misses CSF shunt infection and has no meaningful role in evaluation when shunt infection is suspectedS. epidermidis is the most commonly cultured agent in shunt infections, followed by S. aureus. A traditional lumbar puncture has no role in evaluating potential shunt infection as it has a low sensitivity. A neurosurgeon should be consulted regarding a shunt tap. Eighty percent of all shunt infections occur within 6 months of placement, most in the first 2 weeks. No single sign or symptom can predict shunt malfunction, and presenting complaints may be vague. A decreasing level of consciousness has the highest correlation with shunt malfunction, however. 7Question 4A 24 year-old male presents to the emergency department complaining of headache, fever, and neck stiffness. A lumbar puncture is performed and CSF analysis is consistent with meningitis. Which of the following contacts should receive chemoprophylaxis?Nurse who charted on patient without a maskVisitor who saw the patient without a maskRespiratory therapist who suctioned the patient without a mask Tech who transported patient to the floor without a mask8Answer 4Bacterial meningitis chemoprophylaxisIndicated for close contactsNo clear definitionProlonged contact (>8 hours) while in close proximity (< 3 feet) or sleep/eat in the same dwellingCan be considered in cases up to 1 week before symptom onsetHousehold members, roommates, intimate contacts, individuals at a child-care center, young adults in dormitories, military recruits in training centers, sitting next to a patient for an index patient for more than eight hours on an airplaneIndividuals who have been exposed to oral secretions (intimate kissing, mouth-to-mouth resuscitation, endotracheal intubation or endotracheal tube management, shared utensils)

9Question 5A 50 year-old woman complains of dizziness for 1 day. She states the symptoms began suddenly while rolling over in bed. You suspect benign paroxysmal positional vertigo. Which of the following findings support this diagnosis?Hearing loss can be associated.Onset of symptoms is gradual Symptoms persist with offending head movementsA latency period of 1-5 seconds between assuming the offending head position and onset of vertigo and nystagmusAnswer 5Benign Paroxysmal Positional Vertigo (BPPV)Average age of onset is mid-50sWoman twice as likely affected as menAttacks are sudden in onset Findings supportive of diagnosis of BPPVLatency period of < 30 s between provocative head position and onset of nystagmusIntensity of nystagmus increased to a peak before slowly resolvingDuration of vertigo and nystagmus ranges from 5-40 sIf nystagmus is produced in one direction by placing the head down, then the nystagmus reverses direction when the head is returned to the sitting positionRepeated head positioning causes both the vertigo and accompanying nystagmus to fatigue and subside11Question 6A 40-year-old male with known myasthenia gravis complains of shortness of breath. On physical exam you note a normal airway anatomy but weak respirations and decide to intubate. Which of the following drugs would be preferred for intubation?PancuroniumTubocurarinePropofolSuccinylcholineAnswer 6Myasthenia gravisDue to increased sensitivity to neuromuscular junction inhibitors, and unpredictable reactions to succinylcholine, avoid administration of depolarizing or non-depolarizing paralytic agents when preparing for intubation.Paralytic effects may last 2-3 times longer than in healthy individualsConsider short acting agents such as etomidate, fentanyl, or propofol.Patients with myasthenia gravis should not receive either depolarizing or nondepolarizing paralytic agents if it can be avoided. These patients are extremely sensitive to paralytics, and their effects can last 2-3 times longer than in healthy individuals. Smaller than usual doses of etomidate, fentanyl, or propofol are preferred.

13Question 7A 30-year-old diabetic woman with a history of severe gastroparesis presents obtunded and diaphoretic. She has a rectal temperature of 103.4, heart rate of 140 beats per minute, respiratory rate of 33 breaths per minute, and a blood pressure of 105/60 mm Hg. She has a WBC of 18,000 and when the nurse inserts an indwelling catheter, the urine is dark brown and tests positive for hemoglobin. The most specific treatment would include which of the following?DantroleneEdrophoniumSystemic antibioticsFluids and stress-dose steroidsPhysostigmine14Answer 7Neuroleptic Malignant SyndromeTetrad: fever, muscular rigidity, autonomic dysfunction, and altered mental status (lethargy, agitation, mutism, or coma)Primary treatment is supportiveSpecific pharmacotherapy includes amantadine, bromocriptine, and dantroleneNo specific therapy has been shown to be superior to supportive care alone

Neuroleptic malignant syndrome (NMS) is characterized by fever, altered mental status, and muscle rigidity. Patients can have marked elevation of their CPKs and develop myoglobinuric renal failure. Patients require the ABCs, cooling, and volume replacement. Treatment includes intravenous dantrolene every 6 hours for muscle relaxation. Bromocriptine, a direct dopamine agonist, may help treat hyperthermia.

15Question 8Yesterday you saw a 27-year-old male who had the worse headache of his life. After a normal brain CT scan, you performed a lumbar puncture with normal results. You sent the patient home with appropriate analgesia but the patient returned the following day stating that his headache is worse than before. You suspect postdural puncture headache. Which of the following statements is true?An autologous blood patch will relieve the headache in a majority of patients with this condition.The headache is from a hyperstimulatory overproduction of cerebrospinal fluid and can be relieved by a second tap with removal of more fluid.This is an uncommon complication, occurring in less than 10% of patients.The patient should have remainder super for 2 hours to avoid this complicationAnswer 8Post-lumbar puncture headacheAffects up to 36% of patients who the procedure within 24-48 hoursDue to persistent CSF leakWorse with upright position and relieved with recumbencyMinimized with use of small-bore needles with non-cutting tipsTreatment includes simple analgesics, IV fluids, IV caffeine, or blood patch.Headache is the most common complication of lumbar puncture, occurring in up to 40% of patients. The amount of time a patient remains recumbent after lumbar puncture does not appear to affect the incidence of headache. Certain factors have been implicated as causes of PDPH, including the size or diameter of the spinal needle, the orientation of the bevel during the procedure, and the amount of fluid withdrawn. Smaller-diameter needles will cause less leakage, and it is postulated that inserting the needle with the bevel up (i.e., bevel pointing up when the patient is in the lateral position) will minimize damage to the dural fibers. Using atraumatic needles or pencil-point needles (e.g., Whitaker or Sprotte) has also been shown to significantly reduce the incidence of PDPH. Most PDPH headaches resolve spontaneously within a few days with bed rest and mild analgesics. For persistent headaches, oral caffeine 300 mg every 46 hours or caffeine sodium benzoate (500 mg in 1 L of fluid) may be effective. For severe headaches lasting more than 24 hours, an epidural blood patch (autologous blood clot) will relieve the headache in the majority of patients. 17Question 9Which of the following is true of multiple sclerosis?MRI is normal in most cases of multiple sclerosis.Central vision loss is a common presenting complaint.The majority of patients have a reduction in life expectancy.Relapse is more common in pregnancy.18Answer 9Optic neuritisInflammation at any point along the optic nerveAcute vision loss, reduction of color visionMay also be associated with an afferent pupillary defect, and visual field defectsCan be painful especially with extraocular movementsRed desaturation testOptic neuritis usually causes central vision loss, and it is the initial sign of multiple sclerosis in up to 30% of patients. MRI shows some pathology in almost all multiple sclerosis patients. The majority of multiple sclerosis patients do not have a reduction in overall life expectancy. Exacerbations are less common in pregnancy. 19Question 10A 29-year-old male presents complaining of 5 days of increased bleeding from the gums, blurred vision, headache. He has a known history of B-cell acute lymphoblastic leukemia and has a WBC of 130,000/mm3. Which of the following statements is correct?The diagnostic test of choice is CT or MRI of the head.Immediate therapy should focus rehydration and diuresisThe patient requires immediate chemotherapyContact precautions should be implemented and the patient should receive broad-spectrum antibiotics20Answer 10Hyperviscosity syndromeSeen in polycythemia with hematocrits > 60% and leukemias with WBC > 100,000Triad of mucosal bleeding, visual disturbance, and neurologic manifestationsTemporizing measures in the ED include adequate rehydration and diuresisDefinitive treatment is emergency leukapheresis or plasmapheresis

21