March 8

A 25-year-old woman presents to the emergency department for a headache. She states it has been gradually worsening since she had a lumbar puncture 2 days ago and that it did not improve with rest, fluids, and naproxen. She describes it as a bilateral pressure that is intense. She reports no neurological symptoms. Her temperature is 98.0°F (36.7°C), blood pressure is 112/77 mm Hg, heart rate is 84/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals no focal neurologic deficits with intact cranial nerves. Which of the following is the most appropriate next step in treating this patient?

• Caffeine

• Epidural blood patch

• Ketorolac

• Sumatriptan

Answer explanation

Postdural headaches occur after a lumbar puncture or spinal anesthesia.

It is more common when a large needle or a cutting needle is used. To reduce the incidence of postdural headache, smaller needles and blunt needles should be used. Stylet replacement before needle removal helps too.

If treatment is refractory to fluids and NSAIDs, caffeine has been shown to be effective. If this is not successful then proceed to epidural blood patch.

In addition to a third generation cephalosporin and vancomycin, which additional empiric antibiotic should be considered in adult patients over 50 years of age who are suspected of having bacterial meningitis?

• Ampicillin

• Ciprofloxacin

• Gentamycin

• Rifampin

Answer explanation

High Risk adult groups consist of age over 50, pregnancy, or immunocompromised.

Listeria monocytogenes

Neonates also are high risk and should have coverage for meningitis in the first 30 days of life.

A patient presents to the emergency department with symptoms of right-sided weakness and aphasia which started 30 minutes prior to arrival. The National Institutes of Health Stroke Scale is 10. Which of the following is an absolute contraindication for intravenous thrombolytic therapy?

• Age of 82 years

• Ischemic stroke 4 months prior

• Platelet count 95,000/mm³

• Seizure at onset of symptoms with postictal residual neurologic deficits

Answer explanation

It is not necessary to wait for a platelet count prior to administering thrombolytic therapy unless the patient has a history or exam findings concerning for thrombocytopenia.

Platelet count less than 100,000/mm³

^{is an absolute contraindication}

A 13-year-old boy on chemotherapy for acute lymphoblastic leukemia presents with progressive lower back pain for two weeks. Per the mother, he has had subjective fevers and a “bulge in his lower back” that is warm to touch. He is currently afebrile and has no focal neurologic deficits. An MRI is obtained, as seen in the image above. Which of the following regarding this patient’s condition is true?

• An appropriate antibiotic regimen is cefepime and metronidazole

• Direct extension of skin and soft tissue infections is the most common cause

• Erythrocyte sedimentation rate is a sensitive screening tool

• Most patients present with back pain, fever, and a focal neurologic deficit

Answer explanation

The most common cause of an epidural abscess is hematogenous spread of infection, not direct extension from skin or soft tissue infection. Major risk factors include diabetes, intravenous drug abuse, chronic renal failure, alcoholism, and immunosuppression. The most common organism involved is Staphylococcus aureus.

ESR is a sensitive marker. Elevated ESR and CRP are almost always elevated in these patients.

A 6-month-old boy presents to the emergency department with sudden, brief, symmetric muscle contractions that were first noticed yesterday. These spasms last for < 2 seconds and occur several times per minute. They cause flexion of his neck, trunk, and arms and extension of the legs. They seem involuntary, are not associated with any heart rate change, and are followed by brief crying. Over the last 2 weeks, he has lost the ability to sit without support. A video electroencephalogram shows hypsarrhythmia. Which of the following is most likely to control this patient’s symptoms?

• Corticotropin

• Famotidine

• Midazolam

• Prednisone

Answer explanation

Infantile spasms are a rare epileptic disorder of infants that is refractory to typical antiseizure medications and has a high mortality rate. It is associated with developmental delay and regression.

The initial treatment for infantile spasms is high-dose corticotropin given in twice-daily intramuscular injections over a 2-week period followed by a 2-week taper.

They often occur in clusters.

Most cases are identified by an electroencephalogram that shows high-voltage, random, slow waves and spikes, known as hypsarrhythmia.

A patient is diagnosed with Campylobacter jejuni enteritis, receives treatment, and recovers. He presents with weakness in his legs followed by weakness in his arms 2 weeks later. He reports no dyspnea but reports diplopia and dysphagia. Examination reveals a mild fever, extraocular muscle palsies, hyporeflexia, distal paresthesias, and intact proprioception. Laboratory testing is significant for a normal CBC and a PaO₂ of 88 mmHg. Which of the following is the most appropriate intervention at this time?

• Continuous positive airway pressure (CPAP)

• Corticosteroids

• Plasmapheresis

• Vitamin B12

Answer explanation

Guillain-Barre syndrome (GBS) is a symmetric, progressive ascending muscle weakness that usually starts in the legs and may be acute or subacute.

Lumbar puncture results will demonstrate increased CSF protein but a normal cell count. Treatment is supportive. Plasmapheresis or IVIG may improve recovery time and decrease residual neurologic effects.

A 10-month-old boy presents to the emergency department with trouble breathing. His parents noticed he has seemed fatigued and weak lately. He has not been having bowel movements. Today, he seems to be very weak and is struggling to breathe. The patient has generally been healthy and sees a pediatrician regularly. His parents have tried introducing new foods recently. Physical exam is notable for a child with minimal muscle tone who is limp when picked up. Given his weak respiratory effort, he is intubated. Which of the following treatments is indicated for this patient?

• Botulism antitoxin

• Botulism immune globulin

• Cefepime

• Plasmapheresis

Answer explanation

Infant botulism

Botulism immune globulin is given if the patient is < 1 year of age. For patients > 1 year of age, botulism antitoxin is administered. Botulism immune globulin is indicated for infants due to the risk of anaphylaxis to horse serum (used to make antitoxin).

Globulin for the little Goblins

A 26-year-old woman with a history of dysmenorrhea and depression presents to the ED after having a seizure witnessed by her husband. He reports finding her on the bedroom floor with an empty pill bottle. Which of the following non-steroidal anti-inflammatory (NSAIDs) medications did she most likely ingest?

• Celecoxib

• Ibuprofen

• Aspirin

• Mefenamic acid

• Rofecoxib

Answer explanation

Overdose of mefenamic acid is associated with seizure activity. This typically occurs 2-7 hours following the acute ingestion. Mefenamic acid is a fenamate that is marketed under the trade name Ponstel® in the United States as an analgesic used for pain associated with menstruation.

"me fena" have i-c-zure

A 16-year-old girl presents to the ED reporting that she cannot walk up steps. She has been well recently except for an episode of gastroenteritis 2 weeks ago. On exam, she has decreased strength in her bilateral lower extremities with absent patellar and ankle jerk reflexes. What is the most important next test to perform?

• Electromyography

• Lumbar puncture

• MRI lumbar spine

• Vital capacity

Answer explanation

The most serious complication of GBS is respiratory failure from diaphragmatic weakness. Measuring the vital capacity or negative inspiratory force (NIF) is critical to assessing respiratory effort. These easily repeated tests predict developing diaphragmatic weakness and the need for prophylactic intubation.

Which of the following patients in the setting of a known subarachnoid hemorrhage has the worst prognosis?

• A 39-year-old woman who is confused and has mild right lower extremity weakness

• A 55-year-old man with a severe headache and oculomotor nerve palsy

• A 65-year-old man with a mild headache, nausea, and an episode of vomiting

• A 70-year-old woman with headache, neck stiffness, and an episode of vomiting

Answer explanation

The Hunt and Hess scale is one of several schemes used to classify the severity of a subarachnoid hemorrhage based on the patient’s clinical condition at presentation. It is used as a predictor of outcome. Higher grades correlate with lower survival rates.