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Questions 01/10/2013


Question 1
A 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?
a) Contrast CT scan of the brain followed by lumbar
puncture if negative
b) Non-contrast CT scan of the brain followed by
lumbar puncture if negative
c) MRI scan of the brain
d) Trial of pain medication and CT scan of the head and
lumbar puncture only if headache is unrelieved

Answer 1
Subarachnoid hemorrhage
Present 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

Question 2
Which is considered an indication for
emergent neuroimaging?
a) Headache after lumbar puncture
b) A cluster headache in a patient with a
history of them
c) New headache in an HIV-positive
d) Headache, isolated fever, stiff neck,
and photophobia

Answer 2
ACEP Clinical Policy on Acute Headache
No level A Recommendations
Level B Recommendations
Patients 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
HIV-positive patients with a new type of headache

Level C Recommendations
Patients older than 50 years and presenting with a new
type of headache but with normal neurologic examination

Question 3
Which of the following is true of cerebrospinal fluid
a) A lumbar puncture performed by the
emergency physician is indicated when shunt
infection is suspected
b) Shunt infections are more common the longer
the shunt has been in place
c) Staphylococcus epidermidis is the pathogen
responsible for half of all shunt infections
d) Vomiting is the cardinal sign of a shunt

Answer 3
Shunt infection
In adults, the most commonly culture agent is
Staphylococcus epidermidis
Accounts for 50% of shunt infections
50% of shunt infections present within the first two
weeks, 70% within the first two months, 80% within 6
10% present at > 1 year after placement
To 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 suspected

Question 4
A 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?
a) Nurse who charted on patient without a mask
b) Visitor who saw the patient without a mask
c) Respiratory therapist who suctioned the patient
without a mask
d) Tech who transported patient to the floor without a

Answer 4
Bacterial meningitis chemoprophylaxis
Indicated for close contacts
No clear definition
Prolonged contact (>8 hours) while in close proximity (< 3 feet) or
sleep/eat in the same dwelling
Can be considered in cases up to 1 week before symptom onset

Household 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 airplane
Individuals who have been exposed to oral secretions (intimate
kissing, mouth-to-mouth resuscitation, endotracheal intubation
or endotracheal tube management, shared utensils)

Question 5
A 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?
a) Hearing loss can be associated.
b) Onset of symptoms is gradual
c) Symptoms persist with offending head movements
d) A latency period of 1-5 seconds between assuming
the offending head position and onset of vertigo
and nystagmus

Answer 5

Benign Paroxysmal Positional Vertigo (BPPV)

Average age of onset is mid-50s
Woman twice as likely affected as men
Attacks are sudden in onset
Findings supportive of diagnosis of BPPV
Latency period of < 30 s between provocative head position and
onset of nystagmus
Intensity of nystagmus increased to a peak before slowly resolving
Duration of vertigo and nystagmus ranges from 5-40 s
If nystagmus is produced in one direction by placing the head
down, then the nystagmus reverses direction when the head is
returned to the sitting position
Repeated head positioning causes both the vertigo and
accompanying nystagmus to fatigue and subside

Question 6
A 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?
a) Pancuronium
b) Tubocurarine
c) Propofol
d) Succinylcholine

Answer 6
Myasthenia gravis
Due 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 individuals
Consider short acting agents such as
etomidate, fentanyl, or propofol.

Question 7
A 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?
a) Dantrolene
b) Edrophonium
c) Systemic antibiotics
d) Fluids and stress-dose steroids
e) Physostigmine

Answer 7
Neuroleptic Malignant Syndrome
Tetrad: fever, muscular rigidity, autonomic
dysfunction, and altered mental status
(lethargy, agitation, mutism, or coma)
Primary treatment is supportive
Specific pharmacotherapy includes
amantadine, bromocriptine, and dantrolene
No specific therapy has been shown to be
superior to supportive care alone

Question 8
Yesterday 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?
a) An autologous blood patch will relieve the headache in a majority of
patients with this condition.
b) The headache is from a hyperstimulatory overproduction of
cerebrospinal fluid and can be relieved by a second tap with removal
of more fluid.
c) This is an uncommon complication, occurring in less than 10% of
d) The patient should have remainder super for 2 hours to avoid this

Answer 8
Post-lumbar puncture headache
Affects up to 36% of patients who the
procedure within 24-48 hours
Due to persistent CSF leak
Worse with upright position and relieved with
Minimized with use of small-bore needles
with non-cutting tips
Treatment includes simple analgesics, IV
fluids, IV caffeine, or blood patch.

Question 9
Which of the following is true of multiple
a) MRI is normal in most cases of multiple
b) Central vision loss is a common
presenting complaint.
c) The majority of patients have a
reduction in life expectancy.
d) Relapse is more common in pregnancy.

Answer 9
Optic neuritis
Inflammation at any point along the optic
Acute vision loss, reduction of color vision
May also be associated with an afferent
pupillary defect, and visual field defects
Can be painful especially with extraocular
Red desaturation test

Question 10
A 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?
a) The diagnostic test of choice is CT or MRI of the head.
b) Immediate therapy should focus rehydration and
c) The patient requires immediate chemotherapy
d) Contact precautions should be implemented and the
patient should receive broad-spectrum antibiotics

Answer 10
Hyperviscosity syndrome
Seen in polycythemia with hematocrits >
60% and leukemias with WBC > 100,000
Triad of mucosal bleeding, visual
disturbance, and neurologic manifestations
Temporizing measures in the ED include
adequate rehydration and diuresis
Definitive treatment is emergency
leukapheresis or plasmapheresis