Questions 01/24/2013

Neurology

Question 1A 57-year-old woman presents to the emergency department 45 minutes after onset of severe expressive aphasia, right hemiparesis, and hemi=sensory loss. Her NIH stroke scale score is 16. Past medical history is significant for coronary artery disease, coronary angioplasty and stent placement 4 years ago, and surgery on her left foot 5 days ago. On initial presentation, the patient’s blood pressure was 190/100 mmHg and is now 170/90 mmHg. The patient reports taking aspirin and clopidogrel for coronary artery disease. Emergent laboratory studies, electrocardiogram, and CT scan of the head performed over the next half hour are normal. After the initial evaluation and testing, the patients NIH stroke scal is 3. Which of the following is a contraindication to this patient receiving recombinant tissue plasminogen activator (rt-PA)?a) Current use of aspirin and clopidogrelb) Blood pressure 170/90 mm Hgc) Rapidly resolving symptomsd) Recent minor surgery

Answer 1• Exclusion criteria for fibrinolytic therapy1. Evidence of intracranial hemorrhage on non-contrast head CT2. Only minor or rapidly resolving stroke symptoms3. High clinical suspicion of subarachnoid hemorrhage even with

normal CT findings4. Active internal bleeding (e.g. gastrointestinal or urinary

bleeding within the last 21 days)5. Known bleeding diathesis, including but not limited to

– Platelet count < 100,000/uL– Patient has received heparin within 48 hours and had an elevated

activated partial thromboplastic time (greater than the upper limit of normal for laboratory)

– Recent use of anticoagulant (e.g., warfarin) and elevated prothrombin time > 15 seconds or INR > 1.7

Answer 1

6. Within 3 months of intracranial surgery, serious head trauma, or previous stroke

7. Within 14 days of major surgery or serious trauma8. Recent arterial puncture at noncompressible site9. Lumbar puncture within 7 days10. History of intracranial hemorrhage, arteriovenous

malformation, or aneurysm11. Witnessed seizure at stroke onset12. Recent acute myocardial infarction13. On repeat measurements, systolic blood pressure > 185

mm Hg or diastolic pressure > 110 mm Hg at time of treatment, requiring aggressive treatment to reduce blood pressure to within these limits

Question 2A 66-year-old man with a history of atrial fibrillation presents to the emergency department with acute onset right-sided weakness and sensory loss that occurred 25 minutes prior to presentation. He is alert and swallows normally. His blood pressure is 195/120 mm Hg with a heart rate that is irregular at 90 bpm. Serum glucose is 358 mg/dL. The patient is currently on warfarin and prothrombin time is elevated beyond therapeutic range. Head CT demonstrates is as shown. All of the following are indicated in the immediate management of this patient except:a) IV vitamin Kb) Insulinc) IV labetalold) Phenytoin

Answer 2

• Intracerebral hemorrhage• Endotracheal intubation for decreased level of

consciousness or poor airway protection• Cautious lowering of blood pressure to a MAP of less than

130 mm Hg• Maintain euvolemia using normotonic fluids• Avoid hypertheria, hypothermia• Correct hyperglycemia• Correct coagulopathy with FFP, vitamin K, protamine or

platelet transfusions• Initiate fosphenytoin or other anti-convulsant for seizure

activity of lobar hemorrhage• Transfer to ICU or OR

Question 3

A 32-year-old patient is brought by his fiancée after a witnessed tonic-clonic seizure. The patient experienced bladder incontinence and was lethargic for 15 minutes. On physical exam you note that she has bitten her tongue, but has a normal neurologic exam. Head CT is negative for bleeding or structural abnormalities and lab work is within normal limits. What is the most appropriate next step in the management of this patient?a) Administer a loading dose of phenobarbital and phenytoin

and discharge with a prescription for both.b) Admit the patient for observation despite full recoveryc) Discharge the patient with instructions for prompt follow-up

and instruct not to drive until further noticed) Obtain an EEG in the EDe) Perform a lumbar puncture for CSF analysis

Answer 3

• ACEP Clinical Policy Seizure Management• Which new-onset seizure patients who have

returned to a normal baseline need to be admitted to the hospital and/or started on an antiepileptic drug?– Level A recommendations. None specified– Level B recommendations. None specified– Level C recommendations.

• Patients with a normal neurologic examination can be discharged from the ED with outpatient follow-up.

• Patients with normal neurologic examination, no comorbidities, and no known structural brain disease do not need to be started on an antiepileptic drug in the ED

Question 4

An 80-year-old male presents for evaluation of worsening ataxia. His family notes that he is easily confused and has difficulty with bladder control. Which of the following is the best diagnostic test for this patient?a) CT scan of the brainb) Electromyogram (EMG) and nerve conduction

velocity (NCV)c) Psychiatry consultd) GU consulte) Cobalamin level

Answer 4

• Normal pressure hydrocephalus• Urinary incontinence, cognitive

disturbance, gait difficulty (wet, wacky, wobbly)

• Male to female ratio the same• Increases with age• Image with CT or MRI• Treated with ventricular shunting

Question 5

The most common cause of new-onset seizures in the elderly patient isa) Alzheimer dementiab) Malignancyc) Drug toxicityd) Strokee) Trauma

Answer 5

• Seizure• Ischemic or hemorrhagic stroke is the

cause of new-onset seizures in 40-54% of elderly patients

• Most common cause of status epilepticus is discontinuation of anticonvulsant medication

Question 6

Which of the following is characteristic for Wernicke encephalopathy?a) Normal mental statusb) Tachycardiac) Ophthalmoplegiad) Normal reflexese) Headache

Answer 6

• Wernicke encephalopathy• Vitamin B1 (thiamine) deficiency• Criteria require 2 of the following signs– Dietary deficiency– Oculomotor abnormalities– Cerebellar dysfunction– Altered mental state or mild memory

impairment

• Requires admission and aggressive thiamine and magnesium repletion

Question 7

An 8-year-old male comes to the ED after passing out at school. He ate lunch and felt fine, but in class felt his heart racing. He became sweaty and nauseous, then slumped over at his desk. On EMS arrival, his heart rate was 210, and he was awake. In the ED his heart rate is 120 and regular, and the ECG is normal. The most appropriate study for this patient is which of the following?a) Blood glucoseb) Chest radiographc) Serum electrolytesd) Echocardiograme) Holter monitor

Answer 7• Pediatric syncope• Estimated that 15% of pediatric population experience one

episode of syncope• Routine labs are not required for clear episodes of vasovagal

syncope. • Consider chemistry, hematocrit, thyroid function tests, chest

radiograph, and ECG• Risk factors for serious cause of syncope

– Exertion preceding the event– History of cardiac disease in the patient– Family history of sudden death, deafness, or cardiac disease– Recurrent episodes– Recumbent episode– Prolonged loss of consciousness– Associated chest pain or palpitations– Use of medications that can alter cardiac conduction

Question 8

An 18-month-old boy is brought to the ED after “passing out.” Mom states the child had been playing happily when she called him for dinner. He said no, and mom took his toys away and he began to cry. His face turned blue and he fell to the ground. In the emergency department he is acting normally and his vital signs are normal. Pulse oximetry on room air is 100%. This is an example of which of the following?a) Cyanotic breath-holding spellb) Pallid breath-hold spellc) Situational syncoped) Arrythmia

Answer 8

• Breath holding spells• Typical occurrence in 6-18 month olds• Cyanotic vs. pallid

– Cyanotic – breath holding held in expiration with associated cyanosis. May also have loss of consciousness, limpness, opisthotonic posturing and recovery within 1 minute

– Pallid – Form of reflex syncope usually provoked by antecedent trauma, pain, or fright. May be associated with clonic movements and incontinence. Return of consciousness occurs in less than 1 minute but may be associated with persistent fatigue for several hours

Question 9

A 4-year-old male had hand-foot-mouth disease 2 weeks ago. This has resolved, but this morning the child had an unsteady gait. In the ED, the child has a normal exam except for ataxia upon walking, and mild truncal ataxia when sitting. Of the following, which is the most likely etiology of his ataxia?a) Drug ingestionb) Acute cerebellar ataxiac) Brain tumord) Guillain-Barre syndromee) Brain abscess

Answer 9

• Acute cerebellar ataxia• 40% of ataxia cases in children are due

to acute cerebellar ataxia• Autoimmune phenomenon leading to

cerebellar demyelination• Boys more commonly affected• Highest incidence at ages 2 to 4 years• 70% have history of recent illness• Up to 26% are associated with varicella

Question 10

An 18-year-old female has a history of migraines. She states that they are triggered when she eats hot dogs. Besides meats with sodium nitrite, other foods she should avoid includea) Goat cheeseb) Mexican foodc) American cheesed) White winee) Chinese food

Answer 10

• Tyramine (aged cheese)• Sodium nitrite (hot dogs, smoked meats)• Monosodium glutamate (Chinese food)• Caffeine• Chocolate• Red wine• Drugs (oral contraceptives,

antihypertensive medications, cimetidine, H2 blockers)