cooldudemle
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A 36 y/o woman comes to the ED because of a severe headache. She states that the headache woke her up from sleep 6 hours ago, and was not relieved by aspirin or acetaminophen. She also noticed that she has neck stiffness and that "it hurts" during neck extension and flexion. She was recently diagnosed with Hodgkin's disease, but before that, she was usually "pretty healthy," except for a few UTI and HTN. V/S: T=39.0 C (102.2 F), BP=130/80 mm Hg, PR=75/min, and RR=17/min. She appears lethargic. P/E shows nuchal rigidity, flank tenderness, and a mid-systolic click. Funduscopic examination shows bilateral optic disc swelling. What’s the most appropriate first step to do:
A. B/C & administer IV ceftriaxone
B. order a CT scan of the head
C. order a MR angiogram of the head
D. order an MRI of the head
E. perform a LP
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| nitin_ps
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C. order a MR angiogram of the head ?
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| Doc2378
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Do a CT scan of the head to rule out any cause of increased intracranial pressure (? mets from Hodgkins)...meanwhile do a blood culture (not listed, ofcourse) to determine the possible cause (?bacterial) of meningitis before initiating appropriate therapy.
LP must be withheld as this patient shows evidence of increased cranial pressure
Well???
Edited by Doc2378 on 12/23/05 - 06:18 PM
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Courage does not always ROAR. Sometimes courage is the quiet voice at the end of the day saying, "I will try again tomorrow" - Mary Anne Radmacher
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| cooldudemle
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Well even i too had gone with D ..... by the way blood culture is listed sorry for the shorthand B/C
But the correct ans is A
A) . B/C& IV ceftriaxone
This patient has the signs and symptoms that are suggestive of meningitis, but she also has papilledema (optic disc swelling), which means that an intracranial mass must be ruled out before performing a lumbar puncture (to reduce the risk for brain herniation). However, empiric antimicrobial therapy should be started before the neuroimaging study so that clinical deterioration does not occur.
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| Doc2378
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 ...Thanks Cooldude...I stand corrected!
Why would you do recommend doing an MRI of the brain and not the CT scan...hmmm...just wondering
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Courage does not always ROAR. Sometimes courage is the quiet voice at the end of the day saying, "I will try again tomorrow" - Mary Anne Radmacher
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| cooldudemle
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 ur right... ct would be the imaging study of choice not mri.my mistake!
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