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#1
25.12.2006, 04:20
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A 36-year-old woman comes to the emergency department 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 urinary tract infections and hypertension. Her temperature is 39.0 C (102.2 F), blood pressure is 130/80 mm Hg, pulse is 75/min, and respirations are 17/min. She appears lethargic. Physical examination shows nuchal rigidity, flank tenderness, and a mid-systolic click. Funduscopic examination shows bilateral optic disc swelling. After blood cultures are obtained the most appropriate next step is to
A. administer ceftriaxone, intravenously 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 lumbar puncture 
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#2
25.12.2006, 06:38
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CT can be done in emergency room, but MRI - usually not. IMHO.
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#3
25.12.2006, 07:00
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Субарахноидальное кровоизлияние. Стандартом обследование является КТ. Но я выбираю:
E. perform a lumbar puncture Позволит отдифференцировать субарахноидальное кровоизлияние от менингита.
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#4
25.12.2006, 07:04
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You cannot do spinal tap with elevated ICP, cause you are risking the brain herniation! Take a look what's going on noninvasively first. Subarachnoid bleed is perfectely visible on CT as well as mets from Hodgkins.
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#5
25.12.2006, 07:54
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Цитата:
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#6
25.12.2006, 08:35
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>>B<<
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#7
25.12.2006, 23:27
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Неясно почему вначале blood cultures ? Если у пациентки предполагается то, о чём говоря уважаемые riltsov и papadoctor, может сразу КТ? Ясно, что имеется менингеальная симптоматика, так может предпочтительнее вариант "А"?
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#8
25.12.2006, 23:32
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The correct answer is A. 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.
A CT scan of the head (choice B) is the appropriate next diagnostic procedure in this patient with suspected meningitis and papilledema, but it should be done only after empiric antimicrobial therapy is started. A mass lesion must be ruled out with the CT, but also this patient may have a subarachnoid hemorrhage in which case a CT scan is also indicated (usually before the lumbar puncture). An MR angiogram (choice C) is sometimes used later on in the evaluation of the patient with papilledema, after a CT scan and MRI have ruled out a brain tumor, to evaluate the patient for an arteriovenous shunt or a dural venous sinus occlusion. An MRI of the head (choice D) is part of the evaluation of papilledema, however in this patient with suspected meningitis, an empiric antibiotic should be given before any diagnostic procedure is performed. A lumbar puncture (choice E) is the most important study to evaluate meningitis, however this patient has papilledema (optic disc swelling), and therefore a CT scan must be performed to rule out a mass lesion. Antibiotics should be initiated even before the CT scan, to prevent even further clinical deterioration if the patient does have meningitis. This patient may also have a subarachnoid hemorrhage, which sometimes requires an LP after a CT scan to establish the diagnosis.
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#9
25.12.2006, 23:33
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A 55-year-old woman comes to the office for a periodic health maintenance examination. She has been a patient for a number of years but you have not seen her for five years. Her review of systems is positive for fatigue, recent weight gain, temperature intolerance with hot flashes being frequent, and some mild pruritus over her hands. Her last menstrual period was seven months prior. She had a cholecystectomy at age 43 and an ovarian cyst removal at age 23. Her family history is remarkable for a father who died of a myocardial infarction at age 59 and a mother who is alive and well. Her sister and her aunt both died of breast cancer at age 61. Her father and her grandfather both had diabetes. She smokes one-half pack of cigarettes per day. She appears her stated age, is well and in no distress. Her temperature is 37.0 C (98.6 F), blood pressure is 110/80 mm Hg, and pulse is 65/min. Physical examination is unremarkable. Concerning her post-menopausal status, the most appropriate intervention to reduce long-term morbidity and mortality is
A. annual bone density surveys B. estrogen and progesterone replacement C. estrogen and progesterone replacement and bisphosphonate therapy D. estrogen replacement and bisphosphonate therapy E. estrogen replacement only
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