Answer and Explanation 20

20.  Choice B is the correct answer.  This patient has a history and rash consistent with meningococcal meningitis.  Standard initial treatment for a new diagnosis of meningitis is   2 grams of Rocephin, 1 gram of Vancomycin, and Acyclovir IV.  Steroids will not be helpful nor will griseofulvin.

Question 20

20.  Your patient is a 26 year old female that presents with headache, fever, and the rash below.  Given this information, what is the best management option?

A.  Start the patient on steroids

B.  Give the patient 2 grams of Rocephin, 1 gram of Vancomycin, and Acyclovir IV

C.  Add some coagulation studies to the patients workup

D.  Start the patient on Griesofulvin

Answer and Explanation 19

19.  Choice C is the correct answer.  This patient has a presentation that is concerning for Guillian Barre Syndrome (GBS).  The diagnosis can be confirmed with a lumbar puncture.  This patient should be admitted to the hospital.  Patients who cannot walk should not be discharged home from the Emergency Room.  GBS has been associated with a brief diarrheal illness sometimes usually 2-3 weeks before the onset of symptoms.  Other antecedent infections that have been associated with it include campylobacter jejuni, infectious mononucleosis, cytomegalovirus,  herpes, and mycoplasma.  Steroids have not been shown to be effective in GBS.

Question 19

19.  Your patient is a 51 year old female physician who present complaining of bilateral leg weakness and urinary incontinence.  Her vital signs are as follows BP-120/78, HR, 86, RR-16, Temp-96.7.   Her husband who accompanied her to the Emergency Room relays she has had a lot of trouble walking today.  She has no visual disturbance.  It is a slow day and your were able to get MRI's of her brain, cervical spine, thoracic spine, and lumbar spine with and without contrast that were read as negative.  You also get a laboratory workup that reveals normal CBC, BMP, and Hepatic Panel and Thyroid studies.  The only recent illness is an acute diarrheal illness 2-3 weeks ago.  Given this information, what is the best management option?

A.  Discharge the patient home with close follow up with primary care physician.  There is no further studies that can be done to determine the etiology of the patients symptoms.

B.  Have psychiatry assess the patient for possible conversion disorder

C.  Offer the patient a lumbar puncture

D.  Start the patient on glucocorticoids

Answer and Explanation 18

18.  Choice D is the correct answer.  A foot drop is not associated with a foot drop.  The causes of foot drop can be attributed to anything that can affect the nerves or muscles that allows the foot to stay in the neutral position or dorsiflex the foot.

Question 18

18.  Which of the following conditions have not been attributed to a foot drop?

A.  Tibialis anterior tendon rupture

B.  Mononeuropathy of the deep perineal, common perineal, or sciatic nerves

C.  Direct injury to any of the dorsiflexors

D.  Patella Dislocation

Answer and Explanation 17

17.  Choice C is the correct answer.  This patient is present with a presentation concerning for paraspinous abscess.  This patient has pain out of proportion to what is expected.  In addition with his history of recent back injections and having abnormal vital signs should raise your suspicion.  Admitting the patient to the hospital may seem like a good solution, but delay in the diagnosis and therapeutic intervention can lead to irreversible neurologic damage.  Patients who cannot walk or have abnormal vitals signs should not be discharged from the hospital.