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.

Question 17

17.  Your patient is a 53 year old male that has a history of chronic low back pain that has been getting markedly worse over the last week.  He does get "nerve blocks" every 3 weeks in his back through his pain doctor.  He is complaining of increase pain in his left leg and looks uncomfortable.  The patients vitals are Temp 99.2, HR 121, RR-22, BP 147/78.  He takes percocet on a routine basis as home and today has received multiple doses of Dilaudid IV in the ER. He is still unable to move off the cot and walk. What is the best management plan?

A.  Call the patient's primary care provider and arrange for close outpatient follow up

B.  Call the patient's primary care provider and arrange for admission to the hospital

C.  Get an MRI of the patient's Lumbar Spine

D.  Have security escort the patient out of the hospital.  He is obviously a drug seeker and is malingering.

Answer and Explanation 16

16.  Choice C is the correct answer.  This patient has lateral femoral cutaneous neuropathy.  Typical presentation is an obese patient who sets a lot with paresthesias over the anterior lateral thigh. Given the fact the patient does not have back pain and has a normal exam, MRI's of the head as well as the back are not indicated.  When a patient has a lumbar radiculopathy and has a normal neurological exam, the usual starting place is physical therapy and NSAIDS.   Placing the patient on steroids likely will not help much and may make the patient gain more weight and make her condition worse.

Question 16

16.  Your patient is a 45 year old morbidly obese female that works as a secretary.  She is complaining of pain and paresthesias along her right anterior lateral thigh.  She denies any back pain.  The remainder of her neurological exam is normal.  Given this information, what is the best management option?

A.  Get an MRI of the lumbar spine

B.  Get a MRI of her Brain

C.  Refer patient to physical therapy and start the patient of NSAIDS

D.  Start the patient on steroids