Let's recap the question...
A 61-year-old female with a history of hypertension and tobacco abuse presents with complaints of a headache. She states that it is localized to her left temporal region and started abruptly approximately 12 hours ago while she was washing the dishes.
She tells you that she has never had a headache like this before and that this is by far the worst headache of her life. On physical exam, no focal neurological deficits are appreciated. In addition, a noncontrast CT scan of the head reveals no acute intracranial pathology.
Which of the following represents the most appropriate next step in managing this patient?
a. Digital subtraction angiography
b. CT angiography of head
c. Brain MRI
d. MR angiography of head
e. Lumbar puncture
The above patient’s presentation is very concerning for a subarachnoid hemorrhage (SAH).
Thus, a lumbar puncture is mandatory if there is strong suspicion for a SAH, even despite a normal head CT.
The head CT is very sensitive at making this diagnosis, especially if done within the first 6 hours; the scan has nearly 100% sensitivity within this time frame.
The sensitivity falls to approximately 92%, if the CT is done within 6 hours - 24 hours of the bleed (as in our patient here). The sensitivity then progressively declines over time to approximately 58% on day 5.
Not to mention the sensitivity is also decreased with minor bleeds. Therefore, a lumbar puncture must be done to adequately rule out this diagnosis if a negative scan is seen, especially if there is a strong suspicion for SAH.
Now, let's review the other answer choices...
A, B, and D: Once the diagnosis of a SAH is made, the location of the hemorrhage must be determined, either with CT angiography, MR angiography, or digital subtraction angiography (gold standard).
These tests can be considered to aid in the diagnosis as well (particularly the CTA of the head). However, they can miss small aneurysms less than 3 mm, and if negative as well, a lumbar puncture is necessary to exclude this diagnosis.
C: An MRI with FLAIR and T2 sequences have high sensitivities in patients presenting with subacute bleeds greater than 4 days, although there is limited data to suggest it to be as sensitive in the acute identification of SAH. Thus, even if the patient was to get a negative MRI as well, a lumbar puncture must still be done if the patient is suspected to have a SAH.
Did you get it right? We hope so!
In case you missed our previous sample questions from our question bank:
A 56-year-old male with a history of type 2 diabetes mellitus, hypertension, QT prolongation, hypokalemia, and tobacco abuse presents to the urgent care clinic with complaints of dyspnea and cough.
His symptoms started 3 days ago and his cough is described as mucopurulent. He admits associated pleuritic chest pain, exacerbated with inspiration.
On physical exam, inspiratory crackles are heard in the left lower lobe.
Vital signs reveal a heart rate of 90 beats per minute, blood pressure 130/92 mmHg, respiratory rate 18, temperature 100.1°F, and an oxygen saturation of 96 % on room air.
Which of the following antibiotic(s) would be considered the treatment of choice?
a. Azithromycin and Levofloxacin
c. Amoxicillin/Clavulanate and Doxycycline
e. Amoxicillin/Clavulanate and Azithromycin
The above patient is suffering from community-acquired pneumonia and must be treated with combination therapy.
The reason being is because patients with comorbidities (e.g., COPD, diabetes, CHF) are at a higher risk of being infected with more resistant pathogens.
Of the antibiotic choices, amoxicillin/clavulanate and doxycycline would be the safest options to adequately treat this patient for reasons that will be explained in more detail below.
Choosing any of the remaining answer choices could have deleterious consequences in a patient with known QT interval prolongation. Both fluoroquinolones (e.g., levofloxacin) and macrolides (e.g., azithromycin) will prolong the QT interval, placing the patient at an even higher risk to develop torsades de pointes.
Important clinical pearl***
If you see more than one answer that looks correct, then you must look for a contraindication! In this case, QT prolongation would make the other choices unsafe.
Did you get it right?
Remember, it's just as important to learn from the incorrect answers, as it is from the correct answers.
If you're interested in more like this, than take a look at our Question Bank.
A 37-year-old presents to the emergency room with complaints of severe, sharp, and tearing anterior chest pain after smoking generous amounts of crack cocaine. Initial EKG shows sinus tachycardia without any significant ischemic changes.
Portable chest radiograph reveals a widened mediastinum, and the patient is rushed to the radiology department for advanced cardiovascular imaging.
Unfortunately the patient codes on the table during the study, and despite advanced and aggressive resuscitation dies. Upon delivering this tragic news to the family, the spouse asks if the patient’s underlying genetic disorder, could have contributed to your presumptive diagnosis responsible for the patient’s death.
Of the following genetic disorders, which is not considered a high-risk condition associated with the most likely diagnosis responsible for this patient’s catastrophic death?
a. Marfan syndrome
b. Turner syndrome
c. Tay-Sachs disease
d. Bicuspid aortic valve
e. Ehlers-Danlos syndrome
The correct answer is: c. Tay-Sachs disease
The above vignette depicts a 37-year-old who died secondary to an acute ruptured aortic dissection.
However, those with infantile Tay-Sachs disease life expectancy is only two to five years, with death occurring most commonly secondary to pneumonia.
Tay-Sachs disease is an autosomal recessive neurodegenerative disorder characterized by progressive weakness and loss of motor skills, beginning at two to six months of age, with accompanying hypotonia, hyperreflexia, and a cherry red macula.
Now, let's discuss the incorrect answers and explanations:
A. Marfan syndrome is an inherited disorder of connective tissue that causes aortic root disease, leading to aneurysmal dilation, aortic regurgitation, and aortic dissection. Untreated and undiagnosed individuals are frequently associated with aortic dissections.
B. Aortic dissection or rupture is becoming an increasingly identified cause of death in women with Turner syndrome, occurring in the third or fourth decade of life.
D. Bicuspid aortic valves generally occur sporadically, but can occur as an autosomal dominant inherited disorder with variable penetrance. These patients are at an increased risk for aortic dilation and dissection.
E. Ehlers-Danlos syndrome is a term used for a group of rare genetic conditions due to defects in connective tissue that cause hypermobility of joints and hyperelasticity/fragility of the skin. The vascular type of Ehlers-Danlos syndrome is associated with an increased risk of spontaneous vascular and visceral rupture.
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