The Quizzes about Altered Mental Status (28 test)

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Altered Mental Status

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Question 1

A 69-year-old woman with a past medical history of hyperten- sion, hypercholesterolemia, diabetes mellitus type 1, and alcohol abuse is brought to the emergency department (ED) by her daughter who states that her mom has been acting funny over the last She states that the patient did not know where she was despite being in her own house. She also did not recognize her family and was speaking incomprehensibly. Her blood pressure (BP) is 150/80 mm Hg, heart rate (HR) is 90 beats per min- ute, temperature is 98.9°F, and her respiratory rate (RR) is 16 breaths per minute. On physical examination she is diaphoretic, agitated, and tremu- lous. Electrocardiogram (ECG) is sinus rhythm with normal ST segments and T waves. Which of the following is the most appropriate course of action for this patient?

A	Administer a benzodiazepine to treat her ethanol withdrawal.
B	Activate the stroke team and bring the patient directly to the computed tomo- graphic (CT) scanner.
C	Get a stat fingerstick and administer dextrose if her blood sugar is low.
D	Request a psychiatric consult for probable sundowning.
E	Administer haloperidol for sedation.

Question 1 Explanation:

The patient never received fingerstick glucose at triage. Hypoglycemia can mimic a CVA or seizure. Therefore, it is critical that all patients who present with altered mental status get fingerstick glucose. Glucose level should be considered a vital sign. Hypoglycemia is a common problem in patients with type 1 diabetes. The clinical presentation of hypoglycemia is caused by increased secretion of epinephrine, as well as central nervous system (CNS) dysfunction. Symptoms include diaphoresis, nervousness, tremor, tachycardia, hunger, and neurologic symptoms ranging from confusion and bizarre behavior to seizures and coma. (a) Ethanol withdrawal can present in a similar fashion as hypoglycemia because both include symptoms of an adrenergic state (eg, tachycardia, hypertension, diaphoresis, agitation). Even if you suspect ethanol withdrawal, it is mandatory to check fingerstick glucose. (b) The stroke team should be activated in patients who present with signs and symptoms of a stroke that are not caused by hypoglycemia. Therefore, these patients need fingerstick glucose. (d) Sundowning refers to people who become increasingly confused at the end of the day and into the night. Sundowning isn’t a disease but a symptom that often occurs in people with dementia, such as Alzheimer disease. It is more commonly observed on the hospital wards than in the ED. (e) Haloperidol is commonly used as a sedative for agitated patients. However, this patient is agitated because of an organic cause, hypoglycemia. By treating the underlying cause (administering glucose), the agitation will resolve.

Question 2

A 74-year-old lethargic woman is brought to the ED by her Her daughter states that the patient has been progressively somnolent over the last week and could not be woken up today. The patient takes medications for diabetes, hypertension, hypothyroidism, and a recent ankle sprain, which is treated with a hydrocodone/acetaminophen combination. In the ED, the patient is profoundly lethargic, responsive only to pain, and has periorbital edema and delayed relaxation of the deep tendon reflexes. Her BP is 145/84 mm Hg, HR is 56 beats per minute, temperature is 94.8°F, and RR is 12 breaths per minute. Which of the following is the most likely diagnosis?

A	Hypoglycemia
B	Opioid overdose
C	Stroke
D	Myxedema coma
E	Depression

Question 2 Explanation:

Myxedema coma is a life-threatening complication of hypothyroidism. Mortality in myxedema coma approaches 20% to 50% even with appropriate management. The patient exhibits classic signs and symptoms of the disease: lethargy or coma, hypothermia, bradycardia, periorbital and nonpitting edema, and a delayed relaxation phase of deep tendon reflexes (areflexia in more severe cases). Myxedema coma can be triggered by sepsis, trauma, surgery, congestiv heart failure, prolonged cold exposure, or use of sedatives or narcotics (as seen in this example). (a) It is critical that fingerstick glucose is checked. However, myxedema coma differs from the early stages of hypoglycemia in that myxedema coma results in the progressive slowing of all bodily functions; by contrast, in early hypoglycemia, the body is stimulated by the release of adrenergic hormones. (b) The classic findings in opioid toxicity include miotic pupils and respiratory depression. (c) Stroke should be on the differential in this case, but the patient’s signs and symptoms are more consistent with an abnormal metabolic state than with purely neurovascular change. Depression (e) is an often forgotten diagnosis in the elderly and may present with a wide variety of signs and symptoms. Severe depression may appear as lethargy. It is unlikely, however, to have associated hypothermia and abnormal reflexes.

Question 3

A 79-year-old man presents to the ED by paramedics with the chief complaint of agitation and confusion over the previous 12 He has a past medical history of schizophrenia and is not taking any of his antip- sychotics. His BP is 135/85 mm Hg, HR is 119 beats per minute, RR is 18 breaths per minute, oxygen saturation is 97% on room air, and fingerstick glucose is 135 mg/dL. Because of his agitation at triage, he was placed in wrist restraints. At this time, he is calm but confused. Examination reveals warm and clammy skin and 4-mm pupils that are equal and reactive. His cardiac examination reveals tachycardia and no murmurs. His lungs are clear to auscultation and his abdomen is soft and nontender. He is able to move all of his extremities. Which of the following is the most appropriate next step in management?

A	Administer haloperidol or lorazepam.
B	Consult psychiatry.
C	Order a CT scan of his head.
D	Send a urine toxicologic screen.
E	Obtain a rectal temperature.

Question 3 Explanation:

Patients frequently present to the ED with agitation. It is important to discern what is causing their agitation; the range of etiologies is expansive, from ethanol intoxication to intracerebral bleeding. The approach to the emergency patient always begins with the ABCs (airway, breathing, and circulation). In addition, the vital signs must be obtained early in a patient’s assessment in order to reveal potentially life-threatening conditions. The patient in the vignette presents with agitation and tachycardia. Although it is tempting to attribute his agitation to his untreated schizophrenia, doing this without investigating medical causes of agitation can be disastrous. Finding out that the patient’s temperature is 103.1°F, for instance, will lead you down a different clinical path than if his temperature is 98°F. This patient was ultimately diagnosed with meningitis. (a) Administering a medication to control agitation or psychotic behavior is appropriate even when there are coexistent medical problems. Patients who are too agitated cannot be properly examined. However, it is critical to rule out potential life threats that may be causing the agitation. (b) A psychiatry consultation should be obtained once life-threatening conditions are excluded or in the case of the patient above, when he is stable and communicative as an inpatient. (c and d) A head CT and blood work will need to be obtained in this patient; however, all of the vital signs should be obtained first.

Question 4

A 25-year-old man is brought to the ED by emergency medical ser- vice (EMS) accompanied by his girlfriend who reports that the patient had a seizure 30 minutes ago and is still The girlfriend reports that the patient is a known epileptic who has been doing well on his latest medi- cation regimen. The exact seizure medications are unknown. On arrival to the ED, the patient develops continuous clonic movements of his upper and lower extremities. The patient’s vital signs are BP of 162/85 mm Hg, HR of 110 beats per minute, and pulse oximetry of 91% on room air. Capil- lary glucose level is 95 mg/dL. Which of the following is the most appropri- ate next step in management?

A	Place the patient in a lateral decubitus position.
B	Administer lorazepam.
C	Administer phenytoin.
D	Perform rapid sequence intubation on the patient.
E	Look up the patient’s medical records and administer his current antiepileptic regimen.

Question 4 Explanation:

The initial approach to a seizing patient should involve protecting the patient from injury. Seizing252 Emergency Medicine patients should be immediately placed in a lateral decubitus position to prevent aspiration of gastric contents. Other initial measures are oxygen administration, pulse oxymetry, glucose level determination, and an IV line. Benzodiazepines (eg, lorazepam) (b) are the first-line agents for an actively seizing patient. Benzodiazepines are sedative hypnotics which increase γ-aminobutyric acid (GABA) activity. Phenytoin (c) is a secondline anticonvulsant in a continuously seizing patient. It requires a loading dose and has to be administered slowly because rapid administration may cause hypotension and cardiac dysrhythmias. Rapid sequence intubation (RSI) (d) should not be performed at this time. The patient’s pulse oximetry is 91% on room air and can be improved by supplemental oxygen and a nasopharyngeal airway if necessary. RSI should be done if the patient becomes apneic or his oxygen saturation drops despite oxygen supplementation. Patient’s who are intubated and chemically paralyzed should be placed on continuous electroencephalogram (EEG) to monitor for underlying seizure activity. (e) Once the acute seizure is controlled, levels of the patient’s anticonvulsant medications should be checked and supplemented if subtherapeutic.

Question 5

A 21-year-old college student is brought to the ED by her roommate who states that the patient has been very sleepy She has a history of diabetes and has not refilled her medication in over a week. Her BP is 95/61 mm Hg, HR is 132 beats per minute, temperature is 99.7°F, and RR is 20 breaths per minute. Her fingerstick glucose is 530 mg/dL. Which of the following choices most closely matches what you would expect to find on her arterial blood gas with electrolytes and urinalysis?

A	pH 7.38, anion gap 5, normal urinalysis
B	pH 7.57, anion gap 21, presence of glucose and leukocytes in urine
C	pH 7.47, anion gap 12, presence of glucose and ketones in urine
D	pH 7.26, anion gap 12, presence of glucose and ketones in urine
E	pH 7.26, anion gap 21, presence of glucose and ketones in urine

Question 5 Explanation:

This patient presents with an anion gap metabolic acidosis, glucosuria, and ketonuria, which is consistent with diabetic ketoacidosis (DKA). DKA is an acute, life-threatening disorder occurring in patients with insulin insufficiency. It results in hyperglycemia, ketosis, and osmotic diuresis, and clinically presents with gastrointestinal (GI) distress, polyuria, fatigue, dehydration, mental confusion, lethargy, or coma. When the diagnosis of DKA is clinically suspected and hyperglycemia is confirmed by elevated fingerstick glucose, the results of a blood gas and urinalysis confirm the diagnosis. In DKA, the liver metabolizes free fatty acids into ketone bodies for alternative fuel in the setting of cellular glucose underutilization. The result is ketonuria and anion gap metabolic acidosis (pH < 7.4 and HCO3− < 24). Glucosuria, the result of hyperglycemia-related osmotic diuresis, is another manifestation of DKA. The anion gap is calculated by subtracting Cl− and HCO3− from Na+. Anion gap (AG) = [Na+] − ([Cl−] + [HCO3−]) A normal anion gap is 8 to 12 mEq/L. An elevated gap is a result of an increased concentration of unmeasured anions. In DKA, the elevated anion gap is caused by the production of ketones. Other answers (a, b, c, and d) are incorrect choices in the DKA presentation

Question 6

A 65-year-old actively seizing woman is brought to the ED by She was found slumped over at the bus stop bench. EMS personnel state that when they found the woman, she was diaphoretic and her speech was garbled. En route to the hospital, she started to seize. As you wheel her to a room, the nurse gives you some of her vital signs that are a BP of 150/90 mm Hg, HR of 115 beats per minute, and oxygen saturation of 96%. Which of the following is the next best step in managing this patient?

A	Request a rectal temperature to rule out meningitis.
B	Call the CT technologist and tell them you are bringing over a seizing patient.
C	Ask for a stat ECG and administer an aspirin.
D	Check the patient’s fingerstick blood glucose level.
E	Intubate the patient.

Question 6 Explanation:

TIn a patient who is actively seizing, it is essential to check the blood glucose level. Hypoglycemia is an easily reversible cause of seizure and is corrected with the administration of dextrose, not the usual anticonvulsants. Patients at both extremes of age are particularly susceptible to glucose stress during acute illness. If the blood glucose level is normal, requesting a rectal temperature (a) is appropriate. However, this should be done concomitantly with addressing airway protection, gaining IV access, and administering an anticonvulsant. A CT scan (b) may be necessary in a seizure patient; however, this should occur once the patient is stabilized. An ECG and aspirin (c) are usually the initial management for patients with chest pain. In an actively seizing patient, nothing should be administered by mouth because there is an increased risk for aspiration and the patient may not have a gag254 Emergency Medicine reflex. Intubating (e) the patient may be necessary if the seizure cannot be medically controlled, the patient is hypoxic, or not protecting his or her airway. In the above patient, you’d expect the seizure to cease once glucose is administered. In addition, her oxygen saturation is 96%.

Question 7

A 48-year-old man presents to the ED with ethanol His BP is 150/70 mm Hg, HR is 95 beats per minute, temperature is 97.9°F, RR is 14 breaths per minute, and oxygen saturation is 93% on room air. The patient is somnolent and snoring loudly with occasional gasps for air. On examination, the patient’s gag reflex is intact, his lungs are clear to ausculta- tion, heart is without murmurs, and abdomen is soft and nontender. He is rousable to stimulation. A head CT is negative for intracranial injury. His ethanol level is 270 mg/dL. Which of the following actions is most appro- priate to assist the patient with respirations?

A	Nasal airway
B	Oral airway
C	Bag-valve-mask ventilation
D	Laryngeal mask airway
E	Tracheoesophageal airway

Question 7 Explanation:

A nasal airway is made of a pliable material that allows it to be placed into the nostril of a somnolent patient with an intact gag reflex. The nasal airway is an excellent device that can be placed in a patient who may have decreased pharyngeal muscle tone and an obstructing soft palate and tongue. It allows air to bypass such obstructions. The patient in the vignette is intoxicated and appears to have episodes of transient obstruction. (b) An oral airway is a rigid instrument that is used to prevent the base of the tongue from occluding the hypopharynx. It should be used to maintain the airway only in a patient with an absent gag reflex. (c) Bag-valve-mask ventilation is typically used to oxygenate a patient in preparation for a definitive airway, such as orotracheal intubation. (d and e) Laryngeal mask and tracheoesophageal and airways are devices typically used in the ED as rescue devices in failed intubation or in the prehospital setting when orotracheal intubation is not a viable option. These devices are designed to be placed in apneic, unconscious patients.

Question 8

A 19-year-old college student presents to the ED complaining of headache, sore throat, myalgias, and rash that developed over the previous 12 Her BP is 95/60 mm Hg, HR is 132 beats per minute, temperature is 103.9°F, RR is 19 breaths per minute, and oxygen saturation is 98% on room air. She is confused and oriented only to person. Physical examina- tion is remarkable for pain with neck flexion, a petechial and purpuric rash on her extremities, and delayed capillary refill. Which of the following best describes the emergency physicians’ priority in managing this patient?

A	Collect two sets of blood cultures prior to antibiotic administration.
B	Call the patient’s parents and have them come immediately to the hospital.
C	Call her roommate to gather more information.
D	Begin fluid resuscitation, administer intravenous (IV) antibiotics, and perform a lumbar puncture (LP).
E	Administer acetaminophen to see if her headache and fever resolve.

Question 8 Explanation:

The first question an emergency physician asks for each patient is whether a life-threatening process is causing the patient’s complaint. Emergency medicine is primarily a complaint-oriented, rather than a disease-oriented specialty. Its emphasis rests on anticipating and recognizing a life-threatening process rather than seeking the diagnosis. The goal is to think about and plan to prevent the life-threatening things from happening or progressing in the patient. The patient in the vignette may have meningitis, a life-threatening condition, or a viral syndrome with dehydration. The initial approach is stabilization and treatment or prevention of a life-threatening process. This patient requires fluid resuscitation for her BP, altered mental status, and delayed capillary refill. Antibiotics should be started immediately and an LP performed once increased ICP is evaluated by funduscopic examination or CT scan. She should be placed in isolation. Her disposition is directed by her response to initial resuscitation and results of the LP. (a) It is important to collect blood cultures; however, initial stabilization and treatment is priority. (b) The patient’s parents should be contacted if the patient cannot do it herself, but treatment should proceed in the meantime. (c) Gathering more information is invaluable; however, thisAltered Mental Status Answers 253 should be done after initial stabilization and treatment. (e) Observation in a patient with a life-threatening condition is not recommended.

Question 9

A 52-year-old woman is brought to the ED by her husband for altered mental status for 1 The patient has hypertension and diabetes but has not been taking her medications for the last 5 days since she lost her insur- ance and could not afford her prescriptions. Her BP is 168/91 mm Hg, HR is 125 beats per minute, temperature is 99.8°F, and RR is 18 breaths per minute. Her fingerstick glucose is 900 mg/dL. There is glucose in her urine but no ketones. Which of the following is the most appropriate next step in management?

A	Administer IV fluids and insulin
B	Obtain head CT scan
C	Obtain ECG
D	Obtain chest radiograph and urine culture
E	Administer broad coverage antibiotics

Question 9 Explanation:

Profound hyperglycemia, absence of ketonuria, and diabetes medication noncompliance should raise your suspicion for nonketotic hyperosmolar crisis (NKHC) in this patient. This condition is a syndrome of hyperglycemia without ketoacidosis as small amounts of insulin protect against adipose tissue metabolism. This syndrome is more common in type 2 diabetics. Causes of NKHC are similar to those of DKA and include diabetes medication noncompliance, infection, stroke, and myocardial infarction (MI). Patients are profoundly dehydrated because of osmotic diuresis. The mainstay of NKHC therapy consists of replacing fluid losses. Electrolyte deficiencies should be replaced and insulin administered. Fluid deficit in NKHC is significant and needs to be slowly corrected, as rapid correction may lead to cerebral edema. Insulin requirements in NKHC are usually less than in DKA. Further diagnostic tests are important to obtain, depending on the patient’s presentation and suspicion of an underlying etiology of NKHC. In this case, medication noncompliance is most likely. In other cases, headAltered Mental Status Answers 255 CT for workup of intracranial pathology (b), ECG for evaluation of MI (c), or chest radiograph and urine culture for infectious etiology workup (d) might be necessary. Without an infectious etiology, broad coverage antibiotics (e) are not necessary in this patient.

Question 10

A 45-year-old man is brought to the ED by his coworkers after collapsing to the floor while at A coworker states that the patient mistakenly took several tablets of his oral diabetic medications a few hours ago. The patient is unresponsive and diaphoretic. His BP is 142/78 mm Hg, HR is 115 beats per minute, temperature is 98.9°F, and RR is 12 breaths per minute. A bedside glucose reads 42 mg/dL. Which of the following is the most appropriate management of this patient?

A	Administer IV dextrose, obtain repeat fingerstick glucose every hour, and, if normal after 6 hours, discharge the patient home.
B	Administer IV dextrose and continue monitoring his blood sugar for at least 24 hours.
C	Administer IV fluids and insulin.
D	Administer IV fluids.
E	Administer activated charcoal and IV fluids.

Question 10 Explanation:

This is a case of hypoglycemia caused by oral hypoglycemic medication overdose. Diabetic oral agents that cause hypoglycemia work by increasing pancreatic insulin secretion. This group includes sulfonylureas (glyburide, glipizide) and nonsulfonylurea secretagogues (repaglinide, nateglinide). Other common causes of hypoglycemia are insulin overdose, alcohol abuse (inhibition of gluconeogenesis), and sepsis. The presentation of a hypoglycemic patient generally involves signs and symptoms of CNS dysfunction owing to the release of counterregulatory hormones secondary to the unavailability of glucose. Symptoms include anxiety, diaphoresis, palpitations, and confusion. Don’t be fooled by improved blood glucose levels after dextrose administration in overdose with oral hypoglycemic agents. Hypoglycemia can last more than 24 hours because of long-lasting pancreatic effects and will recur after dextrose infusion. Patients need to be observed in the hospital with frequent bedside glucose checks. They can be placed on a dextrose drip. Octreotide, an inhibitor of insulin release, can also be administered. Choice (a) is inappropriate since hypoglycemia will recur after administration of a single bolus of dextrose. IV fluids and insulin (c) are treatments for hyperglycemia. IV fluid without dextrose (d) is not helpful in hypoglycemia management. Activated charcoal administration (e) is recommended within an hour after certain toxic ingestions or when there may be a coingestion of an unknown toxin.

Question 11

A 59-year-old man is brought into the ED accompanied by his son who states that his father is acting irritable and occasionally The son states that his father has a history of hepatitis from a transfusion he received many years ago. Over the past 5 years, his liver function slowly deteriorated. His vital signs include BP of 145/80 mm Hg, HR of 78 beats per minute, RR of 16 breaths per minute, oxygen saturation of 98%, and temperature of 98°F. Laboratory results are all within normal limits, except for an ammonia level that is significantly elevated. Which of the following is the best therapy?

A	Vancomycin and gentamycin
B	Lactulose and neomycin
C	Ampicillin and gentamycin
D	Levofloxacin
E	Ciprofloxacin

Question 11 Explanation:

he patient has hepatic encephalopathy, which is a clinical state of disordered cerebral function occurring secondary to acute or chronic liver disease. Laboratory tests may be normal in patients, but the serum ammonia level is usually elevated. Lactulose and neomycin represent the main therapeutic agents. Lactulose is a poorly absorbed sugar metabolized by colonic bacteria that traps ammonia and helps excrete it in the stool. Neomycin is a poorly absorbed aminoglycoside that is believed to act by reducing colonic bacteria responsible for producing ammonia. No other antibiotics (a, c, d, and e) are indicated in the management of hepatic encephalopathy

Question 12

A 40-year-old man who is an employee of the hospital is brought to the ED actively A coworker states that the patient has a known sei- zure disorder and currently takes phenytoin for the disorder. He also tells you that the patient has been under stress recently and may not have taken his last few doses of medication. You call for the nurse to place a face mask with 100% oxygen and gain IV access. You then ask for a medication to be drawn up. Which is the most appropriate initial medication you should administer in this actively seizing patient?

A	Phenytoin
B	Diazepam
C	Phenobarbital
D	Valproic acid
E	Lithium

Question 12 Explanation:

Generally, the first-line pharmacologic treatment in an actively seizing patient is a parental benzodiazepine, such as diazepam (Valium), lorazepam (Ativan), or midazolam (Versed). Benzodiazepines are effective in terminating ictal activity in 75% to 90% of patients. Diazepam can be administered intravenously, intramuscularly, or down an endotracheal tube. Lorazepam and midazolam can be given intravenously or intramuscularly. All three have similar efficacy in terminating seizures. Phenytoin (a) is a second-line agent that can be administered intravenously. Although the cause of the patient’s seizure may be because of subtherapeutic levels of phenytoin, benzodiazepines are still the first-line therapy owing to their rapid onset. The onset of diazepam is 2 to 5 minutes while phenytoin is 10 to 30 minutes. In addition, phenytoin requires at least 20 minutes for administration because of its potential to cause hypotension and cardiac dysrhythmias. Phenobarbital (c) is a third-line agent. Its onset of action is 15 to 30 minutes. Valproic acid (d) is rarely used in the acute seizure setting. There is no role for lithium (e) in acute seizure management.

Question 13

A 32-year-old gravida 1, para 1 who gave birth by normal vaginal delivery at 38 weeks’ gestation 2 days ago presents to the ED complain- ing of bilateral hand swelling and severe headache that started 2 hours ago. Her BP is 187/110 mm Hg, HR is 85 beats per minute, temperature is 5°F, and RR is 15 breaths per minute. Urinalysis reveals 3+ protein. When you are examining the patient, she proceeds to have a generalized tonic-clonic seizure. Which of the following is the most appropriate next step in management?

A	Administer magnesium sulfate IV.
B	Administer labetalol to reduce her BP and morphine sulfate to address her headache.
C	Administer sumatriptan and place the patient into a dark quiet room.
D	Administer a loading dose of phenytoin, order a head CT scan, and call for a neurology consult.
E	Administer diazepam and normal saline IV.

Question 13 Explanation:

This patient has postpartum eclampsia, which needs to be managed with magnesium sulfate and admission to the obstetrical service. Preeclampsia is defined as new-onset hypertension (> 140/90 mm Hg) and proteinuria (1 g/L in random specimen or > 3 g/L over 24 hours). Some clinicians also use generalized edema as a requirement. Preeclampsia is most common in the third trimester. Eclampsia occurs with the development of seizures or coma in a patient with preeclampsia. A preeclamptic woman may worsen after delivery and develop late postpartum eclampsia, which usually occurs in the first 24 to 48 hours postpartum but may present several weeks after delivery. Management of eclamptic seizures in the ED involves administering magnesium sulfate, which is believed to act as a membrane stabilizer and vasodilator, reducing cerebral ischemia. Although magnesium sulfate is not a direct antihypertensive, the hypertension associated with eclampsia is often controlled adequately by treating the seizure. (b) Treating the seizure will most likely also lower the patient’s BP. Fewer than 10% of eclamptic patients require specific antihypertensive therapy. (c) This is the treatment for migraines, which this patient does not have. (d and e) This patient’s seizure is secondary to eclampsia. The first-line treatment is with magnesium sulfate. If the seizure is not treatedAltered Mental Status Answers 257 despite appropriate magnesium sulfate, a benzodiazepine can be administered and etiologies of seizure other than eclampsia should be sought.

Question 14

An unconscious 51-year-old woman is brought to the ED by A friend states that the patient was complaining of feeling weak. She vom- ited and subsequently “blacked out” in the ambulance. The friend states that the patient has no medical problems and takes no medications. She also states that the patient smokes cigarettes and uses cocaine, and that they were snorting cocaine together prior to her blacking out. The patient’s BP is 195/80 mm Hg, HR is 50 beats per minute, temperature is 98.6°F, and RR is 7 breaths per minute. What is the eponym associated with her vital signs?

A	Cushing syndrome
B	Cushing reflex
C	Cullen sign
D	Charcot triad
E	Chvostek sign

Question 14 Explanation:

The patient has a triad of hypertension, bradycardia, and respiratory depression, which is called Cushing reflex. This is observed in one-third of patients with a potentially lethal increase in ICP. Increased ICP may result from traumatic brain injury or, as in this patient’s case, from hemorrhagic stroke and subsequent brain edema. Tobacco and cocaine use are known risk factors for hemorrhagic stroke. Increasing ICP can result in cerebral herniation, which has a mortality rate close to 100%. For any chance of survival, it must be rapidly controlled by intubation, elevation of the head of the bed, hyperventilation, mannitol, and definitive neurosurgical intervention. Cushing syndrome (a) describes the hyperadrenal state associated with increased production of cortisol, leading to hypertension, truncal obesity, abdominal striae, and hirsutism. Cullen sign (c) is purplish discoloration around the umbilicus that results from intraperitoneal hemorrhage. Charcot triad (d) constitutes fever, right upper quadrant (RUQ) pain, and jaundice, and is associated with cholangitis. Chvostek sign (e), associated with hypocalcemia, is twitching of the nose or lips with tapping of the facial nerve.

Question 15

A 47-year-old man is brought to the ED by EMS after being persis- tently agitated at a business The patient’s coworkers state that he has been working nonstop for a day and a half and that he always seemed like a healthy guy who frequented bars every night. EMS administered 25 g of dextrose and thiamine with no symptom improvement. In the ED, the patient is anxious, confused, tremulous, and diaphoretic. He denies any medical problems, medications, or drug ingestions. His BP is 182/92 mm Hg, HR is 139 beats per minute, temperature is 100.4°F, RR is 18 breaths per minute, and fingerstick glucose is 103 mg/dL. An ECG reveals sinus tachycardia. Which of the following is the next best step?

A	Administer acetaminophen.
B	Administer folate.
C	Administer diazepam.
D	Recheck fingerstick glucose.
E	Administer labetalol.

Question 15 Explanation:

This patient presents with alcohol withdrawal. Signs and symptoms of this condition occur along a continuum ranging from simple shakes to delirium tremens (DTs) following a reduction or cessation of alcohol. Early symptoms usually appear 6 to 8 hours after cessation of drinking and involve tremulousness, anxiety, mild hypertension, and tachycardia. In more severe withdrawal, these symptoms worsen and paranoia, auditory, and visual hallucinations may develop proceeding to DTs with severe autonomic hyperactivity and profound altered mental status. DTs usually occur 3 to 5 days after alcohol cessation and carry 5% to 15% mortality even with supportive care. Additionally, alcohol withdrawal seizures may occur anywhere from 6 to 48 hours after cessation of alcohol. Benzodiazepines are the mainstay of therapy in alcohol withdrawal, as well as in sympathomimetic overdose and sedative-hypnotic withdrawal. Acetaminophen (a) and labetalol (e) would treat the symptoms of lowgrade fever and hypertension/tachycardia, respectively, without addressing the underlying etiology. Folate (b) should be given to all potentially258 Emergency Medicine undernourished patients, especially alcoholics, to prevent folate-deficient anemia. Dextrose was just administered by EMS without symptom improvement; however, fingerstick glucose (d) levels are important to check in all patients with altered mental status.

Question 16

A 65-year-old man presents to the ED with a headache, drowsiness, and He has a history of long-standing hypertension. His BP is 230/120 mm Hg, pulse 87 beats per minute, RR 18 breaths per minutes, and oxygen saturation 97% on room air. On examination, you note papille- dema. A head CT scan is performed and there is no evidence of ischemia or hemorrhage. Which of the following is the most appropriate method to lower his BP?

A	Administer propofol for rapid reduction in BP.
B	Administer mannitol for rapid reduction in BP and intracranial pressure (ICP).
C	Administer a high-dose diuretic to reduce preload.
D	Administer labetalol until his BP is 140/80 mm Hg.
E	Administer labetalol until his BP is 180/100 mm Hg.

Question 16 Explanation:

The patient has hypertensive encephalopathy, which is defined by a rapid rise in BP that is accompanied by neurologic changes. Patients typically present with a systolic BP greater than 220 mm Hg and diastolic BP greater than 110 mm Hg. Neurologic findings include severe headache, vomiting, drowsiness, confusion, seizure, blindness, focal neurologic deficits, or coma. Hypertensive emergency is a medical emergency. The goal of therapy is to stop and reverse the progression of end-organ dysfunction while maintaining organ perfusion and avoiding complications. Reduction in BP should be done rapidly but carefully. It is important to avoid dropping the pressure too low as this may lead to cerebral ischemia. The immediate goal is to reduce the mean arterial BP by 20% to 30% of pretreatment levels over the first hour of therapy. This can be accomplished by labetalol, a β1-, β2-, and α1-receptor blocker. Another useful medication is nitroprusside, which is a better choice if the patient’s BP is being monitored through an intra-arterial line. Nitroprusside can cause a reflex tachycardia. (a) Propofol is an excellent sedating agent that has a rapid onset of action and metabolizes quickly. It is also known to cause hypotension and apnea as side affects. However, it should not be used as an antihypertensive because of its unpredictable properties. (b) Mannitol is an osmotic agent that is used to lower ICP in patients with impending or actual brain herniation. It is not appropriate as an antihypertensive agent. (c) Diuretics are not useful to acutely lower BP but may be started as a maintenance antihypertensive. (d) Lowering the BP to 140/80 mm Hg can cause cerebral ischemia. The mean arterial pressure should only be lowered by 20% to 30% in the first hour.

Question 17

A 74-year-old woman is brought to the ED by EMS for altered men- tal Her BP is 138/72 mm Hg, HR is 91 beats per minute, RR is 17 breaths per minute, and temperature is 100.9°F. A head CT is normal. LP results revealed the following:

White blood cell (WBC) count 1020/mL with 90% polymorphonuclear cells

Glucose 21 mg/dL

Protein 225 g/L

Which of the following is the most likely diagnosis?

A	TB meningitis
B	Bacterial meningitis
C	Viral meningitis
D	Fungal meningitis
E	Encephalitis

Question 17 Explanation:

The cerebrospinal fluid (CSF) analysis in bacterial meningitis typically shows an elevated WBC count with predominant polymorphonuclear leukocytes. Protein is elevated and glucose is low. A Gram stain may show bacteria. The most specific marker for the diagnosis is a positive culture. Tests that evaluate the presence of antigen in the CSF (eg, latex agglutination studies) are particularly useful in the diagnosis of partially treated bacterial meningitis.Altered Mental Status Answers 259 (a) TB meningitis typically presents with less than 1000 WBC/μL with monocytic predominance. Symptoms are generally insidious in nature, typically not appearing until after a week has passed. (c) In viral meningitis, the CSF WBC count is made up of lymphocytes or monocytes, but early in the disease polys may predominate. CSF glucose is normal and protein is elevated in viral meningitis. A Gram stain will be negative and culture will show no growth. (d) Fungal meningitis is rare and generally presents in immunocompromised patients. LP usually reveals less than 500/μL WBCs. (e) Encephalitis is diagnosed by CSF culture or serology. CSF analysis that reveals blood is suspicious for herpes encephalitis. Test Normal Bacterial Viral Fungal TB Protein < 50 > 200 < 200 > 200 > 200 Glucose > 40 < 40 > 40 < 40 < 40 WBCs < 5 > 1000 < 1000 < 500 < 1000 Cell type Monos > 50% Polys Monos Monos Monos Gram stain Neg Pos Neg Neg Pos (AFB)

Question 18

A 67-year-old man presents to the ED for worsening His wife states that he received his first dose of chemotherapy for lung cancer 2 days ago. Over the last 24 hours, the patient became confused. His BP is 130/70 mm Hg, HR is 87 beats per minute, and temperature is 98.9°F. While in the ED, the patient seizes. You administer an antiepileptic and the seizure immediately stops. You compare his current electrolyte panel to one taken 2 days ago.

Which of the following is the most appropriate treatment?

A	0.45% saline
B	0.9% saline
C	3% saline
D	5% dextrose
E	50% dextrosel

Question 18 Explanation:

Hyponatremia is defined as a measured serum sodium less than 135 mEq/L. However, the development of symptoms secondary to hyponatremia is related more to the rate of change in the serum sodium than to the absolute value. Levels less than 120 mEq/L tend to cause symptoms regardless of the rate to reach this value. Symptoms can include confusion, lethargy, nausea, vomiting, anorexia, muscle cramps, and seizures. There are many causes of hyponatremia, including renal or GI losses, third-spacing, endocrine abnormalities, syndrome of inappropriate antidiuretic hormone (SIADH) release, cirrhosis, CHF, and nephrotic syndrome. Many medications cause SIADH, in addition to pulmonary and CNS disease. This patient, in particular, just started chemotherapy for lung cancer. The treatment for hyponatremia is guided by the cause of the process. However, if a patient is symptomatic (eg, seizing), hypertonic saline (3%) should be carefully administered to raise the serum sodium to 120 mEq/L. A known complication of hypertonic saline, when it is administered too fast and sodium levels rise rapidly, is the development of central pontine myelinosis. (a and b) 0.45% and 0.9% do not provide adequate amounts of sodium to raise the serum level and can actually cause a drop in serum sodium in certain conditions. (d and e) Dextrose is the treatment of choice for hypoglycemic patients.

Question 19

A 31-year-old woman with a history of schizophrenia presents to the ED for altered mental A friend states that the patient is on mul- tiple medications for her schizophrenia. Her BP is 150/80 mm Hg, HR 121 beats per minute, RR 20 breaths per minute, and temperature 104.5°F. On examination, the patient is diaphoretic with distinctive “lead-pipe” rigidity of her musculature. You believe the patient has neuroleptic malig- nant syndrome. After basic stabilizing measures, which of the following medications is most appropriate to administer?

A	Haloperidol
B	Droperidol
C	Dantrolene
D	Diphenhydramine
E	Acetaminophen

Question 19 Explanation:

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal reaction commonly associated with the use of antipsychotic drugs. The classic triad for its clinical presentation includes altered mental status, hyperthermia, and muscle rigidity. The cornerstone of treatment is supportive care with rapid cooling, fluid and electrolyte repletion, and monitoring. Dantrolene, a nonspecific skeletal muscle relaxant, generally used in the treatment of malignant hyperthermia, is also effective for NMS. In addition, benzodiazepines are useful in the treatment of NMS. The offending agent should be discontinued. (a and b) These are both antipsychotic medications that can worsen the symptoms of NMS and should not be administered. (d) Diphenhydramine, an anticholinergic, should be avoided as it is ineffective and may worsen the reaction by interfering with temperature regulation. (e) Acetaminophen, an antipyretic, may help in lowering the temperature. However, NMS is a centrally mediated process. External cooling is more effective

Question 20

A 56-year-old man is brought in from the homeless shelter for strange, irrational behavior, and unsteady gait for 1 A worker at the shelter reports that the patient is a frequent abuser of alcohol. On examination, the patient is alert but oriented to name only and is unable to give full history. He does not appear clinically intoxicated. You note horizontal nystagmus and ataxia. What is the most likely diagnosis?

A	Wernicke encephalopathy
B	Korsakoff syndrome
C	Normal pressure hydrocephalus
D	Central vertigo
E	Alcohol withdrawal

Question 20 Explanation:

This patient exhibits the classic triad of Wernicke encephalopathy (WE): confusion, ataxia, and ophthalmoplegia. WE is a result of thiamine deficiency leading to decreased glucose metabolism and neuronal destruction, primarily in the cerebellum, hypothalamus, vestibular system, and memory. It is typically found in chronic alcoholics caused by nutritional deficiency but can also occur in other malnutrition states, pregnancy, persistent vomiting, or dialysis. WE can mimic acute stroke symptoms and can lead to permanent nystagmus and ataxia. It carries 10% to 20% mortality if untreated. Eye examination findings in WE include horizontal nystagmus, vertical gaze palsy, or cranial nerve VII palsy. Cerebellar destruction presents with ataxic, wide-based gait. WE is a clinical diagnosis. Thiamine deficiency can also lead to the development of high-output cardiac failure and Korsakoff syndrome. The treatment is parenteral thiamine supplementation. Korsakoff syndrome (b) is another sign of thiamine deficiency and involves disorientation and confabulation. Normal-pressure hydrocephalus (c) presents with dementia, ataxic gait, and urinary incontinence. Head CT shows large ventricles. Central vertigo (d) is caused by lesions in the brainstem or cerebellum. It is associated with vertical or rotary nystagmus and nausea and vomiting. Alcohol withdrawal (e) typically presents with sympathetic and CNS overactivity

Question 21

An 18-year-old girl is brought to the ED from a party for agitation and attacking her boyfriend with a Her boyfriend admits that she had several liquor shots and used intranasal cocaine at the party prior to becoming agitated, paranoid, and attacking him. Her BP is 145/80 mm Hg, HR is 126 beats per minute, temperature is 100.8°F, and RR is 20 breaths per minute. The patient is agitated, screaming, and resisting examination. What is the next best step in the management of this patient?

A	IV -blocker
B	IV benzodiazepine
C	Acetaminophen
D	Lithium
E	Drug abuse specialist consult

Question 21 Explanation:

The patient has cocaineinduced autonomic and CNS hyperactivity causing agitation, paranoia, and a hyperadrenergic state. More severe CNS manifestations of cocaine poisoning include hyperthermia, intracranial hemorrhage, seizures, spinal cord infarctions, and acute dystonic reactions. The CNS effects of cocaine are managed with benzodiazepines, which decrease sympathetic tone and prevent hyperthermia and seizures. (a) β-Adrenergic receptor blockers decrease HR and BP. In this case, however, metoprolol administration does not address the underlying cause of the adrenergic hyperactivity. More importantly, β-adrenergic receptor blockade in cocaine poisoning leaves unopposed stimulated α-adrenergic receptors, thus worsening vasoconstriction. Therefore, β-receptor blocker use in cocaine poisoning is contraindicated. Acetaminophen (c) is not helpful in this situation. Fever or hyperthermia in cocaine poisoning is caused by hypothalamic stimulation, and not by inflammatory mediators. Hyperthermia should be treated with cooling methods, such as cool mist spray or ice-bath immersion. Lithium (d) is commonly used in the treatment of depressive and bipolar affective disorders. It has no role in the acute treatment of cocaine intoxication. Drug abuse specialists (e) should be consulted when the patient is medically cleared.

Question 22

A 78-year-old woman is transferred from a nursing home with altered mental status and The nursing home reports that the patient was febrile to 102.3°F, disoriented, confused, and incontinent of urine. Her past medical history includes hypertension, a stroke with residual right-sided weakness, and nighttime agitation for which she was started on haloperidol 3 days ago. Her BP is 215/105 mm Hg, HR is 132 beats per minute, tem- perature is 102.8°F, and RR is 20 breaths per minute. On examination, the patient is oriented to name only, tremulous, diaphoretic, and has marked muscular rigidity and three out of five right upper- and lower-extremity strength. What is the most likely diagnosis?

A	Urinary tract infection
B	Malignant hyperthermia
C	Neuroleptic malignant syndrome
D	Recurrent stroke
E	Meningoencephalitis

Question 22 Explanation:

The patient presents with a rare but potentially life-threatening NMS. Antipsychotic drugs (eg, haloperidol) are the most common offending agents in the development of NMS, causing central dopamine depletion. The disorder is typically characterized by hyperthermia, muscle rigidity, altered mental status, and autonomic instability. Because NMS carries a high mortality, it is important to aggressively treat it with muscle relaxers, such as IV benzodiazepines, dantrolene, and dopamine agonists. Urinary tract infection (a) in a debilitated or nursing home patient can easily lead to altered mental status and sepsis. The patient’s muscular rigidity, however, does not fit this diagnosis. The presentation of malignant hyperthermia (b) is similar to NMS, also involving hyperthermia and muscle rigidity. It is caused by anesthetic agents, which this patient did not receive. Dantrolene is also used for muscle relaxation in malignant hyperthermia. Recurrent stroke (d) is unlikely in this presentation with hyperthermia and muscle rigidity. Right-sided motor findings on examination are residual deficits from the old stroke. Meningoencephalitis (e) is certainly high on the differential in this patient but is unlikely to cause generalized262 Emergency Medicine muscular rigidity. It typically presents with fever, headache, nuchal rigidity, altered mental status, and focal neurologic signs.

Question 23

A 54-year-old man is brought to the ED by his wife for bizarre The wife complains that her husband has not been acting like his usual self over the last several days. She states that he has not had any change in sleep, appetite, or activity level. She also recalls that her husband com- plained of morning headaches for the last 2 months. The patient is other- wise in good health and does not take any medications. His BP is 135/87 mm Hg, HR is 76 beats per minute, temperature is 98.9°F, and RR is 14 breaths per minute. His examination is otherwise unremarkable. Which of the following is the most likely diagnosis?

A	Migraine headache
B	Tension headache
C	Subarachnoid hemorrhage
D	Pseudotumor cerebri
E	Frontal lobe mass

Question 23 Explanation:

The most likely diagnosis in this patient is a space-occupying lesion in the frontal lobe of the brain. Brain tumors can present with morning headaches associated with nausea and vomiting. Neurologic examination is normal in most patients. Papilledema might provide an important clue of increased ICP and the presence of a brain mass. Frontal lobe tumors typically involve personality changes as seen in this patient. Migraine headaches (a) are recurrent headaches that may be unilateral or bilateral. They occur with or without a prodrome. The aura of a migraine may consist of neurologic symptoms, such as dizziness, tinnitus, scotomas, photophobia, or visual scintillations. Persistent morning headaches and personality changes in this case are inconsistent with the diagnosis of tension headache (b). Tension headache is described as bilateral pressure-like pain, not worsened with activity and associated with stress. Headaches in patients older than 50 years are unusual and should be taken seriously and well evaluated. Subarachnoid hemorrhage (c) typically presents with severe headache of acute onset, classically described as “the worst headache of my life,” with associated nausea and vomiting. Pseudotumor cerebri (d) or benign intracranial hypertension is a disorder seen in young obese female patients complaining of chronic headaches.

Question 24

A 27-year-old woman is brought to the ED by her husband after hav- ing a first-time seizure at She has no past medical history and had no complications while delivering her newborn vaginally 1 week prior to pre- sentation. In the ED, her BP is 178/95 mm Hg, HR is 97 beats per minute, temperature is 99.1°F, and RR is 18 breaths per minute. On examination, she has mild edema of her hands and feet. The seizure stopped spontane- ously, but the patient is postictal appearing and cannot answer your ques- tions. Which of the following is the most appropriate diagnostic test?

A	Complete blood count
B	Head CT
C	LP
D	Urinalysis
E	ECG

Question 24 Explanation:

Eclampsia develops after the 20th week of gestation and is considered a complication of severe preeclampsia. The progression from severe preeclampsia to seizures and coma is thought to be a result of hypertensive encephalopathy, vasogenic edema-associated cortical ischemia, edema, or hemorrhage. Therefore, a head CT should be quickly obtained. Eclampsia is a clinical diagnosis with patients having seizures without evidence of CNS, metabolic, or any other seizure etiology. Most patients have systolic BP higher than 160 mm Hg or diastolic BP higher than 110 mm Hg and proteinuria; however, eclampsia can occur with minimally elevated BP—or elevated, relative to baseline—and without proteinuria. Evidence of end-organ damage prior to development of seizures is common. Symptoms include altered mental status, headache, visual disturbances, and abdominal pain; signs include hemolysis, impaired liver function with elevated liver enzyme levels, low platelets (HELLP [hemolysis, elevated liver enzymes, low platelets]), hemoconcentration, proteinuria,Altered Mental Status Answers 263 oliguria, pulmonary edema, generalized peripheral edema, microangiopathic hemolytic anemia, and fetal growth retardation. Eclampsia is most common during the antepartum period, yet 20% to 25% of cases occur during the postpartum period. Although postpartum eclampsia may occur as long after birth as 3 weeks postpartum, most cases (98%) occur on the first postpartum day. Eclampsia is not the cause of seizures that occur during the first trimester or well into the postpartum period. These seizures are suggestive of CNS pathology. A complete blood count (a) and LP (c) are helpful if there is concern for an infectious etiology of the seizure, such as meningitis. In addition, if you are concerned for HELLP syndrome, a complete blood count is necessary. (d) A urinalysis is not required to make the diagnosis of eclampsia since proteinuria may or may not occur. A urinalysis can be used to rule out a urinary tract infection. An (e) ECG should be obtained to complete the patient’s evaluation but can wait until after the head CT.

Question 25

A 46-year-old woman is brought to the ED by her husband for 1 day of worsening The patient has a history of systemic lupus erythematosus (SLE) and takes chronic oral steroids. She has not been feel- ing well for the last few days. Her BP is 167/92 mm Hg, HR is 95 beats per minute, temperature is 100.3°F, and RR is 16 breaths per minute. On examination, the patient is oriented to name and has diffuse petechiae on her torso and extremities. Laboratory results reveal hematocrit 23%, plate- lets 17,000/mL, BUN 38 mg/dL, and creatinine 1.9 mg/dL. Which of the following is the most likely diagnosis?

A	Henoch-Schönlein purpura (HSP)
B	Disseminated intravascular coagulopathy (DIC)
C	von Willebrand disease
D	Idiopathic thrombocytopenic purpura (ITP)
E	Thrombotic thrombocytopenic purpura (TTP)

Question 25 Explanation:

This patient presents with four of the five symptoms classically associated with TTP. These include thrombocytopenia, hemolytic anemia, neurologic deficits, renal impairment, and fever. TTP develops with fibrin-strand deposition in small vessels that attract platelets leading to platelet thrombi and thrombocytopenia. Passing RBCs get sheared in occluded vessels, resulting in microangiopathic hemolytic anemia. Renal and neurologic impairments occur because of the lodging of thrombi in respective circulations. Plasmapheresis decreases TTP mortality from 90% to 10%. Adjunct therapies include fresh frozen plasma infusion and steroids. It is important to realize that although patients may be severely thrombocytopenic, platelet infusion is contraindicated because it exacerbates the underlying cycle of thrombogenesis. Risk factors for TTP include pregnancy, autoimmune disorders, drugs, infection, and malignancy. Hemolytic-uremic syndrome (HUS) is a closely related entity usually seen in children. There is pronounced renal dysfunction without altered mentation. HSP (a) is a small-vessel vasculitis mostly seen in children and associated with a preceding upper respiratory illness in about 50% of patients. It is characterized by purpura, usually lower extremities, abdominal pain, and hematuria. DIC (b) is a coagulopathic state triggered by major trauma, infection, malignancy, drugs, or pregnancy complications. The underlying process activates the coagulation cascade that leads to diffuse thrombosis and coagulopathy as platelets and coagulation factors are consumed.264 Emergency Medicine Patients with DIC have profuse GI or puncture site bleeding, markedly prolonged PT/PTT times, thrombocytopenia, and elevated fibrin split products. DIC management involves treatment of the underlying disorder and replacement of depleted coagulation cascade components. von Willebrand disease (c) is the most common bleeding disorder and involves deficiency or defect in von Willebrand factor, which normally aids in platelet adherence and carries factor VIII in plasma. von Willebrand disease presents clinically with GI bleeding, epis-taxis, easy bruising, and prolonged bleeding. ITP (d) is a disorder of antibody-mediated platelet destruction. It is acute in children, usually following a viral infection, and is chronic in adults who often require splenectomy for definitive treatment.

Question 26

A 63-year-old man presents to the ED complaining of headache, vomiting, and “not being able to think straight” for 1 The patient states that he has hypertension and diabetes but ran out of his medications in the last week. His BP is 245/138 mm Hg, HR is 90 beats per minute, tem- perature is 98.7°F, and his RR is 14 breaths per minute. Fingerstick glucose is 178 mg/dL. On examination, the patient appears slightly confused and oriented to name and place only. The neurologic examination is significant for papilledema. Which of the following is the most appropriate next step in management?

A	Nitroprusside IV
B	Magnesium sulfate IV
C	Metoprolol by mouth
D	Hydrochlorothiazide by mouth
E	Obtain head CT

Question 26 Explanation:

This patient presents with headache and altered mental status in the setting of severe hypertension leading to the diagnosis of hypertensive encephalopathy. A hypertensive emergency is defined by severe hypertension with evidence of organ dysfunction. The BP needs to be aggressively, but carefully, lowered to prevent cerebral bleeding and progression to coma and death. Patients can also present with seizures, focal neurologic deficits, visual acuity changes, or coma. Patients with hypertensive encephalopathy are managed with shortacting titratable IV antihypertensive medications such as IV nitroprusside or labetalol. The BP should not be significantly lowered because it can result in brain hypoperfusion and infarction. Typically, the mean arterial pressure (MAP) is lowered by 20% to 25% in the first hour of treatment. Magnesium sulfate (b) is used in the management of hypertension and seizures in eclampsia. It is not useful in other hypertensive emergency situations. Metoprolol (c) is a useful agent for hypertension but is not helpful in situations requiring rapid and precise BP control. Hydrochlorothiazide (d) is a good agent for chronic hypertension control. It does not offer rapid and precise BP control required in this case. Obtaining a head CT (e) should be considered in this patient since intracranial hemorrhage and brain tumor are in the differential diagnosis.

Question 27

A 26-year-old man with a long history of epilepsy is brought to the ED for a recent While in the ED, he is rhythmically moving his right leg and is unresponsive. Which of the following best describes this seizure pattern?

A	Petit mal seizure
B	Generalized tonic-clonic seizure
C	Partial seizure with secondary generalization
D	Simple partial seizure
E	Complex partial seizure

Question 27 Explanation:

This is a complex partial seizure, also known as temporal seizure, although it does not necessarily originate in the temporal lobe. It is characterized by focal electrical discharges (partial seizure), such as clonic leg activity and alteration of consciousness. Petit mal seizures (a), also known as absence seizures, involve sudden brief loss of consciousness without the loss of postural tone. Patients appearAltered Mental Status Answers 265 detached or withdrawn and do not respond to stimulation. The seizures might be frequent and classically occur in children. A generalized tonicclonic seizure (b) involves both hemispheres and loss of consciousness (generalized component) and clonic activity of the extremities. Partial seizure with secondary generalization (c) starts with focal abnormal activity that spreads to involve bilateral cortex and mimics a generalized seizure. A simple partial seizure (d) is focal abnormal activity and intact consciousness.

Question 28

A 58-year-old woman is brought into the ED after a witnessed syn- copal Upon arrival, the patient appears confused and agitated. Her vitals include HR of 89 beats per minute, BP of 145/70 mm Hg, RR of 16 breaths per minute, and oxygen saturation of 98% on room air. Within a few minutes, the patient is more alert and oriented. She denies any chest pain, headache, abdominal pain, or weakness preceding the event and is currently asymptomatic. She also states that she has not taken her antiepi- leptic medications in 2 days. The patient’s examination is unremarkable including a nonfocal neurologic examination. Given this patient’s history and evolving examination, what is the most likely etiology of this patient’s syncopal event?

A	Cerebrovascular accident (CVA)
B	Transient ischemic attack (TIA)
C	Seizure
D	Aortic dissection
E	Pulmonary embolus

Question 28 Explanation:

The emergency medicine physician is often faced with differentiating whether the cause of a patient losing consciousness is a result of syncope or a seizure. The most likely etiology of this patient’s symptoms is in the history that she gives. She tells you that she has not taken her antiseizure medications in 2 days. Also, given her evolving mental status and improvement in alertness, this patient most likely presented in a postictal state after she has seized. Without any focal deficit and further improvement in her mental status, one might be comfortable with this diagnosis. Serum testing of her antiepileptic drug levels must be performed to further investigate this suspicion. A CT of the head, ECG, and further investigation is warranted if these levels are normal and do not explain her loss of consciousness. Other neurologic causes, such as a CVA (a) and TIA (b) should also be in the differential. Typical TIA symptoms include any neurologic symptom, which improves within 30 minutes. In this case, however, the patient’s history and presentation most likely precludes this diagnosis. The possibility of her having a stroke is further diminished by her normal neurologic examination. This patient did not complain of any chest or abdominal symptoms (d and e), which place aortic dissection and pulmonary embolus further down on the differential list.

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1. A 69-year-old woman with a past medical history of hyperten- sion, hypercholesterolemia, diabetes mellitus type 1, and alcohol abuse is brought to the emergency department (ED) by her daughter who states that her mom has been acting funny over the last She states that the patient did not know where she was despite being in her own house. She also did not recognize her family and was speaking incomprehensibly. Her blood pressure (BP) is 150/80 mm Hg, heart rate (HR) is 90 beats per min- ute, temperature is 98.9°F, and her respiratory rate (RR) is 16 breaths per minute. On physical examination she is diaphoretic, agitated, and tremu- lous. Electrocardiogram (ECG) is sinus rhythm with normal ST segments and T waves. Which of the following is the most appropriate course of action for this patient?

Administer a benzodiazepine to treat her ethanol withdrawal.
Activate the stroke team and bring the patient directly to the computed tomo- graphic (CT) scanner.
Get a stat fingerstick and administer dextrose if her blood sugar is low.
Request a psychiatric consult for probable sundowning.
Administer haloperidol for sedation.

2. A 74-year-old lethargic woman is brought to the ED by her Her daughter states that the patient has been progressively somnolent over the last week and could not be woken up today. The patient takes medications for diabetes, hypertension, hypothyroidism, and a recent ankle sprain, which is treated with a hydrocodone/acetaminophen combination. In the ED, the patient is profoundly lethargic, responsive only to pain, and has periorbital edema and delayed relaxation of the deep tendon reflexes. Her BP is 145/84 mm Hg, HR is 56 beats per minute, temperature is 94.8°F, and RR is 12 breaths per minute. Which of the following is the most likely diagnosis?

Hypoglycemia
Opioid overdose
Stroke
Myxedema coma
Depression

3. A 79-year-old man presents to the ED by paramedics with the chief complaint of agitation and confusion over the previous 12 He has a past medical history of schizophrenia and is not taking any of his antip- sychotics. His BP is 135/85 mm Hg, HR is 119 beats per minute, RR is 18 breaths per minute, oxygen saturation is 97% on room air, and fingerstick glucose is 135 mg/dL. Because of his agitation at triage, he was placed in wrist restraints. At this time, he is calm but confused. Examination reveals warm and clammy skin and 4-mm pupils that are equal and reactive. His cardiac examination reveals tachycardia and no murmurs. His lungs are clear to auscultation and his abdomen is soft and nontender. He is able to move all of his extremities. Which of the following is the most appropriate next step in management?

Administer haloperidol or lorazepam.
Consult psychiatry.
Order a CT scan of his head.
Send a urine toxicologic screen.
Obtain a rectal temperature.

4. A 25-year-old man is brought to the ED by emergency medical ser- vice (EMS) accompanied by his girlfriend who reports that the patient had a seizure 30 minutes ago and is still The girlfriend reports that the patient is a known epileptic who has been doing well on his latest medi- cation regimen. The exact seizure medications are unknown. On arrival to the ED, the patient develops continuous clonic movements of his upper and lower extremities. The patient’s vital signs are BP of 162/85 mm Hg, HR of 110 beats per minute, and pulse oximetry of 91% on room air. Capil- lary glucose level is 95 mg/dL. Which of the following is the most appropri- ate next step in management?

Place the patient in a lateral decubitus position.
Administer lorazepam.
Administer phenytoin.
Perform rapid sequence intubation on the patient.
Look up the patient’s medical records and administer his current antiepileptic regimen.

5. A 19-year-old college student presents to the ED complaining of headache, sore throat, myalgias, and rash that developed over the previous 12 Her BP is 95/60 mm Hg, HR is 132 beats per minute, temperature is 103.9°F, RR is 19 breaths per minute, and oxygen saturation is 98% on room air. She is confused and oriented only to person. Physical examina- tion is remarkable for pain with neck flexion, a petechial and purpuric rash on her extremities, and delayed capillary refill. Which of the following best describes the emergency physicians’ priority in managing this patient?

Collect two sets of blood cultures prior to antibiotic administration.
Call the patient’s parents and have them come immediately to the hospital.
Call her roommate to gather more information.
Begin fluid resuscitation, administer intravenous (IV) antibiotics, and perform a lumbar puncture (LP).
Administer acetaminophen to see if her headache and fever resolve.

6. A 21-year-old college student is brought to the ED by her roommate who states that the patient has been very sleepy She has a history of diabetes and has not refilled her medication in over a week. Her BP is 95/61 mm Hg, HR is 132 beats per minute, temperature is 99.7°F, and RR is 20 breaths per minute. Her fingerstick glucose is 530 mg/dL. Which of the following choices most closely matches what you would expect to find on her arterial blood gas with electrolytes and urinalysis?

pH 7.38, anion gap 5, normal urinalysis
pH 7.57, anion gap 21, presence of glucose and leukocytes in urine
pH 7.47, anion gap 12, presence of glucose and ketones in urine
pH 7.26, anion gap 12, presence of glucose and ketones in urine
pH 7.26, anion gap 21, presence of glucose and ketones in urine

7. A 65-year-old actively seizing woman is brought to the ED by She was found slumped over at the bus stop bench. EMS personnel state that when they found the woman, she was diaphoretic and her speech was garbled. En route to the hospital, she started to seize. As you wheel her to a room, the nurse gives you some of her vital signs that are a BP of 150/90 mm Hg, HR of 115 beats per minute, and oxygen saturation of 96%. Which of the following is the next best step in managing this patient?

Request a rectal temperature to rule out meningitis.
Call the CT technologist and tell them you are bringing over a seizing patient.
Ask for a stat ECG and administer an aspirin.
Check the patient’s fingerstick blood glucose level.
Intubate the patient.

8. A 48-year-old man presents to the ED with ethanol His BP is 150/70 mm Hg, HR is 95 beats per minute, temperature is 97.9°F, RR is 14 breaths per minute, and oxygen saturation is 93% on room air. The patient is somnolent and snoring loudly with occasional gasps for air. On examination, the patient’s gag reflex is intact, his lungs are clear to ausculta- tion, heart is without murmurs, and abdomen is soft and nontender. He is rousable to stimulation. A head CT is negative for intracranial injury. His ethanol level is 270 mg/dL. Which of the following actions is most appro- priate to assist the patient with respirations?

Nasal airway
Oral airway
Bag-valve-mask ventilation
Laryngeal mask airway
Tracheoesophageal airway

9. A 52-year-old woman is brought to the ED by her husband for altered mental status for 1 The patient has hypertension and diabetes but has not been taking her medications for the last 5 days since she lost her insur- ance and could not afford her prescriptions. Her BP is 168/91 mm Hg, HR is 125 beats per minute, temperature is 99.8°F, and RR is 18 breaths per minute. Her fingerstick glucose is 900 mg/dL. There is glucose in her urine but no ketones. Which of the following is the most appropriate next step in management?

Administer IV fluids and insulin
Obtain head CT scan
Obtain ECG
Obtain chest radiograph and urine culture
Administer broad coverage antibiotics

10. A 45-year-old man is brought to the ED by his coworkers after collapsing to the floor while at A coworker states that the patient mistakenly took several tablets of his oral diabetic medications a few hours ago. The patient is unresponsive and diaphoretic. His BP is 142/78 mm Hg, HR is 115 beats per minute, temperature is 98.9°F, and RR is 12 breaths per minute. A bedside glucose reads 42 mg/dL. Which of the following is the most appropriate management of this patient?

Administer IV dextrose, obtain repeat fingerstick glucose every hour, and, if normal after 6 hours, discharge the patient home.
Administer IV dextrose and continue monitoring his blood sugar for at least 24 hours.
Administer IV fluids and insulin.
Administer IV fluids.
Administer activated charcoal and IV fluids.

11. A 59-year-old man is brought into the ED accompanied by his son who states that his father is acting irritable and occasionally The son states that his father has a history of hepatitis from a transfusion he received many years ago. Over the past 5 years, his liver function slowly deteriorated. His vital signs include BP of 145/80 mm Hg, HR of 78 beats per minute, RR of 16 breaths per minute, oxygen saturation of 98%, and temperature of 98°F. Laboratory results are all within normal limits, except for an ammonia level that is significantly elevated. Which of the following is the best therapy?

Vancomycin and gentamycin
Lactulose and neomycin
Ampicillin and gentamycin
Levofloxacin
Ciprofloxacin

12. A 40-year-old man who is an employee of the hospital is brought to the ED actively A coworker states that the patient has a known sei- zure disorder and currently takes phenytoin for the disorder. He also tells you that the patient has been under stress recently and may not have taken his last few doses of medication. You call for the nurse to place a face mask with 100% oxygen and gain IV access. You then ask for a medication to be drawn up. Which is the most appropriate initial medication you should administer in this actively seizing patient?

Phenytoin
Diazepam
Phenobarbital
Valproic acid
Lithium

13. A 32-year-old gravida 1, para 1 who gave birth by normal vaginal delivery at 38 weeks’ gestation 2 days ago presents to the ED complain- ing of bilateral hand swelling and severe headache that started 2 hours ago. Her BP is 187/110 mm Hg, HR is 85 beats per minute, temperature is 5°F, and RR is 15 breaths per minute. Urinalysis reveals 3+ protein. When you are examining the patient, she proceeds to have a generalized tonic-clonic seizure. Which of the following is the most appropriate next step in management?

Administer magnesium sulfate IV.
Administer labetalol to reduce her BP and morphine sulfate to address her headache.
Administer sumatriptan and place the patient into a dark quiet room.
Administer a loading dose of phenytoin, order a head CT scan, and call for a neurology consult.
Administer diazepam and normal saline IV.

14. An unconscious 51-year-old woman is brought to the ED by A friend states that the patient was complaining of feeling weak. She vom- ited and subsequently “blacked out” in the ambulance. The friend states that the patient has no medical problems and takes no medications. She also states that the patient smokes cigarettes and uses cocaine, and that they were snorting cocaine together prior to her blacking out. The patient’s BP is 195/80 mm Hg, HR is 50 beats per minute, temperature is 98.6°F, and RR is 7 breaths per minute. What is the eponym associated with her vital signs?

Cushing syndrome
Cushing reflex
Cullen sign
Charcot triad
Chvostek sign

15. A 47-year-old man is brought to the ED by EMS after being persis- tently agitated at a business The patient’s coworkers state that he has been working nonstop for a day and a half and that he always seemed like a healthy guy who frequented bars every night. EMS administered 25 g of dextrose and thiamine with no symptom improvement. In the ED, the patient is anxious, confused, tremulous, and diaphoretic. He denies any medical problems, medications, or drug ingestions. His BP is 182/92 mm Hg, HR is 139 beats per minute, temperature is 100.4°F, RR is 18 breaths per minute, and fingerstick glucose is 103 mg/dL. An ECG reveals sinus tachycardia. Which of the following is the next best step?

Administer acetaminophen.
Administer folate.
Administer diazepam.
Recheck fingerstick glucose.
Administer labetalol.

16. A 65-year-old man presents to the ED with a headache, drowsiness, and He has a history of long-standing hypertension. His BP is 230/120 mm Hg, pulse 87 beats per minute, RR 18 breaths per minutes, and oxygen saturation 97% on room air. On examination, you note papille- dema. A head CT scan is performed and there is no evidence of ischemia or hemorrhage. Which of the following is the most appropriate method to lower his BP?

Administer propofol for rapid reduction in BP.
Administer mannitol for rapid reduction in BP and intracranial pressure (ICP).
Administer a high-dose diuretic to reduce preload.
Administer labetalol until his BP is 140/80 mm Hg.
Administer labetalol until his BP is 180/100 mm Hg.

17. A 74-year-old woman is brought to the ED by EMS for altered men- tal Her BP is 138/72 mm Hg, HR is 91 beats per minute, RR is 17 breaths per minute, and temperature is 100.9°F. A head CT is normal. LP results revealed the following:

White blood cell (WBC) count 1020/mL with 90% polymorphonuclear cells

Glucose 21 mg/dL

Protein 225 g/L

Which of the following is the most likely diagnosis?

TB meningitis
Bacterial meningitis
Viral meningitis
Fungal meningitis
Encephalitis

18. A 67-year-old man presents to the ED for worsening His wife states that he received his first dose of chemotherapy for lung cancer 2 days ago. Over the last 24 hours, the patient became confused. His BP is 130/70 mm Hg, HR is 87 beats per minute, and temperature is 98.9°F. While in the ED, the patient seizes. You administer an antiepileptic and the seizure immediately stops. You compare his current electrolyte panel to one taken 2 days ago.

Which of the following is the most appropriate treatment?

0.45% saline
0.9% saline
3% saline
5% dextrose
50% dextrose

19. A 31-year-old woman with a history of schizophrenia presents to the ED for altered mental A friend states that the patient is on mul- tiple medications for her schizophrenia. Her BP is 150/80 mm Hg, HR 121 beats per minute, RR 20 breaths per minute, and temperature 104.5°F. On examination, the patient is diaphoretic with distinctive “lead-pipe” rigidity of her musculature. You believe the patient has neuroleptic malig- nant syndrome. After basic stabilizing measures, which of the following medications is most appropriate to administer?

Haloperidol
Droperidol
Dantrolene
Diphenhydramine
Acetaminophen

20. A 56-year-old man is brought in from the homeless shelter for strange, irrational behavior, and unsteady gait for 1 A worker at the shelter reports that the patient is a frequent abuser of alcohol. On examination, the patient is alert but oriented to name only and is unable to give full history. He does not appear clinically intoxicated. You note horizontal nystagmus and ataxia. What is the most likely diagnosis?

Wernicke encephalopathy
Korsakoff syndrome
Normal pressure hydrocephalus
Central vertigo
Alcohol withdrawal

21. An 18-year-old girl is brought to the ED from a party for agitation and attacking her boyfriend with a Her boyfriend admits that she had several liquor shots and used intranasal cocaine at the party prior to becoming agitated, paranoid, and attacking him. Her BP is 145/80 mm Hg, HR is 126 beats per minute, temperature is 100.8°F, and RR is 20 breaths per minute. The patient is agitated, screaming, and resisting examination. What is the next best step in the management of this patient?

IV b-blocker
IV benzodiazepine
Acetaminophen
Lithium
Drug abuse specialist consult

22. A 78-year-old woman is transferred from a nursing home with altered mental status and The nursing home reports that the patient was febrile to 102.3°F, disoriented, confused, and incontinent of urine. Her past medical history includes hypertension, a stroke with residual right-sided weakness, and nighttime agitation for which she was started on haloperidol 3 days ago. Her BP is 215/105 mm Hg, HR is 132 beats per minute, tem- perature is 102.8°F, and RR is 20 breaths per minute. On examination, the patient is oriented to name only, tremulous, diaphoretic, and has marked muscular rigidity and three out of five right upper- and lower-extremity strength. What is the most likely diagnosis?

Urinary tract infection
Malignant hyperthermia
Neuroleptic malignant syndrome
Recurrent stroke
Meningoencephalitis

23. A 54-year-old man is brought to the ED by his wife for bizarre The wife complains that her husband has not been acting like his usual self over the last several days. She states that he has not had any change in sleep, appetite, or activity level. She also recalls that her husband com- plained of morning headaches for the last 2 months. The patient is other- wise in good health and does not take any medications. His BP is 135/87 mm Hg, HR is 76 beats per minute, temperature is 98.9°F, and RR is 14 breaths per minute. His examination is otherwise unremarkable. Which of the following is the most likely diagnosis?

Migraine headache
Tension headache
Subarachnoid hemorrhage
Pseudotumor cerebri
Frontal lobe mass

24. A 27-year-old woman is brought to the ED by her husband after hav- ing a first-time seizure at She has no past medical history and had no complications while delivering her newborn vaginally 1 week prior to pre- sentation. In the ED, her BP is 178/95 mm Hg, HR is 97 beats per minute, temperature is 99.1°F, and RR is 18 breaths per minute. On examination, she has mild edema of her hands and feet. The seizure stopped spontane- ously, but the patient is postictal appearing and cannot answer your ques- tions. Which of the following is the most appropriate diagnostic test?

Complete blood count
Head CT
LP
Urinalysis
ECG

25. A 46-year-old woman is brought to the ED by her husband for 1 day of worsening The patient has a history of systemic lupus erythematosus (SLE) and takes chronic oral steroids. She has not been feel- ing well for the last few days. Her BP is 167/92 mm Hg, HR is 95 beats per minute, temperature is 100.3°F, and RR is 16 breaths per minute. On examination, the patient is oriented to name and has diffuse petechiae on her torso and extremities. Laboratory results reveal hematocrit 23%, plate- lets 17,000/mL, BUN 38 mg/dL, and creatinine 1.9 mg/dL. Which of the following is the most likely diagnosis?

Henoch-Schönlein purpura (HSP)
Disseminated intravascular coagulopathy (DIC)
von Willebrand disease
Idiopathic thrombocytopenic purpura (ITP)
Thrombotic thrombocytopenic purpura (TTP)

26. A 63-year-old man presents to the ED complaining of headache, vomiting, and “not being able to think straight” for 1 The patient states that he has hypertension and diabetes but ran out of his medications in the last week. His BP is 245/138 mm Hg, HR is 90 beats per minute, tem- perature is 98.7°F, and his RR is 14 breaths per minute. Fingerstick glucose is 178 mg/dL. On examination, the patient appears slightly confused and oriented to name and place only. The neurologic examination is significant for papilledema. Which of the following is the most appropriate next step in management?

Nitroprusside IV
Magnesium sulfate IV
Metoprolol by mouth
Hydrochlorothiazide by mouth
Obtain head CT

27. A 26-year-old man with a long history of epilepsy is brought to the ED for a recent While in the ED, he is rhythmically moving his right leg and is unresponsive. Which of the following best describes this seizure pattern?

Petit mal seizure
Generalized tonic-clonic seizure
Partial seizure with secondary generalization
Simple partial seizure
Complex partial seizure

28. A 58-year-old woman is brought into the ED after a witnessed syn- copal Upon arrival, the patient appears confused and agitated. Her vitals include HR of 89 beats per minute, BP of 145/70 mm Hg, RR of 16 breaths per minute, and oxygen saturation of 98% on room air. Within a few minutes, the patient is more alert and oriented. She denies any chest pain, headache, abdominal pain, or weakness preceding the event and is currently asymptomatic. She also states that she has not taken her antiepi- leptic medications in 2 days. The patient’s examination is unremarkable including a nonfocal neurologic examination. Given this patient’s history and evolving examination, what is the most likely etiology of this patient’s syncopal event?

Cerebrovascular accident (CVA)
Transient ischemic attack (TIA)
Seizure
Aortic dissection
Pulmonary embolus

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