A 31-year-old woman presents to the emergency department with a history of fever and vomiting for 2 days and severe headache for a day. Past medical history is significant for migraine diagnosed 10 years ago, but she reports that her current headache is different. She describes the pain as generalized, dull, continuous, severe in intensity, and exacerbated by head movements. Physical examination reveals a blood pressure of 110/76 mm Hg and a temperature of 39.1°C (102.4°F). The patient is awake but in great distress due to pain. A pink-purple petechial rash covers her chest and legs. Extraocular movements are normal. She complains of neck pain and asks you to turn off the lights. Muscle strength is normal in all 4 limbs. Fundoscopic examination is normal. Baseline laboratory investigations are shown: Laboratory test Sodium 145 mEq/L Potassium 3.2 mEq/L Glucose 87 mg/dL Creatinine 1.0 mg/dL White blood cell count 18,900/mm3 Hemoglobin 13.4 g/dL Platelets 165,000/mm3 INR 1.1 Aerobic and anaerobic blood cultures are taken and empiric antibiotics are started. A lumbar puncture is performed. Which of the following cerebrospinal fluid (CSF) findings are expected in this patient?
ACSF: WBC 640 cells/mm3, lymphocytic predominant, protein 180 mg/dL, glucose 24 mg/dL
BCSF: WBC 8,500 cells/mm3, neutrophil predominant, protein 112 mg/dL, glucose 15 mg/dL
CCSF: WBC 145 cells/mm3, lymphocytic predominant, protein 42 mg/dL, glucose 60 mg/dL
DCSF: WBC 4 cells/mm3, protein 35 mg/dL, glucose 66 mg/dL
ECSF: WBC 2 cells/mm3, protein 142 mg/dL, glucose 70 mg/dL
A 53-year-old man is brought to the emergency department for confusion. He was in his usual state of health until about 3 hours ago when he tried to use his sandwich to turn off the TV. He also complained to his wife that he had a severe headache. Past medical history is notable for hypertension, which has been difficult to control on multiple medications. His temperature is 36.7°C (98°F), the pulse is 70/min, and the blood pressure is 206/132 mm Hg. On physical exam he is alert and oriented only to himself, repeating over and over that his head hurts. The physical exam is otherwise unremarkable and his neurologic exam is nonfocal. The noncontrast CT scan of the patient's head is shown and reveals an acute intraparenchymal hemorrhage in the basal ganglia. Which of the following diagnostic tests would be most helpful in determining the underlying cause of this patient's hemorrhage?
ALumbar puncture
BElectroencephalogram (EEG)
CMRI of the brain
DCT angiography of the neck
ECT angiography of the brain
A 72-year-old woman comes to the emergency department 4 hours after the sudden onset of a diffuse, dull, throbbing headache. During this time, she also reports blurred vision, nausea, and one episode of vomiting. She has a history of hypertension and type 2 diabetes mellitus. Her medications include hydrochlorothiazide, lisinopril, atorvastatin, and metformin. She has smoked 1 pack of cigarettes daily for the past 30 years and drinks 1–2 glasses of wine per day. Her temperature is 36.6 °C (97.9 °F), pulse is 90/min, respirations are 14/min, and blood pressure is 185/110 mm Hg. Fundoscopic examination shows bilateral blurring of the optic disc margins. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Urinalysis shows 2+ protein but no WBCs or RBCs. Which of the following is the most likely diagnosis?
AIschemic stroke
BHypertensive emergency
CTransient ischemic attack
DSubarachnoid hemorrhage
EIdiopathic intracranial hypertension
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