266.A 56-year-old man is brought in from the homeless shelter for strange,
irrational behavior and unsteady gait for 1 day. 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
267.An 18-year-old girl is brought to the ED from a party for agitation
and attacking her boyfriend with a knife. 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 β-blocker
b. IV benzodiazepine
c. Acetaminophen
d. Lithium
e. Drug abuse specialist consult
268.A 78-year-old woman is transferred from a nursing home with
altered mental status and fever. 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 weak-
ness, 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, temperature is
102.8°F, and RR is 20 breaths per minute. On examination, the patient is ori-
ented 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
276 Emergency Medicine