331.As a senior resident in the ED, an intern calls you over to see a patient
he treated for a migraine headache. The patient is a 21-year-old woman with
a history of poorly controlled migraines. The patient was using a number of
migraine medications at home and several were administered intravenously.
As you approach the patient, you note her tongue is protruding and her
head is tilted to the left. She is grimacing. The intern is concerned that the
patient is having an acute stroke and would like to obtain a head CT scan.
You advise the intern that the symptoms are likely the result of a medication
side effect. Which of the following medications is likely to have caused the
patient’s symptoms?
a. Morphine sulfate
b. Acetaminophen
c. Metoclopramide
d. Caffeine
e. Sumatriptan
332.A 63-year-old man who lives in a homeless shelter presents to the ED
complaining of headache with photophobia for 6 hours. Upon arrival to
the ED, the triage nurse places him in an isolation room. The triage note
states that the patient was alert and conversant during the nursing inter-
view. You enter the isolation room and attempt to speak to the patient but
he is lethargic and combative. You note that his temperature is 103°F. He is
unwilling to move his neck and winces when you attempt to check his
pupillary reflexes with a penlight. The nurse informs you that laboratory
analyses are delayed this evening because of staffing issues. Which of the
following is the most appropriate next step in management?
a. Diagnostic LP
b. Initiation of IV antibiotic therapy
c. A loading dose of IV corticosteroids
d. Aggressive antipyretic therapy
e. Sedation of the patient and noncontrast head CT
350 Emergency Medicine