338.A 43-year-old homeless man presents to the ED with fever and
nuchal rigidity. His mental status is depressed but his neurologic examina-
tion is otherwise nonfocal. Noncontrast head CT is normal. You obtain an
LP for diagnostic purposes and initiate empiric antibiotic treatment for bac-
terial meningitis. The result of the CSF analysis is complete after 1 hour.
The protein and glucose are within normal range but the WBC count con-
sists of 220 mononuclear cells. The Gram stain is negative. The patient was
recently purified protein derivative (PPD) negative and had a normal chest
x-ray. In addition to the treatment already initiated, what is the next most
appropriate step in this patient’s management?
a. Empiric treatment with isoniazid
b. Empiric treatment with antiviral medications for herpes virus
c. Empiric treatment with antifungals
d. Antibiotic coverage for Bartonellasp.
e. Addition of steroids to the antibiotic regimen
339.During a busy day working in the ED, five patients come in all of
whom you believe require an LP to evaluate for meningitis. From the fol-
lowing list of patients below, which one can you forgo a CT scan and pro-
ceed directly to an LP?
a. A 65-year-old man with fever and headache
b. A 49-year-old woman with acquired immunodeficiency syndrome (AIDS)
c. A 74-year-old man with new right lower extremity motor weakness
d. A 19-year-old man with a fever who is lethargic and disoriented
e. A 51-year-old woman who is febrile and complains of neck stiffness
340.A 53-year-old man presents to your ED stating he has had an excru-
ciating right-sided headache since leaving the movie theater. He states that
the headache is unilateral, severe, and associated with nausea and vomit-
ing. His vision is blurry and notes seeing halos around objects. He denies
trauma or a history of headaches in the past. Physical examination reveals
right conjunctival injection and a pupil that reacts only marginally. Which
examination is likely to yield the correct diagnosis?
a. Measurement of intraocular pressure
b. Funduscopic examination
c. Fluorescein examination
d. LP with cell count
e. Visual acuity testing
354 Emergency Medicine