368 Emergency Medicine
diagnostic consideration but are less likely than viral causes. In this patient,
fungal cultures are recommended in addition to CSF cryptococcal antigen.
Bartonellasp.(d)and other rare causes of meningitis are not considered until
other first- and second-tier analyses are conducted. When given simultaneously
with (or before) the first dose of antibiotic, steroids (e)reduce the inci-
dence of sensorineural hearing loss associated with bacterial meningitis in
children. It also decreases the risk of an unfavorable outcome in adults with
bacterial meningitis.
339.The answer is e.(Hasbun, p 1727.)Indications for brain CT scan-
ning prior to LP include: patients who are older than 60 years, patients
who are immunocompromised, patients with known CNS lesions, patients
who presented with a seizure or who had a seizure within 1 week of pre-
sentation, patients with abnormal level of consciousness, patients with
focal findings on neurologic examination, and patients with papilledema
seen on physical examination with clinical suspicion of elevated ICP. All of
the patients in this scenario presented fit one of these contraindications
except for the 51-year-old woman with fever and neck stiffness.
340.The answer is a.(Tintinalli et al, pp 1459-1460.)The patient presents
withacute angle closure glaucomawhich results from obstruction of
aqueous outflow of the anterior chamber of the eye with a resulting rise in
intraocular pressure.It is the result of a shallow anterior chamber or a
chamber distorted by the development of a cataract. Classically, it occurs
when a patient leaves a prolonged dimly lit situation. When the iris becomes
mid-dilated, it maximally obstructs the trabecular meshwork occluding aque-
ous humor flow. Intraocular pressures may rise from normal (10–21 mm Hg)
to levels as high as 50 to 100. Visual acuity is usually decreasedin the
affected eye as a result of corneal edema. Treatment is aimed at lowering
intraocular pressure with acetazolamide, ophthalmic β-blockers, prostaglandin
analogues, and pilocarpine to induce miosis. Ophthalmologic consultation
and follow-up is indicated. Patients may present complaining of headache,
nausea, and vomiting, but will often endorse that the symptoms began with
acute eye pain.
Funduscopic examination (b)is occasionally abnormal in acute glau-
coma, but associated papilledema rarely develops acutely. Corneal exami-
nation with fluorescein (c)is used to diagnose corneal abrasions or other
corneal pathology (ie, ulcers, keratitis, foreign body, corneal rupture). The
cornea may appear normal or “steamy” in the setting of acute glaucoma as