294 Emergency Medicine
272.The answer is a. (Tintinalli, p 397.)This patient presents with
headache and altered mental status in the setting of severe hypertension lead-
ing to the diagnosis of hypertensive encephalopathy.A hypertensive emer-
gency is defined by severe hypertension with evidence of organ dysfunction.
The BP needs to be aggressively, but carefully lowered to prevent cerebral
bleeding and progression to coma and death. Patients can also present with
seizures, focal neurological deficits, visual acuity changes, or coma. Patients
with hypertensive encephalopathy are managed with short-acting titratable
IV antihypertensive medicationssuch as IV nitroprussideor labetalol.
The BP should not be significantly lowered since it can result in brain hypop-
erfusion and infarction. Typically, the mean arterial pressure (MAP) is low-
ered by 20% to 25% in the first hour of treatment.
Magnesium sulfate (b)is used in the management of hypertension and
seizures in eclampsia. It is not useful in other hypertensive emergency sit-
uations. Metoprolol (c)is a useful agent for hypertension but is not helpful
in situations requiring rapid and precise BP control. Hydrochlorothiazide
(d)is a good agent for chronic hypertension control. It does not offer rapid
and precise BP control required in this case. Obtaining a head CT (e)should
be considered in this patient since intracranial hemorrhage and brain tumor
are in the differential diagnosis.
273.The answer is e.(Tintinalli, p 1409.)This is a complex partial
seizure,also known as temporal seizure; although it does not necessarily
originate in the temporal lobe. It is characterized by focal electrical dis-
charges(partial seizure), such as clonic leg activity and alteration of con-
sciousness.
Petit mal seizures (a), also known as absence seizures, involve sudden
brief loss of consciousness without the loss of postural tone. Patients appear
detached or withdrawn and do not respond to stimulation. The seizures
might be frequent and classically occur in children. A generalized tonic-
clonic seizure (b)involves both hemispheres and loss of consciousness (gen-
eralized component) and clonic activity of the extremities. Partial seizure
with secondary generalization (c)starts with focal abnormal activity which
spreads to involve bilateral cortex and mimics a generalized seizure. A simple
partial seizure (d)is focal abnormal activity and intact consciousness.
274.The answer is c.(Rosen, pp 172-178.)The emergency medicine
physician is often faced with differentiating whether the cause of a patient
losing consciousness is a result of syncope or a seizure.The most likely