Examkin

Soru

Zorluk: OrtaPhysical Examination Findings

A 64-year-old man is evaluated in the emergency department for the sudden onset of severe, continuous dizziness, nausea, and vomiting that began 2 hours ago. He reports feeling as though the room is spinning and is unable to walk without assistance. His medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. His current medications include metformin, lisinopril, and atorvastatin. Vital signs reveal a blood pressure of 168/92 mmHg, a heart rate of 88/min, and a respiratory rate of 16/min. Point-of-care blood glucose is 128 mg/dL. A basic metabolic panel obtained in triage reveals a serum sodium of 134 mEq/L and potassium of 4.1 mEq/L. On physical examination, a targeted bedside vestibular evaluation is performed. When the patient is instructed to fixate his vision on the examiner's nose while his head is rapidly rotated to the left and right, his eyes remain continuously fixed on the target without any corrective saccades. Extraocular movement testing demonstrates nystagmus that beats to the left when looking left, and beats to the right when looking right. Alternate cover testing of the eyes reveals a vertical misalignment. Hearing is intact to finger rub bilaterally. Based on these physical examination findings, which of the following is the most appropriate next step in management?

  1. Admit the patient to the hospital and obtain magnetic resonance imaging of the brainCevap
  2. B
    Discharge the patient home with oral meclizine and arrange primary care follow-up
  3. C
    Perform a therapeutic canalith repositioning maneuver in the emergency department
  4. D
    Administer intravenous hypertonic saline to correct the metabolic abnormality
  5. E
    Perform a diagnostic lumbar puncture to evaluate for cerebrospinal fluid pleocytosis

Cevap

The most appropriate next step is to admit the patient to the hospital and obtain magnetic resonance imaging of the brain.
The correct step addresses the high likelihood of an acute posterior circulation stroke. The HINTS examination is more sensitive than early MRI for detecting acute strokes in the posterior fossa. A 'normal' head impulse test in a patient with continuous vertigo, along with direction-changing nystagmus and vertical skew, are classic indicators of a central neurological lesion. The patient must be admitted for stroke workup and MRI.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation and risk factors.
The patient is an older male with multiple vascular risk factors (diabetes, hypertension, hyperlipidemia) presenting with sudden, unremitting vertigo, raising significant suspicion for an acute cerebrovascular event.
Establishing the pre-test probability helps guide the interpretation of subsequent physical examination maneuvers.
2
Interpret the specific components of the targeted physical examination.
The patient demonstrates a normal head impulse test (eyes remain fixed without corrective saccades), direction-changing nystagmus, and a vertical skew deviation.
These three components make up the HINTS (Head Impulse, Nystagmus, Test of Skew) examination, which is used to differentiate central from peripheral causes of acute vestibular syndrome.
3
Synthesize the examination findings to establish a diagnosis and formulate a management plan.
The presence of any single central sign on the HINTS exam (normal head impulse in the setting of continuous vertigo, bidirectional nystagmus, or skew deviation) strongly points to a central lesion, such as a cerebellar or brainstem infarction. Therefore, the patient requires admission and advanced neuroimaging (MRI).
Acute posterior circulation strokes can be life-threatening and require immediate inpatient evaluation; they are often not visible on initial non-contrast head CT scans, making MRI the preferred imaging modality.

Anahtar Kavram

In patients presenting with acute, continuous vertigo, a positive HINTS exam (normal Head Impulse test, direction-changing Nystagmus, or presence of a Test of Skew) indicates a central etiology such as a posterior circulation stroke, necessitating immediate neuroimaging and hospital admission.
Tahmini Süre:1m 15s
Bu soruyu puanla

Konular

Physical Examination Findings

Bu konudan daha fazla soru