Question of the Week #489

A 35 Year old woman presents for evaluation of recurrent headaches for the past few months.  Lately, she has been waking up with a headache almost daily though it tends to improve in the latter half of the day. She is frustrated as she can not even get some sleep during the attack since lying down makes her feel worse . She has associated nausea. She has transient attacks of light flashes  that resolve spontaneously. Her menstrual history is unremarkable. On physical examination, she has no neurological deficits. Funduscopic examination shown below: QBANK INSTA AD

Which of the following information, if elicited in the patient history, would increase the clinical suspicion of the diagnosis?

A)     Constipation

B)     Family history

C)      Recent weight gain

D)      Galactorrhea

E)   Urinary Incontinence

Question of the week # 488

A 31 Year old woman diagnosed with suspected diagnosis of Idiopathic intracranial hypertension underwent a lumbar puncture for diagnostic purposes. An MRI of the brain that was obtained prior to lumbar puncture did not reveal any structural abnormalities or mass effect. Laboratory investigations including coagulation parameters were normal. About 12 hours after the procedure, the patient complains of moderate to severe headache. Headache is mainly in the occipital region which increases while sitting up and improves on lying flat. She has two episodes of vomiting in the last one hour. She also complains of dizziness and ringing sensation in her ears.  Physical examination does not reveal any papilledema or focal neurological deficits.

Most appropriate next step in managing this patient?

A) Blood cultures

B) MRI of the Lumbar Spine

C) Non-Contrast CT scan of brain

D) Observation

E) Acetazolamide

Question of the Week # 430

430 ) A 70  year-old man is evaluated in your office for fatigue and unsteady gait. His symptoms started 2 months and progressively increasing. He also reports numbness and paresthesias in his bilateral lower extremities. His other issues include ill-fitting dentures for which he used dental adhesives for past 2 years. His past medical history is also significant for gastric bypass surgery approximately 8 years ago for recurrent peptic ulcer disease. He receives Vitamin B12 Subcutaneously every 3 to 6 months. On presentation, he is confined to a wheelchair. Neurological examination revealed markedly decreased vibratory sensation and proprioception in the lower extremities bilaterally. Both pin-prick and light touch sensations were moderately reduced below the knees. Muscle power, bulk, tone, and reflexes were normal. Rest of his physical examination is normal. Laboratory investigations reveal hemoglobin = 8.5 g/dL, MCV= 74 fL, MCHC = 33.6gm/dl, leukopenia with a WBC =1.9k/µl and absolute neutrophil count = 475 cells/µL. His platelet count, iron studies, folate and syphilis serologies were within normal limits.  Vitamin B12 was 900pg/ml ( N = 180 to 400pg/ml) . Serum Zinc level is  600µg/dl  ( Normal is 70-150 µg/dl).

Which of the following is most appropriate at this time?

A) Check Methyl Malonic Acid Level

B) Start Penicillamine

C)  Bone Marrow Biopsy

D) CT scan of the Head

E) Discontinue dental adhesives and check Copper levels

Question of the Week # 429

429) A 72-year-old man presents for an out patient follow up after being discharged from the hospital two days ago. He was admitted for a transient ischemic attack on the right side of his body which resolved spontaneously. He was worked up and subsequently discharged. Review of his in-patient investigations reveal a carotid doppler which revealed 100% stenosis of the left carotid artery and a 40% stenosis of the right carotid artery. He smoked about 1 pack per day for past several years. His past medical history includes chronic atrial fibrillation for which he has been on Aspirin alone. During the last admission, he was started on Coumadin as well. Today, his INR is therapeutic at 2.5 . His fasting lipid profile shows a calculated LDL cholesterol of 60mg%.  On examination, there are no neurological deficits. His blood pressure is 110/70 mm Hg. In addition to recommending smoking cessation and lifestyle changes along with continuation of coumadin, which of the following is most appropriate at this time?

A) Carotid Endarterectomy of Right Carotid Artery

B) Carotid Stenting of left carotid artery

C)  Carotid Endarterectomy of Left Carotid Artery

D) Carotid Magnetic Resonance Angiography

E) No other intervention indicated

Question of the Week # 359

359)  A 50 year old woman with history of Diabetes Mellitus presents to your office with complaining of discomfort in her both legs for past few months. She describes unpleasant sensations as well as abnormal sensations such as including tingling, creeping and itching sensations deep in her legs while sitting. Walking a few steps relieves her symptoms. She denies any pain in the legs upon walking or at rest. Physical examination reveals slightly diminished pulses in bilateral lower extremities.  Which of the following is the first step in managing her symptoms?

A) Nerve Conduction Studies

B) Cilostozol

C) Dopamine Agonists

D) Obtain Serum ferritin

E) Gabapentin

Question of the Week # 358

358)  A 36 year old man presents to your office for an annual health examination. During review of systems, he reports  feeling excessively sleepy during the day and forgetful at work. He states no matter how much he slept, it  does not make him feel rested in the morning. He denies snoring at night. He is athletic and maintains his body weight in a healthy range. He denies alcohol consumption, smoking or excessive caffeine use. His girlfriend reports that he abruptly moves his legs often during the night and that disturbs her as well. She has noticed him flexing his leg and extending his great toe repeatedly. The patient is not aware of this and he denies any pain or discomfort in his legs. Physical examination is unremarkable. Laboratory investigations including complete blood count, serum creatinine, electrolytes and a thyroid stimulating hormone are within normal limits. Which of the following is the most likely diagnosis?

A) Complex Partial Seizures

B) Restless leg syndrome

C) Nocturnal Leg Cramps

D) Myoclonus

E) Periodic Limb Movement Disorder

F) Sleep Apnea

Question of the Week # 357

357)  A 52 year old man is seen in your office for pain in his legs that bothers him during sleep. He describes these episodes as aching and painful tightness particularly, in his posterior calves. The pain is relieved by forcefully stretching his leg muscles in opposite direction. He experiences these at least for about 2 to 3 nights per week and interferes with his sleep. He works as a coach for the local high-school soccer team and is physically very active. He has no other past medical problems and enjoys healthy living. On examination, his blood pressure is 122/80. Oral mucosa re moist.  There are no focal neuroligical deficits. Extremities appear normal with out any deformity, swelling or palpable tenderness. Peripheral pulses are normal. Serum electrolytes, Calcium, magnesium , a complete blood count, thyroid stimulating hormone and blood glucose are all within normal limits.  Which of the following is the most appropriate next step in managing his problem?

A) Start Ropinirole

B) Start Bromocriptine

C) Recommend non-pharmacological measures

D) Quinine Trial

E) Oral Iron Trial

Question of the Week # 356

356) A 7 year old boy is evaluated in your office for frequent episodes of “staring spells” while at school. His teacher reports that he does not seem to concentrate during the class and stares blankly in to space. He has had many such episodes in the past six months that got his teacher very concerned. Waving a hand in front of his eyes and calling out his name does not seem to disrupt these episodes. Often he returns to his norm when the boy next to him physically moves him or tickles him. He is otherwise, healthy and plays well with other kids without any issues. His mother also has noticed such episodes while he was watching television at home. On examination, he appears comfortable and healthy. There are no physical abnormalities.  He is attentive to your questions and does not seem to be distracted. Which of the following is the most appropriate next step?

A) Re-assurance

B) Obtain Electro-Encephalogram

C) Refer to Child Psychiatry

D) Start Methylphenidate trial

E) Refer to Neurology

Question of the Week # 355

355)  A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?

A) Attention Deficit Hyperactivity Disorder

B) Absence Seizures

C) Complex Partial Seizures

D) Simple Partial Seizures

E) Generalized Seizures

Question of the Week # 354

354)  A 74 year old woman is being treated in the hospital for community acquired pneumonia. She has been receiving ceftriaxone and azithromycin. On second day after admission she is found by the nurse to be staring in to the space and shaking her left extremity. When you walk in to the room,  she recognizes you and reports that she is unable to control movements in her left extremity. On examination, she is afebrile and vitals are stable. A rhythmic movement of her left upper extremity is noted. She is conscious  and is repeatedly grinding her teeth. An electroencephalogram has been ordered. Based on the clinical information, which of the following is the most likely diagnosis?

A)  Complex Partial Seizures

B) Generalized Tonic-Clonic Seizures

C) Absence Seizures

D) Aura

E) Drug induced myoclonus

Question of the Week # 353

353)  A 54 year old woman is found by her husband wandering and trying to undress herself two miles away from her home . Her husband tried to question her, however, she did not recognize him, did not respond to his questions and when he tried to restrain her, she became physically aggressive. Upon presentation in the Emergency Department, she appears confused and does not recall the event. There is no history of drug abuse or alcoholism. There is no history of any significant past medical problems. Examination shows normal vitals. There are no focal neurological deficits. She is confused and not oriented to place and person. Which of the following is the most likely diagnosis?

A)  Temporal Lobe Epilepsy

B) Depersonalization Disorder

C) Domestic abuse

D) Dissociative Fugue

E) Manic Episode

Question of the Week # 333

333) A 75 year old woman with past medical history of  Type 2 Diabetes mellitus, Hypertension and Ischemic stroke presents to your office for a new patient visit. She has been under the care of another primary care physician who has retired from practice so the patient has decided to establish care with you. She has left sided residual weakness from her old cerebrovascular accident. She has no other complaints. She requests you for a refill of warfarin which she has been taking for three years . This drug was prescribed by her former physician for “stroke prevention” . Her recent echcardiogram shows an ejection fraction of 60% and a recent cardiovascular stress test was negative for ischemia. Her other medications include Metformin, Glyburide and enalapril.  Her laboratory investigations including complete blood count are normal and her  INR is 1.5. Which of the following is the most appropriate  management?

A) Increase warfarin to achieve a target INR of 2.0 to 3.0

B) Discontinue Warfarin and start Aspirin/Dipyridamole combination

C) Continue low-dose Warfarin with target INR 1.5 to 2.0

D) Add Aspirin to her current regimen

E) Add Clopidogrel to her current regimen

Question of the Week # 323

323)  A 65 year old man is evaluated in your office for slowly progressing involuntary shaking movements in his hands. He noticed these movements about 10 months ago which have slightly worsened now.  Occasionally, he was told by his wife that his head shakes as well. The movements have led him to feel socially embarrassed because they are worse when he attempts to write or hold a cup of coffee or fasten a shirt button. He denies any tremors in his legs. He denies any problems with his gait or muscle pain or stiffness. He reports drinking wine on daily basis since the tremors have started because he thinks alcohol appears to improve the tremors. He denies using any medications. There is no family history of tremors or seizures. On examination, he appears comfortable. Tremors are visible bilaterally with his arms outstretched and they are increased when asked to hold a cup filled with water. His handwriting is large and tremulous. Gait is normal with normal arm-swing. There are no other neurological deficits. Routine chemistry panels including TSH and Liver function tests are normal. Which of the following is the most appropriate next step in management?

A)  MRI brain with contrast

B) Vitamin B12 level

C) Trial of Dopamine Agonist

D) Initiate Propranolol Therapy

E) Serum Cerulopalsmin level

F) Start oral Primidone

Question of the week # 312

312) A 73 year old man with history of Dementia and well-controlled Parkinson’s disease was admitted to the hospital 3 days ago with fever, hypotension and dysuria. He was diagnosed with sepsis secondary to urinary tract infection and has been on treatment with Ampicillin and Gentamicin. Urine cultures revealed enterococci. Over the past two days, his blood pressure improved and he has been afebrile however, he has become increasingly immobile and excessively tremulous. He is unable to rise from a chair or walk without help.  His home medications include Levodopa, Benserazide and Selegeline. On physical examination, blood pressure is 130/80 mm Hg. He is alert, awake and oriented. He has severe bilateral resting tremor, generalized rigidity and bradykinesia . Results of routine blood tests showed no abnormality and CT of the head is normal.  Which of the following is the most appropriate management at this time?

A) Increase Levodopa

B) Add Carbidopa

C) Discontinue Gentamicin

D) Add Piperacillin-Tazobactam

E) Start Bromocriptine

Question of the week # 311

311) A 3 year old male child is brought to the emergency room by his mother after he fell from his tricycle and sustained an injury to his head  . The child was found to be alert and awake after the fall, however, he reported mild pain on the right side of his head. His mother noted a small bruise and swelling over the right side of his scalp. There is no history of vomiting or nausea. He has no past history of convulsions or epilepsy. Family history is unremarkable. At this time, child is quiet and reports mild headache. On examination, he is alert and awake. He is not in distress. There is small contusion on the fronto-parietal aspect of his scalp. There is no evidence of hematoma. Palpation does not reveal any depressed fracture. Neurological examination is normal with out any deficits.  Rest of the physical exam is normal. Which of the following is the most appropriate management at this time?

A) Contact Child Protection Services

B) Perform Head CT scan

C) Admit to Hospital

D) Observe at home

E) Skull X-rays

Question of the Week # 309

309)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most appropriate management of  his dizziness?

A) Discontinue Hydrochlorthiazide

B) Cervical Collar

C) Cerumen Disimpaction

D) Increase Diuretics and add Meclizine

E) Methylprednisolone

Question of the Week # 308

308)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most likely explanation for his Vertigo?

A) Orthostatic Hypotension

B) Vertebral artery occlusion from cervical spondylosis

C) Cerumen Impaction

D) Meniere’s disease

E) Labyrinthitis

Question of the week # 276

276) A 70 year old obese woman is evaluated in your office during an annual follow up visit. Her other medical problems include hypertension, chronic sinusitis, nasal polyps, asthma, osteoarthritis and a history of transient ischemic attack about 2 months ago. She uses acetaminophen for her arthritis pain because ibuprofen makes her “swell up” and causes severe “breathing problems”. Upon review of her medications, you note that she is not on any antiplatelet therapy.  Physical examination is unremarkable except for nasal polyps. Which of the following recommendations is most appropriate management for this patient?

A) Warfarin

B) Aspirin and Dipyridamole

C) Aspirin

D) Clopidogrel

E) Dipyridamole

F) No anti-platelet therapy

Question of the week # 275

275) A 70 year old obese woman is evaluated in your office during an annual follow up visit. She has a history of moderate osteoarthritis and she takes over the counter ibuprofen for arthritis pain. She was recently hospitalized with one episode of gastro-intestinal bleeding about 6 months ago. She is being maintained on a proton pump inhibitor. Her other medical problems include hypertension and a history of transient ischemic attack about 2 months ago. Upon review of her medications, you note that she is not on any antiplatelet therapy.  Physical examination is unremarkable. Which of the following recommendations is most appropriate management for  this patient?

A) Warfarin

B) Aspirin and Dipyridamole

C) Aspirin

D) Clopidogrel

E) Dipyridamole

F) No anti-platelet therapy

Question of the Week # 267

267 )  A 32 year old woman is evaluated in your office for increasing headaches over the past few months. She has a 5 year history of intermittent headaches. The headaches are throbbing in nature and are localized to frontal area. They are often accompanied by nausea and vomiting. Her episodes are usually preceded by irritability and food craving. She usually takes ibuprofen at the onset of headache which seem to relieve her pain. She recently broke up with her partner and has been under severe emotional stress since then. Lately, her headaches have become more frequent occurring about 4 to 5 times per month. The episodes interfere with her quality of life. She denies any headache at this time.  Physical examination including neurological and ophthalmoscopic exam is normal.  Her last menstrual period was 16 weeks ago and a urine pregnancy test returns positive. Which of the following strategies is most appropriate for this patient?

A) Biofeedback

B) Lumbar puncture

C) Start Propranolol

D) Start Sumatriptan

E) Start Valproic acid

Question of the Week # 251

251 )  A 65 year old woman is evaluated in your office for pain in bilateral feet for the past four weeks. The pain is burning in quality and is associated with intense itching. Her past medical history is significant for difficult to control Type II Diabetes Mellitus. Her recent HgbA1C was 7.9% and Creatinine was 1.8mg%.  On physical examination, she is obese, afebrile and in no apparent distress. She has diminished pinprick and vibration sensation in glove and stocking pattern in bilateral upper and lower extremities. Dorsalis pedis and posterior tibial pulses are mildly diminished. There are multiple erythematous tiny vesicles between the toes and on the plantar aspect of the both feet.  Which of the following is the most appropriate treatment option for this patient’s pain?

A)      Oral Pregabilin

B)      Topical Corticosteroids

C)      Oral Cefazolin

D)     Topical Terbinafine

E)     Topical Acyclovir

Question of the Week # 250

250 )  A 30 year old woman presents to your office with complaints of fatigue and headache.  She reports that the headaches occur almost daily and are mild to moderate. They are not associated with nausea or vomiting and are unrelated to menstrual cycles. She also reports chronic diffuse abdominal pain and pelvic pain for the past several months for which she did not seek any medical attention. Her chart reveals that she was seen by your colleague few months ago for similar complaints. She was asked to return after few laboratory investigations but she had been non-compliant with her follow-ups. Physical examination reveals an anxious appearing woman who otherwise appears healthy. She does not make an eye contact. Abdominal and pelvic examination is benign. There are no tender points. There are no neurological deficits. The most appropriate next step in managing this patient:

A)     Support and Counseling

B)     Refer to Psychiatry

C)      Start Selective Serotonin Reuptake Inhibitors

D)     Trial of Tricyclic anti-depressants

E)     Screen for Domestic Violence

Question of the Week # 240

240) A 55 year old woman is evaluated in the emergency room for acute development of double vision and droopy right eyelid. She also reports pain in her right eye. She denies any fever.  She has no significant past medical history. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the right eyelid. Pupillary light reflex is lost. She can not adduct her right eye past the midline. The right eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

The  most appropriate next step in management?

A)     Temporal artery biopsy

B)     Obtain Erythrocyte Sedimentation Rate

C)     Observation

D)     Magenetic Resonance Angiography (MRA)

E)     Ptosis Surgery

Question of the Week # 239

239) A 64 year old woman is evaluated in the emergency room for acute development of double vision and droopy left eyelid. She denies any fever or headache.  Her past medical history is significant for diabetes mellitus and hypertension. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the left eyelid. Pupillary light reflex is intact . She can not adduct her left eye past the midline. The left eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

Which of the following is the most likely eventual outcome of her condition?

A)     Sub-arachnoid hemorrhage

B)     Spontaneous resolution

C)     Cerebellar ataxia

D)     Persistent visual deficits

E)     Aneurysmal Rupture

Question of the Week # 238

238) A 64 year old woman is evaluated in the emergency room for acute development of double vision and droopy left eyelid. She denies any fever or headache.  Her past medical history is significant for diabetes mellitus and hypertension. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the left eyelid. Pupillary light reflex is intact . She can not adduct her left eye past the midline. The left eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

 

Which of the following is the most likely cause of her symptoms?

A)     Ophthalmoplegic migraine

B)     Diabetic Mono-neuropathy

C)     Posterior communicating artery aneurysm

D)     Weber syndrome

E)     Lateral medullary syndrome

Question of the Week # 211

211 )  A 42 year old woman in otherwise good health presents to the Emergency room for severe headache. She has history of migraines in the past for which she uses sumatriptan at the onset of Headache and usually, she has relief. Though this is not the worst headache of her life, she says that it is very severe and is upset that the headache did not resolve even after injecting herself  with a triptan. She denies any fever.  Her physical and neurological examination is benign. There is no neck stiffness.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid. The specimen was transported to the lab for further evaluation. It was processed in the laboratory 12 hours later and the report indicates “Xanthochromia” Which of the following most likely explains  the CSF findings?

A) Status migranosus

B) Meningitis

C) Sub-arachnoid Hemorrhage

D) Sentinel bleed

E) Delay in CSF processing

Question of the Week # 210

210 )  A 42 year old woman in otherwise good health presents to the Emergency room for sudden onset of severe headache 2 hour ago. She has no previous history of headache or migraine . Upon arrival in the ER, she described her headache as “10 out of 10” in severity. She thinks this is the worst headache of her life. She denies any fever or visual problems or drug abuse.  Her physical and neurological examination is benign. There is no neck stiffness at this time.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid which shows decreasing red color in subsequent collection tubes. The last collection tube shows red fluid but much decreased color as opposed to the first collection tube. Which of the following is the most appropriate management decision?

A) Repeat Lumbar Puncture at a different site

B) Immediate CSF centrifugation

C) Neurosurgery evaluation

D) Re-assurance and analgesic therapy

E) Subcutaneous Sumatriptan

Question of the Week # 209

209)  A 35 Year old woman presents for evaluation of recurrent headaches for the past few months.  Lately, she has been waking up with a headache almost daily though it tends to improve in the latter half of the day. She is frustrated as she can not even get some sleep during the attack since lying down makes her feel worse . She has associated nausea. She has transient attacks of light flashes  that resolve spontaneously. Her menstrual history is unremarkable. On physical examination, she has no neurological deficits. Funduscopic examination shown below:

Which of the following information, if elicited in the patient history, would increase the clinical suspicion of the diagnosis?

A)     Constipation

B)      Family History

C)      Recent weight gain

D)      Galactorrhea

E)      Urinary incontinence

Question of the Week # 208

208)  A 31 Year old woman with suspected diagnosis of Idiopathic intracranial hypertension underwent a lumbar puncture. An MRI of the brain that was obtained prior to lumbar puncture did not reveal any structural abnormalities or mass effect. Laboratory investigations including coagulation parameters were normal. About 12 hours after the procedure, she complains of moderate to severe headache. Headache is mainly in the occipital region which increases while sitting up and improves on lying flat. She has two episodes of vomiting in the last one hour. She also complains of dizziness and ringing sensation in her ears.  Physical examination does not reveal any papilledema or focal neurological deficits. Most appropriate next step in managing this patient?

A)     Blood cultures

B)      MRI of the Lumbar Spine

C)      Non-Contrast CT scan of brain

D)     Observation

E)      Acetazolamide

%d bloggers like this: