A 34-Year-Old Woman Is Brought to the Emergency Department with Acute

question 48

Multiple Choice

A 34-year-old woman is brought to the emergency department with acute onset of severe headache followed by generalized tonic-clonic seizures.  The patient was feeling well until 6 hours ago, when she developed a 10/10 throbbing bilateral headache associated with blurry vision.  Her headache is not exacerbated by change in head position, and nothing seems to improve the pain.  She denies any nausea, vomiting, photophobia, vertigo, fever, or neck pain.  She also denies any recent head or neck trauma.  She has had upper respiratory tract symptoms for the last couple of days.
Her other medical problems include chronic migraines and non-essential hypertension related to renal artery stenosis from fibromuscular dysplasia.  Her medications include topiramate and multiple anti-hypertensive agents including amlodipine, hydrochlorothiazide, lisinopril, and metoprolol.  She also takes birth control pills and vitamins.  She has never had a seizure before and has no family history of epilepsy.  She works as a secretary and has smoked 2 packs of cigarettes daily for 10 years.
Her temperature is 37 C (98.6 F) , blood pressure is 210/140 mm Hg, pulse is 80/min and regular, and respirations are 18/min with normal oxygen saturation.  The general physical examination is unremarkable, except for an abdominal bruit.  Neurological examination reveals that she is awake and alert, but is only oriented to person and place.  Funduscopic examination reveals copper and silver wiring in the retina without papilledema.  Pupils are equal, round, and reactive to light.  Visual acuity is 20/200 bilaterally with intact visual fields to confrontation.  There is no nystagmus and extra-ocular movements are full.  The remainder of the neurological examination is unremarkable.
A non-contrast head CT showed hypodense regions with loss of grey-white matter differentiation in the posterior occipital-parietal lobes.  An MRI of the brain without gadolinium (shown below) showed a symmetrical, increased T2/FLAIR signal abnormality in the subcortical white matter of the posterior occipital-parietal lobes.

Which of the following is the most likely diagnosis?

• A)Aneurysmal subarachnoid hemorrhage
• B)Herpes simplex encephalitis
• C)Idiopathic intracranial hypertension
• D)Migraine headache
• E)Posterior reversible encephalopathy syndrome

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Definitions:

Maximizing Utility

The process of choosing the allocation of scarce resources that provides the highest possible satisfaction or happiness to an individual or society.

Marginal Utility

The change in overall satisfaction or utility obtained by consuming one additional unit of a good or service.

Total Utility

The total satisfaction received from consuming a particular quantity of goods and services.

Donuts

Circular or ring-shaped fried dough treats, often sweetened and sometimes filled or topped with various ingredients.