APEA Acute Care and Urgent Presentations 1 — Questions and Answers
Question 1: A 60-year-old patient presents with sudden-onset severe headache described as the worst headache of their life. What is the priority diagnosis to rule out?
- Tension-type headache requiring NSAIDs
- Subarachnoid hemorrhage (SAH) — a neurological emergency requiring immediate CT head without contrast (Correct answer)
- Migraine with aura requiring triptan therapy
- Cluster headache requiring oxygen therapy
Correct answer: Subarachnoid hemorrhage (SAH) — a neurological emergency requiring immediate CT head without contrast
A thunderclap headache is subarachnoid hemorrhage until proven otherwise. Immediate non-contrast CT head is required; if negative but SAH still suspected, lumbar puncture for xanthochromia is indicated.
Subarachnoid hemorrhage typically from a ruptured berry aneurysm presents with sudden onset severe headache reaching maximum intensity within seconds. Mortality is approximately 40% even with treatment. Initial evaluation: non-contrast CT head (more than 90% sensitive within 6 hours). If CT is negative and clinical suspicion is high: lumbar puncture for xanthochromia. Treatment includes neurosurgical consultation, BP control targeting SBP below 160, and nimodipine for vasospasm prevention.
Question 2: A 55-year-old male presents to primary care with right-sided facial droop, arm weakness, and slurred speech of 45-minute duration. The most appropriate immediate action is:
- Schedule an MRI for next week as symptoms may resolve
- Activate emergency medical services immediately — potential ischemic stroke within tPA administration window (Correct answer)
- Administer aspirin 325mg and observe in clinic for 2 hours
- Order outpatient carotid ultrasound and neurology referral
Correct answer: Activate emergency medical services immediately — potential ischemic stroke within tPA administration window
Acute focal neurological deficits consistent with stroke require immediate EMS activation. The tPA administration window is 3-4.5 hours from symptom onset. Any delay reduces treatment eligibility.
Approximately 1.9 million neurons die per minute during ischemic stroke. Primary care NPs must recognize stroke symptoms using FAST (Face drooping, Arm weakness, Speech difficulty, Time to call 911) and avoid any delay that reduces tPA eligibility. IV alteplase eligibility window is 3-4.5 hours from symptom onset. Do not obtain outpatient imaging — call 911 immediately.
Question 3: A 35-year-old female presents with sudden-onset dyspnea, pleuritic chest pain, and leg swelling after a 12-hour flight. D-dimer is elevated. What is the most appropriate next diagnostic step?
- Chest X-ray alone to rule out pneumonia
- CT pulmonary angiography (CTPA) to confirm or exclude pulmonary embolism (Correct answer)
- Echocardiogram as the initial definitive test
- Arterial blood gas only
Correct answer: CT pulmonary angiography (CTPA) to confirm or exclude pulmonary embolism
Elevated D-dimer in the context of high clinical suspicion for PE requires CT pulmonary angiography as the gold standard imaging study to confirm or exclude PE.
Clinical prediction for PE uses the Wells score. With intermediate to high probability, proceed directly to CTPA regardless of D-dimer. CTPA has sensitivity greater than 95% for PE. Treatment includes anticoagulation with DOAC (rivaroxaban or apixaban preferred for outpatient). Massive PE with hemodynamic instability may require systemic thrombolysis or catheter-directed therapy.
Question 4: A 72-year-old diabetic patient presents with a red, hot, swollen knee joint with fever and WBC of 18,000. Joint aspiration reveals WBC of 75,000 with 90% PMNs and gram-positive cocci on Gram stain. The diagnosis is:
- Pseudogout (calcium pyrophosphate crystal arthropathy)
- Septic arthritis — a medical emergency requiring immediate joint irrigation and IV antibiotics (Correct answer)
- Rheumatoid arthritis acute flare
- Gout with secondary infection
Correct answer: Septic arthritis — a medical emergency requiring immediate joint irrigation and IV antibiotics
Synovial fluid WBC above 50,000 with PMN predominance and organisms on Gram stain is diagnostic of septic arthritis, a medical emergency. Untreated septic arthritis causes joint destruction within 24-48 hours.
Septic arthritis: synovial fluid WBC above 50,000 (often above 100,000) with more than 90% PMNs strongly suggests sepsis; Gram stain identifies organism in approximately 75%. Most common organism is Staphylococcus aureus. In young sexually active adults: Neisseria gonorrhoeae. Management: urgent joint irrigation plus IV antibiotics with empiric vancomycin for gram-positive coverage.
Question 5: A 45-year-old male presents with tearing chest pain radiating to the back, unequal blood pressures between arms, and a widened mediastinum on CXR. The most critical diagnosis to evaluate for is:
- Acute STEMI requiring immediate cardiac catheterization
- Aortic dissection — a vascular emergency requiring emergent CT aortography and immediate blood pressure control (Correct answer)
- Costochondritis with referred back pain
- Pulmonary embolism requiring anticoagulation
Correct answer: Aortic dissection — a vascular emergency requiring emergent CT aortography and immediate blood pressure control
Tearing pain radiating to the back, unequal arm blood pressures, and widened mediastinum is the classic triad of aortic dissection — a surgical emergency with mortality of approximately 1-2% per hour without treatment.
Aortic dissection: Stanford Type A involving the ascending aorta requires surgical emergency management. Type B involving descending aorta only receives medical management. Initial management includes immediate BP control targeting SBP 100-120 with IV labetalol or esmolol, pain control, and emergent CT aortography. Thrombolytics are absolutely contraindicated in aortic dissection.
Question 6: A 28-year-old female presents with severe right lower quadrant pain, fever, and vaginal discharge. Pelvic exam reveals cervical motion tenderness, uterine tenderness, and adnexal tenderness. The most likely diagnosis is:
- Appendicitis requiring immediate surgical consultation
- Pelvic inflammatory disease (PID) — treat empirically without waiting for culture results (Correct answer)
- Ovarian torsion requiring only analgesics
- Urinary tract infection causing referred pain
Correct answer: Pelvic inflammatory disease (PID) — treat empirically without waiting for culture results
The clinical triad of cervical motion tenderness plus uterine tenderness plus adnexal tenderness meets minimum CDC diagnostic criteria for PID. Treatment should begin empirically to prevent tubal scarring and infertility.
CDC PID minimum diagnostic criteria: cervical motion tenderness, uterine tenderness, or adnexal tenderness in a sexually active woman with no other explanation. Empiric outpatient treatment for mild to moderate disease: ceftriaxone 500mg IM single dose plus doxycycline 100mg twice daily for 14 days plus metronidazole 500mg twice daily for 14 days. Hospitalize for pregnancy, severe illness, tubo-ovarian abscess, or surgical emergency that cannot be excluded.
APEA Acute Care and Urgent Presentations 1
A 60-year-old patient presents with sudden-onset severe headache described as the worst headache of their life.
What is the priority diagnosis to rule out?