WBR1081

Author	PageAuthor::Chetan Lokhande
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Head and Neck, SubCategory::Neurology
Prompt	[[Prompt::A 54-year-old female with history of diabetes mellitus, hypertension, hypercholesterolemia comes to your primary care clinic with complaints of facial asymmetry since 2 hours. On examination she has one-sided facial droop, asymmetrical smile, difficulty completely closing one eye, and impaired tearing and salivation on left side. She denies any headache or loss of consciousness but she complains of mild weakness of right lower limb and pain on the left side of her chest. On examination, power is 5/5 in all extremities. Her vitals are within normal range. Her EKG is normal. She has multiple red papules about 3-5 mm in diameter in the left 5th inter costal space. What is the next best step?]]
Answer A	AnswerA::Start oral prednisone and acyclovir
Answer A Explanation	AnswerAExp::Acyclovir is the treatment if choice for herpes zoster . Steroids may or may not be added to decrease the pain in zoster. Here CT scan is the correct answer as it is the nest best step.
Answer B	AnswerB::Start oral acyclovir only
Answer B Explanation	AnswerBExp::Acyclovir is the treatment if choice for herpes zoster . Steroids may or may not be added to decrease the pain in zoster. Here CT scan is the correct answer as it is the next best step.
Answer C	AnswerC::Give over the counter analgesics
Answer C Explanation	AnswerCExp::Analgesics may be used to decrease the pain and swelling in patients of herpes zoster .It is not the correct answer here as it is not the bext next step.
Answer D	AnswerD::Do CT Head
Answer D Explanation	AnswerDExp::CT scans are indicated as soon as a stroke is suspected . An ischemic or hemorrhagic stroke is confirmed with a CT scan and then treated accordingly.
Answer E	AnswerE::Do MRI brain
Answer E Explanation	[[AnswerEExp::MRI brain is a time consuming procedure and takes more time than stroke to show subtle changes . It may be done later to confirm as it has high sensitivity and the high predictive value of MRI to ischemia help to avoid unnecessary and potentially dangerous therapeutic interventions and ensure that effective therapies will not be withheld for those who are suitable for these therapies.]]
Right Answer	RightAnswer::D
Explanation	[[Explanation::The patients presents with classical symptoms of stroke. The patient has all the risk factors for stroke like diabetes, hypertension and hypercholesteremia. The patient presents with facial asymmetry , one-sided facial droop, asymmetrical smile, difficulty completely closing one eye, and impaired tearing and salivation on left side . the multiple red papule suggesting Zoster is a distraction . Irrespective of the conditions stroke has to be ruled out first and hence CT Scan is the next best step to rule out stroke. Acyclovir may be started later after stroke is ruled out. Educational Objective If the patient has symptoms of stroke or stroke mimicking symptoms a CT scan should be performed immediately and stroke should be ruled out first before initiating any kind of therapy. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Stroke, WBRKeyword::Herpes
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::