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lumbar puncture

Practice targeted AMC-style multiple-choice questions on lumbar puncture.

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A 3-year-old boy is brought to the emergency department by his parents due to a high fever and irritability. He has had a runny nose and cough for the past two days. On examination, he is lethargic and has a bulging fontanelle. A lumbar puncture is performed, and the cerebrospinal fluid (CSF) analysis shows elevated protein, low glucose, and a high white cell count with a predominance of neutrophils. What is the most likely diagnosis?

A. Tuberculous meningitis
B. Bacterial meningitis
C. Subdural hematoma
D. Viral meningitis
E. Encephalitis
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A 35-year-old man, recently arrived from a country with a high burden of tuberculosis, presents to the emergency department with a 2-week history of worsening headache, low-grade fever, and general malaise. Over the past 48 hours, he has become increasingly drowsy and confused. He denies cough, weight loss, or night sweats. His past medical history is unremarkable, and he is not on any regular medications. On examination, he is febrile (38.5°C), drowsy but rousable, with a Glasgow Coma Scale (GCS) of 13/15 (E3 V4 M6). His neck is stiff, and Kernig's sign is positive. Fundoscopy is normal. Chest auscultation is clear. Neurological examination reveals no focal deficits. Initial blood tests show a mild lymphocytosis, normal electrolytes, and normal renal and liver function. A non-contrast CT scan of the brain shows subtle basal meningeal enhancement. A lumbar puncture is performed. CSF Results: * Appearance: Slightly turbid * Opening pressure: 25 cm H2O (elevated) * White cell count: 150 cells/µL (normal <5), 80% lymphocytes * Red cell count: 5 cells/µL * Protein: 1.5 g/L (normal 0.15-0.45) * Glucose: 1.8 mmol/L (normal 2.5-4.5), simultaneous blood glucose 5.5 mmol/L Given the clinical presentation and investigation findings, what is the most appropriate immediate next step in management?

A. Start empirical broad-spectrum antibiotics (e.g., ceftriaxone and vancomycin).
B. Wait for the results of CSF Gram stain, bacterial culture, and mycobacterial culture before initiating specific therapy.
C. Perform an urgent MRI of the brain to better delineate meningeal involvement.
D. Administer intravenous acyclovir for possible viral encephalitis/meningitis.
E. Initiate empirical anti-tuberculosis therapy including rifampicin, isoniazid, pyrazinamide, and ethambutol, along with adjunctive corticosteroids.
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