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MODULE 13 short answer questions
saq 1.
A 65 year old man presents to your emergency department with acute weakness in his right arm, right face and right leg. He states that the weakness occurred 65 minutes previously and has been consistent since its inception.
An urgent CT of his brain is ordered and a slice is shown below.
An urgent CT of his brain is ordered and a slice is shown below.
Question 1. (3 marks)
What are 2 major abnormalities on the CT and what is the likely diagnosis?
Must include: (1 mark each to 2 marks)
-loss of grey white differentiation in left frontal and parietal lobes (MCA territory)
-loss of definition of sulci and gyri in the same area
-(NOTE, a dense MCA sign is NOT visible on this CT and this scores NO MARKS)
diagnosis (1 mark): L MCA territory ischaemic infarct (note, if vascular territory is not specified answer scores no marks).
Question 2. (6 marks)
Give six absolute contraindications to possible lysis of this man’s CVA that need to be evaluated for in this presentation.
Must include
Previous head trauma/CVA past 3 /12
Previous ICH
Hx of intracranial neoplasm, aneurysm of AVM
Recent major surgery
Recent arterial puncture in a non-compressible site
BP > 185 systolic or 110 diastolic
Active internal bleeding
History of bleeding diathesis
Platelet count <100
INR >1.7
Note, time based criteria receive no marks as with the history given this patient is clearly inside the thrombolysis window.
Question 3. (4 marks)
The patient’s family ask you about the risk benefit of thrombolysis, and ask you if this depends on how quickly the medicine is given. What response will you give?
Must include data similar to that below:
(Based on meta-analysis of stroke trials 2014)
-at <3 hours NNT = 10
-at 3 - 4.5 hours NNT = 20
-there is no benefit to alteplase after 6 hours
-risk of fatal ICH NNH = 50 irrespective of time of lysis
What are 2 major abnormalities on the CT and what is the likely diagnosis?
Must include: (1 mark each to 2 marks)
-loss of grey white differentiation in left frontal and parietal lobes (MCA territory)
-loss of definition of sulci and gyri in the same area
-(NOTE, a dense MCA sign is NOT visible on this CT and this scores NO MARKS)
diagnosis (1 mark): L MCA territory ischaemic infarct (note, if vascular territory is not specified answer scores no marks).
Question 2. (6 marks)
Give six absolute contraindications to possible lysis of this man’s CVA that need to be evaluated for in this presentation.
Must include
Previous head trauma/CVA past 3 /12
Previous ICH
Hx of intracranial neoplasm, aneurysm of AVM
Recent major surgery
Recent arterial puncture in a non-compressible site
BP > 185 systolic or 110 diastolic
Active internal bleeding
History of bleeding diathesis
Platelet count <100
INR >1.7
Note, time based criteria receive no marks as with the history given this patient is clearly inside the thrombolysis window.
Question 3. (4 marks)
The patient’s family ask you about the risk benefit of thrombolysis, and ask you if this depends on how quickly the medicine is given. What response will you give?
Must include data similar to that below:
(Based on meta-analysis of stroke trials 2014)
-at <3 hours NNT = 10
-at 3 - 4.5 hours NNT = 20
-there is no benefit to alteplase after 6 hours
-risk of fatal ICH NNH = 50 irrespective of time of lysis
saq 2.
A 38 year old male presents to your department with a sudden onset severe frontal headache that occurred while he was lifting weights at the gym. He is nauseous and complains of pain when he is looking at bright lights.
An urgent CT scan of the brain is arranged, and an image is shown below.
Question 1. (3 marks)
What are the two major abnormalities on the image, and what is the likely diagnosis?
Must include:
-dense fluid, likely blood, tracking through sulci in posterior section of right frontal lobe
-loss of architecture of sulci and gyri in this area
diagnosis: subarachnoid haemorrhage.
Question 2. (6 marks)
The patient is continuing to complain of severe headache and begins to vomit. His patient’s vital signs are:
HR 115 /min
BP 188/123 mmHg
RR 22 /min
Sats 99% RA
Give 6 management steps you will institute for this man.
Must include:
-administration of appropriate analgesic and dose (eg morphine 0.1mg/kg titrated)
-administration of an antiemetic (ondansetron 8mg)
-administration of titrateable anti-hypertensive (eg hydralazine 5 - 10 mg) titrated to a reasonable BP eg <160mmHg. Note, 1 mark for antihypertensive, another for BP target.
-liaison with neurosurgery
-liaison with intensive care unit
Then any other reasonable steps
-discussion with pt and family RE severity of disease
-ordering a CT angiogram
What are the two major abnormalities on the image, and what is the likely diagnosis?
Must include:
-dense fluid, likely blood, tracking through sulci in posterior section of right frontal lobe
-loss of architecture of sulci and gyri in this area
diagnosis: subarachnoid haemorrhage.
Question 2. (6 marks)
The patient is continuing to complain of severe headache and begins to vomit. His patient’s vital signs are:
HR 115 /min
BP 188/123 mmHg
RR 22 /min
Sats 99% RA
Give 6 management steps you will institute for this man.
Must include:
-administration of appropriate analgesic and dose (eg morphine 0.1mg/kg titrated)
-administration of an antiemetic (ondansetron 8mg)
-administration of titrateable anti-hypertensive (eg hydralazine 5 - 10 mg) titrated to a reasonable BP eg <160mmHg. Note, 1 mark for antihypertensive, another for BP target.
-liaison with neurosurgery
-liaison with intensive care unit
Then any other reasonable steps
-discussion with pt and family RE severity of disease
-ordering a CT angiogram
saq 3.
A 22 year old woman presents to your rural emergency department with a sudden onset frontal headache that occurred while having sexual intercourse the previous evening (10 hours previously). She has an ongoing headache and complains of severe nausea. The CT scanner in your rural hospital has been non-operational for 2 days due to complex maintenance requirements.
Question 1. ( marks)
List 4 differentials
Must include:
Sub arachnoid haemorrhage (1 mark)
Then any others from (1 marks each)
-migraine
-benign sex headache
-meningitis/encephalitis
-tension headache
-cluster headache
-or other reasonable cause of headache.
Question 2. (4 marks)
Give 4 contraindications to lumbar puncture in this patient.
Must include:
-altered level of consciousness
-history of seizure
-focal neurology
-papilloedema on fundoscopy
Question 3. (6 marks)
A lumbar puncture is performed and the results are shown below. The patient has a blood glucose of 5.1mmol/L.
Comment on the results and give a likely diagnosis.
Tube 1:
RBC 9000 /uL
WBC 5 /uL
Glucose 3.2 mmol/L
Protein .20 g/L
Tube 3:
RBC 8720 /uL
WBC 3 /uL
Glucose 3.2 mmol/L
Protein .20 g/L
No formal spectrophotometry is available in your hospital, but the lab rings to tell you the sample has a distinct yellowish tinge when held against white paper.
Must include (1 mark):
-severe elevation of red cell count
Plus:
-normal glucose and BSL:CSF ratio
-normal white cell count
-normal CSF protein
-no significant decrease in red cell count across serial tubes.
Suggests a diagnosis of subarachnoid haemorrhage. (1 mark)
saq 4.
An 18 year old girl presents to your department with her parents who are concerned that she has been behaving erratically for the day. She has complained of severe headache and fevers, and has vomited three times during the afternoon. She is distressed, and is complaining that light hurts her eyes.
Her vital signs on arrival are:
HR 99 /min
BP 121/79 mmHg
RR 24 /min
Sats 99% RA
T 39.6 oC
GCS E3V4M6
As part of her work up a lumbar puncture is performed.
Question 1. (2 marks)
Give 2 interventions you will undertake while the results of the LP are awaited.
Must include:
-administration of dexamethasone 8 - 10mg IV prior to antibiotics
-administration of empiric antibiotics: ceftriaxone 4g or cefotaxime 2g IV
Question 2. (5 marks)
The LP results return and are shown below.
Tube 3:
RBC 1 /uL
WBC 451 /uL
(differential 90% PMNS)
Glucose 1.2 mmol/L (BSL 7.9)
Protein 1.28 g/L
Appearance: turbid
What are the major abnormalities?
Must include:
-gross elevation of white cell count
-significant neutrophilia
-hypoglycaemia/decreased CSF glucose:BSL ratio
-very high protein levels (>1)
-abnormal appearance (turbidity)
Question 3. (2 marks)
What is the likely diagnosis?
Must include : bacterial meningitis
-NO MARKS given unless bacterial meningitis is specified.
Her vital signs on arrival are:
HR 99 /min
BP 121/79 mmHg
RR 24 /min
Sats 99% RA
T 39.6 oC
GCS E3V4M6
As part of her work up a lumbar puncture is performed.
Question 1. (2 marks)
Give 2 interventions you will undertake while the results of the LP are awaited.
Must include:
-administration of dexamethasone 8 - 10mg IV prior to antibiotics
-administration of empiric antibiotics: ceftriaxone 4g or cefotaxime 2g IV
Question 2. (5 marks)
The LP results return and are shown below.
Tube 3:
RBC 1 /uL
WBC 451 /uL
(differential 90% PMNS)
Glucose 1.2 mmol/L (BSL 7.9)
Protein 1.28 g/L
Appearance: turbid
What are the major abnormalities?
Must include:
-gross elevation of white cell count
-significant neutrophilia
-hypoglycaemia/decreased CSF glucose:BSL ratio
-very high protein levels (>1)
-abnormal appearance (turbidity)
Question 3. (2 marks)
What is the likely diagnosis?
Must include : bacterial meningitis
-NO MARKS given unless bacterial meningitis is specified.
SAQ 5.
A 27 year old girl presents with significant frontal headaches. She describes intermittent fevers and significant diurnal variation in her headache, which is worse in the mornings and evenings.
Her vital signs are:
HR 90 /min
BP 111/90 mmHg
RR 21 /min
Sats 99% RA
T 37.6 oC
GCS E4V5M6
As part of her workup a decision is taken to perform a lumbar puncture. The results are shown below.
Tube 3:
RBC 1 /uL
WBC 877 /uL
differential:
50% PMNS
40% lymphocytes
Glucose 3.2 mmol/L (BSL 4.9)
Protein .78 g/L
Appearance: clear and colourless
Question 1. (5 marks)
Comment on the 3 major abnormalities and 2 major normal findings in the lumbar puncture.
Must include:
abnormalities:
-very high white cell count
-mixed differential
-moderate elevation of protein
normal
-glucose and ratio BSL:CSF
-non turbid non xanthochromic appearance CSF
Question 2. (1 mark)
What is the likely diagnosis?
Must include: viral meningitis
Question 3. (4 marks)
Give 4 further tests you will order on this CSF?
must include:
-HSV PCR
-enterovirus PCR
Then any others from
-culture
-Neisseria and strep PCRs
-gram stain
Her vital signs are:
HR 90 /min
BP 111/90 mmHg
RR 21 /min
Sats 99% RA
T 37.6 oC
GCS E4V5M6
As part of her workup a decision is taken to perform a lumbar puncture. The results are shown below.
Tube 3:
RBC 1 /uL
WBC 877 /uL
differential:
50% PMNS
40% lymphocytes
Glucose 3.2 mmol/L (BSL 4.9)
Protein .78 g/L
Appearance: clear and colourless
Question 1. (5 marks)
Comment on the 3 major abnormalities and 2 major normal findings in the lumbar puncture.
Must include:
abnormalities:
-very high white cell count
-mixed differential
-moderate elevation of protein
normal
-glucose and ratio BSL:CSF
-non turbid non xanthochromic appearance CSF
Question 2. (1 mark)
What is the likely diagnosis?
Must include: viral meningitis
Question 3. (4 marks)
Give 4 further tests you will order on this CSF?
must include:
-HSV PCR
-enterovirus PCR
Then any others from
-culture
-Neisseria and strep PCRs
-gram stain