Cases Flashcards
42F who has severe headache and nausea. History of migraine but this one was different - came on after dinner, felt like someone hit her on the back of the head.
What is the diagnosis, what investigations should be ordered + management
Subarachnoid haemorrhage
Investigations: CT, LP if nothing found on CT (xanthochromia)
Manage: nimodipine (CCB) + bed rest + monitoring, angiography once stable, platinum coiling or clipping of aneurysm
32M who feels is having repeated TIAs like his father. every couple of months he suffers from an attack where he sees a shimmering light in the corner of his eyes + ringing in his ears. Often towards the end of the day, lasting half an hour. Fully conscious and never feels dazed or confused afterwards
What is the diagnosis and what treatment can be given
Migraine aura without headache
Slow march of symptoms e.g. visual disturbance that affects more and more of the field and then resolution in a similar fashion
Anti-migraine = sumatriptan Prophylactic = propanolol
16M with runny nose and headache. Has been blowing out green mucus from his nose for a few days. He is getting a headache located above his eyes and is very bad. His nasal septum is lightly deviated and his forehead is tender to gentle tapping.
What is the diagnosis and how is it treated
Infection of the frontal sinuses - green mucus and highly localised pain above the eyes
Treat with antibiotics e.g. amoxicillin, draining of the frontal sinuses (antral lavage)
10F has a persistent headache in the occipital area that is worse in the morning. The parents have noticed that shes become clumsy over the last few months. Fundoscopy shows increased vascularisation and papilloedema
What is the suspected diagnosis and what are the next steps
Raised intracranial pressure e.g. due to brain tumour: in the posterior fossa (occipital pain) or a medulloblastoma in the cerebellum (clumsiness)
urgent MRI to rule out CNS tumour
If found - dexamethasone to reduce inflammation and discussion for surgery
44M on the cardiac care unit who becomes confused and aggressive 4 days after a MI. No unusual obs, drugs history, or blood tests (includes inflammatory markers, electrolytes, liver enzymes)
History of alcoholism, 50-60 units drunk every week
What is the first step, most likely diagnosis and the immediate + long term management
Calm the patient as they are aggressive, consider sedation
Alcohol withdrawal is the most likely diagnosis (delirium tremens) - high risk of developing encephalopathy due to thiamine deficiency
Immediate prescription - chlordiazepoxide, CIWA scale, thiamine
Long-term - counselling on alcohol + specialist referral
65M is confused the day after colorectal cancer resection. Obs and investigations normal before operation. No signs of infection of the wound site, does not look or feel sweaty. Pulses are present, a bit weak, lung field clear.
What are the possible causes of his confusion
Postoperative patients may be confused for multiple reasons:
Hypoxia (blood loss -> anaemia, reduced RR, PE, alectasis)
Opiates (mental state + RR)
Electrolytes (fluid replacement, renal failure caused by hypoperfusion)
Infection
Sleep loss
Alcohol withdrawal
47F after her neighbour found her ‘out of sorts’. Speech is unintelligable. Neighbour says she lives by herself and is self-sufficient. She is a regular churchgoer and is abstinent of alcohol.
Pulse 72bpm, BP 131/83 mmHg, RR 13, temp 37.3, She is thin. Pupils are equal and react to light. intention tremor in both hands and significant ataxia, she can barely stand or walk. GCS 13. Has had bipolar disorder for over 20 years (takes lithium)
What is the most likely diagnosis
Young age + lithium medication - lithium toxicity
Impairment may be due to rehydration
54F who was found by her husband wandering the streets. She does not recognise him. Was behaving aggressively towards the paramedics. AMTS 5/10. Husband says she was fine when she went to bed. She had a headache before going to sleep and took paractamol. No smoking or DM or HTN
Pulse 109, BP 121/78, sats 98%, GCS 14/15,, RR 12, temp 40.3, photophobia. CT normal, LP shows opening pressure 28, gram positive intracellular diplococci
What is the diagnosis
Meningococcal meningitis
High WCC neutrophils, gram positive intracellular diplococcis, protein >1, CSF: blood glucose ratio<0.5
Atypical presentation
59M who is brought in by his son as he is not himself. His speech is unintelligable. Was fine 3 days ago. PMH - lung cancer, currently under MDT care, spread to adrenals. Loss of appetite + fatigue. Has a 40 year pack history.
O/E - 96bpm, 98/58, sats 99%, RR 12, temp, 37.5, GCS 14/15. Dry tongue, no oedema.no focal neurology.
Sodium low, potassium high, urea high.
What is the diagnosis and what investigation should be done
Hyponatraemia
Could be SIADH due to lung cancer, but more likely to be Addison’s
SIADH would cause a euvolaemic hypo, this is hypovolaemic
High potassium, hyponatraemia and hypovolaemia
Short Synacthen test
