AAAAA
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Please point out the code word in this question :
A 75 year-old woman with Alzhemier's disease falls in the nursing home and hits her head. No fractures are noted on a skull radiograph.
She has fluctating levels of consciousness and complains of a severe headache on the left side of her head. Mydriasis is noted in the left pupil.
Which of the following is the most likely diagnosis in this patient?
1. epidural hematoma
2. subdural hematoma
3. subarachnoid hemorrhage
4. intracelebral hemorrhage
5. hemorrhage infarction of the brain
What is the code word ? The key word to pin down the answer
How you separate the important from the useless information in this question ? They are called distraction ?
You have 45 seconds only.
How do you make the diagnosis?
What is the first and most important treatment?
How you differentiate all 5 of them clinically ????
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| AAAAA
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Don't just do the question, learn they are going to ask you a lot of head trauma.
Clear fluid coming from the nose, what's that ?
Fluid coming from the ear, what part of the brain is fracture?
You see air in the brain, which bone is fracture, the frontal view of the skull?
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| AAAAA
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Which cranial nerve most commonly will be affected if the patient has mydriasis?
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| AAAAA
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What is this ? You will see this in the ER with a 75 year-old come in from the ER?
Attached Files:
t1_axial_s_sdh.jpg (14 KB, 11 downloads)
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| AAAAA
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A 75 year old comes in by ambulance from nursing home and CT show this image?
What is the diagnosis and how you treat?
Attached Files:
hydrocephalus.jpg (20 KB, 12 downloads)
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| AAAAA
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Sorry for the multiple attachment, I will try one more time
Attached Files:
hydrocephalus.jpg (4 KB, 10 downloads)
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| mesh
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-answer for the first question is epidural hematoma.
-clear fluid from nose/ear---fracture of base of skull....
-75 yr old male in ER...i think its subdural hematoma....
-couldnt get the last one.....
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| msyamp
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For the First question i go for INTRACRANIAL hemorrhage because of the predispoition of the patient wiht amyloid angiopathy.
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| Rasul
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Dear AAAAA!
I understand that Your thought goes faster, that Your speech, typing abilities etc etc, and that's why You end up posting multiple messages under one topic, but please, please, try not to do that...
R.
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| ruhighazi
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I think the answer (of the 1st question!) is subdural hematoma. Epidural hematomas are often associated with lateral skull fracturs and a "lucid interval".
In intracerebral hemorrhage we see more neurologic signs & no flutuation.
In subdural hematoma we see the classic history of waxing & waning signs & symptoms. In addition the mydriasis can be seen in these patients & is ipsilateral in 90% of cases.
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| AAAAA
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I WILL GIVE THE ANSWER
Sorry for the delay !
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| AAAAA
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Background: Subarachnoid hemorrhage (SAH) implies the presence of blood within the subarachnoid space from some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or arteriovenous malformation (AVM). The scope of this article is limited to these nontraumatic hemorrhages.
Frequency:
In the US: Annual incidence of nontraumatic aneurysmal SAH is 6-25 per 100,000. More than 27,000 Americans suffer ruptured intracranial aneurysms each year. Annual incidence increases with age and probably is underestimated, because death is attributed to other reasons that are not confirmed by autopsies.
Internationally: Varying incidences have been reported in other areas of the world (2-49 per 100,000).
Mortality/Morbidity:
An estimated 10-15% of patients die before reaching the hospital. Mortality rate reaches as high as 40% within the first week. About half die in the first 6 months.
Mortality and morbidity rates increase with age and poorer overall health of the patient.
Advances in the management of SAH have resulted in a relative reduction in mortality rate that exceeds 25%. However, more than one third of survivors have major neurologic deficits.
Race: Blacks have a higher risk for SAH than whites (2.1:1).
Sex: Incidence of aneurysmal SAH is higher in women than in men.
Age: Mean age of SAH is 50 years.
CLINICAL Section 3 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography
History:
Headaches
Patient experiences sudden onset of a severe headache.
Prodromal (warning) headache(s) from minor blood leakage (referred to as sentinel headache) is reported in 30-50% of aneurysmal SAHs.
Sentinel headaches may occur a few hours to a few months before the rupture, with a reported median of 2 weeks prior to diagnosis of SAH.
Minor leaks commonly do not demonstrate signs of elevated intracranial pressure (ICP) or meningeal irritation.
Minor leaks are not a feature of AVM.
More than 25% of patients experience seizures close to the acute onset; the location of a seizure focus has no relationship to the location of the aneurysm.
Nausea and/or vomiting
Symptoms of meningeal irritation (eg, neck stiffness, low back pain, bilateral leg pain): These are seen in over 75% of SAH, but many take several hours to develop.
Photophobia and visual changes
Loss of consciousness: About half of patients experience this at the time of bleeding onset.
Physical: Physical examination findings may be normal, or the clinician may find some of the following:
Global or focal neurologic abnormalities in more than 25% of patients
Syndromes of cranial nerve compression
Oculomotor nerve palsy (posterior communicating artery aneurysms) with or without ipsilateral mydriasis
Abducens nerve palsy
Monocular vision loss (ophthalmic artery aneurysm compressing the ipsilateral optic nerve)
Motor deficits from middle cerebral artery aneurysms in 15% of patients
No localizing signs in 40% of patients
Seizures
Ophthalmologic signs
Subhyaloid retinal hemorrhage (small round hemorrhage, perhaps with visible meniscus, near the optic nerve head); other retinal hemorrhage
Papilledema
Vital signs
About half of patients have mild to moderate blood pressure (BP) elevation.
BP may become labile as ICP increases.
Fever is unusual at presentation but becomes common after the fourth day from blood breakdown in the subarachnoid space.
Tachycardia may be present for several days after the occurrence of a hemorrhage.
Grade SAH according to the following scheme:
Grade I - Mild headache with or without meningeal irritation
Grade II - Severe headache and a nonfocal examination, with or without mydriasis
Grade III - Mild alteration in neurologic examination, including mental status
Grade IV - Obviously depressed level of consciousness or focal deficit
Grade V - Patient either posturing or comatose
Causes:
Primary SAH may result from rupture of the following types of pathologic entities (the first 2 are most common):
Saccular aneurysm
AVM
Mycotic aneurysmal rupture
Angioma
Neoplasm
Cortical thrombosis
SAH may reflect a secondary dissection of blood from an intraparenchymal hematoma (eg, bleeding from hypertension or neoplasm).
Two thirds of nontraumatic SAH are caused by rupture of saccular aneurysms.
Congenital causes also may be responsible for SAH.
Occasional familiar occurrence
Frequency of multiple aneurysms
Association of aneurysms with specific systemic diseases, including Ehlers-Danlos syndrome, Marfan syndrome, coarctation of the aorta, and polycystic kidney disease
Environmental factors associated with acquired vessel wall defects include age, hypertension, smoking, and arthrosclerosis.
DIFFERENTIALS Section 4
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| AAAAA
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She has fluctating levels of consciousness and complains of a severe headache on the left side of her head. Mydriasis is noted in the left pupil.
Oculomotor nerve palsy (posterior communicating artery aneurysms) with or without ipsilateral mydriasis (Third Cranial Nerve oculomotor Nerve)
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| AAAAA
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Mydriasis
Cranial Nerve III paralysis
Posterior Communicating Artery aneurysm
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