Monday, February 02, 2015

Long Case with Dr. Vova

Patient 1

60-year-old man with underlying bronchial asthma and hypertension, presented with 5 days history of fever, lethargy and two episodes of generalised tonic clonic seizure on the day of admission. BP at A&E was 192/118. No history of headache, vomiting or neck stiffness.

Physical examination done on Day 3 of admission revealed a medium build man lying at 45' propped up position. Patient febrile 37.5, BP 180/100, HR 84, RR 16. Neurological examination was normal. Kernig and Brudzinski signs were negative.

1. Provisional diagnosis?
Seizure secondary to meningoencephalitis

2. Differentials?
Can be secondary to electrolyte imbalance

3. Causes of seizure?
  • Infection eg. meningitis, encephalitis
  • Haemorrhage eg. AV malformation, ruptured aneurysm
  • SOL eg. abscess, tumour, haematoma
  • Ischaemic stroke
  • Electrolyte imbalance
  • Brain injury
  • Autoimmune eg. SLE


4. Investigations?
FBC, BUSE, blood C&S, lumbar puncture, CT brain

5. Indications and contraindications for lumbar puncture?

Taken from this website

6. Parameters in lumbar puncture? How to differentiate between bacteria and viral?

Taken from Oxford Handbook of Clinical Medicine 8th edition, Page 833

7. Management?
  • Resuscitate ABC
  • Give antiepileptic IV Diazepam
  • Start empirical antibiotic IV Rocephine and Acyclovir
  • Monitor GCS, vital signs, urine output, fit chart
  • Antihypertensive to control BP IV Isoket then T. Amlodipine


8. Shall this patient go for EEG? What are the indications?

Taken from this website


Patient 2

87-year-old woman with uncontrolled hypertension, presented with one day history of headache, nausea, vomiting, left lower limb weakness and slurred speech. BP at A&E was 200/90. No LOC, fever, neck stiffness, seizure or personality changes.

Physical examination revealed a cachexic elderly with nasogastric tube attached. Patient afebrile, BP 180/100, HR 98, RR 16. Neurological examination of upper limbs showed abnormalities on left side : hypotonia, power 0/5 and hyporeflexia. Sensation intact. On lower limbs examination, left leg was externally rotated, hypotonia, power 0/5, hyporeflexia. Babinski equivocal. No clonus. Sensation intact. Cranial nerves normal.

1. Provisional diagnosis?
  • Left sided hemiparesis with right cerebrovascular accident
  • Hypertensive emergency


2. Differentials?
  • Transient ischaemic attack
  • Meningitis or encephalitis
  • Space-occupying lesions


3. Which is more common, ischemic or haemorrhagic stroke?

Taken from this website

4. Investigations?
FBC, BUSE, PT/APTT, CT brain

5. Management?
  • Resuscitate ABC
  • Do swallowing test, check gag reflex
  • Control BP, aim 25% reduction in 3-12h, not more than 160/90, give IV Labetolol
  • Monitor every hour, look at vital signs, GCS, urine output
  • DVT prophylaxis, prevention of bed sore
  • Stroke education
  • Limb and chest physiotherapy 
  • Prevent second attack by controlling BP


6. Area of arteries involved and the symptoms?

X'Press Revision in Short Cases by UM Press

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