SAQ’s



Neurology SAQ’s

An elderly woman with dementia is sent to your emergency department from a nursing home. In the last 3 days she has had a change in behaviour and is acutely agitated

Question

|a. |List the most likely causes of her agitation |(30%) |

|b. |Describe the initial treatment of her agitation while her diagnostic workup is underway |(70%) |

Answer

Answer and Interpretation

FACEM SAQ Exam 2010.2 – Question 3

. The overall pass rate for this question was  81/92 (88%)

. Pass Criteria

. Part A

1. Adequate list for causes of delirium.

2. Need to mention 5 – 6 from major causes

1. Infection;

2. CNS;

3. Trauma;

4. Cardiac;

5. Metabolic;

6. Drugs;

7. Surgical;

8. Endocrine;

9. Vascular.

10. Specific to elderly.

. Part B

1. Need to cover aspects of:

1. Non-pharmacological therapy;

2. Pharmacological therapy;

3. Involving family/carers;

4. Care plans/advanced health directives.

5. Specific drugs used including doses (age appropriate and considering co-morbidities and potential complications).

. Features of unsuccessful answers

. Poor differential diagnosis.

. Limited or no non-pharmacological approach.

. Poor discussion of pharmacological sedation.

. Discussion of investigation rather than treatment.

. No doses or route given for drug therapy.

Not answered at Consultant level response.

A 72 year old patient presents to the emergency department with acute left hemiparesis.

Question

|a. |Discuss the use of thrombolysis in acute stroke. |(50%) |

|b. |List your differential diagnoses. |(50%) |

Answer

Answer and Interpretation

FACEM SAQ Exam 2005.1 – Question 5

. The overall pass rate for this question was 30 / 44 (68.2%).

. Pass Criteria

. The first question was expected to be answered by considering not just cerebrovascular events but also the commonly encountered stroke mimics.

. It was hoped that the listed differentials would be given some order so that clinical perspective could be demonstrated.

. It was expected that the second question would be answered with some reference to the recent literature and important clinical trials and with an acknowledgement that thrombolysis in stroke in Australasia is controversial and currently has limited utility.

. Features of unsuccessful answers

Features of failing answers included differential diagnoses that were too limited or omitted significant conditions, failure to address both the pros and cons of thrombolysis and inadequate knowledge of the current state of research in this area.

A 19 year old woman is brought to the emergency department by her concerned parents with a two day history of irritability and headache. She has a history of developmental delay and a ventriculo- peritoneal shunt for congenital hydrocephalus.
Her Glasgow Coma Score is 15. Her vital signs are normal.

Question

| |Describe your assessment. |(100%) |

Answer

Answer and Interpretation

FACEM SAQ Exam 2008.1 – Question 6

. The overall pass rate for this question was 55/62 (8.7%).

. Pass Criteria

. The question was felt to deal with a topical Emergency Dept presentation.

. Good answers dealt with a systematic approach to the assessment of the possible shunt and non-shunt related causes of this presentation.

. Features of unsuccessful answers

Poor answers failed to adequately examine the shunt itself and failed to fully assess for non-shunt related conditions.

1. Compare and contrast the investigations you employ to confirm the diagnosis in a patient with suspected subarachnoid haemorrhage.

2. A 2 year old boy with a past history of a seizure disorder is brought to your ED by his distressed parents with a seizure of 40 minutes duration which has continued despite administration of rectal Diazepam at their home.

Describe your approach to this child’s immediate care.

2004/2 (admin)

You are notified by the Director of an Intensive Care Unit at another hospital about a 63 year old male

who had recently presented to your emergency department with a large subarachnoid haemorrhage.

He is now in the Intensive Care Unit with a poor prognosis. This patient had attended your department

48 hours earlier with the presenting complaint of "Headache". He left the waiting room prior to being

seen.

How would you manage this incident?

1999/2

A 32 year old female presents with a 5 day history of progressive weakness in both legs.

Give the differential diagnosis and discuss your assessment and investigation of this patient.

2008/2

A 10 year old boy is brought to hospital by his parents after falling off his skateboard and hitting his head.

(a) What clinical factors would influence your decision to order a brain CT scan? (50%)

After full assessment he is deemed fit for discharge.

(b) Describe your discharge advice. (50%)

2008/2

A 32 year old woman who is 33 weeks pregnant is referred to your emergency department because of a blood pressure of 140/95 and right upper quadrant pain for 24 hours. One hour after arriving in the emergency department, the patient begins to have a grand mal seizure.

Describe your management. (100%)

2003/1

An 84 year old man is brought to the emergency department by his family. His wife notes that his

behaviour has been increasingly aggressive over a period of two weeks, She no longer feels able to

cope with him at home. He has a history of moderately severe dementia, prostatic carcinoma,

ischaemic heart disease and aortic valve replacement.

a) outline your assessment of this patient (70%)

b) outline your management of this patient (30%)

1. Discuss the indications and timing for head CT scans in trauma with reference to the three following cases:

An 18 year old man presents to the Emergency department at 0200. He has been hit on the head with a crow bar multiple times. He has a GCS of 15 and complains of a low grade headache. His ethanol level is 0. He has a very large boggy occipital wound but no heamotympanum. There is a radiographer and radiology reg on call for CT scan.

A 30 year old man has been assaulted. He smells highly of Ethanol. His GCS is 13. He is somewhat confused and lies in the cubicle with his eyes shut if undisturbed. He has evidence of trauma as indicated by a temporal haematoma. Again it is 0200 in the morning in the same type of department as above.

A 70 year old man has had a fall down a few stairs at his home. He lost consciousness for 5 minutes according to his wife. 2 hours later in the ED he has a GCS of 15. He is complaining of a mild headache. There is no evidence of a base of skull fracture but he has a large frontal haematoma evident. It is 1700 at this time – the time your radiology department goes on call.

Brief answer outline.

Discuss = Pro’s and Con’s

Can start with overall outline indications to CT eg Canadian head CT rules

When to CT a mild to moderate head trauma :

significant loss of consciousness, amnesia, vomiting, post-traumatic seizure

(LOC or GCS and failure to improve

Any focal neurology or coagulopathy

Specific issues in these 3 cases are where the money is at

Opinion on each case accepted whether yes or no for scan, as long as reasons discussed

Case 1

Pro’s – relatively few, definitive answer to question of intracranial pathology and discharge of patient might be possible

Con’s – not clinically indicated currently (zero ETOH and no neuro deficit, no evidence BOS#)

- not cost effective (callback of radiographer), staff impact for the next day

- diagnostic errors can be made at night (similar to surgeons operating at night)

- Had an open wound to palpate potential skull # thru whilst cleaning/suturing

Give opinion with reasoning : “ Observe overnight and CT in am given significant mechanism”

What really happened to this patient ( this was a real case) is he was observed and discharged after 6hrs. He returned the next am and was triaged as a 4, CT was arranged. Whilst waiting he deteriorated rapidly, was intubated, CT showed a subdural and he was declared brain dead shortly afterwards.

Case 2

Pro’s – Important issues are presence of ETOH, (GCS13, temporal region over MMA (risk EDH)

- neurosurg intervention may be required

Cons – As per con’s 2 and 3 in case 1, call-out cost and “night reading error”

- Monitor patient instead and CT if deteriorates

- Might require sedation for CT (danger at night in CT)

Case 3

Pro’s – quick, early exclusion of intracerebral pathology

- quicker time to definitive disposition

- low threshold to CT in the elderly

Con’s – Patient needs admission anyway for “falls assessment”, medical and social issues

2. A 26- year-old man presents to the Emergency department with weakness. He gives a history of going to bed last night feeling well. This morning he was so weak he was unable to get out of bed. His wife could not lift him and thus had to call a ambulance. He has no prior history of significant illness. On examination he looks well and is afebrile. His pulse is 70 bpm, RR 16 bpm and BP is 150/80. Brief examination reveals that he is hardly able to lift his legs of the bed but he has better movement of his arms. He complains that his thigh muscles are very weak.

Outline your differential and your assessment of this man?

Acute neurological assessment required, esp questions such as

“What level?” and “Any respiratory compromise?”

Differential:

Acute neurological

GBS ) classically lower>upper, variable sensory loss

Acute Transverse Myelitis ) decreased reflexes and sparing of sphincters

Polyneuritis, eg viral

Other spinal cord event eg aortic dissection, cord infarction, epidural haematoma

MS

Acute spinal cord compression

central disc

trauma, fracture, spondylolysis, spondylolisthesis

tumour1o or 2o

infection

Myopathy

Inflammatory (polymyositis)

Muscular dystrophy

Myasthenia gravis

Electrolyte imbalance

Hyper/hypo-kalaemic periodic paralysis

Others eg hyper/hypo-calcaemia

Endocrine

Thyroid, Addisons

Nutritional

Alcohol/drug induced

eg SACD cord

Toxin

Ciguatera, puffer fish, paralytic shellfish

Envenomation eg tick

Botulism

Organophosphates

Non-physiologic

Conversion disorder, chronic fatigue

Assessment

History – onset, duration, illness, fevers, trauma, AMPLE etc etc

Examination – define level, full neuro, sphincters, resp function

Investigations – give reasons for each : FBC, gluc, UEC, Ca++, Xray, CT, MRI, LP, endocrine

This patient in fact had hypokalaemic periodic paralysis.

3. A 3 year old child has been brought by her mother to your ED with a decreased conscious state. Her GCS is 10. Apart from the altered conscious state there are no abnormal findings on examination. The child has had 4 previous similar presentations. On each previous occasion the child was admitted to hospital for observation and had numerous neurological investigations. All investigations were negative and the child spontaneously returned to normal within 12 hours. What is the differential diagnosis? Outline your management on this occasion.

This may or may not be the same as the previous 4 presentations and must not be automatically assumed to be so until proven and serious illness ruled out. If no definitive diagnosis has been made in the past, the acute presentation time may be where most valuable diagnostic information may be gathered.

Need to get old notes and consult previous treating doctors to see what previous presentations have been like and what investigations have been done.

Presentation sounds very much like Munchausen’s by proxy with possible toxic ingestion, but other diagnoses must be ruled out first.

Differential Diagnosis

1. Cerebral

Trauma – subdural, concussion

Infection – mening/enceph must be considered

Seizure – status, prolonged petit mal

Oedema – Na+ imbalance, SOL

Brainstem lesion

2. Overdose/poisoning

Accidental or toxic ingestion high on the probability list

– Munchausen’s by proxy … check characteristics of mother/other presentations

eg opiate (methadone, heroin IV or IM), benzo, other sedative, hypoglycaemic

Consider envenomation

3. Metabolic

Acid/base, UEC disturbance, sepsis must be ruled out

Endocrine – Addisons, hypothyroid, hypoglycaemia

Environmental – hypothermia, electric shock

4. A’s – Asphyxia (suffocation), hypoxia, arrhythmia

Management

Treat as resuscitation, team approach etc

ABC approach, consider nasopharyngeal airway, high flow O2

IV access, check BSL, usual bloods, FBC, biochem, cultures, A/VBG

Fluid bolus as indicated

Consider metabolic screen

If suspicion sepsis give Ceftriaxone +/- Acyclovir

Detailed examination CVS, rash, neuro, etc

Further exam/investigation/treatment now depends on :

State of patient – vitals etc / response to treatment /

Similarity to previous presentations and what investigations have been done.

Discussion with paediatrician/neurologist who looked after the kid last time

Supportive care, esp of ABC

Further investigations

Urine toxin screen

Consider serum toxin screen for later analysis

EEG if not previously done during episode of (LOC

CT, MRI, LP

8. You are a senior doctor in an emergency depaitruerit. Your intern asks for assistance in performIng a lumbar puncture on a 25-year-old female with a sudden onset headache.

(a) Outline what you would tell the intern regarding performing a lumber puncture.

(b) Discuss the role of lumbar puncture in the investigation of subarachnoid haemorrhage.

1.) Discuss the assessment of a patient with suspected sub-arachnoid haemorrhage

This man is likely to have had a thrombo-embolic stroke in left cerebral artery territory. He has presented early and had a rapid, normal CT scan excluding haeinorrhage.

Management options for consideration:

Supportive

02

IV fluids

Thermal protection

BP control (but must avoid hypotension)

Specific

aspirin

heparin

thrombolysis

neuro-protectlve agents

Disposition

specialised stroke unit vs normal ward.

His past history of HT may be relevant in increasing his risk of subsequent intracranial haemorrhage or from anti-platelet/anticoagulant/thrombolysis and reflux increases his risk of GI haemorrhage

Oxygen

use well accepted.

Cons

limited.

Cost

discomfort.

drying of airway secretions.

lY fluids

Pros

Reduces risk of dehydration while the patient is nil oral

Dysphasia increases aspiration risks and he should be nil oral until formal assessment of gag etc.

Cons

inappropriate rate! choice may cause LVF or electrolyte disturbance

Pros

avoid pressure areas on areas of immobility with associated morbidity and increased admission stays Cons

Short term nursing staff time requirements

SPECIFIC

asuirin

pros

Proven to reduce early death and recurrent stroke (Chinese acute stroke trial) inexpensive

long history of use and well established risk profile minimal nursing time m administration

cons

may not be the most effective treatment (controversial)

requires oral administration ...~.

can predispose to GI bleeding ~note this man has a history of reflux

Heparin

Pros

Potential to reduce thrombosis and reduce the chance of further stroke (unproven)

Cons

May cause haemorrhagic transformation

Not proven to provide benefit. 1ST showed worse outcome.

SE’s include bleeding

Requires testing of APTT

Not recommended for this man.

Thrombolysis

Controversial.

Pros

Aim to salvage penumbra.

May offer benefit to a sub section of those studied (NINDS, sLngle trial only 6)0 natients) who have treatment inititiated within? of symptom onset (this man is likely to meet this requirement). Other studies have not shown this benefit.

Benefit seen only at 3 months.

Main benefit produces increased minimal or no deficit group

risks of intracranial bleed (6% TPA vs 0.6% placebo ) and death. Contra-indicated if BP> 185 systolic.

Stroke mimics exist, 5% with normal CT

Benefits only if treated within 90 minutes of onset. This man likely to be eligible. Not supported by ECASS I and II.

availability likely to be limited to hospitals conducting trials and therefore dependant on trial criteria requires high level of mointoring and coordination with treating neurologists.

Expense (although if effective community cost benefit likely to greatly outweigh) Other bleed esp. GI.

Neuroprotective agents

Ca antagonists. NMDA antagonists, free radical scavengers all unproven to provide benefit.

Endarterectomy

Limited data in acute stroke.

Benefit in TIA 70-99% stenosis, good operator.

Disposition

Stroke unit

Pros

Proven benefit in decreasing mortality

Likely to be better access to multi -disc team

patient and relative education likely to be better

Cons

May exist at the expense of general ward beds with resource/bed block implications. Expense

1. Your tertiary-level ED plans to introduce a protocol for the assessment non-traumatic headache in adults. Outline your approach (100%).

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