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A non-contrast computed tomography (CT) of the head and neck was performed, followed by an MRI of the cervical spine. The CT demonstrated congenital narrowing of the cervical spinal canal, with posterior disc osteophyte complex and disc bulge at C3-4 and C4-5 (arrow). The T2-weighted MRI additionally demonstrated obliteration of the anterior and posterior subarachnoid space at the level of C3-C5, with associated patchy central cord signal abnormality (arrow).
Magnetic resonance imaging of the brain, cervical, thoracic and lumbar spine without contrast was obtained and revealed increased signal throughout the spinal cord from C-1 to the conus medullaris with mild expansion consistent with transverse myelitis.
At the end of this oral board session, examinees will: 1) demonstrate the ability to obtain a complete pediatric medical history; 2) demonstrate an appropriate exam on a pediatric patient including a neurological exam; 3) investigate the broad differential diagnoses for neuromuscular weakness in a pediatric patient; 4) order the appropriate evaluation studies including an MRI; 5) interpret the use of a negative inspiratory force in determining the need for intubation and level of care upon admission; and 6) demonstrate effective communication with parents and caregivers.
ABSTRACT: A 39-year-old previously healthy male presented with three days of right eye pressure and one day of binocular diplopia. He denied history of trauma, headache, or other neurological complaints. He had normal visual acuity, normal intraocular pressure, intact convergence, and no afferent pupillary defect. His neurologic examination was non-focal except for an inability to adduct the right eye past midline
While still in the ED, MRI with and without gadolinium contrast of the brain, orbits, and cervical, thoracic and lumbar spine were obtained to evaluate for possible CNS lesions including encephalitis, myelitis, or demyelination. Imaging, however, demonstrated multiple unexpected findings: a T1 hypointense, T2 hyperintense and heterogeneously enhancing right adrenal mass measuring 2.7 x 2.1 x 3 cm (yellow asterisk) along with heterogenous enhancement at the clivus, C6, C7, T7, T8, T12, and L3 vertebral bodies (red asterisks). There were otherwise no significant intracranial signal or structural abnormalities and normal orbits.
By the end of this simulation session, learners will be able to: (1) manage a patient with altered mental status (AMS) with fever while maintaining a broad differential diagnosis, (2) recognize the risk factors for meningococcal meningitis, (3) manage a patient with worsening shock and perform appropriate resuscitation, (4) develop a differential diagnosis for thrombocytopenia and elevated international normalized ratio (INR) in an altered febrile hypotensive patient with rash, (5) manage the bleeding complications from WFS, (6) discuss the complications of meningococcal meningitis including WFS, and (7) review when meningitis prophylaxis is given.
On vitals, the patient was found to be consistently hypertensive to the 230s/160s. Point-of-care glucose was within normal limits. Noncontrast CT imaging of the head revealed no acute intracranial hemorrhage or evidence of ischemic stroke, but was remarkable for areas of biparietal subcortical low-attenuation (white arrows), concerning for PRES. Patient subsequently underwent CT angiogram imaging of the head with perfusion which revealed no large vessel occlusion.
CT head without contrast demonstrated a minimally displaced fracture of the frontal sinuses at the midline underlying his known laceration that involved the anterior and posterior tables of the calvarium. This is seen on the sagittal view and indicated by the blue arrow. There was a small volume of underlying subarachnoid hemorrhage along the falx. There was also extensive pneumocephalus most pronounced along the bilateral anterior frontal convexity associated with the frontal sinus fracture, seen on the axial image and indicated by the red arrow. This pattern of air is commonly referred to as the “Mount Fuji” sign.6 Other intracranial air can also be seen on the sagittal image and is indicated by the white arrow.
By the end of this simulation learners will be able to: 1) develop a differential for descending paralysis and recognize the signs and symptoms of botulism; 2) understand the importance of consulting public health authorities to obtain botulinum antitoxin in a timely fashion; 3) recognize that botulism will progress during the time period antitoxin is obtained. Early indications of respiratory compromise are expected to worsen during this time window. Secondary learning objectives include: 4) employ advanced evaluation for neurogenic respiratory failure such as physical examination, negative inspiratory force (NIF), forced vital capacity (FVC), and partial pressure of carbon dioxide (pCO2), 5) discuss and review the pathophysiology of botulism, 6) discuss the epidemiology of botulism.
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By the end of the simulation, the learner will be able to: 1) manage an acute seizure 2) discuss imaging modalities to diagnose PRES 3) discuss medical management of PRES.