Students should choose one to complete from either Part 1, Part 2, or Part 3. Note: All case studies are provided as a learning tool for students who wish to have them.
M.S. is a 26-year-old woman who is pregnant with her first child. Her husband accompanied her to all her prenatal visits. An ultrasound during a routine visit at 34 weeks’ gestation revealed that the baby had hydrocephalus and a myelomeningocele. The parents were initially devastated but remained very excited about the birth of their first child. M.S. was scheduled for a cesarean section at 38 weeks’ gestation, and the couple was anxious about their child’s condition and care following birth.
M.S. delivered a baby boy by cesarean section; he was transferred to the pediatric intensive care unit. On admission to the nursery, the baby’s vital signs and weight were within normal limits, but his head circumference was large. He had bulging fontanelles and a high-pitched cry. The nurse noted a saclike projection in the lumbar region of his spine.
Provide responses to the below based on Part 1.
Discuss the rationale for delivering the infant by cesarean section.
Discuss the significance of the infant’s clinical manifestations.
Discuss the acute and long-term treatment strategies for the infant.
Discuss the complications associated with myelomeningocele.
Anna Bryant, a 65-year-old White female, is brought to the emergency department by her daughter, Pat. Ms. Bryant complains of right-sided weakness and a headache that started about 2 hours ago. Her daughter states she found her in bed early this morning and noticed she was having trouble speaking. Ms. Bryant has a history of type 2 diabetes mellitus, for which she takes metformin and rheumatoid arthritis, which she manages with naproxen. She used to smoke but quit 5 years ago. She does not drink alcohol or use illicit drugs.
Her vital signs are as follows: Temperature 99.0°F; heart rate 94 beats per minute and irregular; respirations 20 per minute; blood pressure 150/90 mmHg; pulse oximeter 95%. Upon assessment, Ms. Bryant is alert, but has trouble answering questions. Her speech is slurred, and she appears frightened.
- Answer the following questions.
- 1. Based on her manifestations which cerebral artery is likely affected?
- Vertebral artery
- Basilar artery
Posterior cerebral artery
Middle cerebral artery
2. Which type of stroke is Ms. Bryant likely having?
Ischemic embolic stroke
Ischemic thrombotic stroke
3. Where in the brain is the lesion?
- Left hemisphere
- 4. Based on her history and physical examination findings, what is a possible etiology for a stroke in Ms. Bryant?
- Rheumatoid arthritis
Illicit drug use
5. This question is optional. What diagnostic tests should be ordered in the acute phase? Select all that apply.
- 12-lead electrocardiogram
- Hemoglobin A1c
- Noncontrast CT
- Lipid profile
6. This question is optional. What are treatment strategies for this acute stroke? Select all that apply.
Intravenous thrombolytic therapy administration
Systemic cooling to decrease risk of cerebral edema
- Antihypertensive agents to reduce mean arterial pressure to 80 (e.g., 100/70 mmHg)
- Statin administration
A 45-year-old Hispanic female, Ms. Rodriguez, presents to the clinic complaining of sudden onset headache. She states this headache is different from her previous migraine headaches. The headache pain is described as a 10 on a scale of 0–10 with 10 being the worst pain. The pain is nonradiating, and she has mild photophobia. She did not get relief with sumatriptan (Imitrex), which previously provided relief for her migraines. She feels nauseous and states she vomited twice.
Physical examination findings are as follows:
- Vital signs: temperature 98.8°F; pulse 88 beats per minute; respirations 20 per minute; blood pressure 150/95 mmHg; pulse oximeter 100% on room air.
- General appearance: alert, in mild discomfort due to pain.
Head, Eyes, Ears, Nose, and Throat: normocephalic, atraumatic; pupils equal, round, reactive to light and accommodation; sclera nonicteric; extraocular movements intact; no nystagmus; optic disc margins are sharp with no evidence of papilledema or hemorrhaging noted.
- Lungs: clear to auscultation bilaterally.
- Cardiac: regular rate and rhythm; S1, S2 with no murmur.
Abdomen: soft, depressible, nontender, no organomegaly.
Neuro: cranial nerves II–XII intact; muscle strength 5/5; deep tendon reflexes 2+ and symmetrical throughout; no pronator drift; negative Romberg sign; coordination intact; gait steady.
Answer the following questions or provide responses based on Part 3.
What is your differential diagnosis?
- What are your risk factors for meningitis? Subarachnoid hemorrhage (SAH)?
- What imaging would you like to do?
- Discuss the difference between a headache that presents gradually as compared to a headache that presents suddenly.
- What other history to you want to obtain from this patient?
What clinical findings would you anticipate with meningitis?
What clinical findings would you anticipate with SAH?
Title your document with the part number above completed.
Expert Solution Preview
In this assignment, we will address three different case studies from the field of medicine. Each case study presents a unique scenario, and you are required to provide a comprehensive response based on the given information. You should choose one case study from either Part 1, Part 2, or Part 3 and answer the questions related to that specific case study. The questions aim to evaluate your knowledge and understanding of various medical conditions and their management. Make sure to provide clear and concise answers, supported by relevant explanations and reasoning. Your response should reflect critical thinking and demonstrate your ability to apply theoretical knowledge to practical situations.
Answer to Part 1:
1. The rationale for delivering the infant by cesarean section for M.S. is due to the presence of hydrocephalus and a myelomeningocele in the baby. These conditions require immediate medical attention and specialized care. By performing a cesarean section, the healthcare team can ensure a controlled delivery and minimize the risk of damage or trauma to the baby’s neurologic structures, which could occur during a vaginal delivery.
2. The infant’s clinical manifestations, including bulging fontanelles, high-pitched cry, and saclike projection in the lumbar region of the spine, are significant indicators of myelomeningocele. These manifestations are a result of the congenital neural tube defect that affects the development of the spine and the surrounding tissues. It is crucial to recognize these signs early to initiate appropriate medical interventions promptly.
3. The acute and long-term treatment strategies for the infant with myelomeningocele involve multidisciplinary management. Initially, the baby will require surgical repair of the myelomeningocele to prevent infections and further complications. This procedure typically involves closing the open defect in the spinal cord and surrounding tissues. Following surgery, the baby may require various therapies, such as physical therapy, occupational therapy, and speech therapy, to address potential motor and developmental delays. Long-term management may include monitoring for associated conditions, such as hydrocephalus and neurologic deficits, and providing ongoing support and interventions as needed.
4. Myelomeningocele is associated with several complications. These include a higher risk of developing hydrocephalus due to impaired cerebrospinal fluid circulation and absorption, which may require the placement of a ventriculoperitoneal shunt. Additionally, individuals with myelomeningocele are prone to urinary and fecal incontinence due to neurogenic bladder and bowel dysfunction. The condition can also lead to orthopedic issues, such as scoliosis and clubfoot. Therefore, regular monitoring and appropriate management of these complications are essential for individuals with myelomeningocele.
Answer to Part 2:
1. Based on Ms. Bryant’s manifestations of right-sided weakness and slurred speech, the most likely affected cerebral artery is the Middle Cerebral Artery (MCA). The MCA supplies blood to the lateral aspects of the frontal, temporal, and parietal lobes, which control motor function and speech.
2. Ms. Bryant is likely having an Ischemic thrombotic stroke. This type of stroke occurs when a blood clot forms inside one of the blood vessels supplying the brain, causing a sudden interruption of blood flow to a specific area and subsequent neurological deficits.
3. The lesion in Ms. Bryant’s brain is most likely located in the left hemisphere. Since the MCA supplies blood to the lateral aspects of the frontal, temporal, and parietal lobes, its occlusion in the left hemisphere would result in right-sided weakness and slurred speech.
4. A possible etiology for a stroke in Ms. Bryant could be Atrial Fibrillation (AF). AF is a common heart arrhythmia that increases the risk of blood clots forming in the heart, which can then travel to the brain and cause a stroke.
5. In the acute phase of a suspected stroke, several diagnostic tests should be ordered. These may include a 12-lead electrocardiogram (ECG) to assess for any cardiac abnormalities, a noncontrast CT scan of the head to rule out hemorrhagic stroke, and a lipid profile to evaluate the patient’s lipid levels, as dyslipidemia is a risk factor for atherosclerosis and stroke.
6. Treatment strategies for an acute stroke may include intravenous thrombolytic therapy administration (e.g., alteplase) within the 3-4.5-hour therapeutic window to dissolve the blood clot causing the stroke. Systemic cooling to decrease the risk of cerebral edema is not a standard treatment strategy for stroke. Antihypertensive agents may be considered to reduce mean arterial pressure in certain cases, but blood pressure management should be done cautiously. Statin administration is not an acute treatment for stroke but may be considered in the long-term management of stroke prevention, especially if the patient has underlying atherosclerosis risk factors.
Answer to Part 3:
1. Considering the sudden onset of a severe headache, the differential diagnosis for Ms. Rodriguez may include subarachnoid hemorrhage (SAH), meningitis, and acute migraine attack.
– For meningitis, risk factors may include recent upper respiratory tract infection, immunosuppression, exposure to individuals with meningitis, or recent travel to endemic areas.
– Risk factors for SAH may include a history of cigarette smoking, hypertension, a family history of cerebral aneurysms, or connective tissue disorders.
– Additional differential diagnoses could include tension-type headache, cluster headache, or temporal arteritis, depending on the patient’s history and examination findings.
2. To further evaluate Ms. Rodriguez, an imaging study, such as a noncontrast CT scan of the head, is recommended. This imaging study can help differentiate between SAH and other causes of a sudden severe headache and identify any abnormalities, such as bleeding or structural lesions in the brain.
3. A headache that presents gradually is often associated with primary headache disorders, such as tension-type headache or migraines. It may develop over hours to days and usually does not present with sudden severe pain. On the other hand, a headache that presents suddenly, as in this case, raises concerns for potentially serious conditions such as SAH or meningitis, which require prompt medical evaluation and intervention.
4. In addition to the patient’s medical history of migraine headaches, it is important to obtain more information about her recent activities, recent illnesses, medication changes, trauma, family history of similar headaches, and any associated neurological symptoms that may help further narrow down the differential diagnosis and guide appropriate management.
5. Clinical findings anticipated with meningitis may include neck stiffness (nuchal rigidity), fever, headache, sensitivity to light (photophobia), altered mental status, and positive signs of meningeal irritation, such as Kernig’s sign and Brudzinski’s sign.
6. Clinical findings anticipated with SAH may include a sudden-onset severe headache often described as “the worst headache of my life,” neck stiffness, nausea, vomiting, altered mental status, photophobia, focal neurological deficits, and potentially signs of increased intracranial pressure, such as altered consciousness or seizures.
Please title your document with the part number completed (e.g., “Part 1”).