Part 1
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.
Part 2
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?
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- Vertebral artery
- Basilar artery
- Posterior cerebral artery
- Middle cerebral artery
2. Which type of stroke is Ms. Bryant likely having?
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- Ischemic embolic stroke
- Ischemic thrombotic stroke
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
3. Where in the brain is the lesion?
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- Right hemisphere
- Left hemisphere
4. Based on her history and physical examination findings, what is a possible etiology for a stroke in Ms. Bryant?
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- Endocarditis
- Rheumatoid arthritis
- Atrial fibrillation
- Illicit drug use
5. This question is optional. What diagnostic tests should be ordered in the acute phase? Select all that apply.
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- 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.
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- 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
Part 3
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:
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- 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?
