Weekly classroom discussion

About Stroke - from the Lancet

  1. An arterial stroke is a sudden loss of neurological function caused by brain ischemia. It can be caused by:
  2. A venous stroke is much less common, caused by thrombosis of cerebral venous sinuses or cortical veins, and differs from an arterial stroke in what way?
  3. Why is the historical epidemiological differentiation between TIA and stroke based on duration (less than 24 hours versus more than 24 hours) outdated?
  4. Based on clinical presentation, what criteria should be used to decide which stroke needs to be immediately treated? What is the numerical scale used commonly for decision making in acute stroke?
  5. What are the 2 types of treatment for acute stroke that help to improve brain perfusion?
  6. What is the investigation that is most useful in decision making in acute stroke?
  7. Which investigation modality is preferred when dealing with minor strokes or with strokes involving the posterior circulation?
  8. What will you give a patient (for improving brain perfusion) who presents with an acute arterial stroke that has caused a dense hemiplegia if there are no contraindications?
  9. What are the 3 common systemic factors that adversely affect recovery after an acute stroke?

Questions based on portfolios
1. A 46 year old man presents with 3 months of poor appetite, loss of weight, breathlessness as well as frequent cough and fever with occasional blood in the sputum. He is a smoker with an 80-pack year history of tobacco use. His respiratory examination showed: trachea central; reduced chest movements on the R side; dull percussion note over the entire R hemithorax; absent breath sounds and diminished vocal resonance over the entire R hemithorax. Findings on the L side of chest were normal.

Choose ONE diagnosis that fits the given physical findings
A. Collapse of the lung
B. Collapse of lung with associated pleural effusion
C. Consolidation of the lung
D. Fibrosis of the lung

2. Which ONE of the following statements regarding an empyema is correct?
A. Empyema can be successfully treated by repeated needle aspiration
B. Empyema cannot be due to tuberculosis
C. Intercostal tenderness over the affected area is often present in empyema
D. The typical fluid of empyema contains plenty of lymphocytes

3.Which ONE of the following tests has the greatest sensitivity in detecting acid fast bacilli in a patient with a tuberculous pleural effusion?
A. Pleural fluid AFB smear examination
B. Pleural biopsy and staining
C. Sputum AFB smear examination
D. Gastric aspiration examination

4. When should a chest tube be inserted for draining a pleural effusion?

5. Mr S, a 76 years old Indian male, non-smoker with known case of Type 2 diabetes mellitus, currently on insulin and oral hypoglycaemic agent, hypertension and dyslipidaemia on oral therapy and ischemic heart disease which has undergone a Coronary Artery Bypass Grafting (CABG) 10 years ago presented with shortness of breath for 3 days prior to admission.

1. What are the oral hypoglycemic drugs that are unsafe when combined with insulin?
2. How long does a CABG remain patent?
3. When do you decide that a patient like this needs insulin?
4. How do you initiate insulin therapy in this patient?

6. An 62-year-old man presents with a left sided stroke. He is noted to have AF, a BP of 184/93mm Hg and has cardiomegaly with dilatation of all 4 chambers and a very poor LV contractility (LVEF 25%). His CT brain shows an infarct in the R motor cortex. He is treated with IV labetolol to keep his BP at 140/90 mm Hg. A few days later his conscious level worsens and he is found to have had an extension of his brain infarct.

1. What do you think may be responsible for the extension of his brain infarct?
2. What could be the reason for his cardiomegaly and poor LV contractility?
3. What could be the reason for his AF?

7. A 41 year old man with HPT and bronchial asthma presents with pneumonia and what looks like an acute exacerbation of his bronchial asthma. He is extremely obese with BMI of 35, has hyperinflated lungs on chest x-ray and ABG shows this:

Arterial blood gas:
Item Result Reference range
pH 7.36 7.35 to 7.45
PCO2 51.4mm Hg 35 to 45
PO2 188mm Hg 80 to 100
HCO3 29mmol/L 22 to 28

Does he have:

  1. Acute respiratory acidosis
  2. Chronic respiratory acidosis
  3. Chronic metabolic alkalosis with respiratory compensation
  4. A dual acid-base disorder

8. A 78 year old man has cirrhosis liver. His ascites rapidly accumulates and he needs frequent abdominal paracentesis. What could be the reasons for this? If viral markers for hepatitis are negative and he does not consume alcohol, what could be the reason for his cirrhosis?

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