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BRAIN APPRAISAL & EDITOR ID: stg_intern_qb_mct_post_intern_2020

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Summary / Abstract / Clinical Overview

STG Clinical Brain Guideline Parameters

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Clinical Red Flags & Referral Triggers

Diagnostic Workup & Bedside Investigations

Full Step-by-Step Management Protocol

1. 35yrs man had a seizure, and as per his girlfriend was fatigued for 3 days and confused earlier that morning before the convulsions. With each episode he was unconscious and lasted 4 mins, he is a smoker1 pack for 12 yrs. Also uses heroin occasionally. His temp is 38.8, PR=96, RR=2, BP=11/7. On auscultation had vesicular broth sounds, but he is wasted and lethargic with multiple track arms on both his arms, can't cooperate for neuro exam. Labs show leucocytes 3*19, Hct. 34%, platelets 354*19 and ESR 27mm/h. his CD4 is 84*19. CT scan show two contrast enhanced ring lesion with uneven edge, wats the appropriate next step?
   • First-Line / Correct Key: Amphotericin b and flucytosine
   • Clinical Rationale: Management of Common Opportunistic Infections Among Adults and Adolescents; HIV Guideline - pg. 82
Two leading diagnoses associated with mass effect in developed countries are Toxoplasma encephalitis
and primary central system lymphoma. In the developing world, tuberculomas are a leading diagnostic
consideration
TE lesions are generally multiple an

2. 22yrs man with general body swelling esp. in eyes and lower limb and a BP=15/96 + foamy urine. What's the most appropriate set of investigation in management of this patient>
   • First-Line / Correct Key: Serum albumin, total cholesterol and urine myoglobin
   • Clinical Rationale: Nephrotic Syndrome (Ns); Pediatric STG - pg. 175
It is a renal disorder characterized by urinary protein loss leading to generalized body swelling.
Diagnostic Criteria
* Generalized body swelling worse in the morning.
* Dip stick urine protein ≥3+ or 24 hours urinary protein >4mg/m2/h or a protein-to-creatinine
ratio greater than 2. (more than 2 mg

3. 4 yrs. man at emd with hx of acute vomiting blood preceded by passing black stool for a day. Has hx of working in rice farm, no other family member with similar hx. On exam he is diaphoretic, splenomegaly and melena. His bp at 9/5 PR=122bpm t=37.1 and rr=18 breath/min what would an MO do?
   • First-Line / Correct Key: Insert two 14G cannula, IV fluids, order whole blood, NGT for draining + pantoprazole
   • Clinical Rationale: Gastrointestinal (GI) Bleeding; National STG - pg.192
Bleeding Esophageal Varices National STG - pg. 21
Intraluminal blood loss anywhere from the oropharynx to the anus. Classification: upper = above the
ligament of Treitz; lower = below the ligament of Treitz.  "Severe" GIB: defined as having associated shock,
orthostatic hypotension, fall in hema

4. an 83 yrs. Male admitted with 3wks. Hx of cough, fever and now DIB. Has used azithromycin, amoxiclav and ceftriaxone, you repeat hx no night sweats, tb contact or smoking. On exam has unilateral right basal crackles. His spO2 is 89% at room air with 38C temp. what test will be most useful to confirm the dx?
   • First-Line / Correct Key: Sputum microscopy
   • Clinical Rationale: COVID-19; National STG - pg.13
Fever, Dry Cough and Tiredness + Less common symptoms: Headache, Sore throat, Loss of taste or
smell,Chills, Runny nose, Headache, Chest pain , Muscle aches, Diarrhea,, Conjunctivitis, Skin rash , or
Discoloration of fingers or toes. Serious symptoms- Severe Acute Respiratory Infection (SARI): * Difficulty
breathing o

5. 48yrs obese woman presented with increase tiredness over the past month, blurry vision and increase urinary frequency, she had sleeplessness before the hospital visit due to thirsty. Fasting blood glucose is 15mmol/L. after baseline investigations what's the best choice of treatment?
   • First-Line / Correct Key: Glibenclamide
   • Clinical Rationale: Diabetes Mellitus; National STG - pg.397
WHO diagnostic Criteria 26
* Fasting glucose level ≥ 7. mmol/L (126 mg/dL)
* Plasma glucose≥ 11.1 mmol/L (2 mg/dL) two
hours after 75 g oral glucose load in glucose
tolerance test
* Symptoms of hypogycaemia + casual plasma
glucose ≥11.1 mmol/L (2 mg/dL)
* Glycatedhemoglobin (HbA1c) ≥ 6.5%
Treatment with oral

6. 6 yrs. lady is brought with progressive DIB for 1-month a/w productive cough of foul smelling sputum with blood in it. Its exaggerated by lying on the left side. 2 years ago, she was diagnosed with PTB and treated successful for 6 months. She also has DM2 on metformin and Glibenclamide, on exam spO2 is 89 on room air, BP=11/7, PR=8 she has grade 3 finger clubbing and transmitted sounds on left inframammary region. What the dx?
   • First-Line / Correct Key: bronchiectasis
   • Clinical Rationale: Bronchiectasis; National STG - pg.175
Bronchiectasis is a progressive respiratory disease characterized by permanent dilatation of the bronchi
and associated with a clinical syndrome of cough, sputum production and recurrent respiratory infections.
Induction  of  bronchiectasis  requires  two  factors:  An  infectious  insult  +  Impaired  drainage

7. 45 yrs. female admitted due to yellowish discoloration of eyes and fever. MRDT was +ve microscopy revealed falciparum 12/2 wbc which is most correct antimalaria treatment
   • First-Line / Correct Key: Artesunate inj.
   • Clinical Rationale: Management of Severe Malaria; Malaria Guideline - pg.36
Supportive  investigations  for  suspected  severe
malaria ill patients. Laboratory diagnosis of malaria
can be complemented with laboratory tests such as:
* Blood  glucose  estimation  in  patients  with
altered consciousness
* Haematocrit and/or hemoglobin estimation
* Lumbar puncture (LP) t

8. 13yrs boy present with typical CVA. On CT an infract at MCA other than CNS which system exam is likely to aid dx of underlying condition
   • First-Line / Correct Key: CVS ?
   • Clinical Rationale: Two  broad  categories  of  stroke,  hemorrhage  and  ischemia;  three  main  subtypes  of  brain  ischemia,
Thrombosis, Emboli's, + Systemic hypoperfusion.
Thrombotic strokes
can be divided into either large or small vessel disease. These two subtypes of thrombosis are worth
distinguishing since the causes, outcomes, and treatments are different.

9. 34yrs female with gastric ca who is on chemo presents with fever and neutropenia wat is the appropriate investigation for neutropenic fevers
   • First-Line / Correct Key: Blood culture
   • Clinical Rationale: Febrile Neutropenia; National STG - pg.535
Fever occurs frequently in patients with chemotherapy-induced neutropenia. Factors that contribute to
the pathogenesis of neutropenic fever include the direct effects of chemotherapy on mucosal barriers and
immune  deficits  related  to  the  underlying  malignancy  or  other  immunosuppressive  conditions

10. 3yrs present to you EMD having been diagnosed with DM and started on Glibenclamide 5mg elsewhere She has been on treatment for over a year but has never really controlled her blood glucose level. She reports her fasting blood glucose to range, 1 - 12 mmol/L and postprandial blood glucose between 14- 18 mmol/L since diagnosis. You do all her baseline and find a slightly elevated Creatinine level al 128umol/L, HbA1c at 8% but the rest of the test are normal. Which or the following is most appropriate step to lake?
   • First-Line / Correct Key: Refer her, immediately lo the diabetic clinic for urgent evaluation of her kidney function
   • Clinical Rationale: Diabetes Mellitus; National STG - pg.397
Review the blood glucose at follow-up  clinic and adjust medicines as needed until blood glucose is
controlled.
* If lifestyle measures on their own failure achieve
blood glucose control or blood glucose levels are
persistently high (fasting >11 mmol/l or random
>15  mmol/l)  initiate: metformin  (PO)  5mg
1

11. All of the following are non-pharmacological measure in the treatment of hypertension. except
   • First-Line / Correct Key: Moderate dietary sodium restriction
   • Clinical Rationale: Hypertension; National STG - pg.447
Hypertension is elevation of Blood Pressure SBP ≥ 14 mmHg and DBP ≥9 mmHg measured at least three
separate occasions. Hypertension is a major independent risk factor for the development of CAD, stroke,
and renal failure.
Smoking No exposure to tobacco in any form.
Diet Reduce dietary sodium intake no more
than 1m

12. 65yrs man from on a visit to children has been DM and HTN for 1yrs now complains of fever for 3 days. Gradual worsening DIB and LL swelling. Urine output is normal as well as intake though the appetite has reduced remarkably and loss of sense of smell. What the initial investigation the dx?
   • First-Line / Correct Key: Bacterial pneumonia
   • Clinical Rationale: COVID-19; National STG - pg.13
(COVID-19) disease, caused by SARS-CoV-2, Current evidence suggests that spreads through contaminated
objects or surfaces), or close contact with infected people via mouth and nose secretions
* Suspect  case:  A  patient  with  acute  respiratory  illness  (fever  and  at  least  one  sign/symptom  of
respiratory dise

Peer Review Assessment Rubric & Sign-Off

Rate each clinical dimension on a 1 (Unacceptable) to 5 (Exemplary) academic scale

1. Clinical Accuracy

Correct medical facts, physiological mechanisms, and clinical judgment.

2. Guideline Alignment

Adheres to contemporary clinical guidelines (WHO, AHA, ESC, NICE).

3. Tanzania STG Compliance

Considers Tanzanian MoH Standard Treatment Guidelines & NEMLIT.

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STG Clinical Brain Guideline Parameters

Peer Review Assessment Rubric & Sign-Off

Sudden Cardiac Arrest in Ward 4

ACLS Immediate Initial Action:

Defibrillation Decision:

Next Priority Action:

Patient Resuscitated!

Arrest Protocol Timed Out

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