1.  A 30 year old patient is having high grade fever with altered sensorium.

           On third day the patient develops seizures and has Nuchal rigidity. The CSF

           examination of the patient shows presence of 300 cells/cu.mm, protein

           70mg%, glucose 50mg% (BLOOD GLUCOSE= 95mg%) with polymorph 65%

           and the rest being lymphocytes. The most probable diagnosis of the patient is:

                  a. Herpetic encephalitis

                  b. Tubercular meningitis

                  c. Pyogenic meningitis

                  d. Cerebral malaria.

Answer is C: pyogenic meningitis

Reference: chapter 381 harrison 18 th edition

• Harrison states for viral encephalitis that “CSF examination should

be performed in all patients with suspected viral encephalitis unless

contraindicated by the presence of severely increased ICP. The

characteristic CSF profile is indistinguishable from that of viral

meningitis and typically consists of a lymphocytic pleocytosis, a

mildly elevated protein concentration, and a normal glucose

concentration.

• Polymorphonuclear pleocytosis occurs in 45% of patients with WNV

encephalitis and is also a common feature in CMV myeloradiculitis

in immunocompromised patients. Large numbers of CSF PMNs

may be present in patients with encephalitis due to EEE virus,

echovirus 9, and, more rarely, other enteroviruses. However,

persisting CSF neutrophilia should prompt consideration of

bacterial infection, leptospirosis, amebic infection, and

noninfectious processes such as acute hemorrhagic

leukoencephalitis.

   2.   A middle aged hypertensive male develops sudden onset unconsciousness,

         with nuchal rigidity. Rest of the neurological examination is within normal

         limits.

                  a. SAH

                  b. Intra-parenchymal bleed

                  c. Extra-dural hemorrhage

                 d. Sub dural haemorrhage.

Answer is A: SAH

Reference: Harrison 18 th edition chapter 275

• At the moment of aneurysmal rupture with major SAH, the ICP

suddenly rises. This may account for the sudden transient loss of

consciousness that occurs in nearly half of patients. Sudden loss of

consciousness may be preceded by a brief moment of excruciating

headache, but most patients first complain of headache upon regaining

consciousness. In 10% of cases, aneurysmal bleeding is severe enough

to cause loss of consciousness for several days. In 45% of cases, severe

headache associated with exertion is the presenting complaint. The

patient often calls the headache "the worst headache of my life";

however, the most important characteristic is sudden onset.Occasionally, these ruptures may present as headache of only moderate

intensity or as a change in the patient's usual headache pattern. The

headache is usually generalized, often with neck stiffness, and

vomiting is common.

• Although sudden headache in the absence of focal neurologic

symptoms is the hallmark of aneurysmal rupture, focal neurologic

deficits may occur. Anterior communicating artery or MCA bifurcation

aneurysms may rupture into the adjacent brain or subdural space and

form a hematoma large enough to produce mass effect. The deficits that

result can include hemiparesis, aphasia, and abulia.

• Occasionally, prodromal symptoms suggest the location of a

progressively enlarging unruptured aneurysm. A third cranial nerve

palsy, particularly when associated with pupillary dilation, loss of

ipsilateral (but retained contralateral) light reflex, and focal pain above

or behind the eye, may occur with an expanding aneurysm at the

junction of the posterior communicating artery and the internal carotid

artery. A sixth nerve palsy may indicate an aneurysm in the cavernous

sinus, and visual field defects can occur with an expanding supraclinoid

carotid or anterior cerebral artery aneurysm. Occipital and posterior

cervical pain may signal a posterior inferior cerebellar artery or

anterior inferior cerebellar artery aneurysm.

• Pain in or behind the eye and in the low temple can occur with an

expanding MCA aneurysm. Thunderclap headache if written in

question again favours diagnosis of SAH.

   3.   Pleural tap pierces all except :

                  a. skin

                  b. intercostal muscle

                  c. Endo-thoracic fascia

                 d. pulmonary pleura

Answer is D: Pulmonary pleura

Reference:

This question is probably testing English of doctors. Well we have common sense and

hence can solve this one. Each lung is invested by an exceedingly delicate serous

membrane, the pleura,which is arranged in the form of a closed invaginated sac. A

portion of the serous membrane covers the surface of the lung and dips into the

fissures between its lobes; it is called the pulmonary pleura (or visceral

pleura).Endothoracic fascia is layer of loose connective tissue that separates the ribs

and muscles from the underlying pleural.

The following layers are pierced during thoracocenteis/pleural tapping:

1. skin- superficial fascia

2. Serratus anterior

3. external intercostal

4. internal intercostal

5. innermost intercoastal

6. parietal pleura

7. pleural cavity is reached and fluid is accessed