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Virtual patient example An intracranial mass lesion

Virtual patient example An intracranial mass lesion. www.ebrainJNC.com. Instructions. Slides must all have a title, content and branches. Title Should be brief and unique within this presentation Content Can include text, images, audio, video etc.

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Virtual patient example An intracranial mass lesion

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  1. Virtual patient exampleAn intracranial mass lesion www.ebrainJNC.com

  2. Instructions Slides must all have a title, content and branches. Title Should be brief and unique within this presentation Content Can include text, images, audio, video etc. Try to keep it to one slide and avoid overcrowding – if essential a second slide can be used. Please use red text to give instructions to editors Branches The branch options should be a question followed by a number of answers For each answer give the title of the destination slide to link to Maximum of four answers, minimum of two Alternatively just put “next” and give destination if there is only one route from that slide

  3. Presentation Please insert suitable stock image – male patient with a cough perhaps A 55 year old male patient presents to you in outpatients with a 3 week history of progressive right sided hemiparesis. They were previously fit and well. They have smoked for 20 years. There is a cough that has been a bit worse over the last few months. There is 2 stone of weight loss. Question text: What investigations would you arrange? Answer 1: Chest x-ray Link to page: Chest x-ray Answer 2: CT scan brain Link to page: CT Brain Answer 3: Blood tests Link to page: Bloods Answer 4: No more of these tests - move on Link to page: second line tests

  4. Chest x-ray Here is the chest x-ray. Question text: What does the x-ray show? Answer 1: Lung mass Link to page: CXR answer Answer 2: Normal Link to page: CXR answer Answer 3: Return to previous slide Link to page: Presentation Answer 4: Link to page

  5. CXR answer The chest x-ray is normal Question text: Answer 1: Next Link to page: Presentation Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page

  6. CT Brain This is the contrast enhanced CT scan of the brain. What is the most likely diagnosis? Question text: what does the scan show? Answer 1: An Abscess Link to page: CT brain answer Answer 2: A primary brain tumour Link to page: CT brain answer Answer 3: A secondary brain tumour Link to page: CT brain answer Answer 4: Link to page

  7. CT brain answer The scan shows a left sided 2.5cm lesion. Note 1. The dark core - this is either cystic fluid or necrosis. 2. The bright rim - this is the active tumour or infection. When compared to the precontrast scan there was a brighter appearance - this is called “ring enhancement”. 3. The peritumoural odoema - here it is not severe. Peritumoural odoema is more marked in metastases than primary tumours. Whilst this could be a primary tumour, metastatic tumour or abscess, with these appearances it is probably most likely to be a primary tumour Question text: Answer 1: Next Link to page: Presentation Answer 2: Link to page Answer 3: Link to page Answer 4: Link to page

  8. Bloods Please insert suitable stock image – blood tubes, blood test image or the like Which of the following blood tests would you organise and why? Full blood count U&E CRP / ESR Blood cultures Blood gases PSA / CEA or other tumour markers Question text: Answer 1: Next Link to page: Bloods answers Answer 2: Link to page Answer 3: Link to page Answer 4: Link to page

  9. Bloods answers Here are the blood results Hb 12.6 WCC 9.2 Plts 198 Na+ 139 K+ 4.2 Urea 4.0 CRP 4 The blood results are shown opposite. Full blood count - certainly relevant but note that the white cell count is frequently normal even in patients with a cerebral abscess. Remember dexamethasone pushes up the white cell count. U&E - certainly relevant CRP / ESR - these are sometimes useful to monitor change especially in abscesses but a one off measurement is difficult to interpret. Blood cultures - perhaps if you think this is an abscess Blood gases - surely not PSA / CEA or other tumour markers - advocated by some but prostate very rarely metastasises to the brain and tumour markers are rarely helpful. Question text: Answer 1: Return to presentation Link to page: Presentation Answer 2: Link to page Answer 3: Link to page Answer 4: Link to page

  10. Second line tests So we now know that we have a man with a cerebral lesion, probably a primary but could also be a metastasis or an abscess. What other tests might be relevant? Question text: Answer 1: CT chest abdo pelvis Link to page: CT Chest abdo pelvis Answer 2: MRI brain Link to page: MRI brain Answer 3: Echo Link to page: Echo wait Answer 4: Move on to management Link to page: Management

  11. CT Chest abdo pelvis A representative slice from the CT of the chest abdomen and pelvis is shown opposite - the scan was normal. This investigation is essential if (as here) there is a possibility that this is a metastasis. However in patients with an obvious primary brain tumour on brain imaging a normal chest x-ray is probably adequate. Question text: Answer 1: Next Link to page: Second line tests Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page:

  12. MRI brain A representative slice of the MR is shown opposite - this is a T1, gadolinium enhanced sequence - it shows the single lesion, demonstrates that it is premotor (frontal) and whilst not shown on this slice also showed that the core is cystic. An MRI of the brain is essential in metastatic disease - 50% of patients with a single metastasis on CT will be shown to have multiple metastases on MRI. An MRI of the brain has also become a standard investigation for most patients with primary brain tumours as well. Question text: Answer 1: Next Link to page: Next Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page:

  13. Echo wait The echo will take a week - do you want to wait? Question text: Answer 1: wait Link to page: dead Answer 2: don’t wait Link to page: echo answer Answer 3: Link to page: Answer 4: Link to page:

  14. Echo still wait Two days later the patient’s hemiplegia is a bit worse - they seem a bit more confused. You give them some dexamethasone. Are you still going to wait for the Echo? Question text: Answer 1: wait Link to page: dead Answer 2: don’t wait Link to page: echo answer Answer 3: Link to page: Answer 4: Link to page:

  15. Dead Please insert suitable stock image – coffin perhaps? 4 days later the patient has a seizure, fails to regain consciousness and is ventilated. A repeat CT scan shows extensive enlargement of the mass lesion and severe cerebral odoema. The patient dies At post mortem the lesion is found to be a cerebral abscess, it has enlarged, burst into the ventricle and the patient has died from ventriculitis. There was no endocarditis - there was a tooth abscess. Question text: Answer 1: Restart Link to page: presentation Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page:

  16. Echo answer An Echo to rule out bacterial endocarditis is relevant if this is a cerebral abscess but don’t let it delay treatment. It would therefore be quite uncommon to organise this at this stage. Question text: Answer 1: Next Link to page: second line tests Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page:

  17. Management So we now know that we have a man with a cerebral lesion, probably a primary but could also be a metastasis or an abscess. This is an isolated lesion - there is no disease on the CT of the chest abdomen and pelvis or elsewhere in the brain on MR. How do you want to manage this patient? Question text: Answer 1: Dexamethasone Link to page: Dexamethasone Answer 2: Biopsy Link to page: Biopsy Answer 3: Whole brain radiotherapy Link to page: Whole brain radiotherapy Answer 4: Watch and wait Link to page: dead

  18. Dexamethasone Do we have a picture of dexamethasone tablets or the bottle What dose of dexamethasone would you use? What other drugs should be prescribed at the same time? The 1/2 life of dexamethasone is 48 hours - what are the implications of this? Question text: Answer 1: 4mgs qds Link to page: Dexamethasone answer Answer 2: 16mgs od Link to page: Dexamethasone answer Answer 3: 2 mgs qds Link to page: Dexamethasone answer Answer 4: Link to page:

  19. Dexamethasone answer Do we have a picture of dexamethasone tablets or the bottle The traditional dexamethasone dose of 4mgs qds is now outdated. It should be given once a day in the morning. This way the insomnia can be minimised. It should always be prescribed with a proton pump inhibitor or other medication to protect the gastric mucosa. Nystatin lozenges can also be considered as oral thrush is common. The long half life means that the drug accumulates and does not reach steady state until about 5 days after a change of dose. Question text: Answer 1: Next Link to page: Management Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page:

  20. Biopsy The patient has an image guided biopsy. Pus is found and microbiology confirms that this is a staph aureus abscess. The patient is treated with antibiotics for six weeks. Subsequently a tooth abscess is found. The patient makes a full recovery. Well done! Question text: Answer 1: Summary slide Link to page: summary slide Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page:

  21. Radiotherapy Suitable stock radiotherapy image perhaps Radiotherapy options here would include stereotactic radiosurgery, fractionated radiotherapy (whole brain or focused on mass). The oncology team rather reluctantly agree to proceed with radiotherapy after an MDT confirms that this is thought to be a cerebral primary brain tumour. Question text: Answer 1: Next Link to page: Dead Answer 2: Link to page: Answer 3: Link to page: Answer 4: Link to page:

  22. Summary slide These are the main learning points: 1. It is not possible to distinguish reliably between primary tumours, secondary tumours and abscesses on scans. 2. A CT of chest abdomen and pelvis and an MRI scan of the brain are essential if there is a suspicion of metastatic disease. 3. Don’t delay management of these patients - fast treatment has been shown to improve outcomes in tumours and can be life saving in abscesses. 4. Dexamethasone has a long half life - it can be given once a day and takes a long time to reach a steady state. A proton pump inhibitor should be prescribed concurrently. 5. Don’t give radiotherapy without a histological diagnosis

  23. CXR answer Chest x-ray Start CT Brain CT brain answer Bloods Bloods answer Presentation CT Chest abdo pelvis Echo answer MRI brain 2nd line tests Dead Echo wait Echo still wait Watch and wait Management Radiotherapy Dexamethasone Biopsy Dexamethasone answer Summary slide

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