1. Patient # 3 = Lab Results Your Results: Head CT: Normal LP:
MSU EM Residency, Lansing MI
Patient # 3 = Lab Results
Your Results:
CBC: WNL BMP: WNL
Sed: WNL Urine Preg: neg
Head CT: Normal
LP:
Yellow fluid
Opening pressure: 18cm (normal >15 to 25cm)
WBC: 2 (normal <5 per mm3 )
Tube 1 RBC: 38 (normal <5 per mm3)
% PMNs 5% (normal 0-15%)
% Lymph 55% (normal >50%)
Glucose 50 (normal >40 mg per dL)
Protein 95 (normal <50 mg per dL)
Gram stain negative
What is your diagnosis?
What is your disposition plan?
Explain why CT head is normal with abnormal labs?
Any additional tests you would order on the CSF analysis?

2. Diagnosis & Plan What is your diagnosis?
Subarachnoid hemorrhage
What is your disposition plan?
Admit
Why was the CT normal?
Bleed occurred 3 days ago, decrease sensitivity in identification on non contrast CT
Additional lab - Add Cell count to Tube 4
Can tell bloody tap from a SAH by comparing RBC tube 1 to tube 4.

3. Xanthochromia – Pt has a SAH
Subarachnoid bleed.
Xanthochromia is present in more than 90% of patients within 12 hours of subarachnoid hemorrhage onset
Xanthochromia can persist up to several weeks following a SAH
Greater diagnostic sensitivity than a CT scan of the head without contrast, especially if the SAH occurred > 3-4 days prior to presentation.
Patients with aneurysmal leaks (i.e., sentinel hemorrhages) may present days after headache onset, increasing the likelihood of a false-negative head CT scan.
Viral Meningitis
The symptoms are the same as bacterial meningitis.. The usual etiologic agent are enteroviruses, this is the same family of viruses responsible for the common cold. This is common in the summer and fall months. Incubation is 3 to 7 days. The disease generally lasts 7 to 10 days and complete recovery is expected. The diagnosis is dependent on cerebrospinal fluid analysis and negative bacterial cultures. Treatment is symptomatic. It includes fluids, fever control, rest, pain control, and sometime antiviral medications when a herpes virus is suspected. Transmission is through direct control. A person with a cold may sneeze into his hand and then touch a door handle. Then an unsuspecting individual touches that same door handle and rubs his eyes. This can be prevented by good hand washing and careful attention not to touch mucous membranes.

4. Xanthochromia – Continued
Other causes of Xanthochromia = High Bilirubin
spillover from a very high serum bilirubin level (i.e., >15 mg/dL), however will see patient has jaundice / liver disease
Yellow arrow points to a ruptured giant brain aneurysm with some clot (thrombus) within the main aneurysmal sac.
Green arrow heads point to blood in the subarachnoid space. This image therefore shows aneurysmal subarachnoid hemorrhage (SAH).
Viral Meningitis
The symptoms are the same as bacterial meningitis.. The usual etiologic agent are enteroviruses, this is the same family of viruses responsible for the common cold. This is common in the summer and fall months. Incubation is 3 to 7 days. The disease generally lasts 7 to 10 days and complete recovery is expected. The diagnosis is dependent on cerebrospinal fluid analysis and negative bacterial cultures. Treatment is symptomatic. It includes fluids, fever control, rest, pain control, and sometime antiviral medications when a herpes virus is suspected. Transmission is through direct control. A person with a cold may sneeze into his hand and then touch a door handle. Then an unsuspecting individual touches that same door handle and rubs his eyes. This can be prevented by good hand washing and careful attention not to touch mucous membranes.