Case-based MCQ

⏳ Case-based MCQ | #Case_361 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 72-year-old woman has been on routine dialysis sessions for the past 6 months due to end-stage renal disease. At the beginning of each session, she is found to have a high blood pressure (BP). During the session the BP normalizes, but goes up again after the session.

⏳ Case-based MCQ | #Case_360 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C This patient has the classic presentation of a third cranial nerve palsy. The third cranial nerve supplies the levator muscles of the eyelid and four extraoccular muscles: (1) the medial rectus (eye adduction), (2) superior rectus (eye elevation), (3) inferior rectus (eye depression), (4) and inferior oblique (eye elevation). Additionally, the third cranial nerve constricts the pupil through its parasympathetic fibers that supply the smooth muscles of the ciliary body and the sphincter of the iris. The third nerve begins as a nucleus in the midbrain that consists of several subnuclei innervating the individual extraoccular muscles, the eyelids, and the pupils. The etiology of the third cranial nerve palsy is vast and includes conditions such as: • Ischemia (e.g. diabetes and midbrain infarcts) • Compressive effects of aneurysms such as those of the posterior communicating artery, internal carotid artery and basilar artery. • Trauma • Infections • Infiltrative diseases (e.g. neoplasms) • Demyelination • Space occupying tumors • Meningitis • Herniation • Inflammatory diseases Of the given options, only a posterior communicating aneurysm can cause a third nerve palsy that involves the pupilary reflex. Compression of the third nerve by an enlarging intracranial aneurysm is the most dreaded etiology. The most common site of an aneurysm causing a third nerve palsy is the posterior communicating artery. In the setting of an acute third nerve palsy, the aneurysm is believed to be progressively and acutely enlarging and is at imminent risk of rupture with catastrophic outcomes. ⚠ (Option A) Midbrain infarcts can cause third cranial nerve palsy. However, since the etiology is ischemic (such as in diabetes) the pupillary light reflex is expected to be unaffected most of the time. Furthermore, with a midbrain infarct, an isolated third nerve palsy as the sole presenting symptom is very unlikely and other signs and symptoms related to a midbrain infarct are expected. ⚠ (Option B) Right 6th nerve palsy presents with horizontal binocular diplopia upon looking laterally to the affected side. Furthermore, lesions of the sixth cranial nerve do not cause ptosis. ⚠ (Option D) The fourth cranial nerve palsy presents with binocular vertical diplopia. Ptosis is not a feature. ⚠ (Option E) Lesions of occipital cortex are associated with impaired vision and visual fields deficits, none of which are present here. Furthermore, ptosis is not a feature

⏳ Case-based MCQ | #Case_360 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 56-year-old man presents to the emergency department with complaint of diplopia. On examination, he has right-sided ptosis. His visual acuity and visual fields are unaffected. His right eye is depressed inferiorly and laterally and he is not able to look at to the left side. The pupillary light reflex of the right eye is sluggish. The neurological examination is otherwise unremarkable.

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⏳ Case-based MCQ | #Case_359 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C About 10% of women on combined HRT will have extremely dense breasts; nonetheless, presently, there is not enough evidence to recommend that patients on combined hormone replacement therapy should stop HRT for any length of time before their mammography in an attempt to reduce breast density. Therefore, this patient should continue HRT and have mammography based on current recommendations for other women. Women making decisions as to whether to commence combined HRT should be aware of the fact that HRT may lead to inaccurate mammography results. Furthermore, they should be informed about the increased risk of breast cancer if HRT extends beyond the recommended period (3 to 5 years).

⏳ Case-based MCQ | #Case_359 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 52-year-old lady presents to your GP clinic for breast cancer screening. She has been on combined hormone replacement therapy (HRT) for the past year. Mammogram is the only available method of screening for breast cancer and because of HRT she is expected to have dense breast tissue.

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⏳ Case-based MCQ | #Case_358 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Systemic sclerosis (SS) is a chronic systemic disorder of unknown cause. It is characterized by the thickening of the skin and the involvement of multiple internal organs. Thickening of skin distinguishes this disease from other connective tissue diseases. The disease has two distinct phases: an inflammatory and fibrotic phase. Patients with disease can be classified into two major subsets according to the degree of clinically involved skin. Diffuse cutaneous systemic sclerosis is more severe with prominent internal organ involvement, while in the limited form, it is less severe but is more likely to be associated with pulmonary arterial hypertension. Systemic sclerosis affects 9-19 per 100,000 and is more common in women. African Americans are more susceptible to disease. The age of onset is between 30 and 50 years. Development of sclerodermal renal crisis has been associated with glucocorticoid use, and indeed, the use of these drugs should be avoided in scleroderma. They can, however, be used in small doses to control the early skin symptoms, for myositis associated with scleroderma and for cardiac involvement. Thus, in this patient, prednisolone should be stopped completely (choice E) because it is used for non-life-threatening skin lesions. Other glucocorticoids, including dexamethasone, should be avoided in this patient. 🔖 Key point: Development of sclerodermal renal crisis has been associated with glucocorticoid use, which is managed by glucocorticoid discontinuation.

⏳ Case-based MCQ | #Case_358 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 37-year-old African American woman was diagnosed with diffuse type of scleroderma and was prescribed an antihistamine and prednisolone 5 mg/day to control the pruritus. Two months later, the patient came to you with severe headache, chest pain, and blurred vision. Her BP is 210/118 mmHg. Urinalysis showed proteinuria and microscopic hematuria. Blood urea nitrogen was 11 mmol/L (N 2.9-7.1 mmol/L), and serum creatinine was 124 pmol/L (N 50-90 pmol/L). Your patient was still taking prednisolone 5 mg/day prescribed earlier. You diagnosed your patient with sclerodermal renal crisis and decided to put her on an ACE inhibitor.

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⏳ Case-based MCQ | #Case_357 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E The presentation is classic for choanal atresia. Choanal atresia is a congenital abnormality in which there is failure of canalization of the bucconasal membrane. This can be either unilateral or bilateral and is usually due to a combination of bone and soft tissue anomalies. It occurs in 1:5000 to 1:8000 births. Unilateral atresia is more common, with a predilection for females. 🔆 CHARGE Syndrome (coloboma, heart defect, atresia choanae, retarded growth and development, genital abnormality and ear abnormality) or other congenital abnormalities are present in 50% of patients with bilateral choanal atresia. Bilateral choanal atresia is a relatively rare anomaly of the upper airway. As neonates are obligatory nasal breathers, presentation may be with life-threatening respiratory distress, retractions and paradoxical cyanotic episodes which are relieved by crying as the infant begins to breathe via the mouth. Unilateral choanal atresia does not usually produce severe symptoms. When choanal atresia is suspected the diagnosis can be confirmed with trying to pass a nasogastric tube. It is not possible to pass a nasogastric tube through the nares and choanae if there is choanal atresia. ⚠ In the presence of bilateral choanal atresia, as the history and physical suggest, oxygen through nasal cannula will be of no benefit. ➕ Other measures to consider as parts of management plan include: • Oxygen • Oropharyngeal airway • Intubation and ventilation if there is life-threatening hypoxemia • CT scan • ENT consultation and referral for surgical treatment Since the manifestation is typical of choanal atresia, chest X-ray is not indicated now, but it may be obtained to exclude other possible associated respiratory conditions or anomalies