Case-based MCQ

Correct Answer Is A Chest X-ray shows loss of right heart border silhouette due to partial atelectasis of right middle lobe. Atelectasis is collapse or incomplete expansion of the lung or a part of the lung. Postoperative atelectasis generally occurs within 48 hours. It is an extremely common post-operative complication with some degree of pulmonary collapse occurring after almost every abdominal or trans-thoracic procedure. Postoperative atelactasis can be managed as follows: 1-Removal of impacted secretions by coughing, managed by physiotherapists, and involves active chest percussion and breathing exercises. 2-Passive postural drainage. All other options are incorrect

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A young woman underwent a non-complicated cholecystectomy for painful gallstones.After 24 hours of surgery, she developed a cough and fever.Chest X-ray is done as shown below. How would you manage? A. Chest physiotherapy B. Give morphine C. Give antibiotics D. Give steroids E. Paracetamol as required

Correct Answer Is A This patient’s clinical features are worrisome for iatrogenic septic bursitis, presenting with acute pain following an initial positive response to corticosteroid injection.  Subacromial injections are used to treat subacromial bursitis, rotator cuff tendinopathy, and adhesive capsulitis.  During the procedure, the needle penetrates the subacromial bursa, depositing corticosteroids into the bursa and near the supraspinatus tendon.  However, injection can introduce skin flora (eg, Staphylococcus aureus, Streptococcus pyogenes) into the deep structures. Infection typically manifests as worsening pain, redness, swelling, and systemic symptoms (eg, fever, myalgias) several days after the procedure.  In contrast, postcorticosteroid injection flare (ie, steroid-induced chemical synovitis) typically occurs rapidly and resolves within 48 hours.  In some cases, the bursa communicates with the glenohumeral joint capsule, and septic bursitis may progress to septic arthritis.  When infection is suspected, an image-guided (eg, ultrasound) aspiration of the bursa and/or joint is necessary to assess for infection. Range-of-motion exercises and analgesics are appropriate for adhesive capsulitis, which presents with pain and reduced shoulder motion in multiple axes.  However, adhesive capsulitis is a chronic condition that presents insidiously; this patient’s acute pain, swelling, and myalgias are more consistent with septic bursitis. Intraarticular and soft tissue corticosteroid injections are contraindicated when infection is suspected because they can worsen the infection.  In the absence of infection, repeat injections are typically separated by at least several months to reduce the risk of tendon rupture and cartilage damage. Gout can cause acute inflammatory bursitis resembling septic bursitis but likely would have responded completely to the initial corticosteroid injection.  Furthermore, the serum uric acid level, even when elevated, does not rule out infection and cannot replace a diagnostic aspiration. Shoulder x-ray is useful to assess for fracture (which is unlikely in the absence of trauma) but is not sufficient to rule out infection. During a joint or bursal aspiration or injection, introduction of skin flora may result in septic bursitis or septic arthritis, presenting as worsening pain several days following the procedure.  Diagnostic aspiration of the joint or bursa is necessary to assess for infection.

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A 65-year-old man returns to the office for follow-up 10 days after receiving a subacromial corticosteroid injection for right-sided rotator cuff tendinopathy.  The tendinopathy was confirmed on musculoskeletal ultrasound of the shoulder prior to the injection.  The patient initially experienced mild improvement of the shoulder pain, but starting 2 days ago, the pain significantly worsened and is now accompanied by generalized body ache and fatigue.  He does not report trauma or excessive shoulder use since the injection.  Medical history includes type 2 diabetes mellitus and gout.  Temperature is 37.9 C, blood pressure is 130/85 mm Hg, and pulse is 109/min.  On examination, there is mild swelling in the lateral right shoulder.  Range of motion is limited in multiple axes due to significant pain, which is worse compared to examination prior to the injection.  Which of the following is the most appropriate next step in management of this patient? A. Image-guided aspiration B. Range-of-motion exercises and analgesic therapy C. Repeat corticosteroid injection D. Serum uric acid level E. X-ray of the shoulder

Explanation: Correct Answer Is E This patient has foot and ankle deformities and x-ray findings that indicate neuropathic (Charcot) arthropathy, which occurs most commonly in patients with diabetes mellitus (particularly those with peripheral neuropathy).  Neuropathic arthropathy involves repetitive bone and tissue trauma caused by impaired sensation and joint proprioception that prevent the patient from adjusting weight bearing to avoid mechanically induced wear and tear. Neuropathic arthropathy can present in either of 2 stages: Acute:  Characterized by inflammatory erythema, warmth, and edema of the foot 1-2 days after minor trauma.  X-rays at this stage usually show only soft tissue swelling without bone involvement. Chronic:  Characterized by bone deformities noted on x-ray that typically include osseous fragmentation, new bone formation, and subluxation/dislocation predominantly in the mid and hind foot.  Other common signs are loss of the metatarsal heads (pencil pointing) with osteopenia and phalangeal osteolysis.  These changes often lead to neuropathic ulcers, arch collapse (rocker bottom feet), and callus formation. Osteoarthritis of the foot typically affects the first metatarsophalangeal joint with subchondral sclerosis and osteophyte formation rather than diffuse bone destruction as found in neuropathic arthropathy. Decreased perfusion of the extremities due to atherosclerosis of the tibial arteries (ie, peripheral artery disease) can cause pain (ie, claudication) but would not cause significant bone deformities.  This patient’s peripheral pulses are full and symmetric. Isolated foot involvement due to autoimmune inflammatory arthritis is uncommon but may occur in patients with rheumatoid arthritis.  When it does, it typically presents with bilateral involvement rather than unilateral as in this patient.  However, x-ray findings in advanced rheumatoid arthritis commonly include periarticular osteoporosis, joint erosion, and joint space narrowing rather than grossly destructive changes. Bony destruction from bacterial infection (ie, osteomyelitis) can manifest as periosteal thickening on x-ray, but infection would be unlikely to cause the significant bone deformities seen in this patient.  Osteomyelitis typically occurs in association with a neuropathic ulcer with sinus tracts or exposure of the underlying bone. Chronic neuropathic (Charcot) arthropathy is characterized by bone deformities resulting from repetitive trauma to the foot and ankle.  It develops in patients who have impaired sensation and joint proprioception (eg, diabetic peripheral neuropathy) that prevent the patient from adjusting weight bearing to avoid mechanically induced wear and tear.

A 45-year-old man comes to the office due to mild pain in his left foot and difficulty walking for the past several months.  He now walks with a cane and recently began using an ankle brace for support.  Medical history is significant for type 1 diabetes mellitus, hypertension, and hypercholesterolemia.  Physical examination is notable for a significantly deformed left ankle and a mildly deformed left foot.  Peripheral pulses are full and symmetric.  X-ray of the left foot and ankle with weight bearing reveals osseous fragmentation, new bone formation, and sclerosis, as seen in the image below.  Which of the following is the most likely cause of this patient’s foot condition? A. Age-related degenerative osteoarthritis B. Atherosclerosis of the tibial arteries C. Autoimmune inflammatory arthritis D. Bony destruction from bacterial infection E. Impaired sensation and joint proprioception

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