Case-based MCQ

⏳ Case-based MCQ | #Case_429 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 An elderly alcoholic male is brought to the hospital by his grandson, who found him in poor condition. The grandson reports that his family has not seen the patient in months. The patient denies complaints, but is obviously malnourished, poorly washed, and mildly intoxicated. You admit the patient to the hospital and begin providing supportive care, including intravenous fluids with dextrose, a regular diet, and physical therapy evaluation. On the evening of the second day he becomes weak and more confused. His blood pressure is 88/56 mm Hg, and he has a seizure. Your evaluation includes the following laboratory findings: Glucose: 3.3 mmol/L BUN: 3.2 mmol/L Creatinine: 230 µmol/L Creatine kinase: 480 U/L Troponin I: < 0.1 µg/L Albumin: 27 g/L Calcium: 0.97 mmol/L Phosphate: 0.27 mmol/L ALT (SGPT): 68 U/L AST (SGOT): 88 U/L

⏳ Case-based MCQ | #Case_429 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D This patient presents with dyspnea and has elevated brain natriuretic peptide (BNP). The BNP is secreted by the brain and heart ventricles and is elevated in traumatic brain injury, left ventricular dysfunction, and congestive heart failure (CHF). In the patient with dyspnea, overlapping or even conflicting historical, physical, and radiographic findings often hinder the differentiation between cardiac and noncardiac etiology. Initial misdiagnosis occurs in approximately 15-20% of patients presenting to the emergency department with dyspnea secondary to an acute exacerbation of CHF. This misdiagnosis may incur clinically significant morbidity and mortality. The primary value of BNP testing in the ED is its diagnostic value in the differential diagnosis of acute dyspnea and possible CHF. BNP levels > 400 pg/mL are suggestive of CHF. Since this patient has no history of traumatic brain injury and is presenting with elevated BNP, the most likely cause is decompensated CHF. Initial approach to treatment of ADHF includes supplemental oxygen and ventilatory support (noninvasive ventilation [NIV] or intubation) as indicated, diuretic therapy, and vasodilator therapy (choice D). ⚠ Inhaled ipratropium bromide (choice A) would be used in an acute exacerbation of COPD. The elevated BNP helps us determine the cause of dyspnea in this patient, it is cardiogenic in nature and CHF is the most likely diagnosis. ⚠ Peritoneal dialysis (choice B) would be done if the patient had end-stage renal disease or acute renal failure. No findings suggest this diagnosis in this patient. ⚠ Mannitol (choice C) is incorrect. Circulatory overload due to expansion of extracellular fluid is a serious adverse effect of mannitol. As a consequence, pulmonary edema can be precipitated in a patient with diminished cardiac reserve. ⚠ Diltiazem (choice E) is a calcium channel blocker and is contraindicated in patients with CHF and abnormal LV ejection fraction. While measurements of LV ejection fraction of this patient are not mentioned, studies have shown that there is a negative linear correlation between BNP and LV ejection fraction, and high BNP levels can predict decreased LV ejection fraction levels. Use of diltiazem has been shown to have negative outcomes in CHF. 🔖 Key point: BNP can be used to differentiate cardiogenic dyspnea from non-cardiogenic dyspnea. BNP levels > 400 pg/mL are suggestive of CHF. Initial therapy includes the initiation of treatments aimed at rapidly correcting hemodynamic and intravascular volume abnormalities, such as diuretics and intravenous vasodilator therapy.

⏳ Case-based MCQ | #Case_428 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 68-year-old woman presents to your department with worsening dyspnea. Past medical history includes COPD, coronary artery disease, and Stage III chronic kidney disease. Her brain natriuretic peptide is 1200 pg/mL (normal < 100 pg/mL).

⏳ Case-based MCQ | #Case_428 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C This child presents with no significant past medical history, immunizations are uptodate, but the shortness of breath she reports should be explored even though it is attributed to physical activity. The difference in the BP measurements in the arms and the decreased femoral pulses are common findings in coarctation of aorta (choice C). It is a relatively common defect that accounts for 5-8% of all congenital heart defects. The diagnosis of this condition is often delayed until complications such as congestive heart failure develop. Coarctation of the aorta is defined as a constricted aortic segment that comprises localized medial thickening, with some infolding of the medial and superimposed neointimal tissue. The classic coarctation of the aorta is located in the thoracic aorta distal to the origin of the left subclavian artery at about the level of the ductal structure. This imposes significant afterload on the left ventricle, which results in increased wall stress and compensatory ventricular hypertrophy. The anatomy results in hypertension proximal to the lesion, with diminished blood pressure distal to the obstruction. ⚠ Patent ductus arteriosus (choice A) may be a comorbidity found in patients who have coarctation of aorta but it is not the cause of the difference in BP in the patient’s arms or decreased femoral pulse. ⚠ Aortic stenosis (choice B) would not be the cause of the differing BP measurements in the arms or the decreased femoral pulse. ⚠ Ventricular septal defect (choice D) is associated with a holosystolic murmur along the lower left sternal border. While it may be present in some patients with coarctation of aorta, itself it wouldn’t be the cause of differences in BP in the arms or delayed femoral pulse. ⚠ Renal artery fibromuscular dysplasia (choice E) causes secondary hypertension, may cause abdominal or femoral artery fruits, but it is not associated with varying BP measurements in the arms or decreased femoral pulse. 🔖 Key point: The clinical presentation of shortness of breath, BP measurements differences in the arms, and decreased femoral pulse is highly suggestive of coarctation of aorta. The classic coarctation of the aorta is located in the thoracic aorta distal to the origin of the left subclavian artery

⏳ Case-based MCQ | #Case_428 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 Parents of a 6-year-old girl bring her for pre-school physical examination. The girl reports that sometimes she gets short of breath when “she plays too much” but otherwise she is fine. The child’s past medical history is unremarkable. Her immunizations are up to date. Vital signs reveal variation in blood pressure between the left and right arms. The femoral pulses are decreased.

⏳ Case-based MCQ | #Case_427 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D The location and circumstances are classic for Morton's neuroma, a benign neuroma of the third plantar interdigital nerve. Gout happens to obese, elderly males, and redness and signs of inflammation in the affected joint are evident. Hallux rigidus is osteoarthritis of the first metatarsophalangeal joint. There is deformity and limitation of motion. The joint is tender on physical examination. Metatarsophalangeal articulation pain is likewise associated with misalignment of joint surfaces. There is pain when examining the joint, and there is no history of numbness, burning, or tingling. Plantar fasciitis produces sharp pain on physical examination when pressing the plantar surface of the heel

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‍ 🧩 Medical Mnemonics ✍ Normal pressure hydrocephalus (NPH) refers to a condition of pathologically enlarged ventricular size with normal opening pressures on lumbar puncture. NPH is a form of communicating hydrocephalus and is distinguished from obstructive or noncommunicating hydrocephalus, in which there is a structural blockage of the cerebrospinal fluid (CSF) circulation within the ventricular system (eg, stenosis of aqueduct of Sylvius). 🔺 NPH is associated with a classic triad of dementia, gait disturbance, and urinary incontinence. The patients appear to walk with a broad base and with their feet stuck to the floor (no lifting up the knees). There is a #mnemonic to memorize the Classic (Hakim’s) Triad of NPH Progression: “Wet, Wacky, Wobbly”: Incontinence, dementia, ataxia. Symptoms develop over the course of weeks to months, and brain imaging shows ventricular enlargement, which is disproportionate to the degree of cortical atrophy. 🔺 Neurosurgical ventriculoperitoneal shunt placement may correct the problem. Patients likely to benefit from shunt placement have a clear response to the removal of 30 to 40 mL of spinal fluid, with improved gait and alertness within minutes to hours of the procedure. The shunt diverts CSF from the brain or lumbar spinal sac to the abdominal cavity, where it is then absorbed into the circulation. #neurology #Quick_facts 〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

⏳ Case-based MCQ | #Case_427 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 50-year-old woman, who wears high-heeled, pointed shoes, complains of pain in the forefoot after prolonged standing or walking. Occasionally, she also experiences numbness, a burning sensation, and tingling in the area. Physical examination shows no obvious deformities and a very tender spot in the third interspace, between the third and fourth toes. There is no redness, limitation of motion, or signs of inflammation.

⏳ Case-based MCQ | #Case_426 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Slipped capital femoral epiphysis is often misdiagnosed, as the symptoms are frequently vague. It is the most common hip disorder in adolescents, with the age range being 9 to 15 years. It occurs when the proximal femoral epiphysis slips posteriorly and inferiorly on the femoral neck through the growth plate. The typical presentation is a limping child who may have pain in the groin, hip, thigh, or knee. Very often the pain is vague and poorly localized. It occurs more often in boys, with African-Americans and Pacific Islanders having a higher rate of involvement, possibly due to increased levels of obesity in these population groups. Physical findings vary, depending on the severity of the slippage. A child with a severe slip may not be able to bear weight. Obligatory external rotation of the involved hip is noted when the hip is passively flexed to 90°. Radiographs are needed to diagnose unstable slipped capital epiphysis, and should include frog-leg lateral views and anteroposterior views of both hips. Another cause of hip pain in adolescent patients is apophyseal avulsion fractures. Clinical features include pain after a sudden, forceful movement. Hip apophysitis presents as activity-related hip pain with a history of overuse and negative radiographs. In children under the age of 10 years, transient synovitis is also a common cause of hip pain. It occurs after a viral illness and is associated with negative radiographs but positive laboratory tests. Fractures may be seen in children on occasion, but there will be a history of trauma. Septic arthritis is an infrequent cause of hip pain in children, but patients have a history of fever with elevation of the WBC count and inflammatory joints. The diagnosis would be confirmed by joint aspiration. Legg-Calvé-Perthes disease is also infrequent, and features include vague hip pain with decreased internal rotation of the hip. The diagnosis is based on findings from radiographs or MRI

⏳ Case-based MCQ | #Case_426 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 12-year-old African-American male is brought to your office by his parents because he has been limping for the past month. He says he has pain in the groin and knee, but the pain is poorly localized. On examination he is noted to be obese, with normal findings on examination of the knee. There is some decrease in internal rotation of the hip on the involved side. His gait is antalgic.

⏳ Case-based MCQ | #Case_425 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D The condition of the skin in the affected area helps to differentiate the cause of hair loss. In this case, the abnormal skin suggests a scarring type of alopecia, which may be caused by ¹infection (e.g. syphilis, tuberculosis, acquired immunodeficiency syndrome, herpes zoster), ²autoimmune disease (discoid lupus erythematosus), ³sarcoidosis, ⁴scalp trauma (e.g., injuries, burns), and ⁵radiation therapy. ⚠ The skin is normal in androgenic alopecia, alopecia areata, and drug-induced alopecia. ⚠ Trichotillomania, a compulsive plucking of one’s hair, may occur in the scalp. This can be differentiated from other forms of scarring alopecia by an examination of the scalp showing decreased hair density, as well as broken hairs of various lengths, rather than complete baldness in the affected area. As the patient has known sarcoidosis, this is the most likely cause of her scarring alopecia.

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