Case-based MCQ

⏳ Case-based MCQ | #Case_425 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 59-year-old female with a history of hypertension, posttraumatic stress disorder, and sarcoidosis, reports a 3-month history of hair loss in the right temple area. She has been using an over-the-counter corticosteroid cream without response. Her other medications include ramipril (Altace), hydrochlorothiazide, clonazepam (Klonopin), and bupropion (Wellbutrin). She reports increased stress from caring for her chronically ill husband who has been hospitalized recently. Examination of the skin and scalp is normal except for a 3cm x 4cm irregularly shaped area of alopecia with a slightly red, raised anterior edge located in the right temporal scalp. The affected skin is shiny, with no scaling; no hairs or broken hairs are present.

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✅ C This patient presents with ataxia, which is suggested by the complaints of "reeling" and the description of poor balance. It is also revealed by the tandem walking test, which is abnormal, as the patient cannot walk a straight line heel-to-toe. This .is considered the most sensitive test to evaluate cerebellar function. Ataxia is a common manifestation of cerebellar disorders. Cerebellar ataxia may be genetic or acquired. The onset of ataxia could suggest the underlying disease process. ▫ Ataxia of acute onset (seconds to days) is caused by trauma, intoxication, migraine, and cerebellar hemorrhage or infarction. ▫ Ataxia of subacute onset (days to weeks) may suggest multiple sclerosis, hydrocephalus, viral cerebellitis, Guillain-Barré syndrome, and posterior fossa tumour or abscess. ▫ Chronic ataxia (onset months to years) has a differential that includes alcoholic cerebellar degeneration, paraneoplastic cerebellar syndrome, foramen magnum compression, chronic infection, vitamin E deficiency, hereditary ataxia, and idiopathic degenerative ataxia. Considering the gradual onset of this patient's condition over the past month, he is in the chronic ataxia category, and the two diagnoses that should be highest on our differential are alcoholic cerebellar degeneration and paraneoplastic cerebellar syndrome. By far, the most common cause of chronic acquired cerebellar ataxia is alcoholic cerebellar degeneration. It has been observed that some people who consume alcohol excessively may not have cerebellar degeneration, while those who consume it moderately may present with ataxia. Therefore, alcoholic cerebellar degeneration is not a dose-dependent phenomenon. Genetics are believed to play a role in this phenomenon. In symptomatic ataxia, management must be guided by the underlying cause. The patient's laboratory finding of AST:ALT ratio > 2 strongly suggests alcoholic consumption. The pathogenesis of alcoholic cerebellar degeneration includes both the direct toxic effect of alcohol on the cerebellum and the consequences of thiamine deficiency. The recommended treatment is alcohol abstinence and thiamine (choice C). ⚠ Surgical removal of cerebellar hematoma and physical therapy (choice A) is incorrect. This would be appropriate for patients with cerebellar hemorrhage who meet the criteria for this type of treatment. ⚠ Tumour resection and chemotherapy (choice B) may be beneficial in a patient with lung cancer or cancer-causing paraneoplastic cerebellar syndrome. ⚠ Treatment with intravenous immunoglobulins (choice D) would not be beneficial in the treatment of alcoholic cerebellar degeneration. It is recommended for the management of Guillain-Barré syndrome. ⚠ Treatment with Vitamin B12 (choice E) may be helpful in patients with malnutrition that accompanies alcoholism. Vitamin B12 deficiency is associated with megaloblastic anemia and subacute combined degeneration. However, it is not the best treatment for alcoholic cerebellar degeneration. 🔖 Key point: Cerebellar ataxia with AST:ALT ratio > 2 strongly suggests alcoholic consumption. The pathogenesis of alcoholic cerebellar degeneration includes both the direct toxic effect of alcohol on the cerebellum and the consequences of thiamine deficiency. The recommended treatment is alcohol abstinence and thiamine.

⏳ Case-based MCQ | #Case_424 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 47-year-old male presents to your department with his wife because he has been “reeling” for the past month. His wife reports that during this period he has gradually exhibited tremor, clumsiness, and generally has poor balance. His speech is normal, he has no voice changes, numbness, or hearing loss. Family history is non-remarkable. On neurological exam the the patient cannot walk a straight line heel-to-toe. The patient's AST is found to be 198 U/L (N 0-35 U/L) and his ALT is 85 U/L (N 3-36 U/L).

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⏳ Case-based MCQ | #Case_423 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A A positive Lachman test is strong evidence of an anterior cruciate ligament (ACL) tear.  ⭕ How to perform Lachman test: - Stand next to the supine patient, on the side of the exam table. - Grasp the lateral thigh just above the knee with your upper (contralateral) hand. - Hold the tibia medially with your lower (ipsalateral) hand. - Put your lower thumb on the joint line. - Steady the leg with your upper hand and gently lift it, asking the patient to keep the foot on the table, such that the knee flexes to 30 degrees. - Ask the patient to relax. - Gently yet suddenly apply a juddering force to the tibia in an attempt to subluxate it forward. - Assess in your mind the extent of excursion and the 'quality' of the end point The normal response: There should be a firm restraint to anterior translation. The tibia should not move forward much (the same amount as found on the other side) and it should come to a strong stop, the so-called "good end point" as the ACL reaches its maximum length Again, this end point on the injured leg should be comparable to the normal side. What it means if not normal → ACL deficiency is suggested. Grades of laxity defined by amount of anterior tibial translation relative to contralateral knee: Grade I: 1-5mm Grade II: 6-10mm Grade III: >10mm ▫ The Lachman test is recognized by most authorities as the most reliable and sensitive clinical test for the determination of anterior cruciate ligament integrity, superior to the anterior drawer test commonly used in the past. ⚠ Joint line tenderness is not very helpful for either confirming or ruling out meniscal injury. ⚠ The five criteria in the Ottawa Knee Rule include “inability to flex (not extend) the knee to 90˚” and “inability to bear weight for four steps both immediately and in the examination room regardless of limping”.

⏳ Case-based MCQ | #Case_423 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 40-year-old male comes to the urgent care center with severe pain in his right knee. The pain began suddenly when he pivoted on the knee while playing touch football at a family Thanksgiving gathering. You perform the following: the knee is placed in 30° of flexion, with the patient lying supine. You place one hand behind the tibia (with your thumb being on the tibial tuberosity) and the other on the patient's thigh. On pulling anteriorly on the tibia, you remark about 1cm of tibial anterior translation.

⏳ Case-based MCQ | #Case_423 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 24-year-old female presents with a complaint of mild fullness in the neck. A review of systems is negative, except for some poor sleep related to the care of her 4-month-old infant, and mild palpitations at times when she is tired. Her pregnancy was uneventful, and breastfeeding is going well. Findings on examination are normal except for enlargement of the thyroid. Her TSH level is 0.1 μU/mL (N 0.3-5.0).

⏳ Case-based MCQ | #Case_422 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B This patient’s dramatic change of status with rapidly developing dyspnea and hypotension and possibly disseminated intravascular coagulation (manifested by oozing of blood at the IV site) after labor induction is suggestive of amniotic fluid embolism (choice B). It is a rare obstetric emergency with a pathophysiology that is still incompletely understood, but is potentially fatal and is characterized by dramatic development of hypoxia, hypotension or cardiac arrest, coagulopathy, during labor, Cesarean section, or within 30 minutes post-partum. Risk factors are meconium stained amniotic fluid, precipitous labor, oxytocin-stimulated labor, intrauterine pressure catheter insertion, male sex of the fetus, placental abruption, multiparity, advanced maternal age, uterine overdistention, fetal death, and trauma. Oxytocin-stimulated labor has been associated with 50% of all amniotic fluid embolism cases. ⚠ Uterine atony (choice A) can result in prolonged bleeding and hemorrhage-induced hypotension. It can occur in oxytocin-stimulated labor and a large fetus is a risk factor; however, the respiratory and coagulopathy complications seen in this patient cannot be explained by uterine atony alone. ⚠ Superior vena cava embolism (choice C) is more common in patients with a permanent infusion catheter in the subclavian vein and superior vena cava. This patient’s clinical picture suggests amniotic fluid embolism. ⚠ Transfusion reaction (choice D) is incorrect. Dyspnea and hemodynamic instability occurred before transfusion was performed. ⚠ Epidural anesthesia complication (choice E) can certainly cause hypotension but bradypnea, not tachypnea, is more likely to occur, and the DIC seen in this patient is unlikely to be a side effect or complication anesthesia. 🔖 Key point: Amniotic fluid embolism is a rare obstetric emergency characterized by dramatic development of hypoxia, hypotension or cardiac arrest, coagulopathy, during labor, Cesarean section, or within 30 minutes post-partum. Half of all amniotic embolism cases are associated with oxytocin-stimulated labor.

⏳ Case-based MCQ | #Case_422 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 37-year-old female G3P2 presents to your department in early labor at the 40th week of gestation. The cervix is 4 cm dilated, 40% effaced, anteriorly positioned, firm, and fetal station is at -3. The patient has a contraction every 5 minutes. She is given an epidural anesthesia with bupivacaine. After 3 hours, labor induction is considered. The cervix is ripened with dinoprostone and oxytocin infusion is given to augment contractions. The patient delivers a 4200g baby boy with APGAR score of 7 and 9 at 1 and 5 minutes, respectively. While awaiting placental removal, the patient has tachypnea with 35 respirations per minute, oxygen saturation drops to 78% and her BP is 85/40 mmHg. Immediate intubation is done and blood transfusion is started. 15 minutes later the bloody oozing is noted at IV sites.

⏳ Case-based MCQ | #Case_421 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D This toddler has a foreign body aspiration, as suggested by his lung and CXR findings. A foreign body should always be considered in the differential of a wheezing toddler. Management includes removal under direct visualization by rigid bronchoscopy (choice D). ⚠ Beta agonist therapy (choice A) is appropriate for the management of asthma. ⚠ Steroid therapy (choice B) is used for the management of asthma exacerbation and is not useful in the treatment of a foreign body aspiration. ⚠ Chest tube placement (choice C) is indicated for lung collapse, as opposed to hyperinflation. ⚠ Racemic epinephrine (choice E) is used in the treatment of laryngotracheobronchitis (croup) and is indicated in patients with stridor at rest.

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