Case-based MCQ

⏳ Case-based MCQ | #Case_353 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 36-year-old man is rushed into the emergency department by paramedics after he sustained a head-on collision as an unrestrained driver. He has a hard collar and his head is fixed to a spine board. On a quick review, he is conscious and fully oriented, but in distress as he is not able to feel his arms and legs. There is no visible site of active bleeding or limb deformity. Chest is clear to auscultation, neck veins are not raised, and abdominal exam isinconclusive. His blood pressure is 90/40mmHg, heart rate 50bpm and respiratory rate 18 breath per minute. His oxygen saturation is 88% on room air. Sphincter tone is decreased and there is no sensation or deep tendon reflexes below the neck.

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⏳ Case-based MCQ | #Case_352 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A Drug-induced Parkinsonism (DIP) is the second-most-common etiology of Parkinsonism in the elderly after Parkinson's disease (PD). Many patients with DIP may be misdiagnosed with PD because the clinical features of these two conditions are indistinguishable. Typical antipsychotics such as phenothiazines (e.g. chlorpromazine) and haloperidol are the leading cause of DIP. Metoclopramide is another drug frequently associated with DIP. Other medications with potential ability to cause DIP include calcium channel blockers, atypical antipsychotics, and antiepileptic drugs. The clinical manifestations of DIP are classically described as bilateral and symmetric Parkinsonism without tremor at rest. Although approximately 50% of DIP patients show asymmetrical Parkinsonism and tremor at rest, bilaterality of symptoms is in favor of DIP rather than Parkinson’s disease. Of the option, presence of tremors is more (not definitely) suggestive of Parkinson’s disease rather than DIP. ⚠ Rigidity (option B), masked face (option D) and bradykinesia/hypokinesia (option E) are shared features of both PID and Parkinson’s disease. ⚠ Symmetrical symptoms (option C) is in favor of DIP rather than Parkinson's disease.

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⏳ Case-based MCQ | #Case_351 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D In statistics and epidemiology, relative risk or risk ratio (RR) is the ratio of the probability of an event occurring in an exposed group to the probability of the event occurring in a non-exposed, comparison group. Of 100 diabetic smokers who are on aspirin, 1 person has developed a coronary event. So the incidence of coronary event in this group is 1 % [1 /(1+99)x100], while the incidence of coronary events in the group taking placebo instead of aspirin is 2% [2/(2+98)x100]. In this scenario the exposure is taking aspirin. Exposed group has a 1 % chance of developing a coronary event versus 2% in those who do not take aspirin. The RR is then calculated by dividing the odds of the condition in the exposed group (1 % ) by that of the non-exposed group: RR = P(exposed) / P(non-exposed) : RR =1 % / 2% =0.5 Here, the RR indicates that the odds of developing a coronary event in those diabetic smokers who are on aspirin is half compared to those on placebo. In other words, those who are on aspirin has a 50% risk reduction. Inversely, those who are not taking aspirin are twice as likely to develop a coronary event compared to those who are taking it. So the RR. This means that not taking aspirin is associated with a 200% increase in incidence of coronary events.

⏳ Case-based MCQ | #Case_351 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 In a randomized controlled trial (RCT) conducted to study the effect of aspirin on prevention of coronary artery events among diabetic smokers, the results in the two arms of the study are as above.

⏳ Case-based MCQ | #Case_350 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C The fleshy red lesion on the distal intephalageal joint of this patient is consistent with the diagnosis of pyogenic granuloma (PG). PG is a common benign, acquired vascular neoplasm of the skin and mucous membrane. The etiology is unknown. Some think it might be due to minor trauma especially for PGs of fingers. Pyogenic granuloma is a misnomer because the lesion is neither pyogenic, nor a granuloma ! It is an erythematosus (fleshy red), dome-shaped papule or nodule that bleeds easily, and is prone to ulceration, erosion and crusting. It is most often seen in adolescents and young adults. Up to 5% of pregnant women may experience it. Although very rare, PGs have been reported in the gastrointestinal tract, the larynx, nasal mucosa, conjunctiva and cornea. ⚠ (Options A, D and E) Abscess, epidermoid cyst, and mucous cyst are covered with skin. ⚠ (Option B) Pyoderma gangrenosum typically presents with a well-defined border, which is usually violet or blue. 

⏳ Case-based MCQ | #Case_350 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 Jane, 21 years old, presents with a lesion on the distal interphalangeal joint of her right middle finger. The lesion has been present for the past 2 months and increased in size. The lesion is shown in the above photograph. On examination, she is otherwise healthy.

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⏳ Case-based MCQ | #Case_349 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Lichen sclerosus is a chronic inflammatory dermatosis which usually affects the skin of the anogenital region in women. It presents with general itching and is seen as white atrophic plaques. It occurs in little girls or middle-aged women. It is thought to have an autoimmune mechanism in the pathogenesis. The main complaint is itching which is worse at night. Dyspareunia and pain may be seen in cases of erosions or fissures. Topical steroids are used as part of the management. Follow-up is important and is recommended at three and six months, to ensure respoonse to treatment. This is because long standing, untreated cases show a 4% incidence of malignant change (association with development of squamous cell carcinoma of the vulva).

⏳ Case-based MCQ | #Case_349 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 55 year old woman presents to the clinic with an itchy, tender white plaque on her vulva. The itch is especially worse at night and often disturbs her sleep. Her past medical history includes type 1 diabetes mellitus. She has no family history of cancer.

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⏳ Case-based MCQ | #Case_348 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A Note that the patches of the skull are sclerotic and not lytic. Sclerotic patches represent Paget’s disease (osteitis deformans) whereas if it was lytic lesions on the skull it would represent multiple myeloma. Alkaline phosphatase is seen to be raised in both Paget’s disease and multiple myeloma however it is usually seen raised in multiple myeloma only when associated with fractures. Note that there are two types of Paget’s disease: 1. Paget’s disease of the bone (osteitis deformans) 2. Paget’s disease of the breast