Case-based MCQ

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✔ B This patient is at a high risk of myocardial infarction, one of the most common causes of death in North America. Aspirin has been shown to have a 32 % relative risk reduction for myocardial infarction in men over 45 years of age. It has also been shown to have 17% relative risk reduction for strokes in women over the age of 55. Interestingly, aspirin has little effect on risk reduction of strokes in men and myocardial infarction in women. The antithrombotic effect of aspirin is primarily attributed to the irreversible blockade of the cyclooxygenase-1 (COX-1) enzyme in platelets that leads to attenuation in the production of an important platelet agonist, thromboxane A2. Despite these benefits of aspirin, it has many side effects, and these side effects are dose-dependent. Out of the choices given on this question, the patient is most likely to complain of tinnitus or ringing in the ear (choice B). ⚠ Right lower quadrant abdominal pain (choice A) would suggest lower gastrointestinal lesions caused by aspirin. These are not as common as upper gastrointestinal lesions. Aspirin decreases the production of prostaglandins in the GI tract, thereby decreasing the protective and restorative properties of the gastric and duodenal mucosa and predisposing to ulcers and bleeding. ⚠ Frequent urination (choice C) is a common complaint of patients started on diuretics. ⚠ Lower extremity pain due to thrombosis (choice D) is more common in cyclooxygenase 2 inhibitors such as celecoxib, but is not seen in aspirin, a cyclooxygenase 1 and 2 inhibitor. ⚠ Cutaneous flushing due to increased prostaglandin (choice E) is incorrect. Aspirin is a prostaglandin inhibitor, and it is this mechanism of action that explains its benefit in treating patients who complain of flushing caused by niacin treatment. 🔖 Key point: Aspirin has many side effects and they are dose-dependent. Some common ones include tinnitus, vertigo, nausea, vomiting, and diarrhea.

⏳ Case-based MCQ | #Case_462 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 59-year-old male with a history of hypercholesterolemia, hypertension, and diabetes who has had recent onset of shortness of breath and chest pain, started to take 325 mg aspirin. Despite these benefits of aspirin, it has many side effects. 

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Parvovirus B19 infection (choice C), also known as erythema infectiosum or fifth disease, often occurs in outbreaks among school-aged children, but it can occur in adults as well. It is a fairly common cause of an exanthematous rash and arthritis in younger women. This infection should be particularly suspected in healthcare workers who have frequent contact with children. The specific characteristics of the rash, the pattern of joint involvement, and the place of employment in an otherwise healthy person all offer clues suggesting parvovirus B19 as the infecting agent. See image below. ⚠ Adenovirus (choice A), HIV (choice B) and Measles virus (choice D) rarely cause arthritis, although HIV infection can cause a musculoskeletal syndrome later in the disease. ⚠ Varicella-zoster virus (choice E) may cause large-joint arthritis, but the rash is distinctively vesicular and pruritic. 🔖 Key point: Parvovirus B19 infection, also known as erythema infectiosum or fifth disease, is a fairly common cause of an exanthematous rash and arthritis in younger women

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⏳ Case-based MCQ | #Case_462 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A previously healthy 24-year-old pediatric nurse has a 3-day history of nonpruritic rash, malaise, and arthralgias. The rash covers her thighs and the inner aspects of her upper arms and presents as a faint, maculopapular, irregular, reticulate exanthem. Symmetric synovitis is present in several distal and proximal interphalangeal joints and in her metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted in her left wrist and right elbow.

Explanation: Syncope is a brief period of loss of consciousness accompanied by loss of postural tone. Syncope may either occur abruptly or may be preceded by symptoms of presyncope, including dizziness, light-headedness, sweating, nausea, blurring of vision or even transient blindness. The presyncopal period varies in duration depending on the underlying cause. Syncope may sometimes be accompanied by brief clonic or tonic-clonic seizure-like activity. Neurocardiogenic syncope (vasovagal and vasodepressor) (choice B) is the commonest form of syncope and accounts for about 50% of syncopal attacks. In the absence of any specific features typical of any of the other forms of syncope, neurocardiogenic syncope should be the top diagnosis. However, other forms of syncope must be excluded through ECG and other diagnostic procedures. → Medication-induced syncope (choice A) is very unlikely in patients who are not taking any medications. → Situational syncope (choice C) occurs during a variety of activities, including cough, deglutition, micturition and defecation. Our patient did not complain of cough, difficulty of micturition, dysphagia or constipation. → With syncope due to arrhythmia (choice D), patients may complain of palpitations prior to the attack in case of tachyarrhythmias or describe slowing of their heart rate in case of bradyarrhythmia. This form of syncope must be actively sought and excluded by 12 lead ECG or advanced electrophysiological studies. → Carotid sinus hypersensitivity (choice E) causes syncope while shaving, with tight collars, or turning the head to one side. Key point: Neurocardiogenic syncope (vasovagal and vasodepressor) is the commonest form of syncope and accounts for about 50% of syncopal attacks. In the absence of any specific features typical of any of the other forms of syncope, neurocardiogenic syncope should be the top diagnosis

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