Case-based MCQ

Case-based MCQ | #MCQ_102 •••••••••••••••••••••••••••••••••••••• Correct Answer Is A The sixth cranial nerve (CN-VI) palsy results in isolated weakness of abduction of the affected eye and horizontal binocular diplopia. On examination, there is an esotropia (inward deviation) that is worsened with gaze into the field of the affected lateral rectus muscle. Abduction is commonly limited on the side of the lesion. Poorly controlled diabetes is a predisposing factor. (Option B) In the right sixth cranial nerve palsy the right eye will be in an abnormal position (medially deviated), and the patient is diplopic on looking laterally to the right side. (Option C) The third cranial nerve supplies the levator palpebrae muscle of the eyelid and 4 extraocular muscles: the medial rectus, superior rectus, inferior rectus, and inferior oblique. These muscles adduct, depress, and elevate the eye. Patients with acute acquired third nerve palsy usually complain of the sudden onset of binocular horizontal, vertical, or oblique diplopia and a droopy eyelid. Pupil reflex remains intact in ischemic palsies (e.g. due to diabetes or midbrain infarcts). (Options D and E) A person with fourth nerve palsy may complain of binocular (both eyes open) vertical diplopia and/or subjective tilting of objects (torsional diplopia). The affected eye is usually extorted because the superior oblique muscle is responsible for intorsion of the eye. Objects viewed in primary position, especially in down-gaze may appear double when going down a flight of stairs so that the patient does not know which step to take first

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Case-based MCQ | #MCQ_102 •••••••••••••••••••••••••••••••••••••• Aaron,  73 years old, is a diabetic patient of yours who has presented to the clinic with sudden onset of horizontal diplopia, better when he looks at a near object and worse when looking at distance. On examination, the left eye is deviated towards medial side. Which one of the following is the most likely diagnosis? A. Left sixth cranial nerve palsy. B. Right Sixth cranial nerve palsy. C. Right third cranial nerve palsy. D. Left third cranial nerve palsy. E. Left fourth cranial nerve palsy

Case-based MCQ | #MCQ_101 •••••••••••••••••••••••••••••••••••••• Correct Answer Is D The clinical features described are consistent with left oculomotor (3rd cranial nerve [CN-3]) palsy with sparing of the pupil. The most common causes of the oculomotor nerve palsy sparing the pupil reaction is ischemia of the nerve as a result of vascular compromise due to diabetes mellitus.

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Case-based MCQ | #MCQ_101 •••••••••••••••••••••••••••••••••••••• A 45-year-old man with history of type II diabetes mellitus comes to the emergency department with diplopia and ptosis of his left eye. On examination, the left eye is deviated slightly out and down in straight-ahead gaze. Upward gaze is impaired. Pupils have normal reaction to light. Which one of the following would be the most likely underlying cause of this presentation? A. Aneurysm of the posterior communicating artery. B. Tumor. C. TB meningitis. D. Diabetes mellitus. E. Trans-tentorial brain herniation.

Case-based MCQ | #MCQ_100 •••••••••••••••••••••••••••••••••••••• Correct Answer Is C It is recommended that asymptomatic patients with carotid artery stenosis of equal to or greater than 60% and symptomatic patients with stenosis of equal to or greater than 50% undergo endarterectomy in an attempt to prevent further strokes as the most appropriate management. With a cerebrovascular event and a stenosis of 50%, this patent requires carotid endarterectomy as the most appropriate action to prevent further strokes.

Case-based MCQ | #MCQ_100 •••••••••••••••••••••••••••••••••••••• A 71-year-old man presents to the Emergency Department with weakness of the left arm and leg. His past medical history is significant for coronary angioplasty 5 years ago for which he is currently on daily low-dose aspirin. A non-contrast brain CT scan excludes cerebral hemorrhage. Doppler ultrasonography shows bilateral carotid artery stenosis of 50%. Which one of the following would be the most appropriate action to takef or long-term secondary prevention? A. Add warfarin. B. Add clopidogrel. C. Carotid endarterectomy. D. Continue the same dose of aspirin. E. Increase the dose of aspirin

Case-based MCQ | #MCQ_99 •••••••••••••••••••••••••••••••••••••• Correct Answer Is D Haloperidol is a first-generation antipsychotic that acts by inhibition of dopamine receptors in CNS. On the other hand, the pathophysiology of Parkinson disease is dopamine depletion from the basal ganglia. Consequently, haloperidol results in worsening of extrapyramidal symptoms of Parkinson disease such as bradykinesia and tremors. All antipsychotic drugs are capable of producing extrapyramidal effects in a dose-dependent fashion. Aripiprazole, clozapine and quetiapine are probably exceptions. When extrapyramidal effects develop, it is an indication that the dose of drug has exceeded the optimal therapeutic range for a given patient. In such circumstances, the next best step would be decreasing the dose of the antipsychotic.

Case-based MCQ | #MCQ_99 •••••••••••••••••••••••••••••••••••••• Robert is a 72-year-old patient of yours, who was diagnosed with Parkinson disease 10 years ago. Recently he developed agitation, for which he was prescribed haloperidol. Today, he is brought to you office by his son with complaint of marked increase in his tremors. Which one of the following is the most appropriate management? A. Do nothing. B. Increase the dose of haloperidol. C. Increase the dose of anti-Parkinson medications. D. Decrease the dose of haloperidol. E. Switch to risperidone.

Correct Answer Is E Drawing intersecting pentagons assesses the ability of the patient in constructional praxis (a task which requires three-dimensional manipulation). This is a task of non-dominant (right) parietal lobe. Lesions of non-dominant parietal lobe lead to constructional apraxia

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Case-based MCQ | #MCQ_98 •••••••••••••••••••••••••••••••••••••• On neurological assessment of a patient, he is unable to copy a pentagon. Which one of the following is the site of the lesion? A. Temporal lobe. B. Temporoparietal lobe. C. Frontal lobe. D. Dominant parietal lobe. E. Non-dominant parietal lobe.

Correct Answer Is B The scenario describes a rather common clinical situation: a patient with suspected bacterial pharyngitis develops rash after being started on amoxicillin. This occurs when a patient with infectious mononucleosis is misdiagnosed as bacterial pharyngitis and started on antibiotics. Infectious mononucleosis (IM) is a febrile illness caused by Epstein–Barr virus from herpes family. It can mimic diseases such as primay HIV infection, streptococcal tonsillitis, viral hepatitis and acute lymphatic leukemia. It may occur at any age but is more common between10 and 35 years with the peak incidence among those ages 15-25 years. IM has an incubation period of 4-6 weeks. The disease may initially present with sore throat (the cardinal finding), lymphadenopathy, fever, rash, and hepatosplenomegaly. The rash of IM is almost always related to antibiotics given for tonsillitis. The primary rash, most often non-specific, pinkish and maculopapular (similar to that of rubella), occurs in only about 5% of cases. It is usually blanching and non-pruritic. The secondary rash is most often precipitated by one of the penicillins, especially ampicillin or amoxycillin. About 90–100% of patients prescribed ampicillin or amoxycillin will be affected. This rash is non-blanching and itchy, and develops 5-9 days after antibiotics are started.   The rash of this patient is most likely to be an allergic reaction to the antibiotic. The exact mechanism of rash following administration of antibiotics in IM is not fully understood. Some authors believe it is not a consequence of a genuine allergic reaction because most patients will not be sensitive to the implicated antibiotic after IM resolves. Some theories suggest that the rash is caused by both decreased immune system tolerance and enhanced immune response to the implicated drug during the infection.

Six days ago, a 30-year-old man presented to your practice with complaints of acute sore throat and a fever of 39.2°C. On examination, he had red swollen tonsils with exudate. He was prescribed amoxicillin. Today, he has presented with a non-blanching pruritic rash. Which one of the following options best describes the most likely cause for the rash? A. Infectious mononucleosis. B. Allergic drug reaction. C. Hypersensitivity vasculitis. D. Varicella zoster infection. E. Streptococcal pharyngitis

Case-based MCQ | #MCQ_96 •••••••••••••••••••••••••••••••••••••• Correct Answer Is C The decreased RCC and hemoglobin in this patient represent anemia. With the decreased MCV, the anemia is microcytic. The most common causes of microcytic anemia are iron deficiency and thalassemia. This clinical picture, however, is inconsistent with thalassemia minor (trait) (option B) because although patients with thalassemia minor has isolated mild microcytic anemia, the red cell count, unlike in this patient, is normal of even increased. Moreover, the anemia of thalassemia minor is asymptomatic. Strict vegetarians are prone to vitamin B12 deficiency as this vitamin is only available in animal products such as meat, poultry, fish, eggs, and dairy products. Vitamin B12 deficiency (option E) causes macrocytic anemia that does not explain the microcytosis in this scenario. A vegetarian diet includes green-leaf vegetables that provide adequate dietary iron to prevent from iron deficiency. Anemia caused by vegetarian diet (option D) is more likely to be macrocytic and have been caused by vitamin B12 deficiency. Cecal cancer (option A) and right-sided colon cancer in general often present with anemia and its symptoms such as fatigue and weakness (as opposed to left-sided colorectal cancers that usually manifest with altered bowel habits and rectal bleeding); therefore, should be considered and investigated in patients with microcytic anemia, or iron deficiency anemia to be more specific. This is even more important in older patients. However, colorectal cancer in vegetarians is extremely rare because high-fiber diets are a protective factor against colorectal cancer. Given the history and exclusion of other options, hookworm infestation remains the most likely explanation to this scenario. Human hookworm disease is a common helminth infection predominantly caused by the nematode parasites Necator americanus and Ancylostoma duodenale. Hookworm infection is acquired through skin exposure to larvae in soil contaminated by human feces. Worldwide, hookworms infect an estimated 472 million people. It is endemic in many underdeveloped or developing regions in the work including African, south Asia, Mediterranean region, and south America. The larvae of hookworm from the soil enter the foot sole skin, then migrate through the dermis, enter the bloodstream, and move to the lungs within 10 days. Once in the lungs, they break into alveoli, causing a mild and usually asymptomatic alveolitis with eosinophilia. Form the alveoli, the larvae are carried to the glottis by the ciliary action of the respiratory tract. During pulmonary migration, the host may develop a mild reactive cough, sore throat, and fever that resolve after the worm migrates into the intestines. At the glottis, the larvae are swallowed and carried to their final destination, the small intestine. Of all infested people, only 10% develop symptoms which include iron deficiency anemia due to loss from small intestine in patients with moderate to severe infestation burden.

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