Case-based MCQ

⏳ Case-based MCQ | #Case_391 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 4-year-old is boy is brought to your attention with complaints of intermittent abdominal pain. Each episode lasted for a maximum of 2 to 3 hours before it completely subsided. He has been quite asymptomatic in between the episodes. This time, however, the pain has lasted for 12 hours. On examination, he is afebrile but a mass is palpated in the right upper quadrant (RUQ). The mass is not tender.

⏳ Case-based MCQ | #Case_390 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation The first point that should be noted is the arterial pressure of the oxygen that is above 100 mmHg. There are only two scenarios for an elevated Pa02 above 100 mmHg: 1. Hyperventilation of high concentration oxygen 2. Sampling errors - if there is an air bubble in the blood sample, the Pa02 will be falsely elevated to a level approximate to the oxygen pressure of the room air (almost 140 mmHg) while the PaC02 is falsely decreased. In this patient, sampling error is the cause of the ABG reading because if the cause was hyperventilation of oxygen the PaC02 was expected to be normal or even decreased. In fact, despite the oxygen level on ABG, he is still hypoxic due to suppressed respiratory drive; therefore, the next best step in management would be giving the patient more naloxone to counteract the suppressive effect of opiate on respiratory drive and achieving a respiratory rate of 12 breaths per minute or higher. In the meanwhile the patient should be ventilated with bag and mask attached to the oxygen. If reversal of normal breathing with maximum dose of naloxone is not achieved, other diagnoses should be considered. Intubation and ventilation must be considered if the patient cannot maintain his/her airway patent or treatment with naloxone fails to raise the respiratory rate of the patient. 🔖 NOTE - in approaching to a patient with opiate overdose, the first priority is ensuring airway patency with securing an airway, suction of oropharyngeal secretions and supplemental oxygen, and establishing an intravenous line. The next urgent step is always intravenous naloxone. The patient should receive assisted ventilation with bag and mask attached to 100% oxygen until the target respiratory rate is reached (s12 breaths per minute). ⚠ (Option A) While this patient has hypercarbia and a respiratory rate of 6 breaths ber minute, a reduction in oxygen flow will result in deterioration of his condition. ⚠ (Option C) Repeating the ABG may be indicated after treatment with further doses of naloxone. ⚠ (Option D) Opiate level measurement is not indicated in this scenario. ⚠ (Option E) Intubation and ventilation at this point is not necessary unless indicated otherwise. If the case is opiate overdose, adequate treatment with naoloxone will treat the respiratory suppression

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⏳ Case-based MCQ | #Case_390 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 56-year-old man is brought to the emergency department after he was found drowsy and confused in his house by his son. According to his son, he is on paracetamol, indomethacin, metoprolol and oxycodone. On examination, he is drowsy and hardly arousable and has a pulse rate of 64 bpm, blood pressure of 90/65 mmHg, respiratory rate of 6 breaths per minute and temperature of 36.1°C. His pupils are bilaterally constricted. With the provisional diagnosis of opiate overdose, he is given naloxone 0.4 mg intravenously and a blood sample for ABG is drawn. He is started on oxygen 6 L/min by nasal prongs. The ABG result is back and is as follows: • Pa02: 120mmHg • PaC02: 65mmHg • pH: 7.31 • HC03: 26mEq

⏳ Case-based MCQ | #Case_389 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation The clinical picture of bilateral itchy and watery eyes is consistent with either viral or allergic conjunctivitis. With erythematous eyelids, an allergic reaction would be the most likely diagnosis. Allergic conjunctivitis may be the response of a previously sensitized individual to an allergen, including but not limited to the following: • Household dust • Pollen from trees or grass • Mold spores • Animal dander • Chemical perfumes • Contact lens solutions • Certain medications (systemic or topical) This woman has used a new contact lens solution that is very likely to have caused an allergic reaction. ⚠ (Options A and E) A mucopurulent discharge will be consistent with bacterial conjunctivitis which is unlikely in this scenario. A previous history of bacterial conjunctivitis is unrelated to the current presentation. ⚠ (Option B) A lump in the upper eyelid is a finding in stye or chalazion, which have quite different presentations. ⚠ (Option C) Conjunctivitis does not affect vision. If vision is impaired, some other diagnoses other than conjunctivitis must be considered.

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⏳ Case-based MCQ | #Case_389 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 21-year-old woman presents to your office with itchy and watery eyes. Her symptoms started 2 days ago with redness of both eye, lacrimation and itching. She wears contact lenses. On examination, her upper and lower lids are erythematous bilaterally.

⏳ Case-based MCQ | #Case_388 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation The findings of recurrent asthma exacerbations, patchy opacities and central bronchiectasis on chest X-ray and eosinophilia and elevated IgE level are suggestive of allergic bronchopulmonary aspergillosis. The findings of allergic bronchopulmonary aspergillosis are: ✔ Recurrent episodes of asthma-like attacks ✔ Migratory pulmonary opacities on chest X-ray ✔ Central atelectasis on chest X-ray ✔ Peripheral blood eosinophila ✔ Elevated IgE levels ✔ Positive skin test for aspergillus fugamitus Treatment is with oral corticosteroids. Inhaled corticosteroids are not effective. Antifungal agents may be added

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⏳ Case-based MCQ | #Case_388 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 55-year-old man presents to your practice with increasing wheeze and shortness of breath for the past 2 days. His past medical history includes asthma with recurrent episodes with similar symptoms treated with oral corticosteroids. His current medications are inhaled corticosteroids and salmetrol. On examination, his blood pressure is 120/80mmHg, pulse 94bpm, and respiratory rate 22 breaths per minute. His oxygen saturation is 94% on room air. Respiratory examination is remarkable for widespread wheeze. The rest of the examination is inconclusive. Blood tests shows mild eosinophila and elevated IgE level. Chest X-ray shows central bronchiectasis and patchy opacities.

⏳ Case-based MCQ | #Case_387 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation The age of the child, history of atopy (eczema) and chronic intermittent cough favor the diagnosis of asthma. Asthma is common in this age group and is usually underdiagnosed. In atopic asthma, the child usually has the history of other atopies such as allergic rhinitis, eczema, etc. ⚠ (Option A) Epiglotitis has more pronounced and acute presentation with fever and cough, respiratory distress and drooling.The child is usually very ill. ⚠ (Option B) Chronic sinusitis may present with nocturnal cough caused by post nasal drip, but exertional cough is not usually a feature. Besides, the discharges tend to be more thick and purulent. There is also history of facial tenderness or fullness and recurrent upper respiratory infections. ⚠ (Option D) Gastro-esophageal reflux is rare in this age group. If present,it may cause chronic calf and mimic cough-variant asthma especially at night, but not exertional cough. Moreover, absence of other features such as heart burn makes this diagnosis far less unlikely. ⚠ (Option E) Whooping cough (pertussis) has a different presentation with paroxysms of cough and the terminal inspiratory whoop

⏳ Case-based MCQ | #Case_387 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 5-year-old child is brought to your clinic with complaint of cough. His mother explains that the coughs started 2 months ago, and sometimes wakes him up at night. He also has them when he plays with other children or runs and sometimes is associated with small amount of clear phlegm. On history, you realize that he had flexural eczema when he was 2 years old. There child is afebrile. On chest examination, no wheeze is heard. The rest of the physical exam is inconclusive.

⏳ Case-based MCQ | #Case_386 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation It is very important to consider malaria in all febrile returning travelers to areas where malaria is endemic. Following the bite of an infected female anopheles mosquito, the inoculated sporozoites go to the liver within 1-2 hours. The bitten individual is often asymptomatic for 12 to 35 days; however, symptoms can develop as early as 7 days. The incubation period for plasmodium falaciparum is 7; however, people who have taken antimalarial drugs or have partial immunity due to frequent exposures may develop symptoms much later. The incubation period for relapsing species plasmodium ovale and plasmodium vivax is approximately 2 weeks but clinical symptoms can occur months later due to activation of hypnozoites. The incubation period for plasmodium malariae is about 18 days. This man has been in Thailand for four days and his symptoms have started one day after he has returned. Even if bitten on the first day the diagnosis cannot be malaria given the fact that the minimum reported incubation period for malaria is at least 7 days (A is correct). ⚠ (Option B) In malaria, fever is almost always a feature. The fever is usually fluctuating and is associated with rigors, chills, and sweating. ⚠ (Options C and D) In a non-immune person, the spleen can be palpable after several days of symptoms. In such patients, lack of anemia early in the clinical course is common. Given these, a normal spleen, or the lack of anemia does not exclude malaria as the diagnosis. ⚠ (Option E) Clinical malaria often starts with fever, malaise, fatigue, tachycardia, tachypnea, sweating, headache, cough, anorexia, nausea, vomiting, abdominal pain, diarrhea, arthragia and myalgia. Mild jaundice may also be present. Fluctuating fever is almost always a feature. Since diarrhea can be a manifestation, its presence does not exclude malaria. 🔖 NOTE - In a person with malaria, laboratory findings other than anemia may include: thrombocytopenia, elevated transaminases, increased blood urea nitrogen (BUN) and creatinine, mild coagulopathy and hyperbilirubinemia (often indirect).