Case-based MCQ

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A 4-year-old girl is brought to the emergency department after ingesting an unknown tablet. She was playing on the kitchen floor at her grandfather's house when her mother saw her put a tablet in her mouth. Her parents cannot remember what medications the grandfather takes, but he has a history of hypertension, hyperlipidemia, and type II diabetes mellitus. The child's temperature is 36 C (96.8 F), blood pressure is 88/46 mm Hg, pulse is 120/min, and respirations are 28/min. She is pale, lethargic, and difficult to arouse. Serum glucose level Is 1.3 mmol/L (3.3-5.8). Ingestion of which of the following is the most likely etiology of this patient's symptoms? A. Atenolol B. Clonidine C. Metformin D. Nifedipine E. Glipizide

The correct answer is A. The plain film shows the typical “coffee-bean” sign seen in sigmoid volvulus.  A history of constipation, neuropsychiatric illness, bedridden, or neurologic disease with paralysis are risk factors for the development of this diagnosis, which can lead to a large bowel obstruction.  Early in diagnosis, the patient can present with mild distension, nausea, and tympanic abdomen but late in the presentation they can have pain, severe distension and volvulus can even continue on to perforation due to high pressures causing the severe distension of the large bowel proximal to the volvulus point.  The distension can also lead to an elevated diaphragm thus compromising respiration. ⚠ Choice B and D are not correct: These are both risk factors for the development of mesenteric ischemia, which presents with abdominal pain out of proportion to examination. It also presents in older patients with abdominal pain and bright red blood per rectum. Plain abdominal films are usually normal in these patients but rarely can show pneumatosis intestinalis. Hypertension is also a risk factor for development of aortic aneurysms/dissection. ⚠ Choice C is not correct: Recent antibiotic use predisposes a patient to the development of antibiotic-associated colitis or Clostridium difficile. Plain film imaging is typically negative. A CT scan may show evidence of thickened bowel wall, but the ultimate diagnosis of C. difficile is by identifying the toxin in a patient’s stool sample. Summarized Points: Volvulus can be identified on plain radiography by the "coffee-bean" or "bent-tire" sign

An 88-year-old female presents from a long-term care facility after several hours of vomiting witnessed by the staff.  She has multiple other comorbidities and is unable to provide history, but her examination is remarkable for abdominal distention, tympany, and a lack of auscultated bowel sounds. Vital signs include pulse 108/min, respiratory rate24/min, blood pressure 160/78 and pulse oximetry 93% on room air. A lateral decubitus abdominal film is obtained as the patient is unable to stand due to contractures and is attached. What is the most likely historical feature leading to this patient’s diagnosis? A. Constipation B. Hypertension C. Recent antibiotic use D. History of atrial fibrillation

The correct answer is C. All the new atypical antipsychotics have reduced extrapyramidal side effects, and clozapine has the least effect on the basal ganglia. It works predominantly as an antagonist to D1, D3, and D4 dopamine receptors. Of all the antipsychotics, it has the lowest activity against D2 receptors, which is the best measure of a drug’s potential to cause extrapyramidal side effects. Clozapine appears more effective in the mesolimbic dopamine pathways, which are disrupted in psychotic states and less effective in the nigrostriatal systems crucial to fluid movement. The main limitation to using clozapine is the risk of agranulocytosis (1 to 2%), which requires weekly leukocyte counts for the first 6 months of treatment, then every 2 weeks thereafter. Choice A is not correct: Chlorpromazine is an example of a typical antipsychotic. It is considered a low-potency antipsychotic and has less of a tendency to cause extrapyramidal side effects than do the high-potency antipsychotics. It is still more likely than any of the atypical antipsychotics to worsen this patient’s parkinsonism and should be avoided here. ⚠Choice B is not correct: Clomipramine is a tricyclic antidepressant. In addition to its inhibition of norepinephrine reuptake, it is a strong serotonin reuptake inhibitor, making it a good choice for treatment in obsessive-compulsive disorder (OCD) when SSRIs are poorly tolerated. It has no role in the treatment of psychosis. ⚠Choice D is not correct: Haloperidol is one of the high-potency anti-psychotics, and it may produce prominent extrapyramidal side effects. It would very likely improve this patient’s psychosis but would also worsen her parkinsonian symptoms. In general, haloperidol is never used in patients with Parkinson disease. ⚠Choice E is not correct: Pergolide is a dopamine agonist and may be used as adjuvant therapy in Parkinson disease to lessen the daily Sinemet requirement. It would tend to produce the same CNS side effects as Sinemet, including dyskinesias and visual hallucinations. Summarized Points: Clozapine has less extrapyramidal side effects due to less activity against D2 receptors, therefore is good choice to use for Parkinson psychosis.

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68-year-old woman with a 9-year history of Parkinson disease has developed worsening problems with visual hallucinations. In particular, she complains of seeing cats crawling along the floors in her house. She is taking L-dopa/carbidopa (Sinemet) and has had significant improvement in her rigidity. Which of the following drugs would be most appropriate for her psychosis? A. Chlorpromazine B. Clomipramine C. Clozapine D. Haloperidol E. Pergolide

The correct answer is D. The level of serum sodium in this patient is 170 mmol/L. Infants who have hypernatremic dehydration are irritable and lethargic, and have a high-pitched cry. This type of dehydration results from a greater loss of hypotonic fluid than sodium and accounts for about 15% cases of dehydration. Because the patient has no history of diarrhea or vomiting, the hypernatremia may be due to inadequate supply of mother's milk that does not match the insensible water loss. Another cause can be the high concentration 'Of sodium in mother’s milk. Generally, after the child's birth, sodium in the colostrum decreases from its highest level to its lowest level by the fourth week. However, some mothers continue to excrete high sodium in their milk and can potentially cause recurrent hypernatremia and in some case intracranial hemorrhage in the infant. ⚠Choice A, B, C are not correct: Hypocalcemia, hypoglycemia and hypomagnesemia are all potentially metabolic causes of seizures, however in this vignette serum calcium, glucose and magnesium are within normal limits. In patients with hypernatremic dehydration, hyperglycemia can result due to excess glucagon stimulation. ⚠Choice E is not correct: Meningitis should be considered in any infant with a seizure with or without fever. However, the marked rise of the serum sodium makes this diagnosis unlikely. Summarized Points: Neonates, especially premature newborns, and young infants can develop hypernatremia from excessive sodium due to the decreased ability of immature kidneys to excrete a sodium load. This becomes a problem especially in the premature neonate when intravenous sodium bicarbonate is used to correct a metabolic acidosis. But the most common cause of hypernatremia is due to inadequate supply of mother's milk.

A 3-week-old African American boy is brought to the Emergency Department because of a generalized seizure 2 hours ago. The infant is highly irritable with incessant high pitched crying. The infant's weight is 2.5 kg (250 gm below birth weight), blood pressure is 70 /40 mm Hg, pulse is 145/min and respirations are 50/min. Laboratory results show:   Blood glucose 6.6 mmol/L   Urea nitrogen 18 mmol/L   Serum sodium 170 mmol/L   Serum calcium 2.1 mmol/L   Serum magnesium 0.6mmol/L   Which of the following is the most likely cause of this infant’s seizure? A. A Hypocalcemia B. Hypoglycemia C. Hypomagnesemia D. Intracranial hemorrhage E. Meningitis

The correct answer is B. Rh-negative pregnant women who are carrying an Rh-positive fetus are at risk for Rh isoimmunization. Therefore, if the patient is Rh-positive, or both the patient and her partner are Rh-negative, there is no risk. In Rh isoimmunization, transplacental hemorrhage causes the Rh-negative mother to produce antibodies to the Rh-antigen of the fetus. The antibodies then destroy fetal red blood cells. The first exposure usually does not produce Rh isoimmunization. It is generally the second exposure that causes hemolytic disease in the fetus. Severe exposure can cause anemia, hydrops fetalis, and neonatal kernicterus. ⚠ Choice A is not correct: If both the patient and the father are Rh-negative, there is no risk of Rh isoimmunization. ⚠ Choice C and D are not correct: Rh isoimmunization occurs in Rh-negative, not Rh-positive, women. Summarized Points: To prevent Rh isoimmunization, unless the father is also Rh-negative, all Rh-negative pregnant women should receive the RhoGAM injection at 28-weeks gestation, within 72 hours of delivery if the neonate is Rh-positive, if they experience vaginal bleeding or abdominal trauma during pregnancy, have any form of miscarriage, have an invasive procedure such as CVS or amniocentesis, have an external cephalic version, or experience an ectopic pregnancy.

A 25-year-old woman presents to the emergency department with a chief complaint of vaginal bleeding. She states that she is approximately 18-weeks pregnant and has not received any prenatal care. Laboratory studies, including ABO/Rh testing, are ordered and pending at this time. Which of the following patients should receive the RhoGAM injection to prevent Rh isoimmunization? A. An Rh-negative patient whose partner is Rh-negative B. An Rh-negative patient whose partner's blood type is unknown C. An Rh-positive patient whose partner is Rh-positive D. An Rh-positive patient whose partner's blood type is unknown

The correct answer is C. This patient's presentation is suspicious for child abuse and neglect, considering the developmental delay and disheveled/dirty appearance of the child. Injuries that seem unlikely to be explained by the proposed history should cause the clinician to search out other etiologies. An injury over the posterior legs and buttocks suggests the child was placed into the hot water by her caregiver. If she stepped into the water, she would have a burn over the lower legs and feet, as well as on her buttocks if she sat down in the water. Social services should be notified in all cases of suspected child abuse. ⚠Choice A is not correct: Follow-up care is appropriate, but social services must be contacted first. ⚠Choice B is not correct: Superficial burns should not be managed with hot compresses, but rather cool, loosely wrapped bandages. ⚠Choice D is not correct: A parent whose child had been involved in an accidental injury would certainly require reassurance and counseling, but the pattern of the child's burns indicates that this injury was not accidental. ⚠Choice E is not correct: Referring the parents to family counseling may also be an important intervention. However, social services should be notified first. 🔖 Summarized Points: Child abuse and neglect should be considered when a child's injuries seem unlikely given the reported circumstances. Social services should be notified in all cases of suspected child abuse.

A 2-year-old girl is brought to the hospital by her father because of an acute burn. She is developmentally delayed and is crying loudly. Her father says he was getting her ready for a bath and had not yet tested the water's temperature. However, the child climbed in and burned herself. Physical examination reveals a disheveled child with dirt on her face and intertriginous areas. Examination of the burn area reveals intact bright red, edematous skin extending over the child's buttocks and covering the posterior upper thighs. Which of the following is the most appropriate next step in management? A. Arrange for follow-up care B. Bandage lower limbs with hot compresses C. Contact social services D. Reassure and educate the parent E. Refer parent to family counseling

The correct answer is E. This patient has benign paroxysmal positional vertigo (BPPV), as manifested by brief episodes of vertigo that most often occur with certain head positions. Characteristically, other vestibulocochlear symptoms such as hearing loss or tinnitus are absent. On examination these patients have positional nystagmus, usually when the head is turned into the position that causes vertigo. The condition results from otolith debris accidentally entering one of the semicircular canals and brushing against the sensory cilia. The Dix-Hallpike maneuver will reproduce symptoms. This condition is improved by simple bedside maneuvers such as the Epley maneuver. During this maneuver, the patient's head is turned in a certain direction so that otolith debris moves toward the utricle, and the sequence of movements is repeated until no nystagmus is elicited. ⚠Choice A is not correct: An FM clock-radio tuned between stations at night is a controversial treatment used for patients with severe tinnitus that is especially bothersome at night. ⚠Choice B is not correct: Intratympanic gentamicin is a treatment for severe Meniere's disease that is not responsive to traditional treatment. ⚠Choice C is not correct: A low-salt diet and diuretics are the treatment of choice for Meniere's disease, in which patients present with vertigo, hearing loss, tinnitus, and aural fullness. ⚠Choice D is not correct: Methylprednisolone is used to treat vestibular neuritis, a viral condition that causes nausea and vomiting in addition to vertigo. Summarized Points: Benign paroxysmal positional vertigo presents with brief episodes of vertigo that occur only with certain head positions. It occurs as a result of otolith debris entering the semicircular canals. These patients have a positive Dix-Hallpike maneuver, in which head manipulations will reproduce their symptoms. Treatment includes the Epley maneuver and symptoms usually resolve in a few months.

A 42-year-old woman presents to her primary care physician with complaints of vertigo. She states that the episodes are severe and typically occur when she tilts her head backward. The episodes usually last several seconds to a minute, and most commonly occur while she is in bed. There is no associated hearing loss or tinnitus. Her temperature is 36.7 C (98.1 F), heart rate is 83/min, blood pressure is 125/80 mm Hg, and respiratory rate is 16/min. Apart from positional nystagmus, her neurologic examination is within normal limits.  What is the most appropriate management for this patient's condition? A. An FM clock-radio tuned between stations at night B. Intratympanic gentamicin C. Low-salt diet and diuretics D. Methylprednisolone E. Epley maneuver

To manage her symptoms, she was put on dietary restrictions. She has maintained a daily intake of sodium of <1000 mg for the past 6 weeks. She does not drink or smoke tobacco. However, her symptoms of vertigo, tinnitus, and associated nausea have not been alleviated. Which of the following is the most effective next step in management?   A. Intracochlear gentamicin injection B. Labyrinthectomy C. Metoclopramide D. Sacculotomy E. Trial of diuretics

The correct answer is C. The most appropriate physical examination maneuver to test for complete rupture of the Achilles tendon is the Thompson test, which has a sensitivity of 96% and specificity of 93%. With the patient lying in the prone position, feet hanging off the table, the clinician should squeeze the patient’s calf muscles and observe for the presence of plantar flexion of the foot. If plantar flexion is not observed on calf squeeze, the test is positive and indicates complete rupture of the Achilles tendon. ⚠Choice A is not correct: Tinel’s test is performed at the elbow or wrist to test for signs of nerve entrapment. It is performed by repetitively tapping an area of suspected nerve entrapment to elicit a tingling response in that nerve distribution. ⚠Choice B is not correct: Absence of active plantar flexion is not as reliable as the calf-squeeze test to rule out Achilles tendon rupture because the patient can also use accessory muscles (fibularis longus, fibularis brevis, plantaris, and tibialis posterior) to actively plantar flex and falsely reassure the clinician. ⚠Choice D is not correct: This test is for spine in which examiner passively flexes, abducts, and externally rotates the involved leg until the foot rests on the top of the knee of uninvolved lower extremity; examiner slowly abducts the involved lower extremity towards the table. The positive test is indicative of iliopsoas tightness, sacroiliac dysfunction, or hip joint abnormalities. ⚠Choice E is not correct: Lhermitte sign/ Barber chair phenomenon is flexion of neck producing electric shock like sensations that extend down the spine and shoot into the limbs. indicates spinal canal stenosis, disc impingement, multiple sclerosis, or tumor. Summarized Points: Complete rupture of the Achilles tendon is a clinical diagnosis that can be supported with a positive Thompson test, which is >90% sensitive and specific. The Thompson test observes for plantar flexion of the foot when the calf muscle is squeezed. The absence of plantar flexion signifies complete rupture and a positive test result.

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