Case-based MCQ

Case-based MCQ | #MCQ_105 •••••••••••••••••••••••••••••••••••••• Concerned parents of a 5-year-old boy have brough him to the Emergency department because he has been having palpitations and dizziness since this morning. He is otherwise healthy with no significant medical history, and this is the first time he is experiencing it. An ECG as well as blood tests are arranged. On examination, he has a weak thready pulse which is so rapid that cannot be counted correctly. His blood pressure is 98/60 mmHg. He seems restless but does not seem to be breathless. Extremities are of normal temperature and color. A 12-lead ECG is obtained and is shown in the following photograph. Which one of the following is the most appropriate next step in management of him? A. Immersion of face in cold water. B. Intravenous adenosine. C. Intravenous amiodarone. D. Synchronized cardioversion. E. Intravenous esmolol

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Case-based MCQ | #MCQ_104 •••••••••••••••••••••••••••••••••••••• Explanation: ✔ Correct Answer Is B The scenario describes a baby who has developed dehydration (decreased urine output) as a result of vomiting in the background of UTI. This child needs rehydration as the most appropriate initial management. Dehydration is an indication for hospital admission and fluid resuscitation. Antibiotics should also be started for treatment of UTI. In the following conditions, ultrasound scan of the kidney, ureter and bladder is always indicated: Concurrent bacteremia Atypical UTI organisms: i.e., Staphylococcus aureus, Pseudomonas UTI <3 years old No/inadequate response to 48 hrs of IV antibiotics Abdominal mass Abnormal voiding (e.g., dribbling) Recurrent UTI First febrile UTI and no prompt follow up assured Renal impairment Significant electrolyte derangement No antenatal renal tract imaging in second to third trimester Since this child is younger than 12 months age, he needs an ulrasound as well. It is best to perform the ultrasound within the first 3 days of presentation. If the child is younger than 1 year, either ultrasound or micturating cystoureterogram or both can be used to exclude vesicoureteric reflux (VUR). If the child is older than 1 year, ultrasound is adequate. Early detection of VUR and control of recurrent urinary tract infections could prevent the development of reflux nephropathy and its complications including hypertension and chronic renal failure. NOTE – According to RCH guidelines, ultrasonography is indicated in the following situation (different from international guidelines and even National Guidelines by the Therapeutic Guidelines or RACGP): Children with atypical UTI, those not responding to treatment within 48 hours, and boys <3 months of age should have a renal ultrasound to exclude renal obstruction. Children <6 months should have a renal ultrasound within 6 weeks of diagnosis. It should be performed during the illness if the UTI is atypical or not responding to antibiotics within 48 hours. Older children do not require an ultrasound after the first UTI, but should have a renal ultrasound for recurrent UTI.

A mother brings her 10-month old boy to the Emergency Department with fever, nausea and vomiting. She mentions that she has used fewer nappies in the past 48 hours because he has been less wet. She also mentions that his urine has an offensive odor. A urine analysis is perfomed that is positive for nitrite and leukocytes consistent with urinary tract infection (UTI). This child has never had an UTI before. Which one of the following is the next best step in management?  A. Antibiotics and ultrasound of kidneys, ureter and bladder. B. Antibiotics, intravenous fluids and ultrasound scan of the kidneys, ureter and bladder. C. Antibiotics, oral fluids and discharge home once the child improves. D. Refer to a pediatrician. E. Antibiotics.

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Case-based MCQ | #MCQ_103 •••••••••••••••••••••••••••••••••••••• Correct Answer Is C Constellation of clinical findings in this patient, including vertigo, right Horner syndrome indicated by miosis, ptosis and anhidrosis, right-sided sensorineural hearing loss, blurred vision, and numbness of the right side of the face and left side of the body is highly suggestive of right-sided vertebrobasilar stroke. The vertebral arteries arise from the subclavian arteries, and as they course cephalad in the neck, they pass through the costotransverse foramina of C6 to C2. They enter the skull through the foramen magnum and merge at the pontomedullary junction to form the basilar artery. Each vertebral artery usually gives off the posterior inferior cerebellar artery (PICA). At the top of the pons, the basilar artery divides into 2 posterior cerebral arteries (PCAs). The vertebrobasilar arterial system provides blood supply to the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex. Occlusion of large vessels in this system usually leads to major disability or death (mortality rate>85%). Because of involvement of the brainstem and cerebellum, most survivors have multisystem dysfunction such as quadriplegia or hemiplegia, ataxia, dysphagia, dysarthria, gaze abnormalities, and cranial neuropathies. Fortunately, many vertebrobasilar lesions arise from small vessels and are small and discrete. The clinical correlates of these smaller lesions consist of a variety of focal neurologic deficits, depending on their location within the brainstem. Patients with small lesions usually have a benign prognosis with reasonable functional recovery. Vertebrobasilar strokes have distinct characteristic features that differentiate them from hemispheric strokes caused by lesions of anterior or middle cerebral arteries or internal carotid artery. These features include: When cranial nerves or their nuclei are involved, the corresponding clinical signs are ipsilateral to the lesion and the corticospinal signs are crossed, involving the opposite arm and leg. Cerebellar signs (e.g. dysmetria, ataxia) are frequently observed. Involvement of the ascending sensory pathways may affect the spinothalamic pathway or the medial lemniscus (dorsal columns), resulting in dissociated sensory loss, which is loss of one sensory modality on one side and preservation of other sensory modalities in the opposite limbs (dissociative sensory loss). Dysarthria and dysphagia are typically present. Vertigo, nausea, and vomiting, along with nystagmus, represent involvement of the vestibular system and are seen in vertebrobasilar strokes. Unilateral Horner syndrome occurs with brainstem lesions. Occipital lobe lesions result in visual field loss or visuospatial deficits. Cortical deficits, such as aphasia and cognitive impairments, are absent

Case-based MCQ | #MCQ_103 •••••••••••••••••••••••••••••••••••••• A 45-year-old man presents to the Emergency Department with complaints of acute-onset vertigo, right eyelid drooping, and numbness of the lower right half of the face. He also complains of blurred vision and decreased hearing in the right ear. On examination, he has a blood pressure of 176/95 mmHg, heart rate of 94 bpm, respiratory rate of 20 breaths per minute, temperature of 36.8°C, and oxygen saturation of 96% on room air. There is right-sided miosis, ptosis and anhidrosis. He has nystagmus and ataxic movements and sensory loss of the left upper and lower limbs. Rinne and Weber tests show sensorineural deafness of the right ear. Which one of the following could be the most likely cause of this constellation of symptoms? A. Right-sided Horner syndrome. B. Left vertebral artery thrombosis. C. Right vertebral artery thrombosis. D. Obstruction of the anterior communicating artery. E. Obstruction of the posterior cerebral artery.