Case-based MCQ

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⏳ Case-based MCQ | #Case_359 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C About 10% of women on combined HRT will have extremely dense breasts; nonetheless, presently, there is not enough evidence to recommend that patients on combined hormone replacement therapy should stop HRT for any length of time before their mammography in an attempt to reduce breast density. Therefore, this patient should continue HRT and have mammography based on current recommendations for other women. Women making decisions as to whether to commence combined HRT should be aware of the fact that HRT may lead to inaccurate mammography results. Furthermore, they should be informed about the increased risk of breast cancer if HRT extends beyond the recommended period (3 to 5 years).

⏳ Case-based MCQ | #Case_359 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 52-year-old lady presents to your GP clinic for breast cancer screening. She has been on combined hormone replacement therapy (HRT) for the past year. Mammogram is the only available method of screening for breast cancer and because of HRT she is expected to have dense breast tissue.

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⏳ Case-based MCQ | #Case_358 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Systemic sclerosis (SS) is a chronic systemic disorder of unknown cause. It is characterized by the thickening of the skin and the involvement of multiple internal organs. Thickening of skin distinguishes this disease from other connective tissue diseases. The disease has two distinct phases: an inflammatory and fibrotic phase. Patients with disease can be classified into two major subsets according to the degree of clinically involved skin. Diffuse cutaneous systemic sclerosis is more severe with prominent internal organ involvement, while in the limited form, it is less severe but is more likely to be associated with pulmonary arterial hypertension. Systemic sclerosis affects 9-19 per 100,000 and is more common in women. African Americans are more susceptible to disease. The age of onset is between 30 and 50 years. Development of sclerodermal renal crisis has been associated with glucocorticoid use, and indeed, the use of these drugs should be avoided in scleroderma. They can, however, be used in small doses to control the early skin symptoms, for myositis associated with scleroderma and for cardiac involvement. Thus, in this patient, prednisolone should be stopped completely (choice E) because it is used for non-life-threatening skin lesions. Other glucocorticoids, including dexamethasone, should be avoided in this patient. 🔖 Key point: Development of sclerodermal renal crisis has been associated with glucocorticoid use, which is managed by glucocorticoid discontinuation.

⏳ Case-based MCQ | #Case_358 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 37-year-old African American woman was diagnosed with diffuse type of scleroderma and was prescribed an antihistamine and prednisolone 5 mg/day to control the pruritus. Two months later, the patient came to you with severe headache, chest pain, and blurred vision. Her BP is 210/118 mmHg. Urinalysis showed proteinuria and microscopic hematuria. Blood urea nitrogen was 11 mmol/L (N 2.9-7.1 mmol/L), and serum creatinine was 124 pmol/L (N 50-90 pmol/L). Your patient was still taking prednisolone 5 mg/day prescribed earlier. You diagnosed your patient with sclerodermal renal crisis and decided to put her on an ACE inhibitor.

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⏳ Case-based MCQ | #Case_357 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E The presentation is classic for choanal atresia. Choanal atresia is a congenital abnormality in which there is failure of canalization of the bucconasal membrane. This can be either unilateral or bilateral and is usually due to a combination of bone and soft tissue anomalies. It occurs in 1:5000 to 1:8000 births. Unilateral atresia is more common, with a predilection for females. 🔆 CHARGE Syndrome (coloboma, heart defect, atresia choanae, retarded growth and development, genital abnormality and ear abnormality) or other congenital abnormalities are present in 50% of patients with bilateral choanal atresia. Bilateral choanal atresia is a relatively rare anomaly of the upper airway. As neonates are obligatory nasal breathers, presentation may be with life-threatening respiratory distress, retractions and paradoxical cyanotic episodes which are relieved by crying as the infant begins to breathe via the mouth. Unilateral choanal atresia does not usually produce severe symptoms. When choanal atresia is suspected the diagnosis can be confirmed with trying to pass a nasogastric tube. It is not possible to pass a nasogastric tube through the nares and choanae if there is choanal atresia. ⚠ In the presence of bilateral choanal atresia, as the history and physical suggest, oxygen through nasal cannula will be of no benefit. ➕ Other measures to consider as parts of management plan include: • Oxygen • Oropharyngeal airway • Intubation and ventilation if there is life-threatening hypoxemia • CT scan • ENT consultation and referral for surgical treatment Since the manifestation is typical of choanal atresia, chest X-ray is not indicated now, but it may be obtained to exclude other possible associated respiratory conditions or anomalies

⏳ Case-based MCQ | #Case_357 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 During physical examination of a 3 kg full-term male newborn, you notice that the baby's oxygen saturation decreases when he is laid. The fall in oxygen saturation is sometimes associated with mild cyanosis. However, when the baby starts crying the oxygen saturation increases again.

⏳ Case-based MCQ | #Case_356 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D Open fractures and/or dislocations are defined as the bone and/or joint being exposed to the external environment, or when the fracture or dislocation is caused by blunt or penetrating forces sufficient to disrupt or penetrate skin, subcutaneous tissue, muscle fascia, muscle, and/ or the bone or joint. Open fractures are often contaminated by foreign material (e g., clothing, grass, dirt, gravel), dead or devitalized tissue, and bacteria. Always follow the following rules in open fractures/ dislocations: • Remove any gross contamination off the wound. No provisional irrigation or debridement is performed at this stage. • Take photographs of the wound and dress it with wet sterile cover (the photographs are taken, so that other treating physicians do not need to uncover the wound to see it) • Give patient analgesic (preferably intravenously to both control the pain and prepare for a reduction in the emergency department). Morphine is a good option. • By gentle traction, reduce the fracture and correct misalignments as much as possible. • Start the patient on intravenous prophylactic antibiotics. • Give the patient tetanus prophylaxis If indicated • Obtain X-rays • Urgently arrange for transferring the patient to the operating room for surgical wound debridement and definite treatment of the fracture and dislocation NOTE • Initial irrigation or debridement in the emergency department is not recommended and should be avoided. In this scenario the most appropriate initial management would be reduction of the dislocation by gentle traction after non-surgical removal of any gross contamination, and analgesia. The patient then should be started on intravenous antibiotics and receive tetanus prophylaxis. ⚠ X-ray of the joint (option E) is required pre-operatively to visualize the anatomical disruption. Wound debridement (option A) is crucial but should be performed in the operating room ideally with 1-2 hours of presentation. NOTE - In open fractures, wound treatment may sometimes be more time-consuming and require more work than the treatment of the fracture itself. Debridement may be carried out several times before and after definitive fracture treatment is performed.

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