Case-based MCQ

Case-based MCQ | #MCQ_86 •••••••••••••••••••••••••••••••••••••• The lesion shown has a bluish-glistening color and is dome-shaped. These are characteristics of a benign mucoid cyst. A mucous cyst, also known as a mucocele forms when mucus or saliva escapes into surrounding tissues. A lining of granulation or connective tissue is formed to create a smooth, soft round fluid-filled lump. They most commonly occur on the inner surface of the lower lip (75% of cases) but may also appear on the floor of the mouth or on the gums, buccal mucosa, and tongue. If persistent or bothersome, an incision and evacuation of the cyst are performed. 

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On a routine health examination, the lesion shown in the following photograph is found on the inner side of the lower lip of a 37-year-old man. The lesion is painless. Which one of the following is the most likely diagnosis? A. Sebaceous cyst. B. Peutz - Jegher's syndrome. C. Squamous cell carcinoma of the lip. D. Mucous cyst.  E. Basal cell carcinoma.

Case-based MCQ | #MCQ_85 •••••••••••••••••••••••••••••••••••••• Correct Answer Is A Every lesion suspected of being melanoma should be surgically excised with 2 mm margins both as the initial management and the most appropriate step in diagnosis. Further management is then guided by tne results of the biopsy. If the lesion is proved to be melanoma, a wider excision is needed. The margins of the second excision depend on the reported depth of melanoma. For melanomas greater than 1mm in depth, a sentinel node biopsy is recommended during the second excision to assess the potential metastasis to the subcutaneous tissue and lymph nodes

Case-based MCQ | #MCQ_85 •••••••••••••••••••••••••••••••••••••• A 32-year-old woman presents to your clinic for a skin checkup. On examination, she is found to have a skin lesion on her upper back. The lesion is highly suspected of being melanoma. An excisional biopsy is performed with 2 mm margins and the specimen is sent to a laboratory for histopathological studies. The result is a melanoma of 2.5 mm in depth. The margins, however, are clear. Which one of the following would be the next best step in management? A. A wider excision. B. Radiation therapy. C. Sentinel node biopsy. D. CT scan of the head. E. Chemotherapy

Case-based MCQ | #MCQ_84 •••••••••••••••••••••••••••••••••••••• Carotid endarterectomy is the procedure of choice in some patients with carotid stenosis. This procedure is associated with complications, the most important of which are as follows: Perioperative stroke Myocardial infarction Hyper-reperfusion syndrome Cervical hematoma Nerve injury Infection Carotid restenosis Postoperative cervical wound hematoma is a potentially lethal complication of carotid endarterectomy (CEA). The hematoma can rapidly distort the airway anatomy, making tracheal intubation difficult, and ultimately causing fatal airway obstruction. Post-CEA patients might develop airway emergencies related to hematoma formation either in the hospital or after discharge. The progressive short of breast in this patient is most likely to have been caused by an expanding cervical hematoma. As always, management starts with the ABCD of life support (airway, breathing, circulation, and disability). The first step in this approach is ensuring and maintaining a patent airway.  This patient has a rapidly deteriorating airway in need of urgent attention with intubation (option A). Initial method of airway management is based on the location, severity, and progression of the hematoma. Most patients can be managed successfully using a stepwise approach, beginning with awake fiber-optic intubation if time permits. If this fails, laryngoscopy, with either a direct or video laryngoscope, is a reliable backup. However, in a time-sensitive critical situation where there is impending respiratory compromise or airway loss, opening of all the wound layers at the spot (patient’s bedside in the Emergency Department in this scenario) to decompress the trachea and facilitate airway management should always be considered first as the most immediate action

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A 65-year-old man underwent an uneventful right carotid endarterectomy 4 days ago. Today, he presents with shortness of breath which is progressively becoming worse. Which one of the following would be the best immediate step in management? A. Intubation. B. Tracheostomy. C. Opening all the wound layers in the Emergency Department. D. Supplemental oxygen via face mask. E. Opening all the wound layers in the operating theater

Case-based MCQ | #MCQ_83 •••••••••••••••••••••••••••••••••••••• John has not completed his primary course of tetanus vaccination. On the other hand, his wound is contaminated with soil and is dirty. With an incomplete course of primary immunization and a dirty wound, he should receive TIG for passive and a tetanus-containing vaccine immediately. Since he is under the age of 10 years, the appropriate vaccine for him is a DTPa containing vaccine.

John, 5 years of age, falls from a swing and injures his right leg. Accompanied by his parents, he is now in the Emergency Department. He has a 5 mm deep laceration in a 2x3 abrasion on his right leg. The wound is contaminated with soil. You disinfect the wound and ask his parents about his tetanus vaccination status. He has received 2 doses of DTPa at 2 and 4 months of age, but not the third dose at 6 months or thereafter. Which one of the following is the appropriate management plan for him regarding tetanus vaccination? A. One dose of DTPa now and a booster dose after 2 months. B. One dose of DTPa plus tetanus immunoglobulin (TIG) now. C. One dose of dT plus TIG now. D. One dose of DTPa now plus a 5-day course of topical antibiotic cream. E. One dose of DTPa now plus a 5-day course of oral penicillin

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Case-based MCQ | #MCQ_82 •••••••••••••••••••••••••••••••••••••• Correct Answer Is B To date, medications have been the most common cause of adverse allergic reactions. Allergic reactions can vary from immediate- to late-onset ,and from a not-clinically-significant rash to potentially life-threatening complications and systemic involvement.Lamotrigine, on the other hand, is well known for causing rash as a less frequent adverse effect.  Simultaneous use of lamotrigine and sodium valproate has been associated with the higher chances of rash development. Rash as an adverse effect of lamotrigine occurs between 5 days and 8 weeks (2 months) of taking lamotrigine. The rash might be maculopapular that often do not coalesce. Lesions are not tender on palpation but may be pruritic. The rash is not significant if there are no associated systemic symptoms such as fever, malaise, etc either before the appearance of the rash or contemporaneously.   There is also a more serious, but rarer form of rash that starts as a morbiliform rash progressing more or less rapidly to a diffuse confluent, and infiltrated erythema with follicular accentuation (hair follicles are raised and bumpy). This rash of lamotrigine is often associated with complications such as Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN), or drug reaction with eosinophilia and systemic symptoms (DRESS). On the sight of any rash while the patient is on lamotrigine, the drug should be immediately stopped, and careful evaluation performed. (Option A) Sodium valproate has many potential adverse effects, but rash has been a very rare finding as an adverse reaction associated with this drug. Direct association of the rash and sodium valproate, although not impossible, seems very unlikely. There have been only few reports about such association. (Option C) Amoxicillin and other penicillins are among the most common causes of allergic drug reactions while the patient is taking them. This patient has completed a course of amoxicillin for her UTI. She is not on the medication now; hence amoxicillin is not likely to be the cause of her presentation. (Option D) There is no clue in history suggesting septicaemia as a cause to the rash; furthermore, with septicaemia a higher fever would be expected. (Option E) Rash is not the result of interaction between lamotrigine and sodium valproate. It is more attributable to lamotrigine with enhancement by concomitant use of sodium valproate

A 16-year-old girl, who is a known case of epilepsy for 5 years, has been started on sodium valproate and lamotrigine 4 weeks ago after her previous medications failed to control her seizures. She also has the history of recurrent urinary tract infections (UTI) with last episode 6 weeks ago for which she received amoxicillin. Today, she has presented with a maculopapular rash and a fever of 38°C. Which one of the following is the most likely cause of her presentation? A. Adverse drug reaction to sodium valproate. B. Adverse drug reaction to lamotrigine. C. Adverse drug reaction to amoxicillin. D. Septicemia. E. Drug interaction between lamotrigine and sodium valproate

Correct Answer Is D This patient has overdosed on paroxetine, a selective serotonin reuptake inhibitor (SSRI).  Isolated SSRI ingestions are generally much safer compared to overdose of other antidepressants such as tricyclic antidepressants.  Patients are frequently asymptomatic or have mild CNS depression. Therefore, when a patient with an SSRI overdose has altered mental status (eg, not following commands and withdrawing to painful stimuli) or abnormal physical findings, other causes (eg, coingestions, infections) should be investigated.  This patient’s decreased level of consciousness and respiratory rate suggest an additional ingestant (eg, ethanol, benzodiazepine).  Other coingestants that should be considered include acetaminophen and salicylates. In general, laboratory evaluation of symptomatic patients with suspected SSRI overdose should also include an ECG (although most SSRIs are not cardiotoxic, citalopram and escitalopram can prolong the QT interval), glucose level (useful in any patient with overdose or altered mental status), and serum bicarbonate level (for possible metabolic acidosis). Activated charcoal is a highly absorbent powder that reduces the absorption of certain substances (eg, SSRIs) in the gastrointestinal tract.  It should be administered to awake, alert patients within a few hours of certain toxic ingestions.  Altered mental status is a contraindication to charcoal due to risk of aspiration. Cyproheptadine is the antidote for serotonin syndrome in patients unresponsive to supportive measures and benzodiazepines.  This patient has overdosed on a serotonergic agent but does not have symptoms consistent with serotonin syndrome (eg, autonomic dysregulation, hyperreflexia). Sodium bicarbonate is used to treat cardiac dysrhythmias associated with tricyclic antidepressant (TCA) overdose.  TCA overdose can present with somnolence but also is associated with anticholinergic (eg, dry mucous membranes, urinary retention) and cardiovascular (eg, sinus tachycardia) side effects, which are not present in this patient. Serum levels of SSRIs are not readily available in emergency situations and do not correlate with changes in mental status and symptom severity. Isolated overdose of selective serotonin reuptake inhibitors (SSRIs) is usually well tolerated.  When a patient with SSRI overdose has altered mental status and abnormal physical examination findings, levels of common coingestants (eg, salicylates, ethanol) should be obtained.

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