Case-based MCQ

⏳ Case-based MCQ | #Case_370 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 21-year-old girl is brought to the emergency department with headache and mild neck stiffness. She had kidney transplantation last year. Examination of cerebrospinal fluid (CSF) reveals a cell count of 150 with 70% monocytes. CSF glucose level is 1.2 mmol/L and protein 1.8 g/L.

⏳ Case-based MCQ | #Case_369 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation Nipple discharge is always an abnormal finding except in late pregnancy or the postpartum period. Based on characteristics, there are seven types of nipple discharge: 1. Milky: white discharge; sometimes fat globules are seen under microscopy 2. Multicolored gummous: sticky discharge 3. Purulent: pus with white cells seen under microscopy 4. Watery: colorless discharge 5. Serous: faintly yellow, thin discharge 6. Serosanguineous: thin, clear discharge with pink tint, RBCs seen under microscopy 7. Bloody (sanguinous): pure blood Conditions associated with each type of discharge are as follows: ⚪ Milky Discharge Galactorrhea,or nonpuerperal lactation, usually results from multiple duct discharge from both breasts. The most common cause of nonpuerperal lactation is hyperprolactinemia associated with pituitary adenomas, medications or other causes resulting in increased production of prolactin (e.g. primary hypothyroidism).In many women,galactorrhea can be idiopathic. 🟣 Multicolored and Sticky Discharge Duct ectasia or comedomastitis is the most common cause of a multicolored, sticky discharge that is commonly bilateral and usually in perimenopausal woman.It begins as a dilation of the terminal ducts with an irritating lipid fluid collection and producing an inflammatory reaction resulting in discharge from the nipple. Duct ectasia is most frequently associated with pain,itching, and swelling in the nipple. Palpation of the areola can often reveal a tubular mass, reflecting the dilated ducts. Often a history of nipple manipulation is elicited. If the disease progresses, a mass can develop (plasma cell mastitis) that can mimic cancer. Surgery is indicated only if a mass forms or the discharge changes to serosanguinous or bloody. 🟠 Purulent Discharge In patients with acute puerperal mastitis, chronic lactation mastitis,central breast abscesses,or plasma cell mastitis, nipple discharge is purulent and usually unilateral. Breast cultures and smears may reveal a causative organism. Abscess formation usually requires incision and drainage if appropriate antibiotics and warm compreses are not effective. It is important to remove a portion of an abscess wall for histologic study to exclude an underlying cancer associated with secondary necrosis and infection. 🔴 Watery, serous, serosanguinous, and bloody Discharges Intraductal papillomas are the most common cause of these discharges, but fibrocystic disease, advanced duct ectasia, breast cancer, and vascular engorgement in near-term pregnancy can also be the causes. In patients over 50, malignancy becomes increasingly common, especially if the discharge is unilateral and associated with a mass. Surgical exploration is mandatory in this group of patients with this type of discharge, even if cytologic and mammographic findings are negative. ✅ NOTE - surgical referral is required if the nipple discharge is spontaneous and unilateral, or the patient is older than 60 years. ⚠ (Option B) Paget disease of the breast most commonly presents with a scaly, raw, vesicular, or ulcerated lesion that begins on the nipples and then spreads to the areola. Nipple discharge, if present at all, tends to be bloody rather than clear. ⚠ (Option C) Ductal ectasia presents with multicolored and sticky discharge. Toothpaste like discharge is a classic description of discharge associated with duct ectasia. ⚠ (Option D) With unilateral clear discharge in this woman,the most likely cause is a benign Intraductal papilloma. Although advanced duct ectasia and intraductal carcinoma are among other etiologies, they are less likely to be the cause compared with intraductal papilloma. ⚠ (Option E) Fibroadenoma does not cause nipple discharge.

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⏳ Case-based MCQ | #Case_369 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 55-year-old woman presents to your practice after noticing a clear nipple discharge from her right breast. On physical examination, no palpable mass is found in her breasts. Both nipples appear normal, however, pressure over the right areola causes discharge of clear fluid from the nipple.

⏳ Case-based MCQ | #Case_368 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D Of the options, labyrinthitis, Meniere's disease and lateral medullary syndrome can cause acute onset vertigo, tinnitus and hearing loss. Ataxia can be a presentation in patients with cerebellar or vestibular disease. Of these three, and given the inconclusive neurological examination, labyrinthitis is the most likely diagnosis. Acute labyrinthitis presents with acute vertigo often followed by nausea and vomiting, tinnitus, and hearing loss. A history of preceding viral upper respiratory tract infection is present in up to 50% of patients. Change in head position provokes vertigo. Each episode of vertigo lasts from few seconds to minutes. ⚠ Meniere's disease (option D) also presents with episodes of acute onset vertigo, tinnitus and hearing loss. However, patients with Meniere's disease often complain of ear fullness because the pathophysiology is excess endolymph in the labyrinth. Patients are usually middle-aged women with a positive family history for the condition. Finally, Meniere's disease is much less common compared to labyrinthitis. Given these, Meniere's disease in this patient is a less likely diagnosis compared to labyrinthitis. ⚠ (Option B) Vestibular neuronitis is the inflammation of the vestibular nerve often by a viral infection. Patients usually have a preceding viral upper respiratory infection or herpes zoster. Vertigo and imbalance are the prominent features of vestibular neuronitis and there is no hearing loss or tinnitus. Loss of balance is more prominent in vestibular neuronitis compared to other causes of vertigo, and patient commonly present with vertigo and falls. Symptoms in vestibular neuronitis are aggravated by change in the position of the head. Neurological examination in patients with vestibular neuronitis is otherwise normal. ⚠ (Option C) Acoustic neuromas are intracranial tumors that arise from the Schwann cell sheath of either the vestibular or cochlear nerve. As acoustic neuromas increase in size, they eventually occupy a large portion of the cerebellopontine angle. Although 5-15% of patients with acoustic neuroma present with acute onset of unilateral hearing loss, deafness has an insidious onset in this condition, making it a less likely diagnosis. Gradual hearing loss is overwhelmingly the most common presenting symptom of patients with acoustic neuroma. Imbalance and vertigo is not a prominent feature because as the tumor growth disrupts the vestibular nerve function slowly, there is enough time for compensation. Other features that may be present in patients with acoustic neuroma are headache and facial sensory impairment. ⚠ (Option E) Lateral medullary syndrome, also known as Wallenberg syndrome or posterior inferior cerebellar artery (PICA) syndrome has other clinical features in addition to vertigo, hearing loss, and tinnitus. Such features include cross-body sensory impairment (sensory impairment of the face on the affected side and that of the body on the other side), Horner's syndrome, and signs and symptoms indicative of the involvement of cranial nerves or their nucleus. Such signs and symptoms may include dysphagia (due to involvement of nucleus ambiguus that supplies the vagus and glossopharyngeal nerves), dysarthria, dysphonia, disrupted temperature and pain sensation, palatal clonus and heart rate and blood pressure dysregulation (due to involvement of the vagus nerve).

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⏳ Case-based MCQ | #Case_368 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 54-year-old woman presents to the emergency department with complaints of sudden onset vertigo, nausea, vomiting, and hearing loss in her left ear. On examination, her vital signs are within normal ranges. Hearing is decreased on the left side on whisper test. Rinne and Weber tests establish sensorineural deafness of the left ear. She has also nystagmus with the rapid eye to the left side. The rest of the examination is inconclusive.

⏳ Case-based MCQ | #Case_368 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 54-year-old woman presents to the emergency department with complaints of sudden onset vertigo, nausea, vomiting, and hearing loss in her left ear. On examination, her vital signs are within normal ranges. Hearing is decreased on the left side on whisper test. Rinne and Weber tests establish sensorineural deafness of the left ear. She has also nystagmus with the rapid eye to the left side. The rest of the examination is inconclusive.

⏳ Case-based MCQ | #Case_367 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D With the clinical findings of frontal headache and hypotension in a pregnant woman, pituitary apoplexy should be considered as one of the most important differential diagnoses. Pituitary apoplexy is defined as sudden hemorrhage into the pituitary gland. Hemorrhage often occurs into a pituitary adenoma. The most dramatic presentation of apoplexy is the sudden onset of excruciating headache, diplopia due to pressure on the oculomotor nerve, and hypopituitarism. All pituitary hormonal deficiencies can occur, but a fall in ACTH and, consequently, cortisol is most serious because it can cause life-threatening hypotension. In a series of 35 patients with pituitary apoplexy seen at one center, 97% had headache, 71% had visual field impairment, and 66% had decreased visual acuity. Only a minority had clinical manifestations of hormonal excess or deficiency, but there was biochemical evidence of gonadotropin deficiency in 79%, ACTH deficiency in 76%, and TSH deficiency in 50%. CT scan and MRI can be used for detection of intra-pituitary hemorrhage; however, MRI is more sensitive for evaluation of the pituitary gland. Hypopituitarism and the diplopia may improve after surgical decompression of the pituitary. Both problems may also improve spontaneously as the blood is absorbed over a course of weeks to months after the hemorrhage. For hypotension, high-dose corticosteroids are the mainstay of therapy. ⚠ (Options A and B) With headache and hypotension, subarachnoid hemorrhage can be another differential diagnoses, but headache of SAH tends to be much more severe (the worst headache in life) and often associated with neck stiffness. On the other hand, skull cannot accommodate enough blood to justify the hypotension and the tachycardia in this patient. CT scan of the head (non-contrast) and LP (if CT was inconclusive) are used if SAH is suspected. ⚠ (Option C) Ultrasonography is of no use in assessment of this patient with a possible intracranial pathology. ⚠ (Option E) Preeclampsia is defined as persistent hypertension and proteinuria after 20 weeks’ gestation. FBE, LFT, and urinalysis should be considered for excluding preeclampsia. This woman with hypotension is less likely to have preeclampsia.

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⏳ Case-based MCQ | #Case_367 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 An 18-week pregnat woman is brought to the Emergency Department with complaint of sudden-onset severe frontal headache. On examination, she has a blood pressure of 80/60 mmHg, pulse of 110 bpm,respiratory rate of 17 breaths per minute and temperature of 37.3°C. The rest of the examination is unremarkable. There is no neck stiffness, abdominal pain or tenderness, or uterine contractions.

⏳ Case-based MCQ | #Case_366 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B This clinical picture is suggestive of Noonan syndrome. This is an autosomal dominant disorder with mutation of chromosome 11. It has been described as the male Turner’s syndrome, but affects both sexes. Clinical features of the syndrome include the following: 🔴 Facial/eye features • Triangular face • Hypertelorism (increased distance between the eyes) • Down-slanting eyes • Ptosis • Strabismus - seen in 48% • Amblyopia - seen in 33% • Refractive errors - seen in 61% • Low-set ears with thickened helices • High nasal bridge • Short webbed neck 🔴 Chest/back features • Pectus carinatum/excavatum • Scoliosis 🔴 Cardiac features • Stenotic/dysplastic pulmonic valve is the characteristic cardiac anomaly • Hypertrophic cardiomyopathy (obstructive and non-obstructive)- seen in as many as 30% • Virtually all types of congenital heart defects have been described in patients with Noonan syndrome 🔴 Abdominal features • Hepatosplenomegaly unrelated to cardiac disease - seen in 25% of the patients 🔴 Genitourinary features • Renal anomalies are present in 10% of patients but are not clinically significant • More than half of male patients have undescended testes 🔴 Skeletal features •Joint laxity is present- seen in more than 50% of the patients • Less common findings include talipes equinovarus (club foot) that is an excessively turned-in foot and high medial longitudinal arc, radioulnar synostosis (fusion), cervical spine fusion, and joint contractures. 🔴 Skin findings • Lymphedema • Prominent pads of fingers and toes - seen in 67% • Follicular keratosis of face and extensor surfaces - seen in 14% • Multiple lentigines (a lentigo is a small, sharply circumscribed, pigmented macule surrounded by normal appearing skin) - seen in 3% 🔴 Neurological findings • Hypotonia • Seizure disorders - seen in 13% • Unexplained peripheral neuropathy - not seen frequently • Mental retardation Previously, patients with Noonan syndrome were thought to have a form of Turner syndrome, as clinical picture is similar to that of Turner’s. ⚠ Myopia and ectopic ocular lens is consistent with Marfan syndrome and not are features seen in Noonan syndrome.

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