Case-based MCQ

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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An 18-year-old woman is brought to the emergency department after a suspected drug overdose at 6 AM. The mother states that she had awakened this morning to find her daughter difficult to rouse and covered in emesis. The prescription bottle of paroxetine 20 mg containing 30 pills filled the previous day was next to her and was empty. She does not know when or if her daughter took the medication. She last saw her daughter the previous evening before going to bed at 10 PM. Her daughter has a history of major depressive disorder but has no known previous suicide attempts. Temperature is 36.1 C, blood pressure is 110/70 mm Hg, pulse is 70/min, and respirations are 10/min. Pulse oximetry is 98% on room air. On examination, the patient’s clothes are stained with emesis. Her eyes are closed, and she does not follow commands but moans and withdraws all the extremities to painful stimuli. The pupils are normal sized, equal, and reactive. Muscle tone and reflexes are normal. Cardiopulmonary and abdominal examinations are normal. There is no evidence of trauma. Which of the following is the best next step in management? A. Administer activated charcoal B. Administer cyproheptadine C. Administer sodium bicarbonate D. Evaluate for coingestants E. Obtain serum levels of paroxetine

⚠️ 🔔 𝐒𝐀𝐕𝐄 𝐓𝐇𝐈𝐒 𝐋𝐈𝐒𝐓 𝐅𝐎𝐑 𝐀 𝐑𝐀𝐈𝐍𝐘 𝐃𝐀𝐘 ! ⬇️ 1. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬) 2. 𝗖𝗔𝗦𝗘 - 𝗕𝗔𝗦𝗘𝗗 𝗠𝗖𝗤𝗦 ❔ 3. 🇨🇦 𝗠𝗖𝗖𝗤𝗘 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡 4. 🩺 𝗘𝗗𝗟 𝗠𝗘𝗗𝗜𝗖𝗢𝗦 (𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 𝗔𝗡𝗗 𝗟𝗜𝗡𝗞𝗦) 5. 📚 𝗘𝗗𝗟 𝗣𝗛𝗔𝗥𝗠 6. 🏛📷 𝗢𝗡𝗟𝗜𝗡𝗘 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗦𝗖𝗛𝗢𝗢𝗟 7. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗚𝗘𝗥𝗠𝗔𝗡𝗬 🇩🇪 8. 𝗣𝗥𝗔𝗖𝗧𝗜𝗖𝗘 𝗜𝗡 𝗔𝗨𝗦𝗧𝗥𝗔𝗟𝗜𝗔 🇦🇺 9. 𝗠𝗕𝗕𝗦 & 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗜𝗧𝗔𝗟𝗬 🇮🇹 10. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗞 🇬🇧 11. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗦 🇺🇸 12. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗖𝗔𝗡𝗔𝗗𝗔 🇨🇦 13. 𝗙𝗥𝗘𝗡𝗖𝗛 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇫🇷 14. 𝗚𝗘𝗥𝗠𝗔𝗡 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇩🇪 15. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗦𝗘𝗔𝗥𝗖𝗛 🎓🫥 16. 📸 𝗗𝗘𝗥𝗠𝗔𝗧𝗢𝗟𝗢𝗚𝗬 𝗔𝗧𝗟𝗔𝗦 17. 𝗢𝗘𝗧 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡 ✅ 18. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐 19. 𝗖𝗔𝗥𝗗𝗜𝗢𝗟𝗢𝗚𝗬 𝗖𝗔𝗦𝗘𝗦 🫀 20. 💠 𝗨𝗪𝗢𝗥𝗟𝗗 𝗘𝗗𝗨𝗖𝗔𝗧𝗜𝗢𝗡𝗔𝗟 𝗢𝗕𝗝𝗘𝗖𝗧𝗜𝗩𝗘𝗦 21. 𝗠𝗘𝗗𝗜𝗖𝗖𝗢𝗨𝗡𝗧 - 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗖𝗖𝗢𝗨𝗡𝗧 🔄

Case-based MCQ | #MCQ_80 •••••••••••••••••••••••••••••••••••••• Correct Answer Is B The findings of high blood pressure and bradycardia (Cushing reflex) points towards increased intracranial pressure (ICP) as the most likely cause of such presentation. Cushing reflex (also the vasopressor response, Cushing effect, Cushing phenomenon and Cushing reaction ) is a physiological nervous system response to ICP. Cushing triad is: (1) hypertension, (2) bradycardia and (3) irregular breathing e.g. Cheyne-Stoke. This triad may indicate imminent brain herniation. Increased ICP is more underpinned by the presence of the ‘doll eye’ sign (movement of the eyes in the same direction as the head) signifying involvement of brainstem, probably due t o increased intracranial pressure. The raised ICP is very likely to be compromised by dextrose drip which has already been inappropriately started for the patient. Dextrose is rapidly consumed by cells and the remaining free water shifts into the brain extravascular tissue, and results in worsening of the edema, swelling and more increased ICP. For this reason, the dextrose drip should be stopped first as the most important immediate management. An unconscious patient is not able to maintain airway patency. Furthermore, there is significant risk of aspiration; therefore, the patient should be intubated, but not as the first priority at this stage, considering the fact that the patient is breathing spontaneously and is not hypoxemic (0 2 saturation 95%). The patient should then be taken for CT scan of the head for determination of the likely causes of her problem. Consultation with or referral to the neurosurgery specialist should be arranged. Intravenous methylprednisolone has shown effective in spinal cord compressions and cases of increased ICP due to tumors and abscesses. If, after neuroimaging, the cause of ICP was found to be an abscess or a tumor, corticosteroids may be considered as a part of management plan.  

Case-based MCQ | #MCQ_80 ••••••••••••••••••••••••••••••••••••••  A 12-year-old school girl is brought to the emergency department of a tertiary hospital after she collapsed at school. En route to the hospital, she was started on dextrose 5% drip at a rate of 60 ml/minute. On examination after arrival at the emergency department, she has blood pressure of 180/110 mmHg, pulse rate of 50 bpm and respiratory rate of 12 breaths per minute. Doll eye reflex is present. Which one of the following would be the next best step in management ? A. Arrange for emergency CT scan of the head B. Stop the dextrose drip C. Give intravenous steroids D. Intubate her immediately and start mechanical ventilation E. Neurosurgical reference

Case-based MCQ | #MCQ_79 •••••••••••••••••••••••••••••••••••••• This patient with chronic pain has altered mental status, hypotension, signs of anticholinergic toxicity (eg, facial flushing, dry mouth), and a prolonged QRS interval.  These clinical features suggest tricyclic antidepressant (TCA) poisoning; TCAs are frequently prescribed for migraine prophylaxis. TCAs exert their antidepressant effects by inhibiting presynaptic neurotransmitter reuptake; however, they interact with multiple other receptors, leading to the characteristic manifestations of TCA overdose.  In addition, TCAs can block cardiac fast sodium channels, resulting in conduction abnormalities (QRS and QT interval prolongation), which can lead to fatal arrhythmias (eg, ventricular tachycardia, ventricular fibrillation). Management of TCA poisoning includes supportive care, telemonitoring, intravenous fluids, and benzodiazepines if seizure occurs.  In addition, when the QRS interval >100 msec (as in this patient), intravenous sodium bicarbonate should be given to shorten the QRS interval and reduce the risk of fatal arrhythmias.  Sodium bicarbonate alkalinizes the plasma, which favors the nonionized (neutral) form of the drug and makes it less accessible to bind to sodium channels.  It also increases the extracellular sodium concentration, which helps overcome the sodium channel blockade induced by TCAs. Amiodarone is an antiarrhythmic medication used to treat ventricular fibrillation, ventricular tachycardia, and wide-complex tachycardias.  Although it is not well studied in TCA overdose, amiodarone can cause QTc interval prolongation and is not recommended. Atropine is indicated for organophosphate toxicity, which also presents with altered mental status typically after exposure to agricultural pesticides.  However, signs of cholinergic excess (eg, salivation, urination, diarrhea, bradycardia) would be expected, and QRS interval widening is not typical. Calcium chloride is indicated for treatment of severe hyperkalemia (in addition to insulin with glucose and beta agonists).  It also is indicated for calcium channel blocker (CCB) overdose; CCBs are often used to prevent migraines.  Hyperkalemia causes arrhythmias and QRS interval widening but typically produces other ECG findings (eg, peaked T waves).  CCB overdose frequently causes hypotension and atrioventricular blocks.  However, neither hyperkalemia nor CCB overdose would cause anticholinergic symptoms. Hemodialysis is used in overdoses to increase the elimination of certain substances (eg salicylates, lithium).  However, TCAs have a large volume of distribution, and enhanced elimination has not been shown to be effective. Tricyclic antidepressant overdose can present with CNS, cardiac, and anticholinergic findings.  Sodium bicarbonate is used to treat cardiac toxicity, which is characterized by prolonged QRS duration (>100 msec) and ventricular arrhythmias (eg, ventricular tachycardia, ventricular fibrillation).

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Case-based MCQ | #MCQ_79 •••••••••••••••••••••••••••••••••••••• A 55-year-old man is brought to the emergency department due to altered mental status.  The patient’s wife came home from work and found him confused.  He was fine that morning before she left the house.  The patient has a medical history of chronic migraines and major depression; he has been out of work for a few months due to the pain.  The wife reports her husband has tried “every migraine medication there is” but she does not know which one he is currently taking.  Blood pressure is 80/60 mm Hg, and pulse is 125/min.  The patient is drowsy and does not answer questions or follow commands.  The oral membranes are dry.  There is reddening around the face and neck.  ECG reveals sinus tachycardia with a QRS duration of 120 msec and frequent premature ventricular beats.  Initial laboratory studies are ordered, and intravenous hydration is started.  Which of the following is the best next step in management? A. Amiodarone B. Atropine C. Calcium chloride D. Hemodialysis E. Sodium bicarbonate

Case-based MCQ | #MCQ_78 •••••••••••••••••••••••••••••••••••••• Correct Answer Is D The bilious emesis, abdominal distension, and x-ray findings in this neonate are consistent with jejunal atresia.  Intestinal atresia can occur anywhere along the gastrointestinal tract.  Atresia of the jejunum or ileum is thought to occur due to a vascular accident in utero that causes necrosis and resorption of the fetal intestine, leaving behind blind proximal and distal ends of intestine.  Risk factors include poor fetal gut perfusion from maternal use of vasoconstrictive medications or substances such as cocaine and tobacco.  In contrast to duodenal atresia, jejunal and ileal atresia are not associated with chromosomal abnormalities. A triple bubble sign and gasless colon on abdominal x-ray (above) reflects gas trapping in the stomach, duodenum, and jejunum.  Treatment should begin with resuscitation and stabilization of the patient, followed by surgical correction.  Prognosis depends on the length of affected bowel as well as the patient’s gestational age and birth weight. This infant is premature with intrauterine growth restriction (low birth weight) due to prenatal cocaine exposure.  After birth, these infants are at risk for withdrawal symptoms, including irritability, tremors, and high-pitched cry.  This patient’s bilious emesis and x-ray, however, are highly suggestive of bowel obstruction. Duodenal atresia is thought to result from failure of the duodenum to recanalize and presents with abdominal distension and bilious emesis.  X-ray reveals a double bubble rather than the triple bubble seen in this patient. Hirschsprung disease can present with abdominal distension and bilious emesis as well as delayed passage of meconium (age >48 hours).  This infant is only 12 hours old and is not expected to have passed meconium yet.  Because the obstruction is typically at the level of the rectosigmoid junction, dilated loops of bowel would be seen on x-ray, making this diagnosis less likely. Necrotizing enterocolitis typically presents as abdominal distension, bloody stools, and vital sign instability in premature infants.  The hallmark finding on x-ray is pneumatosis intestinalis (extravasation of gas into the damaged bowel wall). Jejunal atresia presents with bilious vomiting and abdominal distension.  Abdominal x-ray reveals a triple bubble sign and gasless colon.  Risk factors include prenatal exposure to cocaine and other vasoconstrictive substances.

A 55-year-old man is brought to the emergency department due to altered mental status.  The patient’s wife came home from work and found him confused.  He was fine that morning before she left the house.  The patient has a medical history of chronic migraines and major depression; he has been out of work for a few months due to the pain.  The wife reports her husband has tried “every migraine medication there is” but she does not know which one he is currently taking.  Blood pressure is 80/60 mm Hg, and pulse is 125/min.  The patient is drowsy and does not answer questions or follow commands.  The oral membranes are dry.  There is reddening around the face and neck.  ECG reveals sinus tachycardia with a QRS duration of 120 msec and frequent premature ventricular beats.  Initial laboratory studies are ordered, and intravenous hydration is started.  Which of the following is the best next step in management? A. Amiodarone B. Atropine C. Calcium chloride D. Hemodialysis E. Sodium bicarbonate

Case-based MCQ | #MCQ_78 •••••••••••••••••••••••••••••••••••••• Correct Answer Is D The bilious emesis, abdominal distension, and x-ray findings in this neonate are consistent with jejunal atresia.  Intestinal atresia can occur anywhere along the gastrointestinal tract.  Atresia of the jejunum or ileum is thought to occur due to a vascular accident in utero that causes necrosis and resorption of the fetal intestine, leaving behind blind proximal and distal ends of intestine.  Risk factors include poor fetal gut perfusion from maternal use of vasoconstrictive medications or substances such as cocaine and tobacco.  In contrast to duodenal atresia, jejunal and ileal atresia are not associated with chromosomal abnormalities. A triple bubble sign and gasless colon on abdominal x-ray (above) reflects gas trapping in the stomach, duodenum, and jejunum.  Treatment should begin with resuscitation and stabilization of the patient, followed by surgical correction.  Prognosis depends on the length of affected bowel as well as the patient’s gestational age and birth weight. This infant is premature with intrauterine growth restriction (low birth weight) due to prenatal cocaine exposure.  After birth, these infants are at risk for withdrawal symptoms, including irritability, tremors, and high-pitched cry.  This patient’s bilious emesis and x-ray, however, are highly suggestive of bowel obstruction. Duodenal atresia is thought to result from failure of the duodenum to recanalize and presents with abdominal distension and bilious emesis.  X-ray reveals a double bubble rather than the triple bubble seen in this patient. Hirschsprung disease can present with abdominal distension and bilious emesis as well as delayed passage of meconium (age >48 hours).  This infant is only 12 hours old and is not expected to have passed meconium yet.  Because the obstruction is typically at the level of the rectosigmoid junction, dilated loops of bowel would be seen on x-ray, making this diagnosis less likely. Necrotizing enterocolitis typically presents as abdominal distension, bloody stools, and vital sign instability in premature infants.  The hallmark finding on x-ray is pneumatosis intestinalis (extravasation of gas into the damaged bowel wall). Jejunal atresia presents with bilious vomiting and abdominal distension.  Abdominal x-ray reveals a triple bubble sign and gasless colon.  Risk factors include prenatal exposure to cocaine and other vasoconstrictive substances.

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A 12-hour-old girl in the neonatal intensive care unit has bilious emesis.  She was born at 35 weeks gestation by vaginal delivery to a 22-year-old woman who did not receive prenatal care and used cocaine during her pregnancy.  The infant has urinated but has not had a bowel movement.  She was able to take 2 bottle feeds by mouth but has been vomiting green fluid since the third feed.  Birth weight was 2 kg, which is small for gestational age.  Temperature is 36.9 C, pulse is 160/min, and respirations are 40/min.  The abdomen is distended.  The rest of the examination is unremarkable.  Abdominal x-ray is shown below. Which of the following is the most likely diagnosis in this patient? A.Cocaine withdrawal B.Duodenal atresia C.Hirschsprung disease D.Jejunal atresia E.Necrotizing enterocolitis

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