Case-based MCQ

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A 40-year-old man is brought to the emergency department due to retrosternal and epigastric pain after ingesting an unknown amount of sodium hydroxide–based drain cleaner 45 minutes ago.  He has a history of major depressive disorder and a prior suicide attempt.  The patient has difficulty swallowing his saliva and is drooling.  Temperature is 36.8 C, blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min.  Examination shows oropharyngeal erythema and mild edema.  The lungs are clear to auscultation.  Abdominal examination shows tenderness at the epigastrium without rebound or guarding.  Chest x-ray reveals no abnormalities.  Intravenous normal saline infusion is initiated.  Which of the following is the most appropriate next step in management of this patient? A. Activated charcoal in water B. Gastric decontamination with ipecac C. Intravenous methylprednisolone D. Neutralization of alkali with dilute acetic acid solution E. Upper gastrointestinal endoscopy

🧠 Case-based MCQ 🔸 #MCQ_76 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 Correct Answer Is C Subarachnoid hemorrhage (SAH) usually results from rupture of a saccular aneurysm and classically presents with a sudden-onset, severe headache, often called a thunderclap headache.  The location of the headache can be highly variable, but it is commonly accompanied by vomiting and photophobia, and some patients may experience a brief loss of consciousness.  Neck pain (or stiffness) and low-grade fever are also common due to blood-induced meningeal irritation. SAH is associated with high morbidity and mortality, and recognition is complicated by a wide range of clinical presentations.  Although nearly 20% of patients die before reaching the hospital, approximately 40% present in a normal state of alertness without any neurologic deficit.  Noncontrast CT scan of the brain is the initial diagnostic step of choice as it has high sensitivity for detecting blood pooling in the basal cisterns or sulci of the subarachnoid space. If CT scan is unremarkable and there is still reasonable suspicion for SAH, lumbar puncture is performed to evaluate for red blood cells or xanthochromia.  Xanthochromia is a pink or yellow tint of the cerebral spinal fluid (CSF) caused by hemoglobin degradation products (eg, bilirubin) that appear as soon as 2 hours following a subarachnoid bleed and persist in the CSF for weeks. Administration of 100% oxygen is appropriate therapy for a cluster headache, which presents as a unilateral, severe headache that is usually accompanied by signs of parasympathetic hyperactivity (eg, ptosis, miosis, nasal congestion) on the ipsilateral side. Cervical spine x-ray is appropriate to evaluate for fracture following cervical spine trauma, but it is not indicated for spontaneous onset of severe headache. Meningitis can present with fever, neck stiffness, and headache.  However, the dramatic onset and rapidly progressive severity of symptoms in this patient should raise strong suspicion for SAH, and given the high mortality associated with unrecognized SAH, a CT scan—which is less invasive and can generally be performed more rapidly than lumbar puncture—is the best next step.  If the CT scan is negative, lumbar puncture, which would evaluate for both xanthochromia (from SAH) and signs of meningitis, should be considered.  Meningitis patients often have high-grade fever and chills and appear ill. Sumatriptan can be helpful for migraine headaches.  Migraines are often accompanied by nausea and photophobia, but they also typically have a prodrome and are not associated with fever. Subarachnoid hemorrhage typically presents with a sudden-onset, severe headache that may be accompanied by vomiting, neck stiffness, fever, and loss of consciousness.  CT scan of the brain is the best initial diagnostic step.

🧠 Case-based MCQ 🔸 #MCQ_76 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 42-year-old woman is brought to the emergency department due to severe headache.  Three hours ago, the patient suddenly began experiencing bilateral headache, which rapidly worsened in severity.  She also has had neck pain and an episode of vomiting.  The patient has had no prior headaches, and medical history is significant for hypertension.  Temperature is 38.2 C , blood pressure is 154/92 mm Hg, and pulse is 102/min.  Oxygen saturation is 98% on room air.  On physical examination, the patient appears in obvious discomfort and keeps her eyes closed.  She follows simple instructions, and there is no focal weakness or numbness.  Funduscopy shows no papilledema.  There is increased resistance to passive neck flexion, and it also elicits pain.  Which of the following is the best next step in management of this patient? A. 100% oxygen inhalation B. Cervical spine x-ray C. CT scan of the brain D. Lumbar puncture E. Sumatriptan injection

Correct Answer Is A As the presentation is within the eight hours, the next best step is obtaining a blood sample for serum paracetamol level + ALT and starting N-acetyl cysteine (NAC) immediately. Since it is unlikely that Joan’s serum paracetamol level & ALT is available within 8 hours and that Joan had symptoms of toxicity (RUQ pain or tenderness, nausea, vomiting) hence she should be commenced on NAC immediately. The decision to continue or cease NAC is then based on the paracetamol concentration. NAC can be safely stopped if the paracetamol level is within the safe range and continued if it is in the toxic range. Management for paracetamol poisoning is summarized as below:   ALT = alanine aminotransferase. * Cooperative adult patients who have potentially ingested ≥ 10 g or ≥ 200 mg/kg (whichever is less). For paracetamol ingestions ≥ 30 g, activated charcoal should be offered until 4 hours after ingestion. † Baseline ALT measurement. ‡ If paracetamol concentration will not be available until ≥ 8 hours after ingestion, commence acetylcysteine while awaiting paracetamol concentration. § For acetylcysteine dosage, see Box 7. ¶ Patients should be advised that if they develop abdominal pain, nausea or vomiting, further assessment is required.

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Joan is 60-year old woman who is suffering migraine. The pain has been crushing and disabling despite medical therapy with maximum dose of paracetamol. Seven hours ago in a desperate attempt she took 20 500mg paracetamol tablets to make the pain go away. She is now in the emergency department of the tertiary hospital you work in with complaints of right upper quadrant abdominal pain, nausea, and vomiting. She weighs 65 kilograms. Which one of the following is the next best step in management? A. Give her intravenous N-acetyl cysteine infusion immediately B. No treatment required C. Do immediate gastric lavage and give her activated charcoal D. Check liver function tests & serum paracetamol level prior to decision making on giving N-acetyl cysteine E. Refer the patient to toxicology registrar

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A is correct, Now You say why?

🧠 Case-based MCQ 🔸 #MCQ_73 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 70-year-old man presents with a 2-month history of slowly progressive, painless edema of his entire left leg. He is active and otherwise asymptomatic. The physical examination findings reveal no abdominal abnormalities; a small, hard prostate gland; diminished, but symmetric, arterial pulses in the legs; no calf tenderness; and no evidence of adenopathy. Which one of the following imaging tests is indicated? A) Computed tomography of the pelvis. B) Magnetic resonance imaging of the pelvis. C) Lymphangiography of the left leg. D) Computed tomography venography of the left leg. E) Transrectal ultrasonography of the prostate

D OSA is an independent risk factor for hypertension, causing both systolic and diastolic hypertension

A 65-year-old man has persistently elevated blood pressure despite taking the maximum doses of metoprolol, hydrochlorothiazide, amlodipine, and ramipril. His pharmacy provides blister packs and states that he is adherent with the medications. Which one of the following best explains this patient's presentation? A) Periodic limb movement disorder. B) Central sleep apnea secondary to β-blocker. C) Nocturnal hypotension. D) Obstructive sleep apnea–hypopnea syndrome. E) Frequent nocturnal urination secondary to diuretic