Case-based MCQ

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⏳ Case-based MCQ | #Case_406 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A Clozapine is an effective antipsychotic for treatment of resistant schizophrenia, but is associated with serious adverse effects including sedation, postural hypotension, hypersalivation, severe constipation, dyslipidemia, myoclonus and epileptic seizures. Excessive weight gain and glucose intolerance may occur, precipitating type 2 diabetes. The two serious adverse effects of neutropenia (2-3%), agranulocytosis (1%) are of significant concern as well. Tachycardia is another common side effect of clozapine, observed in 25% of patients. Arrhythmias may also occur. Moreover, a minority of clozapine-treated patients experience ECG changes similar to those seen with other antipsychotic drugs, including ST segment depression and flattening or inversion of T-waves, which normalizes after discontinuation of clozapine. Of the given options, clozapine can be associated with tachycardia and palpitations as an adverse effect. NOTE - Myocarditis is a reported serious adverse effect of this drug which necessitates application of close monitoring protocols for patients on treatment with this drug.

⏳ Case-based MCQ | #Case_406 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 24-year-old woman has been started on an antipsychotic drug due to poorly-controlled schizophrenia 3 weeks ago. She has now presented with complaint of palpitations.

⏳ Case-based MCQ | #Case_405 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D COPD patients has type II respiratory failure, which by definition is hypoxia (PaO2<60mmHg (8.0 kPa)) and hypercapnia (PaC02> 50mmHg (6.6 kPa)). Under normal condition, both decrease in Pa02 and increase PaC02 stimulate respiratory centers in the brainstem and increase the respiratory drive as a compensatory mechanism, but in chronic type II respiratory failure, such as in COPD, sustained exposure to high levels of PaC02, desensitizes respiratory centers to elevated concentrations of C02 in the blood. Administration of high-concentration oxygen to these patients decreases the respiratory drive and results in more hypercapnia, dyspnea, paradoxically decreased oxygen saturation and respiratory acidosis. In such patients with deteriorating Pa02 and oxygen saturation despite being on oxygen the next best step in management is to reduce the delivery of oxygen, provided that the patient is not at risk of imminent respiratory arrest or severe acidemia (PH<7.3) in which immediate case assisted ventilation should be considered. ⚠ If patient remains hypoxemic despite adequate controlled oxygen delivery (e.g. by Venturi mask) assisted ventilation such as CPAP or intubation (option A) and mechanical ventilation should be considered next. ⚠ Both increasing the oxygen flow (option C) and cessation of oxygen (option B) will increase the hypoxemia deteriorate the patient’s condition as the first decreases the respiratory drive even more while the second deprives him of oxygen. ⚠ (Option E) While the respiratory drive is suppressed, administration of bronchodilators is not likely to be beneficial for this patient

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⏳ Case-based MCQ | #Case_405 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 71-year-old man, known case of COPD for the past 8 years, is brought to the emergency department by ambulance due to severe difficulty in breathing. On the way to the hospital, he is given oxygen 100% by nasal cannula. Upon arrival to the emergency department, his oxygen saturation is 81% and his shortness of breath is even worse, according to the paramedics.

⏳ Case-based MCQ | #Case_404 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B Indinavir sulfate is an HIV protease inhibitor. Indinavir-induced nephrolithiasis is a well-recognized adverse effect of this drug, occurring in almost 12.4% of patients. If indinavir-induced nephrolithiasis develops, the drug should be discontinued and an alternative antiretroviral be used. Non-contrast helical CT scan (option C) is the criterion standard for evaluation of nephrolithiasis. This modality can detect both stones and urinary tract obstruction. Stones not visualized on IVP or KUB, usually are detected on CT scan; however, since stones secondary to indinavir are not radiopaque and signs of obstruction may be minimal, this modality may not be as accurate and miss the diagnosis. This holds true about x-ray KUB (option D) and ultrasound. Although not accurate as non-contrast helical CT scan, ultrasound can detect obstruction caused by large, clinically significant stones and probably the stone itself. This modality has been recommended as the initial diagnostic option by many authors. It is safe, readily available, cost-effective, and spares patients from the risk of radiation in most cases. Again, the accuracy is reduced in detection of stones secondary to indinavir. In fact, studies have shown that contrast CT-scan is more likely to visualize indinavir-induced stones, but since most of such stones, especially if not large enough to cause obstruction and be detected on ultrasonography, will pass with conservative management, contrast enhanced imaging studies as contrast CT or IVP (option A) unnecessarily puts the patient at risk of radiation and/or contrast media. Contrast CT scan, however, should be considered for patients in whom the symptoms persist or other diagnosis is suspected based on clinical grounds. ⚠ Triple phase CT scan (option E) is mostly used for diagnosis of liver lesions. It is not indicated diagnosis of renal stones but may be considered if an alternative diagnosis

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