Case-based MCQ

⏳ Case-based MCQ | #Case_380 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 45-year-old woman presents to your GP clinic for review. A few months ago, she developed redness around her nose and cheeks that became worse after she drank alcohol. Recently, she was asked, by one of her colleagues at work, if she has alcohol problems because her appearance resembles those with excessive alcohol use. She drinks an average of 10 units of alcohol per week. Her facial appearance is shown in the accompanying photograph.

⏳ Case-based MCQ | #Case_379 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation As a rule, all impaled foreign bodie should be secured in place and not removed until the patient is in the operating room (OR). The rationale behind this approach is that the object could have damaged major blood vessels, which are temporarily tamponaded by the object. If the object is removed, the pressure over the vessels is released, and life - threatening, potentially uncontrollable hemorrhage could ensue. Such patients should be taken to the OR for removal of the impaled object in a controlled environment where potential bleeding after removal can be promptly controlled. A chest tube should be left in place for successful drainage of blood leak or air in the pleural space. As many as 80% of patients with penetrating chest trauma have hemothorax, pneumothorax, or both. ⚠ Any options suggesting removal of the knife in any place other than the OR is incorrect. ⚠ Immediate needle aspiration is the most appropriate next step in patients with tension pneumothorax which is not the case in here. Tension pneumothorax presents with hypotension and difficulty breathing as well as other findings such as diminished air entry into the affected side, tracheal deviation away from the site of the injury, and diminished breath sounds and hyper-resonance of the affected hemithorax

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⏳ Case-based MCQ | #Case_379 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 23-year-old man is brought to the emergency department by ambulance paramedics after he sustained a stab wound in the chest in a street fight. On examination, he as a knife stuck in the left hemithorax. The patient is awake, oriented and cooperative. His blood pressure is 110/65mmHg, hear rate 100 bpm and respiratory rate 18 breaths per minute. There are no raised neck or forehead veins.

⏳ Case-based MCQ | #Case_378 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation In the presence of both hydrochlorothiazide (thiazide diuretic) and carvedilol (beta blocker) in the history, hypokalemia is most likely to have caused this clinical picture. Hypokalemia can cause paralytic ileus and result in the general picture of bowel obstruction including constipation, abdominal distention and pain, nausea and vomiting, and absent or diminished bowel sounds. ACE inhibitors (e.g., ramipril), on the other hand, have shown to ameliorate the hypokalemic effect of thiazide diuretics. Hypokalemia, hyponatremia, hypercalcemia and elevated blood glucose and urate are common side effects of thiazide diuretics. ⚠ Thiazide-induced hypokalemia in this patient may predispose her to digoxin toxicity (option B), and digoxin toxicity results in hyperkalemia (option E); however, gastrointestinal manifestations of digoxin toxicity are anorexia, nausea, vomiting, abdominal pain and diarrhea. Abdominal distention is not a feature of digoxin toxicity or the consequent hyperkalemia. ⚠ Hypocalcemia (option C) presents with muscle spasms, numbness and tingling in the hands, feet and face, and in more severe case central nervous system problems such as hallucinations. There is no clues in the history suggestive of hypocalcemia as the cause, nor is there an identifiable etiology for that. Thiazides can cause hypercalcemia that often presents with symptoms such as loss of appetite, nausea and vomiting, constipation and abdominal pain, increased thirst and frequent urination, fatigue, weakness, muscular pain, confusion and disorientation, headaches, and depression. Hypercalcemia does not cause a clinical picture consistent with bowel obstruction. ⚠ (Option D) The rapid irregular pulse in this patient indicated atrial fibrillation(AF). AF predisposes to mesenteric ischemia; however, acute mesenteric ischemia presents with abdominal pain and bloody diarrhea especially after meals. Chronic mesenteric ischemia has postprandial periumbilical and/or epigastric pain, fear of eating, and weight loss as typical symptoms. Less common features include nausea, vomiting, diarrhea, constipation and flatulence. Although some of this patient's symptoms are seen in chronic mesenteric ischemia as well, abdominal distention goes against this diagnosis

⏳ Case-based MCQ | #Case_378 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 56-year-old man presents to the A 73-year-old woman presents to the emergency department with vomiting, abdominal pain and abdominal distention. She has congestive heart failure (CHF) in the setting of longstanding hypertension. She had been taking carvedilol, ramipril, and atorvastatin until 10 days ago when she had digoxin and hydrochlorothiazide added to her medications for a tighter control of her rather poorly controlled hypertension and CHF. On examination, she has a blood pressure of 130/85 mmHg, an irregular pulse rate of 110 bpm, respiratory rate of 22 breaths per minute and temperature of 37.5°C. Her abdomen is distended but not tender. There is also no guarding or rigidity. Bowel sounds are absent.

⏳ Case-based MCQ | #Case_377 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation The clinical findings are a classic description of acute closed-angle glaucoma - an acute rise in the pressure of the anterior chamber. This condition is real emergency and if left untreated catastrophic results can ensue. Treatment of acute closed-angle glaucoma is with immediate application of topical agents that inhibit aqueous production. The following topical agents might be used: • Topical beta blockers (first-line): timolol, carteolol • Alpha adrenergic agonists : e.g. apraclonodine • Topical prostaglandins Other management options depend on the setting: • If the patient can be seen within 1 hour of presentation, urgent referral to an ophthalmologist will be the next best step. • If the referral is delayed, the patient should be given acetazolamide PO (250mg x2) (Option A). After one hour of treatment, topical pilocarpine (Option B) can be started as well (2 doses 15 minutes apart). 🔖 NOTE - The most frequently drug group in the emergency department is topical beta blockers (timolol, carteolol) and intravenous acetazolamide. Of the given options carteolol, is the most appropriate management option. ⚠ (Option D) Laser iridotomy will be the definite treatment of8 closed-angle glaucoma and is considered after the acute attack subsides. This procedure is not applicable in acute setting. ⚠ (Option E) Topical corticosteroids have shown no benefit in an acute attack but might be helpful in reducing the corneal inflammation after the acute phase has subsided.

⏳ Case-based MCQ | #Case_377 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 56-year-old man presents to the emergency department with acute right eye pain,redness and blurred vision. On examination, he has eye injection and corneal haziness, and the eye feels hard to palpation.

⏳ Case-based MCQ | #Case_375 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation Of significance on the CXR, is the loss of the right heart border shadow, indicating collection in the right middle lobe. The onset of symptoms within the first 24 hours post-operatively, in addition to the CXR findings is consistent with the diagnosis of atelectasis. Atelectasis is very common in abdominal and trans-thoracic procedures. Mucus retention in airways leads to post-obstructive collapse of the distal airways, particularly in the lower parts of the lung. Pneumonia can complicate atelectasis. Post-operative atelectasis is managed as follows: • Removal of impacted secretion by percussion and encouraging the patient to actively cough. • Passive postural drainage. The most important step in management is chest physiotherapy, followed by oxygen supplementation. If the above measures failed, a catheter can be passed through, guided by bronchoscope, for more vigorous removal of the secretions. ⚠ (Options A and C) Antibiotics are not indicated unless fever persists more than 48 hours, suggesting superimposed pulmonary infection (pneumonia). ⚠ (Option B) Morphine is not indicated for management of atelectasis. Furthermore, morphine can decrease respiratory drive and worsens the atelectasis. ⚠ (Option D) Steroids have no role in management of atelectasis.

⏳ Case-based MCQ | #Case_376 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 Eighteen hours after an uneventful cholecystectomy on a 45-year-old woman, she develops a fever and a cough. A chest X-ray (CXR) is obtained that is shown in the following photograph.

⏳ Case-based MCQ | #Case_375 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation Pain control has a fundamental role to play in the management of rib fractures to decrease chest wall splinting and alveolar collapse. Patients with pain due to rib fractures, such as this, try to minimize their chest wall motion by shallow breathing and avoiding coughing efforts. Adequate pain management improves tolerance for deep breathing and coughing that will result in enhanced lung volume and clearance of secretions. These will reduce the risk of lung collapse and pneumonia. A number of inpatient strategies have been proposed to optimize pain control in patients with rib fractures, including: ▫Regional anesthesia - Regional anesthesia techniques available for the management of multiple rib fractures include continuous epidural infusion, paravertebral block, intrapleural infusion, and intercostal nerve block. ▫Intravenous narcotics - Intravenous narcotics e.g. morphine can provide rapid adequate pain control. Intravenous route is preferred over subcutaneous or intramuscular injections because of the rapid and predictable onset of action. Although there is no evidence to support use intravenous nonsteroidal anti-inflammatory drugs (e.g. ketorolac) for pain control in rib fracture, they can be used to supplement and reduce narcotic use. However, these agents are avoided in patients who have a significant bleeding risk (e.g. hemothorax, solid organ injury) and those with renal insufficiency or hypovolemia. Patient-controlled analgesia (PCA) is advocated for patients with rib fractures because of a more timely access to pain medication by the patients and a reduced risk for excessive sedation. The size of the pneumothorax and 02 saturation in this patient, make pain caused by fractured ribs the only respiratory problem for now, and adequate pain control is the first priority forcomfortable and painless breathing. This can be achieved by measures described above. Of the options only morphine can be used for pain control. ⚠ (Option A) Intubation would be the most appropriate option for patients with fail chest with contraindications or inadequate response to less invasive measures such as CPAP or BiPAP. ⚠ (Option B) Needle aspiration is the most appropriate next step in patients with tension pneumothorax for immediate relief. This then is followed by chest tubes and continues underwater-sealed drainage. ⚠ (Option C) Chest strapping by decreasing chest wall movements can be somewhat useful but it decreases adequate ventilation which is in disagreement with the management objectives. It is not an appropriate treatment. ⚠ (Option E) Water-sealed chest drain must be inserted for treatment of the pneumothorax; however, the pneumothorax is small and has not compromised oxygenation yet. It is not a priority at this stage.

⏳ Case-based MCQ | #Case_375 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 42-year-old man, who was involved in a motor vehicle accident, is being evaluated in the emergency department. On examination, he has stable vital signs and an oxygen saturation of 96% on room air; however, he has marked difficulty in breathing due to intractable chest wall pain, which is worse on inspiration. He only takes shallow breaths. On examination, multiple bruises and tender points are noted on his chest. A non-contrast CT scan of the chest reveals multiple bilateral rib fractures as well a small pneumothorax on the right side.

⏳ Case-based MCQ | #Case_374 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation Chest radiographs are the first imaging modality in assessment of a patient with suspected pulmonary embolism (PE) to exclude other pulmonary causes of the patient's presentation. Initially, chest X-rays are normal in most cases of PE; however,in later stages, most patients will develop chest X-ray abnormalities including, atelectasis, small pleural effusions, parenchymal opacities and elevation of the hemidiaphragms. Once pulmonary infarction occurs,the classic radiographic finding is a wedge-shaped, pleural-based triangular opacity with an apex pointing towards the hilus (Hampton hump). This finding is neither common, nor specific. Another infrequent and non-specific finding is decreased pulmonary vascularity and dilated pulmonary vessels (Westermark sign). In general chest X-rays cannot be used to include or exclude PE;however, radiography and ECG may be useful for excluding alternative diagnoses. Ventilation/perfusion scan (V/Q scan) or radioisotope lung scanning is performed using injecting of particles of albumin labeled with technetium-99m. As these particles perfuse the lung, the lungs are imaged by using a gamma camera to obtain anterior, posterior, lateral, and oblique views.In normal lungs,the isotope particles distribute evenly and produce two dark lung-shaped shadows. In PE, the embolus blocks the branches of the pulmonary artery producing a filling defect on the scan. When findings in the perfusion scan are abnormal, a ventilation scan is obtained by using inhalational radioactive xenon -133. Uncomplicated PE does not make any alteration in ventilation scan. As a result a patient with a high probability of PE has an abnormal perfusion scan with a normal ventilation component. Any pre-existing lung abnormality such as COPD, pneumonia, atelectasis, etc, by altering the ventilation scan results, can make interpretation of a V/Q scan difficult and inconclusive; hence, a clear chest X-ray is the essential prerequisite for performing a V/Q scan. According to the aforementioned, the findings in a patient at early stages of PE will be a normal chest X-ray, normal ventilation scan and reduced perfusion on perfusion scan.

⏳ Case-based MCQ | #Case_374 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 You are called to see a 60-year-old man presenting with dyspnea and chest pain that worsens on inspiration. Five days ago, he underwent laparotomy and gastric surgery. On physical examination, he has a temperature of 37.5°C, heart rate of 90bpm and blood pressure of 130/95mmHg. Chest auscultation reveals no abnormal heart or respiratory sounds. There is good air entry into both lungs and the percussion note is resonant in all areas. A chest X-ray and a ventilation/perfusion scan are performed.