Case-based MCQ

⏳ 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.

⏳ Case-based MCQ | #Case_373 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation The therapeutic range of warfarin for most patients varies between 2 to 3.5 (2 - 3, or occasionally 2.5 - 3.5). Increased INR beyond therapeutic levels are associated with higher risk of bleeding. For patients with an INR above the therapeutic range but less than 5, who are not bleeding, skipping the next dose of warfarin and resuming lower doses once the INR is within the therapeutic range is the recommended management. Ceasing warfarin, FFP, vitamin K (intravenously) and Prothrombmex are used in situations where there is active bleeding or the risk of bleeding is high.

⏳ Case-based MCQ | #Case_373 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 70-year-old man from a low-level-of-care nursing home is brought to the hospital after he had a fall 3 hours ago. He is on warfarin for atrial fibrillation (AF). Laboratory studies show that he has an INR of 4.9. A CT scan of the head is ordered which is normal. Other investigations are unremarkable.

⏳ Case-based MCQ | #Case_372 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation No matter what the clues point towards, every patient with dysphagia should undergo appropnate investigation. Just because of weight loss, the patients cannot be told to have esophageal cancer. Although the patients age Is a red flag for dysphagia, the fan that it occurs at initiation of swallowing makes oropharyngeal dysphagia the better bet. On the other hand, every patient with dysphagia, regardless of the etiology, may have weight loss due to decreased calorie intake; nonetheless,a thorough and judicious assessment should be considered for every patient with dysphagia. The best initial step in management of dysphagia depends on provisional diganosis based on the history and clinical findings. when esophageal cancer is suspected, evaluation starts with upper endoscopy and biopsy. With oropharyngeal and motility-related dysphagia, barium studies would be the most appropriate initial approach. in this scenario, oropharyngeal dysphagia probably caused by a retropharyngeal pouch (Zenker's diverticulum) is the most likely diagnosing; therefore barium swallow would be the best initial assessment tool. If a retropharyngeal pouch is diagnosed on barium studies, endoscopy should be avodied. as there is significant risk of the scope perforating the pouch. ⚠ (Option A) Endoscopy Is the initial Investigation when cancer is suspected based on history and clinical features ⚠ (Option B) Surgery is indicated if the cause of dysphagia is found to be cancer or Zenker's diverticulum. Achalasia unresponsive to conservative measures may eventually need surgical intervention as well. ⚠ (Option D) Helicobacter pylori can cause peptic ulcer and consequently strictures of the gastric outlet (more common) or inlet (less common).Stricture at the junction of the oesophagus to the stomach may cause dysphagia,but not described as difficulty in initiation of swallowing. ⚠ (Option E) Manometry can be used once barium meal study suggests a motility disorder such as achalasia

Follow the best Medical Channels on Telegram ✌⭐

Follow the best Medical Channels on Telegram ✌⭐

⏳ Case-based MCQ | #Case_372 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 70-year-old man presents with difficulty in swallowing for the past 6 months and 4-kilogram weight loss in this period. He describes that the most difficult part of swallowing for him is when he tries to start to get the food down his mouth. He had been a smoker for most of his adult life but has quit 10 years ago.

⏳ Case-based MCQ | #Case_371 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation This patient has characteristic features of lower urinary tract symptoms (LUTS). LUTS can present with voiding symptoms (bladder emptying) such as weak urine stream, hesitancy (difficulty starting urination) or intermittency of follow, or with storage (bladder filling) symptoms such as urgency, daytime frequency and nocturia. Predominance of storage symptoms requires exclusion of conditions such as primary bladder pathology/malignancy, diabetes mellitus, and medications with diuretic effects. Where nocturia is the presenting symptom, nocturnal polyuria should be excluded too. Based on the international guidelines, it is important to determine the severity of LUTS and to identify the complicating factors such as urinary retention, macroscopic hematuria, urinary tract infections or a personal or family history of prostate cancer. For every patient presenting with LUTS, initial investigations should be considered to exclude sinister causes LUTS or complications associated with bladder outflow obstruction. These investigations include: • Urinalysis - excluding hematuria, proteinuria, or pyuria - follow up with urine culture is required if there is abnormality on urinalysis • Serum creatinine and estimated glomerular filtration rate (eGFR) - this test is required for exclusion of renal injury from primary renal dysfunction or high-pressure bladder outflow obstruction. • Urinary tract ultrasound - assessment of prostate volume, bladder wall and residual urine and exclusion of hydronephrosis • Prostate specific antigen to exclude prostate cancer - most guidelines recommend the use of serum PSA only if prostate cancer diagnosis will influence management or if the test will assist in decision making Urinary symptoms of this man and the presence of an enlarged prostate on DRE make benign prostatic hyperplasia (BPH) the most likely diagnosis. Additionally, the dull mas over the suprapubic area is very likely to be a distended bladder due to urinary outflow obstruction caused by the enlarged prostate. In this situation and of the options, a serum creatinine level [and calculation of the estimated glomerular filtration rate (eGFR)] would be the most important next step to exclude renal injury caused by the obstruction. If an option, transabdominal ultrasound scan of the bladder was another important test to consider first to assess the residual volume, prostate size and other possible urinary tract anomalies. ⚠ (Option B) While transabdominal ultrasound is a very important investigation for this patient, tansrectal ultrasound is not necessary at this stage. Flowever, it might be applied in patients who are suspected of having prostate cancer for further assessment and as a guide for biopsy. ⚠ (Option C) CT scan is not routinely recommended for patients with LUTS, unless complicating features are suspected. An example could be for staging in a patient with bladder or prostate cancer as the etiologic cause of LUTS. ⚠ (Option D) As mentioned earlier, PSA is among the investigations for male patients with LUTS to exclude for prostate cancer; however, assessment of renal function takes precedence over PSA in this patient. ⚠ (Option E) Urine cytology is a test considered for patients with suspected urothelial carcinoma such as those with hematuria who have risk factors like history of smoking or exposure to certain chemicals. It is not a routine test for patients with LUTS unless there are alarming features

🏅Make Sure To Join All These Medical Pages👇🏻👇🏻

Hello dear subscribers Please let us know if there are any of you who has enough information about the pathway to Practice in Australia 🇦🇺 and wants to help us and become admin in the that group. ✋ Raise your hand in the comments below or message @Mohamm_ADs .

⏳ Case-based MCQ | #Case_371 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 65-year-old man presents to your GP clinic with long-standing history of difficulty starting voiding and terminal dribbling and, recently, nocturia. Abdominal examination reveals a dull mass over the suprapubic area. On digital rectal exam (DRE), the prostate is enlarged but smooth with palpable median sulcus.

⏳ Case-based MCQ | #Case_370 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation The clinical picture suggests meningeal irritation. Cerebrospinal fluid (CSF) analysis shows CSF monocytosis, decreased CSF glucose level (normal 2.5 - 3.5 mmol/L or approximately 60% of simultaneous plasma glucose level), and elevated protein level (normal 0.15 - 0.4 g/L). Monocytosis of the CSF highly suggests fungal meningitis; therefore, Cryptococcus assay of the CSF would be the most appropriate next step to confirm the diagnosis. Invasive fungal infections are a significant complication in solid organ transplant (SOT) recipient. Cryptococcosis is the third most common invasive fungal infection in patients with cell-mediated immune deficiency. Between 53-72% of the cryptococcal disease in SOT recipients is disseminated or involves the central nervous system (CNS). Positive serum cryptococcal antigen has been reported in 88-91% of SOT recipient with cryptococcal meningitis. ⚠ (Option A) With Herpes meningitis,there are often concomitant genital lesions. In herpes meningitis, like other viral meningitides, the CSF glucose level tends to be normal; however, HSV is sometimes associated with decreased CSF glucose. On the other, hand the dominant cell group is lymphocytes rather than monocytes. ⚠ (Option B) Ziehl - Neelsen stain of the CSF is indicated if TB meningitis is suspected. Although TB meningitis can be a possibility, especially in immunocompromised patients, monocytosis is more consistent with fungal meningitis. In TB meningitis, polymorphonuclear cells are dominant at early stages, but lymphocytosis follows. ⚠ (Option C) With decreased CSF glocuse and increased CSF protein, viral meningitis is less likely. In viral meningitis, CSF gluocose and CSF protein are normal or near normal. CSF protein can be increased. ⚠ (Option D) Bacterial culture of the CSF is likely to be positive in bacterial meningitis.Bacterial meningitis often presents with significantly increased protein levels and cell count with PMNs dominating the cell differential

Best Medical Channels On Telegram: @Essential_Anatomy @Ninja_Nerd @DrNajb @Dr_Pdf @Pathoma_Videos @Surgery_Videos @Doctors_in_Training @Usmle_Videos @NeetPG_Books @Lecturio_vid @Mediscussion @DrNajb @Drnejib_Notes @Osmsis