Case-based MCQ

⏳ 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

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⏳ 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

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⏳ 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

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⏳ Case-based MCQ | #Case_370 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 21-year-old girl is brought to the emergency department with headache and mild neck stiffness. She had kidney transplantation last year. Examination of cerebrospinal fluid (CSF) reveals a cell count of 150 with 70% monocytes. CSF glucose level is 1.2 mmol/L and protein 1.8 g/L.

⏳ Case-based MCQ | #Case_369 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation Nipple discharge is always an abnormal finding except in late pregnancy or the postpartum period. Based on characteristics, there are seven types of nipple discharge: 1. Milky: white discharge; sometimes fat globules are seen under microscopy 2. Multicolored gummous: sticky discharge 3. Purulent: pus with white cells seen under microscopy 4. Watery: colorless discharge 5. Serous: faintly yellow, thin discharge 6. Serosanguineous: thin, clear discharge with pink tint, RBCs seen under microscopy 7. Bloody (sanguinous): pure blood Conditions associated with each type of discharge are as follows: ⚪ Milky Discharge Galactorrhea,or nonpuerperal lactation, usually results from multiple duct discharge from both breasts. The most common cause of nonpuerperal lactation is hyperprolactinemia associated with pituitary adenomas, medications or other causes resulting in increased production of prolactin (e.g. primary hypothyroidism).In many women,galactorrhea can be idiopathic. 🟣 Multicolored and Sticky Discharge Duct ectasia or comedomastitis is the most common cause of a multicolored, sticky discharge that is commonly bilateral and usually in perimenopausal woman.It begins as a dilation of the terminal ducts with an irritating lipid fluid collection and producing an inflammatory reaction resulting in discharge from the nipple. Duct ectasia is most frequently associated with pain,itching, and swelling in the nipple. Palpation of the areola can often reveal a tubular mass, reflecting the dilated ducts. Often a history of nipple manipulation is elicited. If the disease progresses, a mass can develop (plasma cell mastitis) that can mimic cancer. Surgery is indicated only if a mass forms or the discharge changes to serosanguinous or bloody. 🟠 Purulent Discharge In patients with acute puerperal mastitis, chronic lactation mastitis,central breast abscesses,or plasma cell mastitis, nipple discharge is purulent and usually unilateral. Breast cultures and smears may reveal a causative organism. Abscess formation usually requires incision and drainage if appropriate antibiotics and warm compreses are not effective. It is important to remove a portion of an abscess wall for histologic study to exclude an underlying cancer associated with secondary necrosis and infection. 🔴 Watery, serous, serosanguinous, and bloody Discharges Intraductal papillomas are the most common cause of these discharges, but fibrocystic disease, advanced duct ectasia, breast cancer, and vascular engorgement in near-term pregnancy can also be the causes. In patients over 50, malignancy becomes increasingly common, especially if the discharge is unilateral and associated with a mass. Surgical exploration is mandatory in this group of patients with this type of discharge, even if cytologic and mammographic findings are negative. ✅ NOTE - surgical referral is required if the nipple discharge is spontaneous and unilateral, or the patient is older than 60 years. ⚠ (Option B) Paget disease of the breast most commonly presents with a scaly, raw, vesicular, or ulcerated lesion that begins on the nipples and then spreads to the areola. Nipple discharge, if present at all, tends to be bloody rather than clear. ⚠ (Option C) Ductal ectasia presents with multicolored and sticky discharge. Toothpaste like discharge is a classic description of discharge associated with duct ectasia. ⚠ (Option D) With unilateral clear discharge in this woman,the most likely cause is a benign Intraductal papilloma. Although advanced duct ectasia and intraductal carcinoma are among other etiologies, they are less likely to be the cause compared with intraductal papilloma. ⚠ (Option E) Fibroadenoma does not cause nipple discharge.

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