Case-based MCQ

⏳ Case-based MCQ | #Case_385 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 38-year old lady presents to your pratice with fatigue, lethargy and weight gain of 5 kg over the past few months. She also has irregular heavy periods. She feels flushed and tremulous. She is hypertensive, and her blood sugar is 10 mmol/L.

⏳ Case-based MCQ | #Case_384 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation Cont. With just headache in the history and absence of other presenting features of pseudotumor cerebri, such diagnosis is unlikely. As a matter of fact, with prolonged use of analgesics for chronic headache and absence of alarming findings in the history and physical examinations, this clinical scenario is most consistent with drug rebound headache, also known as medication overuse headache. Classically, a typical patient is described as a 30-60 years old woman with a history of more than a decade of tension or migraine headache and pain killer use for relief; however, it may affect patients of different ages with a history of infrequent analgesic use for headache even as short as days or weeks. Therefore, a high index of suspicion should be held for every patient presenting with frequent headaches. The characteristic features of medication overuse headache is not uniform but often is similar to quality of pain in the original headache, for which medications are taken. The condition is more prevalent in patient who use prophylaxis for their headaches. In General, medication overuse headache occurs every day or almost every day, often waking up the patient early in the morning when the effect of the painkillers has worn off overnight. The pain is partially improved with medications but returns as the medication wears off again. Medication overuse headache is not associated with focal or lateralizing neurological symptoms. It is, however, common for patients with migraine with aura to experience aura if they develop medication overuse headaches. It is important to note that if the patient’s symptoms have been stable months or years, imaging or neurological examination is not required provided that there is no neurological findings in between headaches.

⏳ Case-based MCQ | #Case_384 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation ⚠ Although early morning headache is characteristic of headaches caused by cerebral tumors (option E) or other space-occupying intracranial lesions, absence of other features such as worsening of the pain on bending forward, sneezing or coughing, no history projectile vomiting or absence of focal neurological findings makes such diagnoses less likely. ⚠ Migraine headache is usually unilateral and felt behind the orbit and/or temporal regions. However, it can progress to affect the entire head and neck. In this patient, the pain is bilateral and other features of migraine such as nausea and vomiting and sensitivity to noise and light are absent. With these, migraine (option B) is an unlikely diagnosis. ⚠ Tension headache (option C) is very common. The pain is bilateral and described as band-like pressure. Nausea and vomiting are not prominent features and patient is not sensitive to light and noise. One important characteristic of tension headache is the fact that it occurs mainly towards the end of the day (evening hours). Adequate response to analgesics is another distinctive feature of tension headaches. Although the headache in this woman is bilateral and not associated with nausea and vomiting and resembles tension headache, the time of onset (early in the morning) and partial and inadequate response to analgesia makes this diagnosis less likely for this woman. ⚠ Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a disorder of unknown etiology. It can occur in all age groups but is most common in obese women of childbearing age. The primary problem in IIH is chronically elevated intracranial pressure (ICP). With increased ICP, the most important neurological finding is papilledema that can result in progressive optic atrophy, visual loss, and potentially blindness. In general and as the name implies, sign and symptoms of IIH are similar to any space-occupying brain lesion such as a cerebral tumor, including: • Headache (typically nonspecific and varying in type, location, intensity, and frequency) • Nausea and vomiting • dizziness • Visual loss (typically visual field but rarely visual acuity loss) • Brief episodes of blindness lasting only a few seconds and affecting one or both eye (visual obscuration) • Diplopia (typically horizontal due to non-localizing sixth nerve palsy but rarely vertical) • Pulsatile tinnitus -ringing in the ears that pulses in time with the heartbeat • Pain in the neck, shoulders or arms (not very common)

⏳ Case-based MCQ | #Case_384 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 35-year-old woman presents with chief complaint of headaches. She describes that she has been having these headaches for the past 8 months. The headaches occurr more often in the evening hours and she took Panadol, ibuprofen, and sometimes codeine for pain relief. Recently, the headache that is varying in intensity comes early in the morning and wakes her up. The ache is felt in the frontal area bilaterally and it seems that the her regular pain killers are not that effective with only a partial relief lasting not more than 2 to 3 hours. She denies nausea and vomiting, light and noise sensitivity, or visual problems. She is otherwise in good shape, smokes 5-10 cigarettes a day, and drinks within healthy limit. Physical examination is inconclusive.

⏳ Case-based MCQ | #Case_383 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation Of the options, only decreased sensation of the lower leg can be specific to an intervertebral disc prolapse and others can be manifestations of non-neurological problems as well. Radicular lower back pain can happen due to chemical or mechanical irritation of nerve roots. The pain is sharp, shooting and has an electric quality. Unilateral leg pain is the more pronounced symptoms and is often worse than pain in the back. Pain concentrates distally, running into the lower limb, usually extending below the knees. Pain, numbness and paresthesia follow a dermatomal distribution. Reflexes may be reduced or even absent. Motor weakness not always would be present. ⚠ Lesions of the cauda equina can present with back pain, leg pain, paresthesia around the anus, and urinary incontinence. However, in this patient, the urinary problem is described as difficulty starting micturition and terminal dribbling, which is consistent with bladder outlet obstruction by causes such as an enlarged prostate. Urinary problems (option A) of this patient is very unlikely to have been caused by an intervertebral disc prolapse. ⚠ Although disc prolapse in the lumbar area can present with back pain (option C) and thigh pain (option B), such pain may have been caused by other factors than radiculopathy. Back pain may be due to a mechanical stressor. In fact, back pain is the common factor between mechanical and neural pain in the back. The accompanying symptoms are the only indicators helping to differentiate between the two. Leg pain may have other causes such as mechanical injuries and vascular problems (e.g., venous insufficiency, arterial disease, etc.). Neural impairments other than radiculopathy may give rise to pain as well. ⚠ Constipation (option E) in this patient may have many other causes as well, with one being bladder obstruction and pressing of a distended bladder on the rectum. Decreased dietary fibers, limited physical activity, and many other factors could have caused the constipation. Disc prolapse is more likley to be associated with fecal incontinence rather than constipation.

⏳ Case-based MCQ | #Case_383 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 68-year-old patient of yours presents for medical evaluation. He is a known-case of benign prostatic enlargement. Today he is complaining of urinary problems in form of difficulty starting micturition and dribbling at the end of urination, as well as constipation. He also has back pain and left thigh pain. On examination, there is decreased sensation over the medial aspect of the left lower leg.

⏳ Case-based MCQ | #Case_382 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation The onset of bloody diarrhea shortly after introduction of formula, the presence of eczema, and family history of atopy makes cow’s milk protein allergy (intolerance) (CMPA) the most likely diagnosis with high certainty. CMPA results from an immunological reaction to one or more milk proteins. This immunological basis distinguishes CMPA from other adverse reactions to cow’s milk protein such as lactose intolerance. CMPA may be immunoglobulin E (IgE) or non-lgE associated. In IgE-associated cases, CMPA may be a manifestation of the atopic diathesis. These reactions may occur as short as minutes after ingestion of cow’s milk or cow’s milk-based formula. These early reactions usually manifest as urticaria, angioedema, vomiting or an acute flare of atopic dermatitis. The remaining 42% show a later reaction, typically atopic dermatitis or gastrointestinal disturbances. Even small amounts of cow’s milk in breast milk of mother’s who take dairy products may trigger the condition. Other options do not justify the clinical presentation.

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⏳ Case-based MCQ | #Case_382 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A mother brings her 3-week-old male baby to the Emergency Department because of his loose bloody bowel motions. The mother says the diarrhea has started 2 days ago after she started her son on formula milk. The mother is lactose-intolerant and does not use dairy products. On examination, the child is mildly dehydrated and has an eczematous rash on his right cheek. He is not febrile. The rest of the exam is inconclusive. Family history is remarkable for atopy including asthma and eczema in his father and older sister. Mother is concerned that his son may have the same allergy to milk and dairy product she has.

⏳ Case-based MCQ | #Case_381 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation The findings on ultrasonography are suggestive of polycystic ovarian syndrome (PCOS). PCOS is the most common cause of infertility due to anovulation. Infertility in women with PCOS, however, is not absolute and many women can conceive even without treatment. In women with infertility due to PCOS, different options are available: Non-pharmacological treatment: ▫If a woman is younger than 35 years of age and has a BMI>25, and no other cause of infertility is suspected an intensive lifestyle program addressing weight loss, without any pharmacological treatment for the first 6 months, is recommended. Small amounts of weight loss (~5%) may restore menstrual cycle regularity and ovulation, providing benefit even if pharmacological intervention is subsequently required Pharmacological treatment: ✔ If pharmacological treatment is required, the best first-line treatment is clomiphene citrate, which has a pregnancy rate of 30-50% after six ovulatory cycles. ✔ In women with a BMI <30-32 kg/m , metformin may have a similar efficacy to clomiphene citrate, and is the first-line treatment (with or without clomiphene citrate) if there is concomitant impaired glucose tolerance. ✔ If clomiphene citrate, metformin or a combination of the two is unsuccessful in achieving pregnancy, gonadotropins are the next pharmacological options. ✔ Laparoscopy with ovarian surgery/drilling (LOS) is an appropriate second-line treatment if clomiphene citrate with metformin has failed. The pregnancy rate with LOS is as effective as 3-6 cycles of gonadotropin ovulation induction. ✔ If all of the above are unsuccessful or if there are other factors contributing to infertility such as endometriosis or male factors, in vitro fertilization or intra-cytoplasmic sperm injection is recommendedit

⏳ Case-based MCQ | #Case_381 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 30-year-old woman presents with a 12-month history of secondary infertility. Her first child, fathered by the same partner, was born 4 years ago after she was conceived spontaneously, and through an uneventful vaginal delivery. She has always had irregular periods occurring every 2 to 4 months. On examination, she is obese (BMI>32) and otherwise normal. Ultrasonography of the pelvis reveals 12 small cyst of 3-6 mm in diameter in the left and 20 cysts of about the same size in the right ovary. A sperm analysis of the partner is normal.

⏳ Case-based MCQ | #Case_380 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation The photograph shows an erythematous butterfly rash. Additionally, the chin is also involved. Several papules and pustules are noted as well. The clinical picture presented in the photograph, along with the history, is suggestive of rosacea (also known as acne rosacea) as the most likely diagnosis. Rosacea is a common chronic disorder that mainly involves the face. It tends to present in middle-age persons but may start at earlier ages. It is more common in cold climates. The condition often begins as exaggerated or prolonged flushing tendency, with erythema affecting the central face or the butterfly area in particular. Sometimes erythema can be seen in the chin and forehead. Initially, the erythema occurs intermittently, but later becomes persistent. Sometimes, rosacea is associated with edema. Telangectiasis is often present. Sterile inflammatory papules, pustules and nodules may be present mimicing acne. The distinguishing feature is the absence of comedones. Patients often complain that their faces feel hot, burn, sting or itch. Patient often report that their face is increasingly easily irritated by topical products. The etiology of rosacea is unknown. Alcohol is not a cause but it can trigger the flushing and worsen the symptoms. Other triggering factors include: ▫Hot or cold temperatures ▫Wind ▫Hot drinks ▫Caffeine ▫Exercise ▫Spicy foods ▫Emotions ▫Topical products that irritate the skin and decrease the barrier ▫Medications that cause flushing In about 50% of the patients, blepharoconjunctivitis is observed. It presents with itching, burning, gritty or foreign body sensation in the eye and erythema and swelling of the eyelid. More advanced cases can develop enlarged sebaceous glands and connective tissue changes resulting in a bulbous, rhinophymatous nose. Seborrheic dermatitis, SLE and erysipelas are among the differential diagnosis but not consistent with the history. None of these conditions have alcohol as a triggering factor. ⚠ (Option A) Seborrhoeic dermatitis has scaling as a prominent feature. ⚠ (Option B) Erysipelas is associated with abrupt onset of erythematous butterfly rash almost always caused by streptococcus pyogenes. There is often fever and constitutional upset. It is not a chronic condition and is not triggered by alcohol use. ⚠ (Option D) Although the rash resembles that of SLE, lack of other signs and symptoms favoring SLE, makes it least likely. ⚠ (Option E) Alcohol-related skin disease a general term not a diagnosis. Rosacea worsens by alcohol but is not caused by it

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