Case-based MCQ

⏳ Case-based MCQ | #Case_403 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 32-year-old man presents to the Emergency Deaprtment with left loin pain and hematuria. He is HIV positive and on an anti-HIV treatment regimen including indinavir. This is the first time he is having sych problem. Urine dipstick is positive for blood but negative for urinary tract infection.

⏳ Case-based MCQ | #Case_403 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C Infective endocarditis (IE) can be uncommonly caused by HACEK group. HACEK group are oral gram-negative bacilli including Hemophilus, Aggregatibacter actinomycetmcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae. These organisms commonly colonize the human oropharynx as normal flora,and may cause mouth infections. HACEK organisms are most often associated with infective endocarditis, accounting for up to 10% of cases. They are also the most common cause of gram-negative endocarditis among persons who do not abuse intravenous drugs. Typically, HACEK organisms grow slowly and have an incubation periods of 7 to 21 days; however, with the advent of improved culture media and automated culture systems, prolonged incubation may no longer be necessary, and a 3-day to 7-day incubation period may suffice for culture. Generally, IE have several complications with embolic events being one of the most lethal ones. Another common complication is mycotic (infective) aneurysms that may occur in 20-40% of patients. In subacute IE, the incidence rises to 60%. Since HACEK organisms are usually associated with a subacute course, microaneurysms are a common complication. Mycotic aneurysms are commonly seen in the bifurcation of the arteries where bacteria easily vegetate. Mycotic aneurysms are usually clinically silent until they rupture. Rupture of an intracranial mycotic aneurysm can lead to catastrophic outcomes. This is why it is recommended that imaging studies be performed to follow up the patients with subacute IE. A number of imaging studies have been used to identify infected aneurysms, including ultrasound, CT scan, MRI and digital subtraction angiography (DSA). Of these, CT angiography is the most useful one for diagnosing mycotic aneurysm. 🔖 NOTE - MRI angiography is the alternative when intravenous contrast is contraindicated. ⚠ (Option A) Colonoscopy is considered in patients with Streptococcus bovis as the cause of their IE because Streptococcus bovis is found to be associated with increased risk of colon cancer. ⚠ (Option B) Abdominal CT scan is not useful for detection of microaneurysms. ⚠ (Options D and E) Trans-thoracic or trans-esophageal echocardiography is not useful for detection of micoraneurysms

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⏳ Case-based MCQ | #Case_403 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 Based on the culture results of a 42-year-old man with infective endocarditis, hemophilus ducreyi is found to be the causative organism. He is treated with a course of intravenous ceftriaxone.

⏳ Case-based MCQ | #Case_402 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A There are some points to take into consideration in this scenario. First is the feeling of 'always afraid that something bad is going to happen soon'. This subjective feeling also described as ‘impending doom' often indicates the presence of anxiety and can be seen during a panic attack, in patients with pheochromocytoma, and in those with hyperthyroidism and thyrotoxicosis. Impending doom is described by patients as if something very bad is just about to happen but they do not know what it is, or as if the world is going to end, or like they are going to die of a heart attack. Some other conditions that can cause such sensation include: • Generalized anxiety disorder • Temporal lobe epilepsy • Excessive caffeine use • Sleep deprivation • Depression in adults • Agoraphobia • Thyroid storm • Hyperthyroidism • Hyperventilation • Hypopituitarism • Anaphylaxis Increased perspiration and palpitation are features seen almost in every hypermetabolic and hypersympathetic state. Sweaty hands can be seen in episodic attacks of pheochromocytoma, hyperthyroid states, anxiety, and during a panic attack. Pheochromocytoma, hyperthyroidism and acute panic attack can present with tachycardia and hypertension. Unless the patient is experiencing an acute panic attack right now, it does not seem to be the case. Elevated blood pressure on examination goes against generalized anxiety disorder (option D) and panic disorder (option B), making these two less likely, but still possible. Sustained elevation of blood pressure is not a typical feature of anxiety disorders. In fact, of the options, pheochromocytoma and hyperthyroidism top the list of differentials. The most common presentation of pheochromocytoma is with episodic headache, tachycardia, hypertension, anxiety and sweating. Although some patients with pheochromocytoma appears to have sustained increased blood pressure, the absence of headache, which is one of the components of the classic triad of the disease (headache, palpitation, and diaphoresis), makes pheochromocytoma (option C) less likely. Moreover, there is no comment regarding episodic nature of the symptoms. Having said these, hyperthyroidism would be the most likely diagnosis. Anxiety, the senses of something bad is going to happen, palpitations, sweatiness and elevated systolic blood pressure are reasonably justified by such a diagnosis. The most frequent symptoms of hyperthyroidism are nervousness (anxiety), heat intolerance, palpitations, and fatigue and weight loss. Common signs on examination include agitation, sinus tachycardia, elevated systolic blood pressure, fine tremors and hyper-reflexia. ⚠ Hypothyroidism (option E) causes bradycaria and dry skin, and is not associated with anxiety and the sense of impending doom

⏳ Case-based MCQ | #Case_402 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 30-year-old man presents to your practice with complaints of anxiety and palpitation. He mentions that he is always afraid that something bad is going to happen soon. On examination,he has a blood pressure of 160/80mmHg and heart rate of 110bpm. His palms are wet.

⏳ Case-based MCQ | #Case_401 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D Alkaline phosphatase levels are usually elevated in hyperparathyroidism. So this patient have primary hyperparathyroidism and is high risk for fracture biochemically. Also she is postmenopausal and high risk of fracture due to osteoporosis. So d is correct. Intact PTH concentrations are generally undetectable or very low in hypercalcaemia of malignancy and are elevated or high-normal in primary hyperparathyroidism. So option a is incorrect. It is unlikely multiple myeloma as there is no information regarding osteolytic bone lesions, hypercalcaemia, anemia and renal failure. So option b is incorrect. There are multiple causes of elevation of serum alkaline phosphatase including bone disease, liver disease, and pregnancy. Alkaline phosphatase is elevated in conditions associated with high bone turnover. These include Paget’s disease, hyperthyroidism, fractures and hyperparathyroidism. PTH is secreted almost instantaneously in response to very small reductions in serum ionized calcium, which are sensed by the calcium-sensing receptor. The increase in PTH release raises the serum calcium concentration toward normal via three actions. 1- Increased bone resorption, which occurs within minutes after PTH secretion increases. 2- Increased intestinal calcium absorption mediated by increased production of calcitriol, the most active form of vitamin D, which occurs days after PTH secretion increases. 3- Decreased urinary calcium excretion due to stimulation of calcium reabsorption in the distal tubule, which occurs within minutes after PTH secretion increases. It is uncommon for patients with hypercalcaemia of malignancy to have elevated PTH levels

⏳ Case-based MCQ | #Case_401 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 77-year-old woman presented with low back pain. She has history of colon cancer surgery 5 years ago. On examination she is tender at T7-T8 level. There is no history of trauma. Investigations show elevated PTH and alkaline phosphatase.

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