Case-based MCQ

⏳ Case-based MCQ | #Case_365 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 Concerned mother of a 6-year-old girl has brought her to your attention because she has frequently noticed blood-stained yellow discharge on her panties. She is otherwise healthy. There is no complaint of itching or urinary symptoms. The girl lives with her mother and birth father. On examination, the vitals are within normal ranges. On inspection, there is mild erythema of the vulva and perianal area and offensive blood-stained yellow discharge in the introitus.

⏳ Case-based MCQ | #Case_364 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B The findings of high blood pressure and bradycardia (Cushing reflex) points towards increased intracranial pressure (ICP) as the most likely cause of such presentation. Cushing reflex (also the vasopressor response, Cushing effect, Cushing phenomenon and Cushing reaction) is a physiological nervous system response to ICP. ⭕ Cushing triad is: (1) hypertension, (2) bradycardia and (3) irregular breathing e.g. Cheyne-Stoke. This triad may indicate imminent brain herniation. Increased ICP is more underpinned by the presence of the 'doll eye' sign (movement of the eyes in the same direction as the head) signifying involvement of brainstem, probably due to increased intracranial pressure. The raised ICP is very likely to be compromised by dextrose drip which has already been inappropriately started for the patient. Dextrose is rapidly consumed by cells and the remaining free water shifts into the brain extravascular tissue, and results in worsening of the edema, swelling and more increased ICP. For this reason, the dextrose drip should be replaced with a normal saline as the most important immediate management. ⚠ An unconscious patient is not able to maintain airway patency. Furthermore, there is significant risk of aspiration; therefore, the patient should be intubated (option D), but not as the first priority at this stage, considering the fact that the patient is breathing spontaneously and is not hypoxemic (O2 saturation 95%). ⚠ The patient should then be taken for CT scan of the head (option A) for determination of the likely causes of her problem. Consultation with or referral to the neurosurgery specialist (option E) should be arranged. ⚠ Intravenous methylprednisolone (option C) has shown effective in spinal cord compressions and cases of increased ICP due to tumors and abscesses. If, after neuroimaging, the cause of ICP was found to be an abscess or a tumor, corticosteroids may be considered as a part of management plan.

⏳ Case-based MCQ | #Case_364 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 12-year-old school girl is brought to the emergency department of a tertiary hospital after she collapsed at school. En route to the hospital, she was started on dextrose 5% drip at a rate of 60 ml/minute. On examination after arrival at the emergency department, she has blood pressure of 180/110 mmHg, pulse rate of 50 bpm and respiratory rate of 12 breaths per minute. Doll eye reflex is present.

⏳ Case-based MCQ | #Case_363 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B Pleuretic chest pain, tachycardia, and tachypnea and the history of immobility is highly suggestive of pulmonary embolism (PE). PE on the other hand, can precipitate a COPD exacerbation that justifies the increased amount of sputum production, hypoxia and hypercapnia. Under these circumstances, an ABG is always the next best investigation to check for hypoxia (the most important concern in both PE and COPD), worsened hypercapnia due to COPD exacerbation, and the blood pH. A chest X-ray (option A) should be obtained for this patient to investigate any other underlying lung pathology that might, other than the PE, has led to the condition, but immediate pulseoxymetry and ABG always come first in priority. ⚠ Ventilation/perfusion scan (option D) or CTPA (preferred) (option C) are diagnostic tools to establish the definite diagnosis of PE.They should be performed to prove the presence if PE prior to treatment with anticoagulation. ⚠ A conventional CT scan of the chest (option E) has no role in management of this patient for now. ⚠ With the underlying COPD and baseline chest X-ray abnormalities, ventilation/perfusion scan is unlikely to be of diagnostic value. Conventional CT scan of the chest would add no relevant piece of information.

⏳ Case-based MCQ | #Case_363 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 67-year-old man with background history of smoking for the past 40 years and chronic obstructive pulmonary disease (COPD) presents with acute shortness of breath, pleuretic chest pain, increased mucus production and severe cough. Last week, he has had an episode of gout in his first metatarsophalangeal joint, for which he was started on indomethacin 75 mg, 8-hourly. Sever pain made him bedbound for 5 days. On examination, he has a blood pressure of 130/95 mmHg, pulse rate of 110 bpm, respiratory rate of 34 breaths per minute and temperature of 37.5°C.

⏳ Case-based MCQ | #Case_362 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B The patient has the provisional diagnosis of the biliary colic, most likely due to biliary stones The ultrasound scan - as the best Initial diagnostic tool- has been used to confirm the diagnosis. Furthermore, any associated inflammation would be evaluated. Inflammation of the gallbladder manifests as the thickening of the wall of the gallbladder and the presence of pericholecystic fluid. Stones might be seen in the common bile duct as well; however, the sensitivity of ultrasound for detection of ductal stones is low (30% - 50%). As a routine procedure, when scanning for biliary problems, the sonographer will scan the liver as well. In this case the sonographer has encountered an incidental finding, irrelevant to the presenting symptoms, for which a triphasic CT scan of the liver has been performed. Early prominent dense enhancement of the lesion during the arterial phase is characteristic of liver hemangioma (the most common benign liver tumor). Hemangiomas are seen in approximately 20% of the general population. They may be solitary or multiple. The lesions typically show intense enhancement during the arterial phase of triphasic CT scan and retain a blush of contrast during the portal venous phase ⚠ (Options A and C) Most malignant Irver tumours (primary or metastatic) are hypovascular and will not have the early enhancement during the arterial phase;rather, they become more pronounced during the portal venous phase. ⚠ (Option D) Cystic lesions In the liver may be simple,multiple (polycystic Irver disease), neoplastic or infective(hydatid cysts). Simple cysts are extremely common and usually asymptomatic. On Imaging, these cysts have a low-density homogenous appearance. With polycystic disease, the number and size of the cysts often lead to symptoms. ⚠ (Option E) Hydatid cysts have a characteristic septate appearance and heterogenous appearance if they contain daughter cysts. Liver abscesses are usually symptomatic and more likely to have a heterogenous appearance

⏳ Case-based MCQ | #Case_362 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 66-year-old man presents with Intermittent right upper quadrant pain. An ultrasound, performed for revealing the cause gallstones, reveals a lesion In the liver. Triple phase CT scan Is performed for more evaluation showing a 35 mm subcortical lesion with early prominent dense enhancement, which spreads through the lesion In the late portal venous phase.

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⏳ Case-based MCQ | #Case_361 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C Although hypotension during hemodialysis is a frequent complication, some patients (5-15%) develop paradoxical hypertension in the later stages of dialysis or when the patients comes off the dialysis machine, a time at which most of the excess fluid has already been removed. The pathogenesis is unclear; however, the following mechanisms have been hypothesized as the cause: 1. Renin-angiotensin system activation because of ultrafiltration (UF) induced hypovolemia 2. Sympathetic overactivity 3. Intradialytic Ca++/k+ variations 4. Blood viscosity/hemoconcentration-induced vasoconstriction caused by erythropoietin treatment 5. Fluid overload 6. Increased cardiac output 7. Endothelin-driven vasoconstriction 8. Antihypertensive drug removal by dialysis treatment The optimal therapy for this problem is not known. While antihypertensive medications such as angiotensin converting enzyme inhibitors (ACE inhibitors) and alpha-blockers have been used before (or during) dialysis, they have not been predictably effective. Carvedilol, which blocks endothelin-1 release, appears to be effective. Although there are no validated universal guidelines regarding management of such patients, fluid removal has been accepted as the first-line treatment for intradialytic hypertension (IDH). Theoretically, increasing the time of the dialysis session and ultrafiltration (UF) rate would be efficient; however, this decision faces many difficulties such as patient refusal or the unit limitations. This treatment should be done with caution to avoid hazardous blood pressure drop that may occur in the elderly or patients with severe comorbidity. The dry weight of patients should be gradually reduced by increasing the dialysis time and the UF rate. In addition, patients should be advised to decrease their daily salt and water intake in between their dialysis sessions. ⚠ (Options A and B) Addition of anti-hypertensive or other medications ACE inhibitors or angiotensin receptor blockers (ARBs), beta blockers, endothelin-1 receptor blockers, furosemide, etc has been associated with conflicting results. In some patients, hypertensive crises may occur. These hypertensive crises are not persistent and usually the blood pressure level quickly decreases spontaneously; however, addition of antihypertensive medications might be indicated. There is no comment regarding a ypertensive crisis in this patient to necessitate addition of antihypertensives. Furosemide is not the first-line option for management of hypertension crisis if it occurs. ⚠ (Option D) Sedation before dialysis has no role in management of IDH or post-dialytic hypertension. ⚠ (Option E) Decreasing the dialysis time results in insufficient excess fluid removal and hypertension due to volume overload

⏳ Case-based MCQ | #Case_361 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 72-year-old woman has been on routine dialysis sessions for the past 6 months due to end-stage renal disease. At the beginning of each session, she is found to have a high blood pressure (BP). During the session the BP normalizes, but goes up again after the session.

⏳ Case-based MCQ | #Case_360 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C This patient has the classic presentation of a third cranial nerve palsy. The third cranial nerve supplies the levator muscles of the eyelid and four extraoccular muscles: (1) the medial rectus (eye adduction), (2) superior rectus (eye elevation), (3) inferior rectus (eye depression), (4) and inferior oblique (eye elevation). Additionally, the third cranial nerve constricts the pupil through its parasympathetic fibers that supply the smooth muscles of the ciliary body and the sphincter of the iris. The third nerve begins as a nucleus in the midbrain that consists of several subnuclei innervating the individual extraoccular muscles, the eyelids, and the pupils. The etiology of the third cranial nerve palsy is vast and includes conditions such as: • Ischemia (e.g. diabetes and midbrain infarcts) • Compressive effects of aneurysms such as those of the posterior communicating artery, internal carotid artery and basilar artery. • Trauma • Infections • Infiltrative diseases (e.g. neoplasms) • Demyelination • Space occupying tumors • Meningitis • Herniation • Inflammatory diseases Of the given options, only a posterior communicating aneurysm can cause a third nerve palsy that involves the pupilary reflex. Compression of the third nerve by an enlarging intracranial aneurysm is the most dreaded etiology. The most common site of an aneurysm causing a third nerve palsy is the posterior communicating artery. In the setting of an acute third nerve palsy, the aneurysm is believed to be progressively and acutely enlarging and is at imminent risk of rupture with catastrophic outcomes. ⚠ (Option A) Midbrain infarcts can cause third cranial nerve palsy. However, since the etiology is ischemic (such as in diabetes) the pupillary light reflex is expected to be unaffected most of the time. Furthermore, with a midbrain infarct, an isolated third nerve palsy as the sole presenting symptom is very unlikely and other signs and symptoms related to a midbrain infarct are expected. ⚠ (Option B) Right 6th nerve palsy presents with horizontal binocular diplopia upon looking laterally to the affected side. Furthermore, lesions of the sixth cranial nerve do not cause ptosis. ⚠ (Option D) The fourth cranial nerve palsy presents with binocular vertical diplopia. Ptosis is not a feature. ⚠ (Option E) Lesions of occipital cortex are associated with impaired vision and visual fields deficits, none of which are present here. Furthermore, ptosis is not a feature

⏳ Case-based MCQ | #Case_360 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 56-year-old man presents to the emergency department with complaint of diplopia. On examination, he has right-sided ptosis. His visual acuity and visual fields are unaffected. His right eye is depressed inferiorly and laterally and he is not able to look at to the left side. The pupillary light reflex of the right eye is sluggish. The neurological examination is otherwise unremarkable.