Case-based MCQ

⏳ Case-based MCQ | #Case_397 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 25. A young man presents to the emergency department after injuring his shoulder in a fall. His X-ray is shown in the following photograph.

⏳ Case-based MCQ | #Case_396 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A If not contraindicated, antithrombotic therapy should be started for all patients with ischemic stroke. In patients with AF, warfarin is the antithrombotic of choice to start. The need for anticoagulation is assessed based on CHA2DS2-VASC system. ⚠ (Options B and C) Aspirin or dipyridamole alone does not appear to provide adequate anticiagulation in patients with AF. ⚠ (Option D) Thrombolyitc therapy is indicated within the first 4.5 hours of symptoms onset. In this patient, 48 hours has past since the start of symptom; therefore, thrombolytic therapy with rTPA is not beneficial for her. ⚠ (Option E) Combination of aspirin and clopidogrel is not recommended for secondary prevention of cerebrovascular disease in patients who do not have acute coronary disease or a recent coronary stent placement. This is due to significantly increased risk of bleeding that outweighs the additional benefit of combinations therapy if no other indication than prevention of ischemic stroke is desired

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⏳ Case-based MCQ | #Case_396 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 72-year-old woman, who is a known case of diabetes and hypertension and on multiple medications, is brought to the emergency department with complaint of left-sided weakness for the past 48 hours. On examination, she has a blood pressure of 150/100 mmHg and an irregular pulse of 98 bpm. Her blood sugar is 8 mmol/L. Three years ago, she had an episode of sudden-onset right vision loss for few hours before she completely recovers. She, however, did not seek any medical attention at that time.

⏳ Case-based MCQ | #Case_395 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A The history of prolonged constipation as well as the exam findings of a tympanic distended abdomen colicky abdominal pain and an empty rectum is more consistent with sigmoid volvulus as the most likely diagnosis (A is correct) A colonic volvulus occurs when a part of the colon twists on as mesentery, causing colonic obstruction. Such obstruction can be acute, subacute or chronic. Although volvulus can occur in any portion of the large bowel the sigmoid colon is the most frequently affected part followed by volvulus of the right colon and terminal ileum namely cecal or cecocolic volvulus. In very rare cases volvulus may develop in the transverse colon or the splenic flexure Patients with colonic volvulus are commonly elderly debilitated and bedridden. A history of dementia or neuropsychtalrtc impairment is often present. The symptoms are acute in more than 60-70% of patients wbie the rest present with subacute or chronic symptoms. A history of chronic constipation is common. The patient may describe previous episodes of abdominal pain distention and obstipation which suggest repeated subctinical episodes of volvulus. Regardless of its anatomic site colonic volvulus presents the same way with cramping abdominal pain distention constipation and/or obstipation. Abdominal distention often increases progressively. The distention ts characteristically tympanic over the gas-filled thin wall colon loop. Tenderness or rebound tenderness indicates that peritonitis has occurred or is just imminent. With progressive obstruction nausea and vomiting occur. The development of constant abdominal pain is an ominous sign indicating the development of a closed-loop obstruction with significant intraluminal pressure. This, m turn portends the development of ischemic gangrene and bowel wall perforation Plain abdominal films are the initial imaging choice. Massive dilation of the sigmoid colon loop arising from the pelvis and extending to the diaphragm is a typical finding of sigmoid volvulus The wais of the loop are evident as three bright lines converging m the pelvis to create a beaklike appearance ⚠ (Option B) A sigmoid tumor can also he the underlying cause of this clinical picture Left sided colon cancer can present with bloody stool, changes m bowel habits and abdominal pain specialty if the tumor has caused partial or complete obstruction However a sigmoid tumor large enough to cause complete obstruction of the colon to result in obstipation is expected to have more pronounced exam findings ⚠ (Option C) Obstruction caused by the entrapment of a loop of the small bowel in an adhesion band formed from previous surgery can cause small bowel obstruction In fact adhesions from previous abdominal surgeries ts the most common cause of small bowel obstruction In this patient however, the clinical picture more favors large bowel rather than small bowel obstruction because in small bowel obstruction nausea and vomiting is a prominent feature that occurs earlier In the course of the process. This patient has not vomited after 24 hours of symptoms onset. ⚠ (Option D) An obstructed hernia is expected to cause constant abdominal pain and tenderness. However in early stages and before the strangulation occuis these findings might be absent. This patient has no clinical findings suggestive of a hernia as the likely cause of this presentation. Furthermore, with obstructed hernias presentation will favor that of the small bowel obstruction with early onset nausea and vomiting the course of the disease ⚠ (Option E) As the name implies this kind of obstruction is caused by impaction of fecal matter often in the rectum An empty rectum excludes this diagnosis

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⏳ Case-based MCQ | #Case_395 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 76 year-old man is brought to the emergency department with colicky abdominal pain and abdominal distention for the past 24 hours He has not passed any stool or gas since He gives the history of constipation for the past month His past medical history is significant for appendectomy at the age of 42 years On examination, he has stable vital signs Abdominal exam reveals a distended abdomen, tympanic to percussion No tenderness, rebound tenderness or guarding ts elicited Rectum is empty with no mass.

⏳ Case-based MCQ | #Case_394 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B Vancomycin can cause several different types of hypersensitivity reactions, ranging from localized skin reactions to generalized cardiovascular collapse. Red man syndrome (RMS) is the most reported adverse reaction. RMS, also called "red neck syndrome" is a rate-dependent infusion reaction, not a true allergic reaction. The etiology is unknown but it does not involve drug-specific antibodies and, in contrast to allergic reactions, may develop with the first administration of vancomycin. RMS is characterized by flushing, erythema, and pruritus, usually affecting the upper body, neck, and face more than the lower body. Pains and muscle spasms in the back and chest, dyspnea, and hypotension may also occur. Chest pain and chest tightness are other reprted clinical features. RMS is rarely life-threatening; however, severe cardiovascular toxicity and even cardiac arrest can occur. IgE-mediated anaphylaxis can present with symptoms similar those of severe RMS. Unlike RMS, an IgE-mediated reaction to vancomycin does not occur with first administration. However, there may be some characteristics distinguishing features. While wheezing, respiratory, and angioedema are more common in anaphylaxis, chest pain or a sense of chest tightness is seen more frequently in RMS. 🔖 NOTE - Since it may not be possible to distinguish anaphylaxis from severe RMS based on clinical presentation, the patient should be assumed to have anaphylaxis and treated promptly if in doubt. Concomitant use of some drugs associated with histamine release may increase the risk of vancomycin adverse reactions. Opiates and contrast media are the most implicated medications. Some studies suggest that the dihydropyridine calcium channel blockers - nifedipine may increase the risk of vancomycin-related adverse drug interaction. Management of RMS is as follows: For mild to moderate reactions, in which the patient is uncomfortable due to flushing or pruritus, but without hemodynamic instability, chest pain or muscle spasms, the infusion should be interrupted and patient be treated with diphenhydramine (50 mg orally or intravenously) and ranitidine (50 mg intravenously). Symptoms usually subside promptly. The infusion can then be restarted at one-half of the initial rate or 10 mg/min, whichever is slower. For Severe reactions associated with muscle spasms, chest pain, or hypotension, the infusion should be interrupted and the patient be treated with diphenhydramine (50 mg intravenously) and ranitidine (50 mg intravenously), and intravenous fluids if there is hypotension. Once symptoms have resolved, the infusion can be restarted, and given over 4 or more hours. For future administration in such patients, premedication with antihistamines before each dose and infusion over 4 hours is recommended. If the reaction to vancomycin is anaphylaxis type, immediate treatment would be intramuscular adrenaline. Vancomycin should never be given again, unless desensitization is performed. Hives, laryngeal edema, and wheezing are suggestive of anaphylaxis. This patient has typical presentation of RMS. Since chest tightness is present, the management would be restarting the infusion at a slower rate (over 4 hours) as well as premedication with histamine (and ranitidine). Unlike antihistamines, addition of prednisolone to vancomycin has not shown to decrease the risk of recurrence of RMS.

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⏳ Case-based MCQ | #Case_394 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 During hospital stay of a 62-year-old woman, she develops pneumonia. Since methicillin resistant staphylococcus aureus (MRSA) is highly suspected, intravenous vancomycin is started. After 20 minutes of infusion, the patient develops a generalized pruritic erythematous rash all over her face, torso and arms. She also complains of chest tightness. The infusion is stopped immediately, and within few minutes the rash resolves. A quick drug history reveals that he is on aspirin and amilodipine for treatment of her hypertension.

⏳ Case-based MCQ | #Case_393 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B Delirium following a major surgery in the elderly is a common postoperative complication. Delirium and confusional state after surgery are most commonly caused by hypoxia. Hypoxia can be caused by the effect of hypoventilation due to anesthetics or analgesics, or simply by shallow breathing due to pain. Fluid and electrolyte disturbances, hypoglycemia, or infections can also cause post-operative delirium. Alcohol withdrawal or delirium tremens are other important etiologies not to miss. Urinary retention or fecal impaction should be thought of as well. Management of delirium is by identification of the underlying etiology and treating it. This woman is febrile, making infection a likely cause of her delirious state. Atthough prophylactic antibiotics decrease the risk of post-operative infections, they do not eliminated such risk. A confused and delirious patient can be difficult to deal with at times, and pharmacological treatment should be considered for sedation before other diagnostic or therapeutic measures are carried out. An ABG is often the very initial step to exclude hypoxemia as the most likely cause of delirium, but attempts to obtain an arterial sample in an agitated delirious patient is not easy and may result in arterial injuries in a combative patient. An agitated patient may not let an oxygen face mask to be fixed in place. Under such conditions, medications are used to sedate and calm the patient. Haloperidol is a convenient drug, which is most frequently used for this purpose and is the most appropriate next step in management. Atypical antipsychotics such as risperidone, olanzapine or ziprasidone are second-line choices that can be used as alternatives; however, in the presence of extrapyramidal symptoms, they should be use in preference to haloperidole. Intravenous diazepam (not an option) is the medication of choice if alcohol withdrawal or delirium tremens are suspected from the history and clinical findings. NOTE - Pharmacological therapy should only be considered in a delirious person with severe behavioral disturbance and/or severe emotional disturbance if their behavior threatens their own safety or the safety of others, is likely to interfere with essential medical or nursing care, or if the disturbance is causing significant distress ⚠ (Option A) Although the patient is febrile, antibiotics should not be administered unless bacterial infections are suspected after initial investigations such as full blood count (FBC), chest X-ray, etc. ⚠ (Option B) This patient has a normal blood pressure and does not seem to be in urgent need for fluid resuscitation. However, it may be considered if further studies indicate otherwise. ⚠ (Options D and E) ABG is often the first-line investigation to exclude hypoxia as the most common cause of post-operative delirium/confusion. A chest X-ray is indicated for evaluation and workup of conditions such as atelectasis, pneumonia or pulmonary embolism if the patient is found to be hypoxic/hypoxemic. Again, obtaining an arterial sample for ABG can be difficult in this patient and should be attempted once the patient is easier to deal with

⏳ Case-based MCQ | #Case_393 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A nurse from the surgery ward calls you to visit a 65-year-old inward patient for agitation. When you arrive at the ward you are informed that she underwent cholecystectomy 48 hours ago. Her file shows that she received prophylactic amoxicillin prior to the surgery. On examination, she is confused and delirious, has a blood pressure of 135/87mmHg, heart rate of 110 and temperature of 38.4°C. She is agitated and difficult to deal with.

⏳ Case-based MCQ | #Case_392 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C This man has bilateral global weakness of distal arms and muscle wasting of both thenar (median-innervated) and hypothenar (ulnar-innervated) eminences. Of the options, syringomyelia best justified the bilaterality of the signs and symptoms, as well as multiple nerves involvement. Syringomyelia is the development of a fluid-filled cavity (syrinx) within the spinal cord. Syrinx extension into the anterior horns of the spinal cord damages motor neurons (lower motor neuron) and causes diffuse muscle atrophy that begins in the hands and progresses proximally to include the forearms and shoulder girdles. Claw-hand may develop. Syrinx also interrupts the decussating spinothalamic fibers that mediate pain and temperature sensibility, resulting in loss of these sensations, while light touch, vibration, and position senses are preserved because their fibers are located in the posterior column that are not affected unless late in the course of the disease (dissociated sensory loss). When the cavity enlarges to involve the posterior columns, position and vibration senses are lost as well. The sensory disturbances usually occur in a shawl-like distribution. ⚠ (Option A) Cervical spine multiple sclerosis can cause muscle weakness, exaggerated reflexes and decreased sensation of the upper limb; however, bilateral symptoms of this patient makes multiple sclerosis a less likely diagnosis. ⚠ (Option B) Bilateral median nerve palsy can cause bilateral atrophy of thenar eminence but not that of hypothenar eminence. ⚠ (Option D) Bilateral ulnar nerve palsy can cause bilateral atrophy of hypothenar eminence but not that of thenar eminence. ⚠ (Option E) Brainstem infarction is associated with contralateral limb weakness. Bilaterality is against brainstem infarction as a likely diagnosis