Case-based MCQ

⏳ Case-based MCQ | #Case_441 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Shoulder pain following a fall may be caused by a strained muscle and/or ligament, an exacerbation of smouldering subacromial bursitis or tendinitis, or a rotator cuff tear. Frequently there is a combination of two or three of these conditions. If the rotator cuff tear is small, treatment is similar to that recommended for the other conditions. However, if a rupture has occurred, immobilization and/or surgical consultation is required. On physical examination, a painful arc of abduction above 90°, inability to lower affected arm from a fully abducted position, and weakness in external rotation would be expected with a torn rotator cuff. Of these three, weakness in external rotation (choice E) is much more specific. ⚠ Inability to flex at the elbow against resistance (choice A) is associated with, for instance, biceps (bicipital) tendonitis. ⚠ Pain with passive forward flexion to 90°, elbow at 90° and internal rotation (choice B) is considered a positive Hawkins sign, which is 90% sensitive for the diagnosis of shoulder impingement syndrome. ⚠ Signs of reduced arterial perfusion of the hand (choice C) would be seen in patients with arterial injury (e.g., trauma, thenar hammer syndrome). ⚠ Swelling of the acromioclavicular joint (choice D) may be associated with osteoarthritis, gout, post-traumatic osteolysis of the clavicle, etc. 🔖 Key point: ¹Positive active painful arc test, ²positive drop arm test, and ³weakness in external rotation suggest a significant rotator cuff tear

⏳ Case-based MCQ | #Case_441 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 55-year-old Hispanic male presents with right shoulder pain for the last three days. The pain started shortly after he caught himself when he fell coming down his front steps. Plain radiographs of the shoulder are normal.

⏳ Case-based MCQ | #Case_440 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C This patient is an 18-month-old male presenting with bloody stools. The absence of fever and diarrhea generally makes infection low on our diagnosis differential, and the fact the child is not fussing suggests that this is painless hematochezia. In this age group, the most common causes of painless hematochezia are Meckel’s diverticulum and polyps. Meckel's diverticulum is a remnant of the prenatal vitellointestinal tract. The yolk sac of the developing embryo is connected to the primitive gut by the omphalomesenteric duct. This structure normally regresses between the fifth and seventh weeks of fetal life. If this process of regression fails, various anomalies can occur, the most common of those anomalies is Meckel's diverticulum. Ectopic gastric mucosa is found in the majority of symptomatic Meckel’s diverticuli. Lower gastrointestinal hemorrhage is the most common presentation in children with Meckel's diverticulum. The incidence rate is about 50%. Besides bleeding, the second most common complication is intestinal obstruction, and for those who have Meckel’s diverticulum in their adult years, it is the most common presenting complication. In pediatric patients, the incidence rate is 25% to 30%. There are various mechanisms by which it can cause intestinal obstruction: volvulus, intussusception, and Littre’s hernia are some of the most common. A technetium-99m pertechnetate scan (choice C), also called Meckel scan, is the investigation of choice to diagnose Meckel's diverticula in children. It is a non-invasive study that uses a radionuclide to bind plasma protein and accumulate in functional gastric mucosa. Meckel’s diverticulum is identified on the scan by a focus of increased activity often mid-abdomen or in the right lower quadrant. ⚠ Nasogastric tube (choice A) is used in children with a history that suggests upper gastrointestinal bleeding. If bloody stools are noted from an upper gastrointestinal source, they are usually dark, also known as melena, and not bright red as seen in this child. ⚠ Barium contrast study (choice B) is used in intestinal malrotation. Patient's history is usually suggestive of the presence of foreign bodies, esophagitis, and polyps. ⚠ Angiography (choice D) is an invasive study that is less preferable than a technetium-99m pertechnetate scan. It is also more useful if the blood loss is in large quantity, which does not appear to be the case here. ⚠ Doppler ultrasonography (choice E) is very sensitive and specific for diagnosis intussusception, but the success rate is operator-dependent.

⏳ Case-based MCQ | #Case_440 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 An 18-month-old child is brought to your department by his parents because they noticed some blood in his stool for the last four days. They describe the color as bright red and the stool as having normal consistency. The frequency of passing stool is not increased. They report that he does not seem to fuss more than usual and they did not observe any fever. He eats a variety of foods, drinks apple juice, and milk. Vital signs are normal, and on physical examination, the abdomen does not appear distended. On palpation, there is no mass or any particularly tender point. You suspect Meckel's diverticulum.

most likely cause of amenorrhea is outflow tract obstruction. Key point: In patients with intrauterine adhesions, the management goal, post adhesions lysis, should be the prevention of adhesions reformation as recurrence rate has been estimated to be between 16% and 42%. The most preferred options are using a balloon catheter or adhesion barriers such as modifications of hyaluronic acid

This patient presents with a history of absent menses for 4 months; however, she reports that she has had regular menses for several years, which makes her condition secondary amenorrhea. This differs from primary amenorrhea, which is generally defined as the absence of menstruation by the age of 16 in a female with complete secondary sexual development or by the age of 14 in a female without secondary sexual development. Secondary amenorrhea is defined as the absence of menstruation for > 3 months in a patient who had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea. Major causes of amenorrhea are shown in the table below. Since pregnancy is the most common cause of secondary amenorrhea, the initial step is to order a pregnancy test as described in the opening stem. In this patient, the test was negative. The following step is usually a pelvic ultrasound if primary amenorrhea is suspected to confirm the presence or absence of a uterus, in this patient's case, this is unnecessary because if she had menses previously, she obviously has a uterus. In patients with a previously well functioning uterus TSH and prolactin are ordered next, if both are normal, the progesterone challenge test follows as this allows evaluation whether amenorrhea is due to progesterone deficiency in a patient with normal estrogen levels. If this is the case, withdrawal bleeding is observed within 7 days. If this does not occur, the estrogen-progesterone challenge test is done. In a patient who has deficiency of both hormones, withdrawal bleeding is observed. The absence of withdrawal bleeding after both hormones are given, suggests outflow tract obstruction as the most likely cause of amenorrhea. In patients with secondary amenorrhea, Asherman disease is the most common cause of outflow tract obstruction. This is usually caused by intrauterine synechiae due to postpartum endometritis, an operative procedure involving the uterus, particularly curettage, elective abortion, or a missed abortion.  Treatment of intrauterine adhesions is focused on two areas: first is the actual management of the adhesions, and second is preventing adhesion re-formation. Hysteroscopy is the treatment of choice with lysis of the adhesions under direct vision. Rigid hysteroscope is preferred for this procedure with operating channel of 3 to 7 Fr diameter. This allows for the use of flexible or semirigid scissors to lyse the adhesion usually at the junction of the adhesion with the endometrium and excise the tissue. Potential complications include uterine perforation, especially when there are lateral adhesions or they are very dense, making it difficult to dissect. After hysteroscopic adhesions lysis, management goal should be the prevention of adhesions re-formation as recurrence rate has been estimated to be between 16% and 42%. The most preferred options are using a balloon catheter or adhesion barriers such as modifications of hyaluronic acid (choice B).  At the conclusion of the procedure, a Foley-type catheter is placed in the uterine cavity and left in place. The length of time varies between 3 days and 14 days. It reduces the risk of reagglutination of the walls of the uterus. Similarly, the hyaluronic acid gel is beneficial in keeping the walls of the uterine cavity separated. Either option can be used to reduce the risk of recurrence. → Clomiphene (choice A) is known to induce ovulation in various secondary amenorrhea conditions such as polycystic ovarian syndrome, but it would be of no benefit after adhesion lysis treatment in Asherman's syndrome. → Maudsley method family-based therapy (choice C) is recommended for patients with anorexia nervosa for remission maintenance but would be of no benefit to this patient. → Bromocriptine (choice D) is used to treat pituitary microadenomas. It would be of no benefit to this patient. → Follitropin alfa (choice E) is a recombinant gonadotropin preparation used as a fertility medication to induce ovulation; it would be of no benefit to this patient because

⏳ Case-based MCQ | #Case_439 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 19-year-old female presents to your department with a complaint of absence of menses for the last four months. She reports that her menarche was at the age of 13 and even though the first two years the menses were irregular, she has had normal menstruation every 30 days after that initial period. She has normal secondary sexual development. Past medical history reveals elective abortion, two years ago. Pregnancy test is negative. TSH and prolactin are within normal limits. Progesterone withdrawal test results in the absence of bleeding. The estrogen-progesterone challenge test is administered, but again there is no withdrawal bleeding.

⏳ Case-based MCQ | #Case_438 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D This patient most likely has both left and right heart failure and is presenting with symptoms of acute pulmonary edema and generalized edema. Other major conditions to consider in the differential diagnosis are acute respiratory distress syndrome and cirrhosis as they may cause some of the signs of edema seen in this patient. The patient’s history of many years of diabetes and hypertension with a myocardial infarction the previous year are major clues to a diagnosis of heart failure. An S3 gallop is a specific finding of congestive heart failure. Orthopnea and signs of pleural effusion point to left heart failure, while the hepatojugular reflex and the Kussmaul’s sign (jugular venous pressure rising on inspiration) point to right heart failure.  Major findings of congestive heart failure that pertain to this case are: • S3 gallop • PCWP > 18 mmHg - Pulmonary capillary wedge pressure is a good approximation of left atrial pressure. In cardiogenic acute pulmonary edema, PCWP is usually greater than 25 mmHg; this is not the case in ARDS induced pulmonary edema. In ARDS, PCWP is less than 18 mmHg, and this feature can help us differentiate the two conditions.  • Central venous pressure of 15 cm H2O or higher - The central venous pressure, also known as the right atrial pressure, describes the pressure in thoracic vena cava near the right atrium. Normal CVP is 0-14 cm H2O at the sternum and 8-15 cm H2O midaxillary line. •  Ventricular hypertrophy - this could be diagnosed using echocardiography and ECG, even though ECG has less sensitivity and specificity when different criteria are combined, the sensitivity and specificity are increased. On the Sokolow-Lyon criteria, S in V1 + R in V5 or V6 (whichever is larger) ≥ 35 mm and R in aVL ≥ 11 mm would suggest left ventricular hypertrophy • Kerley B lines on chest X-ray: they are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs.   Preload is the degree of tension (load) on the ventricular muscle when it begins to contract. The primary determinant of preload is end-diastolic volume. Drugs that decrease preload would decrease end diastolic volume by either decreasing intravascular volume or decreasing venous return through venodilation. Furosemide (a diuretic) and nitrates (venodilators) (choice D) work through this mechanism; therefore the correct answer is D. Nitrates also dilate arteries (reduce afterload). ⚠ Metoprolol and Diltiazem (choice A) is incorrect. Beta-blockers and calcium-channel blockers decrease contractility. ⚠ While hydrochlorothiazide (choice B) is a diuretic that decreases preload, doxazosin is an alpha1-inhibitor and decreases afterload; therefore choice B is incorrect. ⚠ Carvedilol (choice C) is a nonselective beta-blocker and lapha1-blocker. It decreases contractility and afterload, not preload. ⚠ Nifedipine (choice E) is a calcium channel blocker that promotes arterial vasodilation. It decreases afterload.

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⏳ Case-based MCQ | #Case_438 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 63-year-old male with a history of myocardial infarction and atrial fibrillation diagnosed one year ago, presents to your department with fatigue, orthopnea, dyspnea on exertion, and occasional dyspnea at rest. He coughs and spits a pink, frothy sputum. He has a 30-year-history of type II diabetes mellitus and 15-year history of hypertension. He quit smoking six months ago and drinks alcohol occasionally. On physical examination, his temperature is 37.9°C, BP 90/55 mmHg, pulse is 90 bpm, and respirations 24 bpm. Chest auscultation reveals pulmonary rales and S3 gallop. You also find evidence of hepatojugular reflex and pedal edema. The jugular venous pressure rises on inspiration. No muffled heart sounds are heard, and the patient denies chest pain. You quickly initiate an oxygen therapy through a plastic facemask, order an ECG, and also order necessary laboratory and radiological studies.

⏳ Case-based MCQ | #Case_437 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D Xanthomas typically affect adults and are usually a dermatologic sign of dyslipidaemias. Eruptive xanthomas, such as in this patient, have an abrupt onset. They typically present as crops of 1 to 5 mm erythematous to yellow papules with a red rim. The most common sites of involvement are the extensor surfaces of the extremities and buttocks. The papules may be tender and are usually itchy. Skin biopsy may be needed and shows the characteristic lipid-filled macrophages in the dermis. Eruptive xanthomas like these are associated with elevated triglycerides (choice D), obesity, alcohol abuse, diabetes mellitus, and estrogen or retinoid therapies. ⚠ Dermatological manifestations of infective endocarditis (choice A) include Osler's nodes (painful, purple nodular lesions on the tips of fingers and toes) and Janeway lesions (painless erythematous macules on palms and soles). ⚠ Systemic vasculitis (choice B) is more commonly associated with palpable purpura. ⚠ Viral infection of the skin (choice C) is incorrect. The lesions of molluscum contagiosum (poxvirus) can be distinguished from xanthomas by the characteristic central umbilication of molluscum. ⚠ Urticaria (choice E) (hives) presents with migratory, well-circumscribed, erythematous, pruritic plaques on the skin (anywhere) with or without angioedema. 🔖 Key point: Eruptive xanthomas typically present as crops of 1 to 5 mm erythematous to yellow papules with a red rim, on the extensor surfaces of the extremities and buttocks. They are associated with elevated triglycerides, obesity, alcohol abuse, diabetes mellitus, and estrogen or retinoid therapies.

⏳ Case-based MCQ | #Case_437 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 46-year-old man presents with a new itchy rash. Examination reveals multiple tender-to-touch erythematous-to-yellow dome-shaped papules on the extensor surfaces of his extremities (see image above), on his buttocks, and on his hands. A biopsy reveals foamy macrophages and dermal extracellular lipids.

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