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⏳ Case-based MCQ | #Case_408
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A 30-year-old man is concerned about "floating spots" and blurred vision in his right eye. He had a penetrating injury to his left eye several weeks ago, which eventually led to vision loss in that eye. Inspection reveals a moderate perilimbal flush.

⏳ Case-based MCQ | #Case_408 | #answer
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✅ D

Sympathetic ophthalmia is also known as "spared eye injury." It is characterized by an immune-mediated inflammation of one eye (the sympathetic eye) after a penetrating injury to the other eye. The typical manifestation is anterior uveitis, but panuveitis, papillary edema, and blindness may develop. The pathophysiological mechanism is believed to be the uncovering of 'hidden' antigens. Some antigens contained within the eye are protected from immunologic recognition by natural barriers. Breaking these barriers results in the uncovering of 'hidden' antigens. An immune response against these antigens can involve autoantibodies as well as a cell-mediated reaction.

⏳ Case-based MCQ | #Case_409
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A 53-year-old woman comes to the office with a "strange, itchy rash" on her left breast, which has been present for the last month. The patient applied over-the-counter corticosteroid ointment onto this rash with no relief of symptoms. She takes no medications. The patient's last menstrual period was 2 years ago. She has a history of hypertension that improved with weight loss and exercise. Physical examination shows an eczematous plaque on the left nipple and areola.

⏳ Case-based MCQ | #Case_409 | #answer
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✅ A

The hallmark of mammary Paget disease is a painful, itchy, eczematous, and/or ulcerating rash on the nipple that spreads to the areola. The majority of patients with mammary Paget disease have an underlying breast
adenocarcinoma.

⏳ Case-based MCQ | #Case_410
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A 21-year-old woman presents to her obstetrician for urinary problems. She states that she has been stressed because she is working hard to do well on her finals at college. Over the last 2 weeks she finds herself continually rushing to the bathroom, “because I feel like I need to go, but I can’t.” This has never happened to her before, and she has begun wearing pads “just in case.” She denies fevers and dysuria. She is otherwise healthy, exercises regularly, and takes a multivitamin daily. Her physical examination is normal, as is her urinalysis. Cystometry is performed, and her detrusor contraction to bethanechol chloride is greatly exaggerated.

⏳ Case-based MCQ | #Case_410 | #answer
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✅ D

Bethanechol chloride is a parasympathomimetic drug that is used during cystometry to aid in diagnosis. Lack of a contraction to bethanechol chloride suggests detrusor muscle damage and an increased response suggests upper motor neuron dysfunction. Multiple sclerosis is an autoimmune disease that is the result of central nervous system demyelination. It most commonly affects young women and can be exacerbated by stress. Bladder spasticity and urinary retention can be the presenting symptoms.

⚠ Answer A is incorrect. Although acute cystitis is common in young women, it is often accompanied by dysuria and RBCs, WBCs, and
bacteria in the urine. The response to bethanechol chloride should not be influenced by cystitis.

⚠ Answer B is incorrect. Chronic bladder distention, often secondary to outflow obstruction, presents with overflow incontinence, not spasticity, and would not be expected to lead to an increased response to bethanechol chloride

⚠ Answer C is incorrect. The response to bethanechol chloride should be decreased in cases of detrusor dysfunction due to muscle damage.

⚠ Answer E is incorrect. Pelvic floor damage, often secondary to trauma such as childbirth, leads to sphincteric insufficiency and stress, or in severe cases, total incontinence. Spasticity would be an unlikely presentation. Furthermore, the response to bethanechol chloride would not be expected to be increased

⏳ Case-based MCQ | #Case_411
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A 65-year-old patient with a history of bipolar disorder, well-controlled with lithium, is being evaluated for hypernatremia. Her only complaint is 4 months of polyuria and thirst. Her blood pressure is 106/68 mm Hg and pulse is 102/min. Physical examination reveals her mucous membranes are dry, and skin turgor is normal. The remainder of the physical examination is unremarkable. Laboratory studies show:

Na+ 147 mEq/L
K+ 4.7 mEq/L
Cl− 110 mEq/L
HCO3− 24 mEq/L
Blood urea nitrogen 12 mg/dL
Creatinine 1.1 mg/dL
Plasma osmolality 305 mOsm/kg
Urine osmolality 200 mOsm/kg

⏳ Case-based MCQ | #Case_411 | #answer
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✅ E

This patient is suffering from lithium-induced nephrogenic diabetes insipidus (DI) and demonstrates typical elevations in plasma osmolality without compensatory elevations in urine osmolality. Indeed, normal renal function would yield a urine osmolality closer to 700 mOsm/kg or higher in this situation. In the setting of prolonged lithium exposure, there is a 20% risk of permanent insensitivity to ADH. In most cases, however, normal renal function returns with cessation of lithium therapy. Appropriate treatment of lithium-induced DI includes the administration of a thiazide diuretic, which decreases the delivery of filtrate to the distal tubule and limits urine volume. Other therapeutic options include nonsteroidal anti-inflammatory drugs (to decrease filtration at the glomerulus), amiloride (to prevent accumulation of lithium in the collecting duct cells), and, in cases of known partial DI, DDAVP (synthetic ADH).

⚠ Answer A is incorrect. ADH is effective for the diagnosis and treatment of central diabetes insipidus. However, this patient has nephrogenic resistance to ADH, and thus is unlikely to respond to exogenous ADH administration.

⚠ Answer B is incorrect. Temporary fluid restriction is a useful tool in the evaluation of polyuria and hyponatremia. In the setting of elevated plasma sodium and likely volume depletion, however, fluid restriction is inappropriate and may worsen the hypernatremia.

⚠ Answer C is incorrect. Intravenous fluids are a necessary step in the resuscitation phase for the management of acute dehydration. This patient is likely to be dehydrated, but simply administering fluids will have little overall effect on her condition.

⚠ Answer D is incorrect. Although this patient has an elevated sodium concentration, she is likely total body sodium depleted and thus would not benefit from salt restriction

⏳ Case-based MCQ | #Case_412
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A 23-year-old nursing student presents to the ED with shortness of breath, “racing heart,” and a feeling that “something terrible” is happening. She states that this episode began 30 minutes earlier when she awoke from sleep drenched in sweat. She has had several similar episodes in the past, but they resolved without intervention. She states that she has been very anxious about her health lately, and has had intermittent fevers that occur in the evenings and resolve by morning for several weeks.

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⏳ Case-based MCQ | #Case_412 | #answer
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✅ E

The patient is describing symptoms that are consistent with Hodgkin’s disease, including night sweats and Pel-Ebstein (cyclic) fevers. Her shortness of breath may be consistent with a mediastinal mass caused by adenopathy. The patient may also be suffering from other chest pathology, including pulmonary tuberculosis, asthma, and cardiomyopathy, and an x-ray of the chest would be useful in the diagnosis or exclusion of any of these conditions.

⚠ Answer A is incorrect. A bronchoscopy may be warranted in the future but is not indicated in the absence of known lung pathology.

⚠ Answer B is incorrect. Again, HIV testing might be prudent in this patient; however, an x-ray will provide immediate answers regarding her current symptoms.

⚠ Answer C is incorrect. PPD placement might help in the diagnosis of pulmonary tuberculosis; however, this diagnosis will take 24–48
hours. An x-ray is a more appropriate next step in this patient’s care.

⚠ Answer D is incorrect. Although the patient’s symptoms are consistent with a panic attack, the presence of night sweats and intermittent fevers warrants further diagnostic evaluation and testing before empirically treating the patient for panic disorder with a selective serotonin reuptake inhibitor.

⏳ Case-based MCQ | #Case_413
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An abattoir worker has presented with a one-week history of sore throat, chills and sweats, associated with diarrhoea and vomiting. He initially had a nonproductive cough but now has developed pneumonia. Several other workers from the same meat works have also been ill and you suspect the patient may have Q fever (Coxiella burnetii infection).

⏳ Case-based MCQ | #Case_413 | #answer
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✅ C

Diagnosis of Q fever is by serum testing for antibodies against the organism (C is correct).

The organism, a rickettsia, does not grow in standard media on a Petri dish. A vaccine is also available for high risk individuals, such as abattoir workers, with occupational exposure. This patient has Q (for Query) fever, and the most common source of infection of this rickettsial disease is among individuals who may come into contact with the primary reservoir of Coxiella burnetii- cattle. The organism is excreted in the milk, urine and faeces of infected animals. Abattoir workers are particularly at risk from inhalation of infected dust from hides, causing pulmonary and systemic sepsis. The workplace environment can be an important source of infection. It is obviously important in such cases to obtain an accurate history of, not only the type and place of work, but recent travel, drug and sexual habits, and contacts with other potential infected individuals