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⏳ Case-based MCQ | #Case_405 | #answer
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✅ D

COPD patients has type II respiratory failure, which by definition is hypoxia (PaO2<60mmHg (8.0 kPa)) and hypercapnia (PaC02> 50mmHg (6.6 kPa)). Under normal condition, both decrease in Pa02 and increase PaC02 stimulate respiratory centers in the brainstem and increase the respiratory drive as a compensatory mechanism, but in chronic type II respiratory failure, such as in COPD, sustained exposure to high levels of PaC02, desensitizes respiratory centers to elevated concentrations of C02 in the blood. Administration of high-concentration oxygen to these patients decreases the respiratory drive and results in more hypercapnia, dyspnea, paradoxically decreased oxygen saturation and respiratory acidosis.

In such patients with deteriorating Pa02 and oxygen saturation despite being on oxygen the next best step in management is to reduce the delivery of oxygen, provided that the patient is not at risk of imminent respiratory arrest or severe acidemia (PH<7.3) in which immediate case assisted ventilation should be considered.

⚠ If patient remains hypoxemic despite adequate controlled oxygen delivery (e.g. by Venturi mask) assisted ventilation such as CPAP or intubation (option A) and mechanical ventilation should be considered next.

⚠ Both increasing the oxygen flow (option C) and cessation of oxygen (option B) will increase the hypoxemia deteriorate the patient’s condition as the first decreases the respiratory drive even more while the second deprives him of oxygen.

⚠ (Option E) While the respiratory drive is suppressed, administration of bronchodilators is not likely to be beneficial for this patient

⏳ Case-based MCQ | #Case_406
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A 24-year-old woman has been started on an antipsychotic drug due to poorly-controlled schizophrenia 3 weeks ago. She has now presented with complaint of palpitations.

⏳ Case-based MCQ | #Case_406 | #answer
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✅ A

Clozapine is an effective antipsychotic for treatment of resistant schizophrenia, but is associated with serious adverse effects including sedation, postural hypotension, hypersalivation, severe constipation, dyslipidemia, myoclonus and epileptic seizures. Excessive weight gain and glucose intolerance may occur, precipitating type 2 diabetes.

The two serious adverse effects of neutropenia (2-3%), agranulocytosis (1%) are of significant concern as well. Tachycardia is another common side effect of clozapine, observed in 25% of patients. Arrhythmias may also occur. Moreover, a minority of clozapine-treated patients experience ECG changes similar to those seen with other antipsychotic drugs, including ST segment depression and flattening or inversion of T-waves, which normalizes after discontinuation of clozapine.

Of the given options, clozapine can be associated with tachycardia and palpitations as an adverse effect.


NOTE - Myocarditis is a reported serious adverse effect of this drug which necessitates application of close monitoring protocols for patients on treatment with this drug.

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⏳ Case-based MCQ | #Case_407
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A 26-year-old jogger presents to her primary care physician complaining of left lower leg pain when she exercises. She states that when she is not jogging, she is pain free, but when she jogs over 3 miles, she begins to note pain and tightness in her left lower leg. She states that she often has concurrent numbness and tingling in the top of her foot during these episodes of pain. When she ceases strenuous activity, all symptoms slowly subside over the course of half an hour. Physical examination is unremarkable and demonstrates a neurovascularly intact left lower extremity with supple compartments, and no focal areas of tenderness. Plain films of the left knee, tibia, and fibula are similarly unremarkable.

⏳ Case-based MCQ | #Case_407 | #answer
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✅ B

Exertional compartment syndrome is a condition in which the patient experiences pain over the anterior lower leg caused by a pressure buildup within the muscles of the leg. Patients typically complain of pain after a period of activity or exercise, and it is quickly relieved by rest. As blood flow to the muscle increases with activity, the muscle swells and becomes constricted by the encompassing fascia. Pain results from the ensuing ischemia. There may also be associated numbness in the dorsum of the foot or weakness on dorsiflexion at the ankle. The diagnosis is made by measuring pressures within the leg at rest followed by a reading after some exercise. Treatment consists of a surgical fasciotomy, which involves release of the tight fascia.

⚠ Answer A is incorrect. Acute compartment syndrome differs from exercise-induced or chronic compartment syndrome in that the former occurs secondary to a traumatic injury such as a fracture of one of the long bones or a
crush injury. The patient would present with severe pain and clinically tight compartments
at the time of examination with associated paresthesias. Treatment involves immediate
fasciotomy to prevent cell death.

⚠ Answer C is incorrect. Pain associated with knee osteoarthritis would not likely resolve within a half hour of cessation of exercise. Patients typically experience pain, soreness, and swelling with activity that does not necessarily resolve immediately after rest. Treatment includes ice, nonsteroidal anti-inflammatory drugs, and limited activity. In addition, the patient’s age and lack of x-ray findings make this diagnosis unlikely.

⚠ Answer D is incorrect. Patellofemoral knee pain most commonly arises from an imbalance or irregularity of patellar movement or tracking. Conditions that predispose to these abnormalities include an imbalance in quadriceps strength, patella alta, recurrent patellar subluxation, direct trauma to the patella, and meniscal injuries. Patients suffering from any of the patellofemoral knee pain syndromes usually complain of anterior knee pain, and do not present in the manner described in the stem.

⚠ Answer E is incorrect. Stress fractures are tiny cracks in bone that result from overuse. Fatigued muscles and increasing the amount or intensity of an activity too rapidly may cause these cracks. Most stress fractures occur in the weight-bearing bones of the lower leg and the foot. Treatment consists of ice, nonsteroidal anti-inflammatory drugs, and rest for 6–8 weeks which allows ample time for healing. Evidence of fracture may never appear on plain radiographs or may not appear for 2–10. weeks after symptom onset, although triple-phase nuclear bone scans are more sensitive in the detection of stress fractures early in the clinical course. A patient with a tibial stress fracture would not be pain-free within 30 minutes of cessation of activity, nor would the patient likely experience a temporary loss of sensation over the dorsum of the foot.

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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.