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⏳ Case-based MCQ | #Case_414
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An 18-year-old swimmer arrives at the ED and is complaining of ear pain and discharge for the last 2 days. He denies any fever or headache, but states that he does feel some pressure in his head, and pulling on his pinna elicits pain.

⏳ Case-based MCQ | #Case_414 | #answer
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✅ E

Pain elicited by gently pushing/pulling the pinna is classic for otitis externa. In diabetic patients, otitis externa is usually due to Pseudomonas, and can be chronic in patients with seborrhea. The treatment of choice is antibiotic ear drops.

⚠ Answer A is incorrect. CT is a relatively costly test that may do nothing to alter the treatment plan. The patient is afebrile, and it is unlikely that the infection has spread into the bone to become osteomyelitis.

⚠ Answer B is incorrect. Naegleria fowleri is an unrelated infection in which people swimming in colonized ponds get a cerebral infection via the nose. It can be fatal after about a week.

⚠ Answer C is incorrect. MRI is a fairly costly test that may do nothing to alter the treatment plan. The patient is afebrile, and it is unlikely that the infection has spread past the external ear. If osteomyelitis (malignant otitis externa) was suspected an imaging study would be appropriate.

⚠ Answer D is incorrect. Surgical debridement would only be necessary if the patient had malignant otitis externa. Malignant otitis externa is almost exclusively seen in immunocompromised patients. If this patient had a fever or signs of systemic toxicity, then more concern would be raised, and further investigation would be warranted

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⏳ Case-based MCQ | #Case_415
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A 37-year-old normotensive, non-diabetic male has a history of ankylosing spondylitis for the last ten years. He is taking Naproxen, Sulfasalazine, and Methotrexate for six years. Initially, he was feeling well and was capable of doing his regular activities smoothly. The dose of Methotrexate was increased seven months back, but his pain and range of movements were not improving despite regular exercise.

⏳ Case-based MCQ | #Case_415 | #answer
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✅ A

Adalimumab is a biologic agent that is a fully human monoclonal antibody against TNF-alpha. It is usually given along with Methotrexate to prevent loss of efficacy because of antibody formation. Adalimumab (choice A), along with other anti-TNF-alpha drugs (i.e. etanercept, golimumab, certolizumab, and infliximab), is known to alleviate symptoms of spinal and peripheral joint inflammation substantially. It has been shown to improve joint function and quality of life. So, anti-TNF-alpha drugs should be considered if the patient is not improving with NSAIDs and DMARDs.

⚠ The dose of Sulfasalazine may be increased (choice B) up to 2-3g per day, but it has no effect on axial joints; that is why solely increasing the dose to the maximum would not improve axial joint mobility.

⚠ Indomethacin (choice C) is an NSAID. NSAIDs are usually used constantly in the patient of inflammatory arthritis, usually in the evening. This is not the main drug; hence it cannot modify the inflammation.

⚠ Leflunomide (choice D) is a DMARD that exerts its immunomodulatory effects by preventing pyrimidine production in proliferating lymphocytes. Leflunomide and other DMARDs, such as Sulfasalazine and Methotrexate, have effects on peripheral joints, but not on axial joints.

⚠ Injectable methylprednisolone (choice E) is usually used in life-threatening conditions. Oral prednisolone may be used in extra-articular manifestation (e.g. acute anterior uveitis). They do not help with spinal disease.

🔖 Key point:

DMARDs do not improve spinal joint mobility even though they are used more commonly in ankylosing spondylitis. Anti-TNF-alpha drugs are considered if the patient is not improving with NSAIDs and DMARDs.

⏳ Case-based MCQ | #Case_416
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A 40-year-old male is brought to your department complaining of unbearable chest pain and abdominal pain that started about two hours ago. Prior to that, he vomited at a party where “he drank a little too much”. The patient’s history is otherwise non-remarkable. He drinks 5-6 bottles of beer daily and on weekends he can drink 10 bottles of beer and sometimes Whiskey as well. On physical examination subcutaneous emphysema is noted on chest palpation.

⏳ Case-based MCQ | #Case_416 | #answer
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✅ D

This patient has a long history of alcoholism, was at a party where he drank large amounts of alcohol and is presenting with chest pain, abdominal pain, and mediastinal emphysema; these symptoms and signs all point to the diagnosis of Boerhaave syndrome (choice D). This is a spontaneous transmural esophageal rupture caused by forceful emesis. It can be difficult because often no classic symptoms are present and delays in presentation for medical care are common. It is usually a result of intraluminal esophageal pressure produced during vomiting, due to neuromuscular incoordination causing failure of the cricopharyngeus muscle to relax. Patients may have crepitus on palpation of the chest wall due to subcutaneous emphysema. In patients with mediastinal emphysema, mediastinal crackling with each heartbeat may be heard on auscultation especially if the patient is in the left lateral decubitus position (Hamman's sign). However, these signs require at least an hour to develop after an esophageal perforation and even then are present in only a small proportion of patients.

⚠ Mallory-Weiss tear (choice A) is not a transmural rupture of the esophagus. It is a partial tear of the esophageal veins also caused by vomiting. Acute gastrointestinal bleeding is the major clinical manifestation.

⚠ Acute pancreatitis (choice B) can cause acute abdominal pain after binge drinking but the unbearable chest pain and subcutaneous emphysema are suggestive of Boerhaave syndrome.

⚠ Spontaneous pneumothorax (choice C) is characterized by air in the pleural cavity, respiratory distress, deviation of the trachea, hyperresonance on percussion, decreased tactile fremitus, and absent breath sounds.

⚠ Tracheoesophageal fistula (TEF) (choice E) is a congenital or acquired communication between the esophagus and the trachea. Congenital TEF is mostly diagnosed in neonates or during the first year of life, whereas adults rarely present with congenital TEFs that were undiagnosed during their early life.

🔖 Key point:

Excruciating chest pain and subcutaneous emphysema in a patient with significant alcohol history and recent forceful emesis most likely suggest Boerhaave syndrome

⏳ Case-based MCQ | #Case_417
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A 63-year-old female presents to your department complaining of one week history of diffuse abdominal pain and constipation. The patient had mastectomy for breast cancer three years ago and admits to drinking a glass of wine with dinner every evening.

Physical examination reveals shifting dullness on percussion of the abdomen. Ascites analysis reveals an SAAG < 1.1 and cytology reveals neoplastic cells. 

⏳ Case-based MCQ | #Case_417 | #answer
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✅ E

Ascites is the pathological accumulation of fluid within the abdominal cavity. Healthy men have little or no intraperitoneal fluid, but women may normally have as much as 20 mL, depending on the phase of their menstrual cycle. Shifting dullness is usually found on physical examination when the fluid exceeds 500 mL. In patients with smaller amounts of fluid, the puddle sign may suggest ascites. This sign is elicited as the examiner flicks near the flank while using stethoscope to auscultate for increased sound transmission.

Liver disease is the most common cause of ascites and accounts for more than 80% of ascites cases. This usually results from portal hypertension. The second most common cause of ascites is peritoneal carcinomatosis, which is ascites caused by various types of malignancies. An SAAG < 1.1 excludes portal hypertension as the cause of ascites in this patient; this means that congestive heart failure, liver disease, and hepatic metastases are unlikely to be the cause. On the other hand, this SAAG value may be found in peritoneal carcinomatosis, peritoneal tuberculosis, and pancreatitis. The findings of neoplastic cells suggest peritoneal carcinomatosis. The prognosis of peritoneal carcinomatosis is estimated to be 20-24 weeks. Palliative care to improve quality of life is considered to be the main management option.

Common causes of peritoneal carcinomatosis include breast cancer, pancreatic cancer, ovarian cancer, and other gastrointestinal cancers. In Canada, in female patients, breast cancer is the most common cancer and is likely to be the cause of this patient's peritoneal carcinomatosis. It is not uncommon for this condition to present months or even years after mastectomy. Axillary or supraclavicular lymph node enlargement (choice E) is commonly found in patients with breast cancer. It is important to emphasize that in Canada, breast cancer is the most common cause of cancer in women while prostate cancer is the most common cancer in men. GI cancer is the second most common in both men and women and lung cancer takes the third place in both men and women.

⚠ Adnexal masses (choice A) would be suggestive of ovarian cancer. While this cancer should be kept in the differential diagnosis and patients with BRCA1 and BRCA2 genes mutations are at increased risk for both breast cancer and ovarian cancer; ovarian cancer is less common than breast cancer in this particulat patient. This patient already has a history of breast cancer and it should be high on the differential diagnosis. Furthermore, ascites typically develops in the setting of recurrent and/or advanced cancer.

⚠ Hepatomegaly (choice B) that accompanies ascites can be found in patients with liver cancer or in patients with lymphomas. Liver cancer is associated with SAAG > 1.1. Lymphomas are rare causes of peritoneal carcinomatosis and are less likely to be the cause of this patient's condition.

⚠ Rectal bleeding (choice C) would be suggestive of a GI malignancy. While this should be considered on the differential, it is less common than breast cancer in Canadian women; moreover, this patient has already been diagnosed and treated for breast cancer. Therefore, metastasis is more likely to be the cause of this patient's presentation.

⚠ Spider angioma (choice D) is usually seen in cirrhosis, which would be associated with SAAG > 1.1. This patient's SAAG is < 1.1, which excludes cirrhosis or portal hypertension as the cause of the ascites.

🔖 Key point:

Ascites is the pathological accumulation of fluid within the abdominal cavity. Ascites associated with portal hypertension is the most common and its analysis reveals an SAAG > 1.1. Ascites associated with peritoneal carcinomatosis is the second most common cause of ascites and SAAG < 1.1. In a patient with breast cancer history, this cancer should be suspected as the cause of peritoneal carcinomatosis.

⏳ Case-based MCQ | #Case_418
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A 32-year-old primipara is ready to be discharged after a full-term vaginal delivery that was complicated by a prolonged second stage of labor. She required a second-degree posterior vaginal repair, but had no periurethral trauma. A transurethral catheter was removed a few hours after delivery, but 48 hours later she complained of abdominal pain and a persistent need to urinate. The catheter was replaced and yielded approximately 2000 cc of straw-colored urine.

Urinary symptoms quickly resolved, but the patient continues to be unable to void on her own. A perineal examination is normal, as is a urinalysis.

⏳ Case-based MCQ | #Case_418 | #answer
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✅ E

This patient suffers from postpartum urinary retention (PUR). PUR is often defined as a post-void bladder residual of at least 150 cc that is present 6 hours or more after delivery. This condition is more likely to occur in patients who are primiparous, have a prolonged first or second stage of labor, have instrumented vaginal deliveries, or require a cesarean section for failure to progress. The question of whether epidural anesthesia promotes the condition is still debated. Most cases of PUR will resolve 2-6 days after delivery, but some can take up to several weeks. The use of intermittent self-catheterization or a transurethral catheter is recommended until the patient’s ability to spontaneously micturate returns. Imaging studies and referrals to a specialist are rarely necessary, and no medication has been proven helpful.

⏳ Case-based MCQ | #Case_418
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A 9-year-old girl is brought in by her parents, who state that she has been having terrible nightmares recently. Several nights in the last few months, she has woken up the whole family with her bloodcurdling screams. When this occurs, she seems inconsolable and disoriented, crying and hyperventilating for some time, refusing to acknowledge her parents’ presence, and crying until she falls back asleep. The girl admits she is concerned about this, but can’t remember what the nightmares were about. On further history, she says that she is generally happy. She admits that her dog dying last year was stressful for her, but denies that it bothers her much now.

⏳ Case-based MCQ | #Case_419 | #answer
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✅ D

Sleep terror disorder (choice D) is characterized by episodes of awakening from sleep with a scream, accompanied by intense fear and autonomic arousal, with unresponsiveness to others during the episode, and subsequent amnesia for the episode.

⚠ In PTSD (choice A), the traumatic event remains a focus of the person’s symptoms; for example, with persistent intrusive recollections of the event, avoidance of reminders of it, and persistent symptoms of increased arousal.

⚠ In nightmare disorder (choice B), the patient rapidly becomes oriented and responsive on wakening, and remembers the nightmares.

⚠ Panic attacks (choice C) may wake patients from sleep, but there is rarely a history of screaming or disorientation.

⚠ Fear is sometimes a feature of the aura of temporal lobe seizures (choice E), and post-ictal confusion is the rule, but most such seizures start with motionless staring, followed by lip smacking. Screaming and crying during a seizure would be quite unusual.