Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_53 | #answer
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β C
π Explanation
Given this patient's long history of rheumatoid arthritis her drop attacks are most likely caused by atlanto-occipital instability (choice C).The cervical spine is commonly affected by rheumatoid arthritis.The anatomic abnormalities occur as a consequence of the destruction of synovial joints, ligaments, and bone. Abnormalities of the rheumatoid cervical spine generally can be grouped into 3 categories that may be seen in isolation or combined involvement, of which atlantoaxial instability or atlanto-occipital instability is the most common abnormality.Superior migration of the odontoid
is the next most common abnormality, it is also referred to as cranial settling or pseudobasilar invagination.The third and least common deformity is subaxial subluxation.When rheumatoid arthritis affects the cervical spine, compression of the C2 sensory fibers supplying the nucleus of the spinal trigeminal tract can cause facial pain. Compression of the C2 sensory fibers supplying the greater auricular nerve may result in ear pain. Occipital neuralgia results from compression of the C2 sensory fibers supplying the greater occipital nerve. Drop attack in these patients can be either a manifestation of myelopathic symptoms or vertebrobasilar insufficiency or a combination of both.Patients may experience weakness, decreased endurance, gait difficulty, paresthesias of the hands,loss of fine dexterity, and eventually incontinenece.They may also complain of vertigo, loss of equilibrium, visual disturbances, tinnitus, and dysphagia.
β Adrenal insufficiency (choice A) may cause syncope due to hypotension, it also causes muscle weakness and may even cause muscle and joint pains. Since this patient has facial plethora on physical examination and this could occur in a rheumartoid arthritis patient on long-term treatement with corticosteroids, it could be argued that an abrupt discontinuation of corticosteroid treatment could result in adrenal insufficiency. However, some of the symptoms she describes such as incontincence and numbness, and the fact that these symptoms have occured over the last 3 months (and not a sudden adrenal crisis caused by discontinuation of corticosteroid therapy), make this diagnosis less favorable than atlanto-occipital instability.
β Anxiety (choice B) is a less common cause of urinary incontinence than the reverse.Urinary incontinence causes anxiety in many patients. When considering this patient's overall history, complaints of weakness and numbness, her symptoms are most likely associated with neurological dysfunction.
β Cardiac arrhythmia (choice D) may cause syncope accompanied by incontinence in minority of patients; however, in this patient, findings on physical examination and the overall history, should guide us to consider that causes of drop attacks are related to her past medical history , and therefore most likely linked to atlanto-axial instability, a well known complication of rheumatoid arthritis of cervical spine.
β Cerebral ischemia (choice E) is most likely to be associated with atherosclerosis history.While some of the symptoms this patient describes could occur in cerebral ischemia, the history of these attacks for the last 3 months, her rheumatoid arthritis history, findings on physical examination, and absence of cardiovascular diseases in her history,should steer us towards a diagnosis of atlanto-occipital instability caused by rheumatoid arthritis.
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β C
π Explanation
Given this patient's long history of rheumatoid arthritis her drop attacks are most likely caused by atlanto-occipital instability (choice C).The cervical spine is commonly affected by rheumatoid arthritis.The anatomic abnormalities occur as a consequence of the destruction of synovial joints, ligaments, and bone. Abnormalities of the rheumatoid cervical spine generally can be grouped into 3 categories that may be seen in isolation or combined involvement, of which atlantoaxial instability or atlanto-occipital instability is the most common abnormality.Superior migration of the odontoid
is the next most common abnormality, it is also referred to as cranial settling or pseudobasilar invagination.The third and least common deformity is subaxial subluxation.When rheumatoid arthritis affects the cervical spine, compression of the C2 sensory fibers supplying the nucleus of the spinal trigeminal tract can cause facial pain. Compression of the C2 sensory fibers supplying the greater auricular nerve may result in ear pain. Occipital neuralgia results from compression of the C2 sensory fibers supplying the greater occipital nerve. Drop attack in these patients can be either a manifestation of myelopathic symptoms or vertebrobasilar insufficiency or a combination of both.Patients may experience weakness, decreased endurance, gait difficulty, paresthesias of the hands,loss of fine dexterity, and eventually incontinenece.They may also complain of vertigo, loss of equilibrium, visual disturbances, tinnitus, and dysphagia.
β Adrenal insufficiency (choice A) may cause syncope due to hypotension, it also causes muscle weakness and may even cause muscle and joint pains. Since this patient has facial plethora on physical examination and this could occur in a rheumartoid arthritis patient on long-term treatement with corticosteroids, it could be argued that an abrupt discontinuation of corticosteroid treatment could result in adrenal insufficiency. However, some of the symptoms she describes such as incontincence and numbness, and the fact that these symptoms have occured over the last 3 months (and not a sudden adrenal crisis caused by discontinuation of corticosteroid therapy), make this diagnosis less favorable than atlanto-occipital instability.
β Anxiety (choice B) is a less common cause of urinary incontinence than the reverse.Urinary incontinence causes anxiety in many patients. When considering this patient's overall history, complaints of weakness and numbness, her symptoms are most likely associated with neurological dysfunction.
β Cardiac arrhythmia (choice D) may cause syncope accompanied by incontinence in minority of patients; however, in this patient, findings on physical examination and the overall history, should guide us to consider that causes of drop attacks are related to her past medical history , and therefore most likely linked to atlanto-axial instability, a well known complication of rheumatoid arthritis of cervical spine.
β Cerebral ischemia (choice E) is most likely to be associated with atherosclerosis history.While some of the symptoms this patient describes could occur in cerebral ischemia, the history of these attacks for the last 3 months, her rheumatoid arthritis history, findings on physical examination, and absence of cardiovascular diseases in her history,should steer us towards a diagnosis of atlanto-occipital instability caused by rheumatoid arthritis.
π1
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_54
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A 76-year-old male is brought to your office by his son. The patient complains of dizziness that has slowly been worsening over the past year. His description is vague, but he says that he notices the dizziness when he tries to walk.The review of systems is normal, except for increasing problems with his "prostate" in the last 6 months, with dribbling and accidents at times. The patient admits to "going more often", and sometimes "without warning". The son states that his father seems more forgetful, slower of speech, and not as "full of life" as he used to be.A neurologic examination reveals the patient to be oriented x 3, with a somewhat flat affect and a wide-based, slow, shuffling gate. The examination is otherwise normal. His Mini-Mental State Examination (MMSE) score is 22 out of 30. No tremor is noted. A CBC, creatinine level, TSH level, vitamin B12 level and VDRL are all normal.
Which one of the following should you do next?
a) Order a brain MRI
b) Prescribe sertraline (Zoloft)
c) Prescribe carbidopa/levodopa (Sinemet)
d) Order physical therapy
e) Order a brainstem auditory evoked potential
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A 76-year-old male is brought to your office by his son. The patient complains of dizziness that has slowly been worsening over the past year. His description is vague, but he says that he notices the dizziness when he tries to walk.The review of systems is normal, except for increasing problems with his "prostate" in the last 6 months, with dribbling and accidents at times. The patient admits to "going more often", and sometimes "without warning". The son states that his father seems more forgetful, slower of speech, and not as "full of life" as he used to be.A neurologic examination reveals the patient to be oriented x 3, with a somewhat flat affect and a wide-based, slow, shuffling gate. The examination is otherwise normal. His Mini-Mental State Examination (MMSE) score is 22 out of 30. No tremor is noted. A CBC, creatinine level, TSH level, vitamin B12 level and VDRL are all normal.
Which one of the following should you do next?
a) Order a brain MRI
b) Prescribe sertraline (Zoloft)
c) Prescribe carbidopa/levodopa (Sinemet)
d) Order physical therapy
e) Order a brainstem auditory evoked potential
π4
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_54 | #answer
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β A
π Explanation
This patient presents with the classic triad for normal pressure hydrocephalus: ataxia, urinary incontinence, and dementia. MRI should be the first step in the diagnosis of this condition, both to rule out other conditions and to identify changes suggestive of normal pressure hydrocephalus. These include enlargement of the ventricles with preservation of cerebral parenchyma. Brainstem auditory evoked response testing is used for evaluating cochlear problems. While some other features of normal pressure hydrocephalus overlap with those of depression and Parkinson's disease, this patient's constellation of signs and symptoms are more typical for normal pressure hydrocephalus. Physical therapy is not indicated prior to making the diagnosis
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β A
π Explanation
This patient presents with the classic triad for normal pressure hydrocephalus: ataxia, urinary incontinence, and dementia. MRI should be the first step in the diagnosis of this condition, both to rule out other conditions and to identify changes suggestive of normal pressure hydrocephalus. These include enlargement of the ventricles with preservation of cerebral parenchyma. Brainstem auditory evoked response testing is used for evaluating cochlear problems. While some other features of normal pressure hydrocephalus overlap with those of depression and Parkinson's disease, this patient's constellation of signs and symptoms are more typical for normal pressure hydrocephalus. Physical therapy is not indicated prior to making the diagnosis
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_55
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The parents of a 20-month-old female bring her to your office because she has lost consciousness twice recently. They describe two episodes where the child was crying vigorously then βturned purple and passed outβ. The child is an otherwise healthy product of a term delivery. There is no history of head trauma and no family history of seizures or cardiac problems. The episodes are not associated with fever or other symptoms. Physical examination of the child is normal. Which one of the following would be most appropriate at this point?
a) Reassurance
b) A CT scan of the brain
c) An EKG and chest radiograph
d) Measurement of serum glucose, electrolytes, and hematocrit
e) Echocardiography
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The parents of a 20-month-old female bring her to your office because she has lost consciousness twice recently. They describe two episodes where the child was crying vigorously then βturned purple and passed outβ. The child is an otherwise healthy product of a term delivery. There is no history of head trauma and no family history of seizures or cardiac problems. The episodes are not associated with fever or other symptoms. Physical examination of the child is normal. Which one of the following would be most appropriate at this point?
a) Reassurance
b) A CT scan of the brain
c) An EKG and chest radiograph
d) Measurement of serum glucose, electrolytes, and hematocrit
e) Echocardiography
π1
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_55 | #answer
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β A
π Explanation
The parents are describing classic breath-holding spells. These are a form of autonomic syncope frequently misdiagnosed as seizures. They occur in early childhood and infancy. They can be of two forms: cyanotic, as described here, and pallid. The cyanotic form usually occurs after vigorous crying, while the pallid form commonly occurs after a sudden fright or minor injury. The history of a prodrome of injury, vigorous crying, or sudden fright is key to distinguishing a breath-holding spell from a seizure. Parents can be reassured that no brain damage occurs and, in the presence of a classic history, no further workup is necessary. An EKG and chest radiograph would be indicated if the history or examination suggested cardiac syncope. Blood testing would be indicated if the history suggested orthostatic hypotension or diabetes. A head CT scan would be indicated in the evaluation of
seizures.
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β A
π Explanation
The parents are describing classic breath-holding spells. These are a form of autonomic syncope frequently misdiagnosed as seizures. They occur in early childhood and infancy. They can be of two forms: cyanotic, as described here, and pallid. The cyanotic form usually occurs after vigorous crying, while the pallid form commonly occurs after a sudden fright or minor injury. The history of a prodrome of injury, vigorous crying, or sudden fright is key to distinguishing a breath-holding spell from a seizure. Parents can be reassured that no brain damage occurs and, in the presence of a classic history, no further workup is necessary. An EKG and chest radiograph would be indicated if the history or examination suggested cardiac syncope. Blood testing would be indicated if the history suggested orthostatic hypotension or diabetes. A head CT scan would be indicated in the evaluation of
seizures.
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_56
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An 18-month-old white male has been brought into your office multiple times over the past year with a reported fever of over 38Β°C (101Β°F). The childβs reported temperatures at home have usually been higher than those measured at the time of the office visit. The remainder of the history is usually unremarkable. The child has a sibling who is in good health, but another sibling died several years ago for unknown reasons.On two occasions you diagnosed acute otitis media and acute bronchitis. However, at most visits the child has not had any abnormal physical findings. Repeated laboratory studies have been within normal limits, including complete blood counts, erythrocyte sedimentation rates, blood cultures, chest radiographs, and urinalyses. Almost always, the mother has reported little reduction in fever with age-appropriate doses of acetaminophen or ibuprofen.At the last visit the childβs temperature was measured at 40.6Β°C (105.1Β°F). Although the examination was once again unrevealing, it was decided to hospitalize the child for close observation and evaluation by an infectious disease consultant. Closed-circuit television observation in the hospital showed the mother putting the thermometer into hot water before a nurse came to record the patientβs temperature.During the hospitalization you make a diagnosis. Which one of the following is a strong indicator of the suspected final diagnosis?
a) The child has seen no other health-care provider but you
b) Both parents have been involved with each office visit
c) The child is afebrile while staying at the day-care center
d) The parents have resisted having painful or risky diagnostic tests performed on the child
e) The child responds well to usual medical therapies
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An 18-month-old white male has been brought into your office multiple times over the past year with a reported fever of over 38Β°C (101Β°F). The childβs reported temperatures at home have usually been higher than those measured at the time of the office visit. The remainder of the history is usually unremarkable. The child has a sibling who is in good health, but another sibling died several years ago for unknown reasons.On two occasions you diagnosed acute otitis media and acute bronchitis. However, at most visits the child has not had any abnormal physical findings. Repeated laboratory studies have been within normal limits, including complete blood counts, erythrocyte sedimentation rates, blood cultures, chest radiographs, and urinalyses. Almost always, the mother has reported little reduction in fever with age-appropriate doses of acetaminophen or ibuprofen.At the last visit the childβs temperature was measured at 40.6Β°C (105.1Β°F). Although the examination was once again unrevealing, it was decided to hospitalize the child for close observation and evaluation by an infectious disease consultant. Closed-circuit television observation in the hospital showed the mother putting the thermometer into hot water before a nurse came to record the patientβs temperature.During the hospitalization you make a diagnosis. Which one of the following is a strong indicator of the suspected final diagnosis?
a) The child has seen no other health-care provider but you
b) Both parents have been involved with each office visit
c) The child is afebrile while staying at the day-care center
d) The parents have resisted having painful or risky diagnostic tests performed on the child
e) The child responds well to usual medical therapies
π1
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_56 | #answer
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β C
π Explanation
This is a characteristic presentation of factitious disorder by proxy, or what is commonly known as Munchausen syndrome by proxy. Warning signs for this disorder include episodes of illness beginning only when the child is, or has recently been, with the parent (choice C); the parent taking the child to numerous caregivers, resulting in multiple diagnostic evaluations but neither cure nor definitive diagnosis; the other parent (usually the father) being notably uninvolved despite the ostensible health crises; the parent not being assured by normal test results and continually advocating for painful or risky diagnostic tests for the child; the child persistently failing to tolerate or respond to usual medical therapies; and another child in the family having an unexplained illness or childhood death.
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β C
π Explanation
This is a characteristic presentation of factitious disorder by proxy, or what is commonly known as Munchausen syndrome by proxy. Warning signs for this disorder include episodes of illness beginning only when the child is, or has recently been, with the parent (choice C); the parent taking the child to numerous caregivers, resulting in multiple diagnostic evaluations but neither cure nor definitive diagnosis; the other parent (usually the father) being notably uninvolved despite the ostensible health crises; the parent not being assured by normal test results and continually advocating for painful or risky diagnostic tests for the child; the child persistently failing to tolerate or respond to usual medical therapies; and another child in the family having an unexplained illness or childhood death.
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_57
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A 26 year old male was brought to the Emergency Room right after he underwent a motor vehicle accident.
He suffered multiple traumatic fractures including a significant head trauma. He suddenly became dyspneic and tachypneic complaining of chest discomfort and has a syncopal episode.His blood pressure dropped to 70/50 mmHg, pulse is 140/min, and respirations are 30/min. CT angiogram shows a massive obstruction in the main pulmonary artery with saddle shaped extension into both pulmonary arteries. What is the most appropriate line of management for this patient?
a) Coronary catheterization
b) Embolectomy
c) Green field filter
d) Heparin
e) Streptokinase
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A 26 year old male was brought to the Emergency Room right after he underwent a motor vehicle accident.
He suffered multiple traumatic fractures including a significant head trauma. He suddenly became dyspneic and tachypneic complaining of chest discomfort and has a syncopal episode.His blood pressure dropped to 70/50 mmHg, pulse is 140/min, and respirations are 30/min. CT angiogram shows a massive obstruction in the main pulmonary artery with saddle shaped extension into both pulmonary arteries. What is the most appropriate line of management for this patient?
a) Coronary catheterization
b) Embolectomy
c) Green field filter
d) Heparin
e) Streptokinase
π1
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_57 | #answer
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β B
π Explanation
Not want to put him at risk for an intracranial bleeding or a bleeding elsewhere. So the best intervention would be a pulmonary embolectomy.
Heparin is very good for clot stabilization; however it will not dissolve the already existing clot in our patient. The patient is unstable; embolectomy is life saving! A green field filter is an Inferior vena cava filter that is placed when a patient has recurrent DVT occurrence or when there is a contraindication to heparin.Percutaneous coronary intervention (PCI) would be warranted if the patient has an acute MI.
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β B
π Explanation
Not want to put him at risk for an intracranial bleeding or a bleeding elsewhere. So the best intervention would be a pulmonary embolectomy.
Heparin is very good for clot stabilization; however it will not dissolve the already existing clot in our patient. The patient is unstable; embolectomy is life saving! A green field filter is an Inferior vena cava filter that is placed when a patient has recurrent DVT occurrence or when there is a contraindication to heparin.Percutaneous coronary intervention (PCI) would be warranted if the patient has an acute MI.
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_58
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A 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching. She has excoriations from scratching in various areas. She says that she had the same problem during her last pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis of pregnancy. Elevation of which one of the following is most specific and sensitive marker of this disorder?
a) Gamma - Glutamyltransferase (GGT)
b) Bile acids
c) Total bilirubin
d) Chenodeoxycholic acid
e) Alkaline phosphatase
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A 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching. She has excoriations from scratching in various areas. She says that she had the same problem during her last pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis of pregnancy. Elevation of which one of the following is most specific and sensitive marker of this disorder?
a) Gamma - Glutamyltransferase (GGT)
b) Bile acids
c) Total bilirubin
d) Chenodeoxycholic acid
e) Alkaline phosphatase
π2
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_58 | #answer
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β B
π Explanation
Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic/chenodeoxycholic acid level ratio. The elevation of
aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta. Mild elevation of gamma glutamyltransferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.
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β B
π Explanation
Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic/chenodeoxycholic acid level ratio. The elevation of
aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta. Mild elevation of gamma glutamyltransferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_59
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A 68-year-old male presents to your department because of cough and hoarseness that βjust wonβt go awayβ. He has been coughing and had a hoarse voice for 3 weeks now and antitussive OTC medications he has tried have not helped him much. Moreover, the last 3 days he feels that he is getting worse as he felt more lethargic and has been confused at times. He noticed that his shoulder muscles are a bit sore. The patient has lost 8 kg over the last 2 months. He has smoked 150 packs of cigarettes a year the last 42 years.On physical examination only generalized muscle weakness is noted. The patientβs comprehensive metabolic panel reveals: Glucose: 4.1 mmol/l
Urea: 7 mmol/ l
Creatinine: 100 micromol/L
GFR: 70 ml/min/1.73
Sodium: 125 mmol/l
Potassium: 3. 9 mmol/l
Chloride: 99 mmol/l
Calcium: 2. 41 mmol/L
Protein total: 61g/l
Albumin: 40 g/l
Alkaline phosphatase: 60 U/l
AST: 35 U/l
ALT: 45 U/ l
Which of the following is the most likely diagnosis?
a) Oat cell lung carcinoma
b) Sarcoidosis
c) Squamous cell lung carcinoma
d) Laryngeal squamous carcinoma
e) Lung adenocarcinoma
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A 68-year-old male presents to your department because of cough and hoarseness that βjust wonβt go awayβ. He has been coughing and had a hoarse voice for 3 weeks now and antitussive OTC medications he has tried have not helped him much. Moreover, the last 3 days he feels that he is getting worse as he felt more lethargic and has been confused at times. He noticed that his shoulder muscles are a bit sore. The patient has lost 8 kg over the last 2 months. He has smoked 150 packs of cigarettes a year the last 42 years.On physical examination only generalized muscle weakness is noted. The patientβs comprehensive metabolic panel reveals: Glucose: 4.1 mmol/l
Urea: 7 mmol/ l
Creatinine: 100 micromol/L
GFR: 70 ml/min/1.73
Sodium: 125 mmol/l
Potassium: 3. 9 mmol/l
Chloride: 99 mmol/l
Calcium: 2. 41 mmol/L
Protein total: 61g/l
Albumin: 40 g/l
Alkaline phosphatase: 60 U/l
AST: 35 U/l
ALT: 45 U/ l
Which of the following is the most likely diagnosis?
a) Oat cell lung carcinoma
b) Sarcoidosis
c) Squamous cell lung carcinoma
d) Laryngeal squamous carcinoma
e) Lung adenocarcinoma
π€1
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_59 | #answer
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β A
π Explanation
This patient presents with a clinical picture very suspicious for lung cancer. The patientβs symptoms are cough, hoarseness, lethargy, and weight loss. Physical examination reveals muscle weakness. He is a heavy smoker with 150 packs of cigarettes a year for more than 40 years. Laboratory results show hyponatremia, which in this case should make us think of syndrome of inappropriate antidiuretic hormone (SIADH), a paraneoplastic syndrome associated with oat cell carcinoma (choice A). This cancer is also known as small cell lung carcinoma.
β Sarcoidosis (choice B) is multisystem inflammatory disease of unknown etiology that manifests as noncaseating granulomas, predominantly in the lungs and intrathoracic lymph nodes. It presents with cough in 50% of patients and
SIADH is known to affect 5% of sarcoidosis patients, though subclinical and undiagnosed SIADH is much higher. However, this patientβs history of hoarseness, weight loss, age, and long history of heavy smoking seem to point to a diagnosis of oat cell carcinoma.
β Squamous cell lung carcinoma (choice C) is incorrect. The paraneoplastic syndrome commonly seen in squamous cell lung carcinoma is parathyroid-like hormone production, which leads to hypercalcemia.
β Laryngeal squamous carcinoma (choice D) can cause cough, hoarseness, weight loss, and is also associated with cigarette smoking. But lung cancers are far more common than laryngeal cancers, and SIADH is very suggestive of oat cell lung carcinoma.
β Lung adenocarcinoma (choice E) has been recognized as the common type of lung cancer is non-smokers and is not commonly associated with SIADH.
β Key point:
The combination of cough, hoarseness, weight loss, and SIADH in an old patient heavy smoker is suggestive of small cell lung carcinoma also known as oat cell lung carcinoma
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β A
π Explanation
This patient presents with a clinical picture very suspicious for lung cancer. The patientβs symptoms are cough, hoarseness, lethargy, and weight loss. Physical examination reveals muscle weakness. He is a heavy smoker with 150 packs of cigarettes a year for more than 40 years. Laboratory results show hyponatremia, which in this case should make us think of syndrome of inappropriate antidiuretic hormone (SIADH), a paraneoplastic syndrome associated with oat cell carcinoma (choice A). This cancer is also known as small cell lung carcinoma.
β Sarcoidosis (choice B) is multisystem inflammatory disease of unknown etiology that manifests as noncaseating granulomas, predominantly in the lungs and intrathoracic lymph nodes. It presents with cough in 50% of patients and
SIADH is known to affect 5% of sarcoidosis patients, though subclinical and undiagnosed SIADH is much higher. However, this patientβs history of hoarseness, weight loss, age, and long history of heavy smoking seem to point to a diagnosis of oat cell carcinoma.
β Squamous cell lung carcinoma (choice C) is incorrect. The paraneoplastic syndrome commonly seen in squamous cell lung carcinoma is parathyroid-like hormone production, which leads to hypercalcemia.
β Laryngeal squamous carcinoma (choice D) can cause cough, hoarseness, weight loss, and is also associated with cigarette smoking. But lung cancers are far more common than laryngeal cancers, and SIADH is very suggestive of oat cell lung carcinoma.
β Lung adenocarcinoma (choice E) has been recognized as the common type of lung cancer is non-smokers and is not commonly associated with SIADH.
β Key point:
The combination of cough, hoarseness, weight loss, and SIADH in an old patient heavy smoker is suggestive of small cell lung carcinoma also known as oat cell lung carcinoma
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_60
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A 62-year-old female presents to the ED complaining of right leg and knee pain. The pain has progressed over the past 2 weeks so that now she is unable to bear weight on her right leg. She has a history of a recent pulmonary embolus and is on warfarin(Coumadin). Her INR is therapeutic. She is allergic to aspirin and penicillin. On examination she is afebrile. Her pulse rate is 102 beats/min, her blood pressure is 158/96 mmHg, and her respiratory rate is 14/min. Her right knee is erythematous, warm, and tender on palpation over the entire knee joint, and a large effusion is noted. Arthrocentesis reveals numerous WBCs and negatively birefringent crystals.What is the best initial treatment for the patientβs knee problem?
a) Ceftriaxone intravenously
b) Prednisone intra-articularly
c) Colchicine orally
d) Indomethacin orally
e) Allopurinol orally
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A 62-year-old female presents to the ED complaining of right leg and knee pain. The pain has progressed over the past 2 weeks so that now she is unable to bear weight on her right leg. She has a history of a recent pulmonary embolus and is on warfarin(Coumadin). Her INR is therapeutic. She is allergic to aspirin and penicillin. On examination she is afebrile. Her pulse rate is 102 beats/min, her blood pressure is 158/96 mmHg, and her respiratory rate is 14/min. Her right knee is erythematous, warm, and tender on palpation over the entire knee joint, and a large effusion is noted. Arthrocentesis reveals numerous WBCs and negatively birefringent crystals.What is the best initial treatment for the patientβs knee problem?
a) Ceftriaxone intravenously
b) Prednisone intra-articularly
c) Colchicine orally
d) Indomethacin orally
e) Allopurinol orally
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β C
π Explanation
This patient is having an acute gout attack. Nonsteroidal anti-inflammatory drugs or colchicine (choice C) are first-line therapies for acute gout, depending on patient comorbidities. In general, when comorbid conditions limit the use of NSAIDs or colchicine, a preferred option may be an intra-articular steroid injection (unless contraindicated), particularly when a large, easily accessible joint is involved.
β Ceftriaxone (choice A) is not an appropriate treatment for gout.
β Corticosteroids (choice B) can be given to patients with gout who cannot use NSAIDs or colchicine. Steroids can be given orally, IV, intramuscularly, or intra-articularly. Using parenteral corticosteroids confers no advantage unless the patient cannot take oral medications.
β While indomethacin (choice D) is a good choice for treating an acute gout attack, this patient should not take
indomethacin because of the increased risk of bleeding created by warfarin.
β Allopurinol (choice E) should not be used in an acute gout attack as it could make it worse.
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β C
π Explanation
This patient is having an acute gout attack. Nonsteroidal anti-inflammatory drugs or colchicine (choice C) are first-line therapies for acute gout, depending on patient comorbidities. In general, when comorbid conditions limit the use of NSAIDs or colchicine, a preferred option may be an intra-articular steroid injection (unless contraindicated), particularly when a large, easily accessible joint is involved.
β Ceftriaxone (choice A) is not an appropriate treatment for gout.
β Corticosteroids (choice B) can be given to patients with gout who cannot use NSAIDs or colchicine. Steroids can be given orally, IV, intramuscularly, or intra-articularly. Using parenteral corticosteroids confers no advantage unless the patient cannot take oral medications.
β While indomethacin (choice D) is a good choice for treating an acute gout attack, this patient should not take
indomethacin because of the increased risk of bleeding created by warfarin.
β Allopurinol (choice E) should not be used in an acute gout attack as it could make it worse.
β€1
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π¨π¦ MCCQE1,2 | #Case_61
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You are called to the bedside of a 56-year-old male patient in the critical care unit. His nurse informs you that he has become unresponsive. He has a history of hypertension, myocardial infarction, and a 30 pack-year history of smoking. A nurse reads his previous vital signs: blood pressure is 90/55 mmHg, his heart rate is 180 bpm, his respiratory rate is 22 breaths per minute, and oxygen saturation is 98% according to the monitor. Looking at the monitor, you notice the patient has wide QRS complexes. On physical exam, you note the patient grunts in response to pain, is currently on a ventilator, and you are unable to palpate his carotid pulse. You decide to start CPR.Which of the following is the next best step in the treatment of this patient?
a) Adenosine
b) Amiodarone
c) Epinephrine
d) Synchronized cardioversion
e) Unsynchronized cardioversion
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You are called to the bedside of a 56-year-old male patient in the critical care unit. His nurse informs you that he has become unresponsive. He has a history of hypertension, myocardial infarction, and a 30 pack-year history of smoking. A nurse reads his previous vital signs: blood pressure is 90/55 mmHg, his heart rate is 180 bpm, his respiratory rate is 22 breaths per minute, and oxygen saturation is 98% according to the monitor. Looking at the monitor, you notice the patient has wide QRS complexes. On physical exam, you note the patient grunts in response to pain, is currently on a ventilator, and you are unable to palpate his carotid pulse. You decide to start CPR.Which of the following is the next best step in the treatment of this patient?
a) Adenosine
b) Amiodarone
c) Epinephrine
d) Synchronized cardioversion
e) Unsynchronized cardioversion
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β E
π Explanation
This patient's electrocardiogram shows tachycardia with wide QRS complexes. The wide QRS indicates that the electrical conduction originated outside of the normal conduction system (ie. the ventricle). Combining this with the absence of a palpable pulse gives the diagnosis of pulseless ventricular tachycardia (VT), which can be divided into three categories:
βͺ pulseless
βͺ hemodynamically stable (with a pulse)
βͺ hemodynamically unstable (with a pulse) (signs of hemodynamic instability include ischemic chest pain, altered mental status, hypotension, tachycardia, tachypnea, and other signs of shock).
The management of VT differs for each category (see explanations below and in the incorrect answers). According to ACLS guidelines, pulseless VT is treated the same way as ventricular fibrillation. Two minutes of CPR is started first, followed by unsynchronized cardioversion (defibrillation) (choice E) with 120-200J if using a biphasic defibrillator or 360 J for monophasic defibrillator. If two cycles of CPR and defibrillation fail to eliminate the arrhythmia, then epinephrine can be administered, followed by another cycle of CPR and defibrillation, followed by amiodarone.Pulseless VT is most common in patients who have survived a myocardial infarction, and it can progress to ventricular fibrillation and then death.
β Adenosine (choice A) is not used for pulseless VT. It is used to treat supraventricular tachycardia (SVT).
β Amiodarone (choice B) is an incorrect answer. If the rhythm persists after defibrillation, epinephrine, and a second attempt at defibrillation, then amiodarone 300mg IV can be administered. Amiodarone is also used in hemodynamically stable patients with VT.
β Epinephrine (choice C) can be used in pulseless VT, but only after unsynchronized cardioversion and continued CPR have been attempted.
β Synchronized cardioversion (choice D) is not used in pulseless VT. It can be used in patients with VT who are hemodynamically unstable (hypotension, confusion, shortness of breath) but do have a pulse.
β Key point:
Pulseless ventricular tachycardia is treated first with CPR, then as soon as possible, unsynchronized cardioversion (defibrillation). If those measures fail, continued cycles of CPR and defibrillation are attempted followed by epinephrine, according to the most recent ACLS guidelines.
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β E
π Explanation
This patient's electrocardiogram shows tachycardia with wide QRS complexes. The wide QRS indicates that the electrical conduction originated outside of the normal conduction system (ie. the ventricle). Combining this with the absence of a palpable pulse gives the diagnosis of pulseless ventricular tachycardia (VT), which can be divided into three categories:
βͺ pulseless
βͺ hemodynamically stable (with a pulse)
βͺ hemodynamically unstable (with a pulse) (signs of hemodynamic instability include ischemic chest pain, altered mental status, hypotension, tachycardia, tachypnea, and other signs of shock).
The management of VT differs for each category (see explanations below and in the incorrect answers). According to ACLS guidelines, pulseless VT is treated the same way as ventricular fibrillation. Two minutes of CPR is started first, followed by unsynchronized cardioversion (defibrillation) (choice E) with 120-200J if using a biphasic defibrillator or 360 J for monophasic defibrillator. If two cycles of CPR and defibrillation fail to eliminate the arrhythmia, then epinephrine can be administered, followed by another cycle of CPR and defibrillation, followed by amiodarone.Pulseless VT is most common in patients who have survived a myocardial infarction, and it can progress to ventricular fibrillation and then death.
β Adenosine (choice A) is not used for pulseless VT. It is used to treat supraventricular tachycardia (SVT).
β Amiodarone (choice B) is an incorrect answer. If the rhythm persists after defibrillation, epinephrine, and a second attempt at defibrillation, then amiodarone 300mg IV can be administered. Amiodarone is also used in hemodynamically stable patients with VT.
β Epinephrine (choice C) can be used in pulseless VT, but only after unsynchronized cardioversion and continued CPR have been attempted.
β Synchronized cardioversion (choice D) is not used in pulseless VT. It can be used in patients with VT who are hemodynamically unstable (hypotension, confusion, shortness of breath) but do have a pulse.
β Key point:
Pulseless ventricular tachycardia is treated first with CPR, then as soon as possible, unsynchronized cardioversion (defibrillation). If those measures fail, continued cycles of CPR and defibrillation are attempted followed by epinephrine, according to the most recent ACLS guidelines.
π1
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π¨π¦ MCCQE1,2 | #Case_62
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A 25-year-old man presented with red urine. He denied any other urinary symptoms but admitted having sore throat and low grade fever over the last two days. He also admitted to passing red urine at least three times before but it used to clear up in two to three days. Apart from 15 red cells per high power field, urine analysis was otherwise normal. Plain abdominal x-ray was normal. Which of the following investigations would most likely establish the cause of hematuria in this patient?
a) Measurement of serum anti-streptolysin O (ASO) titer
b) Throat swab culture
c) CT scan of the abdomen
d) Renal biopsy
e) Measurement of blood urea and serum creatinine
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A 25-year-old man presented with red urine. He denied any other urinary symptoms but admitted having sore throat and low grade fever over the last two days. He also admitted to passing red urine at least three times before but it used to clear up in two to three days. Apart from 15 red cells per high power field, urine analysis was otherwise normal. Plain abdominal x-ray was normal. Which of the following investigations would most likely establish the cause of hematuria in this patient?
a) Measurement of serum anti-streptolysin O (ASO) titer
b) Throat swab culture
c) CT scan of the abdomen
d) Renal biopsy
e) Measurement of blood urea and serum creatinine
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β D
π Explanation
Renal biopsy (choice D) is the correct choice. The most likely cause of hematuria in this patient is IgA nephropathy and renal biopsy is necessary to make this diagnosis. IgA nephropathy typically presents in the second or third decade of life with recurrent hematuria during or immediately following upper respiratory infection. Hematuria is the only finding early in the disease. These features together with the fact that IgA nephropathy is one of the most common causes of hematuria put IgA nephropathy as the most likely diagnosis in this patient.
β Measurement of serum anti-streptolysin O titer (choice A) and throat swab culture (choice B) are used to diagnose poststreptococcal glomerulonephritis, which is an unlikely cause of hematuria in this patient. Poststreptococcal glomerulonephritis occurs 1 to 3 weeks following streptococcal pharyngitis in children 2 to 12 years old. Our patient developed hematuria immediately after throat infection and is of older age.
β CT scan of the abdomen (choice C) is not the correct choice. The two causes of hematuria namely renal stones and renal cell carcinoma that can be diagnosed by CT scan of the abdomen are unlikely causes of hematuria in this patient. Although renal stones can present with painless hematuria, their presentation is not related to upper respiratory infections. Also, because most renal stones are radiopaque, they are expected to be seen in the X-ray. Renal cell carcinoma usually occurs in older people between 50 to 70 year old and present with hematuria, abdominal pain, and flank mass. Other presenting symptoms include fever, anemia, and weight loss. Renal cell carcinoma is thus, an unlikely diagnosis in this patient.
β Measurement of serum urea and creatinine (choice E) are nonspecific tests. Any disease that impairs renal function may raise serum urea and creatinine.
β Key point:
Renal biopsy is necessary to make the diagnosis of IgA nephropathy
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β D
π Explanation
Renal biopsy (choice D) is the correct choice. The most likely cause of hematuria in this patient is IgA nephropathy and renal biopsy is necessary to make this diagnosis. IgA nephropathy typically presents in the second or third decade of life with recurrent hematuria during or immediately following upper respiratory infection. Hematuria is the only finding early in the disease. These features together with the fact that IgA nephropathy is one of the most common causes of hematuria put IgA nephropathy as the most likely diagnosis in this patient.
β Measurement of serum anti-streptolysin O titer (choice A) and throat swab culture (choice B) are used to diagnose poststreptococcal glomerulonephritis, which is an unlikely cause of hematuria in this patient. Poststreptococcal glomerulonephritis occurs 1 to 3 weeks following streptococcal pharyngitis in children 2 to 12 years old. Our patient developed hematuria immediately after throat infection and is of older age.
β CT scan of the abdomen (choice C) is not the correct choice. The two causes of hematuria namely renal stones and renal cell carcinoma that can be diagnosed by CT scan of the abdomen are unlikely causes of hematuria in this patient. Although renal stones can present with painless hematuria, their presentation is not related to upper respiratory infections. Also, because most renal stones are radiopaque, they are expected to be seen in the X-ray. Renal cell carcinoma usually occurs in older people between 50 to 70 year old and present with hematuria, abdominal pain, and flank mass. Other presenting symptoms include fever, anemia, and weight loss. Renal cell carcinoma is thus, an unlikely diagnosis in this patient.
β Measurement of serum urea and creatinine (choice E) are nonspecific tests. Any disease that impairs renal function may raise serum urea and creatinine.
β Key point:
Renal biopsy is necessary to make the diagnosis of IgA nephropathy
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π¨π¦ MCCQE1,2 | #Case_63
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A 67-year-old female presents with complaints of increasing abdominal distension and intermittent vomiting for the past 4 days. She also reports abdominal pain in the periumbilical region. The pain does not radiate and is not clearly localized. Her past surgical and medical history is significant only for hypertension, which has been well controlled with hydrochlorothiazide. On examination her blood pressure is 120/75 mmHg, temperature is 37.7Β°C, pulse is 95bpm, and respirations 17/min. She appears in distress, has dry mucosa but no jaundice is observed. Abdominal auscultation reveals gurgling and tinkling sounds. Rectal examination reveals no abnormalities. Abdominal X-ray shows distended loops of small bowel with multiple air-fluid levels and pneumobilia. What is the most likely diagnosis?
a) Acute diverticulitis
b) Gallstone ileus
c) Crohn disease free perforation
d) Adhesive small bowel obstruction
e) Pseudomembranous colitis
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A 67-year-old female presents with complaints of increasing abdominal distension and intermittent vomiting for the past 4 days. She also reports abdominal pain in the periumbilical region. The pain does not radiate and is not clearly localized. Her past surgical and medical history is significant only for hypertension, which has been well controlled with hydrochlorothiazide. On examination her blood pressure is 120/75 mmHg, temperature is 37.7Β°C, pulse is 95bpm, and respirations 17/min. She appears in distress, has dry mucosa but no jaundice is observed. Abdominal auscultation reveals gurgling and tinkling sounds. Rectal examination reveals no abnormalities. Abdominal X-ray shows distended loops of small bowel with multiple air-fluid levels and pneumobilia. What is the most likely diagnosis?
a) Acute diverticulitis
b) Gallstone ileus
c) Crohn disease free perforation
d) Adhesive small bowel obstruction
e) Pseudomembranous colitis
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β B
π Explanation
This patientβs clinical scenario is consistent with gallstone ileus (choice B). It is an obstruction of the small bowel (at or near the ileocecal valve) due to impaction of a large (at least 2.5 cm in diameter) gallstone in the ileum after being passed through a biliary-enteric fistula. 60% are cholecystoduodenal fistulas, but cholecystocolonic and cholecystogastric fistulas
can also result in gallstone ileus. Gallstone ileus is a complication of cholelithiasis and gangrenous gallbladder. It presents with intermittent abdominal pain that is poorly localized, abdominal distention, and vomiting. Abdominal X-ray is the best initial study and usually reveals distended loops of small bowel with multiple air-fluid levels and pneumobilia (air in the biliary tract). Rigler's triad: pneumobilia (air in biliary tree), small bowel obstruction (partial or complete), gallstone (usually in right iliac fossa).
β Acute diverticulitis (choice A) is incorrect. The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Left lower quadrant pain is the most common presenting complaint. Plain radiograph films are usually not helpful in acute diverticulitis. In case of bowel perforation, free air may be present, but pneumobilia is not associated with this condition.
β Crohn disease free perforation (choice C) is incorrect. None of the patientβs symptoms is suggestive of Crohn disease.
β Adhesive small bowel obstruction (choice D) would likely occur in a patient with a history of abdominal surgery. This patient never had a surgery.
β Pseudomembranous colitis (choice E) is an antibiotic-associated diarrhea most frequently caused by Clostridium difficile. This patient has no recent history antibiotic use.
β Key point:
Gallstone ileus results from an impaction of a large gallstone in the ileum after being passed through a biliary-enteric fistula. It presents with abdominal distention, abdominal pain, and vomiting. Pneumobilia, air in the biliary tree, can be seen on abdominal X-ray.
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β B
π Explanation
This patientβs clinical scenario is consistent with gallstone ileus (choice B). It is an obstruction of the small bowel (at or near the ileocecal valve) due to impaction of a large (at least 2.5 cm in diameter) gallstone in the ileum after being passed through a biliary-enteric fistula. 60% are cholecystoduodenal fistulas, but cholecystocolonic and cholecystogastric fistulas
can also result in gallstone ileus. Gallstone ileus is a complication of cholelithiasis and gangrenous gallbladder. It presents with intermittent abdominal pain that is poorly localized, abdominal distention, and vomiting. Abdominal X-ray is the best initial study and usually reveals distended loops of small bowel with multiple air-fluid levels and pneumobilia (air in the biliary tract). Rigler's triad: pneumobilia (air in biliary tree), small bowel obstruction (partial or complete), gallstone (usually in right iliac fossa).
β Acute diverticulitis (choice A) is incorrect. The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Left lower quadrant pain is the most common presenting complaint. Plain radiograph films are usually not helpful in acute diverticulitis. In case of bowel perforation, free air may be present, but pneumobilia is not associated with this condition.
β Crohn disease free perforation (choice C) is incorrect. None of the patientβs symptoms is suggestive of Crohn disease.
β Adhesive small bowel obstruction (choice D) would likely occur in a patient with a history of abdominal surgery. This patient never had a surgery.
β Pseudomembranous colitis (choice E) is an antibiotic-associated diarrhea most frequently caused by Clostridium difficile. This patient has no recent history antibiotic use.
β Key point:
Gallstone ileus results from an impaction of a large gallstone in the ileum after being passed through a biliary-enteric fistula. It presents with abdominal distention, abdominal pain, and vomiting. Pneumobilia, air in the biliary tree, can be seen on abdominal X-ray.