⏳ Case-based MCQ | #Case_433
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A 53-year-old man presented to his family physician with episodic retrosternal chest pain that radiates to the left shoulder. During the last four months, he experienced this pain three times, the last of which was two weeks ago and all were while exercising on treadmill and while running for a few minutes. In all three occasions pain subsided within about 5 minutes of rest. He does not smoke and rarely drinks alcohol.
Physical examination is normal. Urine analysis, complete blood count, fasting blood sugar, lipid profile, serum urea and electrolytes, chest X-ray and 12-lead ECG are all normal. Chronic stable angina is suspected.
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A 53-year-old man presented to his family physician with episodic retrosternal chest pain that radiates to the left shoulder. During the last four months, he experienced this pain three times, the last of which was two weeks ago and all were while exercising on treadmill and while running for a few minutes. In all three occasions pain subsided within about 5 minutes of rest. He does not smoke and rarely drinks alcohol.
Physical examination is normal. Urine analysis, complete blood count, fasting blood sugar, lipid profile, serum urea and electrolytes, chest X-ray and 12-lead ECG are all normal. Chronic stable angina is suspected.
👍4
Which of the following investigations should be done next?
Anonymous Poll
13%
A. Measurement of cardiac enzymes
45%
B. ECG exercise testing
10%
C. Cardiac imaging
22%
D. Coronary angiography
10%
E. Echocardiography
🥰2
⏳ Case-based MCQ | #Case_434 | #answer
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✅ C
Exercise ECG testing (choice B) should be done next to verify or refute the diagnosis of angina. A 12-lead ECG is done just before, during and after standardized exercise protocol with increasing work load. Flat or down sloping of ST segment during exercise confirms diagnosis of ischemia. These ECG changes together with the typical symptoms of angina confirm the diagnosis of chronic stable angina.
⚠ There is no indication for measurement of cardiac enzymes (choice A) in this patient. These cardiac biomarkers are measured if the diagnosis of unstable angina or ST elevation myocardial infarction is suspected. Unstable angina is suspected if frequency and duration of pain attacks is increasing; pain is not responding to treatment with nitroglycerine, pain occurs at rest or angina following myocardial infarction.
⚠ Cardiac imaging (choice C) is done only if ECG exercise testing is abnormal to evaluate the extent and site of ischemia.
⚠ Coronary angiography (choice D), an invasive procedure, is indicated only if: diagnosis of disabling chronic stable angina is confirmed; the patient is at high risk of coronary artery disease; diagnosis or prognoses are uncertain; the patient cannot undergo non-invasive testing.
⚠ Echocardiography (choice E) is not indicated in this patient at this point. The initial test in patients able to exercise should be exercise ECG.
🔖 Key point:
In patients with typical episodic chest pain provoked by physical activity, diagnosis of chronic stable angina should be confirmed or refuted by ECG exercise testing
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✅ C
Exercise ECG testing (choice B) should be done next to verify or refute the diagnosis of angina. A 12-lead ECG is done just before, during and after standardized exercise protocol with increasing work load. Flat or down sloping of ST segment during exercise confirms diagnosis of ischemia. These ECG changes together with the typical symptoms of angina confirm the diagnosis of chronic stable angina.
⚠ There is no indication for measurement of cardiac enzymes (choice A) in this patient. These cardiac biomarkers are measured if the diagnosis of unstable angina or ST elevation myocardial infarction is suspected. Unstable angina is suspected if frequency and duration of pain attacks is increasing; pain is not responding to treatment with nitroglycerine, pain occurs at rest or angina following myocardial infarction.
⚠ Cardiac imaging (choice C) is done only if ECG exercise testing is abnormal to evaluate the extent and site of ischemia.
⚠ Coronary angiography (choice D), an invasive procedure, is indicated only if: diagnosis of disabling chronic stable angina is confirmed; the patient is at high risk of coronary artery disease; diagnosis or prognoses are uncertain; the patient cannot undergo non-invasive testing.
⚠ Echocardiography (choice E) is not indicated in this patient at this point. The initial test in patients able to exercise should be exercise ECG.
🔖 Key point:
In patients with typical episodic chest pain provoked by physical activity, diagnosis of chronic stable angina should be confirmed or refuted by ECG exercise testing
👍9❤2
⏳ Case-based MCQ | #Case_434
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 23-year-old female G1P0 at the 34th week of gestation presents to your department with eclampsia. She had last seen her ObGyn at the 20th week of gestation, and the pregnancy was developing normally.
On physical examination, her BP is 190/115 mmHg, temperature 37.7°C, pulse 110 bpm, and respirations 20 bpm. After appropriate initial therapy is given and stabilization achieved, the patient delivers vaginally a 3000g boy. The immediate postpartum period at the hospital is uneventful. You visit the patient few days later for counseling before she is discharged from the hospital. Her BP is 145/100 mmHg.
BP remains elevated in the following 4 weeks, 160/110 mmHg on average. The patient has been breastfeeding the baby.
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A 23-year-old female G1P0 at the 34th week of gestation presents to your department with eclampsia. She had last seen her ObGyn at the 20th week of gestation, and the pregnancy was developing normally.
On physical examination, her BP is 190/115 mmHg, temperature 37.7°C, pulse 110 bpm, and respirations 20 bpm. After appropriate initial therapy is given and stabilization achieved, the patient delivers vaginally a 3000g boy. The immediate postpartum period at the hospital is uneventful. You visit the patient few days later for counseling before she is discharged from the hospital. Her BP is 145/100 mmHg.
BP remains elevated in the following 4 weeks, 160/110 mmHg on average. The patient has been breastfeeding the baby.
👍4
Which of the following is the most suitable treatment?
Anonymous Poll
33%
A. Methyldopa 250 mg every 12 hours
34%
B. Nifedipine 10 mg every 6 hours
16%
C. Metoprolol 50 mg every 12 hours
11%
D. Hydrochlorothiazide 25 mg every 12 hours
5%
E. Furosemide 40 mg every 8 hours
👍9👏3
⏳ Case-based MCQ | #Case_434 | #answer
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✅ B
Hypertension may develop for the first time postpartum, and in 50% of women who had hypertension during pregnancy, it may continue after delivery. If BP is mildly elevated, treatment is usually not required, but close monitoring is advised. In patients with systolic BP > 155 mmHg or diastolic BP > 105 mmHg, antihypertensive medications should be given. Labetalol and nifedipine are the most commonly used. For women who used ACE inhibitors before pregnancy, they can resume taking them. The recommended dose for nifedipine is 10 mg orally every 6 hours (choice B) and a maximum dose of 120 mg/day.
⚠ Some guidelines suggest avoiding methyldopa (choice A) postpartum because of the risk of postnatal depression.
⚠ Metoprolol 50 mg every 12 hours (choice C) is incorrect. Metoprolol, nadolol, and atenolol are excreted in breast milk in high concentration and would not be the best choice of treatment for this patient.
⚠ Hydrochlorothiazide 25 mg every 12 hours (choice D) and Furosemide 40 mg every 8 hours (choice E) are incorrect. Diuretics should generally be avoided in breastfeeding mothers because they significantly reduce milk production.
⚠ Key point:
In postpartum patients with systolic BP > 155 mmHg or diastolic BP > 105 mmHg, antihypertensive medications should be given. Labetalol and nifedipine are the most commonly used
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✅ B
Hypertension may develop for the first time postpartum, and in 50% of women who had hypertension during pregnancy, it may continue after delivery. If BP is mildly elevated, treatment is usually not required, but close monitoring is advised. In patients with systolic BP > 155 mmHg or diastolic BP > 105 mmHg, antihypertensive medications should be given. Labetalol and nifedipine are the most commonly used. For women who used ACE inhibitors before pregnancy, they can resume taking them. The recommended dose for nifedipine is 10 mg orally every 6 hours (choice B) and a maximum dose of 120 mg/day.
⚠ Some guidelines suggest avoiding methyldopa (choice A) postpartum because of the risk of postnatal depression.
⚠ Metoprolol 50 mg every 12 hours (choice C) is incorrect. Metoprolol, nadolol, and atenolol are excreted in breast milk in high concentration and would not be the best choice of treatment for this patient.
⚠ Hydrochlorothiazide 25 mg every 12 hours (choice D) and Furosemide 40 mg every 8 hours (choice E) are incorrect. Diuretics should generally be avoided in breastfeeding mothers because they significantly reduce milk production.
⚠ Key point:
In postpartum patients with systolic BP > 155 mmHg or diastolic BP > 105 mmHg, antihypertensive medications should be given. Labetalol and nifedipine are the most commonly used
👍9❤6
⏳ Case-based MCQ | #Case_435
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A 64-year-old man presents with several months of progressive weakness of the upper and lower extremities, along with ongoing pain in the affected areas. Physical examination shows difficulty standing up from a chair and tenderness over the affected areas. He is also found to have a violaceous erythematous rash over his eyes. A working diagnosis of dermatomyositis is made.
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A 64-year-old man presents with several months of progressive weakness of the upper and lower extremities, along with ongoing pain in the affected areas. Physical examination shows difficulty standing up from a chair and tenderness over the affected areas. He is also found to have a violaceous erythematous rash over his eyes. A working diagnosis of dermatomyositis is made.
👍3
Which of the following features, on history, would be more suggestive of dermatomyositis than polymyositis?
Anonymous Poll
31%
A. Autoimmune disorder
25%
B. Cancer
30%
C. Connective tissue disorder
9%
D. Human immunodeficiency virus infection
6%
E. Parasitic infection
👍10❤6
⏳ Case-based MCQ | #Case_434 | #answer
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✅ B
Dermatomyositis is an inflammatory myopathy, which bears many clinical similarities to entities such as polymyositis and autoimmune myositis. It is characterized by muscle weakness, tenderness, and a "heliotrope rash" around the eyes. Bloodwork will show inflammation (elevated leukocytes and ESR/CRP) in addition to an elevated CK. It may be confirmed with muscle biopsy. Treatment modalities include glucocorticoids, immunosuppressants or immune modulation.
Malignancies (choice B) may be associated with dermatomyositis in up to 15% of cases. The most common associations are ovary, breast, melanoma, GI, and lymphoma.
⚠ Autoimmune disorders (choice A) such as inflammatory bowel disease, vasculitis or celiac disease, are more likely to be associated with polymyositis than dermatomyositis.
⚠ Connective tissue disorders (choice C) can be associated with both dermatomyositis and polymyositis.
⚠ HIV (choice D) or parasitic infection (choice E) are more commonly associated with polymyositis.
🔖 Key point:
Dermatomyositis is one of a number of inflammatory myopathies which can cause muscle weakness, pain, and tenderness. It is usually accompanied by a heliotrope rash and may be associated with malignancy in up to 15% of cases
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ B
Dermatomyositis is an inflammatory myopathy, which bears many clinical similarities to entities such as polymyositis and autoimmune myositis. It is characterized by muscle weakness, tenderness, and a "heliotrope rash" around the eyes. Bloodwork will show inflammation (elevated leukocytes and ESR/CRP) in addition to an elevated CK. It may be confirmed with muscle biopsy. Treatment modalities include glucocorticoids, immunosuppressants or immune modulation.
Malignancies (choice B) may be associated with dermatomyositis in up to 15% of cases. The most common associations are ovary, breast, melanoma, GI, and lymphoma.
⚠ Autoimmune disorders (choice A) such as inflammatory bowel disease, vasculitis or celiac disease, are more likely to be associated with polymyositis than dermatomyositis.
⚠ Connective tissue disorders (choice C) can be associated with both dermatomyositis and polymyositis.
⚠ HIV (choice D) or parasitic infection (choice E) are more commonly associated with polymyositis.
🔖 Key point:
Dermatomyositis is one of a number of inflammatory myopathies which can cause muscle weakness, pain, and tenderness. It is usually accompanied by a heliotrope rash and may be associated with malignancy in up to 15% of cases
👍7❤1
Forwarded from Medical Mnemonics
🧩 Medical Mnemonics
Black named disorders
➖💀 Black death (plague): black areas from bleeding into skin
➖🐕🦺 Black dog: major depression disorder
➖🧟♂ Black sickness (Kala azar—leishmaniasis): dark skin on extremities
➖🫁 Black lung: coal dust pneumoconiosis
➖🚽 Blackwater fever: severe plasmodium falciparum malaria (dark urine)
#confusing_terms
〰〰〰〰〰〰〰〰〰〰〰
©Medical Mnemonics
Black named disorders
➖💀 Black death (plague): black areas from bleeding into skin
➖🐕🦺 Black dog: major depression disorder
➖🧟♂ Black sickness (Kala azar—leishmaniasis): dark skin on extremities
➖🫁 Black lung: coal dust pneumoconiosis
➖🚽 Blackwater fever: severe plasmodium falciparum malaria (dark urine)
#confusing_terms
〰〰〰〰〰〰〰〰〰〰〰
©Medical Mnemonics
👍10🥰4
Forwarded from EDL Backup Channel
⚠ 🔔 𝐒𝐀𝐕𝐄 𝐓𝐇𝐈𝐒 𝐋𝐈𝐒𝐓 𝐅𝐎𝐑 𝐀 𝐑𝐀𝐈𝐍𝐘 𝐃𝐀𝐘 ! ⤵
1. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐
2. 𝗖𝗔𝗦𝗘 - 𝗕𝗔𝗦𝗘𝗗 𝗠𝗖𝗤𝗦 💯
3. 🇨🇦 𝗠𝗖𝗖𝗤𝗘 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡
4. 🩺 𝗘𝗗𝗟 𝗠𝗘𝗗𝗜𝗖𝗢𝗦 (𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 𝗔𝗡𝗗 𝗟𝗜𝗡𝗞𝗦)
5. 📚 𝗘𝗗𝗟 𝗣𝗛𝗔𝗥𝗠
6. 🏛 𝗢𝗡𝗟𝗜𝗡𝗘 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗦𝗖𝗛𝗢𝗢𝗟
7. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗚𝗘𝗥𝗠𝗔𝗡𝗬 🇩🇪
8. 𝗣𝗥𝗔𝗖𝗧𝗜𝗖𝗘 𝗜𝗡 𝗔𝗨𝗦𝗧𝗥𝗔𝗟𝗜𝗔 🇦🇺
9. 𝗠𝗕𝗕𝗦 & 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗜𝗧𝗔𝗟𝗬 🇮🇹
10. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗞 🇬🇧
11. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗦 🇺🇸
12. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗖𝗔𝗡𝗔𝗗𝗔 🇨🇦
13. 𝗙𝗥𝗘𝗡𝗖𝗛 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇫🇷
14. 𝗚𝗘𝗥𝗠𝗔𝗡 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇩🇪
15. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗦𝗘𝗔𝗥𝗖𝗛 🎓
16. 📸 𝗗𝗘𝗥𝗠𝗔𝗧𝗢𝗟𝗢𝗚𝗬 𝗔𝗧𝗟𝗔𝗦
17. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬)
1. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐
2. 𝗖𝗔𝗦𝗘 - 𝗕𝗔𝗦𝗘𝗗 𝗠𝗖𝗤𝗦 💯
3. 🇨🇦 𝗠𝗖𝗖𝗤𝗘 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡
4. 🩺 𝗘𝗗𝗟 𝗠𝗘𝗗𝗜𝗖𝗢𝗦 (𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 𝗔𝗡𝗗 𝗟𝗜𝗡𝗞𝗦)
5. 📚 𝗘𝗗𝗟 𝗣𝗛𝗔𝗥𝗠
6. 🏛 𝗢𝗡𝗟𝗜𝗡𝗘 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗦𝗖𝗛𝗢𝗢𝗟
7. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗚𝗘𝗥𝗠𝗔𝗡𝗬 🇩🇪
8. 𝗣𝗥𝗔𝗖𝗧𝗜𝗖𝗘 𝗜𝗡 𝗔𝗨𝗦𝗧𝗥𝗔𝗟𝗜𝗔 🇦🇺
9. 𝗠𝗕𝗕𝗦 & 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗜𝗧𝗔𝗟𝗬 🇮🇹
10. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗞 🇬🇧
11. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗦 🇺🇸
12. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗖𝗔𝗡𝗔𝗗𝗔 🇨🇦
13. 𝗙𝗥𝗘𝗡𝗖𝗛 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇫🇷
14. 𝗚𝗘𝗥𝗠𝗔𝗡 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇩🇪
15. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗦𝗘𝗔𝗥𝗖𝗛 🎓
16. 📸 𝗗𝗘𝗥𝗠𝗔𝗧𝗢𝗟𝗢𝗚𝗬 𝗔𝗧𝗟𝗔𝗦
17. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬)
👍4👎2
⏳ Case-based MCQ | #Case_435
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 39-year-old multigravida at 36 weeks gestation presents with a temperature of 40.0°C (104.0°F), chills, backache, and vomiting. On physical examination, the uterus is noted to be nontender, but there is slight bilateral costovertebral angle tenderness. A urinalysis reveals many leukocytes, some in clumps, as well as numerous bacteria.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 39-year-old multigravida at 36 weeks gestation presents with a temperature of 40.0°C (104.0°F), chills, backache, and vomiting. On physical examination, the uterus is noted to be nontender, but there is slight bilateral costovertebral angle tenderness. A urinalysis reveals many leukocytes, some in clumps, as well as numerous bacteria.
👍6
What would be the most appropriate therapy at this time?
Anonymous Poll
7%
A. Oral levofloxacin
13%
B. Oral nitrofurantoin
16%
C. Oral trimethoprim/sulfamethoxazole
57%
D. Intravenous ceftriaxone
6%
E. Intravenous doxycycline
❤1👍1
⏳ Case-based MCQ | #Case_435 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital with parenteral agents, at least until the patient is stabilized and cultures are available. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteremic.
Ampicillin plus gentamicin or a cephalosporin (choice D) (e.g., Ceftriaxone, Cefepime) is typically used.
⚠ The safety of levofloxacin (choice A) in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk.
⚠ Oral nitrofurantoin (choice B) may induce hemolysis in patients who are deficient in G6PD, which includes approximately 2% of women.
⚠ Oral trimethoprim/sulfamethoxazole (choice C) is contraindicated late in pregnancy because they may increase the incidence of kernicterus.
⚠ Intravenous doxycycline (choice E) is contraindicated because administration late in pregnancy may lead to discoloration of the child’s deciduous teeth.
🔖 Key point:
Acute pyelonephritis in pregnancy is treated in hospital with intravenous antibiotics (e.g., Ampicillin plus gentamicin, or Ceftriaxone, or Cefepime) until the patient is afebrile for 24 to 48 hours and symptomatically improved.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital with parenteral agents, at least until the patient is stabilized and cultures are available. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteremic.
Ampicillin plus gentamicin or a cephalosporin (choice D) (e.g., Ceftriaxone, Cefepime) is typically used.
⚠ The safety of levofloxacin (choice A) in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk.
⚠ Oral nitrofurantoin (choice B) may induce hemolysis in patients who are deficient in G6PD, which includes approximately 2% of women.
⚠ Oral trimethoprim/sulfamethoxazole (choice C) is contraindicated late in pregnancy because they may increase the incidence of kernicterus.
⚠ Intravenous doxycycline (choice E) is contraindicated because administration late in pregnancy may lead to discoloration of the child’s deciduous teeth.
🔖 Key point:
Acute pyelonephritis in pregnancy is treated in hospital with intravenous antibiotics (e.g., Ampicillin plus gentamicin, or Ceftriaxone, or Cefepime) until the patient is afebrile for 24 to 48 hours and symptomatically improved.
👍8❤2
⏳ Case-based MCQ | #Case_436
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A young male college student is brought to the emergency department as he was found vomiting blood during class. The patient looks pale and dehydrated. You start IV hydration and blood transfusion.
On questioning, the patient says that he has had similar episodes in the past and had been diagnosed with peptic ulcer. He further states that another physician had started him on omeprazole and he takes it regularly. His only other complaint is constipation. Endoscopy was performed in the ED and showed the presence of large ulcers in the distal duodenum and jejunum.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A young male college student is brought to the emergency department as he was found vomiting blood during class. The patient looks pale and dehydrated. You start IV hydration and blood transfusion.
On questioning, the patient says that he has had similar episodes in the past and had been diagnosed with peptic ulcer. He further states that another physician had started him on omeprazole and he takes it regularly. His only other complaint is constipation. Endoscopy was performed in the ED and showed the presence of large ulcers in the distal duodenum and jejunum.
👍10
What is the best diagnostic test to confirm the diagnosis?
Anonymous Poll
6%
A. Low gastric pH
25%
B. Endoscopic ultrasound
12%
C. CT scan
20%
D. Increased gastrin level despite high gastric acid secretion
38%
E. Persistent high gastrin levels after IV secretin administration
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⏳ Case-based MCQ | #Case_436 | #answer
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✅ E
This patient most likely suffers from Zollinger-Ellison Syndrome (ZES). It is caused by a non–beta islet cell, gastrin-secreting tumor of the pancreas. The primary tumor is usually located in the duodenum, the pancreas, and abdominal lymph nodes, but ectopic locations have also been described (e.g., heart, ovary, gall bladder, liver, kidney). Excess gastrin secretion causes increased influx of acid into the stomach causing ulcerative disease. The most common clinical symptom of this disorder is recurrent gastric pain which does not resolve with PPI treatment or other peptic ulcer medications. The characteristics of these ulcers are that they are large (> 1-2 cm), recurrent even after Helicobacter pylori eradication, distal in the duodenum or even jejunum, and are multiple.
The most important initial diagnostic step is to have an endoscopy in the patient who has repeated gastric pain even after taking peptic ulcer medication. Once ulceration is confirmed on endoscopy, the possibility of ZES should be considered. Fasting serum gastrin is the best single screening test. Any PPI or H2 blocker treatment should be stopped before this test.
The best diagnostic test is persistent high gastrin level despite the infusion of secretin (choice E), which normally inhibits the gastrin realease. This test has high sensitivity and specificity.
⚠ Low gastric pH (choice A) is incorrect. Though gastric pH is certainly going to be low due to elevated secretion of gastric acid, it is not the most helpful finding to confirm ZES.
⚠ Endoscopic ultrasound (choice B) is an invasive process and not preferred. Endoscopic ultrasound is one of the newer methods for localizing gastrinomas. Its sensitivity is higher for pancreatic gastrinoma (40-75%) than for duodenal gastrinoma (50%).
⚠ CT scan (choice C) can be performed to localize the tumor and is useful for evaluation for metastatic disease. However, its sensitivity for primary tumor localization is only 50%, and frequently, tumors smaller than 1 cm are missed.
⚠ Increased gastrin level despite high gastric acid secretion (choice D) is an unreliable finding in a patient on PPI treatment. Elevated gastrin levels would only confirm a diagnosis of ZE syndrome if they persist after secretin injection.
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✅ E
This patient most likely suffers from Zollinger-Ellison Syndrome (ZES). It is caused by a non–beta islet cell, gastrin-secreting tumor of the pancreas. The primary tumor is usually located in the duodenum, the pancreas, and abdominal lymph nodes, but ectopic locations have also been described (e.g., heart, ovary, gall bladder, liver, kidney). Excess gastrin secretion causes increased influx of acid into the stomach causing ulcerative disease. The most common clinical symptom of this disorder is recurrent gastric pain which does not resolve with PPI treatment or other peptic ulcer medications. The characteristics of these ulcers are that they are large (> 1-2 cm), recurrent even after Helicobacter pylori eradication, distal in the duodenum or even jejunum, and are multiple.
The most important initial diagnostic step is to have an endoscopy in the patient who has repeated gastric pain even after taking peptic ulcer medication. Once ulceration is confirmed on endoscopy, the possibility of ZES should be considered. Fasting serum gastrin is the best single screening test. Any PPI or H2 blocker treatment should be stopped before this test.
The best diagnostic test is persistent high gastrin level despite the infusion of secretin (choice E), which normally inhibits the gastrin realease. This test has high sensitivity and specificity.
⚠ Low gastric pH (choice A) is incorrect. Though gastric pH is certainly going to be low due to elevated secretion of gastric acid, it is not the most helpful finding to confirm ZES.
⚠ Endoscopic ultrasound (choice B) is an invasive process and not preferred. Endoscopic ultrasound is one of the newer methods for localizing gastrinomas. Its sensitivity is higher for pancreatic gastrinoma (40-75%) than for duodenal gastrinoma (50%).
⚠ CT scan (choice C) can be performed to localize the tumor and is useful for evaluation for metastatic disease. However, its sensitivity for primary tumor localization is only 50%, and frequently, tumors smaller than 1 cm are missed.
⚠ Increased gastrin level despite high gastric acid secretion (choice D) is an unreliable finding in a patient on PPI treatment. Elevated gastrin levels would only confirm a diagnosis of ZE syndrome if they persist after secretin injection.
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