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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
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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
π1
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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
π€1
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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.
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π¨π¦ MCCQE1,2 | #Case_64
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A 38-year-old female presents to the family physician's office complaining of a βwhitishβ discharge from her both nipples, which she first noticed one week ago. She has never been pregnant and her last menstrual bleeding was three months ago. On confrontation visual field testing, she has field defects in upper and temporal quadrants of both eyes. A tumor at which of the following location could explain her signs and symptoms?
a) Sphenoidal ridge
b) Olfactory groove
c) Anterior pituitary
d) Posterior pituitary
e) Pituitary stalk
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A 38-year-old female presents to the family physician's office complaining of a βwhitishβ discharge from her both nipples, which she first noticed one week ago. She has never been pregnant and her last menstrual bleeding was three months ago. On confrontation visual field testing, she has field defects in upper and temporal quadrants of both eyes. A tumor at which of the following location could explain her signs and symptoms?
a) Sphenoidal ridge
b) Olfactory groove
c) Anterior pituitary
d) Posterior pituitary
e) Pituitary stalk
π1
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β C
π Explanation
A visual field defect of the outer hemi-fields of both eyes (bitemporal hemianopia) indicates a midline lesion that affects the optic chiasm. The visual field defect more pronounced on the upper quadrants (βpie in the skyβ) indicates the optic chiasm is compressed from below. The location of the pituitary gland matches this description. Galactorrhea, amenorrhea,
and infertility are seen in hvperprolactinemia, which can be caused by a tumor (adenoma) of the anterior pituitary (choice C).
β Tumors of the sphenoidal ridge (choice A) and olfactory groove (choice B) compresses the optic nerve and mostly causes a monocular visual field deficit (not a bitemporal hemianopia). It also wouldnβt explain the features of hyperprolcatinemia seen in this patient.
β Posterior pituitary (choice D), which stores and releases antidiuretic hormone (ADH) and oxytocin, does not form adenomas.
β Craniopharyngioma is a tumor that arises from the remnants of the Rathke pouch of the pituitary stalk (choice E) and compresses the optic chiasm from above, which results a bitemporal hemianopia with a visual field defect more pronounced in the outer inferior quadrants (not the outer superior quadrant as seen in this patient).
β Key point:
Bitemporal hemianopia points to a lesion compressing the optic chiasm. In a patient with bitemporal hemianopia it is important to look for features of anterior pituitary hormone dysregulation.
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β C
π Explanation
A visual field defect of the outer hemi-fields of both eyes (bitemporal hemianopia) indicates a midline lesion that affects the optic chiasm. The visual field defect more pronounced on the upper quadrants (βpie in the skyβ) indicates the optic chiasm is compressed from below. The location of the pituitary gland matches this description. Galactorrhea, amenorrhea,
and infertility are seen in hvperprolactinemia, which can be caused by a tumor (adenoma) of the anterior pituitary (choice C).
β Tumors of the sphenoidal ridge (choice A) and olfactory groove (choice B) compresses the optic nerve and mostly causes a monocular visual field deficit (not a bitemporal hemianopia). It also wouldnβt explain the features of hyperprolcatinemia seen in this patient.
β Posterior pituitary (choice D), which stores and releases antidiuretic hormone (ADH) and oxytocin, does not form adenomas.
β Craniopharyngioma is a tumor that arises from the remnants of the Rathke pouch of the pituitary stalk (choice E) and compresses the optic chiasm from above, which results a bitemporal hemianopia with a visual field defect more pronounced in the outer inferior quadrants (not the outer superior quadrant as seen in this patient).
β Key point:
Bitemporal hemianopia points to a lesion compressing the optic chiasm. In a patient with bitemporal hemianopia it is important to look for features of anterior pituitary hormone dysregulation.
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π¨π¦ MCCQE1,2 | #Case_65
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A 27-year-old man presented to his family physician with palpitations of about two weeks duration. The palpitations were intermittent, short-lasting, resolved spontaneously, and were not related to exertion. He had no other symptoms. His heart rate was regular at 92 beats per minute and other vital signs were stable. Examination showed the following:
- point of maximum impulse is located in the 5th intercostal space 1cm lateral to the midclavicular line;
- normal first and second heart sounds;
- midsystolic harsh murmur of grade VI/6 with maximal intensity at the left lower sternal border and did not radiate to the axilla, clavicle or carotid artery. The murmur was diminished by squatting and was louder during expiration.The rest of physical examination was normal. Which of the following is the most likely cause of this patient's heart murmur?
a) Aortic stenosis
b) Hypertrophic obstructive cardiomyopathy
c) Mitral regurgitation
d) Large ventricular septal defect complicated by pulmonary hypertension
e) Pulmonary stenosis complicated by pulmonary hypertension
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A 27-year-old man presented to his family physician with palpitations of about two weeks duration. The palpitations were intermittent, short-lasting, resolved spontaneously, and were not related to exertion. He had no other symptoms. His heart rate was regular at 92 beats per minute and other vital signs were stable. Examination showed the following:
- point of maximum impulse is located in the 5th intercostal space 1cm lateral to the midclavicular line;
- normal first and second heart sounds;
- midsystolic harsh murmur of grade VI/6 with maximal intensity at the left lower sternal border and did not radiate to the axilla, clavicle or carotid artery. The murmur was diminished by squatting and was louder during expiration.The rest of physical examination was normal. Which of the following is the most likely cause of this patient's heart murmur?
a) Aortic stenosis
b) Hypertrophic obstructive cardiomyopathy
c) Mitral regurgitation
d) Large ventricular septal defect complicated by pulmonary hypertension
e) Pulmonary stenosis complicated by pulmonary hypertension
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_65 | #answer
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β B
π Explanation
Hypertrophic obstructive cardiomyopathy (HOCM) (choice B) is the most likely cause of the murmur in this patient. HOCM typically presents between 20 and 40 years of age and might be asymptomatic and diagnosed only when the characteristic murmur is found incidentally. Common symptoms include palpitations, angina, syncope or presyncope, shortness of breath with exercise or even sudden death. Physical signs of HOCM include PMI that is displaced laterally and is sustained in nature. Double or triple cardiac impulses are sometimes found. The typical murmur of HOCM is a midsystolic harsh murmur with maximal intensity along the lower sternal border or apex. Unlike most other systolic murmurs, the murmur of HOCM is diminished by squatting and is enhanced by standing because squatting increases venous return and standing decreases it. A high venous return expands the left ventricle including the point of obstruction within the ventricle and thus, softening the murmur in patients with HOCM. Our patient showed most of these and HOCM is thus the most likely cause of murmur. The table below compares the murmur of HOCM to that of aortic stenosis (AS), mitral regurgitation (MR), ventricular septal defect (VSD) and pulmonary stenosis (PS). The peachy color indicates characteristics of the murmur in our patient.
β Aortic stenosis (choice A) is a rather unlikely cause of murmur in this patient. AS might start early in life but most patient develop symptoms in the 6th to 8th decades of life and they usually present with increasing breathlessness on exertion. The murmur of AS is crescendo decrescendo midsystolic murmur with maximum intensity in second intercostal space to the right of sternum and radiates to the clavicle or carotid artery. For all these reasons aortic stenosis is not the likely cause of murmur in this patient.
β Mitral regurgitation (choice C) is an unlikely cause of murmur in this patient. The murmur of MR is a holosystolic rather than midsystolic with maximum intensity at the apex and it usually radiates to axilla.
β Large ventricular septal defect (VSD) with pulmonary hypertension (choice D) usually results in early systolic rather than midsystolic murmur because shunting of blood decreases towards the end of systole. This is because pulmonary hypertension increases right ventricular pressure. Smaller VSDs on the other hand usually cause holosystolic murmurs. Thus, VSD is an unlikely cause of murmur in our patient.
β Pulmonary stenosis (PS) complicated by pulmonary hypertension (choice E) is not the correct choice. In PS the murmur is midsystolic with maximum intensity in the left second intercostal space. Also, this murmur is louder during inspiration. PS is thus, an unlikely cause of the systolic murmur in our patient.
β Key point:
Onset, area of maximum intensity and radiation of a murmur are helpful in identifying its causes. A midsystolic murmur with maximum intensity at apex or along left lower sternal border and that does not radiate is most likely due to HOCM.
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β B
π Explanation
Hypertrophic obstructive cardiomyopathy (HOCM) (choice B) is the most likely cause of the murmur in this patient. HOCM typically presents between 20 and 40 years of age and might be asymptomatic and diagnosed only when the characteristic murmur is found incidentally. Common symptoms include palpitations, angina, syncope or presyncope, shortness of breath with exercise or even sudden death. Physical signs of HOCM include PMI that is displaced laterally and is sustained in nature. Double or triple cardiac impulses are sometimes found. The typical murmur of HOCM is a midsystolic harsh murmur with maximal intensity along the lower sternal border or apex. Unlike most other systolic murmurs, the murmur of HOCM is diminished by squatting and is enhanced by standing because squatting increases venous return and standing decreases it. A high venous return expands the left ventricle including the point of obstruction within the ventricle and thus, softening the murmur in patients with HOCM. Our patient showed most of these and HOCM is thus the most likely cause of murmur. The table below compares the murmur of HOCM to that of aortic stenosis (AS), mitral regurgitation (MR), ventricular septal defect (VSD) and pulmonary stenosis (PS). The peachy color indicates characteristics of the murmur in our patient.
β Aortic stenosis (choice A) is a rather unlikely cause of murmur in this patient. AS might start early in life but most patient develop symptoms in the 6th to 8th decades of life and they usually present with increasing breathlessness on exertion. The murmur of AS is crescendo decrescendo midsystolic murmur with maximum intensity in second intercostal space to the right of sternum and radiates to the clavicle or carotid artery. For all these reasons aortic stenosis is not the likely cause of murmur in this patient.
β Mitral regurgitation (choice C) is an unlikely cause of murmur in this patient. The murmur of MR is a holosystolic rather than midsystolic with maximum intensity at the apex and it usually radiates to axilla.
β Large ventricular septal defect (VSD) with pulmonary hypertension (choice D) usually results in early systolic rather than midsystolic murmur because shunting of blood decreases towards the end of systole. This is because pulmonary hypertension increases right ventricular pressure. Smaller VSDs on the other hand usually cause holosystolic murmurs. Thus, VSD is an unlikely cause of murmur in our patient.
β Pulmonary stenosis (PS) complicated by pulmonary hypertension (choice E) is not the correct choice. In PS the murmur is midsystolic with maximum intensity in the left second intercostal space. Also, this murmur is louder during inspiration. PS is thus, an unlikely cause of the systolic murmur in our patient.
β Key point:
Onset, area of maximum intensity and radiation of a murmur are helpful in identifying its causes. A midsystolic murmur with maximum intensity at apex or along left lower sternal border and that does not radiate is most likely due to HOCM.
β€1π1
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_66
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You are asked to see an 18-year-old man with autism in a busy walk-in clinic who presents with 4 day history of fever, malaise, and sore throat. He has brought his mother in to speak for him. She tells you that he has been making high-pitched sounds during inspiration and spitting out food that he normally enjoys eating due to pain with swallowing. She has also noticed that his voice has been muffled sounding for the last 24 hours.Vital signs: temperature 39.6Β°C, BP: 96/52 mmHg, HR: 102 bpm, RR: 12 rpm. On examination, you notice him leaning toward you. On examination of his throat you notice pooled saliva in the mouth. He has tender anterior cervical lymphadenopathy. The rest of the physical exam is normal. What is your next step in the management of this patient?
a) Reassure the patient and his mother that this is only a viral infection
b) Suggest rest, hydration, and close follow-up with their regular family physician
c) Prescribe Amoxicillin 400mg TID for 7 days with close follow-up.
d) Advise the patient and his mother to go to the emergency department for treatment.
e) Ensure the patient is calm, and call 911 for emergent transfer to the nearest emergency department
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You are asked to see an 18-year-old man with autism in a busy walk-in clinic who presents with 4 day history of fever, malaise, and sore throat. He has brought his mother in to speak for him. She tells you that he has been making high-pitched sounds during inspiration and spitting out food that he normally enjoys eating due to pain with swallowing. She has also noticed that his voice has been muffled sounding for the last 24 hours.Vital signs: temperature 39.6Β°C, BP: 96/52 mmHg, HR: 102 bpm, RR: 12 rpm. On examination, you notice him leaning toward you. On examination of his throat you notice pooled saliva in the mouth. He has tender anterior cervical lymphadenopathy. The rest of the physical exam is normal. What is your next step in the management of this patient?
a) Reassure the patient and his mother that this is only a viral infection
b) Suggest rest, hydration, and close follow-up with their regular family physician
c) Prescribe Amoxicillin 400mg TID for 7 days with close follow-up.
d) Advise the patient and his mother to go to the emergency department for treatment.
e) Ensure the patient is calm, and call 911 for emergent transfer to the nearest emergency department
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_66 | #answer
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β E
π Explanation
Epiglottitis is an inflammation of the epiglottitis and surrounding supraglottic structures that is typically caused by Haemophilus influenzae type B. Without immediate treatment epiglottitis can progress to life-threatening airway obstruction. On history, muffled voice, high pitched breathing (stridor), inability to swallow food (sore throat), and uncertain vaccination history all put him at significant risk for epiglottitis. The suggestive examination findings include leaning forward, drooling, fever, and tender cervical lymphadenopathy. The treatment is supportive, however, it is imperative that the patient not be disturbed and emergent transfer to a Level 3 facility be arranged for airway support.
β The most common cause of epiglottitis in children is Haemophilus influenzae type B (HiB), which is gram-negative coccobacillus. Although HiB is a common cause in adults, most of time the infection results from several other bacteria (choice A).
β Suggesting rest and hydration is a reasonable option for acute bronchitis (choice B) in selected patients. However, in this patient such a suggestion may result in the patient deteriorating further.
β Oral amoxicillin (choice C) is an inappropriate choice for an emergent case of possible airway obstruction.
β While the appropriate place for this patient is the emergency department, it is inappropriate to simply advise them to seek this on their own (choice D). This can be for various reasons including the patient/mother's incomplete understanding of the gravity of the situation, perceived inconvenience etc.
β Key point:
Epiglottitis must be recognized in a febrile patient with sore throat, muffled voice, and stridor with or without a background history of incomplete immunizations. Unrecognized epiglottitis may rapidly lead to airway compromise and resultant death. Maintenance of the airway is the mainstay of treatment of epiglottitis.
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β E
π Explanation
Epiglottitis is an inflammation of the epiglottitis and surrounding supraglottic structures that is typically caused by Haemophilus influenzae type B. Without immediate treatment epiglottitis can progress to life-threatening airway obstruction. On history, muffled voice, high pitched breathing (stridor), inability to swallow food (sore throat), and uncertain vaccination history all put him at significant risk for epiglottitis. The suggestive examination findings include leaning forward, drooling, fever, and tender cervical lymphadenopathy. The treatment is supportive, however, it is imperative that the patient not be disturbed and emergent transfer to a Level 3 facility be arranged for airway support.
β The most common cause of epiglottitis in children is Haemophilus influenzae type B (HiB), which is gram-negative coccobacillus. Although HiB is a common cause in adults, most of time the infection results from several other bacteria (choice A).
β Suggesting rest and hydration is a reasonable option for acute bronchitis (choice B) in selected patients. However, in this patient such a suggestion may result in the patient deteriorating further.
β Oral amoxicillin (choice C) is an inappropriate choice for an emergent case of possible airway obstruction.
β While the appropriate place for this patient is the emergency department, it is inappropriate to simply advise them to seek this on their own (choice D). This can be for various reasons including the patient/mother's incomplete understanding of the gravity of the situation, perceived inconvenience etc.
β Key point:
Epiglottitis must be recognized in a febrile patient with sore throat, muffled voice, and stridor with or without a background history of incomplete immunizations. Unrecognized epiglottitis may rapidly lead to airway compromise and resultant death. Maintenance of the airway is the mainstay of treatment of epiglottitis.
π1
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_67
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A 34-year-old male comes for a follow up of his recent lower respiratory infection treatment. Three weeks ago he had sought medical attention due to 5 days of cough, fever, and night sweats. Chest X-ray had shown pulmonary infiltrates and he was prescribed antibiotics with a presumed community-acquired pneumonia diagnosis. Today he reports that he is still coughing and has been experiencing chest pain. His past medical history is significant for ulcerative colitis, for which he has been receiving treatment for the last 3 years. Chest x-ray repeat shows disseminated pulmonary infiltrates. Laboratory studies reveal weakly acid-fast organisms. Taking his past medical history, current presentation, and all investigation results into consideration, you decide to treat him with trimethoprim- sulfamethoxazole. If his condition improved within the following 3 months, you would assume that the most probable culprit for causing his symptoms was:
a) Pneumocystis jiroveci
b) Nocardia asteroides
c) Mycobacterium tuberculosis
d) Coccidioides immitis
e) Mycoplasma pneumonia
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A 34-year-old male comes for a follow up of his recent lower respiratory infection treatment. Three weeks ago he had sought medical attention due to 5 days of cough, fever, and night sweats. Chest X-ray had shown pulmonary infiltrates and he was prescribed antibiotics with a presumed community-acquired pneumonia diagnosis. Today he reports that he is still coughing and has been experiencing chest pain. His past medical history is significant for ulcerative colitis, for which he has been receiving treatment for the last 3 years. Chest x-ray repeat shows disseminated pulmonary infiltrates. Laboratory studies reveal weakly acid-fast organisms. Taking his past medical history, current presentation, and all investigation results into consideration, you decide to treat him with trimethoprim- sulfamethoxazole. If his condition improved within the following 3 months, you would assume that the most probable culprit for causing his symptoms was:
a) Pneumocystis jiroveci
b) Nocardia asteroides
c) Mycobacterium tuberculosis
d) Coccidioides immitis
e) Mycoplasma pneumonia
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_67 | #answer
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β B
π Explanation
This patientβs clinical picture is suggestive of pleuropulmonary nocardiosis caused by Nocardia asteroides (choice B). It is an acute, subacute, or chronic infectious disease that typically affects immunocompromised hosts, although cases in immunocompetent patients also have been reported. This patientβs long history of inflammatory bowel disease that was most probably treated with immunosuppressive therapy is a typical association with this infection.The disease may present with night sweats, fever, cough, and chest pain. It is characterized by multiple pulmonary infiltrates on chest X-ray with a tendency to central necrosis. Pulmonary infiltrates are often persistent for months as the disease is refractory to antibiotherapy, just as described in this patient. While diagnosis may be challenging, when it is suspected, the organisms can be visualized by a modified Ziehl-Neelsen stain such as Fite-Faraco staining. It is a weakly acid-fast organism. Despite the lack of controlled clinical trials and no general treatment guidelines for norcadiosis, sulfonamides are considered the treatment of choice. Sulfadiazine or trimethoprim-sulfamethoxazole should be given for a period of 6 months.
β Pneumocystis jiroveci (choice A) also could present with cough, fever, and pulmonary infiltrates in
immunocompromised patients. Furthermore, the treatment of choice for this infection is trimethoprim-sulfamethoxazole. However, it is visualized on silver-stain and not Ziehl-Neelsen stain, as it is not an acid-fast organism.
β Mycobacterium tuberculosis (choice C) is classified among unusual organisms that may cause persistent pulmonary infiltrates and just as seen in this patient, it can cause night sweats, fever, cough and is an acid-fast organism visualized on Ziehl-Neelsen stain. However, it is best treated with Isoniazid, rifampin, ethambutol, and pyrazinamide.
β Coccidioides immitis (choice D) is a fungus, treated with ketoconazole.
β Mycoplasma pneumonia (choice E) would probably have been cleared with antibiotics given for community acquired pneumonia. It is not an acid-fast organism.
β Key point:
Pleuropulmonary nocardiosis is associated with persistent pulmonary infiltrates and may be refractory to antibiotherapy. It is a weakly acid-fast organism and the first line treatment is sulfonamides (either sulfadiazine or trimethoprim-sulfamethoxazole).
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β B
π Explanation
This patientβs clinical picture is suggestive of pleuropulmonary nocardiosis caused by Nocardia asteroides (choice B). It is an acute, subacute, or chronic infectious disease that typically affects immunocompromised hosts, although cases in immunocompetent patients also have been reported. This patientβs long history of inflammatory bowel disease that was most probably treated with immunosuppressive therapy is a typical association with this infection.The disease may present with night sweats, fever, cough, and chest pain. It is characterized by multiple pulmonary infiltrates on chest X-ray with a tendency to central necrosis. Pulmonary infiltrates are often persistent for months as the disease is refractory to antibiotherapy, just as described in this patient. While diagnosis may be challenging, when it is suspected, the organisms can be visualized by a modified Ziehl-Neelsen stain such as Fite-Faraco staining. It is a weakly acid-fast organism. Despite the lack of controlled clinical trials and no general treatment guidelines for norcadiosis, sulfonamides are considered the treatment of choice. Sulfadiazine or trimethoprim-sulfamethoxazole should be given for a period of 6 months.
β Pneumocystis jiroveci (choice A) also could present with cough, fever, and pulmonary infiltrates in
immunocompromised patients. Furthermore, the treatment of choice for this infection is trimethoprim-sulfamethoxazole. However, it is visualized on silver-stain and not Ziehl-Neelsen stain, as it is not an acid-fast organism.
β Mycobacterium tuberculosis (choice C) is classified among unusual organisms that may cause persistent pulmonary infiltrates and just as seen in this patient, it can cause night sweats, fever, cough and is an acid-fast organism visualized on Ziehl-Neelsen stain. However, it is best treated with Isoniazid, rifampin, ethambutol, and pyrazinamide.
β Coccidioides immitis (choice D) is a fungus, treated with ketoconazole.
β Mycoplasma pneumonia (choice E) would probably have been cleared with antibiotics given for community acquired pneumonia. It is not an acid-fast organism.
β Key point:
Pleuropulmonary nocardiosis is associated with persistent pulmonary infiltrates and may be refractory to antibiotherapy. It is a weakly acid-fast organism and the first line treatment is sulfonamides (either sulfadiazine or trimethoprim-sulfamethoxazole).
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_68
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A 75-year-old female presents with a acutely swollen, painful, erythematous left knee. Symptoms have been present for 48 hours. She denies previous episodes and trauma. She admits that she had stopped her βthyroid tabletsβ a few months ago, as she prefers natural medicines.On clinical examination all vitals are within normal range, and the patient is afebrile. The left knee is visibly inflamed, red, swollen, and very tender to touch. There are no visible areas of penetrative skin trauma. What would be the next appropriate diagnostic step?
a) A serum thyroid stimulating hormone (TSH) level and T4 level. Stat dose of 200 micrograms levothyroxine and review in 3 days.
b) Immediate referral to an orthopaedic surgeon, as she will probably require an urgent joint replacement
c) Obtain a full blood panel including a complete blood count (CBC), serum uric acid, urea and creatinine,C-reactive protein (CRP). Give a high dose anti-staphylococcal antibiotic and high dose oral corticosteroids whilst awaiting results.
d) Sterile aspiration of synovial fluid. Request polarized light microscopy. Intra-articular corticosteroid directly post aspiration to provide symptomatic relief.
e) Sterile aspiration of synovial fluid. Request urgent microscopy, Gram stain and polarized light microscopy
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A 75-year-old female presents with a acutely swollen, painful, erythematous left knee. Symptoms have been present for 48 hours. She denies previous episodes and trauma. She admits that she had stopped her βthyroid tabletsβ a few months ago, as she prefers natural medicines.On clinical examination all vitals are within normal range, and the patient is afebrile. The left knee is visibly inflamed, red, swollen, and very tender to touch. There are no visible areas of penetrative skin trauma. What would be the next appropriate diagnostic step?
a) A serum thyroid stimulating hormone (TSH) level and T4 level. Stat dose of 200 micrograms levothyroxine and review in 3 days.
b) Immediate referral to an orthopaedic surgeon, as she will probably require an urgent joint replacement
c) Obtain a full blood panel including a complete blood count (CBC), serum uric acid, urea and creatinine,C-reactive protein (CRP). Give a high dose anti-staphylococcal antibiotic and high dose oral corticosteroids whilst awaiting results.
d) Sterile aspiration of synovial fluid. Request polarized light microscopy. Intra-articular corticosteroid directly post aspiration to provide symptomatic relief.
e) Sterile aspiration of synovial fluid. Request urgent microscopy, Gram stain and polarized light microscopy
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_68 | #answer
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β E
π Explanation
The probable diagnosis in this case would be crystal-induced arthritis (gout or pseudogout). Septic arthritis would need to be excluded, but is less likely in a elderly afebrile patient, with no obvious infective source. Sterile aspiration of the affected knee would be the next diagnostic step. In cases of acute monoarthritis, the synovial fluid should always be sent for microscopy and gram stain to exclude septic arthritis. Synovial fluid polarized light microscopy is diagnostic in crystal-induced arthritis and differentiates between the different types of crystals. Gout causes monosodium urate crystals, which are strongly negative birefringent, and needle-like. Calcium pyrophosphate crystal deposits (CCPD) are seen in cases of βpseudogoutβ, they are weakly positive birefringent, rhomboid or rod-shaped. Of the crystal-induced arthropathies, acute calcium pyrophosphate crystal arthritis (CPPD or pseudogout) would be the most likely diagnosis. It tends to affect elderly patients, larger joints more commonly and is associated with hypothyroidism.
β A serum TSH and T4, with high dose levothyroxine (choice A), is incorrect. Hypothyroidism does not typically present with acute inflamed mono-arthritis, it may present with generalized arthralgia. The management of the acute arthritis should take priority; the hypothyroidism should be managed thereafter.
β Immediate referral to an orthopaedic surgeon, as she will probably require a urgent joint replacement (choice B), is incorrect. Acute mono-arthritis should be managed as soon as possible. Diagnostic aspiration of the synovial fluid should be performed immediately, to aid in the diagnosis and to exclude septic arthritis. Joint replacement is not the preferred treatment for septic or crystal-induced arthritis.
β Performing a full blood panel, with high dose anti-staphylococcal antibiotics and oral corticosteroids (choice C), is incorrect. The blood results might aid in differentiating between an infective and non-infective process, but would not be diagnostic. It is preferable to first make a plausible diagnosis before starting treatment. Antibiotics would be indicated once the diagnosis of infective arthritis has been established by synovial tap. Surgical drainage and arthroscopy of the joint would then be indicated. Corticosteroids would be absolutely contraindicated in infective arthritis, but would be a treatment option in crystal-induced arthritis.
β Sterile aspiration of synovial fluid, request polarized light microscopy. Post aspiration intra-articular corticosteroids (choice D), is incorrect. In cases of acute monoarthritis, the synovial fluid should always be sent for microscopy and gram stain to exclude septic arthritis. Septic arthritis is less likely in the afebrile patient with intact skin, but has not been ruled out, as hematological spread from a distant site has not been excluded. Crystal-induced arthritis and infective arthritis may occur simultaneously. Corticosteroids are absolutely contraindicated in septic arthritis.
β Key point:
Sterile aspiration of synovial fluid is the diagnostic test of choice in patients with a mono-arthritis, and should be performed without delay. Polarized light microscopy differentiates between the different types of crystal-induced arthropathies.
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β E
π Explanation
The probable diagnosis in this case would be crystal-induced arthritis (gout or pseudogout). Septic arthritis would need to be excluded, but is less likely in a elderly afebrile patient, with no obvious infective source. Sterile aspiration of the affected knee would be the next diagnostic step. In cases of acute monoarthritis, the synovial fluid should always be sent for microscopy and gram stain to exclude septic arthritis. Synovial fluid polarized light microscopy is diagnostic in crystal-induced arthritis and differentiates between the different types of crystals. Gout causes monosodium urate crystals, which are strongly negative birefringent, and needle-like. Calcium pyrophosphate crystal deposits (CCPD) are seen in cases of βpseudogoutβ, they are weakly positive birefringent, rhomboid or rod-shaped. Of the crystal-induced arthropathies, acute calcium pyrophosphate crystal arthritis (CPPD or pseudogout) would be the most likely diagnosis. It tends to affect elderly patients, larger joints more commonly and is associated with hypothyroidism.
β A serum TSH and T4, with high dose levothyroxine (choice A), is incorrect. Hypothyroidism does not typically present with acute inflamed mono-arthritis, it may present with generalized arthralgia. The management of the acute arthritis should take priority; the hypothyroidism should be managed thereafter.
β Immediate referral to an orthopaedic surgeon, as she will probably require a urgent joint replacement (choice B), is incorrect. Acute mono-arthritis should be managed as soon as possible. Diagnostic aspiration of the synovial fluid should be performed immediately, to aid in the diagnosis and to exclude septic arthritis. Joint replacement is not the preferred treatment for septic or crystal-induced arthritis.
β Performing a full blood panel, with high dose anti-staphylococcal antibiotics and oral corticosteroids (choice C), is incorrect. The blood results might aid in differentiating between an infective and non-infective process, but would not be diagnostic. It is preferable to first make a plausible diagnosis before starting treatment. Antibiotics would be indicated once the diagnosis of infective arthritis has been established by synovial tap. Surgical drainage and arthroscopy of the joint would then be indicated. Corticosteroids would be absolutely contraindicated in infective arthritis, but would be a treatment option in crystal-induced arthritis.
β Sterile aspiration of synovial fluid, request polarized light microscopy. Post aspiration intra-articular corticosteroids (choice D), is incorrect. In cases of acute monoarthritis, the synovial fluid should always be sent for microscopy and gram stain to exclude septic arthritis. Septic arthritis is less likely in the afebrile patient with intact skin, but has not been ruled out, as hematological spread from a distant site has not been excluded. Crystal-induced arthritis and infective arthritis may occur simultaneously. Corticosteroids are absolutely contraindicated in septic arthritis.
β Key point:
Sterile aspiration of synovial fluid is the diagnostic test of choice in patients with a mono-arthritis, and should be performed without delay. Polarized light microscopy differentiates between the different types of crystal-induced arthropathies.
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_69
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A 47-year-old man presented with fatigue. Past medical history was not remarkable. Other than pallor and tachycardia, physical examination was otherwise normal. Complete blood count results were as follows:
Hemoglobin level: Low
hematocrit: Low
Red cell count: Low
Reticulocyte count: Low
Platelet count: Low
Red cell distribution width: Normal
White cell count: Normal
Differential white cell count: Normal
Red cell indices: Normocytic normochromic
Erythrocyte sedimentation rate: Normal
Which of the following investigations should be done next?
a) Direct Coomb's test
b) Indirect Coombβs test
c) Gastrointestinal work-up
d) Bone marrow biopsy
e) Glucose 6 phosphate dehydrogenase assay
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A 47-year-old man presented with fatigue. Past medical history was not remarkable. Other than pallor and tachycardia, physical examination was otherwise normal. Complete blood count results were as follows:
Hemoglobin level: Low
hematocrit: Low
Red cell count: Low
Reticulocyte count: Low
Platelet count: Low
Red cell distribution width: Normal
White cell count: Normal
Differential white cell count: Normal
Red cell indices: Normocytic normochromic
Erythrocyte sedimentation rate: Normal
Which of the following investigations should be done next?
a) Direct Coomb's test
b) Indirect Coombβs test
c) Gastrointestinal work-up
d) Bone marrow biopsy
e) Glucose 6 phosphate dehydrogenase assay
Forwarded from MohammaDJ
π¨π¦ MCCQE1,2 | #Case_69 | #answer
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β D
π Explanation
Bone marrow biopsy (choice D) is the investigation to be done next. The results of the CBC point towards the diagnosis of aplastic anemia or a myelodysplastic syndrome. In these disorders anemia is normocytic normochromic and more than two cell lines (red cells and platelets in our patient) are usually affected. Because the bone marrow is suppressed in these disorders, it can not respond with increased reticulocyte production and reticulocyte count is thus, low.
β Direct Coombβs test (choice A) and Indirect Coombβs test (choice B) Glucose 6 phosphate dehydrogenase (G6PD) assay (choice E) are not the correct choices. These tests would be done if hemolytic anemia were suspected. In hemolytic anemia the bone marrow responds with brisk erythropoiesis associated with pouring of large numbers of reticulocytes in Peripheral blood. Contrary to this, our patient had low reticulocyte count making hemolytic anemia a rather unlikely possibility and Coombβs test whether direct or indirect and G6PD assay are unlikely to be helpful.
β Gastrointestinal work-up (choice C) is not the correct choice. In patients with anemia, GI work-up is used to evaluate acute or chronic GI bleeding. If anemia is due to acute GI bleeding, reticulocytosis is expected which is not the case in our patient who had low reticulocyte count. On the other hand, if anemia is due to chronic GI bleeding, it will be of the microcytic hypochromic type caused by iron deficiency resulting from chronic blood loss. Our patient had normocytic normochromic anemia, instead.
β Key point:
In normocytic anemia with low reticulocyte count, bone marrow biopsy is the investigation of choice
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β D
π Explanation
Bone marrow biopsy (choice D) is the investigation to be done next. The results of the CBC point towards the diagnosis of aplastic anemia or a myelodysplastic syndrome. In these disorders anemia is normocytic normochromic and more than two cell lines (red cells and platelets in our patient) are usually affected. Because the bone marrow is suppressed in these disorders, it can not respond with increased reticulocyte production and reticulocyte count is thus, low.
β Direct Coombβs test (choice A) and Indirect Coombβs test (choice B) Glucose 6 phosphate dehydrogenase (G6PD) assay (choice E) are not the correct choices. These tests would be done if hemolytic anemia were suspected. In hemolytic anemia the bone marrow responds with brisk erythropoiesis associated with pouring of large numbers of reticulocytes in Peripheral blood. Contrary to this, our patient had low reticulocyte count making hemolytic anemia a rather unlikely possibility and Coombβs test whether direct or indirect and G6PD assay are unlikely to be helpful.
β Gastrointestinal work-up (choice C) is not the correct choice. In patients with anemia, GI work-up is used to evaluate acute or chronic GI bleeding. If anemia is due to acute GI bleeding, reticulocytosis is expected which is not the case in our patient who had low reticulocyte count. On the other hand, if anemia is due to chronic GI bleeding, it will be of the microcytic hypochromic type caused by iron deficiency resulting from chronic blood loss. Our patient had normocytic normochromic anemia, instead.
β Key point:
In normocytic anemia with low reticulocyte count, bone marrow biopsy is the investigation of choice
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