⏳ Case-based MCQ | #Case_442
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A 60-year-old black male complains of a one-week history of weakness of the lower left leg, giving away of the knee, and discomfort in the anterior thigh. He has no history of recent trauma. His past medical history is significant for DM2, diagnosed 15 years ago.
A physical examination reveals reduced sensation to pinprick and light touch over the left anterior thigh, reduced motor strength on hip flexion and knee extension, and normal straight leg raising test.
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A 60-year-old black male complains of a one-week history of weakness of the lower left leg, giving away of the knee, and discomfort in the anterior thigh. He has no history of recent trauma. His past medical history is significant for DM2, diagnosed 15 years ago.
A physical examination reveals reduced sensation to pinprick and light touch over the left anterior thigh, reduced motor strength on hip flexion and knee extension, and normal straight leg raising test.
👍4
What is the most likely cause of this patient's presenting condition?
Anonymous Poll
35%
A. Femoral neuropathy
42%
B. Diabetic polyneuropathy
8%
C. Meralgia paresthetica
8%
D. Spinal stenosis
6%
E. Iliofemoral atherosclerosis
👍4❤1
⏳ Case-based MCQ | #Case_442 | #answer
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✅ A
This patient most likely presents with femoral neuropathy (choice A), a mononeuropathy commonly associated with direct trauma, compression, stretch injury, or ischemia. Patients with diabetes have an unusual predisposition for femoral and proximal mononeuropathies.
⚠ Diabetic polyneuropathy (choice B) is marked by symmetric and distal limb sensory and motor deficits.
⚠ Meralgia paresthetica (choice C), or lateral femoral cutaneous neuropathy is characterized by numbness and paresthesia over the anterolateral thigh with no motor dysfunction.
⚠ Spinal stenosis (choice D) causes pain in the legs but is not associated with the neurologic signs seen in this patient, nor with knee problems.
⚠ Iliofemoral atherosclerosis (choice E), a relatively common complication of diabetes mellitus, may produce intermittent claudication involving one or both calf muscles but would not produce the motor weakness noted in this patient.
🔖 Key point:
Patients with femoral neuropathy complain of difficulty with stairs, knee buckling, weakness of the quadriceps muscle, and medial leg and calf numbness.
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✅ A
This patient most likely presents with femoral neuropathy (choice A), a mononeuropathy commonly associated with direct trauma, compression, stretch injury, or ischemia. Patients with diabetes have an unusual predisposition for femoral and proximal mononeuropathies.
⚠ Diabetic polyneuropathy (choice B) is marked by symmetric and distal limb sensory and motor deficits.
⚠ Meralgia paresthetica (choice C), or lateral femoral cutaneous neuropathy is characterized by numbness and paresthesia over the anterolateral thigh with no motor dysfunction.
⚠ Spinal stenosis (choice D) causes pain in the legs but is not associated with the neurologic signs seen in this patient, nor with knee problems.
⚠ Iliofemoral atherosclerosis (choice E), a relatively common complication of diabetes mellitus, may produce intermittent claudication involving one or both calf muscles but would not produce the motor weakness noted in this patient.
🔖 Key point:
Patients with femoral neuropathy complain of difficulty with stairs, knee buckling, weakness of the quadriceps muscle, and medial leg and calf numbness.
👍9❤4👏1
⏳ Case-based MCQ | #Case_443
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A 4-year-old girl has a history of nosebleeds and easy bruising. There is a similar history among female and male family members. Laboratory investigations show prolonged aPTT and normal INR.
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A 4-year-old girl has a history of nosebleeds and easy bruising. There is a similar history among female and male family members. Laboratory investigations show prolonged aPTT and normal INR.
❤1
Which one of the following is the most likely cause of this patient's symptoms?
Anonymous Poll
27%
A. Hemophilia A
8%
B. Christmas disease
14%
C. Factor XIII deficiency
48%
D. Von Willebrand's disease
4%
E. Wiskott-Aldrich syndrome
👍9❤3🔥2😁2
⏳ Case-based MCQ | #Case_443 | #answer
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✅ D
Von Willebrand's disease (choice D) is a hereditary deficiency of von Willebrand's factor (VWF), which causes platelet dysfunction. Bleeding tendency is usually mild. Screening tests show a prolonged bleeding time, normal platelet count, and, possibly, a slightly prolonged PTT. Diagnosis is based on low levels of VWF antigen and abnormal ristocetin cofactor activity. Treatment involves control of bleeding with replacement therapy (cryoprecipitate or pasteurized intermediate-purity factor VIII concentrate) or desmopressin.
⚠ Hemophilia A (choice A) and hemophilia B (Christmas disease) (choice B) are X-linked congenital bleeding disorders affecting male infants, usually diagnosed through family history and prolonged PTT. Undiagnosed hemophilia may cause severe bleeding with circumcision. It can also result in significant ecchymosis with minimal trauma or joint and muscle bleeding, usually by the end of infancy or in early childhood. These children have a significantly prolonged PTT and normal PT. Diagnosis is made through measurement of Factor VIII activity for Hemophilia A and Factor IX activity for Hemophilia B.
⚠ Activated partial thromboplastin time (aPTT) and international normalized ratio (INR) assessments are normal in factor XIII deficiency (choice C).
Wiskott-Aldrich syndrome (choice E) is an X-linked recessive disorder, which is characterized by immunodeficiency, severely dysfunctional platelets, and thrombocytopenia with microthrombocytes. INR and PTT are normal.
🔖 Key point:
Von Willebrand's disease is a hereditary deficiency of von Willebrand's factor (VWF), which causes platelet dysfunction. Bleeding tendency is usually mild. Screening tests show a prolonged bleeding time, normal platelet count, and, possibly, a slightly prolonged PTT
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✅ D
Von Willebrand's disease (choice D) is a hereditary deficiency of von Willebrand's factor (VWF), which causes platelet dysfunction. Bleeding tendency is usually mild. Screening tests show a prolonged bleeding time, normal platelet count, and, possibly, a slightly prolonged PTT. Diagnosis is based on low levels of VWF antigen and abnormal ristocetin cofactor activity. Treatment involves control of bleeding with replacement therapy (cryoprecipitate or pasteurized intermediate-purity factor VIII concentrate) or desmopressin.
⚠ Hemophilia A (choice A) and hemophilia B (Christmas disease) (choice B) are X-linked congenital bleeding disorders affecting male infants, usually diagnosed through family history and prolonged PTT. Undiagnosed hemophilia may cause severe bleeding with circumcision. It can also result in significant ecchymosis with minimal trauma or joint and muscle bleeding, usually by the end of infancy or in early childhood. These children have a significantly prolonged PTT and normal PT. Diagnosis is made through measurement of Factor VIII activity for Hemophilia A and Factor IX activity for Hemophilia B.
⚠ Activated partial thromboplastin time (aPTT) and international normalized ratio (INR) assessments are normal in factor XIII deficiency (choice C).
Wiskott-Aldrich syndrome (choice E) is an X-linked recessive disorder, which is characterized by immunodeficiency, severely dysfunctional platelets, and thrombocytopenia with microthrombocytes. INR and PTT are normal.
🔖 Key point:
Von Willebrand's disease is a hereditary deficiency of von Willebrand's factor (VWF), which causes platelet dysfunction. Bleeding tendency is usually mild. Screening tests show a prolonged bleeding time, normal platelet count, and, possibly, a slightly prolonged PTT
👍7❤6
Forwarded from Medical Mnemonics
🧩 Medical Mnemonics
♂️ When you have a male patient with infertility, you should think of SPERM COUNT!
💻 Join us on the official Instagram page: Online Medical School
#urology
〰〰〰〰〰〰〰〰〰〰〰
©Medical Mnemonics
♂️ When you have a male patient with infertility, you should think of SPERM COUNT!
💻 Join us on the official Instagram page: Online Medical School
#urology
〰〰〰〰〰〰〰〰〰〰〰
©Medical Mnemonics
👍4
⏳ Case-based MCQ | #Case_444
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A woman presents with hair loss. See the picture above 👆
She denies any family history of premature balding. She does state that she has been under severe stress and she has been taking medications for obsessive compulsive disorder.
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A woman presents with hair loss. See the picture above 👆
She denies any family history of premature balding. She does state that she has been under severe stress and she has been taking medications for obsessive compulsive disorder.
👍3
Which of the following is the most likely explanation of this patient's presentation?
Anonymous Poll
10%
A. Telogen effluvium
34%
B. Trichotillomania
38%
C. Alopecia areata
9%
D. Tinea capitus
9%
E. Traction alopecia
👍20❤2👎1🔥1
⏳ Case-based MCQ | #Case_444 | #answer
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✅ B
Trichotillomania (choice B) is a psychiatric condition in which an individual has an uncontrollable desire to pull out their own body hair. It is generally considered to be an impulse control disorder but is sometimes classified as either a subtype or variant of obsessive-compulsive disorder (OCD).
⚠ Telogen effluvium (choice A) is hair loss associated with malnutrition, stress, hypothyroidism, surgery, and drugs. This patient's history of OCD suggests that the hair loss is most likely to be a result of compulsive behavior as a way of dealing with stress.
⚠ Alopecia areata (choice C) is a condition characterized by hair loss from the scalp. It is most commonly associated with autoimmune disorders.
⚠ Tinea capitis (choice D) is a superficial fungal infection of the scalp
⚠ Traction alopecia (choice E) is gradual hair loss caused primarily by pulling force applied to the hair such as from ponytail, pigtails, or braids.
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✅ B
Trichotillomania (choice B) is a psychiatric condition in which an individual has an uncontrollable desire to pull out their own body hair. It is generally considered to be an impulse control disorder but is sometimes classified as either a subtype or variant of obsessive-compulsive disorder (OCD).
⚠ Telogen effluvium (choice A) is hair loss associated with malnutrition, stress, hypothyroidism, surgery, and drugs. This patient's history of OCD suggests that the hair loss is most likely to be a result of compulsive behavior as a way of dealing with stress.
⚠ Alopecia areata (choice C) is a condition characterized by hair loss from the scalp. It is most commonly associated with autoimmune disorders.
⚠ Tinea capitis (choice D) is a superficial fungal infection of the scalp
⚠ Traction alopecia (choice E) is gradual hair loss caused primarily by pulling force applied to the hair such as from ponytail, pigtails, or braids.
👍9
⏳ Case-based MCQ | #Case_445
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A 67-year-old male smoker presents to the clinic with crampy epigastric pain worse after eating and weight loss for the past three months. Past medical history is significant for hypercholesterolemia and coronary artery disease. Physical examination was unremarkable. H. pylori testing, abdominal ultrasound, and colonoscopy were all normal. An upper endoscopy showed mild gastritis.
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A 67-year-old male smoker presents to the clinic with crampy epigastric pain worse after eating and weight loss for the past three months. Past medical history is significant for hypercholesterolemia and coronary artery disease. Physical examination was unremarkable. H. pylori testing, abdominal ultrasound, and colonoscopy were all normal. An upper endoscopy showed mild gastritis.
👍5
Which of the following is the patient's most likely diagnosis?
Anonymous Poll
11%
A. Celiac disease
45%
B. Chronic mesenteric ischemia
10%
C. Colorectal cancer
13%
D. Inflammatory bowel disease
35%
E. Peptic ulcer disease
👍23👎8🔥5🥰5
⏳ Case-based MCQ | #Case_445 | #answer
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✅ B
This patient has multiple atherosclerotic risk factors and known coronary artery disease. The key diagnostic clue, in this case, is the worsening of his dull, crampy epigastric pain after eating. His investigations all came back negative, except for mild gastritis, which does not explain his pain
His symptoms and known atherosclerotic disease make chronic mesenteric ischemia (choice B) the most likely diagnosis. This disorder is otherwise known as ‘intestinal angina' because the abdominal pain occurs with increased oxygen demand in the bowel after eating, just like patients with angina pectoris experience chest pain with increased myocardial oxygen demand. The pain may become so intense that patients avoid eating and subsequently lose weight. Chronic mesenteric ischemia usually progresses slowly due to the large amount of collateral vessels supplying the bowel, and patients often do not become symptomatic until there are multiple high-grade stenoses in the visceral vessels.
Non-invasive tools used in the diagnosis of the disease include CT angiogram, MRI/MR angiogram, and duplex ultrasound. Angiography remains the gold diagnostic tool, and subsequent interventional angioplasty and/or stenting can be done in the same setting.
⚠ This patient's symptoms are related to ingestion of all foods and not just gluten. Celiac disease (choice A) is also more common in women, and it often presents with diarrhea.
⚠ It is recommended that patients with no family history of colorectal cancer (choice C) be screened with a colonoscopy every 10 years after the age of 50. Although this patient's colonoscopy is negative, it is still possible he could have a colorectal neoplasm. However, chronic mesenteric ischemia is more likely given the patient's symptoms and cardiovascular history.
⚠ Inflammatory bowel disease (choice D) usually presents with crampy abdominal pain, bloody stools, and weight loss. Colonoscopy will show inflammation, abnormal vascularity and/or pseudopolyps. The patient's symptoms and normal colonoscopy findings support a diagnosis of chronic mesenteric ischemia.
⚠ Although the patient has dyspepsia, his endoscopy did not show any gastric or duodenal ulcers found in peptic ulcer disease (choice E).
🔖 Key point:
Chronic mesenteric ischemia typically presents with crampy epigastric pain that worsens with meals and should be considered in patients with atherosclerotic risk factors and/or atherosclerosis. CT angiogram, MR angiogram, and duplex ultrasound are all non-invasive diagnostic tools, which can localize the stenosis or occlusion and identify the best route for subsequent angiography
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✅ B
This patient has multiple atherosclerotic risk factors and known coronary artery disease. The key diagnostic clue, in this case, is the worsening of his dull, crampy epigastric pain after eating. His investigations all came back negative, except for mild gastritis, which does not explain his pain
His symptoms and known atherosclerotic disease make chronic mesenteric ischemia (choice B) the most likely diagnosis. This disorder is otherwise known as ‘intestinal angina' because the abdominal pain occurs with increased oxygen demand in the bowel after eating, just like patients with angina pectoris experience chest pain with increased myocardial oxygen demand. The pain may become so intense that patients avoid eating and subsequently lose weight. Chronic mesenteric ischemia usually progresses slowly due to the large amount of collateral vessels supplying the bowel, and patients often do not become symptomatic until there are multiple high-grade stenoses in the visceral vessels.
Non-invasive tools used in the diagnosis of the disease include CT angiogram, MRI/MR angiogram, and duplex ultrasound. Angiography remains the gold diagnostic tool, and subsequent interventional angioplasty and/or stenting can be done in the same setting.
⚠ This patient's symptoms are related to ingestion of all foods and not just gluten. Celiac disease (choice A) is also more common in women, and it often presents with diarrhea.
⚠ It is recommended that patients with no family history of colorectal cancer (choice C) be screened with a colonoscopy every 10 years after the age of 50. Although this patient's colonoscopy is negative, it is still possible he could have a colorectal neoplasm. However, chronic mesenteric ischemia is more likely given the patient's symptoms and cardiovascular history.
⚠ Inflammatory bowel disease (choice D) usually presents with crampy abdominal pain, bloody stools, and weight loss. Colonoscopy will show inflammation, abnormal vascularity and/or pseudopolyps. The patient's symptoms and normal colonoscopy findings support a diagnosis of chronic mesenteric ischemia.
⚠ Although the patient has dyspepsia, his endoscopy did not show any gastric or duodenal ulcers found in peptic ulcer disease (choice E).
🔖 Key point:
Chronic mesenteric ischemia typically presents with crampy epigastric pain that worsens with meals and should be considered in patients with atherosclerotic risk factors and/or atherosclerosis. CT angiogram, MR angiogram, and duplex ultrasound are all non-invasive diagnostic tools, which can localize the stenosis or occlusion and identify the best route for subsequent angiography
👍12❤1
⏳ Case-based MCQ | #Case_446
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A 16-year-old girl brought to your office by her mother because she has not begun menstruating. On further questioning, the patient also complains of decreased sense of smell. There is no significant family history.
Physical examination reveals tall, thin female. There is an absence of breast development and scant pubic and axillary hair. Her vital signs are normal. Pelvic examination reveals no abnormalities including normal uterus. The rest of physical examination is unremarkable.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 16-year-old girl brought to your office by her mother because she has not begun menstruating. On further questioning, the patient also complains of decreased sense of smell. There is no significant family history.
Physical examination reveals tall, thin female. There is an absence of breast development and scant pubic and axillary hair. Her vital signs are normal. Pelvic examination reveals no abnormalities including normal uterus. The rest of physical examination is unremarkable.
👍1
What is the most appropriate management of this patient's condition?
Anonymous Poll
10%
A. Reassurance
5%
B. Oral contraceptive pills
28%
C. Estrogen replacement therapy
50%
D. Pulsatile GnRH therapy
7%
E. Surgical correction
👍10👏5
⏳ Case-based MCQ | #Case_445 | #answer
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✅ D
Kallmann syndrome (KS) is isolated gonadotropin-releasing hormone (GnRH) deficiency (IGD), also referred to as idiopathic hypogonadotropic hypogonadism (IHH), with anosmia. It is a congenital genetic disorder where the primary symptom is a failure to start puberty or a failure to fully complete puberty. It occurs in both males and females.
Deficient hypothalamic GnRH secretion underlies the markedly abnormal gonadotropin secretion patterns in most patients with KS or idiopathic hypogonadotropic hypogonadism. The result is hypogonadism, infertility, and absent, incomplete, or partial pubertal maturation.
Some of the genes involved in the pathogenesis of KS and idiopathic hypogonadotropic hypogonadism have been identified. However, the genes involved remain unidentified in over 50% of patients.
The patient most likely has Kallmann syndrome. Patients with this condition have abnormal gonadotropin secretion with subsequent low levels of estrogen production, causing failure to develop secondary sexual characteristics. Growth hormone production is not affected in KS and height is normal. Axillary and pubic terminal hair may be scantly present in these patients because of circulating adrenal androgens.
Pulsatile administration of GnRH by subcutaneous (choice D) or preferably intravenous infusion restores pituitary-gonadal axis function and fertility in the majority of people with KS and idiopathic hypogonadotropic hypogonadism.
⚠ Estrogen (choice C), and combined oral contraceptive pills (choice B) will not restore reproductive function in this patient.
⚠ Surgical correction (choice E) and reassurance (choice A) are not appropriate options in this situation.
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✅ D
Kallmann syndrome (KS) is isolated gonadotropin-releasing hormone (GnRH) deficiency (IGD), also referred to as idiopathic hypogonadotropic hypogonadism (IHH), with anosmia. It is a congenital genetic disorder where the primary symptom is a failure to start puberty or a failure to fully complete puberty. It occurs in both males and females.
Deficient hypothalamic GnRH secretion underlies the markedly abnormal gonadotropin secretion patterns in most patients with KS or idiopathic hypogonadotropic hypogonadism. The result is hypogonadism, infertility, and absent, incomplete, or partial pubertal maturation.
Some of the genes involved in the pathogenesis of KS and idiopathic hypogonadotropic hypogonadism have been identified. However, the genes involved remain unidentified in over 50% of patients.
The patient most likely has Kallmann syndrome. Patients with this condition have abnormal gonadotropin secretion with subsequent low levels of estrogen production, causing failure to develop secondary sexual characteristics. Growth hormone production is not affected in KS and height is normal. Axillary and pubic terminal hair may be scantly present in these patients because of circulating adrenal androgens.
Pulsatile administration of GnRH by subcutaneous (choice D) or preferably intravenous infusion restores pituitary-gonadal axis function and fertility in the majority of people with KS and idiopathic hypogonadotropic hypogonadism.
⚠ Estrogen (choice C), and combined oral contraceptive pills (choice B) will not restore reproductive function in this patient.
⚠ Surgical correction (choice E) and reassurance (choice A) are not appropriate options in this situation.
👍14❤1
⏳ Case-based MCQ | #Case_446
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 66-year-old male presents to your office with a 2-day history of a sensation of pressure and hearing loss in his left ear.
A physical examination and neurologic examination are both unremarkable. Placing a vibrating tuning fork in the midline of the forehead reveals sound lateralizing to the right ear. An audiogram reveals a 30-decibel hearing loss at three consecutive frequencies in the left ear, with normal hearing on the right.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 66-year-old male presents to your office with a 2-day history of a sensation of pressure and hearing loss in his left ear.
A physical examination and neurologic examination are both unremarkable. Placing a vibrating tuning fork in the midline of the forehead reveals sound lateralizing to the right ear. An audiogram reveals a 30-decibel hearing loss at three consecutive frequencies in the left ear, with normal hearing on the right.
🔥4
Which one of the following would be most appropriate at this point?
Anonymous Poll
13%
A. Acyclovir
19%
B. CBC, metabolic profile, and thyroid studies
32%
C. Computed tomography
7%
D. Nifedipine
29%
E. Oral corticosteroids
👍5❤1👏1
⏳ Case-based MCQ | #Case_446 | #answer
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✅ E
When a patient presents with sudden hearing loss, it is essential to determine whether it is sensorineural or conductive. This patient's Weber test discloses lateralization to the right, meaning there is sensorineural hearing loss on the left. However, audiometry is vital in establishing the diagnosis. A 30-decibel hearing loss at three consecutive frequencies, with no other cause indicated from the physical examination confirms the diagnosis of sensorineural hearing loss. Sudden sensorineural hearing loss is almost always unilateral. Most cases are idiopathic.
Evaluation for retrocochlear pathology, the most frequently identifiable cause of sudden sensorineural hearing loss, may include auditory brainstem response, MRI, or follow-up audiometry. Treatment with glucocorticoids (choice E) should be initiated within two weeks of symptom onset in all patients with sudden sensorineural hearing loss. Hyperbaric oxygen therapy can be used as adjuvant therapy if available.
⚠ Routinely prescribing antiviral agents (choice A), thrombolytics, vasodilators (choice D), vasoactive substances, or antioxidants is not recommended.
⚠ Routine laboratory tests (choice B) are not recommended unless there is clinical suspicion for a particular etiology of the hearing loss.
⚠ The guidelines recommend against CT (choice C) of the head as part of the initial evaluation.
🔖 Key point:
Sudden sensorineural hearing loss is almost always unilateral, and most cases are idiopathic. It is diagnosed by audiometry. Treatment with glucocorticoids should be initiated within two weeks of symptom onset.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ E
When a patient presents with sudden hearing loss, it is essential to determine whether it is sensorineural or conductive. This patient's Weber test discloses lateralization to the right, meaning there is sensorineural hearing loss on the left. However, audiometry is vital in establishing the diagnosis. A 30-decibel hearing loss at three consecutive frequencies, with no other cause indicated from the physical examination confirms the diagnosis of sensorineural hearing loss. Sudden sensorineural hearing loss is almost always unilateral. Most cases are idiopathic.
Evaluation for retrocochlear pathology, the most frequently identifiable cause of sudden sensorineural hearing loss, may include auditory brainstem response, MRI, or follow-up audiometry. Treatment with glucocorticoids (choice E) should be initiated within two weeks of symptom onset in all patients with sudden sensorineural hearing loss. Hyperbaric oxygen therapy can be used as adjuvant therapy if available.
⚠ Routinely prescribing antiviral agents (choice A), thrombolytics, vasodilators (choice D), vasoactive substances, or antioxidants is not recommended.
⚠ Routine laboratory tests (choice B) are not recommended unless there is clinical suspicion for a particular etiology of the hearing loss.
⚠ The guidelines recommend against CT (choice C) of the head as part of the initial evaluation.
🔖 Key point:
Sudden sensorineural hearing loss is almost always unilateral, and most cases are idiopathic. It is diagnosed by audiometry. Treatment with glucocorticoids should be initiated within two weeks of symptom onset.
👍14❤1