Forwarded from MohammaDJ
#Case_18
#answer
✅ E
🔎 Explanation:
Acute partial or complete paralysis of the peripheral facial nerves is called Bell’s palsy. The etiology is still unknown, but it could be genetic, metabolic, autoimmune, vascular, entrapment, or infectious. There is reasonable evidence indicating that the condition may be due to reactivation of herpes simplex virus, resulting in a viral-induced neuritis.Associated infections may be viral (herpes simplex, herpes zoster, HIV, mumps, adenovirus, coxsackievirus, polio, Epstein-Barr virus, influenza) or bacterial (otitis media, Lyme disease, syphilis, leprosy). Women who are pregnant have a risk three times higher than that of nonpregnant women. Sarcoidosis, multiple sclerosis, and post-infectious demyelination are other possibilities. Hypertension, diabetes mellitus, and hypothyroidism may be risk factors, but are probably not etiologic agents.The key diagnostic point is determining the time of onset. If the onset occurs over a day or two and maximal paralysis is reached in 3 weeks or less, it is likely a Bell’s palsy. A prolonged, slowly progressive, or relapsing course suggests tumor,especially if there is no recovery. Examination for middle ear disease and checking for parotid masses should be part of the evaluation.Tests may be necessary if the etiologies noted above have been ruled out. There is some evidence to show that treatment with prednisone and an antiviral agent such as valacyclovir is beneficial
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ E
🔎 Explanation:
Acute partial or complete paralysis of the peripheral facial nerves is called Bell’s palsy. The etiology is still unknown, but it could be genetic, metabolic, autoimmune, vascular, entrapment, or infectious. There is reasonable evidence indicating that the condition may be due to reactivation of herpes simplex virus, resulting in a viral-induced neuritis.Associated infections may be viral (herpes simplex, herpes zoster, HIV, mumps, adenovirus, coxsackievirus, polio, Epstein-Barr virus, influenza) or bacterial (otitis media, Lyme disease, syphilis, leprosy). Women who are pregnant have a risk three times higher than that of nonpregnant women. Sarcoidosis, multiple sclerosis, and post-infectious demyelination are other possibilities. Hypertension, diabetes mellitus, and hypothyroidism may be risk factors, but are probably not etiologic agents.The key diagnostic point is determining the time of onset. If the onset occurs over a day or two and maximal paralysis is reached in 3 weeks or less, it is likely a Bell’s palsy. A prolonged, slowly progressive, or relapsing course suggests tumor,especially if there is no recovery. Examination for middle ear disease and checking for parotid masses should be part of the evaluation.Tests may be necessary if the etiologies noted above have been ruled out. There is some evidence to show that treatment with prednisone and an antiviral agent such as valacyclovir is beneficial
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
Forwarded from MohammaDJ
#Case_19
━━━━━━━━━━━━━━━━
A 31-year-old male with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis and pneumonia.
After initial treatment in the emergency department with intravenous fluids and insulin, laboratory tests reveal a serum phosphate level of 0.80 mmol/L. He is asymptomatic except for related pneumonia symptoms.Which one of the following would be appropriate management of this patient’s low serum phosphate level?
a) No therapy
b) Oral phosphate replacement, 2.5-3.5 g/day in divided doses
c) Oral phosphatereplacement, 2.5-3.5 g/day in divided doses, and oral vitaminD supplementation, 400-800 IU/day
d) Intravenous phosphate replacement, 0.08-0.16 mmol/kg over 6 hours
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
A 31-year-old male with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis and pneumonia.
After initial treatment in the emergency department with intravenous fluids and insulin, laboratory tests reveal a serum phosphate level of 0.80 mmol/L. He is asymptomatic except for related pneumonia symptoms.Which one of the following would be appropriate management of this patient’s low serum phosphate level?
a) No therapy
b) Oral phosphate replacement, 2.5-3.5 g/day in divided doses
c) Oral phosphatereplacement, 2.5-3.5 g/day in divided doses, and oral vitaminD supplementation, 400-800 IU/day
d) Intravenous phosphate replacement, 0.08-0.16 mmol/kg over 6 hours
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
👍3
Forwarded from MohammaDJ
#Case_19
#answer
✅ A
🔎 Explanation:
Symptomatic hypophosphatemia rarely occurs unless serum phosphate levels are below 0.64 mmol/L. Serious symptoms, including rhabdomyolysis, do not occur until serum phosphate concentrations fall below 0.32 mmol/L. Thus, treatment of hypophosphatemia with phosphate levels greater than or equal to 0.64 mmol/L is targeted at an underlying etiology.Hypophosphatemia in diabetic ketoacidosis cases is related to the internal redistribution of phosphate from extracellular fluid during treatment, and will resolve when normal dietary intake resumes (choice A).
⚠ Phosphate supplementation (choice B and choice C) in this setting has not been shown to be beneficial.
⚠ Intravenous administration (choice D) of phosphate can be dangerous, resulting in the precipitation of calcium and producing the adverse effects of hypocalcemia, renal failure, and possibly fatal arrhythmias
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ A
🔎 Explanation:
Symptomatic hypophosphatemia rarely occurs unless serum phosphate levels are below 0.64 mmol/L. Serious symptoms, including rhabdomyolysis, do not occur until serum phosphate concentrations fall below 0.32 mmol/L. Thus, treatment of hypophosphatemia with phosphate levels greater than or equal to 0.64 mmol/L is targeted at an underlying etiology.Hypophosphatemia in diabetic ketoacidosis cases is related to the internal redistribution of phosphate from extracellular fluid during treatment, and will resolve when normal dietary intake resumes (choice A).
⚠ Phosphate supplementation (choice B and choice C) in this setting has not been shown to be beneficial.
⚠ Intravenous administration (choice D) of phosphate can be dangerous, resulting in the precipitation of calcium and producing the adverse effects of hypocalcemia, renal failure, and possibly fatal arrhythmias
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
👍1
Forwarded from MohammaDJ
#Case_20
━━━━━━━━━━━━━━━━
A 77-year-old woman develops acute hoarseness, difficulty swallowing, dizziness, and falling to the right side. On examination, there is decreased sensation to pain on the right side of her face and left side of her body. The palate and pharynx move very little on the right side, and there is loss of coordination of the right arm and leg. Motor power in the arms and legs is normal. While attempting to walk, she falls to the right side, and complains of vertigo. An MRI scan confirms the diagnosis of the ischemic stroke. Which of the following is the most likely location of the stroke?
(A) right medial medulla
(B) right lateral medulla
(C) right internal capsule
(D) right parietal cortex
(E) right cerebellum
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
A 77-year-old woman develops acute hoarseness, difficulty swallowing, dizziness, and falling to the right side. On examination, there is decreased sensation to pain on the right side of her face and left side of her body. The palate and pharynx move very little on the right side, and there is loss of coordination of the right arm and leg. Motor power in the arms and legs is normal. While attempting to walk, she falls to the right side, and complains of vertigo. An MRI scan confirms the diagnosis of the ischemic stroke. Which of the following is the most likely location of the stroke?
(A) right medial medulla
(B) right lateral medulla
(C) right internal capsule
(D) right parietal cortex
(E) right cerebellum
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
Forwarded from MohammaDJ
#Case_20
#answer
✅ B
🔎 Explanation:
The lateral medullary syndrome (also known as Wallenberg syndrome) causes ipsilateral numbness but also contralateral involvement of pain and thermal sense by affecting the spinothalamic tract. It can be caused by occlusion of the vertebral arteries; posterior-inferior cerebellar arteries; and superior, middle, or inferior medullary arteries. Ipsilateral ataxia and falling to the side of the lesion are common. Ipsilateral paralysis of the tongue is characteristic of medial medullary syndrome, which also causes contralateral paralysis of arm and leg. Paralysis of the body is not characteristic of lateral medullary syndrome, but ipsilateral paralysis of palate and vocal cord does occur. Ipsilateral Horner syndrome, nystagmus, diplopia, vettigo, nausea, and vomiting are characteristic.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ B
🔎 Explanation:
The lateral medullary syndrome (also known as Wallenberg syndrome) causes ipsilateral numbness but also contralateral involvement of pain and thermal sense by affecting the spinothalamic tract. It can be caused by occlusion of the vertebral arteries; posterior-inferior cerebellar arteries; and superior, middle, or inferior medullary arteries. Ipsilateral ataxia and falling to the side of the lesion are common. Ipsilateral paralysis of the tongue is characteristic of medial medullary syndrome, which also causes contralateral paralysis of arm and leg. Paralysis of the body is not characteristic of lateral medullary syndrome, but ipsilateral paralysis of palate and vocal cord does occur. Ipsilateral Horner syndrome, nystagmus, diplopia, vettigo, nausea, and vomiting are characteristic.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
👍3
Forwarded from MohammaDJ
#Case_21
━━━━━━━━━━━━━━━━
A 9-mo-old child is brought to the emergency room by her parents. They state the child has been irritable for the last several days and progressively lethargic. The infant vomited several times in the car on the way to the hospital. The parents state that the infant has not been previously ill. They deny any history of trauma or accidental ingestion of medication or poisons. On physical examination, the child is lethargic and difficult to arouse. Her vital signs are normal. There is no evidence of external trauma, but retinal hemorrhages are visible on funduscopic examination. Her fontanel is bulging. Which of the following is the most likely diagnosis?
a. Bacterial meningitis
b. Oligodendroglioma
c. DiGeorge syndrome
d. Fetal alcohol syndrome
e. Shaken baby syndrome
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
A 9-mo-old child is brought to the emergency room by her parents. They state the child has been irritable for the last several days and progressively lethargic. The infant vomited several times in the car on the way to the hospital. The parents state that the infant has not been previously ill. They deny any history of trauma or accidental ingestion of medication or poisons. On physical examination, the child is lethargic and difficult to arouse. Her vital signs are normal. There is no evidence of external trauma, but retinal hemorrhages are visible on funduscopic examination. Her fontanel is bulging. Which of the following is the most likely diagnosis?
a. Bacterial meningitis
b. Oligodendroglioma
c. DiGeorge syndrome
d. Fetal alcohol syndrome
e. Shaken baby syndrome
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
🤔1
Forwarded from MohammaDJ
#Case_21
#answer
✅ E
🔎 Explanation
Retinal hemonhages with no evidence of external trauma along with a history of initability, lethargy, volniting, and a bulging fontanel suggest increased intracranial pressure from a chronic subdural hematoma or "shaken baby syndrome." Increased head circumference is also suggestive of increased intracranial pressure. DiGeorge syndrome is a congenital disorder; infants present with cardiac defects, tetany from hypocalcelnia secondary to an tmderdeveloped parathyroid gland, facial abnormalities, and thymus gland maldevelopment causing an isolated T-cell deficiency. Oligodendroglioma commonly involves the temporal lobe, and patients often present with seizures. Fetal alcohol syndrome is the number one cause of congenital malformations. Infants are born with developmental retardation and facial, heart, lung, and limb abnormalities
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ E
🔎 Explanation
Retinal hemonhages with no evidence of external trauma along with a history of initability, lethargy, volniting, and a bulging fontanel suggest increased intracranial pressure from a chronic subdural hematoma or "shaken baby syndrome." Increased head circumference is also suggestive of increased intracranial pressure. DiGeorge syndrome is a congenital disorder; infants present with cardiac defects, tetany from hypocalcelnia secondary to an tmderdeveloped parathyroid gland, facial abnormalities, and thymus gland maldevelopment causing an isolated T-cell deficiency. Oligodendroglioma commonly involves the temporal lobe, and patients often present with seizures. Fetal alcohol syndrome is the number one cause of congenital malformations. Infants are born with developmental retardation and facial, heart, lung, and limb abnormalities
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
👍1
Forwarded from MohammaDJ
#Case_22
━━━━━━━━━━━━━━━━
During a comprehensive health evaluation a 65-year-old black male reports mild, very tolerable symptoms of benign prostatic hyperplasia. He has never smoked, and his medical history is otherwise unremarkable. Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific antigen level is 1.8 ng/mL. Based on current evidence, which one of the following treatment options is most appropriate at this time?
a) Observation, with repeat evaluation in 1 year
b) Saw palmetto
c) An alpha-receptor antagonist
d) A 5-alpha-reductase inhibitor
e) Urologic referral for transurethral resection of the prostate
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
During a comprehensive health evaluation a 65-year-old black male reports mild, very tolerable symptoms of benign prostatic hyperplasia. He has never smoked, and his medical history is otherwise unremarkable. Objective findings include an enlarged prostate that is firm and nontender, with no nodules. A urinalysis is normal and his prostate-specific antigen level is 1.8 ng/mL. Based on current evidence, which one of the following treatment options is most appropriate at this time?
a) Observation, with repeat evaluation in 1 year
b) Saw palmetto
c) An alpha-receptor antagonist
d) A 5-alpha-reductase inhibitor
e) Urologic referral for transurethral resection of the prostate
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
👍1
Forwarded from MohammaDJ
#Case_22
#answer
✅ A
🔎 Explanation
Watchful waiting with annual follow-up (choice A) is appropriate for men with mild benign prostatic hyperplasia (BPH). Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the treatment of choice, if indicated. PSA levels > 2.0 ng/mL for men in their 60s correlate with a prostatic volume > 40 mL. This patient’s PSA falls below this level.
⚠ A recent high-quality, randomized, controlled trial found no benefit from saw palmetto (choice B) with regard to symptom relief or urinary flow after 1 year of therapy. The current guidelines do not recommend the use of phytotherapy for BPH.
⚠Alpha-blockers (choice C) provide symptomatic relief in men whose disease has progressed to the point that they have moderate to severe BPH symptoms.
⚠In men with a prostatic volume > 40 mL, 5 alpha-reductase inhibitors (choice D) should be considered for treatment.
⚠ Surgical consultation (choice E) is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ A
🔎 Explanation
Watchful waiting with annual follow-up (choice A) is appropriate for men with mild benign prostatic hyperplasia (BPH). Prostate-specific antigen (PSA) levels correlate with prostate volume, which may affect the treatment of choice, if indicated. PSA levels > 2.0 ng/mL for men in their 60s correlate with a prostatic volume > 40 mL. This patient’s PSA falls below this level.
⚠ A recent high-quality, randomized, controlled trial found no benefit from saw palmetto (choice B) with regard to symptom relief or urinary flow after 1 year of therapy. The current guidelines do not recommend the use of phytotherapy for BPH.
⚠Alpha-blockers (choice C) provide symptomatic relief in men whose disease has progressed to the point that they have moderate to severe BPH symptoms.
⚠In men with a prostatic volume > 40 mL, 5 alpha-reductase inhibitors (choice D) should be considered for treatment.
⚠ Surgical consultation (choice E) is appropriate when medical therapy fails or the patient develops refractory urinary retention, persistent hematuria, or bladder stones.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
❤1👍1
Forwarded from MohammaDJ
#Case_23
━━━━━━━━━━━━━━━━
A 25-year-old graduate student is visiting his parents during fall break when he develops an acute headache, fever, and rash. When you see him in your office, he has a widespread petechial rash and a stiff neck, and his blood pressure is 78/40 mm Hg. You start intravenous fluids and ceftriaxone (rocephin) and call for emergency transport. The patient dies shortly after arrival at the hospital's emergency department. The spinal fluid from a tap done just before his death reveals a large number of polynuclear leukocytes and gram-negative diplococci.Which one of the following is true regarding control measures for this disease?
a) Throat and nasopharyngeal cultures of contracts should be performed, and persons with positive cultures treated
b) Since this case likely represents a sporadic one, no contacts in your community should receive prophylaxis
c) Since the attack rate of this disease in household contacts is only slightly higher than that of the general population, these contacts should not receive prophylaxis
d) Immunoprophylaxis with a seragroup-specific, multivalent vaccine is the management of choice for those who need treatment
e) When chemoprophylaxis is indicated, ciprofloxacin (Cipro) is an acceptable agent
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
A 25-year-old graduate student is visiting his parents during fall break when he develops an acute headache, fever, and rash. When you see him in your office, he has a widespread petechial rash and a stiff neck, and his blood pressure is 78/40 mm Hg. You start intravenous fluids and ceftriaxone (rocephin) and call for emergency transport. The patient dies shortly after arrival at the hospital's emergency department. The spinal fluid from a tap done just before his death reveals a large number of polynuclear leukocytes and gram-negative diplococci.Which one of the following is true regarding control measures for this disease?
a) Throat and nasopharyngeal cultures of contracts should be performed, and persons with positive cultures treated
b) Since this case likely represents a sporadic one, no contacts in your community should receive prophylaxis
c) Since the attack rate of this disease in household contacts is only slightly higher than that of the general population, these contacts should not receive prophylaxis
d) Immunoprophylaxis with a seragroup-specific, multivalent vaccine is the management of choice for those who need treatment
e) When chemoprophylaxis is indicated, ciprofloxacin (Cipro) is an acceptable agent
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
🤔1
Forwarded from MohammaDJ
#Case_23
#answer
✅ E
🔎 Explanation
The patient died of presumed Neisseria meningitidis septicemia and meningitis. Only high-risk contacts should receive prophylaxis. Throat and nasopharyngeal cultures are of no value for deciding who should receive prophylaxis. Close contacts of patients with invasive disease, whether it is a sporadic case or part of an outbreak, are at high risk and should receive prophylaxis within 24 hours of the diagnosis of the primary case. The attack rate for household contacts is > 300 times higher than the rate in the general population. If the serogroup identified is contained in the vaccine (A, C, Y, or W-135), immunoprophylaxis may be useful as a secondary control measure. However, chemoprophylaxis is considered the primary treatment option.Ciprofloxacin is an acceptable form of chemoprophylaxis for N. meningitidis in adults. It is not recommended for persons < 18 years of age or pregnant women.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ E
🔎 Explanation
The patient died of presumed Neisseria meningitidis septicemia and meningitis. Only high-risk contacts should receive prophylaxis. Throat and nasopharyngeal cultures are of no value for deciding who should receive prophylaxis. Close contacts of patients with invasive disease, whether it is a sporadic case or part of an outbreak, are at high risk and should receive prophylaxis within 24 hours of the diagnosis of the primary case. The attack rate for household contacts is > 300 times higher than the rate in the general population. If the serogroup identified is contained in the vaccine (A, C, Y, or W-135), immunoprophylaxis may be useful as a secondary control measure. However, chemoprophylaxis is considered the primary treatment option.Ciprofloxacin is an acceptable form of chemoprophylaxis for N. meningitidis in adults. It is not recommended for persons < 18 years of age or pregnant women.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
👍1
Forwarded from MohammaDJ
#Case_24
━━━━━━━━━━━━━━━━
A 40-year-old white female complains of discomfort in her anterior neck. She also gives a history of malaise, low-grade fever, and a tender thyroid gland.Laboratory Findings:
WBCs: 12.1 x 10^9/L
Granulocytes: 30% (N 42-75)
Monocytes: 4% (N 2-9)
Lymphocytes: 66% (N 20-51)
Free thyroxine (FT4): 36 pmol/L,
Erythrocyte sedimendation rate (Westergren): 60 mm/hr (N 0-20)
Which one of the following would most likely be seen on a thyroid nuclear medicine study?
a) Slightly increased uptake
b) Normal uptake
c) Markedly decreased radioactive iodine uptake
d) A single hot node
e) Multiple cold areas
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
A 40-year-old white female complains of discomfort in her anterior neck. She also gives a history of malaise, low-grade fever, and a tender thyroid gland.Laboratory Findings:
WBCs: 12.1 x 10^9/L
Granulocytes: 30% (N 42-75)
Monocytes: 4% (N 2-9)
Lymphocytes: 66% (N 20-51)
Free thyroxine (FT4): 36 pmol/L,
Erythrocyte sedimendation rate (Westergren): 60 mm/hr (N 0-20)
Which one of the following would most likely be seen on a thyroid nuclear medicine study?
a) Slightly increased uptake
b) Normal uptake
c) Markedly decreased radioactive iodine uptake
d) A single hot node
e) Multiple cold areas
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
👍3🤔1
Forwarded from MohammaDJ
#Case_24
#answer
✅ C
🔎 Explanation
This patient has a clinical presentation typical of subacute thyroiditis. An elevated erythrocyte sedimentation rate is an almost certain feature, and slight leukocytosis may also be seen, as well as a modest degree of thyrototoxicosis and a slightly elevated serum T4 level. A small thyroid gland would be expected on a thyroid scan. Because the disease interferes with iodine metabolism, radioiodine uptake is decreased. Hot, toxic nodules or a multinodular goiter would not be expected. Generalized thyroid enlargement and increased radioactive iodine uptake would be expected with Graves’ disease
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ C
🔎 Explanation
This patient has a clinical presentation typical of subacute thyroiditis. An elevated erythrocyte sedimentation rate is an almost certain feature, and slight leukocytosis may also be seen, as well as a modest degree of thyrototoxicosis and a slightly elevated serum T4 level. A small thyroid gland would be expected on a thyroid scan. Because the disease interferes with iodine metabolism, radioiodine uptake is decreased. Hot, toxic nodules or a multinodular goiter would not be expected. Generalized thyroid enlargement and increased radioactive iodine uptake would be expected with Graves’ disease
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
Forwarded from MohammaDJ
#Case_25
━━━━━━━━━━━━━━━━
A 27 year old white male has been in rehabilitation for C6 complete quadriplegia. His health had been good prior to a diving accident 2 months ago which caused his paralysis. The patient has been catheterized since admission and his recovery has been steady. His vital signs have been normal and stable.The nurse calls and tells you that for the past hour the patient has experienced sweating, rhinorrhea, and a pounding headache. His heart rate is 55/min and his blood pressure is 220/115 mm Hg. His temperature and respirations are reported as normal. There has been no vomiting and his neurologic examination is unchanged. The most likely diagnosis is:
a) Cluster headache
b) Autonomic hyperreflexia
c) Sepsis
d) Intracranial hemorrhage
e) Progression of the spinal cord lesion
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
A 27 year old white male has been in rehabilitation for C6 complete quadriplegia. His health had been good prior to a diving accident 2 months ago which caused his paralysis. The patient has been catheterized since admission and his recovery has been steady. His vital signs have been normal and stable.The nurse calls and tells you that for the past hour the patient has experienced sweating, rhinorrhea, and a pounding headache. His heart rate is 55/min and his blood pressure is 220/115 mm Hg. His temperature and respirations are reported as normal. There has been no vomiting and his neurologic examination is unchanged. The most likely diagnosis is:
a) Cluster headache
b) Autonomic hyperreflexia
c) Sepsis
d) Intracranial hemorrhage
e) Progression of the spinal cord lesion
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
👍1
Forwarded from MohammaDJ
#Case_25
#answer
✅ B
🔎 Explanation
Autonomic hyperreflexia is characterized by the sudden onset of headache and hypertension in a patient with a lesion above the T6 level. There may be associated bradycardia, sweating, dilated pupils, blurred vision, nasal stuffiness, flushing, or piloerection. It usually occurs several months after the injury and has an incidence as high as 85% in quadriplegic patients. Frequently, it subsides within 3 years of injury, but it can recur at any time. Bowel and bladder distension are common causes. Hypertension is the major concern because of associated seizures and cerebral hemorrhage.Cluster headaches have a constant unilateral orbital localization. The pain is steady (non-throbbing) and lacrimation and rhinorrhea may be part of the syndrome. Sepsis is usually manifested by chills, fever, nausea, and vomiting. Common signs include tachycardia and hypotension rather than bradycardia and hypertension. Signs and symptoms of intracranial hemorrhage vary depending upon the site of the hemorrhage, but the unchanged neurologic status and the lack of a history of hypertension decrease the likelihood of this diagnosis. There are no neurologic findings or history which suggest progression of the patient’s lesion at C6.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ B
🔎 Explanation
Autonomic hyperreflexia is characterized by the sudden onset of headache and hypertension in a patient with a lesion above the T6 level. There may be associated bradycardia, sweating, dilated pupils, blurred vision, nasal stuffiness, flushing, or piloerection. It usually occurs several months after the injury and has an incidence as high as 85% in quadriplegic patients. Frequently, it subsides within 3 years of injury, but it can recur at any time. Bowel and bladder distension are common causes. Hypertension is the major concern because of associated seizures and cerebral hemorrhage.Cluster headaches have a constant unilateral orbital localization. The pain is steady (non-throbbing) and lacrimation and rhinorrhea may be part of the syndrome. Sepsis is usually manifested by chills, fever, nausea, and vomiting. Common signs include tachycardia and hypotension rather than bradycardia and hypertension. Signs and symptoms of intracranial hemorrhage vary depending upon the site of the hemorrhage, but the unchanged neurologic status and the lack of a history of hypertension decrease the likelihood of this diagnosis. There are no neurologic findings or history which suggest progression of the patient’s lesion at C6.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
Forwarded from MohammaDJ
#Case_26
━━━━━━━━━━━━━━━━
A 31-year-old female who is a successful professional photographer complains of hoarseness that started suddenly 3 weeks ago. She says she can remember exactly what day it was, because her divorce became final the next day. The day the problem began, she was only able to whisper from the time she woke up, and she is able to speak only in a weak whisper while relating her history. She does not appear to strain while speaking. She does not smoke, has had no symptoms of an upper respiratory infection, and has no pain, cough, or wheezing.She is on a proton pump inhibitor prescribed by an urgent care provider 2 weeks ago. This has not changed her symptoms. She takes no other medications and has no known allergies. A head and neck examination, including indirect laryngoscopy, is within normal limits.Which one of the following is the most likely diagnosis?
a) Muscle tension aphonia
b) Laryngopharyngeal reflux
c) Spasmodic dysphonia
d) Vocal abuse
e) Conversion aphonia
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
━━━━━━━━━━━━━━━━
A 31-year-old female who is a successful professional photographer complains of hoarseness that started suddenly 3 weeks ago. She says she can remember exactly what day it was, because her divorce became final the next day. The day the problem began, she was only able to whisper from the time she woke up, and she is able to speak only in a weak whisper while relating her history. She does not appear to strain while speaking. She does not smoke, has had no symptoms of an upper respiratory infection, and has no pain, cough, or wheezing.She is on a proton pump inhibitor prescribed by an urgent care provider 2 weeks ago. This has not changed her symptoms. She takes no other medications and has no known allergies. A head and neck examination, including indirect laryngoscopy, is within normal limits.Which one of the following is the most likely diagnosis?
a) Muscle tension aphonia
b) Laryngopharyngeal reflux
c) Spasmodic dysphonia
d) Vocal abuse
e) Conversion aphonia
〰〰〰〰〰〰〰〰〰〰〰
👥 MCCEE/MCCQ1,2
🤔1
Forwarded from MohammaDJ
#Case_26
#answer
✅ E
🔎 Explanation
This patient has conversion aphonia (choice E). In this condition, the patient loses his or her spoken voice, but the
whispered voice is maintained. The vocal cords appear normal, but if observed closely by an otolaryngologist, there is a loss of vocal cord adduction during phonation, but normal adduction with coughing or throat clearing. This often occurs after a traumatic event (in this case a divorce).
⚠ Muscle tension aphonia (choice A) presents with strained, effortful phonation, vocal fatigue, and normal vocal cords. It is caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including poor breath control and stress, for example.
⚠ The patient with laryngopharyngeal reflux (choice B) presents with a raspy or harsh voice. The hoarseness is usually worse early in the day and improves as the day goes by. There is usually associated heartburn, dysphagia, and/or throat clearing.
⚠ The patient with spasmodic dysphonia (choice C) (also known as laryngeal dystonia) has a halting, strangled vocal quality. It is a distinct neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal laryngeal spasm.
⚠ The hoarseness of vocal abuse (choice D) is usually worse later in the day after effortful singing or talking. The history usually reveals vocal cord abuse, such as with an untrained singer or some other situation that increases demands on the voice. Nodules or cysts may be seen on the vocal cords with this condition.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
#answer
✅ E
🔎 Explanation
This patient has conversion aphonia (choice E). In this condition, the patient loses his or her spoken voice, but the
whispered voice is maintained. The vocal cords appear normal, but if observed closely by an otolaryngologist, there is a loss of vocal cord adduction during phonation, but normal adduction with coughing or throat clearing. This often occurs after a traumatic event (in this case a divorce).
⚠ Muscle tension aphonia (choice A) presents with strained, effortful phonation, vocal fatigue, and normal vocal cords. It is caused by excessive laryngeal or extralaryngeal tension associated with a variety of factors, including poor breath control and stress, for example.
⚠ The patient with laryngopharyngeal reflux (choice B) presents with a raspy or harsh voice. The hoarseness is usually worse early in the day and improves as the day goes by. There is usually associated heartburn, dysphagia, and/or throat clearing.
⚠ The patient with spasmodic dysphonia (choice C) (also known as laryngeal dystonia) has a halting, strangled vocal quality. It is a distinct neuromuscular disorder of unknown cause. Uncontrolled contractions of the laryngeal muscles cause focal laryngeal spasm.
⚠ The hoarseness of vocal abuse (choice D) is usually worse later in the day after effortful singing or talking. The history usually reveals vocal cord abuse, such as with an untrained singer or some other situation that increases demands on the voice. Nodules or cysts may be seen on the vocal cords with this condition.
〰〰〰〰〰〰〰〰〰〰〰
🔗 MCCEE/MCCQE1,2
❤1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_27
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
As you walk into your office your nurse asks you to see an 80-year-old white female who has come on an emergency
basis. The patient has a long history of hypertension and has felt very nauseated and lightheaded since last night. She denies chest pain and dyspnea.
Physical Findings:
Blood pressure: not palpable
Temperature: 36.5°C (97.7°F)
Pulse: 40 beats/min
Respirations: 18/min
Appearance: generalized pallor
HEENT: within normal limits
Chest: bibasilar rales
Heart: 40/min; no gallop, no murmur
Abdomen: soft, no masses
Rectal: stool negative for occult blood
Extremities: no edema
The patient's EKG shows which one of the following?
a) Pericarditis
b) Sinus bradycardia
c) Acute anteroseptal myocardial infarction
d) Acute inferior wall myocardial infarction
e) Idioventricular rhythm
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
As you walk into your office your nurse asks you to see an 80-year-old white female who has come on an emergency
basis. The patient has a long history of hypertension and has felt very nauseated and lightheaded since last night. She denies chest pain and dyspnea.
Physical Findings:
Blood pressure: not palpable
Temperature: 36.5°C (97.7°F)
Pulse: 40 beats/min
Respirations: 18/min
Appearance: generalized pallor
HEENT: within normal limits
Chest: bibasilar rales
Heart: 40/min; no gallop, no murmur
Abdomen: soft, no masses
Rectal: stool negative for occult blood
Extremities: no edema
The patient's EKG shows which one of the following?
a) Pericarditis
b) Sinus bradycardia
c) Acute anteroseptal myocardial infarction
d) Acute inferior wall myocardial infarction
e) Idioventricular rhythm
👍3🤔1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_27 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
🔎 Explanation
There is marked ST-T elevation in the inferior leads consistent with an acute inferior wall myocardial infarction.
Pericarditis almost always presents with severe chest pain, and the ST segment elevation is more diffuse. With anteroseptal infarction, ST elevation is seen only on leads V1-V3.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
🔎 Explanation
There is marked ST-T elevation in the inferior leads consistent with an acute inferior wall myocardial infarction.
Pericarditis almost always presents with severe chest pain, and the ST segment elevation is more diffuse. With anteroseptal infarction, ST elevation is seen only on leads V1-V3.
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_28
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
You are called to the bedside of a 72-year-old female on mechanical ventilation for three days, who suddenly develops chest pain. Her face is contorted in pain, and she points to her chest. She has a 40-pack/year history of smoking, and long standing COPD. Vital signs show blood pressure of 85/55 mmHg, heart rate of 120 beats per minute, respiratory rate of 24 breaths per minute, and oxygen saturation of 80% with an FiO2 of 40%. Physical exam reveals absent breath sounds over the left side of the chest, and normal S1 and S2 heart sounds without any murmurs.
What is the next best step in the management of this patient?
a) Obtain a chest CT
b) Obtain a chest X-ray
c) Insert a chest tube in the left 5th intercostal space in the midaxillary line
d) Insert a large-bore needle into the left 2nd intercostal space
e) Insert a needle under the xiphoid process directed upward and to the patient's left
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
You are called to the bedside of a 72-year-old female on mechanical ventilation for three days, who suddenly develops chest pain. Her face is contorted in pain, and she points to her chest. She has a 40-pack/year history of smoking, and long standing COPD. Vital signs show blood pressure of 85/55 mmHg, heart rate of 120 beats per minute, respiratory rate of 24 breaths per minute, and oxygen saturation of 80% with an FiO2 of 40%. Physical exam reveals absent breath sounds over the left side of the chest, and normal S1 and S2 heart sounds without any murmurs.
What is the next best step in the management of this patient?
a) Obtain a chest CT
b) Obtain a chest X-ray
c) Insert a chest tube in the left 5th intercostal space in the midaxillary line
d) Insert a large-bore needle into the left 2nd intercostal space
e) Insert a needle under the xiphoid process directed upward and to the patient's left
👍2
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_28 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
🔎 Explanation
A history of mechanical ventilation, especially in addition to underlying lung pathology, and a physical exam showing absent breath sounds on one side of the chest suggests a diagnosis of tension pneumothorax. This patient is hypotensive, tachycardic, and tachypneic, so this is a medical emergency. Before any other imaging or intervention is attempted, an immediate needle thoracostomy performed by inserting a 16-18 gauge needle into the 2nd intercostal space (choice D) of the affected side is required to treat this patient. Once this has been accomplished, a rush of air out of the pleural space is expected. Following needle thoracostomy, a chest tube can be inserted, and chest C-ray can be performed.
⚠ Obtaining a chest CT (choice A) would be inappropriate at this time, as this patient is clinically unstable (hypotension, tachypnea, tachycardia), and needs immediate treatment. In the context of a pneumothorax, a chest CT can be used if there is clinical uncertainty, and the patient is stable.
⚠ Obtaining a chest X-ray (choice B) does need to be done, but the first step is needle thoracostomy. Had a chest X-ray been performed, it would have shown deviation of the trachea to the right (the side opposite of the pneumothorax), as well as increased radiolucency on the left side of the chest.
⚠ Inserting a chest tube into the 5th intercostal space in the midaxillary line (choice c) should be done after the initial needle thoracostomy, as the needle decompression can cause a simple pneumothorax which can be treated with chest tube insertion. When a chest tube is inserted, it should be inserted above the rib, as the neurovascular bundle can be struck if
insertion occurs below the rib.
⚠ Pericardiocentesis - inserting a needle under the xiphoid process, upward and leftward (choice E) is incorrect, as this patient does not have cardiac tamponade. The diagnosis of tamponade would require hypotension, decreased heart sounds, and distended neck veins, as well, lungs should be clear to auscultation, which are not seen in this patient.
✅Key point:
Sudden onset of chest pain and decreased or absent breath sounds on one side suggest tension pneumothorax. The first step in treatment is insertion of a large-gauge needle into the second intercostal space of the affected side
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
🔎 Explanation
A history of mechanical ventilation, especially in addition to underlying lung pathology, and a physical exam showing absent breath sounds on one side of the chest suggests a diagnosis of tension pneumothorax. This patient is hypotensive, tachycardic, and tachypneic, so this is a medical emergency. Before any other imaging or intervention is attempted, an immediate needle thoracostomy performed by inserting a 16-18 gauge needle into the 2nd intercostal space (choice D) of the affected side is required to treat this patient. Once this has been accomplished, a rush of air out of the pleural space is expected. Following needle thoracostomy, a chest tube can be inserted, and chest C-ray can be performed.
⚠ Obtaining a chest CT (choice A) would be inappropriate at this time, as this patient is clinically unstable (hypotension, tachypnea, tachycardia), and needs immediate treatment. In the context of a pneumothorax, a chest CT can be used if there is clinical uncertainty, and the patient is stable.
⚠ Obtaining a chest X-ray (choice B) does need to be done, but the first step is needle thoracostomy. Had a chest X-ray been performed, it would have shown deviation of the trachea to the right (the side opposite of the pneumothorax), as well as increased radiolucency on the left side of the chest.
⚠ Inserting a chest tube into the 5th intercostal space in the midaxillary line (choice c) should be done after the initial needle thoracostomy, as the needle decompression can cause a simple pneumothorax which can be treated with chest tube insertion. When a chest tube is inserted, it should be inserted above the rib, as the neurovascular bundle can be struck if
insertion occurs below the rib.
⚠ Pericardiocentesis - inserting a needle under the xiphoid process, upward and leftward (choice E) is incorrect, as this patient does not have cardiac tamponade. The diagnosis of tamponade would require hypotension, decreased heart sounds, and distended neck veins, as well, lungs should be clear to auscultation, which are not seen in this patient.
✅Key point:
Sudden onset of chest pain and decreased or absent breath sounds on one side suggest tension pneumothorax. The first step in treatment is insertion of a large-gauge needle into the second intercostal space of the affected side
👍2