Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_35
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A 20-year-old male college student presents to your department with complaints of fever and headache for 2 days. While in the office he mentions that the light is very disturbing to his eyes.Vital signs are: temperature 39.2°C, BP 115/65 mmHg, heart rate 85 bpm, and respirations 16/min. Petechial rash is noted on the patient’s legs and arms. Nuchal rigidity is also observed. Which of the following CSF findings are most likely to be consistent with this patient’s condition?
a) WBC 5/mm³ with 60% neutrophils; glucose 55mg/dL; protein 75 mg/dL
b) WBC 2500/mm³ with 85% neutrophils; glucose 35 mg/dL; protein 70 mg/dL; Gram negative diplococcus
c) WBC 500/mm³ with 80% lymphocytes; glucose 55mg/dL; protein 70 mg/dl; Herpes simplex virus DNA
d) WBC 3000/mm³ with 90% neutrophils; glucose 30 mg/dL; protein 75 mg/dL; Gram positive cocci
e) WBC 1000/mm³ with 85% lymphocytes; glucose 55 mg/dL; protein 65 mg/dL; Cryptococcal antigen
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A 20-year-old male college student presents to your department with complaints of fever and headache for 2 days. While in the office he mentions that the light is very disturbing to his eyes.Vital signs are: temperature 39.2°C, BP 115/65 mmHg, heart rate 85 bpm, and respirations 16/min. Petechial rash is noted on the patient’s legs and arms. Nuchal rigidity is also observed. Which of the following CSF findings are most likely to be consistent with this patient’s condition?
a) WBC 5/mm³ with 60% neutrophils; glucose 55mg/dL; protein 75 mg/dL
b) WBC 2500/mm³ with 85% neutrophils; glucose 35 mg/dL; protein 70 mg/dL; Gram negative diplococcus
c) WBC 500/mm³ with 80% lymphocytes; glucose 55mg/dL; protein 70 mg/dl; Herpes simplex virus DNA
d) WBC 3000/mm³ with 90% neutrophils; glucose 30 mg/dL; protein 75 mg/dL; Gram positive cocci
e) WBC 1000/mm³ with 85% lymphocytes; glucose 55 mg/dL; protein 65 mg/dL; Cryptococcal antigen
❤1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_35 | #answer
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✅ B
🔎 Explanation
This patient’s symptoms of fever, headache, and photophobia combined with the findings on physical examination like nuchal rigidity and petechial rash are suggestive of meningococcal meningitis. In meningococcal meningitis caused by Neisseria meningitidis, above 60% of adult patients have petechial rash, which is a distinctive finding from meningitis caused by other infectious agents.Laboratory examination of the CSF is the best way to confirm the diagnosis of meningitis. In a case of bacterial meningitis it is established by:
🔹Increased opening pressure ( > 180 mm water)
🔹Pleocytosis of polymorphonuclear leukocytes (white blood cell counts between 10 and 10,000 cells/mm³, predominantly neutrophils above 60%)
🔹 Decreased glucose concentration ( < 45 mg/dL)
🔹Increased protein concentration ( > 45 mg/dL)
Neisseria meningitidis, which is the most likely infectious agents in this case, is a gram-negative diplococcus; this makes WBC 2500/mm³ with 85% neutrophils; glucose 35 mg/dL; protein 70 mg/dL; Gram negative diplococcus (choice B) the CSF findings most consistent with this patient’s condition.
⚠ WBC 5/mm³ with 60% neutrophils; glucose 55mg/dL; protein 75 mg/dL (choice A) shows normal cell count, normal glucose, and elevated protein, which is known as cyto-albuminological dissociation, a finding most likely linked with Guillain-Barré syndrome.
⚠ WBC 500/mm³ with 80% lymphocytes; glucose 55mg/dL; protein 70 mg/Dl; Herpes simplex virus DNA (choice C) shows what would be found in herpes simplex virus encephalo-meningitis. This patient’s condition is most likely caused by Neisseria meningitidis.
⚠ WBC 3000/mm³ with 90% neutrophils; glucose 30 mg/dL; protein 75 mg/dL; Gram positive cocci (choice D) would be consistent with Streptococcus pneumonia meningitis. It is the most common cause of bacterial meningitis and the risks are increased in children aged between 1 year and 5 years of age and adults older than 55-65 years. College-age adults who live in dormitories are at increased risk of Neisseria meningitidis infection and this patient’s petechial rash in addition to other aspects of his clinical presentation is pathognomonic for meningococcal meningitis.
⚠ WBC 1000/mm³ with 85% lymphocytes; glucose 55 mg/dL; protein 65 mg/dL; Cryptococcal antigen (choice E) would be most consistent with Cryptococcus meningitis, which is more likely to occur in immunocompromised patients such as those affected with AIDS.
✅Key point:
Symptoms of fever, headache, photophobia and physical examination of nuchal rigidity and petechial rash are suggestive of meningococcal meningitis. CSF studies show elevated WBC with neutrophil predominance, elevated protein, decreased glucose, and the presence of gram-negative diplococcus
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✅ B
🔎 Explanation
This patient’s symptoms of fever, headache, and photophobia combined with the findings on physical examination like nuchal rigidity and petechial rash are suggestive of meningococcal meningitis. In meningococcal meningitis caused by Neisseria meningitidis, above 60% of adult patients have petechial rash, which is a distinctive finding from meningitis caused by other infectious agents.Laboratory examination of the CSF is the best way to confirm the diagnosis of meningitis. In a case of bacterial meningitis it is established by:
🔹Increased opening pressure ( > 180 mm water)
🔹Pleocytosis of polymorphonuclear leukocytes (white blood cell counts between 10 and 10,000 cells/mm³, predominantly neutrophils above 60%)
🔹 Decreased glucose concentration ( < 45 mg/dL)
🔹Increased protein concentration ( > 45 mg/dL)
Neisseria meningitidis, which is the most likely infectious agents in this case, is a gram-negative diplococcus; this makes WBC 2500/mm³ with 85% neutrophils; glucose 35 mg/dL; protein 70 mg/dL; Gram negative diplococcus (choice B) the CSF findings most consistent with this patient’s condition.
⚠ WBC 5/mm³ with 60% neutrophils; glucose 55mg/dL; protein 75 mg/dL (choice A) shows normal cell count, normal glucose, and elevated protein, which is known as cyto-albuminological dissociation, a finding most likely linked with Guillain-Barré syndrome.
⚠ WBC 500/mm³ with 80% lymphocytes; glucose 55mg/dL; protein 70 mg/Dl; Herpes simplex virus DNA (choice C) shows what would be found in herpes simplex virus encephalo-meningitis. This patient’s condition is most likely caused by Neisseria meningitidis.
⚠ WBC 3000/mm³ with 90% neutrophils; glucose 30 mg/dL; protein 75 mg/dL; Gram positive cocci (choice D) would be consistent with Streptococcus pneumonia meningitis. It is the most common cause of bacterial meningitis and the risks are increased in children aged between 1 year and 5 years of age and adults older than 55-65 years. College-age adults who live in dormitories are at increased risk of Neisseria meningitidis infection and this patient’s petechial rash in addition to other aspects of his clinical presentation is pathognomonic for meningococcal meningitis.
⚠ WBC 1000/mm³ with 85% lymphocytes; glucose 55 mg/dL; protein 65 mg/dL; Cryptococcal antigen (choice E) would be most consistent with Cryptococcus meningitis, which is more likely to occur in immunocompromised patients such as those affected with AIDS.
✅Key point:
Symptoms of fever, headache, photophobia and physical examination of nuchal rigidity and petechial rash are suggestive of meningococcal meningitis. CSF studies show elevated WBC with neutrophil predominance, elevated protein, decreased glucose, and the presence of gram-negative diplococcus
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_36
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A 28-year-old male who is known by your department for heroin abuse presents with complaints of severe abdominal pain that radiates to the groin. He has elevated blood pressure, tachycardia, tachypnea, and microscopic hematuria. He appears in acute distress, has no visible trauma, and refuses physical examination because of the extreme pain. Which of the following options is the best next step in the management of this patient?
a) Tell the patient that without physical examination you won’t be able to treat him
b) Tell the patient that he is going to be taken to the radiology room for abdominal CT scan
c) Tell the patient that he is going to have an abdominal ultrasound to diagnose his condition
d) Offer the patient high dose analgesics despite the fact that he is a narcotic abuser
e) Give oral codeine as it has less potential for abuse until you determine the diagnosis
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A 28-year-old male who is known by your department for heroin abuse presents with complaints of severe abdominal pain that radiates to the groin. He has elevated blood pressure, tachycardia, tachypnea, and microscopic hematuria. He appears in acute distress, has no visible trauma, and refuses physical examination because of the extreme pain. Which of the following options is the best next step in the management of this patient?
a) Tell the patient that without physical examination you won’t be able to treat him
b) Tell the patient that he is going to be taken to the radiology room for abdominal CT scan
c) Tell the patient that he is going to have an abdominal ultrasound to diagnose his condition
d) Offer the patient high dose analgesics despite the fact that he is a narcotic abuser
e) Give oral codeine as it has less potential for abuse until you determine the diagnosis
👍2
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_36 | #answer
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✅ D
🔎 Explanation
This patient is known to abuse narcotics and is complaining of severe abdominal pain that radiates to the groin, has elevated blood pressure, tachycardia, tachypnea, and microscopic hematuria. The combination of these symptoms, vital signs, and dipstick findings is unlikely to be a product of malingering. Therefore, at this point, the presumptive diagnosis of nephrolithiasis should be considered and the patient should receive analgesia just as any other patient who is not a narcotic abuser would. The most appropriate next step in management is to offer high dose analgesics (choice D).
⚠ Tell the patient that without physical examination you won’t be able to treat him (choice A) is incorrect. The severity of this patient’s pain is most likely real and based on other findings, it would be inappropriate to refuse giving pain relief to this patient.
⚠ Tell the patient that he is going to be taken to the radiology room for abdominal CT scan (choice B) is incorrect. This patient is unlikely to tolerate being taken for abdominal CT scan until his pain is controlled. It is unethical to prolong the patient’s excruciating pain when it is almost obvious that he is suffering from renal colic.
⚠ Tell the patient that he is going to have an abdominal ultrasound to diagnose his condition (choice C) is incorrect. The most appropriate next step is to alleviate the patient’s pain before doing any imaging study.
⚠ Give oral codeine as it has less potential for abuse until you determine the diagnosis (choice E) is incorrect. While codeine is a low potency opioid with less potential for abuse, it is used for mild and moderate pain and is not the best option for this patient’s excruciating pain. According to the WHO pain ladder for guidance on correct use of analgesics, they should be prescribed according to pain intensity as evaluated by a scale of intensity of pain. This patient should be given analgesics based on his own perception of the pain and not the healthcare staff’s perception of the pain.
✅Key point:
A patient (whether a drug-addict or not) in severe pain, such as renal colic, should receive pain treatment with high dose high potency opioid
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✅ D
🔎 Explanation
This patient is known to abuse narcotics and is complaining of severe abdominal pain that radiates to the groin, has elevated blood pressure, tachycardia, tachypnea, and microscopic hematuria. The combination of these symptoms, vital signs, and dipstick findings is unlikely to be a product of malingering. Therefore, at this point, the presumptive diagnosis of nephrolithiasis should be considered and the patient should receive analgesia just as any other patient who is not a narcotic abuser would. The most appropriate next step in management is to offer high dose analgesics (choice D).
⚠ Tell the patient that without physical examination you won’t be able to treat him (choice A) is incorrect. The severity of this patient’s pain is most likely real and based on other findings, it would be inappropriate to refuse giving pain relief to this patient.
⚠ Tell the patient that he is going to be taken to the radiology room for abdominal CT scan (choice B) is incorrect. This patient is unlikely to tolerate being taken for abdominal CT scan until his pain is controlled. It is unethical to prolong the patient’s excruciating pain when it is almost obvious that he is suffering from renal colic.
⚠ Tell the patient that he is going to have an abdominal ultrasound to diagnose his condition (choice C) is incorrect. The most appropriate next step is to alleviate the patient’s pain before doing any imaging study.
⚠ Give oral codeine as it has less potential for abuse until you determine the diagnosis (choice E) is incorrect. While codeine is a low potency opioid with less potential for abuse, it is used for mild and moderate pain and is not the best option for this patient’s excruciating pain. According to the WHO pain ladder for guidance on correct use of analgesics, they should be prescribed according to pain intensity as evaluated by a scale of intensity of pain. This patient should be given analgesics based on his own perception of the pain and not the healthcare staff’s perception of the pain.
✅Key point:
A patient (whether a drug-addict or not) in severe pain, such as renal colic, should receive pain treatment with high dose high potency opioid
👍1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_37
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A 49-year-old male is brought to the emergency department by his son after three episodes of vomiting bright red blood. He says that he has vomited “quite large amounts” though he is not sure he can specify the quantity. He denies dark stool, blood in stool, or diarrhea. He has not vomited since he arrived at the emergency department. He had never had a similar episode in the past. He was diagnosed of liver cirrhosis 2 years ago secondary to alcoholic liver disease.The patient is alert to person, place, and time. His vital signs are temperature 37.4°C, blood pressure 85/60 mmHg, pulse 120 bpm, and respirations 20/min. His abdomen is dull to percussion. A nasogastric tube is inserted, and bright red blood is found when stomach contents are aspirated. Which of the following are the most appropriate next steps in management of this patient?
a) Intravenous normal saline and terlipressin
b) Octreotide and selective decompressive shunts
c) Norepinephrine and endoscopic sclerotherapy
d) Propranolol and omeprazole
e) Normal saline and devascularization of lower esophagus
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A 49-year-old male is brought to the emergency department by his son after three episodes of vomiting bright red blood. He says that he has vomited “quite large amounts” though he is not sure he can specify the quantity. He denies dark stool, blood in stool, or diarrhea. He has not vomited since he arrived at the emergency department. He had never had a similar episode in the past. He was diagnosed of liver cirrhosis 2 years ago secondary to alcoholic liver disease.The patient is alert to person, place, and time. His vital signs are temperature 37.4°C, blood pressure 85/60 mmHg, pulse 120 bpm, and respirations 20/min. His abdomen is dull to percussion. A nasogastric tube is inserted, and bright red blood is found when stomach contents are aspirated. Which of the following are the most appropriate next steps in management of this patient?
a) Intravenous normal saline and terlipressin
b) Octreotide and selective decompressive shunts
c) Norepinephrine and endoscopic sclerotherapy
d) Propranolol and omeprazole
e) Normal saline and devascularization of lower esophagus
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_37 | #answer
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✅ A
🔎 Explanation
This patient has an upper gastrointestinal bleeding as suggested by the history and nasogastric tube aspiration. Given his underlying condition of liver cirrhosis, the most likely cause of his presentation is esophageal varices, a consequence of portal hypertension. Patients with esophageal varices have a strong tendency to develop bleeding. Because this patient is not currently vomiting, is alert to person, place and time, airways and breathing are not as big of a concern as his hemodynamic instability. The initial management, therefore, should be intravenous normal saline and vasopressin analogues such as terlipressin (choice A).
The initial goal is to avoid prolonged hypotension and maintain systolic blood pressure around 100 mmHg, this is also particularly important in preventing renal failure and infection. Vasopressin (terlipressin) has been used in these scenarios for many years. It blunts the increase in portal hypertension induced by volume expansion. It is believed that this effect is achieved by its direct vasoconstrictor activity on splanchnic arterioles and precapillary sphincters, with secondary reduction in portal venous blood flow and variceal pressure. Its side effects include increased peripheral vascular resistance, reduced cardiac output, and decreased coronary blood flow. Studies have shown that these side effects are best prevented by the use of vasopressin in combination with glyceryl trinitrate.
⚠ Octreotide and selective decompressive shunts (choice B) is incorrect. Octreotide is considered the first step in management of hemodynamically stable patients. While a surgical shunt provides better control of rebleeding when compared to the combination therapy of beta-blocker and endoscopic variceal ligation, it would not be the best next step in the management of this patient.
⚠ Norepinephrine and endoscopic sclerotherapy (choice C) is incorrect. Endoscopic sclerotherapy is a secondary prophylaxis performed at weekly intervals to prevent bleeding. This patient needs to be stabilized first.
⚠ Propranolol and omeprazole (choice D) is incorrect. Propranolon and nadolol significantly reduce the risks of bleeding and are used as prophylaxis against esophageal varices bleeding, but they have no role in a patient with acute bleeding. Omeprazole is beneficial in patients treated with endoscopic variceal ligation who develop ulcers as complications; it has no role in the management of acute variceal bleeding.
⚠ Normal saline and devascularization of lower esophagus (choice E) is incorrect. While normal saline would be a good initial step in management, devascularization of lower esophagus is rarely performed and is reserved for patients with portal and splenic vein thrombosis who are not suitable candidates for shunt procedures and who continue to have variceal bleeding despite endoscopic and pharmacologic treatment.
✅Key point:
Portal hypertension is associated with esophageal variceal bleeding. Patients who present with significant bleeding and hemodynamic instability should first be managed with intravenous normal saline and vasopressin analogues.
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✅ A
🔎 Explanation
This patient has an upper gastrointestinal bleeding as suggested by the history and nasogastric tube aspiration. Given his underlying condition of liver cirrhosis, the most likely cause of his presentation is esophageal varices, a consequence of portal hypertension. Patients with esophageal varices have a strong tendency to develop bleeding. Because this patient is not currently vomiting, is alert to person, place and time, airways and breathing are not as big of a concern as his hemodynamic instability. The initial management, therefore, should be intravenous normal saline and vasopressin analogues such as terlipressin (choice A).
The initial goal is to avoid prolonged hypotension and maintain systolic blood pressure around 100 mmHg, this is also particularly important in preventing renal failure and infection. Vasopressin (terlipressin) has been used in these scenarios for many years. It blunts the increase in portal hypertension induced by volume expansion. It is believed that this effect is achieved by its direct vasoconstrictor activity on splanchnic arterioles and precapillary sphincters, with secondary reduction in portal venous blood flow and variceal pressure. Its side effects include increased peripheral vascular resistance, reduced cardiac output, and decreased coronary blood flow. Studies have shown that these side effects are best prevented by the use of vasopressin in combination with glyceryl trinitrate.
⚠ Octreotide and selective decompressive shunts (choice B) is incorrect. Octreotide is considered the first step in management of hemodynamically stable patients. While a surgical shunt provides better control of rebleeding when compared to the combination therapy of beta-blocker and endoscopic variceal ligation, it would not be the best next step in the management of this patient.
⚠ Norepinephrine and endoscopic sclerotherapy (choice C) is incorrect. Endoscopic sclerotherapy is a secondary prophylaxis performed at weekly intervals to prevent bleeding. This patient needs to be stabilized first.
⚠ Propranolol and omeprazole (choice D) is incorrect. Propranolon and nadolol significantly reduce the risks of bleeding and are used as prophylaxis against esophageal varices bleeding, but they have no role in a patient with acute bleeding. Omeprazole is beneficial in patients treated with endoscopic variceal ligation who develop ulcers as complications; it has no role in the management of acute variceal bleeding.
⚠ Normal saline and devascularization of lower esophagus (choice E) is incorrect. While normal saline would be a good initial step in management, devascularization of lower esophagus is rarely performed and is reserved for patients with portal and splenic vein thrombosis who are not suitable candidates for shunt procedures and who continue to have variceal bleeding despite endoscopic and pharmacologic treatment.
✅Key point:
Portal hypertension is associated with esophageal variceal bleeding. Patients who present with significant bleeding and hemodynamic instability should first be managed with intravenous normal saline and vasopressin analogues.
👍2
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_38
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A 52-year-old man presents to the clinic with history of cough of 2 weeks duration. Cough is non-productive and non-spasmodic. He has received a course of amoxicillin for five days with no relief. There is no history of fever or weight loss. He is non-diabetic and smokes 2 packs a day for past 30 years.There is no abnormality detected on physical examination. His complete blood count is within normal limits and his erythrocyte sedimentation rate (ESR) is 45mm in first hour by Westergren method. Chest CT scan shows a contrast enhancing solitary nodule measuring 2 cm in the inferior lobe of left lung. A chest radiograph done 2 years prior was reported to be normal.
What is the most appropriate next step in management of this patient?
a) Repeat chest CT scan in 3 months
b) Repeat chest CT scan in 6 months
c) Biopsy of the lesion
d) Mantoux test (Tuberculin test)
e) Chest Magnetic Resonance Imaging scan
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A 52-year-old man presents to the clinic with history of cough of 2 weeks duration. Cough is non-productive and non-spasmodic. He has received a course of amoxicillin for five days with no relief. There is no history of fever or weight loss. He is non-diabetic and smokes 2 packs a day for past 30 years.There is no abnormality detected on physical examination. His complete blood count is within normal limits and his erythrocyte sedimentation rate (ESR) is 45mm in first hour by Westergren method. Chest CT scan shows a contrast enhancing solitary nodule measuring 2 cm in the inferior lobe of left lung. A chest radiograph done 2 years prior was reported to be normal.
What is the most appropriate next step in management of this patient?
a) Repeat chest CT scan in 3 months
b) Repeat chest CT scan in 6 months
c) Biopsy of the lesion
d) Mantoux test (Tuberculin test)
e) Chest Magnetic Resonance Imaging scan
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_38 | #answer
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✅ C
🔎 Explanation
Evaluation guidelines for solitary pulmonary nodule are based on nodule size and patient’s risk factors for cancer. Nodule diameter of 8mm or more, ‘ground glass’ opacity, irregular borders and doubling of size in one month to one year, are pointers to malignancy. History of smoking, old age, and extra-pulmonary malignancy are considered as risk factor for cancer.History of smoking and nodule of more than 8mm in the case described in the stem, indicate high probability of malignancy. Hence, biopsy of the lesion (choice C) is the most appropriate measure for accurate diagnosis.Most solitary pulmonary nodules are benign lesions, such as infectious granulomas and hamartomas. Malignant lesions include lung cancer, carcinoid tumor or metastasis. Survival rates of lung cancer are very low but early diagnosis can improve prognosis.
⚠Solitary nodule smaller than 8mm on a CT scan, in a person with high risk for malignancy, can be followed by repeat
CT scan at 3-6 months, (choice A and B) and again at 12 and 24 months if the lesion remains stable. This is not relevant to the case described as the lesion size is 20mm. Solitary nodule smaller than 8mm on a CT scan in a person with low risk of malignancy, can be followed by repeat CT scan at 6-12 months. If there is no change in size at 12 months, no further
follow up is indicated.
⚠ Positive Mantoux test (choice D) is a pointer to the diagnosis of tuberculosis but it does not rule out the possibility of neoplastic lung lesion.
⚠ Chest MRI (choice E) is indicated when it is not possible to do CT chest for reasons such as contrast allergy or renal insufficiency.
✅Key point:
Any patient with evidence of large pulmonary nodule or nodule with notable growth during follow-up should undergo biopsy for diagnosis.
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✅ C
🔎 Explanation
Evaluation guidelines for solitary pulmonary nodule are based on nodule size and patient’s risk factors for cancer. Nodule diameter of 8mm or more, ‘ground glass’ opacity, irregular borders and doubling of size in one month to one year, are pointers to malignancy. History of smoking, old age, and extra-pulmonary malignancy are considered as risk factor for cancer.History of smoking and nodule of more than 8mm in the case described in the stem, indicate high probability of malignancy. Hence, biopsy of the lesion (choice C) is the most appropriate measure for accurate diagnosis.Most solitary pulmonary nodules are benign lesions, such as infectious granulomas and hamartomas. Malignant lesions include lung cancer, carcinoid tumor or metastasis. Survival rates of lung cancer are very low but early diagnosis can improve prognosis.
⚠Solitary nodule smaller than 8mm on a CT scan, in a person with high risk for malignancy, can be followed by repeat
CT scan at 3-6 months, (choice A and B) and again at 12 and 24 months if the lesion remains stable. This is not relevant to the case described as the lesion size is 20mm. Solitary nodule smaller than 8mm on a CT scan in a person with low risk of malignancy, can be followed by repeat CT scan at 6-12 months. If there is no change in size at 12 months, no further
follow up is indicated.
⚠ Positive Mantoux test (choice D) is a pointer to the diagnosis of tuberculosis but it does not rule out the possibility of neoplastic lung lesion.
⚠ Chest MRI (choice E) is indicated when it is not possible to do CT chest for reasons such as contrast allergy or renal insufficiency.
✅Key point:
Any patient with evidence of large pulmonary nodule or nodule with notable growth during follow-up should undergo biopsy for diagnosis.
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_39
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A 5-year-old is brought to your department because of fever and headaches. He has had these symptoms for the last 48 hours and initially parents gave him Tylenol but he seems to be getting worse. The child’s immunization scheduled was not properly followed. His vital signs are: temperature 39.9°C, blood pressure 105/65 mmHg, pulse 100 bpm, and respirations 19/min. On physical examination he has no petechial rashes, his skin is warm, and nuchal rigidity is noted. CSF studies reveal elevated neutrophil count, elevated protein, and decreased glucose. Which of the following is the most common complication to be evaluated on his 6-week-treatment follow-up appointment?
a) Subdural effusions
b) Rheumatic heart disease
c) Hearing loss
d) Cortical blindness
e) Postinfection glomerulonephritis
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A 5-year-old is brought to your department because of fever and headaches. He has had these symptoms for the last 48 hours and initially parents gave him Tylenol but he seems to be getting worse. The child’s immunization scheduled was not properly followed. His vital signs are: temperature 39.9°C, blood pressure 105/65 mmHg, pulse 100 bpm, and respirations 19/min. On physical examination he has no petechial rashes, his skin is warm, and nuchal rigidity is noted. CSF studies reveal elevated neutrophil count, elevated protein, and decreased glucose. Which of the following is the most common complication to be evaluated on his 6-week-treatment follow-up appointment?
a) Subdural effusions
b) Rheumatic heart disease
c) Hearing loss
d) Cortical blindness
e) Postinfection glomerulonephritis
👍4
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_39 | #answer
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✅ C
🔎 Explanation
This child’s symptoms of fever, headache, and the findings on physical examination of nuchal rigidity are suggestive of meningitis. The CSF studies with elevated neutrophil, increased protein, and decreased glucose point to bacterial meningitis. Children who are not properly immunized are particularly at risk. Bacterial meningitis can have serious sequelae even after appropriate treatment. Sensorineural hearing loss (choice C) is noted in 20% to 30% of Hemophilus influenza meningitis survivors. Audiologic assessments are recommended in these patients in 4 to 6 weeks after antibiotic treatment clears the infection. There are other possible complications such as hydrocephalus, cortical blindness, epilepsy, behavioral changes, motor coordination, and intellectual disability; however, the most common complication that should be assessed 6 weeks after treatment is hearing loss.
⚠ Subdural effusions (choice A) are asymptomatic complications that generally resolve without neurological sequelae.
⚠ Rheumatic heart disease (choice B) occurs as a complication of group A Streptococcus pharyngitis. It is unlikely to be the cause of meningitis in children of this age. The most common causes are Pneumococcus pneumonia, Meningococcal meningitis, and Hemophilus influenza.
⚠ Cortical blindness (choice D) is a rare complication of meningitis. It is far less common than hearing loss.
⚠ Post-infection glomerulonephritis (choice E) is not known to be a complication of the major bacteria associated with meningitis in children of this age. It can occur in children with group A streptococcus.
✅Key point:
Bacterial meningitis is characterized by elevated neutrophil count, elevated protein, and decreased glucose in the CSF. Neurologic complications are common and the most common neurologic sequelae is sensorineural hearing loss and children should have audiologic assessment 4 to 6 weeks after treatment.
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✅ C
🔎 Explanation
This child’s symptoms of fever, headache, and the findings on physical examination of nuchal rigidity are suggestive of meningitis. The CSF studies with elevated neutrophil, increased protein, and decreased glucose point to bacterial meningitis. Children who are not properly immunized are particularly at risk. Bacterial meningitis can have serious sequelae even after appropriate treatment. Sensorineural hearing loss (choice C) is noted in 20% to 30% of Hemophilus influenza meningitis survivors. Audiologic assessments are recommended in these patients in 4 to 6 weeks after antibiotic treatment clears the infection. There are other possible complications such as hydrocephalus, cortical blindness, epilepsy, behavioral changes, motor coordination, and intellectual disability; however, the most common complication that should be assessed 6 weeks after treatment is hearing loss.
⚠ Subdural effusions (choice A) are asymptomatic complications that generally resolve without neurological sequelae.
⚠ Rheumatic heart disease (choice B) occurs as a complication of group A Streptococcus pharyngitis. It is unlikely to be the cause of meningitis in children of this age. The most common causes are Pneumococcus pneumonia, Meningococcal meningitis, and Hemophilus influenza.
⚠ Cortical blindness (choice D) is a rare complication of meningitis. It is far less common than hearing loss.
⚠ Post-infection glomerulonephritis (choice E) is not known to be a complication of the major bacteria associated with meningitis in children of this age. It can occur in children with group A streptococcus.
✅Key point:
Bacterial meningitis is characterized by elevated neutrophil count, elevated protein, and decreased glucose in the CSF. Neurologic complications are common and the most common neurologic sequelae is sensorineural hearing loss and children should have audiologic assessment 4 to 6 weeks after treatment.
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_40
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 20-year-old female presents to your department with difficulty speaking, excessive salivation, and clumsiness with the hands. She takes no medications except oral contraceptive pills. Family history is significant for a paternal uncle who had a similar condition and died at the age of 48.Physical examination reveals mild spasticity at the knees. Slit lamp examination shows a hyperpigmented ring around the iris. Liver function tests shows ALT: 108 U/L and AST: 97 U/L.
After the patient's diagnosis is made and treatment is started, which of the following test would be the best to monitor therapy?
a) Genetic testing
b) Serum ceruloplasmin
c) Abdominal CT scan
d) Urinary copper excretion
e) Cerebrospinal fluid studies
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 20-year-old female presents to your department with difficulty speaking, excessive salivation, and clumsiness with the hands. She takes no medications except oral contraceptive pills. Family history is significant for a paternal uncle who had a similar condition and died at the age of 48.Physical examination reveals mild spasticity at the knees. Slit lamp examination shows a hyperpigmented ring around the iris. Liver function tests shows ALT: 108 U/L and AST: 97 U/L.
After the patient's diagnosis is made and treatment is started, which of the following test would be the best to monitor therapy?
a) Genetic testing
b) Serum ceruloplasmin
c) Abdominal CT scan
d) Urinary copper excretion
e) Cerebrospinal fluid studies
👍1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_40 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
🔎 Explanation
The neurological symptoms described in this patient of difficulty speaking and clumsiness with the hands combined with the findings of spasticity at the knees, the Kayser-Fleischer ring noted on slit lamp examination, and the abnormal liver function tests all point to a diagnosis of Wilson disease. It is an autosomal recessive inheritance disease of the copper metabolism characterized by excessive deposition of copper in the liver, brain, and other tissues.Out of the choices given, urinary copper excretion (choice D) would be the best way to confirm it. In untreated patients, the 24-hour urinary excretion of copper reflects the amount of non-ceruloplasmin-bound copper in the circulation. Normally urinary copper excretion should not exceed 40 microgram/day but in patients with Wilson disease urinary copper excretion is above 100 microgram/day. Chelating agents such as D -penicillamine are therefore prescribed to promote 24-hour excretion of approximately 2 mg of copper in the urine, to induce a negative copper balance. Regular measurement of the 24-hour urinary excretion of copper provides an important index of copper removal from the body. If the excretion level in a compliant patient decreases to less than 0.5 mg daily, the dose can be lowered.
⚠ Genetic testing (choice A) is impractical in Wilson disease due multiplicity of mutations involved; about 200 mutations of the ATP7B gene have been identified and currently there are no commercially available genetic testing. It is not the best follow up test.
⚠ Serum ceruloplasmin (choice B) is considered useful in patients with classic symptoms and the Kayser-Fleischer ring -It is the major carrier of copper in the blood but is also present as the protein without copper the copper. It is an important test to order as initial test and in a patient with neurological symptoms it can point to the diagnosis; however, it is also an acute phase reactant that can increase in infections, hepatic inflammations, pregnancy, and estrogen use. It is also decreased in malnutrition, nephrotic syndrome, malabsorption, and protein-losing enteropathy. Serum ceruloplasmin levels would be unreliable in this patient, who is on oral contraceptive pills and is also not the best follow up test to monitor therapy.
⚠ Abdominal CT scan (choice C) is uninformative with findings neither specific nor sensitive for Wilson disease and would not be helpful as follow up test in a patient receiving therapy.
⚠ Cerebrospinal fluid studies (choice E) would not be useful in monitoring chelation therapy for Wilson disease in this patient.
✅Key point:
Wilson disease is an autosomal recessive inheritance disease of the copper metabolism characterized by excessive deposition of copper in the liver, brain, and other tissues. Wilson disease is treated with D-penicillamine, a copper chelating agent and the best test to monitor therapy is urinary copper excretion.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ D
🔎 Explanation
The neurological symptoms described in this patient of difficulty speaking and clumsiness with the hands combined with the findings of spasticity at the knees, the Kayser-Fleischer ring noted on slit lamp examination, and the abnormal liver function tests all point to a diagnosis of Wilson disease. It is an autosomal recessive inheritance disease of the copper metabolism characterized by excessive deposition of copper in the liver, brain, and other tissues.Out of the choices given, urinary copper excretion (choice D) would be the best way to confirm it. In untreated patients, the 24-hour urinary excretion of copper reflects the amount of non-ceruloplasmin-bound copper in the circulation. Normally urinary copper excretion should not exceed 40 microgram/day but in patients with Wilson disease urinary copper excretion is above 100 microgram/day. Chelating agents such as D -penicillamine are therefore prescribed to promote 24-hour excretion of approximately 2 mg of copper in the urine, to induce a negative copper balance. Regular measurement of the 24-hour urinary excretion of copper provides an important index of copper removal from the body. If the excretion level in a compliant patient decreases to less than 0.5 mg daily, the dose can be lowered.
⚠ Genetic testing (choice A) is impractical in Wilson disease due multiplicity of mutations involved; about 200 mutations of the ATP7B gene have been identified and currently there are no commercially available genetic testing. It is not the best follow up test.
⚠ Serum ceruloplasmin (choice B) is considered useful in patients with classic symptoms and the Kayser-Fleischer ring -It is the major carrier of copper in the blood but is also present as the protein without copper the copper. It is an important test to order as initial test and in a patient with neurological symptoms it can point to the diagnosis; however, it is also an acute phase reactant that can increase in infections, hepatic inflammations, pregnancy, and estrogen use. It is also decreased in malnutrition, nephrotic syndrome, malabsorption, and protein-losing enteropathy. Serum ceruloplasmin levels would be unreliable in this patient, who is on oral contraceptive pills and is also not the best follow up test to monitor therapy.
⚠ Abdominal CT scan (choice C) is uninformative with findings neither specific nor sensitive for Wilson disease and would not be helpful as follow up test in a patient receiving therapy.
⚠ Cerebrospinal fluid studies (choice E) would not be useful in monitoring chelation therapy for Wilson disease in this patient.
✅Key point:
Wilson disease is an autosomal recessive inheritance disease of the copper metabolism characterized by excessive deposition of copper in the liver, brain, and other tissues. Wilson disease is treated with D-penicillamine, a copper chelating agent and the best test to monitor therapy is urinary copper excretion.
👍5
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_41
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At a routine physical examination, the Pap smear of a 27-year-old woman shows evidence of marked inflammation suggestive of moderate dysplasia (HGSIL). Her last Pap smear 2 years ago was normal. Pelvic examination today is normal. She has never been pregnant and her menstrual periods are regular. She has been in a stable relationship with the same man for 3 years and she uses a diaphragm with spermicidal jelly for contraception. The best next step is to:
a) Advise the patient that her partner should use condoms for contraception and repeat the Pap smear in 3 months
b) Do colposcopic examination of the cervix after application of 5% acetic acid solution
c) Do conization of the cervix
d) Reassure the patient and repeat the Pap smear in 3 months
e) Treat the patient with metronidazole for 2 weeks and repeat the Pap smear in 3 months
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
At a routine physical examination, the Pap smear of a 27-year-old woman shows evidence of marked inflammation suggestive of moderate dysplasia (HGSIL). Her last Pap smear 2 years ago was normal. Pelvic examination today is normal. She has never been pregnant and her menstrual periods are regular. She has been in a stable relationship with the same man for 3 years and she uses a diaphragm with spermicidal jelly for contraception. The best next step is to:
a) Advise the patient that her partner should use condoms for contraception and repeat the Pap smear in 3 months
b) Do colposcopic examination of the cervix after application of 5% acetic acid solution
c) Do conization of the cervix
d) Reassure the patient and repeat the Pap smear in 3 months
e) Treat the patient with metronidazole for 2 weeks and repeat the Pap smear in 3 months
👍1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_41 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ B
🔎 Explanation
The Papanicolaou smear is a screening test for precancerous cells. Any cervical dysplasia (formerly cervical intraepithelial neoplasia IIII, now low-grade and high-grade squamous intraepithelial lesion) necessitates colposcopy for definitive diagnosis. The diaphragm has not been associated with abnormal Pap smears, so changing the method of contraception would not be of any use. Conization of the cervix is always preceded by a colposcopy, and is indicated for unsatisfactory colposcopy, inconsistency of colposcopic findings with Pap smear findings, an endocervical curettage with abnormal cells, or a lesion on colposcopy extending into the endocervix. Reassurance and repeating the Pap smear in three months can be used for ASCUS (atypical squamous cells of undetermined significance); two serial ASCUS Pap smears necessitate colposcopy.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ B
🔎 Explanation
The Papanicolaou smear is a screening test for precancerous cells. Any cervical dysplasia (formerly cervical intraepithelial neoplasia IIII, now low-grade and high-grade squamous intraepithelial lesion) necessitates colposcopy for definitive diagnosis. The diaphragm has not been associated with abnormal Pap smears, so changing the method of contraception would not be of any use. Conization of the cervix is always preceded by a colposcopy, and is indicated for unsatisfactory colposcopy, inconsistency of colposcopic findings with Pap smear findings, an endocervical curettage with abnormal cells, or a lesion on colposcopy extending into the endocervix. Reassurance and repeating the Pap smear in three months can be used for ASCUS (atypical squamous cells of undetermined significance); two serial ASCUS Pap smears necessitate colposcopy.
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_42
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A 47-year-old patient comes in with a complaint of severe muscle pain. His symptoms have been present for two weeks now. His medical records disclose another visit for acute febrile diarrhea and abdominal cramps, from 4 weeks ago following his barbeque birthday party. He recovered well following appropriate supportive therapy.Today, on physical exam he shows signs of muscle weakness and tenderness. Blood work reveals eosinophilia, elevated creatine phosphokinase and lactic dehydrogenase levels.What is considered a definitive diagnostic test for the most likely diagnosis in this patient?
a) Muscle biopsy
b) Stool culture
c) Stool gram stain
d) Stool ova and parasites
e) Abdominal CT scan
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 47-year-old patient comes in with a complaint of severe muscle pain. His symptoms have been present for two weeks now. His medical records disclose another visit for acute febrile diarrhea and abdominal cramps, from 4 weeks ago following his barbeque birthday party. He recovered well following appropriate supportive therapy.Today, on physical exam he shows signs of muscle weakness and tenderness. Blood work reveals eosinophilia, elevated creatine phosphokinase and lactic dehydrogenase levels.What is considered a definitive diagnostic test for the most likely diagnosis in this patient?
a) Muscle biopsy
b) Stool culture
c) Stool gram stain
d) Stool ova and parasites
e) Abdominal CT scan
👍2🤔1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_42 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ A
🔎 Explanation
Trichinosis is infection with Trichinella spiralis or related Trichinella species. The usual incubation period of trichinellosis is 8-15 days.
Trichinellosis may progress from an enteric (ie, intestinal) phase to a parenteral (ie, invasive) phase to a period of convalescence. The intestinal phase usually causes symptoms in the first week of illness: diarrhea, constipation, anorexia, and diffuse weakness, nausea, vomiting, and diarrhea, dyspnea may occur with exertion, abdominal discomfort and cramps may occur.The invasive phase corresponds to the migration of the larvae from the intestine to the circulatory system and eventually to the striated muscles. This phase is associated with a higher rate of symptoms than the intestinal stage. The duration varies from weeks to months. Severe myalgia develops in 89% of patients. The central nervous system is involved in 10%-24% of patients, with a mortality rate of 50%. Approximately 52% of patients present with headaches. Other symptoms include deafness, ocular disturbances, weakness, and monoparesis. Cardiac system involvement occurs during the third week of infection. Death may result from congestive heart failure and/or arrhythmias.There is no definitively positive laboratory test. CBC reveals eosinophilia. Creatine phosphokinase and lactic dehydrogenase levels are elevated in 90% of patients once the muscle invasion phase begins. CK levels are elevated. Urinalysis may reveal myoglobinuria. Plain radiographs of the extremities may show calcified densities in the muscles. Radiographs do not help evaluate acute infestation.CT scanning may be helpful in patients demonstrating neurologic symptoms.A muscle biopsy is the definitive diagnostic test. Larvae are found free or encapsulated, depending on the species of Trichinella causing the infection
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ A
🔎 Explanation
Trichinosis is infection with Trichinella spiralis or related Trichinella species. The usual incubation period of trichinellosis is 8-15 days.
Trichinellosis may progress from an enteric (ie, intestinal) phase to a parenteral (ie, invasive) phase to a period of convalescence. The intestinal phase usually causes symptoms in the first week of illness: diarrhea, constipation, anorexia, and diffuse weakness, nausea, vomiting, and diarrhea, dyspnea may occur with exertion, abdominal discomfort and cramps may occur.The invasive phase corresponds to the migration of the larvae from the intestine to the circulatory system and eventually to the striated muscles. This phase is associated with a higher rate of symptoms than the intestinal stage. The duration varies from weeks to months. Severe myalgia develops in 89% of patients. The central nervous system is involved in 10%-24% of patients, with a mortality rate of 50%. Approximately 52% of patients present with headaches. Other symptoms include deafness, ocular disturbances, weakness, and monoparesis. Cardiac system involvement occurs during the third week of infection. Death may result from congestive heart failure and/or arrhythmias.There is no definitively positive laboratory test. CBC reveals eosinophilia. Creatine phosphokinase and lactic dehydrogenase levels are elevated in 90% of patients once the muscle invasion phase begins. CK levels are elevated. Urinalysis may reveal myoglobinuria. Plain radiographs of the extremities may show calcified densities in the muscles. Radiographs do not help evaluate acute infestation.CT scanning may be helpful in patients demonstrating neurologic symptoms.A muscle biopsy is the definitive diagnostic test. Larvae are found free or encapsulated, depending on the species of Trichinella causing the infection
👍1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_43
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
An 83-year-old female presents to your office as a new patient. She recently moved to the area to be closer to her family. A history reveals that she has been in excellent health, has no complaints, and is on no medication except occasional acetaminophen for knee pain. She has never been in hospital and has not had any operations. She says that she feels well.The examination is normal, with expected age-related changes, except that her blood pressure on three different readings averages 174/70 mm Hg. These readings are confirmed on a subsequent follow-up visit.In addition to lifestyle changes, which one of the following would be most appropriate for the initial management of this
patient's hypertension?
a) An alpha-blocker
b) An ACE inhibitor
c) A beta-blocker
d) An angiotensin receptor blocker
e) A thiazide diuretic
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
An 83-year-old female presents to your office as a new patient. She recently moved to the area to be closer to her family. A history reveals that she has been in excellent health, has no complaints, and is on no medication except occasional acetaminophen for knee pain. She has never been in hospital and has not had any operations. She says that she feels well.The examination is normal, with expected age-related changes, except that her blood pressure on three different readings averages 174/70 mm Hg. These readings are confirmed on a subsequent follow-up visit.In addition to lifestyle changes, which one of the following would be most appropriate for the initial management of this
patient's hypertension?
a) An alpha-blocker
b) An ACE inhibitor
c) A beta-blocker
d) An angiotensin receptor blocker
e) A thiazide diuretic
🤔1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_43 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ A
🔎 Explanation
Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 150 mm Hg. Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg. The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy.
⚠ Alpha-blockers are not recommended.
⚠ ACE inhibitors, beta-blockers, and angiotensin receptor blockers are used when certain compelling indications are present, e.g. in a patient with diabetes or who has had a myocardial infarction.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ A
🔎 Explanation
Clinical trials support the treatment of systolic hypertension in the older person with a systolic blood pressure of at least 150 mm Hg. Systolic hypertension is defined as systolic blood pressure of at least 140 mm Hg and a diastolic blood pressure of less than 90 mm Hg. The studies most strongly support the use of thiazide diuretics and long-acting calcium channel blockers as first-line therapy.
⚠ Alpha-blockers are not recommended.
⚠ ACE inhibitors, beta-blockers, and angiotensin receptor blockers are used when certain compelling indications are present, e.g. in a patient with diabetes or who has had a myocardial infarction.
👍1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_44
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A 40-year-old man presents to the emergency department with acute onset pain and inability to open his right eye.On examination you find, on his right eye, there is complete eyelid ptosis, lateral deviation of the eye, and a dilated pupil, which does not react to light. Which investigation is most useful for confirming or excluding a diagnosis that would require an urgent intervention in this patient?
a) Magnetic Resonance Imaging (MRI) of head
b) Magnetic Resonance Angiogram (MRA) of head
c) Serum glucose level
d) Lumbar puncture
e) Computed Tomography (CT) scan of the head
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
A 40-year-old man presents to the emergency department with acute onset pain and inability to open his right eye.On examination you find, on his right eye, there is complete eyelid ptosis, lateral deviation of the eye, and a dilated pupil, which does not react to light. Which investigation is most useful for confirming or excluding a diagnosis that would require an urgent intervention in this patient?
a) Magnetic Resonance Imaging (MRI) of head
b) Magnetic Resonance Angiogram (MRA) of head
c) Serum glucose level
d) Lumbar puncture
e) Computed Tomography (CT) scan of the head
👍1
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_44 | #answer
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ B
🔎 Explanation
Third cranial nerve(oculomotor nerve) supplies all extraocular muscles (levator palpebrae, superior rectus, medial rectus, inferior rectus, and the inferior oblique) except the lateral rectus (supplied by the sixth cranial nerve) and the superior oblique (supplied by the fourth cranial nerve). Third cranial nerve also gives parasympathetic fibers to iris sphincter (constrictor) and the ciliary muscle of the eye. In a cross section of the nerve, the parasympathetic fibers are found closer to the surface of the nerve; therefore are almost always affected when a compressive lesion (e.g. berry aneurysm of the circle of Willis) is the cause for the third nerve palsy. The patient would have a dilated pupil in addition to eyelid ptosis and lateral deviation of the eye ball. In contrast, when third nerve palsy is the result of microvascular disease (e.g. diabetes, hypertension) these parasympathetic fibers may be spared and the patient may have eye lid ptosis and lateral
deviation of the eye without pupillary dilation. Patient with a third nerve palsy may not complain of double vision
(diplopia) if the eyelid ptosis is severe enough to cover the visual axis of the affected eye.Any patient presenting with eyelid ptosis, lateral deviation of the eye, and a dilated pupil should be investigated to exclude a compressive lesion. If the third cranial nerve palsy is caused by a Berry aneurysm of the circle of Willis, surgical
intervention may not only relieve patient’s symptoms but could also be lifesaving. Among the choices given, MRA (a non-invasive test) is the investigation of choice to confirm a diagnosis of Berry aneurysm (choice B).
⚠ Serum glucose level (choice C) is useful, to confirm or exclude diabetes (i.e. microvascular disease), if the patient had eyelid ptosis and lateral deviation of the eye without pupillary involvement.
⚠ MRI of head (choice A) and CT scan of head (choice E) may not be sensitive enough to detect a small Berry aneurysm unless an intravenous contrast agent is used.
⚠ A lumbar puncture (choice D) should not be performed prior to neuroimaging in a patient suspected of having an intracranial lesion as it may lead to either trans-tentorial or uncal herniation and acute neurological deterioration.
✅Key point:
In a patient presenting with eyelid ptosis, lateral deviation of eye (with or without double vision) and a dilated pupil the possibility of a Berry aneurysm of the circle of Willis impinging on the third cranial nerve must be considered. MRA of head is the investigation of choice under such circumstances.
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
✅ B
🔎 Explanation
Third cranial nerve(oculomotor nerve) supplies all extraocular muscles (levator palpebrae, superior rectus, medial rectus, inferior rectus, and the inferior oblique) except the lateral rectus (supplied by the sixth cranial nerve) and the superior oblique (supplied by the fourth cranial nerve). Third cranial nerve also gives parasympathetic fibers to iris sphincter (constrictor) and the ciliary muscle of the eye. In a cross section of the nerve, the parasympathetic fibers are found closer to the surface of the nerve; therefore are almost always affected when a compressive lesion (e.g. berry aneurysm of the circle of Willis) is the cause for the third nerve palsy. The patient would have a dilated pupil in addition to eyelid ptosis and lateral deviation of the eye ball. In contrast, when third nerve palsy is the result of microvascular disease (e.g. diabetes, hypertension) these parasympathetic fibers may be spared and the patient may have eye lid ptosis and lateral
deviation of the eye without pupillary dilation. Patient with a third nerve palsy may not complain of double vision
(diplopia) if the eyelid ptosis is severe enough to cover the visual axis of the affected eye.Any patient presenting with eyelid ptosis, lateral deviation of the eye, and a dilated pupil should be investigated to exclude a compressive lesion. If the third cranial nerve palsy is caused by a Berry aneurysm of the circle of Willis, surgical
intervention may not only relieve patient’s symptoms but could also be lifesaving. Among the choices given, MRA (a non-invasive test) is the investigation of choice to confirm a diagnosis of Berry aneurysm (choice B).
⚠ Serum glucose level (choice C) is useful, to confirm or exclude diabetes (i.e. microvascular disease), if the patient had eyelid ptosis and lateral deviation of the eye without pupillary involvement.
⚠ MRI of head (choice A) and CT scan of head (choice E) may not be sensitive enough to detect a small Berry aneurysm unless an intravenous contrast agent is used.
⚠ A lumbar puncture (choice D) should not be performed prior to neuroimaging in a patient suspected of having an intracranial lesion as it may lead to either trans-tentorial or uncal herniation and acute neurological deterioration.
✅Key point:
In a patient presenting with eyelid ptosis, lateral deviation of eye (with or without double vision) and a dilated pupil the possibility of a Berry aneurysm of the circle of Willis impinging on the third cranial nerve must be considered. MRA of head is the investigation of choice under such circumstances.
👍2
Forwarded from MohammaDJ
🇨🇦 MCCQE1,2 | #Case_45
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
An 18-year-old female is brought to your department by her worried parents, because of her missed menstrual periods for the last 4 months and a very low weight. On questioning, the patient says that she has no appetite, denies any vomiting, and says that she is more interested in exercise to stay fit because she thinks she is “still super fat.” She denies laxative use. She reports having a boyfriend but she is not sexually active.Physical examination reveals a BMI of 15 kg/m2, dry skin, and cold hands. Which of the following is most likely to be present in this patient?
a) Bradycardia
b) Elevated serum FSH
c) Elevated serum beta-hCG
d) Hypoalbuminemia
e) Shortened QT interval on ECG
〰〰〰〰〰〰〰〰〰〰〰〰〰〰
An 18-year-old female is brought to your department by her worried parents, because of her missed menstrual periods for the last 4 months and a very low weight. On questioning, the patient says that she has no appetite, denies any vomiting, and says that she is more interested in exercise to stay fit because she thinks she is “still super fat.” She denies laxative use. She reports having a boyfriend but she is not sexually active.Physical examination reveals a BMI of 15 kg/m2, dry skin, and cold hands. Which of the following is most likely to be present in this patient?
a) Bradycardia
b) Elevated serum FSH
c) Elevated serum beta-hCG
d) Hypoalbuminemia
e) Shortened QT interval on ECG
🤔1