⏳ Case-based MCQ | #Case_362 | #answer
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✅ B

🔎 Explanation

The patient has the provisional diagnosis of the biliary colic, most likely due to biliary stones The ultrasound scan - as the best Initial diagnostic tool- has been used to confirm the diagnosis. Furthermore, any associated inflammation would be evaluated. Inflammation of the gallbladder manifests as the thickening of the wall of the gallbladder and the presence of pericholecystic fluid. Stones might be seen in the common bile duct as well; however, the sensitivity of ultrasound for detection of ductal stones is low (30% - 50%).

As a routine procedure, when scanning for biliary problems, the sonographer will scan the liver as well. In this case the sonographer has encountered an incidental finding, irrelevant to the presenting symptoms, for which a triphasic CT scan of the liver has been performed.

Early prominent dense enhancement of the lesion during the arterial phase is characteristic of liver hemangioma (the most common benign liver tumor). Hemangiomas are seen in approximately 20% of the general population. They may be solitary or multiple. The lesions typically show intense enhancement during the arterial phase of triphasic CT scan and retain a blush of contrast during the portal venous phase

⚠ (Options A and C) Most malignant Irver tumours (primary or metastatic) are hypovascular and will not have the early enhancement during the arterial phase;rather, they become more pronounced during the portal venous phase.

⚠ (Option D) Cystic lesions In the liver may be simple,multiple (polycystic Irver disease), neoplastic or infective(hydatid cysts). Simple cysts are extremely common and usually asymptomatic. On Imaging, these cysts have a low-density homogenous appearance. With polycystic disease, the number and size of the cysts often lead to symptoms.

⚠ (Option E) Hydatid cysts have a characteristic septate appearance and heterogenous appearance if they contain daughter cysts. Liver abscesses are usually symptomatic and more likely to have a heterogenous appearance

⏳ Case-based MCQ | #Case_363
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A 67-year-old man with background history of smoking for the past 40 years and chronic obstructive pulmonary disease (COPD) presents with acute shortness of breath, pleuretic chest pain, increased mucus production and severe cough. Last week, he has had an episode of gout in his first metatarsophalangeal joint, for which he was started on indomethacin 75 mg, 8-hourly. Sever pain made him bedbound for 5 days. On examination, he has a blood pressure of 130/95 mmHg, pulse rate of 110 bpm, respiratory rate of 34 breaths per minute and temperature of 37.5°C.

⏳ Case-based MCQ | #Case_363 | #answer
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✅ B

🔎 Explanation

Pleuretic chest pain, tachycardia, and tachypnea and the history of immobility is highly suggestive of pulmonary embolism (PE). PE on the other hand, can precipitate a COPD exacerbation that justifies the increased amount of sputum production, hypoxia and hypercapnia. Under these circumstances, an ABG is always the next best investigation to check for hypoxia (the most important concern in both PE and COPD), worsened hypercapnia due to COPD exacerbation, and the blood pH. A chest X-ray (option A) should be obtained for this patient to investigate any other underlying lung pathology that might, other than the PE, has led to the condition, but immediate pulseoxymetry and ABG always come first in priority.

⚠ Ventilation/perfusion scan (option D) or CTPA (preferred) (option C) are diagnostic tools to establish the definite diagnosis of PE.They should be performed to prove the presence if PE prior to treatment with anticoagulation.

⚠ A conventional CT scan of the chest (option E) has no role in management of this patient
for now.

⚠ With the underlying COPD and baseline chest X-ray abnormalities, ventilation/perfusion scan is unlikely to be of diagnostic value. Conventional CT scan of the chest would add no relevant piece of information.

⏳ Case-based MCQ | #Case_364
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A 12-year-old school girl is brought to the emergency department of a tertiary hospital after she collapsed at school. En route to the hospital, she was started on dextrose 5% drip at a rate of 60 ml/minute. On examination after arrival at the emergency department, she has blood pressure of 180/110 mmHg, pulse rate of 50 bpm and respiratory rate of 12 breaths per minute. Doll eye reflex is present.

⏳ Case-based MCQ | #Case_364 | #answer
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✅ B

🔎 Explanation

The findings of high blood pressure and bradycardia (Cushing reflex) points towards increased intracranial pressure (ICP) as the most likely cause of such presentation. Cushing reflex (also the vasopressor response, Cushing effect, Cushing phenomenon and Cushing reaction) is a physiological nervous system response to ICP.

⭕ Cushing triad is: (1) hypertension, (2) bradycardia and (3) irregular breathing e.g. Cheyne-Stoke. This triad may indicate imminent brain herniation.

Increased ICP is more underpinned by the presence of the 'doll eye' sign (movement of the eyes in the same direction as the head) signifying involvement of brainstem, probably due to increased intracranial pressure.

The raised ICP is very likely to be compromised by dextrose drip which has already been inappropriately started for the patient. Dextrose is rapidly consumed by cells and the remaining free water shifts into the brain extravascular tissue, and results in worsening of the edema, swelling and more increased ICP. For this reason, the dextrose drip should be replaced with a normal saline as the most important immediate management.

⚠ An unconscious patient is not able to maintain airway patency. Furthermore, there is significant risk of aspiration; therefore, the patient should be intubated (option D), but not as the first priority at this stage, considering the fact that the patient is breathing spontaneously and is not hypoxemic (O2 saturation 95%).

⚠ The patient should then be taken for CT scan of the head (option A) for determination of the likely causes of her problem. Consultation with or referral to the neurosurgery specialist (option E) should be arranged.

⚠ Intravenous methylprednisolone (option C) has shown effective in spinal cord compressions and cases of increased ICP due to tumors and abscesses. If, after neuroimaging, the cause of ICP was found to be an abscess or a tumor, corticosteroids may be considered as a part of management plan.

⏳ Case-based MCQ | #Case_365
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Concerned mother of a 6-year-old girl has brought her to your attention because she has frequently noticed blood-stained yellow discharge on her panties. She is otherwise healthy. There is no complaint of itching or urinary symptoms. The girl lives with her mother and birth father. On examination, the vitals are within normal ranges. On inspection, there is mild erythema of the vulva and perianal area and offensive blood-stained yellow discharge in the introitus.

⏳ Case-based MCQ | #Case_365 | #answer
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✅ B

🔎 Explanation

Blood-stained vaginal discharge in female children should always be taken seriously and investigated promptly. One exception is vaginal bleeding in the first week of birth in female neonates that is caused by withdrawal from maternal estrogen upon birth.

Causes of vaginal bleeding in children include the following:
• Vaginal foreign body
• Severe vulvovaginitis
• Trauma (including straddle injury and sexual abuse)
• Excoriation associated with threadworms
• Onset of first menstruation
• Hematuria
• Urethral prolapse (an inflamed "doughnut" of tissue is visible at the urethral meatus

Of the above, a vaginal foreign body is the most common cause of bloody vaginal discharge. The foreign body is often toilet t papers. Foreign body in the vagina causes offensive purulent vaginal discharge that recurs frequently despite successful initial management with antibiotic unless the foreign body is removed. It can also cause vaginal bleeding. Children with suspected vaginal foreign body should be referred to pediatrics specialist for removal of the foreign body.

⚠ (Option A) Monilial (Candida) vulvovaginitis is almost never seen in prepubertal girls except as an association with nappy rash. It cannot be the cause of such presentation in a 6-year-old girl.

⚠ (Option C) Atrophic vulvovaginitis is a less common condition in prepubertal girls and if present should raise suspicion against lichen sclerosus. Even in case of atrophic vaginitis, itching and mucoid discharge would be the expected presentation. With a blood-stained yellow discharge, atrophic vaginitis is very unlikely.

⚠ (Option D) Infection with chlamydia, gonorrhea and trichomonas can cause offensive bloody vaginal discharge. These infections in children are highly suggestive of sexual abuse. For every child with vaginal discharge associated with unusual features such as persistent and significant discharge or blood in the discharge, sexual abuse should be considered as a possibility and approached appropriately. Although sexual abuse should also be considered and thought of in such situation, the most likely cause of such presentation remains a vaginal foreign body, unless investigations establish the presence of chlamydia, gonorrhea or trichomonas, in which case sexual abuse is almost always the cause.

⚠ (Option E) Infection with threadworm may vulvovaginitis, in which case, itching is the most prominent symptom. Excoriation can cause bleeding: however, absence of itching makes this diagnosis almost unlikely.

⏳ Case-based MCQ | #Case_366
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A 2-year-old boy is brought to your clinic due to a 3-day history of fever with occasional cough
and coryza. On clinical history, viral upper respiratory tract infection is suspected. On physical examination, the patient is noted to have down-slanting of palpebral fissures, eyes that are apart more than usual and low-set ears. The height of the patient is smaller than the standard.

⏳ Case-based MCQ | #Case_366 | #answer
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✅ B

🔎 Explanation

This clinical picture is suggestive of Noonan syndrome. This is an autosomal dominant disorder with mutation of chromosome 11. It has been described as the male Turner’s syndrome, but affects both sexes.

Clinical features of the syndrome include the following:

🔴 Facial/eye features
• Triangular face
• Hypertelorism (increased distance between the eyes)
• Down-slanting eyes
• Ptosis
• Strabismus - seen in 48%
• Amblyopia - seen in 33%
• Refractive errors - seen in 61%
• Low-set ears with thickened helices
• High nasal bridge
• Short webbed neck

🔴 Chest/back features
• Pectus carinatum/excavatum
• Scoliosis

🔴 Cardiac features
• Stenotic/dysplastic pulmonic valve is the characteristic cardiac anomaly
• Hypertrophic cardiomyopathy (obstructive and non-obstructive)- seen in as many as 30%
• Virtually all types of congenital heart defects have been described in patients with Noonan syndrome

🔴 Abdominal features
• Hepatosplenomegaly unrelated to cardiac disease - seen in 25% of the patients

🔴 Genitourinary features
• Renal anomalies are present in 10% of patients but are not clinically significant
• More than half of male patients have undescended testes

🔴 Skeletal features
•Joint laxity is present- seen in more than 50% of the patients
• Less common findings include talipes equinovarus (club foot) that is an excessively turned-in foot and high medial longitudinal arc, radioulnar synostosis (fusion), cervical spine fusion, and joint contractures.

🔴 Skin findings
• Lymphedema
• Prominent pads of fingers and toes - seen in 67%
• Follicular keratosis of face and extensor surfaces - seen in 14%
• Multiple lentigines (a lentigo is a small, sharply circumscribed, pigmented macule surrounded by normal appearing skin) - seen in 3%

🔴 Neurological findings
• Hypotonia
• Seizure disorders - seen in 13%
• Unexplained peripheral neuropathy - not seen frequently
• Mental retardation

Previously, patients with Noonan syndrome were thought to have a form of Turner syndrome, as clinical picture is similar to that of Turner’s.

⚠ Myopia and ectopic ocular lens is consistent with Marfan syndrome and not are features seen in Noonan syndrome.

⏳ Case-based MCQ | #Case_367
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An 18-week pregnat woman is brought to the Emergency Department with complaint of sudden-onset severe frontal headache. On examination, she has a blood pressure of 80/60 mmHg, pulse of 110 bpm,respiratory rate of 17 breaths per minute and temperature of 37.3°C. The rest of the examination is unremarkable. There is no neck stiffness, abdominal pain or tenderness, or uterine contractions.

⏳ Case-based MCQ | #Case_367 | #answer
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✅ D

🔎 Explanation

With the clinical findings of frontal headache and hypotension in a pregnant woman, pituitary apoplexy should be considered as one of the most important differential diagnoses. Pituitary apoplexy is defined as sudden hemorrhage into the pituitary gland. Hemorrhage often occurs into a pituitary adenoma.

The most dramatic presentation of apoplexy is the sudden onset of excruciating headache, diplopia due to pressure on the oculomotor nerve, and hypopituitarism.

All pituitary hormonal deficiencies can occur, but a fall in ACTH and, consequently, cortisol is most serious because it can cause life-threatening hypotension.

In a series of 35 patients with pituitary apoplexy seen at one center, 97% had headache, 71% had visual field impairment, and 66% had decreased visual acuity. Only a minority had clinical manifestations of hormonal excess or deficiency, but there was biochemical evidence of gonadotropin deficiency in 79%, ACTH deficiency in 76%, and TSH deficiency in 50%.

CT scan and MRI can be used for detection of intra-pituitary hemorrhage; however, MRI is more sensitive for evaluation of the pituitary gland. Hypopituitarism and the diplopia may improve after surgical decompression of the pituitary. Both problems may also improve spontaneously as the blood is absorbed over a course of weeks to months after the hemorrhage.

For hypotension, high-dose corticosteroids are the mainstay of therapy.

⚠ (Options A and B) With headache and hypotension, subarachnoid hemorrhage can be another differential diagnoses, but headache of SAH tends to be much more severe (the worst headache in life) and often associated with neck stiffness. On the other hand, skull cannot accommodate enough blood to justify the hypotension and the tachycardia in this patient. CT scan of the head (non-contrast) and LP (if CT was inconclusive) are used if SAH is suspected.

⚠ (Option C) Ultrasonography is of no use in assessment of this patient with a possible intracranial pathology.

⚠ (Option E) Preeclampsia is defined as persistent hypertension and proteinuria after 20 weeks’ gestation. FBE, LFT, and urinalysis should be considered for excluding preeclampsia. This woman with hypotension is less likely to have preeclampsia.

⏳ Case-based MCQ | #Case_368
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A 54-year-old woman presents to the emergency department with complaints of sudden onset vertigo, nausea, vomiting, and hearing loss in her left ear. On examination, her vital signs are within normal ranges. Hearing is decreased on the left side on whisper test. Rinne and Weber tests establish sensorineural deafness of the left ear. She has also nystagmus with the rapid eye to the left side. The rest of the examination is inconclusive.

⏳ Case-based MCQ | #Case_368 | #answer
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✅ D

🔎 Explanation

Of the options, labyrinthitis, Meniere's disease and lateral medullary syndrome can cause acute onset vertigo, tinnitus and hearing loss. Ataxia can be a presentation in patients with cerebellar or vestibular disease. Of these three, and given the inconclusive neurological examination, labyrinthitis is the most likely diagnosis. Acute labyrinthitis presents with acute vertigo often followed by nausea and vomiting, tinnitus, and hearing loss. A history of preceding viral upper respiratory tract infection is present in up to 50% of patients. Change in head position provokes vertigo. Each episode of vertigo lasts from few seconds to minutes.

⚠ Meniere's disease (option D) also presents with episodes of acute onset vertigo, tinnitus and hearing loss. However, patients with Meniere's disease often complain of ear fullness because the pathophysiology is excess endolymph in the labyrinth. Patients are usually middle-aged women with a positive family history for the condition. Finally, Meniere's disease is much less common compared to labyrinthitis. Given these, Meniere's disease in this patient is a less likely diagnosis compared to labyrinthitis.

⚠ (Option B) Vestibular neuronitis is the inflammation of the vestibular nerve often by a viral infection. Patients usually have a preceding viral upper respiratory infection or herpes zoster. Vertigo and imbalance are the prominent features of vestibular neuronitis and there is no hearing loss or tinnitus. Loss of balance is more prominent in vestibular neuronitis compared to other causes of vertigo, and patient commonly present with vertigo and falls. Symptoms in vestibular neuronitis are aggravated by change in the position of the head. Neurological examination in patients with vestibular neuronitis is otherwise normal.

⚠ (Option C) Acoustic neuromas are intracranial tumors that arise from the Schwann cell sheath of either the vestibular or cochlear nerve. As acoustic neuromas increase in size, they eventually occupy a large portion of the cerebellopontine angle. Although 5-15% of patients with acoustic neuroma present with acute onset of unilateral hearing loss, deafness has an insidious onset in this condition, making it a less likely diagnosis. Gradual hearing loss is overwhelmingly the most common presenting symptom of patients with acoustic neuroma. Imbalance and vertigo is not a prominent feature because as the tumor growth disrupts the vestibular nerve function slowly, there is enough time for compensation. Other features that may be present in patients with acoustic neuroma are headache and facial sensory impairment.

⚠ (Option E) Lateral medullary syndrome, also known as Wallenberg syndrome or posterior inferior cerebellar artery (PICA) syndrome has other clinical features in addition to vertigo, hearing loss, and tinnitus. Such features include cross-body sensory impairment (sensory impairment of the face on the affected side and that of the body on the other side), Horner's syndrome, and signs and symptoms indicative of the involvement of cranial nerves or their nucleus. Such signs and symptoms may include dysphagia (due to involvement of nucleus ambiguus that supplies the vagus and glossopharyngeal nerves), dysarthria, dysphonia, disrupted temperature and pain sensation, palatal clonus and heart rate and blood pressure dysregulation (due to involvement of the vagus nerve).