⏳ 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.
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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.
Which one of the following is the investigation more likely to establish the diagnosis?
Anonymous Poll
9%
a)Lumbar puncture
26%
b) CT scan of the head
12%
c) Ultrasonography
28%
d) MRI of the head
26%
e) Full blood exam (FBE) and liver function tests (LFT)
🔥3
⏳ 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.
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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.
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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.
Which one of the following could be the most likely diagnosis?
Anonymous Poll
15%
a) Labyrinthitis
22%
b) Vestibular neuronitis
14%
c) Acoustic neuroma
37%
d) Meniere’s disease
12%
e) Lateral medullary syndrome
👍4
⏳ 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).
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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).
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⏳ Case-based MCQ | #Case_369
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A 55-year-old woman presents to your practice after noticing a clear nipple discharge from her right breast. On physical examination, no palpable mass is found in her breasts. Both nipples appear normal, however, pressure over the right areola causes discharge of clear fluid from the nipple.
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A 55-year-old woman presents to your practice after noticing a clear nipple discharge from her right breast. On physical examination, no palpable mass is found in her breasts. Both nipples appear normal, however, pressure over the right areola causes discharge of clear fluid from the nipple.
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Which one of the following could be the most likely diagnosis?
Anonymous Poll
36%
a) Benign ductal papilloma
12%
b) Paget disease of the breast
31%
c) Ductal ectasia
13%
d) Intraductal breast carcinoma
8%
e) Breast fibroadenoma
⏳ Case-based MCQ | #Case_369 | #answer
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✅ A
🔎 Explanation
Nipple discharge is always an abnormal finding except in late pregnancy or the postpartum period. Based on characteristics, there are seven types of nipple discharge:
1. Milky: white discharge; sometimes fat globules are seen under microscopy
2. Multicolored gummous: sticky discharge
3. Purulent: pus with white cells seen under microscopy
4. Watery: colorless discharge
5. Serous: faintly yellow, thin discharge
6. Serosanguineous: thin, clear discharge with pink tint, RBCs seen under microscopy
7. Bloody (sanguinous): pure blood
Conditions associated with each type of discharge are as follows:
⚪ Milky Discharge
Galactorrhea,or nonpuerperal lactation, usually results from multiple duct discharge from both breasts. The most common cause of nonpuerperal lactation is hyperprolactinemia associated with pituitary adenomas, medications or other causes resulting in increased production of prolactin (e.g. primary hypothyroidism).In many women,galactorrhea can be idiopathic.
🟣 Multicolored and Sticky Discharge
Duct ectasia or comedomastitis is the most common cause of a multicolored, sticky discharge that is commonly bilateral and usually in perimenopausal woman.It begins as a dilation of the terminal ducts with an irritating lipid fluid collection and producing an inflammatory reaction resulting in discharge from the nipple.
Duct ectasia is most frequently associated with pain,itching, and swelling in the nipple. Palpation of the areola can often reveal a tubular mass, reflecting the dilated ducts. Often a history of nipple manipulation is elicited. If the disease progresses, a mass can develop (plasma cell mastitis) that can mimic cancer. Surgery is indicated only if a mass forms or the discharge changes to serosanguinous or bloody.
🟠 Purulent Discharge
In patients with acute puerperal mastitis, chronic lactation mastitis,central breast abscesses,or plasma cell mastitis, nipple discharge is purulent and usually unilateral. Breast cultures and smears may reveal a causative organism.
Abscess formation usually requires incision and drainage if appropriate antibiotics and warm compreses are not effective. It is important to remove a portion of an abscess wall for histologic study to exclude an underlying cancer associated with secondary necrosis and infection.
🔴 Watery, serous, serosanguinous, and bloody Discharges
Intraductal papillomas are the most common cause of these discharges, but fibrocystic disease, advanced duct ectasia, breast cancer, and vascular engorgement in near-term pregnancy can also be the causes.
In patients over 50, malignancy becomes increasingly common, especially if the discharge is unilateral and associated with a mass. Surgical exploration is mandatory in this group of patients with this type of discharge, even if cytologic and mammographic findings are negative.
✅ NOTE - surgical referral is required if the nipple discharge is spontaneous and unilateral, or the patient is older than 60 years.
⚠ (Option B) Paget disease of the breast most commonly presents with a scaly, raw, vesicular, or ulcerated lesion that begins on the nipples and then spreads to the areola. Nipple discharge, if present at all, tends to be bloody rather than clear.
⚠ (Option C) Ductal ectasia presents with multicolored and sticky discharge. Toothpaste like discharge is a classic description of discharge associated with duct ectasia.
⚠ (Option D) With unilateral clear discharge in this woman,the most likely cause is a benign Intraductal papilloma. Although advanced duct ectasia and intraductal carcinoma are among other etiologies, they are less likely to be the cause compared with intraductal papilloma.
⚠ (Option E) Fibroadenoma does not cause nipple discharge.
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✅ A
🔎 Explanation
Nipple discharge is always an abnormal finding except in late pregnancy or the postpartum period. Based on characteristics, there are seven types of nipple discharge:
1. Milky: white discharge; sometimes fat globules are seen under microscopy
2. Multicolored gummous: sticky discharge
3. Purulent: pus with white cells seen under microscopy
4. Watery: colorless discharge
5. Serous: faintly yellow, thin discharge
6. Serosanguineous: thin, clear discharge with pink tint, RBCs seen under microscopy
7. Bloody (sanguinous): pure blood
Conditions associated with each type of discharge are as follows:
⚪ Milky Discharge
Galactorrhea,or nonpuerperal lactation, usually results from multiple duct discharge from both breasts. The most common cause of nonpuerperal lactation is hyperprolactinemia associated with pituitary adenomas, medications or other causes resulting in increased production of prolactin (e.g. primary hypothyroidism).In many women,galactorrhea can be idiopathic.
🟣 Multicolored and Sticky Discharge
Duct ectasia or comedomastitis is the most common cause of a multicolored, sticky discharge that is commonly bilateral and usually in perimenopausal woman.It begins as a dilation of the terminal ducts with an irritating lipid fluid collection and producing an inflammatory reaction resulting in discharge from the nipple.
Duct ectasia is most frequently associated with pain,itching, and swelling in the nipple. Palpation of the areola can often reveal a tubular mass, reflecting the dilated ducts. Often a history of nipple manipulation is elicited. If the disease progresses, a mass can develop (plasma cell mastitis) that can mimic cancer. Surgery is indicated only if a mass forms or the discharge changes to serosanguinous or bloody.
🟠 Purulent Discharge
In patients with acute puerperal mastitis, chronic lactation mastitis,central breast abscesses,or plasma cell mastitis, nipple discharge is purulent and usually unilateral. Breast cultures and smears may reveal a causative organism.
Abscess formation usually requires incision and drainage if appropriate antibiotics and warm compreses are not effective. It is important to remove a portion of an abscess wall for histologic study to exclude an underlying cancer associated with secondary necrosis and infection.
🔴 Watery, serous, serosanguinous, and bloody Discharges
Intraductal papillomas are the most common cause of these discharges, but fibrocystic disease, advanced duct ectasia, breast cancer, and vascular engorgement in near-term pregnancy can also be the causes.
In patients over 50, malignancy becomes increasingly common, especially if the discharge is unilateral and associated with a mass. Surgical exploration is mandatory in this group of patients with this type of discharge, even if cytologic and mammographic findings are negative.
✅ NOTE - surgical referral is required if the nipple discharge is spontaneous and unilateral, or the patient is older than 60 years.
⚠ (Option B) Paget disease of the breast most commonly presents with a scaly, raw, vesicular, or ulcerated lesion that begins on the nipples and then spreads to the areola. Nipple discharge, if present at all, tends to be bloody rather than clear.
⚠ (Option C) Ductal ectasia presents with multicolored and sticky discharge. Toothpaste like discharge is a classic description of discharge associated with duct ectasia.
⚠ (Option D) With unilateral clear discharge in this woman,the most likely cause is a benign Intraductal papilloma. Although advanced duct ectasia and intraductal carcinoma are among other etiologies, they are less likely to be the cause compared with intraductal papilloma.
⚠ (Option E) Fibroadenoma does not cause nipple discharge.
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⏳ Case-based MCQ | #Case_370
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A 21-year-old girl is brought to the emergency department with headache and mild neck stiffness. She had kidney transplantation last year. Examination of cerebrospinal fluid (CSF) reveals a cell count of 150 with 70% monocytes. CSF glucose level is 1.2 mmol/L and protein 1.8 g/L.
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A 21-year-old girl is brought to the emergency department with headache and mild neck stiffness. She had kidney transplantation last year. Examination of cerebrospinal fluid (CSF) reveals a cell count of 150 with 70% monocytes. CSF glucose level is 1.2 mmol/L and protein 1.8 g/L.
👍1
Which one of the following investigation is most important to consider for this patient?
Anonymous Poll
15%
a) Immunofluorescence assay for herpes simplex virus (HSV)
16%
b) Ziehl - Neelsen stain of the CSF
17%
c) Viral culture of the CSF
25%
d)Bacterial culture of the CSF
27%
e) Cryptococcus assay of the CSF
👍2
⏳ Case-based MCQ | #Case_370 | #answer
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✅ E
🔎 Explanation
The clinical picture suggests meningeal irritation. Cerebrospinal fluid (CSF) analysis shows CSF monocytosis, decreased CSF glucose level (normal 2.5 - 3.5 mmol/L or approximately 60% of simultaneous plasma glucose level), and elevated protein level (normal 0.15 - 0.4 g/L).
Monocytosis of the CSF highly suggests fungal meningitis; therefore, Cryptococcus assay of the CSF would be the most appropriate next step to confirm the diagnosis.
Invasive fungal infections are a significant complication in solid organ transplant (SOT) recipient. Cryptococcosis is the third most common invasive fungal infection in patients with cell-mediated immune deficiency.
Between 53-72% of the cryptococcal disease in SOT recipients is disseminated or involves the central nervous system (CNS). Positive serum cryptococcal antigen has been reported in 88-91% of SOT recipient with cryptococcal meningitis.
⚠ (Option A) With Herpes meningitis,there are often concomitant genital lesions. In herpes meningitis, like other viral meningitides, the CSF glucose level tends to be normal; however, HSV is sometimes associated with decreased CSF glucose. On the other, hand the dominant
cell group is lymphocytes rather than monocytes.
⚠ (Option B) Ziehl - Neelsen stain of the CSF is indicated if TB meningitis is suspected.
Although TB meningitis can be a possibility, especially in immunocompromised patients,
monocytosis is more consistent with fungal meningitis. In TB meningitis, polymorphonuclear cells are dominant at early stages, but lymphocytosis follows.
⚠ (Option C) With decreased CSF glocuse and increased CSF protein, viral meningitis is less
likely. In viral meningitis, CSF gluocose and CSF protein are normal or near normal. CSF
protein can be increased.
⚠ (Option D) Bacterial culture of the CSF is likely to be positive in bacterial meningitis.Bacterial meningitis often presents with significantly increased protein levels and cell count with PMNs dominating the cell differential
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✅ E
🔎 Explanation
The clinical picture suggests meningeal irritation. Cerebrospinal fluid (CSF) analysis shows CSF monocytosis, decreased CSF glucose level (normal 2.5 - 3.5 mmol/L or approximately 60% of simultaneous plasma glucose level), and elevated protein level (normal 0.15 - 0.4 g/L).
Monocytosis of the CSF highly suggests fungal meningitis; therefore, Cryptococcus assay of the CSF would be the most appropriate next step to confirm the diagnosis.
Invasive fungal infections are a significant complication in solid organ transplant (SOT) recipient. Cryptococcosis is the third most common invasive fungal infection in patients with cell-mediated immune deficiency.
Between 53-72% of the cryptococcal disease in SOT recipients is disseminated or involves the central nervous system (CNS). Positive serum cryptococcal antigen has been reported in 88-91% of SOT recipient with cryptococcal meningitis.
⚠ (Option A) With Herpes meningitis,there are often concomitant genital lesions. In herpes meningitis, like other viral meningitides, the CSF glucose level tends to be normal; however, HSV is sometimes associated with decreased CSF glucose. On the other, hand the dominant
cell group is lymphocytes rather than monocytes.
⚠ (Option B) Ziehl - Neelsen stain of the CSF is indicated if TB meningitis is suspected.
Although TB meningitis can be a possibility, especially in immunocompromised patients,
monocytosis is more consistent with fungal meningitis. In TB meningitis, polymorphonuclear cells are dominant at early stages, but lymphocytosis follows.
⚠ (Option C) With decreased CSF glocuse and increased CSF protein, viral meningitis is less
likely. In viral meningitis, CSF gluocose and CSF protein are normal or near normal. CSF
protein can be increased.
⚠ (Option D) Bacterial culture of the CSF is likely to be positive in bacterial meningitis.Bacterial meningitis often presents with significantly increased protein levels and cell count with PMNs dominating the cell differential
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⏳ Case-based MCQ | #Case_371
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A 65-year-old man presents to your GP clinic with long-standing history of difficulty starting voiding and terminal dribbling and, recently, nocturia. Abdominal examination reveals a dull mass over the suprapubic area. On digital rectal exam (DRE), the prostate is enlarged but smooth with palpable median sulcus.
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A 65-year-old man presents to your GP clinic with long-standing history of difficulty starting voiding and terminal dribbling and, recently, nocturia. Abdominal examination reveals a dull mass over the suprapubic area. On digital rectal exam (DRE), the prostate is enlarged but smooth with palpable median sulcus.
Which one of the following is the most appropriate next step in management of this patient?
Anonymous Poll
18%
a) Serum creatinine level
30%
b) Transrectal ultrasonography (TURS)
13%
c)CT scan of the abdomen
33%
d) PSA
5%
e)Urine cytology
👍3
⏳ Case-based MCQ | #Case_371 | #answer
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✅ A
🔎 Explanation
This patient has characteristic features of lower urinary tract symptoms (LUTS). LUTS can
present with voiding symptoms (bladder emptying) such as weak urine stream, hesitancy (difficulty starting urination) or intermittency of follow, or with storage (bladder filling) symptoms such as urgency, daytime frequency and nocturia.
Predominance of storage symptoms requires exclusion of conditions such as primary bladder pathology/malignancy, diabetes mellitus, and medications with diuretic effects. Where nocturia is the presenting symptom, nocturnal polyuria should be excluded too.
Based on the international guidelines, it is important to determine the severity of LUTS and to identify the complicating factors such as urinary retention, macroscopic hematuria, urinary tract infections or a personal or family history of prostate cancer.
For every patient presenting with LUTS, initial investigations should be considered to exclude
sinister causes LUTS or complications associated with bladder outflow obstruction. These investigations include:
• Urinalysis - excluding hematuria, proteinuria, or pyuria - follow up with urine culture is required if there is abnormality on urinalysis
• Serum creatinine and estimated glomerular filtration rate (eGFR) - this test is required for exclusion of renal injury from primary renal dysfunction or high-pressure bladder outflow obstruction.
• Urinary tract ultrasound - assessment of prostate volume, bladder wall and residual urine
and exclusion of hydronephrosis
• Prostate specific antigen to exclude prostate cancer - most guidelines recommend the use of serum PSA only if prostate cancer diagnosis will influence management or if the test will assist in decision making
Urinary symptoms of this man and the presence of an enlarged prostate on DRE make benign prostatic hyperplasia (BPH) the most likely diagnosis. Additionally, the dull mas over the suprapubic area is very likely to be a distended bladder due to urinary outflow obstruction caused by the enlarged prostate. In this situation and of the options, a serum creatinine level [and calculation of the estimated glomerular filtration rate (eGFR)] would be the most important next step to exclude renal injury caused by the obstruction.
If an option, transabdominal ultrasound scan of the bladder was another important test to
consider first to assess the residual volume, prostate size and other possible urinary tract
anomalies.
⚠ (Option B) While transabdominal ultrasound is a very important investigation for this patient, tansrectal ultrasound is not necessary at this stage. Flowever, it might be applied in patients who are suspected of having prostate cancer for further assessment and as a guide for biopsy.
⚠ (Option C) CT scan is not routinely recommended for patients with LUTS, unless complicating features are suspected. An example could be for staging in a patient with bladder or prostate cancer as the etiologic cause of LUTS.
⚠ (Option D) As mentioned earlier, PSA is among the investigations for male patients with LUTS to exclude for prostate cancer; however, assessment of renal function takes precedence over PSA in this patient.
⚠ (Option E) Urine cytology is a test considered for patients with suspected urothelial carcinoma such as those with hematuria who have risk factors like history of smoking or exposure to certain chemicals. It is not a routine test for patients with LUTS unless there are alarming features
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✅ A
🔎 Explanation
This patient has characteristic features of lower urinary tract symptoms (LUTS). LUTS can
present with voiding symptoms (bladder emptying) such as weak urine stream, hesitancy (difficulty starting urination) or intermittency of follow, or with storage (bladder filling) symptoms such as urgency, daytime frequency and nocturia.
Predominance of storage symptoms requires exclusion of conditions such as primary bladder pathology/malignancy, diabetes mellitus, and medications with diuretic effects. Where nocturia is the presenting symptom, nocturnal polyuria should be excluded too.
Based on the international guidelines, it is important to determine the severity of LUTS and to identify the complicating factors such as urinary retention, macroscopic hematuria, urinary tract infections or a personal or family history of prostate cancer.
For every patient presenting with LUTS, initial investigations should be considered to exclude
sinister causes LUTS or complications associated with bladder outflow obstruction. These investigations include:
• Urinalysis - excluding hematuria, proteinuria, or pyuria - follow up with urine culture is required if there is abnormality on urinalysis
• Serum creatinine and estimated glomerular filtration rate (eGFR) - this test is required for exclusion of renal injury from primary renal dysfunction or high-pressure bladder outflow obstruction.
• Urinary tract ultrasound - assessment of prostate volume, bladder wall and residual urine
and exclusion of hydronephrosis
• Prostate specific antigen to exclude prostate cancer - most guidelines recommend the use of serum PSA only if prostate cancer diagnosis will influence management or if the test will assist in decision making
Urinary symptoms of this man and the presence of an enlarged prostate on DRE make benign prostatic hyperplasia (BPH) the most likely diagnosis. Additionally, the dull mas over the suprapubic area is very likely to be a distended bladder due to urinary outflow obstruction caused by the enlarged prostate. In this situation and of the options, a serum creatinine level [and calculation of the estimated glomerular filtration rate (eGFR)] would be the most important next step to exclude renal injury caused by the obstruction.
If an option, transabdominal ultrasound scan of the bladder was another important test to
consider first to assess the residual volume, prostate size and other possible urinary tract
anomalies.
⚠ (Option B) While transabdominal ultrasound is a very important investigation for this patient, tansrectal ultrasound is not necessary at this stage. Flowever, it might be applied in patients who are suspected of having prostate cancer for further assessment and as a guide for biopsy.
⚠ (Option C) CT scan is not routinely recommended for patients with LUTS, unless complicating features are suspected. An example could be for staging in a patient with bladder or prostate cancer as the etiologic cause of LUTS.
⚠ (Option D) As mentioned earlier, PSA is among the investigations for male patients with LUTS to exclude for prostate cancer; however, assessment of renal function takes precedence over PSA in this patient.
⚠ (Option E) Urine cytology is a test considered for patients with suspected urothelial carcinoma such as those with hematuria who have risk factors like history of smoking or exposure to certain chemicals. It is not a routine test for patients with LUTS unless there are alarming features
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⏳ Case-based MCQ | #Case_372
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A 70-year-old man presents with difficulty in swallowing for the past 6 months and 4-kilogram weight loss in this period. He describes that the most difficult part of swallowing for him is when he tries to start to get the food down his mouth. He had been a smoker for most of his adult life but has quit 10 years ago.
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A 70-year-old man presents with difficulty in swallowing for the past 6 months and 4-kilogram weight loss in this period. He describes that the most difficult part of swallowing for him is when he tries to start to get the food down his mouth. He had been a smoker for most of his adult life but has quit 10 years ago.
Which one of the following would be the most appropriate management option at this point?
Anonymous Poll
50%
a) Endoscopy
6%
b) Surgery
31%
c) Upper series barium study
6%
d) Helicobacter pylori testing
7%
e) Manometry
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⏳ Case-based MCQ | #Case_372 | #answer
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✅ C
🔎 Explanation
No matter what the clues point towards, every patient with dysphagia should undergo appropnate investigation. Just because of weight loss, the patients cannot be told to have esophageal cancer. Although the patients age Is a red flag for dysphagia, the fan that it occurs at initiation of swallowing makes oropharyngeal dysphagia the better bet. On the other hand, every patient with dysphagia, regardless of the etiology, may have weight loss due to decreased calorie intake; nonetheless,a thorough and judicious assessment should be considered for every patient with dysphagia.
The best initial step in management of dysphagia depends on provisional diganosis based on the history and clinical findings. when esophageal cancer is suspected, evaluation starts with upper endoscopy and biopsy. With oropharyngeal and motility-related dysphagia, barium studies would be the most appropriate initial approach. in this scenario, oropharyngeal dysphagia probably caused by a retropharyngeal pouch (Zenker's diverticulum) is the most likely diagnosing; therefore barium swallow would be the best initial assessment tool. If a retropharyngeal pouch is diagnosed on barium studies, endoscopy should be avodied. as there is significant risk of the scope perforating the pouch.
⚠ (Option A) Endoscopy Is the initial Investigation when cancer is suspected based on history and clinical features
⚠ (Option B) Surgery is indicated if the cause of dysphagia is found to be cancer or Zenker's diverticulum. Achalasia unresponsive to conservative measures may eventually need surgical intervention as well.
⚠ (Option D) Helicobacter pylori can cause peptic ulcer and consequently strictures of the gastric outlet (more common) or inlet (less common).Stricture at the junction of the oesophagus to the stomach may cause dysphagia,but not described as difficulty in initiation of swallowing.
⚠ (Option E) Manometry can be used once barium meal study suggests a motility disorder such as achalasia
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✅ C
🔎 Explanation
No matter what the clues point towards, every patient with dysphagia should undergo appropnate investigation. Just because of weight loss, the patients cannot be told to have esophageal cancer. Although the patients age Is a red flag for dysphagia, the fan that it occurs at initiation of swallowing makes oropharyngeal dysphagia the better bet. On the other hand, every patient with dysphagia, regardless of the etiology, may have weight loss due to decreased calorie intake; nonetheless,a thorough and judicious assessment should be considered for every patient with dysphagia.
The best initial step in management of dysphagia depends on provisional diganosis based on the history and clinical findings. when esophageal cancer is suspected, evaluation starts with upper endoscopy and biopsy. With oropharyngeal and motility-related dysphagia, barium studies would be the most appropriate initial approach. in this scenario, oropharyngeal dysphagia probably caused by a retropharyngeal pouch (Zenker's diverticulum) is the most likely diagnosing; therefore barium swallow would be the best initial assessment tool. If a retropharyngeal pouch is diagnosed on barium studies, endoscopy should be avodied. as there is significant risk of the scope perforating the pouch.
⚠ (Option A) Endoscopy Is the initial Investigation when cancer is suspected based on history and clinical features
⚠ (Option B) Surgery is indicated if the cause of dysphagia is found to be cancer or Zenker's diverticulum. Achalasia unresponsive to conservative measures may eventually need surgical intervention as well.
⚠ (Option D) Helicobacter pylori can cause peptic ulcer and consequently strictures of the gastric outlet (more common) or inlet (less common).Stricture at the junction of the oesophagus to the stomach may cause dysphagia,but not described as difficulty in initiation of swallowing.
⚠ (Option E) Manometry can be used once barium meal study suggests a motility disorder such as achalasia
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⏳ Case-based MCQ | #Case_373
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A 70-year-old man from a low-level-of-care nursing home is brought to the hospital after he had a fall 3 hours ago. He is on warfarin for atrial fibrillation (AF). Laboratory studies show that he has an INR of 4.9. A CT scan of the head is ordered which is normal. Other investigations are unremarkable.
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A 70-year-old man from a low-level-of-care nursing home is brought to the hospital after he had a fall 3 hours ago. He is on warfarin for atrial fibrillation (AF). Laboratory studies show that he has an INR of 4.9. A CT scan of the head is ordered which is normal. Other investigations are unremarkable.
Which one of the following is the next best step in management?
Anonymous Poll
23%
a) Stop warfarin
25%
b) Skip one dose of warfarin
15%
c) Give fresh frozen plasma (FFP)
20%
d) Give vitamin K
16%
e) Repeat CT scan of the head in 2 days
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