⏳ Case-based MCQ | #Case_377 | #answer
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✅ C

🔎 Explanation

The clinical findings are a classic description of acute closed-angle glaucoma - an acute rise in the pressure of the anterior chamber. This condition is real emergency and if left untreated catastrophic results can ensue.

Treatment of acute closed-angle glaucoma is with immediate application of topical agents that inhibit aqueous production. The following topical agents might be used:
• Topical beta blockers (first-line): timolol, carteolol
• Alpha adrenergic agonists : e.g. apraclonodine
• Topical prostaglandins

Other management options depend on the setting:
• If the patient can be seen within 1 hour of presentation, urgent referral to an ophthalmologist will be the next best step.
• If the referral is delayed, the patient should be given acetazolamide PO (250mg x2) (Option A). After one hour of treatment, topical pilocarpine (Option B) can be started as well (2 doses 15 minutes apart).

🔖 NOTE - The most frequently drug group in the emergency department is topical beta blockers (timolol, carteolol) and intravenous acetazolamide.

Of the given options carteolol, is the most appropriate management option.

⚠ (Option D) Laser iridotomy will be the definite treatment of8 closed-angle glaucoma and is considered after the acute attack subsides. This procedure is not applicable in acute setting.

⚠ (Option E) Topical corticosteroids have shown no benefit in an acute attack but might be helpful in reducing the corneal inflammation after the acute phase has subsided.

⏳ Case-based MCQ | #Case_378
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A 56-year-old man presents to the A 73-year-old woman presents to the emergency department with vomiting, abdominal pain and abdominal distention. She has congestive heart failure (CHF) in the setting of longstanding hypertension. She had been taking carvedilol, ramipril, and atorvastatin until 10 days ago when she had digoxin and hydrochlorothiazide added to her medications for a tighter control of her rather poorly controlled hypertension and CHF. On examination, she has a blood pressure of 130/85 mmHg, an irregular pulse rate of 110 bpm, respiratory rate of 22 breaths per minute and temperature of 37.5°C. Her abdomen is distended but not tender. There is also no guarding or rigidity. Bowel sounds are absent.

⏳ Case-based MCQ | #Case_378 | #answer
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✅ A

🔎 Explanation

In the presence of both hydrochlorothiazide (thiazide diuretic) and carvedilol (beta blocker) in the history, hypokalemia is most likely to have caused this clinical picture. Hypokalemia can cause paralytic ileus and result in the general picture of bowel obstruction including constipation, abdominal distention and pain, nausea and vomiting, and absent or diminished bowel sounds. ACE inhibitors (e.g., ramipril), on the other hand, have shown to ameliorate the hypokalemic effect of thiazide diuretics. Hypokalemia, hyponatremia, hypercalcemia and elevated blood glucose and urate are common side effects of thiazide diuretics.


⚠ Thiazide-induced hypokalemia in this patient may predispose her to digoxin toxicity (option B), and digoxin toxicity results in hyperkalemia (option E); however, gastrointestinal manifestations of digoxin toxicity are anorexia, nausea, vomiting, abdominal pain and diarrhea. Abdominal distention is not a feature of digoxin toxicity or the consequent hyperkalemia.

⚠ Hypocalcemia (option C) presents with muscle spasms, numbness and tingling in the hands, feet and face, and in more severe case central nervous system problems such as hallucinations. There is no clues in the history suggestive of hypocalcemia as the cause, nor is there an identifiable etiology for that. Thiazides can cause hypercalcemia that often presents with symptoms such as loss of appetite, nausea and vomiting, constipation and abdominal pain, increased thirst and frequent urination, fatigue, weakness, muscular pain, confusion and disorientation, headaches, and depression. Hypercalcemia does not cause a clinical picture consistent with bowel obstruction.

⚠ (Option D) The rapid irregular pulse in this patient indicated atrial fibrillation(AF). AF predisposes to mesenteric ischemia; however, acute mesenteric ischemia presents with abdominal pain and bloody diarrhea especially after meals. Chronic mesenteric ischemia has postprandial periumbilical and/or epigastric pain, fear of eating, and weight loss as typical symptoms. Less common features include nausea, vomiting, diarrhea, constipation and flatulence. Although some of this patient's symptoms are seen in chronic mesenteric ischemia as well, abdominal distention goes against this diagnosis

⏳ Case-based MCQ | #Case_379
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A 23-year-old man is brought to the emergency department by ambulance paramedics after
he sustained a stab wound in the chest in a street fight. On examination, he as a knife stuck in the left hemithorax. The patient is awake, oriented and cooperative. His blood pressure is 110/65mmHg, hear rate 100 bpm and respiratory rate 18 breaths per minute. There are no raised neck or forehead veins.

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⏳ Case-based MCQ | #Case_379 | #answer
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✅ C

🔎 Explanation

As a rule, all impaled foreign bodie should be secured in place and not removed until the patient is in the operating room (OR). The rationale behind this approach is that the object could have damaged major blood vessels, which are temporarily tamponaded by the object. If the object is removed, the pressure over the vessels is released, and life - threatening, potentially uncontrollable hemorrhage could ensue.

Such patients should be taken to the OR for removal of the impaled object in a controlled
environment where potential bleeding after removal can be promptly controlled. A chest tube should be left in place for successful drainage of blood leak or air in the pleural space. As many as 80% of patients with penetrating chest trauma have hemothorax, pneumothorax, or both.

⚠ Any options suggesting removal of the knife in any place other than the OR is incorrect.

⚠ Immediate needle aspiration is the most appropriate next step in patients with tension pneumothorax which is not the case in here. Tension pneumothorax presents with hypotension and difficulty breathing as well as other findings such as diminished air entry into the affected side, tracheal deviation away from the site of the injury, and diminished breath sounds and hyper-resonance of the affected hemithorax

⏳ Case-based MCQ | #Case_380
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A 45-year-old woman presents to your GP clinic for review. A few months ago, she developed redness around her nose and cheeks that became worse after she drank alcohol. Recently, she was asked, by one of her colleagues at work, if she has alcohol problems because her appearance resembles those with excessive alcohol use. She drinks an average of 10 units of alcohol per week. Her facial appearance is shown in the accompanying photograph.

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⏳ Case-based MCQ | #Case_380 | #answer
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✅ C

🔎 Explanation

The photograph shows an erythematous butterfly rash. Additionally, the chin is also involved. Several papules and pustules are noted as well. The clinical picture presented
in the photograph, along with the history, is suggestive of rosacea (also known as acne rosacea) as the most likely diagnosis.

Rosacea is a common chronic disorder that mainly involves the face. It tends to present in middle-age persons but may start at earlier ages. It is more common in cold climates.

The condition often begins as exaggerated or prolonged flushing tendency, with erythema affecting the central face or the butterfly area in particular. Sometimes erythema can be seen in the chin and forehead. Initially, the erythema occurs intermittently, but later becomes persistent. Sometimes, rosacea is associated with edema. Telangectiasis is often present. Sterile inflammatory papules, pustules and nodules may be present mimicing acne. The distinguishing feature is the absence of comedones.

Patients often complain that their faces feel hot, burn, sting or itch. Patient often report that their face is increasingly easily irritated by topical products.

The etiology of rosacea is unknown. Alcohol is not a cause but it can trigger the flushing and worsen the symptoms. Other triggering factors include:

▫Hot or cold temperatures
▫Wind
▫Hot drinks
▫Caffeine
▫Exercise
▫Spicy foods
▫Emotions
▫Topical products that irritate the skin and decrease the barrier
▫Medications that cause flushing

In about 50% of the patients, blepharoconjunctivitis is observed. It presents with itching, burning, gritty or foreign body sensation in the eye and erythema and swelling of the eyelid. More advanced cases can develop enlarged sebaceous glands and connective tissue changes resulting in a bulbous, rhinophymatous nose.

Seborrheic dermatitis, SLE and erysipelas are among the differential diagnosis but not consistent with the history. None of these conditions have alcohol as a triggering factor.

⚠ (Option A) Seborrhoeic dermatitis has scaling as a prominent feature.

⚠ (Option B) Erysipelas is associated with abrupt onset of erythematous butterfly rash almost always caused by streptococcus pyogenes. There is often fever and constitutional upset. It is not a chronic condition and is not triggered by alcohol use.

⚠ (Option D) Although the rash resembles that of SLE, lack of other signs and symptoms favoring SLE, makes it least likely.

⚠ (Option E) Alcohol-related skin disease a general term not a diagnosis. Rosacea worsens by alcohol but is not caused by it

⏳ Case-based MCQ | #Case_381
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A 30-year-old woman presents with a 12-month history of secondary infertility. Her first child, fathered by the same partner, was born 4 years ago after she was conceived spontaneously, and through an uneventful vaginal delivery. She has always had irregular periods occurring every 2 to 4 months. On examination, she is obese (BMI>32) and otherwise normal. Ultrasonography of the pelvis reveals 12 small cyst of 3-6 mm in diameter in the left and 20 cysts of about the same size in the right ovary. A sperm analysis of the partner is normal.

⏳ Case-based MCQ | #Case_381 | #answer
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✅ B

🔎 Explanation

The findings on ultrasonography are suggestive of polycystic ovarian syndrome (PCOS). PCOS is the most common cause of infertility due to anovulation. Infertility in women with PCOS, however, is not absolute and many women can conceive even without treatment. In women with infertility due to PCOS, different options are available:


Non-pharmacological treatment:

▫If a woman is younger than 35 years of age and has a BMI>25, and no other cause of infertility is suspected an intensive lifestyle program addressing weight loss, without any pharmacological treatment for the first 6 months, is recommended. Small amounts of weight loss (~5%) may restore menstrual cycle regularity and ovulation, providing benefit even if pharmacological intervention is subsequently required


Pharmacological treatment:

✔ If pharmacological treatment is required, the best first-line treatment is clomiphene citrate, which has a pregnancy rate of 30-50% after six ovulatory cycles.

✔ In women with a BMI <30-32 kg/m , metformin may have a similar efficacy to clomiphene citrate, and is the first-line treatment (with or without clomiphene citrate) if there is concomitant impaired glucose tolerance.

✔ If clomiphene citrate, metformin or a combination of the two is unsuccessful in achieving pregnancy, gonadotropins are the next pharmacological options.

✔ Laparoscopy with ovarian surgery/drilling (LOS) is an appropriate second-line treatment if clomiphene citrate with metformin has failed. The pregnancy rate with LOS is as effective as 3-6 cycles of gonadotropin ovulation induction.

✔ If all of the above are unsuccessful or if there are other factors contributing to infertility such as endometriosis or male factors, in vitro fertilization or intra-cytoplasmic sperm injection is recommendedit

⏳ Case-based MCQ | #Case_382
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A mother brings her 3-week-old male baby to the Emergency Department because of his
loose bloody bowel motions. The mother says the diarrhea has started 2 days ago after she
started her son on formula milk. The mother is lactose-intolerant and does not use dairy products. On examination, the child is mildly dehydrated and has an eczematous rash on his right cheek. He is not febrile. The rest of the exam is inconclusive. Family history is remarkable for atopy including asthma and eczema in his father and older sister. Mother is concerned that his son may have the same allergy to milk and dairy product she has.

⏳ Case-based MCQ | #Case_382 | #answer
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✅ E

🔎 Explanation

The onset of bloody diarrhea shortly after introduction of formula, the presence of eczema, and family history of atopy makes cow’s milk protein allergy (intolerance) (CMPA) the most likely diagnosis with high certainty.

CMPA results from an immunological reaction to one or more milk proteins. This immunological basis distinguishes CMPA from other adverse reactions to cow’s milk protein such as lactose intolerance.

CMPA may be immunoglobulin E (IgE) or non-lgE associated. In IgE-associated cases, CMPA may be a manifestation of the atopic diathesis. These reactions may occur as short as minutes after ingestion of cow’s milk or cow’s milk-based formula. These early reactions usually manifest as urticaria, angioedema, vomiting or an acute flare of atopic dermatitis. The remaining 42% show a later reaction, typically atopic dermatitis or gastrointestinal disturbances.

Even small amounts of cow’s milk in breast milk of mother’s who take dairy products may trigger the condition.

Other options do not justify the clinical presentation.

⏳ Case-based MCQ | #Case_383
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A 68-year-old patient of yours presents for medical evaluation. He is a known-case of benign prostatic enlargement. Today he is complaining of urinary problems in form of difficulty starting micturition and dribbling at the end of urination, as well as constipation. He also has back pain and left thigh pain. On examination, there is decreased sensation over the medial aspect of the left lower leg.

⏳ Case-based MCQ | #Case_383 | #answer
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✅ D

🔎 Explanation

Of the options, only decreased sensation of the lower leg can be specific to an intervertebral disc prolapse and others can be manifestations of non-neurological problems as well.

Radicular lower back pain can happen due to chemical or mechanical irritation of nerve roots. The pain is sharp, shooting and has an electric quality. Unilateral leg pain is the more pronounced symptoms and is often worse than pain in the back. Pain concentrates distally, running into the lower limb, usually extending below the knees. Pain, numbness and paresthesia follow a dermatomal distribution. Reflexes may be reduced or even absent. Motor weakness not always would be present.

⚠ Lesions of the cauda equina can present with back pain, leg pain, paresthesia around the anus, and urinary incontinence. However, in this patient, the urinary problem is described as difficulty starting micturition and terminal dribbling, which is consistent with bladder outlet obstruction by causes such as an enlarged prostate. Urinary problems (option A) of this patient is very unlikely to have been caused by an intervertebral disc prolapse.

⚠ Although disc prolapse in the lumbar area can present with back pain (option C) and thigh pain (option B), such pain may have been caused by other factors than radiculopathy. Back pain may be due to a mechanical stressor. In fact, back pain is the common factor between mechanical and neural pain in the back. The accompanying symptoms are the only indicators helping to differentiate between the two. Leg pain may have other causes such as mechanical injuries and vascular problems (e.g., venous insufficiency, arterial disease, etc.). Neural impairments other than radiculopathy may give rise to pain as well.

⚠ Constipation (option E) in this patient may have many other causes as well, with one being bladder obstruction and pressing of a distended bladder on the rectum. Decreased dietary fibers, limited physical activity, and many other factors could have caused the constipation. Disc prolapse is more likley to be associated with fecal incontinence rather than constipation.