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dr_b.e.s.m
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Questions
« on: /October/ 04, 2005, 04:56:19 AM »

1] A previously healthy 50-year-old woman comes to the physician because of double vision for three days. Her temperature is 37 C (98.6 F). The patient denies nausea or vomiting. Examination reveals ptosis and slight divergence of the right eye. Extraocular movements are limited in all directions, except laterally. The right pupil is larger than the left and poorly reactive to light. Examination of the fundus fails to reveal papilledema. Which of the following is the most likely underlying condition?
A. Aneurysm of the posterior communicating artery
B. Carcinoma of the right pulmonary apex
C. Diabetes mellitus
D. Giant cell arteritis
E. Syphilis
F. Systemic hypertension


2] A 57-year-old man comes to the emergency department because of excruciating pain in his right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past. He admits to a few "drinking binges" over the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show: Serum
Leukocytes........16,000/mm3
Uric acid...........15 mg/dL
Calcium.............9 mg/dL
Which of the following is the most appropriate pharmacotherapy?

A Allopurinol
B Ceftriaxone
C Indomethacin
D Probenecid
E eSulfinpyrazone


3] A 43-year-old man presents with a 4-year history of joint pain. The distribution is asymmetric, involving the proximal and distal small joints of the right hand, the left knee, the ankle, and right elbow. Pain and morning stiffness are moderate. Physical examination reveals mild nail pitting, and the distal third interphalangeal joint is partially subluxated. X-rays of the hands show resorption of the distal end of the phalanx. The erythrocyte sedimentation rate (ESR) is elevated to 46 mm/hr, and rheumatoid factor is negative. Which of the following is the most likely diagnosis?
A. Primary generalized osteoarthritis
B. Pseudogout
C. Psoriatic arthritis
D. Rheumatoid arthritis


4] A 57-year-old man presents to his physician for a preoperative evaluation. He has been a long-time patient in this office and has been treated for hypertension and gastritis. He has been scheduled for an elective open cholecystectomy in 2 days. He currently takes omeprazole for his gastritis and thiazide for his hypertension daily. He smokes two packs of cigarettes per day. His home blood pressure log shows that his systolic pressures range from 150 to 190 mm Hg, and his diastolic pressures range from 80 to 105 mm Hg, indicating that his blood pressure may be not adequately controlled for the surgical procedure. Which of the following medications is most appropriate in the perioperative period for added blood pressure control?
A. Captopril
B. Clonidine
C. Metoprolol
D. Nifedipine
E. Prazosin
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dr_ahmedsalah
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Re: Questions
« Reply #1 on: /October/ 04, 2005, 09:09:29 AM »

ايه الأسئله الجامده دي
براحه علينا شويه

احنا لسه صغننين
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dr_b.e.s.m
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Re: Questions
« Reply #2 on: /October/ 04, 2005, 04:36:25 PM »

you are right , the questions are tough and to be honest I am not sure of the answers of some of them  Smiley   , but the aim of the questions is to learn , for example , we can look in a textbook or in the net in order to find an answer so we'll learn . Also the discussion about the questions is very useful. I mean questions don't always mean an exam  ill 
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dr_ahmedsalah
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Re: Questions
« Reply #3 on: /October/ 04, 2005, 05:10:48 PM »

  You are right dr Bahaa but at least one should have an over all view to enable him thinking in those cases.

Not one still in the 4th year.

Am I right ?
« Last Edit: /October/ 04, 2005, 05:14:50 PM by dr_ahmedsalah » Logged
 
dr_b.e.s.m
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Re: Questions
« Reply #4 on: /October/ 04, 2005, 05:15:43 PM »

yes you are right . most of these questions are internal medicine which you'll study next year insha`allah.
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dr_b.e.s.m
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Re: Questions
« Reply #5 on: /October/ 05, 2005, 10:46:27 AM »

Question 1

A previously healthy 50-year-old woman comes to the physician because of double vision for three days. Her temperature is 37 C (98.6 F). The patient denies nausea or vomiting. Examination reveals ptosis and slight divergence of the right eye. Extraocular movements are limited in all directions, except laterally. The right pupil is larger than the left and poorly reactive to light. Examination of the fundus fails to reveal papilledema. Which of the following is the most likely underlying condition?

Findings
- A patient with right ptosis and extraoccular muscle paralysis. Eye movement is affected in all directions except laterally. So this is third cranial nerve (occulomotor) palsy. Lateral movement is spared because it's controlled by 6th cranial nerve (abducent).

- Patient also has dilated poorly reactive right pupil. This is important to identify the cause of occulomotor palsy. How?!

- Patient has no symptoms of increased intra cranial tension (nausea, vomiting , headache) and has no signs (papilledema).

- Patient is previously healthy ie. has no known chronic disease.

So the question now is the cause of third cranial nerve palsy. Causes are classified into 2 main groups : local compression and systemic disease. Here it's local compression (choice A : PCA aneurysm) why? Because compression has early pupil affection and because patient has no known systemic disease eg DM , htn , syphilis.

Another cause of occulomotor compression is uncal herniation but it occurs with increased intra cranial pressure which is excluded here by symptoms and signs.

Carcinoma of the right pulmonary apex can cause ptosis, through compression of the cervical autonomic ganglia [Horner syndrome]. But it'll be assosiated with small pupil [miosis] and with intact eye movement. Another difference is that ptosis in Horner syndrome is incomplete.

So the most important point here is that occulomotor palsy with dilated poorly reactive pupil is due to local compression not systemic condition.
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dr_b.e.s.m
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Re: Questions
« Reply #6 on: /October/ 06, 2005, 09:31:13 AM »

This is a good simple approach to a case of diplopia , read it and try to apply it to the previous case.


Third Nerve Palsy
-Third nerve palsy may be associated with aneurysm, microvascular infarct (particularly with diabetes or hypertension), tumor, trauma, and uncal herniation. Some patients may experience pain.
-A droopy eyelid is seen on the involved side. The pupil may be fixed and dilated. If the pupil is involved, the cause of the disorder is probably an aneurysm (of the posterior communicating artery). If the pupil is not involved, microvascular ischemia is usually the cause. Because the third nerve controls superior, inferior, and medial movements, the eye is usually pointed down and out.

Fourth Nerve Palsy
-The fourth nerve controls vertical eye movement, so fourth nerve palsy causes vertical diplopia. Some patients report difficulty reading but may have no symptoms. This palsy may occur with trauma, microvascular infarct (particularly with diabetes or hypertension), tumor, and aneurysm.
-The involved eye is higher than the uninvolved eye. The deviation may be so slight that detecting the difference on gross examination is difficult. Patients may have a head tilt that eliminates the double vision.

Sixth Nerve Palsy
-The sixth nerve controls lateral eye movements. Patients therefore complain of horizontal diplopia. Sixth nerve palsy may be associated with trauma, microvascular infarct (from diabetes or hypertension), increased intracrania pressure, temporal arteritis, cavernous sinus tumor, and aneurysm.
-An inability to move the eye outward with the involved eye pointing in (esotropia) is significant.

Decompensated Strabismus
-The patient may report a history of strabismus or previous eye muscle surgery.
-Horizontal (esotropia/exotropia) or vertical deviation may be present depending on the muscles involved.

Myasthenia Gravis
-Patients may have the typical symptoms of myasthenia gravis, including fatigue, weakness, and difficulty swallowing, chewing, and breathing; these symptoms may fluctuate during the day. The double vision also tends to fluctuate during the day and worsens with fatigue.
-Droopy eyelids that become worse toward the end of the day or when the individual is fatigued are significant. With sustained upgaze, the droopy eyelids may worsen. Systemic edrophonium chloride (Tensilon) often improves the eyelid droop and/or double vision. Weakness of the facial muscles and limb muscles may occur, but no pupil abnormalities are present.

Thyroid Eye Disease
-Eye disease is usually associated with hyperthyroidism; however, patients may have a normal-functioning thyroid gland. The eye disease may be present even when the systemic disease is under good control.
-Unilateral or bilateral proptosis may be present, and the conjunctiva can be injected or filled with fluid (chemosis). Eye movement may be limited, particularly up and out. When the patient looks down slowly, the upper eyelids may lag behind the eye movement such that the superior sclera is visible (lid lag). The proptosis may lead to an inability to fully close the lids, causing dry eye signs and symptoms.

Orbital Pseudotumor
-Patients report severe pain and redness, usually in one eye.
-The conjunctiva is usually injected, and swelling of the conjunctiva (chemosis) may occur. The eyelids are often red and swollen. Proptosis and restriction of movement in one eye occur, and a palpable orbital mass may be present. The vision in the involved eye may be decreased.

Blow-Out Fracture
-Blow-out fracture is associated with a history of blunt trauma to the orbit.
-Restricted eye movement, particularly in upgaze and/or lateral gaze, is significant. Subcutaneous air (crepitus) and numbness in the distribution of the infraorbital nerve, which involves the cheek and upper lip, are possible.
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