MCQS 202-204 :A 68 year old woman with a ten year history of breast carcinoma complains of a two weeks history of severe pain in her right lower limb pain in the region of her proximal femur.

A 68 year old woman with a ten year history of breast carcinoma complains of a two weeks history of severe pain in her right lower limb pain in the region of her proximal femur. The pain wakes her up at night and interferes with her daily activities. Bone radiography of the femur is normal but a bone scan reveals moderate increased uptake suggestive of metastases, together with multiple other bony metastases. The most appropriate treatment for her pain would be:
a) laminectomy
b) Peripheral nerve block
c) intravenous morphine
d) oral morphine
e) radiotherapy
f) mechanical ventilation
g) Amitriptyline
h) ibuprofen
i) metallic stent
j) paracetemol
A 37 year old female with a history of asthma presents with tachypnea, and acute shortness of breath with audible wheezing. A physical exam revealed the following: HR 110, respiratory rate of 40. Ausculation revealed decreased breath sounds with inspiratory and expiratory wheezing. SaO2 was 93% on room air. An appropriate management would include
a) Bronchoalveolar lavage
b) transbronchial biopsy
c) Specific beta2 -Agonists
d) tube thoracostomy
e) mechanical ventilation
f) epidural analgesia
g) Pulmonary artery embolisation
h) Bronchial Arterial Embolization
i) Aminophylline
j) Methyprednisolone intravenously
A ten year old boy with anorexia is noticed to be jaundiced. On examination he is noted to have hepatomegaly. A slit-lamp examination reveals greenish deposits at the periphery of the iris of the eye. These features are suggestive of
a) septicemia
b) hepatic veno-occlusive disease
c) cystic fibrosis
d) viral hepatitis
e) physiologic jaundice
f) primary biliary cirrhosis
g) sclerosing cholangitis
h) Dubin-Johnson syndrome
i) Budd-Chiari syndrome
j) Wilson's disease
Correct Answer: D
Oral morphine is the drug of choice in the management of moderate or severe chronic cancer pain. The administration of short-release tablets allows fast absorption, with plasma peak concentrations appearing after 20 to 90 minutes and effective analgesia lasting approximately four to six hours. Bioavailability varies from 35% to 75%, whereas the plasma half-life variability ranging from approximately one to five hours may require variations of dosage in different patients. Morphine clearance decreases in patients over 50 years of age, which may explain why older patients require relatively lower doses of morphine for the same analgesic results.
Correct Answer: C
Short-acting Beta Agonists eg. salbutamol (Ventolin, Respolin, Respax, Asmol); terbutaline (Bricanyl); fenoterol hydrobromide (Berotec) are the mainstay drugs for the acute relief of asthma symptoms. The first intervention should be a beta-2 agonist delivered promptly by an age-appropriate inhalational device, applied repeatedly as needed. An inhaled beta-2 agonist is also the most effective means of prophylaxis for exercise-induced bronchospasm. Careful instruction regarding appropriate use of the prescribed device is essential. In the case of subresponsiveness to beta-2 agonists, high dose oral corticosteroids should be initiated immediately and continued until the patient is symptom-free for 24 hours. This usually requires a 5 to 10 day course of therapy. Salbutamol and terbutaline are the most widely used drugs. They should generally be used on an 'as needed' basis, rather regularly. The inhaled route using either a pressurised metered dose inhaler (MDI or Autohaler) or a dry powder device (Turbuhaler, Diskhaler or Rotacaps) is the preferred method of delivery. Oral therapy should be discouraged in all age groups. It may have a limited role in the treatment of children under 2-3 years of age with mild occasional asthma but a small volume spacer with an attached face mask is an effective and preferable alternative. With oral administration, the onset of action is slower (30-60 minutes) and the incidence of behavioural side-effects and sleep disturbance is reasonably high and often limits its acceptability. When an inhalation device is prescribed, careful instruction about its use is mandatory, preferably accompanied by demonstration. Approximately 30% of adults and 50% of children do not use their pressurised metered dose inhalers correctly. Inhalation technique must be checked at subsequent visits, especially if the symptom control is poor. If the MDI inhaler technique is poor, add a spacer or choose a different delivery device, e.g. a breath actuated device such as the Autohaler or Turbuhaler. In general, neither are suitable for young children. A spacer should always be used during acute symptomatic phases to improve the effectiveness of treatment. A valved spacer should be used in adults and older children and a small volume spacer with an attached face mask can be used in children under 2-4 years of age. Give your patient specific instructions about the dosage to be used for minor and acute symptoms. Administration of beta2 agonist by nebuliser is usually reserved for treatment of acute asthma and is not recommended for maintenance therapy in either adults or children. Ensure that patients understand that decreasing symptom relief from the usual beta-2- agonist dosage indicates worsening asthma. If the patient's usual dose provides relief of symptoms for less than 3-4 hours, patients should follow their Action Plan, rather than use increasing amounts of beta2 agonist
Correct Answer: J
One of the classic physical findings in Wilson's disease is the Kayser-Fleischer ring, which is present in almost all patients with neurologic involvement. These are green-to-brown deposits at the periphery of the iris of the eye. The hepatic presentation of Wilson disease is more common in children. Wilson disease should be considered as a possible diagnosis in any child, symptomatic or not, with hepatomegaly, persistently elevated serum levels of aminotransferases, or evidence of fatty liver. Symptoms may be vague and nonspecific, such as fatigue, anorexia, or abdominal pain. Occasionally patients have a self-limited clinical illness resembling acute hepatitis, with malaise, anorexia and nausea, jaundice, elevated serum levels of aminotransferases, and abnormal findings on coagulation tests The classic Kayser-Fleischer ring, found at the limbus, is caused by copper deposition in Descemet's membrane. Copper is actually distributed throughout the cornea, but fluid streaming favors accumulation in this area, especially at the superior and inferior poles and, eventually, circumferentially around the iris. Kayser-Fleischer rings are usually visible only on direct inspection or with an ophthalmoscope, mainly when iris pigmentation is light and copper deposition heavy. A skilled slit-lamp examination is mandatory. Copper deposition in the lens (sunburst cataracts), which does not interfere with vision, may be seen on slit-lamp examination and, like Kayser-Fleischer rings, disappears on chelation therapy.


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