NND Clinical Vignettes Ed 2.

A Primigravida with unknown LMP presents with vaginal spotting and cramping, a
transvaginal sonography examination was performed and the image is given below. The
finding represents a pregnancy of what gestational age

A. 3 weeks B. 5 weeks
C. 7 weeks D. 9 weeks
Explanation
Correct Answer (B) The picture shows a gestational sac , it shows an echogenic rim along
one side of the decidua, we can also see two concentric rings surrounding the sac and it is
positioned eccentrically A gestational sac—a small anechoic fluid collection within the
endometrial cavity—is the first sonographic evidence of pregnancy. It may be seen with
transvaginal sonography by 4 to 5 weeks' gestation. A fluid collection, however, can also be
seen within the endometrial cavity with an ectopic pregnancy and is termed a pseudo
gestational sac Other potential indicators of early intrauterine pregnancy are an anechoic
center surrounded by a single echogenic rim—the intradecidual sign—or two concentric
echogenic rings surrounding the gestational sac— the double decidual sign. If sonography
yields equivocal findings—the so-called pregnancy of unknown location, then serial serum
hCG levels can also help differentiate a normal intrauterine pregnancy from an extra uterine
pregnancy or an early miscarriage.

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A female at 12 weeks of gestation with first trimester sonographic evaluation. The nuchal
translucency is measured and was 4.6mm. She undergoes subsequent CVS and her
karyotype is 46XY. Her fetus still needs evaluation in second trimester for which of the
following

A. aneuploidy B. cardiac defects

C. Duodenal atresia D. Cleft lip and palate

Explanation
Correct Answer (B) NUCHAL TRANSLUCENCY represents the maximum thickness of the
subcutaneous translucent area between the skin and soft tissue overlying the fetal spine at
the back of the neck. It is measured in the sagittal plane between 11 and 14 weeks using
precise criteria. When the nuchal translucency is increased, the risk for fetal aneuploidy and
various structural anomalies—including heart defects—is significantly elevated. Aneuploidy
screening using nuchal translucency measurement in conjunction with assessment of
maternal serum human chorionic gonadotropin and pregnancy-associated plasma protein A
levels is called as combined test.

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A 30 year old male presents with genital ulcerations and uveitis. Oral examination shows
the following findings. Which of the following statement is true about this condition

A. Associated with HLA B 27 B. Chlamydia can be a preceding infection

C. Less common in females D. SVC obstruction can be seen
Explanation
(D). This is a case of Behcet's disease fulfilling the criteria which are Recurrent oral
ulceration plus two of the following Recurrent genital ulceration Eye lesions Skin lesions
Pathergy test Behcet's can be associated with SVC obstruction.

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 NND Clinical Vignettes Ed 2.0

62 An 82-year-old male with a history of Parkinson disease presents to the emergency

department with headaches and mild left-sided weakness. An emergent computed
tomography scan of his brain demonstrates a small, right-sided intracerebral hemorrhage
in the internal capsule. His blood pressure remains above 220 systolic despite two doses
of intravenous labetalol. His wife mentions he was recently started on a new medication
for his Parkinson disease. Which of the following is the most likely causative agent?
A. Rasagaline B. Amantadine
C. Ropinirole D. Entacapone

Explanation
Correct Answer (A) Rasagaline is a monoamine oxidase B inhibitor, which is involved in the
breakdown of dopamine and norepinephrine, so it has a potentially serious side effect of
malignant hypertension, particularly when combined with some selective serotonin
reuptake inhibitors, resulting in serotonin syndrome. Entacapone is a catecholamine
methyltransferase inhibitor (catechol-O-methyl transferase) that slows the degradation of
dopamine. Serious complications include orthostasis, syncope, hallucinations, and psychosis.
Amantadine is an antiviral agent also used in Parkinson disease that has possible side effects
of psychosis, seizures, and arrhythmias. L-dopa and Ropinirole have similar side effect
profiles, including orthostasis, excessive reward-seeking behavior, psychosis, dyskinesia, and
arrhythmias.

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 NND Clinical Vignettes Ed 2.0

Q.72 A trauma patient arrives following a stab wound to the left chest. SBP is 85 mm Hg,
which improves slightly with IV fluid resuscitation. PR - 95/mi n. Chest X-ray demonstrates
clear lung fields. What is the most appropriate next step?
A. CT scan of the chest & abdomen B. Insertion of a chest tube in the left
hemi-thorax
C. FAST D. Immediate laparotomy
Explanation
Correct Answer (C) Focused assessment with sonography in trauma (commonly abbreviated
as FAST) is a rapid bedside ultrasound examination performed by surgeons. Emergency
physicians. and certain paramedics as a screening test for blood around the heart
(pericardial effusion) or abdominal organs (hemoperitoneum) after trauma. The four classic
areas that are examined for free fluid are the per hepatic space (including Morison's pouch
or the hepatorenal recess). Perisplenic space, pericardium. And the pelvis. With this
technique it is possible to identify the presence of intraperitoneal or pericardial free fluid. In
the context of traumatic injury, this fluid will usually be due to bleeding. The extended FAST
(eFAST) allows for the examination of both lungs by adding bilateral anterior thoracic
sonography to the FAST exam. This allows for the detection of a pneumothorax with the
absence of normal lung-sliding' and 'comet-tail' artifact (seen on the ultrasound screen).
Compared with supine chest radiography. With CT or clinical course as the gold standard,
bedside sonography has superior sensitivity (49-99% versus 27-75%), similar specificity (95-
100%), and can be performed in under a minute.

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 NND Clinical Vignettes Ed 2.0

A 45-year-old man has recently moved from Delhi. He suffers a focal seizure followed by
secondary generalization. He denies symptoms of active infection and has not suffered
any recent trauma. His neurological examination has returned to normal in the emergency
room. A magnetic resonance image (MRI) of the brain is shown. Which of the following is
the next best step in management?
A. Levetriacetam with albendazole. B. Levetriacetam with acyclovir.
C. Locsamide with biopsy of the lesion. D. Locsamide, vancomycin and
cefepime.

Explanation
Correct Answer (A) The clinical presentation and MRI findings are classic for
neurocysticercosis, a tapeworm infection with Taenia sodium, which is often related to
ingestion of undercooked pork. This disease is commonly seen in individuals from Mexico
and South America. Whereas treatment with an antihelminth may be safely avoided in cases
of completely calcified cysts, the cysts on this patient's MRI appear active with a scolex.
Suggesting that treatment may be beneficial in reducing subsequent seizure risk. As such,
treating with both Levetriacetam and albendazole is warranted. Levetriacetam and acyclovir
is not suggested, as there is no evidence of viral infection in the history or on MRI. Although
Locsamide may also be used for focal seizures, neither a biopsy nor antibiotics would be
warranted in this patient currently.

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 NND Clinical Vignettes Ed 2.0

A home delivered child is born with huge abdominal lump. He was brought to the hospital
where USG showed huge right sided sever hydronephrois and invisible ureter. Pelvis is
dilated till PUJ. MAG3 scan showed compromised renal function and 7% function. Next
step in management should be.
A. Repeat Scan B. Immediate nephrostomy
C. Immediate nephrectomy D. Immediate pyeloplasty

Explanation
Correct Answer B
• Treatment of PUJ obstruction depends on degree of obstruction and renal reserve o If the
renal function is good (>20% in adult and >10% in children)-Immediate pyeloplasty should
be done o If renal function is compromised (<20% in adults and < 10% in children)-
Immediate Nephrostomy should be done are case reassessed after 4-6 weeks o If renal
function is very poor - Nephrectomy is the treatment of choice
• In children, the procedure of choice is an Anderson-Hynes dismembered pyeloplasty. •
Other procedures are: • Ante grade or retrograde endopyelotomy. • The Foley V-V plasty is
useful for the high insertion variant. • Spiral and vertical Haps, such as Culp and DeWeerd
and Scardino and Prince, are useful when a long-structured segment of diseased ureter is
encountered. • Ureterocalicostomy. Anastomosis of the ureter to a lower pole renal calyx. is
most often reserved for failed open pyeloplasty where there is no extra renal pelvis.

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 NND Clinical Vignettes Ed 2.0

A 50 yrs. male presented with intermittent mild Dysphagia, mainly for solid. He doesn't
have any problem in swallowing liquids. Barium swallow is Given below. What is most
probable cause for his dysphagia?

A. A ring B. B Ring
C. C Ring D. Achalasia

Explanation
Correct Answer (B) A Schatzki ring, also called Schatzki-Gary ring. is symptomatically narrow
esophageal B-ring occurring in the distal esophagus and usually associated with a hiatus
hernia. The pathogenesis of the Schatzki ring is unclear with conflicting hypotheses that
include redundant pleats of mucosa, congenital abnormalities and modified peptic strictures.
Interestingly, there is a reduced incidence of Barrett esophagus in patients with a Schatzki
ring. Depending on its luminal diameter, an esophageal B-ring may be symptomatic or
asymptomatic : <13 mm: almost always symptomatic 13-20 mm: sometimes
symptomatic >20 mm: rarely symptomatic When itis symptomatic, it is termed a "Schatzki
ring".

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 NND Clinical Vignettes Ed 2.0

A 30 year old male patient has a large, foul-smelling, spreading exuberant ulcer with
bright red granulation tissue over the glans penis. There was no lymphadenopathy. The
most likely causative organism is
A. Treponema pallidum B. Herpes simplex virus type 1
C. Herpes simplex virus type 2 D. Calymmatobacterium granulomatis

Explanation
Correct Answer (C) Donovanosis (Granuloma inguinale) is a chronic bacterial infection that
frequently is associated with other sexually transmitted diseases. Granuloma inguinale is
characterized by intracellular inclusions in macrophages referred to as Donovan bodies.
Granuloma inguinale usually affects the skin and mucous membranes in the genital region.
where it results in nodular lesions that evolve into ulcers. The ulcers have granulation tissue
on the floor and bleed easily. The ulcers are "beefy red". Inguinal lymphadenopathy is not
seen.

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 NND Clinical Vignettes Ed 2.0

Female patient presents you with history of microstomia and breathlessness. CXR is
shown to you. What does the CXR indicate?

A. ILD B. Bronchieetasis
C. Cystic disease of the lung D. Chronic obstructive lung disease
Explanation
Correct Answer (A) History of microstomia is given here as a clue to scleroderma. Interstitial
lung disease (ILD) is one of the major types of lung involvement in systemic sclerosis (SSc).
SSc-associated ILD consists of various histopathologic subtypes, most commonly nonspecific
interstitial pneumonitis and usual interstitial pneumonitis. The classic radiographic features
of established SSc-associated ILD consist of symmetric, reticular, or ground glass opacities.
These are usually most pronounced at the lung bases. Among patients with SSc-associated
ILD, the most common pathologic pattern. NSIP, is associated with the HRCT finding of
ground glass opacities in a peripheral distribution. The earliest HRCT change is usually a
narrow, often ill-defined. subpleural crescent of increased density in the posterior
(dependent) segments of the lower lobes. As the disease progresses, there is volume loss
associated with a reticular appearance and traction bronchiectasis. The honeycomb pattern
is rarely seen with NSIP. In the subset of patients with a histologic UIP pattern, the HRCT
appearance is usually similar to that of fibrotic NSIP. However, sometimes the HRCT pattern
is more consistent with that of UIP with bibasilar reticular opacities, associated with traction
bronchiectasis and the development of subpleural honeycomb air spaces, which ultimately
coalesce into large cystic air spaces

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 NND Clinical Vignettes Ed 2.0

A 31-year-old woman develops mild acute pancreatitis and is managed conservatively. It

is her third episode of pancreatitis but there is no history of excess alcohol consumption
and an abdominal ultrasound is normal. Magnetic resonance cholangiopancreatography
(MRCP) is performed and is reported as showing evidence of pancreas divisum. Which one
of the following findings is likely to have been present on MRCP?
A. An accessory pancreatic duct passing around the duodenum
B. The common bile duct draining into the minor papilla
C. The dorsal pancreatic duct (duct of Santorini) draining into the minor papilla
D. The ventral pancreatic duct draining into the minor papilla

Explanation
Correct Answer (C) It appears that relative stenosis of the cranially sited minor papilla
results in increased risk of
Pancreatitis in these patients.

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 NND Clinical Vignettes Ed 2.0

A 2 day old boy manifests poor feeding, vomiting, and lethargy leading to coma.
Laboratory data reveal respiratory alkalosis and hyperammonemia. The urine orotic acid
level is also elevated. The most likely diagnosis is:
A. Methyl malonic acidemia B. Carbamoyl phosphate synthase
deficiency
C. Ornithine transcarboxylase (OTC) deficiency D. Galactosemia

Explanation
Correct Answer (C) OTC deficiency Ornithine transcarboxylase. The defective enzyme in this
disorder. is the final enzyme in the proximal portion of the urea cycle. It is responsible for
converting carbamoyl phosphate and ornithine into citrulline. OTC deficiency is inherited in
an X-linked recessive manner. Meaning males are more commonly affected than females. In
the classic presentation, a male infant appears well initially, but by the second day of life
becomes irritable. Lethargic. And stops feeding. Infants may have poorly-controlled body
temperature and respiratory rates. And may experience seizures. Without urgent
intervention, a metabolic encephalopathy develops; this can progress to coma and death
within the first week of life. High levels of ammonia cause preferential damage to the brain.
Leading to devastating consequences

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 NND Clinical Vignettes Ed 2.0

A premature infant is undergoing mechanical ventilation for respiratory distress

syndrome. Peak inspiratory pressure is 32 cm H2O, positive end-expiratory pressure (PEEP)
is 5 cm H2O, and ventilatory rate is 30 breaths/min. The infant has decreased peripheral
perfusion, manifested as a prolonged capillary refill time and weak arterial pulses. The
central venous pressure measured at the right atrium with an umbilical venous catheter is
2 mm Hg (or approximately 3 cm H20). Pa02 is 80 mm Hg, and PaCO2 is 38 mm Hg. Which
of the following measures is most likely to result in an improvement in this infant's
perfusion?
A. Reduce PEEP to 3 cm H2O B. Reduce peak inspiratory pressure to 28
cm H2O
C. Reduce ventilatory rate to 26 breaths/min D. Administer 10 mL/kg of normal saline

Explanation
Correct Answer (D) This infant has evidence of poor perfusion and has hypoxemia despite
adequate ventilation. Most likely the patients’ hypovolemia is contributing to V/Q mismatch
(dead space ventilation). The V/Q relationship is adversely affected in a variety of
pathophysiologic states.

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 NND Clinical Vignettes Ed 2.0

A lady with PCOS undergoing infertility treatment with gonadotropins suddenly presents
with abdominal pain and distension. The following is the ultrasound of the patient all
statement are true for her except.

A. Her lab evaluation will show hemodilution B. HCG is implicated in aetiology

C. Treatment is supportive D. Young age is risk factor
Explanation
Correct Answer (A) The clinical features and the ultrasound image are consistent with the
diagnosis of ovarian hyper stimulation syndrome The aetiology o ovarian hyper stimulation
syndrome (OHSS) is complex. But hCG. either exogenous or endogenous (derived from a
resulting pregnancy). is believed to be an early contributing actor. Development of OHSS
involves increased vascular permeability and loss o uid. Protein. And electrolytes into the
peritoneal cavity. which leads to hemoconcentration. Increased capillary permeability is elt
to result rem vasoactive substances produced by the corpus luteum. Vascular endothelial
growth actor (VEGF) is thought to play a major role. and angiotensin II may also be involved.
Predisposing actors or OHSS include multi follicular ovaries such as with PCOS. young age.
high estradiol levels during ovulation induction. and pregnancy

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 NND Clinical Vignettes Ed 2.0

A previously normal newborn infant in a community hospital nursery is noted to be

cyanotic at 14 hours of life. She is placed on a face mask with oxygen flowing at 10 L/min.
She remains cyanotic, and her pulse oximetry reading does not change. An arterial blood
gas shows her Pa02 to be 23 mm Mg. Bilateral breath sounds are present, and she has no
murmur. She is breathing deeply and quickly, but she is not retracting. While you are
waiting for the transport team from the nearby children's hospital, you should initiate
which of the following?
A. Indomethacin Infusion B. Saline infusion
C. Adenosine infusion D. Prostaglandin El Infusion

Explanation
Correct Answer (D) the vignette describes an infant with a ductal-dependent cyanotic
congenital heart lesion. In this example. The child had pulmonary atresia without a
corresponding VSO: another example would have been transposition of the great vessels
without a septa! Defect to allow mixing of oxygenated and non-oxygenated blood. Cyanotic
infants who do not improve their saturations with supplemental oxygen should be
evaluated carefully for structural heart disease. the ductusarteriosis typically closes in the
first few hours of life: thus. These children will develop their cyanosis in the same time
frame. Prostaglandin El will help keep the ductus patent until a surgical procedure can be
performed. PGE1 does have the tendency to cause hypoventilation.so arrangements must
be made for a potential artificial airway if necessary. Indomethacin closes a patent
ductuSarteriOSIS. Adenosine is used for supraventricular tachycardia.

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 NND Clinical Vignettes Ed 2.0

A 35-year-old man who lives in a group home says that his roommates are spying on him
by listening to him through the electrical outlets. For this reason, he has changed
roommates a number of times over the last 5 years. He dresses strangely, is dirty with
unkempt hair, and seems preoccupied. He reports that he has trouble paying attention to
the doctor's questions because "I am listening to my leader giving me instructions in my
head:' Neuropsychological evaluation of this patient when he is not hearing voices is most
likely to reveal
A. Memory impairment B. inability to state his name and lack of orientation
to place
C. Mental retardation D. Frontal lobe dysfunction
Explanation
Correct Answer (D) This man, who dresses strangely, shows poor grooming. and has
paranoid delusions and auditory hallucinations over a prolonged period, is most likely to
have schizophrenia. Neuropsychological evaluation of a patient with schizophrenia is most
likely to reveal frontal lobe dysfunction. People with schizophrenia usually show intact
memory: orientation to person, place, and time: and normal intelligence.

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 NND Clinical Vignettes Ed 2.0

A 4 yr old previously well girl presents with fever (temperature of 103°F), nonproductive
cough, dyspnea, and left-sided chest pain. Initial examination reveals an ill-appearing child;
pulse rate is 125 beats/min, respiratory rate is 40 breaths/min, and room air oxygen
saturation is 89%. Auscultation demonstrates decreased air movement on the left side,
with crackles. Chest radiograph shows a left lower lobe consolidation. What is the
appropriate initial antibiotic therapy?
A. IV ampicillin/sulbactam B. IV cefotaxime
C. IV cIinclamycin D. PO amoxicillin

Explanation
Correct Answer (B) Treatment of suspected bacterial pneumonia is based on the
presumptive cause and the age and clinical appearance of the child. For mildly ill children
who do not require hospitalization. Amoxicillin is recommended. In communities with a high
percentage of penicillin-resistant pneumococci, high doses of amoxicillin (80-90 mg/kg/24 hr)
should be prescribed. Therapeutic alternatives include cefuroxime axetil and amoxicillin /
clavulanate. For school-aged children and in children in whom infection with M.
pneumoniae or C. pneumoniae is suggested, a macrolide antibiotic such as azithromycin is
an appropriate choice. In adolescents, a respiratory fluoroquinolone (levofloxacin,
moxifloxacin. gemifloxacin) may be considered as an alternative. The empirical treatment of
suspected bacterial pneumonia in a hospitalized child requires an approach based on the
clinical manifestations at the time of presentation. Parenteral cefotaxime or ceftriaxone is
the mainstay of therapy when bacterial pneumonia is suggested.

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 NND Clinical Vignettes Ed 2.0

Arterial blood gas analysis of a patient reveals pH-7.2, HCO3-36 mmo1/1.. and PaCO2 - 60
mmHg.The abnormality is
A. Respiratory acidosis with metabolic acidosis B. Respiratory acidosis with
metabolic alkalosis
C. Respiratory acidosis D. Respiratory alkalosis with
metabolic acidosis
Explanation
Correct Answer (B) Respiratory acidosis is a state in which decreased ventilation
(hypoventilation) increases the concentration of carbon dioxide in the blood and decreases
the blood's pH (a condition generally called acidosis). Carbon dioxide is produced
continuously as the body's cells respire, and this CO2 will accumulate rapidly if the lungs do
not adequately expel it through alveolar ventilation. Alveolar hypoventilation thus leads to
an increased PaCO2 (a condition called hypercapnia). The increase in PaCO2 in turn
decreases the HCO3-/PaCO2 ratio and decreases pH. Metabolic alkalosis: Metabolic alkalosis
is a metabolic condition in which the pH of tissue is elevated beyond the normal range
(7.35-7.45). This is the result of decreased hydrogen ion concentration, leading to increased
bicarbonate. or alternatively a direct result of increased bicarbonate concentrations. The
condition typically cannot last long if the kidneys are functioning properly. Mild cases of
metabolic alkalosis often cause no symptoms. Typical manifestations of moderate to severe
metabolic alkalosis include abnormal sensations. neuromuscular irritability. tetany,
abnormal heart rhythms (usually due to accompanying electrolyte abnormalities such as low
levels of potassium in the blood), coma, seizures. and temporary waxing and waning
confusion.

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