Interactive MCQ in Internal Medicine

[The reader]

Let's get started!

This is an interactive case discussion. I will present it in a MCQs format. Don't feel shy to put your response and your explanation. We are doing this to learn. If you will be shy or worried about your "social image" if you answered wrongly, you will never learn!


A 42 year old male journalist presents to the ER with 2 days history of pain and progressive swelling of his R-knee to the point that he could not put any weight on it. There is history of fever, rigors and chills. He had a sore throat prior to the current symptoms. He is not taking any medications. The patient is febrile at 38.9 C, HR=105, regular, BP= 135/90 RR=24. There is reddness over the R-knee and severe effusion with very limited range of motion due to severe pain.

What is your immediate next step for your carring of this patient:

A) Obtain a more detailed history and do a thorugh physical examination.
B) Perform a R-knee joint aspiration and send fluid for Gr. stain, culture, cell count and diff. and for crystals.
C) Send septic work-up including CBC, CXR, blood cultures and urine culture
D)Start the patient on IV broad spectrum antibiotics and admit him to the hospital.
E) Send this patient home with NSAIDs and oral antiotics to treat for both septic arthritis and gout.

Read it for a second time, what is your response and why?
In the future we can make these inteaction live, if you wish,
I hope that you will like this excersise.

My regards,

[Totti]

Asalam 3alikom

welcomk doctor

my answer is :
C) Send septic work-up including CBC, CXR, blood cultures and urine culture


and I hope that is correct
:eye:
Totti

[The reader]

Why did you choose C, totti?

[Totti]

sorry doctor but I changed my answer to D

now my new answer is:
D)Start the patient on IV broad spectrum antibiotics and admit him to the hospital

because from the history I think they are clinical features of septic arthritis and we have to start with blind antibiotic until we know the organisms that caused the symptoms by Performing a R-knee joint aspiration and send fluid for Gr. stain, culture, cell count and diff. and for crystals then give the suitable antibiotic .


:eye:

Totti

[The reader]

What other people think??

Do you agree with what totte is saying?

Come on!
Express your opinion. Show us your thinking!

[WaLeeD]

AssaLamu3LaiKuM..

UmmMm..
Deardoctor..
I do think that it is D

Bcoz the information mentioned in the Q are enough..
And since the infection has progressed to be septic..
I think we should exert an urgent attension..
And try to limit the infection.. then we can go for other investigations..

This is my openion..
Thanx

[Scarface]

salam

im so glad to see you here doctor

it's really a wide step

to improve ourselves as well as our fourm...


about that case,,,

i think im going with ((D))

Start the patient on IV broad spectrum antibiotics and admit him to the hospital...

because we can't let him just go by the same complains for sure, and i think there is need to do some investigations at that time, IV broad spectrum antibiotics till the patient shows well if not change accourding to the investigations then send him back home with antibiotics if he need,,,


i hope im saying thing!!!



doctor hani thanks again...


bye,

[The reader]

The justification of choice D is absolutely right! But (D) is not the right answer for this question!

Is it mysterious?

Think again and see what is more "immediate" next step in management?

Don't hate me!!

By the way I am Hani, not doctor!! Even in the internet Y Waleed!!!

Good luck

[profnoni]

ok i ll give u my point of view in ER dep cos im working for more than 6moth in er so doc the issue is here that all of them are right except E but the problem in ur piriority of care
soo for me to know better about the pt i ll go for A as Hx but i can do blood work up in the same time of taking the Hx and u cant take a full hx without the blood results and u cant start ur treatment and ur last final diagnosis without the blood results
so it ll go like this A& c then b then D...
cos u cant start the pt on AB without ur cultures and sensetivity cos the best results is when the temp is in the peak even before giving analgesics..
i hope i got nearly to yhr right answer..
thanx for making my brain working at this time...
good luck
:eye:

[WaLeeD]

SaLaaAam

Haha Sorry Sir..
:15:

UmmMm..
Well.. if D is not the correct answer of this Q..
so I'll change to A.. UmmMm I dont know if we really in a need to know more details about this pt.. since it is written in the choice E that it is septic arthritis and gout..


UmmMm..
Ok it is A ..

[profnoni]

ok im lost
but i ll go to A if u already v the dx as in E that its septic artheritis and gout but the issue here is it very bad or the pt could tolerate it
is the pt diabetic on insulin ....or other meds or he is having other disease that may contraindicate with the condition now
i think more hx so u can decide to admit or discharge..
thanx man....
:eye:

:sun:

[H@SSOOM]

Salam all

I am here to learn and I will do mistakes as I want
No marks here


The patient is a journalist
This is maby usefull


He had a sore throat prior to the current symptoms
This is also important


It seems that there is no wrong answer but the problem is to decide what to do first


A) Obtain a more detailed history and do a thorugh physical examination
I think this choice is closely correct
But even if he told me there is a history of arthritis or gout or trauma , I think my aim is to relief his pain first by any way.


B) Perform a R-knee joint aspiration and send fluid for Gr. stain, culture, cell count and diff. and for crystals.
Yes we can do this later but not now in ER

C) Send septic work-up including CBC, CXR, blood cultures and urine culture
Yes septicemia is possible but I think we can do that later on

Here I have a question; can you clarify what is the benefit of CXR?? Is it to investigate a pericardial problem?


D)Start the patient on IV broad spectrum antibiotics and admit him to the hospital
This was my answer but I changed it when you said it is wrong


D) Send this patient home with NSAIDs and oral antiotics to treat for both septic arthritis and gout.
From pharmacology I think we need a very large dose of NSAIDs which is not recommended
But I have no idea bout antiotics

Gout is treated by Allopurinol or colchicines which are not mentioned here



About Cardiac arrest replay he said
"and I need to do a full physical examination "from head to toe"
Then i will proceed to other investigations."




But can you do that full examination while the patient is complaining of sever pain?????


Hmmmmmm I am thinking if there is a possibility of a history of trauma on his knee but if that is correct then the sentence "
He had a sore throat prior to the current symptoms" will be useless


Finaly
My answer is B
B) Perform a R-knee joint aspiration and send fluid for Gr. stain, culture, cell count and diff. and for crystals.
Because the Aspiration will relief the sever pain and will allow me to do my history and physical examination kindly at the same time the results of cultures will direct me to further steps
So the Aspiration is Diagnostic and therapeutic or I can say " symptomatic treatmen"



Sorry for talking too much

And I am waiting for the correct answer

[profnoni]

intresting doc :?:

i think ur right the way of thinking is critical nd that what we need in ER
critical thinking in sake of the pt

i hope u r right cos i agree w u

ihope man..:eye:

[Scarface]

salam again,

D is wrong,,,

isn't that cheating..

i like it in the learning way

thank you



so, let's see now..

A) Obtain a more detailed history and do a thorugh physical examination.

for sure it's highly needed but acutally i still don't know if we have a full picture here or not... left it for a while,

B) Perform a R-knee joint aspiration and send fluid for Gr. stain, culture, cell count and diff. and for crystals.

i think it's important, when we can't recognize the disease -as this status ( for meee)- , and also it's not need if it's a known one... may be but not imprtant and immediate...,

C) Send septic work-up including CBC, CXR, blood cultures and urine culture

really you drive me to read about investigations, because i have a blind idea about its needs, when and for what!!?

D)Start the patient on IV broad spectrum antibiotics and admit him to the hospital.

my previous choice, which was wrong...
i'ld like to choose it again..!
nooo not that much.. it still correct but it wasnt the answer

E) Send this patient home with NSAIDs and oral antiotics to treat for both septic arthritis and gout.

with those complains.....----> i dont think so,





depending on my low educational level and poore knowlage...

i decided to choose A

i need to know more... at least things i know...

thanks again,

[The reader]

Very mature and excellent scientific discussions!

I wish if we could run our lectures and sessions with this kind of discussions! I had a student telling me the only way to learn is to have someone tell the information so the barin can absorb it?? I was shocked to hear that! This is a classical example of passive learning! I will be realy reluctant to send my family to such doctors in the future!!

Anyhow back to the question:

The major objective was to make sure that the learner is able to recognize and manage septic arthritis as a medical emergency. I admit that it is a "dirty" question but I brought it so we can learn:
1- how to read what is required from the question realy carefully."immediate next step"

2- how to think about medical emergencies.

There is nothing to add to what is mentioned in the question to help you decide to admit or discharge the patient. He is in sepsis and you suspect septic arthritis (IV antibiotics) and all that requires definite hospital admission.
For sure you can take full histosy and examination and start your management without knowing the full results of the blood tests. In the case presented delaying management and taking more history is inappropriate. You can always come back again to take more history and do more detailed examination after setteling your patient down and this is what is happening in real life. There are many times in medicine where you should or more strictly you must start your management prior to complete your history and PE. (think of acute MI, Status epilepticus,..). On the other hand, this is not to underestimate the value of history taking.
In this question A is placed to test your clinical sense; you have a patient with sepsis, and you suspect septic arthritis, do you still want to take more history and PE in addition to what is mentioned plus he is in severe pain??

(E) is out, as septic arthritis is a medical emergency. We should think of it as we think about meningitis. Delayed management leads to irreversible damages!!

(B, C, D) well be done simultaneously in clinical practice or they have to be done!!(CXR is to look for a septic focus that lead to the dissemination of bacteria to the blood then to the joint). Keep in mind that joint aspiration is No1 thing that you have to do to establish your diagnosis and as a theraputic intervention as well. It is easy and quick. You can not start treating something embrically unless you can not isolate the cauastive agent or it is not worth isolating it (as in the case of community acquired pneumonia that does not need hospital admission). Here you should aspirate first and then start your empiric antibiotic (cloxacillin 2gm IV every 4h, why?) then you have to adjust your antibiotic according to the culture results.

daily aspiration is part of septic arthritis mangement.

So...the correct answer is (B), credits for Hussam. His justification is correct with little modification. (you can treat gout with NSAIDs, pharmacology is to teach you about medications but not how and when to treat diseases).

I hope that you will like this discussion.

I want to hear your comments and your response or reaction to what is mentioned above. In other words what did you learn out of this? Even if you don't want to write it, just mention it to yourself!

Should we continue with these excercises??

My regards...

[dr_messo]

woooooow

dr.hani really this is very nice discussion


for sure we need to cont. this type of scientific discusions


in our lovely forum

[H@SSOOM]

Salam dears


I think this is the most useful topic I ve seen in this forum

and I hope if we continou like that but


1 it is better if we think loudly " by writing what we are thinking in " not just put the answer
we did that but we have to improve it




2 If we have a case every week , very nice
of course we can do more but let's make this as a standerd


dr hani why you don't tell as during the final exam that number D is wrong???!!:o:




finally thanx alot for inducing us to think

[reda0007]

Assalmu Alykom

Really gret topic and extremely useful discussion

Please we need to continue more and more

one of the widespread faults in the system of teaching i think

is Ignoring of corretcting of mistakes

Unfortunatly ,, doctors blam much times but correct far less times

and really rare to discuss the mistakes

thanks brother Hani and Jazk ALLAH kheer

and pliz discuss more and more

regards

[Scarface]

Salam again 2

Ooh, Hani..

We were always like that... and you knew it!!

No that much..

About the idea,

A very terrific modern learning way with a great interesting teacher, good follower and reader. I hope it to stay.. ( it will insha'a Allah )

Actually I learn a lot of things at that exercise starting from how to think in MCQs which such way.. give the possibilities to answer.. not every ture giving information is an answer.. CXR importance as well.. and my bad thinking and wrong answer(s)..

My hope,..

Please complete what did you start, we felt the benefit from the beginning…
At least once weakly..

Thanx;