A 78 year old man has low back pain for 6 weeks and is seen in his GP surgery. There is no radiation of pain. He has no history of trauma. Investigations: Haemoglobin 78 g/L, ESR 98 mm/hr. Which is the most likely diagnosis?

Correct Answer: C

Rationale: The correct answer is C) Multiple myeloma. In this case, the patient presents with low back pain, anemia (Hb 78 g/L), and an elevated ESR (98 mm/hr), which are concerning for a systemic condition like multiple myeloma. Multiple myeloma is a malignancy of plasma cells that can present with bone pain, anemia, and elevated inflammatory markers like ESR. Option A) Discitis typically presents with localized back pain, fever, and tenderness over the affected vertebrae, often following a recent infection or procedure. The absence of these symptoms makes discitis less likely. Option B) Mechanical back pain is a common cause of back pain, usually related to musculoskeletal strain or injury. However, the presence of anemia and elevated ESR in this case suggests a more systemic issue than mechanical back pain. Option D) Osteoporotic wedge fracture is common in older adults and can cause back pain, but it typically does not present with anemia and elevated ESR. In this case, the laboratory findings are more suggestive of a systemic process like multiple myeloma. In an educational context, this question highlights the importance of considering systemic conditions in older adults presenting with nonspecific symptoms like back pain and anemia. Understanding the clinical features and laboratory findings associated with different conditions helps healthcare providers make accurate diagnoses and provide appropriate care for patients with psychiatric emergencies.

Correct Answer: A

Rationale: In this scenario, the most likely medication responsible for the woman's presentation is Amitriptyline (Option A). Amitriptyline is a tricyclic antidepressant that can cause anticholinergic toxicity, leading to symptoms such as dilated pupils, dry mucous membranes, and urinary retention (palpable bladder) due to its potent anticholinergic effects. Fluoxetine (Option B) is a selective serotonin reuptake inhibitor (SSRI) and typically does not cause the anticholinergic symptoms described in the case. Lithium (Option C) is a mood stabilizer and is not known to produce these specific anticholinergic effects. Phenelzine (Option D) is a monoamine oxidase inhibitor (MAOI) and does not typically result in anticholinergic toxicity. In an educational context, understanding the side effect profiles of different psychiatric medications is crucial for healthcare professionals, especially those working in emergency settings. Recognizing the signs of anticholinergic toxicity can aid in prompt and appropriate management of psychiatric emergencies, ensuring patient safety and optimal outcomes.

Correct Answer: D

Rationale: In this scenario, the most likely affected nerve is the Radial nerve. The Radial nerve innervates the muscles responsible for extension at the elbow, wrist, and fingers. Following recovery from general anesthesia, a common complication is compression or injury to the Radial nerve, leading to weakness in grip strength. The other options can be ruled out based on their respective innervations and functions: - Axillary nerve: Innervates the deltoid and teres minor muscles, not responsible for grip strength. - Median nerve: Innervates muscles of the forearm and hand responsible for flexion, not directly related to grip strength loss. - Musculocutaneous nerve: Innervates the biceps brachii muscle, involved in elbow flexion, not grip strength. Educationally, understanding the innervation and functions of major nerves is crucial in diagnosing and managing neurological deficits postoperatively. This knowledge aids in identifying the specific nerve affected based on the presenting symptoms, guiding appropriate interventions and preventing further complications.

Correct Answer: D

Rationale: In this scenario, the most appropriate management for the 65-year-old woman presenting with symptoms of depression and suicidal ideation for 8 weeks would be option D) Sertraline, a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. Sertraline is a recommended first-line treatment for major depressive disorder due to its efficacy in improving mood, reducing suicidal ideation, and addressing associated symptoms like poor concentration, low energy, and sleep disturbances. SSRIs are often preferred over tricyclic antidepressants like Amitriptyline (option A) due to their more favorable side effect profile and safety in overdose situations. While therapy modalities like Cognitive Behavioral Therapy (CBT) (option B) and Psychodynamic Therapy (option C) are valuable adjuncts to pharmacological treatment for depression, in acute cases with significant suicidal ideation, initiating medication like Sertraline is crucial for immediate symptom relief and risk reduction. Educationally, understanding the rationale behind choosing the appropriate medication in psychiatric emergencies is vital for healthcare professionals working with individuals experiencing mental health crises. This case highlights the importance of timely intervention, risk assessment, and evidence-based treatment selection to ensure the safety and well-being of patients in crisis.

Correct Answer: D

Rationale: In the context of a 64-year-old man presenting with retrosternal chest pain, the most appropriate immediate test is an ECG (Option D). An ECG is crucial in the evaluation of patients with chest pain as it can quickly detect abnormalities indicative of acute coronary syndromes such as ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI). An angiogram (Option A) is an invasive procedure used to visualize blood vessels and is typically not the first-line test in the acute setting of chest pain. A chest X-ray (Option B) may help identify other causes of chest pain like pneumonia or pneumothorax but does not provide immediate information on cardiac status. Checking creatine kinase levels (Option C) can aid in diagnosing myocardial infarction but is not as immediate or specific as an ECG in diagnosing acute coronary syndromes. In an educational context, it is important for healthcare providers to understand the significance of prompt and accurate assessment of patients presenting with chest pain, especially in the setting of a potential cardiac emergency. Teaching the appropriate use of diagnostic tests like ECGs can help improve patient outcomes by enabling timely intervention and treatment.