(MCQS 364-366):a 67-year-old football fan complains of recent onset of hoarseness and easy fatigability of his voice

Correct Answer: J
Patients with unilateral vocal cord paralysis typically present with a breathy, weak voice caused by incomplete adduction of the paralyzed vocal cord. A unilateral vocal cord paralysis can occur as a result of a lesion anywhere along the path of the vagus or recurrent laryngeal nerve, and the evaluation of this condition may necessitate imaging from the base of the skull to the level of the arch of the aorta. Other etiologies include injury of the recurrent laryngeal nerve during thyroid surgery, carotid endarterectomy, anterior cervical laminectomy, thoracic surgery or cervical trauma.7 Speech therapy and surgery aimed at medializing the paralyzed vocal cord (medialization laryngoplasty) are the primary treatment options after identifying and treating the etiology of the paralysis.
Correct Answer: D
There is a critical and potentially life-threatening complication associated with recurrent hypoglycemia: Hypoglycemia Unawareness and Reduced Counterregulatory Responses. While the mechanisms for this syndrome of hypoglycemia-associated autonomic failure are still under investigation, the dangers of the self-defeating response are apparent. If hypoglycemia leads to further and more severe hypoglycemia, a vicious cycle is set forth and the patient becomes more vulnerable to CNS damage. Prolonged hypoglycemia may cause permanent neurological deficit or death. Unrecognized infection causing hypoglycemia in diabetic patients may result in recurrent hypoglycemic spells or progression of the infection This patient should be switched to continuous subcutaneous insulin infusion, this may result in better control of her glycemia. Alternatively her dosage should be reviewed.
Correct Answer: E
Loose-jointedness is often striking in patients with the Marfan syndrome. Flat feet (pes planus), hyperextensibility at the knees (genu recurvatum), elbows, and fingers, congenital dislocation of the hips, and recurrent dislocation of the patellae are manifestations of laxity of ligaments and joint capsules. A relatively narrow palm of the hand, long thumb, and longitudinal laxity of the hand are the bases for the Steinberg thumb sign: the thumb apposed across the palm extends well beyond the ulnar margin of the hand. Depression of the sternum (pectus excavatum), protrusion, or an asymmetric combination often results. The vertebral column is frequently deformed. The normal thoracic kyphos is often reduced, resulting in a 'straight back' or an outright thoracic lordosis. Scoliosis may involve multiple segments and may progress rapidly, particularly during the adolescent growth spurt. Most patients with the Marfan syndrome have myopia and about one-half have subluxation of the lenses (ectopia lentis). The ascending aorta bears the main stress of ventricular ejection, leading to progressive dilatation beginning in the sinuses of Valsalva. Aortic regurgitation and dissection are the main causes of death.


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