Case-based MCQ

Case-based MCQ | #MCQ_99 •••••••••••••••••••••••••••••••••••••• Robert is a 72-year-old patient of yours, who was diagnosed with Parkinson disease 10 years ago. Recently he developed agitation, for which he was prescribed haloperidol. Today, he is brought to you office by his son with complaint of marked increase in his tremors. Which one of the following is the most appropriate management? A. Do nothing. B. Increase the dose of haloperidol. C. Increase the dose of anti-Parkinson medications. D. Decrease the dose of haloperidol. E. Switch to risperidone.

Correct Answer Is E Drawing intersecting pentagons assesses the ability of the patient in constructional praxis (a task which requires three-dimensional manipulation). This is a task of non-dominant (right) parietal lobe. Lesions of non-dominant parietal lobe lead to constructional apraxia

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Case-based MCQ | #MCQ_98 •••••••••••••••••••••••••••••••••••••• On neurological assessment of a patient, he is unable to copy a pentagon. Which one of the following is the site of the lesion? A. Temporal lobe. B. Temporoparietal lobe. C. Frontal lobe. D. Dominant parietal lobe. E. Non-dominant parietal lobe.

Correct Answer Is B The scenario describes a rather common clinical situation: a patient with suspected bacterial pharyngitis develops rash after being started on amoxicillin. This occurs when a patient with infectious mononucleosis is misdiagnosed as bacterial pharyngitis and started on antibiotics. Infectious mononucleosis (IM) is a febrile illness caused by Epstein–Barr virus from herpes family. It can mimic diseases such as primay HIV infection, streptococcal tonsillitis, viral hepatitis and acute lymphatic leukemia. It may occur at any age but is more common between10 and 35 years with the peak incidence among those ages 15-25 years. IM has an incubation period of 4-6 weeks. The disease may initially present with sore throat (the cardinal finding), lymphadenopathy, fever, rash, and hepatosplenomegaly. The rash of IM is almost always related to antibiotics given for tonsillitis. The primary rash, most often non-specific, pinkish and maculopapular (similar to that of rubella), occurs in only about 5% of cases. It is usually blanching and non-pruritic. The secondary rash is most often precipitated by one of the penicillins, especially ampicillin or amoxycillin. About 90–100% of patients prescribed ampicillin or amoxycillin will be affected. This rash is non-blanching and itchy, and develops 5-9 days after antibiotics are started.   The rash of this patient is most likely to be an allergic reaction to the antibiotic. The exact mechanism of rash following administration of antibiotics in IM is not fully understood. Some authors believe it is not a consequence of a genuine allergic reaction because most patients will not be sensitive to the implicated antibiotic after IM resolves. Some theories suggest that the rash is caused by both decreased immune system tolerance and enhanced immune response to the implicated drug during the infection.

Six days ago, a 30-year-old man presented to your practice with complaints of acute sore throat and a fever of 39.2°C. On examination, he had red swollen tonsils with exudate. He was prescribed amoxicillin. Today, he has presented with a non-blanching pruritic rash. Which one of the following options best describes the most likely cause for the rash? A. Infectious mononucleosis. B. Allergic drug reaction. C. Hypersensitivity vasculitis. D. Varicella zoster infection. E. Streptococcal pharyngitis

Case-based MCQ | #MCQ_96 •••••••••••••••••••••••••••••••••••••• Correct Answer Is C The decreased RCC and hemoglobin in this patient represent anemia. With the decreased MCV, the anemia is microcytic. The most common causes of microcytic anemia are iron deficiency and thalassemia. This clinical picture, however, is inconsistent with thalassemia minor (trait) (option B) because although patients with thalassemia minor has isolated mild microcytic anemia, the red cell count, unlike in this patient, is normal of even increased. Moreover, the anemia of thalassemia minor is asymptomatic. Strict vegetarians are prone to vitamin B12 deficiency as this vitamin is only available in animal products such as meat, poultry, fish, eggs, and dairy products. Vitamin B12 deficiency (option E) causes macrocytic anemia that does not explain the microcytosis in this scenario. A vegetarian diet includes green-leaf vegetables that provide adequate dietary iron to prevent from iron deficiency. Anemia caused by vegetarian diet (option D) is more likely to be macrocytic and have been caused by vitamin B12 deficiency. Cecal cancer (option A) and right-sided colon cancer in general often present with anemia and its symptoms such as fatigue and weakness (as opposed to left-sided colorectal cancers that usually manifest with altered bowel habits and rectal bleeding); therefore, should be considered and investigated in patients with microcytic anemia, or iron deficiency anemia to be more specific. This is even more important in older patients. However, colorectal cancer in vegetarians is extremely rare because high-fiber diets are a protective factor against colorectal cancer. Given the history and exclusion of other options, hookworm infestation remains the most likely explanation to this scenario. Human hookworm disease is a common helminth infection predominantly caused by the nematode parasites Necator americanus and Ancylostoma duodenale. Hookworm infection is acquired through skin exposure to larvae in soil contaminated by human feces. Worldwide, hookworms infect an estimated 472 million people. It is endemic in many underdeveloped or developing regions in the work including African, south Asia, Mediterranean region, and south America. The larvae of hookworm from the soil enter the foot sole skin, then migrate through the dermis, enter the bloodstream, and move to the lungs within 10 days. Once in the lungs, they break into alveoli, causing a mild and usually asymptomatic alveolitis with eosinophilia. Form the alveoli, the larvae are carried to the glottis by the ciliary action of the respiratory tract. During pulmonary migration, the host may develop a mild reactive cough, sore throat, and fever that resolve after the worm migrates into the intestines. At the glottis, the larvae are swallowed and carried to their final destination, the small intestine. Of all infested people, only 10% develop symptoms which include iron deficiency anemia due to loss from small intestine in patients with moderate to severe infestation burden.

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A 70-year-old woman presents to your practice with complaints of weakness and easy fatigability for the past 5 months. She is a recent immigrant from Algeria landing on Australia almost 8 months ago. She has been a vegetarian most of her adult life. Past medical history is insignificant for any chronic condition otherwise. Based on the history and physical findings, you suspect anemia and order a full blood examination (FBE) which is significant for a red cell count (RCC) of 2.9x1012/L (4.5-6.5x1012/L), hemoglobin of 90 g/L (120-160 g/L), MCV of 62 fL (80-100 fL). Which one of the following could be the most likely cause of this presentation? A. Cecal cancer. B. Thalassemia minor. C. Hookworm infestation. D. The vegetarian diet. E. Vitamin B12 deficiency.

Case-based MCQ | #MCQ_95 •••••••••••••••••••••••••••••••••••••• Correct Answer Is A For those, whose warfarin therapy has been stopped before major surgical procedures, it is recommended that the previous maintenance dose of warfarin be resumed on the night of surgery (12-24 hours). In addition to warfarin, low molecular weight heparin (LMWH) in prophylactic dose or unfractionated heparin (UFH) with slow infusion is started at the same time. The target APTT is 1.5 times the normal. LMWH or UFH is continued for at least 5 days and is ceased 48 after the target INR is reached (≥1.8)

A 55-year-old man has been on warfarin for AF for the past 3 months. He presented with an incarcerated inguinal hernia and was booked for emergent surgery. Warfarin was stopped and fresh frozen plasma was given. Which one of the following is the time to resume warfarin therapy? A. 12 hours post-op. B. 48 hours post-op. C. Immediately after recovery from anesthesia. D. 5 days post-op. E. When INR is less than 1.8 again

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Case-based MCQ | #MCQ_94 •••••••••••••••••••••••••••••••••••••• Correct Answer Is B The Scenario describes a healthy child with a platelet type of bleeding. In bleeding disorders with faulty platelet or platelet-mediated coagulation, the bleeding tends to occur immediately after insult and is superficial. In patients with factor deficiency (factor type of bleeding), the bleeding is deep (e.g., into muscles and joints) and delayed, because initially, platelets will establish homeostasis. Von Willebrand disease (VWD) is an inherited disease with many different types (22 types) and clinical pictures. Almost all types cause mild bleeding problems with excellent prognosis. The most common types often have an autosomal dominant inheritance. This disease is very common (1 in 100 population) and is the most common inherited bleeding disorder. Von Willebrand factor is a circulating factor that is attached to factor VIII. This factor by gluing platelets together and to the vascular lining plays the earliest role in coagulation. Because the clinical disease can be very mild, most cases will never be diagnosed, but if symptomatic, the symptoms can include: - Easy bruising - Mucosal bleeding (e.g., epistaxis, menorrhagea, gastrointestinal bleeding, etc) - No history of haemarthroses or intramuscular hematomas (except for type 3, which is very rare but can have musculoskeletal manifestations) - Prolonged bleeding after trauma or surgery The clinical picture and a normal platelet count suggest VWD as the most likely diagnosis.

Case-based MCQ | #MCQ_94 •••••••••••••••••••••••••••••••••••••• Joseph, 5 years old, is brought to the emergency department by his mother. About one hour ago and while running at home, he hits his face against the coffee table and gets a nose bleed. The mother tried to stop the bleeding by compressing the nose and applying ice, to no avail. On physical examination, the child looks otherwise quite healthy with no remarkable finding. A full blood exam (FBE) is inconclusive. Which one of the following could be the most likely cause of this persistent bleeding? A. Immune thrombocytopenic purpura (ITP). B. Von Willebrand disease. C. Hemophilia. D. Leukemia. E. Factor V Leiden mutation.

Case-based MCQ | #MCQ_93 •••••••••••••••••••••••••••••••••••••• Correct Answer Is E The dyspepsia manifested by bloating and belching after cholecystectomy is suggestive of post-cholecystectomy syndrome (PCS) as the most likely diagnosis. PCS affects between 10-15% of patients with cholecystectomy and is characterized by a heterogenous group of symptoms, including: Upper abdominal pain Nausea and vomiting Diarrhea Jaundice Bloating Excessive gas Dyspepsia. These symptoms can be the continuation of symptoms thought to be caused by gallbladder pathology, the development of new symptoms normally attributed to the gallbladder, or symptoms caused by removal of the gallbladder In 90% of the time an etiology can be found. The most common etiologies are: Choledocholithiasis – stones remained or formed in the common bile duct or cystic duct remnant Biliary dyskinesia Continuously increased bile flow to the GI tract Dilation of cystic duct remnant NOTE – choledocholithiasis is the most common cause of PCS. It can involve the common bile duct of the cystic duct remnant. Choledocholithiasis is classified as retained, if found within 2 years of cholecystectomy or recurrent, if the stone id found 2 years after the surgery. Recurrent stones formed as a result of the biliary stasis are often caused by strictures, papillary stenosis, and biliary dyskinesia. 🏷NOTE – Ultrasonography is the initial imaging study of choice for patients with suspected PCS. PCS is a provisional diagnosis, and the presentation should be renamed after a specific cause as an explanation for the symptoms is clinched.