Case-based MCQ

#Case_18 ━━━━━━━━━━━━━━━━ A 53-year-old male accountant comes to your office with progressive facial weakness on the left side that began yesterday. He also reports pain behind the left ear and decreased lacrimation from the left eye. He has been in good health and had his yearly physical examination 1 week ago, which was normal. His lipid levels, chemistry profile, and CBC were all normal. He has not been involved in any outdoor activities, nor does he engage in any high-risk sexual behavior.On examination, there is flattening of the left nasolabial fold and decreased ability to close the left eye. The mouth appears to be drawn to the right. The remainder of his general examination and neurologic examination are normal.Which one of the following would be the most appropriate management at this time? a) Carotid ultrasonography b) High-resolution CT c) MRI with gadolinium enhancement d) Aspirin and observation e) Prednisone and valacyclovir (Valtrex) 〰〰〰〰〰〰〰〰〰〰〰 👥 MCCEE/MCCQ1,2

#Case_17 #answer ✅ A 🔎 Explanation: For patients with asymptomatic PAD with an ABI < 0.9, low-dose ASA (75-162 mg daily) may be considered for those at high risk because of associated atherosclerotic risk factors in the absence of risk factors for bleeding (Class IIb, Level C). For patients with symptomatic PAD without overt CAD or cerebrovascular disease, low-dose ASA (75-162 mg daily) or clopidogrel 75 mg daily (choice A) is recommended providing the risk for bleeding is low (Class IIb, Level B). The choice of drug may depend on patient preference and cost considerations. For patients allergic or intolerant to ASA, use of clopidogrel is suggested (Class IIa, Level B). For patients with intermittent claudication, dipyridamole should not be used in addition to ASA (Class III, Level C). ⚠ For patients with intermittent claudication, using clopidogrel 75 mg daily in addition to ASA 75-162 mg daily (choice B) is not recommended unless the patient is judged to be at high vascular risk along with a low risk of bleeding. ⚠ Neither pentoxifylline (choice C) nor ginkgo biloba (choice D), a dietary supplement with antiplatelet, vasodilating, and antioxidant activity, has been shown to be more effective than placebo. At best, they would be a weak intervention for peripheral artery disease. ⚠ If the patient has been compliant with risk reduction strategies, yet six months to a year of exercise therapy and adjunctive pharmacotherapy have failed to provide satisfactory improvement, referral for possible intervention (choice E) can be suggested. 〰〰〰〰〰〰〰〰〰〰〰 🔗 MCCEE/MCCQE1,2

#Case_17 A 65-year-old white female presents with symptoms and signs of intermittent claudication. She has a history of increasing angina pectoris leading to coronary artery bypass surgery three years ago. She has generally done well since the surgery, and you have provided appropriate medical management forpostoperative coronary artery disease. She has reduced her cigarette smoking, but still smokes and leads a sedentary lifestyle.In addition to emphasizing smoking cessation and recommending an exercise program, which one of the following would be most effective for managing this patient’s claudication? a) Clopidogrel b) Aspirin + Clopidogrel c) Pentoxifylline d) Ginkgo biloba e) Percutaneous intervention 〰〰〰〰〰〰〰〰〰〰〰 👥 MCCEE/MCCQ1,2

#Case_16 #answer ✅ D 🔎 Explanation: This patient has a reduced FVC with an FEV1/FVC ratio of 87.5%. This is consistent with moderately severe pulmonary restriction. Most likely the patient has chronic interstitial restrictive lung disease. Nitrofurantoin can cause this picture, usually after continuous treatment for 6 or more months, and pulmonary function may be impaired permanently. A wide variety of additional causes have been described including noxious gases, pulmonary hypersensitivities, neoplasia, and systemic diseases (e.g., sarcoidosis). Management includes avoidance of the offending agent or treatment of the underlying condition. 〰〰〰〰〰〰〰〰〰〰〰 🔗 MCCEE/MCCQE1,2

#Case_16 A 40-year-old black female presents to your office complaining of a persistent dry cough for the last 3 months. This seemed to start with a “bad chest cold”. She went to an urgent-care facility 6 weeks ago and the physician prescribed albuterol (Proventil, Ventolin) by metered-dose inhaler empirically for presumed reactive airways disease. This did not help. Now she also reports dyspnea on exertion that is noticeable when walking uphill. She has been taking nitrofurantoin (Macrodantin) for chronic urinary tract infections, but has an otherwise negative history. She works as a legal secretary. On examination, she is tachypneic. There is no cyanosis or clubbing. Her lungs are clear. Her height is 160 cm (63 in) and her weight is 60 kg (132 lb). Office pulmonary function tests reveal a forced vital capacity (FVC) of 1.6 L (average 3.3) and a 1-second forced expiratory volume (FEV1) of 1.4 L (average 2.8). An inhaled bronchodilator produces no improvement in these numbers.Which one of the following is the most likely cause of her problem? a) Chronic asthma b) Persistent coughing resulting from a viral respiratory illness c) Cardiac disease d) Interstitial lung disease 〰〰〰〰〰〰〰〰〰〰〰 👥 MCCEE/MCCQ1,2

#Case_15 #answer ✅ A 🔎 Explanation: The patient described has diverticulosis leading to diverticulitis. You must start antibiotics that cover the gram-positive cocci, gram-negative bacilli and anaerobes found in the abdomen. Cefoxitin (choice A) fits the bill.The severity of the inflammatory and infectious processes, as well as the underlying health of the patient, determines the appropriate treatment for patients with diverticulitis. Hospitalization is recommended if patients show signs of significant inflammation, are unable to take oral fluids, are older than 85 years, or have significant comorbid conditions. These patients should be placed on bowel rest and treated with intravenous fluids and intravenous antibiotics. ⚠ Immediate surgery (choice B) is too aggressive at this point. Most patients with acute diverticulitis respond to conservative inpatient medical management. ⚠The usual outpatient antibiotic regimen includes ciprofloxacin (500 mg PO twice daily) plus metronidazole (500 mg PO three times daily). For patients intolerant to metronidazole, clindamycin (choice C) may be an acceptable alternative. ⚠ Continuing the present therapy (choice D) is incorrect because the worsening pain and chills imply infection. ⚠ Colonoscopy (choice E) is dangerous in diverticulitis because it can lead to perforation 〰〰〰〰〰〰〰〰〰〰〰 🔗 MCCEE/MCCQE1,2

#Case_15 ━━━━━━━━━━━━━━━━ A 62-year-old woman comes to the office because of pain in the left lower quadrant of her abdomen for the past 48 hours. The pain is associated with tenesmus, loss of appetite and a sensation of being febrile. She has a history of long standing irritable bowel symptoms and has not taken any pharmacotherapy. Vital signs are: temperature 37.3°C (99.2°F), pulse 84/min and regular and respirations 12/min. On physical examination the abdomen is tender in the left lower quadrant; there is no rebound tenderness and bowel sounds are normal. Leukocyte count is 10.2 x10^9/L with 71% segmented neutrophils and 3% band forms. The patient is sent home on a liquid diet and amoxicillin-clavulanate therapy. Three days later she returns because the pain has become worse and she is now having chills.Which of the following is the most appropriate next step? a) Admit her to the hospital and begin cefoxitin therapy, intravenously b) Admit her to the hospital and prepare her for an immediate operation c) Change to clindamycin therapy, orally, and send her home d) Continue the present course of therapy e) Do colonoscopy 〰〰〰〰〰〰〰〰〰〰〰 👥 MCCEE/MCCQ1,2

#Case_14 #answer ✅ D 🔎 Explanation: This case demonstrates the clinical outcome of abnormal placental attachment. In this situation, the placenta has either partially or completely attached to the myometrium instead of the endometrium, which normally sloughs after birth, thus resulting in detachment of the placenta. The three forms of abnormal attachment (accreta, increta, and percreta) are difficult to differentiate by examination and are treated as the same condition, sometimes generally referred to as “placenta accreta”. No conservative mode of management will definitively treat these conditions when a significant portion of the placenta is abnormally attached. Therefore, if bleeding becomes profuse and the patient’s condition is unstable, prompthysterectomy is required.This patient has low blood pressure and an elevated pulse, likely due to significant blood loss. It is inappropriate to await spontaneous delivery of the placenta, which may never occur. Trying further to remove the placenta will only result in increased bleeding. Pulling on the umbilical cord may result in uterine inversion. There is no indication for any other manual maneuver. 〰〰〰〰〰〰〰〰〰〰〰 🔗 MCCEE/MCCQE1,2

#Case_14 ━━━━━━━━━━━━━━━━ A 28-year-old gravida 2 para 1 successfully delivers a full-term infant vaginally. Her first child was delivered by cesarean section. With this delivery there are no signs of maternal pain, significant bleeding, or hemodynamic compromise during the first two stages of labor. However, 30 minutes after delivery of the infant there is still no umbilical cord elongation or contraction of the uterus, and the placenta is not at the cervical os. Manual exploration of the uterus reveals that the placenta is attached in a low anterior position and there is no easily discernible plane of separation. During this procedure, uterine bleeding becomes brisk and continues despite bimanual massage and administration of oxytocin (Pitocin), 10 U intramuscularly. Vital Signs: Temperature: 37.0°C (98.6°F) Pulse: 120 beats/min Blood pressure: 88/46 mm Hg Respirations: 20/min O2 saturation: 98% on room air.Which one of the following should be done next? a) Increase traction on the umbilical cord b) Insert a fist into the uterine fundus and use firm upward pressure toward the patient’s head c) Use a ring forceps to forcefully remove the placenta from the uterus d) Prepare for urgent hysterectomy e) Wait an additional 15-20 minutes for spontaneous placental separation 〰〰〰〰〰〰〰〰〰〰〰 👥 MCCEE/MCCQ1,2

#Case_13 #answer ✅ A 🔎 Explanation : This patient’s symptoms of pain in lower limbs that travels from one leg to another, findings on physical examination of an erythematous nodule of a superficial leg vein that is firm, thickened and possibly thrombosed is suggestive of superficial thrombophlebitis. When it travels from one place to another, it is also known as thrombophlebitis migrans. In this patient, who also presents with 8 kg weight loss over the last 3 months, thrombophlebitis migrans is concerning for malignancy. The most common cancers associated with this condition are pancreatic and lung cancer but it could also be noted in other cancers such as colon and gastric cancers. Thrombophlebitis migrans is also known as Trousseau sign of malignancy. Given the link between this sign and pancreatic cancer, out of the choices given, the best study that would reveal the underlying disease in this patient is abdominal CT scan (choice A). ⚠ Peripheral angiography (choice B) would be done to confirm the extent of peripheral artery disease. This patient’s condition is thrombophlebitis migrans. ⚠ Ventilation perfusion scan (choice C) is done in patients suspected of pulmonary embolism, which can be a complication of deep vein thrombosis. This patient’s clinical presentation doesn’t suggest pulmonary embolism. ⚠ D-dimer test (choice D) is the degradation product of crosslinked fibrin. It reflects ongoing activation of the hemostatic system and is done as a screening test for deep vein thrombosis in patients suspected to have it with low probability. While usually work-up is done in patients with superficial thrombophlebitis to rule out deep vein thrombosis, this question is asking about a study that would confirm the primary cause of this patient’s condition. In the presence of thrombophlebitis migrans, weight loss, and a long history of cigarette smoking, doing an abdominal cancer work up is more appropriate. ⚠ Antinuclear antibodies and rheumatoid factor (choice E) are non-specific tests that may be positive in a number of autoimmune and rheumatologic conditions. This patient’s most likely diagnosis is thrombophlebitis migrans caused by a malignant tumor. ✅ Key point: Migratory superficial thrombophlebitis and weight loss in an elderly patient with a long cigarette smoking history is suggestive of malignancy until proven otherwise. Work-up should include abdominal CT scan to rule out pancreatic cancer 〰〰〰〰〰〰〰〰〰〰〰 🔗 MCCEE/MCCQE1,2

#Case_13 ━━━━━━━━━━━━━━━━ A 62-year-old male presents to your department complaining of pain in the lower limbs. This is the second visit in the last 3 weeks.Three weeks ago the pain was mostly in the right leg but this time the pain is in the left leg. The patient denies any recent trauma or hospitalization. The patient has lost 3 kg over the last 3 weeks and a total of 8 kg the last 3 months. He drinks alcohol occasionally and has smoked one pack of cigarettes a day for the last 37 years. You note an erythematous nodule on the saphenous vein of the left leg. Palpation reveals a firm, thickened, and possibly thrombosed vein.Which of the following is most likely to confirm the original cause of this patient’s condition? a) Abdominal CT scan b) Peripheral angiography c) Ventilation perfusion scan d) D-dimer test e) Antinuclear antibodies and rheumatoid factor 〰〰〰〰〰〰〰〰〰〰〰 🌐https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_12 #answer ✅ C 🔎 Explanation: It is generally not considered necessary to refer patients with classic polymyalgia rheumatica for a temporal artery biopsy in the absence of symptoms or signs of giant cell arteritis (e.g., headache, visual complaints, jaw claudication, fever, scalp tenderness, abnormal funduscopic exam). Corticosteroids should be started at relatively low doses (10-20 mg daily) and the patient followed for what should be a rapid clinical response. 〰〰〰〰〰〰〰〰〰〰〰 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_12 〰〰〰〰〰〰〰〰〰〰〰 A 75-year-old female presents with a 1-month history of pain in her hips and shoulders bilaterally, accompanied by marked stiffness in the mornings. In addition, she reports a 4-lb weight loss and fatigue. She denies fever,chills, sweats, nausea, vomiting, swallowing disturbances, or changes in bowel habits. She specifically denies any visual symptoms of headache. Her physical examination is unremarkable, except for changes suggestive of osteoarthritis in the knees and hands. Laboratory testing reveals a hemoglobin level of 118 g/L, a hematocrit of 36%, and an erythrocyte sedimentation rate of 84 mm/hr (N < 20). What is the most appropriate management at this point? a) Begin prednisone, 60 mg daily, and refer for a temporal artery biopsy as soon as possible b) Begin prednisone, 60 mg daily, and plan to refer for a temporal artery biopsy if her symptoms do not respond c) Begin prednisone, 15 mg daily, with no plans for a biopsy d) Begin a COX-2 inhibitor such as rofecoxib (Vioxx), with no plans for a biopsy e) Refer for a temporal artery biopsy and wait for the results before starting drug therapy. 〰〰〰〰〰〰〰〰〰〰〰 🌐https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_11 #answer ✅ A 🔎 Explanation: The child’s clinical picture is suggestive of bronchiolitis obliterans secondary to adenovirus respiratory infection. Adenovirus infections commonly affect children between 1 and 3 years of age and besides respiratory infection it may cause follicular conjunctivitis,gastroenteritis,intussusception, hemorrhagic cystitis, and myocarditis. Adenovirus pneumonitis is associated with the development of bronchiolitis obliterans. The diagnosis of bronchiolitis obliterans can be made based on history, physical examination, imaging and ventilation/perfusion scan. Initial symptoms may be cough, chest pain, or hemoptysis. After the initial episode a clinical plateau ensues that may last several days to one month during which symptoms appear to abate. However, following this period dyspnea worsens and cough becomes more frequent. Chest X-ray findings are non-specific and include peri-bronchial thickening and hyperinflation. The latter is characterized by lowered diaphragm, increased air contrast of the lungs, and increased retro-sternal space in the lateral view. Atelectasis is also a common finding. Ventilation/Perfusion scans show the distinctive pattern of a matched ventilation -perfusion defects and the segmental or lobar distribution of post-infectious bronchiolitis obliterans. This provides an assessment of the distribution pattern of the compromised areas of the lung. On histo-pathology, early lesions of bronchiolitis obliterans demonstrate submucosal lymphocytic inflammation and disruption of the epithelium of small airways, followed by an ingrowth of fibromyxoid granulation tissue (polyploid plug of fibrotic tissue) into the airway lumen, resulting in partial or completeobstruction (choice A). ⚠ Progressively worsening emphysema and development of liver cirrhosis (choice B) would occur in a patient with anti-trypsin deficiency. ⚠ Bronchieactasis and pancreatic enzyme insufficiency with fat malabsorption (choice C) would be seen in a patient with cystic fibrosis. ⚠ Bronchogenic adenocarcinoma at the periphery of the lungs (choice D) is incorrect as there’s no association between adenovirus pneumonitis and lung cancer. ⚠ Systemic dissemination with nodules consisting of central caseating necrosis (choice E) would be seen in miliary tuberculosis. This child’s clinical picture is more consistent with adenovirus infection. ✅ Key point: In pediatric patients bronchiolitis obliterans is often a complication of adenovirus infection of lower respiratory tract. In later stages, its histopathology is characterized by fibromyxoid granulation tissue in the airway lumen, resulting in partial or complete obstruction. 〰〰〰〰〰〰〰〰〰〰〰 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_11 〰〰〰〰〰〰〰〰〰〰〰 A 16-month-old male is brought to the emergency department by his mother because of coughing and severe shortness of breath. The cough is described as nonproductive. He was born at 40 weeks gestation with 3.4 kg and he has been meeting all developmental milestones. The mother denies any recent family travel or exposure to any toxic gases. She reports that the child’s 3-year-old sister had flu, conjunctivitis, and hemorrhagic cystitis 3 weeks ago. Around the same time the boy had what seemed to be common cold for 2 days but it had resolved spontaneously. On physical examination the child has intercostal retractions, wheezes, and fine crackles. Chest X-ray reveals peribronchial thickening, lowered diaphragm, increased air contrast of the lungs, and right lower lobe atelectasis. Which of the following is most likely to occur as a result of this condition? a) Intraluminal polyploid plug of fibrotic tissue and obliteration of airways b) Progressively worsening emphysema and development of liver cirrhosis c) Bronchiectasis and pancreatic enzyme insufficiency with fat malabsorption d) Bronchogenic adenocarcinoma at the periphery of the lungs e) Systemic dissemination with nodules consisting of central caseating necrosis 〰〰〰〰〰〰〰〰〰〰〰 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_10 #answer ✅ D 🔎 Explanation: The differential diagnosis of urinary retention in the elderly is broad. While most causes are benign and readily treated, the physician must be vigilant in looking for conditions that require urgent intervention. This patient presents with many possible causes of urinary retention, with the most common being benign prostatic hyperplasia. Acute prostatitis, especially in a male with an enlarged prostate, is another relatively common reason for obstructive symptoms. This patient’s physical examination and abnormal urinalysis support this diagnosis, but his normal vital signs and lack of fever suggest he can be treated with an oral fluroquinolone and does not require hospital admission for intravenous therapy.Medications such as oral decongestants can contribute to urinary retention in men with enlarged prostate glands, and should be used with caution and discontinued if obstructive symptoms occur. Obstipation (severe constipation caused by intestinal obstruction) with stool impaction is another relatively common reason for urinary retention in the elderly and can be treated with manual disimpaction and enemas.In this patient, the presence of increasing low back pain and leg weakness, and the findings of anal sphincter laxity and numbness in the perianal area on examination, suggest the presence of a serious neurologic etiology such as cauda equina syndrome. Urgent diagnosis and treatment are necessary to reduce morbidity, and MRI should be performed immediately.The presence of a mildly elevated post-void residual is not an indication for urgent decompression with a Foley catheter. 〰〰〰〰〰〰〰〰〰〰〰 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_10 〰〰〰〰〰〰〰〰〰〰〰 A 65-year-old male presents with a 1-month history of problems passing urine. He says that his bladder will feel full when he needs to urinate, but the urine stream is weak and his bladder does not feel as if it has emptied completely. The symptoms have become increasingly severe over the past week. Other symptoms include upper respiratory congestion for 3 days which he has treated with an over-the-counter decongestant with some relief, constipation with no passage of stool in the past 9 days, and increasing low back pain incompletely relieved with ibuprofen, with associated weakness in both legs. Examination shows a healthy-appearing male who is moderately overweight. He is afebrile and vital signs are normal. There is no abdominal tenderness and no masses are detected. A rectal examination reveals a large amount of hard stool in the rectum; a markedly enlarged (4+), boggy, tender prostate gland; laxity of the anal sphincter; and numbness in the perianal area. Urinalysis shows trace protein and 10-20 WBCs/hpf. Ultrasonography shows a post-void residual volume of 250 mL (normal for age < 100). Which one of the following must be done urgently in this patient? a) Foley catheterization b) Hospitalization for intravenous antibiotics c) Digital disimpaction of the rectum, and Fleet enemas until clear d) MRI of the lumbosacral spine 〰〰〰〰〰〰〰〰〰〰〰 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_9 #answer ✅ B 🔎 Explanation: The patient has symptoms, signs, and laboratory findings consistent with a diagnosis of Waldenström’s macroglobulinemia. This illness is due to an uncontrolled proliferation of lymphocytes and plasma cells, which produce IgM proteins with light chains. The average age at the time of diagnosis is 65 years old. Weakness, fatigue, weight loss, bleeding, and recurrent infections are common presenting symptoms. Physical findings include pallor, hepatosplenomegaly, and lymphadenopathy. Typical laboratory findings include moderate anemia and monoclonal IgM peaks on serum electrophoresis. Bence-Jones protein is seen in 80% of cases, but is typically absent in monoclonal gammopathy of undetermined significance. Unlike in multiple myeloma, lytic bone lesions are not seen, and marrow biopsy reveals mostly lymphocytes. Sarcoidosis usually presents with hilar lymphadenopathy and a polyclonal gammopathy. Non-Hodgkin’s lymphoma presents with similar symptoms, lymphadenopathy, and hepatosplenomegaly, but generally lacks a monoclonal gammopathy and Bence-Jones proteinemia, and has distinctive malignant lymphocytes on bone marrow biopsy. 〰〰〰〰〰〰〰〰〰〰〰 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_9 〰〰〰〰〰〰〰〰〰〰〰 A 65-year-old white female presents with weight loss and fatigue. On examination, she has lymphadenopathy, hepatomegaly, and mild splenomegaly. Her hemoglobin level is 9.0 g/dL (N 12.0-16.0), and a chemistry panel reveals a serum protein level of 9.0 g/dL (N 6.0-8.0). You order a chest radiograph, which shows clear lung fields and no evidence of lytic lesions in the thoracic spine. Serum protein electrophoresis reveals a monoclonal(gamma-globulin) spike, which on immunoelectrophoresis is found to be due to IgM 6- protein. Urine for Bence-Jones protein is positive. A bone marrow biopsy from the iliac crest demonstrates hypercellularity, with a large number of lymphocytes, but normal-appearing plasma cells. Which one of the following is the most likely diagnosis? a) Multiple myeloma b) Waldenstrom’s macroglobulinemia c) Sarcoidosis d) Monoclonal gammopathy of undetermined significance e) Non-Hodgkin’s lymphoma 〰〰〰〰〰〰〰〰〰〰〰 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_8 #answer ✅ E 🔎 Explanation: Our patient is young and hypertensive, with a family history of early onset renal failure. He presents with renal failure and palpable enlarged bilateral kidneys, without urinary symptoms. This constellation is highly suspicious for autosomal dominant polycystic kidney disease.A renal ultrasound would be the initial diagnostic investigation of choice. It is cost effective, easily accessible and is performed without intravenous contrast (which would be contraindicated in impaired renal function). A renal ultrasound would also exclude bilateral hydronephrosis and would be a good screening test for renal cell carcinoma.If polycystic kidneys are proven on ultrasound, this patient should probably be considered for further imaging to exclude intracranial aneurysms. Intracranial aneurysms are one of the extra-renal manifestations of the disease, and should beconsidered in all patients with polycystic kidney disease and recurrent severe headaches. Other extra-renal manifestations include colonic diverticular disease, mitral valve prolapse, and hepatic and pancreatic cysts. ⚠ No further investigation is required at this time, follow-up in 6 months (choice A), is incorrect. A patient with newly diagnosed renal failure and bilateral enlarged kidneys needs renal imaging as soon as possible to exclude obstructive uropathy and to visualize renal morphology. ⚠ Repeat renal function in 1 month. Weekly blood pressure review, to ensure perfect control (choice B), is incorrect. This patient first requires imaging. Control of the blood pressure is key, but first a diagnosis needs to be made. ⚠Urgent chromosomal studies (choice C), is incorrect. You would require a diagnosis before requesting chromosomal studies. Renal ultrasound is the diagnostic test. Genetic testing that detects mutations in PKD1 and PKD2 genes is available and would be indicated in possible familial renal donors (to exclude disease in the donor), young asymptomatic family members to optimize blood pressure control thereby slowing the loss of renal function and female family members considering pregnancy. ⚠ Urgent intravenous pyelogram (choice D), is incorrect. This test requires the administration of intravenous contrast, which could lead to worsening renal failure. It would show the abnormal renal morphology, but exposes the patient to possible harm. ✅Key point: Renal ultrasound is the screening test and, in most cases, the diagnostic test of choice for patients presenting with suspected polycystic kidney disease. It should be requested urgently in all patients with clinically enlarged kidneys or family history of polycystic kidney disease. 〰〰〰〰〰〰〰〰〰〰〰 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ