Case-based MCQ

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🧩 Medical Mnemonics Causes of delirium 🇮‌  ‌🇼‌‌🇦‌‌🇹‌‌🇨‌‌🇭‌    ‌🇩‌‌🇪‌‌🇦‌‌🇹‌‌🇭‌ ❗👽 🪧 🅘nfectious (encephalitis, meningitis, UTI) 🪧 🅦ithdrawal (alcohol, benzodiazepines) 🪧 🅐cute metabolic disorder (electrolyte imbalance) 🪧 🅣rauma (head injury, postoperative) 🪧 🅒NS pathology (stroke, hemorrhage, tumor) 🪧 🅗ypoxia (anemia, cardiac failure) 🪧 🅓eficiencies (vitamin B12, folic acid, thiamine) 🪧 🅔ndocrinopathies (thyroid, glucose) 🪧 🅐cute vascular (shock, vasculitis, hypertension) 🪧 🅣oxins, substance use, medications 🪧 🅗eavy metals (arsenic, lead, mercury) #psychiatry  〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

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Felty syndrome ⚪Clinical features Rheumatoid arthritis Severe erosive joint disease & deformity Rheumatoid nodules Vasculitis (mononeuritis multiplex, necrotizing skin lesions) Neutropenia (ANC <2000/µL) Splenomegaly ⚪Diagnosis Anti-CCP & RF are positive in >90% of patients Markedly elevated ESR, often >85 mm/hr Peripheral smear & bone marrow biopsy to rule out other causes of neutropenia ANC = absolute neutrophil count; anti-CCP = anticyclic citrullinated peptide; ESR = erythrocyte sedimentation rate; RF = rheumatoid factor. This patient with swollen, deformed hand joints and an elevated erythrocyte sedimentation rate likely has untreated inflammatory polyarthritis.  The presence of concurrent neutropenia and splenomegaly raise strong suspicion for Felty syndrome, an uncommon but serious complication of long-standing, erosive rheumatoid arthritis (RA). Felty syndrome is marked by the formation of autoantibodies against neutrophil components and granulocyte colony-stimulating factor, leading to neutropenia (ie, absolute neutrophil count <2,000/mm3) and an increased risk of recurrent bacterial infection (particularly of the skin and sinuses).  Neutrophils coated with antibodies are also trapped in the spleen, which usually results in splenomegaly.  Most patients also have extraarticular manifestations of RA such as lymphadenopathy, rheumatoid nodules, and/or necrotizing skin lesions. The diagnosis is made based on clinical features but is supported by the presence of high-titer rheumatoid factor and anticitrullinated peptide antibodies (both of which are usually elevated in RA).  Most patients are also HLA-DR4 positive (indicating a genetic susceptibility).  Other causes of neutropenia should be ruled out with bone marrow biopsy and peripheral smear prior to establishing the diagnosis.  Symptoms generally improve with treatment of the underlying RA.

A 76-year-old woman comes to the office for evaluation of leukopenia.  The patient came to the United States to visit her son a month ago and was seen at an urgent care clinic 2 weeks ago for acute sinusitis, where she was found to have leukopenia.  She was prescribed an oral antibiotic, and a repeat blood test was advised.  The patient has had 2 episodes of skin infections over the past 3 months.  She also has had pain and swelling in the joints of her hands and knees for the past several years.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (98.9 F), blood pressure is 130/80 mm Hg, and pulse is 74/min.  Physical examination shows normal heart and lung sounds, moderate splenomegaly, generalized lymphadenopathy, no sinus tenderness, and well-healing lower extremity ulcerations.  The small joints of the hands are swollen and deformed.  Laboratory results are as follows: Hemoglobin 11.8 g/dL Mean corpuscular volume 92 µm3 Platelets 280,000/mm3 Leukocytes 1,800/mm3 (20% neutrophils) Creatinine 0.8 mg/dL Calcium 9.2 mg/dL Erythrocyte sedimentation rate 68 mm/h HIV serology negative Additional evaluation of this patient is most likely to reveal which of the following? A. Anticitrullinated peptide antibodies B. Decreased vitamin B12 level C. Hypocellular bone marrow D. Philadelphia (Ph1) chromosome E. Serum monoclonal proteins

🧩 Medical Mnemonics Hallucinations are: ••• 𝗛𝘆𝗽𝗻𝗮𝗚𝗢𝗴𝗶𝗰 : occur when you 𝗚𝗢 to sleep. ••• 𝗛𝘆𝗽𝗻𝗼𝗣𝗼𝗺𝗽𝗶𝗰 : occur when you wake u𝗣. #psychiatry   〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

Clinical manifestations of hereditary hemochromatosis Skin Hyperpigmentation (bronze diabetes) Musculoskeletal Arthralgia, arthropathy & chondrocalcinosis Gastrointestinal Elevated hepatic enzymes with hepatomegaly (early), cirrhosis (later) & increased risk of hepatocellular carcinoma Endocrine Diabetes mellitus, secondary hypogonadism & hypothyroidism Cardiac Restrictive or dilated cardiomyopathy & conduction abnormalities Infections Increased susceptibility to Listeria, Vibrio vulnificus & Yersinia enterocolitica This patient has acute monoarticular arthritis with chondrocalcinosis (calcified articular cartilage on radiographs), diagnostic of calcium pyrophosphate dihydrate crystal deposition (CPPD) disease (pseudogout).  Patients with pseudogout should be evaluated for secondary causes such as hyperparathyroidism, hypothyroidism, and hemochromatosis.  Given this patient's recently diagnosed diabetes mellitus and hepatomegaly, hereditary hemochromatosis (HH) is highly likely.  HH-induced iron deposition in the synovial fluid appears to promote CPPD.  Diabetes in HH appears to be due primarily to loss of insulin secretion and often requires injectable insulin; however, mild or early disease is frequently managed with oral agents. The initial evaluation of HH includes serum iron studies, which will show increased levels of serum iron, ferritin, and transferrin saturation.  The diagnosis can be confirmed with genetic testing for hemochromatosis-associated mutations (eg, HFE).  Liver biopsy is not required but may be useful to stage the extent of liver involvement (eg, in patients with significant liver function test abnormalities) or to confirm the diagnosis in patients who have iron studies indicating iron overload but negative results on the classic HFE gene markers (Choice C).  Long-term management of hemochromatosis involves serial phlebotomy to deplete excess iron stores. (Choices A and E)  Chondrocalcinosis is not a typical feature of gout or rheumatoid arthritis (which is associated with anticitrullinated peptide antibodies). (Choice B)  Antismooth muscle antibodies are seen in autoimmune hepatitis, which can be associated with other autoimmune disorders including type 1 diabetes mellitus, thyroid disease, and rheumatoid arthritis.  Patients may develop a subacute, symmetric polyarthritis involving the small joints, but acute monoarthritis with chondrocalcinosis would not be seen. (Choice F)  Slit-lamp eye examination is helpful in identifying the Kayser-Fleischer rings of Wilson disease.  Wilson disease can cause hepatomegaly; however, it typically presents with neuropsychiatric manifestations, and almost all patients are diagnosed before age 35. Educational objective: Hereditary hemochromatosis is commonly associated with calcium pyrophosphate dihydrate crystal deposition in joints, leading to chondrocalcinosis, pseudogout, and chronic arthropathy.  Patients commonly also have diabetes and liver disease.  Diagnosis is suggested by iron overload on serum iron studies and can be confirmed by genetic tests

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A 43-year-old man comes to the physician reporting acute-onset right knee pain.  He was diagnosed with diabetes mellitus a year ago and takes metformin.  He does not use tobacco, alcohol, or illicit drugs.  The patient is in a monogamous relationship.  His father also has diabetes.  His temperature is 37 C (98.6 F), blood pressure is 134/86 mm Hg, pulse is 86/min, and respirations are 16/min.  BMI is 26 kg/m2.  Physical examination shows a slightly swollen and tender right knee and mild hepatomegaly.  Right knee x-ray reveals chondrocalcinosis and a moderate effusion.  Appropriate analgesic is administered for joint pain.  Which of the following is the best next step in management of this patient? A. Anticitrullinated peptide antibodies B. Antismooth muscle antibodies C. Liver biopsy D. Serum iron studies E. Serum uric acid level F. Slit-lamp eye examination

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🧩 Medical Mnemonics Electrolytes affected by Tumor Lysis Syndrome 🤮 🇵‌‌🇺‌‌🇰‌‌🇪‌   ‌🇨‌‌🇦‌‌🇱‌‌🇨‌‌🇮‌‌🇺‌‌🇲‌ 〰 🅟hosphorus, 〰 🅤ric acid, and 〰 🅚 (potassium) are 〰 🅔levated, 〰 but 🅒🅐🅛🅒🅘🅤🅜 is decreased! #hematology   〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

🧩 Medical Mnemonics Criteria for metabolic syndrome ⭕ ‌🇼‌‌ 🇪‌‌🇮‌🇬‌‌ 🇭‌‌ 🇹‌ 🪃 🅦aist 🅔xpanded 🪃 🅘mpaired 🅖lucose 🪃 🅗ypertension 🪃 🅗DL ↓ 🪃 🅣riglycerides ↑ #endocrinology   〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

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🧩 Medical Mnemonics Pentad of features for TTP 🕊‌🇱‌‌🇲‌‌🇳‌‌🇴‌‌🇵‌ 🫧 🅛ow platelet count (thrombocytopenia) 🫧 🅜icroangiopathic hemolytic anemia 🫧 🅝eurologic changes 🫧 🅞bsolete renal function 🫧 🅟yrexia #hematology  〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

The ratio of plasma aldosterone concentration to plasma renin activity is the preferred initial screening test for primary hyperaldosteronism.  Adrenal suppression testing can confirm the diagnosis, and positive tests require further adrenal imaging.  Adrenal venous sampling is the most sensitive test for differentiating adrenal adenoma and bilateral adrenal hyperplasia in patients without discrete unilateral adrenal mass on imaging.

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