Case-based MCQ

⏳ Case-based MCQ | #Case_311 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 20‐year‐old primigravid comes to you for her first prenatal visit at 12 weeks. She works in a daycare facility and developed a maculopapular rash at 11 weeks’ gestation. It disappears after 3 days and she feels fine. a) You should reassure her since the symptoms were mild b) Offer termination of the pregnancy c) Obtain her rubella IgG titer d) Obtain a throat culture and treat with penicillin for 10 days e) Obtain a toxoplasmosis IgG titer

⏳ Case-based MCQ | #Case_310 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon’s function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity. The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture. Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-­leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem. While treatment with acetaminophen or NSAIDs provides short-­term pain relief, neither affects long-­term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2-­3 weeks.

⏳ Case-based MCQ | #Case_310 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 45-­year‐old female presents to your office with a 1‐month history of pain and swelling posterior to the medial malleolus. She does not recall any injury, but reports that the pain is worse with weight bearing and with inversion of the foot. Plantar flexion against resistance elicits pain, and the patient is unable to perform a single-­‐leg heel raise. Which one of the following is true regarding this problem? a) The patient most likely has a medial ankle sprain b) NSAIDs will improve the long‐term outcome c) Injecting a corticosteroid into the tendon sheath of the involved tendon is recommended d) A lateral heel wedge should be prescribed e) Immobilization in a cast boot for 3 weeks is indicated

⏳ Case-based MCQ | #Case_309 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D This patient with a mild persistent asthma is presenting with an acute asthma attack (acute asthma exacerbation). The findings on physical examination of pulsus paradoxus (decrease of systolic BP of 10 mmHg on inspiration), use of respiratory accessory muscles, The SaO2 which is less than 94% but greater than 89%, the peak expiratory flow of predicted less than 70% but greater than 40% suggest an exacerbation of moderate severity. In mild exacerbation there is no respiratory accessory muscle use, the SaO2 is greater than 94%, the peak expiratory flow is at least 70% of predicted, and the pulsus paradoxus is absent. In severe exacerbation SaO2 is <90%, peak expiratory flow <40%, and pulsus paradoxus presents with more than 25 mmHg decrease in systolic BP on inspiration. When peak expiratory flow is <25%, the exacerbation is considered life-­threatening. In a patient whose symptoms persist despite home use of short acting beta agonists, management of moderate asthma exacerbation in the ED consists of continuing inhaled short acting beta agonists (e.g. albuterol) with 3 doses delivered in the first hour and oral/intravenous corticosteroids. Oral and intravenous corticosteroids are considered of equivalent effectiveness. If oxygen saturation is <90%, then oxygen supplementation should be given until saturation ≥ 90% is achieved. Therefore, the best answer is inhaled albuterol and oral prednisone (choice D). ⚠ Admitting the patient (choice A) is indicated if the patient’s condition does not improve after 3 doses of inhaled albuterol with vital signs and peak expiratory flow remaining abnormal. Pulse oximetry is indicated for patients who are in severe distress and have peak expiratory flow <40% of predicted. ⚠ While inhaled pirbuterol (choice B) is consistent with the guidelines of moderate exacerbation management as it is a short acting beta agonist, recommended corticosteroids should be administered orally or intravenously and not by inhalation. ⚠ Oxygen, inhaled ipratropium, and inhaled fluticasone (choice C) is incorrect. Oxygen is given to patients who need to achieve ≥90% oxygen saturation. Ipratropium is not first-­line therapy and is added to short acting beta-­‐agonists in severe exacerbation. ⚠ Intubation and 100% oxygen (choice E) is indicated in life-­‐threatening asthma exacerbation with peak expiratory flow <25% that improves less than 10% after treatment is initiated. 🔖 Key point: To manage acute asthma exacerbation, the classification into mild, moderate, severe, and life threatening should be ascertained first. Moderate acute asthma is managed with inhaled short acting beta-­agonists and oral/intravenous corticosteroids.

⏳ Case-based MCQ | #Case_309 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 19‐year‐old male college student with a history of mild persistent asthma presents to the ED with wheezing and dyspnea. It started 3 hours ago and has persisted despite inhaled albuterol as prescribed 6 months ago when he had a similar attack. He feels like there is tightening of his neck and chest muscles. He denies doing any physical exercise today and uses his medications as prescribed. On physical examination the patient’s temperature is 37.8°C, BP is 115/65 mmHg, pulse is 100bpm, and respirations 25/min. His BP becomes 100/60 mmHg on inspiration. Accessory muscle use and suprasternal retractions are noted. Loud wheezing throughout expiration is heard on auscultation. The patient’s SaO2 is 91% and peak expiratory flow of predicted in the ED is 50%. Which of the following is the best next step in management of this patient? a) Admit to the hospital and do pulse oximetry b) Inhaled fluticasone and pirbuterol immediately c) Oxygen, inhaled ipratropium, and inhaled fluticasone d) Inhaled albuterol and oral prednisone e) Intubation with 100% oxygen and intravenous prednisone

⏳ Case-based MCQ | #Case_308 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Platelets are acute phase reactants and their number increases with infections and other inflammatory conditions (reactive thrombocytosis). As reported by Andrew and Schafer, only 8 out of 10,000 patients with incidental thrombocytosis were found to have high platelet counts a few weeks later. Therefore, given this patient's clinical scenario (incidental finding), platelet count should be repeated a few weeks later (choice E). ⚠ Bone marrow biopsy to rule out essential thrombocytosis (choice A) should be done only after reactive thrombocytosis is excluded. ⚠ There is no clear indication for lymph node biopsy (choice B) in this patient. The tender anterior cervical lymphadenopathy is most likely due to streptococcal pharyngitis and will usually subside in a few weeks. In addition, our patient did not have symptoms, signs or lab results suggestive of diseases associated with lymphadenopathy and thrombocytosis like myeloproliferative diseases. ⚠ Platelet retention test (choice C) is used to evaluate adhesiveness of platelets, which is known to be reduced in some diseases like Von Willebrand disease, uremia and thrombocytosis that accompany myeloproliferative diseases. Our patient, however, did not have any symptoms or signs suggestive of any of these diseases. Ruling out of reactive thrombocytosis is the priority in this patient. ⚠ Platelet release reaction (choice D) is used to evaluate ability of platelets to release their granules when activated. When platelets fail to release their granules, primary hemostasis is impaired and bleeding tendency might result. Our patient did not have bleeding tendency to suggest such an abnormality and ruling out reactive thrombocytosis is the priority in this patient. 🔖 Key point: Like ESR and CRP, platelets are acute phase reactants and platelet count can increase in response to infection. In presence of infection, reactive thrombocytosis should be excluded by repeating platelet count in four to six weeks before proceeding to any further investigation.

⏳ Case-based MCQ | #Case_308 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 7-­year-­old girl presented with fever, sore throat and tender anterior lymphadenopathy. With appropriate work-­up, the diagnosis of streptococcal pharyngitis was established. Because she had two attacks of otitis media in the past year, complete blood count (CBC) was performed. The only positive findings in the CBC were as follows: white cell count of 12.5 x 109/L, platelet count of 650 x 109/L and an erythrocyte sedimentation rate of 19 mm/hour. She was prescribed amoxicillin 40mg/kg. Regarding this patient's thrombocytosis, which of the following is the most appropriate next step in management? a) Order bone marrow biopsy b) Order lymph node biopsy c) Order platelet retention test d) Order platelet release reaction e) Repeat platelet count in four weeks

⏳ Case-based MCQ | #Case_307 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D A family history of sudden death and recurrent syncope is highly suspicious for genetic long-­QT syndrome. It is best diagnosed with a resting EKG that shows a QTc >460 msec in females and >440 msec in males. This syndrome especially places young people at risk for sudden death. Management may include beta‐blockers, an implantable cardioverter-­defibrillator, and no participation in competitive sports. Ref: Roden DM: Long-­‐QT syndrome. N Engl J Med 2008;358(2):169-­‐176.

🧩 Medical Mnemonics Learn Pencil-in-cup deformity in Psoriatic Arthritis by #visual_mnemonics. ━━━━━━━━━━━━━━━━ 🖥 IMAGING Explanation The appearance results from periarticular erosions and bone resorption giving the appearance of a pencil in a cup #radiology 〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

⏳ Case-based MCQ | #Case_307 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 17‐year‐old soccer player presents for a preparticipation examination. His family history is significant for the autopsy-­negative sudden death of his 12‐year‐old sister while playing basketball, and for his mother and maternal grandmother having recurrent syncopal episodes. His medical history and examination are completely normal. Prior to approving his participation in sports, which one of the following is recommended? a) A resting EKG b) A stress EKG c) An echocardiogram d) Pulmonary function testing e) No further evaluation

⏳ Case-based MCQ | #Case_306 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation The chest radiograph of a child with meconium aspiration syndrome will show patchy atelectasis or consolidation. If the child has a normal chest film and respiratory distress, a noncardiopulmonary source should be considered (i.e., a neurologic or metabolic etiology). The chest film of a child with transient tachypnea of the newborn will show a “wet silhouette” around the heart, diffuse parenchymal infiltrates, or intralobar fluid accumulation. Homogeneous opaque infiltrates with air bronchograms on a chest radiograph are seen with hyaline membrane disease.

⏳ Case-based MCQ | #Case_306 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A male infant is delivered at 41 weeks gestation by spontaneous vaginal delivery. The amniotic fluid is meconium stained. Apgar scores are 7 at 1 minute and 7 at 5 minutes. The baby is noted to have respiratory distress from birth and is hypoxic by pulse oximetry. Respiration improves with supplemental oxygen, as does the hypoxia, but does not return to normal. Which one of the following would most likely be seen on a chest radiograph? a) A normal heart and lungs b) Fluid in the pulmonary fissures c) Homogeneous opaque infiltrates with air bronchograms d) Patchy atelectasis

⏳ Case-based MCQ | #Case_305 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation This child has a respiratory syncytial virus (RSV) infection. Supportive care is the mainstay of therapy. If the child can take in fluids by mouth and tolerate room air, outpatient management with close physician contact as needed is reasonable, especially in the absence of significant underlying risk factors. Routine use of corticosteroids is not recommended. Although up to 60% of infants hospitalized for bronchiolitis receive corticosteroid therapy, studies have not provided sufficient evidence to support their use. Inhaled corticosteroids have not been shown to be beneficial, and the safety of high doses in infants is unclear. Supplemental oxygen should be administered if functional oxygen saturation (SpO2) persistently falls below 90% and can be discontinued when an adequate level returns. Antiviral therapy for RSV bronchiolitis is controversial because of its marginal benefit, cumbersome delivery, potential risk to caregivers, and high cost. Studies of ribavirin in patients with bronchiolitis have produced inconsistent findings.Palivizumab is a preventive measure, and is not used for treatment of the active disease. It may be considered in select infants and children with prematurity, chronic lung disease of prematurity, or congenital heart disease. If used, it should be administered intramuscularly in five monthly doses of 15 mg/kg, usually beginning in November or December.

⏳ Case-based MCQ | #Case_305 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 You see a 9-­month-­old male with a 1-­day history of cough and wheezing. He has previously been healthy and was born after an uncomplicated term pregnancy. He is up to date on his immunizations. On examination his temperature is 38.6°C (101.5°F) and his respiratory rate is 30/min. He has diffuse wheezing and his oxygen saturation on room air is 94%. Because it is midwinter, you obtain a swab for influenza, which is negative. A chest radiograph shows peribronchiolar edema. Appropriate management would include which one of the following? a) Supportive care only b) Inhaled corticosteroids c) Ribavirin (Rebetol) d) Palivizumab (Synagis) e) Supplemental oxygen

⏳ Case-based MCQ | #Case_304 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation Roseola is characterized by 3 days of high fever, which disappears suddenly as the typical rash appears. Roseola is typically characterized by a history of 3 days of high fever (often up to 40°C) followed by rapid defervescence and a characteristic rash (fades within a few hours to 2 d) which is: ‐Maculopapular or erythematous -­Typically beginning on the trunk and may spread to involve the neck and extremities ‐Nonpruritic -Blanches on pressure ⚠ A. Rubella is typically only a 3-­day illness and the rash would already be present. ⚠ B. Children are unlikely to have fever with erythema infectiosum. ⚠ C. Erythema toxicum is a common normal newborn rash. ⚠ E. This diagnosis is unlikely because the child is acting well between fevers and does not appear toxic; he is also not seriously ill after a 3-­day history of illness.

⏳ Case-based MCQ | #Case_304 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 2‐year‐old boy presents to the office with an intermittent fever of 40°C (104°F) for the past three days. The physical examination reveals no source of infection. However, you notice faint pink maculopapular rash on his trunk. The patient does not appear toxic, and the parents feel that he appears well between fevers. They also add that the rash was not seen earlier. The differential diagnosis includes: a) Rubella b) Erythema infectiosum (Fifth disease) c) Erythema toxicum d) Roseola e) Meningitis

⏳ Case-based MCQ | #Case_303 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation Trismus is almost universally present with peritonsillar abscess. Voice change, otalgia, and odynophagia may or may not be present with peritonsillar abscess. Pharyngotonsillits and peritonsillar cellulites may also be associated with these complaints. Otalgia is common with peritonsillar abscess, otitis media, temporomandibular joint disorders, and a variety of other conditions. Peritonsillar abscess is rarely present without at least a 3 day history of progressive sore throat.

🇨🇦 MCCQE1,2 | #Case_303 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 The mother of a 16-­year-­old male calls to report that her son has a severe sore throat and has been running a fever of 38.9°C (102°F). Which one of the following additional findings would be most specific for peritonsillar abscess? a) A 1 day duration of illness b) Ear pain c) Difficulty opening his mouth d) Hoarseness e) Pain with swallowing

🇨🇦 MCCQE1,2 | #Case_302 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation Marcus Gunn pupil is a medical sign observed during the swinging‐flashlight test whereupon the patient's pupils constrict less (therefore appearing to dilate) when the light swings from the unaffected "good" eye to the affected "bad" eye. There is no anisocoria, and the "bad eye" still senses light and produces pupillary constriction to some degree, albeit reduced. The commonest cause of Marcus Gunn pupil is a lesion of the optic nerve (before the optic chiasm) or severe retinal disease. The Marcus Gunn phenomenon is a relative afferent pupillary defect. That is to say, the "bad eye" can still perceive light and respond to it, but not as much as the "good eye"; the bad eye is relatively less responsive than the good eye, but both eyes are still responsive to light. If you shine the light in the bad eye, both pupils will constrict (due to the still-­‐intact consensual light response). However, if you shine the light in the "good eye", the pupils will constrict even more. It is as if you are shining a light of lesser intensity at the bad eye. In context of the swinging flashlight test, you first shine the light in the good eye, causing full pupillary contraction in both eyes. Then you move the light to the bad eye. The bad eye perceives this same light as if were not as bright, and thus causes the pupils to constrict less. This gives the illusion that both pupils are now dilating as a response to the light. They are actually still constricting in response to the light, but constricting less than when the light was shining at the good eye, because the bad eye perceives a dimmer light.

🇨🇦 MCCQE1,2 | #Case_302 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A six-­year-­old boy presents with sudden loss of vision in his right eye of one day's duration. His vision in the right eye is restricted to light perception only. His vision in the left eye is 20/20. Pupils are 4 mm in size each eye, pupillary reactions are sluggish right eye, but brisk with a normal consensual reaction when the light is shown to the left eye. Swinging the flashlight from left to right eye, the right pupil dilates. Swinging the flashlight from right to left eye, the left pupil constricts. The pupillary reactions demonstrated represent: a) Horner’s Syndrome (impaired pupil dilatation) b) Adie’s pupil (pathological pupil reaction) c) Afferent pupillary defect (Marcus‐Gunn pupil) d) Normal pupillary reactions e) Anisocoria (inequality of pupils in diameter)