Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_30 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 44-year-old woman presents complaining of lower left leg pain. Three weeks ago, she started intensive training in preparation for an upcoming 10-kilometer race. Her pain becomes more severe while she is running and intermittently occurs while she is walking. On physical examination, there is localized tenderness at the junction of the middle and distal portions of the tibia.

- Mild (minimal edema, itching) - Moderate (edema, itching, canal erythema) - Severe (canal closed due to severe edema, fever, lymphadenopathy)

🧠 Case-based MCQ 🔸 #MCQ_29 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Otitis externa (OE)usually presents with ear pain, pruritus, and discharge. Examination findings of external otitis include tenderness when the tragus is pushed or the auricle is pulled, as well as erythema and swelling of the external auditory canal. The otoscopic examination should also assess for otitis media, tympanic membrane perforation, and signs of other diseases. OE often arises due to excess moisture and skin maceration or other factors that disrupt the skin-cerumen barrier. Risk factors for developing external otitis include swimming (or other water exposure), trauma (e.g., ear scratching, cotton swabs), occlusive ear devices (e.g., hearing aids, earphones), allergic contact dermatitis (e.g., due to shampoos, cosmetics), and dermatologic conditions (e.g., psoriasis). The most common causative organisms in OE include Staphylococcus aureus and Pseudomonas aeruginosa. The diagnosis is based on history and examination findings (e.g., pain with tragal pressure or traction on the auricle). The initial step in the management of OE is to gently clear cerumen and debris. A wire curette or cotton swab can be used under direct visualization, and any remaining material can be removed with irrigation using dilute hydrogen peroxide. Second step is treating inflammation and infection based on severity: For mild OE with minimal erythema and edema, topical acidifiers (e.g., acetic acid) for 7-10 days are usually adequate. For moderate OE with more significant pain, erythema, and edema (as in this patient), topical antibiotics (e.g., ciprofloxacin, neomycin/polymyxin) are recommended. For severe OE with intense pain, and the canal is completely occluded from edema. Fever, periauricular erythema, and regional lymphadenopathy, topical therapy, wick placement, and, oral antibiotics. Based on case presentation, this patient has moderate OE therefore topical antibiotics plus corticosteroid to reduce inflammation. In general, patients will report some change in symptoms within 36 to 48 hours after initiation of treatment, with a total symptom resolution of approximately six days. Patients should also be advised on preventive measures, including avoiding moisture in the ears, drying ears thoroughly after swimming or bathing, and using acidifiers at the onset of recurrent symptoms. ❌Choice A is not correct: Topical glucocorticoids decrease inflammation, resulting in relief of pruritus and decreased pain. Preparations used to treat external otitis include hydrocortisone, dexamethasone, and prednisolone They are generally well-tolerated. Symptomatic therapy alone, however, is not recommended and antimicrobial therapy should be given. ❌Choice B is not correct: Many patients with ear pain levels that are mild to moderate will have prompt relief from topical therapy. Those with pain will usually respond to oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen that can be started at the initial visit Opioid analgesics may be needed in patients with serious pain associated with severe disease. Again, symptomatic therapy alone, however, is not recommended and antimicrobial therapy should be given. ❌Choice C is not correct: Systemic antibiotics are reserved for invasive infection (malignant OE) or for immunosuppressed patients. Uncomplicated OE will respond to topical therapy. ❌Choice D is not correct: Wick placement is indicated for patients with severe otitis, especially if swelling of the canal prevents penetration of antibiotic solutions. The wick allows for topical medications to reach deeper into the swollen ear canal. This patient has moderate OE with a patent canal; a wick is not necessary. ✅Summarized Points: Otitis externa treated in two steps: 1st step → Cleaning cerumen and debris from the external ear canal 2nd step → treating inflammation and infection based on the severity

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🧠 Case-based MCQ 🔸 #MCQ_29 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 26-year-old man presents to the clinic with complaints of left-sided ear pain for the past 3 days. Physical examination reveals tenderness on palpation of the left tragus and partial occlusion of the ear canal. Excoriations and a mild discharge from the left ear are also seen. There is no periauricular erythema or lymphadenopathy. Following gentle removal of debris from the canal under direct visualization, the tympanic membrane is fully inspected and appears normal.  The right ear is normal, and the patient is otherwise healthy.

🧠 Case-based MCQ 🔸 #MCQ_28 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Durable power of attorney is a type of advance directive that goes into effect if a patient becomes incapable of making medical decisions. In that event, the designated proxy assumes legal responsibility for all decisions regarding the patient's care. Although the durable power of attorney transfers decision-making capacity to another individual, the choice of proxy must be made while the patient retains his or her own decision-making capacity. In cases such as Alzheimer's disease, for instance, it is imperative that the health care proxy be designated early in the course of the disease, before dementia makes it impossible for the patient to do so. ❌Choice A is not correct: Instructional directive is a modification of a living will, in which the patient decides on a certain treatment modality given several specific clinical scenarios. The scenarios may include coma with no chance of recovery, coma with chance of partial recovery, advanced dementia with concurrent terminal illness, and so forth. ❌Choice B is not correct: A living will also goes into effect if a person becomes incapacitated. However, instead of designating a second party to make decisions, it allows an individual to describe what measures should be taken given certain medical conditions. However, these desires are often vague and apply to the dying patient, not one who is simply demented or otherwise medically stable and incapacitated. In most states, living wills carry moral weight, but individual decisions must still be made for each specific clinical situation. ❌Choice C is not correct: Medical futility refers to situations in which treatment would not achieve the desired outcome for a patient. The determination of futility rests on the treatment goals for the patient, which can vary between individuals, particularly among family members and physicians. The patient in the vignette is not in a medical situation in which medical futility would be a concern. ❌Choice D is not correct: A values history makes use of a questionnaire in which the patient outlines certain beliefs that may be helpful in determining how he or she would want to die. The areas of inquiry often include religious beliefs, views on independence and autonomy, and attitudes concerning health and health care providers. These questionnaires are often helpful for patients, but it is unclear how the information should guide physicians in treatment decisions. ✅Summarized Points: Durable power of attorney is a type of advance directive that goes into effect if a patient becomes incapable of making medical decisions. In that event, the designated proxy assumes legal responsibility for all decisions regarding the patient's care.

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🧠 Case-based MCQ 🔸 #MCQ_28 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An 86-year-old man presents to his family physician for an annual check-up. His only medical condition is hypertension controlled with a diuretic and a β-blocker. He has had regular screenings for colon cancer and prostate cancer. He lives with his wife, who is 82 years old and also in good health. When the physician asks the patient about advance directives, he states that he has been putting it off because he is healthy and does not want to think about death. When encouraged, the patient responds that if he were to become incapacitated, he would want his wife to make medical decisions for him.

🧠 Case-based MCQ 🔸 #MCQ_27 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. This patient’s symptoms are consistent with perimenopause. Paroxetine has been shown to confer a modest improvement (25%-30%) over placebo in treating the vasomotor symptoms of menopause. While hormone replacement therapy (HRT) is generally the most effective treatment for hot flashes (by replacing the missing hormones), a history of deep vein thrombosis is a contraindication for HRT because of the known increase in the risk of blood clots. ❌Choice A is not correct: Oral bisphosphonates such as alendronate are drugs used to treat osteoporosis and osteopenia. There is a direct relationship between the lack of estrogen after menopause and the development of osteoporosis. Bisphosphonates would not be used to treat perimenopausal hot flashes. ❌Choice B is not correct: Citalopram has been studied for the treatment of vasomotor symptoms at a dose of 30 mg/d, but it has not shown any significant benefit over placebo. ❌Choice D is not correct: Clinical trials have not shown a clear benefit from the use of clonidine for the relief of the vasomotor symptoms of menopause. In addition, clonidine can cause significant adverse effects, including hypotension, drowsiness, and rebound hypertension. ❌Choice E is not correct: While HRT is the most effective treatment for hot flashes, with (-.- 94% efficacy), a history of deep vein thrombosis is a contraindication for HRT because of the known increase in the risk of blood clots and pulmonary emboli. ✅Summarized Points: Perimenopausal symptoms are caused by an overall drop and fluctuations in the levels of estrogen, progestin, and testosterone. Vasomotor symptoms include hot flashes and palpitations. Psychological symptoms include depression, anxiety, irritability, and mood swings. Selective serotonin reuptake inhibitors (such as paroxetine) and serotonin-norepinephrine uptake inhibitors (such as venlafaxine) are generally the initial treatment of choice for vasomotor symptoms of menopause when HRT is contraindicated.

🧠 Case-based MCQ 🔸 #MCQ_27 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 54-year-old woman presents to her primary medical doctor complaining of frequent hot flashes that interfere with her regular daily activities. Her last menstrual period was 18 months ago. Her past medical history is significant for a deep vein thrombosis 6 years ago, for which she was treated with 6 months of warfarin. She requests treatment for her hot flashes. is married, works as a store manager, and does not smoke or consume alcohol. Family history is negative for coronary heart disease, stroke, cancer, and venous thromboembolism. Blood pressure is 128/76 mm Hg and pulse is 68/min, respiratory rate is 14/min, temperature is 37C. BMI is 29 kg/m2. Physical examination is normal.

🧠 Case-based MCQ 🔸 #MCQ_26 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is B. Meckel diverticulum is a remnant of the omphalomesenteric duct and is the most common malformation of the small intestine in children and is associated with the rule of 2's (diverticulum is 2 cm wide and 2 cm long and usually located within 2 feet of the ileocecal valve and usually presents before the age of 2). Classically, a male patient less than 5 years old will present with massive, painless, brick-red coloured rectal bleeding. Diagnosis is through a technetium scan or Meckel scan. Sixty percent of these will contain heterotopic gastric, pancreatic, or endometrial tissue which is the reason for the complications associated with these diverticula including, ulceration, and bleeding. ❌Choice A is not correct: Intussusception is common under the age of 2 and will present with the triad of abdominal pain, bloody stools (currant jelly), and vomiting. Currant-jelly stools are a late finding. Earlier in the disease process they may only have occult bloody stools. ❌Choice C is not correct: Milk allergy is a common cause of gastrointestinal bleeding during infancy and not during childhood. Necrotizing enterocolitis is a common cause of gastrointestinal bleeding during infancy but not during childhood. ❌Choice D is not correct: Necrotizing enterocolitis (NEC) is due to bacterial overgrowth in the bowel wall. Common predisposing factors include prematurity (seen in 90% of cases), bowel ischemia, infection, and introduction of parental feeding. It typically occurs in the first few days of life but can appear as late as 1 month of age. Symptoms include abdominal dissension, emesis, bloody stools, sepsis and abdominal x-ray will show pneumatosis intestinalis, or gas in the bowel wall. Treatment is with broad-spectrum antibiotics and surgical consultation. ✅Summarized Points: Meckel diverticulum is classically described as painless rectal bleeding that is a brick coloured in a male less than 5 years old

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🧠 Case-based MCQ 🔸 #MCQ_26 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 2-year-old boy presents to the emergency department due to a large amount of painless rectal bleeding that his mother describes as "brick-red in colour". Currently, he has no complaints and looks nontoxic. Vital signs are within normal limits and abdominal exam is benign.