Case-based MCQ

A 78-year-old patient with dementia and a percutaneous endoscopic gastrostomy (PEG) tube placed 8 weeks ago for dysphagia presents after the tube was accidentally pulled out 3 hours ago during routine care. The patient appears comfortable with normal vital signs. Physical examination shows a patent stoma site without erythema, induration, or discharge. What is the most appropriate next step in management? A. Start empiric antibiotics and monitor for peritonitis B. Consult gastroenterology for endoscopic tube replacement C. Apply sterile dressing and schedule outpatient replacement 👍D. Insert a replacement gastrostomy tube or Foley catheter E. Obtain abdominal CT with contrast to assess for perforation For late dislodgement (> 4 weeks after placement), bedside gastrostomy tube replacement is safe and appropriate. A replacement tube or Foley catheter should be inserted immediately to prevent tract closure, which occurs within hours of tube removal.

68-year-old patient with congestive heart failure (ejection fraction 30%) and moderate COPD presents to the emergency department with anterior shoulder dislocation after a fall. Vital signs are BP, 100/65; P, 92; R, 22; oxygen saturation, 90% on room air. The patient appears uncomfortable and requires immediate closed reduction. The patient has been NPO for 6 hours. Which sedative agent is most appropriate for this procedure? A. Ketamine B. Dexmedetomidine C. Midazolam 👍 D. Etomidate E. Propofol

A 28-year-old man presents with altered mental status and vomiting after falling from a ladder. Vital signs are BP, 100/65; P, 55. His Glasgow Coma Scale score is 8. Neurological examination reveals anisocoria with sluggish pupillary responses. He requires emergency intubation for airway protection. Which induction agent is most appropriate? A. Fentanyl B. Propofol C. Ketamine 👍 D. Etomidate E. Midazolam Correct Answer Is D Correct – Etomidate is the preferred induction agent for patients with suspected increased ICP because it can reduce ICP while having minimal effect on blood pressure.

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👍Correct Answer Is A Correct – This patient, who was recently started on empagliflozin, likely has euglycemic diabetic ketoacidosis (DKA), as evidenced by his calculated anion gap of 22 mEq/L, low bicarbonate, and ketonuria despite normal glucose levels. The deep, rapid breathing represents respiratory compensation for metabolic acidosis. Initial management of DKA includes intravenous fluid resuscitation to correct dehydration and insulin therapy to halt ketogenesis and correct the metabolic acidosis. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors such as empagliflozin are a recognized cause of euglycemic DKA

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A 65-year-old man presents to the emergency department with a 2-day history of progressive dyspnea and fatigue. His medical history includes hypertension, type 2 diabetes, COPD, and heart failure with reduced ejection fraction. Routine echocardiography 3 months ago showed an ejection fraction of 45%. HbA1c was 7.9% 2 months ago. His regular medications include carvedilol, valsartan, spironolactone, metformin, and a combination LABA/LAMA inhaler. In addition to these, empagliflozin was started 2 months ago. He reports nausea but denies chest pain, orthopnea, or paroxysmal nocturnal dyspnea. Vital signs are BP, 105/65; P, 108; R, 28; T, 36.9°C (98.4°F); O2 saturation 98% on room air. Physical examination shows an alert patient with deep, rapid respirations. The cardiovascular exam shows a regular rhythm without murmurs, no jugular venous distension, and minimal bilateral pretibial edema. Lungs are clear to auscultation bilaterally. Laboratory results: WBC 8,200/μL, Hgb 13.2 g/dL, platelets 245,000/μL, sodium 140 mEq/L, potassium 4.2 mEq/L, chloride 106 mEq/L, bicarbonate 12 mEq/L, BUN 32 mg/dL, creatinine 1.2 mg/dL, glucose 180 mg/dL. Urinalysis shows +2 ketones. Which of the following is the most appropriate next step in management for this patient? A.  Intravenous fluids and insulin therapy B. CT pulmonary angiogram C. ECG and troponin levels D. Intravenous furosemide E. Bronchodilators and systemic corticosteroids

Correct Answer Is C This patient demonstrates red flags requiring urology referral including recurrent UTIs and persistent hematuria. Recurrent infections in the setting of incontinence may indicate underlying anatomical abnormalities or incomplete bladder emptying, while persistent hematuria warrants specialist evaluation with advanced diagnostic studies such as cystoscopy

 A 62-year-old woman presents to the emergency department with worsening urinary incontinence over the past month. She reports involuntary urine leakage that occurs both with coughing and with sudden urges to urinate. She has had three urinary tract infections treated by her primary care physician in the past 4 months, with the most recent one finishing antibiotic treatment 2 weeks ago. Physical examination reveals mild suprapubic tenderness. Urinalysis shows microscopic hematuria. Including discharge, which of the following is the most appropriate disposition? A. Primary care follow-up B. Home bladder training C. Urology referral D. Prescription for anticholinergic medication E. Referral for pelvic floor physical therapy

🧩 Medical Mnemonics 📌 Conus 🆚 Cauda — Easy to remember 🧠 Conus Medullaris = 4S  ✖ Sudden onset  ✖ Symmetric deficits  ✖ Saddle anesthesia  ✖ Sphincters early  🐎 Cauda Equina = 4P  ✖ Pain (radicular, severe)  ✖ Patchy deficits (asymmetric)  ✖ Progressive onset  ✖ Pee late #neurology 〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

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