Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_45 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is C The absolute risk reduction in this study is the risk in the placebo group, 350 / (350 + 1050) = 0.25, minus the risk in the losartan group, 300 / (300 + 1200) = 0.20. Thus, the ARR = 0.25 - 0.20 = 0.05. Therefore, the number needed to treat is 1/0.05 = 20 patients. This means that for every 20 patients treated, one death will be prevented. For every 200 patients treated, 10 deaths will be prevented.       Choice A is not correct: This value is the number needed to treat, which is calculated by taking the inverse of the ARR. In this study, the ARR is the risk in the placebo group, 350 / (350 + 1050) = 0.25, minus the risk in the losartan group, 300 / (300 + 1200) = 0.20. Thus, the ARR = 0.25 - 0.20 = 0.05. The NNT is therefore 1/0.05 = 20 patients. However, the question asks how many deaths will be prevented if 200 patients with congestive heart failure and an ejection fraction < 30% were treated with losartan in addition to an ACE inhibitor and a beta-blocker. ❌Choice B is not correct: This value is the risk of cardiovascular death in the placebo group, which is calculated by dividing the number of deaths in the placebo group by the number at risk in the placebo group: 350 / (350 + 1050) = 0.25. ❌Choice D is not correct: This value is the difference in the number of cardiovascular deaths in the placebo group (350) and the losartan group (300). This does not relate to the number of deaths that would be prevented if 200 patients with congestive heart failure and an ejection fraction < 30% were treated with losartan in addition to an ACE inhibitor and a beta-blocker. ❌Choice E is not correct: This value is the absolute risk reduction. In this study, the ARR is the risk in the placebo group, 350 / (350 + 1050) = 0.25, minus the risk in the losartan group, 300 / (300 + 1200) = 0.20. Thus, the ARR = 0.25 - 0.20 = 0.05. ✅Summarized Points: To answer this question correctly, calculate the number needed to treat (NNT) (i.e., the number of individuals that must be treated for one person to benefit from treatment), which is the inverse of absolute risk reduction (1/ARR).

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🧠 Case-based MCQ 🔸 #MCQ_45 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A randomized controlled trial is conducted to evaluate the relationship between the angiotensin receptor blocker losartan and cardiovascular death in patients with congestive heart failure (diagnosed as ejection fraction < 30%) who are already being treated with an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker. Patients are randomized either to losartan (N = 1500) or placebo (N = 1400). The results of the study has been shown in the table. Based on this information, if 200 patients with congestive heart failure and an ejection fraction < 30% were treated with losartan in addition to an ACE inhibitor and a beta-blocker, on average, how many cases of cardiovascular death would be prevented? A. 20 B. 0.25 C. 10 D. 50 E. 0.05

🧠 Case-based MCQ 🔸 #MCQ_44 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is C Surgical resection is associated with minimal risk for the fetus regardless of the gestational age and chemotherapy may be given after the first trimester. Given the patient's tumor size of 3.0 cm, she falls into the category of high-risk patients and should, therefore, undergo adjuvant chemotherapy.   ❌Choice A is not correct: Surgical resection is associated with minimal risk to the fetus regardless of gestational age, but radiotherapy should not be used during pregnancy because of the risk of fetal damage. ❌Choice B is not correct: The combination of hormonal therapy and trastuzumab is a recommended adjuvant treatment after surgical resection for estrogen-receptor-positive, HER2-positive breast cancer. However, both treatment options are contraindicated during pregnancy because of the risk of fetal damage. ❌Choice D is not correct: Although chemotherapy may be safely administrated to this patient, radiotherapy is contraindicated during pregnancy as it may harm the fetus. ❌Choice E is not correct: Termination of pregnancy is not recommended in this patient because there is treatment available that is associated with only minimal risk of fetal damage. Furthermore, pregnancy termination is not associated with better breast cancer survival. ✅Summarized Points: For gestational breast cancer surgery is the treatment of choice (radiation therapy is contraindicated during pregnancy). Adjuvant chemotherapy only in the second and third trimester.

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🧠 Case-based MCQ 🔸 #MCQ_44 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An obese 34-year-old primigravid woman at 20 weeks' gestation comes to the physician for a follow-up examination for a mass she found in her left breast 2 weeks ago. Until pregnancy, menses had occurred at 30- to 40-day intervals since the age of 11 years. Vital signs are within normal limits. Examination shows a 3.0-cm, non-mobile, firm, and nontender mass in the upper outer quadrant of the left breast. There is no palpable axillary lymphadenopathy. Pelvic examination shows a uterus consistent in size with a 20-week gestation. Mammography and core needle biopsy confirm an infiltrating lobular carcinoma. The pathological specimen is positive for estrogen and human epidermal growth factor receptor 2 (HER2) receptors and negative for progesterone receptors. Staging shows no distant metastatic disease. Which of the following is the most appropriate management?   A. Surgical resection and radiotherapy B. Hormonal therapy and trastuzumab C. Surgical resection and chemotherapy D. Radiotherapy and chemotherapy E. Termination of pregnancy

🧠 Case-based MCQ 🔸 #MCQ_43 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D Systemic thromboembolism is a major cause of morbidity in patients with atrial fibrillation (AF). Treatment with warfarin or target-specific oral anticoagulants (TSOACs) has been shown to significantly reduce the risk of embolization in patients at moderate to high risk for thromboembolic events. Recent guidelines have recommended the use of a modified CHA2DS2-VASc score for stroke risk assessment in patients with nonvalvular AF. This patient has a CHA2DS2-VASc score of 4 (female sex, age > 65, hypertension, and diabetes) and should be managed with anticoagulation. TSOACs (rivaroxaban, dabigatran, apixaban, and edoxaban) have proven efficacy in preventing thromboembolic events in patients with nonvalvular AF. TSOACs are not recommended for use in patients with mitral stenosis, prosthetic heart valves, end-stage renal disease, and severe decompensated valvular disease likely to require valve replacement; warfarin is preferred for these patients. ❌Choice A and B are not correct: Antiplatelet therapy with aspirin or a combination of aspirin and clopidogrel is significantly less effective in reducing the risk of thromboembolism compared to anticoagulant therapy with warfarin or TSOACs. ❌Choice C is not correct: Dipyridamole is occasionally used for secondary prevention of non-cardioembolic ischemic stroke in patients with recent transient ischemic attack or stroke. It has no role in the prevention of systemic thromboembolism in patients with AF. ❌Choice E is not correct: Ticagrelor is a reversible P2Y12 platelet receptor inhibitor and is used in the management of patients with acute coronary syndrome. It is not used in patients with AF. ✅Summarized Points: Anticoagulation with warfarin or target-specific oral anticoagulants (e.g., dabigatran, rivaroxaban) is recommended to prevent thromboembolic events in patients with nonvalvular atrial fibrillation. Warfarin is preferred for patients with mitral stenosis, prosthetic heart valves, end-stage renal disease, and severe decompensated valvular disease likely to require valve replacement.

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🧠 Case-based MCQ 🔸 #MCQ_43 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 66-year-old woman with hypertension and type 2 diabetes mellitus comes to the emergency department with palpitations and is diagnosed with atrial fibrillation. The arrhythmia resolves spontaneously in the emergency department without intervention. Her renal function is normal and she has no history of bleeding. Which of the following is the best treatment option for this patient? A. Aspirin B. Aspirin and clopidogrel C. Dipyridamole D. Rivaroxaban E. Ticagrelor

🧠 Case-based MCQ 🔸 #MCQ_42 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E Subacute thyroiditis (ST) is a self-limited condition. The hyperthyroid phase may last a few weeks, followed by a transient hypothyroid phase and eventual return to a euthyroid state. Treatment is primarily supportive, and most cases can be managed with a nonsteroidal anti-inflammatory drug to relieve pain; glucocorticoids can be used in severe or refractory cases. In addition, patients can be given a beta-blocker (e.g., propranolol, atenolol) to minimize the hyperadrenergic symptoms of thyrotoxicosis (e.g., sweating, palpitations). ❌Choice A is not correct: Radioiodine thyroid ablation is used for the definitive treatment of Graves’ disease and nodular thyroid disease. It is not necessary in ST, which is a self-limited illness, and would not be effective as thyroid uptake of the radioiodine dose is very low. ❌Choice B and C are not correct: Suppurative infection of the thyroid gland (infectious thyroiditis) is a rare condition that causes high-grade fever and pain at the thyroid gland. Patients will often have evidence of a thyroid abscess on examination or ultrasound, but are usually euthyroid as involvement of the thyroid gland is focal. Bacterial thyroid infections are treated with systemic antibiotics, and surgical drainage may be required. ❌Choice D is not correct: Thyrotoxicosis in ST is due to the release of preformed thyroid hormone. Antithyroid drugs (e.g., methimazole), which work by decreasing the synthesis of thyroid hormones, are ineffective. ✅Summarized Points: Subacute thyroiditis is a self-limited condition. Treatment consists primarily of nonsteroidal anti-inflammatory drugs for pain relief and beta-blockers to minimize thyrotoxic symptoms. Severe or refractory cases may require glucocorticoid therapy.

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🧠 Case-based MCQ 🔸 #MCQ_42 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 36-year-old woman presented with painful swelling in her neck of one-week duration. Her last menstrual period was 2 weeks ago. She is adopted, and her family history is unknown. Temperature is 38.3 C (100.9 F), blood pressure is 156/60 mm Hg, pulse is 110/min, and respirations are 22/min. The thyroid gland is diffusely enlarged, firm, and very tender. The extremities are warm and moist. Eye examination shows lid lag but no proptosis. The remainder of the examination is unremarkable. Laboratory results are as follows:   Leukocytes 11,000/µL   Thyroid-stimulating 0.01 µU/mL (0.4-5.0)   Free thyroxine (T4), serum 175 nmol/L (60-145)   Triiodothyronine (T3), serum 1.8 nmol/L (1.1-3.0)   Erythrocyte sedimentation rate 90 mm/h   Which of the following is the best treatment for this patient? A. Radioactive iodine B. Systemic antibiotics C. Incision and drainage D. Methimazole, nonsteroidal anti-inflammatory drug, and beta-blocker E. Nonsteroidal anti-inflammatory drug and beta-blocker

🧠 Case-based MCQ 🔸 #MCQ_41 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E This child fulfills all of the 5 minor criteria of the modified Duke criteria for the diagnosis of infective endocarditis (IE). These include a predisposing heart condition (ventricular septal defect), fever ≥ 38°C (100.4°F), vascular phenomenon (splinter hemorrhages and Janeway lesions, i.e., purplish lesions on her palms and soles), immunologic phenomenon (glomerulonephritis and Roth spots, i.e, retinal hemorrhages), and a positive blood culture for atypical microorganisms consistent with IE. The fulfillment of these 5 criteria (even in the absence of vegetations on the transthoracic echocardiography) is adequate to make a diagnosis of IE.   ❌Choice A is not correct: Kawasaki disease is an autoimmune vasculitis more commonly seen in boys under 5 years of age. The criteria for diagnosing Kawasaki disease include fever > 5 days, bilateral nonpurulent conjunctivitis, mucositis, cervical lymphadenopathy, and a diffuse erythematous rash over the palms and soles. Although this girl has had a fever > 5 days, she does not have any other criteria. Additionally, Kawasaki disease does not present with retinal hemorrhages or glomerulonephritis. ❌Choice B is not correct: This patient fulfills one major (carditis) and three minor (fever, arthralgia, and ↑ ESR) of the Jones criteria for rheumatic fever. However, rheumatic fever occurs 2–4 weeks after(!) an infection with S. pyogenes (tonsillitis or pharyngitis), and it is not associated with positive blood cultures, hemorrhages, or signs of glomerulonephritis. Additionally, although rheumatic fever is the most common cause of cardiovascular disease in developing countries, it is rare in developed countries. Finally, this patient fulfills all of the criteria for another condition, making it the more likely diagnosis – especially in a patient with underlying heart disease. ❌Choice C is not correct: Hand-foot-mouth disease is a contagious illness caused by Coxsackie virus that can present with fever, malaise, and a rash on the hands and feet. However, HFMD does not cause glomerulonephritis or retinal hemorrhages. Additionally, the positive S. pyogenes blood culture makes HFMD an unlikely diagnosis in this child. ❌Choice D is not correct: Acute lymphoblastic leukemia is the most common childhood malignancy. It typically presents with hepatosplenomegaly or lymphadenopathy, and anemia or thrombocytopenia, which are all absent in this patient. Although ALL can present with fever and malaise, and predispose to infection, it does not cause positive blood cultures, glomerulonephritis, or retinal hemorrhages as seen above. ✅Summarized Points: This patient with an underlying structural heart disease presents with edema, hematuria, and mild proteinuria, suggesting glomerulonephritis. She also has hemorrhages on her palms, soles, and under her fingernails as well as retinal hemorrhages, fever ≥ 38°C (100.4°F), arthralgia, and positive blood cultures. These findings fulfill all of the diagnostic criteria for one of the conditions below.