Case-based MCQ

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🧠 Case-based MCQ 🔸 #MCQ_16 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 28-year-old female psychiatry patient is extremely interested in everything the physician says, exclaiming, “Wow, doctor, you really understand me, you’re the best!” She tells the physician about the verbal abuse that she suffered during her childhood from a mother who gave her notably inconsistent parenting. She says that she currently feels empty inside, like she has no direction. She discusses the large number of tumultuous relationships that she has had throughout her life, giving vague reasons as to why they have not worked out. When the physician asks her to describe herself further, she states that she is “impulsive.” When the physician suggests that her personality structure may be to blame, she screams, “You’re just like the rest of them!” and runs out.

🧠 Case-based MCQ 🔸 #MCQ_15 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. Preterm infants are at higher risk for vaccine-preventable diseases than term infants and should be vaccinated based on their chronological (absolute) age rather than adjusting for prematurity. Immunizations elicit robust, protective antibody responses in preterm infants. Therefore, clinically stable preterm infants should receive standard immunizations based on the routine immunization schedule, even if they are still in the neonatal intensive care unit. ❌Choice B is not correct: Most centers in Canada delay rotavirus vaccination until hospital discharge, as it is a live virus and could theoretically be transmitted to other infants. ❌Choice C is not correct: Infants born prematurely are more likely than term infants to contract vaccine-preventable diseases, so their vaccinations should be based on their chronological (absolute) age rather than adjusting for prematurity. ❌Choice D and E are not correct: The exceptions include hepatitis B and rotavirus vaccines. For infants with <2 kg (4.4 Ib) birth weight who are born to hepatitis B surface antigen-negative mothers, hepatitis B vaccination should be delayed until age 30 days or hospital discharge (whichever comes first) due to potentially lower immunogenicity at lower birth weights. Infants born to hepatitis B surface antigen-positive mothers should receive hepatitis B vaccine and hepatitis B immune globulin within 12 hours regardless of birth weight. ✅ Summarized Points: Preterm infants are at higher risk for vaccine-preventable infections and should follow the standard immunization schedule and receive most immunizations based on their chronological age.

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🧠 Case-based MCQ 🔸 #MCQ_14 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 2-month-old girl is brought to the clinic for her first visit following hospital discharge. She was born at 31 weeks gestation and spent 10 weeks in the neonatal intensive care unit. She was discharged 3 days ago. The patient was born small for gestational age but has been gaining weight well on 27-kcal/oz preterm formula. She currently weighs 1.9 kg (4.2 Ib). Her vital signs and physical examination are normal.

🧠 Case-based MCQ 🔸 #MCQ_14 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. Paget disease of the breast (PDB), is an infiltrating cancer of the breast directly underneath the areola that is permeating the skin lymphatics and the skin itself. It usually presents as scaly, erythematous, crusty, and thickened plaques on the nipple, spreading to the surrounding areolar areas, are typical. Diagnosis of PDB is by tissue biopsy (e.g., wedge, punch). Many patients with PDB have an underlying breast malignancy (e.g., intraductal carcinoma, ductal carcinoma in situ). Therefore, all patients with PDB require bilateral mammography. Although it is true that the areola is not immune to other benign skin conditions, missing cancer would be lethal. Thus, any other answer that does not seek to rule out cancer first is wrong. ❌Choice B is not correct: Treatment with estrogens assumes a benign, age-related atrophy, which is common in the vagina but not in the areola. ❌Choice C is not correct: A mammogram and galactogram are indicated to find intraductal papilloma, the presentation of which is bloody nipple discharge in a younger woman. ❌Choice D is not correct: Glucagonoma shows up as an intractable skin condition, but it is migratory, necrolytic, and exfoliative. It occurs in anemic diabetic patients with glossitis and shows no preference for the areola. ❌Choice E is not correct: Culture and topical antibiotics is the intuitive answer if you assume that this is a nasty skin infection, but never make that your first diagnosis in this setting! ✅ Summarized Points: Paget disease of the breast is characterized by a unilateral, erythematous, intensely pruritic, ulcerative lesion of the nipple-areolar complex. Diagnosis is by tissue biopsy. Patients also require diagnostic bilateral mammography, as many have underlying breast malignancy.

🧠 Case-based MCQ 🔸 #MCQ_14 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 65-year-old woman has an eczematoid lesion in the areola of her right breast that has been present for 3 months. She has self-medicated with skin lotions and over-the-counter steroid ointments, but the area has not improved. On physical examination, the nipple is inverted, the skin of the areola is reddish and desquamated, and the entire area feels firm, with no discrete mass demarcated from the rest of the breast.

🧠 Case-based MCQ 🔸 #MCQ_13 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is B. With rare exceptions, patients are entitled to know their diagnosis and prognosis, even if they are old, their condition is probably terminal, and they have anxious personalities and/ or psychiatric diagnoses. Exceptions to the physician's obligation to discuss the diagnosis with the patient, include the previous request of the patient to not be informed or the belief of the physician that disclosure would severely harm the patient. ❌Choice A is not correct: It would be unethical to acquiesce to the family's request. If nondisclosure is the patient's request as well, then the physician will be able to honor it. ❌Choice C is not correct: Even if the entire family wants to keep the diagnosis from the patient, if the patient him- or herself wants to be informed, the physician is obligated to tell the patient the diagnosis. ❌Choice D is not correct: Rarely will consultation be a correct answer on a USMLE examination. The physician has the information needed to act and should do so. ❌Choice E is not correct: Psychiatric evaluation is not warranted at this time. All physicians can judge decision-making capacity, and if the patient has the capacity to decide whether he or she wants to be informed of the diagnosis, the obligation then exists to abide by that wish. ✅Summarized Points: Patients are entitled to know their diagnosis and prognosis. Exceptions to the physician's obligation to discuss the diagnosis with the patient include the patient's previous request to not be informed or the physician's belief that disclosure would severely harm the patient.

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🧠 Case-based MCQ 🔸 #MCQ_12 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 92-year-old man was admitted to the hospital because of weakness and rectal bleeding for the previous 24 hours. Questioning reveals, a decrease in stool caliber over the past several months. Examination reveals a nontender mass in the left lower quadrant. Stool heme is positive. Serum hemoglobin is 88 g/L. Further work-up reveals colon cancer, Duke stage D. The patient's spouse and only child are no longer living, but the patient's 50-year-old granddaughter pleads with the physician not to inform her grandfather of the diagnosis, stating that he is an anxious man and that she wants him to enjoy his remaining time.