Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_12 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. This patient's tender, erythematous ear swelling is consistent with an auricular hematoma, which results from blood collection in the subperichondrial space of the external ear, typically after blunt trauma. This injury occurs most often in wrestlers, rugby players, boxers, and mixed martial artists. Patients classically present with acute ear tenderness, swelling, erythema, and ecchymoses. Treatment involves auricular hematomas that are <2 cm in diameter and present for up to 48 hours undergo needle aspiration. Auricular hematomas ≥2 cm in diameter and all hematomas present from 48 hours up to seven days receive either incision and drainage or evacuation using an intravascular catheter rather than needle aspiration. The procedure should be performed immediately to prevent cauliflower ear, a permanent deformity due to fibrous and cartilaginous overgrowth. Because of the risk of infection to an area with tenuous blood supply, recommended that all patients who undergo auricular hematoma drainage receive a 7-to-10-day course of empiric oral antibiotics with activity against skin flora and Pseudomonas aeruginosa (e.g., levofloxacin). After auricular hematoma drainage, patients warrant daily follow-up for three to five days to evaluate for reaccumulation of the hematoma or infection. Return to sports can occur as early as seven days after the initial injury if the hematoma does not reaccumulate. Athletes should be strongly advised to wear protective headgear to prevent reinjury. ❌Choice A is not correct: Antibiotic ear drops (e.g., levofloxacin) are the first-line treatment for otitis extern, which presents with ear pain, pruritus, drainage, and hearing loss. Patients with otitis externs typically have pain with manipulation of the tragus and/or auricle. In patients with auricular hematomas, antibiotics can be considered for empiric coverage of auricular skin flora and Pseudomonas, but only after incision and drainage (the primary treatment) has been performed. ❌Choice B is not correct: Pressure dressings consist of gauze that is firmly applied to a wound to prevent blood and serous fluid accumulation. Such dressings should be applied after incision and drainage to decrease reaccumulation risk. ❌Choice C is not correct: Auricular hematomas require immediate incision and drainage. Observation without intervention would increase the risk of complications. ❌Choice E is not correct: Temporal bone CT without contrast is indicated for patients with suspected temporal basilar skull fractures, which commonly present with subcutaneous bleeding over the mastoid process (Battle sign). Basilar skull fractures can also present with subcutaneous bleeding around the orbits (raccoon eyes), hemotympanum, cranial nerve deficits, and cerebrospinal fluid otorrhea or rhinorrhea. This patient's injury is localized to the external ear; a CT scan is not indicated. ✅Summarized Points: Auricular hematomas are caused by blunt trauma to the external ear. Classic findings include an erythematous, tender swelling in the auricular fossa. Incision and drainage should be performed immediately to prevent cauliflower ear. A pressure dressing is subsequently applied to prevent reaccumulation of blood and serous fluid.

🧠 Case-based MCQ 🔸 #MCQ_12 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 20-year-old boy is brought to the emergency department with acute left ear pain and swelling. He was competing in a boxing tournament and was kicked in the side of the head 3 hours ago. Examination shows a 3-cm area of erythema and tenderness with fluctuant swelling over the fossa of the left ear. The tympanic membrane is clear and intact.

🧠 Case-based MCQ 🔸 #MCQ_11 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. This patient's clinical presentation—posttraumatic shoulder pain with normal passive range of motion (ROM) but limited active abduction—is most likely due to a rotator cuff tear. Rotator cuff tears occur mainly in patients age >40, often after a fall on an outstretched arm. Atraumatic, degenerative tears can also occur, usually in elderly individuals. The associated pain at the lateral shoulder is typically worsened by raising the arm overhead or lying on the affected side. Of the major rotator cuff components, the supraspinatus tendon is most commonly affected. Injury to the supraspinatus can lead to weakness of abduction and external rotation and a positive drop arm sign (i.e., when the arm is released at 90 degrees of abduction, the patient is unable to smoothly lower it to the side). X-ray is usually normal and is primarily done to rule out fracture; MRI and ultrasound have higher sensitivity. Treatment of an acute tear usually involves surgery, with best results if performed within 6 weeks of the injury. ❌Choice B is not correct: Examination in acromioclavicular (AC) joint separation shows a prominent, high-riding distal clavicle with focal tenderness and crepitus at the AC joint There is pain with cross-body abduction of the arm (a movement that compresses the AC joint), and x-ray shows widening of the AC joint. ❌Choice C is not correct: Frozen shoulder (adhesive capsulitis) often presents with pain that is worse at night and is a potential complication of rotator cuff injury. However, it is associated with stiffness and marked limitation in both active and passive ROM. ❌Choice D is not correct: Calcific tendinopathy of the shoulder is characterized by hydroxyapatite deposits in the rotator cuff tendons. It presents with a gradual onset of pain that is worsened by abduction. The pain can be severe and may limit active ROM, but true weakness is absent Calcifications of the tendons are visible on x-ray. ❌Choice E is not correct: Both rotator cuff tendinopathy/ impingement and tear may present with pain on reaching or abduction. However, tendinopathy/impingement without tear does not cause weakness and reduced ROM. ✅Summarized Points: Rotator cuff tear is characterized by acute shoulder pain with normal passive range of motion but weakness of abduction and external rotation. It occurs mainly in patients age >40, often after a fall. X-ray is usually normal, but MRI and ultrasound have higher sensitivity. Treatment usually involves surgery within 6 weeks.

🧠 Case-based MCQ 🔸 #MCQ_11 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 62-year-old man comes to the clinic due to shoulder pain that began after a fall 3 weeks ago. The pain is felt over the patient's lateral shoulder and often keeps him awake. It makes it difficult for him to lift anything overhead. Shoulder passive range of motion is normal; however, motion against any resistance is limited, and the patient is unable to maintain 90 degrees of abduction. There is weakness in abduction and external rotation. X-ray of the shoulder is normal.

🧠 Case-based MCQ 🔸 #MCQ_10 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. This patient likely has wet-type age-related macular degeneration (ARMD). She has a loss of central vision over a period of weeks to months and subretinal fluid and retinal detachment. Neovascularization is the underlying mechanism of wet ARMD and can be treated with thermal laser photocoagulation, photodynamic therapy, or intravitreal injection of a vascular endothelial growth factor inhibitor.   ❌Choice A is not correct: Decreased scleral elasticity is a proposed mechanism for dry ARMD. This patients presentation with unilateral visual loss over weeks to months and findings of subretinal fluid are more consistent with wet ARMD, which is due to neovascularization. ❌Choice B is not correct: Ischemic damage to photoreceptors is a proposed mechanism for dry ARMD. A patient with dry ARMD would have areas of retinal atrophy, depigmentation, and drusen on funduscopic examination, and not subretinal fluid as in this patient with wet ARMD. ❌Choice C is not correct: This patient has wet age-related macular degeneration secondary to neovascularization. This may lead to subretinal hemorrhages or fluid collections. Optic nerve atrophy is not involved in the acute presentation of this disease but is seen in glaucoma. ❌Choice E is not correct: Thromboembolism is unlikely to be the cause of this patient’s visual loss. Her presentation of worsening central vision over a month and funduscopic examination findings are more consistent with wet ARMD. Thromboembolism presents acutely. ✅Summarized Points: Neovascularization is the underlying mechanism of wet-type age-related macular degeneration, which may present with loss of central vision over a period of weeks to months, subretinal fluid, and retinal detachment.

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🧠 Case-based MCQ 🔸 #MCQ_10 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An 85-year-old woman with a 40-pack-year smoking history presents to her physician with declining vision in her left eye over the past month. She has trouble seeing her needlework or reading because there appears to be a dark circle in the center of her visual field. Her blood pressure is 140/90 mmHg, pulse is 90/min, respiratory rate is 14/min, temperature is 37C (98.6 F). On funduscopic examination, her left eye shows subretinal fluid and a localized exudative retinal detachment.

🧠 Case-based MCQ 🔸 #MCQ_9 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Cat saliva contains multiple different bacteria (e.g., Streptococcus, anaerobic bacteria); Pasteurella multocida in particular is found in nearly 50% of cat bites. Cat bites can be quite deep, and infections due to these organisms can progress to bone and/or joint infections. Antibiotic prophylaxis can reduce infection rates and is recommended for cat bites as wet as for any animal bite wounds near lymphatics or blood vessels, bites on the hand or close to joints and/or bones, bites requiring surgical intervention, or in immunocompromised patients. Amoxicillin/clavulanate is the preferred antibiotic for prophylaxis. A three-day to seven-day course of prophylactic antibiotics is likely adequate. Tetanus vaccination is recommended after an animal bite if it has been more than five years since the patient has been immunized. Wounds should be irrigated for debris removal and examined closely for secondary injury to bones or ligaments. Animal bite wounds should usually be left open to heal by secondary intention, although primary closure may be considered for bites on the face, where cosmetic concerns are more significant and blood flow is generally heavy. ❌Choice A and B are not correct: Antibiotics ineffective against P multocida include first-generation cephalosporins (e.g., cephalexin), penicillinase-resistant penicillins (e.g., dicloxacillin), and macrolides (e.g., erythromycin). ❌Choice C is not correct: In patients with penicillin allergy, doxycycline + metronidazole could be an alternative. ❌Choice D is not correct: Topical antibiotics, such as neomycin, have not been extensively studied for bite wounds and are not recommended. ✅Summarized Points: Prophylactic antibiotics are warranted following a cat bite with deep injury. Antibiotic coverage should include an agent that treats Pasteurella multocida. Amoxicillin/clavulanate is preferred as first-line therapy.

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🧠 Case-based MCQ 🔸 #MCQ_9 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Cat saliva contains multiple different bacteria (e.g., Streptococcus, anaerobic bacteria); Pasteurella multocida in particular is found in nearly 50% of cat bites. Cat bites can be quite deep, and infections due to these organisms can progress to bone and/or joint infections. Antibiotic prophylaxis can reduce infection rates and is recommended for cat bites as wet as for any animal bite wounds near lymphatics or blood vessels, bites on the hand or close to joints and/or bones, bites requiring surgical intervention, or in immunocompromised patients. Amoxicillin/clavulanate is the preferred antibiotic for prophylaxis. A three-day to seven-day course of prophylactic antibiotics is likely adequate. Tetanus vaccination is recommended after an animal bite if it has been more than five years since the patient has been immunized. Wounds should be irrigated for debris removal and examined closely for secondary injury to bones or ligaments. Animal bite wounds should usually be left open to heal by secondary intention, although primary closure may be considered for bites on the face, where cosmetic concerns are more significant and blood flow is generally heavy. ❌Choice A and B are not correct: Antibiotics ineffective against P multocida include first-generation cephalosporins (e.g., cephalexin), penicillinase-resistant penicillins (e.g., dicloxacillin), and macrolides (e.g., erythromycin). ❌Choice C is not correct: In patients with penicillin allergy, doxycycline + metronidazole could be an alternative. ❌Choice D is not correct: Topical antibiotics, such as neomycin, have not been extensively studied for bite wounds and are not recommended. ✅Summarized Points: Prophylactic antibiotics are warranted following a cat bite with deep injury. Antibiotic coverage should include an agent that treats Pasteurella multocida. Amoxicillin/clavulanate is preferred as first-line therapy.

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🧠 Case-based MCQ 🔸 #MCQ_9 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 27-year-old woman comes to the emergency department with a house cat bite. There was blood at the puncture site, which she promptly cleaned with water. The patient has no significant past medical history and received a tetanus booster 4 years ago. Physical examination demonstrates one deep puncture wound and one superficial laceration on the right arm.

🧠 Case-based MCQ 🔸 #MCQ_8 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is B. Paget’s disease history is a distraction in this case. Paget’s disease does not cause hypercalcemia unless the patient is immobilized because of poor control. The hypercalcemia in Paget’s is secondary to prolonged immobilization and not because of Paget’s disease. This patient is physically very active. This patient has an acute kidney injury, punched-out lesions on the skull radiograph, and hypercalcemia, which all point to multiple myeloma (MM).The diagnosis of MM is often suspected because of one (or more) of the following clinical presentations: Bone pain with lytic lesions discovered on routine skeletal films or other imaging modalities An increased total serum protein concentration and/or the presence of a monoclonal (M) protein in the serum or urine Systemic signs or symptoms suggestive of malignancy, such as unexplained anemia Hypercalcemia, which is either symptomatic or discovered incidentally Acute kidney failure with a bland urinalysis or rarely the nephrotic syndrome due to concurrent primary amyloidosis In patients with suspected MM or related disorders, appropriate initial screening tests include serum and urine protein electrophoresis along with immunofixation and a serum free light chain (FLC) assay. Serum and urine electrophoresis with immunofixation may reveal a monoclonal spike and be useful for confirmation of the diagnosis. ❌Choice A is not correct: Paget’s disease, on the other hand, is characterized by mixed osteolytic and osteoblastic phases. Alkaline phosphatase is typically elevated in patients with Paget's. The skull radiograph will show a “cotton wool” appearance caused by irregular areas of sclerosis (mixed lytic and blastic areas). ❌Choice C is not correct: Do not order a bone scan if you are suspecting MM. MM causes lytic lesions in the bone, but these lesions are not seen on the bone scans since there is no associated new bone formation. A skeletal survey is a more appropriate test for detecting lytic lesions. ❌Choice D is not correct: Although the pathology of MM involves a bone marrow biopsy, this is not the best next step in this scenario. This invasive procedure is reserved for clear indications (i.e., abnormal immunoelectrophoresis). ❌Choice E is not correct: A renal biopsy may be needed later if the myeloma workup is negative. ✅Summarized Points: Suspect multiple myeloma in an elderly patient with anemia, renal failure, and hypercalcemia.

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