Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_61 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. This patient's acute onset pelvic pain and tender adnexal mass are concerning for ovarian torsion, a gynecologic emergency. During ovarian torsion, the ovary rotates around the infundibulopelvic ligament, resulting in ovarian vessel occlusion and subsequent loss of its blood supply. Ovarian blood flow can be assessed via Doppler evaluation of the ovary during pelvic ultrasound which shows decreased or absent blood flow in patients with ovarian torsion. This impeded ovarian blood supply causes the ovary to become edematous (e.g., acute pain, tender adnexal mass) and, eventually, necrotic (e.g., fever, leukocytosis). Because ovarian torsion is common in reproductive-age women (particularly during pregnancy or ovulation induction), immediate surgical management is required as ovarian necrosis can result in the loss of ovarian function (e.g., infertility, menopause). Surgery definitively diagnoses ovarian torsion and allows for mechanical ovarian detorsion and removal of any contributory cysts or masses. If the ovary still appears necrotic after these measures, oophorectomy is performed. ❌Choice B is not correct: An ectopic pregnancy can present with acute unilateral pelvic pain and a tender adnexal mass. This patient has a negative pregnancy test, making this diagnosis unlikely. ❌Choice C is not correct: The cysts associated with polycystic ovary syndrome are small; therefore, patients usually have bilateral, minimally enlarged ovaries. Due to chronic anovulation, patients do not typically have associated pain. ❌Choice D is not correct: A tubo-ovarian abscess can present with unilateral adnexal tenderness; however, patients typically have associated fever, making this diagnosis unlikely. ❌Choice E is not correct: A pedunculated uterine leiomyoma can present as an adnexal mass; however, patients typically have a concomitant enlarged, irregularly shaped uterus. ✅Summarized Points: Ovarian torsion typically presents with acute-onset unilateral pelvic pain and a tender adnexal mass. It is a gynecologic emergency requiring immediate surgical management as prolonged torsion can result in ovarian necrosis and loss of ovarian function

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🧠 Case-based MCQ 🔸 #MCQ_61 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤

🧠 Case-based MCQ 🔸 #MCQ_59 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 32-year-old woman comes to the emergency department due to right-sided pelvic pain. The pain began suddenly 2 hours ago and is not relieved with ibuprofen. For the past hour, the patient has also had uncontrolled vomiting. Temperature is 36.7 C (98 F), blood pressure is 146/80 mm Hg, and pulse is 110/min. Physical examination reveals a small, mobile uterus and a tender mass in the right adnexa. The urine pregnancy test is negative. Which of the following is the most likely diagnosis in this patient? A. Ovarian torsion B. Ectopic pregnancy C. Polycystic ovary syndrome D. Tubo-ovarian abscess E. Uterine leiomyoma

🧠 Case-based MCQ 🔸 #MCQ_59 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 🔤 The correct answer is A. Biliary atresia is the most common congenital biliary anomaly. Typical symptoms include variable degrees of jaundice, dark urine, and light stools. In most cases of biliary atresia, infants are typically full-term, although a higher incidence of low birth weight may be observed. In the majority of cases, acholic stools are not noted at birth but develop over the first few weeks of life. Conjugated hyperbilirubinemia can be seen in laboratory evaluation. A "triangular cord sign" can be seen on abdominal ultrasound. No primary medical treatment is relevant in the management of extrahepatic biliary atresia. Once biliary atresia is suspected, surgical intervention is the only mechanism available for a definitive diagnosis (intraoperative cholangiogram) and therapy (Kasai portoenterostomy). ❌Choice B is not correct: Autoimmune hepatitis typically presents with elevated liver transaminases and does not typically cause jaundice in a newborn. ❌Choice C is not correct: Choanal atresia refers to obliteration or blockage of the posterior nasal aperture and is not a cause of jaundice. ❌Choice D is not correct: Hemolytic disease of the newborn, or erythroblastosis fetalis, presents with jaundice within the first 24 hour of life. In the above scenario, jaundice is not identified at birth and the newborn is discharged 24 hour following a term vaginal delivery, suggesting another etiology. ✅Summarized Points: Suspect biliary atresia in newborns who develop jaundice, dark urine, and light-coloured stools several weeks following birth

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🧠 Case-based MCQ 🔸 #MCQ_59 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 2-week-old infant develops new-onset jaundice and light-coloured stools. The infant was delivered via spontaneous vaginal delivery at term and was discharged from the hospital 24 hour later with no complications. No jaundice was noted at the time of discharge. What is the most likely diagnosis? A. Biliary atresia B. Autoimmune hepatitis C. Choanal atresia D. Erythroblastosis fetalis

🧠 Case-based MCQ 🔸 #MCQ_59 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is B. Cyanosis is a bluish discoloration of the skin that is often caused by hypoxia. It is not a sensitive indicator of hypoxia, as it is only apparent with more severe hypoxia (often at a saturation < 85%). Cyanosis is often classified as central and peripheral. Central cyanosis is always considered pathologic and is caused by impaired oxygenation. Possible causes may include hypoventilation from respiratory depression, ventilation-perfusion mismatch in the lung, bronchospastic lung disease (such as in asthma), hypothermia, heart failure, and structural heart abnormalities. In contrast, peripheral cyanosis occurs in the extremities such as the fingertips and may or may not be pathologic or life-threatening. Possible causes of peripheral cyanosis include heart failure, cardiogenic shock, local vasoconstriction (such as from cold or Raynaud phenomenon), and arterial obstruction. On occasion, differential cyanosis may be seen, which is a difference in cyanosis between the upper and lower extremities and may indicate congenital cardiac abnormalities (such as aortic coarctation). ❌Choice A, C and D are not correct: Arterial vasospasm, hyperviscosity, and hypothermia are all possible causes of peripheral cyanosis but would not cause isolated central cyanosis. ✅Summarized Points: When the systemic arterial concentration of deoxygenated hemoglobin (Hb) in the blood exceeds 50 g/L (oxygen saturation≤ 85 percent), the patient develops central cyanosis. In contrast, patients with peripheral cyanosis, on the other hand, have normal systemic arterial oxygen saturation, but enhanced oxygen extraction causes a large systemic arteriovenous oxygen difference and increased deoxygenated blood on the venous side of the capillary beds. Causes include vasomotor instability, vasoconstriction caused by exposure to cold, venous obstruction, elevated venous pressure; polycythemia; and low cardiac output.

A 12-hour-old girl presents to the emergency department for what her mother describes as “turning blue.” She was born at home without prenatal care. Her mother states she did not notice any abnormalities at birth. Vitals and intravenous access are being obtained. Physical exam reveals the finding below. Which of the following is a possible cause of this patient’s symptoms? A. Arterial vasospasm B. Congenital heart lesion C. Hyperviscosity D. Hypothermia

🧠 Case-based MCQ 🔸 #MCQ_58 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is A: Internal hemorrhoids are highly vascularized submucosal cushions located in the anal canal. They are classified as: First degree if no prolapse is present. Second degree if prolapse occurs with spontaneous reduction. Third degree if they require manual reduction. Fourth degree if they are irreducible. Treatment is based on the symptoms and degree of prolapse. Nearly all patients with first- and second degree hemorrhoids should initially be placed on a trial of conservative measures including a bowel management program with high fiber diet to avoid straining and constipation, frequent warm baths, and an anti-inflammatory topical cream. ❌Choice B, C, D are not correct: If symptoms continue, both rubber band ligation (a small rubber band is placed at the neck of the hemorrhoid resulting in eventual death and detachment of tissue) and infrared coagulation (controlled burn of the vessels at the neck of the hemorrhoid) are good alternatives to surgical therapy. ❌Choice E is not correct: For refractory first- and second-degree hemorrhoids, most third-degree and all fourth-degree hemorrhoids, surgical hemorrhoidectomy is the treatment of choice. ✅Summarized Points: The best initial therapy for first and second degree internal hemorrhoid is conservative measures such as High fiber diet, frequent sitz baths, and topical steroid ointment.

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🧠 Case-based MCQ 🔸 #MCQ_58 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 46-year-old male truck driver presents for evaluation of bright red rectal bleeding with bowel movements. He also has the feeling that something protrudes through his anus while he strains to move his bowels but that it withdraws into the bowel when he relaxes. He has no abdominal pain, weight loss, or other symptoms. A colonoscopy reveals no polyps or tumors but does note internal hemorrhoids. Which of the following is the best initial treatment for him? A. High fiber diet, frequent sitz baths, and topical steroid ointment B. Rubber band ligation C. Sclerotherapy injection D. Infrared coagulation E. Surgical hemorrhoidectomy

🧠 Case-based MCQ 🔸 #MCQ_57 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. The ECG shows sinus bradycardia and Osborn waves in the setting of environmental exposure that led to profound hypothermia. Osborn waves are characterized by a positive J-point deflection in the precordial leads with reciprocal negative J-point deflection in leads aVR and V1. They are not pathognomonic for hypothermia but are commonly seen with core temperatures < 32°C. Other ECG abnormalities associated with hypothermia include shivering artifact, prolonged QTc interval, low voltage, ventricular dysrhythmias, and bradydysrhythmias, including slow junctional rhythms, atrioventricular blocks, and atrial fibrillation with slow ventricular response. Treatment with antidysrhythmics, atropine, and transcutaneous pacing can be considered, but these cardiac abnormalities usually resolve with warming alone. ❌Choice B is not correct: An accessory electrical pathway, as seen in Wolff-Parkinson-White syndrome, will result in short PR intervals and delta waves. ❌Choice C is not correct: Arrhythmogenic right ventricular cardiomyopathy (ARVC) can lead to sudden cardiac death in young adults and is associated with epsilon wave, a small positive deflection at the end of the QRS complex. Treatment for ARVC includes antidysrhythmic drugs, anticoagulation, insertion of implantable cardioverter-defibrillator, and in severe cases, heart transplantation. ❌Choice D is not correct: Transmural myocardial ischemia caused by sudden and complete occlusion of a coronary artery will result in ST segment elevations within the affected region. Those types of changes are not evident in the above ECG. ✅Summarized Points: Osborn waves produce prominent convex deflections at the J point (junction of QRS and ST segments) that are best seen in the precordial leads. The J waves or Osborn waves are characteristic of severe hypothermia and resolve with rewarming.

🧠 Case-based MCQ 🔸 #MCQ_57 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 27-year-old man is brought to the emergency department by paramedics after being found minimally responsive on the street. There is no evidence of traumatic injuries on physical exam. Blood glucose level is 6.9 mmol/L (3.3‐5.8). Which of the following conditions is associated with the patient’s clinical presentation and the ECG shown below? A. Environmental exposure B. Accessory electrical pathway C. Right ventricular cardiomyopathy D. Transmural myocardial ischemia

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