Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_6 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 77-year-old man with a history of hypertension, Paget’s disease, and peripheral vascular disease presents to you with complaints of chronic hearing impairment on the right side. He is otherwise very physically active. Physical examination is benign except for a right-sided sensorineural hearing deficit. A skull x-ray was obtained to evaluate Paget’s disease. Lab studies reveal:   Hemoglobin 97 gr/L (125–170)   Platelets     310x 109/L (130–380)   Leukocyte count 10 x 109/L (3.5–10.5)   Blood urea nitrogen   13 mmol/L (2.5‐8.0)   Creatinine 123 µmol/L (70‐120)   Ca+2 2.8 mmol/L (2.18‐2.58)   The patient is currently on alendronate for Paget’s disease.

🧠 Case-based MCQ 🔸 #MCQ_7 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. This elderly patient has delirium associated with acute urinary retention (AUR). In a patient with underlying benign prostate hyperplasia, sympathomimetics (e.g., pseudoephedrine) or antihistamines with anticholinergic properties (e.g., diphenhydramine) in cold medications can precipitate acute urinary retention. Urinary retention with increased bladder tension likely stimulates the sympathetic nervous system, resulting in catecholamines release and consequent delirium. Patients often have confusion and/or agitation but may not experience abdominal discomfort or specific urinary symptoms. Physical examination can demonstrate a distended bladder with discomfort on deep suprapubic palpation. The diagnosis of acute urinary retention can be confirmed with bladder ultrasound showing urine volume ≥300 mL. Patients with a highly suggestive history and physical examination can proceed directly to urinary catheterization as it is both diagnostic and therapeutic. Symptoms typically resolve rapidly after bladder decompression. ❌Choice A is not correct: This patient's abdominal examination findings are strongly suggestive of urinary retention with bladder distension; CT scan of the abdomen/pelvis may not be necessary as urinary catheterization may resolve his symptoms. ❌Choice B is not correct: Respiratory fluoroquinolones such as moxifloxacin can be used for outpatient treatment of community-acquired pneumonia. This patient has a normal cardiopulmonary examination and no evidence of fever, dyspnea, or pleuritic chest pain, making pneumonia less likely. ❌Choice C is not correct: Intravenous fluids can be helpful in dehydrated patients with delirium but would not address this patient's urinary retention. ❌Choice E is not correct: Lumbar puncture may be performed in patients with altered mental status and suspected meningitis or encephalitis. However, the absence of fever headache, and nuchal rigidity makes these less likely. ✅ Summarized Points: Acute urinary retention is an important cause of delirium in the elderly, although these patients often do not develop abdominal discomfort or specific urinary symptoms. Rapid resolution of symptoms typically occurs after bladder decompression.

🧠 Case-based MCQ 🔸 #MCQ_7 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 72-year-old man is brought to the hospital due to 1-day history of confusion. For the past 3 days, he has also had nasal congestion, sore throat, and a non-productive cough. Family members say that he has been acting strangely, asking the same questions repeatedly, talking to his deceased brother, and getting out of bed multiple times at night. The patient has a history of hypertension and benign prostate hyperplasia. His medications include amlodipine, tamsulosin, and over-the-counter cold medicine. He does not use tobacco, alcohol, or illicit drugs. His temperature is 37.2 C (99 F), blood pressure is 140/80 rum Hg, and pulse is 92/min. On examination, the patient appears to be in distress and is disoriented. Moderate pharyngeal erythema without exudate is present. Cardiopulmonary examination is normal. The abdomen is soft with tenderness and a palpable mass in the suprapubic region. His prostate is enlarged and smooth. There is no neck rigidity and he moves all extremities with equal strength. Laboratory results are as follows:   Hematocrit 38%   Leukocytes 11x 109/L (3.5–10.5)   Serum Sodium 142 mmol/L (135‐145)   Serum Potassium 4.2 mmol/L (3.5‐5.0)   Blood urea nitrogen 11 mmol/L (2.5‐8.0)   Creatinine 106 µmol/L (70‐120)

🧠 Case-based MCQ 🔸 #MCQ_6 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. This child's clinical presentation is classic for tinea versicolor (i.e., pityriasis versicolor). Tinea versicolor is a superficial fungal infection caused primarily by Malassezia globosa. Although Malassezia yeasts are part of normal skin flora, overgrowth causing clinical disease is common in temperate climates. The rash can have a variety of appearances and may present as either hyperpigmented or hypopigmented macules sometimes covered by a fine scale. Affected children usually have facial lesions; adolescents and adults typically have lesions on the trunk and proximal upper extremities. Diagnosis is confirmed by the presence of hyphae and yeast cells in a "spaghetti & meatballs" pattern on potassium hydroxide (KOH) preparation. The preferred treatment for tinea versicolor includes topical ketoconazole 2% cream or shampoo or selenium sulfide 2.5% lotion or foam. A 2-week course is often effective, but some cases take several months to resolve. Recurrence is also very common. Tinea versicolor is not contagious and children can return to school or daycare with no restrictions. ❌Choice A is not correct: Diluted bleach water soaks may be used as part of the treatment of eczema to reduce the risk of bacterial skin infections in these patients. Bleach baths have also been used to decrease skin colonization of methicillin-resistant Staphylococcus aureus; however, they do not play a role in the prevention of tinea versicolor. ❌Choice B is not correct: Oral antifungal agents (e.g., ketoconazole, itraconazole) can be used for recalcitrant or widespread tinea versicolor but are associated with increased side effects (e.g., transaminitis). ❌Choice C is not correct: Vitiligo can be differentiated from tinea versicolor by completely depigmented macules and patches. Treatment of vitiligo includes topical and oral corticosteroids, topical calcineurin inhibitors, and ultraviolet light. ❌Choice D is not correct: Permethrin is used in the treatment of lice and scabies but not tinea versicolor. ✅Summarized Points: Thee versicolor is a common fungal infection in temperate climates and manifests as hypopigmented or hyperpigmented lesions. First-line treatment includes topical ketoconazole or selenium sulfide.

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🧠 Case-based MCQ 🔸 #MCQ_6 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 4-year-old boy is brought to the physician for evaluation of a rash. The rash has been present for at least a month and became more prominent as the child spent more time playing outside during the summer. He has not used any new soaps, lotions, or detergents. Examination shows several hypopigmented macules on each cheek. Each macule is approximately 1 cm in diameter and is covered with a fine-scale. No other rashes or lesions are seen.

🧠 Case-based MCQ 🔸 #MCQ_5 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 ✔️The Correct answer is D. This patient has symptoms of an acute stroke. Strokes can be ischemic, caused by embolic events cutting cerebral blood flow, or hemorrhagic. CT scan of the head without contrast is the first best initial imaging study that needs to be ordered. This differentiates an ischemic from a hemorrhagic infarction. Ischemic strokes appear as dark areas on the CT scan Hemorrhagic strokes appear as white areas on the CT scan ❌Choice A is not correct: MRI of brain is more sensitive than CT scan. Identifies all infarcts, and does so earlier than CT scan. 95% of infarcts identified on MRI within 24 hours. However, not preferred in an emergency setting because it is time consuming and is not suitable for potentially unstable patients. ❌Choice B, C, E are not correct: First we need to identify with noncontract CT of head that patient has hemorrhagic or ischemic stroke. because they are contraindicated in the setting of a hemorrhagic stroke. ✅ Summarized Points: In all patient with suspicion of stroke first stabilize patient in primary survey doing ABC, Order labs like Noncontrast-CT scan of the brain, ECG, chest radiograph, CBC, platelet count, PT, PTT, Serum electrolytes, Glucose level, Bilateral carotid ultrasound and Echocardiogram. Noncontrast-CT scan will decide further treatment.

🧠 Case-based MCQ 🔸 #MCQ_5 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 68-year-old male presents to the emergency department with a complaint of right upper extremity weakness and slurred speech. His symptoms started 5 hours ago and have not improved. He has a medical history significant for hypertension and diabetes. His physical examination is notable for weakness in the right arm only and dysarthria, Right biceps reflex is brisk. The rest of the examination is normal. His temperature is 37.5, blood pressure is 190/100 mm Hg, the pulse is 75/min, respiratory rate is 12 /min.

🧠 Case-based MCQ 🔸 #MCQ_4 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 ✔️ The Correct answer is A. Pseudogout is joint inflammation caused by calcium pyrophosphate crystals. it happens in Elderly and Osteoarthritis joint. Its Presentation is similar to gout cause redness, swelling, tenderness, but typically occurs in larger joints (knee). Three main conditions that may increase crystal deposition include hemochromatosis, hyperparathyroidism, hypothyroidism (3 H’s). ❌Choice B is not correct: The uric acid crystals of gout are needle-shaped and negatively birefringent. ❌Choice C is not correct: This patient WBC count in the synovial fluid over 55.000 which suggest a septic arthritis, but the crystals point to pseudogout. ❌Choice D is not correct: Rheumatoid arthritis is symmetrical arthritis and usually involve hands. ❌Choice E is not correct: Osteoarthritis not come with fever, and synovial fluid WBC in osteoarthritis is less than 2000 and there is no crystal. 💠 Summarized Points: Fever and single joint pain next step is joint aspiration. Rhomboid crystal associated with Pseudogout. Risk factors for Pseudogout are hypothyroidism, Hemochromatosis, hyperparathyroidism. Pseudogout happen in Elderly and Osteoarthritis joint.

🧠 Case-based MCQ 🔸 #MCQ_5 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 58-year-old male presents to an emergency department complaining of severe knee pain which has been worsening over the past 2 days. He denies any trauma to the area. When questioned about his medical history, the patient reports that he is being treated for hypothyroidism. On examination, the patient has a temperature of 38 C (100.3 F). His left knee is warm, erythematous, and tender. There is a large effusion in the knee joint. He has painful limitation of motion of the knee. He has no rashes, and no other joints are involved. Arthrocentesis is performed and shows 75,000 WBC/mm3. A polarizing microscope shows rhomboid, positively birefringent crystals in the fluid.