Case-based MCQ

🇨🇦 MCCQE1,2 | #Case_128 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 79-year-old male presents with left-sided hemiparesis. His previous medical history is significant for long-standing hypertension and type 2 diabetes mellitus. On examination his blood pressure is 220/130 mm Hg and his pulse rate is 96 beats/min. CT of the head shows no acute bleeding. An EKG shows left ventricular hypertrophy with diffuse nonspecific changes. Which one of the following would be most appropriate with regard to his blood pressure at this time? a) Watchful waiting b) Reduction of systolic blood pressure (SBP) to 190 mm Hg c) Reduction of SBP to 170 mm Hg d) Reduction of SBP to 150 mm Hg e) Reduction of SBP to 130 mm Hg

🇨🇦 MCCQE1,2 | #Case_127 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation Dupuytren’s contracture is characterized by changes in the palmar fascia, with progressive thickening and nodule formation that can progress to a contracture of the associated finger. The fourth finger is most commonly affected. Pitting or dimpling can occur over the nodule because of the connection with the skin. Degenerative joint disease is not associated with a palmar nodule. Trigger finger is related to the tendon, not the palmar fascia, and causes the finger to lock and release. Ganglions also affect the tendons or joints, are not located in the fascia, and are not associated with contractures. Flexor tenosynovitis, an inflammation, is associated with pain, which is not usually seen with Dupuytren’s contracture

🇨🇦 MCCQE1,2 | #Case_127 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 52-year-old male presents with a small nodule in his palm just proximal to the fourth metacarpophalangeal joint. It has grown larger since it first appeared, and he now has mild flexion of the finger, which he is unable to straighten. He reports that his father had similar problems with his fingers. On examination you note pitting of the skin over the nodule. The most likely diagnosis is: a) Degenerative joint disease b) Trigger finger c) Dupuytren’s contracture d) A ganglion e) Flexor tenosynovitis

🇨🇦 MCCQE1,2 | #Case_126 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the presenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and distortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individuals in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful when dissection is suspected. CT with intravenous contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography.Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a beta-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Vasodilation will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissections, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain).

🧩 Medical Mnemonics #Crohn's disease features 🎄🎄 MERRY CHRISTMAS with lots of love.💓 🎅Malabsorption 🎅Eye involvement(uveitis, iritis, and episcleritis) 🎅Renal stone(oxalate) 🎅Reduced bone mass(osteoprosis) 🎅Yeast infections(Candida) 🎅Cobblestones appearance 🎅High temperature(fever) 🎅Reduced lumen 🎅Intestinal fistulae 🎅Skin lesions(Erythema nodosum, pyoderma gangrenosum) 🎅Transmural ulceration 🎅Musculoskeletal involvement(Arthritis, Hypertrophic osteoarthropathy) 🎅Abdominal pain 🎅Submucous fibrosis/String Sign on barium X ray #gastroenterology 〰〰〰〰〰〰〰〰〰〰〰 📡 Medical Mnemonics

🇨🇦 MCCQE1,2 | #Case_125 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation This patient has classic presentation of toxic megacolon. The most common cause of toxic colon is inflammatory bowel disease (IBD), especially ulcerative colitis. The three week history of diarrhea in a young person that has worsened dramatically ending in bowel obstruction with systemic toxicity is a classic scenario of ulcerative colitis complicated with toxic megacolon. Toxic megacolon is an emergent life threatening condition that should be managed immediately with IV fluids, steroids and NG tube. ⚠ In the absence of antibiotics intake, pseudomembrenous colitis (choice A) becomes unlikely. ⚠ Colon cancer (choice B) is very unlikely to present as toxic megacolon; moreover, the patient’s young age favors against this diagnosis. ⚠ Although Crohn’s disease (choice C) can also lead to a fulminant colitis, it is very rare. ⚠ Intestinal perforation, not fulminant colitis, is the classic complication described in typhoid fever (choice D).

🇨🇦 MCCQE1,2 | #Case_125 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 28-year-old male comes to the ED complaining of intermittent cramps in his lower abdominal pain, rectal urgency and diarrhea with occasional blood in the stools of 3 weeks duration. His condition has been worsening progressively for the last 3 days. He has vomited several times and feels chilly. He denies the intake of any antibiotics recently. Vitals signs show: pulse is PR: 102/min, BP is 125/75 mmHg, Temp is 39°C and RR is 16/ min. Physical exam reveals a distended and tender to palpation abdomen without any evidence of peritoneal signs. Bowel sounds are absent. Rectal exam shows blood and mucus. Upright X-ray film of the abdomen discloses a hugely distended transverse colon filled with gas. Which of the following diseases would be the most likely precipitant of the patient’s condition? a) Clostridium difficile colitis b) Colon cancer c) Crohn’s disease d) Typhoid enteritis e) Ulcerative colitis

🇨🇦 MCCQE1,2 | #Case_124 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation Malignant otitis externa (MOE), skull base osteomyelitis, is the most likely diagnosis of this patient. MOE is usually seen in diabetics and immunosuppressed patients and often presents with a very intense ear pain and ear discharge. Fever is often present and the pain may radiate to the TMJ. Resistance to topical antibiotics along with the history of diabetes should be a useful clue. The most common cause of malignant otitis externa is Pseudomonas aeruginosa(choice C). ⚠ Aspergillus species (choice A) especially the fumigatus type may be occasionally the cause of MOE. ⚠ Escherichia coli (choice B) is the most common cause of UTI and not MOE. ⚠ Streptococcus pneumoniae (choice D) is the most common cause of otitis media and not externa. ⚠ Streptococcus pyogenes (choice E) and Staphylococcus aureus may be superadded; however very rarely to be the responsible agents. 🔖 Key point: Know the infections associated with diabetes well! Malignant otitis externa, erysipelas, cellulitis, mucormycosis, fournier’s gangrene and emphysematous cholecystitis are frequently asked!

🇨🇦 MCCQE1,2 | #Case_124 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 65-year-old diabetic male comes to the office complaining of excruciating pain in his left ear that began last night. The pain is 10/10 in intensity and radiates to his mandible. He also complains of ear discharge along with the pain. His condition is worsening progressively despite the use of Tobradex™ ear drops (Tobramycin + dexamethasone). Review of systems is otherwise normal. His vitals signs are within normal limits except for a temp of 38°C. HEENT exam shows the presence of granulation tissue in the lower part of his external auditory canal at the junction between the cartilaginous and bony parts of the canal. When the patient is asked to smile, some weakness of the left facial nerve is noticed. Which of the following pathogens is most likely to be responsible for this patient’s condition? a) Aspergillus nigrican b) Escherichia coli c) Pseudomonas aeruginosa d) Streptococcus pneumonia e) Streptococcus pyogenes

🇨🇦 MCCQE1,2 | #Case_123 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation This female has Prinzmetal variant angina, which is caused by coronary vasospasms. Sumatriptan is a 5HT1D and 1B agonist, which will have a vasoconstrictive effect. A side effect of this particular drug is that it induces vasospasms, hence contraindicated in individuals with this particular angina

🇨🇦 MCCQE1,2 | #Case_123 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 43-year-old female with a known history of migraines comes to your office today complaining of unusual chest pains. There is no family history of any coronary artery disease and she is neither a smoker nor does she have hypertension. She describes the discomfort occurring at times of rest and during exertion. However the episodes vary and arise unexpectedly. She is otherwise healthy with no other complaints. Which of the following is contraindicated in this patient? a) Nifedipine b) Sumatriptan c) Lisinopril d) Verapamil e) Flunarizine

🇨🇦 MCCQE1,2 | #Case_122 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation Instead of dementia, this patient has signs of pseudodementia of depression, which usually has a subacute onset. Memory usually is intact when adequate time is taken to carefully evaluate the patient. ⚠ The onset of Alzheimer’s disease, however, is gradual and includes memory loss. ⚠ Lewy body dementia is associated with hallucinations, and the onset is gradual. ⚠ Frontotemporal dementia generally occurs before age 60. Memory is usually preserved for orientation, although information retrieval may be difficult. ⚠ The onset of mild cognitive impairment is gradual and includes memory loss.

🇨🇦 MCCQE1,2 | #Case_122 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 72-year-old Asian-Canadian female is brought to your office by her husband because he thinks she might have Alzheimer’s disease. For the past 3 months she has complained of confusion, poor appetite, and lack of energy. She has been unable to do routine housework. On brief questioning, her short-term recall seems to be impaired, but a more detailed examination indicates that her memory is fine.Which one of the following is the most likely diagnosis? a) Alzheimer’s disease b) Lewy body dementia c) Frontotemporal dementia d) Pseudodementia e) Mild cognitive impairment

🇨🇦 MCCQE1,2 | #Case_121 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation Staphylococcus aureus is an unusual genitourinary pathogen; when found in the urine, it should be assumed to have migrated from a primary location. The patient should be examined carefully for a portal of entry such as a skin ulcer, intravenous site, or area of dermatitis. ⚠ An echocardiogram is often required to rule out endocarditis. ⚠ Methicillin-sensitive S. aureus can be treated with a penicillinase-resistant penicillin or a first-generation cephalosporin. ⚠ Vancomycin should be reserved for treating methicillin-resistant S. aureus. ⚠ Although oral cephalexin can be used to treat methicillin-sensitive S. aureus, this particular patient is too ill and needs to be evaluated for bacteremia

🇨🇦 MCCQE1,2 | #Case_121 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 76-year-old female is hospitalized for fever and weakness of several days’ duration. Her history and physical findings are otherwise unremarkable except for a temperature of 38.2°C (100.8°F), a pulse rate of 100 beats/min, and a blood pressure of 110/70 mm Hg. A urinalysis reveals 10-15 WBCs/hpf and a urine culture reveals methicillin-sensitive Staphylococcus aureus. The most appropriate action at this point is to: a) reculture the urine, as the bacteria on the first urine culture is most likely a skin contaminant b) obtain a blood culture and examine the patient for a portal of entry c) obtain a blood culture and start the patient on intravenous vancomycin (Vancocin) d) start the patient on oral cephalexin (Keflex) e) order echocardiogram

🇨🇦 MCCQE1,2 | #Case_120 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation The combination of a painful arc and pain on use of the supraspinatus muscle indicates impingement syndrome (also called painful arc syndrome, supraspinatus syndrome, swimmer's shoulder, and thrower's shoulder), which is due to irritation of the rotator cuff under the coracoacromial arch. It is by far the most common cause of shoulder pain seen by family. ⚠ Subdeltoid bursitis is a much more acute problem, and impairs shoulder mobility in all directions. ⚠ Adhesive capsulitis produces loss of external rotation. ⚠ Glenohumeral arthritis produces pain with external rotation, and variable amounts of impaired mobility, depending on progression of the problem over time. ⚠ Acromioclavicular joint arthritis produces a positive scarf sign, and often a visible bump over the joint, since it lies so close to the skin surface

🇨🇦 MCCQE1,2 | #Case_120 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 35-year-old male complains of 2 months of right shoulder pain. He does not recall an injury, but says it is painful to lie on his right side or to work with his right hand above his head. On examination, the shoulder appears normal and there is no pain with external rotation of the shoulder, bringing the arm across the body (scarf test), or attempted external and internal rotation of the shoulder against resistance. Lowering the arm from full abduction (painful arc), attempted abduction above 45° against resistance, and elevating the internally rotated arm above 90° against resistance are all painful.The most likely diagnosis is: a) Subdeltoid bursitis b) Adhesive capsulitis c) Impingement syndrome d) Glenohumeral osteoarthritis e) Acromioclavicular osteoarthritis

🇨🇦 MCCQE1,2 | #Case_119 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. A neutrophil count > 250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results. Bloody ascites with abnormal cytology may be seen with hepatoma, but is not typical of peritonitis. The ascitic fluid pH does not become abnormal until well after the neutrophil count has risen, so it is a less reliable finding for treatment purposes. A protein level > 1 g/dL is actually evidence against spontaneous bacterial peritonitis

🇨🇦 MCCQE1,2 | #Case_119 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 For two weeks, a 62-year-old male with biopsy-documented cirrhosis and ascites has had diffuse abdominal discomfort, fever, and night sweats. His current medications are furosemide (Lasix) and spironolactone (Aldactone). On examination, his temperature is 38.0°C (100.4°F), blood pressure 100/60 mm Hg, heart rate 92 beats/min and regular. The heart and lung examination is normal. The abdomen is soft with vague tenderness in all quadrants. There is no rebound or guarding. The presence of ascites is easily verified. Bowel sounds are quiet. The rectal examination is normal, and the stool is negative for occult blood. You perform diagnostic paracentesis and send a sample of fluid for analysis. Which one of the following findings would best establish the suspected diagnosis of spontaneous bacterial peritonitis? a) pH < 7.2 b) Bloody appearance c) Neutrophil count > 300/mL d) Positive cytology e) Total protein > 1 g/dL

🇨🇦 MCCQE1,2 | #Case_118 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation Focal glomerular sclerosis is the type of nephropathy most commonly seen in IV drug users with AIDS. It is likely to lead to a very rapid loss of renal function.There is no clinical evidence to indicate that this person has diabetes, making diabetic nephropathy unlikely. Minimal change disease and IgA nephropathy and membranous nephropathy are only very rarely associated with AIDS.