Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_44 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is C Surgical resection is associated with minimal risk for the fetus regardless of the gestational age and chemotherapy may be given after the first trimester. Given the patient's tumor size of 3.0 cm, she falls into the category of high-risk patients and should, therefore, undergo adjuvant chemotherapy.   ❌Choice A is not correct: Surgical resection is associated with minimal risk to the fetus regardless of gestational age, but radiotherapy should not be used during pregnancy because of the risk of fetal damage. ❌Choice B is not correct: The combination of hormonal therapy and trastuzumab is a recommended adjuvant treatment after surgical resection for estrogen-receptor-positive, HER2-positive breast cancer. However, both treatment options are contraindicated during pregnancy because of the risk of fetal damage. ❌Choice D is not correct: Although chemotherapy may be safely administrated to this patient, radiotherapy is contraindicated during pregnancy as it may harm the fetus. ❌Choice E is not correct: Termination of pregnancy is not recommended in this patient because there is treatment available that is associated with only minimal risk of fetal damage. Furthermore, pregnancy termination is not associated with better breast cancer survival. ✅Summarized Points: For gestational breast cancer surgery is the treatment of choice (radiation therapy is contraindicated during pregnancy). Adjuvant chemotherapy only in the second and third trimester.

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🧠 Case-based MCQ 🔸 #MCQ_44 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An obese 34-year-old primigravid woman at 20 weeks' gestation comes to the physician for a follow-up examination for a mass she found in her left breast 2 weeks ago. Until pregnancy, menses had occurred at 30- to 40-day intervals since the age of 11 years. Vital signs are within normal limits. Examination shows a 3.0-cm, non-mobile, firm, and nontender mass in the upper outer quadrant of the left breast. There is no palpable axillary lymphadenopathy. Pelvic examination shows a uterus consistent in size with a 20-week gestation. Mammography and core needle biopsy confirm an infiltrating lobular carcinoma. The pathological specimen is positive for estrogen and human epidermal growth factor receptor 2 (HER2) receptors and negative for progesterone receptors. Staging shows no distant metastatic disease. Which of the following is the most appropriate management?   A. Surgical resection and radiotherapy B. Hormonal therapy and trastuzumab C. Surgical resection and chemotherapy D. Radiotherapy and chemotherapy E. Termination of pregnancy

🧠 Case-based MCQ 🔸 #MCQ_43 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D Systemic thromboembolism is a major cause of morbidity in patients with atrial fibrillation (AF). Treatment with warfarin or target-specific oral anticoagulants (TSOACs) has been shown to significantly reduce the risk of embolization in patients at moderate to high risk for thromboembolic events. Recent guidelines have recommended the use of a modified CHA2DS2-VASc score for stroke risk assessment in patients with nonvalvular AF. This patient has a CHA2DS2-VASc score of 4 (female sex, age > 65, hypertension, and diabetes) and should be managed with anticoagulation. TSOACs (rivaroxaban, dabigatran, apixaban, and edoxaban) have proven efficacy in preventing thromboembolic events in patients with nonvalvular AF. TSOACs are not recommended for use in patients with mitral stenosis, prosthetic heart valves, end-stage renal disease, and severe decompensated valvular disease likely to require valve replacement; warfarin is preferred for these patients. ❌Choice A and B are not correct: Antiplatelet therapy with aspirin or a combination of aspirin and clopidogrel is significantly less effective in reducing the risk of thromboembolism compared to anticoagulant therapy with warfarin or TSOACs. ❌Choice C is not correct: Dipyridamole is occasionally used for secondary prevention of non-cardioembolic ischemic stroke in patients with recent transient ischemic attack or stroke. It has no role in the prevention of systemic thromboembolism in patients with AF. ❌Choice E is not correct: Ticagrelor is a reversible P2Y12 platelet receptor inhibitor and is used in the management of patients with acute coronary syndrome. It is not used in patients with AF. ✅Summarized Points: Anticoagulation with warfarin or target-specific oral anticoagulants (e.g., dabigatran, rivaroxaban) is recommended to prevent thromboembolic events in patients with nonvalvular atrial fibrillation. Warfarin is preferred for patients with mitral stenosis, prosthetic heart valves, end-stage renal disease, and severe decompensated valvular disease likely to require valve replacement.

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🧠 Case-based MCQ 🔸 #MCQ_43 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 66-year-old woman with hypertension and type 2 diabetes mellitus comes to the emergency department with palpitations and is diagnosed with atrial fibrillation. The arrhythmia resolves spontaneously in the emergency department without intervention. Her renal function is normal and she has no history of bleeding. Which of the following is the best treatment option for this patient? A. Aspirin B. Aspirin and clopidogrel C. Dipyridamole D. Rivaroxaban E. Ticagrelor

🧠 Case-based MCQ 🔸 #MCQ_42 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E Subacute thyroiditis (ST) is a self-limited condition. The hyperthyroid phase may last a few weeks, followed by a transient hypothyroid phase and eventual return to a euthyroid state. Treatment is primarily supportive, and most cases can be managed with a nonsteroidal anti-inflammatory drug to relieve pain; glucocorticoids can be used in severe or refractory cases. In addition, patients can be given a beta-blocker (e.g., propranolol, atenolol) to minimize the hyperadrenergic symptoms of thyrotoxicosis (e.g., sweating, palpitations). ❌Choice A is not correct: Radioiodine thyroid ablation is used for the definitive treatment of Graves’ disease and nodular thyroid disease. It is not necessary in ST, which is a self-limited illness, and would not be effective as thyroid uptake of the radioiodine dose is very low. ❌Choice B and C are not correct: Suppurative infection of the thyroid gland (infectious thyroiditis) is a rare condition that causes high-grade fever and pain at the thyroid gland. Patients will often have evidence of a thyroid abscess on examination or ultrasound, but are usually euthyroid as involvement of the thyroid gland is focal. Bacterial thyroid infections are treated with systemic antibiotics, and surgical drainage may be required. ❌Choice D is not correct: Thyrotoxicosis in ST is due to the release of preformed thyroid hormone. Antithyroid drugs (e.g., methimazole), which work by decreasing the synthesis of thyroid hormones, are ineffective. ✅Summarized Points: Subacute thyroiditis is a self-limited condition. Treatment consists primarily of nonsteroidal anti-inflammatory drugs for pain relief and beta-blockers to minimize thyrotoxic symptoms. Severe or refractory cases may require glucocorticoid therapy.

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🧠 Case-based MCQ 🔸 #MCQ_42 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 36-year-old woman presented with painful swelling in her neck of one-week duration. Her last menstrual period was 2 weeks ago. She is adopted, and her family history is unknown. Temperature is 38.3 C (100.9 F), blood pressure is 156/60 mm Hg, pulse is 110/min, and respirations are 22/min. The thyroid gland is diffusely enlarged, firm, and very tender. The extremities are warm and moist. Eye examination shows lid lag but no proptosis. The remainder of the examination is unremarkable. Laboratory results are as follows:   Leukocytes 11,000/µL   Thyroid-stimulating 0.01 µU/mL (0.4-5.0)   Free thyroxine (T4), serum 175 nmol/L (60-145)   Triiodothyronine (T3), serum 1.8 nmol/L (1.1-3.0)   Erythrocyte sedimentation rate 90 mm/h   Which of the following is the best treatment for this patient? A. Radioactive iodine B. Systemic antibiotics C. Incision and drainage D. Methimazole, nonsteroidal anti-inflammatory drug, and beta-blocker E. Nonsteroidal anti-inflammatory drug and beta-blocker

🧠 Case-based MCQ 🔸 #MCQ_41 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E This child fulfills all of the 5 minor criteria of the modified Duke criteria for the diagnosis of infective endocarditis (IE). These include a predisposing heart condition (ventricular septal defect), fever ≥ 38°C (100.4°F), vascular phenomenon (splinter hemorrhages and Janeway lesions, i.e., purplish lesions on her palms and soles), immunologic phenomenon (glomerulonephritis and Roth spots, i.e, retinal hemorrhages), and a positive blood culture for atypical microorganisms consistent with IE. The fulfillment of these 5 criteria (even in the absence of vegetations on the transthoracic echocardiography) is adequate to make a diagnosis of IE.   ❌Choice A is not correct: Kawasaki disease is an autoimmune vasculitis more commonly seen in boys under 5 years of age. The criteria for diagnosing Kawasaki disease include fever > 5 days, bilateral nonpurulent conjunctivitis, mucositis, cervical lymphadenopathy, and a diffuse erythematous rash over the palms and soles. Although this girl has had a fever > 5 days, she does not have any other criteria. Additionally, Kawasaki disease does not present with retinal hemorrhages or glomerulonephritis. ❌Choice B is not correct: This patient fulfills one major (carditis) and three minor (fever, arthralgia, and ↑ ESR) of the Jones criteria for rheumatic fever. However, rheumatic fever occurs 2–4 weeks after(!) an infection with S. pyogenes (tonsillitis or pharyngitis), and it is not associated with positive blood cultures, hemorrhages, or signs of glomerulonephritis. Additionally, although rheumatic fever is the most common cause of cardiovascular disease in developing countries, it is rare in developed countries. Finally, this patient fulfills all of the criteria for another condition, making it the more likely diagnosis – especially in a patient with underlying heart disease. ❌Choice C is not correct: Hand-foot-mouth disease is a contagious illness caused by Coxsackie virus that can present with fever, malaise, and a rash on the hands and feet. However, HFMD does not cause glomerulonephritis or retinal hemorrhages. Additionally, the positive S. pyogenes blood culture makes HFMD an unlikely diagnosis in this child. ❌Choice D is not correct: Acute lymphoblastic leukemia is the most common childhood malignancy. It typically presents with hepatosplenomegaly or lymphadenopathy, and anemia or thrombocytopenia, which are all absent in this patient. Although ALL can present with fever and malaise, and predispose to infection, it does not cause positive blood cultures, glomerulonephritis, or retinal hemorrhages as seen above. ✅Summarized Points: This patient with an underlying structural heart disease presents with edema, hematuria, and mild proteinuria, suggesting glomerulonephritis. She also has hemorrhages on her palms, soles, and under her fingernails as well as retinal hemorrhages, fever ≥ 38°C (100.4°F), arthralgia, and positive blood cultures. These findings fulfill all of the diagnostic criteria for one of the conditions below.

⚠️ 🔔 𝐒𝐀𝐕𝐄 𝐓𝐇𝐈𝐒 𝐋𝐈𝐒𝐓 𝐅𝐎𝐑 𝐀 𝐑𝐀𝐈𝐍𝐘 𝐃𝐀𝐘 ! ⬇️ 1. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬) 2. 𝗖𝗔𝗦𝗘 - 𝗕𝗔𝗦𝗘𝗗 𝗠𝗖𝗤𝗦 ❔ 3. 🇨🇦 𝗠𝗖𝗖𝗤𝗘 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡 4. 🩺 𝗘𝗗𝗟 𝗠𝗘𝗗𝗜𝗖𝗢𝗦 (𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 𝗔𝗡𝗗 𝗟𝗜𝗡𝗞𝗦) 5. 📚 𝗘𝗗𝗟 𝗣𝗛𝗔𝗥𝗠 6. 🏛📷 𝗢𝗡𝗟𝗜𝗡𝗘 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗦𝗖𝗛𝗢𝗢𝗟 7. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗚𝗘𝗥𝗠𝗔𝗡𝗬 🇩🇪 8. 𝗣𝗥𝗔𝗖𝗧𝗜𝗖𝗘 𝗜𝗡 𝗔𝗨𝗦𝗧𝗥𝗔𝗟𝗜𝗔 🇦🇺 9. 𝗠𝗕𝗕𝗦 & 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗜𝗧𝗔𝗟𝗬 🇮🇹 10. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗞 🇬🇧 11. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗦 🇺🇸 12. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗖𝗔𝗡𝗔𝗗𝗔 🇨🇦 13. 𝗙𝗥𝗘𝗡𝗖𝗛 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇫🇷 14. 𝗚𝗘𝗥𝗠𝗔𝗡 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇩🇪 15. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗦𝗘𝗔𝗥𝗖𝗛 🎓🫥 16. 📸 𝗗𝗘𝗥𝗠𝗔𝗧𝗢𝗟𝗢𝗚𝗬 𝗔𝗧𝗟𝗔𝗦 17. 𝗢𝗘𝗧 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡 ✅ 18. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐 19. 𝗖𝗔𝗥𝗗𝗜𝗢𝗟𝗢𝗚𝗬 𝗖𝗔𝗦𝗘𝗦 🫀 20. 💠 𝗨𝗪𝗢𝗥𝗟𝗗 𝗘𝗗𝗨𝗖𝗔𝗧𝗜𝗢𝗡𝗔𝗟 𝗢𝗕𝗝𝗘𝗖𝗧𝗜𝗩𝗘𝗦 21. 𝗠𝗘𝗗𝗜𝗖𝗖𝗢𝗨𝗡𝗧 - 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗖𝗖𝗢𝗨𝗡𝗧 🔄

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🧠 Case-based MCQ 🔸 #MCQ_41 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 9-year-old girl is brought to the physician by her mother because of a 3-day history of face and foot swelling, dark urine, and a rash on her hands and feet. The mother reports that her daughter has had a low-grade fever, shortness of breath, and a dry cough for the past 8 days. She has had generalized weakness and pain in her right knee and ankle. She has a ventricular septum defect that was diagnosed at birth. The patient appears lethargic. Her temperature is 38.4 (101.1°F), pulse is 130/min, respirations are 34/min, and blood pressure is 110/60 mm Hg. Examination shows small, non-blanching, purple lesions on her palms, soles, and under her fingernails. There is edema of the eyelids and feet. Funduscopic examination shows retinal hemorrhages. Holosystolic and early diastolic murmurs are heard. Laboratory studies show:   Hemoglobin 113 g/L (115–155 )   Erythrocyte sedimentation rate 61 mm/h (0–20 )   Leukocyte count 15× 109/L (3.5–10.5)   Platelet count 326× 109/L (130–380)  Urine:       Blood 4+     Glucose negative     Protein 1+     Ketones negative   Transthoracic echocardiography shows a small outlet ventricular septum defect and a mild right ventricular enlargement. There are no wall motion abnormalities, valvular heart disease, or deficits in the pump function of the heart. Blood cultures grow Streptococcus pyogenes. Which of the following is the most likely diagnosis? A. Kawasaki disease B. Rheumatic fever C. Hand-foot-mouth disease D. Acute lymphoblastic leukemia E. Infective endocarditis

🧠 Case-based MCQ 🔸 #MCQ_40 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D This patient’s presentation is most likely due to hypertrophic cardiomyopathy (HCM). Mutations in the sarcomere genes lead to disorganized, proliferating myocytes that can become significantly hypertrophic and obstruct the left ventricular outflow tract. The obstruction (and the accompanying systolic murmur) is exacerbated by low-volume states, such as dehydration or tachycardia. For this reason, patients are often symptomatic during vigorous exercise. Maneuvers that improve venous return to the heart (e.g., squatting, fist-clenching) will decrease the intensity of the murmur. Many patients are asymptomatic and are identified by sports preparticipation screening (e.g., family history of HCM). However, symptomatic patients can present with chest pain, dyspnea, fatigue, palpitations, and syncope. Rarely, the initial presentation may be a fatal dysrhythmia or cardiogenic shock. Patients generally have a systolic ejection murmur and left ventricular hypertrophy on ECG. Echocardiography is required to confirm the diagnosis. Once HCM is identified, all first-degree relatives should also be screened due to autosomal dominant inheritance. Affected individuals should undergo exercise stress testing. Beta-blockers can improve ventricular filling and minimize obstruction. ❌Choice A is not correct: Commotio Cordis, or ventricular fibrillation following chest wall impact, is a rare event that immediately follows trauma to the chest. Unlike this patient who recovered quickly, commotio cordis is virtually always fatal unless defibrillation is available. ❌Choice B is not correct: Heart block can present with syncope. However, there is no evidence of an abnormal PR interval on this patient’s ECG, and heart block would not account for his ventricular hypertrophy or murmur. ❌Choice C is not correct: Myocardial infarction is extremely rare in otherwise healthy teenagers. It is associated with uncontrolled dyslipidemias or with structurally abnormal hearts or coronary arteries. This patient has no evidence of myocardial infarction on his ECG (i.e., ST changes), and an infarction would not account for his ventricular hypertrophy. ❌Choice E is not correct: Wolff-Parkinson-White syndrome (WPW) can present with palpitations, syncope, chest pain, or even sudden death. The hallmark of WPW is preexcitation or a delta wave at the beginning of the QRS complex that shortens the PR interval and lengthens the QRS complex. This patient has no evidence of preexcitation on ECG. ✅Summarized Points: Hypertrophic cardiomyopathy can be asymptomatic or may present with chest pain, dyspnea, or syncope, particularly during exercise. Classic findings include a systolic murmur and left ventricular hypertrophy on ECG and echocardiography. First-degree relatives should undergo screening for hypertrophic cardiomyopathy.