Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_66 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An 82-year-old man presents with urinary urgency and 2 episodes of gross hematuria over the past month. He has a history of immunoglobulin nephropathy. He has been feeling generally well and is afebrile. His urine culture is negative, and his creatinine level is stable at 180 µmol/L (49–93). Which one of the following is the most appropriate next step? A) Retrograde pyelography. B) Renal biopsy. C) Urine test for cytology. D) Prostate-specific antigen level. E) Pelvic ultrasonography

The Correct answer is C Haloperidol, a typical antipsychotic drug, is the preferred initial treatment for an agitated and combative patient with acute mania. Its quick onset will allow for rapid sedation. A mood stabilizer should eventually be initiated and titrated for long-term maintenance therapy, but this will take a few days to take effect and she is in need of rapid stabilization at this time.   Choice A is not correct: Valproate, an anticonvulsant, is commonly used to treat bipolar disorder and tonic-clonic seizures. Its mood-stabilizing effects make it a first-line choice for long-term maintenance treatment following an acute manic episode. However, its slow onset makes it less useful as initial treatment in an agitated patient with acute mania. Choice B is not correct: Venlafaxine, serotonin norepinephrine reuptake inhibitors (SNRI), is commonly used in the treatment of major depressive disorder, anxiety, and panic disorder. It can actually worsen or trigger manic episodes, and should not be used in patients with history of mania. Choice D is not correct: Lithium, a mood stabilizer, is still commonly used for the treatment of bipolar affective disorder. It is effective in preventing both manic episodes and depression in bipolar patients when employed for long-term maintenance therapy. However, its slower onset makes it less useful as initial therapy in an agitated patient with an acute manic episode. Choice E is not correct: Clozapine, an antipsychotic, is used for treatment-resistant schizophrenia. Because of its potential adverse effect of agranulocytosis, it is reserved as maintenance therapy in patients with refractory schizophrenia and requires close monitoring. It is not used for the treatment of bipolar disorder or acute mania, as this patient has. Summarized Points: This patient's history of elevated mood, reckless behavior, insomnia, pressured speech, and psychosis are consistent with an acute manic episode. Her uncooperative and combative nature will influence our choice of initial therapy.

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🧠 Case-based MCQ 🔸 #MCQ_65 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 24-year-old woman comes to the office due to 3 days of burning with urination and increased urinary frequency. She has had no fever, abdominal pain, back pain, or vaginal discharge. The patient has no known drug allergies. Vital signs are normal. Examination shows suprapubic tenderness without flank tenderness. The remainder of the examination is normal. Urine pregnancy test is negative. Urinalysis shows trace blood, moderate leukocyte esterase, and moderate nitrites. Which of the following is the best next step in the management of this patient? A. Amoxicillin B. Azithromycin C. Nitrofurantoin D. Ceftriaxone E. Ciprofloxacin

🧠 Case-based MCQ 🔸 #MCQ_64 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is C Haloperidol, a typical antipsychotic drug, is the preferred initial treatment for an agitated and combative patient with acute mania. Its quick onset will allow for rapid sedation. A mood stabilizer should eventually be initiated and titrated for long-term maintenance therapy, but this will take a few days to take effect and she is in need of rapid stabilization at this time.   ❌Choice A is not correct: Valproate, an anticonvulsant, is commonly used to treat bipolar disorder and tonic-clonic seizures. Its mood-stabilizing effects make it a first-line choice for long-term maintenance treatment following an acute manic episode. However, its slow onset makes it less useful as initial treatment in an agitated patient with acute mania. ❌Choice B is not correct: Venlafaxine, serotonin norepinephrine reuptake inhibitors (SNRI), is commonly used in the treatment of major depressive disorder, anxiety, and panic disorder. It can actually worsen or trigger manic episodes, and should not be used in patients with history of mania. ❌Choice D is not correct: Lithium, a mood stabilizer, is still commonly used for the treatment of bipolar affective disorder. It is effective in preventing both manic episodes and depression in bipolar patients when employed for long-term maintenance therapy. However, its slower onset makes it less useful as initial therapy in an agitated patient with an acute manic episode. ❌Choice E is not correct: Clozapine, an antipsychotic, is used for treatment-resistant schizophrenia. Because of its potential adverse effect of agranulocytosis, it is reserved as maintenance therapy in patients with refractory schizophrenia and requires close monitoring. It is not used for the treatment of bipolar disorder or acute mania, as this patient has. ✅Summarized Points: This patient's history of elevated mood, reckless behavior, insomnia, pressured speech, and psychosis are consistent with an acute manic episode. Her uncooperative and combative nature will influence our choice of initial therapy.

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🧠 Case-based MCQ 🔸 #MCQ_64 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 22-year-old woman is brought to the emergency department 20 minutes after being detained by campus police for attempting to steal from the bookstore. Her roommate says that the patient has been acting strangely over the last 2 weeks. She has not slept in 4 days and has painted her room twice in that time span. She has also spent all of her savings on online shopping and lottery tickets. She has no history of psychiatric illness or substance abuse and takes no medications. During the examination, she is uncooperative, combative, and refusing care. She screams, “Let me go, God has a plan for me and I must go finish it!”. Her temperature is 37.2°C (99°F), pulse is 75/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, she describes her mood as “amazing.” She has a labile affect, speaks rapidly, and her thought process is tangential. She denies having any hallucinations. Which of the following is the most appropriate initial pharmacotherapy?   A. Valproate B. Venlafaxine C. Haloperidol D. Lithium E. Clozapine

🧠 Case-based MCQ 🔸 #MCQ_63 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. The "number needed to treat" (NNT) is the number of patients who need to be treated in order to prevent one additional bad outcome. It is an important way to present the results of a study or assess the usefulness of treatment or prophylaxis.   Myocardial infarction No Myocardial infarction     Aspirin Group 40   400   Placebo Group 80   400   Total     800   number needed to treat (NNT) = 1/Absolute risk reduction  Absolute risk reduction = Incidence of Event in control arm – Incidence of Event in treatment arm Incidence of Event in control arm= 80/400 = 0.2 Incidence of Event in treatment arm= 40/400=0.1 Absolute risk reduction= 0.2-0.1=0.1 NNT= 1/0.1= 10   ✅Summarized Points: Number needed to treat (NNT) is the number of patients who need to be treated in order to prevent one additional bad outcome; it is actually the inverse of absolute risk reduction.

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A study of Aspirin for secondary prevention in coronary artery disease was recently completed. The treatment group had 400 patients, of whom 40 had a myocardial infarction. The control group had 400 patients, of whom 80 had a myocardial infarction. What is the number needed to treat for Aspirin to prevent one myocardial infarction? A. 25 B. 125 C. 1,000 D. 800 E. 10

🧠 Case-based MCQ 🔸 #MCQ_62 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Varenicline is a partial nicotinic acetylcholine agonist and the most effective single intervention for smoking cessation. Varenicline reduces the symptoms of nicotine withdrawal by blocking nicotine from binding to the receptor that mediates the reinforcing effects of nicotine that lead to nicotine dependence. Through this action, varenicline reduces the rewarding aspects of cigarette smoking. It does this by binding with high affinity and producing partial stimulation of the alpha-4 beta-2 nicotinic receptor. Although varenicline has been associated with a possible increase in cardiac events (e.g., myocardial ischemia, arrhythmia), the risks are minimal. Any risk is likely outweighed by the benefits of smoking cessation. Despite initial concerns about possible serious adverse neuropsychiatric effects from varenicline, the black box warning for these adverse effects was removed in 2016. Based on newer findings, varenicline does not appear to increase the risk of suicidality or depression compared with placebo. There also appear to be no differences between the rates of serious psychiatric symptoms in patients taking bupropion, nicotine replacement therapy, or varenicline (the 3 U. S. Food and Drug Administration [FAD]-approved treatments for smoking cessation). However, the FDA still recommends a cautious approach and monitoring patients for new or unusual behaviors (e.g., hostility, agitation, depressed mood, suicidal ideation). Varenicline should be discontinued if any new neuropsychiatric symptoms emerge soon after it is started. ❌Choice B and C are not correct: Cytochrome P450 3A4 (CYP3A4) system inhibitors increase bleeding risk in patients taking prasugrel and also increase myopathy risk in those taking statins. However, varenicline is not associated with CYP3A4 inhibition. Myopathy is common with statins, but routine monitoring is not required. ❌Choice D is not correct: Statins may cause increases in hepatic transaminases after initiation or dose change, but severe hepatotoxicity is rare. Routine monitoring is not needed. In addition, varenicline is not associated with significant liver function test abnormalities. ❌Choice E is not correct: Weight gain is common after smoking cessation, but early monitoring is not required. ✅Summarized Points: Varenicline is an effective treatment for smoking cessation. Despite initial concerns about adverse neuropsychiatric symptoms, it does not appear to increase the risk of suicide or depression in patients with past psychiatric symptoms. However, varenicline should be discontinued if any new neuropsychiatric symptoms emerge soon after it is started.

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🧠 Case-based MCQ 🔸 #MCQ_61 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 45-year-old man returns to the office after experiencing an acute ST-elevation myocardial infarction 4 weeks ago. The patient underwent urgent right coronary artery revascularization with the placement of a drug-eluting stent. He is motivated to quit smoking but thinks that he needs help. The patient's discharge medications include atorvastatin, metoprolol, aspirin, and prasugrel. Physical examination is unremarkable. During the current visit, he is prescribed varenicline. Appropriate behavioral support is also provided.  Which of the following should be assessed at this patient's follow-up visit in a week? A. Weight gain B. Muscle aches C. Bleeding issues D. Liver function tests E. Unusual behaviors

🧠 Case-based MCQ 🔸 #MCQ_61 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Maternal vaccination is beneficial to both mother and fetus, and the optimal time for administration is prior to conception. Vaccinations during pregnancy are indicated if the vaccine has minimal risk if a significant risk exists for infection exposure and if increased morbidity and mortality are associated with infection. Vaccines that are safe during pregnancy include immunoglobulins (e.g., Rho(D) immunoglobulin), toxoids (e.g., tetanus toxoid), and inactivated vaccines (e.g., tetanus toxoid-reduced diphtheria toxoid-acellular pertussis [Tdap], injectable influenza virus). Live-attenuated vaccines (e.g., intranasal influenza, measles-mumps-rubella [MMR], varicella) are contraindicated during pregnancy due to the theoretical risk of congenital infection. Pertussis (whooping cough) in infants is associated with high rates of disease complications (e.g., seizure, renal failure, pneumonia) and mortality. Because infant pertussis infection is so severe, Tdap vaccination is recommended for women during each pregnancy regardless of vaccination history. The Tdap vaccine is safe during every trimester. Vaccination during the third trimester is preferred, as it facilitates both the maternal antibody response and the transfer of maternal antibodies through the placenta, providing passive immunity to the fetus. ❌Choice A,B and D are not correct: Due to the theoretical risk of congenital infection, live-attenuated vaccines (e.g., intranasal influenza, measles-mumps-rubella [MMR], varicella) are contraindicated during pregnancy. ❌Choice C is not correct: The pneumococcal vaccine is safe in pregnancy; however, it is recommended for patients who have risk factors for invasive pneumococcal infection (e.g., chronic lung disease, immune deficiency). ✅Summarized Points: Tetanus toxoid-reduced diphtheria toxoid-acellular pertussis vaccination is recommended for women during each pregnancy regardless of vaccination history. Vaccination during the third trimester protects the mother against pertussis and provides passive immunity to the infant

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