Case-based MCQ

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An 18-year-old boy is brought to the emergency department after a syncopal episode during football practice. Twenty minutes prior to fainting, the patient was tackled and developed chest pain. He was standing on the sideline when he suddenly passed out and regained consciousness within a few seconds. The patient had no head injury. He feels better after receiving intravenous normal saline. Heart rate and blood pressure are normal. Physical examination shows a grade 2/6 systolic ejection murmur at the right upper sternal border. An electrocardiogram (ECG) is obtained and is shown below. Which of the following is the most likely cause of this patient's syncope? A. Commotio cordis B. First-degree heart block C. Myocardial infarction D. Hypertrophic cardiomyopathy E. Wolff-Parkinson-White syndrome

🧠 Case-based MCQ 🔸 #MCQ_39 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D To meet the criteria for a major depressive disorder, a patient must have 5 or more symptoms of depression (SIGECAPS), one of which must be depressed mood or anhedonia, for at least 2 consecutive weeks. Symptoms must not be attributable to substance use or other medical condition. Bipolar disorder and psychosis must also be excluded. This patient meets the criteria because she has had 7.5 months of insomnia, anhedonia (used to enjoy cooking), exhaustion, poor concentration, and decreased appetite. She has never had an episode of hypomania or mania and her symptoms are not better explained by a psychotic disorder or substance use. The next best step in management for this patient is starting her on an antidepressant, such as an SSRI, and attempting lifestyle changes, possibly with the help of psychotherapy.  l ❌Choice A is not correct: Postpartum blues are mild depressive symptoms (e.g., tearfulness or sadness) that may last up to 2 weeks following delivery. This patient has had severe depressive symptoms for 7.5 months, which started 6 weeks post-delivery. ❌Choice B is not correct: Adjustment disorder is a response to a psychosocial stressor that may manifest as symptoms of depression or anxiety (which do not meet the full criteria for any other psychiatric diagnosis) that last for up to 3–6 months after resolution of the stressful event. Because this patient has now had symptoms for 7.5 months after her delivery, adjustment disorder can be ruled out. ❌Choice C is not correct: To meet the DSM-V criteria for depression with peripartum-onset, symptoms must fulfill the criteria for major depressive disorder and onset of symptoms must begin during pregnancy or within 4 weeks of delivery. Although this patient meets the criteria for a major depressive episode, her symptoms started 6 weeks after her delivery. ❌Choice E is not correct: Normal behavior may include occasional feelings of sadness or tearfulness for < 2 weeks. While this patient has had recent stress which may trigger such feelings, she has had multiple, significant depressive symptoms for 7.5 months, which is no longer considered normal. ✅Summarized Points: This patient might have also had difficulty making decisions for more than 2 weeks.

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🧠 Case-based MCQ 🔸 #MCQ_39 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 25-year-old woman comes to the physician because of sadness that started 6 weeks after her 9-month-old daughter was born. Since then, she has not returned to work. Her daughter usually sleeps through the night, but the patient still has difficulty staying asleep. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?   A. Postpartum blues B. Adjustment disorder C. Depression with peripartum-onset D. Major depressive disorder E. Normal behavior

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🧠 Case-based MCQ 🔸 #MCQ_38 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is A Syndrome inappropriate antidiuretic hormone (SIADH) is an adverse effect of several medications, including carbamazepine, SSRIs, and cyclophosphamide and is characterized by an inappropriately elevated serum ADH despite low plasma osmolality (e.g., the patient is not hypovolemic). Risk factors for developing medication-induced SIADH include older age (> 65 years old), concomitant use of other antiseizure drugs and diuretics, and history of hyponatremia. Other causes of SIADH include CNS disorders, pulmonary disease, and ectopic production of ADH (e.g., small cell lung cancer). ❌Choice B is not correct: Low cardiac output (e.g., due to congestive heart failure) results in hypervolemic hyponatremia due to low renal perfusion and subsequent activation of RAAS and ADH secretion, which in turn stimulates water (and sodium) reabsorption. This patient lacks other signs of low cardiac output, including pitting edema, pulmonary edema, and/or elevated JVP, making this etiology unlikely. ❌Choice C is not correct: Hyperglycemia (e.g., from type 1 diabetes mellitus) can cause both hypovolemic and/or dilutional hyponatremia. Hypovolemic hyponatremia is a characteristic feature of diabetic ketoacidosis and occurs due to the osmotic diuresis from hyperglycemia and glucosuria. In dilutional hyponatremia, increased serum osmolality from hyperglycemia causes water to shift from the intracellular to the extracellular space, resulting in a decreased serum sodium concentration. This patient's normal metabolic panel and euvolemia on exam make hyponatremia due to hyperglycemia very unlikely. ❌Choice D is not correct: Aldosterone deficiency (e.g., due to adrenal insufficiency, type 4 RTA, or congenital hypoaldosteronism) can also manifest with hyponatremia and elevated ADH due to decreased sodium resorption in the collecting ducts. This patient does not have characteristic signs or symptoms of aldosterone deficiency, such as hyperkalemia, metabolic acidosis, or hypotension. ❌Choice E is not correct: Increased levels of cortisol (e.g., Cushing syndrome) classically manifest with hypernatremia, not hyponatremia. Other characteristic laboratory findings include hypocalcemia, hyperglycemia, and hypokalemia. ✅Summarized Points: This patient is euvolemic and has a low serum sodium level with high ADH levels, suggesting a diagnosis of SIADH

🧠 Case-based MCQ 🔸 #MCQ_38 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 75-year-old man with a seizure disorder is brought to the emergency department by a friend because of progressive confusion over the past two weeks. He is unable to provide any history. His vital signs are within normal limits. He appears lethargic and is only oriented to person. Oral mucosa is moist. There is no jugular venous distention. A basic metabolic panel shows a serum sodium concentration of 115 mEq/L but is otherwise normal. Serum osmolality is low and the antidiuretic hormone level is elevated. X-ray of the chest shows no abnormalities. Which of the following is the most likely cause of this patient’s hyponatremia? A. Medication effect B. Low cardiac output C. Insulin deficiency D. Aldosterone deficiency E. Excess cortisol

🧠 Case-based MCQ 🔸 #MCQ_37 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E Ureterorenoscopy (URS) with stone removal is the first-line therapy for patients with urinary stones in the middle or distal ureter ≥ 10 mm, and unlike shock wave lithotripsy it is effective even in morbidly obese patients and, therefore, recommendable in this patient. It is also the suggested treatment in patients with ureteral stones who decide against or fail a trial of spontaneous stone passage. Overall, URS is the intervention with the greatest stone-free rate. ❌Choice A is not correct: Extracorporeal shock wave lithotripsy is a first-line treatment option for patients with ureteral stones > 10 mm. Among the interventions used in the treatment of urolithiasis, it is the procedure associated with the lowest complication rate. However, it is not the preferred treatment in morbidly obese patients, such as this woman. Excess fat tissue impairs adequate targeting of the stone via ultrasound and centering of the stone in the shock wave focus, which are prerequisites for extracorporeal shock wave lithotripsy. ❌Choice B is not correct: All patients with uncomplicated ureteral stones ≤ 10 mm should be offered a trial of the spontaneous stone passage under observation. However, this patient has a 12-mm stone that is unlikely to pass spontaneously. ❌Choice C is not correct: Ureteral stenting is recommended in patients with ureteral stones who develop complications such as (infected) hydronephrosis or sepsis. This patient does not have fever, leukocytosis, or an elevated WBCs on urine microscopy, which would suggest a urinary tract infection. Furthermore, ureteral stenting is not routinely recommended prior to any ureteral intervention. ❌Choice D is not correct: Thiazide diuretics may be indicated in patients with hypercalciuria or distal renal tubular acidosis who develop recurrent calcium-containing urinary stones. It is important to analyze the composition of stones in all first-time stone patients because in many cases lifestyle guidance, diet changes, and initiation of medical treatment (e.g, thiazide diuretics, allopurinol) can prevent future stone formation. However, specific guidance can only be provided after stone analysis. ✅Summarized Points: This morbidly obese patient presents with severe unilateral colicky flank pain, vomiting, costovertebral angle tenderness, and hematuria suggestive of urolithiasis. The CT scan of the abdomen and pelvis confirm an uncomplicated large stone in the distal right ureter.

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🧠 Case-based MCQ 🔸 #MCQ_37 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 33-year-old woman comes to the emergency department because of severe right flank pain for 2 hours. The pain is colicky in nature and she describes it as 9 out of 10 in intensity. She has had 2 episodes of vomiting. She has no history of similar episodes in the past. She is 160 cm (5 ft 3 in) tall and weighs 104 kg (229 lb); BMI is 41 kg/m2. Her temperature is 37.3°C (99.1°F), pulse is 96/min, respirations are 16/min and blood pressure is 116/76 mm Hg. The abdomen is soft and there is mild tenderness to palpation in the right lower quadrant. Bowel sounds are reduced. The remainder of the examination shows no abnormalities. Her leukocyte count is 7,400/mm3. A low-dose CT scan of the abdomen and pelvis shows a round 12 mm stone in the distal right ureter. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows RBCs and no WBCs. 0.9% saline infusion is begun and intravenous ketorolac is administered. Which of the following is the most appropriate next step in management? A. Extracorporeal shock wave lithotripsy B. Observation C. Ureteral stenting D. Thiazide diuretic therapy E. Ureterorenoscopy

🧠 Case-based MCQ 🔸 #MCQ_36 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. Ehlers-Danlos syndrome is a genetic connective tissue disorder characterized by increased joint mobility, skin extensibility, and connective tissue fragility. While multiple subtypes exist, all involve genetic defects in the synthesis and processing of different subtypes of collagen, leading to abnormal connective tissue production. Although clinical manifestations differ slightly based on the subtype, hypermobility, poor wound healing, and frequent joint dislocations should raise suspicion for this condition. Mitral valve prolapse is also common, and patients have an elevated risk of vascular dissection. The diagnosis is mainly clinical using specified criteria for major features of this condition. The most severe form, known as the vascular variant, presents without significant hypermobility of large joints, although small joints may be abnormal. This subtype places patients at especially high risk for visceral organ and major arterial rupture, with a median life expectancy of 48 years. No specific disease-modifying treatment is available, but physical therapy, wound precautions, and close cardiovascular and orthopedic monitoring is recommended. ❌Choice A is not correct: Fibrillin mutations are associated with Marfan syndrome, characterized by joint laxity, tall stature, pectus deformities, and aortic dilatation. ❌Choice B is not correct: Elastin mutations are associated with cutis laxa, which includes redundant skin, valvular regurgitation, and an increased risk of hernia. ❌Choice C is not correct: Filamin B is implicated in Larsen syndrome, characterized by joint dislocations and short stature. Patients can also have specific orofacial features, including a depressed nasal bridge and cleft palate. ❌Choice E is not correct:  The TGF-beta pathway is implicated in Loeys-Dietz syndrome, characterized by cleft palate, bifid uvula, and arterial tortuosity. ✅Summarized Points: Ehlers-Danlos syndrome is due to defects in the synthesis and processing of collagen. Features include increased joint mobility, skin extensibility, connective tissue fragility, and an increased risk for arterial dissection and rupture.