Case-based MCQ

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🧠 Case-based MCQ 🔸 #MCQ_36 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An 18-year-old presents to the emergency department after dislocating her shoulder while getting dressed. She denies significant trauma and has a history of multiple joint dislocations. Physical examination reveals multiple atrophic scars, skin hyperextensibility (shown below), and joint hypermobility. No other abnormalities are noted. This patient's symptoms are likely related to a defect in which of the following? A. Fibrillin B. Elastin C. Filamin B D. Collagen synthesis E. TGF-beta pathway

🧠 Case-based MCQ 🔸 #MCQ_35 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. This patient has adult onset polycystic kidney disease (APKD). APKD is an autosomal dominant disease that presents with hypertension, renal cysts, hematuria, and possible renal failure, usually after age 30. There is a 10 to 20% incidence of berry aneurysms in these patients, and they need to be screened with angiography to determine the presence or absence of these malformations. A magnetic resonance angiogram (MRA) of the brain is the standard option for such imaging in most medical centers. ❌Choice A is not correct: CT scan of the pelvis is not indicated since clinical history and renal ultrasound alone can make the diagnosis of APKD. The concern here is to screen for the concomitant presence of intracranial pathology. ❌Choice B is not correct: CT scan of the thorax is incorrect. Unless these lesions were mistaken for renal cell carcinoma, there is no indication to scan a distant site like the lungs as this disease has no malignant potential. ❌Choice C is not correct: MRI of the brain is not useful for detecting circulatory malformations without the aid of angiographic contrast material. ❌Choice D is not correct: Intravenous pyelography (IVP) is used to evaluate the collecting system of the urinary tract and is not indicated in this case, as the diagnosis of APKD is almost certainly based on the ultrasound and clinical presentation. This study adds no diagnostic information to the results of the ultrasound already obtained. ✅Summarized Points: There is a 10 to 20% incidence of berry aneurysms in these patients, and they need to be screened with angiography to determine the presence or absence of these malformations.

🧠 Case-based MCQ 🔸 #MCQ_35 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 58-year-old man presents to his urologist for continued evaluation of hypertension and hematuria. The patient has a 10-year history of hypertension and recent onset of painless hematuria for which he sought the attention of a urologist 3 months ago. On detailed questioning, the man states that he has been having severe headaches that are refractory to narcotic analgesics. Three days ago, a renal ultrasound was obtained that demonstrated bilaterally enlarged kidneys with multiple cysts. Which of the following is the most appropriate next step in diagnosis? A. CT scan of the pelvis B. CT scan of the thorax C. MRI of the brain D. Intravenous pyelography (IVP) E. Magnetic resonance angiogram (MRA) of the brain

🧠 Case-based MCQ 🔸 #MCQ_34 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. AIDS-related Kaposi sarcoma (KS) is a vascular tumor due to coinfection with HIV and human herpesvirus 8 and is considered an AIDS-defining illness. KS occurs most commonly in patients with CD4 counts <200 cells/ µL. Commonly involved areas include the skin, oral cavity, gastrointestinal tract, and lung. Cutaneous KS most often appears on the lower extremities, genitalia, and face. The lesions are typically painless elliptical papules of various colors (e.g., brown, red, purple) arranged in a linear fashion along with skin tension areas. However, early KS can appear similar to purpura, angiomas, hematomas, nevi, or dermatofibromas. Some patients may also have lymphedema due to obstruction of lymphatics by associated lymphadenopathy. ❌Choice B is not correct: Herpes zoster is due to varicella-zoster virus and typically presents as discrete grouped papules or plaques that eventually become vesicles in a dermatomal distribution. ❌Choice C is not correct: Psoriasis is typically characterized by sharply demarcated, raised, erythematous plaques with an overlying silvery scale on the extensor surfaces (e.g., elbows and knees, hands, feet, trunk). ❌Choice D is not correct: Seborrheic dermatitis usually presents as pruritic, erythematous plaques with fine, greasy scales. Lesions typically occur on the face (e.g., eyebrows, nasolabial folds), scalp, and chest. ❌Choice E is not correct: Subcutaneous lipoma forms a benign, solitary, painless, and mobile subcutaneous nodule. Commonly affected areas include the neck, trunk, and extremities. ✅Summarized Points: AIDS-related cutaneous Kaposi sarcoma typically presents as painless elliptical papules of various colors arranged in a linear fashion along with skin tension areas. However, early lesions can appear similar to purpura, angiomas, hematomas, nevi, or dermatofibromas.

🧠 Case-based MCQ 🔸 #MCQ_34 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 44-year-old former drug abuser with known HIV infection comes in for a follow-up. He has not been compliant with office visits or his medications. His last CD4 count was 22/µL. A close friend recently died from disseminated Kaposi sarcoma, and he is afraid of getting the disease. Which of the following would most likely resemble early Kaposi sarcoma in this patient? A. Purpura B. Herpes zoster C. Psoriasis D. Seborrheic dermatitis E. Subcutaneous lipoma

🧠 Case-based MCQ 🔸 #MCQ_33 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. Intense clinical investigations have been conducted to identify the most effective screening approach to prostatic cancer detection. The aim of an effective screening program is to detect prostatic cancer in the earliest stages, when surgery results in high cure rates. Currently, most cases of prostate cancer are identified by Digital rectal examination (DRE) and prostate-specific antigen (PSA) evaluation are the two components used in prostate cancer screening. ❌Choice A is not correct: Cytologic examination of prostatic secretion has proved ineffective in detecting prostatic cancer. ❌Choice B is not correct: Digital rectal examination (DRE) alone is a specific but not sensitive method; 1.5% of men older than 50 are found to have prostatic neoplasia on DRE alone. ❌Choice C is not correct: Because of the considerable overlap between the values due to prostatic hyperplasia and those resulting from prostatic cancer, serum PSA alone is sensitive but not specific. Approximately 2% of men older than 50 are found to have prostatic neoplasia by serum PSA measurements without DRE. The combination of abnormal DRE and elevated PSA affords the highest positive predictive value. Increasingly more centers are using age-specific reference ranges of serum PSA, along with ratios between free and protein-bound PSA, to improve sensitivity and specificity of this test. ❌Choice E is not correct: Transrectal ultrasonography is too expensive as a screening test and it does not significantly improve the detection rate when compared with combined DRE and serum PSA. Transrectal ultrasonography should be reserved mainly for staging purposes and to guide prostatic biopsies. ✅Summarized Points: Currently, most cases of prostate cancer are identified by Digital rectal examination (DRE) and prostate-specific antigen (PSA) evaluation are the two components used in prostate cancer screening.

🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 65-year-old man comes to the physician for a health maintenance examination. Which of the following screening methods would allow the highest detection rate of prostatic carcinoma in early stages? A. Cytologic examination of prostatic secretion B. Digital rectal examination alone C. Serum prostate-specific antigen determination alone D. Serum prostate-specific antigen and digital rectal examination E. Transrectal ultrasonography

🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. Clinical features and laboratory studies support the diagnosis of immune thrombocytopenic purpura (ITP). Petechiae and ecchymoses without lymphadenopathy or splenomegaly are supportive findings. Laboratory findings are limited to a low platelet count. On the peripheral blood smear, platelets appear as small purplish cells without a nucleus. As a rule of thumb, approximately seven platelets are normally seen per 100-power field. Giant platelets are typically associated with increased platelet production secondary to the stress of increased peripheral platelet destruction. In adults with newly diagnosed ITP and a platelet count less than 30 x 109/L who are asymptomatic or have minor mucocutaneous bleeding, treatment with glucocorticoids is recommended. Initial therapy includes a short course (<6 weeks) of prednisone or dexamethasone. The response to intravenous immune globulin is faster and may be indicated in patients with more severe thrombocytopenia and life-threatening bleeding. ❌Choice B is not correct: Initial treatment of thrombotic thrombocytopenic purpura (TTP) involves therapeutic plasma exchange to remove the high-molecular-weight von Willebrand factor multimers and replace the deficient ADAMTS13. Glucocorticoids are added to decrease autoantibody production. This patient lacks any evidence for microangiopathic hemolysis needed to establish the diagnosis of TTP such as schistocytes on the peripheral blood smear. ❌Choice C is not correct: Platelet transfusion is not generally indicated in patients with thrombocytopenia in the absence of trauma, surgery, or bleeding unless the platelet count decreases to less than 10-20 x109/L; the lower platelet count is more applicable to patients with chronic thrombocytopenia who are otherwise stable. The transfusion threshold for patients with bleeding, trauma, or both is approximately 50 x 109/L. This mildly symptomatic patient without overt bleeding does not require a platelet transfusion. ❌Choice D is not correct: ITP may be asymptomatic and discovered in the evaluation of thrombocytopenia as an incidental finding on a routine complete blood count. Patients with such incidentally discovered ITP and platelet counts greater than 30 x 109/L may be observed without the need for drug therapy or platelet transfusions. This patient's symptoms indicate more severe thrombocytopenia requiring treatment with glucocorticoids; platelet transfusions are not indicated for patients with ITP who are not actively bleeding. ✅Summarized Points: Platelet transfusion is not generally indicated in patients with thrombocytopenia in the absence of trauma, surgery, or bleeding unless the platelet count decreases to less than 10-20 x 109/L. Glucocorticoid treatment is indicated in patients with immune thrombocytopenic purpura and a platelet count less than 30 x 109/L.

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🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 19-year-old woman is evaluated for easy bruising of 2 weeks' duration. She has no other symptoms, and medical history is unremarkable. She takes no medications. On physical examination, vital signs are normal. Examination findings are limited to petechiae on the lower extremities and small, scattered ecchymoses. Laboratory studies show a platelet count of 15 x 109/L; the remainder of the complete blood count is normal. The peripheral blood smear is shown below. HIV and hepatitis C testing is pending.

🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. The most appropriate next step for this patient is to perform a stereotactic brain aspiration for a culture to guide antibiotic therapy. This patient has a brain abscess. Brain abscesses in immunocompetent patients are mainly caused by bacteria that enter the brain through contiguous spread (e.g., following otitis, mastoiditis, sinusitis, neurosurgical procedures, or cranial trauma) or hematogenous dissemination (e.g., infective endocarditis, bacteremia from a dental source). Headache is the most common presenting symptom, with the classic triad (fever, headache, focal neurologic deficit) seen in only approximately 20% of patients. The most common bacteria causing brain abscesses are streptococci (e.g., Streptococcus milleri), Staphylococcus aureus, Enterobacteriaceae, and anaerobes. The diagnosis is usually made by CT or MRI with contrast. Aspiration is especially recommended if the brain abscess is larger than 2.5 cm. The yield of blood cultures is low (around 25%): even with positive blood culture, aspiration should be performed for a large abscess. ❌Choice A is not correct: Intravenous vancomycin would be an appropriate empiric antibiotic selection for a patient with a brain abscess and evidence of endocarditis or intravenous drug use. However, these predisposing factors are not present and the best first management step is abscess aspiration, Gram stain, and culture. ❌Choice B is not correct: Treatment with intravenous penicillin and metronidazole is an appropriate empiric antibiotic selection for brain abscess secondary to odontogenic infection. However, the source of this patient's infection is most likely mastoiditis, and empiric antibiotic treatment with metronidazole plus a third-generation cephalosporin following abscess aspiration and Gram stain, while waiting for culture results, would be more appropriate. ❌Choice D is not correct: Performing a lumbar puncture is not indicated because it could place the patient at risk for herniation; additionally, the yield of cerebrospinal fluid (CSF) culture is low. The CSF culture can be positive if the abscess ruptures into the ventricles; this would be an indication for an emergent craniotomy and ventricular lavage. ✅Summarized Points: Brain abscesses in immunocompetent patients are mainly caused by bacteria that enter the brain through contiguous spread (e.g., following otitis, mastoiditis, sinusitis, neurosurgical procedures, or cranial trauma) or hematogenous dissemination (e.g., infective endocarditis, bacteremia from a dental source). Empiric antibiotic therapy for brain abscess should be guided by the source of infection and Gram stain, and directed therapy should be guided by culture results whenever possible.

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🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 41-year-old man is evaluated in the emergency department for new-onset seizures; he also reports a 2-week history of headaches and right ear drainage. Medical history is noncontributory, and he takes no medications. On physical examination, vital signs are normal. Purulent drainage is seen from the right external ear canal. The right mastoid is tender. CT scan of the head with and without contrast shows a 3-cm right temporal ring-enhancing lesion and a right otomastoiditis.

🧠 Case-based MCQ 🔸 #MCQ_31 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. Endophthalmitis is an inflammatory process (usually infectious) of the vitreous or aqueous humor of the globe. It is most frequently caused by recent surgery, but other etiologies include penetrating trauma (e.g. hammering steel, high-powered machinery) and hematogenous spread. Symptoms may include eye pain, decreased visual acuity, photophobia, discharge, loss of vision or headache. Physical examination reveals eyelid edema, scleral injection, chemosis and hypopyon (leukocyte exudate in the anterior chamber). Ophthalmology consultation is required and management is with intravitreal antibiotics. Systemic antibiotics have not been proven to add benefit to the treatment of postsurgical endophthalmitis. This varies from the treatment indicated for posttraumatic or endogenous endophthalmitis which includes both intravitreal and systemic antibiotics. ❌Choice A is not correct: Anterior uveitis is inflammation of the iris, ciliary body, or choroid. It is either autoimmune or secondary to trauma or infection. Patients have direct and often consensual photophobia (pain in the affected eye when light is shined in the unaffected eye), as well as scleral injection, tearing, and blurry vision. Slit lamp examination reveals white blood cells and proteinaceous transudate, termed “cells and flare.” ❌Choice B is not correct: Conjunctivitis is an inflammatory process of the palpebral or bulbar conjunctiva and can be viral, bacterial, fungal, allergic, toxic, or chemical in nature. The presence of a hypopyon is not characteristic of conjunctivitis and should prompt search for an alternative diagnosis. ❌Choice D is not correct: Orbital cellulitis is an infection of the post-septal orbital structures and excludes the globe. Therefore, it is clinically distinct from endophthalmitis. Signs include periorbital edema, erythema, warmth, and tenderness to palpation. Features consistent with orbital cellulitis include proptosis, pain with extraocular movement, abnormal pupil response, and decreased visual acuity. ✅Summarized Points: Postoperative endophthalmitis is the most common form of endophthalmitis and is almost always due to bacteria. It typically manifests itself within six weeks of surgery, with 75 percent of cases presenting within the first postoperative week. Patients usually present with pain and decreased visual acuity. Examination reveals swollen eyelids and conjunctiva, hypopyon, corneal edema, and infection. Treatment aggressiveness is based on the severity of visual acuity impairment: Hand motion vision or better: vitreous tap for culture and intravitreal antibiotics (vancomycin and/or ceftazidime) Light perception vision only or worse: admission, vitreous tap for culture, immediate vitrectomy, and intravitreal antibiotics (vancomycin and/or ceftazidime) to prevent loss of vision

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