Case-based MCQ

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🧠 Case-based MCQ 🔸 #MCQ_51 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D Mittelschmerz is a common, benign phenomenon in women of reproductive age that is caused by follicular enlargement or rupture of the follicular cyst during ovulation, which leads to the release of small amounts of intraperitoneal fluid and subsequent peritoneal irritation. The pain is self-limited and usually subsides within hours to two days. Patients should be reassured and receive symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) as needed.   Choice A is not correct: A CT scan of the pelvis can be considered in patients with pelvic pain and abnormal findings (e.g., tenderness to palpation) if the diagnosis remains uncertain after laboratory evaluation and other imaging modalities are unavailable or inconclusive. This is, however, not the case in this patient. Furthermore, due to the radiation exposure associated with a CT scan, it is not the preferred imaging method for the evaluation of a young patient's reproductive organs. ❌Choice B is not correct: Diagnostic laparoscopy is indicated in patients with acute pelvic pain, if the diagnosis cannot be established with less invasive methods or if a surgical condition (e.g., appendicitis, ovarian torsion) is suspected. This patient has episodic pain and a normal abdominal and pelvic exam. Therefore, invasive diagnostic methods are not warranted at this time. ❌Choice C is not correct: Combined oral contraceptive pills can be used in the management of a variety of gynecological conditions such as primary dysmenorrhea. Although primary dysmenorrhea also commonly presents with episodic pelvic pain in adolescent women with a normal physical examination, the pain typically occurs immediately before or at the onset of the menstrual period, rather than midcycle as in this patient. ❌Choice E is not correct: Pelvic ultrasonography should be performed in postmenarchal adolescents with pelvic pain and adnexal mass or tenderness on examination to evaluate for ovarian cysts, ovarian torsion, and gynecological neoplasms. Although this patient complains of pelvic pain, her examination shows no abnormalities. Imaging is, therefore, not indicated at this time. ✅Summarized Points: Recurrent midcycle, unilateral, lower abdominal pain in an adolescent girl is suggestive of mittelschmerz.

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🧠 Case-based MCQ 🔸 #MCQ_51 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 17-year-old girl comes to the physician because of left lower abdominal pain for 1 day. She describes the pain as 6 out of 10 in intensity. Over the past 5 months, she has had similar episodes of pain that occur once a month and last 1 to 2 days. Menses occur at regular 28-day intervals and last 5 to 6 days. Menarche was at the age of 13 years, and her last menstrual period was 2 weeks ago. She has been sexually active with 1 male partner in the past and has used condoms inconsistently. She tested negative for sexually transmitted infections on her last visit 6 months ago. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient's symptoms?   A. CT scan of the pelvis B. Diagnostic laparoscopy C. Combined oral contraceptive pill D. Reassurance E. Pelvic ultrasonography

🧠 Case-based MCQ 🔸 #MCQ_50 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is B This patient's symptoms for the last 2 weeks are suggesting acute bacterial rhinosinusitis (ABRS).Acute rhinosinusitis is the symptomatic inflammation of the nasal and sinus mucosa for <4 weeks. The majority of cases are due to viral upper respiratory pathogens (e.g., influenza virus, rhinovirus, adenovirus) and resolve within 10 days. However, 2%-10% of patients develop a secondary bacterial infection, most commonly with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. Diagnosis of ABRS is typically made when ≥1 of the following is present: Persistent symptoms/signs of rhinosinusitis for >10 days Severe symptoms, high fever (>39 C [102.2 F]), purulent nasal discharge, and/or facial pain for >3 consecutive days "Double sickening" - initial improvement of viral upper respiratory symptoms for 5-6 days, followed by clinical deterioration (e.g., worsened fever, headache, nasal discharge) Patients with ABRS are usually treated with 5-7 days of oral amoxicillin-clavulanate to reduce symptom duration. Intranasal saline irrigation and analgesics are also often recommended ❌Choice A is not correct: Reassurance and supportive treatment with antipyretics, analgesics, and nasal decongestants are usually sufficient in the treatment of patients with viral rhinosinusitis. However, because this patient has had symptoms for more than 10 days and a mucopurulent discharge suggestive of a bacterial infection, a different treatment is indicated. ❌Choice C is not correct: A CT scan of the paranasal sinuses is not routinely performed in acute sinusitis. It may be used if complications (e.g., osteomyelitis, orbital cellulitis) occur, to rule out differential diagnoses (e.g., neoplasms), or preoperatively in patients with chronic sinusitis (e.g., surgical debridement of necrotic tissue and/or removal of anatomical obstructions). ❌Choice D is not correct: X-ray of the sinuses is usually not recommended in acute sinusitis because it does not help to differentiate between etiologies, and findings from it rarely influence the choice of treatment. ❌Choice E is not correct: Patients with poorly controlled diabetes mellitus (particularly with ketoacidosis) are at risk for rhino-orbital mucormycosis, which is treated with intravenous fungal medications (e.g., Amphotericin B). Manifestations typically progress rapidly and include fever, nasal necrosis, facial swelling, sinusitis, and headache. This patient is on antidiabetic mediations likely has well-controlled diabetes mellitus; he would be at low risk for mucormycosis. ✅Summarized Points: Acute rhinosinusitis is most commonly due to viral pathogens and usually resolves within 10 days. Patients with persistent symptoms >10 days, severe symptoms, or deterioration after several days of improvement often have acute bacterial rhinosinusitis, which is usually treated empirically with 5-7 days of oral amoxicillin-clavulanate. 

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🧠 Case-based MCQ 🔸 #MCQ_50 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 43-year-old man comes to the physician because of nasal congestion and fatigue for 2 weeks. During this period, he has had fevers and severe pain over his cheeks. His nasal discharge was initially clear, but it has turned yellowish over the last couple of days. He has no visual complaints. He has been taking an over-the-counter nasal decongestant and acetaminophen without much relief. He has type 2 diabetes mellitus and hypertension. He underwent an appendectomy 23 years ago. He does not smoke or drink alcohol. His current medications include metformin, sitagliptin, and enalapril. He appears tired. His temperature is 38.5°C (101.3°F), pulse is 96/min, and blood pressure is 138/86 mm Hg. Examination shows purulent discharge in the nose and pharynx and normal-appearing ears. The left maxillary sinus is tender to palpation. Laboratory studies show:   Hemoglobin 146 g/L (125–170)   Leukocyte count 10.8 x 109/L (3.5–10.5)   Platelet count 263 x 109/L (130–380)   ESR 22 mm/hr   Serum Glucose 6 mmol/L (3.3‐5.8)   Which of the following is the most appropriate next step in management? A. Reassurance and follow-up in 1 week B. Oral amoxicillin-clavulanate C. CT scan of the paranasal sinuses D. X-ray of the sinuses E. Intravenous amphotericin B

🧠 Case-based MCQ 🔸 #MCQ_49 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D Symptoms of spontaneous episodic hypoglycemia that resolve with glucose administration or rest should raise concern for the Whipple triad. If hypoglycemia is not present at the time of evaluation, a 72-hour fasting test is indicated to reproduce hypoglycemic symptoms in order to reach a definitive diagnosis. Glucose and hypoglycemic studies, including measurement of insulin, C-peptide, proinsulin, and β-hydroxybutyrate, should be obtained at the beginning of the test and then repeated every 6 hours until the serum glucose falls below 3.3 mmol/L (60 mg/dL). C-peptide and proinsulin are measures of the endogenous production of insulin and are decreased in hypoglycemia; hypoglycemia with elevated c-peptide and proinsulin levels should raise concern for an insulinoma. ❌Choice A is not correct: A 24-hour urine catecholamine test is used to diagnose pheochromocytoma. This patient's episodic palpitations and diaphoresis may be associated with pheochromocytoma. However, because his symptoms improve with glucose administration, they are consistent with episodic hypoglycemia, which is atypical in patients with pheochromocytoma. ❌Choice B is not correct: A dexamethasone suppression test is a screening test for Cushing syndrome, which could explain this patient's weight gain and fatigue. However, Cushing syndrome more commonly causes hyperglycemia, as opposed to the hypoglycemic episodes seen in this patient. Other clinical features associated with hypercortisolism include central and neck obesity, easy bruising, striae, and proximal muscle weakness, none of which are present. ❌Choice C is not correct: A water deprivation test is used to diagnose diabetes insipidus (DI). Although this patient has a history of hydrochlorothiazide use, which is associated with nephrogenic DI, findings of polyuria, polydipsia, and hypernatremia would be expected. ❌Choice E is not correct: A corticotropin stimulation test is a gold standard for diagnosing primary adrenal insufficiency, which can also manifest with hypoglycemia (due to decreased levels of cortisol), nausea, and fatigue. But adrenal insufficiency would typically lead to hypotension, whereas this patient is normotensive. Moreover, adrenal insufficiency is more commonly associated with weight loss, in contrast to this patient's weight gain. ✅Summarized Points: This patient's episodes of palpitations, nausea, fatigue, and diaphoresis that improve with the consumption of sugar, should raise concern for episodic hypoglycemia.

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