Case-based MCQ

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⏳ Case-based MCQ | #Case_434 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C Exercise ECG testing (choice B) should be done next to verify or refute the diagnosis of angina. A 12-lead ECG is done just before, during and after standardized exercise protocol with increasing work load. Flat or down sloping of ST segment during exercise confirms diagnosis of ischemia. These ECG changes together with the typical symptoms of angina confirm the diagnosis of chronic stable angina. ⚠ There is no indication for measurement of cardiac enzymes (choice A) in this patient. These cardiac biomarkers are measured if the diagnosis of unstable angina or ST elevation myocardial infarction is suspected. Unstable angina is suspected if frequency and duration of pain attacks is increasing; pain is not responding to treatment with nitroglycerine, pain occurs at rest or angina following myocardial infarction. ⚠ Cardiac imaging (choice C) is done only if ECG exercise testing is abnormal to evaluate the extent and site of ischemia. ⚠ Coronary angiography (choice D), an invasive procedure, is indicated only if: diagnosis of disabling chronic stable angina is confirmed; the patient is at high risk of coronary artery disease; diagnosis or prognoses are uncertain; the patient cannot undergo non-invasive testing. ⚠ Echocardiography (choice E) is not indicated in this patient at this point. The initial test in patients able to exercise should be exercise ECG. 🔖 Key point: In patients with typical episodic chest pain provoked by physical activity, diagnosis of chronic stable angina should be confirmed or refuted by ECG exercise testing

⏳ Case-based MCQ | #Case_433 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 53-year-old man presented to his family physician with episodic retrosternal chest pain that radiates to the left shoulder. During the last four months, he experienced this pain three times, the last of which was two weeks ago and all were while exercising on treadmill and while running for a few minutes. In all three occasions pain subsided within about 5 minutes of rest. He does not smoke and rarely drinks alcohol. Physical examination is normal. Urine analysis, complete blood count, fasting blood sugar, lipid profile, serum urea and electrolytes, chest X-ray and 12-lead ECG are all normal. Chronic stable angina is suspected.

⏳ Case-based MCQ | #Case_432 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B There are approximately 300 lymph nodes in the neck region. A regional lymphatic system is composed of the first, second, third and even fourth or much more intercalated nodes along the lymphatic route from the periphery to the venous angle or the thoracic duct. The third or fourth node is usually termed the last-intercalated node or end node along the route. One of the supraclavicular nodes is known to correspond to the end node along the thoracic duct. It is generally called Virchow's node. It is the site of Virchow’s metastases of gastric cancer (choice B). It is also called the sentinel node. Virchow’s node is where the lymphatic drainage from the thoracic duct enters the venous circulation via the left subclavian vein. By the time gastric cancer presents with a Virchow’s node it is already in its advanced stage. Various intra-abdominal malignancies besides gastric cancer could present with the Virchow’s node (e.g. gallbladder, pancreas, kidneys, testicles, ovaries, or prostate). ⚠ Esophageal cancer (choice A), Hodgkin lymphoma (choice C), and Lung cancer (choice D) can present with an enlarged right supraclavicular lymph node, which tends to drain thoracic malignancies. Out of the choices given only gastric cancer is most likely to present with the Virchow’s node. ⚠ Thyroid cancer (choice E) can usually be found relatively early because of its location. When it metastasizes to lymph nodes, the pretracheal, paratracheal and prelaryngeal nodes are affected. 🔖 Key point: The left supraclavicular adenopathy (Virchow's node) suggests abdominal malignancy (e.g. stomach, gallbladder, pancreas, kidneys, testicles, ovaries, or prostate).

⏳ Case-based MCQ | #Case_432 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 58-year-old male presents with nausea and vomiting for two days. He had noticed that he lost 7 kg over the last two months but he did not think too much about it, as he was overweight. Past medical history is significant for smoking 20 packs of cigarettes a year. Physical examination reveals an enlarged, hard, painless left-sided supraclavicular lymph node.

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⏳ Case-based MCQ | #Case_431 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C The key to making a diagnosis of imperforate hymen, aside from the obvious finding on physical examination, lies in the systematic drawing of inferences. One can speculate that this patient’s recurrent crescendo abdominal cramping represents six menstrual sheddings, with no egress from the body. Her delay in menarche, despite normal growth parameters, offers another clue that the structural amenorrhea is present. Amounts of retained blood vary among patients; up to 3000 mL have been reported. A large volume can accumulate without causing any permanent damage, and subsequent fertility is usually normal. Hymenotomy will relieve the pressure, and normal menses should ensue.

⏳ Case-based MCQ | #Case_431 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 13-year-old white female reports a 6 month history of intermittent abdominal cramping, with each episode becoming progressively worse. Based on her history, there is no obvious relationship to eating, voiding, or defecating. She report that she has not yet begun menstruating and is not sexually active. Her weight has been stable. She appears to be in mild emotional distress about being the “last girl in her class to have a period”. She is in no physical discomfort and her vital signs are normal. Secondary sexual characteristics appear to be developing normally. She is in the 57th percentile for height and the 65th percentile for weight. A complete physical examination confirms your presumptive diagnosis.

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⏳ Case-based MCQ | #Case_430 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C This patient is presenting with a history of hypertension that is not responding to calcium channel blockers and has non-specific symptoms like nausea and vomiting. The major clue to the cause of this patient’s condition is the laboratory tests results that show hypokalemia and mild hypernatremia. These electrolyte abnormalities are associated with hyperaldosteronism and given the history of resistant hypertension, the patient’s most likely diagnosis is Conn’s syndrome (choice C). Other aspects of clinical presentation that may be noted are weakness, abdominal distention, Ileus from hypokalemia (which can cause nausea and vomiting), findings related to complications of hypertension such as cardiac failure, hemiparesis due to stroke, carotid bruits, abdominal bruits, proteinuria, renal insufficiency, and hypertensive encephalopathy. ⚠ Liver cirrhosis (choice A) may cause abdominal distension and vomiting with portal hypertension and ascites and even hypokalemia. Hypokalemia in liver cirrhosis is usually multifactorial and may be associated with diuretics use, magnesium depletion in alcoholics, vomiting, and secondary hyperaldosteronism. However, this patient’s scenario doesn’t present risk factors of liver cirrhosis and primary aldosteronism is far more common than secondary aldosteronism. ⚠ Cushing's syndrome (choice B) can also cause hypertension and even hypokalemia with extremely high levels of cortisol. However, it would also cause findings often remarkable on physical examination such as facial plethora, hirsutism, buffalo hump, etc. ⚠ Pheochromocytoma (choice D) presents with episodes of severe hypertension due catecholamine secretion. Other classic 3 symptoms are diaphoresis, palpitations, and headaches. It may be associated with multiple endocrine neoplasia type II. Hypernatremia and hypokalemia are more likely to be seen with elevated aldosterone secretion than with increased catecholamine secretions. ⚠ Addison’s disease (choice E) is adrenal insufficiency and would cause the inverse of what is noted in this patient, with hypotension, hyponatremia, and hyperkalemia being the major findings. 🔖 Key point: Hyperaldosteronism such as seen in Conn's syndrome is associated with hypertension, hypernatremia, and hypokalemia

⏳ Case-based MCQ | #Case_430 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 37-year-old female presents to your department because complaining of nausea and vomiting for the last 3 days. She has also been having headaches. Physical examination is only remarkable for abdominal distension and BP 165/100 mmHg. Her BP has been high the last 3 months despite treatment with amlodipine that was started at 5 mg once a day and was later increased to 10 mg once a day. Comprehensive metabolic panel reveals: BUN: 7 mmol/L Creatinine: 80 micromol/L Calcium: 2.40 mmol/L Chloride: 96 mmol/L Bicarbonate: 31 mmol/L   Glucose test: 5 mmol/L Potassium test: 2.7 mmol/L Sodium: 148 mmol/L Albumin: 42 g/L

⏳ Case-based MCQ | #Case_429 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Severe hypophosphatemia (choice E) is a medical emergency. In poorly nourished patients, refeeding syndrome can occur. Symptoms usually occur by the second or third day of improved nutrition, and are often multisystemic. Findings may include weakness, confusion, dysrhythmias, respiratory failure, congestive heart failure, hypotension, ileus, metabolic acidosis, seizures, coma, and sudden death. This constellation of problems results from decreased insulin secretion as stores of intracellular phosphate become depleted. Providing carbohydrates through intravenous fluids or refeeding increases insulin secretion, which stimulates cells to take up phosphate, causing severe hypophosphatemia. In this setting cells are unable to produce enough 2,3 diphosphoglycerate and adenosine triphosphate to meet metabolic demands ⚠ While hypoglycemia (choice A) is another medical emergency, this patient’s glucose level is not low enough to cause these symptoms. ⚠ Similarly, renal failure (choice B) of some type is present, as is an elevated creatine kinase (choice C) suggesting rhabdomyolysis; however, neither of these problems would be expected to cause this patient’s symptoms. ⚠ Hypocalcemia (choice D) can cause multisystemic problems, including weakness and seizures, but this level is not critically low and is not associated with hypotension.