Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_25 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. This patient has personality changes, forgetfulness, and signs of impaired neurocognitive function. Given her longstanding HIV disease, this presentation is most likely due to HIV-associated neurocognitive disorder (HAND). HAND is characterized by a chronic decline in multiple cognitive domains (e.g., memory, attention, calculation, executive function). Mood and behavior disturbances are common. The diagnosis is based primarily on clinical features and neuropsychological testing, but MRI may also be helpful and shows a diffuse increase in intensity in the white matter. HAND is due to replication of HIV in the central nervous system (CNS) and can present with a broad range of deficits from an asymptomatic decline noted only on neuropsychological testing to severe dementia. With the widespread use of highly active antiretroviral therapy, the incidence of HIV dementia has declined, but less severe syndromes are common and may affect up to 69% of patients with chronic HIV. The risk increases with  duration of disease and is greatest in patients age >50 and with CD4 counts <200/µL. ❌Choice A is not correct: Cytomegalovirus neurological disease is a potential complication of chronic HIV disease. However, it is usually seen in patients with severely low CD4 counts (<50 cells/µL). In addition, it generally presents with more acute changes in mental status than seen in this patient and often has associated focal deficits. ❌Choice B is not correct: Major depressive disorder may cause distractibility and feelings of worthlessness, which may lead to medical noncompliance. However, this patient's motor signs are more consistent with HAND. ❌Choice D is not correct: Mixed cryoglobulinemia is a possible complication of chronic hepatitis C. However, neurological manifestations generally include peripheral neuropathy or mononeuropathy multiplex rather than CNS findings. ❌Choice E is not correct: CNS toxoplasmosis is occasionally seen in patients with advanced HIV disease, usually in those with CD4 cell counts <100 cells/µL. In addition to confusion, typical manifestations include headache, seizures, and focal neurological deficits. ✅Summarized Points: HIV-associated neurocognitive disorder is characterized by a chronic decline in multiple cognitive domains. Mood and behavior disturbances are common. The risk increases with the duration of HIV infection and is greatest in patients age >50 and with CD4 counts <200/µL.

🧠 Case-based MCQ 🔸 #MCQ_25 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 55-year-old woman with chronic HIV disease is brought to the office by her family due to noncompliance with medical therapy. The patient has been on a stable regimen of antiretroviral medications for several years, but over the last few months, she has had several pills left in the bottle when she is due to pick up refills from the pharmacy. The patient also frequently forgets to feed her cat and has become increasingly withdrawn from her friends and family. Medical history is notable for chronic hepatitis C, for which the patient has declined antiviral therapy. Vital signs are normal. The patient is alert but easily distractible. Neurological examination shows Impaired finger-to-nose testing and a prolonged timed Get Up and Go test. CD4 cell count is 150/µL.

🧠 Case-based MCQ 🔸 #MCQ_25 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. A penetrating wound to the chest will produce either a pneumothorax, a hemothorax, or both. The absence of breath sounds confirms that one of those has occurred, and the hyperresonance to percussion indicates that air is present. The patient’s good vital signs indicate that there is time to do the proper diagnostic study (chest x-ray). The appropriate treatment for a pneumothorax is placement of a chest tube. ❌Choice A is not correct: Infusion of 2 L Ringer lactate would have been appropriate if the findings had suggested hemothorax (as evidenced by dullness to percussion), and he had been bleeding (as evidenced by low blood pressure and a fast pulse). ❌Choice B is not correct: A patient who is fully awake and alert, and who is speaking in a normal tone of voice, has an airway and can maintain it. ❌Choice C is not correct: Immediate insertion of a needle into the right pleural space would be appropriate management for a tension pneumothorax. If the patient had a tension pneumothorax, he would have been in shock and severe respiratory distress, and the mediastinum would have been shifted (evidenced by tracheal deviation). ❌Choice E is not correct: Sonographically guided evacuation of the pericardial sac would be appropriate management for pericardial tamponade, which is not present in this patient. If the patient had developed tamponade, he would have been in shock, with a high central venous pressure (or distended veins). ✅Summarized Points: If vital sign of patient is stable then there is time to do chest x-ray, and the appropriate treatment for a pneumothorax is placement of a chest tube.

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🧠 Case-based MCQ 🔸 #MCQ_24 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 25-year-old man is stabbed in the right chest with a 5-cm-long knife blade. On arrival at the emergency department, he is wide awake and alert. He is speaking with a normal tone of voice but complaining of shortness of breath. The right hemithorax is hyperresonant to percussion and has no breath sounds; the rest of the initial survey is negative. His blood pressure is 100/75 mm Hg, pulse is 86/min, and venous pressure is 4 cm H2O. Pulse oximetry shows a saturation of 86%.

🧠 Case-based MCQ 🔸 #MCQ_23 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. The sympathomimetic toxidrome is seen with the acute abuse of cocaine, amphetamines, or decongestants. Cocaine causes the release of dopamine, epinephrine, norepinephrine, and serotonin. The greatest impact comes from adrenergic stimulation by norepinephrine and epinephrine. Norepinephrine causes vasoconstriction by stimulating alpha-adrenergic receptors on vascular smooth muscle. Epinephrine increases myocardial contractility and heart rate through stimulation of beta-1-adrenergic receptors. In addition to causing catecholamine release, the reuptake of these neurotransmitters is inhibited. Clinically, patients are usually hypertensive, tachycardic, and exhibit mydriatic pupils. In massive overdoses, cardiovascular collapse can result in shock and wide-complex dysrhythmias. central nervous system effects include seizures. Sympathomimetic toxidrome is sometimes difficult to distinguish from anticholinergic toxidrome. The difference is that patients usually present with dry mucous membranes with an anticholinergic overdose, whereas patients are diaphoretic with sympathomimetics. Treatment is usually supportive. Benzodiazepines should be administered for agitation, hypertension, and hyperthermia. ❌Choice B is not correct: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). In overdose, the increased serotonin has its greatest effect on the gastrointestinal (nausea, vomiting, abdominal pain), cardiovascular (tachycardia, bradycardia, QTc prolongation), and central nervous systems (dizziness, hyperreflexia, agitation). Overdose of fluoxetine alone rarely produces serotonin syndrome. ❌Choice C is not correct: Phencyclidine (PCP) is a dissociative agent that, when smoked, leads to a wide variety of findings. Patients may exhibit bizarre behavior, agitation, and violence. A blank or catatonic stare is common. Vertical, horizontal, and rotary nystagmus are often present. ❌Choice D is not correct: Dextromethorphan, a common ingredient in cold preparations, shares similar properties to phencyclidine (PCP) and other opioid compounds. It inhibits the uptake of serotonin and blocks the N-methyl-D-aspartate receptor at the PCP binding site. Clinically, overdose causes lethargy, agitation, dysarthria, ataxia, diaphoresis, hypertension, and nystagmus. At high doses, intoxication resembles that of LSD, with euphoria and hallucinations. Dystonic reactions have been reported in children after therapeutic administration. Because dextromethorphan inhibits the uptake of serotonin when it is ingested with a serotonin reuptake inhibitor, it can induce serotonin syndrome. ✅Summarized Points: Cocaine intoxication causes sympathomimetic toxidrome, which causes diaphoresis (unlike anticholinergic overdose), seizures and agitation (treated with benzodiazepines), and wide-complex dysrhythmias (treated with sodium bicarbonate). Beta-blockers should be avoided in cocaine intoxication.

🧠 Case-based MCQ 🔸 #MCQ_23 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 19-year-old man presents to the emergency department in police custody after using an unknown drug. Vital signs include a blood pressure of 170/85 mm Hg, pulse 120/min, temperature 37.8°C, respiratory rate 18/min, and pulse ox 99% on room air. On exam, he is agitated and diaphoretic. His pupils are 7 mm and reactive.

🧠 Case-based MCQ 🔸 #MCQ_22 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. The study involved taking a group of people who had exposure to a risk factor and a control group with minimal exposure, and following them over time to determine whether there is a relationship between sun exposure and skin cancer. This describes a cohort study. ❌Choice A is not correct: A case series study is useful for studying rare diseases. It involves descriptions of the clinical presentation of several people who are believed to have a particular disease. There is no control group, so causality is not able to be established. ❌Choice B is not correct: A case-control study is a retrospective study that is useful for studying rare diseases. This type of study involves finding a group of people with a disease and a control group without the disease and then looking for risk factors that led to the disease. ❌Choice D is not correct: This type of study is useful for determining the prevalence of a disease in a population. It involves a one-time sampling of a population to determine whether they have a certain disease and then examining the prevalence of risk factors in the population. It cannot establish causality. ❌Choice E is not correct: A randomized clinical trial is the gold standard of studies. It involves randomly separating two groups and then exposing one group to the trial substance and the other group to placebo to determine the effects of the exposure. Randomization helps control for confounding factors. ✅Summarized Points: Cohort studies are prospective studies that examine a group exposed to a risk factor and a group not exposed, and then determine who gets the disease.

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🧠 Case-based MCQ 🔸 #MCQ_2 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A group of investigators wants to study the relationship between sun exposure and squamous cell skin cancer. They enroll a group of lifeguards from several different high schools in three different states, as well as some of their classmates who have minimal sun exposure. This group is followed over the next 40 years for the development of skin cancer.

🧠 Case-based MCQ 🔸 #MCQ_21 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is A Studies show that most stable patients with upper gastrointestinal bleeding have better outcomes with restrictive red blood cell transfusion (e.g., transfusion for hemoglobin <70 g/L) versus liberal transfusion (transfusion for hemoglobin <90 g/L). Restrictive transfusion may be associated with fewer complications, fewer episodes of rebleeding, and decreased mortality. Patients with variceal hemorrhage may have worsened bleeding if blood transfusion results in hemoglobin >100 g/L. ❌Choice B, C, D, and E are not correct: Patients at risk for morbidity in the setting of severe anemia (e.g., unstable coronary artery disease) can benefit from maintaining hemoglobin levels >90 g/L. Also, patients with massive bleeding and hemodynamic instability might require blood transfusion regardless of hemoglobin levels as the levels do not accurately reflect the amount of blood loss. This patient has no comorbidities and is hemodynamically stable without signs of active bleeding; therefore, blood transfusion for hemoglobin >70 g/L is not appropriate. Transfusion with fresh frozen plasma or platelets should be considered in patients with upper gastrointestinal bleeding and evidence of coagulopathy (INR >1.5 or platelets <50,000/mm3). The target INR is <3 prior to endoscopy. Endoscopy can be performed safely with mild to moderate coagulopathy provided patients receive fresh frozen plasma during the procedure. ✅Summarized Points: The threshold for blood transfusion in most stable patients with upper gastrointestinal bleeding is hemoglobin <70 g/L. Patients at risk for morbidity in the setting of severe anemia (e.g., unstable coronary artery disease) may benefit from maintaining hemoglobin >90 g/L.

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