Case-based MCQ

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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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🧠 Case-based MCQ 🔸 #MCQ_49 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 60-year-old man comes to the emergency department because of recurrent episodes of fatigue, palpitations, nausea, and diaphoresis over the past 6 months. The episodes have become more frequent in the last 2 weeks and he has missed work several times because of them. His symptoms usually improve after he drinks some juice and rests. He has had a 2-kg (4.5-lb) weight gain in the past 6 months. He has a history of bipolar disorder, hypertension, and asthma. His sister has type 2 diabetes mellitus and his mother has a history of medullary thyroid carcinoma. His medications include lithium, hydrochlorothiazide, aspirin, and a budesonide inhaler. His temperature is 36.3°C (97.3°F), pulse is 92/min and regular, respirations are 20/min, and blood pressure is 118/65 mm Hg. Abdominal examination shows no abnormalities. Serum studies show:   Na+ 145 mEq/L   K+ 3.9 mEq/L   Cl- 103 mEq/L   Ca+2  2.3 mmol/L   Glucose 4.2 mmol/l   Which of the following is the most appropriate next step in diagnosis?   A. 24-hour urine catecholamine test B. Dexamethasone suppression test C. Water deprivation test D. 72-hour fasting test E. Corticotropin stimulation test

🧠 Case-based MCQ 🔸 #MCQ_48 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D Breast-conserving therapy and sentinel node biopsy are diagnostic and therapeutic procedures used as a first-line intervention in patients with newly diagnosed invasive ductal carcinoma. All patients who undergo lumpectomy require postoperative radiation to the whole breast to minimize the risk of recurrence. Sentinel node biopsy is necessary to stage cancer, which will determine subsequent treatment. Moreover, given the HER2-positive immunohistochemical staining, this patient will benefit from adjuvant systemic chemotherapy in the form of trastuzumab.   ❌Choice A is not correct: Tamoxifen is a selective estrogen receptor modulator that is primarily used in patients with estrogen receptor-positive breast cancer, but this patient's stain is estrogen receptor-negative. ❌Choice B is not correct: A whole-body PET/CT scan is required in all patients with stage IIIA or higher disease to assess for metastases. Additionally, patients who present with signs of metastatic disease, such as abdominal pain, elevated LFTs, or palpable abdominal masses, may benefit from a whole-body PET/CT scan. However, the stage of this patient's cancer has not yet been determined and she does not have any signs of metastatic disease, so a whole-body PET-CT would not be indicated at this time. ❌Choice C is not correct: A bilateral mastectomy with lymph node dissection is commonly performed in patients with bilateral disease, or in patients who have a BRCA gene mutation. Although a BRCA mutation has not explicitly been ruled out in this patient, BRCA mutation carriers generally have a personal and/or family history of breast, ovarian, tubal, or peritoneal cancer, and may also have more advanced disease at presentation (triple-negative or bilateral breast cancer). This patient does not have any of these conditions, which makes a BRCA mutation unlikely. In addition, a HER2 mutation has already been identified as the likely culprit. ❌Choice E is not correct: A bone scan is commonly obtained in patients who present with bone pain or elevated alkaline phosphatase in the setting of newly diagnosed breast cancer, which may be indicative of metastatic disease. This patient does not have either of these findings. ✅Summarized Points: Given the mammography and core-needle biopsy results, this patient most likely has localized breast cancer. She will require further staging and treatment

🧠 Case-based MCQ 🔸 #MCQ_48 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show:   Hemoglobin 125 g/L  Serum   Na+ 140 mEq/L   Cl- 103 mEq/L   K+ 4.2 mEq/L   HCO3- 26 mEq/L   Ca+2 2.29 mmol/L   Urea Nitrogen 4.2 mmol/L   Glucose 6.1 mmol/L   Alkaline Phosphatase 25 U/L   Alanine aminotransferase (ALT) 15 U/L   Aspartate aminotransferase (AST) 13 U/L   Which of the following is the most appropriate next step in management?   A. Tamoxifen therapy B. Whole-body PET/CT C. Bilateral mastectomy with lymph node dissection D. Breast-conserving therapy and sentinel lymph node biopsy E. Bone scan

🧠 Case-based MCQ 🔸 #MCQ_47 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E Sudden infant death syndrome (SIDS) is the leading cause of death during the first year of life. SIDS peaks at age 2-4 months, with the vast majority of cases occurring before age 6 months. Sleep positioning is the most important modifiable risk factor. The overall incidence has decreased by >50% since the American Academy of Pediatrics recommended supine sleep positioning through the "Back to Sleep"; campaign. All parents and caregivers should be advised to place infants on their backs on a firm mattress in a crib or bassinet. In early infancy, sleeping on the side is not recommended as the infant could roll into a prone position. When infants can roll from back to front and vice versa (age -6 months), they may choose their own sleep position. Throughout infancy, the sleep area should be devoid of pillows, stuffed animals, loose bedding, excessive clothing, or sleep positioners, as these objects are potential suffocation/strangulation hazards. Another significant modifiable risk factor is smoke exposure. Smoking during pregnancy and postnatal secondhand smoke exposure are both associated with an increased risk of SIDS. This patient should receive positive reinforcement for smoking cessation and encouraged to avoid secondhand smoke ❌Choice A is not correct: Exposing infants to secondhand smoke increases their risk of SIDS and should, therefore, be avoided. However, it is not the most important recommendation for SIDS prevention. ❌Choice B is not correct: There is no association between the time at which a baby is fed and the reduction of the risk of SIDS. ❌Choice C is not correct: Bed-sharing is not regarded as a safe practice, according to recommendations of the American Academy of Pediatrics. Studies have shown that children sleeping near an adult are at increased risk for SIDS. Some features of adult beds, e.g., soft surfaces and additional bedding, may contribute to this risk. ❌Choice D is not correct: Excessive swaddling may increase the risk of SIDS. Some studies show that the risk of SIDS increases with the amount of blankets or clothing. Swaddling is a safe and recommended practice in newborns. However, it should be discouraged among children beyond two months of age because it may increase the risk of suffocation if the baby rolls over. ✅Summarized Points: Having the baby sleep in the supine position is a strategy recommended by the American Academy of Pediatrics for reducing the risk of sudden infant death syndrome (SIDS). Several studies have shown that sleeping in the prone position is the most significant modifiable risk factor for SIDS. Although the mechanism is not clear, sleeping in the prone position seems to predispose children to suffocation. “Back to Sleep, Front to Play” (place infant on back when sleeping)

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🧠 Case-based MCQ 🔸 #MCQ_47 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 4-month-old African-American infant is brought to the pediatrician for a well-baby check-up. He was born at term through a normal vaginal delivery and has been well since. His 4-year old brother has sickle-cell disease. He is exclusively breastfed and receives vitamin D supplements. His immunizations are up-to-date. He appears healthy. His length is at the 70th percentile and weight is at the 75th percentile. Cardiopulmonary examination is normal. His mother has heard reports of sudden infant death syndrome (SIDS) being common in his age group and would like to hear more information about it. Which of the following is the most important recommendation to prevent this condition? A. Make sure that no one smokes around the baby B. Avoid feeding the baby close to bedtime C. Have the baby sleep with the parent D. Keep the baby warm with thick blankets E. Have the baby sleep in supine position