Case-based MCQ

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🧠 Case-based MCQ 🔸 #MCQ_42 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 36-year-old woman presented with painful swelling in her neck of one-week duration. Her last menstrual period was 2 weeks ago. She is adopted, and her family history is unknown. Temperature is 38.3 C (100.9 F), blood pressure is 156/60 mm Hg, pulse is 110/min, and respirations are 22/min. The thyroid gland is diffusely enlarged, firm, and very tender. The extremities are warm and moist. Eye examination shows lid lag but no proptosis. The remainder of the examination is unremarkable. Laboratory results are as follows:   Leukocytes 11,000/µL   Thyroid-stimulating 0.01 µU/mL (0.4-5.0)   Free thyroxine (T4), serum 175 nmol/L (60-145)   Triiodothyronine (T3), serum 1.8 nmol/L (1.1-3.0)   Erythrocyte sedimentation rate 90 mm/h   Which of the following is the best treatment for this patient? A. Radioactive iodine B. Systemic antibiotics C. Incision and drainage D. Methimazole, nonsteroidal anti-inflammatory drug, and beta-blocker E. Nonsteroidal anti-inflammatory drug and beta-blocker

🧠 Case-based MCQ 🔸 #MCQ_41 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E This child fulfills all of the 5 minor criteria of the modified Duke criteria for the diagnosis of infective endocarditis (IE). These include a predisposing heart condition (ventricular septal defect), fever ≥ 38°C (100.4°F), vascular phenomenon (splinter hemorrhages and Janeway lesions, i.e., purplish lesions on her palms and soles), immunologic phenomenon (glomerulonephritis and Roth spots, i.e, retinal hemorrhages), and a positive blood culture for atypical microorganisms consistent with IE. The fulfillment of these 5 criteria (even in the absence of vegetations on the transthoracic echocardiography) is adequate to make a diagnosis of IE.   ❌Choice A is not correct: Kawasaki disease is an autoimmune vasculitis more commonly seen in boys under 5 years of age. The criteria for diagnosing Kawasaki disease include fever > 5 days, bilateral nonpurulent conjunctivitis, mucositis, cervical lymphadenopathy, and a diffuse erythematous rash over the palms and soles. Although this girl has had a fever > 5 days, she does not have any other criteria. Additionally, Kawasaki disease does not present with retinal hemorrhages or glomerulonephritis. ❌Choice B is not correct: This patient fulfills one major (carditis) and three minor (fever, arthralgia, and ↑ ESR) of the Jones criteria for rheumatic fever. However, rheumatic fever occurs 2–4 weeks after(!) an infection with S. pyogenes (tonsillitis or pharyngitis), and it is not associated with positive blood cultures, hemorrhages, or signs of glomerulonephritis. Additionally, although rheumatic fever is the most common cause of cardiovascular disease in developing countries, it is rare in developed countries. Finally, this patient fulfills all of the criteria for another condition, making it the more likely diagnosis – especially in a patient with underlying heart disease. ❌Choice C is not correct: Hand-foot-mouth disease is a contagious illness caused by Coxsackie virus that can present with fever, malaise, and a rash on the hands and feet. However, HFMD does not cause glomerulonephritis or retinal hemorrhages. Additionally, the positive S. pyogenes blood culture makes HFMD an unlikely diagnosis in this child. ❌Choice D is not correct: Acute lymphoblastic leukemia is the most common childhood malignancy. It typically presents with hepatosplenomegaly or lymphadenopathy, and anemia or thrombocytopenia, which are all absent in this patient. Although ALL can present with fever and malaise, and predispose to infection, it does not cause positive blood cultures, glomerulonephritis, or retinal hemorrhages as seen above. ✅Summarized Points: This patient with an underlying structural heart disease presents with edema, hematuria, and mild proteinuria, suggesting glomerulonephritis. She also has hemorrhages on her palms, soles, and under her fingernails as well as retinal hemorrhages, fever ≥ 38°C (100.4°F), arthralgia, and positive blood cultures. These findings fulfill all of the diagnostic criteria for one of the conditions below.

⚠️ 🔔 𝐒𝐀𝐕𝐄 𝐓𝐇𝐈𝐒 𝐋𝐈𝐒𝐓 𝐅𝐎𝐑 𝐀 𝐑𝐀𝐈𝐍𝐘 𝐃𝐀𝐘 ! ⬇️ 1. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬) 2. 𝗖𝗔𝗦𝗘 - 𝗕𝗔𝗦𝗘𝗗 𝗠𝗖𝗤𝗦 ❔ 3. 🇨🇦 𝗠𝗖𝗖𝗤𝗘 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡 4. 🩺 𝗘𝗗𝗟 𝗠𝗘𝗗𝗜𝗖𝗢𝗦 (𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 𝗔𝗡𝗗 𝗟𝗜𝗡𝗞𝗦) 5. 📚 𝗘𝗗𝗟 𝗣𝗛𝗔𝗥𝗠 6. 🏛📷 𝗢𝗡𝗟𝗜𝗡𝗘 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗦𝗖𝗛𝗢𝗢𝗟 7. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗚𝗘𝗥𝗠𝗔𝗡𝗬 🇩🇪 8. 𝗣𝗥𝗔𝗖𝗧𝗜𝗖𝗘 𝗜𝗡 𝗔𝗨𝗦𝗧𝗥𝗔𝗟𝗜𝗔 🇦🇺 9. 𝗠𝗕𝗕𝗦 & 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗜𝗧𝗔𝗟𝗬 🇮🇹 10. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗞 🇬🇧 11. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗦 🇺🇸 12. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗖𝗔𝗡𝗔𝗗𝗔 🇨🇦 13. 𝗙𝗥𝗘𝗡𝗖𝗛 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇫🇷 14. 𝗚𝗘𝗥𝗠𝗔𝗡 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇩🇪 15. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗦𝗘𝗔𝗥𝗖𝗛 🎓🫥 16. 📸 𝗗𝗘𝗥𝗠𝗔𝗧𝗢𝗟𝗢𝗚𝗬 𝗔𝗧𝗟𝗔𝗦 17. 𝗢𝗘𝗧 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡 ✅ 18. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐 19. 𝗖𝗔𝗥𝗗𝗜𝗢𝗟𝗢𝗚𝗬 𝗖𝗔𝗦𝗘𝗦 🫀 20. 💠 𝗨𝗪𝗢𝗥𝗟𝗗 𝗘𝗗𝗨𝗖𝗔𝗧𝗜𝗢𝗡𝗔𝗟 𝗢𝗕𝗝𝗘𝗖𝗧𝗜𝗩𝗘𝗦 21. 𝗠𝗘𝗗𝗜𝗖𝗖𝗢𝗨𝗡𝗧 - 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗖𝗖𝗢𝗨𝗡𝗧 🔄

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🧠 Case-based MCQ 🔸 #MCQ_41 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 9-year-old girl is brought to the physician by her mother because of a 3-day history of face and foot swelling, dark urine, and a rash on her hands and feet. The mother reports that her daughter has had a low-grade fever, shortness of breath, and a dry cough for the past 8 days. She has had generalized weakness and pain in her right knee and ankle. She has a ventricular septum defect that was diagnosed at birth. The patient appears lethargic. Her temperature is 38.4 (101.1°F), pulse is 130/min, respirations are 34/min, and blood pressure is 110/60 mm Hg. Examination shows small, non-blanching, purple lesions on her palms, soles, and under her fingernails. There is edema of the eyelids and feet. Funduscopic examination shows retinal hemorrhages. Holosystolic and early diastolic murmurs are heard. Laboratory studies show:   Hemoglobin 113 g/L (115–155 )   Erythrocyte sedimentation rate 61 mm/h (0–20 )   Leukocyte count 15× 109/L (3.5–10.5)   Platelet count 326× 109/L (130–380)  Urine:       Blood 4+     Glucose negative     Protein 1+     Ketones negative   Transthoracic echocardiography shows a small outlet ventricular septum defect and a mild right ventricular enlargement. There are no wall motion abnormalities, valvular heart disease, or deficits in the pump function of the heart. Blood cultures grow Streptococcus pyogenes. Which of the following is the most likely diagnosis? A. Kawasaki disease B. Rheumatic fever C. Hand-foot-mouth disease D. Acute lymphoblastic leukemia E. Infective endocarditis

🧠 Case-based MCQ 🔸 #MCQ_40 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D This patient’s presentation is most likely due to hypertrophic cardiomyopathy (HCM). Mutations in the sarcomere genes lead to disorganized, proliferating myocytes that can become significantly hypertrophic and obstruct the left ventricular outflow tract. The obstruction (and the accompanying systolic murmur) is exacerbated by low-volume states, such as dehydration or tachycardia. For this reason, patients are often symptomatic during vigorous exercise. Maneuvers that improve venous return to the heart (e.g., squatting, fist-clenching) will decrease the intensity of the murmur. Many patients are asymptomatic and are identified by sports preparticipation screening (e.g., family history of HCM). However, symptomatic patients can present with chest pain, dyspnea, fatigue, palpitations, and syncope. Rarely, the initial presentation may be a fatal dysrhythmia or cardiogenic shock. Patients generally have a systolic ejection murmur and left ventricular hypertrophy on ECG. Echocardiography is required to confirm the diagnosis. Once HCM is identified, all first-degree relatives should also be screened due to autosomal dominant inheritance. Affected individuals should undergo exercise stress testing. Beta-blockers can improve ventricular filling and minimize obstruction. ❌Choice A is not correct: Commotio Cordis, or ventricular fibrillation following chest wall impact, is a rare event that immediately follows trauma to the chest. Unlike this patient who recovered quickly, commotio cordis is virtually always fatal unless defibrillation is available. ❌Choice B is not correct: Heart block can present with syncope. However, there is no evidence of an abnormal PR interval on this patient’s ECG, and heart block would not account for his ventricular hypertrophy or murmur. ❌Choice C is not correct: Myocardial infarction is extremely rare in otherwise healthy teenagers. It is associated with uncontrolled dyslipidemias or with structurally abnormal hearts or coronary arteries. This patient has no evidence of myocardial infarction on his ECG (i.e., ST changes), and an infarction would not account for his ventricular hypertrophy. ❌Choice E is not correct: Wolff-Parkinson-White syndrome (WPW) can present with palpitations, syncope, chest pain, or even sudden death. The hallmark of WPW is preexcitation or a delta wave at the beginning of the QRS complex that shortens the PR interval and lengthens the QRS complex. This patient has no evidence of preexcitation on ECG. ✅Summarized Points: Hypertrophic cardiomyopathy can be asymptomatic or may present with chest pain, dyspnea, or syncope, particularly during exercise. Classic findings include a systolic murmur and left ventricular hypertrophy on ECG and echocardiography. First-degree relatives should undergo screening for hypertrophic cardiomyopathy.

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An 18-year-old boy is brought to the emergency department after a syncopal episode during football practice. Twenty minutes prior to fainting, the patient was tackled and developed chest pain. He was standing on the sideline when he suddenly passed out and regained consciousness within a few seconds. The patient had no head injury. He feels better after receiving intravenous normal saline. Heart rate and blood pressure are normal. Physical examination shows a grade 2/6 systolic ejection murmur at the right upper sternal border. An electrocardiogram (ECG) is obtained and is shown below. Which of the following is the most likely cause of this patient's syncope? A. Commotio cordis B. First-degree heart block C. Myocardial infarction D. Hypertrophic cardiomyopathy E. Wolff-Parkinson-White syndrome

🧠 Case-based MCQ 🔸 #MCQ_39 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D To meet the criteria for a major depressive disorder, a patient must have 5 or more symptoms of depression (SIGECAPS), one of which must be depressed mood or anhedonia, for at least 2 consecutive weeks. Symptoms must not be attributable to substance use or other medical condition. Bipolar disorder and psychosis must also be excluded. This patient meets the criteria because she has had 7.5 months of insomnia, anhedonia (used to enjoy cooking), exhaustion, poor concentration, and decreased appetite. She has never had an episode of hypomania or mania and her symptoms are not better explained by a psychotic disorder or substance use. The next best step in management for this patient is starting her on an antidepressant, such as an SSRI, and attempting lifestyle changes, possibly with the help of psychotherapy.  l ❌Choice A is not correct: Postpartum blues are mild depressive symptoms (e.g., tearfulness or sadness) that may last up to 2 weeks following delivery. This patient has had severe depressive symptoms for 7.5 months, which started 6 weeks post-delivery. ❌Choice B is not correct: Adjustment disorder is a response to a psychosocial stressor that may manifest as symptoms of depression or anxiety (which do not meet the full criteria for any other psychiatric diagnosis) that last for up to 3–6 months after resolution of the stressful event. Because this patient has now had symptoms for 7.5 months after her delivery, adjustment disorder can be ruled out. ❌Choice C is not correct: To meet the DSM-V criteria for depression with peripartum-onset, symptoms must fulfill the criteria for major depressive disorder and onset of symptoms must begin during pregnancy or within 4 weeks of delivery. Although this patient meets the criteria for a major depressive episode, her symptoms started 6 weeks after her delivery. ❌Choice E is not correct: Normal behavior may include occasional feelings of sadness or tearfulness for < 2 weeks. While this patient has had recent stress which may trigger such feelings, she has had multiple, significant depressive symptoms for 7.5 months, which is no longer considered normal. ✅Summarized Points: This patient might have also had difficulty making decisions for more than 2 weeks.

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🧠 Case-based MCQ 🔸 #MCQ_39 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 25-year-old woman comes to the physician because of sadness that started 6 weeks after her 9-month-old daughter was born. Since then, she has not returned to work. Her daughter usually sleeps through the night, but the patient still has difficulty staying asleep. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?   A. Postpartum blues B. Adjustment disorder C. Depression with peripartum-onset D. Major depressive disorder E. Normal behavior

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