Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_29 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 26-year-old man presents to the clinic with complaints of left-sided ear pain for the past 3 days. Physical examination reveals tenderness on palpation of the left tragus and partial occlusion of the ear canal. Excoriations and a mild discharge from the left ear are also seen. There is no periauricular erythema or lymphadenopathy. Following gentle removal of debris from the canal under direct visualization, the tympanic membrane is fully inspected and appears normal.  The right ear is normal, and the patient is otherwise healthy.

🧠 Case-based MCQ 🔸 #MCQ_28 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Durable power of attorney is a type of advance directive that goes into effect if a patient becomes incapable of making medical decisions. In that event, the designated proxy assumes legal responsibility for all decisions regarding the patient's care. Although the durable power of attorney transfers decision-making capacity to another individual, the choice of proxy must be made while the patient retains his or her own decision-making capacity. In cases such as Alzheimer's disease, for instance, it is imperative that the health care proxy be designated early in the course of the disease, before dementia makes it impossible for the patient to do so. ❌Choice A is not correct: Instructional directive is a modification of a living will, in which the patient decides on a certain treatment modality given several specific clinical scenarios. The scenarios may include coma with no chance of recovery, coma with chance of partial recovery, advanced dementia with concurrent terminal illness, and so forth. ❌Choice B is not correct: A living will also goes into effect if a person becomes incapacitated. However, instead of designating a second party to make decisions, it allows an individual to describe what measures should be taken given certain medical conditions. However, these desires are often vague and apply to the dying patient, not one who is simply demented or otherwise medically stable and incapacitated. In most states, living wills carry moral weight, but individual decisions must still be made for each specific clinical situation. ❌Choice C is not correct: Medical futility refers to situations in which treatment would not achieve the desired outcome for a patient. The determination of futility rests on the treatment goals for the patient, which can vary between individuals, particularly among family members and physicians. The patient in the vignette is not in a medical situation in which medical futility would be a concern. ❌Choice D is not correct: A values history makes use of a questionnaire in which the patient outlines certain beliefs that may be helpful in determining how he or she would want to die. The areas of inquiry often include religious beliefs, views on independence and autonomy, and attitudes concerning health and health care providers. These questionnaires are often helpful for patients, but it is unclear how the information should guide physicians in treatment decisions. ✅Summarized Points: Durable power of attorney is a type of advance directive that goes into effect if a patient becomes incapable of making medical decisions. In that event, the designated proxy assumes legal responsibility for all decisions regarding the patient's care.

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🧠 Case-based MCQ 🔸 #MCQ_28 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An 86-year-old man presents to his family physician for an annual check-up. His only medical condition is hypertension controlled with a diuretic and a β-blocker. He has had regular screenings for colon cancer and prostate cancer. He lives with his wife, who is 82 years old and also in good health. When the physician asks the patient about advance directives, he states that he has been putting it off because he is healthy and does not want to think about death. When encouraged, the patient responds that if he were to become incapacitated, he would want his wife to make medical decisions for him.

🧠 Case-based MCQ 🔸 #MCQ_27 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. This patient’s symptoms are consistent with perimenopause. Paroxetine has been shown to confer a modest improvement (25%-30%) over placebo in treating the vasomotor symptoms of menopause. While hormone replacement therapy (HRT) is generally the most effective treatment for hot flashes (by replacing the missing hormones), a history of deep vein thrombosis is a contraindication for HRT because of the known increase in the risk of blood clots. ❌Choice A is not correct: Oral bisphosphonates such as alendronate are drugs used to treat osteoporosis and osteopenia. There is a direct relationship between the lack of estrogen after menopause and the development of osteoporosis. Bisphosphonates would not be used to treat perimenopausal hot flashes. ❌Choice B is not correct: Citalopram has been studied for the treatment of vasomotor symptoms at a dose of 30 mg/d, but it has not shown any significant benefit over placebo. ❌Choice D is not correct: Clinical trials have not shown a clear benefit from the use of clonidine for the relief of the vasomotor symptoms of menopause. In addition, clonidine can cause significant adverse effects, including hypotension, drowsiness, and rebound hypertension. ❌Choice E is not correct: While HRT is the most effective treatment for hot flashes, with (-.- 94% efficacy), a history of deep vein thrombosis is a contraindication for HRT because of the known increase in the risk of blood clots and pulmonary emboli. ✅Summarized Points: Perimenopausal symptoms are caused by an overall drop and fluctuations in the levels of estrogen, progestin, and testosterone. Vasomotor symptoms include hot flashes and palpitations. Psychological symptoms include depression, anxiety, irritability, and mood swings. Selective serotonin reuptake inhibitors (such as paroxetine) and serotonin-norepinephrine uptake inhibitors (such as venlafaxine) are generally the initial treatment of choice for vasomotor symptoms of menopause when HRT is contraindicated.

🧠 Case-based MCQ 🔸 #MCQ_27 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 54-year-old woman presents to her primary medical doctor complaining of frequent hot flashes that interfere with her regular daily activities. Her last menstrual period was 18 months ago. Her past medical history is significant for a deep vein thrombosis 6 years ago, for which she was treated with 6 months of warfarin. She requests treatment for her hot flashes. is married, works as a store manager, and does not smoke or consume alcohol. Family history is negative for coronary heart disease, stroke, cancer, and venous thromboembolism. Blood pressure is 128/76 mm Hg and pulse is 68/min, respiratory rate is 14/min, temperature is 37C. BMI is 29 kg/m2. Physical examination is normal.

🧠 Case-based MCQ 🔸 #MCQ_26 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is B. Meckel diverticulum is a remnant of the omphalomesenteric duct and is the most common malformation of the small intestine in children and is associated with the rule of 2's (diverticulum is 2 cm wide and 2 cm long and usually located within 2 feet of the ileocecal valve and usually presents before the age of 2). Classically, a male patient less than 5 years old will present with massive, painless, brick-red coloured rectal bleeding. Diagnosis is through a technetium scan or Meckel scan. Sixty percent of these will contain heterotopic gastric, pancreatic, or endometrial tissue which is the reason for the complications associated with these diverticula including, ulceration, and bleeding. ❌Choice A is not correct: Intussusception is common under the age of 2 and will present with the triad of abdominal pain, bloody stools (currant jelly), and vomiting. Currant-jelly stools are a late finding. Earlier in the disease process they may only have occult bloody stools. ❌Choice C is not correct: Milk allergy is a common cause of gastrointestinal bleeding during infancy and not during childhood. Necrotizing enterocolitis is a common cause of gastrointestinal bleeding during infancy but not during childhood. ❌Choice D is not correct: Necrotizing enterocolitis (NEC) is due to bacterial overgrowth in the bowel wall. Common predisposing factors include prematurity (seen in 90% of cases), bowel ischemia, infection, and introduction of parental feeding. It typically occurs in the first few days of life but can appear as late as 1 month of age. Symptoms include abdominal dissension, emesis, bloody stools, sepsis and abdominal x-ray will show pneumatosis intestinalis, or gas in the bowel wall. Treatment is with broad-spectrum antibiotics and surgical consultation. ✅Summarized Points: Meckel diverticulum is classically described as painless rectal bleeding that is a brick coloured in a male less than 5 years old

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🧠 Case-based MCQ 🔸 #MCQ_26 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 2-year-old boy presents to the emergency department due to a large amount of painless rectal bleeding that his mother describes as "brick-red in colour". Currently, he has no complaints and looks nontoxic. Vital signs are within normal limits and abdominal exam is benign.

🧠 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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