Case-based MCQ

🧠 Case-based MCQ ✅ #MCQ_4 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 34-year-old man is evaluated during a follow-up visit after passing his third calcium oxalate kidney stone in 4 years despite maintaining a high urine volume. He has no other medical problems. His only medication is potassium citrate, which was initiated after passing the most recent stone. He drinks 4 cups of coffee daily and typically eats meals at fast-food restaurants. Physical examination findings, including vital signs, are normal. Laboratory studies:  24-Hour urine studies    Volume 2600 mL    pH 6.5    Calcium 7.3 mmol (2.5–7.5)    Citrate 9 mmol (0.6–6.0)    Oxalate 0.35 mmol (0.44)    Uric acid 4.0 mmol (1.48–4.43)   The patient is counselled to start a low sodium diet.

🧠 Case-based MCQ 🔸 #MCQ_3 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 ✔️The correct answer is B. The production of calcitonin and carcinoembryonic antigen (CEA) is characteristic of medullary thyroid cancer, and these are useful markers for diagnosis and follow-up. Patients typically present with dysphagia, diarrhea, facial flushing, and a solitary thyroid nodule. Medullary thyroid cancer is a neuroendocrine tumor of the parafollicular or C cells of the thyroid gland. The diagnosis of medullary thyroid cancer is made after a fine-needle aspiration biopsy of the thyroid nodule. Treatment is with the removal of the affected thyroid lobes, and for nodules that are 4 cm or larger, diagnostic lobectomy is recommended over fine-needle aspiration. ❌Choice A and C are not correct: Although most cases of medullary thyroid cancer are acquired sporadically, genetic inheritance can be seen in cases of multiple endocrine neoplasia type 2 (MEN2). MEN2 is associated with medullary thyroid cancer, pheochromocytoma. and primary parathyroid hyperplasia. Therefore, additional testing for coexisting tumors such as biochemical evaluation for pheochromocytoma and germline RET mutation testing is recommended. ❌Choice D is not correct: Once medullary thyroid cancer is confirmed with fine-needle aspiration biopsy, further evaluation should include ultrasonography of the neck to look for lymph node involvement. ✅Summarized Points: Thyroid Carcinoma physical exam will show a solitary hard nodule. Labs will show normal thyroid function, cold nodule. Initial Diagnosis is ultrasound, and Confirmation is Fine-needle biopsy. 🔴Papillary: most common, least aggressive 🔴Anaplastic: least common, most aggressive 🔴Medullary: associated with MEN2, calcitonin can be used as a tumor marker

🧠 Case-based MCQ ✅ #MCQ_3 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 48-year-old woman presents to the clinic with dysphagia, diarrhea, and facial flushing. Physical examination reveals a solitary thyroid nodule and cervical lymphadenopathy. Laboratory studies show elevated serum calcitonin and elevated carcinoembryonic antigen levels.

🧠 Case-based MCQ 🔸 #MCQ_2 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 ✔️ The correct answer is E. This patient's presentation (3 months of fevers, abdominal pain, melena, and diarrhea) is concerning for intestinal lymphoma, specifically enteropathy-associated T cell lymphoma (EATL). This is a rare and aggressive lymphoma that is seen more commonly in celiac disease patients with poor dietary compliance. Patients present with abdominal pain, hepatosplenomegaly, ascites, duodenal masses, B symptoms (e.g., fever, night sweats, and weight loss), and gastrointestinal bleeding. Some patients may present with obstruction or perforation. The tumor is commonly located in the proximal jejunum and less frequently in the stomach, small bowel, or colon. A strict gluten-free diet also appears to reduce the incidence of EATL. EATL should also be suspected in patients with refractory sprue despite good dietary compliance and failure of treatment with glucocorticoids. It may also be helpful to test for underlying celiac disease in all patients with a T cell lymphoma with or without gut involvement as celiac disease is undiagnosed in many individuals. However, EATL is uncommon in individuals diagnosed with celiac disease at a young age (< 33 years). Diagnosis is confirmed on pathology of resected tumor, which demonstrates multiple jejunal ulcers often with gut perforation. EATL has a poor prognosis and treatment consists of combination chemotherapy used for other aggressive T cell lymphomas. ❌Choice A is not correct: Clostridium perfringens usually presents with self-limited watery diarrhea and enteritis necroticans (hemorrhagic necrosis of the jejunum), both of which would not cause symptoms for 3 months. ❌Choice B is not correct: Poor patient compliance with a gluten-free diet is the most common cause of recurrence of bowel symptoms in celiac disease. However, poor compliance and disease recurrence usually do not cause persistent fever, as seen in this patient. ❌Choice C is not correct: Patients with celiac disease may have coexisting pancreatic insufficiency. However, bloody stools and fever are not typically seen in chronic pancreatic insufficiency. Choice D is not correct: Refractory sprue is defined as persistent intestinal pathological changes despite a strict gluten-free diet for 12 months. However, this would not explain this patient's B symptoms or bloody diarrhea. ✅ Summarized Points: Enteropathy-associated T cell lymphoma is an aggressive lymphoma commonly seen in patients with celiac disease and poor dietary control. Patients present with abdominal pain, B symptoms, hepatosplenomegaly, ascites, bowel obstruction/perforation, and/or gastrointestinal bleeding. Diagnosis is confirmed by pathology of resected tumor. Prognosis is poor, and treatment involves combination chemotherapy.

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The correct answer is E. This patient's presentation (3 months of fevers, abdominal pain, melena, and diarrhea) is concerning for intestinal lymphoma, specifically enteropathy-associated T cell lymphoma (EATL). This is a rare and aggressive lymphoma that is seen more commonly in celiac disease patients with poor dietary compliance. Patients present with abdominal pain, hepatosplenomegaly, ascites, duodenal masses, B symptoms (e.g., fever, night sweats, and weight loss), and gastrointestinal bleeding. Some patients may present with obstruction or perforation. The tumor is commonly located in the proximal jejunum and less frequently in the stomach, small bowel, or colon. A strict gluten-free diet also appears to reduce the incidence of EATL. EATL should also be suspected in patients with refractory sprue despite good dietary compliance and failure of treatment with glucocorticoids. It may also be helpful to test for underlying celiac disease in all patients with a T cell lymphoma with or without gut involvement as celiac disease is undiagnosed in many individuals. However, EATL is uncommon in individuals diagnosed with celiac disease at a young age (< 33 years). Diagnosis is confirmed on pathology of resected tumor, which demonstrates multiple jejunal ulcers often with gut perforation. EATL has a poor prognosis and treatment consists of combination chemotherapy used for other aggressive T cell lymphomas. Choice A is not correct: Clostridium perfringens usually presents with self-limited watery diarrhea and enteritis necroticans (hemorrhagic necrosis of the jejunum), both of which would not cause symptoms for 3 months. Choice B is not correct: Poor patient compliance with a gluten-free diet is the most common cause of recurrence of bowel symptoms in celiac disease. However, poor compliance and disease recurrence usually do not cause persistent fever, as seen in this patient. Choice C is not correct: Patients with celiac disease may have coexisting pancreatic insufficiency. However, bloody stools and fever are not typically seen in chronic pancreatic insufficiency. Choice D is not correct: Refractory sprue is defined as persistent intestinal pathological changes despite a strict gluten-free diet for 12 months. However, this would not explain this patient's B symptoms or bloody diarrhea. Summarized Points: Enteropathy-associated T cell lymphoma is an aggressive lymphoma commonly seen in patients with celiac disease and poor dietary control. Patients present with abdominal pain, B symptoms, hepatosplenomegaly, ascites, bowel obstruction/perforation, and/or gastrointestinal bleeding. Diagnosis is confirmed by pathology of resected tumor. Prognosis is poor, and treatment involves combination chemotherapy.

🧠 Case-based MCQ ✅ #MCQ_1 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 40-year-old man with a 3-year history of celiac disease comes to the physician with fatigue, low-grade fevers, abdominal pain, and diarrhea for 3 months. He was symptom free for 2 years when he followed a strict gluten-free diet. However, in the past year, he developed symptoms twice due to poor dietary compliance. His temperature is 38.3° C (101° F), blood pressure is 110/80 mm Hg, and pulse is 80/min. The abdomen is soft but tender in the periumbilical area. There is no rebound tenderness or rigidity. Rectal examination shows dark stools positive for blood. Laboratory results are as follows:   Hemoglobin 99 g/L   Mean corpuscular volume 70 fL   Platelets 280,000/µL   Leukocytes 9,800/µL   Blood urea nitrogen 4 mmol/L (2.5-8.0)   Creatinine 70 µmol/L (70-120)   Albumin 31 g/L (35-50)   Erythrocyte sedimentation rate 87 mm/h (<15)

🧠 Case-based MCQ 🔸 #MCQ_1 〰️〰️〰️〰️〰️〰️〰️〰️〰️〰️〰️〰️〰️〰️ ✔️The correct answer is E. Sarcoidosis is a multisystem inflammatory disease of unknown etiology that manifests as noncaseating granulomas, predominantly in the lungs and intrathoracic lymph nodes. Incidence peaks in persons aged 25-35 years. A second peak occurs for women aged 45-65 years. Male-to-female ratio is approximately 1:2. Morbidity, mortality, and extrapulmonary involvement are higher in affected females. Approximately 5% of cases are asymptomatic and incidentally detected by chest radiography. Systemic complaints of fever, anorexia, and arthralgias occur in 45% of cases. Pulmonary complaints — dyspnea on exertion, cough, chest pain, and hemoptysis (rare) — occur in 50% of cases. The patient’s clinical picture is consistent with possible sarcoidosis. Tissue biopsy showing noncaseating granulomas along with ruling out other diseases is essential for the diagnosis.One of the major risk factors of sarcoidosis is being African American. ❌Choice A is not correct: Serum calcium will be elevated in a subset of sarcoid patients but this is not sensitive enough to make the diagnosis. ❌Choice B is not correct: CT chest will yield more information in regard to lung imaging but will not confirm a diagnosis. ❌Choice C is not correct: Angiotensin-converting enzyme level is not sensitive enough to confirm a diagnosis. ❌Choice D is not correct: Biopsy of a leg lesion that is easily accessible will reveal inflammation as the patient has findings consistent with erythema nodosum; however, this will NOT show noncaseating granulomas so this will not confirm a diagnosis of sarcoid. ✅ Summarized Points: Diagnosis of sarcoidosis requires biopsy in most cases. If therapy is to be given, tissue confirmation is essential. Standard transbronchial needle aspiration allows successful lymph node sampling in nearly all patients with sarcoidosis and is associated with high diagnostic yield regardless of disease stage.

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🧠 Case-based MCQ 🟩 #MCQ_1 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 38-year-old African-American female presents to your office with a 4-month history of dry cough, shortness of breath, and fatigue. She has a 10-pack-per-year smoking history. Her blood pressure is 132/79 mmHg, pulse is 74/min, respiratory rate is 16 /min, temperature is 36.7 C (98.2 F). Pulse oximetry shows 96% O2 saturation on room air. Examination reveals crackles bilaterally in the lower lung fields. There is no wheezing. She has two tender erythematous nodules on her right leg measuring approximately 3 x 3 cm. Chest X-ray shows bilateral hilar adenopathy.

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The correct answer is A. Amiodarone is an antiarrhythmic medication that may be used for prophylaxis or treatment of serious arrhythmias, especially ventricular arrhythmias. This patient has a history of ventricular tachycardia, and therefore has an indication to be taking amiodarone. This drug has many toxicities, and therefore when started the patient must have baseline pulmonary function tests, thyroid function tests, and liver function tests due to the toxicity involving each of these organs. Other notable side effects include blue-gray discoloration of the skin, corneal deposits, and peripheral neuropathy. This patient developed pulmonary fibrosis as a result of chronic amiodarone use. ⚠Choice B, C, and E are not correct: Digoxin, lisinopril, and losartan are not associated with pulmonary fibrosis. ⚠Choice D is not correct: Bleomycin can cause pulmonary fibrosis, but it is an antineoplastic drug and the patient has no reason to be taking this medication. Summarized Points: Amiodarone is an antiarrhythmic medication that may be used for prophylaxis or treatment of serious arrhythmias, especially ventricular arrhythmias. This drug has many toxicities, and therefore when started the patient must have baseline pulmonary function tests, thyroid function tests, and liver function tests due to the toxicity involving each of these organs.

A 77-year-old female is brought to the emergency department with a complaint of shortness of breath and progressive dyspnea. Her medical history is significant for a previous myocardial infarction 5 years ago and mild congestive heart failure. The patient has also had several episodes of ventricular tachycardia that ultimately required cardioversion. She is currently taking a prophylactic medication and has not had any recurrent arrhythmias. On physical examination, she is in moderate respiratory distress and she has dry rales throughout her lung fields. Her blood pressure is 138/75 mmHg, pulse is 96 /min, respiratory rate is 28/min, temperature is 37.2 C (99.1 F). Chest x-ray is normal, but CT scan of the chest shows diffuse ground-glass opacities. Which of the following is contributing to this patient’s symptoms and clinical findings? A. Amiodarone B. Digoxin C. Lisinopril D. Bleomycin E. Losartan

The Correct answer is E Fibromuscular dysplasia (FMD) typically occurs in young persons, particularly women <35 years of age. The abrupt onset of hypertension in a young patient with a lateralizing abdominal bruit suggests the diagnosis. For patients with suspected renal artery fibromuscular dysplasia, CT angiography (CTA) is the initial imaging modality of choice.  CT angiography is a noninvasive imaging method that has high accuracy in confirming the diagnosis of fibromuscular dysplasia, which most commonly affects the renal and carotid arteries. Renal artery stenosis due to FMD leads to hypertension, as seen here. Imaging typically shows a so-called “string of beads” appearance of the renal arteries due to segmental hyperplasia of the tunica media. Other imaging methods that can be used to diagnose FMD are duplex ultrasonography and magnetic resonance angiography. Patients with fibromuscular dysplasia are at risk for aneurysm formation and/or dissection, most commonly of the renal, carotid, and intracranial arteries. Patients with fibromuscular dysplasia should undergo at least a one-time assessment for intracranial aneurysm with brain CTA or MRA. ⚠Choice A is not correct: Echocardiography with Doppler is used e.g., to confirm coarctation of the aorta. Although coarctation of the aorta can lead to hypertension, other symptoms are also typically present, such as hypotension and claudication of the lower extremities, or a continuous murmur below the left clavicula and between the shoulder blades. An abdominal bruit, however, would not be expected. Echocardiography has no role in diagnosing fibromuscular dysplasia. ⚠Choice B is not correct: Serum PTH levels are used in the diagnostic evaluation of hyperparathyroidism. Primary hyperparathyroidism can lead to hypertension due to progressive calcification of the arteries and heart muscle. However, this condition is typically associated with other findings, such as nephrolithiasis, constipation, gastric ulcers, psychological symptoms (e.g., depression, fatigue), and/or bone, muscle, and joint pain. In addition, primary hyperparathyroidism would not explain this patient's abdominal bruit. ⚠Choice C is not correct: A high-dose dexamethasone suppression test is used to confirm Cushing syndrome. While Cushing syndrome is a common cause of secondary hypertension, it is usually accompanied by other symptoms, such as obesity, hirsutism, and easily bruisable skin with stretch marks. In addition, Cushing syndrome would not explain this patient's abdominal bruit. ⚠Choice D is not correct: Oral sodium loading test is used to confirm primary hyperaldosteronism. Although primary hyperaldosteronism is a common cause of secondary hypertension in young people, symptoms of hypokalemia, such as fatigue or muscle weakness, are also typically present. In addition, primary hyperaldosteronism would not explain this patient's abdominal bruit. Summarized Points: In a young woman (<35 years of age) with a hypertensive emergency (blood pressure of 185/125 mm Hg, papilledema, severe headache) and an epigastric or flank bruit on examination, fibromuscular dysplasia (FMD) is the most likely diagnosis. The best initial test for renal FMD is duplex ultrasonography and/or CT angiography. The common finding is “string of beads” sign which is from segmental hyperplasia of the media and beaded stenosis.