Case-based MCQ

⏳ Case-based MCQ | #Case_436 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E This patient most likely suffers from Zollinger-Ellison Syndrome (ZES). It is caused by a non–beta islet cell, gastrin-secreting tumor of the pancreas. The primary tumor is usually located in the duodenum, the pancreas, and abdominal lymph nodes, but ectopic locations have also been described (e.g., heart, ovary, gall bladder, liver, kidney). Excess gastrin secretion causes increased influx of acid into the stomach causing ulcerative disease. The most common clinical symptom of this disorder is recurrent gastric pain which does not resolve with PPI treatment or other peptic ulcer medications. The characteristics of these ulcers are that they are large (> 1-2 cm), recurrent even after Helicobacter pylori eradication, distal in the duodenum or even jejunum, and are multiple. The most important initial diagnostic step is to have an endoscopy in the patient who has repeated gastric pain even after taking peptic ulcer medication. Once ulceration is confirmed on endoscopy, the possibility of ZES should be considered. Fasting serum gastrin is the best single screening test. Any PPI or H2 blocker treatment should be stopped before this test.   The best diagnostic test is persistent high gastrin level despite the infusion of secretin (choice E), which normally inhibits the gastrin realease. This test has high sensitivity and specificity. ⚠ Low gastric pH (choice A) is incorrect. Though gastric pH is certainly going to be low due to elevated secretion of gastric acid, it is not the most helpful finding to confirm ZES. ⚠ Endoscopic ultrasound (choice B) is an invasive process and not preferred. Endoscopic ultrasound is one of the newer methods for localizing gastrinomas. Its sensitivity is higher for pancreatic gastrinoma (40-75%) than for duodenal gastrinoma (50%). ⚠ CT scan (choice C) can be performed to localize the tumor and is useful for evaluation for metastatic disease. However, its sensitivity for primary tumor localization is only 50%, and frequently, tumors smaller than 1 cm are missed. ⚠ Increased gastrin level despite high gastric acid secretion (choice D) is an unreliable finding in a patient on PPI treatment. Elevated gastrin levels would only confirm a diagnosis of ZE syndrome if they persist after secretin injection.

⏳ Case-based MCQ | #Case_436 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A young male college student is brought to the emergency department as he was found vomiting blood during class. The patient looks pale and dehydrated. You start IV hydration and blood transfusion. On questioning, the patient says that he has had similar episodes in the past and had been diagnosed with peptic ulcer. He further states that another physician had started him on omeprazole and he takes it regularly. His only other complaint is constipation. Endoscopy was performed in the ED and showed the presence of large ulcers in the distal duodenum and jejunum.

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⏳ Case-based MCQ | #Case_435 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital with parenteral agents, at least until the patient is stabilized and cultures are available. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteremic. Ampicillin plus gentamicin or a cephalosporin (choice D) (e.g., Ceftriaxone, Cefepime) is typically used. ⚠ The safety of levofloxacin (choice A) in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk. ⚠ Oral nitrofurantoin (choice B) may induce hemolysis in patients who are deficient in G6PD, which includes approximately 2% of women. ⚠ Oral trimethoprim/sulfamethoxazole (choice C) is contraindicated late in pregnancy because they may increase the incidence of kernicterus. ⚠ Intravenous doxycycline (choice E) is contraindicated because administration late in pregnancy may lead to discoloration of the child’s deciduous teeth. 🔖 Key point: Acute pyelonephritis in pregnancy is treated in hospital with intravenous antibiotics (e.g., Ampicillin plus gentamicin, or Ceftriaxone, or Cefepime) until the patient is afebrile for 24 to 48 hours and symptomatically improved.

⏳ Case-based MCQ | #Case_435 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 39-year-old multigravida at 36 weeks gestation presents with a temperature of 40.0°C (104.0°F), chills, backache, and vomiting. On physical examination, the uterus is noted to be nontender, but there is slight bilateral costovertebral angle tenderness. A urinalysis reveals many leukocytes, some in clumps, as well as numerous bacteria.

⚠ 🔔 𝐒𝐀𝐕𝐄 𝐓𝐇𝐈𝐒 𝐋𝐈𝐒𝐓 𝐅𝐎𝐑 𝐀 𝐑𝐀𝐈𝐍𝐘 𝐃𝐀𝐘 ! ⤵ 1. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐 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. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬)

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🧩 Medical Mnemonics Black named disorders ➖💀 Black death (plague): black areas from bleeding into skin ➖🐕‍🦺 Black dog: major depression disorder ➖🧟‍♂ Black sickness (Kala azar—leishmaniasis): dark skin on extremities ➖🫁 Black lung: coal dust pneumoconiosis ➖🚽 Blackwater fever: severe plasmodium falciparum malaria (dark urine) #confusing_terms 〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics

⏳ Case-based MCQ | #Case_434 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B Dermatomyositis is an inflammatory myopathy, which bears many clinical similarities to entities such as polymyositis and autoimmune myositis. It is characterized by muscle weakness, tenderness, and a "heliotrope rash" around the eyes. Bloodwork will show inflammation (elevated leukocytes and ESR/CRP) in addition to an elevated CK.  It may be confirmed with muscle biopsy.  Treatment modalities include glucocorticoids, immunosuppressants or immune modulation. Malignancies (choice B) may be associated with dermatomyositis in up to 15% of cases. The most common associations are ovary, breast, melanoma, GI, and lymphoma. ⚠ Autoimmune disorders (choice A) such as inflammatory bowel disease, vasculitis or celiac disease, are more likely to be associated with polymyositis than dermatomyositis. ⚠ Connective tissue disorders (choice C) can be associated with both dermatomyositis and polymyositis. ⚠ HIV (choice D) or parasitic infection (choice E) are more commonly associated with polymyositis. 🔖 Key point: Dermatomyositis is one of a number of inflammatory myopathies which can cause muscle weakness, pain, and tenderness. It is usually accompanied by a heliotrope rash and may be associated with malignancy in up to 15% of cases

⏳ Case-based MCQ | #Case_435 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 64-year-old man presents with several months of progressive weakness of the upper and lower extremities, along with ongoing pain in the affected areas. Physical examination shows difficulty standing up from a chair and tenderness over the affected areas. He is also found to have a violaceous erythematous rash over his eyes. A working diagnosis of dermatomyositis is made.

⏳ Case-based MCQ | #Case_434 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C Hypertension may develop for the first time postpartum, and in 50% of women who had hypertension during pregnancy, it may continue after delivery. If BP is mildly elevated, treatment is usually not required, but close monitoring is advised. In patients with systolic BP > 155 mmHg or diastolic BP > 105 mmHg, antihypertensive medications should be given. Labetalol and nifedipine are the most commonly used. For women who used ACE inhibitors before pregnancy, they can resume taking them. The recommended dose for nifedipine is 10 mg orally every 6 hours (choice B) and a maximum dose of 120 mg/day. ⚠ Some guidelines suggest avoiding methyldopa (choice A) postpartum because of the risk of postnatal depression. ⚠ Metoprolol 50 mg every 12 hours (choice C) is incorrect. Metoprolol, nadolol, and atenolol are excreted in breast milk in high concentration and would not be the best choice of treatment for this patient. ⚠ Hydrochlorothiazide 25 mg every 12 hours (choice D) and Furosemide 40 mg every 8 hours (choice E) are incorrect. Diuretics should generally be avoided in breastfeeding mothers because they significantly reduce milk production. ⚠ Key point: In postpartum patients with systolic BP > 155 mmHg or diastolic BP > 105 mmHg, antihypertensive medications should be given. Labetalol and nifedipine are the most commonly used

⏳ Case-based MCQ | #Case_434 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 23-year-old female G1P0 at the 34th week of gestation presents to your department with eclampsia. She had last seen her ObGyn at the 20th week of gestation, and the pregnancy was developing normally.  On physical examination, her BP is 190/115 mmHg, temperature 37.7°C, pulse 110 bpm, and respirations 20 bpm. After appropriate initial therapy is given and stabilization achieved, the patient delivers vaginally a 3000g boy. The immediate postpartum period at the hospital is uneventful. You visit the patient few days later for counseling before she is discharged from the hospital. Her BP is 145/100 mmHg. BP remains elevated in the following 4 weeks, 160/110 mmHg on average. The patient has been breastfeeding the baby.

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