Case-based MCQ

🇨🇦 MCCQE1,2 | #Case_58 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching. She has excoriations from scratching in various areas. She says that she had the same problem during her last pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis of pregnancy. Elevation of which one of the following is most specific and sensitive marker of this disorder? a) Gamma - Glutamyltransferase (GGT) b) Bile acids c) Total bilirubin d) Chenodeoxycholic acid e) Alkaline phosphatase

🇨🇦 MCCQE1,2 | #Case_57 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B 🔎 Explanation Not want to put him at risk for an intracranial bleeding or a bleeding elsewhere. So the best intervention would be a pulmonary embolectomy. Heparin is very good for clot stabilization; however it will not dissolve the already existing clot in our patient. The patient is unstable; embolectomy is life saving! A green field filter is an Inferior vena cava filter that is placed when a patient has recurrent DVT occurrence or when there is a contraindication to heparin.Percutaneous coronary intervention (PCI) would be warranted if the patient has an acute MI.

🇨🇦 MCCQE1,2 | #Case_57 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 26 year old male was brought to the Emergency Room right after he underwent a motor vehicle accident. He suffered multiple traumatic fractures including a significant head trauma. He suddenly became dyspneic and tachypneic complaining of chest discomfort and has a syncopal episode.His blood pressure dropped to 70/50 mmHg, pulse is 140/min, and respirations are 30/min. CT angiogram shows a massive obstruction in the main pulmonary artery with saddle shaped extension into both pulmonary arteries. What is the most appropriate line of management for this patient? a) Coronary catheterization b) Embolectomy c) Green field filter d) Heparin e) Streptokinase

🇨🇦 MCCQE1,2 | #Case_56 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation This is a characteristic presentation of factitious disorder by proxy, or what is commonly known as Munchausen syndrome by proxy. Warning signs for this disorder include episodes of illness beginning only when the child is, or has recently been, with the parent (choice C); the parent taking the child to numerous caregivers, resulting in multiple diagnostic evaluations but neither cure nor definitive diagnosis; the other parent (usually the father) being notably uninvolved despite the ostensible health crises; the parent not being assured by normal test results and continually advocating for painful or risky diagnostic tests for the child; the child persistently failing to tolerate or respond to usual medical therapies; and another child in the family having an unexplained illness or childhood death.

🇨🇦 MCCQE1,2 | #Case_56 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 An 18-month-old white male has been brought into your office multiple times over the past year with a reported fever of over 38°C (101°F). The child’s reported temperatures at home have usually been higher than those measured at the time of the office visit. The remainder of the history is usually unremarkable. The child has a sibling who is in good health, but another sibling died several years ago for unknown reasons.On two occasions you diagnosed acute otitis media and acute bronchitis. However, at most visits the child has not had any abnormal physical findings. Repeated laboratory studies have been within normal limits, including complete blood counts, erythrocyte sedimentation rates, blood cultures, chest radiographs, and urinalyses. Almost always, the mother has reported little reduction in fever with age-appropriate doses of acetaminophen or ibuprofen.At the last visit the child’s temperature was measured at 40.6°C (105.1°F). Although the examination was once again unrevealing, it was decided to hospitalize the child for close observation and evaluation by an infectious disease consultant. Closed-circuit television observation in the hospital showed the mother putting the thermometer into hot water before a nurse came to record the patient’s temperature.During the hospitalization you make a diagnosis. Which one of the following is a strong indicator of the suspected final diagnosis? a) The child has seen no other health-care provider but you b) Both parents have been involved with each office visit c) The child is afebrile while staying at the day-care center d) The parents have resisted having painful or risky diagnostic tests performed on the child e) The child responds well to usual medical therapies

🇨🇦 MCCQE1,2 | #Case_55 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation The parents are describing classic breath-holding spells. These are a form of autonomic syncope frequently misdiagnosed as seizures. They occur in early childhood and infancy. They can be of two forms: cyanotic, as described here, and pallid. The cyanotic form usually occurs after vigorous crying, while the pallid form commonly occurs after a sudden fright or minor injury. The history of a prodrome of injury, vigorous crying, or sudden fright is key to distinguishing a breath-holding spell from a seizure. Parents can be reassured that no brain damage occurs and, in the presence of a classic history, no further workup is necessary. An EKG and chest radiograph would be indicated if the history or examination suggested cardiac syncope. Blood testing would be indicated if the history suggested orthostatic hypotension or diabetes. A head CT scan would be indicated in the evaluation of seizures.

🇨🇦 MCCQE1,2 | #Case_55 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 The parents of a 20-month-old female bring her to your office because she has lost consciousness twice recently. They describe two episodes where the child was crying vigorously then “turned purple and passed out”. The child is an otherwise healthy product of a term delivery. There is no history of head trauma and no family history of seizures or cardiac problems. The episodes are not associated with fever or other symptoms. Physical examination of the child is normal. Which one of the following would be most appropriate at this point? a) Reassurance b) A CT scan of the brain c) An EKG and chest radiograph d) Measurement of serum glucose, electrolytes, and hematocrit e) Echocardiography

🇨🇦 MCCQE1,2 | #Case_54 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A 🔎 Explanation This patient presents with the classic triad for normal pressure hydrocephalus: ataxia, urinary incontinence, and dementia. MRI should be the first step in the diagnosis of this condition, both to rule out other conditions and to identify changes suggestive of normal pressure hydrocephalus. These include enlargement of the ventricles with preservation of cerebral parenchyma. Brainstem auditory evoked response testing is used for evaluating cochlear problems. While some other features of normal pressure hydrocephalus overlap with those of depression and Parkinson's disease, this patient's constellation of signs and symptoms are more typical for normal pressure hydrocephalus. Physical therapy is not indicated prior to making the diagnosis

🇨🇦 MCCQE1,2 | #Case_54 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 76-year-old male is brought to your office by his son. The patient complains of dizziness that has slowly been worsening over the past year. His description is vague, but he says that he notices the dizziness when he tries to walk.The review of systems is normal, except for increasing problems with his "prostate" in the last 6 months, with dribbling and accidents at times. The patient admits to "going more often", and sometimes "without warning". The son states that his father seems more forgetful, slower of speech, and not as "full of life" as he used to be.A neurologic examination reveals the patient to be oriented x 3, with a somewhat flat affect and a wide-based, slow, shuffling gate. The examination is otherwise normal. His Mini-Mental State Examination (MMSE) score is 22 out of 30. No tremor is noted. A CBC, creatinine level, TSH level, vitamin B12 level and VDRL are all normal. Which one of the following should you do next? a) Order a brain MRI b) Prescribe sertraline (Zoloft) c) Prescribe carbidopa/levodopa (Sinemet) d) Order physical therapy e) Order a brainstem auditory evoked potential

🇨🇦 MCCQE1,2 | #Case_53 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C 🔎 Explanation Given this patient's long history of rheumatoid arthritis her drop attacks are most likely caused by atlanto-occipital instability (choice C).The cervical spine is commonly affected by rheumatoid arthritis.The anatomic abnormalities occur as a consequence of the destruction of synovial joints, ligaments, and bone. Abnormalities of the rheumatoid cervical spine generally can be grouped into 3 categories that may be seen in isolation or combined involvement, of which atlantoaxial instability or atlanto-occipital instability is the most common abnormality.Superior migration of the odontoid is the next most common abnormality, it is also referred to as cranial settling or pseudobasilar invagination.The third and least common deformity is subaxial subluxation.When rheumatoid arthritis affects the cervical spine, compression of the C2 sensory fibers supplying the nucleus of the spinal trigeminal tract can cause facial pain. Compression of the C2 sensory fibers supplying the greater auricular nerve may result in ear pain. Occipital neuralgia results from compression of the C2 sensory fibers supplying the greater occipital nerve. Drop attack in these patients can be either a manifestation of myelopathic symptoms or vertebrobasilar insufficiency or a combination of both.Patients may experience weakness, decreased endurance, gait difficulty, paresthesias of the hands,loss of fine dexterity, and eventually incontinenece.They may also complain of vertigo, loss of equilibrium, visual disturbances, tinnitus, and dysphagia. ⚠ Adrenal insufficiency (choice A) may cause syncope due to hypotension, it also causes muscle weakness and may even cause muscle and joint pains. Since this patient has facial plethora on physical examination and this could occur in a rheumartoid arthritis patient on long-term treatement with corticosteroids, it could be argued that an abrupt discontinuation of corticosteroid treatment could result in adrenal insufficiency. However, some of the symptoms she describes such as incontincence and numbness, and the fact that these symptoms have occured over the last 3 months (and not a sudden adrenal crisis caused by discontinuation of corticosteroid therapy), make this diagnosis less favorable than atlanto-occipital instability. ⚠ Anxiety (choice B) is a less common cause of urinary incontinence than the reverse.Urinary incontinence causes anxiety in many patients. When considering this patient's overall history, complaints of weakness and numbness, her symptoms are most likely associated with neurological dysfunction. ⚠Cardiac arrhythmia (choice D) may cause syncope accompanied by incontinence in minority of patients; however, in this patient, findings on physical examination and the overall history, should guide us to consider that causes of drop attacks are related to her past medical history , and therefore most likely linked to atlanto-axial instability, a well known complication of rheumatoid arthritis of cervical spine. ⚠ Cerebral ischemia (choice E) is most likely to be associated with atherosclerosis history.While some of the symptoms this patient describes could occur in cerebral ischemia, the history of these attacks for the last 3 months, her rheumatoid arthritis history, findings on physical examination, and absence of cardiovascular diseases in her history,should steer us towards a diagnosis of atlanto-occipital instability caused by rheumatoid arthritis.

🇨🇦 MCCQE1,2 | #Case_53 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 46-year-old woman has had rheumatoid arthritis for 8 years. Her hands now show moderate ulnar deviation of the fingers and she says her wrists and knees also hurt. She says, "I had several drop attacks during the past 3 months." She characterizes these attacks as episodes of weakness and loss of feeling in her legs for several minutes. During one of these episodes, she became incontinent. On physical examination she has facial plethora and swollen and painful metacarpophalangeal and knee joints, bilaterally. The rest of the examination is normal. Which of the following is the most likely cause of her "drop attacks?" a) Adrenal insufficiency b) Anxiety c) Atlanto-occipital instability d) Cardiac arrhythmia e) Cerebral ischemia

🇨🇦 MCCQE1,2 | #Case_52 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation The condition of the skin in the affected area helps to differentiate the cause of hair loss. In this case, the abnormal skin suggests a scarring type of alopecia, which may be caused by infection (e.g. syphilis, tuberculosis, acquired immunodeficiency syndrome, herpes zoster), autoimmune disease (discoid lupus erythematosus), sarcoidosis, scalp trauma (e.g., injuries, burns), and radiation therapy. ⚠ The skin is normal in androgenic alopecia, alopecia areata, and drug-induced alopecia. ⚠ Trichotillomania, a compulsive plucking of one’s hair, may occur in the scalp. This can be differentiated from other forms of scarring alopecia by an examination of the scalp showing decreased hair density, as well as broken hairs of various lengths, rather than complete baldness in the affected area. ✏As the patient has known sarcoidosis, this is the most likely cause of her scarring alopecia.

🇨🇦 MCCQE1,2 | #Case_52 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 59-year-old female with a history of hypertension, posttraumatic stress disorder, and sarcoidosis, reports a 3-month history of hair loss in the right temple area. She has been using an over-the-counter corticosteroid cream without response. Her other medications include ramipril (Altace), hydrochlorothiazide, clonazepam (Klonopin), and bupropion (Wellbutrin). She reports increased stress from caring for her chronically ill husband who has been hospitalized recently. Examination of the skin and scalp is normal except for a 3cm x 4cm irregularly shaped area of alopecia with a slightly red, raised anterior edge located in the right temporal scalp. The affected skin is shiny, with no scaling; no hairs or broken hairs are present. The most likely cause of this patient’s hair loss is: a) Drug-induced alopecia b) Androgenic alopecia c) Stress-induced alopecia areata d) Sarcoidosis e) Trichotillomania

🇨🇦 MCCQE 1,2 | #Case_51 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation Whether or not to initiate treatment and type of treatment of dyslipidemia is based on coronary artery disease (CAD) risk. Those in the high risk group should receive medical treatment with HMG-CoA reductase immediately. Our patient has family history of premature coronary artery disease (CAD) in first degree relative and this is known to double the risk of CAD. Thus, the 10 years risk of CAD in our patient is 26% (13 x 2) and this puts him in the high risk group. That's why the best management option is to initiate medical treatment with HMG-CoA reductase inhibitors (choice D). ⚠ Reassessment for risk of coronary artery disease in 3 years before considering treatment (choice A) is not the best management option. This patient has a high risk of CAD and treatment should start immediately. However, risk assessment should be performed every three years for this patient or any patient for whom risk assessment is indicated. ⚠ Reassess for risk of CAD in one year before considering treatment (choice B) is not the best management option. This patient has a high risk of CAD and treatment should start immediately. Also, if risk assessment were indicated it would be done every three years. ⚠ Initiate conservative treatment for 4 to 6 months with smoking cessation, diet, and exercise before considering medical treatment (choice C) is not the best management option. This patient has a high risk of CAD and treatment should start immediately. ⚠ Performing exercise stress testing (choice E) is not the best management option. Dyslipidemia is not an indication for exercise stress testing. This type of testing is indicated in patients with intermediate probability (10 to 90%) of having CAD based on age, gender, and presence of symptoms. Asymptomatic men and women have < 10% probability of having CAD and stress test is not indicated. ✅Key point: After calculating the 10-year-risk score, consider risk modifiers like family history of premature CAD to decide on treatment of dyslipidemias. For patients in the high risk category medical treatment with HMG-CoA reductase inhibitors should be initiated immediately

🇨🇦 MCCQE1,2 | #Case_51 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 44-year-old man presented to his family physician for evaluation of coronary artery disease (CAD) risk after his 47 years old brother sustained myocardial infarction a week ago. He has been a smoker for 20 years now, with smoking history of 20-pack year. Apart from his blood pressure of 145/87 mmHg, vital signs are otherwise stable. Lipid profile is as follows: LDL: 3.5 mmol/L Total cholesterol: 5.0 mmol/L HDL: 0.8 mmol/L His 10 years Framingham Risk Score is 13%.What is the best management option for this patient? a) Reassess for risk of CAD in three years before considering treatment b) Reassess for risk of CAD in one year before considering treatment c) Initiate conservative treatment for 4 to 6 months with smoking cessation, diet and exercise before considering medical treatment d) Initiate medical treatment with HMG-CoA reductase inhibitors immediately e) Perform exercise stress testing before considering treatmen

🇨🇦 MCCQE1,2 | #Case_50 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D 🔎 Explanation This individual is experiencing claudicating pain, which is pain that begins upon exertion and ends with rest. Claudication is defined as reproducible ischemic muscle pain, which occurs during physical activity and is relieved after a short rest. Pain develops because of inadequate blood flow. A normal ABPI is between 0.9 and 1.2. You should expect the ABPI in someone with claudicating pain to lie between 0.7-0.4. When the ABPI is below 0.4, rest pain is a key sign to be aware of, and would indicate urgent vascular surgery to alleviate the ischemia.

🇨🇦 MCCQE1,2 | #Case_50 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 67-year-old smoker, with a 40 pack year history of smoking cigarettes, comes to your office for an annual check up. He is known to have uncontrolled hypertension, with a BP today of 159/89 mmHg. Today he tells you that he is becoming short of breath, more so than usual. He also can manage about 2 blocks before he needs to sit at a bench, before he can resume. He tells you that his calf muscles begin to ache at the end of the two blocks and the pain is relieved after resting.You take an ankle-brachial pressure index (ABPI) measurement.What do you expect his ABPI value to be between? a) > 1.5 b) 1 c) 1.0-0.7 d) 0.7-0.4 e) < 0.35

🇨🇦 MCCQE1,2 | #Case_49 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation Cluster headaches are repetitive headaches that occur for weeks or months at a time. They are more common in men between the ages of 30 and 50. The headaches begin without warning and reach a crescendo within minutes. Most times the headaches are located behind the eye or at the temple, and are associated with ipsilateral lacrimation, redness of the eye, nasal stuffiness,sweating, pallor, and Horner’s syndrome. Patients note that they are sensitive to alcohol. They often prefer to remain active rather than rest in a dark, quiet room as someone with a migraine would likely do. A typical attack will last from 30 minutes to 3 hours. It is common for the pain to recur each day at the same time. These attacks occur 1-3 times a day over a 4- to 8-week period. The patient will often remain pain-free for 6 months to a year.A cluster headache can be distinguished from a migraine, a tension-type headache, and a brain tumor by its presentation. Headaches associated with a brain tumor are often accompanied by nausea, vomiting, and worsening of the pain (which is usually bifrontal) with change in body position. There are usually positive findings on neurologic examination, as well as a change from the previous headache pattern. Migraines are more common in women and may be associated with an aura. They are throbbing in nature and accompanied by nausea, photophobia, and phonophobia. These patients are usually much more comfortable in the dark. Both cluster and migraine headaches will respond to abortive therapy with triptan medications.Prophylaxis for migraine is normally begun if there are four or more attacks within a month. In contrast, once the diagnosis of cluster headache is made, it is important to initiate both abortive and prophylactic therapy right away. Abortive therapy can be with 100% oxygen, triptans, octreotide, or dihydroergotamine. A number of prophylactic medications are available, including verapamil, lithium, prednisone (short-term use only), ergotamine, cyproheptadine, and indomethacin

🇨🇦 MCCQE1,2 | #Case_49 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 35-year-old male who works as an EMT has recently developed deep, severe, continuous headaches behind his left eye. The headaches occur daily around 10:00 a.m. and last 1-2 hours. He notes that the headaches bother him less when he remains active. When the headaches occur he also has tearing from the left eye and a nasal discharge from the left naris.He has found that using oxygen gives him relief. A physical examination reveals no significant findings. Which one of the following would be most appropriate at this time? a) MRI b) Carbamazepine (Tegretol) c) Neurologic consultation d) Avoiding triptan medications such as sumatriptan (Imitrex) e) Daily therapy with verapamil (Isoptin)

🇨🇦 MCCQE1,2 | #Case_48 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E 🔎 Explanation Reflex syncope is a strong diagnostic consideration for episodes of syncope associated with a characteristic precipitating factor. The major categories of syncope include carotid sinus hypersensitivity, and neurally mediated and situational syncopes. The most common and benign forms of syncope are neurally mediated or vasovagal types with sudden hypotension, frequently accompanied by bradycardia. Other terms for this include neurocardiogenic, vasomotor, neurovascular, or vasodepressive syncope. Most patients are young and otherwise healthy. The mechanism of the syncope seems to be a period of high sympathetic tone (often induced by pain or fear), followed by sudden sympathetic withdrawal, which then triggers a paradoxical vasodilation and hypotension. Attacks occur with upright posture, often accompanied by a feeling of warmth or cold sweating, lightheadedness, yawning, or dimming of vision. If the patient does not lie down quickly he or she will fall, with the horizontal position allowing a rapid restoration of central perfusion. Recovery is rapid, with no focal neurologic sense of confusion or headache. The event can be duplicated with tilt testing, demonstrating hypotension and bradycardia.