Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. Clinical features and laboratory studies support the diagnosis of immune thrombocytopenic purpura (ITP). Petechiae and ecchymoses without lymphadenopathy or splenomegaly are supportive findings. Laboratory findings are limited to a low platelet count. On the peripheral blood smear, platelets appear as small purplish cells without a nucleus. As a rule of thumb, approximately seven platelets are normally seen per 100-power field. Giant platelets are typically associated with increased platelet production secondary to the stress of increased peripheral platelet destruction. In adults with newly diagnosed ITP and a platelet count less than 30 x 109/L who are asymptomatic or have minor mucocutaneous bleeding, treatment with glucocorticoids is recommended. Initial therapy includes a short course (<6 weeks) of prednisone or dexamethasone. The response to intravenous immune globulin is faster and may be indicated in patients with more severe thrombocytopenia and life-threatening bleeding. ❌Choice B is not correct: Initial treatment of thrombotic thrombocytopenic purpura (TTP) involves therapeutic plasma exchange to remove the high-molecular-weight von Willebrand factor multimers and replace the deficient ADAMTS13. Glucocorticoids are added to decrease autoantibody production. This patient lacks any evidence for microangiopathic hemolysis needed to establish the diagnosis of TTP such as schistocytes on the peripheral blood smear. ❌Choice C is not correct: Platelet transfusion is not generally indicated in patients with thrombocytopenia in the absence of trauma, surgery, or bleeding unless the platelet count decreases to less than 10-20 x109/L; the lower platelet count is more applicable to patients with chronic thrombocytopenia who are otherwise stable. The transfusion threshold for patients with bleeding, trauma, or both is approximately 50 x 109/L. This mildly symptomatic patient without overt bleeding does not require a platelet transfusion. ❌Choice D is not correct: ITP may be asymptomatic and discovered in the evaluation of thrombocytopenia as an incidental finding on a routine complete blood count. Patients with such incidentally discovered ITP and platelet counts greater than 30 x 109/L may be observed without the need for drug therapy or platelet transfusions. This patient's symptoms indicate more severe thrombocytopenia requiring treatment with glucocorticoids; platelet transfusions are not indicated for patients with ITP who are not actively bleeding. ✅Summarized Points: Platelet transfusion is not generally indicated in patients with thrombocytopenia in the absence of trauma, surgery, or bleeding unless the platelet count decreases to less than 10-20 x 109/L. Glucocorticoid treatment is indicated in patients with immune thrombocytopenic purpura and a platelet count less than 30 x 109/L.

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🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 19-year-old woman is evaluated for easy bruising of 2 weeks' duration. She has no other symptoms, and medical history is unremarkable. She takes no medications. On physical examination, vital signs are normal. Examination findings are limited to petechiae on the lower extremities and small, scattered ecchymoses. Laboratory studies show a platelet count of 15 x 109/L; the remainder of the complete blood count is normal. The peripheral blood smear is shown below. HIV and hepatitis C testing is pending.

🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. The most appropriate next step for this patient is to perform a stereotactic brain aspiration for a culture to guide antibiotic therapy. This patient has a brain abscess. Brain abscesses in immunocompetent patients are mainly caused by bacteria that enter the brain through contiguous spread (e.g., following otitis, mastoiditis, sinusitis, neurosurgical procedures, or cranial trauma) or hematogenous dissemination (e.g., infective endocarditis, bacteremia from a dental source). Headache is the most common presenting symptom, with the classic triad (fever, headache, focal neurologic deficit) seen in only approximately 20% of patients. The most common bacteria causing brain abscesses are streptococci (e.g., Streptococcus milleri), Staphylococcus aureus, Enterobacteriaceae, and anaerobes. The diagnosis is usually made by CT or MRI with contrast. Aspiration is especially recommended if the brain abscess is larger than 2.5 cm. The yield of blood cultures is low (around 25%): even with positive blood culture, aspiration should be performed for a large abscess. ❌Choice A is not correct: Intravenous vancomycin would be an appropriate empiric antibiotic selection for a patient with a brain abscess and evidence of endocarditis or intravenous drug use. However, these predisposing factors are not present and the best first management step is abscess aspiration, Gram stain, and culture. ❌Choice B is not correct: Treatment with intravenous penicillin and metronidazole is an appropriate empiric antibiotic selection for brain abscess secondary to odontogenic infection. However, the source of this patient's infection is most likely mastoiditis, and empiric antibiotic treatment with metronidazole plus a third-generation cephalosporin following abscess aspiration and Gram stain, while waiting for culture results, would be more appropriate. ❌Choice D is not correct: Performing a lumbar puncture is not indicated because it could place the patient at risk for herniation; additionally, the yield of cerebrospinal fluid (CSF) culture is low. The CSF culture can be positive if the abscess ruptures into the ventricles; this would be an indication for an emergent craniotomy and ventricular lavage. ✅Summarized Points: Brain abscesses in immunocompetent patients are mainly caused by bacteria that enter the brain through contiguous spread (e.g., following otitis, mastoiditis, sinusitis, neurosurgical procedures, or cranial trauma) or hematogenous dissemination (e.g., infective endocarditis, bacteremia from a dental source). Empiric antibiotic therapy for brain abscess should be guided by the source of infection and Gram stain, and directed therapy should be guided by culture results whenever possible.

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🧠 Case-based MCQ 🔸 #MCQ_32 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 41-year-old man is evaluated in the emergency department for new-onset seizures; he also reports a 2-week history of headaches and right ear drainage. Medical history is noncontributory, and he takes no medications. On physical examination, vital signs are normal. Purulent drainage is seen from the right external ear canal. The right mastoid is tender. CT scan of the head with and without contrast shows a 3-cm right temporal ring-enhancing lesion and a right otomastoiditis.

🧠 Case-based MCQ 🔸 #MCQ_31 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is C. Endophthalmitis is an inflammatory process (usually infectious) of the vitreous or aqueous humor of the globe. It is most frequently caused by recent surgery, but other etiologies include penetrating trauma (e.g. hammering steel, high-powered machinery) and hematogenous spread. Symptoms may include eye pain, decreased visual acuity, photophobia, discharge, loss of vision or headache. Physical examination reveals eyelid edema, scleral injection, chemosis and hypopyon (leukocyte exudate in the anterior chamber). Ophthalmology consultation is required and management is with intravitreal antibiotics. Systemic antibiotics have not been proven to add benefit to the treatment of postsurgical endophthalmitis. This varies from the treatment indicated for posttraumatic or endogenous endophthalmitis which includes both intravitreal and systemic antibiotics. ❌Choice A is not correct: Anterior uveitis is inflammation of the iris, ciliary body, or choroid. It is either autoimmune or secondary to trauma or infection. Patients have direct and often consensual photophobia (pain in the affected eye when light is shined in the unaffected eye), as well as scleral injection, tearing, and blurry vision. Slit lamp examination reveals white blood cells and proteinaceous transudate, termed “cells and flare.” ❌Choice B is not correct: Conjunctivitis is an inflammatory process of the palpebral or bulbar conjunctiva and can be viral, bacterial, fungal, allergic, toxic, or chemical in nature. The presence of a hypopyon is not characteristic of conjunctivitis and should prompt search for an alternative diagnosis. ❌Choice D is not correct: Orbital cellulitis is an infection of the post-septal orbital structures and excludes the globe. Therefore, it is clinically distinct from endophthalmitis. Signs include periorbital edema, erythema, warmth, and tenderness to palpation. Features consistent with orbital cellulitis include proptosis, pain with extraocular movement, abnormal pupil response, and decreased visual acuity. ✅Summarized Points: Postoperative endophthalmitis is the most common form of endophthalmitis and is almost always due to bacteria. It typically manifests itself within six weeks of surgery, with 75 percent of cases presenting within the first postoperative week. Patients usually present with pain and decreased visual acuity. Examination reveals swollen eyelids and conjunctiva, hypopyon, corneal edema, and infection. Treatment aggressiveness is based on the severity of visual acuity impairment: Hand motion vision or better: vitreous tap for culture and intravitreal antibiotics (vancomycin and/or ceftazidime) Light perception vision only or worse: admission, vitreous tap for culture, immediate vitrectomy, and intravitreal antibiotics (vancomycin and/or ceftazidime) to prevent loss of vision

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🧠 Case-based MCQ 🔸 #MCQ_31 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 66-year-old man presents to the emergency department with left eye pain, photophobia and blurry vision. His past medical history includes cataracts which were removed three days ago. His physical examination is shown below.

🧠 Case-based MCQ 🔸 #MCQ_30 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. The patient has a stress fracture of the tibia. It is caused by repetitive overload to the bone, usually from a change in training habits. The junction of the middle and distal thirds of the tibia is a common site. ❌Choice B is not correct: Chronic exertional compartment syndrome is caused by elevated pressure within an enclosed leg fascial compartment. There is no localized bony tenderness on examination. ❌Choice C is not correct: In overuse myositis, there is tenderness over the muscle-tendon units instead of along the tibia. ❌Choice D is not correct: Acute compartment syndrome is caused by a short-term increase in tissue pressure within a fascial compartment. Patients have severe pain, weakness of muscles in the compartment, and elevated compartment pressures. ❌Choice E is not correct: Patients with anterior tibialis tendonitis have pain over the dorsum of the feet. There is tenderness, and sometimes swelling, over the anterior tibialis tendon. ✅Summarized Points: Tibial stress fractures are common in athletes and nonathletes who suddenly increase their physical activity. Clinical features include pain, localized tenderness, and swelling.

🫀Cardiology Cases | #case5 A 58-year-old woman with diabetes and hypertension presented with altered mentation and weakness.

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