Case-based MCQ

🧠 Case-based MCQ 🔸 #MCQ_11 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 62-year-old man comes to the clinic due to shoulder pain that began after a fall 3 weeks ago. The pain is felt over the patient's lateral shoulder and often keeps him awake. It makes it difficult for him to lift anything overhead. Shoulder passive range of motion is normal; however, motion against any resistance is limited, and the patient is unable to maintain 90 degrees of abduction. There is weakness in abduction and external rotation. X-ray of the shoulder is normal.

🧠 Case-based MCQ 🔸 #MCQ_10 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. This patient likely has wet-type age-related macular degeneration (ARMD). She has a loss of central vision over a period of weeks to months and subretinal fluid and retinal detachment. Neovascularization is the underlying mechanism of wet ARMD and can be treated with thermal laser photocoagulation, photodynamic therapy, or intravitreal injection of a vascular endothelial growth factor inhibitor.   ❌Choice A is not correct: Decreased scleral elasticity is a proposed mechanism for dry ARMD. This patients presentation with unilateral visual loss over weeks to months and findings of subretinal fluid are more consistent with wet ARMD, which is due to neovascularization. ❌Choice B is not correct: Ischemic damage to photoreceptors is a proposed mechanism for dry ARMD. A patient with dry ARMD would have areas of retinal atrophy, depigmentation, and drusen on funduscopic examination, and not subretinal fluid as in this patient with wet ARMD. ❌Choice C is not correct: This patient has wet age-related macular degeneration secondary to neovascularization. This may lead to subretinal hemorrhages or fluid collections. Optic nerve atrophy is not involved in the acute presentation of this disease but is seen in glaucoma. ❌Choice E is not correct: Thromboembolism is unlikely to be the cause of this patient’s visual loss. Her presentation of worsening central vision over a month and funduscopic examination findings are more consistent with wet ARMD. Thromboembolism presents acutely. ✅Summarized Points: Neovascularization is the underlying mechanism of wet-type age-related macular degeneration, which may present with loss of central vision over a period of weeks to months, subretinal fluid, and retinal detachment.

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🧠 Case-based MCQ 🔸 #MCQ_10 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An 85-year-old woman with a 40-pack-year smoking history presents to her physician with declining vision in her left eye over the past month. She has trouble seeing her needlework or reading because there appears to be a dark circle in the center of her visual field. Her blood pressure is 140/90 mmHg, pulse is 90/min, respiratory rate is 14/min, temperature is 37C (98.6 F). On funduscopic examination, her left eye shows subretinal fluid and a localized exudative retinal detachment.

🧠 Case-based MCQ 🔸 #MCQ_9 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Cat saliva contains multiple different bacteria (e.g., Streptococcus, anaerobic bacteria); Pasteurella multocida in particular is found in nearly 50% of cat bites. Cat bites can be quite deep, and infections due to these organisms can progress to bone and/or joint infections. Antibiotic prophylaxis can reduce infection rates and is recommended for cat bites as wet as for any animal bite wounds near lymphatics or blood vessels, bites on the hand or close to joints and/or bones, bites requiring surgical intervention, or in immunocompromised patients. Amoxicillin/clavulanate is the preferred antibiotic for prophylaxis. A three-day to seven-day course of prophylactic antibiotics is likely adequate. Tetanus vaccination is recommended after an animal bite if it has been more than five years since the patient has been immunized. Wounds should be irrigated for debris removal and examined closely for secondary injury to bones or ligaments. Animal bite wounds should usually be left open to heal by secondary intention, although primary closure may be considered for bites on the face, where cosmetic concerns are more significant and blood flow is generally heavy. ❌Choice A and B are not correct: Antibiotics ineffective against P multocida include first-generation cephalosporins (e.g., cephalexin), penicillinase-resistant penicillins (e.g., dicloxacillin), and macrolides (e.g., erythromycin). ❌Choice C is not correct: In patients with penicillin allergy, doxycycline + metronidazole could be an alternative. ❌Choice D is not correct: Topical antibiotics, such as neomycin, have not been extensively studied for bite wounds and are not recommended. ✅Summarized Points: Prophylactic antibiotics are warranted following a cat bite with deep injury. Antibiotic coverage should include an agent that treats Pasteurella multocida. Amoxicillin/clavulanate is preferred as first-line therapy.

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🧠 Case-based MCQ 🔸 #MCQ_9 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Cat saliva contains multiple different bacteria (e.g., Streptococcus, anaerobic bacteria); Pasteurella multocida in particular is found in nearly 50% of cat bites. Cat bites can be quite deep, and infections due to these organisms can progress to bone and/or joint infections. Antibiotic prophylaxis can reduce infection rates and is recommended for cat bites as wet as for any animal bite wounds near lymphatics or blood vessels, bites on the hand or close to joints and/or bones, bites requiring surgical intervention, or in immunocompromised patients. Amoxicillin/clavulanate is the preferred antibiotic for prophylaxis. A three-day to seven-day course of prophylactic antibiotics is likely adequate. Tetanus vaccination is recommended after an animal bite if it has been more than five years since the patient has been immunized. Wounds should be irrigated for debris removal and examined closely for secondary injury to bones or ligaments. Animal bite wounds should usually be left open to heal by secondary intention, although primary closure may be considered for bites on the face, where cosmetic concerns are more significant and blood flow is generally heavy. ❌Choice A and B are not correct: Antibiotics ineffective against P multocida include first-generation cephalosporins (e.g., cephalexin), penicillinase-resistant penicillins (e.g., dicloxacillin), and macrolides (e.g., erythromycin). ❌Choice C is not correct: In patients with penicillin allergy, doxycycline + metronidazole could be an alternative. ❌Choice D is not correct: Topical antibiotics, such as neomycin, have not been extensively studied for bite wounds and are not recommended. ✅Summarized Points: Prophylactic antibiotics are warranted following a cat bite with deep injury. Antibiotic coverage should include an agent that treats Pasteurella multocida. Amoxicillin/clavulanate is preferred as first-line therapy.

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🧠 Case-based MCQ 🔸 #MCQ_9 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 27-year-old woman comes to the emergency department with a house cat bite. There was blood at the puncture site, which she promptly cleaned with water. The patient has no significant past medical history and received a tetanus booster 4 years ago. Physical examination demonstrates one deep puncture wound and one superficial laceration on the right arm.

🧠 Case-based MCQ 🔸 #MCQ_8 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is B. Paget’s disease history is a distraction in this case. Paget’s disease does not cause hypercalcemia unless the patient is immobilized because of poor control. The hypercalcemia in Paget’s is secondary to prolonged immobilization and not because of Paget’s disease. This patient is physically very active. This patient has an acute kidney injury, punched-out lesions on the skull radiograph, and hypercalcemia, which all point to multiple myeloma (MM).The diagnosis of MM is often suspected because of one (or more) of the following clinical presentations: Bone pain with lytic lesions discovered on routine skeletal films or other imaging modalities An increased total serum protein concentration and/or the presence of a monoclonal (M) protein in the serum or urine Systemic signs or symptoms suggestive of malignancy, such as unexplained anemia Hypercalcemia, which is either symptomatic or discovered incidentally Acute kidney failure with a bland urinalysis or rarely the nephrotic syndrome due to concurrent primary amyloidosis In patients with suspected MM or related disorders, appropriate initial screening tests include serum and urine protein electrophoresis along with immunofixation and a serum free light chain (FLC) assay. Serum and urine electrophoresis with immunofixation may reveal a monoclonal spike and be useful for confirmation of the diagnosis. ❌Choice A is not correct: Paget’s disease, on the other hand, is characterized by mixed osteolytic and osteoblastic phases. Alkaline phosphatase is typically elevated in patients with Paget's. The skull radiograph will show a “cotton wool” appearance caused by irregular areas of sclerosis (mixed lytic and blastic areas). ❌Choice C is not correct: Do not order a bone scan if you are suspecting MM. MM causes lytic lesions in the bone, but these lesions are not seen on the bone scans since there is no associated new bone formation. A skeletal survey is a more appropriate test for detecting lytic lesions. ❌Choice D is not correct: Although the pathology of MM involves a bone marrow biopsy, this is not the best next step in this scenario. This invasive procedure is reserved for clear indications (i.e., abnormal immunoelectrophoresis). ❌Choice E is not correct: A renal biopsy may be needed later if the myeloma workup is negative. ✅Summarized Points: Suspect multiple myeloma in an elderly patient with anemia, renal failure, and hypercalcemia.

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🧠 Case-based MCQ 🔸 #MCQ_6 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 77-year-old man with a history of hypertension, Paget’s disease, and peripheral vascular disease presents to you with complaints of chronic hearing impairment on the right side. He is otherwise very physically active. Physical examination is benign except for a right-sided sensorineural hearing deficit. A skull x-ray was obtained to evaluate Paget’s disease. Lab studies reveal:   Hemoglobin 97 gr/L (125–170)   Platelets     310x 109/L (130–380)   Leukocyte count 10 x 109/L (3.5–10.5)   Blood urea nitrogen   13 mmol/L (2.5‐8.0)   Creatinine 123 µmol/L (70‐120)   Ca+2 2.8 mmol/L (2.18‐2.58)   The patient is currently on alendronate for Paget’s disease.

🧠 Case-based MCQ 🔸 #MCQ_7 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. This elderly patient has delirium associated with acute urinary retention (AUR). In a patient with underlying benign prostate hyperplasia, sympathomimetics (e.g., pseudoephedrine) or antihistamines with anticholinergic properties (e.g., diphenhydramine) in cold medications can precipitate acute urinary retention. Urinary retention with increased bladder tension likely stimulates the sympathetic nervous system, resulting in catecholamines release and consequent delirium. Patients often have confusion and/or agitation but may not experience abdominal discomfort or specific urinary symptoms. Physical examination can demonstrate a distended bladder with discomfort on deep suprapubic palpation. The diagnosis of acute urinary retention can be confirmed with bladder ultrasound showing urine volume ≥300 mL. Patients with a highly suggestive history and physical examination can proceed directly to urinary catheterization as it is both diagnostic and therapeutic. Symptoms typically resolve rapidly after bladder decompression. ❌Choice A is not correct: This patient's abdominal examination findings are strongly suggestive of urinary retention with bladder distension; CT scan of the abdomen/pelvis may not be necessary as urinary catheterization may resolve his symptoms. ❌Choice B is not correct: Respiratory fluoroquinolones such as moxifloxacin can be used for outpatient treatment of community-acquired pneumonia. This patient has a normal cardiopulmonary examination and no evidence of fever, dyspnea, or pleuritic chest pain, making pneumonia less likely. ❌Choice C is not correct: Intravenous fluids can be helpful in dehydrated patients with delirium but would not address this patient's urinary retention. ❌Choice E is not correct: Lumbar puncture may be performed in patients with altered mental status and suspected meningitis or encephalitis. However, the absence of fever headache, and nuchal rigidity makes these less likely. ✅ Summarized Points: Acute urinary retention is an important cause of delirium in the elderly, although these patients often do not develop abdominal discomfort or specific urinary symptoms. Rapid resolution of symptoms typically occurs after bladder decompression.