Case-based MCQ

⏳ Case-based MCQ | #Case_320 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ E Hyperbilirubinemia can occur in up to 60% of term newborns during the first week of life. Early guidelines on management of elevated bilirubin were based on studies of bilirubin toxicity in infants who had hemolytic disease. Current recommendations now support the use of less intensive therapy in term newborns with jaundice who are otherwise healthy. Phototherapy should be initiated when the bilirubin level is above 15 mg/dL for infants at age 29-­48 hours old, at 18 mg/dL for infants 49-­‐72, and at 20 mg/dL in infants older than 72 hours. Generally, this problem is not considered pathologic unless it presents during the first hours after birth and the total serum bilirubin rises by more than 5 mg/dL/day or is higher than 17 mg/dL, or if the infant has signs or symptoms suggestive of a serious underlying illness such as sepsis. Fortunately, very few term newborns with jaundice have serious underlying pathology. Physiologic jaundice follows a pattern, with the bilirubin level peaking on the third or fourth day of life and then declining over the first week after birth. Infants with multiple risk factors may develop an exaggerated form of physiologic jaundice, with the total bilirubin level rising as high as 17 mg/dL. Breastfed infants are at an increased risk for exaggerated physiologic jaundice because of relative caloric deprivation in the first few days of life. Compared with formula-­‐fed infants, those who are breastfed are six times more likely to experience moderate jaundice, with the bilirubin rising above 12 mg/dL. For breastfed newborns who have an early onset of hyperbilirubinemia, the frequency of feeding should be increased to more than 10 times per day. If the newborn has a decrease in weight gain, delayed stooling, and continued poor intake, then formula supplementation may be necessary. Breastfeeding should be continued to maintain breast milk production. Supplemental water or dextrose and water should not be given, as this can decrease breast milk production and may place the infant at risk for iatrogenic hyponatremia.

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⏳ Case-based MCQ | #Case_320 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A full-­term newborn, born 72 hours ago, is noted to be jaundiced. The pregnancy was uneventful and the delivery uncomplicated. The mother has type A‐positive blood and the child has type O-­positive. The child is breastfed and has lost 9 ounces from a birth weight of 8 lb. He is feeding for 20 minutes every 4 hours, and except for being icteric, has a normal examination. Laboratory evaluation reveals a total serum bilirubin level of 16 mg/dL (N 1.4-­‐8.7), with a conjugated bilirubin level of 1.0 mg/dL. His hemoglobin level is 17.8 g/dL (N 13.4-­‐19.8), his hematocrit is 55% (N 41-­‐65), and his reticulocyte count is 3% (N 3-­7). Appropriate management would include: a) Phototherapy b) Exchange transfer c) Blood cultures and antibiotic therapy d) Dextrose and water supplementation e) A recommendation to increase feedings to 10 times a day

⏳ Case-based MCQ | #Case_319 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D An acute onset and fluctuating course, along with an altered level of consciousness, illusions, and distractibility are consistent with delirium according to current diagnostic criteria. A normal neurologic and general physical examination, as well as memory and orientation problems, are common to both states.

⏳ Case-based MCQ | #Case_319 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 70 year old white female who has been your patient for 10 years had an emergency cholecystectomy 2 days ago. When you see her today while making rounds, she appears to be confused. When you ask her how she is, she just stares at your stethoscope, and then says, “That snake may bite you”. When you ask further questions she seems distracted and does not answer the question asked. At times, she closes her eyes and seems to fall asleep unless questioning. She does not know her daughter, who is in the room when you are. Which one of the following additional observations would help you differentiate delirium from dementia? a) Her pulse, blood pressure, temperature, and respiratory rate are all normal b) She cannot remember today’s date or the day of the month, interpret proverbs, name the president, or even remember your name c) Her neurologic examination is normal, except for the noted mental status changes d) Her mental status was normal before surgery, and on successive visits it fluctuates

⏳ Case-based MCQ | #Case_318 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D The Advisory Committee on Immunization Practices of the Centers for Disease Control recommends that for a clean, minor wound, tetanus toxoid should be given if the patient has not had a tetatnus toxoid shot within 10 years, with a total of at least 3 prior tetanus toxoid shots.

⏳ Case-based MCQ | #Case_318 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 72‐year‐old woman cuts herself with a clean knife. The wound is 4 cm long on the volar surface of the right forearm. A reliable history of which one of the following would make tetanus toxoid unnecessary at this time? a) Tetanus toxoid 1 year ago b) Tetanus toxoid 5 years ago c) Tetanus toxoid 11 years ago d) Tetanus toxoid 5 years ago and 3 tetanus toxoid shots over her lifetime e) Tetanus toxoid 11 years ago and 3 tetanus toxoid shots over her lifetime

⏳ Case-based MCQ | #Case_317 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C Magnetic resonance (MR) angiography is used to examine blood vessels in key areas of the body, including the: brain and kidneys. Physicians use the procedure to: identify disease and aneurysms in the aorta or in other major blood vessels. Detect atherosclerosis disease in the carotid artery of the neck, which may limit blood flow to the brain and cause a stroke. Identify a small aneurysm or arteriovenous malformation inside the brain and to detect injury to one of more arteries in trauma patients. In this patient an MR angiography of the cerebral vessels is indicated.

⏳ Case-based MCQ | #Case_317 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 An 80 year old woman suffers cervical spinal soft‐tissue injury in a motor vehicle accident with no skeletal or neurologic damage documented at the time. Three months later, she presents with sudden onset of homonymous right upper quadrantanopia. CT demonstrates a non‐hemorrhagic lesion in the left lower occipital lobe. Which imaging study would likely yield the most useful information? a) Carotid Doppler ultrasound b) Echocardiography c) MR angiography d) SPECT scan e) C-­spine plain films

⏳ Case-based MCQ | #Case_316 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C The factor that immediately points to dissection of the aorta is that the patient has Marfan syndrome. Cardiovascular problems are the most common causes of morbidity and mortality in such patients. Mitral valve prolapse often develops early, and are seen in more than 80% of adult Marfan syndrome patients. However, of most concern is disease of the ascending aorta, of which dilation of the aortic root is most serious, since a possibly fatal subsequent dissection and rupture can occur. One must always think acute aortic dissection for a Marfan patient with sudden onset of severe chest pain. The “tearing” quality of the pain also tends to point toward aortic dissection. The pain results from stimulation of nerve endings in the adventitia, and it begins abruptly, rapidly becoming severe.

⏳ Case-based MCQ | #Case_316 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 41-­year‐old man with Marfan syndrome, aortic insufficiency and mitral regurgitation comes to the emergency department because of severe substernal chest pain for the past 3 hours. He describes the pain as tearing in quality and radiating to the neck. One week earlier he experienced similar, but less severe, chest pain and treated himself with aspirin. Which of the following is the most likely underlying cause for his worsening symptoms? a) Acute bacterial endocarditis b) Acute myocardial infarction c) Dissection of the aorta d) Esophageal reflux with spasm e) Perforated peptic ulcer

⏳ Case-based MCQ | #Case_315 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ A The only clue in this history as to the etiology of the patient’s current issues is the daily consumption of barbiturate for a number of years. This daily intake will have resulted in a certain physical and psychological tolerance that, once the medication is stopped, would result in “withdrawal” symptoms and signs. In addition, the history is quite clear that during a prior attempt to lower the dosage, the patient reportedly suffered from seizures at that time. Therefore, the most likely etiology of the seizures in this case is barbiturate withdrawal.

⏳ Case-based MCQ | #Case_315 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 76 year old woman was brought to the hospital by her daughter‐in-­law following a fall at her home. On physical examination, she is dazed, has no memory of her fall and is unable to respond to any questions about her health. X-­ray films of the pelvis taken upon arrival at the hospital show a fracture of the left femoral neck. She is known to have taken butabarbital daily for many years and her daughter‐in-­law states that since the patient had a seizure several years ago during attempts to lower the butabarbital dosage, she assumed that the medication was for epilepsy. A bag of medications found at the patient's home contains multivitamins, an acetaminophen/codeine combination and naproxen. Uneventful surgical repair of the femur fracture is done the morning after admission. On the evening after the operation, the patient becomes combative, begins to hallucinate and has a brief, generalized tonic-­clonic seizure. Which of the following is the most likely cause for the change in her behavior? a) Barbiturate withdrawal b) Cerebral concussion c) Inadequate treatment of an underlying epileptic disorder d) Potentiation of morphine by phenytoin e) Warfarin side effect

⏳ Case-based MCQ | #Case_314 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B Peptic strictures (choice B) are the endstage result of chronic reflux esophagitis. Hiatal hernias are found in 10‐15% of the general population, and 85% of patients with peptic esophageal strictures. Patients may present with heartburn, dysphagia, odynophagia, food impaction, weight loss, and chest pain. Progressive dysphagia for solids is the most common presenting symptom. This may progress to include liquids. Atypical presentations include chronic cough and asthma secondary to aspiration of food or acid. ⚠ Dysphagia secondary to a Schatzki ring (choice A) is usually intermittent and nonprogressive. ⚠ Mallory‐Weiss Syndrome (choice C) patients usually present with upper gastrointestinal hemorrhage following excessive alcohol consumption, persistent retching and vomiting. ⚠ Benign esophageal strictures usually produce dysphagia with slow and insidious progression (ie, months to years) of frequency and severity with minimal weight loss. Malignant esophageal strictures (choice D) result in a rapid progression (ie, weeks to months) of severity and frequency of dysphagia and are associated frequently with significant weight loss. ⚠ Dysphagia for solids and liquids simultaneously should alert you to the possibility of a motility disorder such as achalasia (choice E) or collagen vascular disorders.

⏳ Case-based MCQ | #Case_314 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 67‐year-­old male with longstanding history of gastroesophageal reflux and hiatal hernia wants to be checked. He usually treats himself with oral antacids but lately they have not been as effective. For the past 6 months, he has been having some pain and a sticking sensation after swallowing solid foods, even a piece of bread. Each time he could not swallow, he was able to push down the food with water and did not find it necessary to seek medical attention. He denies any fever, change in bowel movements or weight loss. He has a 50-­pack year smoking history. What is the most likely diagnosis? a) Schatzki ring b) Peptic stricture c) Esophageal carcinoma d) Mallory-­Weiss Syndrome e) Achalasia

⏳ Case-based MCQ | #Case_313 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ D Complete androgen insensitivity syndrome is due to a congenital lack of androgen receptors. The patient never develops the Mullerian system since the gonad produces anti‐Mullerian hormone (AMH or MIF) form the Sertoli cells during organogenesis. Although the patient has a male level of testosterone and male levels of estrogen, since the androgens are not recognized, the breasts develop due to the presence of estrogens. Without androgens, these patients often have sparse to no sexual hair. As the gonad is an XY gonad, it must be removed to prevent the risk of malignant transformation; this is rare prior to puberty, so it can be removed after normal pubertal development has occurred (most common malignancy is a gonadoblastoma). ⚠A. One would see the effects of excess androgen: hair growth, virilization, etc. ⚠B. The vagina would be behind the imperforate hymen and not visible. If menses has begun, then there would be a bluish bulging mass (vagina full of old menstrual blood). ⚠C. A uterus is present in Turner syndrome. ⚠E. Although a uterus is absent in this syndrome, sexual hair should be present since there is no defect in either androgen production or in androgen receptors.

⏳ Case-based MCQ | #Case_313 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A concerned mother brings in her 16-­year-­old daughter because she hasn’t ever had a menstrual period. On exam, the girl is 5 feet 8 inches tall with mature adult breast development and scant to no pubic nor axillary hair. Vaginal exam is difficult and you are unable to identify a cervix nor palpate a uterus. The most likely diagnosis is: a) Androgenital syndrome b) Imperforate hymen c) Turner syndrome d) Complete androgen insensitivity syndrome e) Rokitansky Kuster Hauser syndrome

⏳ Case-based MCQ | #Case_312 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ B Hallucination-­like dreams occurring at sleep onset (hypnogogic hallucinations) or on waking (hypnopompic hallucinations) are often associated with narcolepsy. The most common presentation of narcolepsy is of excessive daytime fatigue and irresistible attacks of refreshing sleep. Cataplexy is also common, and is defined as the sudden loss of muscle tone, usually precipitated by intense emotions. ⚠A. This is a separate sleep disorder. ⚠C. Cogwheel rigidity occurs in parkinsonism. ⚠D. Loud snoring is characteristic of obstructive sleep apnea, which also presents with excessive sleepiness, but is not associated with cataplexy. ⚠E. Palpitations might be associated with syncope, which by definition involves loss of consciousness.

⏳ Case-based MCQ | #Case_312 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 A 23-­year-­old male student presents with a six-­month history of extreme daytime fatigue and repeatedly falling asleep in classes, on the bus, and other inappropriate places. On review of systems, he admits to sometimes “fainting” when he is upset. He describes these fainting spells as a sudden feeling of weakness, causing him to fall down, but with preserved consciousness throughout. On further questioning which of the following symptoms are also likely to be present in this patient? a) Somnambulism (sleepwalking) b) Hallucination-­like dreams c) Cogwheel rigidity d) Loud snoring e) Palpitations

⏳ Case-based MCQ | #Case_311 | #answer 〰〰〰〰〰〰〰〰〰〰〰〰〰〰 ✅ C If a woman is nonimmune to rubella, then the risk of congenital rubella syndrome is 20% for a primary infection in the first trimester. Cataracts, patent ductus arteriosus, and deafness are the most common findings. In this case, she is coming to you within a few days of having an exanthem; if the patient’s rubella IgG shows immunity, then the rash was not due to rubella. If she is rubella IgG negative, then obtain an IgM titer. ⚠A. Rubella infection in an adult can be a mild viral exanthem. This finding should never be ignored in a pregnant female. ⚠B. No diagnosis of the condition has been made at this time. ⚠D. Streptococcal pharyngitis is usually associated with a fever, lymphadenopathy, and pharyngeal symptoms. ⚠E. Toxoplasmosis is not associated with a maculopapular rash.