Case-based MCQ

A 6-year-old girl is brought to the physician for a routine examination. She has no complaints and is enjoying first grade. Her favourite drink is orange juice, and she enjoys chips and cookies. The girl has no medical problems and takes no medications. The review of the systems is negative. Several maternal relatives are obese, but no family members have heart disease or stroke. There are no smokers in the home. Body mass index (BMI) was previously in the 80th percentile but is now in the 99th percentile. Vital signs are normal. Examination reveals central adiposity. No acanthosis nigricans is seen. Which of the following is the best next step in the management of this patient? A. Serum lipid panel B. 12-lead electrocardiogram C. Liver ultrasound D. No testing indicated at this age E. Serum thyroid function test

The correct answer is B. The patient in this question is presenting with acute cholecystitis. He is presenting with fever, right upper quadrant pain after a fatty meal that radiates to the right scapula, and positive Murphy sign (pain on palpation in the right upper quadrant with cessation of inspiration). Additional nonspecific findings include vomiting, leukocytosis, and mild elevation in transaminases. Acute cholecystitis usually arises from gallstone formation that obstructs the cystic duct. The symptoms occur after eating a fatty meal because the fat stimulates gallbladder contraction, and in the presence of cystic duct obstruction, this leads to colicky pain. Infection results from stasis that contributes to bacterial growth in the gallbladder. ⚠Choice A is not correct: Alcoholic liver disease does not present with this constellation of symptoms. ⚠Choice C is not correct: Similar to common bile duct obstruction, obstruction from a carcinoma of the head of the pancreas would cause severely elevated alkaline phosphatase levels and would normally present with weight loss and painless jaundice. ⚠Choice D is not correct: Importantly, alkaline phosphatase is not elevated in this patient with acute cholecystitis. Assume if laboratories are not shown, they are normal. If it were elevated (in addition to total bilirubin and direct bilirubin), this might indicate common bile duct obstruction in the setting of jaundice (choledocolithiasis). ⚠Choice E is not correct: Pancreatitis should definitely be ruled out with a lipase check, but pain typically is only epigastric in nature and radiates to the back. Summarized Points: acute cholecystitis presents with fever, right upper quadrant pain after a fatty meal that radiates to the right scapula, and positive Murphy sign (pain on palpation in the right upper quadrant with cessation of inspiration). Usually caused by gallstone formation that obstructs the cystic duct.

A 49-year-old female presents to the emergency department with complaint of severe epigastric and right upper quadrant (RUQ) abdominal pain. Her symptoms started 3 days ago but have progressively worsened over the past 12 hours. Her symptoms are worse with meals. She has had two episodes of vomiting in the past 12 hours and is nauseous currently. Past medical history is significant for diabetes, osteoarthritis, and hypertension. Her blood pressure is 146/80 mmHg, pulse is 110/min, respiratory rate is 16/min, temperature is 39 C (102.3 F). On physical examination, there is severe right upper quadrant pain on deep palpation, most pronounced on palpation after deep inspiration. Bowel sounds are diminished. The patient is lying on her side holding an emesis basin. Which of the following is causing this patient’s disorder? A. Alcoholic liver disease B. Gallstone obstruction in the cystic duct C. Obstruction from carcinoma of the head of the pancreas D. Gallstone obstruction in the common bile duct E. Pancreatic inflammation

This patient with known asthma has recurrent exacerbations with fever and expectoration of dark brown mucus, which is suggestive of allergic bronchopulmonary aspergillosis (ABPA). Patients may experience additional systemic symptoms (e.g., anorexia, malaise, or weight loss) or have hemoptysis. ABPA is caused by hypersensitivity to bronchial colonization by Aspergillus fumigatus. It occurs more commonly in asthmatics and patients with cystic fibrosis. Proteolytic enzymes and mycotoxins induce an intense inflammatory reaction that can eventually cause bronchiectasis and fibrosis. Early diagnosis is important as the onset of bronchiectasis is associated with poor outcomes. Diagnosis is based on clinical and radiographic features and immunologic testing. Immediate cutaneous hypersensitivity to skin prick testing is a characteristic finding. If negative, intradermal reactivity may be tested for confirmation. A negative skin prick test and intradermal reactivity excludes the diagnosis. If positive, immunologic testing is performed. High-resolution CT characteristically shows infiltrates, central bronchiectasis, and mucus-filled bronchi (mucoid impaction). A positive bronchodilator response on pulmonary function tests is only seen in about 50% of patients. Treatment involves a combination of corticosteroids and antifungal agents (e.g., itraconazole). ⚠ Choice A is not correct: Bronchoalveolar lavage specimens may show Aspergillus species. However, the test is more invasive and is usually not indicated. ⚠ Choice B is not correct: Common variable immunodeficiency (CVID) can present with recurrent pulmonary infections and bronchiectasis, but it does not cause recurrent asthma exacerbations responsive to steroids. ⚠ Choice C is not correct: Induced sputum for Pneumocystis jirovecii may be helpful to diagnose Pneumocystis pneumonia in an asthmatic taking high-dose chronic oral steroids. However, this patient was only on intermittent steroids. ⚠ Choice D is not correct: Patients with tuberculosis may also present with chronic cough and constitutional symptoms, but these are progressive (not intermittent) and do not respond to steroids. Summarized Points: Allergic bronchopulmonary aspergillosis is a hypersensitivity reaction to Aspergillus that may colonize the airways of patients with asthma and cystic fibrosis. It presents with worsening asthma symptoms, fever, fleeting infiltrates, pleuritic chest pain, and peripheral eosinophilia. The first step in diagnosis is Aspergillus skin testing. If left untreated, the disorder can result in bronchiectasis with a poor prognosis.

A 36-year-old life-long asthmatic has repeated episodes of asthma exacerbation accompanied by fever and thick brownish sputum that respond to oral prednisone therapy. His leukocyte count is 8,500/µL with 15% eosinophils. Chest x-ray reveals bronchiectasis on the left side. Which of the following is the best next step in the management of this patient? A. Bronchoscopy with bronchoalveolar lavage B. Immunoglobulin levels to evaluate for immunodeficiency C. Induced sputum for Pneumocystis jirovecii D. Purified protein derivative test E. Aspergillus skin testing

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The correct answer is A. Supraventricular tachycardias (SVT) include paroxysmal, reentry, or preexcitation tachycardias. Reentry SVTs include AV nodal reentry (AVNRT), atrioventricular reentry, or atrial reentry. Reentry circuits require the presence of at least two different conduction pathways with differential refractory times. It is characterized by an abrupt onset and termination of tachycardia, that distinguishes it from sinus tachycardia, which has gradual changes in rate. It is precipitated by a premature atrial or ventricular contraction or hyperadrenergic state. Other triggers include hyperthyroidism and stimulants, including caffeine, drugs, and alcohol. This patient has supraventricular tachycardia (SVT) likely related to atrioventricular nodal reentrant tachycardia (AVNRT) and he has no concerning symptoms. The ECG shows a regular, fast rhythm with absent P waves and a narrow QRS complex. Unstable patients require immediate synchronized cardioversion. Stable patients, such as the patient above, should first undergo vagal maneuvers. Some common vagal maneuvers include holding your breath and bearing down (Valsalva maneuver), coughing, gagging, and immersing your face in ice-cold water. If vagal maneuvers are unsuccessful, adenosine is used both diagnostically and therapeutically. Adenosine transiently blocks the AV-node and allows the circuit to “reset.” ⚠Choice B is not correct: Adenosine is very short acting and can be used if vagal maneuvers fail to terminate the arrhythmia. ⚠Choice C is not correct: Metoprolol would also be considered if the above measures failed. ⚠Choice D is not correct: Digoxin would also inhibit the AV node but has more potential side effects than the other medications and is rarely used for this purpose. ⚠Choice E is not correct: Cardioversion would be reserved for hemodynamic instability including hypotension, heart failure, or angina. Summarized Points: This patient has SVT likely related to AVNRT and he has no concerning symptoms. The initial attempts at termination should use vagal maneuvers such as the Valsalva maneuver.

A 40-year-old man is evaluated for palpitations in the emergency department. He has had these symptoms several times over the past year but this episode is worse. He denies any associated chest pain, lightheadedness, or syncope. He denies any history of medical problems and takes no medications. Examination reveals an adult male in no significant distress. Cardiac examination is significant for regular tachycardia with no jugular venous pressure elevation. Lungs are clear without crackles or wheezing. There is no lower extremity edema. ECG shown below. What is the best intervention at this point? A. Valsalva maneuver B. Adenosine C. Metoprolol D. Digoxin E. Cardioversion

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- MCCQE Part I Full-length Preparatory Examination (PE) Qbank (April 2023) (PDF) 🇨🇦 https://mcc.ca/examinations/mccqe-part-i/preparation-resources/preparatory-products/ Contents included: - 210 Multiple-Choice Questions (MCQs) - 38 Clinical Decision-Making cases (CDMs) - Full answer key including rationales and references 📲➕ Contact Admin: @Mediccounts

🧩 Medical Mnemonics Crigler-Najjar and Gilbert have problems with CoNjuGation of bilirubin while Dubin-Johnson and Rotor have a defective DooR for secretion of bilirubin. #in_a_tweet #pediatrics 〰〰〰〰〰〰〰〰〰〰〰 ©Medical Mnemonics