Case-based MCQ

#Case_8 〰〰〰〰〰〰〰〰〰〰〰 A 52-year-old male presents to your practice for the first time. He complains of recurrent severe headache and general malaise. He was diagnosed as hypertensive at the age of 30 years by his general practitioner, but he can not recall that he had any blood tests or investigations at that time, or since then. He is using captopril daily. His father and grandfather required hemodialysis from the age of 50 years. He has no urinary complaints.His blood pressure is 170/70 mmHg, pulse rate 67 per minute, temperature 37°C. On fundoscopy you note AV nipping and silverwiring. The rest of the examination is unremarkable except for bilateral slightly tender and enlarged kidneys. Bloods urgently sent shows a creatinine of 340 mcmol/L, random serum glucose is 4.6 mmol/L, serum potassium 4.8 mmol/L. What would be the next most appropriate investigation in this patient? a) No further investigation is required at this time, follow-up in 6 months. b) Repeat renal function in 1 month. Weekly blood pressure review, to ensure optimal control. c) Urgent chromosomal studies. d) Urgent intravenous pyelogram. e) Urgent renal ultrasound. 〰〰〰〰〰〰〰〰〰〰〰 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_7 #answer ✅ C 🔎 Explanation: This patient is presenting with a history of hypertension that is not responding to calcium channel blockers and has nonspecific symptoms like nausea and vomiting. The major clue to the cause of this patient’s condition is the laboratory tests results that show hypokalemia and mild hypernatremia. These electrolyte abnormalities are associated with hyperaldosteronism and given the history of resistant hypertension, the patient’s most likely diagnosis is Conn’s syndrome. Other aspects of clinical presentation that may be noted are weakness, abdominal distention, Ileus from hypokalemia (which can cause nausea and vomiting), findings related to complications of hypertension such as cardiac failure, hemiparesis due to stroke, carotid bruits, abdominal bruits, proteinuria, renal insufficiency, and hypertensive encephalopathy. ⚠ Liver cirrhosis (choice A) may cause abdominal distension and vomiting with portal hypertension and ascites and even hypokalemia. Hypokalemia in liver cirrhosis is usually multifactorial and may be associated with diuretics use, magnesium depletion in alcoholics, vomiting, and secondary hyperaldosteronism. However, this patient’s scenario doesn’t present risk factors of liver cirrhosis and primary aldosteronism is far more common than secondary aldosteronism. ⚠ Cushing's syndrome (choice B) can also cause hypertension and even hypokalemia with extremely high levels of cortisol. However, it would also cause findings often remarkable on physical examination such as facial plethora, hirsutism, buffalo hump, etc. ⚠ Pheochromocytoma (choice D) presents with episodes of severe hypertension due catecholamine secretion. Other classic 3 symptoms are diaphoresis, palpitations, and headaches. It may be associated with multiple endocrine neoplasia type II. Hypernatremia and hypokalemia are more likely to be seen with elevated aldosterone secretion than with increased catecholamine secretions. ⚠ Addison’s disease (choice E) is adrenal insufficiency and would cause the inverse of what is noted in this patient, with hypotension, hyponatremia, and hyperkalemia being the major findings. ✅Key point: Hyperaldosteronism such as seen in Conn's syndrome is associated with hypertension, hypernatremia, and hypokalemia. 〰〰〰〰〰〰〰〰〰〰〰 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_7 〰〰〰〰〰〰〰〰〰〰〰 A 37-year-old female presents to your department because complaining of nausea and vomiting for the last 3 days. She has also been having headaches. Physical examination is only remarkable for abdominal distension and BP 165/100 mmHg. Her BP has been high the last 3 months despite treatment with amlodipine that was started at 5 mg once a day and was later increased to 10 mg once a day. Comprehensive metabolic panel reveals: BUN: 7 mmol/L Creatinine: 80 micromol/L Calcium: 2.40 mmol/L Chloride: 96 mmol/L Bicarbonate: 31 mmol/L Glucose test: 5 mmol/L Potassium test: 2.7 mmol/L Sodium: 148 mmol/L Albumin: 42 g/L What is the most likely diagnosis? a) Liver cirrhosis b) Cushing's syndrome c) Conn's syndrome d) Pheochromocytoma e) Addison’s disease 〰〰〰〰〰〰〰〰〰〰〰 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_6 〰〰〰〰〰〰〰〰〰〰〰 A 67-year-old male comes to your office with severe periumbilical abdominal pain, vomiting, and diarrhea which began suddenly several hours ago. His temperature is 37.0°C (98.6°F), blood pressure 110/76 mm Hg, and respirations 28/min. His abdomen is slightly distended, soft, and diffusely tender; bowel sounds are normal. Other findings include clear lungs, a rapid and irregularly irregular heartbeat, and a pale left forearm and hand with no palpable left brachial pulse. Right arm and lower extremity pulses are normal. Urine and stool are both positive for blood on chemical testing. His hemoglobin level is 164 g/L and his WBC count is 25.3 x 10^9/L.The diagnostic imaging procedure most likely to produce a specific diagnosis of his abdominal pain is: a) Intravenous pyelography (IVP) b) Sonography of the abdominal aorta c) A barium enema d) Celiac and mesenteric arteriography e) Contrast venography 〰〰〰〰〰〰〰〰〰〰〰 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_5 #answer ✅ A 🔎 Explanation: The patient described in the clinical vignette most likely has petit mal or absence seizures. The characteristic EEG pattern for these seizures is the generalized symmetric 3-per-second spike and wave pattern. Petit mal or absence seizures are brief, repetitive episodes associated with alterations in consciousness, and the child is unaware of the episodes. There is usually no post-ictal period and the child quickly returns to the task at hand. Hypsarryhthmia is the characteristic EEG pattern seen in infantile spasm. The two other EEG patterns listed are not specific for any particular disorder. 〰〰〰〰〰〰〰〰〰〰〰 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_5 〰〰〰〰〰〰〰〰〰〰〰 A 6-year-old boy comes to your office for evaluation. He is not doing well in school and has a difficult time finishing his school work in the time allotted. His mother tells you that his teacher is constantly having to redirect him, and that at time he is staring off into space day-dreaming. When you question Mom, she has also noticed that he has recurrent episodes of brief staring spells. You examine the patient and order an EEG. What is the EEG likely to show? a) Generalized symmetric 3-per-second spike and wave pattern b) Generalized, diffuse slowing c) Hypsarrhythmia d) Localized spike and wave pattern 〰〰〰〰〰〰〰〰〰〰〰 #pediatrics 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_4 #answer ✅E 🔎 Explanation: De Quervain’s tenosynovitis is a cumulative movement disorder due to chronic overuse of the wrist and hand, involving the abductor pollicis longus and extensor pollicis brevis tendons, which share a common tendon sheath. Repeated forceful gripping, grasping, and wringing movements lead to thickening of the tendon sheath and subsequent inflammation and stenosis of the sheath as it passes over the distal radius. This can progress to fibrosis and loss of flexibility in the thumb in flexion. The condition is more common in pregnancy, after trauma, and with rheumatoid arthritis. The diagnosis is made by physical examination. There is tenderness over the radial styloid, and resisting thumb extension and abduction will elicit pain. Finkelstein’s test, folding the fingers over the thumb and gently passively deviating the thumb in an ulnar direction, will often cause such pain that the patient will lift the shoulder to prevent the examiner from stretching the tendon. ⚠→ Other diagnostic considerations include osteoarthritis of the first carpometacarpal joint (choice A), which may also cause pain over the radial styloid, and a positive Finkelstein’s test. If injecting the site with local anesthetic gives relief, an arthritic etiology can be excluded. ⚠→ Navicular (scaphoid) fracture (choice B) is caused by a fall or a direct blow to the wrist. The symptoms are pain on the thumb side of the wrist, swelling in that area, and difficulty gripping objects. ⚠→ Individuals with radial sensory nerve entrapment (choice C) will have paresthesias over the dorsum of the hand and a positive Tinel’s sign over the nerve in the mid-forearm, just distal to the belly of the brachioradialis muscle. Hyperpronation of the forearm reproduces these symptoms. ⚠→ Carpal tunnel syndrome (choice D) involves entrapment of the median nerve, causing pain in the thumb, index finger, long finger, and radial half of the ring finger. 〰〰〰〰〰〰〰〰〰〰〰 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_4 〰〰〰〰〰 A 28-year-old white female at 28 weeks gestation with an uncomplicated pregnancy presents with pain in the right wrist. She thinks it may be related to hand-washing several articles of clothing in a creek and hanging them on a line to dry while on a camping trip. The pain in the wrist radiates down the thumb and the radial side of the wrist. There is no history of trauma or penetrating injury. On examination there is tenderness when the right radial styloid is compressed. The pain is exacerbated by ulnar rotation of the wrist while the patient’s fingers are folded over the thumb. What is the most likely diagnosis? a) Osteoarthritis of the first carpometacarpal joint b) Occult navicular fracture c) Radial sensory nerve entrapment d) Carpal tunnel syndrome e) De Quervain’s tenosynovitis 〰〰〰〰〰〰〰〰〰〰〰〰〰〰〰 #orthopedics 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_3 #answer ✅D Explanation: Pseudomembrenous colitis is a very hot topic for the licensing exams! Our patient has developed severe watery diarrhea, abdominal pain, and fever while taking antibiotics for long duration. She is most likely suffering from pseudomembranous colitis caused by Clostridium difficile. After proper diagnosis with Cytotoxin assay of the stool, oral metronidazole is the antibiotics of choice for this condition. The antibiotics should be always stopped; however, discontinuing the antibiotics alone is not enough, the patient is complaining of severe symptoms. IV metronidazole is not as effective as oral metronidazole; we need the highest concentration of the drug in the colon! Oral vancomycin is a very effective medication against C. diff; however, it is an expensive drug and we do not want to use it too much in order to decrease the incidence of vancomycin resistant enterococci. 📎 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_3 An elderly female patient has been hospitalized for urosepsis. She was started on Piperacillin/tazobactam empirically. One week later, the patient recovered and was discharged on oral antibiotics. 6 days later, she developed severe watery diarrhea associated with abdominal colic and fever. Vitals reveal: pulse is 110/min, Temp is 39°C, BP: 120/70mm Hg and RR is 16/min. abdominal exam reveals tenderness in the lower abdomen with no evidence of peritoneal signs.CBC shows a WBC count of 16 x10^9/L. After adequate fluid rehydration, what is the most appropriate next step in the management of this patient? a) Give metronidazole and continue the antibiotics b) Stop the antibiotics c) Stop the antibiotics and give IV metronidazole d) Stop the antibiotics and give oral metronidazole e) Stop the antibiotics and give oral vancomycin #infectious_disease #gastroenterology ✍ https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_2 ✅A Pulmonary atelectasis is the most common cause of early postoperative fever and tachycardia after all classes of surgery

#Case_2 A thyrotoxic patient was subjected to subtotal thyroidectomy after she had been made euthyroid by medical treatment. The day after the operation her temperature is 39°C and her pulse rate 110/min and regular. She is most likely to be suffering from which one of the following? A.  Pulmonary atelectasis. B.  Thyroid crisis. C.  Pulmonary emboli. D.  Wound infection. E.  Septicemia. #pulmonology 👥 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ

#Case_1 ✅D

#Case_1 A 72-year-old man, who speaks no English, attends with his son who is able to explain that his father has just arrived in Australia as a refugee from Bosnia 1 month before. He teds you that his father is suffering from irritability, insomnia and nightmares connected with his experiences in the civil war. On further questioning, the father appears vague, concentrates poorly and cannot recall details of his recent experiences in Bosnia. The MOST LIKELY diagnosis is A. jet lag. B. culture shock. C. depression. D. post-traumatic stress disorder. E. dementia ✏#psychiatry 🌐 https://t.me/joinchat/De8XUlQZJDf4yxHQlHyFcQ