Case-based MCQ

🧠 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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🧠 Case-based MCQ 🔸 #MCQ_30 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 44-year-old woman presents complaining of lower left leg pain. Three weeks ago, she started intensive training in preparation for an upcoming 10-kilometer race. Her pain becomes more severe while she is running and intermittently occurs while she is walking. On physical examination, there is localized tenderness at the junction of the middle and distal portions of the tibia.

- Mild (minimal edema, itching) - Moderate (edema, itching, canal erythema) - Severe (canal closed due to severe edema, fever, lymphadenopathy)

🧠 Case-based MCQ 🔸 #MCQ_29 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. Otitis externa (OE)usually presents with ear pain, pruritus, and discharge. Examination findings of external otitis include tenderness when the tragus is pushed or the auricle is pulled, as well as erythema and swelling of the external auditory canal. The otoscopic examination should also assess for otitis media, tympanic membrane perforation, and signs of other diseases. OE often arises due to excess moisture and skin maceration or other factors that disrupt the skin-cerumen barrier. Risk factors for developing external otitis include swimming (or other water exposure), trauma (e.g., ear scratching, cotton swabs), occlusive ear devices (e.g., hearing aids, earphones), allergic contact dermatitis (e.g., due to shampoos, cosmetics), and dermatologic conditions (e.g., psoriasis). The most common causative organisms in OE include Staphylococcus aureus and Pseudomonas aeruginosa. The diagnosis is based on history and examination findings (e.g., pain with tragal pressure or traction on the auricle). The initial step in the management of OE is to gently clear cerumen and debris. A wire curette or cotton swab can be used under direct visualization, and any remaining material can be removed with irrigation using dilute hydrogen peroxide. Second step is treating inflammation and infection based on severity: For mild OE with minimal erythema and edema, topical acidifiers (e.g., acetic acid) for 7-10 days are usually adequate. For moderate OE with more significant pain, erythema, and edema (as in this patient), topical antibiotics (e.g., ciprofloxacin, neomycin/polymyxin) are recommended. For severe OE with intense pain, and the canal is completely occluded from edema. Fever, periauricular erythema, and regional lymphadenopathy, topical therapy, wick placement, and, oral antibiotics. Based on case presentation, this patient has moderate OE therefore topical antibiotics plus corticosteroid to reduce inflammation. In general, patients will report some change in symptoms within 36 to 48 hours after initiation of treatment, with a total symptom resolution of approximately six days. Patients should also be advised on preventive measures, including avoiding moisture in the ears, drying ears thoroughly after swimming or bathing, and using acidifiers at the onset of recurrent symptoms. ❌Choice A is not correct: Topical glucocorticoids decrease inflammation, resulting in relief of pruritus and decreased pain. Preparations used to treat external otitis include hydrocortisone, dexamethasone, and prednisolone They are generally well-tolerated. Symptomatic therapy alone, however, is not recommended and antimicrobial therapy should be given. ❌Choice B is not correct: Many patients with ear pain levels that are mild to moderate will have prompt relief from topical therapy. Those with pain will usually respond to oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen that can be started at the initial visit Opioid analgesics may be needed in patients with serious pain associated with severe disease. Again, symptomatic therapy alone, however, is not recommended and antimicrobial therapy should be given. ❌Choice C is not correct: Systemic antibiotics are reserved for invasive infection (malignant OE) or for immunosuppressed patients. Uncomplicated OE will respond to topical therapy. ❌Choice D is not correct: Wick placement is indicated for patients with severe otitis, especially if swelling of the canal prevents penetration of antibiotic solutions. The wick allows for topical medications to reach deeper into the swollen ear canal. This patient has moderate OE with a patent canal; a wick is not necessary. ✅Summarized Points: Otitis externa treated in two steps: 1st step → Cleaning cerumen and debris from the external ear canal 2nd step → treating inflammation and infection based on the severity