🧠 Case-based MCQ 🔸 #MCQ_49
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A 60-year-old man comes to the emergency department because of recurrent episodes of fatigue, palpitations, nausea, and diaphoresis over the past 6 months. The episodes have become more frequent in the last 2 weeks and he has missed work several times because of them. His symptoms usually improve after he drinks some juice and rests. He has had a 2-kg (4.5-lb) weight gain in the past 6 months. He has a history of bipolar disorder, hypertension, and asthma. His sister has type 2 diabetes mellitus and his mother has a history of medullary thyroid carcinoma. His medications include lithium, hydrochlorothiazide, aspirin, and a budesonide inhaler. His temperature is 36.3°C (97.3°F), pulse is 92/min and regular, respirations are 20/min, and blood pressure is 118/65 mm Hg. Abdominal examination shows no abnormalities. Serum studies show:

  Na+ 145 mEq/L
  K+ 3.9 mEq/L
  Cl- 103 mEq/L
  Ca+2  2.3 mmol/L
  Glucose 4.2 mmol/l
 

Which of the following is the most appropriate next step in diagnosis?

 

A. 24-hour urine catecholamine test
B. Dexamethasone suppression test
C. Water deprivation test
D. 72-hour fasting test
E. Corticotropin stimulation test

🧠 Case-based MCQ 🔸 #MCQ_49
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The Correct answer is D

Symptoms of spontaneous episodic hypoglycemia that resolve with glucose administration or rest should raise concern for the Whipple triad. If hypoglycemia is not present at the time of evaluation, a 72-hour fasting test is indicated to reproduce hypoglycemic symptoms in order to reach a definitive diagnosis. Glucose and hypoglycemic studies, including measurement of insulin, C-peptide, proinsulin, and β-hydroxybutyrate, should be obtained at the beginning of the test and then repeated every 6 hours until the serum glucose falls below 3.3 mmol/L (60 mg/dL). C-peptide and proinsulin are measures of the endogenous production of insulin and are decreased in hypoglycemia; hypoglycemia with elevated c-peptide and proinsulin levels should raise concern for an insulinoma.

❌Choice A is not correct:

A 24-hour urine catecholamine test is used to diagnose pheochromocytoma. This patient's episodic palpitations and diaphoresis may be associated with pheochromocytoma. However, because his symptoms improve with glucose administration, they are consistent with episodic hypoglycemia, which is atypical in patients with pheochromocytoma.

❌Choice B is not correct:

A dexamethasone suppression test is a screening test for Cushing syndrome, which could explain this patient's weight gain and fatigue. However, Cushing syndrome more commonly causes hyperglycemia, as opposed to the hypoglycemic episodes seen in this patient. Other clinical features associated with hypercortisolism include central and neck obesity, easy bruising, striae, and proximal muscle weakness, none of which are present.

❌Choice C is not correct:

A water deprivation test is used to diagnose diabetes insipidus (DI). Although this patient has a history of hydrochlorothiazide use, which is associated with nephrogenic DI, findings of polyuria, polydipsia, and hypernatremia would be expected.

❌Choice E is not correct:

A corticotropin stimulation test is a gold standard for diagnosing primary adrenal insufficiency, which can also manifest with hypoglycemia (due to decreased levels of cortisol), nausea, and fatigue. But adrenal insufficiency would typically lead to hypotension, whereas this patient is normotensive. Moreover, adrenal insufficiency is more commonly associated with weight loss, in contrast to this patient's weight gain.

✅Summarized Points:

This patient's episodes of palpitations, nausea, fatigue, and diaphoresis that improve with the consumption of sugar, should raise concern for episodic hypoglycemia.

🧠 Case-based MCQ 🔸 #MCQ_50
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A 43-year-old man comes to the physician because of nasal congestion and fatigue for 2 weeks. During this period, he has had fevers and severe pain over his cheeks. His nasal discharge was initially clear, but it has turned yellowish over the last couple of days. He has no visual complaints. He has been taking an over-the-counter nasal decongestant and acetaminophen without much relief. He has type 2 diabetes mellitus and hypertension. He underwent an appendectomy 23 years ago. He does not smoke or drink alcohol. His current medications include metformin, sitagliptin, and enalapril. He appears tired. His temperature is 38.5°C (101.3°F), pulse is 96/min, and blood pressure is 138/86 mm Hg. Examination shows purulent discharge in the nose and pharynx and normal-appearing ears. The left maxillary sinus is tender to palpation. Laboratory studies show:

  Hemoglobin 146 g/L (125–170)
  Leukocyte count 10.8 x 109/L (3.5–10.5)
  Platelet count 263 x 109/L (130–380)
  ESR 22 mm/hr
  Serum Glucose 6 mmol/L (3.3‐5.8)
 

Which of the following is the most appropriate next step in management?

A. Reassurance and follow-up in 1 week
B. Oral amoxicillin-clavulanate
C. CT scan of the paranasal sinuses
D. X-ray of the sinuses
E. Intravenous amphotericin B

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🧠 Case-based MCQ 🔸 #MCQ_50
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The Correct answer is B

This patient's symptoms for the last 2 weeks are suggesting acute bacterial rhinosinusitis (ABRS).Acute rhinosinusitis is the symptomatic inflammation of the nasal and sinus mucosa for <4 weeks. The majority of cases are due to viral upper respiratory pathogens (e.g., influenza virus, rhinovirus, adenovirus) and resolve within 10 days. However, 2%-10% of patients develop a secondary bacterial infection, most commonly with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.

Diagnosis of ABRS is typically made when ≥1 of the following is present:

Persistent symptoms/signs of rhinosinusitis for >10 days
Severe symptoms, high fever (>39 C [102.2 F]), purulent nasal discharge, and/or facial pain for >3 consecutive days
"Double sickening" - initial improvement of viral upper respiratory symptoms for 5-6 days, followed by clinical deterioration (e.g., worsened fever, headache, nasal discharge)
Patients with ABRS are usually treated with 5-7 days of oral amoxicillin-clavulanate to reduce symptom duration. Intranasal saline irrigation and analgesics are also often recommended

❌Choice A is not correct:

Reassurance and supportive treatment with antipyretics, analgesics, and nasal decongestants are usually sufficient in the treatment of patients with viral rhinosinusitis. However, because this patient has had symptoms for more than 10 days and a mucopurulent discharge suggestive of a bacterial infection, a different treatment is indicated.

❌Choice C is not correct:

A CT scan of the paranasal sinuses is not routinely performed in acute sinusitis. It may be used if complications (e.g., osteomyelitis, orbital cellulitis) occur, to rule out differential diagnoses (e.g., neoplasms), or preoperatively in patients with chronic sinusitis (e.g., surgical debridement of necrotic tissue and/or removal of anatomical obstructions).

❌Choice D is not correct:

X-ray of the sinuses is usually not recommended in acute sinusitis because it does not help to differentiate between etiologies, and findings from it rarely influence the choice of treatment.

❌Choice E is not correct:

Patients with poorly controlled diabetes mellitus (particularly with ketoacidosis) are at risk for rhino-orbital mucormycosis, which is treated with intravenous fungal medications (e.g., Amphotericin B). Manifestations typically progress rapidly and include fever, nasal necrosis, facial swelling, sinusitis, and headache. This patient is on antidiabetic mediations likely has well-controlled diabetes mellitus; he would be at low risk for mucormycosis.

✅Summarized Points:

Acute rhinosinusitis is most commonly due to viral pathogens and usually resolves within 10 days. Patients with persistent symptoms >10 days, severe symptoms, or deterioration after several days of improvement often have acute bacterial rhinosinusitis, which is usually treated empirically with 5-7 days of oral amoxicillin-clavulanate. 

🧠 Case-based MCQ 🔸 #MCQ_51
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A 17-year-old girl comes to the physician because of left lower abdominal pain for 1 day. She describes the pain as 6 out of 10 in intensity. Over the past 5 months, she has had similar episodes of pain that occur once a month and last 1 to 2 days. Menses occur at regular 28-day intervals and last 5 to 6 days. Menarche was at the age of 13 years, and her last menstrual period was 2 weeks ago. She has been sexually active with 1 male partner in the past and has used condoms inconsistently. She tested negative for sexually transmitted infections on her last visit 6 months ago. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient's symptoms?

 

A. CT scan of the pelvis
B. Diagnostic laparoscopy
C. Combined oral contraceptive pill
D. Reassurance
E. Pelvic ultrasonography

🧠 Case-based MCQ 🔸 #MCQ_51
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The Correct answer is D

Mittelschmerz is a common, benign phenomenon in women of reproductive age that is caused by follicular enlargement or rupture of the follicular cyst during ovulation, which leads to the release of small amounts of intraperitoneal fluid and subsequent peritoneal irritation. The pain is self-limited and usually subsides within hours to two days. Patients should be reassured and receive symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) as needed.

 

Choice A is not correct:

A CT scan of the pelvis can be considered in patients with pelvic pain and abnormal findings (e.g., tenderness to palpation) if the diagnosis remains uncertain after laboratory evaluation and other imaging modalities are unavailable or inconclusive. This is, however, not the case in this patient. Furthermore, due to the radiation exposure associated with a CT scan, it is not the preferred imaging method for the evaluation of a young patient's reproductive organs.

❌Choice B is not correct:

Diagnostic laparoscopy is indicated in patients with acute pelvic pain, if the diagnosis cannot be established with less invasive methods or if a surgical condition (e.g., appendicitis, ovarian torsion) is suspected. This patient has episodic pain and a normal abdominal and pelvic exam. Therefore, invasive diagnostic methods are not warranted at this time.

❌Choice C is not correct:

Combined oral contraceptive pills can be used in the management of a variety of gynecological conditions such as primary dysmenorrhea. Although primary dysmenorrhea also commonly presents with episodic pelvic pain in adolescent women with a normal physical examination, the pain typically occurs immediately before or at the onset of the menstrual period, rather than midcycle as in this patient.

❌Choice E is not correct:

Pelvic ultrasonography should be performed in postmenarchal adolescents with pelvic pain and adnexal mass or tenderness on examination to evaluate for ovarian cysts, ovarian torsion, and gynecological neoplasms. Although this patient complains of pelvic pain, her examination shows no abnormalities. Imaging is, therefore, not indicated at this time.

✅Summarized Points:

Recurrent midcycle, unilateral, lower abdominal pain in an adolescent girl is suggestive of mittelschmerz.

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🧠 Case-based MCQ 🔸 #MCQ_52
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A 54-year-old man has been in the intensive care unit for the past 10 days recovering from an exploratory laparotomy performed for a perforated duodenal ulcer. Postoperatively he developed pneumonia and sepsis. His thyroid hormone studies are abnormal. He does not have any previous history of thyroid disease. Physical examination of the thyroid gland is normal. Labs show:

  Thyroid-stimulating 2 µU/mL (0.4-5.0)
  Free thyroxine (T4), serum 60 nmol/L (60-145)
  Triiodothyronine (T3), serum 0.7 nmol/L (1.1-3.0)
 

Which of the following is the best next step in the management of this patient's thyroid abnormalities?

A. Repeat thyroid function tests in 8 weeks
B. Assay for antithyroid peroxidase antibody
C. Measure reverse T3 level
D. Start levothyroxine (T4) therapy
E. Start liothyronine (T3) therapy

🧠 Case-based MCQ 🔸 #MCQ_52
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The Correct answer is A

Euthyroid sick syndrome (ESS) encompasses a variety of alterations in thyroid physiology, the most common of which is termed "low T3 syndrome" and is thought to be primarily the result of decreased conversion of T4 to T3. T4 is produced exclusively in the thyroid gland, whereas T3 is produced mainly by peripheral conversion of T4 by deiodination. Factors in acute illness that inhibit peripheral deiodination include high endogenous cortisol levels, inflammatory cytokines (e.g., tumor necrosis factor), starvation, and certain medications (e.g., glucocorticoids, amiodarone). TSH and T4 levels are often normal in ESS, although they also may fall in severe or prolonged cases, and ESS may represent transient central hypothyroidism rather than a true euthyroid state.

The patient's results showing low T3, normal free T4, and normal TSH are consistent with ESS due to sepsis. ESS is considered by some experts to be an adaptive response to stress, and thyroid hormone supplementation in ESS has not been found to improve clinical outcomes.

❌Choice B is not correct:

Antithyroid peroxidase antibodies are a marker for chronic lymphocytic (Hashimoto) thyroiditis. They are also a predictor of progression to overt hypothyroidism in patients with subclinical hypothyroidism (normal T4, elevated TSH). They are not useful in the acute evaluation of patients with normal TSH.

❌Choice C is not correct:

Reverse T3 (rT3) is an inactive metabolite of T4. In severe nonthyroidal illness (e.g., ESS), clearance of rT3 is reduced and levels will be elevated. rT3 is primarily used in patients with low TSH to differentiate central hypothyroidism (low T4 leads to low rT3) from ESS.

❌Choice D is not correct:

Treatment should therefore be deferred unless abnormal thyroid function persists after the patient has returned to baseline health.

❌Choice E is not correct:

T3 has a very short half-life, and treatment with liothyronine (oral T3 supplement) produces wide fluctuations in blood levels. Therefore, liothyronine supplementation is not recommended for routine use.

✅Summarized Points:

Euthyroid sick syndrome is often characterized by low T3 levels with normal TSH and T4 in patients with acute illness. It is primarily due to decreased peripheral conversion of T4 to T3. Treatment is not recommended unless abnormal thyroid function persists after the patient has returned to baseline health.

🧠 Case-based MCQ 🔸 #MCQ_53
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A 47-year-old man comes to the emergency department with upper abdominal pain. He describes it as nagging and constant and rates it 6/10. The pain started 6 hours ago and was not relieved by over-the-counter antacids. It gets somewhat better when he sits up and leans forward. The patient has had 2 episodes of vomiting since the pain started. He smokes a pack of cigarettes daily. He drinks 4-6 cans of beer a day and several more on weekends. He does not use illicit drugs. The patient's temperature is 37.8 C (100 F), blood pressure is 100/70 mm Hg, pulse is 110/min, and respirations are 20/min. Abdominal examination shows mild epigastric tenderness without guarding or rebound. Electrocardiogram shows sinus tachycardia and T-wave inversion in leads V4-V6. Chest x-ray shows a small left-sided pleural effusion. Which of the following is the most likely diagnosis in this patient?

A. Intra-abdominal abscess
B. Mesenteric ischemia
C. Acute pancreatitis
D. Myocardial infarction
E. Peptic ulcer perforation

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🧠 Case-based MCQ 🔸 #MCQ_53
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The Correct answer is C

This patient's clinical features are most consistent with acute pancreatitis. Pancreatitis is characterized by:

Persistent, moderate-to-severe epigastric abdominal pain
Pain that radiates to the back and may be relieved by sitting up and leaning forward
Nausea and vomiting
Variable physical examination findings, which may range from minimal tenderness in the epigastric area to severe tenderness with guarding and rebound
Gallstones and chronic alcohol abuse account for about 75% of cases of acute pancreatitis. Nearly one-third of patients have chest x-ray abnormalities, including pleural effusions, atelectasis, elevated hemidiaphragm, or pulmonary infiltrates. These complications are often due to activated pancreatic enzymes (e.g., phospholipase, trypsin) and cytokines (e.g., tumor necrosis factor) that are released from the pancreas into the circulation and cause focal or systemic inflammation. Other potential complications include ileus, acute respiratory distress syndrome, and renal failure.


❌Choice A is not correct:

Infra-abdominal abscess often presents in a subacute or insidious fashion with fever, nausea, vomiting, and/or abdominal pain. This patient's acute symptom onset is less consistent with an abdominal abscess.

❌Choice B is not correct:

Mesenteric ischemia usually presents with severe acute periumbilical abdominal pain that is out of proportion to findings on physical examination. Risk factors include advanced age, diffuse atherosclerosis, valvular abnormality, cardiac arrhythmias (i.e., atrial fibrillation), and recent myocardial infarction (MI). Mesenteric ischemia would be less likely than pancreatitis in a patient of this age, even with atherosclerotic risk factors.

❌Choice D is not correct:

Acute MI (especially inferior MI) can occasionally present with nausea, vomiting, and epigastric pain. However, pain improving with sitting up or leaning forward is not consistent with MI, and abdominal tenderness is more characteristic of pancreatitis.

❌Choice E is not correct:

Patients with perforated peptic ulcer usually complain of sudden-onset epigastric pain, nausea, vomiting, and hematemesis, and may show peritoneal signs (e.g., guarding, rigidity, rebound tenderness) on physical examination. Upright chest x-ray will show free air under the diaphragm.

✅Summarized Points:

Acute pancreatitis is characterized by epigastric abdominal pain associated with nausea and vomiting. Alcohol abuse and gallstone disease are the most common causes. Potential complications include pleural effusion, acute respiratory distress syndrome, ileus, and renal failure.

🧠 Case-based MCQ 🔸 #MCQ_54
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A 7-month-old boy is brought to the physician for a well-child examination. He was born at 36 weeks' gestation and has been healthy since. He is at the 60th percentile for length and weight. Vital signs are within normal limits. The abdomen is soft and nontender. The external genitalia appears normal. Examination shows a single palpable testicle in the right hemiscrotum. The scrotum is nontender and not enlarged. There is a palpable mass in the left inguinal canal. Which of the following is the most appropriate next best step in management?

 

A. Ultrasound of the abdomen and pelvis
B. Exploration under anesthesia
C. Gondadotropin therapy
D. Orchidopexy
E. Reassurance

🧠 Case-based MCQ 🔸 #MCQ_54
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The Correct answer is D

Surgical correction of the undescended testis is recommended in boys 4–6 months of age because spontaneous descent is unlikely to occur after that. Early surgery optimizes normal testicular growth and maximizes fertility potential. Ideally, orchidopexy should be performed before 1 year of age. Since the infant has a palpable testis in the inguinal canal, orchidopexy is the surgical procedure of choice.

 

❌Choice A is not correct:

Since ultrasound of the abdomen and pelvis in a patient with a palpable undescended testis, as is the case here, rarely contributes further to the diagnosis and would thus not affect the course of treatment, it is not indicated in this patient. Even in patients with nonpalpable undescended testis, imaging studies would not be indicated because they do not eliminate the need for exploratory surgery.

❌Choice B is not correct:

Exploration under anesthesia is recommended in infants with cryptorchidism and nonpalpable testes in order to evaluate for the presence and location of the testes. A nonpalpable testis may be absent (blind ending cord structures indicate absent testes), atrophic, or located anywhere along the line of testicular descent (intra-abdominal or within the inguinal canal). Since the left testicle of this infant is palpable in the left inguinal canal, exploration under anesthesia is not necessary.

❌Choice C is not correct:

Gonadotropin therapy involves the administration of either human chorionic gonadotropin (hCG) or gonadotropin releasing hormone (GnRH) to stimulate gonadal steroidogenesis and promote testicular descent. However, the success rates of gonadotropin therapy are highly variable and there is a possibility of long-term adverse effects (e.g., low testicular volume, infertility) in infants who received gonadotropin therapy. Hormonal therapy with gonadotropins is not recommended for the treatment of cryptorchidism.

❌Choice E is not correct:

Reassurance for cryptorchidism is indicated in boys < 3 months of age since a majority of undescended testicles descend spontaneously by 3 months of age. Spontaneous descent most likely occurs at this time due to a gonadotropic hormone surge (FSH and LH) at around 60–90 days of life. However, spontaneous descent is unlikely to occur after 6 months of age and, therefore, reassurance is not appropriate because uncorrected cryptorchidism is associated with subfertility/infertility, testicular torsion, inguinal hernia, and testicular malignancy.

✅Summarized Points:

Spontaneous testicular descent should occur by 6 months of age.

🧠 Case-based MCQ 🔸 #MCQ_54
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A 16-year-old girl comes to the physician because she is worried about gaining weight. She reports that at least twice a week, she eats excessive amounts of food but feels ashamed about losing control soon after. She is very active in her high school's tennis team and goes running daily to lose weight. She has a history of cutting her forearms with the metal tab from a soda can. Her last menstrual period was 3 weeks ago. She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2. Physical examination shows enlarged, firm parotid glands bilaterally. There are erosions of the enamel on the lingual surfaces of the teeth. Which of the following is the most likely diagnosis?

 

A. Borderline personality disorder
B. Anorexia nervosa
C. Bulimia nervosa
D. Binge eating disorder
E. Body dysmorphic disorder