⚠ 🔔 𝐒𝐀𝐕𝐄 𝐓𝐇𝐈𝐒 𝐋𝐈𝐒𝐓 𝐅𝐎𝐑 𝐀 𝐑𝐀𝐈𝐍𝐘 𝐃𝐀𝐘 ! ⤵


1. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗔𝗠𝗔𝗭𝗢𝗡 🌐

2. 𝗖𝗔𝗦𝗘 - 𝗕𝗔𝗦𝗘𝗗 𝗠𝗖𝗤𝗦 💯

3. 🇨🇦 𝗠𝗖𝗖𝗤𝗘 𝗣𝗥𝗘𝗣𝗔𝗥𝗔𝗧𝗜𝗢𝗡

4. 🩺 𝗘𝗗𝗟 𝗠𝗘𝗗𝗜𝗖𝗢𝗦 (𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 𝗔𝗡𝗗 𝗟𝗜𝗡𝗞𝗦)

5. 📚 𝗘𝗗𝗟 𝗣𝗛𝗔𝗥𝗠

6. 🏛 𝗢𝗡𝗟𝗜𝗡𝗘 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗦𝗖𝗛𝗢𝗢𝗟

7. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗚𝗘𝗥𝗠𝗔𝗡𝗬 🇩🇪

8. 𝗣𝗥𝗔𝗖𝗧𝗜𝗖𝗘 𝗜𝗡 𝗔𝗨𝗦𝗧𝗥𝗔𝗟𝗜𝗔 🇦🇺

9. 𝗠𝗕𝗕𝗦 & 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗜𝗧𝗔𝗟𝗬 🇮🇹

10. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗞 🇬🇧

11. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗨𝗦 🇺🇸

12. 𝗥𝗘𝗦𝗜𝗗𝗘𝗡𝗖𝗬 𝗜𝗡 𝗖𝗔𝗡𝗔𝗗𝗔 🇨🇦

13. 𝗙𝗥𝗘𝗡𝗖𝗛 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇫🇷

14. 𝗚𝗘𝗥𝗠𝗔𝗡 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗕𝗢𝗢𝗞𝗦 🇩🇪

15. 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗥𝗘𝗦𝗘𝗔𝗥𝗖𝗛 🎓

16. 📸 𝗗𝗘𝗥𝗠𝗔𝗧𝗢𝗟𝗢𝗚𝗬 𝗔𝗧𝗟𝗔𝗦

17. 🧩 𝗠𝗘𝗗𝗜𝗖𝗔𝗟 𝗠𝗡𝗘𝗠𝗢𝗡𝗜𝗖𝗦 (𝗟𝗘𝗔𝗥𝗡 𝗘𝗔𝗦𝗜𝗟𝗬)

⏳ Case-based MCQ | #Case_435
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A 39-year-old multigravida at 36 weeks gestation presents with a temperature of 40.0°C (104.0°F), chills, backache, and vomiting. On physical examination, the uterus is noted to be nontender, but there is slight bilateral costovertebral angle tenderness. A urinalysis reveals many leukocytes, some in clumps, as well as numerous bacteria.

⏳ Case-based MCQ | #Case_435 | #answer
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✅ D

Pyelonephritis is the most common medical complication of pregnancy. The diagnosis is usually straightforward, as in this case. Since the patient is quite ill, treatment is best undertaken in the hospital with parenteral agents, at least until the patient is stabilized and cultures are available. Escheria coli is the offending bacteria in approximately 75% of cases. About 15% of women with acute pyelonephritis are bacteremic.
Ampicillin plus gentamicin or a cephalosporin (choice D) (e.g., Ceftriaxone, Cefepime) is typically used.

⚠ The safety of levofloxacin (choice A) in pregnancy has not been established, and it should not be used unless the potential benefit outweighs the risk.

⚠ Oral nitrofurantoin (choice B) may induce hemolysis in patients who are deficient in G6PD, which includes approximately 2% of women.

⚠ Oral trimethoprim/sulfamethoxazole (choice C) is contraindicated late in pregnancy because they may increase the incidence of kernicterus.

⚠ Intravenous doxycycline (choice E) is contraindicated because administration late in pregnancy may lead to discoloration of the child’s deciduous teeth.

🔖 Key point:

Acute pyelonephritis in pregnancy is treated in hospital with intravenous antibiotics (e.g., Ampicillin plus gentamicin, or Ceftriaxone, or Cefepime) until the patient is afebrile for 24 to 48 hours and symptomatically improved.

⏳ Case-based MCQ | #Case_436
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A young male college student is brought to the emergency department as he was found vomiting blood during class. The patient looks pale and dehydrated. You start IV hydration and blood transfusion.

On questioning, the patient says that he has had similar episodes in the past and had been diagnosed with peptic ulcer. He further states that another physician had started him on omeprazole and he takes it regularly. His only other complaint is constipation. Endoscopy was performed in the ED and showed the presence of large ulcers in the distal duodenum and jejunum.

⏳ Case-based MCQ | #Case_436 | #answer
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✅ E

This patient most likely suffers from Zollinger-Ellison Syndrome (ZES). It is caused by a non–beta islet cell, gastrin-secreting tumor of the pancreas. The primary tumor is usually located in the duodenum, the pancreas, and abdominal lymph nodes, but ectopic locations have also been described (e.g., heart, ovary, gall bladder, liver, kidney). Excess gastrin secretion causes increased influx of acid into the stomach causing ulcerative disease. The most common clinical symptom of this disorder is recurrent gastric pain which does not resolve with PPI treatment or other peptic ulcer medications. The characteristics of these ulcers are that they are large (> 1-2 cm), recurrent even after Helicobacter pylori eradication, distal in the duodenum or even jejunum, and are multiple.

The most important initial diagnostic step is to have an endoscopy in the patient who has repeated gastric pain even after taking peptic ulcer medication. Once ulceration is confirmed on endoscopy, the possibility of ZES should be considered. Fasting serum gastrin is the best single screening test. Any PPI or H2 blocker treatment should be stopped before this test.
 
The best diagnostic test is persistent high gastrin level despite the infusion of secretin (choice E), which normally inhibits the gastrin realease. This test has high sensitivity and specificity.

⚠ Low gastric pH (choice A) is incorrect. Though gastric pH is certainly going to be low due to elevated secretion of gastric acid, it is not the most helpful finding to confirm ZES.

⚠ Endoscopic ultrasound (choice B) is an invasive process and not preferred. Endoscopic ultrasound is one of the newer methods for localizing gastrinomas. Its sensitivity is higher for pancreatic gastrinoma (40-75%) than for duodenal gastrinoma (50%).

⚠ CT scan (choice C) can be performed to localize the tumor and is useful for evaluation for metastatic disease. However, its sensitivity for primary tumor localization is only 50%, and frequently, tumors smaller than 1 cm are missed.

⚠ Increased gastrin level despite high gastric acid secretion (choice D) is an unreliable finding in a patient on PPI treatment. Elevated gastrin levels would only confirm a diagnosis of ZE syndrome if they persist after secretin injection.

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⏳ Case-based MCQ | #Case_437
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A 46-year-old man presents with a new itchy rash. Examination reveals multiple tender-to-touch erythematous-to-yellow dome-shaped papules on the extensor surfaces of his extremities (see image above), on his buttocks, and on his hands. A biopsy reveals foamy macrophages and dermal extracellular lipids.

⏳ Case-based MCQ | #Case_437 | #answer
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✅ D

Xanthomas typically affect adults and are usually a dermatologic sign of dyslipidaemias. Eruptive xanthomas, such as in this patient, have an abrupt onset. They typically present as crops of 1 to 5 mm erythematous to yellow papules with a red rim. The most common sites of involvement are the extensor surfaces of the extremities and buttocks. The papules may be tender and are usually itchy. Skin biopsy may be needed and shows the characteristic lipid-filled macrophages in the dermis.

Eruptive xanthomas like these are associated with elevated triglycerides (choice D), obesity, alcohol abuse, diabetes mellitus, and estrogen or retinoid therapies.

⚠ Dermatological manifestations of infective endocarditis (choice A) include Osler's nodes (painful, purple nodular lesions on the tips of fingers and toes) and Janeway lesions (painless erythematous macules on palms and soles).

⚠ Systemic vasculitis (choice B) is more commonly associated with palpable purpura.

⚠ Viral infection of the skin (choice C) is incorrect. The lesions of molluscum contagiosum (poxvirus) can be distinguished from xanthomas by the characteristic central umbilication of molluscum.

⚠ Urticaria (choice E) (hives) presents with migratory, well-circumscribed, erythematous, pruritic plaques on the skin (anywhere) with or without angioedema.

🔖 Key point:

Eruptive xanthomas typically present as crops of 1 to 5 mm erythematous to yellow papules with a red rim, on the extensor surfaces of the extremities and buttocks. They are associated with elevated triglycerides, obesity, alcohol abuse, diabetes mellitus, and estrogen or retinoid therapies.

⏳ Case-based MCQ | #Case_438
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A 63-year-old male with a history of myocardial infarction and atrial fibrillation diagnosed one year ago, presents to your department with fatigue, orthopnea, dyspnea on exertion, and occasional dyspnea at rest. He coughs and spits a pink, frothy sputum. He has a 30-year-history of type II diabetes mellitus and 15-year history of hypertension. He quit smoking six months ago and drinks alcohol occasionally.

On physical examination, his temperature is 37.9°C, BP 90/55 mmHg, pulse is 90 bpm, and respirations 24 bpm. Chest auscultation reveals pulmonary rales and S3 gallop. You also find evidence of hepatojugular reflex and pedal edema. The jugular venous pressure rises on inspiration. No muffled heart sounds are heard, and the patient denies chest pain. You quickly initiate an oxygen therapy through a plastic facemask, order an ECG, and also order necessary laboratory and radiological studies.

⏳ Case-based MCQ | #Case_438 | #answer
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✅ D

This patient most likely has both left and right heart failure and is presenting with symptoms of acute pulmonary edema and generalized edema. Other major conditions to consider in the differential diagnosis are acute respiratory distress syndrome and cirrhosis as they may cause some of the signs of edema seen in this patient. The patient’s history of many years of diabetes and hypertension with a myocardial infarction the previous year are major clues to a diagnosis of heart failure. An S3 gallop is a specific finding of congestive heart failure. Orthopnea and signs of pleural effusion point to left heart failure, while the hepatojugular reflex and the Kussmaul’s sign (jugular venous pressure rising on inspiration) point to right heart failure. 

Major findings of congestive heart failure that pertain to this case are:
• S3 gallop
• PCWP > 18 mmHg - Pulmonary capillary wedge pressure is a good approximation of left atrial pressure. In cardiogenic acute pulmonary edema, PCWP is usually greater than 25 mmHg; this is not the case in ARDS induced pulmonary edema. In ARDS, PCWP is less than 18 mmHg, and this feature can help us differentiate the two conditions. 
• Central venous pressure of 15 cm H2O or higher - The central venous pressure, also known as the right atrial pressure, describes the pressure in thoracic vena cava near the right atrium. Normal CVP is 0-14 cm H2O at the sternum and 8-15 cm H2O midaxillary line.
•  Ventricular hypertrophy - this could be diagnosed using echocardiography and ECG, even though ECG has less sensitivity and specificity when different criteria are combined, the sensitivity and specificity are increased. On the Sokolow-Lyon criteria, S in V1 + R in V5 or V6 (whichever is larger) ≥ 35 mm and R in aVL ≥ 11 mm would suggest left ventricular hypertrophy
• Kerley B lines on chest X-ray: they are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs.
 
Preload is the degree of tension (load) on the ventricular muscle when it begins to contract. The primary determinant of preload is end-diastolic volume. Drugs that decrease preload would decrease end diastolic volume by either decreasing intravascular volume or decreasing venous return through venodilation. Furosemide (a diuretic) and nitrates (venodilators) (choice D) work through this mechanism; therefore the correct answer is D. Nitrates also dilate arteries (reduce afterload).

⚠ Metoprolol and Diltiazem (choice A) is incorrect. Beta-blockers and calcium-channel blockers decrease contractility.

⚠ While hydrochlorothiazide (choice B) is a diuretic that decreases preload, doxazosin is an alpha1-inhibitor and decreases afterload; therefore choice B is incorrect.

⚠ Carvedilol (choice C) is a nonselective beta-blocker and lapha1-blocker. It decreases contractility and afterload, not preload.

⚠ Nifedipine (choice E) is a calcium channel blocker that promotes arterial vasodilation. It decreases afterload.

⏳ Case-based MCQ | #Case_439
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A 19-year-old female presents to your department with a complaint of absence of menses for the last four months. She reports that her menarche was at the age of 13 and even though the first two years the menses were irregular, she has had normal menstruation every 30 days after that initial period. She has normal secondary sexual development. Past medical history reveals elective abortion, two years ago.

Pregnancy test is negative. TSH and prolactin are within normal limits. Progesterone withdrawal test results in the absence of bleeding. The estrogen-progesterone challenge test is administered, but again there is no withdrawal bleeding.

⏳ Case-based MCQ | #Case_439 | #answer
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✅ B

This patient presents with a history of absent menses for 4 months; however, she reports that she has had regular menses for several years, which makes her condition secondary amenorrhea. This differs from primary amenorrhea, which is generally defined as the absence of menstruation by the age of 16 in a female with complete secondary sexual development or by the age of 14 in a female without secondary sexual development. Secondary amenorrhea is defined as the absence of menstruation for > 3 months in a patient who had regular menstruation previously or absence of menstruation for 9 months in a patient who had oligomenorrhea.
Major causes of amenorrhea are shown in the table below.


Since pregnancy is the most common cause of secondary amenorrhea, the initial step is to order a pregnancy test as described in the opening stem. In this patient, the test was negative. The following step is usually a pelvic ultrasound if primary amenorrhea is suspected to confirm the presence or absence of a uterus, in this patient's case, this is unnecessary because if she had menses previously, she obviously has a uterus. In patients with a previously well functioning uterus TSH and prolactin are ordered next, if both are normal, the progesterone challenge test follows as this allows evaluation whether amenorrhea is due to progesterone deficiency in a patient with normal estrogen levels. If this is the case, withdrawal bleeding is observed within 7 days. If this does not occur, the estrogen-progesterone challenge test is done. In a patient who has deficiency of both hormones, withdrawal bleeding is observed. The absence of withdrawal bleeding after both hormones are given, suggests outflow tract obstruction as the most likely cause of amenorrhea. In patients with secondary amenorrhea, Asherman disease is the most common cause of outflow tract obstruction. This is usually caused by intrauterine synechiae due to postpartum endometritis, an operative procedure involving the uterus, particularly curettage, elective abortion, or a missed abortion. 

Treatment of intrauterine adhesions is focused on two areas: first is the actual management of the adhesions, and second is preventing adhesion re-formation. Hysteroscopy is the treatment of choice with lysis of the adhesions under direct vision. Rigid hysteroscope is preferred for this procedure with operating channel of 3 to 7 Fr diameter. This allows for the use of flexible or semirigid scissors to lyse the adhesion usually at the junction of the adhesion with the endometrium and excise the tissue. Potential complications include uterine perforation, especially when there are lateral adhesions or they are very dense, making it difficult to dissect.

After hysteroscopic adhesions lysis, management goal should be the prevention of adhesions re-formation as recurrence rate has been estimated to be between 16% and 42%. The most preferred options are using a balloon catheter or adhesion barriers such as modifications of hyaluronic acid (choice B). 

At the conclusion of the procedure, a Foley-type catheter is placed in the uterine cavity and left in place. The length of time varies between 3 days and 14 days. It reduces the risk of reagglutination of the walls of the uterus. Similarly, the hyaluronic acid gel is beneficial in keeping the walls of the uterine cavity separated. Either option can be used to reduce the risk of recurrence.

⚠ Clomiphene (choice A) is known to induce ovulation in various secondary amenorrhea conditions such as polycystic ovarian syndrome, but it would be of no benefit after adhesion lysis treatment in Asherman's syndrome.

⚠ Maudsley method family-based therapy (choice C) is recommended for patients with anorexia nervosa for remission maintenance but would be of no benefit to this patient.

⚠ Bromocriptine (choice D) is used to treat pituitary microadenomas. It would be of no benefit to this patient.

⚠ Follitropin alfa (choice E) is a recombinant gonadotropin preparation used as a fertility medication to induce ovulation; it would be of no benefit to this patient because most likely cause of amenorrhea is outflow tract obstruction.

🔖 Key point:

In patients with intrauterine adhesions, the management goal, post adhesions lysis, should be the prevention of adhesions reformation as recurrence rate has been estimated to be between 16% and 42%. The most preferred options are using a balloon catheter or adhesion barriers such as modifications of hyaluronic acid.

⏳ Case-based MCQ | #Case_440
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An 18-month-old child is brought to your department by his parents because they noticed some blood in his stool for the last four days. They describe the color as bright red and the stool as having normal consistency. The frequency of passing stool is not increased. They report that he does not seem to fuss more than usual and they did not observe any fever. He eats a variety of foods, drinks apple juice, and milk.

Vital signs are normal, and on physical examination, the abdomen does not appear distended. On palpation, there is no mass or any particularly tender point. You suspect Meckel's diverticulum.