🧠 Case-based MCQ 🔸 #MCQ_1
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A 38-year-old African-American female presents to your office with a 4-month history of dry cough, shortness of breath, and fatigue. She has a 10-pack-per-year smoking history. Her blood pressure is 132/79 mmHg, pulse is 74/min, respiratory rate is 16 /min, temperature is 36.7 C (98.2 F). Pulse oximetry shows 96% O2 saturation on room air. Examination reveals crackles bilaterally in the lower lung fields. There is no wheezing. She has two tender erythematous nodules on her right leg measuring approximately 3 x 3 cm. Chest X-ray shows bilateral hilar adenopathy.

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🧠 Case-based MCQ 🔸 #MCQ_1
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✔️The correct answer is E.

Sarcoidosis is a multisystem inflammatory disease of unknown etiology that manifests as noncaseating granulomas, predominantly in the lungs and intrathoracic lymph nodes. Incidence peaks in persons aged 25-35 years. A second peak occurs for women aged 45-65 years. Male-to-female ratio is approximately 1:2. Morbidity, mortality, and extrapulmonary involvement are higher in affected females.

Approximately 5% of cases are asymptomatic and incidentally detected by chest radiography. Systemic complaints of fever, anorexia, and arthralgias occur in 45% of cases. Pulmonary complaints — dyspnea on exertion, cough, chest pain, and hemoptysis (rare) — occur in 50% of cases.

The patient’s clinical picture is consistent with possible sarcoidosis. Tissue biopsy showing noncaseating granulomas along with ruling out other diseases is essential for the diagnosis.One of the major risk factors of sarcoidosis is being African American.

❌Choice A is not correct:

Serum calcium will be elevated in a subset of sarcoid patients but this is not sensitive enough to make the diagnosis.

❌Choice B is not correct:

CT chest will yield more information in regard to lung imaging but will not confirm a diagnosis.

❌Choice C is not correct:

Angiotensin-converting enzyme level is not sensitive enough to confirm a diagnosis.

❌Choice D is not correct:

Biopsy of a leg lesion that is easily accessible will reveal inflammation as the patient has findings consistent with erythema nodosum; however, this will NOT show noncaseating granulomas so this will not confirm a diagnosis of sarcoid.

✅ Summarized Points:

Diagnosis of sarcoidosis requires biopsy in most cases. If therapy is to be given, tissue confirmation is essential. Standard transbronchial needle aspiration allows successful lymph node sampling in nearly all patients with sarcoidosis and is associated with high diagnostic yield regardless of disease stage.

🧠 Case-based MCQ ✅ #MCQ_2
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A 40-year-old man with a 3-year history of celiac disease comes to the physician with fatigue, low-grade fevers, abdominal pain, and diarrhea for 3 months. He was symptom free for 2 years when he followed a strict gluten-free diet. However, in the past year, he developed symptoms twice due to poor dietary compliance. His temperature is 38.3° C (101° F), blood pressure is 110/80 mm Hg, and pulse is 80/min. The abdomen is soft but tender in the periumbilical area. There is no rebound tenderness or rigidity. Rectal examination shows dark stools positive for blood. Laboratory results are as follows:

  Hemoglobin 99 g/L
  Mean corpuscular volume 70 fL
  Platelets 280,000/µL
  Leukocytes 9,800/µL
  Blood urea nitrogen 4 mmol/L (2.5-8.0)
  Creatinine 70 µmol/L (70-120)
  Albumin 31 g/L (35-50)
  Erythrocyte sedimentation rate 87 mm/h (<15)

🧠 Case-based MCQ 🔸 #MCQ_2
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✔️ The correct answer is E.

This patient's presentation (3 months of fevers, abdominal pain, melena, and diarrhea) is concerning for intestinal lymphoma, specifically enteropathy-associated T cell lymphoma (EATL). This is a rare and aggressive lymphoma that is seen more commonly in celiac disease patients with poor dietary compliance. Patients present with abdominal pain, hepatosplenomegaly, ascites, duodenal masses, B symptoms (e.g., fever, night sweats, and weight loss), and gastrointestinal bleeding. Some patients may present with obstruction or perforation. The tumor is commonly located in the proximal jejunum and less frequently in the stomach, small bowel, or colon. A strict gluten-free diet also appears to reduce the incidence of EATL.

EATL should also be suspected in patients with refractory sprue despite good dietary compliance and failure of treatment with glucocorticoids. It may also be helpful to test for underlying celiac disease in all patients with a T cell lymphoma with or without gut involvement as celiac disease is undiagnosed in many individuals. However, EATL is uncommon in individuals diagnosed with celiac disease at a young age (< 33 years). Diagnosis is confirmed on pathology of resected tumor, which demonstrates multiple jejunal ulcers often with gut perforation. EATL has a poor prognosis and treatment consists of combination chemotherapy used for other aggressive T cell lymphomas.

❌Choice A is not correct:

Clostridium perfringens usually presents with self-limited watery diarrhea and enteritis necroticans (hemorrhagic necrosis of the jejunum), both of which would not cause symptoms for 3 months.

❌Choice B is not correct:

Poor patient compliance with a gluten-free diet is the most common cause of recurrence of bowel symptoms in celiac disease. However, poor compliance and disease recurrence usually do not cause persistent fever, as seen in this patient.

❌Choice C is not correct:

Patients with celiac disease may have coexisting pancreatic insufficiency. However, bloody stools and fever are not typically seen in chronic pancreatic insufficiency.

❌Choice D is not correct:

Refractory sprue is defined as persistent intestinal pathological changes despite a strict gluten-free diet for 12 months. However, this would not explain this patient's B symptoms or bloody diarrhea.

✅ Summarized Points:

Enteropathy-associated T cell lymphoma is an aggressive lymphoma commonly seen in patients with celiac disease and poor dietary control. Patients present with abdominal pain, B symptoms, hepatosplenomegaly, ascites, bowel obstruction/perforation, and/or gastrointestinal bleeding. Diagnosis is confirmed by pathology of resected tumor. Prognosis is poor, and treatment involves combination chemotherapy.

🧠 Case-based MCQ ✅ #MCQ_3
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A 48-year-old woman presents to the clinic with dysphagia, diarrhea, and facial flushing. Physical examination reveals a solitary thyroid nodule and cervical lymphadenopathy. Laboratory studies show elevated serum calcitonin and elevated carcinoembryonic antigen levels.

🧠 Case-based MCQ 🔸 #MCQ_3
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✔️The correct answer is B.

The production of calcitonin and carcinoembryonic antigen (CEA) is characteristic of medullary thyroid cancer, and these are useful markers for diagnosis and follow-up. Patients typically present with dysphagia, diarrhea, facial flushing, and a solitary thyroid nodule. Medullary thyroid cancer is a neuroendocrine tumor of the parafollicular or C cells of the thyroid gland. The diagnosis of medullary thyroid cancer is made after a fine-needle aspiration biopsy of the thyroid nodule. Treatment is with the removal of the affected thyroid lobes, and for nodules that are 4 cm or larger, diagnostic lobectomy is recommended over fine-needle aspiration.


❌Choice A and C are not correct:

Although most cases of medullary thyroid cancer are acquired sporadically, genetic inheritance can be seen in cases of multiple endocrine neoplasia type 2 (MEN2). MEN2 is associated with medullary thyroid cancer, pheochromocytoma. and primary parathyroid hyperplasia. Therefore, additional testing for coexisting tumors such as biochemical evaluation for pheochromocytoma and germline RET mutation testing is recommended.

❌Choice D is not correct:

Once medullary thyroid cancer is confirmed with fine-needle aspiration biopsy, further evaluation should include ultrasonography of the neck to look for lymph node involvement.

✅Summarized Points:

Thyroid Carcinoma physical exam will show a solitary hard nodule. Labs will show normal thyroid function, cold nodule. Initial Diagnosis is ultrasound, and Confirmation is Fine-needle biopsy.

🔴Papillary: most common, least aggressive
🔴Anaplastic: least common, most aggressive
🔴Medullary: associated with MEN2, calcitonin can be used as a tumor marker

🧠 Case-based MCQ ✅ #MCQ_4
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A 34-year-old man is evaluated during a follow-up visit after passing his third calcium oxalate kidney stone in 4 years despite maintaining a high urine volume. He has no other medical problems. His only medication is potassium citrate, which was initiated after passing the most recent stone. He drinks 4 cups of coffee daily and typically eats meals at fast-food restaurants. Physical examination findings, including vital signs, are normal. Laboratory studies:

 24-Hour urine studies
   Volume 2600 mL
   pH 6.5
   Calcium 7.3 mmol (2.5–7.5)
   Citrate 9 mmol (0.6–6.0)
   Oxalate 0.35 mmol (0.44)
   Uric acid 4.0 mmol (1.48–4.43)
 

The patient is counselled to start a low sodium diet.

🧠 Case-based MCQ 🔸 #MCQ_4
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✔️The correct answer is E.

This patient's urinary calcium excretion is in the high-normal range. The threshold that defines high urinary calcium excretion and when to initiate a thiazide diuretic for the prevention of calcium oxalate stones is unclear. However, the underlying principle is that the risk for stone formation is continuous with increasing amounts of calcium in the urine. Patients with ongoing stone formation despite dietary and fluid management should be considered for medical therapy with a thiazide diuretic to decrease urinary calcium excretion.

Thiazide diuretics can decrease calcium excretion by up to 50% and reduce the recurrence of calcium oxalate stones. Chlorthalidone is the preferred agent because of its long half-life. Chlorthalidone increases calcium reabsorption in the kidney primarily by causing mild volume depletion, which increases sodium and calcium reabsorption in the proximal tubule. When hydrochlorothiazide is used, twice-daily dosing is recommended. In addition to chlorthalidone, urinary calcium excretion can also be reduced by limiting sodium and protein intake.

❌Choice A is not correct:

Because calcium complexes with oxalate in the gastrointestinal tract, decreasing calcium intake allows for increased oxalate absorption and increased risk for stone formation. Therefore, unless a person is on a high-calcium diet (>1500 mg/d), intake should not be limited.

❌Choice B is not correct:

There is no evidence that excess coffee intake is associated with kidney stone disease, so reduction in coffee intake would not be expected to be beneficial.

Choice C is not correct:

Except in patients with hyperoxaluria, limiting oxalate intake has not been shown to decrease the incidence of stones, and thus the patient does not need to decrease intake.

❌Choice D is not correct:

Because uric acid may serve as a nidus for stone formation, allopurinol has been used to reduce stone occurrence, especially in patients with high levels of uric acid in the urine, which is not present in this patient.

✅Summarized Points:

Thiazide diuretics decrease calcium excretion by up to 50% and can be used to manage recurrent calcium oxalate kidney stones. In patients with recurrent calcium oxalate kidney stones, urinary calcium excretion can be reduced by limiting sodium and protein intake.

🧠 Case-based MCQ 🔸 #MCQ_5
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A 58-year-old male presents to an emergency department complaining of severe knee pain which has been worsening over the past 2 days. He denies any trauma to the area. When questioned about his medical history, the patient reports that he is being treated for hypothyroidism. On examination, the patient has a temperature of 38 C (100.3 F). His left knee is warm, erythematous, and tender. There is a large effusion in the knee joint. He has painful limitation of motion of the knee. He has no rashes, and no other joints are involved. Arthrocentesis is performed and shows 75,000 WBC/mm3. A polarizing microscope shows rhomboid, positively birefringent crystals in the fluid.

🧠 Case-based MCQ 🔸 #MCQ_4
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✔️ The Correct answer is A.

Pseudogout is joint inflammation caused by calcium pyrophosphate crystals. it happens in Elderly and Osteoarthritis joint. Its Presentation is similar to gout cause redness, swelling, tenderness, but typically occurs in larger joints (knee).

Three main conditions that may increase crystal deposition include hemochromatosis, hyperparathyroidism, hypothyroidism (3 H’s).


❌Choice B is not correct:

The uric acid crystals of gout are needle-shaped and negatively birefringent.

❌Choice C is not correct:

This patient WBC count in the synovial fluid over 55.000 which suggest a septic arthritis, but the crystals point to pseudogout.

❌Choice D is not correct:

Rheumatoid arthritis is symmetrical arthritis and usually involve hands.

❌Choice E is not correct:

Osteoarthritis not come with fever, and synovial fluid WBC in osteoarthritis is less than 2000 and there is no crystal.

💠 Summarized Points:

Fever and single joint pain next step is joint aspiration. Rhomboid crystal associated with Pseudogout. Risk factors for Pseudogout are hypothyroidism, Hemochromatosis, hyperparathyroidism. Pseudogout happen in Elderly and Osteoarthritis joint.

🧠 Case-based MCQ 🔸 #MCQ_5
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A 68-year-old male presents to the emergency department with a complaint of right upper extremity weakness and slurred speech. His symptoms started 5 hours ago and have not improved. He has a medical history significant for hypertension and diabetes. His physical examination is notable for weakness in the right arm only and dysarthria, Right biceps reflex is brisk. The rest of the examination is normal. His temperature is 37.5, blood pressure is 190/100 mm Hg, the pulse is 75/min, respiratory rate is 12 /min.