🧠 Case-based MCQ 🔸 #MCQ_10
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤


An 85-year-old woman with a 40-pack-year smoking history presents to her physician with declining vision in her left eye over the past month. She has trouble seeing her needlework or reading because there appears to be a dark circle in the center of her visual field. Her blood pressure is 140/90 mmHg, pulse is 90/min, respiratory rate is 14/min, temperature is 37C (98.6 F). On funduscopic examination, her left eye shows subretinal fluid and a localized exudative retinal detachment.

🧠 Case-based MCQ 🔸 #MCQ_10
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤



The correct answer is D.

This patient likely has wet-type age-related macular degeneration (ARMD). She has a loss of central vision over a period of weeks to months and subretinal fluid and retinal detachment. Neovascularization is the underlying mechanism of wet ARMD and can be treated with thermal laser photocoagulation, photodynamic therapy, or intravitreal injection of a vascular endothelial growth factor inhibitor.


 

❌Choice A is not correct:

Decreased scleral elasticity is a proposed mechanism for dry ARMD. This patients presentation with unilateral visual loss over weeks to months and findings of subretinal fluid are more consistent with wet ARMD, which is due to neovascularization.

❌Choice B is not correct:

Ischemic damage to photoreceptors is a proposed mechanism for dry ARMD. A patient with dry ARMD would have areas of retinal atrophy, depigmentation, and drusen on funduscopic examination, and not subretinal fluid as in this patient with wet ARMD.

❌Choice C is not correct:

This patient has wet age-related macular degeneration secondary to neovascularization. This may lead to subretinal hemorrhages or fluid collections. Optic nerve atrophy is not involved in the acute presentation of this disease but is seen in glaucoma.

❌Choice E is not correct:

Thromboembolism is unlikely to be the cause of this patient’s visual loss. Her presentation of worsening central vision over a month and funduscopic examination findings are more consistent with wet ARMD. Thromboembolism presents acutely.

✅Summarized Points:

Neovascularization is the underlying mechanism of wet-type age-related macular degeneration, which may present with loss of central vision over a period of weeks to months, subretinal fluid, and retinal detachment.

🧠 Case-based MCQ 🔸 #MCQ_11
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤
A 62-year-old man comes to the clinic due to shoulder pain that began after a fall 3 weeks ago. The pain is felt over the patient's lateral shoulder and often keeps him awake. It makes it difficult for him to lift anything overhead. Shoulder passive range of motion is normal; however, motion against any resistance is limited, and the patient is unable to maintain 90 degrees of abduction. There is weakness in abduction and external rotation. X-ray of the shoulder is normal.

🧠 Case-based MCQ 🔸 #MCQ_11
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤

The correct answer is A.

This patient's clinical presentation—posttraumatic shoulder pain with normal passive range of motion (ROM) but limited active abduction—is most likely due to a rotator cuff tear. Rotator cuff tears occur mainly in patients age >40, often after a fall on an outstretched arm. Atraumatic, degenerative tears can also occur, usually in elderly individuals.

The associated pain at the lateral shoulder is typically worsened by raising the arm overhead or lying on the affected side. Of the major rotator cuff components, the supraspinatus tendon is most commonly affected. Injury to the supraspinatus can lead to weakness of abduction and external rotation and a positive drop arm sign (i.e., when the arm is released at 90 degrees of abduction, the patient is unable to smoothly lower it to the side).

X-ray is usually normal and is primarily done to rule out fracture; MRI and ultrasound have higher sensitivity. Treatment of an acute tear usually involves surgery, with best results if performed within 6 weeks of the injury.

❌Choice B is not correct:

Examination in acromioclavicular (AC) joint separation shows a prominent, high-riding distal clavicle with focal tenderness and crepitus at the AC joint There is pain with cross-body abduction of the arm (a movement that compresses the AC joint), and x-ray shows widening of the AC joint.

❌Choice C is not correct:

Frozen shoulder (adhesive capsulitis) often presents with pain that is worse at night and is a potential complication of rotator cuff injury. However, it is associated with stiffness and marked limitation in both active and passive ROM.

❌Choice D is not correct:

Calcific tendinopathy of the shoulder is characterized by hydroxyapatite deposits in the rotator cuff tendons. It presents with a gradual onset of pain that is worsened by abduction. The pain can be severe and may limit active ROM, but true weakness is absent Calcifications of the tendons are visible on x-ray.

❌Choice E is not correct:

Both rotator cuff tendinopathy/ impingement and tear may present with pain on reaching or abduction. However, tendinopathy/impingement without tear does not cause weakness and reduced ROM.

✅Summarized Points:

Rotator cuff tear is characterized by acute shoulder pain with normal passive range of motion but weakness of abduction and external rotation. It occurs mainly in patients age >40, often after a fall. X-ray is usually normal, but MRI and ultrasound have higher sensitivity. Treatment usually involves surgery within 6 weeks.

🧠 Case-based MCQ 🔸 #MCQ_12
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤


A 20-year-old boy is brought to the emergency department with acute left ear pain and swelling. He was competing in a boxing tournament and was kicked in the side of the head 3 hours ago. Examination shows a 3-cm area of erythema and tenderness with fluctuant swelling over the fossa of the left ear. The tympanic membrane is clear and intact.

🧠 Case-based MCQ 🔸 #MCQ_12
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤

The correct answer is D.

This patient's tender, erythematous ear swelling is consistent with an auricular hematoma, which results from blood collection in the subperichondrial space of the external ear, typically after blunt trauma. This injury occurs most often in wrestlers, rugby players, boxers, and mixed martial artists. Patients classically present with acute ear tenderness, swelling, erythema, and ecchymoses.

Treatment involves auricular hematomas that are <2 cm in diameter and present for up to 48 hours undergo needle aspiration. Auricular hematomas ≥2 cm in diameter and all hematomas present from 48 hours up to seven days receive either incision and drainage or evacuation using an intravascular catheter rather than needle aspiration. The procedure should be performed immediately to prevent cauliflower ear, a permanent deformity due to fibrous and cartilaginous overgrowth.

Because of the risk of infection to an area with tenuous blood supply, recommended that all patients who undergo auricular hematoma drainage receive a 7-to-10-day course of empiric oral antibiotics with activity against skin flora and Pseudomonas aeruginosa (e.g., levofloxacin). After auricular hematoma drainage, patients warrant daily follow-up for three to five days to evaluate for reaccumulation of the hematoma or infection. Return to sports can occur as early as seven days after the initial injury if the hematoma does not reaccumulate. Athletes should be strongly advised to wear protective headgear to prevent reinjury.

❌Choice A is not correct:

Antibiotic ear drops (e.g., levofloxacin) are the first-line treatment for otitis extern, which presents with ear pain, pruritus, drainage, and hearing loss. Patients with otitis externs typically have pain with manipulation of the tragus and/or auricle. In patients with auricular hematomas, antibiotics can be considered for empiric coverage of auricular skin flora and Pseudomonas, but only after incision and drainage (the primary treatment) has been performed.

❌Choice B is not correct:

Pressure dressings consist of gauze that is firmly applied to a wound to prevent blood and serous fluid accumulation. Such dressings should be applied after incision and drainage to decrease reaccumulation risk.

❌Choice C is not correct:

Auricular hematomas require immediate incision and drainage. Observation without intervention would increase the risk of complications.

❌Choice E is not correct:

Temporal bone CT without contrast is indicated for patients with suspected temporal basilar skull fractures, which commonly present with subcutaneous bleeding over the mastoid process (Battle sign). Basilar skull fractures can also present with subcutaneous bleeding around the orbits (raccoon eyes), hemotympanum, cranial nerve deficits, and cerebrospinal fluid otorrhea or rhinorrhea. This patient's injury is localized to the external ear; a CT scan is not indicated.

✅Summarized Points:

Auricular hematomas are caused by blunt trauma to the external ear. Classic findings include an erythematous, tender swelling in the auricular fossa. Incision and drainage should be performed immediately to prevent cauliflower ear. A pressure dressing is subsequently applied to prevent reaccumulation of blood and serous fluid.

🧠 Case-based MCQ 🔸 #MCQ_13
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤
A 92-year-old man was admitted to the hospital because of weakness and rectal bleeding for the previous 24 hours. Questioning reveals, a decrease in stool caliber over the past several months. Examination reveals a nontender mass in the left lower quadrant. Stool heme is positive. Serum hemoglobin is 88 g/L. Further work-up reveals colon cancer, Duke stage D. The patient's spouse and only child are no longer living, but the patient's 50-year-old granddaughter pleads with the physician not to inform her grandfather of the diagnosis, stating that he is an anxious man and that she wants him to enjoy his remaining time.

🇨🇦 Offical MCCQE Part I Preparatory Materials



✅ MCCQE Part I - MCQ and CDM Test - (August 2023)


✅ MCCQE Part I - Prep Exam-Lite (July 2023) - MCQ + CDM


✅ MCCQE Part I Full - length Preparatory Examination (PE) Qbank (April 2023)



🔻 Follow @Mediccount

🔻 Contact Admin: @Mediccounts

🧠 Case-based MCQ 🔸 #MCQ_13
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤

The correct answer is B.

With rare exceptions, patients are entitled to know their diagnosis and prognosis, even if they are old, their condition is probably terminal, and they have anxious personalities and/ or psychiatric diagnoses. Exceptions to the physician's obligation to discuss the diagnosis with the patient, include the previous request of the patient to not be informed or the belief of the physician that disclosure would severely harm the patient.

❌Choice A is not correct:


It would be unethical to acquiesce to the family's request. If nondisclosure is the patient's request as well, then the physician will be able to honor it.

❌Choice C is not correct:

Even if the entire family wants to keep the diagnosis from the patient, if the patient him- or herself wants to be informed, the physician is obligated to tell the patient the diagnosis.

❌Choice D is not correct:

Rarely will consultation be a correct answer on a USMLE examination. The physician has the information needed to act and should do so.

❌Choice E is not correct:

Psychiatric evaluation is not warranted at this time. All physicians can judge decision-making capacity, and if the patient has the capacity to decide whether he or she wants to be informed of the diagnosis, the obligation then exists to abide by that wish.

✅Summarized Points:

Patients are entitled to know their diagnosis and prognosis. Exceptions to the physician's obligation to discuss the diagnosis with the patient include the patient's previous request to not be informed or the physician's belief that disclosure would severely harm the patient.

🧠 Case-based MCQ 🔸 #MCQ_14
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤
A 65-year-old woman has an eczematoid lesion in the areola of her right breast that has been present for 3 months. She has self-medicated with skin lotions and over-the-counter steroid ointments, but the area has not improved. On physical examination, the nipple is inverted, the skin of the areola is reddish and desquamated, and the entire area feels firm, with no discrete mass demarcated from the rest of the breast.

🧠 Case-based MCQ 🔸 #MCQ_14
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤


The correct answer is A.

Paget disease of the breast (PDB), is an infiltrating cancer of the breast directly underneath the areola that is permeating the skin lymphatics and the skin itself. It usually presents as scaly, erythematous, crusty, and thickened plaques on the nipple, spreading to the surrounding areolar areas, are typical. Diagnosis of PDB is by tissue biopsy (e.g., wedge, punch). Many patients with PDB have an underlying breast malignancy (e.g., intraductal carcinoma, ductal carcinoma in situ). Therefore, all patients with PDB require bilateral mammography. Although it is true that the areola is not immune to other benign skin conditions, missing cancer would be lethal. Thus, any other answer that does not seek to rule out cancer first is wrong.

❌Choice B is not correct:

Treatment with estrogens assumes a benign, age-related atrophy, which is common in the vagina but not in the areola.

❌Choice C is not correct:

A mammogram and galactogram are indicated to find intraductal papilloma, the presentation of which is bloody nipple discharge in a younger woman.

❌Choice D is not correct:

Glucagonoma shows up as an intractable skin condition, but it is migratory, necrolytic, and exfoliative. It occurs in anemic diabetic patients with glossitis and shows no preference for the areola.

❌Choice E is not correct:

Culture and topical antibiotics is the intuitive answer if you assume that this is a nasty skin infection, but never make that your first diagnosis in this setting!

✅ Summarized Points:

Paget disease of the breast is characterized by a unilateral, erythematous, intensely pruritic, ulcerative lesion of the nipple-areolar complex. Diagnosis is by tissue biopsy. Patients also require diagnostic bilateral mammography, as many have underlying breast malignancy.

🧠 Case-based MCQ 🔸 #MCQ_15
🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤

A 2-month-old girl is brought to the clinic for her first visit following hospital discharge. She was born at 31 weeks gestation and spent 10 weeks in the neonatal intensive care unit. She was discharged 3 days ago. The patient was born small for gestational age but has been gaining weight well on 27-kcal/oz preterm formula. She currently weighs 1.9 kg (4.2 Ib). Her vital signs and physical examination are normal.

🧩 Medical Mnemonics

😵‍💫 ABCDEF of Renovascular disease

🌐 Follow our official Instagram page: Online Medical School

#nephrology
〰〰〰〰〰〰〰〰〰〰〰
©Medical Mnemonics