🧠 Case-based MCQ 🔸 #MCQ_42
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The Correct answer is E

Subacute thyroiditis (ST) is a self-limited condition. The hyperthyroid phase may last a few weeks, followed by a transient hypothyroid phase and eventual return to a euthyroid state. Treatment is primarily supportive, and most cases can be managed with a nonsteroidal anti-inflammatory drug to relieve pain; glucocorticoids can be used in severe or refractory cases. In addition, patients can be given a beta-blocker (e.g., propranolol, atenolol) to minimize the hyperadrenergic symptoms of thyrotoxicosis (e.g., sweating, palpitations).

❌Choice A is not correct:

Radioiodine thyroid ablation is used for the definitive treatment of Graves’ disease and nodular thyroid disease. It is not necessary in ST, which is a self-limited illness, and would not be effective as thyroid uptake of the radioiodine dose is very low.

❌Choice B and C are not correct:

Suppurative infection of the thyroid gland (infectious thyroiditis) is a rare condition that causes high-grade fever and pain at the thyroid gland. Patients will often have evidence of a thyroid abscess on examination or ultrasound, but are usually euthyroid as involvement of the thyroid gland is focal. Bacterial thyroid infections are treated with systemic antibiotics, and surgical drainage may be required.

❌Choice D is not correct:

Thyrotoxicosis in ST is due to the release of preformed thyroid hormone. Antithyroid drugs (e.g., methimazole), which work by decreasing the synthesis of thyroid hormones, are ineffective.

✅Summarized Points:

Subacute thyroiditis is a self-limited condition. Treatment consists primarily of nonsteroidal anti-inflammatory drugs for pain relief and beta-blockers to minimize thyrotoxic symptoms. Severe or refractory cases may require glucocorticoid therapy.

🧠 Case-based MCQ 🔸 #MCQ_43
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A 66-year-old woman with hypertension and type 2 diabetes mellitus comes to the emergency department with palpitations and is diagnosed with atrial fibrillation. The arrhythmia resolves spontaneously in the emergency department without intervention. Her renal function is normal and she has no history of bleeding. Which of the following is the best treatment option for this patient?

A. Aspirin
B. Aspirin and clopidogrel
C. Dipyridamole
D. Rivaroxaban
E. Ticagrelor

🧠 Case-based MCQ 🔸 #MCQ_43
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The Correct answer is D

Systemic thromboembolism is a major cause of morbidity in patients with atrial fibrillation (AF). Treatment with warfarin or target-specific oral anticoagulants (TSOACs) has been shown to significantly reduce the risk of embolization in patients at moderate to high risk for thromboembolic events. Recent guidelines have recommended the use of a modified CHA2DS2-VASc score for stroke risk assessment in patients with nonvalvular AF. This patient has a CHA2DS2-VASc score of 4 (female sex, age > 65, hypertension, and diabetes) and should be managed with anticoagulation. TSOACs (rivaroxaban, dabigatran, apixaban, and edoxaban) have proven efficacy in preventing thromboembolic events in patients with nonvalvular AF. TSOACs are not recommended for use in patients with mitral stenosis, prosthetic heart valves, end-stage renal disease, and severe decompensated valvular disease likely to require valve replacement; warfarin is preferred for these patients.

❌Choice A and B are not correct:

Antiplatelet therapy with aspirin or a combination of aspirin and clopidogrel is significantly less effective in reducing the risk of thromboembolism compared to anticoagulant therapy with warfarin or TSOACs.

❌Choice C is not correct:

Dipyridamole is occasionally used for secondary prevention of non-cardioembolic ischemic stroke in patients with recent transient ischemic attack or stroke. It has no role in the prevention of systemic thromboembolism in patients with AF.

❌Choice E is not correct:

Ticagrelor is a reversible P2Y12 platelet receptor inhibitor and is used in the management of patients with acute coronary syndrome. It is not used in patients with AF.

✅Summarized Points:

Anticoagulation with warfarin or target-specific oral anticoagulants (e.g., dabigatran, rivaroxaban) is recommended to prevent thromboembolic events in patients with nonvalvular atrial fibrillation. Warfarin is preferred for patients with mitral stenosis, prosthetic heart valves, end-stage renal disease, and severe decompensated valvular disease likely to require valve replacement.

🧠 Case-based MCQ 🔸 #MCQ_44
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An obese 34-year-old primigravid woman at 20 weeks' gestation comes to the physician for a follow-up examination for a mass she found in her left breast 2 weeks ago. Until pregnancy, menses had occurred at 30- to 40-day intervals since the age of 11 years. Vital signs are within normal limits. Examination shows a 3.0-cm, non-mobile, firm, and nontender mass in the upper outer quadrant of the left breast. There is no palpable axillary lymphadenopathy. Pelvic examination shows a uterus consistent in size with a 20-week gestation. Mammography and core needle biopsy confirm an infiltrating lobular carcinoma. The pathological specimen is positive for estrogen and human epidermal growth factor receptor 2 (HER2) receptors and negative for progesterone receptors. Staging shows no distant metastatic disease. Which of the following is the most appropriate management?

 

A. Surgical resection and radiotherapy
B. Hormonal therapy and trastuzumab
C. Surgical resection and chemotherapy
D. Radiotherapy and chemotherapy
E. Termination of pregnancy

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🧠 Case-based MCQ 🔸 #MCQ_44
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The Correct answer is C

Surgical resection is associated with minimal risk for the fetus regardless of the gestational age and chemotherapy may be given after the first trimester. Given the patient's tumor size of 3.0 cm, she falls into the category of high-risk patients and should, therefore, undergo adjuvant chemotherapy.

 

❌Choice A is not correct:

Surgical resection is associated with minimal risk to the fetus regardless of gestational age, but radiotherapy should not be used during pregnancy because of the risk of fetal damage.

❌Choice B is not correct:

The combination of hormonal therapy and trastuzumab is a recommended adjuvant treatment after surgical resection for estrogen-receptor-positive, HER2-positive breast cancer. However, both treatment options are contraindicated during pregnancy because of the risk of fetal damage.

❌Choice D is not correct:

Although chemotherapy may be safely administrated to this patient, radiotherapy is contraindicated during pregnancy as it may harm the fetus.

❌Choice E is not correct:

Termination of pregnancy is not recommended in this patient because there is treatment available that is associated with only minimal risk of fetal damage. Furthermore, pregnancy termination is not associated with better breast cancer survival.

✅Summarized Points:

For gestational breast cancer surgery is the treatment of choice (radiation therapy is contraindicated during pregnancy). Adjuvant chemotherapy only in the second and third trimester.

🧠 Case-based MCQ 🔸 #MCQ_45
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A randomized controlled trial is conducted to evaluate the relationship between the angiotensin receptor blocker losartan and cardiovascular death in patients with congestive heart failure (diagnosed as ejection fraction < 30%) who are already being treated with an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker. Patients are randomized either to losartan (N = 1500) or placebo (N = 1400). The results of the study has been shown in the table.

Based on this information, if 200 patients with congestive heart failure and an ejection fraction < 30% were treated with losartan in addition to an ACE inhibitor and a beta-blocker, on average, how many cases of cardiovascular death would be prevented?


A. 20
B. 0.25
C. 10
D. 50
E. 0.05

🧠 Case-based MCQ 🔸 #MCQ_45
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The Correct answer is C

The absolute risk reduction in this study is the risk in the placebo group, 350 / (350 + 1050) = 0.25, minus the risk in the losartan group, 300 / (300 + 1200) = 0.20. Thus, the ARR = 0.25 - 0.20 = 0.05. Therefore, the number needed to treat is 1/0.05 = 20 patients. This means that for every 20 patients treated, one death will be prevented. For every 200 patients treated, 10 deaths will be prevented.

 

 

 

Choice A is not correct:

This value is the number needed to treat, which is calculated by taking the inverse of the ARR. In this study, the ARR is the risk in the placebo group, 350 / (350 + 1050) = 0.25, minus the risk in the losartan group, 300 / (300 + 1200) = 0.20. Thus, the ARR = 0.25 - 0.20 = 0.05. The NNT is therefore 1/0.05 = 20 patients. However, the question asks how many deaths will be prevented if 200 patients with congestive heart failure and an ejection fraction < 30% were treated with losartan in addition to an ACE inhibitor and a beta-blocker.

❌Choice B is not correct:

This value is the risk of cardiovascular death in the placebo group, which is calculated by dividing the number of deaths in the placebo group by the number at risk in the placebo group: 350 / (350 + 1050) = 0.25.

❌Choice D is not correct:

This value is the difference in the number of cardiovascular deaths in the placebo group (350) and the losartan group (300). This does not relate to the number of deaths that would be prevented if 200 patients with congestive heart failure and an ejection fraction < 30% were treated with losartan in addition to an ACE inhibitor and a beta-blocker.

❌Choice E is not correct:

This value is the absolute risk reduction. In this study, the ARR is the risk in the placebo group, 350 / (350 + 1050) = 0.25, minus the risk in the losartan group, 300 / (300 + 1200) = 0.20. Thus, the ARR = 0.25 - 0.20 = 0.05.

✅Summarized Points:

To answer this question correctly, calculate the number needed to treat (NNT) (i.e., the number of individuals that must be treated for one person to benefit from treatment), which is the inverse of absolute risk reduction (1/ARR).

🧠 Case-based MCQ 🔸 #MCQ_46
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A 30-year-old woman comes to the physician with her husband because they have been trying to conceive for 15 months with no success. They have been sexually active at least twice a week. The husband sometimes has difficulties maintaining erection during sexual activity. During attempted vaginal penetration, the patient has discomfort and her pelvic floor muscles tighten up. Three years ago, the patient was diagnosed with body dysmorphic disorder. There is no family history of serious illness. She does not smoke or drink alcohol. She takes no medications. Vital signs are within normal limits. Pelvic examination shows normal appearing vulva without redness; there is no vaginal discharge. An initial attempt at speculum examination is aborted after the patient's pelvic floor muscles tense up and she experiences discomfort. Which of the following is the most likely diagnosis?

 

A. Genito-pelvic pain disorder
B. Vulvodynia
C. Psychogenic dyspareunia
D. Inadequate lubrication
E. Endometriosis

🧠 Case-based MCQ 🔸 #MCQ_46
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The Correct answer is A

This patient's symptoms are suggestive of genitopelvic pain/penetration disorder (penetration disorder) formally known as vaginismus, a condition that is characterized by persistent or recurrent difficulties during sexual intercourse. Characteristic symptoms include difficulty with vaginal penetration, vulvovaginal or pelvic pain during intercourse, anticipatory anxiety, and pronounced tightening of the pelvic floor muscles during attempted vaginal penetration. The disorder often presents in individuals with relationship issues (e.g., sexual problems also present in the partner), poor body image (e.g., body dysmorphic disorder), and psychiatric disorders (e.g., depression, anxiety).

 

❌Choice B is not correct:

Women affected by vulvodynia experience soreness and burning of the vulva that may be present continuously or triggered by touch or pressure (e.g., sexual intercourse, tampon use). The combination of discomfort and tightening of pelvic floor muscles on penetration experienced by this patient is not consistent with vulvodynia.

❌Choice C is not correct:

Psychogenic dyspareunia describes pain during sexual intercourse that is not due to an underlying organic cause (e.g., endometriosis, vaginal infections). Nonorganic causes for dyspareunia include emotional and psychological factors like stress, anxiety, depression or a history of sexual abuse, and are often difficult to identify. Although dyspareunia often occurs in conjunction with this patient's condition, it is not usually associated with tightening of the pelvic floor muscles or difficult penetration.

❌Choice D is not correct:

Inadequate vaginal lubrication can have a number of reasons, including female sexual arousal disorder, hormonal changes (e.g., menopause), nerve injury (e.g., multiple sclerosis, diabetic peripheral neuropathy), and medication intake (e.g., SSRIs). This patient's examination findings indicate that the vaginal discomfort and pelvic floor tightening are independent of possible discomfort secondary to dryness and inadequate lubrication. This patient's outer genital examination also does not indicate any signs of dryness or irritation, which are common if inadequate vaginal secretion is present. Additionally, she has neither associated features of sexual arousal disorder (e.g., no absent interest or participation in sexual activity) nor a history of illness or medication intake.

❌Choice E is not correct:

Women with endometriosis present with dysmenorrhea, menorrhagia, and infertility. Although dyspareunia is another common symptom, in the absence of menstrual abnormalities and chronic pelvic pain, endometriosis can be ruled out.

✅Summarized Points:

The best initial management of this patient's condition is pelvic floor physical therapy

🧠 Case-based MCQ 🔸 #MCQ_47
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A 4-month-old African-American infant is brought to the pediatrician for a well-baby check-up. He was born at term through a normal vaginal delivery and has been well since. His 4-year old brother has sickle-cell disease. He is exclusively breastfed and receives vitamin D supplements. His immunizations are up-to-date. He appears healthy. His length is at the 70th percentile and weight is at the 75th percentile. Cardiopulmonary examination is normal. His mother has heard reports of sudden infant death syndrome (SIDS) being common in his age group and would like to hear more information about it. Which of the following is the most important recommendation to prevent this condition?

A. Make sure that no one smokes around the baby
B. Avoid feeding the baby close to bedtime
C. Have the baby sleep with the parent
D. Keep the baby warm with thick blankets
E. Have the baby sleep in supine position

🧠 Case-based MCQ 🔸 #MCQ_47
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The Correct answer is E

Sudden infant death syndrome (SIDS) is the leading cause of death during the first year of life. SIDS peaks at age 2-4 months, with the vast majority of cases occurring before age 6 months. Sleep positioning is the most important modifiable risk factor. The overall incidence has decreased by >50% since the American Academy of Pediatrics recommended supine sleep positioning through the "Back to Sleep"; campaign. All parents and caregivers should be advised to place infants on their backs on a firm mattress in a crib or bassinet. In early infancy, sleeping on the side is not recommended as the infant could roll into a prone position. When infants can roll from back to front and vice versa (age -6 months), they may choose their own sleep position. Throughout infancy, the sleep area should be devoid of pillows, stuffed animals, loose bedding, excessive clothing, or sleep positioners, as these objects are potential suffocation/strangulation hazards. Another significant modifiable risk factor is smoke exposure. Smoking during pregnancy and postnatal secondhand smoke exposure are both associated with an increased risk of SIDS. This patient should receive positive reinforcement for smoking cessation and encouraged to avoid secondhand smoke

❌Choice A is not correct:

Exposing infants to secondhand smoke increases their risk of SIDS and should, therefore, be avoided. However, it is not the most important recommendation for SIDS prevention.

❌Choice B is not correct:

There is no association between the time at which a baby is fed and the reduction of the risk of SIDS.

❌Choice C is not correct:

Bed-sharing is not regarded as a safe practice, according to recommendations of the American Academy of Pediatrics. Studies have shown that children sleeping near an adult are at increased risk for SIDS. Some features of adult beds, e.g., soft surfaces and additional bedding, may contribute to this risk.

❌Choice D is not correct:

Excessive swaddling may increase the risk of SIDS. Some studies show that the risk of SIDS increases with the amount of blankets or clothing. Swaddling is a safe and recommended practice in newborns. However, it should be discouraged among children beyond two months of age because it may increase the risk of suffocation if the baby rolls over.

✅Summarized Points:

Having the baby sleep in the supine position is a strategy recommended by the American Academy of Pediatrics for reducing the risk of sudden infant death syndrome (SIDS). Several studies have shown that sleeping in the prone position is the most significant modifiable risk factor for SIDS. Although the mechanism is not clear, sleeping in the prone position seems to predispose children to suffocation.

“Back to Sleep, Front to Play” (place infant on back when sleeping)

🧠 Case-based MCQ 🔸 #MCQ_48
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The patient undergoes a mammogram, which shows a 6.5mm sized mass with an irregular border and spiculated margins. A subsequent core needle biopsy of the mass shows infiltrating ductal carcinoma with HER2-positive, estrogen-negative, and progesterone-negative immunohistochemistry staining. Blood counts and liver function tests are normal. Laboratory studies show:

  Hemoglobin 125 g/L
 Serum
  Na+ 140 mEq/L
  Cl- 103 mEq/L
  K+ 4.2 mEq/L
  HCO3- 26 mEq/L
  Ca+2 2.29 mmol/L
  Urea Nitrogen 4.2 mmol/L
  Glucose 6.1 mmol/L
  Alkaline Phosphatase 25 U/L
  Alanine aminotransferase (ALT) 15 U/L
  Aspartate aminotransferase (AST) 13 U/L
 

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

 

A. Tamoxifen therapy
B. Whole-body PET/CT
C. Bilateral mastectomy with lymph node dissection
D. Breast-conserving therapy and sentinel lymph node biopsy
E. Bone scan

🧠 Case-based MCQ 🔸 #MCQ_48
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The Correct answer is D

Breast-conserving therapy and sentinel node biopsy are diagnostic and therapeutic procedures used as a first-line intervention in patients with newly diagnosed invasive ductal carcinoma. All patients who undergo lumpectomy require postoperative radiation to the whole breast to minimize the risk of recurrence. Sentinel node biopsy is necessary to stage cancer, which will determine subsequent treatment. Moreover, given the HER2-positive immunohistochemical staining, this patient will benefit from adjuvant systemic chemotherapy in the form of trastuzumab.

 

❌Choice A is not correct:

Tamoxifen is a selective estrogen receptor modulator that is primarily used in patients with estrogen receptor-positive breast cancer, but this patient's stain is estrogen receptor-negative.

❌Choice B is not correct:

A whole-body PET/CT scan is required in all patients with stage IIIA or higher disease to assess for metastases. Additionally, patients who present with signs of metastatic disease, such as abdominal pain, elevated LFTs, or palpable abdominal masses, may benefit from a whole-body PET/CT scan. However, the stage of this patient's cancer has not yet been determined and she does not have any signs of metastatic disease, so a whole-body PET-CT would not be indicated at this time.

❌Choice C is not correct:

A bilateral mastectomy with lymph node dissection is commonly performed in patients with bilateral disease, or in patients who have a BRCA gene mutation. Although a BRCA mutation has not explicitly been ruled out in this patient, BRCA mutation carriers generally have a personal and/or family history of breast, ovarian, tubal, or peritoneal cancer, and may also have more advanced disease at presentation (triple-negative or bilateral breast cancer). This patient does not have any of these conditions, which makes a BRCA mutation unlikely. In addition, a HER2 mutation has already been identified as the likely culprit.

❌Choice E is not correct:

A bone scan is commonly obtained in patients who present with bone pain or elevated alkaline phosphatase in the setting of newly diagnosed breast cancer, which may be indicative of metastatic disease. This patient does not have either of these findings.

✅Summarized Points:

Given the mammography and core-needle biopsy results, this patient most likely has localized breast cancer. She will require further staging and treatment

🧠 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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