🧠 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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🧠 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