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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

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🧠 Case-based MCQ 🔸 #MCQ_53
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The Correct answer is C

This patient's clinical features are most consistent with acute pancreatitis. Pancreatitis is characterized by:

Persistent, moderate-to-severe epigastric abdominal pain
Pain that radiates to the back and may be relieved by sitting up and leaning forward
Nausea and vomiting
Variable physical examination findings, which may range from minimal tenderness in the epigastric area to severe tenderness with guarding and rebound
Gallstones and chronic alcohol abuse account for about 75% of cases of acute pancreatitis. Nearly one-third of patients have chest x-ray abnormalities, including pleural effusions, atelectasis, elevated hemidiaphragm, or pulmonary infiltrates. These complications are often due to activated pancreatic enzymes (e.g., phospholipase, trypsin) and cytokines (e.g., tumor necrosis factor) that are released from the pancreas into the circulation and cause focal or systemic inflammation. Other potential complications include ileus, acute respiratory distress syndrome, and renal failure.


❌Choice A is not correct:

Infra-abdominal abscess often presents in a subacute or insidious fashion with fever, nausea, vomiting, and/or abdominal pain. This patient's acute symptom onset is less consistent with an abdominal abscess.

❌Choice B is not correct:

Mesenteric ischemia usually presents with severe acute periumbilical abdominal pain that is out of proportion to findings on physical examination. Risk factors include advanced age, diffuse atherosclerosis, valvular abnormality, cardiac arrhythmias (i.e., atrial fibrillation), and recent myocardial infarction (MI). Mesenteric ischemia would be less likely than pancreatitis in a patient of this age, even with atherosclerotic risk factors.

❌Choice D is not correct:

Acute MI (especially inferior MI) can occasionally present with nausea, vomiting, and epigastric pain. However, pain improving with sitting up or leaning forward is not consistent with MI, and abdominal tenderness is more characteristic of pancreatitis.

❌Choice E is not correct:

Patients with perforated peptic ulcer usually complain of sudden-onset epigastric pain, nausea, vomiting, and hematemesis, and may show peritoneal signs (e.g., guarding, rigidity, rebound tenderness) on physical examination. Upright chest x-ray will show free air under the diaphragm.

✅Summarized Points:

Acute pancreatitis is characterized by epigastric abdominal pain associated with nausea and vomiting. Alcohol abuse and gallstone disease are the most common causes. Potential complications include pleural effusion, acute respiratory distress syndrome, ileus, and renal failure.

🧠 Case-based MCQ 🔸 #MCQ_54
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A 7-month-old boy is brought to the physician for a well-child examination. He was born at 36 weeks' gestation and has been healthy since. He is at the 60th percentile for length and weight. Vital signs are within normal limits. The abdomen is soft and nontender. The external genitalia appears normal. Examination shows a single palpable testicle in the right hemiscrotum. The scrotum is nontender and not enlarged. There is a palpable mass in the left inguinal canal. Which of the following is the most appropriate next best step in management?

 

A. Ultrasound of the abdomen and pelvis
B. Exploration under anesthesia
C. Gondadotropin therapy
D. Orchidopexy
E. Reassurance

🧠 Case-based MCQ 🔸 #MCQ_54
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The Correct answer is D

Surgical correction of the undescended testis is recommended in boys 4–6 months of age because spontaneous descent is unlikely to occur after that. Early surgery optimizes normal testicular growth and maximizes fertility potential. Ideally, orchidopexy should be performed before 1 year of age. Since the infant has a palpable testis in the inguinal canal, orchidopexy is the surgical procedure of choice.

 

❌Choice A is not correct:

Since ultrasound of the abdomen and pelvis in a patient with a palpable undescended testis, as is the case here, rarely contributes further to the diagnosis and would thus not affect the course of treatment, it is not indicated in this patient. Even in patients with nonpalpable undescended testis, imaging studies would not be indicated because they do not eliminate the need for exploratory surgery.

❌Choice B is not correct:

Exploration under anesthesia is recommended in infants with cryptorchidism and nonpalpable testes in order to evaluate for the presence and location of the testes. A nonpalpable testis may be absent (blind ending cord structures indicate absent testes), atrophic, or located anywhere along the line of testicular descent (intra-abdominal or within the inguinal canal). Since the left testicle of this infant is palpable in the left inguinal canal, exploration under anesthesia is not necessary.

❌Choice C is not correct:

Gonadotropin therapy involves the administration of either human chorionic gonadotropin (hCG) or gonadotropin releasing hormone (GnRH) to stimulate gonadal steroidogenesis and promote testicular descent. However, the success rates of gonadotropin therapy are highly variable and there is a possibility of long-term adverse effects (e.g., low testicular volume, infertility) in infants who received gonadotropin therapy. Hormonal therapy with gonadotropins is not recommended for the treatment of cryptorchidism.

❌Choice E is not correct:

Reassurance for cryptorchidism is indicated in boys < 3 months of age since a majority of undescended testicles descend spontaneously by 3 months of age. Spontaneous descent most likely occurs at this time due to a gonadotropic hormone surge (FSH and LH) at around 60–90 days of life. However, spontaneous descent is unlikely to occur after 6 months of age and, therefore, reassurance is not appropriate because uncorrected cryptorchidism is associated with subfertility/infertility, testicular torsion, inguinal hernia, and testicular malignancy.

✅Summarized Points:

Spontaneous testicular descent should occur by 6 months of age.

🧠 Case-based MCQ 🔸 #MCQ_54
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A 16-year-old girl comes to the physician because she is worried about gaining weight. She reports that at least twice a week, she eats excessive amounts of food but feels ashamed about losing control soon after. She is very active in her high school's tennis team and goes running daily to lose weight. She has a history of cutting her forearms with the metal tab from a soda can. Her last menstrual period was 3 weeks ago. She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2. Physical examination shows enlarged, firm parotid glands bilaterally. There are erosions of the enamel on the lingual surfaces of the teeth. Which of the following is the most likely diagnosis?

 

A. Borderline personality disorder
B. Anorexia nervosa
C. Bulimia nervosa
D. Binge eating disorder
E. Body dysmorphic disorder

🧠 Case-based MCQ 🔸 #MCQ_54
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The Correct answer is C

Patients with bulimia nervosa engage in compulsive binge eating followed by compensatory actions aimed at preventing weight gain. Despite this, patients are of normal weight or slightly underweight (BMI > 18.5 kg/m2 or ≥ 10th percentile). Physical examination may show the effects of frequent vomiting, including salivary gland swelling and erosion of tooth enamel due to gastric acid, as seen in this patient, while laboratory studies typically show characteristic electrolyte imbalances.

 

❌Choice A is not correct:

While patients with borderline personality disorder (BPD) may also engage in self-injurious activities such as cutting or burning themselves, BPD is characterized by the inability to maintain interpersonal relationships and a high degree of impulsivity without regard for consequences. Although BPD cannot be completely ruled out in this patient from the information provided, her physical symptoms are more consistent with another diagnosis.

❌Choice B is not correct:

Patients with anorexia nervosa are also often young women who fear to gain weight and may present with signs of frequent vomiting (such as the parotid gland swelling) and electrolyte imbalances. However, unlike this girl with a normal BMI, patients with anorexia nervosa are significantly underweight (BMI < 18.5 kg/m2 or < 10th percentile) and are frequently amenorrheic.

❌Choice D is not correct:

Binge eating disorder is characterized by frequent episodes of overeating, with patients feeling like they have a lack of control over how much or how quickly they eat and typically feeling guilty thereafter, which is seen in this patient. Many patients with binge eating disorder are obese. However, patients with binge eating disorder do not attempt to compensate for excess calorie intake and are not preoccupied with gaining weight.

❌Choice E is not correct:

While some patients with body dysmorphic disorder are concerned about gaining weight, this patient does not display a preoccupation with a specific aspect of her physical appearance, which is characteristic of body dysmorphic disorder. Moreover, body dysmorphic disorder is a psychiatric diagnosis and would not present with the abnormal physical examination findings seen in this patient.

✅Summarized Points:

Laboratory studies would likely show hypochloremic, hypokalemic metabolic alkalosis

🧠 Case-based MCQ 🔸 #MCQ_55
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A 15-year-old girl comes to the physician with 4 days of fever and worsening sore throat, voice changes, and difficulty opening her mouth. She has prescribed antibiotics for streptococcal pharyngitis 2 days ago but did not take the pills due to difficulty swallowing. The patient has no underlying health problems, takes no medications, and her immunizations are up-to-date. Her temperature is 39.4 C (103 F), blood pressure is 115/64 mm Hg, pulse is 110/min, and respirations are 17/min. Oral examination is somewhat limited due to trismus, but an inflamed oropharyngeal mucosa, 4+ right tonsil covered with exudates, and leftward uvula deviation are seen. Multiple small, mobile, and tender lymph nodes are palpable in the right neck. Her voice is muffled but she has no stridor. Lung, cardiac, and abdominal examinations are normal. Which of the following is the best next step in the management of this patient?

A. Endotracheal intubation
B. Intravenous antibiotics
C. Neck CT scan with contrast
D. Neck x-ray
E. Tonsillar needle aspiration

🧠 Case-based MCQ 🔸 #MCQ_55
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The Correct answer is E

Peritonsillar abscess (PTA) is a potential complication of untreated streptococcal pharyngitis. This patient's fever, dysphagia, unilateral peritonsillar swelling, uvula deviation away from the swollen tonsil, trismus, and voice changes are concerning for PTA. In addition to Streptococcus pyogenes (group A Streptococcus), the abscess is usually comprised of Staphylococcus aureus and respiratory anaerobes. When the diagnosis is suspected on examination, the patient should be referred to an otolaryngologist for needle aspiration, incision and drainage, or tonsillectomy. If the patient is cooperative, needle aspiration is the procedure of choice as it is better tolerated as an outpatient, less painful, and less invasive than incision and drainage. If possible, broad-spectrum parenteral antibiotics are recommended after diagnostic and therapeutic needle aspiration so that culture data are not obscured. Patients can switch to oral antibiotics after clinical improvement and fever resolution.

Drainage, antibiotics, analgesia, and hydration result in resolution in >90% of cases. Delays in treatment can result in complications such as airway obstruction or infection spread from the peritonsillar space to other deep neck spaces and the bloodstream.

❌Choice A is not correct:

Although airway obstruction is a potentially fatal, albeit rare, complication of PTA, endotracheal intubation is not indicated in this patient given the lack of stridor, dyspnea, or other signs of acute airway obstruction.

❌Choice B is not correct:

To avoid obscuring culture data, broad-spectrum parenteral antibiotics are recommended after diagnostic and therapeutic needle aspiration. After clinical improvement and fever resolution, patients can transition to oral antibiotics.

❌Choice C and D are not correct:

Neck imaging is not necessary given the classic clinical features of peritonsillar abscess in this patient. In patients with severe trismus, when the posterior oropharynx cannot be adequately visualized or if there is a concern for spread beyond the peritonsillar space, CT with intravenous contrast is the preferred imaging modality for delineating infections of the deep neck space. X-ray does not provide enough soft tissue detail.

✅Summarized Points:

Peritonsillar abscess is a potential complication of streptococcal pharyngitis. Classic findings include dysphagia, unilateral peritonsillar swelling, uvula deviation, and trismus. The purulence should be drained promptly and broad-spectrum antibiotics administered intravenously

🧠 Case-based MCQ 🔸 #MCQ_56
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A 61-year-old man with Alzheimer's disease is brought to the emergency department 20 minutes after ingesting an unknown amount of his medications in a suicide attempt. He reports abdominal cramps, diarrhea, diaphoresis, and muscular weakness and spasms in his extremities. His temperature is 38.4°C (101.1°F), pulse is 51/min, respirations are 12/min and labored, and blood pressure is 88/56 mm Hg. Physical examination shows excessive salivation and tearing, and small pupils bilaterally. Treatment with atropine is initiated. Shortly after, most of his symptoms have resolved, but he continues to have muscular spasms. Administration of which of the following is the most appropriate next step in management of this patient?

A. Carbachol
B. Physostigmine
C. Pancuronium
D. Pralidoxime
E. Benztropine

🧠 Case-based MCQ 🔸 #MCQ_56
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The Correct answer is D

When taken in excess, medications for Alzheimer's disease such as donepezil can result in symptoms similar to that of organophosphate poisoning. In such cases, pralidoxime is given to restore activity of acetylcholinesterase, which then catalyzes the breakdown of excessive acetylcholine to reverse symptoms. Atropine does not act on nicotinic cholinergic receptors and thus cannot treat symptoms of neuromuscular dysfunction, for which pralidoxime is still necessary. Pralidoxime has poor blood-brain barrier penetration and can lead to a transient worsening of acetylcholinesterase inhibition following administration, which is why atropine is typically administered first to treat CNS symptoms and prevent further acetylcholinesterase inhibition.

 

❌Choice A is not correct:

Carbachol directly binds to acetylcholine receptors of both muscarinic and nicotinic type and is used in the treatment of glaucoma. It would further exacerbate this patient's symptoms of acetylcholine excess and must be avoided in this patient.

❌Choice B is not correct:

Physostigmine can be used as an antidote in atropine overdose or as a treatment for myasthenia gravis. However, in this patient with symptoms of acetylcholine excess, it would lead to exacerbation of this patient's symptoms by further increasing cholinergic stimulation.

❌Choice C is not correct:

Pancuronium belongs to the class of nondepolarizing muscle relaxants that bind to acetylcholine receptors at the neuromuscular junction, which blocks nicotinic stimulation by acetylcholine. Even though the administration of pancuronium would lead to a reversal of neuromuscular symptoms in this patient, muscular paralysis and possibly even respiratory impairment would result. The risks of pancuronium, therefore, outweigh its potential benefits, especially considering that safer alternatives are available.

❌Choice E is not correct:

Benztropine is a selective antagonist of muscarinic receptors that particularly decreases cholinergic overactivity in the CNS. It is typically used to treat tremor in Parkinson disease and extrapyramidal symptoms caused by antipsychotics. However, since this patient's muscarinic symptoms have mostly resolved following the administration of atropine, an additional muscarinic inhibitor would not be particularly useful.

✅Summarized Points:

This patient presents with symptoms of muscarinic acetylcholine excess (e.g., diarrhea, diaphoresis, bradycardia, bronchospasm, salivation, lacrimation, miosis) and nicotinic acetylcholine excess (e.g., muscle weakness). Atropine can only reverse the muscarinic effects.

🧠 Case-based MCQ 🔸 #MCQ_57
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A 12-day-old girl is brought to the emergency department for fever. The infant seems sleepier than usual and is less interested in feeding today. The patient was born full-term by spontaneous labor and vaginal delivery and had an uneventful nursery course. Her mother's prenatal laboratory results were normal, and the group B Streptococcus screen was negative. The patient's temperature is 38.3 C (101 F), blood pressure is 84/44 mm Hg, pulse is 162/min, and respirations are 42/min. Examination shows a sleepy but arousable infant She breastfeeds for 15 minutes in the emergency department without difficulty. Complete blood count, urinalysis, and cerebrospinal fluid profile are normal. Blood, urine, and cerebrospinal fluid cultures are pending. Which of the following is the most appropriate next step in the management of this infant?

 
A. Intramuscular ceftriaxone
B. Intravenous ampicillin plus ceftriaxone
C. Intravenous vancomycin plus ceftriaxone
D. Intravenous ampicillin plus gentamicin
E. Oral cephalexin

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🧠 Case-based MCQ 🔸 #MCQ_57
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The Correct answer is D

As history and examination cannot distinguish between viral and bacterial infection in young infants, all febrile infants age ≤60 days should undergo a full sepsis evaluation with blood, urine, and cerebrospinal fluid cultures. Infectious manifestations are often subtle at this age (e.g., fever can be the only symptom), though some infants may have hypothermia, lethargy, poor feeding, or decreased urine output. Regardless of initial laboratory data, all febrile infants age ≤60 days should be hospitalized. As culture data are pending, empiric intravenous antibiotics should be administered empirically based on the infant's age. Group B Streptococcus (GBS) and Escherichia coil are the most common pathogens in patients age <28 days. Patients are also evaluated for Listeria monocytogenes as it is potentially devastating even though far less common. The recommended empiric regimen is ampicillin plus either gentamicin or cefotaxime. Ampicillin provides good coverage for GBS and L monocytogenes. E Coli Is often resistant to ampicillin but usually sensitive to gentamicin or cefotaxime. Cefotaxime is often used when meningitis is suspected, owing to better penetration of the cerebrospinal fluid.


❌Choice A and B are not correct:

Ampicillin should be included, but ceftriaxone is generally avoided in infants age ≤28 days as it can potentially displace bilirubin from albumin-binding sites and increase the risk for kernicterus. Cefotaxime does not increase the risk for hyperbilirubinemia.

❌Choice C is not correct:

Vancomycin is indicated when there is a high risk of Streptococcus pneumoniae meningitis in infants age >28 days and/or when methicillin-resistant Staphylococcus aureus (MRSA) is suspected (e.g., due to pre-existing influenza infection and concurrent skin and soft-tissue infection). MRSA is not a common pathogen in neonatal sepsis. Ceftriaxone can potentially displace bilirubin from albumin-binding sites in infants age ≤28 days and increase the risk for kernicterus.

❌Choice E is not correct:

Oral antibiotics are inappropriate at the outset as bacteria can rapidly spread hematogenously to vital organs.

✅Summarized Points:

All febrile infants age <60 days should undergo blood, urine, and cerebrospinal fluid evaluation. Fever may be the only manifestation of a serious bacterial infection. When culture results are pending, ampicillin plus either gentamicin or cefotaxime should be given to cover Group B Streptococcus, Escherichia coli, and Listeria monocytogenes