Case-based MCQ | #MCQ_84
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A 65-year-old man underwent an uneventful right carotid endarterectomy 4 days ago. Today, he presents with shortness of breath which is progressively becoming worse. Which one of the following would be the best immediate step in management?
A. Intubation.
B. Tracheostomy.
C. Opening all the wound layers in the Emergency Department.
D. Supplemental oxygen via face mask.
E. Opening all the wound layers in the operating theater
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A 65-year-old man underwent an uneventful right carotid endarterectomy 4 days ago. Today, he presents with shortness of breath which is progressively becoming worse. Which one of the following would be the best immediate step in management?
A. Intubation.
B. Tracheostomy.
C. Opening all the wound layers in the Emergency Department.
D. Supplemental oxygen via face mask.
E. Opening all the wound layers in the operating theater
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Case-based MCQ | #MCQ_84
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Carotid endarterectomy is the procedure of choice in some patients with carotid stenosis. This procedure is associated with complications, the most important of which are as follows:
Perioperative stroke
Myocardial infarction
Hyper-reperfusion syndrome
Cervical hematoma
Nerve injury
Infection
Carotid restenosis
Postoperative cervical wound hematoma is a potentially lethal complication of carotid endarterectomy (CEA). The hematoma can rapidly distort the airway anatomy, making tracheal intubation difficult, and ultimately causing fatal airway obstruction. Post-CEA patients might develop airway emergencies related to hematoma formation either in the hospital or after discharge.
The progressive short of breast in this patient is most likely to have been caused by an expanding cervical hematoma. As always, management starts with the ABCD of life support (airway, breathing, circulation, and disability). The first step in this approach is ensuring and maintaining a patent airway. This patient has a rapidly deteriorating airway in need of urgent attention with intubation (option A). Initial method of airway management is based on the location, severity, and progression of the hematoma. Most patients can be managed successfully using a stepwise approach, beginning with awake fiber-optic intubation if time permits. If this fails, laryngoscopy, with either a direct or video laryngoscope, is a reliable backup. However, in a time-sensitive critical situation where there is impending respiratory compromise or airway loss, opening of all the wound layers at the spot (patient’s bedside in the Emergency Department in this scenario) to decompress the trachea and facilitate airway management should always be considered first as the most immediate action
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Carotid endarterectomy is the procedure of choice in some patients with carotid stenosis. This procedure is associated with complications, the most important of which are as follows:
Perioperative stroke
Myocardial infarction
Hyper-reperfusion syndrome
Cervical hematoma
Nerve injury
Infection
Carotid restenosis
Postoperative cervical wound hematoma is a potentially lethal complication of carotid endarterectomy (CEA). The hematoma can rapidly distort the airway anatomy, making tracheal intubation difficult, and ultimately causing fatal airway obstruction. Post-CEA patients might develop airway emergencies related to hematoma formation either in the hospital or after discharge.
The progressive short of breast in this patient is most likely to have been caused by an expanding cervical hematoma. As always, management starts with the ABCD of life support (airway, breathing, circulation, and disability). The first step in this approach is ensuring and maintaining a patent airway. This patient has a rapidly deteriorating airway in need of urgent attention with intubation (option A). Initial method of airway management is based on the location, severity, and progression of the hematoma. Most patients can be managed successfully using a stepwise approach, beginning with awake fiber-optic intubation if time permits. If this fails, laryngoscopy, with either a direct or video laryngoscope, is a reliable backup. However, in a time-sensitive critical situation where there is impending respiratory compromise or airway loss, opening of all the wound layers at the spot (patient’s bedside in the Emergency Department in this scenario) to decompress the trachea and facilitate airway management should always be considered first as the most immediate action
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Case-based MCQ | #MCQ_85
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A 32-year-old woman presents to your clinic for a skin checkup. On examination, she is found to have a skin lesion on her upper back. The lesion is highly suspected of being melanoma. An excisional biopsy is performed with 2 mm margins and the specimen is sent to a laboratory for histopathological studies. The result is a melanoma of 2.5 mm in depth. The margins, however, are clear. Which one of the following would be the next best step in management?
A. A wider excision.
B. Radiation therapy.
C. Sentinel node biopsy.
D. CT scan of the head.
E. Chemotherapy
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A 32-year-old woman presents to your clinic for a skin checkup. On examination, she is found to have a skin lesion on her upper back. The lesion is highly suspected of being melanoma. An excisional biopsy is performed with 2 mm margins and the specimen is sent to a laboratory for histopathological studies. The result is a melanoma of 2.5 mm in depth. The margins, however, are clear. Which one of the following would be the next best step in management?
A. A wider excision.
B. Radiation therapy.
C. Sentinel node biopsy.
D. CT scan of the head.
E. Chemotherapy
Case-based MCQ | #MCQ_85
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Correct Answer Is A
Every lesion suspected of being melanoma should be surgically excised with 2 mm margins both as the initial management and the most appropriate step in diagnosis. Further management is then guided by tne results of the biopsy. If the lesion is proved to be melanoma, a wider excision is needed. The margins of the second excision depend on the reported depth of melanoma.
For melanomas greater than 1mm in depth, a sentinel node biopsy is recommended during the second excision to assess the potential metastasis to the subcutaneous tissue and lymph nodes
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Correct Answer Is A
Every lesion suspected of being melanoma should be surgically excised with 2 mm margins both as the initial management and the most appropriate step in diagnosis. Further management is then guided by tne results of the biopsy. If the lesion is proved to be melanoma, a wider excision is needed. The margins of the second excision depend on the reported depth of melanoma.
For melanomas greater than 1mm in depth, a sentinel node biopsy is recommended during the second excision to assess the potential metastasis to the subcutaneous tissue and lymph nodes
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Case-based MCQ | #MCQ_86
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On a routine health examination, the lesion shown in the following photograph is found on the inner side of the lower lip of a 37-year-old man. The lesion is painless. Which one of the following is the most likely diagnosis?
A. Sebaceous cyst.
B. Peutz - Jegher's syndrome.
C. Squamous cell carcinoma of the lip.
D. Mucous cyst.
E. Basal cell carcinoma.
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On a routine health examination, the lesion shown in the following photograph is found on the inner side of the lower lip of a 37-year-old man. The lesion is painless. Which one of the following is the most likely diagnosis?
A. Sebaceous cyst.
B. Peutz - Jegher's syndrome.
C. Squamous cell carcinoma of the lip.
D. Mucous cyst.
E. Basal cell carcinoma.
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Case-based MCQ | #MCQ_86
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The lesion shown has a bluish-glistening color and is dome-shaped. These are characteristics of a benign mucoid cyst. A mucous cyst, also known as a mucocele forms when mucus or saliva escapes into surrounding tissues. A lining of granulation or connective tissue is formed to create a smooth, soft round fluid-filled lump. They most commonly occur on the inner surface of the lower lip (75% of cases) but may also appear on the floor of the mouth or on the gums, buccal mucosa, and tongue. If persistent or bothersome, an incision and evacuation of the cyst are performed.
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The lesion shown has a bluish-glistening color and is dome-shaped. These are characteristics of a benign mucoid cyst. A mucous cyst, also known as a mucocele forms when mucus or saliva escapes into surrounding tissues. A lining of granulation or connective tissue is formed to create a smooth, soft round fluid-filled lump. They most commonly occur on the inner surface of the lower lip (75% of cases) but may also appear on the floor of the mouth or on the gums, buccal mucosa, and tongue. If persistent or bothersome, an incision and evacuation of the cyst are performed.
Case-based MCQ | #MCQ_87
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The lesion shown in the accompanying photograph has been present on the finger of a 56-year-old woman for the past 8 months. It has slowly enlarged since then and is causing mild discomfort. Which one of the following is the most likely diagnosis?
A. Chronic paronychia.
B. Heberden’s node of osteoarthritis.
C. Pyogenic granuloma.
D. Mucous (synovial) cyst of the finger.
E. Rheumatoid nodule
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The lesion shown in the accompanying photograph has been present on the finger of a 56-year-old woman for the past 8 months. It has slowly enlarged since then and is causing mild discomfort. Which one of the following is the most likely diagnosis?
A. Chronic paronychia.
B. Heberden’s node of osteoarthritis.
C. Pyogenic granuloma.
D. Mucous (synovial) cyst of the finger.
E. Rheumatoid nodule
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Case-based MCQ | #MCQ_87
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The shiny nodule shown in the photograph which appears to be fluid-filled is suggestive of the digital synovial cyst (mucous cyst of the finger ).
Mucous (synovial) cysts of the finger are subcutaneous cystic lesions found on the dorsal aspect of the distal phalanx, distal to the distal interphalangeal joint, and overlying the germinal nail bed. They may cause distortion of the nail growth. They are located in the midline or laterally. They grow slowly and may undergo spontaneous resolution. Recurrence is likely if they are inadequately excised.
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The shiny nodule shown in the photograph which appears to be fluid-filled is suggestive of the digital synovial cyst (mucous cyst of the finger ).
Mucous (synovial) cysts of the finger are subcutaneous cystic lesions found on the dorsal aspect of the distal phalanx, distal to the distal interphalangeal joint, and overlying the germinal nail bed. They may cause distortion of the nail growth. They are located in the midline or laterally. They grow slowly and may undergo spontaneous resolution. Recurrence is likely if they are inadequately excised.
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Case-based MCQ | #MCQ_88
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A 52-year-old golfer man presents to your GP clinic with an ulcer on his right pinna. He says the lesion is itchy and easily bleeds on scratching. On examination, deeply sunburned areas around the lesion are noted. The lesion is shown in the accompanying photograph. Which one of the following can be the most likely diagnosis?
A. Basal cell carcinoma.
B. Squamous cell carcinoma.
C. Malignant melanoma.
D. Bowen’s disease.
E. Keratoacanthoma
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A 52-year-old golfer man presents to your GP clinic with an ulcer on his right pinna. He says the lesion is itchy and easily bleeds on scratching. On examination, deeply sunburned areas around the lesion are noted. The lesion is shown in the accompanying photograph. Which one of the following can be the most likely diagnosis?
A. Basal cell carcinoma.
B. Squamous cell carcinoma.
C. Malignant melanoma.
D. Bowen’s disease.
E. Keratoacanthoma
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Case-based MCQ | #MCQ_88
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Correct Answer Is B
The photograph shows a flat amelanotic lesion on the left pinna that has undergone ulceration and is slightly crusted. The appearance of the lesion is consistent with cutaneous squamous cell carcinoma (SCC) as the most likely diagnosis.
The classic presentation of a cutaneous SCC includes a shallow ulcer with heaped-up edges, often covered by a plaque usually in a sun-exposed area. Typical surface changes may include the following:
Scaling
Ulceration
Crusting
A cutaneous horn
Less commonly, cutaneous SCC presents as a pink cutaneous nodule without overlying surface changes. Regional spread of head and neck cutaneous SCCs, may result in enlarged preauricular, submandibular, or cervical lymph nodes.
NOTE - Although, the appearance of the lesion resembles SCC, it should be noted that at times SCC, keratoacanthoma, BCC, or even amelanotic forms of melanoma may look similar and the definite diagnosis cannot be made unless biopsy and histologic studies are performed. However, because of the classic features of the lesion and also the fact that squamous SCC is the most common skin cancer, SCC would be the most likely diagnosis in this case.
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Correct Answer Is B
The photograph shows a flat amelanotic lesion on the left pinna that has undergone ulceration and is slightly crusted. The appearance of the lesion is consistent with cutaneous squamous cell carcinoma (SCC) as the most likely diagnosis.
The classic presentation of a cutaneous SCC includes a shallow ulcer with heaped-up edges, often covered by a plaque usually in a sun-exposed area. Typical surface changes may include the following:
Scaling
Ulceration
Crusting
A cutaneous horn
Less commonly, cutaneous SCC presents as a pink cutaneous nodule without overlying surface changes. Regional spread of head and neck cutaneous SCCs, may result in enlarged preauricular, submandibular, or cervical lymph nodes.
NOTE - Although, the appearance of the lesion resembles SCC, it should be noted that at times SCC, keratoacanthoma, BCC, or even amelanotic forms of melanoma may look similar and the definite diagnosis cannot be made unless biopsy and histologic studies are performed. However, because of the classic features of the lesion and also the fact that squamous SCC is the most common skin cancer, SCC would be the most likely diagnosis in this case.
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Case-based MCQ | #MCQ_89
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The following photograph shows skin lesions on the hand of a 73-year-old woman, who resides in a nursing home. The lesions are severely itchy and she keeps scratching them, especially in the night. The itch prevents her from a good night sleep. On examination, she looks disheveled and poorly cared for. Which one of the following would be the most appropriate treatment for her?
A. Permethrin 5% cream.
B. Itraconazole cream.
C. Topical corticosteroids.
D. Gamma benzene hexachloride.
E. Topical erythromycin
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The following photograph shows skin lesions on the hand of a 73-year-old woman, who resides in a nursing home. The lesions are severely itchy and she keeps scratching them, especially in the night. The itch prevents her from a good night sleep. On examination, she looks disheveled and poorly cared for. Which one of the following would be the most appropriate treatment for her?
A. Permethrin 5% cream.
B. Itraconazole cream.
C. Topical corticosteroids.
D. Gamma benzene hexachloride.
E. Topical erythromycin
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Case-based MCQ | #MCQ_89
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The itching, the appearance of the lesions and living in a nursing home all favor of scabies as the most likely diagnosis. First-line medication for treatment of scabies is permethrin 5% cream. If treatment with permethrin fails or the patient is sensitive to this drug, benzyl benzoate can be used as second-line therapy. Benzyl benzoate is more irritating to skin and the treatment is likely to fail due to inadequate adherence.
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The itching, the appearance of the lesions and living in a nursing home all favor of scabies as the most likely diagnosis. First-line medication for treatment of scabies is permethrin 5% cream. If treatment with permethrin fails or the patient is sensitive to this drug, benzyl benzoate can be used as second-line therapy. Benzyl benzoate is more irritating to skin and the treatment is likely to fail due to inadequate adherence.
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Case-based MCQ | #MCQ_90
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A 50-year-old woman presents to your clinic with multiple lumps. She has had these lumps for 20 years. The only complaint, apart from her concerns about the look of the lumps, is that they become painful at times. On examination, about 30 mobile subcutaneous lumps feel soft, rubbery, and lobulated when palpated. They are distributed bilaterally in her upper and lower extremities, chest, and back. She mentions that her mother has the same problem. She is otherwise healthy. Which one of the following is the most likely diagnosis?
A. Adipose dolorosa.
B. Multiple desmoid tumors.
C. Multiple epidermoid cysts.
D. Multiple symmetrical subcutaneous lipomas.
E. Neurofibromatosis type I (Von Recklinghausen disease of nerve).
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A 50-year-old woman presents to your clinic with multiple lumps. She has had these lumps for 20 years. The only complaint, apart from her concerns about the look of the lumps, is that they become painful at times. On examination, about 30 mobile subcutaneous lumps feel soft, rubbery, and lobulated when palpated. They are distributed bilaterally in her upper and lower extremities, chest, and back. She mentions that her mother has the same problem. She is otherwise healthy. Which one of the following is the most likely diagnosis?
A. Adipose dolorosa.
B. Multiple desmoid tumors.
C. Multiple epidermoid cysts.
D. Multiple symmetrical subcutaneous lipomas.
E. Neurofibromatosis type I (Von Recklinghausen disease of nerve).
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Case-based MCQ | #MCQ_90
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Correct Answer Is D
The clinical findings such as mobility, subcutaneous location, and the consistency of the lumps make the multiple symmetrical lipomas the most likely diagnosis. Being lobulated is another important clue, as is the positive family history.
Lipomas are benign tumors of mature fat cells. They are quite common and can be found in subcutaneous tissue. Although the subcutaneous fat layer is the most common site for lipomas to arise, they may be subfascial, intramuscular, or be found in many other sites. There is usually a genetic predisposition.
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Correct Answer Is D
The clinical findings such as mobility, subcutaneous location, and the consistency of the lumps make the multiple symmetrical lipomas the most likely diagnosis. Being lobulated is another important clue, as is the positive family history.
Lipomas are benign tumors of mature fat cells. They are quite common and can be found in subcutaneous tissue. Although the subcutaneous fat layer is the most common site for lipomas to arise, they may be subfascial, intramuscular, or be found in many other sites. There is usually a genetic predisposition.
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Case-based MCQ | #MCQ_90
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A 65-year-old man presents with an exquisitely painful vesicular rash, which has been present for the past 7 days and is increasingly painful. The rash is shown in the following photograph. His past medical history is unremarkable. Physical examination is otherwise inconclusive. Which one of the following is the most appropriate immediate management?
A. Oral famciclovir.
B. Intravenous famciclovir.
C. Oral amitriptyline.
D. Intramuscular immunoglobulin.
E. Oral Phenergan® (promethazine).
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A 65-year-old man presents with an exquisitely painful vesicular rash, which has been present for the past 7 days and is increasingly painful. The rash is shown in the following photograph. His past medical history is unremarkable. Physical examination is otherwise inconclusive. Which one of the following is the most appropriate immediate management?
A. Oral famciclovir.
B. Intravenous famciclovir.
C. Oral amitriptyline.
D. Intramuscular immunoglobulin.
E. Oral Phenergan® (promethazine).
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Case-based MCQ | #MCQ_90
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Correct Answer Is C
The appearance of the rash and the history suggest herpes zoster (shingles) infection as the most likely diagnosis.
Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus (VZV). It usually occurs in adults but can be seen in children and in the first 2 years of life if there has been a history of maternal varicella.
Pain is a significant complaint in patients with shingles. Tricyclic antidepressants and the anticonvulsant gabapentin are the most effective medications for pain control in neuropathic pain associated with shingles.
⚠ (Options A and B) Antiviral agents such as famciclovir, valacyclovir, or acyclovir should be used in any patient seen within 72 hours of the onset of vesicles, all patients with ophthalmic herpes zoster, and in immunocompromised patients. For pregnant women, only acyclovir (first line) or valaciclovir (second line) are used because the safety of famciclovir during pregnancy has yet to be established
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Correct Answer Is C
The appearance of the rash and the history suggest herpes zoster (shingles) infection as the most likely diagnosis.
Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus (VZV). It usually occurs in adults but can be seen in children and in the first 2 years of life if there has been a history of maternal varicella.
Pain is a significant complaint in patients with shingles. Tricyclic antidepressants and the anticonvulsant gabapentin are the most effective medications for pain control in neuropathic pain associated with shingles.
⚠ (Options A and B) Antiviral agents such as famciclovir, valacyclovir, or acyclovir should be used in any patient seen within 72 hours of the onset of vesicles, all patients with ophthalmic herpes zoster, and in immunocompromised patients. For pregnant women, only acyclovir (first line) or valaciclovir (second line) are used because the safety of famciclovir during pregnancy has yet to be established
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❤2
Case-based MCQ | #MCQ_91
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A 34-year-old woman presents to your clinic complaining of abdominal pain and diarrhea one week after she returned from a trip to Thailand. While she was on the trip, she first noticed abdominal pain in the right iliac fossa which resolved subsequently. On examination, the abdomen is non-tender and soft with no rigidity or guarding. However, digital rectal exam is tender. Which one of the following is the most likely diagnosis?
A. Giardiasis.
B. Celiac disease.
C. Rotavirus infection.
D. Urinary tract infection.
E. Appendicitis
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A 34-year-old woman presents to your clinic complaining of abdominal pain and diarrhea one week after she returned from a trip to Thailand. While she was on the trip, she first noticed abdominal pain in the right iliac fossa which resolved subsequently. On examination, the abdomen is non-tender and soft with no rigidity or guarding. However, digital rectal exam is tender. Which one of the following is the most likely diagnosis?
A. Giardiasis.
B. Celiac disease.
C. Rotavirus infection.
D. Urinary tract infection.
E. Appendicitis
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