статистика аудиторії Case-based MCQ

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🧠 Case-based MCQ 🔸 #MCQ_40 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D This patient’s presentation is most likely due to hypertrophic cardiomyopathy (HCM). Mutations in the sarcomere genes lead to disorganized, proliferating myocytes that can become significantly hypertrophic and obstruct the left ventricular outflow tract. The obstruction (and the accompanying systolic murmur) is exacerbated by low-volume states, such as dehydration or tachycardia. For this reason, patients are often symptomatic during vigorous exercise. Maneuvers that improve venous return to the heart (e.g., squatting, fist-clenching) will decrease the intensity of the murmur. Many patients are asymptomatic and are identified by sports preparticipation screening (e.g., family history of HCM). However, symptomatic patients can present with chest pain, dyspnea, fatigue, palpitations, and syncope. Rarely, the initial presentation may be a fatal dysrhythmia or cardiogenic shock. Patients generally have a systolic ejection murmur and left ventricular hypertrophy on ECG. Echocardiography is required to confirm the diagnosis. Once HCM is identified, all first-degree relatives should also be screened due to autosomal dominant inheritance. Affected individuals should undergo exercise stress testing. Beta-blockers can improve ventricular filling and minimize obstruction. ❌Choice A is not correct: Commotio Cordis, or ventricular fibrillation following chest wall impact, is a rare event that immediately follows trauma to the chest. Unlike this patient who recovered quickly, commotio cordis is virtually always fatal unless defibrillation is available. ❌Choice B is not correct: Heart block can present with syncope. However, there is no evidence of an abnormal PR interval on this patient’s ECG, and heart block would not account for his ventricular hypertrophy or murmur. ❌Choice C is not correct: Myocardial infarction is extremely rare in otherwise healthy teenagers. It is associated with uncontrolled dyslipidemias or with structurally abnormal hearts or coronary arteries. This patient has no evidence of myocardial infarction on his ECG (i.e., ST changes), and an infarction would not account for his ventricular hypertrophy. ❌Choice E is not correct: Wolff-Parkinson-White syndrome (WPW) can present with palpitations, syncope, chest pain, or even sudden death. The hallmark of WPW is preexcitation or a delta wave at the beginning of the QRS complex that shortens the PR interval and lengthens the QRS complex. This patient has no evidence of preexcitation on ECG. ✅Summarized Points: Hypertrophic cardiomyopathy can be asymptomatic or may present with chest pain, dyspnea, or syncope, particularly during exercise. Classic findings include a systolic murmur and left ventricular hypertrophy on ECG and echocardiography. First-degree relatives should undergo screening for hypertrophic cardiomyopathy.

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An 18-year-old boy is brought to the emergency department after a syncopal episode during football practice. Twenty minutes prior to fainting, the patient was tackled and developed chest pain. He was standing on the sideline when he suddenly passed out and regained consciousness within a few seconds. The patient had no head injury. He feels better after receiving intravenous normal saline. Heart rate and blood pressure are normal. Physical examination shows a grade 2/6 systolic ejection murmur at the right upper sternal border. An electrocardiogram (ECG) is obtained and is shown below. Which of the following is the most likely cause of this patient's syncope? A. Commotio cordis B. First-degree heart block C. Myocardial infarction D. Hypertrophic cardiomyopathy E. Wolff-Parkinson-White syndrome

🧠 Case-based MCQ 🔸 #MCQ_39 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is D To meet the criteria for a major depressive disorder, a patient must have 5 or more symptoms of depression (SIGECAPS), one of which must be depressed mood or anhedonia, for at least 2 consecutive weeks. Symptoms must not be attributable to substance use or other medical condition. Bipolar disorder and psychosis must also be excluded. This patient meets the criteria because she has had 7.5 months of insomnia, anhedonia (used to enjoy cooking), exhaustion, poor concentration, and decreased appetite. She has never had an episode of hypomania or mania and her symptoms are not better explained by a psychotic disorder or substance use. The next best step in management for this patient is starting her on an antidepressant, such as an SSRI, and attempting lifestyle changes, possibly with the help of psychotherapy.  l ❌Choice A is not correct: Postpartum blues are mild depressive symptoms (e.g., tearfulness or sadness) that may last up to 2 weeks following delivery. This patient has had severe depressive symptoms for 7.5 months, which started 6 weeks post-delivery. ❌Choice B is not correct: Adjustment disorder is a response to a psychosocial stressor that may manifest as symptoms of depression or anxiety (which do not meet the full criteria for any other psychiatric diagnosis) that last for up to 3–6 months after resolution of the stressful event. Because this patient has now had symptoms for 7.5 months after her delivery, adjustment disorder can be ruled out. ❌Choice C is not correct: To meet the DSM-V criteria for depression with peripartum-onset, symptoms must fulfill the criteria for major depressive disorder and onset of symptoms must begin during pregnancy or within 4 weeks of delivery. Although this patient meets the criteria for a major depressive episode, her symptoms started 6 weeks after her delivery. ❌Choice E is not correct: Normal behavior may include occasional feelings of sadness or tearfulness for < 2 weeks. While this patient has had recent stress which may trigger such feelings, she has had multiple, significant depressive symptoms for 7.5 months, which is no longer considered normal. ✅Summarized Points: This patient might have also had difficulty making decisions for more than 2 weeks.

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🧠 Case-based MCQ 🔸 #MCQ_39 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 25-year-old woman comes to the physician because of sadness that started 6 weeks after her 9-month-old daughter was born. Since then, she has not returned to work. Her daughter usually sleeps through the night, but the patient still has difficulty staying asleep. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?   A. Postpartum blues B. Adjustment disorder C. Depression with peripartum-onset D. Major depressive disorder E. Normal behavior

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🧠 Case-based MCQ 🔸 #MCQ_38 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is A Syndrome inappropriate antidiuretic hormone (SIADH) is an adverse effect of several medications, including carbamazepine, SSRIs, and cyclophosphamide and is characterized by an inappropriately elevated serum ADH despite low plasma osmolality (e.g., the patient is not hypovolemic). Risk factors for developing medication-induced SIADH include older age (> 65 years old), concomitant use of other antiseizure drugs and diuretics, and history of hyponatremia. Other causes of SIADH include CNS disorders, pulmonary disease, and ectopic production of ADH (e.g., small cell lung cancer). ❌Choice B is not correct: Low cardiac output (e.g., due to congestive heart failure) results in hypervolemic hyponatremia due to low renal perfusion and subsequent activation of RAAS and ADH secretion, which in turn stimulates water (and sodium) reabsorption. This patient lacks other signs of low cardiac output, including pitting edema, pulmonary edema, and/or elevated JVP, making this etiology unlikely. ❌Choice C is not correct: Hyperglycemia (e.g., from type 1 diabetes mellitus) can cause both hypovolemic and/or dilutional hyponatremia. Hypovolemic hyponatremia is a characteristic feature of diabetic ketoacidosis and occurs due to the osmotic diuresis from hyperglycemia and glucosuria. In dilutional hyponatremia, increased serum osmolality from hyperglycemia causes water to shift from the intracellular to the extracellular space, resulting in a decreased serum sodium concentration. This patient's normal metabolic panel and euvolemia on exam make hyponatremia due to hyperglycemia very unlikely. ❌Choice D is not correct: Aldosterone deficiency (e.g., due to adrenal insufficiency, type 4 RTA, or congenital hypoaldosteronism) can also manifest with hyponatremia and elevated ADH due to decreased sodium resorption in the collecting ducts. This patient does not have characteristic signs or symptoms of aldosterone deficiency, such as hyperkalemia, metabolic acidosis, or hypotension. ❌Choice E is not correct: Increased levels of cortisol (e.g., Cushing syndrome) classically manifest with hypernatremia, not hyponatremia. Other characteristic laboratory findings include hypocalcemia, hyperglycemia, and hypokalemia. ✅Summarized Points: This patient is euvolemic and has a low serum sodium level with high ADH levels, suggesting a diagnosis of SIADH

🧠 Case-based MCQ 🔸 #MCQ_38 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 75-year-old man with a seizure disorder is brought to the emergency department by a friend because of progressive confusion over the past two weeks. He is unable to provide any history. His vital signs are within normal limits. He appears lethargic and is only oriented to person. Oral mucosa is moist. There is no jugular venous distention. A basic metabolic panel shows a serum sodium concentration of 115 mEq/L but is otherwise normal. Serum osmolality is low and the antidiuretic hormone level is elevated. X-ray of the chest shows no abnormalities. Which of the following is the most likely cause of this patient’s hyponatremia? A. Medication effect B. Low cardiac output C. Insulin deficiency D. Aldosterone deficiency E. Excess cortisol

🧠 Case-based MCQ 🔸 #MCQ_37 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The Correct answer is E Ureterorenoscopy (URS) with stone removal is the first-line therapy for patients with urinary stones in the middle or distal ureter ≥ 10 mm, and unlike shock wave lithotripsy it is effective even in morbidly obese patients and, therefore, recommendable in this patient. It is also the suggested treatment in patients with ureteral stones who decide against or fail a trial of spontaneous stone passage. Overall, URS is the intervention with the greatest stone-free rate. ❌Choice A is not correct: Extracorporeal shock wave lithotripsy is a first-line treatment option for patients with ureteral stones > 10 mm. Among the interventions used in the treatment of urolithiasis, it is the procedure associated with the lowest complication rate. However, it is not the preferred treatment in morbidly obese patients, such as this woman. Excess fat tissue impairs adequate targeting of the stone via ultrasound and centering of the stone in the shock wave focus, which are prerequisites for extracorporeal shock wave lithotripsy. ❌Choice B is not correct: All patients with uncomplicated ureteral stones ≤ 10 mm should be offered a trial of the spontaneous stone passage under observation. However, this patient has a 12-mm stone that is unlikely to pass spontaneously. ❌Choice C is not correct: Ureteral stenting is recommended in patients with ureteral stones who develop complications such as (infected) hydronephrosis or sepsis. This patient does not have fever, leukocytosis, or an elevated WBCs on urine microscopy, which would suggest a urinary tract infection. Furthermore, ureteral stenting is not routinely recommended prior to any ureteral intervention. ❌Choice D is not correct: Thiazide diuretics may be indicated in patients with hypercalciuria or distal renal tubular acidosis who develop recurrent calcium-containing urinary stones. It is important to analyze the composition of stones in all first-time stone patients because in many cases lifestyle guidance, diet changes, and initiation of medical treatment (e.g, thiazide diuretics, allopurinol) can prevent future stone formation. However, specific guidance can only be provided after stone analysis. ✅Summarized Points: This morbidly obese patient presents with severe unilateral colicky flank pain, vomiting, costovertebral angle tenderness, and hematuria suggestive of urolithiasis. The CT scan of the abdomen and pelvis confirm an uncomplicated large stone in the distal right ureter.

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🧠 Case-based MCQ 🔸 #MCQ_37 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 33-year-old woman comes to the emergency department because of severe right flank pain for 2 hours. The pain is colicky in nature and she describes it as 9 out of 10 in intensity. She has had 2 episodes of vomiting. She has no history of similar episodes in the past. She is 160 cm (5 ft 3 in) tall and weighs 104 kg (229 lb); BMI is 41 kg/m2. Her temperature is 37.3°C (99.1°F), pulse is 96/min, respirations are 16/min and blood pressure is 116/76 mm Hg. The abdomen is soft and there is mild tenderness to palpation in the right lower quadrant. Bowel sounds are reduced. The remainder of the examination shows no abnormalities. Her leukocyte count is 7,400/mm3. A low-dose CT scan of the abdomen and pelvis shows a round 12 mm stone in the distal right ureter. Urine dipstick is mildly positive for blood. Microscopic examination of the urine shows RBCs and no WBCs. 0.9% saline infusion is begun and intravenous ketorolac is administered. Which of the following is the most appropriate next step in management? A. Extracorporeal shock wave lithotripsy B. Observation C. Ureteral stenting D. Thiazide diuretic therapy E. Ureterorenoscopy

🧠 Case-based MCQ 🔸 #MCQ_36 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. Ehlers-Danlos syndrome is a genetic connective tissue disorder characterized by increased joint mobility, skin extensibility, and connective tissue fragility. While multiple subtypes exist, all involve genetic defects in the synthesis and processing of different subtypes of collagen, leading to abnormal connective tissue production. Although clinical manifestations differ slightly based on the subtype, hypermobility, poor wound healing, and frequent joint dislocations should raise suspicion for this condition. Mitral valve prolapse is also common, and patients have an elevated risk of vascular dissection. The diagnosis is mainly clinical using specified criteria for major features of this condition. The most severe form, known as the vascular variant, presents without significant hypermobility of large joints, although small joints may be abnormal. This subtype places patients at especially high risk for visceral organ and major arterial rupture, with a median life expectancy of 48 years. No specific disease-modifying treatment is available, but physical therapy, wound precautions, and close cardiovascular and orthopedic monitoring is recommended. ❌Choice A is not correct: Fibrillin mutations are associated with Marfan syndrome, characterized by joint laxity, tall stature, pectus deformities, and aortic dilatation. ❌Choice B is not correct: Elastin mutations are associated with cutis laxa, which includes redundant skin, valvular regurgitation, and an increased risk of hernia. ❌Choice C is not correct: Filamin B is implicated in Larsen syndrome, characterized by joint dislocations and short stature. Patients can also have specific orofacial features, including a depressed nasal bridge and cleft palate. ❌Choice E is not correct:  The TGF-beta pathway is implicated in Loeys-Dietz syndrome, characterized by cleft palate, bifid uvula, and arterial tortuosity. ✅Summarized Points: Ehlers-Danlos syndrome is due to defects in the synthesis and processing of collagen. Features include increased joint mobility, skin extensibility, connective tissue fragility, and an increased risk for arterial dissection and rupture.

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🧠 Case-based MCQ 🔸 #MCQ_36 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 An 18-year-old presents to the emergency department after dislocating her shoulder while getting dressed. She denies significant trauma and has a history of multiple joint dislocations. Physical examination reveals multiple atrophic scars, skin hyperextensibility (shown below), and joint hypermobility. No other abnormalities are noted. This patient's symptoms are likely related to a defect in which of the following? A. Fibrillin B. Elastin C. Filamin B D. Collagen synthesis E. TGF-beta pathway

🧠 Case-based MCQ 🔸 #MCQ_35 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is E. This patient has adult onset polycystic kidney disease (APKD). APKD is an autosomal dominant disease that presents with hypertension, renal cysts, hematuria, and possible renal failure, usually after age 30. There is a 10 to 20% incidence of berry aneurysms in these patients, and they need to be screened with angiography to determine the presence or absence of these malformations. A magnetic resonance angiogram (MRA) of the brain is the standard option for such imaging in most medical centers. ❌Choice A is not correct: CT scan of the pelvis is not indicated since clinical history and renal ultrasound alone can make the diagnosis of APKD. The concern here is to screen for the concomitant presence of intracranial pathology. ❌Choice B is not correct: CT scan of the thorax is incorrect. Unless these lesions were mistaken for renal cell carcinoma, there is no indication to scan a distant site like the lungs as this disease has no malignant potential. ❌Choice C is not correct: MRI of the brain is not useful for detecting circulatory malformations without the aid of angiographic contrast material. ❌Choice D is not correct: Intravenous pyelography (IVP) is used to evaluate the collecting system of the urinary tract and is not indicated in this case, as the diagnosis of APKD is almost certainly based on the ultrasound and clinical presentation. This study adds no diagnostic information to the results of the ultrasound already obtained. ✅Summarized Points: There is a 10 to 20% incidence of berry aneurysms in these patients, and they need to be screened with angiography to determine the presence or absence of these malformations.

🧠 Case-based MCQ 🔸 #MCQ_35 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 58-year-old man presents to his urologist for continued evaluation of hypertension and hematuria. The patient has a 10-year history of hypertension and recent onset of painless hematuria for which he sought the attention of a urologist 3 months ago. On detailed questioning, the man states that he has been having severe headaches that are refractory to narcotic analgesics. Three days ago, a renal ultrasound was obtained that demonstrated bilaterally enlarged kidneys with multiple cysts. Which of the following is the most appropriate next step in diagnosis? A. CT scan of the pelvis B. CT scan of the thorax C. MRI of the brain D. Intravenous pyelography (IVP) E. Magnetic resonance angiogram (MRA) of the brain

🧠 Case-based MCQ 🔸 #MCQ_34 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is A. AIDS-related Kaposi sarcoma (KS) is a vascular tumor due to coinfection with HIV and human herpesvirus 8 and is considered an AIDS-defining illness. KS occurs most commonly in patients with CD4 counts <200 cells/ µL. Commonly involved areas include the skin, oral cavity, gastrointestinal tract, and lung. Cutaneous KS most often appears on the lower extremities, genitalia, and face. The lesions are typically painless elliptical papules of various colors (e.g., brown, red, purple) arranged in a linear fashion along with skin tension areas. However, early KS can appear similar to purpura, angiomas, hematomas, nevi, or dermatofibromas. Some patients may also have lymphedema due to obstruction of lymphatics by associated lymphadenopathy. ❌Choice B is not correct: Herpes zoster is due to varicella-zoster virus and typically presents as discrete grouped papules or plaques that eventually become vesicles in a dermatomal distribution. ❌Choice C is not correct: Psoriasis is typically characterized by sharply demarcated, raised, erythematous plaques with an overlying silvery scale on the extensor surfaces (e.g., elbows and knees, hands, feet, trunk). ❌Choice D is not correct: Seborrheic dermatitis usually presents as pruritic, erythematous plaques with fine, greasy scales. Lesions typically occur on the face (e.g., eyebrows, nasolabial folds), scalp, and chest. ❌Choice E is not correct: Subcutaneous lipoma forms a benign, solitary, painless, and mobile subcutaneous nodule. Commonly affected areas include the neck, trunk, and extremities. ✅Summarized Points: AIDS-related cutaneous Kaposi sarcoma typically presents as painless elliptical papules of various colors arranged in a linear fashion along with skin tension areas. However, early lesions can appear similar to purpura, angiomas, hematomas, nevi, or dermatofibromas.

🧠 Case-based MCQ 🔸 #MCQ_34 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 44-year-old former drug abuser with known HIV infection comes in for a follow-up. He has not been compliant with office visits or his medications. His last CD4 count was 22/µL. A close friend recently died from disseminated Kaposi sarcoma, and he is afraid of getting the disease. Which of the following would most likely resemble early Kaposi sarcoma in this patient? A. Purpura B. Herpes zoster C. Psoriasis D. Seborrheic dermatitis E. Subcutaneous lipoma

🧠 Case-based MCQ 🔸 #MCQ_33 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 The correct answer is D. Intense clinical investigations have been conducted to identify the most effective screening approach to prostatic cancer detection. The aim of an effective screening program is to detect prostatic cancer in the earliest stages, when surgery results in high cure rates. Currently, most cases of prostate cancer are identified by Digital rectal examination (DRE) and prostate-specific antigen (PSA) evaluation are the two components used in prostate cancer screening. ❌Choice A is not correct: Cytologic examination of prostatic secretion has proved ineffective in detecting prostatic cancer. ❌Choice B is not correct: Digital rectal examination (DRE) alone is a specific but not sensitive method; 1.5% of men older than 50 are found to have prostatic neoplasia on DRE alone. ❌Choice C is not correct: Because of the considerable overlap between the values due to prostatic hyperplasia and those resulting from prostatic cancer, serum PSA alone is sensitive but not specific. Approximately 2% of men older than 50 are found to have prostatic neoplasia by serum PSA measurements without DRE. The combination of abnormal DRE and elevated PSA affords the highest positive predictive value. Increasingly more centers are using age-specific reference ranges of serum PSA, along with ratios between free and protein-bound PSA, to improve sensitivity and specificity of this test. ❌Choice E is not correct: Transrectal ultrasonography is too expensive as a screening test and it does not significantly improve the detection rate when compared with combined DRE and serum PSA. Transrectal ultrasonography should be reserved mainly for staging purposes and to guide prostatic biopsies. ✅Summarized Points: Currently, most cases of prostate cancer are identified by Digital rectal examination (DRE) and prostate-specific antigen (PSA) evaluation are the two components used in prostate cancer screening.

🧠 Case-based MCQ 🔸 #MCQ_33 🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤🔤 A 65-year-old man comes to the physician for a health maintenance examination. Which of the following screening methods would allow the highest detection rate of prostatic carcinoma in early stages? A. Cytologic examination of prostatic secretion B. Digital rectal examination alone C. Serum prostate-specific antigen determination alone D. Serum prostate-specific antigen and digital rectal examination E. Transrectal ultrasonography