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Thread: MCQ's With Explanations

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    Default A 19-year-old pregnant patient gives a history of the recent onset of an involuntary movement disord

    Question

    A 19-year-old pregnant patient gives a history of the recent onset of an involuntary movement disorder that involves relatively rapid and fluid, but not rhythmic, limb and trunk movements. Which of the following is the most likely diagnosis?

    a.Chorea gravidarum

    b.Huntington's chorea

    c.Alzheimer's disease

    d.Multiple sclerosis

    e.Amyotrophic lateral sclerosis

    Answer / Explanation:


    [HIDE]The answer is a, Chorea gravidarum.

    Chorea gravidarum designates an involuntary movement disorder that occurs during pregnancy and involves relatively rapid and fluid, but not rhythmic, limb and trunk movements. This type of movement disorder may also appear with estrogen use, but the fundamental problem is a dramatic change in the hormonal environment of the brain. At the end of pregnancy or with the withdrawal of the offending estrogen, the movements abate. The movements that develop with chorea gravidarum may be quite asymmetric and forceful. Huntington's chorea is a progressive, uniformly fatal hereditary disease that does not fit well with the given history. The other choices are not typically characterized by this type of movement disorder.
    [/HIDE]

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    Question

    The influenza epidemic of 1918 to 1926 was associated with von Economo's encephalitis and left many persons with a syndrome indistinguishable from which of the following?


    a.Sydenham's chorea


    b.Alzheimer's disease


    c.Multiple sclerosis


    d.Amyotrophic lateral sclerosis


    e.Parkinson's disease

    Answer / Explanation:


    [HIDE]The answer is e, Parkinson's disease.

    A variety of agents can induce signs and symptoms of parkinsonism on a temporary basis, but few will evoke a persistent Parkinsonian syndrome. After the epidemic of encephalitis lethargica of 1918 to 1926, there were many cases of postencephalitic parkinsonism. The causative agent was believed to be an influenza virus, but it could not be isolated with the techniques available at the time of the epidemic. Postinfluenzal parkinsonism still develops, but the incidence is too rare to establish that this virus is the only virus capable of producing parkinsonism. Early in the infection, patients may exhibit a transient chorea. As the chorea abates, the parkinsonism appears and persists.[/HIDE]

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    Question

    A 43-year-old man has a father who died from Huntington's disease. The son was tested and found to have the gene for Huntington's disease. Which of the following is true regarding the offspring of those with Huntington's disease?


    a.Half the offspring are at risk only if the affected parent is male

    b.Half the offspring are at risk only if the affected parent is female

    c.Half the offspring are at risk if either parent is symptomatic for the disease before the age of 30

    d.Half the offspring are at risk for the disease

    e.One out of four children is at risk for the disease

    Answer / Explanation:


    [HIDE]
    The answer is d, Half the offspring are at risk for the disease.

    Huntington's disease is transmitted in an autosomal dominant fashion. The age at which the patient becomes symptomatic is variable and has no effect on the probability of transmitting the disease. The defect underlying this degenerative disease is an abnormal expansion of a region of chromosome 4 containing a triplicate repeat (CAG) sequence. Normal individuals have between 6 and 34 copies of this CAG section; patients with Huntington's disease may have from 37 to more than 100 repeats. Once expanded beyond 40 copies, the repeats are unstable and may further increase as they are passed on from one generation to the next. An increased number of repeats leads to a phenomenon known as anticipation, by which successive generations have earlier disease onset.[/HIDE]

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    Arrow What is the First Step in a Patient With Troublesome Urinary Leakage?

    What is the First Step in a Patient With Troublesome Urinary Leakage?


    Question 1

    A 53-year-old postmenopausal woman, gravida 3, para 3, presents for evaluation of troublesome urinary leakage 6 weeks in duration. Which of the following is the most appropriate first step in this patient's evaluation?

    a.Urinalysis and culture

    b.Urethral pressure profiles

    c.Intravenous pyelogram

    d.Cystourethrogram

    e.Urethrocystoscopy

    Answer / Explanation:

    [HIDE]The answer is a, Urinalysis and culture.

    When patients present with urinary incontinence, a urinalysis and culture should be performed. In patients diagnosed with a urinary tract infection, treatment should be initiated and then the patient should be reevaluated. It is not uncommon for symptoms of urinary leakage to resolve after appropriate therapy. After obtaining the history and physical examination and evaluating a urinalysis (including urine culture), initial evaluation of the incontinent patient includes a cystometrogram, check for residual urine volume, stress test, and urinary diary. A cystometrogram is a test that determines urethral and bladder pressures as a function of bladder volume; also noted are the volumes and pressures when the patient first has the sensation of need to void, when maximal bladder capacity is reached, and so on. Residual urine volume is determined by bladder catheterization after the patient has voided; when urine remains after voiding, infection and incontinence may result.
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    Last edited by trimurtulu; 12-24-2008 at 07:58 AM.

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    What is the First Step in a Patient With Troublesome Urinary Leakage?


    Question 2


    A postmenopausal woman is undergoing evaluation for fecal incontinence. She has no other diagnosed medical problems. She lives by herself and is self-sufficient, oriented, and an excellent historian. Physical examination is completely normal. Which of the following is the most likely cause of this patient's condition?


    a.Rectal prolapse

    b.Diabetes

    c.Obstetric trauma

    d.Senility

    e.Excessive caffeine intake

    Answer / Explanation:

    [HIDE]The answer is c, Obstetric trauma.

    The most common cause of fecal incontinence is obstetric trauma with inadequate repair. The rectal sphincter can be completely lacerated, but as long as the patient retains a functional puborectalis sling, a high degree of continence will be maintained. Generally the patient is continent of formed stool but not of flatus. Other causes of fecal incontinence include senility, central nervous system (CNS) disease, rectal prolapse, diabetes, chronic diarrhea, and inflammatory bowel disease. While rectal prolapse, CNS disease, and senility are thus potential causes of this condition, they can be excluded by the history of the patient in the question. Approximately 20% of all diabetics complain of fecal incontinence. Therapy for fecal incontinence includes bulk-forming and antispasmodic agents, especially in those patients presenting with diarrhea. All caffeinated beverages should be stopped. Biofeedback and electrical stimulation of the rectal sphincter are other possible conservative treatments. Surgical repair of a defect is indicated when conservative measures fail, when the defect is large, or when symptoms warrant a more aggressive treatment approach.
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    Last edited by trimurtulu; 12-24-2008 at 07:57 AM.

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    What is the First Step in a Patient With Troublesome Urinary Leakage?


    Question 3


    You are discussing surgical options with a patient with symptomatic pelvic relaxation. Partial colpocleisis (Le Fort procedure) may be more appropriate than vaginal hysterectomy and anterior and posterior (A&P) repair for patients in which of the following circumstances?


    a.Do not desire retained sexual function

    b.Need periodic endometrial sampling

    c.Have had endometrial dysplasia

    d.Have cervical dysplasia that requires colposcopic evaluation

    e.Have a history of urinary incontinence

    Answer / Explanation:

    [HIDE]The answer is a, Do not desire retained sexual function.

    Partial colpocleisis by the Le Fort procedure is reasonable for elderly patients who are not good candidates for vaginal hysterectomy and anterior and posterior (A&P) repair as treatment for vaginal and uterine prolapse. The technique involves partial denudation of opposing surfaces of the vaginal mucosa followed by surgical apposition, thereby resulting in partial obliteration of the vagina. Patients who are candidates for this procedure must have no evidence of cervical dysplasia or endometrial hyperplasia, have an atrophic endometrium, and no longer desire sexual function since the vagina is essentially obliterated and there is no longer access to the cervix or uterus via the vagina. Urinary incontinence can be a side effect of this procedure, so care must be exercised in the denudation of vaginal mucosa near the bladder. In a patient who already has urinary incontinence, the Le Fort operation would be relatively contraindicated. An A&P repair essentially involves excision of redundant mucosa along the anterior and posterior walls of the vagina, at the same time strengthening the vaginal walls by suturing the lateral paravaginal fascia together in the midline.
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    Arrow Which Diagnosis Best Fits These Symptoms?

    Which Diagnosis Best Fits These Symptoms?


    Question 1

    A 2-year-old child is admitted to your hospital team. The child's primary care doctor has been following the child for several days and has noted her to have had high fever, peeling skin, abdominal pain, and a bright red throat. You are concerned because two common pediatric problems that could explain this child's condition have overlapping presenting signs and symptoms. Which of the following statements comparing these two diseases in your differential is true?


    A. Neither has cardiac complications

    B. Serologic tests are helpful in diagnosing both

    C. Only one of the diseases has mucocutaneous and lymph node involvement

    D. Pharyngeal culture aids in the diagnosis of one of the conditions

    E. A specific antibiotic therapy is recommended for one of the conditions, but only supportive care is recommended for the other

    Answer / Explanation:


    [HIDE]
    The answer is d, Pharyngeal culture aids in the diagnosis of one of the conditions.


    The two conditions in consideration are Kawasaki disease and scarlet fever (i.e., "strep" throat). Kawasaki disease is an acute febrile illness of unknown etiology and shares many of its clinical manifestations with scarlet fever. Scarlatiniform rash, desquamation, erythema of the mucous membranes that produces an injected pharynx and strawberry tongue, and cervical lymphadenopathy are prominent findings in both. The most serious complication of Kawasaki disease and scarlet fever is cardiac involvement. Erythrogenic toxin-producing group A -hemolytic streptococcus is the agent responsible for scarlet fever. Isolation of the organism from the nasopharynx and a rise in antistreptolysin titers will confirm the diagnosis. Serologic tests for a variety of infectious agents, both viral and bacterial, have been negative in Kawasaki disease. Rheumatic heart disease is a serious sequela of streptococcal pharyngitis, which can be prevented by appropriate treatment with penicillin. Coronary artery aneurysm and thrombosis are the most serious complications of Kawasaki disease. The current approach to treatment of Kawasaki disease, which includes specific therapy with aspirin and IV gamma globulin administered within a week of the onset of fever, appears to lower the prevalence of coronary artery dilatation and aneurysm and to shorten the acute phase of the illness.[/HIDE]

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    Last edited by trimurtulu; 12-24-2008 at 01:32 PM.

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    Which Diagnosis Best Fits These Symptoms?


    Question 2




    A patient with hair loss is shown below. The lesion does not fluoresce with a Wood's lamp and has not responded well to a variety of topical agents. The lesion is boggy, is spreading, and has tiny pinpoint black dots throughout. Which of the following is the most likely diagnosis?







    A. Traction alopecia

    B. Infection with Trichophyton tonsurans

    C. Alopecia areata

    D. Biotinidase deficiency

    E. Hypothyroidism

    Answer / Explanation:


    [HIDE]
    The answer is b, Infection with Trichophyton tonsurans.



    Trichophyton tonsurans is a major cause of tinea capitis. It produces an infection within the hair follicle that is unresponsive to topical treatment alone and requires long-term therapy with griseofulvin for eradication. Fluorescence is absent on examination by Wood's lamp. Diagnosis is made by microscopic examination of KOH preparation of infected hairs and by culture on appropriate media. A severe form of tinea capitis known as kerion is shown in the photograph. A diagnosis of tinea capitis, and not seborrhea, should be considered in any child between the ages of 6 months and puberty who presents with scaliness and hair loss, even if mild. Seborrhea rarely occurs in that age group.

    Traction alopecia typically is seen in children who have their hair tied tightly in bows or braids; the hair loss is linear following the area of traction, and is often associated with regional adenopathy. Alopecia areata can appear similar to fungal infections, but the hairs near the active lesion often can be extracted with gentle traction resulting in an attenuated or catagen bulb at the termination of the hair shaft (exclamation hair); it does not produce a kerion as shown in the photograph. Children with biotinidase deficiency and those with hypothyroidism would be unlikely to have only isolated hair loss as the presenting symptom; rather, symptoms might include a variety of neurologic, dermatologic, and ocular complaints.

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    Which Diagnosis Best Fits These Symptoms?


    Question 3




    An 8-year-old sickle cell patient arrives at the emergency room in respiratory distress. Over the previous several days, the child has become progressively tired and pale. The child's hemoglobin concentration in the emergency room is 3.1 mg/dL. Which of the following viruses commonly causes such a clinical picture?




    A. Roseola

    B. Parvovirus B19

    C. Coxsackie A16

    D. Echovirus 11

    E. Cytomegalovirus


    Answer / Explanation:


    [HIDE]
    The answer is b, Parvovirus B19.



    Fifth disease (erythema infectiosum), long recognized as a benign mild exanthem of school-age children, is now known to be caused by human parvovirus B19. In the compromised patient, the parvovirus can cause serious anemia by infecting red-cell precursors and causing them to lyse. Patients with hemolytic conditions, such as sickle cell anemia, thus develop a transient aplastic crisis. A poorly functioning bone marrow (for a week or more) in a patient with a reduced red-cell life span (about 30 days) can result in profound anemia. Other problems can result in patients infected with parvovirus B19. In patients with immunodeficiency, the B19 infection can be persistent and lead to life-threatening chronic anemia. Infection in a pregnant woman can result in severe anemia in the infected fetus, with secondary hydrops fetalis and death. Roseola is now thought to be caused most often by the human herpesvirus 6. Coxsackie A16 virus causes hand-foot-and-mouth disease. Echo-11 virus frequently causes viral meningitis, and cytomegalovirus causes a congenital infection.


    [/HIDE]
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    Arrow What is the Likely Diagnosis for a Two-Year-Old With Bruising?

    What is the Likely Diagnosis for a Two-Year-Old With Bruising?



    Question 1

    Two weeks after a viral syndrome, a 2-year-old child develops bruising and generalized petechiae, more prominent over the legs. No hepatosplenomegaly or lymph node enlargement is noted. The examination is otherwise unremarkable. Laboratory testing shows the patient to have a normal hemoglobin, hematocrit, and white blood count and differential. The platelet count is 15,000/L. Which of the following is the most likely diagnosis?


    A. von Willebrand disease

    B. Acute leukemia

    C. Idiopathic (immune) thrombocytopenic purpura

    D. Aplastic anemia

    E. Thrombotic thrombocytopenic purpura

    Answer / Explanation:

    [HIDE]
    The answer is c, Idiopathic (immune) thrombocytopenic purpura.


    In children, idiopathic or immune thrombocytopenic purpura (ITP) is the most common form of thrombocytopenic purpura. In most cases, a preceding viral infection can be noted. No diagnostic test identifies this disease; exclusion of the other diseases listed in the question is necessary. In this disease, the platelet count is frequently less than 20,000/L, but other laboratory tests yield essentially normal results, including the bone marrow aspiration (if done). For ITP, platelets are sequestered and destroyed at the spleen by the reticuloendothelial system (RES) that binds self-immunoglobulins attached to the platelet. Treatment for ITP consists of observation and/or gamma globulin and steroids. Splenectomy is reserved for the most severe and chronic forms. Exogenous IV gamma globulin can work to saturate the RES binding sites for platelet-bound self-immunoglobulin. Thus, there is less platelet uptake and destruction by the spleen. Aplastic anemia is unlikely if the other cell lines are normal. Von Willebrand disease might be expected to present with bleeding and not just bruising. It is unlikely that acute leukemia would present with thrombocytopenia only. Thrombotic thrombocytopenic purpura is rare in children.[/HIDE]
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