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Thread: MCQ's With Explanations

  1. #41
    trimurtulu is offline MedicalGeek Resident
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    Arrow An 81-year-old, fair-skinned woman presents for evaluation of lesions that she has had for about two

    Diagnosis At A Glance

    Case Report:

    An 81-year-old, fair-skinned woman presents for evaluation of lesions that she has had for about two years on both legs. She admits to ample sun exposure in the past and has had a skin cancer removed from her face. Although the lesions are largely asymptomatic, several have bled following minor trauma. An examination of the patientÕs legs reveals mild edema as well as multiple erythematous patches and thin plaques of varying sizes.

    -------------

    What is your Diagnosis?

    Cross check here

    [HIDE]
    Disseminated superficial actinic porokeratosis (DSAP) presents as multiple flat to barely elevated brownish-red patches on the extremities. The inheritance pattern of the disorder is autosomal dominant with variable penetrance. In genetically predisposed individuals, chronic sun exposure is implicated in the development of lesions, which tend to appear beginning in the fourth decade. Most cases can be diagnosed based on clinical appearance; histopathology will confirm the diagnosis. Uncommonly, DSAP may evolve into squamous cell carcinoma. Some lesions may respond to cryosurgery or topical application of 5-fluorouracil or imiquimod cream.
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  2. #42
    trimurtulu is offline MedicalGeek Resident
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    Default Ocular Sarcoidosis: A systems-based approach to diagnosis and treatment

    Ocular Sarcoidosis: A systems-based approach to diagnosis and treatment

    The patient is a 46 year-old female with no significant ocular history who was referred from an outside ophthalmologist for evaluation of persistent floaters in both eyes for four months. She denies seeing flashing lights in either eye. She has no history of trauma to either eye. She also denies decreased vision, eye pain, or eye redness.
    Chief Complaint: Floaters in both eyes (OU) for four months.

    History of Present Illness: The patient is a 46 year-old female with no significant ocular history who was referred from an outside ophthalmologist for evaluation of persistent floaters in both eyes for four months. She denies seeing flashing lights in either eye. She has no history of trauma to either eye. She also denies decreased vision, eye pain, or eye redness.

    Past Ocular History: No history of ocular surgery. She wears reading glasses.

    Past Medical History: The patient has a history of bipolar disorder and gastro-esophageal reflux disease (GERD).

    Past Surgical History: Uterine cryotherapy for dysfunctional uterine bleeding, tubal ligation, lipoma resection from anterior abdomen, and surgical decompression of “trigger thumb”

    Medications: Wellbutrin, Risperdal, Lamictal, Prevacid

    Allergies: Sulfa-containing drugs cause pruritis.

    Family History: The patient’s mother and grandmother have diabetes. Her grandmother also has “heart problems.”

    Social History: The patient is married and has three children. She denies alcohol use, but she has been smoking one pack of cigarettes every week for the last 6 months.

    Review of Systems: Negative apart from the ocular symptoms noted above.

    Ocular Examination:
    •Visual Acuity, without correction: Right eye (OD)--20/20-1; Left eye (OS)--20/20-1
    •Intraocular pressure (IOP) by applanation: 40 mmHg OD and 19 mmHg OS
    ◦Gonioscopy: Open bilaterally 360 degrees without peripheral anterior synechiae (PAS). No neovascularization of the angle.
    •Pupils:
    ◦OD: 4mm in dark, constricting to 3.5mm in light
    ◦OS: 3.5mm in dark, constricting to 2.5mm in light
    ◦No relative afferent pupillary defect (RAPD).
    •Ocular motility: Full, OU
    •Slit lamp examination:
    ◦OD: Mild conjunctival hyperemia. Small granulomatous keratic precipitates in the inferonasal aspect of cornea OD (Figure 1A). 5-10 WBC per HPF and 1+ flare in anterior chamber OD. Nodular irregularity of the iris at approximately 3 o’clock with surrounding dilated blood vessels and thickening of iris stroma (Figure 1B).
    ◦OS: Normal
    •Dilated fundus examination (DFE), OU: Normal discs with increased cupping of right disc as compared to the left. No pallor or edema, OU. Macula, vasculature, and peripheral retina were normal, OU.
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    Full details with Pictures

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  3. #43
    trimurtulu is offline MedicalGeek Resident
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    Default Case: 5 y.o. WF presenting with dog bite to left side of face

    Canalicular Laceration - Dog Bite:

    5 y.o. WF presenting with dog bite to left side of face.

    CC:
    5 y.o. WF presenting with dog bite to left side of face.
    HPI:
    5 hours prior to this evaluation, patient was playing with the black Labrador retriever of a family friend. Family witnessed the dog making a single lunge at the girl’s face, and an incomplete bite resulted with only the top jaw making contact. The dog did not attack further, and the incomplete bite to the left face was the only injury sustained.
    POH/PMH/SH:
    No past ocular history. No past medical history. No medications nor allergies. Well-adjusted kindergarten child lives at home with parents. Childhood immunizations up to date.
    OCULAR EXAM
    • VA 20/25 OD and OS without correction
    • Extraocular motility and IOP were normal, OU
    • CVF: Full OD, OS
    • Lids: Right side - Normal
    • Lids: Left side - 2 lacerations on the left upper lid, the larger and deeper of the laceration passes just medial to the upper punctum. Initial exploration of laceration raises concerns for probable canalicular involvment, but further detailed examination in this anxious pediatric patient was unable to be accomplished in the ER (See Photos).
    The patient was taken to the operating suite for examination under anesthesia (EUA) and laceration repair, likely to include canalicular repair (see Photos).

    Continuation of the examination in the operating suite revealed that the remainder of the anterior segment examination and DFE were normal.

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  4. #44
    trimurtulu is offline MedicalGeek Resident
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    Arrow A Case of Maternal Herpes Simplex Virus Encephalitis During Late Pregnancy


    CME/CE Test


    A Case of Maternal Herpes Simplex Virus Encephalitis During Late Pregnancy

    The Case

    A pregnant 25-year-old woman at 32 weeks' gestation was admitted to an emergency unit after her husband had found her drowsy and with her tongue bitten. The day before admission, the patient had developed a fever of 39 °C, was suffering from headaches, was nauseated and had vomited. On admission, she had anterograde and retrograde amnesia, but no somatic neurological deficits were detected.
    Investigations:
    Routine laboratory testing, lumbar puncture, cerebrospinal fluid analysis, routine bacteriology, brain MRI, and polymerase chain reaction testing for neurotropic viruses including herpes simplex virus types 1 and 2.
    Diagnosis:
    Maternal herpes simplex virus type 1 encephalitis.
    Management:
    Antiviral and anticonvulsive therapy, supportive treatment, and cesarean section.
    The Case Details:

    A pregnant 25-year-old woman at 32 weeks' gestation was admitted to an emergency unit after her husband had found her drowsy and with her tongue bitten. The patient had anterograde and retrograde amnesia suggestive of a postictal state, indicating that she had experienced a first-ever generalized seizure. For the previous 3 days, she had been experiencing frontotemporal headaches associated with phonophobia and photophobia.

    On the day before admission, the patient had developed a fever of 39 °C, was nauseated and had vomited. On admission, no somatic neurological deficits were detected. There were no signs of eclampsia as a possible underlying cause of the seizures–the patient's blood pressure was normal and proteinuria was absent. The patient had no history of genital lesions or their symptoms.



    Figure 1. (click image to zoom) Brain MRI scans of a patient with acute herpes simplex type 1 encephalitis. (A) On admission, coronal FLAIR imaging showed T2 hyperintensities within the right temporopolar and temporomesial region (arrow). (B) Corresponding diffusion restriction was seen on axial diffusion-weighted sequences (arrow). (C,D) Repeat imaging was performed after the patient had experienced two further epileptic seizures and was somnolent. The right temporal lobe lesion was seen to have increased in size on the FLAIR sequences (C; arrow), and there was corresponding increased diffusion restriction, with the diffusion abnormalities now also involving the cortex (D; arrow). The repeat FLAIR images suggested that another lesion had appeared in the medial aspect of the left temporal lobe (C; arrowhead). No diffusion restriction was detected for this possible new lesion (D). Abbreviation: FLAIR, fluid-attenuated inversion recovery.

    Laboratory examination of the patient's blood revealed leukocytosis (15.6 x 109 white blood cells/l; normal range 3.5-10.5 x 109 white blood cells/l) due to increased neutrophils (13.95 x 109 cells/l; normal range 1.6-7.4 x 109 cells/l), and raised levels of C-reactive protein (17 mg/l; normal value < 5 mg/l).

    Lumbar puncture was performed and cerebro-spinal fluid (CSF) analysis revealed a pleocytosis with predominantly mononuclear cells (99%) of 125 cells/ul and 10 erythrocytes/ul, a normal protein level (0.37 g/l; normal value < 0.42 g/l) and a slightly increased lactate level (2.3 mmol/l; normal value < 2.1 mmol/l). A brain MRI scan with coronal fluid-attenuated inversion recovery (FLAIR) sequences revealed a temporopolar and mesial hyperintensity on the right side of the patient's brain (Figure 1A). On diffusion-weighted MRI sequences, the lesion showed areas of diffusion restriction (Figure 1B).

    Herpes simplex virus encephalitis (HSE) was suspected on the basis of the patient's medical history, clinical presentation, and CSF and MRI findings, and antiviral therapy with intravenous aciclovir (12.5 mg/kg every 8 h) was started, together with anticonvulsive prophylaxis consisting of four doses of 1 mg intravenous lorazepam administered at 6 h intervals. In addition, betamethasone (two doses of 12 mg given intramuscularly 24 h apart) was administered to stimulate lung maturation in the fetus. Polymerase chain reaction (PCR) testing of the patient's CSF was positive for herpes simplex virus type 1 (HSV-1) and negative for herpes simplex virus type 2 (HSV-2), confirming a diagnosis of HSV-1 encephalitis. Serology was negative for HSV-1 IgG, indicating that the patient had a primary herpes virus infection.

    On the third day of hospitalization, the patient experienced a second generalized seizure, along with increasing drowsiness and meningeal signs, which prompted the instigation of intravenous anticonvulsive therapy with 100 mg lamotrigine once daily; this regimen was supplemented with 2.5 mg levetiracetam once daily after the patient had a third seizure on the fifth day of hospitali-zation. A second MRI scan at this point showed that the right-sided herpetic lesion had increased in volume and that signs of another lesion had appeared in the medial aspect of the left temporal lobe (Figure 1C). No diffusion restriction was detected for this possible new lesion (Figure 1D).


    The deterioration of the patient's clinical status and the progression of the HSV-1 lesions in her brain led to concerns for the safety of the fetus, and a cesarean section was, therefore, performed under general anesthesia. No complications were experienced during the procedure, and a preterm but otherwise healthy infant (2,340 g birth weight) was delivered. The newborn was immediately started on aciclovir prophylaxis and was transferred to the neonatal intensive care unit. No viral copies were detected on HSV-1 PCR of the amniotic fluid, umbilical cord blood or venous blood of the infant drawn at delivery, and consequently its aciclovir prophylaxis was discontinued.


    The mother experienced no further seizures and her aciclovir therapy was stopped 21 days after its initiation when her PCR results from a second CSF examination were negative for HSV-1. Other findings were a 98% mononuclear pleocytosis of 40 cells/ul, a protein level of 0.51 g/l and a lactate level of 1.4 mmol/l. No neurological or neuro-psychological deficits were present in the mother or her newborn infant at discharge 4 weeks after initial hospitalization. The mother did not experience any further seizures, but anticonvulsive prophylaxis with lamotrigine was continued until the first follow-up 6 months after discharge.

    Questions:

    1. Which of the following viruses is the most common cause of sporadic encephalitis in the United States?

    • Cytomegalovirus
    • Influenza A virus
    • Herpes simplex virus (HSV)
    • Echovirus
    2. Which of the following symptoms is not among the triad that forms the clinical hallmark of acute viral encephalitis?
    • Seizures
    • Fever
    • Headache
    • Altered mental state
    3. Which of the following is the most common cause of neonatal herpes infection?
    • HSV-1
    • HSV-2
    • Herpes zoster
    • None of the above
    4. Which of the following tests is most likely to be recommended for the diagnosis of encephalitis during pregnancy?
    • Magnetic resonance imaging (MRI)
    • Computed tomography (CT)
    • Angiography
    • Electroencephalography (EEG)
    5. Which of the following tests is the modality of choice for diagnosing HSV CNS disease in adults?
    • Brain biopsy
    • HSV serum antibodies
    • Polymerase chain reaction (PCR) testing of CSF
    • CSF cytology
    -------------------

    Answers & Explanations:

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  5. #45
    trimurtulu is offline MedicalGeek Resident
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    Arrow Impact of Cancers and Cardiovascular Diseases in Chronic Obstructive Pulmonary Disease

    Impact of Cancers and Cardiovascular Diseases in Chronic Obstructive Pulmonary Disease


    Abstract

    Purpose of Review: Cardiovascular disease and cancer are the two leading causes of morbidity and mortality in patients with chronic obstructive pulmonary disease. The epidemiological and mechanistic evidence linking these disorders, however, is uncertain.

    Recent Findings: In patients with mild chronic obstructive pulmonary disease, cardiovascular disease accounts for nearly 50% of all hospitalizations and over 20% of all deaths, whereas lung cancer accounts for about a third of all mortality. Collectively, cancer is responsible for over 50% of all deaths in mild chronic obstructive pulmonary disease. In general, chronic obstructive pulmonary disease increases the risk of cardiovascular disease and lung cancer by two-fold, with increasing risk as the disease progresses. The mechanisms linking these disorders have not been well worked out. Shared genetic risk factors, and perturbations in the inflammatory, oxidative and neurohumoral responses, are implicated. Epidemiological studies suggest that anti-inflammatory drugs may reduce the risk of cardiovascular disease and lung cancer but have not been confirmed.

    Summary: Cardiovascular diseases and lung cancer are major sources of morbidity and mortality in chronic obstructive pulmonary disease. Patients should be assessed carefully for additional risk factors and be treated aggressively with interventions to mitigate the risk of cardiovascular disease and lung cancer.

    Introduction

    Chronic obstructive pulmonary disease (COPD) affects over 600 million people worldwide, representing 10% of adults 40 years and older. COPD is the leading cause of medical hospitalization in many Western countries and the fourth leading cause of mortality (soon to be the third leading cause). However, these figures grossly underestimate the true health burden of COPD in the population. In patients with mild to moderate COPD [Global Initiative for Chronic Obstructive Lung Disease (GOLD), stages 1 and 2], which make up more than 80% of COPD cases in the community, the leading cause of morbidity is cardiovascular disease (CVD) and the leading cause of mortality is lung cancer. Surprisingly, very few patients with GOLD stage 1 or 2 disease experience COPD-related hospitalization or death. In general, compared to individuals without COPD, patients with COPD have a two-three-fold increase in the risk for CVD and lung cancer. In this paper we will review the relationship of COPD with CVD and lung cancer and the purported mechanisms linking these disorders.

    -----------

    Questions:

    1. Which of the following statements about the relationship between lung function and cardiovascular disease (CVD) is most accurate?

    • Reduced forced expiratory volume in 1 second (FEV1) only increases the risk for CVD among smokers
    • There is no association with regard to the degree of impairment of FEV1 and the risk for CVD
    • The presence of hypertension is synergistic with reduced FEV1 in promoting CVD
    • Emphysema severity does not correlate with arterial stiffness
    2. Which of the following groups of medications has been associated with an increased risk for CVD or arrhythmia in patients with chronic obstructive pulmonary disease (COPD)?
    • Cardioselective oral beta-blockers only
    • Inhaled ipratropium only
    • Inhaled ipratropium and inhaled beta2-agonists only
    • Inhaled ipratropium, cardioselective oral beta-blockers, and inhaled beta2-agonists
    3. All of the following statements about the use of heart-protective drugs among patients with COPD are accurate, except:
    • Large, randomized controlled trials have demonstrated better CVD outcomes with these drugs
    • Statins plus angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have been demonstrated to reduce rates of hospitalization for COPD, myocardial infarction, and mortality
    • Treatment with statins may reduce mortality
    • Low-dose inhaled corticosteroids have been associated with reduced risks for myocardial infarction, arrhythmias, and CVD mortality
    4. Which of the following statements about the relationship between COPD and cancer is most accurate?
    • Moderate-to-severe COPD is associated with a particular risk for squamous cell carcinoma of the lung
    • COPD increases the risk for lung cancer only among adults with a history of smoking
    • The risk for cancer falls faster than the risk for CVD following smoking cessation
    • Even quitting smoking on a part-time basis is associated with a large reduction in the risk for lung cancer
    ----------------
    Answers / Explanations:

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    Last edited by trimurtulu; 01-09-2009 at 10:23 PM.

  6. #46
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    Arrow A 56-year-old has not received any medical care nor seen a physician for years

    Question


    A 56-year-old has not received any medical care nor seen a physician for years. He reports reduced exercise tolerance over the past 5 years. On occasion in the past year he has noted chest pain after ascending a flight of stairs.

    He smokes 2 packs of cigarettes per day. He is found to have a blood pressure of 155/95 mm Hg. His body mass index is 30. Laboratory findings include a total serum cholesterol of 245 mg/dL with an HDL cholesterol that is 22 mg/dL. Which of the following vascular abnormalities is most likely to be his most serious health risk?

    A Hyperplastic arteriolosclerosis

    B Lymphedema

    C Medial calcific sclerosis

    D Atherosclerosis

    E Deep venous thrombosis

    F Plexiform arteriopathy
    C)

    Answer & Explanation:

    [HIDE]D) CORRECT. He has multiple risk factors for atherosclerosis, including his weight, smoking, hypertension, and high total cholesterol with low 'good' HDL cholesterol. His findings suggest coronary artery disease.[/HIDE]
    .
    Last edited by trimurtulu; 01-12-2009 at 06:54 PM.

  7. #47
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    Arrow A 55-year-old previously healthy woman is hospitalized for pneumonia.

    Question


    A 55-year-old previously healthy woman is hospitalized for pneumonia. On the 10th hospital day she is found to have swelling and tenderness of her right leg, which apparently has developed over the past 48 hours. Raising the leg elicits pain. An ultrasound examination reveals findings suggestive of femoral vein thrombosis. Which of the following conditions is most likely to have contributed the most to the appearance of these findings?


    A Trousseau syndrome

    B Protein C deficiency

    C Prolonged immobilization

    D Pregnancy

    E Chronic alcoholism

    F Hypertension
    C)

    Answer & Explanation:

    [HIDE]C) CORRECT.
    The immobilization would predispose to thrombosis of leg veins. This is the most common cause for deep venous thrombosis.
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  8. #48
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    Arrow A 63-year-old man has had insulin dependent diabetes mellitus for over two decades.

    Case Report

    A 63-year-old man has had insulin dependent diabetes mellitus for over two decades. The degree of control of his disease is characterized by the laboratory finding of a hemoglobin A1C of 10.1%. He has noted episodes of abdominal pain following meals. These episodes have worsened over the past year. On physical examination, there are no masses and no organomegaly of the abdomen, and he has no tenderness to palpation. Which of the following pathologic findings is most likely to be present in this man?

    A Ruptured aortic aneurysm

    B Hepatic infarction

    C Mesenteric artery occlusion

    D Acute pancreatitis

    E Chronic renal failure
    ----------

    Answer & Explanation:

    [HIDE](C) CORRECT. He has 'abdominal angina' from diminished blood flow to the bowel as a consequence of severe atherosclerosis. Persons with diabetes mellitus may have this finding, because all branches of major arteries to the bowel are affected by atherosclerosis. [/HIDE]
    ......

  9. #49
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    Arrow A 62-year-old man has experienced substernal chest pain upon exertion with increasing frequency over

    Case Report

    A 62-year-old man has experienced substernal chest pain upon exertion with increasing frequency over the past 6 months. An electrocardiogram shows features consistent with ischemic heart disease. He has a total serum cholesterol of 262 mg/dL. By angiography, there is 75% narrowing of the left anterior descending artery. Which of the following vascular complications is most likely to occur in this patient?


    A A systemic artery embolus from thrombosis in a peripheral vein.

    B A systemic artery embolus from a left atrial mural thrombus.

    C Pulmonary embolism from a left ventricular mural thrombus.

    D A systemic artery embolus from a left ventricular mural thrombus.

    E Pulmonary embolism from thrombosis in a peripheral vein.
    ----------

    Answer & Explanation:

    [HIDE](D) CORRECT. Left ventricular mural thrombi are prone to embolize to the systemic arterial circulation. Such mural thrombi are likely to result from damage to the left ventricle from ischemic heart disease, either acutely with an underlying myocardial infarction, or with a left ventricular aneurysm formed following resolution of a large myocardial infarction. [/HIDE]
    ......

  10. #50
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    Arrow A 10-year-old previously healthy child has been noted by her parents to be constantly thirsty.

    Case Report

    A 10-year-old previously healthy child has been noted by her parents to be constantly thirsty. She is consuming large amounts of soft drinks. She is urinating often. Her diet and exercise patterns have not changed, except for an increased appetite, yet she appears cachectic and has lost 7 kg over the past 4 months. On physical examination there are no abnormal findings, other than peripheral muscle wasting and weakness.
    Which of the following laboratory findings would you most strongly suspect is present in this girl?

    [COLOR="Navy"]A Increased blood insulin

    B Decreased blood glucagon

    C Ketonuria

    D Markedly increased serum osmolality

    E Decreased plasma hydrogen ion (alkalosis)

    F Decreased plasma cortisol
    Answer

    [HIDE]
    C) CORRECT.
    Ketonuria is typical for type I diabetes mellitus.
    [/HIDE]

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