MCQs General medicine: case scenarios

Question # 1 A middle aged man was brought to the hospital emergency after he suffered a blunt traumatic injury to his chest and abdomen in a car accident. He was found to be hemodynamically stable and well oriented. He was in no immediate distress but severe pain in the left lower chest. Chest Xrays were taken as shown in the figure. Which of the following is true regarding the injury shown in the radiograph?

Options:
a. It is the most common injury after a blunt abdominal trauma
b. Surgical repair is indicated during the current hospitalization
c. Patient can be sent home and surgical repair carried out later
d. A thoracotomy is indicated e. Incidental discovery of this injury should not be repaired

Question # 2 A 23 year old man arrives in the emergency after a high speed motor accident while riding a motorcycle. Initial examination reveals an unstable pelvis and blood oozing out from the urethral meatus. Which of the following investigations would help identify a urethral injury?
Options:
a. CT scan of the pelvis
b. Retrograde urethrogram
c. Anterograde urethrogram
d. Intravenous pyelogram e. Stress Cystogram

Question # 3 A 2.5 year old boy is being brought to the clinic by his parents for evaluation of his eyes. His mother describes that she has observed something white in his left eye. She describes that her elder son has no such problem. On physical examination, the vital signs of the child are normal. Cardiovascular and respiratory examination is normal. Abdominal examination reveals soft non tender abdomen with no visceromegaly. The clinician diagnosed it as a case of retinoblastoma. Which of the following is the best test to confirm the diagnosis of this patient?
Options:
a. B-scan
b. A-scan
c. Excisional biopsy
d. Fine needle aspiration e. CT scan


Question # 4 A 65 year old man comes to the clinic complaining of difficulty in breathing on exertion and lying straight on bed. His past history is significant for systemic lupus erythematosus. His vital signs are temperature 37°C(98.6°F), pulse 76/min, blood pressure 160/80 mmHg, respirations 18/min. The cardiovascular examination reveals bounding radial pulses. The apex beat is displaced downwards and outwards. On auscultation there is high pitched early diastolic murmur. His echocardiogram confirms the diagnosis of aortic regurgitation. Which of the following drugs is most helpful in reducing his systolic hypertension?
Options:
a. Hydralazine
b. Verapamil
c. ACE inhibitors
d. Beta blocker e. Nitrates


Question # 5 A 50 year old, overweight, hypertensive patient came to her physician for a routine checkup. The physician advised her to lose weight to which she agreed. She agreed to start an exercise program. After one month she again came to the physician who noticed that she had gained 4 pounds of weight. She reports that she has not exercised yet because “the gym was so crowded that I couldn’t get in” Which of the following disorders best fit this picture?
Options:
a. Paranoid personality disorder
b. Histrionic personality disorder
c. Passive aggressive personality disorder
d. Narcissistic personality disorder


Question # 6A 15 year old boy presents to a clinic with complaints of fever, night sweats, lethargy and anorexia. His vital signs are temperature 38.3°C (101°F), pule 104/min, blood pressure 110/80 mmHg, respiratory rate of 18/min. On physical examination two cervical lymph nodes are palpable, around 5cm enlarged. Excisional biopsy of one node was done. Histopathology report describes presence of large, multilobed cells with prominent nucleoli surrounded by halo of clear nucleoplasm. Which of the following organisms is most likely to be associated with the condition of this patient?
Options:
a. Mycobacterium tuberculosis
b. Hepatitis B
c. Epstein Barr virus
d. Hepatitis C
e. Human T-cell leukemia virus type 1


Question # 7 A 65 year-old-male comes to the clinic complaining of blood in his mucus and urine. On detailed history he describes that he has chronic cough for last 6 months and now it is accompanied with hemoptysis since last week. He explains that he has also noticed blood in his urine two days ago. He denies smoking or any past medical history. On physical examination, there is pallor and edema of feet. Rest of the examination is unremarkable. His laboratory findings reveal:Hemoglobin: 8.7g/dL BUN: 40mg/dL Creatinine: 2.5 mg/dL What is the most likely diagnosis of this patient?
Options:
a. Wegener’s granulomatosis
b. Goodpasture syndrome
c. Berger disease
d. Polyarteritis nodosa
e. Alport syndrome

Question # 8 A 45-year-old man is admitted to the hospital because of chest pain for 1 hour. He has a sedentary lifestyle, and his diet is high in fat and sodium. The diagnosis of acute angina is made, and the appropriate treatment is administered. After the patient's condition is stabilized, the physician recommends an exercise regimen and a low-fat, low-sodium diet. Two weeks later, the patient returns for a follow-up examination. He indicates that he has not yet returned to work and spends most of the day lying on the couch. He has not had any chest pain, shortness of breath, dyspnea with exertion, or peripheral edema. Which of the following initial statements by the physician is most appropriate?
Options:
a. Are you afraid you might have a heart attack if you exercise?
b. Are you doing any types of exercise other than channel surfing?
c. Have you also not been following the diet I recommended?
d. What do you think is interfering with your ability to resume activity?
e. When would you like to start working on improving your health?

Question # 9 A 24 year old female contracts primary genital herpes virus infection during her 25th week of gestation. In your opinion which one of the below mentioned statements is true?
Options:
a. She has a high risk of miscarriage
b. She should be treated with antiviral therapy for 7-14 days
c. She should be scheduled for cesarean section at term
d. She should be advised against breastfeeding her infant

Question # 10 A 19-year-old girl presents to the emergency department with a history of excessive vaginal bleeding that started yesterday but has been increasing since early morning. She indicates that she had her first period (menarche) at age of 13 years and since then her periods have been irregular and unpredictable. She denies any sexual activity and a pregnancy test is negative. She looks pale but her vital signs are stable. Examination reveals significant uterine bleeding that soaks one pad every 3 hours. She is admitted to the hospital. She has had two dilation and curettages (D&Cs) over the past 9 months, which have failed to resolve her symptoms, and oral contraceptives and antiprostaglandins have not decreased the abnormal bleeding. Which of the following options is most appropriate at this time?
Options:
a. Perform a hysterectomy
b. Perform hysteroscopy
c. Perform endometrial ablation
d. Treat with GnRH agonist
e. Start the patient on high dose progestational agent

ANSWERS TO THE ABOVE QUESTIONS
Question # 1 Correct Answer is: b
Explanation: a. Only 4% of the abdominal blunt trauma patients present with diaphragmatic rupture. b. The patient needs immediate exploratory laprotomy with repair of the injury. The radiographs shows a gas bubble in the left side of the chest with a nasoagastric tube. This shows a diaphagmatic insult and herniation of the stomach into the thorax. This needs immediate repair because a negative pressure in the thorax will force more abdominal contents to enter, if left untreated, resulting in complete lung collapse. c. The patient must not be allowed to go home as further herniation of abdominal contents into the chest may cause pressure effects on the heart and lung collapse. A negative pressure in the thorax favour this herniation. d. An exploratory laprotomy is the next step in management of this patient as it gives a clearer view and easy repair of the diaphragm. e. If a diaphragmatic rupture is an incidental finding, it should be immediately repaired.

Question # Correct Answer is: b
Explanation: a. A CT scan of the pelvis will not be helpful in identifying urethral injury b. A retrograde urethrogram is essential for the diagnosis of urethral injury. A folley's catheter is minimally inflated after passing into the distal urethra. A water soluble dye is injected and a plain X-Ray obtained. The folley's catheter is not inserted upto the bladder untill urethral injury has been ruled out. c. Anterograde urethrogram is not useful in identifying urethral injury d. Intravenous pyelogram is used to detect any demage to the kidneys. e. Stress cystogram is used to evaluate the urinary bladder.

Question # 3 Correct Answer is: e
Explanation: a. B-scan is used to diagnose pathology of posterior segment like vitreous hemorrhage, retinal detachment, choroidal detachment or intraocular foreign body. b. A-scan is used to detect the reflectivity of intraocular foreign body, tumors and assessment of axial length of an eyeball for biometry. c. Biopsy is contraindicated in suspicion of retinoblastoma. d. Fine needle aspiration is also contraindicated in case of retinoblastoma. e. CT scan is done to confirm the diagnosis of retinoblastoma.

Question # 4 Correct Answer is: c
Explanation: a. Hydralazine is not useful in treating systolic hypertension of patient suffering from aortic regurgitation. b. Verapamil is not useful in treating systolic hypertension of patient suffering from aortic regurgitation. c. ACE inhibitors and nifedipine should be used in controlling systolic hypertension in patients suffering from aortic regurgitation. d. Beta blocker is not useful in treating systolic hypertension of patient suffering from aortic regurgitation. e. Nitrates are not useful in treating systolic hypertension of patient suffering from aortic regurgitation.

Question # 5 Correct Answer is: c
Explanation: a. Paranoid personality disorder (PPD) is a mental disorder characterized by paranoia and a pervasive, long- standing suspiciousness and generalized mistrust of others. Individuals with this personality disorder may be hypersensitive, easily feel slighted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. Paranoid individuals are eager observers. They think they are in danger and look for signs and threats of that danger, potentially not appreciating other evidence. b. Histrionic personality disorder, often abbreviated as HPD, is a type of personality disorder in which the affected individual displays an enduring pattern of attention-seeking and excessively dramatic behaviors beginning in early adulthood and present across a broad range of situations. Individuals with HPD are highly emotional, charming, energetic, manipulative, seductive, impulsive, erratic, and demanding. c. This 50 year old woman, who agreed to start an exercise program and then makes weak excuses for her failure to follow the program, is demonstrating passive aggressive personality disorder. She really never intended to follow the doctor’s exercise program (was inwardly defiant) but agreed to do it (was outwardly compliant). d. Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they're superior to others and have little regard for other people's feelings.

Question #6 Correct Answer is: c
Explanation: a. Mycobacterium tuberculosis infection shows granulomas on histopathology. b. Hepatitis B is not associated with enlargement of cervical lymph nodes. c. The histopathology repot describes classical Reed-Sternberg cells, which is characteristic finding of Hodgkin lymphoma. Epstein Barr virus is associated with mixed cellularity Hodgkin lymphoma in more than 50% of cases. d. Hepatitis C rarely causes acute infection and it is also not associated with enlargement of cervical lymph nodes. e. Human T-cell leukemia virus type 1 is associated with adult T-cell lymphoma or leukemia.

Question # 7 Correct Answer is: b
Explanation: a. Wegener's granulomatosis is an uncommon disorder that causes inflammation of your blood vessels. This inflammation restricts blood flow to various organs. It often affects your kidneys, lungs and upper respiratory tract. It may also present with pulmonary and renal involvement but it has associated upper respiratory tract findings like sinusitis and sinus abscesses. b. This patients presents with typical signs and symptoms of Goodpasture syndrome. His laboratory tests show anemia and elevated BUN and creatinine levels. Goodpasture syndrome is an eponym that has been used to describe the clinical entity of diffuse pulmonary hemorrhage and acute or rapidly progressive glomerulonephritis. There is no upper respiratory tract involvement in this syndrome. It is also limited to just the lung and kidney, so signs of vasculitis are absent. There is no skin, joint, gastrointestinal, eye or neurological involvement. On the complete blood cell count, anemia may be observed secondary to iron deficiency caused by intrapulmonary bleeding. Blood urea nitrogen (BUN) and serum creatinine levels are raised secondary to renal dysfunction. c. Berger disease presents with recurrent episodes of gross hematuria 1-2 days after an upper respiratory tract infection. d. Polyarteritis nodosa is a systemic vasculitis of small and medium sized arteries that most commonly affects the kidney. Virtually every organ of the body can be affected, but it tends to spare the lung. It is associated with glomerulonephritis, abdominal pain and neurological and dermatological involvement. e. Alport syndrome is a congenital defect of collagen that results in glomerular disease combined with sensorineural hearing loss and visual disturbance.

Question # 8 Correct Answer is: d
Explanation: a. It is a close ended question and should be asked as an opener to the interview b. This type of statement might offend the patient and is more like an allegation c. This is not an appropriate initial statement d. Knowing what the patient thinks is the correct choice as it will lead to encouragement of the patient to speak about his problems and will be able to share his fears with the doctor. It is an open ended question and will benefit in the treatment of the patient. e. Again this question is like an allegation or a taunt and should never be used as an initial question.

Question # 9 Correct Answer is: b
Explanation: a. During pregnancy if women develops primary herpes virus (HSV) infection they deliver healthy babies. No study has shown reports of Miscarriage particularly after 1st trimester. b. Recent guidelines recommend that in pregnancy antiviral agents should be administered for primary (HSV) infection. c. In routine there is no indication of a Cesarian section in an HSV infected woman. It is only indicated if there is an active viral lesion at the time of delivery. d. No risk of infection in the neonate is associated with breast feeding.

Question # 10Correct Answer is: b
Explanation: a. Hysterectomy is never a procedure of choice in abnormal bleeding, even if the patient has completed child bearing and is having significant abnormal bleeding. b. In patients with abnormal bleeding who are not responding to standard therapy, hysteroscopy should be performed. Hysteroscopy can rule out endometrial polyps or small fibroids, which, if present, can be resected. c. In patients with heavy abnormal bleeding who no longer desire fertility, an endometrial ablation can be performed d. Treatment with a GnRH agonist would only temporarily relieve symptoms e. Progestational agent is a temporary solution.