Trial Test – Part 1

The most likely diagnosis is B) Acute diverticulitis

Left lower quadrant pain is a hallmark of acute diverticulitis, as the sigmoid colon commonly affected in diverticulosis is located in the LLQ.

Recurrent episodes of LLQ pain suggest prior diverticulitis, which is common in patients with diverticulosis. Tenderness and rebound tenderness in the LLQ support localized inflammation in the sigmoid colon.

Explanation

A) Acute cholecystitis presents with right upper quadrant pain, often radiating to the shoulder, nausea, and fever, not LLQ pain.

C) Acute pyelonephritis causes flank pain, fever, and significant pyuria or bacteriuria, which are not prominent in this patient.

D) Appendicitis causes right lower quadrant pain, starting periumbilical and migrating. LLQ pain excludes this.

E) Spontaneous bacterial peritonitis typically occurs in cirrhotic patients with ascites, presenting with diffuse abdominal pain, not localized LLQ pain.

The best next course of management is C) Intravenous fluids, broad-spectrum antibiotics, wound sample for gram stain, and above-knee amputation if warranted

Signs of necrotizing infection: The presence of crepitus, rapid progression with systemic toxicity, and blebs indicates a life-threatening infection, most likely clostridial myonecrosis (gas gangrene). This condition requires urgent and aggressive treatment to prevent systemic complications and death.

Management priorities: 1. Resuscitation: Intravenous fluids and broad-spectrum antibiotics to stabilize the patient and address septic shock.2. Wound assessment: A sample for gram stain and culture helps guide further antimicrobial therapy and 3. Surgical intervention: Debridement or amputation is mandatory to remove necrotic tissue and halt disease progression. If the infection has spread extensively, an above-knee amputation is often required to save the patient’s life.

Explanation

A) Intravenous fluids, broad-spectrum antibiotics, wound sample for culture and sensitivity:

While antibiotics and wound sampling are crucial, surgery is the cornerstone for treating necrotizing infections. Delaying surgery worsens the prognosis.

B) Intravenous fluids, broad-spectrum antibiotics, incision and drainage: Incision and drainage are insufficient for deep, necrotizing infections like gas gangrene. Radical debridement or amputation is required.

D) Immediate transmetatarsal amputation of the foot: The infection has already spread above the knee as indicated by blebs. A transmetatarsal amputation would leave infected tissue in place.

E) Immediate above-knee amputation of the leg: While this might ultimately be needed, the decision for amputation should follow proper resuscitation, imaging, and assessment of the infection’s extent.

The correct answer is: E) Ileoanal pouch

Surgical management for Crohn’s disease focuses on relieving complications and managing disease progression while preserving as much bowel function as possible. However, not all surgical procedures are suitable for Crohn’s disease due to the nature of the disease.

This procedure is typically performed for ulcerative colitis, not Crohn’s disease, because Crohn’s can affect any part of the gastrointestinal tract and has a high risk of recurrence at the surgical site. The creation of an ileoanal pouch in Crohn’s patients is contraindicated due to a high failure rate.

Explanation

A) Ileostomy: Used in cases where part of the intestine must be bypassed or removed. Temporary or permanent ileostomy can help manage severe disease or complications.

B) Colostomy: Sometimes required if part of the colon is removed or bypassed due to complications like strictures, perforation, or fistulas.

C) Fistulectomy: Often used to treat perianal fistulas, a common complication of Crohn’s disease.

D) Ileocolostomy: A common surgical procedure in Crohn’s disease involving resection of the diseased bowel segment and anastomosis of the ileum to the remaining colon.

The correct answer is: C) Normal-pressure hydrocephalus (NPH)

Normal-pressure hydrocephalus (NPH) is a triad of symptoms often described as “wet, wobbly, and wacky”:

Urinary incontinence (“wet”).

Gait disturbance (“wobbly”) – often described as difficulty initiating walking, with a magnetic or shuffling gait.

Cognitive decline (“wacky”) – often resembling dementia.

This patient’s history of progressive memory issues, difficulty initiating walking, and urinary incontinence fits the classical presentation of NPH.

Explanation

While memory issues are prominent in Alzheimer’s(A), urinary incontinence and significant gait disturbances are not part of the early presentation.

Parkinson’s(B) features include bradykinesia, rigidity, and resting tremor, but urinary incontinence and dementia are late-stage symptoms.

Pick’s disease(D)is a form of frontotemporal dementia, it presents with early behavioral changes and personality shifts, not the triad seen in NPH.

Progressive supranuclear palsy (E) Presents with postural instability, vertical gaze palsy, and bradykinesia, but not urinary incontinence or the described cognitive pattern.

The correct answer is: A) Hallucinations
Lewy body dementia is characterized by the presence of visual hallucinations and fluctuating cognition. These hallucinations tend to occur early in the course of the disease and are more common in LBD compared to Alzheimer’s dementia.

Explanation
Lip smacking (B)is more associated with tardive dyskinesia, not specifically with Lewy body dementia.
While tremor (C)is a hallmark symptom of Parkinson’s disease, it is less common in Lewy body dementia and not a primary feature. In LBD, the tremor may be less prominent than in Parkinson’s disease.
Emotional lability (D) can occur in both Lewy body dementia and Alzheimer’s disease, but it is not a distinguishing feature.
Repetitive behavior (E)is more commonly seen in Alzheimer’s disease and not a prominent feature of Lewy body dementia.

The correct answer is: C) development of Kluver–Bucy syndrome

 Explanation

Pick’s disease (a type of frontotemporal dementia) is associated with behavioral changes such as apathy, disinhibition, and socially inappropriate behaviors (e.g., sexually inappropriate actions). The lip-smacking behavior described is a form of oral stereotypy, which is commonly seen in Kluver-Bucy syndrome, a condition associated with damage to the medial temporal lobes, including the amygdala.

Kluver–Bucy syndrome is characterized by:

• Apathy
• Hyperorality e.g., lip smacking
• Hypersexuality or sexually inappropriate behavior

These symptoms may occur in Pick’s disease as a result of frontal and temporal lobe degeneration.

Explanation

A) Elder abuse: While inappropriate behavior can sometimes be attributed to abuse, the context of the patient’s symptoms; lip smacking, sexual inappropriateness, apathy suggests a neurodegenerative cause rather than external abuse.

 B) Medication side effects: Some medications can cause lip smacking or other movement disorders such as tardive dyskinesia, but the combination of apathy and sexual inappropriateness fits more with a neurodegenerative disorder, like Pick’s disease.

 D) Toxin exposure: Toxins may cause neurodegenerative symptoms, but there is no indication from the history provided that this patient has been exposed to any harmful substances.

 E) Chronic hypoxia: While chronic hypoxia can lead to cognitive decline, it is not typically associated with the specific symptoms of lip smacking, apathy, and sexual inappropriateness seen in this patient.

The correct answer is B) aphthous stomatitis.

Aphthous stomatitis (B) is characterized by recurrent, painful ulcers on the mucous membranes of the mouth or lips. These ulcers are often associated with triggers like stress, hormonal changes (e.g., onset of menses), or smoking, as described in this patient.

The fact that the ulcers are recurrent, painful, and correlate with her menstrual cycle strongly supports this diagnosis.

Explanation

 Kawasaki disease (A) is a vasculitis seen primarily in young children usually under age 5, presenting with features like prolonged fever, conjunctivitis, rash, changes in the oral mucosa e.g., strawberry tongue, cervical lymphadenopathy, and extremity changes e.g., swelling, peeling.

 Squamous cell carcinoma of the lip (C) typically presents as a persistent ulcer, nodule, or plaque on the lip or skin that is not painful in its early stages. It is associated with risk factors like smoking and sun exposure; however, this patient’s ulcer is recurrent and painful, which is not consistent with squamous cell carcinoma.

Syphilis (D) Syphilis can present with a painless chancre during its primary stage, usually at the site of infection, the painful nature of this ulcer and its recurrent pattern make syphilis less likely.

Kolpik’s spot (E) are small, white spots with a red halo on the buccal mucosa, typically seen in measles before the rash appears. They are not painful ulcers and do not occur on the lower lip.

The correct answer is B) telogen effluvium.

Telogen effluvium (B) is a common condition characterized by diffuse hair shedding that often occurs a few months after a significant physical or emotional stressor, such as childbirth. It is the most likely diagnosis in this case because postpartum women often experience hormonal shifts that cause more hair to enter the telogen phase and subsequently shed.  

Explanation

 Alopecia areata (A) is an autoimmune condition characterized by sudden, patchy hair loss. It typically presents as smooth, circular bald patches rather than diffuse hair thinning. This does not match the patient’s description of excessive postpartum hair loss.

Trichotillomania (C) is a psychiatric disorder where individuals compulsively pull out their own hair. It results in irregular patterns of hair loss and does not typically align with the patient’s report of generalized, excessive hair loss postpartum.

Tinea capitis (D) is a fungal infection of the scalp that causes patchy hair loss, scaling, and sometimes inflammation or pustules.

Hypothyroidism (E) H can cause hair thinning or hair loss, but it is usually associated with other systemic symptoms such as fatigue, weight gain, cold intolerance, and dry skin. In this case, there is no mention of additional symptoms suggesting hypothyroidism.

The correct answer is A) pityriasis rosea.

 Pityriasis rosea (A) typically starts with a herald patch, a single, large, red, oval lesion that precedes the generalized rash by about a week. The subsequent rash often appears as smaller, scaly lesions distributed in a Christmas-tree pattern along the lines of skin tension, especially on the chest and back. The timing, non-itchy nature, and description of the rash strongly point to pityriasis rosea, making it the most likely diagnosis.

Explanation

 Tinea versicolor (B) is a superficial fungal infection caused by Malassezia. It typically presents as hypopigmented, hyperpigmented, or erythematous macules or patches on the trunk and arms. The rash is not usually red, does not follow a herald patch or Christmas-tree pattern, and often causes mild itching, which makes this diagnosis unlikely in this case.

Herpes zoster (C) presents as a painful, vesicular rash that follows a dermatomal distribution. It does not form a generalized or Christmas-tree pattern, and pain or tingling usually precedes the rash. The absence of vesicles and pain makes herpes zoster an unlikely diagnosis.

 Varicella (D) is caused by the varicella-zoster virus and presents with a generalized pruritic rash that progresses through macules, papules, vesicles, and crusted lesions, often in different stages of development. The lack of itching and the rash’s specific pattern rule out varicella in this patient.

 Lyme disease (E) is caused by Borrelia burgdorferi and typically starts with erythema migrans, a red, expanding “bull’s-eye” rash at the site of a tick bite. Secondary rashes may occur later but are not described as a Christmas-tree pattern. The absence of systemic symptoms like fever, fatigue, or joint pain, and the description of the rash, make Lyme disease unlikely.