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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Collaborator
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>> New MCCQE Exam Objectives <<
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NEW QUESTION # 45
A 16-year-old boy is brought to the office for examination, which reveals the lesion in the attached image and similar lesions on other parts of his body. You also notice multiple scattered subcutaneous tumors that he says have been there for a long time. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
The presence of multiple cutaneous lesions along with numerous longstanding subcutaneous tumors is most consistent with neurofibromatosis type 1 (NF1) . MCCQE objectives emphasize recognizing classic dermatologic findings of NF1, which include multiple neurofibromas (soft, skin-colored subcutaneous nodules) and characteristic pigmented lesions such as cafe-au-lait macules and axillary or inguinal freckling.
These lesions typically develop during childhood or adolescence and increase in number over time.
Sarcoidosis can cause skin lesions but is not associated with multiple benign peripheral nerve sheath tumors.
Dermatofibromas are usually solitary, firm nodules rather than numerous soft tumors. Vitiligo presents as depigmented macules without subcutaneous masses. Lipomatosis involves multiple lipomas but lacks the associated pigmentary skin findings seen in NF1.
NF1 is an autosomal dominant condition caused by mutation of the NF1 gene. Diagnosis is clinical based on established criteria. Recognition is important because patients require surveillance for complications such as optic gliomas, learning disabilities, skeletal abnormalities, and malignant peripheral nerve sheath tumors.
NEW QUESTION # 46
A 40-year-old woman has not left her house for 6 months. She says that she is trying to avoid the intense anxiety, palpitations, tremors, sweating, dizziness, choking sensation, and breathlessness that develops when she leaves home. Which one of the following is the best next step?
Answer: C
Explanation:
This patient's symptoms are consistent with panic disorder with agoraphobia , characterized by recurrent panic attacks and avoidance of places where escape may be difficult. She has avoided leaving her home for 6 months due to fear of panic symptoms (palpitations, tremors, sweating, dyspnea, choking sensation), which is classic for agoraphobia.
MCCQE objectives emphasize that first-line management includes cognitive behavioral therapy (CBT) with graded exposure therapy , which involves gradual, systematic exposure to feared situations (e.g., short walks progressing to longer distances). Encouraging incremental exposure directly addresses avoidance behavior and reduces anxiety over time.
Lithium is used for bipolar disorder, not panic disorder. Chlorpromazine (an antipsychotic) is not first-line and carries unnecessary side effects. Reassurance alone is insufficient because panic disorder significantly impairs functioning. Hospitalization is not indicated unless there is suicidality or inability to care for oneself.
Therefore, gradual exposure through increasing walks is the most appropriate next step, consistent with evidence-based management of panic disorder with agoraphobia.
NEW QUESTION # 47
A 24-year-old woman presents with rapidly increasing lower leg pain. Less than 24 hours ago, she fell off her bicycle and had some minor abrasions. On examination, she is in severe pain and appears anxious. Local examination of her leg reveals mild discoloration with marked tenderness but no swelling in her calf. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
Rapid progression of pain out of proportion to exam, systemic symptoms (anxiety), and skinchanges without major swelling are classic for necrotizing fasciitis-a surgical emergency. Discoloration and extreme tenderness should raise immediate concern.
Toronto Notes 2023 - Emergency Medicine / Surgery:
"Necrotizing fasciitis presents with severe pain, systemic toxicity, rapid progression, and early skin changes (discoloration). Pain out of proportion is a key clue." MCCQE1 Objectives (Emergency Medicine > 51-1: Soft Tissue Infections):
"Candidates must recognize necrotizing fasciitis and initiate urgent surgical consultation." Plantaris rupture (A) is benign and localized. DVT (B) is more gradual and often with swelling. Cellulitis (C) progresses more slowly and is less painful. Baker's cyst (D) causes posterior knee pain, not severe systemic illness.
NEW QUESTION # 48
A 4-year-old boy is brought by his parents to your walk-in clinic with a 3-week history of fatigue, bruising, and intermittent fever. He was previously healthy. Physical examination reveals hepatosplenomegaly and petechiae. His complete blood count shows the following:
Platelet count, blood: 15.0 × 10#/L (206.4-443.3)
White blood cell (WBC) count, blood: 1.0 × 10#/L (4.7-13.5)
Hemoglobin (Hgb), blood: 70 g/L (105-135)
Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
This child has pancytopenia (severe thrombocytopenia, leukopenia, and anemia) plus systemic symptoms (fatigue, intermittent fever) and hepatosplenomegaly, strongly suggesting bone marrow failure/infiltration, most commonly acute lymphoblastic leukemia (ALL) in this age group. MCCQE objectives emphasize recognizing red flags for childhood malignancy: unexplained bruising/petechiae from thrombocytopenia, recurrent or persistent fever, pallor, and organomegaly due to leukemic infiltration or extramedullary hematopoiesis.
Immune thrombocytopenia typically causes isolated thrombocytopenia with otherwise normal hemoglobin and WBC count and usually no hepatosplenomegaly. Iron deficiency anemia causes microcytic anemia but does not explain profound thrombocytopenia and leukopenia. Viral illness may transiently suppress counts but is less likely to cause marked pancytopenia with significant organomegaly. Bacterial sepsis can cause thrombocytopenia but usually presents with acute toxicity and does not typically produce this pattern of sustained pancytopenia and hepatosplenomegaly.
Next steps (clinically) would include urgent peripheral smear, oncology referral, and bone marrow evaluation.
NEW QUESTION # 49
A 55-year-old woman presents to the office with a 2-month history of right shoulder pain and limited function that started after she began an upper body weight training program. Examination shows tenderness inferior to the acromion. She has full passive range of motion of the shoulder but significant pain with abduction from
30° to 120° of arc. Which one of the following is the best next step?
Answer: A
Explanation:
The presentation is consistent with rotator cuff tendinopathy or subacromial impingement. The painful arc between 30°-120° with preserved passive ROM suggests this. Ultrasound is the preferred initial imaging modality due to its availability, safety, and ability to visualize soft tissues dynamically.
Toronto Notes 2023 - Orthopedics, "Shoulder Pathologies" Section:
"In rotator cuff injuries or impingement syndromes, initial imaging with musculoskeletal ultrasound is appropriate. It can identify tendinopathy, partial tears, or subacromial bursitis." MCCQE1 Objectives (Surgery > 84-7: Musculoskeletal Pain):
"Candidates should initiate workup for rotator cuff or impingement syndromes with ultrasound as the first- line test, reserving more invasive or costly procedures for unresolved or complex cases." CT (A) is used for bony detail, not soft tissues. Arthroscopy (C) is invasive and therapeutic. Arthrography (D) is outdated and largely replaced by MRI or ultrasound.
NEW QUESTION # 50
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