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| Section | Objectives |
|---|---|
| Dimensions of Care | - Acute Care
|
| Physician Activities | - Management
|
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NEW QUESTION # 142
You are asked to assess an 85-year-old man who was admitted to the hospital for management of a bowel obstruction. The patient is in bed and has a faint pulse with no detectable blood pressure. There is vomitus on his bed and clothing. He has central cyanosis, and oxygen saturation is 75% on supplemental oxygen. Which one of the following is the best next step?
Answer: B
Explanation:
This patient is critically unstable with severe hypoxia (SpO# 75% despite oxygen), central cyanosis, hypotension (no detectable blood pressure), and evidence of active vomiting-placing him at extremely high risk of airway compromise and aspiration . According to MCCQE resuscitation objectives and ABC principles, airway management is the immediate priority in a patient with respiratory failure and compromised airway protection.
Endotracheal intubation provides definitive airway control, allows suctioning of vomitus, prevents further aspiration, and enables mechanical ventilation with high-concentration oxygen. Noninvasive ventilation is contraindicated in patients with vomiting and impaired airway protection due to high aspiration risk. Chest compressions are indicated only if there is no pulse; this patient has a faint pulse. Intravenous fluids are important for hypotension but must follow airway stabilization. Nasogastric tube insertion does not address the immediate life-threatening hypoxia.
Early definitive airway control in unstable patients with hypoxemia and aspiration risk is essential to prevent cardiac arrest and improve survival outcomes.
NEW QUESTION # 143
An 84-year-old woman is brought by ambulance to the emergency department after she was found by a neighbour. She had fallen, sustained a hip fracture, and was unable to move for the past 2 days. After starting rehydration, she reports hip pain and numbness and tingling in both her legs. Physical examination reveals faint pulses in both legs and severely swollen lower legs that are painful to palpation. The urine in the Foley catheter bag seems to be darker than normal. Which one of the following is the best next step?
Answer: C
Explanation:
This patient presents with signs of acute compartment syndrome (pain out of proportion, paresthesia, pallor, swelling, decreased pulses, and dark urine indicating rhabdomyolysis). Measuring compartment pressures is the diagnostic test of choice to confirm the diagnosis and guide urgent surgical fasciotomy.
Toronto Notes 2023 - Orthopedics:
"Acute compartment syndrome should be suspected in any patient with severe extremity pain, swelling, sensory deficits, and tense compartments. Confirm with compartment pressure measurements. Fasciotomy is indicated if pressure is >30 mmHg or within 30 mmHg of diastolic pressure." MCCQE1 Objectives (Surgery > 51-2: Limb Trauma):
"Candidates must diagnose acute compartment syndrome and initiate appropriate surgical referral after confirming with pressure measurements." Angiography and Doppler studies assess vascular compromise but are not the first step in suspected compartment syndrome. Fixing the hip (C) and testing myoglobin (E) are not diagnostic steps.
NEW QUESTION # 144
A 45-year-old man with a developmental delay and a history of disruptive behavior presents to the clinic looking for his family doctor. He is well known to the clinic. He appears drunk and has accidentally broken 2 large beer bottles in the waiting room but remains calm. The office staff requests your help to deal with this situation. Which one of the following is the most appropriate initial step?
Answer: C
Explanation:
This is a known patient with intellectual disability and behavioral concerns. The presentation of alcohol intoxication in a calm patient who inadvertently broke bottles warrants prompt, nonjudgmental clinical assessment before escalating. De-escalation and safety assessment come first.
Toronto Notes 2023 - Psychiatry, "Psychiatric Emergencies and Crisis Management":
"In agitated or intoxicated individuals with developmental disability, a calm approach and prompt physician assessment are essential to prevent escalation and assess for medical or psychiatric needs." MCCQE1 Objectives (Psychiatry > Crisis and Acute Presentations > 72-2):
"Candidates must assess potentially disruptive patients with dignity and caution before involving law enforcement or security. Physician engagement is often calming." Police intervention (A) is premature and may escalate matters. Ignoring (B) risks safety. Asking him to leave (C) without assessment is inappropriate. Social work (E) may help, but after medical triage.
NEW QUESTION # 145
A 70-year-old man presents with severe, postprandial, mid-abdominal pain which has become more severe over the past 6 to 9 months. It is associated with nausea but has not caused him to vomit or changed his bowel habits. He has lost 14 kg over the last 6 months. Abdominal and rectal examination is normal. Upper gastrointestinal series is unremarkable. Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
Chronic mesenteric ischemia (also known as "intestinal angina") presents as postprandial abdominal pain, leading to food avoidance and significant weight loss. GI exams may be normal. Imaging (e.g., angiography or CT angio) confirms the diagnosis.
Toronto Notes 2023 - Gastroenterology, "Chronic Mesenteric Ischemia":
"Classic triad: postprandial abdominal pain, weight loss, and food aversion. Physical exam and GI series may be normal." MCCQE1 Objectives (Gastroenterology > 47-1: Abdominal Pain):
"Candidates must suspect mesenteric ischemia in older adults with risk factors and postprandial pain leading to weight loss." PUD (A) usually causes epigastric pain relieved by food. Cholelithiasis (B) causes RUQ pain. Colon cancer (D) presents with altered bowel habits or bleeding. Mesenteric adenitis (C) occurs in younger patients, often with infection.
NEW QUESTION # 146
A mother brings her 13-year-old daughter to the office. The girl has had intermittent lower abdominal pain, constipation, and difficulty voiding for 3 months. She says that she is not sexually active. She looks well. She has reached age-specific developmental milestones, and her vital signs are within normal range. On abdominal examination, she is found to have a palpable suprapubic mass that persists after voiding. The girl says that her older sister started having menstrual periods at this age. The patient is surprised that hers have not started. Which one of the following is the best next step?
Answer: C
Explanation:
The clinical picture suggests an obstructive anomaly of the female reproductive tract, such as imperforate hymen or vaginal outflow tract obstruction, leading to hematocolpos. The first essential step is physical examination of the external genitalia.
Toronto Notes 2023 - Pediatrics and Gynecology, "Amenorrhea" Section:
"In girls with primary amenorrhea and cyclic abdominal pain, perform an external genital exam to rule out obstructive anomalies (e.g., imperforate hymen or transverse vaginal septum). Examination should always precede imaging." MCCQE1 Objectives (Pediatrics > 78-3: Puberty and Menstrual Disorders):
"Candidates must evaluate delayed menarche with physical exam, including inspection of the genitalia to rule out anatomic obstruction." Pelvic ultrasound (D) is helpful but should follow physical exam. Radiography (B), hCG (C), and urinalysis (E) are not primary steps in evaluating amenorrhea with a mass.
NEW QUESTION # 147
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