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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Collaborator
|
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307. Frage
A 43-year-old car mechanic, with no prior history, comes to the Emergency Department because of a sudden loss of balance at work. He also feels lightheaded, slightly disoriented and nauseous. Physical examination and basic blood work-up are normal. He tells you this is the 3rd time this has happened at work. Which one of the following is the most likely diagnosis?
Antwort: D
Begründung:
The most likely diagnosis is organic solvent intoxication because the episodes are recurrent, acute, and specifically occur at work in a car mechanic. MCCQE objectives in occupational and environmental medicine emphasize recognizing workplace exposures that cause transient neurologic symptoms. Organic solvents (e.g., toluene, xylene, gasoline vapors, degreasers) can produce acute CNS effects such as dizziness, imbalance
/ataxia, nausea, lightheadedness, and mild confusion or disorientation, often with a normal routine exam and basic labs once exposure ceases. The clear temporal relationship to the workplace and repeated similar episodes strongly supports an exposure-related cause. Lead toxicity is typically subacute/chronic, presenting with abdominal pain, constipation, neuropathy (wrist/foot drop), cognitive changes, anemia, and basophilic stippling-rather than brief episodic disequilibrium. A cerebellar tumor would cause progressive, persistent symptoms and focal neurologic findings. Ear infection-related vertigo would not reliably recur only at work and usually has ear symptoms or exam findings. Alcohol intoxication is less consistent with a repeated workplace-only pattern without corroborating signs.
308. Frage
A 77-year-old woman is brought to the Emergency Department by ambulance because she has severe heel ulcers and dehydration. Her husband reports that she has been sick for the past 6 to 8 weeks with a cough and congestion. He shares that he has tried to bring her to medical attention on several occasions, but she refused.
The paramedics reported that her bed at home was soiled and that they could hardly reach her room due to clutter. On questioning, her answers seem reasonable. Which one of the following is the most critical next step?
Antwort: E
Begründung:
When elder neglect is suspected-especially in cases of self-neglect or unclear caregiver dynamics-the most important immediate step is to assess the patient's decision-making capacity. If she lacks capacity, protective intervention is warranted.
Toronto Notes 2023 - Geriatrics, "Elder Abuse and Capacity Assessment":
"Decision-making capacity must be assessed when a patient is refusing care despite evidence of harm or risk." MCCQE1 Objectives (ELOM > 90-1: Capacity and Consent):
"Candidates must assess capacity in elderly patients before attributing decisions to autonomy, particularly in complex care situations." Evaluating criminal records (B) or clutter (C) may be relevant later but do not take precedence over capacity assessment. Alcohol/substance use (D) and financial abuse (E) are differential concerns, not the critical first step.
309. Frage
A 69-year-old woman with long-standing hypertension presents to the emergency department with a 2-hour history of persistent chest and back pain. A posteroanterior chest radiograph shows suspicious widening of the mediastinal shadow. Which one of the following is most likely to yield a clinical diagnosis?
Antwort: C
Begründung:
The presentation is highly suspicious for acute aortic dissection - sudden chest/back pain and mediastinal widening on chest x-ray. The most definitive and widely available test is contrast-enhanced computed tomography (CT) of the chest.
Toronto Notes 2023 - Cardiology, Aortic Dissection:
"CT angiography of the chest is the gold standard for stable patients with suspected aortic dissection. Look for mediastinal widening on chest x-ray as a clue." MCCQE1 Objectives - Internal Medicine > Cardiovascular Disease:
"Candidates should recognize acute aortic dissection and select appropriate imaging, such as CT chest, for diagnosis in stable patients." Transthoracic echo (A) may miss dissections. ECG (C) helps rule out MI but not dissection. V/Q scan (D) and pulmonary angiography (E) are for suspected pulmonary embolism.
310. Frage
A 3-week-old boy is brought by his parents to your clinic for a well-child visit. The newborn was born at term after an uncomplicated pregnancy. He is exclusively breastfed and is thriving. Physical examination findings are normal except for jaundice. Total bilirubin is 172 #mol/L (#100), and conjugated bilirubin is 4 #mol/L (#5). Results of a complete blood count and reticulocyte count are within the normal range. The results of a direct antiglobulin (Coombs) test were negative. Which one of the following, if any, is the most appropriate investigation?
Antwort: D
311. Frage
The developers of a urinary protein dipstick test have indicated that they have reduced the problem of false positive results by changing the test so that it becomes positive at a higher concentration of protein. Which one of the following statements best describes how this screening test will be affected?
Antwort: B
Begründung:
By increasing the threshold required for a positive test result, the developers have made the test more stringent. This reduces false positives, thereby increasing specificity. However, increasing the cutoff also means that some individuals with lower (but still clinically significant) levels of proteinuria will now test negative. As a result, the number of false negatives increases and sensitivity decreases. This reflects the fundamental trade-off between sensitivity and specificity when adjusting a diagnostic threshold. Screening tests typically favor high sensitivity to minimize missed cases, particularly for serious but treatable conditions.
Raising the threshold shifts the balance toward higher specificity at the expense of sensitivity. Positive predictive value (PPV) would likely increase because fewer false positives occur, but PPV also depends on disease prevalence. According to MCCQE objectives, candidates must understand how changes in diagnostic thresholds affect test characteristics, including sensitivity, specificity, predictive values, and false positive
/false negative rates, and apply these principles appropriately in screening and clinical decision-making.
312. Frage
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