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| Section | Objectives |
|---|---|
| Physician Activities | - Professionalism
|
| Dimensions of Care | - Psychosocial Aspects
|
>> MCCQE Reliable Test Topics <<
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NEW QUESTION # 143
A 32-year-old woman presents to your outpatient clinic with concerns regarding a 6-month history of both a pulsatile buzzing sound in her ears and headaches. There is no history of hearing loss, vertigo, ear pain, or discharge from the ears. There is a long-standing history of prolonged exposure to occupational noise. She has a BMI of 32. Otoscopic examination is unremarkable, and there are no neck masses present. You determine that the buzzing sound is synchronous with her radial pulse. Which of the following investigations should be ordered next?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
Pulsatile tinnitus synchronous with the pulse may be vascular in origin. The association with headaches and elevated BMI (a risk factor for idiopathic intracranial hypertension, IIH) warrants neuroimaging to assess for cerebral venous sinus thrombosis, vascular malformations, or raised intracranial pressure.
Toronto Notes 2023 - Neurology / ENT:
"Pulsatile tinnitus requires investigation for vascular causes including idiopathic intracranial hypertension.
MRI or MRV is the next step."
MCCQE1 Objectives (Neurology > 35-1: Headache and Tinnitus):
"Candidates must investigate pulsatile tinnitus with neuroimaging when vascular causes are suspected." Audiogram (A) is for hearing loss. EEG (C) is not useful for tinnitus. CRP (D) is irrelevant.
NEW QUESTION # 144
A 33-year-old man with severe bacterial meningitis is intubated and unresponsive in the Intensive Care Unit.
If he receives immediate treatment, his prognosis is excellent. If he does not, he will likely die. Three years ago, the patient had Huntington disease diagnosed, but he has been asymptomatic since then. His advance directive, which was made before this hospitalization, states that he should be allowed to die if he contracts a life-threatening illness. His parents demand that he be treated for the meningitis. Which one of the following is the best next step?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
An advance directive is a legally binding document that outlines a competent person's preferences regarding future medical care. If the patient clearly stated a refusal of treatment in the event of a life-threatening condition, this directive must be followed, even if the patient is currently incapacitated and family disagrees.
Toronto Notes 2023 - Ethics and Law:
"Advance directives must be respected when valid, clear, and applicable. Substitute decision-makers cannot override them." MCCQE1 Objectives (ELOM > 90-4: Informed Consent and Advance Directives):
"Candidates must apply valid advance directives to guide care for incapacitated patients." B (parents as SDMs) is incorrect if an advance directive exists. A and D are irrelevant-capacity has already been documented. C is unnecessary when an advance directive is clear.
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NEW QUESTION # 145
A 63-year-old man presents to the office with a 2-year history of episodic swallowing problems that have been increasing in frequency. He states that food seems to stick in his throat, and these episodes are often associated with coughing or regurgitating undigested food. Physical examination reveals that the patient has halitosis; otherwise, findings are normal. Which one of the following is the best next step to confirm the most likely diagnosis?
Answer: B
Explanation:
This presentation is classic for Zenker diverticulum , characterized by progressive dysphagia, regurgitation of undigested food, coughing, and halitosis due to food retention in a pharyngoesophageal pouch. Symptoms are chronic and episodic, often involving regurgitation hours after eating. MCCQE objectives emphasize selecting the safest and most appropriate diagnostic test. The best initial test is a barium swallow (contrast esophagram)
, which clearly visualizes the posterior outpouching above the upper esophageal sphincter.
Endoscopy is not the first step because there is a risk of perforation if a large diverticulum is present. pH monitoring and PPI trials are used for gastroesophageal reflux disease, which does not explain regurgitation of undigested food and halitosis. CT chest is unnecessary for diagnosis.
Therefore, a barium swallow is the safest and most informative investigation to confirm suspected Zenker diverticulum before considering surgical or endoscopic management.
NEW QUESTION # 146
A 20-year-old woman, gravida 0, para 0, presents with increased facial hair. Her periods are regular and moderate. Her BMI is 24, and her blood pressure is 110/70 mm Hg. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
Idiopathic hirsutism is the most likely diagnosis because this patient has isolated hirsutism with normal vital signs, normal BMI, and regular menstrual cycles , suggesting preserved ovulation and no clinically significant endocrine disturbance. MCCQE objectives emphasize that the most common causes of hirsutism are PCOS and idiopathic hirsutism; PCOS typically includes menstrual irregularity/oligo-ovulation and often metabolic features (overweight, insulin resistance), none of which are present here. Androgen-secreting ovarian tumors (hilar cell or Sertoli-Leydig cell tumors) usually cause rapid onset, severe hyperandrogenism and virilization (deepening voice, clitoromegaly, marked acne) and often disrupt menses-features not described. Nonclassic congenital adrenal hyperplasia can present with hirsutism, but it more commonly associates with acne, infertility, or menstrual abnormalities and requires biochemical suspicion rather than being the "most likely" with normal cycles. Therefore, idiopathic hirsutism-often due to increased peripheral androgen sensitivity or local 5-alpha reductase activity-is the best fit.
NEW QUESTION # 147
A 40-year-old woman presents to the Emergency Department with confusion and fever (38.5°C). She has a history of hypothyroidism managed with levothyroxine. Key findings include:
Blood pressure
114/78 mm Hg
Heart rate
85/min
Temperature
38.5°C
Hemoglobin
90 g/L123-157 g/L
Platelet count
25 × 10#/L130-400 × 10#/L
Peripheral blood film
Schistocytes present
Creatinine
200 #mol/L50-90 #mol/L
Answer: C
Explanation:
This patient presents with fever, confusion, anemia with schistocytes, thrombocytopenia, and renal impairment - fulfilling the classic pentad of thrombotic thrombocytopenic purpura (TTP). TTP is a hematologic emergency requiring plasma exchange.
Toronto Notes 2023 - Hematology, "Microangiopathic Hemolytic Anemia" Section:
"TTP is a medical emergency. Features include MAHA, thrombocytopenia, renal failure, neurologic symptoms, and fever. Schistocytes on blood film are diagnostic." MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Disorders):
"Candidates must urgently recognize TTP and initiate emergent plasma exchange therapy." AML (B) does not present with schistocytes. HIV (C) can cause thrombocytopenia but not MAHA. ITP (D) causes isolated thrombocytopenia without anemia or schistocytes.
NEW QUESTION # 148
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