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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Leader (Manager)
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NEW QUESTION # 325
A 42-year-old woman presents to the emergency department with a 24-hour history of severe pain in her right eye. On examination, you notice a right conjunctival injection that is worst adjacent to the iris. Direct and consensual responses to light are intact but sluggish, with severe photophobia in the right pupil is slightly smaller than the left. The patient's visual acuity is 20/20 on the left and 20/40 on the right. Visual field testing results are normal. Intraocular pressure findings are normal. Slit-lamp examination findings of the cornea are normal, and there are no cells in the anterior chamber. You are unable to visualize her fundus. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
The most likely diagnosis is acute anterior uveitis (iritis). The key MCCQE clinical pattern is painful red eye with ciliary flush (injection worst adjacent to the iris/limbus) and marked photophobia, especially consensual photophobia, which strongly points to inflammation of the iris and ciliary body. The sluggish light response and miosis (smaller pupil) are also typical of iritis due to sphincter spasm and inflammation. Intraocular pressure is normal, helping to rule out acute angle-closure glaucoma, which usually presents with elevated IOP, corneal haze, and a mid-dilated fixed pupil. Optic neuritis classically causes decreased color vision and pain with eye movement rather than ciliary flush. Viral conjunctivitis causes diffuse conjunctival injection and irritation/grittiness, not severe pain with consensual photophobia. Scleritis causes deep "boring" pain and violaceous scleral hue, not miosis/consensual photophobia as dominant features. Difficulty visualizing the fundus can occur with significant miosis.
NEW QUESTION # 326
A 29-year-old man comes to the office for an initial visit. He is being treated for schizophrenia and epilepsy.
He has a 20 pack-year history of smoking. His medications are carbamazepine, clozapine, and quetiapine. In the past year, he has gained a considerable amount of weight. Asidefrom a BMI of 32, the results of his physical examination are unremarkable. Which one of the following conditions should he be investigated for?
Answer: B
Explanation:
Clozapine and quetiapine are associated with significant weight gain and increased risk of type 2 diabetes.
With a BMI of 32 and weight gain over the past year, screening for diabetes is appropriate and evidence- based.
Toronto Notes 2023 - Endocrinology, Diabetes & Psychiatry Sections:
"Second-generation antipsychotics such as clozapine increase the risk of metabolic syndrome and type 2 diabetes. Regular screening is recommended for patients with these risk factors." MCCQE1 Objectives - Internal Medicine > Endocrinology:
"Candidates should screen high-risk individuals, especially those on antipsychotics with weight gain, for diabetes using fasting glucose or HbA1c." While sleep apnea (C) is also possible, diabetes screening is the most appropriate and urgent next step in this patient. COPD (A) would present with respiratory symptoms. Cushing's (B) and acromegaly (E) are less common and have other distinct features.
NEW QUESTION # 327
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: B
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 # 328
A 38-year-old man is brought by his wife to the Emergency Department with fatigue, dizziness, and nausea after completing a hiking tour on a hot, humid day. His wife became worried after he had collapsed. He has been sweating heavily and vomited twice on the drive in. His medical history is unremarkable, and he takes no medications. His vital signs on arrival are as follows:
Blood pressure
85/57 mm Hg
Heart rate
120/min
Respiratory rate
18/min
Temperature
40.1 °C
Oxygen saturation
95%, room air
-
On physical examination, the patient's skin is dry, flushed, and warm to the touch. He has a diffuse erythematous papular rash. Findings of a thorough physical examination are otherwise unremarkable. An electrocardiogram shows sinus tachycardia. Which one of the following is the best next step?
Answer: E
Explanation:
This patient has classic features of exertional heat stroke-hyperthermia, hypotension, CNS symptoms (collapse), and hot, dry skin. A key complication of heat stroke is rhabdomyolysis, which can cause renal failure. Serum creatine kinase (CK) is the best next diagnostic step to confirm muscle breakdown.
Toronto Notes 2023 - Emergency Medicine, "Environmental Exposures":
"In heat stroke, check for rhabdomyolysis (#CK), renal impairment, and coagulopathy. Prompt cooling and hydration are critical." MCCQE1 Objectives (Internal Medicine > 59-3: Environmental and Toxic Exposures):
"Candidates must recognize heat-related illnesses and investigate for complications such as rhabdomyolysis and acute kidney injury." CT head (C) is not indicated unless persistent neurological symptoms. TSH (B), CRP (D), and blood cultures (E) are irrelevant to acute exertional hyperthermia.
NEW QUESTION # 329
An 83-year-old woman presents to your office with a 2-day history of confusion. Her past medical history is significant for lung cancer, and she is being treated with radiation. On physical examination, she is euvolemic.
Her blood work reveals a serum sodium of 118 mmol/L (135-140) as compared with 134 mmol/L (8 days ago). Which one of the following will be most helpful in establishing the cause of her laboratory abnormality?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
Hyponatremia in a patient with lung cancer and euvolemia strongly suggests syndrome of inappropriate antidiuretic hormone secretion (SIADH), especially from small cell carcinoma. Serum osmolality is the best initial test to confirm hypotonic hyponatremia and distinguish true hyponatremia from pseudohyponatremia or other causes.
Toronto Notes 2023 - Endocrinology, "Hyponatremia":
"Serum osmolality helps classify hyponatremia as hypotonic, isotonic, or hypertonic. SIADH typically causes hypotonic hyponatremia in euvolemic patients." MCCQE1 Objectives (Endocrinology > 37-1: Electrolyte Disorders):
"Candidates must evaluate the type and cause of hyponatremia using clinical status and laboratory tests including serum osmolality." Urine sodium (B) is useful after confirming hypotonicity. PTHrP (E) is associated with hypercalcemia of malignancy, not hyponatremia. Urinalysis (A) and CrCl (D) are less directly informative.
NEW QUESTION # 330
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