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| Section | Objectives |
|---|---|
| Dimensions of Care | - Chronic Care
|
| Physician Activities | - Assessment
|
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NEW QUESTION # 280
A 72-year-old man reports that his wife says he has hearing trouble. Examination reveals that air conduction on the right side is less than on the left side and greater than bone conduction bilaterally. He hears a tuning fork placed on the top of his head better with his left ear. Which one of the following is the most appropriate next step in management?
Answer: D
Explanation:
The patient demonstrates signs of asymmetric sensorineural hearing loss (SNHL). In Weber test, sound localizes to the better ear in SNHL. Air conduction > bone conduction on Rinne test bilaterally supports SNHL. Audiometry is the best next diagnostic step to quantify and characterize the hearing loss.
Toronto Notes 2023 - ENT, "Hearing Loss":
"Audiometry is the first-line investigation to distinguish conductive from sensorineural hearing loss and to assess severity and frequency involvement." MCCQE1 Objectives (Medicine > ENT > 20-1):
"Candidates must know the approach to hearing loss and interpret Weber and Rinne tests to guide investigations such as audiometry." Imaging (A, C) is reserved for red flags such as unilateral persistent SNHL, which may later prompt MRI to rule out acoustic neuroma. Wax removal (D) is for conductive loss. Hearing aids (E) are management, not diagnostic, and come after audiologic evaluation.
NEW QUESTION # 281
A 72-year-old man has had 4 episodes of weakness in her right arm and leg lasting 10 to 15 minutes each.
During 1 episode, she had difficulty speaking and had blurring of the vision in the left eye. Which one of the following is the most likely diagnosis?
Answer: A
Explanation:
These are recurrent, brief (10-15 minute), fully resolving focal neurologic deficits, which fits transient ischemic attacks (TIAs) rather than completed stroke. The combination of right-sided arm and leg weakness and difficulty speaking localizes to the left cerebral hemisphere (dominant hemisphere for language in most patients). The additional symptom of transient blurring of vision in the left eye is characteristic of amaurosis fugax, caused by retinal ischemia from emboli or hypoperfusion in the ipsilateral internal carotid circulation.
Together, this pattern strongly suggests left internal carotid artery occlusive disease (e.g., high-grade stenosis with artery-to-artery embolization).
Left MCA thrombosis would typically produce persistent deficits rather than multiple short, self-resolving episodes. Intracerebral hemorrhage usually presents with sudden severe symptoms that do not resolve quickly and often includes headache or reduced consciousness. Epilepsy would more likely cause positive symptoms (jerking, automatisms) and postictal confusion. Vertebrobasilar disease causes posterior circulation symptoms (vertigo, diplopia, ataxia), not unilateral monocular vision loss plus contralateral weakness.
NEW QUESTION # 282
A 15-year-old boy is brought to the office by his father because he is having headaches. When alone, the boy appears withdrawn and admits to suicidal ideation. He shares that he is gay but does not want to tell his parents. He says that he faked the headaches so that one of his parents would make an appointment for him.
Which one of the following is the best next step?
Answer: C
Explanation:
The presence of suicidal ideation in a minor mandates urgent assessment to ensure safety and access mental health care. Disclosure of sexual orientation should be handled delicately and is not urgent compared to suicidal risk.
Toronto Notes 2023 - Psychiatry, "Child and Adolescent Psychiatry" Section:
"Any adolescent disclosing suicidal ideation should be referred for urgent mental health evaluation.
Concurrent issues such as sexual orientation may contribute to distress and should be addressed with appropriate support over time." MCCQE1 Objectives (Psychiatry > 79-2: Suicide Risk Assessment):
"Candidates must immediately refer for psychiatric assessment when a minor reports suicidal ideation, regardless of other social or developmental concerns." Antidepressants (A) may be appropriate but must follow specialist evaluation. Encouraging disclosure (B) or peer groups (C) is premature without ensuring safety.
NEW QUESTION # 283
A 62-year-old man, who has not seen a physician in 20 years, presents to your clinic with a burning sensation in his feet. The symptoms have been progressing slowly over the last 6 months. There is no associated motor weakness or skin changes. He reports no significant past medical history and takes no medications. His alcohol intake is minimal. On examination, he has reduced pinprick/vibration sensation and proprioception in the ankles with absent ankle reflexes. Which one of the following blood tests would you expect to be abnormal?
Answer: A
Explanation:
This is a classic presentation of diabetic peripheral neuropathy: bilateral distal sensory symptoms with preserved motor function and no other systemic findings. The most useful test to confirm this in a previously undiagnosed patient is HbA1c.
Toronto Notes 2023 - Endocrinology, Diabetes Complications:
"Peripheral neuropathy is a common complication of undiagnosed or poorly controlled diabetes. Confirm with HbA1c if diagnosis is not yet established." MCCQE1 Objectives - Internal Medicine > Endocrinology:
"Candidates should evaluate for diabetes in patients with peripheral neuropathy and screen appropriately with HbA1c." Folate (B) and B12 deficiency may also cause neuropathy but are less likely in the absence of nutritional risk factors. Other choices (A, D, E) are unrelated to this pattern.
NEW QUESTION # 284
On screening for dyslipidemia, a 45-year-old man is found to have a low high-density lipoprotein (HDL) cholesterol level. Which one of the following recommendations is the most appropriate?
Answer: C
Explanation:
Low HDL is best managed with lifestyle changes such as increased aerobic physical activity, smoking cessation, and weight loss. Vigorous exercise has the strongest evidence for raising HDL levels.
Toronto Notes 2023 - Cardiology, Dyslipidemia:
"Increasing physical activity is among the most effective ways to raise HDL cholesterol. There is no consistent benefit to supplements such as garlic, nor does reducing salt or caffeine meaningfully raise HDL." MCCQE1 Objectives - Population Health > Cardiovascular Risk Management:
"Candidates should recommend evidence-based lifestyle interventions such as exercise to improve lipid profiles, particularly to increase HDL." Alcohol cessation (C) is generally beneficial for overall health but may actually lower HDL slightly. Garlic (D) and caffeine (E) are not evidence-based interventions for dyslipidemia.
NEW QUESTION # 285
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