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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Professional
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87. Frage
A 54-year-old man presents to the office because of progressively severe frontal headaches that are worse in the morning. He also has a chronic productive cough. He has a 30 pack-year history of smoking tobacco cigarettes. His blood pressure is 160/95 mm Hg. Which one of the following is the best next step?
Antwort: C
Begründung:
This presentation has "red flags" for raised intracranial pressure: headaches that are progressive, worse in the morning, and worsened by coughing/valsalva. In MCCQE objectives, these features require urgent evaluation for secondary causes (e.g., intracranial mass, hemorrhage, obstructive hydrocephalus) rather than empiric treatment for primary headache. His chronic cough and heavy smoking increase concern for an underlying malignancy with possible brain metastasis or paraneoplastic processes, further strengthening the indication for neuroimaging. Therefore, the best next step is CT head (often the fastest initial test to identify mass effect, hemorrhage, or hydrocephalus; MRI may follow depending on findings).
Treating presumed migraine with a triptan is inappropriate when secondary headache is possible and could also pose vascular risk. His blood pressure is elevated but not in a hypertensive emergency and does not explain these classic intracranial pressure features; serial BP monitoring or starting antihypertensives should not delay imaging. Temporal arteritis is less likely without temporal tenderness, jaw claudication, visual symptoms, or systemic inflammatory clues.
88. Frage
A previously well 2-year-old girl is brought to the Emergency Department with difficulty breathing that has been gradually worsening over the last 24 hours. Her parents say she has a sore throat. On examination, you note that she appears ill. She has stridor and is in moderate respiratory distress, drooling and emitting a muffled voice. Vital signs are as follows: respiratory rate 34/min, heart rate 160/min, temperature 40.2°C.
Which one of the following is the most likely diagnosis?
Antwort: C
Begründung:
Retropharyngeal abscess is most likely because the child is toxic-appearing with very high fever (40.2°C), sore throat, drooling, muffled "hot potato" voice, and stridor with progressively worsening respiratory distress over about 24 hours. In toddlers, retropharyngeal lymph nodes can become infected following an upper respiratory or pharyngeal infection and form an abscess, causing posterior pharyngeal swelling that obstructs the airway and makes swallowing painful, leading to drooling. Croup typically presents with a barking cough and hoarseness, usually with low-grade fever; drooling and muffled voice suggest a deeper space infection rather than viral laryngotracheitis. Foreign body aspiration usually has sudden onset and often lacks fever.
Laryngomalacia is a chronic infant condition (not acute, febrile illness). Bronchiolitis causes wheeze/crackles rather than prominent stridor and drooling. MCCQE priorities are airway-first management (minimize agitation, be prepared for a difficult airway), then prompt IV antibiotics and urgent ENT assessment for possible drainage.
89. Frage
A 25-year-old man presents to the Emergency Department with diffuse abdominal pain and anorexia. He was tackled in a football game yesterday. He reports a 3-week history of sore throat and fatigue. Vital signs are as follows:
Blood pressure: 95/45 mm Hg
Heart rate: 96/min
Temperature: 37.6°C
Which one of the following is the most likely diagnosis?
Antwort: C
Begründung:
This patient presents with hypotension, diffuse abdominal pain, and a history of contact sports injury with preceding symptoms of infectious mononucleosis (sore throat, fatigue). The spleen is commonly enlarged in mononucleosis, making it vulnerable to rupture after even minor trauma.
Toronto Notes 2023 - General Surgery and Infectious Diseases Sections:
"Splenic rupture is a known complication of mononucleosis, particularly after trauma. Symptoms may include diffuse abdominal pain, hypotension, and signs of hemorrhagic shock." MCCQE1 Objectives (Surgery > 84-1: Abdominal Trauma):
"Candidates should identify splenic rupture as a cause of hypotension and abdominal pain following blunt abdominal trauma, especially in patients with splenomegaly." Appendicitis (B) would present with localized right lower quadrant pain. Pneumonia (C) and pyelonephritis (D) would present with respiratory or urinary symptoms. Ruptured duodenum (E) is much less likely without specific trauma to that region or signs of peritonitis.
90. Frage
A 16-year-old boy is brought to the office for examination, which reveals the lesion in the attached image and similar lesions on other parts of his body. You also notice multiple scattered subcutaneous tumors that he says have been there for a long time. Which one of the following is the most likely diagnosis?
Antwort: E
Begründung:
The presence of multiple cutaneous lesions along with numerous longstanding subcutaneous tumors is most consistent with neurofibromatosis type 1 (NF1) . MCCQE objectives emphasize recognizing classic dermatologic findings of NF1, which include multiple neurofibromas (soft, skin-colored subcutaneous nodules) and characteristic pigmented lesions such as cafe-au-lait macules and axillary or inguinal freckling.
These lesions typically develop during childhood or adolescence and increase in number over time.
Sarcoidosis can cause skin lesions but is not associated with multiple benign peripheral nerve sheath tumors.
Dermatofibromas are usually solitary, firm nodules rather than numerous soft tumors. Vitiligo presents as depigmented macules without subcutaneous masses. Lipomatosis involves multiple lipomas but lacks the associated pigmentary skin findings seen in NF1.
NF1 is an autosomal dominant condition caused by mutation of the NF1 gene. Diagnosis is clinical based on established criteria. Recognition is important because patients require surveillance for complications such as optic gliomas, learning disabilities, skeletal abnormalities, and malignant peripheral nerve sheath tumors.
91. Frage
A 9-year-old girl from a remote community is brought to the clinic with a 2-week history of swelling in her neck. She has been afebrile but has had some night sweats. On examination, you note a fixed, unilateral, and nontender supraclavicular lymph node measuring 3 cm. The overlying skin color is unremarkable. In addition, you note a slightly enlarged spleen and liver. Which one of the following is the most likely diagnosis?
Antwort: B
Begründung:
This child presents with "red flag" features for malignancy: a firm, fixed, nontender supraclavicular lymph node >2 cm in size, with associated hepatosplenomegaly and night sweats. These features are most concerning for lymphoma.
Toronto Notes 2023 - Pediatrics, "Lymphadenopathy in Children":
"Malignant lymphadenopathy tends to be firm, fixed, painless, and located in supraclavicular areas. Systemic signs (fever, weight loss, hepatosplenomegaly, night sweats) are concerning for lymphoma." MCCQE1 Objectives (Pediatrics > 78-3: Hematology/Oncology):
"Candidates should differentiate between benign and malignant lymphadenopathy and recognize features suggestive of lymphoma." Cat-scratch disease (B) is usually tender and associated with cat exposure. Kawasaki disease (C) presents with fever and mucocutaneous findings. Acute bacterial lymphadenitis (D) is painful, warm, and rapid in onset.
Viral lymphadenopathy (E) is often bilateral, small, and tender.
92. Frage
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