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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Professional
|
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NEW QUESTION # 189
A 14-year-old girl is brought to the Emergency Department with a 20-minute history of difficulty breathing that started during a school assembly. She has had similar symptoms 3 times in the last 2 weeks. These episodes develop rapidly and resolve gradually over several minutes. She reports tingling in her fingers and toes. On examination, her vital signs are as follows:
Blood pressure
120/80 mm Hg
Heart rate
100/min
Respiratory rate
22/min
Oxygen saturation on room air
95%
Temperature
36.9 °C, orally
Apart from mildly dilated pupils, her examination is otherwise normal. Which one of the following is the most likely diagnosis?
Answer: C
Explanation:
This teenager presents with acute-onset dyspnea, paresthesias, and normal physical findings, consistent with a panic attack. Panic attacks often mimic cardiopulmonary pathology but are marked by symptoms like hyperventilation, tingling in the extremities, palpitations, and subjective air hunger with normal vitals and oxygenation.
Toronto Notes 2023 - Psychiatry:
"Panic attacks are characterized by sudden onset of intense fear or discomfort, accompanied by somatic symptoms such as dyspnea, paresthesias, tachycardia, and fear of losing control." MCCQE1 Objectives (Psychiatry > 71-3: Anxiety Disorders):
"Candidates must recognize panic attacks based on clinical features and differentiate them from cardiopulmonary conditions." Normal O2 saturation and physical exam rule out asthma or pericarditis. Cocaine use would present with more systemic toxicity. PSVT would cause consistent tachycardia.
NEW QUESTION # 190
A 19-year-old woman presents to the office. She is a new mother. She shares that she does not intend to vaccinate her son. Which one of the following is the best next step?
Answer: C
Explanation:
When encountering vaccine hesitancy, the first and most effective step is to open a non-judgmental conversation and explore the patient's reasons. This helps build trust and tailor subsequent education and counseling.
Toronto Notes 2023 - Public Health and Preventive Medicine, Immunization:
"Addressing vaccine hesitancy requires understanding parental concerns. Begin with open-ended questions to identify underlying beliefs and information gaps." MCCQE1 Objectives - Preventive Medicine > Immunization:
"Candidates must demonstrate effective communication with vaccine-hesitant parents, beginning with eliciting their rationale before providing evidence-based recommendations." Jumping to education (B) or punitive measures (C, D) may close communication. The patient is an adult; speaking with her parents (E) violates her autonomy.
NEW QUESTION # 191
A 31-year-old man presents with nocturnal non-exertional chest pain. During an exercise stress test, he does not experience chest pain, and there are no significant ST segment changes on the electrocardiogram. He achieves 17 metabolic equivalent of task (MET), a blood pressure of 190/96 mm Hg (resting blood pressure of
130/80 mm Hg), and a maximum heart rate of 162/min (85% of age-predicted maximum). Which one of the following is the most appropriate next step?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
This patient demonstrates excellent exercise tolerance (17 METs) and no ischemic changes or exertional symptoms, which makes cardiac ischemia unlikely. However, the hypertensive response to exercise (BP >
190 systolic) indicates masked or latent hypertension. This should be managed proactively, typically starting with a thiazide.
Toronto Notes 2023 - Cardiology:
"An exaggerated hypertensive response during exercise is predictive of future hypertension. Treatment with antihypertensive agents such as thiazides may be warranted." MCCQE1 Objectives (Internal Medicine > 31-1: Hypertension and Risk Management):
"Candidates must identify abnormal BP responses to exercise and initiate appropriate treatment." Reassurance alone (A) ignores the hypertensive response. Catheterization (C) and beta-blockers (D) are unnecessary without ischemia. Advising against exercise (B) is counterproductive in a young, otherwise healthy patient.
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NEW QUESTION # 192
An 80-year-old woman presents to the Emergency Department with dizziness. She has a medical history of coronary artery disease. On examination, she is alert and oriented. Her vital signs are as follows:
Her electrocardiogram is shown in the image.
Which one of the following is the most likely diagnosis?
Blood pressure
80/60 mm Hg
Heart rate
40/min
Respiratory rate
12/min
Her electrocardiogram is shown in the attached image. Which one of the following is the most likely diagnosis?
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
The ECG reveals:
Regular P waves that are not consistently followed by QRS complexes
A dissociation between the atrial (P wave) and ventricular (QRS complex) activity A slow ventricular rate (~40 bpm) independent of atrial rate These findings are characteristic of a third-degree (complete) atrioventricular (AV) block, where there is no conduction of atrial impulses to the ventricles. The atria and ventricles beat independently, and the ventricular rate is maintained by an escape rhythm, often junctional or ventricular in origin.
This correlates with the patient's symptoms (dizziness, hypotension) and bradycardia, suggesting inadequate cardiac output due to AV dissociation.
Toronto Notes 2023 - Cardiology:
"Third-degree AV block shows complete AV dissociation with independent atrial and ventricular activity. It typically presents with bradycardia and hypotension. Urgent pacing may be required." MCCQE1 Objectives (Cardiology > 34-2: Bradyarrhythmias and Conduction Disorders):
"Candidates must identify complete heart block and recognize its clinical urgency." Ruling out other options:
A). Sinus bradycardia would show regular P waves with 1:1 P-QRS conduction.
B). First-degree AV block has prolonged PR intervals ( > 200 ms) but all P waves are conducted.
D). Junctional escape rhythm may present with bradycardia, but P waves would be absent, inverted, or occur after QRS complexes.
E). Mobitz type I (Wenckebach) has progressively lengthening PR intervals before a dropped QRS.
NEW QUESTION # 193
A 16-month-old boy is brought to your office because of red, itchy and crusted patches on his cheeks and chin. Physical examination also reveals similar patches in the flexor creases of both arms. The groin and axillae regions are clear. Which one of the following is most likely to contribute to this condition?
Answer: A
Explanation:
This child's presentation is classic for atopic dermatitis (eczema) : pruritic, erythematous, crusted patches involving the cheeks in infants and the flexural creases in toddlers. Sparing of the groin and axillae is typical.
MCCQE objectives emphasize recognizing age-specific distribution and identifying risk factors. The strongest contributor is a family history of atopy (e.g., asthma, allergic rhinitis, eczema), reflecting a genetic predisposition involving impaired skin barrier function and immune dysregulation (often associated with filaggrin mutations).
Vaccination (e.g., MMR) does not cause eczema. Oral amoxicillin may trigger a transient rash but would not produce chronic pruritic flexural dermatitis. Early introduction of cereals is not an established cause of atopic dermatitis. Varicella-zoster infection produces a vesicular rash in various stages, not chronic flexural eczema.
Thus, a family history of atopic reactions is the most important contributing factor to this child's condition.
NEW QUESTION # 194
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