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| Section | Objectives |
|---|---|
| Dimensions of Care | - Health Promotion and Illness Prevention
|
| Physician Activities | - Management
|
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153. 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: A
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.
154. Frage
A 72-year-old woman presents with swelling of her right leg that developed overnight. She had an abdominal hysterectomy 10 days ago. On examination, there is pitting edema of the leg that extends from the foot to the groin. The calf is 3 cm larger in diameter than the calf on the left leg. Which one of the following is the most likely diagnosis?
Antwort: A
Begründung:
This patient has classic features of proximal deep vein thrombosis (DVT) after recent major pelvic surgery:
acute unilateral leg swelling with pitting edema and a significant calf circumference difference ( > 3 cm). The edema extending from foot to groin strongly suggests a proximal (iliofemoral) thrombosis, which produces more extensive swelling than calf-vein DVT because venous outflow from the entire limb is impaired.
MCCQE objectives highlight postoperative patients as high risk for venous thromboembolism due to immobility, endothelial injury, and hypercoagulability.
Superficial thrombophlebitis typically causes a localized, tender, palpable cord along a superficial vein rather than diffuse whole-leg edema. Phlegmasia cerulea dolens is a severe, limb-threatening form of massive DVT characterized by marked pain, tense
155. Frage
An 8-year-old boy is brought to the Emergency Department because he is experiencing sudden respiratory distress. You suspect that he has a spontaneous tension pneumothorax. On physical examination, which one of the following best supports this diagnosis?
Antwort: D
Begründung:
A tension pneumothorax occurs when air enters the pleural space and cannot escape, creating progressively rising intrathoracic pressure. MCCQE objectives emphasize rapid recognition of life-threatening causes of respiratory distress based on bedside findings. As pressure builds, the affected hemithorax compresses the lung and pushes the mediastinum to the opposite side, producing tracheal deviation away from the affected side -a classic, high-specificity sign of tension physiology (often accompanied by severe dyspnea, tachycardia, unilateral absent breath sounds, hyperresonance, distended neck veins, and hypotension from impaired venous return).
The other options do not specifically support tension pneumothorax: ecchymoses suggest trauma; bilateral wheezing suggests asthma or bronchiolitis; abdominal distension is nonspecific; inspiratory stridor indicates upper airway obstruction (e.g., croup, foreign body). Because tension pneumothorax is a clinical diagnosis, MCCQE priorities are immediate decompression (needle thoracostomy) followed by chest tube placement- without waiting for imaging if the child is unstable.
156. Frage
A 60-year-old man presents to the office with concerns regarding a pruritic rash, which he has had for several years. He reports a "crawling" sensation on his skin. He is concerned that this rash may be caused by a parasite he may have picked up while serving in the military overseas. On examination, you note multiple crusted lesions on his forearms, neck, chest, scalp, and thighs. There is a complete sparing of the skin on his back. He brought a bottle with fibrous material of different colours that he picked from his wounds. He is otherwise healthy and reports no other symptoms except some chronic fatigue and insomnia related to the itching. Which one of the following treatments is the most appropriate?
Antwort: A
Begründung:
This case describes classic signs of delusional parasitosis (also known as Morgellons syndrome).However, the presence of widespread crusted lesions raises suspicion for crusted scabies, particularly in older adults.
Crusted scabies may be misinterpreted as chronic dermatitis or psychocutaneous disorder. The most effective treatment is oral ivermectin.
Toronto Notes 2023 - Dermatology:
"Crusted scabies presents as widespread hyperkeratotic plaques with crusting. First-line treatment is oral ivermectin, often with topical permethrin." MCCQE1 Objectives (Medicine > Dermatology > 23-1):
"Candidates must recognize presentations of ectoparasitic infections, including scabies, and provide appropriate treatment." Permethrin (B) is for typical scabies, but crusted scabies often requires systemic ivermectin due to severity and spread.
157. Frage
A 3-week-old boy is brought by his parents to your clinic for a well-child visit. The newborn was born at term after an uncomplicated pregnancy. He is exclusively breastfed and is thriving. Physical examination findings are normal except for jaundice. Total bilirubin is 172 #mol/L (#100), and conjugated bilirubin is 4 #mol/L (#5). Results of a complete blood count and reticulocyte count are within the normal range. The results of a direct antiglobulin (Coombs) test were negative. Which one of the following, if any, is the most appropriate investigation?
Antwort: A
158. Frage
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