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| Section | Objectives |
|---|---|
| Dimensions of Care | - Chronic Care
|
| Physician Activities | - Management
|
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NEW QUESTION # 350
A 28-year-old woman presents to your office with a 6-month history of intermittent dizziness associated with nausea and a rotational sensation. Physical examination shows pallor of 1 optic disk, generalized hyperreflexia and nystagmus to the left. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
Multiple sclerosis (MS) is most likely because the patient has vertigo-like symptoms plus objective central neurologic signs : optic disc pallor (suggesting prior optic neuritis with optic atrophy), generalized hyperreflexia (upper motor neuron involvement), and nystagmus (can be central when accompanied by other CNS findings). MCCQE objectives emphasize differentiating peripheral from central causes of vertigo.
Peripheral disorders (labyrinthitis, Meniere disease) typically present with vertigo and nausea but do not cause optic nerve abnormalities or diffuse hyperreflexia . Acoustic neuroma can cause vestibular symptoms but usually features progressive unilateral hearing loss/tinnitus and does not explain optic disc pallor and generalized UMN signs. Prolactinoma causes endocrine symptoms (galactorrhea, amenorrhea, infertility) and may cause bitemporal hemianopia from chiasmal compression, not intermittent vertigo with UMN findings.
MS commonly affects young women and can produce brainstem/cerebellar involvement (vertigo, nystagmus) and optic nerve involvement, with symptoms separated in time, matching a 6-month intermittent course.
NEW QUESTION # 351
An otherwise healthy 21-year-old college student is brought to the Emergency Department after falling from the rooftop terrace of a night club. A grade III splenic laceration measuring 3 cm is identified on computed tomography scan. You elect to manage the patient non-operatively with close monitoring, repeat examinations and hemoglobin levels. A repeat computed tomography at 48 hours shows no deterioration. Diet is resumed and over the next few days, the patient resumes ambulation. Which one of the following do you discuss with your patient prior to discharge?
Answer: D
Explanation:
This patient has a grade III splenic laceration successfully managed non-operatively. MCCQE surgical objectives emphasize that in hemodynamically stable patients, non-operative management (NOM) is standard for many blunt splenic injuries to preserve splenic function. Because the spleen remains intact, vaccination against encapsulated organisms is not required (this is indicated after splenectomy or functional asplenia).
Prior to discharge, the most important counseling point is activity restriction to reduce the risk of delayed splenic rupture. Patients are advised to avoid vigorous physical activity, contact sports, and heavy lifting for approximately 3 months , depending on injury severity and follow-up imaging protocols. This allows adequate healing of splenic parenchyma.
Routine interval splenectomy is not indicated after successful NOM. Angiography with embolization is reserved for ongoing bleeding or vascular blush on imaging. Weekly hemoglobin checks are not routinely required if the patient is clinically stable.
Thus, counseling regarding avoidance of vigorous activity is the key discharge recommendation.
NEW QUESTION # 352
You are the emergency physician on duty in a rural hospital when heavy rains in the community cause a large landslide. There are multiple casualties expected to arrive in the emergency department. Your colleague has heard about the incident and arrives to help. Which one of the following is the best next step?
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
During mass casualty incidents, effective triage is essential to optimize care delivery. A trained physician is best used in triage or direct care. Triage is the foundation of disaster management.
Toronto Notes 2023 - Public Health / Disaster Medicine:
"In disaster response, trained healthcare providers should be deployed to triage and stabilize patients in emergency departments." MCCQE1 Objectives (Public Health > 65-1: Disaster Response):
"Candidates must understand principles of mass casualty management and assign appropriate roles during triage and care delivery." Media (D) and logistics (A, C) are secondary roles. Triage and direct care take priority.
NEW QUESTION # 353
A 33-year-old woman presents to a walk-in clinic with a severe right-sided facial paralysis that started suddenly this morning. She denies any numbness or limb weakness. She has no headache or fever. Which one of the following findings on history/physical examination would suggest a more concerning diagnosis?
Answer: E
Explanation:
This patient presents with acute unilateral facial paralysis, most consistent with Bell palsy , a peripheral (lower motor neuron) facial nerve palsy. MCCQE objectives emphasize distinguishing peripheral facial palsy from central (upper motor neuron) causes , such as stroke.
In a peripheral lesion (e.g., Bell palsy), the entire ipsilateral face is affected, including the forehead, because the facial nucleus receives ipsilateral input. Therefore, patients cannot wrinkle their forehead, close their eye, or smile on the affected side. Associated findings may include hyperacusis and loss of corneal reflex. A recent viral illness supports Bell palsy and is not concerning.
In contrast, a central lesion (e.g., stroke) spares the forehead due to bilateral cortical innervation of the upper facial muscles. Thus, ability to wrinkle the forehead on the affected side suggests a central cause, which is more concerning and requires urgent evaluation for cerebrovascular disease. Recognizing forehead sparing is critical in differentiating stroke from Bell palsy in acute facial paralysis.
NEW QUESTION # 354
You performed a surgical procedure on a 32-year-old woman for a herniated disk that was causing neurologic impairment. At the 8-month follow-up visit, she has healed well; however, she requests a prescription renewal of her narcotic analgesics (hydromorphone). Her pharmacy confirms that the patient adheres to the dosage you prescribed, that she has not consulted other physicians, and that her behavior has always been respectful.
You think that she no longer requires narcotic analgesics. Which one of the following approaches is most helpful to the patient?
Answer: E
Explanation:
The patient's pain is no longer medically justified for opioids, but there is no evidence of misuse. The most appropriate and supportive action is to explain concerns, provide education about opioid tapering or dependency, and transition care to her family physician for ongoing management.
Toronto Notes 2023 - ELOM, "Safe Prescribing and Opioid Stewardship" Section:
"When opioids are no longer indicated, engage the patient in a conversation about tapering and arrange appropriate follow-up. Coordinate care with primary providers when long-term management is needed." MCCQE1 Objectives (ELOM > 99-1: Professionalism and Substance Use):
"Candidates must address the risk of dependency, counsel the patient, and ensure a safe transition to appropriate care without abrupt termination." Methadone (E) and fentanyl (A) are for opioid use disorder or chronic pain, not for tapering in low-risk patients. Discharging the patient (B) or reporting (C) is punitive and unnecessary.
NEW QUESTION # 355
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