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| Section | Objectives |
|---|---|
| Topic 1: Physician Activities | - Professionalism
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| Topic 2: Dimensions of Care | - Acute Care
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NEW QUESTION # 34
A 12-year-old girl is brought to your clinic by her parents 6 weeks after experiencing a minimally displaced buckle fracture of her distal radius. It was immobilized in a cast for 3 weeks. On examination, she supports her forearm with the opposite hand. She is unwilling to move her elbow, wrist, and fingers. The findings of her neurovascular examination are normal, and the soft tissue is supple. A repeat radiograph shows bony union. Which one of the following is the most likely diagnosis?
Answer: A
Explanation:
Complex regional pain syndrome (CRPS type I) is the most likely diagnosis because the child has persistent, function-limiting pain behavior and marked unwillingness to move the entire limb despite a minor fracture that is now healed radiographically and has a normal neurovascular exam. MCCQE objectives emphasize recognizing pain that is disproportionate to tissue injury and persists beyond expected healing, often accompanied by guarding and fear of movement. CRPS can occur after fractures or immobilization and may present with severe allodynia, hyperalgesia, edema, color/temperature changes, and motor dysfunction; however, early cases may primarily show avoidance of movement and pain with otherwise normal objective findings.
An unrecognized scaphoid fracture would cause localized wrist pain (classically snuffbox tenderness) rather than refusal to move elbow, wrist, and fingers, and would not be explained by a distal radius buckle fracture that has united. Ischemic (Volkmann) contracture would involve a tense forearm, fixed flexion deformity, and neurovascular compromise. Median nerve compression would produce sensory changes and thenar weakness.
School avoidance alone does not explain the post-injury limb-protective pattern with normal healing.
Management focuses on reassurance, early mobilization, physiotherapy, and multidisciplinary pain strategies.
NEW QUESTION # 35
You are asked to assess an 85-year-old man who was admitted to the hospital for management of a bowel obstruction. The patient is in bed and has a faint pulse with no detectable blood pressure. There is vomitus on his bed and clothing. He has central cyanosis, and oxygen saturation is 75% on supplemental oxygen. Which one of the following is the best next step?
Answer: E
Explanation:
This patient is critically unstable with severe hypoxia (SpO# 75% despite oxygen), central cyanosis, hypotension (no detectable blood pressure), and evidence of active vomiting-placing him at extremely high risk of airway compromise and aspiration . According to MCCQE resuscitation objectives and ABC principles, airway management is the immediate priority in a patient with respiratory failure and compromised airway protection.
Endotracheal intubation provides definitive airway control, allows suctioning of vomitus, prevents further aspiration, and enables mechanical ventilation with high-concentration oxygen. Noninvasive ventilation is contraindicated in patients with vomiting and impaired airway protection due to high aspiration risk. Chest compressions are indicated only if there is no pulse; this patient has a faint pulse. Intravenous fluids are important for hypotension but must follow airway stabilization. Nasogastric tube insertion does not address the immediate life-threatening hypoxia.
Early definitive airway control in unstable patients with hypoxemia and aspiration risk is essential to prevent cardiac arrest and improve survival outcomes.
NEW QUESTION # 36
A 2-year-old boy is brought by his parents to your clinic because of sudden onset of high fever, refusal to drink, and drooling. Examination reveals cervical lymphadenopathy as well as multiple ulcers on the inner lips, tongue, and gums. Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
Primary herpetic gingivostomatitis caused by HSV-1 is common in toddlers. It presents with high fever, irritability, drooling, refusal to eat, and painful oral ulcers on the lips, gums, and tongue. Cervical lymphadenopathy is common.
Toronto Notes 2023 - Pediatrics, "Infectious Conditions in Children":
"Primary HSV-1 infection in children presents with high fever, cervical lymphadenopathy, and painful oral ulcers (gingivostomatitis)." MCCQE1 Objectives (Pediatrics > 75-2: Infectious Diseases):
"Candidates must recognize viral exanthems and enanthems, including herpetic gingivostomatitis, based on clinical findings." Kawasaki (A) includes conjunctivitis, strawberry tongue, and extremity changes. Epiglottitis (B) presents with drooling but without oral ulcers. Mono (C) lacks the ulcerative pattern. Hand-foot-mouth (D) affects palms and soles, not inner lips and gums predominantly.
NEW QUESTION # 37
A 19-year-old woman returns to your clinic to discuss her recent laboratory tests. She initially presented with dysuria, dyspareunia, and abnormal uterine bleeding. Her vulvovaginal examination was normal. Her last sexual encounter was 3 weeks prior to the onset of her symptoms. Which one of the following pathogens is most likely to explain this clinical presentation?
Answer: C
Explanation:
Chlamydia trachomatis is the most common cause of cervicitis in young sexually active women and frequently presents with dysuria, dyspareunia, intermenstrual bleeding, and a normal vulvovaginal exam. It may be asymptomatic or have subtle signs and often affects the endocervix.
Toronto Notes 2023 - Gynecology, "Sexually Transmitted Infections" Section:
"Chlamydia is the most common bacterial STI. Symptoms may include intermenstrual bleeding, postcoital bleeding, dyspareunia, mucopurulent cervical discharge, and dysuria. The vulva and vagina may appear normal." MCCQE1 Objectives (Obstetrics and Gynecology > 82-1: Abnormal Uterine Bleeding):
"Candidates should evaluate STI-related cervicitis as a common cause of postcoital and intermenstrual bleeding in young women." Other options:
* A. Actinomyces israelii is associated with IUD use, not relevant here.
* B. Herpes simplex virus usually presents with painful ulcerations, not abnormal bleeding.
* C. Treponema pallidum (syphilis) causes painless ulcers or systemic symptoms in later stages.
* D. HPV causes warts or asymptomatic cervical dysplasia, not acute symptoms.
NEW QUESTION # 38
You are evaluating a 75-year-old man with recently diagnosed prostate cancer and 2 painful metastases of the lumbar spine. Which one of the following therapeutic options is the most appropriate?
Answer: B
Explanation:
Palliative radiotherapy is the treatment of choice for painful bone metastases, including those from prostate cancer. It provides localized pain relief and functional improvement.
Toronto Notes 2023 - Oncology, "Metastatic Bone Pain":
"External beam radiotherapy is first-line treatment for localized bone pain from metastases. Relief occurs within days to weeks." MCCQE1 Objectives (Internal Medicine > Oncology > 52-1):
"Candidates must identify treatment options for symptom control in metastatic cancer, including palliative radiotherapy for painful bone lesions." Androgen deprivation therapy (B, C) treats systemic disease but doesn't address acute pain. Opioids (D) may be used, but radiotherapy provides disease-targeted relief. Intrathecal steroids (A) are not standard for prostate metastases.
NEW QUESTION # 39
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