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| Section | Objectives |
|---|---|
| Topic 1: Dimensions of Care | - Psychosocial Aspects
|
| Topic 2: Physician Activities | - Communication
|
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NEW QUESTION # 278
A 34-year-old man presents to your office with a 2-week history of headaches and double vision when he looks to the right. On physical examination, you note that he is unable to gaze laterally with his right eye.
Which one of the following cranial nerves is most likely affected?
Answer: E
Explanation:
The inability to gaze laterally with the right eye indicates dysfunction of the right lateral rectus muscle , which is innervated by cranial nerve VI (the abducens nerve). The primary action of the lateral rectus muscle is abduction of the eye (movement away from the midline). Damage to the abducens nerve results in an inability to abduct the affected eye, leading to horizontal diplopia that worsens when looking toward the side of the lesion.
MCCQE objectives emphasize understanding cranial nerve function and localization. The oculomotor nerve (CN III) controls most extraocular movements but not lateral rectus. Trochlear nerve (CN IV) innervates the superior oblique muscle, affecting downward and inward gaze. The optic nerve (CN II) is responsible for vision, not eye movement. The trigeminal nerve (CN V) provides facial sensation and mastication motor function.
Headache with a new sixth nerve palsy may raise concern for increased intracranial pressure or intracranial pathology, as CN VI is vulnerable due to its long intracranial course. Further evaluation is warranted.
NEW QUESTION # 279
You are undertaking the retrospective analysis of a laboratory-confirmed influenza A virus outbreak that occurred in a long-term care facility last year. Among the 163 residents in the facility during the outbreak, 101 residents had new-onset fever, cough, myalgias, and congestion. Of these, 37 residents were transferred to acute care. Of these, 17 residents died. Which one of the following is the best estimate of the attack rate in residents at the facility?
Answer: B
Explanation:
The attack rate is a measure of cumulative incidence used in outbreak investigations. It represents the proportion of individuals at risk who develop the disease during a specified time period. MCCQE objectives emphasize understanding key epidemiologic measures, particularly in institutional outbreaks.
In this scenario, 163 residents were at risk during the influenza outbreak. Of these, 101 developed new-onset symptoms consistent with influenza. Therefore, the attack rate is calculated as:
Number of new cases ÷ Number of people at risk
= 101 ÷ 163
The number transferred to acute care (37) reflects disease severity but does not represent all cases. The number of deaths (17) would be used to calculate the case fatality rate (17/101), not the attack rate.
Thus, the best estimate of the attack rate among residents is 101/163 , representing the proportion of the at- risk population who became ill during the outbreak.
NEW QUESTION # 280
A 70-year-old hypertensive woman with a history of congestive heart failure (CHF) secondary to left ventricular dysfunction presents to your office with a persistent dry hacking cough. She claims it began when she was started on ramipril. Which one of the following medications would be most appropriate to replace ramipril, to ensure that the risk of morbidity associated with CHF remains low?
Answer: A
Explanation:
ACE inhibitors such as ramipril are first-line for CHF with reduced ejection fraction, but a common adverse effect is a dry cough due to bradykinin accumulation. Angiotensin II receptor blockers (ARBs) offer the same hemodynamic and survival benefits without causing cough.
Toronto Notes 2023 - Cardiology, "Heart Failure" Section:
"In patients intolerant to ACE inhibitors due to cough, an ARB (e.g., losartan, valsartan) is the recommended substitute. ARBs also reduce mortality and hospitalizations in heart failure with reduced ejection fraction." MCCQE1 Objectives (Internal Medicine > 76-3: Congestive Heart Failure):
"Candidates should recognize ARBs as an alternative to ACE inhibitors in patients who develop adverse effects such as cough, while maintaining the mortality benefit." Other options (B-E) do not offer mortality benefits in CHF and may worsen the condition (e.g., CCBs, alpha- blockers, NSAIDs like COX-2 inhibitors).
NEW QUESTION # 281
A 39-year-old man presents to a psychiatrist. He says, "It often seems to me that I am not part of this world.
My voice sounds strange to me, and other people seem like figures in a dream." He has had these feelings intermittently for about 2 years. There is no history of hallucinations, and there are no current indications of disorganized thinking. Which one of the following is the most likely diagnosis?
Answer: E
Explanation:
The patient describes classic symptoms of depersonalization ("my voice sounds strange to me") and derealization ("others seem like figures in a dream"), which define depersonalization/derealization disorder.
There is preserved reality testing and no psychosis.
Toronto Notes 2023 - Psychiatry, "Dissociative Disorders" Section:
"Depersonalization/derealization disorder involves persistent or recurrent experiences of detachment from oneself (depersonalization) or surroundings (derealization), with intact reality testing and no delusions or hallucinations." MCCQE1 Objectives (Psychiatry > 79-4: Dissociative Disorders):
"Candidates must identify depersonalization/derealization disorder as a dissociative disorder distinct from psychosis or mood disorders." Schizophrenia (A) would include hallucinations or disorganized thinking. Conversion disorder (B) presents with neurological symptoms inconsistent with known diseases. Persistent depressive disorder (D) involves chronic low mood. Delusional disorder (E) would involve fixed false beliefs, which are not present here.
NEW QUESTION # 282
An otherwise healthy 57-year-old man with a 20 pack-year history of smoking presents with a 2-day history of reddish-brown urine that has not cleared. There is no history of abdominal or flank pain. Urinalysis reveals
5 red blood cells per high power field. Which one of the following is the best next step?
Answer: E
Explanation:
This patient has gross painless hematuria (reddish-brown urine) and is over age 50 with a smoking history- major risk factors for urothelial carcinoma (bladder cancer) . MCCQE objectives emphasize that any episode of gross painless hematuria in adults warrants urgent evaluation for malignancy , regardless of the number of red blood cells seen on urinalysis. Even microscopic hematuria in higher-risk individuals requires thorough workup.
The most important next step is cystoscopy , which directly visualizes the bladder and lower urinary tract to identify tumors, the most common cause of painless hematuria in this demographic. Imaging (e.g., CT urography) is also part of a complete evaluation, but cystoscopy is essential for diagnosing bladder lesions.
Intravenous pyelography is outdated and less sensitive. Ultrasonography may detect masses but does not replace cystoscopy. Reassurance or delayed repeat urinalysis would risk missing a malignancy.
Therefore, immediate urologic referral for cystoscopic evaluation is the appropriate next step.
NEW QUESTION # 283
......
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