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| Section | Objectives |
|---|---|
| Dimensions of Care | - Chronic Care
|
| Physician Activities | - Management
|
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130. Frage
You are providing antenatal consultation to a primiparous woman of 37 weeks' gestation who was admitted for labour induction. Repeat prenatal ultrasounds confirm a chronically small fetus who has never demonstrated easily detectable fetal movement. Maternal health has been normal throughout the pregnancy and she has received all antenatal serum screening. This fetus is at significant risk for which one of the following?
Antwort: D
Begründung:
A fetus that is chronically growth-restricted and has persistently reduced fetal movement raises concern for an underlying fetal condition rather than isolated placental insufficiency. MCCQE objectives emphasize that early-onset or persistent fetal growth restriction , especially when accompanied by abnormal fetal behavior (notably reduced movement), is associated with higher rates of aneuploidy and other chromosomal disorders (e.g., trisomy syndromes), as well as congenital anomalies and neuromuscular disorders. Among the listed options, chromosomal abnormalities best fit the combined pattern of longstanding small size and consistently diminished movement.
Normal maternal serum screening reduces risk but does not eliminate it; screening tests can miss chromosomal abnormalities, and some aneuploidies may not be reliably detected depending on the test used and gestational timing. Spina bifida is more typically associated with elevated maternal serum AFP and structural findings on ultrasound. Fetal stroke is usually an acute event with more abrupt changes. Congenital hypothyroidism and infantile diabetes are not typical causes of markedly reduced fetal movement with chronic growth restriction.
131. Frage
A 42-year-old businessman known to have type 2 diabetes and ischemic heart disease is admitted to hospital with acute coronary syndrome. He admits to drinking 4 beers a day for the last 6 years and to binge drinking twice a year when his school buddies are in town. Your chart review reveals that he had a seizure secondary to alcohol withdrawal during his last admission. Which one of the following elements of his history puts him at highest risk of having another such seizure?
Antwort: E
Begründung:
A history of previous alcohol withdrawal seizures is the single greatest predictor of future withdrawal seizures. This establishes a sensitization response within the central nervous system.
Toronto Notes 2023 - Addiction Medicine:
"A prior history of alcohol withdrawal seizures is the most important risk factor for recurrent seizures during future withdrawal episodes." MCCQE1 Objectives (Internal Medicine > Substance Use > 58-3):
"Candidates must identify individuals at high risk for severe alcohol withdrawal based on past withdrawal history, including seizures and delirium tremens." Although quantity, duration, and comorbidities contribute to risk, a prior withdrawal seizure most strongly predicts recurrence.
132. Frage
A 72-year-old man has had 4 episodes of weakness in her right arm and leg lasting 10 to 15 minutes each.
During 1 episode, she had difficulty speaking and had blurring of the vision in the left eye. Which one of the following is the most likely diagnosis?
Antwort: C
Begründung:
These are recurrent, brief (10-15 minute), fully resolving focal neurologic deficits, which fits transient ischemic attacks (TIAs) rather than completed stroke. The combination of right-sided arm and leg weakness and difficulty speaking localizes to the left cerebral hemisphere (dominant hemisphere for language in most patients). The additional symptom of transient blurring of vision in the left eye is characteristic of amaurosis fugax, caused by retinal ischemia from emboli or hypoperfusion in the ipsilateral internal carotid circulation.
Together, this pattern strongly suggests left internal carotid artery occlusive disease (e.g., high-grade stenosis with artery-to-artery embolization).
Left MCA thrombosis would typically produce persistent deficits rather than multiple short, self-resolving episodes. Intracerebral hemorrhage usually presents with sudden severe symptoms that do not resolve quickly and often includes headache or reduced consciousness. Epilepsy would more likely cause positive symptoms (jerking, automatisms) and postictal confusion. Vertebrobasilar disease causes posterior circulation symptoms (vertigo, diplopia, ataxia), not unilateral monocular vision loss plus contralateral weakness.
133. Frage
A 38-year-old woman presents with diffuse nodularity in the outer upper quadrant of her right breast. There is no obvious dominant mass, nipple discharge, or skin dimpling. There are no palpable lymph nodes. Which one of the following is the most likely diagnosis?
Antwort: A
Begründung:
Fibrocystic change is the most common benign breast condition in women of reproductive age. It typically presents with diffuse nodularity or "lumpy" areas, especially in the upper outer quadrant, and varies with the menstrual cycle. No dominant mass or systemic signs are expected.
Toronto Notes 2023 - Gynecology, "Benign Breast Conditions":
"Fibrocystic changes often present with bilateral or unilateral nodularity, most commonly in the upper outer quadrants, without discrete masses." MCCQE1 Objectives (Gynecology > 81-1: Breast Conditions):
"Candidates must differentiate benign breast conditions from malignant ones based on presentation and physical exam findings." Paget disease (B) presents with nipple changes. Intraductal carcinoma (C) typically shows a discrete mass or suspicious features. Phyllodes tumours are usually well-circumscribed. Mastitis (E) is inflammatory and associated with erythema, fever, and tenderness.
134. Frage
A 4-month-old boy is brought to the office by his parents to ask about the rotavirus vaccine. They would like to avoid the possibility of the infant coming down with gastroenteritis. Their older child was hospitalized with gastroenteritis at age 10 months. They have a friend who had intussusception after getting the rotavirus immunization, and they are worried about a possible link to the vaccine. Which one of the following is the most appropriate response?
Antwort: D
Begründung:
The most appropriate response is to recommend vaccination and explain that the risk of intussusception after rotavirus vaccination is extremely low , while the benefits in preventing severe rotavirus gastroenteritis are substantial. MCCQE objectives in immunization and preventive pediatrics emphasize balancing risks and benefits using evidence-based data. Current rotavirus vaccines are associated with a very small increased risk of intussusception (on the order of a few additional cases per 100,000 vaccinated infants), but this risk is far outweighed by the prevention of hospitalizations, severe dehydration, and complications from rotavirus infection.
Option B overstates the risk as "markedly increased," which is inaccurate and may heighten parental anxiety.
Intussusception is not always easily treatable and can be serious (C). It occurs most commonly in infants under 1 year, not only in 1- to 3-year-olds (D). Rotavirus can cause significant morbidity in healthy infants, so routine vaccination is recommended (E). Clear, balanced counselling supports informed parental decision- making.
135. Frage
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