MCCQE1 Ques ons and answers |Updated RATED A+|
NEW EDITION
An 80-year-old woman comes to the urgent care clinic with dyspnoea on exer on. On physical
examina on, her blood pressure is 100/70, and her pulse is 75. She has no pulsus paradoxus.
Her jugular veins are distended, and she has distant heart sounds. In addi on, she has extra
third and fourth heart sounds. Her liver is enlarged, and she has pedal oedema. She has
occasional premature ventricular contrac ons on her electrocardiogram. A chest x-ray reveals
clear lung fields with a dilated cardiac silhoue)e. Her echocardiogram reveals ventricular walls
with a "speckled pa)ern". Which of the following is the most likely diagnosis?
- Alcoholic cardiomyopathy
- Amyloidosis
- Haemochromatosis
- Tuberculosis
- Viral myocardi s - Answer Amyloidosis
Restric ve cardiomyopathy with 'speckled' le2 ventricular wall
Primary cardiac amyloidosis usually develops into diastolic dysfunc on
Alcoholic cardiomyopathy: biventricular dilated cardiomyopathy
A 92-year-old man with a 45-year history of chronic obstruc ve pulmonary disease is intubated
in the ICU because of a bout of viral pneumonia that fails to improve a2er 72 hours of
an bio cs. Although the inspired frac on of oxygen is 100%, the pa ent's pO2 remains at 57
mmHg. Posi ve-end expiratory pressure (PEEP) is added to allow the inspired frac on of
oxygen. Twelve hours a2er the introduc on of PEEP the pa ent suddenly become hypotensive.
At the same me, his oxygen satura on drops from 92% to 61%. On physical examina on, his BP
is 80/50 mmHg and his pulse is 124/min. He has distended neck veins and distant heart sounds.
Which of the following would also most likely be seen on this pa ent's physical examina on?
- Absence of breath sounds in the right hemithorax
- High amplitude caro d artery upstroke
,- A pleural fric on rub
- Pulsus alternans
- Splenomegaly - Answer Absence of breath sounds in the right hemithorax
Pa ent has developed a tension pneumothorax, characterised by PEEP followed by sudden
hypotension and decreased oxygena on
Jugular venous disten on occurs because venous return to the right side of the heart is being
compressed
Rx: immediate needle/tube thoracostomy
A 46-year-old man with a history of hypertension and hypercholesterolemia visits the physician
for a rou ne followup. The pa ent's job involves a lot of travelling, and he admits to
occasionally forgeAng to take his medica ons with him when he travels. He complains of
several episodes of chest pain in the past few months. The pain is sharp in nature, mainly over
his lower chest and epigastrium, and tends to come on when walking. He believes these
episodes are due to indiges on and has been taking antacids. There is a family history of heart
disease, and his father died of a heart a)ack at age 48. On physical examina on, his blood
pressure is 150/80 mmHg and heart rate is 86/min. His lungs are clear to ausculta on. Cardiac
ausculta on reveals normal rate and rhythm, without rubs, gallops, or murmurs. There is no
pedal oedema. He is sent for an exercise stress test. Five minutes into the test, he develops ST -
Answer Coronary angiography
Mul ple risk factors for atherosclero c coronary artery disease
A stress test is considered posi ve when there are ST depression of >1mm for longer than 0.08
seconds
Posi ve stress test = coronary angiography
A 74-year-old woman, who has been followed for the past 25 years for chronic obstruc ve
pulmonary disease comes to the ED complaining of 48 hours of temperature to 38.6 C and
worsening shortness of breath. She has a chronic produc ve cough, which has become more
copious. On physical examina on, she has rhonchi and increased fremitus in the posterior mid-
lung field. A Gram's stain reveals many epithelial cells and mul ple gram-posi ve and gram-
nega ve organisms; no neutrophils are seen. Which of the following is the most likely organism
causing the symptoms?
,- Escherichia coli
- Haemophilus influenzae
- Klebsiella pneumoniae
- Mycobacterium tuberculosis
- Mycoplasma pneumoniae - Answer Haemophilus influenzae
Evidence of community-acquired pneumonia and common organisms in pa ents with COPD are
Strep. pneumoniae, Haem. influenzae and Moraxella catarrhalis.
Klebseilla pneumonia is typically found in alcoholic pa ents.
Primary E. coli pneumonia is rare and there is no history of infec on elsewhere (e.g. UTI).
Mycoplasma pneumoniae does not present with a lobar consolida on and generally occurs in
younger pa ents - x-ray reveals faint bilateral inters al infiltrates.
A 62-year-old man is being treated for an acute myocardial infarc on. He originally came to the
ED with substernal chest pain and diaphoresis. Given his risk factors of hypertension, diabetes,
tobacco use, and family history, he is considered high risk. An ECG in the ED reveals a le2-bundle
branch pa)ern, and cardiac enzymes are elevated slightly. A2er a focused evalua on in the ED,
the pa ent receives IV thromboly cs. Although his bundle branch pa)ern never resolves, the
pa ent is chest pain-free and haemodynamically stable a2er thrombolysis. Two days later,
however, the pa ent reports episodes of recurrent chest discomfort and shortness of breath
overnight. In evalua ng for poten al myocardial reinfarc on, which of the following is the most
appropriate diagnos c test?
- Crea nine kinase
- Dynamic ECG changes
- Lactate dehydrogenase
- Myoglobin levels
- Troponin I level - Answer Crea nine kinase
CK, total levels and specific MB frac on, are elevated as early as 3 hours a2er onset of chest
pain and have a dura on of no more than 2 days, peaking within 18-24 hours
Myoglobin is the first enzyme elevated and lasts no more than 1 day, but is nonspecific to AMI
, Troponin levels increase in 3-12 hours, peak in approximately 1 day, and gradually taper over
the next 10 days
A 41-year-old man comes to the clinic complaining of a chronic cough over the past 4 months,
which has now been accompanied by haemoptysis. He denies smoking or any past medical
history. On physical examina on, his head and neck examina on is normal. His lungs have
diffuse bilateral rales. Cardiac examina on is normal. Laboratory findings reveal Na 142 mEq/L,
K 4.2 mEq/L, Cl 110 mEq/L, HCO3 24 mEq/L, BUN (blood urea nitrogen) 39 mg/dL, crea nine 2.9
mg/dL. Urinalysis reveals microscopic haematuria and 4+ proteinuria. Which of the following
serologic blood tests would most help confirm the suspected diagnosis?
- An -glomerular basement membrane an bodies
- An -mitochondrial an bodies
- An -neutrophilic an bodies
- An -parietal cell an bodies
- An -smooth muscle an bodies - Answer An -glomerular basement membrane an bodies
Haematuria + haemoptysis raises possibility of Goodpasture syndrome
An -mitochondrial = primary biliary cirrhosis
An -neutrophilic cytoplasmic = Wegener granulomatosisn (similar but + URTI sx)
An -parietal cell: pernicious anaemia
An -smooth muscle: autoimmune hepa s
The parents of a 9-year-old girl bring their daughter to the ED. For the last 12 hours, the child
has suffered severe nausea and vomi ng, as well as diarrhoea and abdominal cramps. Further
discussion with the child indicates that she suffers from blurred vision and headache. The
parents originally were worried about bringing the child to the ED because they feared
deporta on since the family are illegal immigrants employed to pick strawberries on a nearby
farm. On direct ques onning, the parents admit that the child was assis ng with spraying crops
with pes cides the previous day. None of the family members was wearing any protec ng
clothing. Her BP is 88/48 mmHg, pulse is 90/min, RR 33/min, Temp 38 C. The child appears
sweaty and confused. Ausculta on of the lungs reveals a diffuse wheeze bilaterally. Pupils are
NEW EDITION
An 80-year-old woman comes to the urgent care clinic with dyspnoea on exer on. On physical
examina on, her blood pressure is 100/70, and her pulse is 75. She has no pulsus paradoxus.
Her jugular veins are distended, and she has distant heart sounds. In addi on, she has extra
third and fourth heart sounds. Her liver is enlarged, and she has pedal oedema. She has
occasional premature ventricular contrac ons on her electrocardiogram. A chest x-ray reveals
clear lung fields with a dilated cardiac silhoue)e. Her echocardiogram reveals ventricular walls
with a "speckled pa)ern". Which of the following is the most likely diagnosis?
- Alcoholic cardiomyopathy
- Amyloidosis
- Haemochromatosis
- Tuberculosis
- Viral myocardi s - Answer Amyloidosis
Restric ve cardiomyopathy with 'speckled' le2 ventricular wall
Primary cardiac amyloidosis usually develops into diastolic dysfunc on
Alcoholic cardiomyopathy: biventricular dilated cardiomyopathy
A 92-year-old man with a 45-year history of chronic obstruc ve pulmonary disease is intubated
in the ICU because of a bout of viral pneumonia that fails to improve a2er 72 hours of
an bio cs. Although the inspired frac on of oxygen is 100%, the pa ent's pO2 remains at 57
mmHg. Posi ve-end expiratory pressure (PEEP) is added to allow the inspired frac on of
oxygen. Twelve hours a2er the introduc on of PEEP the pa ent suddenly become hypotensive.
At the same me, his oxygen satura on drops from 92% to 61%. On physical examina on, his BP
is 80/50 mmHg and his pulse is 124/min. He has distended neck veins and distant heart sounds.
Which of the following would also most likely be seen on this pa ent's physical examina on?
- Absence of breath sounds in the right hemithorax
- High amplitude caro d artery upstroke
,- A pleural fric on rub
- Pulsus alternans
- Splenomegaly - Answer Absence of breath sounds in the right hemithorax
Pa ent has developed a tension pneumothorax, characterised by PEEP followed by sudden
hypotension and decreased oxygena on
Jugular venous disten on occurs because venous return to the right side of the heart is being
compressed
Rx: immediate needle/tube thoracostomy
A 46-year-old man with a history of hypertension and hypercholesterolemia visits the physician
for a rou ne followup. The pa ent's job involves a lot of travelling, and he admits to
occasionally forgeAng to take his medica ons with him when he travels. He complains of
several episodes of chest pain in the past few months. The pain is sharp in nature, mainly over
his lower chest and epigastrium, and tends to come on when walking. He believes these
episodes are due to indiges on and has been taking antacids. There is a family history of heart
disease, and his father died of a heart a)ack at age 48. On physical examina on, his blood
pressure is 150/80 mmHg and heart rate is 86/min. His lungs are clear to ausculta on. Cardiac
ausculta on reveals normal rate and rhythm, without rubs, gallops, or murmurs. There is no
pedal oedema. He is sent for an exercise stress test. Five minutes into the test, he develops ST -
Answer Coronary angiography
Mul ple risk factors for atherosclero c coronary artery disease
A stress test is considered posi ve when there are ST depression of >1mm for longer than 0.08
seconds
Posi ve stress test = coronary angiography
A 74-year-old woman, who has been followed for the past 25 years for chronic obstruc ve
pulmonary disease comes to the ED complaining of 48 hours of temperature to 38.6 C and
worsening shortness of breath. She has a chronic produc ve cough, which has become more
copious. On physical examina on, she has rhonchi and increased fremitus in the posterior mid-
lung field. A Gram's stain reveals many epithelial cells and mul ple gram-posi ve and gram-
nega ve organisms; no neutrophils are seen. Which of the following is the most likely organism
causing the symptoms?
,- Escherichia coli
- Haemophilus influenzae
- Klebsiella pneumoniae
- Mycobacterium tuberculosis
- Mycoplasma pneumoniae - Answer Haemophilus influenzae
Evidence of community-acquired pneumonia and common organisms in pa ents with COPD are
Strep. pneumoniae, Haem. influenzae and Moraxella catarrhalis.
Klebseilla pneumonia is typically found in alcoholic pa ents.
Primary E. coli pneumonia is rare and there is no history of infec on elsewhere (e.g. UTI).
Mycoplasma pneumoniae does not present with a lobar consolida on and generally occurs in
younger pa ents - x-ray reveals faint bilateral inters al infiltrates.
A 62-year-old man is being treated for an acute myocardial infarc on. He originally came to the
ED with substernal chest pain and diaphoresis. Given his risk factors of hypertension, diabetes,
tobacco use, and family history, he is considered high risk. An ECG in the ED reveals a le2-bundle
branch pa)ern, and cardiac enzymes are elevated slightly. A2er a focused evalua on in the ED,
the pa ent receives IV thromboly cs. Although his bundle branch pa)ern never resolves, the
pa ent is chest pain-free and haemodynamically stable a2er thrombolysis. Two days later,
however, the pa ent reports episodes of recurrent chest discomfort and shortness of breath
overnight. In evalua ng for poten al myocardial reinfarc on, which of the following is the most
appropriate diagnos c test?
- Crea nine kinase
- Dynamic ECG changes
- Lactate dehydrogenase
- Myoglobin levels
- Troponin I level - Answer Crea nine kinase
CK, total levels and specific MB frac on, are elevated as early as 3 hours a2er onset of chest
pain and have a dura on of no more than 2 days, peaking within 18-24 hours
Myoglobin is the first enzyme elevated and lasts no more than 1 day, but is nonspecific to AMI
, Troponin levels increase in 3-12 hours, peak in approximately 1 day, and gradually taper over
the next 10 days
A 41-year-old man comes to the clinic complaining of a chronic cough over the past 4 months,
which has now been accompanied by haemoptysis. He denies smoking or any past medical
history. On physical examina on, his head and neck examina on is normal. His lungs have
diffuse bilateral rales. Cardiac examina on is normal. Laboratory findings reveal Na 142 mEq/L,
K 4.2 mEq/L, Cl 110 mEq/L, HCO3 24 mEq/L, BUN (blood urea nitrogen) 39 mg/dL, crea nine 2.9
mg/dL. Urinalysis reveals microscopic haematuria and 4+ proteinuria. Which of the following
serologic blood tests would most help confirm the suspected diagnosis?
- An -glomerular basement membrane an bodies
- An -mitochondrial an bodies
- An -neutrophilic an bodies
- An -parietal cell an bodies
- An -smooth muscle an bodies - Answer An -glomerular basement membrane an bodies
Haematuria + haemoptysis raises possibility of Goodpasture syndrome
An -mitochondrial = primary biliary cirrhosis
An -neutrophilic cytoplasmic = Wegener granulomatosisn (similar but + URTI sx)
An -parietal cell: pernicious anaemia
An -smooth muscle: autoimmune hepa s
The parents of a 9-year-old girl bring their daughter to the ED. For the last 12 hours, the child
has suffered severe nausea and vomi ng, as well as diarrhoea and abdominal cramps. Further
discussion with the child indicates that she suffers from blurred vision and headache. The
parents originally were worried about bringing the child to the ED because they feared
deporta on since the family are illegal immigrants employed to pick strawberries on a nearby
farm. On direct ques onning, the parents admit that the child was assis ng with spraying crops
with pes cides the previous day. None of the family members was wearing any protec ng
clothing. Her BP is 88/48 mmHg, pulse is 90/min, RR 33/min, Temp 38 C. The child appears
sweaty and confused. Ausculta on of the lungs reveals a diffuse wheeze bilaterally. Pupils are
