MCCQE1 Questions And Answers 2022

An 80-year-old woman comes to the urgent care clinic with dyspnoea on exertion. On physical examination, 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 addition, she has extra third and fourth heart sounds. Her liver is enlarged, and she has pedal oedema. She has occasional premature ventricular contractions on her electrocardiogram. A chest x-ray reveals clear lung fields with a dilated cardiac silhouette. Her echocardiogram reveals ventricular walls with a "speckled pattern". Which of the following is the most likely diagnosis? - Alcoholic cardiomyopathy - Amyloidosis - Haemochromatosis - Tuberculosis - Viral myocarditis Amyloidosis Restrictive cardiomyopathy with 'speckled' left ventricular wall Primary cardiac amyloidosis usually develops into diastolic dysfunction Alcoholic cardiomyopathy: biventricular dilated cardiomyopathy A 92-year-old man with a 45-year history of chronic obstructive pulmonary disease is intubated in the ICU because of a bout of viral pneumonia that fails to improve after 72 hours of antibiotics. Although the inspired fraction of oxygen is 100%, the patient's pO2 remains at 57 mmHg. Positive-end expiratory pressure (PEEP) is added to allow the inspired fraction of oxygen. Twelve hours after the introduction of PEEP the patient suddenly become hypotensive. At the same time, his oxygen saturation drops from 92% to 61%. On physical examination, 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 patient's physical examination? - Absence of breath sounds in the right hemithorax - High amplitude carotid artery upstroke - A pleural friction rub - Pulsus alternans - Splenomegaly Absence of breath sounds in the right hemithorax Patient has developed a tension pneumothorax, characterised by PEEP followed by sudden hypotension and decreased oxygenation Jugular venous distention 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 routine followup. The patient's job involves a lot of travelling, and he admits to occasionally forgetting to take his medications 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 indigestion and has been taking antacids. There is a family history of heart disease, and his father died of a heart attack at age 48. On physical examination, his blood pressure is 150/80 mmHg and heart rate is 86/min. His lungs are clear to auscultation. Cardiac auscultation 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 depression of 3mm in leads V1-V5. The ST segment depression is greater than 0.12 seconds in duration and the stress test is stopped. Which of the following is the most appropriate next step in management? - Coronary angiography - Holter monitor - No further tests are required - Repeat stress test with thallium - Upper gastrointestinal endoscopy Coronary angiography Multiple risk factors for atherosclerotic coronary artery disease A stress test is considered positive when there are ST depression of >1mm for longer than 0.08 seconds Positive stress test = coronary angiography A 74-year-old woman, who has been followed for the past 25 years for chronic obstructive 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 productive cough, which has become more copious. On physical examination, she has rhonchi and increased fremitus in the posterior mid-lung field. A Gram's stain reveals many epithelial cells and multiple gram-positive and gram-negative 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 Haemophilus influenzae Evidence of community-acquired pneumonia and common organisms in patients with COPD are Strep. pneumoniae, Haem. influenzae and Moraxella catarrhalis. Klebseilla pneumonia is typically found in alcoholic patients. Primary E. coli pneumonia is rare and there is no history of infection elsewhere (e.g. UTI). Mycoplasma pneumoniae does not present with a lobar consolidation and generally occurs in younger patients - x-ray reveals faint bilateral interstitial infiltrates. A 62-year-old man is being treated for an acute myocardial infarction. 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 left-bundle branch pattern, and cardiac enzymes are elevated slightly. After a focused evaluation in the ED, the patient receives IV thrombolytics. Although his bundle branch pattern never resolves, the patient is chest pain-free and haemodynamically stable after thrombolysis. Two days later, however, the patient reports episodes of recurrent chest discomfort and shortness of breath overnight. In evaluating for potential myocardial reinfarction, which of the following is the most appropriate diagnostic test? - Creatinine kinase - Dynamic ECG changes - Lactate dehydrogenase - Myoglobin levels - Troponin I level Creatinine kinase CK, total levels and specific MB fraction, are elevated as early as 3 hours after onset of chest pain and have a duration 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 examination, his head and neck examination is normal. His lungs have diffuse bilateral rales. Cardiac examination 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, creatinine 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? - Anti-glomerular basement membrane antibodies - Anti-mitochondrial antibodies - Anti-neutrophilic antibodies - Anti-parietal cell antibodies - Anti-smooth muscle antibodies Anti-glomerular basement membrane antibodies Haematuria + haemoptysis raises possibility of Goodpasture syndrome Anti-mitochondrial = primary biliary cirrhosis Anti-neutrophilic cytoplasmic = Wegener granulomatosisn (similar but + URTI sx) Anti-parietal cell: pernicious anaemia Anti-smooth muscle: autoimmune hepatitis 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 vomiting, 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 deportation since the family are illegal immigrants employed to pick strawberries on a nearby farm. On direct questionning, the parents admit that the child was assisting with spraying crops with pesticides the previous day. None of the family members was wearing any protecting clothing. Her BP is 88/48 mmHg, pulse is 90/min, RR 33/min, Temp 38 C. The child appears sweaty and confused. Auscultation of the lungs reveals a diffuse wheeze bilaterally. Pupils are miotic and the child has diffuse muscle weakness. Which of the following interventions is the most appropriate treatment? - Atropine - Charcoal - Glucagon - Naloxone - Pralidoxime Pralidoxime Pesticide exposure: consider organophosphate poisoning, which inhibits cholinesterase and results in accumulation of ACh in both muscarinic and nicotinic sites. Pralidoxime activates ACh Atropine competes with ACh only at muscarinic receptors, but will not reverse nicotinic effects Charcoal = gastric decontamination Glucagon = reverse beta-blocker overdose Naloxone = reverse effects of opioids A 5-year-old boy suddenly begins coughing while eating peanuts. He is choking and gagging. When he is brought to the ED, but he is awake and is able to give his name. On physical examination, his vital signs are stable. On examination of the chest, inspiratory stridor and intercostal and suprasternal retractions are apparent. Which of the following is the most appropriate initial step in management? - Allow patient to clear foreign object by spontaneous coughing - Clear oropharynx with multiple blind sweeps with finger - Position patient and perform back blows - Stand behind patient and perform abdominal thrusts - Perform emergency tracheostomy and take to surgery Allow patient to clear foreign object by spontaneous coughing If patient can cough and breathe it is best to initially observe and allow spontaneous resolution, since intervention may actually be damaging A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate her long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of nausea and has two episodes of vomiting. The physical administers 0.625 mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient's neck is involuntarily flexed to one side. She is alert, oriented, and conversation and has an otherwise normal neurological examination. Which of the following is the most likely diagnosis? - Cerebral vascular accident - Conversion disorder - Dystonic reaction to droperidol - Munchausen syndrome - Seizure Dystonic reaction to droperidol Droperidol antagnosies dopaminergic receptors in the vomiting centre, which can produce torticollic or other dystonias Munchausen syndrome: mental disorder in which a person fakes illness to gain attention and sympathy Conversion disorder: neurological sx without a definable organic cause A 35-year-old woman comes to the ED complaining of chest pressure. She has had such episodes intermittently over the last 5 years, usually when sleeping, but over the last year she has had more frequent severe symptoms that are occasionally associated with severe migraine headaches. The pain is midsternal and is described as pressure that extends as a band around her chest. The ED physician is initially dubious that the pain is cardiac in origin, because the woman has no coronary disease risk factors. An ECG, however, shows 2mm ST-segment elevation and inverted T waves in leads V1 through V5 and 1mm ST-segment depression in leads II, III, and aVF. Before the cardiologist arrives in the ED, the patient's ECG has returned to normal. This repeat normal ECG is obtained after the administration of aspirin, nitroglycerin, morphine, and oxygen. Which of the following is most likely for these findings? - Diffuse intimal thickening with focal areas of atherosclerotic narrowing - Intermittent thrombus formation and lysis in the left anterior descending artery - Intermittent thrombus formation and lysis in the right coronary artery - Plaque rupture and thrombus formation in the left anterior descending artery - Transiently increased coronary vascular tone in the right coronary artery Transiently increased coronary vascular tone in the right coronary artery Classic presentation of variant angina, caused by coronary vasospasm that induces transient ischaemia and ST-segment elevations Raynaud phenomenon or migraines are common clues to the diagnosis ST-segment elevation that responds to nitroglycerin makes the diagnosis almost certain A 73-year-old man comes to the ED complaining of abdominal pain. He describes a dull, aching, constant pain in his mid-umbilical region. The pain has persisted over the past few days with increasing intensity, and it is not relieved by changes in position or eating. The patient has a past medical history significant for hypertension and coronary artery disease. He had a myocardial infarction 3 years ago. The man has moderate peripheral vascular disease with a prior femoral-popliteal bypass graft on the left. On physical examination, his BP is 180/100 mmHg, and his pulse is 86/min. He has a loud S4, a pulsatile, midline abdominal mass and venous stasis changes bilaterally on his lower extremities. Which of the following is the most appropriate diagnostic test at this time? - Abdominal US - Lumbosacral spine films - CT of the spine - CT of the abdomen - Spinal MRI Abdominal ultrasound (most cost-effective) Suspected abdominal aortic aneurysm A 42-year-old man comes to the physician for his annual physical examination. He was last seen 2 years ago for a periodic health examination and was in god health. He is on no medications. His past medical history is significant for a cholecystectomy 2 years ago and rheumatic fever at age 15. He has been smoking approximately 10 cigarettes daily for the past 23 years. On physical examination, his BP is 154/56 mmHg, pulse 68/min, RR 14/min. He is afebrile. A head and neck examination is normal. His lungs are clear. He has a regular heart rhythm with a II/VI blowing decrescendo diastolic murmur heard at the aortic area. His abdominal and rectal examinations are normal. Complete blood count, electrolytes, and thyroid function tests are normal. Which of the following is the most appropriate advice for this man regarding future preventive health maintenance? - Antibiotic prophylaxis before dental work - Annual chest x-ray film - Annual ECG - Annual flexible sigmoidoscopy - Annual prostate specific antigen testing Antibiotic prophylaxis before undergoing dental work Physical examination is consistent with asymptomatic aortic insufficiency as a result of childhood rheumatic fever. Patients with any significant cardiac valvular disease should be instructed to have abx prophylaxis before dental work to reduce the risk of subacute bacterial endocarditis. Sigmoidoscopy and PSA testing would be recommended when >50 years A 23-year-old man is admitted to the medical services with a severe asthma attack. He is also nauseous and has vomited twice today. The patient has a long history of severe asthma with multiple hospitalisations and one intubation 3 years ago. Two days prior to admission, he was exposed to dust while moving a file cabinet in his basement. Since that time, he has had progressively worsening shortness of breath. He had tried home albuterol and ipratropium nubulizers, as well as his standard cromolyn therapy, but none of these interventions relieved his symptoms. In the hospital, the man's peak flow rates are decreased by nearly 50% from baseline. Which of the following agents should most likely be added to the patient's therapy to alleviate his current symptoms? - Beclomethasone - Disodium cromoglycate - Hydrocortisone - Prednisolone - Theophylline Hydrocortisone (IV steroidal agent) to augment the action of bronchodilators by reducing inflammation surrounding the airways. Beclomethasone (aerosol) is surface-acting and is used with side effects of systemic steroids needs to be avoided. Disodium cromoglycate: preventer Prednisolone (oral) Theophylline: chronic control A 16-year-old girl is brought to the ED by ambulance after she was extracted from a burning vehicle that had been in an accident on the local highway. She was the only person in her car, which burst into flames after being rear-ended at high speed. She swayer off the road and collided with the side railing. When the ambulance arrived, she was unconscious in the driver's seat. On arrival at the emergency center, the patient is in moderate respiratory distress. Her pulse is 120/min, BP 80/40, and RR 30/min. After securing the airway and administering oxygen and IV fluid, the physician evaluates the extent of the sustained burn injury. There is diffuse erythema and oedema of her face and most of her scalp hair is scorched, with some blistering of the underlying skin. Both arms show diffuse erythema, oedema, and areas of extensive blistering. The rest of her body shows no significant burns. Which of the following is the estimated body surface area of the burn? 27% First-degree burns of the face and superficial second-degree burns of scalp and arms - rule of 9s Head = 9% Arms = 9% each Legs = 18% each Trunk = 18% for front and 18% for back A previously healthy 27-year-old man comes to the physician complaining of a cough with sputum production for the past 3 days. The cough has been keeping him up at night and it is affecting his job performance. He has no prior history of respiratory disease. His temperature is 37 C, BP 130/80, pulse 70, and RR 18. Physical examination is unremarkable. Which of the following is the most appropriate next step in management? - Admit for medical management - Perform chest x-ray - Perform sputum culture - Send home with abx - Send home with no therapy Send home with no therapy Likely dx: acute viral bronchitis If >1 week, macrolide abx may be given A female infant was born at 31 weeks gestational age following a spontaneous vaginal delivery. The mother had regular prenatal care with negative serologies. Labour lasted 13 hours, and nitrous oxide was used for pain control. Apgar scores were 6 and 7 at 1 and 5 minutes, respectively, because of por respiratory effort and decreased tone. She is transferred to the neonatal intensive care unit, where vitals are monitored continuously and nasal CPAP is begun. Periodic changes in breathing were noted, with absent respiration of 20s duration with each episode. Apneic episodes are associated with a HR of 95 and PaO2 of 70. HR returns to 140 and PaO2 to 95 between episodes. The patient's temperature is 36.8 C, RR 60, BP 90/50, and birth weight 1680g. Physical exam and routine laboratory results are otherwise normal. Which of the following is the most appropriate pharmacotherapy for this infant's apnoea? - Bicarbonate - Dextrose - Epinephrine - Naloxone - Theophylline - Phenobarbitol Theophylline Apnoea of prematurity: cessation of air flow/exchange for >20s and often associated with bradycardia and hypoxaemia. Occurs in ~50% of infants born at 30-31 weeks due to immaturity of the infant's neurologic and respiratory systems. First line pharmacologic agents: methylxanthines (caffeine, theophylline) which stimulate respiratory neurons Bicarbonate: correct acidosis Dextrose: correct hypoglycaemia Epinephrine: neonatal resuscitation when HR>80 despite effective ventilation and chest compressions for >30 seconds