🇨🇦 MCCQE1,2 | #Case_121
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A 76-year-old female is hospitalized for fever and weakness of several days’ duration. Her history and physical findings are otherwise unremarkable except for a temperature of 38.2°C (100.8°F), a pulse rate of 100 beats/min, and a blood pressure of 110/70 mm Hg. A urinalysis reveals 10-15 WBCs/hpf and a urine culture reveals methicillin-sensitive Staphylococcus aureus. The most appropriate action at this point is to:

a) reculture the urine, as the bacteria on the first urine culture is most likely a skin contaminant
b) obtain a blood culture and examine the patient for a portal of entry
c) obtain a blood culture and start the patient on intravenous vancomycin (Vancocin)
d) start the patient on oral cephalexin (Keflex)
e) order echocardiogram

🇨🇦 MCCQE1,2 | #Case_121 | #answer
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✅ B

🔎 Explanation

Staphylococcus aureus is an unusual genitourinary pathogen; when found in the urine, it should be assumed to have migrated from a primary location. The patient should be examined carefully for a portal of entry such as a skin ulcer, intravenous site, or area of dermatitis.

⚠ An echocardiogram is often required to rule out endocarditis.

⚠ Methicillin-sensitive S. aureus can be treated with a penicillinase-resistant penicillin or a first-generation
cephalosporin.

⚠ Vancomycin should be reserved for treating methicillin-resistant S. aureus.

⚠ Although oral cephalexin can be used to treat methicillin-sensitive S. aureus, this particular patient is too ill and needs to be evaluated for bacteremia

🇨🇦 MCCQE1,2 | #Case_122
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A 72-year-old Asian-Canadian female is brought to your office by her husband because he thinks she might have Alzheimer’s disease. For the past 3 months she has complained of confusion, poor appetite, and lack of energy. She has been unable to do routine housework. On brief questioning, her short-term recall seems to be impaired, but a more detailed examination indicates that her memory is fine.Which one of the following is the most likely diagnosis?

a) Alzheimer’s disease
b) Lewy body dementia
c) Frontotemporal dementia
d) Pseudodementia
e) Mild cognitive impairment

🇨🇦 MCCQE1,2 | #Case_122 | #answer
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✅ D

🔎 Explanation

Instead of dementia, this patient has signs of pseudodementia of depression, which usually has a subacute onset. Memory usually is intact when adequate time is taken to carefully evaluate the patient.

⚠ The onset of Alzheimer’s disease, however, is gradual and includes memory loss.

⚠ Lewy body dementia is associated with hallucinations, and the onset is gradual.

⚠ Frontotemporal dementia generally occurs before age 60. Memory is usually preserved for orientation, although information retrieval may be difficult.

⚠ The onset of mild cognitive impairment is gradual and includes memory loss.

🇨🇦 MCCQE1,2 | #Case_123
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A 43-year-old female with a known history of migraines comes to your office today complaining of unusual chest pains. There is no family history of any coronary artery disease and she is neither a smoker nor does she have hypertension. She describes the discomfort occurring at times of rest and during exertion. However the episodes vary and arise unexpectedly. She is otherwise healthy with no other complaints. Which of the following is contraindicated in this patient?

a) Nifedipine
b) Sumatriptan
c) Lisinopril
d) Verapamil
e) Flunarizine

🇨🇦 MCCQE1,2 | #Case_123 | #answer
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✅ B

🔎 Explanation

This female has Prinzmetal variant angina, which is caused by coronary vasospasms. Sumatriptan is a 5HT1D and 1B agonist, which will have a vasoconstrictive effect. A side effect of this particular drug is that it induces vasospasms, hence contraindicated in individuals with this particular angina

🇨🇦 MCCQE1,2 | #Case_124
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A 65-year-old diabetic male comes to the office complaining of excruciating pain in his left ear that began last night. The pain is 10/10 in intensity and radiates to his mandible. He also complains of ear discharge along with the pain. His condition is worsening progressively despite the use of Tobradex™ ear drops (Tobramycin + dexamethasone). Review of systems is otherwise normal. His vitals signs are within normal limits except for a temp of 38°C. HEENT exam shows the presence of granulation tissue in the lower part of his external auditory canal at the junction between the cartilaginous and bony parts of the canal. When the patient is asked to smile, some weakness of the left facial nerve is noticed. Which of the following pathogens is most likely to be responsible for this patient’s condition?

a) Aspergillus nigrican
b) Escherichia coli
c) Pseudomonas aeruginosa
d) Streptococcus pneumonia
e) Streptococcus pyogenes

🇨🇦 MCCQE1,2 | #Case_124 | #answer
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✅ C

🔎 Explanation

Malignant otitis externa (MOE), skull base osteomyelitis, is the most likely diagnosis of this patient. MOE is usually seen in diabetics and immunosuppressed patients and often presents with a very intense ear pain and ear discharge. Fever is often present and the pain may radiate to the TMJ. Resistance to topical antibiotics along with the history of diabetes should be a useful clue. The most common cause of malignant otitis externa is Pseudomonas aeruginosa(choice C).

⚠ Aspergillus species (choice A) especially the fumigatus type may be occasionally the cause of MOE.

⚠ Escherichia coli (choice B) is the most common cause of UTI and not MOE.

⚠ Streptococcus pneumoniae (choice D) is the most common cause of otitis media and not externa.

⚠ Streptococcus pyogenes (choice E) and Staphylococcus aureus may be superadded; however very rarely to be the responsible agents.

🔖 Key point:

Know the infections associated with diabetes well! Malignant otitis externa, erysipelas, cellulitis, mucormycosis, fournier’s gangrene and emphysematous cholecystitis are frequently asked!

🇨🇦 MCCQE1,2 | #Case_125
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A 28-year-old male comes to the ED complaining of intermittent cramps in his lower abdominal pain, rectal urgency and diarrhea with occasional blood in the stools of 3 weeks duration. His condition has been worsening progressively for the last 3 days. He has vomited several times and feels chilly. He denies the intake of any antibiotics recently. Vitals signs show: pulse is PR: 102/min, BP is 125/75 mmHg, Temp is 39°C and RR is 16/ min. Physical exam reveals a distended and tender to palpation abdomen without any evidence of peritoneal signs. Bowel sounds are absent. Rectal exam shows blood and mucus. Upright X-ray film of the abdomen discloses a hugely distended transverse colon filled with gas. Which of the following diseases would be the most likely precipitant of the patient’s condition?

a) Clostridium difficile colitis
b) Colon cancer
c) Crohn’s disease
d) Typhoid enteritis
e) Ulcerative colitis

🇨🇦 MCCQE1,2 | #Case_125 | #answer
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✅ E

🔎 Explanation

This patient has classic presentation of toxic megacolon. The most common cause of toxic colon is inflammatory bowel disease (IBD), especially ulcerative colitis. The three week history of diarrhea in a young person that has worsened dramatically ending in bowel obstruction with systemic toxicity is a classic scenario of ulcerative colitis complicated with toxic megacolon. Toxic megacolon is an emergent life threatening condition that should be managed immediately with IV
fluids, steroids and NG tube.

⚠ In the absence of antibiotics intake, pseudomembrenous colitis (choice A) becomes unlikely.

⚠ Colon cancer (choice B) is very unlikely to present as toxic megacolon; moreover, the patient’s young age favors against this diagnosis.

⚠ Although Crohn’s disease (choice C) can also lead to a fulminant colitis, it is very rare.

⚠ Intestinal perforation, not fulminant colitis, is the classic complication described in typhoid fever (choice D).

🧩 Medical Mnemonics


#Crohn's disease features

🎄🎄 MERRY CHRISTMAS with lots of love.💓

🎅Malabsorption
🎅Eye involvement(uveitis, iritis, and episcleritis)
🎅Renal stone(oxalate)
🎅Reduced bone mass(osteoprosis)
🎅Yeast infections(Candida)

🎅Cobblestones appearance
🎅High temperature(fever)
🎅Reduced lumen
🎅Intestinal fistulae
🎅Skin lesions(Erythema nodosum, pyoderma gangrenosum)
🎅Transmural ulceration
🎅Musculoskeletal involvement(Arthritis, Hypertrophic osteoarthropathy)
🎅Abdominal pain
🎅Submucous fibrosis/String Sign on barium X ray


#gastroenterology
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📡 Medical Mnemonics

🇨🇦 MCCQE1,2 | #Case_126 | #answer
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✅ E

🔎 Explanation

Patients with thoracic aneurysms often present without symptoms. With dissecting aneurysms, however, the presenting symptom depends on the location of the aneurysm. Aneurysms can compress or distort nearby structures, resulting in branch vessel compression or embolization of peripheral arteries from a thrombus within the aneurysm. Leakage of the aneurysm will cause pain, and rupture can occur with catastrophic results, including severe pain, hypotension, shock, and death. Aneurysms in the ascending aorta may present with acute heart failure brought about by aortic regurgitation from aortic root dilatation and distortion of the annulus. Other presenting findings may include hoarseness, myocardial ischemia, paralysis of a hemidiaphragm, wheezing, coughing, hemoptysis, dyspnea, dysphagia, or superior vena cava syndrome. This diagnosis should be suspected in individuals in their sixties and seventies with the same risk factors as those for coronary artery disease, particularly smokers. A chest radiograph may show widening of the mediastinum, enlargement of the aortic knob, or tracheal displacement. Transesophageal echocardiography can be very useful when dissection is suspected. CT with intravenous contrast is very accurate for showing the size, extent of disease, pressure of leakage, and nearby pathology. Angiography is the preferred method for evaluation and is best for evaluation of branch vessel pathology. MR angiography provides noninvasive multiplanar image reconstruction, but does have limited availability and lower resolution than traditional contrast angiography.Acute dissection of the ascending aorta is a surgical emergency, but dissections confined to the descending aorta are managed medically unless the patient demonstrates progression or continued hemorrhage into the retroperitoneal space or pleura. Initial management should reduce the systolic blood pressure to 100-120 mm Hg or to the lowest level tolerated. The use of a beta-blocker such as propranolol or labetalol to get the heart rate below 60 beats/min should be first-line therapy. If the systolic blood pressure remains over 100 mm Hg, intravenous nitroprusside should be added. Vasodilation will induce reflex activation of the sympathetic nervous system, causing increased ventricular contraction and increased shear stress on the aorta. For descending dissections, surgery is indicated only for complications such as occlusion of a major aortic branch, continued extension or expansion of the dissection, or rupture (which may be manifested by persistent or recurrent pain).

🇨🇦 MCCQE1,2 | #Case_127
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A 52-year-old male presents with a small nodule in his palm just proximal to the fourth metacarpophalangeal joint. It has grown larger since it first appeared, and he now has mild flexion of the finger, which he is unable to straighten. He reports that his father had similar problems with his fingers. On examination you note pitting of the skin over the nodule. The most likely diagnosis is:

a) Degenerative joint disease
b) Trigger finger
c) Dupuytren’s contracture
d) A ganglion
e) Flexor tenosynovitis

🇨🇦 MCCQE1,2 | #Case_127 | #answer
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✅ C

🔎 Explanation

Dupuytren’s contracture is characterized by changes in the palmar fascia, with progressive thickening and nodule formation that can progress to a contracture of the associated finger. The fourth finger is most commonly affected. Pitting or dimpling can occur over the nodule because of the connection with the skin. Degenerative joint disease is not associated with a palmar nodule. Trigger finger is related to the tendon, not the palmar fascia, and causes the finger to lock and release. Ganglions also affect the tendons or joints, are not located in the fascia, and are not associated with contractures. Flexor tenosynovitis, an inflammation, is associated with pain, which is not usually seen with Dupuytren’s contracture

🇨🇦 MCCQE1,2 | #Case_128
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A 79-year-old male presents with left-sided hemiparesis. His previous medical history is significant for long-standing hypertension and type 2 diabetes mellitus. On examination his blood pressure is 220/130 mm Hg and his pulse rate is 96 beats/min. CT of the head shows no acute bleeding. An EKG shows left ventricular hypertrophy with diffuse nonspecific changes. Which one of the following would be most appropriate with regard to his blood pressure at this time?

a) Watchful waiting
b) Reduction of systolic blood pressure (SBP) to 190 mm Hg
c) Reduction of SBP to 170 mm Hg
d) Reduction of SBP to 150 mm Hg
e) Reduction of SBP to 130 mm Hg

🇨🇦 MCCQE1,2 | #Case_128 | #answer
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✅ B

🔎 Explanation

Cautious reduction of systolic blood pressure by 10%-15% while monitoring neurologic status seems to be the safest treatment goal in the setting of acute ischemic stroke when the systolic blood pressure is > 220 mm Hg or the diastolic blood pressure is 120-140 mm Hg. According to JNC-7, more aggressive blood pressure reduction may increase cerebrovascular complications

🇨🇦 MCCQE1,2 | #Case_129
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A 45-year-old male sees you for follow-up after a pre-employment physical examination reveals blood in his urine. He brings a copy of a urinalysis report that shows 3-5 RBCs/hpf. He has not seen any gross blood himself. He is asymptomatic, is on no medications, and does not smoke. You perform a physical examination, with normal findings. A repeat urinalysis confirms the presence of red blood cells but is otherwise normal. Which one of the following would you order first to evaluate this patient?

a) Observation and reassurance
b) A repeat urinalysis in 6 months
c) Urine culture
d) Cystoscopy
e) Renal biopsy

🇨🇦 MCCQE1,2 | #Case_129 | #answer
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✅ C

🔎 Explanation

The current guidelines define clinically significant microscopic hematuria as 3 RBCs/hpf. Microscopic hematuria is frequently an incidental finding, but may be associated with urologic malignancy in up to 10% of adults. All patients should have a urine culture (choice C) first to exclude infection prior to evaluation of hematuria. Patients who have a positive urine culture should be treated for infection with close follow-up

🇨🇦 MCCQE1,2 | #Case_130
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A 46-year-old female presents to your office complaining of wheezing for the past 2 weeks. She denies a history of asthma or any major medical illness. She is a non-smoker but drinks alcohol on the weekends. She admits to having intermittent hoarseness of voice for the past few weeks. Her vitals are within normal limits. Examination of the upper respiratory tract reveals a red and inflamed larynx. Chest is clear to auscultation and percussion. Based on the history and physical exam, what is the most appropriate initial treatment for this patient?

a) A trial of antibiotics
b) Omeprazole daily
c) Oral steroids
d) Salbutamol + Ipratropium inhaler
e) Salbutamol inhaler

🇨🇦 MCCQE1,2 | #Case_130 | #answer
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✅ B

🔎 Explanation

When it is unclear whether the patient has nocturnal asthma or gastroesophageal reflux disease, a trial of proton pump inhibitors (choice B) is both diagnostic and therapeutic.

⚠ There is no evidence of bacterial infectious process; thus empiric antibiotics (choice A) are inappropriate.

⚠ Oral steroids (choice C) would worsen the GERD and even if this were nocturnal asthma, they are never appropriate as an initial approach.

⚠ Salbutamol and/or Ipratropium (choice D and choice E) would be appropriate for asthma or COPD control.

🇨🇦 MCCQE1,2 | #Case_131
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A 57-year-old man underwent pneumonectomy to remove an epithelioma. Complete blood count, renal and liver functions tests were normal. He was prescribed 100units/kg of low molecular weight heparin (LMWH) as prophylaxis against venous thrombosis. His calculated daily dose of 6000 units was given subcutaneously, twice daily. Which one of the following is recommended for monitoring of the anticoagulant effects of LMWH?

a) Measurement of international normalized ratio (INR)
b) Measurement of activated partial thromboplastin time (aPPT)
c) Measurement of plasma antifactor Xa levels
d) Measurement of serum levels of LMWH
e) No monitoring is required