🇨🇦 MCCQE1,2 | #Case_56
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An 18-month-old white male has been brought into your office multiple times over the past year with a reported fever of over 38°C (101°F). The child’s reported temperatures at home have usually been higher than those measured at the time of the office visit. The remainder of the history is usually unremarkable. The child has a sibling who is in good health, but another sibling died several years ago for unknown reasons.On two occasions you diagnosed acute otitis media and acute bronchitis. However, at most visits the child has not had any abnormal physical findings. Repeated laboratory studies have been within normal limits, including complete blood counts, erythrocyte sedimentation rates, blood cultures, chest radiographs, and urinalyses. Almost always, the mother has reported little reduction in fever with age-appropriate doses of acetaminophen or ibuprofen.At the last visit the child’s temperature was measured at 40.6°C (105.1°F). Although the examination was once again unrevealing, it was decided to hospitalize the child for close observation and evaluation by an infectious disease consultant. Closed-circuit television observation in the hospital showed the mother putting the thermometer into hot water before a nurse came to record the patient’s temperature.During the hospitalization you make a diagnosis. Which one of the following is a strong indicator of the suspected final diagnosis?

a) The child has seen no other health-care provider but you
b) Both parents have been involved with each office visit
c) The child is afebrile while staying at the day-care center
d) The parents have resisted having painful or risky diagnostic tests performed on the child
e) The child responds well to usual medical therapies

🇨🇦 MCCQE1,2 | #Case_56 | #answer
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✅ C

🔎 Explanation

This is a characteristic presentation of factitious disorder by proxy, or what is commonly known as Munchausen syndrome by proxy. Warning signs for this disorder include episodes of illness beginning only when the child is, or has recently been, with the parent (choice C); the parent taking the child to numerous caregivers, resulting in multiple diagnostic evaluations but neither cure nor definitive diagnosis; the other parent (usually the father) being notably uninvolved despite the ostensible health crises; the parent not being assured by normal test results and continually advocating for painful or risky diagnostic tests for the child; the child persistently failing to tolerate or respond to usual medical therapies; and another child in the family having an unexplained illness or childhood death.

🇨🇦 MCCQE1,2 | #Case_57
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A 26 year old male was brought to the Emergency Room right after he underwent a motor vehicle accident.
He suffered multiple traumatic fractures including a significant head trauma. He suddenly became dyspneic and tachypneic complaining of chest discomfort and has a syncopal episode.His blood pressure dropped to 70/50 mmHg, pulse is 140/min, and respirations are 30/min. CT angiogram shows a massive obstruction in the main pulmonary artery with saddle shaped extension into both pulmonary arteries. What is the most appropriate line of management for this patient?

a) Coronary catheterization
b) Embolectomy
c) Green field filter
d) Heparin
e) Streptokinase

🇨🇦 MCCQE1,2 | #Case_57 | #answer
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✅ B

🔎 Explanation

Not want to put him at risk for an intracranial bleeding or a bleeding elsewhere. So the best intervention would be a pulmonary embolectomy.
Heparin is very good for clot stabilization; however it will not dissolve the already existing clot in our patient. The patient is unstable; embolectomy is life saving! A green field filter is an Inferior vena cava filter that is placed when a patient has recurrent DVT occurrence or when there is a contraindication to heparin.Percutaneous coronary intervention (PCI) would be warranted if the patient has an acute MI.

🇨🇦 MCCQE1,2 | #Case_58
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A 26-year-old gravida 2 para 1 presents at 30 weeks gestation with a complaint of severe itching. She has excoriations from scratching in various areas. She says that she had the same problem during her last pregnancy, and her medical records reveal a diagnosis of intrahepatic cholestasis of pregnancy. Elevation of which one of the following is most specific and sensitive marker of this disorder?

a) Gamma - Glutamyltransferase (GGT)
b) Bile acids
c) Total bilirubin
d) Chenodeoxycholic acid
e) Alkaline phosphatase

🇨🇦 MCCQE1,2 | #Case_58 | #answer
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✅ B

🔎 Explanation

Intrahepatic cholestasis of pregnancy (ICP) classically presents as severe pruritus in the third trimester. Characteristic findings include the absence of primary skin lesions and elevation of serum levels of total bile acids.The most specific and sensitive marker of ICP is total serum bile acid (BA) levels greater than 10 micromol/L. In addition to the elevation in serum BA levels, the cholic acid level is significantly increased and the chenodeoxycholic acid level is mildly increased, leading to elevation in the cholic/chenodeoxycholic acid level ratio. The elevation of
aminotransferases associated with ICP varies from a mild increase to a 10- to 25-fold increase.Total bilirubin levels are also increased but usually the values are less than 5 mg/dL. Alkaline phosphatase (AP) is elevated in ICP up to 4-fold, but this is not helpful for diagnosis of the disorder since AP is elevated in pregnancy due to production by the placenta. Mild elevation of gamma glutamyltransferase (GGT) is seen with ICP but occurs in fewer than 30% of cases. However, if GGT is elevated in cases of ICP, that patient is more likely to have a genetic component of the liver disease.

🇨🇦 MCCQE1,2 | #Case_59
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A 68-year-old male presents to your department because of cough and hoarseness that “just won’t go away”. He has been coughing and had a hoarse voice for 3 weeks now and antitussive OTC medications he has tried have not helped him much. Moreover, the last 3 days he feels that he is getting worse as he felt more lethargic and has been confused at times. He noticed that his shoulder muscles are a bit sore. The patient has lost 8 kg over the last 2 months. He has smoked 150 packs of cigarettes a year the last 42 years.On physical examination only generalized muscle weakness is noted. The patient’s comprehensive metabolic panel reveals: Glucose: 4.1 mmol/l
Urea: 7 mmol/ l
Creatinine: 100 micromol/L
GFR: 70 ml/min/1.73
Sodium: 125 mmol/l
Potassium: 3. 9 mmol/l
Chloride: 99 mmol/l
Calcium: 2. 41 mmol/L
Protein total: 61g/l
Albumin: 40 g/l
Alkaline phosphatase: 60 U/l
AST: 35 U/l
ALT: 45 U/ l

Which of the following is the most likely diagnosis?

a) Oat cell lung carcinoma
b) Sarcoidosis
c) Squamous cell lung carcinoma
d) Laryngeal squamous carcinoma
e) Lung adenocarcinoma

🇨🇦 MCCQE1,2 | #Case_59 | #answer
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✅ A

🔎 Explanation

This patient presents with a clinical picture very suspicious for lung cancer. The patient’s symptoms are cough, hoarseness, lethargy, and weight loss. Physical examination reveals muscle weakness. He is a heavy smoker with 150 packs of cigarettes a year for more than 40 years. Laboratory results show hyponatremia, which in this case should make us think of syndrome of inappropriate antidiuretic hormone (SIADH), a paraneoplastic syndrome associated with oat cell carcinoma (choice A). This cancer is also known as small cell lung carcinoma.

⚠ Sarcoidosis (choice B) is multisystem inflammatory disease of unknown etiology that manifests as noncaseating granulomas, predominantly in the lungs and intrathoracic lymph nodes. It presents with cough in 50% of patients and
SIADH is known to affect 5% of sarcoidosis patients, though subclinical and undiagnosed SIADH is much higher. However, this patient’s history of hoarseness, weight loss, age, and long history of heavy smoking seem to point to a diagnosis of oat cell carcinoma.

⚠ Squamous cell lung carcinoma (choice C) is incorrect. The paraneoplastic syndrome commonly seen in squamous cell lung carcinoma is parathyroid-like hormone production, which leads to hypercalcemia.

⚠ Laryngeal squamous carcinoma (choice D) can cause cough, hoarseness, weight loss, and is also associated with cigarette smoking. But lung cancers are far more common than laryngeal cancers, and SIADH is very suggestive of oat cell lung carcinoma.

⚠ Lung adenocarcinoma (choice E) has been recognized as the common type of lung cancer is non-smokers and is not commonly associated with SIADH.

✅Key point:

The combination of cough, hoarseness, weight loss, and SIADH in an old patient heavy smoker is suggestive of small cell lung carcinoma also known as oat cell lung carcinoma

🇨🇦 MCCQE1,2 | #Case_60
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A 62-year-old female presents to the ED complaining of right leg and knee pain. The pain has progressed over the past 2 weeks so that now she is unable to bear weight on her right leg. She has a history of a recent pulmonary embolus and is on warfarin(Coumadin). Her INR is therapeutic. She is allergic to aspirin and penicillin. On examination she is afebrile. Her pulse rate is 102 beats/min, her blood pressure is 158/96 mmHg, and her respiratory rate is 14/min. Her right knee is erythematous, warm, and tender on palpation over the entire knee joint, and a large effusion is noted. Arthrocentesis reveals numerous WBCs and negatively birefringent crystals.What is the best initial treatment for the patient’s knee problem?

a) Ceftriaxone intravenously
b) Prednisone intra-articularly
c) Colchicine orally
d) Indomethacin orally
e) Allopurinol orally

🇨🇦 MCCQE1,2 | #Case_60 | #answer
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✅ C

🔎 Explanation

This patient is having an acute gout attack. Nonsteroidal anti-inflammatory drugs or colchicine (choice C) are first-line therapies for acute gout, depending on patient comorbidities. In general, when comorbid conditions limit the use of NSAIDs or colchicine, a preferred option may be an intra-articular steroid injection (unless contraindicated), particularly when a large, easily accessible joint is involved.

⚠ Ceftriaxone (choice A) is not an appropriate treatment for gout.

⚠ Corticosteroids (choice B) can be given to patients with gout who cannot use NSAIDs or colchicine. Steroids can be given orally, IV, intramuscularly, or intra-articularly. Using parenteral corticosteroids confers no advantage unless the patient cannot take oral medications.

⚠ While indomethacin (choice D) is a good choice for treating an acute gout attack, this patient should not take
indomethacin because of the increased risk of bleeding created by warfarin.

⚠ Allopurinol (choice E) should not be used in an acute gout attack as it could make it worse.

🇨🇦 MCCQE1,2 | #Case_61
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You are called to the bedside of a 56-year-old male patient in the critical care unit. His nurse informs you that he has become unresponsive. He has a history of hypertension, myocardial infarction, and a 30 pack-year history of smoking. A nurse reads his previous vital signs: blood pressure is 90/55 mmHg, his heart rate is 180 bpm, his respiratory rate is 22 breaths per minute, and oxygen saturation is 98% according to the monitor. Looking at the monitor, you notice the patient has wide QRS complexes. On physical exam, you note the patient grunts in response to pain, is currently on a ventilator, and you are unable to palpate his carotid pulse. You decide to start CPR.Which of the following is the next best step in the treatment of this patient?

a) Adenosine
b) Amiodarone
c) Epinephrine
d) Synchronized cardioversion
e) Unsynchronized cardioversion

🇨🇦 MCCQE1,2 | #Case_61 | #answer
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✅ E

🔎 Explanation

This patient's electrocardiogram shows tachycardia with wide QRS complexes. The wide QRS indicates that the electrical conduction originated outside of the normal conduction system (ie. the ventricle). Combining this with the absence of a palpable pulse gives the diagnosis of pulseless ventricular tachycardia (VT), which can be divided into three categories:
▪ pulseless
▪ hemodynamically stable (with a pulse)
▪ hemodynamically unstable (with a pulse) (signs of hemodynamic instability include ischemic chest pain, altered mental status, hypotension, tachycardia, tachypnea, and other signs of shock).

The management of VT differs for each category (see explanations below and in the incorrect answers). According to ACLS guidelines, pulseless VT is treated the same way as ventricular fibrillation. Two minutes of CPR is started first, followed by unsynchronized cardioversion (defibrillation) (choice E) with 120-200J if using a biphasic defibrillator or 360 J for monophasic defibrillator. If two cycles of CPR and defibrillation fail to eliminate the arrhythmia, then epinephrine can be administered, followed by another cycle of CPR and defibrillation, followed by amiodarone.Pulseless VT is most common in patients who have survived a myocardial infarction, and it can progress to ventricular fibrillation and then death.

⚠ Adenosine (choice A) is not used for pulseless VT. It is used to treat supraventricular tachycardia (SVT).

⚠ Amiodarone (choice B) is an incorrect answer. If the rhythm persists after defibrillation, epinephrine, and a second attempt at defibrillation, then amiodarone 300mg IV can be administered. Amiodarone is also used in hemodynamically stable patients with VT.

⚠ Epinephrine (choice C) can be used in pulseless VT, but only after unsynchronized cardioversion and continued CPR have been attempted.

⚠ Synchronized cardioversion (choice D) is not used in pulseless VT. It can be used in patients with VT who are hemodynamically unstable (hypotension, confusion, shortness of breath) but do have a pulse.

✅ Key point:

Pulseless ventricular tachycardia is treated first with CPR, then as soon as possible, unsynchronized cardioversion (defibrillation). If those measures fail, continued cycles of CPR and defibrillation are attempted followed by epinephrine, according to the most recent ACLS guidelines.

🇨🇦 MCCQE1,2 | #Case_62
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A 25-year-old man presented with red urine. He denied any other urinary symptoms but admitted having sore throat and low grade fever over the last two days. He also admitted to passing red urine at least three times before but it used to clear up in two to three days. Apart from 15 red cells per high power field, urine analysis was otherwise normal. Plain abdominal x-ray was normal. Which of the following investigations would most likely establish the cause of hematuria in this patient?

a) Measurement of serum anti-streptolysin O (ASO) titer
b) Throat swab culture
c) CT scan of the abdomen
d) Renal biopsy
e) Measurement of blood urea and serum creatinine

🇨🇦 MCCQE1,2 | #Case_62 | #answer
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✅ D

🔎 Explanation

Renal biopsy (choice D) is the correct choice. The most likely cause of hematuria in this patient is IgA nephropathy and renal biopsy is necessary to make this diagnosis. IgA nephropathy typically presents in the second or third decade of life with recurrent hematuria during or immediately following upper respiratory infection. Hematuria is the only finding early in the disease. These features together with the fact that IgA nephropathy is one of the most common causes of hematuria put IgA nephropathy as the most likely diagnosis in this patient.

⚠ Measurement of serum anti-streptolysin O titer (choice A) and throat swab culture (choice B) are used to diagnose poststreptococcal glomerulonephritis, which is an unlikely cause of hematuria in this patient. Poststreptococcal glomerulonephritis occurs 1 to 3 weeks following streptococcal pharyngitis in children 2 to 12 years old. Our patient developed hematuria immediately after throat infection and is of older age.

⚠ CT scan of the abdomen (choice C) is not the correct choice. The two causes of hematuria namely renal stones and renal cell carcinoma that can be diagnosed by CT scan of the abdomen are unlikely causes of hematuria in this patient. Although renal stones can present with painless hematuria, their presentation is not related to upper respiratory infections. Also, because most renal stones are radiopaque, they are expected to be seen in the X-ray. Renal cell carcinoma usually occurs in older people between 50 to 70 year old and present with hematuria, abdominal pain, and flank mass. Other presenting symptoms include fever, anemia, and weight loss. Renal cell carcinoma is thus, an unlikely diagnosis in this patient.

⚠ Measurement of serum urea and creatinine (choice E) are nonspecific tests. Any disease that impairs renal function may raise serum urea and creatinine.

✅Key point:

Renal biopsy is necessary to make the diagnosis of IgA nephropathy

🇨🇦 MCCQE1,2 | #Case_63
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A 67-year-old female presents with complaints of increasing abdominal distension and intermittent vomiting for the past 4 days. She also reports abdominal pain in the periumbilical region. The pain does not radiate and is not clearly localized. Her past surgical and medical history is significant only for hypertension, which has been well controlled with hydrochlorothiazide. On examination her blood pressure is 120/75 mmHg, temperature is 37.7°C, pulse is 95bpm, and respirations 17/min. She appears in distress, has dry mucosa but no jaundice is observed. Abdominal auscultation reveals gurgling and tinkling sounds. Rectal examination reveals no abnormalities. Abdominal X-ray shows distended loops of small bowel with multiple air-fluid levels and pneumobilia. What is the most likely diagnosis?

a) Acute diverticulitis
b) Gallstone ileus
c) Crohn disease free perforation
d) Adhesive small bowel obstruction
e) Pseudomembranous colitis

🇨🇦 MCCQE1,2 | #Case_63 | #answer
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✅ B

🔎 Explanation

This patient’s clinical scenario is consistent with gallstone ileus (choice B). It is an obstruction of the small bowel (at or near the ileocecal valve) due to impaction of a large (at least 2.5 cm in diameter) gallstone in the ileum after being passed through a biliary-enteric fistula. 60% are cholecystoduodenal fistulas, but cholecystocolonic and cholecystogastric fistulas
can also result in gallstone ileus. Gallstone ileus is a complication of cholelithiasis and gangrenous gallbladder. It presents with intermittent abdominal pain that is poorly localized, abdominal distention, and vomiting. Abdominal X-ray is the best initial study and usually reveals distended loops of small bowel with multiple air-fluid levels and pneumobilia (air in the biliary tract). Rigler's triad: pneumobilia (air in biliary tree), small bowel obstruction (partial or complete), gallstone (usually in right iliac fossa).

⚠ Acute diverticulitis (choice A) is incorrect. The clinical presentation of diverticulitis depends on the location of the affected diverticulum, the severity of the inflammatory process, and the presence of complications. Left lower quadrant pain is the most common presenting complaint. Plain radiograph films are usually not helpful in acute diverticulitis. In case of bowel perforation, free air may be present, but pneumobilia is not associated with this condition.

⚠ Crohn disease free perforation (choice C) is incorrect. None of the patient’s symptoms is suggestive of Crohn disease.

⚠ Adhesive small bowel obstruction (choice D) would likely occur in a patient with a history of abdominal surgery. This patient never had a surgery.

⚠ Pseudomembranous colitis (choice E) is an antibiotic-associated diarrhea most frequently caused by Clostridium difficile. This patient has no recent history antibiotic use.

✅Key point:

Gallstone ileus results from an impaction of a large gallstone in the ileum after being passed through a biliary-enteric fistula. It presents with abdominal distention, abdominal pain, and vomiting. Pneumobilia, air in the biliary tree, can be seen on abdominal X-ray.

🇨🇦 MCCQE1,2 | #Case_64
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A 38-year-old female presents to the family physician's office complaining of a ‘whitish’ discharge from her both nipples, which she first noticed one week ago. She has never been pregnant and her last menstrual bleeding was three months ago. On confrontation visual field testing, she has field defects in upper and temporal quadrants of both eyes. A tumor at which of the following location could explain her signs and symptoms?

a) Sphenoidal ridge
b) Olfactory groove
c) Anterior pituitary
d) Posterior pituitary
e) Pituitary stalk

🇨🇦 MCCQE1,2 | #Case_64 | #answer
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✅ C

🔎 Explanation

A visual field defect of the outer hemi-fields of both eyes (bitemporal hemianopia) indicates a midline lesion that affects the optic chiasm. The visual field defect more pronounced on the upper quadrants (‘pie in the sky’) indicates the optic chiasm is compressed from below. The location of the pituitary gland matches this description. Galactorrhea, amenorrhea,
and infertility are seen in hvperprolactinemia, which can be caused by a tumor (adenoma) of the anterior pituitary (choice C).

⚠ Tumors of the sphenoidal ridge (choice A) and olfactory groove (choice B) compresses the optic nerve and mostly causes a monocular visual field deficit (not a bitemporal hemianopia). It also wouldn’t explain the features of hyperprolcatinemia seen in this patient.

⚠ Posterior pituitary (choice D), which stores and releases antidiuretic hormone (ADH) and oxytocin, does not form adenomas.

⚠ Craniopharyngioma is a tumor that arises from the remnants of the Rathke pouch of the pituitary stalk (choice E) and compresses the optic chiasm from above, which results a bitemporal hemianopia with a visual field defect more pronounced in the outer inferior quadrants (not the outer superior quadrant as seen in this patient).

✅Key point:

Bitemporal hemianopia points to a lesion compressing the optic chiasm. In a patient with bitemporal hemianopia it is important to look for features of anterior pituitary hormone dysregulation.

🇨🇦 MCCQE1,2 | #Case_65
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A 27-year-old man presented to his family physician with palpitations of about two weeks duration. The palpitations were intermittent, short-lasting, resolved spontaneously, and were not related to exertion. He had no other symptoms. His heart rate was regular at 92 beats per minute and other vital signs were stable. Examination showed the following:
- point of maximum impulse is located in the 5th intercostal space 1cm lateral to the midclavicular line;
- normal first and second heart sounds;
- midsystolic harsh murmur of grade VI/6 with maximal intensity at the left lower sternal border and did not radiate to the axilla, clavicle or carotid artery. The murmur was diminished by squatting and was louder during expiration.The rest of physical examination was normal. Which of the following is the most likely cause of this patient's heart murmur?

a) Aortic stenosis
b) Hypertrophic obstructive cardiomyopathy
c) Mitral regurgitation
d) Large ventricular septal defect complicated by pulmonary hypertension
e) Pulmonary stenosis complicated by pulmonary hypertension

🇨🇦 MCCQE1,2 | #Case_65 | #answer
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✅ B

🔎 Explanation

Hypertrophic obstructive cardiomyopathy (HOCM) (choice B) is the most likely cause of the murmur in this patient. HOCM typically presents between 20 and 40 years of age and might be asymptomatic and diagnosed only when the characteristic murmur is found incidentally. Common symptoms include palpitations, angina, syncope or presyncope, shortness of breath with exercise or even sudden death. Physical signs of HOCM include PMI that is displaced laterally and is sustained in nature. Double or triple cardiac impulses are sometimes found. The typical murmur of HOCM is a midsystolic harsh murmur with maximal intensity along the lower sternal border or apex. Unlike most other systolic murmurs, the murmur of HOCM is diminished by squatting and is enhanced by standing because squatting increases venous return and standing decreases it. A high venous return expands the left ventricle including the point of obstruction within the ventricle and thus, softening the murmur in patients with HOCM. Our patient showed most of these and HOCM is thus the most likely cause of murmur. The table below compares the murmur of HOCM to that of aortic stenosis (AS), mitral regurgitation (MR), ventricular septal defect (VSD) and pulmonary stenosis (PS). The peachy color indicates characteristics of the murmur in our patient.

⚠ Aortic stenosis (choice A) is a rather unlikely cause of murmur in this patient. AS might start early in life but most patient develop symptoms in the 6th to 8th decades of life and they usually present with increasing breathlessness on exertion. The murmur of AS is crescendo decrescendo midsystolic murmur with maximum intensity in second intercostal space to the right of sternum and radiates to the clavicle or carotid artery. For all these reasons aortic stenosis is not the likely cause of murmur in this patient.

⚠ Mitral regurgitation (choice C) is an unlikely cause of murmur in this patient. The murmur of MR is a holosystolic rather than midsystolic with maximum intensity at the apex and it usually radiates to axilla.

⚠ Large ventricular septal defect (VSD) with pulmonary hypertension (choice D) usually results in early systolic rather than midsystolic murmur because shunting of blood decreases towards the end of systole. This is because pulmonary hypertension increases right ventricular pressure. Smaller VSDs on the other hand usually cause holosystolic murmurs. Thus, VSD is an unlikely cause of murmur in our patient.

⚠ Pulmonary stenosis (PS) complicated by pulmonary hypertension (choice E) is not the correct choice. In PS the murmur is midsystolic with maximum intensity in the left second intercostal space. Also, this murmur is louder during inspiration. PS is thus, an unlikely cause of the systolic murmur in our patient.

✅Key point:

Onset, area of maximum intensity and radiation of a murmur are helpful in identifying its causes. A midsystolic murmur with maximum intensity at apex or along left lower sternal border and that does not radiate is most likely due to HOCM.

🇨🇦 MCCQE1,2 | #Case_66
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You are asked to see an 18-year-old man with autism in a busy walk-in clinic who presents with 4 day history of fever, malaise, and sore throat. He has brought his mother in to speak for him. She tells you that he has been making high-pitched sounds during inspiration and spitting out food that he normally enjoys eating due to pain with swallowing. She has also noticed that his voice has been muffled sounding for the last 24 hours.Vital signs: temperature 39.6°C, BP: 96/52 mmHg, HR: 102 bpm, RR: 12 rpm. On examination, you notice him leaning toward you. On examination of his throat you notice pooled saliva in the mouth. He has tender anterior cervical lymphadenopathy. The rest of the physical exam is normal. What is your next step in the management of this patient?

a) Reassure the patient and his mother that this is only a viral infection
b) Suggest rest, hydration, and close follow-up with their regular family physician
c) Prescribe Amoxicillin 400mg TID for 7 days with close follow-up.
d) Advise the patient and his mother to go to the emergency department for treatment.
e) Ensure the patient is calm, and call 911 for emergent transfer to the nearest emergency department