🇨🇦 MCCQE1,2 | #Case_265
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A 9-year-old girl is brought in by her parents, who state that she has been having terrible nightmares recently. Several nights in the last few months, she has woken up the whole family with her bloodcurdling screams. When this occurs, she seems inconsolable and disoriented, crying and hyperventilating for some time, refusing to acknowledge her parents’ presence, and crying until she falls back asleep. The girl admits she is concerned about this, but can’t remember what the nightmares were about. On further history, she says that she is generally happy. She admits that her dog dying last year was stressful for her, but denies that it bothers her much now. What is the diagnosis?

a) Post-traumatic stress disorder, with delayed onset
b) Nightmare disorder
c) Panic disorder
d) Sleep terror disorder
e) Temporal lobe epilepsy

🇨🇦 MCCQE1,2 | #Case_265 | #answer
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✅ D

🔎 Explanation

Sleep terror disorder is characterized by episodes of awakening from sleep with a scream, accompanied by intense fear and autonomic arousal, with unresponsiveness to others during the episode, and subsequent amnesia for the episode.

⚠A. In PTSD, the traumatic event remains a focus of the person’s symptoms; for example, with persistent intrusive recollections of the event, avoidance of reminders of it, and persistent symptoms of increased arousal.

⚠B. In nightmare disorder, the patient rapidly becomes oriented and responsive on wakening, and remembers the nightmares.

⚠C. Panic attacks may wake patients from sleep, but there is rarely a history of screaming or disorientation.

⚠E. Fear is sometimes a feature of the aura of temporal lobe seizures, and post-ictal confusion is the rule, but most such seizures start with motionless staring, followed by lip smacking. Screaming and crying during a seizure would be quite unusual

🇨🇦 MCCQE1,2 | #Case_266
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An inpatient with multiple injuries sustained in car accident felt cold last night and was seen by a family medicine resident who among other investigations ordered thyroid function tests, which showed low serum total and free T3 level, normal total and free T4, and normal TSH level. Which one of the following management options would be best for this patient?

a) Start injection of liothyronine (T3) 10µg every 12 hours, immediately
b) Prescribe thyroxine (T4) at 50 µg per day, immediately
c) Order radioiodine uptake and thyroid scan
d) Order serum thyroglobulin level
e) Observe and monitor during recovery

🇨🇦 MCCQE1,2 | #Case_266 | #answer
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✅ E

🔎 Explanation

Low serum T3 with normal T4 and TSH in patients with severe diseases or trauma is the most common presentation of the sick euthyroid syndrome. In this syndrome, thyrotid function is normal(euthyroid) as indicated by normal serum TSH. These patients need no more than observation and monitoring during recovery (choice E). Indeed, without strong suspicion of thyroid disorders, it is not advisable to perform thyroid function tests in patients with acute severe diseases or trauma.

⚠ Starting injection of liothyronine (choice A) or thyroxine (choice B) are not the correct choices. In the absence of history or physical signs suggestive of hypothyroidism, it is not advisable to give thyroid hormone replacement therapy. Indeed, according to some reports, thyroid hormone replacement therapy might worsen the outcome of the diseases causing sick euthyroid syndrome.

⚠ Ordering radioiodine uptake and thyroid scan (choice C) or serum thyroglobulin level (choice D) are not the correct choices. In the absence of history or physical signs suggestive of thyroid disease together with the thyroid hormone profile typical of sick euthyroid syndrome, no further investigation is required.

🔖 Key point:

Severe acute disease or trauma may lead to abnormalities of serum thyroid hormone profile. These disturbance, however, usually resolve spontaneously when patients recover from the acute disease or trauma

🇨🇦 MCCQE1,2 | #Case_267
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A 28-year-old female presents 2 weeks post partum complaining of palpitations, diarrhea, weight loss, and being “jumpy.” Her examination is normal except for a slightly enlarged and tender thyroid gland. Her TSH level is 0.02 µU/mL (N 0.5-5.5), with a higher than normal level of free T3. Which one of the following would be the most appropriate treatment?

a) Levothyroxine
b) Prednisone
c) Propranolol
d) Propylthiouracil
e) Radioactive iodine

🇨🇦 MCCQE1,2 | #Case_267 | #answer
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✅ C

🔎 Explanation

This patient presents with signs, symptoms, and laboratory evidence of postpartum thyroiditis. This is an autoimmune attack of the thyroid gland that occurs in 5%-10% of all mothers within a year of delivery. The transient increase of thyroid hormone that results is often unnoticed but can cause clinical hyperthyroidism. A ß-blocker is recommended to reduce heart irregularities and other symptoms related to high levels of circulating thyroid hormone. Propylthiouracil
prevents the production of new thyroid hormone and is not indicated because this condition results only in a release of thyroid hormone that has already been created. Up to one-third of women with this condition will become chronically hypothyroid and will require regular thyroid replacement. This patient is not currently hypothyroid, so she would not benefit from replacement with levothyroxine.

🇨🇦 MCCQE1,2 | #Case_268
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A 30-year-old gravida 3 para 2 at 28 weeks gestation is a restrained passenger in a high-speed motor vehicle accident. After initial stabilization in the field with supplemental oxygen and intravenous fluids, she is brought into the emergency department on a backboard and wearing a cervical collar. Until you are able to rule out a spinal injury, in what position should the patient be kept?

a) Supine
b) Supine, with the uterus manually deflected laterally
c) Prone
d) Trendelenburg’s position
e) Left lateral decubitus

🇨🇦 MCCQE1,2 | #Case_268 | #answer
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✅ B

🔎 Explanation

In general, it is best to place a woman who is greater than 20 weeks pregnant in the left lateral decubitus position because the uterus can compress the great vessels, resulting in decreased systolic blood pressure and uterine blood flow. However, in the case of trauma where a spinal cord injury cannot be ruled out, the woman needs to be kept supine on a backboard. The weight of the uterus can be shifted off the great vessels by either manual deflection laterally or by elevating the right hip 4-6 inches by placing towels under the backboard. The Trendelenburg position does not relieve the weight of the uterus on the great vessels. The prone position does not provide adequate spinal cord protection, and would be extremely awkward in a large pregnant woman

🇨🇦 MCCQE1,2 | #Case_269
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A 60-year-old male presents to the office complaining of a productive cough for the past 3 months. He mentions that the sputum is plentiful and foul smelling. He is a chain smoker. Vitals are within normal limits except for a mild fever of 37.60C. Physical exam shows finger clubbing. Auscultation of the lungs shows coarse crepitations in both lungs. Chest x-ray reveals increased vascular markings and peribronchial thickening. What is the diagnostic test of choice for this patient?

a) Bronchography
b) Bronchoscopy
c) High resolution CT Scan of the lung
d) Sputum for acid-fast bacilli
e) Sputum gram stain and culture

🇨🇦 MCCQE1,2 | #Case_269 | #answer
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✅ C

🔎 Explanation

High resolution CT scan of the lung is the diagnostic modality of choice for bronchiectasis. Copious foul smelling sputum is a clue. The chest x-ray of our patient is characteristic of bronchiectasis: peribronchial thickening (Tram track appearance). Bronchography is an old method of diagnosis and it has been replaced nowadays by HRCT. Bronchoscopy and biopsy would be warranted if a bronchial lesion were seen on chest X ray or CT scan. Sputum examination and Culture and sputum smear for AFB should be done in clinical practice; however the question is clear and asks for the diagnostic modality of choice.

🇨🇦 MCCQE1,2 | #Case_270
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A 50-year-old man comes to the emergency room with a history of vomiting for three days' duration. His past history reveals that for approximately 20 years, he has been getting epigastric pain, lasting for two to three weeks. He remembers getting relief from pain by taking milk and antacids. Physical examination showed a fullness in the epigastric area with visible peristalsis, absence of tenderness and normal active bowel sounds. Which one of the following is the most likely diagnosis?

a) Gastric outlet obstruction
b) Small bowel obstruction
c) Volvulus of the colon
d) Incarcerated umbilical hernia
e) Cholecystitis

🇨🇦 MCCQE1,2 | #Case_270 | #answer
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✅ A

🔎 Explanation

Intrinsic or extrinsic obstruction of the pyloric channel or duodenum is the usual pathophysiology of gastric outlet obstruction (GOO). Nausea and vomiting are the cardinal symptoms of GOO. Vomiting usually is described as nonbilious, and it characteristically contains undigested food particles. In the early stages of obstruction, vomiting may be intermittent and usually occurs within 1 hour of a meal. Early satiety and epigastric fullness are common. Weight loss is frequent when the condition approaches chronicity and is
most significant in patients with malignant disease. Abdominal pain is not frequent. Physical examination often demonstrates the presence of chronic dehydration and malnutrition. A dilated stomach may be appreciated as a tympanitic mass in the epigastric area and/or left upper quadrant. Plain abdominal radiographs, contrast upper GI studies (Gastrografin or barium), and CT scans with oral contrast are helpful. Plain radiographs, including the obstruction series (ie, supine abdomen, upright abdomen, chest posteroanterior), can demonstrate the presence of gastric dilatation and may be helpful in distinguishing the differential diagnosis. Upper endoscopy can help visualize the gastric outlet and may provide a tissue diagnosis when the obstruction is intraluminal. Treatment is surgical

🇨🇦 MCCQE1,2 | #Case_271
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An 77-year-old man presents to the emergency department with a loss of consciousness episode. His stool has been black. His hemoglobin is 68 g/L and INR 7.2. He is on warfarin for atrial fibrillation. What is the best next step in management of his INR level?

a) Hold warfarin for 3 days
b) Desmopressin (DDAVP)
c) Vitamin K, 1 mg orally
d) Vitamin K, 10 mg intravenously
e) 4 units of fresh frozen plasma in addition to 10mg of IV Vitamin K

🇨🇦 MCCQE1,2 | #Case_271 | #answer
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✅ E

🔎 Explanation

If the INR is between 5.0-9.0 and bleeding is absent, you should cease warfarin therapy; consider reasons for elevated INR and patient-specific factors. If bleeding risk is high, give vitamin K (1.0-2.0 mg orally or 0.5-1.0 mg intravenously). Measure INR within 24 hours, resume warfarin at a reduced dose once INR is in therapeutic range. However, if there is any clinically significant bleeding where warfarin-induced coagulopathy is considered a contributing factor, you should cease warfarin therapy, give 5.0-10.0 mg vitamin K intravenously, as well as fresh frozen plasma (150-300 mL), assess patient continuously until INR < 5.0, and bleeding stops.

🇨🇦 MCCQE1,2 | #Case_272
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A 65-year-old male, who has been recently retired from a cement manufacturing company in Manitoba, complains of shortness of breath, fatigue, and a chronic progressive cough that is resistant to antibiotic treatment. An x-ray shows multiple small coin-like lesions in the upper lobe of the right lung. The TB skin test was negative twice. Which one of the following is the most likely cause?

a) Legionellosis
b) Tuberculosis
c) Silicosis
d) Dimorphic mycosis
e) Atypical mycobacteria

🇨🇦 MCCQE1,2 | #Case_272 | #answer
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✅ C

🔎 Explanation

Silicosis is caused by inhalation of crystalline-free silica dust and is characterized by nodular pulmonary fibrosis. Chronic silicosis initially causes no symptoms or only mild dyspnea but over years can advance to involve most of the lung and cause dyspnea, hypoxemia, pulmonary hypertension, and respiratory impairment. Diagnosis is based on history and chest x-ray. No effective treatment exists except supportive care and, for severe cases, lung transplantation

🇨🇦 MCCQE1,2 | #Case_273
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A 64-year-old white male presents to the emergency department with a 48-hour history of left lower quadrant pain. After a thorough history and a physical examination you conclude that the patient has diverticulitis. The patient is allergic to metronidazole (Flagyl). You recommend a clear-liquid diet, a follow-up visit with his primary care physician in 48 hours, and treatment with:

a) Amoxicillin
b) Amoxicillin/clavulanate
c) Ciprofloxacin
d) Doxycycline
e) Azithromycin

🇨🇦 MCCQE1,2 | #Case_273 | #answer
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✅ B

🔎 Explanation

Patients with mild diverticulitis can be started on an outpatient treatment regimen. This consists of a clear liquid diet and 7-10 days of oral broad-spectrum antimicrobial therapy: one typical oral antibiotic regimen is a combination of ciprofloxacin (or trimethoprim-sulfamethoxazole) and metronidazole. Moxifloxacin is appropriate monotherapy for outpatient treatment of uncomplicated diverticulitis. Amoxicillin/clavulanic acid monotherapy is acceptable as well

🇨🇦 MCCQE1,2 | #Case_273
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A 54-year-old man presents with extreme pain and swelling of the left middle finger. Four days earlier, he suffered a small puncture wound to the volar aspect of the finger at the level of the distal flexor crease. Passive extension of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints severely aggravates his symptoms. Which one of the following is the most likely diagnosis?

a) Pulp space infection
b) Cellulitis
c) Mid-palmar space infection
d) Septic tenosynovitis
e) Septic arthritis distal interphalangeal (DIP) joint

🇨🇦 MCCQE1,2 | #Case_273 | #answer
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✅ D

🔎 Explanation

The cardinal signs of infectious flexor tenosynovitis include:
•Tenderness along the course of the flexor sheath
•Symmetric enlargement of the affected digit
•Slightly flexed finger at rest
•Pain along the tendon with passive extension
Pain with passive extension is the earliest finding; tenderness along the tendon sheath was a late sign of infection. Severe pain and tenderness following a bite or puncture wound should suggest the presence of tenosynovitis regardless of
whether it is associated with all, some, or none of the above findings. The diagnosis is made by eliciting tenderness on palpation of the tendon and sheath and by noting swelling and possibly a nodule. In later stages, triggering or snapping of the digit occurs on flexion (trigger finger)

🇨🇦 MCCQE1,2 | #Case_274
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A 16-year-old white female experiences the sudden onset of tender, bleeding gums, malodorous breath, and a bad taste in her mouth. On examination she is febrile and has cervical lymphadenopathy and tachycardia. Her mouth has marginal punched-out, crater like depression of the interdental gingival papillae and gingival margins that are covered with a gray pseudomembranous slough. The drug of choice for treating this condition is:

a) Acyclovir (Zovirax)
b) Penicillin
c) Clotrimazole troche (Mycelex)
d) Ketoconazole (Nizoral)
e) Prednisone