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NEW QUESTION # 165
A 32-year-old woman presents to your outpatient clinic with concerns regarding a 6-month history of both a pulsatile buzzing sound in her ears and headaches. There is no history of hearing loss, vertigo, ear pain, or discharge from the ears. There is a long-standing history of prolonged exposure to occupational noise. She has a BMI of 32. Otoscopic examination is unremarkable, and there are no neck masses present. You determine that the buzzing sound is synchronous with her radial pulse. Which of the following investigations should be ordered next?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
Pulsatile tinnitus synchronous with the pulse may be vascular in origin. The association with headaches and elevated BMI (a risk factor for idiopathic intracranial hypertension, IIH) warrants neuroimaging to assess for cerebral venous sinus thrombosis, vascular malformations, or raised intracranial pressure.
Toronto Notes 2023 - Neurology / ENT:
"Pulsatile tinnitus requires investigation for vascular causes including idiopathic intracranial hypertension.
MRI or MRV is the next step."
MCCQE1 Objectives (Neurology > 35-1: Headache and Tinnitus):
"Candidates must investigate pulsatile tinnitus with neuroimaging when vascular causes are suspected." Audiogram (A) is for hearing loss. EEG (C) is not useful for tinnitus. CRP (D) is irrelevant.
NEW QUESTION # 166
A 38-year-old man is brought by his wife to the Emergency Department with fatigue, dizziness, and nausea after completing a hiking tour on a hot, humid day. His wife became worried after he had collapsed. He has been sweating heavily and vomited twice on the drive in. His medical history is unremarkable, and he takes no medications. His vital signs on arrival are as follows:
Blood pressure
85/57 mm Hg
Heart rate
120/min
Respiratory rate
18/min
Temperature
40.1 °C
Oxygen saturation
95%, room air
-
On physical examination, the patient's skin is dry, flushed, and warm to the touch. He has a diffuse erythematous papular rash. Findings of a thorough physical examination are otherwise unremarkable. An electrocardiogram shows sinus tachycardia. Which one of the following is the best next step?
Answer: E
Explanation:
This patient has classic features of exertional heat stroke-hyperthermia, hypotension, CNS symptoms (collapse), and hot, dry skin. A key complication of heat stroke is rhabdomyolysis, which can cause renal failure. Serum creatine kinase (CK) is the best next diagnostic step to confirm muscle breakdown.
Toronto Notes 2023 - Emergency Medicine, "Environmental Exposures":
"In heat stroke, check for rhabdomyolysis (#CK), renal impairment, and coagulopathy. Prompt cooling and hydration are critical." MCCQE1 Objectives (Internal Medicine > 59-3: Environmental and Toxic Exposures):
"Candidates must recognize heat-related illnesses and investigate for complications such as rhabdomyolysis and acute kidney injury." CT head (C) is not indicated unless persistent neurological symptoms. TSH (B), CRP (D), and blood cultures (E) are irrelevant to acute exertional hyperthermia.
NEW QUESTION # 167
A 29-year-old woman presents with vaginal spotting after 6 weeks of amenorrhea. She is asymptomatic otherwise. Serum #-hCG is 2150 IU/L, and pelvic ultrasound shows an empty uterus. She has been trying to conceive for 7 months. Which one of the following is the best next step?
Answer: C
Explanation:
An empty uterus with #-hCG >1500-2000 IU/L raises concern for a pregnancy of unknown location (PUL), including the possibility of ectopic pregnancy. However, the patient is hemodynamically stable and asymptomatic. In such cases, the best initial step is to repeat serum #-hCG in 48 hours to assess the rise or fall of hCG levels.
Toronto Notes 2023 - Obstetrics, "First Trimester Bleeding":
"If #-hCG >1500 IU/L and no intrauterine pregnancy is visualized on ultrasound, repeat #-hCG in 48 hours to determine rise or decline. A suboptimal rise (less than 66%) suggests ectopic pregnancy." MCCQE1 Objectives (Obstetrics > 79-1: Early Pregnancy Complications):
"In a patient with early pregnancy bleeding, the candidate must interpret quantitative #-hCG trends to distinguish ectopic pregnancy, miscarriage, or viable intrauterine pregnancy." Immediate administration of methotrexate or invasive procedures such as D&C or laparoscopy are not appropriate until further diagnostic clarification is obtained.
NEW QUESTION # 168
An 18-year-old man presents to your clinic with a history of intermittent, dull, achy pain on the left side of his scrotum, and he has now noted left scrotal enlargement. On examination, you note a swelling in the left scrotum when he is standing that disappears when he is supine. Which one of the following is the most likely diagnosis?
Answer: C
Explanation:
A varicocele is a dilatation of the pampiniform plexus that presents with a "bag of worms" appearance, worsens with standing, and improves when lying down. It is most common on the left side due to anatomical drainage differences.
Toronto Notes 2023 - Urology, Scrotal Disorders:
"Varicoceles often present with a dull, aching pain and scrotal swelling that worsens when upright and disappears when supine." MCCQE1 Objectives - Internal Medicine > Urology:
"Candidates must recognize and diagnose varicocele by physical exam findings and typical symptom history." Cryptorchidism (A) refers to undescended testes. Torsion (B) presents acutely with severe pain. Hydrocele (C) transilluminates and is not posture-dependent. "Spermatocyte" (D) is not a clinical diagnosis.
NEW QUESTION # 169
A 3.5-year-old girl has developed a stutter in the last 3 months. She repeats whole words several times before finishing a sentence. Her paternal uncle had a severe stuttering issue as a child. She has reached the developmental milestones for her age. Her new sibling was born 4 months ago. Which one of the following is the best next step?
Answer: B
Explanation:
This presentation describesnormal developmental dysfluency, which typically occurs between ages 2-5 and often worsens duringtimes of stress or change, such as a new sibling. It is characterized byword repetition and does not require intervention unless it persists >6 months, worsens, or causes distress.
Toronto Notes 2023 - Pediatrics, "Developmental and Behavioral Pediatrics" Section:
"Developmental stuttering is common between 2-5 years and often resolves without intervention.
Reassurance is appropriate unless there are signs of persistent or severe stuttering, secondary behaviors, or parental concern." MCCQE1 Objectives (Pediatrics > 78-1: Development and Behavior):
"Candidates must recognize typical patterns of developmental speech dysfluency and differentiate them from pathological speech disorders. Observation and reassurance are often the appropriate initial step." Because the child is otherwise developing normally and the onset coincides with a known psychosocial stressor,reassuranceis the most appropriate step. Formal speech or behavioral therapy is not indicated at this time.
NEW QUESTION # 170
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