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질문 # 177
A 72-year-old man reports that his wife says he has hearing trouble. Examination reveals that air conduction on the right side is less than on the left side and greater than bone conduction bilaterally. He hears a tuning fork placed on the top of his head better with his left ear. Which one of the following is the most appropriate next step in management?
정답：C
설명：
The patient demonstrates signs of asymmetric sensorineural hearing loss (SNHL). In Weber test, sound localizes to the better ear in SNHL. Air conduction > bone conduction on Rinne test bilaterally supports SNHL. Audiometry is the best next diagnostic step to quantify and characterize the hearing loss.
Toronto Notes 2023 - ENT, "Hearing Loss":
"Audiometry is the first-line investigation to distinguish conductive from sensorineural hearing loss and to assess severity and frequency involvement." MCCQE1 Objectives (Medicine > ENT > 20-1):
"Candidates must know the approach to hearing loss and interpret Weber and Rinne tests to guide investigations such as audiometry." Imaging (A, C) is reserved for red flags such as unilateral persistent SNHL, which may later prompt MRI to rule out acoustic neuroma. Wax removal (D) is for conductive loss. Hearing aids (E) are management, not diagnostic, and come after audiologic evaluation.
질문 # 178
A 37-year-old man comes to the office for follow-up of his opioid use disorder. He receives opioid agonist treatment, including some take-home doses. At this follow-up visit, he reports some nonprescription opioid use since his last visit. Which one of the following is the best next step?
정답：C
설명：
Nonprescription opioid use during opioid agonist therapy is not uncommon. The response shouldbe supportive and not punitive. Increasing the frequency of follow-up enhances monitoring, supports adherence, and prevents relapse.
Toronto Notes 2023 - Psychiatry, "Substance Use Disorders":
"Patients who relapse during opioid agonist treatment benefit from closer monitoring and increased support, including more frequent follow-up and psychosocial interventions." MCCQE1 Objectives (Psychiatry > 71-5: Substance Use and Addiction):
"Candidates must manage relapses in opioid use by optimizing follow-up and support, not by discontinuing or reducing therapy prematurely." Tapering or discontinuing therapy (A, E) risks destabilizing treatment. Removing take-home doses (B) may be warranted later but not first. Cannabinoids (D) are not first-line adjuncts.
질문 # 179
A 26-year-old woman, gravida 2, para 2, aborta 0, has just delivered a full-term newborn via spontaneous vaginal delivery after 4 hours of labor. Following oxytocin administration and placental expulsion, there continues to be a steady trickle of bright red blood from her vagina. On examination, the placenta is intact and the fundus feels firm. Her vital signs are within normal range.
Which one of the following is the most likely diagnosis?
정답：C
설명：
Comprehensive and Detailed Explanation:
In postpartum hemorrhage with a firm uterine fundus and intact placenta, a common cause is trauma such as a vaginal or cervical tear. Uterine atony (A) typically presents with a boggy uterus. The absence of systemic instability or coagulopathy makes options D and E less likely.
Toronto Notes 2023 - Obstetrics, Postpartum Hemorrhage:
"Continued bleeding despite a firm fundus and intact placenta should raise suspicion for genital tract trauma, especially cervical or vaginal lacerations." MCCQE1 Objectives - Obstetrics > Postpartum Complications:
"Candidates must differentiate causes of postpartum hemorrhage and identify when bleeding is due to trauma vs uterine atony."
질문 # 180
A 29-year-old man comes to the office for an initial visit. He is being treated for schizophrenia and epilepsy.
He has a 20 pack-year history of smoking. His medications are carbamazepine, clozapine, and quetiapine. In the past year, he has gained a considerable amount of weight. Asidefrom a BMI of 32, the results of his physical examination are unremarkable. Which one of the following conditions should he be investigated for?
정답：B
설명：
Clozapine and quetiapine are associated with significant weight gain and increased risk of type 2 diabetes.
With a BMI of 32 and weight gain over the past year, screening for diabetes is appropriate and evidence- based.
Toronto Notes 2023 - Endocrinology, Diabetes & Psychiatry Sections:
"Second-generation antipsychotics such as clozapine increase the risk of metabolic syndrome and type 2 diabetes. Regular screening is recommended for patients with these risk factors." MCCQE1 Objectives - Internal Medicine > Endocrinology:
"Candidates should screen high-risk individuals, especially those on antipsychotics with weight gain, for diabetes using fasting glucose or HbA1c." While sleep apnea (C) is also possible, diabetes screening is the most appropriate and urgent next step in this patient. COPD (A) would present with respiratory symptoms. Cushing's (B) and acromegaly (E) are less common and have other distinct features.
질문 # 181
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?
정답：D
설명：
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.
질문 # 182
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