MCCQE PDF問題集で2025年12月23日最近更新された問題
MCCQE試験問題有効なMCCQE問題集PDF
質問 # 121
A 4-year-old girl is brought to the family practice by her father. The child has a 2-week history of low-grade fever, fatigue, and sore throat. She has also developed several small, round, mildly tender lumps bilaterally in her neck. She was previously well. Which one of the following is most likely to be found on abdominal examination?
- A. Shifting dullness
- B. Generalized tenderness
- C. Abdominal bruit
- D. Renal mass
- E. Palpable spleen
正解：E
解説：
This child likely has infectious mononucleosis caused by Epstein-Barr virus (EBV), characterized by fever, sore throat, cervical lymphadenopathy, fatigue, and splenomegaly. A palpable spleen is a hallmark of EBV in children.
Toronto Notes 2023 - Pediatrics, "Infectious Mononucleosis":
"Key features include fever, pharyngitis, lymphadenopathy, and splenomegaly. Children may have milder symptoms but often exhibit palpable spleen." MCCQE1 Objectives (Pediatrics > 75-2: Infectious Disease):
"Candidates should recognize common viral syndromes such as EBV and identify complications including splenomegaly." Other options (renal mass, ascites, etc.) are inconsistent with this viral presentation.
質問 # 122
A 65-year-old woman presents to the office for follow-up regarding vaginal bleeding. Her last visit was 2 months ago. At that visit, the results of a pelvic examination and a Papanicolaou test were normal. She also had an endometrial biopsy but there was "insufficient material for diagnosis." She reports that she is still losing small amounts of blood almost every day. On history, she has been taking continuous combined hormone replacement therapy for 10 years because of vasomotor symptoms. Which one of the following is the most appropriate next step in management?
- A. Order a colposcopy.
- B. Change hormones to a selective estrogen receptor modulator.
- C. Organize a hysteroscopy.
- D. Decrease the dosage of progestin.
- E. Refer for a hysterectomy.
正解：C
解説：
Persistent postmenopausal bleeding requires thorough evaluation. An inadequate endometrial biopsy result does not rule out pathology. Hysteroscopy allows for direct visualization and targeted biopsy and is the gold standard when biopsy is non-diagnostic.
Toronto Notes 2023 - Gynecology, "Abnormal Uterine Bleeding and Endometrial Cancer" Section:
"Persistent bleeding with insufficient biopsy requires further evaluation, preferably via hysteroscopy and directed biopsy. This is especially important in patients on HRT or with risk factors for endometrial pathology." MCCQE1 Objectives (Obstetrics & Gynecology > 82-9: Postmenopausal Bleeding):
"Candidates must investigate abnormal bleeding in postmenopausal women with hysteroscopy when endometrial sampling is non-diagnostic." Changing hormones (A), reducing progestin (E), or performing colposcopy (C) are not appropriate without confirming the cause of bleeding.
質問 # 123
A 32-year-old primigravid woman is receiving magnesium sulfate for tocolysis. Her pregnancy is at 26 weeks' gestation. You suspect magnesium sulfate toxicity. Which one of the following is the first sign of magnesium sulfate toxicity?
- A. Tachycardia
- B. Tachypnea
- C. Oliguria
- D. Absent patellar reflexes
- E. Hypotension
正解：D
解説：
Magnesium sulfate toxicity is dose-dependent. The earliest and most sensitive clinical sign is theloss of deep tendon reflexes (especially patellar), which occurs before respiratory depression or cardiac changes.
Toronto Notes 2023 - Obstetrics Chapter:
"Toxicity from magnesium sulfate is progressive and typically presents first with loss of deep tendon reflexes.
Respiratory depression and cardiac arrest occur at higher serum levels. Regular monitoring of reflexes, respiratory rate, and urine output is essential." MCCQE1 Objectives (Obstetrics > 83-3: Preterm Labour and Tocolysis):
"The candidate must recognize early signs of magnesium sulfate toxicity including areflexia and respiratory depression." Tachycardia (B), hypotension (C), and tachypnea (D) are not typical early signs. Oliguria (E) may be a risk factor for accumulation but is not the first sign of toxicity.
質問 # 124
A 25-year-old man presents to the Emergency Department with diffuse abdominal pain and anorexia. He was tackled in a football game yesterday. He reports a 3-week history of sore throat and fatigue. Vital signs are as follows:
Blood pressure: 95/45 mm Hg
Heart rate: 96/min
Temperature: 37.6°C
Which one of the following is the most likely diagnosis?
- A. Appendicitis
- B. Ruptured duodenum
- C. Pneumonia
- D. Pyelonephritis
- E. Ruptured spleen
正解：E
解説：
This patient presents with hypotension, diffuse abdominal pain, and a history of contact sports injury with preceding symptoms of infectious mononucleosis (sore throat, fatigue). The spleen is commonly enlarged in mononucleosis, making it vulnerable to rupture after even minor trauma.
Toronto Notes 2023 - General Surgery and Infectious Diseases Sections:
"Splenic rupture is a known complication of mononucleosis, particularly after trauma. Symptoms may include diffuse abdominal pain, hypotension, and signs of hemorrhagic shock." MCCQE1 Objectives (Surgery > 84-1: Abdominal Trauma):
"Candidates should identify splenic rupture as a cause of hypotension and abdominal pain following blunt abdominal trauma, especially in patients with splenomegaly." Appendicitis (B) would present with localized right lower quadrant pain. Pneumonia (C) and pyelonephritis (D) would present with respiratory or urinary symptoms. Ruptured duodenum (E) is much less likely without specific trauma to that region or signs of peritonitis.
質問 # 125
A 26-year-old man presents to the office with a tender mass in his right neck. He was recently treated for a dental infection but is otherwise well. On examination, there is a 2-cm tender, mobile lymph node in the right anterior cervical chain. No other lymphadenopathy or abnormalities are found on physical examination.
Which one of the following is the best next step?
- A. Bone marrow biopsy
- B. Computed tomography of the neck
- C. Ultrasonography of the spleen
- D. Lymph node biopsy
- E. Follow-up in 8 weeks
正解：E
解説：
A tender, mobile lymph node following a recent localized infection (e.g., dental infection) is most likely reactive. In a young, otherwise well patient with no systemic symptoms or concerning features, observation is appropriate.
Toronto Notes 2023 - Internal Medicine, Lymphadenopathy:
"In patients with localized lymphadenopathy and a recent infection, observation for 4-8 weeks is often appropriate before further investigation." MCCQE1 Objectives - Internal Medicine > Hematology:
"Candidates should recognize benign features of lymphadenopathy (tender, mobile, <2 cm, localized) and manage conservatively unless red flags are present." Biopsy (B) and imaging (C, E) are premature. Bone marrow biopsy (D) is not relevant.
質問 # 126
You are caring for a 78-year-old man admitted to hospital for heart failure. On your rounds, he asks why he is not getting better. He has a history of heart failure, hypertension, and type 2 diabetes. He has an implantable cardioverter-defibrillator. This is his fourth admission in the past 6 months for acute decompensation of his heart failure. Between hospital admissions, he reports worsening shortness of breath and a progressive decline in function. Which one of the following is the next best step?
- A. Explain the end-stage nature of the patient's illness
- B. Reassure the patient that his condition will improve with proper medication adherence
- C. Advise the patient to have his defibrillator deactivated
正解：A
解説：
Comprehensive and Detailed Explanation:
This patient has end-stage heart failure with frequent hospitalizations, progressive symptoms, and functional decline. The most appropriate next step is to initiate a goals-of-care conversation, including acknowledgment of the prognosis.
Toronto Notes 2023 - Cardiology / Palliative Care:
"In advanced heart failure with recurrent admissions and functional decline, a goals-of-care discussion should be initiated to align treatment with patient values." MCCQE1 Objectives (Cardiology > 34-4 / ELOM > 90-2):
"Candidates must recognize end-stage illness and provide appropriate communication and palliative care planning." Deactivating the defibrillator (B) may be appropriate later but should follow a goals-of-care conversation.
Reassuring (C) ignores the true clinical trajectory.
質問 # 127
An 88-year-old married man is admitted following a cardiac arrest at home. He was not expected to recover, and after 2 weeks, he remains in a coma. His wife states, "I cannot let him go. That would be murder." As the attending physician looking after her husband, which one of the following is the best next course of action?
- A. Seek advice from the provincial or territorial public guardian
- B. Encourage her to imagine what her husband would have wanted
- C. Emphasize that the duration of his stay in the Intensive Care Unit will be limited
- D. Remove him from life support as this would not be murder
- E. Say nothing further and wait until she comes around to accepting his state
正解：B
解説：
In discussions about end-of-life care, it is critical to shift the focus from the substitute decision-maker's own feelings to what the patient would have wanted. This approach promotes ethically sound and patient-centered decisions. It is respectful, supportive, and maintains trust.
Toronto Notes 2023 - ELOM, "Advance Care Planning and End-of-Life Decisions":
"When a patient cannot express wishes, decisions must be based on known prior wishes or substituted judgment-what the patient would have wanted." MCCQE1 Objectives (ELOM > 90-2: Capacity, Consent, and End-of-Life Care):
"Candidates must guide surrogate decision-makers toward reflecting on the patient's values and previously expressed wishes." Options A and B are inappropriate-waiting without engagement or unilateral withdrawal is unethical. C does not address the wife's emotional or ethical concerns. E is premature unless the wife is clearly unable or unfit to act as decision-maker.
質問 # 128
A 73-year-old woman is seen in the office 2 weeks after a coronary bypass surgical procedure. The site of saphenous vein removal in the left thigh shows an area of tenderness and a 3 × 5 cm palpable mass. The skin is intact. Her temperature is 37.7 °C, hemoglobin is 110 g/L (125-167), and white blood cell count is 8 × 10#
/L (4-10). Which one of the following is the most likely diagnosis?
- A. Wound abscess
- B. Thrombophlebitis
- C. Wound hematoma
- D. Femoral artery aneurysm
- E. Acute venous bleeding
正解：C
解説：
Comprehensive and Detailed Explanation:
A localized mass with tenderness at a recent surgical site, intact skin, low-grade temperature, and normal white count is most consistent with a wound hematoma. This is a common complication at saphenous vein graft harvest sites post-CABG.
Toronto Notes 2023 - Surgery / Cardiac:
"Wound hematoma presents as localized swelling and tenderness near recent surgical sites. Abscess is suggested by erythema, warmth, and systemic signs." MCCQE1 Objectives (Surgery > 50-2: Postoperative Complications):
"Candidates must identify and differentiate wound complications, including hematoma, seroma, and abscess." Abscess (E) would show redness, fluctuance, and fever. Aneurysm (B) is rare and pulsatile. Bleeding (A) would not form a stable mass 2 weeks post-op. Thrombophlebitis (C) usually involves superficial veins and erythema.
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質問 # 129
A 72-year-old woman is brought to the Emergency Department by her daughter because of significant functional decline and progressive shortness of breath. She has widespread metastatic breast cancer and recently stopped chemotherapy due to progression and intolerance. She has been bedridden for 4 weeks. On examination:
* BP: 100/70 mm Hg with pulsus paradoxus of 20 mm Hg
* HR: 99/min
* Temp: 36.5°C
* SpO#: 94% room air
* JVP: elevated
* Heart sounds: muffled
* Chest X-ray: large globular heart
Labs:
* Hemoglobin: 90 g/L
* Sodium: 118 mmol/L
* Creatinine: 94 µmol/L
Which one of the following is the best next step?
- A. Normal saline infusion
- B. Consult with the Intensive Care Unit
- C. Blood transfusion
- D. Discussion on goals of care
- E. Pericardiocentesis
正解：D
解説：
This patient has classic signs of cardiac tamponade (Beck's triad: hypotension, muffled heartsounds, elevated JVP, plus pulsus paradoxus). However, she also has advanced metastatic cancer, functional decline, and has stopped active treatment. In this context, a goals-of-care discussion is the most appropriate next step to determine her wishes regarding interventions like pericardiocentesis.
Toronto Notes 2023 - Palliative Care:
"End-of-life care should prioritize quality of life and patient preferences. In patients with terminal illness and life-threatening conditions (e.g., tamponade), initiate a conversation about goals before aggressive intervention." MCCQE1 Objectives - Internal Medicine > Palliative and End-of-Life Care:
"Candidates must assess prognosis, patient values, and initiate appropriate end-of-life discussions before invasive treatment." Although pericardiocentesis (A) may relieve symptoms, it should follow consent based on the patient's goals.
ICU (E), fluids (B), or transfusion (D) are not appropriate without this discussion.
質問 # 130
A 39-year-old woman comes to the office for a periodic health examination. She reports that her father had a recent diagnosis of breast cancer (at age 62 years) and that a paternal aunt had ovarian cancer in her early 40s.
The results of mammography are normal. Which one of the following is the most appropriate recommendation for this patient?
- A. Annual mammography starting at age 50 years.
- B. Prophylactic tamoxifen therapy.
- C. Genetic screening.
- D. Bilateral mastectomy.
- E. Random fine-needle sampling of the breasts.
正解：C
解説：
This patient has a family history of both male breast cancer (father) and early-onset ovarian cancer (aunt), which are red flags for BRCA1/2 mutations. Genetic counseling and BRCA testing are the appropriate next steps to stratify cancer risk and guide screening and prevention.
Toronto Notes 2023 - Oncology, "Breast Cancer Risk" Section:
"BRCA testing is recommended for individuals with a strong family history of breast or ovarian cancer, particularly if involving male relatives or early-onset cases." MCCQE1 Objectives (Population Health > 97-5: Screening and Prevention):
"Candidates must identify high-risk individuals who require genetic counseling and screening beyond population guidelines." Tamoxifen (A) and prophylactic mastectomy (E) are only considered after confirming mutation status. Annual screening starting at 50 (D) is for average-risk women. Fine-needle sampling (C) is not a screening tool.
質問 # 131
You are seeing a 5-month-old infant who has had intermittent stridor since age 2 months. He is otherwise healthy. He has been drinking well and has been reaching all the age-specific developmental milestones.
Which one of the following is the most likely diagnosis?
- A. Subglottic hemangioma.
- B. Aspiration of a foreign body.
- C. Laryngomalacia.
- D. Vascular ring.
- E. Tracheoesophageal fistula.
正解：C
解説：
Laryngomalacia is the most common cause of chronic stridor in infants. It presents with inspiratory stridor that worsens with feeding, supine positioning, or agitation. The child remains otherwise well and meets developmental milestones.
Toronto Notes 2023 - Pediatrics, Airway Disorders:
"Laryngomalacia presents with intermittent inspiratory stridor, typically beginning in the first few months of life. Diagnosis is clinical and prognosis is usually good." MCCQE1 Objectives - Pediatrics > Respiratory Disorders:
"Candidates must recognize the typical presentation of laryngomalacia and differentiate it from other causes of pediatric stridor." Vascular ring (A) or subglottic hemangioma (C) often present with more severe or progressive symptoms.
Foreign body aspiration (D) presents acutely. TE fistula (E) usually causes feeding difficulties from birth.
質問 # 132
A 59-year-old woman is referred to you because of a 2-month history of left nipple discharge. She is otherwise healthy and is not on any medication. There are no palpable lesions on breast examination. She is able to express a small amount of blood-tinged liquid from her breast. Which one of the following would be the best next step?
- A. Galactography.
- B. Serum prolactin.
- C. Magnetic resonance imaging of breast.
- D. Mammography.
- E. Biopsy of nipple complex.
正解：D
解説：
Spontaneous, unilateral, blood-tinged nipple discharge in a postmenopausal woman is considered pathologic and warrants imaging to rule out intraductal pathology including malignancy. The best initial test is diagnostic mammography, often with ultrasound if indicated.
Toronto Notes 2023 - Breast Disorders:
"Unilateral, spontaneous, bloody nipple discharge should be evaluated with mammography and targeted ultrasound. Further tests such as MRI or duct excision are based on findings." MCCQE1 Objectives (Gynecology > 81-1: Breast Conditions):
"Candidates must recognize red flags for breast malignancy and apply appropriate initial diagnostic imaging." Serum prolactin (C) is indicated in galactorrhea. Galactography (D) and MRI (E) are second-line. Biopsy (A) is premature without imaging.
質問 # 133
A mother brings her 13-year-old daughter to the office. The girl has had intermittent lower abdominal pain, constipation, and difficulty voiding for 3 months. She says that she is not sexually active. She looks well. She has reached age-specific developmental milestones, and her vital signs are within normal range. On abdominal examination, she is found to have a palpable suprapubic mass that persists after voiding. The girl says that her older sister started having menstrual periods at this age. The patient is surprised that hers have not started. Which one of the following is the best next step?
- A. Measurement of serum human chorionic gonadotropin.
- B. Urinalysis.
- C. Pelvic ultrasonography.
- D. Abdominal radiography.
- E. Examination of external genitalia.
正解：E
解説：
The clinical picture suggests an obstructive anomaly of the female reproductive tract, such as imperforate hymen or vaginal outflow tract obstruction, leading to hematocolpos. The first essential step is physical examination of the external genitalia.
Toronto Notes 2023 - Pediatrics and Gynecology, "Amenorrhea" Section:
"In girls with primary amenorrhea and cyclic abdominal pain, perform an external genital exam to rule out obstructive anomalies (e.g., imperforate hymen or transverse vaginal septum). Examination should always precede imaging." MCCQE1 Objectives (Pediatrics > 78-3: Puberty and Menstrual Disorders):
"Candidates must evaluate delayed menarche with physical exam, including inspection of the genitalia to rule out anatomic obstruction." Pelvic ultrasound (D) is helpful but should follow physical exam. Radiography (B), hCG (C), and urinalysis (E) are not primary steps in evaluating amenorrhea with a mass.
質問 # 134
A 72-year-old man presents to your clinic accompanied by his 70-year-old husband. The patient reports that, over the last several months, his libido has been very low. Which one of the following would be the best next step?
- A. Prescribe testosterone
- B. Refer for couple's counselling
- C. Order serum testosterone levels
- D. Assess for depression
- E. Interview the couple together
正解：D
解説：
Comprehensive and Detailed Explanation:
Decreased libido in elderly patients can be multifactorial, but depression is a common and important cause that must be ruled out before hormone therapy or other steps. A proper mental health screen should precede further interventions.
Toronto Notes 2023 - Psychiatry / Geriatrics:
"In elderly men, reduced libido may be linked to depression, medical illness, or medications. Depression screening is essential." MCCQE1 Objectives (Psychiatry > 71-1: Mood Disorders / Sexual Health):
"Candidates must consider depression as a common cause of decreased libido and assess accordingly before initiating hormone therapy." Testosterone testing (D) may follow. Prescribing (C) is premature. Couples counselling (B) may help if interpersonal issues are identified. Interviewing together (A) may inhibit disclosure.
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質問 # 135
A 40-year-old woman presents to the Emergency Department with confusion and fever (38.5°C). She has a history of hypothyroidism managed with levothyroxine. Key findings include:
Blood pressure
114/78 mm Hg
Heart rate
85/min
Temperature
38.5°C
Hemoglobin
90 g/L123-157 g/L
Platelet count
25 × 10#/L130-400 × 10#/L
Peripheral blood film
Schistocytes present
Creatinine
200 #mol/L50-90 #mol/L
- A. Idiopathic thrombocytopenic purpura
- B. Human immunodeficiency virus
- C. Acute myelogenous leukemia
- D. Thrombotic thrombocytopenic purpura
- E. Cirrhosis
正解：D
解説：
This patient presents with fever, confusion, anemia with schistocytes, thrombocytopenia, and renal impairment - fulfilling the classic pentad of thrombotic thrombocytopenic purpura (TTP). TTP is a hematologic emergency requiring plasma exchange.
Toronto Notes 2023 - Hematology, "Microangiopathic Hemolytic Anemia" Section:
"TTP is a medical emergency. Features include MAHA, thrombocytopenia, renal failure, neurologic symptoms, and fever. Schistocytes on blood film are diagnostic." MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Disorders):
"Candidates must urgently recognize TTP and initiate emergent plasma exchange therapy." AML (B) does not present with schistocytes. HIV (C) can cause thrombocytopenia but not MAHA. ITP (D) causes isolated thrombocytopenia without anemia or schistocytes.
質問 # 136
You are called to attend an 18-year-old woman, gravida 2, para 1, aborta 0, who is in precipitous labour. She did not realize she was pregnant and has not had any prenatal care. After the delivery, you examine the newborn boy; he is vigorous, and it appears that he was born at full term. Physical examination findings of the newborn are normal. Review of the prenatal record from the mother's last pregnancy shows the following:
* HIV: Negative
* Hepatitis B surface antibody: Positive
* Hepatitis C: Negative
* Syphilis serology: Negative
The mother's previous child was placed in foster care. The mother is withdrawn and uncommunicative after delivery. Which one of the following is the best next step?
- A. Collect urine from the newborn for a drug screen
- B. Recommend immediate skin-to-skin care
- C. Initiate feeding with donor breast milk
- D. Administer hepatitis B vaccine to the newborn
正解：A
解説：
Given the lack of prenatal care, the mother's withdrawal, and prior involvement of child protection services, a newborn drug screen is warranted to assess for possible in utero exposure. This is part of the safety assessment.
Toronto Notes 2023 - Pediatrics, Newborn Assessment:
"Infants born to mothers with no prenatal care or prior social concerns should undergo a full newborn screening, including toxicology if indicated." MCCQE1 Objectives - Pediatrics > Newborn Care and Social Issues:
"Candidates must identify social risk factors and initiate appropriate newborn evaluations, including toxicology screens when substance use is suspected." The mother was previously immune to hepatitis B, so (A) is not immediately required. Skin-to-skin care (D) is beneficial but secondary to screening in this context. Donor milk (B) is not indicated unless breastfeeding is contraindicated.
質問 # 137
A 42-year-old woman presents to your clinic requesting an increase in her stimulant dosage for the treatment of her adult attention-deficit/hyperactivity disorder. Her medical history includes hypertension and type 1 diabetes with associated nephropathy. She has been taking methylphenidate daily for 15 years. Which one of the following would need to be addressed before the dosage can be increased?
- A. Random glucose level that is often higher than 18.0 mmol/L (4.0-11.0).
- B. Estimated glomerular filtration rate of less than 30 mL/min/1.73 m² (#60).
- C. Average home blood pressure reading of 150/80 mm Hg.
正解：C
解説：
Stimulants like methylphenidate can increase heart rate and blood pressure. In patients with cardiovascular risk (e.g., hypertension, nephropathy), stimulants should not be increased without first addressing elevated blood pressure.
Toronto Notes 2023 - Psychiatry, "ADHD in Adults":
"Stimulants can exacerbate hypertension and must be used cautiously. Evaluate cardiovascular risk factors and control blood pressure before dose increases." MCCQE1 Objectives (Psychiatry > 71-1: ADHD):
"Candidates must consider the cardiovascular risks of stimulant therapy and monitor for hypertension prior to adjusting doses." While poor glycemic control (B) and renal disease (A) are important, BP control is most critical for immediate stimulant safety.
質問 # 138
A 6-year-old girl is found to have a blood pressure of 130/75 mm Hg. She was born prematurely at 32 weeks' gestation and required ventilation. There is a family history of hypertension in 3 grandparents. Clinical examination reveals a grade 1/6 mid-systolic murmur, no renal bruits, and femoral pulses are difficult to feel.
Which one of the following is the most likely diagnosis?
- A. Essential hypertension
- B. Aortic coarctation
- C. Reflux nephropathy
- D. Ventricular septal defect
- E. Renal artery thrombosis
正解：B
解説：
Comprehensive and Detailed Explanation:
The combination of upper extremity hypertension and weak femoral pulses is classic for aortic coarctation. A soft systolic murmur may be present. This condition often becomes apparent during routine screening in school-aged children.
Toronto Notes 2023 - Pediatrics / Cardiology:
"Coarctation of the aorta presents with upper limb hypertension, diminished femoral pulses, and sometimes a systolic murmur. BP discrepancy is key." MCCQE1 Objectives (Pediatrics > 78-1: Congenital Heart Disease):
"Candidates must recognize signs of aortic coarctation, including weak lower limb pulses and systemic hypertension in children." VSD (A) typically presents with a louder murmur. Reflux nephropathy (B) may cause hypertension but without femoral pulse discrepancy. Renal artery thrombosis (C) is rare. Essential hypertension (D) is less likely in this age group with these findings.
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質問 # 139
A 16-year-old boy presents to the emergency department with a 12-hour history of fever and rigors. He has sickle cell anemia. On examination, his vital signs include the following:
Heart rate
110/min (60-100)
Respiratory rate
20/min (12-18)
Temperature
38.8 °C, oral (36.5-37.5)
Which one of the following places this patient at risk for sepsis?
- A. Systemic iron overload
- B. Neutrophil dysfunction
- C. Functional asplenia
- D. Immunoglobulin deficiency
- E. Chronic anemia
正解：C
解説：
Patients with sickle cell anemia often develop functional asplenia due to repeated splenic infarction. The spleen plays a critical role in clearing encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis. Functional asplenia significantly increases the risk of overwhelming sepsis.
Toronto Notes 2023 - Hematology, "Sickle Cell Disease":
"Functional asplenia is common in sickle cell disease and increases the risk for sepsis due to impaired clearance of encapsulated bacteria." MCCQE1 Objectives (Pediatrics > 77-2: Hematology):
"Candidates must recognize that patients with functional asplenia are at increased risk for sepsis and require prompt evaluation for fever." Neutrophil dysfunction (B) and immunoglobulin deficiency (C) are not typical features of sickle cell anemia.
Chronic anemia (D) and iron overload (E) do not directly increase sepsis risk.
質問 # 140
A 9-year-old girl from a remote community is brought to the clinic with a 2-week history of swelling in her neck. She has been afebrile but has had some night sweats. On examination, you note a fixed, unilateral, and nontender supraclavicular lymph node measuring 3 cm. The overlying skin color is unremarkable. In addition, you note a slightly enlarged spleen and liver. Which one of the following is the most likely diagnosis?
- A. Acute bacterial lymphadenitis
- B. Kawasaki disease
- C. Cat-scratch disease
- D. Viral reactive lymphadenopathy
- E. Lymphoma
正解：E
解説：
This child presents with "red flag" features for malignancy: a firm, fixed, nontender supraclavicular lymph node >2 cm in size, with associated hepatosplenomegaly and night sweats. These features are most concerning for lymphoma.
Toronto Notes 2023 - Pediatrics, "Lymphadenopathy in Children":
"Malignant lymphadenopathy tends to be firm, fixed, painless, and located in supraclavicular areas. Systemic signs (fever, weight loss, hepatosplenomegaly, night sweats) are concerning for lymphoma." MCCQE1 Objectives (Pediatrics > 78-3: Hematology/Oncology):
"Candidates should differentiate between benign and malignant lymphadenopathy and recognize features suggestive of lymphoma." Cat-scratch disease (B) is usually tender and associated with cat exposure. Kawasaki disease (C) presents with fever and mucocutaneous findings. Acute bacterial lymphadenitis (D) is painful, warm, and rapid in onset.
Viral lymphadenopathy (E) is often bilateral, small, and tender.
質問 # 141
A 58-year-old woman presents to your office with heavy vaginal bleeding. She has a history of type 2 diabetes and hypertension. Some active bleeding is visible on speculum examination. Ultrasound reveals an endometrial thickness of 12 mm. Endometrial biopsy shows complex hyperplasia with atypia. Which one of the following is the best next step?
- A. Obtain consent for dilatation and curettage
- B. Refer for hysterectomy and bilateral salpingo-oophorectomy
- C. Arrange endometrial ablation
- D. Prescribe topical progesterone
- E. Organize hysteroscopy
正解：B
解説：
Comprehensive and Detailed Explanation:
Complex endometrial hyperplasia with atypia carries a high risk of progression to or concurrent endometrial carcinoma. Definitive management in postmenopausal women is total hysterectomy with bilateral salpingo- oophorectomy.
Toronto Notes 2023 - Gynecology, Abnormal Uterine Bleeding:
"Endometrial hyperplasia with atypia in postmenopausal women is best managed surgically due to the risk of malignancy." MCCQE1 Objectives - Gynecology > Postmenopausal Bleeding:
"Candidates should identify endometrial hyperplasia with atypia as an indication for hysterectomy in appropriate patients." Ablation (A) is contraindicated. Progesterone (B) is used for non-atypical hyperplasia. D&C (C) and hysteroscopy (D) are diagnostic but not definitive.
質問 # 142
You are conducting a virtual appointment by voice-only call with a 68-year-old man regarding back pain.
When he answers, you ask for him by name and identify yourself and the clinic from which you are calling.
Which one of the following is the best next step?
- A. Ask for additional confirmation of the patient's identity.
- B. Confirm the name of the patient's primary care provider.
- C. Establish the reason for the virtual care visit.
正解：A
解説：
Before proceeding with any virtual consultation, particularly by voice-only, it is essential to confirm the patient's identity beyond name alone - for example, by verifying date of birth or health card number. This protects privacy and ensures medical confidentiality.
Toronto Notes 2023 - ELOM, Virtual Care Section:
"Virtual care must begin by verifying patient identity using at least two identifiers (e.g., full name and date of birth) to prevent disclosure of personal health information to unintended individuals." MCCQE1 Objectives - Ethical, Legal, and Professionalism > Virtual Care:
"The candidate must confirm patient identity and consent before initiating any virtual medical encounter, especially when video is not available." Option A (reason for visit) should follow identity confirmation. Option B (confirming primary care provider) is irrelevant to identity verification.
質問 # 143
A 15-year-old boy is brought to your office because of concerns about his breast development. He has no other symptoms. His physical examination does not reveal any other abnormality. Which one of the following is the best next step?
- A. Order cranial magnetic resonance imaging
- B. Perform serum prolactin level
- C. Reassure the patient
- D. Order adrenal ultrasound
- E. Perform serum estrogen level
正解：C
解説：
Comprehensive and Detailed Explanation:
The image and clinical history are consistent with physiologic pubertal gynecomastia, which is common in adolescent boys. It usually resolves spontaneously within 6 months to 2 years and does not require investigation unless other signs of endocrine pathology are present.
Toronto Notes 2023 - Pediatrics / Endocrinology:
"Pubertal gynecomastia is benign, self-limited, and common in adolescent males. No further investigation is needed in the absence of systemic signs." MCCQE1 Objectives (Pediatrics > 77-2: Endocrine Disorders):
"Candidates must differentiate physiologic gynecomastia from pathologic causes based on history and physical exam." Other tests (A-C, E) are unnecessary unless there are red flags (e.g., testicular mass, rapid progression, neurological symptoms).
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質問 # 144
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