FREE MCCQE QUESTIONS

General Medicine Questions

1) A family physician cares for a family consisting of a 45-year old husband, 43-year-old wife

and a 12-year-old daughter. The family reports that recently the 77-year-old maternal

grandmother who lived with them died after a prolonged respiratory infection. Autopsy

subsequently confirms that she had active pulmonary tuberculosis at the time of death. The

organism tested sensitive to all anti-tuberculosis drugs. In responding to the grandmother's

illness, which of the following is the most appropriate step in management?

A. Obtain leukocyte counts on all family members

B. Obtain sputum cultures for acid fast bacilli

C. Obtain chest computerized tomograms on all members

D. Place protein purified derivative (PPD) test on all members

E. Schedule bronchoscopy lavage for the adults

Explanation:

The correct answer is D. The immediate step is to screen the family for TB exposure. The most

effective manner in which to accomplish this is by placing PPDs on all members and working up

those with a positive test. The white cell count may be elevated for a variety of reasons and

would not necessarily help in diagnosis or management (choice A).

Sputum cultures will take 6 months to grow and may be too cumbersome to obtain (choice B).

Chest CT scans may show the tuberculosis lesion but a more effective method would be to place

the PPD and perhaps then scan those with a positive test (choice C).

A bronchoscopy would be too invasive an option at this point (choice E).

2) A 57-year-old man comes to the emergency department because of excruciating pain in his

right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no

chronic medical conditions, does not take any medications, and denies any similar episodes in

the past. He admits to a few "drinking binges" over

the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and

pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender

right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and

shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within

polymorphonuclear leukocytes (PMNs). Laboratory studies show:

Serum

Leukocytes........16,000/mm3

Uric acid...........15 mg/dL

Calcium.............9 mg/dL

Which of the following is the most appropriate pharmacotherapy?

A. Allopurinol

B. Ceftriaxone

C. Indomethacin

D. Probenecid

E. Sulfinpyrazone

Explanation:

The correct answer is C. This patient has the classic presentation of a patient with acute gouty

arthritis with the sudden onset of severe pain (typically in the middle of the night), swelling,

erythema and warmth of a single joint. Low-grade fever and leukocytosis may be seen. It is more

common in men and it is associated with hyperuricemia, usually due to decreased renal excretion

of uric acid. Common causes are thiazides and alcohol. Diagnosis is made by examination of

joint fluid under polarizing light. Negatively birefringent, needle-shaped crystals within

polymorphonuclear leukocytes, hyperuricemia, and acute monoarticular arthritis make the

definitive diagnosis of gout. Indomethacin or colchicine is the treatment during an acute attack.

Allopurinol, probenecid, and sulfinpyrazone are used for prophylaxis against further attacks.

Allopurinol (choice A) is a xanthine oxidase inhibitor that is used as an antihyperuricemic agent

by individuals with recurrent gouty attacks. Common side effects include rash, headache, and

gastrointestinal upset.

Ceftriaxone (choice B) is the treatment of acute gonococcal arthritis. It has no role in the

treatment of gout.

Probenecid (choice D) is a uricosuric agent that increases the rate of urate excretion. It is used to

prevent gouty attacks. It may precipitate nephrolithiasis.

Sulfinpyrazone (choice E) is another uricosuric agent that increases urate excretion. It is used to

prevent gouty attacks. It, too, may precipitate nephrolithiasis.

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