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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Medical Expert
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NEW QUESTION # 170
An otherwise healthy 43-year-old woman presents to your clinic for a left breast mass. Six months ago, she underwent a bilateral breast magnetic resonance imaging (MRI) after watching a television program on breast cancer prevention. An ultrasound-guided biopsy of a 1.5 cm massconfirmed, at the time, that she had fibroadenoma. The follow-up ultrasound now reveals a mass measuring 1.7 cm. Which one of the following is the best next step in the management of this patient?
Answer: B
Explanation:
Fibroadenomas can grow slightly or fluctuate in size. A minimal increase (from 1.5 cm to 1.7 cm) over six months is clinically insignificant. No malignant features are reported, and the previous biopsy confirmed benign nature. Annual follow-up is appropriate.
Toronto Notes 2023 - Obstetrics and Gynecology, "Breast Disorders" Section:
"Fibroadenomas are benign breast masses that may slightly enlarge. Routine imaging follow-up at 6 to 12 months is appropriate for lesions with benign imaging and histology." MCCQE1 Objectives (Obstetrics and Gynecology > 82-3: Breast Mass):
"Candidates must distinguish between benign and suspicious masses and determine appropriate intervals for follow-up imaging." Repeat biopsy (A) or surgery (B) is unwarranted without suspicious change. MRI (C) is not needed in stable, benign lesions. Tamoxifen (D) is not used for fibroadenomas.
NEW QUESTION # 171
A 27-year-old woman, gravida 2, para 1, aborta 0, presents to the office seeking guidance on the management of her baby once it is born. The patient is in renal failure and has been taking methadone for 3 years to manage her opioid use disorder. During her pregnancy, she has been taking a stable dose of 80 mg of methadone once daily. Which one of the following is the most appropriate next step?
Answer: C
Explanation:
Methadone maintenance therapy during pregnancy is the recommended treatment for opioid use disorder and should be continued at a stable dose. However, regardless of maternal dose stability, neonates are at significant risk of neonatal abstinence syndrome (NAS) due to in utero opioid exposure. MCCQE objectives emphasize anticipatory guidance and appropriate newborn monitoring in substance-exposed pregnancies.
Symptoms of NAS (irritability, tremors, poor feeding, vomiting, diarrhea, seizures) typically begin within 24-
72 hours after birth but may be delayed with long-acting opioids such as methadone. Therefore, routine observation in hospital for at least 72 hours is recommended to monitor for withdrawal and initiate supportive or pharmacologic treatment if needed.
Naloxone is contraindicated in opioid-dependent neonates except in life-threatening respiratory depression because it may precipitate severe withdrawal. Stable maternal dosing does not eliminate NAS risk, so early discharge is inappropriate. Breastfeeding is generally encouraged in stable methadone-maintained mothers, as methadone transfer in breast milk is minimal and may reduce withdrawal severity. Continuing methadone during pregnancy is safer than untreated opioid use.
NEW QUESTION # 172
A 12-year-old boy is brought by his mother to your clinic with a history of attention-deficit/hyperactivity disorder. His mother reports that he has been taking immediate-release methylphenidate for 2 years. Although the medication was initially effective, it no longer seems to work. The teachers say he is disorganized and fidgety, verbally interrupts class, and does not complete his work. His mother tells you that he does listen at home. Which one of the following is the most important next step in management?
Answer: A
Explanation:
Management of ADHD requires ongoing reassessment using standardized rating scales from multiple informants (e.g., parents and teachers) to evaluate symptom control and functional impairment across settings.
This child demonstrates persistent school-related symptoms despite prior response to immediate-release methylphenidate. Before adjusting therapy, it is essential to objectively reassess symptom severity, adherence, timing of doses relative to school hours, and potential environmental factors. Completion of validated rating scales helps determine whether symptoms remain clinically significant and guides appropriate dose titration.
Stimulant medications such as methylphenidate are first-line treatment, and inadequate response often requires dose optimization before switching agents. Simply increasing the dose without reassessment is not best practice. Risperidone is not indicated for uncomplicated ADHD. An EEG is unnecessary unless there are seizure concerns. Switching to atomoxetine is premature without confirming inadequate response to optimized stimulant therapy. MCCQE objectives emphasize systematic monitoring, multi-informant assessment, dose titration, and evidence-based pharmacologic management in pediatric ADHD.
NEW QUESTION # 173
A 3-week-old boy is brought by his parents to your clinic for a well-child visit. The newborn was born at term after an uncomplicated pregnancy. He is exclusively breastfed and is thriving. Physical examination findings are normal except for jaundice. Total bilirubin is 172 #mol/L (#100), and conjugated bilirubin is 4 #mol/L (#5). Results of a complete blood count and reticulocyte count are within the normal range. The results of a direct antiglobulin (Coombs) test were negative. Which one of the following, if any, is the most appropriate investigation?
Answer: B
NEW QUESTION # 174
A 6-week-old boy is brought to your office by his parents for a follow-up following a recent urinary tract infection. His abdominal ultrasound shows dilated urinary bladder and ureters as well as bilateral hydronephrosis. Which one of the following historical findings would be most helpful in establishing the correct diagnosis?
Answer: D
Explanation:
This infant has evidence of urinary outflow obstruction on ultrasound. The most common cause in male infants is posterior urethral valves. Poor urinary stream is a hallmark symptom of bladder outlet obstruction in neonates.
Toronto Notes 2023 - Pediatrics, "Pediatric Urology" Section:
"Posterior urethral valves should be suspected in male infants with recurrent UTIs, hydronephrosis, and a weak urinary stream. Diagnosis is confirmed by voiding cystourethrogram." MCCQE1 Objectives (Pediatrics > 78-4: Urinary Tract Abnormalities):
"Candidates must identify congenital causes of urinary obstruction. Poor stream and hydronephrosis are classic features of posterior urethral valves." Crying with urination (E) is nonspecific. Hematuria (B) and malodorous urine (D) are common with infections. Circumcision (A) is unrelated.
NEW QUESTION # 175
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