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| Section | Objectives |
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| Topic 1: Physician Roles (CanMEDS Framework) | - Professional
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NEW QUESTION # 201
A 56-year-old woman comes to your office because she has not been herself since her husband died in a car crash 6 weeks ago. She has no prior psychiatric history. Her son is concerned because she cries frequently, has a poor appetite, rarely leaves home and is distraught. Her sadness fluctuates and increases when she thinks of her husband. She often thinks about death, and she wishes she could join her deceased husband. Which one of the following is the best next step?
Answer: A
Explanation:
Her presentation at 6 weeks after a spouse's death is most consistent with acute/normal grief : intense sadness, crying, social withdrawal, reduced appetite, and waves of distress triggered by reminders of the deceased.
MCCQE objectives stress distinguishing grief from major depressive disorder by the fluctuating nature of symptoms , grief "pangs," and the link to thoughts of the deceased. Although she expresses wishing to "join" her husband, this can occur in normal bereavement; the key clinical duty is to assess safety (suicidal intent, plan, means, past attempts, protective factors). In the absence of imminent risk or psychosis, inpatient/day- hospital admission is not the default. "Reassurance" alone is insufficient because she is significantly impaired and needs structured support. The best next step is referral for bereavement-focused support (often via social work), which can provide grief counseling, coping strategies, mobilization of supports, and monitoring, and can facilitate escalation if complicated grief or major depression emerges. Family systems therapy may help later, but immediate practical and grief-specific support plus safety assessment is the priority.
NEW QUESTION # 202
A 19-year-old woman with a long-standing history of abuse and borderline personality disorder presents to your office. She has a number of superficial lacerations over her arms and legs. They look like they were caused by a sharp edge such as a knife. They are at various stages of healing, and some look like they are a few hours old, though none require stitches. Which one of the following is the most likely comment she would make about the injuries?
Answer: C
Explanation:
Patients with borderline personality disorder commonly engage in non-suicidal self-injury (NSSI) such as superficial cutting. According to MCCQE objectives in psychiatry, this behavior is typically a maladaptive coping mechanism used to regulate intense emotional distress, feelings of emptiness, anger, or dissociation.
The act of cutting often produces a transient sense of relief due to reduction of psychological tension and may be reinforced by endogenous opioid release. Therefore, patients frequently report that they "feel better afterward." It is important to distinguish NSSI from suicidal intent. Although individuals with borderline personality disorder are at increased risk of suicide, superficial cutting behavior is most often performed to relieve affective dysregulation rather than to die. It is not primarily attention-seeking, obsession with blood, or body modification. Management priorities include thorough suicide risk assessment, validation of emotional distress, establishing safety, and referral for evidence-based psychotherapy such as dialectical behavior therapy (DBT), which specifically targets emotional regulation and self-harm behaviors.
NEW QUESTION # 203
An 18-month-old girl is brought in with a 3-day history of frequently passing loose stools. The stools are not bloody, but when she passes the stools, she is in obvious pain. She started vomiting earlier today, but she is still wetting diapers. On examination, she is mildly dehydrated but active and alert. Physical examination findings are otherwise normal. Which one of the following is the best management of this patient's case?
Answer: A
Explanation:
This child has acute viral gastroenteritis with mild dehydration. She remains alert, active, and continues to produce urine, indicating mild volume depletion. According to MCCQE objectives and pediatric guidelines, the first-line management of mild to moderate dehydration due to gastroenteritis is oral rehydration therapy (ORT) using a commercially prepared oral rehydration solution (ORS). ORS contains the appropriate balance of glucose and electrolytes to promote sodium and water absorption via the sodium-glucose cotransporter in the intestine. Antidiarrheal agents such as loperamide are contraindicated in young children due to risk of adverse effects and limited benefit. Withholding food until diarrhea resolves is unnecessary; early refeeding with an age-appropriate diet is recommended once rehydration begins. Apple juice and chicken broth do not provide the correct electrolyte composition and may worsen diarrhea due to high osmolarity. Routine lactose restriction is not indicated unless persistent symptoms suggest secondary lactose intolerance. Early ORT reduces the need for intravenous fluids and hospital admission.
NEW QUESTION # 204
A 45-year-old man presents to your family practice for follow-up because he has had repeated transient ischemic attacks and had been advised not to drive. During the interview, you find out that he is still driving.
He explains that he only drives to the grocery store and his wife, who also has a driver's license, is always a passenger with him. He insists he can drive. You think that he should no longer be driving a car. Which one of the following is the best next step?
Answer: A
Explanation:
In most Canadian provinces and territories, physicians are legally obligated to report patients who pose a danger due to medical conditions affecting driving ability. Given the history of TIAs and continued unsafe driving, reporting is necessary for public safety.
Toronto Notes 2023 - ELOM, "Fitness to Drive" Section:
"Physicians must report to motor vehicle authorities if a patient poses a risk to public safety due to a medical condition. TIAs are considered reportable if they impair ability and the patient does not comply with driving restrictions." MCCQE1 Objectives (ELOM > 99-1: Medical Fitness and Reporting):
"Candidates must recognize situations requiring mandatory reporting of patients unfit to drive due to neurologic or other impairing conditions." You may still discuss with the patient (B), but this does not replace the duty to report. Physically taking the license (C) is illegal. Refusing care (D) is unethical. A neurologist (E) could be helpful but would delay action in a clear case.
NEW QUESTION # 205
A 40-year-old woman presents to your clinic for follow-up regarding her major depressive disorder, which is being treated with the starting dosage of escitalopram. Most of her symptoms have now improved. However, she has noted anorgasmia since taking this medication. This has significantly affected her relationship with her wife. Which one of the following is the best next step?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
Sexual dysfunction, including anorgasmia, is a common side effect of SSRIs like escitalopram. Bupropion, a norepinephrine-dopamine reuptake inhibitor, has minimal sexual side effects and can be safely added to mitigate this issue while preserving the antidepressant effect.
Toronto Notes 2023 - Psychiatry / Pharmacology:
"SSRI-induced sexual dysfunction can be managed by dose reduction, switching agents, or adding bupropion." MCCQE1 Objectives (Psychiatry > 71-1: Depressive Disorders):
"Candidates should be able to address side effects of antidepressants, including sexual dysfunction, and adjust therapy appropriately." Increasing the dose (A) may worsen sexual dysfunction. Venlafaxine (B), an SNRI, also has sexual side effects. D (no change) does not address the patient's concern.
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NEW QUESTION # 206
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