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| Section | Weight | Objectives |
|---|---|---|
| Dimensions of Care | 50% | - Acute Care - Chronic Care - Assessment and Diagnosis - Health Promotion and Illness Prevention |
| Physician Activities | 50% | - Professional Behaviours - Management - Communication - Psychosocial Aspects |
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NEW QUESTION # 319
You are working in a busy family practice. Your colleague's 48-year-old female patient presents with a 6- month history of fatigue and gastrointestinal symptoms. A recent colonoscopy was normal. Her chart indicates multiple investigations for similar symptoms over the past 2 years, all of which have been non- revealing. Your working diagnosis is somatic symptom disorder. Which one of the following is the most appropriate treatment?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
Cognitive behavioral therapy (CBT) is the most effective first-line treatment for somatic symptom disorder. It helps patients reframe dysfunctional thoughts and improve coping strategies for perceived physical symptoms.
Toronto Notes 2023 - Psychiatry, "Somatic Symptom and Related Disorders":
"CBT is first-line for somatic symptom disorder. Antidepressants may be considered if comorbid depression or anxiety is present." MCCQE1 Objectives (Psychiatry > 71-2: Somatic Symptom Disorders):
"Candidates must manage somatic symptom disorder with appropriate psychosocial interventions." Citalopram (B) or amitriptyline (E) may be used adjunctively if mood symptoms are prominent. Risperidone (C) and ERP (D) are not indicated.
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NEW QUESTION # 320
A 37-year-old man presents with chronic back, neck, and shoulder pain following a workplace injury 4 years ago. He has a history of alcohol misuse and PTSD related to the incident. Current medications (acetaminophen, naproxen, amitriptyline, gabapentin) provide inadequate pain relief. He requests oxycodone after self-trialing it with temporary benefit. After history and physical assessment, which one of the following is the best next step?
Answer: C
Explanation:
The patient has chronic non-cancer pain with comorbid PTSD and alcohol misuse - high-risk factors for opioid use disorder. Before any opioid prescribing, a comprehensive interdisciplinary approach including mental health and substance use support is essential.
Toronto Notes 2023 - Pain Management and Addiction Medicine:
"In chronic pain patients with substance use or mental health comorbidities, refer to addiction/mental health services before considering opioid therapy." MCCQE1 Objectives (ELOM > 99-4: Safe Prescribing):
"Candidates must assess for substance use risk factors and manage chronic pain using a multidisciplinary approach." Imaging (A) is unlikely to alter management. Opioids (B, C) should not be first-line in this context. Cannabis (E) is not first-line and lacks robust evidence in complex chronic pain.
NEW QUESTION # 321
A 62-year-old woman with type 2 diabetes comes in for follow-up. She has noticed that her vision has been getting blurry over the past year and that she now needs a bright light to look at photos of her grandchildren.
Upon fundoscopic examination, you note yellow deposits in the central retina. Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
Yellow deposits in the central retina (macula) are most consistent with drusen, the hallmark finding of age- related macular degeneration (AMD). MCCQE objectives emphasize correlating key funduscopic findings with patterns of vision loss. AMD typically causes gradual, progressive central vision blurring (difficulty reading, recognizing faces, and seeing fine detail), while peripheral vision is relatively preserved. The history of needing brighter light for near tasks aligns with impaired macular function and reduced contrast sensitivity seen in AMD.
Diabetic retinopathy more commonly shows microaneurysms, dot-blot hemorrhages, hard exudates scattered in the retina, venous beading, and/or neovascularization rather than discrete drusen in the macula as the defining feature. Retinal vein occlusion usually presents more abruptly with extensive hemorrhages and
"blood and thunder" appearance. Cataracts cause lens opacity with impaired red reflex and generalized haze on fundoscopy rather than macular deposits. Open-angle glaucoma causes optic disc cupping and peripheral field loss, not central drusen. Recognizing AMD prompts appropriate counseling (smoking cessation, risk factor control), vision monitoring, and ophthalmology referral to assess for dry vs wet AMD.
NEW QUESTION # 322
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?
Answer: C
Explanation:
Magnesium sulfate toxicity is dose-dependent. The earliest and most sensitive clinical sign is the loss 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.
NEW QUESTION # 323
A 16-year-old girl presents to the clinic with concerns about her toenails. The lesions, as shown in the attached image, have been present for 2 to 3 months. She is otherwise healthy and is in training for a triathlon.
Which one of the following is the best next step?
Answer: B
Explanation:
In a healthy adolescent training for a triathlon, the most likely cause of subacute toenail changes is repetitive microtrauma from running-often due to shoes with inadequate toe box space or downhill running-leading to nail plate injury (e.g., subungual hemorrhage/onycholysis and dystrophic discoloration). MCCQE objectives emphasize choosing the most probable diagnosis based on context and initiating the least invasive, most appropriate first-line management. The key intervention is correcting the mechanical cause: ensuring adequate toe space, proper shoe fit, and appropriate nail trimming, which typically prevents progression and allows gradual regrowth over months.
Topical antifungal creams are unlikely to help if the primary issue is trauma and, even in onychomycosis, topical creams generally do not penetrate the nail plate effectively. Hygiene advice and avoiding pools/hot tubs may reduce superficial fungal exposure but does not address the principal driver in this scenario. Biopsy is unnecessary for typical trauma-related nail changes in a low-risk patient without concerning features (rapid growth, pigment extending onto adjacent skin, or mass).
NEW QUESTION # 324
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