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| Section | Weight | Objectives |
|---|---|---|
| Dimensions of Care | 50% | - Health Promotion and Illness Prevention - Chronic Care - Assessment and Diagnosis - Acute Care |
| Physician Activities | 50% | - Psychosocial Aspects - Communication - Management - Professional Behaviours |
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NEW QUESTION # 336
A 71-year-old man with stable chronic low back pain on hydromorphone (8 mg twice daily) presents upset, requesting an early refill. He reports his granddaughter has been stealing his medication and pressuring him for refills. Which one of the following is the best next step?
Answer: B
Explanation:
This case suggests diversion of prescription opioids, a serious safety and regulatory concern. The physician must balance maintaining patient care with minimizing risk. Daily dispensing via a monitored pharmacy is the safest and most practical solution to prevent misuse or theft, while avoiding immediate discontinuation of the patient's needed medication.
Toronto Notes 2023 - Chronic Pain & Substance Use:
"In cases of concern for opioid diversion, consider witnessed daily dispensing, prescription monitoring, and involving caregivers when appropriate." MCCQE1 Objectives (Internal Medicine > Pain Management > 56-2):
"The candidate must demonstrate understanding of strategies for safe prescribing and monitoring of controlled substances, including mitigation of diversion." Calling the police (A) is not the physician's immediate duty. Providing an early refill (B) worsens risk.
Tapering (C) may be appropriate later, but first the medication must be safeguarded. Increasing quantity (D) is inappropriate.
NEW QUESTION # 337
A 67-year-old woman presents with headaches, muscle weakness, pain in her shoulders and hips, weight loss, and depression. While also arranging appropriate investigations to confirm a diagnosis, which one of the following is the most important objective of treatment?
Answer: A
Explanation:
This clinical picture suggests giant cell arteritis (GCA) associated with polymyalgia rheumatica: new-onset headache in an older patient, proximal muscle pain and stiffness (shoulders and hips), systemic symptoms (weight loss), and mood changes. MCCQE objectives emphasize that GCA is a medical emergency because inflammation of the temporal and other cranial arteries can lead to irreversible vision loss due to ischemic optic neuropathy.
The most important objective of treatment is prevention of blindness , which requires prompt initiation of high-dose corticosteroids-often before confirmatory temporal artery biopsy-to reduce arterial inflammation and prevent vascular occlusion. While improving musculoskeletal pain and headache are important symptomatic goals, they are secondary to preventing permanent complications. Jaw claudication is a symptom of arterial insufficiency but not itself the primary outcome to prevent.
Early recognition and immediate corticosteroid therapy significantly reduce the risk of bilateral, permanent visual loss. Therefore, prevention of blindness is the most critical treatment objective.
NEW QUESTION # 338
A 55-year-old man presents to the Emergency Department with intractable nausea and vomiting. He is diaphoretic, tremulous and tachycardic. In a private conversation with his spouse, you learn that for the last several weeks, he has been drinking 1.2 L of vodka daily. On questioning, he says that since he retired, he has been drinking socially and plans to continue doing so. With respect to his alcohol use, which one of the following best describes the patient's current stage of change?
Answer: E
Explanation:
This patient is in the precontemplation stage because he does not recognize his alcohol use as a problem and has no intention to change his drinking behavior. Despite evidence of harm-heavy daily intake (1.2 L vodka
/day) and current symptoms compatible with alcohol withdrawal/autonomic hyperactivity (tremor, diaphoresis, tachycardia, nausea/vomiting)-he frames his drinking as "social" and explicitly states he plans to continue. In the transtheoretical model, precontemplation describes individuals who are unaware, unwilling, or resistant to change within the foreseeable future. Contemplation would involve ambivalence and acknowledgement of a potential problem; preparation includes intention and planning to change soon; action involves active behavior change; maintenance refers to sustaining change over time. MCCQE objectives emphasize identifying readiness to change to guide counseling: in precontemplation, the clinician focuses on building rapport, providing clear, nonjudgmental feedback about risks, exploring discrepancies between goals and behavior, and using motivational interviewing to enhance insight rather than pushing immediate abstinence plans.
NEW QUESTION # 339
A 91-year-old man comes to the Emergency Department reporting blood in his stools, which has now resolved. He is able to give a history and mentions that this also happened 2 years ago. At that time, a colonoscopy was done and revealed diverticular disease as the cause. Which one of the following is the best next step?
Answer: C
Explanation:
In a patient with known diverticular bleeding and no red flags (e.g., weight loss, anemia, family history), repeating colonoscopy is not required. Diverticular bleeding is typically self-limited. Colonoscopy within the past few years with clear findings suffices.
Toronto Notes 2023 - Gastroenterology, Lower GI Bleed:
"Patients with known diverticulosis and self-limited bleeding who have had prior complete colonoscopy do not require repeat endoscopy unless symptoms recur or persist." MCCQE1 Objectives - Internal Medicine > Gastroenterology:
"Candidates must recognize when no further invasive investigation is necessary in elderly patients with known benign findings and resolved symptoms." Option E is considerate but not clinically necessary for independent patients. Options A, B, and D are not indicated in resolved, low-risk cases.
NEW QUESTION # 340
A 72-year-old woman presents with swelling of her right leg that developed overnight. She had an abdominal hysterectomy 10 days ago. On examination, there is pitting edema of the leg that extends from the foot to the groin. The calf is 3 cm larger in diameter than the calf on the left leg. Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
This patient has classic features of proximal deep vein thrombosis (DVT) after recent major pelvic surgery:
acute unilateral leg swelling with pitting edema and a significant calf circumference difference ( > 3 cm). The edema extending from foot to groin strongly suggests a proximal (iliofemoral) thrombosis, which produces more extensive swelling than calf-vein DVT because venous outflow from the entire limb is impaired.
MCCQE objectives highlight postoperative patients as high risk for venous thromboembolism due to immobility, endothelial injury, and hypercoagulability.
Superficial thrombophlebitis typically causes a localized, tender, palpable cord along a superficial vein rather than diffuse whole-leg edema. Phlegmasia cerulea dolens is a severe, limb-threatening form of massive DVT characterized by marked pain, tense
NEW QUESTION # 341
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