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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Leader (Manager)
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NEW QUESTION # 303
A 24-year-old man is brought to the Emergency Department by ambulance with a severe pelvic fracture from a motor vehicle collision. After resuscitation and stabilization, he is noted to have a bloody penile discharge.
Which one of the following is the best next step?
Answer: E
Explanation:
In a patient with a pelvic fracture and blood at the urethral meatus, urethral injury must be strongly suspected.
Other signs may include perineal hematoma, high-riding prostate, or inability to void. The key principle is do not insert a Foley catheter until urethral integrity is confirmed, as blind catheterization may worsen a partial tear into a complete disruption. The appropriate next diagnostic step is retrograde urethrography (RUG), which evaluates the urethra for extravasation of contrast and identifies the site and extent of injury.
Voiding cystography evaluates bladder injury and is performed after urethral integrity is confirmed or via suprapubic access. Transrectal ultrasound and penile sonography are not appropriate in acute trauma assessment of suspected urethral disruption. Continuous bladder irrigation is contraindicated until urethral injury is excluded.
MCCQE objectives emphasize recognition of urethral injury in pelvic trauma and adherence to trauma principles: stabilize first, suspect urethral injury when blood is present at the meatus, and perform retrograde urethrography prior to catheterization.
NEW QUESTION # 304
A 54-year-old man presents to the office because of progressively severe frontal headaches that are worse in the morning. He also has a chronic productive cough. He has a 30 pack-year history of smoking tobacco cigarettes. His blood pressure is 160/95 mm Hg. Which one of the following is the best next step?
Answer: D
Explanation:
This presentation has "red flags" for raised intracranial pressure: headaches that are progressive, worse in the morning, and worsened by coughing/valsalva. In MCCQE objectives, these features require urgent evaluation for secondary causes (e.g., intracranial mass, hemorrhage, obstructive hydrocephalus) rather than empiric treatment for primary headache. His chronic cough and heavy smoking increase concern for an underlying malignancy with possible brain metastasis or paraneoplastic processes, further strengthening the indication for neuroimaging. Therefore, the best next step is CT head (often the fastest initial test to identify mass effect, hemorrhage, or hydrocephalus; MRI may follow depending on findings).
Treating presumed migraine with a triptan is inappropriate when secondary headache is possible and could also pose vascular risk. His blood pressure is elevated but not in a hypertensive emergency and does not explain these classic intracranial pressure features; serial BP monitoring or starting antihypertensives should not delay imaging. Temporal arteritis is less likely without temporal tenderness, jaw claudication, visual symptoms, or systemic inflammatory clues.
NEW QUESTION # 305
A 78-year-old woman is brought to the Emergency Department by her son because she has a sodium level of
124 mmol/L (136-146). The sodium was checked as part of a blood work panel ordered by her primary health care provider to investigate symptoms of urinary frequency, fatigue, and thirst. Today, she has a blood glucose level of 44.0 mmol/L (4.0-11.0). The original blood work done by her primary health care provider did not include glucose. The patient is treated for hyperglycemia and dehydration and begins insulin. The patient and her son repeatedly express their frustration that their primary health care provider missed the diagnosis. Which one of the following is the best next step?
Answer: A
Explanation:
In situations involving potential oversight, the appropriate next step is to contact the other physician directly.
This supports collegial communication, continuity of care, and provides an opportunity to clarify the clinical situation. It avoids premature judgment while allowing the primary provider to respond and address concerns.
Toronto Notes 2023 - ELOM, "Professionalism and Interprofessional Communication":
"When concerns arise about another provider's care, direct communication is preferred before considering formal reporting. This maintains collaboration and fairness." MCCQE1 Objectives (ELOM > 90-2: Communication and Accountability):
"Candidates must demonstrate collegiality and appropriate methods for addressing concerns regarding another physician's care." Empathizing (D) and validating blame is unprofessional. Reporting (B) is premature. Offering another provider (C) could undermine continuity. (E) is incorrect since the glucose should have been checked based on the presenting symptoms.
NEW QUESTION # 306
A 31-year-old woman, gravida 4, para 3, aborta 0, presents at 8 weeks' gestation with scant vaginal bleeding and no abdominal pain. Her heart rate is 90/min and blood pressure is 100/70 mm Hg. A speculum examination reveals a closed cervix. The beta-human chorionic gonadotropin level is 300,000 IU/L. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
A molar pregnancy (gestational trophoblastic disease) is the most likely diagnosis because the #-hCG level is markedly elevated (300,000 IU/L) for an 8-week gestation, far exceeding typical levels for a normal intrauterine pregnancy. MCCQE objectives highlight that unusually high #-hCG-often accompanied by first- trimester bleeding-should raise strong suspicion for a hydatidiform mole. Bleeding is common due to abnormal trophoblastic proliferation and placental separation. A closed cervix does not exclude a molar pregnancy; it simply indicates that products of conception are not being expelled at the time of exam.
Ectopic (tubal) pregnancy more often presents with abdominal/pelvic pain and typically has lower or inappropriately rising #-hCG. Incomplete abortion usually features heavier bleeding, cramping, and an open cervix. Threatened abortion involves bleeding with a closed cervix but does not explain an extremely high #- hCG. Implantation bleeding occurs earlier (around the time of missed menses), not at 8 weeks, and would not be associated with very high #-hCG.
NEW QUESTION # 307
A 30-year-old man comes to the office and asks you to write him a note for his employer that recommends a stress leave. He says he feels entitled to a rest. He comes across as irritable and impulsive. He appears to show little regard for the law and admits to recently embezzling $5,000 from his employer. He justifies his actions and shows no remorse. He has a history of attention-deficit/hyperactivity disorder as a child. Which one of the following is the most likely diagnosis?
Answer: D
NEW QUESTION # 308
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