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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Scholar
|
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42. Frage
A mother brings her 10-year-old son for his well-child check-up. She mentions that her 38-year-old husband has just had a heart attack due to high cholesterol levels and wants information regarding prevention of cardiovascular disease for her son. Which one of the following is the best approach to managing this problem?
Antwort: A
Begründung:
Children with a first-degree relative who has premature coronary artery disease or hypercholesterolemia should undergo fasting lipid screening between ages 2-10. Since the child is 10, screening is indicated.
Toronto Notes 2023 - Pediatrics, "Preventive Care in Children":
"Lipid screening is recommended for children #2 years old with a family history of early cardiovascular disease or hypercholesterolemia." MCCQE1 Objectives (Pediatrics > 78-1: Preventive Medicine):
"Candidates must screen children at high risk of cardiovascular disease appropriately, including lipid profile for familial hyperlipidemia." Diet and exercise counseling may follow screening, but testing is the first step. Reassurance alone (C) is inappropriate. Homocysteine (E) and HbA1c are not first-line tests in this setting.
43. Frage
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?
Antwort: C
44. Frage
A 50-year-old man with prostate cancer, which is complicated by bony and cerebral metastases, presents to your office. He has a 24-hour history of increasing lower back pain and weakness in his legs. On examination, you note decreased knee and ankle reflexes on both sides. Earlier today he had fecal incontinence. Which one of the following is the best next step?
Antwort: C
Begründung:
This patient with known metastatic prostate cancer presents with acute back pain, bilateral lower limb weakness, decreased reflexes, and new fecal incontinence-classic red flags for malignant spinal cord compression . MCCQE objectives emphasize that this is an oncologic emergency requiring immediate intervention to prevent irreversible neurologic damage.
The first step is prompt administration of high-dose parenteral corticosteroids (e.g., dexamethasone) to reduce vasogenic edema around the spinal cord and preserve neurologic function. Steroids should be given immediately upon suspicion, even before confirmatory imaging. Urgent MRI of the spine and consultation with oncology, radiation oncology, and/or neurosurgery follow for definitive management (radiotherapy or surgical decompression depending on stability and prognosis).
Bed rest and analgesia alone are inadequate. A stellate ganglion block is unrelated. Although radiotherapy or surgery will likely be required, steroids must be administered first without delay. Early treatment significantly improves the likelihood of maintaining ambulation and continence.
45. Frage
A 78-year-old man, who is accompanied by his eldest son, presents for follow-up of his chronic kidney disease and neurocognitive disorder due to vascular disease. He is married and has 4 children. His creatinine clearance has slowly deteriorated over the last few years and has reached the stage where you are considering starting renal replacement therapy. After your discussion, it is clear that the patient, his son, and his wife want to start dialysis. Based on your assessment, it is clear that he does not understand the information you have relayed to him. You inform the patient that you believe he is incapable of making this decision and he agrees.
His son would prefer not to start dialysis as he is concerned about the impact this would have on his father's quality of life. Which one of the following is the best next step?
Antwort: B
Begründung:
This patient has been assessed as incapable of making the decision regarding dialysis. MCCQE ELOM objectives emphasize that when a patient lacks decision-making capacity, treatment decisions must be made by a legally authorized substitute decision-maker (SDM) according to provincial/territorial hierarchy. The appropriate next step is to determine whether a formal SDM has been appointed (e.g., power of attorney for personal care) or identify the legally ranked default SDM.
Although the wife may often be the default SDM, this depends on jurisdiction and whether a formal representative has been designated. It is inappropriate to automatically follow the son's wishes, as he may not be the legal SDM. Nor should the physician impose their own recommendation without engaging the proper decision-making process. A large family meeting may be helpful later but does not replace identifying the legally authorized decision-maker.
Once identified, the SDM must make decisions based on the patient's prior capable wishes or, if unknown, the patient's best interests. Properly establishing the SDM ensures ethical and legal compliance in incapacity situations.
46. Frage
A mother brings her 13-year-old daughter to the office. The girl has had intermittent lower abdominal pain, constipation, and difficulty voiding for 3 months. She says that she is not sexually active. She looks well. She has reached age-specific developmental milestones, and her vital signs are within normal range. On abdominal examination, she is found to have a palpable suprapubic mass that persists after voiding. The girl says that her older sister started having menstrual periods at this age. The patient is surprised that hers have not started. Which one of the following is the best next step?
Antwort: C
Begründung:
The clinical picture suggests an obstructive anomaly of the female reproductive tract, such as imperforate hymen or vaginal outflow tract obstruction, leading to hematocolpos. The first essential step is physical examination of the external genitalia.
Toronto Notes 2023 - Pediatrics and Gynecology, "Amenorrhea" Section:
"In girls with primary amenorrhea and cyclic abdominal pain, perform an external genital exam to rule out obstructive anomalies (e.g., imperforate hymen or transverse vaginal septum). Examination should always precede imaging." MCCQE1 Objectives (Pediatrics > 78-3: Puberty and Menstrual Disorders):
"Candidates must evaluate delayed menarche with physical exam, including inspection of the genitalia to rule out anatomic obstruction." Pelvic ultrasound (D) is helpful but should follow physical exam. Radiography (B), hCG (C), and urinalysis (E) are not primary steps in evaluating amenorrhea with a mass.
47. Frage
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