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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Professional
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NEW QUESTION # 79
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: D
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 # 80
A 3.5-year-old girl has developed a stutter in the last 3 months. She repeats whole words several times before finishing a sentence. Her paternal uncle had a severe stuttering issue as a child. She has reached the developmental milestones for her age. Her new sibling was born 4 months ago. Which one of the following is the best next step?
Answer: E
Explanation:
This presentation describesnormal developmental dysfluency, which typically occurs between ages 2-5 and often worsens duringtimes of stress or change, such as a new sibling. It is characterized byword repetition and does not require intervention unless it persists >6 months, worsens, or causes distress.
Toronto Notes 2023 - Pediatrics, "Developmental and Behavioral Pediatrics" Section:
"Developmental stuttering is common between 2-5 years and often resolves without intervention.
Reassurance is appropriate unless there are signs of persistent or severe stuttering, secondary behaviors, or parental concern." MCCQE1 Objectives (Pediatrics > 78-1: Development and Behavior):
"Candidates must recognize typical patterns of developmental speech dysfluency and differentiate them from pathological speech disorders. Observation and reassurance are often the appropriate initial step." Because the child is otherwise developing normally and the onset coincides with a known psychosocial stressor,reassuranceis the most appropriate step. Formal speech or behavioral therapy is not indicated at this time.
NEW QUESTION # 81
A 31-year-old man presents with nocturnal non-exertional chest pain. During an exercise stress test, he does not experience chest pain, and there are no significant ST segment changes on the electrocardiogram. He achieves 17 metabolic equivalent of task (MET), a blood pressure of 190/96 mm Hg (resting blood pressure of
130/80 mm Hg), and a maximum heart rate of 162/min (85% of age-predicted maximum). Which one of the following is the most appropriate next step?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
This patient demonstrates excellent exercise tolerance (17 METs) and no ischemic changes or exertional symptoms, which makes cardiac ischemia unlikely. However, the hypertensive response to exercise (BP >190 systolic) indicates masked or latent hypertension. This should be managed proactively, typically starting with a thiazide.
Toronto Notes 2023 - Cardiology:
"An exaggerated hypertensive response during exercise is predictive of future hypertension. Treatment with antihypertensive agents such as thiazides may be warranted." MCCQE1 Objectives (Internal Medicine > 31-1: Hypertension and Risk Management):
"Candidates must identify abnormal BP responses to exercise and initiate appropriate treatment." Reassurance alone (A) ignores the hypertensive response. Catheterization (C) and beta-blockers (D) are unnecessary without ischemia. Advising against exercise (B) is counterproductive in a young, otherwise healthy patient.
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NEW QUESTION # 82
A 72-year-old man reports that his wife says he has hearing trouble. Examination reveals that air conduction on the right side is less than on the left side and greater than bone conduction bilaterally. He hears a tuning fork placed on the top of his head better with his left ear. Which one of the following is the most appropriate next step in management?
Answer: B
Explanation:
The patient demonstrates signs of asymmetric sensorineural hearing loss (SNHL). In Weber test, sound localizes to the better ear in SNHL. Air conduction > bone conduction on Rinne test bilaterally supports SNHL. Audiometry is the best next diagnostic step to quantify and characterize the hearing loss.
Toronto Notes 2023 - ENT, "Hearing Loss":
"Audiometry is the first-line investigation to distinguish conductive from sensorineural hearing loss and to assess severity and frequency involvement." MCCQE1 Objectives (Medicine > ENT > 20-1):
"Candidates must know the approach to hearing loss and interpret Weber and Rinne tests to guide investigations such as audiometry." Imaging (A, C) is reserved for red flags such as unilateral persistent SNHL, which may later prompt MRI to rule out acoustic neuroma. Wax removal (D) is for conductive loss. Hearing aids (E) are management, not diagnostic, and come after audiologic evaluation.
NEW QUESTION # 83
A 25-year-old woman, gravida 1, para 1, aborta 0, gave birth to a newborn who is hypotonic with a large protruding tongue and brachycephaly. The newborn has a single palmar crease bilaterally and short, broad hands with a curved fifth digit. These features best support a clinical diagnosis of which one of the following?
Answer: C
Explanation:
This constellation of features-hypotonia, macroglossia, brachycephaly, single palmar crease, short broad hands with clinodactyly-is classic for Down syndrome (Trisomy 21).
Toronto Notes 2023 - Pediatrics, "Genetic Syndromes":
"Trisomy 21 features include hypotonia, upslanting palpebral fissures, epicanthic folds, flat nasal bridge, brachycephaly, macroglossia, single palmar crease, and clinodactyly." MCCQE1 Objectives (Pediatrics > 78-3: Congenital and Genetic Disorders):
"Candidates must recognize key dysmorphic features associated with common genetic syndromes including Trisomy 21." Prader-Willi and congenital hypothyroidism may have hypotonia but lack the full phenotypic pattern. Turner syndrome is seen in females with short stature and webbed neck. Fetal alcohol syndrome presents with smooth philtrum and microcephaly.
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NEW QUESTION # 84
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