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| Section | Weight | Objectives |
|---|---|---|
| Dimensions of Care | 50% | - Assessment and Diagnosis - Health Promotion and Illness Prevention - Acute Care - Chronic Care |
| Physician Activities | 50% | - Management - Professional Behaviours - Communication - Psychosocial Aspects |
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NEW QUESTION # 186
A 45-year-old woman presents to the emergency department after being involved in a motor vehicle collision.
She reports severe right hip pain. On examination, the right hip is flexed and adducted. A radiograph shows a posterior dislocation. Which one of the following is the most appropriate management?
Answer: B
Explanation:
A posterior hip dislocation is an orthopedic emergency . The classic position is a shortened limb held in flexion, adduction, and internal rotation after high-energy trauma. MCCQE objectives emphasize immediate recognition and urgent management to prevent complications, especially avascular necrosis (AVN) of the femoral head and sciatic nerve injury . The key treatment is prompt closed reduction (ideally within hours) under procedural sedation or anesthesia, after appropriate analgesia and neurovascular assessment. Post- reduction priorities include confirming concentric reduction with imaging, repeating a neurovascular exam (particularly sciatic nerve function), and evaluating for associated fractures (acetabular or femoral head/neck) that may require CT and possible operative management.
Open reduction is reserved for irreducible dislocations, incarcerated fragments, or associated fractures preventing stable closed reduction. Skeletal traction is not definitive acute management. Total hip arthroplasty is not indicated as first-line in an acute traumatic dislocation in this context. Urgent closed reduction best aligns with time-sensitive limb- and joint-preserving care.
NEW QUESTION # 187
A prepubertal 9-year-old girl with severe developmental disability is brought to your office by her parents.
They are seeing you to discuss some difficulties that might occur with puberty. They are afraid that menses will complicate hygiene care and they have heard of significant mood/behavioural changes in this population when menses occur. Which one of the following recommendations is the most appropriate?
Answer: A
Explanation:
In girls with developmental disabilities, menstrual management should follow the same ethical and clinical principles as for other adolescents, emphasizing least invasive, reversible options and respect for future autonomy. Menstrual suppression may be appropriate to assist with hygiene and quality of life; however, hormonal methods are generally initiated after the onset of menarche to confirm pubertal development and exclude underlying endocrine disorders. Therefore, extended progestin-only therapy (e.g., depot medroxyprogesterone acetate) should not be started before menses begin. Hysterectomy is inappropriate as first-line management due to its irreversible nature, surgical risks, and significant ethical concerns regarding sterilization. Continuous combined oral contraceptives are not contraindicated and are commonly used for therapeutic amenorrhea. Evidence does not show consistent worsening of behavioural symptoms with appropriate hormonal suppression. Girls with developmental disabilities typically experience normal pubertal progression. MCCQE objectives emphasize patient-centered care, least restrictive interventions, ethical considerations in consent and capacity, and appropriate menstrual management strategies in adolescents with special needs.
NEW QUESTION # 188
An 84-year-old woman is brought by ambulance to the emergency department after she was found by a neighbour. She had fallen, sustained a hip fracture, and was unable to move for the past 2 days. After starting rehydration, she reports hip pain and numbness and tingling in both her legs. Physical examination reveals faint pulses in both legs and severely swollen lower legs that are painful to palpation. The urine in the Foley catheter bag seems to be darker than normal. Which one of the following is the best next step?
Answer: C
Explanation:
This patient presents with signs of acute compartment syndrome (pain out of proportion, paresthesia, pallor, swelling, decreased pulses, and dark urine indicating rhabdomyolysis). Measuring compartment pressures is the diagnostic test of choice to confirm the diagnosis and guide urgent surgical fasciotomy.
Toronto Notes 2023 - Orthopedics:
"Acute compartment syndrome should be suspected in any patient with severe extremity pain, swelling, sensory deficits, and tense compartments. Confirm with compartment pressure measurements. Fasciotomy is indicated if pressure is >30 mmHg or within 30 mmHg of diastolic pressure." MCCQE1 Objectives (Surgery > 51-2: Limb Trauma):
"Candidates must diagnose acute compartment syndrome and initiate appropriate surgical referral after confirming with pressure measurements." Angiography and Doppler studies assess vascular compromise but are not the first step in suspected compartment syndrome. Fixing the hip (C) and testing myoglobin (E) are not diagnostic steps.
NEW QUESTION # 189
A 79-year-old woman is brought by a long-term care (LTC) facility staff member to your clinic with concerning behaviours. On history, she was admitted to an LTC facility 6 months ago with vascular dementia.
Three days ago, she became very aggressive towards her caregivers. There is no clear pattern to her aggression. Some staff members report that she is quieter than usual, whereas others report that she is agitated, talks to herself, and picks at her clothes. On examination, she appears very confused. She does not finish her answers and seems to "drift off" during conversation. Which one of the following is the most likely diagnosis?
Answer: E
Explanation:
Delirium is the most likely diagnosis because the change is acute (3 days) with fluctuating level of activity (quiet at times, agitated at others) and prominent inattention (does not finish answers, "drifts off" during conversation). MCCQE objectives emphasize distinguishing delirium from dementia: dementia is typically chronic and progressive , whereas delirium is a sudden, reversible syndrome characterized by disturbed attention and awareness, often with altered sleep-wake cycle, perceptual disturbances, and psychomotor changes (hyperactive, hypoactive, or mixed). This patient's new aggression, confusion, and variable behavior strongly suggest delirium superimposed on existing vascular dementia-a common and high-risk scenario in LTC residents. Major depressive disorder can cause apathy and reduced concentration but does not typically cause a fluctuating course with acute confusion. Lewy body dementia is associated with chronic cognitive fluctuations and visual hallucinations/parkinsonism, not a sudden 3-day deterioration. Late-onset delusional disorder would feature fixed delusions with otherwise clearer consciousness. The next clinical priority is to search for and treat underlying causes (infection, medications, metabolic disturbance, pain, dehydration) while ensuring safety and supportive care.
NEW QUESTION # 190
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: C
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 # 191
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