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| Section | Objectives |
|---|---|
| Dimensions of Care | - Health Promotion and Illness Prevention
|
| Physician Activities | - Communication
|
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NEW QUESTION # 194
A 22-year-old woman is brought to the Emergency Department by her boyfriend, who says that she is experiencing a fentanyl overdose. She is unresponsive and cyanotic. She regains consciousness after naloxone is injected intravenously and demonstrates no further respiratory depression during 8 hours of observation.
She states that she is 22 weeks' pregnant and wants to stop using opioids. Which one of the following is the best next step?
Answer: A
Explanation:
For pregnant patients with opioid use disorder, opioid agonist therapy with methadone or buprenorphine is the standard of care. Detoxification is not recommended in pregnancy due to increased risk of fetal distress, preterm labor, and relapse. Methadone reduces illicit opioid use and stabilizes both mother and fetus.
Toronto Notes 2023 - Addiction Medicine / Obstetrics:
"Methadone maintenance therapy is the treatment of choice for pregnant patients with opioid use disorder.
Detoxification is not advised during pregnancy due to relapse risk and potential harm to the fetus." MCCQE1 Objectives (Obstetrics > 80-3: Substance Use in Pregnancy):
"Candidates must manage opioid use disorder in pregnancy with evidence-based therapies, including referral for methadone or buprenorphine." Counselling alone (D) is insufficient as first-line therapy. Home detox (C) is unsafe. Inpatient detox (A) is not recommended in pregnancy.
NEW QUESTION # 195
A 62-year-old woman is taken to the operating room for an elective laparoscopic cholecystectomy. Induction of anesthesia triggers a severe hypertensive crisis that ultimately resolves after administration of a 5 mg bolus of phentolamine.
Which one of the following is most consistent with this presentation?
Answer: A
Explanation:
This presentation is classic for an undiagnosed pheochromocytoma, which causes episodic or crisis-level hypertension due to excess catecholamines. Anesthesia or surgical manipulation can trigger massive catecholamine release, leading to hypertensive crisis. Phentolamine, an alpha-blocker, is the appropriate treatment.
Toronto Notes 2023 - Endocrinology, Pheochromocytoma:
"Pheochromocytomas may precipitate hypertensive crises during surgery. Elevated plasma catecholamines and urinary metanephrines confirm diagnosis." MCCQE1 Objectives - Internal Medicine > Endocrinology:
"Candidates should suspect pheochromocytoma in perioperative hypertensive crises and confirm with plasma or urine catecholamines/metanephrines." Low metanephrines (E) would argue against pheochromocytoma. TSH (A), cortisol (D), and renin (C) are unrelated to acute intraoperative hypertensive episodes of this nature.
NEW QUESTION # 196
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: D
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 # 197
When updating the firmware on an NVLink switch transceiver, how can an engineer apply new firmware without interrupting the network?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
NVIDIA's LinkX optical transceivers and active copper cables often require firmware updates to ensure compatibility and performance optimizations. In a production DGX SuperPOD environment, interrupting the NVLink fabric can cause GPU-to-GPU communication failures and crash training jobs. To mitigate this, NVIDIA utilizes the `flint` utility (part of MFT) with specific flags for " Live " or " Seamless " updates. The
`--linkx` flag targets the transceiver or cable specifically, rather than the switch ASIC itself. The `-- linkx_auto_update` flag automates the sequence, while the `--activate` flag ensures the new firmware is applied to the module ' s active memory without requiring a full system reboot or a manual flap of the network link. This " in-service " update capability is essential for large-scale AI clusters where uptime is measured in weeks or months of continuous training. By using the `-lid` (Logical Identifier) target, an administrator can address specific modules across the fabric from a central management node, ensuring that the high-bandwidth NVLink mesh remains stable while maintaining the latest hardware optimizations.
NEW QUESTION # 198
A 62-year-old man, who has not seen a physician in 20 years, presents to your clinic with a burning sensation in his feet. The symptoms have been progressing slowly over the last 6 months. There is no associated motor weakness or skin changes. He reports no significant past medical history and takes no medications. His alcohol intake is minimal. On examination, he has reduced pinprick/vibration sensation and proprioception in the ankles with absent ankle reflexes. Which one of the following blood tests would you expect to be abnormal?
Answer: C
Explanation:
This is a classic presentation of diabetic peripheral neuropathy: bilateral distal sensory symptoms with preserved motor function and no other systemic findings. The most useful test to confirm this in a previously undiagnosed patient is HbA1c.
Toronto Notes 2023 - Endocrinology, Diabetes Complications:
"Peripheral neuropathy is a common complication of undiagnosed or poorly controlled diabetes. Confirm with HbA1c if diagnosis is not yet established." MCCQE1 Objectives - Internal Medicine > Endocrinology:
"Candidates should evaluate for diabetes in patients with peripheral neuropathy and screen appropriately with HbA1c." Folate (B) and B12 deficiency may also cause neuropathy but are less likely in the absence of nutritional risk factors. Other choices (A, D, E) are unrelated to this pattern.
NEW QUESTION # 199
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