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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Leader (Manager)
|
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質問 # 237
A 15-year-old boy is brought to the office by his father because he is having headaches. When alone, the boy appears withdrawn and admits to suicidal ideation. He shares that he is gay but does not want to tell his parents. He says that he faked the headaches so that one of his parents would make an appointment for him.
Which one of the following is the best next step?
正解：A
解説：
The presence of suicidal ideation in a minor mandates urgent assessment to ensure safety and access mental health care. Disclosure of sexual orientation should be handled delicately and is not urgent compared to suicidal risk.
Toronto Notes 2023 - Psychiatry, "Child and Adolescent Psychiatry" Section:
"Any adolescent disclosing suicidal ideation should be referred for urgent mental health evaluation.
Concurrent issues such as sexual orientation may contribute to distress and should be addressed with appropriate support over time." MCCQE1 Objectives (Psychiatry > 79-2: Suicide Risk Assessment):
"Candidates must immediately refer for psychiatric assessment when a minor reports suicidal ideation, regardless of other social or developmental concerns." Antidepressants (A) may be appropriate but must follow specialist evaluation. Encouraging disclosure (B) or peer groups (C) is premature without ensuring safety.
質問 # 238
A 38-year-old man presents to the office for a follow-up visit. For several years, he has been having constant abdominal pain and intermittent constipation. He struggles to fall asleep because he is worried about his symptoms, and he often spends hours researching possible investigations and causes. Although he recently had extensive investigations, which have all had normal results, he continues to visit multiple physicians hoping for more investigations. He worries that he will die because no one is taking him seriously. Which one of the following is the best next step?
正解：A
解説：
This presentation is most consistent with somatic symptom disorder/illness anxiety : persistent distressing physical symptoms (abdominal pain/constipation) with excessive health-related anxiety, repeated reassurance- seeking, and "doctor shopping" despite normal investigations. MCCQE objectives emphasize avoiding iatrogenic harm from repeated testing and using a structured, therapeutic relationship to manage medically unexplained or disproportionate symptom concerns. The best next step is regularly scheduled follow-up visits with one consistent physician (e.g., monthly), focused on validating symptoms, addressing fears, monitoring for new objective findings, and gradually shifting toward coping strategies and functional goals. This approach reduces unnecessary investigations, reinforces continuity, and helps interrupt the cycle of anxiety- driven health-care utilization.
Repeating investigations (B) perpetuates reassurance-seeking and increases false positives and harm.
Consulting additional specialists (A) without new red flags similarly reinforces maladaptive beliefs and fragmentation of care. Exercise (D) may be beneficial as an adjunct but is not the core management strategy.
Therefore, planned, regular appointments are the most appropriate next step.
質問 # 239
A 76-year-old man is brought to the emergency department in an unresponsive state. He has a history of chronic kidney disease with a baseline serum creatinine level of 300 µmol/L (49-93) and a history of dilated cardiomyopathy with an ejection fraction of 30%. On assessment, he has no pulse or blood pressure. Cardiac monitor demonstrates a wide complex tachycardia. Which one of the following recently started medications is the most likely cause of this arrhythmia?
正解：A
解説：
Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, especially in patients with impaired renal function. Hyperkalemia can lead to life-threatening arrhythmias, particularly wide complex tachycardia or ventricular fibrillation.
Toronto Notes 2023 - Cardiology and Nephrology, "Hyperkalemia" Section:
"Patients with CKD are at increased risk for hyperkalemia, particularly when taking potassium-sparing medications such as spironolactone. Severe hyperkalemia may cause bradycardia or wide-complex tachyarrhythmias." MCCQE1 Objectives (Internal Medicine > 76-2: Electrolyte Abnormalities):
"Candidates must recognize drug-induced hyperkalemia as a cause of cardiac arrhythmias, especially in patients with renal dysfunction." Hydrochlorothiazide (B) can cause hypokalemia. Metoprolol (C) and diltiazem (E) are rate-controlling agents but do not typically cause wide complex tachycardia. Clopidogrel (D) has no effect on cardiac conduction.
質問 # 240
A 23-year-old woman with borderline personality disorder is brought to the Emergency Department having ingested non-lethal substances after her boyfriend broke up with her. The staff tells you that she has consulted
8 times under similar circumstances in the past 3 years. Which one of the following pieces of information would be useful to provide to the staff?
正解：C
解説：
Comprehensive and Detailed Explanation:
While borderline personality disorder is challenging, symptoms (particularly impulsivity and suicidal behaviors) often attenuate with age and appropriate therapy (e.g., dialectical behavior therapy). Providing hope and clinical context to staff improves care and reduces stigma.
Toronto Notes 2023 - Psychiatry, "Personality Disorders":
"BPD is associated with emotional dysregulation and impulsivity. Long-term prognosis is better than once believed, with many patients showing symptom remission over time." MCCQE1 Objectives (Psychiatry > 71-4: Personality Disorders):
"Candidates must provide appropriate education to patients and staff regarding prognosis and treatment of BPD." Statements A-D are false, stigmatizing, or dangerous.
質問 # 241
A 47-year-old man presents to the office with a 1-month history of passing blood in his stool 2 to 3 times per week. He is otherwise healthy and denies any systemic symptoms. Other than a small lateral skin tag on digital rectal examination, the physical examination findings are unremarkable. Which one of the following is the best next step?
正解：E
解説：
Visible rectal bleeding, even in the absence of systemic symptoms, warrants diagnostic colonoscopy to rule out colorectal cancer, polyps, or IBD-especially in adults over 40. FIT is for asymptomatic screening only.
Toronto Notes 2023 - Gastroenterology, "Approach to Lower GI Bleeding":
"In patients with overt rectal bleeding, colonoscopy is the investigation of choice regardless of age or FIT status." MCCQE1 Objectives (Internal Medicine > Gastroenterology > 47-1):
"Candidates must evaluate rectal bleeding with colonoscopy, even in the presence of minor findings on physical exam (e.g., skin tag)." FIT (A) is not appropriate for symptomatic patients. CEA (D) is a tumor marker for surveillance, not diagnosis. CT colonography (C) is less sensitive for lesions than colonoscopy.
質問 # 242
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