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| Section | Objectives |
|---|---|
| Topic 1: Physician Activities | - Assessment
|
| Topic 2: Dimensions of Care | - Chronic Care
|
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NEW QUESTION # 259
A 63-year-old man is brought to the Emergency Department by ambulance after he injured his abdomen.
While working on a house, he fell 1 m from a scaffold and landed on a metal pipe. He is clinically stable but reports localized abdominal pain. On examination, he has a 17-cm laceration to his abdomen in the left hypochondrium. The laceration is 4 cm deep, but there is no fascial laceration. Which one of the following is the best next step?
Answer: B
Explanation:
This patient has a traumatic abdominal wall laceration but is hemodynamically stable , and importantly, there is no fascial violation . MCCQE objectives emphasize that the key determinant in abdominal trauma is whether the peritoneum/fascia has been breached , as this determines the risk of intra-abdominal injury. In the absence of fascial penetration and with stable vital signs, the injury is limited to the soft tissues of the abdominal wall.
Therefore, the appropriate management is local wound care and primary repair after adequate irrigation and assessment. Abdominal CT or exploratory laparotomy is not indicated because there is no evidence of peritoneal violation or intra-abdominal injury. Surgical debridement with delayed closure is typically reserved for grossly contaminated wounds or high infection risk. Antibiotic irrigation alone is insufficient without proper closure.
Thus, for a stable patient with a superficial abdominal wall laceration that does not penetrate fascia, primary repair is the correct next step.
NEW QUESTION # 260
A 52-year-old man presents to the Emergency Department with a history of back, neck, and shoulder pain sustained from a workplace incident 4 years ago. He is under observation by a multidisciplinary pain clinic, and his next appointment is not for another 4 weeks. He does not report any recent change in his symptoms.
His medications are as follows:
Acetaminophen
1000 mg orally 4 times daily
Naproxen
500 mg orally twice daily
Amitriptyline
25 mg orally at bedtime
* Acetaminophen 1000 mg orally four times daily
* Naproxen 500 mg orally twice daily
* Amitriptyline 25 mg orally at bedtime
The patient has not taken his medications for several weeks because he thinks they are not working. He requests a prescription for oxycodone because he tried some that a friend sold him, and it worked very well.
After completing an assessment and providing counseling, which one of the following is the best next step?
Answer: A
Explanation:
Given the request for opioids and history of non-prescribed opioid use (oxycodone obtained from a friend), the next appropriate step is to conduct a urine drug screen. This helps assess current substance use and guides safe prescribing decisions.
Toronto Notes 2023 - Pain Management and Addiction Medicine:
"Urine drug screening is recommended before initiating opioid therapy or when there is suspicion of substance misuse. A history of using non-prescribed opioids mandates assessment for opioid use disorder and further risk stratification." MCCQE1 Objectives - Internal Medicine > Chronic Pain:
"Candidates must assess for opioid misuse and dependence before initiating opioid therapy. Urine drug testing is a standard tool in this assessment." Providing naloxone (A) may be appropriate later if opioids are prescribed, but the priority is evaluation.
Cannabis (B) is not first-line and lacks controlled evidence in chronic pain. Tramadol (D) is an opioid-like agent and not appropriate until misuse risk is evaluated.
NEW QUESTION # 261
A 16-year-old girl is brought to the Emergency Department with a 12-hour history of worsening right lower quadrant abdominal pain and nausea. She is in no distress and vital signs are normal. Her abdomen is soft but locally tender in the right iliac fossa, and bowel sounds are active. White blood cell count is 7.6 × 10#/L (4-
10), C-reactive protein is 2.3 mg/L ( < 10) and serum beta human chorionic gonadotropin is undetectable.
Ultrasound reveals a small amount of fluid in the pelvis, and the appendix is not clearly apparent. Which one of the following is the best next management step?
Answer: C
Explanation:
This adolescent presents with possible early appendicitis but currently has mild clinical findings, normal vital signs, normal white blood cell count, and low CRP. Ultrasound does not visualize the appendix and shows only minimal pelvic fluid, which can be physiologic in adolescent females. According to MCCQE surgical objectives, when the diagnosis of appendicitis is uncertain and the patient is clinically stable, the preferred approach is observation with serial abdominal examinations rather than immediate imaging with CT or operative intervention.
CT scanning exposes a young patient to ionizing radiation and is not indicated when clinical suspicion is low to moderate and the patient is stable. Immediate appendectomy is inappropriate without stronger clinical or laboratory evidence. Empiric IV antibiotics are reserved for confirmed or strongly suspected appendicitis.
Serial radiography has no role in diagnosing appendicitis.
Careful monitoring over 12-24 hours allows progression of signs if appendicitis is present, improving diagnostic accuracy while avoiding I have cross-referenced your exam scores with NVIDIA's official technical documentation for **DGX H100
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### **Batch 1: Questions 1 - 5
NEW QUESTION # 262
A 10-day-old boy is brought to the Emergency Department with a fever. The newborn looks well. Other than a rectal temperature of 38.6 °C, findings of the physical examination are unremarkable. When you list all the recommended testing their baby will have to undergo, the parents become upset at all the testing their baby will have to undergo. Which one of the following is the best approach?
Answer: B
Explanation:
A febrile neonate (#28 days old) requires a full sepsis evaluation (e.g., blood cultures, urine testing, lumbar puncture) because of the high risk of serious bacterial infection despite a well appearance. MCCQE objectives emphasize both appropriate medical management and effective communication with parents. When caregivers are distressed about painful procedures, the best approach is empathetic communication and reassurance that adequate analgesia and comfort measures (e.g., topical anesthetic, oral sucrose, swaddling) will be provided.
Threatening child protection involvement is inappropriate unless there is clear refusal of life-saving care after thorough discussion. Saying the infant "will not remember" dismisses parental concerns and undermines trust.
Proceeding without addressing concerns violates principles of shared decision-making. Excluding parents from procedures may increase anxiety and is not routinely recommended.
The physician should acknowledge concerns, explain the rationale for testing (risk of occult sepsis), outline pain-control strategies, and invite questions. This maintains trust while ensuring timely, evidence-based care.
NEW QUESTION # 263
A 72-year-old man presents to your office with reports of a hard lump slowly enlarging in the right inguinal area. He is otherwise healthy. Which one of the following is most likely to reveal the cause of his lump?
Answer: C
Explanation:
A slowly enlarging, hard inguinal "lump" in an older adult is concerning for inguinal lymphadenopathy or an inguinal hernia , and MCCQE objectives emphasize targeted examination of the regional drainage areas to identify a primary source. Inguinal lymph nodes receive lymphatic drainage from the external genitalia and scrotal skin , perineum, and lower abdominal wall and lower extremity. Therefore, careful genital examination
-including the testicles/scrotum-can reveal common underlying causes such as skin malignancy of the scrotum , penile/scrotal lesions, chronic infection, or other local pathology that would explain a hard inguinal node.
Digital rectal examination assesses the prostate and rectum, whose lymphatic drainage is primarily to pelvic nodes rather than superficial inguinal nodes, making it less likely to identify the cause here. Palpation of liver or spleen looks for systemic malignancy/hematologic disease but is less likely to reveal the cause of a unilateral inguinal mass. Sexual history may suggest STI-related nodes, but these are typically tender and acute; a focused physical exam is more likely to reveal the etiology.
NEW QUESTION # 264
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