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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Professional
|
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NEW QUESTION # 188
A 43-year-old man comes to your office for the first time. He has not seen a doctor in over 5 years and has no known past medical history. On examination, his blood pressure is 120/70 mm Hg, and the remainder of his examination is normal. As part of the initial visit, you order some screening blood work that reveals a fasting blood glucose of 6.3 mmol/L (3.3-5.8) and a hemoglobin A1c of 6.1% (4-6). Which one of the following is the best next step?
Answer: D
Explanation:
This patient's lab results suggest impaired fasting glucose and an elevated A1c just below the threshold for diabetes. The gold standard to confirm diabetes in such intermediate cases is the 75 g oral glucose tolerance test (OGTT).
Toronto Notes 2023 - Endocrinology, "Diabetes Mellitus" Section:
"If A1c is in the 6.0-6.4% range or fasting glucose 6.1-6.9 mmol/L, a 75 g OGTT is recommended to establish the diagnosis of diabetes or confirm impaired glucose tolerance." MCCQE1 Objectives (Internal Medicine > 76-4: Diabetes):
"Candidates must correctly apply diabetes screening and diagnostic criteria and follow up abnormal results with appropriate confirmatory testing." Urine ACR (C) is useful in diagnosed diabetes, not for initial screening. TSH (A), capillary glucose testing (B), and exercise testing (E) are not indicated at this stage.
NEW QUESTION # 189
A 38-year-old man is brought by his wife to the Emergency Department with fatigue, dizziness, and nausea after completing a hiking tour on a hot, humid day. His wife became worried after he had collapsed. He has been sweating heavily and vomited twice on the drive in. His medical history is unremarkable, and he takes no medications. His vital signs on arrival are as follows:
Blood pressure
85/57 mm Hg
Heart rate
120/min
Respiratory rate
18/min
Temperature
40.1 °C
Oxygen saturation
95%, room air
-
On physical examination, the patient's skin is dry, flushed, and warm to the touch. He has a diffuse erythematous papular rash. Findings of a thorough physical examination are otherwise unremarkable. An electrocardiogram shows sinus tachycardia. Which one of the following is the best next step?
Answer: A
Explanation:
This patient has classic features of exertional heat stroke-hyperthermia, hypotension, CNS symptoms (collapse), and hot, dry skin. A key complication of heat stroke is rhabdomyolysis, which can cause renal failure. Serum creatine kinase (CK) is the best next diagnostic step to confirm muscle breakdown.
Toronto Notes 2023 - Emergency Medicine, "Environmental Exposures":
"In heat stroke, check for rhabdomyolysis (#CK), renal impairment, and coagulopathy. Prompt cooling and hydration are critical." MCCQE1 Objectives (Internal Medicine > 59-3: Environmental and Toxic Exposures):
"Candidates must recognize heat-related illnesses and investigate for complications such as rhabdomyolysis and acute kidney injury." CT head (C) is not indicated unless persistent neurological symptoms. TSH (B), CRP (D), and blood cultures (E) are irrelevant to acute exertional hyperthermia.
NEW QUESTION # 190
A 34-year-old woman, gravida 3, para 2, comes to your office for prenatal care. Past medical history includes
2 precipitous uncomplicated term deliveries of infants greater than 4200 g. Which one of the following is she most at risk of developing?
Answer: B
Explanation:
This patient's obstetric history suggests recurrent fetal macrosomia (birthweight > 4000-4500 g) and rapid (precipitous) labours. MCCQE objectives emphasize identifying maternal risk factors for postpartum hemorrhage (PPH) , particularly those associated with uterine atony , the most common cause of PPH.
Delivery of a macrosomic infant increases uterine overdistension, which reduces effective postpartum uterine contraction and predisposes to atony and hemorrhage. In addition, precipitous labour can be associated with genital tract trauma, which can also contribute to postpartum bleeding, but the strongest and most consistent risk factor in the options provided is PPH from atony related to prior large infants.
The other choices are less supported by the stem: prior macrosomic term deliveries do not inherently increase risk of preterm delivery, gestational hypertension, or DVT. Therefore, the most likely risk to anticipate and plan for is postpartum hemorrhage, prompting proactive intrapartum planning (active management of the third stage, readiness with uterotonics, and risk-based monitoring).
NEW QUESTION # 191
A 4-year-old boy is brought by his parents to your walk-in clinic with a 3-week history of fatigue, bruising, and intermittent fever. He was previously healthy. Physical examination reveals hepatosplenomegaly and petechiae. His complete blood count shows the following:
Platelet count, blood: 15.0 × 10#/L (206.4-443.3)
White blood cell (WBC) count, blood: 1.0 × 10#/L (4.7-13.5)
Hemoglobin (Hgb), blood: 70 g/L (105-135)
Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
This child has pancytopenia (severe thrombocytopenia, leukopenia, and anemia) plus systemic symptoms (fatigue, intermittent fever) and hepatosplenomegaly, strongly suggesting bone marrow failure/infiltration, most commonly acute lymphoblastic leukemia (ALL) in this age group. MCCQE objectives emphasize recognizing red flags for childhood malignancy: unexplained bruising/petechiae from thrombocytopenia, recurrent or persistent fever, pallor, and organomegaly due to leukemic infiltration or extramedullary hematopoiesis.
Immune thrombocytopenia typically causes isolated thrombocytopenia with otherwise normal hemoglobin and WBC count and usually no hepatosplenomegaly. Iron deficiency anemia causes microcytic anemia but does not explain profound thrombocytopenia and leukopenia. Viral illness may transiently suppress counts but is less likely to cause marked pancytopenia with significant organomegaly. Bacterial sepsis can cause thrombocytopenia but usually presents with acute toxicity and does not typically produce this pattern of sustained pancytopenia and hepatosplenomegaly.
Next steps (clinically) would include urgent peripheral smear, oncology referral, and bone marrow evaluation.
NEW QUESTION # 192
A 31-year-old nulligravid woman presents to your office after 5 months of attempting to get pregnant without success. Her menses are regular, and she is otherwise healthy. Her husband is healthy and has never fathered any children before. Which one of the following is the best next step?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
Infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse in women under 35 years. Since she has been trying for only 5 months, reassurance is appropriate.
Toronto Notes 2023 - Gynecology:
"Investigations for infertility in women under 35 should begin after 12 months of attempting to conceive, unless other risk factors are present." MCCQE1 Objectives (Gynecology > 82-1: Infertility):
"Candidates must apply appropriate timing and indications for infertility investigations based on patient age and history." Earlier testing is not warranted here. Options A-D are part of the infertility work-up but not before 12 months.
NEW QUESTION # 193
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