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| Section | Objectives |
|---|---|
| Physician Activities | - Assessment
|
| Dimensions of Care | - Chronic Care
|
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NEW QUESTION # 253
A 68-year-old man with a history of diabetes, hypertension, delirium tremens, and tobacco addiction comes to the Emergency Department with his daughter. She tells you that his behavior has become unmanageable and she feels he may require an increased level of care. His vital signs are:
Blood pressure: 162/105 mm Hg
Heart rate: 112/min, regular
Temperature: 37.8°C
On history, his daughter explains she had to confiscate a half-empty bottle of alcohol from his room yesterday. He is now convinced that there are bugs crawling all over him and he will not relax. He appears pale, sweaty, and shaky. His most recent blood glucose is 7.8 mmol/L (3.8-11.1). Which one of the following is the best next step?
Answer: C
Explanation:
The presentation is consistent with acute alcohol withdrawal with delirium tremens: autonomic instability, agitation, visual hallucinations (formication), and recent alcohol reduction. This is a medical emergency requiring immediate treatment with benzodiazepines and supportive care.
Toronto Notes 2023 - Psychiatry, Substance Use Disorders:
"Delirium tremens is a life-threatening complication of alcohol withdrawal. Clinical features include agitation, hallucinations, tachycardia, hypertension, and diaphoresis. Management includes high-dose benzodiazepines and IV fluids." MCCQE1 Objectives - Psychiatry > Substance Use Disorders:
"Candidates must recognize and treat alcohol withdrawal delirium promptly with benzodiazepines and supportive measures." Antipsychotics (B) are not first-line in withdrawal states. Private interviews (A) and psychiatric consults (D) delay life-saving treatment.
NEW QUESTION # 254
A 53-year-old man presents to the Emergency Department with a 3-week history of believing his neighbor is poisoning him by pumping gas through his home's air vent. He appears distracted, irritable, and is speaking very quickly. He has a family history of depression. Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
This man exhibits a classic manic episode with psychotic features: persecutory delusions, distractibility, pressured speech, irritability, and possible grandiosity. The chronicity and mood symptoms are most consistent with Bipolar I disorder.
Toronto Notes 2023 - Psychiatry, "Mood Disorders" Section:
"Bipolar I disorder is characterized by episodes of mania, often with psychotic features.Symptoms include grandiosity, decreased need for sleep, distractibility, and mood-congruent delusions." MCCQE1 Objectives (Psychiatry > 79-1: Mood Disorders):
"Candidates must recognize mania and differentiate from brief psychosis or organic causes." Delirium (A) is acute, fluctuating, and involves impaired attention. Malingering (B) requires external gain.
Brief psychotic disorder (C) resolves within 1 month. Brain injury-related psychosis (E) would require a supporting history or findings.
(Part 2 )
NEW QUESTION # 255
A 16-year-old boy is brought to the office for examination, which reveals the lesion in the attached image and similar lesions on other parts of his body. You also notice multiple scattered subcutaneous tumors that he says have been there for a long time. Which one of the following is the most likely diagnosis?
Answer: E
Explanation:
The presence of multiple cutaneous lesions along with numerous longstanding subcutaneous tumors is most consistent with neurofibromatosis type 1 (NF1) . MCCQE objectives emphasize recognizing classic dermatologic findings of NF1, which include multiple neurofibromas (soft, skin-colored subcutaneous nodules) and characteristic pigmented lesions such as cafe-au-lait macules and axillary or inguinal freckling.
These lesions typically develop during childhood or adolescence and increase in number over time.
Sarcoidosis can cause skin lesions but is not associated with multiple benign peripheral nerve sheath tumors.
Dermatofibromas are usually solitary, firm nodules rather than numerous soft tumors. Vitiligo presents as depigmented macules without subcutaneous masses. Lipomatosis involves multiple lipomas but lacks the associated pigmentary skin findings seen in NF1.
NF1 is an autosomal dominant condition caused by mutation of the NF1 gene. Diagnosis is clinical based on established criteria. Recognition is important because patients require surveillance for complications such as optic gliomas, learning disabilities, skeletal abnormalities, and malignant peripheral nerve sheath tumors.
NEW QUESTION # 256
A 44-year-old woman presents to the office to discuss contraception. During the gynecologic examination, you notice an anterior cystocele to the hymenal ring. The woman denies any bulge symptoms but does report dribbling of urine, especially when she coughs or jogs.
Which one of the following is the best next step?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
This patient has stress urinary incontinence and an incidental cystocele. First-line management of mild pelvic organ prolapse and stress incontinence includes pelvic floor physiotherapy (e.g., Kegel exercises). Surgical options are reserved for severe or refractory cases.
Toronto Notes 2023 - Gynecology, Pelvic Floor Disorders:
"For asymptomatic prolapse or mild stress incontinence, recommend pelvic floor strengthening. Conservative management is preferred before surgical referral." MCCQE1 Objectives - Gynecology > Urogynecology:
"Candidates should initiate pelvic floor therapy in women with mild prolapse or urinary leakage prior to specialist referral." Topical estrogen (B) helps with atrophic vaginitis, not stress incontinence. Hysterectomy (A) and specialist referral (C) are premature. Avoiding impact sports (E) is not a treatment.
NEW QUESTION # 257
A 12-year-old boy is brought by his mother to your clinic with a history of attention-deficit/hyperactivity disorder. His mother reports that he has been taking immediate-release methylphenidate for 2 years. Although the medication was initially effective, it no longer seems to work. The teachers say he is disorganized and fidgety, verbally interrupts class, and does not complete his work. His mother tells you that he does listen at home. Which one of the following is the most important next step in management?
Answer: D
Explanation:
Management of ADHD requires ongoing reassessment using standardized rating scales from multiple informants (e.g., parents and teachers) to evaluate symptom control and functional impairment across settings.
This child demonstrates persistent school-related symptoms despite prior response to immediate-release methylphenidate. Before adjusting therapy, it is essential to objectively reassess symptom severity, adherence, timing of doses relative to school hours, and potential environmental factors. Completion of validated rating scales helps determine whether symptoms remain clinically significant and guides appropriate dose titration.
Stimulant medications such as methylphenidate are first-line treatment, and inadequate response often requires dose optimization before switching agents. Simply increasing the dose without reassessment is not best practice. Risperidone is not indicated for uncomplicated ADHD. An EEG is unnecessary unless there are seizure concerns. Switching to atomoxetine is premature without confirming inadequate response to optimized stimulant therapy. MCCQE objectives emphasize systematic monitoring, multi-informant assessment, dose titration, and evidence-based pharmacologic management in pediatric ADHD.
NEW QUESTION # 258
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