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| Section | Objectives |
|---|---|
| Topic 1: Dimensions of Care | - Acute Care
|
| Topic 2: Physician Activities | - Assessment
|
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NEW QUESTION # 333
You perform a literature search of journal articles on the effectiveness of a new antihypertensive for first-line treatment of people aged 35 to 50. You find reports of 4 good quality studies. Three of them show that statistically, the new drug is significantly more effective than the standard treatment, and one shows no difference. Before you conclude that the new antihypertensive is more effective in this group of patients, which one of the following concepts must be given consideration?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
Publication bias refers to the tendency for positive results to be published more often than negative or inconclusive ones. In your review, 3 of 4 studies show positive findings. However, studies showing no effect may not have been published, skewing your impression.
Toronto Notes 2023 - Public Health, Critical Appraisal:
"Publication bias can lead to overestimation of treatment efficacy. Systematic reviews must account for unpublished or negative findings." MCCQE1 Objectives - Preventive Medicine > Critical Appraisal:
"Candidates must recognize and account for biases such as publication bias in interpreting literature." Random error (A) and power (D) affect individual studies. Systematic and information biases (B, E) affect data quality, not publication trends.
NEW QUESTION # 334
An 88-year-old man is admitted to hospital with an upper gastrointestinal bleed. He is confused on admission, but his sensorium clears with resuscitation and stabilization. The patient lives in his own home with assistance from his children. Work-up shows metastatic gastric carcinoma for which no curative treatment can be offered. The family insists that the patient not be told the diagnosis because they fear he will have a "mental breakdown." Which one of the following is the best next step?
Answer: A
Explanation:
Once the patient's confusion has resolved, he should be presumed capable unless an assessment shows otherwise. MCCQE ethics objectives prioritize patient autonomy, informed decision-making, and confidentiality . Families may request "therapeutic privilege" or nondisclosure, but this is not the default and cannot override a capable patient's right to information needed to make decisions. The appropriate first step is to explore the patient's preferences about receiving serious news (some patients prefer limited information or to delegate decisions). Asking the patient whether he wants to know the diagnosis respects autonomy while remaining sensitive to potential distress. Simply telling him immediately (without checking preferences) may conflict with patient-centered disclosure, and automatically complying with the family's request violates the patient's rights and undermines informed consent for goals-of-care planning. A palliative care consult is appropriate, but only after clarifying the patient's understanding and wishes and beginning honest, preference- guided communication. The clinician should also support the family, explain ethical duties, and reassure them that disclosure can be done gradually and compassionately.
NEW QUESTION # 335
A 72-year-old woman is brought to the Emergency Department by her daughter because of significant functional decline and progressive shortness of breath. She has widespread metastatic breast cancer and recently stopped chemotherapy due to progression and intolerance. She has been bedridden for 4 weeks. On examination:
* BP: 100/70 mm Hg with pulsus paradoxus of 20 mm Hg
* HR: 99/min
* Temp: 36.5°C
* SpO#: 94% room air
* JVP: elevated
* Heart sounds: muffled
* Chest X-ray: large globular heart
Labs:
* Hemoglobin: 90 g/L
* Sodium: 118 mmol/L
* Creatinine: 94 µmol/L
Which one of the following is the best next step?
Answer: E
Explanation:
This patient has classic signs of cardiac tamponade (Beck's triad: hypotension, muffled heartsounds, elevated JVP, plus pulsus paradoxus). However, she also has advanced metastatic cancer, functional decline, and has stopped active treatment. In this context, a goals-of-care discussion is the most appropriate next step to determine her wishes regarding interventions like pericardiocentesis.
Toronto Notes 2023 - Palliative Care:
"End-of-life care should prioritize quality of life and patient preferences. In patients with terminal illness and life-threatening conditions (e.g., tamponade), initiate a conversation about goals before aggressive intervention." MCCQE1 Objectives - Internal Medicine > Palliative and End-of-Life Care:
"Candidates must assess prognosis, patient values, and initiate appropriate end-of-life discussions before invasive treatment." Although pericardiocentesis (A) may relieve symptoms, it should follow consent based on the patient's goals.
ICU (E), fluids (B), or transfusion (D) are not appropriate without this discussion.
NEW QUESTION # 336
You are an attending physician at a palliative care unit and are asked to see an 80-year-old woman who is dying of lung cancer. She has been unresponsive for the last 2 days and had her last dose of morphine 4 hours ago. Her son just arrived in town this afternoon and pleads with you to wake her up so she can sign her will.
Which one of the following is the best next step?
Answer: E
Explanation:
At the end of life, decreasing consciousness and unresponsiveness are common and expected physiologic changes. MCCQE ELOM objectives emphasize prioritizing patient comfort, respecting goals of care, and communicating clearly with families about prognosis and the dying process. The best next step is to explain that her reduced level of consciousness is most consistent with imminent dying and that she is unlikely to have the decision-making capacity required to execute legal documents (capacity requires understanding and appreciation of the decision and its consequences).
Withholding morphine to attempt to increase alertness risks causing pain and dyspnea, violating the duty to relieve suffering. Administering naloxone is inappropriate because it may precipitate acute pain and distress and is not indicated when opioids are being used appropriately for symptom control. A legal opinion or ethics consult may be considered later if conflict persists, but the immediate priority is compassionate communication, clarifying that "waking her to sign" is unlikely feasible or ethically justified, and supporting the son through anticipatory grief while continuing comfort-focused care.
NEW QUESTION # 337
A 60-year-old man presents to the office with concerns regarding a pruritic rash, which he has had for several years. He reports a "crawling" sensation on his skin. He is concerned that this rash may be caused by a parasite he may have picked up while serving in the military overseas. On examination, you note multiple crusted lesions on his forearms, neck, chest, scalp, and thighs. There is a complete sparing of the skin on his back. He brought a bottle with fibrous material of different colours that he picked from his wounds. He is otherwise healthy and reports no other symptoms except some chronic fatigue and insomnia related to the itching. Which one of the following treatments is the most appropriate?
Answer: C
Explanation:
This case describes classic signs of delusional parasitosis (also known as Morgellons syndrome).However, the presence of widespread crusted lesions raises suspicion for crusted scabies, particularly in older adults.
Crusted scabies may be misinterpreted as chronic dermatitis or psychocutaneous disorder. The most effective treatment is oral ivermectin.
Toronto Notes 2023 - Dermatology:
"Crusted scabies presents as widespread hyperkeratotic plaques with crusting. First-line treatment is oral ivermectin, often with topical permethrin." MCCQE1 Objectives (Medicine > Dermatology > 23-1):
"Candidates must recognize presentations of ectoparasitic infections, including scabies, and provide appropriate treatment." Permethrin (B) is for typical scabies, but crusted scabies often requires systemic ivermectin due to severity and spread.
NEW QUESTION # 338
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