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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Dimensions of Care | 50% | - Assessment and Diagnosis - Health Promotion and Illness Prevention - Acute Care - Chronic Care |
| Topic 2: Physician Activities | 50% | - Professional Behaviours - Communication - Psychosocial Aspects - Management |
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188. Frage
A 42-year-old woman is admitted to the Intensive Care Unit with a massive pulmonary embolism. Her condition is stabilized with intubation, hydration, inotropic support, and intravenous administration of heparin. Her partner provides you with a list of her medications. A combination oral contraceptive pill was recently prescribed. She smokes tobacco cigarettes, and her BMI is 36. Which one of the following is the best next step?
Antwort: C
Begründung:
Oral contraceptives increase the risk of thromboembolic events, particularly in patients with risk factors such as smoking and obesity. However, informing the patient's partner of potential contributing factors in a factual, non-judgmental manner is appropriate and does not imply fault.
Toronto Notes 2023 - ELOM, "Informed Consent and Risk Communication":
"Patients and families should be informed of all relevant information, including potential drug-related adverse events. Blame must not be assigned without full investigation." MCCQE1 Objectives (ELOM > 90-2: Physician-Patient Communication):
"Candidates must be able to communicate adverse outcomes factually, while respecting confidentiality and without prematurely assigning fault." Discussing the case with the ethics committee or reporting the prescribing doctor without context is premature and inappropriate (A, D). Telling the partner the physician was at fault (C) is speculative and unethical.
189. Frage
A 62-year-old woman is referred to your clinic for evaluation of hypercalcemia. She has a history of hypertension and vitamin D deficiency. Her medications include hydrochlorothiazide and vitamin D supplements. Laboratory investigations are as follows:
* Calcium: 2.72 mmol/L (#)
* Phosphate: 0.9 mmol/L (#)
* Parathyroid hormone (PTH): 0.9 pmol/L (#)
* 25-hydroxy vitamin D: 80 nmol/L (normal)
Which one of the following is the best next step?
Antwort: E
Begründung:
Comprehensive and Detailed Explanation:
This patient has hypercalcemia with suppressed PTH, ruling out primary hyperparathyroidism. The differential includes malignancy-associated hypercalcemia, vitamin D intoxication, and medications. Given the low PTH and normal vitamin D level, malignancy (e.g., multiple myeloma) is a leading concern. Serum protein electrophoresis and urine for Bence-Jones proteins (light chains) are appropriate next steps.
Toronto Notes 2023 - Endocrinology, "Hypercalcemia":
"PTH-independent hypercalcemia should prompt investigation for malignancy. Multiple myeloma is a common cause in older adults-order SPEP and UPEP." MCCQE1 Objectives (Endocrinology > 37-1: Calcium Disorders):
"Candidates must investigate non-PTH mediated hypercalcemia, including consideration of multiple myeloma." A (urine calcium) helps in familial hypocalciuric hypercalcemia, but this is unlikely given low PTH. B (calcitriol) would worsen hypercalcemia. C is inappropriate because PTH is suppressed. D (changing HCTZ) may help, but malignancy must be ruled out first.
190. Frage
A 40-year-old woman presents to the Emergency Department with confusion and fever (38.5°C). She has a history of hypothyroidism managed with levothyroxine. Key findings include:
Blood pressure
114/78 mm Hg
Heart rate
85/min
Temperature
38.5°C
Hemoglobin
90 g/L123-157 g/L
Platelet count
25 × 10#/L130-400 × 10#/L
Peripheral blood film
Schistocytes present
Creatinine
200 #mol/L50-90 #mol/L
Antwort: E
Begründung:
This patient presents with fever, confusion, anemia with schistocytes, thrombocytopenia, and renal impairment - fulfilling the classic pentad of thrombotic thrombocytopenic purpura (TTP). TTP is a hematologic emergency requiring plasma exchange.
Toronto Notes 2023 - Hematology, "Microangiopathic Hemolytic Anemia" Section:
"TTP is a medical emergency. Features include MAHA, thrombocytopenia, renal failure, neurologic symptoms, and fever. Schistocytes on blood film are diagnostic." MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Disorders):
"Candidates must urgently recognize TTP and initiate emergent plasma exchange therapy." AML (B) does not present with schistocytes. HIV (C) can cause thrombocytopenia but not MAHA. ITP (D) causes isolated thrombocytopenia without anemia or schistocytes.
191. Frage
You are counselling the wife of a 75-year-old man admitted under your care after a fall. The patient is confused, disoriented, barely sleeps at night and has complex visual hallucinations of animals running through his room. Given his state, which one of the following is the best advice for the wife?
Antwort: B
Begründung:
This scenario describes acute delirium, common in hospitalized elderly patients. Patients may say things they don't mean. Reassuring family members not to take hurtful comments personally is an important part of family counseling.
Toronto Notes 2023 - Geriatrics, "Delirium":
"Patients may become agitated, hallucinate, or be aggressive. Families should be counseled not to take the behavior personally and continue to support orientation." MCCQE1 Objectives (Geriatrics > 41-1: Cognitive Disorders):
"Candidates must support caregivers of delirious patients, providing guidance on managing emotional and behavioral symptoms." Avoiding visits (A), confronting the patient (C), or emotional withdrawal (E) are counterproductive.
Providing gentle information is appropriate (contradicts B).
192. Frage
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?
Antwort: D
Begründung:
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.
193. Frage
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