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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Communicator
|
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NEW QUESTION # 136
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: B
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 # 137
A 35-year-old woman presents to your clinic for follow-up regarding her persistent primary immune thrombocytopenic purpura. She was admitted to hospital with a relapse and received treatment with dexamethasone, intravenous immunoglobulin, and rituximab. She was recently discharged from hospital with a platelet count of 55 × 10#/L (130-360), and also continues to take 10 mg of prednisone once daily. She is scheduled for a splenectomy in 4 weeks. Which one of the following is the best next step in preparation for the patient ' s surgical procedure?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
Patients undergoing splenectomy are at lifelong risk for overwhelming post-splenectomy infection (OPSI), particularly from encapsulated organisms. Vaccination against Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis is recommended at least 2 weeks prior to elective splenectomy.
Toronto Notes 2023 - Hematology / Surgery:
"Patients undergoing elective splenectomy should receive vaccines against pneumococcus, H. influenzae type b, and meningococcus at least 2 weeks before surgery." MCCQE1 Objectives (Hematology > 38-2: Thrombocytopenia and Splenectomy):
"Candidates must ensure vaccination prior to splenectomy to prevent postsplenectomy sepsis." Calcium (B) may be considered in chronic steroid users but is not the priority. Azithromycin (C) is not indicated. D is unsafe without tapering. E is only for acute bleeding or extremely low platelets.
NEW QUESTION # 138
A 32-year-old primigravid woman is receiving magnesium sulfate for tocolysis. Her pregnancy is at 26 weeks
' gestation. You suspect magnesium sulfate toxicity. Which one of the following is the first sign of magnesium sulfate toxicity?
Answer: E
Explanation:
Magnesium sulfate toxicity is dose-dependent. The earliest and most sensitive clinical sign is the loss of deep tendon reflexes (especially patellar), which occurs before respiratory depression or cardiac changes.
Toronto Notes 2023 - Obstetrics Chapter:
"Toxicity from magnesium sulfate is progressive and typically presents first with loss of deep tendon reflexes.
Respiratory depression and cardiac arrest occur at higher serum levels. Regular monitoring of reflexes, respiratory rate, and urine output is essential." MCCQE1 Objectives (Obstetrics > 83-3: Preterm Labour and Tocolysis):
"The candidate must recognize early signs of magnesium sulfate toxicity including areflexia and respiratory depression." Tachycardia (B), hypotension (C), and tachypnea (D) are not typical early signs. Oliguria (E) may be a risk factor for accumulation but is not the first sign of toxicity.
NEW QUESTION # 139
A 33-year-old primigravid woman presents to the office with gestational hypertension. Her pregnancy is at 37 weeks' gestation. The ultrasound findings are as follows:
Head circumference: 5th percentile
Biparietal diameter: 10th percentile
Abdominal circumference: 5th percentile
Femur length: 25th percentile
Amniotic fluid volume: 5.0 cm
Umbilical Doppler: Reversed end-diastolic flow
Which one of the following is the best next step?
Answer: A
Explanation:
This pregnancy demonstrates fetal growth restriction (FGR) with biometric measurements at or below the
10th percentile and oligohydramnios (AFI 5 cm). Most concerning is the finding of reversed end-diastolic flow (REDF) in the umbilical artery Doppler, which indicates severe placental insufficiency and significantly increased risk of fetal hypoxia, acidosis, and intrauterine demise. MCCQE objectives emphasize that abnormal umbilical artery Doppler findings-particularly absent or reversed end-diastolic flow-represent critical fetal compromise.
At 37 weeks' gestation, the fetus is term. The risks of continued intrauterine exposure in the setting of REDF outweigh the risks of delivery. Therefore, immediate delivery is indicated. Expectant management with nonstress testing or delayed reassessment is inappropriate because REDF is associated with high perinatal mortality.
Prompt delivery (often by cesarean section depending on fetal status and cervical factors) is required to prevent stillbirth and severe neonatal morbidity.
NEW QUESTION # 140
A 12-year-old girl presents to your office in late November with an exacerbation of asthma which has been well controlled since her diagnosis at age 5. The family has had cats for 3 years. Last June, they moved to a basement apartment. Which one of the following is the most likely cause of her asthma exacerbation?
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
Basement apartments are often damp environments, increasing the risk of mold exposure. Mold is a well- known asthma trigger. Given the timing (autumn/winter) and environment change, mold allergy is the most likely cause.
Toronto Notes 2023 - Respirology / Allergy:
"Mold is a common indoor allergen, especially in damp environments. It frequently exacerbates asthma, particularly in fall/winter." MCCQE1 Objectives (Pediatrics > 75-2: Asthma Triggers):
"Candidates must identify common environmental triggers for asthma, including mold exposure in humid or poorly ventilated housing." Cat allergy (B) would have triggered earlier. Pollen (D) is less relevant in winter. Cold intolerance (E) is not a major asthma trigger without exercise. Fungal infection (A) is unlikely without systemic symptoms.
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NEW QUESTION # 141
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