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| Section | Objectives |
|---|---|
| Dimensions of Care | - Chronic Care
|
| Physician Activities | - Management
|
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NEW QUESTION # 78
A 29-year-old woman presents with vaginal spotting after 6 weeks of amenorrhea. She is asymptomatic otherwise. Serum #-hCG is 2150 IU/L, and pelvic ultrasound shows an empty uterus. She has been trying to conceive for 7 months. Which one of the following is the best next step?
Answer: C
Explanation:
An empty uterus with #-hCG >1500-2000 IU/L raises concern for a pregnancy of unknown location (PUL), including the possibility of ectopic pregnancy. However, the patient is hemodynamically stable and asymptomatic. In such cases, the best initial step is to repeat serum #-hCG in 48 hours to assess the rise or fall of hCG levels.
Toronto Notes 2023 - Obstetrics, "First Trimester Bleeding":
"If #-hCG >1500 IU/L and no intrauterine pregnancy is visualized on ultrasound, repeat #-hCG in 48 hours to determine rise or decline. A suboptimal rise (less than 66%) suggests ectopic pregnancy." MCCQE1 Objectives (Obstetrics > 79-1: Early Pregnancy Complications):
"In a patient with early pregnancy bleeding, the candidate must interpret quantitative #-hCG trends to distinguish ectopic pregnancy, miscarriage, or viable intrauterine pregnancy." Immediate administration of methotrexate or invasive procedures such as D&C or laparoscopy are not appropriate until further diagnostic clarification is obtained.
NEW QUESTION # 79
A 15-year-old boy is brought to your office because of concerns about his breast development. He has no other symptoms. His physical examination does not reveal any other abnormality. Which one of the following is the best next step?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
The image and clinical history are consistent with physiologic pubertal gynecomastia, which is common in adolescent boys. It usually resolves spontaneously within 6 months to 2 years and does not require investigation unless other signs of endocrine pathology are present.
Toronto Notes 2023 - Pediatrics / Endocrinology:
"Pubertal gynecomastia is benign, self-limited, and common in adolescent males. No further investigation is needed in the absence of systemic signs." MCCQE1 Objectives (Pediatrics > 77-2: Endocrine Disorders):
"Candidates must differentiate physiologic gynecomastia from pathologic causes based on history and physical exam." Other tests (A-C, E) are unnecessary unless there are red flags (e.g., testicular mass, rapid progression, neurological symptoms).
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NEW QUESTION # 80
A 60-year-old man presents because of a 6-month history of involuntary lip smacking and tongue movements.
His medical history is significant for schizophrenia, which has been very stable with haloperidol for the past
20 years. When educating the patient about these particular symptoms, which one of the following statements is accurate?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
This patient has tardive dyskinesia, a late-onset, often irreversible movement disorder caused by chronic dopamine receptor blockade (e.g., haloperidol). It is especially common in older adults and may not resolve after stopping the drug.
Toronto Notes 2023 - Psychiatry, "Extrapyramidal Symptoms":
"Tardive dyskinesia is often irreversible and typically occurs after prolonged antipsychotic use. Elderly patients are at greater risk." MCCQE1 Objectives (Psychiatry > 71-5: Side Effects of Psychotropics):
"Candidates must recognize tardive dyskinesia and understand that it can persist or worsen even after discontinuation of antipsychotics." Anticholinergics may worsen it (D). The condition does not reliably improve with age (C). It does not affect a majority of patients (A).
NEW QUESTION # 81
A 31-year-old man presents with nocturnal non-exertional chest pain. During an exercise stress test, he does not experience chest pain, and there are no significant ST segment changes on the electrocardiogram. He achieves 17 metabolic equivalent of task (MET), a blood pressure of 190/96 mm Hg (resting blood pressure of
130/80 mm Hg), and a maximum heart rate of 162/min (85% of age-predicted maximum). Which one of the following is the most appropriate next step?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
This patient demonstrates excellent exercise tolerance (17 METs) and no ischemic changes or exertional symptoms, which makes cardiac ischemia unlikely. However, the hypertensive response to exercise (BP >
190 systolic) indicates masked or latent hypertension. This should be managed proactively, typically starting with a thiazide.
Toronto Notes 2023 - Cardiology:
"An exaggerated hypertensive response during exercise is predictive of future hypertension. Treatment with antihypertensive agents such as thiazides may be warranted." MCCQE1 Objectives (Internal Medicine > 31-1: Hypertension and Risk Management):
"Candidates must identify abnormal BP responses to exercise and initiate appropriate treatment." Reassurance alone (A) ignores the hypertensive response. Catheterization (C) and beta-blockers (D) are unnecessary without ischemia. Advising against exercise (B) is counterproductive in a young, otherwise healthy patient.
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NEW QUESTION # 82
A 56-year-old woman with a 4-year history of fibromyalgia presents for follow-up. She reports that she is struggling with her health and daily life. She is unhappy with her lack of progress and says she feels tired all the time and stays in bed all day. When asked why, she states she is confused about why she is not getting better. Physical exam and investigations are unchanged from baseline. Which one of the following is the best next step?
Answer: B
Explanation:
Patient education is foundational in managing fibromyalgia. Understanding the chronic but non-progressive nature of the disease, reassurance, and emphasis on self-management are crucial. It helps set realistic expectations and enhances engagement in therapy.
Toronto Notes 2023 - Rheumatology, Fibromyalgia:
"Patient education is essential. Explain the nature of fibromyalgia, emphasizing that although it is chronic, it is non-deforming and can be managed through exercise, sleep hygiene, and cognitive strategies." MCCQE1 Objectives - Psychiatry & Rheumatology > Chronic Pain Syndromes:
"Candidates must recognize the value of education and behavioral interventions in managing functional syndromes." SSRIs (D) may be used if depression is present. Iron/B12 (B) are not indicated without evidence of deficiency. Cannabinoids (A) lack strong evidence in fibromyalgia.
NEW QUESTION # 83
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