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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Health Advocate
|
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NEW QUESTION # 240
A 31-year-old woman, gravida 4, para 3, aborta 0, presents at 8 weeks' gestation with scant vaginal bleeding and no abdominal pain. Her heart rate is 90/min and blood pressure is 100/70 mm Hg. A speculum examination reveals a closed cervix. The beta-human chorionic gonadotropin level is 300,000 IU/L. Which one of the following is the most likely diagnosis?
Answer: C
Explanation:
A molar pregnancy (gestational trophoblastic disease) is the most likely diagnosis because the #-hCG level is markedly elevated (300,000 IU/L) for an 8-week gestation, far exceeding typical levels for a normal intrauterine pregnancy. MCCQE objectives highlight that unusually high #-hCG-often accompanied by first- trimester bleeding-should raise strong suspicion for a hydatidiform mole. Bleeding is common due to abnormal trophoblastic proliferation and placental separation. A closed cervix does not exclude a molar pregnancy; it simply indicates that products of conception are not being expelled at the time of exam.
Ectopic (tubal) pregnancy more often presents with abdominal/pelvic pain and typically has lower or inappropriately rising #-hCG. Incomplete abortion usually features heavier bleeding, cramping, and an open cervix. Threatened abortion involves bleeding with a closed cervix but does not explain an extremely high #- hCG. Implantation bleeding occurs earlier (around the time of missed menses), not at 8 weeks, and would not be associated with very high #-hCG.
NEW QUESTION # 241
A 45-year-old man presents to your family practice for follow-up because he has had repeated transient ischemic attacks and had been advised not to drive. During the interview, you find out that he is still driving.
He explains that he only drives to the grocery store and his wife, who also has a driver's license, is always a passenger with him. He insists he can drive. You think that he should no longer be driving a car. Which one of the following is the best next step?
Answer: D
Explanation:
In most Canadian provinces and territories, physicians are legally obligated to report patients who pose a danger due to medical conditions affecting driving ability. Given the history of TIAs and continued unsafe driving, reporting is necessary for public safety.
Toronto Notes 2023 - ELOM, "Fitness to Drive" Section:
"Physicians must report to motor vehicle authorities if a patient poses a risk to public safety due to a medical condition. TIAs are considered reportable if they impair ability and the patient does not comply with driving restrictions." MCCQE1 Objectives (ELOM > 99-1: Medical Fitness and Reporting):
"Candidates must recognize situations requiring mandatory reporting of patients unfit to drive due to neurologic or other impairing conditions." You may still discuss with the patient (B), but this does not replace the duty to report. Physically taking the license (C) is illegal. Refusing care (D) is unethical. A neurologist (E) could be helpful but would delay action in a clear case.
NEW QUESTION # 242
A 79-year-old woman presents to the Emergency Department with sudden-onset severe chest and back pain that started 1 hour ago. She has a history of hypertension and looks unwell. Her vital signs are as follows:
blood pressure 168/108 mm Hg, heart rate 110/min, respiratory rate 22/min, temperature 36.7°C. Findings of a physical examination of the chest and abdomen are normal. An urgent computed tomography (CT) scan of the chest and abdomen shows an aortic dissection extending from the descending thoracic aorta to the upper abdominal aorta. The branches of the abdominal aorta are patent. Following initial resuscitation, which one of the following is the best next step?
Answer: C
Explanation:
This patient has a Stanford type B aortic dissection , involving the descending thoracic aorta distal to the left subclavian artery, with no evidence of branch vessel compromise or rupture. MCCQE objectives emphasize that uncomplicated type B dissections are managed medically , whereas type A dissections (ascending aorta) require urgent surgical repair.
The immediate priority is to reduce shear stress on the aortic wall by controlling heart rate and blood pressure
. Intravenous beta-blockers such as labetalol or esmolol are first-line therapy. The goal is to reduce heart rate to approximately 60 bpm and lower systolic blood pressure to 100-120 mm Hg. This decreases the force of left ventricular contraction (dP/dt), limiting propagation of the dissection.
Endovascular or open repair is reserved for complicated cases (e.g., malperfusion, rupture, refractory pain, uncontrolled hypertension). Anticoagulation with heparin is contraindicated due to bleeding risk. Observation alone without blood pressure control is inappropriate.
Therefore, intravenous labetalol is the best next step.
NEW QUESTION # 243
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?
Answer: C
Explanation:
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).
NEW QUESTION # 244
A 34-year-old man with trisomy 21 is brought to the Emergency Department because of a painful, red great toe. He is accompanied by an older woman who begins giving you the history as you enter the room. The patient is sitting on the examination table with the foot exposed, but he does not speak. Which one of the following is the best next step?
Answer: C
Explanation:
Patients with developmental disabilities must still be engaged directly unless clearly incapable. It is vital to first establish the companion's relationship to the patient and give the patient the opportunity to communicate.
Toronto Notes 2023 - ELOM, Consent and Capacity:
"Presume capacity in adults with developmental disabilities unless proven otherwise. Direct communication with the patient is essential, and the identity of accompanying individuals should be clarified." MCCQE1 Objectives - ELOM > Patient Autonomy and Consent:
"Candidates must respect patient autonomy and include developmentally delayed individuals in medical discussions unless incapacity is determined." Options A and C delay establishing capacity and relationship. Option D is premature. Option E bypasses consent and interaction with the patient.
NEW QUESTION # 245
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