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| Section | Objectives |
|---|---|
| Topic 1: Dimensions of Care | - Acute Care
|
| Topic 2: Physician Activities | - Assessment
|
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25. Frage
A prepubertal 9-year-old girl with severe developmental disability is brought to your office by her parents.
They are seeing you to discuss some difficulties that might occur with puberty. They are afraid that menses will complicate hygiene care and they have heard of significant mood/behavioural changes in this population when menses occur. Which one of the following recommendations is the most appropriate?
Antwort: D
Begründung:
In girls with developmental disabilities, menstrual management should follow the same ethical and clinical principles as for other adolescents, emphasizing least invasive, reversible options and respect for future autonomy. Menstrual suppression may be appropriate to assist with hygiene and quality of life; however, hormonal methods are generally initiated after the onset of menarche to confirm pubertal development and exclude underlying endocrine disorders. Therefore, extended progestin-only therapy (e.g., depot medroxyprogesterone acetate) should not be started before menses begin. Hysterectomy is inappropriate as first-line management due to its irreversible nature, surgical risks, and significant ethical concerns regarding sterilization. Continuous combined oral contraceptives are not contraindicated and are commonly used for therapeutic amenorrhea. Evidence does not show consistent worsening of behavioural symptoms with appropriate hormonal suppression. Girls with developmental disabilities typically experience normal pubertal progression. MCCQE objectives emphasize patient-centered care, least restrictive interventions, ethical considerations in consent and capacity, and appropriate menstrual management strategies in adolescents with special needs.
26. Frage
You have just completed a well-baby check on a 6-month-old in the office where you have recently begun to practice. You ask the registered nurse to give the immunizations. She refuses, saying this is not within her scope of practice. Which one of the following is the best next step?
Antwort: D
Begründung:
MCCQE ELOM objectives emphasize patient safety, appropriate delegation, and respecting professional scope of practice. If a nurse states an activity is outside their scope (or they are not authorized/competent in that setting), the physician should not pressure or coerce them to perform it. Delegation requires that the delegated act is permitted by regulation and workplace policy, that the person has the competence to perform it, and that appropriate supports/medical directives exist. Supervision alone does not make an out-of-scope act acceptable, so offering to "be present" does not address the underlying legal/professional boundary.
Escalating immediately to the regulator is inappropriate without first clarifying the issue locally, and simply
"refraining from asking again" fails to ensure the infant receives indicated care today.
The best immediate step is to ensure timely care by administering the immunizations yourself. Afterward, discuss the matter with the nurse to clarify clinic policy, required medical directives, training/competency, and how immunizations should be handled in this practice going forward (e.g., establishing protocols so authorized staff can provide vaccines safely).
27. Frage
A 38-year-old man is brought by his wife to the Emergency Department with fatigue, dizziness, and nausea after completing a hiking tour on a hot, humid day. His wife became worried after he had collapsed. He has been sweating heavily and vomited twice on the drive in. His medical history is unremarkable, and he takes no medications. His vital signs on arrival are as follows:
Blood pressure
85/57 mm Hg
Heart rate
120/min
Respiratory rate
18/min
Temperature
40.1 °C
Oxygen saturation
95%, room air
-
On physical examination, the patient's skin is dry, flushed, and warm to the touch. He has a diffuse erythematous papular rash. Findings of a thorough physical examination are otherwise unremarkable. An electrocardiogram shows sinus tachycardia. Which one of the following is the best next step?
Antwort: D
Begründung:
This patient has classic features of exertional heat stroke-hyperthermia, hypotension, CNS symptoms (collapse), and hot, dry skin. A key complication of heat stroke is rhabdomyolysis, which can cause renal failure. Serum creatine kinase (CK) is the best next diagnostic step to confirm muscle breakdown.
Toronto Notes 2023 - Emergency Medicine, "Environmental Exposures":
"In heat stroke, check for rhabdomyolysis (#CK), renal impairment, and coagulopathy. Prompt cooling and hydration are critical." MCCQE1 Objectives (Internal Medicine > 59-3: Environmental and Toxic Exposures):
"Candidates must recognize heat-related illnesses and investigate for complications such as rhabdomyolysis and acute kidney injury." CT head (C) is not indicated unless persistent neurological symptoms. TSH (B), CRP (D), and blood cultures (E) are irrelevant to acute exertional hyperthermia.
28. Frage
A 40-year-old woman presents with a 3-month history of discharge from her right nipple. The discharge was initially milky white, but over the last 2 weeks, the patient has noted blood stains on her bra. There is mild discomfort in the same breast around the time of menses periods. On physical examination, the upper outer quadrant of the breast is tender, but there are no palpable lumps. You are able to express fluid from the nipple which is in fact blood-tinged. Which one of the following is the most likely diagnosis?
Antwort: A
Begründung:
Intraductal papilloma is the most likely diagnosis because it classically presents with spontaneous unilateral bloody or blood-tinged nipple discharge in a woman aged 30-50 years, often without a palpable mass.
MCCQE objectives emphasize that the most common cause of pathologic nipple discharge (unilateral, spontaneous, from a single duct, and bloody/serous) is intraductal papilloma. These benign tumors arise within a lactiferous duct and can cause intermittent bleeding.
Ductal carcinoma in situ (DCIS) may cause nipple discharge but more often presents with mammographic microcalcifications and may have an associated mass. Mammary duct ectasia typically occurs in perimenopausal women and causes thick, greenish or multicolored discharge rather than bloody discharge.
Staphylococcal infection (mastitis) presents with erythema, warmth, systemic symptoms, and purulent discharge. Paget disease involves eczematous changes of the nipple-areolar complex with underlying malignancy, not isolated bloody discharge without skin changes.
Therefore, in a 40-year-old woman with unilateral blood-tinged discharge and no palpable mass, intraductal papilloma is the most likely diagnosis and warrants further imaging and surgical evaluation.
29. Frage
A 3-year-old boy is brought to the office because he is not using his right arm after a fall from a swing.
Radiographs reveal a new fracture and old healing fractures. The parents deny any previous injuries. In addition to providing care for the fracture, which one of the following is the best next step?
Antwort: A
Begründung:
The clinical presentation ofmultiple fractures at different stages of healingin a young child raisesstrong suspicion of physical abuse(non-accidental trauma). In such situations,mandatory reporting to child protection services is legally and ethically required, even in the absence of parental admission or clear history.
Toronto Notes 2023 - Pediatrics, Child Maltreatment Section:
"Red flags include inconsistent history, delay in seeking care, multiple injuries in various stages of healing, and injuries not consistent with developmental level. Health care professionals arelegally obligatedto report suspected child abuse or neglect to child protection authorities without delay." MCCQE1 Objectives (Medical Expert > Pediatrics > 77-2):
"The candidate must be able to recognize when the findings are consistent with child abuse... When child abuse is suspected,the physician has a legal obligation to report to the appropriate child protection agency immediately." Options B, C, D, and E do not address the immediate child safety risk and legal duty. Social work involvement (E) is supportive but must follow or accompany notification to child protection, not replace it.
30. Frage
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