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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Health Advocate
|
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NEW QUESTION # 87
A 32-year-old woman presents to the office and reports that she feels unwell and tired. She is worried about long-standing episodic diarrhea and vague abdominal discomfort. Laboratory investigations reveal a hemoglobin of 90 g/L (123-157), mean corpuscular volume of 75 fL (80-100), and serum ferritin level of 4 µg
/L (11-307). Which one of the following tests is most likely to produce a diagnosis?
Answer: E
Explanation:
This patient has microcytic anemia (MCV 75 fL) with very low ferritin , confirming iron deficiency anemia.
In a young woman with chronic diarrhea and abdominal discomfort, MCCQE objectives emphasize investigating for malabsorption syndromes , particularly celiac disease . Iron deficiency may be the only presenting feature of celiac disease due to impaired absorption in the proximal small intestine (duodenum), where iron uptake normally occurs.
The most appropriate diagnostic test is IgA tissue transglutaminase (tTG) antibody , which is the recommended first-line serologic test for celiac disease. If positive, diagnosis is typically confirmed with small bowel biopsy. Total iron-binding capacity would only further characterize iron deficiency but would not identify the underlying cause. Fecal fat testing evaluates steatorrhea but is less specific and not first-line for suspected celiac disease. Stool cultures are indicated for acute infectious diarrhea. Helicobacter pylori infection may contribute to anemia but does not explain chronic malabsorptive symptoms.
Thus, IgA tTG testing is most likely to establish the underlying diagnosis.
NEW QUESTION # 88
An 18-year-old woman presents to the Emergency Department with a 3-day history of vomiting and right upper quadrant pain. She is alert but appears unwell and jaundiced. She was previously healthy and has not travelled recently. She has no risk factors for blood-borne pathogens. She denies hematemesis or hematochezia. On further history, she reports that she took a full bottle of pills that she found in her parents' medicine cabinet several hours before she started vomiting. Without intervention, which one of the following is the most likely outcome?
Answer: E
Explanation:
This is a classic presentation of acute acetaminophen (paracetamol) overdose. The most serious consequence, especially with delayed treatment, is fulminant hepatic failure.
Toronto Notes 2023 - Toxicology, Acetaminophen Toxicity:
"Acetaminophen overdose is the most common cause of acute liver failure. Delayed presentation leads to jaundice, coagulopathy, encephalopathy, and possible death." MCCQE1 Objectives - Internal Medicine > Toxicology:
"Candidates must identify acetaminophen overdose by clinical history and recognize fulminant hepatic failure as a primary complication." Cerebral edema (C) may occur secondarily, but fulminant hepatic failure is the most direct and expected outcome. Renal failure (B), arrhythmias (E), and seizures (A) are not typical with acetaminophen.
NEW QUESTION # 89
A 61-year-old man presents to the office for follow-up of recent laboratory test results. He has hypertension for which he takes amlodipine daily. His blood pressure is 148/94 mm Hg. His creatinine level is 140 µmol/L (normal 70-120), and his urine protein-to-creatinine ratio is persistently elevated. You would like to prescribe ramipril, but he refuses to take any additional medication. Which one of the following is the best next step?
Answer: B
Explanation:
Respecting patient autonomy requires understanding their perspective before offering persuasion or incentives. The best next step is to explore the reason for non-compliance. This builds rapport and informs a shared decision-making process.
Toronto Notes 2023 - ELOM, Patient-Centered Communication:
"When a patient refuses recommended treatment, explore the reason behind the refusal before proceeding.
Shared decision-making is crucial."
MCCQE1 Objectives - ELOM > Communication and Consent:
"Candidates must demonstrate an ability to explore reasons for treatment refusal before counseling or modifying management." Options B and C may follow later. Options D and E can undermine appropriate pharmacologic care or violate ethics if not consented.
NEW QUESTION # 90
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?
Answer: A
Explanation:
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.
NEW QUESTION # 91
A 6-year-old boy is brought to the Emergency Department by his daycare provider because he has an injured left arm. Physical examination findings show a swollen left arm just below the shoulder and bruising around both knees and the upper right arm. Radiographs of the left arm show a fracture with early callus formation around the proximal humeral shaft. Which one of the following is the most important next step?
Answer: A
Explanation:
This presentation is classic for Zenker diverticulum, characterized by progressive dysphagia, regurgitation of undigested food, coughing, and halitosis due to food retention in a pharyngoesophageal pouch. Symptoms are chronic and episodic, often involving regurgitation hours after eating. MCCQE objectives emphasize selecting the safest and most appropriate diagnostic test. The best initial test is a barium swallow (contrast esophagram), which clearly visualizes the posterior outpouching above the upper esophageal sphincter.
Endoscopy is not the first step because there is a risk of perforation if a large diverticulum is present. pH monitoring and PPI trials are used for gastroesophageal reflux disease, which does not explain regurgitation of undigested food and halitosis. CT chest is unnecessary for diagnosis.
Therefore, a barium swallow is the safest and most informative investigation to confirm suspected Zenker diverticulum before considering surgical or endoscopic management.
NEW QUESTION # 92
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