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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Physician Activities | 50% | - Communication - Professional Behaviours - Management - Psychosocial Aspects |
| Topic 2: Dimensions of Care | 50% | - Chronic Care - Health Promotion and Illness Prevention - Assessment and Diagnosis - Acute Care |
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質問 # 282
A 72-year-old woman presents with swelling of her right leg that developed overnight. She had an abdominal hysterectomy 10 days ago. On examination, there is pitting edema of the leg that extends from the foot to the groin. The calf is 3 cm larger in diameter than the calf on the left leg. Which one of the following is the most likely diagnosis?
正解：D
解説：
This patient has classic features of proximal deep vein thrombosis (DVT) after recent major pelvic surgery:
acute unilateral leg swelling with pitting edema and a significant calf circumference difference ( > 3 cm). The edema extending from foot to groin strongly suggests a proximal (iliofemoral) thrombosis, which produces more extensive swelling than calf-vein DVT because venous outflow from the entire limb is impaired.
MCCQE objectives highlight postoperative patients as high risk for venous thromboembolism due to immobility, endothelial injury, and hypercoagulability.
Superficial thrombophlebitis typically causes a localized, tender, palpable cord along a superficial vein rather than diffuse whole-leg edema. Phlegmasia cerulea dolens is a severe, limb-threatening form of massive DVT characterized by marked pain, tense
質問 # 283
A 47-year-old man presents to the office with a 1-month history of passing blood in his stool 2 to 3 times per week. He is otherwise healthy and denies any systemic symptoms. Other than a small lateral skin tag on digital rectal examination, the physical examination findings are unremarkable. Which one of the following is the best next step?
正解：A
解説：
Visible rectal bleeding, even in the absence of systemic symptoms, warrants diagnostic colonoscopy to rule out colorectal cancer, polyps, or IBD-especially in adults over 40. FIT is for asymptomatic screening only.
Toronto Notes 2023 - Gastroenterology, "Approach to Lower GI Bleeding":
"In patients with overt rectal bleeding, colonoscopy is the investigation of choice regardless of age or FIT status." MCCQE1 Objectives (Internal Medicine > Gastroenterology > 47-1):
"Candidates must evaluate rectal bleeding with colonoscopy, even in the presence of minor findings on physical exam (e.g., skin tag)." FIT (A) is not appropriate for symptomatic patients. CEA (D) is a tumor marker for surveillance, not diagnosis. CT colonography (C) is less sensitive for lesions than colonoscopy.
質問 # 284
A 70-year-old hypertensive woman with a history of congestive heart failure (CHF) secondary to left ventricular dysfunction presents to your office with a persistent dry hacking cough. She claims it began when she was started on ramipril. Which one of the following medications would be most appropriate to replace ramipril, to ensure that the risk of morbidity associated with CHF remains low?
正解：C
解説：
ACE inhibitors such as ramipril are first-line for CHF with reduced ejection fraction, but a common adverse effect is a dry cough due to bradykinin accumulation. Angiotensin II receptor blockers (ARBs) offer the same hemodynamic and survival benefits without causing cough.
Toronto Notes 2023 - Cardiology, "Heart Failure" Section:
"In patients intolerant to ACE inhibitors due to cough, an ARB (e.g., losartan, valsartan) is the recommended substitute. ARBs also reduce mortality and hospitalizations in heart failure with reduced ejection fraction." MCCQE1 Objectives (Internal Medicine > 76-3: Congestive Heart Failure):
"Candidates should recognize ARBs as an alternative to ACE inhibitors in patients who develop adverse effects such as cough, while maintaining the mortality benefit." Other options (B-E) do not offer mortality benefits in CHF and may worsen the condition (e.g., CCBs, alpha- blockers, NSAIDs like COX-2 inhibitors).
質問 # 285
A 3.5-year-old girl has developed a stutter in the last 3 months. She repeats whole words several times before finishing a sentence. Her paternal uncle had a severe stuttering issue as a child. She has reached the developmental milestones for her age. Her new sibling was born 4 months ago. Which one of the following is the best next step?
正解：D
解説：
This presentation describesnormal developmental dysfluency, which typically occurs between ages 2-5 and often worsens duringtimes of stress or change, such as a new sibling. It is characterized byword repetition and does not require intervention unless it persists >6 months, worsens, or causes distress.
Toronto Notes 2023 - Pediatrics, "Developmental and Behavioral Pediatrics" Section:
"Developmental stuttering is common between 2-5 years and often resolves without intervention.
Reassurance is appropriate unless there are signs of persistent or severe stuttering, secondary behaviors, or parental concern." MCCQE1 Objectives (Pediatrics > 78-1: Development and Behavior):
"Candidates must recognize typical patterns of developmental speech dysfluency and differentiate them from pathological speech disorders. Observation and reassurance are often the appropriate initial step." Because the child is otherwise developing normally and the onset coincides with a known psychosocial stressor,reassuranceis the most appropriate step. Formal speech or behavioral therapy is not indicated at this time.
質問 # 286
A 14-year-old girl, accompanied by her mother, presents to your office with a 3-month history of feeling " dizzy. " After you take an initial history, which one of the following is the most appropriate next step?
正解：B
解説：
In adolescents presenting with vague or potentially sensitive symptoms, it is critical to speak with them alone to obtain a complete and honest history, including mental health, sexual activity, substance use, and abuse screening.
Toronto Notes 2023 - Pediatrics, Adolescent Medicine:
"Private interviews are essential to obtain accurate histories in adolescents, especially when symptoms may have underlying psychosocial or reproductive causes." MCCQE1 Objectives - Pediatrics > Adolescent Health:
"Candidates must demonstrate adolescent-appropriate interviewing techniques, including private questioning to identify sensitive or risk-related concerns." Physical examination and pregnancy testing (A, B, D) may follow based on the private history. Vital signs (E) are standard but do not replace psychosocial assessment.
質問 # 287
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