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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Scholar
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NEW QUESTION # 60
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: E
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 # 61
A new patient, a 19-year-old man, presents to your office with low back pain. He has a history of opioid dependence and is now on a methadone maintenance treatment program. He is requesting opiate analgesics.
After examination, you decide not to prescribe opiates for pain control. The patient gets upset and threatens to file a complaint with your licensing authority. Which one of the following is the best next step?
Answer: A
Explanation:
MCCQE ELOM objectives stress that physicians must prescribe controlled substances responsibly, use evidence-based pain management, and maintain professional boundaries despite pressure or threats of complaints. A threat to complain does not obligate opioid prescribing, especially in a patient with opioid use disorder where opioids increase risk of relapse, overdose, and diversion. The appropriate response is to remain calm, document the assessment and rationale, and ensure the patient is offered safe alternatives and continuity of care. Directing him to his methadone maintenance program is best because it supports coordinated management within an established addiction-treatment framework (often with structured monitoring, agreements, and access to addiction/pain expertise).
Prescribing "a small amount" or giving an injection undermines safe prescribing practices and reinforces drug- seeking behavior. Calling police is reserved for immediate safety threats, not dissatisfaction. Lumbar radiography is not the next step unless red flags are present; it does not address the ethical issue. Coordinated care with the methadone program and non-opioid strategies is the safest, most appropriate action.
NEW QUESTION # 62
While covering for a colleague away on holidays, you receive the following laboratory results for one of her patients, a 24-year-old woman:
White blood cell count: 10 × 10#/L (4-10)
Hemoglobin: 80 g/L (123-157)
Mean corpuscular volume: 76 fL (80-100)
Platelet count: 150 × 10#/L (130-400)
You have arranged a follow-up appointment for the patient with your colleague. Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
These results show a significant anemia (Hb 80 g/L) with microcytosis (MCV 76 fL) and otherwise preserved cell lines (WBC at the upper end of normal; platelets normal). MCCQE objectives emphasize using CBC patterns to classify anemia and prioritize common causes. In a young woman, the most likely cause of microcytic anemia is iron deficiency , most often due to menstrual blood loss and/or inadequate iron intake, and it can be severe.
Leukemia and myelodysplasia typically present with abnormalities in multiple cell lines (e.g., leukocytosis with blasts or cytopenias) and are less consistent with an isolated microcytic anemia and normal platelets.
Anemia of chronic disease is usually normocytic or mildly microcytic and is less likely to produce such a low hemoglobin without an obvious chronic inflammatory condition. Thalassemia trait classically has marked microcytosis with relatively preserved hemoglobin (often only mild anemia) and is suggested by a lifelong history and family/ethnic background. The next clinical step (at follow-up) would be iron studies (ferritin first) and assessment for bleeding sources.
NEW QUESTION # 63
A 21-year-old man presents to the office with persistent pain and swelling of the wrist 2 weeks after falling on his outstretched hand. Anteroposterior and lateral radiographs of the wrist taken at the time of the injury showed no evidence of fracture or dislocation. Which one of the following is the most likely cause of the patient's symptoms?
Answer: A
Explanation:
Scaphoid fractures are often radiographically occult on initial presentation and can present later with persistent pain and swelling in the anatomical snuffbox. They typically occur following a fall on an outstretched hand. If missed, they can lead to avascular necrosis.
Toronto Notes 2023 - Orthopedics, Wrist Injuries:
"Scaphoid fractures are the most common carpal fractures. X-rays may be negative early, so high suspicion requires immobilization and repeat imaging after 10-14 days." MCCQE1 Objectives - Surgery > Musculoskeletal Trauma:
"Candidates must recognize that some fractures, such as scaphoid, may not appear on initial imaging but require clinical suspicion and follow-up imaging or immobilization." Other options (B and C) are less likely without radiographic evidence. De Quervain tenosynovitis (D) presents with radial wrist pain unrelated to trauma and worsens with thumb movement.
NEW QUESTION # 64
A 42-year-old man presents with a history of fatigue and weight loss. He looks unwell, has a darker than usual complexion and his liver is enlarged. He is also found to have marked glycosuria. Which one of the following is the most useful diagnostic test?
Answer: C
Explanation:
This presentation suggests hereditary hemochromatosis. Common features include hyperpigmentation ("bronze diabetes"), hepatomegaly, diabetes, fatigue, and elevated liver enzymes. Serum ferritin is a screening test for iron overload, and elevated levels support the diagnosis.
Toronto Notes 2023 - Endocrinology / Gastroenterology:
"Hemochromatosis presents with skin hyperpigmentation, hepatomegaly, diabetes, fatigue. Diagnosis begins with serum ferritin and transferrin saturation." MCCQE1 Objectives (Internal Medicine > Metabolic and Endocrine > 37-1):
"Candidates must investigate iron overload syndromes using ferritin and transferrin saturation." Cortisol (B) is for adrenal insufficiency. A1AT (C) is a liver disease cause but not typical here. Amylase (E) is for pancreatitis. A1c (A) would confirm diabetes but not the underlying cause.
NEW QUESTION # 65
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