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| Section | Objectives |
|---|---|
| Topic 1: Dimensions of Care | - Chronic Care
|
| Topic 2: Physician Activities | - Communication
|
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NEW QUESTION # 287
A 1-month-old breastfed baby is brought to your office by his parents for his well-baby check-up. He was born at 32 weeks' gestation. Growth parameters at birth revealed head circumference, weight and length at the
50th percentile. Today, his weight is at the 10th percentile. Which one of the following is the most appropriate plan of action?
Answer: D
Explanation:
This infant was born at 32 weeks' gestation and therefore growth must be interpreted using corrected (adjusted) age , not chronological age. At 1 month chronological age, his corrected age is approximately term (40 weeks). MCCQE pediatric objectives emphasize that preterm infants commonly shift percentiles after birth due to expected postnatal fluid changes and adaptation. A drop from the 50th to the 10th percentile in the first month-particularly in a clinically well, breastfed infant-can be normal when plotted appropriately on preterm growth charts and corrected for gestational age. There is no information suggesting feeding difficulty, malabsorption, or systemic illness. A sweat chloride test (for cystic fibrosis) or celiac serology is not indicated in a thriving 1-month-old infant. Routine formula supplementation is unnecessary without evidence of poor intake or failure to thrive. The appropriate management is reassurance, continued monitoring of growth using corrected age, and support for breastfeeding, with follow-up to ensure appropriate weight gain trajectory.
NEW QUESTION # 288
A 26-year-old woman, gravida 2, para 2, aborta 0, has just delivered a full-term newborn via spontaneous vaginal delivery after 4 hours of labor. Following oxytocin administration and placental expulsion, there continues to be a steady trickle of bright red blood from her vagina. On examination, the placenta is intact and the fundus feels firm. Her vital signs are within normal range.
Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
In postpartum hemorrhage with a firm uterine fundus and intact placenta, a common cause is trauma such as a vaginal or cervical tear. Uterine atony (A) typically presents with a boggy uterus. The absence of systemic instability or coagulopathy makes options D and E less likely.
Toronto Notes 2023 - Obstetrics, Postpartum Hemorrhage:
"Continued bleeding despite a firm fundus and intact placenta should raise suspicion for genital tract trauma, especially cervical or vaginal lacerations." MCCQE1 Objectives - Obstetrics > Postpartum Complications:
"Candidates must differentiate causes of postpartum hemorrhage and identify when bleeding is due to trauma vs uterine atony."
NEW QUESTION # 289
A 42-year-old woman is admitted to the Intensive Care Unit with a massive pulmonary embolism. Her condition is stabilized with intubation, hydration, inotropic support, and intravenous administration of heparin. Her partner provides you with a list of her medications. A combination oral contraceptive pill was recently prescribed. She smokes tobacco cigarettes, and her BMI is 36. Which one of the following is the best next step?
Answer: B
Explanation:
Oral contraceptives increase the risk of thromboembolic events, particularly in patients with risk factors such as smoking and obesity. However, informing the patient's partner of potential contributing factors in a factual, non-judgmental manner is appropriate and does not imply fault.
Toronto Notes 2023 - ELOM, "Informed Consent and Risk Communication":
"Patients and families should be informed of all relevant information, including potential drug-related adverse events. Blame must not be assigned without full investigation." MCCQE1 Objectives (ELOM > 90-2: Physician-Patient Communication):
"Candidates must be able to communicate adverse outcomes factually, while respecting confidentiality and without prematurely assigning fault." Discussing the case with the ethics committee or reporting the prescribing doctor without context is premature and inappropriate (A, D). Telling the partner the physician was at fault (C) is speculative and unethical.
NEW QUESTION # 290
A 19-year-old primigravid woman presents to the office with a rapid increase of abdominal girth and shortness of breath. Her pregnancy is at 27 weeks' gestation, as confirmed by early ultrasonogram. The symphysis-fundal height is 45 cm. The fetal heart rate is 150/min (110-160). Which one of the following is the most likely diagnosis?
Answer: E
Explanation:
Polyhydramnios is the most likely diagnosis given the rapid increase in abdominal girth , maternal shortness of breath , and a symphysis-fundal height (45 cm) significantly greater than expected for 27 weeks' gestation.
MCCQE objectives emphasize that fundal height should approximately correspond (±2-3 cm) to gestational age in weeks after 20 weeks. A discrepancy this large suggests excessive amniotic fluid volume.
Polyhydramnios leads to uterine overdistension, which explains dyspnea and rapid abdominal enlargement.
Twin pregnancy can cause a large fundal height, but early ultrasound confirmation of gestational age would likely have identified multiple gestation. Partial mole is typically associated with abnormal bleeding and abnormal fetal findings. Fetal macrosomia increases fundal height but usually not to this degree at 27 weeks and is more gradual. Ovarian tumor with ascites is less likely in a confirmed intrauterine pregnancy with normal fetal heart rate. Polyhydramnios is commonly associated with maternal diabetes or fetal anomalies affecting swallowing and requires further evaluation with ultrasound and glucose screening.
NEW QUESTION # 291
A 70-year-old man presents with severe, postprandial, mid-abdominal pain which has become more severe over the past 6 to 9 months. It is associated with nausea but has not caused him to vomit or changed his bowel habits. He has lost 14 kg over the last 6 months. Abdominal and rectal examination is normal. Upper gastrointestinal series is unremarkable. Which one of the following is the most likely diagnosis?
Answer: A
Explanation:
Chronic mesenteric ischemia (also known as "intestinal angina") presents as postprandial abdominal pain, leading to food avoidance and significant weight loss. GI exams may be normal. Imaging (e.g., angiography or CT angio) confirms the diagnosis.
Toronto Notes 2023 - Gastroenterology, "Chronic Mesenteric Ischemia":
"Classic triad: postprandial abdominal pain, weight loss, and food aversion. Physical exam and GI series may be normal." MCCQE1 Objectives (Gastroenterology > 47-1: Abdominal Pain):
"Candidates must suspect mesenteric ischemia in older adults with risk factors and postprandial pain leading to weight loss." PUD (A) usually causes epigastric pain relieved by food. Cholelithiasis (B) causes RUQ pain. Colon cancer (D) presents with altered bowel habits or bleeding. Mesenteric adenitis (C) occurs in younger patients, often with infection.
NEW QUESTION # 292
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