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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Physician Activities | 50% | - Professional Behaviours - Communication - Psychosocial Aspects - Management |
| Topic 2: Dimensions of Care | 50% | - Health Promotion and Illness Prevention - Chronic Care - Assessment and Diagnosis - Acute Care |
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NEW QUESTION # 304
A 17-year-old boy is brought by his 2 roommates to the emergency department (ED) after a party where he had been drinking and smoking cannabis. He reportedly was having a good time when he suddenly wanted to jump out of a window. His roommates describe him as "normal prior to a breakup with his girlfriend a week ago." He has since become anxious and unable to sleep. On examination, he is somnolent and appears intoxicated. Which one of the following is the most appropriate initial management?
Answer: A
Explanation:
This adolescent exhibited acute suicidal behavior (attempted to jump out of a window), which is a psychiatric emergency. Regardless of intoxication or cause, such behavior mandates a safety-first approach: involuntary psychiatric assessment and protection from self-harm.
Toronto Notes 2023 - Psychiatry, "Suicide and Crisis Intervention" Section:
"Involuntary psychiatric admission is indicated when a patient poses a danger to themselves or others.
Suicidal ideation or attempts require immediate evaluation and monitoring." MCCQE1 Objectives (Psychiatry > 79-2: Suicide and Risk Management):
"Candidates must identify suicidal behavior and initiate appropriate action, including involuntary admission if necessary for safety." Observation (B) may miss the window for action. Parents (A) should be contacted but are not a substitute for admission. Chlordiazepoxide (C) is not first-line in this scenario.
NEW QUESTION # 305
You are an attending physician at a palliative care unit and are asked to see an 80-year-old woman who is dying of lung cancer. She has been unresponsive for the last 2 days and had her last dose of morphine 4 hours ago. Her son just arrived in town this afternoon and pleads with you to wake her up so she can sign her will.
Which one of the following is the best next step?
Answer: A
Explanation:
At the end of life, decreasing consciousness and unresponsiveness are common and expected physiologic changes. MCCQE ELOM objectives emphasize prioritizing patient comfort, respecting goals of care, and communicating clearly with families about prognosis and the dying process. The best next step is to explain that her reduced level of consciousness is most consistent with imminent dying and that she is unlikely to have the decision-making capacity required to execute legal documents (capacity requires understanding and appreciation of the decision and its consequences).
Withholding morphine to attempt to increase alertness risks causing pain and dyspnea, violating the duty to relieve suffering. Administering naloxone is inappropriate because it may precipitate acute pain and distress and is not indicated when opioids are being used appropriately for symptom control. A legal opinion or ethics consult may be considered later if conflict persists, but the immediate priority is compassionate communication, clarifying that "waking her to sign" is unlikely feasible or ethically justified, and supporting the son through anticipatory grief while continuing comfort-focused care.
NEW QUESTION # 306
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 # 307
A 10-year-old boy and his mother present to your office with a concern about handwashing. The mother explains that her son has been at a new school for the past month and that teachers have noticed that he is washing his hands all day. He has also hidden hand sanitizer in his desk. The hand-cleaning is a response to a constant anxiety that his hands are dirty, and that he might pass an infection to someone. Which one of the following is the most appropriate initial management?
Answer: D
Explanation:
This child demonstrates classic features of obsessive-compulsive disorder (OCD): intrusive contamination fears (obsession) and repetitive handwashing behaviors (compulsion) performed to reduce anxiety. The symptoms are excessive, impairing school function, and persist beyond normal developmental concerns.
According to MCCQE objectives, first-line treatment for mild to moderate pediatric OCD is cognitive- behavioral therapy (CBT) with exposure and response prevention (ERP). ERP involves gradual exposure to feared contaminants while preventing the compulsive handwashing response, thereby reducing anxiety through habituation and cognitive restructuring. Pharmacologic treatment with selective serotonin reuptake inhibitors (e.g., fluoxetine) is indicated for moderate to severe cases or when CBT alone is insufficient, but it is not the preferred initial intervention when psychotherapy is accessible. Risperidone is not first-line and may be considered only as augmentation in refractory cases. Changing schools or providing a teaching assistant does not address the underlying anxiety disorder. Early evidence-based intervention improves prognosis and functional outcomes in pediatric OCD.
NEW QUESTION # 308
A 9-year-old girl from a remote community is brought to the clinic with a 2-week history of swelling in her neck. She has been afebrile but has had some night sweats. On examination, you note a fixed, unilateral, and nontender supraclavicular lymph node measuring 3 cm. The overlying skin color is unremarkable. In addition, you note a slightly enlarged spleen and liver. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
This child presents with "red flag" features for malignancy: a firm, fixed, nontender supraclavicular lymph node >2 cm in size, with associated hepatosplenomegaly and night sweats. These features are most concerning for lymphoma.
Toronto Notes 2023 - Pediatrics, "Lymphadenopathy in Children":
"Malignant lymphadenopathy tends to be firm, fixed, painless, and located in supraclavicular areas. Systemic signs (fever, weight loss, hepatosplenomegaly, night sweats) are concerning for lymphoma." MCCQE1 Objectives (Pediatrics > 78-3: Hematology/Oncology):
"Candidates should differentiate between benign and malignant lymphadenopathy and recognize features suggestive of lymphoma." Cat-scratch disease (B) is usually tender and associated with cat exposure. Kawasaki disease (C) presents with fever and mucocutaneous findings. Acute bacterial lymphadenitis (D) is painful, warm, and rapid in onset.
Viral lymphadenopathy (E) is often bilateral, small, and tender.
NEW QUESTION # 309
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