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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Medical Expert
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NEW QUESTION # 309
You are asked to assess an 85-year-old man who was admitted to the hospital for management of a bowel obstruction. The patient is in bed and has a faint pulse with no detectable blood pressure. There is vomitus on his bed and clothing. He has central cyanosis, and oxygen saturation is 75% on supplemental oxygen. Which one of the following is the best next step?
Answer: B
Explanation:
This patient is critically unstable with severe hypoxia (SpO# 75% despite oxygen), central cyanosis, hypotension (no detectable blood pressure), and evidence of active vomiting-placing him at extremely high risk of airway compromise and aspiration . According to MCCQE resuscitation objectives and ABC principles, airway management is the immediate priority in a patient with respiratory failure and compromised airway protection.
Endotracheal intubation provides definitive airway control, allows suctioning of vomitus, prevents further aspiration, and enables mechanical ventilation with high-concentration oxygen. Noninvasive ventilation is contraindicated in patients with vomiting and impaired airway protection due to high aspiration risk. Chest compressions are indicated only if there is no pulse; this patient has a faint pulse. Intravenous fluids are important for hypotension but must follow airway stabilization. Nasogastric tube insertion does not address the immediate life-threatening hypoxia.
Early definitive airway control in unstable patients with hypoxemia and aspiration risk is essential to prevent cardiac arrest and improve survival outcomes.
NEW QUESTION # 310
A 35-year-old woman presents to your clinic for follow-up regarding her persistent primary immune thrombocytopenic purpura. She was admitted to hospital with a relapse and received treatment with dexamethasone, intravenous immunoglobulin, and rituximab. She was recently discharged from hospital with a platelet count of 55 × 10#/L (130-360), and also continues to take 10 mg of prednisone once daily. She is scheduled for a splenectomy in 4 weeks. Which one of the following is the best next step in preparation for the patient ' s surgical procedure?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
Patients undergoing splenectomy are at lifelong risk for overwhelming post-splenectomy infection (OPSI), particularly from encapsulated organisms. Vaccination against Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis is recommended at least 2 weeks prior to elective splenectomy.
Toronto Notes 2023 - Hematology / Surgery:
"Patients undergoing elective splenectomy should receive vaccines against pneumococcus, H. influenzae type b, and meningococcus at least 2 weeks before surgery." MCCQE1 Objectives (Hematology > 38-2: Thrombocytopenia and Splenectomy):
"Candidates must ensure vaccination prior to splenectomy to prevent postsplenectomy sepsis." Calcium (B) may be considered in chronic steroid users but is not the priority. Azithromycin (C) is not indicated. D is unsafe without tapering. E is only for acute bleeding or extremely low platelets.
NEW QUESTION # 311
A 37-year-old woman diagnosed with schizophrenia comes to her family physician because she has been choking on her food lately. She has a history of mild spasmodic dysphonia. She was recently started on haloperidol for auditory hallucinations. Which one of the following is the best short-term management?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
This patient is likely experiencing extrapyramidal symptoms (dysphagia/dystonia) due to haloperidol.
Switching to an atypical antipsychotic (like quetiapine), which has a lower risk of EPS, is appropriate.
Dysphagia in the context of antipsychotic use requires prompt medication review.
Toronto Notes 2023 - Psychiatry, "Antipsychotics and Extrapyramidal Effects":
"Dysphagia can be a sign of extrapyramidal side effects. Consider switching to an atypical antipsychotic with lower EPS risk." MCCQE1 Objectives (Psychiatry > 71-5: Antipsychotic Adverse Effects):
"Candidates must recognize and manage EPS, including drug-induced dysphagia." Dantrolene (C) is for neuroleptic malignant syndrome, not isolated dysphagia. Laryngoscopy (B) may be useful later but not first-line. Reassurance (D) is unsafe. Lorazepam (E) may help in dystonia but doesn't address the root cause.
NEW QUESTION # 312
A 58-year-old woman presents to your office with heavy vaginal bleeding. She has a history of type 2 diabetes and hypertension. Some active bleeding is visible on speculum examination. Ultrasound reveals an endometrial thickness of 12 mm. Endometrial biopsy shows complex hyperplasia with atypia. Which one of the following is the best next step?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
Complex endometrial hyperplasia with atypia carries a high risk of progression to or concurrent endometrial carcinoma. Definitive management in postmenopausal women is total hysterectomy with bilateral salpingo- oophorectomy.
Toronto Notes 2023 - Gynecology, Abnormal Uterine Bleeding:
"Endometrial hyperplasia with atypia in postmenopausal women is best managed surgically due to the risk of malignancy." MCCQE1 Objectives - Gynecology > Postmenopausal Bleeding:
"Candidates should identify endometrial hyperplasia with atypia as an indication for hysterectomy in appropriate patients." Ablation (A) is contraindicated. Progesterone (B) is used for non-atypical hyperplasia. D&C (C) and hysteroscopy (D) are diagnostic but not definitive.
NEW QUESTION # 313
A 71-year-old man with stable chronic low back pain on hydromorphone (8 mg twice daily) presents upset, requesting an early refill. He reports his granddaughter has been stealing his medication and pressuring him for refills. Which one of the following is the best next step?
Answer: A
Explanation:
This case suggests diversion of prescription opioids, a serious safety and regulatory concern. The physician must balance maintaining patient care with minimizing risk. Daily dispensing via a monitored pharmacy is the safest and most practical solution to prevent misuse or theft, while avoiding immediate discontinuation of the patient's needed medication.
Toronto Notes 2023 - Chronic Pain & Substance Use:
"In cases of concern for opioid diversion, consider witnessed daily dispensing, prescription monitoring, and involving caregivers when appropriate." MCCQE1 Objectives (Internal Medicine > Pain Management > 56-2):
"The candidate must demonstrate understanding of strategies for safe prescribing and monitoring of controlled substances, including mitigation of diversion." Calling the police (A) is not the physician's immediate duty. Providing an early refill (B) worsens risk.
Tapering (C) may be appropriate later, but first the medication must be safeguarded. Increasing quantity (D) is inappropriate.
NEW QUESTION # 314
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