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| Section | Objectives |
|---|---|
| Topic 1: Physician Activities | - Assessment
|
| Topic 2: Dimensions of Care | - Acute Care
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NEW QUESTION # 224
You are meeting an otherwise healthy 10-year-old boy in your office for the first time. His BMI is at the 80th percentile. He has no symptoms and his physical examination is normal. Which one of the following is the best next step?
Answer: B
Explanation:
Children with a BMI #85th percentile (overweight) and risk factors such as sedentary lifestyle or family history should be screened for cardiovascular risk. A fasting lipid profile is recommended starting at age 9-11 as part of universal screening per guidelines.
Toronto Notes 2023 - Pediatrics:
"Universal lipid screening is recommended for children aged 9-11 and 17-21. Children who are overweight should undergo targeted screening including fasting lipids." MCCQE1 Objectives (Pediatrics > 78-1: Preventive Pediatrics):
"Candidates must recognize screening indications for common pediatric risk factors, including dyslipidemia in overweight children." Thyroid and cortisol testing (C, D) are not indicated without symptoms. HbA1c (E) is used in children with BMI >95% or with additional diabetes risk factors.
NEW QUESTION # 225
A 36-year-old woman, gravida 1, para 0, aborta 0, presents to the Labour and Delivery unit of a primary care hospital. She is at 40 weeks' gestation. She is having contractions and leaking fluid. She is fearful and does not want to deliver vaginally. Which one of the following is the best next step?
Answer: B
Explanation:
The most appropriate next step is to explore her concerns and provide counselling regarding labour and pain management options . MCCQE objectives emphasize patient-centered care, informed decision-making, and respect for autonomy while ensuring that patients receive appropriate information about risks and benefits.
This patient is in active labour at term with ruptured membranes and expresses fear about vaginal delivery.
The immediate priority is to assess the source of her fear (pain, complications, prior trauma, misinformation) and provide education about available analgesia options (e.g., epidural, intravenous opioids, nonpharmacologic methods) and the relative risks and benefits of cesarean versus vaginal delivery.
Automatically arranging a cesarean without discussion is inappropriate, particularly in a primary care setting without clear medical indication. Conversely, refusing cesarean outright is paternalistic and fails to address her concerns. Analgesia may be appropriate but should follow exploration of her preferences. Therefore, empathetic discussion and shared decision-making are the best initial approach.
NEW QUESTION # 226
A 94-year-old woman with severe dementia is referred for vaginal bleeding and a persistent foul odour from the vagina. She lives in a long-term care facility. She has been using a ring pessary for the past 15 years. Her current pessary has not been replaced in 2 years. On examination, there is moderate vaginal atrophy. After removing the pessary, which one of the following is the best next step?
Answer: E
Explanation:
In elderly women with long-term pessary use and signs of vaginal atrophy (thin epithelium, bleeding, odor), local estrogen is the most appropriate initial treatment to restore the vaginal epithelium and reduce inflammation and discharge. Vaginal estrogen improves mucosal integrity and reduces complications like ulceration, infection, and bleeding.
Toronto Notes 2023 - Gynecology, "Pelvic Organ Prolapse and Pessary Care" Section:
"Local vaginal estrogen therapy is recommended for postmenopausal women with vaginal atrophy who are using pessaries. It reduces the risk of erosions, bleeding, and infection, especially when pessary follow-up has been suboptimal." MCCQE1 Objectives (Obstetrics and Gynecology > 82-9: Vaginal Bleeding in Postmenopausal Women):
"Candidates should recognize vaginal atrophy as a common and treatable cause of bleeding in elderly women using pessaries." A biopsy (E) may be needed if symptoms persist after atrophy is treated. Hysteroscopy (A) is invasive and not first-line in this setting. Metronidazole (B) is not indicated without evidence of bacterial vaginosis. Daily saline douching (D) is not recommended and may irritate atrophic mucosa.
NEW QUESTION # 227
A 68-year-old man with a history of diabetes, hypertension, delirium tremens, and tobacco addiction comes to the Emergency Department with his daughter. She tells you that his behavior has become unmanageable and she feels he may require an increased level of care. His vital signs are:
Blood pressure: 162/105 mm Hg
Heart rate: 112/min, regular
Temperature: 37.8°C
On history, his daughter explains she had to confiscate a half-empty bottle of alcohol from his room yesterday. He is now convinced that there are bugs crawling all over him and he will not relax. He appears pale, sweaty, and shaky. His most recent blood glucose is 7.8 mmol/L (3.8-11.1). Which one of the following is the best next step?
Answer: A
Explanation:
The presentation is consistent with acute alcohol withdrawal with delirium tremens: autonomic instability, agitation, visual hallucinations (formication), and recent alcohol reduction. This is a medical emergency requiring immediate treatment with benzodiazepines and supportive care.
Toronto Notes 2023 - Psychiatry, Substance Use Disorders:
"Delirium tremens is a life-threatening complication of alcohol withdrawal. Clinical features include agitation, hallucinations, tachycardia, hypertension, and diaphoresis. Management includes high-dose benzodiazepines and IV fluids." MCCQE1 Objectives - Psychiatry > Substance Use Disorders:
"Candidates must recognize and treat alcohol withdrawal delirium promptly with benzodiazepines and supportive measures." Antipsychotics (B) are not first-line in withdrawal states. Private interviews (A) and psychiatric consults (D) delay life-saving treatment.
NEW QUESTION # 228
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: B
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 # 229
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