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| Section | Objectives |
|---|---|
| Topic 1: Dimensions of Care | - Chronic Care
|
| Topic 2: Physician Activities | - Assessment
|
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問題 #43
A 47-year-old man presents to the office with a 1-month history of passing blood in his stool 2 to 3 times per week. He is otherwise healthy and denies any systemic symptoms. Other than a small lateral skin tag on digital rectal examination, the physical examination findings are unremarkable. Which one of the following is the best next step?
答案：A
解題說明：
Visible rectal bleeding, even in the absence of systemic symptoms, warrants diagnostic colonoscopy to rule out colorectal cancer, polyps, or IBD-especially in adults over 40. FIT is for asymptomatic screening only.
Toronto Notes 2023 - Gastroenterology, "Approach to Lower GI Bleeding":
"In patients with overt rectal bleeding, colonoscopy is the investigation of choice regardless of age or FIT status." MCCQE1 Objectives (Internal Medicine > Gastroenterology > 47-1):
"Candidates must evaluate rectal bleeding with colonoscopy, even in the presence of minor findings on physical exam (e.g., skin tag)." FIT (A) is not appropriate for symptomatic patients. CEA (D) is a tumor marker for surveillance, not diagnosis. CT colonography (C) is less sensitive for lesions than colonoscopy.
問題 #44
A 51-year-old man comes to your clinic for follow-up regarding his type 1 diabetes. His hemoglobin A1c is
12.5% (normal 4-6%). He has never had such high blood sugar results. He drinks 2 beers per night to help with sleep. He is not well rested because he has been sleeping on a friend's couch since losing his job last year. Which one of the following is the best next step?
答案：B
解題說明：
This patient is experiencing social instability (homelessness, job loss) likely contributing to poorly controlled diabetes. Before investigating or prescribing further, it is essential to address his ability to afford and manage self-monitoring and insulin.
Toronto Notes 2023 - Endocrinology, Diabetes:
"Social determinants such as housing insecurity and financial barriers significantly affect diabetes self- management. Addressing access to glucose monitoring and insulin is critical." MCCQE1 Objectives - Internal Medicine > Chronic Disease Management:
"Candidates must assess barriers to effective disease control, including financial and psychosocial limitations." Antidepressants (B) may be helpful later if depression is suspected. Thyroid testing (C) is not the priority. A dietitian (D) may help long-term, but immediate access and adherence are more urgent.
問題 #45
A 72-year-old man presents to your clinic accompanied by his 70-year-old husband. The patient reports that, over the last several months, his libido has been very low. Which one of the following would be the best next step?
答案：D
解題說明：
Comprehensive and Detailed Explanation:
Decreased libido in elderly patients can be multifactorial, but depression is a common and important cause that must be ruled out before hormone therapy or other steps. A proper mental health screen should precede further interventions.
Toronto Notes 2023 - Psychiatry / Geriatrics:
"In elderly men, reduced libido may be linked to depression, medical illness, or medications. Depression screening is essential." MCCQE1 Objectives (Psychiatry > 71-1: Mood Disorders / Sexual Health):
"Candidates must consider depression as a common cause of decreased libido and assess accordingly before initiating hormone therapy." Testosterone testing (D) may follow. Prescribing (C) is premature. Couples counselling (B) may help if interpersonal issues are identified. Interviewing together (A) may inhibit disclosure.
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問題 #46
A 56-year-old woman with a 4-year history of fibromyalgia presents for follow-up. She reports that she is struggling with her health and daily life. She is unhappy with her lack of progress and says she feels tired all the time and stays in bed all day. When asked why, she states she is confused about why she is not getting better. Physical exam and investigations are unchanged from baseline. Which one of the following is the best next step?
答案：B
解題說明：
Patient education is foundational in managing fibromyalgia. Understanding the chronic but non-progressive nature of the disease, reassurance, and emphasis on self-management are crucial. It helps set realistic expectations and enhances engagement in therapy.
Toronto Notes 2023 - Rheumatology, Fibromyalgia:
"Patient education is essential. Explain the nature of fibromyalgia, emphasizing that although it is chronic, it is non-deforming and can be managed through exercise, sleep hygiene, and cognitive strategies." MCCQE1 Objectives - Psychiatry & Rheumatology > Chronic Pain Syndromes:
"Candidates must recognize the value of education and behavioral interventions in managing functional syndromes." SSRIs (D) may be used if depression is present. Iron/B12 (B) are not indicated without evidence of deficiency. Cannabinoids (A) lack strong evidence in fibromyalgia.
問題 #47
You are asked to see a 30-year-old woman, gravida 8, para 4, aborta 1, for symptoms of postpartum depression. She immigrated to Canada 8 months ago. She has been reluctant to speak to members of the medical team without her family members, even when an interpreter is present. Which one of the following is the best next step?
答案：D
解題說明：
In cross-cultural care, especially for recent immigrants, it is essential to build rapport and respect patient preferences regarding family involvement. Involving family in the interview respects cultural norms and improves trust. A trained interpreter should be used to maintain confidentiality and accuracy, but collaboration with the family initially may encourage later private disclosure.
Toronto Notes 2023 - Ethics and Communication, "Cultural Competence":
"When encountering language or cultural barriers, patient comfort and cultural context must be respected.
Interviewing the patient and family together may facilitate trust, after which individual conversations may be possible." MCCQE1 Objectives (ELOM > 90-1: Communication and Patient-Centered Care):
"Candidates must approach patients in a culturally sensitive manner, particularly recent immigrants or those with language barriers, and foster trust." Insisting on a private interview (A) may alienate the patient. Family members should not act as interpreters (C). Written accounts (D) are inefficient and impersonal in acute mental health settings.
問題 #48
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