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| Section | Objectives |
|---|---|
| Dimensions of Care | - Psychosocial Aspects
|
| Physician Activities | - Assessment
|
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NEW QUESTION # 282
A 62-year-old woman presents with abdominal pain, fever and chills. She was hospitalized 4 weeks ago for sigmoid diverticulitis. She felt well after her discharge from hospital until 5 days ago when the fever started.
She is now anorexic. On examination, she has right upper quadrant pain and her temperature is 38.5 °C.
Which one of the following investigations is most likely to confirm the diagnosis?
Answer: A
Explanation:
This patient presents with fever, chills, anorexia, and right upper quadrant (RUQ) pain several weeks after hospitalization for sigmoid diverticulitis . A key complication of intra-abdominal infections such as diverticulitis is portal pylephlebitis with hepatic abscess formation , due to bacterial spread via the portal venous system. MCCQE objectives emphasize recognizing liver abscess as a delayed complication of intra- abdominal sepsis, particularly when new RUQ pain and fever develop after an initial abdominal infection.
The most appropriate initial imaging test to confirm this diagnosis is ultrasound of the abdomen , which can detect hepatic abscesses and guide further management. CT abdomen is also highly sensitive, but among the listed options, ultrasound is most appropriate.
Chest and abdominal radiographs are nonspecific. HIDA scan evaluates cystic duct obstruction in suspected acute cholecystitis, which is less likely given the recent diverticulitis and systemic features. ERCP is used for biliary obstruction or ascending cholangitis, typically associated with jaundice.
Thus, abdominal ultrasound is most likely to confirm a hepatic abscess.
NEW QUESTION # 283
A 24-year-old woman with chronic anorexia nervosa presents to the Emergency Department with diarrhea, chest pain and palpitations. She is noted to have a BMI of 13, a heart rate of 48/min, significant orthostatic hypotension and a temperature of 35.9 °C. Her electrocardiogram shows frequent premature ventricular contractions. Her blood work indicates elevated liver transaminases and evidence of acute kidney injury from dehydration. She agrees to admission for medical stabilization only if she does not receive fluids either orally or intravenously, as they will cause her to gain weight and to feel bloated. Which one of the following is the best next step?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
The most appropriate next step is to assess the patient's capacity to consent to or refuse treatment. Patients with severe anorexia nervosa may lack decision-making capacity due todistorted thinking and perception, particularly if refusal of treatment is life-threatening. If she is found incapable, treatment can proceed in her best interests.
Toronto Notes 2023 - Psychiatry / Ethics:
"If a patient with anorexia nervosa refuses treatment but is medically unstable, assess capacity. If incapable, substitute decision-making may be initiated." MCCQE1 Objectives (ELOM > 90-4: Informed Consent and Capacity):
"Candidates must assess decision-making capacity when a patient refuses essential care, especially in life- threatening psychiatric or medical conditions." Psychiatric consult (B) may follow, but the immediate action is capacity assessment. D is premature without determining capacity. A and E are also premature or inappropriate.
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NEW QUESTION # 284
A 35-year-old maintenance worker presents to your office because he thinks he has been exposed to asbestos and is afraid of developing asbestosis. He has no respiratory symptoms and is a non-smoker. Which one of the following is the best next step?
Answer: A
Explanation:
In any suspected occupational exposure, the first step is a detailed occupational history to assess the nature, intensity, and duration of the exposure. This determines whether surveillance or further testing is appropriate.
Toronto Notes 2023 - Respiratory Medicine, "Occupational Lung Diseases" Section:
"When a patient presents with concerns about exposure to occupational hazards such as asbestos, detailed history is essential. Ask about job tasks, duration of exposure, use of personal protective equipment, and prior workplace assessments." MCCQE1 Objectives (Population Health > 97-2: Environmental and Occupational Health):
"Candidates must be able to obtain a detailed environmental and occupational history and determine the risk of exposure before ordering investigations." Ordering a chest radiograph (B) or PFTs (E) without confirming meaningful exposure is premature. Referral to a specialist (D) and reassurance (A) come only after the exposure risk is assessed.
NEW QUESTION # 285
A 30-year-old woman presents to the office with her partner and reports that they are planning for her to conceive soon. They visited Mexico recently and are concerned about exposure to the Zika virus. Which one of the following is the best next step?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
The Zika virus can be sexually transmitted and poses a serious risk of congenital Zika syndrome if infection occurs during pregnancy. The CDC and WHO recommend that couples delay conception for at least 3 months after potential male exposure due to the virus's persistence in semen.
Toronto Notes 2023 - Infectious Diseases / Travel Medicine:
"Zika virus may persist in semen for weeks. Couples should delay conception for 3 months after male exposure, even if asymptomatic." MCCQE1 Objectives (Public Health > 65-3: Travel Medicine and Reproductive Health):
"Candidates must counsel appropriately regarding risks of Zika in conception and apply current public health recommendations." Testing (B) is not reliable for asymptomatic individuals. Antivirals (E) are ineffective. Condoms (D) do reduce risk. Specialist referral (A) is not needed in most cases with no complications.
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NEW QUESTION # 286
A 46-year-old woman with a palpable breast lump underwent diagnostic mammography that revealed a suspicious mass in her right breast. The radiologist recommended a breast biopsy. The referring physician did not see the mammogram report or the recommendation for biopsy. One year later, invasive breast cancer is diagnosed in the patient. Which one of the following is most likely to prevent this issue from happening again?
Answer: B
Explanation:
This case represents a failure of follow-up of a critical test result , a common systems error in ambulatory care. MCCQE ELOM objectives emphasize physician responsibility for ensuring that ordered investigations are reviewed, communicated, and acted upon appropriately. The most effective prevention strategy is implementing a system-level tracking process for all investigative reports, ensuring that results are received, reviewed, documented, and followed up-especially abnormal findings requiring urgent action.
Relying on ad hoc communication (e.g., radiologists phoning every result) is impractical and not sustainable.
Booking routine return appointments does not guarantee abnormal results are addressed in a timely manner.
Informing patients only if abnormal findings exist is insufficient, as missed reports may still go unnoticed.
Asking patients to retrieve their own results shifts professional responsibility inappropriately.
A structured tracking system (e.g., electronic alerts, mandatory acknowledgment of results, reconciliation logs) reduces missed diagnoses and enhances patient safety. This systems-based approach aligns with quality improvement principles and shared accountability in healthcare delivery.
NEW QUESTION # 287
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