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| Section | Weight | Objectives |
|---|---|---|
| Physician Activities | 50% | - Management - Communication - Professional Behaviours - Psychosocial Aspects |
| Dimensions of Care | 50% | - Health Promotion and Illness Prevention - Acute Care - Assessment and Diagnosis - Chronic Care |
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NEW QUESTION # 182
A 42-year-old man comes to your family practice. He has started seeing a reflexologist to help manage his chronic back pain. He presents to you a letter from the reflexologist outlining the weekly necessary treatments, each costing $300, and a list of blood tests for the patient to have done. The patient asks you to order the laboratory testing and send the results to his "other doctor." Which one of the following is the best next step?
Answer: C
Explanation:
Physicians should order investigations only when clinically indicated based on their own assessment and an evidence-based differential diagnosis, not solely at the request of a non-physician practitioner. The appropriate next step is to decline to order the requested tests as written and perform (or arrange) a proper evaluation of the patient's chronic back pain, including red-flag screening, functional impact, and prior work- up/treatments. This aligns with MCCQE objectives on stewardship of health resources and professional accountability: unnecessary testing can cause harm (false positives, downstream procedures) and misuses publicly funded services. Sending results to a reflexologist as "other doctor" is also inappropriate without confirming the person's role, ensuring relevance to care, and obtaining appropriate patient consent for disclosure; even with consent, the physician should not facilitate non-indicated testing. Reporting (A/B) or directing the patient to stop (E) is premature; the initial focus should be patient-centred care, education about evidence-based options, and collaborative planning while respecting patient autonomy and addressing potential safety concerns.
NEW QUESTION # 183
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: A
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 # 184
You are providing antenatal consultation to a primiparous woman of 37 weeks' gestation who was admitted for labour induction. Repeat prenatal ultrasounds confirm a chronically small fetus who has never demonstrated easily detectable fetal movement. Maternal health has been normal throughout the pregnancy and she has received all antenatal serum screening. This fetus is at significant risk for which one of the following?
Answer: A
Explanation:
A fetus that is chronically growth-restricted and has persistently reduced fetal movement raises concern for an underlying fetal condition rather than isolated placental insufficiency. MCCQE objectives emphasize that early-onset or persistent fetal growth restriction , especially when accompanied by abnormal fetal behavior (notably reduced movement), is associated with higher rates of aneuploidy and other chromosomal disorders (e.g., trisomy syndromes), as well as congenital anomalies and neuromuscular disorders. Among the listed options, chromosomal abnormalities best fit the combined pattern of longstanding small size and consistently diminished movement.
Normal maternal serum screening reduces risk but does not eliminate it; screening tests can miss chromosomal abnormalities, and some aneuploidies may not be reliably detected depending on the test used and gestational timing. Spina bifida is more typically associated with elevated maternal serum AFP and structural findings on ultrasound. Fetal stroke is usually an acute event with more abrupt changes. Congenital hypothyroidism and infantile diabetes are not typical causes of markedly reduced fetal movement with chronic growth restriction.
NEW QUESTION # 185
A 25-year-old woman presents to the Emergency Department with a 4-hour history of severe left flank pain.
Her vital signs are as follows:
* Heart rate: 94/min
* Blood pressure: 130/80 mm Hg
* Temperature: 37.3 °C
A non-contrast computed tomography shows a 6 mm stone in the distal left ureter with mild associated hydronephrosis. In addition to appropriate analgesia, which one of the following is the best next step?
Answer: C
Explanation:
Alpha blockers such as tamsulosin can facilitate the passage of ureteral stones, especially those between 5-10 mm. This is part of medical expulsive therapy.
Toronto Notes 2023 - Urology, Nephrolithiasis:
"Alpha blockers help relax the ureteral smooth muscle and improve stone passage in symptomatic distal ureteral stones." MCCQE1 Objectives - Surgery > Urologic Emergencies:
"Candidates should initiate medical expulsive therapy for ureteral stones under 10 mm with alpha blockers." Reassurance alone (A) is inadequate. Antibiotics (B) are not indicated without infection. IV fluids (E) do not significantly aid stone passage. Urology consult (D) is not needed unless there's infection, intractable pain, or obstruction.
NEW QUESTION # 186
A 30-year-old woman presents to your office with a 6-week history of left lower quadrant pain and dyspareunia. A pelvic ultrasound is normal. Which one of the following is the most important immediate investigation?
Answer: B
Explanation:
This clinical presentation is highly suggestive of chronic pelvic inflammatory disease (PID), especially given the left lower quadrant pain and dyspareunia with a normal pelvic ultrasound. PID is often caused by sexually transmitted infections (STIs), such as Chlamydia trachomatis or Neisseria gonorrhoeae, which may not be evident on imaging.
Toronto Notes 2023 - Gynecology:
"Cervical swabs for N. gonorrhoeae and C. trachomatis are essential in the workup of suspected PID or cervicitis, even when imaging is normal. Dyspareunia and chronic pelvic pain with normal imaging should prompt testing for STIs." MCCQE1 Objectives (Obstetrics & Gynecology > 82-6: Pelvic Pain):
"Candidates must consider and investigate for infectious causes of pelvic pain, including PID, which requires cervical swab testing as an essential first-line investigation." Laparoscopy (A) is invasive and reserved for uncertain or refractory cases. Hysterosalpingography (C) is used in infertility workups, not acute pain. Endometrial biopsy (D) and MRI (E) are not first-line.
NEW QUESTION # 187
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