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| Section | Objectives |
|---|---|
| Topic 1: Physician Activities | - Communication
|
| Topic 2: Dimensions of Care | - Health Promotion and Illness Prevention
|
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NEW QUESTION # 161
A 42-year-old man presents to your clinic for follow-up regarding his anxiety. He lost his job 1 year ago.
Since then, he constantly thinks about what happened, trying to understand what went wrong and how he could fix it or prevent it in the future. He is unable to sleep because of this. He has become socially isolated and when he does see friends, he worries constantly that he may say something hurtful. He wishes he could get past what happened and find another job but feels consumed by the fear that he may offend someone in the future. On history, his symptoms did not respond to escitalopram, sertraline, fluvoxamine, or venlafaxine, all at maximum tolerated doses. Which one of the following medications is the most appropriate?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
This patient likely has treatment-resistant obsessive-compulsive disorder (OCD), with classicsymptoms of rumination, excessive guilt, and fear of causing harm. Clomipramine, a tricyclic antidepressant with strong serotonergic activity, is effective in treatment-resistant OCD and is often used after failure of multiple SSRIs or SNRIs.
Toronto Notes 2023 - Psychiatry, OCD:
"Clomipramine is a first-line tricyclic antidepressant for OCD, particularly after failed SSRI/SNRI trials. It is effective due to potent serotonergic action." MCCQE1 Objectives - Psychiatry > OCD and Anxiety Disorders:
"Candidates must identify treatment strategies for resistant OCD, including the role of clomipramine and augmentation therapy." Quetiapine (C) may be used as augmentation. Paroxetine (E) is another SSRI. Vortioxetine (A) and amitriptyline (D) are not first-line or preferred for OCD.
NEW QUESTION # 162
A 37-year-old man comes to the office for follow-up of his opioid use disorder. He receives opioid agonist treatment, including some take-home doses. At this follow-up visit, he reports some nonprescription opioid use since his last visit. Which one of the following is the best next step?
Answer: C
Explanation:
Nonprescription opioid use during opioid agonist therapy is not uncommon. The response shouldbe supportive and not punitive. Increasing the frequency of follow-up enhances monitoring, supports adherence, and prevents relapse.
Toronto Notes 2023 - Psychiatry, "Substance Use Disorders":
"Patients who relapse during opioid agonist treatment benefit from closer monitoring and increased support, including more frequent follow-up and psychosocial interventions." MCCQE1 Objectives (Psychiatry > 71-5: Substance Use and Addiction):
"Candidates must manage relapses in opioid use by optimizing follow-up and support, not by discontinuing or reducing therapy prematurely." Tapering or discontinuing therapy (A, E) risks destabilizing treatment. Removing take-home doses (B) may be warranted later but not first. Cannabinoids (D) are not first-line adjuncts.
NEW QUESTION # 163
A 26-year-old woman, gravida 3, para 2, presents for her 1st antenatal visit. She states she is at 26 weeks' gestation and is healthy. On abdominal examination, her fundus is palpated at the umbilicus. Which one of the following is the most likely explanation for this finding?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
At 20 weeks' gestation, the uterine fundus typically reaches the umbilicus. If the fundal height is lower than expected at a stated gestational age of 26 weeks, the most likely explanation-especially with no prior care- is a dating error.
Toronto Notes 2023 - Obstetrics:
"Fundal height at the umbilicus corresponds to ~20 weeks. In women lacking early prenatal care, dating errors are common causes of fundal height discrepancy." MCCQE1 Objectives (Obstetrics > 80-3: Routine Antenatal Care):
"Candidates must interpret fundal height and reconcile discrepancies with gestational age." IUGR and oligohydramnios are possible but require imaging confirmation. Bicornuate uterus may cause fundal shape anomalies but not significant dating discrepancy. A mole (D) would increase, not decrease, size.
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NEW QUESTION # 164
A 32-year-old man presents to the clinic for assessment of a dog bite sustained 3 days ago while traveling in another country. He recalls having seen the dog eat where he was staying, and the animal did not appear well.
On examination, the patient has 2 distinct deep puncture wounds on his left leg. There is an erythematous border but no exudate. He is unsure of his immunization status. Which one of the following is the most appropriate management?
Answer: E
Explanation:
Dog bites from animals of unknown rabies status, especially from endemic regions and in patients with uncertain immunization status, require immediate post-exposure prophylaxis (PEP) including both rabies immunoglobulin and vaccine. The decision is urgent given the fatal nature of rabies.
Toronto Notes 2023 - Infectious Diseases, "Rabies Exposure":
"Rabies PEP is indicated for bites from animals with unknown vaccination status or those showing abnormal behavior, particularly in endemic regions. PEP includes both vaccine and immunoglobulin." MCCQE1 Objectives (Public Health > 64-1: Rabies and Animal Bites):
"Candidates must recognize indications for rabies post-exposure prophylaxis." Ciprofloxacin (C) is not the antibiotic of choice (amoxicillin-clavulanate is preferred). Hydrogen peroxide (E) can be cytotoxic. Debridement (B) and CK (D) are not immediate priorities here.
NEW QUESTION # 165
Following a potluck supper organized by the residency director of your training program, many of your fellow residents and other guests fall ill with gastroenteritis. Which one of the following is the best way to identify the source of this food-borne outbreak?
Answer: C
Explanation:
Calculating food-specific attack rates (i.e., number of people who became ill after eating aparticular food divided by the total number who ate that food) is the most effective method to identify the probable source of infection in a known cohort outbreak.
Toronto Notes 2023 - Public Health, Outbreak Investigations:
"Foodborne outbreaks are best analyzed using food-specific attack rates to determine associations between individual foods and illness." MCCQE1 Objectives - Preventive Medicine > Epidemiologic Principles:
"Candidates must use epidemiologic tools, such as attack rates, to identify probable sources during outbreak investigations." Cohort study (C) is also acceptable but more time-intensive. Stool and food cultures (B, D) confirm the pathogen but not the source. HACCP (E) is a preventive method, not a tool for outbreak investigation.
NEW QUESTION # 166
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