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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Medical Expert
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NEW QUESTION # 133
A 55-year-old woman presents to the office with a 2-month history of right shoulder pain and limited function that started after she began an upper body weight training program. Examination shows tenderness inferior to the acromion. She has full passive range of motion of the shoulder but significant pain with abduction from
30° to 120° of arc. Which one of the following is the best next step?
Answer: B
Explanation:
The presentation is consistent with rotator cuff tendinopathy or subacromial impingement. The painful arc between 30°-120° with preserved passive ROM suggests this. Ultrasound is the preferred initial imaging modality due to its availability, safety, and ability to visualize soft tissues dynamically.
Toronto Notes 2023 - Orthopedics, "Shoulder Pathologies" Section:
"In rotator cuff injuries or impingement syndromes, initial imaging with musculoskeletal ultrasound is appropriate. It can identify tendinopathy, partial tears, or subacromial bursitis." MCCQE1 Objectives (Surgery > 84-7: Musculoskeletal Pain):
"Candidates should initiate workup for rotator cuff or impingement syndromes with ultrasound as the first- line test, reserving more invasive or costly procedures for unresolved or complex cases." CT (A) is used for bony detail, not soft tissues. Arthroscopy (C) is invasive and therapeutic. Arthrography (D) is outdated and largely replaced by MRI or ultrasound.
NEW QUESTION # 134
A 38-year-old man presents to the office for a follow-up visit. For several years, he has been having constant abdominal pain and intermittent constipation. He struggles to fall asleep because he is worried about his symptoms, and he often spends hours researching possible investigations and causes. Although he recently had extensive investigations, which have all had normal results, he continues to visit multiple physicians hoping for more investigations. He worries that he will die because no one is taking him seriously. Which one of the following is the best next step?
Answer: C
Explanation:
This presentation is most consistent with somatic symptom disorder/illness anxiety : persistent distressing physical symptoms (abdominal pain/constipation) with excessive health-related anxiety, repeated reassurance- seeking, and "doctor shopping" despite normal investigations. MCCQE objectives emphasize avoiding iatrogenic harm from repeated testing and using a structured, therapeutic relationship to manage medically unexplained or disproportionate symptom concerns. The best next step is regularly scheduled follow-up visits with one consistent physician (e.g., monthly), focused on validating symptoms, addressing fears, monitoring for new objective findings, and gradually shifting toward coping strategies and functional goals. This approach reduces unnecessary investigations, reinforces continuity, and helps interrupt the cycle of anxiety- driven health-care utilization.
Repeating investigations (B) perpetuates reassurance-seeking and increases false positives and harm.
Consulting additional specialists (A) without new red flags similarly reinforces maladaptive beliefs and fragmentation of care. Exercise (D) may be beneficial as an adjunct but is not the core management strategy.
Therefore, planned, regular appointments are the most appropriate next step.
NEW QUESTION # 135
A 34-year-old woman, gravida 3, para 2, comes to your office for prenatal care. Past medical history includes
2 precipitous uncomplicated term deliveries of infants greater than 4200 g. Which one of the following is she most at risk of developing?
Answer: B
Explanation:
This patient's obstetric history suggests recurrent fetal macrosomia (birthweight > 4000-4500 g) and rapid (precipitous) labours. MCCQE objectives emphasize identifying maternal risk factors for postpartum hemorrhage (PPH) , particularly those associated with uterine atony , the most common cause of PPH.
Delivery of a macrosomic infant increases uterine overdistension, which reduces effective postpartum uterine contraction and predisposes to atony and hemorrhage. In addition, precipitous labour can be associated with genital tract trauma, which can also contribute to postpartum bleeding, but the strongest and most consistent risk factor in the options provided is PPH from atony related to prior large infants.
The other choices are less supported by the stem: prior macrosomic term deliveries do not inherently increase risk of preterm delivery, gestational hypertension, or DVT. Therefore, the most likely risk to anticipate and plan for is postpartum hemorrhage, prompting proactive intrapartum planning (active management of the third stage, readiness with uterotonics, and risk-based monitoring).
NEW QUESTION # 136
A 34-year-old woman, gravida 2, para 1, aborta 0, presents to the labor and delivery ward at 32 weeks' gestation with a 24-hour history of worsening frontal headache, photophobia, and neck stiffness. Vitals:
* BP: 121/78 mm Hg
* HR: 90 bpm
* Temp: 38°C
Neuro exam reveals a 2-beat ankle clonus. Tone and power are otherwise normal. No localizing signs or papilledema. Abdomen is soft, fetus is cephalic.
Which one of the following is the best next investigation?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
This patient is pregnant and febrile with a new headache, photophobia, and clonus - all features concerning for preeclampsia with neurologic involvement. Clonus is a key finding suggestive of central nervous system irritability. Urine protein/creatinine ratio helps confirm the diagnosis of preeclampsia.
Toronto Notes 2023 - Obstetrics, Hypertensive Disorders in Pregnancy:
"Headache, clonus, and visual disturbances are concerning for severe preeclampsia. A urine protein/creatinine ratio or 24-hour urine collection confirms diagnosis." MCCQE1 Objectives - Obstetrics > Hypertension in Pregnancy:
"Candidates must recognize signs of preeclampsia and assess with appropriate biochemical testing." CT (A) or LP (B) are not indicated unless focal neurologic signs or seizures are present. Fetal imaging and amniocentesis (C, D) do not address maternal symptoms.
NEW QUESTION # 137
A 66-year-old woman suffering from a progressive neurological disease is admitted to a long-term care centre. Her husband does not wish to participate in discussions about the seriousness of his wife's disease and is convinced that she will soon come back home. During his 2nd visit to the centre, he gives you a cheque for a substantial sum made out to you, the treating physician, for your own research. Which one of the following is the best response to your patient's husband?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
Physicians must avoid conflicts of interest and maintain professional boundaries with patients and their families. Accepting a personal financial gift, regardless of intent, is inappropriate and unethical.
Toronto Notes 2023 - Ethics and Professionalism:
"Personal gifts of significant value from patients or families should be declined to avoid real or perceived conflicts of interest." MCCQE1 Objectives (ELOM > 90-3: Professionalism and Boundaries):
"Candidates must maintain ethical boundaries and refuse financial incentives that could compromise or appear to compromise clinical judgment." Other options (A, B, E) still involve a conflict. D is helpful, but the ethical obligation is to decline the cheque directly.
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NEW QUESTION # 138
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