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| Section | Objectives |
|---|---|
| Physician Activities | - Communication
|
| Dimensions of Care | - Health Promotion and Illness Prevention
|
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NEW QUESTION # 124
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 Arthrography (D) is outdated and largely replaced by MRI or ultrasound.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 # 125
A 42-year-old businessman known to have type 2 diabetes and ischemic heart disease is admitted to hospital with acute coronary syndrome. He admits to drinking 4 beers a day for the last 6 years and to binge drinking twice a year when his school buddies are in town. Your chart review reveals that he had a seizure secondary to alcohol withdrawal during his last admission. Which one of the following elements of his history puts him at highest risk of having another such seizure?
Answer: D
Explanation:
A history of previous alcohol withdrawal seizures is the single greatest predictor of future withdrawal seizures. This establishes a sensitization response within the central nervous system.
Toronto Notes 2023 - Addiction Medicine:
"A prior history of alcohol withdrawal seizures is the most important risk factor for recurrent seizures during future withdrawal episodes." MCCQE1 Objectives (Internal Medicine > Substance Use > 58-3):
"Candidates must identify individuals at high risk for severe alcohol withdrawal based on past withdrawal history, including seizures and delirium tremens." Although quantity, duration, and comorbidities contribute to risk, a prior withdrawal seizure most strongly predicts recurrence.
NEW QUESTION # 126
A 56-year-old woman comes to your office because she has not been herself since her husband died in a car crash 6 weeks ago. She has no prior psychiatric history. Her son is concerned because she cries frequently, has a poor appetite, rarely leaves home and is distraught. Her sadness fluctuates and increases when she thinks of her husband. She often thinks about death, and she wishes she could join her deceased husband. Which one of the following is the best next step?
Answer: A
Explanation:
Her presentation at 6 weeks after a spouse's death is most consistent with acute/normal grief : intense sadness, crying, social withdrawal, reduced appetite, and waves of distress triggered by reminders of the deceased.
MCCQE objectives stress distinguishing grief from major depressive disorder by the fluctuating nature of symptoms , grief "pangs," and the link to thoughts of the deceased. Although she expresses wishing to "join" her husband, this can occur in normal bereavement; the key clinical duty is to assess safety (suicidal intent, plan, means, past attempts, protective factors). In the absence of imminent risk or psychosis, inpatient/day- hospital admission is not the default. "Reassurance" alone is insufficient because she is significantly impaired and needs structured support. The best next step is referral for bereavement-focused support (often via social work), which can provide grief counseling, coping strategies, mobilization of supports, and monitoring, and can facilitate escalation if complicated grief or major depression emerges. Family systems therapy may help later, but immediate practical and grief-specific support plus safety assessment is the priority.
NEW QUESTION # 127
A 42-year-old man presents for a follow-up visit for mild hypertension. His blood pressure has been consistently elevated over the last 2 visits. In discussion with the patient, you decide to initiate antihypertensives. He had previously been on ramipril and stopped when he developed tongue swelling. His past medical history consists of asthma and hyperlipidemia. Which one of the following is the most appropriate treatment at this time?
Answer: A
Explanation:
This patient requires antihypertensive therapy for persistent mild hypertension. He previously developed tongue swelling on ramipril , consistent with ACE inhibitor-induced angioedema , which is a contraindication to further ACE inhibitor use (e.g., enalapril). MCCQE objectives emphasize avoiding re-exposure to ACE inhibitors after angioedema due to risk of recurrence, which can be life-threatening.
Beta-blockers such as metoprolol are not first-line for uncomplicated hypertension and should be used cautiously in patients with asthma due to risk of bronchospasm (even though cardioselective agents are safer, alternatives are preferred). Clonidine and hydralazine are not first-line agents for chronic management due to side effects and rebound hypertension risk.
A thiazide diuretic (hydrochlorothiazide) is an appropriate first-line therapy for uncomplicated hypertension.
Thiazides have strong evidence for cardiovascular risk reduction and are suitable in patients without contraindications.
Thus, hydrochlorothiazide is the most appropriate initial therapy in this patient.
NEW QUESTION # 128
A 45-year-old man presents to your family practice for follow-up because he has had repeated transient ischemic attacks and had been advised not to drive. During the interview, you find out that he is still driving.
He explains that he only drives to the grocery store and his wife, who also has a driver's license, is always a passenger with him. He insists he can drive. You think that he should no longer be driving a car. Which one of the following is the best next step?
Answer: B
Explanation:
In most Canadian provinces and territories, physicians are legally obligated to report patients who pose a danger due to medical conditions affecting driving ability. Given the history of TIAs and continued unsafe driving, reporting is necessary for public safety.
Toronto Notes 2023 - ELOM, "Fitness to Drive" Section:
"Physicians must report to motor vehicle authorities if a patient poses a risk to public safety due to a medical condition. TIAs are considered reportable if they impair ability and the patient does not comply with driving restrictions." MCCQE1 Objectives (ELOM > 99-1: Medical Fitness and Reporting):
"Candidates must recognize situations requiring mandatory reporting of patients unfit to drive due to neurologic or other impairing conditions." You may still discuss with the patient (B), but this does not replace the duty to report. Physically taking the license (C) is illegal. Refusing care (D) is unethical. A neurologist (E) could be helpful but would delay action in a clear case.
NEW QUESTION # 129
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