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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Health Advocate
|
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NEW QUESTION # 19
A 47-year-old man presents to the office with a 1-month history of passing blood in his stool 2 to 3 times per week. He is otherwise healthy and denies any systemic symptoms. Other than a small lateral skin tag on digital rectal examination, the physical examination findings are unremarkable. Which one of the following is the best next step?
Answer: B
Explanation:
Visible rectal bleeding, even in the absence of systemic symptoms, warrants diagnostic colonoscopy to rule out colorectal cancer, polyps, or IBD-especially in adults over 40. FIT is for asymptomatic screening only.
Toronto Notes 2023 - Gastroenterology, "Approach to Lower GI Bleeding":
"In patients with overt rectal bleeding, colonoscopy is the investigation of choice regardless of age or FIT status." MCCQE1 Objectives (Internal Medicine > Gastroenterology > 47-1):
"Candidates must evaluate rectal bleeding with colonoscopy, even in the presence of minor findings on physical exam (e.g., skin tag)." FIT (A) is not appropriate for symptomatic patients. CEA (D) is a tumor marker for surveillance, not diagnosis. CT colonography (C) is less sensitive for lesions than colonoscopy.
NEW QUESTION # 20
A 58-year-old woman presents to your office with heavy vaginal bleeding. She has a history of type 2 diabetes and hypertension. Some active bleeding is visible on speculum examination. Ultrasound reveals an endometrial thickness of 12 mm. Endometrial biopsy shows complex hyperplasia with atypia. Which one of the following is the best next step?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
Complex endometrial hyperplasia with atypia carries a high risk of progression to or concurrent endometrial carcinoma. Definitive management in postmenopausal women is total hysterectomy with bilateral salpingo- oophorectomy.
Toronto Notes 2023 - Gynecology, Abnormal Uterine Bleeding:
"Endometrial hyperplasia with atypia in postmenopausal women is best managed surgically due to the risk of malignancy." MCCQE1 Objectives - Gynecology > Postmenopausal Bleeding:
"Candidates should identify endometrial hyperplasia with atypia as an indication for hysterectomy in appropriate patients." Ablation (A) is contraindicated. Progesterone (B) is used for non-atypical hyperplasia. D&C (C) and hysteroscopy (D) are diagnostic but not definitive.
NEW QUESTION # 21
You are taking over a practice from a retiring family physician. The practice has paper records of patients dating back many years, including records of former patients. Which one of the following organizations is the most appropriate to contact regarding medical record retention requirements?
Answer: C
Explanation:
Medical record retention is governed by laws and policies established by the provincial or territorial medical regulatory authorities (e.g., College of Physicians and Surgeons of Ontario).These bodies set requirements for how long patient records must be maintained and how to handle former patients' data.
Toronto Notes 2023 - Ethics and Health Systems:
"Retention of medical records is regulated by provincial/territorial colleges, which outline minimum retention periods and storage responsibilities." MCCQE1 Objectives (ELOM > Legal Requirements > Professional Responsibilities):
"The candidate must be able to identify the legal responsibilities of physicians regarding record-keeping, as guided by regulatory authorities." National organizations such as Health Canada, CFPC, CMA, and MCC do not set these rules for individual practice management.
NEW QUESTION # 22
A 24-year-old man is brought to the Emergency Department by ambulance with a severe pelvic fracture from a motor vehicle collision. After resuscitation and stabilization, he is noted to have a bloody penile discharge.
Which one of the following is the best next step?
Answer: D
Explanation:
In a patient with a pelvic fracture and blood at the urethral meatus, urethral injury must be strongly suspected.
Other signs may include perineal hematoma, high-riding prostate, or inability to void. The key principle is do not insert a Foley catheter until urethral integrity is confirmed, as blind catheterization may worsen a partial tear into a complete disruption. The appropriate next diagnostic step is retrograde urethrography (RUG), which evaluates the urethra for extravasation of contrast and identifies the site and extent of injury.
Voiding cystography evaluates bladder injury and is performed after urethral integrity is confirmed or via suprapubic access. Transrectal ultrasound and penile sonography are not appropriate in acute trauma assessment of suspected urethral disruption. Continuous bladder irrigation is contraindicated until urethral injury is excluded.
MCCQE objectives emphasize recognition of urethral injury in pelvic trauma and adherence to trauma principles: stabilize first, suspect urethral injury when blood is present at the meatus, and perform retrograde urethrography prior to catheterization.
NEW QUESTION # 23
You are asked to see a 34-year-old patient at his long-term care facility for a 2-day history of fever. You diagnose a urinary tract infection. He has multiple sclerosis diagnosed 5 years ago and has lived in this long- term care facility for the past 2 years. He is bedbound and has an indwelling urinary catheter. For the past 3 months, he has been non-communicative. Prior to this, he had made it clear that he did not want any life- prolonging measures. Which one of the following is the best next step?
Answer: B
Explanation:
This patient is currently non-communicative and therefore likely lacks decision-making capacity. MCCQE ethics objectives emphasize that when a patient's prior capable wishes are clearly known, clinicians must follow those expressed values and directives. He previously stated he did not want life-prolonging measures; escalation (hospital transfer) and potentially curative treatment aimed primarily at prolonging life would conflict with that directive. The immediate best step is to provide comfort-focused care, addressing symptoms such as fever and distress with antipyretics and other palliative measures.
Calling family to "consider antibiotics" risks substituting others' preferences for the patient's known wishes; substitute decision makers are meant to apply the patient's prior expressed wishes, not override them. Starting antibiotics while waiting to contact family similarly risks initiating life-prolonging therapy inconsistent with the directive. Catheter change may be clinically useful in catheter-associated infection, but the question frames a clear limit on life-prolonging interventions; symptom relief is the priority. Ongoing care should include reassessment of comfort, clear documentation of goals of care, and communication with family about the patient's previously stated wishes and the plan for palliative management.
NEW QUESTION # 24
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