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| Section | Objectives |
|---|---|
| Physician Activities | - Management
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| Dimensions of Care | - Chronic Care
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NEW QUESTION # 58
A 33-year-old primigravid woman presents to the office with gestational hypertension. Her pregnancy is at 37 weeks' gestation. The ultrasound findings are as follows:
Head circumference: 5th percentile
Biparietal diameter: 10th percentile
Abdominal circumference: 5th percentile
Femur length: 25th percentile
Amniotic fluid volume: 5.0 cm
Umbilical Doppler: Reversed end-diastolic flow
Which one of the following is the best next step?
Answer: D
Explanation:
This pregnancy demonstrates fetal growth restriction (FGR) with biometric measurements at or below the
10th percentile and oligohydramnios (AFI 5 cm). Most concerning is the finding of reversed end-diastolic flow (REDF) in the umbilical artery Doppler, which indicates severe placental insufficiency and significantly increased risk of fetal hypoxia, acidosis, and intrauterine demise. MCCQE objectives emphasize that abnormal umbilical artery Doppler findings-particularly absent or reversed end-diastolic flow-represent critical fetal compromise.
At 37 weeks' gestation, the fetus is term. The risks of continued intrauterine exposure in the setting of REDF outweigh the risks of delivery. Therefore, immediate delivery is indicated. Expectant management with nonstress testing or delayed reassessment is inappropriate because REDF is associated with high perinatal mortality.
Prompt delivery (often by cesarean section depending on fetal status and cervical factors) is required to prevent stillbirth and severe neonatal morbidity.
NEW QUESTION # 59
An otherwise healthy 43-year-old woman presents to your clinic for a left breast mass. Six months ago, she underwent a bilateral breast magnetic resonance imaging (MRI) after watching a television program on breast cancer prevention. An ultrasound-guided biopsy of a 1.5 cm massconfirmed, at the time, that she had fibroadenoma. The follow-up ultrasound now reveals a mass measuring 1.7 cm. Which one of the following is the best next step in the management of this patient?
Answer: C
Explanation:
Fibroadenomas can grow slightly or fluctuate in size. A minimal increase (from 1.5 cm to 1.7 cm) over six months is clinically insignificant. No malignant features are reported, and the previous biopsy confirmed benign nature. Annual follow-up is appropriate.
Toronto Notes 2023 - Obstetrics and Gynecology, "Breast Disorders" Section:
"Fibroadenomas are benign breast masses that may slightly enlarge. Routine imaging follow-up at 6 to 12 months is appropriate for lesions with benign imaging and histology." MCCQE1 Objectives (Obstetrics and Gynecology > 82-3: Breast Mass):
"Candidates must distinguish between benign and suspicious masses and determine appropriate intervals for follow-up imaging." Repeat biopsy (A) or surgery (B) is unwarranted without suspicious change. MRI (C) is not needed in stable, benign lesions. Tamoxifen (D) is not used for fibroadenomas.
NEW QUESTION # 60
A 45-year-old man presents to the office and reports difficulty understanding conversations that happen in a noisy environment. Ear examination findings are normal. You request audiography, from which results show bilateral high-frequency sensorineural hearing loss with a notch at 4000 Hz. Which one of the following is the most likely cause of this patient's hearing loss?
Answer: A
Explanation:
The audiogram pattern of bilateral high-frequency sensorineural hearing loss with a 4000 Hz "notch" is classic for noise-induced hearing loss (NIHL) . MCCQE objectives in occupational health emphasize recognizing NIHL as a common, preventable condition caused by chronic exposure to loud sounds, especially in workplaces such as construction, mining, and manufacturing. The 4 kHz notch occurs because this frequency region is particularly vulnerable to cochlear hair-cell damage from acoustic trauma; over time, loss can widen to adjacent frequencies and impair speech discrimination, especially in noisy settings-matching the patient's complaint.
Among the options, 20 years of construction work best represents sustained occupational noise exposure and is most likely to produce this characteristic bilateral pattern. Firearm exposure at a range can also cause NIHL, but episodic seasonal practice is generally less consistent than long-term daily occupational exposure for producing this typical presentation. Childhood ear infections mainly cause conductive loss, hereditary causes vary and are not defined by a 4 kHz notch, and diabetes does not produce this specific audiometric signature.
NEW QUESTION # 61
A 35-year-old woman, gravida 3, para 0, aborta 3, presents with her male partner because she has been unable to conceive despite trying for more than 1 year. Her menstrual cycles have been absent for 9 months, and she has occasional mild cyclic pain. She has a medical history of 3 suction curettages. Her BMI is 24.
Investigation results are as follows:
Hysterosalpingogram: Obliterated uterine cavity, no tubal dye spill
Progesterone (midluteal): 48.0 nmol/L (16.4-59.0)
Partner's semen: All parameters normal
Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
This patient has secondary amenorrhea, infertility, and a history of multiple uterine curettages, which strongly points toward Asherman syndrome (intrauterine adhesions or synechiae). The hysterosalpingogram shows an obliterated uterine cavity and no tubal dye spill-classic for intrauterine synechiae. Her midluteal progesterone level is normal, indicating ovulation.
Toronto Notes 2023 - Gynecology, "Infertility" section:
"Asherman syndrome results from intrauterine adhesions due to curettage, leading to amenorrhea and infertility. HSG shows an obliterated or irregular uterine cavity." MCCQE1 Objectives (Gynecology > 82-1: Infertility):
"Candidates should evaluate secondary amenorrhea and interpret imaging such as hysterosalpingogram in the diagnosis of intrauterine abnormalities." Other options are ruled out by the presence of normal ovulation (rules out hypothalamic and PCOS) and by imaging (not suggestive of fibroids or perimenopause).
NEW QUESTION # 62
A 35-year-old woman presents to your clinic for follow-up regarding her persistent primary immune thrombocytopenic purpura. She was admitted to hospital with a relapse and received treatment with dexamethasone, intravenous immunoglobulin, and rituximab. She was recently discharged from hospital with a platelet count of 55 × 10#/L (130-360), and also continues to take 10 mg of prednisone once daily. She is scheduled for a splenectomy in 4 weeks. Which one of the following is the best next step in preparation for the patient ' s surgical procedure?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
Patients undergoing splenectomy are at lifelong risk for overwhelming post-splenectomy infection (OPSI), particularly from encapsulated organisms. Vaccination against Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis is recommended at least 2 weeks prior to elective splenectomy.
Toronto Notes 2023 - Hematology / Surgery:
"Patients undergoing elective splenectomy should receive vaccines against pneumococcus, H. influenzae type b, and meningococcus at least 2 weeks before surgery." MCCQE1 Objectives (Hematology > 38-2: Thrombocytopenia and Splenectomy):
"Candidates must ensure vaccination prior to splenectomy to prevent postsplenectomy sepsis." Calcium (B) may be considered in chronic steroid users but is not the priority. Azithromycin (C) is not indicated. D is unsafe without tapering. E is only for acute bleeding or extremely low platelets.
NEW QUESTION # 63
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