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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Communicator
|
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NEW QUESTION # 98
You are providing antenatal consultation to a primiparous woman of 37 weeks' gestation who was admitted for labour induction. Repeat prenatal ultrasounds confirm a chronically small fetus who has never demonstrated easily detectable fetal movement. Maternal health has been normal throughout the pregnancy and she has received all antenatal serum screening. This fetus is at significant risk for which one of the following?
Answer: E
Explanation:
A fetus that is chronically growth-restricted and has persistently reduced fetal movement raises concern for an underlying fetal condition rather than isolated placental insufficiency. MCCQE objectives emphasize that early-onset or persistent fetal growth restriction , especially when accompanied by abnormal fetal behavior (notably reduced movement), is associated with higher rates of aneuploidy and other chromosomal disorders (e.g., trisomy syndromes), as well as congenital anomalies and neuromuscular disorders. Among the listed options, chromosomal abnormalities best fit the combined pattern of longstanding small size and consistently diminished movement.
Normal maternal serum screening reduces risk but does not eliminate it; screening tests can miss chromosomal abnormalities, and some aneuploidies may not be reliably detected depending on the test used and gestational timing. Spina bifida is more typically associated with elevated maternal serum AFP and structural findings on ultrasound. Fetal stroke is usually an acute event with more abrupt changes. Congenital hypothyroidism and infantile diabetes are not typical causes of markedly reduced fetal movement with chronic growth restriction.
NEW QUESTION # 99
A 25-year-old woman who is at 8 weeks ' gestation plans to travel to rural Cambodia to care for her ill mother. Which one of the following treatments should be provided to her before the trip?
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
Travel to rural Cambodia poses a high risk of malaria, which can be life-threatening in pregnancy.
Antimalarial prophylaxis is strongly recommended for pregnant women traveling to endemic regions.
Chloroquine or mefloquine (depending on resistance patterns) may be used in pregnancy under specialist guidance.
Toronto Notes 2023 - Infectious Disease / Travel Medicine:
"Malaria prophylaxis is indicated in pregnant women traveling to endemic regions. The risk of severe malaria and poor fetal outcomes is high." MCCQE1 Objectives (Public Health > 65-3: Travel Medicine and Pregnancy):
"Candidates must provide preventive care to pregnant travelers including vaccination and malaria prophylaxis." Tetanus boosters (D) are given every 10 years. Hep B Ig (B) is for acute post-exposure prophylaxis.
Ciprofloxacin (C) is contraindicated in pregnancy.
NEW QUESTION # 100
A 65-year-old man presents to your clinic with a 2-month history of persistent erectile dysfunction. He reports having difficulties maintaining an erection. His last hemoglobin A1c level result was 6.4% (4.8-6.0). He had a negative result on his cardiac stress test 1 month ago. He has been taking stable dosages of citalopram, metformin, and ramipril for the past 2 years. His physical examination findings are normal, and his mood appears euthymic. Which one of the following investigations should be ordered before initiating treatment with sildenafil?
Answer: A
Explanation:
Erectile dysfunction (ED) in older men is commonly vascular, medication-related, or associated with diabetes.
This patient has well-controlled diabetes (HbA1c 6.4%) and a recent negative cardiac stress test , suggesting he is at low cardiovascular risk for sexual activity. MCCQE objectives emphasize cardiovascular risk stratification prior to prescribing phosphodiesterase-5 (PDE-5) inhibitors. Patients who are stable and cleared for moderate physical exertion (e.g., recent negative stress test) do not require additional cardiac testing before initiating sildenafil.
There is no indication for routine CBC, urine culture, PSA, or echocardiography in the absence of relevant symptoms or findings. PSA screening is unrelated to ED management and should follow age-appropriate shared decision-making guidelines. Echocardiography is unnecessary without cardiac symptoms or abnormal exam.
The key contraindication to sildenafil is concurrent nitrate therapy or unstable cardiovascular disease, neither of which is present. Therefore, no additional investigations are required before initiating treatment.
Counseling should include discussion of medication interactions, side effects (e.g., headache, flushing), and avoidance with nitrates.
NEW QUESTION # 101
A 39-year-old man presents to a psychiatrist. He says, "It often seems to me that I am not part of this world.
My voice sounds strange to me, and other people seem like figures in a dream." He has had these feelings intermittently for about 2 years. There is no history of hallucinations, and there are no current indications of disorganized thinking. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
The patient describes classic symptoms of depersonalization ("my voice sounds strange to me") and derealization ("others seem like figures in a dream"), which define depersonalization/derealization disorder.
There is preserved reality testing and no psychosis.
Toronto Notes 2023 - Psychiatry, "Dissociative Disorders" Section:
"Depersonalization/derealization disorder involves persistent or recurrent experiences of detachment from oneself (depersonalization) or surroundings (derealization), with intact reality testing and no delusions or hallucinations." MCCQE1 Objectives (Psychiatry > 79-4: Dissociative Disorders):
"Candidates must identify depersonalization/derealization disorder as a dissociative disorder distinct from psychosis or mood disorders." Schizophrenia (A) would include hallucinations or disorganized thinking. Conversion disorder (B) presents with neurological symptoms inconsistent with known diseases. Persistent depressive disorder (D) involves chronic low mood. Delusional disorder (E) would involve fixed false beliefs, which are not present here.
NEW QUESTION # 102
During an office visit, your 14-year-old patient requests a prescription for oral contraceptives. The province where you are working does not have a statutory age of consent. Which one of the following is the best next step?
Answer: E
Explanation:
In Canada, a minor may consent to medical care if the physician believes they have the capacity to understand the nature, benefits, and risks. This is known as the "mature minor doctrine." Capacity is based on understanding, not age.
Toronto Notes 2023 - ELOM, "Consent and Capacity" Section:
"A minor may consent to treatment if they demonstrate sufficient maturity and understanding. It is the physician's responsibility to assess capacity prior to prescribing." MCCQE1 Objectives (ELOM > 99-3: Consent and Confidentiality):
"Candidates must assess the patient's ability to understand and make informed decisions, regardless of age." Prescribing without assessment (B) is premature. Reporting to child services (A) is only necessary if there are signs of abuse or coercion. Parental involvement (C) is not mandatory. Refusal based on age (E) contradicts legal and ethical practice.
NEW QUESTION # 103
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