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| Section | Objectives |
|---|---|
| Physician Activities | - Professionalism
|
| Dimensions of Care | - Psychosocial Aspects
|
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NEW QUESTION # 88
A 22-year-old woman presents to the office for episodic mood changes that her boyfriend has noticed. During such episodes, she cries suddenly, is irritable and sad, and withdraws from socializing. Which one of the following would be most useful in establishing a diagnosis?
Answer: D
Explanation:
A mood journal is a structured tool that allows the patient to record mood fluctuations, triggers, and timing. It is particularly helpful in identifying mood disorders such as premenstrual dysphoric disorder, bipolar disorder, or cyclothymia.
Toronto Notes 2023 - Psychiatry, Mood Disorders:
"Mood diaries are useful in identifying temporal patterns, such as menstrual cycle-linked mood changes, and in distinguishing between affective disorders." MCCQE1 Objectives - Psychiatry > Diagnostic Evaluation:
"Candidates should use clinical tools such as symptom diaries to assist in establishing the pattern and nature of psychiatric symptoms." Personality testing (A) is not first-line. Urine drug screen (B) is only indicated with suspicion of substance use. Lorazepam (D) treats symptoms, not diagnosis. Interviewing the boyfriend (E) may help, but only as a supplement to direct observation and self-report.
NEW QUESTION # 89
A 70-year-old hypertensive woman with a history of congestive heart failure (CHF) secondary to left ventricular dysfunction presents to your office with a persistent dry hacking cough. She claims it began when she was started on ramipril. Which one of the following medications would be most appropriate to replace ramipril, to ensure that the risk of morbidity associated with CHF remains low?
Answer: A
Explanation:
ACE inhibitors such as ramipril are first-line for CHF with reduced ejection fraction, but a common adverse effect is a dry cough due to bradykinin accumulation. Angiotensin II receptor blockers (ARBs) offer the same hemodynamic and survival benefits without causing cough.
Toronto Notes 2023 - Cardiology, "Heart Failure" Section:
"In patients intolerant to ACE inhibitors due to cough, an ARB (e.g., losartan, valsartan) is the recommended substitute. ARBs also reduce mortality and hospitalizations in heart failure with reduced ejection fraction." MCCQE1 Objectives (Internal Medicine > 76-3: Congestive Heart Failure):
"Candidates should recognize ARBs as an alternative to ACE inhibitors in patients who develop adverse effects such as cough, while maintaining the mortality benefit." Other options (B-E) do not offer mortality benefits in CHF and may worsen the condition (e.g., CCBs, alpha- blockers, NSAIDs like COX-2 inhibitors).
NEW QUESTION # 90
A 16-year-old boy is brought to the office for examination, which reveals the lesion in the attached image and similar lesions on other parts of his body. You also notice multiple scattered subcutaneous tumors that he says have been there for a long time. Which one of the following is the most likely diagnosis?
Answer: E
Explanation:
The presence of multiple cutaneous lesions along with numerous longstanding subcutaneous tumors is most consistent with neurofibromatosis type 1 (NF1) . MCCQE objectives emphasize recognizing classic dermatologic findings of NF1, which include multiple neurofibromas (soft, skin-colored subcutaneous nodules) and characteristic pigmented lesions such as cafe-au-lait macules and axillary or inguinal freckling.
These lesions typically develop during childhood or adolescence and increase in number over time.
Sarcoidosis can cause skin lesions but is not associated with multiple benign peripheral nerve sheath tumors.
Dermatofibromas are usually solitary, firm nodules rather than numerous soft tumors. Vitiligo presents as depigmented macules without subcutaneous masses. Lipomatosis involves multiple lipomas but lacks the associated pigmentary skin findings seen in NF1.
NF1 is an autosomal dominant condition caused by mutation of the NF1 gene. Diagnosis is clinical based on established criteria. Recognition is important because patients require surveillance for complications such as optic gliomas, learning disabilities, skeletal abnormalities, and malignant peripheral nerve sheath tumors.
NEW QUESTION # 91
A 60-year-old man presents because of a 6-month history of involuntary lip smacking and tongue movements.
His medical history is significant for schizophrenia, which has been very stable with haloperidol for the past
20 years. When educating the patient about these particular symptoms, which one of the following statements is accurate?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
This patient has tardive dyskinesia, a late-onset, often irreversible movement disorder caused by chronic dopamine receptor blockade (e.g., haloperidol). It is especially common in older adults and may not resolve after stopping the drug.
Toronto Notes 2023 - Psychiatry, "Extrapyramidal Symptoms":
"Tardive dyskinesia is often irreversible and typically occurs after prolonged antipsychotic use. Elderly patients are at greater risk." MCCQE1 Objectives (Psychiatry > 71-5: Side Effects of Psychotropics):
"Candidates must recognize tardive dyskinesia and understand that it can persist or worsen even after discontinuation of antipsychotics." Anticholinergics may worsen it (D). The condition does not reliably improve with age (C). It does not affect a majority of patients (A).
NEW QUESTION # 92
A 54-year-old woman presents to your office to discuss breast cancer screening. She is asymptomatic with no history of breast cancer. She had a fibroadenoma removed when she was 24 years old. The patient is not on any medications. Her family history is significant for a great-aunt with breast cancer. The patient has not had genetic testing but had normal breast screening 2 years ago. Which one of the following is the best next step?
Answer: D
Explanation:
According to Canadian guidelines, women aged 50 to 74 at average risk for breast cancer should undergo routine screening mammography every 2 to 3 years. A great-aunt with breast cancer does not raise this patient
' s risk to high. Mammography is appropriate as she is now due for the next screen.
Toronto Notes 2023 - Population Health, "Screening Guidelines" Section:
"Routine mammography is recommended every 2 years for average-risk women aged 50 to 74. Family history in second-degree or more distant relatives (e.g., great-aunt) does not qualify for high-risk screening or MRI." MCCQE1 Objectives (Population Health > 97-5: Screening and Prevention):
"Candidates should apply Canadian screening recommendations including mammography for average-risk women #50 years old." Self-breast exams (C) are not recommended for screening. PET scan (D) and MRI (E) are reserved for high- risk populations or diagnostic clarification.
NEW QUESTION # 93
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