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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Dimensions of Care | 50% | - Acute Care - Assessment and Diagnosis - Chronic Care - Health Promotion and Illness Prevention |
| Topic 2: Physician Activities | 50% | - Professional Behaviours - Management - Psychosocial Aspects - Communication |
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NEW QUESTION # 284
A 34-year-old woman, gravida 3, para 2, comes to your office for prenatal care. Past medical history includes
2 precipitous uncomplicated term deliveries of infants greater than 4200 g. Which one of the following is she most at risk of developing?
Answer: C
Explanation:
This patient's obstetric history suggests recurrent fetal macrosomia (birthweight > 4000-4500 g) and rapid (precipitous) labours. MCCQE objectives emphasize identifying maternal risk factors for postpartum hemorrhage (PPH) , particularly those associated with uterine atony , the most common cause of PPH.
Delivery of a macrosomic infant increases uterine overdistension, which reduces effective postpartum uterine contraction and predisposes to atony and hemorrhage. In addition, precipitous labour can be associated with genital tract trauma, which can also contribute to postpartum bleeding, but the strongest and most consistent risk factor in the options provided is PPH from atony related to prior large infants.
The other choices are less supported by the stem: prior macrosomic term deliveries do not inherently increase risk of preterm delivery, gestational hypertension, or DVT. Therefore, the most likely risk to anticipate and plan for is postpartum hemorrhage, prompting proactive intrapartum planning (active management of the third stage, readiness with uterotonics, and risk-based monitoring).
NEW QUESTION # 285
A 50-year-old man with prostate cancer, which is complicated by bony and cerebral metastases, presents to your office. He has a 24-hour history of increasing lower back pain and weakness in his legs. On examination, you note decreased knee and ankle reflexes on both sides. Earlier today he had fecal incontinence. Which one of the following is the best next step?
Answer: A
Explanation:
This patient with known metastatic prostate cancer presents with acute back pain, bilateral lower limb weakness, decreased reflexes, and new fecal incontinence-classic red flags for malignant spinal cord compression . MCCQE objectives emphasize that this is an oncologic emergency requiring immediate intervention to prevent irreversible neurologic damage.
The first step is prompt administration of high-dose parenteral corticosteroids (e.g., dexamethasone) to reduce vasogenic edema around the spinal cord and preserve neurologic function. Steroids should be given immediately upon suspicion, even before confirmatory imaging. Urgent MRI of the spine and consultation with oncology, radiation oncology, and/or neurosurgery follow for definitive management (radiotherapy or surgical decompression depending on stability and prognosis).
Bed rest and analgesia alone are inadequate. A stellate ganglion block is unrelated. Although radiotherapy or surgery will likely be required, steroids must be administered first without delay. Early treatment significantly improves the likelihood of maintaining ambulation and continence.
NEW QUESTION # 286
A 29-year-old concert pianist with severe chronic kidney disease presents with a 6-month history of loss of appetite and pruritus. Although the issue of initiating dialysis has been discussed with him and his questions answered, he has declined dialysis thus far. You understand his concerns that it will interfere with his concert tour and recording schedule. Which one of the following is the best next step?
Answer: D
Explanation:
When a competent patient declines dialysis, the next step is to support shared decision-making and explore options that align with their lifestyle. Peritoneal dialysis may allow more flexibility and autonomy compared to hemodialysis, making it more acceptable to patients with demanding schedules.
Toronto Notes 2023 - Nephrology, Chronic Kidney Disease Section:
"Peritoneal dialysis offers the advantage of home-based treatment and flexible scheduling. Patient education and peer support can improve acceptance and adherence to dialysis initiation." MCCQE1 Objectives - Internal Medicine > Nephrology:
"The candidate should explore treatment alternatives collaboratively, emphasizing patient autonomy, while addressing misconceptions and lifestyle concerns related to dialysis." Simply warning the patient or withdrawing engagement (Options B and C) may undermine rapport. Access to medical records (D) is a right, but does not actively address treatment planning. Exploring new employment (E) is inappropriate at this stage.
NEW QUESTION # 287
A previously well 4-year-old boy is brought to your office by his mother. She is concerned by his behaviour.
Shortly after falling asleep, he awakens, screams loudly and cries. He appears frightened and does not respond to his mother's efforts to calm him. During these episodes, he appears agitated and flushed. After 15-20 minutes, he settles back to sleep. Physical examination is unremarkable. Which one of the following is the most likely diagnosis?
Answer: C
Explanation:
This presentation is characteristic of a non-rapid eye movement (NREM) sleep arousal disorder (sleep terror)
. MCCQE objectives highlight that sleep terrors typically occur in children aged 3-7 years and arise during the first third of the night , shortly after sleep onset, during deep NREM (slow-wave) sleep. Children abruptly awaken screaming, appear terrified, flushed, and autonomically aroused, and are inconsolable and minimally responsive to caregivers. Episodes usually last 10-20 minutes and resolve spontaneously, with the child returning to sleep and having no memory of the event the next morning.
Nightmares, in contrast, occur during REM sleep (later in the night); the child is awake, alert, consolable, and can recall the dream. Nocturnal seizures are typically brief, stereotyped, and may include tonic-clonic activity or a postictal state. Panic disorder occurs during wakefulness. Temper tantrums occur while awake and are behaviorally triggered.
Management is reassurance and ensuring safety; most children outgrow sleep terrors without intervention.
NEW QUESTION # 288
An 88-year-old married man is admitted following a cardiac arrest at home. He was not expected to recover, and after 2 weeks, he remains in a coma. His wife states, "I cannot let him go. That would be murder." As the attending physician looking after her husband, which one of the following is the best next course of action?
Answer: D
Explanation:
In discussions about end-of-life care, it is critical to shift the focus from the substitute decision-maker's own feelings to what the patient would have wanted. This approach promotes ethically sound and patient-centered decisions. It is respectful, supportive, and maintains trust.
Toronto Notes 2023 - ELOM, "Advance Care Planning and End-of-Life Decisions":
"When a patient cannot express wishes, decisions must be based on known prior wishes or substituted judgment-what the patient would have wanted." MCCQE1 Objectives (ELOM > 90-2: Capacity, Consent, and End-of-Life Care):
"Candidates must guide surrogate decision-makers toward reflecting on the patient's values and previously expressed wishes." Options A and B are inappropriate-waiting without engagement or unilateral withdrawal is unethical. C does not address the wife's emotional or ethical concerns. E is premature unless the wife is clearly unable or unfit to act as decision-maker.
NEW QUESTION # 289
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