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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Physician Activities | 50% | - Professional Behaviours - Management - Psychosocial Aspects - Communication |
| Topic 2: Dimensions of Care | 50% | - Chronic Care - Assessment and Diagnosis - Health Promotion and Illness Prevention - Acute Care |
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NEW QUESTION # 269
An 84-year-old woman is brought by ambulance to the emergency department after she was found by a neighbour. She had fallen, sustained a hip fracture, and was unable to move for the past 2 days. After starting rehydration, she reports hip pain and numbness and tingling in both her legs. Physical examination reveals faint pulses in both legs and severely swollen lower legs that are painful to palpation. The urine in the Foley catheter bag seems to be darker than normal. Which one of the following is the best next step?
Answer: E
Explanation:
This patient presents with signs of acute compartment syndrome (pain out of proportion, paresthesia, pallor, swelling, decreased pulses, and dark urine indicating rhabdomyolysis). Measuring compartment pressures is the diagnostic test of choice to confirm the diagnosis and guide urgent surgical fasciotomy.
Toronto Notes 2023 - Orthopedics:
"Acute compartment syndrome should be suspected in any patient with severe extremity pain, swelling, sensory deficits, and tense compartments. Confirm with compartment pressure measurements. Fasciotomy is indicated if pressure is >30 mmHg or within 30 mmHg of diastolic pressure." MCCQE1 Objectives (Surgery > 51-2: Limb Trauma):
"Candidates must diagnose acute compartment syndrome and initiate appropriate surgical referral after confirming with pressure measurements." Angiography and Doppler studies assess vascular compromise but are not the first step in suspected compartment syndrome. Fixing the hip (C) and testing myoglobin (E) are not diagnostic steps.
NEW QUESTION # 270
A 56-year-old woman presents to your office with a 9-month history of intolerable sweating, palpitations, and periodic anxiety. Her last period was 12 months ago. She continues to have regular Papanicolaou testing with no worrisome pathology. She is otherwise healthy. Which one of the following is the most effective treatment for these symptoms?
Answer: C
Explanation:
In postmenopausal women with severe vasomotor symptoms, hormone therapy (estrogen with progesterone in women with an intact uterus) is the most effective treatment. It improves hot flashes, sleep, and mood symptoms.
Toronto Notes 2023 - Gynecology, Menopause Management:
"Combination hormone therapy is first-line for moderate to severe menopausal symptoms. Non-hormonal agents may be considered if contraindications exist." MCCQE1 Objectives - Gynecology > Menopause:
"Candidates must recognize the indication and benefits of hormone therapy for vasomotor symptoms in appropriate patients." Lifestyle changes (A) are supportive but insufficient. Primrose oil (C) lacks robust evidence. SSRIs (D) and clonidine (E) are second-line.
NEW QUESTION # 271
A 69-year-old man presents with a 4-day history of a painful right knee. On history, he denies any trauma or similar previous episodes. Examination reveals effusion of the right knee that is warm to the touch. Which one of the following is the best next step?
Answer: B
Explanation:
The first step in evaluating a new, hot, swollen joint is arthrocentesis to rule out septic arthritis and crystal arthropathy. Joint aspiration provides fluid for microscopy, culture, and crystal analysis, which guides definitive diagnosis and treatment.
Toronto Notes 2023 - Rheumatology, Monoarthritis:
"Joint aspiration is the most important first step in evaluating monoarthritis. Septic arthritis must be ruled out before initiating any therapy." MCCQE1 Objectives - Internal Medicine > Rheumatology:
"Candidates should perform joint aspiration in the presence of acute monoarthritis to differentiate between septic arthritis, gout, and other causes." Radiography (A) and serum uric acid (B) do not establish cause acutely. Empiric antibiotics (D) and NSAIDs (E) should only be started after ruling out septic arthritis.
NEW QUESTION # 272
A 9-year-old girl from a remote community is brought to the clinic with a 2-week history of swelling in her neck. She has been afebrile but has had some night sweats. On examination, you note a fixed, unilateral, and nontender supraclavicular lymph node measuring 3 cm. The overlying skin color is unremarkable. In addition, you note a slightly enlarged spleen and liver. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
This child presents with "red flag" features for malignancy: a firm, fixed, nontender supraclavicular lymph node >2 cm in size, with associated hepatosplenomegaly and night sweats. These features are most concerning for lymphoma.
Toronto Notes 2023 - Pediatrics, "Lymphadenopathy in Children":
"Malignant lymphadenopathy tends to be firm, fixed, painless, and located in supraclavicular areas. Systemic signs (fever, weight loss, hepatosplenomegaly, night sweats) are concerning for lymphoma." MCCQE1 Objectives (Pediatrics > 78-3: Hematology/Oncology):
"Candidates should differentiate between benign and malignant lymphadenopathy and recognize features suggestive of lymphoma." Cat-scratch disease (B) is usually tender and associated with cat exposure. Kawasaki disease (C) presents with fever and mucocutaneous findings. Acute bacterial lymphadenitis (D) is painful, warm, and rapid in onset.
Viral lymphadenopathy (E) is often bilateral, small, and tender.
NEW QUESTION # 273
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: D
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 # 274
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