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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Health Advocate
|
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NEW QUESTION # 245
A 45-year-old man presents to your clinic for follow-up regarding his obsessive-compulsive disorder. He currently takes a high dosage of paroxetine, which he would like to discontinue because he feels well. His condition has been stable taking this medication since he was discharged from inpatient care 2 years ago.
Which one of the following is the most appropriate recommendation?
Answer: D
Explanation:
Obsessive-compulsive disorder (OCD) is a chronic and often relapsing condition. MCCQE objectives emphasize that patients with severe OCD requiring hospitalization or prolonged high-dose SSRI therapy are at significant risk of relapse if medication is discontinued. This patient has remained stable for 2 years on a high dose of paroxetine after inpatient treatment, suggesting a history of more severe disease.
For moderate-to-severe or recurrent OCD, long-term or indefinite maintenance pharmacotherapy is often recommended, particularly when the patient has responded well and tolerated the medication. Abrupt discontinuation or large dose reductions (e.g., 50%) increase the risk of relapse and discontinuation syndrome, especially with paroxetine, which has a short half-life. Switching to another SSRI is unnecessary when the current medication is effective and tolerated. Supportive psychotherapy alone is generally insufficient for patients with previously severe OCD.
Therefore, the most appropriate recommendation is to maintain the current dosage , while discussing risks and benefits and reassessing periodically.
NEW QUESTION # 246
A 6-year-old girl is found to have a blood pressure of 130/75 mm Hg. She was born prematurely at 32 weeks' gestation and required ventilation. There is a family history of hypertension in 3 grandparents. Clinical examination reveals a grade 1/6 mid-systolic murmur, no renal bruits, and femoral pulses are difficult to feel.
Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
The combination of upper extremity hypertension and weak femoral pulses is classic for aortic coarctation. A soft systolic murmur may be present. This condition often becomes apparent during routine screening in school-aged children.
Toronto Notes 2023 - Pediatrics / Cardiology:
"Coarctation of the aorta presents with upper limb hypertension, diminished femoral pulses, and sometimes a systolic murmur. BP discrepancy is key." MCCQE1 Objectives (Pediatrics > 78-1: Congenital Heart Disease):
"Candidates must recognize signs of aortic coarctation, including weak lower limb pulses and systemic hypertension in children." VSD (A) typically presents with a louder murmur. Reflux nephropathy (B) may cause hypertension but without femoral pulse discrepancy. Renal artery thrombosis (C) is rare. Essential hypertension (D) is less likely in this age group with these findings.
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NEW QUESTION # 247
A 56-year-old man is admitted to hospital with pyelonephritis and started on intravenous antibiotics. On day 2 of his hospitalization, he continues to report right flank pain, but he is able to walk. His vital signs are as follows:
Temperature: 38.5°C
Blood pressure: 90/60 mm Hg
Heart rate: 105/min
The patient is mentating well but is concerned about his dog that is home alone due to his unexpected hospitalization. He requests to be released from hospital as he needs to make arrangements for his dog. Which one of the following is the best next step?
Answer: B
Explanation:
The patient is alert and capable of making his own decisions. The most ethical and respectful approach is to ensure he understands the risks and accept his choice. Holding his bed maintains continuity of care. Forcing him to stay (C) or discharging him AMA (A) is inappropriate if he intends to return.
Toronto Notes 2023 - ELOM, Consent and Autonomy:
"Capable patients have the right to refuse or leave treatment. Physicians must ensure informed decision- making and maintain therapeutic rapport." MCCQE1 Objectives - ELOM > Capacity and Patient Autonomy:
"Candidates must respect a capable patient's right to leave care after informed discussion of risks and alternatives." Offering to enter his apartment (E) is inappropriate and unethical. Oral antibiotics (B) may not be clinically appropriate given hypotension.
NEW QUESTION # 248
A 40-year-old woman presents to the Emergency Department with confusion and fever (38.5°C). She has a history of hypothyroidism managed with levothyroxine. Key findings include:
Blood pressure
114/78 mm Hg
Heart rate
85/min
Temperature
38.5°C
Hemoglobin
90 g/L123-157 g/L
Platelet count
25 × 10#/L130-400 × 10#/L
Peripheral blood film
Schistocytes present
Creatinine
200 #mol/L50-90 #mol/L
Answer: C
Explanation:
This patient presents with fever, confusion, anemia with schistocytes, thrombocytopenia, and renal impairment - fulfilling the classic pentad of thrombotic thrombocytopenic purpura (TTP). TTP is a hematologic emergency requiring plasma exchange.
Toronto Notes 2023 - Hematology, "Microangiopathic Hemolytic Anemia" Section:
"TTP is a medical emergency. Features include MAHA, thrombocytopenia, renal failure, neurologic symptoms, and fever. Schistocytes on blood film are diagnostic." MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Disorders):
"Candidates must urgently recognize TTP and initiate emergent plasma exchange therapy." AML (B) does not present with schistocytes. HIV (C) can cause thrombocytopenia but not MAHA. ITP (D) causes isolated thrombocytopenia without anemia or schistocytes.
NEW QUESTION # 249
A 45-year-old woman presents to the emergency department after being involved in a motor vehicle collision.
She reports severe right hip pain. On examination, the right hip is flexed and adducted. A radiograph shows a posterior dislocation. Which one of the following is the most appropriate management?
Answer: B
Explanation:
A posterior hip dislocation is an orthopedic emergency . The classic position is a shortened limb held in flexion, adduction, and internal rotation after high-energy trauma. MCCQE objectives emphasize immediate recognition and urgent management to prevent complications, especially avascular necrosis (AVN) of the femoral head and sciatic nerve injury . The key treatment is prompt closed reduction (ideally within hours) under procedural sedation or anesthesia, after appropriate analgesia and neurovascular assessment. Post- reduction priorities include confirming concentric reduction with imaging, repeating a neurovascular exam (particularly sciatic nerve function), and evaluating for associated fractures (acetabular or femoral head/neck) that may require CT and possible operative management.
Open reduction is reserved for irreducible dislocations, incarcerated fragments, or associated fractures preventing stable closed reduction. Skeletal traction is not definitive acute management. Total hip arthroplasty is not indicated as first-line in an acute traumatic dislocation in this context. Urgent closed reduction best aligns with time-sensitive limb- and joint-preserving care.
NEW QUESTION # 250
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