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| Section | Objectives |
|---|---|
| Physician Activities | - Management
|
| Dimensions of Care | - Chronic Care
|
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NEW QUESTION # 54
A 70-year-old man presents with severe, postprandial, mid-abdominal pain which has become more severe over the past 6 to 9 months. It is associated with nausea but has not caused him to vomit or changed his bowel habits. He has lost 14 kg over the last 6 months. Abdominal and rectal examination is normal. Upper gastrointestinal series is unremarkable. Which one of the following is the most likely diagnosis?
Answer: C
Explanation:
Chronic mesenteric ischemia (also known as "intestinal angina") presents as postprandial abdominal pain, leading to food avoidance and significant weight loss. GI exams may be normal. Imaging (e.g., angiography or CT angio) confirms the diagnosis.
Toronto Notes 2023 - Gastroenterology, "Chronic Mesenteric Ischemia":
"Classic triad: postprandial abdominal pain, weight loss, and food aversion. Physical exam and GI series may be normal." MCCQE1 Objectives (Gastroenterology > 47-1: Abdominal Pain):
"Candidates must suspect mesenteric ischemia in older adults with risk factors and postprandial pain leading to weight loss." PUD (A) usually causes epigastric pain relieved by food. Cholelithiasis (B) causes RUQ pain. Colon cancer (D) presents with altered bowel habits or bleeding. Mesenteric adenitis (C) occurs in younger patients, often with infection.
NEW QUESTION # 55
A 77-year-old woman is brought to the Emergency Department by ambulance because she has severe heel ulcers and dehydration. Her husband reports that she has been sick for the past 6 to 8 weeks with a cough and congestion. He shares that he has tried to bring her to medical attention on several occasions, but she refused.
The paramedics reported that her bed at home was soiled and that they could hardly reach her room due to clutter. On questioning, her answers seem reasonable. Which one of the following is the most critical next step?
Answer: A
Explanation:
When elder neglect is suspected-especially in cases of self-neglect or unclear caregiver dynamics-the most important immediate step is to assess the patient's decision-making capacity. If she lacks capacity, protective intervention is warranted.
Toronto Notes 2023 - Geriatrics, "Elder Abuse and Capacity Assessment":
"Decision-making capacity must be assessed when a patient is refusing care despite evidence of harm or risk." MCCQE1 Objectives (ELOM > 90-1: Capacity and Consent):
"Candidates must assess capacity in elderly patients before attributing decisions to autonomy, particularly in complex care situations." Evaluating criminal records (B) or clutter (C) may be relevant later but do not take precedence over capacity assessment. Alcohol/substance use (D) and financial abuse (E) are differential concerns, not the critical first step.
NEW QUESTION # 56
An 85-year-old man is transferred from an acute care hospital to your long-term care (LTC) facility after treatment for a hip fracture. He has a fever, headache, myalgia, and malaise. He has been in contact with LTC staff and family but not with other residents. None of the other residents or LTC staff are symptomatic. As additional investigations are being arranged, which one of the following is the best next step?
Answer: B
Explanation:
This elderly resident presents with symptoms suggestive of influenza or another respiratory viral illness shortly after admission to a long-term care (LTC) facility. MCCQE population health objectives emphasize early outbreak prevention in institutional settings. The first and most immediate step when a potentially contagious illness is identified is to isolate the symptomatic individual using appropriate droplet and contact precautions.
Prompt isolation reduces the risk of transmission to other vulnerable LTC residents, who are at high risk of severe complications. Additional steps-such as notifying public health authorities or closing the facility-are considered if an outbreak is confirmed or multiple cases occur. At this stage, there is only a single symptomatic patient.
Immunization during an acute febrile illness is not appropriate and would not provide immediate protection.
Therefore, immediate isolation while arranging diagnostic testing and monitoring for additional cases is the correct infection prevention and control measure.
NEW QUESTION # 57
A 53-year-old man presents to the Emergency Department with a 3-week history of believing his neighbor is poisoning him by pumping gas through his home's air vent. He appears distracted, irritable, and is speaking very quickly. He has a family history of depression. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
This man exhibits a classic manic episode with psychotic features: persecutory delusions, distractibility, pressured speech, irritability, and possible grandiosity. The chronicity and mood symptoms are most consistent with Bipolar I disorder.
Toronto Notes 2023 - Psychiatry, "Mood Disorders" Section:
"Bipolar I disorder is characterized by episodes of mania, often with psychotic features.Symptoms include grandiosity, decreased need for sleep, distractibility, and mood-congruent delusions." MCCQE1 Objectives (Psychiatry > 79-1: Mood Disorders):
"Candidates must recognize mania and differentiate from brief psychosis or organic causes." Delirium (A) is acute, fluctuating, and involves impaired attention. Malingering (B) requires external gain.
Brief psychotic disorder (C) resolves within 1 month. Brain injury-related psychosis (E) would require a supporting history or findings.
(Part 2 )
NEW QUESTION # 58
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: B
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 # 59
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