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| Section | Weight | Objectives |
|---|---|---|
| Dimensions of Care | 50% | - Chronic Care - Health Promotion and Illness Prevention - Acute Care - Assessment and Diagnosis |
| Physician Activities | 50% | - Management - Communication - Professional Behaviours - Psychosocial Aspects |
>> MCCQE Most Reliable Questions <<
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NEW QUESTION # 137
You performed a surgical procedure on a 32-year-old woman for a herniated disk that was causing neurologic impairment. At the 8-month follow-up visit, she has healed well; however, she requests a prescription renewal of her narcotic analgesics (hydromorphone). Her pharmacy confirms that the patient adheres to the dosage you prescribed, that she has not consulted other physicians, and that her behavior has always been respectful.
You think that she no longer requires narcotic analgesics. Which one of the following approaches is most helpful to the patient?
Answer: D
Explanation:
The patient's pain is no longer medically justified for opioids, but there is no evidence of misuse. The most appropriate and supportive action is to explain concerns, provide education about opioid tapering or dependency, and transition care to her family physician for ongoing management.
Toronto Notes 2023 - ELOM, "Safe Prescribing and Opioid Stewardship" Section:
"When opioids are no longer indicated, engage the patient in a conversation about tapering and arrange appropriate follow-up. Coordinate care with primary providers when long-term management is needed." MCCQE1 Objectives (ELOM > 99-1: Professionalism and Substance Use):
"Candidates must address the risk of dependency, counsel the patient, and ensure a safe transition to appropriate care without abrupt termination." Methadone (E) and fentanyl (A) are for opioid use disorder or chronic pain, not for tapering in low-risk patients. Discharging the patient (B) or reporting (C) is punitive and unnecessary.
NEW QUESTION # 138
A 25-year-old man presents to the Emergency Department with diffuse abdominal pain and anorexia. He was tackled in a football game yesterday. He reports a 3-week history of sore throat and fatigue. Vital signs are as follows:
Blood pressure: 95/45 mm Hg
Heart rate: 96/min
Temperature: 37.6°C
Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
This patient presents with hypotension, diffuse abdominal pain, and a history of contact sports injury with preceding symptoms of infectious mononucleosis (sore throat, fatigue). The spleen is commonly enlarged in mononucleosis, making it vulnerable to rupture after even minor trauma.
Toronto Notes 2023 - General Surgery and Infectious Diseases Sections:
"Splenic rupture is a known complication of mononucleosis, particularly after trauma. Symptoms may include diffuse abdominal pain, hypotension, and signs of hemorrhagic shock." MCCQE1 Objectives (Surgery > 84-1: Abdominal Trauma):
"Candidates should identify splenic rupture as a cause of hypotension and abdominal pain following blunt abdominal trauma, especially in patients with splenomegaly." Appendicitis (B) would present with localized right lower quadrant pain. Pneumonia (C) and pyelonephritis (D) would present with respiratory or urinary symptoms. Ruptured duodenum (E) is much less likely without specific trauma to that region or signs of peritonitis.
NEW QUESTION # 139
A 63-year-old man presents to the office with a 2-year history of episodic swallowing problems that have been increasing in frequency. He states that food seems to stick in his throat, and these episodes are often associated with coughing or regurgitating undigested food. Physical examination reveals that the patient has halitosis; otherwise, findings are normal. Which one of the following is the best next step to confirm the most likely diagnosis?
Answer: A
Explanation:
This presentation is classic for Zenker diverticulum , characterized by progressive dysphagia, regurgitation of undigested food, coughing, and halitosis due to food retention in a pharyngoesophageal pouch. Symptoms are chronic and episodic, often involving regurgitation hours after eating. MCCQE objectives emphasize selecting the safest and most appropriate diagnostic test. The best initial test is a barium swallow (contrast esophagram)
, which clearly visualizes the posterior outpouching above the upper esophageal sphincter.
Endoscopy is not the first step because there is a risk of perforation if a large diverticulum is present. pH monitoring and PPI trials are used for gastroesophageal reflux disease, which does not explain regurgitation of undigested food and halitosis. CT chest is unnecessary for diagnosis.
Therefore, a barium swallow is the safest and most informative investigation to confirm suspected Zenker diverticulum before considering surgical or endoscopic management.
NEW QUESTION # 140
You are examining a newborn in the delivery room. He was born at full term by spontaneous vaginal delivery.
On examination, he is active, and his vital signs are within normal range. His head circumference is at the third percentile, with height and weight at the 10th percentile. Auscultation of his chest is clear with normal cardiovascular examination findings. The abdomen is protuberant with a liver edge palpable at 4 cm below the costal margin and mild splenomegaly. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
Microcephaly, intrauterine growth restriction, hepatosplenomegaly, and normal vital signs in a term newborn strongly suggest congenital viral infection (e.g., CMV, toxoplasmosis, rubella).
Toronto Notes 2023 - Pediatrics, Congenital Infections:
"Signs of congenital TORCH infections include microcephaly, hepatosplenomegaly, and growth restriction.
Early identification is key."
MCCQE1 Objectives - Pediatrics > Infectious Disease:
"Candidates must recognize signs suggestive of congenital infections and distinguish from genetic or structural abnormalities." Cephalic molding (A) is benign and resolves spontaneously. Lipid storage diseases (B) are not present at birth. Cystic fibrosis (C) does not cause microcephaly or hepatosplenomegaly at birth. Trisomy 21 (D) has distinct dysmorphic features not described here.
NEW QUESTION # 141
A 78-year-old man presents to the office with urinary hesitancy, straining to void his bladder, and a sensation of incomplete bladder emptying. On history, he has a BMI of 36 and type 2 diabetes. Which one of the following medications would most likely help the patient's symptoms?
Answer: D
Explanation:
This elderly man has classic lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) : hesitancy, straining, and incomplete emptying (obstructive symptoms). MCCQE objectives emphasize recognizing obstructive voiding symptoms in older men as most commonly due to prostatic enlargement causing bladder outlet obstruction.
First-line pharmacologic therapy for symptomatic BPH is an alpha-1 adrenergic receptor blocker (e.g., tamsulosin), which relaxes smooth muscle in the prostate and bladder neck, thereby improving urinary flow and reducing obstruction. Tamsulosin works relatively quickly and is appropriate for symptomatic relief.
Nitrofurantoin treats urinary tract infections, which are not suggested here. Fesoterodine is an antimuscarinic used for overactive bladder and could worsen urinary retention in obstructive BPH. Empagliflozin (an SGLT2 inhibitor) increases urinary glucose excretion and may worsen urinary frequency. Hydrochlorothiazide increases urine output and would not relieve obstructive symptoms.
Therefore, tamsulosin is the most appropriate medication to improve this patient's symptoms.
NEW QUESTION # 142
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