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| Section | Weight | Objectives |
|---|---|---|
| Dimensions of Care | 50% | - Chronic Care - Assessment and Diagnosis - Health Promotion and Illness Prevention - Acute Care |
| Physician Activities | 50% | - Professional Behaviours - Communication - Psychosocial Aspects - Management |
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NEW QUESTION # 327
A 52-year-old man presents to the Emergency Department with a history of back, neck, and shoulder pain sustained from a workplace incident 4 years ago. He is under observation by a multidisciplinary pain clinic, and his next appointment is not for another 4 weeks. He does not report any recent change in his symptoms.
His medications are as follows:
Acetaminophen
1000 mg orally 4 times daily
Naproxen
500 mg orally twice daily
Amitriptyline
25 mg orally at bedtime
* Acetaminophen 1000 mg orally four times daily
* Naproxen 500 mg orally twice daily
* Amitriptyline 25 mg orally at bedtime
The patient has not taken his medications for several weeks because he thinks they are not working. He requests a prescription for oxycodone because he tried some that a friend sold him, and it worked very well.
After completing an assessment and providing counseling, which one of the following is the best next step?
Answer: D
Explanation:
Given the request for opioids and history of non-prescribed opioid use (oxycodone obtained from a friend), the next appropriate step is to conduct a urine drug screen. This helps assess current substance use and guides safe prescribing decisions.
Toronto Notes 2023 - Pain Management and Addiction Medicine:
"Urine drug screening is recommended before initiating opioid therapy or when there is suspicion of substance misuse. A history of using non-prescribed opioids mandates assessment for opioid use disorder and further risk stratification." MCCQE1 Objectives - Internal Medicine > Chronic Pain:
"Candidates must assess for opioid misuse and dependence before initiating opioid therapy. Urine drug testing is a standard tool in this assessment." Providing naloxone (A) may be appropriate later if opioids are prescribed, but the priority is evaluation.
Cannabis (B) is not first-line and lacks controlled evidence in chronic pain. Tramadol (D) is an opioid-like agent and not appropriate until misuse risk is evaluated.
NEW QUESTION # 328
A 26-year-old woman, gravida 1, para 0, aborta 0, presents to your office at 10 weeks' gestation to review the results of her antenatal blood work. She tested positive for hepatitis C. Which one of the following is most advisable to share with her regarding the risks to her and her unborn child?
Answer: E
Explanation:
For pregnant women with hepatitis C infection , vertical transmission risk is approximately 5-6% and is higher with high maternal viral load or HIV coinfection. However, MCCQE objectives emphasize that breastfeeding is not contraindicated in mothers with hepatitis C, as HCV is not transmitted through breast milk. Breastfeeding should only be temporarily avoided if there are cracked or bleeding nipples, which could expose the infant to blood.
Termination of pregnancy is not recommended solely due to hepatitis C infection. Pregnancy does not reliably increase viral load in a clinically significant way, and routine antiviral therapy during pregnancy is generally not recommended because current direct-acting antivirals are not yet standard in pregnancy. The infant does not automatically require antiviral treatment; instead, postnatal monitoring with HCV RNA testing and/or antibody testing at the appropriate age is recommended. While chronic hepatitis C increases long-term risk of cirrhosis and hepatocellular carcinoma, this is not an inevitable outcome.
Therefore, reassuring her that breastfeeding is safe is the most appropriate counselling point.
NEW QUESTION # 329
A 33-year-old primigravid woman presents to the office with gestational hypertension. Her pregnancy is at 37 weeks' gestation. The ultrasound findings are as follows:
Head circumference: 5th percentile
Biparietal diameter: 10th percentile
Abdominal circumference: 5th percentile
Femur length: 25th percentile
Amniotic fluid volume: 5.0 cm
Umbilical Doppler: Reversed end-diastolic flow
Which one of the following is the best next step?
Answer: C
Explanation:
This pregnancy demonstrates fetal growth restriction (FGR) with biometric measurements at or below the
10th percentile and oligohydramnios (AFI 5 cm). Most concerning is the finding of reversed end-diastolic flow (REDF) in the umbilical artery Doppler, which indicates severe placental insufficiency and significantly increased risk of fetal hypoxia, acidosis, and intrauterine demise. MCCQE objectives emphasize that abnormal umbilical artery Doppler findings-particularly absent or reversed end-diastolic flow-represent critical fetal compromise.
At 37 weeks' gestation, the fetus is term. The risks of continued intrauterine exposure in the setting of REDF outweigh the risks of delivery. Therefore, immediate delivery is indicated. Expectant management with nonstress testing or delayed reassessment is inappropriate because REDF is associated with high perinatal mortality.
Prompt delivery (often by cesarean section depending on fetal status and cervical factors) is required to prevent stillbirth and severe neonatal morbidity.
NEW QUESTION # 330
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: E
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 # 331
You are examining a full-term baby girl in the nursery. You notice that her left forefoot is adducted and supinated relative to the contralateral foot, which makes her left foot appear C-shaped. Which one of the following findings is most instrumental in deciding on the management of this issue?
Answer: D
Explanation:
The description is classic for metatarsus adductus. The most important clinical factor guiding management is whether the foot is flexible or rigid. Flexible deformities typically resolve spontaneously and do not require intervention.
Toronto Notes 2023 - Pediatrics, "Musculoskeletal Conditions":
"Metatarsus adductus: inward deviation of the forefoot. Management depends on flexibility. Flexible cases are benign and resolve spontaneously; rigid forms may need casting." MCCQE1 Objectives (Pediatrics > 78-2: Musculoskeletal Disorders):
"Candidates must assess and differentiate between flexible and rigid deformities to guide treatment in foot abnormalities." Other findings (B-E) are either unrelated or not determinant in metatarsus adductus management.
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NEW QUESTION # 332
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