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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Dimensions of Care | 50% | - Health Promotion and Illness Prevention - Acute Care - Chronic Care - Assessment and Diagnosis |
| Topic 2: Physician Activities | 50% | - Management - Professional Behaviours - Communication - Psychosocial Aspects |
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10. Frage
A 12-year-old boy is brought by his mother to your clinic with a history of attention-deficit/hyperactivity disorder. His mother reports that he has been taking immediate-release methylphenidate for 2 years. Although the medication was initially effective, it no longer seems to work. The teachers say he is disorganized and fidgety, verbally interrupts class, and does not complete his work. His mother tells you that he does listen at home. Which one of the following is the most important next step in management?
Antwort: E
Begründung:
Management of ADHD requires ongoing reassessment using standardized rating scales from multiple informants (e.g., parents and teachers) to evaluate symptom control and functional impairment across settings.
This child demonstrates persistent school-related symptoms despite prior response to immediate-release methylphenidate. Before adjusting therapy, it is essential to objectively reassess symptom severity, adherence, timing of doses relative to school hours, and potential environmental factors. Completion of validated rating scales helps determine whether symptoms remain clinically significant and guides appropriate dose titration.
Stimulant medications such as methylphenidate are first-line treatment, and inadequate response often requires dose optimization before switching agents. Simply increasing the dose without reassessment is not best practice. Risperidone is not indicated for uncomplicated ADHD. An EEG is unnecessary unless there are seizure concerns. Switching to atomoxetine is premature without confirming inadequate response to optimized stimulant therapy. MCCQE objectives emphasize systematic monitoring, multi-informant assessment, dose titration, and evidence-based pharmacologic management in pediatric ADHD.
11. Frage
A 42-year-old woman is admitted to the Intensive Care Unit with a massive pulmonary embolism. Her condition is stabilized with intubation, hydration, inotropic support, and intravenous administration of heparin. Her partner provides you with a list of her medications. A combination oral contraceptive pill was recently prescribed. She smokes tobacco cigarettes, and her BMI is 36. Which one of the following is the best next step?
Antwort: E
Begründung:
Oral contraceptives increase the risk of thromboembolic events, particularly in patients with risk factors such as smoking and obesity. However, informing the patient's partner of potential contributing factors in a factual, non-judgmental manner is appropriate and does not imply fault.
Toronto Notes 2023 - ELOM, "Informed Consent and Risk Communication":
"Patients and families should be informed of all relevant information, including potential drug-related adverse events. Blame must not be assigned without full investigation." MCCQE1 Objectives (ELOM > 90-2: Physician-Patient Communication):
"Candidates must be able to communicate adverse outcomes factually, while respecting confidentiality and without prematurely assigning fault." Discussing the case with the ethics committee or reporting the prescribing doctor without context is premature and inappropriate (A, D). Telling the partner the physician was at fault (C) is speculative and unethical.
12. Frage
A 38-year-old man presents to the office for a follow-up visit. For several years, he has been having constant abdominal pain and intermittent constipation. He struggles to fall asleep because he is worried about his symptoms, and he often spends hours researching possible investigations and causes. Although he recently had extensive investigations, which have all had normal results, he continues to visit multiple physicians hoping for more investigations. He worries that he will die because no one is taking him seriously. Which one of the following is the best next step?
Antwort: D
Begründung:
This presentation is most consistent with somatic symptom disorder/illness anxiety : persistent distressing physical symptoms (abdominal pain/constipation) with excessive health-related anxiety, repeated reassurance- seeking, and "doctor shopping" despite normal investigations. MCCQE objectives emphasize avoiding iatrogenic harm from repeated testing and using a structured, therapeutic relationship to manage medically unexplained or disproportionate symptom concerns. The best next step is regularly scheduled follow-up visits with one consistent physician (e.g., monthly), focused on validating symptoms, addressing fears, monitoring for new objective findings, and gradually shifting toward coping strategies and functional goals. This approach reduces unnecessary investigations, reinforces continuity, and helps interrupt the cycle of anxiety- driven health-care utilization.
Repeating investigations (B) perpetuates reassurance-seeking and increases false positives and harm.
Consulting additional specialists (A) without new red flags similarly reinforces maladaptive beliefs and fragmentation of care. Exercise (D) may be beneficial as an adjunct but is not the core management strategy.
Therefore, planned, regular appointments are the most appropriate next step.
13. Frage
An intoxicated 28-year-old man is brought to the Emergency Department after being found in the snow. His vital signs are as follows:
Temperature: 33°C
Respiratory rate: 22/min
Heart rate: 123/min
The patient is shivering and displays some dysarthria and ataxia. After his wet clothing is removed, he is provided with a warm blanket. The results of the subsequent physical examination are unremarkable, except for frostbite of the ears and fingers. Which one of the following is the best next step?
Antwort: C
Begründung:
This patient is experiencing mild hypothermia (32-35°C), evidenced by shivering, ataxia, and tachycardia.
First-line management includes passive external rewarming - removing wet clothing, providing warm blankets, and ensuring a warm environment (ambient temperature ~28°C).
Toronto Notes 2023 - Emergency Medicine, Environmental Injuries:
"Mild hypothermia (32-35°C): Treatment includes passive rewarming (warm blankets, warm environment).
Avoid active rewarming methods to extremities due to risk of afterdrop." MCCQE1 Objectives - Internal Medicine > Environmental Exposure:
"Candidates must recognize appropriate levels of hypothermia and select evidence-based rewarming strategies based on severity." Options A, C, and D are used in moderate to severe hypothermia (<32°C or unconscious patients). Heating pads (B) may cause tissue damage, especially with frostbite.
14. Frage
A 78-year-old woman is brought to the Emergency Department by her son because she has a sodium level of
124 mmol/L (136-146). The sodium was checked as part of a blood work panel ordered by her primary health care provider to investigate symptoms of urinary frequency, fatigue, and thirst. Today, she has a blood glucose level of 44.0 mmol/L (4.0-11.0). The original blood work done by her primary health care provider did not include glucose. The patient is treated for hyperglycemia and dehydration and begins insulin. The patient and her son repeatedly express their frustration that their primary health care provider missed the diagnosis. Which one of the following is the best next step?
Antwort: A
Begründung:
In situations involving potential oversight, the appropriate next step is to contact the other physician directly.
This supports collegial communication, continuity of care, and provides an opportunity to clarify the clinical situation. It avoids premature judgment while allowing the primary provider to respond and address concerns.
Toronto Notes 2023 - ELOM, "Professionalism and Interprofessional Communication":
"When concerns arise about another provider's care, direct communication is preferred before considering formal reporting. This maintains collaboration and fairness." MCCQE1 Objectives (ELOM > 90-2: Communication and Accountability):
"Candidates must demonstrate collegiality and appropriate methods for addressing concerns regarding another physician's care." Empathizing (D) and validating blame is unprofessional. Reporting (B) is premature. Offering another provider (C) could undermine continuity. (E) is incorrect since the glucose should have been checked based on the presenting symptoms.
15. Frage
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