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| Section | Objectives |
|---|---|
| Physician Roles (CanMEDS Framework) | - Communicator
|
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NEW QUESTION # 12
A 66-year-old woman has a 3-month history of dry cough and weight loss. A new chest radiograph reveals a large 2-cm mass in her right upper lobe, which is consistent with carcinoma. You look at her previous films and realize that you had read her chest radiograph as normal 1 year ago, but now clearly see a faint opacity in precisely the same location as her current lesion. Which one of the following is the best next step?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
Physicians must be transparent and honest in documentation. If a previous abnormality was missed, it must be acknowledged. The correct action is to comment on both the previous and current findings in your report and follow institutional disclosure policies.
Toronto Notes 2023 - ELOM, "Medical Error and Disclosure":
"Physicians must report and document prior missed findings honestly and provide full disclosure when reviewing comparative studies." MCCQE1 Objectives (ELOM > 90-2: Accountability and Communication):
"Candidates must accurately document previous findings when reviewing comparative data, even if it reveals past oversight." Delaying reporting (C-E) or omitting prior findings (A) is unethical.
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NEW QUESTION # 13
A 42-year-old man comes to your family practice. He has started seeing a reflexologist to help manage his chronic back pain. He presents to you a letter from the reflexologist outlining the weekly necessary treatments, each costing $300, and a list of blood tests for the patient to have done. The patient asks you to order the laboratory testing and send the results to his "other doctor." Which one of the following is the best next step?
Answer: E
Explanation:
Physicians should order investigations only when clinically indicated based on their own assessment and an evidence-based differential diagnosis, not solely at the request of a non-physician practitioner. The appropriate next step is to decline to order the requested tests as written and perform (or arrange) a proper evaluation of the patient's chronic back pain, including red-flag screening, functional impact, and prior work- up/treatments. This aligns with MCCQE objectives on stewardship of health resources and professional accountability: unnecessary testing can cause harm (false positives, downstream procedures) and misuses publicly funded services. Sending results to a reflexologist as "other doctor" is also inappropriate without confirming the person's role, ensuring relevance to care, and obtaining appropriate patient consent for disclosure; even with consent, the physician should not facilitate non-indicated testing. Reporting (A/B) or directing the patient to stop (E) is premature; the initial focus should be patient-centred care, education about evidence-based options, and collaborative planning while respecting patient autonomy and addressing potential safety concerns.
NEW QUESTION # 14
A 42-year-old woman presents to the emergency department with a 24-hour history of severe pain in her right eye. On examination, you notice a right conjunctival injection that is worst adjacent to the iris. Direct and consensual responses to light are intact but sluggish, with severe photophobia in the right pupil is slightly smaller than the left. The patient's visual acuity is 20/20 on the left and 20/40 on the right. Visual field testing results are normal. Intraocular pressure findings are normal. Slit-lamp examination findings of the cornea are normal, and there are no cells in the anterior chamber. You are unable to visualize her fundus. Which one of the following is the most likely diagnosis?
Answer: A
Explanation:
The most likely diagnosis is acute anterior uveitis (iritis). The key MCCQE clinical pattern is painful red eye with ciliary flush (injection worst adjacent to the iris/limbus) and marked photophobia, especially consensual photophobia, which strongly points to inflammation of the iris and ciliary body. The sluggish light response and miosis (smaller pupil) are also typical of iritis due to sphincter spasm and inflammation. Intraocular pressure is normal, helping to rule out acute angle-closure glaucoma, which usually presents with elevated IOP, corneal haze, and a mid-dilated fixed pupil. Optic neuritis classically causes decreased color vision and pain with eye movement rather than ciliary flush. Viral conjunctivitis causes diffuse conjunctival injection and irritation/grittiness, not severe pain with consensual photophobia. Scleritis causes deep "boring" pain and violaceous scleral hue, not miosis/consensual photophobia as dominant features. Difficulty visualizing the fundus can occur with significant miosis.
NEW QUESTION # 15
A 30-year-old woman presents to your office with a 6-week history of left lower quadrant pain and dyspareunia. A pelvic ultrasound is normal. Which one of the following is the most important immediate investigation?
Answer: D
Explanation:
This clinical presentation is highly suggestive of chronic pelvic inflammatory disease (PID), especially given the left lower quadrant pain and dyspareunia with a normal pelvic ultrasound. PID is often caused by sexually transmitted infections (STIs), such as Chlamydia trachomatis or Neisseria gonorrhoeae, which may not be evident on imaging.
Toronto Notes 2023 - Gynecology:
"Cervical swabs for N. gonorrhoeae and C. trachomatis are essential in the workup of suspected PID or cervicitis, even when imaging is normal. Dyspareunia and chronic pelvic pain with normal imaging should prompt testing for STIs." MCCQE1 Objectives (Obstetrics & Gynecology > 82-6: Pelvic Pain):
"Candidates must consider and investigate for infectious causes of pelvic pain, including PID, which requires cervical swab testing as an essential first-line investigation." Laparoscopy (A) is invasive and reserved for uncertain or refractory cases. Hysterosalpingography (C) is used in infertility workups, not acute pain. Endometrial biopsy (D) and MRI (E) are not first-line.
NEW QUESTION # 16
A 62-year-old woman with type 2 diabetes comes in for follow-up. She has noticed that her vision has been getting blurry over the past year and that she now needs a bright light to look at photos of her grandchildren.
Upon fundoscopic examination, you note yellow deposits in the central retina. Which one of the following is the most likely diagnosis?
Answer: D
Explanation:
Yellow deposits in the central retina (macula) are most consistent with drusen, the hallmark finding of age- related macular degeneration (AMD). MCCQE objectives emphasize correlating key funduscopic findings with patterns of vision loss. AMD typically causes gradual, progressive central vision blurring (difficulty reading, recognizing faces, and seeing fine detail), while peripheral vision is relatively preserved. The history of needing brighter light for near tasks aligns with impaired macular function and reduced contrast sensitivity seen in AMD.
Diabetic retinopathy more commonly shows microaneurysms, dot-blot hemorrhages, hard exudates scattered in the retina, venous beading, and/or neovascularization rather than discrete drusen in the macula as the defining feature. Retinal vein occlusion usually presents more abruptly with extensive hemorrhages and
"blood and thunder" appearance. Cataracts cause lens opacity with impaired red reflex and generalized haze on fundoscopy rather than macular deposits. Open-angle glaucoma causes optic disc cupping and peripheral field loss, not central drusen. Recognizing AMD prompts appropriate counseling (smoking cessation, risk factor control), vision monitoring, and ophthalmology referral to assess for dry vs wet AMD.
NEW QUESTION # 17
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