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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Professional
|
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NEW QUESTION # 113
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: E
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 # 114
A 72-year-old woman is brought to the Emergency Department by her daughter because of significant functional decline and progressive shortness of breath. She has widespread metastatic breast cancer and recently stopped chemotherapy due to progression and intolerance. She has been bedridden for 4 weeks. On examination:
* BP: 100/70 mm Hg with pulsus paradoxus of 20 mm Hg
* HR: 99/min
* Temp: 36.5°C
* SpO#: 94% room air
* JVP: elevated
* Heart sounds: muffled
* Chest X-ray: large globular heart
Labs:
* Hemoglobin: 90 g/L
* Sodium: 118 mmol/L
* Creatinine: 94 µmol/L
Which one of the following is the best next step?
Answer: A
Explanation:
This patient has classic signs of cardiac tamponade (Beck's triad: hypotension, muffled heartsounds, elevated JVP, plus pulsus paradoxus). However, she also has advanced metastatic cancer, functional decline, and has stopped active treatment. In this context, a goals-of-care discussion is the most appropriate next step to determine her wishes regarding interventions like pericardiocentesis.
Toronto Notes 2023 - Palliative Care:
"End-of-life care should prioritize quality of life and patient preferences. In patients with terminal illness and life-threatening conditions (e.g., tamponade), initiate a conversation about goals before aggressive intervention." MCCQE1 Objectives - Internal Medicine > Palliative and End-of-Life Care:
"Candidates must assess prognosis, patient values, and initiate appropriate end-of-life discussions before invasive treatment." Although pericardiocentesis (A) may relieve symptoms, it should follow consent based on the patient's goals.
ICU (E), fluids (B), or transfusion (D) are not appropriate without this discussion.
NEW QUESTION # 115
A 28-year-old woman presents to the office in great distress because she has no money for groceries or rent.
She is a single mother of a 7-year-old girl. She has a history of gambling disorder. She has felt unable to cope for the last 3 months and has started gambling again. Today, she is crying, and she shares that her boyfriend became violent with her yesterday. Which one of the following is the highest priority for assessment?
Answer: B
Explanation:
The highest priority is the immediate safety of the patient and her child. In the presence of domestic violence, risk assessment for harm or neglect must be conducted urgently, particularly since a child may be at risk.
Safety trumps psychiatric or social evaluations in triage.
Toronto Notes 2023 - Psychiatry, "Crisis and Risk Assessment" Section:
"When intimate partner violence (IPV) is disclosed, it is critical to assess immediate safety and consider mandatory reporting, especially when children are involved." MCCQE1 Objectives (Psychiatry > 79-6: Violence and Abuse):
"Candidates must assess for and respond to risk of harm in situations of domestic violence, especially when dependents are involved. This includes ensuring immediate safety and following legal obligations for child protection." Although the other concerns (e.g., gambling, depression, substance use, financial need) are valid, the presence of violence makes D the first and most urgent priority.
NEW QUESTION # 116
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?
Answer: D
Explanation:
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.
NEW QUESTION # 117
In a research study, it is found that people who smoke tobacco cigarettes drink more coffee and have higher rates of lung cancer than people who do not smoke. However, the consumption of coffee alone is not associated with lung cancer. Which one of the following best describes the contribution of drinking coffee in the study?
Answer: D
Explanation:
A confounder is a variable associated with both the exposure and the outcome but not in the causal pathway.
In this study, coffee drinking is associated with smoking (the actual risk factor for lung cancer), but not independently associated with lung cancer.
Toronto Notes 2023 - Epidemiology Chapter:
"A confounder is a third variable that distorts the observed association between an exposure and an outcome.
It must be associated with both the exposure and the outcome, but not a result of the exposure." MCCQE1 Objectives (Population Health > 97-3: Study Design and Bias):
"Recognize and control for confounding in the interpretation of observational study data." Coffee is not a risk factor (B) since it's not independently associated with lung cancer, and it's not selection bias (C), which involves how participants are enrolled in a study.
NEW QUESTION # 118
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