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| Section | Weight | Objectives |
|---|---|---|
| Dimensions of Care | 50% | - Chronic Care - Acute Care - Health Promotion and Illness Prevention - Assessment and Diagnosis |
| Physician Activities | 50% | - Management - Psychosocial Aspects - Professional Behaviours - Communication |
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NEW QUESTION # 302
An 18-month-old boy is brought to the office by his guardians for a well-child visit. His guardians are concerned that his eyes do not look the same. On examination, his eyes appear as shown in the referenced photo.
Which one of the following best represents the patient's condition?
Answer: A
Explanation:
The image shows an asymmetrical light reflex (corneal light reflex not centered in both eyes), which is diagnostic of strabismus. This misalignment of the eyes must be treated early to prevent amblyopia (lazy eye).
Toronto Notes 2023 - Pediatrics, Ophthalmology:
"Strabismus presents with misaligned visual axes. The Hirschberg light reflex is off-center in the affected eye.
Prompt referral is necessary to prevent amblyopia."
MCCQE1 Objectives - Pediatrics > Vision and Developmental Disorders:
"Candidates must recognize strabismus on visual screening and refer early for correction to prevent permanent vision impairment." Pseudostrabismus (B) can be ruled out here because the light reflex is not symmetric. Ptosis (A) involves drooping of the eyelid, which is not evident. Cataracts (D) would typically present with a leukocoria (white reflex), not misalignment.
NEW QUESTION # 303
A 33-year-old man with severe bacterial meningitis is intubated and unresponsive in the Intensive Care Unit.
If he receives immediate treatment, his prognosis is excellent. If he does not, he will likely die. Three years ago, the patient had Huntington disease diagnosed, but he has been asymptomatic since then. His advance directive, which was made before this hospitalization, states that he should be allowed to die if he contracts a life-threatening illness. His parents demand that he be treated for the meningitis. Which one of the following is the best next step?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
An advance directive is a legally binding document that outlines a competent person's preferences regarding future medical care. If the patient clearly stated a refusal of treatment in the event of a life-threatening condition, this directive must be followed, even if the patient is currently incapacitated and family disagrees.
Toronto Notes 2023 - Ethics and Law:
"Advance directives must be respected when valid, clear, and applicable. Substitute decision-makers cannot override them." MCCQE1 Objectives (ELOM > 90-4: Informed Consent and Advance Directives):
"Candidates must apply valid advance directives to guide care for incapacitated patients." B (parents as SDMs) is incorrect if an advance directive exists. A and D are irrelevant-capacity has already been documented. C is unnecessary when an advance directive is clear.
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NEW QUESTION # 304
A 34-year-old woman, gravida 2, para 1, aborta 0, presents to the labor and delivery ward at 32 weeks' gestation with a 24-hour history of worsening frontal headache, photophobia, and neck stiffness. Vitals:
* BP: 121/78 mm Hg
* HR: 90 bpm
* Temp: 38°C
Neuro exam reveals a 2-beat ankle clonus. Tone and power are otherwise normal. No localizing signs or papilledema. Abdomen is soft, fetus is cephalic.
Which one of the following is the best next investigation?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
This patient is pregnant and febrile with a new headache, photophobia, and clonus - all features concerning for preeclampsia with neurologic involvement. Clonus is a key finding suggestive of central nervous system irritability. Urine protein/creatinine ratio helps confirm the diagnosis of preeclampsia.
Toronto Notes 2023 - Obstetrics, Hypertensive Disorders in Pregnancy:
"Headache, clonus, and visual disturbances are concerning for severe preeclampsia. A urine protein/creatinine ratio or 24-hour urine collection confirms diagnosis." MCCQE1 Objectives - Obstetrics > Hypertension in Pregnancy:
"Candidates must recognize signs of preeclampsia and assess with appropriate biochemical testing." CT (A) or LP (B) are not indicated unless focal neurologic signs or seizures are present. Fetal imaging and amniocentesis (C, D) do not address maternal symptoms.
NEW QUESTION # 305
A 38-year-old man is brought by his wife to the Emergency Department with fatigue, dizziness, and nausea after completing a hiking tour on a hot, humid day. His wife became worried after he had collapsed. He has been sweating heavily and vomited twice on the drive in. His medical history is unremarkable, and he takes no medications. His vital signs on arrival are as follows:
Blood pressure
85/57 mm Hg
Heart rate
120/min
Respiratory rate
18/min
Temperature
40.1 °C
Oxygen saturation
95%, room air
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On physical examination, the patient's skin is dry, flushed, and warm to the touch. He has a diffuse erythematous papular rash. Findings of a thorough physical examination are otherwise unremarkable. An electrocardiogram shows sinus tachycardia. Which one of the following is the best next step?
Answer: E
Explanation:
This patient has classic features of exertional heat stroke-hyperthermia, hypotension, CNS symptoms (collapse), and hot, dry skin. A key complication of heat stroke is rhabdomyolysis, which can cause renal failure. Serum creatine kinase (CK) is the best next diagnostic step to confirm muscle breakdown.
Toronto Notes 2023 - Emergency Medicine, "Environmental Exposures":
"In heat stroke, check for rhabdomyolysis (#CK), renal impairment, and coagulopathy. Prompt cooling and hydration are critical." MCCQE1 Objectives (Internal Medicine > 59-3: Environmental and Toxic Exposures):
"Candidates must recognize heat-related illnesses and investigate for complications such as rhabdomyolysis and acute kidney injury." CT head (C) is not indicated unless persistent neurological symptoms. TSH (B), CRP (D), and blood cultures (E) are irrelevant to acute exertional hyperthermia.
NEW QUESTION # 306
A 10-year-old boy and his mother present to your office with a concern about handwashing. The mother explains that her son has been at a new school for the past month and that teachers have noticed that he is washing his hands all day. He has also hidden hand sanitizer in his desk. The hand-cleaning is a response to a constant anxiety that his hands are dirty, and that he might pass an infection to someone. Which one of the following is the most appropriate initial management?
Answer: E
Explanation:
This child demonstrates classic features of obsessive-compulsive disorder (OCD): intrusive contamination fears (obsession) and repetitive handwashing behaviors (compulsion) performed to reduce anxiety. The symptoms are excessive, impairing school function, and persist beyond normal developmental concerns.
According to MCCQE objectives, first-line treatment for mild to moderate pediatric OCD is cognitive- behavioral therapy (CBT) with exposure and response prevention (ERP). ERP involves gradual exposure to feared contaminants while preventing the compulsive handwashing response, thereby reducing anxiety through habituation and cognitive restructuring. Pharmacologic treatment with selective serotonin reuptake inhibitors (e.g., fluoxetine) is indicated for moderate to severe cases or when CBT alone is insufficient, but it is not the preferred initial intervention when psychotherapy is accessible. Risperidone is not first-line and may be considered only as augmentation in refractory cases. Changing schools or providing a teaching assistant does not address the underlying anxiety disorder. Early evidence-based intervention improves prognosis and functional outcomes in pediatric OCD.
NEW QUESTION # 307
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