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| Section | Weight | Objectives |
|---|---|---|
| Dimensions of Care | 50% | - Health Promotion and Illness Prevention - Chronic Care - Assessment and Diagnosis - Acute Care |
| Physician Activities | 50% | - Management - Psychosocial Aspects - Communication - Professional Behaviours |
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NEW QUESTION # 289
You receive a note from a pharmacist about your 82-year-old patient who is taking oxycodone extended- release 20 mg 3 times daily for spinal stenosis. The pharmacist suggests that you consider tapering the medication. Your patient has been taking his current dosage for 1 year. When you saw him a month ago, he was functioning well with no adverse effects from the medication. Which one of the following is the best next step?
Answer: A
Explanation:
Long-term opioid therapy requires ongoing assessment of benefits, risks, function, adverse effects, and safety, particularly in older adults. MCCQE objectives emphasize regular reassessment before making changes to chronic controlled medications. Although the pharmacist has appropriately raised concern about prolonged opioid use, the patient was reported one month ago to be functioning well without adverse effects.
The appropriate next step is to reassess the patient directly-including pain control, functional status, cognition, fall risk, constipation, signs of misuse, and overall goals of care-before altering therapy.
Automatic dose reduction without evaluation may destabilize pain control. Immediate referral to a specialist is unnecessary if the patient is stable and well managed. Adjunct therapies such as physiotherapy may be considered but should not replace proper reassessment.
Shared decision-making is essential. If reassessment reveals limited benefit, adverse effects, or safety concerns, a gradual taper can then be discussed. Clinical decisions regarding opioids should be individualized rather than based solely on duration of use.
NEW QUESTION # 290
A 29-year-old woman, gravida 1, para 0, aborta 0, presents to your clinic. Her pregnancy is at 22 weeks' gestation. Her blood pressure is 158/96 mm Hg. Which one of the following antihypertensive medications is contraindicated for this patient?
Answer: B
Explanation:
Ramipril, an ACE inhibitor, is contraindicated in pregnancy due to risks of fetal renal dysgenesis, oligohydramnios, and fetal death, especially in the second and third trimesters.
Toronto Notes 2023 - Obstetrics, Hypertensive Disorders of Pregnancy:
"ACE inhibitors and ARBs are contraindicated in pregnancy due to their teratogenic potential and adverse fetal effects." MCCQE1 Objectives - Obstetrics > Hypertension in Pregnancy:
"Candidates must identify safe antihypertensives during pregnancy and contraindicated medications such as ACE inhibitors and ARBs." Methyldopa, labetalol, nifedipine, and hydralazine are considered safe and are commonly used in pregnancy.
NEW QUESTION # 291
A 71-year-old man with stable chronic low back pain on hydromorphone (8 mg twice daily) presents upset, requesting an early refill. He reports his granddaughter has been stealing his medication and pressuring him for refills. Which one of the following is the best next step?
Answer: B
Explanation:
This case suggests diversion of prescription opioids, a serious safety and regulatory concern. The physician must balance maintaining patient care with minimizing risk. Daily dispensing via a monitored pharmacy is the safest and most practical solution to prevent misuse or theft, while avoiding immediate discontinuation of the patient's needed medication.
Toronto Notes 2023 - Chronic Pain & Substance Use:
"In cases of concern for opioid diversion, consider witnessed daily dispensing, prescription monitoring, and involving caregivers when appropriate." MCCQE1 Objectives (Internal Medicine > Pain Management > 56-2):
"The candidate must demonstrate understanding of strategies for safe prescribing and monitoring of controlled substances, including mitigation of diversion." Calling the police (A) is not the physician's immediate duty. Providing an early refill (B) worsens risk.
Tapering (C) may be appropriate later, but first the medication must be safeguarded. Increasing quantity (D) is inappropriate.
NEW QUESTION # 292
A 56-year-old woman with a 4-year history of fibromyalgia presents for follow-up. She reports that she is struggling with her health and daily life. She is unhappy with her lack of progress and says she feels tired all the time and stays in bed all day. When asked why, she states she is confused about why she is not getting better. Physical exam and investigations are unchanged from baseline. Which one of the following is the best next step?
Answer: B
Explanation:
Patient education is foundational in managing fibromyalgia. Understanding the chronic but non-progressive nature of the disease, reassurance, and emphasis on self-management are crucial. It helps set realistic expectations and enhances engagement in therapy.
Toronto Notes 2023 - Rheumatology, Fibromyalgia:
"Patient education is essential. Explain the nature of fibromyalgia, emphasizing that although it is chronic, it is non-deforming and can be managed through exercise, sleep hygiene, and cognitive strategies." MCCQE1 Objectives - Psychiatry & Rheumatology > Chronic Pain Syndromes:
"Candidates must recognize the value of education and behavioral interventions in managing functional syndromes." SSRIs (D) may be used if depression is present. Iron/B12 (B) are not indicated without evidence of deficiency. Cannabinoids (A) lack strong evidence in fibromyalgia.
NEW QUESTION # 293
A 43-year-old car mechanic, with no prior history, comes to the Emergency Department because of a sudden loss of balance at work. He also feels lightheaded, slightly disoriented and nauseous. Physical examination and basic blood work-up are normal. He tells you this is the 3rd time this has happened at work. Which one of the following is the most likely diagnosis?
Answer: A
Explanation:
The most likely diagnosis is organic solvent intoxication because the episodes are recurrent, acute, and specifically occur at work in a car mechanic. MCCQE objectives in occupational and environmental medicine emphasize recognizing workplace exposures that cause transient neurologic symptoms. Organic solvents (e.g., toluene, xylene, gasoline vapors, degreasers) can produce acute CNS effects such as dizziness, imbalance
/ataxia, nausea, lightheadedness, and mild confusion or disorientation, often with a normal routine exam and basic labs once exposure ceases. The clear temporal relationship to the workplace and repeated similar episodes strongly supports an exposure-related cause. Lead toxicity is typically subacute/chronic, presenting with abdominal pain, constipation, neuropathy (wrist/foot drop), cognitive changes, anemia, and basophilic stippling-rather than brief episodic disequilibrium. A cerebellar tumor would cause progressive, persistent symptoms and focal neurologic findings. Ear infection-related vertigo would not reliably recur only at work and usually has ear symptoms or exam findings. Alcohol intoxication is less consistent with a repeated workplace-only pattern without corroborating signs.
NEW QUESTION # 294
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