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| Section | Objectives |
|---|---|
| Topic 1: Physician Activities | - Professionalism
|
| Topic 2: Dimensions of Care | - Chronic Care
|
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NEW QUESTION # 100
A 35-year-old woman, gravida 3, para 0, aborta 3, presents with her male partner because she has been unable to conceive despite trying for more than 1 year. Her menstrual cycles have been absent for 9 months, and she has occasional mild cyclic pain. She has a medical history of 3 suction curettages. Her BMI is 24.
Investigation results are as follows:
Hysterosalpingogram: Obliterated uterine cavity, no tubal dye spill
Progesterone (midluteal): 48.0 nmol/L (16.4-59.0)
Partner's semen: All parameters normal
Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
This patient has secondary amenorrhea, infertility, and a history of multiple uterine curettages, which strongly points toward Asherman syndrome (intrauterine adhesions or synechiae). The hysterosalpingogram shows an obliterated uterine cavity and no tubal dye spill-classic for intrauterine synechiae. Her midluteal progesterone level is normal, indicating ovulation.
Toronto Notes 2023 - Gynecology, "Infertility" section:
"Asherman syndrome results from intrauterine adhesions due to curettage, leading to amenorrhea and infertility. HSG shows an obliterated or irregular uterine cavity." MCCQE1 Objectives (Gynecology > 82-1: Infertility):
"Candidates should evaluate secondary amenorrhea and interpret imaging such as hysterosalpingogram in the diagnosis of intrauterine abnormalities." Other options are ruled out by the presence of normal ovulation (rules out hypothalamic and PCOS) and by imaging (not suggestive of fibroids or perimenopause).
NEW QUESTION # 101
A previously well 4-year-old boy is brought to your office by his mother. She is concerned by his behaviour.
Shortly after falling asleep, he awakens, screams loudly and cries. He appears frightened and does not respond to his mother's efforts to calm him. During these episodes, he appears agitated and flushed. After 15-20 minutes, he settles back to sleep. Physical examination is unremarkable. Which one of the following is the most likely diagnosis?
Answer: A
Explanation:
This presentation is characteristic of a non-rapid eye movement (NREM) sleep arousal disorder (sleep terror)
. MCCQE objectives highlight that sleep terrors typically occur in children aged 3-7 years and arise during the first third of the night , shortly after sleep onset, during deep NREM (slow-wave) sleep. Children abruptly awaken screaming, appear terrified, flushed, and autonomically aroused, and are inconsolable and minimally responsive to caregivers. Episodes usually last 10-20 minutes and resolve spontaneously, with the child returning to sleep and having no memory of the event the next morning.
Nightmares, in contrast, occur during REM sleep (later in the night); the child is awake, alert, consolable, and can recall the dream. Nocturnal seizures are typically brief, stereotyped, and may include tonic-clonic activity or a postictal state. Panic disorder occurs during wakefulness. Temper tantrums occur while awake and are behaviorally triggered.
Management is reassurance and ensuring safety; most children outgrow sleep terrors without intervention.
NEW QUESTION # 102
A 4-year-old girl is brought to the family practice by her father. The child has a 2-week history of low-grade fever, fatigue, and sore throat. She has also developed several small, round, mildly tender lumps bilaterally in her neck. She was previously well. Which one of the following is most likely to be found on abdominal examination?
Answer: E
Explanation:
This child likely has infectious mononucleosis caused by Epstein-Barr virus (EBV), characterized by fever, sore throat, cervical lymphadenopathy, fatigue, and splenomegaly. A palpable spleen is a hallmark of EBV in children.
Toronto Notes 2023 - Pediatrics, "Infectious Mononucleosis":
"Key features include fever, pharyngitis, lymphadenopathy, and splenomegaly. Children may have milder symptoms but often exhibit palpable spleen." MCCQE1 Objectives (Pediatrics > 75-2: Infectious Disease):
"Candidates should recognize common viral syndromes such as EBV and identify complications including splenomegaly." Other options (renal mass, ascites, etc.) are inconsistent with this viral presentation.
NEW QUESTION # 103
A 45-year-old man presents to your clinic for follow-up regarding his obsessive-compulsive disorder. He currently takes a high dosage of paroxetine, which he would like to discontinue because he feels well. His condition has been stable taking this medication since he was discharged from inpatient care 2 years ago.
Which one of the following is the most appropriate recommendation?
Answer: C
Explanation:
Obsessive-compulsive disorder (OCD) is a chronic and often relapsing condition. MCCQE objectives emphasize that patients with severe OCD requiring hospitalization or prolonged high-dose SSRI therapy are at significant risk of relapse if medication is discontinued. This patient has remained stable for 2 years on a high dose of paroxetine after inpatient treatment, suggesting a history of more severe disease.
For moderate-to-severe or recurrent OCD, long-term or indefinite maintenance pharmacotherapy is often recommended, particularly when the patient has responded well and tolerated the medication. Abrupt discontinuation or large dose reductions (e.g., 50%) increase the risk of relapse and discontinuation syndrome, especially with paroxetine, which has a short half-life. Switching to another SSRI is unnecessary when the current medication is effective and tolerated. Supportive psychotherapy alone is generally insufficient for patients with previously severe OCD.
Therefore, the most appropriate recommendation is to maintain the current dosage , while discussing risks and benefits and reassessing periodically.
NEW QUESTION # 104
A 70-year-old woman presents to the Emergency Department with a 2-day history of dysuria and right flank pain. Upon arrival, she is quite unwell. Her vital signs are as follows: blood pressure 70/38 mm Hg, heart rate
130/min, respiratory rate 24/min, temperature 39.4 °C.
Due to difficulty obtaining peripheral access, a central line is inserted. There is a lot of ongoing bleeding around the line insertion site. Her blood work shows:
White blood cell count: 19.8 × 10#/L (4-10)
Hemoglobin: 101 g/L (123-157)
Platelets: 85 × 10#/L (130-400)
Blood film: schistocytes
INR: 1.9 (0.9-1.2)
Fibrinogen: < 1 g/L (2-4)
Which one of the following is the most likely cause of her ongoing bleeding?
Answer: D
Explanation:
This patient is in septic shock, likely from pyelonephritis, with hypotension, tachycardia, and fever. Her laboratory findings demonstrate thrombocytopenia (platelets 85 × 10#/L), elevated INR, very low fibrinogen (
< 1 g/L), and schistocytes on blood film, along with active bleeding from the central line site. These findings are classic for disseminated intravascular coagulation (DIC).
MCCQE objectives emphasize recognizing DIC as a complication of severe sepsis. In DIC, systemic activation of coagulation leads to widespread microthrombi formation and consumption of platelets and clotting factors (consumptive coagulopathy), resulting in both thrombosis and bleeding. Low fibrinogen and prolonged INR are key distinguishing features.
ITP causes isolated thrombocytopenia without coagulation abnormalities. TTP presents with thrombocytopenia and schistocytes but typically has normal coagulation studies. Heparin-induced thrombocytopenia requires prior heparin exposure and does not cause elevated INR or low fibrinogen.
Vitamin K deficiency causes prolonged INR but does not produce thrombocytopenia or schistocytes.
Thus, DIC secondary to sepsis is the most likely cause of her bleeding.
NEW QUESTION # 105
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