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| Section | Objectives |
|---|---|
| Dimensions of Care | - Psychosocial Aspects
|
| Physician Activities | - Professionalism
|
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NEW QUESTION # 50
A 67-year-old woman presents with headaches, muscle weakness, pain in her shoulders and hips, weight loss, and depression. While also arranging appropriate investigations to confirm a diagnosis, which one of the following is the most important objective of treatment?
Answer: A
Explanation:
This clinical picture suggests giant cell arteritis (GCA) associated with polymyalgia rheumatica: new-onset headache in an older patient, proximal muscle pain and stiffness (shoulders and hips), systemic symptoms (weight loss), and mood changes. MCCQE objectives emphasize that GCA is a medical emergency because inflammation of the temporal and other cranial arteries can lead to irreversible vision loss due to ischemic optic neuropathy.
The most important objective of treatment is prevention of blindness , which requires prompt initiation of high-dose corticosteroids-often before confirmatory temporal artery biopsy-to reduce arterial inflammation and prevent vascular occlusion. While improving musculoskeletal pain and headache are important symptomatic goals, they are secondary to preventing permanent complications. Jaw claudication is a symptom of arterial insufficiency but not itself the primary outcome to prevent.
Early recognition and immediate corticosteroid therapy significantly reduce the risk of bilateral, permanent visual loss. Therefore, prevention of blindness is the most critical treatment objective.
NEW QUESTION # 51
A 54-year-old woman presents to your office to discuss breast cancer screening. She is asymptomatic with no history of breast cancer. She had a fibroadenoma removed when she was 24 years old. The patient is not on any medications. Her family history is significant for a great-aunt with breast cancer. The patient has not had genetic testing but had normal breast screening 2 years ago. Which one of the following is the best next step?
Answer: D
Explanation:
According to Canadian guidelines, women aged 50 to 74 at average risk for breast cancer should undergo routine screening mammography every 2 to 3 years. A great-aunt with breast cancer does not raise this patient
' s risk to high. Mammography is appropriate as she is now due for the next screen.
Toronto Notes 2023 - Population Health, "Screening Guidelines" Section:
"Routine mammography is recommended every 2 years for average-risk women aged 50 to 74. Family history in second-degree or more distant relatives (e.g., great-aunt) does not qualify for high-risk screening or MRI." MCCQE1 Objectives (Population Health > 97-5: Screening and Prevention):
"Candidates should apply Canadian screening recommendations including mammography for average-risk women #50 years old." Self-breast exams (C) are not recommended for screening. PET scan (D) and MRI (E) are reserved for high- risk populations or diagnostic clarification.
NEW QUESTION # 52
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: A
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 # 53
A 66-year-old woman with metastatic breast cancer presents with hard, difficult-to-pass stools. She has been experiencing this issue since starting morphine to control her pain. Which one of the following is the best next step?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
Opioid-induced constipation is best managed with stimulant laxatives like senna or bisacodyl. Stool softeners such as docusate are insufficient as monotherapy. Senna stimulates peristalsis, making it more effective.
Toronto Notes 2023 - Palliative Care:
"Opioid-induced constipation requires stimulant laxatives such as senna. Stool softeners alone are not adequate." MCCQE1 Objectives (Palliative Care > 92-1: Symptom Management):
"Candidates must treat opioid-related side effects appropriately, including use of stimulant laxatives for constipation." Bulk agents (C) can worsen symptoms. Reducing morphine (D) may compromise pain control. Activity (E) helps but is insufficient as first-line management.
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NEW QUESTION # 54
A 72-year-old man reports that his wife says he has hearing trouble. Examination reveals that air conduction on the right side is less than on the left side and greater than bone conduction bilaterally. He hears a tuning fork placed on the top of his head better with his left ear. Which one of the following is the most appropriate next step in management?
Answer: A
Explanation:
The patient demonstrates signs of asymmetric sensorineural hearing loss (SNHL). In Weber test, sound localizes to the better ear in SNHL. Air conduction > bone conduction on Rinne test bilaterally supports SNHL. Audiometry is the best next diagnostic step to quantify and characterize the hearing loss.
Toronto Notes 2023 - ENT, "Hearing Loss":
"Audiometry is the first-line investigation to distinguish conductive from sensorineural hearing loss and to assess severity and frequency involvement." MCCQE1 Objectives (Medicine > ENT > 20-1):
"Candidates must know the approach to hearing loss and interpret Weber and Rinne tests to guide investigations such as audiometry." Imaging (A, C) is reserved for red flags such as unilateral persistent SNHL, which may later prompt MRI to rule out acoustic neuroma. Wax removal (D) is for conductive loss. Hearing aids (E) are management, not diagnostic, and come after audiologic evaluation.
NEW QUESTION # 55
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