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| Section | Objectives |
|---|---|
| Topic 1: Physician Activities | - Assessment
|
| Topic 2: Dimensions of Care | - Health Promotion and Illness Prevention
|
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NEW QUESTION # 25
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
-
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: D
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 # 26
A 19-year-old woman with a long-standing history of abuse and borderline personality disorder presents to your office. She has a number of superficial lacerations over her arms and legs. They look like they were caused by a sharp edge such as a knife. They are at various stages of healing, and some look like they are a few hours old, though none require stitches. Which one of the following is the most likely comment she would make about the injuries?
Answer: E
Explanation:
Patients with borderline personality disorder commonly engage in non-suicidal self-injury (NSSI) such as superficial cutting. According to MCCQE objectives in psychiatry, this behavior is typically a maladaptive coping mechanism used to regulate intense emotional distress, feelings of emptiness, anger, or dissociation.
The act of cutting often produces a transient sense of relief due to reduction of psychological tension and may be reinforced by endogenous opioid release. Therefore, patients frequently report that they "feel better afterward." It is important to distinguish NSSI from suicidal intent. Although individuals with borderline personality disorder are at increased risk of suicide, superficial cutting behavior is most often performed to relieve affective dysregulation rather than to die. It is not primarily attention-seeking, obsession with blood, or body modification. Management priorities include thorough suicide risk assessment, validation of emotional distress, establishing safety, and referral for evidence-based psychotherapy such as dialectical behavior therapy (DBT), which specifically targets emotional regulation and self-harm behaviors.
NEW QUESTION # 27
A 26-year-old man presents to your office with fever, chills, and malaise. Aside from an episode of dysuria 8 weeks ago, which spontaneously resolved, he has been healthy. On examination, his left wrist and right ankle are tender. There is a cluster of vesiculopustular lesions on his right hand. Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
Disseminated gonococcal infection (DGI) typically presents with the classic triad of polyarthralgia, tenosynovitis, and skin lesions (especially pustules on extremities). A prior urogenital infection and systemic symptoms further support this diagnosis.
Toronto Notes 2023 - Infectious Disease, STIs:
"DGI presents with arthritis-dermatitis syndrome: fever, asymmetric polyarthralgia, tenosynovitis, and vesiculopustular skin lesions. It may follow asymptomatic or unrecognized urogenital infection." MCCQE1 Objectives - Infectious Disease > STIs:
"Candidates must recognize systemic manifestations of gonorrhea including DGI and distinguish it from other forms of arthritis or systemic illness." Reactive arthritis (C) may follow STI but includes conjunctivitis and urethritis. HIV (A) does not typically cause this triad. RA (D) has different distribution and chronicity. Varicella (E) presents with diffuse vesicular rash, not joint pain.
NEW QUESTION # 28
A 38-year-old man presents to the office for a follow-up visit. For several years, he has been having constant abdominal pain and intermittent constipation. He struggles to fall asleep because he is worried about his symptoms, and he often spends hours researching possible investigations and causes. Although he recently had extensive investigations, which have all had normal results, he continues to visit multiple physicians hoping for more investigations. He worries that he will die because no one is taking him seriously. Which one of the following is the best next step?
Answer: D
Explanation:
This presentation is most consistent with somatic symptom disorder/illness anxiety : persistent distressing physical symptoms (abdominal pain/constipation) with excessive health-related anxiety, repeated reassurance- seeking, and "doctor shopping" despite normal investigations. MCCQE objectives emphasize avoiding iatrogenic harm from repeated testing and using a structured, therapeutic relationship to manage medically unexplained or disproportionate symptom concerns. The best next step is regularly scheduled follow-up visits with one consistent physician (e.g., monthly), focused on validating symptoms, addressing fears, monitoring for new objective findings, and gradually shifting toward coping strategies and functional goals. This approach reduces unnecessary investigations, reinforces continuity, and helps interrupt the cycle of anxiety- driven health-care utilization.
Repeating investigations (B) perpetuates reassurance-seeking and increases false positives and harm.
Consulting additional specialists (A) without new red flags similarly reinforces maladaptive beliefs and fragmentation of care. Exercise (D) may be beneficial as an adjunct but is not the core management strategy.
Therefore, planned, regular appointments are the most appropriate next step.
NEW QUESTION # 29
A 42-year-old woman presents to your clinic requesting an increase in her stimulant dosage for the treatment of her adult attention-deficit/hyperactivity disorder. Her medical history includes hypertension and type 1 diabetes with associated nephropathy. She has been taking methylphenidate daily for 15 years. Which one of the following would need to be addressed before the dosage can be increased?
Answer: A
Explanation:
Stimulants like methylphenidate can increase heart rate and blood pressure. In patients with cardiovascular risk (e.g., hypertension, nephropathy), stimulants should not be increased without first addressing elevated blood pressure.
Toronto Notes 2023 - Psychiatry, "ADHD in Adults":
"Stimulants can exacerbate hypertension and must be used cautiously. Evaluate cardiovascular risk factors and control blood pressure before dose increases." MCCQE1 Objectives (Psychiatry > 71-1: ADHD):
"Candidates must consider the cardiovascular risks of stimulant therapy and monitor for hypertension prior to adjusting doses." While poor glycemic control (B) and renal disease (A) are important, BP control is most critical for immediate stimulant safety.
NEW QUESTION # 30
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