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| Section | Weight | Objectives |
|---|---|---|
| Topic 1: Physician Activities | 50% | - Communication - Management - Psychosocial Aspects - Professional Behaviours |
| Topic 2: Dimensions of Care | 50% | - Health Promotion and Illness Prevention - Acute Care - Chronic Care - Assessment and Diagnosis |
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NEW QUESTION # 347
A 27-year-old man with a bowel obstruction secondary to a terminal ileum stricture has been on various medications since he was diagnosed with Crohn disease 8 years ago. You recommend a bowel resection, but he refuses this option because he is fearful of short bowel syndrome. He states that the only surgical procedure he will undergo is a bypass of the diseased segment so that the affected bowel will heal. You know that this is the wrong operation. Which one of the following is the best next step?
Answer: E
Explanation:
This case addresses informed consent and professional integrity. MCCQE ELOM objectives emphasize that competent patients have the right to refuse recommended treatment, but they cannot demand a treatment that is medically inappropriate or contrary to the standard of care. If a proposed intervention (e.g., bypass of a strictured Crohn segment expected not to heal) is not clinically indicated and may cause harm, the physician is not ethically obligated to provide it.
The appropriate response is to decline to perform the inappropriate procedure while clearly explaining the rationale, including risks, benefits, alternatives, and likely outcomes. Shared decision-making and addressing the patient's fears (e.g., risk of short bowel syndrome) are essential. If disagreement persists, offering a second opinion is reasonable-but transferring care solely to find someone willing to perform an inappropriate surgery is unethical.
A formal competency assessment is unnecessary unless there is evidence of impaired decision-making capacity. Performing a different surgery than agreed upon would violate consent. The physician must balance respect for autonomy with nonmaleficence and adherence to evidence-based practice.
NEW QUESTION # 348
A 6-week-old boy is brought to your office by his parents for a follow-up following a recent urinary tract infection. His abdominal ultrasound shows dilated urinary bladder and ureters as well as bilateral hydronephrosis. Which one of the following historical findings would be most helpful in establishing the correct diagnosis?
Answer: B
NEW QUESTION # 349
A 21-year-old man presents to the office with persistent pain and swelling of the wrist 2 weeks after falling on his outstretched hand. Anteroposterior and lateral radiographs of the wrist taken at the time of the injury showed no evidence of fracture or dislocation. Which one of the following is the most likely cause of the patient's symptoms?
Answer: D
Explanation:
Scaphoid fractures are often radiographically occult on initial presentation and can present later with persistent pain and swelling in the anatomical snuffbox. They typically occur following a fall on an outstretched hand. If missed, they can lead to avascular necrosis.
Toronto Notes 2023 - Orthopedics, Wrist Injuries:
"Scaphoid fractures are the most common carpal fractures. X-rays may be negative early, so high suspicion requires immobilization and repeat imaging after 10-14 days." MCCQE1 Objectives - Surgery > Musculoskeletal Trauma:
"Candidates must recognize that some fractures, such as scaphoid, may not appear on initial imaging but require clinical suspicion and follow-up imaging or immobilization." Other options (B and C) are less likely without radiographic evidence. De Quervain tenosynovitis (D) presents with radial wrist pain unrelated to trauma and worsens with thumb movement.
NEW QUESTION # 350
A 79-year-old woman presents to the Emergency Department with sudden-onset severe chest and back pain that started 1 hour ago. She has a history of hypertension and looks unwell. Her vital signs are as follows:
blood pressure 168/108 mm Hg, heart rate 110/min, respiratory rate 22/min, temperature 36.7°C. Findings of a physical examination of the chest and abdomen are normal. An urgent computed tomography (CT) scan of the chest and abdomen shows an aortic dissection extending from the descending thoracic aorta to the upper abdominal aorta. The branches of the abdominal aorta are patent. Following initial resuscitation, which one of the following is the best next step?
Answer: A
Explanation:
This patient has a Stanford type B aortic dissection , involving the descending thoracic aorta distal to the left subclavian artery, with no evidence of branch vessel compromise or rupture. MCCQE objectives emphasize that uncomplicated type B dissections are managed medically , whereas type A dissections (ascending aorta) require urgent surgical repair.
The immediate priority is to reduce shear stress on the aortic wall by controlling heart rate and blood pressure
. Intravenous beta-blockers such as labetalol or esmolol are first-line therapy. The goal is to reduce heart rate to approximately 60 bpm and lower systolic blood pressure to 100-120 mm Hg. This decreases the force of left ventricular contraction (dP/dt), limiting propagation of the dissection.
Endovascular or open repair is reserved for complicated cases (e.g., malperfusion, rupture, refractory pain, uncontrolled hypertension). Anticoagulation with heparin is contraindicated due to bleeding risk. Observation alone without blood pressure control is inappropriate.
Therefore, intravenous labetalol is the best next step.
NEW QUESTION # 351
A 24-year-old man is brought to the Emergency Department by ambulance with a severe pelvic fracture from a motor vehicle collision. After resuscitation and stabilization, he is noted to have a bloody penile discharge.
Which one of the following is the best next step?
Answer: A
Explanation:
In a patient with a pelvic fracture and blood at the urethral meatus, urethral injury must be strongly suspected.
Other signs may include perineal hematoma, high-riding prostate, or inability to void. The key principle is do not insert a Foley catheter until urethral integrity is confirmed, as blind catheterization may worsen a partial tear into a complete disruption. The appropriate next diagnostic step is retrograde urethrography (RUG), which evaluates the urethra for extravasation of contrast and identifies the site and extent of injury.
Voiding cystography evaluates bladder injury and is performed after urethral integrity is confirmed or via suprapubic access. Transrectal ultrasound and penile sonography are not appropriate in acute trauma assessment of suspected urethral disruption. Continuous bladder irrigation is contraindicated until urethral injury is excluded.
MCCQE objectives emphasize recognition of urethral injury in pelvic trauma and adherence to trauma principles: stabilize first, suspect urethral injury when blood is present at the meatus, and perform retrograde urethrography prior to catheterization.
NEW QUESTION # 352
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