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| Section | Objectives |
|---|---|
| Physician Activities | - Professionalism
|
| Dimensions of Care | - Chronic Care
|
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307. Frage
A 1-month-old boy is brought to your clinic after being born with asymmetric intrauterine growth restriction (third percentile at birth). He was born at 36 weeks' gestation. He has been breastfeeding well and continues to grow around the third percentile. Which one of the following would be the best next step?
Antwort: C
Begründung:
This infant was born late preterm (36 weeks) with asymmetric intrauterine growth restriction (IUGR) and remains at the 3rd percentile. Although he is breastfeeding well, infants with IUGR and late prematurity often require enhanced caloric intake to support catch-up growth. MCCQE objectives emphasize optimizing postnatal nutrition in growth-restricted infants to promote appropriate weight gain while monitoring growth velocity.
Caloric fortification of expressed breast milk (or use of higher-calorie formula if needed) increases energy density without increasing feeding volume, supporting growth in infants who are small for gestational age.
Simply continuing standard feeds may not provide sufficient calories for catch-up growth.
High-dose vitamin D is not indicated; routine supplementation (400 IU daily) is appropriate for breastfed infants. Early introduction of solids is not recommended before about 6 months of age. Switching to hydrolyzed formula is unnecessary without evidence of milk protein allergy.
Therefore, caloric-fortified feeding is the most appropriate next step to promote optimal growth in this infant.
308. Frage
An 80-year-old man is admitted to hospital with what turns out to be tuberculosis. The attending physician informs all staff at the hospital of the patient ' s identity and diagnosis. Which one of the following best describes privacy concerns in this situation?
Antwort: E
Begründung:
Tuberculosis is a communicable disease, so there can be a justified "duty to protect" others in the hospital through infection-control measures and public health notification. However, MCCQE ethics objectives emphasize that confidentiality remains the default obligation even when disclosure is permitted or required. In such cases, disclosure must follow the minimum necessary principle: only the information essential to reduce risk should be shared, and only with those who need it to perform their role (e.g., direct care team, infection prevention and control, occupational health, and public health). Informing "all staff at the hospital" and including the patient's identity generally exceeds what is required and constitutes an avoidable breach of privacy.
Consent is not always required when disclosure is mandated by law (reportable diseases) or necessary to prevent serious harm, so option B is too absolute. Option A wrongly implies loss of privacy rights. Option D is incorrect because limited disclosure may be ethically and legally permitted to protect others. Option E is false; clinicians and institutions can be accountable for unjustified or excessive disclosure.
309. Frage
A 67-year-old farmer presents with a 6-month history of progressive weakness in both arms. He now has difficulty in climbing but says he can still drive his tractor. Examination shows slight but definite atrophy of muscles of pectoral girdle, especially over his scapula. Fasciculations are visible. There is hyperreflexia of most tendon reflexes of arms and legs, left ankle clonus and left Babinski reflex. Which one of the following is the most likely diagnosis?
Antwort: D
Begründung:
This presentation is most consistent with amyotrophic lateral sclerosis (ALS), characterized by progressive degeneration of both upper motor neurons (UMN) and lower motor neurons (LMN). The patient has LMN signs in the upper limbs-muscle atrophy of the shoulder girdle and visible fasciculations-alongside UMN signs-hyperreflexia, ankle clonus, and a Babinski reflex. The combination of UMN and LMN findings in multiple body regions with a gradual, progressive course over months strongly supports ALS. Multiple sclerosis typically produces disseminated neurologic deficits separated in time and space and does not usually cause prominent fasciculations or progressive LMN wasting. Cerebellar degeneration causes ataxia, dysmetria, and gait instability rather than mixed UMN/LMN signs. A pontine astrocytoma would more often cause cranial nerve deficits and brainstem signs and is less likely to present as a diffuse, progressive mixed motor neuron syndrome in an older adult. Parkinson disease causes bradykinesia, rigidity, and resting tremor, not Babinski or fasciculations. MCCQE objectives emphasize recognizing mixed UMN/LMN patterns and identifying ALS as a key progressive motor neuron disorder.
310. Frage
A 78-year-old man presents to the Emergency Department with chest pain. His electrocardiogram and blood work confirm an acute myocardial infarction. He is admitted to the Intensive Care Unit. Three days later, he develops right-sided abdominal pain. An ultrasonogram reveals an inflamed gallbladder with no evidence of stones. He does not improve after 48 hours of antibiotics. Which one of the following is the best next step?
Antwort: D
Begründung:
This presentation is consistent with acute acalculous cholecystitis, often seen in critically ill or post-MI patients. If unresponsive to antibiotics, percutaneous cholecystostomy is the preferred next step in those who are poor surgical candidates.
Toronto Notes 2023 - General Surgery, "Hepatobiliary Disorders" Section:
"Acalculous cholecystitis occurs in critically ill patients and is often managed with percutaneous cholecystostomy if the patient is not a candidate for surgery." MCCQE1 Objectives (Surgery > 84-3: Biliary Disease):
"Candidates must be able to diagnose and manage acalculous cholecystitis. Management includes antibiotics and drainage via percutaneous cholecystostomy in unstable patients." Laparoscopic cholecystectomy (C) is standard but not suitable in acutely ill ICU patients. Broadening antibiotics (A) alone is insufficient after failure of initial therapy. ERCP (B) is for biliary obstruction or cholangitis. HIDA scan (E) is diagnostic, not therapeutic.
311. Frage
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?
Antwort: B
Begründung:
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 cancerdoes 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.
312. Frage
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