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| Section | Objectives |
|---|---|
| Topic 1: Physician Activities | - Management
|
| Topic 2: Dimensions of Care | - Acute Care
|
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NEW QUESTION # 38
A 60-year-old man presents because of a 6-month history of involuntary lip smacking and tongue movements.
His medical history is significant for schizophrenia, which has been very stable with haloperidol for the past
20 years. When educating the patient about these particular symptoms, which one of the following statements is accurate?
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
This patient has tardive dyskinesia, a late-onset, often irreversible movement disorder caused by chronic dopamine receptor blockade (e.g., haloperidol). It is especially common in older adults and may not resolve after stopping the drug.
Toronto Notes 2023 - Psychiatry, "Extrapyramidal Symptoms":
"Tardive dyskinesia is often irreversible and typically occurs after prolonged antipsychotic use. Elderly patients are at greater risk." MCCQE1 Objectives (Psychiatry > 71-5: Side Effects of Psychotropics):
"Candidates must recognize tardive dyskinesia and understand that it can persist or worsen even after discontinuation of antipsychotics." Anticholinergics may worsen it (D). The condition does not reliably improve with age (C). It does not affect a majority of patients (A).
NEW QUESTION # 39
A 56-year-old man is admitted to hospital with pyelonephritis and started on intravenous antibiotics. On day 2 of his hospitalization, he continues to report right flank pain, but he is able to walk. His vital signs are as follows:
Temperature: 38.5°C
Blood pressure: 90/60 mm Hg
Heart rate: 105/min
The patient is mentating well but is concerned about his dog that is home alone due to his unexpected hospitalization. He requests to be released from hospital as he needs to make arrangements for his dog. Which one of the following is the best next step?
Answer: A
Explanation:
The patient is alert and capable of making his own decisions. The most ethical and respectful approach is to ensure he understands the risks and accept his choice. Holding his bed maintains continuity of care. Forcing him to stay (C) or discharging him AMA (A) is inappropriate if he intends to return.
Toronto Notes 2023 - ELOM, Consent and Autonomy:
"Capable patients have the right to refuse or leave treatment. Physicians must ensure informed decision- making and maintain therapeutic rapport." MCCQE1 Objectives - ELOM > Capacity and Patient Autonomy:
"Candidates must respect a capable patient's right to leave care after informed discussion of risks and alternatives." Offering to enter his apartment (E) is inappropriate and unethical. Oral antibiotics (B) may not be clinically appropriate given hypotension.
NEW QUESTION # 40
You receive a note from a pharmacist about your 82-year-old patient who is taking oxycodone extended- release 20 mg 3 times daily for spinal stenosis. The pharmacist suggests that you consider tapering the medication. Your patient has been taking his current dosage for 1 year. When you saw him a month ago, he was functioning well with no adverse effects from the medication. Which one of the following is the best next step?
Answer: D
Explanation:
Long-term opioid therapy requires ongoing assessment of benefits, risks, function, adverse effects, and safety, particularly in older adults. MCCQE objectives emphasize regular reassessment before making changes to chronic controlled medications. Although the pharmacist has appropriately raised concern about prolonged opioid use, the patient was reported one month ago to be functioning well without adverse effects.
The appropriate next step is to reassess the patient directly-including pain control, functional status, cognition, fall risk, constipation, signs of misuse, and overall goals of care-before altering therapy.
Automatic dose reduction without evaluation may destabilize pain control. Immediate referral to a specialist is unnecessary if the patient is stable and well managed. Adjunct therapies such as physiotherapy may be considered but should not replace proper reassessment.
Shared decision-making is essential. If reassessment reveals limited benefit, adverse effects, or safety concerns, a gradual taper can then be discussed. Clinical decisions regarding opioids should be individualized rather than based solely on duration of use.
NEW QUESTION # 41
A 45-year-old man is brought to the Emergency Department with chest pain. He has no significant medical history. He is anxious and agitated, and he reports severe central chest pain that began about 90 minutes ago.
His vital signs are as follows: blood pressure 200/110 mm Hg, heart rate 140/min, respiratory rate 30/min, oxygen saturation 98% on supplemental oxygen. Physical examination reveals a restless and slightly tremulous man. Pupils are 7 mm reactive. There are no focal neurologic signs. Cardiopulmonary examination is normal. The 12-lead electrocardiogram reveals sinus tachycardia; findings are otherwise normal. Which one of the following is the most likely cause of this clinical presentation?
Answer: C
Explanation:
This presentation most strongly suggests cocaine intoxication . MCCQE objectives emphasize recognizing toxidromes and life-threatening causes of chest pain. Cocaine is a potent sympathomimetic that increases catecholamines and causes marked hypertension, tachycardia, agitation/anxiety, tremor, tachypnea, and mydriasis , and it can precipitate severe chest pain via coronary vasospasm, increased myocardial oxygen demand, platelet activation, and potential aortic dissection. An ECG may show only sinus tachycardia early despite significant ischemic risk. In contrast, opioids (heroin, oxycodone) typically cause CNS depression, miosis , and respiratory depression. Alcohol intoxication does not usually cause extreme hypertension, mydriasis, and severe sympathomimetic agitation. Cannabis may cause anxiety and tachycardia but is less likely to produce this degree of hypertension and classic stimulant features. Therefore, cocaine best explains the combination of acute severe chest pain with a prominent sympathetic toxidrome. Immediate priorities include cardiac evaluation and treating stimulant toxicity (e.g., benzodiazepines and blood pressure control while avoiding isolated beta-blockade).
NEW QUESTION # 42
You are asked to see a 50-year-old man 2 hours after he underwent a laparotomy for gastric resection. Lab results are as follows:
pH
7.28 (7.35-7.45)
PaCO#
60 mm Hg (35-40)
PaO#
60 mm Hg (85-105) with 4 L/min via nasal prongs
Bicarbonate (HCO#)
24 mmol/L (24-30)
Which one of the following is most consistent with this clinical presentation?
Answer: E
Explanation:
This ABG reveals primary respiratory acidosis (#pH, #PaCO#, normal HCO#), likely from hypoventilation due to postoperative pain, sedation, or narcotics. PaO# is also low, suggesting inadequate oxygenation.
Toronto Notes 2023 - Respiratory, "Postoperative Respiratory Complications":
"Postoperative respiratory acidosis results from hypoventilation, often due to pain, sedatives, or poor respiratory effort. Assess airway, breathing, and support oxygenation." MCCQE1 Objectives (Internal Medicine > 44-3: Acid-Base Disturbances):
"Candidates must recognize respiratory acidosis on ABG and relate findings to common postoperative complications." Metabolic acidosis (C) would show #HCO#. Compensated alkalosis (D) would show opposite ABG changes.
Hypermetabolic states increase respiratory drive, not decrease it.
NEW QUESTION # 43
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