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| Section | Weight | Objectives |
|---|---|---|
| Physician Activities | 50% | - Communication - Psychosocial Aspects - Management - Professional Behaviours |
| Dimensions of Care | 50% | - Health Promotion and Illness Prevention - Acute Care - Chronic Care - Assessment and Diagnosis |
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NEW QUESTION # 212
A 45-year-old man presents to your family practice for follow-up because he has had repeated transient ischemic attacks and had been advised not to drive. During the interview, you find out that he is still driving.
He explains that he only drives to the grocery store and his wife, who also has a driver's license, is always a passenger with him. He insists he can drive. You think that he should no longer be driving a car. Which one of the following is the best next step?
Answer: B
Explanation:
In most Canadian provinces and territories, physicians are legally obligated to report patients who pose a danger due to medical conditions affecting driving ability. Given the history of TIAs and continued unsafe driving, reporting is necessary for public safety.
Toronto Notes 2023 - ELOM, "Fitness to Drive" Section:
"Physicians must report to motor vehicle authorities if a patient poses a risk to public safety due to a medical condition. TIAs are considered reportable if they impair ability and the patient does not comply with driving restrictions." MCCQE1 Objectives (ELOM > 99-1: Medical Fitness and Reporting):
"Candidates must recognize situations requiring mandatory reporting of patients unfit to drive due to neurologic or other impairing conditions." You may still discuss with the patient (B), but this does not replace the duty to report. Physically taking the license (C) is illegal. Refusing care (D) is unethical. A neurologist (E) could be helpful but would delay action in a clear case.
NEW QUESTION # 213
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: A
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 # 214
A 42-year-old man presents to your clinic for follow-up regarding his anxiety. He lost his job 1 year ago.
Since then, he constantly thinks about what happened, trying to understand what went wrong and how he could fix it or prevent it in the future. He is unable to sleep because of this. He has become socially isolated and when he does see friends, he worries constantly that he may say something hurtful. He wishes he could get past what happened and find another job but feels consumed by the fear that he may offend someone in the future. On history, his symptoms did not respond to escitalopram, sertraline, fluvoxamine, or venlafaxine, all at maximum tolerated doses. Which one of the following medications is the most appropriate?
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
This patient likely has treatment-resistant obsessive-compulsive disorder (OCD), with classicsymptoms of rumination, excessive guilt, and fear of causing harm. Clomipramine, a tricyclic antidepressant with strong serotonergic activity, is effective in treatment-resistant OCD and is often used after failure of multiple SSRIs or SNRIs.
Toronto Notes 2023 - Psychiatry, OCD:
"Clomipramine is a first-line tricyclic antidepressant for OCD, particularly after failed SSRI/SNRI trials. It is effective due to potent serotonergic action." MCCQE1 Objectives - Psychiatry > OCD and Anxiety Disorders:
"Candidates must identify treatment strategies for resistant OCD, including the role of clomipramine and augmentation therapy." Quetiapine (C) may be used as augmentation. Paroxetine (E) is another SSRI. Vortioxetine (A) and amitriptyline (D) are not first-line or preferred for OCD.
NEW QUESTION # 215
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: D
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 # 216
A 91-year-old man comes to the Emergency Department reporting blood in his stools, which has now resolved. He is able to give a history and mentions that this also happened 2 years ago. At that time, a colonoscopy was done and revealed diverticular disease as the cause. Which one of the following is the best next step?
Answer: C
Explanation:
In a patient with known diverticular bleeding and no red flags (e.g., weight loss, anemia, family history), repeating colonoscopy is not required. Diverticular bleeding is typically self-limited. Colonoscopy within the past few years with clear findings suffices.
Toronto Notes 2023 - Gastroenterology, Lower GI Bleed:
"Patients with known diverticulosis and self-limited bleeding who have had prior complete colonoscopy do not require repeat endoscopy unless symptoms recur or persist." MCCQE1 Objectives - Internal Medicine > Gastroenterology:
"Candidates must recognize when no further invasive investigation is necessary in elderly patients with known benign findings and resolved symptoms." Option E is considerate but not clinically necessary for independent patients. Options A, B, and D are not indicated in resolved, low-risk cases.
NEW QUESTION # 217
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