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| Section | Weight | Objectives |
|---|---|---|
| Physician Activities | 50% | - Professional Behaviours - Communication - Psychosocial Aspects - Management |
| Dimensions of Care | 50% | - Acute Care - Chronic Care - Assessment and Diagnosis - Health Promotion and Illness Prevention |
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NEW QUESTION # 231
A 72-year-old man has had 4 episodes of weakness in her right arm and leg lasting 10 to 15 minutes each.
During 1 episode, she had difficulty speaking and had blurring of the vision in the left eye. Which one of the following is the most likely diagnosis?
Answer: E
Explanation:
These are recurrent, brief (10-15 minute), fully resolving focal neurologic deficits, which fits transient ischemic attacks (TIAs) rather than completed stroke. The combination of right-sided arm and leg weakness and difficulty speaking localizes to the left cerebral hemisphere (dominant hemisphere for language in most patients). The additional symptom of transient blurring of vision in the left eye is characteristic of amaurosis fugax, caused by retinal ischemia from emboli or hypoperfusion in the ipsilateral internal carotid circulation.
Together, this pattern strongly suggests left internal carotid artery occlusive disease (e.g., high-grade stenosis with artery-to-artery embolization).
Left MCA thrombosis would typically produce persistent deficits rather than multiple short, self-resolving episodes. Intracerebral hemorrhage usually presents with sudden severe symptoms that do not resolve quickly and often includes headache or reduced consciousness. Epilepsy would more likely cause positive symptoms (jerking, automatisms) and postictal confusion. Vertebrobasilar disease causes posterior circulation symptoms (vertigo, diplopia, ataxia), not unilateral monocular vision loss plus contralateral weakness.
NEW QUESTION # 232
A 76-year-old man is brought to the emergency department in an unresponsive state. He has a history of chronic kidney disease with a baseline serum creatinine level of 300 µmol/L (49-93) and a history of dilated cardiomyopathy with an ejection fraction of 30%. On assessment, he has no pulse or blood pressure. Cardiac monitor demonstrates a wide complex tachycardia. Which one of the following recently started medications is the most likely cause of this arrhythmia?
Answer: A
Explanation:
Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia, especially in patients with impaired renal function. Hyperkalemia can lead to life-threatening arrhythmias, particularly wide complex tachycardia or ventricular fibrillation.
Toronto Notes 2023 - Cardiology and Nephrology, "Hyperkalemia" Section:
"Patients with CKD are at increased risk for hyperkalemia, particularly when taking potassium-sparing medications such as spironolactone. Severe hyperkalemia may cause bradycardia or wide-complex tachyarrhythmias." MCCQE1 Objectives (Internal Medicine > 76-2: Electrolyte Abnormalities):
"Candidates must recognize drug-induced hyperkalemia as a cause of cardiac arrhythmias, especially in patients with renal dysfunction." Hydrochlorothiazide (B) can cause hypokalemia. Metoprolol (C) and diltiazem (E) are rate-controlling agents but do not typically cause wide complex tachycardia. Clopidogrel (D) has no effect on cardiac conduction.
NEW QUESTION # 233
A 42-year-old woman, gravida 2, para 2, aborta 0, comes to the office for the first time. She reports a 6-month history of thirst, urinary frequency, and recurrent vaginitis. Aside from a BMI of 28, her physical examination findings are unremarkable. She takes no medications. Which one of the following would support the most likely diagnosis?
Answer: A
Explanation:
This patient's symptoms of polyuria, polydipsia, and recurrent vaginitis are classic for type 2 diabetes mellitus (T2DM) . Recurrent vaginal candidiasis occurs due to glycosuria promoting yeast overgrowth. MCCQE objectives emphasize identifying risk factors and historical features supporting diabetes. A prior delivery of a macrosomic infant ( > 4000-4500 g) is strongly associated with gestational diabetes mellitus (GDM) , which significantly increases the future risk of developing T2DM. Therefore, a history of macrosomia supports undiagnosed or previous gestational hyperglycemia and increases suspicion for current diabetes.
High-risk sexual behaviors relate to sexually transmitted infections, not diabetes. Family history of hypertension is a cardiovascular risk factor but does not specifically support diabetes. Recent antibiotic use may predispose to candidiasis but would not explain polyuria and polydipsia. Dry eyes are more suggestive of autoimmune conditions (e.g., Sjogren syndrome).
Thus, prior delivery of a macrosomic newborn strengthens the likelihood that her current symptoms are due to type 2 diabetes mellitus.
NEW QUESTION # 234
A 46-year-old woman presents with concerns because she has not had a period for the past 13 months. She has not had any hot flashes or night sweats, but she has noted some problems staying asleep for the past 6 months. She feels "foggy," which has made her work more difficult. She is in a same-sex relationship and has no pain with sexual activity. In discussing options with her, which one of the following is most appropriate?
Answer: D
Explanation:
Amenorrhea for #12 consecutive months in a woman over age 45 is diagnostic of menopause and does not require laboratory confirmation in the absence of atypical features. MCCQE objectives emphasize that routine measurement of estrogen or progesterone levels is unnecessary in typical cases, as hormone levels fluctuate widely during the perimenopausal transition. This patient has mild menopausal symptoms (sleep disturbance and cognitive "fog") without vasomotor symptoms, abnormal bleeding, or pelvic pain.
Pelvic ultrasound or endometrial biopsy is not indicated because she has no postmenopausal bleeding. SSRI therapy may be considered for significant vasomotor or mood symptoms but is not first-line for mild cognitive or sleep complaints in otherwise healthy menopausal women. Sleep apnea investigation is not suggested by the history.
Therefore, the most appropriate step is to explain that she is menopausal and provide reassurance, along with education about lifestyle strategies for sleep and cognitive symptoms, and discussion of treatment options if symptoms become bothersome.
NEW QUESTION # 235
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 # 236
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