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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Leader (Manager)
|
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NEW QUESTION # 317
A 24-year-old nulligravid woman presents to the office with an absence of menstruation since discontinuing her oral contraceptives 8 months ago. She previously had a regular menstrual cycle when taking oral contraceptives for the past 10 years but stopped because of headaches, which have only gotten worse since.
She also noticed mild breast discharge for the past several months. Which one of the following examination findings is most likely?
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
This patient has secondary amenorrhea, galactorrhea, and worsening headaches-suggestive of hyperprolactinemia, possibly due to a pituitary adenoma (prolactinoma). Visual field defects (typically bitemporal hemianopia) can result from optic chiasm compression.
Toronto Notes 2023 - Endocrinology / Reproductive Health:
"Prolactinomas may cause amenorrhea, galactorrhea, headaches, and visual field defects. Evaluate with serum prolactin and visual field testing." MCCQE1 Objectives (Endocrinology > 37-2: Pituitary Disorders):
"Candidates must recognize clinical signs of prolactinomas and know when to assess visual fields." Hirsutism (D) suggests androgen excess. Low BMI (B) can cause hypothalamic amenorrhea but wouldn't explain galactorrhea. Nodular breast findings (A) are not related.
NEW QUESTION # 318
A 1-month-old breastfed baby is brought to your office by his parents for his well-baby check-up. He was born at 32 weeks' gestation. Growth parameters at birth revealed head circumference, weight and length at the
50th percentile. Today, his weight is at the 10th percentile. Which one of the following is the most appropriate plan of action?
Answer: E
Explanation:
This infant was born at 32 weeks' gestation and therefore growth must be interpreted using corrected (adjusted) age , not chronological age. At 1 month chronological age, his corrected age is approximately term (40 weeks). MCCQE pediatric objectives emphasize that preterm infants commonly shift percentiles after birth due to expected postnatal fluid changes and adaptation. A drop from the 50th to the 10th percentile in the first month-particularly in a clinically well, breastfed infant-can be normal when plotted appropriately on preterm growth charts and corrected for gestational age. There is no information suggesting feeding difficulty, malabsorption, or systemic illness. A sweat chloride test (for cystic fibrosis) or celiac serology is not indicated in a thriving 1-month-old infant. Routine formula supplementation is unnecessary without evidence of poor intake or failure to thrive. The appropriate management is reassurance, continued monitoring of growth using corrected age, and support for breastfeeding, with follow-up to ensure appropriate weight gain trajectory.
NEW QUESTION # 319
A 32-year-old woman, gravida 0, comes to your office for contraception counselling, specifically about insertion of a levonorgestrel-releasing intrauterine device. She has a past history of breast cancer and is presently on tamoxifen. Which one of the following is the best advice for your patient?
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
The levonorgestrel-releasing intrauterine device (LNG-IUD) is generally contraindicated in current or recent breast cancer due to the progestin component, but may be considered in selectpatients on tamoxifen, especially if non-hormonal options are unsuitable. Consultation with the oncologist is required to evaluate risks and benefits.
Toronto Notes 2023 - Gynecology, "Contraception in Special Populations":
"Levonorgestrel IUDs are generally avoided in patients with a history of hormone-sensitive cancers; however, decisions should be made collaboratively with oncology." MCCQE1 Objectives (Gynecology > 82-2: Contraception):
"Candidates must tailor contraceptive advice to patients with medical comorbidities, including cancer survivors." Irregular bleeding (A) is a common but not contraindicating side effect. No pre-procedure antibiotics (D) are typically needed. The IUD does not cause infertility (E). Risk of recurrence (C) is unconfirmed and must be individualized.
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NEW QUESTION # 320
A 78-year-old man, who is accompanied by his eldest son, presents for follow-up of his chronic kidney disease and neurocognitive disorder due to vascular disease. He is married and has 4 children. His creatinine clearance has slowly deteriorated over the last few years and has reached the stage where you are considering starting renal replacement therapy. After your discussion, it is clear that the patient, his son, and his wife want to start dialysis. Based on your assessment, it is clear that he does not understand the information you have relayed to him. You inform the patient that you believe he is incapable of making this decision and he agrees.
His son would prefer not to start dialysis as he is concerned about the impact this would have on his father's quality of life. Which one of the following is the best next step?
Answer: D
Explanation:
This patient has been assessed as incapable of making the decision regarding dialysis. MCCQE ELOM objectives emphasize that when a patient lacks decision-making capacity, treatment decisions must be made by a legally authorized substitute decision-maker (SDM) according to provincial/territorial hierarchy. The appropriate next step is to determine whether a formal SDM has been appointed (e.g., power of attorney for personal care) or identify the legally ranked default SDM.
Although the wife may often be the default SDM, this depends on jurisdiction and whether a formal representative has been designated. It is inappropriate to automatically follow the son's wishes, as he may not be the legal SDM. Nor should the physician impose their own recommendation without engaging the proper decision-making process. A large family meeting may be helpful later but does not replace identifying the legally authorized decision-maker.
Once identified, the SDM must make decisions based on the patient's prior capable wishes or, if unknown, the patient's best interests. Properly establishing the SDM ensures ethical and legal compliance in incapacity situations.
NEW QUESTION # 321
A 25-year-old man presents to the Emergency Department with diffuse abdominal pain and anorexia. He was tackled in a football game yesterday. He reports a 3-week history of sore throat and fatigue. Vital signs are as follows:
Blood pressure: 95/45 mm Hg
Heart rate: 96/min
Temperature: 37.6°C
Which one of the following is the most likely diagnosis?
Answer: B
Explanation:
This patient presents with hypotension, diffuse abdominal pain, and a history of contact sports injury with preceding symptoms of infectious mononucleosis (sore throat, fatigue). The spleen is commonly enlarged in mononucleosis, making it vulnerable to rupture after even minor trauma.
Toronto Notes 2023 - General Surgery and Infectious Diseases Sections:
"Splenic rupture is a known complication of mononucleosis, particularly after trauma. Symptoms may include diffuse abdominal pain, hypotension, and signs of hemorrhagic shock." MCCQE1 Objectives (Surgery > 84-1: Abdominal Trauma):
"Candidates should identify splenic rupture as a cause of hypotension and abdominal pain following blunt abdominal trauma, especially in patients with splenomegaly." Appendicitis (B) would present with localized right lower quadrant pain. Pneumonia (C) and pyelonephritis (D) would present with respiratory or urinary symptoms. Ruptured duodenum (E) is much less likely without specific trauma to that region or signs of peritonitis.
NEW QUESTION # 322
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