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| Section | Objectives |
|---|---|
| Topic 1: Physician Roles (CanMEDS Framework) | - Medical Expert
|
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NEW QUESTION # 156
An 85-year-old woman who is your patient has advanced metastatic lung cancer. You are visiting her at her home for palliative care. She has previously indicated to you and her family that she hoped to die at home and that comfort is her priority. She is now weak to get out of bed and has had no oral intake for 2 days. She is confused most of the time, with brief lucid episodes. Despite attentive symptom management, her family reports that she is suffering and asks that you increase her medications to expedite her death. Which one of the following is the best next step?
Answer: B
Explanation:
This scenario raises end-of-life ethics: balancing relief of suffering with the prohibition against intentionally hastening death. MCCQE ELOM objectives emphasize compassionate communication, capacity, consent, and appropriate use of palliative interventions. The immediate best step is to acknowledge the family's distress, explore what they are witnessing (pain, dyspnea, agitation, delirium), and reassure them that you will continue to prioritize the patient's comfort.
Options B and C are inappropriate because the family cannot authorize "expediting death," and MAID requires a voluntary request from the patient with decision-making capacity (and other legal safeguards); a substitute decision-maker cannot request MAID on the patient's behalf. Option D (midazolam for deep sedation) may be appropriate only if the patient has refractory symptoms despite optimal treatment and after careful assessment, consent discussions (with the patient if capable or SDM for goals-of-care), and proportional dosing aimed at symptom relief-not to cause death.
Therefore, the ethically correct next step is supportive, clarifying communication and reassessment of symptom control.
NEW QUESTION # 157
A 35-year-old woman presents to your clinic for follow-up regarding her persistent primary immune thrombocytopenic purpura. She was admitted to hospital with a relapse and received treatment with dexamethasone, intravenous immunoglobulin, and rituximab. She was recently discharged from hospital with a platelet count of 55 × 10#/L (130-360), and also continues to take 10 mg of prednisone once daily. She is scheduled for a splenectomy in 4 weeks. Which one of the following is the best next step in preparation for the patient ' s surgical procedure?
Answer: E
Explanation:
Comprehensive and Detailed Explanation:
Patients undergoing splenectomy are at lifelong risk for overwhelming post-splenectomy infection (OPSI), particularly from encapsulated organisms. Vaccination against Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis is recommended at least 2 weeks prior to elective splenectomy.
Toronto Notes 2023 - Hematology / Surgery:
"Patients undergoing elective splenectomy should receive vaccines against pneumococcus, H. influenzae type b, and meningococcus at least 2 weeks before surgery." MCCQE1 Objectives (Hematology > 38-2: Thrombocytopenia and Splenectomy):
"Candidates must ensure vaccination prior to splenectomy to prevent postsplenectomy sepsis." Calcium (B) may be considered in chronic steroid users but is not the priority. Azithromycin (C) is not indicated. D is unsafe without tapering. E is only for acute bleeding or extremely low platelets.
NEW QUESTION # 158
A 28-year-old woman presents because of spotting mid-menstrual cycle. Speculum examination reveals an ulcerated endocervical polyp. Which one of the following is the most appropriate management?
Answer: A
Explanation:
Endocervical polyps are common and often benign. An ulcerated polyp may bleed but is not itself suspicious unless it shows atypical features. The appropriate management is to remove the polyp (polypectomy) and send it for histopathology to exclude malignancy.
Toronto Notes 2023 - Gynecology, Cervical Pathology:
"Endocervical polyps are removed by polypectomy and sent for histological analysis. Most are benign.
Atypical or ulcerated appearance may raise concern, but biopsy is unnecessary if the entire lesion is excised." MCCQE1 Objectives - Gynecology > Abnormal Bleeding and Cervical Lesions:
"Candidates should recognize that cervical polyps causing intermenstrual bleeding should be removed and assessed histologically." Colposcopy (B) is reserved for abnormal cytology or high-risk lesions. Cryotherapy (A) is for cervical dysplasia. Punch biopsy (E) is used for lesions that are not amenable to polypectomy.
NEW QUESTION # 159
A 50-year-old man with prostate cancer, which is complicated by bony and cerebral metastases, presents to your office. He has a 24-hour history of increasing lower back pain and weakness in his legs. On examination, you note decreased knee and ankle reflexes on both sides. Earlier today he had fecal incontinence. Which one of the following is the best next step?
Answer: B
Explanation:
This patient with known metastatic prostate cancer presents with acute back pain, bilateral lower limb weakness, decreased reflexes, and new fecal incontinence-classic red flags for malignant spinal cord compression . MCCQE objectives emphasize that this is an oncologic emergency requiring immediate intervention to prevent irreversible neurologic damage.
The first step is prompt administration of high-dose parenteral corticosteroids (e.g., dexamethasone) to reduce vasogenic edema around the spinal cord and preserve neurologic function. Steroids should be given immediately upon suspicion, even before confirmatory imaging. Urgent MRI of the spine and consultation with oncology, radiation oncology, and/or neurosurgery follow for definitive management (radiotherapy or surgical decompression depending on stability and prognosis).
Bed rest and analgesia alone are inadequate. A stellate ganglion block is unrelated. Although radiotherapy or surgery will likely be required, steroids must be administered first without delay. Early treatment significantly improves the likelihood of maintaining ambulation and continence.
NEW QUESTION # 160
A 29-year-old woman presents to the sexually transmitted infection clinic with concerns regarding a copious vaginal discharge. Ten percent potassium hydroxide was used to confirm the diagnosis of which one of the following?
Answer: E
Explanation:
A 10% potassium hydroxide (KOH) preparation is commonly used in the evaluation of vaginal discharge. In bacterial vaginosis (BV) , adding KOH to a vaginal sample produces a characteristic "whiff test" -a strong fishy amine odor caused by volatilization of amines from anaerobic bacteria (e.g., Gardnerella vaginalis and other anaerobes). MCCQE objectives emphasize recognition of BV as the most common cause of abnormal vaginal discharge in reproductive-age women. Clinical features include thin, gray-white, malodorous discharge without significant inflammation.
KOH microscopy may also reveal clue cells (vaginal epithelial cells coated with bacteria).
Trichomonas vaginalis is diagnosed by saline wet mount showing motile trichomonads or by nucleic acid amplification testing (NAAT), not primarily by KOH. Chlamydia trachomatis and gonorrhea are diagnosed by NAAT. Group B streptococcus is identified by culture.
Thus, use of 10% KOH to confirm a fishy odor (positive whiff test) supports the diagnosis of bacterial vaginosis .
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NEW QUESTION # 161
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