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| Section | Objectives |
|---|---|
| Topic 1: Dimensions of Care | - Chronic Care
|
| Topic 2: Physician Activities | - Professionalism
|
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NEW QUESTION # 234
A 42-year-old woman presents to your clinic requesting an increase in her stimulant dosage for the treatment of her adult attention-deficit/hyperactivity disorder. Her medical history includes hypertension and type 1 diabetes with associated nephropathy. She has been taking methylphenidate daily for 15 years. Which one of the following would need to be addressed before the dosage can be increased?
Answer: C
Explanation:
Stimulants like methylphenidate can increase heart rate and blood pressure. In patients with cardiovascular risk (e.g., hypertension, nephropathy), stimulants should not be increased without first addressing elevated blood pressure.
Toronto Notes 2023 - Psychiatry, "ADHD in Adults":
"Stimulants can exacerbate hypertension and must be used cautiously. Evaluate cardiovascular risk factors and control blood pressure before dose increases." MCCQE1 Objectives (Psychiatry > 71-1: ADHD):
"Candidates must consider the cardiovascular risks of stimulant therapy and monitor for hypertension prior to adjusting doses." While poor glycemic control (B) and renal disease (A) are important, BP control is most critical for immediate stimulant safety.
NEW QUESTION # 235
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: E
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 # 236
You are meeting an otherwise healthy 10-year-old boy in your office for the first time. His BMI is at the 80th percentile. He has no symptoms and his physical examination is normal. Which one of the following is the best next step?
Answer: B
Explanation:
Children with a BMI #85th percentile (overweight) and risk factors such as sedentary lifestyle or family history should be screened for cardiovascular risk. A fasting lipid profile is recommended starting at age 9-11 as part of universal screening per guidelines.
Toronto Notes 2023 - Pediatrics:
"Universal lipid screening is recommended for children aged 9-11 and 17-21. Children who are overweight should undergo targeted screening including fasting lipids." MCCQE1 Objectives (Pediatrics > 78-1: Preventive Pediatrics):
"Candidates must recognize screening indications for common pediatric risk factors, including dyslipidemia in overweight children." Thyroid and cortisol testing (C, D) are not indicated without symptoms. HbA1c (E) is used in children with BMI >95% or with additional diabetes risk factors.
NEW QUESTION # 237
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: C
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 # 238
A 12-year-old girl is brought to your clinic by her parents 6 weeks after experiencing a minimally displaced buckle fracture of her distal radius. It was immobilized in a cast for 3 weeks. On examination, she supports her forearm with the opposite hand. She is unwilling to move her elbow, wrist, and fingers. The findings of her neurovascular examination are normal, and the soft tissue is supple. A repeat radiograph shows bony union. Which one of the following is the most likely diagnosis?
Answer: E
Explanation:
Complex regional pain syndrome (CRPS type I) is the most likely diagnosis because the child has persistent, function-limiting pain behavior and marked unwillingness to move the entire limb despite a minor fracture that is now healed radiographically and has a normal neurovascular exam. MCCQE objectives emphasize recognizing pain that is disproportionate to tissue injury and persists beyond expected healing, often accompanied by guarding and fear of movement. CRPS can occur after fractures or immobilization and may present with severe allodynia, hyperalgesia, edema, color/temperature changes, and motor dysfunction; however, early cases may primarily show avoidance of movement and pain with otherwise normal objective findings.
An unrecognized scaphoid fracture would cause localized wrist pain (classically snuffbox tenderness) rather than refusal to move elbow, wrist, and fingers, and would not be explained by a distal radius buckle fracture that has united. Ischemic (Volkmann) contracture would involve a tense forearm, fixed flexion deformity, and neurovascular compromise. Median nerve compression would produce sensory changes and thenar weakness.
School avoidance alone does not explain the post-injury limb-protective pattern with normal healing.
Management focuses on reassurance, early mobilization, physiotherapy, and multidisciplinary pain strategies.
NEW QUESTION # 239
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