[Dec-2025] Feel Medical Council of Canada MCCQE Dumps PDF Will likely be The best Option
MCCQE exam torrent Medical Council of Canada study guide
NEW QUESTION # 103
A 6-year-old girl is found to have a blood pressure of 130/75 mm Hg. She was born prematurely at 32 weeks' gestation and required ventilation. There is a family history of hypertension in 3 grandparents. Clinical examination reveals a grade 1/6 mid-systolic murmur, no renal bruits, and femoral pulses are difficult to feel.
Which one of the following is the most likely diagnosis?
- A. Aortic coarctation
- B. Reflux nephropathy
- C. Renal artery thrombosis
- D. Essential hypertension
- E. Ventricular septal defect
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
The combination of upper extremity hypertension and weak femoral pulses is classic for aortic coarctation. A soft systolic murmur may be present. This condition often becomes apparent during routine screening in school-aged children.
Toronto Notes 2023 - Pediatrics / Cardiology:
"Coarctation of the aorta presents with upper limb hypertension, diminished femoral pulses, and sometimes a systolic murmur. BP discrepancy is key." MCCQE1 Objectives (Pediatrics > 78-1: Congenital Heart Disease):
"Candidates must recognize signs of aortic coarctation, including weak lower limb pulses and systemic hypertension in children." VSD (A) typically presents with a louder murmur. Reflux nephropathy (B) may cause hypertension but without femoral pulse discrepancy. Renal artery thrombosis (C) is rare. Essential hypertension (D) is less likely in this age group with these findings.
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NEW QUESTION # 104
A 54-year-old woman presents to your office to discuss breast cancer screening. She is asymptomatic with no history of breast cancer. She had a fibroadenoma removed when she was 24 years old. The patient is not on any medications. Her family history is significant for a great-aunt with breast cancer. The patient has not had genetic testing but had normal breast screening 2 years ago. Which one of the following is the best next step?
- A. Mammography.
- B. Reassurance.
- C. Positron emission tomography scan.
- D. Breast magnetic resonance imaging.
- E. Monthly self-breast examination.
Answer: A
Explanation:
According to Canadian guidelines, women aged 50 to 74 at average risk for breast cancer should undergo routine screening mammography every 2 to 3 years. A great-aunt with breast cancerdoes not raise this patient's risk to high. Mammography is appropriate as she is now due for the next screen.
Toronto Notes 2023 - Population Health, "Screening Guidelines" Section:
"Routine mammography is recommended every 2 years for average-risk women aged 50 to 74. Family history in second-degree or more distant relatives (e.g., great-aunt) does not qualify for high-risk screening or MRI." MCCQE1 Objectives (Population Health > 97-5: Screening and Prevention):
"Candidates should apply Canadian screening recommendations including mammography for average-risk women #50 years old." Self-breast exams (C) are not recommended for screening. PET scan (D) and MRI (E) are reserved for high- risk populations or diagnostic clarification.
NEW QUESTION # 105
A 42-year-old woman presents with a 2-day history of a low-grade fever and a painful left breast mass. On examination, there is a fluctuant erythematous tender mass with surrounding induration in the left breast and enlarged lymph nodes in the left axilla. An ultrasound shows a loculated cystic mass. Which one of the following is the most likely diagnosis?
- A. Abscess
- B. Fibrocystic changes
- C. Inflammatory breast cancer
- D. Fibroadenoma
- E. Ductal ectasia
Answer: A
Explanation:
Comprehensive and Detailed Explanation:
A fluctuant, erythematous, tender breast mass with systemic signs (fever, lymphadenopathy) and ultrasound showing a cystic lesion is diagnostic for a breast abscess. It commonly arises from untreated mastitis.
Toronto Notes 2023 - Surgery, "Breast Disease":
"Abscess presents as a fluctuant, erythematous mass. Ultrasound confirms loculated fluid. Treatment includes drainage and antibiotics." MCCQE1 Objectives (Surgery > 50-1: Breast Conditions):
"Candidates must identify signs of infection and abscess and differentiate from malignancy or benign lesions." Fibroadenoma (C) is non-tender, mobile, and firm. Ductal ectasia (B) causes nipple discharge. Fibrocystic changes (D) are bilateral and cyclic. Inflammatory breast cancer (E) is rapidly progressive but lacks fluctuation and cystic features.
NEW QUESTION # 106
A 43-year-old man is referred to you for an incidental finding of elevated hemoglobin. Laboratory results are as follows:
Hemoglobin
185 g/L (130-170)
Mean corpuscular volume
92 fL (60-100)
White blood cells
7.8×1037.8×103 / L (4-10)
Platelets
250×103250×103 / L (130-400)
His BMI is 23. He has type 2 diabetes for which he takes gliclazide MR 60 mg daily. Which one of the following features on history could explain his laboratory abnormality?
- A. Alcohol abuse
- B. Cirrhosis
- C. Hypertension
- D. Central sleep apnea
- E. Hypothyroidism
Answer: D
Explanation:
Elevated hemoglobin in the absence of polycythemia vera can be due to secondary causes such as chronic hypoxia. Central sleep apnea, often associated with diabetes or neurologic conditions, leads to intermittent hypoxia and compensatory erythropoiesis.
Toronto Notes 2023 - Hematology and Respiratory Medicine, "Polycythemia" Section:
"Secondary erythrocytosis may result from hypoxic conditions including sleep apnea, COPD, or high altitude.
Assess for sleep-disordered breathing in patients with elevated hemoglobin and no myeloproliferative features." MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Abnormalities):
"Candidates must investigate secondary causes of elevated hemoglobin, including hypoxia-related conditions." Hypertension (A), hypothyroidism (C), and cirrhosis (D) do not cause polycythemia. Alcohol (B) typically causes macrocytosis and anemia.
NEW QUESTION # 107
A 76-year-old man is brought by his family to your clinic with new-onset urinary incontinence. They state that the patient is experiencing a slowly progressing cognitive decline marked by memory disturbance, apathy, and attentional problems. Examination reveals that the patient has a stooped, forward-leaning posture and a wide-based gait. Which one of the following is the most likely diagnosis?
- A. Alzheimer disease
- B. Frontotemporal dementia
- C. Normal pressure hydrocephalus
- D. Parkinson disease
- E. Lewy body dementia
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
This patient presents with the classic triad of normal pressure hydrocephalus (NPH): gait disturbance (often wide-based and magnetic), cognitive decline, and urinary incontinence. The combination, especially with the gait being most prominent, is highly suggestive.
Toronto Notes 2023 - Geriatrics / Neurology:
"NPH presents with gait disturbance, dementia, and urinary incontinence. Gait is typically broad-based and magnetic. Imaging shows ventriculomegaly without elevated pressure." MCCQE1 Objectives (Geriatrics > 41-1: Cognitive Disorders):
"Candidates must identify NPH and distinguish it from other dementias based on clinical triad and gait features." Alzheimer's (B) primarily presents with memory loss. Parkinson's (A) has bradykinesia and rigidity. Lewy body dementia (C) includes visual hallucinations and fluctuating cognition. FTD (E) has personality and behavioral changes.
NEW QUESTION # 108
You are conducting a virtual appointment by voice-only call with a 68-year-old man regarding back pain.
When he answers, you ask for him by name and identify yourself and the clinic from which you are calling.
Which one of the following is the best next step?
- A. Confirm the name of the patient's primary care provider.
- B. Establish the reason for the virtual care visit.
- C. Ask for additional confirmation of the patient's identity.
Answer: C
Explanation:
Before proceeding with any virtual consultation, particularly by voice-only, it is essential to confirm the patient's identity beyond name alone - for example, by verifying date of birth or health card number. This protects privacy and ensures medical confidentiality.
Toronto Notes 2023 - ELOM, Virtual Care Section:
"Virtual care must begin by verifying patient identity using at least two identifiers (e.g., full name and date of birth) to prevent disclosure of personal health information to unintended individuals." MCCQE1 Objectives - Ethical, Legal, and Professionalism > Virtual Care:
"The candidate must confirm patient identity and consent before initiating any virtual medical encounter, especially when video is not available." Option A (reason for visit) should follow identity confirmation. Option B (confirming primary care provider) is irrelevant to identity verification.
NEW QUESTION # 109
A 45-year-old woman presents with a 2-week history of a sore left breast. It has become red and swollen. She was previously well, and her menstrual cycles are regular. She has no history of breast cancer, and she has no children. On examination, she has a red, tender, indurated area in her left breast that has only partially responded to oral antibiotics after 10 days. Which one of the following is the most appropriate next step?
- A. Perform a breast biopsy.
- B. Change the oral antibiotic.
- C. Start intravenous antibiotics.
- D. Proceed with incision and drainage.
- E. Start nonsteroidal anti-inflammatory agents.
Answer: A
Explanation:
In a non-lactating woman with a partially responsive breast mass after antibiotics, inflammatory breast cancer must be ruled out. A breast biopsy (core or excisional) is indicated to assess for malignancy. Inflammatory breast cancer may mimic mastitis but does not improve with antibiotics.
Toronto Notes 2023 - Breast Disorders:
"In non-lactating women, persistent breast inflammation should raise suspicion for inflammatory breast cancer. If symptoms persist after antibiotic therapy, proceed with imaging and biopsy." MCCQE1 Objectives - Gynecology > Breast Disease:
"Candidates must differentiate between mastitis and inflammatory breast cancer and initiate appropriate investigations such as biopsy when response to antibiotics is incomplete." Options A, D, and E may be appropriate for a confirmed abscess or infectious cause, but further investigation is mandatory in this scenario. NSAIDs (C) are symptomatic but do not address the diagnostic concern.
NEW QUESTION # 110
A 42-year-old woman is admitted to the Intensive Care Unit with a massive pulmonary embolism. Her condition is stabilized with intubation, hydration, inotropic support, and intravenous administration of heparin. Her partner provides you with a list of her medications. A combination oral contraceptive pill was recently prescribed. She smokes tobacco cigarettes, and her BMI is 36. Which one of the following is the best next step?
- A. Tell her partner that the physician should not have prescribed the oral contraceptive pill
- B. Discuss the case with the hospital ethics committee
- C. Advise the patient's partner to seek legal advice
- D. Inform the patient's partner that the oral contraceptive pill may have caused her condition
- E. Report the prescribing physician to the provincial or territorial medical regulatory authority
Answer: D
Explanation:
Oral contraceptives increase the risk of thromboembolic events, particularly in patients with risk factors such as smoking and obesity. However, informing the patient's partner of potential contributing factors in a factual, non-judgmental manner is appropriate and does not imply fault.
Toronto Notes 2023 - ELOM, "Informed Consent and Risk Communication":
"Patients and families should be informed of all relevant information, including potential drug-related adverse events. Blame must not be assigned without full investigation." MCCQE1 Objectives (ELOM > 90-2: Physician-Patient Communication):
"Candidates must be able to communicate adverse outcomes factually, while respecting confidentiality and without prematurely assigning fault." Discussing the case with the ethics committee or reporting the prescribing doctor without context is premature and inappropriate (A, D). Telling the partner the physician was at fault (C) is speculative and unethical.
NEW QUESTION # 111
A 6-week-old boy is brought to your office by his parents for a follow-up following a recent urinary tract infection. His abdominal ultrasound shows dilated urinary bladder and ureters as well as bilateral hydronephrosis. Which one of the following historical findings would be most helpful in establishing the correct diagnosis?
- A. Crying during micturition
- B. Macroscopic hematuria
- C. Recent circumcision
- D. Malodorous urine
- E. Poor urinary stream
Answer: E
Explanation:
This infant has evidence of urinary outflow obstruction on ultrasound. The most common cause in male infants is posterior urethral valves. Poor urinary stream is a hallmark symptom of bladder outlet obstruction in neonates.
Toronto Notes 2023 - Pediatrics, "Pediatric Urology" Section:
"Posterior urethral valves should be suspected in male infants with recurrent UTIs, hydronephrosis, and a weak urinary stream. Diagnosis is confirmed by voiding cystourethrogram." MCCQE1 Objectives (Pediatrics > 78-4: Urinary Tract Abnormalities):
"Candidates must identify congenital causes of urinary obstruction. Poor stream and hydronephrosis are classic features of posterior urethral valves." Crying with urination (E) is nonspecific. Hematuria (B) and malodorous urine (D) are common with infections. Circumcision (A) is unrelated.
NEW QUESTION # 112
A 39-year-old man presents to a psychiatrist. He says, "It often seems to me that I am not part of this world.
My voice sounds strange to me, and other people seem like figures in a dream." He has had these feelings intermittently for about 2 years. There is no history of hallucinations, and there are no current indications of disorganized thinking. Which one of the following is the most likely diagnosis?
- A. Depersonalization/derealization disorder.
- B. Conversion disorder.
- C. Delusional disorder.
- D. Schizophrenia.
- E. Persistent depressive disorder.
Answer: A
Explanation:
The patient describes classic symptoms of depersonalization ("my voice sounds strange to me") and derealization ("others seem like figures in a dream"), which define depersonalization/derealization disorder.
There is preserved reality testing and no psychosis.
Toronto Notes 2023 - Psychiatry, "Dissociative Disorders" Section:
"Depersonalization/derealization disorder involves persistent or recurrent experiences of detachment from oneself (depersonalization) or surroundings (derealization), with intact reality testing and no delusions or hallucinations." MCCQE1 Objectives (Psychiatry > 79-4: Dissociative Disorders):
"Candidates must identify depersonalization/derealization disorder as a dissociative disorder distinct from psychosis or mood disorders." Schizophrenia (A) would include hallucinations or disorganized thinking. Conversion disorder (B) presents with neurological symptoms inconsistent with known diseases. Persistent depressive disorder (D) involves chronic low mood. Delusional disorder (E) would involve fixed false beliefs, which are not present here.
NEW QUESTION # 113
A 24-year-old man presents to your clinic with a 6-month history of fatigue. On examination, he is pale. His BMI is 16, and his blood pressure is 92/58 mm Hg. Initial laboratory work shows the following:
* Creatinine: 64 µmol/L (49-93)
* Potassium: 3.0 mmol/L (3.5-5.1)
* Sodium: 138 mmol/L (136-146)
* TSH: 2.40 mIU/L (0.34-5.60)
* CBC: Normal
Which one of the following is the best next step?
- A. Ask permission to discuss the patient's weight
- B. Refer the patient to the emergency department
- C. Advise increased caloric intake
- D. Consult gastroenterology
Answer: A
Explanation:
This patient has clinical signs of an eating disorder - fatigue, low BMI, hypotension, and hypokalemia - likely secondary to nutritional deficiencies or purging. The first step is to sensitively explore the patient's perception of weight and body image. Effective management requires rapport and careful conversation.
Toronto Notes 2023 - Psychiatry, Eating Disorders:
"Approach patients with suspected eating disorders non-judgmentally. Begin with permission to discuss weight or body image. Screening tools like SCOFF can help guide further assessment." MCCQE1 Objectives - Psychiatry > Eating Disorders:
"Candidates must recognize signs of eating disorders and initiate a respectful and effective patient-centered discussion." Referring to the ED (B) is not urgent without hemodynamic instability. Advising caloric intake (C) bypasses assessment. GI referral (D) is not appropriate at this stage.
NEW QUESTION # 114
On screening for dyslipidemia, a 45-year-old man is found to have a low high-density lipoprotein (HDL) cholesterol level. Which one of the following recommendations is the most appropriate?
- A. Vigorous exercise program.
- B. Garlic supplementation.
- C. Alcohol cessation.
- D. Low-salt diet.
- E. Elimination of caffeine.
Answer: A
Explanation:
Low HDL is best managed with lifestyle changes such as increased aerobic physical activity, smoking cessation, and weight loss. Vigorous exercise has the strongest evidence for raising HDL levels.
Toronto Notes 2023 - Cardiology, Dyslipidemia:
"Increasing physical activity is among the most effective ways to raise HDL cholesterol. There is no consistent benefit to supplements such as garlic, nor does reducing salt or caffeine meaningfully raise HDL." MCCQE1 Objectives - Population Health > Cardiovascular Risk Management:
"Candidates should recommend evidence-based lifestyle interventions such as exercise to improve lipid profiles, particularly to increase HDL." Alcohol cessation (C) is generally beneficial for overall health but may actually lower HDL slightly. Garlic (D) and caffeine (E) are not evidence-based interventions for dyslipidemia.
NEW QUESTION # 115
A 53-year-old man presents to the Emergency Department with a 3-week history of believing his neighbor is poisoning him by pumping gas through his home's air vent. He appears distracted, irritable, and is speaking very quickly. He has a family history of depression. Which one of the following is the most likely diagnosis?
- A. Psychotic disorder secondary to traumatic brain injury
- B. Delirium
- C. Bipolar I disorder
- D. Malingering
- E. Brief psychotic disorder
Answer: C
Explanation:
This man exhibits a classic manic episode with psychotic features: persecutory delusions, distractibility, pressured speech, irritability, and possible grandiosity. The chronicity and mood symptoms are most consistent with Bipolar I disorder.
Toronto Notes 2023 - Psychiatry, "Mood Disorders" Section:
"Bipolar I disorder is characterized by episodes of mania, often with psychotic features.Symptoms include grandiosity, decreased need for sleep, distractibility, and mood-congruent delusions." MCCQE1 Objectives (Psychiatry > 79-1: Mood Disorders):
"Candidates must recognize mania and differentiate from brief psychosis or organic causes." Delirium (A) is acute, fluctuating, and involves impaired attention. Malingering (B) requires external gain.
Brief psychotic disorder (C) resolves within 1 month. Brain injury-related psychosis (E) would require a supporting history or findings.
(Part 2 )
NEW QUESTION # 116
A mother brings her 10-year-old son for his well-child check-up. She mentions that her 38-year-old husband has just had a heart attack due to high cholesterol levels and wants information regarding prevention of cardiovascular disease for her son. Which one of the following is the best approach to managing this problem?
- A. Request a serum homocysteine and hemoglobin A1c
- B. Send the son for a lipid profile test
- C. Prescribe a low-fat diet for the son
- D. Reassure the mother as children do not have elevated lipid levels
- E. Prescribe a weight-lifting exercise program for her son
Answer: B
Explanation:
Children with a first-degree relative who has premature coronary artery disease or hypercholesterolemia should undergo fasting lipid screening between ages 2-10. Since the child is 10, screening is indicated.
Toronto Notes 2023 - Pediatrics, "Preventive Care in Children":
"Lipid screening is recommended for children #2 years old with a family history of early cardiovascular disease or hypercholesterolemia." MCCQE1 Objectives (Pediatrics > 78-1: Preventive Medicine):
"Candidates must screen children at high risk of cardiovascular disease appropriately, including lipid profile for familial hyperlipidemia." Diet and exercise counseling may follow screening, but testing is the first step. Reassurance alone (C) is inappropriate. Homocysteine (E) and HbA1c are not first-line tests in this setting.
NEW QUESTION # 117
A 62-year-old woman is taken to the operating room for an elective laparoscopic cholecystectomy. Induction of anesthesia triggers a severe hypertensive crisis that ultimately resolves after administration of a 5 mg bolus of phentolamine.
Which one of the following is most consistent with this presentation?
- A. Low urinary metanephrines
- B. Elevated plasma catecholamines
- C. High plasma cortisol
- D. Increased thyrotropin (thyroid-stimulating hormone) level
- E. Low renal vein renin
Answer: B
Explanation:
This presentation is classic for an undiagnosed pheochromocytoma, which causes episodic or crisis-level hypertension due to excess catecholamines. Anesthesia or surgical manipulation can trigger massive catecholamine release, leading to hypertensive crisis. Phentolamine, an alpha-blocker, is the appropriate treatment.
Toronto Notes 2023 - Endocrinology, Pheochromocytoma:
"Pheochromocytomas may precipitate hypertensive crises during surgery. Elevated plasma catecholamines and urinary metanephrines confirm diagnosis." MCCQE1 Objectives - Internal Medicine > Endocrinology:
"Candidates should suspect pheochromocytoma in perioperative hypertensive crises and confirm with plasma or urine catecholamines/metanephrines." Low metanephrines (E) would argue against pheochromocytoma. TSH (A), cortisol (D), and renin (C) are unrelated to acute intraoperative hypertensive episodes of this nature.
NEW QUESTION # 118
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?
- A. Random glucose level that is often higher than 18.0 mmol/L (4.0-11.0).
- B. Average home blood pressure reading of 150/80 mm Hg.
- C. Estimated glomerular filtration rate of less than 30 mL/min/1.73 m² (#60).
Answer: B
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 # 119
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?
- A. Perform a computed tomography colonoscopy.
- B. Order a fecal immunochemical test (FIT).
- C. Discuss the issue with his family before making a decision.
- D. Reassure him that a colonoscopy does not need to be repeated.
- E. Recommend a surgical resection of the diverticular disease.
Answer: D
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 # 120
A 37-year-old man comes to the office for follow-up of his opioid use disorder. He receives opioid agonist treatment, including some take-home doses. At this follow-up visit, he reports some nonprescription opioid use since his last visit. Which one of the following is the best next step?
- A. Increase the frequency of follow-up visits
- B. Taper the dosage of the opioid agonist
- C. Slowly taper and discontinue the opioid agonist
- D. Discontinue take-home doses
- E. Prescribe a cannabinoid
Answer: A
Explanation:
Nonprescription opioid use during opioid agonist therapy is not uncommon. The response shouldbe supportive and not punitive. Increasing the frequency of follow-up enhances monitoring, supports adherence, and prevents relapse.
Toronto Notes 2023 - Psychiatry, "Substance Use Disorders":
"Patients who relapse during opioid agonist treatment benefit from closer monitoring and increased support, including more frequent follow-up and psychosocial interventions." MCCQE1 Objectives (Psychiatry > 71-5: Substance Use and Addiction):
"Candidates must manage relapses in opioid use by optimizing follow-up and support, not by discontinuing or reducing therapy prematurely." Tapering or discontinuing therapy (A, E) risks destabilizing treatment. Removing take-home doses (B) may be warranted later but not first. Cannabinoids (D) are not first-line adjuncts.
NEW QUESTION # 121
A 40-year-old woman presents to your clinic for follow-up regarding her major depressive disorder, which is being treated with the starting dosage of escitalopram. Most of her symptoms have now improved. However, she has noted anorgasmia since taking this medication. This has significantly affected her relationship with her wife. Which one of the following is the best next step?
- A. Maintain the current medication
- B. Switch escitalopram to venlafaxine
- C. Add bupropion
- D. Increase the patient's dosage of escitalopram
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
Sexual dysfunction, including anorgasmia, is a common side effect of SSRIs like escitalopram. Bupropion, a norepinephrine-dopamine reuptake inhibitor, has minimal sexual side effects and can be safely added to mitigate this issue while preserving the antidepressant effect.
Toronto Notes 2023 - Psychiatry / Pharmacology:
"SSRI-induced sexual dysfunction can be managed by dose reduction, switching agents, or adding bupropion." MCCQE1 Objectives (Psychiatry > 71-1: Depressive Disorders):
"Candidates should be able to address side effects of antidepressants, including sexual dysfunction, and adjust therapy appropriately." Increasing the dose (A) may worsen sexual dysfunction. Venlafaxine (B), an SNRI, also has sexual side effects. D (no change) does not address the patient's concern.
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NEW QUESTION # 122
A 56-year-old woman with a 4-year history of fibromyalgia presents for follow-up. She reports that she is struggling with her health and daily life. She is unhappy with her lack of progress and says she feels tired all the time and stays in bed all day. When asked why, she states she is confused about why she is not getting better. Physical exam and investigations are unchanged from baseline. Which one of the following is the best next step?
- A. Initiate iron and vitamin B12 supplementation
- B. Start a selective serotonin reuptake inhibitor
- C. Prescribe cannabinoid therapy
- D. Educate the patient about her illness
Answer: D
Explanation:
Patient education is foundational in managing fibromyalgia. Understanding the chronic but non-progressive nature of the disease, reassurance, and emphasis on self-management are crucial. It helps set realistic expectations and enhances engagement in therapy.
Toronto Notes 2023 - Rheumatology, Fibromyalgia:
"Patient education is essential. Explain the nature of fibromyalgia, emphasizing that although it is chronic, it is non-deforming and can be managed through exercise, sleep hygiene, and cognitive strategies." MCCQE1 Objectives - Psychiatry & Rheumatology > Chronic Pain Syndromes:
"Candidates must recognize the value of education and behavioral interventions in managing functional syndromes." SSRIs (D) may be used if depression is present. Iron/B12 (B) are not indicated without evidence of deficiency. Cannabinoids (A) lack strong evidence in fibromyalgia.
NEW QUESTION # 123
A 32-year-old woman presents to your outpatient clinic with concerns regarding a 6-month history of both a pulsatile buzzing sound in her ears and headaches. There is no history of hearing loss, vertigo, ear pain, or discharge from the ears. There is a long-standing history of prolonged exposure to occupational noise. She has a BMI of 32. Otoscopic examination is unremarkable, and there are no neck masses present. You determine that the buzzing sound is synchronous with her radial pulse. Which of the following investigations should be ordered next?
- A. Audiogram
- B. C-reactive protein
- C. Magnetic resonance imaging of the brain
- D. Electroencephalography
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
Pulsatile tinnitus synchronous with the pulse may be vascular in origin. The association with headaches and elevated BMI (a risk factor for idiopathic intracranial hypertension, IIH) warrants neuroimaging to assess for cerebral venous sinus thrombosis, vascular malformations, or raised intracranial pressure.
Toronto Notes 2023 - Neurology / ENT:
"Pulsatile tinnitus requires investigation for vascular causes including idiopathic intracranial hypertension.
MRI or MRV is the next step."
MCCQE1 Objectives (Neurology > 35-1: Headache and Tinnitus):
"Candidates must investigate pulsatile tinnitus with neuroimaging when vascular causes are suspected." Audiogram (A) is for hearing loss. EEG (C) is not useful for tinnitus. CRP (D) is irrelevant.
NEW QUESTION # 124
A 6-year-old boy is brought to the Emergency Department with a 2-day history of a limp. On examination, he looks well, has a temperature of 38 °C and is able to weight-bear. His hip examination reveals mild decreased range of motion. Radiographs of his hip and pelvis show no abnormality. His C-reactive protein level is 8 mg
/L (< 6). Which one of the following is the most likely diagnosis?
- A. Septic arthritis
- B. Transient synovitis
- C. Trochanteric bursitis
- D. Osteomyelitis
- E. Juvenile rheumatoid arthritis
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
Transient synovitis is the most common cause of hip pain and limp in children aged 3-10 years. It is often preceded by a viral infection. Patients appear well, can often bear weight, and have only mild to moderate elevation in inflammatory markers. Radiographs are normal.
Toronto Notes 2023 - Pediatrics, "Limping Child":
"Transient synovitis is benign and self-limiting. Presentation includes mild limp, low-grade fever, normal or slightly elevated CRP/ESR, and ability to bear weight." MCCQE1 Objectives (Pediatrics > 78-2: Musculoskeletal Disorders):
"Candidates must distinguish between transient synovitis and more serious causes of limping, such as septic arthritis." Septic arthritis (A) usually causes inability to bear weight and more significant fever and CRP elevation.
Osteomyelitis (B) typically presents with localized tenderness and systemic signs. Bursitis (D) is rare in young children. JIA (E) is chronic.
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NEW QUESTION # 125
A 71-year-old man with stable chronic low back pain on hydromorphone (8 mg twice daily) presents upset, requesting an early refill. He reports his granddaughter has been stealing his medication and pressuring him for refills. Which one of the following is the best next step?
- A. Increase the dispensed quantity of the patient's hydromorphone.
- B. Begin tapering the hydromorphone.
- C. Arrange for daily dispensing of hydromorphone.
- D. Provide an early refill of hydromorphone.
- E. Call the police and report the patient's granddaughter.
Answer: C
Explanation:
This case suggests diversion of prescription opioids, a serious safety and regulatory concern. The physician must balance maintaining patient care with minimizing risk. Daily dispensing via a monitored pharmacy is the safest and most practical solution to prevent misuse or theft, while avoiding immediate discontinuation of the patient's needed medication.
Toronto Notes 2023 - Chronic Pain & Substance Use:
"In cases of concern for opioid diversion, consider witnessed daily dispensing, prescription monitoring, and involving caregivers when appropriate." MCCQE1 Objectives (Internal Medicine > Pain Management > 56-2):
"The candidate must demonstrate understanding of strategies for safe prescribing and monitoring of controlled substances, including mitigation of diversion." Calling the police (A) is not the physician's immediate duty. Providing an early refill (B) worsens risk.
Tapering (C) may be appropriate later, but first the medication must be safeguarded. Increasing quantity (D) is inappropriate.
NEW QUESTION # 126
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