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NEW QUESTION # 60
A 25-year-old woman, gravida 1, para 1, aborta 0, gave birth to a newborn who is hypotonic with a large protruding tongue and brachycephaly. The newborn has a single palmar crease bilaterally and short, broad hands with a curved fifth digit. These features best support a clinical diagnosis of which one of the following?
- A. Turner syndrome.
- B. Congenital hypothyroidism.
- C. Trisomy 21.
- D. Prader-Willi syndrome.
- E. Fetal alcohol syndrome.
Answer: C
Explanation:
This constellation of features-hypotonia, macroglossia, brachycephaly, single palmar crease, short broad hands with clinodactyly-is classic for Down syndrome (Trisomy 21).
Toronto Notes 2023 - Pediatrics, "Genetic Syndromes":
"Trisomy 21 features include hypotonia, upslanting palpebral fissures, epicanthic folds, flat nasal bridge, brachycephaly, macroglossia, single palmar crease, and clinodactyly." MCCQE1 Objectives (Pediatrics > 78-3: Congenital and Genetic Disorders):
"Candidates must recognize key dysmorphic features associated with common genetic syndromes including Trisomy 21." Prader-Willi and congenital hypothyroidism may have hypotonia but lack the full phenotypic pattern. Turner syndrome is seen in females with short stature and webbed neck. Fetal alcohol syndrome presents with smooth philtrum and microcephaly.
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NEW QUESTION # 61
A 55-year-old woman presents with a 6-month history of poor memory and impaired concentration. She has bipolar I disorder that has been treated with lithium carbonate for 4 years. She has gained a lot of weight since starting lithium. Physical examination findings are otherwise normal. She is concerned about her memory issues, but there are no other perception, mood, or cognition abnormalities. Which one of the following tests is most likely to have abnormal findings?
- A. Creatinine clearance
- B. Serum sodium level
- C. Liver function tests
- D. Serum thyrotropin (thyroid-stimulating hormone) level
- E. Parathyroid hormone
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
Lithium commonly causes hypothyroidism, which can lead to fatigue, cognitive slowing, weight gain, and memory impairment. Thyroid-stimulating hormone (TSH) levels are often elevated in such cases.
Toronto Notes 2023 - Psychiatry / Endocrinology:
"Lithium is associated with hypothyroidism and renal impairment. Monitor TSH regularly in patients on lithium therapy." MCCQE1 Objectives (Psychiatry > 71-5: Mood Stabilizers):
"Candidates must recognize the endocrine side effects of lithium, including hypothyroidism and the importance of TSH monitoring." Creatinine clearance (C) may also be affected but is less directly associated with memory issues. Liver function (A), sodium (D), and PTH (E) are not typically the first abnormal values in this presentation.
NEW QUESTION # 62
Three months ago, a physician colleague approached you in the hospital corridor for advice regarding one of his patients. You are now being named by this patient in a malpractice action. Which one of the following is the most likely reason why you may be found liable?
- A. You were given the patient's name
- B. You gave advice on how to treat the patient
- C. You were given confidential patient health information
- D. You advised the physician to consult one of your colleagues
- E. You did not see the patient
Answer: B
Explanation:
Comprehensive and Detailed Explanation:
Providing clinical advice (particularly treatment advice) without formally seeing or evaluating the patient creates a physician-patient relationship, potentially establishing a duty of care. If the advice leads to harm, you could be found liable, even if you never saw the patient directly.
Toronto Notes 2023 - Legal Medicine:
"Giving specific medical advice about diagnosis or treatment may imply a physician-patient relationship and establish duty of care." MCCQE1 Objectives (ELOM > 90-2: Legal Risk Management):
"Candidates must understand that liability can arise from informal consultations where medical advice is given." Providing advice (D) is riskier than simply hearing about a case or patient (A, C). Recommending consultation (B) does not establish duty of care. Not seeing the patient (E) does not automatically shield from liability if treatment advice was given.
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NEW QUESTION # 63
You are treating a 78-year-old man for recent onset of diarrhea, tenesmus, and minor bleeding when he wipes.
He has a history of prostate cancer that was treated by radiotherapy. Rectal examination findings are normal.
Colonoscopy reveals a pale rectum with ulcerations and areas of mucosal hemorrhage. Which one of the following is the most likely explanation for this clinical presentation?
- A. Diverticulosis
- B. Radiation proctitis
- C. Rectal cancer
- D. Recurrent prostate cancer
- E. Ulcerative colitis
Answer: B
Explanation:
Radiation proctitis is a well-known complication of pelvic radiation therapy (e.g., for prostate cancer). It presents months to years after treatment with rectal bleeding, tenesmus, and mucosal ulceration on colonoscopy.
Toronto Notes 2023 - Gastroenterology, "Radiation-Induced GI Injury":
"Radiation proctitis presents with rectal bleeding, tenesmus, urgency. Colonoscopy shows pale, friable mucosa, ulcerations, and telangiectasia." MCCQE1 Objectives (Gastroenterology > 47-2: GI Bleeding and Complications):
"Candidates must recognize radiation proctitis based on history of radiation and characteristic endoscopic findings." Ulcerative colitis (B) usually starts younger and is more diffuse. Diverticulosis (C) affects the left colon and causes painless bleeding. Recurrent prostate cancer (D) and rectal cancer (E) would show mass or infiltration.
NEW QUESTION # 64
You are called to the Emergency Department to see a 6-month-old boy with a 3-day history of fever. Physical examination reveals an irritable infant with a temperature of 38.1°C. His vital signs are:
Blood pressure: 87/50 mm Hg
Respiratory rate: 80/min
Heart rate: 140/min
Oxygen saturation: 92% on room air
The infant has no skin findings. On chest examination, you hear coarse crackles on the right side of the chest.
Which one of the following is the best next step in the management of this child?
- A. Reassurance.
- B. Intravenous antibiotics.
- C. Oral antibiotics.
- D. Intravenous fluids.
- E. Oral steroids.
Answer: B
Explanation:
This 6-month-old presents with signs of systemic illness, tachypnea, hypoxia, and focal lung findings. In this age group, pneumonia can rapidly progress, and given the severity of symptoms, oral treatment is insufficient.
Intravenous antibiotics are urgently indicated.
Toronto Notes 2023 - Pediatrics, Respiratory Infections in Infants:
"Infants under 6 months with signs of systemic illness, hypoxia (SpO2 < 94%), and respiratory distress should receive IV antibiotics. Delayed treatment may result in rapid clinical deterioration." MCCQE1 Objectives - Pediatrics > Respiratory Conditions:
"Candidates must recognize signs of serious lower respiratory tract infection in infants and initiate prompt IV antibiotic therapy when criteria for hospitalization are met." Oral antibiotics (C) are appropriate for mild outpatient pneumonia. Reassurance (B) and oral steroids (A) are inappropriate. IV fluids (D) may be supportive but do not address the infectious cause.
NEW QUESTION # 65
A 2-month-old infant is brought by his parents to your clinic with concerns regarding his frequent crying spells. He has been crying for more than 3 hours daily for many weeks. The infant has reached all age-specific developmental milestones. Which one of the following is the most important to share with the parents regarding this situation?
- A. Most infants respond well to low-dose sedative medications
- B. Investigations are required to confirm a diagnosis
- C. This is a self-limited condition
- D. There is an increased risk for dependent personality traits in adulthood
- E. Resolution of the crying spells is expected between ages 6 and 12 months
Answer: C
Explanation:
This infant likely has infantile colic, defined by the "rule of 3s": crying >3 hours per day, >3 days per week, for >3 weeks, usually starting in the first few months of life. It is benign and self-limited, typically resolving by 3-4 months of age.
Toronto Notes 2023 - Pediatrics, "Common Concerns in Infancy":
"Colic is self-limited. No routine testing is required in healthy, thriving infants. Reassurance and support for parents are key." MCCQE1 Objectives (Pediatrics > 78-1: Behavioral Pediatrics):
"Candidates must recognize normal variations such as colic and avoid unnecessary interventions. Counseling and reassurance are essential." Sedatives (D) are contraindicated. Investigations (C) are unnecessary without red flags. Resolution (B) usually occurs by 3-4 months, not as late as 12 months.
NEW QUESTION # 66
A 15-year-old boy is brought to the office by his father because he is having headaches. When alone, the boy appears withdrawn and admits to suicidal ideation. He shares that he is gay but does not want to tell his parents. He says that he faked the headaches so that one of his parents would make an appointment for him.
Which one of the following is the best next step?
- A. Refer the patient for an immediate mental health assessment.
- B. Suggest that the patient join a group at school for peer support.
- C. Start an antidepressant medication.
- D. Encourage the patient to disclose his sexual orientation to his parents.
Answer: A
Explanation:
The presence of suicidal ideation in a minor mandates urgent assessment to ensure safety and access mental health care. Disclosure of sexual orientation should be handled delicately and is not urgent compared to suicidal risk.
Toronto Notes 2023 - Psychiatry, "Child and Adolescent Psychiatry" Section:
"Any adolescent disclosing suicidal ideation should be referred for urgent mental health evaluation.
Concurrent issues such as sexual orientation may contribute to distress and should be addressed with appropriate support over time." MCCQE1 Objectives (Psychiatry > 79-2: Suicide Risk Assessment):
"Candidates must immediately refer for psychiatric assessment when a minor reports suicidal ideation, regardless of other social or developmental concerns." Antidepressants (A) may be appropriate but must follow specialist evaluation. Encouraging disclosure (B) or peer groups (C) is premature without ensuring safety.
NEW QUESTION # 67
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. Begin tapering the hydromorphone.
- B. Provide an early refill of hydromorphone.
- C. Call the police and report the patient's granddaughter.
- D. Increase the dispensed quantity of the patient's hydromorphone.
- E. Arrange for daily dispensing of hydromorphone.
Answer: E
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 # 68
A 26-year-old woman, gravida 2, para 1, presents with a positive pregnancy test. Her previous pregnancy was associated with preeclampsia, and she delivered a 1000 g boy at 34 weeks' gestation. Her blood pressure is 130
/86 mm Hg. Which one of the following is the best recommendation for this pregnancy?
- A. Amniocentesis for karyotyping.
- B. Genetic assessment and counseling.
- C. Complete bed rest starting at 20 weeks' gestation.
- D. Accurate dating by ultrasound.
- E. Prophylactic labetalol.
Answer: D
Explanation:
Accurate dating is critical in pregnancies at high risk for preeclampsia and intrauterine growthrestriction. First- trimester ultrasound is used to establish gestational age, which guides monitoring and interventions.
Toronto Notes 2023 - Obstetrics, High-Risk Pregnancy:
"In women with a history of preeclampsia, early and accurate dating allows for appropriate fetal surveillance and timely delivery." MCCQE1 Objectives - Obstetrics > Prenatal Care:
"Candidates should recognize the importance of accurate pregnancy dating in high-risk pregnancies." Prophylactic labetalol (E) is not indicated in normotensive patients. Genetic testing (A, B) is not appropriate unless additional risk factors are present. Bed rest (D) is not evidence-based for preeclampsia prevention.
NEW QUESTION # 69
You are seeing a 5-month-old infant who has had intermittent stridor since age 2 months. He is otherwise healthy. He has been drinking well and has been reaching all the age-specific developmental milestones.
Which one of the following is the most likely diagnosis?
- A. Laryngomalacia.
- B. Vascular ring.
- C. Aspiration of a foreign body.
- D. Tracheoesophageal fistula.
- E. Subglottic hemangioma.
Answer: A
Explanation:
Laryngomalacia is the most common cause of chronic stridor in infants. It presents with inspiratory stridor that worsens with feeding, supine positioning, or agitation. The child remains otherwise well and meets developmental milestones.
Toronto Notes 2023 - Pediatrics, Airway Disorders:
"Laryngomalacia presents with intermittent inspiratory stridor, typically beginning in the first few months of life. Diagnosis is clinical and prognosis is usually good." MCCQE1 Objectives - Pediatrics > Respiratory Disorders:
"Candidates must recognize the typical presentation of laryngomalacia and differentiate it from other causes of pediatric stridor." Vascular ring (A) or subglottic hemangioma (C) often present with more severe or progressive symptoms.
Foreign body aspiration (D) presents acutely. TE fistula (E) usually causes feeding difficulties from birth.
NEW QUESTION # 70
A 40-year-old woman presents to the Emergency Department with confusion and fever (38.5°C). She has a history of hypothyroidism managed with levothyroxine. Key findings include:
Blood pressure
114/78 mm Hg
Heart rate
85/min
Temperature
38.5°C
Hemoglobin
90 g/L123-157 g/L
Platelet count
25 × 10#/L130-400 × 10#/L
Peripheral blood film
Schistocytes present
Creatinine
200 #mol/L50-90 #mol/L
- A. Thrombotic thrombocytopenic purpura
- B. Human immunodeficiency virus
- C. Cirrhosis
- D. Idiopathic thrombocytopenic purpura
- E. Acute myelogenous leukemia
Answer: A
Explanation:
This patient presents with fever, confusion, anemia with schistocytes, thrombocytopenia, and renal impairment - fulfilling the classic pentad of thrombotic thrombocytopenic purpura (TTP). TTP is a hematologic emergency requiring plasma exchange.
Toronto Notes 2023 - Hematology, "Microangiopathic Hemolytic Anemia" Section:
"TTP is a medical emergency. Features include MAHA, thrombocytopenia, renal failure, neurologic symptoms, and fever. Schistocytes on blood film are diagnostic." MCCQE1 Objectives (Internal Medicine > 76-7: Hematologic Disorders):
"Candidates must urgently recognize TTP and initiate emergent plasma exchange therapy." AML (B) does not present with schistocytes. HIV (C) can cause thrombocytopenia but not MAHA. ITP (D) causes isolated thrombocytopenia without anemia or schistocytes.
NEW QUESTION # 71
An investigator interested in the etiology of neonatal jaundice conducted a study where he selected 150 children diagnosed with this condition and 150 children born in the same time period and in the same hospital who did not have a diagnosis of neonatal jaundice. He then reviewed the delivery records of their mothers to determine various prenatal and perinatal exposures. This is an example of which one of the following?
- A. Clinical trial
- B. Ecological study
- C. Cross-sectional study
- D. Case-control study
- E. Cohort study
Answer: D
Explanation:
In a case-control study, participants are selected based on outcome (e.g., presence or absence of neonatal jaundice), and then past exposures are evaluated. This is consistent with the described methodology.
Toronto Notes 2023 - Epidemiology, "Study Designs":
"Case-control studies start with the outcome and look backward to assess exposures. They are efficient for studying rare conditions or those with long latency." MCCQE1 Objectives (Population Health > 65-2: Epidemiology and Study Design):
"Candidates must distinguish between common study designs and recognize the correct classification based on study structure." Cross-sectional studies (A) assess exposure and outcome at the same time. Cohort studies (C) begin with exposure and follow forward. Clinical trials (D) are interventional. Ecological studies (E) analyze population- level data.
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NEW QUESTION # 72
A 39-year-old woman comes to the office for a periodic health examination. She reports that her father had a recent diagnosis of breast cancer (at age 62 years) and that a paternal aunt had ovarian cancer in her early 40s.
The results of mammography are normal. Which one of the following is the most appropriate recommendation for this patient?
- A. Annual mammography starting at age 50 years.
- B. Genetic screening.
- C. Bilateral mastectomy.
- D. Random fine-needle sampling of the breasts.
- E. Prophylactic tamoxifen therapy.
Answer: B
Explanation:
This patient has a family history of both male breast cancer (father) and early-onset ovarian cancer (aunt), which are red flags for BRCA1/2 mutations. Genetic counseling and BRCA testing are the appropriate next steps to stratify cancer risk and guide screening and prevention.
Toronto Notes 2023 - Oncology, "Breast Cancer Risk" Section:
"BRCA testing is recommended for individuals with a strong family history of breast or ovarian cancer, particularly if involving male relatives or early-onset cases." MCCQE1 Objectives (Population Health > 97-5: Screening and Prevention):
"Candidates must identify high-risk individuals who require genetic counseling and screening beyond population guidelines." Tamoxifen (A) and prophylactic mastectomy (E) are only considered after confirming mutation status. Annual screening starting at 50 (D) is for average-risk women. Fine-needle sampling (C) is not a screening tool.
NEW QUESTION # 73
A 36-year-old woman presents to the office with a 2-month history of multiple asymptomatic bumps on her vulva. She is not currently sexually active but has had 2 male sexual partners in the past, with the most recent relationship ending 1 year ago. On examination, she appears to have genital warts. She has not received the human papillomavirus (HPV) vaccine and is not interested in any treatment that is not absolutely necessary.
Which of the following is the best next step?
- A. Cryotherapy.
- B. Contact tracing.
- C. Papanicolaou test.
- D. HPV vaccine.
- E. Excisional biopsy.
Answer: D
Explanation:
The patient has clinical evidence of genital warts (condyloma acuminata), which are caused by low-risk HPV types. Even though she is not currently sexually active and has visible warts, HPV vaccination is still beneficial for protection against other oncogenic strains (especially types 16 and 18). Vaccination is safe and recommended up to age 45.
Toronto Notes 2023 - Gynecology, "STIs and HPV":
"Vaccination is recommended up to age 45, regardless of prior exposure or visible warts. It may prevent reinfection with or acquisition of high-risk HPV strains." MCCQE1 Objectives (Gynecology > 83-3: STIs and HPV):
"Candidates must counsel patients appropriately on prevention, including the role of HPV vaccination, even after exposure or infection." Pap testing (B) is routine screening, not management of visible warts. Cryotherapy (D) is optional if the patient desires removal, but she declined treatment. Biopsy (A) is reserved for atypical lesions. Contact tracing (E) is not typically required for HPV warts.
NEW QUESTION # 74
A 42-year-old man presents to your office with acute left knee pain and difficulty walking. He denies any trauma. He reports 2 painful episodes involving his right great toe in the last year. He smokes half a pack of cigarettes a day and drinks at least 3 beers daily. He has a temperature of 38.2°C and has a red, swollen and warm left knee. Which one of the following is the best next step?
- A. Start acetaminophen.
- B. Order blood cultures.
- C. Order radiography of the knee.
- D. Aspirate the knee joint.
- E. Start indomethacin.
Answer: D
Explanation:
The patient presents with an acutely inflamed joint and fever, raising concern for septic arthritis. A history of gout does not exclude infection. The first and most urgent step in any monoarthritis with systemic signs (fever) is joint aspiration to assess for crystals, white cells, and organisms.
Toronto Notes 2023 - Rheumatology, "Monoarthritis":
"Always rule out septic arthritis in a hot, swollen joint, especially when fever is present. Joint aspiration is essential to differentiate infection from crystal arthropathy." MCCQE1 Objectives (Medicine > Rheumatology > 49-1):
"Candidates must identify red flags for septic arthritis and understand that arthrocentesis is the first step in diagnosis and management." Initiating NSAIDs or acetaminophen without diagnosis (C, D) can delay appropriate care. Radiographs (B) do not help differentiate gout from infection acutely. Blood cultures (E) may help, but aspiration is more diagnostic.
NEW QUESTION # 75
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