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You are called to attend an 18-year-old woman, gravida 2, para 1, aborta 0, who is in precipitous labour. She did not realize she was pregnant and has not had any prenatal care. After the delivery, you examine the newborn boy; he is vigorous, and it appears that he was born at full term. Physical examination findings of the newborn are normal. Review of the prenatal record from the mother's last pregnancy shows the following:
* HIV: Negative
* Hepatitis B surface antibody: Positive
* Hepatitis C: Negative
* Syphilis serology: Negative
The mother's previous child was placed in foster care. The mother is withdrawn and uncommunicative after delivery. Which one of the following is the best next step?
A. Recommend immediate skin-to-skin care
B. Initiate feeding with donor breast milk
C. Collect urine from the newborn for a drug screen
D. Administer hepatitis B vaccine to the newborn
Answer: C
Explanation:
Given the lack of prenatal care, the mother's withdrawal, and prior involvement of child protection services, a newborn drug screen is warranted to assess for possible in utero exposure. This is part of the safety assessment.
Toronto Notes 2023 - Pediatrics, Newborn Assessment:
"Infants born to mothers with no prenatal care or prior social concerns should undergo a full newborn screening, including toxicology if indicated." MCCQE1 Objectives - Pediatrics > Newborn Care and Social Issues:
"Candidates must identify social risk factors and initiate appropriate newborn evaluations, including toxicology screens when substance use is suspected." The mother was previously immune to hepatitis B, so (A) is not immediately required. Skin-to-skin care (D) is beneficial but secondary to screening in this context. Donor milk (B) is not indicated unless breastfeeding is contraindicated.
NEW QUESTION # 110
In a research study, it is found that people who smoke tobacco cigarettes drink more coffee and have higher rates of lung cancer than people who do not smoke. However, the consumption of coffee alone is not associated with lung cancer. Which one of the following best describes the contribution of drinking coffee in the study?
A. Risk factor
B. Confounder
C. Predictor
D. Selection bias
Answer: B
Explanation:
A confounder is a variable associated with both the exposure and the outcome but not in the causal pathway.
In this study, coffee drinking is associated with smoking (the actual risk factor for lung cancer), but not independently associated with lung cancer.
Toronto Notes 2023 - Epidemiology Chapter:
"A confounder is a third variable that distorts the observed association between an exposure and an outcome.
It must be associated with both the exposure and the outcome, but not a result of the exposure." MCCQE1 Objectives (Population Health > 97-3: Study Design and Bias):
"Recognize and control for confounding in the interpretation of observational study data." Coffee is not a risk factor (B) since it's not independently associated with lung cancer, and it's not selection bias (C), which involves how participants are enrolled in a study.
NEW QUESTION # 111
A 22-year-old woman, gravida 1, para 0, aborta 0, comes to the office at 10 weeks' gestation for her first prenatal visit. When you ask how she is doing, she becomes tearful and says she has had severe nausea and vomiting. She is not taking her prenatal vitamins regularly and feels very guilty about it. She is worried that she is harming the fetus. Which one of the following is the most appropriate management of this patient's case?
A. Suggest that she take cannabinoids 30 minutes before taking her prenatal vitamins
B. Refer her for counselling to manage her feelings of guilt
C. Advise her to replace her vitamin with folic acid only until her nausea improves
D. Prescribe ginger tablets to be taken 4 times daily
E. Tell her she should continue to take her prenatal vitamins daily regardless of nausea
Answer: D
Explanation:
Comprehensive and Detailed Explanation:
Ginger is a first-line, evidence-based non-pharmacologic treatment for nausea and vomiting in pregnancy. It's well tolerated and effective. Addressing nausea will help her resume vitamin use and reduce distress.
Toronto Notes 2023 - Obstetrics, "Nausea and Vomiting in Pregnancy":
"Ginger 250 mg four times daily is safe and effective for mild to moderate nausea." MCCQE1 Objectives (Obstetrics > 80-1: Early Pregnancy Management):
"Candidates must treat nausea and vomiting in pregnancy using safe and effective options." Folic acid alone (A) is less effective than a full prenatal vitamin. B may help, but nausea should be addressed first. C lacks empathy for her symptoms. D (cannabinoids) is not recommended in pregnancy.
NEW QUESTION # 112
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?
A. Discuss this further with him.
B. Communicate your concerns to the motor vehicle licensing authority.
C. Physically take away his license.
D. Consult a neurologist to assess whether the patient is fit to drive.
E. Refuse to treat him further unless he stops driving.
Answer: B
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 # 113
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. Bilateral mastectomy.
C. Random fine-needle sampling of the breasts.
D. Genetic screening.
E. Prophylactic tamoxifen therapy.
Answer: D
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 # 114
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