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An 88-year-old married man is admitted following a cardiac arrest at home. He was not expected to recover, and after 2 weeks, he remains in a coma. His wife states, "I cannot let him go. That would be murder." As the attending physician looking after her husband, which one of the following is the best next course of action?
A. Remove him from life support as this would not be murder
B. Seek advice from the provincial or territorial public guardian
C. Encourage her to imagine what her husband would have wanted
D. Emphasize that the duration of his stay in the Intensive Care Unit will be limited
E. Say nothing further and wait until she comes around to accepting his state
Answer: C
Explanation:
In discussions about end-of-life care, it is critical to shift the focus from the substitute decision-maker's own feelings to what the patient would have wanted. This approach promotes ethically sound and patient-centered decisions. It is respectful, supportive, and maintains trust.
Toronto Notes 2023 - ELOM, "Advance Care Planning and End-of-Life Decisions":
"When a patient cannot express wishes, decisions must be based on known prior wishes or substituted judgment-what the patient would have wanted." MCCQE1 Objectives (ELOM > 90-2: Capacity, Consent, and End-of-Life Care):
"Candidates must guide surrogate decision-makers toward reflecting on the patient's values and previously expressed wishes." Options A and B are inappropriate-waiting without engagement or unilateral withdrawal is unethical. C does not address the wife's emotional or ethical concerns. E is premature unless the wife is clearly unable or unfit to act as decision-maker.
NEW QUESTION # 175
You are covering for your colleague who is on vacation this week. You receive the results from an ultrasonography that had been ordered for a 32-year-old woman, gravida 2, para 1, aborta 0. The ultrasonography-estimated fetal weight is below the fifth percentile for 30 weeks' gestation; gestational age was confirmed by an earlier ultrasonogram. The amniotic fluid volume is within normal range. Her first child's birth weight was 2800 g at full term. Which one of the following is the best next step?
A. Schedule an urgent uterine artery Doppler ultrasonography
B. Discuss the benefits of acetylsalicylic acid
C. Ask the patient to present to the obstetrics ward for further fetal assessment
D. Plan a follow-up appointment as soon as your colleague is back from vacation
E. Reassure the patient that the fetus is probably at the lower range of normal weight
Answer: C
Explanation:
Comprehensive and Detailed Explanation:
An estimated fetal weight below the 5th percentile at 30 weeks is concerning for intrauterine growth restriction (IUGR). This warrants prompt evaluation of fetal well-being via biophysical profile and Doppler assessment. The patient should be referred for further fetal assessment immediately to rule out placental insufficiency or other complications.
Toronto Notes 2023 - Obstetrics, "Fetal Growth Restriction":
"EFW < 10th percentile, especially < 5th, warrants further evaluation including Doppler studies and biophysical profile. Immediate assessment is warranted to determine fetal well-being." MCCQE1 Objectives (Obstetrics > 80-4: Antepartum Surveillance):
"Candidates must initiate urgent assessment in cases of abnormal fetal growth to reduce perinatal morbidity." Delaying care (B) is inappropriate. Reassurance (A) is unsafe. ASA (D) is preventative, not corrective.
Doppler (E) is important but should be coordinated through obstetrical triage.
NEW QUESTION # 176
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. Excisional biopsy.
B. Papanicolaou test.
C. Contact tracing.
D. HPV vaccine.
E. Cryotherapy.
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 # 177
A 19-year-old woman presents to the office. She is a new mother. She shares that she does not intend to vaccinate her son. Which one of the following is the best next step?
A. Contact child protection services.
B. Tell the patient you cannot follow her in your practice but will refer her to a colleague.
C. Provide education on the risks and benefits of vaccination.
D. Ask to speak with the patient's parents.
E. Explore with the patient her rationale for not vaccinating her child.
Answer: E
Explanation:
When encountering vaccine hesitancy, the first and most effective step is to open a non-judgmental conversation and explore the patient's reasons. This helps build trust and tailor subsequent education and counseling.
Toronto Notes 2023 - Public Health and Preventive Medicine, Immunization:
"Addressing vaccine hesitancy requires understanding parental concerns. Begin with open-ended questions to identify underlying beliefs and information gaps." MCCQE1 Objectives - Preventive Medicine > Immunization:
"Candidates must demonstrate effective communication with vaccine-hesitant parents, beginning with eliciting their rationale before providing evidence-based recommendations." Jumping to education (B) or punitive measures (C, D) may close communication. The patient is an adult; speaking with her parents (E) violates her autonomy.
NEW QUESTION # 178
Following a potluck supper organized by the residency director of your training program, many of your fellow residents and other guests fall ill with gastroenteritis. Which one of the following is the best way to identify the source of this food-borne outbreak?
A. Culture the stool of guests
B. Calculate food-specific attack rates
C. Perform a cohort study
D. Perform a hazard analysis of critical control points
E. Culture leftover food samples
Answer: B
Explanation:
Calculating food-specific attack rates (i.e., number of people who became ill after eating aparticular food divided by the total number who ate that food) is the most effective method to identify the probable source of infection in a known cohort outbreak.
Toronto Notes 2023 - Public Health, Outbreak Investigations:
"Foodborne outbreaks are best analyzed using food-specific attack rates to determine associations between individual foods and illness." MCCQE1 Objectives - Preventive Medicine > Epidemiologic Principles:
"Candidates must use epidemiologic tools, such as attack rates, to identify probable sources during outbreak investigations." Cohort study (C) is also acceptable but more time-intensive. Stool and food cultures (B, D) confirm the pathogen but not the source. HACCP (E) is a preventive method, not a tool for outbreak investigation.
NEW QUESTION # 179
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