MCCQE Part 1 MCCQE Release Date

Comprehensive and Detailed Explanation:

This patient has hypercalcemia with suppressed PTH, ruling out primary hyperparathyroidism. The differential includes malignancy-associated hypercalcemia, vitamin D intoxication, and medications. Given the low PTH and normal vitamin D level, malignancy (e.g., multiple myeloma) is a leading concern. Serum protein electrophoresis and urine for Bence-Jones proteins (light chains) are appropriate next steps.

Toronto Notes 2023 – Endocrinology, “Hypercalcemia”:

“PTH-independent hypercalcemia should prompt investigation for malignancy. Multiple myeloma is a common cause in older adults—order SPEP and UPEP.”

MCCQE1 Objectives (Endocrinology > 37-1: Calcium Disorders):

“Candidates must investigate non-PTH mediated hypercalcemia, including consideration of multiple myeloma.”

A (urine calcium) helps in familial hypocalciuric hypercalcemia, but this is unlikely given low PTH. B (calcitriol) would worsen hypercalcemia. C is inappropriate because PTH is suppressed. D (changing HCTZ) may help, but malignancy must be ruled out first.

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This infant was born late preterm (36 weeks) with asymmetric intrauterine growth restriction (IUGR) and remains at the 3rd percentile. Although he is breastfeeding well, infants with IUGR and late prematurity often require enhanced caloric intake to support catch-up growth. MCCQE objectives emphasize optimizing postnatal nutrition in growth-restricted infants to promote appropriate weight gain while monitoring growth velocity.

Caloric fortification of expressed breast milk (or use of higher-calorie formula if needed) increases energy density without increasing feeding volume, supporting growth in infants who are small for gestational age. Simply continuing standard feeds may not provide sufficient calories for catch-up growth.

High-dose vitamin D is not indicated; routine supplementation (400 IU daily) is appropriate for breastfed infants. Early introduction of solids is not recommended before about 6 months of age. Switching to hydrolyzed formula is unnecessary without evidence of milk protein allergy.

Therefore, caloric-fortified feeding is the most appropriate next step to promote optimal growth in this infant.

Comprehensive and Detailed Explanation:

Opioid-induced constipation is best managed with stimulant laxatives like senna or bisacodyl. Stool softeners such as docusate are insufficient as monotherapy. Senna stimulates peristalsis, making it more effective.

Toronto Notes 2023 – Palliative Care:

“Opioid-induced constipation requires stimulant laxatives such as senna. Stool softeners alone are not adequate.”

MCCQE1 Objectives (Palliative Care > 92-1: Symptom Management):

“Candidates must treat opioid-related side effects appropriately, including use of stimulant laxatives for constipation.”

Bulk agents (C) can worsen symptoms. Reducing morphine (D) may compromise pain control. Activity (E) helps but is insufficient as first-line management.

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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.

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