Question: 1

A 44-year-old woman requests screening for lung cancer. She has a 30 pack-year
smoking history. Which one of the following is the most accurate statement?

A. High-dose computed tomography (CT) is more effective in screening for

lung cancer than low-dose CT.T
B. Chest radiography is as effective as CT.
C. Screening should have been started at age 40 years.
D. Smoking cessation would be more beneficial than screening.
E. If she has less than a 40 pack-year smoking history, screening would be
ineffective.
Question: 2
A 23-year-old woman has made frequent visits to the office over the past 12
months regarding her acne. She has tried topical treatments, oral antibiotics, and
isotretinoin, and she is dissatisfied with the results. On examination, her skin
appears to be fairly clear, with only a few papules on her forehead. She spends
most of her day worrying about her skin and feels disfigured. She no longer
attends university or goes out with her friends because she is self-conscious about
her appearance. Which one of the following is the most likely diagnosis?

A. Delusional disorder, somatic type.

B. Generalized anxiety disorder.
C. Social anxiety disorder (social phobia).
D. Body dysmorphic disorder.
E. Illness anxiety disorder.
Question 3
A 74-year-old woman comes to the clinic for the first time to renew her
prescription for lorazepam, which she has been taking nightly for the past 30
years. She requests an increased dose because she feels that her sleep is
worsening. Which one of the following is the best next step?

A. Decline to increase the lorazepam dose.

B. Initiate a cross-taper to clonazepam instead.
C. Discontinue lorazepam and prescribe trazodone.
D. Prescribe a short course of additional lorazepam.
E. Advise the patient to discontinue lorazepam immediately.
Question: 4
A 45-year-old woman undergoes abdominal hysterectomy for symptomatic
uterine leiomyomas. On postoperative day 2, she is nauseated and vomits
repeatedly. Physical examination reveals a tympanic and distended abdomen.
There is slight diffuse tenderness. Urine output is 300 mL over the previous 24
hours. Plain abdominal radiographs show free air in the abdomen and multiple
distended small-bowel loops. In addition to fluid replacement, which one of the
following is the most appropriate management?

A. Intravenous antiemetic medication.

B. Nasogastric tube drainage.
C. Intravenous diuretic.
D. Intravenous albumin.
E. Immediate surgical exploration.
Question: 5
A wound infection is diagnosed in a hospital inpatient 4 days after her surgical
procedure. Her family members are distressed and threaten to complain to the
hospital's chief executive officer. Which one of the following is the most
appropriate course of action?

A. Conduct a full investigation, then meet with the family.

B. Reassure the family that the patient will make a full recovery.
C. Take no action other than referring the issue to the chief of staff.
D. Advise the patient that her care will be transferred to another surgeon.
E. Express regret that the incident occurred and explain that it was likely due
to an inherent risk of the surgical procedure.
Question: 6
A 16-year-old boy with muscular dystrophy comes to the office for his semiannual
visit. He uses a wheelchair and attends a public school. He is thinking of trying
cannabis but has some concerns about the effect it might have on his body. He
also has questions about contraception and the prevention of sexually
transmitted infections. Which one of the following is the best next step?

A. Inform the parents about their son's interest in trying cannabis and
becoming sexually active.
B. Tell the patient that he is too weak to be sexually active.
C. Inform the patient that you will answer his questions when his parents are
present.
D. Tell the patient that you will no longer be his physician if he engages in
these behaviours.
E. Provide information on cannabis use and sexual health.
Question: 7
A 12-year-old boy presents with a 2-month history of back and heel pain. He was
previously healthy. On examination, the child looks well and has vital signs within
normal range. He has mild limitation in the range of motion in his lumbar spine.
Which one of the following is the most likely diagnosis?

A. Juvenile idiopathic arthritis.

B. Scheuermann disease.
C. Osteoarthritis.
D. Juvenile ankylosing spondylitis
E. Growing pains.
Question: 8
A 38-year-old woman, gravida 1, para 1, aborta 0, comes to the office for
preconception counselling. She has hypertension, a hemoglobin A1c level of
11.2% (4.0–6.0), and a BMI of 46.5. She smokes 1 pack of tobacco cigarettes daily.
One year ago, she delivered a newborn weighing 4.65 kg, who has a cardiac
defect. Which one of the following recommendations will most likely reduce the
patient's risk for giving birth to another child with a birth defect?

A. Lose weight.
B. Ensure tight glycemic control.
C. Stop smoking.
D. Stabilize blood pressure.
E. Take a vitamin D supplement.
Question: 9
A 74-year-old woman has a long history of lower abdominal discomfort and
intermittent diarrhea. Her weight is stable, but she appears lethargic and unwell.
The results of a recent colonoscopy were normal. Which one of the following is
most helpful in supporting the diagnosis?

A. Malodorous stools.
B. Gastroesophageal reflux.
C. Recurrent vomiting.
D. Micronutrient deficiencies.
E. Fetor hepaticus.
Question: 10
A 22-month-old boy is brought in because of a nontender, hard mass in the left
upper abdominal quadrant. He is otherwise healthy. Urinalysis results show a
blood level of 4+. Which one of the following is the most likely cause of this
presentation?

A. Multi cystic kidney disease.

B. Hepatoblastoma.
C. Non-Hodgkin lymphoma.
D. Neuroblastoma.
E. Nephroblastoma.
Question: 11
A 3-month-old girl is found dead in her crib by her parents. She was born at term
and was growing well. She did not have any fever or signs of acute illness. Her
physical examination findings at the 2-month well-child visit were normal. Which
one of the following is associated with the most likely diagnosis?

A. The infant was put to sleep on her back.

B. The mother smoked during the pregnancy.
C. The infant was given a pacifier at bedtime.
D. The infant was breastfed until age 2 months.
E. The mother has a history of asthma.
Question: 12
You are a family physician, and you are seeing a 21-year-old primigravid woman
who is 8 weeks' pregnant. You learn that she has never received any vaccinations
because her parents had objections. She asks which vaccinations she should
receive during the pregnancy. Which one of the following is the most appropriate
advice?

A. No vaccinations should be given during pregnancy

B. Thimerosal-containing vaccines are contraindicated.
C. Nasal spray influenza vaccine is the most effective and most recommended
in pregnancy.
D. Tetanus, diphtheria, and acellular pertussis vaccine is safe and
recommended during pregnancy.
E. Immunizing with measles, mumps, and rubella vaccine is a priority to
protect against congenital rubella.
Question: 13
A 45-year-old man presents with a 2-month history of anxiety and trouble
sleeping, which he has been experiencing since he started a new job. Because the
increased occupational demands were too much for him, he started smoking 1
joint of recreational cannabis daily. When he left work 3 weeks ago to go on
short-term disability leave, his anxiety and trouble sleeping resolved completely,
and he stopped smoking cannabis. He becomes anxious when he thinks about
returning to work. He had no similar symptoms in his previous jobs. Which one of
the following is the most appropriate next step?

A. Refer to an addiction program.

B. Extend the duration of his disability leave.
C. Prescribe zopiclone.
D. Recommend counselling and a gradual return to work.
E. Prescribe a selective serotonin reuptake inhibitor.
Question: 14
A 20-year-old woman, gravida 1, para 0, aborta 0, is at 33 weeks' gestation with
twins. Her blood pressure is 120/88 mm Hg. She has gained 14 kg and has mild
ankle edema. The ultrasonography report is as follows:

Monochorionic diamnionic twin pregnancy

Twin A Twin B
Presentation: cephalic Presentation: cephalic
Amniotic fluid: normal Amniotic fluid: normal
Fetal anatomic survey: normal Fetal anatomic survey: normal
Estimated gestational age: Estimated gestational age:
32 weeks, 5 days 30 weeks, 0 days
Umbilical artery end-diastolic flow: Umbilical artery end-diastolic flow:
normal normal

Which one of the following is the most likely explanation for these findings?

A. Selective intrauterine growth restriction in twin B.

B. Twin–twin transfusion syndrome.
C. Intrauterine infection.
D. Twin anemia-polycythemia sequence.
E. Preeclampsia.
Question: 15
A 70-year-old man presents with a 2-month history of slowly progressive, painless
edema of his entire left leg. He is active and otherwise asymptomatic. The
physical examination findings reveal no abdominal abnormalities; a small, hard
prostate gland; diminished, but symmetric, arterial pulses in the legs; no calf
tenderness; and no evidence of adenopathy. Which one of the following imaging
tests is indicated?

A. Computed tomography of the pelvis.

B. Magnetic resonance imaging of the pelvis.
C. Lymphangiography of the left leg.
D. Computed tomography venography of the left leg.
E. Transrectal ultrasonography of the prostate.
Question: 16
The parents of a 4-year-old boy are concerned because their child is extremely
active, has trouble focusing on tasks, and is constantly in motion. His preschool
teachers report having difficulty with his disruptive behaviour. Which one of the
following is the best next step?

A. Prescribe methylphenidate.
B. Order screening electrocardiography.
C. Recommend an age-appropriate structured routine.
D. Recommend a sugar-free diet.
E. Advise the parents not to discipline their child for impulsive behaviour.
Question: 17
A 65-year-old man has persistently elevated blood pressure despite taking the
maximum doses of metoprolol, hydrochlorothiazide, amlodipine, and ramipril. His
pharmacy provides blister packs and states that he is adherent with the
medications. Polysomnography is ordered. Which one of the following best
explains this patient's presentation?

A. Periodic limb movement disorder.

B. Central sleep apnea secondary to β-blocker.
C. Nocturnal hypotension.
D. Obstructive sleep apnea–hypopnea syndrome.
E. Frequent nocturnal urination secondary to diuretic.
Question: 18
A 45-year-old man presents with a 3-day history of vomiting and diarrhea. You
have treated 2 other members of his family for similar illnesses over the past
month. Stool samples for both of them were positive for drug-resistant
Escherichia coli. The patient lives on a farm that has pigs and dairy cattle. Which
one of the following is the best course of action?

A. Advise the family to test their well for contamination.

B. Ask which family members have contact with the animals.
C. Review the family's consumption of ground beef.
D. Treat all family members with prophylactic antibiotics.
E. Ask the family when they last had their septic tank inspected.
Question: 19
A 9-month-old infant is brought to the office for a respiratory illness. You perform
a thorough assessment and determine that the symptoms are consistent with a
mild viral illness. The parent is very concerned about the possibility of pneumonia
and requests a prescription for antibiotics. Which one of the following is the most
appropriate next step?

A. Prescribe antibiotics to start in 2 days if there is no improvement.

B. Prescribe antibiotics to start immediately.
C. Order chest radiography.
D. Provide symptomatic therapy and watch for signs of deterioration.
E. Order a nasopharyngeal aspirate specimen to be tested for respiratory
viruses.
Question: 20
A 69-year-old man presents with a 2-week history of frequent episodes of
transient visual loss. On history, the patient describes fading vision, like a curtain
descending, in the right eye only. It subsides on its own. His medical history
includes type 2 diabetes and hypertension. Which one of the following must be
included in the immediate management plan?

A. Urgent referral to an ophthalmologist.

B. Initiation of acetylsalicylic acid.
C. Urgent referral to a vascular surgeon.
D. Administration of steroid drops to the right eye.
E. Initiation of oral prednisone.
Question: 21
A 55-year-old man is undergoing elective rotator cuff repair. He has type 2
diabetes. Which one of the following measures is best for lowering the risk for
surgical site infection?

A. Perioperative glycemic control.

B. Nasal swab for methicillin-resistant Staphylococcus aureus.
C. 24-hour postoperative antibiotic coverage.
D. Daily postoperative dressing changes for 1 week.
E. Maintenance of a lower body temperature during the operation.
Question: 22
A 26-year-old woman, gravida 2, para 1, aborta 0, is admitted to hospital with
vaginal bleeding and abdominal pain following an 8-week period of amenorrhea.
Her physical examination findings are normal except for mild lower abdominal
tenderness. Pelvic examination reveals a soft, nontender, closed cervix with a
bulky anteverted uterus. There is some tenderness in her left adnexa. Her
hemoglobin level is 130 g/L (123–157), and her pregnancy test result is positive.
Which one of the following is the most appropriate diagnostic investigation?

A. Coagulation profile.
B. Blood type and antibody screen.
C. Pelvic ultrasonography.
D. Serial serum β-human chorionic gonadotropin testing.
E. Endometrial biopsy.
Question: 23
An 82-year-old man presents because he has persistent concerns that he is
infested with insects and feels them crawling on his skin. He has had his house
fumigated and has tried topical treatments such as permethrin without
improvement. On examination, his skin is unremarkable. He often brings in jars
containing what he believes to be dead insects, but the jars contain only debris.
His appetite and sleep are unchanged, and he still enjoys playing bridge regularly.
Which one of the following is the most likely diagnosis?

A. Body dysmorphic disorder.

B. Delusional disorder, somatic type.
C. Schizophrenia.
D. Illness anxiety disorder.
E. Lewy body dementia.
Question: 24
An 18-year-old man fell through a window. He is bleeding profusely from a 6-cm
wound on his left calf. Which one of the following is the most appropriate
immediate management of the wound?

A. Apply a tourniquet to the wound.

B. Place direct pressure on the wound.
C. Pack the wound with gauze.
D. Apply direct pressure on the femoral artery.
E. Irrigate and debride devitalized tissue and administer tetanus prophylaxis.
Question: 25
A 16-year-old girl comes to the clinic because she has missed her menstrual
period for the last 3 months. Her menstrual cycle used to be regular. She is not
using any contraception and denies being sexually active. She trains for 4 hours
daily as a competitive figure skater and feels healthy. She eats a balanced diet and
denies purging. Her BMI is 17, and her pregnancy test result is negative. Which
one of the following is the most likely diagnosis?

A. Anorexia nervosa.
B. Exercise-induced amenorrhea.
C. Avoidant or restrictive food intake disorder.
D. Bulimia nervosa.
E. Malabsorption syndrome.
Question: 26
An 18-month-old girl was brought to the Emergency Department 2 days ago
because she had nasal congestion and fever. A urinary tract infection was
diagnosed based on a urinalysis that had a positive result only for leukocyte
esterase. She was discharged with a prescription for oral antibiotics. The bag
urine culture grew 50,000 colony-forming units/mL of Escherichia coli. The patient
is brought to the office for a follow-up visit. She looks well. Her physical
examination findings are normal. Which one of the following principles best
supports discontinuing the medication?

A. Generalizability.
B. Negative predictive value.
C. Reliability.
D. Sensitivity.
E. Validity.
Question: 27
In an 8-year-old child with homozygous familial hypercholesterolemia, which one
of the following physical signs is most likely to be found?

A. Obesity.
B. Acanthosis nigricans.
C. Liver enlargement.
D. Hypertension.
E. Xanthelasma.
Question: 28
A 70-year-old neurosurgeon continues to perform surgical procedures. Some of
his colleagues are concerned that he has lost his clinical skills. You share this
concern. Which one of the following is the most appropriate next step?

A. Convene a meeting with the neurosurgeon and several colleagues to

discuss possible solutions.
B. Lodge a complaint with the medical regulatory authority.
C. Ensure that his colleagues refer complex cases to other neurosurgeons.
D. Meet with the neurosurgeon and suggest that he agree to an audit of his
practice.
E. Contact the medical chief of staff to suggest that the neurosurgeon's
privileges be suspended
Question: 29
A 25-year-old man involved in a high-speed motor vehicle collision is intubated at
the scene. He is brought to the Emergency Department with an oxygen saturation
of 78% on fraction of inspired oxygen 0.50 and a systolic blood pressure of 80 mm
Hg. He is receiving an infusion of 1 L of normal saline. He has a near-amputation
of his left leg. Which one of the following is the best next step?

A. Insert a central venous catheter.

B. Place a tourniquet.
C. Transfuse 1 unit of packed red blood cells
D. Reassess the airway and listen to breath sounds.
E. Order chest radiography.
Question: 30
You are the medical advisor to the municipal council, and you are asked for your
opinion as to where a new outdoor recreation area should be located. The new
facilities will allow for skating and sliding in the winter and field activities in the
summer. Which one of the following locations is likely to provide the greatest
health benefit?

A. On a city-owned property in an area with where the population has low

socioeconomic status.
B. In front of the municipal hall, where the recreation area will be highly
visible.
C. Beside the municipal pool, where recreational activities can be well
supervised.
D. On a community college property, where the recreation area can be floodlit
at night.
E. Close to a health centre, which could handle injuries if necessary.
Question: 31
A 36-year-old man presents with a 3-month history of fatigue. He is unable to fall
asleep before 2 a.m. and wakes up at 6 a.m. to go to work. He has been having
difficulty concentrating because of the fatigue, but his mood and appetite are
unchanged. He does not consume alcohol and drinks 3 to 4 cups of coffee daily.
Which one of the following is the most appropriate next step?
A. Prescribe zopiclone for 1 month.
B. Refer for a sleep study.
C. Recommend that he exercise in the evening.
D. Recommend that he decrease his screen time in the late afternoon.
E. Recommend that he decrease his caffeine intake.
Question: 32
A 75-year-old man has a hemoglobin level of 110 g/L (130–170) with a mean
corpuscular volume of 70 fL (80–100). Platelet and white blood cell counts are
within normal range. Five years ago, his hemoglobin level was 142 g/L. Physical
examination findings are unremarkable. Which one of the following is the most
appropriate next step?

A. Digital rectal examination.

B. Fecal immunochemical test or fecal occult blood test.
C. Hemoglobin electrophoresis.
D. Colonoscopy.
E. Blood smear.
Question: 33
A 5-year-old boy is brought to the Emergency Department after an episode of
bilateral tonic-clonic movements associated with a loss of consciousness. On
examination, he is still drowsy and is not moving his left arm and leg. These
symptoms resolve over the next few minutes. He is afebrile. Which one of the
following is the most likely diagnosis?

A. Left intracranial space-occupying lesion.

B. Cerebrovascular accident.
C. Right-sided cerebellar astrocytoma.
D. Bleeding berry aneurysm.
E. Todd paralysis following a seizure.
Question: 34
A 25-year-old woman presents with severe lower abdominal pain that started
suddenly 1 hour ago. She is sexually active, and she reports irregular menstrual
cycles. On examination, she has rebound tenderness and right-sided adnexal and
cervical motion tenderness. Which one of the following is the most likely
diagnosis?

A. Diverticulitis.
B. Endometriosis.
C. Ruptured ovarian cyst.
D. Ectopic pregnancy.
E. Pelvic inflammatory disease.
Question: 35
A 67-year-old woman's atrial fibrillation is diagnosed. After careful consideration,
you decide to start treatment with a direct oral anticoagulant. Which one of the
following is a contraindication to this medication?

A. Advanced liver impairment.

B. Advanced renal dysfunction.
C. Untreated thyroid disease.
D. Congestive heart failure.
E. Chronic obstructive pulmonary disease.
Question: 36
A 28-year-old woman, gravida 1, para 0, aborta 0, is at 34 weeks' gestation. She
has a diagnosis of gestational diabetes that is well controlled by diet. She is
otherwise healthy. At which one of the following gestational ages is delivery
recommended?

A. 36 weeks.
B. 37 weeks.
C. 42 weeks.
D. 41 weeks.
E. 39 weeks.
Question: 37
A 60-year-old man who has undergone resection of a stage II adenocarcinoma of
the jejunum presents to the office. The oncologists have told him that there are
no data available supporting adjuvant treatment because the disease is rare. One
of the oncologists wants to enroll the patient in a clinical trial that she is
conducting. Another oncologist recommends observation. The patient seeks your
advice. Which one of the following is the most appropriate next step?

A. Follow up every 6 months to check for a recurrence of the disease.

B. Search the medical literature for other treatment modalities available.
C. Advise the patient to seek another medical expert opinion.
D. Review the patient's options and encourage him to explore further.
E. Advise the patient to seek naturopathic options.
Question: 38
One week after birth, 2 fraternal twin girls are seen for a routine visit. On physical
examination, the first twin has a bloody mucous vaginal discharge, and both girls
have small bilateral breast buds. They were born at 36 weeks' gestation.
Management of the first twin should include which one of the following?

A. Referral to child protection services.

B. Measurement of serum luteinizing hormone and follicle-stimulating
hormone.
C. Reassurance about the findings of the physical examination.
D. Genital examination under anesthesia.
E. Pelvic ultrasonography.
Question: 39
A 4-year-old boy is brought in because of ear pain and a temperature of 38.7°C.
Findings of the physical examination are unremarkable, except for bilateral red
tympanic membranes with a left middle ear effusion. Which one of the following
is the most appropriate treatment?

A. Oral antipyretics.
B. Topical corticosteroids.
C. Oral antibiotics.
D. Topical antibiotics.
E. Oral decongestants.
Question: 40
A 26-year-old primigravid woman attends a regular prenatal appointment at 30
weeks' gestation. She states that for the past 3 weeks, she has noticed an
increasing number of bumps around her vagina. She finds that her underwear
irritates them and occasionally causes them to bleed. On examination, her
perineum appears as in the referenced image. Which one of the following is the
most likely cause of this presentation?

A. Chlamydia trachomatis.
B. Human papillomavirus.
C. Treponema pallidum.
D. Squamous intraepithelial lesions.
E. Herpes simplex virus.

old
Question: 41
An 8-week-old infant is brought to the Emergency Department with nonbilious
projectile vomiting. The infant is otherwise well. Which one of the following is the
best diagnostic test?

A. Abdominal ultrasonography.
B. Upper gastrointestinal contrast study.
C. Colonic contrast enema.
D. Rectal biopsy.
E. Computed tomography of the abdomen and pelvis.
Question: 42
You are the family physician for a 60-year-old man. Six months ago, you
diagnosed his prediabetes. He would prefer to manage his condition through
exercise and diet, but so far, he has failed to adhere to a consistent exercise plan
and has not lost any weight. Which one of the following is the best next step?

A. Have the patient keep a daily diary to document his mood and activities.
B. Review the patient's personal goals and barriers to achieving them.
C. Encourage the patient to attend a fitness centre and offer to refer him to a
dietician.
D. Suggest that the patient join a support group.
E. Emphasize the need to begin medication if the patient cannot achieve his
weight goal.
Question: 43
A 17-year-old girl presents with a 6-month history of amenorrhea. Her β-human
chorionic gonadotropin level is negative for pregnancy. Her medical history is
unremarkable, and findings from her physical examination, including pelvic
examination, are normal. Which one of the following is the most appropriate
investigation?

A. Pelvic ultrasonography.
B. Computed tomography of the head.
C. Serum estradiol level.
D. Serum follicle-stimulating hormone level.
E. Serum progesterone level.
Question: 44
A 23-year-old woman is scheduled to receive test results showing that she is now
positive for HIV. She has controlled schizophrenia. You are not sure whether she
knows that she has been tested for HIV. Although she is mentally competent, she
has often allowed her mother to attend appointments and participate in her care
decisions. Which one of the following is the best approach to sharing this new
information?

A. Call the patient's mother before the appointment to advise her of the
diagnosis.
B. Tell the patient and her mother about the new HIV status at the same time.
C. Tell the patient that her test shows a chronic medical problem for which
she will need medication.
D. Ask the patient whether she wants her mother to be present at the
appointment.
E. Ask the patient to come alone to the scheduled appointment and inform
her of the HIV result then.
Question: 45
You are examining a 6-year-old girl who reports an earache. She is accompanied
by her 26-year-old mother. Her father is in the waiting room. The child refuses to
let you examine her until the mother slaps the child's leg with an open hand. You
diagnose otitis media. The child seems otherwise healthy. Which one of the
following is the best response to the mother striking her child?

A. Inform the child's father of the incident.

B. Report the case to child protection services.
C. Record the incident in the child's medical record.
D. Ask the mother for her views on corporal punishment.
E. Advise the mother of the negative effects of corporal punishment.
Question: 46
During an influenza outbreak in the community, a pregnant woman comes to the
office with her 3-year-old daughter. The mother is concerned because neither she
nor her daughter has ever received an influenza vaccination. Which one of the
following is the best next step?

A. Immunize the daughter with 1 standard dose immediately, but do not

immunize the mother.
B. Immunize the daughter with 2 standard doses 28 days apart, but do not
immunize the mother.
C. Immunize the mother and daughter immediately, and arrange for the
daughter's second standard dose in 28 days.
D. Immunize the daughter with 2 half-doses 28 days apart, and immunize the
mother immediately.
E. Immunize the mother and the daughter with standard doses immediately,
and recommend yearly immunization.
Question: 47
A 21-year-old man is brought to the clinic by his girlfriend. She explains that he
has had a worsening sore throat for 3 days. He has severe pain that is worse when
he talks or swallows. On examination, his temperature is 39°C, his uvula is swollen
and displaced to the right, and his left tonsil is swollen and shifted medially.
Which one of the following is the most appropriate management?

A. Send a swab for culture and treat accordingly.

B. Prescribe a topical anesthetic spray.
C. Prescribe oral penicillin.
D. Prescribe intravenous ciprofloxacin and metronidazole.
E. Refer the patient urgently to a surgeon.
Question: 48
A 25-year-old man presents to the Emergency Department because he has had
chronic pain since a fracture that occurred 6 months ago. His physician prescribed
opioid analgesics at the time of the fracture but has now refused to give the
patient any more. The patient pleads for a prescription, claiming that his pain is
severe. Which one of the following is the best next step?

A. Prescribe opioid medication after documenting that the patient has been
informed of the risks of opioid use.
B. Prescribe opioid medication if the patient agrees to routine follow-up at the
local outpatient clinic.
C. Offer a 1-day supply of opioid medication to give you time to determine
whether the patient is in severe pain.
D. Advise the patient to return to his physician for an alternative treatment
plan.
E. Advise the patient that he appears to be opioid-dependent and needs to
enter a detoxification program.
Question: 49
An 8-year-old boy is brought to the Emergency Department after falling from a
tree. His elbow is extremely tender and swollen and is held in an extended and
valgus position. His hand is pale and pulseless. Radiologic examination reveals a
displaced supracondylar fracture of the humerus. Which one of the following is
the most appropriate next step?

A. Urgent angiography of the limb.

B. Operative fixation of the fracture.
C. Systemic anticoagulation.
D. Traction and splinting of the arm.
E. Warming of the affected hand.
Question: 50
A 30-year-old man presents with a request for a prescription for opioid analgesics.
He has a work-related back injury and was recently tapered off opioids according
to a management plan drawn up by your colleague who is away for 2 weeks. The
patient acutely reinjured his back while out with friends, and a 3-day course of
opioids was prescribed in the Emergency Department; he is now requesting more.
Which one of the following is the best next step?

A. Prescribe a low daily dose of opioids for the next 2 weeks.

B. Start a methadone program for opioid substitution.
C. Prescribe 7 more days of a tapering dose of opioids.
D. Refer to an exercise rehabilitation program.
E. Start a regular regimen of a nonopioid analgesic.
Question: 51
A 21-year-old man who was in a motor vehicle collision is brought to the
Emergency Department. He is alert, his blood pressure is 120/80 mm Hg, and his
heart rate is 75/min. His respiratory rate is within normal range, but he reports
chest pain. The only abnormal findings on chest radiography are nondisplaced
fractures of the right fourth and fifth ribs. He has no other injuries. Which one of
the following is the most appropriate next step?

A. Insertion of right chest tube.

B. Computed tomography of the chest.
C. Application of chest binder for pain control.
D. Administration of analgesic medication.
E. Insertion of large-bore intravenous catheter.
Question: 52
You are seeing a 30-year-old woman and her 2-month-old infant for a well-child
visit. They are new patients. This is the mother's first child, and she is
breastfeeding the infant. She steadfastly refuses any vaccinations for the infant
because her chiropractor has strongly advised against them. Besides explaining
the benefits and risks of immunization, which one of the following is the most
appropriate course of action?

A. Delay further discussion about immunization until the infant is 6 months

old because breast milk will provide adequate interim protection.
B. Notify the local public health authority about the mother's views so that it
can legally require the child to be immunized.
C. Transfer the mother and child to another physician because you cannot act
in the best interests of the child or the public.
D. Require the mother to sign a release that she has been informed about
immunization, refuses it, and accepts full responsibility.
E. Report the chiropractor to the chiropractic regulatory authority because he
is practising outside the scope of regulated chiropractic practice.
Question: 53
A 60-year-old man presents because of abnormal chest radiograph findings, which
show a 2-cm lung nodule. He is asymptomatic. Which one of the following is most
important to elicit on history to establish the most likely diagnosis?

A. Previous motor vehicle collisions.

B. Prior history of chest radiography.
C. HIV status.
D. Occupational history.
E. History of recreational intravenous drug use.
Question: 54
You receive a consultation report from an ophthalmologist stating that your
patient is now legally blind. Your patient is a 66-year-old man with type 2
diabetes. At his next visit, you are surprised to learn that he is still driving, and
you tell him he must stop driving immediately. You also inform him that you will
be notifying the motor vehicle licensing authority that his poor vision makes him
unfit to drive. He denies that he is blind and angrily refuses to stop driving. Which
one of the following is the best next step?

A. Tell the patient that he may drive in the interim if he agrees to be referred
for a second opinion.
B. Tell the patient that your decision is final and that there is no appeal
mechanism.
C. Tell the patient not to drive while awaiting the final decision of the motor
vehicle licensing authority.
D. Tell the patient that he is free to seek another opinion and to drive at his
own risk.
E. Tell the patient that the ophthalmologist should have reported him, so he
should not be angry with you.
Question: 55
A 22-year-old woman is experiencing severe recurrent attacks of swelling of the
face and lips accompanied by respiratory distress. Her mother and brother have
had similar episodes. Which one of the following will be most helpful to confirm
the most likely diagnosis?

A. Skin testing for food allergies.

B. Measurement of serum immunoglobulin level.
C. Assay of C1 esterase inhibitor.
D. Estimation of urinary porphyrin.
E. Blood eosinophil count.
Question: 56
A 35-year-old woman, gravida 3, para 2, aborta 0, presents at 34 weeks' gestation
with newly diagnosed invasive cervical cancer (stage IIA). Which one of the
following is the most appropriate management of her pregnancy?

A. Arrange for immediate induction of labour.

B. Allow spontaneous labour and delivery.
C. Arrange chemotherapy followed by cesarean delivery.
D. Plan a cesarean delivery and radical hysterectomy.
E. Arrange chemotherapy followed by induction of labour.
Question: 57
A 25-year-old man presents because he is concerned about a persistent urge to
rub himself sexually on women he sees during the day. He has a girlfriend and is
sexually active, but he finds more sexual satisfaction in his fantasies than he does
in his relationship. These fantasies and urges have been present since age 16
years, but he only recently started rubbing his groin against women on crowded
buses. He knows this behaviour is inappropriate and is worried it will get him
arrested. Which one of the following best describes this presentation?

A. Exhibitionistic disorder.
B. Voyeuristic disorder.
C. Obsessive-compulsive disorder.
D. Frotteuristic disorder.
E. Fetishistic disorder.
Question: 58
You are a family physician, and you attend a social event after work, where you
meet one of your patients. During your conversation, he confides that he is
worried about his wife, who is also your patient, and her excessive drinking. He
directs your attention to her as she is drinking a glass of wine and asks for your
advice on what should be done. Which one of the following is the best next step?

A. Get a more detailed history from him about his wife's alcohol consumption.
B. Offer to refer his wife to a community-based program for alcohol use
disorder.
C. See if there is a private room where you can talk to both of them.
D. Tell the husband that his wife's drinking is concerning
E. Agree to talk with his wife about his concern when you next see her in
clinic.
Question: 59
A 28-year-old woman presents to the office pacing and appearing agitated, while
screaming that the police are following her. During the visit, she is asked, "When
was the last time you used cocaine?" She replies, "Why, yesterday, of course; do
you think I would lie? I would not glither to you." Which one of the following best
describes her response?

A. Loosening of associations.
B. Clanging.
C. Formation of neologisms.
D. Confabulation.
E. Flight of ideas.
Question: 60
A 65-year-old woman had a right hemicolectomy for cancer. You are called on
postoperative day 2 because the patient has a temperature of 38.3°C. Which one
of the following is the most likely cause of this fever?

A. Urinary tract infection.

B. Atelectasis.
C. Wound infection.
D. Intra-abdominal abscess
E. Superficial thrombophlebitis.
Question: 61
The local health authority posts a list of the town's health statistics. Compared
with the province as a whole, the statistics show increased rates of tuberculosis,
infant mortality, type 2 diabetes, and tobacco smoking. In contrast, the rates of
malignant melanoma are lower. Which one of the following is the most likely
explanation for these findings?

A. The town has a high proportion of people with low socioeconomic status.
B. The town has frequent episodes of poor air quality.
C. The town had a recent influx of new residents.
D. The town has an older population.
E. The town has a poor public health monitoring system.
Question: 62
You are involved in a project in your community to provide education about and
promote joint health. Which one of the following is a risk factor for osteoarthritis?

A. Osteoporosis.
B. Tobacco smoking.
C. Obesity.
D. Male sex.
E. Alcohol use.
Question: 63
A 78-year-old man presents with dyspnea. He had a mitral valve replacement 10
years ago and takes warfarin. Complete blood count shows a hemoglobin level of
65 g/L (130–170) and an elevated lactate dehydrogenase level. The blood smear is
shown in the referenced image. Which one of the following is the most likely
cause of his anemia?

A. Gastrointestinal bleeding.
B. Traumatic hemolytic anemia.
C. Myelodysplastic syndrome.
D. Anemia of chronic disease.
E. Autoimmune hemolytic anemia.
Question: 64
A 26-year-old woman was tripped while playing soccer. She was immediately
unable to bear weight and marked swelling and pain developed in the right knee.
Examination of the knee is limited because of pain. The findings of knee
radiography are unremarkable. Which one of the following is the most likely
diagnosis?

A. Tibial plateau fracture.

B. Ruptured Baker cyst.
C. Anterior cruciate ligament tear.
D. Quadriceps tendon rupture.
E. Knee dislocation.
Question: 65
A 70-year-old woman presents with somnolence. On history, she shares that she
has been feeling tired for a few months and is having difficulty performing her
daily activities. She does not smoke. Her BMI is 35. Her vital signs are as follows:

Blood pressure 160/90 mm Hg

Heart rate 100/min
Respiratory rate 16/min
Oxygen saturation 93% on room air

Complete blood count shows a hemoglobin level of 180 g/L (123–157). Her white
blood cell and platelet counts are within normal range. Which one of the
following is the most likely cause of this hematologic abnormality?

A. Renal cell carcinoma producing erythropoietin.

B. Hemoconcentration
C. Polycythemia secondary to hypoxemia.
D. Polycythemia rubra vera.
E. Laboratory error.
Question: 66
A 22-year-old woman comes to the Emergency Department with severe pain of
the right upper abdominal quadrant a
White blood cell count 16 × 109/L (4–10)
Hemoglobin 120 g/L (123–157)
Aspartate aminotransferase 5800 U/L (18–40)
Alanine aminotransferase 500 U/L (17–63)
Alkaline phosphatase 260 U/L (38–126)
Bilirubin, total 32 µmol/L (< 26)

Which one of the following is the most likely cause of the right upper quadrant
pain?

A. Acute hepatitis.
B. Biliary colic.
C. Cholecystitis.
D. Choledocholithiasis.
E. Primary biliary cholangitis.
Question: 67
A mother brings her 3-year-old child to the clinic because of recurrent pruritic and
erythematous plaques in the popliteal and antecubital fossae. As an infant, the
child had similar patches on her cheeks and scalp. These signs are most suggestive
of which one of the following diagnoses?

A. Psoriasis.
B. Scabies.
C. Tinea corporis.
D. Atopic dermatitis.
E. Seborrheic dermatitis.
Question: 68
A 22-year-old woman with trisomy 21 presents with progressive slowing in all of
her activities (e.g., walking, talking, eating, bathing, dressing). These activities now
take her approximately 3 times longer than before the onset of her symptoms 1
year ago. She repeatedly writes in her journal, "Slow down, slow down ... slow
down." Which one of the following is the most likely diagnosis?

A. Neurocognitive disorder.
B. Bipolar I disorder.
C. Social anxiety disorder (social phobia).
D. Obsessive-compulsive disorder.
E. Schizophrenia.
Question: 69
Computed tomography (CT) of the chest and abdomen was performed on a 45-
year-old female trauma patient as part of a trauma protocol. The CT scan
indicated a small lesion on her right kidney, and repeat CT in 3 months was
recommended. Unfortunately, at hospital discharge 1 month later, the results of
the CT scan were not communicated to the patient's family physician; as a result,
the repeat CT was not performed. The following year, metastatic renal cell
carcinoma was diagnosed. Which one of the following is most likely to prevent
this from happening again?

A. Requiring the admitting hospital physician to be responsible for following up all studies.
B. Requiring the physician who ordered the CT scan to be responsible for following up all
studies.
C. Requiring the radiologist to phone the most responsible physician with all abnormal
results.
D. Having the most responsible physician ensure that all important results are noted in the
discharge summary.
E. Making the patient responsible for knowing the results of all of their imaging studies.
Question: 70
A 40-year-old man presents with a long-standing history of perfectionism and
needing objects in his environment to be organized in specific ways. He becomes
very upset and irritable if other people make changes in his environment or are
late for meetings. He spends nearly 1 hour daily organizing objects and having
recurrent thoughts. He is a conscientious and successful worker but has not been
promoted because he is highly critical of and blunt with others. Given the
differential diagnosis, which one of the following best differentiates his disorder
from similar presentations?

A. Conscientiousness at work.
B. Hoarding of objects.
C. Irritability with others.
D. Success in the workplace.
E. Lack of distress about perfectionism.
Question: 71
You are a resident training in orthopedics. During a complex trauma case, you
receive a needle-stick injury while treating a patient who uses recreational
intravenous drugs. You were previously vaccinated against hepatitis B and are
shown to be immune. After initial wound management, which one of the
following is the most appropriate next step?

A. Request that the anesthesiologist draw blood from the patient and test for
HIV and hepatitis B and C viruses.
B. Get tested for HIV immediately and every 2 months for 6 months.
C. Get tested for HIV and hepatitis B and C viruses immediately and every 2
months for 6 months.
D. Obtain informed consent from the patient to test them for HIV and
hepatitis C virus.
E. Request that the anesthesiologist draw blood from the patient and test for
HIV and hepatitis C virus.
Question: 72
A 44-year-old man presents with an 18-month history of coughing. He does not
smoke tobacco, has no medical history except for seasonal environmental
allergies, and takes no medications. He does not have shortness of breath,
wheezing, or heartburn. His physical examination findings are normal. Which one
of the following is the most appropriate initial investigation?

A. Esophageal pH monitoring.
B. Computed tomography of the chest.
C. Pulmonary function testing.
D. Laryngoscopy.
E. Chest radiography.
Question: 73
A 68-year-old woman presents with a 6-month history of intermittent vaginal
bleeding. She takes no medication. She has had regular Papanicolaou tests with
normal results. Findings of both the physical and pelvic examinations are normal.
Endometrial biopsy performed at the office shows a serous adenocarcinoma of
the uterus. Which one of the following is the most appropriate management?

A. Hysteroscopy and curettage.

B. High-dose progestin therapy.
C. Chemotherapy.
D. Pelvic radiation.
E. Hysterectomy, bilateral salpingo-oophorectomy, and pelvic
lymphadenectomy.
Question: 74
A 20-year-old woman, gravida 1, para 0, aborta 0, at 21 weeks' gestation has
received treatment for alcohol use disorder. She has missed her last 2
appointments, and you have received a call from the patient's mother, who tells
you that the patient has been drinking to excess again. Which one of the following
is the best next step?

A. Notify social services to locate the patient and provide support.

B. Attempt to contact the patient and encourage her to attend for care.
C. Document the mother's call and wait for the patient to attend for care.
D. Contact the patient's mother, tell her about the missed appointments, and
ask her to bring her daughter in to see you.
E. Contact the police.
Question: 75
A 33-year-old woman is at 38 weeks' gestation based on a first trimester
ultrasonogram. At her prenatal visit, she has a fundal height of 33 cm. You order
obstetric ultrasonography, which reveals a cephalic presentation with low
amniotic fluid volume and an estimated fetal weight of 2000 g. Which one of the
following management options is the most appropriate?

A. Perform a contraction stress test twice weekly.

B. Perform a biophysical profile assessment twice weekly.
C. Repeat the estimation of fetal weight in 7 days.
D. Admit the woman to hospital for observation.
E. Admit the woman to hospital and plan for induction of labour.
Question: 76
A 19-year-old woman presents to the office with concerns regarding stress and
fatigue. Recently completed blood work showed levels of hemoglobin, iron, and
thyrotropin (thyroid-stimulating hormone) within normal range. Her symptoms
started about 1 month ago, after she came to Canada to attend university. She is
finding it difficult to juggle school and her new part-time job, and she has not
found much time to make friends. She is otherwise asymptomatic. Which one of
the following is the best next step?

A. Repeat blood tests.

B. Provide supportive counselling.
C. Prescribe a stimulant.
D. Prescribe a selective serotonin reuptake inhibitor.
E. Refer for sleep study.
Question: 77
You diagnosed a 63-year-old woman's hypertension 3 months ago. She does not
smoke, and she has a BMI of 26. You prescribed exercise and a new
antihypertensive medication. Today, her blood pressure is 150/95 mm Hg, the
same as it was 3 months ago. She says she walks 30 minutes daily. Her weight is
stable. Which one of the following is the best next step?

A. Increase the dose of medication.

B. Reassess the patient's renal function.
C. Advise a reduction in dietary salt intake.
D. Recommend a weight-loss program.
E. Ask the patient how she pays for the medication.
Question: 78
The parents of a 3.5-year-old girl are concerned about her toilet training. She
initially learned to urinate in the toilet at age 2 years. However, she still has
urinary incontinence 3 or 4 times per week. The incontinence occurs during the
day, especially when she is busy playing, and at night when she is sleeping. She is
otherwise healthy and has grown well. Review of systems and physical
examination findings are unremarkable. Which one of the following is the best
response?

A. Girls are more likely to be delayed in toilet training.

B. Urinalysis is required.
C. The girl is being defiant, and better discipline is needed.
D. The girl has a small bladder capacity, for which medication will be
helpful.
E. Occasional daytime and nocturnal urinary incontinence are expected at
this age.
Question: 79
A 9-month-old boy is brought in because of a 3-day history of nasal congestion,
cough, fever, and fussiness. He is able to breastfeed. On examination, his heart
rate is 120/min, his respiratory rate is 36/min, and there are wheezes and crackles
throughout his chest. Which one of the following investigations will be most
helpful in determining whether this infant requires admission to hospital?

A. Radiography of the chest.

B. Measurement of oxygen saturation.
C. Respiratory syncytial virus antigen test.
D. Complete blood count test.
E. C-reactive protein level.
Question: 80
A 23-year-old woman comes in for a prenatal visit. She is at 18 weeks' gestation.
On physical examination, you note bruises on her breast. She shares that her
partner hit her. She tells you that he has been violent with her before, but she
does not want to disclose this information to anyone else. In addition to
documenting the incident, assessing her risk, and developing a safety plan, which
one of the following is the most important next step?

A. Ask her partner to attend the next visit to discuss the situation.
B. Provide appropriate information about community resources.
C. Notify the police because you are legally obligated to do so.
D. Do nothing unless the patient requests assistance.
E. Involve family members to provide the patient with support.
Question: 81
A 75-year-old woman admitted to the hospital for angina is treated successfully.
She is alert, afebrile, and mobilizing well. She does not have any urinary tract
symptoms. Her urinalysis is positive for leukocyte esterase and demonstrates
moderate bacteria. Which one of the following is the most appropriate next step?

A. Start nitrofurantoin.
B. Increase oral fluids.
C. Start trimethoprim-sulfamethoxazole.
D. Send urine sample for culture.
E. Do not start any antibiotics.
Question: 82
A 14-year-old boy presents with a limp and knee pain. He has a BMI of 33.
Physical examination reveals apparent shortening of the affected leg and limited
abduction of the hip. Which one of the following is the most likely diagnosis?

A. Developmental dysplasia of the hip.

B. Avascular necrosis of the femoral head.
C. Osgood-Schlatter disease.
D. Slipped capital femoral epiphysis.
E. Osteochondritis dissecans.
Question: 83
A 75-year-old man comes to the Emergency Department. He only speaks a
language that you do not understand. The patient points to his low back and
hands you a note. The note states that he has had pain in his low back for 5 days.
The patient's vital signs are within normal range. There are no interpreters in the
building, but one is usually in the clinic next door. Which one of the following is
the best next step?

A. While doing a physical examination, determine whether you need an

interpreter.
B. Observe the patient moving about before treating his pain.
C. Ask whether any of the patients in the waiting room speaks the patient's
language.
D. Request that the interpreter come immediately.
E. Order radiography of the lumbar spine.
Question: 84
A 75-year-old woman has a vertebral compression fracture. Two months earlier,
she sustained a right Colles fracture after slipping on the floor. Which one of the
following medications should be prescribed in addition to calcium and vitamin D?

A. Parathyroid hormone.
B. Nonsteroidal anti-inflammatory drug.
C. Estrogen.
D. Calcitonin.
E. Bisphosphonate.
Question: 85
A 59-year-old woman with cervical cancer presents with a 2-week history of
profuse, constant discharge. Six months ago, she underwent external beam and
intracavitary radiotherapy. Which one of the following is the most likely
diagnosis?

A. Vault necrosis.
B. Ureterolithiasis.
C. Vesicovaginal fistula.
D. Radiation enteritis.
E. Radiation cystitis.
Question: 86
A 33-year-old woman is scheduled for elective anterior cruciate ligament
reconstruction. She has a BMI of 24 and no history of venous thromboembolic
disease. Which one of the following measures is recommended to minimize the
risk for venous thromboembolism?

A. Prescribe enoxaparin injections for 10 days.

B. Prescribe rivaroxaban for 10 days.
C. Perform postoperative Doppler ultrasonography.
D. Prescribe warfarin for 10 days.
E. Encourage early postoperative ambulation.
Question: 87
A 20-year-old man presents with an abscess on the dorsum of his left hand
following a cat bite he sustained 6 days ago. After incision and drainage, which
one of the following is the most appropriate treatment?

A. Amoxicillin with clavulanic acid.

B. Metronidazole.
C. Ciprofloxacin.
D. Cephalexin.
E. Gentamicin.
Question: 88
A 26-year-old woman, gravida 2, para 1, aborta 0, presents at 8 weeks' gestation
with vaginal bleeding and mild lower abdominal pain. On pelvic examination, the
cervix is soft, nontender, and open. The uterus is slightly bulky. Her vital signs are
stable, and her complete blood count results are normal. Which one of the
following investigations is the most important next step?

A. Clotting factors.
B. Repeat of the complete blood count test in 4 hours.
C. Cervical swab for Chlamydia trachomatis and Neisseria gonorrhoeae.
D. Blood type and antibody screen.
E. Urinalysis for culture and sensitivity.
Question: 89
A 22-year-old man presents to the clinic and requests a prescription for
methylphenidate. He is a student, and he has a known history of substance
(recreational cannabis) and alcohol use disorder. Recently, he was having
difficulty focusing in class, and his girlfriend offered him some methylphenidate,
which she takes for her attention-deficit/hyperactivity disorder (ADHD). He found
this medication quite effective and has been taking more of her medication
without her knowledge. Which one of the following is the most appropriate
response?

A. Prescribe a short-term trial of a dextroamphetamine-based stimulant

instead.
B. Decline the patient's request, and offer a selective serotonin reuptake
inhibitor instead.
C. Advise that ADHD does not occur in adults without symptoms in childhood.
D. Contact the patient's girlfriend and inform her that he is taking her
medication without her permission.
E. Decline the patient's request because of his history of substance use
disorder, and offer ADHD screening.
Question: 90
A 26-year-old man presents with a 3-year history of a lump in his mouth. There is
a 3-mm nontender mass on his hard palate. Which one of the following is the
most likely cause?

A. Vascular disorder.
B. Malignancy.
C. Benign bony growth.
D. Infection.
E. Trauma.
Question: 91
A 30-year-old woman comes to the office because she and her husband are
planning to travel to Florida but are worried about the Zika virus. She is not
pregnant. Which one of the following is the best next step?

A. Screen the patient and her husband for the virus now; if the results are
negative, they can travel.
B. Recommend use of diethyltoluamide (DEET)-containing insect repellent
while travelling
C. Recommend that the patient cancel the trip.
D. Recommend the use of contraception from now until 3 months after travel.
E. Tell the patient that it is safe for her husband to travel, but not for her.
Question: 92
A 10-year-old girl is brought in by her mother, who is concerned about her
daughter spending a lot of time alone in her room and about her daughter's
apparent lack of friends. The girl is healthy, although her BMI is at the 95th
percentile. Her physical examination findings are otherwise normal. Which one of
the following is the best next step?

A. Recommend a low-fat, low-sugar diet and 120 minutes of physical activity daily.
B. Inquire whether there is a family history of eating disorders, depression, or substance
use disorders.
C. Advise the mother to give desserts and sweets only as rewards for physical activity.
D. Ask the girl about bullying, her self-esteem, and stressors in the home and at school.
E. Reassure the mother that the girl's weight should improve with her pubertal growth
spurt.
Question: 93
An 85-year-old woman presents to the Emergency Department with loss of
appetite, weight loss, and weakness. Investigations reveal a serum potassium
level of 1.9 mmol/L (3.5–5.0). Despite receiving 60 mEq of intravenous potassium
chloride, her serum potassium level is 2.0 mmol/L (3.5–5.0). Which one of the
following best explains her lack of response to potassium replacement?

A. Pancreatitis.
B. Adrenal insufficiency.
C. Hypomagnesemia.
D. Digoxin toxicity.
E. Renal failure.
Question: 94
A 61-year-old man has a history of inadequately controlled back pain. He also has
a history of anxiety for which he takes venlafaxine and for which he requires
lorazepam 3 times daily. He has been taking long-acting morphine for his back
pain. Which one of the following puts this patient at greatest risk for opioid
overdose?

A. The combination of a benzodiazepine with an opioid.

B. His age.
C. The long-standing nature of his pain.
D. The combination of venlafaxine with an opioid.
E. His sex.
Question: 95
A 19-year-old man with asthma has poorly controlled symptoms despite
treatment with inhaled salbutamol and fluticasone. He also has a history of
tobacco smoking, frequent upper respiratory tract infections, gastroesophageal
reflux disease, and migraines. Which one of the following should be considered to
eliminate a potential asthma trigger?

A. Pseudoephedrine.
B. Ergotamine.
C. Omeprazole.
D. Antibiotic prophylaxis.
E. Ipratropium bromide.
Question: 96
A 55-year-old woman presents with a 2-year history of an itchy vulvar lesion, as
shown in the referenced image. She is otherwise healthy. The lesion has failed to
respond to topical steroidal therapy. Which one of the following is the most likely
diagnosis?

A. Extramammary Paget disease of the vulva.

B. Behçet syndrome.
C. Amelanotic melanoma of the vulva.
D. Squamous cell carcinoma of the vulva.
E. Basal cell carcinoma of the vulva.
Question: 97
A 46-year-old man presents to the Emergency Department for the third time this
week after falling to the ground and having what appears to be a pseudoseizure.
His medical history includes a mild intellectual disability and schizophrenia, which
has been stable with long-term risperidone therapy. He remains adherent with his
medication. His previous investigation results were normal. Which one of the
following is the best next step?

A. Admit to hospital for a psychiatric evaluation.

B. Consult neurology.
C. Prescribe a second antipsychotic medication.
D. Discuss any stressors that he is experiencing.
E. Prescribe a loading dose of phenytoin.
Question: 98
A 4-year-old boy has a 3-day history of cough, fever, and lethargy. He has been
fully immunized. On examination, there are crackles in the left lower lobe. A chest
radiograph reveals consolidation of the left lower lobe. Which one of the
following would indicate the need for admission to hospital?

A. Oxygen saturation of 92% on room air.

B. Respiratory rate of 32/min.
C. Oral temperature of 39.9°C.
D. Heart rate of 120/min.
E. Capillary refill time of 4 seconds.
Question: 99
While working as a labourer, a 32-year-old man sustained a deep laceration
through the volar aspect of his forearm just above the wrist. One hour after the
injury, he arrives at the Emergency Department with the wound bandaged. Which
one of the following is the best method for initial assessment of the extent of the
injury?

A. Removal of the dressing in the Emergency Department and examination of the wound.
B. Examination of hand function.
C. Radiography of the forearm.
D. Arteriography of the limb.
E. Exploration of the laceration in the operating room.
Question: 100
A 19-year-old man with no known medical problems has fainted twice in the past
2 weeks. His friends observed 1 episode at the gym and say that he was running
on the treadmill and just collapsed. He did not have any obvious seizure activity.
The patient states that the second syncopal episode occurred while he was
playing basketball in his backyard. Examination shows blood pressure in both
arms of 130/70 mm Hg while lying down and 132/74 mm Hg while standing. He
has a regular heart rate of 65/min. Physical examination findings reveal an audible
S4, no obvious murmur, and a normal carotid upstroke. Electrocardiogram shows
left ventricular hypertrophy. The results of neurologic a examination are normal.
Which one of the following is the most likely diagnosis?

A. Hypertrophic cardiomyopathy.
B. Congenital long QT syndrome.
C. Aortic insufficiency.
D. Vasovagal syncope.
E. Coarctation of aorta.