A 24-year-old woman presents with rapidly increasing lower leg pain. Less than 24 hours ago, she fell off her bicycle and had some minor abrasions. On examination, she is in severe pain and appears anxious. Local examination of her leg reveals mild discoloration with marked tenderness but no swelling in her calf. Which one of the following is the most likely diagnosis?
A 48-year-old woman presents with a 2-year history of regular, heavy menstrual flow. She has a BMI of 54, poorly controlled type 2 diabetes, and obstructive sleep apnea. Laboratory results are as follows:
Hemoglobin: 82 g/L (123–157)
Ferritin: 6 µg/L (11–307)
Endometrial biopsy: Absence of hyperplasia or malignancy
Transvaginal ultrasound:
• Uterus: 12 cm × 8.2 cm × 6 cm
• Intramural fibroids
• Endometrial thickness: 14 mm
• Ovaries: Normal
Which one of the following is the best next step?
A 47-year-old man presents to the office with a 1-month history of passing blood in his stool 2 to 3 times per week. He is otherwise healthy and denies any systemic symptoms. Other than a small lateral skin tag on digital rectal examination, the physical examination findings are unremarkable. Which one of the following is the best next step?
A 3-year-old boy is brought to your office because his daycare teachers are concerned about his language development. His parents speak both English and French at home, and he can say around 15 words combined in both languages. His history reveals that he has minimal interest in playing with other children. Which one of the following is most appropriate?
A 39-year-old man presents to a psychiatrist. He says, " It often seems to me that I am not part of this world. My voice sounds strange to me, and other people seem like figures in a dream. " He has had these feelings intermittently for about 2 years. There is no history of hallucinations, and there are no current indications of disorganized thinking. Which one of the following is the most likely diagnosis?
A 10-year-old girl is brought to the Emergency Department by her mother because her daughter is crying and says she " can’t pee. " Her daughter fell on the monkey bars at school earlier that day. On examination, there is a large vulvar bruise anteriorly. Which one of the following is the best next step?
A 45-year-old man with a developmental delay and a history of disruptive behavior presents to the clinic looking for his family doctor. He is well known to the clinic. He appears drunk and has accidentally broken 2 large beer bottles in the waiting room but remains calm. The office staff requests your help to deal with this situation. Which one of the following is the most appropriate initial step?
A 29-year-old man comes to the office for an initial visit. He is being treated for schizophrenia and epilepsy. He has a 20 pack-year history of smoking. His medications are carbamazepine, clozapine, and quetiapine. In the past year, he has gained a considerable amount of weight. Aside from a BMI of 32, the results of his physical examination are unremarkable. Which one of the following conditions should he be investigated for?
A 51-year-old man comes to your clinic for follow-up regarding his type 1 diabetes. His hemoglobin A1c is 12.5% (normal 4–6%). He has never had such high blood sugar results. He drinks 2 beers per night to help with sleep. He is not well rested because he has been sleeping on a friend’s couch since losing his job last year. Which one of the following is the best next step?
A mother brings her previously healthy 4-month-old girl for evaluation due to fussiness for 3 weeks. The infant becomes irritable and cries with occasional body arching 1-2 hours after feeding, frequently spits up after feeds, has developed feeding aversion, and shows slowing weight gain. She has been on cow ' s milk-based formula since birth. Stools are normal, and physical examination is unremarkable. Which one of the following is the most likely diagnosis?
A 72-year-old woman presents with swelling of her right leg that developed overnight. She had an abdominal hysterectomy 10 days ago. On examination, there is pitting edema of the leg that extends from the foot to the groin. The calf is 3 cm larger in diameter than the calf on the left leg. Which one of the following is the most likely diagnosis?
A 42-year-old man presents for a follow-up visit for mild hypertension. His blood pressure has been consistently elevated over the last 2 visits. In discussion with the patient, you decide to initiate antihypertensives. He had previously been on ramipril and stopped when he developed tongue swelling. His past medical history consists of asthma and hyperlipidemia. Which one of the following is the most appropriate treatment at this time?
A 26-year-old woman, gravida 3, para 2, presents for her 1st antenatal visit. She states she is at 26 weeks ' gestation and is healthy. On abdominal examination, her fundus is palpated at the umbilicus. Which one of the following is the most likely explanation for this finding?
A 62-year-old woman is referred to your clinic for evaluation of hypercalcemia. She has a history of hypertension and vitamin D deficiency. Her medications include hydrochlorothiazide and vitamin D supplements. Laboratory investigations are as follows:
Calcium: 2.72 mmol/L (↑)
Phosphate: 0.9 mmol/L (↓)
Parathyroid hormone (PTH): 0.9 pmol/L (↓)
25-hydroxy vitamin D: 80 nmol/L (normal)
Which one of the following is the best next step?
A 2.5-year-old boy is brought to the Emergency Department after he consumed a button-shaped battery. Chest and abdomen radiographies are performed. Which one of the following locations mandates urgent removal of the battery?
A 40-year-old woman presents to your clinic for follow-up regarding her major depressive disorder, which is being treated with the starting dosage of escitalopram. Most of her symptoms have now improved. However, she has noted anorgasmia since taking this medication. This has significantly affected her relationship with her wife. Which one of the following is the best next step?
A 14-month-old boy is brought to see you for a well-baby check-up and is noted to have only one testis. Ultrasound confirms an undescended testis. Which one of the following is the best next step?
A 70-year-old woman consults you for progressive vision problems. She describes seeing haloes at night around street lights and having double vision. Her near vision has improved. Which one of the following is an ophthalmologic examination most likely to uncover?
You are being consulted for a 79-year-old man who is about to undergo a total hip arthroplasty. His orthopedic surgeon is aware of the diagnosis of Alzheimer disease and would like your suggestions to help avoid acute postsurgical delirium. To that end, which one of the following is the most effective strategy?
A 60-year-old man is admitted to hospital, and lung cancer is diagnosed. When his family physician reviews the discharge summary, she reviews the patient’s chart and finds a chest radiograph report from 1 year ago that mentions a suspicious nodule and recommends a computed tomography scan. The family physician recalls seeing this report and did not order the scan. Which one of the following is the family physician’s best next step?
A 1-month-old breastfed baby is brought to your office by his parents for his well-baby check-up. He was born at 32 weeks’ gestation. Growth parameters at birth revealed head circumference, weight and length at the 50th percentile. Today, his weight is at the 10th percentile. Which one of the following is the most appropriate plan of action?
A 59-year-old woman comes to the office because her 48-year-old sister was recently diagnosed with cervical cancer. Your patient thinks her mother may have also had cervical cancer. A Papanicolaou (Pap) test performed 16 months ago had normal results, as did all previous Pap tests. Which one of the following is the best next step?
A 2-year-old boy is brought by his parents to your clinic because of sudden onset of high fever, refusal to drink, and drooling. Examination reveals cervical lymphadenopathy as well as multiple ulcers on the inner lips, tongue, and gums. Which one of the following is the most likely diagnosis?
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 young man and woman who are in a relationship present to the office for prenatal counselling. During the visit, you observe that the man ' s lips appear as shown in the referenced photo.
[Image shows grouped vesicular lesions on erythematous base affecting the lips—classic for herpes labialis (HSV-1).]
Which one of the following is the best advice?
A 17-year-old boy is brought by his 2 roommates to the emergency department (ED) after a party where he had been drinking and smoking cannabis. He reportedly was having a good time when he suddenly wanted to jump out of a window. His roommates describe him as “normal prior to a breakup with his girlfriend a week ago.” He has since become anxious and unable to sleep. On examination, he is somnolent and appears intoxicated. Which one of the following is the most appropriate initial management?
A 56-year-old woman comes to your office because she has not been herself since her husband died in a car crash 6 weeks ago. She has no prior psychiatric history. Her son is concerned because she cries frequently, has a poor appetite, rarely leaves home and is distraught. Her sadness fluctuates and increases when she thinks of her husband. She often thinks about death, and she wishes she could join her deceased husband. Which one of the following is the best next step?
While covering for a colleague away on holidays, you receive the following laboratory results for one of her patients, a 24-year-old woman:
White blood cell count: 10 × 10⁹/L (4–10)
Hemoglobin: 80 g/L (123–157)
Mean corpuscular volume: 76 fL (80–100)
Platelet count: 150 × 10⁹/L (130–400)
You have arranged a follow-up appointment for the patient with your colleague. Which one of the following is the most likely diagnosis?
A 24-year-old man presents to your clinic with a 6-month history of fatigue. On examination, he is pale. His BMI is 16, and his blood pressure is 92/58 mm Hg. Initial laboratory work shows the following:
Creatinine: 64 µmol/L (49–93)
Potassium: 3.0 mmol/L (3.5–5.1)
Sodium: 138 mmol/L (136–146)
TSH: 2.40 mIU/L (0.34–5.60)
CBC: Normal
Which one of the following is the best next step?
You are meeting an otherwise healthy 10-year-old boy in your office for the first time. His BMI is at the 80th percentile. He has no symptoms and his physical examination is normal. Which one of the following is the best next step?
You are examining a full-term baby girl in the nursery. You notice that her left forefoot is adducted and supinated relative to the contralateral foot, which makes her left foot appear C-shaped. Which one of the following findings is most instrumental in deciding on the management of this issue?
You are counselling a couple that is concerned about the risk that their second child could be affected by the same X-linked recessive disorder (hemophilia A) as their last child, a boy. Neither parent has this disorder. What is the probability that their second child will be affected?
A 25-year-old man presents to the Emergency Department with diffuse abdominal pain and anorexia. He was tackled in a football game yesterday. He reports a 3-week history of sore throat and fatigue. Vital signs are as follows:
Blood pressure: 95/45 mm Hg
Heart rate: 96/min
Temperature: 37.6°C
Which one of the following is the most likely diagnosis?
A 52-year-old man presents to the Emergency Department with a history of back, neck, and shoulder pain sustained from a workplace incident 4 years ago. He is under observation by a multidisciplinary pain clinic, and his next appointment is not for another 4 weeks. He does not report any recent change in his symptoms. His medications are as follows:
Acetaminophen
1000 mg orally 4 times daily
Naproxen
500 mg orally twice daily
Amitriptyline
25 mg orally at bedtime
Acetaminophen 1000 mg orally four times daily
Naproxen 500 mg orally twice daily
Amitriptyline 25 mg orally at bedtime
The patient has not taken his medications for several weeks because he thinks they are not working. He requests a prescription for oxycodone because he tried some that a friend sold him, and it worked very well. After completing an assessment and providing counseling, which one of the following is the best next step?
A 31-year-old woman, gravida 1, para 0, presents to Labour and Delivery with regular contractions at approximately 24 weeks’ gestation. As you review her prenatal records, which one of the following is the most reliable way of establishing gestational age?
You are on duty in the Emergency Department when 5 patients are brought in by ambulance after a high-speed motor vehicle collision. Which one of the following patients requires the most urgent medical care?
An otherwise well 18-month-old girl is brought to your family practice office for routine immunization. Her mouth is as shown in the attached image. She has no symptoms. Which one of the following is the most likely cause of this presentation?
Image description: Severe black and brown decay of multiple upper front teeth, with relatively spared lower teeth.
A 1-month-old boy is brought to your clinic after being born with asymmetric intrauterine growth restriction (third percentile at birth). He was born at 36 weeks’ gestation. He has been breastfeeding well and continues to grow around the third percentile. Which one of the following would be the best next step?
A 70-year-old hypertensive woman with a history of congestive heart failure (CHF) secondary to left ventricular dysfunction presents to your office with a persistent dry hacking cough. She claims it began when she was started on ramipril. Which one of the following medications would be most appropriate to replace ramipril, to ensure that the risk of morbidity associated with CHF remains low?
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 same-sex couple asks to join a family physician’s practice. The physician tells them that she does not treat same-sex couples and will refer them to a physician with more clinical experience with same-sex couples. Which one of the following best describes the physician’s obligation under the Canadian Charter of Rights and Freedoms?
A 29-year-old woman, gravida 1, para 0, aborta 0, presents to your clinic. Her pregnancy is at 22 weeks’ gestation. Her blood pressure is 158/96 mm Hg. Which one of the following antihypertensive medications is contraindicated for this patient?
A 78-year-old man, who is accompanied by his eldest son, presents for follow-up of his chronic kidney disease and neurocognitive disorder due to vascular disease. He is married and has 4 children. His creatinine clearance has slowly deteriorated over the last few years and has reached the stage where you are considering starting renal replacement therapy. After your discussion, it is clear that the patient, his son, and his wife want to start dialysis. Based on your assessment, it is clear that he does not understand the information you have relayed to him. You inform the patient that you believe he is incapable of making this decision and he agrees. His son would prefer not to start dialysis as he is concerned about the impact this would have on his father’s quality of life. Which one of the following is the best next step?
You are providing medical care to a 78-year-old man and notice a skin lesion which you suspect is malignant melanoma. He has been living in a long-term care facility for 2 years because of incontinence, mobility and vision problems. He is well-liked by facility staff and residents, manages his own affairs and communicates clearly. He has designated his daughter to be his substitute decision-maker and has signed a Do Not Resuscitate (DNR) order. Which one of the following is the best next step in providing care to this patient for his skin lesion?
A patient ' s mother comes to you with a prospective cohort study linking autism to the measles, mumps and rubella vaccine. After reviewing the study carefully, you question the results because of problems with the study design and execution. Which one of the following sources of error would be most important in the study design or execution?
A 32-year-old man presents to the clinic for assessment of a dog bite sustained 3 days ago while traveling in another country. He recalls having seen the dog eat where he was staying, and the animal did not appear well. On examination, the patient has 2 distinct deep puncture wounds on his left leg. There is an erythematous border but no exudate. He is unsure of his immunization status. Which one of the following is the most appropriate management?
A 26-year-old man presents with pain, numbness, and weakness in his right upper extremity. He works as a computer programmer, and his BMI is 32. Symptoms have worsened since he started spending more time on the keyboard. He reports that his right hand feels clumsier while he is typing. Physical examination reveals mild weakness in the intrinsic muscles of that hand, with a positive Tinel sign at the ulnar nerve. Which one of the following is the best next step?
A 66-year-old woman with metastatic breast cancer presents with hard, difficult-to-pass stools. She has been experiencing this issue since starting morphine to control her pain. Which one of the following is the best next step?
A 46-year-old woman presents to the emergency department with left-sided pleuritic chest pain that improves when she sits up and leans forward. Her medical history is unremarkable and she takes no medications. Examination reveals a pericardial friction rub; the findings are otherwise normal. An electrocardiogram reveals diffuse ST segment elevation and PR interval depression. An echocardiogram reveals a small pericardial effusion. Which one of the following is the most appropriate treatment?
A 30-year-old woman presents to your office for a follow-up assessment of a sports-related musculoskeletal injury to her right leg. She requests a letter for her employer regarding her return to work. You feel she should be able to manage some aspects of her factory work. Which one of the following is most appropriate to include in your medical note to this patient ' s employer?
A 4-month-old boy is brought to the office by his parents to ask about the rotavirus vaccine. They would like to avoid the possibility of the infant coming down with gastroenteritis. Their older child was hospitalized with gastroenteritis at age 10 months. They have a friend who had intussusception after getting the rotavirus immunization, and they are worried about a possible link to the vaccine. Which one of the following is the most appropriate response?
You are a family physician caring for a healthy 60-year-old woman. Which one of the following preventative interventions is most useful?
A 43-year-old man comes to your office for the first time. He has not seen a doctor in over 5 years and has no known past medical history. On examination, his blood pressure is 120/70 mm Hg, and the remainder of his examination is normal. As part of the initial visit, you order some screening blood work that reveals a fasting blood glucose of 6.3 mmol/L (3.3–5.8) and a hemoglobin A1c of 6.1% (4–6). Which one of the following is the best next step?
A 44-year-old woman presents to the office to discuss contraception. During the gynecologic examination, you notice an anterior cystocele to the hymenal ring. The woman denies any bulge symptoms but does report dribbling of urine, especially when she coughs or jogs.
Which one of the following is the best next step?
A 42-year-old businessman known to have type 2 diabetes and ischemic heart disease is admitted to hospital with acute coronary syndrome. He admits to drinking 4 beers a day for the last 6 years and to binge drinking twice a year when his school buddies are in town. Your chart review reveals that he had a seizure secondary to alcohol withdrawal during his last admission. Which one of the following elements of his history puts him at highest risk of having another such seizure?
A 70-year-old woman presents to the Emergency Department with a 2-day history of dysuria and right flank pain. Upon arrival, she is quite unwell. Her vital signs are as follows: blood pressure 70/38 mm Hg, heart rate 130/min, respiratory rate 24/min, temperature 39.4 °C.
Due to difficulty obtaining peripheral access, a central line is inserted. There is a lot of ongoing bleeding around the line insertion site. Her blood work shows:
White blood cell count: 19.8 × 10⁹/L (4–10)
Hemoglobin: 101 g/L (123–157)
Platelets: 85 × 10⁹/L (130–400)
Blood film: schistocytes
INR: 1.9 (0.9–1.2)
Fibrinogen: < 1 g/L (2–4)
Which one of the following is the most likely cause of her ongoing bleeding?
A 56-year-old woman is admitted to hospital with gastrointestinal bleeding. Her hemoglobin level is low and the physician who saw her in the Emergency Department has recommended a blood transfusion. You attend her on the unit and tell her that a blood transfusion will help her feel better. Which one of the following is the best next step?
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 56-year-old woman presents to your office with a 9-month history of intolerable sweating, palpitations, and periodic anxiety. Her last period was 12 months ago. She continues to have regular Papanicolaou testing with no worrisome pathology. She is otherwise healthy. Which one of the following is the most effective treatment for these symptoms?
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 3-week-old boy is brought by his parents to your clinic for a well-child visit. The newborn was born at term after an uncomplicated pregnancy. He is exclusively breastfed and is thriving. Physical examination findings are normal except for jaundice. Total bilirubin is 172 μmol/L (≤100), and conjugated bilirubin is 4 μmol/L (≥5). Results of a complete blood count and reticulocyte count are within the normal range. The results of a direct antiglobulin (Coombs) test were negative. Which one of the following, if any, is the most appropriate investigation?
One of your patients presents to your clinic for a consultation regarding their recurrent hemoptysis. On review of their chart, you realize that although you had ordered chest radiography 2 months ago, the result cannot be found in the chart. You call the radiology department and are relieved to find that the chest radiography was done and that it did not reveal any pathology. After informing the patient of this lapse in reporting, which one of the following is the best next step?
A 43-year-old car mechanic, with no prior history, comes to the Emergency Department because of a sudden loss of balance at work. He also feels lightheaded, slightly disoriented and nauseous. Physical examination and basic blood work-up are normal. He tells you this is the 3rd time this has happened at work. Which one of the following is the most likely diagnosis?
A mother brings her 1-month-old infant for routine health examination. The infant was born at term with no complications. He is exclusively breastfed every 3–4 hours and growth parameters are normal. His mother tells you that feedings are difficult (the baby cries any time she tries to put him down) and that she is exhausted. Her husband has been on a military mission since the infant was 2-weeks-old. Which one of the following is the most appropriate next step in management?
A 63-year-old man presents to the office with a 2-year history of episodic swallowing problems that have been increasing in frequency. He states that food seems to stick in his throat, and these episodes are often associated with coughing or regurgitating undigested food. Physical examination reveals that the patient has halitosis; otherwise, findings are normal. Which one of the following is the best next step to confirm the most likely diagnosis?
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?
You have been asked to develop a program in your hospital for people who are at the highest risk of death by suicide. The hospital administrator asks you to describe the types of patients they should expect in the program. Which one of the following groups is the most likely prominent demographic?
A 55-year-old woman presents to the office with a 2-month history of right shoulder pain and limited function that started after she began an upper body weight training program. Examination shows tenderness inferior to the acromion. She has full passive range of motion of the shoulder but significant pain with abduction from 30° to 120° of arc. Which one of the following is the best next step?
A 4-month-old girl is brought by a parent to your clinic with a history of recurrent vomiting since birth. She cries with feeding and has not gained weight in the last 2 weeks. Her hemoglobin level is 95 g/L (100–125). The patient is currently being fed thickened hypoallergenic formula. Which one of the following is the most appropriate therapy?
A 61-year-old man presents to the office for follow-up of recent laboratory test results. He has hypertension for which he takes amlodipine daily. His blood pressure is 148/94 mm Hg. His creatinine level is 140 µmol/L (normal 70–120), and his urine protein-to-creatinine ratio is persistently elevated. You would like to prescribe ramipril, but he refuses to take any additional medication. Which one of the following is the best next step?
You are a physician working at a university campus health centre. Staff at the centre are thinking about initiating a campus-wide education campaign on stimulant medication use and misuse. From a physician ' s perspective, which one of the following is the key message to include in this campaign?
A 1-week-old boy born at full term is brought by his parents to the office with a 2-day history of eye swelling and watery discharge. This morning, the discharge became thick and yellow. On physical exam, he is afebrile and fussy with bilateral eyelid edema, purulent discharge, and erythematous conjunctivae. After taking appropriate cultures of the eyes, which one of the following is the best next step?
You have just completed a well-baby check on a 6-month-old in the office where you have recently begun to practice. You ask the registered nurse to give the immunizations. She refuses, saying this is not within her scope of practice. Which one of the following is the best next step?
You are caring for a 78-year-old man admitted to hospital for heart failure. On your rounds, he asks why he is not getting better. He has a history of heart failure, hypertension, and type 2 diabetes. He has an implantable cardioverter-defibrillator. This is his fourth admission in the past 6 months for acute decompensation of his heart failure. Between hospital admissions, he reports worsening shortness of breath and a progressive decline in function. Which one of the following is the next best step?
A 28-year-old woman presents to your office with a 6-month history of intermittent dizziness associated with nausea and a rotational sensation. Physical examination shows pallor of 1 optic disk, generalized hyperreflexia and nystagmus to the left. Which one of the following is the most likely diagnosis?
A 72-year-old man reports that his wife says he has hearing trouble. Examination reveals that air conduction on the right side is less than on the left side and greater than bone conduction bilaterally. He hears a tuning fork placed on the top of his head better with his left ear. Which one of the following is the most appropriate next step in management?
During an office visit, your 14-year-old patient requests a prescription for oral contraceptives. The province where you are working does not have a statutory age of consent. Which one of the following is the best next step?
A 76-year-old man is brought by his family to your clinic with new-onset urinary incontinence. They state that the patient is experiencing a slowly progressing cognitive decline marked by memory disturbance, apathy, and attentional problems. Examination reveals that the patient has a stooped, forward-leaning posture and a wide-based gait. Which one of the following is the most likely diagnosis?
A 45-year-old man presents to your clinic for follow-up regarding his obsessive-compulsive disorder. He currently takes a high dosage of paroxetine, which he would like to discontinue because he feels well. His condition has been stable taking this medication since he was discharged from inpatient care 2 years ago. Which one of the following is the most appropriate recommendation?
A 72-year-old man has had 4 episodes of weakness in her right arm and leg lasting 10 to 15 minutes each. During 1 episode, she had difficulty speaking and had blurring of the vision in the left eye. Which one of the following is the most likely diagnosis?
You are examining a newborn in the delivery room. He was born at full term by spontaneous vaginal delivery. On examination, he is active, and his vital signs are within normal range. His head circumference is at the third percentile, with height and weight at the 10th percentile. Auscultation of his chest is clear with normal cardiovascular examination findings. The abdomen is protuberant with a liver edge palpable at 4 cm below the costal margin and mild splenomegaly. Which one of the following is the most likely diagnosis?
A 45-year-old woman presents to your clinic for follow-up regarding her asthma. She is planning to attend a cultural event that includes ceremonial burning of tobacco. Which one of the following is the best next step?
Which one of the following bodies decides whether a physician is permitted to practise medicine in a province or territory?
On screening for dyslipidemia, a 45-year-old man is found to have a low high-density lipoprotein (HDL) cholesterol level. Which one of the following recommendations is the most appropriate?
A 16-year-old girl is brought to the Emergency Department with a 12-hour history of worsening right lower quadrant abdominal pain and nausea. She is in no distress and vital signs are normal. Her abdomen is soft but locally tender in the right iliac fossa, and bowel sounds are active. White blood cell count is 7.6 × 10⁹/L (4–10), C-reactive protein is 2.3 mg/L ( < 10) and serum beta human chorionic gonadotropin is undetectable. Ultrasound reveals a small amount of fluid in the pelvis, and the appendix is not clearly apparent. Which one of the following is the best next management step?
A 46-year-old woman with a palpable breast lump underwent diagnostic mammography that revealed a suspicious mass in her right breast. The radiologist recommended a breast biopsy. The referring physician did not see the mammogram report or the recommendation for biopsy. One year later, invasive breast cancer is diagnosed in the patient. Which one of the following is most likely to prevent this issue from happening again?
A 10-year-old boy and his mother present to your office with a concern about handwashing. The mother explains that her son has been at a new school for the past month and that teachers have noticed that he is washing his hands all day. He has also hidden hand sanitizer in his desk. The hand-cleaning is a response to a constant anxiety that his hands are dirty, and that he might pass an infection to someone. Which one of the following is the most appropriate initial management?
A 34-year-old woman, gravida 3, para 2, comes to your office for prenatal care. Past medical history includes 2 precipitous uncomplicated term deliveries of infants greater than 4200 g. Which one of the following is she most at risk of developing?
An 18-year-old woman comes to the office because of fatigue. She tells you she is struggling in her first year of university. She mentions that she spends much of her time rewriting her notes and filing and organizing her study materials. She is doing all the work in her group assignments because she feels others cannot do the work to a high enough standard. She has abandoned all enjoyable activities and seems to be constantly working and worrying about her grades. Which one of the following is the most likely diagnosis?
A 64-year-old man presents with a 3-month history of gradually increasing neck pain and stiffness. The pain radiates into his upper back, and he is having difficulty driving because of limitation of neck rotation secondary to pain. Physical examination shows restricted neck motion in all directions and neck muscle spasms. There is no abnormality on neurologic examination. A radiograph shows narrowing of all of the cervical disc spaces with prominent osteophytes. Which one of the following is the most appropriate next step?
A 28-year-old woman presents to the office in great distress because she has no money for groceries or rent. She is a single mother of a 7-year-old girl. She has a history of gambling disorder. She has felt unable to cope for the last 3 months and has started gambling again. Today, she is crying, and she shares that her boyfriend became violent with her yesterday. Which one of the following is the highest priority for assessment?
Your colleague ' s receptionist asks you to assess her 4-year-old daughter who has had 2 episodes of acute otitis media in the last month. The mother wants you to arrange a consultation with an ear, nose and throat (ENT) specialist to get a tympanostomy before her daughter starts school. You do not believe there is a surgical indication at this time. Which one of the following is the best next step?
A 42-year-old woman presents to your clinic requesting an increase in her stimulant dosage for the treatment of her adult attention-deficit/hyperactivity disorder. Her medical history includes hypertension and type 1 diabetes with associated nephropathy. She has been taking methylphenidate daily for 15 years. Which one of the following would need to be addressed before the dosage can be increased?
A 27-year-old woman presents to her family physician ' s office and states that she is pregnant and would like to be referred for an abortion. She is at approximately 9 weeks ' gestation by dates. The family physician has personal conscience-based objections to the procedure. Which one of the following would be the best next step for this physician?
You are 1 of 3 physicians on an interdisciplinary brain injury team at a hospital. The team ' s physiotherapist has concerns regarding a patient ' s medication. Which one of the following is the most appropriate course of action for communicating with the physiotherapist?
A 24-year-old man is brought to the Emergency Department by ambulance with a severe pelvic fracture from a motor vehicle collision. After resuscitation and stabilization, he is noted to have a bloody penile discharge. Which one of the following is the best next step?
A 10-day-old boy is brought to the Emergency Department with a fever. The newborn looks well. Other than a rectal temperature of 38.6 °C, findings of the physical examination are unremarkable. When you list all the recommended testing their baby will have to undergo, the parents become upset at all the testing their baby will have to undergo. Which one of the following is the best approach?
A 65-year-old man presents to your clinic with a 2-month history of persistent erectile dysfunction. He reports having difficulties maintaining an erection. His last hemoglobin A1c level result was 6.4% (4.8–6.0). He had a negative result on his cardiac stress test 1 month ago. He has been taking stable dosages of citalopram, metformin, and ramipril for the past 2 years. His physical examination findings are normal, and his mood appears euthymic. Which one of the following investigations should be ordered before initiating treatment with sildenafil?
A 91-year-old man comes to the Emergency Department reporting blood in his stools, which has now resolved. He is able to give a history and mentions that this also happened 2 years ago. At that time, a colonoscopy was done and revealed diverticular disease as the cause. Which one of the following is the best next step?
A 30-year-old woman presents to the office with her partner and reports that they are planning for her to conceive soon. They visited Mexico recently and are concerned about exposure to the Zika virus. Which one of the following is the best next step?
An otherwise healthy 57-year-old man with a 20 pack-year history of smoking presents with a 2-day history of reddish-brown urine that has not cleared. There is no history of abdominal or flank pain. Urinalysis reveals 5 red blood cells per high power field. Which one of the following is the best next step?
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TESTED 07 Apr 2026
