Canada Q Bank Family Medicine

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Initial!treatment!in!this!patient!would!be!empirical!as!the!results!of!bacterial!culture!have!not!yet!been!obtained.!IV!
vancomycin!(choice!B)!is!considered!the!best!initial!therapy!as!it!has!adequate!coverage!against!methicillin]resistant!
staphylococcus.!
!
!
>!IV!nafcillin!(choice!A)!is!inappropriate!for!empiric!treatment!because!of!high!resistance!rate,!estimated!to!be!30%.!
>!IV!ciprofloxacin!(choice!B)!would!be!effective!against!Kingella!kingae,!but!not!against!Staphylococcus!aureus.!For!
younger!children,!fluoroquinolones!are!also!known!to!cause!cartilaginous!tissue!damage.!
>!IV!doxycycline!(choice!D)!is!inappropriate!in!children!who!are!8!years!old!and!younger!due!to!its!adverse!effects!on!
teeth.!Currently,!there’s!no!sufficient!data!to!support!its!effectiveness!against!methicillin!resistant!staphylococcus.!
>!IV!ceftriaxone!(choice!E)!might!be!helpful!in!a!child!with!sickle!cell!anemia!who!might!have!Salmonella!or!Haemophilus!
influenza,!but!is!not!the!best!choice!in!this!patient!who!is!more!likely!to!be!infected!with!Staphylococcus!aureus.!
!
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vancomycin.!
! Canada Q bank
Staphylococcus!aureus!is!the!most!common!cause!of!osteomyelitis!in!children!and!the!best!empiric!treatment!is!IV!
Canada Q Bank FM
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Question!#245!
QID:!11272!
Topic:!Lyme!Disease!
Subject:!Pediatrics!
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!A!7]year]old!male!is!brought!to!the!hospital!by!his!parents!with!complaints!of!difficulty!closing!his!right!eye!and!a!feeling!
of!dryness!and!itchiness!in!the!same!eye.!His!left!eye!is!completely!normal.!His!parents!say!that!they!recently!went!with!
him!on!a!vacation!in!Vermont!and!had!noticed!an!annular!homogenous!rash!on!his!neck.!
On!physical!examination!while!assessing!the!cranial!nerves!you!note!that!he!cannot!puff!up!the!right!cheek.!Which!of!the!
a)!!!Prednisone!
b)!!!Doxycycline!
Family Medicine
following!is!the!most!appropriate!treatment!of!the!most!likely!underlying!disease?!
c)!!!Amoxicillin!
d)!!!Clarithromycin!
e)!!!Ice!packs!on!face!
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The!correct!answer!is!c)!
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Explanation:!
This!child’s!facial!symptoms!are!characteristic!of!facial!nerve!palsy.!Considering!his!recent!trip!to!Vermont!and!the!rash!
the!parents!describe,!most!likely!to!be!erythema!migrans,!we!can!conclude!that!his!diagnosis!is!Lyme!disease.!Erythema!
migrans!is!a!sign!of!early!Lyme!disease!after!an!Ixodes!tick!bite.!Borrelia!burgdorferi!is!the!main!cause!of!Lyme!disease.!
Patients!often!have!a!recent!outdoor!activity!especially!in!the!endemic!areas!which!are!Southern!and!eastern!Ontario,!
Southeastern!Quebec,!parts!of!Newbrunswick!and!Nova!Scotia.!It!is!also!commonly!found!in!the!Northeastern!region!of!
the!United!States.!
!
Administration!of!doxycycline!or!amoxicillin!for!14]21!days!is!recommended!for!treatment!of!early!localized!or!early!
disseminated!Lyme!disease!associated!with!erythema!migrans,!in!the!absence!of!neurological!involvement!or!third]
degree!atrioventricular!heart!block.!Patients!with!an!isolated!facial!nerve!palsy!(like!this!patient)!(i.e.,!normal!
cerebrospinal!fluid!examination)!can!be!treated!with!a14]day!course!of!the!same!antibiotics!used!to!treat!erythema!
migrans.!
!
→!Prednisone!(choice!A)!is!an!effective!treatment!for!idiopathic!Bell’s!palsy.!This!question!asks!the!appropriate!treatment!
for!his!underlying!disease!which!is!Lyme!disease.!
→!Doxycycline!(choice!B)!is!associated!with!teeth!discoloration!in!children!8!years!old!or!younger.!
→!Clarithromycin!(choice!D)!is!not!the!most!appropriate!treatment!for!Lyme!disease.!
→!Ice!packs!on!face!(choice!E)!would!not!be!effective!against!Borreria!burgdorferi!
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Maha su 1
Lyme!disease!is!treated!with!doxycycline!in!adults!and!children!older!than!8!years!of!age,!and!it!is!treated!with!amoxicillin!
in!children!8!years!old!or!younger.!
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1. If(the(threshold(of(a(screening(test(is(increased.(How(it(will(affect(sensitivity(and(specificity?!
a)!!Sensitivity!increase!&!specificity!decrease!
b)!!Sensitivity!decrease!and!specificity!increase!
c)!!Both!sensitivity!and!specificity!increase!
d)!!Both!sensitivity!and!specificity!decrease!
!
The!correct!answer!is!b)!
!
• Explanation:!
In!the!classic!model!above.!The!definitions!are!as!follows:!
Sensitivity!=!a/(a+c)!which!is!the!true!positive!rate.!Meaning!of!all!the!people!with!the!disease!the!portion!that!will!
actually!test!positive.!
Specificity!=!d/(b+d)!which!is!the!true!negative!rate.!Meaning!of!all!the!people!without!the!disease!the!portion!that!
will!actually!test!negative.!
2
• A!real!world!example!will!clearly!explain!that!will!happen!if!the!threshold!is!increased.!Say!we!are!testing!people!for!
diabetes.!We!are!using!our!current!random!blood!sugar!value!of!200!and!a!threshold!for!a!positive!test.!We!test!40!
people.!See!the!model,!where!the!black!circles!represent!normal!people!and!the!red!are!those!with!diabetes.!Then!
we!test!again!using!a!threshold!value!of!250!for!random!blood!sugar.!
• Calculations!of!the!sensitivity!and!specificity!clearly!shows!that!when!you!increase!the!threshold!the!sensitivity!will!
decrease!and!the!specificity!will!increase.!
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2. A(man(suspects(that(he(may(have(gonorrhea.(Tests(confirm(it.(He(tells(you(that(his(wife(works(at(the(hospital(and(
he(wishes(to(keep(this(a(secret(to(avoid(possible(conflicts(and(embarrassment.(What(is(the(appropriate(way(to(
handle(this(situation(at(this(point?!
a)!!Inform!the!patient!about!the!nature!and!implications!of!the!infection!and!importance!of!treating!his!wife!as!well!
b)!!You!must!call!his!wife!and!let!her!know.!
c)!!Don’t!listen!to!him!
d)!!Send!his!wife!a!letter!
e)!!Suggest!relationship!counselling!
!
The!correct!answer!is!a)!
!
Explanation:!
Gonnorhea!should!be!reported!to!local!public!health!unit.!Since!gonorrhea!is!an!STD!that!is!communicable,!his!
partner!should!know!about!it!also.!Since!patient!confidentiality!must!be!respected,!it!is!best!to!ask!him!to!tell!his!wife!
about!this.!
Contact!tracing!includes!an!educational!component,!in!order!to!ensure!that!the!index!case!and!contacts!are!informed!
about!the!nature!and!implications!of!the!infection,!modes!of!transmission!and!prevention,!and!treatment!options.!
The!health!care!provider!should!be!culturally!aware!and!have!basic!counselling!skills!and!other!personal!qualities!such!
as!tact,!empathy!and!awareness!of!the!physical,!emotional,!and!social!conditions!of!the!client.!The!provider!also!
needs!current!and!accurate!knowledge!of!treatment!and!support!services!and!must!be!familiar!with!the!HPPA!and!
other!legal!aspects!of!STI!management!
!
3. Coronary(artery(disease((CAD)(is(more(common(in(men(compared(to(women.(Which(of(the(following(is(also(true?!
a)!!After!menopause,!the!incidence!of!CAD!in!women!decreases!
b)!All!diagnostic!tests!work!equally!well!in!both!men!and!women!
c)!Women!have!worse!outcomes!following!MI!compared!to!men!
d)!!Many!more!men!than!women!display!"atypical"!patterns!when!they!develop!CAD!
e)!!!The!male!survivors!of!MI!have!a!worse!prognosis!than!the!female!survivors!
!
Explanation:!
Men!run!a!higher!risk!of!developing!the!disease!than!premenopausal!women.!After!menopause,!the!incidence!of!CAD!
in!women!increases,!and!can!be!equal!to!men.!
!
Coronary!artery!disease!is!a!leading!cause!of!death!of!women!throughout!the!world.!
Women!have!unique!risk!factors!for!heart!disease.!These!risk!factors!include!hormone!replacement!therapy,!birth!
control!pills,!and!pregnancy]related!problems.!
Unfortunately,!many!more!women!than!men!display!"atypical"!patterns!when!they!develop!CAD,!and!these!atypical!
patterns!all!too!often!lead!to!missed!diagnoses!and!inadequate!therapy,!and!therefore,!to!worse!outcomes.!
!
Diagnostic!tests!that!work!quite!well!in!men!can!be!misleading!in!women.!The!most!common!problem!is!seen!with!
stress!testing!]!in!women,!the!electrocardiogram!(ECG)!during!exercise!can!often!show!changes!suggesting!CAD,!
whether!CAD!is!present!or!not,!making!the!study!difficult!to!interpret.!
!
Among!survivors,!18%!of!men!and!34%!of!women!have!a!second!MI!within!6!years,!7%!of!men!and!6%!of!women!die!
suddenly,!22%!of!men!and!46%!of!women!are!disabled!with!CHF,!and!8%!of!men!and!11%!of!women!have!a!stroke.!
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4. If(a(child(develops(diphtheria(now,(the(mortality(is(almost(the(same(as(it(was(50(years(ago.(But(now(the(disease(is(
not(so(common(because:!
a)!!Incidence!decreased!
b)!!Prevalence!decreased!
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c)!!Effective!antibiotics!have!been!developed!
d)!!Incidence!increased!
e)!!Prevalence!increase!
!
Explanation:!
Prevalence!is!the!number!of!events!in!a!population!at!a!designated!time.!Incidence!is!the!number!of!new!events!
arising!within!a!specified!time!period.!The!incidence!of!diphtheria!has!been!significantly!decreased!because!of!routine!
immunization.!
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5. A(713year3old(male(dies(in(the(hospital.(He(was(admitted(into(the(hospital(4(days(ago(because(of(acute(small(bowel(
obstruction.(He(underwent((abdominal(surgery(for(adhesion(lysis.(He(had(been(recovering(fairly(well(when(he(
developed(a(massive(pulmonary(embolus(12(hours(ago(that(was(confirmed(by(ventilation3perfusion(scan.(His(past(
medical(history(is(significant(for(diverticulitis(15(years(ago,(COPD(diagnosed(12(years(ago(,and(small(cell(lung(
carcinoma(diagnosed(6(months(with(metastases(to(the(brain(confirmed(3(months(ago.(What(is(the(immediate(
cause(of(death?!
a)!!Pulmonary!embolism!
b)!!Acute!small!bowel!obstruction!
c)!!Abdominal!surgery!
d)!!Small!cell!lung!carcinoma!
e)!!!Chronic!obstructive!pulmonary!disease!
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Explanation:!
Physicians!are!called!upon!to!pronounce!and!certify!the!deaths!of!patients!in!various!settings,!including!acute!care!
hospitals,!long]term!care!facilities,!and!patients’!homes.!Some!physicians!report!being!uncomfortable!with!this!duty!
but!this!need!not!be.!
Medical!certification!of!death!has!two!parts!on!section!for!the!cause!of!death.!
]Part!I!is!for!reporting!a!chain!of!events!leading!directly!to!death,!with!the!immediate!cause!of!death!(the!final!
disease,!injury,!or!complication!directly!causing!death)!on!Line!A!and!the!underlying!cause!of!death!(the!disease!or!
injury!that!initiated!the!chain!of!morbid!events!that!led!directly!and!inevitably!to!death)!on!the!lowest!used!line.!
]Part!II!is!for!reporting!all!other!significant!diseases,!conditions,!or!injuries!that!contributed!to!death!but!which!did!not!
result!in!the!underlying!cause!of!death!given!in!Part!I.!
This!person!died!of!a!pulmonary!embolism!that!resulted!from!post]operative!bed!rest!and!abdominal!surgery!for!
acute!small!bowel!osbtruction.!Pulmonary!embolism!is!the!immediate!cause!of!death!(choice!A),!while!abdominal!
surgery!and!acute!small!bowel!obstruction!are!conditions!leading!to!the!immediate!cause!of!death.!COPD!and!Small!
cell!lung!carcinoma!are!conditions!that!contributed!to!the!patient's!cause!of!death.!
!
→!Acute!small!bowel!obstruction!(choice!B)!is!a!condition!leading!to!the!immediate!cause!of!death!to!be!written!
under!pulmonary!embolism!but!it!is!not!the!immediate!cause!of!death!to!enter!on!Part!I.!
→!Abdominal!surgery!(choice!C)!is!also!another!condition!leading!to!the!immediate!cause!of!death!that!should!be!
written!under!pulmonary!embolism,!but!itself!is!not!the!immediate!cause!of!death.!
→!Small!cell!lung!carcinoma!(choice!D)!contributed!to!the!pro]thrombotic!state!of!the!patient!but!it!is!not!the!
immediate!cause!of!death.!
→!COPD!(choice!E)!is!also!a!contributing!condition!to!the!cause!of!death!but!not!the!immediate!cause!of!death.!
Key!Point:!Cause!of!death!on!medical!certificate!of!death!has!two!parts:!Part!I!has!The!immediate!cause!of!death!with!!
conditions!leading!to!it!or!antencedent!causes!right!under!the!immediate!cause.!Part!II!has!diseases!in!past!medical!
history!that!contributed!to!the!cause!of!death.!
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6. About(30(people(came(back(home(from(a(party(where(there(was(a(lot(of(food(such(as(pastries,(cheese(sandwiches(
with(mayonnaise(and(sweets.(Within(436(hours(later,(most(of(them(develop(vomiting(and(have(loose(diarrhea.(
What(is(the(most(likely(organism(to(cause(this?!
a)!!Staphylococcus!
b)!!Salmonella!
c)!!Campylobacter!
d)!!E.!coli!
e)!!Giardia!
!
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Explanation:!The!is!a!classic!case!of!food!poisoning.!Many!different!bugs!can!cause!food!poisoning!including!all!of!the!
above!choices.!
When!vomiting!is!the!major!presenting!symptom,!suspect!Staphylococcus!aureus.!Improperly!stored!foods!with!high!
salt!or!sugar!content!favor!growth!of!staphylococci.!Intense!vomiting!and!watery!diarrhea!start!1]4!hours!after!
ingestion!and!last!as!long!as!24]48!hours.!
→!Salmonella!(choice!B)!is!found!in!beef,!poultry,!eggs,!and!dairy!products.!Abrupt!onset!of!moderate!to!large!
amount!of!diarrhea!with!low]grade!fever!is!seen!and!in!some!cases,!bloody!diarrhea.!
→!Campylobacter!jejuni!(choice!C)!is!found!in!domestic!animals,!cattle,!chickens.!It!is!spread!through!fecal]oral!
transmission!in!humans!and!will!cause!foul!smelling!watery!diarrhea!followed!by!bloody!diarrhea.!
→!Enterohemorrhagic!coli!(eg,!E!coli!O157:H7)!(choice!D)!is!found!in!improperly!cooked!hamburger!meat!and!recently!
spinach!and!is!the!most!commonly!isolate!pathogen!in!bloody!diarrhea.!Diarrhea!starts!3]4!days!after!ingestion!and!
usually!progresses!from!watery!to!bloody!diarrhea.!It!lasts!for!3]8!days.!
→!Giardia!lamblia!(choice!E)!is!found!in!contaminated!ground!water.!Campers!are!a!common!group!who!get!this!
infection.!It!is!spread!through!fecal]oral!transmission!and!will!cause!mild!bloody!diarrhea!with!nausea!and!abdominal!
cramps,!which!start!2]3!days!after!ingestion,!lasting!for!1!week.!
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7. What(is(the(most(common(cause(of(death(in(women((all(age)(worldwide?!
a)!!Stroke!
b)!!Breast!cancer!
c)!!HIV!
d)!!Ischaemic!heart!disease!
e)!!Respiratory!system!disease!
!
The!correct!answer!is!d)!
8. In(comparing(experimental(studies(with(observational(studies,(which(of(the(following(statements(is(false?!
a)!!The!Hawthorne!studies!are!an!example!of!an!experimental!study!
b)!An!observational!study!uses!a!survey!to!collect!observations!and!perform!statistical!analysis!
c)!An!experimental!study!does!not!involve!experimental!manipulation!
d)!An!observational!study!does!not!involve!experimental!manipulation!
Explanation:!
In!both!types!of!studies,!the!effect!of!differences!of!an!independent!variable!(or!variables)!on!the!behavior!of!the!
dependent!variable!are!observed.!The!difference!between!the!two!types!is!in!how!the!study!is!actually!conducted.!
An!experimental!study!involves!taking!measurements!of!the!system!under!study,!manipulating!the!system,!and!then!
taking!additional!measurements!using!the!same!procedure!to!determine!if!the!manipulation!may!have!modified!the!
values!of!the!measurements.!
In!contrast,!an!observational!study!does!not!involve!experimental!manipulation.!Instead!data!are!gathered!and!
correlations!between!predictors!and!the!response!are!investigated.!
!
An!example!of!an!experimental!study!is!the!famous!Hawthorne!studies!which!attempted!to!test!changes!to!the!
working!environment!at!the!Hawthorne!plant!of!the!Western!Electric!Company.!The!researchers!were!interested!in!
whether!increased!illumination!would!increase!the!productivity!of!the!assembly!line!workers.!The!researchers!first!
measured!productivity!in!the!plant!then!modified!the!illumination!in!an!area!of!the!plant!to!see!if!changes!in!
illumination!would!affect!productivity.!As!it!turns!out,!productivity!improved!under!all!the!experimental!conditions!
(see!Hawthorne!effect).!
!
An!example!of!an!observational!study!is!a!study!which!explores!the!correlation!between!smoking!and!lung!cancer.!
This!type!of!study!typically!uses!a!survey!to!collect!observations!about!the!area!of!interest!and!then!perform!
statistical!analysis.!In!this!case,!the!researchers!would!collect!observations!of!both!smokers!and!non]smokers,!
perhaps!through!a!case]control!study,!and!then!look!at!the!number!of!cases!of!lung!cancer!in!each!group.!
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9. Medication(compliance(can(be(increased(by:!
a)!!Complicated!instructions!
b)!!More!number!of!drugs!for!treatment!
c)!!Trust!between!patient!and!doctor!
d)!!High!cost!of!drugs!
e)!!!Mental!disorder!
5
(
• The!correct!answer!is!c!
• Explanation:!Compliance!in!a!medical!context!refers!to!a!patient!agreeing!to!and!then!undergoing!some!part!of!a!
treatment!program!as!advised!by!a!doctor!or!other!healthcare!worker.!Most!commonly!it!is!a!patient!taking!
medication!(drug!compliance).!
• Causes!for!poor!compliance!include:!
1)!Forgetfulness!
2)!Prescription!not!collected!or!not!dispensed!
3)!Purpose!of!treatment!not!clear!
4)!Perceived!lack!of!effect!
5)!Real!or!perceived!side]effects!
6)!Instructions!for!administration!not!clear!
7)!Physical!difficulty!in!complying!(e.g.!opening!medicine!containers,!handling!small!tablets,!swallowing!difficulties,!
travel!to!place!of!treatment)!
8)!Unattractive!formulation,!such!as!unpleasant!taste!
9)!Complicated!regimen!
10)!High!cost!of!drugs!
11)!Mental!disorder!
• Compliance!with!treatment!can!be!improved!by:!
1)!Only!recommending!treatments!that!are!effective!in!circumstances!when!they!are!required!
2)!Selecting!treatments!with!lower!levels!of!side!effect!or!fewer!concerns!for!long]term!use!
3)!Prescribing!the!minimum!number!of!different!medications!
4)!Simplifying!dosage!regimen!
5)!Explanation!of!possible!side!effects!
6)!Advice!on!coping!with!side!effects!
7)!Developing!trust!between!patient!and!doctor!
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10. Which(of(the(following(cancer(is(caused(by(vinyl(chloride(the(most?!
a)!!Lung!cancer!
b)!!Esophagus!cancer!
c)!!Pharyngeal!cancer!
d)!!Liver!cancer!
e)!!Bladder!cancer!
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Explanation:!
Vinyl!chloride!is!a!toxic!chemical!compound!frequently!used!in!manufacturing.!It!is!a!combustible,!colorless!gas.!A!
known!human!carcinogen,!vinyl!chloride!can!cause!liver!cancer,!brain!cancer,!angiosarcoma!and!less!commonly!lung!
cancer.!People!are!exposed!to!vinyl!chloride!by!either!breathing!in!air!containing!vinyl!chloride!or!consuming!water!
contaminated!with!it.!
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11. What!is!the!best!way!to!measure!the!quality!of!health!care!during!pregnancy!and!delivery!in!Canada?!
a)!!Neonatal!mortality!rate!
b)!!Perinatal!mortality!rate!
c)!!Infant!mortality!rate!
d)!!Maternal!mortality!rate!
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Explanation:!
Perinatal!mortality!reflects!quality!of!obstetric!and!pediatric!care,!as!well!as!the!effectiveness!of!public!health!
initiatives.!
Perinatal!mortality!is!defined!as!the!rate!of!stillbirths!and!early!neonatal!deaths!(deaths!in!the!first!week!of!life)!per!
1,000!total!births!(live!births!and!stillbirths).!Stillbirths!are!defined!as!fetal!deaths!with!a!birth!weight!of!500!g!or!
more,!and!/!or!a!gestational!age!of!20!weeks!or!more!(other!jurisdictions!may!have!a!different!definition!of!stillbirth!
by!length!of!gestation!(≥20,!22,!or!28!weeks),!or!weight!(≥400!g,!500!g,!or!1,000!g),!or!both.!Therefore!provincial!or!
international!comparisons!of!stillbirth!and!perinatal!mortality!rates!should!be!made!with!caution).!It!is!usually!
reported!on!an!annual!basis.!It!is!a!major!marker!to!assess!the!quality!of!health!care!delivery.!In!Canada,!6.7!perinatal!
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deaths!occur!for!every!1,000!total!births.!
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12. All!of!the!following!can!cause!cancer,!except:!
a)!!Monosodium!glutamate!
b)!!Fat!
c)!!Alcohol!
d)!!Smoking!
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Explanation:!
Monosodium!glutamate!(MSG)!is!a!flavor!enhancer!commonly!added!to!Chinese!food,!canned!vegetables,!soups!and!
processed!meats.!Although!the!Food!and!Drug!Administration!(FDA)!has!classified!MSG!as!a!food!ingredient!that!is!
"generally!recognized!as!safe,"!the!use!of!MSG!remains!controversial.!
!
MSG!has!been!used!as!a!food!additive!for!decades.!A!comprehensive!review!of!all!available!scientific!data!on!
glutamate!safety!sponsored!by!the!FDA!reaffirmed!the!safety!of!MSG!when!consumed!at!levels!typically!used!in!
cooking!and!food!manufacturing.!The!report!found!no!evidence!to!suggest!that!MSG!contributes!to!any!long]term!
health!problems,!such!as!Alzheimer's!disease.!But!it!did!acknowledge!that!some!people!may!have!short]term!
reactions!to!MSG.!These!reactions!may!include:!headache,!flushing,!sweating,!sense!of!facial!pressure!or!tightness,!
numbness,!tingling!or!burning!in!or!around!the!mouth,!rapid,!fluttering!heartbeats!(heart!palpitations),!chest!pain!and!
shortness!of!breath.!
High!fat!diet!can!cause!colon!cancer,!alcohol!can!causes!liver!cancer!and!smoking!causes!numerous!cancers,!most!
commonly!of!the!lung.!
!
13. Rehabilitation!after!a!motor!vehicle!accident!is!a!type!of:!
a)!!Primary!prevention!
b)!!Secondary!prevention!
c)!!Tertiary!prevention!
d)!!None!of!the!above!
!
Explanation:!
Primary!Prevention!is!trying!to!prevent!a!problem!before!it!shows!any!signs!of!appearing.!Goal!is!to!remove!risk!
factors.!
Examples:!In!people!with!no!signs!of!heart!disease,!educating!them!on!exercise!and!diet,!and!urging!them!not!to!
smoke.!Giving!immunizations!to!kids!so!that!they!don’t!get!the!diseases.!
Secondary!Prevention!is!dealing!with!the!early!signs!of!a!potential!problem.!Designed!for!early!detection!and!
treatment.!
Examples:!Intervening!with!people!who!have!high!blood!pressure!(an!early!condition!that!might!lead!to!heart!
disease),!through!medication!or!other!methods.!Screening!higher!risk!patients!with!tests!(eg!cholesterol!levels!for!
obese!patients,!colonoscopy!for!those!with!positive!family!history!of!colon!cancer).!
Tertiary!Prevention:!is!treating!people!who!have!the!full,!actual!illness.!
Examples:!Performing!heart!surgery!on!people!with!advanced!disease.!Giving!rehab!to!someone!who!has!had!a!stroke!
or!been!in!an!accident.!
!
14. Occupational!hearing!loss!is!characterized!by:!
a)!!Worst!at!high!frequencies!
b)!!Worst!at!low!frequencies!
c)!!Progressive!even!if!exposure!stopped!
d)!!Conductive!in!nature!
!
The!correct!answer!is!a!
Explanation:!
Occupational!(Noise]induced)!hearing!loss!is!a!high]frequency!sensorineural!hearing!deficit!caused!by!chronic!
exposure!to!excessive!sound!levels.!Avoiding!noise!exposure!stops!further!progression!of!the!damage.!Once!exposure!
to!damaging!noise!levels!is!discontinued,!further!significant!progression!of!hearing!loss!stops.!
!
7
Conductive!hearing!loss!is!usually!due!to!some!blockage!such!as!a!tumor,!cerumen!or!foreign!body.!
!
15. Which!of!the!following!is!not!a!risk!factor!for!pancreatic!cancer?!
a)!!Caffeine!
b)!!Pancreatitis!
c)!!Diabetes!mellitus!
d)!!Smoking!
e)!!Obesity!
!
!
!
Explanation:!
Estimates!indicate!that!40%!of!pancreatic!cancer!cases!are!sporadic!in!nature.!Another!30%!are!related!to!smoking,!
and!20%!may!be!associated!with!dietary!factors.!Only!5]10%!are!hereditary!in!nature.!
!
>Smoking!is!the!most!common!environmental!risk!factor!for!pancreatic!carcinoma.!Estimates!indicate!that!smoking!
accounts!for!up!to!30%!of!cases!of!pancreatic!cancer.!People!who!smoke!have!at!least!a!2]fold!greater!risk!for!
pancreatic!cancer!than!do!nonsmokers.!
>In!a!number!of!studies,!obesity,!especially!central,!has!been!associated!with!a!higher!incidence!of!pancreatic!cancer.!
>Diabetes!mellitus!may!be!associated!with!a!2]fold!increase!in!the!risk!of!developing!pancreatic!cancer.!
>Long]standing,!chronic!pancreatitis!is!a!substantial!risk!factor!for!the!development!of!pancreatic!cancer.!The!risk!of!
pancreatic!cancer!is!even!higher!in!patients!with!hereditary!pancreatitis.!
>Approximately!5]10%!of!patients!with!pancreatic!carcinoma!have!some!genetic!predisposition!to!developing!the!
disease!
>Alcohol!consumption!does!not!appear!to!be!an!independent!risk!factor!for!pancreatic!cancer!unless!it!is!associated!
with!chronic!pancreatitis.!
!
16. A!50]year]old!man!has!come!for!a!yearly!checkup!and!has!no!complaints.!His!medical!history!and!family!history!are!
unremarkable.!What!screening!test!would!you!recommend?!
a)!!Urine!culture!
b)!!Stool!for!occult!blood!
c)!!PSA!
d)!!CXR!
e)!!Colonoscopy!
!
!
!
Explanation:!
The!following!table!illustrates!the!screening!tests!recommended!for!men!based!on!age!group:!
*PSA!testing!screening!guidelines!not!established!(Insufficient!evidence,!in!quantity!of!quality,!to!make!a!
recommendation;!however,!other!factors!may!influence!decision]making)!
For!those!at!average!risk!for!colorectal!cancer!the!Fecal!Occult!Blood!Test!(FOBT)!]!once!a!year!is!recommended.!For!
those!at!increased!risk!because!of!a!family!history!of!one!or!more!first]degree!relatives!(parent,!sibling!or!child)!with!a!
diagnosis!of!colorectal!cancer,!colonoscopy!is!advised.!
Note:!If!you!find!two!logical!answers,!try!to!choose!the!less!invasive!one.!
!
17. What!is!the!appropriate!prophylaxis!for!contacts!of!someone!who!has!developed!a!meningococcus!infection?!
a)!!Vancomycin!
b)!!Ampicillin!
c)!!Rifampin!
d)!!Penicillin!
!
Explanation:!
Meningococcal!diseases!are!infections!caused!by!Neisseria!meningitidis!(also!called!the!meningococcus)!and!include!
serious!infections!of!the!fluid!and!lining!surrounding!the!brain!(meningitis),!bloodstream!(bacteremia!and!sepsis),!
8
lungs!(pneumonia),!and!joints!(arthritis).!
!
Symptoms!include!sudden!high!fever!(usually!39º!C!or!more),!chills,!severe!headache,!difficulty!breathing,!stiff!neck!
and!back,!painful!joints!and!vomiting.!Antibiotics,!such!as!penicillin!G!or!ceftriaxone,!can!be!used!to!treat!people!with!
meningococcal!disease.!
!
The!bacteria!is!present!in!the!noses!and!throats!of!ill!persons!and!is!spread!to!close!contacts!through!saliva!or!nose!
and!throat!secretions!when!talking,!coughing,!sneezing,!kissing,!etc.!
!
Close!contacts!of!people!with!meningococcal!disease!are!at!increased!risk!for!acquiring!disease!and!should!receive!a!
prophylactic!antibiotic.!Options!include!rifampin!and!ceftriaxone.!
!
18. Which!is!the!least!likely!cause!of!HIV!infection!nowadays?!
a)!!Homosexuality!
b)!!Heterosexuality!
c)!!Prostitution!
d)!!Drug!abuse!
e)!!Blood!transfusion!
!
The!correct!answer!is!e)!
!
!
Explanation:!
When!HIV!first!started!appearing!in!large!numbers!in!North!America!in!the!early!1980’s!is!was!called!the!disease!of!
the!4!H’s!(Heroin!users,!Homosexuals,!Hepatitis!patients!and!Haitians).!Since!then!the!mode!of!transmission!of!the!
virus!has!extensively!studied!and!the!following!are!the!primary!modes!of!transmission!of!HIV!are:!
!
1)!Blood]to]blood!transmission!]!through!transfusion!of,!or!direct!contact!with,!HIV]infected!blood,!exposure!to!HIV]
contaminated!needles,!syringes,!and!other!equipment.!
!
2)!Sexual!contact!]!unprotected!vaginal,!oral,!or!anal!intercourse!direct!contact!with!HIV]infected!body!fluids!such!as!
semen!and!cervical!and!vaginal!secretions.!
!
3)!Mother!to!newborn!]!during!pregnancy,!labor!and!delivery.!
!
Since!1985!all!blood!products!all!blood!products!are!routinely!tested!for!HIV!before!being!given!during!transfusions.!
!
19. All!of!the!following!viruses!have!fecal!oral!transmission,!except:!
a)!!Hepatitis!A!
b)!!Ebstein!Barr!Virus!
c)!!Norwalk!virus!
d)!!Polio!virus!
e)!!Hepatitis!E!
!
!
Explanation:!
Viruses!that!are!transmitted!via!fecal!oral!route!include:!hepatitis!A!virus,!hepatitis!E!virus,!norwalk,!polio,!and!
numerous!others.!The!Ebstein!Barr!virus!(EBV)!causes!mononucleosis!and!is!spread!via!person]to]person!through!the!
oropharyngeal!route!via!saliva!and!possibly!spread!via!blood!transfusion.!
!
20. A!man!comes!to!you!for!genetic!counseling.!He!states!there!is!Huntington!disease!in!his!family.!His!paternal!
grandmother!died!of!it.!His!paternal!uncles!all!developed!it.!His!father!died!of!a!car!accident!at!35!years!of!age.!What!
are!the!chances!this!man!will!develop!Huntington!disease?!
a)!!50%!
b)!!100%!
c)!!0%!
d)!!25%!
9
!
!
!
Explanation:!
!
In!the!above!pedigree,!red!represents!Huntington's!disease!and!blue!represents!normal.!The!man’s!father!died!at!age!
35!and!he!is!represented!by!the!square!with!a!cross.!Since!the!age!of!onset!of!Huntington's!is!usually!after!35,!we!do!
not!know!if!the!father!had!the!disease!or!not.!The!man!himself!is!indicated!by!the!question!mark.!The!pedigree!is!
labeled!with!the!corresponding!alleles.!
!
Huntington's!disease!is!autosomal!dominant,!needing!only!one!affected!allele!from!either!parent!to!inherit!the!
disease.!This!generally!means!there!is!a!one!in!two!chance!of!inheriting!the!disorder!from!an!affected!parent.!
!
The!man's!father!will!get!one!copy!of!the!recessive!allele!‘a’!from!his!father!while!his!second!allele!has!a!50%!
probability!of!being!dominant!"A"!and!a!50%!probability!of!being!a!recessive!‘a’.!
The!man!will!get!one!recessive!‘a’!allele!from!his!mother!and!the!other!allele!depends!on!his!father's!genotype.!The!
tables!below!illustrate!the!possible!genotypes!in!the!man:!
!
!
!
Of!the!8!possible!outcomes,!the!man!will!be!affected!only!2!times.!Therefore!the!probability!is!25%!of!him!developing!
Huntington's.!
!
21. In(which(of(the(following(foods(does(botulism(occur(more(commonly?!
a)!!Frozen!packaged!foods!
b)!!Vacuum!packaged!canned!foods!
c)!!Unpacked/open!foods!
d)!!Fried!foods!
!
Explanation:!
Botulism!is!neuromuscular!poisoning!from!Clostridium!botulinum!toxin.!Symptoms!are!weakness!and!paralysis.!
Diagnosis!is!clinical!and!with!laboratory!identification!of!toxin.!Treatment!is!with!support!and!antitoxin.!
Home]canned!foods!are!the!most!common!sources,!but!commercially!prepared!foods!have!been!implicated!in!about!
10%!of!outbreaks.!Vegetables,!fish,!fruits,!and!condiments!are!the!most!common!vehicles,!but!beef,!milk!products,!
pork,!poultry,!and!other!foods!have!been!involved.!
C.!botulinum!spores!are!highly!heat]resistant!and!may!survive!boiling!for!several!hours!at!100°!C.!However,!exposure!
to!moist!heat!at!120°!C!for!30!min!kills!the!spores.!Toxins,!on!the!other!hand,!are!readily!destroyed!by!heat,!and!
cooking!food!at!80°!C!for!30!min!safeguards!against!botulism.!
!
22. A(woman,(who(is(33(weeks(pregnant,(complains(of(shoulder,(neck,(back(and(abdominal(pain(and(denies(any(recent(
trauma.(
She(later(discloses(that(her(husband(is(an(alcohol(addict.(What(is(important(to(assess(during(your(interview?!
a)!!Ask!her!about!spouse!abuse!
b)!!Ask!her!how!much!her!spouse!drinks!
c)!!Ask!her!if!she!did!something!to!cause!her!pain!
d)!!Ask!her!if!she!would!like!some!testing!done!
e)!!!Ask!about!possible!seizure!disorder!
!
Explanation:!
Studies!have!estimated!the!prevalence!of!physical!abuse!during!pregnancy!to!be!about!6%.!In!addition,!64%!of!the!
abused!women!reported!increased!abuse!during!pregnancy.!When!a!pregnant!woman!presents!with!multiple!somatic!
complaints!and!has!a!risk!factor!for!domestic!abuse,!such!as!an!alcoholic!spouse,!it!is!important!to!assess!for!this!
during!your!interview.!
!
10
23. Primary!prevention!will!lead!to!a:!
a)!!Decrease!in!the!prevalence!of!a!disease!
b)!!Decrease!in!the!incidence!of!a!disease!
c)!!Increase!in!the!prevalence!of!a!disease!
d)!!Increase!in!the!incidence!of!a!disease!
!
Explanation:!
Prevalence!is!defined!as!the!number!of!cases!of!diseases!at!a!specific!point!in!time.!Incidence!is!the!number!of!new!
cases!of!a!disease!arising!within!a!specified!time!period.!
Primary!prevention!generally!involves!the!prevention!of!diseases!and!conditions!before!their!biological!onset.!
Examples!include!giving!immunizations!to!children!and!education!to!diminish!risk]taking!behaviors.!
Primary!prevention!will!therefore!decrease!the!incidence!of!a!disease.!
!
24. An!81]year]old!woman!has!an!advanced!directive!that!states!that!she!refuses!artificial!nutrition!if!she!is!terminally!ill.!
She!has!terminal!cancer.!What!is!the!best!management!at!this!time?!
a)!!Tube!feeding!
b)!!IV!Fluid!
c)!!Gastrostomy!
d)!!Palliative!end!care!
e)!!Offer!assistance!with!euthanasia!
!
!
!
Explanation:!
Advance!directives!are!legal!documents!that!allow!you!to!convey!your!decisions!about!end]of]life!care!ahead!of!time.!
They!provide!a!way!for!you!to!communicate!your!wishes!to!family,!friends!and!health!care!professionals,!and!to!avoid!
confusion!later!on.!
!
Since!this!patient!is!terminal,!the!appropriate!management!consists!of!palliative!care!in!a!hospice!(choice!D).!
!
Hospice!care!is!for!people!who!are!nearing!the!end!of!their!lives.!Hospice!care!is!designed!to!relieve!or!decrease!pain,!
or!other!symptoms,!and!provide!as!much!quality!time!as!possible!with!family!and!friends.!But!unlike!other!medical!
care,!the!focus!of!hospice!care!is!no!longer!on!curing!or!treating!the!underlying!disease.!The!goal!of!hospice!care!is!to!
offer!as!high!a!quality!of!life!as!possible!during!a!person's!final!days.!
!
→!Tube!feeding!(choice!A)!is!an!artificial!nutrition!that!is!delivered!via!percutaneous!endoscopic!gastrostomy!(choice!
C),!and!both!are!not!consistent!with!this!patient's!wishes!of!end]of]life!care.!
→!IV!fluids!(choice!B)!is!considered!artificial!hydration,!which!is!a!form!of!artificial!nutrition!that!can!also!include!total!
parenteral!nutrition.!If!a!patient!declined!artificial!nutrition,!usually!this!includes!total!parenteral!nutrition!and!
artificial!hydration!delivered!intravenously.!Hospice!centers!usually!have!dieticians!who!can!support!patient's!with!
their!nutrition!needs!in!ways!that!do!not!contradict!their!advanced!directives.!
→!Offer!assistance!with!euthanasia!(choice!E)!is!incorrect.!Active!euthanasia!is!illegal!in!Canada!and!offering!palliative!
care!would!be!the!best!management!plan.!
!
!
25. An!82]year]old!woman!with!severe!uncontrolled!diabetes!develops!gangrene!of!her!right!leg.!She!will!need!an!
amputation!of!her!leg!but!states!she!does!not!want!the!operation.!A!day!later!she!becomes!drowsy,!unconscious,!
disoriented,!develops!sepsis!and!goes!into!a!coma.!Her!family!tells!you!do!this!operation.!What!do!you!do?!
a)!!Do!the!operation!as!family!wishes!
b)!!Call!the!lawyer!in!hospital!
c)!!Treat!her!sepsis!but!don't!do!the!operation!
d)!!Do!nothing!
!
Explanation:!
Legal!and!ethical!issues!are!often!difficult!to!deal!with.!The!physician!however!should!follow!this!general!series!of!
11
events:!
1)!Do!what!the!patient!says!
2)!If!patient!is!unable!to!communicate!or!is!incompetent,!do!what!the!patient!has!written!in!their!healthcare!advance!
directive!
3)!If!no!such!document!exists,!do!what!the!patient’s!health!care!proxy!says!(someone!who!the!patient!had!previously!
designated!to!make!decisions!of!their!behalf)!
4)!If!no!health!care!proxy!exists,!do!what!the!family!says!
5)!If!no!family!exists,!or!family!is!unable!to!reach!agreement,!then!involve!the!hospital!ethics!committee!and/or!the!
lawyers/courts!
In!this!scenario.!Since!this!patient!had!stated!to!you!while!she!was!competent!that!she!did!not!want!an!amputation,!
you!must!document!and!follow!her!wishes.!Even!though!the!family!is!present!and!has!agreed!upon!a!plan,!the!
physician!should!follow!the!previously!expressed!wishes!of!the!patient.!
!
26. The!best!measure!to!prevent!hepatitis!A!in!the!community!is?!
a)!!Screening!of!blood!products!
b)!!Reducing!IV!drug!use!
c)!!Safe!sex!practices!
d)!!Good!hygiene!
!
Explanation:!
Hepatitis!A!is!spread!primarily!from!the!stool!of!one!person!to!the!mouth!of!another,!usually!because!of!poor!hygiene.!
For!example,!when!an!infected!person!prepares!food!with!unwashed!hands.!Hepatitis!A!is!sometimes!spread!in!day!
care!centers,!where!caregivers!and!children!can!come!in!contact!with!infected!stool!in!diapers.!
!
Epidemics,!usually!linked!to!contamination!of!water!supplies!by!stool,!are!common,!especially!in!developing!
countries.!
!
Good!hygiene!in!handling!food!and!avoiding!contamination!of!water!supplies!is!important.!Vaccination!against!
hepatitis!A!is!recommended!for!all!children.!It!is!also!recommended!for!adults!at!high!risk!of!exposure!to!the!
infection.!
!
Hepatitis!B,!C!and!D!are!transmitted!parenterally!and!their!prevention!is!with!answer!choices!a),!b)!and!c).!
!
27. A!developing!country!has!started!an!immunization!program!for!measles!for!their!children.!What!is!least!likely!to!
happen?!
a)!!Reduced!cost!of!hospitalization!due!to!measles!
b)!!Reduced!surveillance!for!break!out!in!community!
c)!!Reduced!incidence!of!measles!
d)!!Reduced!overall!cost!of!health!care!related!to!measles!
e)!!Reduced!length!of!hospital!stays!due!to!measles!
!
!
!
Explanation:!
Immunizations!are!a!form!of!primary!prevention.!Primary!prevention!aims!to!prevent!the!disease!from!occurring.!So!
primary!prevention!reduces!both!the!incidence!and!prevalence!of!a!disease.!
!
E)!falls!under!tertiary!prevention.!
!
28. Which!of!the!following!is!true!regarding!most!cases!of!elderly!abuse?!
a)!!Depression!in!the!elderly!decreases!the!incidence!
b)!!Medical!condition!in!the!elderly!decreases!the!incidence!
c)!!The!abuser!is!not!a!relative!
d)!!Victims!are!usually!men!
e)!!Perpetrator!is!usually!the!caregiver!
!
12
!
!
Explanation:!
Elder!abuse!is!an!extremely!complex!problem.!Caring!for!a!non]well!older!adult!suffering!from!a!mental!or!physical!
impairment!is!highly!stressful.!Individuals!who!do!not!have!the!requisite!skills,!information,!resources,!etc.!and!who!
are!otherwise!ill]prepared!for!the!caregiving!role!may!experience!extreme!stress!and!frustration.!This!may!lead!to!
elder!abuse!and/or!neglect.!
!
It!has!been!argued!that!as!an!older!adult’s!dependency!increases!so!does!the!resentment!and!stress!of!the!caregiver.!
Studies!have!found!that!individuals!in!poor!health!are!more!likely!to!be!abused!than!individuals!who!are!in!relatively!
good!health.!In!addition,!caregivers!who!are!dependent!on!the!elder!financially!are!also!more!likely!to!perpetrate!
abuse!(choice!E).!Women!are!believed!to!be!the!most!common!victims!of!abuse,!perhaps!because!they!report!abuse!
at!higher!rates!or!because!the!severity!of!injury!in!women!typically!is!greater!than!in!men.!
!
29. A!pregnant!woman!tells!you!that!she!plans!to!go!to!Cambodia!to!care!for!her!mother.!Which!of!the!following!is!the!
most!appropriate!advice?!
a)!!Chloroquine!prophylaxis!cannot!be!given!as!this!is!teratogenic!
b)!!Hepatitis!A!vaccine!cannot!be!given!
c)!!She!needs!diphtheria!and!tetanus!booster!if!her!last!dose!was!given!10!years!ago!
d)!!She!will!need!the!MMR!vaccine!
!
!
!
Explanation:!
When!traveling!to!Cambodia,!malaria!prophylaxis!is!recommended.!Chloroquine!is!pregnancy!category!C!and!risk!and!
benefits!must!be!weighed!before!giving!this!drug!to!a!pregnant!woman.!
!
The!safety!of!hepatitis!A!vaccination!during!pregnancy!has!not!been!determined;!however,!because!hepatitis!A!
vaccine!is!produced!from!inactivated!hepatitis!A!virus,!the!theoretical!risk!to!the!developing!fetus!is!expected!to!be!
low.!The!risk!associated!with!vaccination!should!be!weighed!against!the!risk!for!hepatitis!A!in!pregnant!women!who!
may!be!at!high!risk!for!exposure!to!hepatitis!A!virus.!
!
Pregnancy!is!not!a!contraindication!for!use!of!Tdap.!
!
Measles]mumps]rubella!(MMR)!vaccine!and!its!component!vaccines!should!not!be!administered!to!women!known!to!
be!pregnant.!
!
30. Five(physicians(are(deliberating(over(whether(the(patient(they(have(examined(is(exhibiting(the(auscultatory(signs(of(
mitral(valve(prolapse(or(not.(Assuming(that(there(would(be(agreement(by(chance(of(50%,(but,(in(fact,(four(of(the(
five(physicians(actually(agree(on(the(findings,(what(is(the(chance3corrected(agreement((kappa)(for(the(clinical(
findings?!
a)!!0.8!
b)!!0.75!
c)!!0.7!
d)!!0.6!
e)!!0.5!
!
Explanation:!
Kappa!is!an!index!which!compares!the!agreement!against!that!which!might!be!expected!by!chance.!Kappa!can!be!
thought!of!as!the!chance]corrected!proportional!agreement,!and!possible!values!range!from!+1!(perfect!agreement)!
via!0!(no!agreement!above!that!expected!by!chance)!to!]1!(complete!disagreement).!
Kappa!=!(Observed!agreement!]!Chance!agreement)/(1!]!Chance!agreement)!
In!this!question,!Kappa!=!(0.8!]!0.5)!/!(1!]!0.5)!=!0.3/0.5!=!0.6.!
!
13
31. What!is!the!most!important!advice!to!give!to!a!traveler!to!prevent!transmission!of!cholera?!
a)!!Do!not!use!public!washrooms!
b)!!Hand!washing!
c)!!Avoid!taking!ice!water!that!has!not!been!boiled!
d)!!Immunization!
e)!!Do!not!eat!meat!
!
Explanation:!
Cholera!is!an!acute!infection!of!the!small!bowel!by!Vibrio!cholerae,!which!secretes!a!toxin!that!produces!copious!
watery!diarrhea,!leading!to!dehydration,!oliguria,!and!collapse.!Infection!is!typically!through!contaminated!water!or!
seafood.!Diagnosis!is!by!culture!or!serology.!Treatment!is!vigorous!rehydration!and!electrolyte!replacement!along!
with!doxycycline.!
To!control!cholera,!human!excrement!must!be!properly!disposed!of!and!water!supplies!purified.!Drinking!water!
should!be!boiled!or!chlorinated!and!vegetables!and!fish!cooked!thoroughly.!
!
32. A!15]year]old!girl!comes!to!your!office!and!is!asking!for!oral!contraceptive!pills!(OCP’s).!What!is!the!appropriate!
action?!
a)!!Advise!and!offer!OCP!
b)!!Request!a!letter!of!parental!consent!
c)!!Refuse!to!prescribe!OCP!
d)!!Offer!non]OCP!alternative!(eg!abstinence,!condom!etc)!
!
!
!
Explanation:!
According!to!Canadian!law,!there!is!no!minimum!age!to!prescribe!contraception,!and!youth!are!under!no!legal!
obligation!to!inform!their!parents!that!they!are!being!prescribed!or!are!using!contraception.!Clinical!staff!is!also!under!
no!legal!obligation!to!report!contraceptive!use!to!parents.!In!fact,!reporting!contraceptive!use!would!breach!patient!
confidentiality.!
!
!
33. Medication!nonadherence!in!patients!leads!to!considerable!worsening!of!disease,!death,!and!increased!health!care!
costs.!The!consequence!of!nonadherence!is!waste!of!medication,!disease!progression,!reduced!functional!abilities,!a!
lower!quality!of!life,!increased!use!of!medical!resources!such!as!nursing!homes,!hospital!visits!and!hospital!
admissions.!Which!of!the!following!is!most!related!to!patient!compliance!with!medication?!
a)!!Age!and!Gender!
b)!!Number!of!medications!in!drug!therapy!
c)!!Chornic!vs!acute!disease!
d)!!Number!of!comorbid!diseases!
e)!!Use!of!tablets/pills!versus!use!of!elixirs!
!
!
Explanation:!
Patient!compliance!can!be!affected!by!the!following:!side!effects,!convenience!of!dosing,!cost!and!socioeconomic!
status!and!polypharmacy.!
a)!Cost!]!There!is!greater!cost!with!multiple!drugs.!
b)!Convenience!]!It!is!easier!to!forget!to!take!multiple!drugs.!
c)!Confusion!]!Patients!often!become!confused!by!multiple!drugs!and!frequently!dose!them!incorrectly.!
!
Patients!most!often!become!non]compliant!for!chronic!diseases,!like!hypertension,!where!they!do!not!have!any!
unpleasant!symptoms!even!without!strict!compliance!to!medication!regimen.!
!
34. A!new!screening!test!for!a!type!of!cancer!is!carried!out!on!10,000!subjects.!One!hundred!and!sixty!have!a!positive!
result,!of!whom!eight!are!determined!to!actually!have!the!disease.!These!eight!subjects!survived!longer!than!other!
persons!suffering!from!the!same!type!of!cancer!diagnosed!by!other!means.!Which!one!of!the!following!statements!is!
14
correct?!
a)!!The!sensitivity!of!this!test!is!4%!(10,000]160)/10,000!
b)!!The!incidence!of!the!disease!in!this!population!is!80!per!100,000!
c)!!Early!detection!by!this!test!improves!survival!
d)!!The!predictive!value!of!a!positive!test!is!5%!(8/160)!
e)!!The!predictive!value!of!a!negative!test!is!95%!(152/160)!
!
Explanation:!
The!above!graphic!illustrates!how!to!calculate!various!epidemiological!values.!If!we!use!the!information!in!the!
question!we!obtain!the!following!table:!
!
!
!
The!positive!predictive!value!(PPV)!=!8/160!=!5%!
!
!
Question!#35!
QID:!381!
Topic:!Correlation!Coefficient!
Subject:!PMCH!
!
The!statistical!measure!of!the!degree!of!relationship!between!two!sets!of!numbers!is:!
a)!!The!average!
b)!!The!standard!deviation!
c)!!The!normal!distribution!
d)!!The!standardized!scores!
e)!!The!correlation!coefficient!
!
!
!
Explanation:!
In!epidemiology,!the!‘correlation!coefficient’,!indicates!the!strength!and!direction!of!a!linear!relationship!between!
two!random!variables.!
!
In!general!statistical!usage,!correlation!or!co]relation!refers!to!the!departure!of!two!variables!from!independence.!In!
this!broad!sense!there!are!several!coefficients,!measuring!the!degree!of!correlation,!adapted!to!the!nature!of!data.!
!
!
Question!#36!
QID:!385!
Topic:!Palliative!Care!
Subject:!PMCH!
!
An!elderly!man!with!cancer!of!the!prostate!and!metastasis,!is!now!complaining!of!increased!intolerable!back!pain!and!
constipation.!He!states!he!is!already!tired!of!all!aggressive!treatments.!What!is!the!best!initial!therapy!for!this!
patient's!condition?!
a)!!Radiation!treatment!
b)!!Morphine!to!relieve!pain!
c)!!Dexamethasone!
d)!!Lidocaine!patch!
e)!!Chemical!epidural!neurolysis!
!
!
!
Explanation:!
15
!No!treatment!has!been!proven!to!increase!the!life!expectancy!of!patients!with!spinal!metastasis.!The!goals!of!therapy!
are!pain!control!and!functional!preservation.!The!most!important!prognostic!indicator!for!spinal!metastases!is!the!
initial!functional!score.!The!ability!to!ambulate!at!the!time!of!presentation!is!a!favorable!prognostic!sign.!Loss!of!
sphincter!control!is!a!poor!prognostic!feature!and!mostly!irreversible.!
!
For!this!patient,!the!best!initial!therapy!is!dexamethasone!(choice!C).!Steroid!therapy!is!effective!in!treating!bone!
pain.!Of!all!the!corticosteroids,!dexamethasone!has!the!least!mineralocorticoid!effect!and!is!least!likely!to!be!
associated!with!infection!or!cognitive!dysfunction.!Complications!from!treatment!with!dexamethasone!are!likely!to!
occur!after!3!weeks!of!treatment.!In!about!70]80%!of!patients,!symptoms!improve!within!48!hours!of!treatment.In!
most!patients,!steroid!use!must!be!continued!until!radiotherapy!is!completed.!
!
>!!Radiation!therapy!(choice!A)!is!the!mainstay!treatment!preferred!in!bone!metastases.!CT!or!MRI!of!the!spine!should!
be!done!first!to!precisely!know!the!location!of!tumor!and!critical!normal!structures.!The!traditional!treatment!plan,!or!
radiation!port,!is!to!include!2!vertebral!bodies!above!and!2!below!the!lesion.!This!range!is!based!on!the!fact!that!
recurrence!is!most!common!in!bodies!contiguous!to!the!site!of!involvement.!While!this!treatment!may!eventually!be!
done!for!this!patient,!the!best!initial!treatment!is!dexamethasone.!
>!Morphine!to!relieve!pain!(choice!B)!is!likely!to!worsen!the!patient's!constipation.!The!severity!of!pain!in!these!
patients!makes!treatment!with!strong!opioids!an!important!option!and!often!laxatives!are!considered!in!constipated!
patients!who!need!morphine,!while!this!patient!may!eventually!have!to!opt!for!that!option,!out!of!the!choices!we!
have!here!dexamethasone!is!the!best!initial!treatment.!
>!Lidocaine!patch!(choice!D)!is!less!effective!than!dexamethasone!in!relieving!pain!in!these!patients.!
>Chemical!epidural!neurolysis!!(choice!E)!is!infrequently!used!to!treat!medically!intractable!pain.!!It!is!effective!for!
interrupting!single!or!multiple!radicular!pain,!but!it!poses!a!risk!of!acute!deterioration!especially!when!structural!
instability!or!compression!is!present.!
!
!
!
Question!#37!
QID:!424!
Topic:!Epidemiological!Values!
Subject:!PMCH!
!
From!information!recorded!at!school!A!it!was!found!that,!out!of!a!total!of!400!missed!'person!days'!during!November,!
100!were!due!to!measles;!200!to!"flu";!and!the!rest!to!various!other!causes.!At!school!B!in!the!same!neighborhood,!
during!the!same!period!of!time,!a!total!of!75!children!were!absent!for!1!or!more!days.!Of!these,!25!had!suffered!from!
measles;!25!from!"flu"!and!the!rest!from!various!other!causes.!It!can!be!concluded!that:!
a)!!The!incidence!of!measles!was!greater!in!school!"B"!than!in!school!"A"!
b)!!The!incidence!of!"flu"!was!greater!in!school!"B"!than!in!school!"A"!
c)!!The!overall!morbidity!rate!was!higher!in!school!"A"!than!in!school!"B"!
d)!!The!incidence!of!"other!causes"!was!greater!in!school!"A"!than!in!school!"B"!
e)!!None!of!the!above!conclusions!can!be!reached!with!the!data!provided!
!
!
!
Explanation:!
Morbidity,!is!defined!as!a!diseased!condition!or!state,!the!incidence!of!a!disease!or!of!all!diseases!in!a!population.!In!
epidemiology,!the!term!"morbidity!rate"!can!refer!to!either!the!incidence!rate,!or!the!prevalence!of!a!disease!or!
medical!condition.!
Incidence!rate!=!Number!of!new!cases!of!a!disease!occurring!in!the!population!during!a!specified!time!period!/!
Number!of!persons!exposed!to!risk!of!developing!the!disease!during!that!period!of!time.!
!
None!of!the!above!conclusions!can!be!reached!with!the!data!provided.!
!
!
Question!#38!
QID:!426!
16
Subject:!PMCH!
!
A!case!control!study!was!conducted!in!which!50!cases!and!50!controls!were!interviewed!to!inquire!about!their!history!
of!exposure!to!substance!'X'.!The!following!table!resulted:!
!
!
!
The!'odds!ratio'!(estimate!of!the!relative!risk)!is:!
a)!!0.17!
b)!!1.50!
c)!!2.0!
d)!!3.0!
e)!!6.0!
!
!
!
Explanation:!
!
!
The!above!graphic!illustrates!how!to!calculate!the!‘odds!ratio’.!In!this!question!the!calculation!would!be:!(40x30)!/!
(20x10)!=!6.!
!
!
Question!#39!
QID:!441!
Topic:!Immunization!
Subject:!PMCH!
!
Haemophilus!influenzae!Type!B!vaccine!has!been!recommended!for!which!one!of!the!following!groups?!
a)!!All!children!at!the!time!of!their!first!birthday!
b)!!Any!child!with!impaired!immunity!or!chronic!disease!
c)!!All!children!after!the!age!of!5!years!
d)!!Siblings!and!daycare!contacts!of!children!who!develop!systemic!Haemophilus!influenzae!Type!B!infections,!
regardless!of!age!
e)!!All!children!at!age!2!months!
!
!
!
Explanation:!
Hib!disease!is!preventable!by!immunizing!all!children!under!age!5!years!with!an!approved!Hib!vaccine.!Several!Hib!
vaccines!are!available.!The!general!recommendation!is!to!immunize!children!with!a!first!dose!at!2!months!of!age!and!
to!follow!with!additional!doses!based!on!the!schedule!for!the!vaccine!being!used.!If!a!child!under!age!5!has!missed!
getting!immunized,!a!health]care!provider!can!give!details!on!the!required!vaccine!dosage!and!schedule.!
!
!
Question!#40!
QID:!447!
Subject:!PMCH!
!
The!incidence!of!a!particular!disease!is!greater!in!men!than!in!women,!but!the!prevalence!shows!no!sex!difference.!
The!most!probable!explanation!is!that:!
a)!!The!mortality!rate!is!higher!in!women!
b)!!The!case!fatality!rate!is!higher!in!women!
c)!!The!duration!of!the!disease!is!longer!in!women!
d)!!Women!receive!less!adequate!medical!care!for!the!disease!
17
e)!!This!diagnosis!is!more!often!missed!in!women!
!
!
!
Explanation:!
Incidence!is!defined!as!the!number!of!new!cases!of!a!disease.!Prevalence!is!the!number!of!existing!cases!of!a!disease!
at!a!particular!point!in!time.!If!the!duration!of!the!disease!is!longer!in!women,!then!there!would!be!no!difference!in!
prevalence,!even!if!the!incidence!is!higher!in!men!(choice!C).!The!increased!number!of!males!with!the!disease!would!
die!sooner!and!therefore!the!overall!number!would!not!affect!the!prevalence.!
!
!
Question!#41!
QID:!448!
Topic:!Cholera!
Subject:!PMCH!
!
The!causative!organism!of!cholera,!Vibrio!cholerae,!has!been!recognized!for!100!years.!Outbreaks!of!cholera!often!
reach!epidemic!proportions,!the!history!of!seven!pandemics!can!now!be!traced.!Which!one!of!the!following!is!the!
spread!of!this!infection,!enhanced!by!modern!transportation?!
a)!!Fomites!
b)!!Mosquitoes!
c)!!Contaminated!food!sources!
d)!!Person]to]person!
e)!!Domestic!flies!
!
!
!
Explanation:!
Cholera!is!an!acute!infection!of!the!small!intestine!caused!by!the!bacterium!Vibrio!cholerae!and!characterized!by!
extreme!diarrhea!with!rapid!and!severe!depletion!of!body!fluids!and!salts.!Cholera!has!often!risen!to!epidemic!
proportions!in!sub]Saharan!Africa!and!South!Asia,!particularly!in!India!and!Bangladesh.!In!the!past!two!centuries,!
seven!pandemics!(global!epidemics)!of!cholera!have!been!reported.!
!
Cholera!is!typically!transmitted!by!either!contaminated!food!or!water.!
!
!
Question!#42!
QID:!450!
Topic:!Occupational!Asthma!
Subject:!PMCH!
!
Which!is!not!associated!with!occupational!asthma?!
a)!!Polyvinyl!chloride!
b)!!Isocyanate!
c)!!Anhydride!
d)!!Radiation!
!
!
!
Explanation:!
Numerous!substances!are!associated!with!occupation!asthma!including!plastic!and!rubber!dusts!(polyvinyl!chloride),!
isocyanates!and!acid!anhydrides.!
!
!
Question!#43!
18
QID:!452!
Topic:!Life!Expectancy!
Subject:!PMCH!
!
Life!expectancy!is!a!comprehensive!measure!of!the!health!status!of!a!population.!This!measure!is:!
a)!!On!the!average,!the!expected!number!of!years!to!be!lived!by!a!cohort!
b)!!The!usual!amount!of!time!a!person!in!a!population!can!expect!to!live!free!of!disease!
c)!!The!age!beyond!which!less!than!about!0.1%!of!the!original!cohort!of!people!live!
d)!!The!age!where!50%!or!more!of!a!population!cohort!have!died!
e)!!The!maximum!age!that!human!beings!as!a!species!could!reach!under!optimum!conditions!
!
!
!
Explanation:!
Life!expectancy!is!a!statistical!measure!of!the!average!length!of!survival!of!a!living!thing.!It!is!often!calculated!
separately!for!differing!gender!and!geographic!location.!Popularly,!it!is!most!often!construed!to!mean!the!life!
expectancy!at!birth!for!a!given!human!population,!which!is!the!same!as!the!expected!age!at!death.!However,!
technically,!life!expectancy!means!the!expected!time!remaining!to!live,!and!it!can!be!calculated!for!any!age.!
!
!
Question!#44!
QID:!463!
Topic:!Fluoride!Supplements!
Subject:!PMCH!
!
To!promote!good!dental!health!among!children!living!in!areas!with!low!natural!fluoride!in!the!water!supply,!it!is!
recommended!that!fluoride!supplements!be!given!from:!
a)!!Birth!to!adolescence!
b)!!The!third!month!of!pregnancy!to!age!6!years!
c)!!The!time!of!appearance!of!the!first!tooth!until!the!eruption!of!the!first!molar!
d)!!Birth!to!age!2!years!
e)!!Age!6!months!to!age!16!years!
!
!
!
Explanation:!
It!is!suggested!that!only!children!living!in!non]fluoridated!areas!use!dietary!fluoride!supplements!between!the!ages!of!
six!months!to!16!years.!
!
!
Question!#45!
QID:!482!
Topic:!Relative!Risk!
Subject:!PMCH!
!
Calculate!the!relative!risk!in!the!following!epidemiological!table:!
!
!
a)!!100!
b)!!10!
c)!!0.5!
d)!!0.1!
!
!
!
19
Explanation:!
!
!
The!above!graphic!illustrates!how!to!calculate!the!relative!risk.!In!this!question!would!be:!
(50/100)!/!(5/1000)!=!100.!
!
Relative!risk!is!a!ratio!of!the!probability!of!the!event!occurring!in!the!exposed!group!versus!the!control!(non]exposed)!
group.!
!
For!example,!if!the!probability!of!developing!lung!cancer!among!smokers!was!20%!and!among!non]smokers!1%,!then!
the!relative!risk!of!cancer!associated!with!smoking!would!be!20.!Smokers!would!be!twenty!times!as!likely!as!non]
smokers!to!develop!lung!cancer.!
!
!
Question!#46!
QID:!497!
Topic:!CVA!Prevention!
Subject:!PMCH!
!
Which!of!the!following!is!the!most!important!factor!for!preventing!a!cerebrovascular!accident!(CVA)?!
a)!!Hypertension!control!
b)!!Smoking!cessation!
c)!!Lipid!lowering!agent!
d)!!Aspirin!
!
!
!
Explanation:!
Cerebrovascular!Accident!(CVA),!also!known!as!stroke,!involves!heterogeneous!group!of!vascular!disorders!that!result!
in!brain!injury.!
!
More!impressive!than!the!mortality!rates!are!the!ways!in!which!stroke!changes!the!survivor's!quality!of!life.!Daily!
functioning!in!the!workplace,!home,!and!community!is!often!reduced,!and!many!stroke!patients!are!impaired!in!their!
ability!to!walk,!see,!and!feel.!Some!cannot!read,!recall,!think,!speak,!or!otherwise!communicate!as!well!as!they!could!
before!the!stroke.!Dementia!may!result,!especially!if!multiple!lacunar!infarcts!occur.!
!
Prevention!of!CVA!is!by!controlling!blood!pressure,!avoiding!smoking!and!watching!cholesterol!levels.!
!
!
Question!#47!
QID:!503!
Topic:!Cohort!
Subject:!PMCH!
!
In!studies!of!prognosis,!a!cohort!of!patients!should!be!studied!to!provide!accurate!information!on!survival.!This!cohort!
is!best!assembled!by!enrolling:!
a)!!All!patients!with!the!disease!of!interest!and!estimating!the!date!of!onset!of!first!symptoms!
b)!!All!patients!on!the!same!calendar!date!
c)!!Patients!when!they!develop!the!first!complications!of!the!disease!
d)!!Only!patients!compliant!with!treatment!for!their!disease!
e)!!Patients!at!an!early!and!uniform!point!in!the!course!of!their!disease!
!
!
!
Explanation:!
A!cohort!is!a!group!of!people,!identified!by!a!common!characteristic,!which!are!studied!over!a!period!of!time!as!part!
20
of!a!scientific!or!medical!investigation.!
The!survival!time!is!considered!to!be!from!symptom!onset!to!death.!Survival!rates!are!important!for!prognosis.!For!
any!study!of!prognosis,!it!is!important!to!identify!patients!at!an!early!and!uniform!point!in!the!course!of!their!disease.!
!
!
Question!#48!
QID:!506!
Subject:!PMCH!
!
Which!one!of!the!following!descriptors!of!a!diagnostic!test!is!directly!influenced!by!the!prevalence!of!the!disease!
being!tested!for:!
a)!!Specificity!
b)!!Sensitivity!
c)!!Accuracy!
d)!!Positive!predictive!value!
e)!!Reliability!
!
!
!
Explanation:!
!
!
Positive!predictive!value!(PPV)!is!defined!as:!of!all!the!people!with!a!positive!test!for!a!disease,!the!number!that!
actually!have!the!disease!being!tested.!It!is!related!(directly!proportional)!to!the!prevalence!of!the!disease.!The!higher!
the!prevalence,!the!higher!the!PPV!will!be.!
!
!
Question!#49!
QID:!519!
Topic:!Medication!Management!
Subject:!PMCH!
!
A!nicotine!patch!is!contraindicated!in!which!of!the!following:!
a)!!Pregnancy!
b)!!CVA!
c)!!Mild!arrhythmia!
d)!!Depression!
e)!!Hyperthyroidism!
!
!
!
Explanation:!
The!nicotine!patch!is!contraindicated!in!the!following:!
!
Pregnancy!]!Pregnant!smokers!should!first!be!encouraged!to!quit!without!pharmacologic!treatment.!The!Nicotine!
Patch!should!be!used!during!pregnancy!only!if!the!likelihood!of!smoking!abstinence,!with!its!potential!benefits,!
outweighs!the!risk!of!nicotine!replacement!and!potential!concomitant!smoking.!A!nicotine!patch!is!contraindicated!
during!pregnancy!because!it!causes!vasoconstriction,!and!pre!eclampsia.!
!
CONTRAINDICATIONS!for!Nicotine!Patches!
>Under!age!18!
>Women!who!are!pregnant!or!nursing!
>Immediate!post]myocardial!infarction!period!
>Patients!with!severe!arrhythmia!
>Patients!with!severe!or!worsening!angina!pectoris!
21
!
Use!with!CAUTION:!
>hyperthyroidism!
>pheochromocytoma!
>insulin]dependent!diabetes!
>active!peptic!ulcers!
>very!high!blood!pressure!
>severe!skin!conditions!
>!kidney!or!liver!disease!
!
!
Question!#50!
QID:!532!
Topic:!Tertiary!Prevention!
Subject:!PMCH!
!
An!example!of!tertiary!prevention!is:!
a)!!Immunizations!
b)!!Screening!tests!
c)!!Rehabilitation!
d)!!Education!about!diet!and!exercise!
!
!
!
Explanation:!
factors.!
!
!
treatment.!
!
Examples:!Intervening!with!people!who!have!high!blood!pressure,!through!medication!or!other!methods.!Screening!
higher!risk!patients!with!tests!(eg!cholesterol!levels!for!obese!patients,!colonoscopy!for!those!with!positive!family!
history!of!colon!cancer).!
!
!
!
!
Question!#51!
QID:!567!
Topic:!Primary!Prevention!
Subject:!PMCH!
!
All!of!the!following!are!examples!of!primary!prevention,!except:!
a)!!Immunizations!
b)!!Health!related!education!
c)!!Pap!smear!
d)!!Risk!factor!identifying!and!altering!
!
!
22
!
Explanation:!
Primary!Prevention!is!trying!to!prevent/inhibit!a!problem!before!it!shows!any!signs!of!appearing.!Goal!is!to!remove!
risk!factors.!
!
!
treatment.!(it!is!also!called!'screening')!
!
Examples:!Intervening!with!people!who!have!high!blood!pressure,!through!medication!or!other!methods.!Screening!
higher!risk!patients!with!tests!(eg!cholesterol!levels!for!obese!patients,!colonoscopy!for!those!with!positive!family!
history!of!colon!cancer).!
!
!
!
!
Question!#52!
QID:!597!
Subject:!PMCH!
!
All!of!the!following!are!live!attenuated!vaccines,!except:!
a)!!BCG!
b)!!Yellow!fever!
c)!!Rubella!
d)!!Measles!
e)!!Diptheria!
!
!
!
Explanation:!
Vaccines!which!contain!tiny!amounts!of!live!cells!of!a!particular!disease!are!considered!live!vaccines.!In!healthy!
people,!this!is!just!enough!to!give!them!protection!against!infection.!But!these!vaccines!can!be!dangerous!in!people!
that!are!immunocompromised!and!they!should!not!have!them,!unless!under!specialist!supervision.!
!
Live!vaccines!are!those!given!for!measles,!mumps!and!rubella!(MMR),!TB!(BCG!vaccine),!yellow!fever,!and!the!oral!
typhoid!vaccine.!
!
!
Question!#53!
QID:!619!
Topic:!Risk!Factors!
Subject:!PMCH!
!
The!relation!between!asbestosis!and!smoking!in!the!cause!of!lung!cancer!is!known!as:!
a)!!Additive!
b)!!Synergistic!
c)!!Antagonist!
d)!!Exclusive!
!
!
23
!
Explanation:!
It!is!not!uncommon!for!the!effect!of!two!risk!factors!for!a!disease!to!be!greater!than!the!effect!of!each!individually,!or!
the!sum!of!the!individual!effects.!The!presence!of!one!risk!factor!enhances!the!effects!of!the!second.!This!is!called!a!
synergistic!effect!or!synergy,!and!the!risk!factors!are!sometimes!described!as!showing!synergism.!The!mathematical!
equation!to!represent!synergism!is!1+1=3.!
!
!
Question!#54!
QID:!644!
Topic:!Salmonella!Prevention!
Subject:!PMCH!
!
A!restaurant!owner!is!worried!about!an!outbreak!of!Salmonella!in!the!community.!What!is!the!best!preventive!
measure!she!can!take!to!avoid!a!similar!incident!in!her!customers?!
a)!!Keep!restrooms!clean!
b)!!Cook!poultry,!ground!beef,!and!eggs!thoroughly.!
c)!!Do!not!add!MSG!to!any!food!
d)!!Turn!off!all!air!conditioners!
e)!!Wash!hands,!kitchen!work!surfaces,!and!utensils!with!hot!water!immediately!after!they!have!been!used.!
!
!
!
Explanation:!
Salmonella,!primarily!produces!gastroenteritis,!bacteremia,!and!focal!infection.!Symptoms!may!be!diarrhea,!high!
fever!with!prostration,!or!those!of!focal!infection.!
!
Human!disease!occurs!by!direct!and!indirect!contact!with!numerous!species!of!infected!animals,!the!foodstuffs!
derived!from!them,!and!their!excreta.!Infected!meat,!poultry,!raw!milk,!eggs,!and!egg!products!are!common!sources!
of!Salmonella.!Other!reported!sources!include!infected!pet!turtles!and!reptiles,!carmine!red!dye,!and!contaminated!
marijuana.!
!
Drinking!water!should!be!purified,!sewage!should!be!disposed!of!effectively,!milk!should!be!pasteurized,!chronic!
carriers!should!avoid!handling!food,!and!adequate!patient!isolation!precautions!should!be!implemented.!Special!
attention!to!enteric!precautions!is!important.!Wash!hands,!kitchen!work!surfaces,!and!utensils!with!soap!and!water!
immediately!after!they!have!been!in!contact!with!raw!meat!or!poultry.!Cook!poultry,!ground!beef,!and!eggs!
thoroughly.!Do!not!eat!or!drink!foods!containing!raw!eggs,!or!raw!(unpasteurized)!milk.!
!
Diagnosis!is!by!cultures!of!blood,!stool,!or!site!specimens.!Treatment,!when!indicated,!is!with!trimethoprim]
sulfamethoxazole!or!ciprofloxacin.!
!
!
!
Question!#55!
QID:!699!
Topic:!Research!Bias!
Subject:!PMCH!
!
Following!introduction!of!a!screening!program!in!a!population,!the!mean!survival!time!after!diagnosis!of!breast!cancer!
increased!by!18!months.!The!major!problem!in!assessing!the!effectiveness!of!the!program!is:!
a)!!Interobserver!error!
b)!!Lead!time!bias!
c)!!Multiple!comparisons!
d)!!Selection!bias!
e)!!Changing!natural!history!of!the!disease!
!
24
!
!
Explanation:!
Lead!time!bias!is!the!overestimation!of!survival!duration!among!screen]detected!cases!when!survival!is!measured!
from!diagnosis.!In!the!figure!below!(representing!one!patient)!there!is!a!10!year!survival!at!the!point!of!the!clinical!
diagnosis!(old),!but!a!15!year!survival!from!the!early!diagnosis!(new).!This!is!simply!a!reflection!of!earlier!diagnosis,!
however,!as!the!overall!survival!time!of!the!patient!is!unchanged.!
!
!
!
!
Question!#56!
QID:!754!
Topic:!Case!Control!Study!
Subject:!PMCH!
!
A!physician!resident!wished!to!determine!the!relationship!between!an!ear!infection!in!young!children!and!parental!
history!of!the!same!infection.!From!the!records!of!a!large!pediatric!practice,!he!identified!100!children!between!one!
and!three!years!of!age!who!had!experienced!at!least!three!ear!infections!in!the!past!year.!100!children!in!the!same!
age!group,!treated!by!the!same!practice!for!other!illnesses,!were!also!identified.!The!physician!interviewed!the!
parents!of!subjects!in!both!groups!to!determine!their!history!of!the!target!illness!as!young!children.!
Which!of!the!following!study!types!is!being!used!by!this!physician?!
a)!!Randomized!clinical!trial!
b)!!Cohort!study!
c)!!Case]control!study!
d)!!Cross]sectional!study!
e)!!Controlled!trial!
!
!
!
Explanation:!
A!case!control!study!is!a!study!that!compares!two!groups!of!people:!those!with!the!disease!or!condition!under!study!
(cases)!and!a!very!similar!group!of!people!who!do!not!have!the!disease!or!condition!(controls).!Researchers!study!the!
medical!and!lifestyle!histories!of!the!people!in!each!group!to!learn!what!factors!may!be!associated!with!the!disease!or!
condition.!For!example,!one!group!may!have!been!exposed!to!a!particular!substance!that!the!other!was!not.!Also!
called!a!retrospective!study.!
!
!
Question!#57!
QID:!770!
Topic:!Attack!Rate!
Subject:!PMCH!
!
In!a!classroom!of!25!students!(15!males!and!10!females),!5!males!develop!hepatitis!A!over!a!2!week!period.!During!the!
next!6!weeks,!an!additional!3!males!and!2!females!develop!the!infection.!The!attack!rate!of!hepatitis!A!in!this!
classroom!is:!
a)!!25%!
b)!!30%!
c)!!35%!
d)!!40%!
e)!!45%!
!
!
!
Explanation:!
An!attack!rate!in!epidemiology!is!the!cumulative!incidence!of!infection!in!a!group!of!people!observed!over!a!period!of!
25
time!during!an!epidemic,!usually!in!relation!to!foodborne!illness.!
!
The!term!is!defined!as!the!number!of!exposed!persons!infected!with!the!disease!divided!by!the!total!number!of!
exposed!persons.!
!
In!this!question!the!attack!rate!is!(5+3+2)/25!=!40%!
!
!
Question!#58!
QID:!776!
Topic:!Asbestos!
Subject:!PMCH!
!
The!occurrence!of!malignant!mesothelioma!has!been!correlated!with!industrial!exposure!to:!
a)!!Asbestos!
b)!!Beryllium!
c)!!Coal!dust!
d)!!Nitrogen!dioxide!
e)!!Silica!
!
!
!
Explanation:!
Asbestos]related!disorders!are!caused!by!inhalation!of!asbestos!fibers.!The!disorders!include!asbestosis;!lung!
carcinoma;!nonmalignant!pleural!plaque!formation!and!thickening;!benign!pleural!effusions;!and!malignant!
mesothelioma.!Asbestosis!and!mesothelioma!both!cause!progressive!dyspnea.!
!
Diagnosis!is!based!on!history!and!chest!x]ray!or!CT!and,!in!the!case!of!malignancy,!tissue!biopsy.!Treatment!is!
supportive,!except!for!malignancies,!which!may!require!surgery!and/or!chemotherapy.!
!
!
Question!#59!
QID:!808!
Topic:!Pesticides!
Subject:!PMCH!
!
A!local!farmer!experiences!peculiar!symptoms!after!using!a!pesticide.!From!which!source!could!you!most!easily!and!
quickly!get!toxicological!data!on!a!pesticide?!
a)!!Environmental!Protection!Agency!
b)!!Medical!Officer!of!Health!
c)!!Provincial!department!or!ministry!of!Agriculture!
d)!!Canadian!Manufacturers!Association!
e)!!Poison!Control!Center!
!
!
!
Explanation:!
Poison!Control!Centers!(PCC)!play!a!major!role!in!reducing!the!morbidity!and!mortality!associated!with!poisonings.!
These!centers!are!staffed!24!hours!a!day!with!trained!poison!information!specialists,!including!pharmacists,!nurses!
and!physicians.!They!have!access!to!numerous!resources!including!‘Poisondex’,!a!computerized!system!containing!
information!and!treatment!protocols!for!more!than!800,000!products.!
!
PCCs!aid!in!the!prevention,!diagnosis!and!management!of!specific!poisonings!through!rapid!and!efficient!assessment!
of!the!poison!exposure;!identification!of!toxic!ingredients!and!plants;!increasing!public!awareness!of!the!importance!
of!avoiding!potentially!hazardous!home!remedies;!providing!location!of!specific!antidotes!and!other!special!
treatments;!reducing!healthcare!costs!through!home!management!of!minor!exposures!and!prevention!of!minor!
26
hospital!visits;!public!education!campaigns;!and!provision!of!phone!numbers!for!other!important!toxicology!
resources.!
!
!
Question!#60!
QID:!809!
Topic:!Substitute!Decision!Making!
Subject:!PMCH!
!
You!are!asked!to!see!a!75]year]old!woman!with!dementia!and!severe!pneumonia.!You!discuss!the!issues!surrounding!
her!illness!with!her!son!who!is!her!only!living!next]of]kin.!He!is!firm!that!she!would!not!want!intubation!for!respiratory!
failure!in!this!situation.!This!is!an!example!of!which!one!of!the!following?!
a)!!Physician]assisted!suicide!
b)!!Substitute!decision]making!
c)!!Euthanasia!
d)!!Voluntarism!
e)!!Resource!allocation!
!
!
!
Explanation:!
If!a!physician!finds!a!patient!incapable!of!making!their!own!decisions!about!any!form!of!medical!treatment,!he/she!
will!ask!another!person!to!make!decisions!for!the!patient.!This!other!person!is!called!a!"substitute!decision]maker"!
(SDM).!The!SDM!has!to!follow!particular!rules!when!making!treatment!decisions!for!the!patient.!
!
The!physician!determines!who!is!the!appropriate!SDM.!The!physician!then!asks!the!SDM!to!make!treatment!decisions!
for!the!patient.!The!person!named!SDM!could!be!one!of!the!patients:!guardian,!attorney,!a!family!member,!or,!if!
there!is!no!one!else!willing!to!act,!the!Public!Guardian!and!Trustee!(PGT).!If!there!is!more!than!one!person!named!
SDM!(for!example,!there!are!2!brothers)!both!must!agree!on!the!treatment!decisions.!
!
Before!any!medical!treatment!begins!(except!in!specific!cases!of!emergency)!either!the!person!or!the!SDM!must!give!
"informed!consent"!to!the!treatment.!An!SDM!is!entitled!to!all!of!the!information!that!the!person!would!be!entitled!
to!before!making!a!decision!about!treatment.!
!
!
Question!#61!
QID:!828!
Topic:!Public!Health!Physician's!Responsibilities!
Subject:!PMCH!
!
The!public!health!physician's!responsibilities!in!the!community!include!all!of!the!following,!except:!
a)!!Prevention!of!sexually!transmitted!diseases!(STDs)!
b)!!Control!of!workplace!air!quality!
c)!!Preventive!dental!programs!for!children!
d)!!Infectious!disease!surveillance!
e)!!Health!promotion!activities!
!
!
!
Explanation:!
The!public!health!physician's!responsibilities!in!the!community!include!prevention!of!sexually!transmitted!diseases!
(STD),!preventive!dental!programs!for!children,!infectious!disease!surveillance!and!health!promotion!activities.!The!
Occupational!Safety!&!Health!Administration!(OHSA)!is!responsible!for!control!of!workplace!air!quality.!
!
!
Question!#62!
27
QID:!833!
Subject:!PMCH!
!
Administration!of!fluoride!is!known!to!prevent!dental!caries.!Which!one!of!the!following!is!the!most!effective!
community!health!measure!for!the!provision!of!fluorides?!
a)!!Daily!brushing!of!teeth!with!toothpaste!containing!fluoride!
b)!!Fluoride!enrichment!of!dry!breakfast!cereals!
c)!!Daily!fluoride!supplements!in!the!form!of!tablets!or!drops!
d)!!Fluoridation!of!public!drinking!water!supplies!
e)!!Intensive!topical!application!program!for!school!children!
!
!
!
Explanation:!
Fluoridation!of!public!water!supplies!is!a!safe,!economical,!and!effective!measure!to!prevent!dental!caries.!Physicians!
should!know!the!fluoride!content!of!local!drinking!water!supplies,!educate!patients!to!prevent!excessive!fluoride!
intake,!and!be!knowledgeable!about!the!health!risks!and!benefits!associated!with!fluoride.!Dietary!fluoride!
supplements!should!be!considered!for!children!from!ages!6!months!through!16!years!when!drinking!water!levels!are!
suboptimal.!
!
!
Question!#63!
QID:!834!
Topic:!Prophylaxis,!Haemophilus!influenzae!
Subject:!PMCH!
!
You!have!just!made!the!diagnosis!of!Haemophilus!influenzae!type!B!epiglottitis!in!a!3]year]old!boy.!You!know!that!
your!patient!has!a!1]year]old!unimmunized!brother.!Which!preventive!measure!among!family!contacts!is!
appropriate?!
a)!!Rifampin!prophylaxis!in!all!family!members!
b)!!Rifampin!prophylaxis!in!adults!only!
c)!!Rifampin!prophylaxis!in!children!only!
d)!!Immunization!in!children!less!than!18!months!old!
e)!!Immunization!of!all!family!members!
!
!
!
Explanation:!
Epiglottitis!is!a!rapidly!progressive!bacterial!infection!of!the!epiglottis!and!surrounding!tissues!that!may!lead!to!
sudden!respiratory!obstruction!and!death.!Symptoms!include!severe!sore!throat,!dysphagia,!high!fever,!drooling,!and!
inspiratory!stridor.!Diagnosis!requires!direct!visualization!of!the!supraglottic!structures,!which!is!not!to!be!performed!
until!full!respiratory!support!is!available.!
!
Treatment!includes!airway!protection!and!antibiotics.!If!a!child!is!diagnosed!with!epiglottitis,!the!child's!family!or!
other!close!contacts!are!usually!treated!with!a!medication!called!Rifampin,!to!prevent!the!disease!in!those!people!
who!might!have!been!exposed.!
!
!
Question!#64!
QID:!839!
Topic:!Life!Expectancy!
Subject:!PMCH!
!
Over!the!last!40!years,!expectation!of!life!in!Canada!has!improved!steadily!in!both!sexes.!The!main!reason!for!this!
overall!increase!in!life!expectancy!is:!
28
a)!!The!trend!toward!lower!fertility!rates!
b)!!The!average!age!of!the!population!is!increasing!
c)!!Improvements!in!cause]specific!mortality!rates!
d)!!The!decline!in!the!infant!mortality!rate!
e)!!Decreases!in!death!rates!at!older!ages!
!
!
!
Explanation:!
Life!expectancy!in!Canada!for!both!sexes!combined!has!surpassed!80!years.!Between!1979!and!2004,!life!expectancy!
among!men!rose!6.4!years,!while!among!women,!it!increased!only!3.8!years.!
!
Life!expectancy!rose!in!2004!for!both!sexes,!but!the!growth!was!stronger!among!men.!For!men,!life!expectancy!
increased!by!0.4!years!to!77.8!years,!while!for!women,!it!went!up!by!only!0.2!years!to!82.6.!The!main!contributing!
factor!is!that!during!the!past!25!years,!the!infant!mortality!rate!has!declined!by!52%.!
!
Life!expectancy!is!defined!as!!the!average!number!of!years!that!a!newborn!could!expect!to!live,!if!he!or!she!were!
subject!to!the!age]specific!mortality!rates!of!a!given!period.!An!average!national!life!expectancy!is!calculated!based!on!
age,!race,!gender,!social!status,!and!causes!of!death.!In!the!past!,!a!very!simple!model!of!age]specific!mortality!used!
the!Gompertz!function,!but!now!more!sophisticated!methods!are!used.!Life!expectancy!increases!with!age!as!the!
individual!survives!the!higher!mortality!rates!associated!with!childhood!(choice!D).!In!recent!years!with!widespread!of!
vaccination!against!infectious!disease!that!used!to!kill!young!children!(!eg:!Hemophilus!influenza!vaccine),!eradication!
of!some!diseases,!and!improved!healthcare!for!others!(e.g!better!surgical!care!of!some!congenital!heart!diseases),!
have!increased!the!average!life!expectancy.!As!risks!of!mortality!for!dying!young!in!a!national!population!decrease,!
life!expectancy!increases.!
!
>!The!trend!toward!lower!fertility!rates!(choice!A)!is!incorrect.!While!high!fertility!rate!is!often!associated!with!a!rise!in!
the!rates!of!maternal!and!child!mortality,!low!fertility!rate!without!improved!care!for!children!who!are!born!or!people!
in!general!would!not!by!itself!improve!life!expectancy.!Lower!fertility!is!strongly!associated!with!increased!income!per!
capita,!which,!indirectly,!can!contribute!to!increased!life!expectancy,!but!this!is!not!the!main!reason!of!the!
significantly!improved!life!expectancy!over!the!last!40!years.!
!
!>Improvements!in!cause]specific!mortality!rates!(choice!C),!which!leads!to!an!increased!average!age!of!the!
population!(choice!B)!and!decrease!in!death!rates!at!older!ages!(choice!E)!can!indeed!contribute!to!national!life!
expectancy,!but!considering!changes!over!the!last!40!years,!this!contribution!is!minimal!and!is!not!the!main!reason!of!
increased!life!expectancy.!This!has!largely!been!affected!by!drastic!falls!in!child!mortality!as!improved!healthcare!
provision!saved!lives!of!children!who!could!have!died!at!a!young!age.!
!
!
Question!#65!
QID:!848!
Topic:!Canada!Health!Act!
Subject:!PMCH!
!
The!Canada!Health!Act!(1984)!penalizes!provinces!which:!
a)!!Have!not!established!a!health]planning!mechanism!
b)!!Do!not!have!a!province]wide!homecare!program!
c)!!Permit!extra]billing!by!physicians!
d)!!Do!not!have!a!province]wide!public!health!and!prevention!program!
e)!!Cover!only!part!of!hospital!construction!costs!
!
!
!
Explanation:!
The!Canada!Health!Act’s!mandatory!and!discretionary!penalties!are:!
!
29
Mandatory!penalties!]!under!the!Canada!Health!Act,!provinces!and!territories!that!allow!extra]billing!and!user!charges!
are!subject!to!mandatory!dollar]for]dollar!deductions!from!the!federal!transfer!payments.!For!example,!if!it!has!been!
determined!that!a!province!has!allowed!$500,000!in!extra]billing!by!physicians,!the!federal!transfer!payments!to!that!
province!would!be!reduced!by!that!amount.!
!
Discretionary!penalties!]!breaches!of!the!five!criteria!and!two!conditions!of!the!Canada!Health!Act!are!subject!to!
discretionary!penalties.!The!amount!of!any!deduction!is!based!on!the!gravity!of!the!default.!
!
!
Question!#66!
QID:!857!
Topic:!Statistical!Significance!
Subject:!PMCH!
!
During!a!clinical!trial,!the!difference!in!the!success!rates!of!two!drugs!was!not!statistically!significant.!This!means!that:!
a)!!There!is!no!difference!in!drug!effectiveness!
b)!!There!is!a!sizable!probability!that!the!demonstrated!difference!in!the!drugs'!effectiveness!could!occur!due!to!
chance!alone!
c)!!The!demonstrated!difference!in!the!drugs'!effectiveness!is!too!small!to!be!clinically!meaningful!
d)!!The!two!samples!of!patients!on!which!the!drugs!were!tested!came!from!the!same!population!
!
!
!
Explanation:!
Epidemiology!and!statistics,!describes!a!mathematical!measure!of!difference!between!groups.!The!difference!is!said!
to!be!significant!if!it!is!greater!than!what!might!be!expected!to!happen!by!chance!alone.!This!is!also!called!statistically!
significant.!
!
!
Question!#67!
QID:!862!
Topic:!HIV!
Subject:!PMCH!
!
Prior!to!1988,!among!Canadian!children!less!than!18!years!of!age,!which!one!of!the!following!group!made!up!the!
largest!number!of!individuals!infected!with!human!immunodeficiency!virus!(HIV)?!
a)!!Infants!of!HIV]positive!mothers!
b)!!Male!hemophiliacs!
c)!!Victims!of!sexual!abuse!
d)!!Children!of!mothers!who!are!intravenous!drug!abusers!
e)!!Teenage!runaways!
!
!
!
Explanation:!
In!Canadian!children!less!than!18!years!of!age,!the!largest!number!of!individuals!infected!with!human!
immunodeficiency!virus!(HIV)!is!among!male!hemophiliacs.!
!
The!most!serious!complications!of!hemophilia!in!the!last!20!years!have!been!blood]borne!infections.!Many!
hemophiliacs!in!Canada!have!been!infected!with!HIV!(Human!Immuno]deficiency!Virus),!hepatitis!B!and!hepatitis!C.!
They!received!these!infections!from!the!plasma,!cryoprecipitate!and,!especially,!the!factor!concentrates!which!were!
supposed!to!make!their!lives!normal.!
!
In!Canada!approximately!35%!of!hemophiliacs!were!infected!with!HIV.!This!tragedy!forced!very!rapid!changes!in!the!
way!blood!products!were!manufactured.!As!a!result!there!have!been!no!HIV!infections!through!factor!concentrates!in!
Canada!since!1988.!
30
!
!
Question!#68!
QID:!876!
Topic:!Food!Poisoning!
Subject:!PMCH!
!
Which!one!of!the!following!is!least!helpful!in!the!investigation!of!an!outbreak!of!suspected!food!poisoning?!
a)!!Culture!of!vomitus!of!affected!persons!
b)!!Culture!of!feces!of!affected!persons!
c)!!Rapid!identification!of!cases!
d)!!Collection!of!samples!of!food!eaten!
e)!!Identification!of!foods!consumed!by!individuals!
!
!
!
Explanation:!
In!the!investigation!of!a!food!poisoining!outbreak!it!is!important!to!have!rapid!identification!of!cases.!All!samples!of!
food!eaten!should!be!collected!and!identified.!To!know!with!certainty!that!a!bacterium!is!causing!food!poisoning,!the!
bacterium!must!be!cultured,!usually!from!stool!and!is!rarely!ever!done!from!vomitus.!
!
!
Question!#69!
QID:!887!
Topic:!Health!Insurance!
Subject:!PMCH!
!
To!qualify!for!federal!contributions,!provincial!health!insurance!plans!must!guarantee!all!of!the!following,!except:!
a)!!Portability!of!coverage!from!province!to!province!
b)!!Benefits!include!all!necessary!out]of]hospital!drugs,!dental!care!and!prostheses!
c)!!Universal!coverage!on!uniform!terms!and!conditions!
d)!!Administration!on!a!non]profit!basis!
e)!!Benefits!include!all!necessary!hospital!care!and!physicians'!services!
!
!
!
Explanation:!
To!qualify!for!federal!contributions,!provincial!health!insurance!plans!must!guarantee!portability!of!coverage!from!
province!to!province,!universal!coverage!on!uniform!terms!and!conditions,!administration!on!a!non]profit!basis!and!
benefits!include!all!necessary!hospital!care!and!physicians'!services.!Benefits!such!as!out]of]hospital!drugs,!dental!
care!and!prostheses!are!not!part!of!the!provincial!health!insurance!plans.!
!
!
Question!#70!
QID:!911!
Topic:!P!value!
Subject:!PMCH!
!
Two!medical!students!poll!a!random!sample!of!classmates!concerning!their!choices!for!residency!training!and!find!
that!the!percentage!of!women!who!plan!to!train!in!primary!care!is!significantly!higher!than!the!percentage!of!men!
(p<0.05).!The!probability!is!less!than!5%!that:!
a)!!The!sampled!men!will!enter!a!primary!care!field!
b)!!The!difference!between!the!men!and!women!is!real!
c)!!All!the!women!in!the!class!will!enter!a!primary!care!field!
d)!!The!difference!between!the!sampled!men!and!women!is!due!to!chance!
e)!!This!sample!reflects!the!choices!of!the!whole!class!
31
!
!
!
Explanation:!
The!p]value!is!a!measure!of!how!likely!it!is!to!get!data!if!no!real!difference!existed.!Therefore,!a!small!p]value!(0.05)!
indicates!that!there!is!a!small!chance!of!getting!this!data!if!no!real!difference!existed!and!therefore!one!decides!that!
the!difference!in!group!expression!data!is!statistically!significant.!
!
For!example,!in!a!study!if!the!p]value!is!0.05,!that!means!that!there!is!a!5%!probability!that!the!results!are!due!to!
chance!alone.!
!
!
Question!#71!
QID:!912!
Subject:!PMCH!
!
A!total!of!10,000!Vietnam!veterans,!with!and!without!cancer!were!asked!to!give!a!history!of!their!exposure!to!Agent!
Orange.!This!scenario!best!illustrates!which!one!of!the!following?!
a)!!Case!series!report!
b)!!Case]control!study!
c)!!Clinical!trial!
d)!!Cohort!study!
e)!!Case!report!
!
!
!
Explanation:!
A!case]control!study!is!a!study!that!compares!two!groups!of!people:!those!with!the!disease!or!condition!under!study!
!
[A!retrospective!study!looks!backwards!and!examines!exposures!to!suspected!risk!or!protection!factors!in!relation!to!
an!outcome!that!is!established!at!the!start!of!the!study.!Case]Control!studies!are!usually!but!not!exclusively!
retrospective,!the!opposite!is!true!for!cohort!studies.]!
!
!
!
Question!#72!
QID:!913!
Topic:!World's!Population!
Subject:!PMCH!
!
The!population!of!less]developed!countries!is!growing.!Which!one!of!the!following!statements!is!most!responsible!for!
this!trend?!
a)!!Policies!to!limit!family!size!have!been!ineffective!
b)!!Their!birth!rates!are!increasing!
c)!!Birth!control!programs!have!been!ineffective!
d)!!Their!mortality!rates!are!decreasing!
e)!!Population!equilibrium!cannot!be!attained!in!less]developed!countries!
!
!
!
32
Explanation:!
We!are!living!in!a!world!of!unprecedented!demographic!change.!After!growing!very!slowly!for!most!of!human!history,!
the!world’s!population!more!than!doubled!in!the!last!half!century!to!reach!6!billion!in!late!1999.!By!2007!it!had!
reached!6.7!billion.!Lower!mortality,!longer!life!expectancy!and!a!youthful!population!in!countries!where!fertility!
remains!high!all!contributed!to!the!rapid!population!growth!of!recent!decades.!
!
According!to!the!2007!Revision,!the!world!population!is!expected!to!rise!in!the!next!43!years!by!2.5!billion,!to!reach!a!
total!of!9.2!billion!in!2050.!The!increase!is!equivalent!to!the!total!world!population!in!1950.!Essentially!all!of!the!
growth!will!take!place!in!the!less!developed!countries,!and!will!be!concentrated!among!the!poorest!populations!in!
urban!areas.!
!
By!contrast,!the!overall!population!of!the!more!developed!countries!is!likely!to!show!little!change!over!the!next!43!
years,!remaining!at!about!1.2!billion.!Fertility!is!below!replacement!level!in!all!45!developed!countries!or!areas,!as!
well!as!in!28!developing!countries!including!China.!The!population!of!developed!regions!is!aging!and!would!actually!
decline!were!it!not!for!migration.!The!populations!of!Germany,!Italy,!Japan!and!most!of!the!successor!states!of!the!
former!Soviet!Union!are!expected!to!be!lower!in!2050!than!they!are!today.!
!
!
Question!#73!
QID:!931!
Subject:!PMCH!
!
Live!rubella!vaccine!should!be!given!to:!
a)!!Children!between!one!year!and!puberty!
b)!!Infants!less!than!one!year!
c)!!All!adults!
d)!!Pregnant!women!
e)!!All!exposed!patients!
!
!
!
Explanation:!
Rubella!vaccine!is!recommended!for!all!children!and!for!adolescents!and!adults!without!documented!evidence!of!
immunity.!It!is!especially!important!to!verify!that!all!women!of!child]bearing!age!are!immune!to!rubella!before!they!
get!pregnant.!
!
The!first!dose!of!MMR!(measles,!mumps,!rubella)!should!be!given!on!or!after!the!first!birthday;!the!recommended!
range!is!from!12]15!months.!A!dose!given!before!12!months!of!age!may!not!be!counted,!so!the!child's!medical!
appointment!should!be!scheduled!with!this!in!mind.!
!
The!second!dose!is!usually!given!when!the!child!is!4]6!years!old,!or!before!he!or!she!enters!kindergarten!or!first!grade.!
However,!the!second!dose!can!be!given!anytime!as!long!as!it!is!at!least!four!weeks!after!the!first!dose.!MMR!can!only!
be!given!through!age!12!years.!
!
Severely!immunocompromised!persons!should!not!be!given!MMR!vaccine.!Women!are!advised!not!to!receive!the!
rubella!vaccine!during!pregnancy!as!a!safety!precaution!based!on!the!theoretical!possibility!of!a!live!vaccine!causing!
disease,!in!this!case!"congenital!rubella!syndrome".!
!
!
Question!#74!
QID:!933!
Topic:!Echoviruses!
Subject:!PMCH!
!
Echoviruses!have!been!implicated!as!etiology!of!which!one!of!the!following!diseases?!
a)!!Aseptic!meningitis!
33
b)!!Guillain]Barré!syndrome!
c)!!Reye's!syndrome!
d)!!Orchitis!
e)!!Hemolytic!uremic!syndrome!
!
!
!
Explanation:!
More!than!90%!of!community]acquired!cases!of!viral!and!acute!aseptic!meningitis!are!caused!by!group!B!
coxsackieviruses!or!echoviruses.!Group!B!coxsackievirus!serotypes!2]5!and!echovirus!serotypes!4,!6,!9,!11,!16,!and!30!
are!found!most!commonly.!Echoviruses!can!also!cause!encephalitis!vesicular!rashes!and!herpangina.!
!
!
Question!#75!
QID:!945!
Topic:!Disease!Transmission!
Subject:!PMCH!
!
The!mode!of!disease!transmission!that!is!most!difficult!to!prevent!is:!
a)!!Person]to]person!spread!
b)!!Droplet!spread!
c)!!Vector!spread!
d)!!Vehicle!spread!
e)!!Airborne!spread!
!
!
!
Explanation:!
The!most!difficult!mode!of!transmission!to!prevent!is!airborne!spread.!An!organism!must!be!transmitted,!either!
directly!or!indirectly,!from!one!place!to!another.!Direct!transmission!included!person]to]person!spread!by!skin!
contact!and!droplet!spread!produced!by!coughing,!sneezing,!talking!or!singing!within!close!proximity!of!a!susceptible!
host.!
!
Indirect!transmission!occurs!when!the!reservoir!and!the!susceptible!host!are!separated.!This!type!of!transmission!
involves!vector!spread,!vehicle!spread!and!airborne!spread.!
!
Disease!disseminated!by!the!airborne!route!are!the!most!difficult!to!prevent!and!thus!are!able!to!infect!large!numbers!
of!individuals!in!a!relatively!short!period!of!time.!For!example,!a!new!strain!of!influenza!virus!can!spread!throughout!
the!world!in!a!relatively!short!period!of!time.!
!
!
Question!#76!
QID:!948!
Topic:!Randomization!
Subject:!PMCH!
!
In!a!randomized!controlled!clinical!trial,!the!purpose!of!randomization!is!to:!
a)!!Keep!the!study!subjects!"blind"!to!treatment!received!
b)!!Keep!the!observers!"blind"!to!treatment!received!
c)!!Get!a!random!sample!of!the!population!for!treatment!
d)!!Minimize!the!bias!between!the!two!groups!
!
!
!
Explanation:!
34
Randomization!is!a!process!that!assigns!research!participants!by!chance,!rather!than!by!choice,!to!either!the!
investigational!group!or!the!control!group!of!a!clinical!trial.!Each!study!participant!has!a!fair!and!equal!chance!of!
receiving!either!the!new!intervention!being!studied!(by!being!placed!in!the!investigational!group),!or!of!receiving!the!
existing!or!"control"!intervention!(by!being!placed!in!the!control!group).!
!
Research!participants!are!randomized!in!clinical!trials!so!that!bias!does!not!weaken!the!study!results.!Bias!consists!of!
human!choices,!beliefs!or!any!other!factors!besides!those!being!studied!that!can!affect!a!clinical!trial's!results.!If!
physicians!or!participants!themselves!choose!the!group,!assignments!might!be!personally!influenced!and!therefore!
unevenly!slanted!toward!one!side!or!the!other.!
!
For!instance,!if!a!study!is!not!randomized,!physicians!might!unconsciously!assign!participants!with!a!more!hopeful!
prognosis!to!the!experimental!group,!thus!making!the!new!therapy!seem!more!effective!than!it!really!is.!Conversely,!
participants!with!a!less!hopeful!prognosis!might!pick!the!experimental!treatment,!leading!it!to!look!less!effective!than!
it!really!is.!Randomization!prevents!such!bias.!In!a!randomized!trial,!investigators!use!a!computer!program!or!a!table!
of!random!numbers!to!assign!each!study!participant!to!a!group.!
!
!
Question!#77!
QID:!964!
Subject:!PMCH!
!
Which!one!of!the!following!conditions!contraindicates!routine!immunization!in!Canada?!
a)!!Prematurity!
b)!!Anaphylaxis!to!a!component!of!the!vaccine!
c)!!Antibiotic!therapy!
d)!!Living!with!a!pregnant!woman!
e)!!Allergy!to!penicillin!
!
!
!
Explanation:!
Every!patient!should!be!screened!for!contraindications!and!precautions!before!receiving!any!vaccine!dose.!Checklists!
and!routine!screening!questions!are!useful!ways!to!ensure!that!this!takes!place.!
!
The!only!three!contraindications!to!vaccines!approved!in!Canada!that!may!exist!are!the!following:!
1.!Anaphylaxis!to!a!component!of!the!vaccine!(can!occur!with!any!vaccine)!
2.!Significant!immunosuppression!(live!vaccines!only)!
3.!Pregnancy!(live!vaccines!only)!
!
For!more!detailed!information,!please!refer!to:!
http://www.phac]aspc.gc.ca/publicat/cig]gci/p02]02]eng.php!
!
!
Question!#78!
QID:!965!
Topic:!Tertiary!Prevention!
Subject:!PMCH!
!
Lung!cancer!is!an!important!cause!of!morbidity!and!mortality.!With!respect!to!lung!cancer,!which!one!of!the!following!
measures!would!be!described!as!tertiary!prevention?!
a)!!Higher!taxes!on!tobacco!products!
b)!!Pulmonary!rehabilitation!programs!for!patients!following!lung!cancer!resection!
c)!!Municipal!bylaws!to!restrict!tobacco!smoking!in!the!workplace!
d)!!Annual!chest!x]ray!in!smokers!over!the!age!50!
e)!!High!school!education!programs!describing!the!link!between!smoking!and!lung!cancer!
!
35
!
!
Explanation:!
factors.!
!
!
treatment.!
!
!
!
!
!
Question!#79!
QID:!966!
Subject:!PMCH!
!
A!pediatrician!hypothesizes!that!children!who!consume!large!amounts!of!a!particular!food!additive!are!more!likely!to!
be!hyperactive!than!children!who!do!not.!To!test!this!hypothesis,!he!interviews!the!parents!of!100!hyperactive!
children!(identified!from!the!medical!records!of!six!child!psychiatrists)!and!100!children!undergoing!treatment!by!one!
of!the!same!six!physicians!for!other!behavioural!problems!to!determine!the!dietary!habits!of!their!children!over!the!
preceding!two!years.!This!study!is!an!example!of!which!one!of!the!following?!
a)!!Cohort!study!
b)!!Case]control!study!
c)!!Cross]sectional!prevalence!survey!
d)!!Case!series!report!
e)!!Non]randomized!controlled!trial!
!
!
!
Explanation:!
Case]control!study!is!an!epidemiological!study!which!involves!identifying!patients!who!have!the!outcome!of!interest!
(cases)!and!control!patients!who!do!not!have!that!same!outcome,!and!looking!back!to!see!if!they!had!the!exposure!of!
interest.!The!exposure!could!be!some!environmental!factor,!a!behavioural!factor,!or!exposure!to!a!drug!or!other!
therapeutic!intervention.!
!
!
Question!#80!
QID:!997!
Subject:!PMCH!
!
Hemochromatosis!has!a!prevalence!of!0.5%!in!the!general!population.!The!treatment!of!choice!is!regular!phlebotomy.!
You!have!decided!to!initiate!a!new!test!for!this!disease.!The!literature!indicates!a!sensitivity!of!80%!and!a!specificity!of!
89.5%!for!this!test.!You!decide!to!screen!1000!people!and!institute!treatment!solely!on!the!results!of!the!test.!Which!
one!of!the!following!is!correct?!
36
a)!!You!will!treat!40!people!with!phlebotomy!
b)!!995!people!will!not!be!treated!
c)!!105!people!who!do!not!have!the!disease!will!be!treated!with!phlebotomy!
d)!!80%!of!the!subjects!will!be!correctly!diagnosed!
e)!!200!people!who!have!the!disease!will!be!denied!treatment!
!
!
!
Explanation:!
!
!
Using,!sensitivity!=!a/(a+c)=!80%!and!specificity!=!d/(b+d)!=!89.5%!and!the!fact!that!the!total!group!has!1000!people!
and!the!percentage!with!the!disease!on!average!is!0.5%,!we!arrive!at!the!following!table!for!this!example:!
!
!
!
Thus,!you!will!treat!109!people!with!the!positive!test.!
891!people!will!not!be!treated!since!they!have!a!negative!diagnostic!test.!
105!people!who!actually!do!not!have!the!disease!will!be!treated!since!they!have!a!positive!test.!894!(4!+!890)!people!
actually!had!a!correct!diagnosis,!which!is!approx!89%.!
Finally,!only!1!person!who!has!the!disease!will!not!be!treated.!
!
!
Question!#81!
QID:!1057!
Subject:!PMCH!
!
A!7]year]old!girl!has!terminal!bone!cancer!unresponsive!to!chemotherapy.!She!has!been!in!the!hospital!for!palliative!
care!for!just!over!3!weeks.!Today!she!is!feeling!tired,!she!is!repeatedly!complaining!of!pain!in!her!leg,!and!wants!to!be!
held!in!her!mother’s!arms.!She!refuses!to!eat!because!according!to!her!there!is!no!point!in!eating!if!she!will!die!
anyway.!Which!of!the!following!procedures!is!appropriate!for!this!patient:!
a)!!Force!feed!
b)!!Provide!adequate!analgesia!
c)!!Initiate!parental!nutrition!
d)!!Prescribe!antidepressants!
!
!
!
Explanation:!
Terminally!ill!patients!often!report!that!they!fear!intractable!pain!more!than!they!do!dying.!Patients!frequently!
express!the!desire!to!have!open!and!honest!dialogue!about!pain!and!want!to!be!involved!fully!in!planning!their!pain!
management.!A!doctor!must!be!able!to!get!alongside!the!patient!and!their!family!and!to!spend!time!presenting!
options,!answering!questions!and!quelling!fears.!Having!promised!to!keep!the!patient!relatively!pain]free,!it!is!
paramount!to!meet!this!promise!to!preserve!trust.!Pain!is!easier!to!prevent!than!it!is!to!relieve!and!drugs!should!be!
prescribed!on!a!prophylactic!basis!with!no!other!consideration!than!maintaining!the!patient's!quality!of!life.!
!
Pain!is!a!complex!subjective!phenomenon!and!is!affected!by!the!emotional!context!in!which!it!is!endured.!Adequate!
psychological!support!is!critical!as!removing!the!fear!of!pain!in!itself!will!help!to!optimize!pain!control.!A!patient!who!
is!fearful,!withdrawn!and!depressed!often!appears!to!have!a!lower!pain!threshold!than!one!who!is!still!actively!
engaged!in!enjoying!what!is!left!of!their!lives,!even!though!they!may!have!same!stage!disease.!Non]drug!measures!to!
help!psychological!or!spiritual!distress!may!be!as!important!as!medication!in!relieving!pain!and!suffering.!
!
!
Question!#82!
QID:!1070!
37
Topic:!Hearing!
Subject:!PMCH!
!
The!frequencies!most!necessary!for!the!understanding!of!speech!extend!from!about:!
a)!!20]20!000!Hz!
b)!!400]5!000!Hz!
c)!!100]8!000!Hz!
d)!!100]5!000!Hz!
!
!
!
Explanation:!
The!best!hearing!range!for!sounds!is!from!around!400!Hz!to!about!5000!Hz.!The!lower!and!higher!frequencies!require!
progressively!louder!sounds!for!us!to!hear.!The!frequency!range!for!audible!sound!is!between!20]20.000!Hz.!
!
!
Question!#83!
QID:!1071!
Topic:!Lead!
Subject:!PMCH!
!
Lead!exposure!typically!results!in:!
a)!!Chronic!dermatitis!
b)!!Resting!and!intention!tremor!
c)!!Extensor!muscle!weakness!
d)!!Arrhythmias!
e)!!Cerebellar!ataxia!
!
!
!
Explanation:!
Peripheral!neuropathy!may!occur!after!chronic!exposure!and!is!characterized!by!extensor!muscle!weakness,!
particularly!in!the!dominant!limb!with!minimal!sensory!loss.!Lead!affects!the!peripheral!and!central!nervous!system.!
The!most!common!sign!of!peripheral!neuropathy!due!to!chronic!lead!poisoning!is!painless!wrist!drop!(weakness!of!
the!extensor!muscles!of!hand)!which!usually!develops!after!many!weeks!of!exposure.!
!
!
Question!#84!
QID:!1080!
Topic:!Patient!Confidentiality!
Subject:!PMCH!
!
A!15]year]old!girl!comes!to!the!office!because!she!has!missed!a!menstrual!period!and!a!home!pregnancy!test!was!
positive.!Bimanual!examination!discloses!an!enlarged!uterus,!and!a!urine!pregnancy!test!is!positive.!She!is!estimated!
to!be!approximately!6!to!8!weeks!pregnant.!You!have!been!the!family's!physician!since!she!was!born.!She!asks!that!
you!please!not!tell!her!parents.!Which!of!the!following!is!the!most!appropriate!immediate!response?!
a)!!Attempt!to!persuade!her!to!share!the!information!with!at!least!one!adult!member!of!her!family!
b)!!Explain!that!by!law!you!are!unable!to!maintain!confidentiality!
c)!!Explore!with!her!the!reasons!for!her!not!feeling!comfortable!sharing!the!information!with!her!parents!
d)!!Point!out!that!she!will!not!be!able!to!hide!her!pregnancy!for!very!long!
e)!!Reassure!her,!but!notify!her!mother!after!she!leaves!
!
!
!
Explanation:!
38
Explore!with!the!patient!her!reasons!for!not!feeling!comfortable!with!sharing!this!information.!In!this!manner,!you!
can!discuss!specific!reasons!for!her!reluctance!to!involve!her!parents,!and!counsel!her!appropriately.!An!attempt!to!
persuade!her!to!share!the!information!with!a!parent!may!only!exacerbate!an!already!tenuous!relationship!with!her!
parents.!
!
Explaining!that!by!law!you!are!unable!to!maintain!confidentiality!is!incorrect.!She!requires!counseling!and!telling!her!
that!you!an!unable!to!maintain!confidentiality!will!only!make!it!more!difficult!for!her!to!trust!you.!A!minor!is!typically!
considered!to!be!an!
“emancipated!minor”!and!capable!of!making!independent!medical!decisions!if!they!become!pregnant!or!have!a!
sexually!transmitted!disease,!therefore!breaching!confidentiality!is!incorrect.!
!
Indicating!that!she!will!not!be!able!to!hide!her!pregnancy!for!long!is!a!nonproductive!argument,!and!does!not!
preempt!a!discussion.!It!is!a!clear!breech!of!doctor]patient!confidentiality!to!reassure,!and!then!notify!a!parent.!
!
!
Question!#85!
QID:!1083!
Topic:!Relative!Risk!
Subject:!PMCH!
!
In!a!cohort!study!of!disease!“X”!in!people!with!risk!factor!“Y”!versus!those!who!are!without!risk!factor!“Y”,!the!
following!results!were!obtained:!
!
!
!
The!relative!risk!of!developing!“X”!in!“Y”!versus!no!“Y”!is:!
a)!!4!
b)!!0.3!
c)!!0.625!
d)!!1.6!
!
!
!
Explanation:!
!
!
In!epidemiology,!relative!risk!(RR)!is!the!risk!of!an!event!(or!of!developing!a!disease)!relative!to!exposure.!Relative!risk!
is!a!ratio!of!the!probability!of!the!event!occurring!in!the!exposed!group!versus!the!control!(non]exposed)!group.!
!
Relative!Risk!=!(a!/!(a+b))!/!(c!/!(c+d))!=!(in!this!question)!(80/100)!/!(50/100)!=!1.6!
!
!
Question!#86!
QID:!1084!
Topic:!Attributable!Risk!
Subject:!PMCH!
!
In!a!cohort!study!of!disease!“X”!in!people!with!risk!factor!“Y”!versus!those!who!are!without!risk!factor!“Y”,!the!
following!results!were!obtained:!
!
!
!
The!attributable!risk!of!factor!“Y”!to!disease!“X”!would!be:!
a)!!1.6!
b)!!0.3!
c)!!4!
d)!!0.25!
39
!
!
!
Explanation:!
!
!
The!attributable!risk!of!a!disease!given!an!exposure!is!simply!the!rate!of!disease!(incidence)!in!the!exposed!people!
minus!the!rate!in!the!unexposed!people.!
!
Attributable!risk:!(a!/!(a+b))!]!(c!/!(c+d))!=!(in!this!question)!(80/100)!]!(50/100)!=!0.3.!
!
!
Question!#87!
QID:!1085!
Topic:!Attack!Rate!
Subject:!PMCH!
!
A!group!of!50!people!are!exposed!to!virus!“A”.!Of!those!50!people,!9!develop!a!mild!infection,!10!become!seriously!ill,!
and!3!die.!The!attack!rate!of!virus!“A”!in!the!population!would!be:!
a)!!22/50!
b)!!9/50!
c)!!10/50!
d)!!19/50!
e)!!13/50!
!
!
!
Explanation:!
An!attack!rate!is!defined!as!the!number!of!new!cases!of!disease!during!a!specified!time!period,!divided!by!the!total!
population!at!risk!during!the!same!time!period.!
In!this!question,!attack!rate!=!(9+10+3)/50!=!22/50.!
!
!
Question!#88!
QID:!1086!
Topic:!Test!Specificity!
Subject:!PMCH!
!
The!following!indicate!the!results!of!screening!test!“Q”!in!screening!for!disease!“Z”:!
!
!
!
The!specificity!of!test!“Q”!would!be:!
a)!!40/70!
b)!!120/130!
c)!!40/50!
d)!!120/150!
e)!!40/130!
!
!
!
Explanation:!
!
!
Specificity!=!d/(b+d)!which!is!the!true!negative!rate.!Meaning!of!all!the!people!without!the!disease!the!portion!that!
40
will!actually!test!negative.!In!this!question,!specificity!=!120/130.!
!
!
!
Question!#89!
QID:!1087!
Topic:!Test!PPV!
Subject:!PMCH!
!
The!following!indicate!the!results!of!screening!test!“Q”!in!screening!for!disease!“Z”:!
!
!
!
The!positive!predictive!value!would!be:!
a)!!40/70!
b)!!120/130!
c)!!40/50!
d)!!120/150!
e)!!70/200!
!
!
!
Explanation:!
!
!
Positive!predictive!value!(PPV)!is!defined!as:!of!all!the!people!with!a!positive!test!for!a!disease,!the!number!that!
actually!have!the!disease!being!tested.!
!
In!this!question,!PPV!=!40/50.!
!
!
Question!#90!
QID:!1088!
Topic:!Odds!Ratio!
Subject:!PMCH!
!
To!determine!an!odds!ratio!one!would!have!to!perform!which!of!the!following!studies?!
a)!!Cross!sectional/prevalence!study!
b)!!Randomized!controlled!trial!
c)!!Cohort!study!
d)!!Case!study!
e)!!Case!control!study!
!
!
!
Explanation:!
Odds!Ratio!is!the!risk!of!disease!in!those!exposed!to!a!certain!factor,!divided!by!the!risk!of!disease!in!those!not!
exposed!to!that!factor.!Odds!ratio!can!be!calculated!in!a!retrospective!study!such!as!a!case!control!study.!
!
!
!
41
Question!#91!
QID:!1089!
Topic:!Secondary!Prevention!
Subject:!PMCH!
!
Examples!of!secondary!prevention!would!include!all!of!the!following,!except:!
a)!!Pap!smear!for!cervical!cancer!
b)!!Chemoprophylaxis!in!a!recent!TB!converter!
c)!!Proctoscopy!for!rectal!cancer!
d)!!Immunization!for!Haemophilus!influenza!B!
e)!!Mammography!for!breast!cancer!
!
!
!
Explanation:!
factors.!
!
!
treatment.!
!
!
!
!
!
Question!#92!
QID:!1091!
Topic:!Test!Prevalence!
Subject:!PMCH!
!
Which!one!of!the!following!descriptors!of!a!diagnostic!test!is!influenced!by!the!prevalence!of!the!disease!being!tested!
for:!
a)!!Specificity!
b)!!Sensitivity!
c)!!Accuracy!
d)!!Positive!predictive!value!
e)!!Reliability!
!
!
!
Explanation:!
Positive!predictive!value!(PPV)!is!a!proportion!of!people!with!a!positive!test!who!have!the!disease.!It!is!related!to!
prevalence.!The!higher!the!prevalence,!the!higher!the!PPV!will!be.!
!
Note:!Do!not!confuse!PPV!with!sensitivity,!which!is!a!proportion!of!people!with!disease!who!are!correctly!identified!by!
a!positive!test.!
!
42
!
Question!#93!
QID:!1093!
Topic:!Physician]Patient!Relationship!
Subject:!PMCH!
!
A!male!colleague!asks!you!to!write!a!prescription!for!a!narcotic!analgesic!for!one!of!his!female!patients.!You!have!
noticed!that!this!patient!has!been!coming!by!the!office!to!see!your!colleague!too!frequently,!and!that!most!of!the!
visits!have!been!marked!"No!complaints/Normal!physical!exam".!When!you!ask!your!colleague!why!he!cannot!write!
the!prescription!himself,!he!seems!defensive!and!says,!"because!I!don't!want!anybody!to!get!the!wrong!idea."!Which!
of!the!following!is!the!most!appropriate!initial!response!to!your!colleague?!
a)!!"It!sounds!like!there!is!more!to!this!story!than!you!are!telling!me;!maybe!we!should!talk!about!it."!
b)!!"I!wish!I!could!help!you,!but!I!never!prescribe!that!medication!for!a!patient!unless!I!have!seen!the!patient!myself."!
c)!!"I!will!do!this!for!you!once,!but!I!will!need!to!see!your!patient!in!the!office!before!I!can!write!another!prescription."!
d)!!"Maybe!I!should!see!your!patient!in!the!office!myself,!and!then!decide!if!she!needs!the!medication."!
e)!!"You!have!seemed!a!little!nervous!lately.!You!aren't!getting!in!over!your!head,!are!you?"!
!
!
!
Explanation:!
This!question!clearly!describes!a!situation!in!which!a!colleague!may!be!behaving!inappropriately!with!a!female!
patient.!This!is!suggested!by!the!frequent!“no!complaints”!visits!and!his!defensive!posture!when!questioned.!This!
choice!indicates!awareness!by!the!physician!of!a!possible!inappropriate!physician]patient!relationship,!and!indicates!a!
willingness!to!help.!It!would!not!be!appropriate!to!accuse!the!colleague!directly,!given!the!lack!of!evidence.!On!the!
other!hand,!there!is!clearly!enough!information!given!in!this!question!to!raise!suspicion.!
!
!
Question!#94!
QID:!1095!
Topic:!Health!Care!System!
Subject:!PMCH!
!
What's!the!component!of!Canada's!health!care!system!that!receives!the!highest!percentage!of!the!health!care!
budget?!
a)!!Hospitals!
b)!!Physician!fees!
c)!!Drug!benefit!plans!
d)!!Laboratory!services!
e)!!Administration!
!
!
!
Explanation:!
!
!
Hospitals!comprise!the!component!of!Canada's!health!care!system!that!receives!the!highest!percentage!of!the!health!
care!budget.!
!
!
Question!#95!
QID:!1097!
Subject:!PMCH!
!
A!55]year]old!man!with!severe!chronic!obstructive!pulmonary!disease!returns!to!the!office!following!a!recent!
evaluation!for!possible!lung!transplantation!in!another!city.!He!says!he!had!been!considered!a!suitable!candidate,!in!
43
all!respects,!but!was!rejected!by!the!transplant!program!when!a!random!urine!test!was!positive!for!a!nicotine!
metabolite.!He!had!previously!told!you!that!he!had!stopped!smoking!3!years!ago.!He!stands!by!this!and!is!at!a!loss!to!
explain!the!positive!urine!test.!He!wants!to!know!what!he!should!do!now.!Which!of!the!following!is!the!most!
appropriate!next!step?!
a)!!Advise!him!again!to!stop!smoking!and!refer!him!to!another!transplant!program!
b)!!Advise!him!that!the!transplant!program!cannot!turn!him!down!on!this!basis,!according!to!the!Disabilities!Act!
c)!!Contact!the!transplant!program!to!learn!their!reasons!for!turning!him!down!
d)!!Explain!to!the!patient!that!transplantation!is!out!of!the!question!as!a!result!of!what!has!occurred!
e)!!Write!to!the!transplant!program!and!insist!that!they!give!him!another!opportunity!
!
!
!
Explanation:!
This!choice!demonstrates!that!the!physician!is!acting!as!the!patient’s!advocate,!and!is!accepting!his!version!as!the!
truth.!On!the!other!hand,!while!it!is!possible!that!the!patient!has!indeed!continued!to!smoke,!this!may!be!insufficient!
reason!to!deny!him!a!lung!transplant.!Contacting!the!transplant!program!to!determine!whether!there!are!other!
reasons!for!rejecting!the!patient!as!a!candidate!is!appropriate.!Advising!him!to!stop!smoking!implies!that!the!
physician!does!not!believe!that!the!patient!has!already!stopped.!
!
!
Question!#96!
QID:!1101!
Topic:!Physician!Privilege!to!Practice!Medicine!
Subject:!PMCH!
!
A!39]year]old!physician!is!convicted!of!narcotic!abuse.!He!successfully!completes!a!3!month!drug!rehabilitation!
program.!Following!this!treatment,!his!privilege!to!practice!medicine!will!be!determined!by!which!of!the!following?!
a)!!RCPSC!or!CFPC!
b)!!Credentials!committee!of!his!hospital!
c)!!Provincial!medical!board!
d)!!He!will!not!be!permitted!to!practice!
!
!
!
Explanation:!
Depending!upon!the!specialty!of!medicine!and!the!province!in!which!the!physician!practices,!provincial!medical!board!
determines!whether!a!physician!known!to!have!abused!narcotics!can!practice!medicine!again.!In!anesthesia,!for!
example,!a!rehabilitated!physician!can!no!longer!practice!anesthesia,!but!may!continue!to!practice!in!another!
specialty.!These!regulations!vary!widely!from!province!to!province!and!from!profession!to!profession.!The!key!factor!
is!the!successful!completion!of!a!board]mandated!drug!rehabilitation!program.!The!provincial!medical!board!
determines!his!privilege!to!practice.!
!
!
Question!#97!
QID:!1105!
Topic:!Long!Term!Management!
Subject:!PMCH!
!
You!are!discussing!treatment!options!with!a!75]year]old!woman!with!chronic!renal!failure.!Her!medical!history!also!
includes!diabetes!mellitus,!hypertension,!hypercholesterolemia,!and!a!left!above]the]knee!amputation!secondary!to!
severe!peripheral!vascular!disease.!She!lives!with!her!dog!in!a!one]bedroom!apartment!in!the!suburbs!and!is!
dependent!upon!a!wheelchair!for!ambulation.!Her!support!system!includes!a!home!health!aide,!several!friends!who!
live!5!to!6!miles!from!her!apartment!and!Meals]on]Wheels.!Which!of!the!following!is!the!most!appropriate!advice!to!
give!this!patient!regarding!long]term!management?!
a)!!Dialysis!is!not!an!appropriate!option!because!of!her!age!and!medical!disabilities!
b)!!Home!dialysis!would!permit!the!greatest!independence!and!convenience!
44
c)!!Peritoneal!dialysis!is!not!an!option!because!of!her!diabetes!mellitus!
d)!!She!must!name!a!health!care!surrogate!to!make!decisions!regarding!her!care!
e)!!You!will!arrange!for!dialysis!at!a!center!near!her!home!if!she!can!arrange!transportation!
!
!
!
Explanation:!
The!most!common!cause!of!chronic!renal!failure!is!diabetes!mellitus.!This!patient!has!dialysis!dependent!renal!failure!
and!very!specific!social!constraints!on!her!ability!to!receive!therapy.!For!this!reason,!the!initiation!of!dialysis!at!home!
would!suit!both!her!medical!needs!and!her!social!needs.!
!
Physicians!do!not!make!decisions!about!excluding!patients!from!care!based!upon!social,!financial!or!any!other!factor.!
Physicians!present!to!their!patients!all!of!the!options!for!their!care!and!assist!the!patient!in!making!the!best!decision!
for!them.!The!physician!acts!as!the!patient!advocate.!If!the!patient!refuses!dialysis!after!being!presented!with!that!
option!by!her!physician,!that!is!her!right.!
!
Peritoneal!dialysis!is!an!option!for!this!patient,!but!generally,!hemodialysis!is!utilized!first!for!a!number!of!reasons.!
Once!patients!have!exhausted!access!to!their!circulation,!or!they!have!a!specific!contra]indication!to!hemodialysis,!a!
peritoneal!dialysis!(PD)!catheter!can!be!placed!and!PD!can!be!utilized.!
!
!
Question!#98!
QID:!1106!
Subject:!PMCH!
!
Active!immunization!is!important!in!the!control!of!each!of!the!following!childhood!communicable!diseases,!except:!
a)!!Diphtheria!
b)!!Polio!
c)!!Measles!
d)!!Scarlet!fever!
e)!!Pertussis!
!
!
!
Explanation:!
Immunizations!exists!for!polio!(IPV)!and!for!diphtheria,!tetanus!and!pertussis!(DTaP)!and!for!measles,!mumps!and!
rubella!(MMR).!Currently!there!is!no!vaccine!against!scarlet!fever.!
!
!
Question!#99!
QID:!1107!
Topic:!Disease!Distribution!
Subject:!PMCH!
!
The!occurrence!of!an!illness,!in!a!specific!population!or!area,!suddenly!and!in!numbers!clearly!in!excess!of!normal!
expectancy!is!called:!
a)!!Hyperendemic!
b)!!Epidemic!
c)!!Endemic!
d)!!Enzootic!
e)!!Pandemic!
!
!
!
45
Explanation:!
Hyperendemic!disaese!]!a!disease!that!is!constantly!present!at!a!high!incidence!and/or!prevalence!rate!and!affects!all!
age!groups!equally.!
An!epidemic!disease!is!a!disease!that!many!people!acquire!over!a!short!periodoccurring!suddenly!in!numbers!clearly!
in!excess!of!normal!expectancy.!
An!endemic!disease!is!one!that!is!always!present!in!a!population!and!is!occurring!at!the!usual!expected!rate.!
Enzootic!disease!]!prevalent!among!or!restricted!to!animals!of!a!specific!geographic!area.!
A!pandemic!disease!is!a!world]wide!epidemic!disease.!
!
!
Question!#100!
QID:!1108!
Subject:!PMCH!
!
Each!of!the!following!statements!applies!to!case!control!studies,!except:!
a)!!Control!group!is!disease]free!
b)!!Suitable!for!rare!diseases!
c)!!Relatively!inexpensive!
d)!!Prolonged!follow]up!required!
e)!!There!may!be!a!problem!in!selecting!and!matching!controls!
!
!
!
Explanation:!
!
!
Question!#101!
QID:!1110!
Topic:!Standardization!
Subject:!PMCH!
!
A!clinician!who!has!been!examining!the!patterns!of!mortality!in!your!community!says!that!the!rates!for!heart!disease!
and!lung!cancer!are!higher!in!this!community!than!in!an!adjacent!community.!Which!of!the!following!questions!
should!you!ask!first?!
a)!!How!did!the!clinician!choose!the!comparison!community?!
b)!!Have!the!rates!been!standardized!for!age?!
c)!!Are!tobacco!sales!significantly!different!in!the!two!communities?!
d)!!Are!the!facilities!to!treat!these!diseases!comparable!in!the!two!areas?!
e)!!Are!the!numbers!of!deaths!comparable!in!each!area?!
!
!
!
Explanation:!
Age]specific!Rate:!The!number!of!cases!or!deaths!per!100,000!persons!per!year!for!a!specified!age!group.!Five]year!
age!groups!are!commonly!used.!
!
Age]standardized!Rate:!An!adjusted!rate!which!represents!what!the!crude!rate!would!have!been!in!the!study!
population!(such!as!a!province!or!a!census!division)!if!that!population!had!the!same!age!distribution!as!the!standard!
population.!One!must!know,!however,!that!because!standardization!produces!a!summary!measure,!it!may!obscure!
important!differences!in!the!age]specific!patterns.!Also,!standardized!rates!can!only!be!compared!to!each!other!when!
46
the!same!standard!population!has!been!used!to!obtain!the!rate.!
!
!
Question!#102!
QID:!1111!
Topic:!Cross!Sectional!Study!
Subject:!PMCH!
!
Which!of!the!following!observational!types!of!studies!is!usually!used!to!estimate!prevalence!of!a!health!condition!or!
prevalence!of!a!behavior,!risk!factor,!or!potential!for!disease?!
a)!!Case]control!
b)!!Cross]sectional!
c)!!Randomized!controlled!trial!
d)!!Cohort!
e)!!Quasi]Experimental!
!
!
!
Explanation:!
Cross]sectional!study:!A!study!done!at!one!time,!not!over!the!course!of!time.!A!cross]sectional!study!might!be!of!a!
disease!such!as!AIDS!at!one!point!in!time!to!learn!its!prevalence!and!distribution!within!the!population.!Also!known!as!
a!synchronic!study.!
!
First,!distinguish!between!observational!(cross]sectional,!cohort,!case]control)!and!experimental!(Randomized!
Controlled!Trial,!Quasi]Experimental)!studies.!In!observational!studies,!the!researcher!observes!and!systematically!
collects!information,!but!does!not!try!to!change!the!people!being!observed.!In!an!experiment,!by!contrast,!the!
researcher!intervenes!to!change!something!and!then!observes!what!happens.!In!an!observational!study!there!is!no!
intervention.!
!
!
Question!#103!
QID:!1112!
Topic:!Epidemiology!Triad!
Subject:!PMCH!
!
The!classical!“epidemiological!triad”!of!disease!causation!consists!of!factors!which!fall!into!which!of!the!following!
categories:!
a)!!Host,!reservoir,!environment!
b)!!Host,!vector,!environment!
c)!!Host,!agent,!environment!
d)!!Reservoir,!agent,!vector!
e)!!Host,!age,!environment!
!
!
!
Explanation:!
The!triad!is!‘host,!agent!and!environmental’!factors.!
!
>!Age!is!a!host!factor.!
>!Reservoir!and!vector!are!environmental!factors.!
!
!
!
!
Question!#104!
QID:!1113!
47
Topic:!Statistical!Significance!
Subject:!PMCH!
!
During!a!clinical!trial,!the!difference!in!the!success!rates!of!two!drugs!was!not!statistically!significant.!This!means!that:!
a)!!There!is!no!difference!in!drug!effectiveness!
b)!!There!is!a!sizable!probability!that!the!demonstrated!difference!in!the!drugs’!effectiveness!could!occur!due!to!
chance!alone!
c)!!The!demonstrated!difference!in!the!drugs’!effectiveness!is!too!small!to!be!clinically!meaningful!
d)!!The!two!samples!of!patients!on!which!the!drugs!were!tested!came!from!the!same!population!
!
!
!
Explanation:!
In!statistics,!a!result!is!called!statistically!significant!if!it!is!unlikely!to!have!occurred!by!chance.!"A!statistically!
significant!difference"!simply!means!there!is!statistical!evidence!that!there!is!a!difference.!
!
!
Question!#105!
QID:!1115!
Topic:!Attack!Rate!
Subject:!PMCH!
!
You!are!given!this!data!pertaining!to!an!outbreak!of!diarrhea!in!a!daycare:!
!
Age,!#!of!Children,!#!with!Diarrhea!
1,!20,!17!
2,!19,!15!
3,!39,!13!
4,!39,!4!
5,!38,!5!
6+,!18,!1!
!
What!is!the!attack!rate!of!this!illness?!
a)!!25%!
b)!!30%!
c)!!32%!
d)!!40%!
e)!!50%!
!
!
!
Explanation:!
Attack!rate!is!the!number!of!people!who!get!sick!divided!by!the!total!number!of!people!exposed!or!unexposed.!
In!this!question,!
attack!rate!=!(total!number!of!patients!with!diarrhea)!/!(total!number!of!children)!
=!(17+15+13+4+5+1)!/!(20+19+39+39+38+18)!
=!55!/!173!
=!0.3179!
=!32%!
!
!
Question!#106!
QID:!1134!
Subject:!PMCH!
!
48
The!various!species!of!Campylobacter!can!cause!diseases!ranging!from!acute!enteritis!to!bacteremia.!Which!of!the!
following!modes!of!transmission!does!not!apply!to!Campylobacter?!
a)!!Contact!with!infected!animals!
b)!!Contaminated!food!and!water!
c)!!Improperly!cooked!poultry!
d)!!Aerolized!droplets!
e)!!Person!to!person!spread!via!fecal]oral!route!
!
!
!
Explanation:!
Campylobacter!species!are!widely!distributed!in!most!warm]blooded!animals.!They!are!prevalent!in!food!animals!such!
as!poultry,!cattle,!pigs,!sheep,!ostriches!and!shellfish;!and!in!pets,!including!cats!and!dogs.!
!
The!main!route!of!transmission!is!generally!believed!to!be!foodborne,!via!undercooked!meat!and!meat!products,!as!
well!as!raw!or!contaminated!milk.!Contaminated!water!or!ice!is!also!a!source!of!infection.!A!proportion!of!cases!occur!
following!contact!with!contaminated!water!during!recreational!activities.!
!
Campylobacteriosis!is!a!zoonosis,!a!disease!transmitted!to!humans!from!animals!or!animal!products.!Most!often,!
carcasses!or!meat!are!contaminated!by!Campylobacter!from!faeces!during!slaughtering.!In!animals,!Campylobacter!
seldom!causes!disease.!
!
Although!not!common,!person]to]person!transmission!can!also!occur.!
!
!
!
Question!#107!
QID:!1155!
Topic:!Lead!
Subject:!PMCH!
!
Which!of!the!following!ages!is!most!vulnerable!to!lead!poisoning?!
a)!!0]6!years!
b)!!7]15!years!
c)!!15]25!years!
d)!!25]40!years!
e)!!60]80!years!
!
!
!
Explanation:!
Children!are!at!risk!for!lead!toxicity!if!they!live!in!homes!with!lead]based!paint,!if!folk!remedies!are!used,!or!if!their!
parents,!siblings,!or!caregivers!are!involved!in!lead]related!occupations.!Children!younger!than!3!years!are!at!the!
greatest!risk!for!lead!poisoning.!This!is!because!these!children!are!most!likely!to!put!things!containing!lead!into!their!
mouths!and!because!their!brains!are!rapidly!developing!and!are!most!vulnerable!to!any!disorganizing!influence.!
Physicians!and!other!health!care!professionals!must!be!aware!that!lead!poisoning!can!occur!in!children!of!any!age.!
!
!
Question!#108!
QID:!1162!
Subject:!PMCH!
!
A!37]year]old!married!man!who!is!a!patient!in!your!practice!comes!to!the!office!because!of!low!back!pain.!After!you!
enter!the!examining!room!and!establish!rapport,!he!appears!embarrassed!and!says!that!back!pain!is!not!why!he!is!
here.!Upon!further!questioning,!he!admits!to!a!sexual!encounter!on!a!recent!business!trip!and!says!he!now!has!a!
49
greenish!urethral!discharge.!Tests!for!gonorrhea!are!positive.!He!admits!to!having!exposed!his!wife!since!returning!
from!the!trip.!He!does!not!want!his!wife!to!know!about!this.!Because!his!wife!is!also!a!patient!in!your!practice,!which!
of!the!following!is!the!most!ethical!approach?!
a)!!Without!telling!him,!report!the!case!to!the!state!health!department!and!let!them!handle!contacting!his!wife!
b)!!Request!that!he!inform!his!wife!of!her!exposure!and!the!need!for!treatment!and!offer!to!assist!as!necessary.!
c)!!Suggest!that!he!bring!his!wife!to!the!office!tomorrow!so!that!you!can!explain!the!situation!and!the!need!for!
treatment!for!both!of!them!
d)!!Telephone!his!wife!after!he!leaves,!inform!her!of!the!problem!and!request!that!she!come!to!the!office!for!
treatment!
e)!!Treat!him!now!and!treat!his!wife!when!she!comes!to!the!office!for!her!next!annual!Pap!smear!2!weeks!from!now!
!
!
!
Explanation:!
Although!emotion!may!suggest!a!proper!course!of!action!during!such!a!clinical!scenario,!the!issues!are!clear,!and!
therefore,!so!is!the!course!of!action.!This!patient!has!requested!that!his!medical!condition!not!be!discussed!with!
anyone,!including!his!wife.!Therefore,!the!most!that!can!be!done!is!for!proper!clinical!advice!to!be!offered!to!the!
patient.!Making!yourself!available!as!needed!for!your!patient!and!offering!a!method!by!which!he!could!inform!his!wife!
are!both!appropriate!adjunctive!measures.!
!
!
Question!#109!
QID:!1185!
Topic:!Screening!Tests!
Subject:!PMCH!
!
A!43]year]old!man!comes!for!an!annual!physical!exam.!He!has!no!significant!past!medical!history!but!he!does!have!a!
strong!family!history!of!cancer!and!heart!disease.!His!father!and!his!brother!both!had!myocardial!infarctions!before!
age!of!60,!and!his!sister,!mother,!and!aunt!had!breast!cancer.!He!exercises!regularly!and!eats!well,!with!most!of!his!
diet!being!low!in!saturated!fat!and!cholesterol.!He!smokes!one!pack!of!cigarettes!per!week.!Which!of!the!following!is!
an!age]appropriate!screening!test!in!this!patient?!
a)!!Lipid!panel!
b)!!Colonoscopy!
c)!!Chest!X]Ray!
d)!!Prostate!examination!
!
!
!
Explanation:!
The!current!recommendations!for!routine,!age]appropriate!screening!is!that,!at!least!every!5!years,!a!lipid!panel!
should!be!checked.!Prostate!examinations!are!recommended!annually!after!age!50.!Flexible!sigmoidoscopy!is!
indicated!every!5!years!or!colonoscopy!every!10!years!for!people!aged!50!or!older!with!no!other!risk!factors.!
!
!
Question!#110!
QID:!1217!
Topic:!TB!
Subject:!PMCH!
!
You!care!for!a!family!that!consists!of!a!husband,!a!wife,!a!daughter,!and!a!son.!Each!family!member!is!healthy.!The!71]
year]old!maternal!grandmother!lived!with!the!family!until!4!weeks!ago!when!she!died!suddenly!after!a!prolonged!
respiratory!illness.!Autopsy!revealed!that!she!had!active!pulmonary!tuberculosis!at!the!time!of!her!death.!The!
organism!tested!sensitive!to!all!commonly!used!anti]tuberculosis!drugs.!
In!following!up!on!the!grandmother's!illness,!the!most!appropriate!first!step!in!managing!this!family!is!to:!
a)!!Obtain!leukocyte!count!and!erythrocyte!sedimentation!rate!on!all!family!members!
b)!!Obtain!sputum!or!gastric!washings!of!all!family!members!for!culture!for!acid]fast!bacilli!
50
c)!!Place!PPD!skin!tests!on!all!family!members!
d)!!Place!TB!tine!tests!on!the!two!children!and!PPD!skin!tests!on!the!adults!
e)!!Schedule!bronchoscopy!and!alveolar!lavage!on!the!adults!
!
!
!
Explanation:!
The!entire!family!has!been!exposed!to!the!grandmother,!who!has!had!active!tuberculosis.!As!close!contacts,!they!are!
at!risk!for!transmission!of!TB.!The!appropriate!screening!test!at!this!time!would!be!PPD!testing.!The!family!members!
should!be!considered!at!intermediate!risk!for!TB,!and!therefore,!a!5!mm!area!of!induration!would!be!considered!a!
positive!test.!
!
A!PPD!Test!is!considered!positive!when!the!induration!is:!
>!15!mm!(Patients!with!no!known!risk!factors)!
>!10!mm!(Patients!with!risk!factors!for!TB!including:!Immigrant!from!endemic!areas,!prisoners,!home!care!residents,!
injection!drug!users;!persons!with!the!following!clinical!conditions!that!place!them!at!high!risk:!silicosis,!DM,!chronic!
renal!failure!etc;!children!under!4!years!of!age!or!infants,!children!and!adolescents!exposed!to!adults!at!high]risk)!
>!5!mm!(for!immunocompromised!patients!such!as!HIV!patients,!children!taking!chemotherapy,!chronic!corticosteroid!
treatment,!recent!contacts!of!TB!case!patients,!persons!with!fibrotic!changes!on!chest!radiograph!consistent!with!
prior!TB,!patients!with!organ!transplants).!
!
!
Question!#111!
QID:!1246!
Topic:!Terminal!Illness!
Subject:!PMCH!
!
A!61]year]old!man!who!manages!his!own!accounting!firm!has!a!5!year!history!of!malignant!melanoma!that!has!been!
treated!with!local!excision!and!immunotherapy.!He!now!is!admitted!to!the!hospital!for!evaluation!of!constant!pain!in!
his!back!and!left!hip!and!an!11!kg!(24!lb)!weight!loss.!He!and!his!wife!of!35!years!are!worried!that!"the!cancer!may!be!
back."!Pelvic!and!abdominal!CT!scans!show!multiple!bony!metastases.!He!tells!you,!"I!just!want!to!die.!I!can't!bear!
this."!Which!of!the!following!is!the!most!appropriate!initial!intervention?!
a)!!Adjust!his!analgesic!regimen!
b)!!Arrange!for!him!to!be!transferred!to!a!psychiatric!service!
c)!!Begin!antidepressant!medication!
d)!!Initiate!hyperalimentation!
e)!!Refer!him!to!a!cancer!patient!support!group!
!
!
!
Explanation:!
The!patient!is!medically!unstable,!should!remain!on!a!medical!service,!and!should!not!be!transferred!to!a!psychiatric!
service.!Pain!is!the!number]one!cause!of!suicide!in!the!terminally!ill!and!decreasing!the!pain!by!maximizing!analgesia!
will!help!the!patient!face!dying!with!dignity.!Providing!adequate!pain!relief!when!you!are!dealing!with!a!terminally!ill!
patient!is!crucial!to!maintaining!the!highest!possible!quality!of!life.!If!this!man’s!pain!is!this!severe,!then!adjusting!the!
analgesic!regimen!is!the!only!logical!step.!There!is!no!evidence!of!a!clinical!syndrome!of!major!depression!so!an!
antidepressant!is!not!indicated.!
!
Hyperalimentation!may!be!needed!if!the!patient!is!not!eating,!or!is!unable!to!eat.!This!is!most!likely!due!to!
chemotherapy,!or!pain!or!cachexia!secondary!to!cancer.!Decreasing!the!pain!can!result!in!increased!appetite.!A!
cancer!patient!support!group!will!be!useful!in!the!long!run,!but!will!not!help!the!patient!until!the!acute!crisis!is!
resolved,!namely!the!wish!to!die.!
!
!
Question!#112!
QID:!1258!
51
Subject:!PMCH!
!
You!plan!to!discharge!an!78]year]old!woman!in!a!few!days!following!a!3!week!stay!in!the!hospital!for!repair!of!a!
fractured!hip!that!she!sustained!while!gardening.!Her!daughter,!who!is!in!the!room!with!the!patient,!says,!"I!want!to!
take!Mother!home!with!me!because!I'm!concerned!that!she!could!fall!and!break!her!hip!again.!Mom!says!she!doesn't!
really!want!to!leave!her!own!home,!but!she!will!do!what!is!best."!The!daughter!turns!to!her!mother!and!says!firmly,!
"Isn't!that!right,!Mom?"!The!mother!says,!"Yes,!I!guess!so,"!averting!eye!contact!with!both!her!daughter!and!you!by!
looking!down!toward!the!floor.!The!most!appropriate!response!to!the!mother!is:!
a)!!"Are!you!sure!you!want!to!go!home!with!your!daughter?"!
b)!!"How!would!you!feel!if!you!fell!again!and!had!another!fracture?"!
c)!!"Is!this!really!your!decision!or!is!it!your!daughter's?"!
d)!!"I!would!like!to!talk!with!you!in!private!now"!
e)!!"You!are!lucky!to!have!a!daughter!who!wants!to!take!care!of!you"!
!
!
!
Explanation:!
This!question!describes!an!elderly!woman!who!is!still!capable!of!making!informed!decisions.!However,!it!is!clear!from!
the!description!of!this!scenario!that!the!daughter!is!trying!to!coerce!her!mother!into!a!decision!with!which!she!does!
not!necessarily!agree.!It!would!therefore!be!appropriate!to!speak!to!the!patient!privately!in!order!to!better!ascertain!
the!mother’s!true!feelings!regarding!this!situation.!Note!that!even!though!the!daughter!is!acting!in!what!she!assumes!
is!the!mother’s!best!interest,!the!concept!of!patient!autonomy!dictates!that!the!mother!is!allowed!to!make!her!own!
independent!decision.!
!
!
Question!#113!
QID:!1259!
Topic:!Falls!in!Elderly!
Subject:!PMCH!
!
You!plan!to!discharge!an!78]year]old!woman!in!a!few!days!following!a!3]week]stay!in!the!hospital!for!repair!of!a!
fractured!hip!that!she!sustained!while!gardening.!She!now!ambulates!with!difficulty!using!a!walker,!but!she!is!
determined!to!become!independent!again!and!to!return!to!her!own!home.!Her!daughter,!who!is!in!the!room!with!the!
patient,!says,!"I!want!to!take!Mother!home!with!me!because!I'm!concerned!that!she!could!fall!and!break!her!hip!
again."!The!step!most!likely!to!prevent!another!fall!and!a!possible!fracture!in!this!patient!is!to:!
a)!!Advise!her!to!walk!only!when!accompanied!by!an!adult!
b)!!Ensure!that!she!does!not!have!orthostatic!hypotension!
c)!!Provide!her!with!assistance!for!activities!of!daily!living!
d)!!Provide!her!with!an!electric!wheelchair!
e)!!Request!a!homecare!nurse!to!assess!the!safety!of!her!living!environment!
!
!
!
Explanation:!
Falls!are!a!major!cause!of!morbidity!in!the!elderly,!especially!in!those!living!alone.!A!very!effective!measure!to!prevent!
falls!is!to!have!an!experienced!homecare!nurse!assess!the!various!hazards!that!may!exist!in!the!patient’s!home.!
Typical!measures!that!are!then!taken!include!installing!guardrails!around!the!bathtub!and!toilet,!ensuring!adequate!
lighting,!making!sure!that!all!stairways!in!the!home!are!well]lit,!and!that!the!stairs!are!demarcated!from!the!adjoining!
floor,!and!eliminating!loose!rugs,!wires,!or!other!objects!that!may!predispose!to!tripping!and!falling.!While!advising!
her!to!walk!only!when!accompanied!by!an!adult,!ensuring!that!she!does!not!have!orthostatic!hypotension!providing!
her!with!assistance!with!activities!of!daily!living!and!an!electric!wheelchair!may!reduce!the!number!of!falls,!it!is!best!
to!have!her!environment!evaluated!to!reduce!the!hazards!that!she!is!facing!in!daily!life.!
!
!
Question!#114!
52
QID:!1262!
Topic:!DNR!Order!
Subject:!PMCH!
!
A!57]year]old!woman!with!metastatic!breast!cancer!is!admitted!to!the!hospital!for!an!investigational!chemotherapy!
protocol.!Her!cancer!has!thus!far!been!unresponsive!to!treatment.!At!her!request,!the!attending!physician!writes!a!
"Do!Not!Resuscitate"!order.!Two!days!later,!at!1:30!AM,!the!patient!has!suddenly!slumped!over!and!the!nurse!is!
unable!to!obtain!a!pulse!or!blood!pressure!reading.!The!patient!has!agonal!respirations!and!then!stops!breathing.!The!
first!physician!to!arrive!at!the!patient's!bedside!should:!
a)!!Call!the!attending!physician!
b)!!Call!the!patient's!husband!
c)!!Pronounce!the!patient!dead!
d)!!Initiate!cardiopulmonary!resuscitation!
e)!!Initiate!intravenous!chemical!resuscitation!
!
!
!
Explanation:!
The!patient!has!likely!died.!Her!agonal!respirations!and!cessation!of!respiratory!effort!suggest!this.!Given!that!the!
patient!has!clear!do!not!resuscitate!orders,!the!first!priority!is!to!establish!that!death!has!occurred.!Pronouncement!of!
death!requires!a!physician.!
!
Calling!the!attending!physician!or!the!patient’s!husband!should!not!occur!until!it!is!certain!that!the!patient!has!in!fact!
died.!The!reasons!for!this!are!obvious.!Once!the!patient!has!been!pronounced!dead!however,!these!are!appropriate!
phone!calls!to!make.!
!
Initiating!CPR!is!inappropriate!since!the!patient!has!clearly!expressed!her!wishes!not!to!be!resuscitated.!Chest!
compressions,!electrical!cardioversion!or!chemical!resuscitation!are!all!components!that!the!patient!expressed!a!
desire!not!to!have!performed!on!her.!
!
!
Question!#115!
QID:!1264!
Topic:!Diagnostic!Errors!
Subject:!PMCH!
!
A!46]year]old!woman!comes!to!the!emergency!department!because!of!respiratory!distress.!Chest!x]ray!film!discloses!
patchy!infiltration!of!the!right!lower!lobe.!The!patient!is!diagnosed!as!having!community]acquired!pneumonia,!and!
she!is!sent!home!with!a!prescription!for!erythromycin.!The!patient!returns!2!days!later!complaining!of!new!onset!of!
swelling!of!her!right!leg!and!foot.!Doppler!studies!show!a!proximal!deep!venous!thrombosis!in!the!right!leg,!and!
ventilation]perfusion!lung!scan!is!interpreted!as!high!probability!for!a!pulmonary!embolus.!The!care!this!patient!
received!initially!is!best!characterized!as!which!of!the!following?!
a)!!An!error!in!diagnostic!accuracy!
b)!!Legal!negligence!
c)!!Malpractice!
d)!!A!therapeutic!misadventure!
e)!!Violation!of!the!principle!of!nonmaleficence!
!
!
!
Explanation:!
Scenarios!such!as!this!are!quite!common!in!clinical!medicine.!Diagnostic!errors!and!their!study!is!a!large!field!that!
occupies!many!people.!The!causes!why!physicians!make!diagnostic!errors!are!legion,!but!many!relate!to!“heuristic!
triggers”!and!failure!to!interpret!new!data!in!light!of!changing!diagnostic!hypotheses.!This!patient!had!many!signs!and!
symptoms!suggestive!of!pneumonia.!Some!of!these!findings,!such!as!the!localized!pleuritic!chest!pain,!are!not!100%!
specific.!A!more!detailed!history!of!the!duration!of!symptoms!and!their!rapidity!of!onset!(rapid!favors!diagnosis!of!an!
53
embolism)!would!have!been!helpful.!
!
Legal!negligence!like!malpractice!is!a!legal!terms!that!reflects!errors!which!occur!outside!the!standard!of!accepted!
medical!practice.!Duty,!breach,!causation,!damages!are!elements!of!a!negligence!action!and!such!a!determination!can!
be!made!only!by!a!judge.!Malpractice!specifically!relates!to!care!not!within!the!accepted!practice!guidelines.!There!is!
no!evidence!from!this!vignette!that!the!patient!was!misdiagnosed!based!upon!practice!outside!this!standard.!She!had!
signs!and!symptoms!suggestive!of!pneumonia,!a!chest!radiograph!suggested!pneumonia!and!she!was!given!an!
antibiotic!appropriate!for!community!acquired!pneumonia.!
!
!
Question!#116!
QID:!1266!
Topic:!Emancipated!Minors!
Subject:!PMCH!
!
A!16]year]old!girl!comes!to!the!emergency!department!because,!she!says,!"something!is!sticking!out!of!my!bottom!
since!I!had!a!bowel!movement!this!morning."!She!denies!previous!episodes,!although!for!more!than!one!year!she!has!
had!occasional!difficulty!passing!stools.!In!response!to!your!questions,!she!tells!you!that!she!moved!away!from!home!
more!than!a!year!ago!and!her!parents!contribute!nothing!to!her!support.!She!has!a!6]month]old!child,!a!part!time!job!
and!lives!with!a!28]year]old!female!cousin.!In!order!to!follow!the!correct!procedure!for!treating!a!minor,!which!of!the!
following!is!the!most!appropriate!step!prior!to!evaluating!this!patient's!rectal!problem?!
a)!!Accept!the!girl's!consent!as!sufficient!
b)!!Obtain!a!court!order!permitting!evaluation!
c)!!Obtain!the!written!consent!of!at!least!two!licensed!physicians!
d)!!Obtain!written!consent!from!at!least!one!of!her!parents!
e)!!Obtain!written!consent!from!her!28!year!old!cousin!
!
!
!
Explanation:!
A!small!number!of!minors,!particularly!at!older!ages!such!as!16!or!17,!may!be!considered!'emancipated'!or!freed!of!
the!need!to!have!parental!consent!for!any!medical!care.!The!criteria!are!that!the!minor!is!married,!self]supporting!and!
living!independently,!in!the!military,!or!the!parent!of!a!child!that!they!themselves!support.!The!criteria!for!being!an!
emancipated!minor!relate!to!being!no!longer!dependent!on!one's!parents!for!support.!
!
An!emancipated!minor!is!free!to!make!health!care!decisions!in!all!areas,!not!only!just!STDs,!prenatal!care,!
contraception,!or!substance!abuse.!
!
!
Question!#117!
QID:!1278!
Topic:!Child!Abuse!
Subject:!PMCH!
!
A!4]year]old!boy!is!brought!to!the!emergency!department!by!his!parents!because!of!a!swollen!pinna.!The!father!says!
that!the!boy!fell!off!his!tricycle!in!a!playground.!On!physical!examination!the!child's!left!ear!is!severely!edematous!and!
discolored.!There!is!concern!for!the!child!because!this!is!his!third!emergency!department!visit!in!the!past!6!months.!
When!discussing!these!concerns!and!the!need!for!further!evaluation!with!the!parents,!they!become!angry!and!want!
to!take!the!child!home!now.!
!
This!case!should!be!reported!to!the!child!protective!service!agency:!
a)!!If!another!licensed!physician!agrees!with!the!current!assessment!and!documents!this!in!the!chart!
b)!!If!there!is!a!pattern!of!repeated!suspicious!injury!
c)!!If!there!is!proof!that!the!parents!inflicted!the!injury!
d)!!If!the!injury!is!judged!to!be!life]threatening!
e)!!On!the!basis!of!the!current!suspicion!alone!
!
54
!
!
Explanation:!
There!is!no!need!for!another!physician!to!agree!with!your!assessment.!A!single!physician,!social!worker,!or!nurse!can!
and!must!file!a!report!with!child!protective!services.!There!does!not!need!to!be!a!pattern!of!repeated!suspicious!
injury!or!proof!of!parental!abuse.!The!injury!need!not!be!life]threatening.!The!injury!need!only!be!strongly!suggestive!
of!abuse.!
!
!
Question!#118!
QID:!1279!
Topic:!Child!Abuse!
Subject:!PMCH!
!
!
Even!after!informing!the!parents!of!the!decision!to!report!the!case!to!the!child!protective!services,!they!continue!to!
deny!having!hurt!the!child!and!are!furious.!If!the!diagnosis!of!child!abuse!is!incorrect,!the!reporting!physician!is!liable!
for:!
a)!!Civil!charges!
b)!!Criminal!charges!
c)!!Medical!license!revocation!
d)!!Provincial!medical!society!censure!
e)!!No!damages!or!penalties!
!
!
!
Explanation:!
The!reporting!physician!is!only!liable!if!he!does!not!report.!The!physician!can!be!brought!up!on!charges!and!suffer!
professional!penalties!only!if!he!does!not!report.!Civil!and!criminal!charges!may!not!be!brought!against!the!physician!
if!the!charge!of!abuse!is!incorrect.!Likewise,!his!license!may!not!be!revoked,!nor!his!medical!society!membership!
censured.!The!law!aims!to!foster!reporting!of!reasonable!suspicions.!
!
!
Question!#119!
QID:!1317!
Topic:!Child!Abuse!
Subject:!PMCH!
!
A!6]year]old!child!is!brought!into!the!emergency!room!by!his!father!because!of!a!fractured!arm.!Although!his!father!
states!that!the!child!fell!off!his!bike,!the!fracture!does!not!seem!consistent!with!this!story.!On!inspection,!you!discover!
that!the!child!seems!to!have!a!number!of!old!bruises!on!his!back!and!on!his!legs,!some!of!which!seem!reminiscent!of!
finger!markings.!Which!of!the!following!steps!is!not!appropriate!in!this!circumstance?!
a)!!Let!the!child!go!home!with!his!father!since!you!cannot!really!prove!anything!
b)!!Document!the!injuries!that!you!saw!with!possible!photographs!
c)!!Call!the!childrens!aid!society!and!inform!them!
d)!!Try!to!interview!the!child!alone!
e)!!Do!additional!investigations!(e.g.!skeletal!survey)!
!
!
!
55
Explanation:!
Child!maltreatment!is!behavior!toward!a!child!that!is!outside!the!norms!of!conduct!and!entails!substantial!risk!of!
causing!physical!or!emotional!harm.!Four!types!of!maltreatment!are!generally!recognized:!physical!abuse,!sexual!
abuse,!emotional!abuse!(psychologic!abuse),!and!neglect.!The!causes!of!child!maltreatment!are!varied!and!not!well!
understood.!Abuse!and!neglect!are!often!associated!with!physical!injuries,!delayed!growth!and!development,!and!
mental!problems.!Diagnosis!is!based!on!history!and!physical!examination.!Management!includes!documentation!and!
treatment!of!any!injuries!and!urgent!physical!and!mental!conditions,!mandatory!reporting!to!appropriate!state!
agencies,!and!sometimes!hospitalization!or!other!steps!such!as!foster!care!to!keep!the!child!safe.!
!
!
Question!#120!
QID:!1430!
Topic:!Involuntary!Hospitalization!
Subject:!PMCH!
!
Criteria!for!involuntary!hospitalization!of!a!suicidal!patient!include!all!of!the!following,!except:!
a)!!Acute!risk!of!harm!to!themselves!
b)!!Ability!to!care!for!self!and!provide!for!basic!physical!needs!
c)!!Acute!risk!of!harm!to!others!
d)!!Presence!of!mental!disorder!
e)!!Inability!to!guard!against!serious!harm!
!
!
!
Explanation:!
At!times,!involuntary!hospitalization!becomes!necessary.!If!at!all!possible,!voluntary!hospitalization!is!always!better.!
However,!often!the!reasoning!ability!of!a!mentally!ill!person!in!crisis!is!impaired,!and!it!is!not!always!possible!to!
convince!him!of!the!need!for!inpatient!treatment.!
!
Consequently,!a!person!may!be!seriously!ill,!but!if!he!refuses!treatment,!he!cannot!be!committed!to!a!hospital!against!
his!will!unless!he!meets!all!of!the!following!criteria:!
He/she!must!have!a!mental!illness,!his/her!behavior!and!actions!must!be!driven!by!or!be!a!consequence!of!this!
mental!illness,!because!of!his/her!behavior,!there!must!be!a!reasonable!expectation!that!serious!physical!harm!to!self!
or!others!will!occur!in!the!near!future.!
!
Also!one!of!the!following!three!conditions!must!be!present:!
There!is!an!imminent!threat!that!the!person!will!harm!himself!or!herself,!there!is!an!imminent!threat!that!the!person!
will!cause!serious!physical!harm!to!someone!else,!or!the!person!is!not!able!to!provide!for!his!or!her!basic!physical!
needs!so!as!to!guard!against!serious!harm.!
!
!
Question!#121!
QID:!1547!
Subject:!PMCH!
!
A!healthy!68]year]old!white!male!comes!to!your!office!for!a!health!maintenance!visit.!He!tells!you!he!last!saw!a!
physician!6!years!ago,!and!he!recalls!receiving!a!“flu!shot”!and!a!“pneumonia!shot”!at!that!time.!According!to!current!
Centers!for!Disease!Control!(CDC)!recommendations!for!giving!pneumococcal!vaccine!(Pneumovax)!in!the!elderly,!this!
patient!should!be!revaccinated:!
a)!!Every!5!years!
b)!!Every!3!years!
c)!!Yearly!
d)!!Once!
e)!!Never!
!
56
!
!
Explanation:!
According!to!the!most!recent!guidelines!from!the!Centers!for!Disease!Control,!pneumococcal!vaccine!should!be!given!
to!ALL!persons!65!or!over,!including!both!previously!unvaccinated!persons!and!those!who!received!the!vaccine!before!
age!65!but!were!vaccinated!over!5!years!ago.!This!patient!was!age!62!when!he!received!the!vaccine,!indicating!he!
should!be!revaccinated!at!the!time!of!the!health!maintenance!visit.!Data!from!a!single!epidemiologic!study!suggest!
that!the!vaccine!may!provide!protection!for!at!least!9!years!after!receipt!of!the!initial!dose;!however,!data!to!support!
the!need!for!subsequent!doses!of!pneumococcal!vaccine!are!not!available,!and!because!there!is!insufficient!data!
concerning!the!safety!of!pneumococcal!vaccine!when!administered!three!or!more!times,!revaccination!following!a!
second!dose!is!not!routinely!recommended.!
!
!
Question!#122!
QID:!1550!
Subject:!PMCH!
!
Now!that!the!blood!supply!is!routinely!screened!for!antibody!to!hepatitis!C!virus!(HCV),!what!has!become!the!leading!
mode!of!transmission!of!HCV?!
a)!!Injection!drug!use!
b)!!Sexual!transmission!
c)!!Perinatal!maternal]child!transmission!
d)!!Occupational!exposure!of!health]care!workers!
e)!!Household!and!day]care!contact!
!
!
!
Explanation:!
Illegal!drug!use!is!currently!the!leading!cause!of!new!cases!of!hepatitis!C.!It!is!estimated!that!60%!of!new!cases!of!
hepatitis!C!in!Canada!are!due!to!injection!drug!use.!Intranasal!cocaine!use!has!been!associated!with!hepatitis!C,!but!its!
importance!as!a!route!of!transmission!is!controversial!and!it!occurs!at!a!much!lower!frequency,!if!at!all.!
!
Sexual!transmission!of!hepatitis!C!is!a!less!frequent!cause!of!initial!infection.!Hepatitis!B!and!HIV!are!transmitted!more!
efficiently!by!sexual!contact.!Men!who!engage!in!homosexual!intercourse!have!rates!of!hepatitis!C!similar!to!those!of!
heterosexuals!who!engage!in!high]risk!sexual!practices.!Among!partners!who!are!hepatitis!C]positive,!male]to]female!
transmission!seems!to!be!more!efficient.!
!
Maternal]child!perinatal!transmission!rates!are!thought!to!be!less!than!6%.!Breastfeeding!is!not!thought!to!be!a!risk.!
Occupational!transmission!is!infrequent.!No!significant!household!or!day]care!risk!is!thought!to!exist!in!the!absence!of!
blood!exposure.!
!
!
Question!#123!
QID:!1556!
Subject:!PMCH!
!
Cutaneous!larva!migrans!is!transmitted!via:!
a)!!Contaminated!food!
b)!!Contaminated!drinking!water!
c)!!Aerosol!inhalation!
d)!!Skin!contact!with!soil!
e)!!Mosquitoes!
!
!
57
!
Explanation:!
Larva!migrans!is!transmitted!by!skin!contact!with!soil!contaminated!with!hookworm!larvae!from!dog!and!cat!feces!in!
tropical!and!subtropical!areas.!Wearing!shoes!and!sitting!on!a!towel!rather!than!directly!on!the!ground!are!protective!
measures.!
!
!
Question!#124!
QID:!1558!
Topic:!HPV!
Subject:!PMCH!
!
Which!one!of!the!following!statements!about!genital!human!papillomavirus!(HPV)!infection!is!true?!
a)!!Cervical!cancer!and!genital!warts!result!from!the!same!HPV!types!
b)!!A!single!sexual!encounter!with!a!person!infected!with!external!genital!warts!carries!a!low!risk!of!infection!
c)!!Direct!culture!of!cervical!lesions!is!the!most!accurate!diagnostic!method!
d)!!The!most!important!risk!factor!for!acquiring!HPV!infection!is!a!history!of!multiple!sexual!partners!
!
!
!
Explanation:!
In!the!late!1980s!human!papillomavirus!(HPV)!was!linked!to!cervical!cancer!and!clinicians!were!advised!to!aggressively!
treat!all!patients!with!suspected!HPV!disease,!including!those!with!genital!warts.!More!recent!data!indicate!clearly!
that!cervical!cancer!and!genital!warts!result!from!different!HPV!types!and!do!not!appear!to!be!linked.!Specifically,!
external!genital!warts!usually!contain!HPV!types!6!or!11,!and!cervical!cancer!is!associated!with!HPV!types!16,!18,!31,!
33,!and!others.!In!the!1970s,!it!was!demonstrated!that!a!single!sexual!contact!with!a!person!infected!with!external!
genital!warts!carries!about!a!60%!chance!of!transmission.!A!history!of!multiple!partners!is!the!most!important!risk!
factor!for!acquiring!HPV!infection.!Because!it!is!not!possible!to!culture!papillomavirus!in!cells,!alternative!methods!are!
used!to!detect!genital!HPV!expression:!inspection!with!the!unaided!eye!or!with!hand]held!lens!magnification,!
colposcopy,!cytologic!smears!or!biopsies,!and!viral!DNA!detection!methods.!
!
!
Question!#125!
QID:!1561!
Subject:!PMCH!
!
An!18]year]old!patient!presents!with!his!father!for!a!pre]college!physical!examination.!The!student!plans!to!attend!
college!in!a!nearby!state!and!will!live!in!a!university]owned!residence!hall.!A!review!of!his!record!shows!that!he!
received!all!of!the!currently!recommended!immunizations!on!time!throughout!childhood.!The!benefits!of!vaccination!
against!which!one!of!the!following!organisms!should!be!discussed!during!this!visit?!
a)!!Measles!
b)!!Tetanus!
c)!!Pertussis!
d)!!Meningococcus!
e)!!Polio!
!
!
!
Explanation:!
College!freshmen,!especially!those!who!live!in!dormitories,!are!at!a!modestly!increased!risk!for!meningococcal!disease!
compared!with!other!persons!of!the!same!age,!and!vaccination!with!the!currently!available!quadrivalent!
meningococcal!polysaccharide!vaccine!will!decrease!their!risk.!The!Advisory!Committee!on!Immunization!Practices!of!
the!Centers!for!Disease!Control!and!Prevention!recommends!that!incoming!and!current!college!freshmen,!and!their!
parents,!be!informed!about!meningococcal!disease!and!the!benefits!of!vaccination.!This!is!particularly!true!for!those!
who!live!in!dormitories!and!residence!halls.!In!this!case,!the!patient!has!received!vaccinations!against!measles,!polio,!
58
pertussis,!and!tetanus!at!the!recommended!times,!and!booster!vaccinations!are!not!indicated!now.!
!
!
Question!#126!
QID:!1580!
Topic:!Cardiac!Rehabilitation!Program!
Subject:!PMCH!
!
You!approach!the!administrator!of!your!small]town!hospital!about!the!possibility!of!starting!a!cardiac!rehabilitation!
program.!Which!one!of!the!following!is!true!concerning!such!programs?!
a)!!Patients!should!have!a!baseline!exercise!stress!test!before!starting!cardiac!rehabilitation!
b)!!A!standard!exercise!prescription!is!appropriate!for!all!cardiac!patients!
c)!!Cardiac!rehabilitation!has!no!effect!on!exercise!capacity!
d)!!Coronary!events!are!frequent!in!rehabilitation!settings!
!
!
!
Explanation:!
Cardiac!rehabilitation!programs!are!safe!and!effective.!Rates!of!coronary!events!in!rehabilitation!setting!are!very!low.!
Cardiac!rehabilitation!consistently!improves!exercise!capacity!and!has!favorable!effects!on!coronary!risk!factors,!even!
without!nutritional!counseling.!A!baseline!exercise!stress!test!prior!to!starting!cardiac!rehabilitation!is!necessary!to!
screen!for!exertional!ischemia!or!arrhythmias,!and!serves!as!a!basis!for!prescribing!an!exercise!regimen.!The!exercise!
prescription!is!individualized!based!on!results!of!the!exercise!stress!test,!the!age!of!the!patient,!and!the!patient’s!
clinical!status.!
!
!
Question!#127!
QID:!1585!
Topic:!Prostate!Cancer!
Subject:!PMCH!
!
What!is!the!prevalence!of!microscopic!carcinoma!of!the!prostate!among!80]year]old!males!examined!in!autopsy!
studies?!
a)!!3%!
b)!!10%!
c)!!20%!
d)!!40%!
e)!!70%!
!
!
!
Explanation:!
An!astonishingly!high!prevalence!of!microscopic!foci!of!well]differentiated!adenocarcinoma!has!been!found!at!
autopsy!in!serial!sections!of!prostate!glands!considered!to!be!normal!from!men!over!the!age!of!50.!The!incidence!of!
such!tumors!nearly!doubles!with!each!decade!of!age,!starting!at!10%!for!men!in!their!50s!and!rising!to!70%!for!men!in!
their!80s.!
!
!
Question!#128!
QID:!1592!
Topic:!Ovarian!Cancer!
Subject:!PMCH!
!
Which!one!of!the!following!is!associated!with!a!decreased!risk!for!ovarian!cancer?!
a)!!Use!of!fertility!drugs!
b)!!Use!of!oral!contraceptives!
59
c)!!Nulliparity!
d)!!Postmenopausal!hormone!replacement!therapy!
e)!!Age!>!50!
!
!
!
Explanation:!
Ovarian!cancer!is!the!deadliest!gynecologic!malignancy!in!Canada.!The!risk!for!this!cancer!increases!with!age,!with!the!
greatest!incidence!in!postmenopausal!women.!Screening!for!early!detection!of!ovarian!malignancies!has!not!proven!
effective,!and!its!benefit!is!quite!controversial!even!in!patients!with!a!known!genetic!risk.!Thus,!primary!prevention!
may!prove!to!be!the!most!important!method!for!reducing!morbidity!and!mortality!from!this!malignancy.!
!
The!pathogenesis!of!ovarian!cancer!is!unclear,!but!it!is!strongly!believed!that!constant,!uninterrupted!ovulation!may!
lead!to!an!increased!risk.!This!may!explain!why!events!such!as!pregnancy,!breastfeeding,!and!oral!contraceptive!use!
are!associated!with!a!decreased!risk!of!ovarian!cancer,!while!the!use!of!fertility!drugs!poses!an!increased!risk.!
Postmenopausal!use!of!hormone!replacement!therapy!is!also!associated!with!an!increased!risk!of!developing!ovarian!
cancer,!although!the!effect!is!weak!and!the!overall!risk!is!low.!
!
!
Question!#129!
QID:!1608!
Subject:!PMCH!
!
A!new!drug!treatment!is!shown!to!reduce!the!incidence!of!a!complication!of!a!disease!by!50%.!If!the!usual!incidence!
of!this!complication!were!1%!per!year,!how!many!patients!with!this!disease!would!have!to!be!treated!with!this!
medication!for!1!year!to!prevent!one!occurrence!of!this!complication?!
a)!!20!
b)!!50!
c)!!100!
d)!!200!
e)!!500!
!
!
!
Explanation:!
Considering!relative!risk!reduction!without!also!considering!the!absolute!rate!can!distort!the!importance!of!a!therapy.!
A!useful!way!to!assess!the!importance!of!a!therapy!is!to!determine!the!“number]needed]to]treat”!for!that!therapy.!
To!calculate!this!number,!the!absolute!risk!reduction!would!be!0.5%!(0.5!x!.01).!Thus,!the!number]needed]to]treat!for!
the!example!cited!would!be!200!(100/0.5).!
!
More!detailed!explanation:!
!
NNT!=!1/ARR!
Where!ARR!=!CER!(Control!Event!Rate)!]!EER!(Experimental!Event!Rate).!
!
The!ARR!is!the!amount!by!which!your!therapy!reduces!the!risk!of!the!bad!outcome.!For!example,!if!your!drug!reduces!
the!risk!of!a!bad!outcome!from!50%!to!30%,!the!ARR!is:!
!
ARR!=!CER!]!EER!=!0.5!]!0.3!=!0.2!(20%)!
!
In!this!specific!case,!the!new!drug!reduces!the!incidence!by!50%!]!from!1%!to!0.5%).!
!
Therefore!ARR!=!1/100!]!0.5/100!=!0.005!
Then!NNT!=!1/0.005!=!200!
!
60
!
Question!#130!
QID:!1630!
Topic:!Radon!Exposure!
Subject:!PMCH!
!
Residential!and!occupational!exposure!to!radon!is!most!closely!linked!with!the!development!of:!
a)!!Breast!cancer!
b)!!Multiple!myeloma!
c)!!Non]Hodgkin’s!lymphoma!
d)!!Lung!cancer!
e)!!Thyroid!cancer!
!
!
!
Explanation:!
Radon!is!a!naturally!occurring,!inert,!radioactive!gas!which!is!a!decay!product!of!uranium.!It!can!seep!from!soil!
beneath!homes!and!reach!concentrations!in!excess!of!the!EPA!standard!of!4!picocuries.!The!EPA!and!the!Surgeon!
General!have!recommended!that!all!homes!be!tested!for!radon!levels.!Radon!abatement!measures!can!reduce!radon!
concentration!below!EPA!thresholds.!Epidemiologic!studies!implicated!radon!as!the!second!leading!cause!of!lung!
cancer!in!Canada,!responsible!for!up!to!30,000!of!the!150,000!annual!cases!of!bronchogenic!cancer.!Risk!is!
heightened!by!concomitant!exposure!to!tobacco!smoke.!
!
!
Question!#131!
QID:!1640!
Subject:!PMCH!
!
You!are!caring!for!a!70]year]old!male!with!widespread!metastatic!prostate!cancer.!Surgery,!radiation,!and!hormonal!
therapy!have!failed!to!stop!the!cancer,!and!the!goal!of!his!care!is!now!symptom!relief.!He!is!being!cared!for!through!a!
local!hospice.!Over!the!past!few!days!he!has!been!experiencing!respiratory!distress.!His!oxygen!saturation!is!94%!on!
room!air!and!his!lungs!are!clear!to!auscultation.!His!respiratory!rate!is!16/min.!Which!one!of!the!following!would!be!
best!at!this!point?!
a)!!Morphine!
b)!!Oxygen!
c)!!Albuterol!(Proventil,!Ventolin)!
d)!!Haloperidol!(Haldol)!
!
!
!
Explanation:!
Dyspnea!is!a!frequent!and!distressing!symptom!in!terminally!ill!patients.!In!the!absence!of!hypoxia,!oxygen!is!not!
likely!to!be!helpful.!Opiates!are!the!mainstay!of!symptomatic!treatment.!Morphine!is!very!effective!in!reducing!the!
patient's!anxiety,!easing!breathing,!and!improving!blood!flow!(acts!as!a!venous!vasodilator).!
!
!
Question!#132!
QID:!1646!
Topic:!Laboratory/Imaging!Investigations!
Subject:!PMCH!
!
Elevated!levels!of!which!one!of!the!following!are!associated!with!atherosclerosis?!
a)!!Vitamin!B6!
b)!!Vitamin!B12!
c)!!Folate!
61
d)!!Homocysteine!
!
!
!
Explanation:!
Multiple!prospective!and!case]control!studies!have!shown!that!a!moderately!elevated!plasma!homocysteine!
concentration!is!an!independent!risk!factor!for!atherothrombotic!vascular!disease.!
!
!
Question!#133!
QID:!1652!
Subject:!PMCH!
!
An!epidemiologic!study!to!determine!possible!correlates!of!testicular!cancer!is!being!developed.!A!group!of!100!men!
with!testicular!cancer!has!been!identified,!as!well!as!a!group!of!100!men!without!testicular!cancer.!The!200!men!were!
asked!to!give!an!exhaustive!accounting!of!their!past!dietary!habits!to!look!for!possible!dietary!differences!between!
those!with!and!those!without!testicular!cancer.!This!epidemiologic!study!uses:!
a)!!A!case]control!design!
b)!!A!cross]sectional!design!
c)!!A!clinical!series!
d)!!A!cohort!design!
e)!!An!experimental!design!
!
!
!
Explanation:!
This!study!uses!a!case]control!design.!It!is!an!explanatory!study,!as!are!the!experimental,!cross]sectional,!and!follow]
up!designs.!A!clinical!series!is!not!an!explanatory!study,!but!rather!a!descriptive!study!design.!
!
Like!cross]sectional!and!follow]up!designs,!case]control!is!an!observational!design!that!begins!with!an!outcome!(e.g.,!
testicular!cancer)!and!then!looks!for!common!features!(e.g.,!diet)!among!people!who!share!that!outcome.!A!cohort,!
or!prospective,!design!begins!with!people!who!have!not!yet!experienced!an!outcome:!characteristics!of!the!group!to!
be!studied!are!measured!and!catalogued,!and!then!the!researchers!wait!for!the!outcome.!
!
The!cross]sectional!design!is!an!observational!design!that!takes!a!population!or!cohort!and!makes!a!simultaneous!
assessment!of!outcomes!and!potential!predictors.!It!is!a!slice]of]time!design!also!referred!to!as!a!prevalence!study.!
With!the!experimental!design,!one!begins!with!a!group!free!of!the!outcome,!then!divides!the!population!into!two!
groups,!allowing!and!likewise!limiting!variables!between!each!group!to!see!how!the!outcome!varies!between!the!two!
groups.!The!clinical!series!is!a!descriptive!type!of!study!that!records!events,!observations,!and!activities,!but!does!not!
provide!a!detailed!explanation!for!the!cause!of!disease.!This!type!of!study!often!leads!to!the!development!of!more!in]
depth!explanatory!studies.!
!
!
Question!#134!
QID:!1664!
Topic:!Prophylaxis,!rabies!
Subject:!PMCH!
!
It!would!be!most!appropriate!to!withhold!rabies!prophylaxis!for!which!one!of!the!following?!
a)!!A!mouse!bite!occurring!in!the!patient’s!basement!
b)!!A!bat!bite!sustained!on!a!hiking!trip!
c)!!A!dog!bite!from!an!unprovoked!cocker!spaniel,!unvailable!for!observation!
d)!!A!raccoon!bite!occurring!on!a!hiking!trip!
!
62
!
!
Explanation:!
Rabies!postexposure!prophylaxis!(RPEP)!should!be!given!for!all!bat!bites!and!most!raccoon!bites!unless!brain!test!
results!will!be!available!within!48!hours.!
Bites!from!small!rodents!(e.g.,!rats,!mice,!squirrels)!never!require!RPEP.!
RPEP!should!be!given!after!a!domestic!animal!bite!if!it!was!unprovoked!and/or!the!animal!demonstrated!abnormal!
behavior!and!is!not!available!for!observation.!
!
!
!
Rabies!
!
!
Question!#135!
QID:!1670!
Subject:!PMCH!
!
Which!one!of!the!following!is!current!recommendation!regarding!influenza!vaccine?!
a)!!Recommend!nfluenza!vaccine!to!all!persons!age!50!and!over!
b)!!Recommend!influenza!vaccine!to!persons!under!age!65!only!if!they!are!at!high!risk!
c)!!Recommend!influenza!vaccine!for!pediatric!patients!
d)!!Recommend!routine!administration!of!pneumococcal!vaccine!whenever!an!initial!influenza!vaccination!is!given!
e)!!Recommend!influenza!vaccine!to!everyone!6!months!of!age!and!older!
!
!
!
Explanation:!
Recommended!recipients!of!influenza!vaccine!for!the!2013]2014!season:!
People!at!high!risk!of!influenza]related!complications!or!hospitalization:!
Adults!(including!pregnant!women)!and!children!with!the!following!chronic!health!conditions:!
cardiac!or!pulmonary!disorders!(including!bronchopulmonary!dysplasia,!cystic!fibrosis!and!asthma);!
diabetes!mellitus!and!other!metabolic!diseases;!
cancer,!immune!compromising!conditions!(due!to!underlying!disease!and/or!therapy);!
renal!disease;!
anemia!or!hemoglobinopathy;!
conditions!that!compromise!the!management!of!respiratory!secretions!and!are!associated!with!an!increased!risk!of!
aspiration;!
morbid!obesity!(BMI!≥!40);!and!
children!and!adolescents!with!conditions!treated!for!long!periods!with!acetylsalicylic!acid.!
People!of!any!age!who!are!residents!of!nursing!homes!and!other!chronic!care!facilities.!
People!≥!65!years!of!age.!
All!children!6!to!59!months!of!age.!
Healthy!pregnant!women!(the!risk!of!influenza]related!hospitalization!increases!with!length!of!gestation,!i.e.!it!is!
higher!in!the!third!than!in!the!second!trimester)!
Aboriginal!Peoples.!
!
People!capable!of!transmitting!influenza!to!those!at!high!risk:!
Health!care!and!other!care!providers!in!facilities!and!community!settings!who,!through!their!activities,!are!capable!of!
transmitting!influenza!to!those!at!high!risk!of!influenza!complications.!
Household!contacts!(adults!and!children)!of!individuals!at!high!risk!of!influenza]related!complications!(whether!or!not!
the!individual!at!high!risk!has!been!immunized):!
household!contacts!of!individuals!at!high!risk,!as!listed!in!the!section!above;!
household!contacts!of!infants!<!6!months!of!age!as!these!infants!are!at!high!risk!of!complications!from!influenza!but!
cannot!receive!influenza!vaccine;!and!
members!of!a!household!expecting!a!newborn!during!the!influenza!season.!
63
Those!providing!regular!child!care!to!children!≤!59!months!of!age,!whether!in!or!out!of!the!home.!
Those!who!provide!services!within!closed!or!relatively!closed!settings!to!persons!at!high!risk!(e.g.!crew!on!a!ship).!
!
Others:!
People!who!provide!essential!community!services.!
People!in!direct!contact!during!culling!operations!with!poultry!infected!with!avian!influenza.!
Note:!Healthy!persons!aged!5!to!64!years!who!do!not!have!contraindications!to!influenza!vaccine!are!also!encouraged!
to!receive!influenza!vaccine!even!if!they!are!not!in!one!of!the!recommended!recipient!groups.!
!
!
Question!#136!
QID:!1674!
Subject:!PMCH!
!
Which!one!of!the!following!is!the!best!screening!test!for!hereditary!hemochromatosis?!
a)!!Hemoglobin!
b)!!ALT!(SGPT)!
c)!!Serum!transferrin!saturation!
d)!!Serum!iron!
e)!!Liver!biopsy!
!
!
!
Explanation:!
Hereditary!hemochromatosis!is!one!of!the!most!common!genetic!disorders!in!Canada.!Serum!transferrin!saturation!is!
the!best!and!most!sensitive!screening!test.!Liver!biopsy,!long!considered!the!gold!standard!for!diagnosing!
hemochromatosis,!is!far!too!invasive.!The!other!tests!listed!lack!sensitivity!or!selectivity.!
!
!
Question!#137!
QID:!1682!
Subject:!PMCH!
!
Which!one!of!the!following!is!a!contraindication!to!immunization!with!MMR?!
a)!!The!patient!had!a!tuberculosis!skin!test!(PPD)!within!the!previous!2!days!
b)!!A!household!member!of!the!patient!has!an!immunodeficiency!
c)!!The!mother!of!the!patient!is!pregnant!
d)!!The!patient!is!pregnant!
e)!!The!patient!is!breastfeeding!her!newborn!infant!
!
!
!
Explanation:!
The!failure!to!provide!immunizations!because!of!perceived!contraindications!is!one!of!the!most!common!reasons!for!
an!inadequately!protected!population.!A!PPD!may!be!falsely!negative!if!administered!2]30!days!after!MMR!
administration,!not!the!reverse.!If!the!patient!is!immunodeficient!or!pregnant,!rather!than!a!household!contact,!then!
MMR!is!contraindicated.!Breastfeeding!is!not!a!contraindication.!
!
!
Question!#138!
QID:!1686!
Topic:!Hypertension!
Subject:!PMCH!
!
64
Which!one!of!the!following!would!be!most!likely!to!have!secondary!hypertension?!
a)!!A!39]year]old!white!male!who!weighs!119!kg!(262!lb)!and!whose!blood!pressure!is!142/94!mm!Hg!
b)!!A!48]year]old!black!female!with!left!ventricular!hypertrophy!on!echocardiography!whose!blood!pressure!is!162/98!
mm!Hg!
c)!!A!62]year]old!black!male!with!a!strong!family!history!of!hypertension!
d)!!A!78]year]old!white!female!with!abdominal!bruits!whose!blood!pressure!is!182/102!mm!Hg!
e)!!An!88]year]old!white!male!with!hemiparesis!due!to!a!previous!stroke!whose!blood!pressure!is!192/88!mm!Hg!
!
!
!
Explanation:!
Physical!findings!which!suggest!secondary!hypertension!include!the!presence!of!abdominal!bruits,!particularly!those!
that!lateralize!or!have!a!diastolic!component.!Excess!body!weight!is!correlated!closely!with!increased!blood!pressure,!
but!is!not!a!cause!of!secondary!hypertension.!Hypertension!is!the!most!important!risk!factor!for!stroke,!but!a!history!
of!stroke!is!not!an!indication!of!secondary!hypertension.!Left!ventricular!hypertrophy!is!a!result!of!hypertension,!but!
is!not!an!indication!of!secondary!hypertension.!The!prevalence!of!hypertension!is!greater!in!blacks!than!in!whites,!but!
black!race!is!not!a!risk!factor!for!secondary!hypertension.!
!
!
Question!#139!
QID:!1714!
Subject:!PMCH!
!
Which!one!of!the!following!is!a!major!risk!factor!for!prostate!cancer?!
a)!!Asian!ethnicity!
b)!!A!family!history!of!prostate!cancer!
c)!!Age!<!50!
d)!!Urinary!hesitancy!and!nocturia!
e)!!Uncontrolled!diabetes!mellitus!
!
!
!
Explanation:!
The!main!risk!factors!for!prostate!cancer!include!a!positive!family!history,!black!race,!and!age!over!50.!Urinary!
symptoms!associated!with!benign!prostatic!hypertrophy!are!not!associated!with!increased!risk,!nor!is!uncontrolled!
diabetes!mellitus.!
!
!
Question!#140!
QID:!1720!
Topic:!Disease!Outbreak!
Subject:!PMCH!
!
Your!community!recently!experienced!an!outbreak!of!infectious!diarrheal!illness!due!to!the!protozoan!
Cryptosporidium,!a!chlorine]resistant!organism.!A!reporter!from!the!local!newspaper!asks!you!if!there!are!other!
chlorine]resistant!fecal!organisms!that!could!contaminate!public!drinking!water.!You!would!tell!the!reporter!that!such!
organisms!include:!
a)!!Escherichia!coli!
b)!!Vibrio!cholerae!
c)!!Campylobacter!jejuni!
d)!!Giardia!cysts!
e)!!Rotavirus!
!
!
65
!
Explanation:!
Organisms!that!can!persist!in!water!environments!and!survive!disinfection,!especially!chlorination,!are!most!likely!to!
cause!disease!outbreaks!related!to!drinking!water.!Cryptosporidium!oocysts!and!Giardia!cysts!are!resistant!to!chlorine!
and!are!important!causes!of!gastroenteritis!from!drinking!water.!Entamoeba!histolytica!and!hepatitis!A!virus!are!also!
relatively!chlorine!resistant.!The!other!organisms!listed!are!chlorine!sensitive.!
!
!
Question!#141!
QID:!1735!
Topic:!HIV!
Subject:!PMCH!
!
You!regularly!volunteer!your!professional!services!to!a!free!clinic!in!an!underserved!community!in!a!large!Canadian!
city!where!various!infectious!diseases!are!prevalent.!You!are!helping!the!staff!develop!some!recommendations!
regarding!infectious!diseases!that!place!infants!at!risk!during!breastfeeding.!Which!maternal!infectious!disease!listed!
below!should!be!included!as!an!absolute!contraindication!to!breastfeeding!in!otherwise!healthy!infants.!
a)!!Hepatitis!A!virus!infection!
b)!!Cytomegalovirus!infection!
c)!!Malaria!
d)!!The!common!cold!
e)!!HIV!infection!
!
!
!
Explanation:!
HIV!and!HTLV!]!1!(human!T]cell!lymphotropic!virus)!infections!are!the!only!infectious!diseases!that!are!considered!
absolute!contraindications!to!breastfeeding!in!developed!countries!such!as!Canada.!The!other!infections!listed!may!
require!temporary!insolation!of!the!baby!from!the!mother,!prophylactic!treatment,!or!immunization!of!the!baby!
and/or!feeding!pumped!breast!milk,!but!none!are!absolute!contraindications!to!breastfeeding.!
!
>!If!the!diagnosis!of!maternal!hepatitis!A!(choice!A)!is!made!within!the!period!of!contagiousness!(approximately!3!
weeks),!careful!handwashing!by!the!mother!is!appropriate,!and!the!infant!can!receive!immunoglobulin!and!hepatitis!A!
virus!vaccination.!
>!Studies!have!shown!that!in!full]term,!healthy!infants,!acquisition!of!cytomegalovirus!(choice!B)!from!breast!milk!
does!not!result!in!significant!clinical!disease!and!is!considered!natural!vaccination.!
>!With!parasitic!infections!such!as!malaria!(choice!C),!breastfeeding!should!be!continued!provided!the!mother’s!
clinical!condition!allows!for!it.!While!the!antimalarials!chloroquine,!hydroxychloroquine!and!quinine!are!found!in!
variable!quantities!in!breast!milk,!all!three!are!regarded!as!compatible!with!breastfeeding.!
>!For!some!common!infections,!such!as!the!common!cold!(choice!D),!infants!have!already!been!exposed!by!maternal!
contact!during!the!prodomal!period,!and!interrupting!breastfeeding!would!be!counterproductive!given!that!it!
provides!the!infant!with!antibodies!and!other!anti]inflammatory!and!immunomodulating!substances.!
!
!
Question!#142!
QID:!1740!
Topic:!Food!Poisoning!
Subject:!PMCH!
!
Outbreaks!of!diarrheogenic!Escherichia!coli!0157:H7!have!been!associated!with!which!one!of!the!following?!
a)!!Pet!turtles!
b)!!Ice!cream!
c)!!Ground!beef!
d)!!Canned!sardines!
e)!!Home]preserved!vegetables!
!
66
!
!
Explanation:!
Recent!outbreak!of!E.coli!0157:H7]related!illnesses!have!been!associated!with!contaminated!ground!beef!brought!
either!uncooked!in!supermarkets!or!as!cooked!hamburgers!at!fast]food!restaurants.!
!
!
Question!#143!
QID:!1746!
Topic:!Hepatitis!
Subject:!PMCH!
!
Which!one!of!the!following!patients!should!be!screened!for!hepatitis!C!virus!(HCV)!infection?!
a)!!A!45]year]old!who!received!a!blood!transfusion!in!1996!subsequent!to!a!serious!motor!vehicle!accident!
b)!!A!35]year]old!nurse!finishing!her!first!year!of!work!in!a!dialysis!unit!
c)!!A!30]year]old!day]care!worker!after!a!1]year]old!child!in!her!room!was!diagnosed!with!HCV!
d)!!A!9]month]old!born!to!a!mother!positive!for!HCV!
!
!
!
Explanation:!
Hepatitis!C!(HCV)!screening!is!indicated!for!recipients!of!a!transfusion!prior!to!July!1992,!patients!with!needle!stick!or!
mucosal!exposure!to!HCV,!and!children!born!to!mothers!with!HCV!infection.!
!
!
Question!#144!
QID:!1748!
Topic:!Occupational!Exposure!
Subject:!PMCH!
!
The!most!common!illness!related!to!occupational!exposure!is:!
a)!!Asthma!
b)!!Bronchitis!
c)!!Chronic!obstructive!pulmonary!disease!
d)!!Pulmonary!fibrosis!
e)!!Eosinophilic!pneumonia!
!
!
!
Explanation:!
While!occupational!exposure!to!large!and!small!particles!and!gases!is!common!and!can!lead!to!long]term!pulmonary!
difficulties,!asthma!remains!the!most!common!illness!related!to!on]the]job!exposures.!Bronchitis,!obstructive!
pulmonary!disease,!and!pulmonary!fibrosis!can!be!associated!with!occupational!exposure!to!various!toxins,!but!the!
incidence!is!less!than!that!of!asthma.!
!
!
Question!#145!
QID:!1751!
Topic:!Abuse!
Subject:!PMCH!
!
Female!victims!of!domestic!assault:!
a)!!Are!less!likely!to!be!abused!during!pregnancy!
b)!!Seldom!spontaneously!offer!accounts!of!partner!abuse!
c)!!Usually!resent!unsolicited!questions!about!abuse!
d)!!Usually!seek!medical!care!for!their!injuries!
67
!
!
!
Explanation:!
Sexual!abuse!has!been!reported!in!54%!of!violent!marriages.!Abuse!generally!escalates!during!pregnancy.!Victims!are!
often!reluctant!to!speak!out!spontaneously,!and!often!respond!to!neutral!questioning!by!their!family!physician.!
Studies!estimate!that!only!8%!]!39%!of!females!who!are!abused!seek!care.!
!
!
Question!#146!
QID:!1755!
Topic:!Reference!Range!
Subject:!PMCH!
!
To!establish!a!reference!range!for!a!particular!blood!test!in!pregnant!teenagers,!your!laboratory!has!plotted!
measurements!for!large!cohort!of!healthy!subjects.!The!laboratory!finds!that!these!measurements!fit!a!Gaussian!
distribution,!and!sets!its!reference!range!to!include!measurements!within!two!standard!deviations!above!and!below!
the!mean.!What!is!the!approximate!probability!that!a!healthy!person!will!have!a!test!result!that!falls!outside!the!
laboratory!reference!range?!
a)!!10%!
b)!!5%!
c)!!1%!
d)!!0.1%!
e)!!0.01%!
!
!
!
Explanation:!
This!is!a!common!method!of!setting!laboratory!reference!ranges.!The!result!is!that!approximately!5%!of!healthy!
individuals!will!measure!outside!of!the!reference!ranges!on!any!given!chance.!Or,!if!20!tests!are!performed!on!a!
healthy!subject,!the!results!of!one!of!these!tests!will!likely!fall!outside!of!the!reference!ranges.!
!
!
Question!#147!
QID:!1756!
Topic:!HIV!
Subject:!PMCH!
!
Your!office!nurse!reports!an!accidental!needlestick!with!a!used!venipuncture!needle.!She!had!drawn!blood!from!a!35]
year]old!white!male,!who!is!a!new!patient!undergoing!evaluation!for!hypertension!and!hyperlipidemia.!He!has!no!
evidence!of!other!health!problems!and!no!risk!factors!for!HIV.!Both!the!nurse!and!the!patient!are!found!to!be!HIV!
negative.!Which!one!of!the!following!would!be!the!most!appropriate!advice?!
a)!!No!further!testing!for!HIV!is!necessary!
b)!!She!should!have!repeat!HIV!testing!at!6,!12,!24,!and!52!weeks!after!the!exposure!
c)!!She!should!begin!treatment!with!prophylactic!antiretroviral!therapy!within!the!next!48!hours!
d)!!She!should!refrain!from!patient!contact,!unless!she!wears!gloves,!until!another!negative!test!12!weeks!after!the!
exposure!
e)!!She!should!refrain!from!unprotected!sexual!contact!with!her!husband!until!another!negative!test!6!weeks!after!the!
exposure!
!
!
!
Explanation:!
If!the!patient!the!nurse!was!exposed!to!is!HIV!negative!and!asymptomatic!at!the!time!of!exposure,!no!further!HIV!
testing!of!the!recipient!is!necessary!(choice!A),!although!some!prefer!additional!tests!for!peace!of!mind.!Prophylactic!
68
treatment!is!unnecessary!in!this!situation,!although!it!might!be!recommended!if!the!source!has!an!unknown!HIV!
status.!As!both!HIV!statuses!are!negative,!the!nurse!need!not!follow!more!stringent!guidelines!than!universal!
precautions.!
!
!
Question!#148!
QID:!1763!
Subject:!PMCH!
!
An!85]year]old!white!male!with!terminal!pancreatic!cancer!is!expected!to!survive!for!another!2!weeks.!His!pain!has!
been!satisfactorily!controlled!with!sustained]release!morphine.!He!has!now!developed!a!disturbed!self]image,!
hopelessness,!and!anhedonia,!and!has!told!family!members!that!he!has!thought!about!suicide.!Psychomotor!
retardation!is!also!noted.!His!family!is!supportive.!His!daughter!feels!that!he!is!depressed,!while!his!son!feels!this!is!
more!of!a!grieving!process.!Which!one!of!the!following!would!be!the!most!appropriate!management!of!this!problem?!
a)!!Fluoexetine!
b)!!Sertraline!
c)!!Clozapine!
d)!!Olanzapine!
e)!!Methylphenidate!
!
!
!
Explanation:!
Distinguishing!between!preparatory!grief!and!depression!in!a!dying!patient!is!not!always!simple.!Initially!one!should!
evaluate!for!unresolved!physical!symptoms!and!treat!any!that!are!present.!If!the!patient!remains!in!distress,!mood!
should!be!evaluated.!If!it!waxes!and!wanes!with!time!and!if!self]esteem!is!normal,!this!is!likely!preparatory!grief.!The!
patient!may!have!fleeting!thoughts!of!suicide!and!likely!will!express!worry!about!separation!from!loved!ones.!This!
usually!responds!to!counselling.!
!
In!patients!with!anhedonia,!persistent!dysphoria,!disturbed!self]image,!hopelessness,!poor!sense!of!self]worth,!
rumination!about!death!and!suicide,!or!an!active!desire!for!early!death,!depression!is!the!problem.!For!patients!who!
are!expected!to!live!only!a!few!days,!psychostimulants!such!as!methylphenidate(choice!E)!should!be!used.!For!those!
who!are!expected!to!survive!longer,!SSRIs!are!a!good!choice.!This!is!because!SSRI!are!the!best!drugs!for!the!
management!of!long]term!depression.!
!
>!Fluoxetine!(choice!A)!and!Sertraline!(choice!B)!are!SSRI!that!would!be!more!appropriate!for!the!management!of!
long]term!depression.!SSRI!usually!do!not!manifest!their!effects!until!2]!3!weeks!into!treatment,!so!this!patient!would!
have!died!by!the!time!SSRI!would!start!to!have!benefits.!
>!Clozapine!(choice!C)!and!Olanzapine!(choice!D)!are!atypical!antipsychotics.!
!
!
Question!#149!
QID:!1775!
Subject:!PMCH!
!
In!addition!to!routine!immunizations,!which!one!of!the!following!is!specifically!indicated!for!adolescent!males!who!
have!sex!with!other!males?!
a)!!Polio!vaccine!
b)!!Varicella!virus!vaccine!
c)!!Pneumococcal!polysaccharide!vaccine!
d)!!Hepatitis!A!vaccine!
e)!!MMR!
!
!
69
!
Explanation:!
Hepatitis!A!vaccine!should!be!administered!to!unvaccinated!adolescents!who!plan!to!travel!to!or!work!in!an!area!of!
high!endemicity!of!hepatitis!A!virus!infection,!those!who!receive!clotting!factors,!those!who!have!chronic!liver!disease!
or!use!illegal!drugs,!and!males!who!have!sex!with!males.!Routine!hepatitis!A!vaccination!of!all!children!has!been!
proposed!and!implementation!strategies!are!being!studied.!
!
!
Question!#150!
QID:!1776!
Topic:!Incidence!
Subject:!PMCH!
!
Which!one!of!the!following!best!describes!the!reason!for!the!marked!decline!in!the!incidence!of!epiglottitis!in!the!
pediatric!population?!
a)!!Genetic!drift!in!strains!of!parainfluenza!virus!
b)!!More!effective!use!of!appropriate!broad]spectrum!cephalosporin!antibiotics!
c)!!Immunization!with!Haemophilus!influenzae!type!b!vaccine!
d)!!Increased!use!of!the!new!polyvalent!pneumococcal!vaccines!
!
!
!
Explanation:!
The!dramatic!decrease!in!the!incidence!of!epiglottitis!is!the!result!of!routine!vaccination!with!Haemophilus!influenzae!
type!b!vaccine.!This!decreased!incidence!has!also!dramatically!reduced!morbidity!and!mortality.!
!
!
Question!#151!
QID:!1789!
Subject:!PMCH!
!
Which!one!of!the!following!vaccination!practices!is!consistent!with!current!recommendations?!
a)!!A!fourth!dose!of!DtaP!for!an!18]month]old!girl!with!symptomatic!HIV!infection!
b)!!Influenza!vaccine!for!a!30]year]old!practicing!nurse!who!has!a!history!of!hives!after!egg!ingestion!
c)!!A!second!dose!of!MMR!vaccine!for!a!6]year]old!girl!who!had!an!anaphylactic!reaction!to!gelatin!last!year!
d)!!Varicella!vaccine!for!a!15]month]old!boy!who!is!being!treated!for!lymphoma!
e)!!Rubella!vaccine!for!a!susceptible!24]year]old!woman!who!intends!to!try!to!become!pregnant!within!the!next!
month!
!
!
!
Explanation:!
Patients!with!altered!immunocompetence,!such!as!those!with!HIV!infection,!leukemia,!or!lymphoma,!should!not!be!
vaccinated!with!live!viral!vaccines.!Thus,!the!patient!with!HIV!may!be!vaccinated!with!the!killed!DtaP!vaccine,!while!
the!patient!with!lymphoma!may!not!be!vaccinated!with!the!varicella!vaccine.!Persons!with!a!history!of!anaphylactic!or!
anaphylactic]like!allergy!to!eggs!or!egg!proteins!should!not!be!given!vaccine!prepared!using!embryonated!chicken!
eggs,!such!as!influenza!vaccine.!
!
Although!no!cases!of!congenital!rubella!or!abnormalities!attributable!to!fetal!infection!have!been!observed!among!
infants!born!to!susceptible!women!who!received!rubella!vaccine!during!pregnancy,!the!Advisory!Committee!on!
Immunization!Practices!recommend!that!women!avoid!becoming!pregnant!during!the!4!weeks!following!
immunization.!The!rubella!vaccine!is!grown!in!human!diploid!cell!cultures!and!can!be!safely!administered!to!persons!
with!a!history!of!severe!allergy!to!egg!and!egg!proteins.!The!rare!serious!allergic!reactions!after!MMR!are!not!believed!
to!be!caused!by!egg!antigens,!but!to!other!components!of!the!vaccine,!such!as!gelatin.!MMR!and!its!component!
vaccines,!as!well!as!some!other!vaccines,!contain!hydrolyzed!gelatin!as!a!stabilizer.!Extreme!caution!should!be!
70
exercised!when!administering!vaccines!that!contain!gelatin!to!persons!who!have!a!history!of!an!anaphylactic!reaction!
to!gelatin!or!gelatin]containing!products.!
!
!
Question!#152!
QID:!1804!
Topic:!Asbestos!
Subject:!PMCH!
!
The!local!school!district!has!found!that!there!is!asbestos!in!many!of!the!classrooms.!The!asbestos!is!contained!in!
ceiling!material!used!as!acoustical!insulation.!Which!one!of!the!following!statements!is!true!regarding!this!situation?!
a)!!The!asbestos!must!be!removed!by!mandate!of!the!Environmental!Protection!Agency!
b)!!Workers!removing!the!ceiling!material!without!respiratory!protection!would!have!an!increased!risk!of!
mesothelioma!
c)!!Children!with!asthma!are!at!increased!risk!in!classrooms!containing!asbestos!materials!
d)!!Cigarette!smoking!adds!negligibly!to!the!risk!from!asbestos!exposure!
!
!
!
Explanation:!
Asbestos!removal!from!public!buildings!is!not!mandated!by!the!Environmental!Protection!Agency!unless!there!is!
severe!and!extensive!damage!and!there!are!no!other!options!such!as!special!repairs!or!encapsulation!that!will!control!
fiber!release.!
!
Asbestos!exposure!has!been!associated!with!a!variety!of!cancers,!including!lung!cancer,!mesothelioma,!cancer!of!the!
oropharynx,!cancer!of!the!larynx,!and!gastrointestinal!cancer.!Cigarette!smoking!amplifies!the!effects!of!asbestos!
exposure.!Smoking,!drug!and!alcohol!abuse,!improper!diet,!and!inadequate!exercise!are!all!greater!public!health!
hazards!than!asbestos.!
!
Asthmatics,!especially!when!exercising,!can!be!influenced!by!a!variety!of!inhaled!irritants,!including!sulfur!dioxide!and!
acidic!aerosols!in!concentrations!present!in!many!cities,!but!not!including!asbestos.!
!
!
Question!#153!
QID:!1820!
Subject:!PMCH!
!
When!a!screening!test!identifies!a!cancer!earlier,!thereby!increasing!the!time!between!diagnosis!and!death!without!
prolonging!life,!this!is!called:!
a)!!Length]time!bias!
b)!!Lead]time!bias!
c)!!A!false]positive!screening!test!
d)!!Increasing!the!positive!predictive!value!of!the!screening!test!
e)!!Attributable!risk!
!
!
!
Explanation:!
Lead]time!bias!is!when!a!screening!test!identifies!a!cancer!earlier,!thereby!increasing!the!time!between!diagnosis!and!
death!without!actually!prolonging!life.!Length]time!bias!is!when!a!screening!test!finds!a!disproportionate!number!of!
cases!of!slowly!progressive!disease!and!misses!the!aggressive!cases,!thereby!leading!to!an!overestimate!of!the!
effectiveness!of!the!screening.!A!false]positive!test!is!one!that!suggests!cancer!where!no!cancer!exists.!The!positive!
predictive!value!is!the!proportion!of!positive!test!results!that!are!true!positives.!Attributable!risk!is!the!difference!in!
risk!of!a!disease!that!can!be!accounted!for!by!a!specific!risk!factor.!
!
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!
Question!#154!
QID:!1828!
Subject:!PMCH!
!
At!a!routine!annual!visit,!a!healthy!65]year]old!male!is!given!pneumococcal!vaccine.!When!should!he!receive!a!
booster!dose!of!this!vaccine?!
a)!!Never!
b)!!In!3!years!
c)!!In!5!years!
d)!!In!7!years!
e)!!In!10!years!
!
!
!
Explanation:!
If!an!otherwise!healthy!patient!receives!pneumococcal!vaccine!at!age!65!or!later,!a!second!dose!is!not!needed.!If!a!
healthy!patient!receives!the!vaccine!before!age!65,!a!second!dose!should!be!given!after!age!65!if!at!least!5!years!have!
elapsed!since!the!first!dose.!
!
!
Question!#155!
QID:!1829!
Subject:!PMCH!
!
Which!one!of!the!following!groups!is!at!increased!risk!of!prostate!cancer?!
a)!!Whites!
b)!!Hispanics!
c)!!Blacks!
d)!!Aboriginal!peoples!
e)!!Asians!
!
!
!
Explanation:!
Prostate!cancer!is!the!most!common!cancer!in!Canadian!men.!Blacks!are!1.5!times!as!likely!as!whites!to!develop!
prostate!cancer.!A!family!history!of!prostate!cancer!in!a!first!degree!relative!also!increases!the!risk.!No!risk!association!
has!been!demonstrated!for!other!racial!or!ethnic!groups.!
!
!
Question!#156!
QID:!1831!
Topic:!Hepatitis!
Subject:!PMCH!
!
A!nurse!who!completed!a!hepatitis!B!vaccine!series!a!year!ago!is!accidentally!stuck!by!a!needle!that!has!just!been!
used!on!a!dialysis!patient.!The!patient!is!known!to!be!HbsAg]positive.!Your!first!response!should!be!to:!
a)!!Provide!reassurance!only!
b)!!Test!the!nurse!for!hepatitis!B!antibody!
c)!!Repeat!the!hepatitis!B!vaccine!series!
d)!!Administer!hepatitis!B!immune!globulin!(HBIG)!only!
e)!!Administer!HBIG!plus!a!booster!of!hepatitis!B!vaccine!
!
72
!
!
Explanation:!
Postexposure!prophylaxis!after!hepatitis!B!exposure!via!the!percutaneous!route!depends!upon!the!source!of!the!
exposure!and!the!vaccination!state!of!the!exposed!person.!In!the!case!described,!a!vaccinated!person!has!been!
exposed!to!a!known!positive!individual.!The!exposed!person!should!be!tested!for!hepatitis!B!antibodies;!if!antibody!
levels!are!inadequate!(<!10!IU/L!by!radioimmunoassay,!negative!by!enzyme!immunoassay)!HBIG!should!be!
administered!immediately,!as!well!as!hepatitis!B!vaccine!booster!dose.!An!unvaccinated!individual!in!this!same!setting!
should!receive!HBIG!immediately!(preferably!within!24!hours!after!exposure)!followed!by!the!hepatitis!B!vaccine!
series!(injection!in!1!week!or!less,!followed!by!a!second!dose!in!1!month!and!a!third!dose!in!6!months).!
!
!
Question!#157!
QID:!1834!
Topic:!Smoking!cessation!medications!
Subject:!PMCH!
!
An!84]year]old!white!female!presents!to!your!office!with!symptoms!of!an!upper!respiratory!infection!and!a!hacking!
cough.!She!admits!to!smoking!one!pack!of!cigarettes!daily!since!she!was!21!years!of!age.!Which!one!of!the!following!is!
true!with!regard!to!her!tobacco!use?!
a)!!If!she!is!unable!to!quit!smoking!she!should!switch!to!a!low]tar,!low]nicotine!cigarette!
b)!!Individuals!this!age!do!not!benefit!from!smoking!cessation!
c)!!Nicotine!patches!should!not!be!used!if!she!has!coexisting!coronary!artery!disease!
d)!!Sustained]release!bupropion!(Wellbutrin!SR)!has!been!shown!to!reduce!the!relapse!rate!for!up!to!12!months!
!
!
!
Explanation:!
Sustained]release!bupropion!has!been!shown!to!reduce!the!relapse!rate!for!smoking!cessation!and!blunt!weight!gain!
for!12!months.!Beneficial!effects!of!smoking!cessation!are!seen!even!among!older!smokers.!Evidence!has!now!shown!
that!smokers!who!switch!to!low]tar!or!low]nicotine!cigarettes!do!not!significantly!decrease!their!health!risks.!The!
approved!Food!and!Drug!Administration!medications!for!smoking!cessation!(sustained]release!bupropion,!nicotine!
patch,!nicotine!gum,!nicotine!inhaler,!and!nicotine!nasal!spray)!have!been!shown!to!be!safe!and!should!be!
recommended!for!all!patients!without!contraindications!who!are!trying!to!quit!smoking.!The!nicotine!patch,!in!
particular,!is!safe,!and!has!been!shown!not!to!cause!adverse!cardiovascular!effects.!
!
!
Question!#158!
QID:!1837!
Topic:!Tick!Removal!
Subject:!PMCH!
!
The!best!way!to!remove!a!tick!is!to:!
a)!!Crush!the!tick!and!remove!it!
b)!!Manually!extract!it!with!blunt!forceps!
c)!!Carefully!apply!a!lit!match!
d)!!Apply!petroleum!jelly!to!the!tick!
!
!
!
Explanation:!
The!best!way!to!remove!a!tick!is!by!manual!extraction!with!blunt!forceps.!Improper!removal!may!cause!harm!by!
allowing!the!tick!to!regurgitate!infection!material.!Heat!and!petrolatum!are!ineffective.!
!
!
Question!#159!
73
QID:!1840!
Topic:!Disease!Outbreak!
Subject:!PMCH!
!
Outbreaks!of!dermatitis!and!folliculitis!associated!with!swimming!pools!and!hot!tubs!are!often!caused!by!which!one!
of!the!following?!
a)!!Listeria!
b)!!Pseudomonas!
c)!!Streptococcus!
d)!!Shigella!
e)!!Staphylococcus!
!
!
!
Explanation:!
Pseudomonas!organisms!have!been!associate!with!outbreaks!of!otitis!externa,!dermatitis,!and!folliculitis!in!persons!
using!swimming!pools!and!hot!tubs.!
!
!
Question!#160!
QID:!1845!
Topic:!Breast!Cancer!
Subject:!PMCH!
!
When!advising!women!about!the!need!for!breast!cancer!screening,!which!one!of!the!following!statements!is!accurate!
regarding!risk!factors!and!the!need!for!screening?!
a)!!Most!women!with!breast!cancer!have!no!identifiable!risk!factors!
b)!!Hereditary!breast!cancer!is!more!common!in!postmeopausal!women!
c)!!Having!several!second!degree!relatives!with!breast!cancer!carries!the!same!risk!as!having!one!first!degree!relative!
with!breast!cancer!
d)!!When!hereditary!breast!cancer!strikes!several!generations!of!a!family,!women!descended!from!a!male!family!
member!are!not!at!increased!risk!
e)!!!Women!of!Ashkenazi!Jewish!descent!have!a!lower!risk!of!developing!breast!cancer!
!
!
!
Explanation:!
Most!women!with!breast!cancer!have!no!identifiable!risk!factors!(choice!A).!
!
→!Hereditary!breast!cancer!is!more!common!in!premenopausal!women!(choice!B!is!incorrect).!
→!The!risk!is!increased!three]!to!fourfold!in!women!with!a!first!degree!relative!who!has!had!breast!cancer.!Having!
several!second!degree!relatives!with!breast!cancer!results!in!increased!risk,!but!this!risk!has!not!been!quantified!
(choice!C!is!incorrect).!
→!Even!women!with!hereditary!breast!cancer!on!the!paternal!side!are!at!some!increased!risk!(choice!D!is!incorrect).!
→!Women!of!Ashkenazi!Jewish!descent!have!a!higher!risk!of!developing!breast!cancer!(choice!E!is!incorrect).!This!is!
because!about!1!in!40!Ashkenazi!Jewish!women!carry!a!BRCA!gene!mutation,!while!only!1!in!500!women!in!the!
general!population!have!it.!
!
!
Question!#161!
QID:!1855!
Topic:!PVD!
Subject:!PMCH!
!
Which!one!of!the!following!treatments!has!been!shown!to!produce!the!most!benefit!for!patients!with!peripheral!
vascular!disease?!
74
a)!!Smoking!cessation!
b)!!Diet!modification!
c)!!Aspirin!
d)!!Pentoxifylline!(Trental)!
e)!!Lipid]lowering!drugs!
!
!
!
Explanation:!
Patients!with!peripheral!vascular!disease!who!stops!smoking!have!a!twofold!increase!in!their!5]year!survival!rate.!Diet!
modification!and!lipid]lowering!drugs!can!slow!progression,!but!not!as!dramatically.!Aspirin!and!pentoxifylline!are!
minimally!effective.!
!
!
Question!#162!
QID:!1869!
Subject:!PMCH!
!
Which!one!of!the!following!statements!is!most!accurate!regarding!prostate!cancer?!
a)!!Most!men!who!have!prostate!cancer!are!undiagnosed!before!death!
b)!!Randomized!trials!have!shown!that!screening!for!prostate!cancer!is!effective!in!prolonging!life!
c)!!Prostate!cancer!is!uncommon!
d)!!Neither!benign!nor!malignant!changes!of!the!prostate!have!a!relationship!to!aging!
!
!
!
Explanation:!
The!process!of!aging!is!associated!with!both!benign!and!malignant!alterations!or!changes!of!the!prostate!gland,!but!in!
most!men!these!will!remain!undiscovered!at!the!time!of!death.!The!incidence!and!mortality!rate!for!prostate!cancer!
have!declined!over!the!past!few!years.!Screening!for!prostate!cancer!has!not!proven!effective!in!prospective!
randomized!trials.!Prostate!cancer!is!the!most!common!of!all!cancer!diagnoses,!and!is!the!second!leading!cause!of!
cancer!death!in!men.!
!
!
Question!#163!
QID:!1872!
Topic:!STD!
Subject:!PMCH!
!
Screening!for!Chlamydia!trachomatis!infection!should!be!performed!on!which!one!of!the!following!asymptomatic!
patients!who!present!for!routine!evaluation?!
a)!!A!16]year]old!female!who!states!that!she!is!not!sexually!active!
b)!!A!20]year]old!female!who!uses!birth!control!pills!for!contraception!and!has!a!new!sexual!partner!
c)!!A!26]year]old!male!with!multiple!sexual!partners!with!no!STD!history!who!uses!condoms!consistently!
d)!!A!28]year]old!female!who!is!married,!has!no!history!of!sexually!transmitted!disease,!and!uses!the!rhythm!method!
to!avoid!pregnancy!
!
!
!
Explanation:!
It!is!estimated!that!70%]90%!of!women!and!a!large!percentage!of!men!with!Chlamydia!trachomatis!infection!are!
asymptomatic.!The!most!predictive!risk!factor!for!the!presence!of!the!disease!is!sexual!activity!at!a!young!age.!Other!
risks!include!being!unmarried,!black!race,!a!past!history!of!sexually!transmitted!disease,!new!or!multiple!sexual!
partners,!cervical!ectopy,!and!inconsistent!use!of!barrier!contraceptives.!Asymptomatic!Chlamydia!infection!can!cause!
75
pelvic!inflammatory!disease!and!result!in!ectopic!pregnancy,!infertility,!and!chronic!pelvic!pain!in!women.!
!
There!are!good!screening!tests!available!and!effective!treatments!for!women!with!the!disease.!Unfortunately,!there!
are!currently!no!studies!describing!the!effectiveness!of!routine!screening!or!early!treatment!of!men.!The!Preventive!
Services!Task!Force!strongly!recommends!(class!A)!routine!screening!for!Chlamydia!infection!in!all!sexually!active!
women!25!years!and!younger,!as!well!as!in!other!asymptomatic!women!at!increased!risk.!The!Centers!for!Disease!
Control!and!Prevention!recommend!routine!screening!of!sexually!active!adolescent!women!and!screening!of!older!
women!who!are!at!increased!risk!for!the!disease.!
!
!
Question!#164!
QID:!1881!
Subject:!PMCH!
!
A!recent!study!of!cholesterol]reducing!medication!shows!that!healthy!patients!taking!the!investigational!drug!over!5!
years!had!a!5%!incidence!of!myocardial!infarction,!whereas!7%!of!control!subjects!not!taking!the!drug!suffered!from!a!
myocardial!infarction.!How!many!patients!must!be!treated!with!the!new!drug!for!5!years!in!order!to!prevent!one!
myocardial!infarction?!
a)!!2!
b)!!14!
c)!!20!
d)!!35!
e)!!50!
!
!
!
Explanation:!
The!number!needed!to!treat!(NNT)!refers!to!the!number!of!people!who!need!to!be!treated!in!order!to!prevent!one!
undesirable!outcome.!This!statistic!has!become!increasingly!useful!for!interpretation!of!clinical!research!results,!and!it!
is!an!understandable!form!in!which!to!present!information!to!patients.!It!is!calculated!as!the!reciprocal!of!the!
absolute!risk!reduction!(ARR).!The!ARR!is!the!rate!in!the!control!group!minus!the!rate!in!the!study!group.!Therefore,!
the!calculation!in!this!example!is:!NNT!=!1/0.07!]!0.05!=!1/0.02!=!50.!
!
!
Question!#165!
QID:!1893!
Topic:!Adverse!Drug!Effects!
Subject:!PMCH!
!
The!most!common!hospital!errors!associated!with!preventable!adverse!drug!effects!are!in!the!stage!of:!
a)!!Ordering!
b)!!Transcription!
c)!!Dispensing!
d)!!Administration!
!
!
!
Explanation:!
Adverse!drug!events!are!common!and!are!often!preventable.!Studies!of!the!incidence!of!preventable!adverse!drug!
events!reveal!that!49%!of!errors!occurred!in!the!ordering!stage,!11%!in!the!transcription!stage,!14%!in!the!dispensing!
stage,!and!26%!in!the!administration!stage.!Errors!are!much!more!likely!to!be!intercepted!if!they!occur!in!an!early!
stage.!Wrong!dose!was!the!most!common!ordering!error!encountered,!with!other!errors!including!wrong!choice!of!
medicine,!known!allergy,!wrong!frequency,!and!drug]drug!interaction.!
!
The!economic!implications!of!this!study!could!potentially!be!important!if!prevention!procedures!are!adhered!to.!
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!
!
Question!#166!
QID:!1896!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!concerning!the!use!of!tobacco?!
a)!!Tobacco!withdrawal!symptoms!abate!in!3!days!
b)!!Physician’s!advice!to!patients!to!stop!smoking!is!ineffectual!
c)!!Of!all!the!products!available!for!smoking!cessation,!only!bupropion!(Wellbutrin)!is!consistently!effective!
d)!!Nicotine!replacement!therapy!is!dangerous!for!patients!with!stable!angina!
e)!!Nicotine!causes!physical!dependence!
!
!
!
Explanation:!
Nicotine!causes!both!physical!dependence!and!tolerance.!Withdrawal!from!nicotine!can!last!several!weeks!or!months.!
Physicians’!advice!to!stop!smoking!increases!the!rate!of!stopping!smoking!by!about!30%.!Bupropion!is!no!more!or!less!
effective!than!other!products!for!smoking!cessation.!Nicotine!replacement!therapy!is!safe!in!patients!with!stable!
angina.!
!
!
Question!#167!
QID:!1899!
Topic:!Occupational!Exposure!
Subject:!PMCH!
!
Which!one!of!the!following!chemical!occupational!exposures!is!associated!with!leukemia?!
a)!!Arsenic!
b)!!Benzene!
c)!!Cadmium!
d)!!Organophosphates!
e)!!Perchloroethylene!(tetrachloroethylene)!
!
!
!
Explanation:!
Benzene!is!a!human!carcinogen!and!causes!aplastic!anemia,!leukemia,!and!multiple!myeloma.!It!is!absorbed!through!
the!skin!and!respiratory!tract.!
!
>!Arsenic!is!more!toxic!in!the!inorganic!form!and!causes!epidermal!cancer.!
>!Cadmium!is!associated!with!kidney!toxicity.!
>!Organophosphates!are!the!most!widely!used!insecticides!today.!They!are!one!type!of!pesticide!that!works!by!
damaging!acetylcholinesterase.!Long]term!exposure!to!organophosphates!can!cause!confusion,!anxiety,!loss!of!
memory,!loss!of!appetite,!disorientation,!depression,!and!personality!changes.!Organophosphates!have!been!linked!
to!non]Hodgkins!lymphoma,!lung!cancer!and!leukemia,!but!the!studies!failed!to!account!for!multiple!exposures!to!
different!pesticides.!Therefore,!no!clear!causative!connection!has!been!made.!
>!Perchloroethylene!causes!peripheral!neuropathy,!chemical!hepatitis,!liver!damage,!and!kidney!damage.!
!
!
Question!#168!
QID:!1908!
Topic:!Substance!Toxicity!
Subject:!PMCH!
!
77
As!a!member!of!the!local!emergency!response!management!team!you!are!asked!about!the!treatment!of!nerve!gas!
(e.g.,!sarin)!poisoning.!Which!one!of!the!following!is!most!effective!in!reversing!the!symptoms!of!nerve!gas!toxicity?!
a)!!Albuterol!(Proventil,!Ventolin)!via!inhalation!
b)!!Ciprofloxacin!(Cipro)!
c)!!Atropine!
d)!!Parenteral!verapamil!(Calan,!Isoptin)!
e)!!Parenteral!corticosteroids!
!
!
!
Explanation:!
Nerve!gas!agents!such!as!sarin!resemble!organophosphate!insecticides!and!inactivate!cholinesterase,!leading!to!the!
accumulation!of!acetylcholine!at!nerve!endings.!Respiratory!symptoms!include!rhinorrhea,!bronchorrhea,!
brochospasm,!and!respiratory!muscule!paralysis.!gastrointestinal!symptoms!include!nausea,!vomiting,!and!diarrhea.!
Central!nervous!system!symptoms!include!headache,!vertigo,!agitation,!seizures,!and!coma.!Exposed!patients!benefit!
from!treatment!with!atropine,!which!competitively!inhibits!acetylcholine.!Pralidoxime!chloride!and!diazepam!are!also!
beneficial.!
!
>!Although!Beta]agonists!and!corticosteroids!are!beneficial!in!the!general!tratment!of!bronchospasm,!atropine!is!
preferred!in!this!situation.!
>!Verapamil!and!ciprofloxacin!have!no!role!in!the!treatment!of!nerve!gas!exposure.!
!
!
Question!#169!
QID:!1917!
Topic:!P!value!
Subject:!PMCH!
!
The!results!of!a!given!study!are!reported!as!achieving!significance!at!a!p]value!of!<0.05!(the!5%!level).!True!
statements!about!this!finding!include!which!one!of!the!following?!
a)!!There!is!!a!<5%!likelihood!of!the!results!having!occurred!by!chance!alone!
b)!!If!the!study!were!replicated!100!times,!95!studies!would!repeat!this!finding!and!5!would!not!
c)!!The!confidence!interval!is!0%]10%!
d)!!The!null!hypothesis!has!a!5%!chance!of!being!true!
e)!!The!Beta!or!type!II!error!is!<5%!
!
!
!
Explanation:!
The!p]value!is!a!level!of!statistical!significance,!and!characterizes!the!likelihood!of!achieving!the!observed!results!of!a!
study!by!chance!alone,!and!in!this!case!that!likelihood!is!<5%.!(In!this!case,!<5%!of!the!results!can!be!achieved!by!
chance!alone!and!still!be!significant).!
!
>The!confidence!interval!is!a!measure!of!variance!and!is!derived!from!the!test!data.!
>The!p]value!in!and!of!itself!says!nothing!about!the!truth!or!falsity!of!the!null!hypothesis,!only!that!the!likelihood!of!
the!observed!results!occurring!by!chance!is!5%.!
>The!Alpha!or!type!I!error!is!akin!to!the!error!of!false]positive!assignment;!the!Beta!or!type!II!error!is!analogous!to!the!
false]negative!rate,!or!1!]!specificity,!and!cannot!be!calculated!from!the!information!given.!
!
!
Question!#170!
QID:!1918!
Subject:!PMCH!
!
Which!one!of!the!following!can!be!used!in!both!adults!and!children!(>!2yr)!!to!prevent!influenza!and!its!
78
complications?!
a)!!Acyclovir!(Zovirax)!
b)!!Azithromycin!(Zithromax)!
c)!!Oseltamivir!(Tamiflu)!
d)!!Intranasal!influenza!vaccine!(FluMist)!
e)!!Amantadine!(Symmetrel)!
!
!
!
Explanation:!
Vaccination!has!been!established!as!the!first]line!intervention!to!prevent!influenza!and!its!complications.!Flumist!can!
be!used!in!children,!adolescents,!and!adults!age!2!]!59.!
!
!
Question!#171!
QID:!1952!
Topic:!Hepatitis!
Subject:!PMCH!
!
Hepatitis!C!screening!is!routinely!recommended!in!which!one!of!the!following?!
a)!!Pregnant!women!
b)!!Nonsexual!household!contacts!of!hepatitis!C]positive!persons!
c)!!Health!care!workers!
d)!!Persons!with!a!history!of!illicit!intravenous!drug!use!
!
!
!
Explanation:!
Screening!of!individuals!at!high!risk!of!infection!including!individuals!with!a!history!of!injection!drug!use,!
incarceration,!body!piercing,!tattooing,!blood!transfusion!in!Canada!prior!to!April!1992!or!any!other!high!risk!
exposures.!
!
Early!detection!of!HCV!infection!is!important,!so!that!treatment!may!be!initiated!if!indicated!and!infected!persons!
may!initiate!lifestyle!changes!to!reduce!other!exposures!that!might!increase!the!risk!of!liver!damage.!Response!to!
treatment!may!also!be!enhanced!in!individuals!with!a!shorter!duration!of!infection.!
!
!
!
Question!#172!
QID:!1953!
Topic:!Herbal!Preparations!
Subject:!PMCH!
!
Black!cohosh!is:!
a)!!A!form!of!herbal!licorice!with!gastrointestinal!effects!
b)!!A!botanical!medicine!used!to!alleviate!menopausal!symptoms!
c)!!A!type!of!toxic!hallucinogenic!mushroom!
d)!!A!variety!of!Cannabis!sativa!
e)!!A!form!of!dried!hashish!
!
!
!
Explanation:!
Black!cohosh!is!an!herbal!preparation!widely!used!in!the!treatment!of!menopausal!symptoms!and!menstrual!
dysfunction.!Studies!have!demonstrated!that!this!botanic!medicine!appears!to!be!effective!in!alleviating!menopausal!
79
symptoms.!It!has!not!been!proven!effective!in!randomized!controlled!trials!and!should!not!be!used!to!prevent!
osteoporosis.!Questions!as!to!its!stimulating!effect!on!endometrial!tissue!are!as!yet!unanswered.!
!
!
Question!#173!
QID:!1956!
Subject:!PMCH!
!
The!mother!of!a!toddler!presents!to!your!office!with!questions!regarding!immunizations!for!her!child.!She!has!read!in!
a!popular!magazine!that!immunization!for!pertussis!and!measles!may!predispose!to!asthma!and!other!atopic!
illnesses.!
a)!!Pertussis!and!measles!immunizations!should!be!withheld!in!children!with!a!strong!family!history!of!asthma!
b)!!Because!of!association!between!pertussis!vaccine!and!atopic!disease,!an!antihistamine!should!be!administered!
before!giving!pertussis!vaccine!
c)!!There!is!no!conclusive!evidence!that!pertussis!or!measles!immunization!carries!any!risk!of!increased!atopic!disease!
d)!!Measles!vaccine!should!not!be!administered!to!any!child!with!a!history!of!urticaria!
!
!
!
Explanation:!
Although!some!older!studies!showed!a!possible!increase!in!asthma!and!other!atopic!illness!in!children!vaccinated!for!
pertussis,!more!recent,!better!controlled!trials!have!shown!no!association.!Studies!have!failed!to!demonstrate!an!
association!between!atopic!disease!and!measles!immunization.!Therefore,!there!is!no!recommendation!to!withhold!
immunizations!from!children!to!prevent!atopic!disease.!Allergy!to!the!specific!vaccine!would,!of!course,!be!a!valid!
reason!not!to!vaccinate.!
!
!
Question!#174!
QID:!1964!
Subject:!PMCH!
!
The!scabies!mite!is!predominantly!transmitted!by:!
a)!!Bedclothes!
b)!!Personal!contact!
c)!!Hats!
d)!!Pets!
!
!
!
Explanation:!
The!scabies!mite!is!predominantly!transmitted!by!direct!personal!contact.!Infestation!from!indirect!contact!with!
clothing!or!bedding!is!believed!to!be!infrequent.!Hats!are!frequent!transmitters!of!head!lice,!but!not!scabies.!
!
!
Question!#175!
QID:!1980!
Topic:!Leading!Cause!of!Death!
Subject:!PMCH!
!
Which!one!of!the!following!is!the!leading!cause!of!death!in!Canada?!
a)!!Accidents!
b)!!Stroke!
c)!!Cancer!
d)!!Osteoporosis!
80
e)!!Cardiovascular!disease!
!
!
!
Explanation:!
Cancer!and!heart!disease!are!once!again!the!leading!causes!of!death!for!Canadians,!according!to!a!report!by!Statistics!
Canada.!The!federal!government!agency!said!cancer!accounted!for!30%!of!deaths!and!heart!disease!22%.!!Stroke!was!
third!overall!at!6%.!Statistics!Canada!said!the!rate!of!cancer!deaths!was!up!slightly!from!2000.!Heart!disease!and!
stroke!declined!slightly.!
!
!
!
!
!
Question!#176!
QID:!1991!
Subject:!PMCH!
!
Which!one!of!the!following!is!best!(most!sensitive)!initial!screening!test!for!hereditary!hemochromatosis?!
a)!!Serum!iron!concentration!and!liver!biopsy!
b)!!Serum!transferrin!saturation!
c)!!HFE!gene!analysis!
d)!!Hemoglobin!electrophoresis!
e)!!CT!scan!
!
!
!
Explanation:!
The!diagnosis!of!hereditary!hemochromatosis!is!based!on!a!combination!of!clinical,!laboratory,!and!pathologic!
criteria.!Serum!transferrin!saturation!is!the!best!initial!screening!value.!
!
>!Serum!ferritin!concentration!is!a!sensitive!measure!of!iron!overload,!but!ferritin!is!an!acute]phase!reactant!and!is!
therefore!elevated!in!a!variety!of!infectious!and!inflammatory!conditions!in!the!absence!of!iron!overload.!Ferritin!
levels!are!less!sensitive!than!transferrin!saturation!in!screening!tests!for!hemochromatosis.!
>!Genetic!tests!for!the!C282Y!and!H63D!mutations!are!widely!available.!Detection!of!hemochromatosis]associated!
mutations!is!conducted!to!confirm!the!diagnosis!or!to!discover!asymptomatic!patients.!Genetic!testing!for!the!HFE!
mutation!is!indicated!in!all!first]degree!relatives!of!patients!with!hemochromatosis!and!also!in!patients!with!evidence!
of!iron!overload!
>!Hemoglobin!electrophoresis!is!used!as!a!screening!test!to!identify!variant!and!abnormal!hemoglobins,!and!has!no!
implication!in!diagnosis!of!hemochromatosis.!
>!Computed!tomography!scanning!is!neither!sensitive!nor!specific!for!the!detection!of!mild!hepatic!iron!overload.!
Magnetic!resonance!imaging!may!be!more!sensitive,!but!this!modality!has!not!been!validated!as!a!diagnostic!test!to!
help!confirm!hemochromatosis.!
!
!
Question!#177!
QID:!1994!
Topic:!Contraceptive!Use!
Subject:!PMCH!
!
A!30]year]old!female!requests!advice!about!the!use!of!oral!contraceptive!pills!(OCP).!In!discussing!potential!risks!you!
explain!that!OCPs!may:!
a)!!Increase!her!risk!of!anemia!
b)!!Increase!her!risk!of!endometrial!cancer!
c)!!Increase!her!risk!of!exacerbation!of!her!acne!
81
d)!!Decrease!her!risk!of!thrombophlebitis!
e)!!Decrease!her!risk!of!ovarian!cancer!
!
!
!
Explanation:!
The!risk!of!ovarian!cancer!is!decreased!by!at!least!half!among!women!who!use!oral!contraceptives,!including!those!
who!use!low]estrogen!formulations.!With!the!use!of!oral!contraceptives,!the!risk!of!thromboembolism!is!increased,!
the!risk!of!anemia!is!decreased,!the!risk!of!endometrial!cancer!is!decreased,!and!the!severity!of!acne!is!decreased.!
!
!
Question!#178!
QID:!2004!
Topic:!Nutrition!
Subject:!PMCH!
!
In!Canada,!the!most!common!nutritional!deficiency!is:!
a)!!Iron!
b)!!Vitamin!B12!
c)!!Vitamin!D!
d)!!Calories!
e)!!Protein!
!
!
!
Explanation:!
Iron!deficiency!is!the!most!common!known!form!of!nutritional!deficiency.!Its!prevalence!is!highest!in!children!and!in!
women!of!childbearing!age!(especially!pregnant!women).!
!
!
Question!#179!
QID:!2006!
Subject:!PMCH!
!
Which!one!of!the!following!is!an!effective!screening!method!for!ovarian!cancer!in!elderly!females!at!average!risk?!
a)!!Annual!CA]125!assays!
b)!!Annual!pelvic!ultrasonography!
c)!!Annual!Papanicolaou!(Pap)!tests!and!pelvic!examinations!
d)!!No!currently!available!method!
!
!
!
Explanation:!
Two!large!European!trials!studied!the!use!of!CA]125!and!CA]125!with!transvaginal!ultrasonography!(TVU)!as!screening!
methods!for!ovarian!cancer.!TVU!has!been!reviewed!separately.!None!of!these!methods!is!effective!as!a!screening!
test.!No!major!organization!recommends!screening!women!at!average!risk.!The!Cancer!Society!does!not!recommend!
routine!screening;!the!College!of!Obstetricians!and!Gynecologists!recommends!against!population]based!screening;!
an!NIH!consensus!conference!recommended!obtaining!a!family!history!and!performing!annual!pelvic!examinations.!
The!Preventive!Services!Task!Force!graded!routine!screening!for!ovarian!cancer!as!a!“D”,!meaning!that!there!is!fair!
evidence!to!recommend!excluding!ovarian!cancer!screening!as!a!part!of!the!periodic!health!examination.!This!
recommendation!reflects!both!a!lack!of!benefit!from!screening!and!the!fact!that!a!significant!number!of!women!have!
to!undergo!exploratory!surgery!to!find!a!single!case.!
!
!
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Question!#180!
QID:!2009!
Subject:!PMCH!
!
Intranasal!influenza!immunization!would!be!most!appropriate!for!which!one!of!the!following?!
a)!!A!healthy!1!year!old!seen!for!a!routine!well]child!visit!
b)!!An!8!year!old!who!has!just!been!diagnosed!with!asthma!
c)!!An!otherwise!healthy!20!year!old!with!allergic!rhinitis!
d)!!An!otherwise!healthy!27!year!old!with!a!history!of!egg!allergy!
e)!!A!67!year!old!with!COPD!who!has!a!fear!of!injections!
!
!
!
Explanation:!
Live!Attenuated!Influenza!Vaccine!is!approved!for!use!in!healthy!people!2!through!49!years!of!age!who!are!not!
pregnant.!
!
Who!should!NOT!be!vaccinated!with!the!nasal!spray!flu!vaccine?!
]!Children!younger!than!2!years!(choice!A)!
]!Adults!50!years!and!older!(choice!E)!
]!People!with!a!history!of!severe!allergic!reaction!to!any!component!of!the!vaccine!or!to!a!previous!dose!of!any!
influenza!vaccine!(choice!D)!
]!People!with!asthma!(choice!B)!
]!Children!or!adolescents!on!long]term!aspirin!treatment.!
]!Children!and!adults!who!have!chronic!pulmonary,!cardiovascular!(except!isolated!hypertension),!renal,!hepatic,!
neurologic/neuromuscular,!hematologic,!or!metabolic!disorders!
]!Children!and!adults!who!have!immunosuppression!(including!immunosuppression!caused!by!medications!or!by!HIV)!
]!Pregnant!women!
!
!
Question!#181!
QID:!2036!
Topic:!Vitamin!Supplements!
Subject:!PMCH!
!
A!50]year]old!male!who!is!a!heavy!smoker!asks!you!about!vitamin!supplementation!to!prevent!cancer!and!
cardiovascular!disease.!The!patient!is!unwilling!to!stop!smoking.!According!to!the!recommendations!of!the!Preventive!
Services!Task!Force,!which!one!of!the!following!is!true!regarding!vitamin!supplementation!in!adults!who!are!middle]
age!or!older?!
a)!!Large!supplemental!doses!of!Beta]carotene!may!increase!the!risk!of!lung!cancer!in!heavy!smokers!
b)!!Beta]Carotene!supplementation!decreases!the!risk!of!cardiovascular!disease!and!cancer!in!nonsmokers!
c)!!Supplementation!with!vitamins!A,!C,!and!E!plus!folic!acid!decreases!the!risk!of!cardiovascular!disease!
d)!!Supplementation!with!antioxidant!combination!vitamins!plus!folic!acid!decreases!the!risk!of!cancer!
!
!
!
Explanation:!
The!Preventive!Services!Task!Force!found!that!Beta]carotene!was!associated!with!a!higher!incidence!of!lung!cancer!
and!all]cause!mortality.!In!general,!little!evidence!was!found!to!determine!whether!supplementation!of!any!of!the!
mentioned!vitamins!reduces!the!risk!of!cardiovascular!disease!or!cancer.!
!
!
Question!#182!
QID:!2039!
Topic:!Alternative!Medicine!
83
Subject:!PMCH!
!
A!33]year]old!white!female!has!a!12]year]history!of!headache!occurring!3]4!times!per!month,!accompanied!by!nausea!
and!vomiting.!She!takes!over]the]counter!analgesics,!but!relief!is!usually!obtained!only!when!she!falls!asleep.!This!is!
her!first!visit!to!you!for!this!problem.!You!diagnose!migraine!without!aura.!Although!the!patient!is!willing!to!consider!
prescription!drugs,!she!says!that!she!would!prefer!“something!that!is!natural!and!without!side!effects”.!Which!one!of!
the!following!would!be!the!best!recommendation?!
a)!!Biofeedback!
b)!!Ma!huang!
c)!!Oxygen!
d)!!Epley!canalith!repositioning!maneuver!
e)!!Phototherapy!
!
!
!
Explanation:!
Of!the!listed!options!covering!the!realm!of!complementary!and!alternative!medicine,!only!biofeedback!has!been!
shown!to!have!a!therapeutic!effect!on!migraine.!Specifically,!the!modality!that!seeks!to!control!physiologic!response!
to!skin!temperature!and!skin!conductance!appears!to!be!the!most!successful.!It!is!best!performed!in!a!medical!office!
by!caring,!supportive!staff!members!under!physician!supervision.!Oxygen!is!used!to!treat!cluster!headaches.!The!Epley!
maneuver!is!used!for!managing!benign!positional!vertigo,!and!phototherapy!is!useful!in!seasonal!affective!disorder.!
Ma!huang,!a!Chinese!herb,!has!ephedrine!properties!but!is!not!useful!in!treating!migraine!headaches.!
!
!
Question!#183!
QID:!2046!
Topic:!Traveler's!Diarrhea!
Subject:!PMCH!
!
A!family!of!four,!consisting!of!the!parents,!a!4]year]old!daughter,!and!a!teenage!son,!is!planning!a!trip!to!Guatemala!
with!a!church!group.!Which!one!of!the!following!is!appropriate!advice!concerning!traveler’s!diarrhea?!
a)!!All!family!members!may!use!an!antimotility!agent!such!as!loperamide!(Imodium)!for!mild!disease!
b)!!Most!cases!of!traveler’s!diarrhea!are!caused!by!parasites,!so!antibiotics!are!ineffective!
c)!!Ciprofloxacin!is!indicated!for!treatment!of!any!family!member!with!dysenteric!diarrhea!
d)!!Prophylactic!antibiotic!treatment!should!begin!2!days!before!leaving,!and!should!be!continued!until!1!week!after!
returning!home!
!
!
!
Explanation:!
Traveler's!diarrhea!may!be!caused!by!any!of!several!bacteria,!viruses,!or,!less!commonly,!parasites.!However,!
enterotoxigenic!E.!coli!is!most!common.!
!
The!mainstay!of!treatment!is!fluid!replacement!and!an!antimotility!agent!such!as!loperamide!or!diphenoxylate!is!
preferred.!Antimotility!agents!are!contraindicated!in!patients!with!fever!or!bloody!stools!and!in!children!<!2!years.!
!
Generally,!antibiotics!are!not!necessary!for!mild!diarrhea.!In!patients!with!moderate!to!severe!diarrhea!(≥!3!loose!
stools!over!8!h),!antibiotics!are!given,!especially!if!vomiting,!abdominal!cramps,!fever,!or!bloody!stools!are!present.!
For!adults,!ciprofloxacin!or!levofloxacin!is!recommended.!For!children!azithromycin!is!preferred.!
!
Prevention:!
Travelers!should!dine!at!restaurants!with!a!reputation!for!safety!and!avoid!foods!and!beverages!from!street!vendors.!
They!should!consume!only!cooked!foods!that!are!still!steaming!hot,!fruit!that!can!be!peeled,!and!carbonated!
beverages!without!ice!served!in!sealed!bottles!(bottles!of!noncarbonated!beverages!can!contain!tap!water!added!by!
unscrupulous!vendors);!uncooked!vegetables!should!be!avoided.!Buffets!and!fast!food!restaurants!pose!an!increased!
risk.!
84
!
Prophylactic!antibiotics!are!effective!in!preventing!diarrhea,!but!because!of!concerns!about!adverse!effects!and!
development!of!resistance,!they!should!probably!be!reserved!for!immunocompromised!patients.!
!
!
Question!#184!
QID:!2053!
Topic:!Prophylaxis,!meningococcal!disease!
Subject:!PMCH!
!
A!case!of!meningococcal!meningitis!has!just!been!confirmed!at!a!day]care!center.!The!susceptibility!of!the!
microorganism!is!not!yet!known.!At!this!point,!you!should!do!which!one!of!the!following!for!the!day]care!center!
contacts?!
a)!!Culture!their!nasopharyngeal!secretions!
b)!!Administer!meningococcal!vaccine!
c)!!Prescribe!sulfadiazine!
d)!!Prescribe!chloramphenicol!(Chloromycetin)!
e)!!Prescribe!rifampin!(Rifadin)!
!
!
!
Explanation:!
Rifampin,!in!the!absence!of!major!contraindications,!is!the!drug!of!choice!for!preventing!the!spread!of!meningococcal!
disease!when!the!susceptibility!of!the!organism!is!not!known.!In!this!situation,!meningococcal!vaccines!are!of!no!value!
because!their!protective!effects!take!a!few!days!to!develop,!and!because!they!do!not!protect!against!group!B!
meningococci,!the!most!prevalent!strain!for!meningococcal!disease.!Sulfadiazine!is!the!drug!of!choice!if!the!
meningococcus!is!known!to!be!susceptible!to!it.!Chloramphenicol!and!penicillin,!which!are!effective!in!treating!the!
disease,!are!ineffective!in!eliminating!nasopharyngeal!carriers!of!meningococci,!possibly!because!they!do!not!appear!
in!high!concentrations!in!saliva.!Culturing!contacts!for!meningococcal!carriage!in!the!nasopharynx!has!no!value!for!
identifying!those!at!risk!for!meningococcal!disease.!
!
!
Question!#185!
QID:!2062!
Subject:!PMCH!
!
Which!one!of!the!following!is!the!best!definition!of!specificity?!
a)!!The!true!positive!rate!of!a!test!
b)!!The!false!positive!rate!of!a!test!
c)!!The!true!negative!rate!of!a!test!
d)!!The!false!negative!rate!of!a!test!
e)!!None!of!the!above!
!
!
!
Explanation:!
The!specificity!of!a!test!is!the!true]negative!rate,!or!how!well!the!test!correctly!identifies!patients!without!disease.!
That!is,!it!!measures!the!proportion!of!negatives!which!are!correctly!identified.!
The!sensitivity!of!a!test!is!the!true]positive!rate!of!the!test.!It!!measures!the!proportion!of!actual!positives!which!are!
correctly!identified!as!such!(e.g.!the!percentage!of!sick!people!who!are!correctly!identified!as!having!the!condition).!
!
!
Question!#186!
QID:!2069!
Topic:!Basic!Life!Support!
85
Subject:!PMCH!
!
The!use!of!automated!external!defibrillators!by!lay!persons!in!out]of]hospital!settings:!
a)!!Has!been!frustrated!by!liability!concerns!
b)!!Has!been!hampered!by!an!unwillingness!to!place!the!devices!in!public!areas!
c)!!Has!been!shown!to!contribute!to!significant!gains!in!full!neurologic!and!functional!recovery!
d)!!Has!been!eclipsed!by!the!widespread!use!of!internal!cardiac!defibrillators!in!high]risk!patients!
!
!
!
Explanation:!
The!use!of!automated!external!defibrillators!(AEDs)!by!lay!person,!trained!and!otherwise,!has!been!quite!successful,!
with!up!to!40%!of!those!treated!recovering!full!neurologic!and!functional!capacity.!Good!Samaritan!laws!have!been!
passed!covering!the!use!of!AEDs!by!well]intentioned!lay!persons.!There!are!initiatives!for!widespread!placement!of!
AEDs,!to!include!commercial!airlines!and!other!public!facilities.!Implantable!cardioverter!defibrillators!(ICDs)!are!
useful!in!known!at]risk!patients,!but!the!use!of!AEDs!is!for!the!population!at!large.!
!
!
Question!#187!
QID:!2094!
Subject:!PMCH!
!
Which!one!of!the!following!unimmunized!patients!should!receive!two!doses!of!influenza!vaccine?!
a)!!A!5]year]old!with!asthma!
b)!!A!10]year]old!with!cystic!fibrosis!
c)!!A!15]year]old!with!sickle!cell!anemia!
d)!!A!30]year]old!with!HIV!infection!
e)!!A!65]year]old!with!bullous!emphysema!
!
!
!
Explanation:!
Children!who!have!been!previously!immunized!with!seasonal!influenza!vaccine!and!adults!are!to!receive!one!dose!of!
influenza!vaccine!each!year.!Children!6!months!to!<!9!years!of!age!receiving!seasonal!influenza!vaccine!for!the!first!
time!should!be!given!two!doses,!with!a!minimum!interval!of!four!weeks!between!doses.!
!
[The!National!Advisory!Committee!on!Immunization!(NACI)!provides!the!Public!Health!Agency!of!Canada!(hereafter!
referred!to!as!the!Agency)!with!ongoing!and!timely!medical,!scientific!and!public!health!advice!relating!to!
immunization.]!
!
!
Question!#188!
QID:!2101!
Topic:!Preventive!Health!Care!
Subject:!PMCH!
!
A!rural!community!college!has!requested!your!guidance!in!offering!a!preventive!health!program!to!its!students.!The!
most!appropriate!plan!would!include!which!one!of!the!following?!
a)!!Mammograms!for!female!students!
b)!!Lead!poisoning!screening!for!all!students!
c)!!Stool!occult!blood!kits!
d)!!Smoking!cessation!programs!
e)!!A!annual!routine!physical!examination!for!all!students!
!
86
!
!
Explanation:!
The!Preventive!Services!Task!Force!recommends!a!routine!physical!examination!every!3]5!years!for!young!adults!until!
the!age!of!40.!Counseling!on!tobacco!use!and!other!substance!abuse!is!recommended!as!part!of!all!routine!preventive!
care.!
!
>Mammograms!are!not!recommended!until!age!40.!
>Lead!screening!is!recommended!for!at]risk!individuals!between!6!months!and!6!years!of!age.!
>Colorectal!cancer!screening!for!average]risk!individuals!is!recommended!at!age!50.!
!
!
Question!#189!
QID:!2665!
Subject:!PMCH!
!
Current!guidelines!for!periodic!health!examinations!strongly!recommend!which!one!of!the!following!for!women?!
a)!!Annual!Papanicolaou!smears!for!women!of!all!ages!
b)!!Annual!pelvic!ultrasonography!in!women!with!a!family!history!of!ovarian!cancer!
c)!!Screening!for!chlamydial!infection!in!all!sexually!active!women!age!25!or!younger!
d)!!Routine!screening!for!human!papillomavirus!in!women!age!25!or!younger!
e)!!Screening!for!hepatitis!B!at!least!once!by!age!25!
!
!
!
Explanation:!
Current!guidelines!strongly!recommend!screening!all!sexually!active!females!age!25!or!younger!and!other!women!at!
increased!risk!for!chlamydial!infection!(choice!C).!
!
→!Papanicolaou!test!(choice!A)!is!strongly!recommended!at!least!every!3!years!for!all!women!(who!are!or!have!been!
sexually!active)!between!the!ages!of!21!and!70!and!have!a!cervix.!
→!For!women!with!a!strong!family!history!of!ovarian!cancer,!there!is!insufficient!evidence!to!recommend!for!or!
against!annual!pelvic!ultrasonography!(choice!B).!
→!There!is!insufficient!evidence!to!recommend!for!or!against!routine!screening!for!human!papillomavirus!(choice!D).!
→!Screening!for!hepatitis!B,!although!strongly!recommended!for!pregnant!women,!is!not!recommended!for!the!
general!asymptomatic!population!(choice!E).!
!
!
!
Question!#190!
QID:!2694!
Topic:!TB!
Subject:!PMCH!
!
A!health]care!worker!has!a!negative!tuberculin!skin!test!(Mantoux!method).!A!second!test!10!days!later!is!positive.!
This!result!indicates:!
a)!!Previous!vaccination!with!BCG!
b)!!A!false]positive!skin!test!
c)!!Recent!conversion!
d)!!Long]standing,!latent!infection!
e)!!Probable!immunodeficiency!
!
!
!
Explanation:!
87
A!positive!result!on!the!second,!but!not!the!first,!step!of!a!two]step!Mantoux!tuberculin!skin!test!indicates!long]
standing,!latent!infection.!
!
!
!
Question!#191!
QID:!2700!
Topic:!Safety!Regulations!
Subject:!PMCH!
!
Which!one!of!the!following!is!the!most!correct!recommendation!regarding!seat!belt!use!for!a!woman!at!38!weeks!
gestation?!
a)!!The!seat!belt!should!be!positioned!over!the!dome!of!the!uterus!and!the!shoulder!harness!should!be!positioned!
between!the!breasts!
b)!!The!seat!belt!should!be!positioned!under!the!abdomen!over!both!the!anterior!superior!iliac!spines!and!pubic!
symphysis;!the!belt!should!be!applied!with!some!slack!
c)!!The!seat!belt!should!be!positioned!under!the!abdomen!over!both!the!anterior!superior!iliac!spines!and!the!pubic!
symphysis;!the!shoulder!harness!should!be!positioned!between!the!breasts;!the!belt!should!be!applied!as!snugly!as!
comfort!will!allow!
d)!!Seat!belts!should!not!be!used!in!the!later!stages!of!pregnancy!
!
!
!
Explanation:!
Pregnant!women!can!and!should!always!wear!a!seat!belt!when!driving!or!riding!in!a!car.!The!seat!belt!should!be!
positioned!under!the!pregnant!woman’s!abdomen!over!both!the!anterior!superior!iliac!spines!and!the!pubic!
symphysis.!The!shoulder!harness!should!be!positioned!between!the!breasts.!
!
!
!
Question!#192!
QID:!2716!
Subject:!PMCH!
!
A!32]year]old!female!is!concerned!about!ovarian!cancer.!She!has!no!symptoms!at!this!time.!However,!she!has!a!close!
friend!who!was!recently!diagnosed!with!ovarian!cancer!at!an!advanced!stage.!This!friend!told!the!patient!that!a!
“simple!blood!test”!for!CA]125!could!detect!ovarian!cancer!at!a!curable!stage.!
!
As!part!of!your!discussion,!you!inform!the!patient!that!which!one!of!the!following!is!true?!
a)!!Most!consensus!opinions!recommend!performing!this!test!for!average]risk!women!
b)!!Detecting!ovarian!cancer!at!an!earlier!stage!using!serum!CA]125!has!not!been!shown!to!reduce!mortality!
c)!!A!high!serum!CA]125!level!is!a!confirmatory!test!for!ovarian!cancer!
d)!!Measurement!of!serum!CA]125!level!has!not!been!shown!to!detect!ovarian!cancer!at!an!earlier!stage!
e)!!This!test!should!not!be!ordered!due!to!its!high!price.!
!
!
!
Explanation:!
One!of!the!tragedies!of!ovarian!cancer!is!that!it!is!often!found!in!otherwise!healthy!women!at!an!advanced!stage.!The!
measurement!of!serum!CA]125!is!a!convenient,!inexpensive!test!which!has!been!shown!to!detect!ovarian!cancer!at!an!
earlier!stage.!However,!there!has!been!no!conclusive!evidence!that!finding!ovarian!cancer!at!an!earlier!stage!using!
this!test!will!result!in!an!improved!chance!of!a!woman!surviving!this!condition.!Furthermore,!since!the!incidence!of!
ovarian!cancer!is!low,!99%!of!average]risk!women!with!high!values!of!CA]125!will!not!have!ovarian!cancer.!For!these!
reasons,!most!consensus!opinions!recommend!against!measuring!this!antigen!in!average]risk!women.!
!
88
!
Question!#193!
QID:!2718!
Subject:!PMCH!
!
You!are!a!student!health!director!for!a!community!college.!An!administrator!calls!regarding!recommendations!for!
students!exposed!to!another!student!with!meningococcal!meningitis.!
!
The!most!appropriate!action!would!be!to:!
a)!!Close!the!dormitories!and!send!the!students!home!for!at!least!10!days!
b)!!Place!all!exposed!students!on!prophylactic!antibiotics!
c)!!Place!all!students!that!have!not!received!meningococcal!vaccine!on!antibiotic!prophylaxis!
d)!!Immunize!all!students!who!have!not!yet!received!meningococcal!vaccine!
!
!
!
Explanation:!
The!quadrivalent!A,!C,!Y,!W]135!meningococcal!vaccine!does!not!provide!immunity!against!type!B!meningococcus,!
which!is!responsible!for!30%!]!50%!of!cases!of!invasive!meningococcal!disease.!Therefore,!antibiotic!prophylaxis!with!
rifampin,!ciprofloxacin,!or!ceftriaxone!is!indicated!for!all!exposed!persons.!
!
!
!
Question!#194!
QID:!2733!
Topic:!STD!
Subject:!PMCH!
!
A!31]year]old!female!presents!with!her!first!outbreak!of!genital!herpes.!She!has!been!married!for!4!years!and!says!she!
has!not!had!sexual!relations!with!anyone!other!than!her!husband!since!they!started!dating.!
!
When!counseling!this!patient,!which!one!of!the!following!would!be!appropriate!advice?!
a)!!Because!the!average!incubation!period!for!herpes!is!3!months,!her!husband!has!most!likely!had!another!sexual!
partner!in!the!past!few!months!
b)!!Suppressive!therapy!can!decrease!transmission!to!sexual!partners!
c)!!If!type]specific!serologies!are!negative,!genital!herpes!can!be!ruled!out!
d)!!Daily!application!of!topical!acyclovir!(Zovirax)!is!effective!for!suppressant!therapy!
!
!
!
Explanation:!
The!average!incubation!period!after!contracting!genital!herpes!is!4!days.!However,!a!significant!number!of!patients!do!
not!recognize!the!initial!infection.!
!
Type]specific!serologic!tests!can!assist!in!the!classification!of!infection!as!primary!or!recurrent,!but!there!is!significant!
potential!for!false]negative!results.!Oral!once]daily!suppressant!therapy!can!reduce!the!risk!of!transmission!of!herpes!
simplex!to!uninfected!partners!but!topical!therapy!is!not!effective.!Acyclovir,!valacyclovir,!and!famciclovir!are!all!
effective!for!suppressive!therapy.!
!
!
!
Question!#195!
QID:!2734!
Subject:!PMCH!
89
!
You!are!considering!how!useful!a!new!treatment!might!be!in!preventing!stroke.!A!well!designed!study!is!reported!
with!200!patients!in!the!treated!group!and!200!patients!in!the!untreated!group.!The!study!finds!a!5]year!risk!of!stroke!
of!3%!in!the!treated!group!versus!5%!in!the!untreated!group.!
!
Assuming!this!study!is!valid!and!applicable!to!your!patient!population,!how!many!patients!would!you!have!to!treat!for!
5!years!to!prevent!one!stroke!(number!needed!to!treat,!or!NNT)?!
a)!!400!
b)!!200!
c)!!100!
d)!!50!
e)!!25!
!
!
!
Explanation:!
The!relative!risk!reduction!(RRR)!is!the!proportional!decrease!in!disease!incidence!in!the!treated!group!relative!to!the!
incidence!in!the!control!group.!In!this!example,!the!3%!incidence!in!the!treated!group!is!40%!less!than!the!5%!
incidence!in!the!control!group:!(5%!]!3%)/5%!=!40%.!The!absolute!risk!reduction!(ARR)!is!the!difference!between!the!
incidence!of!disease!in!the!treatment!group!and!the!incidence!in!the!control!group.!In!this!example!the!ARR!is!5%!
minus!3%=!2%.!The!number!needed!to!treat!(NNT)!equals!the!reciprocal!of!the!ARR:!1/.02!=!50.!
!
The!RRR!is!not!a!very!useful!clinical!statistic!in!clinical!practice.!It!amplifies!small!differences!and!makes!clinically!
insignificant!findings!appear!significant!because!it!essentially!ignores!the!baseline!risk!“How!much!will!I!decrease!my!
patient’s!risk!of!an!adverse!outcomes!by!this!treatment?”.!The!NNT!is!also!very!useful!for!clinicians,!as!it!answers!the!
question,!“How!many!patients!will!I!need!to!treat!to!prevent!one!adverse!outcome?”!
!
!
Question!#196!
QID:!2742!
Subject:!PMCH!
!
Which!one!of!the!following!has!been!shown!to!transmit!Salmonella!infections!to!humans?!
a)!!Iguanas!
b)!!Rabbits!
c)!!Civet!cats!
d)!!Guinea!pigs!
e)!!Ferrets!
!
!
!
Explanation:!
Pet]associated!salmonellosis!was!a!significant!problem!in!the!1970s.!In!1975,!Canada!banned!the!importation!of!
turtles.!However,!the!popularity!of!iguanas!and!other!reptiles!is!increasing;!these!reptiles!can!also!transmit!
Salmonella!to!humans.!Reptile]associated!salmonellosis!causes!febrile!gastroenteritis,!septicemia,!and!meningitis.!
!
!
!
Question!#197!
QID:!2767!
Topic:!Melanoma!
Subject:!PMCH!
!
Your!hospital!administrator!asks!you!to!develop!a!community!screening!program!for!melanoma.!Which!one!of!the!
following!is!true!concerning!screening!for!this!disease?!
90
a)!!Screening!for!melanoma!is!not!indicated!since!the!disease!is!rare!
b)!!Screening!for!melanoma!is!not!indicated!since!screening!takes!too!much!time!
c)!!No!definite!clinical!evidence!has!shown!that!screening!for!melanoma!reduces!mortality!
d)!!Because!of!sunbathing,!female!patients!are!the!most!important!population!to!screen!
!
!
!
Explanation:!
There!have!been!no!randomized,!controlled!trials!or!other!definitive!data!to!indicate!that!screening!of!melanoma!
reduces!mortality.!There!are,!however,!factors!which!indicate!that!screening!would!be!beneficial,!including!the!
increasing!prevalence!of!the!disease!and!the!fact!that!screening!is!time]effective!and!safe.!If!screening!is!performed,!
populations!at!greatest!risk!should!be!considered.!Men,!especially!those!over!age!50,!have!the!highest!incidence!of!
melanoma.!
!
!
Question!#198!
QID:!2776!
Topic:!Vitamin!Supplements!
Subject:!PMCH!
!
Recent!studies!and!meta]analyses!have!shown!that!supplementation!with!a!particular!vitamin!may!do!more!harm!
than!good.!This!has!resulted!in!a!reversal!in!the!recommendation!for!its!use!in!patients!with!known!coronary!artery!
disease,!and!a!recommendation!for!caution!in!its!use!in!general!for!elderly!patients.!
!
This!is!true!of!which!one!of!the!following?!
a)!!Vitamin!A!
b)!!Vitamin!B6!
c)!!Vitamin!C!
d)!!Vitamin!B12!
e)!!Vitamin!E!
!
!
!
Explanation:!
At!one!time,!studies!indicated!that!the!antioxidant!vitamin!E!should!be!recommended!to!patients!with!heart!disease!
for!prevention!of!on!ongoing!heart!changes.!However,!results!of!a!meta]analysis!of!19!randomized,!placebo]
controlled!trials!suggest!that!high!doses!of!vitamin!E!increases!the!risk!of!all]cause!mortality,!and!this!dose]dependent!
increase!begins!at!doses!of!150!IU/day.!Cardiovascular!disease!prevention!guidelines!state!that!supplemental!vitamin!
E!is!not!recommended.!This!reversal!of!thought!on!vitamin!E!in!the!past!10!years!or!so!exemplifies!the!need!for!
physicians!to!monitor!closely!both!the!recommendations!of!physician!study!groups!and!the!advertisements!of!
alternative!medicine!and!related!fields.!
!
!
!
Question!#199!
QID:!2786!
Topic:!Flying!Regulations!
Subject:!PMCH!
!
A!72]year]old!female!has!stable!but!moderately!severe!COPD!requiring!2!L!of!continuous!oxygen.!She!plans!to!attend!
the!college!graduation!of!her!first!grandchild,!and!wants!to!fly!to!avoid!a!12]hour!car!ride.!Her!PaO2!on!room!air!is!55!
mm!Hg.!
!
According!to!the!Federal!Air!Regulations,!she!must:!
a)!!Bring!her!own!oxygen!from!home!
b)!!Bring!a!medical!certificate!from!you!certifying!that!she!is!cleared!to!fly!without!oxygen!
91
c)!!Arrange!through!the!airline!for!oxygen!to!be!available!on!board!and!in!the!airports!
d)!!Find!a!form!of!transportation!other!than!air!travel!
e)!!Undergo!preflight!testing,!including!pulmonary!function!testing!and!high]altitude!simulation!testing,!before!she!
can!be!cleared!to!fly!
!
!
!
Explanation:!
According!to!Federal!Air!Regulations,!passengers!who!require!oxygen!for!stable!medical!conditions!cannot!bring!their!
own!supplies!and!equipment!and!must!arrange!through!the!airline,!24]48!hours!in!advance,!for!oxygen!to!be!made!
available!on!board,!at!layovers,!and!at!final!destinations.!Anyone!with!a!preflight!sea!level!PaO2!below!68]70!mm!Hg!
is!advised!NOT!to!fly!unless!supplemental!oxygen!can!be!arranged.!This!is!because!commercial!aircraft!maintain!a!
relative!cabin!altitude!between!5000!and!8000!feet!during!routine!flight.!This!altitude!corresponds!to!a!decreased!
barometric!pressure,!which!causes!a!corresponding!drop!in!the!normal!baseline!PaO2.!In!normal!healthy!individuals,!
this!corresponds!to!a!drop!from!a!PaO2!of!98!mm!Hg!to!a!PaO2!of!60]70!mm!Hg.!On!the!oxyhemoglobin!dissociation!
curve,!a!PaO2!of!60!mm!Hg!is!the!point!at!which!there!is!a!steep!gradient!of!the!pressure/saturation!relationship.!This!
patient!has!a!baseline!PaO2!of!only!55!mm!Hg,!so!she!certainly!could!not!sustain!a!flight!without!oxygen.!
!
While!it!may!be!prudent!to!have!a!given!patient!complete!some!respiratory!testing!prior!to!flying,!no!specific!preflight!
testing!is!required.!
!
!
!
Question!#200!
QID:!2789!
Subject:!PMCH!
!
Which!one!of!the!following!strategies!for!osteoporosis!screening!is!supported!by!current!clinical!evidence?!
a)!!Begin!universal!screening!5!years!after!the!date!of!the!last!menstrual!period!
b)!!Begin!universal!screening!at!age!55!of!both!men!and!women!
c)!!Begin!universal!screening!at!age!65!of!both!men!and!women!
d)!!Screen!only!those!women!at!increased!risk!for!hip!fracture!based!on!a!multiple!risk]assessment!scale!
e)!!Screen!all!postmenopausal!women!and!men!50]64!years!of!age.!
!
!
!
Explanation:!
No!single!study!has!evaluated!the!effectiveness!of!osteoporosis!screening.!Universal!screening!(with!bone!mineral!
density!test)!is!recommended!for:!
!
>All!women!and!men!65!years!or!older!
>Postmenopausal!women!and!men!50!]!64!with!risk!factors!for!fracture!including:!
Fragility!fracture!after!age!40!
Vertebral!fracture!or!low!bone!mass!identified!on!x]ray!
Parental!hip!fracture!
High!alcohol!intake!
Current!smoking!
Low!body!weight,!i.e.!less!than!132!lbs!or!60!kg!
Weight!loss!since!age!25!greater!than!10%!
High!risk!medication!use:!prolonged!glucocorticoid!use,!aromatase!inhibitors!for!breast!cancer,!androgen!deprivation!
therapy!for!prostate!cancer!
Rheumatoid!arthritis!
Other!disorders!that!may!contribute!to!bone!loss!
!
>Younger!men!or!women!(under!50)!with!a!disease!or!condition!associated!with!low!bone!mass!or!bone!loss:!
92
Fragility!fractures!
High]risk!medication!use!(steroid!use,!aromatase!inhibitors,!androgen!deprivation!therapy)!
Rheumatoid!arthritis!
Other!chronic!inflammatory!conditions!
Cushing’s!disease!
Malabsorption!syndrome!
Uncontrolled!hyperthyroidism!
Primary!hyperparathyroidism!
Hypogonadism;!Early!menopause!(<!45)!
Other!disorders!associated!with!rapid!bone!loss/fractures!
!
!
Question!#201!
QID:!2791!
Topic:!West!Nile!Virus!
Subject:!PMCH!
!
You!are!asked!by!the!local!Chamber!of!Commerce!to!give!a!talk!to!business!leaders!about!West!Nile!virus.!Which!one!
of!the!following!is!true!regarding!infection!with!this!virus?!
a)!!Most!deaths!are!due!to!hemorrhagic!complications!
b)!!In!confirmed!cases,!antiviral!medications!are!effective!
c)!!Transmission!occurs!through!infected!bird!droppings!
d)!!The!most!severely!affected!patients!have!serious!neurologic!involvement!
e)!!Infected!patients!typically!develop!migratory!arthritis!
!
!
!
Explanation:!
!West!Nile!virus!(WNV)!is!transmitted!to!humans!by!the!bite!of!mosquitoes!infected!after!biting!virus]carrying!birds.!
Originally!discovered!in!West!Africa,!it!was!first!seen!in!the!North!America!in!New!York!City!in!1999.!It!is!currently!
widespread!throughout!the!continental!U.S.!Although!the!virus!is!a!human!neuropathogen,!most!infected!persons!
have!no!symptoms.!One!out!of!150!human!infections!results!in!severe!neurologic!disease!with!encephalitis,!
meningitis,!flaccid!paralysis,!or!coma.!The!elderly!are!at!greatest!risk!for!severe!disease.!
!
Most!symptomatic!patients!have!a!self]limited!febrile!illness!with!chills,!headache,!myalgias,!and!fatigue.!Stiff!neck,!
arthralgias,!cough,!and!rash!are!uncommon!symptoms.!Hemorrhage!is!not!associated!with!WNV!infection!and!
infected!bird!droppings!are!not!a!mode!of!WNV!transmission.!
!
Treatment!is!supportive,!even!in!severe!disease.!The!efficacy!of!antiviral!medicines!is!anecdotal!and!is!not!supported!
by!the!results!of!controlled!clinical!trials.!
!
!
Question!#202!
QID:!2798!
Topic:!Elderly!Abuse!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!abuse!of!the!elderly?!
a)!!Men!are!most!often!the!victims!of!abuse!
b)!!Perpetrators!of!abuse!are!most!often!the!adult!children!of!the!victims!
c)!!Most!elder!abuse!is!reported!
d)!!Financial!exploitation!is!the!most!common!form!of!abuse!
!
!
!
Explanation:!
93
Accurate!information!on!elder!abuse!is!difficult!to!obtain,!but!it!is!estimated!that!it!occurs!up!to!five!times!more!often!
than!it!is!reported.!There!are!seven!different!kinds!of!elder!abuse:!physical!abuse,!sexual!abuse,!psychological!abuse,!
financial!abuse,!neglect,!abandonment,!and!self]neglect.!The!most!common!form!of!abuse!substantiated!by!Adult!
Protective!Services!is!neglect,!with!sexual!abuse!being!the!least!common.!Another!study!listed!physical!abuse!as!the!
most!prevalent,!followed!by!verbal!aggression!and!neglect.!
!
Women!are!most!often!the!victims!of!elder!abuse.!Approximately!90%!of!abusers!are!related!to!the!victim,!with!the!
adult!children!being!the!most!likely!perpetrators.!As!abusers,!an!equal!number!of!men!and!women!are!guilty!of!
neglect,!but!other!forms!of!abuse!are!predominantly!committed!by!men.!If!the!spouse!is!the!perpetrator,!there!is!
likely!a!previous!history!of!violence!in!the!relationship.!Abusers!are!often!alcohol!or!drug!abusers!and!many!times!are!
dependent!on!the!victim!for!money!and!housing.!
!
!
!
Question!#203!
QID:!2799!
Topic:!Clinical!Guidelines!
Subject:!PMCH!
!
The!National!Cholesterol!Education!Program!published!updated!guidelines!for!cholesterol!testing!and!management,!
as!recommended!by!its!Expert!Panel!on!Detection,!Evaluation,!and!Treatment!of!High!Blood!Cholesterol!in!Adults.!
According!to!these!guidelines!and!the!recent!Adult!Treatment!Panel!(ATP)!III!Update,!the!target!LDL!cholesterol!for!
patients!with!type!2!diabetes!mellitus!is:!
a)!!1.5!mmol/L!
b)!!2.0!mmol/L!
c)!!3.5!mmol/L!
d)!!4.0!mmol/L!
e)!!5.0!mmol/L!
!
!
!
Explanation:!
The!National!Cholesterol!Education!Program!Adult!Treatment!Panel!III!guidelines!and!the!recent!update,!as!well!as!
guidelines!previously!published!by!the!Canadian!Diabetes!Association,!have!established!a!target!LDL!cholesterol!level!
of!2.0!mmol/L!for!patients!with!diabetes.!This!target!is!also!applicable!for!individuals!with!known!coronary!artery!
disease!(CAD),!symptomatic!carotid!artery!disease,!abdominal!aortic!aneurysm,!peripheral!vascular!disease,!and!
multiple!risk!factors!that!confer!a!10]year!risk!for!coronary!heart!disease!that!is!>!20%.!An!LDL!level!of!3.5!mmol/L!is!
acceptable!for!other!individuals!with!only!two!risk!factors!for!CAD!and!a!10]year!CAD!risk!<!20%,!and!4.0!mmol/L!is!
the!upper!limit!of!acceptability!for!patients!with!no!more!than!one!risk!factor!for!CAD!and!a!10]year!CAD!risk!<!20%.!
!
!
Question!#204!
QID:!2803!
Topic:!STD!
Subject:!PMCH!
!
A!70]year]old!white!female!presents!with!a!pruritic!rash!on!her!sacrum!that!has!occurred!intermittently!over!the!last!
6!years.!She!reports!that!the!area!is!always!very!tender!just!before!the!blister]like!lesions!erupt.!She!is!otherwise!in!
good!health,!and!takes!no!medications.!Her!past!medical!history!is!unremarkable.!You!provide!appropriate!treatment!
for!the!condition.!
!
You!should!advise!the!patient!to!avoid!which!one!of!the!following!during!future!outbreaks?!
a)!!Excessive!intake!of!green,!leafy!vegetables!
b)!!Sexual!contact!
c)!!Perfumed!soaps!or!body!lotions!
d)!!Sun!exposure!
e)!!Prolonged!sitting!
94
!
!
!
Explanation:!
Genital!herpes!is!the!most!common!sexually!transmitted!genital!ulcer!disease.!It!can!occur!at!any!age,!and!data!
suggests!that!it!may!be!the!most!common!sexually!transmitted!disease!in!women!over!the!age!of!50!years.!
Extragenital!sites!are!involved!in!one]fourth!of!infected!women,!and!the!sacrum!and!buttocks!are!frequent!locations.!
Sacral!nerve!innervations!from!the!vaginal!area!provides!a!pathway!for!the!virus.!Prevention!of!transmission!depends!
upon!cogent!patient!education!advising!abstinence!from!skin]to]skin!contact!when!active!lesions!are!present.!
!
!
Question!#205!
QID:!2804!
Topic:!Stages!of!Change!Model!
Subject:!PMCH!
!
In!the!Stages!of!Change!model!of!behavior!change!(also!called!the!Transtheoretical!Model),!relapses:!
a)!!Are!usually!permanent!
b)!!Indicate!failure!of!motivation!by!the!patient!
c)!!Indicate!failure!in!the!behaviour!change!technique!of!the!physician!
d)!!Are!usually!recurrent,!and!are!a!part!of!the!change!process!
e)!!Suggest!the!need!to!check!the!patient’s!health!beliefs!about!the!desired!change!
!
!
!
Explanation:!
In!the!Stages!of!Change!model,!relapses!are!usually!recurrent!and!are!a!part!of!the!change!process.!It!does!not!
necessarily!indicate!failure!of!motivation!or!a!failure!in!the!technique!of!the!physician,!but!should!be!used!by!the!
patient!to!identify!ways!to!improve!their!future!attempts!at!the!same!behaviour!change.!Relapses!are!not!usually!
permanent.!The!patient’s!health!beliefs!are!more!important!when!he!or!she!is!in!the!precontemplation!or!
contemplation!stage!of!behaviour!change.!
!
!
Question!#206!
QID:!2815!
Topic:!TB!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!PPD!testing!for!tuberculosis?!
a)!!Patients!who!have!converted!within!the!past!year!should!be!treated,!regardless!of!age!
b)!!In!patients!who!previously!received!a!BCG!vaccination,!the!threshold!for!a!positive!test!is!25!mm!of!induration!
c)!!Patients!who!test!positive!only!on!the!second!step!of!a!two]step!PPD!test,!given!weeks!after!the!first!test,!are!at!
high!risk!for!development!of!active!disease!
d)!!PPD!testing!is!contraindicated!in!patients!who!are!HIV!positive!
!
!
!
Explanation:!
Because!the!risk!of!developing!active!disease!is!highest!in!patients!within!2!years!after!conversion,!recent!converters!
should!generally!be!treated!regardless!of!age.!BCG!vaccination!has!a!limited!effect!on!PPD!reactivity;!tests!should!not!
be!interpreted!any!differently!in!patients!who!have!previously!received!BCG.!The!use!of!a!two]step!approach!(i.e.!
retesting!1]4!weeks!later!in!patients!who!initially!test!negative)!is!designed!to!decrease!the!false]negative!rate!of!PPD!
testing.!The!significance!of!a!positive!result!on!either!phase!of!the!test!is!the!same.!Patients!who!are!HIV!positive!are!
at!a!higher!risk!for!false]negative!PPDs!and!active!disease,!but!PPD!testing!is!not!contraindicated.!
!
95
!
!
Question!#207!
QID:!2831!
Subject:!PMCH!
!
The!best!method!of!influenza!prophylaxis!in!high]risk!patients!is!administration!of:!
a)!!Influenza!vaccine!intramuscularly!prior!to!the!influenza!season!
b)!!Oral!amantadine!(Symmetrel)!daily!during!the!influenza!season!
c)!!Oral!rimantadine!(Flumadine)!daily!during!the!influenza!season!
d)!!Oral!oseltamivir!(Tamiflu)!daily!during!the!influenza!season!
e)!!Oral!oseltamivir!(Tamiflu)!weekly!prior!to!the!influenza!season!
!
!
!
Explanation:!
Although!they!may!be!used!for!prophylaxis,!amantadine!and!rimantadine!are!limited!by!lack!of!activity!against!
influenza!B,!resistance,!and!adverse!effects.!Zanamivir!and!oseltamivir!are!about!70%]90%!effective!against!influenza,!
including!influenza!B,!but!zanamivir!is!approved!only!for!treatment!of!influenza.!None!of!these!drugs!should!be!
considered!a!substitute!for!vaccination,!which!remains!the!mainstay!of!protection!against!influenza.!
!
!
!
Question!#208!
QID:!2843!
Subject:!PMCH!
!
Of!the!following,!which!one!has!the!greatest!potential!to!spread!via!human]to]human!transmission?!
a)!!Inhalation!anthrax!
b)!!Typhoidal!tularaemia!
c)!!Pneumonic!plague!
d)!!Botulism!
e)!!Coxiella!burnetti!(Q!fever)!
!
!
!
Explanation:!
There!is!a!host!of!microorganisms!and!their!biological!products!that!could!be!used!as!agents!of!mass!destruction.!The!
CDC!has!identified!six!agents!as!having!a!high!likelihood!for!production!and!lethal!dissemination.!Yersinia!pestis,!the!
organism!responsible!for!pneumonic!plague,!can!induce!infection!in!humans!through!skin!penetration!or!direct!
ingestion!of!fewer!than!10!organisms.!Patients!suspected!of!having!pneumonic!plague!should!be!maintained!under!
strict!droplet!precautions!until!they!have!completed!4!days!of!antibiotic!therapy.!Person]to]person!spread!of!disease!
from!inhalation!anthrax!is!not!known!to!occur.!Neither!isolation!nor!quarantine!is!required!for!typhoidal!tularaemia,!
botulism,!or!Q!fever,!although!standard!precautions!should!be!taken.!
!
!
!
Question!#209!
QID:!2844!
Topic:!Abuse!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!the!risk!of!physical!spousal!abuse?!
a)!!It!decreases!during!pregnancy!
96
b)!!It!decreases!when!a!woman!exits!an!abusive!relationship!
c)!!It!increases!with!alcohol!and!substance!abuse!
d)!!It!increases!as!socioeconomic!status!rises!
e)!!It!is!higher!among!patients!from!racial!minorities!
!
!
!
Explanation:!
Pregnancy!represents!a!time!of!heightened!risk!for!abuse,!and!prompts!a!shift!in!the!area!of!physical!abuse!from!the!
head!and!neck!to!the!breasts!and!abdomen.!Although!some!studies!have!shown!a!higher!prevalence!of!partner!abuse!
among!some!minority!women,!a!National!Crime!Victimization!Survey!concluded!that!women!of!all!races!and!ethnic!
backgrounds!are!equally!likely!to!be!abused!by!an!intimate.!Alcohol!and/or!substance!abuse!is!a!significant!risk!factors!
associated!with!the!occurrence!of!partner!abuse!and!family!violence!in!general.!Less!education!and!lower!
occupational!status!or!income!(particularly!when!total!family!income!is!less!than!$10,000!per!year)!have!been!found!
to!increase!the!risk!of!violence.!
!
Women!who!have!separated!from!their!spouses!are!3!times!more!likely!to!be!victimized!than!those!who!are!already!
divorced!and!25!times!more!likely!than!women!who!are!married.!A!woman’s!danger!substantially!increases!at!the!
point!of!exiting!an!abusive!relationship.!
!
!
!
Question!#210!
QID:!2857!
Topic:!Hospital!Complications!
Subject:!PMCH!
!
Of!the!following,!which!is!the!most!common!adverse!event!to!complicate!hospital!course!of!patients!age!65!and!over?!
a)!!Fluid!related!events!
b)!!Wound!infections!
c)!!Drug]related!events!
d)!!Surgery]related!events!
e)!!Alcohol!withdrawal!!and!delirium!tremens!
!
!
!
Explanation:!
An!adverse!event!has!been!defined!as!!an!unintended!injury!or!complication!that!results!in!disability!at!the!time!of!
discharge,!death,!or!prolonged!hospital!stay,!and!that!is!caused!by!healthcare!management!rather!than!by!the!
patient’s!underlying!disease!process.!The!three!most!common!adverse!events!to!occur!are!surgery,!medication,!and!
infection.!
!
Canadian!national!study!of!adverse!event!by!Ross!Baker!and!Peter!Norton!revealed!that!!surgery]related!problems!
(choice!D)!are!the!most!common!type!of!adverse!event,!and!for!hospitalized!patients!the!rate!of!these!events!
increases!with!the!patient’s!age.!Surgery]related!events!are!followed!by!drug]related!and!fluid]related!adverse!
events.!
!
>!Fluid!related!events!(choice!A)!and!Drug]related!events!(choice!C)!come!as!second!most!common!cause!of!adverse!
events!after!surgery.!
>!Wound!infections!(choice!B)!come!after!drug]related!and!fluid]related!events!in!terms!of!rate!of!occurence.!
>!Alcohol!withdrawal!!and!delirium!tremens!(choice!E)!occur!in!many!patients!admitted!in!hospitals,!but!these!usually!
are!not!due!to!error!of!health!professionals.!
!
!
Question!#211!
QID:!2984!
97
Subject:!PMCH!
!
The!guidelines!for!prevention!of!dental!caries!in!preschool!children!recommend!which!one!of!the!following?!
a)!!Fluoride!supplementation!beginning!at!birth!for!children!who!are!breastfed!
b)!!Fluoride!supplementation!for!children!at!6!months!of!age!if!the!fluoride!concentration!in!their!drinking!water!is!
below!recommended!levels!
c)!!Fluoride!supplementation!for!all!children!beginning!at!6!months!of!age!
d)!!Fluoride!supplementation!for!children!determined!to!be!at!high!risk!for!dental!caries!based!on!a!formal!
assessment!of!risk!
e)!!Topical!fluoride!applications!instead!of!oral!supplementation!
!
!
!
Explanation:!
It!is!recommended!that!oral!fluoride!supplementation!for!children!beginning!at!6!months!of!age,!if!their!drinking!
water!is!deficient!in!fluoride!concentration.!Some!areas!fluoridate!their!water,!while!others!do!not.!In!certain!abutting!
neighborhoods,!it!may!be!difficult!for!the!physician!to!tell!which!water!system!a!house!uses.!Physicians!must!make!
sure!that!each!family!is!aware!of!their!water!source.!
!
Fluoride!can!also!be!found!in!natural!well!water.!If!a!community!has!pockets!of!natural!fluoride!concentration!in!well!
water,!home!fluoride!quantitation!kits!should!be!obtained!for!the!family!and!sent!to!the!state!before!fluoride!
supplementation!is!begun.!Topical!fluoride!applications!are!an!adjunct!to!oral!supplementation!and!should!not!take!
their!place.!
!
!
!
!
Question!#212!
QID:!2985!
Topic:!Basic!Life!Support!
Subject:!PMCH!
!
Current!recommendations!suggest!using!which!one!of!the!following!to!check!the!pulse!of!an!unresponsive!apneic!
infant!under!1!year!of!age?!
a)!!The!brachial!artery!
b)!!The!carotid!artery!
c)!!The!radial!artery!
d)!!The!apical!cardiac!impulse!
!
!
!
Explanation:!
It!is!recommended!to!check!the!brachial!pulse!in!unresponsive,!apneic!infants!under!1!year!of!age,!although!the!
femoral!pulse!may!be!used!as!an!alternative.!The!radial!artery!is!peripheral!and!difficult!to!palpate!even!in!a!normal!
infant.!The!short,!chubby!neck!of!infants!makes!rapid!location!of!the!carotid!artery!difficult;!palpitation!may!also!lead!
to!inadvertent!compression!of!the!airway!and!stimulation!of!a!vagal!response.!Checking!the!apical!pulse!is!not!
recommended!because!precordial!activity!represents!an!impulse!rather!than!a!pulse.!In!addition,!the!infant’s!or!
child’s!precordium!may!be!quiet,!and!a!precordial!pulse!may!not!be!palpated!despite!the!presence!of!satisfactory!
cardiac!function!and!a!strong!central!pulse.!
!
!
!
!
Question!#213!
QID:!2986!
98
Subject:!PMCH!
!
You!are!leading!a!community!health!forum.!A!58]year]old!male!with!COPD!asks!whether!he!should!get!another!
“pneumonia!shot”!this!year!even!though!he!has!received!one!2!years!ago.!He!is!otherwise!healthy.!You!advise!that!he:!
a)!!Should!receive!the!vaccine!every!5!years!
b)!!Should!receive!the!vaccine!at!age!65!
c)!!Should!receive!the!vaccine!every!5!years!only!if!he!is!living!with!an!immuno]compromised!person!
d)!!Should!not!receive!the!vaccine!again!
e)!!Should!receive!the!vaccine!every!year!
!
!
!
Explanation:!
The!pneumococcal!polysaccharide!vaccine!(PPV)!is!recommended!for!all!persons!age!65!or!older,!and!for!persons!age!
2!and!older!with!high]!risk!conditions.!These!high]risk!conditions!include!diabetes,!heart!disease,!chronic!liver!disease!
(including!alcoholism),!chronic!pulmonary!disease!(excluding!asthma),!congenital!immunodeficiency,!leukemia,!
lymphoma,!generalized!malignancy,!cerebrospinal!fluid!leaks,!renal!failure,!end]stage!renal!disease,!asplenia,!and!HIV.!
Other!factors!associated!with!high!risk!include!undergoing!hemodialysis,!receiving!clotting!factor!concentrates,!and!
taking!alkylating!agents!or!high!doses!of!corticosteroids.!
!
For!people!who!have!received!the!vaccine!before!age!65,!only!one!revaccination!is!indicated!when!they!are!65!years!
of!age!or!older!and!5!or!more!years!have!elapsed!since!the!first!immunization.!Antibody!levels!are!significantly!
increased!after!this!second!vaccination,!but!do!not!increase!after!a!third!dose.!
!
[note:!Exception!]!Quebec:!
The!pneumococcal!polysaccharide!vaccine!may!be!given!from!the!age!of!2.!It!is!recommended!for!persons!65!years!or!
over!and!for!people!aged!2!to!64!years!with!a!medical!condition!that!increases!their!risk!of!serious!pneumococcal!
infection.!The!vaccine!is!usually!administered!only!once.!
The!following!individuals!have!a!higher!risk!of!serious!pneumococcal!infection:!people!with!a!defective!spleen!or!no!
spleen!(due!to!surgery!or!certain!illnesses),!people!who!have!undergone!a!cochlear!implant,!people!who!suffer!from!
certain!chronic!illnesses!such!as!heart,!lung!or!kidney!disease,!diabetes!or!cancer,!and!people!with!a!suppressed!
immune!system.!
The!pneumococcal!polysaccharide!vaccine!is!safe.!Most!reactions!are!harmless!and!do!not!last!long.!Symptoms!
experienced!after!vaccination!are!not!necessarily!caused!by!the!vaccine.]!
!
!
Question!#214!
QID:!2987!
Topic:!Hygiene!
Subject:!PMCH!
!
You!are!on!the!infection!control!committee!for!your!hospital.!The!control!charts!indicate!an!increase!in!methicillin]
resistant!Staphylococcus!aureus!(MRSA)!on!the!surgery!unit!of!the!hospital.!Based!on!anecdotal!reports!the!
committee!has!received,!there!apparently!is!poor!hand!hygiene!on!the!surgery!on!the!part!of!the!nurses!and!
surgeons.!
!
When!making!recommendations!for!improvements,!the!use!of!soap!and!water!would!be!preferred!for!hand!washing!
in!which!one!of!the!following!situations?!
a)!!In!all!situations!
b)!!Only!periodically,!to!remove!bacteria!that!are!not!killed!by!alcohol]based!hand!rubs!
c)!!Only!when!health!care!workers!are!using!gloves!
d)!!When!hands!are!visibly!soiled!or!exposure!to!spore]forming!organisms!is!proven!or!strongly!suspected!
e)!!To!prevent!irritation!when!frequent!washing!is!required!
!
!
99
!
Explanation:!
A!key!element!in!improving!hand!hygiene!is!the!use!of!an!alcohol]based!rub!instead!of!washing!with!soap!and!water.!
An!alcohol]based!hand!rub!requires!less!time,!is!microbiologically!more!effective!and!less!irritating!to!skin!than!
traditional!hand!washing!with!soap!and!water.!Therefore,!alcohol]based!hand!rubs!should!replace!hand!washing!as!
the!standard!for!hand!hygiene!in!health!care!settings!unless!the!hands!are!visibly!soiled.!
!
According!to!WHO:!"Perform!hand!washing!with!soap!and!water!if!hands!are!visibly!soiled,!or!exposure!to!spore]
forming!organisms!is!proven!or!strongly!suspected,!or!after!using!the!restroom.!Otherwise,!if!resources!permit,!
perform!hand!rubbing!with!an!alcohol]based!preparation."!
!
!
!
!
Question!#215!
QID:!2989!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!adolescent!idiopathic!scoliosis?!
a)!!Routine!annual!screening!for!all!adolescents!is!recommended!
b)!!The!forward!bending!test!using!a!scoliometer!is!a!reliable!way!to!detect!idiopathic!scoliosis!in!adolescents!
c)!!Treatment!of!idiopathic!scoliosis!during!adolescence!leads!to!significant!health!benefits!in!a!high!percentage!of!
afflicted!patients!
d)!!Scoliosis!requiring!aggressive!treatment!is!likely!to!be!detected!without!community!screenings!
e)!!Most!adolescents!who!are!found!to!have!idiopathic!scoliosis!during!community!screenings!are!compliant!with!
recommended!follow]up!
!
!
!
Explanation:!
Current!guidelines!recommend!against!the!routine!screening!of!asymptomatic!adolescents!for!idiopathic!scoliosis.!
The!forward!bending!test,!with!or!without!scoliometer!use,!has!a!variable!ability!to!detect!idiopathic!scoliosis.!Also,!
there!is!evidence!of!poor!follow]up!in!adolescents!with!idiopathic!scoliosis!who!are!identified!during!these!screening!
programs.!Fair!evidence!was!found!that!only!a!small!portion!of!adolescents!that!are!treated!for!idiopathic!scoliosis!
receive!health!benefits.!Most!cases!of!scoliosis!that!require!aggressive!treatment!are!likely!to!be!detected!without!
community!screenings.!
!
!
!
!
Question!#216!
QID:!2990!
Subject:!PMCH!
!
Which!one!of!the!following!should!be!offered!to!college!freshmen!prior!to!their!arrival!on!campus!if!they!are!planning!
on!living!in!a!dormitory?!
a)!!Hepatitis!A!vaccine!
b)!!Varicella!zoster!vaccine!
c)!!Pneumococcal!vaccine!
d)!!Meningococcal!vaccine!
e)!!Influenza!vaccine!
!
!
!
100
Explanation:!
College!students!living!on!campus!have!a!higher!risk!of!meningococcal!infection!compared!to!students!living!off!
campus.!It!has!been!recommended!that!students!entering!college!be!offered!meningococcal!vaccine.!This!vaccine!
contains!antigens!to!serotypes!A,!C,!Y,!and!W]135,!which!cause!over!75%!of!cases!among!college!students.!The!
vaccine!has!an!efficacy!of!over!85%!in!this!population!group.!
!
Hepatitis!A!vaccine!is!indicated!for!individuals!traveling!abroad!and!men!engaging!in!sex!with!men.!Varicella!zoster!
vaccine!is!usually!given!during!the!second!year!of!life!or!to!individuals!without!a!previous!history!of!chickenpox.!
Pneumococcal!vaccine!is!given!to!individuals!with!chronic!medical!illnesses!and!at!age!65.!Influenza!vaccine!is!
indicated!for!college!students,!as!well!as!the!general!population,!but!is!usually!administered!in!the!late!fall!or!early!
winter.!
!
!
!
!
Question!#217!
QID:!2991!
Subject:!PMCH!
!
Statistics!used!for!evaluating!a!study!including!relative!risk!reduction!(RRR),!absolute!risk!reduction!(ARR),!and!
number!needed!to!treat!(NNT).!Which!one!of!the!following!is!the!correct!formula!for!calculating!NNT?!
a)!!1/(RRR!+!ARR)!
b)!!1/RRR!
c)!!1/ARR!
d)!!100!x!ARR!
e)!!100!x!RRR!
!
!
!
Explanation:!
The!absolute!risk!reduction!(ARR)!is!the!difference!in!the!outcome!event!rate!between!the!control!group!and!the!
experimental!group!in!a!given!study.!The!relative!risk!reduction!(RRR)!is!the!percent!reduction!in!the!measured!
outcome!between!the!experimental!and!control!groups.!In!evaluating!a!clinical!study,!the!single!most!clinically!useful!
statistic!may!be!the!number!needed!to!treat!(NNT).!The!NNT!is!the!number!of!the!patients!who!must!be!treated!to!
prevent!one!adverse!outcome,!or!the!number!of!patients!who!must!be!treated!for!one!patient!to!benefit.!The!NNT!is!
simply!the!inverse!of!the!ARR.!Thus,!1/ARR!is!the!correct!formula!for!calculating!NNT.!
!
!
!
!
Question!#218!
QID:!2994!
Subject:!PMCH!
!
A!63]year]old!white!female!with!ovarian!cancer!is!approaching!death.!She!is!unresponsive,!begins!to!retain!pulmonary!
secretions,!and!develops!harsh!gurgling.!
!
The!best!treatment!for!this!patient!would!be:!
a)!!An!oral!expectorant!
b)!!An!albuterol!(preoventil,!Ventolin)!nebulizer!
c)!!A!scopolamine!patch!(Transderm]Scop)!
d)!!Increase!in!oral!fluid!intake!
e)!!Oxygen!
!
101
!
!
Explanation:!
As!the!level!of!consciousness!decreases!in!the!dying!process,!patients!lose!their!ability!to!swallow!and!clear!oral!
secretions.!As!air!moves!over!the!secretions,!which!have!pooled!in!the!oropharynx!and!bronchi,!the!resulting!
turbulence!produces!noisy!ventilation!with!each!breath,!described!as!‘gurgling!‘or!‘rattling!noises.’!
This!patient!has!terminal!congestion,!often!called!the!“death!rattle.”!Other!than!positioning!on!the!left!side,!this!is!
best!treated!with!anticholinergics!such!as!scopolamine,!hyoscyamine,!glycopyrrolate,!and!atropine.!
!
>!Reduction!(not!increase)!of!fluid!intake!is!part!of!non]pharmacological!treatment!
>!An!expectorant!is!not!indicated!when!the!patient!is!unresponsive.!
>!There!is!no!bronchospasm,!so!albuterol!would!not!be!helpful.!
>!Oxygen!is!indicated!for!hypoxia!and!would!not!be!useful!in!the!treatment!of!terminal!congestion.!
!
!
Question!#219!
QID:!2995!
Subject:!PMCH!
!
What!is!the!current!recommendation!regarding!lung!cancer!screening!strategy!in!smokers?!
a)!!Helical!CT!every!5!years!
b)!!Low]dose!CT!annually!
c)!!Sputum!examinations!every!6!months!
d)!!Chest!radiographs!annually,!combined!with!sputum!examinations!every!6!months!
e)!!No!screening!strategy!is!currently!recommended!
!
!
!
Explanation:!
Examples!of!screening!tests!for!lung!cancer!include:!
•Chest!X]rays.!
•Sputum!cytology!
•Spiral!(helical)!CT!scans!of!the!lungs!
!
There!is!fair!evidence!that!low]dose!CAT!scans,!chest!X]rays,!and!sputum!cytology!can!find!cancers!earlier!than!they!
would!be!found!without!screening,!but!there!is!little!evidence!that!these!screening!tests!actually!prevent!people!from!
dying!from!lung!cancer.!
!
Experts!do!not!know!if!the!benefits!of!screening!outweigh!the!potential!harms.!For!these!reasons,!experts!do!not!
currently!recommend!for!or!against!lung!cancer!screening.!Screening!for!lung!cancer!with!chest!X]rays!was!once!
promoted!by!some!experts,!but!researchers!found!out!that!people!who!were!screened!did!not!have!a!lower!death!
rate!than!people!who!were!not!screened.!
!
!
Question!#220!
QID:!2996!
Topic:!Traveler's!Diarrhea!
Subject:!PMCH!
!
A!20]year]old!college!student!is!anxious!to!avoid!traveler’s!diarrhea!during!a!4]week!visit!to!Central!America.!You!
would!advise!him!that!which!one!of!the!following!is!generally!safe?!
a)!!Baked!foods!such!as!breads!
b)!!Ice!added!to!bottled!beverages!
c)!!Fresh!raw!vegetables!
d)!!Fresh!raw!seafood!products!
!
102
!
!
Explanation:!
Baked!goods!such!as!breads!can!generally!be!considered!safe!from!most!causes!of!traveler’s!diarrhea.!Ice!from!local!
water!sources!is!commonly!contaminated,!as!freezing!does!not!kill!most!causes!of!traveler’s!diarrhea.!Raw!vegetables!
are!often!contaminated!because!human!and!animal!wastes!are!commonly!used!for!fertilizer.!Alcohol!is!not!an!
effective!disinfectant!for!traveler’s!diarrhea!pathogens.!Raw!fish!and!shellfish!are!high]risk!foods.!
!
!
!
!
Question!#221!
QID:!2997!
Topic:!Hepatitis!
Subject:!PMCH!
!
A!35]year]old!male!presents!for!routine!follow!up.!His!recent!laboratory!studies!reveal!elevated!liver!enzymes.!He!has!
had!elevated!liver!enzymes!for!the!last!12!months.!A!negative!test!for!which!one!of!the!following!makes!further!
serologic!testing!for!chronic!hepatitis!B!unnecessary?!
a)!!Hepatitis!B!viral!DNA!(HBV]DNA)!
b)!!Hepatitis!B!surface!antibody!(HBsAb)!
c)!!Hepatitis!B!surface!antigen!(HBsAg)!
d)!!Hepatitis!B!e!antigen!(HBeAg)!
e)!!IgM!antibody!to!Hepatitis!B!core!antigen!(IgM!anti]HBc)!
!
!
!
Explanation:!
The!development!of!antibodies!(HBcAb,!HBsAb)!occurs!after!acute!infection!in!all!patients,!and!can!confer!immunity.!
HBeAg!may!fade,!even!with!chronic!infection.!HBsAg!(choice!C)!is!present!with!acute!infection,!and!usually!disappears!
at!5!months.!Without!its!continued!presence,!further!serologic!testing!for!chronic!hepatitis!B!is!unnecessary.!
!
→!In!the!early!stages!of!chronic!hepatitis!B!infection,!hepatitis!B!viral!DNA!(choice!A)!appears!in!the!serum.!This!
marker!can!disappear!over!time!as!the!infection!enters!a!non]replicated!phase.!These!patients!can!develop!
subsequent!reactivation!of!their!infection,!with!concomitant!deterioration!of!hepatic!function!parameters.!
→!Hepatitis!B!surface!antibody!(choice!B)!is!generally!interpreted!as!indicating!recovery!and!immunity!from!HBV!
infection.!Anti]HBs!also!develops!in!a!person!who!has!been!successfully!vaccinated!against!Hepatitis!B.!
→!Hepatitis!B!e!antigen!(choice!D)!is!a!secreted!product!of!the!nucleocapsid!gene!of!HBV!that!is!found!in!serum!
during!acute!and!chronic!Hepatitis!B.!Its!presence!indicates!that!the!virus!is!replicating!and!the!infected!person!has!
high!levels!of!HBV.!
→!IgM!antibody!to!Hepatitis!B!core!antigen!(choice!E)!!indicates!recent!infection!with!HBV!(≤!6!months).!Its!presence!
indicates!acute!infection.!
!
!
!
!
Question!#222!
QID:!2998!
Topic:!Respirator!Use!
Subject:!PMCH!
!
A!civic!group!in!your!community!is!concerned!about!airborne!bioterrorism,!and!requests!your!advice!concerning!the!
use!of!respirators!in!the!event!of!an!attack.!Which!one!of!the!following!would!be!accurate!advice?!
a)!!Some!medical!conditions!are!adversely!affected!by!use!of!a!respirator!
b)!!Size!and!facial!features!need!not!be!considered!when!fitting!a!respirator!
c)!!Air]purifying!respirators!are!adequate!in!oxygen]deficient!spaces!
103
d)!!Comfort!is!the!most!important!factor!to!consider!when!choosing!a!respirator!
e)!!A!universal!filter!is!available!which!protects!against!all!environmental!airborne!hazards!
!
!
!
Explanation:!
The!increased!work!of!breathing!associated!with!respirator!use!may!adversely!affect!patients!with!certain!medical!
problems,!including!asthma,!COPD,!coronary!artery!disease,!and!anxiety!states.!Some!facial!features,!such!as!a!beard!
or!large!mustache,!affect!the!fit!of!a!respirator.!Air]purifying!respirators!do!not!protect!from!hypoxia!in!confined,!
oxygen]deficient!spaces.!Comfort!is!important!for!increasing!compliance!with!respirator!use,!but!the!respirator!should!
be!chosen!based!on!the!protection!provided!rather!than!on!comfort.!There!is!no!single!filter!that!will!work!for!all!
exposures!under!all!conditions.!
!
!
!
!
Question!#223!
QID:!2999!
Subject:!PMCH!
!
Caring!for!patient’s!with!Alzheimer’s!disease!at!home!often!imposes!a!considerable!financial!burden!on!the!family.!
Which!one!of!the!following!services!is!not!covered!by!Medicare!for!homebound!individuals!with!dementia?!
a)!!Occupational!therapy!
b)!!Physical!therapy!
c)!!Counseling!for!caregivers!
d)!!Transportation!to!and!from!health!care!services!
e)!!Part]time!home!health!aides!
!
!
!
Explanation:!
!
!
Question!#224!
QID:!3000!
Subject:!PMCH!
!
An!18]year]old!male!student!presents!for!a!physical!examination!prior!to!attending!nursing!college.!His!records!
indicate!that!he!was!not!immunized!against!hepatitis!B!as!a!child.!
!
Based!on!current!guidelines,!this!patient!should:!
a)!!Receive!hepatitis!B!immunization!regardless!of!risk!factors!
b)!!Receive!hepatitis!B!immunization!only!if!he!is!residing!in!a!dormitory!
c)!!Receive!hepatitis!B!immunization!only!if!he!is!considering!foreign!study!
d)!!Receive!hepatitis!B!immunization!only!if!he!is!engaged!in!high]risk!activity!
e)!!Not!receive!hepatitis!B!immunization!
!
!
!
Explanation:!
Hepatitis!B!vaccine!is!indicated!in!all!health!professional!students;!it!is!recommended!as!part!of!the!route!childhood!
immunization!schedule,!and!should!be!given!to!students!who!have!not!previously!been!immunized.!This!
recommendation!holds!regardless!of!living!situations!or!risk!factors.!
104
!
!
!
!
Question!#225!
QID:!3001!
Subject:!PMCH!
!
You!have!just!finished!giving!instructions!and!a!prescription!to!a!28]year]old!male!from!China!who!speaks!some!
English,!but!not!well.!You!gave!the!instructions!with!the!aid!of!an!interpreter,!but!are!concerned!that!the!patient!
might!not!fully!understand!them.!
!
Which!one!of!the!following!is!the!best!course!of!action?!
a)!!Refer!the!patient!to!a!website!about!his!condition!
b)!!Repeat!the!instructions!slowly!to!the!interpreter!and!ask!him!or!her!to!speak!clearly!to!the!patient!
c)!!Contact!a!family!member!who!speaks!English!and!ask!him!or!her!to!repeat!the!instructions!to!the!patient!
d)!!Ask!the!patient!to!repeat!the!instructions!to!you!in!his!own!words!
!
!
!
Explanation:!
In!order!to!be!sure!that!cross]cultural!patients!understand!your!instructions,!it!is!most!helpful!to!ask!them!to!repeat!
the!instructions!to!you!in!their!own!words.!A!website!would!probably!not!normally!be!specific!or!culturally!sensitive!
to!the!patient’s!condition.!The!physician!should!speak!in!a!normal!tone!to!the!patient!and!not!to!the!interpreter.!
Family!members!may!be!used!as!convenient!translators,!but!to!maintain!confidentiality!it!is!best!to!use!a!trained!
medical!interpreter.!
!
!
!
!
Question!#226!
QID:!3002!
Subject:!PMCH!
!
Which!one!of!the!following!best!characterizes!the!current!recommendations!on!screening!asymptomatic!women!for!
ovarian!cancer?!
a)!!Screening!is!recommended!for!all!women!over!age!18!
b)!!Screening!is!recommended!for!postmenopausal!women!
c)!!Screening!is!recommended!for!women!with!a!family!history!of!ovarian!cancer!
d)!!Screening!is!not!recommended!
e)!!There!is!no!recommendation!for!or!against!screening!
!
!
!
Explanation:!
In!2004,!current!evidence!regarding!ovarian!cancer!was!reevaluted,!and!recommendations!were!made!against!routine!
screening!of!asymptomatic!women.!“Fair!evidence”!was!cited!that!screening!could!lead!to!harmful!outcomes!and!that!
this!risk!outweighed!the!potential!benefit!of!screening.!(Rating!of!D).!
!
The!incidence!of!ovarian!cancer!is!higher!in!women!over!60!years!of!age!but!it!occurs!throughout!the!age!spectrum;!
therefore,!there!is!no!recommendation!for!screening!particular!age!groups.!While!there!is!some!evidence!to!support!
the!screening!of!women!with!a!positive!family!history!of!ovarian!cancer,!there!is!not!yet!sufficient!evidence!from!
ongoing!clinical!trials!to!evaluate!the!potential!benefit!of!doing!so.!
!
105
!
!
!
Question!#227!
QID:!3003!
Subject:!PMCH!
!
According!to!current!guidelines,!which!one!of!the!following!conditions!necessitates!administration!of!the!23]valent!
pneumococcal!vaccine!for!patients!2]64!years!of!age?!
a)!!Cholecystopathy!
b)!!Diabetes!mellitus!
c)!!Systemic!lupus!erythematosus!
d)!!Rheumatoid!arthritis!
e)!!Hypertension!
!
!
!
Explanation:!
According!to!current!guidelines,!the!23]valent!pneumococcal!polysaccharide!(PPSV23)!vaccine!is!recommended!for!all!
people!who!meet!any!of!the!criteria!below:!
!
1.!!!!!!All!adults!age!65!yrs!and!older!
2.!!!!!!Age!2!through!64!yrs!with!any!of!the!following!conditions:!
a.!!!!!!cigarette!smokers!age!19!yrs!and!older!
b.!!!!!!chronic!cardiovascular!disease!(e.g.,!congestive!heart!failure,!cardiomyopathies;!excluding!hypertension)!
c.!!!!!!chronic!pulmonary!disease!(including!COPD!and!emphysema,!and!for!adults!ages!19!years!and!older,!asthma)!
d.!!!!!!diabetes!mellitus!
e.!!!!!!alcoholism!
f.!!!!!!chronic!liver!disease,!cirrhosis!
g.!!!!!!candidate!for!or!recipient!of!cochlear!implant!
h.!!!!!!cerebrospinal!fluid!(CSF)!leak!
i.!!!!!!functional!or!anatomic!asplenia!(e.g.,!sickle!cell!disease,!splenectomy)!
j.!!!!!!immunocompromising!conditions!(e.g.,!HIV!infection,!leukemia,!congenital!immunodeficiency,!Hodgkin's!disease,!
lymphoma,!multiple!myeloma,!generalized!malignancy)!or!on!immunosuppressive!therapy!
k.!!!!!!solid!organ!transplantation;!for!bone!marrow!transplantation!
l.!!!!!!chronic!renal!failure!or!nephrotic!syndrome!
!
!
Question!#228!
QID:!3004!
Subject:!PMCH!
!
A!87]year]old!black!female!who!is!near!death!is!receiving!hospice!care!and!has!developed!failure!to!thrive.!She!
refuses!to!eat!and!the!family!is!concerned!that!she!will!starve!to!death.!
!
Which!one!of!the!following!would!be!most!appropriate?!
a)!!Initiate!parenteral!peripheral!nutrition!
b)!!Arrange!for!gastrostomy!tube!feeding!
c)!!Arrange!for!jejunostomy!tube!feeding!
d)!!Prescribe!a!high]calorie!diet!with!frequent!feedings!
e)!!Reassure!the!family!that!not!feeding!the!patient!is!appropriate!
!
!
!
106
Explanation:!
Families!and!professional!caregivers!often!interpret!cessation!of!eating!as!starving!to!death.!Loss!of!appetite!is!part!of!
the!dying!process!and!most!dying!patients!who!stop!eating!are!not!hungry.!Parenteral!or!enteral!feeding!at!the!end!of!
life!does!not!improve!symptoms!control!or!lengthen!life.!
!
!
!
!
Question!#229!
QID:!3005!
Topic:!Feeding!Tube!
Subject:!PMCH!
!
Various!studies!have!evaluated!the!use!of!feeding!tubes.!Which!one!of!the!following!is!true!regarding!the!use!of!
feeding!tubes!in!patients!who!are!unable!to!eat!and!swallow!normally!due!to!significant!dementia?!
a)!!They!promote!healing!of!decubitis!ulcers!
b)!!They!help!prevent!aspiration!pneumonia!
c)!!They!help!prevent!malnutrition!
d)!!They!reduce!discomfort!resulting!from!the!inability!to!eat!and!chew!
e)!!No!specific!benefit!from!the!use!of!feeding!tubes!has!been!shown!
!
!
!
Explanation:!
Physicians!commonly!rely!on!feeding!tubes!to!supply!nutrition!to!severely!demented!patients!who!are!unable!to!chew!
and/or!swallow!normally.!However,!various!studies!have!not!shown!the!use!of!feeding!tubes!to!be!effective!in!healing!
pressure!sores,!preventing!aspiration!pneumonia,!preventing!malnutrition,!providing!comfort,!improving!functional!
status,!or!extending!life.!Furthermore,!the!associated!complications!increase!the!difficulty!of!caring!for!demented!
patients.!While!hand!feeding!may!not!prevent!malnutrition!or!dehydration,!it!does!have!the!advantage!of!maintaining!
patient!comfort.!
!
!
!
!
Question!#230!
QID:!3006!
Topic:!Hepatitis!
Subject:!PMCH!
!
Who!of!the!following!should!be!screened!for!hepatitis!C?!
a)!!Health!care!workers!
b)!!The!general!population!
c)!!Public!safety!workers!
d)!!Pregnant!women!
e)!!Individuals!with!persistent!abnormal!ALT!(SGPT)!
!
!
!
Explanation:!
Individuals!with!persistently!abnormal!alanine!aminotransferase!levels!should!be!routinely!tested!for!hepatitis!C!virus!
infection.!Routine!hepatitis!C!screening!is!not!recommended!for!health!care!workers,!public!safety!workers,!the!
general!population,!or!pregnant!women.!
!
!
!
!
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Question!#231!
QID:!3007!
Topic:!Patient!Compliance!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!concerning!patient!adherence?!
a)!!Most!physicians!can!recognize!when!patients!are!nonadherent!
b)!!Patients!take!complex!dosing!regimens!more!seriously,!and!are!more!likely!to!adhere!to!them!
c)!!Patient!adherence!tends!to!be!highest!immediately!after!a!visit!and!to!steadily!decrease!until!after!the!next!follow]
up!
d)!!Self]monitoring!of!blood!pressure!improves!adherence!with!hypertension!regimens!
e)!!Pediatric!patients!with!chronic!illnesses!are!more!compliant!than!adults!with!similar!illnesses!
!
!
!
Explanation:!
Active!participation!by!the!patient!in!the!selection!and!adjustment!of!a!therapeutic!regimen!improves!adherence.!
Self]monitoring!of!blood!pressure!increases!participation!and!thus!increases!adherence!to!hypertension!regimens.!
!
Physicians!rarely!identify!nonadherent!patients.!Complicated!drug!regimens!reduce!compliance!by!confusing!patients.!
Patients!frequently!become!more!adherent!just!before!an!appointment.!Chronically!ill!pediatric!patients!are!no!more!
likely!to!be!adherent!than!chronically!ill!adult!patients.!
!
!
!
!
Question!#232!
QID:!3008!
Subject:!PMCH!
!
You!see!a!20]year]old!Korean!female!who!is!a!new!patient.!She!has!just!recently!moved!to!Canada.!
!
Which!one!of!the!following!is!a!characteristic!of!this!patient’s!culture!which!could!be!important!when!providing!
medical!care?!
!
a)!!A!need!for!balance!between!“hot”!and!“cold”!illnesses!and!therapies!
b)!!A!tendency!to!smile!to!indicate!understanding!and!agreement!
c)!!A!belief!that!the!bare!foot!should!be!examined!as!part!of!the!diagnostic!workup!
d)!!A!belief!that!psychiatric!diseases!are!often!the!root!cause!of!illness,!and!should!be!actively!sought!and!treated!
!
!
!
Explanation:!
It!is!important!to!try!to!understand!the!cultural!background!of!patients,!as!cultural!beliefs!can!affect!the!physician’s!
ability!to!diagnose!and!manage!illness.!The!Asian!population!in!general!has!a!need!for!balance!between!“hot”!and!
“cold”!illnesses!and!treatments.!They!consider!psychiatric!conditions!shameful,!may!smile!from!embarrassment!
rather!than!to!indicate!understanding!or!agreement,!and!find!exposing!the!sole!of!the!foot!an!anathema.!
!
!
!
!
Question!#233!
QID:!3009!
Topic:!TB!
Subject:!PMCH!
108
!
Which!one!of!the!following!is!true!regarding!direct!observational!therapy!(DOT)!in!the!treatment!of!active!
tuberculosis?!
a)!!DOT!guarantees!patient!compliance!with!the!prescribed!regimen!
b)!!DOT!is!recommended!only!in!the!office!or!clinic!setting!
c)!!DOT!patients!require!less!monitoring!for!signs!of!treatment!failure!
d)!!DOT!with!incentives!and!reminders!assures!the!highest!treatment!completion!rates!
!
!
!
Explanation:!
In!the!treatment!of!active!tuberculosis,!direct!observational!therapy!(DOT)!involves!providing!the!antituberculosis!
drugs!directly!to!patients!and!watching!them!swallow!the!medications.!It!is!the!preferred!care!management!strategy!
for!all!patients!with!tuberculosis.!The!use!of!DOT!does!no!guarantee!the!ingestion!of!all!doses!of!every!medication,!as!
patients!may!miss!appointments,!may!not!actually!swallow!the!pills,!or!may!(deliberately!or!otherwise)!regurgitate!
the!medication.!
!
Research!has!shown!that!DOT!cannot!be!limited!merely!to!passive!observation!of!medication!ingestion.!There!must!
be!aggressive!interventions!when!patients!miss!doses.!DOT!should!be!used!for!all!patients!residing!in!institutional!
settings,!such!as!hospitals,!nursing!homes,!or!correctional!facilities,!or!other!settings,!such!as!methadone!treatment!
sites,!that!are!conducive!to!observational!therapy.!Because!DOT!does!not!guarantee!complete!compliance!with!an!
antituberculosis!regimen,!all!patients!should!continue!to!be!monitored!for!signs!of!treatment!failure.!Enhanced!DOT!
(DOT!along!with!incentives!and!enablers)!produces!the!highest!treatment!completions!rates!(in!excess!of!90%!across!
a!range!of!geographic!and!socioeconomic!settings),!and!reinforces!the!importance!of!patient]related!factors!in!
designing!and!implementing!case!management.!Examples!of!enablers!are!reminder!systems!and!follow]up!for!missed!
appointments,!as!well!as!personnel!who!speak!the!languages!of!the!populations!served.!Incentives!include!such!
things!as!clothing!or!personal!products,!as!well!as!use!of!a!patient!contract.!
!
!
!
!
Question!#234!
QID:!3010!
Topic:!CME!
Subject:!PMCH!
!
In!April!2003,!guidelines!for!internal!compliance!programs!at!pharmaceutical!companies!were!issued.!According!to!
these!guidelines,!which!one!of!the!following!is!likely!to!be!considered!appropriate?!
a)!!Compensating!physicians!for!attending!a!continuing!medical!education!(CME)!activity!
b)!!Requiring!that!CME!activities!be!organized!by!the!marketing!department!of!the!company!
c)!!Requiring!inclusion!of!product!endorsements!in!CME!activities!
d)!!Requiring!that!speakers!for!the!CME!activities!be!selected!from!a!company]approved!list!
e)!!Requiring!disclosure!of!sponsorship!of!CME!activities!
!
!
!
Explanation:!
In!2003,!guidelines!for!internal!compliance!programs!at!pharmaceutical!companies!were!issued,!providing!
information!about!practices!likely!to!provoke!government!prosecution!under!current!law.!With!regard!to!sponsorship!
of!continuing!medical!education!(CME)!activities,!the!OIG!recommends!disclosure!of!industry!sponsorship!and!
potential!conflicts!of!interest.!Unacceptable!industry!practices!include!compensating!physicians!for!attending!CME!
activities,!as!well!as!influencing!the!choice!of!speakers!and!content!of!CME!activities.!The!OIG!recommends!separating!
CME!functions!and!the!awarding!of!grants!from!the!sales!and!marketing!divisions!of!a!company.!
!
!
Question!#235!
109
QID:!3129!
Subject:!PMCH!
!
False]positive!urine!screens!for!drug!abuse!can!occur!as!a!result!of:!
a)!!Passive!inhalation!of!crack!cocaine!
b)!!Passive!inhalation!of!marijuana!smoke!
c)!!Eating!poppy!seed!muffins!
d)!!Consuming!products!containing!hemp!
e)!!Use!of!black!cohosh!
!
!
!
Explanation:!
Eating!as!little!as!one!poppy!seed!muffin!can!produce!amounts!of!morphine!and!codeine!detectable!by!immunoassay,!
as!well!as!by!gas!chromatography!and!mass!spectrometry.!Passively!inhaled!crack!cocaine!or!marijuana!(unless!an!
extreme!amount!is!inhaled),!and!ingested!products!containing!hemp!or!other!common!herbal!preparations!do!not!
produce!positive!urine!drug!screens.!
!
In!addition!to!poppy!seeds,!substances!reported!to!cause!false]positive!urine!drug!screens!include!selegiline,!Vicks!
inhalers,!NSAIDs,!oxaprozin,!fluoroquinolones,!rifampin,!venlafaxine,!and!dextromethorphan.!
!
!
Question!#236!
QID:!3139!
Topic:!Hospice!
Subject:!PMCH!
!
An!85]year]old!female!with!hypertension!is!receiving!hospice!care!for!oral!cancer.!Which!one!of!the!following!services!
typically!would!not!be!covered!under!hospice?!
a)!!Dietary!counseling!
b)!!Short]term!inpatient!care!
c)!!Drugs!for!symptom!control!
d)!!Drugs!for!hypertension!
e)!!Speech!therapy!
!
!
!
Explanation:!
Hospice!covers!a!wide!array!of!services,!including!dietary!counseling;!short]term!hospital!and!respite!care;!medicine!
and!supplies!to!treat!symptoms!of!terminal!illness;!physical,!occupational,!and!speech!therapies;!and!many!other!
benefits!as!deemed!appropriate!by!the!hospice!team.!However,!medicine!used!to!cure!the!illness!that!led!to!hospice!
care,!as!well!as!medicines!that!treat!other!comorbid!illnesses,!are!not!covered!under!the!hospice!benefit.!Therefore,!it!
is!important!for!patients!to!maintain!other!coinsurances.!
!
!
Question!#237!
QID:!3156!
Subject:!PMCH!
!
Which!one!of!the!following!statements!regarding!palliative!care!services!is!most!consistent!with!the!National!
Consensus!Project!for!Quality!Palliative!Care!guidelines?!
a)!!Palliative!care!services!are!limited!to!patients!with!diseases!that!reduce!life!expectancy!
b)!!Palliative!care!begins!at!the!onset!of!terminal!disability!from!the!diagnosed!condition!
c)!!The!unit!of!care!comprises!the!patient!and!his!or!her!family,!as!defined!by!the!patient!or!surrogate!
110
d)!!Palliative!care!failures!are!directly!related!to!deviating!from!the!initial!care!plan!
e)!!Pain!management!should!focus!on!modalities!that!will!not!promote!addiction!or!dependency!
!
!
!
Explanation:!
Palliative!care!services!are!provided!to!patients!of!all!ages!who!have!a!chronic!illness,!condition,!or!injury!that!
adversely!affects!daily!functioning!or!reduces!life!expectancy.!Ideally,!palliative!care!begins!when!a!condition!is!
diagnosed!and!continues!through!cure!or!until!death!and!family!bereavement.!The!unit!of!care!comprises!the!patient!
and!his!or!her!family!as!defined!by!the!patient!or!surrogate.!
!
The!care!plan!changes!according!to!the!evolving!needs!and!preferences!of!the!patient!and!the!family,!and!may!involve!
additional!input!from!other!specialists!and!caregivers.!The!care!team!should!help!patients!and!families!understand!
any!changes!that!occur!in!the!condition!and!how!they!affect!ongoing!care!and!goals!of!treatment.!The!evolving!care!
plan!should!be!documented!clearly!throughout,!including!alternative!options!for!settings!and!treatment,!and!should!
be!conveyed!to!all!involved.!
!
The!management!of!pain!should!incorporate!pharmacologic,!nonpharmacologic,!and!complementary!therapies.!
Barriers!to!effective!pain!management,!such!as!fear!of!side!effects,!addiction,!or!respiratory!depression,!should!be!
recognized!and!addressed.!Because!controlled!substances!are!often!used!for!long]term!symptom!management,!
palliative!care!professionals!need!to!work!with!policy!makers,!law!enforcement!representatives,!and!regulators!to!
ensure!that!efforts!to!address!drug!abuse!do!not!interfere!with!the!care!of!patients!who!are!in!pain.!
!
!
Question!#238!
QID:!3190!
Topic:!Patient!Compliance!
Subject:!PMCH!
!
Which!one!of!the!following!statements!is!true!regarding!medication!for!homeless!populations?!
a)!!For!children!>5!years!old,!a!liquid!formulation!is!preferred!
b)!!Sleeping!pills!should!be!prescribed!to!improve!rest!in!noisy!shelters!
c)!!Pseudoephedrine!can!be!used!to!make!crack!cocaine!
d)!!Once]daily!therapy!is!preferable!
!
!
!
Explanation:!
Homeless!patients!face!many!barriers!in!accessing!and!complying!with!medical!care.!The!goal!of!a!provider!should!be!
to!decrease!the!difficulty!of!adhering!to!medical!regimens.!Using!the!simplest!medical!regimen!warranted!by!standard!
clinical!guidelines!is!helpful,!with!once]daily,!directly!observed!therapy!being!preferable.!Liquid!formulations!should!
be!avoided!if!possible,!because!of!the!need!for!measuring!and!refrigerating.!Medications!with!sedative!effects!may!
compromise!a!patient’s!safety!on!the!streets!or!in!shelters.!Pseudoephedrine!should!be!prescribed!carefully,!as!it!can!
be!used!to!make!methamphetamine.!Albuterol!can!be!used!to!enhance!the!effects!of!crack!cocaine.!Diuretics!can!be!
problematic!for!patients!who!have!limited!access!to!bathroom!facilities!during!the!day.!
!
!
Question!#239!
QID:!3195!
Subject:!PMCH!
!
A!14]year]old!male!presents!to!your!office!with!a!high!fever!that!began!suddenly.!He!has!a!diffuse!petechial!rash!and!
some!nuchal!rigidity!on!examination.!A!lumbar!puncture!is!performed,!and!gram]negative!diplococci!are!found.!You!
admit!him!to!the!hospital.!
!
111
Which!one!of!the!following!would!be!most!appropriate!at!this!time?!
a)!!Immediate!chemoprophylaxis!for!his!entire!school!
b)!!Immediate!vaccination!of!all!contacts!
c)!!Chemoprophylaxis!for!family!members!and!very!close!contacts!only!
d)!!Isolation!of!all!family!members!for!1!week!
e)!!No!preventive!measures!until!culture!results!are!available!
!
!
!
Explanation:!
Meningococcal!disease!remains!a!leading!cause!of!sepsis!and!meningitis.!Those!in!close!contact!with!patients!who!
have!presumptive!meningococcal!disease!are!at!heightened!risk.!While!secondary!cases!have!been!reported,!they!are!
rare!because!of!prompt!chemoprophylaxis!of!household!members!and!anyone!directly!exposed!to!the!index!patient’s!
oral!secretions.!There!is!no!need!to!isolate!family!members.!The!risk!for!secondary!disease!among!closest!contacts!is!
highest!during!the!first!few!days!after!the!onset!of!illness!in!the!index!patient,!mandating!immediate!
chemoprophylaxis!of!those!exposed.!The!delay!in!immunity!post!vaccination!makes!it!necessary!to!use!other!
preventive!measures!instead.!
!
!
Question!#240!
QID:!3205!
Subject:!PMCH!
!
Cultural!traditions!and!ceremonies!sometimes!mandate!actions!that!conflict!with!standard!treatment!regimens.!
Which!one!of!the!following!patients!would!require!modification!of!a!medication!schedule?!
a)!!A!Malaysian!male!experiencing!koro!
b)!!A!Muslim!during!Ramadan!
c)!!A!Mexican!affected!with!bilis!
d)!!A!Jehovah’s!Witness!observing!his!birthday!
e)!!A!Chinese]Canadian!grandmother!receiving!cupping!treatments!
!
!
!
Explanation:!
In!a!nation!as!diverse!as!Canada,!cultural!sensitivity!on!the!part!of!the!prescribing!physician!is!an!essential!component!
for!negotiating!a!successful!therapeutic!regimen.!Culture]based!belief!systems!can!be!quite!complex!and!confusing!to!
those!unfamiliar!with!them,!but!this!is!often!overcome!when!the!physician!demonstrates!sincere!interest,!
understanding,!and!respect!for!each!patient.!The!month]long!daytime!fast!observed!during!Ramadan!generally!
requires!an!adaptive!dosing!schedule.!Jehovah’s!Witnesses!do!not,!as!a!rule,!celebrate!birthdays.!Cupping!treatment!
does!not!affect!timing!of!medications.!Koro!is!a!delusional!state!in!which!the!affected!man!has!a!sensation!that!his!
penis!is!shrivelling!or!being!drawn!into!his!abdomen.!It!would!not!affect!a!medication!regimen.!Bilis!is!an!outburst!of!
anger.!
!
!
Question!#241!
QID:!3232!
Topic:!Malpractice!
Subject:!PMCH!
!
Which!one!of!the!following!statements!is!true!regarding!malpractice!cases?!
a)!!The!majority!of!patients!who!sustain!medical!injury!do!not!sue!the!physician!
b)!!Family!physicians!are!the!most!frequently!sued!physicians!
c)!!The!majority!of!malpractice!claims!involve!trivial!injury!
d)!!Plaintiffs!typically!win!cases!brought!to!trial!
e)!!The!time!between!injury!and!resolution!of!a!case!is!typically!2!years!
112
!
!
!
Explanation:!
The!vast!majority!of!medically!injured!patients!do!not!sue.!The!usual!time!to!resolution!of!malpractice!cases!is!5!years,!
although!many!take!6!years!or!more!to!resolve.!Obstetrician]gynecologists!are!the!most!frequently!sued!doctors.!
Malpractice!claims!typically!involve!severe!injuries!or!death.!Plaintiffs!win!only!one]fifth!of!cases!brought!to!court.!
!
!
Question!#242!
QID:!3245!
Topic:!Pertussis!
Subject:!PMCH!
!
An!18]year]old!white!female!who!works!at!a!day]care!center!sees!you!because!of!a!cough.!Three!weeks!ago!she!
developed!cold!symptoms!that!have!progressed!to!paroxysms!of!coughing!with!post]tussive!emesis.!She!reports!that!
there!are!children!at!the!day]care!center!who!have!coughs!and!colds,!but!none!have!been!diagnosed!with!pertussis.!
She!has!always!been!healthy,!has!no!known!drug!allergies,!and!had!all!of!the!routine!childhood!immunizations.!A!
polymerase!chain!reaction!(PCR)!is!negative!for!pertussis!and!a!chest!film!appears!normal.!
!
Which!one!of!the!following!would!be!most!appropriate!at!this!point?!
a)!!Tetanus!diphtheria!acellular!pertussis!(TDaP)!vaccine!
b)!!Albuterol!
c)!!Promethazine!
d)!!Azithromycin!(Zithromax)!
e)!!Prednisolone!(Orapred)!
!
!
!
Explanation:!
This!person!works!in!an!environment!where!pertussis!may!be!contracted!from!unvaccinated!or!incompletely!
vaccinated!individuals.!According!to!the!Centers!for!Disease!Control!and!Prevention!(CDC)!this!patient!has!“clinical”!
pertussis,!defined!as!an!acute!cough!for!14!days!with!no!other!apparent!cause,!plus!one!of!the!following:!paroxysmal!
cough,!post]tussive!emesis,!or!inspiratory!“whooping.”!A!negative!PCR!does!not!exclude!clinical!pertussis.!
!
The!CDC!recommends!treating!clinical!cases!with!erythromycin,!azithromycin,!or!clarithromycin.!Because!pertussis!is!
highly!contagious,!antibiotics!are!recommended!to!control!outbreaks.!
!
The!effectiveness!of!symptom]reducing!treatments!(e.g.,!antihistamines,!corticosteroids,!ß]agonists,!or!
immunoglobulins)!is!unclear.!A!systematic!review!showed!little!evidence!to!justify!their!use!for!pertussis.!The!CDC’s!
Advisory!Committee!on!Immunization!Practices!no!longer!recommends!the!Td!booster,!and!Td!would!not!boost!her!
immunity!to!pertussis.!Because!of!the!waning!of!pertussis!immunity!after!routine!childhood!immunizations,!the!
newer!tetanus!toxoid,!reduced!diphtheria!toxoid!and!acellular!pertussis!(Tdap)!vaccine!is!recommended!for!
adolescents.!Although!it!is!unclear!whether!this!patient!needs!Tdap!because!of!boosted!immunity!resulting!from!
clinical!pertussis,!immunization!would!not!be!the!first!treatment!in!this!case.!
!
!
Question!#243!
QID:!3255!
Subject:!PMCH!
!
Results!of!a!clinical!study!show!a!relative!risk!reduction!(RRR)!of!33%!and!an!absolute!risk!reduction!(ARR)!of!20%.!
There!are!1000!patients!each!in!the!treatment!and!control!groups.!To!help!determine!the!potential!benefit!of!the!
treatment!it!is!necessary!to!identify!the!number!needed!to!treat!(NNT).!
!
113
Which!one!of!the!following!is!the!NNT!for!this!clinical!study?!
a)!!3!
b)!!5!
c)!!13!
d)!!130!
e)!!The!number!cannot!be!determined!from!the!information!provided!
!
!
!
Explanation:!
The!number!needed!to!treat!(NNT)!is!one!of!the!most!useful!calculations!for!assessing!the!benefit!of!a!treatment.!
Simplified,!the!NNT!is!the!number!of!patients!necessary!to!treat!in!order!for!one!patient!to!benefit.!The!relative!risk!
reduction!(RRR),!often!quoted!in!the!press!or!by!those!promoting!a!treatment,!can!be!misleading!to!both!the!general!
public!and!to!physicians.!Much!more!useful!is!the!absolute!risk!reduction!(ARR);!NNT!is!the!mathematical!reciprocal!of!
ARR!(i.e.,!1/ARR).!
In!this!case!it's!1/0.2!=!5!OR!100/20=5!
!
!
!
Question!#244!
QID:!3311!
Subject:!PMCH!
!
A!pregnant!20]year]old!female!is!diagnosed!with!a!Chlamydia!infection.!She!is!treated!and!the!infection!is!cured,!but!
she!tests!positive!again!at!a!follow]up!visit.!In!this!situation,!contacting!her!sexual!partners!is!considered!a!reasonable!
breach!of!confidentiality!because:!
a)!!There!is!a!public!health!risk!
b)!!There!is!a!risk!to!the!fetus!
c)!!The!patient’s!Chlamydia!infection!has!become!resistant!to!antibiotics!
d)!!There!is!a!risk!of!pelvic!inflammatory!disease!
!
!
!
Explanation:!
There!are!three!situations!when!a!breach!of!confidentiality!is!justified:!abuse!of!a!vulnerable!person!(child!or!elderly),!
a!public!health!risk!(communicable!disease),!or!substantial!danger!to!the!patient!or!others.!While!Chlamydia!is!not!
usually!considered!life]threatening!or!dangerous,!it!is!communicable.!Contacting!sexual!partners!to!notify!and!treat!
them!to!stem!the!spread!of!disease!is!recommended.!
!
!
Question!#245!
QID:!3346!
Subject:!PMCH!
!
The!fact!that!avian!influenza!has!affected!only!a!small!number!of!humans!is!most!likely!due!to:!
a)!!The!rarity!of!human]to]human!spread!
b)!!Its!lack!of!spread!to!animals!other!than!birds!
c)!!Its!lack!of!spread!to!domesticated!poultry!
d)!!Its!lack!of!spread!to!swine!
e)!!Well]established!human!immunity!to!similar!strains!of!influenza!
!
!
!
114
Explanation:!
Human]to]human!transmission!of!the!H5N1!avian!influenza!strain!has,!to!date,!been!relatively!rare!and!has!occurred!
via!means!that!have!not!been!sustained.!Domestic!pets,!poultry,!and!swine!have!been!infected!and!are!potential!
sources!of!infection.!Humans!have!not!developed!immunity!to!this!strain!as!a!result!of!recent!epidemics!of!similar!
strains.!
!
!
Question!#246!
QID:!5381!
Topic:!TB!
Subject:!PMCH!
!
A!30]year]old!African!man,!recently!immigrated!to!Toronto,!Canada!from!Somalia,!comes!to!your!office!to!get!his!PPD!
test!results!for!pre]employment!checkup.!
!
You!measure!the!induration!reaction!and!you!find!it!to!be!12!mm!in!diameter.!The!patient!denies!any!fever,!weight!
loss,!night!sweats,!cough!or!chest!pain.!He!claims!that!he!has!been!always!healthy.!He!states!that!he!took!BCG!vaccine!
long!time!ago.!His!chest!X]ray!is!normal!and!physical!exam!is!unremarkable.!
!
Which!of!the!following!is!the!most!appropriate!next!step!in!the!management!of!this!patient?!
a)!!Isolate!the!patient!and!do!not!approve!the!pre]employment!request!
b)!!No!treatment!is!required!
c)!!Prescribe!Isoniazid!for!9!months!
d)!!Prescribe!Rifampin,!Isoniazid,!Pyrazinamide!and!Ethambutol!for!6!months!
e)!!The!PPD!result!is!considered!negative!due!his!history!of!BCG!Vaccination!
!
!
!
Explanation:!
A!PPD!Test!is!considered!positive!when!the!induration!is:!
]!>!15!mm!(Patients!with!no!known!risk!factors)!
]!>!10!mm!(Patients!with!risk!factors!for!TB!including:!Immigrant!from!endemic!areas,!prisoners,!home!care!
residents…)!
]!>!5mm!(for!immunocompromised!patients!such!as!HIV!patients,!Children!taking!chemotherapy,!chronic!
corticosteroid!treatment…)!
!
A!positive!PPD!test!without!any!clinical!or!radiologic!signs!of!TB!means!latent!infection.!A!latent!infection!should!be!
treated!with!Isoniazid!(INH)!for!9!month.!Pyridoxine!(VitB6)!should!be!added!to!prevent!peripheral!neuropathy!
caused!by!INH.!
!
In!Canada,the!decision!to!treat!patients!!should!be!taken!based!on!the!clinical,!radiologic!and!PPD!results!regardless!
of!the!BCG!vaccination!history.!
!
Rifampin,!Isoniazid,!Pyrazinamide!and!Ethambutol!for!6!months!should!be!prescribed!for!active!TB.!
!
→!The!Patient!has!no!active!infection;!thus!he!can!resume!his!work!and!normal!life!activities!(choice!A).!
→!No!treatment!is!required!(choice!B)!is!incorrect.!This!patient!is!a!recent!immigrant!from!a!TB!endemic!region!and!
the!PPD!is!considered!positive.!He!should!be!treated!with!INH.!
→!Prescribe!Rifampin,!Isoniazid,!Pyrazinamide!and!Ethambutol!for!6!months!(choice!D)!are!used!for!the!treatment!!of!
active!TB!
→!The!PPD!result!is!considered!negative!due!his!history!of!BCG!vaccination!(choice!E)!is!incorrect.!While!it!!is!common!
to!see!positive!PPD!results!in!immigrants!who!received!the!BCG!vaccine,!this!usually!is!not!taken!into!account!while!
recommending!whether!to!treat!patients!with!isoniazid!or!not.!In!Canada!while!the!tuberculin!skin!test!is!acceptable!
in!patients!with!BCG!history,!the!interferon!gamma!release!assays!(IGRA)!is!increasingly!becoming!the!preferred!test!
in!these!patients!to!avoid!how!a!previous!BCG!vaccine!would!affect!the!skin!test.!
!
!
115
Question!#247!
QID:!5435!
Subject:!PMCH!
!
Regular!breast!self]examinations!to!screen!for!breast!cancer:!
a)!!Are!performed!by!most!women!in!Canada!
b)!!Reduce!mortality!due!to!breast!cancer!
c)!!Reduce!all]cause!mortality!in!women!
d)!!Are!recommended!by!recent!guidelines!
e)!!Increase!the!number!of!breast!biopsies!performed!
!
!
!
Explanation:!
Most!women!do!not!regularly!perform!breast!self]examinations,!even!though!it!allows!motivated!women!to!be!in!
control!of!this!aspect!of!their!health!care.!Evidence!from!large,!well]designed,!randomized!trials!of!adequate!duration!
has!shown!that!the!performance!of!regular!breast!self]examinations!by!trained!women!does!not!reduce!breast!
cancer]specific!mortality!or!all]cause!mortality.!The!current!guidelines!have!found!insufficient!evidence!to!
recommend!breast!self]examinations.!A!Cochrane!review!concluded!that!breast!self]examinations!have!no!beneficial!
effect!and!increase!the!number!of!biopsies!performed.!
!
!
Question!#248!
QID:!5440!
Subject:!PMCH!
!
The!pneumococcal!polyvalent!vaccine!(Pneumovax!23)!would!be!recommended!for!which!one!of!the!following!
patients?!
a)!!A!1]year]old!patient!as!a!routine!immunization!
b)!!An!18]month]old!patient!diagnosed!with!cystic!fibrosis!
c)!!A!35]year]old!patient!recently!diagnosed!with!HIV!infection!
d)!!A!healthy!49]year]old!patient!
e)!!Previously!healthy!!55!year!old!who!has!been!coughing!for!2!weeks!
!
!
!
Explanation:!
The!Advisory!Committee!on!Immunization!Practices!(ACIP)!recommends!routine!pneumococcal!vaccination!for!
healthy!patients!starting!at!age!65!years.!Patients!over!2!years!of!age!with!various!chronic!diseases!and!patients!who!
are!immunocompromised!also!should!be!vaccinated!(choice!C).!Children!less!than!2!years!of!age!should!receive!the!7]
valent!conjugate!vaccine!as!a!part!of!their!routine!well!child!vaccinations!at!2,!4,!6,!and!12!months!of!age.!There!is!a!
lack!of!data!concerning!the!safety!of!the!vaccine!when!given!three!or!more!times.!
!
>A!1]year]old!patient!as!a!routine!immunization!(choice!A)!is!incorrect.!For!children!under!the!age!of!2,!the!!7]valent!
conjugate!vaccine!is!given!!as!a!part!of!their!routine!well!child!vaccinations!at!2,!4,!6,!and!12!months!of!age.!
>!An!18]month]old!patient!diagnosed!with!cystic!fibrosis!(choice!B)!is!incorrect.!A!child!with!cystic!fibrosis!should!be!
at!least!2!years!of!age!to!receive!the!pneumococcal!polyvalent!vaccine.!
>A!healthy!49]year]old!patient!(choice!D)!is!incorrect.!For!healthy!patients,!the!vaccination!is!not!recommended!until!
age!65!is!reached.!
>Previously!healthy!!55!year!old!who!has!been!coughing!for!2!weeks!(choice!E)!is!incorrect.!While!the!cause!of!the!
patient's!cough!needs!to!be!determined,!!the!vaccination!is!not!recommended!simply!based!on!these!symptoms.!
Vaccination!is!recommended!in!patients!with!chronic!diseases!such!as!COPD.!
!
!
116
!
Question!#249!
QID:!5451!
Subject:!PMCH!
!
Which!one!of!the!following!preventive!measures!is!recommended!for!nearly!all!international!travelers!to!developing!
countries?!
a)!!Gamma]Globulin!
b)!!Hepatitis!A!vaccine!
c)!!Hepatitis!B!vaccine!
d)!!Typhoid!vaccine!
e)!!Yellow!fever!vaccine!
!
!
!
Explanation:!
More!than!a!dozen!vaccines!are!available!for!diseases!with!a!high!prevalence!in!developing!countries.!The!primary!
care!physician!should!make!sure!that!international!travelers!are!up!to!date!on!routine!immunizations,!given!that!
vaccine]based!immunity!to!tetanus,!diphtheria,!polio,!and!measles!wanes!over!time,!and!that!these!diseases!are!
highly!prevalent!abroad.!While!location]specific!situations!may!require!particular!immunizations!such!as!typhoid,!
yellow!fever,!or!hepatitis!B!vaccine,!and/or!administration!of!]globulin,!hepatitis!A!vaccine!is!recommended!for!nearly!
all!international!travelers.!
!
!
Question!#250!
QID:!5458!
Subject:!PMCH!
!
A!45]year]old!male!asks!about!using!nicotine!replacement!therapy!(NRT)!to!help!him!quit!smoking.!You!tell!him!that!
recent!evidence!shows!that:!
a)!!NRT!usually!doubles!a!smoker’s!chance!of!quitting!
b)!!NRT!must!be!tapered!off!
c)!!NRT!should!be!used!for!at!least!6!months!to!be!effective!
d)!!Nicotine!patches!are!the!most!effective!form!of!NRT!
e)!!Using!combinations!of!NRT!reduces!the!likelihood!that!a!relapsed!smoker!will!quit!
!
!
!
Explanation:!
A!Cochrane!meta]analysis!of!nicotine!replacement!therapy!(NRT)!found!that!it!almost!doubles!a!smoker’s!chances!of!
quitting!(SOR!A).!There!was!no!benefit!to!tapering!NRT!as!compared!to!abrupt!discontinuation.!Treatment!for!8!weeks!
was!as!effective!as!a!longer!course.!No!one!type!of!NRT!is!significantly!more!effective,!but!combining!several!types!
may!aid!a!relapsed!smoker!in!his!or!her!next!quit!attempt.!
!
!
Question!#251!
QID:!5474!
Subject:!PMCH!
!
In!a!study!to!evaluate!a!test!as!a!screen!for!the!presence!of!a!disease,!235!of!the!250!people!with!the!disease!had!a!
positive!test!and!600!of!the!680!people!without!the!disease!had!a!negative!test.!Based!on!this!data,!the!specificity!of!
the!test!for!the!disease!is:!
a)!!235/250!=!94%!
117
b)!!15/250!=!6%!
c)!!600/680!=!88%!
d)!!80/680!=!12%!
e)!!15/80!=!19%!
!
!
!
Explanation:!
The!specificity!of!a!test!for!a!disease!is!the!proportion!or!percentage!of!those!without!the!disease!who!have!a!
negative!test.!In!this!case,!option!A!is!the!sensitivity,!i.e.,!the!proportion!of!those!with!the!disease!who!have!a!positive!
test.!Option!B!is!the!false]negative!rate!and!option!D!is!the!false]positive!rate.!Option!E!is!the!ratio!of!false]negative!
tests!to!false]positive!tests,!a!meaningless!ratio.!The!predictive!values!of!positive!and!negative!tests!are!extremely!
important!characteristics!of!a!screening!test.!Determination!of!these!values!requires!knowledge!of!the!prevalence!of!
the!disease!in!the!population!screened,!as!well!as!the!sensitivity,!specificity,!and!false]positive!and!false]negative!
rates.!Since!the!prevalence!of!most!diseases!is!low,!the!percentage!of!those!with!a!positive!test!(the!predictive!value!
of!a!positive!test)!is!relatively!low,!even!when!sensitivity!and!specificity!are!high.!When!prevalence!is!low,!however,!
the!predictive!value!of!a!negative!test!is!very!high!and!may!approach!100%.!
!
!
Question!#252!
QID:!5477!
Topic:!Aging!Changes!
Subject:!PMCH!
!
Many!of!the!changes!that!occur!as!part!of!aging!affect!pharmacokinetics.!Which!one!of!the!following!is!increased!in!
geriatric!patients?!
a)!!Drug!absorption!
b)!!Glomerular!filtration!rate!
c)!!Lean!body!mass!
d)!!Volume!of!distribution!of!water]soluble!compounds!such!as!digoxin!
e)!!Percentage!of!body!fat!
!
!
!
Explanation:!
The!physiologic!changes!that!accompany!aging!result!in!altered!pharmacokinetics.!Drug!distribution!is!one!important!
factor.!In!older!persons,!there!is!a!relative!increase!in!body!fat!and!a!relative!decrease!in!lean!body!mass,!which!
causes!increased!distribution!of!fat]soluble!drugs!such!as!diazepam.!This!also!increases!the!elimination!half]life!of!
such!medications.!The!volume!of!distribution!of!water]soluble!compounds!such!as!digoxin!is!decreased!in!older!
patients,!which!means!a!smaller!dose!is!required!to!reach!a!given!target!plasma!concentration.!There!is!a!predictable!
reduction!in!glomerular!filtration!rate!and!tubular!secretion!with!aging,!which!causes!decreased!clearance!of!
medications!in!the!geriatric!population.!The!absorption!of!drugs!changes!little!with!advancing!age.!All!of!these!
changes!are!important!factors!in!choosing!dosages!of!medications!in!the!elderly!population.!
!
!
Question!#253!
QID:!5510!
Subject:!PMCH!
!
Your!patient!is!moving!to!another!province!and!requests!transfer!of!his!medical!records.!Which!one!of!the!following!is!
true!regarding!this!patient’s!request?!
a)!!The!medical!record!should!be!released!only!with!written!permission!from!a!patient!or!legal!representative!
b)!!Although!it!is!kept!by!the!physician,!the!actual!medical!record!is!the!property!of!the!patient!
c)!!A!physician!may!withhold!medical!record!information!that!could!cause!undue!stress!to!a!patient!
d)!!In!spite!of!a!patient!request,!the!physician!may!withhold!information!from!a!third!party!
118
e)!!A!physician!has!the!right!to!withhold!the!medical!record!until!medical!bills!are!paid!in!full!
!
!
!
Explanation:!
Permission!for!the!release!of!patient!information!should!always!be!in!writing.!Although!the!actual!medical!record!is!
the!property!of!the!physician,!the!information!in!the!chart!is!the!property!of!the!patient.!Ethically!and!legally,!patients!
have!a!right!to!the!information!in!their!medical!records,!and!it!cannot!be!withheld!from!the!patient!or!a!third!party!(at!
the!request!of!the!patient),!even!if!medical!bills!are!unpaid!or!the!physician!is!concerned!about!the!patient.!
!
!
Question!#254!
QID:!5512!
Subject:!PMCH!
!
The!parents!of!three!children!ask!your!advice!about!the!need!for!fluoride!supplementation!in!order!to!prevent!tooth!
decay.!Which!one!of!the!following!is!true!regarding!current!guidelines!for!fluoride!supplementation?!
a)!!It!is!not!recommended!due!to!potential!fluoride!toxicity!
b)!!Dental!fluoride!varnish!is!too!toxic!for!routine!use!
c)!!Oral!fluoride!supplementation!is!recommended!if!the!primary!drinking!water!source!is!low!in!fluoride!
d)!!Fluoridated!toothpaste!provides!adequate!protection!if!used!as!soon!as!the!child!has!teeth!
e)!!The!need!for!fluoride!supplementation!is!determined!by!serum!fluoride!levels!
!
!
!
Explanation:!
The!current!recommendation!is!that!children!over!the!age!of!6!months!receive!oral!fluoride!supplementation!if!the!
primary!drinking!water!source!is!deficient!in!fluoride.!They!cite!“fair!evidence”!(B!recommendation)!that!such!
supplementation!reduces!the!incidence!of!dental!caries!and!conclude!that!the!overall!benefit!outweighs!the!potential!
harm!from!dental!fluorosis.!
!
Dental!fluorosis!is!chiefly!a!cosmetic!staining!of!the!teeth,!is!uncommon!with!currently!recommended!doses,!and!has!
no!other!functional!or!physiologic!consequences.!Fluoridated!toothpaste!can!cause!fluorosis!in!children!younger!than!
2!years!of!age,!and!is!therefore!not!recommended!in!this!age!group.!By!itself!it!does!not!reliably!prevent!tooth!decay.!
!
Fluoride!varnish,!applied!by!a!dental!or!medical!professional,!is!another!treatment!option!to!prevent!caries.!It!
provides!longer!lasting!protection!than!fluoride!rinses,!but!since!it!is!less!concentrated,!it!may!carry!a!lower!risk!of!
fluorosis!than!other!forms!of!supplementation.!
!
Oral!fluoride!supplementation!for!children!over!the!age!of!6!months!is!based!not!only!on!age!but!on!the!
concentration!of!fluoride!in!the!primary!source!of!drinking!water,!whether!it!be!tap!water!or!bottled!water.!Most!
water!supplies!in!Canada!are!adequately!fluoridated,!but!concentrations!vary.!Fluoride!concentrations!in!bottled!
water!vary!widely.!If!the!concentration!is!greater!than!0.6!ppm!no!supplementation!is!needed,!and!if!given,!may!
result!in!fluorosis.!Lower!concentrations!of!fluoride!may!indicate!the!need!for!partial!or!full]dose!supplementation.!
!
!
Question!#255!
QID:!5517!
Subject:!PMCH!
!
One!day!after!a!nurse!performs!CPR!on!an!emergency]department!patient,!she!learns!that!the!patient!had!
meningococcal!meningitis.!Which!one!of!the!following!is!the!most!appropriate!chemoprophylaxis!for!this!condition?!
a)!!Penicillin!G!benzathine!(Bicillin),!1.2!million!units!intramuscularly!
b)!!Rifampin!(Rifadin),!600!mg!every!12!hours!for!2!days!
119
c)!!Oral!prednisone,!40!mg!daily!for!5!days!
d)!!Quadrivalent!meningococcal!vaccine!
e)!!No!prophylaxis!
!
!
!
Explanation:!
Health]care!workers!exposed!to!a!patient!with!meningococcal!meningitis!are!at!increased!risk!of!developing!systemic!
disease!and!should!receive!chemoprophylaxis,!especially!if!the!contact!is!intimate.!Secondary!cases!usually!occur!
within!4!days!of!the!initial!case.!Therefore,!prophylactic!treatment!should!begin!as!soon!as!possible.!Rifampin!has!
been!shown!to!be!90%!effective!in!eliminating!meningococcus!from!the!nasopharynx.!Other!appropriate!
chemoprophylactic!agents!include!minocycline!and!ciprofloxacin.!
!
Even!high!doses!of!penicillin!may!not!eradicate!nasopharyngeal!meningococci.!Prednisone!has!no!place!in!
chemoprophylaxis.!Meningococcal!vaccine!appears!to!have!clinical!efficacy,!but!it!usually!takes!more!than!5!days!to!
become!effective.!
!
!
!
Question!#256!
QID:!5519!
Topic:!Abuse!
Subject:!PMCH!
!
Which!one!of!the!following!variables!is!the!most!important!risk!factor!for!being!a!victim!of!domestic!abuse?!
a)!!Educational!background!
b)!!Psychological!problems!
c)!!Race!
d)!!Gender!
e)!!Socioeconomic!status!
!
!
!
Explanation:!
Domestic!violence!can!affect!children,!intimate!partners,!and!older!adults.!It!is!a!serious!medical!problem!that!should!
be!considered!in!the!care!of!patients!and!families.!There!is!great!variation!in!the!profiles!of!patients!affected!by!
domestic!violence.!Neither!demographic!factors!nor!psychological!problems!have!been!found!to!be!consistent!
predictors!of!victimization!or!violence.!Domestic!violence!cuts!across!all!racial,!socioeconomic,!religious,!and!ethnic!
lines.!The!only!consistent!risk!factor!for!being!a!victim!of!domestic!violence!is!female!gender.!
!
!
Question!#257!
QID:!5541!
Topic:!Test!Sensitivity!
Subject:!PMCH!
!
Which!one!of!the!following!best!defines!the!sensitivity!of!a!diagnostic!test!for!a!particular!disease?!
a)!!The!test’s!accuracy!in!correctly!identifying!patients!without!the!disease!
b)!!The!test’s!accuracy!in!correctly!identifying!patients!with!the!disease!
c)!!The!difference!between!the!false]positive!and!false]negative!rates!
d)!!A!value!calculated!from!the!test’s!specificity!
!
!
!
Explanation:!
120
Sensitivity!is!the!ability!of!a!test!to!identify!patients!who!actually!have!the!disease,!or!the!true]positive!rate.!
Independent!of!the!sensitivity!is!the!test’s!specificity,!which!is!the!ability!to!correctly!identify!patients!who!do!not!
have!the!disease,!or!the!true]negative!rate.!The!greater!the!test’s!specificity,!the!lower!the!false]positive!rate;!the!
greater!the!test’s!sensitivity,!the!lower!the!false]negative!rate.!
!
!
Question!#258!
QID:!5544!
Topic:!Right!To!Refuse!Treatment!
Subject:!PMCH!
!
A!7]year]old!male!is!hospitalized!after!sustaining!abdominal!trauma!in!an!accident.!The!child!is!conscious.!His!pulse!
rate!is!150!beats/min,!his!systolic!blood!pressure!is!palpated!at!60!mm!Hg,!and!his!respiratory!rate!is!40/min.!His!
hemoglobin!level!is!4.0!g/dL!because!of!trauma]related!blood!loss.!His!clinical!condition!is!deteriorating!despite!an!
infusion!of!intravenous!volume!expanders,!but!the!parents!are!Jehovah’s!Witnesses!and!refuse!to!consent!to!a!blood!
transfusion!because!of!their!religious!convictions.!Your!prognosis!is!that!without!a!blood!transfusion!the!patient!will!
die.!According!to!medical]legal!precedent,!which!one!of!the!following!is!correct?!
a)!!The!patient!should!receive!the!transfusion!regardless!of!the!parents’!wishes!
b)!!The!patient!can!be!transfused!regardless!of!the!parents’!wishes!once!he!becomes!asystolic!
c)!!The!parents!may!refuse!the!transfusion!if!they!are!in!agreement!
d)!!The!parents!may!refuse!the!transfusion!if!the!patient!identifies!himself!as!a!Jehovah’s!Witness!
e)!!The!parents!may!refuse!the!transfusion!if!there!is!a!legally!executed!advance!directive!
!
!
!
Explanation:!
The!refusal!to!accept!any!medical!intervention,!including!life]saving!blood!transfusions,!has!been!well!established!for!
adults!who!have!the!ability!to!definitively!communicate!their!wishes.!Also,!parents!have!the!power!to!give!or!
withhold!consent!to!medical!treatment!on!behalf!of!their!children.!However,!Western!courts!have!deemed!that!
parents!cannot!refuse!emergency,!life]saving!treatment!to!children!based!on!these!principles:!(1)!the!child’s!interests!
outweigh!parental!rights!to!refuse!medical!treatment;!(2)!parental!rights!do!not!give!parents!life!and!death!authority!
over!their!children;!and!(3)!parents!do!not!have!an!absolute!right!to!refuse!medical!treatment!for!their!children,!if!
that!refusal!is!regarded!as!unreasonable.!
!
!
Question!#259!
QID:!5549!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!the!use!of!opiates!in!terminally!ill!patients?!
a)!!They!are!frequently!addictive!
b)!!They!are!indicated!for!relieving!dyspnea!
c)!!A!medication!“contract”!is!required!by!law!
d)!!Respiratory!depression!is!the!first!sign!of!excessive!dosage!
e)!!Gastrointestinal!hypermotility!is!a!common!side!effect!
!
!
!
Explanation:!
In!terminally!ill!patients,!the!most!common!physical!symptoms!are!pain,!fatigue,!and!dyspnea.!Opiates!are!useful!for!
controlling!pain!and!relieving!dyspnea!as!well.!Even!small!doses!of!a!weaker!opiate!can!reduce!the!sensation!of!
shortness!of!breath!in!cancer!patients!and!in!those!with!heart!failure!or!chronic!obstructive!lung!disease.!
!
Addiction!is!rare!in!terminally!ill!patients!who!are!being!treated!with!opiates!for!pain!and/or!dyspnea.!A!medication!
contract!between!physician!and!patient!is!not!required!by!law!and!generally!is!not!necessary!in!this!situation,!unless!
121
diversion!of!the!medication!from!the!patient!by!the!caregivers!is!suspected.!Constipation!due!to!decreased!
gastrointestinal!motility!is!a!very!common,!if!not!universal,!side!effect.!Respiratory!depression!is!a!late,!not!early,!sign!
of!excessive!opiate!dosage.!Another!sign!of!opiate!excess,!pinpoint!pupils,!occurs!before!respiratory!depression!and!is!
therefore!a!useful!parameter!for!monitoring!these!patients.!
!
!
!
Question!#260!
QID:!5550!
Subject:!PMCH!
!
A!67]year]old!male!who!recently!had!a!screening!colonoscopy!presents!for!follow]up.!During!the!procedure,!a!mass!
was!discovered!in!the!sigmoid!colon!and!a!biopsy!revealed!a!poorly!differentiated!adenocarcinoma.!When!you!tell!the!
patient!you!have!the!test!results!and!can!provide!information!about!the!prognosis,!he!says,!“To!be!honest,!I!can!tell!
that!the!news!is!not!good,!and!I!would!rather!not!talk!about!it!right!now.”!Which!one!of!the!following!would!be!the!
most!appropriate!next!step?!
a)!!Relay!the!prognosis,!but!focus!as!much!as!possible!on!any!positives!
b)!!Discuss!the!prognosis!with!the!patient’s!wife,!who!is!in!the!waiting!room!
c)!!Ask!the!patient!if!he!would!like!to!talk!again!at!another!time!
d)!!Refer!the!patient!to!a!support!group!
!
!
!
Explanation:!
When!giving!bad!news!to!a!patient,!it!is!important!to!assess!how!much!information!the!patient!wants!to!know!and!
tailor!the!discussion!accordingly!(SOR!C).!If!the!patient!states!that!he!does!not!want!to!know!about!the!prognosis,!the!
most!appropriate!response!is!to!ask!if!he!would!like!to!talk!again!at!another!time.!The!physician!may!be!regarded!as!
rude,!cruel,!or!uncaring!if!he!persists!in!providing!information!that!the!patient!is!not!ready!to!hear.!In!addition,!the!
patient!is!more!at!risk!for!feelings!of!hopelessness,!depression,!or!anxiety!if!he!is!not!psychologically!ready!to!hear!a!
bad!prognosis.!Once!the!patient!verbalizes!a!readiness!to!discuss!the!prognosis,!specific!information!can!be!provided,!
focusing!on!both!the!positive!and!negative!aspects!of!the!situation.!
!
It!is!not!appropriate!to!discuss!the!case!with!the!patient’s!wife,!unless!he!specifically!requests!she!be!a!proxy!to!
receive!the!information.!Referrals!to!either!a!support!group!or!an!oncologist!should!be!deferred!until!the!information!
has!been!discussed!with!the!patient.!
!
!
!
Question!#261!
QID:!5568!
Subject:!PMCH!
!
According!to!recent!guidelines,!which!one!of!the!following!patients!should!be!screened!for!an!abdominal!aortic!
aneurysm?!
a)!!A!52]year]old!male!with!type!2!diabetes!mellitus!
b)!!An!asymptomatic!67]year]old!male!smoker!with!no!chronic!illness!
c)!!A!61]year]old!female!with!a!history!of!coronary!artery!disease!
d)!!A!76]year]old!male!with!a!history!of!chronic!renal!failure!
e)!!A!76]year]old!female!with!a!history!of!chronic!renal!failure!
!
!
!
Explanation:!
The!current!guidelines!(The!Preventive!Care!Checklist!Form!update!by!Duerksen!et!al!in!the!January!2012!issue;!AAA!
122
screening!has!been!supported!by!the!US!Preventive!Services!Task!Force,!the!Canadian!Society!for!Vascular!Surgery,!
and!the!Ontario!Health!Technology!Advisory!Committee)!for!abdominal!aortic!aneurysm!(AAA)!recommend!one]time!
screening!with!ultrasonography!for!AAA!in!men!65]75!years!of!age!who!have!ever!smoked.!
!
>!Individualized!investigation!of!women!>65!years!old!with!multiple!risk!factors!for!AAA!(smoking!history,!
cerebrovascular!disease,!family!history!of!AAA)!may!be!beneficial.!
>!Screening!men!or!women!<65!years!old!is!not!likely!to!be!beneficial.!
>!Screening!provides!borderline!to!no!benefit!for!men!75!to!80!years!old.!
!
!
!
Question!#262!
QID:!5584!
Topic:!CPT!Codes!
Subject:!PMCH!
!
The!Current!Procedural!Terminology!(CPT)!code!to!document!a!patient!encounter!can!be!determined!by!the!amount!
of!face]to]face!time!spent!with!the!patient!when:!
a)!!The!office!visit!exceeds!1!hour!
b)!!Counseling!or!coordinating!care!accounts!for!more!than!50%!of!the!face]to]face!time!spent!with!the!patient!
c)!!The!intensity!of!the!visit!supports!a!higher!code!than!is!supported!by!the!level!of!history,!examination,!and!medical!
decision!making!
d)!!A!comprehensive!history!and!examination!or!complex!medical!decision!making!is!conducted!
e)!!Considerable!time!is!spent!outside!the!office!visit!coordinating!prior!authorizations!or!referrals!on!behalf!of!the!
patient!
!
!
!
Explanation:!
The!times!published!for!Current!Procedural!Terminology!codes!are!typical!for!each!level!of!office!visit,!but!there!is!no!
requirement!associated!with!them!unless!counseling!or!coordination!of!care!accounts!for!more!than!50%!of!the!face]
to]face!time!of!the!encounter.!In!such!cases!physicians!are!able!to!code!on!the!basis!of!time.!
!
!
Question!#263!
QID:!5588!
Topic:!Cause!of!Death!
Subject:!PMCH!
!
The!risk!of!heat!wave]related!death!to!elderly!patients!is!highest!in!those!who:!
a)!!take!extra!showers!or!baths!
b)!!have!diabetes!and!are!insulin]dependent!
c)!!lack!of!use!of!fans!
d)!!are!5]65!years!old!
e)!!are!living!alone!
!
!
!
Explanation:!
All!persons!are!at!risk!for!hyperthermia!when!exposed!to!a!sustained!period!of!excessive!heat;!however,!factors!that!
increase!the!risk!for!hyperthermia!and!heat]related!death!include!age!(e.g.,!the!elderly),!chronic!health!conditions!
(e.g.,!cardiovascular!disease!or!respiratory!diseases),!mental!illness!(e.g.,!schizophrenia),!social!circumstances!(e.g.,!
living!alone),!and!other!conditions!that!might!interfere!with!the!ability!to!care!for!oneself.!
Other!risk!factors!are!alcohol!consumption,!which!may!cause!dehydration,!previous!heatstroke,!physical!exertion!in!
exceptionally!hot!environments,!the!use!of!medications!that!interfere!with!the!body's!heat!regulatory!system,!such!as!
neuroleptics!(e.g.,!antipsychotics!and!major!tranquilizers),!and!medications!with!anticholinergic!effects!(e.g.,!tricyclic!
123
antidepressants,!antihistamines,!some!antiparkinsonian!agents,!and!some!over]the]counter!sleep!medication).!
Persons!working!in!hot!indoor!or!outdoor!environments!should!take!10]14!days!to!acclimate!to!high!temperatures.!
Although!adequate!salt!intake!is!important,!salt!tablets!are!not!recommended!and!can!be!hazardous!to!some!persons.!
Although!the!use!of!fans!may!increase!comfort!at!temperatures!<90!F!(<32.2!C),!fans!are!not!protective!against!
heatstroke!when!temperatures!reach!>!90!F!(>!32.2!C)!and!humidity!exceeds!35%.!
Measures!for!preventing!heat]related!illness!and!death!during!a!heat!wave!include!spending!time!in!air!conditioned!
environments,!increasing!nonalcoholic!fluid!intake,!exercising!only!during!cooler!parts!of!the!day,!and!taking!cool!
baths.!Elderly!persons!should!be!encouraged!to!take!advantage!of!air!conditioned!environments!(e.g.,!shopping!malls,!
senior!centers,!and!public!libraries),!even!for!part!of!the!day.!Public!health!information!about!exceptionally!high!
temperatures!should!be!directed!toward!persons!aged!>!65!years!and!<!5!years.!
!
!
Question!#264!
QID:!5602!
Topic:!Contraceptive!Use!
Subject:!PMCH!
!
The!Canadian!OBGYN!and!Pediatrics!guidelines!support!the!advance!provision!of!drugs!and!instructions!for!
emergency!contraception!to!sexually!active!women,!so!that!they!have!ready!access!to!them!if!they!are!needed.!The!
evidence!shows!that!advance!provision!of!emergency!contraception:!
a)!!Decreases!pregnancy!rates!on!a!population!level!
b)!!Decreases!the!time!from!unprotected!sex!to!use!of!emergency!contraception!
c)!!Decreases!contraception!use!by!the!patient!prior!to!sexual!activity!
d)!!Increases!rates!of!sexually!transmitted!infection!
e)!!Increases!rates!of!unprotected!intercourse!
!
!
!
Explanation:!
A!Cochrane!review!including!randomized,!controlled!trials!(RCTs)!compared!standard!access!to!emergency!
contraception!(EC)!with!advance!provision.!The!review!found!eight!trials,!five!of!which!were!conducted.!Two!of!the!
RCTs!were!sufficiently!powered!to!show!a!difference!in!pregnancy!rates.!No!study!showed!that!giving!advance!EC!
reduced!pregnancy!rates!on!a!population!level.!However,!women!who!were!provided!with!advance!EC!took!the!pills!
an!average!of!approximately!15!hours!sooner!than!women!without!advance!access.!
!
Five!studies!that!reported!on!contraception!use!did!not!show!a!difference!in!type!or!frequency!of!regular!
contraception!use!among!women!who!were!provided!advance!EC.!Women!randomized!to!the!advance!EC!groups!
were!2.5!times!more!likely!to!use!EC!once,!and!4!times!more!likely!to!use!it!2!or!more!times,!compared!to!those!
without!advance!access.!
!
Three!studies!reported!rates!of!sexually!transmitted!infection!and!none!found!differences!between!the!advance!and!
standard!access!EC!groups.!Six!studies!reported!rates!of!unprotected!sexual!intercourse!and!found!no!difference.!
!
The!Cochrane!review!concludes!that!advance!access!to!EC!appears!to!be!safe,!but!does!not!reduce!pregnancy!on!a!
population!level.!However,!advance!provision!might!be!beneficial!because!it!increases!the!speed!and!frequency!of!EC!
use.!
!
!
!
Question!#265!
QID:!5604!
Subject:!PMCH!
!
The!intranasal!live,!attenuated!influenza!vaccine!would!be!appropriate!for!which!one!of!the!following?!
a)!!A!3]year]old!female!who!is!otherwise!healthy!
b)!!A!6]year]old!male!who!has!a!history!of!severe!persistent!asthma!
124
c)!!A!21]year]old!female!who!has!a!history!of!Guillain]Barré!syndrome!
d)!!A!24]year]old!female!who!is!24!weeks!pregnant!
e)!!A!55]year]old!healthy!male!who!requests!influenza!vaccine!
!
!
!
Explanation:!
The!live,!attenuated!influenza!vaccine!(LAIV)!is!an!option!for!vaccinating!healthy,!nonpregnant!individuals!age!2]49!
years.!The!vaccine!is!administered!intranasally.!It!is!not!indicated!in!patients!with!underlying!medical!conditions,!such!
as!chronic!pulmonary!or!cardiovascular!disease,!children!<!5!years!old!with!a!history!of!recurrent!wheezing,!or!in!
patients!with!a!history!of!Guillain]Barré!syndrome,!pregnant!patients,!or!children!and!adolescents!who!receive!long]
term!aspirin!or!salicylate!therapy.!Patients!with!a!history!of!hypersensitivity!to!eggs!also!should!not!receive!this!
vaccine.!
!
!
Question!#266!
QID:!5606!
Topic:!Meta]analyses!
Subject:!PMCH!
!
Information!derived!from!which!one!of!the!following!provides!the!best!evidence!when!selecting!a!specific!treatment!
plan!for!a!patient?!
a)!!Meta]analysis!
b)!!Prospective!cohort!studies!
c)!!Expert!opinion!
d)!!Case!control!studies!
e)!!!Non]randomized!intervention!studies!
!
!
!
Explanation:!
In!general,!the!strongest!evidence!for!treatment,!screening,!or!prevention!strategies!is!found!in!systematic!reviews,!
meta]analyses,!randomized!controlled!trials!(RCTs)!with!consistent!findings,!or!a!single!high]quality!RCT.!Second]tier!
levels!of!evidence!would!be!poorer!quality!RCTs!with!inconsistent!findings,!cohort!studies,!or!case]control!studies.!
The!lowest!quality!of!evidence!would!come!from!such!sources!as!expert!opinion,!consensus!guidelines,!or!usual!
practice!recommendations.!
!
→!Prospective!cohort!study!(choice!A)!follows!over!time!a!group!of!similar!individuals!(cohorts)!who!differ!with!
respect!to!certain!factors!under!study,!to!determine!how!these!factors!affect!rates!of!a!certain!outcome.!In!disease!
prevention!and!treatment,!meta]analysis,!systematic!reviews,!and!randomized!controlled!trials!!have!!much!stronger!
level!of!evidence.!
→!Expert!opinion!(choice!B)!doesn't!have!as!strong!evidence!as!meta]analysis!and!systematic!reviews!
→!Case!control!studies!(choice!C)!similary!to!cohort!study!is!considered!as!a!second]tier!level!of!evidence!
→!Non]randomized!intervention!studies!(choice!E)!are!not!as!reliable!as!randomized!controlled!trials,!and!therefore!
have!a!level!of!evidence!inferior!to!randomized!controlled!studies,!meta]analysis,!and!systematic!reviews.!
!
!
Question!#267!
QID:!5611!
Subject:!PMCH!
!
A!67]year]old!male!sees!you!for!knee!pain!from!osteoarthritis.!It!has!not!responded!to!his!usual!treatment,!and!you!
treat!him!with!an!intra]articular!corticosteroid!injection.!It!is!mid]November,!and!he!tells!you!that!he!has!not!received!
the!influenza!vaccine!this!year.!He!has!also!never!received!pneumococcal!vaccine.!He!has!a!history!of!allergic!rhinitis,!
treated!with!intranasal!corticosteroids.!Which!one!of!the!following!is!true!regarding!pneumococcal!vaccine!and!
125
injected!influenza!vaccine!for!this!patient?!
a)!!The!immunizations!should!be!administered!at!least!4!weeks!apart!
b)!!Administration!of!both!immunizations!should!be!delayed!4!weeks!because!of!immunosuppression!
c)!!Administration!of!injected!influenza!vaccine!should!be!delayed!for!4!weeks!because!it!is!a!live!attenuated!vaccine!
d)!!Administration!of!pneumococcal!vaccine!should!be!delayed!for!4!weeks!because!it!is!contraindicated!with!
simultaneous!intra]articular!corticosteroids!
e)!!It!is!acceptable!to!administer!both!immunizations!at!this!visit!
!
!
!
Explanation:!
Low]dose!topical,!oral,!nasal,!and!intra]articular!corticosteroids!are!not!immunosuppressive!and!do!not!
contraindicate!administration!of!any!vaccine.!Injected!influenza!vaccine!and!pneumococcal!vaccine!can!be!given!
together.!Neither!is!a!live!vaccine.!
!
!
Question!#268!
QID:!5631!
Subject:!PMCH!
!
A!53]year]old!male!presents!for!follow]up!after!a!routine!screening!colonoscopy.!He!is!healthy!and!takes!no!
medications,!but!his!family!history!is!positive!for!colon!cancer.!During!a!thorough,!relatively!easy!colonoscopy,!two!
adenomatous!polyps!measuring!0.7!mm!were!removed.!His!next!surveillance!colonoscopy!should!be!in:!
a)!!1!year!
b)!!3!years!
c)!!5!years!
d)!!7!years!
e)!!10!years!
!
!
!
Explanation:!
Canadian!Association!of!Gastroenterology!and!the!Canadian!Digestive!Health!Foundation:!Guidelines!on!colon!cancer!
screening!
!
Approach!to!higher!risk!screening.!AAPC!Attenuated!adenomatous!polyposis;!FAP!Familial!adenomatous!polyposis;!
First]degree!relative!Parents,!siblings,!children;!HNPCC!Hereditary!nonpolyposis!colorectal!cancer;!Second]degree!
Grandparent,!aunt!or!uncle;!Third]degree!Great!grandparent!or!cousin!
!
!
!
Question!#269!
QID:!5634!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!the!schedule!for!administering!rotavirus!vaccine?!
a)!!The!first!dose!should!be!given!prior!to!12!weeks!of!age!
b)!!The!vaccine!should!be!given!at!2!months,!6!months,!and!12!months!of!age!
c)!!A!catch]up!vaccination!can!be!administered!up!to!3!years!of!age!
d)!!The!minimum!time!between!doses!is!2!weeks!
!
!
!
126
Explanation:!
The!rotavirus!vaccine!is!an!oral!vaccine!recommended!for!infants!in!a!3]dose!schedule!at!ages!2,!4,!and!6!months!(OR!
in!2!doses!at!2!and!4!months!of!age).!The!first!dose!should!be!given!between!6!and!12!weeks!of!age,!with!additional!
doses!given!at!4]!to!10]week!intervals.!The!vaccine!cannot!be!initiated!after!12!weeks!of!age!and!should!not!be!
administered!after!32!weeks!of!age.!
!
The!first!rotavirus!vaccine!was!taken!off!the!market!in!1999!after!an!increased!risk!of!intussusception!was!noted!in!
infants!when!the!first!dose!of!the!vaccine!was!given!after!12!weeks!of!age.!Because!of!this,!the!two!vaccines!licensed!
in!2006!carry!the!recommendation!that!the!vaccine!not!be!initiated!in!infants!over!12!weeks!of!age.!There!is!no!data!
regarding!safety!and!efficacy!after!this!age.!
!
!
!
Question!#270!
QID:!5636!
Subject:!PMCH!
!
Of!the!following,!which!one!causes!the!most!deaths!in!Canada?!
a)!!Colorectal!cancer!
b)!!Breast!cancer!
c)!!Prostate!cancer!
d)!!Lung!cancer!
!
!
!
Explanation:!
Lung!cancer!is!the!leading!cause!of!cancer]related!deaths!in!Canada.!Lung!cancer!causes!more!deaths!than!colorectal,!
breast,!and!prostate!cancers!combined.!
!
!
Question!#271!
QID:!5639!
Subject:!PMCH!
!
Which!one!of!the!following!community!health!programs!best!fits!the!definition!of!secondary!prevention?!
!
a)!!A!smoking!education!program!at!a!local!middle!school!
b)!!A!blood!pressure!screening!in!people!older!than!age!50!at!a!local!church!
c)!!A!condom!distribution!program!
d)!!Cardiac!or!stroke!rehabilitation!program!
e)!!Chronic!pain!management!program!
!
!
!
Explanation:!
Prevention!traditionally!has!been!divided!into!three!categories:!primary,!secondary,!and!tertiary.!
Primary!prevention!targets!individuals!who!may!be!at!risk!to!develop!a!medical!condition!and!intervenes!to!prevent!
the!onset!of!that!condition!(e.g.,!childhood!vaccination!programs,!water!fluoridation,!antismoking!programs,!and!
education!about!safe!sex).!(choice!A!and!choice!C)!
Secondary!prevention!happens!after!an!illness!or!serious!risk!factors!have!already!been!diagnosed.!The!goal!is!to!halt!
or!slow!the!progress!of!disease!(if!possible)!in!its!earliest!stages;!in!the!case!of!injury,!goals!include!limiting!long]term!
disability!and!preventing!re]injury.!(e.g.,!routine!Papanicolaou!smears,!and!screening!for!hypertension,!diabetes,!or!
hyperlipidemia).!(choice!B)!
Tertiary!prevention!focuses!on!helping!people!manage!complicated,!long]term!health!problems!such!as!diabetes,!
127
heart!disease,!cancer!and!chronic!musculoskeletal!pain.!The!goals!include!preventing!further!physical!deterioration!
and!maximizing!quality!of!life!(e.g.,!cardiac!or!stroke!rehabilitation!programs,!chronic!pain!management!programs,!
patient!support!groups).!(choice!D!and!choice!E)!
!
!
Question!#272!
QID:!5652!
Topic:!End]of]life!Care!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!about!end]of]life!care?!
a)!!Physicians!underestimate!life!expectancies!
b)!!Most!physicians!are!comfortable!with!their!level!of!education!in!palliative!care!and!pain!control!
c)!!Most!patients!who!qualify!for!hospice!care!receive!services!early!in!the!course!of!their!illness!
d)!!Most!terminal!patients!want!their!lives!prolonged!as!much!as!possible!
e)!!Most!terminal!patients!express!a!desire!for!a!sense!of!control!
!
!
!
Explanation:!
End]of]life!issues!are!a!challenge!to!primary!care!physicians!because!of!concerns!about!a!lack!of!education!in!pain!
control!and!palliative!care.!Trying!to!determine!the!prognosis!of!patients!is!difficult,!and!even!with!established!
criteria,!the!estimated!prognosis!is!right!only!50%!of!the!time.!There!is!a!tendency!for!most!physicians!to!
overestimate!life!expectancy!in!a!terminal!patient.!
!
Most!patients!who!are!appropriate!candidates!for!hospice!care!do!not!receive!referrals!until!late!in!their!illness,!if!at!
all.!Patients!at!the!end!of!life!have!five!main!areas!of!concern:!control!of!pain!and!other!symptoms;!avoiding!a!
prolongation!of!the!dying!process;!having!a!sense!of!control;!relieving!burdens!on!family!and!loved!ones;!and!
strengthening!relationships!with!family!and!friends.!
!
!
!
Question!#273!
QID:!5832!
Topic:!Disease!Distribution!
Subject:!PMCH!
!
The!constant!presence!of!a!disease!or!infectious!agent!in!a!given!area!or!population!is!termed:!
a)!!Pandemic!
b)!!Outbreak!
c)!!Endemic!
d)!!Epidemic!
e)!!Virulence!
!
!
!
Explanation:!
Infectious!disease!statistical!terminology:!
!
Pandemic:!Epidemic!or!outbreak!across!a!wide!area,!crossing!international!borders!and!affecting!a!large!number!of!
people!
Outbreak:!Occurrence!of!new!cases!in!excess!of!baseline!disease!frequency!in!a!population!in!a!given!period!of!time.!
Endemic:!The!constant!presence!of!a!disease!or!infectious!agent!in!a!given!area!or!population.!
Epidemic:!is!synonymous!with!outbreak!(excessive!rate!of!disease!compared!to!baseline)!
Virulence:!the!degree!of!pathogenicity!of!an!infectious!agent,!indicated!by!case]fatality!rates!and/or!the!ability!of!the!
agent!to!invade!and!damage!tissues!of!the!host!
128
Pathogenicity:!the!property!of!an!infectious!agent!that!determines!the!extent!to!which!overt!disease!is!produced!in!an!
infected!population,!or!the!power!of!an!organism!to!produce!disease.!
Attack!rate:!the!cumulative!incidence!of!infection!within!a!given!population!in!a!specified!time!during!an!epidemic.!
!
PEARL:!An!infectious!disease!is!endemic!if!it!is!constantly!present!in!a!given!area!or!population.!
!
!
Question!#274!
QID:!5833!
Topic:!Economic!Burden!of!Illness!
Subject:!PMCH!
!
The!economic!cost!and!burden!of!disease!in!Canada!can!be!predominantly!attributed!to:!
a)!!Acute!disease!
b)!!Chronic!disease!
c)!!Re]emerging!infectious!disease!
d)!!Medical!error!
e)!!Low!physician!to!patient!ratios!
!
!
!
Explanation:!
Chronic!disease!burden!
!
One!hundred!years!ago,!the!major!causes!of!death!were!due!to!infectious!etiologies!such!as!tuberculosis,!dysentery,!
and!diphtheria.!Through!public!health!efforts!such!as!education,!prevention!and!vaccination!programs!the!incidence!
of!these!diseases!began!to!fall.!This,!along!with!social!reforms!and!the!advent!of!new!technologies!has!led!to!an!
increase!in!life!expectancy!(LE).!In!1900,!a!person!had!a!LE!at!birth!of!less!than!50!years;!the!LE!of!a!person!at!birth!in!
2011!is!80.7!years.!However,!during!the!last!hundred!years,!the!incidence!and!prevalence!rates!of!chronic!disease!
have!also!risen!dramatically.!
!
Chronic!illness!including:!cardiovascular!diseases,!cancers,!pulmonary!diseases,!endocrine!disorders,!musculoskeletal!
disorders,!diseases!of!the!nervous!system!and!sense!organs,!and!mental!illness!cause!tremendous!human!suffering!
and!cost!billions!of!dollars!to!the!Canadian!government.!
!
Combining!direct!medical!costs!($38.9!billion)!and!indirect!productivity!losses!($54.4!billion),!the!total!economic!
burden!of!the!aforementioned!chronic!illness!categories!comes!to!more!than!$93!billion!a!year.!This!amounts!to!more!
than!half!of!the!total!economic!cost!of!illness!in!Canada,!or!9%!of!the!country’s!total!gross!domestic!product.!(Based!
on!statistical!calculations!of!data!available!in!2002).!
!
PEARL:!The!burden!of!disease!in!Canada!has!shifted!from!acute/infectious!disease!to!chronic!disease.!
!
!
Question!#275!
QID:!5834!
Subject:!PMCH!
!
Screening!for!breast!cancer!in!high!risk!patients!is!considered:!
a)!!Passive!prevention!
b)!!Primary!prevention!
c)!!Secondary!prevention!
d)!!Tertiary!prevention!
e)!!Active!prevention!
!
!
129
!
Explanation:!
Disease!prevention!strategies!
!
With!respect!to!healthcare,!disease!prevention!strategies!can!be!broken!down!into!3!categories:!
1.!!!!!!Primary!prevention,!option!(b),!is!a!strategy!put!in!place!before!disease!occurs!(e.g.!immunization,!smoking!
cessation!programs).!
!
2.!!!!!!Secondary!prevention,!option!(c),!involves!establishing!screening!methods!to!detect!disease!at!(hopefully)!an!
early!stage!(e.g.!mammograms,!pap!smears).!
!
3.!!!!!!Tertiary!prevention!(d)!is!treating!an!existing!disease!to!prevent!or!retard!further!complications!from!arising!(e.g.!
prescribing!ACE!inhibitors!for!hypertension).!
!
Option!(a),!passive!prevention!strategies!are!measures!put!in!place!that!protect!a!person!without!their!active!efforts,!
e.g.!having!airbags!standard!in!cars.!Whereas,!active!prevention!(e)!are!measures!the!individual!must!do!on!their!own!
accord!such!as!wearing!a!seat!belt.!
!
PEARL:!!Screening!is!a!secondary!prevention!measure.!
!
!
Question!#276!
QID:!5835!
Topic:!Public!Policy!
Subject:!PMCH!
!
An!example!of!a!fiscal!policy!would!be:!
a)!!Creating!an!anti]smoking!bylaw!
b)!!Ensuring!adequate!income!of!citizenry!
c)!!Providing!affordable!housing!to!citizenry!
d)!!Mandating!the!use!of!bicycle!helmets!
e)!!Placing!high!tax!rates!on!cigarettes!
!
!
!
Explanation:!
Public!Policy!
!
Public!policy!can!be!broken!down!into!3!main!categories:!Fiscal,!Legislative!and!Social!policy.!Fiscal!policy!(example!e)!
can!be!adopted!to!impose!additional!costs!for!undertaking!unhealthy!behaviors!in!hopes!of!creating!an!economic!
deterrent.!Options!(a)!&!(d)!are!examples!of!Legislative!policies,!in!which,!legal!deterrents!are!put!in!place!to!reduce!
certain!risky!behaviors.!Options!(b)!&!(c)!are!examples!of!Social!policies!in!which!a!system!is!put!in!place!to!create!an!
environment!of!reasonable!and!equitable!opportunity!in!hopes!of!supporting!individuals!across!all!socioeconomic!
statuses.!
!
PEARL:!!Fiscal!policy!imposes!an!additional!cost!burden!to!unhealthy!behaviors.!
!
!
Question!#277!
QID:!5836!
Subject:!PMCH!
!
Local!sanitation,!monitoring!of!reportable!diseases,!water!and!food!safety!enforcement!all!fall!under!the!jurisdiction!
of!the:!
a)!!Public!health!unit!
b)!!Municipal!government!
130
c)!!Provincial!government!
d)!!Federal!government!
e)!!World!Health!Organization!
!
!
!
Explanation:!
Environmental!Health!Jurisdiction!
!
a)!!!!!!Public!health!unit:!is!responsible!for!local!sanitation,!monitoring!of!reportable!diseases,!water!and!food!safety!
enforcement,!and!local!environmental!risk!assessment.!
!
b)!!!!!!Municipal!government!administers!garbage!disposal!and!recycling!
!
c)!!!!!!Provincial!government!is!responsible!for!maintaining!water!and!air!quality!standards,!regulating!industrial!
emissions!and!toxic!waste!disposal.!
!
d)!!!!!!Federal!government!designates!and!regulates!toxic!substances,!regulates!food!products!and!sets!policies!for!
pollutants!able!to!cross!provincial!boundaries.!
!
e)!!!!!!World!Health!Organization:!is!the!directing!and!coordinating!authority!for!health!within!the!United!Nations!
system.!It!is!responsible!for!providing!leadership!on!global!health!matters,!shaping!the!health!research!agenda,!
setting!norms!and!standards,!articulating!evidence]based!policy!options,!providing!technical!support!to!countries!and!
monitoring!and!assessing!health!trends.!
!
PEARL:!Public!health!units!are!responsible!for!local!sanitation,!monitoring!reportable!diseases,!assessing!
environmental!risks!and!enforcing!water!&!food!safety.!
!
!
Question!#278!
QID:!6014!
Subject:!PMCH!
!
According!to!current!guidelines,!which!one!of!the!following!is!true!regarding!prostate!cancer!screening?!
a)!!All!men!70!years!of!age!and!older!should!be!screened!for!prostate!cancer!with!the!prostate]specific!antigen!test.!
b)!!A!serum!PSA!determination!should!be!obtained!for!any!man!over!the!age!of!40!years.!
c)!!When!the!PSA!is!below!4.0!µg/L!and!the!DRE!is!negative,!no!further!action!is!required.!
d)!!A!digital!rectal!examination!has!greater!sensitivity!than!prostate]specific!antigen!(PSA)!testing!for!detecting!
prostate!cancer!
e)!!Health!outcomes!are!improved!by!monitoring!PSA!velocity!and!doubling!time!
!
!
!
Explanation:!
Prostate!cancer!is!the!most!commonly!diagnosed!non–skin!cancer!in!men!and!the!third!leading!cause!of!cancer]
related!death!among!men!in!Canada.!
A!PSA!determination!is!recommended!for!any!man,!with!a!life!expectancy!of!ten!years!or!more,!found!to!have!:!a!
prostatic!nodule!on!DRE,!an!abnormal]feeling!prostate,!focal!lesion,!discrete!change!either!in!texture,!fullness!or!
symmetry!which!provokes!increased!suspicion!of!prostate!cancer,!and!when!investigating!a!secondary!carcinoma!of!
unknown!origin.!
The!use!of!a!PSA!test!is!also!recommended!for!men!with!moderate!or!severe!symptoms!of!prostatism!in!whom!
treatment!is!contemplated.!Severe!and!moderate!symptoms!are!defined!according!to!the!International!Prostatic!
Symptom!Score.!
!
When!the!PSA!is!below!the!laboratory's!diagnostic!cutoff!(e.g.!4.0!µg/L!or!an!age]adjusted!value),!and!the!DRE!is!
131
negative,!no!further!action!is!usually!taken,!other!than!possible!periodic!repeat!testing!(e.g.!every!two!years).!
!
→!CTFPHC!Guidelines!2014!recommend!not!screening!for!prostate!cancer!with!the!prostate]specific!antigen!test!(for!
all!three!age!groups:!under!55,!55]69,!and!over!70)!
→!A!serum!PSA!determination!may!be!considered!for!any!man!over!the!age!of!40!years!with!a!life!expectancy!of!10!
years!or!more,!who!has!a!higher!risk!of!prostate!cancer.!Within!the!context!of!higher!risk!is!included!a!family!history!
(first!degree!relative)!of!prostate!cancer!or!men!of!African!ancestry.!
→!Prostate]specific!antigen!(PSA)!is!more!sensitive!than!the!digital!rectal!examination.!
→!Utilizing!PSA!velocity!and!doubling!time!has!not!been!shown!to!improve!health!outcomes.!
!
!
Question!#279!
QID:!6029!
Topic:!Healing!Traditions!
Subject:!PMCH!
!
A!4]year]old!male!is!brought!to!your!office!for!evaluation!of!fever,!coryza,!and!cough.!On!examination,!the!child!
appears!mildly!ill!but!in!no!respiratory!distress.!His!temperature!is!37.4°C!(99.3°F)!and!other!vital!signs!are!within!the!
normal!range.!HEENT!examination!is!significant!only!for!light!yellow!rhinorrhea!and!reddened!nasal!mucous!
membranes.!Lung!auscultation!reveals!good!air!flow!with!a!few!coarse!upper!airway!sounds.!While!performing!the!
examination!you!note!multiple!red!welts!and!superficial!abrasions!scattered!on!the!chest!and!upper!back.!When!you!
question!the!parents,!they!tell!you!the!marks!are!where!“the!sickness!is!leaving!his!body,”!and!were!produced!by!
rubbing!the!skin!with!a!coin.!
!
This!traditional!healing!custom!is!practiced!principally!by!people!from!which!geographic!region?!
a)!!Sub]Saharan!Africa!
b)!!Southeast!Asia!
c)!!The!Middle!East!
d)!!Caribbean!islands!
e)!!Andean!South!America!
!
!
!
Explanation:!
Coin!rubbing!is!a!traditional!healing!custom!practiced!primarily!in!east!Asian!countries!such!as!Cambodia,!Korea,!
China,!and!Vietnam.!The!belief!is!that!one’s!illness!must!be!drawn!out!of!the!body,!and!the!red!marks!produced!by!
rubbing!the!skin!with!a!coin!are!evidence!of!the!body’s!“release”!of!the!illness.!These!marks!may!be!confused!with!
abuse,!trauma!from!some!other!source,!or!an!unusual!manifestation!of!the!illness!itself.!
!
!
!
Question!#280!
QID:!6038!
Topic:!Involuntary!Hospitalization!
Subject:!PMCH!
!
A!34]year]old!white!male!is!brought!to!the!emergency!department!following!an!automobile!accident!in!which!he!was!
the!only!occupant!of!the!vehicle.!He!lost!control!of!the!vehicle!and!hit!a!utility!pole.!He!was!knocked!unconscious!
initially,!but!he!is!now!awake!and!combative.!You!note!a!strong!smell!of!alcohol.!He!has!a!frontal!hematoma!
approximately!3!cm!in!diameter!and!an!actively!bleeding!4]cm!laceration!of!the!occiput.!He!will!not!permit!you!to!
examine!him!further!and!he!prepares!to!leave!the!emergency!department.!
!
You!should:!
a)!!Detain!him!in!the!emergency!department!
b)!!Make!him!sign!out!against!medical!advice!
c)!!Tell!him!that!he!cannot!return!if!he!leaves!
d)!!Tell!him!that!if!he!leaves!he!can!return!later!
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!
!
!
Explanation:!
Two!of!the!most!important!ethical!principles!in!medicine!are!respect!for!autonomy!and!beneficence.!Respect!for!
autonomy!means!regarding!patients!as!rightfully!self]governing!in!matters!of!choice!and!action.!To!make!an!
autonomous!decision,!the!patient!must!be!mentally!sound,!have!knowledge!and!understanding!of!the!facts,!and!be!
free!of!coercion.!Beneficence!means!that!physicians!are!motivated!solely!by!what!is!good!for!the!patient.!There!are!
often!ethical!conflicts!between!these!two!principles.!This!particular!patient!is!clearly!in!need!of!further!emergency!
treatment,!but!he!refuses.!He!has!had!a!significant!head!injury,!is!combative!and!possibly!intoxicated,!and!therefore!
cannot!be!considered!mentally!sound.!The!physician!should!detain!him!for!his!own!good!and!provide!the!appropriate!
care.!Threatening!the!patient,!having!him!sign!out!against!medical!advice,!or!encouraging!him!to!return!later!is!not!
appropriate!because!his!mentation!is!impaired.!
!
!
!
Question!#281!
QID:!6048!
Subject:!PMCH!
!
You!are!caring!for!a!70]year]old!male!with!widespread!metastatic!prostate!cancer.!Surgery,!radiation,!and!hormonal!
therapy!have!failed!to!stop!the!cancer,!and!the!goal!of!his!care!is!now!symptom!relief.!He!is!being!cared!for!through!a!
local!hospice.!Over!the!past!few!days!he!has!been!experiencing!respiratory!distress.!His!oxygen!saturation!is!94%!on!
room!air!and!his!lungs!are!clear!to!auscultation.!His!respiratory!rate!is!16/min.!
!
Which!one!of!the!following!would!be!best!at!this!point?!
a)!!Morphine!
b)!!Oxygen!
c)!!Albuterol!(Proventil,!Ventolin)!
d)!!Haloperidol!
!
!
!
Explanation:!
Dyspnea!is!a!frequent!and!distressing!symptom!in!terminally!ill!patients.!In!the!absence!of!hypoxia,!oxygen!is!not!
likely!to!be!helpful.!Opiates!are!the!mainstay!of!symptomatic!treatment.!
!
!
Question!#282!
QID:!6051!
Subject:!PMCH!
!
You!would!recommend!pneumococcal!vaccine!for!which!one!of!the!following?!
a)!!A!20]year]old!male!who!smokes!1!pack!of!cigarettes!daily!
b)!!A!52]year]old!male!with!type!2!diabetes!mellitus!who!received!pneumococcal!vaccine!3!years!ago!
c)!!A!60]year]old!male!who!is!a!long]term!resident!of!a!nursing!home!because!of!a!previous!stroke,!and!who!received!
pneumococcal!vaccine!at!age!54!
d)!!A!62]year]old!male!with!chronic!renal!failure!who!received!pneumococcal!vaccine!at!age!50!and!age!55!
e)!!A!71]year]old!male!with!no!medical!problems!who!received!pneumococcal!vaccine!at!age!65!
!
!
!
Explanation:!
133
A!single!dose!of!pneumococcal!23]valent!polysaccharide!vaccine!is!recommended!for!all!adults!65!years!of!age!and!
older,!and!for!adults!less!than!65!years!of!age!in!long!term!care!facilities!or!who!have!conditions!putting!them!at!
increased!risk!of!pneumococcal!disease.!Some!conditions!include:!
]Persons!with!alcoholism!
]Smokers!
]Persons!who!are!homeless!
]Asthma,!only!if!associated!with!chronic!obstructive!pulmonary!disease,!emphysema,!or!need!for!prolonged!systemic!
corticosteroid!
]Individuals!who!use!illicit!drugs!should!also!be!considered!for!vaccination!with!Pneu]P]23!vaccine.!
!
Therefore,!all!persons!between!the!ages!of!19!and!64!who!smoke!should!receive!this!vaccine!(choice!A).!One]time!
revaccination!after!5!years!is!recommended!for!persons!with!chronic!renal!failure,!asplenia!(functional!or!anatomic),!
or!other!immunocompromising!conditions.!Because!there!are!insufficient!data!to!recommend!repeated!
administration!of!Pneu]P]23!vaccine,!re]vaccination!following!a!second!dose!is!not!routinely!recommended.!
!
→!The!diabetic!patient!(choice!B)!and!the!nursing]home!resident!(choice!C)!have!both!received!one!immunization!and!
should!not!receive!a!second!dose!until!age!65.!
→!The!patient!with!chronic!renal!failure!(choice!D)!in!this!question!has!already!received!two!immunizations.!
→!The!71]year]old!(choice!E)!has!already!been!immunized!after!age!65,!and!a!repeat!immunization!is!not!
recommended.!
!
!
Question!#283!
QID:!6066!
Topic:!Physical!Examination!
Subject:!PMCH!
!
You!test!a!patient’s!muscles!and!find!that!his!maximum!performance!consists!of!the!ability!to!move!with!gravity!
neutralized.!This!qualifies!as!which!grade!of!muscle!strength,!on!a!scale!of!5?!
a)!!0!
b)!!1!
c)!!2!
d)!!3!
e)!!4!
!
!
!
Explanation:!
Muscle!strength!is!scored!on!a!scale!of!0!to!5.!The!inability!to!contract!a!muscle!is!scored!as!0.!Contraction!without!
movement!constitutes!grade!1!strength.!Movement!with!the!effect!of!gravity!neutralized!is!grade!2!strength,!while!
movement!against!gravity!only!is!grade!3!strength.!Movement!against!gravity!plus!some!additional!resistance!
indicates!grade!4!strength.!Normal,!or!grade!5,!strength!is!demonstrated!by!movement!against!substantial!resistance.!
!
!
!
Question!#284!
QID:!6078!
Topic:!Hospice!
Subject:!PMCH!
!
Under!current!guidelines,!hospice!programs!are!most!likely!to!serve!patients!dying!from:!
a)!!Heart!failure!
b)!!COPD!
c)!!Severe!dementia!
d)!!Multiple!strokes!
e)!!Cancer!
!
134
!
!
Explanation:!
The!general!requirement!for!enrolling!an!individual!in!hospice!is!that!they!have!a!terminal!illness!and!an!estimated!life!
expectancy!of!6!months!or!less.!Given!these!criteria,!it!is!not!surprising!that!over!40%!of!hospice!patients!have!a!
cancer!diagnosis.!Cancer!usually!has!a!short!period!of!obvious!decline!at!the!end!and!is!predictable!to!a!degree.!
Diseases!such!as!COPD,!end]stage!liver!disease,!and!heart!failure!result!in!long]term!disability!with!periodic!
exacerbations,!any!one!of!which!could!result!in!death,!but!far!less!predictably.!Those!with!severe!dementia!or!frailty!
often!experience!a!dwindling!course!that!is!also!difficult!to!predict.!
!
!
!
Question!#285!
QID:!6079!
Subject:!PMCH!
!
A!healthy!48]year]old!bookkeeper!who!works!in!a!medical!office!has!a!positive!PPD!on!routine!yearly!screening.!
Which!one!of!the!following!would!be!most!appropriate!at!this!point?!
a)!!A!chest!radiograph!
b)!!A!repeat!PPD!
c)!!Treatment!with!isoniazid!and!one!other!antituberculous!drug!for!12!months!
d)!!Anergy!testing!
!
!
!
Explanation:!
Clinical!evaluation!and!a!chest!radiograph!are!recommended!in!asymptomatic!patients!with!a!positive!PPD.!The!use!of!
a!two]step!approach!(i.e.!retesting!1]4!weeks!later!in!patients!who!initially!test!negative)!is!designed!to!decrease!the!
false]negative!rate!of!PPD!testing.!
Asymptomatic!patients!with!a!positive!PPD!and!an!abnormal!chest!film!should!have!a!sputum!culture!for!TB,!but!a!
culture!is!not!required!if!the!chest!film!is!negative.!
Persons!with!a!PPD!conversion!should!be!encouraged!to!take!INH!for!9!months!with!proper!medical!supervision.!
Patients!with!a!negative!PPD!who!are!still!at!high!risk!for!TB,!especially!HIV]positive!patients,!could!be!evaluated!for!
anergy,!but!it!is!not!recommended!at!this!time.!
!
!
!
Question!#286!
QID:!6082!
Subject:!PMCH!
!
The!best!available!evidence!supports!which!one!of!the!following!guidelines!for!discussing!serious!illnesses?!
a)!!Physicians!should!delay!having!a!detailed!discussion!with!the!patient!about!the!expected!prognosis!of!cancer!until!
staging!is!completed!
b)!!For!patients!who!are!ambivalent!about!knowing!their!prognosis,!the!discussion!should!focus!on!optimal!potential!
outcomes!and!providing!hope,!even!if!this!is!unrealistic!
c)!!Physicians!should!delay!discussions!about!palliative!care!until!curative!measures!have!failed!
d)!!Physicians!should!respect!the!family’s!wishes!regarding!how!much!information!to!share!with!the!patient!
!
!
!
Explanation:!
It!is!best!to!discuss!prognosis!after!accurate!cancer!staging,!when!specific!details!about!survival!rates!will!give!a!much!
135
clearer!and!more!accurate!picture.!After!assessing!the!patient’s!readiness!to!receive!prognostic!information,!the!
physician!should!focus!on!communicating!an!accurate!prognosis!without!giving!a!false!sense!of!hope.!Using!
simultaneous]care!models,!physicians!can!provide!palliative!and!curative!care!at!the!same!time.!Physicians!should!
initiate!a!discussion!about!the!availability!of!coordinated,!symptom]!directed!services!such!as!palliative!care!early!in!
the!disease!process;!as!the!disease!progresses,!patients!should!transition!from!curative!to!palliative!therapy.!How!
much!information!to!share!with!the!patient!depends!on!the!physician’s!assessment!of!the!patient’s!level!of!
understanding!about!the!disease!and!how!much!patients!themselves!want!to!know.!
!
!
!
Question!#287!
QID:!6101!
Topic:!Advance!Directives!
Subject:!PMCH!
!
The!advance!directive!specifications!contained!in!an!individual’s!living!will!become!effective:!
a)!!At!the!time!it!is!signed!and!witnessed!
b)!!When!it!is!confirmed!by!the!individual’s!health!care!surrogate!
c)!!At!the!time!of!admission!to!a!health!care!facility!such!as!a!hospital!
d)!!When!the!patient!develops!a!terminal!illness!
e)!!When!the!individual!becomes!unable!to!communicate!health!care!wishes!
!
!
!
Explanation:!
The!living!will,!a!written!advance!directive,!allows!a!competent!person!to!indicate!his!or!her!health!care!preferences!
while!cognitively!and!physically!healthy.!A!living!will!may!list!medical!interventions!the!patient!would!prefer!to!have!
withheld!or!withdrawn!when!he!or!she!becomes!unable!to!communicate.!
!
!
!
Question!#288!
QID:!6103!
Subject:!PMCH!
!
A!55]year]old!male!is!found!to!have!three!hyperplastic!polyps!on!a!routine!screening!colonoscopy.!He!has!no!personal!
or!family!history!of!colon!cancer.!
!
This!patient’s!next!colonoscopy!should!be!in:!
a)!!1!year!
b)!!3!years!
c)!!5!years!
d)!!10!years!
!
!
!
Explanation:!
Colonoscopy!is!the!gold!standard!for!screening!for!colon!cancer.!Because!of!differences!in!recommended!screening!
intervals,!the!recommendations!for!follow]up!in!2006!to!bring!some!uniformity!to!the!guidelines.!
]Patients!with!hyperplastic!polyps!are!considered!to!have!normal!colonoscopy!findings!and!can!be!followed!up!in!10!
years,!unless!they!have!hyperplastic!polyposis!syndrome.!
]Patients!with!one!or!two!small!adenomas!(<1!cm,!with!no]!or!low]grade!dysplasia)!are!considered!at!low!risk!and!can!
be!followed!up!in!5]10!years,!depending!on!family!history,!previous!colonoscopy!findings,!and!patient!and!physician!
preference.!
]Patients!with!three!or!more!small!adenomas,!or!one!adenoma!>1!cm!in!size!should!be!followed!up!in!3!years!if!the!
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adenomas!are!completely!removed.!
]Patients!who!have!had!a!sessile!adenoma!removed!piecemeal!should!have!repeat!colonoscopy!in!2]6!months!to!
make!sure!that!the!polyp!has!been!completely!removed.!
Other!factors!that!influence!the!screening!interval!include!the!quality!of!the!preparation!and!the!ability!of!the!
physician!to!see!the!entire!colon.!Although!this!patient!had!three!hyperplastic!polyps!removed,!he!is!at!low!risk!for!
colon!cancer!and!should!have!repeat!screening!at!the!normal!10]year!interval.!
!
!
!
Question!#289!
QID:!6113!
Topic:!Good!Samaritan!Law!
Subject:!PMCH!
!
In!which!one!of!the!following!scenarios!is!a!physician!most!likely!to!be!protected!by!a!Good!Samaritan!statute?!
a)!!Assisting!flight!attendants!with!the!care!of!a!fellow!passenger!who!develops!respiratory!distress!while!in!flight!
b)!!Attending!to!an!unconscious!player!while!acting!as!an!unpaid!volunteer!physician!at!a!high]school!football!game!
c)!!Attending!to!a!bicyclist!with!heat!exhaustion!while!volunteering!at!a!first]aid!station!during!a!fund]raising!ride!
d)!!Attending!to!the!family!member!of!a!patient!who!slips!and!falls!in!the!waiting!room!at!the!physician’s!office!
e)!!Attending!to!a!nurse’s!aide!who!collapses!while!the!physician!is!staffing!the!hospital!emergency!department!
!
!
!
Explanation:!
Generally,!Good!Samaritan!laws!apply!to!situations!in!which!the!physician!does!not!have!a!preexisting!duty!to!provide!
care!to!the!patient.!A!physician!who!volunteers!as!a!standby!health!care!provider!at!an!event!assumes!a!duty!to!care!
for!illness!or!injury!in!the!participants.!Likewise,!physicians!have!a!duty!to!provide!emergency!care!to!a!person!in!need!
within!a!facility!where!they!are!working,!such!as!a!medical!office!or!an!emergency!department.!On!an!airplane,!there!
is!no!preexisting!duty!for!a!physician!to!attend!to!a!fellow!passenger!who!becomes!ill.!In!addition,!a!specific!federal!
law,!the!Aviation!Medical!Assistance!Act,!ensures!that!physicians!have!Good!Samaritan!protection!if!they!provide!
medical!assistance!while!in!flight!over!Canada.!
!
!
!
Question!#290!
QID:!6116!
Subject:!PMCH!
!
A!40]year]old!male!with!a!20]pack]year!history!of!smoking!is!concerned!about!lung!cancer.!He!denies!any!
constitutional!symptoms,!or!breathing!or!weight!changes.!You!encourage!him!to!quit!smoking!and!order!which!one!of!
the!following!screening!tests?!
a)!!No!testing!
b)!!A!chest!radiograph!
c)!!Low]dose!CT!of!the!chest!
d)!!Sputum!cytology!
!
!
!
Explanation:!
This!patient!is!at!risk!for!lung!cancer,!even!with!no!symptoms.!He!should!be!encouraged!to!stop!smoking,!especially!if!
he!has!concerns!that!may!help!motivate!him!to!quit.!No!study!has!demonstrated!that!screening!with!any!of!the!tests!
listed!improves!survival,!and!no!major!organization!endorses!lung!cancer!screening.!
!
!
Question!#291!
137
QID:!6119!
Topic:!Test!PPV!
Subject:!PMCH!
!
A!study!finds!that!the!positive!predictive!value!of!a!new!test!for!breast!cancer!is!75%,!which!means:!
a)!!If!100!patients!with!known!breast!cancer!have!the!test,!75!(75%)!will!have!a!positive!test!result!
b)!!If!100!patients!with!no!breast!cancer!have!the!test,!75!(75%)!will!have!a!negative!test!
c)!!75%!of!patients!who!test!positive!actually!have!breast!cancer!
d)!!75%!of!patients!who!test!negative!do!not!have!breast!cancer!
!
!
!
Explanation:!
Positive!predictive!value!refers!to!the!percentage!of!patients!with!a!positive!test!for!a!disease!who!actually!have!the!
disease.!The!negative!predictive!value!of!a!test!is!the!proportion!of!patients!with!negative!test!results!who!do!not!
have!the!disorder.!The!percentage!of!patients!with!a!disorder!who!have!a!positive!test!for!that!disorder!is!a!test’s!
sensitivity.!The!percentage!of!patients!without!a!disorder!who!have!a!negative!test!for!that!disorder!is!a!test’s!
specificity.!
!
!
Question!#292!
QID:!6125!
Subject:!PMCH!
!
A!patient!dying!of!cancer!is!suffering!from!pain!in!spite!of!his!narcotic!regimen.!You!increase!his!dosage!of!morphine,!
knowing!it!will!probably!hasten!his!death.!
!
Which!ethical!principle!are!you!following?!
a)!!Distributive!justice!
b)!!Double!effect!
c)!!Death!with!dignity!
d)!!Futility!
e)!!Autonomy!
!
!
!
Explanation:!
The!concept!of!“double!effect”!dates!back!to!the!Middle!Ages.!It!is!used!to!justify!medical!treatment!designed!to!
relieve!suffering!when!death!is!an!unintended!but!foreseeable!consequence.!It!is!based!on!two!basic!presuppositions:!
first,!that!the!doctor’s!motivation!is!to!alleviate!suffering,!and!second,!that!the!treatment!is!appropriate!to!the!illness.!
Distributive!justice!relates!to!the!allocations!of!resources.!Death!with!dignity!is!a!recently!introduced!concept!and!is!
not!a!factor!in!the!scenario!described!here.!Futility!refers!to!using!a!treatment!for!which!there!is!no!rational!
justification.!Autonomy!refers!to!the!patient’s!ability!to!direct!his!or!her!own!care,!which!is!not!an!issue!in!this!case.!
!
!
!
Question!#293!
QID:!6126!
Topic:!Nosocomial!Infections!
Subject:!PMCH!
!
You!are!a!member!of!a!committee!at!your!local!hospital!that!has!been!asked!to!develop!measures!to!reduce!the!
incidence!of!postoperative!methicillin]resistant!Staphylococcus!aureus!(MRSA)!infections.!Which!one!of!the!following!
would!be!most!effective!for!preventing!these!infections?!
a)!!Give!preoperative!antibiotics!to!all!surgical!patients!to!eradicate!bacteria!
138
b)!!Screen!all!admitted!patients!for!MRSA!and!use!antibiotics!pre]!and!postoperatively!in!positive!cases!
c)!!Culture!the!nares!of!all!hospital!employees!upon!hiring!and!on!a!routine!basis!thereafter!
d)!!Institute!an!intensive!program!of!good!hand!washing!for!all!employees!
!
!
!
Explanation:!
Nosocomial!infections!are!a!significant!factor!in!morbidity!and!cost!in!the!health!care!field.!Methicillinresistant!
Staphylococcus!aureus!(MRSA)!has!rapidly!increased!in!frequency,!first!being!found!only!at!tertiary!centers,!then!local!
hospitals,!and!now!in!the!outpatient!setting.!Of!those!who!are!found!to!be!colonized,!either!at!the!time!of!
hospitalization!or!later!by!a!routine!culture,!25%!will!develop!a!MRSA!infection.!However,!a!recent!study!showed!that!
of!93!patients!who!became!infected!with!the!organism,!57%!were!not!colonized!at!the!time!of!infection.!The!study!
also!attempted!to!screen!all!patients!for!MRSA!on!admission,!but!found!that!even!though!337!previously!unknown!
carriers!were!found!(in!addition!to!those!already!known!to!harbor!the!organism),!there!was!not!a!significant!decrease!
in!the!rate!of!MRSA!infections!during!the!study.!Although!MRSA!infections!can!be!serious,!they!comprise!only!8%!of!
nosocomial!infections!in!the!hospital,!and!concentrating!prevention!efforts!only!on!MRSA!has!little!effect!on!that!8%,!
and!no!effect!on!the!92%!of!infections!caused!by!other!organisms.!Iatrogenic!complications!arise!from!trying!to!treat!
MRSA!carriers,!including!both!drug!reactions!and!the!development!of!other!resistant!organisms.!Costs!related!to!
attempts!at!prophylaxis!also!go!up.!Culturing!all!hospital!employees!has!not!been!proven!to!be!of!value,!as!employees!
can!pick!up!the!organism!after!screening,!and!also!can!spontaneously!eradicate!the!organism!without!treatment.!The!
best!way!to!prevent!complications!and!postoperative!infections!is!to!aggressively!advocate!universal!and!frequent!
hand!washing!and!room!cleaning,!and!use!good!isolation!techniques!and!methods!of!preventing!infection,!such!as!
strict!catheter!and!intravenous!tubing!protocols.!
!
!
!
Question!#294!
QID:!6131!
Subject:!PMCH!
!
When!a!screening!test!identifies!a!cancer!earlier,!thereby!increasing!the!time!between!diagnosis!and!death!without!
prolonging!life,!this!is!called:!
a)!!Length]time!bias!
b)!!Lead]time!bias!
c)!!A!false]positive!screening!test!
d)!!Increasing!the!positive!predictive!value!of!the!screening!test!
e)!!Attributable!risk!
!
!
!
Explanation:!
Lead]time!bias!is!when!a!screening!test!identifies!a!cancer!earlier,!thereby!increasing!the!time!between!diagnosis!and!
death!without!actually!prolonging!life.!Length]time!bias!is!when!a!screening!test!finds!a!disproportionate!number!of!
cases!of!slowly!progressive!disease!and!misses!the!aggressive!cases,!thereby!leading!to!an!overestimate!of!the!
effectiveness!of!the!screening.!A!false]positive!test!is!one!that!suggests!cancer!when!no!cancer!exists.!The!positive!
predictive!value!is!the!proportion!of!positive!test!results!that!are!true!positives.!Attributable!risk!is!the!amount!of!
difference!in!risk!for!a!disease!that!can!be!accounted!for!by!a!specific!risk!factor.!
!
!
!
Question!#295!
QID:!6144!
Topic:!Advance!Directives!
Subject:!PMCH!
!
139
A!72]year]old!male!is!brought!by!ambulance!to!the!emergency!department!with!weakness!and!numbness!of!his!left!
side!that!began!earlier!this!morning.!While!in!the!emergency!department!he!becomes!comatose!with!infrequent,!
gasping!breaths!and!is!quickly!intubated!and!placed!on!a!ventilator.!A!full!evaluation!shows!an!acute!ischemic!right]
sided!stroke.!His!wife!states!that!she!wishes!to!have!the!ventilator!stopped,!as!she!believes!this!would!be!consistent!
with!her!husband’s!wishes!in!this!circumstance.!She!understands!that!this!would!precipitate!the!patient’s!death.!The!
wife!presents!a!legally!valid!advance!directive!confirming!her!as!the!patient’s!healthcare!proxy.!
!
Which!one!of!the!following!responses!to!the!wife’s!request!is!most!ethically!appropriate?!
a)!!Withdraw!the!ventilator!as!requested!
b)!!Contact!the!hospital!ethics!committee!to!initiate!the!legal!requirements!to!process!the!wife’s!request!
c)!!Inform!the!wife!that!all!life]sustaining!care!should!be!given!until!the!patient’s!condition!has!been!determined!to!be!
irreversible!
d)!!Inform!the!wife!that!intubation!may!have!been!avoided!in!the!emergency!department,!but!once!life]sustaining!
care!has!been!initiated!it!should!not!be!withdrawn!
e)!!Promptly!contact!hospital!security!or!the!local!law!enforcement!agency!to!report!the!wife’s!request!
!
!
!
Explanation:!
Competent!adult!patients!have!the!right!to!refuse!any!medical!intervention,!even!if!forgoing!this!treatment!may!
result!in!their!death.!Legally!and!ethically!it!does!not!matter!whether!the!patient!requests!that!care!be!withheld!
before!it!is!started!or!that!it!be!withdrawn!once!it!is!begun.!All!states!currently!allow!competent!patients!to!legally!
designate!a!health]care!proxy!to!make!these!decisions!for!them!if!they!become!unable!to!communicate!or!are!no!
longer!competent!to!decide!for!themselves.!The!patient!in!this!example!has!instituted!such!a!legal!advance!directive!
and!his!proxy’s!request!should!be!respected!as!his!own!and!the!care!withdrawn.!If!there!were!no!advance!directive!
the!decision!in!this!case!would!become!more!difficult,!and!might!require!a!family!conference!or!the!involvement!of!an!
ethics!committee.!A!patient’s!condition!does!not!need!to!be!terminal!or!irreversible!to!allow!the!removal!of!life]
sustaining!therapy.!Legal!involvement!is!rarely!required!in!situations!where!advance!directives!are!already!available!
and!valid.!
!
!
!
Question!#296!
QID:!6147!
Topic:!Herbal!Preparations!
Subject:!PMCH!
!
An!elderly!male!patient!takes!aspirin,!81!mg!daily,!for!prevention!of!a!heart!attack.!He!also!takes!herbal!supplements.!
!
Which!one!of!the!following!supplements!can!have!a!negative!interaction!with!aspirin?!
a)!!Kava!
b)!!Yohimbine!
c)!!Saw!palmetto!
d)!!Echinacea!
e)!!Ginkgo!biloba!
!
!
!
Explanation:!
Herbal!and!dietary!supplements!can!affect!the!absorption,!metabolism,!and!disposition!of!other!drugs.!Ginkgo!biloba!
has!been!associated!with!serious!intracerebral!bleeding.!In!most!of!these!patients,!concurrent!anticoagulant!drugs!
were!being!used.!Ginkgo!has!been!shown!in!vitro!to!inhibit!platelet!aggregation!and!has!been!associated!with!case!
reports!of!spontaneous!bleeding.!Caution!is!recommended!when!using!this!supplement!with!aspirin!or!other!
anticoagulants.!Kava!is!associated!with!gastrointestinal!side!effects!and!skin!rashes.!Yohimbine!is!associated!with!
hypertension.!Saw!palmetto!and!echinacea!are!not!associated!with!bleeding.!
!
140
!
!
Question!#297!
QID:!6155!
Topic:!Clinical!Guidelines!
Subject:!PMCH!
!
This!question!is!no!longer!available.!
Thank!you!for!your!understanding!and!cooperation.!
!
The!correct!answer!is!
!
!
Explanation:!
!
!
Question!#298!
QID:!6180!
Subject:!PMCH!
!
In!Canada,!the!number!of!deaths!has!increased!in!recent!years!for!which!one!of!the!following!vaccine]preventable!
illnesses?!
a)!!Tetanus!
b)!!Hepatitis!C!
c)!!Rubella!
d)!!Pertussis!
e)!!West!Nile!virus!
!
!
!
Explanation:!
In!Canada,!deaths!from!pertussis!increased!from!4!deaths!in!1996!to!17!deaths!in!2001,!and!a!total!of!56!deaths!from!
2001!to!2003.!Immunity!has!decreased!in!previously!vaccinated!adolescents!and!adults,!and!now!they!are!a!reservoir!
for!infection.!Tdap!vaccine!is!recommended!as!a!single!booster!for!patients!age!19]65,!and!those!between!the!ages!of!
11!and!18!years!should!receive!Tdap!rather!than!a!Td!booster.!The!Tdap!vaccine!protects!against!pertussis,!in!addition!
to!tetanus!and!diphtheria.!Tetanus!and!rubella!deaths!are!not!increasing.!There!are!no!vaccines!for!hepatitis!C!or!
West!Nile!virus.!
!
!
!
Question!#299!
QID:!6182!
Subject:!PMCH!
!
Studies!indicate!that!patients!most!frequently!want!physicians!to!ask!about!their!spiritual!beliefs!in!which!one!of!the!
following!situations?!
a)!!When!being!treated!for!a!potentially!fatal!illness!
b)!!During!the!annual!preventive!visit!
c)!!During!the!initial!office!visit!with!the!physician!
d)!!Only!if!specifically!requested!by!the!patient,!a!family!member,!their!minister,!or!a!chaplain!
e)!!When!prayer!is!suggested!by!the!patient!or!physician!
!
!
!
141
Explanation:!
Patients!often!welcome!spiritual!discussion,!depending!on!the!situation.!The!percentage!that!welcome!this!discussion!
increases!with!the!severity!of!illness,!and!is!greatest!among!those!who!are!very!seriously!ill!with!a!potentially!fatal!
disease.!Spiritual!inquiry!during!medical!care!should!focus!on!understanding,!compassion,!and!hope,!and!should!be!
directed!toward!individuals!who!suffer!from!serious!illness.!
!
!
!
Question!#300!
QID:!6209!
Topic:!Obesity!
Subject:!PMCH!
!
According!to!current!guidelines,!in!order!to!burn!fat!stores!obese!patients!should!exercise:!
a)!!A!minimum!of!30!minutes!3!days/week!
b)!!A!minimum!of!30!minutes!at!least!5!days/week!
c)!!A!minimum!of!20!minutes!every!day!
d)!!A!minimum!of!10!minutes!at!least!3!times!daily!
!
!
!
Explanation:!
Because!glycogen!is!the!primary!energy!source!for!muscles!during!the!first!20!minutes!of!exercise,!at!least!30!minutes!
of!exercise!is!necessary!to!begin!burning!fat!stores.!Current!guidelines!recommend!a!minimum!of!30!minutes!of!
exercise!5!days!per!week.!Twenty!minutes!of!exercise!daily!or!three!10]minute!sessions!daily!does!improve!
cardiovascular!fitness,!but!does!not!cause!significant!weight!loss.!Walking,!on!land!or!in!water,!and!stationary!biking!
are!equivalent!in!benefit.!
!
!
!
Question!#301!
QID:!6234!
Topic:!End]of]life!Care!
Subject:!PMCH!
!
You!have!just!received!test!results!confirming!that!a!78]year]old!patient!has!metastatic!lung!cancer.!She!informs!you!
she!does!not!want!to!know!the!results!of!the!tests!and!is!“leaving!it!in!God’s!hands.”!You!know!that!additional!issues!
need!to!be!explored,!such!as!her!desire!for!chemotherapy!and!hospice!care.!
!
Which!one!of!the!following!is!the!most!appropriate!strategy!for!determining!her!wishes?!
a)!!Acknowledge!her!concerns,!but!proceed!with!a!discussion!of!her!diagnosis!and!prognosis!
b)!!Ask!family!members!to!gently!break!the!news!to!your!patient!and!tell!them!you!will!return!later!to!discuss!the!
details!and!answer!questions!
c)!!Have!a!hospice!representative!visit!and!discuss!the!diagnosis!and!options!for!care!
d)!!Ask!the!patient!to!designate!someone!with!whom!you!can!discuss!the!results!and!prognosis!
!
!
!
Explanation:!
In!a!patient]centered!approach!to!communication!regarding!end]of]life!care,!a!patient’s!wishes!to!not!know!about!a!
diagnosis!or!prognosis!should!be!respected.!However,!it!is!reasonable!to!ask!the!patient!to!name!a!proxy!with!whom!
you!may!discuss!the!issues!(choice!D).!The!other!options!listed!do!not!respect!the!patient’s!desire!to!not!know!her!
diagnosis!or!prognosis.!
!
!
!
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Question!#302!
QID:!6239!
Topic:!Drug!Adverse!Effects!
Subject:!PMCH!
!
Most!sympathomimetic!decongestants!such!as!pseudoephedrine!and!phenylephrine!can!be!problematic!in!elderly!
patients!because!they!can:!
a)!!Decrease!blood!pressure!
b)!!Reduce!intraocular!pressure!
c)!!Worsen!existing!urinary!obstruction!
d)!!Enhance!the!anticholinergic!effects!of!other!medications!
e)!!Enhance!the!sedative!effects!of!other!medications!
!
!
!
Explanation:!
Sympathomimetic!agents!can!elevate!blood!pressure!and!intraocular!pressure,!may!worsen!existing!urinary!
obstruction,!and!adversely!interact!with!beta]blockers,!methyldopa,!tricyclic!antidepressants,!and!oral!hypoglycemic!
agents!and!MAOIs.!They!also!speed!up!the!heart!rate!or!may!cause!severe!reflex!bradycardia.!First]generation!
nonprescription!antihistamines!can!enhance!the!anticholinergic!and!sedative!effects!of!other!medications.!
!
!
!
Question!#303!
QID:!6245!
Subject:!PMCH!
!
The!specificity!of!a!screening!test!is!best!described!as!the!proportion!of!persons:!
a)!!With!the!condition!who!test!positive!
b)!!With!the!condition!who!test!negative!
c)!!With!the!condition!who!test!positive,!compared!to!the!total!number!screened!
d)!!Without!the!condition!who!test!positive!
e)!!Without!the!condition!who!test!negative!
!
!
!
Explanation:!
A!screening!test’s!specificity!is!the!proportion!of!persons!without!the!condition!who!test!negative!for!that!condition.!
In!other!words,!it!is!a!measure!of!the!test’s!ability!to!properly!identify!those!who!do!not!have!the!disease.!Conversely,!
the!sensitivity!of!a!screening!test!is!the!proportion!of!those!with!the!condition!who!test!positive.!The!other!options!
listed!describe!false]negatives,!false]positives,!and!prevalence.!
!
!
Question!#304!
QID:!6260!
Subject:!PMCH!
!
For!a!52]year]old!sedentary,!normotensive,!non]smoking!white!male!who!is!not!overweight,!drinks!60!mL!of!whiskey!
per!day!and!plays!golf!occasionally,!which!one!of!the!following!conditions!is!most!likely!to!cause!death!within!the!next!
10!years?!
a)!!Motor!vehicle!accident!
b)!!Cerebrovascular!disease!
c)!!Suicide!
d)!!Cirrhosis!of!the!liver!
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e)!!Ischemic!heart!disease!
!
!
!
Explanation:!
In!a!male!over!the!age!of!50!with!low!risk!factors,!the!most!common!cause!of!morbidity!is!due!to!ischemic!heart!
disease.!
!
Ischemic!heart!disease!(IHD),!or!myocardial!ischemia,!is!a!disease!characterized!by!reduced!blood!supply!to!the!heart!
muscle,!usually!due!to!coronary!artery!disease!(atherosclerosis!of!the!coronary!arteries).!Its!risk!increases!with!age,!
smoking,!hypercholesterolemia!(high!cholesterol!levels),!diabetes,!hypertension!(high!blood!pressure)!and!is!more!
common!in!men!and!those!who!have!close!relatives!with!ischemic!heart!disease.!
!
It!is!the!most!common!cause!of!death!in!most!Western!countries,!and!a!major!cause!of!hospital!admissions.!There!is!
limited!evidence!for!population!screening,!but!prevention!(with!a!healthy!diet!and!sometimes!medication!for!
diabetes,!cholesterol!and!high!blood!pressure)!is!used!both!to!prevent!IHD!and!to!decrease!the!risk!of!complications.!
!
!
Question!#305!
QID:!6273!
Topic:!Falls!in!Elderly!
Subject:!PMCH!
!
Which!of!the!following!is!false!with!regard!to!falls!in!the!elderly?!
a)!!Falls!are!the!leading!cause!of!injury]related!visits!to!emergency!departments!
b)!!The!mortality!rate!for!falls!increases!dramatically!with!age!in!both!sexes!
c)!!In!persons!over!age!75,!fractures!of!the!upper!extremity!are!about!twice!as!common!as!fractures!of!the!lower!
extremity!
d)!!Falls!can!be!markers!of!poor!health!and!declining!function!
e)!!Risk!factors!for!falls!in!the!elderly!include!increasing!age,!medication!use,!cognitive!impairment!and!sensory!
deficits!
!
!
!
Explanation:!
Falls!are!the!leading!cause!of!injury]related!visits!to!emergency!departments!(choice!A)!and!the!primary!etiology!of!
accidental!deaths!in!persons!over!the!age!of!65!years.!The!mortality!rate!for!falls!increases!dramatically!with!age!in!
both!sexes!(choice!B)!and!in!all!racial!and!ethnic!groups,!with!falls!accounting!for!70%!of!accidental!deaths!in!persons!
75!years!of!age!and!older.!Falls!can!be!markers!of!poor!health!and!declining!function!(choice!D),!and!they!are!often!
associated!with!significant!morbidity.!
!
More!than!90%!of!hip!fractures!occur!as!a!result!of!falls,!with!most!of!these!fractures!occurring!in!persons!over!70!
years!of!age.!In!persons!over!age!75,!fractures!of!the!lower!extremity!are!about!twice!as!common!as!fractures!of!the!
upper!extremity!(statement!in!choice!C!is!incorrect).!One!third!of!community]dwelling!elderly!persons!and!60%!of!
nursing!home!residents!fall!each!year.!Risk!factors!for!falls!in!the!elderly!include!increasing!age,!medication!use,!
cognitive!impairment!and!sensory!deficits.!Outpatient!evaluation!of!a!patient!who!has!fallen!includes!a!focused!
history!with!an!emphasis!on!medications,!a!directed!physical!examination!and!simple!tests!of!postural!control!and!
overall!physical!function.!
!
!
Question!#306!
QID:!6274!
Topic:!Diagnostic!Investigations!
Subject:!PMCH!
!
A!35]year]old!man!who!is!a!new!city!employee!was!driving!a!city]owned!car!when!he!was!struck!from!behind!by!
144
another!car.!He!experienced!immediate!neck!and!shoulder!pain!and!was!seen!and!examined!by!you!in!the!emergency!
department.!Physical!examination!showed!slight!cervical!muscle!spasm.!Cervical!spine!and!shoulder!x]ray!films!at!that!
time!were!normal.!You!reassured!him!that!no!structural!damage!was!evident!on!the!studies.!He!was!treated!with!
nonsteroidal!anti]inflammatory!drugs!(NSAIDs)!and!was!scheduled!for!a!return!visit!in!the!office!in!2!weeks.!The!
patient!is!demanding!further!and!more!complete!investigation!before!he!goes!home!as!he!wants!to!"be!100%!sure!
that!he!was!not!more!seriously!injured."!
What!would!be!your!next!best!step!in!management?!
a)!!Inform!the!patient!that!no!additional!studies!are!needed!
b)!!Order!a!CT!scan!of!the!cervical!spine!
c)!!Order!an!MRI!of!the!cervical!spine!
d)!!Order!studies!the!patient!requests!
e)!!Refer!him!to!a!neurologist!
!
!
!
Explanation:!
Despite!the!patient!requests,!there!is!nothing!at!this!time!to!suggest!any!additional!work]up.!It!is!important!to!
communicate!clearly!to!the!patient!that!you!are!not!giving!up,!and!that!it!is!your!assessment!that!no!further!testing!is!
needed!at!this!time.!Assure!him!that!you!will!continue!to!follow!up!this!problem!with!him.!
!
The!other!choices,!any!further!testing!or!consults!would!have!a!low!yield!result,!and!would!cause!great!expense!in!a!
situation!where!there!is!low!suspicion!and!a!possibility!of!false!positives.!
!
!
Question!#307!
QID:!6435!
Subject:!PMCH!
!
A!40]year]old!sedentary!white!male!with!a!family!history!of!stroke!sees!you!for!a!health!maintenance!visit.!His!blood!
pressure!averages!150/100!mm!Hg!over!several!visits.!His!LDL!cholesterol!level!is!4.4!mmol/L.!
!
Which!one!of!the!following!would!have!the!greatest!impact!on!decreasing!his!future!risk!of!stroke?!
a)!!Drug!therapy!for!reducing!his!blood!pressure!to!normal!levels!
b)!!Reducing!his!LDL!cholesterol!level!to!<!3.4!mmol/L!
c)!!Aspirin,!81!mg!daily!
d)!!A!program!of!regular!exercise!
e)!!!Strict!diet!
!
!
!
Explanation:!
Stroke!is!the!third!leading!cause!of!death!in!Canada,!and!hypertension!is!the!most!consistently!powerful!predictor!of!
stroke.!There!is!strong!and!consistent!evidence!supporting!the!efficacy!of!antihypertensive!therapy!in!reducing!stroke!
risk.!Several!other!interventions!have!been!shown!to!lower!stroke!risk!to!a!lesser!extent,!including!statin!treatment!of!
high!cholesterol,!daily!aspirin,!and!regular!exercise.!
!
!
Question!#308!
QID:!6439!
Topic:!Hypertension!
Subject:!PMCH!
!
Which!one!of!the!following!antihypertensive!agents!may!help!preserve!bone!mineral!density?!
a)!!Atenolol!(Tenormin)!
b)!!Doxazosin!(Cardura)!
145
c)!!Enalapril!(Vasotec)!
d)!!Hydrochlorothiazide!
e)!!Nifedipine!(Procarda,!Adalat)!
!
!
!
Explanation:!
In!healthy!older!adults,!low]dose!hydrochlorothiazide!preserves!bone!mineral!density!of!the!hip!and!spine.!The!
modest!effects!observed!over!3!years,!if!accumulated!over!10]20!years,!may!explain!the!one]third!reduction!in!risk!for!
hip!fracture!associated!with!thiazide!use!in!many!epidemiologic!studies.!There!are!no!such!benefits!reported!for!the!
other!medications!listed.!
!
!
Question!#309!
QID:!6442!
Topic:!Exercise!Routine!
Subject:!PMCH!
!
In!prescribing!an!exercise!program!for!elderly,!community]dwelling!patients,!it!is!important!to!note!that:!
a)!!Graded!exercise!stress!testing!should!be!done!before!beginning!the!program!
b)!!Target!heart!rates!should!be!80%!of!the!predicted!maximum!
c)!!The!initial!routines!can!be!as!short!as!6!minutes!repeated!throughout!the!week!and!still!be!beneficial!
d)!!Treadmill!walking!is!especially!beneficial!to!patients!with!neuropathy!
!
!
!
Explanation:!
Initial!exercise!routines!for!the!elderly!can!be!as!short!as!6!minutes!in!duration.!Even!30!minutes!per!week!of!exercise!
has!been!shown!to!be!beneficial.!Graded!exercise!testing!need!not!be!done,!especially!if!low]level!exercise!is!planned.!
A!target!heart!rate!of!60%]75%!of!the!predicted!maximum!should!be!set!as!a!ceiling.!Patients!with!peripheral!
neuropathy!should!not!perform!treadmill!walking!or!step!aerobics!because!of!the!risk!of!damage!to!their!feet.!
!
!
Question!#310!
QID:!6445!
Topic:!Medication!Management!
Subject:!PMCH!
!
You!are!the!attending!physician!at!a!long]term!care!facility.!A!new!resident,!an!85]year]old!female,!presents!for!an!
initial!visit.!Upon!reviewing!her!history,!you!find!that!she!is!on!18!different!medications.!While!attempting!to!obtain!
additional!history!and!medical!information,!you!decide!to!stop!or!decrease!some!of!her!medications!and!monitor!her!
response.!
!
Which!one!of!the!following!would!be!most!appropriate!to!stop!or!decrease!initially?!
a)!!Sertraline!(Zoloft),!25!mg!daily!
b)!!Acetaminophen/diphenhydramine!(Tylenol!PM!HS),!500!mg/25!mg!daily!
c)!!Dipyridamole/aspirin!(Aggrenox),!200!mg/25!mg!
d)!!Digoxin,!0.125!mg!every!other!day!
e)!!Fexofenadine,!60!mg!bid!
!
!
!
Explanation:!
Polypharmacy!is!a!term!commonly!associated!with!physicians’!prescribing!tendencies!for!the!elderly!population.!
Although!the!term!carries!a!negative!connotation,!the!use!of!numerous!medications!is!necessary!in!some!elderly!
146
patients.!However,!some!medications!have!been!identified!as!having!a!considerably!higher!potential!to!cause!
problems!when!prescribed!to!elderly!patients.!
!
The!older!antihistamines,!primarily!diphenhydramine,!cause!many!adverse!CNS!effects!such!as!cognitive!slowing!and!
delirium!in!older!patients.!This!effect!is!more!pronounced!in!elderly!patients!with!some!degree!of!preexisting!
cognitive!impairment.!The!anticholinergic!properties!of!older!antihistamines!produce!effects!such!as!dry!mouth,!
constipation,!blurred!vision,!and!drowsiness.!Thus,!the!use!of!antihistamines!as!sleeping!agents!or!for!symptomatic!
relief!often!leads!to!problems!in!elderly!patients.!The!sedative!effect!of!older!antihistamines!also!increases!older!
patients’!risks!of!falls.!Hip!fracture!and!subsequent!death!have!been!reported!in!patients!who!use!older!
antihistamines!such!as!diphenhydramine.!Thus,!the!acetaminophen/diphenhydramine!would!be!an!appropriate!
medication!to!stop!initially.!
!
>Sertraline!is!an!SSRI,!a!preferred!class!for!the!treatment!of!depression!in!the!elderly!as!compared!to!the!tricyclic!
antidepressants,!which!are!associated!with!several!side!effects.!
>When!used!in!elderly!patients!with!congestive!heart!failure,!digoxin!should!be!given!in!a!dosage!no!greater!than!
0.125!mg!daily;!the!low!dose!used!in!this!individual!is!not!inappropriate!until!the!reason!for!its!use!is!clarified.!
>Fexofenadine!is!one!of!the!newer!nonsedating!antihistamines!that!is!recommended!for!treating!allergy!symptoms!in!
the!elderly.!For!seasonal!allergies!the!recommended!dose!for!adults!and!children!12!years!or!older!is!60!mg!twice!
daily!or!180!mg!once!daily.!
>!Short]acting!dipyridamole!may!cause!orthostatic!hypotension.!Do!not!consider!the!long]acting!dipyridamole!(which!
has!better!properties!than!the!short]acting!in!older!adults)!except!with!patients!with!artificial!heart!valves.!Do!not!
stop!before!obtaining!full!medical!history.!
!
!
Question!#311!
QID:!6451!
Topic:!Nutrition!
Subject:!PMCH!
!
Which!one!of!the!following!oils!has!the!highest!content!of!omega]3!fatty!acid!per!tablespoon?!
a)!!Olive!
b)!!Soybean!
c)!!Canola!
d)!!Flaxseed!
e)!!Walnut!
!
!
!
Explanation:!
Many!health]minded!individuals!are!cooking!with!flaxseed!oil!to!increase!their!intake!of!omega]3!fatty!acids.!It!has!
the!highest!content!of!omega]3!fatty!acids!of!the!oils!listed!(8.5!g!per!tablespoon).!Canola!and!walnut!oils!are!also!
good!source,!with!1.3!and!1.4!g!of!α]linolenic!acid!per!tablespoon.!
!
!
Question!#312!
QID:!7908!
Topic:!DNR!Order!
Subject:!PMCH!
!
An!elderly!female!who!has!been!your!patient!for!several!years!is!discovered!lying!on!the!floor!of!her!kitchen!by!a!
Meals]on]Wheels!volunteer.!She!is!transported!to!the!hospital!in!an!unresponsive!state.!After!a!thorough!evaluation,!
you!diagnose!a!massive!cerebral!infarct.!On!several!previous!occasions!the!patient!verbalized!to!you!her!desire!to!not!
be!subjected!to!life]prolonging!treatments!should!she!ever!be!rendered!incapacitated;!however,!she!declined!your!
suggestion!to!confirm!this!in!writing.!The!patient!is!admitted!to!the!hospital!with!“do!not!resuscitate”!(DNR)!orders!
and!supportive!measures!are!instituted.!A!neurology!consultant!evaluates!her!and!agrees!that!her!condition!is!
terminal!and!irreversible.!The!patient’s!nephew!is!angered!by!the!DNR!status!and,!noting!that!she!has!insurance!
coverage,!demands!every!medical!treatment!that!might!prolong!his!aunt’s!life,!including!resuscitation.!
147
!
Which!one!of!the!following!would!be!the!best!course!of!action!in!terms!of!legality!and!ethics?!
!
a)!!Institution!of!aggressive!medical!therapies,!including!full!resuscitation!in!the!event!of!cardiac!arrest!and!ventilator!
support!in!the!event!of!respiratory!arrest!
b)!!Continuation!of!a!supportive!treatment!plan,!provided!full!resuscitation!is!initiated!in!the!event!of!cardiac!arrest!
and!ventilator!support!is!provided!in!the!event!of!respiratory!arrest!
c)!!Performance!of!full!CPR!for!cardiopulmonary!arrest,!but!no!ventilator!support!for!respiratory!failure!
d)!!Continuation!of!the!current!treatment!plan!
!
!
!
Explanation:!
An!adult!patient!or!their!legally!authorized!representative!has!the!right!to!refuse!any!medical!treatment,!regardless!of!
its!likelihood!of!success;!however,!there!is!no!legal!right!to!receive!any!and!all!treatment!demanded.!When!patients!
have!explicit!advance!directives!in!writing,!their!wishes!are!clear.!When!no!written!document!exists,!but!the!patient’s!
desire!is!well!known!to!his!or!her!physician,!the!physician!is!ethically!bound!to!honor!these!wishes.!This!responsibility!
must!be!balanced!against!the!physician’s!ethical!obligation!not!to!perform!futile!treatments!of!no!benefit!to!the!
patient.!A!family!member!acting!as!a!medical!decision]making!proxy!is!obligated!to!represent!what!they!believe!to!be!
the!patient’s!wishes,!even!in!the!face!of!conflict!with!their!personal!beliefs.!
!
This!case!highlights!two!commonly!encountered!issues:!honoring!the!patient’s!wishes!when!there!is!conflicting!
evidence!of!what!their!wishes!may!be,!and!withholding!medically!futile!treatment.!In!this!case,!the!futility!of!the!
patient’s!condition!overrides!any!confusion!as!to!her!wishes,!and!the!admission!treatment!plan!is!the!most!
appropriate.!Naturally,!it!would!be!best!to!discuss!this!with!the!nephew!and!attempt!to!arrive!at!a!consensus,!with!
the!patient’s!best!interest!being!the!primary!concern.!
!
!
Question!#313!
QID:!7911!
Topic:!Patient!Competence!
Subject:!PMCH!
!
One!year!after!being!diagnosed!with!early!Alzheimer’s!disease,!one!of!your!long]time!patients!develops!symptomatic!
carotid!stenosis.!A!vascular!surgeon!has!recommended!surgical!treatment,!but!the!patient’s!family!is!uncertain!
whether!he!should!have!the!surgery!or!whether!he!is!capable!of!making!the!decision.!The!children!are!evenly!split!in!
their!opinion!regarding!the!surgery,!and!they!ask!your!opinion!about!this!decision.!
!
Which!one!of!the!following!is!true!regarding!this!situation?!
!
a)!!The!patient!is!incapable!of!making!this!decision!because!of!his!dementia!
b)!!The!Mini]Mental!State!Examination!score!determines!competence!
c)!!The!patient!should!be!evaluated!by!a!psychiatrist!
d)!!A!judicial!determination!of!competence!should!be!obtained!
e)!!The!patient's!decision]making!capacity!can!be!adequately!assessed!by!clinical!evaluation!
!
!
!
Explanation:!
The!primary!care!physician!can!assess!a!patient’s!decision]making!capacity!based!on!ability!to!reason,!communicate,!
understand!the!proposed!treatment,!and!grasp!the!consequences!of!accepting!or!declining!the!suggested!treatment.!
!
Formal!mental!status!testing!and!determination!of!capacity!are!different!functions.!However,!there!is!a!certain!level!
of!cognitive!impairment!where!a!patient!simply!lacks!any!ability!to!receive!and!process!health!information.!At!
somewhat!higher!levels!of!cognition!a!patient!might!lack!specific!mental!abilities,!but!still!be!able!to!satisfy!the!
requirements!for!making!treatment!decisions.!
148
!
Accurate!mental!status!testing!is!helpful!for!assessing!the!capacity!to!choose;!however,!there!is!not!a!specific!score!
that!determines!capacity.!Determination!of!capacity!does!not!require!legal!intervention!or!psychiatric!expertise.!
There!is!no!specific!test!for!decision]making!capacity.!
!
Competence!is!a!legal!term!in!this!situation.!Decisions!regarding!competence!are!judicial!determinations!when!
evaluating!the!capacity!of!a!person!to!make!nonmedical!decisions!such!as!financial!decisions.!Under!the!law,!adults!
are!presumed!to!be!competent!until!a!specific!action!of!the!appropriate!court!finds!them!otherwise.!
!
!
Question!#314!
QID:!7912!
Topic:!Ambulatory!Aids!
Subject:!PMCH!
!
A!76]year]old!male!has!fallen!twice!as!a!result!of!buckling!of!the!left!knee!during!ambulation.!Neither!fall!resulted!in!
injury,!and!he!is!advised!to!use!an!offset!walking!cane.!The!patient!is!left!hand]dominant!and!has!normal!strength!in!
all!four!extremities.!Crepitus!is!present!in!both!knees,!but!is!much!more!pronounced!in!the!left!knee.!
!
Which!one!of!the!following!describes!the!best!method!for!use!of!a!cane!by!this!patient?!
!
a)!!Place!the!cane!in!the!left!hand!and!advance!it!at!the!same!time!as!the!left!leg!
b)!!Place!the!cane!in!the!left!hand!and!advance!it!at!the!same!time!as!the!right!leg!
c)!!Place!the!cane!in!the!right!hand!and!advance!it!at!the!same!time!as!the!left!leg!
d)!!Place!the!cane!in!the!right!hand!and!advance!it!at!the!same!time!as!the!right!leg!
e)!!Switch!the!cane!between!hands!at!intervals!of!several!hours!to!distribute!the!load!equally!
!
!
!
Explanation:!
The!standard!walking!cane!generally!is!designed!as!a!tool!to!aid!in!balance!and,!to!a!lesser!degree,!reduce!weight!
bearing!on!a!specific!leg.!The!offset!cane!design!results!in!the!downward!force!vector!being!placed!directly!over!the!
shaft,!making!this!choice!ideal!where!improved!balance!and!reduction!of!weight!bearing!on!a!particular!leg!is!desired.!
Mechanical!advantage!produces!maximum!benefit!when!the!cane!is!placed!in!the!hand!opposite!the!most!severely!
affected!leg,!and!the!movement!of!the!cane!tracks!the!movement!of!the!affected!leg,!consistent!with!normal!gait.!
!
!
Question!#315!
QID:!7913!
Topic:!Laboratory/Imaging!Investigations!
Subject:!PMCH!
!
A!healthy!45]year]old!male!comes!to!your!office!for!a!routine!visit.!Findings!are!normal!on!a!review!of!systems!and!
physical!examination.!After!you!discuss!the!findings!and!provide!routine!counseling!about!a!healthy!lifestyle,!the!
patient!asks!if!he!should!have!a!full]body!CT!scan!just!to!make!sure!he!is!healthy.!
!
Which!one!of!the!following!would!be!appropriate!advice?!
!
a)!!This!is!a!reasonable!option,!but!most!insurance!companies!will!not!pay!for!it!
b)!!The!chance!of!finding!an!abnormality!is!very!low,!but!for!a!person!anxious!about!his!or!her!health!the!reassurance!
is!worth!the!expense!
c)!!The!amount!of!radiation!exposure!from!low]dose!full]body!CT!is!minimal!
d)!!In!a!healthy!patient,!incidental!findings!will!lead!to!unnecessary!biopsies,!anxiety,!and!significant!radiation!
exposure!
!
!
149
!
Explanation:!
With!financial!incentives!driving!the!health!care!industry,!full]body!CT!has!been!promoted!by!private!scanning!
facilities.!However,!the!Preventive!Services!Task!Force,!the!College!of!Radiology,!and!many!other!organizations!that!
have!studied!full]body!CT!screening!are!opposed!to!it.!No!study!has!shown!the!final!outcome!of!such!screening!to!be!
in!the!best!interest!of!the!patient,!and!it!may!actually!be!detrimental.!
!
Although!the!initial!cost!of!$1000!may!seem!high!by!itself,!the!final!cost!also!includes!the!expense!of!further!testing!
due!to!false]positive!findings,!the!time!taken!off!work!for!the!initial!test,!and!the!time!required!for!any!further!tests!
and!consultations!that!might!take!place.!Various!studies!have!shown!that!significant!disease!is!found!in!1.9%]2.0%!of!
those!scanned,!yet!87%]91%!of!all!patients!scanned!will!have!positive!findings.!Of!these,!37%!will!be!asked!to!undergo!
further!studies!to!prove!the!findings!are!benign.!Findings!such!as!noncalcified!pulmonary!nodules!will!either!
necessitate!procedures!such!as!lung!needle!biopsies!or!wedge!resections,!or!will!be!left!alone,!causing!increased!
anxiety!to!the!patient!and!also!affecting!the!patient’s!future!insurability.!
!
The!radiation!exposure!from!a!full]body!CT!scan!is!estimated!to!be!equivalent!to!500!chest!radiographs,!or!100!chest!
radiographs!for!low]dose!scanning.!
!
!
Question!#316!
QID:!7914!
Subject:!PMCH!
!
A!48]year]old!white!female!who!has!always!been!in!good!health!sees!you!for!a!routine!check]up.!She!has!recently!had!
two!friends!affected!by!cardiovascular!disease,!and!asks!if!she!should!be!taking!any!drugs!to!help!her!stay!healthy.!
She!does!not!smoke!and!her!blood!pressure!is!130/85!mmHg.!Her!total!cholesterol!level!is!6!mmol/L,!with!an!HDL!
level!of!1.8!mmol/L!and!an!LDL!level!of!3.4!mmol/L.!Her!father!had!heart!problems!beginning!at!age!65.!
!
You!recommend!exercise,!maintaining!ideal!weight,!and!staying!on!a!low]saturated!fat!diet.!Which!one!of!the!
following!additional!recommendations!would!be!most!appropriate?!
!
a)!!Hydrochlorothiazide!to!lower!her!blood!pressure!to!<!120/80!mm!Hg,!plus!aspirin,!81!mg/day!
b)!!Hydrochlorothiazide!to!lower!her!blood!pressure!to!<!120/80!mm!Hg,!a!statin!to!lower!her!LDL!to!<!3.4!mmol/L,!
and!aspirin,!81!mg/day!
c)!!Aspirin,!81!mg/day!
d)!!Hydrochlorothiazide!to!lower!her!blood!pressure!to!<!120/80!mm!Hg,!plus!a!statin!to!lower!her!LDL!to!<!3.4!
mmol/L!
e)!!No!medications!
!
!
!
Explanation:!
Cardiovascular!risk!assessment,!using!the!“10]Year!Risk”!provided!by!the!Framingham!model,!should!be!completed!
every!3]5!years!for!men!age!40]75,!and!women!age!50]75!years.!This!should!be!modified!(percent!risk!doubled)!when!
family!history!of!premature!CVD!is!positive!(ie,!first]degree!relative!<!55!years!for!men!and!<!65!years!of!age!for!
women).!A!risk!assessment!might!also!be!completed!whenever!a!patient's!expected!risk!status!changes.!Younger!
individuals!with!at!least!one!risk!factor!for!premature!CVD!might!also!benefit!from!a!risk!assessment!to!motivate!
them!to!improve!their!lifestyle.!
This!patient!has!no!high!risk!features!and!her!FRS!is!less!than!10.!In!addition,!her!LDL!<!5!mmol/L,!therefore,!
pharmacologic!lipid]lowering!treatment!is!not!advised!(choice!E).!
!
!
Question!#317!
QID:!7915!
Subject:!PMCH!
150
!
A!55]year]old!male!with!a!5]year!history!of!type!2!diabetes!mellitus!comes!to!your!office!for!follow]up.!He!has!lost!9!
kg!(20!lb)!in!the!past!year!and!reports!good!control!of!his!glucose!levels.!His!examination!is!unremarkable,!and!his!
blood!pressure!is!130/80!mm!Hg.!Laboratory!results!reveal!a!normal!CBC!and!blood!chemistry,!and!his!urine!is!
negative!for!microalbumin.!His!hemoglobin!A1c!is!6.5%,!while!a!lipid!profile!reveals!an!HDL!level!of!2.3mmol/L,!an!LDL!
level!of!5.4mmol/L,!and!a!triglyceride!level!of!8.2mmol/L.!
!
This!patient’s!risk!of!sudden!death,!myocardial!infarction,!and!stroke!can!be!decreased!by!adding:!
!
a)!!Niacin!
b)!!Lisinopril!(Prinivil,!Zestril)!
c)!!Metoprolol!(Lopressor)!
d)!!Hydrochlorothiazide!
e)!!Simvastatin!(Zocor)!
!
!
!
Explanation:!
The!Heart!Protection!Study!demonstrated!a!significant!decrease!in!the!rates!of!major!vascular!events!(myocardial!
infarction,!stroke,!and!death)!when!simvastatin!was!added!to!the!medical!regimen!of!individuals!at!high!risk.!Benefits!
for!those!with!coronary!artery!disease,!peripheral!vascular!disease,!cerebrovascular!disease,!or!diabetes!mellitus,!and!
for!males!older!than!65!with!hypertension,!were!significant!regardless!of!lipid!levels.!
!
!
Question!#318!
QID:!7916!
Subject:!PMCH!
!
A!58]year]old!white!male!has!a!negative!screening!colonoscopy.!He!has!no!symptoms!and!no!family!history!of!colon!
carcinoma.!His!next!screening!colonoscopy!should!be!scheduled!in:!
!
a)!!1!year!
b)!!3!years!
c)!!5!years!
d)!!10!years!
!
!
!
Explanation:!
The!evidence!supports!a!10]year!interval!for!colonoscopy!in!patients!less!than!80!years!old.!
!
For!patients!with!a!family!history!of!colon!cancer!a!5]year!interval!is!recommended,!or!3!years!if!benign!polyps!are!
found.!
!
Screening!in!patients!over!80!years!old!is!controversial.!
!
!
Question!#319!
QID:!7918!
Topic:!Driving!Regulations!
Subject:!PMCH!
!
An!elderly!male!with!mild!dementia!is!involved!in!a!motor!vehicle!accident,!and!his!son!is!concerned!that!it!may!no!
longer!be!safe!for!him!to!drive.!Which!one!of!the!following!has!the!legal!authority!to!revoke!or!restrict!this!patient’s!
driver’s!license?!
151
!
a)!!The!patient's!son!
b)!!A!psychiatric!consultant!
c)!!The!person!designated!as!having!power!of!attorney!
d)!!The!family!physician!
e)!!Ministry!of!Transportation!
!
!
!
Explanation:!
The!family!physician!or!a!consulting!psychiatrist!can!make!recommendations!regarding!driving,!and!the!patient’s!
family!or!the!person!designated!as!having!power!of!attorney!can!withhold!access!to!a!vehicle.!
In!Ontario!the!law!requires!that!physicians!report!patients!who,!in!the!opinion!of!the!physician,!may!be!unfit!to!drive!
for!medical!reasons.!A!report!is!sent!to!Ministry!of!Transportation.!Some!cases!are!more!complex!and/or!have!
technical!test!reports/results!and!require!a!review!by!the!ministry's!Medical!Advisory!Committee.!
!
Medical!reports!are!prioritized!according!to!the!risk!to!road!safety!as!either!high!risk!or!low!risk.!
High!risk!conditions!are!conditions!that!are!chronic,!deteriorating,!unstable!or!progressive!such!as!
Advanced!dementia!or!Alzheimer's!disease!
Uncontrolled!seizures!or!diabetes!
Substance!abuse,!psychiatric!disorders!with!symptoms!of!suicidal!thoughts,!extreme!agitation,!impulsive!or!violent!
behaviour!etc.!
Uncontrolled!sleep!apnea!refusing!treatment!
Low!risk!conditions!are!deemed!to!be!those!that!do!not!pose!an!immediate!or!serious!risk!to!road!safety;!conditions!
that!are!stable!and/or!temporary,!such!as!
Controlled!sleep!apnea!
Seizure!occurring!one!year!ago!or!more!
Controlled!diabetes!
Heart!disease!
Reactive!depression!
Cast/splints!
Stable!psychiatric!disorders!
(www.mto.gov.on.ca)!
!
!
Question!#320!
QID:!7919!
Subject:!PMCH!
!
A!63]year]old!female!presents!for!a!routine!evaluation.!She!asks!if!she!and!her!husband,!age!69,!would!benefit!from!
the!herpes!zoster!vaccine.!You!advise!her!that:!
!
a)!!The!vaccine!is!more!than!90%!effective!in!preventing!herpes!zoster!
b)!!Postherpetic!pain!reduction!is!the!greatest!benefit!of!the!vaccine!
c)!!The!efficacy!of!the!vaccine!decreases!after!age!70!
d)!!The!vaccine!reduces!both!incidence!of!herpes]zoster!and!severity!of!postherpetic!neuralgia!
e)!!The!vaccine!is!safely!administered!to!the!immunodeficient!population.!
!
!
!
Explanation:!
The!live!attenuated!varicella]zoster!vaccine!has!been!shown!to!reduce!outbreaks!of!herpes!zoster!by!51%!in!
vaccinated!individuals.!The!greatest!benefit!is!the!reduction!in!the!severity!and!duration!of!postherpetic!neuralgia.!
Efficacy!does!not!decrease!after!age!70,!the!age!group!at!greatest!risk!for!postherpetic!neuralgia.!The!vaccine!is!
contraindicated!in!the!immunodeficient!population.!
152
!
!
Question!#321!
QID:!7920!
Topic:!Drug!Adverse!Effects!
Subject:!PMCH!
!
Which!one!of!the!following!is!a!significant!side!effect!of!varenicline!(Chantix)?!
!
a)!!Facial!hirsutism!
b)!!Paroxysmal!dysrhythmias!
c)!!Pleurisy]like!symptoms!
d)!!Suicidal!ideation!
e)!!Constipation!
!
!
!
Explanation:!
Education,!support,!and!medications!are!all!valuable!tools!in!assisting!patients!with!a!smoking!habit.!Varenicline,!a!
clinically!effective!smoking]cessation!product,!has!been!associated!with!patient!mood!changes!following!the!initiation!
of!therapy,!including!suicidal!thoughts!and!aggressive!and!erratic!behaviour.!
!
!
Question!#322!
QID:!7923!
Topic:!Exercise!Routine!
Subject:!PMCH!
!
At!a!routine!visit,!a!40]year]old!female!asks!about!beginning!an!exercise!regimen.!She!has!a!family!history!of!heart!
disease!and!hypertension.!She!currently!has!no!medical!problems,!but!she!is!sedentary.!
!
Which!one!of!the!following!would!be!the!most!appropriate!recommendation!for!this!patient?!
!
a)!!Fast!walking!for!30!minutes!on!5!or!more!days!per!week!
b)!!Jogging!for!30!minutes!every!other!day!
c)!!Weight!training!once!weekly!
d)!!An!exercise!stress!test!prior!to!beginning!exercise!
e)!!A!baseline!EKG!and!rhythm!strip!
!
!
!
Explanation:!
This!patient!would!benefit!from!exercise!to!prevent!or!delay!the!onset!of!heart!disease!and!hypertension,!and!to!
manage!her!weight.!Exercise!stress!testing!is!not!specifically!indicated!for!this!patient.!Current!recommendations!are!
for!healthy!adults!to!engage!in!30!minutes!of!accumulated!moderate]intensity!physical!activity!on!5!or!more!days!per!
week.!
!
!
Question!#323!
QID:!7924!
Topic:!Skin!Infection!
Subject:!PMCH!
!
The!most!common!identifiable!cause!of!skin!and!soft]tissue!infections!presenting!to!metropolitan!emergency!
departments!is:!
!
153
a)!!Staphylococcus!epidermidis!
b)!!Streptococcus!pneumoniae!
c)!!Pseudomonas!aeruginosa!
d)!!Methicillin]resistant!Staphylococcus!aureus!(MRSA)!
e)!!Bacillus!cereus!
!
!
!
Explanation:!
Recent!clinical!experience!has!shown!that!methicillin]resistant!Staphylococcus!aureus!(MRSA)!is!the!most!common!
identifiable!cause!of!skin!and!soft]tissue!infections!among!patients!presenting!to!emergency!departments.!The!other!
responses!should!be!considered!in!evaluating!these!infections,!but!they!are!not!as!common!as!MRSA!infections.!
!
!
Question!#324!
QID:!7925!
Topic:!Abuse!
Subject:!PMCH!
!
!
It!would!be!most!appropriate!to:!
!
a)!!Arrange!for!the!child!to!be!admitted!for!evaluation!and!protection!
b)!!Discharge!the!child!to!another!relative!or!neighbor!if!available!
c)!!Keep!the!child!and!initiate!foster!care!placement!
d)!!Send!the!child!home!with!his!parents,!but!notify!the!police!of!the!situation!
e)!!Send!the!child!home!and!arrange!for!a!social!worker!to!make!a!family!assessment!on!a!home!visit!
!
!
!
Explanation:!
Most!states!have!laws!that!mandate!that!a!clinician!who!suspects!physical!or!sexual!abuse!must!act!immediately,!
separating!the!child!from!the!parents!if!necessary.!Discharge!to!another!relative!or!neighbor!will!not!prevent!the!
abusing!parent!from!retrieving!the!child!and!inflicting!further!abuse.!Foster!care!placement!can!only!be!applied!for!
after!there!is!proof!of!physical!abuse.!If!your!suspicions!of!abuse!are!high,!do!not!send!the!child!home!with!the!
parents!under!any!circumstances.!
!
Again,!sending!the!child!home,!even!with!an!impending!social!work!evaluation,!leaves!the!child!open!for!continued!
abuse.!When!angered,!the!abusing!parent!may!inflict!greater!injury!after!a!quiescent!phase,!resulting!in!death!of!the!
child.!In!a!possible!abuse!case,!the!physician!should!take!steps!to!both!protect!the!child!and!investigate!further.!
!
!
Question!#325!
QID:!8707!
Topic:!Osteoporosis!Prevention!
Subject:!PMCH!
!
The!most!effective!daily!doses!of!vitamin!D!and!calcium!for!hip!fracture!prevention!in!postmenopausal!women!are:!
a)!!800!IU!vitamin!D!and!500!mg!calcium!
b)!!400!IU!vitamin!D!and!500!mg!calcium!
c)!!400!IU!vitamin!D!and!1000!mg!calcium!
154
d)!!800!IU!vitamin!D!and!1200!mg!calcium!
e)!!1200!IU!vitamin!D!and!1200!mg!calcium!
!
!
!
Explanation:!
The!most!effective!daily!dose!of!vitamin!D!for!hip!fracture!prevention!in!postmenopausal!women!is!800!IU,!and!the!
recommended!daily!dose!of!calcium!is!1200!mg!(choice!D).!
!
NIH!recommended!daily!intake!
Elemental!calcium!and!vitamin!D!
19]50!years:!1000!mg/200!IU!daily!
≥!51]70!years!(females):!1200!mg/400!IU!
≥!51!years!(males):!1000!mg/400!IU!
≥!70!years!(females):!1200!mg/600!IU!
Osteoporosis!prevention!in!adults!≥!50!years:!Vitamin!D!intake!may!need!to!be!increased!to!800]1000!IU/day!
!
!
Question!#326!
QID:!8725!
Subject:!PMCH!
!
During!a!routine!office!visit,!a!19]year]old!patient!requests!contraception.!After!discussing!options,!you!prescribe!an!
oral!contraceptive.!Several!days!later!her!father!calls,!asking!if!you!prescribed!oral!contraceptives!for!his!daughter.!
!
Your!response!is!best!guided!by!which!of!the!following!principles?!
!
a)!!Honesty!
b)!!Beneficence!
c)!!Confidentiality!
d)!!Informed!consent!
e)!!Justice!
!
!
!
Explanation:!
Beneficence!is!the!obligation!to!promote!the!wellbeing!of!others.!
Justice!is!the!right!of!individuals!to!claim!what!is!due!them!based!on!certain!personal!properties!or!characteristics.!
Informed!consent!can!be!defined!as!the!willing!acceptance!of!a!medical!intervention!after!adequate!disclosure!by!the!
physician.!
Honesty!means!that!the!patient!is!given!complete!and!truthful!information!about!her!condition.!
Confidentiality!means!that!a!patient!has!the!right!to!make!decisions!about!her!own!care!and!to!decide!to!whom!these!
decisions!and!her!medical!information!are!communicated.!
!
!
Question!#327!
QID:!8728!
Topic:!Aging!Changes!
Subject:!PMCH!
!
A!patient!complains!that!her!otherwise!healthy!66]year]old!husband!takes!longer!to!achieve!an!erection!that!he!did!at!
age!40.!You!advise!that:!
!
a)!!At!his!age,!sexual!response!is!naturally!slower!
b)!!He!makes!an!appointment!with!a!sex!therapist!
155
c)!!He!takes!20!mg!of!methyltestosterone!daily!
d)!!She!uses!psychogenic!stimulation!
e)!!He!makes!an!appointment!with!a!urologist!
!
!
!
Explanation:!
Part!of!the!normal!aging!process!changes!in!the!human!sexual!response.!Although!it!is!natural!for!a!66—year]old!man!
to!take!longer!to!achieve!an!erection,!it!is!possible!that!other!factors!may!be!involved.!This!includes!the!use!of!other!
medications!and!chronic!medical!conditions.!Should!this!be!the!case,!then!appropriate!referral!is!indicated.!
!
!
Question!#328!
QID:!8739!
Subject:!PMCH!
!
An!84]year]old!woman!is!brought!to!the!office!by!her!daughter,!who!is!your!patient.!The!mother!has!just!moved!in!
with!the!family!because!she!can!no!longer!care!for!herself!due!to!progressive,!long]standing!dementia.!On!physical!
examination!the!mother!does!not!respond!to!your!words!or!to!the!physical!examination.!You!notice!that!she!smells!of!
urine.!On!examination!of!the!pelvis!there!is!a!diffuse!erythematous!rash!extending!over!the!perineum!and!the!medial!
thighs!bilaterally.!You!suspect!the!rash!relates!to!urinary!incontinence.!
!
Which!of!the!following!is!the!most!appropriate!statement!to!the!daughter?!
!
a)!!"How!long!have!you!left!your!mother!in!this!condition?"!
b)!!"This!is!a!rash!caused!by!urine.!My!nurse!will!insert!a!Foley!catheter."!
c)!!"This!rash!should!respond!to!cleansing!with!mild!soap!and!drying!with!a!clean!towel!three!times!a!day."!
d)!!"You!should!take!better!care!of!your!mother."!
e)!!"Your!mother!needs!to!wear!diapers."!
!
!
!
Explanation:!
This!choice!demonstrates!that!the!physician!is!in!the!position!of!offering!guidance!for!care!of!this!elderly!woman.!
Answers!a)!and!d)!indicate!that!the!physician!is!disapproving!of!the!daughter’s!care,!and!in!admonishing!her,!
demonstrates!a!lack!of!empathy.!Answers!b)!and!e)!are!inappropriate!suggestions,!but!answer!c)!indicates!a!safe,!
practical,!and!noninvasive!approach!to!treatment!of!this!patient.!
!
!
Question!#329!
QID:!8740!
Topic:!Physical!Abuse!
Subject:!PMCH!
!
A!44]year]old!housewife!and!mother!of!four!children!(ages!6!to!13!years)!has!been!coming!to!you!for!management!of!
tension!headaches!that!have!not!improved!with!trials!of!several!appropriate!medications.!She!has!been!married!to!a!
police!officer!for!the!past!six!years.!You!ask!if!she!has!been!under!extra!stress,!and!she!begins!to!cry.!You!notice!
bruises!on!her!arms.!On!further!questioning,!you!learn!that!her!husband!hits!her!whenever!he!is!drunk,!which!is!at!
least!two!nights!per!week.!Her!husband!is!also!a!patient!of!yours.!
!
Which!of!the!following!is!the!most!appropriate!intervention?!
!
a)!!Advise!her!to!leave!her!home!with!her!children!and!move!in!with!her!relatives!
b)!!Contact!her!husband's!supervisor!to!discuss!recent!stress!levels!on!the!job!
c)!!Gather!more!information!while!remaining!neutral,!since!both!the!husband!and!wife!are!your!patients!
156
d)!!Refer!her!to!a!domestic!violence!program!
e)!!Seek!a!restraining!order!against!her!husband!on!her!behalf!
!
!
!
Explanation:!
In!this!case!the!physician!must!act!as!an!advocate!for!this!woman.!The!question!clearly!describes!evidence!of!physical!
abuse!and!an!ongoing!risk!of!possible!physical!harm!from!this!husband.!In!this!regard!the!physician!should!refer!the!
patient!to!a!battered!women’s!program!much!in!the!same!way!that!a!pediatrician!would!contact!the!bureau!of!child!
welfare!if!he!suspected!child!abuse.!Choices!a),!c)!and!e)!offer!logistical!advice!that!do!not!directly!address!protection!
of!the!woman.!Contacting!her!husband’s!supervisor!would!violate!confidentiality.!Although!both!the!husband!and!
wife!may!be!patients!of!this!physician,!the!woman!is!clearly!the!individual!who!is!at!ongoing!risk.!
!
!
Question!#330!
QID:!8747!
Topic:!Physician's!Duty!to!Warn!and!Protect!
Subject:!PMCH!
!
A!45]year]old!male!presents!to!your!office!in!extreme!agitation!after!a!verbal!altercation!with!his!boss,!during!which!
he!was!fired.!He!feels!overwhelmed!and!very!angry,!and!states!that!he!is!going!to!“get”!his!boss!and!then!“who!knows!
what.”!
!
Which!one!of!the!following!is!true!regarding!this!situation?!
a)!!Physicians!have!a!duty!to!warn!and!protect!intended!victims!of!a!patient!
b)!!It!is!dangerous!to!ask!the!patient!about!suicidal!tendencies!
c)!!If!the!patient!is!at!high!risk!for!suicide!and!needs!inpatient!care,!but!refuses,!he!may!be!allowed!to!go!home!if!
accompanied!by!a!family!member!
d)!!You!and!your!staff!are!not!at!risk!for!harm!
e)!!The!patient's!family!may!be!reassured!that!they!are!not!at!risk!for!harm,!as!only!his!boss!has!been!directly!
threatened!
!
!
!
Explanation:!
It!has!been!legally!established!that!physicians!have!a!duty!to!warn!and!protect!intended!victims!of!a!patient.!
Evaluation!of!suicide!and!homicide!risks!in!a!crisis!situation,!including!direct!questioning!of!the!patient!about!suicidal!
and!homicidal!tendencies,!is!important!and!does!not!lead!to!further!harm.!If!a!suicidal!or!homicidal!patient!who!
needs!hospitalization!refuses,!law!enforcement!authorities!should!be!contacted.!Policies!should!be!in!place!to!ensure!
the!safety!of!clinic!staff!in!crisis!situations.!The!patient’s!family!may!be!at!risk!for!harm,!and!plans!to!ensure!their!
safety,!if!needed,!are!appropriate.!
!
!
Question!#331!
QID:!10245!
Topic:!Gender!Pharmacokinetic!
Subject:!PMCH!
!
Which!one!of!the!following!is!a!physiologic!difference!between!males!and!females!that!can!affect!the!
pharmacokinetics!of!medications!with!a!narrow!therapeutic!index?!
!
a)!!A!consistently!higher!glomerular!filtration!rate!in!women!
b)!!The!typically!higher!BMI!in!women!
c)!!Smaller!fat!stores!in!women!
d)!!Greater!gastric!acid!secretion!in!women!
e)!!Slower!gastrointestinal!transit!times!in!women!
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!
!
!
Explanation:!
There!are!key!physiologic!differences!between!women!and!men!that!can!have!important!implications!for!drug!
activity.!Gastrointestinal!transit!times!are!slower!in!women!than!in!men,!which!can!diminish!the!absorption!of!
medications!such!as!metoprolol,!theophylline,!and!verapamil.!In!addition,!women!should!wait!longer!after!eating!
before!taking!medications!that!should!be!administered!on!an!empty!stomach,!such!as!ampicillin,!captopril,!
levothyroxine,!loratadine,!and!tetracycline.!
!
Women!also!secrete!less!gastric!acid!than!men,!so!they!may!need!to!drink!an!acidic!beverage!to!aid!in!absorption!of!
medications!that!require!an!acidic!environment,!such!as!ketoconazole.!Women!usually!have!lower!BMIs!than!men,!
and!may!need!smaller!loading!or!bolus!dosages!of!medications!to!avoid!unnecessary!adverse!reactions.!Women!
typically!have!higher!fat!stores!than!men,!so!lipophilic!drugs!such!as!benzodiazepines!and!neuromuscular!blockers!
have!a!longer!duration!of!action.!Women!also!have!lower!glomerular!filtration!rates!than!men,!resulting!in!slower!
clearance!of!medications!that!are!eliminated!renally,!such!as!digoxin!and!methotrexate.!
!
!
Question!#332!
QID:!10256!
Subject:!PMCH!
!
Mr.!and!Mrs.!Smith,!74!and!72]year]old!respectively,!come!to!clinic!for!herpes!zoster!(HZ)!vaccination.!They!report!
that!Mrs.!Smith!had!HZ!infection!5!years!ago!and!she!described!the!pain!as!“worse!than!childbirth.”!Mr.!Smith's!past!
history!of!chicken!pox!is!unknown.!They!know!they!have!to!pay!out!of!pocket!for!the!vaccines.!Assuming!there!are!no!
contradictions!for!the!vaccination,!what!would!be!the!most!appropriate!recommendation?!
a)!!Neither!of!them!needs!vaccination!
b)!!Both!of!them!could!have!the!vaccine.!
c)!!Vaccination!is!recommended!for!Mr.!Smith!but!not!for!Mrs.!Smith.!
d)!!Vaccination!is!recommended!for!Mrs.!Smith!but!not!for!Mr.!Smith.!
e)!!Mr.!Smith's!immunity!levels!need!to!be!tested!first.!
!
!
!
Explanation:!
Shingles!vaccine!is!recommended!by!the!Advisory!Committee!on!Immunization!Practices!(ACIP)!to!reduce!the!overall!
burden!and!severity!of!herpes!zoster!and!its!associated!pain!in!people!60!years!old!or!older!without!contraindications.!
The!vaccine!reduces!the!incidence!of!herpes!zoster!(HZ)!by!about!50%!and!the!occurrence!of!postherpetic!neuralgia!
(PHN)!by!two]thirds,!with!vaccinated!individuals!experiencing!attenuated!or!shortened!symptoms.!
!
>!Having!an!episode!of!HZ!has!an!immunizing!effect,!greatly!reducing!the!probability!of!a!second!event.!That!said,!
patients!with!a!history!of!severe!HZ!are!often!the!most!insistent!on!receiving!the!vaccine,!and!concerns!have!been!
raised!about!the!validity!of!patient!histories!of!HZ.!For!these!reasons,!both!the!Centers!for!Disease!Control!and!
Prevention!and!the!ACIP!recommend!that!adults!be!vaccinated!whether!or!not!they!report!a!previous!episode!of!HZ.!
>!An!estimated!90%!of!Canadian!adults!have!had!a!previous!varicella]zoster!virus!(VZV)!infection.!Thus,!almost!all!
adults!60!years!of!age!or!older!have!been!infected!with!VZV,!regardless!of!patient]reported!history!or!recall.!There!is!
no!need!to!test!immunity!levels!before!administering!the!vaccine.!
!
The!herpes!zoster!(HZ)!vaccine!is!a!safe!and!effective!preventive!measure!for!reducing!the!overall!burden!and!severity!
of!HZ!in!adults!aged!60!years!and!older.!
!
!
Question!#333!
QID:!10268!
Topic:!Pertussis!Treatment!Rationale!
158
Subject:!PMCH!
!
Which!one!of!the!following!is!an!appropriate!rationale!for!antibiotic!treatment!of!Bordetella!pertussis!infections?!
!
a)!!It!delays!progression!from!the!catarrhal!stage!to!the!paroxysmal!stage!
b)!!It!is!indicated!if!symptoms!are!present!for!longer!than!a!month!
c)!!It!reduces!the!duration!of!illness!
d)!!It!reduces!the!risk!of!transmission!to!others!
e)!!It!reduces!the!need!for!hospitalization!
!
!
!
Explanation:!
Antibiotic!treatment!for!pertussis!will!decrease!infectivity!and!symptom!severity!but!not!change!course!of!illness.!
Antimicrobial!therapy!is!indicated!if!B.!pertussis!is!isolated,!or!symptoms!are!present!for!<21!days.!
!
The!CDC!recommends!macrolides!for!primary!treatment!of!pertussis.!The!preferred!antimicrobial!regimen!is!
azithromycin!for!3]5!days!or!clarithromycin!for!7!days.!These!regimens!are!as!effective!as!longer!therapy!with!
erythromycin!and!have!fewer!side!effects.!Children!under!1!month!of!age!should!be!treated!with!azithromycin.!There!
is!an!association!between!erythromycin!and!hypertrophic!pyloric!stenosis!in!young!infants.!
Trimethoprim/sulfamethoxazole!can!be!used!in!patients!who!are!unable!to!take!macrolides!or!where!macrolide!
resistance!may!be!an!issue,!but!should!not!be!used!in!children!under!the!age!of!2!months.!Fluoroquinolones!have!
been!shown!to!reduce!pertussis!in!vitro!but!have!not!been!shown!to!be!clinically!effective!(SOR!A).!
!
!
Question!#334!
QID:!10270!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!concerning!breast!cancer!screening?!
!
a)!!It!is!useful!for!detecting!premalignant!conditions!
b)!!It!can!predict!which!of!the!discovered!cancers!are!indolent,!with!a!low!potential!for!harm!
c)!!The!decrease!in!mortality!from!breast!cancer!can!be!attributed!almost!entirely!to!early!detection!
d)!!It!has!resulted!in!an!increase!in!the!diagnosis!of!localized!disease!
e)!!It!has!resulted!in!a!significant!decrease!in!the!incidence!of!regional!and!metastatic!disease!
!
!
!
Explanation:!
Breast!cancer!screening!has!resulted!in!an!increase!in!the!diagnosis!of!localized!disease!without!a!commensurate!
decrease!in!the!incidence!of!more!widespread!disease.!Unfortunately,!it!cannot!predict!which!of!the!discovered!
cancers!are!more!aggressive,!and!cannot!accurately!detect!premalignant!lesions.!
!
The!decrease!in!the!mortality!rate!of!breast!cancer!is!due!both!to!earlier!detection!and!better!follow]up!medical!care.!
!
!
Question!#335!
QID:!10275!
Topic:!NSAIDs!Contraindication!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!NSAIDs?!
!
a)!!They!are!cardioprotective!
159
b)!!They!should!be!avoided!in!persons!with!cirrhotic!liver!disease!
c)!!Asthma!is!not!affected!by!NSAIDs!
d)!!They!are!all!contraindicated!in!lactating!women!
e)!!!They!should!be!avoided!in!pregnancy;!may!cause!patent!ductus!arteriosus!
!
!
!
Explanation:!
NSAIDs!are!prescribed!commonly!and!many!are!available!over!the!counter.!It!is!important!for!clinicians!to!understand!
when!they!are!not!appropriate!for!clinical!use.!They!should!be!avoided,!if!possible,!in!persons!with!hepatic!cirrhosis.!
While!hepatotoxicity!with!NSAIDs!is!rare,!they!can!increase!the!risk!of!bleeding!in!cirrhotic!patients,!as!they!further!
impair!platelet!function.!In!addition,!NSAIDs!decrease!blood!flow!to!the!kidneys!and!can!increase!the!risk!of!renal!
failure!in!patients!with!cirrhosis.!
!
>!Although!aspirin!is!cardioprotective,!other!NSAIDs!can!worsen!congestive!heart!failure,!can!increase!blood!pressure,!
and!are!related!to!adverse!cardiovascular!events,!such!as!myocardial!infarction!and!ischemia.!
>!Asthma!may!be!induced!or!exacerbated!by!NSAIDs.!
>!Ibuprofen,!indomethacin,!and!naproxen!are!considered!safe!for!lactating!women.!
>!Although!most!NSAIDs!are!likely!safe!in!pregnancy,!they!should!be!avoided!in!the!last!six!to!eight!weeks!of!
pregnancy!to!prevent!prolonged!gestation!from!inhibition!of!prostaglandin!synthesis,!premature!closure!of!the!ductus!
arteriosus,!and!maternal!and!fetal!complications!from!antiplatelet!activity.!
!
!
Question!#336!
QID:!10296!
Topic:!Latent!Tuberculosis!Screening!
Subject:!PMCH!
!
A!40]year]old!male!who!recently!immigrated!from!central!Africa!presents!to!a!public!health!clinic!where!you!are!
working.!He!was!referred!by!a!physician!in!the!local!emergency!department,!who!made!a!diagnosis!of!type!2!diabetes!
mellitus.!The!patient!has!no!history!of!fever!or!night!sweats,!weight!loss,!or!cough.!He!does!have!a!history!of!receiving!
bacille!Calmette]Guérin!(BCG)!vaccine!in!the!past.!Screening!tests!for!HIV!and!hepatitis!performed!in!the!emergency!
department!were!negative.!
!
Which!one!of!the!following!is!true!regarding!screening!for!latent!tuberculosis!infection!by!in!vitro!interferon]gamma!
release!assay!(IGRA)!compared!to!screening!by!the!traditional!targeted!tuberculin!skin!test!(TST)!in!this!patient?!
a)!!Both!tests!require!subjective!interpretation!
b)!!BCG!vaccine!interferes!with!IGRA!results!
c)!!IGRAs!cannot!distinguish!between!latent!infection!and!active!tuberculosis!(TB)!disease,!and!should!not!be!used!for!
diagnosis!of!active!TB.!
d)!!IGRA!results!are!valid!if!the!sample!is!analyzed!within!24!hours!
e)!!IGRA!should!be!done!in!tandem!with!TST!
!
!
!
Explanation:!
In!vitro!interferon]gamma!release!assays!(IGRAs)!are!a!new!way!of!screening!for!latent!tuberculosis!infection.!One!of!
the!advantages!of!IGRA!is!that!it!targets!antigens!specific!to!Mycobacterium!tuberculosis.!These!proteins!are!absent!
from!the!BCG!vaccine!strains!and!from!commonly!encountered!nontuberculous!mycobacteria.!Unlike!skin!testing,!the!
results!of!IGRA!are!objective.!It!is!unnecessary!for!IGRA!to!be!done!in!tandem!with!skin!testing,!and!it!eliminates!the!
need!for!two]step!testing!in!high]risk!patients.!IGRAs!are!labor!intensive,!however,!and!the!blood!sample!must!be!
received!by!a!qualified!laboratory!and!incubated!with!the!test!antigens!within!12!hours!of!the!time!it!was!drawn.!
!
IGRAs!do!not!help!differentiate!latent!tuberculosis!infection!(LTBI)!from!tuberculosis!disease.!A!diagnosis!of!LTBI!
requires!that!TB!disease!be!excluded!by!medical!evaluation.!This!should!include!checking!for!signs!and!symptoms!
suggestive!of!TB!disease,!a!chest!radiograph,!and,!when!indicated,!examination!of!sputum!or!other!clinical!samples!
160
for!the!presence!of!M.!tuberculosis.!
!
!
!
Tuberculosis!
!
!
Question!#337!
QID:!10300!
Topic:!Colonoscopy!Screening!Guidelines!
Subject:!PMCH!
!
On!his!first!screening!colonoscopy,!a!67]year]old!male!is!found!to!have!a!0.5]cm!adenomatous!polyp!with!low]grade!
dysplasia.!
According!to!current!guidelines,!when!should!this!patient!have!his!next!colonoscopy?!
a)!!6!months!
b)!!1!year!
c)!!3!years!
d)!!5!years!
e)!!Screening!is!no!longer!necessary!
!
!
!
Explanation:!
Overuse!of!colonoscopy!has!significant!costs.!According!to!current!guidelines,!patients!with!one!or!two!small!(<!1!cm)!
tubular!adenomas,!including!those!with!only!low]grade!dysplasia,!should!have!their!next!colonoscopy!in!5!years.!
!
!
Question!#338!
QID:!10315!
Topic:!TB!
Subject:!PMCH!
!
Which!one!of!the!following!Mantoux!tuberculin!skin!test!results!should!be!read!as!negative!for!latent!tuberculosis!
infection?!
!
a)!!7!mm!induration!on!an!individual!having!recent!household!contact!with!a!tuberculosis!patient!
b)!!8!mm!induration!on!an!HIV]positive!individual!who!has!no!documented!previous!test!result!
c)!!10!mm!induration!on!a!nursing]home!resident!
d)!!12!mm!induration!on!a!homeless!individual!
e)!!9!mm!induration!on!a!hospital]based!nurse!who!had!a!test!with!2!mm!induration!1!year!ago!
!
!
!
Explanation:!
Three!different!cutoff!levels!defining!a!positive!reaction!on!a!tuberculin!skin!test!are!recommended,!each!based!on!
the!level!of!risk!and!consideration!of!immunocompetence.!
!
>!For!those!who!are!at!highest!risk!and/or!immunocompromised,!including!HIV]positive!patients!(choice!B),!
transplant!patients,!and!household!contacts!of!a!tuberculosis!patient!(choice!A),!an!induration!5!mm!is!considered!
positive.!
>!For!those!at!low!risk!of!exposure,!a!screening!test!is!not!recommended,!but!if!one!is!performed,!≥15!mm!is!
considered!positive.!
>!For!those!who!have!an!increased!probability!of!exposure!or!risk,!an!induration!10mm!should!be!read!as!positive.!
This!group!includes!children;!employees!or!residents!of!nursing!homes!(choice!C),!correctional!facilities,!or!homeless!
shelters!(choice!D);!recent!immigrants;!intravenous!drug!users;!hospital!workers;!and!those!with!chronic!illnesses.!
161
>!For!individuals!who!are!subject!to!repeated!testing,!such!as!health]care!workers,!an!increase!in!induration!of!10!mm!
or!more!within!a!2]year!period!would!be!considered!positive!and!an!indication!of!a!recent!infection!with!
Mycobacterium!tuberculosis.!A!nurse!with!a!9]mm!induration!would!be!considered!to!have!a!negative!PPD!]!choice!E!
is!the!correct!answer.!
!
!
Question!#339!
QID:!10316!
Topic:!Coronary!Heart!Disease!Risk!Factors!
Subject:!PMCH!
!
Estimating!the!10]year!risk!of!developing!coronary!heart!disease!with!the!Framingham!Heart!Study!Score!Sheet!would!
be!most!reliable!when!applied!to!which!one!of!the!following!individuals?!
!
a)!!A!19]year]old!female!with!a!strong!family!history!of!cardiac!disease!
b)!!An!obese!50]year]old!male!with!a!history!of!a!previous!myocardial!infarction!
c)!!An!otherwise!healthy!36]year]old!white!male!smoker!
d)!!A!postmenopausal!54]year]old!female!with!angina!
e)!!A!78]year]old!male!with!a!history!of!hypertension!
!
!
!
Explanation:!
The!10]year!risk!of!developing!coronary!heart!disease!can!be!effectively!predicted!with!the!algorithmic!calculator!
developed!using!multivariable!data!collected!over!a!period!of!more!than!half!a!century!as!part!of!the!Framingham!
Heart!Study.!This!iconic!study!defined!what!are!now!commonly!known!as!major!risk!factors:!elevated!blood!pressure,!
cigarette!smoking,!cholesterol!levels,!diabetes!mellitus,!and!advancing!age.!Using!measurements!of!each!of!these!risk!
factors!and!consideration!of!the!gender!of!the!individual,!a!reliable!determination!of!risk!can!be!obtained!in!
individuals!30]74!years!of!age!who!have!no!overt!coronary!heart!disease.!The!largely!white!study!population!
presumptively!makes!the!risk!determination!most!accurate!for!white!patients.!
!
!
Question!#340!
QID:!10321!
Topic:!Anticoagulation!Guidelines!
Subject:!PMCH!
!
Which!one!of!the!following!would!be!most!appropriate!for!stroke!prevention!in!a!patient!with!hypertension,!diabetes!
mellitus,!and!atrial!fibrillation?!
!
a)!!Clopidogrel!
b)!!Aspirin!
c)!!Dipyridamole!
d)!!Warfarin!
e)!!Enoxaparin!
!
!
!
Explanation:!
The!CHADS2!score!is!a!validated!clinical!prediction!rule!for!determining!the!risk!of!stroke!and!who!should!be!
anticoagulated.!Points!are!assigned!based!on!the!patient’s!comorbidities.!One!point!is!given!for!each!of!the!following:!
history!of!congestive!heart!failure!(C),!hypertension!(H),!age!75!(A),!and!diabetes!mellitus!(D).!Two!points!are!assigned!
for!a!previous!stroke!or!TIA!(S2).!
!
For!patients!with!a!score!of!0!or!1,!the!risk!of!stroke!is!low!and!warfarin!would!not!be!recommended.!Warfarin!is!the!
agent!of!choice!for!the!prevention!of!stroke!in!patients!with!atrial!fibrillation!and!a!score!>2.!In!these!patients,!the!risk!
162
of!stroke!is!higher!than!the!risks!associated!with!taking!warfarin.!
!
Enoxaparin!is!an!expensive!injectable!anticoagulant!and!is!not!indicated!for!the!long]term!prevention!of!stroke.!
!
!
Question!#341!
QID:!10322!
Topic:!Vitamin!B12!Deficiency!Work!Up!
Subject:!PMCH!
!
An!elevation!of!serum!methylmalonic!acid!is!both!sensitive!and!specific!for!a!cellular!deficiency!of!which!vitamin?!
!
a)!!Vitamin!A!
b)!!Vitamin!B6!
c)!!Vitamin!B12!
d)!!Vitamin!D!
e)!!Folate!
!
!
!
Explanation:!
An!elevation!in!serum!methylmalonic!acid!is!both!sensitive!and!specific!for!cellular!vitamin!B!12!deficiency.!
!
!
!
Vitamin!B12!Deficiency!
!
!
Question!#342!
QID:!10323!
Topic:!Hypertension!With!Comorbidity!Management!
Subject:!PMCH!
!
The!Canadian!Hypertension!Education!Panel!(CHEP),!in!collaboration!with!the!Canadian!Diabetes!Association,!have!
recommended!that!patients!with!diabetes!mellitus!should!be!treated!to!attain!BP!of:!
!
a)!!<!140/95!mm!Hg!
b)!!<!135/90!mm!Hg!
c)!!<!130/80!mm!Hg!
d)!!<!120/80!mm!Hg!
e)!!<!120/75!mm!Hg!
!
!
!
Explanation:!
Persons!with!diabetes!mellitus!should!be!treated!to!attain!SBP!<130!mm!Hg!and!DBP!<80!mm!Hg.!These!target!BP!
levels!are!the!same!as!the!BP!treatment!thresholds.!Combination!therapy!using!2!first]line!agents!may!also!be!
considered!as!initial!treatment!of!hypertension!if!SBP!is!20!mm!Hg!above!target!or!if!DBP!is!10!mm!Hg!above!target.!
However,!caution!should!be!exercised!in!patients!in!whom!a!substantial!fall!in!BP!is!more!likely!or!poorly!tolerated!
(e.g.!elderly!patients,!patients!with!autonomic!neuropathy).!
!
{Treatment!of!Hypertension!Canadian!Diabetes!Association!Clinical!Practice!Guidelines!Expert!Committee,!2013}!
!
!
!
Question!#343!
163
QID:!10337!
Topic:!Hypoglycemic!Agents!Effects!
Subject:!PMCH!
!
The!best!available!evidence!supports!which!one!of!the!following!statements!regarding!the!cardiovascular!effects!of!
hypoglycemic!agents?!
!
a)!!Sulfonylureas!increase!cardiovascular!events!
b)!!Metformin!(Glucophage)!reduces!cardiovascular!mortality!rates!
c)!!Incretin!mimetics!reduce!the!risk!of!cardiovascular!events!
d)!!Alpha]Glucosidase!inhibitors!have!no!effect!on!cardiovascular!events!
!
!
!
Explanation:!
Metformin!is!the!only!hypoglycemic!agent!shown!to!reduce!mortality!rates!in!patients!with!type!2!diabetes!mellitus.!A!
recent!systematic!review!concluded!that!cardiovascular!events!are!neither!increased!nor!decreased!with!the!use!of!
sulfonylureas.!The!effect!of!incretin!mimetics!and!incretin!enhancers!on!cardiovascular!events!has!not!been!
determined.!The!STOP]NIDDM!study!suggests!that!"]glucosidase!inhibitors!reduce!the!risk!of!cardiovascular!events!in!
patients!with!impaired!glucose!tolerance.!
!
!
Question!#344!
QID:!10353!
Topic:!Diverticular!Bleeding!
Subject:!PMCH!
!
A!65]year]old!asymptomatic!female!is!found!to!have!extensive!sigmoid!diverticulosis!on!screening!colonoscopy.!She!
asks!whether!there!are!any!dietary!changes!she!should!make.!
!
In!addition!to!increasing!fiber!intake,!which!one!of!the!following!would!you!recommend?!
!
a)!!Limiting!intake!of!dairy!products!
b)!!Limiting!intake!of!spicy!foods!
c)!!Limiting!intake!of!wheat!flour!
d)!!Limiting!intake!of!nuts!
e)!!No!limitations!on!other!intake!
!
!
!
Explanation:!
Patients!with!diverticulosis!should!increase!dietary!fiber!intake!or!take!fiber!supplements!to!reduce!progression!of!the!
diverticular!disease.!Avoidance!of!nuts,!corn,!popcorn,!and!small!seeds!has!not!been!shown!to!prevent!complications!
of!diverticular!disease.!
!
!
Question!#345!
QID:!10355!
Topic:!Nephrolithiasis!
Subject:!PMCH!
!
Which!one!of!the!following!is!the!best!radiographic!test!for!confirming!the!diagnosis!of!renal!colic?!
!
a)!!A!KUB!radiography!(Kidney,!Ureter,!Bladder!X]ray)!
b)!!Ultrasonography!
c)!!CT!scan!
164
d)!!Intravenous!pyelography!
e)!!MRI!
!
!
!
Explanation:!
Non]contrast!helical!CT!is!the!gold!standard!for!the!diagnosis!of!renal!colic.!Its!sensitivity!and!specificity!are!superior!
to!those!of!ultrasonography!(choice!B)!and!intravenous!pyelography!(choice!D).!Noncalcium!stones!may!be!missed!by!
plain!radiography!(choice!A)!but!visualized!by!CT.!MRI!(choice!E)!is!a!poor!tool!for!visualizing!stones.!
!
!
Question!#346!
QID:!10360!
Topic:!Psoriasis!
Subject:!PMCH!
!
A!27]year]old!white!male!construction!worker!suffers!from!severe!plaque]type!psoriasis!that!has!required!systemic!
therapy.!Which!one!of!the!following!is!associated!with!this!condition?!
!
a)!!A!reduced!overall!risk!of!cardiovascular!mortality!
b)!!A!decreased!risk!of!skin!cancer!with!successful!treatment!
c)!!A!low!likelihood!of!recurrence!with!successful!treatment!
d)!!An!increased!risk!for!the!condition!in!the!children!of!affected!individuals!
e)!!Low!body!mass!index!and!difficulty!maintaining!weight!
!
!
!
Explanation:!
Psoriasis!is!a!genetic!inflammatory!condition!that!has!been!associated!with!a!significant!risk!of!cardiovascular!
morbidity!and!mortality.!Children!of!patients!with!the!disorder!are!at!increased!risk.!This!is!especially!true!if!both!
parents!have!the!disorder.!Life!expectancy!is!somewhat!reduced!in!patients!with!severe!psoriasis,!particularly!if!the!
disease!had!an!early!onset.!Plaque!psoriasis!is!usually!a!lifelong!disease;!this!is!in!contrast!to!guttate!psoriasis,!which!
may!be!self]limited!and!never!recur.!
!
Cigarette!smoking!may!increase!the!risk!of!developing!psoriasis.!Psoriasis!is!also!associated!with!an!increased!
likelihood!of!obesity,!diabetes!mellitus,!and!metabolic!syndrome.!
!
!
Question!#347!
QID:!10368!
Topic:!Geriatric!Physical!Activity!
Subject:!PMCH!
!
Staff!members!of!an!assisted]living!facility!ask!for!your!advice!regarding!aerobic!exercise!programs!for!their!older!
residents.!The!evidence!is!greatest!for!which!one!of!the!following!benefits!of!physical!activity!in!the!elderly?!
!
a)!!Maintaining!weight!after!weight!loss!
b)!!Improving!quality!of!sleep!
c)!!Increasing!bone!density!
d)!!Reducing!the!risk!of!falls!
!
!
!
Explanation:!
There!is!strong!evidence!that!physical!activity!will!prevent!falls!in!the!elderly.!The!evidence!for!maintaining!weight,!
165
improving!sleep,!and!increasing!bone!density!is!not!as!strong.!
!
!
Question!#348!
QID:!10369!
Topic:!Prophylactic!Aspirin!Recommendations!
Subject:!PMCH!
!
The!recent!CMA!guidelines!have!stated!that!the!potential!cardiovascular!benefits!of!daily!aspirin!use!outweigh!the!
potential!harms!of!gastrointestinal!hemorrhage!in!certain!populations.!The!CMA!currently!recommends!daily!aspirin!
use!for!which!one!of!the!following!populations?!
!
a)!!Males!25–44!years!of!age!
b)!!Males!over!80!years!of!age!
c)!!Females!25–44!years!of!age!
d)!!Females!over!45!years!of!age!
e)!!Females!55–79!years!of!age!
!
!
!
Explanation:!
The!CMA!recommends!daily!aspirin!use!for!males!45]79!years!of!age!when!the!potential!benefit!of!a!reduction!in!
myocardial!infarction!outweighs!the!potential!harm!of!an!increase!in!gastrointestinal!hemorrhage,!and!for!females!
55]79!years!of!age!when!the!potential!benefit!of!a!reduction!in!ischemic!strokes!outweighs!the!potential!harm!of!an!
increase!in!gastrointestinal!hemorrhage.!
!
The!CMA!has!concluded!that!the!current!evidence!is!insufficient!to!assess!the!balance!of!benefits!and!harms!of!aspirin!
for!cardiovascular!disease!prevention!in!men!and!women!80!years!of!age!or!older.!It!recommends!against!the!use!of!
aspirin!for!stroke!prevention!in!women!younger!than!55,!and!for!myocardial!infarction!prevention!in!men!younger!
than!45.!
!
!
Question!#349!
QID:!10376!
Topic:!Hantavirus!
Subject:!PMCH!
!
Hantavirus!pulmonary!syndrome!results!from!exposure!to!the!excreta!of:!
!
a)!!Migratory!fowl!
b)!!Bats!
c)!!Parrots!
d)!!Mice!
e)!!Turtles!
!
!
!
Explanation:!
Hantavirus!pulmonary!syndrome!results!from!exposure!to!rodent!droppings,!mainly!the!deer!mouse.!About!10%!of!
deer!mice!are!estimated!to!be!infected!with!hantavirus.!In!other!parts!of!the!country!the!virus!is!carried!by!the!white]
footed!mouse.!While!other!rodents!are!carriers!of!the!virus,!they!are!less!likely!to!live!near!dwellings,!and!populations!
are!less!dense.!
!
!
Question!#350!
QID:!10386!
166
Topic:!Pelvic!Inflammatory!Disease!Management!
Subject:!PMCH!
!
According!to!the!current!recommendations,!which!one!of!the!following!conditions!in!female!patients!requires!empiric!
treatment!of!male!sexual!partners?!
!
a)!!Vaginal!candidiasis!
b)!!Vaginal!warts!
c)!!Pelvic!inflammatory!disease!
d)!!Bacterial!vaginosis!
!
!
!
Explanation:!
The!promise!of!a!reduction!in!the!incidence!and!prevalence!of!sexually!transmitted!diseases!through!partner!
notification!and!treatment!programs!remains!elusive,!as!evidence!supporting!this!effect!is!scarce!and!inconclusive.!
What!is!clear!is!that!treating!sexual!partners!does!reduce!reinfection!of!the!index!patient.!
!
Programs!such!as!contact!notification,!counseling!and!scheduling!of!appointments!for!evaluation!of!the!partner,!and!
expedited!partner!therapy!(EPT),!in!which!sexual!contacts!of!infected!patients!are!provided!antibiotics!delivered!by!
the!index!patient!without!evaluation!or!counseling,!have!demonstrated!only!limited!effectiveness;!in!the!case!of!EPT!
this!limited!benefit!has!been!shown!only!with!trichomoniasis.!Because!currently!available!evidence!fails!to!
demonstrate!benefit!from!treating!the!male!sexual!contacts!of!women!with!vaginal!candidiasis,!vaginal!warts,!or!
bacterial!vaginosis,!the!guidelines!state!that!treating!the!male!partner!is!not!indicated!with!these!infections.!
!
In!the!case!of!pelvic!inflammatory!disease!(PID),!evaluation!and!treatment!of!males!with!a!history!of!sexual!contact!
with!the!patient!during!the!60!days!preceding!the!onset!of!symptoms!is!imperative!because!of!the!high!risk!of!
reinfection.!Current!guidelines!recommend!empiric!treatment!of!these!male!contacts!with!antibiotic!regimens!
effective!against!both!chlamydial!and!gonococcal!infection,!regardless!of!the!presumed!etiology!of!the!PID.!
!
!
!
Pelvic!Inflammatory!Disease!(PID)!
!
!
Question!#351!
QID:!10387!
Topic:!Abdominal!Aortic!Aneurysm!Screening!Recommendations!
Subject:!PMCH!
!
An!asymptomatic!68]year]old!male!sees!you!for!a!health!maintenance!visit.!He!is!a!former!cigarette!smoker,!but!quit!
20!years!ago.!
!
According!to!the!CMA,!evidence!shows!that!the!potential!benefit!exceeds!the!risk!for!which!one!of!the!following!
screening!tests!in!this!patient?!
!
a)!!A!chest!radiograph!
b)!!Abdominal!ultrasonography!
c)!!Ophthalmic!tonometry!
d)!!A!prostate]specific!antigen!level!
e)!!An!EKG!
!
!
!
Explanation:!
The!CMA!recommends!one]time!screening!for!abdominal!aortic!aneurysm!(AAA)!by!ultrasonography!in!men!aged!65]
167
75!who!have!ever!smoked.!The!CMA!found!good!evidence!that!screening!these!patients!for!AAA!and!surgical!repair!of!
large!AAAs!(!>!5.5!cm)!leads!to!decreased!AAA]specific!mortality.!There!is!good!evidence!that!abdominal!
ultrasonography,!performed!in!a!setting!with!adequate!quality!assurance!(i.e.,!in!an!accredited!facility!with!
credentialed!technologists),!is!an!accurate!screening!test!for!AAA.!
!
There!is!also!good!evidence!of!important!harms!from!screening!and!early!treatment,!including!an!increased!number!
of!operations,!with!associated!clinically!significant!morbidity!and!mortality,!and!short]term!psychological!harms.!
Based!on!the!moderate!magnitude!of!net!benefit,!the!CMA!concluded!that!the!benefits!of!screening!for!AAA!in!men!
aged!65]75!who!have!ever!smoked!outweighs!the!potential!harm.!
!
While!they!may!be!considered!for!making!the!diagnosis!in!patients!who!have!symptoms,!none!of!the!other!tests!listed!
have!evidence!to!support!a!net!benefit!from!their!use!as!routine!screening!tools!in!patients!like!the!one!described!
here.!
!
!
Question!#352!
QID:!10390!
Topic:!Hba1c!And!Serum!Glucose!
Subject:!PMCH!
!
A!hemoglobin!A1C!of!7.0%!would!correspond!to!which!one!of!the!following!mean!(average)!plasma!glucose!levels?!
!
a)!!126!mg/dL!
b)!!154!mg/dL!
c)!!183!mg/dL!
d)!!212!mg/dL!
e)!!240!mg/dL!
!
!
!
Explanation:!
A!hemoglobin!A1c!(HbA1c)!of!6.0%!correlates!with!a!mean!plasma!glucose!level!of!126!mg/dL!or!7.0!mmol/dL.!A!
calculator!to!convert!HbA1c!levels!into!estimated!average!glucose!levels!is!available!
at!http://professional.diabetes.org/eAG.!
!
A!rough!guide!for!estimating!average!plasma!glucose!levels!assumes!that!an!HbA!1c!of!6.0%!equals!an!average!
glucose!level!of!120!mg/dL.!Each!percentage!point!increase!in!HbA1c!is!equivalent!to!a!30]mg/dL!rise!in!average!
glucose.!An!HbA1c!of!7.0%!is!therefore!roughly!equivalent!to!an!average!glucose!level!of!150!mg/dL,!and!an!HbA1c!of!
8.0%!translates!to!an!average!glucose!level!of!180!mg/dL.!
!
!
Question!#353!
QID:!10397!
Topic:!CT!Scan!Side!Effects!
Subject:!PMCH!
!
Which!one!of!the!following!is!true!regarding!the!risk!of!inducing!cancer!with!CT!scanning?!
!
a)!!CT!of!the!chest!is!associated!with!a!greater!risk!than!CT!of!the!head!
b)!!The!risk!increases!with!age!at!the!time!of!the!scan!
c)!!Males!have!a!greater!risk!of!ultimately!developing!CT]induced!lung!cancer!than!females!
d)!!Current!techniques!with!rapid!scanners!make!the!risk!comparable!to!that!associated!with!standard!radiographs!of!
the!same!area!
e)!!The!risk!in!neonates!is!markedly!reduced!because!of!the!efficiency!of!DNA!repair!processes!at!this!age!
!
!
168
!
Explanation:!
CT!of!the!chest!or!abdomen!leads!to!significantly!more!radiation!exposure!and!cancer!risk!than!CT!of!the!brain.!
Younger!patients,!including!neonates,!have!a!greater!lifetime!risk!of!developing!cancer!after!radiation!exposure,!and!
CT!imaging!carries!substantially!more!risk!than!plain!radiographs!of!the!same!area.!
!
Women!are!at!greater!risk!for!developing!lung!cancer!after!a!chest!CT!than!men,!and!CT!also!increases!their!risk!of!
developing!breast!cancer.!
!
!
Question!#354!
QID:!10416!
Topic:!TB!
Subject:!PMCH!
!
A!51]year]old!immigrant!from!Laos!presents!with!a!3]week!history!of!nocturnal!fever,!sweats,!cough,!and!weight!loss.!
A!chest!radiograph!reveals!a!right!upper!lobe!cavitary!infiltrate.!A!PPD!produces!17!mm!of!induration,!and!acid]fast!
bacilli!are!present!on!a!smear!of!induced!sputum.!
!
While!awaiting!formal!laboratory!identification!of!the!bacterium,!which!one!of!the!following!would!be!most!
appropriate?!
!
a)!!Observation!only!
b)!!INH!only!
c)!!INH!and!ethambutol!(Myambutol)!
d)!!INH,!ethambutol,!and!pyrazinamide!
e)!!INH,!ethambutol,!rifampin!(Rifadin),!and!pyrazinamide!
!
!
!
Explanation:!
Leading!authorities,!mandate!aggressive!initial!four]drug!treatment!when!tuberculosis!is!suspected.!Delays!in!
diagnosis!and!treatment!not!only!increase!the!possibility!of!disease!transmission,!but!also!lead!to!higher!morbidity!
and!mortality.!Standard!regimens!including!INH,!ethambutol,!rifampin,!and!pyrazinamide!are!recommended,!
although!one!regimen!does!not!include!pyrazinamide!but!extends!coverage!with!the!other!antibiotics.!Treatment!
regimens!can!be!modified!once!culture!results!are!available.!
!
!
Question!#355!
QID:!10423!
Topic:!Gadolinum!Associated!Nephrogenic!Fibrosis!
Subject:!PMCH!
!
A!62]year]old!male!on!hemodialysis!develops!a!pruritic!rash!on!his!arms!and!chest,!with!erythematous,!thickened!
plaques!and!edema.!He!had!brain!imaging!with!a!gadolinium]enhanced!MRI!for!neurologic!symptoms!10!days!ago.!
!
Which!one!of!the!following!is!true!regarding!this!problem?!
!
a)!!A!skin!biopsy!is!diagnostic!
b)!!The!problem!is!limited!to!the!skin!
c)!!Immediate!treatment!is!critical!
d)!!The!disease!is!more!common!in!males!
e)!!Death!from!the!disease!is!unusual!
!
!
!
169
Explanation:!
This!patient!has!gadolinium]associated!nephrogenic!systemic!fibrosis,!which!is!associated!with!the!use!of!gadolinium]
based!contrast!material!in!patients!with!severe!renal!dysfunction,!often!on!dialysis.!Associated!proinflammatory!
states,!such!as!recent!surgery,!malignancy,!and!ischemia,!are!often!present!as!well.!This!condition!occurs!without!
regard!to!gender,!race,!or!age.!Dermatologic!manifestations!are!usually!seen,!but!multiple!organ!systems!may!be!
involved.!There!is!no!effective!treatment,!and!mortality!is!approximately!30%.!A!deep!biopsy!of!the!affected!skin!is!
diagnostic.!
!
!
Question!#356!
QID:!10442!
Topic:!Latex!Allergy!
Subject:!PMCH!
!
Which!one!of!the!following!is!a!frequent!cause!of!cross]reactive!food]allergy!symptoms!in!latex]allergic!individuals?!
!
a)!!Avocadoes!
b)!!Goat's!milk!
c)!!Pecans!
d)!!Pastrami!
e)!!Peppermint!
!
!
!
Explanation:!
The!majority!of!patients!who!are!latex]allergic!are!believed!to!develop!IgE!antibodies!that!cross]react!with!some!
proteins!in!plant]derived!foods.!These!food!antigens!do!not!survive!the!digestive!process,!and!thus!lack!the!capacity!
to!sensitize!after!oral!ingestion!in!the!traditional!food]allergy!pathway.!Antigenic!similarity!with!proteins!present!in!
latex,!to!which!an!individual!has!already!been!sensitized,!results!in!an!indirect!allergic!response!limited!to!the!
exposure!that!occurs!prior!to!alteration!by!digestion,!localized!primarily!in!and!around!the!oral!cavity.!The!frequent!
association!with!certain!fruits!has!been!labeled!the!“latex]fruit!syndrome.”!Although!many!fruits!and!vegetables!have!
been!implicated,!fruits!most!commonly!linked!to!this!problem!are!bananas,!avocadoes,!and!kiwi.!
!
!
Question!#357!
QID:!10463!
Topic:!Good!Samaritan!Law!
Subject:!PMCH!
!
Which!one!of!the!following!situations!is!most!likely!to!result!in!immunity!from!court]awarded!damages!for!personal!
injuries!occurring!as!a!result!of!reasonable!and!ordinary!emergency!care?!
!
a)!!Evaluating!a!football!injury!as!a!volunteer!team!physician!at!a!local!high]school!game!
b)!!Stabilizing!an!injured!victim!at!the!scene!of!an!automobile!accident!until!EMS!arrives!
c)!!Providing!emergency!care!to!your!office!nurse!after!he!collapses!while!on!the!job!
d)!!Responding!to!the!collapse!of!one!of!your!patients!in!the!hospital!parking!lot!
e)!!Treating!an!asthma!attack!while!staffing!the!first]aid!shelter!at!an!outdoor!rock!concert!
!
!
!
Explanation:!
Laws!providing!immunity!from!civil!damages!for!injuries!or!death!resulting!from!care!deemed!reasonable!under!the!
circumstance!(ordinary!negligence)!are!generally!described!as!Good!Samaritan!laws.!Good!Samaritan!statutes!have!
been!enacted!to!protect!physicians!from!liability!(in!the!absence!of!gross!negligence)!if!they!provide!emergency!care!
to!individuals!with!whom!they!share!no!preexisting!obligation!to!provide!medical!care.!
!
170
A!preexisting!obligation!to!provide!care!exists!in!each!of!the!examples!given,!except!for!the!provision!of!care!at!the!
scene!of!a!traffic!accident.!
!
>!Providing!stabilizing!care!at!the!scene!of!an!accident!clearly!fits!within!the!protections!defined!by!Good!Samaritan!
laws.!
>!The!obligation!to!provide!care!when!volunteering!at!an!event!such!as!a!football!game!or!concert!is!implied!even!if!it!
is!provided!without!charge.!
>!An!obligation!to!provide!care!for!someone!identified!as!your!patient!exists!even!outside!of!the!office!setting;!a!
similar!responsibility!to!provide!emergency!care!for!office!employees!is!generally!accepted.!
!
Canadian!law!provides,!by!statute,!for!similar!Good!Samaritans,!protection!from!liability!to!physicians!who!respond!to!
in]flight!emergencies!originating!in!Canada.!
!
!
Question!#358!
QID:!10469!
Topic:!Hepatitis!A!
Subject:!PMCH!
!
Which!one!of!the!following!patients!is!unlikely!to!benefit!from!vaccination!against!hepatitis!A?!
!
a)!!A!missionary!traveling!to!Mexico!
b)!!A!man!who!has!sex!with!men!
c)!!A!methamphetamine!addict!
d)!!A!patient!with!chronic!hepatitis!C!
e)!!A!40]year!old!recent!immigrant!from!India!
!
!
!
Explanation:!
Each!of!the!individuals!listed!is!at!increased!risk!for!hepatitis!A!infection!or!its!complications,!except!for!the!Indian!
immigrant.!Hepatitis!A!is!so!prevalent!in!developing!countries!such!as!India!that!virtually!everyone!is!infected!by!the!
end!of!childhood,!and!therefore!immune.!Infection!with!hepatitis!A!confers!lifelong!immunity,!so!an!adult!from!a!
highly!endemic!area!such!as!India!has!little!to!gain!from!vaccination.!
!
!
Question!#359!
QID:!10481!
Topic:!Verenicline!Side!Effects!
Subject:!PMCH!
!
A!42]year]old!male!seeks!your!advice!regarding!smoking!cessation.!You!recommend!a!smoking!cessation!class,!as!well!
as!varenicline.!
!
You!caution!him!that!the!most!common!side!effect!is:!
!
a)!!Dermatitis!
b)!!Diarrhea!
c)!!Edema!
d)!!Hirsutism!
e)!!Nausea!
!
!
!
Explanation:!
The!most!common!adverse!event!attributed!to!varenicline!at!a!dosage!of!1!mg!twice!a!day!is!nausea,!occurring!in!
171
approximately!30%]50%!of!patients.!Taking!the!drug!with!food!lessens!the!nausea.!
!
!
Question!#360!
QID:!10489!
Topic:!Osteoporosis!Work!Up!And!Treatment!
Subject:!PMCH!
!
A!60]year]old!Chinese!female!asks!you!about!being!tested!for!osteoporosis.!She!is!postmenopausal!and!has!never!
used!hormone!therapy.!She!does!not!consume!dairy!products!because!she!has!lactose!intolerance.!She!is!on!no!
medications,!is!otherwise!healthy,!and!has!no!history!of!falls!or!fractures.!Her!mother!had!osteoporosis!and!vertebral!
compression!fractures.!Her!BMI!is!20!kg/m².!
!
Which!one!of!the!following!tests!would!be!best!to!determine!whether!this!patient!has!osteoporosis?!
a)!!A!central!DXA!scan!of!the!lumbar!spine!and!hips!
b)!!A!forearm!DXA!scan!
c)!!Quantitative!CT!of!the!lumbar!spine!
d)!!Quantitative!calcaneal!ultrasonography!
e)!!Measurement!of!biochemical!markers!of!bone!turnover!in!the!urine!
!
!
!
Explanation:!
This!patient!has!several!risk!factors!for!osteoporosis:!Asian!ethnicity,!low!body!weight,!positive!family!history,!
postmenopausal!status!with!no!history!of!hormone!replacement,!and!low!calcium!intake.!The!best!diagnostic!test!for!
osteoporosis!is!a!central!dual]energy!X]ray!absorptiometry!(DXA,!previously!DEXA)!of!the!hip,!femoral!neck,!and!
lumbar!spine!(choice!A).!
!
→!Quantitative!CT!(choice!C)!is!accurate,!but!cost!and!radiation!exposure!are!issues.!
→!Peripheral!DXA!(choice!B)!and!calcaneal!sonography!(choice!D)!results!do!not!correlate!well!with!central!DXA.!
→!Measurement!of!biochemical!marker!(choice!E)!s!is!not!recommended!for!the!diagnosis!of!osteoporosis.!
!
!
Question!#361!
QID:!10490!
Topic:!COPD!
Subject:!PMCH!
!
A!56]year]old!female!has!a!35]pack]year!smoking!history.!She!is!concerned!that!she!may!have!COPD,!although!she!has!
no!history!of!chronic!cough,!chest!pain,!or!other!pulmonary!symptoms.!Her!family!history!is!remarkable!for!a!mother!
with!COPD!who!was!a!smoker,!but!there!is!no!family!history!of!Alpha]1]antitrypsin!disease.!
!
Which!one!of!the!following!would!you!recommend!with!regard!to!screening!spirometry?!
!
a)!!Screening,!based!on!her!age!
b)!!Screening,!based!on!her!family!history!
c)!!Screening,!based!on!her!smoking!history!
d)!!No!screening,!based!on!lack!of!benefit!
!
!
!
Explanation:!
COPD!is!one!of!the!leading!cause!of!death!in!Canada.!The!diagnosis!is!made!by!documenting!airflow!obstruction!in!the!
presence!of!symptoms!and/or!risk!factors.!Airflow!limitation!cannot!be!accurately!predicted!by!the!history!and!
examination.!
!
172
The!CMA!Force!recently!concluded!that!there!is!“moderate!certainty”!that!screening!asymptomatic!patients!for!COPD!
using!spirometry!has!little!or!no!benefit!and!is!not!recommended.!This!recommendation!applies!to!otherwise!healthy!
individuals!without!a!family!history!of!alpha]1]antitrypsin!disease.!
!
!
Question!#362!
QID:!10574!
Topic:!Health!of!Special!Populations!
Subject:!PMCH!
!
A!24]year]old!First!Nations!woman!lives!in!a!nearby!First!Nations!community!that!you!commute!to!on!a!weekly!basis.!
On!this!week's!visit!a!patient!is!concerned!about!illnesses!she!may!be!at!higher!risk!for!because!of!her!First!Nations!
background.!She!has!read!that!First!Nations!people!suffer!more!disease!burden!than!other!Canadians!and!is!
wondering!if!she!may!be!able!to!avoid!these.!Which!of!the!following!are!First!Nations!people!NOT!over]represented!
for!in!Canada?!
a)!!Tuberculosis!
b)!!Diabetes!mellitus!type!2!
c)!!Breast!cancer!
d)!!Suicide!
e)!!Rheumatoid!arthritis!
!
!
!
Explanation:!
Lower!rates!of!breast,!lung,!colorectal!and!prostate!cancers!are!found!among!First!Nations!as!compared!to!the!non]
First!Nations!population.!
!
>!The!active!TB!reported!incidence!rate!for!First!Nations!living!on]reserve!in!the!seven!regions!of!Health!Canada's!First!
Nations!and!Inuit!Health!Branch!was!26.6!per!100,000!in!2008,!which!was!29.6!times!higher!than!the!Canadian]born!
non]Aboriginal!population.!
>!When!controlling!for!the!different!age!demographics!among!the!two!populations,!the!age]standardized!prevalence!
of!diabetes!for!First!Nations!people!is!3!to!5!times!that!of!the!general!population!
>!Suicide!rates!of!First!Nations!youth!(aged!15!to!24)!are!eight!times!higher!than!the!national!rate!for!females!and!five!
times!higher!than!the!national!rate!for!males.!
>!Age]standardized!(adjusted!for!differences!in!age!distribution)!prevalence!estimate!for!arthritis/rheumatism!in!on]
reserve!First!Nations!adults!aged!20!years!and!older!was!1.3!times!higher!than!the!age]standardized!estimate!for!
arthritis!in!the!Canadian!population!aged!20!years!and!older.!
!
First!Nations!people!suffer!disproportionately!from!diseases!than!non]First!Nations!people.!
!
!
Question!#363!
QID:!10687!
Subject:!PMCH!
!
You!have!been!a!physician!of!a!32]year]old!female!who!suggests!that!you!should!come!on!a!date!with!her!at!a!local!
restaurant.!Which!of!the!following!is!the!most!appropriate!response?!
a)!!I!would!come!if!you!promised!to!tell!no!one!
b)!!The!physician]patient!relationship!has!to!end!first!
c)!!It!is!wrong!for!you!to!suggest!this,!I!can!no!longer!be!your!doctor!
d)!!It!is!appropriate!that!our!relationship!remains!doctor]patient!only!
e)!!Going!on!a!date!with!you!would!jeopardize!my!career!
!
!
!
173
Explanation:!
Medical!ethics!require!physicians!to!avoid!boundary!violations!that!undermine!the!physician]patient!relationship.!
Examples!are!sexual/physical!relationships,!economic!involvement,!overtly!political!requests,!or!similar!conduct!that!
the!patient!would!not!otherwise!engage!in!if!it!were!not!for!the!trust!he/she!has!for!the!physician.!Physicians!should!
avoid!dating!current!or!former!patients!because!romantic!relationships!between!a!physician!and!a!former!patient!
may!be!unduly!influenced!by!the!previous!patient]physician!relationship.!On!this!question!the!most!appropriate!
answer!the!physician!should!give!the!patient!is!that!the!most!appropriate!course!of!action!is!to!keep!the!relationship!
physician]patient!only.!
!
→!"I!would!come!if!you!promised!to!tell!no!one"!(choice!A)!is!incorrect.!Around!4%!of!physicians!date!their!patients!
while!20%!of!physicians!report!of!knowing!a!colleague!romantically!involved!with!a!patient.!Whether!this!is!known!by!
colleagues!or!anyone!else!or!not,!it!is!not!in!alignment!with!standard!medical!ethics!and!physicians!should!avoid!it.!
→!"The!physician]patient!relationship!has!to!end!first"!(choice!B)!is!incorrect.!While!some!authorities!believe!that!
depending!on!the!physician’s!specialty!and!the!time!elapsed!since!the!physician]patient!relationship!ended!(6!months!
recommended)!this!relationship!might!be!okay,!the!American!Medical!Association!stipulates!that!a!former!patient!
may!still!be!influenced!by!the!previous!relationship!and!may!not!be!able!to!function!in!an!equal,!consenting!adult!
manner.!
→!"It!is!wrong!for!you!to!suggest!this,!I!can!no!longer!be!your!doctor"!(choice!C)!is!not!the!best!way!to!handle!this!
situation!as!the!patient!might!be!unaware!of!the!medical!ethics!the!physician!is!obligated!to!abide!by.!The!physician!
should!decline!the!invitation!while!reaffirming!the!commitment!to!be!the!patient’s!physician.!The!physician]patient!
relationship!should!be!ended!only!if!the!physician!feels!that!the!professional!relationship!or!neutrality!is!no!longer!
possible.!
→!"Going!on!a!date!with!you!would!jeopardize!my!career"!(choice!E)!is!not!the!best!way!to!decline!the!patient’s!
invitation!as!it!may!leave!the!patient!feeling!that!it!is!all!about!your!career.!When!declining,!the!physician!should!
clearly!communicate!to!the!patient!that!it!is!best!for!their!physician]patient!relationship!not!to!have!a!personal!
relationship!so!that!he/she!can!better!devote!his/her!attention!to!the!patient’s!health.!
!
Key!point:!
It!is!inappropriate!for!a!physician!to!date!a!patient.!If!requested!by!the!patient,!the!physician!should!say!that!it!is!
appropriate!that!the!relationship!remains!physician]patient!only.!If!for!some!reason!the!physician!senses!that!this!
patient]physician!relationship!has!been!compromised,!he/!she!has!to!end!the!relationship!with!the!patient.!
!
!
Question!#364!
QID:!10691!
Topic:!Colon!Cancer!Screening!
Subject:!PMCH!
!
A!39]year]old!woman!came!for!a!scheduled!Pap!test.!After!the!test!was!done,!she!expressed!some!concerns!about!
colon!cancer!because!two!of!her!cousins!had!colon!cancer!at!age!of!52!and!55!years.!Also,!her!grandmother!died!of!
endometrial!cancer!at!the!age!of!67.!She!was!not!aware!of!any!other!first,!second!or!third!degree!relatives!who!had!
colon!or!endometrial!cancer.!She!asked!for!advice!on!colon!cancer!screening.!
!
Which!of!the!following!screening!modalities!would!you!recommend!for!this!patient?!
!
a)!!Average!risk!screening!starting!at!40!years!of!age!
b)!!Average!risk!screening!starting!at!50!years!of!age!
c)!!Colonoscopy!every!five!years!starting!at!45!years!of!age!
d)!!Colonoscopy!every!ten!years!starting!at!42!years!of!age!
e)!!Genetic!counselling!and!testing!immediately!
!
!
!
Explanation:!
Hereditary!non]polyposis!colorectal!cancer!(HNPCC)!is!inherited!as!autosomal!dominant.!This!type!of!colon!cancer!has!
early!age!of!onset!and!affects!the!right!more!than!the!left!colon.!All!the!following!criteria!are!required!for!diagnosis!of!
this!cancer:!
174
1]!At!least!three!relatives!with!colorectal!cancer!or!HNPCC!related!cancers!which!include!endometrial,!ovarian,!
hepatobiliary!and!small!intestine!cancers.!
2]!Two!or!more!generations!are!involved!and!one!must!be!the!first!degree!relative!of!the!other!two.!
3]!One!case!must!be!diagnosed!before!50!years!of!age.!
4]!Familial!adenomatous!polyposis!is!excluded!
!
Although!three!of!this!patient's!relatives!had!HNPCC]associated!cancer!(two!cousins!with!colon!cancer!and!a!
grandmother!with!endometrial!cancer),!none!of!these!is!a!first!degree!relative!of!the!other!two.!In!addition,!both!
developed!cancer!at!ages!>50!years.!Thus,!the!diagnosis!of!HNPCC!cannot!be!made.!
!
However,!although!this!patient’s!age!is!less!than!50!years,!her!family!history!of!colon!cancer!raises!her!risk!of!
developing!this!type!of!cancer.!Since!her!third!degree!(rather!than!her!first!degree)!relatives!were!affected,!she!
should!still!undergo!average!risk!screening,!which!starts!at!age!50!using!fecal!occult!blood!(every!2!years),!flexible!
sigmoidoscopy!or!colonoscopy!(every!5!years).!
!
If!she!had!any!first]degree!relatives!with!colon!cancer,!she!would!start!average!risk!screening!starting!at!42!years!of!
age.!
Colonoscopy!every!five!years!starting!at!age!42!would!be!the!right!recommendation!if!the!youngest!affected!relative!
(52!years!old!in!this!case)!were!her!first!degree!relative.!
Colonoscopy!every!five!years!starting!at!40!would!be!the!right!recommendation!if!the!youngest!affected!relative!(52!
years!old!in!this!case)!were!her!first!degree!relative.!
Genetic!counselling!and!testing!starting!should!be!done!if!she!had!family!history!of!Familial!adenomatous!polyposis!
(FAB)!or!Hereditary!nonpolyposis!colorectal!cancer!HNPCC.!
Colorectal!cancer!screening!recommendations.!
!
!
!
Question!#365!
QID:!10726!
Topic:!Dog!bite!
Subject:!PMCH!
!
An!11]year]old!boy!is!brought!to!the!ED!by!his!parents.!He!was!trying!to!play!with!a!neighbor’s!dog!and!got!bitten!by!
the!dog!on!his!right!wrist!and!forearm.!He!says!it!is!painful!and!he!bled.!His!parents!provided!first!aid!before!bringing!
him!to!the!ED.!The!child’s!immunizations!are!uptodate.!He!is!currently!not!taking!any!medications!and!has!no!known!
drug!allergies.!
On!physical!examination!you!note!the!patient!is!stable!with!a!puncture]type!wound!on!the!bite!site.!The!neighbor’s!
dog!is!immunized!and!usually!does!not!attack!people.!Which!of!the!following!is!the!first]line!treatment!for!this!
patient?!
a)!!Doxycycline!
b)!!Amoxicillin]clavulanate!
c)!!Erythromycin!
d)!!Dicloxacillin!
e)!!Vancomycin!
!
!
!
Explanation:!
The!Canadian!Hospitals!Injury!Reporting!and!Prevention!Program!(CHIRPP)!reports!about!1,040!per!100,000!people!
dog!bites!in!Canada!annually.!Once!a!patient!bitten!by!a!dog!arrives!at!the!ED,!it!is!important!first!to!confirm!the!
victim!is!medically!stable,!then!proceed!with!taking!the!patient’s!history.!Several!medical!conditions!place!a!patient!at!
high!risk!of!wound!and!rabies!virus!infection!from!a!dog!bite.!These!include!chronic!disease,!diabetes!mellitus,!
immunosuppression,!prosthetic!valve,!splenectomy,!and!liver!dysfunction.!Information!that!can!help!determine!the!
patient's!risk!of!infection!includes!the!time!of!the!injury,!whether!the!animal!was!provoked,!general!health,!
immunization!status,!and!current!location!of!the!animal.!Also,!the!patient's!tetanus!immunization!status!must!be!
noted.!
Since!this!patient!is!stable,!is!not!taking!any!medications,!has!no!allergies,!immunizations!are!uptodate,!and!the!dog’s!
175
immunization!status!is!known,!it!is!safe!to!proceed!with!the!appropriate!treatment!to!prevent!infection.!Most!dog!
bites!are!polymicrobial,!with!both!aerobic!and!anaerobic!bacteria.!Pasteurella!multocida!and!Staphylococcus!aureus!
are!the!most!common!aerobic!organisms!occurring!in!about!25%!of!infected!dog!bite!wounds.!Amoxicillin]clavulanate!
(choice!A)!is!the!first]line!antibiotic!for!a!dog!bite.!
!
!
>!Doxycycline!(choice!A)!is!an!alternative!to!amoxicillin]clavulanate!in!patients!with!penicillin!allergies!except!for!
pregnant!women!and!children!younger!than!8!years.!
>Erythromycin!(choice!C)!may!be!used!but!it!is!associated!with!a!high!rate!of!resistance!and!failure.!
>!Dicloxacillin!(choice!D)!and!Vancomycin!(choice!E)!are!incorrect.!Based!on!in!vitro!susceptibility!data!dicloxacillin,!
vancomycin,!cephalexin,!cefaclor,!cefadroxil,!and!erythromycin!should!not!be!used!empirically!against!Pasteurella!
multocida.!
!
!
In!a!dog]bite!case,!the!possibility!of!rabies!infection!has!to!be!evaluated.!If!both!the!patient!and!dog!are!properly!
immunized,!antibiotic!treatment!can!be!given.!Amoxicillin]clavulanate!is!the!drug!of!choice,!doxycycline!can!be!used!
as!an!alternative!for!those!with!penicillin!allergies!except!where!it!is!contraindicated.!
!
!
Question!#366!
QID:!10760!
Topic:!Feco]oral!transmission!
Subject:!PMCH!
!
At!the!emergency!department!you!encounter!a!patient!with!an!infectious!condition!that!might!have!been!contracted!
through!the!fecal]oral!route.!Which!of!the!following!infectious!agents!is!least!likely!to!infect!through!this!route?!
a)!!Clostridium!difficile!
b)!!Hepatitis!A!virus!
c)!!Epstein!Barr!virus!
d)!!Norwalk!virus!
e)!!Polio!virus!
!
!
!
Explanation:!
Infectious!diseases!can!be!transmitted!through!various!routes,!they!may!be!airborne,!transmitted!through!human]
animal!contact,!food!poisoning,!fecal]oral!route,!sexual!contact,!via!a!vector,!droplet!contact,!or!iatrogenic.!
!
Epstein]Barr!virus!is!a!herpes!virus!spread!by!kissing!through!the!saliva!of!an!infected!person!and!airborne!
transmission!in!dormitories!or!between!siblings!in!a!family.!
!
Clostridium!difficile,!Hepatitis!A!virus,!Norwalk!virus,!and!Polio!virus!can!all!cause!infections!through!fecal]oral!route!
transmission.!Clostridium!difficile!is!also!commonly!seen!after!few!days!to!weeks!of!antibiotic!treatment.!
!
Other!common!infectious!agents!that!can!be!transmitted!through!the!fecal]oral!route!include!Giardia!lamblia,!
Hepatitis!E!virus,!Rotavirus,!Shigella!dysenteriae,!Vibrio!cholera,!Cryptosporidium!parvum,!and!Ascaris!lumbricoides.!
!
!
>!Clostridium!difficile!(choice!A),!Hepatitis!A!virus!(choice!B),!Norwalk!virus!(choice!C),!and!Polio!virus!(choice!D)!can!
all!cause!infections!through!fecal]oral!route!transmission.!
!
!
Common!infectious!agents!that!can!be!transmitted!through!the!fecal]oral!route!include!Polio!virus,!Norwalk!virus,!
Hepatitis!A!virus,!Clostridium!difficile,!Giardia!lamblia,!Hepatitis!E!virus,!Rotavirus,!Shigella!dysenteriae,!Vibrio!cholera,!
Cryptosporidium!parvum,!and!Ascaris!lumbricoides.!
!
!
176
Question!#367!
QID:!10770!
Topic:!Hepatitis!A!
Subject:!PMCH!
!
A!15]year]old!boy!came!to!his!family!physician!complaining!of!fatigue,!nausea!and!vomiting!for!the!last!week.!He!
relates!that!4!weeks!ago!he!returned!from!a!trip!to!his!home!country!in!Africa!together!with!his!family.!No!other!
symptoms!could!be!elicited!and!all!other!family!members!were!quite!well.!
Apart!from!his!body!temperature!of!37.7°C,!his!vital!signs!were!normal.!The!rest!of!physical!examination!was!also!
normal.!Liver!function!test!showed!elevated!transaminase!and!serum!bilirubin.!Hepatitis!IgM!was!elevated.!Diagnosis!
of!hepatitis!A!virus!infection!was!established.!
Which!of!the!following!is!the!least!effective!public!health!measure!to!be!undertaken!by!the!family!physician?!
a)!!Advise!patient!and!contacts!to!use!ether!for!hand!disinfection!
b)!!Give!hepatitis!A!immunoglobulin!to!close!contacts!
c)!!Report!case!to!local!medical!officer!of!health!
d)!!Initiate!contact!tracing!
e)!!Try!to!locate!the!primary!source!of!the!infection!
!
!
!
Explanation:!
Hepatitis!A!virus!(HAV)!is!one!of!the!most!common!causes!of!acute!hepatitis!but!the!frequency!of!infection!with!this!
virus!dropped!significantly!in!the!western!world.!Foreign!travel!is!thus!an!important!risk!factor!for!acquiring!hepatitis!
A!infection.!Because!humans!are!the!only!reservoir!for!this!virus,!personal!contact!is!required!for!transmission!of!this!
infection.!During!the!prodromal!phase,!patients!with!hepatitis!A!infection!might!present!with!flu!like!symptoms!with!
anorexia,!nausea,!vomiting,!fatigue,!malaise!and!low!grade!fever.!During!the!icteric!phase!patients!may!have!
abdominal!pain!in!addition!to!jaundice.!Hepatomegaly!may!be!demonstrated!in!patients!with!hepatitis!A!infection.!
Hepatitis!A!virus!infection!does!not!cause!chronic!hepatitis!but!it!can!cause!fulminant!hepatic!failure.!Treatment!is!
generally!supportive!and!no!specific!treatment!is!required.!Post]exposure!prophylaxis!is!strongly!recommended!for!
management!of!close!contacts.!This!involves!both!passive!an!active!immunization!as!well!as!other!public!health!
measures.!
!
Hepatitis!A!virus!is!resistant!to!disinfection!with!ether!(choice!A).!It!is!also!resistant!to!drying,!acid!pH!of!3,!heating!to!
temperatures!up!to!56°C!and!freezing!to!]20°C.!Boiling!water,!however,!is!effective!in!destroying!it!and!can!be!used!by!
this!family!for!washing!kitchen!utensils.!
!
→!Giving!hepatitis!A!immunoglobulin!to!close!contacts!(choice!B)!is!recommended!to!protect!them!from!infection!by!
hepatitis!A!virus.!
→!Reporting!hepatitis!A!cases!to!local!medical!officer!of!health!(choice!C)!is!mandatory!in!Canada.!
→!The!family!physician!should!initiate!contact!tracing!(choice!D).!This!can!lead!to!identification!of!the!primary!source!
and!also!helps!identifying!those!who!might!be!or!might!have!been!exposed!to!the!virus!through!contact!with!patient!
or!the!primary!sources.!
→!For!this!case,!the!primary!source!might!be!outside!Canada!(patient's!home!country)!(choice!E).!However,!this!does!
not!exclude!a!local!primary!source.!Thus,!the!family!physician!should!try!to!locate!the!primary!source!of!the!infection.!
!
Key!point:!
Patients!with!HAV!infection!who!are!treated!at!home!and!those!around!them!should!follow!strict!enteric!precautions.!
!
!
Question!#368!
QID:!10771!
Topic:!Clinical!Trial!Study!
Subject:!PMCH!
!
During!development!of!a!drug,!the!drug!is!studied!first!in!animals!and!then!in!human!beings.!Clinical!trials!involve!the!
study!of!investigational!drug!in!human!beings!]!either!in!normal!healthy!volunteers!or!in!diseased!subjects!and!are!
carried!out!in!phases!]!1,!2!and!3.!Once!approval!to!market!a!drug!has!been!obtained,!phase!4!begins.!Drug!may!fail!
177
either!in!earlier!phases!of!development!or!may!be!withdrawn!after!it!is!marketed.!Which!phase!of!clinical!trial!has!
highest!rate!of!drug!failure?!
a)!!Phase!0!
b)!!Phase!1!
c)!!Phase!2!
d)!!Phase!3!
e)!!Phase!4!
!
!
!
Explanation:!
Drug!development!process!is!a!dynamic!process!and!unfortunately,!only!10]15%!of!the!new!drugs!that!achieve!
marketing!approval!represent!significant!advances!in!safety!and!effectiveness;!the!remainder!are!merely!molecular!
variants!(“me]too!drugs”)!on!true!breakthrough!drugs.!
Clinical!trials!are!conducted!in!a!series!of!steps,!called!phases!]!each!phase!is!designed!to!answer!a!separate!research!
question.!Clinical!trials!involving!new!drugs!are!commonly!classified!into!four!phases.!
!
In!phase!2!or!“proof!of!concept”,!the!drug!is!studied!in!patients!with!the!target!disease!to!determine!its!efficacy.!This!
is!the!first!time!when!the!drug!is!studied!in!diseased!subjects.!Both!efficacy!and!safety!in!target!disease!is!first!studied!
in!this!phase!and!a!broader!range!of!toxicities!may!be!detected!in!this!phase.!Thus,!Phase!2!trials!have!the!highest!
rate!of!drug!failures!]!either!drug!fails!due!to!efficacy!or!safety!aspect.!
!
!
>!Even!though!phase!0!studies!are!done!in!humans,!this!type!of!study!is!not!much!like!the!other!phases!of!clinical!
trials.!Phase!0!studies!are!exploratory!studies!that!often!use!only!a!few!small!doses!of!a!new!drug.!Phase!0!studies!
help!researchers!find!out!whether!the!drugs!do!what!they!are!expected!to!do.!
>!In!phase!1,!the!effects!of!the!drug!as!a!function!of!dosage!are!established!in!a!small!number!(20]100)!of!healthy!
volunteers.!Phase!1!trials!are!done!to!determine!the!probable!limits!of!the!safe!clinical!dosage!range.!Many!
predictable!toxicities!are!detected!in!this!phase.!So!efficacy!and!safety!aspect!of!the!drug!in!target!disease!is!not!
sought!in!this!phase.!
>!In!phase!3,!the!drug!is!evaluated!in!much!larger!numbers!of!patients!with!the!target!disease,!usually!thousands,!to!
further!establish!and!confirm!safety!and!efficacy.!Phase!3!trials!are!usually!performed!in!settings!similar!to!those!
anticipated!for!the!ultimate!use!of!the!drug.!Only!25%!of!innovative!drugs!move!on!to!phase!3.!
>!Once!approval!to!market!a!drug!has!been!obtained,!phase!4!begins.!This!constitutes!monitoring!the!safety!of!the!
new!drug!under!actual!conditions!of!use!in!large!numbers!of!patients.!
!
!
Clinical!trials!involving!new!drugs!are!commonly!classified!into!four!phases.!Phase!2!trials!have!the!highest!rate!of!
drug!failures.!
!
!
Question!#369!
QID:!10826!
Topic:!case!control!study!
Subject:!PMCH!
!
The!Canadian!Cancer!Society!(CCS)!recommends!that!adults!living!in!Canada!should!consider!taking!vitamin!D!
supplementation!of!1,000!IU!daily!for!the!prevention!of!colorectal!and!breast!cancer.!Suppose!that!a!researcher!
claims!that!this!recommendation!also!reduces!the!incidence!of!vertebral!fracture.!To!prove!his!claim,!he!randomly!
studied!the!medical!records!of!210!patients!from!those!who!were!diagnosed!with!vertebral!fracture!over!the!last!5!
years!in!two!regional!hospitals.!He!also!selected!an!age!and!sex!matched!control!group!of!450!patients!presented!to!
the!same!hospitals!with!other!minor!complaints!during!the!same!period!of!time.!
!
Use!of!vitamin!D!supplements!
Vertebral!fracture!
!
Case!
178
Control!
Yes!
10!
50!
No!
200!
400!
!
The!odds!of!taking!vitamin!D!supplements!in!those!who!developed!vertebral!fracture!is:!
a)!!2.500!
b)!!0.500!
c)!!0.400!
d)!!0.125!
e)!!0.050!
!
!
!
Explanation:!
The!study!in!this!question!is!a!case!control!study!in!which!a!group!of!patients!with!a!specific!disease!(vertebral!
fracture)!is!compared!to!a!control!group!without!the!disease!regarding!exposure!to!a!certain!factor!(vitamin!D!
supplements).!The!results!of!such!studies!are!evaluated!using!odds!of!exposure!and!odds!ratio.!Odds!of!exposure!are!
calculated!simply!by!dividing!the!number!of!those!exposed!to!the!factor!(who!took!vitamin!D!supplements)!by!the!
number!of!those!not!exposed!to!the!factor!(who!did!not!take!vitamin!D!supplements).!Odds!of!exposure!can!be!
calculated!for!both!the!case!group!and!control!group.!Odds!ratio,!on!the!other!hand,!is!the!ratio!of!the!odds!of!
exposure!in!one!group!to!the!odds!of!exposure!in!the!other!group.!
!
Our!question!here!is!about!odds!of!exposure!(taking!vitamin!D!supplements)!in!those!who!developed!vertebral!
fracture!and!is!thus!calculated!by!dividing!the!number!of!those!who!took!vitamin!D!supplements!(10)!by!the!number!
of!those!who!did!not!take!vitamin!D!supplements!(200)!in!the!case!group.!The!correct!answer!would!thus!be!0.05!
(10/200).!
!
→!2.5!(choice!A)!is!the!odds!ratio!of!taking!vitamin!D!supplements!in!the!control!group!(those!with!minor!complaints).!
Calculated!as!follows:!50/400!divided!by!10/200!or!(50x200)/(10x400).!This!means!that!those!in!the!control!group!
were!more!likely!(2.5!times)!to!have!taken!vitamin!D!supplement!than!those!in!the!case!group.!
→!0.5!(choice!B)!would!be!the!result!if!one!calculates!the!relative!risk!from!this!study.!Relative!risk!is!calculated!from!
cohort!studies!which!start!with!two!cohorts!of!subjects!one!exposed!and!another!not!exposed!to!a!certain!factor.!The!
two!groups!are!then!followed!and!checked!for!the!development!of!disease.!Could!be!calculated!as!follows:!10/60!
divided!by!200/600!or!(10x600)/(60x200).!
→!0.4!(choice!C)!is!the!odds!ratio!of!taking!vitamin!D!supplements!in!the!case!group!(those!who!had!vertebral!
fracture).!Calculated!as!follows:!10/200!divided!by!50/400!or!(10x400)/(50x200).!This!means!that!those!in!case!group!
were!less!likely!(0.4!times)!to!have!taken!vitamin!D!supplement!than!those!in!the!control!group.!
→!0.125!(choice!D)!is!the!odds!of!taking!vitamin!D!supplement!in!the!control!group!(those!presented!with!other!minor!
complaints).!Calculated!as!follows:!50/400.!
Key!point:!
Odds!of!exposure!and!odds!ratio!are!calculated!for!case!control!studies!while!relative!risk!is!calculated!for!cohort!
studies.!Odds!of!exposure!is!the!proportion!of!those!exposed!to!the!factor!in!any!of!the!two!study!groups.!By!
contrast,!odds!ratio!is!the!ratio!of!odds!of!exposure!in!one!group!to!that!in!the!other!group.!
!
!
!
Question!#370!
QID:!10881!
Topic:!Organophosphate!poisoning!
Subject:!PMCH!
!
A!42]year]old!farmer!is!brought!to!the!emergency!department!by!his!wife!with!symptoms!of!sudden!difficulty!
breathing,!muscle!twitching,!muscle!weakness,!sweating,!and!anxiety.!He!was!spraying!a!pesticide!when!this!
179
occurred.!They!rushed!to!the!emergency!department!and!it’s!only!been!30!minutes!since!symptoms!started.!The!
patient!is!given!atropine,!and!observed!for!response!(need!of!intubation).!Which!of!the!following!is!the!most!
appropriate!medication!to!add!to!his!treatment?!
a)!!Clonidine!
b)!!Pralidoxime!
c)!!Dantrolene!
d)!!Succinylcholine!
e)!!Physostigmine!
!
!
!
Explanation:!
This!patient’s!history!and!presentation!are!suggestive!of!organophosphate!poisoning!from!pesticide!exposure.!
Organophosphates!act!by!inhibiting!carboxyl!ester!hydrolases,!particularly!acetylcholinesterase!(AChE).!AChE!is!an!
enzyme!that!degrades!the!neurotransmitter!acetylcholine!(ACh)!into!choline!and!acetic!acid.!Organophosphates!
inactivate!AChE!by!phosphorylating!the!serine!hydroxyl!group!located!at!the!active!site!of!AChE.!Once!AChE!has!been!
inactivated,!ACh!accumulates!throughout!the!nervous!system,!resulting!in!overstimulation!of!muscarinic!and!nicotinic!
receptors.!
!
In!patients!who!present!within!few!hours!of!exposure,!pralidoxime!(choice!B)!can!be!given!for!treatment.!It!is!an!AChE!
reactivator!that!must!be!administered!IV!within!few!hours!of!exposure!because!it!is!ineffective!after!effects!of!“aging”!
(i.e.,!strengthening!of!the!alkylophosphoryl]serine!bond!formed!between!AChE!and!organophosphate).!Aging!is!
generally!considered!to!occur!after!48!hours.!This!antidote!is!also!effective!in!the!treatment!of!neurotoxin!agents!
poisoning!(e.g!sarin).!It!is!most!effective!at!the!neuromuscular!junction!and!not!effective!in!the!CNS!and!against!
carbamylated!AChE.!Atropine,!a!muscarinic!receptor!antagonist!is!also!used!in!the!treatment!of!organophosphate!
poisoning.!Atropine!has!CNS!effects!and!long!duration!of!action.!Because!pralidoxime!does!not!significantly!relieve!
depression!of!respiratory!center!or!decrease!muscarinic!effects!of!AChE!poisoning,!atropine!should!be!administered!
concomitantly!to!block!these!effects!of!organophosphate!poisoning.!According!to!the!opening!stem,!atropine!has!
already!been!initiated!in!this!patient!so!the!most!appropriate!drug!to!add!is!pralidoxime.!
!
!
>!Clonidine!(choice!A)!is!a!centrally!acting!alpha]2!agonist!in!the!vasomotor!center!of!the!medulla.!It!reduces!
sympathetic!tone!and!blood!pressure;!it!is!not!used!in!organophosphate!poisoning.!
>!Dantrolene!(choice!C)!is!ryanodine!receptor!antagonist!that!interferes!with!calcium!release!and!is!used!to!treat!
malignant!hyperthermia.!It!is!not!useful!in!the!treatment!of!organophosphate!poisoning.!
>!Succinylcholine!(choice!D)!should!be!avoided!because!it!is!degraded!by!AChE!and!may!result!in!prolonged!paralysis.!
>!Physostigmine!(choice!E)!in!an!indirect]acting!parasympathomimetic!agent!that!inhibits!AchE!and!increase!Ach!
levels.!It!is!used!to!treat!atropine!overdose.!
!
!
Exposure!to!pesticide!results!in!organophosphate!poisoning,!which!leads!to!inhibition!of!acetylcholinesterase.!
Pralidoxime,!an!AChE!reactivator!should!be!given!in!patients!who!present!within!few!hours!of!exposure!with!nicotinic!
receptor!symptoms.!It!has!no!CNS!effects.!Atropine!is!concomitantly!given!for!its!muscarinic!receptors!effects!and!
CNS!effects.!
!
!
Question!#371!
QID:!11066!
Topic:!Confidence!interval!
Subject:!PMCH!
!
In!a!study!which!involved!thousands!of!patients,!a!drug!that!is!currently!used!to!treat!hypertension!was!shown!to!
cause!a!10mmHg!drop!in!mean!arterial!pressure!(MAP)!with!a!standard!deviation!of!5!mmHg.!A!new!drug!has!been!
tested!in!a!sample!of!hundred!patients!and!caused!a!drop!in!MAP!of!12!mmHg.!The!95%!confidence!interval!around!
the!sample!mean!is!11!to!13!mmHg.!
Which!of!the!following!interpretations!is!correct!for!this!confidence!interval?!
a)!!In!any!trial!with!the!new!drug!in!a!sample!of!100!patients,!there!is!a!95%!probability!that!the!population!mean!
180
drop!in!MAP!is!between!11!and!13mmHg!
b)!!In!repeated!trials!with!the!new!treatment!in!samples!of!100!patients,!the!population!mean!drop!in!MAP!is!
between!11!and!13mmHg!in!95%!of!the!samples!
c)!!There!is!a!95%!probability!that!the!new!treatment!is!more!effective!than!the!old!treatment!
d)!!In!repeated!trials!with!the!new!treatment!in!samples!of!100!patients,!the!population!mean!drop!in!MAP!is!more!
than!13mmHg!in!5%!of!the!trials.!
e)!!The!effect!of!the!new!treatment!is!not!significantly!different!from!the!effect!of!the!current!treatment!
!
!
!
Explanation:!
In!repeated!trials!with!the!new!treatment!in!samples!of!100!patients,!the!population!mean!drop!in!mean!arterial!
pressure!(MAP)!is!between!11!and!13mmHg!in!95%!of!the!samples!(choice!B)!is!the!correct!choice.!By!definition,!
confidence!interval!is!the!range!of!values!that!has!a!specified!probability!(95%!in!this!case)!of!containing!the!
parameter!(population!mean!for!those!given!the!new!treatment).!For!calculation!of!confidence!interval,!the!standard!
error!of!the!mean!is!first!calculated!by!dividing!the!population!standard!deviation!(5mmHg)!by!the!square!root!of!the!
sample!size!(100).!This!will!give!0.5!mmHg.!The!95%!confidence!interval!is!the!sample!mean!plus!or!minus!1.96!x!
standard!error!of!the!mean!(1.96!x!0.5!or!approximately!1)!or!between!11!mmHg!and!13!mmHg.!Thus,!in!repeated!
samples!of!100!patients!given!the!new!treatment,!the!parameter!is!expected!to!be!between!11mmHg!and!13mmHg!in!
95%!of!the!samples.!
!
→!In!any!trial!with!the!new!drug!in!a!sample!of!100!patients,!there!is!a!95%!probability!that!the!population!mean!drop!
in!MAP!is!between!11!and!13mmHg!(choice!A)!is!not!the!correct!choice.!The!population!mean!or!parameter!is!not!a!
random!variable!but!rather!a!single!value.!This!parameter!is!either!in!or!out!of!the!range!between!11mmHg!and!
13mmHg.!In!other!words,!for!any!single!trial!there!is!a!50%!chance!of!the!population!mean!to!be!within!the!95%!
confidence!interval!around!the!sample!mean.!
→!There!is!a!95%!probability!that!the!new!treatment!is!more!effective!than!the!old!treatment!(choice!C)!is!not!the!
correct!choice.!Confidence!interval!does!not!give!any!information!on!the!effectiveness!of!the!new!treatment!in!
comparison!with!current!treatment.!In!case!of!95%!confidence!interval,!a!population!mean!outside!the!specified!
confidence!interval!has!less!than!5%!probability!occurring!by!chance!or!in!other!words!statistically!significantly!
different.!Effectiveness!of!drugs!is!a!specific!term!that!describes!the!maximum!effect!a!drug!causes!and!requires!
development!of!dose!response!curves.!
→!In!repeated!trials!with!the!new!treatment!in!samples!of!100!patients,!the!population!mean!drop!in!MAP!is!more!
than!13mmHg!in!5%!of!the!trials!(choice!D)!is!not!the!correct!choice.!In!repeated!trials!with!the!new!treatment!in!
samples!of!100!patients,!the!population!mean!drop!in!MAP!is!more!than!13mmHg!in!2.5%!of!the!trials!and!is!less!than!
11mmHg!is!2.5%!of!the!trials.!Confidence!interval!extends!on!both!sides!of!the!mean!and!is!equivalent!to!a!two]sided!
significance!testing.!
→!The!effect!of!the!new!treatment!is!not!significantly!different!from!the!effect!of!the!current!treatment!(choice!E)!is!
not!the!correct!choice.!Because!the!mean!drop!in!MAP!of!patients!given!the!current!treatment!(10mmHg)!is!outside!
the!confidence!interval,!the!effect!of!the!new!treatment!is!significantly!different!than!the!current!treatment!at!p<!5%.!
!
Key!point:!
Confidence!interval!encompasses!the!true!population!mean!with!the!specified!probability.!When!population!mean!is!
outside!a!confidence!interval,!a!significant!difference!exists.!
!
!
!
Question!#372!
QID:!11181!
Topic:!ETEC!Vaccine!
Subject:!PMCH!
!
A!35]year]old!Canadian!businessman!developed!watery!diarrhea!when!he!visited!Mexico!a!week!ago.!Assuming!this!
was!caused!by!the!most!common!infectious!agent!of!traveler’s!diarrhea,!which!of!the!following!statements!about!
vaccination!against!this!disease!is!correct?!
a)!!ETEC!vaccines!should!contain!aroC,!ompC,!and!ompF!and!delivered!orally!
b)!!ETEC!vaccine!should!contain!colonization!factors,!CS1]CS6,!and!LT!toxoid!
181
c)!!ETEC!vaccines!should!be!live!attenuated!three]strain!recombinant!delivered!by!injection!
d)!!ETEC!vaccine!should!contain!heat!stable!strains!expressing!CS!13!and!CS!23!
e)!!The!oral!cholera!killed!whole]cell!vaccine!is!recommended!for!protection!
!
!
!
Explanation:!
This!patient!presents!with!traveler’s!diarrhea!and!the!most!common!cause!is!Enterotoxigenic!Escherichia!coli!(ETEC).!
ETEC!infection!is!transmitted!by!ingestion!of!contaminated!food!or!water.!Disease!results!from!adherence!and!
colonization!of!the!small!intestine!and!the!subsequent!elaboration!of!two!distinct!enterotoxins:!heat]labile!toxin!and!
heat]stable!toxin.!Heat]labile!toxin!leads!to!secretory!diarrhea!by!activating!cAMP!while!heat]stable!toxin!activates!
cGMP.!
Although!there!is!no!effective!ETEC!vaccine!available!yet,!there!is!strong!evidence!to!support!that!such!a!vaccine!may!
be!developed.!It!has!been!observed!that!in!regions!of!the!world!where!ETEC!is!highly!endemic!there!is!a!decline!in!
ETEC!diarrheal!incidence!with!increasing!age!whereas!no!such!age]related!association!is!evident!in!short!time!visitors!
to!endemic!areas.!However,!the!incidence!of!ETEC!rapidly!decreases!also!in!persons!from!developed!countries!during!
prolonged!stay!in!ETEC!endemic!areas.!These!observations!strongly!suggest!that!effective!immunity!may!develop!
after!repeated!infections!and,!as!a!consequence!protection!by!way!of!an!effective!ETEC!vaccine!is!achievable.!
!
Since!the!key!pathogenic!mechanisms!that!contribute!to!the!pathogenesis!of!ETEC!are!the!production!of!colonization!
factors!(CFs)!and!a!heat]labile!enterotoxin!and/or!a!heat]stable!enterotoxin,!an!ideal!vaccine!with!broad]spectrum!
protection!should!contain!colonization!factor!antigens,!coli!surface!(CS)!antigens!1!through!6,!which!are!associated!
with!majority!of!E.!coli]linked!diarrhea,!and!the!labile!toxin!(choice!B).!
!
→!ETEC!vaccines!should!contain!aroC,!ompC,!and!ompF!and!delivered!orally!(choice!A)!is!incorrect.!AroC,!ompC,!and!
ompF!are!toxin!genes!and!are!generally!deleted!to!attenuate!potential!vaccines.!
→!ETEC!vaccines!should!be!live!attenuated!three]strain!recombinant!delivered!by!injection!(choice!C)!is!incorrect.!
While!studies!involving!live!attenuated!three]strain!recombinant!bacterial!vaccine!are!on]going!and!have!shown!
promises,!they!can!be!taken!orally!and!do!not!have!to!be!injected.!Potential!vaccines!given!by!sublingual!routes!have!
been!shown!to!be!very!efficient!in!inducing!intestinal!immune!responses.!
→!ETEC!vaccine!should!contain!heat!stable!strains!expressing!CS!13!and!CS!23!(choice!D)!is!incorrect.!The!presence!of!
CS13!is!not!frequent!within!ETEC!strains!causing!diarrhea!in!humans.!Moreover,!studies!have!recently!shown!that!CS!
23!is!similar!to!CS!13!in!this!regard.!If!widely!distributed!ETEC!adhesins!are!to!be!considered!in!a!strategy!for!vaccine!
development,!CS!13!and!CS!23!would!most!likely!not!be!suitable!candidates!compared!with!others!(such!as!CS6)!that!
are!more!commonly!identified!in!clinical!isolates.!
→!The!oral!cholera!killed!whole]cell!vaccine!is!recommended!for!protection!(choice!E)!is!incorrect.!The!cholera!
vaccine,!dukoral,!has!shown!some!minimal!benefits!in!protecting!people!against!Enterotoxigenic!E.!coli]associated!
diarrhea,!but!this!is!not!recommended!for!vaccination!against!E.!coli!infection.!
!
Key!point:!
To!provide!broad]spectrum!protection,!an!ETEC!vaccine!should!contain!colonization!factor!antigens,!coli!surface!(CS)!
antigens!1!through!6,!which!are!associated!with!majority!of!E.!coli]linked!diarrhea,!and!the!labile!toxin.!
!
!
Question!#373!
QID:!11230!
Topic:!Colon!polyps!
Subject:!PMCH!
!
!What!percentage!of!the!Canada’s!population!will!have!colonic!polyps!by!the!age!of!50?!
a)!!!0.5%!
b)!!!5%!
c)!!!10%!
d)!!!30%!
e)!!!50%!
!
182
!
!
Explanation:!
The!“30]40]50!by!50]60]70”!rule!can!help!you!remember!this!statistic.!That!is,!30%!of!the!population!will!have!polyps!
by!the!age!of!50,!40%!by!age!60!and!50%!by!70.!
The!more!common!of!these!polyps!will!be!the!tubular!variety!(60!to!80%),!which!are!less!than!2!cm,!pedunculated,!
evenly!distributed!in!the!colon!and!of!low!malignant!potential.!Less!commonly!occurring!polyps!will!be!of!the!villous!
variety!(10%).!These!are!larger!than!2!cm,!sessile,!usually!distributed!on!the!left!side!of!the!colon!and!highly!
malignant.!Remember:!“Villous!is!a!villain”.!
Colonoscopy!is!the!gold!standard!for!detection.!
!
PEARLS:!About!1/3!of!Canadians!will!have!colonic!polyps!by!age!50;!villous!polyps!have!high!malignancy!potential.!
!
Note:!The!MCCEE!and!LMCC!exams!devote!a!good!proportion!of!content!on!these!kinds!of!epidemiology!questions!
(specific!to!Canada).!
!
!
Question!#374!
QID:!11253!
Topic:!human!bite!
Subject:!PMCH!
!
A!woman!presented!to!the!emergency!department!after!being!bitten!on!her!upper!arm!by!another!woman!during!a!
clash!at!a!shopping!center.!You!took!care!of!the!wound!and!prescribed!amoxicillin.!The!patient!is!concerned,!
however,!of!getting!infected!with!HIV!because!she!heard!some!rumors!that!the!biter!has!HIV!infection.!Which!of!the!
following!should!be!done?!
!
a)!!Draw!a!sample!of!blood!to!test!for!HIV!status!
b)!!Ask!the!patient!to!come!back!for!HIV!testing!in!3!months!
c)!!Ask!the!patient!to!come!back!for!HIV!testing!in!6!months!
d)!!Tell!the!patient!that!no!HIV!testing!is!required!before!HIV!status!of!the!biter!is!ascertained!
e)!!Assure!the!patient!that!HIV!transmission!is!very!unlikely!and!that!HIV!testing!is!not!required!
!
!
!
Explanation:!
When!faced!with!a!patient!bitten!by!someone!suspected!of!having!HIV!infection!you!should!draw!blood!to!test!for!HIV!
status!(choice!A)!to!determine!a!baseline!or!pre]exposure!HIV!status.!This!is!important!from!a!legal!point!of!view!since!
the!one!bitten!or!the!bitter!might!already!have!HIV!infection.!If!the!patient!is!found!to!be!HIV!positive,!he!must!have!
been!infected!by!HIV!before!being!bitten!even!if!the!biter!is!HIV!positive!because!seroconversion!requires!between!
three!weeks!to!three!months!to!develop.!Negative!HIV!testing!of!the!patient,!however,!does!not!totally!exclude!
infection!with!HIV!because!the!infection!might!still!be!in!the!incubation!period.!
!
>!Ask!the!patient!to!come!back!for!HIV!testing!in!3!months!(choice!B)!or!6months!(choice!C)!are!not!correct!choices.!
Positive!HIV!test!after!these!periods!of!time!could!be!due!to!the!bite!or!an!infection!incurred!before!that.!Some!
severe!legal!consequences!might!follow.!
>!Tell!the!patient!that!no!HIV!testing!is!required!before!HIV!status!of!the!biter!is!ascertained!(choice!D)!is!not!correct.!
The!patient!concern!must!be!alleviated!and!future!legal!problems!must!be!anticipated!and!avoided.!This!is!also!
important!for!the!biter!in!case!the!one!bitten!is!HIV!positive.!
>!Assure!the!patient!that!HIV!transmission!is!very!unlikely!and!that!HIV!testing!is!not!required!(choice!E)!is!not!correct.!
Although!transmission!of!HIV!by!human!bites!is!rare,!it!does!occur.!Given!the!immense!potential!legal!consequences,!
HIV!testing!should!be!done.!
!
Key!point:!
Baseline!HIV!status!must!be!determined!immediately!if!a!patient!is!bitten!by!someone!suspected!of!having!HIV.!
!
!
183
Question!#375!
QID:!11254!
Topic:!Statistics:!case]control!study!
Subject:!PMCH!
!
The!vital!statistics!department!of!a!regional!hospital!recorded!birth!of!a!100!babies!with!atrial!septal!defect!(ASD)!over!
a!period!of!time,!of!whom!60!were!born!to!mothers!who!drank!alcohol!during!pregnancy.!150!newborn!babies!who!
did!not!have!atrial!septal!defect!were!selected!as!control.!Among!these,!only!60!were!born!to!mothers!who!drank!
alcohol!during!pregnancy.!The!table!below!presents!these!data:!
!
!
!
!!!!!!!!!!!!!!!!!!!!!!!!ASD!
Total!
!
!
Yes!
NO!
!
Drank!alcohol!
Yes!
60!
60!
120!
No!
40!
90!
130!
!
The!odds!ratio!is!2.25!and!the!95%!confidence!interval!on!odds!ratio!is!1.34!to!3.77.!Which!of!the!following!
statements!is!correct!regarding!these!results?!
!
a)!!Drinking!alcohol!during!pregnancy!significantly!(P!<!0.05)!increases!the!chance!of!giving!birth!to!a!baby!with!ASD!
b)!!Drinking!alcohol!during!pregnancy!increases!the!chance!of!giving!birth!to!a!baby!with!ASD!by!an!average!of!1.34!
times!
c)!!Drinking!alcohol!during!pregnancy!increases!the!chance!of!giving!birth!to!a!baby!with!ASD!by!an!average!of!3.77!
times!
d)!!The!incidence!of!ASD!in!babies!born!to!mothers!who!drink!alcohol!during!pregnancy!is!about!50%!(60/120)!
e)!!It!is!not!possible!to!make!a!conclusion!regarding!association!between!alcohol!consumption!during!pregnancy!and!
the!risk!of!developing!ASD!because!the!sample!size!of!ASD!cases!was!small!in!this!study!
!
!
!
Explanation:!
From!this!study!one!can!conclude!that!drinking!alcohol!during!pregnancy!significantly!(P!<!0.05)!increases!the!chance!
of!giving!birth!to!a!baby!with!atrial!septal!defect!(ASD)!(choice!A).!This!conclusion!is!based!on!the!fact!that!the!95%!
confidence!interval!(1.34]3.77)!does!not!include!the!value!1.!The!interpretation!of!the!95%!confidence!interval!in!this!
study!is!that!there!is!a!95%!chance!of!the!true!odds!ratio!being!between!1.34!and!3.77!and!the!chance!of!it!being!
outside!this!range!is!less!than!5%!(P!<!0.05).!
!
!
→!Drinking!alcohol!during!pregnancy!increases!the!chance!of!giving!birth!to!a!baby!with!ASD!by!an!average!of!1.34!
times!(choice!B)!is!not!correct.!The!1.34!is!the!lower!limit!of!the!95%!confidence!interval!and!this!means!that!the!
chance!of!the!true!odds!ratio!being!less!than!1.34!is!less!than!2.5%!(two!sided!distribution!is!used!and!5%!is!divided!by!
two,!half!for!the!lower!tail!and!half!for!the!upper!tail!of!the!distribution)!
→!Drinking!alcohol!during!pregnancy!increases!the!chance!of!giving!birth!to!a!baby!with!ASD!by!an!average!of!3.77!
times!(choice!C)!is!not!correct.!The!3.77!is!the!upper!limit!of!the!95%!confidence!interval!and!this!means!that!chance!
184
of!the!true!odds!ratio!being!greater!than!3.77!is!less!than!2.5%!(two!sided!distribution!is!used!and!5%!is!divided!by!
two,!half!for!the!lower!tail!and!half!for!the!upper!tail!of!the!distribution)!
→!The!incidence!of!ASD!in!babies!born!to!mothers!who!drink!alcohol!during!pregnancy!is!about!50%!(60/120)!(choice!
C)!is!not!correct.!This!study!is!a!case!control!study!which!unlike!cohort!studies!is!not!suitable!for!calculating!incidence!
of!disease.!In!case!control!studies,!investigators!start!by!selecting!cases!and!then!look!for!exposure!to!a!potential!risk!
factor!(alcohol!drinking!for!this!study).!In!cohort!study!investigators!follow!prospectively!two!groups,!one!exposed!
and!another!not!exposed!and!look!for!development!of!the!suspected!disease.!Any!case!of!disease!that!develops!is!by!
definition!an!incident!case.!By!the!end!of!a!cohort!study,!incidence!can!then!be!calculated!as!the!number!of!cases!
among!exposed!and!non]exposed.!
→!It!is!not!possible!to!make!a!conclusion!regarding!association!between!alcohol!consumption!during!pregnancy!and!
the!risk!of!developing!ASD!because!the!sample!size!of!ASD!cases!was!small!in!this!study!(choice!E)!is!not!correct.!A!
conclusion!on!whether!there!is!a!significant!association!between!alcohol!drinking!during!pregnancy!and!the!risk!of!
giving!birth!to!babies!with!ASD!should!be!based!on!whether!the!odds!ratio!is!significantly!different!from!1!or!not!and!
not!on!the!sample!size.!Indeed,!the!size!of!the!sample!is!considered!in!calculation!of!the!95%!confidence!interval.!As!
explained!above!the!odds!ratio!is!significant!in!this!study!and!the!above!conclusion!(choice!A)!can!be!made.!
!
Key!point:!
If!the!value!1!is!not!within!the!95%!confidence!interval,!then!the!odds!ratio!is!statistically!significant!at!the!5%!level!(P!
<!0.05).!
!
!
!
Question!#376!
QID:!11263!
Topic:!Coronary!Heart!Disease!Risk!Factors!
Subject:!PMCH!
!
During!a!routine!visit!you!find!that!your!45]year]old!patient!has!tendinous!xanthomas!over!his!right!Achilles!tendon!
and!left!patella.!Your!patient!tells!you!that!a!few!months!ago!he!started!smoking!and!that!his!older!brother!was!
diagnosed!with!familial!hypercholesterolemia!a!few!years!ago.!
Physical!examination:!heart!rate!79!bpm,!respiratory!rate!18!bpm,!blood!pressure!134/87!mmHg!and!body!
temperature!36.9°C.!Other!than!the!xanthomas!you!noted!earlier,!physical!examination!is!normal.!You!screen!your!
patient!by!measuring!serum!total!cholesterol!and!low!density!lipoprotein!and!you!find!that!both!are!high.!
Which!of!the!following!should!you!obtain!in!order!to!calculate!Framingham!Risk!Score!of!coronary!artery!disease!for!
your!patient?!
!
a)!!Level!of!physical!activity!
b)!!Number!of!cigarettes!smoked!per!day!
c)!!Family!history!of!coronary!artery!disease!
d)!!Waist!circumference!or!body!mass!index!
e)!!Level!of!high!density!lipoprotein!cholesterol!
!
!
!
Explanation:!
Level!of!high!density!lipoprotein!cholesterol!(choice!E)!is!required!for!calculation!of!the!10!years!risk!of!coronary!
artery!disease!in!this!patient.!Calculation!of!Framingham!Risk!Score!uses!five!items:!
!
age!
smoking!status!
systolic!blood!pressure!
total!serum!cholesterol!and!
high!density!lipoprotein!cholesterol!
The!first!four!factors!are!provided!in!the!case!scenario!and!thus!you!need!to!obtain!the!fifth!one,!high!density!
lipoprotein!cholesterol!(HDL]C).!It!is!noteworthy!that!high!levels!of!serum!HDL]C!decrease!the!risk!of!coronary!artery!
disease.!
!
185
!
>!Level!of!physical!activity!(choice!A)!is!not!required!for!calculation!of!Framingham!Risk!Score.!The!level!of!physical!
activity,!however,!influences!the!risk!of!coronary!artery!disease!irrespective!of!the!Framingham!Risk!Score.!It!is!not!
known!how!physical!activity!influences!the!risk!of!coronary!heart!disease!but!physical!activity!influences!other!risk!
factors!of!coronary!artery!disease!like,!body!mass!index,!waist!circumference!and!blood!lipid!profile.!Thus,!although!
the!level!of!physical!activity!is!not!incorporated!in!the!equation!used!to!calculate!Framingham!Risk!Score,!it!remains!
an!important!tool!for!modifying!the!risk!of!coronary!artery!disease.!
>!Number!of!cigarettes!smoked!per!day!(choice!B)!is!not!required!for!calculation!of!Framingham!Risk!Score.!
Calculation!is!based!on!whether!or!not!the!subject!smokes!irrespective!of!number!of!cigarettes!smoked.!However,!the!
risk!of!coronary!heart!disease!increases!as!the!number!of!cigarettes!smoked.!
>!Family!history!of!coronary!artery!disease!(choice!C)!is!not!required!for!calculation!of!Framingham!Risk!Score.!But,!
coronary!heart!disease!in!a!male!first!degree!relative!at!<!55!years!of!age!or!a!female!first!degree!relative!at!<!65!years!
of!age!is!considered!a!major!risk!factor!for!coronary!artery!disease.!
>!Waist!circumference!or!body!mass!index!(BMI)!(choice!D)!is!not!required!for!calculation!of!Framingham!Risk!Score.!
Obesity!as!indicated!by!BMI!is!a!minor!risk!factor!for!coronary!heart!disease.!The!effect!of!obesity!on!the!risk!of!
coronary!artery!disease!is!potentiated!by!waist!circumference!of!>!102!cm!in!men!and!>!88!in!women.!
!
!
Framingham!Risk!Score!is!calculated!on!the!basis!of!age;!smoking;!systolic!blood!pressure;!total!serum!cholesterol!and!
serum!level!of!high!density!lipoprotein!cholesterol.!Not!all!known!risk!factors!are!used!for!calculation!of!Framingham!
Risk!Score!of!coronary!artery!disease.!
!
!
Question!#377!
QID:!11273!
Topic:!Autism!tertiary!prevention!
Subject:!PMCH!
!
A!4]year]old!boy!who!had!developed!some!language!skills!by!age!2!has!regressed!and!lost!verbal!communication!
skills.!Moreover,!the!child!does!not!use!nonverbal!communication!skills!such!as!pointing!a!finger!to!an!object!of!
interest.!The!child!does!not!make!an!eye!contact!with!his!parents!when!they!try!to!communicate!with!him!and!does!
not!seem!enthusiastic!when!they!try!to!play!with!him.!He!likes!to!arrange!his!toys!in!a!row!and!resists!any!type!of!
rearrangement.!Recently,!he!has!started!biting!his!hands!and!this!has!become!a!matter!of!concern!for!his!parents.!
Structured!teaching!to!reduce!the!deficits!associated!with!this!disorder!is!considered:!
a)!!Passive!primary!prevention!
b)!!Active!primary!prevention!
c)!!Secondary!prevention!
d)!!Passive!tertiary!prevention!
e)!!Active!tertiary!prevention!
!
!
!
Explanation:!
This!child’s!most!likely!diagnosis!is!autism.!It!is!a!pervasive!disorder!that!manifests!in!early!childhood!and!is!
characterized!by!qualitative!abnormalities!in!social!interactions,!markedly!aberrant!communication!skills,!and!
restricted!repetitive!behaviors,!interests,!and!activities.!This!question!is!an!epidemiology!question!that!can!be!asked!
on!any!other!type!of!disease!and!requires!knowing!the!definition!of!primary,!secondary,!and!tertiary!prevention:!
]!Primary!prevention!aims!at!preventing!a!disease!from!occurring.!It!reduces!both!the!incidence!and!prevalence!of!a!
disease.!Primary!prevention!decreases!incidence.!
]!Secondary!prevention!includes!procedures!that!detect!and!treat!pre]clinical!pathological!changes!and!thereby!
control!disease!progression.!Screening!procedures!such!as!mammography!are!often!the!first!step,!leading!to!early!
interventions!that!are!more!cost!effective!than!intervening!once!symptoms!appear.!Secondary!prevention!decreases!
prevalence.!
]!Tertiary!prevention!seeks!to!soften!the!impact!caused!by!the!disease!on!the!patient’s!function,!longevity,!and!quality!
of!life.!Currently!there!are!no!known!means!of!primary!prevention!of!autism!to!decrease!incidence!as!its!etiology!has!
yet!to!be!completely!understood.!
!
186
Structured!teaching!in!children!with!autism!is!a!key!feature!of!what!is!known!as!the!TEACCH!program!(Treatment!and!
Education!of!Autistic!and!related!Communication!handicapped!Children).!It!is!a!tertiary!prevention!that!aims!at!
reducing!the!deficits!and!symptoms!of!autism.!Generally,!passive!prevention!doesn’t!require!any!human!action!to!be!
effective!while!active!prevention!requires!individual!intervention!to!function!correctly.!Structured!teaching!is!a!form!
of!active!tertiary!prevention!(choice!E).!
!
!
>!Passive!primary!prevention!(choice!A)!and!active!primary!prevention!(choice!B)!are!currently!not!available!for!
autistic!disorder.!Examples!of!primary!prevention!are!smoking!cessation!and!vaccination.!
>!Secondary!prevention!(choice!C)!involves!detecting!pre]clinical!condition!through!routine!screening.!Structured!
teaching!to!manage!this!child’s!autism!would!be!a!tertiary!prevention!since!the!disorder!has!already!manifested.!
>!Passive!tertiary!prevention!(choice!D)!is!incorrect,!as!structured!teaching!requires!active!involvement!of!different!
individuals.!
!
!
Structured!teaching!in!autism!disorder!is!a!form!of!active!tertiary!prevention.!
!
!
Question!#378!
QID:!11356!
Subject:!PMCH!
!
A!patient!diagnosed!as!having!a!fetus!with!trisomy!18!asks!that!you!do!not!share!this!finding!with!her!family.!You!may!
discuss!her!tests!with:!
!
a)!!!!Her!husband!
b)!!!!Her!mother!
c)!!!!Her!father!
d)!!!!Her!son!
e)!!!!No!one!
!
!
!
Explanation:!
This!question!covers!the!ethical!concept!of!confidentiality.!Even!though!her!husband!is!the!father!of!the!affected!
child,!the!patient!has!the!right!to!request!that!you!do!not!disclose!this!information!to!him.!
!
!
Question!#379!
QID:!11372!
Topic:!Biostatistics!Applications!
Subject:!PMCH!
!
A!69]year]old!female!presents!with!postmenopausal!bleeding.!You!consider!whether!to!begin!your!evaluation!with!
vaginal!probe!ultrasonography!to!assess!the!thickness!of!her!endometrium.!
In!evaluating!the!usefulness!of!this!test!to!either!support!or!exclude!a!diagnosis!of!endometrial!cancer,!which!one!of!
the!following!statistics!is!most!useful?!
!
a)!!Likelihood!ratio!
b)!!!Number!needed!to!treat!
c)!!!Prevalence!
d)!!Incidence!
e)!!Relative!risk!
!
!
187
!
Explanation:!
There!has!been!a!large!increase!in!the!number!of!diagnostic!tests!available!over!the!past!20!years.!Although!tests!may!
aid!in!supporting!or!excluding!a!diagnosis,!they!are!associated!with!expense!and!the!potential!for!harm.!In!addition,!
the!characteristics!of!a!particular!test!and!how!the!results!will!affect!management!and!outcomes!must!be!considered.!
The!statistics!that!are!clinically!useful!for!evaluating!diagnostic!tests!include!the!positive!predictive!value,!negative!
predictive!value,!and!likelihood!ratios.!
!
Likelihood!ratios!indicate!how!a!positive!or!negative!test!correlates!with!the!likelihood!of!disease.!Ratios!greater!than!
5]10!greatly!increase!the!likelihood!of!disease,!and!those!less!than!0.1]0.2!greatly!decrease!it.!In!the!example!given,!if!
the!patient’s!endometrial!stripe!is!>!25!mm,!the!likelihood!ratio!is!15.2!and!her!post]test!probability!of!endometrial!
cancer!is!63%.!However,!if!it!is!4mm,!the!likelihood!ratio!is!0.02!and!her!post]test!probability!of!endometrial!cancer!is!
0.2%.!
!
→!The!number!needed!to!treat!(choice!B)!is!useful!for!evaluating!data!regarding!treatments,!not!diagnosis.!
→!Prevalence!(choice!C)!is!the!existence!of!a!disease!in!the!current!population,!and!incidence!(choice!D)!describes!the!
occurrence!of!new!cases!of!disease!in!a!population!over!a!defined!time!period.!
→!The!relative!risk!(choice!E)!is!the!risk!of!an!event!in!the!experimental!group!versus!the!control!group!in!a!clinical!
trial.!
!
!
Question!#380!
QID:!11416!
Topic:!Hba1c!And!Serum!Glucose!
Subject:!PMCH!
!
Early!in!September,!a!family!physician!sees!his!diabetic!patient!after!5!month.!The!patient!is!not!feeling!well!and!
random!blood!glucose!is!11.2!mmol/L.!Hemoglobin!A1C!(HbA1c)!is!7.8%.!
!
One!month's!average!blood!glucose!probably!contributed!most!to!HbA1c!in!this!patient.!Which!one!is!it?!
!
a)!!August!
b)!!July!
c)!!June!
d)!!May!
e)!!April!
!
!
!
Explanation:!
The!average!blood!sugar!of!month!prior!to!measurement,!August!(choice!A),!probably!contributed!most!to!
hemoglobin!A1C!(HbA1c)!in!this!patient.!The!average!life!span!of!red!blood!cells!is!120!days!or!four!months.!Of!the!
circulating!red!cells!in!this!patient!at!the!time!of!measurement!of!HbA1c,!very!little!is!produced!more!than!120!days!
ago!(April!and!earlier),!a!small!proportion!is!produced!between!90!and!120!days!(May)!ago,!a!slightly!larger!
proportion!is!produced!60!and!90!(June)!days!ago!and!the!largest!proportion!is!produced!within!the!30!days!or!last!
month!(August).!It!follows!that!glycated!hemoglobin!produced!in!the!prior!month!contributes!to!about!50%!of!
circulating!HbA1c.!
!
Key!point:!
Although!hemoglobin!A1C!(HbA1c)!continues!to!be!produced!over!the!entire!lifespan!of!red!cells,!it!is!more!reflective!
of!changes!in!average!blood!glucose!of!the!previous!one!or!two!months!prior!to!measurement.!
!
!
!
!
Question!#381!
QID:!11453!
188
Topic:!Blood!Transfusion!in!Jehovah's!Witnesses!
Subject:!PMCH!
!
A!5]year]old!female!is!brought!to!the!ED!by!ambulance!with!her!mother.!Both!patients!have!been!in!a!motor!vehicle!
accident.!The!daughter!is!unresponsive.!Upon!arrival!the!mother!is!agitated!and!conscious,!but!is!hypotensive.!Upon!
attempting!to!obtain!consent!for!a!blood!transfusion,!the!mother!states!that!they!are!devout!Jehovah's!witnesses,!
and!neither!she,!nor!her!daughter!would!want!any!blood!products!for!any!reason,!and!she!understands!the!risks!
associated!with!not!receiving!a!blood!transfusion!if!needed.!The!father!arrives!shortly!after,!and!confirms!his!desire!
that!neither!his!wife!nor!daughter!be!treated!with!any!blood!products.!Both!patients!clinically!deteriorate,!and!it!is!
decided!that!they!require!immediate!blood!transfusions.!
!
Which!of!the!following!is!the!best!decision!with!respect!to!a!blood!transfusion!for!these!patients?!
a)!!!Adhere!to!the!mother!and!father's!wishes!and!do!not!transfuse!either!patient.!
b)!!!Adhere!to!the!mother's!wishes!and!do!not!transfuse!her,!but!do!transfuse!the!child.!
c)!!!Contact!Child!and!Family!Services!to!inform!them!the!parents!are!not!acting!in!the!best!interest!of!their!child.!
d)!!!Obtain!a!court!order!to!administer!the!blood!transfusion!to!the!child.!
e)!!!Transfuse!both!patients!since!the!mother!is!likely!not!competent!to!make!such!a!refusal!of!treatment.!
!
!
!
Explanation:!
This!situation!is!difficult,!requiring!the!balance!of!beneficence,!and!patient!autonomy,!and!is!further!complicated!by!
applying!those!to!a!minor.!However,!there!are!two!key!principles!here:!
1)!Competent!patients!can!refuse!treatment!for!themselves.!
2)!Parents!cannot!refuse!life!saving!treatment!for!their!children.!
!
In!this!case,!it!is!not!only!acceptable,!but!mandatory!to!withhold!the!blood!transfusion!from!the!mother,!since!she!
understands!the!risks!of!not!receiving!the!transfusion,!and!has!clearly!stated!her!desire!to!abstain!from!it.!Transfusing!
her!against!her!will!would!be!unacceptable.!
However,!you!must!transfuse!the!child.!She!is!a!minor!in!need!of!emergent!lifesaving!treatment,!and!her!parents!do!
not!have!the!right!to!withhold!that!treatment,!and!that!the!obligation!to!protect!the!child!supersedes!religious!
freedom.!
As!this!is!an!emergency,!and!the!child!needs!an!immediate!blood!transfusion,!obtaining!a!court!order!would!take!too!
long,!and!could!fatally!delay!the!administration!of!the!transfusion.!
!
>!Adhere!to!the!mother!and!father's!wishes!and!do!not!transfuse!either!patient!(choice!A)!would!be!an!inappropriate!
action!in!this!case,!because!parents!cannot!refuse!lifesaving!treatment!for!their!children.!
>!Contacting!child!and!family!services!(choice!C)!does!not!address!the!emergent!nature!of!the!situation,!nor!would!it!
be!the!best!way!to!make!the!child!a!ward!of!the!state!in!order!to!administer!necessary!treatment.!
>!Obtaining!a!court!order!(choice!D)!would!be!appropriate!if!the!nature!of!the!intervention!was!not!so!time!sensitive!
(the!transfusion!is!required!immediately).!In!this!case!there!is!not!time!to!get!a!court!order.!
>!Transfusing!both!the!mother!and!the!child!(choice!E)!is!incorrect.!There!is!no!indication!that!the!mother!is!
incompetent!to!make!medical!decisions.!She!understands!the!consequences!of!not!receiving!the!transfusion!and!
should!be!granted!the!autonomy!to!make!such!a!decision.!Transfusing!the!child!is!the!correct!option,!since!competent!
or!not,!parents!cannot!withhold!lifesaving!treatments!from!their!children.!
!
Key!point:!
Adult!patients!(and!in!some!cases!mature!minors)!can!refuse!even!lifesaving!treatment!and!this!refusal!should!be!
honoured.!Parents!cannot,!however,!refuse!life!or!limb!saving!treatment!for!their!children.!Also!bear!in!mind!that!a!
refusal!of!blood!products!does!not!mean!a!refusal!of!all!treatment,!or!even!a!refusal!of!all!IV!products.!
!
!
Question!#382!
QID:!11780!
Topic:!Colon!Cancer!Screening!
Subject:!PMCH!
!
189
A!family!physician!has!a!short!break!between!seeing!patients!in!her!busy!clinic.!Looking!over!her!survey,!she!wants!to!
identify!which!patients!need!to!be!referred!for!screening!colonoscopy.!
Which!of!the!following!patients!should!be!screened!for!colon!cancer?!
a)!!A!47]year]old!hypertensive!female!with!no!personal!or!family!history!of!colon!cancer!
b)!!A!30]year]old!diabetic!male!with!a!family!history!of!colon!cancer!in!his!father!at!the!age!of!45!
c)!!A!40]year]old!male!with!Peutz]Jeghers!syndrome!and!no!family!history!of!cancer!
d)!!A!25]year]old!male!with!a!personal!and!family!hereditary!non]polyposis!colorectal!cancer!
e)!!A!60]year]old!male!with!a!history!of!colon!cancer!resection!2!years!ago!and!a!colonoscopy!1!year!ago!
!
!
!
Explanation:!
As!of!2014,!colorectal!cancer!is!the!second!most!common!cause!of!cancer!death!in!males,!and!third!most!common!
cause!of!cancer!death!in!females.!Screening!can!take!the!form!of!a!screening!colonoscopy,!flexible!sigmoidoscopy,!
fecal!occult!blood!testing,!barium!enema,!and!CT!colonography!("virtual!colonoscopy").!The!most!preferred!test!is!the!
colonoscopy!for!its!accuracy,!and!because!it!allows!direct!visualization!and!biopsy!of!lesions.!
!
Screening!colonoscopy!guidelines!include!the!following:!
]!General!population:!colonoscopy!every!10!years!
]!Family!history!of!colon!cancer:!colonoscopy!starting!at!the!age!of!40,!or!10!years!before!incidence!in!the!family!
member,!whichever!comes!first!
]!Personal!history!of!colon!cancer:!colonoscopy!at!1,!3,!and!5!years!after!resection!of!the!cancer!
]!Personal!history!of!adenomatous!polyps:!colonoscopy!every!3]5!years!after!
]!Ulcerative!colitis:!colonoscopy!every!1]2!years!starting!8]10!years!after!colonic!involvement!
]!Hereditary!non]poliposis!colorectal!cancer!(choice!D):!colonoscopy!evey!1]2!years!starting!at!the!age!of!25!
]!Familial!Adenomatous!Polyposis!Coli:!sigmoidoscopies!starting!at!10]12!years!with!colectomy!when!polyps!are!
found.!
!
→!A!47]year]old!hypertensive!female!with!no!personal!or!family!history!of!colon!cancer!(choice!A)!is!incorrect.!She!
does!not!need!screening!for!another!three!years.!Hypertension!does!not!alter!the!screening!schedule.!
→!A!30]year]old!diabetic!male!with!a!family!history!of!colon!cancer!in!his!father!at!the!age!of!45!(choice!B)!does!not!
need!screening!until!age!35!(10!years!before!onset!in!family!member).!
→!A!40]year]old!male!with!Peutz]Jeghers!syndrome!and!no!family!history!of!cancer!(choice!C)!would!follow!the!
screening!recommendations!for!the!normal!population.!Peutz]Jeghers!and!Turcot!syndrome!are!not!grounds!for!
advanced!screening.!
→!A!60]year]old!male!with!a!history!of!colon!cancer!resection!2!years!ago!and!a!colonoscopy!1!year!ago!(choice!E)!
does!not!need!a!colonoscopy!for!another!two!years.!Patients!with!previous!colon!cancer!resection!receive!screening!
colonoscopy!at!1,!3,!and!5!years!after!resection.!
!
Key!point:!
Colon!cancer!is!an!important!cause!of!morbidity!and!mortality.!Screening!exists!to!detect!and!treat!it!early.!Screening!
starts!at!the!age!of!50!in!the!general!population,!and!at!25!in!patients!with!Hereditary!non]poliposis!colorectal!cancer!
(HNPCC).!
!
!
Question!#383!
QID:!11786!
Topic:!Cervical!Cancer!
Subject:!PMCH!
!
A!21]year]old!nulligravid!comes!to!your!office!for!a!routine!physical!exam.!She!is!sexually!active!and!has!never!had!a!
Pap!smear!performed.!She!asks!you!what!benefit!the!pap!smear!has!for!her.!When!detected!at!its!earliest!stage,!
cervical!cancer!has!a!5]year!relative!survival!rate!of!approximately:!
a)!!!10%!
b)!!!30%!
c)!!!50%!
d)!!!70%!
190
e)!!!90%!
!
!
!
Explanation:!
The!ultimate!goal!of!cervical!screening!is!to!decrease!the!incidence!of!and!mortality!from!invasive!cervical!cancer.!The!
use!of!the!routine!Pap!smear!as!a!screening!tool!for!cervical!cancer!has!helped!to!significantly!decrease!the!number!of!
women!dying!from!this!disease!over!the!last!50+!years.!
Cervical!cancer!accounts!for!approximately!1.1%!of!all!female!cancer!deaths!in!Canada.!1!in!150!women!is!expected!to!
develop!cervical!cancer!during!her!lifetime,!and!1!in!423!will!die!of!it.!Most!cervical!cancer!(67%)!occurs!in!women!
aged!30]59.!
When!detected!at!its!earliest!stage,!cervical!cancer!has!a!5]year!relative!survival!rate!of!approximately!91%!(choice!E).!
For!regional!disease,!it!is!approximately!57%.!If!cancer!has!spread!to!distant!organs,!5]year!survival!drops!to!
approximately!16%.!In!general,!the!prognosis!is!affected!by!the!extent!of!disease!at!the!time!of!diagnosis.!
!
!
Question!#384!
QID:!11803!
Topic:!Biostatistics!Applications!
Subject:!PMCH!
!
A!head!to!head!clinical!trial!is!underway!to!test!the!effects!of!a!new!blood!pressure!medication!against!the!current!
standard!first!line!treatment.!Three!hundred!participants!with!newly!diagnosed!hypertension!who!have!not!taken!
antihypertensives!before!have!been!randomly!assigned!to!taking!the!new!or!the!old!medication.!Their!baseline!blood!
pressure!was!measured,!and!compared!to!their!blood!pressure!after!three!months!of!taking!their!respective!
medication.!Systolic!and!diastolic!blood!pressures!were!compared!separately.!The!results!are!summarized!in!the!chart!
below:!
!
!!!!!!!!!!!Mean!Systolic!Blood!Pressure!Before!!!!!95%!Confidence!Interval!!!!!!!!!Mean!Systolic!Blood!Pressure!After!!!!!!95%!
Confidence!Interval!
Experimental!Treatment!!!!!!!!!!!!155!!!!!!!!147]163!!!!!!!!!145!!!!!!!!!!!!!!141]149!
Standard!Treatment!!!!!!!!!!!!!!!!155!!!!!!!!147]163!!!!!!!!!150!!!!!!!!!!!!!!146]155!
!
!!!!!!!!!!!Mean!Diastolic!Blood!Pressure!Before!!!!95%!Confidence!Interval!!!!!!!!!Mean!Diastolic!Blood!Pressure!After!!!!
!95%!Confidence!Interval!
Experimental!Treatment!!!!!!!!!!!!100!!!!!!!!96]104!!!!!!!!!!85!!!!!!!82]88!
Standard!Treatment!!!!!!!!!!!!!!!!100!!!!!!!!96]104!!!!!!!!!!95!!!!!!!91]99!
!
Assuming!a!p]value!of!0.001,!which!of!the!following!statements!is!most!reasonable?!
a)!!The!experimental!drug!lowers!systolic!blood!pressure!to!a!greater!extent!than!the!standard!treatment!
b)!!The!experimental!drug!lowers!diastolic!blood!pressure!to!a!greater!extent!than!the!standard!treatment!
c)!!The!results!for!systolic!and!diastolic!blood!pressure!are!not!statistically!significant!
d)!!Both!systolic!and!diastolic!blood!pressures!are!lowered!to!a!greater!extent!with!the!experimental!drug!compared!
to!the!standard!treatment!
e)!!There!is!not!enough!information!to!make!any!conclusions!about!this!study!
!
!
!
Explanation:!
When!comparing!two!different!groups,!it!is!not!enough!to!compare!the!means!of!the!two!groups,!bute!there!are!
other!measures!that!must!be!examined.!The!95%!confidence!interval!is!one!such!measure.!This!measure!states!that!
there!is!95%!certainty!that!the!true!mean!value!being!measured!is!somewhere!in!that!range.!As!such,!when!
interpreting!a!confidence!interval,!it!is!important!to!understand!that!all!of!the!values!in!the!interval!are!equally!likely!
to!be!the!true!mean.!When!the!two!confidence!intervals!overlap,!one!can!conclude!that!there!is!no!difference!
between!the!means,!and!therefore,!there!is!no!difference!between!the!two!groups.!An!important!distinction!to!make!
is!that!the!confidence!interval!involves!the!mean,!and!is!not!a!measure!of!the!range!of!values!(i.e.!a!95%!confidence!
191

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