Family/Emergency Med
OBGYN/Peds
Hospital Medicine
Surgery/Anesthesia
Planetary Health
100
Before ordering DEXA screening for osteoporosis in females >/65 yrs, what needs to be done?
FRAX Risk Assessment Score
Rationale:
Use the results from the Canadian clinical FRAX risk assessment tool to facilitate a discussion on preventive medication. At this initial assessment, bone mineral density (BMD) measurement is not required.
After this discussion, if preventive medication is being considered, perform a BMD measurement. Then re-calculate fracture risk by adding the BMD T-score into the FRAX assessment tool.
100
The use of cold and cough remedies are not recommended to children under the age of?
6 years
Rationale: Cough and cold remedies sold over the counter often contain combinations of several medications. Research shows that they are not effective when given to children. They can, however, cause serious harmful effects, including accidental overdose, particularly when combined with other medications. For these reasons, since 2008, Health Canada has advised against their use in children less than six years of age.
100
True or False: Routine neuroimaging (CT, MRI, or carotid dopplers) is recommended for patients with simple syncope and a normal neurological examination.
False
Explanation: Neuroimaging is not routinely indicated for patients with simple syncope who have a normal neurological examination. Imaging studies are typically unnecessary unless there are concerning neurological signs or symptoms.
100
True or False
Ultrasound is warranted for evaluation of an inguinal hernia when a palpable wall defect is present.
Answer: False
Don’t use ultrasound routinely to evaluate clinically evident inguinal hernias.
Rationale: The diagnosis of most inguinal hernias can be made with a focused patient history and physical examination. Routine ultrasounds add little value to the diagnosis and management of clinically evident inguinal hernias and can result in treatment delay. These investigations should therefore be limited to use in the evaluation of occult inguinal hernias.
100
Which of the following clinical decisions aligns best with environmentally sustainable healthcare delivery?
A) Ordering routine pre-op labs for all patients regardless of surgical risk
B) Prioritizing in-person visits over virtual care to ensure “face time”
C) Choosing tests and treatments that are evidence-based and clinically necessary
D) Repeating imaging tests frequently to avoid missing any findings
C) Choosing tests and treatments that are evidence-based and clinically necessary
Explanation: Avoiding low-value care helps reduce unnecessary resource use and emissions, while maintaining high-quality, patient-centered clinical care. Sustainable care is about doing more of what matters, not just more.
200
Do not order imaging for back pain unless RED FLAGS are present. Can you name 3 red flags that would warrant imaging?
Rationale: Red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes.
200
Only give antenatal corticosteroid therapy if the risk of delivery within the next __ days is very high.
7 days
200
What is the recommended approach for patients on long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms?
A) Continue the PPI indefinitely without review
B) Attempt to reduce or stop the PPI at least once per year in most patients
C) Switch to a different class of medication without reducing PPI dose
D) Increase the PPI dose annually for better symptom control
E) Only stop the PPI if the patient reports new symptoms
B) Attempt to reduce or stop the PPI at least once per year in most patients
Explanation: It’s important to periodically reassess the need for continued PPI therapy and attempt to reduce or stop the medication annually, except in specific conditions like Barrett’s esophagus or significant esophagitis.
200
Mr. Thompson is a 68-year-old man scheduled for an elective inguinal hernia repair next week. He presents to your preoperative clinic for evaluation. He reports feeling well and denies chest pain, shortness of breath, palpitations, syncope, or decreased exercise tolerance. His past medical history includes well-controlled hypertension and hyperlipidemia. He is a non-smoker and exercises regularly. His physical exam is normal, and vital signs are within normal limits.
Which of the following investigations would you order for this Mr. Thompson pre-op?
Baseline ECG
Laboratory studies (complete blood count, coagulation testing, or serum biochemistry)
Cardiac stress test
Echocardiogram
All of the above
None of the above
Answer: None of the above!
Rationale: https://choosingwiselycanada.org/recommendation/anesthesiology/
200
A 59-year-old woman with a history of well-controlled hypertension and stable generalized anxiety disorder requests a follow-up appointment. She prefers a virtual visit, stating she has no new symptoms and finds travel to clinic appointments burdensome.
Which of the following best supports proceeding with a virtual visit rather than in-person care?
A) Virtual visits are only appropriate for new diagnostic assessments.
B) Chronic disease management and mental health care can be delivered virtually with outcomes comparable to in-person care.
C) In-person visits are more clinically effective and environmentally neutral for stable conditions.
D) Physical examination is always required to renew prescriptions for antihypertensives and SSRIs.
B) Chronic disease management and mental health care can be delivered virtually with outcomes comparable to in-person care.
Explanation: For stable chronic conditions like hypertension and anxiety, virtual care can be equivalent in safety and effectiveness, while also reducing travel-related emissions and improving convenience for patients who prefer it.
300
What percent of Canadians felt that they were recommended a test or treatment by a physician that they did not feel was beneficial for their health?
A) 25%
B) 38%
C) 65%
D) 80%
300
Which of the following is a recommended routine part of antenatal care in a healthy, uncomplicated pregnancy?
Urinalysis (glucose and protein)
Umblical artery dopper studies
Electronic fetal monitoring during labour
Non-invasive prenatal testing (NIPT)
300
In a patient with anemia but without symptoms of coronary disease, heart failure, or stroke, which of the following is the most appropriate approach to red blood cell (RBC) transfusion?
A) Transfuse when hemoglobin is below 8 g/dL
B) Transfuse when hematocrit is below 30%
C) Transfuse at any hemoglobin level below 10 g/dL
D) Restrict transfusion unless the patient is symptomatic or has underlying cardiovascular disease
E) Transfuse at any signs of anemia regardless of symptoms
D) Restrict transfusion unless the patient is symptomatic or has underlying cardiovascular disease
Explanation: Transfusions should not be performed based solely on arbitrary thresholds for hemoglobin or hematocrit. A restrictive approach is recommended, focusing on clinical symptoms and the patient’s underlying condition.
300
A 45-year-old woman is scheduled for elective cataract surgery. She has no significant past medical history, takes no medications, and denies any symptoms such as chest pain, shortness of breath, or fatigue. Her physical examination is unremarkable, and she is classified as ASA Physical Status Class II (mild systemic disease).
Which of the following is the most appropriate preoperative plan?
A) Order a chest x-ray and complete blood count
B) Order a basic metabolic panel and coagulation studies
C) Proceed with surgery without additional testing
D) Delay surgery until laboratory testing is reviewed
E) Refer for cardiology evaluation prior to surgery
C) Proceed with surgery without additional testing
Rationale: In asymptomatic patients undergoing low-risk procedures (like cataract surgery) with no significant systemic disease (ASA I or II), routine preoperative tests (e.g., chest x-ray, CBC, BMP, coagulation studies) are not recommended. These tests rarely change management or outcomes and may lead to unnecessary delays or interventions. A focused history and physical examination should guide testing decisions.
300
A 40-year-old man presents with low back pain for 5 days after lifting a heavy object. He has no red flags, neurologic deficits, or systemic symptoms. He requests imaging for reassurance. From both a clinical and planetary health perspective, what is the most appropriate next step?
A) Reassure and defer imaging
B) Order lumbar spine X-rays
C) Order an MRI lumbar spine
D) Prescribe opioids and schedule follow-up
E) Refer to orthopedic surgery
A) Reassure and defer imaging
Explanation: Imaging in acute, uncomplicated low back pain does not improve outcomes, exposes patients to unnecessary radiation (if CT), and contributes to resource overuse and emissions.
400
Which of the following treatments is first line for a sinus tract infection?
A) Amoxicillin
B) CT Scan
C) Rest
D) Oral decongestants
Answer: Rest
Rationale: Millions of people are prescribed antibiotics each year for sinus infections, a frequent complication of the common cold, hay fever, and other respiratory allergies. In fact, 15 to 21 percent of all antibiotic prescriptions for adults in outpatient care are for treating sinus infections.
They’re usually required only when symptoms last longer than a week, start to improve but then worsen again, or are very severe. Worrisome symptoms that can warrant immediate antibiotic treatment include a fever over 38.6°C, extreme pain and tenderness over your sinuses, or signs of a skin infection, such as a hot, red rash that spreads quickly.
400
A 2-year-old previously healthy boy is brought to the emergency department by his parents after experiencing a seizure at home. The event lasted approximately 3 minutes and involved generalized tonic-clonic activity. The parents report that he had a fever of 38.9°C (102°F) earlier in the day but was otherwise acting normally. There was no history of head trauma, vomiting, recent travel, or ingestion. He has no prior seizure history and no family history of epilepsy.
By the time of evaluation in the ED, he is alert, interactive, and at his baseline mental status. Physical examination is normal, and there are no focal neurologic deficits.
Which of the following is the most appropriate next step in management?
A) Order a serum electrolyte panel and glucose level
B) Order a non-contrast head CT scan
C) Admit for overnight observation and EEG
D) Provide parental reassurance and discharge with outpatient follow-up
E) Start empiric antiepileptic medication
D) Provide parental reassurance and discharge with outpatient follow-up
Rationale: This is a classic presentation of a simple febrile seizure—a brief (<15 minutes), generalized seizure in a child between 6 months and 5 years, associated with fever, and without focal findings or a history of neurologic disease. In children who return to their baseline mental status, routine blood work and neuroimaging (e.g., head CT) are not indicated. These investigations rarely affect acute management, expose the child to unnecessary risk (e.g., radiation, sedation), and increase healthcare costs. The appropriate management is supportive care, parental education, and outpatient follow-up.
400
Which of the following is the recommended first-line intervention for preschool-aged children with Attention-Deficit Hyperactivity Disorder (ADHD)?
A) Psychostimulants
B) Atypical antipsychotics
C) Parent education and behavioral management
D) Cognitive Behavioral Therapy (CBT)
E) Family therapy
C) Parent education and behavioral management
Rationale: Preschool children with ADHD should initially receive support through parent education and behavioral management. Psychostimulants may be considered later, but not as a first-line intervention due to potential side effects at this young age.
400
For which of the following patients would a tonsillectomy be appropriate?
A) A 6-year-old boy with 3 sore throat infections this year, all treated with antibiotics.
B) A 9-year-old girl with 4 episodes of strep throat in each of the past two years.
C) A 7-year-old boy with 7 documented throat infections in the past year, each with fever and swollen lymph nodes.
D) A 5-year-old girl with 2 throat infections this year and 3 last year, none with significant symptoms.
Answer: C
Rationale: Tonsillectomy is generally reserved for children with frequent, well-documented episodes of throat infection:
7 or more episodes in one year
5 or more per year for two years
3 or more per year for three years
Each episode should ideally include features such as fever, cervical lymphadenopathy, tonsillar exudates, or a positive strep test.
400
A 65-year-old woman with moderate COPD is well controlled on a salbutamol metered-dose inhaler (MDI) and a long-acting muscarinic antagonist (LAMA) dry powder inhaler (DPI). She is open to switching her salbutamol inhaler to a lower-carbon alternative. On inhaler technique testing, she demonstrates effective use of dry powder inhalers and soft-mist inhalers.
Which of the following is the most appropriate next step to reduce her treatment’s environmental impact without compromising clinical care?
A) Continue the salbutamol MDI because it’s familiar
B) Switch to a salbutamol DPI if available and clinically appropriate
C) Discontinue short-acting bronchodilator altogether
D) Add a second MDI with lower frequency of use
B) Switch to a salbutamol DPI if available and clinically appropriate
Explanation: When patients are capable of using alternative inhalers effectively and prefer the switch, choosing dry powder or soft-mist inhalers over high GWP MDIs reduces greenhouse gas emissions while maintaining effective disease control.
500
Joe comes into the emergency room after a MVA. Your preceptor asks you to take a history and decide if Joe needs imaging based on the Canadian C-spine rule. Which of the following are false?
A) The mechanism matters! If Joe was on a bicycle and got hit by a car, we should image.
B) If Joe experiences any numbness or tingling in his legs, we should image.
C) Age over 50 years is a high risk factor.
D) You must have a normal GCS for the C-spine rule to apply.
Answer: C --> age greater than 65 years is high risk factor
500
A 27-year-old primigravida woman is in active labor at 39 weeks gestation. She has no medical complications and has had a healthy pregnancy. She is now in the second stage of labor, and the fetal heart tracing is reassuring. The fetal head is crowning, and the perineum is stretching gradually. The attending physician suggests performing an episiotomy "to speed things up and prevent tearing."
Question:
What is the most appropriate management at this time?
A. Proceed with routine episiotomy to prevent uncontrolled perineal tearing
B. Perform an episiotomy only if there is evidence of fetal distress or obstructed delivery
C. Perform an episiotomy routinely with all primigravid patients
D. Proceed with cesarean section to prevent perineal trauma
Answer: B. Perform an episiotomy only if there is evidence of fetal distress or obstructed delivery
Explanation:
Routine episiotomy is not recommended as it has been associated with more harm than benefit, including increased perineal trauma, suturing, and complications. A restrictive approach results in fewer complications with no significant difference in pain or severe trauma. Episiotomy should be reserved for specific clinical indications, such as when the perineum is obstructing delivery and there is evidence of fetal distress
500
A 72-year-old patient with Stage 5 chronic kidney disease (CKD) has an estimated glomerular filtration rate (eGFR) of 12 mL/min but is currently asymptomatic. He is seen in your clinic, and you are considering initiating dialysis. What is the most appropriate course of action based on current guidelines?
A) Initiate dialysis immediately due to the low eGFR
B) Refer for dialysis access placement as a precaution
C) Start dialysis to prevent future complications
D) Closely monitor the patient, deferring dialysis until uremic symptoms or other clinical indicators develop
E) Perform a biopsy to assess kidney function further
D) Closely monitor the patient, deferring dialysis until uremic symptoms or other clinical indicators develop
Explanation: Dialysis should not be initiated in patients with Stage 5 CKD in the absence of uremic symptoms or other clinical indications. Current guidelines recommend close monitoring, with dialysis deferred until symptoms like uremia, volume overload, or severe electrolyte abnormalities arise.
500
Which of the following statements best reflects current recommendations regarding opioid prescribing for pain management?
A) Opioids should be continued as long as the patient reports any level of pain, regardless of duration.
B) Opioids are the preferred first-line treatment for chronic non-cancer pain.
C) Prolonged use of opioids after acute pain or surgery should be avoided in favor of non-opioid and non-pharmacologic therapies.
D) Higher doses of opioids are generally safer and more effective for managing long-term pain.
Answer: C
Rationale: Opioid use poses considerable health risks to patients including opioid use disorder, overdose, and side-effects such as psychomotor impairment. While opioid analgesia may be appropriate in select circumstances, prolonged use of opioids beyond the immediate postoperative period and for chronic non-cancer pain is not recommended. Instead, clinicians and patients should consider alternative therapies, such as non-opioid pharmacologic therapy or non-pharmacologic therapies. If opioid analgesia is required, the lowest effective dose, potency, and number of doses required to address the acute pain episode should be prescribed.
500
How often should ventilator tubing and in-line suction catheters be changed?
Daily
Every other day
Weekly
When visibly soiled
Answer: When visibly soiled
Rationale: Decreasing the frequency of ventilator tubing or in-line suction catheter changes has been shown to result in equal or lower rates of ventilator-associated pneumonia. Therefore, current guidelines suggest conducting changes on an as needed basis, as opposed to a fixed replacement schedule.