Question #1

A 50-year-old male business development executive comes to request an overall health checkup. He has seen you
in the past for seasonal upper respiratory infections and minor MVA injuries. He states that he has been feeling well
and has no current complaints. His past medical history is uneventful. He tells you that his father died of a sudden
heart attack at the age of 60 and that his mother was treated for high BP for years. He is a non-smoker, occasionally
has a glass of wine, is not taking any medications and admits that he rarely exercises. He shows you a piece of paper
which is a Shoppers Drug Mart blood pressure machine reading: BP of 142/93 mmHg and 144/91 mmHg (10min
apart) from 10 days ago.

Examination findings:
BP: 145/90 mmHg
Wt: 90 kg
Ht: 170 cm

Complete physical examination is unremarkable.

Which of the following should be included in your discussion with the patient following his physical exam?
Select up to 7 Answers

1. "I have good news. There are no abnormal findings."

2. "Your blood pressure is normal, but I suggest it should be checked in one year."
3. “You have hypertension, mild category, and this should be checked on two further occasions to determine if
this level is sustained before instituting any treatment.”
4. "Your weight is above normal for height."
5. “Your Body Mass Index is 31 kg/m², which is above normal.”
6. "Because of your weight I suggest we arrange a test on your thyroid gland."
7. “Thyroid function tests are helpful in your situation.”
8. “Reduction in dietary fat and regular exercise most days of the week will help this problem.”
9. “Regular monitoring of BP and body weight, initially at monthly intervals, will be necessary.”
10. “Anti-hypertensive drugs are not indicated at present.”
11. “Non-pharmacological therapy is the approach of choice.”
12. “You have the same risk of dying early as your father.”
13. “You have no risk factors for heart disease.”
14. “Your BP is normal, so you do not need to exercise.”
Explanation
Correct Answers: 3, 4, 5, 8, 9, 10 and 11
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Question #2
You find it necessary to talk about cardiovascular disease risk factors and its associated clinical conditions. Which of
the following are NOT associated with these?
Select up to 3 Answers

1. Men > 45 years

2. Women > 65 years
3. Smoking
4. Total cholesterol > 6.5mmol/L
5. Diabetes Type 2
6. Family history of premature CVD
7. Ischaemic stroke
8. TIA
9. MI
10. Angina
11. Active lifestyle
12. LVH
13. Proteinuria
14. Haemorrhages or exudates
15. Anaemia
16. High risk ethnic group
17. Dissecting aneurysm
18. Raised Fibrinogen
Explanation
Correct Answers: 1, 11 and 15
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Topic: Cardiovascular Disease
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 3, 4, 5, 8, 9, 10, 11.

Question 2 - Correct answer(s): 1, 11, 15.

Detailed Explanation:

Patients frequently open up a consultation in this general way even when they have some more specific health
concerns like a pain, a cough, worries about serious disease, etc. It is important to determine whether this
consultation is a true request for a ‘well person check,'or merely his way of seeking help about a specific problem yet
to be revealed. Alec tells you he has no symptoms, but this request is from his employer. The patient's Body Mass
Index (BMI) is 31 kg/m², which is above normal.

Risk factors for cardiovascular disease:

Used for risk stratification:
- levels of SBP and DBP
- men > 55 years
- women > 65 years
- smoking
- total cholesterol > 6.5mmol/L
- diabetes mellitus
- family history of premature CVD
Other factors adversely influencing prognosis:
- reduced HDL-C
- raised LDL-C
- microalbuminuria in diabetes mellitus
- impaired glucose tolerance
- obesity
- sedentary lifestyle
- raised fibrinogen
- high-risk socioeconomic group
- high-risk ethnic group
- high-risk geographic region

Associated clinical conditions:

Cerebrovascular disease
- ischaemic stroke
- cerebral haemorrhage
- transient ischaemic attack

Heart disease
- myocardial infarction
- angina
- coronary revascularisation
- congestive heart failure

Renal disease
- diabetic nephropathy
- renal failure

Vascular disease
- dissecting aneurysm
- symptomatic arterial disease
Advanced hypertensive retinopathy
- haemorrhages or exudates
- papilloedema

Target organ damage:

Left ventricular hypertrophy
- proteinuria and/or slight of plasma creatinine concentration
- ultrasound or radiological evidence of atherosclerotic plaque
- generalized or focal narrowing of the retinal arteries
Question #3
A 45-year-old male presents because a male friend at work, and his own age, has just been diagnosed with prostate
cancer. He told him he should also be ‘checked out.' He is here today for prostate check-up and to learn more about
prostate cancer.
Which of the following would you include in this patient's visit?
Select up to 8 Answers

1. Advise him his lifetime risk is 1 in 50

2. Ask about any incidents of impotence
3. Ask about any incidents of incontinence
4. Establish his anxiety level about the condition
5. Establish the patient's knowledge about prostate disease
6. Order prostate-specific antigen (PSA)
7. Take a history, including familial history
8. Take a history, including urinary history
9. Tell him early treatment and detection do not necessarily convey any benefit in terms of mortality
10. Tell him that cancer of the prostate gland progresses slowly and, most of the time, can be treated
effectively after diagnosis
11. Tell him that there are not any dramatic side effects of the treatment options
12. Tell him to adopt preventive strategies
13. Tell your patient not to worry, as he is still relatively young
Explanation
Correct Answers: 2, 3, 4, 5, 7, 8, 9 and 10
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Question #4
A year later the patient returns and tells you that his older brother, aged 52, has just been diagnosed with prostate
cancer.

What would you do at this point?

Select up to 4 Answers

1. Advise the patient to start taking aspirin 81mg

2. Ask the patient to decrease alcohol intake
3. Communicate that he is now in a higher-risk category
4. Order prostate biopsy
5. Order PSA
6. Order transrectal ultrasonography
7. Order PSA to distinguish between aggressive cancer and slow-growing cancer
8. Tell him that benign prostatic hyperplasia increases the risk for prostate cancer
9. Tell him you will need to perform a rectal examination
10. Tell the patient that first-degree relatives have a four-fold risk
11. Tell the patient that 75% of prostate cancers are diagnosed in the early stages
Explanation
Correct Answers: 3, 5, 9 and 11
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Question #5
Which of the following regarding PSA in the detection of carcinoma are correct?
Select up to 8 Answers

1. 5-alpha-reductase inhibitors produce a great decrease in serum PSA

2. Can be ‘normal' in 5% of patients with cancer
3. Cancer is always present if PSA is elevated
4. Digital rectal exam can increase PSA
5. Ejaculation can increase PSA
6. It is prostate-specific, not cancer-specific
7. Normal level is less than 7 μg/L
8. Levels 4-10 μg/L are equivocal
9. Levels > 20 μg/L are suggestive of cancer
10. PSA has a half-life of 7 days
11. The age specific PSA reference range for this patient is 0-2.5 μg/L
Explanation
Correct Answers: 1, 2, 4, 5, 6, 8, 9 and 11
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Topic: Prostate Cancer
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 2, 3, 4, 5, 7, 8, 9, 10.

Question 2 - Correct answer(s): 3, 5, 9, 11.
Question 3 - Correct answer(s): 1, 2, 4, 5, 6, 8, 9, 11.

Detailed Explanation:

Q1.
Obtaining a medical history is appropriate for every patient. Medical history includes an inquiry into the patient's
medical history, past surgical history, family medical history, social history, allergies, and medications (choice 2,
choice 3, choice 7, choice 8).
You would need to establish the patient's level of knowledge about the prostatic disease (choice 5) and make an
assessment of his level of anxiety (choice 4). Early detection and treatment do not necessarily convey any benefit
in terms of mortality and may contribute to an increase in morbidity (choice 9). Prostate cancer usually progresses
slowly and, in many cases, can be treated effectively after diagnosis (choice 10). Impotence and incontinence are
dramatic side effects of many treatment options. Both total prostatectomy and radical radiotherapy are potentially
curative treatments. However, both have perioperative mortality of 0.5%. Acceptable continence is achieved in 90%
of cases though potency rates are considerably lower.

→ Advise him his lifetime risk is 1 in 50 (choice 1) is incorrect. It is estimated that about 1 in 7 Canadian men will
develop prostate cancer during their lifetime and 1 in 29 will die from it.
→ Order PSA (choice 6) is incorrect. As the patient is asymptomatic, any investigation would constitute screening,
and there is no evidence that screening for prostate cancer by prostate-specific antigen (PSA) or digital rectal
examination (DRE) is useful.
→ Impotence and incontinence are dramatic side effects of many treatment options (choice 11), though it is causing
undue concern to mention this to the patient at this stage.
→ Tell him to adopt preventive strategies (choice 12) is incorrect. There is no proven prostate cancer prevention
strategy.
→ Tell your patient not to worry, as he is still relatively young (choice 13) is incorrect. All men are at risk for prostate
cancer. Prostate cancer mainly affects men over 50. However, there are cases of prostate cancer in men in their 20s
and 30s.

Q2.
First-degree relatives have a two-fold increase in the risk of developing prostate cancer. Second-degree relatives
have a 1:7 increased risk. With an older brother diagnosed with prostate cancer, your patient is now in a higher risk
category (choice 3). As the patient's risk for prostate cancer is increased, he may benefit from obtaining prostate-
specific antigen (PSA) level (choice 5) with or without digital rectal examination (DRE) (choice 9). You need to discuss
this with him and make a mutual decision about testing. About 75% of prostate cancers are diagnosed early, at stage
I and II ( (choice 11).

→ Advise the patient to start taking aspirin 81mg (choice 1) is incorrect. Many studies have found that aspirin use did
not achieve a statistically significant reduction of prostate cancer.
→ Ask the patient to decrease alcohol intake (choice 2) is incorrect. There is no known direct link between alcohol
and prostate cancer risk.
→ Order prostate biopsy (choice 4) and Order transrectal ultrasonography (choice 6) are incorrect answers. These
would be ordered if the initial screening was positive.
→ Order PSA to distinguish between aggressive cancer and slow-growing cancer (choice 7) is incorrect. PSA test
does not distinguish between aggressive cancer and slow-growing cancer.
→ Benign prostatic hyperplasia increases the risk for prostate cancer (choice 8) is incorrect. Significant evidence
reveals no link between benign prostatic hyperplasia and a higher risk for prostate cancer.
→ First-degree relatives have a two-fold increase (not the four-fold increase as in choice 10) in the risk of developing
prostate cancer.
Q3.
Prostate-specific antigen (PSA) is a glycoprotein with a half-life of 2.2 days, that is expressed by both normal and
neoplastic prostate tissue. A number of assays are available to measure serum PSA; although the exact value that
is considered "abnormal" is highly controversial, historically, a concentration above 4 μg/L was considered abnormal
in most.

Age-specific reference ranges:

40 to 49 years-old - 0 to 2.5 μg/L (choice 11)
50 to 59 years-old - 0 to 3.5 μg/L
60 to 69 years-old - 0 to 4.5 μg/L
70 to 79 years-old - 0 to 6.5 μg/L

The major causes of an elevated serum PSA include Benign prostatic hyperplasia (BPH), Prostate cancer, Prostatic
inflammation/infection, and Perineal trauma. Ejaculation can increase PSA levels by up to 0.8 μg/L (choice 5). Digital
rectal examination has minimal effect on PSA levels, leading to transient elevations of only 0.26 to 0.4 μg/L (choice
4).
Finasteride and dutasteride, inhibitors of 5-alpha-reductase, produce an approximately 50 percent or greater
decrease in serum PSA (choice 1).
PSA is prostate-specific, not cancer-specific (choice 6); levels between 4 and 10 μg/L are equivocal (choice 8); levels
> 20 μg/L are highly suspicious of cancer (choice 9).
In past analysis, the estimated sensitivity of a PSA cutoff of 4.0 μg/L was 21% for detecting any prostate cancer and
51% for detecting high-grade cancers. PSA can be ‘normal' in 5% of cancers (choice 2).

→ Cancer is always present if PSA is elevated (choice 3) is incorrect. In past analysis, the estimated sensitivity of a
PSA cutoff of 4.0 μg/L was 21% for detecting any prostate cancer and 51% for detecting high-grade cancers.
→ PSA level below 4 μg/L is considered normal (not 7 μg/L as in choice 7).
→ PSA is a glycoprotein with a half-life of 2.2 days (not 7 days as in choice 10).

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Prostate Cancer
Question #6
A 68-year-old patient had been longstanding patients of yours. Her husband died three years ago of colon
cancer. She appears nervous and uncomfortable and tells you that for the past three weeks she has been ‘passing
blood like her husband did before he got cancer.'
What will you do/say next?
Select up to 2 Answers

1. Tell her that she may have cancer if she is bleeding from the anus.
2. Reassure the patient that it is probably not cancer.
3. Tell her that it is probably just a haemorrhoid.
4. Tell her that it will not be the same as her husband’s problem as she is not a blood relative.
5. Ask her about the bleeding and if it is constant or associated with bowel movements.
6. Perform a rectal examination immediately.
7. Examine the patient.
8. Perform a colonoscopy.
9. Perform sigmoidoscopy.
10. Perform proctoscopy.
11. Ask her if there is anything else that she would like to tell you.
Explanation
Correct Answers: 5 and 7
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Question #7
Which of the following questions would not be useful to ask your patient?
Select up to 2 Answers

1. Aspects of her general health.

2. When does the bleeding usually occur?
3. Does she feel tired or lethargic?
4. What colour is the blood - (bright red or darker)?
5. Is there any associated pain or discomfort?
6. Does it cause her anxiety?
7. Does she think it may be a haemorrhoid?
8. Has she had these symptoms before?
9. Does she have home help?
10. About her current medications
11. What else does she think the lesion may be?
Explanation
Correct Answers: 7 and 11
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Question #8
Further history taking reveals that the bleeding is bright red in colour and occurs after the patient uses her bowels.
While there is not much associated pain, she says she ‘thinks she feels something there' when going to the toilet.
She has been generally well.

What examinations will you now perform?

Select up to 7 Answers

1. Inspect her general health

2. Inspect anorectal area
3. Abdominal examination looking for masses
4. Proctoscopy
5. Colonoscopy
6. Sigmoidoscopy
7. CBC
8. Digital rectal examination
9. Serum electrolytes levels and coagulation profile
10. Histology
11. X-ray
12. ECG
Explanation
Correct Answers: 1, 2, 3, 4, 7, 8 and 9
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Question #9
What are your differential diagnoses?
Select up to 2 Answers

1. Haemorrhoids
2. Rectal prolapse
3. Tubular villous adenoma (rectal polyp)
4. Carcinoma (malignant polyp)
5. Anal fissure
6. Anal tag
7. Anal warts
8. Pilonidal sinus
9. Fistula
10. Abscess
11. Boils
Explanation
Correct Answers: 1 and 3
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Topic: Colorectal Cancer
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 5, 7.

Question 2 - Correct answer(s): 7, 11.
Question 3 - Correct answer(s): 1, 2, 3, 4, 7, 8, 9.
Question 4 - Correct answer(s): 1, 3.

Detailed Explanation:

While the patient may have cancer, it is too early to make any judgment at this stage, and this response will further
alarm her. It is also too early to reassure her. You need to take further history and perform an examination. Further
history will reveal the nature and type of bleeding. It is important to examine the patient at the earliest possibility in
case she does have rectal cancer. While you may refer the patient for a colonoscopy, it is premature at this stage.
Appropriate blood tests include a complete blood cell (CBC); serum electrolytes levels, and a coagulation profile,
including activated partial thromboplastin time (aPTT), prothrombin time (PT), manual platelet count, and bleeding
time.

Polyps especially villous adenomas or even tubular villous adenomas - those with a stalk, may be benign or
malignant. There is often a grey area. A polypoid tubular villous adenoma can usually be readily removed at
colonoscopy with a snare. If there is some suggestion of malignancy in the polyp, the polypectomy still is usually all
that is required. However, with a villous adenoma, there may be multifocal areas of malignancy and the decision as
to whether excision at colonoscopy is sufficient can be difficult. You note that there is a lower rectal benign looking
flat lesion suggesting a villous adenoma.
As well as making the referral for the patient, and as there is a possibility that the lesion could be malignant, and
because of the anxiety of the patient, an attempt is made for an early consultation with the specialist.

It may be a carcinoma in situ or an invasive carcinoma. Further assessments with ultrasound or scans may be
required. The patient will then require regular follow up.
Question #10
A patient’s job with an international company requires him to travel to various cities in countries in the Asian, South
Asian and Oceania regions. He is 39 years old and has a wife and three children. On a recent visit to Northern
Pakistan, he suffered a febrile illness with aching joints and saw a doctor there who made a clinical diagnosis of
dengue fever and treated him with acetaminophen.

He has since made a complete recovery but comes to see you for advice regarding his future travel in the region.
Which of the following is correct?
Select up to 6 Answers

1. The patient has protective immunity to dengue and cannot contract it again.
2. The patient has protective immunity to a particular serotype of dengue fever only.
3. If he contracts dengue fever again, it is likely to be clinically mild.
4. He is generally more at risk from complications should he get dengue fever again.
5. Dengue fever is more commonly found in urban areas.
6. The main vector is the Aedes aegypti mosquito which prefers to breed in clean water.
7. Peak incidence is in the drier months.
8. All resort areas in South East Asia are considered risk areas.
9. Dengue fever is most prolific in rice growing areas.
10. Dengue fever is now found in northern Australia.
11. Dengue fever is spreading into colder areas.
Explanation
Correct Answers: 2, 4, 5, 6, 8 and 10
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Question #11
Which of the following clinical manifestations regarding Dengue fever are not true?
Select up to 3 Answers

1. Clinically the incubation period is short (5-10 days).

2. Initial symptoms are usually lethargy and fever.
3. Fever is classically is biphasic: that is, with two days of fever which recedes and is then followed by a
‘second fever.’
4. Headache may be present, especially retro-orbital pain, increased by eye movement.
5. There is no arthralgia or myalgia.
6. A rash may be present.
7. With the appearance of a rash the patients usually deteriorate.
8. Treatment of uncomplicated cases is with bed rest and paracetamol.
9. The complications of Dengue Shock Syndrome (DSS) and Dengue Haemorrhagic Fever (DHF) may be
fatal.
10. Serious complications are more common in children and young adults.
11. Dengue IgG will remain positive long term, usually for life.
12. The patient is now more at risk.
13. Prevention is via vaccination.
Explanation
Correct Answers: 5, 7 and 13
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Topic: Dengue Fever
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 2, 4, 5, 6, 8, 10.

Question 2 - Correct answer(s): 5, 7, 13.

Detailed Explanation:

Dengue is a common arboviral infection throughout the tropics and especially in South and South-East Asia. It is also
an evolving problem in Oceania, including northern Australia.

As the main vector is the Aedes aegypti mosquito which prefers to breed in clean water, such as flower pots, it is
common in urban areas. Most cases are reported in cities with peak incidences in the wetter months.

Clinically the incubation period is short (5-10 days), and initial symptoms are usually lethargy and fever, which
classically is biphasic: that is, with two days of fever which recedes and is then followed by a ‘second fever.'

Headache may be present, especially retro-orbital pain, increased by eye movement.

Arthralgia and myalgia may be profound, hence the old name ‘breakbone fever.'

A rash may be present, typically appearing with the ‘second fever’ and is usually maculopapular, starting on the trunk
and spreading to the limbs and face. Soon after the rash the temperature usually falls, and the patient recovers.
Treatment of uncomplicated cases is with bed rest and paracetamol.

The complications of Dengue Shock Syndrome (DSS) and Dengue Haemorrhagic Fever (DHF) may be fatal. These
conditions appear to have an immunological basis and the people most at risk are those who have previous immunity
to one or more of the dengue serotypes. Serious complications are more common in children and young adults.
In this patient’s case, serology will confirm the presence of antibodies to the dengue virus. Dengue IgG will remain
positive long term, usually for life.

The patient should be counselled that these antibodies do not afford general protection from Dengue fever, which
may be caused by one of the several serotypes and that he is now more at risk of complications should he contract
Dengue fever again.

In Canada, there is no vaccine or medication that protects against dengue fever.

Question #12
A mother and her four children, aged from 2 to 10, are going to stay with her sister in a well appointed house in a
wealthier part of Kathmandu. She will be staying there for about ten days. She has read about Japanese Encephalitis
(JE) in a newspaper and asks whether the family should be immunized.
With regard to the transmission of Japanese Encephalitis, which of the following is/are not true?
Select up to 4 Answers

1. JE is the leading cause of viral encephalitis in Asia.

2. The virus can be transmitted by droplet spread from person to person.
3. The vector is a common later-afternoon biting mosquito.
4. The risk of exposure in a modern city is low.
5. Pork should be avoided because pigs can be infected.
6. JE was first recognised in Japan, China, and Korea.
7. India, Nepal, and Vietnam are severely affected by JE.
8. Parts of Papua New Guinea and Oceania are now affected.
9. The vector is usually a Culex mosquito.
10. JE is a zoonosis with pigs and Aeneid birds, such as herons, acting as amplifying hosts.
11. There is a seasonal distribution reflecting the months of higher rainfall and ‘wet’ rice cropping.
12. The incubation period is three weeks.
13. The W.H.O. estimates that over 10,000 people, predominantly children, die each year.
14. Ten times that number survive with neurological sequelae.
Explanation
Correct Answers: 2, 5, 12 and 14
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Question #13
What are its clinical manifestations?
Select up to 6 Answers

1. The incubation period is 3 weeks.

2. The disease is characterised by a sudden onset of fever, chills and aches, including headaches.
3. Sometimes meningismus is present.
4. Gastrointestinal symptoms and convulsions are less common in children.
5. It is likely that many infected have a mild or sub-clinical infection.
6. Of those developing encephalitis, about two thirds will die.
7. Deaths to JE mainly affect children.
8. Many survivors are left with neurological sequelae.
9. W.H.O. estimates that 10,000 people die each year from JE.
Explanation
Correct Answers: 2, 3, 5, 7, 8 and 9
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Question #14
In relation to protective measures, which of the following are not true?
Select up to 3 Answers

1. Avoid mosquitoes, especially from dawn to dusk.

2. Vaccination should be offered to those spending more than six months in risk areas.
3. Agricultural workers are particularly exposed.
4. Vaccine is a neurotissue vaccine made from mouse brain extract.
5. The standard course of vaccine is two injections over a month.
6. Vaccine is usually well tolerated.
7. Serious allergic reactions to vaccine can cause death within a few days.
8. Mosquito bites should be avoided, especially overnight.
9. It is preferable for vaccine to be administered in a specialist centre.
10. Advise the mother that the greatest risk to herself and her children is from Dengue.
11. It rarely affects children.
12. Lavender oil will help repel the mosquitoes.
Explanation
Correct Answers: 2, 11 and 12
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Topic: Encephalitis
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 2, 5, 12, 14.

Question 2 - Correct answer(s): 2, 3, 5, 7, 8, 9.
Question 3 - Correct answer(s): 2, 11, 12.

Detailed Explanation:

Japanese Encephalitis (JE) is the leading cause of viral encephalitis in Asia. First recognised in Japan, China, and
Korea, the incidence of JE has now decreased in those countries but has increased in recent years throughout
Southern and South-East Asia. Countries such as India, Nepal, and Vietnam are severely affected by JE, but no
country in the region is unaffected.

The vector for JE is usually a Culex mosquito which breeds in large numbers in rice paddies and swampy water. JE
is a zoonosis with pigs and Aeneid birds, such as herons, acting as amplifying hosts for the virus. There is a seasonal
distribution reflecting the months of higher rainfall and ‘wet’ rice cropping. It is not exclusively rural, but the risk in
residential areas of most cities is low.

The incubation period is 4 to 14 days, and clinically the disease is characterised by a sudden onset of fever, chills,
and aches, including headaches and sometimes meningismus. Gastrointestinal symptoms and convulsions are more
common in children. It is likely that many infected have a mild or sub-clinical infection, but of those developing
encephalitis about one-third will die and most survivors are left with neurological sequelae. WHO estimates over
10,000 people, predominantly children, die each year of JE.

Avoid mosquitoes, especially from dawn to dusk. Vaccination should be given to high-risk travellers spending more
than a month in risk areas, and certainly to agricultural workers. Vaccine offered in western countries is a neuro-
tissue vaccine made from mouse brain extract. The standard course of vaccine is two injections over a month (day
0 and 28) but is not suitable for those travelling to risk areas on a few days notice. While the vaccine is usually well
tolerated there have been cases of serious allergic reactions: even deaths have happened within a few days after
vaccination. This too limits the use of vaccination for travellers going to these areas on short notice.
Question #15
Two Canadian students were enjoying the sights and sounds of India, travelling on bicycle and foot, on a limited
budget.

Unfortunately, one of the many dogs they encountered ran out barking and snapped at the girl's foot as she was
riding by, resulting in a small wound.

The bitten girl was not able to afford rabies vaccine before leaving home.
What immediate actions should be taken?
Select as many as appropriate

1. Wash the wound thoroughly

2. Have the animal captured
3. Have the animal captured and killed
4. Rabies Immunoglobulin
5. Prophylactic antibiotics for the girl
6. Wait until any symptoms develop
7. Blood cultures
8. Wound cultures
9. Post exposure prophylaxis with vaccine
10. Run a rabies titer
Explanation
Correct Answers: 1, 4, 5 and 9
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Question #16
Regarding the epidemiology of rabies, which of the following are incorrect?
Select up to 2 Answers

1. Canine rabies is highly endemic in India, Nepal, Africa, and Central and South America.
2. Australia is rabies free.
3. Most of Pacific Oceania is rabies free.
4. Exception to pre-exposure vaccination: those staying over 60 days in rural areas of highly endemic
countries.
5. Post Exposure Prophylaxis (PEP) is difficult to locate in many parts of Africa and India.
6. PEP is highly recommended for African overland travelling.
7. PEP is highly recommended for those ‘backpacking’ in Nepal.
8. Those working with animals (vets, wildlife tv crews) do not need PEP, as they are highly trained to act
properly in an emergency situation.
9. CDC Health Information for Travelers has up-to-date information on endemic areas.
10. Those traveling to endemic areas for more than 30 days should seriously consider the rabies vaccine.
11. Infected animals include dogs, cats, monkeys, and feral (wild) animals.
Explanation
Correct Answers: 4 and 8
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Topic: Rabies
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 1, 4, 5, 9.

Question 2 - Correct answer(s): 4, 8.

Detailed Explanation:

Immediate actions include:

-washing the wound thoroughly to remove all traces of saliva by using soap and water and antiseptic. This action
alone reduces the risk of rabies by 90%.
-rabies immunoglobulin, preferably within 24 hours. 20IU/kg should be infiltrated into and around the wound to
neutralise the rabies virus before it enters the nervous system. Treatment is still needed even if the dog had been
vaccinated.
-postexposure prophylaxis with rabies vaccine should be started within 24 hours.

Antibiotic prophylaxis is indicated for patients with clinically uninfected wounds and any one of the following:
●Lacerations undergoing primary closure and wounds requiring surgical repair
●Wounds on the hand(s), face, or genital area
●Wounds in close proximity to a bone or joint (including prosthetic joints)
●Wounds in areas of underlying venous and/or lymphatic compromise
●Wounds in immunocompromised hosts
●Deep puncture wounds or laceration
●Wounds with associated crush injury

Canine rabies is highly endemic in India, Nepal, Africa, and Central and South America.

Most of Pacific Oceania is rabies free. Those staying over 60 days in rural areas of highly endemic countries should
consider pre exposure vaccination.

Availability of Post Exposure Prophylaxis (PEP) is difficult to locate in many parts of Africa and India. PEP is highly
recommended for African overland travelling. PEP is highly recommended for those ‘backpacking' in Nepal. Those
working with animals (vets, wildlife tv crews) should have PEP. CDC Health Information for Travelers has up to date
information on endemic areas. Those traveling to endemic areas for more than 30 days should seriously consider the
rabies vaccine.

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Rabies
Question #17
A 45-year-old orchard worker is driven to see you by a farmhand and presents after experiencing a sudden onset of
profuse sweating, vomiting, and feeling that ‘his legs would not hold him up.' The farmhand informs you that during
the journey he developed slurred speech and abdominal pains and the urgent desire to defecate. He also brought a
tin of pesticide (labelled "Parathion") that they were using. According to his helper, the patient had wiped up some
liquid that was spilt earlier, without wearing gloves or overalls.

On examination, the patient has constricted pupils and is salivating. His pulse rate is regular at 65 bpm. There were
generalised rhonchi on chest auscultation.
Which of the following are not important when dealing with occupational and environmental health and toxicology?
Select up to 3 Answers

1. Adverse effects of substances in the workplace are rare - always consider a differential diagnosis.
2. For a substance to do harm within the body, sufficient must get in.
3. Changing the dose of a substance can change the severity of effect.
4. Environmental exposure to substances is commonly much less intense but more sustained, making
identification difficult.
5. The standard method of treatment of a chronic adverse effect is typically to remove the patient from
continuing exposure.
6. Acute poisoning usually requires spillage of a volatile substance.
7. Acute poisoning does not result from a hypersensitivity reaction.
8. Acute poisoning can result from skin absorption of a concentrated formulation.
9. Occupations at risk include painters.
10. Occupations at risk include plastic foam manufacturers.
11. Occupations at risk include joiners.
12. Occupations at risk include I.T. workers.
13. Compensation considerations have the potential to selectively affect memory.
Explanation
Correct Answers: 7, 12 and 13
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Question #18
In relation to this presentation, which of the following are not true?
Select up to 4 Answers

1. Parathion is an organophosphorus compound with anti-cholinesterase action.

2. Anti-cholinesterase pesticides are an uncommon cause of acute poisoning in orchardists and gardeners.
3. Organophosphorus compounds readily penetrate the skin.
4. Clinical features vary depending on the relative effects on parasympathetic nerves, sympathetic ganglia,
and neuro-muscular junctions.
5. Initial effects are due to parasympathetic activity.
6. Sympathetic ganglia activity may lead to lowered heart rate.
7. Weakness of skeletal muscle is due to enzyme suppression at neuro-muscular junctions.
8. Treat by administering 2 mg atropine intravenously every 30 minutes until symptoms are relieved.
9. Send the patient to the hospital for observation and follow up with a 5 ml blood sample in a heparinised
tube.
10. Atropine blocks parasympathetic overactivity.
11. Blood samples are used to measure red cell enzyme activity as an estimate of enzyme activity in the
nervous system.
12. Symptoms occur when red cell cholinesterase activity falls below 10% of normal.
13. The patient should be followed up over 1 to 3 months until red cell cholinesterase activity returns to normal.
Explanation
Correct Answers: 2, 6, 8 and 12
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Topic: Organophosphate Poisoning
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 7, 12, 13.

Question 2 - Correct answer(s): 2, 6, 8, 12.

Detailed Explanation:

Adverse effects of substances in the workplace are rare - always consider a differential diagnosis. For a substance to
do harm within the body, sufficient must get in. Changing the dose of a substance can change the severity of effect.
Environmental exposure to substances is commonly much less intense but more sustained, making identification
difficult. The standard method of treatment of a chronic adverse effect is typically to remove the patient from
continuing exposure. Acute poisoning usually requires spillage of a volatile substance, a hypersensitivity reaction, or
skin absorption of a concentrated formulation. Occupations at risk include painters, market gardeners, plastic foam
manufacturers, joiners, non-ferrous foundry workers, lead (Pb) workers.

Parathion is an organophosphorus compound with anti-cholinesterase action. Anti-cholinesterase pesticides are

the most common cause of acute poisoning in orchardists and gardeners. Organophosphorus compounds readily
penetrate the skin. Clinical features vary depending on the relative effects on parasympathetic nerves, sympathetic
ganglia, and neuro-muscular junctions. Initial effects are due to parasympathetic activity

Sympathetic ganglia activity may lead to a normal or raised heart rate Weakness of skeletal muscle is due to enzyme
suppression at neuro-muscular junctions. Treat by administering 2 mg atropine intravenously every few minutes until
symptoms are relieved. Send the patient to the hospital for observation and follow up with a 5 ml blood sample in a
heparinised tube. Atropine blocks parasympathetic overactivity. Blood samples are used to measure red cell enzyme
activity as an estimate of enzyme activity in the nervous system Symptoms occur when red cell cholinesterase activity
falls below 30% of normal The patient should be followed up over 1 to 3 months until red cell cholinesterase activity
returns to normal.

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Question #19
A 19-year-old student who presents during the height of the flu season with general malaise, headaches and aches
and pains. He has just returned from a sporting trip to Austria and the Czech Republic. A week ago after running on
an orienteering course, he had two ticks removed.
Which of the following is true?
Select up to 7 Answers

1. Patient probably has the flu

2. Tick borne encephalitis (TBE) needs to be considered.
3. TBE is caused by a flavivirus transmitted by hard ticks
4. The case fatality rate is high
5. Most cases occur during Spring or Summer
6. RSSE (Russian Spring Summer Encephalitis) occurs in the former USSR
7. A rapid schedule involves two injections given in opposite arms on day 0 and day 3
8. A special immune globulin is available in Europe
9. Ticks in other parts of the world can cause fatal illnesses
10. Patient should have been immunised prior to travelling
Explanation
Correct Answers: 1, 2, 3, 5, 6, 8 and 9
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Question #20
The following are not true of a tick bite:
Select up to 5 Answers

1. Some species can be very dangerous to humans

2. They are less dangerous to children
3. They are usually found on the legs or arms
4. If they attach themselves to the head or neck, a serious problem exists
5. Distinguish between dangerous and non-dangerous types
6. Early removal is mandatory
7. The tick should be completely removed
8. The mouth parts should not be left behind
9. Grab the tick by its body and tug
10. Grab the tick by its head with fine forceps or tweezers
11. Pull the tick straight up
12. In the field try to lubricate the tick with oil, alcohol, Vaseline, or similar for easy removal
13. Careful observation is needed after removal
Explanation
Correct Answers: 2, 3, 5, 9 and 12
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Topic: Encephalitis
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 1, 2, 3, 5, 6, 8, 9.

Question 2 - Correct answer(s): 2, 3, 5, 9, 12.

Detailed Explanation:

This patient probably has the flu. The diagnosis of tick borne encephalitis (TBE) needs to be considered. TBE is
caused by a flavivirus transmitted by hard ticks in a number of European countries like Austria, Poland, Hungary,
Germany, Czech Republic, the Balkans, Scandinavia, and Russia. The case fatality rate is low. Most cases occur
during Spring or Summer. A subtype known as RSSE (Russian Spring Summer Encephalitis) occurs in the former
USSR, China, Korea, and Japan. A rapid vaccination schedule involves two injections given in opposite arms on
day 0 and day 7. A special immune globulin is available in Europe. Ticks in other parts of the world can cause fatal
illnesses.

Some species can be very dangerous to humans. They are particularly dangerous to children. They are usually found
in the scalp. If they attach themselves to the head or neck, a serious problem exists. It is impossible to distinguish
between dangerous and non-dangerous types. Early removal is mandatory. There are no contraindications for
removal. The tick should be completely removed. The mouth parts should not be left behind. Do not grab the tick by
its body and tug. Grab the tick by its head with fine forceps or tweezers. Remove the tick by pulling upwards. Do not
try to burn the tick with a match or other hot object. Do not twist the tick when pulling it out. Do not try to kill, smother,
or lubricate the tick with oil, alcohol, Vaseline, or similar material. Doing so only prolongs exposure time and may
cause the tick to eject infectious organisms into the body. Careful observation is needed after removal.
Question #21
Postmenopausal 55-year-old woman comes to the clinic for her annual physical examination and health check. She
says a healthy friend of hers had recently fallen and fractured her hip and was told that she had osteoporosis. She
had also read articles in women's magazines recommending osteoporosis screening for postmenopausal women.
She asks if she needs to be tested.
Which of the following regarding screening and risk factors for osteoporosis are not correct?
Select up to 2 Answers

1. All asymptomatic women age 50 years and older need screening

2. Osteoporosis risk factor information helps guide screening decisions
3. The SCORE (Simple Calculated Osteoporosis Risk Estimation) is a validated clinical prediction rule that
selects patients who are appropriate candidates
4. Many risk factors are modifiable
5. In adulthood, inadequate calcium intake results in negative calcium balance and loss of bone
6. Genetic factors play no significant role in determination of bone mineral density and fracture risk
7. Active smoking is an important risk factor for fractures
8. Low body weight and weight loss after menopause are associated with an increased risk of fracture
9. In post-menopausal women, fracture risk is inversely related to level of physical activity
10. An exercise program increases BMD in pre-menopausal women
11. A physically active childhood and young adulthood improve peak bone mass
Explanation
Correct Answers: 1 and 6
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Question #22
Upon reviewing her risk factors, you learn that she fractured her fibula at the age of 45 years playing tennis, and her
mother broke her hip at the age of 70 years. On further questioning, the patient complained of back pain. X-ray of the
back revealed a vertebral compression fracture.

Which of the following are true?

Select up to 7 Answers

1. Incidence and prevalence of vertebral fractures are easy to ascertain as hip fractures
2. These mild fractures have no significance on her future health
3. The presence of a vertebral fracture increases the risk of a new fracture by about four times
4. The EPOS study (Lunt) found that overall the risk of a new vertebral fracture was 6.1 times more likely if
there was a prevalent fracture
5. Intake of calcium and Vitamin D has a protective factor
6. The patient’s history of a personal history of fracture after age 40 does not contribute to her risk
7. Family history of fracture in first-degree relative (particularly prior to age 80) does contribute to her risk
8. Oestrogen deficiency does contribute to her risk
9. The decision to screen for osteoporosis in postmenopausal women is based on willingness to be treated
with medication if result dictates
10. Low body weight, < 57 kg (127 lbs), regardless of height is a risk factor
Explanation
Correct Answers: 3, 4, 5, 7, 8, 9 and 10
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Topic: Osteoporosis
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 1, 6.

Question 2 - Correct answer(s): 3, 4, 5, 7, 8, 9, 10.

Detailed Explanation:

Bone mineral density (BMD) measurement is indicated in all women and men age ≥ 65 years (asymptomatic
screening); and menopausal women, and men aged 50-64 years who have an additional risk for osteoporosis,
based on medical history and other findings. Additional risk factors for osteoporosis that might be considered include
estrogen deficiency, a history of maternal hip fracture that occurred after the age of 50 years, low body mass (less
than 57kg), history of amenorrhea (more than one year before age 42 years).
The SCORE (Simple Calculated Osteoporosis Risk Estimation) is a validated clinical prediction rule that selects
patients who are appropriate candidates for DEXA screening. SCORE has superior performance characteristics
when compared to the National Osteoporosis Foundation guidelines

Though genetic factors play a significant role in the determination of bone mineral density and fracture risk, there are
a number of risk factors under the patient's control. Some of the most important of these modifiable risk factors are
listed below.

• Calcium intake: From childhood to young adulthood, adequate calcium intake is important in achieving maximum
potential peak bone mass. In adulthood, inadequate calcium intake results in negative calcium balance and loss
of bone. A number of randomized trials in elderly women with low intake of calcium or established osteoporosis
demonstrated positive effects on bone density and fracture incidence.
• Vitamin D intake: Adequate vitamin D intake or sun exposure sufficient to maintain adequate levels are essential
for the preservation of bone mass and efficient calcium absorption. Occult vitamin D deficiency is widespread among
some populations of adults. Vitamin D supplementation attenuates bone loss and decreases fracture rate in older
men and women.
• Smoking: Active smoking is an important risk factor for fractures. Smoking is associated with a reduction in calcium
absorption, greater bone loss post-menopause and an increased predisposition to falls. Smoking cessation should
be actively encouraged for this and other potential health effects. Evidence concerning men is limited.
• Body weight: Low body weight and weight loss after menopause are associated with an increased risk of fracture.
Maintenance of normal body weight may be protective. In one study, women in the lowest percentiles of percentage
of body fat or BMI in the placebo group had up to 12% lower BMD at baseline and a more than 2-fold higher 2-year
bone loss as compared with women in the highest percentiles (p=0.004).
• Level of physical activity: In post-menopausal women, fracture risk is inversely related to the level of physical
activity. Improvement in measures such as falls, strength, and balance, as well as BMD, may be responsible for this
association. An exercise program increases BMD in pre-menopausal women, and a physically active childhood and
young adulthood improve peak bone mass.

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 Question #23
A 35-year-old executive presents for an annual check-up. He has always tried to maintain a healthy lifestyle - diet
and exercise, and his presentation today is part of his general attitude toward his health. From his family history, you
note his father died of colon cancer at the age of 45 years. The patient has no history of inflammatory bowel disease
or other gastrointestinal problems. He has no other known health problems.
Which one of the following is the correct statement regarding this patient?
Select up to 1 Answer

1. He is considered to be at average risk of developing colorectal cancer and should begin colorectal cancer
screening with colonoscopy every five years.
2. He is considered to be at average risk of developing colorectal cancer and should begin colorectal cancer
screening with fecal immunochemical test
3. He is considered to be at average risk of developing colorectal cancer and should begin colorectal cancer
screening with flexible sigmoidoscopy
4. He is considered to be at average risk of developing colorectal cancer and should begin colorectal cancer
screening with FOBT
5. He is considered to be at increased risk of developing colorectal cancer and should begin colorectal cancer
screening with colonoscopy every five years
6. He is considered to be at increased risk of developing colorectal cancer and should begin colorectal cancer
screening with colonoscopy every ten years
7. He is considered to be at increased risk of developing colorectal cancer and should begin colorectal cancer
screening with annual fecal immunochemical test
8. He is considered to be at increased risk of developing colorectal cancer and should begin colorectal cancer
screening with flexible sigmoidoscopy every five years
9. He is considered to be at increased risk of developing colorectal cancer and should begin colorectal cancer
screening with flexible sigmoidoscopy every ten years
10. He is considered to be at increased risk of developing colorectal cancer and should begin colorectal cancer

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 screening with annual FOBT

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 Explanation
Correct Answers: 5
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 Question #24
The patient agrees to having appropriate colorectal cancer screening which comes back negative. Despite the
negative result, he remains concerned and asks more about the colorectal cancer risk factors.

Which of the following risk factors have not been linked to colorectal cancer?
Select up to 3 Answers

1. Alcohol consumption
2. Age
3. Heredity
4. Gastric ulcer
5. Diet
6. Smoking
7. Race
8. Colorectal polyps
9. Gender
10. Obesity
11. Regular physical activity

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 Explanation
Correct Answers: 4, 9 and 11
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Topic: Colorectal Cancer
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 5.

Question 2 - Correct answer(s): 4, 9, 11.

Detailed Explanation:

Q1.
The Canadian Task Force on Preventive Health Care and the Canadian Association of Gastroenterology/Canadian
Digestive Health Foundation have released guidelines in Canada in respect of colorectal cancer screening:
- Screening of individuals at average risk: Individuals between 50 and 74 years with a negative family history
should undergo screening with fecal occult blood testing (FOBT, either gFOBT or FIT) every two years or flexible
sigmoidoscopy every ten years.
- Screening of individuals at increased risk: Colonoscopy at age 50 or 10 years earlier than youngest affected relative
(whichever comes first) (1) For persons with a first-degree relative diagnosed < 60 years old (repeat every 5 years),
(2) For persons with a first-degree relative diagnosed at ≥ 60 years old (repeat every 10 years).

Cancer screening participation rates are still considered too low for colorectal cancer, despite the fact that colorectal
cancer is cancer that can be prevented through proper screening. Fortunately, the majority of provinces and territories
have now made commitments to establishing organized colorectal cancer screening programs with hopes to increase
compliance rates throughout the nation. In an effort to and with the goal of encouraging all Canadians age 50-74
to actively gain information and seek screening within their provincial program options, the Colorectal Cancer

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 Association of Canada has developed a Screening and Treatment Map organized according to each provincial
jurisdiction such that information on every provincial screening program and treatment may be easily accessed and
acted on.

Q2.
A multitude of risk factors have been linked to colorectal cancer, including:
- Age: the older one is, the more likely he/she is to develop colorectal cancer. Age is a well-known risk factor for
colorectal cancer, as it is for many other solid tumors. The timeline for progression from the early premalignant lesion
to malignant cancer ranges from 10-20 years. The incidence of colorectal cancer peaks at about age 65 years.
- Heredity: one is more likely to develop colorectal cancer if someone in the family, especially a first-degree relative
(child, sibling, parent) has been diagnosed with it
- Diet: a diet high in red meat and low in fruits and vegetables may increase the risk
- Weight: obesity and a lack of physical activity increase the risk
- Alcohol consumption: alcohol, especially beer, may increase the risk. Lower rates of colorectal cancer have been
found in those who drink no alcohol
- Smoking: smoking also increases the risk of developing colorectal cancer
- Colorectal polyps
- Race - Recent trends suggest a disproportionally higher incidence and death from colon cancer in African
Americans than in whites. Hispanic persons have the lowest incidence and mortality from colorectal cancer.

- Sex - The incidence of colorectal cancer is about equal for males and females.
- Gastric ulcer disease is associated with an increased risk for gastric cancer

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 Question #25
A 28-year-old medical student returns from Kenya after a six-week elective. Two weeks later she complains of fever,
rigors, malaise, and headache occurring daily for the past four days.
You suspect malaria. What physical findings would you specifically look for?
Select up to 3 Answers

1. Hepatomegaly
2. Helminthic infestation
3. Ear pain
4. Blood in urine
5. Dry cough
6. Generalised erythema with ‘islands of sparing’
7. Pain behind eyes
8. Severe pain on palpation of abdomen
9. Pallor
10. Splenomegaly

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 Explanation
Correct Answers: 1, 9 and 10
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 Question #26
What laboratory investigations would you order?
Select up to 2 Answers

1. Abdominal ultrasound
2. Herpes-type virus serology
3. Blood cultures
4. LDH
5. Chest x-ray
6. Liver function tests
7. CD4 cell count
8. Lyme serology
9. Cold agglutinins
10. CBC
11. Creatinine PPD
12. CT scan head
13. EEG
14. Serology for dengue fever
15. Stool cultures
16. Hepatitis A serology
17. Stool for ova and parasites
18. Hepatitis B surface antigen
19. Thick smear for malaria
20. Heterophile antibodies

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 Explanation
Correct Answers: 10 and 19
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Topic: Malaria
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 1, 9, 10.

Question 2 - Correct answer(s): 10, 19.

Detailed Explanation:

Malaria is infection of red blood cells with one of four species of Plasmodium, a protozoan. Malaria causes fever,
chills, sweating, an enlarged spleen, and anemia (due to the breakdown of infected red blood cells).

Worldwide, about 300 to 500 million people are infected with malaria, and 1 to 2 million deaths occur each year. Most
of these deaths occur in children who are younger than five years and live in Africa.

Q1.
After infection occurs, symptoms usually appear within a few weeks to several months, but they may not occur until
years later. The initial symptoms of all forms of malaria are similar. As the infected red blood cells rupture and release
parasites, a person typically develops a shaking chill followed by a fever that can exceed 104° F (40° C). Fatigue and
vague discomfort (malaise), headache, body aches, and nausea are common. The fever typically falls after several
hours, and heavy sweating and extreme fatigue follow. Fevers occur unpredictably at first, but with time, they may
become periodic.

As the infection progresses, the spleen enlarges, and anemia may become severe. Jaundice may develop.The level

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 of sugar (glucose) in the blood can fall in people infected with Plasmodium falciparum.

Q2.
Demonstration of the parasite in a smear of the blood definitely establishes the presence of malaria. A negative
finding on examination does not rule out malaria. Only 50% of children with malaria have positive smear findings,
even on repeated examination.
Both thick and thin films are essential. If the parasitemia is light, a thin film examination may miss the diagnosis. Thick
films save time in the diagnosis of scanty infections but make species identification of the parasite difficult.
Serological tests provide confirmation of past malaria in patients and are valuable for epidemiological studies (not
good for diagnosis of acute malaria).
Anemia is so common in malaria that it is considered almost a part of the disease. The degree of anemia is much
greater than can be explained by the destruction of parasitized erythrocytes. Malarial anemia can be quite severe,
sometimes causing death.
Imaging studies are not needed in malaria.

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 Question #27
An 87-year-old female with advanced renal failure is admitted to the intensive care unit. She has also developed
sepsis from an infection she acquired recently from a dialysis treatment.

The patient is intubated and cannot speak for herself. She does not have anything written such as a living will. You
as the physician and one of your specialist colleagues have both verified this.

She also does not have a health care power of attorney designated to make decisions on her behalf. You decide to
have a meeting with the family. During it, the family makes it clear that the patient always said she wanted to "die in
peace." Therefore, the family members state they do not want her to suffer any more and that they do not want her
to have CPR or any other such potentially invasive or harmful procedures done, and that the doctors should let her
‘die in peace.'
Which of the following is the most appropriate order that the physician should write in the patient's chart to comply
with the family’s wishes for this patient?
Select up to 1 Answer

1. Cardiopulmonary resuscitation (CPR)

2. Full Code
3. Limited Code
4. DNI (Do not intubate)
5. DNR (Do not resuscitate)
6. No antibiotics
7. Irreversible coma
8. Terminally ill
9. Life-sustaining treatments
10. Palliative care
11. No transfusions

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 12. No dialysis
13. Consult with hospital attorney
14. No oxygen
15. Transfer to Hospice

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 Explanation
Correct Answers: 5
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 Question #28
Which of the following terms is used to describe measures taken to keep a terminally ill person as comfortable as
possible?
Select up to 1 Answer

1. Cardiopulmonary resuscitation
2. Full Code
3. Limited Code
4. DNI (Do not intubate)
5. DNR (Do not resuscitate)
6. Life-sustaining treatments
7. Palliative care
8. Hospice care
9. Elderly care
10. Chaplain care
11. Pain management
12. Symptomatic treatment
13. Terminal sedation
14. Spiritual care
15. Euthanasia

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 Explanation
Correct Answers: 7
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Topic: Living Will
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 5.

Question 2 - Correct answer(s): 7.

Detailed Explanation:

A living will allows a patient to document his/her wishes concerning medical treatments at the end of life. Before the
living will can guide medical decision-making two physicians must certify:

The patient is unable to make medical decisions.

The patient is in the medical condition specified in the state's living will law (such as "terminal illness" or "permanent
unconsciousness").

A medical power of attorney (or healthcare proxy) allows a patient to appoint a person they trust as their healthcare
agent (or surrogate decision maker), who is authorized to make medical decisions on their behalf.

Before a medical power of attorney goes into effect a person’s physician must conclude that they are unable to make
their own medical decisions. In addition:

If a person regains the ability to make decisions, the agent cannot continue to act on the person's behalf.

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 A do-not-resuscitate (DNR) order placed in a person's medical record by a doctor informs the medical staff that
cardiopulmonary resuscitation (CPR) should not be performed. This order has been useful in preventing unnecessary
and unwanted invasive treatment at the end of life.

Doctors discuss with patients the possibility of cardiopulmonary arrest (when the heart stops and breathing ceases),
describe CPR procedures, and ask patients about treatment preferences. If a person is incapable of making a
decision about CPR, a surrogate may make the decision based on the person's previously expressed preferences or,
if such preferences are unknown, in accordance with the person's best interests.

A DNR order does not mean "do not treat." Rather, it means only that CPR will not be performed. Other treatments
(for example, antibiotic therapy, transfusions, dialysis, or use of a ventilator) that may prolong life can still be provided.
Treatment that keeps the person free of pain and comfortable (called palliative care) should always be given.

DNR orders, Comfort Care orders, No CPR orders, or other terms generally, they require the signature of the
physician and patient (or patient's surrogate), and they provide the patient with a visually distinct quick identification
form or bracelet or necklace that emergency medical services personnel can identify and comply with. These
orders are especially important for terminally ill people living in the community who want only comfort care and no
resuscitation if their heart or breathing stops. Living wills and durable powers of attorney for health care are not
generally effective in emergency situations.

Medical Terms Related to Life-Sustaining Treatment

Cardiopulmonary resuscitation (CPR): An action taken to revive a person whose heart stops (cardiac arrest), whose
breathing stops (respiratory arrest), or whose heart and breathing stop (cardiopulmonary arrest).

Code: The summoning of professionals trained in CPR to revive a person in cardiac, respiratory, or cardiopulmonary
arrest.

No code: An order signed by a patient's doctor stating that CPR should not be performed. (Also called a do-not-
resuscitate [DNR] order.)

Irreversible coma: A coma or persistent vegetative state from which the person will not recover.

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 Terminally ill: The medical state of being near death where there is no hope of a cure.

Life-sustaining treatment: Any treatment given to postpone the death of a terminally ill person.

Palliative care: Measures taken to keep a terminally ill person as comfortable as possible.

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 Question #29
As part of the family medicine residency program, you are required to fly into one of the Indigenous reserves in
Alberta to be part of their clinic for a period of one month. You will be expected to see patients from all age groups,
and you will need to offer advice to pregnant women and teach the mothers about the proper ways of taking care of
their children.

In order to know more about your patients and understand their specific needs and special health concerns, you did
some research on the different parameters of public health related to this specific population. Your research included
epidemiological and medical documents that are directly related to this subject.
In terms of demographical and general statistical information pertaining to the Indigenous populations, which of the
following statements are correct?
Select up to 4 Answers

1. The Indigenous population represents around 1% of the total Canadian population

2. The Indigenous population represents around 5% of the total Canadian population
3. The Indigenous population represents around 10% of the total Canadian population
4. The fertility rate is higher in the Indigenous population compared to the national Canadian one
5. The fertility rate is lower in the Indigenous population compared to the national Canadian one
6. The fertility rate is roughly the same in the Indigenous population compared to national Canadian one
7. The highest number of Indigenous people is in Ontario
8. The highest number of Indigenous people is in Quebec
9. The highest number of Indigenous people is in Nunavut
10. The size of the Indigenous population has decreased since the beginning of the 20th century
11. The size of the Indigenous population has increased since the beginning of the 20th century
12. The size of the Indigenous population stayed roughly the same throughout the 20th century up until now

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 Explanation
Correct Answers: 2, 4, 7 and 11
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Question #30
Upon further questioning, the mother tells you that she got married at a very young age and is currently living with
her husband in a very small one room apartment. The husband and she are both unemployed. They both smoke and
drink alcohol. She denies drinking a lot but tells you that her husband is a heavy drinker and is involved in gambling
as well.

The above described situation is not very uncommon in the Indigenous community. In terms of lifestyle and
behavioral risk factors, which of he following is true?
Select up to 3 Answers

1. Because of alcohol, the rate of Fetal Alcohol Syndrome and Fetal Alcohol Effects in the Indigenous
population is 300 times that of the general Canadian population
2. Because of alcohol, the rate of Fetal Alcohol Syndrome and Fetal Alcohol Effects in the Indigenous
population is ten times that of the general Canadian population
3. Because of alcohol, the rate of Fetal Alcohol Syndrome and Fetal Alcohol Effects in the Indigenous
population is three times that of the general Canadian population
4. The smoking rate amongst the Indigenous population is the same as that of the general Canadian
population
5. The smoking rate amongst the Indigenous population is three times that of the general Canadian population
6. The smoking rate amongst the Indigenous population is twice that of the general Canadian population
7. Previous studies in Alberta show that around 20% of Indigenous people aged 15 and above are problem
gamblers
8. Previous studies in Alberta show that around 40% of Indigenous people aged 15 and above are problem
gamblers
9. Previous studies in Alberta show that around 80% of Indigenous people aged 15 and above are problem
gamblers
Explanation
Correct Answers: 1, 6 and 7
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Question #31
The above described situation is not that uncommon in the Indigenous population. You already know that this family
is more prone to problems in the future and more help and time should be devoted to them.

In terms of the health status and the probable consequences for this family, which of the following statements are
correct?
Select up to 3 Answers

1. Concerning suicide rates, the rate for individuals aged 15 to 24 is around 8 times that of their Canadian
counterparts
2. Concerning suicide rates, the rate for individuals aged 15 to 24 is around 50 times that of their Canadian
counterparts
3. Concerning suicide rates, the rate for individuals aged 15 to 24 is around 300 times that of their Canadian
counterparts
4. The mortality rate is higher in the Indigenous population as compared to the general Canadian one
5. The mortality rate is lower in the Indigenous population as compared to the general Canadian one
6. The mortality rate is the same in the Indigenous population as compared to the general Canadian one
7. The potential-years-of-life-lost (PYLL) in the Indigenous population is ten times that of the Canadian one
8. The potential-years-of-life-lost (PYLL) in the Indigenous population is the same as compared to the
Canadian one
9. The potential-years-of-life-lost (PYLL) in the Indigenous population is twice that of the Canadian one
Explanation
Correct Answers: 1, 4 and 9
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Topic: Indigenous Populations
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 2, 4, 7, 11.

Question 2 - Correct answer(s): 1, 6, 7.
Question 3 - Correct answer(s): 1, 4, 9.

Detailed Explanation:

The Indigenous population of Canada has its own special situation with respect to health. The community lacks
in almost all health indicators as compared to the general public in Canada. There are many reasons for this.
Perhaps the most important are those related to the colonization of what is now known as modern Canada. This
movement has led them to losing their land, their autonomy and more importantly their traditional way of life. Like
many Indigenous populations in the world (for example those of Australia), the impact was detrimental to their health
and social well-being as a whole.

Q1
The Indigenous population in Canada reached its lowest numbers at the beginning of the past century. Today the
numbers are recovering, and the population size is increasing. The number of people who identify themselves as
indigenous (aboriginal) was around 980,000. This was published after the 2001 census, and they roughly represent
3.3% of the general Canadian population (2001 census). Although life expectancy for both males and females in
the Indigenous populations is still roughly 6-7 years lower than that of the Canadian national numbers, there is an
overall growth in the population size due to natural increase. In addition, the fertility rate of the Indigenous population
is 50% higher than the national rate. Coupling this to the lower life expectancy mentioned above makes the
Indigenous population median age lower than that of the general Canadian one (24.7 years for the Indigenous one
and 37.7 for the general Canadian one).

Ontario currently has the highest absolute number of Indigenous peoples (188,315). However, in terms of
percentages of the total provincial or territorial population, Nunavut ranks as number one with around 85% of the
population identifying themselves as Indigenous.

The psychosocial and the socioeconomic states of the Indigenous peoples are considered substandard and lacking
in many aspects as compared to that of the general Canadian population.

Studies currently show that an indigenous child is much more likely to become a victim of abuse or violence in his/
her respective community as compared to other Canadian kids. Up to 40% of Indigenous children have been abused
in the lifetime. The same can be applied to women, where those studies show that up to 75% of Indigenous women
are subjected to family violence as compared to only 7% of the general Canadian population.

When comparing the living conditions according to the low-income-cut-off standard (LICO), one can find that the
Indigenous population is lacking behind the general Canadian population. Twice as many Indigenous peoples have
incomes falling below the LICO, and twice as many children (around 32%) live in single family homes or very low-
income families.

Q2
As expected, the Indigenous population tends to be at a higher risk of getting exposed to lifestyle risk factors like
smoking, substance abuse, and gambling. Around 60% of the Indigenous population smokes, making that double
that of the general Canadian average. The same thing can be seen in substance abuse and gambling trends. Again,
the numbers are higher in the Indigenous population in any type substance abuse, and the same goes for gambling.
Clear examples are the high rates of births affected by alcohol and the Alberta studies on gambling.

Q3
All the above mentioned problems have severe consequences for the Indigenous population. This is reflected in the
higher suicide rate as compared to the general Canadian rate (8 times higher).
Their mortality rate is also higher due to their overall status and the complications of early disease and lifestyle risk
factors. The potential years of life lost (PYLL) also demonstrates that. This is attributed to higher levels of injuries and
poisonings as per 1997 studies, and deaths occurring in the perinatal period as per 1993 studies.
Question #32
Most Canadian physicians are in private practice and bill the provincial government for their services. The provinces
receive their funding from the federal government. The physicians also have medical liability insurance through the
Canadian Medical Protective Association that defends them in medical malpractice suits.
Which of the following criteria in the Canada Health Act must be satisfied by the Canadian provinces in order to be
funded by the federal government?
Select up to 5 Answers

1. Accessibility
2. Automatic enrollment
3. Capacity
4. Civil liability
5. Comprehensiveness
6. Consequential Loss
7. Conversion
8. Denunciation
9. Deterrence
10. Healthcare in absencia
11. Portability
12. Public administration
13. Repatriation
14. Retribution
15. Universality
Explanation
Correct Answers: 1, 5, 11, 12 and 15
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Question #33
An anesthesiologist in your practice is being sued by a former patient. What is true regarding medical malpractice
lawsuits in Canada and your colleague's situation?
Select up to 7 Answers

1. Awards against Canadian physicians are much less frequent than in the United States
2. Awards against Canadian physicians may be much smaller for similar injuries than in the United States
3. Canadian Medical Protective Association will defend this malpractice lawsuit very vigorously
4. He is uninsurable moving forward
5. He will be disciplined by Canadian Medical Protective Association
6. His malpractice liability insurance fees will increase
7. His malpractice liability insurance fees will not increase
8. Proving negligence can be harder in Canada
9. This will discourage him from repeating the same in his future
10. This will discourage his colleagues from repeating his mistakes
11. The Supreme Court of Canada has set out guidelines that effectively cap awards for pain and suffering
12. The purpose of punitive damages is to compensate the plaintiff
13. Punitive damages are sometimes given when other penalties are inadequate in achieving deterrence,
denunciation or retribution
Explanation
Correct Answers: 1, 2, 3, 7, 8, 11 and 13
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Question #34
Which of the following can be acts of negligence in the delivery of health care?
Select up to 9 Answers

1. An error of judgment
2. Failure to attend a patient
3. Failure to communicate with other physicians
4. Failure to confront a patient that is faking an illness
5. Failure to disclose information to a relative without patient's consent
6. Failure to disclose information to insurance companies without patient's consent
7. Failure to disclose information to the police department without patient’s consent
8. Failure to protect or warn third parties
9. Failure to report abuse
10. Failures in consultation
11. Failures in diagnosis
12. Failures in re-diagnosis
13. Failures in referral
14. Substandard treatment
Explanation
Correct Answers: 2, 3, 8, 9, 10, 11, 12, 13 and 14
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Topic: Concepts of Health and Its Determinants
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 1, 5, 11, 12, 15.

Question 2 - Correct answer(s): 1, 2, 3, 7, 8, 11, 13.
Question 3 - Correct answer(s): 2, 3, 8, 9, 10, 11, 12, 13, 14.

Detailed Explanation:

Canadian Health Care System differs considerably from other countries. The physicians are essentially employed by
the state, and all provinces have a single health insurance program that covers virtually all residents. These provincial
health insurance plans are funded by the federal government.

Q1.
The provinces have to fulfill five criteria established by the Canada Health Act in order to receive funds:
1. Public administration – the health insurance plan must be administered on a non-profit basis by a public authority;
2. Comprehensiveness – the health care insurance plan of a province must insure all services that are “medically
necessary”;
3. Universality – insured services are available to every Canadian resident anywhere in Canada;
4. Portability – provinces are required to cover insured health services provided to their citizens while they are
temporarily absent from their province of residence or from Canada. If they have temporarily moved to another
province, then the payment is made at the rate negotiated by the governments of the two provinces. For out-of-
Canada services, the amount paid is equivalent to the amount the province of residence would pay for similar
services rendered in that province.
5. Accessibility – insured persons must have reasonable and uniform access to insured health services, regardless
of their income, age, or health status.

→ Automatic enrollment (choice 2) is incorrect. This is not part of the criteria. Some insurance plans offer this option,
especially to students.
→ Capacity (choice 3), Civil liability (choice 4), Consequential Loss (choice 6), Conversion (choice 7), Denunciation
(choice 8), Deterrence (choice 9) are incorrect answers as they are not part of the criteria.
→ Healthcare in absentia (choice 10) is incorrect. This is not part of the criteria. This is an increasing trend where
there is an absence of personal contact between the physician and the patient.
→ Repatriation (choice 13) is a type of a benefit that some insurance companies cover. It is not a criterion.
→ Retribution (choice 14) is not part of the criteria.

Q2.
Most physicians are in private practice and choose to bill the provincial insurance plans for their services. Any
physician in Canada who is in private practice or works for a hospital is required to obtain medical liability insurance.
This is available through the Canadian Medical Protective Association (CMPA). The membership fees are based on
the type of work a physician does and the region of practice. There are three fee regions in Canada: Quebec, Ontario,
and the Rest of Canada. CMPA has been criticized for defending medical malpractice suits extremely vigorously.

→ Awards against Canadian physicians are much less frequent than in the United States (choice 1) is correct.
→ Awards against Canadian physicians may be much smaller for similar injuries than in the United States (choice 2)
is correct.
→ Canadian Medical Protective Association will defend this malpractice lawsuit very vigorously (choice 3) is correct.
→ He is uninsurable moving forward (choice 4) is incorrect. The Canadian Medical Protective Association (CMPA)
has published Fee Schedules, and the fees are not based upon a physician’s record. Neither are the fees increased
for a history of complaints or on account of claims paid.
→ He will be disciplined by Canadian Medical Protective Association (choice 5) is incorrect. The critics of CMPA
contend that the system does little to penalize physicians who are found to be liable for malpractice even on multiple
occasions. However, the physicians are disciplined by their provincial licensing body, and the discipline can range
from suspensions to losses of the privilege to continue practicing medicine.
→ His malpractice liability insurance fees will increase (choice 6) is incorrect because CMPA’s fees are not based
upon a physician’s record.
→ His malpractice liability insurance fees will not increase (choice 7) is correct because CMPA’s fees are not based
upon a physician’s record.
→ Proving negligence can be harder in Canada (choice 8) is correct. Canada’s liability laws make establishing
negligence much more difficult than in the United States.
→ This will discourage him from repeating the same in his future (choice 9) is incorrect. Just a malpractice lawsuit is
unlikely to achieve deterrence. However, if the plaintiff wins and is awarded damages, then deterrence is achieved.
This question does not state whether the plaintiff won the case.
→ This will discourage his colleagues from repeating his mistakes (choice 10) is incorrect. Just a malpractice lawsuit
is unlikely to achieve deterrence. However, if the plaintiff wins and is awarded damages, then deterrence is achieved.
This question does not state whether the plaintiff won the case.
→ The Supreme Court of Canada has set out guidelines that effectively cap awards for pain and suffering (choice
11) is correct.
→ The purpose of punitive damages is to compensate the plaintiff (choice 12) is incorrect. Punitive damages are not
awarded to compensate the plaintiff but to deter, retribute and denunciate the defendant.
→ Punitive damages are sometimes given when other penalties are inadequate in achieving deterrence,
denunciation or retribution (choice 13) is correct. Deterrence is to discourage the defendant and others from similar
misconduct in the future, denunciation is the collective disapproval of the negligence act by the community and
retribution is the punishment that is inflicted for a wrongful act.

Q3.
In order to successfully prove negligence in the delivery of healthcare, a plaintiff must show that:
1. The defendant owed him or her a duty of care;
2. The defendant did not deliver the standard of care owed;
3. The plaintiff’s injuries were reasonably foreseeable and;
4. The defendant’s breach of the duty of care was the proximate cause of the plaintiff’s injuries.

→ An error of judgment (choice 1) is incorrect. This is not necessarily negligence even if it causes injury.
→ Failure to attend a patient (choice 2) is correct because in this situation a plaintiff is able to successfully show that
the defendant owed him or her a duty of care, the defendant did not deliver the standard of care owed, the plaintiff’s
injuries were reasonably foreseeable, and the defendant’s breach of the duty of care was the proximate cause of the
plaintiff’s injuries.
→ Failure to communicate with other physicians (choice 3) is correct for the same reasons as explained under option
2.
→ Failure to confront a patient that is faking an illness (choice 4) is incorrect and is not considered negligence. It is
not mandatory to confront a malingerer and in some cases may result in hostile behavior.
→ Failure to disclose information to a relative without patient’s consent (choice 5) is incorrect and is not considered
negligence. A patient’s consent is required to release any information to a third party.
→ Failure to disclose information to insurance companies without patient’s consent (choice 6) is incorrect and is not
considered negligence. A patient’s consent is required to release any information to a third party.
→ Failure to disclose information to the police department without patient’s consent (choice 7) is incorrect and is not
considered negligence. A patient’s consent is required to release any information to a third party.
→ Failure to protect or warn third parties (choice 8) is correct for the same reasons as explained under option 2.
→ Failure to report abuse (choice 9), Failures in consultation (choice 10), Failures in diagnosis (choice 11), Failures in
re-diagnosis (choice 12), Failures in referral (choice 13), Substandard treatment (choice 14) are the correct answers
for the same reasons as explained under option 2.
Question #35
A 51-year-old woman presents to the physician for her annual well woman examination. She reports that she
continues to feel healthy, with no medical issues, medications or allergies. She goes on to tell you that she works as a
receptionist at a local hotel, and one of the other employees recently found a suspicious lump while taking a shower.
She has begun monthly breast-self examination and wonders about a number of “lumps” on both breasts. She has
never been for a screening mammogram. Family history and social history are unremarkable.

Physical examination reveals a temperature of 37.1°C, heart rate of 78 bpm, respiratory rate of 18 bpm, and a blood
pressure of 134/86 mmHg. She is not in any distress and is alert and oriented. Cardiac, respiratory, and abdominal
examination are within normal parameters. The head and neck examination is unremarkable and does not reveal any
lymphadenopathy. Breast examination reveals dense breast tissue without suspicious masses. There is no axillary
lymphadenopathy.

You reassure your patient that the examination shows no worrisome findings, and proceed to book her for a screening
mammogram with a follow-up in one month’s time.
Which of the following findings on clinical history, physical examination, or mammogram would be worrisome for a
breast malignancy?
Select up to 5 Answers

1. Asymmetry in size of the breasts

2. Asymmetry in the contours of the breasts
3. Axillary lymph node (5mm diameter)
4. Bilateral milky discharge
5. Clustered micro-calcifications
6. Erythema and tenderness surrounding the nipple
7. Firm mass upper outer quadrant of the breast
8. Macro calcifications on mammogram
9. Micro-calcifications on an area of fat necrosis
10. Multiple masses of fluctuating size
11. Unilateral bloody discharge (spontaneous)
12. Unilateral opaque discharge (when stimulated)
Explanation
Correct Answers: 2, 5, 6, 7 and 11
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Question #36
Which of the following screening modalities are appropriate for population level of screening of average risk women?
Select as many as appropriate

1. Breast self-examination
2. CA-125 levels
3. Chest X-ray
4. Clinical breast examination
5. Compression mammography views
6. Genetic screening for BRCA-1 and BRCA-2 high risk mutations
7. Magnetic Resonance Imaging
8. Mammograms yearly, ages 50-69
9. Mammograms every 2-3 years, ages 50-69
10. Mammograms every 2-3 years, ages 70-74
11. Mammograms every 2-3 years, ages 40-49
12. Screening ultrasound
Explanation
Correct Answers: 9 and 10
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Question #37
Which of the following are proven risk factors for the development of breast cancer?
Select as many as appropriate

1. Age > 50 years

2. Asian ancestry
3. Atypical hyperplasia
4. Early menopause (age < 55 years)
5. Estrogen-progestin based hormone replacement therapy
6. First degree relative with breast cancer
7. First live birth at age > 30 years
8. Late menarche (age > 14 years)
9. North European ancestry
10. Previous breast biopsy
11. Second degree relative with breast cancer
12. Simple hyperplasia
Explanation
Correct Answers: 1, 3, 5, 6, 7, 9, 10 and 11
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Topic: Breast Cancer
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 2, 5, 6, 7, 11.

Question 2 - Correct answer(s): 9, 10.
Question 3 - Correct answer(s): 1, 3, 5, 6, 7, 9, 10, 11.

Detailed Explanation:

Breast cancer, and the broader topic of breast pathologies, which may share similar signs and symptoms, are
an important topic for the Canadian physician. The Canadian Cancer Society reports that 26% of all new cancer
diagnoses and 13% of all cancer deaths among females involved a malignancy of the breast during the past year.
It is crucial to note that population level screening guidelines have changed over the last decade. The pathway
between a suspicious mammogram and an outright diagnosis of breast malignancy may be protracted, involving spot
compression mammographic views, either ultrasound or stereotactic biopsies and finally the surgery itself, along with
adjuvant therapies. For this reason, physicians should be in a position of knowledge and be prepared to act as a
navigator as their patients are subjected to multiple investigative modalities and treating specialties. The stress and
apprehension associated with the diagnosis and subsequent management is most understandable.

Q1.
Classic physical examination findings of breast cancer include asymmetry of the contours of the breast, which could
indicate pull on the suspensory mammary (Cooper's) ligaments from an underlying malignancy (choice 2), erythema
and tenderness surrounding the nipple, which is indicative of the rare but rapidly progressing inflammatory breast
cancer (choice 6), palpation of a firm mass in the upper outer quadrant of the breast; this being the most common
location for a breast malignancy (choice 7), and unilateral spontaneous bloody discharge which may represent an
intraductal papilloma.

Mammogram abnormalities include masses, calcifications, asymmetry, and architectural distortion. The most specific
mammographic feature of malignancy is a spiculated soft tissue mass; other findings include clustered micro-
calcifications (choice 5), which are characteristic of an early ductal carcinoma in situ (DCIS).

→ Asymmetry in the size of the breasts (choice 1) is incorrect because this is a natural variant in the majority of
women.
→ A solitary < 1 cm mobile, rubbery lymph node (choice 3) is not characteristic of a node occupied by metastatic
breast cancer.
→ Bilateral milky discharge (choice 4) is more concerning for a prolactinoma. Be sure to ask about headache, and
recent visual disturbances.
→ Macro calcifications (choice 8) and micro calcifications (choice 9) on a background of lipid necrosis do not
represent malignant potential.
→ Multiple masses of fluctuating size (choice 10) represent benign masses which are responsive to cyclical hormone
fluctuations.
→ Stimulated non-bloody unilateral discharge from a breast (choice 12) does not present a concern for malignancy.
If the discharge is spontaneous, there is a higher risk of malignancy.

Q2.
The Canadian Task Force on Preventative Health Care (CTFPHC) only recommends screening mammograms in
women aged 50-69 and 70-74 (choice 9, choice 10). It is recommended to conduct these at a 2-3 year interval. These
represent screening guidelines for average risk asymptomatic women without complaints of breast masses or any of
the worrisome clinical findings in the preceding question. The mammogram also has utility as an initial study in the
workup of a woman with a strong family history, any blood relation with male breast cancer, carriers of the BRCA 1
or 2 gene variants, and anyone presenting with worrisome breasts masses or spontaneous unilateral discharge.

→ Breast self-examination (choice 1) is not currently recommended by CTFPHC.

→ CA-125 (choice 2) is a tumor marker for ovarian cancer, it is not used in the workup of breast cancer.
→ Chest X-ray (choice 3) is of limited utility in identifying early breast lesions. Mammography uses carefully chosen
angles which maximize the sensitivity of the exam.
→ Clinical breast examination (choice 4) while useful in the assessment of a high-risk patient (as described above),
is not recommended for average risk population screening by the CTFPHC.
→ Compression mammographic views (choice 5) are ordered by the radiologist when there are anomalies on the
initial screening mammogram.
→ Genetic screening (choice 6) is not an initial screening modality.
→ Magnetic resonance imaging (choice 7) offers excellent resolution of soft tissue lesions and anomalies. Due to
cost and accessibility, the CTFPHC d recommend it as a screening modality.
→ Yearly mammograms in the 50-69 target demographic (choice 8) would be too frequent.
→ Mammograms before the age of 50 (choice 11) are not recommended for average risk patients.
→ Ultrasound (choice 12) is not used as a screening modality.

Q3.
There are many risk factors for the diagnosis of breast cancer. Some of these are intimately related to genetics, such
as the existence of a first or even second degree relative with breast cancer (choice 6 and choice 11 respectively),
Northern European ancestry (choice 9). Increased age is also associated with increased risk (choice 1), as are
certain forms of benign breast pathology such as atypical hyperplasia (choice 3). Having had a previous breast biopsy
(choice 10) is a risk factor, regardless of the pathology result.

Another broad category of risk factors focuses around lifetime exposure to estrogen such as combined HRT (choice
5), later age at first live birth (choice 7), along with later menopause or early menarche.

→ Asian ancestry (choice 2) is associated with lower risk of development of breast cancer. Interestingly, the risk
approaches that of Caucasian North Americans for first and second generation descendants of Asian immigrants.
This might suggest that cultural and/or lifestyle differences may be a confounding variable in this particular risk factor
assessment, as opposed to a difference that can be attributed purely to genetics.
→ Early menopause (age < 55 years) and late menarche (age > 14 years) are actually protective factors since they
lessen the lifetime exposure to estrogen (choice 4 and choice 8).
→ Simple hyperplasia (choice 12) has not been shown to be a statistically significant risk factor for the subsequent
development of breast cancer.
Question #38
A mother comes in with a 3-month-old boy who sees you for the first time. She states that the whole family has been
sick ever since they moved to Toronto, a month ago, and that is why they missed the two-month check-up. The baby
is developing well. He was delivered by spontaneous vaginal delivery at full term without any complications.
Immunization against which of the following diseases is recommended during this visit?
Select up to 7 Answers

1. Chickenpox
2. Diphtheria
3. Haemophilus influenzae type B infections
4. Human Papilloma Virus infection
5. Invasive pneumococcal infection
6. Measles
7. Meningococcal disease (strains A, C, Y, W135)
8. Mumps
9. Pertussis
10. Polio
11. Rotavirus infection
12. Rubella
13. Shingles
14. Tetanus
Explanation
Correct Answers: 2, 3, 5, 9, 10, 11 and 14
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Question #39
According to the current National Advisory Committee on Immunization (NACI) recommendations in most provinces,
at what age should a child receive DTaP-IPV-HiB vaccine?
Select as many as appropriate

1. 1 month old
2. 2 months old
3. 3 months old
4. 4 months old
5. 6 months old
6. 8 months old
7. 10 months old
8. 12 months old
9. 14 months old
10. 16 months old
11. 18 months old
12. 20 months old
13. 22 months old
14. 24 months old
Explanation
Correct Answers: 2, 4, 5 and 11
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Question #40
Regarding specific contraindications and precautions to immunization, which of the following statements is/are true?
Select as many as appropriate

1. Active tuberculosis is a contraindication to administration of both inactivated and live vaccines.

2. Asthma (mild, moderate, severe) is an absolute contraindication to immunization.
3. Administration of seasonal vaccine should usually be postponed in persons with serious acute illness.
4. Both inactivated and live vaccines are contraindicated in immunocompromised persons (due to underlying
condition).
5. Influenza vaccine is contraindicated in patients on warfarin.
6. Influenza vaccine should not be given to people who have had an anaphylactic reaction to a previous
dose.
7. Live attenuated influenza vaccine is contraindicated in breastfeeding mothers.
8. Live attenuated influenza vaccine is contraindicated in most persons who are on immunosuppressive
therapy.
9. Rotavirus vaccine is contraindicated in children with an uncorrected congenital malformation of the
gastrointestinal tract.
10. Vaccination is contraindicated in persons with a history of intussusception.
Explanation
Correct Answers: 3, 6, 8 and 9
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Topic: Immunization
Subject: PMCH

Correct Answers:

Question 1 - Correct answer(s): 2, 3, 5, 9, 10, 11, 14.

Question 2 - Correct answer(s): 2, 4, 5, 11.
Question 3 - Correct answer(s): 3, 6, 8, 9.

Detailed Explanation:

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.

Q1.
This patient should receive his first set of vaccines which are usually administered at two months of age. They
include:
• DTaP-IPV-Hib: Diphtheria (choice 2), Tetanus (choice 14), Whooping Cough (choice 9), Polio (choice 10),
Haemophilus influenzae type B (choice 3)
• Pneu-C-13: Pneumococcal disease (choice 5)
• Rot: Rotavirus (choice 11)

→ Chickenpox (choice 1) is an incorrect answer since varicella vaccine is usually administered at 12 or 15 months of
age (depends on the province).
→ Human Papilloma Virus (choice 4) vaccine is indicated in grade 6 or 7.
→ Measles (choice 6), Mumps (choice 8), Rubella (choice 12) - MMR vaccine is administered at 12 months of age.
→ Meningococcal (choice 7) vaccine (Men-C-ACYW-135) is indicated at grade 6, 7 or 9 (depending on the province).
→ Shingles (choice 13) vaccine is indicated in seniors 65-70 years of age, as this is the age group that is highly
susceptible to getting shingles.

Q2.
DTaP-IPV-HiB vaccine is a combined vaccine against diphtheria, tetanus, pertussis, polio, and serious conditions
(e.g., meningitis, epiglottitis) caused by Haemophilus influenzae type b.

Immunization against diphtheria, tetanus, pertussis, and polio is required by law for all children attending school.

In most Canadian provinces, this vaccine is given to children at 2 months (choice 2), 4 months (choice 4), 6 months
(choice 5) and 18 months (choice 11) of age.

Reference:
http://healthycanadians.gc.ca/healthy-living-vie-saine/immunization-immunisation/schedule-calendrier/alt/infants-
children-vaccination-enfants-nourrissons-eng.pdf

Q3.
There are numerous of reasons for not administering vaccines. Sometimes they cannot be given or need to be
delayed due to contraindications or precautions. Contraindications are conditions that increase chances of a serious
adverse reaction in vaccine recipients, and the vaccine should not be administered when a contraindication is
present. Precautions should be reviewed for potential risks and benefits for vaccine recipients.

Inactivated vaccines and live, attenuated vaccines authorized and available for use in Canada List
• Inactivated vaccines
Acellular pertussis
Cholera and travellers' diarrhea
Diphtheria toxoid
Haemophilus influenzae type b (Hib)
Hepatitis A
 Hepatitis B
Human papillomavirus (HPV)
Inactivated poliomyelitis
Japanese encephalitis
Meningococcal
Pneumococcal
Rabies
Tetanus toxoid-
Tick-borne encephalitis
Trivalent inactivated influenza (TIV)
Typhoid (injectable formulation)
• Live, attenuated vaccines
Bacillus Calmette-Gérin (BCG)
Herpes Zoster (shingles)
Live attenuated influenza (LAIV)
Measles
Mumps
Rotavirus
Rubella
Smallpox
Typhoid (oral formulation)
Varicella (chickenpox)
Yellow fever

Please refer to the image below for contraindications and selected precautions for vaccine administration.
 Administration of the seasonal vaccine should usually be postponed in persons with serious acute illness (choice 3).
It is usually postponed until the symptoms have abated. However, flu-shot should not be delayed because of minor
acute illness, with or without fever.

Influenza vaccine should not be given to people who have had an anaphylactic reaction to a previous dose (choice
6). Furthermore, it should not be given to people who have had an anaphylactic reaction to any of the vaccine
components, with the exception of egg.

Live attenuated influenza vaccine is contraindicated in most persons who are on immunosuppressive therapy (choice
8). If vaccines cannot be given before the therapy, it is advisable to delay vaccines until after immunosuppressive
therapy has stopped. Inactivated vaccines should be delayed 3 months and live vaccines should be delayed 1-3
months.

Rotavirus vaccine is contraindicated in children with an uncorrected congenital malformation of gastrointestinal tract
(choice 9) is also correct as shown in the table above.

→ Active tuberculosis is a contraindication to administration of both inactivated and live vaccines (choice 1) is
incorrect as shown in the table above.
→ Asthma (mild, moderate, severe) is an absolute contraindication to immunization (choice 2) is an incorrect
statement as seen in the table above.
→ Both inactivated and live vaccines are contraindicated in immunocompromised persons (due to underlying
condition) (choice 4) is incorrect as displayed in the table above.
→ Influenza vaccine is contraindicated in patients on warfarin (choice 5) is a false statement. Patients receiving long-
term anticoagulation (warfarin or heparin) are not considered to be at higher risk of bleeding complications following
immunization and may be safely immunized.
→ Live attenuated influenza vaccine is not contraindicated in breastfeeding mothers (choice 7). It is contraindicated
in pregnant women. In fact, all live vaccines are contraindicated in pregnancy.
→ Vaccination is contraindicated in persons with a history of intussusception (choice 10) is a false statement
because in these patients only rotavirus vaccine is contraindicated and there is no contraindication or precaution to
administration of inactivated vaccines.

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