Canada QBank

The correct answer is c.
All users average of this question: 65%

Topic: Hantavirus
Subject: PMCH
Type: Diagnosis
Dimensions of Care: Acute care
Physician Activities: Assessment and diagnosis
Difficulty: Average

Explanation:

The diagnosis of Hantavirus pulmonary syndrome requires a high degree of clinical suspicion, as the presenting symptoms are often indistinguishable from influenza virus infection. The key feature to suspect Hantavirus infection is exposure to mouse droppings. In Canada, the animal reservoir of Hantavirus, also known as Sin Nombre virus, is the deer mouse (choice C). Elsewhere in North and South America, other rodents are reservoirs. The virus is transmitted through aerosolization of the animal droppings.

Hantavirus is a single stranded negative sense enveloped RNA virus in the Bunyaviridae family. It causes two main syndromes. In the Eastern Hemisphere, the Hemorrhagic fever with renal syndrome occurs with exposure to rodent droppings. In the Western Hemisphere, the Hantavirus pulmonary syndrome is caused by infection with Hantavirus (Sin Nombre virus). Symptoms begin with a flu-like illness, but progress to increased shortness of breath, and pulmonary edema. Treatment involves supportive care with intubation and mechanical ventilation, and diuretic use. The disease maintains a high fatality rate despite adequate care.

When studying zoonotic diseases, it is important to understand the disease host, reservoir, and vector. The reservoir is the animal in which a virus, bacteria, or parasite can survive indefinitely, without causing illness to that animal. The reservoir can also be the definitive host; the animal in which the infective agent matures and reproduces sexually. The vector is the animal that transmits disease from reservoir to another animal, or to humans.

→ Bats (choice a A) are not the reservoir of Hantavirus. They are a host reservoir (along with skunks, foxes, and raccoons) for the rabies virus.
→ Fleas (choice b B) is incorrect. Fleas are the vector for Yersinia pestis.
→ Rabbits (choice d D) are among many animals that can host Fransicella tularensis, a gram negative bacteria that causes tularemia.
→ Ticks (choice e E) are responsible for the transmission of many diseases including Lyme disease and Rocky mountain spotted fever. They are not the host reservoir for Hantavirus.

Key point:

In North and South America, Hantavirus causes Hantavirus pulmonary syndrome. The most common reservoir in Canada is the deer mouse.

Hantavirus Infection

https://www.youtube.com/watch?v=XPo-_3a4gXo

Explanation:

Cervical cancer is one of the most preventable cancers; the Pap smear test has been used to screen for pre-cancerous lesions and has significantly helped reduce the incidence of cervical cancer. The Canadian Task Force on Preventive Healthcare (CTFPHC) recommends routine screening for women in the 25 to 69 years old age group. Since studies have shown that screening done annually and screening done every three years have almost similar benefits, it is recommended that for those with previous negative results, screening should be done every three years.

At the time of the appointment for a Pap smear, the patient should be informed that certain conditions are better than others for screening. Patients should not douche the vagina for 48 hours prior to the examination. Smears should not be taken during menstruation. The optimal time is mid-cycle or just before ovulation. The patient should be informed that the date of her last menstrual period would be required (choice E). However, if these conditions cannot be met, and it is possible the patient will not return on time, a pap smear should be done.

→ Optimal results are obtained when the vagina is douched the night before the test (choice A) is incorrect. The vagina should not be douched 48 hours prior to the examination.
→ There is not necessarily an optimal time of the month for a Pap smear test in all women (choice B) is incorrect. Optimal time is mid-cycle or just before ovulation.
→ Timing, the Pap smear during the follicular phase of the menstrual cycle, is optimal (choice C) is incorrect, as explained earlier.
→ If conditions for optimal Pap smear testing cannot be met, it is absolutely discouraged to do it (choice D) is incorrect. If conditions cannot be met, and it is possible the patient will not return on time, a pap smear should be done.

Key point:
At the time of the appointment for a Pap smear, the patient should be informed that the date of her last menstrual period would be required. The optimal time for Pap smear is mid-cycle or just before ovulation.

Cervical Cancer

https://www.youtube.com/watch?v=YuCRoob5gqQ&t=1s

Explanation:

This patient presents with traveler’s diarrhea and the most common cause is Enterotoxigenic Escherichia coli (ETEC). ETEC infection is transmitted by ingestion of contaminated food or water. Disease results from adherence and colonization of the small intestine and the subsequent elaboration of two distinct enterotoxins: heat-labile toxin and heat-stable toxin. Heat-labile toxin leads to secretory diarrhea by activating cAMP while heat-stable toxin activates cGMP.
Although there is no effective ETEC vaccine available yet, there is strong evidence to support that such a vaccine may be developed. It has been observed that in regions of the world where ETEC is highly endemic there is a decline in ETEC diarrheal incidence with increasing age whereas no such age-related association is evident in short time visitors to endemic areas. However, the incidence of ETEC rapidly decreases also in persons from developed countries during prolonged stay in ETEC endemic areas. These observations strongly suggest that effective immunity may develop after repeated infections and, as a consequence protection by way of an effective ETEC vaccine is achievable.

Since the key pathogenic mechanisms that contribute to the pathogenesis of ETEC are the production of colonization factors (CFs) and a heat-labile enterotoxin and/or a heat-stable enterotoxin, an ideal vaccine with broad-spectrum protection should contain colonization factor antigens, coli surface (CS) antigens 1 through 6, which are associated with majority of E. coli-linked diarrhea, and the labile toxin (choice B).

→ ETEC vaccines should contain aroC, ompC, and ompF and delivered orally (choice A) is incorrect. AroC, ompC, and ompF are toxin genes and are generally deleted to attenuate potential vaccines.
→ ETEC vaccines should be live attenuated three-strain recombinant delivered by injection (choice C) is incorrect. While studies involving live attenuated three-strain recombinant bacterial vaccine are on-going and have shown promises, they can be taken orally and do not have to be injected. Potential vaccines given by sublingual routes have been shown to be very efficient in inducing intestinal immune responses.
→ ETEC vaccine should contain heat stable strains expressing CS 13 and CS 23 (choice D) is incorrect. The presence of CS13 is not frequent within ETEC strains causing diarrhea in humans. Moreover, studies have recently shown that CS 23 is similar to CS 13 in this regard. If widely distributed ETEC adhesins are to be considered in a strategy for vaccine development, CS 13 and CS 23 would most likely not be suitable candidates compared with others (such as CS6) that are more commonly identified in clinical isolates.
→ The oral cholera killed whole-cell vaccine is recommended for protection (choice E) is incorrect. The cholera vaccine, dukoral, has shown some minimal benefits in protecting people against Enterotoxigenic E. coli-associated diarrhea, but this is not recommended for vaccination against E. coli infection.

Key point:

To provide broad-spectrum protection, an ETEC vaccine should contain colonization factor antigens, coli surface (CS) antigens 1 through 6, which are associated with majority of E. coli-linked diarrhea, and the labile toxin.

Explanation:

This patient presents with complaints of severe cancer-related pain. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. The subjectivity of pain is widely accepted, and it is often said: "pain is what the patient says it is."

While opioids are beneficial to manage pain in patients like this, there is always a concern for dependence and adverse events associated with the use of these medications. In recent years, there have been as many deaths from narcotic drug use as there were car accident-related deaths, and for every opioid-related death, there are 130 opioid dependence cases and 825 non-medical users. Despite this risk, it is widely accepted that treating severe pain with opioids is a humane treatment of patients when indicated. Physicians often require patients to sign agreements to use opioids for pain management to ensure there is no abuse or diversion of use of these medications.

Most of these agreements also generally state that it is the patient's responsibility to get refills during the primary prescriber's working hours, and they should not seek to get these medications from local emergency departments. Given the patient's history of metastatic cancer, the request for pain medication at the ED should not be dismissed. Generally, the emergency department physician should attempt to contact the primary care physician (choice C) or primary prescriber before giving the patient enough medications until the office of the primary opioid prescriber opens.

→ Prescribe NSAIDs and do not prescribe opioids (choice A) is incorrect. For metastatic cancer, opioids are preferred over NSAIDs. While prescribing non-opioid analgesics may be an easy way for a physician to avoid liability, the prescribed medications' effectiveness should be the primary goal.
→ Prescribe opioids that last him until Monday (choice B) may indeed be the course of action to take at the end of this visit, but the patient risks being fired from the primary care physician's practice. It would be appropriate to attempt contacting the primary care physician first.
→ Call the patient's pharmacy to check the monitoring system (choice D) is usually advised if the primary care physician is not reachable. All provinces have controlled substance prescription monitoring systems to mitigate drug abuse. These systems can provide real-time information on all controlled substances prescribed in the province and can help alert doctor shopping or other inappropriate behaviour.
→ Tell the patient to endure the pain till Monday (choice E) would not be the correct way to manage this patient.

Key point:
Generally, the emergency department physician should attempt to contact the primary care physician or primary prescriber before giving the patient enough medications until the office of the primary opioid prescriber opens.

Explanation:

Case-Control studies are ideal in outbreaks and situations where the source of the outbreak needs to be determined quickly. They compare cases (or people who have particular outcomes or diseases) with controls (people from a similar group, but without the outcome or disease). They are, by their very nature retrospective. In choosing a case group, the cases should be representative of the entire spectrum of the disease or case being studied. The control group must not have the disease, have otherwise similar characteristics, and have an equal chance of being exposed to the disease or case in question.

Advantages of Case-Control studies are that they are:
-fast and cheap
-can be used in outbreaks
-can be used for diseases that are rare in a population

Disadvantages of Case-Control studies:
-Possibility of recall bias
-Possibility of confounding bias
-No incidence of the disease (have already chosen the number of individuals affected with the case or disease) (choice D)
-Control selection can be difficult (chance of selection bias)
-May be difficult to establish temporality (when did one get exposed?)
-Record keeping may be unreliable.
-Only one outcome can be measured (one has already chosen the outcome)

→ Case-control studies are fast and cheap, therefore Expensive (choice A) and Cannot be used in outbreaks because it is slow (choice C) are incorrect.
→ Possibility of recall bias and confounding bias (choice B) are main disadvantages of case-control studies.
→ Case-control study has an advantage (not the disadvantage, choice E) that it can be used for diseases that are rare in a population.

Key point:
Case-Control studies are fast and cheap , can be used in outbreaks, can be used for diseases that are rare in a population but cannot determine the incidence of the disease.

The correct answer is d.
All users average of this question: 47%

Topic: Canada Health Act
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Communication
Difficulty: Difficult

Explanation:

The Canada Health Act is a legislation enacted in 1984 to ensure continued access to quality healthcare without financial or other barriers, to maintain the health and well-being of Canadians. It articulates a social contract that that defines healthcare as a basic right. It sets standards the provincial governments, including the territories, must meet to receive federal funding for healthcare.

Insured health services are defined this way:
- hospital services that are medically necessary for the purpose of maintaining health, preventing disease or diagnosing or treating an injury, illness or disability, including accommodation and meals, physician and nursing services, drugs and all medical and surgical equipment and supplies;
- any medically required services rendered by medical practitioners; and
- any medically or dentally required surgical-dental procedures which can only be properly carried out in a hospital.

Penalties under the CHA are linked to federal transfers to the provinces. Each provincial healthcare insurance plan must comply with the requirements of the Act before the province receives its total entitlement of cash transfers. The federal government may withhold part or all cash transfers to provinces that do not meet the requirements. The federal government has expanded the penalties to include cash for social programs and other fields besides healthcare (choice D). The federal Minister of Health remains the final authority to interpret and enforce the CHA.

→ The provincial superior court is the final authority to interpret the Canada Health Act and determine penalties (choice A) is incorrect. The federal Minister of Health is the final authority to interpret and enforce the CHA.
→ Financial penalties to provinces are applied by withholding cash transfers only earmarked for healthcare (choice B) is incorrect. Financial penalties have not been limited solely to federal cash transfers for healthcare, the government has expanded the penalties to cover other cash transfers related to other fields.
→ The financial penalties stipulated in the Act are the same regardless of the default (choice C) is incorrect. The financial penalties stipulated in the Act vary depending on whether a default is directly related to extra-billing and user charges or involves failure to satisfy criteria or conditions
→ The Act requires the federal government to impose a fine on any province that doesn't meet its obligations (choice E) is incorrect. The penalties are discretionary in nature, the federal government has an option of penalizing provinces that default their obligations, but it is not required to do so by the CHA.

Key point:
The federal government may withhold part or all cash transfers to provinces that do not meet the requirements. The federal government has expanded the penalties to include cash for social programs and other fields besides healthcare. The federal Minister of Health remains the final authority to interpret and enforce the Canada Health Act.

The correct answer is b.
All users average of this question: 74%

Topic: Medical Ethics - Patient Confidentiality
Subject: PMCH
Type: Evaluation
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Communication
Difficulty: Easy

Explanation:

This patient is an airplane pilot who has been taking amphetamines. He reports that he takes them to stay awake and concentrated. Questions need to be asked to find out whether he has a genuine medical condition or he is using them off-label. It appears he got discharged from the air force, and it is known that the US air force, which conducts joint operations with the Canadian air force, allows the use of amphetamines for fatigue management. Dextroamphetamine, commonly known as a "go-pill," is prescribed by flight surgeons and is used under supervision during flight operations. The pills are not allowed for pilots in civil aviation. The only legal way he would have these pills would be if they were prescribed.

While the information shared or obtained through the physician-patient relationship is strictly confidential and should not be disclosed without the patient's consent, there are certain scenarios where reporting is permitted and some even mandatory. The following list cites the most common, but it is not exhaustive:

1. Communicable disease
2. Child abuse and neglect
3. Vulnerable adults (elder abuse)
4. Driving safety
5. Births, stillbirths, and death
6. Airplane pilots and aircraft controllers, train, and maritime safety
7. Fitness to work
8. Gunshot wounds
9. Healthcare fraud
10. Certain criminal activities

The Aeronautics Act requires physicians to report pilots with conditions likely to constitute a hazard to aviation safety. The public interest in this circumstance supersedes the patient's right to privacy. Regardless of whether he takes the medications for a genuine medical condition or they are recreational drugs, their use is a matter of concern. Reporting should be made to the Civil Aviation Authority medical advisor (choice B).

→ Detain the patient for treatment to protect the public (choice A) is incorrect. The patient seems cooperative, and detaining him to protect the public is not necessary as he is not aggressive or violent. The public will be best protected by contacting the Civil Aviation Authority.
→ Respect patient's confidentiality and refer to substance abuse treatment program (choice C) is incorrect. The Aeronautics Act makes reporting mandatory.
→ Do nothing because this is common among pilots because of their job (choice D) is incorrect. Amphetamines are not allowed in Canadian civil aviation.
→ Disclose information to the local police department (choice E) is incorrect. Generally, substance abuse is not reported to the police unless they have a warrant. Even if a patient is brought to the ED by police and they pressure the physician to release toxicology screen results, they should not be given unless there is a warrant or court order.

Key point:
The Aeronautics Act requires physicians to report pilots with conditions likely to constitute a hazard to aviation safety. Reporting should be made to the Civil Aviation Authority medical advisor.

The correct answer is d.
All users average of this question: 36%

Topic: Canadian Medical Protective Association
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Professional behaviours
Difficulty: Difficult

Explanation:

The Canadian Medical Protective Association is an organization headquartered in Ottawa, Ontario that provides legal defence, liability protection, and risk management education for physicians in Canada, and provides compensation to patients and their families proven to have been harmed by negligent clinical care. Any physician licensed to practice medicine in any province or territory of Canada is eligible to apply for membership in the association. By the end of 2020, it had 103,000 Canadian physicians who were members. The main role of CMPA is serving and protecting the interests of physicians.

Any physician licensed to practice medicine in any province or territory of Canada is eligible to apply for membership in the Association. Each applicant for membership submits to the Executive Director an application in the form specified by the Council of the Association. Upon the Association's receipt of an acceptable application, the applicant may be admitted to membership by the Executive Director. The Executive Director may refer any application to the Council for consideration at its next meeting. Where the Executive Director does not admit an applicant to membership, the applicant may request that the application be referred to Council at its next meeting. The Council may, in its absolute discretion, either accept or refuse any application without cause assigned.

Membership is terminated by the death of the member, receipt of a written resignation of the member, default of the member in any payment due to the association for more than 1 month (choice D), or when a member is no longer licensed to practice medicine.

→ Admission to membership takes effect at the CMPA annual meeting (choice A) is incorrect. The Executive Director may admit a physician to be a member upon receipt of an acceptable application.
→ There is a flat rate membership fee for each specialty, and no special levies (choice B) is incorrect. Besides the annual membership fee, the association may call upon members to pay special levies in the event of a financial emergency.
→ Annual membership fees are used by CMPA, and they are not reimbursable (choice C) is incorrect. Membership fees are generally reimbursed by the provinces, and the reimbursements may reach as high as 80% of the malpractice liability fee paid to CMPA.
→ A member needs five signatures to cause a motion for consideration at the annual meeting (choice E) is incorrect. A member needs an endorsement of 10 signatures to cause a motion to be considered at the CMPA annual meeting.

Key point:
CMPA membership is terminated by the death of the member, receipt of a written resignation of the member, default of the member in any payment due to the association for more than one month, or when a member is no longer licensed to practice medicine.

The correct answer is d.
All users average of this question: 36%

Topic: Canadian Medical Protective Association
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Professional behaviours
Difficulty: Difficult

Explanation:

The Canadian Medical Protective Association is an organization headquartered in Ottawa, Ontario that provides legal defence, liability protection, and risk management education for physicians in Canada, and provides compensation to patients and their families proven to have been harmed by negligent clinical care. Any physician licensed to practice medicine in any province or territory of Canada is eligible to apply for membership in the association. By the end of 2020, it had 103,000 Canadian physicians who were members. The main role of CMPA is serving and protecting the interests of physicians.

Any physician licensed to practice medicine in any province or territory of Canada is eligible to apply for membership in the Association. Each applicant for membership submits to the Executive Director an application in the form specified by the Council of the Association. Upon the Association's receipt of an acceptable application, the applicant may be admitted to membership by the Executive Director. The Executive Director may refer any application to the Council for consideration at its next meeting. Where the Executive Director does not admit an applicant to membership, the applicant may request that the application be referred to Council at its next meeting. The Council may, in its absolute discretion, either accept or refuse any application without cause assigned.

Membership is terminated by the death of the member, receipt of a written resignation of the member, default of the member in any payment due to the association for more than 1 month (choice D), or when a member is no longer licensed to practice medicine.

→ Admission to membership takes effect at the CMPA annual meeting (choice A) is incorrect. The Executive Director may admit a physician to be a member upon receipt of an acceptable application.
→ There is a flat rate membership fee for each specialty, and no special levies (choice B) is incorrect. Besides the annual membership fee, the association may call upon members to pay special levies in the event of a financial emergency.
→ Annual membership fees are used by CMPA, and they are not reimbursable (choice C) is incorrect. Membership fees are generally reimbursed by the provinces, and the reimbursements may reach as high as 80% of the malpractice liability fee paid to CMPA.
→ A member needs five signatures to cause a motion for consideration at the annual meeting (choice E) is incorrect. A member needs an endorsement of 10 signatures to cause a motion to be considered at the CMPA annual meeting.

Key point:
CMPA membership is terminated by the death of the member, receipt of a written resignation of the member, default of the member in any payment due to the association for more than one month, or when a member is no longer licensed to practice medicine.

The correct answer is d.
All users average of this question: 49%

Topic: Levels of Prevention
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Communication
Difficulty: Difficult

Explanation:

There are three traditional levels of prevention:

• Primary prevention is preventing the onset of the disease either by reducing exposure to risk factors or by increasing the individuals' resistance to them. Measures of population impact are very useful in helping to identify exposures that are potentially responsible for large numbers of cases of a particular disease in the population.
• Secondary prevention is aimed at reducing mortality from a particular disease through early detection and treatment. Screening tests are an important part of secondary prevention.
• Tertiary prevention is aimed at improving the prognosis and quality of life of affected individuals by offering them the best available treatment and rehabilitation programs.

The Association of Faculties of Medicine of Canada (AFMC) adds primordial prevention as the fourth level and this precedes primary prevention, dealing with health determinants rather than preventing exposure to risk factors. An example of primordial prevention is developing green energy programs. The World organization of family physicians (WONCA) goes even further to add quaternary prevention, by advocating to identify patients at risk of over-medicalization and prevent them from having unnecessary medical invasion.

Selective prevention focuses on groups whose risk of developing problems of alcohol abuse or dependence is above average. The subgroups may be distinguished by characteristics such as age, gender, family history, or economic status. For example, drug campaigns in recreational settings (choice D).

→ Basic prevention (choice A) is not a level of disease prevention.
→ Indicated prevention (choice B) involves a screening process, and aims to identify individuals who exhibit early signs of substance abuse and other problem behaviors. Identifiers may include falling grades among students, known problem consumption or conduct disorders, alienation from parents, school, and positive peer groups, etc.
→ Secondary prevention (choice C) happens after an illness or serious risk factors have already been diagnosed. The goal is to halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury. (e.g., routine Papanicolaou smears, and screening for hypertension, diabetes, or hyperlipidemia).
→ Tertiary prevention (choice E) focuses on helping people manage complicated, long-term health problems such as diabetes, heart disease, cancer and chronic musculoskeletal pain. The goals include preventing further physical deterioration and maximizing quality of life (e.g., cardiac or stroke rehabilitation programs, chronic pain management programs, patient support groups).

Key point:
Selective prevention focuses on groups whose risk of developing problems of alcohol abuse or dependence is above average. The subgroups may be distinguished by characteristics such as age, gender, family history, or economic status. For example, drug campaigns in recreational settings.

The correct answer is b.
All users average of this question: 42%

Topic: Biostatistics Applications
Subject: PMCH
Type: Evaluation
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

When comparing two different groups, it is not enough to compare the means of the two groups, but there are other measures that must be examined. The 95% confidence interval is one such measure. This measure states that there is 95% certainty that the true mean value being measured is somewhere in that range. As such, when interpreting a confidence interval, it is important to understand that all of the values in the interval are equally likely to be the true mean. When the two confidence intervals overlap, one can conclude that there is no difference between the means, and therefore, there is no difference between the two groups. An important distinction to make is that the confidence interval involves the mean, and is not a measure of the range of values (i.e. a 95% confidence interval does not mean that it contains 95% of the measured values).

When analyzing the data, we can see that the 95% confidence interval for standard and experimental treatments overlaps for systolic blood pressure, but does not for diastolic blood pressure. Thus, the experimental drug does lower diastolic blood pressure to a greater extent than the standard treatment (choice B).

→ The experimental drug does not lower the systolic blood pressure to a greater extent than the standard treatment (choice A). The 95% confidence intervals for the standard and experimental drugs overlap. This means that there is no difference between the two groups with respect to the mean blood pressure.
→ The experimental drug has the same effect on both systolic and diastolic pressures as the standard treatment (choice C) is false, as explained above.
→ Both systolic and diastolic blood pressures are not lower with the experimental drug compared to the standard treatment (choice D). Diastolic blood pressure is lower in the experimental group but is not lower for systolic blood pressure, because of the overlapping confidence intervals.
→ The assertion that there is not enough information to make any conclusions about this study (choice E) is false. While it is always advisable to seek additional information, there is enough information given to tell that the experimental drug lowers diastolic blood pressure (but not systolic blood pressure) compared to the standard therapy.

Key point:
A 95% confidence interval has a 95% chance of containing the true mean value. If two confidence intervals overlap, it is the same as saying that there is no difference in the mean values. There is no statistical difference between groups that have overlapping confidence intervals.

The correct answer is a.
All users average of this question: 49%

Topic: Hba1c And Serum Glucose
Subject: PMCH
Type: Evaluation
Dimensions of Care: Acute care
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

The average blood sugar of month prior to measurement, August (choice A), probably contributed most to hemoglobin A1C (HbA1c) in this patient. The average life span of red blood cells is 120 days or four months. Of the circulating red cells in this patient at the time of measurement of HbA1c, very little is produced more than 120 days ago (April and earlier), a small proportion is produced between 90 and 120 days (May) ago, a slightly larger proportion is produced 60 and 90 (June) days ago and the largest proportion is produced within the 30 days or last month (August). It follows that glycated hemoglobin produced in the prior month contributes to about 50% of circulating HbA1c.

Key point:
Although hemoglobin A1C (HbA1c) continues to be produced over the entire lifespan of red cells, it is more reflective of changes in average blood glucose of the previous one or two months prior to measurement.

The correct answer is d.
All users average of this question: 52%

Topic: Parkinson's Disease
Subject: PMCH
Type: Diagnosis
Dimensions of Care: Chronic care
Physician Activities: Assessment and diagnosis
Difficulty: Average

Explanation:

Parkinson's disease (PD) is a chronic, progressive, neurodegenerative brain disorder that is a clinical diagnosis.

The prevalence of PD rises exponentially with age (choice D) after the age of 65.

→ PD affects males and females about equally or with a slight male predominance (choice A).
→ Onset in persons younger than 40 years is relatively uncommon (choice B). About 10% of patients have an onset of PD before the age of 40 - "young-onset" Parkinson's disease.
→ Approximately 0.3% of the general population and 3% of people over the age of 65 have idiopathic PD diagnosed clinically (choice C).
→ The average age of onset of PD is approximately 60 years (choice E).

Key point:
The prevalence of Parkinson's disease rises exponentially with age after the age of 65. The average age of onset is approximately 60 years.

The correct answer is c.
All users average of this question: 78%

Topic: Organ Transplantation
Subject: PMCH
Type: Evaluation
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Communication
Difficulty: Easy

Explanation:

The patient's husband is aged 59 and has had no health problems (choice C). He is blood type O, has read a lot about kidney donation on the Internet, and is keen to help. You would advise him to proceed.

→ The brother is aged 56 and is generally healthy, but he is blood type B (choice A), which is incompatible with the patient who is type O.
→ The daughter is aged 18 and wants to have a family one day. She appears relatively uncertain about undergoing surgery to donate a kidney (choice B). Women who may wish to become pregnant subsequent to donation are generally viewed as less desirable donors, given the stress pregnancy may place on the remaining kidney. Therefore, she would be a poor operative risk.
→ The patient's parents (choice D, choice E) are too old and frail.

Key point:
Group O is the universal donor but can only receive blood/transplant from group O donors.

The correct answer is b.
All users average of this question: 27%

Topic: Statistical Significance
Subject: PMCH
Type: Evaluation
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

Applicability of research results should not be judged solely on statistical significance of results. Significance testing is performed by a method called statistical inference in which investigators try to estimate a population parameter from a sample statistic (by induction). Studies start by setting the null hypothesis stating that the sample statistic is not different from the population parameter. By chance alone, however, the sample statistic might turn out to be different from the population parameter.

Therefore, evidence from relevant studies (choice B) should also be looked at before application of the results; results of a single study, irrespective of the quality of the study are usually not sufficient because chance variation could be the major factor responsible for the difference between the statistic and parameter. Indeed, if results are significant at p < 0.05, there is a chance of 5% that the observed results have arisen purely by chance. In addition to evidence from relevant studies, plausibility of the initial hypothesis should also be evaluated.

→ Confidence interval (choice A) is just another way of expressing statistical significance and is not needed for interpretation and applicability of research results.
→ Sample size (choice C) is not required for interpretation and applicability of research results. Sample size, however, influences the power of statistical tests (probability of rejecting a false null hypothesis). For instance, a small sample size is associated with a weak test in which there is a high probability of failure to detect a statistically significant difference when it really exists. After obtaining a statistically significant result, power of the test is irrelevant. Therefore, sample size is not needed for interpretation of research results.
→ Sampling error of the mean (choice D) is employed by the statistician or statistical software for calculation of the p-value associated with the result. Thus, sampling error of the mean is not needed for interpretation and applicability or research results.
→ As explained, statistical power of the test used (choice E) describes the likelihood of rejecting a false null hypothesis and should be considered before the study is conducted. Investigators rather than readers or consumers of research results are concerned with statistical power of the tests used.

Key point:

Statistical significance is not sufficient for proper interpretation and applicability of research results. Support from other studies and plausibility of initial hypothesis should also be taken in consideration.

The correct answer is d.
All users average of this question: 30%

Topic: Chance-corrected Proportional Agreement
Subject: PMCH
Type: Evaluation
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

The kappa statistic (Cohen's Kappa, Cohen's κ-coefficient) is often used to test data collectors' reliability, which represents the degree to which the data collected in the study are correct representations of the variables measured.

Kappa can be thought of as the chance-corrected proportional agreement, and possible values range from +1 (perfect agreement) via 0 (no agreement above that expected by chance) to -1 (complete disagreement).

Kappa = (Observed agreement - Chance agreement)/(1 - Chance agreement)

In this question, Kappa = (0.8 - 0.5) / (1 - 0.5) = 0.3/0.5 = 0.6 (choice D).

Key point:
The kappa statistic is often used to test data collectors' reliability. Kappa = (Observed agreement - Chance agreement)/(1 - Chance agreement).

Explanation:

The triad is ‘host, agent and environmental' factors (choice C).

→ Age (choice E) is a host factor.
→ Reservoir (choice A, choice D) and vector (choice B, choice D) are environmental factors.

Key point:
The classical “epidemiological triad” of disease causation consists of the host, agent and environmental factors.

DEBATABLE 

The correct answer is d.
All users average of this question: 38%

Topic: Life Expectancy
Subject: PMCH
Type: Evaluation
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Communication
Difficulty: Difficult

Explanation:

Life expectancy in Canada for both sexes combined has surpassed 80 years. Between 1979 and 2004, life expectancy among men rose 6.4 years, while among women, it increased by only 3.8 years.

Life expectancy rose in 2004 for both sexes, but the growth was stronger among men. For men, life expectancy increased by 0.4 years to 77.8 years, while for women, it went up by only 0.2 years to 82.6. The main contributing factor is that during the past 25 years, the infant mortality rate has declined by 52%.

Life expectancy is defined as the average number of years that a newborn could expect to live if he or she were subject to the age-specific mortality rates of a given period. An average national life expectancy is calculated based on age, race, gender, social status, and causes of death. In the past, a very simple model of age-specific mortality used the Gompertz function, but now more sophisticated methods are used. Life expectancy increases with age as the individual survives the higher mortality rates associated with childhood (choice D). In recent years with widespread of vaccination against the infectious diseases that used to kill young children (e.g., Hemophilus influenza vaccine), eradication of some diseases, and improved healthcare for others (e.g., better surgical care of some congenital heart diseases), have increased the average life expectancy. As risks of mortality for dying young in a national population decrease, life expectancy increases.

→ The trend toward lower fertility rates (choice A) is incorrect. While a high fertility rate is often associated with a rise in the rates of maternal and child mortality, low fertility rate without improved care for children who are born or people, in general, would not by itself improve life expectancy. Lower fertility is strongly associated with increased income per capita, which, indirectly, can contribute to increased life expectancy, but this is not the main reason of the significantly improved life expectancy over the last 40 years.
→ Improvements in cause-specific mortality rates (choice C), which leads to increased average age of the population (choice B) and decreased death rates at older ages (choice E) can indeed contribute to national life expectancy, but considering changes over the last 40 years, this contribution is minimal and is not the main reason of increased life expectancy. This has largely been affected by drastic falls in child mortality as improved healthcare provision saved lives of children who could have died at a young age.

Key point:
Life expectancy is defined as the average number of years that a newborn could expect to live if he or she were subject to the age-specific mortality rates of a given period. Life expectancy increases with age as the individual survives the higher mortality rates associated with childhood.

DEBATABLE 

The correct answer is b.
All users average of this question: 54%

Topic: Suicide, Aboriginal population
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Management
Difficulty: Average

Explanation:

Suicide is a preventable cause of death that disproportionately affects Indigenous peoples. Suicide attempts must be treated seriously. Understanding the risks and management of suicide will help in the prevention of future suicide attempts.

Primary prevention is aimed at decreasing the risk of suicide in the general population. Secondary prevention is aimed at decreasing the risk of suicide in high-risk individuals. Telephone crisis lines (choice B) are an example of secondary prevention, as they intervene with people at high risk of attempting suicide.

→ School programs that promote problem-solving (choice A) and mental health training for "gatekeepers" (those who regularly interact with youths) (choice D) are examples of effective primary prevention.
→ The portrayal of suicide by the media can either contribute to suicide clusters (if suicide is highly publicized and romanticized), or can act as a primary prevention tool by focusing on alternatives to suicide (choice C).
→ Restricting available means of suicide is another example of primary prevention, but the effect of restricting alcohol (choice E) has not reliably been shown to decrease suicide.

Key point:
Secondary prevention is aimed at decreasing the risk of suicide in high-risk individuals. Telephone crisis lines are an example of secondary prevention, as they intervene with people at high risk of attempting suicide.

DEBATABLE 

The correct answer is a.
All users average of this question: 47%

Topic: Medical Ethics - Informed Consent
Subject: PMCH
Type: Treatment
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Communication
Difficulty: Difficult

Explanation:

This patient is scheduled to undergo a surgical operation, and informed consent should be obtained. Informed consent forms the basis of the relationship between the patient and the surgeon. It ensures the patient's autonomy and independence. It is defined as a voluntary, uncoerced decision made by a sufficiently competent autonomous person on the basis of adequate information and deliberation to accept some proposed course of action that will affect him or her. It has been suggested to call this rather informed choice because patients may choose to refuse the proposed treatment.

Informed consent in surgery should include five elements:
• Explanation of the nature of the procedure
• Reasonable alternatives to the proposed intervention
• The relevant risks, benefits, and uncertainties related to each alternative
• Assessment of the patient's understanding
• The acceptance of the intervention by the patient

It is generally believed that the attending surgeon should obtain informed consent and, if possible, do so in the presence of the resident who will assist in surgery. It should be stated to the patient that the resident will play a role in surgery (choice A). Forms usually state that the surgeon will perform the operation "with such assistants as the attending surgeon shall select."

→ You should inform the patient the specific role the resident will play in surgery (choice B) is incorrect. Surveys have found less than a third of patients would consent if the exact role of a resident were volunteered before surgery. This could be counterproductive in a teaching hospital. It has been deemed sufficient to inform the patients that the resident will assist the attending surgeon. The information about the specific role of the resident should be saved for the questions and answers time after the procedure, and alternatives have been described if the patient insists on knowing the specific role the resident will play.
→ You should inform the patient that you will be in charge of the operation (choice C) is incorrect. This is considered insufficient in obtaining informed consent. If assistants, such as residents, will participate, it should be mentioned to the patient while obtaining informed consent.
→ You should tell the patient that this is a teaching hospital and trainees must be involved (choice D) is incorrect. While teaching hospitals have duties to teach the next generation of physicians, patients still retain their autonomy, and informed consent should be obtained appropriately.
→ You are not obligated to inform the patient about the resident's role in surgery as it is a teaching hospital (choice E) is incorrect, as explained above.

Key point:
It is generally believed that the attending surgeon should obtain informed consent and, if possible, do so in the presence of the resident who will assist in surgery. It should be stated to the patient that the resident will play a role in surgery.

Consent & Decision Making

https://www.youtube.com/watch?v=K85jyLlIUjA&t=1s

DEBATABLE 

The correct answer is a.
All users average of this question: 38%

Topic: Teenager Pregnancy
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

This patient is considered a teen mother. This term is given to females who had a teen pregnancy and delivered their children before the 20th birthday. Over the last 20 years, there has been a trend of decreasing teen pregnancy rates despite earlier initiation of sexual intercourse among teens. This decline is attributed to a number of factors; the most important factor is the use of contraceptive methods. Statistics continue to show that with the increase in the percentage of teenagers that have used contraceptive methods, pregnancies have fallen proportionally.

Several factors affect teen pregnancy. Some of them are considered easily modifiable, some are difficult to modify, while others, in fact, cannot be changed at all. The acclaimed work of Douglas Kirby on teen pregnancy research has divided these risk factors that influence teen pregnancy in 4 levels. At the individual level, there are genetic traits, personality, attitudes, and behaviour. The microsystem level includes people the teenager interacts with, such as peers and parents. The exosystem level I includes institutions that indirectly influence the individual, such as neighbourhood and communities. Finally, the macrosystem includes things that are considered cultural norms and laws.

Factors at the individual level are considered the easiest to modify. Behaviours such as age at sexual debut, frequency of sex, and contraceptives use are easily modifiable. Attitudes and beliefs, such as pregnancy intentions and low prevention, are other factors that can be changed easily. Finally, antisocial development also at the individual level can be modified to reduce the risks; these are negative views about prosocial institutions, low academic performance, and low expectations for the future (choice A).

→ Low parental educational attainment (choice B) is one of the microsystem factors that influence teen pregnancy. This is also more difficult to modify than individual factors.
→ Neighbourhood and community characteristics (choice C) belongs to an exosystem level factor and is not easy to modify.
→ Socioeconomic status of the teenager (choice D) is one of the factors that influence teen pregnancy. Poverty is associated with a higher teen pregnancy rate. While this is modifiable, it takes many years and would not be considered easy enough to lead to quick change.
→ Substance use prior to sexual activity (choice E) should be seen as one of the risky behaviours of teenagers just as sexual activity, so even if it is a factor that influences teen pregnancy, it is a secondary factor, which in itself has an underlying factor. Low expectation for the future is a factor that could influence both substance use and risky sexual activity in teenagers.

Key point:
Regarding teen pregnancy prevention programs, factors at the individual level are considered the easiest to modify, such as behaviours (i.e., frequency of sex, and contraceptives use), attitudes and beliefs (i.e., pregnancy intentions), and antisocial development (i.e., negative views about prosocial institutions, low academic performance, low expectations for the future).

The correct answer is d.
All users average of this question: 32%

Topic: Hospital Complications
Subject: PMCH
Type: Treatment
Dimensions of Care: Chronic care
Physician Activities: Management
Difficulty: Difficult

Explanation:

An adverse event has been defined as an unintended injury or complication that results in disability at the time of discharge, death, or prolonged hospital stay, and that is caused by healthcare management rather than by the patient's underlying disease process. The three most common adverse events to occur are surgery, medication, and infection.

Canadian national study of adverse event by Ross Baker and Peter Norton revealed that surgery-related problems (choice D) are the most common type of adverse event, and for hospitalized patients the rate of these events increases with the patient's age. Surgery-related events are followed by drug-related and fluid-related adverse events.

→ Fluid related events (choice A) and Drug-related events (choice C) are less common adverse events than surgery.
→ Wound infections (choice B) come after drug-related and fluid-related events in terms of rate of occurence.
→ Alcohol withdrawal and delirium tremens (choice E) occur in many patients admitted in hospitals, but these usually are not due to error of health professionals.

Key point:
The three most common adverse events to complicate hospital course of patients age 65 and over, include surgery, medication, and infection.

The correct answer is d.
All users average of this question: 32%

Topic: Osteoporosis
Subject: PMCH
Type: Evaluation
Dimensions of Care: Chronic care
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

2023 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada (see image below).

According to the above guidelines, screening BMD is recommended in all postmenopausal women and men who are 50-64 years old with a previous fracture (choice D) or two or more risk factors for osteoporosis and fractures; 65-69 years old with one risk factor and > 70 years old without risk factors. A previous fracture denotes more accurately a previous fracture in adult life occurring spontaneously, or a fracture arising from trauma which, in a healthy individual, would not have resulted in a fracture.

→ Fall in the past 12 months (choice A) is incorrect. BMD should be considered in all women who are 50-64 years old with a previous fracture or two or more risk factors for osteoporosis and fractures. Two or more falls in the past year is a risk factor.
→ Heavy alcohol use (choice B), Parent with fractured hip (choice C) and Smoking (choice E) are incorrect. Alcohol use of three or more drinks per day or Parent with fractured hip or Smoking is a risk factor, but solely, it is not an indication for BMD.

Key point:
According to 2023 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada, screening BMD is recommended in all postmenopausal women and men who are 50-64 years old with a previous fracture or two or more risk factors for osteoporosis and fractures; 65-69 years old with one risk factor and > 70 years old without risk factors.

https://www.youtube.com/watch?v=AenUs3cOkhk

The correct answer is a.
All users average of this question: 29%

Topic: Prescribing Controlled Substances
Subject: PMCH
Type: History and Physical Exam
Dimensions of Care: Chronic care
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

While opioids are beneficial to manage pain in patients, there is always a concern for dependence and adverse events associated with the use of these medications. In recent years, there have been as many deaths from narcotic drugs use as there were car accident-related deaths and for every opioid-related death, there are 130 opioid dependence cases, and 825 non-medical users. Despite this risk, it is widely accepted that treating severe pain with opioids is humane treatment of patients when indicated. Physicians often require patients to sign agreements to use opioids for pain management to ensure there is no abuse or diversion of use of these medications.

When considering long-term use of opioids for chronic pain, given the potential risks of opioid analgesics, careful and thorough patient assessment is critical. Risk stratification is one of the most important things a physician should do to prescribe these medications responsibly and mitigate potentially adverse consequences of prescribing opioids. The opioid risk tool is widely recognized as a useful scoring system to alert a physician to a patient at high risk of drug abuse. Personal history of prescription abuse is by far the greatest indicator of potential future drug abuse and is given 5 points on the opioid risk tool. Use of illegal drugs has 4 points while alcohol abuse has 3 points. Another aspect of personal history with 3 points is a history of preadolescent sexual abuse for females (choice A). For males, this is not considered a significant risk factor.

→ A male who was sexually molested at the age 9 (choice B) is given 0 points on the risk stratification of opioid risk tool.
→ A male with a history of attention deficit hyperactivity disorder (choice C) is given 2 points on the risk stratification of opioid risk tool.
→ A female with a history of major depressive disorder (choice D) is given 1 point on the risk stratification of opioid risk tool.
→ A 25-year-old male with chronic back pain (choice E) counts as 1 point, similarly to all people aged between 16 and 45 without any other risk factor.

Key point:
The opioid risk tool is widely recognized as a useful scoring system to alert a physician to a patient at high risk of drug abuse. Personal history of prescription abuse is by far the greatest indicator of potential future drug abuse and is given 5 points on the opioid risk tool. Use of illegal drugs has 4 points while alcohol abuse has 3 points. Another aspect of personal history with 3 points is a history of preadolescent sexual abuse for females. For males, this is not considered a significant risk factor.

The correct answer is c.
All users average of this question: 32%

Topic: Medical Ethics - Patient Confidentiality
Subject: PMCH
Type: Prevention
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Management
Difficulty: Difficult

Explanation:

This patient has breast cancer and believes she has been harmed by healthcare providers and is now seeking legal assistance. The interaction between law and medicine permeates almost all aspects of a physician's practice and, of course, goes far beyond events or issues that might give rise to litigation. It is generally believed that better risk management can reduce or even prevent many malpractice lawsuits. If patients are noncompliant or leave the hospital against medical advice, for example, it should be properly documented because they are at risk of serious complications and even death. This is especially important if the patient is re-admitted with those complications because the prognosis might have changed by the initial refusal to be properly treated.

While a patient's lawyer letter can be taken as an announcement that legal action is about to be taken against a physician, if the letter requests only medical records, it should be provided to the lawyer after appropriate fees for copies have been paid (choice C). At this point, a physician is not obligated to write a narrative letter. This is the time a properly written chart can be truly valuable. If changes need to be made in the chart, it is generally advised to sign and date when the changes are made. Physicians could have easy cases hurt by panicking and making changes to charts without dating the changes, and those changes, if discovered later, could be misinterpreted.

→ Contact the College of Physicians and Surgeons of your province (choice A) is incorrect. While the College of Physicians and Surgeons has an advisory council that can be contacted by physicians facing problems, if a lawyer requests medical records and the patient has consented to release the information, it is appropriate to give the information.
→ Making copies of the relevant chart and sending them to the lawyer (choice B) should be done but compared to choice C, which adds charging a fee for service, it is 'less correct'. The attorney should be notified what copy charges are, and if copies of imaging such as X-rays are requested, appropriate fees should be charged.
→ Invite the lawyer to the office to review the original chart (choice D) is incorrect. Original chart or X-rays should not be sent to the attorney, and it is not necessary for the attorney to review the original. Copies are sufficient.
→ Contact the Canadian Medical Protective Association (choice E) is incorrect. At this point, it may be too early to contact the Canadian Medical Protective Association if all the patient's lawyer is asking is reviewing medical records. If a demand letter is sent to a physician or the patient's lawyer clarifies the intent to sue, then it would be important for the physician to contact the Canadian Medical Protective Association.

Key point:
While a patient's lawyer letter can be taken as an announcement that legal action is about to be taken against a physician, if the letter requests only medical records, then it should be provided to the lawyer after appropriate fees for copies have been paid.

The correct answer is b.
All users average of this question: 40%

Topic: Huntington Disease
Subject: PMCH
Type: Evaluation
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Difficult

Explanation:

In the above pedigree, red represents Huntington disease (HD) and blue represents normal. The man's father died at age 35 and he is represented by the square with a cross. Since the age of onset of HD is usually after 35, we do not know if the father had the disease or not. The man himself is indicated by the question mark. The pedigree is labelled with the corresponding alleles.

HD is autosomal dominant, needing only one affected allele from either parent to inherit the disease. This generally means there is a one in two chance of inheriting the disorder from an affected parent.

The man's father will get one copy of the recessive allele ‘a' from his father, while his second allele has a 50% probability of being dominant "A" and a 50% probability of being a recessive ‘a'.
The man will get one recessive ‘a' allele from his mother and the other allele depends on his father's genotype. The tables below illustrate the possible genotypes in the man:

Of the 8 possible outcomes, the man will be affected only 2 times. Therefore the probability is 25% of him developing HD (choice B).

Key point:
Huntington disease is autosomal dominant, needing only one affected allele from either parent to inherit the disease. This generally means there is a one in two chance of inheriting the disorder from an affected parent.

The correct answer is a.
All users average of this question: 40%

Topic: Immunization
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Management
Difficulty: Difficult

Explanation:

The rotavirus (RV) vaccine is an oral vaccine recommended for infants in a 3-dose schedule at ages 2, 4, and 6 months (OR in 2 doses at 2 and 4 months of age). The first dose should be given between 6 and 15 weeks of age (choice A), with additional doses given at 4- to 10-week intervals.

→ The vaccine should be given at 2 months, 6 months, and 12 months of age (choice B) is incorrect, as explained above. It should be at ages 2, 4, and 6 months.
→ A catch-up vaccination can be administered up to 3 years of age (choice C) is incorrect. The vaccine cannot be initiated after 14 weeks of age and should not be administered after 32 weeks of age
→ The minimum time between doses is 2 weeks (choice D) is incorrect. The first dose should be given between 6 and 15 weeks of age, with additional doses given at 4- to 10-week intervals.
→ Prematurity is a contraindication for its administration (choice E) is incorrect. Premature infants are at higher risk for severe rotavirus infection. The NACI recommends RV vaccine in preterm infants who are clinically stable, following the same schedule as for term infants.

Key point:
Rotavirus vaccines are given orally and can be started at six weeks of age, in a 3-dose schedule at ages 2, 4, and 6 months or in 2 doses at 2 and 4 months of age.

The correct answer is b.
All users average of this question: 66%

Topic: Botulism
Subject: PMCH
Type: Diagnosis
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Average

Explanation:

Botulism is neuromuscular poisoning from Clostridium botulinum toxin. Symptoms are weakness and paralysis. Diagnosis is clinical and with laboratory identification of toxin. Treatment is with support and antitoxin.

Home-canned foods are the most common sources (choice B). Commercially prepared foods have been implicated in about 10% of outbreaks. Vegetables, fish, fruits, and condiments are the most common vehicles, but beef, milk products, pork, poultry, and other foods have been involved.

C. botulinum spores are highly heat-resistant and may survive boiling for several hours at 100°C. However, exposure to moist heat at 120°C for 30 min kills the spores. Toxins, on the other hand, are readily destroyed by heat and cooking food at 80°C for 30 min safeguards against botulism.

Key point:
Botulism is neuromuscular poisoning from Clostridium botulinum toxin. Home-canned foods are the most common sources.

https://www.youtube.com/watch?v=OX97penRbWc&t=1s

Botulism

The correct answer is e.
All users average of this question: 72%

Topic: Public Policy
Subject: PMCH
Type: Diagnosis
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Communication
Difficulty: Easy

Explanation:

Public policy can be broken down into 3 main categories: Fiscal, Legislative and Social policy. Fiscal policy (choice E) can be adopted to impose additional costs for undertaking unhealthy behaviors in hopes of creating an economic deterrent.

→ Creating an anti-smoking bylaw (choice A) and Mandating the use of bicycle helmets (choice D) are examples of Legislative policies, in which, legal deterrents are put in place to reduce certain risky behaviors.
→ Ensuring adequate income of citizenry (choice B)  and Providing affordable housing to citizenry (choice C) are examples of Social policies in which a system is put in place to create an environment of reasonable and equitable opportunity in hopes of supporting individuals across all socioeconomic statuses.

Key point:
Fiscal policy imposes an additional cost burden to unhealthy behaviors.

The correct answer is c.
All users average of this question: 58%

Topic: Prostate Cancer
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Average

Explanation:

Prostate cancer is the most commonly diagnosed non-skin cancer in men and the third leading cause of cancer-related death among men in Canada. A Prostate Specific Antigen (PSA) determination is recommended for any man, with a life expectancy of ten years or more, found to have: a prostatic nodule on DRE, an abnormal-feeling prostate, focal lesion, discrete change either in texture, fullness or symmetry which provokes increased suspicion of prostate cancer, and when investigating a secondary carcinoma of unknown origin.

The use of a PSA test is also recommended for men with moderate or severe symptoms of prostatism in whom treatment is contemplated. Severe and moderate symptoms are defined according to the International Prostatic Symptom Score.

When the PSA is below the laboratory's diagnostic cutoff (e.g. 4.0 µg/L or an age-adjusted value), and the DRE is negative, no further action is usually taken, other than possible periodic repeat testing (e.g. every two years) (choice C).

→ CTFPHC Guidelines 2014 recommend not screening for prostate cancer with the prostate-specific antigen test (for all three age groups: under 55, 55-69, and over 70) (choice A).
→ A serum PSA determination may be considered for any man over the age of 40 years with a life expectancy of 10 years or more, who has a higher risk of prostate cancer (choice B). Within the context of higher risk is included a family history (first degree relative) of prostate cancer or men of African ancestry.
→ Prostate-specific antigen (PSA) is more sensitive for prostate cancer detection than the digital rectal examination (choice D).
→ Utilizing PSA velocity and doubling time has not been shown to improve health outcomes (choice E).

Key point:
Prostate Specific Antigen (PSA) determination is recommended for any man, with a life expectancy of ten years or more, found to have: a prostatic nodule on DRE, an abnormal-feeling prostate, focal lesion, discrete change either in texture, fullness or symmetry which provokes increased suspicion of prostate cancer, and when investigating a secondary carcinoma of unknown origin. When the PSA is below the laboratory's diagnostic cutoff (e.g. 4.0 µg/L or an age-adjusted value), and the DRE is negative, no further action is usually taken.
https://www.youtube.com/watch?v=GfU-Kbj1oPw&t=1s

The correct answer is b.
All users average of this question: 70%

Topic: Suicide, Aboriginal population
Subject: PMCH
Type: Treatment
Dimensions of Care: Acute care
Physician Activities: Management
Difficulty: Easy

Explanation:

Suicide is a preventable cause of death that disproportionately affects Indigenous peoples. Suicide attempts must be treated seriously. Understanding the risks and management of suicide will help in the prevention of future suicide attempts.

Selective serotonin reuptake inhibitors (SSRIs) are the first line of treatment for depression, but if they can be combined with cognitive behavioural therapy, they are more effective (choice B).

→ Electroconvulsive therapy (ECT) (choice A) is used in medication-resistant depression or for those in need of a rapid response due to acute risk of suicide. This patient has not failed two antidepressant medications with appropriate dosing and compliance and is not acutely suicidal, so he is not an appropriate candidate for ECT.
→ Monoamine oxidase inhibitors like phenelzine (choice C) are not first-line drugs. They are used if SSRIs do not alleviate symptoms of depression.
→ Dialectical behavioural therapy (choice D) is superior in reducing suicide in patients with borderline personality disorder.
→ A recent study on combining medications in depression showed that the combination of Venlafaxine and Mirtazapine (choice E) might increase suicidal ideation.

Key point:
Selective serotonin reuptake inhibitors are the first line of treatment for depression, but if they can be combined with cognitive behavioural therapy, they are more effective.

The correct answer is b.
All users average of this question: 60%

Topic: Breast Cancer
Subject: PMCH
Type: Evaluation
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Average

Explanation:

This patient is asymptomatic, and her past medical history is non-remarkable, making the focus of management preventive in nature. Her family history raises concerns about a possible hereditary breast cancer susceptibility gene. She should receive genetic counselling and be tested for BRCA1 and 2 gene mutation (choice B) because while the average woman in the general population has an 11% lifetime risk of developing breast cancer, a patient who is BRCA1 carrier has an estimated risk of 65% by age 70.

→ Patient should be reassured that her risk remains low (choice A) is incorrect. Simply reassuring the patient at this point would be inappropriate.
→ Patient should be scheduled for immediate mammography (choice C) or Mammography at age 40 (choice D) are incorrect. While mammography is a useful routine test in the general population, women who are > 35 years old with family members diagnosed with breast cancer should receive genetic counselling and test for BRCA1 and BRCA2.
→ Patient should undergo linkage analysis (choice E) is incorrect. While linkage analysis should be considered in families with more than one affected family member from different generations, her grandmother is not available for testing as she has already died. The preferred genetic test for BRCA mutations is the protein truncation test.

Key point:
When a patient's history raises concerns about a possible hereditary breast cancer susceptibility gene, he/she should receive genetic counselling and be tested for BRCA1 and 2 gene mutations. A patient who is BRCA1 carrier has an estimated risk of 65% of developing breast cancer by age 70, compared to the average woman in the general population with an 11% lifetime risk.

The correct answer is a.
All users average of this question: 36%

Topic: Medical Ethics - Conscientious Objection
Subject: PMCH
Type: Evaluation
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Professional behaviours
Difficulty: Difficult

Explanation:

Conscientious objection laws give health care professionals the legal right to refuse, on the basis of personal beliefs, to perform specific procedures or provide care for certain patients. Physicians may refuse to provide treatment but must ensure the patients can access services elsewhere by referring the patient to a willing practitioner.

According to the CMA, certain legitimate reasons to refuse care to a patient may include:
• personal values of a physician can influence the care and treatment of the patient (e.g. such as this case, a physician is personally strongly against vaccine-refusal).
• care is no longer necessary and the physician has advised the patient within a reasonable time delay before the end of treatment.

→ A DNR patient (choice B) is incorrect. It would be unethical to refuse to provide end-of-life care according to the patient's wishes.
→ A Jehova's witness who refuses blood transfusion (choice C) is incorrect. It is illegal for a physician to refuse services based on religion. The patient's autonomy must be respected.
→ A patient who asks for a referral for sex reassignment surgery (choice D) is incorrect. It is illegal for a physician to refuse services based on gender or sexual orientation. The patient's autonomy must be respected.
→ A patient who is Asian and does not speak English well (choice e) is incorrect. It is illegal for a physician to refuse services based on race or ethnicity.

Key point:
Physicians may refuse to provide treatment on the basis of conscientious objection law but must provide appropriate assistance (e.g., referral) and ensure the patients can access services elsewhere.

The correct answer is c.
All users average of this question: 49%

Topic: Medical Ethics - Informed Consent
Subject: PMCH
Type: Treatment
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Communication
Difficulty: Difficult

Explanation:

This patient is scheduled to undergo a surgical operation, and informed consent should be obtained. Informed consent forms the basis of the relationship between the patient and the surgeon. It ensures the patient's autonomy and independence. It is defined as a voluntary, uncoerced decision made by a sufficiently competent autonomous person on the basis of adequate information and deliberation to accept some proposed course of action that will affect him or her. It has been suggested to call this rather informed choice, because patients may choose to refuse the proposed treatment.

Informed consent in surgery should include five elements:
• Explanation of the nature of the procedure
• Reasonable alternatives to the proposed intervention
• The relevant risks, benefits, and uncertainties related to each alternative
• Assessment of the patient's understanding
• The acceptance of the intervention by the patient

If a patient specifically requests that a certain action during the operation be performed by the attending surgeon, unless there is an emergency or another good cause, that action has to be done by the attending surgeon. Failure to do so is considered to be in contravention of the patient's request and makes void of the informed consent (choice C).

→ The resident is not liable if she was not aware of the specific request of the patient (choice A) is incorrect. Unfortunately, this resident could be sued along with the attending surgeon.
→ No one is liable since this is a risk that was probably discussed with the patient (choice B) is incorrect. If the risk was indeed discussed with the patient and standard care was given, there may not be negligence of duty case (choice D is therefore also incorrect), but still, the attending surgeon is liable for not obtaining consent.
→ Since this is a teaching hospital, the surgeon did what was appropriate in this case (choice E) is incorrect. Informed consent was not obtained; therefore, this was inappropriate.

Key point:
If a patient specifically requests that a certain action during the operation be performed by the attending surgeon, unless there is an emergency or another good cause, that action has to be done by the attending surgeon. Failure to do so is considered to be in contravention of the patient's request and makes void of the informed consent.

https://www.youtube.com/watch?v=K85jyLlIUjA

The correct answer is a.
All users average of this question: 34%

Topic: Blood Transfusion in Jehovah's Witnesses
Subject: PMCH
Type: Evaluation
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Management
Difficulty: Difficult

Explanation:

The main ethical dilemma in the management of Jehovah's Witness patients lies in a conflict between beneficence and autonomy, where, in Canadian law, autonomy is generally given precedence over beneficence.

Legal minors usually fall under the provisions of provincial regulations that often require involving the hospital's legal and risk management services. Therefore, it would be appropriate to initiate legal proceedings via the hospital administrator to allow the transfusion (choice A).

→ Proceeding with transfusion (choice B) would be inappropriate and illegal.
→ Referring to the ethics committee (choice C) would be an inappropriate action at this time. In this situation, the guidelines are clear, and the hospital's legal team needs to be involved.
→ Transferring to another hospital (choice D) would also be inappropriate and time-consuming. The patient is under your care, and unless the parents demand the transfer, you have a legal duty to provide care to your patient.
→ Withholding the transfusion (choice E) would be the correct answer if the patient were an adult. Patients have the right to refuse to provide consent for the clinically necessary blood transfusion based on religious beliefs. In the eyes of the law, minors are treated differently than adults.

Key point:
In case of need for blood transfusion for a child whose parents refuse the treatment based on religious beliefs, it would be appropriate to initiate legal proceedings and ask the court to allow the transfusion.

The correct answer is a.
All users average of this question: 43%

Topic: Medical Ethics - Physician-Patient Relationship
Subject: PMCH
Type: Evaluation
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Communication
Difficulty: Difficult

Explanation:

Providing quality health care to individuals from diverse sociocultural backgrounds requires effective communication. Low health literacy makes communication more difficult. When a language barrier exists, it is better to have a professional interpreter than a family member (choice A), and children should be used as interpreters only in cases of emergency when no other source is available.

→ The typical approach to medical care assumes that patients want to make their own decisions (choice C) based on guidance from their health care providers (choice B). However, there are cultures in which patient autonomy is not the norm. There may be a specific authority figure in the family that is regarded as the decision maker.
→ Effective communication also involves knowledge of communication styles within various cultures. Nonverbal communication can be through touch, eye contact (choice D), and personal space. For example, there are cultures in which direct eye contact is avoided, but in other cultures, it is considered a sign of respect.
→ Speaking clearly and slowly (choice E), louder but without yelling and enunciating complex words carefully, but using simple language as much as possible will improve the communication and make the patients feel like the valued partners in their own care that they are.

Key point:
When a language barrier exists, it is better to have a professional interpreter than a family member, except for cases of emergency when no other source is available.

The correct answer is b.
All users average of this question: 72%

Topic: Disease Distribution
Subject: PMCH
Type: Evaluation
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Communication
Difficulty: Easy

Explanation:

An epidemic disease (choice B) is a disease that many people acquire over a short period occurring suddenly in numbers clearly in excess of normal expectancy.

→ Hyperendemic disease (choice A) - a disease that is constantly present at a high incidence and/or prevalence rate and affects all age groups equally.
→ An endemic disease (choice C) is one that is always present in a population and is occurring at the usual expected rate.
→ Enzootic disease (choice D) - prevalent among or restricted to animals of a specific geographic area.
→ A pandemic disease (choice E) is a worldwide epidemic disease.

Key point:
An epidemic disease is a disease that many people acquire over a short period occurring suddenly in numbers clearly in excess of normal expectancy.

The correct answer is d.
All users average of this question: 39%

Topic: Pertussis
Subject: PMCH
Type: Treatment
Dimensions of Care: Acute care
Physician Activities: Management
Difficulty: Difficult

Explanation:

Pertussis is one of the diseases that can be prevented by vaccination but it still exists both in sporadic and epidemic forms. The main sources of infection are people with subclinical infection or those who are not diagnosed because the disease is mild. In Canada, between 1000 and 3000 people contract pertussis each year.

The major rationale of antibiotic treatment of pertussis is to limit spread of infection to susceptible contacts i.e. to decrease the secondary attack rate (choice D) of pertussis. Secondary attack rate is defined as the proportion of susceptible contacts that develop the disease. Pertussis is highly contagious with secondary attack rate of 80% and antibiotic treatment has been shown to reduce this high secondary attack rate. Also, because of this high secondary attack rate, all household contacts of the patient should be given antibiotic treatment. The macrolides azithromycin, erythromycin and clarithromycin as well as trimethoprim/sulfamethoxazole are the drugs of choice.

→ Antibiotic treatment has not been shown to significantly shorten the duration of paroxysm (choice A), or decrease duration of the disease (choice E). No treatment has been shown to reduce the number of paroxysm but patients with severe paroxysms should be admitted to hospital and closely observed and assisted during paroxysms.
→ Pertussis has no chronic carrier state and thus minimizing likelihood of chronic carrier state (choice B) is not a rationale for antibiotic treatment.
→ Antibiotic treatment has not been shown to decrease the number of paroxysm (choice C) in pertussis. Number of paroxysms may be reduced by removing the patient from environment polluted by irritants. Number of paroxysm may also be reduced by avoiding environment with excessively light, sound or sources of thermal irritation.

Key point:

Once the diagnosis of pertussis is confirmed or suspected antibiotic treatment should be immediately initiated. Antibiotic treatment may not benefit the patient but it will limit spread of the infection to close contacts.

The correct answer is b.
All users average of this question: 52%

Topic: Medical Ethics - Principle of Double Effect
Subject: PMCH
Type: Diagnosis
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Professional behaviours
Difficulty: Difficult

Explanation:

The bioethical principle of double effect (PDE) (choice B) is important to patients and to the clinicians who care for these individuals. The doctrine holds that, in the context of actions that have both good and bad effects, an action that has a bad effect is morally permissible if (a) the action itself is good, (b) its perpetrator's intention is solely to produce the good effect, (c) the good effect is not achieved through the bad, and (d) there is sufficient reason to permit the bad effect.

Therefore, in this particular example, the physician does not intend to cause the death of the fetus, although it is expected. The key element of PDE is that the intentions of the actor are only good, even if a bad effect is anticipated.

→ Distributive justice (choice A) relates to the allocation of resources.
→ Death with dignity (choice C) is a recently introduced concept and is not a factor in the scenario described here.
→ Futility (choice D) refers to using a treatment for which there is no rational justification.
→ Autonomy (choice E) refers to the patient's ability to direct his or her own care, which is not an issue in this case.

Key point:
The bioethical principle of double effect holds that, in the context of actions that have both good and bad effects, an action that has a bad effect is morally permissible if (a) the action itself is good, (b) its perpetrator's intention is solely to produce the good effect, (c) the good effect is not achieved through the bad, and (d) there is sufficient reason to permit the bad effect.

The correct answer is b.
All users average of this question: 44%

Topic: Cancer
Subject: PMCH
Type: History and Physical Exam
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Communication
Difficulty: Difficult

Explanation:

In 2017, an estimated:
- 28,600 Canadians were diagnosed with lung cancer. This represents 14% of all new cancer cases in 2017.
- 21,100 Canadians died from lung cancer. This represents 26% of all cancer deaths in 2017.
- 14,400 men were diagnosed with lung cancer and 11,100 died from it.
- 14,200 women were diagnosed with lung cancer and 10,000 died from it.
- On average, 78 Canadians were diagnosed with lung cancer every day.
- On average, 58 Canadians died from lung cancer every day.
(Canadian Cancer Statistics)

While still elevated, the incidence rate seems to be levelling off in women. In men, the incidence has been decreasing. The death rate for both men and women is decreasing. However, men continue to have a higher rate of lung cancer death than women. (choice B).

→ Lung cancer death rates continue to climb among women while decreasing among men (choice A) is an incorrect statement. As explained above, the death rate for both men and women is decreasing.
→ Lung cancer death rates continue to increase in both men and women (choice C) is an incorrect statement, as explained above.
→ In men, the incidence of lung cancer has been increasing (choice D) is incorrect. In fact, it has been decreasing.
→ In women, the incidence of lung cancer is low (choice E) is incorrect. The incidence is still high.

Key point:
The death rate from lung cancer for both men and women is decreasing. However, men continue to have a higher rate of lung cancer death than women.

The correct answer is e.
All users average of this question: 50%

Topic: Treating Minors
Subject: PMCH
Type: Treatment
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Communication
Difficulty: Difficult

Explanation:

Whether a child is competent to provide consent is decided on a case-by-case basis. When a child is determined incapable of consenting to treatment, the parents/legal guardians have the legal responsibility to consent to the medical care and necessary procedures they consider to be in the child's best interest. However, if a physician decides that the child has the mental capacity to provide consent, parental consent is not needed. In these cases, the physician should obtain consent from the child, even when he/she is accompanied by a parent or legal guardian.

If a patient is under 19 years old, he/she can normally get medical treatment without parents' or guardian's knowledge or consent for things like birth control, abortion, mental health problems, sexually transmitted diseases, and alcohol and drug addiction problems.

The procedure requested by the mother is not medically necessary to treat her daughter, and given the daughter's refusal to assent, her wishes should be respected. It is most appropriate to advise what will encourage the adolescent to keep trusting the physician and foster a good relationship with her mother. It would be appropriate for them to gain a better understanding of the situation before proceeding. Therefore, advising them to discuss further the issue and come back in a week (choice E) would be the best next step.
An answer option stating "determine the patient's competence" would be the correct answer, if it were offered.

→ Do what the mother requests because the patient is a minor (choice A) is incorrect. The procedure requested by the mother is not medically necessary, and it would be appropriate to discuss the issue further to gain a better understanding of the situation.
→ Do not remove the ring because the girl has not consented to the procedure (choice B) is incorrect. A physician should first determine whether or not a child has the capacity to consent.
→ Advise them that you will request a court hearing on the matter before you proceed (choice C) could be an option to consider if they have discussed and have not been able to reach an agreeable understanding.
→ Explain to the daughter that she is a minor and her mother should make all medical decisions for her (choice D) is incorrect. The daughter's opinions should be heard and wishes taken seriously. It would be appropriate to encourage them to seek a better understanding of the situation before proceeding since the procedure is not medically necessary.

Key point:
Only patients who have appropriate decisional capacity and legal empowerment can give their informed consent to medical care. When a child is determined incapable of consenting to treatment, the parents/legal guardians have the legal responsibility to consent to the medical care and necessary procedures they consider to be in the child's best interest.

The correct answer is b.
All users average of this question: 43%

Topic: Physician and Clinical Research
Subject: PMCH
Type: Evaluation
Dimensions of Care: Psychosocial aspects of care
Physician Activities: Communication
Difficulty: Difficult

Explanation:

Physicians have a moral duty to support human research in order to assist in maintaining evidence-based practice and the advancement of the care of their patients. They may participate in this duty in a number of ways, including serving on research ethics boards, designing and conducting research studies or playing a role in the recruitment of patients or in the routine care of a patient who is participating or has participated in human research.

Physicians must never include patients in research without their expressed consent or that of an appropriate surrogate. They should ensure that each participant has been appropriately informed and has given voluntary consent (choice B).

→ Ask patients to sign consent since you know them well (choice A) is incorrect. Additional information is often required by patients as not everything is adequately captured in standard consent forms. Therefore, physicians should discuss these issues with potential research subjects directly.
→ Inform patients of the study (choice C) is incorrect. Physicians who have taken on the role of recruiting subjects should do so in more depth.
→ Providing a list of patients to researchers (choice D) is legally wrong as it is considered a breach of confidentiality.

Key point:
Physicians should ensure that each research participant has been appropriately informed and has given voluntary consent.

The correct answer is c.
All users average of this question: 75%

Topic: Levels of Prevention
Subject: PMCH
Type: Prevention
Dimensions of Care: Health promotion and illness prevention
Physician Activities: Assessment and diagnosis
Difficulty: Easy

Explanation:

Prevention has traditionally been divided into three categories: primary, secondary, and tertiary.
- Primary prevention targets individuals who may be at risk of developing a medical condition and intervenes to prevent the onset of that condition (e.g., childhood vaccination programs, water fluoridation, antismoking programs, and education about safe sex).
- Secondary prevention happens after an illness, or serious risk factors have already been diagnosed. The goal is to halt or slow the progress of disease (if possible) in its earliest stages; in the case of injury, goals include limiting long-term disability and preventing re-injury. (e.g., routine Papanicolaou tests, and screening for hypertension, diabetes, or hyperlipidemia).
- Tertiary prevention focuses on helping people manage complicated, long-term health problems such as diabetes, heart disease, cancer and chronic musculoskeletal pain. The goals include preventing further physical deterioration and maximizing quality of life (e.g., cardiac or stroke rehabilitation programs, chronic pain management programs, patient support groups) (choice C).

Key point:
Tertiary prevention focuses on helping people manage complicated, long-term health problems such as diabetes, heart disease, cancer and chronic musculoskeletal pain. The goals include preventing further physical deterioration and maximizing quality of life (e.g., cardiac or stroke rehabilitation programs, chronic pain management programs, and patient support groups).