A 42-year-old man presents with a history of fatigue and weight loss. He looks unwell, has a darker than usual complexion and his liver is enlarged. He is also found to have marked glycosuria. Which one of the following is the most useful diagnostic test?

A 19-year-old woman with a long-standing history of abuse and borderline personality disorder presents to your office. She has a number of superficial lacerations over her arms and legs. They look like they were caused by a sharp edge such as a knife. They are at various stages of healing, and some look like they are a few hours old, though none require stitches. Which one of the following is the most likely comment she would make about the injuries?

You performed a surgical procedure on a 32-year-old woman for a herniated disk that was causing neurologic impairment. At the 8-month follow-up visit, she has healed well; however, she requests a prescription renewal of her narcotic analgesics (hydromorphone). Her pharmacy confirms that the patient adheres to the dosage you prescribed, that she has not consulted other physicians, and that her behavior has always been respectful. You think that she no longer requires narcotic analgesics. Which one of the following approaches is most helpful to the patient?

A 37-year-old woman presents to your clinic with frequent palpitations. She has no other symptoms and is quite active. Physical examination and resting electrocardiogram findings are normal. Which one of the following is the best next step?

A 30-year-old man (assigned female at birth) presents to your clinic for a periodic health examination. He declines a gynecologic examination because such examinations lead to intense emotional distress for him. He also believes that he does not require a Papanicolaou (Pap) test because he is not in a sexual relationship with a man. After acknowledging the patient ' s distress and providing education regarding the need for Pap screening, which one of the following would be the best next step?

A 78-year-old woman is brought to the Emergency Department by her son because she has a sodium level of 124 mmol/L (136–146). The sodium was checked as part of a blood work panel ordered by her primary health care provider to investigate symptoms of urinary frequency, fatigue, and thirst. Today, she has a blood glucose level of 44.0 mmol/L (4.0–11.0). The original blood work done by her primary health care provider did not include glucose. The patient is treated for hyperglycemia and dehydration and begins insulin. The patient and her son repeatedly express their frustration that their primary health care provider missed the diagnosis. Which one of the following is the best next step?

A 42-year-old woman presents with a 2-day history of a low-grade fever and a painful left breast mass. On examination, there is a fluctuant erythematous tender mass with surrounding induration in the left breast and enlarged lymph nodes in the left axilla. An ultrasound shows a loculated cystic mass. Which one of the following is the most likely diagnosis?

A 72-year-old man presents to your clinic accompanied by his 70-year-old husband. The patient reports that, over the last several months, his libido has been very low. Which one of the following would be the best next step?

An 80-year-old woman presents to the Emergency Department with dizziness. She has a medical history of coronary artery disease. On examination, she is alert and oriented. Her vital signs are as follows:

Her electrocardiogram is shown in the image.

Which one of the following is the most likely diagnosis?

Blood pressure

80/60 mm Hg

Heart rate

40/min

Respiratory rate

12/min

Her electrocardiogram is shown in the attached image. Which one of the following is the most likely diagnosis?

A 76-year-old man is brought to the emergency department in an unresponsive state. He has a history of chronic kidney disease with a baseline serum creatinine level of 300 µmol/L (49–93) and a history of dilated cardiomyopathy with an ejection fraction of 30%. On assessment, he has no pulse or blood pressure. Cardiac monitor demonstrates a wide complex tachycardia. Which one of the following recently started medications is the most likely cause of this arrhythmia?

A 44-year-old woman presents to the office to discuss contraception. During the gynecologic examination, you notice an anterior cystocele to the hymenal ring. The woman denies any bulge symptoms but does report dribbling of urine, especially when she coughs or jogs.

Which one of the following is the best next step?

A 30-year-old woman presents to the office with her partner and reports that they are planning for her to conceive soon. They visited Mexico recently and are concerned about exposure to the Zika virus. Which one of the following is the best next step?

A 60-year-old woman presents with a 7-day history of bloody diarrhea and diffuse mild abdominal tenderness. Stool tests (culture, ova/parasites) are negative. Which one of the following is the best next step?

A 2-month-old infant is brought by his parents to your clinic with concerns regarding his frequent crying spells. He has been crying for more than 3 hours daily for many weeks. The infant has reached all age-specific developmental milestones. Which one of the following is the most important to share with the parents regarding this situation?

A 64-year-old man presents with a 3-month history of gradually increasing neck pain and stiffness. The pain radiates into his upper back, and he is having difficulty driving because of limitation of neck rotation secondary to pain. Physical examination shows restricted neck motion in all directions and neck muscle spasms. There is no abnormality on neurologic examination. A radiograph shows narrowing of all of the cervical disc spaces with prominent osteophytes. Which one of the following is the most appropriate next step?

A 22-year-old woman is brought to the Emergency Department by her boyfriend, who says that she is experiencing a fentanyl overdose. She is unresponsive and cyanotic. She regains consciousness after naloxone is injected intravenously and demonstrates no further respiratory depression during 8 hours of observation. She states that she is 22 weeks ' pregnant and wants to stop using opioids. Which one of the following is the best next step?

A 47-year-old man has been training for a marathon. After a long run, he develops mild pain and swelling in his left knee. Examination shows a mild joint effusion and a soft tissue mass in the popliteal fossa. The knee radiograph is normal. Which one of the following is the best method of confirming the diagnosis?

One of your patients presents to your clinic for a consultation regarding their recurrent hemoptysis. On review of their chart, you realize that although you had ordered chest radiography 2 months ago, the result cannot be found in the chart. You call the radiology department and are relieved to find that the chest radiography was done and that it did not reveal any pathology. After informing the patient of this lapse in reporting, which one of the following is the best next step?

A 19-year-old woman returns to your clinic to discuss her recent laboratory tests. She initially presented with dysuria, dyspareunia, and abnormal uterine bleeding. Her vulvovaginal examination was normal. Her last sexual encounter was 3 weeks prior to the onset of her symptoms. Which one of the following pathogens is most likely to explain this clinical presentation?

In a research study, it is found that people who smoke tobacco cigarettes drink more coffee and have higher rates of lung cancer than people who do not smoke. However, the consumption of coffee alone is not associated with lung cancer. Which one of the following best describes the contribution of drinking coffee in the study?

You are asked to assess an 85-year-old man who was admitted to the hospital for management of a bowel obstruction. The patient is in bed and has a faint pulse with no detectable blood pressure. There is vomitus on his bed and clothing. He has central cyanosis, and oxygen saturation is 75% on supplemental oxygen. Which one of the following is the best next step?

A 28-year-old woman, gravida 1, para 0, aborta 0, presents to your clinic for a prenatal visit. Her pregnancy is at 20 weeks’ gestation. Her ultrasonogram shows a normal fetus and a low-lying placenta. Which one of the following is the best next step?

You are seeing a 78-year-old man for follow-up of metastatic cholangiocarcinoma diagnosed 8 months ago and currently being treated with thermotherapy. He has just completed his 2nd cycle and reports frequently feeling hopeless, worthless, and helpless, with no sense of a positive future. He states he is turning away invitations to socialize with family and friends. He feels like sleeping all the time and reports no appetite. Which one of the following is the most likely diagnosis?

A 26-year-old woman, gravida 1, para 0, aborta 0, consults you at 36 weeks’ gestation regarding newborn care. She has HIV. Which one of the following is the best advice regarding reducing the risk for transmission of HIV to her newborn?

A 46-year-old woman presents to the emergency department with left-sided pleuritic chest pain that improves when she sits up and leans forward. Her medical history is unremarkable and she takes no medications. Examination reveals a pericardial friction rub; the findings are otherwise normal. An electrocardiogram reveals diffuse ST segment elevation and PR interval depression. An echocardiogram reveals a small pericardial effusion. Which one of the following is the most appropriate treatment?

A 37-year-old man presents with chronic back, neck, and shoulder pain following a workplace injury 4 years ago. He has a history of alcohol misuse and PTSD related to the incident. Current medications (acetaminophen, naproxen, amitriptyline, gabapentin) provide inadequate pain relief. He requests oxycodone after self-trialing it with temporary benefit. After history and physical assessment, which one of the following is the best next step?

A 72-year-old man presents to your clinic with worsening lower leg edema. He has hypertension, type 2 diabetes, and a history of heavy drinking. On examination, he is pale and has a BMI of 35. Vital signs are as follows:

Blood pressure: 110/60 mm Hg

Heart rate: 102/min

Temperature: Afebrile

His jugular venous pressure is 4 cm above the sternal angle. Cardiac auscultation is normal, and his lungs are clear. His liver is not palpable; he has abdominal distension, bulging flanks, and pitting edema below the knees. While awaiting test results, which one of the following is the best next step?

A 4-month-old boy is brought to the office by his parents to ask about the rotavirus vaccine. They would like to avoid the possibility of the infant coming down with gastroenteritis. Their older child was hospitalized with gastroenteritis at age 10 months. They have a friend who had intussusception after getting the rotavirus immunization, and they are worried about a possible link to the vaccine. Which one of the following is the most appropriate response?

A 27-year-old woman presents with an enlarged thyroid. She had not noticed it herself until her mother brought it to her attention. She is asymptomatic from an endocrine perspective, and her serum thyroid-stimulating hormone (TSH) is normal.

Which one of the following is the most appropriate next step?

A 20-year-old nulligravid woman presents with severe pain during menstruation. She is unable to take nonsteroidal anti-inflammatory drugs (NSAIDs) and is adamant about not taking any hormonal therapy. She has questions about non-medicinal therapeutic options. Which one of the following recommendations is the most appropriate?

A 19-year-old woman presents to the office. She is a new mother. She shares that she does not intend to vaccinate her son. Which one of the following is the best next step?

A 39-year-old woman comes to the office for a periodic health examination. She reports that her father had a recent diagnosis of breast cancer (at age 62 years) and that a paternal aunt had ovarian cancer in her early 40s. The results of mammography are normal. Which one of the following is the most appropriate recommendation for this patient?

An 85-year-old man is transferred from an acute care hospital to your long-term care (LTC) facility. He has a fever, fatigue, myalgia, and malaise. His test result is positive for influenza A virus. Two other residents and 1 LTC staff member have experienced the same symptoms. Which one of the following is the best next step to prevent further infections at the LTC facility?

A 72-year-old woman presents with swelling of her right leg that developed overnight. She had an abdominal hysterectomy 10 days ago. On examination, there is pitting edema of the leg that extends from the foot to the groin. The calf is 3 cm larger in diameter than the calf on the left leg. Which one of the following is the most likely diagnosis?

A 25-year-old woman who is at 8 weeks ' gestation plans to travel to rural Cambodia to care for her ill mother. Which one of the following treatments should be provided to her before the trip?

A 21-year-old man presents to the Emergency Department with a 6-month history of unusual behavior. He believes that he has been specially chosen to found a new religion. He says he has seen visions of angels in his bedroom. He appears disheveled and malodorous. On further inspection, you note that he drinks 2 liters daily. Which one of the following is the most appropriate initial management?

A 15-year-old boy is brought to your office because of concerns about his breast development. He has no other symptoms. His physical examination does not reveal any other abnormality. Which one of the following is the best next step?

A 63-year-old woman presents to your office with a history of progressive abdominal discomfort over the past five months. She reports bloating and difficult digestion with constipation. She has no urinary symptoms and denies vaginal or rectal bleeding. An abdominal ultrasound shows a large complex pelvic mass with internal multiloculation and moderate ascites. The cancer antigen 125 (CA 125) is elevated at 1023 U/mL ( < 35 U/mL). Which one of the following is the most likely diagnosis?

A 56-year-old woman with a 4-year history of fibromyalgia presents for follow-up. She reports that she is struggling with her health and daily life. She is unhappy with her lack of progress and says she feels tired all the time and stays in bed all day. When asked why, she states she is confused about why she is not getting better. Physical exam and investigations are unchanged from baseline. Which one of the following is the best next step?

You are examining a full-term baby girl in the nursery. You notice that her left forefoot is adducted and supinated relative to the contralateral foot, which makes her left foot appear C-shaped. Which one of the following findings is most instrumental in deciding on the management of this issue?

An otherwise healthy 57-year-old man with a 20 pack-year history of smoking presents with a 2-day history of reddish-brown urine that has not cleared. There is no history of abdominal or flank pain. Urinalysis reveals 5 red blood cells per high power field. Which one of the following is the best next step?

A 62-year-old woman is taken to the operating room for an elective laparoscopic cholecystectomy. Induction of anesthesia triggers a severe hypertensive crisis that ultimately resolves after administration of a 5 mg bolus of phentolamine.

Which one of the following is most consistent with this presentation?

A 9-year-old girl is brought to the Emergency Department because she has generalized urticaria, abdominal cramping, and postural dizziness 30 minutes after eating at a friend’s birthday party. Which one of the following is the most appropriate route of administration for epinephrine?

A 45-year-old man with confusion is brought to the Emergency Department by ambulance. He has end-stage renal disease and has missed his last 3 dialysis appointments. He also has a past medical history of antisocial personality disorder and hepatitis C. On examination, he is in respiratory distress. His blood pressure is 170/90 mm Hg, and his oxygen saturation is 84% on room air. His jugular venous pressure is 8 cm above the sternal angle, and he has crackles in his lungs bilaterally. A venous blood gas shows a bicarbonate of 11 mmol/L (24–30) and potassium of 7.1 mmol/L (3.5–5.0). Which one of the following is the best next step?

You are undertaking the retrospective analysis of a laboratory-confirmed influenza A virus outbreak that occurred in a long-term care facility last year. Among the 163 residents in the facility during the outbreak, 101 residents had new-onset fever, cough, myalgias, and congestion. Of these, 37 residents were transferred to acute care. Of these, 17 residents died. Which one of the following is the best estimate of the attack rate in residents at the facility?

You have been asked to develop a program in your hospital for people who are at the highest risk of death by suicide. The hospital administrator asks you to describe the types of patients they should expect in the program. Which one of the following groups is the most likely prominent demographic?

A 3-year-old boy is brought to the office because he has progressive weight gain and short stature. He has marked truncal obesity, hypertrichosis of the upper lip, and facial swelling. Which one of the following is a physical examination most likely to reveal?

A 42-year-old businessman known to have type 2 diabetes and ischemic heart disease is admitted to hospital with acute coronary syndrome. He admits to drinking 4 beers a day for the last 6 years and to binge drinking twice a year when his school buddies are in town. Your chart review reveals that he had a seizure secondary to alcohol withdrawal during his last admission. Which one of the following elements of his history puts him at highest risk of having another such seizure?

A 38-year-old woman has progressive renal failure despite optimal medical treatment for her glomerulonephritis. Her ex-husband asks if he might be considered as a kidney donor. They have joint custody of their 10-year-old son. Which one of the following is the best response to the ex-husband’s request?

A 56-year-old man is admitted to hospital with pyelonephritis and started on intravenous antibiotics. On day 2 of his hospitalization, he continues to report right flank pain, but he is able to walk. His vital signs are as follows:

Temperature: 38.5°C

Blood pressure: 90/60 mm Hg

Heart rate: 105/min

The patient is mentating well but is concerned about his dog that is home alone due to his unexpected hospitalization. He requests to be released from hospital as he needs to make arrangements for his dog. Which one of the following is the best next step?

An 85-year-old man is transferred from an acute care hospital to your long-term care (LTC) facility after treatment for a hip fracture. He has a fever, headache, myalgia, and malaise. He has been in contact with LTC staff and family but not with other residents. None of the other residents or LTC staff are symptomatic. As additional investigations are being arranged, which one of the following is the best next step?

A 58-year-old woman presents to your office with heavy vaginal bleeding. She has a history of type 2 diabetes and hypertension. Some active bleeding is visible on speculum examination. Ultrasound reveals an endometrial thickness of 12 mm. Endometrial biopsy shows complex hyperplasia with atypia. Which one of the following is the best next step?

A 68-year-old man presents with a 3-day history of multiple tender joints. On examination, he has a temperature of 38.2°C and swelling and redness of his left large toe. Which one of the following is the most likely diagnosis?

A 27-year-old woman presents to her family physician ' s office and states that she is pregnant and would like to be referred for an abortion. She is at approximately 9 weeks ' gestation by dates. The family physician has personal conscience-based objections to the procedure. Which one of the following would be the best next step for this physician?

A 63-year-old man is brought to the Emergency Department by ambulance after he injured his abdomen. While working on a house, he fell 1 m from a scaffold and landed on a metal pipe. He is clinically stable but reports localized abdominal pain. On examination, he has a 17-cm laceration to his abdomen in the left hypochondrium. The laceration is 4 cm deep, but there is no fascial laceration. Which one of the following is the best next step?

An 83-year-old woman presents to your office with a 2-day history of confusion. Her past medical history is significant for lung cancer, and she is being treated with radiation. On physical examination, she is euvolemic. Her blood work reveals a serum sodium of 118 mmol/L (135–140) as compared with 134 mmol/L (8 days ago). Which one of the following will be most helpful in establishing the cause of her laboratory abnormality?

A 35-year-old woman presents to your clinic with double vision and a gritty sensation in her eyes for the past several weeks. On examination, you notice her eyes are bulging. There is inflammation of her conjunctivae and swelling around her eyes. Which one of the following is the most likely diagnosis?

A 14-year-old girl is brought to the Emergency Department with a 20-minute history of difficulty breathing that started during a school assembly. She has had similar symptoms 3 times in the last 2 weeks. These episodes develop rapidly and resolve gradually over several minutes. She reports tingling in her fingers and toes. On examination, her vital signs are as follows:

Blood pressure

120/80 mm Hg

Heart rate

100/min

Respiratory rate

22/min

Oxygen saturation on room air

95%

Temperature

36.9 °C, orally

Apart from mildly dilated pupils, her examination is otherwise normal. Which one of the following is the most likely diagnosis?

A 91-year-old man comes to the Emergency Department reporting blood in his stools, which has now resolved. He is able to give a history and mentions that this also happened 2 years ago. At that time, a colonoscopy was done and revealed diverticular disease as the cause. Which one of the following is the best next step?

A 70-year-old woman presents to the Emergency Department with a 2-day history of dysuria and right flank pain. Upon arrival, she is quite unwell. Her vital signs are as follows: blood pressure 70/38 mm Hg, heart rate 130/min, respiratory rate 24/min, temperature 39.4 °C.

Due to difficulty obtaining peripheral access, a central line is inserted. There is a lot of ongoing bleeding around the line insertion site. Her blood work shows:

White blood cell count: 19.8 × 10⁹/L (4–10)

Hemoglobin: 101 g/L (123–157)

Platelets: 85 × 10⁹/L (130–400)

Blood film: schistocytes

INR: 1.9 (0.9–1.2)

Fibrinogen: < 1 g/L (2–4)

Which one of the following is the most likely cause of her ongoing bleeding?

A 31-year-old nulligravid woman presents to your office after 5 months of attempting to get pregnant without success. Her menses are regular, and she is otherwise healthy. Her husband is healthy and has never fathered any children before. Which one of the following is the best next step?

A 28-year-old woman presents to the office in great distress because she has no money for groceries or rent. She is a single mother of a 7-year-old girl. She has a history of gambling disorder. She has felt unable to cope for the last 3 months and has started gambling again. Today, she is crying, and she shares that her boyfriend became violent with her yesterday. Which one of the following is the highest priority for assessment?

A 45-year-old man with a developmental delay and a history of disruptive behavior presents to the clinic looking for his family doctor. He is well known to the clinic. He appears drunk and has accidentally broken 2 large beer bottles in the waiting room but remains calm. The office staff requests your help to deal with this situation. Which one of the following is the most appropriate initial step?

A 62-year-old man, who has not seen a physician in 20 years, presents to your clinic with a burning sensation in his feet. The symptoms have been progressing slowly over the last 6 months. There is no associated motor weakness or skin changes. He reports no significant past medical history and takes no medications. His alcohol intake is minimal. On examination, he has reduced pinprick/vibration sensation and proprioception in the ankles with absent ankle reflexes. Which one of the following blood tests would you expect to be abnormal?

A 55-year-old man presents to the Emergency Department with intractable nausea and vomiting. He is diaphoretic, tremulous and tachycardic. In a private conversation with his spouse, you learn that for the last several weeks, he has been drinking 1.2 L of vodka daily. On questioning, he says that since he retired, he has been drinking socially and plans to continue doing so. With respect to his alcohol use, which one of the following best describes the patient’s current stage of change?

A 3-year-old boy is brought to the office because he is not using his right arm after a fall from a swing. Radiographs reveal a new fracture and old healing fractures. The parents deny any previous injuries. In addition to providing care for the fracture, which one of the following is the best next step?

A 6-year-old girl is found to have a blood pressure of 130/75 mm Hg. She was born prematurely at 32 weeks ' gestation and required ventilation. There is a family history of hypertension in 3 grandparents. Clinical examination reveals a grade 1/6 mid-systolic murmur, no renal bruits, and femoral pulses are difficult to feel. Which one of the following is the most likely diagnosis?

A 54-year-old woman presents to your office to discuss breast cancer screening. She is asymptomatic with no history of breast cancer. She had a fibroadenoma removed when she was 24 years old. The patient is not on any medications. Her family history is significant for a great-aunt with breast cancer. The patient has not had genetic testing but had normal breast screening 2 years ago. Which one of the following is the best next step?

A 4-year-old boy is brought by his parents to your walk-in clinic with a 3-week history of fatigue, bruising, and intermittent fever. He was previously healthy. Physical examination reveals hepatosplenomegaly and petechiae. His complete blood count shows the following:

Platelet count, blood: 15.0 × 10⁹/L (206.4–443.3)

White blood cell (WBC) count, blood: 1.0 × 10⁹/L (4.7–13.5)

Hemoglobin (Hgb), blood: 70 g/L (105–135)

Which one of the following is the most likely diagnosis?

You are called to the Emergency Department to see a 6-month-old boy with a 3-day history of fever. Physical examination reveals an irritable infant with a temperature of 38.1°C. His vital signs are:

Blood pressure: 87/50 mm Hg

Respiratory rate: 80/min

Heart rate: 140/min

Oxygen saturation: 92% on room air

The infant has no skin findings. On chest examination, you hear coarse crackles on the right side of the chest. Which one of the following is the best next step in the management of this child?

A 26-year-old woman, gravida 3, para 2, presents for her 1st antenatal visit. She states she is at 26 weeks ' gestation and is healthy. On abdominal examination, her fundus is palpated at the umbilicus. Which one of the following is the most likely explanation for this finding?

A 35-year-old man comes to your office with a history of headaches that last 1 hour and are relieved by 1000 mg of acetaminophen. These headaches, which started 6 months ago after he got his first job as a lawyer, occur regularly. The patient wants a computed tomography scan of his head to rule out a tumour. Physical examination reveals no abnormality. Review of systems does not contribute any positive findings. Which one of the following is the best management?

A 47-year-old man presents to the office with a 1-month history of passing blood in his stool 2 to 3 times per week. He is otherwise healthy and denies any systemic symptoms. Other than a small lateral skin tag on digital rectal examination, the physical examination findings are unremarkable. Which one of the following is the best next step?

You are an attending physician at a palliative care unit and are asked to see an 80-year-old woman who is dying of lung cancer. She has been unresponsive for the last 2 days and had her last dose of morphine 4 hours ago. Her son just arrived in town this afternoon and pleads with you to wake her up so she can sign her will. Which one of the following is the best next step?

A 60-year-old postmenopausal woman presents with 2 culture-proven uncomplicated urinary tract infections in the last 5 months. She finds them quite distressing and would like to prevent recurrence. Which one of the following is the best next step?

A 53-year-old man with a history of bipolar I disorder is brought to the office by his family. Recently, he has been sleeping for 4 to 5 hours per night, has been fidgety, and is increasingly preoccupied with his granddaughter ' s safety. Five days ago, he consulted with your physician colleague and was instructed to exercise and meditate. Last night, he was found running in the street and attempted to hit a relative who was trying to calm him down. His son is dissatisfied with your physician colleague ' s management. Which one of the following is the most appropriate response?

A 43-year-old man comes to your office for the first time. He has not seen a doctor in over 5 years and has no known past medical history. On examination, his blood pressure is 120/70 mm Hg, and the remainder of his examination is normal. As part of the initial visit, you order some screening blood work that reveals a fasting blood glucose of 6.3 mmol/L (3.3–5.8) and a hemoglobin A1c of 6.1% (4–6). Which one of the following is the best next step?

A 20-year-old man is brought by a friend to the emergency department with an elevated temperature, generalized muscle rigidity, hypovolemia, a fluctuating level of consciousness, and impaired attention. The patient also may be responding to auditory hallucinations. The friend informs you that the patient overdosed with a prescribed medication. Which one of the following medications is most likely to cause these symptoms?

A 77-year-old woman is brought to the Emergency Department by ambulance because she has severe heel ulcers and dehydration. Her husband reports that she has been sick for the past 6 to 8 weeks with a cough and congestion. He shares that he has tried to bring her to medical attention on several occasions, but she refused. The paramedics reported that her bed at home was soiled and that they could hardly reach her room due to clutter. On questioning, her answers seem reasonable. Which one of the following is the most critical next step?

A 57-year-old man presents with low back pain. Radiographs of the lumbar spine show a narrowed disk space at L4-L5, anterior osteophyte formation at this level, and sclerosis of the L4-L5 end plates. Which one of the following is the most likely diagnosis?

A 37-year-old man comes to the office for follow-up of his opioid use disorder. He receives opioid agonist treatment, including some take-home doses. At this follow-up visit, he reports some nonprescription opioid use since his last visit. Which one of the following is the best next step?

A 35-year-old maintenance worker presents to your office because he thinks he has been exposed to asbestos and is afraid of developing asbestosis. He has no respiratory symptoms and is a non-smoker. Which one of the following is the best next step?

A 10-day-old boy is brought to the Emergency Department with a fever. The newborn looks well. Other than a rectal temperature of 38.6 °C, findings of the physical examination are unremarkable. When you list all the recommended testing their baby will have to undergo, the parents become upset at all the testing their baby will have to undergo. Which one of the following is the best approach?

A 25-year-old nulligravida woman presents after trying to conceive for 2 years without success. She is healthy, with regular menstrual periods. She denies any unusual hair growth, weight changes, or breast discharge. She gets occasional outbreaks of acne. Blood work done with her next menstrual period produces the following results:

Follicle-stimulating hormone, follicular phase: 6.2 U/L (5.0–20.0) on day 3 of menstrual cycle

Luteinizing hormone, follicular phase: 6 U/L (5–22) on day 3 of menstrual cycle

Estradiol: 163 pmol/L (50–200) on day 15 of menstrual cycle

Thyrotropin (thyroid-stimulating hormone): 2.5 mU/L (0.4–5.0)

Prolactin: 40 µg/L (4–30)

Given the results of her blood work, which one of the following is the best next step?

A 15-year-old boy is brought to the office by his father because he is having headaches. When alone, the boy appears withdrawn and admits to suicidal ideation. He shares that he is gay but does not want to tell his parents. He says that he faked the headaches so that one of his parents would make an appointment for him. Which one of the following is the best next step?

A 24-year-old man is brought to the Emergency Department by ambulance with a severe pelvic fracture from a motor vehicle collision. After resuscitation and stabilization, he is noted to have a bloody penile discharge. Which one of the following is the best next step?

You are conducting a virtual appointment by voice-only call with a 68-year-old man regarding back pain. When he answers, you ask for him by name and identify yourself and the clinic from which you are calling. Which one of the following is the best next step?

An 88-year-old man is admitted to hospital with an upper gastrointestinal bleed. He is confused on admission, but his sensorium clears with resuscitation and stabilization. The patient lives in his own home with assistance from his children. Work-up shows metastatic gastric carcinoma for which no curative treatment can be offered. The family insists that the patient not be told the diagnosis because they fear he will have a “mental breakdown.” Which one of the following is the best next step?

A 60-year-old man has a strong family history of aortic aneurysms. Screening abdominal ultrasonography reveals an incidental < 1 cm mass in his left kidney. Computed tomography confirms that the mass is consistent with renal adenocarcinoma. Which one of the following is the most appropriate step in management?

A 60-year-old man is admitted to hospital, and lung cancer is diagnosed. When his family physician reviews the discharge summary, she reviews the patient’s chart and finds a chest radiograph report from 1 year ago that mentions a suspicious nodule and recommends a computed tomography scan. The family physician recalls seeing this report and did not order the scan. Which one of the following is the family physician’s best next step?

A 73-year-old woman is seen in the office 2 weeks after a coronary bypass surgical procedure. The site of saphenous vein removal in the left thigh shows an area of tenderness and a 3 × 5 cm palpable mass. The skin is intact. Her temperature is 37.7 °C, hemoglobin is 110 g/L (125–167), and white blood cell count is 8 × 10⁹/L (4–10). Which one of the following is the most likely diagnosis?

You are asked to see a 50-year-old man 2 hours after he underwent a laparotomy for gastric resection. Lab results are as follows:

pH

7.28 (7.35–7.45)

PaCO₂

60 mm Hg (35–40)

PaO₂

60 mm Hg (85–105) with 4 L/min via nasal prongs

Bicarbonate (HCO₃)

24 mmol/L (24–30)

Which one of the following is most consistent with this clinical presentation?

A 2.5-year-old boy is brought to the Emergency Department after he consumed a button-shaped battery. Chest and abdomen radiographies are performed. Which one of the following locations mandates urgent removal of the battery?

A 38-year-old woman presents with diffuse nodularity in the outer upper quadrant of her right breast. There is no obvious dominant mass, nipple discharge, or skin dimpling. There are no palpable lymph nodes. Which one of the following is the most likely diagnosis?

A 67-year-old farmer presents with a 6-month history of progressive weakness in both arms. He now has difficulty in climbing but says he can still drive his tractor. Examination shows slight but definite atrophy of muscles of pectoral girdle, especially over his scapula. Fasciculations are visible. There is hyperreflexia of most tendon reflexes of arms and legs, left ankle clonus and left Babinski reflex. Which one of the following is the most likely diagnosis?

You are providing medical care to a 78-year-old man and notice a skin lesion which you suspect is malignant melanoma. He has been living in a long-term care facility for 2 years because of incontinence, mobility and vision problems. He is well-liked by facility staff and residents, manages his own affairs and communicates clearly. He has designated his daughter to be his substitute decision-maker and has signed a Do Not Resuscitate (DNR) order. Which one of the following is the best next step in providing care to this patient for his skin lesion?

A 26-year-old man presents with pain, numbness, and weakness in his right upper extremity. He works as a computer programmer, and his BMI is 32. Symptoms have worsened since he started spending more time on the keyboard. He reports that his right hand feels clumsier while he is typing. Physical examination reveals mild weakness in the intrinsic muscles of that hand, with a positive Tinel sign at the ulnar nerve. Which one of the following is the best next step?

A 70-year-old woman consults you for progressive vision problems. She describes seeing haloes at night around street lights and having double vision. Her near vision has improved. Which one of the following is an ophthalmologic examination most likely to uncover?

A 14-year-old girl, accompanied by her mother, presents to your office with a 3-month history of feeling " dizzy. " After you take an initial history, which one of the following is the most appropriate next step?

A 78-year-old man presents to the Emergency Department with chest pain. His electrocardiogram and blood work confirm an acute myocardial infarction. He is admitted to the Intensive Care Unit. Three days later, he develops right-sided abdominal pain. An ultrasonogram reveals an inflamed gallbladder with no evidence of stones. He does not improve after 48 hours of antibiotics. Which one of the following is the best next step?

You are counselling a couple that is concerned about the risk that their second child could be affected by the same X-linked recessive disorder (hemophilia A) as their last child, a boy. Neither parent has this disorder. What is the probability that their second child will be affected?

A 7-year-old boy is brought to your clinic with a 2-day history of being mildly unwell with malaise and decreased appetite but no fever. This morning, it was discovered that he had oral lesions as shown in the attached image. His mother wonders how she can prevent this from spreading to his younger siblings.

Which one of the following is the best advice?

A 28-year-old nulligravid woman presents to your clinic with grey-green vaginal discharge that has a “fishy-type odour.” Microscopy reveals superficial squamous cells with blurred borders caused by adherent bacteria. The patient’s symptoms abate after therapy with vaginal metronidazole. Which one of the following is the most likely cause of this clinical presentation?

A 79-year-old woman presents to the Emergency Department with sudden-onset severe chest and back pain that started 1 hour ago. She has a history of hypertension and looks unwell. Her vital signs are as follows: blood pressure 168/108 mm Hg, heart rate 110/min, respiratory rate 22/min, temperature 36.7°C. Findings of a physical examination of the chest and abdomen are normal. An urgent computed tomography (CT) scan of the chest and abdomen shows an aortic dissection extending from the descending thoracic aorta to the upper abdominal aorta. The branches of the abdominal aorta are patent. Following initial resuscitation, which one of the following is the best next step?