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Each question has 5 possible answers from which to choose. Only one choice is the most correct answer. Each choice may be accompanied by an explanation.

A father brings his 4-year-old child to the office because the child is not weight bearing following a "fall from a swing." X-rays of both lower extremities reveal a new fracture and other healing fractures. The father denies the child has ever been injured.

In addition to providing clinical care for the fracture, what is your best next step?

A 50-year-old female is investigated with angiography using a femoral approach. The procedure is uneventful. In the following days, she experiences significant swelling and bruising in the groin, and a 12 cm hematoma is identified.

The patient files a complaint, stating she was not told this recognized complication might occur.

What is the most accurate statement?

A 57-year-old male collapsed while walking alone. On arrival at the hospital by ambulance, he was unresponsive, with laboured respirations, but adequate blood pressure. The emergency physician considered whether immediate endotracheal intubation was necessary.

What is the best next step?

A 72-year-old Chinese speaking male arrives at hospital, unconscious, hypotensive, and with an endotracheal tube in place. You initiate further resuscitation. The family arrives and explains that the patient has inoperable lung cancer with metastatic disease and suffers constant pain. The patient's wife (the SDM), with her elder son translating, states, "everything possible should be done," whereas the son states his father has recently told him "he wished to die." (A substitute decision maker (SDM) is a person who is legally authorized to make decisions on behalf of the patient.) There is no advance directive.

What is the best next step? Choose the best answer.

A 70-year-old female with presumptive giant cell (temporal) arteritis is started on corticosteroids pending urgent temporal artery biopsy.

What information should the physician provide to the patient before she leaves the office? Choose the best answer.

A 44-year-old part-time street musician experiences persistent numbness of the palm and first 3 digits of the hand, requiring carpel tunnel release.

As the surgeon performing the procedure, what is the next best step?

An emotionally mature and mentally capable (competent) 15-year-old female attends your clinic, seeking the oral contraceptive pill (OCP) for contraception. She has no contraindications. Although she is unaccompanied, you have provided care to her entire family for many years.

What is the best next step?

A patient has appendicitis. The surgeon decides to delegate certain aspects of the appendectomy to the senior resident.

What should the surgeon tell the patient? Choose the best answer.

A 25-year-old male is seen in an emergency department with multiple trauma injuries after a car crash. Based on the clinical examination, the physician suspects the patient is intoxicated with ethanol.

The police arrive and inquire whether the patient is intoxicated.

What information can the physician give the police immediately? Choose the best answer.

A 32-year-old male presents with a 2-day history of intermittent chest pain, not related to exertion. He smokes but has no other risk factors for coronary artery disease (CAD), including denying use of cocaine. The chest wall is tender to palpation seemingly reproducing the pain. An ECG is normal. He is diagnosed with costochondritis and discharged home. He returns shortly thereafter with a large myocardial infarction (MI). It is revealed that he has been taking cocaine regularly. A legal action follows, alleging failure to fully investigate and diagnose CAD at the initial visit. The case is subsequently dismissed.

Although all clinical notes are important, which documentation in the medical record likely helped the defence most in this case?

A chest CT scan confirms a 42-year-old woman has aspirated a foreign body. A thoracic surgeon successfully performs bronchoscopy to remove it. The radiology report also notes an incidental finding of a suspicious nodule in the lung. Follow-up is recommended.

The report is sent to the surgeon but is filed in the patient's medical record without being seen. The patient is not required to see the surgeon again and no one discusses the abnormal report with the patient. Although the imaging report is in the electronic medical record, the family physician is not directly informed of the radiology finding.

Three years later the patient is investigated for shoulder pain. A Pancoast tumor with metastatic spread is identified.

This case best exemplifies the need for:

A 30-year-old woman with a longstanding history of psychiatric illness with alcohol and addiction problems presents to the emergency department of a community hospital late one evening. It is particularly busy and the nurses urge the locum physician working that night to quickly discharge this woman. They explain that she is well known to the emergency department staff and is a drug seeking individual who frequents the department with frivolous complaints.

The physician finds the patient is unable to give a history or even allow a physical examination as she is writhing in pain. The physician orders analgesia. With an abundance of caution, she orders an abdominal CT to rule out any abdominal pathology. The radiologist and the emergency physician are surprised to discover findings indicating appendicitis.

Which one of the following likely contributed most to the successful diagnosis?


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