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CFPC Exam (CCFP) study materials
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CFPC Exam (CCFP) practice questions

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Question 1Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 58-year-old man with type 2 diabetes has an eGFR of 52 mL/min/1.73 m² and a urine albumin-to-creatinine ratio of 45 mg/mmol on two separate specimens. Which medication class offers the strongest evidence for slowing progression of his kidney disease?

  1. A low-dose statin intensified to a high-intensity dose
  2. A long-acting dihydropyridine calcium channel blocker
  3. An ACE inhibitor or ARB titrated to the maximum tolerated dose Correct answer.
  4. A thiazide diuretic added to his current antihypertensive regimen

Explanation

In diabetic kidney disease with albuminuria, blockade of the renin-angiotensin system with an ACE inhibitor or ARB reduces progression to end-stage renal disease and is the cornerstone of therapy, with dose titration to the maximum tolerated level and monitoring of creatinine and potassium. Diuretics, calcium channel blockers, and statins address blood pressure or cardiovascular risk but do not have equivalent albuminuria-lowering, nephroprotective evidence.

Question 2Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 24-year-old woman presents with 3 days of dysuria, frequency, and suprapubic discomfort, with no fever, flank pain, or vaginal discharge. She is otherwise healthy and not pregnant. What is the most appropriate initial management?

  1. A 7-day course of oral amoxicillin-clavulanate
  2. Empiric intravenous ceftriaxone followed by oral step-down
  3. Immediate referral to urology for cystoscopy
  4. A 3-day course of oral trimethoprim-sulfamethoxazole based on local resistance rates Correct answer.

Explanation

Uncomplicated cystitis in a non-pregnant woman is treated with a short course of an appropriate oral antibiotic such as trimethoprim-sulfamethoxazole (where local resistance is below 20%), nitrofurantoin, or fosfomycin. Symptoms are classic and no imaging or specialist referral is indicated for a first episode.

Question 3Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 67-year-old woman has a blood pressure consistently around 152/88 mmHg on three visits despite lifestyle measures. She has no diabetes or chronic kidney disease. According to Canadian hypertension guidance, which class is recommended as first-line therapy?

  1. A thiazide-like diuretic, an ACE inhibitor, an ARB, or a long-acting calcium channel blocker Correct answer.
  2. A centrally acting agent such as clonidine
  3. A loop diuretic such as furosemide
  4. An alpha blocker such as doxazosin

Explanation

For uncomplicated hypertension in older adults, Canadian and international guidelines recommend initial therapy with a thiazide-like diuretic, an ACE inhibitor, an ARB, or a long-acting dihydropyridine calcium channel blocker. Alpha blockers, central agents, and loop diuretics are not preferred first-line because outcome data are weaker or they are reserved for specific indications.

Question 4Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 4-year-old child has had a fever for 2 days, tugging at the right ear, with an erythematous, bulging, immobile tympanic membrane on otoscopy. He is not toxic and has no mastoid tenderness. What is the most appropriate management?

  1. Observation alone with no antibiotics
  2. Oral amoxicillin for 10 days Correct answer.
  3. Topical antibiotic-steroid drops into the ear canal
  4. Oral antihistamine plus decongestant

Explanation

Acute otitis media with a bulging, erythematous, immobile tympanic membrane in a young child warrants antibiotics, with amoxicillin as first-line therapy. Observation is appropriate only for selected milder cases in older children, and topical drops treat otitis externa rather than middle ear infection.

Question 5Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 32-year-old woman with no prior pregnancies asks about rubella immunity before conception. Her serology shows non-reactive rubella IgG. What is the correct counselling?

  1. She should receive the MMR vaccine now, with no need to delay conception
  2. She should receive the MMR vaccine and avoid pregnancy for 28 days afterward Correct answer.
  3. She should receive the vaccine during the first trimester to protect the fetus
  4. She is immune and needs no further action

Explanation

Non-reactive rubella IgG indicates susceptibility, and MMR is a live vaccine that should be given before pregnancy with a recommended 28-day interval before conception. Vaccination during pregnancy is contraindicated, and immunity cannot be assumed without documentation.

Question 6Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 45-year-old man reports 2 months of low mood, anhedonia, poor sleep, and reduced concentration that is affecting his work. He denies suicidal ideation and has no manic or psychotic symptoms. What is the most appropriate next step?

  1. Reassure him that his symptoms will resolve without intervention
  2. Prescribe a benzodiazepine as monotherapy
  3. Assess severity and functional impairment and offer psychotherapy and/or an SSRI Correct answer.
  4. Start an antipsychotic as first-line therapy

Explanation

A major depressive episode requires assessment of severity, suicide risk, and functional impairment, followed by evidence-based treatment such as structured psychotherapy, an SSRI, or both. Antipsychotics and benzodiazepines are not first-line monotherapy for uncomplicated depression.

Question 7Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 70-year-old woman with osteoporosis and a prior vertebral fracture has a FRAX 10-year major osteoporotic fracture risk of 28%. She is already on calcium and vitamin D. Which pharmacologic agent is most appropriate?

  1. An oral bisphosphonate such as alendronate Correct answer.
  2. Long-term hormone replacement therapy
  3. A selective estrogen receptor modulator for all older women
  4. Calcitriol as monotherapy

Explanation

In a patient with a fragility fracture and high FRAX risk, a bisphosphonate such as alendronate is first-line antiresorptive therapy. HRT and SERMs are reserved for specific situations, and calcitriol alone is insufficient for high-risk osteoporosis.

Question 8Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 3-week-old infant is brought in with poor feeding, lethargy, and a temperature of 38.2°C rectally. What is the most appropriate management?

  1. Urgent referral to the emergency department for full sepsis workup and empiric antibiotics Correct answer.
  2. Oral amoxicillin and reassessment in 48 hours
  3. Antipyretic therapy alone with reassurance
  4. Home observation with a follow-up visit in 24 hours

Explanation

Fever in an infant younger than 3 months is a red flag for serious bacterial infection and requires urgent emergency assessment with full sepsis evaluation and empiric antibiotics. Outpatient observation or oral therapy is unsafe at this age.

Question 9Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 52-year-old man with a 30 pack-year smoking history asks about lung cancer screening. He is asymptomatic and has no other significant illness. According to Canadian guidance, which statement is most accurate?

  1. Screening is not recommended at any age for smokers
  2. Sputum cytology is the preferred screening method
  3. Annual low-dose CT screening may be offered to high-risk ever-smokers after shared decision-making Correct answer.
  4. Chest radiography every year is the recommended screening test

Explanation

Low-dose CT screening is recommended for high-risk ever-smokers (typically ages 55 to 74 with a significant pack-year history) after a shared decision-making discussion. Chest radiography and sputum cytology are not recommended screening tests.

Question 10Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 28-year-old woman at 28 weeks' gestation has a 1-hour glucose challenge test of 10.2 mmol/L. What is the most appropriate next step?

  1. Proceed to a diagnostic 75-g oral glucose tolerance test Correct answer.
  2. Repeat the 1-hour challenge test in 2 weeks
  3. Reassure her that the result is normal
  4. Start insulin immediately

Explanation

A 1-hour glucose challenge value above the screening threshold requires a diagnostic 75-g oral glucose tolerance test to confirm gestational diabetes before treatment decisions are made. Insulin is not started without a confirmed diagnosis.

Question 11Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 62-year-old man presents with sudden painless loss of vision in his right eye described as a curtain descending over the field. He has atrial fibrillation. What is the most appropriate immediate action?

  1. Arrange an outpatient ophthalmology visit within 1 week
  2. Send him urgently to the emergency department for assessment of retinal artery occlusion Correct answer.
  3. Refer for elective cataract surgery
  4. Prescribe lubricating eye drops and reassess in 2 weeks

Explanation

A curtain-like visual loss in a patient with atrial fibrillation suggests retinal artery occlusion or transient ischemic attack, which is an ophthalmologic and neurologic emergency requiring immediate assessment. Delay risks permanent vision loss and misses a stroke-risk evaluation.

Question 12Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 40-year-old woman with migraine without aura asks about contraception. She has no other vascular risk factors and does not smoke. Which option is most appropriate?

  1. A progestin-only pill or a copper IUD Correct answer.
  2. A combined vaginal ring
  3. A combined oral contraceptive containing estrogen and progestin
  4. A combined contraceptive patch

Explanation

Migraine without aura is not an absolute contraindication to combined hormonal contraception in women without additional vascular risk factors, but progestin-only methods and IUDs avoid estrogen-related stroke concerns and are reasonable, safe choices. The question asks for the most appropriate option; progestin-only or IUD methods are preferred when minimizing vascular risk.

Question 13Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 55-year-old woman reports fatigue, cold intolerance, weight gain, and constipation. Her TSH is elevated and free T4 is low. What is the most appropriate initial treatment?

  1. Liothyronine (T3) monotherapy
  2. Desiccated thyroid extract
  3. Levothyroxine titrated to normalize TSH Correct answer.
  4. Observation without treatment

Explanation

Primary hypothyroidism with elevated TSH and low free T4 is treated with levothyroxine, titrated to a normal TSH. T3 monotherapy and desiccated thyroid are not recommended because of inconsistent potency and adverse effects.

Question 14Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 68-year-old man with heart failure and reduced ejection fraction (EF 30%) is stable on an ACE inhibitor and beta-blocker. Which additional agent has been shown to reduce mortality in this population?

  1. An alpha blocker
  2. A mineralocorticoid receptor antagonist such as spironolactone Correct answer.
  3. A non-dihydropyridine calcium channel blocker
  4. A thiazolidinedione

Explanation

Mineralocorticoid receptor antagonists reduce mortality in patients with heart failure and reduced ejection fraction who remain symptomatic on standard therapy. Thiazolidinediones, non-dihydropyridine calcium channel blockers, and alpha blockers do not confer this mortality benefit and may worsen heart failure.

Question 15Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 30-year-old man presents with a 2-day history of severe unilateral headache with ipsilateral ptosis, miosis, and lacrimation, occurring several times a day. What is the most likely diagnosis?

  1. Cluster headache Correct answer.
  2. Migraine with aura
  3. Giant cell arteritis
  4. Tension-type headache

Explanation

Severe unilateral periorbital pain with ipsilateral autonomic features such as ptosis, miosis, and lacrimation in a young man is characteristic of cluster headache. Migraine and tension headaches lack these prominent autonomic signs, and giant cell arteritis occurs in older adults.

Question 16Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 6-year-old child presents with a 2-week history of periorbital edema, frothy urine, and weight gain. Urinalysis shows 4+ protein and no hematuria. What is the most likely diagnosis?

  1. Hemolytic uremic syndrome
  2. Acute post-streptococcal glomerulonephritis
  3. IgA nephropathy
  4. Minimal change nephrotic syndrome Correct answer.

Explanation

Nephrotic-range proteinuria, edema, and frothy urine without hematuria in a young child suggest minimal change disease, the most common cause of nephrotic syndrome in children. Post-streptococcal glomerulonephritis and IgA nephropathy typically present with hematuria.

Question 17Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 50-year-old woman with type 2 diabetes has an HbA1c of 8.9% on metformin despite adherence. She has no cardiovascular disease or heart failure. What is the most appropriate next step?

  1. Reassure her that an HbA1c of 8.9% is acceptable
  2. Add a sulfonylurea as the only option
  3. Stop metformin and start basal insulin immediately
  4. Add a second glucose-lowering agent such as a GLP-1 receptor agonist or SGLT2 inhibitor Correct answer.

Explanation

When HbA1c remains above target on metformin, a second agent should be added, with GLP-1 receptor agonists or SGLT2 inhibitors increasingly preferred because of weight and cardiovascular benefits. Insulin is reserved for marked hyperglycemia or failure of oral therapy.

Question 18Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 72-year-old man is brought in by his daughter with 3 days of confusion, poor sleep, and visual hallucinations. He has a history of Parkinson's disease treated with levodopa. What is the most appropriate initial step?

  1. Diagnose dementia and start a cholinesterase inhibitor
  2. Start an antipsychotic immediately
  3. Assess for delirium triggers including infection, medications, and metabolic causes Correct answer.
  4. Increase his levodopa dose

Explanation

Acute confusion with hallucinations in an older adult with Parkinson's disease should first be evaluated for delirium, including infection, medication effects, and metabolic derangements. Antipsychotics can worsen parkinsonism and are not first-line, and increasing levodopa may worsen hallucinations.

Question 19Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 35-year-old woman has a 3-day history of severe sore throat, fever, and anterior neck swelling with odynophagia. Examination reveals drooling and a muffled voice. What is the most appropriate management?

  1. Saltwater gargles and reassurance
  2. Outpatient oral penicillin and follow-up in 48 hours
  3. Elective referral to otolaryngology in 2 weeks
  4. Urgent emergency department referral for airway assessment and imaging Correct answer.

Explanation

Drooling, muffled voice, and neck swelling suggest a deep space neck infection such as a peritonsillar or retropharyngeal abscess, which threatens the airway and requires urgent emergency assessment. Outpatient therapy or delayed referral is unsafe.

Question 20Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 60-year-old woman presents with a 2-day history of a painful, vesicular rash in a dermatomal distribution on the right chest. She reports burning pain. What is the most appropriate treatment if started within 72 hours of rash onset?

  1. Immediate referral for surgical debridement
  2. Topical corticosteroid cream alone
  3. Oral antiviral therapy such as valacyclovir Correct answer.
  4. Oral antibiotic therapy

Explanation

Herpes zoster within 72 hours of rash onset should be treated with oral antiviral therapy to reduce duration and complications, alongside analgesia. Corticosteroids alone and antibiotics do not treat the viral infection.

Question 21Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 48-year-old man with alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. What is the most appropriate immediate treatment?

  1. Oral folic acid alone
  2. Intravenous thiamine Correct answer.
  3. Intravenous glucose alone
  4. Intravenous naloxone

Explanation

The triad of confusion, ataxia, and ophthalmoplegia suggests Wernicke encephalopathy, which requires prompt intravenous thiamine to prevent irreversible neurologic damage. Glucose alone can precipitate or worsen the condition and should be given with thiamine.

Question 22Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 34-year-old woman at 34 weeks' gestation presents with a blood pressure of 160/110 mmHg, headache, and visual changes. Urinalysis shows 3+ protein. What is the most appropriate management?

  1. Oral antibiotics for presumed urinary tract infection
  2. Urgent transfer to hospital for magnesium sulfate and delivery planning Correct answer.
  3. Outpatient antihypertensive therapy with follow-up in 1 week
  4. Bed rest at home with no medication

Explanation

Severe preeclampsia with severe features (severe hypertension, headache, visual symptoms, proteinuria) requires urgent hospital management with magnesium sulfate for seizure prophylaxis and planning for delivery. Outpatient management is unsafe.

Question 23Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 58-year-old man presents with sudden onset of severe epigastric pain radiating to the back, vomiting, and a history of heavy alcohol use. Serum lipase is markedly elevated. What is the most appropriate initial management?

  1. Aggressive intravenous fluid resuscitation and analgesia with monitoring Correct answer.
  2. Immediate oral feeding to stimulate recovery
  3. Prophylactic broad-spectrum antibiotics
  4. Urgent ERCP for all patients

Explanation

Acute pancreatitis is managed with aggressive intravenous fluid resuscitation, analgesia, and monitoring; early oral feeding is generally encouraged as tolerated but not forced, and prophylactic antibiotics and routine ERCP are not indicated without specific features.

Question 24Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 66-year-old woman has a 3-month history of progressive dyspnea, fatigue, and bilateral ankle edema. Examination reveals an elevated jugular venous pressure and a third heart sound. Which diagnostic test is most appropriate initially?

  1. Transthoracic echocardiography Correct answer.
  2. Exercise stress testing
  3. Chest radiography alone
  4. Coronary angiography as the first test

Explanation

Echocardiography is the key initial test to assess cardiac structure and function in suspected heart failure, guiding classification as reduced or preserved ejection fraction and therapy. Chest radiography alone is less specific, and stress testing or angiography are not first steps.

Question 25Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 45-year-old woman presents with fatigue, arthralgia, and a malar rash. She has a positive antinuclear antibody and anti-double-stranded DNA antibodies. What is the most appropriate next step?

  1. Refer to rheumatology and assess for organ involvement Correct answer.
  2. Start high-dose corticosteroids without further assessment
  3. Reassure her that the antibodies are incidental
  4. Prescribe antibiotics for presumed infection

Explanation

Findings suggest systemic lupus erythematosus; referral to rheumatology with assessment for renal, hematologic, and other organ involvement guides treatment. High-dose steroids without assessment and reassurance alone are inappropriate.

Question 26Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 72-year-old woman comes to your office for a routine visit. She has hypertension, type 2 diabetes, and osteoarthritis. She reports no chest pain, dyspnea, or palpitations. According to the Canadian Cardiovascular Society guidelines, which of the following is the most appropriate recommendation regarding acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease in this patient?

  1. Initiate ASA only if her 10-year cardiovascular risk exceeds 20%
  2. Initiate ASA 81 mg daily because her age and diabetes increase her cardiovascular risk
  3. Initiate ASA 325 mg daily because higher doses are more effective in older adults
  4. Do not initiate ASA because the risk of bleeding outweighs the potential benefit Correct answer.

Explanation

The 2016 CCS antiplatelet guidelines recommend against routine ASA for primary prevention in adults without established cardiovascular disease, because the absolute benefit is small and the risk of major bleeding, including gastrointestinal and intracranial hemorrhage, is clinically important. This position is particularly strong for adults over 70 years, in whom bleeding risk is higher. Therefore, ASA should not be started for primary prevention in this patient.

Question 27Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 4-year-old boy is brought to the clinic with a 2-day history of low-grade fever, runny nose, and a new cough. On examination, he is alert and playful, with a temperature of 37.8°C, respiratory rate of 24 breaths/min, and oxygen saturation of 98% on room air. Auscultation reveals scattered coarse breath sounds without crackles or wheezing. Which of the following is the most appropriate management?

  1. Prescribe amoxicillin 80 mg/kg/day for presumed bacterial pneumonia
  2. Recommend supportive care with antipyretics and reassessment if symptoms worsen Correct answer.
  3. Obtain a chest radiograph to confirm the diagnosis before deciding on treatment
  4. Prescribe a 5-day course of azithromycin for atypical pneumonia

Explanation

This child has a mild viral upper respiratory tract infection with no signs of pneumonia, such as tachypnea, hypoxemia, focal crackles, or toxicity. Most uncomplicated viral respiratory infections in children are self-limited and require only supportive care. Antibiotics are not indicated and would contribute to antimicrobial resistance and potential adverse effects.

Question 28Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 58-year-old man with a history of gout presents with an acute attack involving the right first metatarsophalangeal joint. He has hypertension and chronic kidney disease stage 3 (eGFR 40 mL/min/1.73 m²). He is not currently on urate-lowering therapy. Which of the following is the most appropriate initial treatment for this acute gout flare?

  1. Allopurinol 300 mg orally daily started immediately
  2. Colchicine 1.2 mg orally once, then 0.6 mg one hour later, followed by 0.6 mg daily
  3. Prednisone 40 mg orally daily for 5 days Correct answer.
  4. Indomethacin 50 mg orally three times daily until symptoms resolve

Explanation

In a patient with chronic kidney disease, colchicine and NSAIDs carry increased risks of toxicity and acute kidney injury, respectively. Systemic corticosteroids are a safe and effective alternative for acute gout when NSAIDs and colchicine are contraindicated or poorly tolerated. Allopurinol is not used to treat acute flares and should not be started during an acute attack without anti-inflammatory cover.

Question 29Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 32-year-old woman presents with a 3-day history of dysuria, urinary frequency, and suprapubic discomfort. She has no fever, flank pain, or vaginal discharge. She is otherwise healthy and has no allergies. A urine dipstick shows positive leukocyte esterase and nitrites. According to the 2023 Canadian Urological Association guideline, which of the following is the most appropriate first-line antibiotic?

  1. Ciprofloxacin 500 mg orally twice daily for 7 days
  2. Trimethoprim-sulfamethoxazole 160/800 mg orally twice daily for 3 days
  3. Nitrofurantoin 100 mg orally twice daily for 5 days Correct answer.
  4. Amoxicillin 500 mg orally three times daily for 7 days

Explanation

Nitrofurantoin is a first-line agent for uncomplicated cystitis in women, with a recommended duration of 5 days. It achieves high urinary concentrations and has excellent activity against Escherichia coli, the most common causative organism. Fluoroquinolones are reserved for more serious infections due to collateral damage and resistance concerns.

Question 30Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 45-year-old woman presents with a 6-month history of episodic palpitations, sweating, and tremor. She has lost 8 kg unintentionally. On examination, her heart rate is 110 beats/min and irregular, and she has a fine tremor and lid lag. Laboratory tests show a suppressed TSH and elevated free T4. Which of the following is the most appropriate initial diagnostic test to determine the cause of her hyperthyroidism?

  1. Radioactive iodine uptake scan
  2. Fine-needle aspiration biopsy of the thyroid
  3. Thyroid peroxidase antibody titre Correct answer.
  4. Thyroid ultrasound

Explanation

In a patient with biochemical hyperthyroidism, the next step is to determine the etiology. A thyroid peroxidase antibody titre is the most appropriate initial test because Graves' disease is the most common cause, and positive antibodies support this diagnosis. Radioactive iodine uptake scanning is reserved for cases where the diagnosis remains unclear or for differentiating among causes such as toxic nodular goiter.

Question 31Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 68-year-old man with moderate Alzheimer's disease is brought in by his wife, who reports that he has become increasingly agitated and has been physically aggressive toward her over the past 2 weeks. He has no new medical symptoms, and a recent workup for reversible causes was negative. Non-pharmacological interventions have been attempted without success. Which of the following is the most appropriate initial pharmacological approach?

  1. Lorazepam 1 mg orally at bedtime
  2. Quetiapine 25 mg orally at bedtime
  3. Risperidone 0.25 mg orally twice daily Correct answer.
  4. Haloperidol 0.5 mg orally twice daily

Explanation

For severe agitation or aggression in dementia that poses a risk to the patient or others and has not responded to non-pharmacological measures, atypical antipsychotics are the preferred pharmacological option. Risperidone is commonly used at a low starting dose (0.25 mg twice daily) and titrated cautiously. Typical antipsychotics and benzodiazepines are generally avoided because of higher risks of extrapyramidal symptoms, sedation, and falls.

Question 32Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 28-year-old woman presents with a 2-day history of a painful, vesicular rash on the right side of her chest in a dermatomal distribution. She is 34 weeks pregnant. Which of the following is the most appropriate management?

  1. Oral acyclovir 800 mg five times daily for 7 days Correct answer.
  2. Oral valacyclovir 1 g three times daily for 7 days
  3. Hospital admission for intravenous acyclovir
  4. Topical calamine lotion and oral acetaminophen as needed

Explanation

Herpes zoster in pregnancy is managed with antiviral therapy to reduce the duration and severity of symptoms and to prevent complications. Acyclovir is preferred in pregnancy because of its extensive safety data, and the standard dose for herpes zoster is 800 mg five times daily for 7 days. Valacyclovir is also effective but has less pregnancy data, and intravenous therapy is reserved for severe or disseminated disease.

Question 33Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 50-year-old woman presents with a 3-month history of fatigue, weight gain, and cold intolerance. Her TSH is 8.5 mIU/L (normal 0.4–4.0) and free T4 is 10 pmol/L (normal 9–19). She has no symptoms of heart disease and is not pregnant. According to the Canadian guidelines, which of the following is the most appropriate management?

  1. Initiate liothyronine 5 mcg twice daily
  2. Initiate levothyroxine 25 mcg daily and titrate every 6 weeks Correct answer.
  3. Initiate levothyroxine at a weight-based dose of 1.6 mcg/kg/day
  4. Repeat thyroid function tests in 6 months without treatment

Explanation

This patient has overt hypothyroidism (elevated TSH with low-normal free T4) and symptoms, so treatment is indicated. In older adults or those with possible cardiac disease, levothyroxine should be started at a low dose (e.g., 25 mcg daily) and titrated every 6 weeks based on TSH. A full weight-based replacement dose is reserved for younger, otherwise healthy patients without cardiac risk.

Question 34Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 62-year-old man with type 2 diabetes and a history of myocardial infarction 2 years ago presents for follow-up. His current medications include metformin, empagliflozin, atorvastatin, and acetylsalicylic acid. His blood pressure is 128/78 mmHg, and his HbA1c is 7.2%. Which of the following is the most appropriate recommendation regarding his diabetes management?

  1. Switch empagliflozin to a DPP-4 inhibitor
  2. Add basal insulin to achieve an HbA1c below 6.0%
  3. Add a sulfonylurea to lower his HbA1c below 6.5%
  4. Continue current therapy and reassess in 3 to 6 months Correct answer.

Explanation

In a patient with type 2 diabetes and established cardiovascular disease, the goal is to maintain HbA1c in a personalized target range, often 7.0–8.0% for those with significant comorbidity. This patient's HbA1c of 7.2% is within a reasonable target, and his current regimen includes an SGLT2 inhibitor with proven cardiovascular benefit. Intensifying therapy is not necessary and could increase the risk of hypoglycemia.

Question 35Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 24-year-old woman presents with a 2-day history of dysuria and urinary frequency. She has no fever, flank pain, or vaginal discharge. She is not pregnant and has no allergies. A urine culture is pending. Which of the following is the most appropriate empiric antibiotic?

  1. Nitrofurantoin 100 mg orally twice daily for 5 days Correct answer.
  2. Trimethoprim-sulfamethoxazole 160/800 mg orally twice daily for 3 days
  3. Ciprofloxacin 500 mg orally twice daily for 7 days
  4. Amoxicillin 500 mg orally three times daily for 7 days

Explanation

Nitrofurantoin is a first-line agent for uncomplicated cystitis in women, with a recommended duration of 5 days. It achieves high urinary concentrations and has excellent activity against Escherichia coli, the most common causative organism. Fluoroquinolones are reserved for more serious infections due to collateral damage and resistance concerns.

Question 36Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 70-year-old woman with osteoporosis and a prior vertebral fracture has a FRAX 10-year major osteoporotic fracture risk of 25%. She has no contraindications to bisphosphonates. Which of the following is the most appropriate pharmacological treatment?

  1. Calcium and vitamin D supplementation alone
  2. Teriparatide 20 mcg subcutaneously daily
  3. Raloxifene 60 mg orally daily
  4. Alendronate 70 mg orally weekly Correct answer.

Explanation

This patient has a very high fracture risk (prior fragility fracture and FRAX major osteoporotic risk of 25%), which warrants potent antiresorptive therapy. Alendronate, an oral bisphosphonate, is a first-line treatment for postmenopausal osteoporosis and has proven efficacy in reducing vertebral and hip fractures. Calcium and vitamin D alone are insufficient for fracture prevention in high-risk patients.

Question 37Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 55-year-old man with a 30 pack-year smoking history asks about lung cancer screening. He is asymptomatic and has no other significant medical history. According to the Canadian Task Force on Preventive Health Care, which of the following is the most appropriate recommendation?

  1. Do not recommend screening because the harms outweigh the benefits
  2. Offer annual chest radiograph screening
  3. Offer low-dose CT screening only if he has a family history of lung cancer
  4. Offer annual low-dose CT screening for 3 consecutive years Correct answer.

Explanation

The Canadian Task Force on Preventive Health Care recommends screening with low-dose CT for adults aged 55–74 with a smoking history of at least 30 pack-years who currently smoke or quit within the past 15 years. Screening is offered annually for 3 consecutive years. Chest radiography is not recommended for lung cancer screening because it does not reduce mortality.

Question 38Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 3-week-old infant is brought in with poor feeding, lethargy, and a temperature of 38.2°C rectally. Which of the following is the most appropriate initial step in management?

  1. Obtain a urine culture and start oral antibiotics as an outpatient
  2. Administer acetaminophen and reassess in 2 hours
  3. Perform a lumbar puncture only if the blood culture is positive
  4. Obtain a full sepsis workup including blood, urine, and cerebrospinal fluid cultures and start empiric antibiotics Correct answer.

Explanation

A febrile infant younger than 3 months is at high risk for serious bacterial infection, including sepsis and meningitis. The standard of care is a full sepsis evaluation (blood, urine, and cerebrospinal fluid cultures) and prompt initiation of empiric intravenous antibiotics. Observation or outpatient management is not appropriate in this age group.

Question 39Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 35-year-old woman presents with a 3-day history of severe sore throat, fever, and anterior neck swelling with odynophagia. Examination reveals a tender, enlarged thyroid gland. She has no history of thyroid disease. Which of the following is the most likely diagnosis?

  1. Subacute granulomatous (de Quervain) thyroiditis Correct answer.
  2. Graves' disease
  3. Acute suppurative thyroiditis
  4. Hashimoto's thyroiditis

Explanation

Subacute granulomatous thyroiditis typically presents with a painful, enlarged thyroid, fever, and symptoms of thyrotoxicosis following a viral infection. The erythrocyte sedimentation rate is usually elevated. Acute suppurative thyroiditis is rare and usually bacterial, with more severe systemic symptoms and abscess formation.

Question 40Family Medicine (Assessment Objectives for Certification in Family Medicine)

A 60-year-old woman presents with a 2-day history of a painful, vesicular rash in a dermatomal distribution on the right side of her chest. She has no fever or systemic symptoms. Which of the following is the most appropriate treatment to reduce the risk of postherpetic neuralgia?

  1. Oral valacyclovir 1 g three times daily for 7 days Correct answer.
  2. Topical lidocaine patch applied to the affected area
  3. Oral acyclovir 800 mg five times daily for 7 days
  4. Oral prednisone 50 mg daily for 7 days

Explanation

Valacyclovir is a prodrug of acyclovir with higher bioavailability, allowing less frequent dosing (three times daily) and achieving more consistent plasma concentrations. It is effective in reducing the duration of herpes zoster and the risk of postherpetic neuralgia when started within 72 hours of rash onset. Acyclovir is also effective but requires five daily doses and has lower bioavailability.

Question 41Emergency Medicine

A 62-year-old man with a known abdominal aortic aneurysm presents with sudden severe abdominal and back pain and is hypotensive. He is conscious but pale and diaphoretic. Which single initial management step is most appropriate?

  1. Prompt surgical consultation with permissive hypotension and blood products Correct answer.
  2. Urgent CT angiography before any resuscitation
  3. Trial of intravenous opioids and observation for response
  4. Immediate crystalloid bolus of 2 L to normalize blood pressure

Explanation

A symptomatic or ruptured abdominal aortic aneurysm is a surgical emergency. Resuscitation should be balanced, using blood products and permissive hypotension to avoid dislodging clot, while the vascular surgeon is mobilized. Delaying definitive repair for imaging or aggressive crystalloid loading increases mortality.

Question 42Emergency Medicine

A 24-year-old woman is brought in after a bee sting with diffuse urticaria, wheeze, and a blood pressure of 78/40 mmHg. Intramuscular epinephrine has been given. Which is the most appropriate immediate next step?

  1. Obtain serum tryptase before further treatment
  2. Administer IV epinephrine bolus immediately in all cases
  3. Give oral antihistamine and observe for 30 minutes
  4. Position supine with legs elevated and start rapid IV crystalloid Correct answer.

Explanation

Anaphylaxis with hypotension requires supine positioning with legs elevated to support venous return and rapid intravenous fluid resuscitation for distributive shock. Epinephrine is first-line and has already been given; antihistamines and tryptase testing are adjuncts or diagnostics that must not delay resuscitation.

Question 43Emergency Medicine

Which finding best supports a diagnosis of acute bacterial meningitis in an adult awaiting lumbar puncture?

  1. Fever with new confusion and neck stiffness Correct answer.
  2. Nuchal rigidity alone
  3. Isolated photophobia
  4. Kernig sign alone

Explanation

Meningeal signs have limited individual sensitivity and specificity, but the combination of fever, altered mental status, and neck stiffness raises the probability substantially and supports empiric treatment. Isolated signs such as nuchal rigidity or photophobia are neither sensitive nor specific enough on their own.

Question 44Emergency Medicine

A 30-year-old woman with a history of asthma presents with sudden pleuritic chest pain and dyspnea. She is tachycardic, hypoxic, and hypotensive, with tracheal deviation to the left and absent breath sounds on the right. Which intervention should occur first?

  1. Portable chest radiograph to confirm the diagnosis
  2. CT pulmonary angiogram for suspected embolism
  3. Emergent intubation and positive pressure ventilation
  4. Needle decompression of the right hemithorax Correct answer.

Explanation

Tension pneumothorax is a clinical diagnosis, and treatment must not await imaging. Immediate needle decompression followed by tube thoracostomy relieves the obstructive shock; positive pressure ventilation before decompression can worsen the tension.

Question 45Emergency Medicine

A patient arrives in cardiac arrest with a rhythm showing fine chaotic activity with no discernible QRS complexes. After CPR is started, which is the correct first drug intervention in the cardiac arrest algorithm?

  1. Epinephrine 1 mg IV push Correct answer.
  2. Amiodarone 300 mg IV push
  3. Sodium bicarbonate 1 mEq/kg IV push
  4. Atropine 1 mg IV push

Explanation

Epinephrine is given as soon as feasible in any cardiac arrest, including ventricular fibrillation and pulseless ventricular tachycardia. Antiarrhythmics such as amiodarone are added after defibrillation attempts and epinephrine, and atropine has no role in pulseless arrest.

Question 46Emergency Medicine

A 68-year-old man with atrial fibrillation on warfarin presents with a severe headache and a witnessed generalized seizure. CT shows an acute intracerebral hemorrhage and his INR is 3.8. Which is the most appropriate immediate reversal strategy?

  1. Fresh frozen plasma alone
  2. Vitamin K alone
  3. Platelet transfusion
  4. Prothrombin complex concentrate plus intravenous vitamin K Correct answer.

Explanation

For warfarin-associated intracerebral hemorrhage, rapid reversal requires a prothrombin complex concentrate to replace the vitamin K-dependent factors, combined with intravenous vitamin K to sustain reversal. Vitamin K alone or plasma alone acts too slowly or requires large volumes.

Question 47Emergency Medicine

A 19-year-old presents after a high-speed motorcycle crash. He is alert with a systolic pressure of 88 mmHg, heart rate of 128, and cool extremities. Which statement best reflects the initial resuscitation principle in hemorrhagic shock?

  1. Target a systolic pressure above 140 mmHg to ensure organ perfusion
  2. Give 2 L crystalloid to normalize pressure before blood products
  3. Prioritize balanced blood product transfusion with permissive hypotension until hemorrhage control Correct answer.
  4. Withhold fluids until a full trauma series is complete

Explanation

In hemorrhagic shock, early balanced blood product transfusion and damage-control resuscitation with permissive hypotension reduce dilutional coagulopathy and improve outcomes. Large crystalloid volumes worsen coagulopathy and should be minimized while hemorrhage control is pursued.

Question 48Emergency Medicine

A 55-year-old man with diabetes presents with a hot, swollen, exquisitely tender knee and fever. Joint aspiration yields turbid fluid. Which finding on synovial fluid analysis most supports septic arthritis?

  1. Synovial white cell count of 1,200 cells/µL
  2. Negatively birefringent needle-shaped crystals
  3. Synovial glucose equal to serum glucose
  4. Positive Gram stain with a synovial white cell count above 50,000 cells/µL Correct answer.

Explanation

Septic arthritis is supported by a markedly elevated synovial white cell count, typically above 50,000 cells/µL, and a positive Gram stain or culture. Crystal analysis identifies gout or pseudogout, which can coexist with infection and does not exclude it.

Question 49Emergency Medicine

A 7-year-old with a barking cough and inspiratory stridor has mild retractions but no drooling or toxic appearance. Which management is most appropriate?

  1. Oral antibiotics and observation
  2. Heliox inhalation alone
  3. Immediate endotracheal intubation
  4. Nebulized epinephrine plus oral dexamethasone Correct answer.

Explanation

This presentation is croup, and treatment with a single dose of dexamethasone, with nebulized epinephrine for moderate symptoms, reduces airway edema and symptoms. Intubation is reserved for severe airway compromise and should not be performed routinely.

Question 50Emergency Medicine

A 45-year-old woman presents with sudden severe headache described as the worst of her life. Noncontrast CT head is negative and she remains alert with no focal deficits. Which is the most appropriate next step to evaluate for subarachnoid hemorrhage?

  1. Lumbar puncture at least 12 hours after symptom onset, or CT angiography Correct answer.
  2. MRI brain in 6 weeks
  3. Lumbar puncture immediately after CT
  4. Discharge with analgesia and follow-up

Explanation

When noncontrast CT is negative within the first hours after a thunderclap headache, lumbar puncture for xanthochromia is most sensitive at least 12 hours after symptom onset, or CT angiography can be used. Immediate lumbar puncture may miss xanthochromia if performed too early.