(BQ) Part 1 book Essentials for the Canadian medical licensing exam - Review and prep for MCCQE part I presents the following contents: Introduction; cultural-Communication, legal, ethical and organizational aspects of medicine; cardiology and cardiovascular surgery, dermatology, emergency medicine, endocrinology, otolaryngology, family and community medicine, gastroenterology, general surgery.
Essentials for the Canadian Medical Licensing Exam REVIEW AND PREP FOR MCCQE PART I Jeeshan H Chowdhury BSc, MSc (Oxon) Joint MD/DPhil Student University of Alberta Edmonton, Alberta University of Oxford Oxford, United Kingdom Shaheed Merani PhD Joint MD/PhD Student University of Alberta Edmonton, Alberta Acquisitions Editor: Charley Mitchell Managing Editor: Kelly Horvath, Kelley Squazzo Marketing Manager: Emilie Moyer Production Editor: Julie Montalbano Designer: Stephen Druding Compositor: Laserwords Private Limited, Chennai, India Copyright © 2010 by Lippincott Williams & Wilkins, a Wolters Kluwer business 351 West Camden Street Baltimore, MD 21201 530 Walnut Street Philadelphia, PA 19106 Printed in the United States of America All rights reserved This book is protected by copyright No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright To request permission, please contact Lippincott Williams & Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via email at permissions@lww.com, or via website at lww.com (products and services) Library of Congress Cataloging-in-Publication Data Essentials for the Canadian medical licensing exam : review and prep for MCCQE / [edited by] Jeeshan Chowdhury, Shaheed Merani p ; cm Includes bibliographical references and index ISBN 978-0-7817-7650-9 (alk paper) Physicians—Licenses—Canada—Examinations—Study guides I Chowdhury, Jeeshan II Merani, Shaheed [DNLM: Medicine—Canada—Examination Questions W 18.2 E78 2010] RC58.E87 2010 610.71’171—dc22 2009000750 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: at http://www.lww.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 AM to PM, EST Dedicated to my parents and brothers —Jeeshan H Chowdhury Dedicated to my family, especially my grandmother —Shaheed Merani PR E F A C E The Medical Council of Canada Qualifying Examination (MCCQE) Part I is an important milestone for medical students, signifying a culmination of years’ of training in basic science and clinical medicine The Medical Council of Canada (MCC) recommends numerous separate texts as reference for this exam preparation Such a vast reading list is neither a practical nor a feasible means of approaching this critical exam for most candidates The singular intent of this text is to provide a succinct yet complete review for the MCCQE Part I using the most efficient and effective means This book is based entirely on the MCC’s Objectives for the Qualifying Examination ‘‘that lay out exactly what you have to know for any of the MCC examinations.’’ This text contains only the specific and essential information required to meet the Objectives—all extraneous information has been deliberately omitted This text avoids time-wasting prose and effusive lists Information is presented only in concise and easily assimilated visual formats A focus on tables and flow charts allow complex and detailed concepts to be swiftly and effectively reviewed for comprehension and retention Text within boxes signals the reader to key competencies highlighted by the Objectives This text is a collaborative project that combines the perspective and insights of students preparing for the examination with the experience of residents and acumen of faculty The result is a novel and innovative resource to aid in the process of preparing for the MCCQE Part I As medical school curricula are becoming more tailored to the exam, we believe it will also prove useful in your general studies as well We would appreciate your feedback on how to improve this resource and wish you the best success in the MCCQE Part I Jeeshan H Chowdhury and Shaheed Merani v N OT E TO RE A D E R S Please read the following carefully: This publication is provided to assist you in preparing for the Medical Council of Canada Licensing Examination, Part I Under no circumstances should the information contained in this publication be relied upon for any other purpose Although the authors have made reasonable efforts to ensure the accuracy of the information contained herein, the authors, editors, and publisher not guarantee or represent that this information is accurate, complete, current, or suitable for any particular purpose or jurisdiction The authors, editors, and publisher make no warranty whatsoever, whether express or implied, with respect to this publication and its contents, and in no event will the authors, editors, or publisher be liable for any loss, damage, or injury arising from or connected to use of this publication, including without limitation loss of profits, direct, indirect, special, incidental, consequential, or punitive damages This exclusion of liability will apply whether such loss, damage, or injury is based in contract, tort, or negligence (including without limitation gross negligence) vi CO N T R I B U T O R S Contributing Editor Aleem M.F Bharwani, MD, FRCP(C) General Internal Medicine Fellow Department of Medicine University of Calgary Calgary, Alberta Specialist in Internal Medicine Alberta Health Services; Master in Public Policy Harvard Kennedy School Cambridge, Massachusettes, USA Contributors Al’a Abdo Medical Student Universit´e de Montr´eal Montreal, Quebec Hernish Jayant Acharya, MD Resident Department of Physical Medicine and Rehabilitation Glenrose Rehabilitation Hospital, University of Alberta Edmonton, Alberta Martha Ainslie, MD, FRCPC Clinical Assistant Professor Department of Medicine University of Calgary Calgary, Alberta; Respirologist, Division of Respiratory Medicine Department of Medicine Peter Lougheed Hospital Calgary, Alberta Meghan Brison, MD Resident Department of Emergency Medicine University of British Columbia Vancouver, British Columbia Michael F Byrne, MD (Cantab), BA, MA, MRCP (UK), FRCPC Clinical Associate Professor University of British Columbia Vancouver, British Columbia Michelle L Catton, MD Resident Department of Internal Medicine University of Saskatchewan Saskatoon, Saskatchewan Andrea Cheung, MD Family Medicine Resident Toronto East General Hospital University of Toronto Toronto, Ontario Franc¸ois B´enard, MD, FRCSC Program Director Department of Urology Universit´e de Montr´eal Montreal, Quebec Oliver Haw For Chin, MD, FRCPC Assistant Professor Division of General Internal Medicine Department of Medicine University of Calgary Calgary, Alberta Fraser R Brenneis, MD, CCFC, FCFP Senior Associate Dean (Education) Faculty of Medicine & Dentistry Department of Family Medicine University of Alberta Edmonton, Alberta Jeeshan H Chowdhury, BSc, MSc (Oxon) Joint MD/DPhil Student University of Alberta, Edmonton Alberta, Canada; University of Oxford Oxford, United Kingdom vii viii Contributors Raiyan Chowdhury, BSc, MD Resident Division of Otolaryngology Head and Neck Surgery University of Alberta Edmonton, Alberta John Crossley, MD, CCFP(EM), FRCPC Assistant Professor; Program Director Royal College Training Program in Emergency Medicine Division of Emergency Medicine Department of Medicine McMaster University Hamilton, Ontario Yen Dang, MD Resident Division of General Surgery Department of Surgery Queen’s University Kingston, Ontario Niloofar Dehghan Medical Student University of Ottawa Ottawa, Ontario Myriam Farah, MD Chief Medical Resident Department of Medicine University of British Columbia Vancouver, British Columbia Robert J Feibel, MD, FRCSC Associate Professor Department of Orthopaedic Surgery The Ottawa Hospital Ottawa, Ontario W.L Alan Fung, MD, MPhil, ScM Resident Physician Department of Psychiatry University of Toronto, Toronto Ontario, Canada; Department of Epidemiology Harvard University, Boston Massachusetts, USA; Gerontology Research Unit Massachusetts General Hospital Harvard Medical School Boston, Massachusetts, USA Ahmed Galal, MD, FRCP Director McGill Stem Cell Transplant Program Montreal, Quebec; Attending Staff Division of Hematology, Department of Medicine Royal Victoria Hospital Montreal, Quebec; Associate Professor Faculty of Medicine McGill University Montreal, Quebec Stephane Michel Gauthier, MD Resident Department of Internal Medicine University of Ottawa Ottawa, Ontario Ralph George, MD, FRCS Medical Director CIBC Breast Centre St Michael’s Hospital Toronto, Ontario Nicholas Giacomantonio, MD, FRCPC Associate Professor of Medicine Department of Medicine Dalhousie University Halifax, Nova Scotia; Cardiologist Department of Medicine QE II Health Sciences Centre Halifax, Nova Scotia Jeremy Gilbert, MD, FRCPC Department of Medicine Division of Endocrinology University of Toronto Toronto, Ontario Andr´ee Gruslin, MD, FRCS Associate Professor Faculty of Medicine Department of Obstetrics and Gynecology University of Ottawa Ottawa, Ontario; Maternal Fetal Medicine Specialist Department of Obstetrics and Gynecology The Ottawa Hospital Ottawa, Ontario Mohamed Shahul Hameed, MD Attending Physician Eastern Maine Medical Centre Bangor, Maine, USA 274 Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I Table 10.4 Approach to Abdominal Mass by Location Condition Anatomical Location Signs/Symptoms Workup Management Hepatomegaly Right subcostal area Palpable lower border of liver, liver span >12 cm Hepatic U/S and CT Jaundice, scleral icterus, deep palpation-induced pain, Hx of right shoulder pain AFP serology, Hepatic U/S and CT See Chapter 9— Hepatomegaly General surgery referral Recent onset of diabetes mellitus, darkening urine, changing color stools Hx of acute or chronic pancreatitis, abdominal trauma Positive Castell sign, palpable spleen CA 19-9 serology, abdominal U/S and CT Abdominal U/S and CT Hx of abnormal vaginal bleeding ± discharge Endometrial biopsy Hx of abdominal pain, bloating, irregular menses or change in bowels Hx of fatigue, breast tenderness or enlargement, N/V, increased urination, amenorrhea CA-125 serology Hx of urinary frequency, dysuria, change in urine appearance Bladder U/S Irregular abdominal mass, exclusively in pediatric patients CBC, ESR, AXR, and CT Hepatoma Pancreatic tumor Left subcostal area Pancreatic pseudocyst Splenomegaly Uterine tumor Suprapubic area Ovarian tumor Pregnancy Enlarged bladder Neuroblastoma Crosses the midline General surgery referral See Chapter 11— Splenomegaly hCG test, suprapubic U/S Gynecology referral See Chapter 14 —Antepartum Care Treat cause Oncology referral Table 10.5 Biopsies Pathologic Condition Type of Biopsy Percutaneous Hepatomegaly X Enlarged kidneys X Lymphomasa Sarcomasa Endoscopic Laparoscopic X X X X X X Gastrointestinal cancers Endometrial X Ovarian cancer X Uterine cancer X Neuroblastoma X Abdominal wall mass X X is a checkmark to indicate biopsy performed Biopsies are not indicated for pelvic organ enlargement or in abdominal aortic aneurysms a Type of biopsy used depends on mass location ABDOMINAL MASS – ADRENAL MASS DEFINITION Located in the adrenal medulla or cortex, most are nonfunctioning and are found incidentally during radiologic investigation of the abdomen Functioning masses must be surgically removed Chapter 10 • General Surgery 275 CAUSAL CONDITIONS Figure 10.6 Adrenal masses (From Bickley, LS and Szilagyi, P Bates’ guide to physical examination and history taking, 8th ed Philadelphia: Lippincott Williams & Wilkins; 2003.) CLINICAL BOX Fine Needle Biopsy • • • • • CLINICAL BOX Classic Triad of Pheochromocytoma Episodic headaches Sweating Tachycardia Differentiates between primary and metastatic adrenal tumors Cannot differentiate between a benign adrenal mass and rare adrenal carcinomas Use has fallen with advances in imaging modalities Indicated if there is suspicion of cancer outside the adrenal gland and in staging of a known cancer Pheochromocytoma should be first ruled out before fine needle biopsy to prevent progression to a hypertensive crisis APPROACH RADIOLOGIC FEATURES OF ADRENAL MASSES Benign Adenomas • • • • • Round and homogeneous density Smooth contour and sharp margination Unilateral 10 HU Chapter 10 • General Surgery Figure 10.8 Approach to adrenal mass discovery in patient with hormonal excess state Adrenal Metastases • Irregularly shaped and inhomogeneous density • Larger masses are invasive, irregular, and may present with central necrosis or hemorrhage • Bilateral • High unenhanced CT attenuation values >10 HU 277 278 Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I MANAGEMENT OF A FUNCTIONING MASS Cushing Syndrome • Unilateral adrenalectomy often curative • Medical treatment if surgery unsuccessful • Ketoconazole used to control hypercortisolism Conn Syndrome • Correction of hypokalemia • Hypertension control with spirolactone, thiazides, or ACE inhibitors • Surgical resection Pheochromocytoma • α- Adrenergic receptor blocker to control blood pressure and restore plasma volume • β- Blockers should never be started before α-blockers to avert hypertensive crisis • Surgical resection ABDOMINAL MASS – HERNIA DEFINITION CLINICAL BOX Common Types of Hernia Indirect inguinal: Sac lies within the spermatic cord Direct inguinal: Sac parallels the spermatic cord Femoral hernia: Sac descends through the femoral canal beneath the inguinal ligament Figure 10.9 Causal conditions of hernia Protrusion of peritoneal structures through a congenital or acquired abnormal opening in the walls of their containing cavities One in four males develop an inguinal hernia May be: Reducible or irreducible (incarcerated) Obstructed Strangulated Inflamed CAUSAL CONDITIONS Chapter 10 • General Surgery 279 CLINICAL BOX CLINICAL BOX Peritoneal Signs Hernias in Males • Guarding • Rebound tenderness • Indirect inguinal hernias more frequent in males for embryological reasons • Related to failure of processus vaginalis closure in the male embryogenesis Figure 10.10 Differential diagnosis of a mass in the groin APPROACH MANAGEMENT Asymptomatic reducible hernias treated through open or laparoscopic surgery Irreducible hernias at a high risk for strangulation and must be treated urgently UNTREATED HERNIAS COMPLICATIONS Incarceration, obstruction, and strangulation Herniation of the female genitalia, pregnancy in a hernial sac Involvement of the hernial sac in disease processes (e.g., carcinoma, peritonitis, acute appendicitis, endometriosis) Rupture of the hernia, spontaneous or traumatic Urinary tract complications, hernia of the bladder, the ureter, and of a urinary ileal conduit Testicular strangulation (infants, adults with large giant inguinoscrotal hernias) FACTORS AFFECTING POSTOPERATIVE RECURRENCE Aberrant Collagen States or Metabolic Disorders Ehler–Danlos syndrome Osteogenesis imperfect Compromised Tissue Healing Malnutrition Compromised or suppressed immunity Increased Intra-Abdominal Pressure Obesity Ascites 280 Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I Peritoneal dialysis Chronic cough Intraperitoneal mass Organomegaly Pregnancy Constipation Straining on urination 10 Prostatism 11 Lifting heavy weights Iatrogenic Factors Postoperative infection Failure to repair internal inguinal ring Damage to floor of inguinal canal Use of absorbable sutures Inadequate sac reduction INVESTIGATIONS Cough impulse: Patient should stand erect Coughing results in mass swelling and increase in tension Transillumination: Serous-containing enlargements (e.g., hydrocele or spermatocele) will light up brightly Herniography: Uncommon, used in investigating hidden hernias Ultrasonography See Figure 10.11 ACUTE ABDOMINAL PAIN DEFINITION Defined as pain 20 min, radiates to shoulder or back Dull ache and tenderness along McBurney point Appendicitisa Peptic ulcer disease/gastritis Clinical Onset − Acute hepatitis Biliary colic Burning epigastric pain after eating, relieved by food and antacids RUQ pain Progressive aching, cramping epigastric or RUQ pain a few hours after a meal and lasting 0.5 –6 h LUQ pain Splenic infarct Gastroesophageal reflux disease Epigastric pain Hepatic abscess RUQ pain LUQ pain and tenderness Fever, splenomegaly Hx of infection, embolic disease, trauma, malignant hematologic conditions, or immune-suppression + = present; – = absent a Appendicitis typically presents as diffuse central abdominal pain that later localizes to the RLQ Gastroenterology referral General surgery referral Treat cause Serum aminotransferase levels Abdominal U/S 24-h esophageal pH test Supportive treatment General surgery referral if condition worsens Education, reassurance, dietary/lifestyle changes; general surgery referral if condition worsens General surgery referral Chapter 10 • General Surgery 285 Table 10.8 Approach to Patient with Lower Abdominal Pain Condition Peritoneal Signs? Clinical Onset Other Signs Workup Management Diverticulitis + Persistent LLQ pain Abdominal distension, N/V, constipation, anorexia, fever Anorexia, N/V, guarding, positive Rovsing, psoas, and obturator signs Painful enlargement of previous hernia, abdominal distension, N/V, constipation, anorexia Vaginal bleeding Abdominal CT Urgent general surgery referral Temperature >38◦ C, cervical/vaginal discharge Pelvic U/S, pap smear, CBC N/V, fever, Hx of recent strenuous physical activity Pelvic U/S, Doppler N/V before pain onset, fever, diarrhea, anorexia, current or Hx of URTI Abdominal CT General surgery referral Diarrhea, rectal bleeding, tenesmus, occult blood loss, anemia, weight loss, fever Dysuria, urgency, urge incontinence, fever N/V Contrast AXR Gastroenterology referral Urinalysis and urine culture Urinalysis, abdominal U/S, or CT Treat cause Appendicitisa Dull ache and tenderness along McBurney point Lower abdominal pain Incarcerated hernia Ectopic pregnancy Sudden cramping genital pain in pregnant female patient Lower abdominal, bilateral adnexal, and cervical motion tenderness Sudden, severe unilateral lower abdominal pain that worsens intermittently Breast tenderness, N/V, fatigue, abdominal distension Pelvic inflammatory disease/salpingitis Ovarian torsion Mesenteric lymphadenitis Inflammatory bowel disease Urinary tract infection Renal colic a − Mild RLQ pain Fever, limitation of hip movement, Hx of Crohn disease, or appendicitis Crampy RLQ pain Lower abdominal aching pain Intermittent sudden onset of severe flank pain originating at the costovertebral angle and radiating anteriorly in waves to the groin Appendicitis typically presents as diffuse central abdominal pain that later localizes to the RLQ General surgery referral None Pelvic U/S Urgent OB/GYN referral Urology referral 286 Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I APPLIED SCIENTIFIC CONCEPTS Figure 10.13 Neurologic basis of abdominal pain ANORECTAL PAIN DEFINITION • Caused by infectious, dermatologic, or anorectal disease • May require urgent surgical referral CAUSAL CONDITIONS ANORECTAL DISEASE • • • • • • • • • Abscess (related to IBD) Fistula (related to IBD) Fissures Hemorrhoids • Internal hemorrhoid • External hemorrhoid Chemotherapy Neuropathic Psychological Coccygeal pain Other pelvic floor muscle syndromes DERMATOLOGIC DISEASE • • • • Psoriasis Contact/atopic dermatitis Malignancy Ulcer INFECTIONS • • • • Sexually transmitted diseases Bacterial infections Fungal infections Parasitic infections APPROACH CLINICAL BOX Anoscopy and Sigmoidoscopy • Anoscopy: viewing hemorrhoids or potential erosions in the mucosal wall • Sigmoidoscopy: detecting friability or ulceration within the rectal mucosa Chapter 10 • General Surgery Figure 10.14 Approach to patient with anorectal pain 287 288 Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I Table 10.9 Approach to Patient with Defecation-Associated Pain Description One or more para-anal openings, palpable cord-like para-anal tract, Hx of previous abscesses, intermittent or constant purulent or serous anginous discharge from para-anal opening Tender anorectal mass, fever, DRE reveals a tender fluctuant mass on rectal wall, Hx of continuous deep seated pain and rectal discomfort that worsens with ambulation or straining Anal canal tear along posterior or anterior midline, bleeding, hypertrophic papillae, skin tags, Hx of hard, large, painful stools, ‘‘knife-like’’ pain lasting up to several hours post defecation Painful, bluish perianal swellings, skin tags, sensation of incomplete defecation, pruritus, bloody stools, or prolapsed mass Hx of pregnancy, constipation, or portal hypertension; anoscopy shows anal swellings Diagnosis Anorectal fistula Anorectal abscess Anal fissures External hemorrhoids Management General surgery referral Urgent general surgery referral Manage symptoms Manage symptoms Table 10.10 Approach to Patient with Perianal Rash, Erythema, or Lesions Clinical presentation Sharply demarcated inflamed, bright red pruritic perianal lesions Investigation Diagnosis Psoriasis Management Papulovesicles with surrounding erythema, weeping and crusted lesions, Hx suggestive of chronic contact with potentially allergic agents (eg., latex condoms, sanitary wipes) Generalized xerosis, erythematous, lichenified, pruritic patches and papules; Hx of asthma, allergic rhinoconjunctivitis Single of multiple papillary eruptions, Hx of receptive anal activity, immunosuppression Ulcerating anal or perianal lesion, Hx of bleeding, HPV infection, receptive anal intercourse, or cancer (especially cervical, vulvar, or vaginal) Symmetric sharply demarcated erythematous rash, Hx of recurrent anal pruritis and rash, contact sport participation Closed patch test Antibody serology Acetowhitening test, anoscopy Malignancy Potassium hydroxide wet mount of scales Contact dermatitis Atopic dermatitis HPV Malignancy Fungal Infection Oncology referral Treat cause See Chapter 4—Skin Rash: Papules CLINICAL BOX Infectious Agents Sexually transmitted • • • • N gonorrhoeae C trachomatis HSV Syphilis CLINICAL BOX Management of Hemorrhoids • Oral fiber intake, stool softeners, or supplements • Toilet retraining • Treatment of underlying disease CLINICAL BOX Bacteria • • • • Salmonella C difficile Shigella Campylobacter Fungi • Tinea (ringworm) Parasites • E vermicularis (pinworm) Sitz Bath • Patient sits in bath and the buttocks and hips are covered with warm water • For management of hemorrhoid pain ... Questions 19 6 60 cases × 1 4 questions HOW TO USE THIS TEXT? Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I is written for medical students and international medical. .. management strategies required of the competent examinee Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I Table 1. 1 Summary of MCCQE Sections MCQ CDM When Morning... of the justification will depend on the circumstances Essentials for the Canadian Medical Licensing Exam: Review and Prep for MCCQE Part I bad MMSE performance may lead a physician to suspect the