A 64-year-old woman presents to the Emergency Department with an acute pulmonary embolism. Her heart rate is 90 bpm, blood pressure is 118/76 mmHg, respiratory rate is 18/min, and oxygen saturation is 95% on room air. She has no signs of right heart strain on ECG or imaging, and a negative troponin. She is able to ambulate comfortably in the ED. Her PE is unprovoked.
Which one of the following best describes her risk category and appropriate disposition?
A. High risk; requires ICU admission and immediate thrombolysis
B. Intermediate-low risk; monitor on the ward with supportive care
C. Low risk; consider outpatient management with oral anticoagulation
D. Low risk; observe in hospital for 24 hours before initiating anticoagulation
A 64-year-old woman presents to the Emergency Department with an acute pulmonary embolism. Her heart rate is 90 bpm, blood pressure is 118/76 mmHg, respiratory rate is 18/min, and oxygen saturation is 95% on room air. She has no signs of right heart strain on ECG or imaging, and a negative troponin. She is able to ambulate comfortably in the ED. Her PE is unprovoked.
Which one of the following best describes her risk category and appropriate disposition?
A. High risk; requires ICU admission and immediate thrombolysis
B. Intermediate-low risk; monitor on the ward with supportive care
C. Low risk; consider outpatient management with oral anticoagulation
She is hemodynamically stable, with no signs of RV dysfunction or biomarker elevation - low risk, suitable for outpatient management if reliable follow-up is available. Whether a PE is provoked or unprovoked does not matter for admission or not.
D. Low risk; observe in hospital for 24 hours before initiating anticoagulation
Background reading 24 PE: Page 6 - Risk Stratification
A 50-year-old woman with no past medical history presents with pleuritic chest pain. Her Wells score is 1.5, and she otherwise appears well.
What is the best next step in management?
A. CT pulmonary angiogram
B. Initiate empiric anticoagulation
C. Perform D-dimer
D. Perform a PERC score
E. Lower limb ultrasound
A 50-year-old woman with no past medical history presents with pleuritic chest pain. Her Wells score is 1.5.
What is the best next step in management?
A. CT pulmonary angiogram
B. Initiate empiric anticoagulation
C. Perform D-dimer
In low or moderate pre-test probability, D-dimer is the appropriate next step. A normal result can rule out PE. Would start with that rather than unnecesary imaging. Not appropriate for PERC rule due to age.
D. Perform a PERC score
E. Lower limb ultrasound
Background reading 24 PE: Page 3 - Diagnosis of PE
A 72-year-old man collapses at home. On arrival to the ED, he is hypotensive (BP 66/38 mmHg), tachycardic (HR 130), and hypoxic and has a lactate of 8. His workup reveals an acute pulmonary embolism.
Which one of the following is the most appropriate next step in management?
A. Administer systemic thrombolysis
B. Start warfarin
C. Order a D-dimer to confirm suspicion
D. Place an IVC filter
E. Begin IV fluids and monitor closely
A 72-year-old man collapses at home. On arrival to the ED, he is hypotensive (BP 66/38 mmHg), tachycardic (HR 130), and hypoxic and has a lactate of 8. . His workup reveals an acute pulmonary embolism.
Which one of the following is the most appropriate next step in management?
A. Administer systemic thrombolysis
Hemodynamic instability in suspected PE is an indication for empiric thrombolysis. This person is in shock and needs help now!
B. Start warfarin
C. Order a D-dimer to confirm suspicion
D. Place an IVC filter
E. Begin IV fluids and monitor closely
Background reading 24 PE: Page 6 - Massive PE
A 54-year-old woman presents to the emergency department with a 2-day history of pleuritic chest pain and dry cough. She denies hemoptysis, fever, or recent travel. She has no past medical history but reports that she’s been less active sustaining an ankle fracture requiring a cast 2 weeks ago. She has no other PMhx. She takes no regular medications. On exam, her temperature is 37.0°C, HR 108 bpm, BP 124/80 mmHg, RR 22, and O2 saturation is 94% on room air. There are no signs of DVT on exam. ECG shows sinus tachycardia. You suspect a diagnosis of PE.
What is her Well’s Score?
A. 4
B. 4.5
C. 5
D. 5.5
E. 6
A 54-year-old woman presents to the emergency department with a 2-day history of pleuritic chest pain and dry cough. She denies hemoptysis, fever, or recent travel. She has no past medical history but reports that she’s been less active sustaining an ankle fracture requiring a cast 2 weeks ago. She has no other PMhx. She takes no regular medications. On exam, her temperature is 37.0°C, HR 108 bpm, BP 124/80 mmHg, RR 22, and O2 saturation is 94% on room air. There are no signs of DVT on exam. ECG shows sinus tachycardia. You suspect a diagnosis of PE.
What is her Well’s Score?
A. 4
B. 4.5
C. 5
D. 5.5
E. 6 1.5 points for HR, 1.5 points for immobilization, 3 points for #1 suspicion
Background reading 24 PE: Page 2-4 - Non-specific PE presentation
A 35-year-old man presents with sudden-onset dyspnea and chest pain. His Wells score is 7. He is hemodynamically stable.
What is the next most appropriate diagnostic step?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography
D. Ventilation/perfusion scan
E. Lower limb Doppler ultrasound
A 35-year-old man presents with sudden-onset dyspnea and chest pain. His Wells score is 7. He is hemodynamically stable.
What is the next most appropriate diagnostic step?
A. Chest X-ray
B. D-dimer
C. CT pulmonary angiography (CTPA)
With a high pre-test probability, D-dimer is not useful - move directly to CTPA.
D. Ventilation/perfusion scan
E. Lower limb Doppler ultrasound
Background reading 24 PE: Page 3 - Diagnosis of PE
Which of the following clinical presentations is most specific for pulmonary embolism?
A. Dyspnea
B. Tachypnea
C. Chest pain
D. Hemoptysis
E. Syncope
Which of the following clinical presentations is most specific for pulmonary embolism?
A. Dyspnea
B. Tachypnea
C. Chest pain
D. Hemoptysis
Hemoptysis is relatively uncommon but more specific to PE than other symptoms like dyspnea or tachypnea, which are common in many conditions.
E. Syncope
Background reading 24 PE: Page 2 - Clinical Presentation
A 65-year-old woman presents to the ED with acute shortness of breath and pleuritic chest pain that began suddenly this morning. She has a history of hypertension and GERD and reports taking omeprazole daily. She was hospitalized two weeks ago for a hip fracture and underwent surgery, after which she was discharged to a rehab facility and remains mostly non-ambulatory. On exam, she is alert, afebrile, with a heart rate of 112 bpm, respiratory rate of 24, and oxygen saturation of 94% on room air. Her left calf is swollen and tender to palpation. ECG shows sinus tachycardia. CXR is normal. There is no fever, cough, or history of hemoptysis.
What is her Wells score and corresponding risk category?
A. 2.0
B. 4.0
C. 6.0
D. 8.5
E. 9.0
A 65-year-old woman presents to the ED with acute shortness of breath and pleuritic chest pain that began suddenly this morning. She has a history of hypertension and GERD and reports taking omeprazole daily. She was hospitalized two weeks ago for a hip fracture and underwent surgery, after which she was discharged to a rehab facility and remains mostly non-ambulatory. On exam, she is alert, afebrile, with a heart rate of 112 bpm, respiratory rate of 24, and oxygen saturation of 94% on room air. Her left calf is swollen and tender to palpation. ECG shows sinus tachycardia. CXR is normal. There is no fever, cough, or history of hemoptysis.
What is her Wells score and corresponding risk category?
A. 2.0
B. 4.0
C. 6.0
D. 8.5
**E. 9.0 **
Clinical signs of DVT (leg swelling/tenderness): +3
Recent surgery with immobilization: +1.5
Heart rate >100: +1.5
No alternate diagnosis more likely than PE: +3
Background reading 24 PE: Page 3 - Wells Score criteria
A 68-year-old man presents with fatigue and shortness of breath. His hemoglobin is 88 g/L, MCV is 72 fL, and ferritin is 11 µg/L.
Which of the following is the most likely diagnosis?
A. Anemia of chronic disease
B. Vitamin B12 deficiency
C. Iron deficiency anemia
D. Hemolytic anemia
E. Thalassemia trait
A 68-year-old man presents with fatigue and shortness of breath. His hemoglobin is 88 g/L, MCV is 72 fL, and ferritin is 11 µg/L.
Which of the following is the most likely diagnosis?
A. Anemia of chronic disease
B. Vitamin B12 deficiency
C. Iron deficiency anemia
Low hemoglobin, microcytosis, and low ferritin strongly suggest iron deficiency
D. Hemolytic anemia
E. Thalassemia trait
Background reading 25 Anemia: Page 5 - Iron studies
Which of the following best exemplifies a primary source of medical literature?
A. UpToDate review on anemia
B. Randomized controlled trial evaluating iron therapy
C. Clinical guideline from the WHO
D. Textbook chapter on hematology
E. Meta-analysis of anemia treatments
Which of the following best exemplifies a primary source of medical literature?
A. UpToDate review on anemia
B. Randomized controlled trial evaluating iron therapy
Primary literature refers to original research reports such as RCTs, cohort studies, or case-control studies. These are the first publication of data. Meta-analyses and reviews are considered secondary, and textbook chapters or UpToDate are tertiary.
C. Clinical guideline from the WHO
D. Textbook chapter on hematology
E. Meta-analysis of anemia treatments
Background reading 25 Anemia: Page 6 - Types of literature
You are in a busy clinic and want a rapid, evidence-based summary of how to approach anemia workup in elderly patients. Which literature type is most appropriate?
A. Primary literature
B. Secondary literature
C. Tertiary literature
D. Case series
E. Cohort study
You are in a busy clinic and want a rapid, evidence-based summary of how to approach anemia workup in elderly patients. Which literature type is most appropriate?
A. Primary literature
B. Secondary literature
C. Tertiary literature
Tertiary literature is ideal for fast, accessible summaries and includes resources like UpToDate, guidelines, and textbooks. These are best suited for time-pressured clinical settings. Primary or secondary sources require more time and critical appraisal.
D. Case series
E. Cohort study
Background reading 25 Anemia: Page 6 - Types of literature
Which of the following pairs correctly matches the study or source with its literature type?
A. Textbook chapter — Primary
B. Practice guideline — Secondary
C. Systematic review — Tertiary
D. Clinical trial — Secondary
E. Narrative review — Secondary
**Which of the following pairs correctly matches the study or source with its literature type?
**
A. Textbook chapter — Primary
B. Practice guideline — Secondary
C. Systematic review — Tertiary
D. Clinical trial — Secondary
E. Narrative review — Secondary
Secondary literature summarizes and interprets primary studies (e.g., systematic reviews, narrative reviews).
Background reading 25 Anemia: Page 6 - Types of literature
A 45-year-old woman has the following results:
Hemoglobin: 96 g/L
MCV: 102 fL
Reticulocytes: low
B12: borderline low
LDH: mildly elevated
Bilirubin: normal
What is the most likely diagnosis?
A. Vitamin B12 deficiency
B. Thalassemia minor
C. Iron deficiency anemia
D. Hemolytic anemia
E. Anemia of chronic disease
A 45-year-old woman has the following results:
Hemoglobin: 96 g/L
MCV: 102 fL
Reticulocytes: low
B12: borderline low
LDH: mildly elevated
Bilirubin: normal
What is the most likely diagnosis?
A. Vitamin B12 deficiency
Macrocytic anemia with low reticulocytes and borderline B12 suggests B12 deficiency.
B. Thalassemia minor
C. Iron deficiency anemia
D. Hemolytic anemia
E. Anemia of chronic disease
Background reading 25 Anemia: Page 4 - Macrocytic anemia
A 76-year-old woman presents to clinic with a 3-month history of worsening fatigue, exertional dyspnea, and difficulty concentrating. Her medical history includes hypertension, osteoarthritis, and mild hearing loss. She lives alone and has had a recent decline in appetite, attributing it to poor dentition. On examination, she appears pale but is hemodynamically stable. There is no lymphadenopathy or hepatosplenomegaly.
Initial labs show:
TSH: Normal
Creatinine: Normal
Hemoglobin: 88 g/L
MCV: 72 fL
WBC and platelets: within normal limits
Which of the following is the most likely diagnosis?
A. Depression
B. Iron deficiency anemia
C. Myelodysplastic syndrome
D. Hypothyroidism
E. Early Alzheimer’s disease
A 76-year-old woman presents to clinic with a 3-month history of worsening fatigue, exertional dyspnea, and difficulty concentrating. She has also noticed increased headaches and has been chewing ice frequently. Her medical history includes hypertension, osteoarthritis, and mild hearing loss. She lives alone and has had a recent decline in appetite, attributing it to poor dentition. On examination, she appears pale but is hemodynamically stable. There is no lymphadenopathy or hepatosplenomegaly.
Initial labs show:
TSH: Normal
Creatinine: Normal
Hemoglobin: 88 g/L
MCV: 72 fL
WBC and platelets: within normal limits
Which of the following is the most likely diagnosis?
A. Depression
B. Iron deficiency anemia
Iron deficiency anemia is supported by:
Low hemoglobin
Microcytosis (low MCV)
Low ferritin
Also, iron deficiency is the most common type of anemia
C. Myelodysplastic syndrome
D. Hypothyroidism
E. Early Alzheimer’s disease
Background reading 25 Anemia: Page 2 - Causes of anemia
A 70-year-old woman with rheumatoid arthritis presents with mild anemia. Labs show:
Hb 110 g/L
MCV 88 fL
Ferritin 200 µg/L
Serum iron low
TIBC low
What is the most likely diagnosis?
A. Iron deficiency anemia
B. Sideroblastic anemia
C. Aplastic anemia
D. Anemia of chronic disease
E. Folate deficiency
A 70-year-old woman with rheumatoid arthritis presents with mild anemia. Labs show:
Hb 110 g/L
MCV 88 fL
Ferritin 200 µg/L
Serum iron low
TIBC low
What is the most likely diagnosis?
A. Iron deficiency anemia
B. Sideroblastic anemia
C. Aplastic anemia
D. Anemia of chronic disease
Normal MCV, high ferritin, low iron, and low TIBC suggest anemia of inflammation.
E. Folate deficiency
Background reading 25 Anemia: Page 4 - Anemia of Chronic Disease
Which of the following is NOT a criterion in the Wells score for DVT?
A. Entire leg swollen
B. Paresis
C. Pregnancy
D. Recent immobilization
E. Calf swelling ≥3 cm compared to the other leg
Which of the following is NOT a criterion in the Wells score for DVT?
A. Entire leg swollen
B. Active cancer
C. Pregnancy
Pregnancy is a general risk factor for DVT but not part of the Wells score.
D. Recent immobilization
E. Calf swelling ≥3 cm compared to the other leg
Background reading 26 DVT: Page 3 - Wells score
A 45-year-old woman presents to your acute care clinic with tender right calf pain. She recalls arriving home from South Africa just yesterday. Being a diligent medical student you calculate her to have a moderate pretest probability for DVT based on Wells score.
Preliminary bloodwork shows her to have a normal D-dimer.
What is the most appropriate next step?
A. Start anticoagulation
B. No further testing is needed
C. Order a CT venogram
D. Perform contrast venography
E. Schedule repeat ultrasound in 1 week
A 45-year-old woman presents to your acute care clinic with tender right calf pain. She recalls arriving home from South Africa just yesterday. Being a diligent medical student you calculate her to have a moderate pretest probability for DVT based on Wells score.
Preliminary bloodwork shows her to have a normal D-dimer.
What is the most appropriate next step?
A. Start anticoagulation
B. No further testing is needed
A normal D-dimer in low/moderate risk patients rules out DVT.
C. Order a CT venogram
D. Perform contrast venography
E. Schedule repeat ultrasound in 1 week
Background reading 26 DVT: Page 3 - Wells score
You are evaluating five patients with suspected DVT. Assuming none of them actually have a venous thromboembolism, in which patient would a normal D-dimer be most likely?
A. A 68-year-old woman with mild dyspnea and chronic kidney disease, presenting with a red, swollen calf after a recent flu-like illness.
B. A 40-year-old woman in her third trimester of pregnancy, complaining of leg heaviness and mild pitting edema.
C. A 76-year-old man with chronic atrial fibrillation and new unilateral leg pain; his temperature is 38.9°C.
D. A 55-year-old woman undergoing chemotherapy for breast cancer, who reports dull left calf discomfort for 3 days.
E. A 27-year-old male with type 1 diabetes who developed calf soreness two days. He is returning from a hiking trip during which he sprained his ankle.
You are evaluating five patients with suspected DVT. Assuming none of them actually have a venous thromboembolism, in which patient would a normal D-dimer be most likely?
A. A 68-year-old woman with mild dyspnea and chronic kidney disease, presenting with a red, swollen calf after a recent flu-like illness.
B. A 40-year-old woman in her third trimester of pregnancy, complaining of leg heaviness and mild pitting edema.
C. A 76-year-old man with chronic atrial fibrillation and new unilateral leg pain; his temperature is 38.9°C.
D. A 55-year-old woman undergoing chemotherapy for breast cancer, who reports dull left calf discomfort for 3 days.
E. A 27-year-old male with type 1 diabetes who developed calf soreness two days. He is returning from a hiking trip during which he sprained his ankle.
All other patients have clinical confounders known to raise D-dimer levels in the absence of VTE: such as older age, malignancy, pregnancy and infection
Background reading 26 DVT: Page 4 - D-dimer assay
Which of the following presentations is least concerning for a DVT?
A. Sudden onset unilateral leg swelling, erythema, and tenderness
B. Patient with prior DVT presenting with leg edema after long travel
C. Warm swollen leg with palpable superficial veins after recent hip replacement
D. Bilateral leg swelling and pitting edema without tenderness
Which of the following presentations is least concerning for a DVT?
A. Sudden onset unilateral leg swelling, erythema, and tenderness
B. Patient with prior DVT presenting with leg edema after long travel
C. Warm swollen leg with palpable superficial veins after recent hip replacement
D. Bilateral leg swelling and pitting edema without tenderness
Background reading 26 DVT: Page 7 - Illness scripts
Which of the following best defines a diagnostic cascade?
A. The sequence of follow-up tests, procedures, or treatments triggered by an initial incidental or low-value test result.
B. The cycle of ordering increasingly invasive tests to resolve diagnostic uncertainty in complex cases.
C. The stepwise increase in diagnostic certainty as additional investigations are ordered to confirm a suspected condition.
D. The use of multiple concurrent tests to minimize the chance of missing a serious diagnosis.
E. The process by which a clinician broadens the differential diagnosis after receiving an unexpected test result.
Which of the following best defines a diagnostic cascade?
A. The sequence of follow-up tests, procedures, or treatments triggered by an initial incidental or low-value test result.
B. The cycle of ordering increasingly invasive tests to resolve diagnostic uncertainty in complex cases.
C. The stepwise increase in diagnostic certainty as additional investigations are ordered to confirm a suspected condition.
D. The use of multiple concurrent tests to minimize the chance of missing a serious diagnosis.
E. The process by which a clinician broadens the differential diagnosis after receiving an unexpected test result.
Background reading 26 DVT: Page 7 - Diagnostic cascade
A 68-year-old man presents to the emergency department with a 2-day history of increasing pain and swelling in his left lower leg. He describes the pain as dull and throbbing, worse with standing. He denies any trauma or recent travel. On examination, his left calf is erythematous, warm to the touch, and mildly tender. He is febrile at 38.3°C and reports feeling fatigued. He has a history of type 2 diabetes and peripheral vascular disease.
**Which of the following is the most likely diagnosis?
**
A. Cellulitis
B. Deep vein thrombosis
C. Ruptured Baker’s cyst
D. Chronic venous insufficiency
E. Acute arterial occlusion
A 68-year-old man presents to the emergency department with a 2-day history of increasing pain and swelling in his left lower leg. He describes the pain as dull and throbbing, worse with standing. He denies any trauma or recent travel. On examination, his left calf is erythematous, warm to the touch, and mildly tender. He is febrile at 38.3°C and reports feeling fatigued. He has a history of type 2 diabetes and peripheral vascular disease.
Which of the following is the most likely diagnosis?
A. Cellulitis
Cellulitis presents with unilateral leg swelling, erythema, warmth, fever, and systemic symptoms
B. Deep vein thrombosis
C. Ruptured Baker’s cyst
D. Chronic venous insufficiency
E. Acute arterial occlusion
Background reading 26 DVT: Page 7 - Illness scripts
A 67-year-old woman reports an 3.6 kg (8 lb) weight loss over the past 6 months. She now weighs 76 kg (168 lbs) She appears well and denies any symptoms. What is the most appropriate approach?
A. Order a CT chest-abdomen-pelvis
B. Begin broad serologic testing for occult infection
C. Reassure and follow up in 1–3 months
D. Refer for colonoscopy
E. Order screening FOBT
A 67-year-old woman reports an 8 lb (3.6 kg) weight loss over the past 6 months. She appears well and denies any symptoms. What is the most appropriate approach?
A. Order a CT chest-abdomen-pelvis
B. Begin broad serologic testing for occult infection
C. Reassure and follow up in 1–3 months
Less than 5% weight loss over 6–12 months is not considered clinically significant and can be followed with close observation.
D. Refer for colonoscopy
E. Order screening FOBT
Background reading 27 Weight loss: Page 2
Which of the following is considered a second-line investigation in the workup of unintentional weight loss when no cause is identified through history, physical exam, and initial lab tests?
A. Abdominal ultrasound
B. HIV and Hepatitis C serology
C. Urinalysis
D. Colonoscopy
E. Chest X-ray
Which of the following is considered a second-line investigation in the workup of unintentional weight loss when no cause is identified through history, physical exam, and initial lab tests?
A. Abdominal ultrasound
B. HIV and Hepatitis C serology
C. Urinalysis
D. Colonoscopy
Colonoscopy is part of the second-line workup when no diagnosis is evident after history, physical exam, and initial bloodwork/urine testing.
E. Chest X-ray
Background reading 27 Weight loss: Page 2
A 60-year-old woman presents to her family doctor with a 2-month history of a 10 lb weight loss. She reports decreased energy, difficulty sleeping, and intermittent nausea. She denies abdominal pain, vomiting, or change in bowel habits. She describes having “no appetite”. Her past medical history includes hypertension and osteoarthritis. On examination, her vitals are normal and physical exam is unremarkable. Initial investigations including CBC, TSH, and liver enzymes are within normal limits.
Which of the following is her most likely diagnosis?
A. Occult gastrointestinal malignancy
B. Hyperthyroidism
C. Major depressive disorder
D. Chronic infection
E. Early Parkinson’s disease
A 60-year-old woman presents to her family doctor with a 2-month history of a 10 lb weight loss. She reports decreased energy, difficulty sleeping, and intermittent nausea. She denies abdominal pain, vomiting, or change in bowel habits. She describes having “no appetite”. Her past medical history includes hypertension and osteoarthritis. On examination, her vitals are normal and physical exam is unremarkable. Initial investigations including CBC, TSH, and liver enzymes are within normal limits.
Which of the following is her most likely diagnosis?
A. Occult gastrointestinal malignancy
B. Hyperthyroidism
C. Major depressive disorder
Best matches the illness script: chronicity, nonspecific GI complaints, low mood, sleep disturbances
D. Chronic infection
E. Early Parkinson’s disease
Background reading 27 Weight loss: Page 2
A 73-year-old man presents with an 8 kg unintentional weight loss over 4 months. He reports fatigue but denies fever, night sweats, or GI symptoms. Physical exam is unremarkable. You plan to initiate the first-line workup for unintentional weight loss.
Which of the following laboratory tests is least likely to be useful in the initial workup of this patient?
A. Creatine kinase (CK)
B. Thyroid-stimulating hormone (TSH)
C. Serum calcium
D. C-reactive protein (CRP)
E. Complete blood count (CBC)
A 73-year-old man presents with an 8 kg unintentional weight loss over 4 months. He reports fatigue but denies fever, night sweats, or GI symptoms. Physical exam is unremarkable. You plan to initiate the first-line workup for unintentional weight loss.
Which of the following laboratory tests is least likely to be useful in the initial workup of this patient?
A. Creatine kinase (CK)
Not a standard part of the initial workup for weight loss unless neuromuscular symptoms are present.
B. Thyroid-stimulating hormone (TSH)
C. Serum calcium
D. C-reactive protein (CRP)
E. Complete blood count (CBC)
Background reading 27 Weight loss: Page 2