CFPC SAMP 2013-2015

2015 SAMP

1. Barrett esophagus (squamous -> columnar epithelium @ distal esophagus): 56yo smoker, 3xETOH/d, with worsening reflux. Rx PPi

  • List 4 risk factors for developing Barrett esophagus
    • Cigarette smoking
    • chronic reflux symptoms / GERD
    • Hiatal Hernia
    • Increasing age (>50yo), male, white race
    • Obesity
  • 8 wk later, Tom comes back to the clinic and has lost 2kg. Ix showed anemia. Which red flags are indications for endoscopy (routine screening in pt with GERD not recommended). List 2
    • Wt loss
    • anemia
    • dysphagia
    • symptoms persist despite adequate PPi
    • Evidence of bleeding or obstruction: melena
    • Multiple risk factors of Barrett 
  • 1 mo later, his esophageal biopsy shows a low-grade dysplasia. When will you order the f/u endoscopy? Less than 12 mo
  • If the esophageal biopsy had shown a high-grade dysplasia, when would the surveillance endoscopy be scheduled? In 3 mo
  • As pt is taking a PPi, you can reassure him that the medication can sig reduce the development of dysplsia. True, but not delay or prevent progression to cancer

2. 44yo F with incidental gallstones on u/s. No symptoms

  • What % of asymptomatic pt will eventually become symptomatic within 5-20 yr of dx?
    • 10-20%
  • List 4 risk facrtors for the developement of gallstones
    • Female
    • Family Hx of gallstones
    • Increasing age
    • Obesity
    • Diet high in calories and refined carbohydrates, low in fiber and unsaturated fats. 
    • Low-grade physical activity
    • Pregnancy
    • Prolonged fasting, rapid wt loss
    • Alcoholic cirrhosis, bariatric surgery, DM, dyslipidemia, estrogen therapy, gallbladder or intestinal stasis, hyperinsulinism, metabolic syndrome
  • What is the best Tx options for pt with incidentally detected, asymptomatic gallstones?
    • Expectant Management.
  • Biliary colic 6mo later. C/o RUQ pain. Steady, moderate to severe in intensity, starts abruptly without fluctuations, not relieved with a BM, reaches a peak within 1hr, and resolved gradually over 1-5 hr. What are appropriate pain control Tx for biliary colic?
    • NSAIDs > narcotic, antispasmodic (scopolamine)
  • What are the potential c/i of gallstones?
    • acute Cholecystitis
    • acute cholangitis
      • (Charcot triad: fever, jaundice, abd pain; Reynolds pentad – HoTN or LOC)
    • gallstone pancreatitis, choledocholithiasis
  • What imaging test if symptoms suggestive of biliary colic with negative u/s results?
    • CT
    • HIDA scan
    • MRCP
  • What b/w would you order in pt with suspected c/i?
    • CBC, Lipase, total bilirubin, GGT, ALP, AST, ALT
  • What prophylactic Tx is recommended for pt with symtomatic gallstones?
    • Prophylactic Tx with laparoscopic cholecystectomy for pt with complications of gallstones

2014 SAMP

1. 45yoM with insomnia x 4 wk

  • What q would you ask to evaluate his insomnia? List 4
    • What are your typical sleep and wake-up times on weekdays and weekends?
    • Bedtime routines & sleep environment
    • coffee, alcohol, and other drug use
    • How well do you function during the day?
  • Pt declines medical Tx. He would like to try CBT. What advice would you give?
    • CBT – changing false beliefs about sleep
    • Sleep hygiene education: no ptes, no caffeine after 4pm, keep bedroom cool, no watching the bedroom clock, no nicotine use, no exercising within 3-4 hours before bedtime
    • Sleep restriction: reduce time in bed to improve sleep efficiency, and add 15min / wk after reaches 90% efficiency
    • Stimulus control: go to bed only when sleep, bed only for sleep and sex, go to another room if unable to fall asleep within 15-20min, read and return to bed only when sleepy
  • Unfortunately, pt’s insomnia doesn’t improve with CBT. He declines medical therapy. What ould be the next step?
    • Referral to sleep center for further testing and Tx

2. late fall, 2yo F to ED w/ barky cough, fever, difficulty breathing. She was worse earlier. Croup (edema of upper airway)

  • What are the s/sx of croup? name 3
    • Preceded by 24-72hr of nonspecific cough
    • Inspiratory Stridor
    • rhinorrhea, fever
    • Hoarse voice
    • barky cough of abrupt onset
  • What investigations are needed, if any?
    • No, clinical diagnosis, just ensure O2 Sat is above 92%
  • What other causes of inspiratory stridor should you consider?
    • FB aspiration, retropharyngeal abscess
    • Bacterial tracheitis, epiglottitis
    • angioedema, allergic reaction
    • laryngeal diphtheria
  • One of the nurse wants to get the cool mist equipment. Is cool mist an effective intervention?
    • No, and should not be given
  • What are 2 tx that have been shown to e beneficial, and how are they administered?
    • dexamethasone 0.6mg/kg po x 1
    • Epi 0.5mg neb
    • O2 blow-by if in respiratory distress
  • Pt with no stridor or chest wall indrawing at rest may be d/c home safely, whereas pt with persistent stridor and chest wall indrawing >2hr after corticosteroids should be admitted to hospital.

3. 62yoM w/ worsening leg pain x 2yr, brought on by walking & going up stiars. Overweight, HTN, chronic back pain, smoker. ?PAD

  • List 3 risk factors for PAD
    • Smoking
    • Diabetes
    • Hyperlipidemia
    • CKD eGFR <60, HTN
  • What office-based procedure could you use to support a dx of PAD?
    • ABI – Ankle brachial index
  • Name 2 lifestyle modifications that can improve walking distance in pt with PAD.
    • exercise
    • smoking cessation 
  • What medical Tx are available for PAD?
    • ASA / plavix – reduce the risk of MI, stroke, and other vascular dz
    • statin therapy
    • Ramipril 

4. 50yoM w/ severe low back pain after a minor cough. x-ray reveals a L compression # & punched-out lytic lesions. MM (proliferation of malignant plasma cells within the bone marrow, which produces monoclonal paraprotein + evidence of end organ damage)

  • The acronym CRAB has been used to describe the classical c/i of Multiple myeloma. what are these 4 classical complications?
    • Ca – Hypercalcemia
    • Renal impairment
    • Anemia
    • Bony Lesions
  • Name 2 other less conventional presentations.
    • Recurrent bacterial infections (>2/yr) secondary to hypogammaglobulinemia
    • Symptomatic hyperviscosity leading to: confusion, visual changes, headaches, vertigo
  • List baseline lab and imaging investigations that you would consider ordering.
    • CBC and blood film
    • Creatinine, urea, electrolytes,
    • Ca, albumin, magnesium, phosphate, liver function tests, LDH
    • SPEP, UPEP
    • Imaging: skeletal survey (whole body x-ray)
  • Monoclonal gammopathy of undetermined significance (MGUS) and smouldering myeloma are related to multiple myeloma. What are they and how do they differ from multiple myeloma?
    • MGUS (serum paraprotein <30g/L with a marrow plasma cell infiltrate <10%) and smouldering myeloma (serum paraprotein >30g/L or bone marrow plasmacytosis >10%) are asymptomatic with no evidence of end organ damage. 

5. 35yoF, chronic hyposmia x few years, hx of perennial allergies and no other PMH or Meds

  • List 3 typical symptoms of chronic rhinosinusitis: CPODS
    • Congestion or fullness;
    • Pain and pressure – facial
    • Obstruction or blockage – nasal
    • Drainage – purulent ant or posterior nasal drainage
    • Smell disorder
  • risk factors of chronic rhinosinusitis
    • increased age and female
    • asthma and COPD
    • hx of allergy
  • Pt has >=2 typical symptoms for >8 week, what other evidence do you need to dx chronic rhinosinusitis? (3 criteria for dx of CRS)
    • objective documentation of sinus inflammation with CT or with endoscopy
  • Sinus CT showed sinus inflammation w/o nasal polyps. List the 2 classes of medication Rx as initial Tx.
    • IntraNasal corticosteroids: Nasonex +/- po corticosteroids
    • Abx
  • What would you do differently if she had polyps?
    • Intranasal corticosteroids + oral steroids (endoscopic sinus surgery only for refractory cases)
    • abx only if the pt has pain, documented purulence or recurrent episodes of sinusitis
  • List 2 indications for referral to an otolaryngologist:
    • urgent referral:
      • Immunocompromised pt
      • suspected invasive fungal sinusitis
      • Severe symptoms of pain or swelling of the sinuses
    • Referral:
      • refractory to maximal medical Tx
      • >=4 sinus infections / yr

6. Depression

  • What is the approximate remission rate using SSRI monotherapy? 1/3 (28%)
  • What is the approximate remission rate at 12 months after using up to four different antidepressants? 60%
  • dx: treatment-refractory depression: Name three advantages of repetitive transcranial magnetic stimulation (TMS) over electroconvulsive therapy (ECT)?
    • Non-invasive
    • Tolerability
    • Safety
    • No anesthetic required
  • Name one common adverse effect of TMS
    • Headache, Local pain
  • You admit her to hospital for her own safety and ECT is recommended. Is ECT as effective as medication? Yes, more effective
  • Is it as effective as TMS? Yes, more effective
    • Guidelines recommend ECT as a first-line treatment for major depressive disorder in patients with acute suicidal ideation or psychotic features and as a second-line treatment for major depressive disorder resistant to pharmacotherapy
  • How long does a clinically significant response usually take? One to three weeks
  • Name three common adverse effects of ECT
    • Myalgia
    • Headache
    • Disorientation,
    • retrograde amnesia
  • Her psychiatrist knows of a trial in the city that is offering deep brain stimulation for refractory cases like Sue. Is there evidence this treatment is effective for people like her? Two studies show its efficacy
  • What are two possible adverse effects of such a treatment?
    • deep brain stimulation carries a small risk of serious complications (e.g., intracranial hemorrhage) and other perioperative risks (e.g., wound infection, anesthetic complications).

7. 32yoM with acute diarrhea (stool with increased water content, volume, or frequency that lasts less than 14 days.) x 3d. Watery non-bloody stool, decreased u/o, dizziness, and vomiting

  • What is the most common infectious cause of acute diarrhea and the most likely cause of pt’s diarrhea? Viral diarrhea
  • What diagnostic tests would be indicated? None, self-limited
    • specific diagnostic investigation can be reserved for patients with severe dehydration, more severe illness, persistent fever, bloody stool, or immunosuppression, >3-7days, and for cases of suspected nosocomial infection or outbreak.
  • If pt suffering from fever, tenesmus, and diarrhea with grossly bloody stool, then what would be the most likely infectious cause of Colin’s diarrhea?
    • EHEC or other invasive bacterial infection
  • Ordering a stool culture in this situation would be a reasonable investigation. Yes
  • What test would you order if Colin had been discharged from hospital three days ago? C diff toxin A & B
  • What is the first step in treating acute diarrhea?
    • ReHydration – IV only if not tolerating po therapy
    • An oral rehydration solution (ORS) must contain a mixture of salt and glucose in combination with cellular transport mechanism.
  • Colin now feels better after his initial treatment. He would like to eat solid food
  • again. He is not thrilled about eating a BRAT diet. Early refeeding with solid foods is not recommended. False

8. 50yo M, recent ED visit with abd pain after eating a spicy meal, resolved completely with antacid. ED ordered u/s to r/o cholelithiasis, negative for cholelithiasis, but incidental cystic lesion on R kidney.

  • List three ultrasound features suggestive of a simple renal cyst.
    • spherical or ovoid shape w/o internal echoes
    • A think smooth wall separate from the surrounding parenchyma
    • Posterior wall enhancement caused by increased transmission through the water-filled cyst
  • What features should prompt further investigation?
    • Inadequate u/s visualization
    • Evidence of calcifications
    • Septa with multiple chambers
  • Upon review of the ultrasound report, you decide further investigation is warranted. What test should you order next?
    • Renal CT
  • Further testing shows that the lesion contains a few thin-walled septa with minimal calcification, but no measurable enhancement. What is the approximate risk of
  • malignancy with the above features?
    • ~20%
  • What follow-up is recommended?
    • Class IIF cysts require f/u at 6mo with CT/MRI, then annually for at least 5 years
  •  Approximately 30% of individuals aged 50 and older will have at least one renal cyston CT. True
  • Secondary cysts may form when solid tumors obstruct tubules of normal parenchyma. True
  • Cystic lesions containing enhancing soft tissue unattached to the wall are likely benign. False, likely malignant

9. 52F, 2wk abn vaginal bleeding, pelvic pain, a sense of bloating. Palpate fullness in L adnexa. ?Ovarian ca

  • 4 risk factors for ovarian cancer
    • Family Hx of BRCA1/2 mutation; breast ca and ovarian ca; Lynch syndrome
    • Increasing age
    • Early menarche and late menopause; endometriosis
    • Nulloiparity / primary infertility
  • TVS identifies 1 10cm mass in the L ovary with complex solid components. What other imaging modality may be useful to characterize this mass further.
    • MRI
  • Ca-125 is appropriate for this pt. Widely accepted as an adjunct to imaging to distinguish benign from malignant masses.

10. 34M w/ facial & dental pain, nasal obstruction, cough for the past week. Hx of fatigue, headache, postnasal discharge, halitosis, smell disorder, along with some ear pressure.

  • Which of the symptoms suggests a dx of acute bacterial rhinosinusitis
    • PODS – Facial pain, nasal obstruction, postnasal discharge, smell disorder
  • What are the diagnostic criteria for acute bacterial rhinosinusitis?
    • symptom-specific + duration-based
    • >=2 symptoms (one must be nasal obstruction / purulence / discolored postnasal d/c) >=7 days w/o improvement or in a biphasic fever-illness pattern. 
  • If s/sx are steady but tolerable and don’t interfere with activity or sleep, what will you first suggest for tx?
    • intraNasal irrigation, intranasal corticosteroids 
  • If no clinical response in 72hr, what is the preferred 1st abx? Amoxicillin

11. 50yo M with a 4cm swollen, erythematous, tender nodule in his left axilla. ?abscess

  • What additional tests can confirm the dx?
    • u/s or needle aspiration (confirm but doesn’t r/o)
  • A dx test confirm dx of an abscess. Which of the following statements are true?
    • u/s guided needle aspiration has lower success rate than I&D
    • Primary closure of the abscess cavity can shorten healing time.
  • I&D done, but require a large incision. 2 contraindications to primary closure of the abscess cavity:
    • Pt with systemic infection or a risk factor for systemic infection
    • Pt with infected sebaceous cysts, LN, or other infections of chronic skin lesions
    • Adequacy of drainage is in doubt
  • RN assisting you tot akes a swab of the wound. A wound culture infrequently alters management. True
  • Pt wants to know if he should take abx: List 2 indications for abx tx:
    • severe or extensive dz – multiple sites of infection
    • rapid dz progression and associated cellulitis
    • s/sx of systemic illness
    • associated co-existing conditions or immunosuppression
    • Very young or advanced age
    • an abscess in an area difficult to drain (face, hands, genitalia)
    • Associated septic phlebitis
  • Name one appropriate antibiotic:
    • Clindamycin, septra, doxycycline
  • at 2wk f/u, abscess has healed nicely & Cx shows MRSA. Pt has 3 MRSA abscesses in 6mo. Is there a decolonization regimen shown to decrease risk of subsequent MRSA infections?
    • yes, 10-day regimen of nasal mupirocin twice daily, 3% hexachlorophene body wash daily, and an oral anti-MRSA antibiotic (TMP-SMX, doxycycline, or minocycline)

12. 62M w/ HTN and DM, c/o a slight fatigue & 2kg wt loss in the alst 2mo. Unremarkable exam. Ix showed WBC >115

  • You suspect leukemia; what other symptoms would support this diagnosis? List three.
    • fever, wt loss, wt loss
    • Anemia: SOB / chest pain, fatigue
    • thrombocytopenia: xs bruising, nosebleeds, heavy menstrual periods in women
  • List two risk factors associated with the development of leukemia in adults.
    • ionizing radiation or medical radiation exposure
    • hx of hematologic malignancy
    • Down syndrome, neurofibromatosis,
    • exposure to benzene
  • Mr. Macdonald shows no signs of bruising or bleeding. Which other physical findings should you pay attention to? List two.
    • Lymphadenopathy
    • hepatosplenomegaly
  • At this step, which laboratory test would interest you in the evaluation of a possible leukemia? List two.
    • Peripheral blood smear
    • a bone marrow specimen
  • If Mr. Macdonald were febrile when you met him, which medical tests should be ordered? List three
    • CXR
    • Blood Cx
    • Urine Cx / U/A
  •  Mr. Macdonald started chemotherapy two weeks ago. Which are the most feared complications associated with chemotherapy? Name two
    • febrile neutropenia
    • tumor lysis syndrome

2013 SAMP

1. 55yoF with 2mo of nocturnal leg cramps. PMH: HTN, dyslipidemia. Meds: HCZ25, atorvastatin20, conjugated estrogens 0.625 & progesterone 200 x 2mo for night sweats

  • Which muscles are usually involves in leg cramps?
    • Posterior calf muscles
  •  Nocturnal leg cramps have been associated with electrolyte disturbances. False
    • muscle fatigue is a primary cause of leg cramps. associated with a higher-than-normal intensity of exercise
    • Neither exercise-related cramps nor nocturnal cramps have been associated with hypovolemia or electrolyte disturbances.
  • What should you look for in the PE?
    • Neurovascular exam: palpation of the pulses, evaluation of touch & pinkprink sensation, strength, and DTR
    • Inspection of the legs and feet
    • BP
  • Which non-pharmacologic intervention could you recommend?
    • Passive Stretching & Deep tissue massage

2. 58yoF palliative pt with 1d crampy abd pain + nausea.  Subtotal colectomy 2 yo ago for colon ca + transverse rectal anastomosis. Recurrence of the cancer 6mo ago. She has diffuse peritoneal carcinomatosis and ascites requiring frequent paracentesis. On 30mg morphine daily.

  • In addition to malignant tumors causing mechanical occlusion, name three other possible causes in patients who present with gastrointestinal obstruction.
    • Adhesion after surgery, sigmoid volvulus, intussusception 
    • Functional obstructions (mesentery, celiac, enteric plexus infltrated by tumor, causing the peristalsis to malfunction)
  • After determining the level of care your patient desires, you send her to the local hospital for an abdominal series of x-rays to assess bowel distension and air-fluid levels. Are plain films generally diagnostic in determining whether the patient is obstructed versus constipated?
    • No, 75% of plain films are nondiagnostic
  • A complete blood count shows no change from previous values. Creatinine is mildly elevated and electrolytes are normal. You start intravenous hydration and give Mrs. Shapiro nothing by mouth. She refuses placement of a nasogastric tube. List three different classes of medication that you can use to treat Mrs. Shapiro’s pain, along with an example of each class.
    • Opioids: hydromorphone IV
    • Steroids: dexamethasone
    • antispasmodic-anticholinergic: Buscopan, scopolamine
  • What type of medication should be avoided in patients with crampy pain?
    • Pro-kinetics – metoclopramide
  • You decide to treat Mrs. Shapiro’s nausea with the regular administration of haloperidol, a medication commonly used in this situation. Name two other antiemetic drugs you could try.
    • Ondasetron, Gravol (dimenhydrinate)
    • Methotrimeprazine
    • olanzapine
  • Mrs. Shapiro presents an absolute contraindication to surgery. What is it?
    • Ascites requiring frequent paracentesis (functional obstruction, obstruction at multipel sites)
  • Name three relative contraindications to decompressive surgery in palliative care patients.
    • Poor performance status
    • Diffuse carcinomatosis
    • Previous radiotherapy to abdomen or pelvis
    • Metastasis with poor symptom control
  • Mrs. Shapiro understands that she is not a candidate for decompressive surgery, but wonders if any other techniques or interventions might help relieve her symptoms. Name two possible interventions in patients who are not candidates for decompressive surgery and have failed to respond to maximal medical therapy. List a contraindication and a complication for each intervention.
    • i. Intervention: Percutaneous gastrostomy
      • Contraindication: Massive ascites, portal HTN, predisposition to bleeding
      • Complication: bleeding in peristoma or in gastric wall; perforation; peritonitis
    • ii. Intervention: Endoscopically-placed stenting of proximal small or large bowel obstruction
      • Contraindication: Poor performance status, poor prognosis (<30d), perforation with peritonitis, multipe stenosis
      • Complication: Bowel perforation, stent dysfunction, bleeding, Biliary obstruction

3. 78M, confused, N/V x 1d and not voided x24hr – AkI

  • As his family physician, you are concerned about a sudden decompensation in renal function (acute kidney injury). List three risk factors for acute kidney injury.
    • Cardiac / liver failure
    • DM or CKD
    • Exposure to nephrotoxin, eg contrast IV
    • Sepsis / UTI
    • Age >75
  • You ask Miriam to confirm the medications her husband is taking. List two medications that are associated with acute kidney injury.
    • Diuretics: ACEi, Lasix
    • NSAIDs
  • Pt is listless and confused, not oriented to day or place, and has a lower than average blood pressure. He has no rash. List three laboratory investigations to order when acute kidney injury is suspected.
    • serum Creatinine, BUN, eGFR
    • Electrolytes
    • U/A 
    • CBC & peripheral smear (HUS or TTP)
  • What imaging study is particularly warranted in this patient to rule out a postrenal cause for his acute kidney injury?
    • Renal U/S r/o hydronephrosis (perform in most pt with AKI)
  • Unfortunately, in pt’s sudden decompensation in mental status, altered vitals and having more than one possibility for his acute kidney injury warrant hospitalization and consultation with a nephrologist. It is determined that a combination of factors contributed to his acute kidney injury. In the hospital, pt’s medications are adjusted. What diabetic medication should not be given to patients with acute kidney injury?
    • Metformin

4. 19yoF w/ non-inflammatory acne with whiteheads and blackheads on her face. Healthy and no meds.

  • What would you prescribe for her?
    • Topical retinoid: adapalene
  • Pt tries this for a few months and has some initial success. Unfortunately, her acne worsens and she develops mild to moderate inflammatory papules and pustules with a few nodules on her neck, chest, and upper back. What would you prescribe for her now? List three options.
    • Clindoxyl 2% gel (mix of clindamycin and benzoyl peroxide)
    • Benzoyl peroxide gel 
    • Doxycycline po
    • OCP
  • Natalie wants to avoid eating chocolate to help treat her acne. Does avoidance of chocolate work? No
  • Natalie would like to try microdermabrasion to help treat her acne. Does microdermabrasion work? No
  • Natalie would like to try tea tree oil to help treat her acne. Does tea tree oil work?
    • Effective for total lesion reduction of papules, pustules, and comedones in mild to moderate acne
  • Pathophys:
    • 1. increased sebum production by sebaceous glands, in which androgens have an important role.
    • 2. hyperkeratinization of the follicle, leading to a microcomedo that eventually enlarges into a comedo.
    • 3. colonization of the follicle by the anaerobe Propionibacterium acnes.
    • 4. an inflammatory reaction. The inflammatory events may begin before hyperkeratinization of the follicle.

5. 18yoF with plantar+ genital wart. Decide to use cryo

  • How long should the liquid nitrogen be applied to each of her lesions? 10-60sec – visible white ice formation
  • List the number of times per month the typical treatment regimen is performed. 3
  • For what other benign skin conditions is cryosurgery indicated? List four.
    • Seborheic Keratosis,
    • Skin tag,
    • molluscum contagiosum,
    • cutaneous horn,
    • oral mucocele,
    • pyogenic granuloma
  • For what premaligant skin conditions is cryosurgery indicated? List two.
    • Actinic Keratosis,
    • Bowen disease,
    • lentigo maligna (excision preferred)
    • keratoacanthoma
  • Melanie Plant, a 55-year-old patient and the mother of the pt, is at your office today because she suspects that she has a new basal cell carcinoma lesion with a 1 cm diameter on her forehead. She has previously been treated for basal cell carcinoma of her forehead by a dermatologist. She is a “snowbird” and is going to Florida tomorrow for a few months. She would like to get treatment before she leaves. Can you apply liquid nitrogen with a cotton-tipped applicator to treat this lesion?
    • No, doesn’t freeze to an adequate depth

6. 32yo PhD student, itchy rash x few days after returning from a conference. ?bed bugs

  • What are the possible clinical reactions to bed bugs? List three.
    •  2-5mm pruritic maculopapular lesions with a central hemorrhagic punctum, on uncovered areas of the body. 
    • breakfast-lunch-dinner alignment
    • isolated pruritis
    • papules / nodules, bullous eruptions
  • What is the differential diagnosis for bed bugs bites? List three.
    • arthropod bites: fleas, scabies
    • bullous dermatitis, 
    • erythema multiforme
  • If pt complains of pruritis (associated with sleeping difficulties) but has no sign of secondary infection of lesions. How should she be treated?
    • antihistamines or topical steroids
  • Mrs Bugatti wonders if she brought back any bed bugs. You tell her to look for brown,  wingless, flat, 2-5 mm long insects that resemble apple seeds, and how to detect their fecal traces. What can she do to decontaminate potentially infested clothing?
    • Wash with hot water at 60oC, drying at 40oC, dry cleaning, freezing

7. 31yoM low-grade fever, cough, rhinorrhea, nasal congestion, and sore throat -dx w/ common cold.

  • Which one of the following therapies has been shown to be effective for cold symptoms in adults?
    • Zinc lozenges, take within the first 24hr
  • Pt has a three-year-old daughter and wonders what she can take to help prevent her getting a cold. List three options.
    • Vitamin C,
    • Zinc sulfate,
    • nasal saline irrigation,
    • Probiotics
  • If his daughter is contaminated despite frequent hand washing, which one of the following therapies has been shown to be effective for cold symptoms in children?
    • Nasal irrigation with saline
    • Buckwheat honey is superior to placebo for reducing frequency of cough, reducing bothersome cough, and improving quality of sleep for the child.

8. 45yoF c/o fatigue. HTN + chronic low back pain x 10yr. Amlodipine 5mg, gabapentin300mg tid. Ix showed hgb = 114 and MCV = 80

  • List at least two causes for her anemia.
    • Xs menstruation, GIB
  • List two medical causes other than iron deficiency for microcytosis.
    • thalassemia, sideroblastic anemia
    • Chronic inflammatory states, Lead poisoning
  • You get the results to identify iron deficiency anemia. Blood work shows the ferritin level is 60 μg/ml (μg/mL=ug/L); the iron level has decreased to 5 μmol/L, the iron binding capacity is increased and the transferrin saturation is low. Besides neoplasia, which gastrointestinal diagnosis should be ruled out in adults with iron deficiency?
    • Celiac disease
  • Five years later, Monica has been diagnosed with rheumatoid arthritis and has the same ferritin level, iron level almost normal and a slightly increased iron binding capacity. Which test unaffected by inflammatory states would help identify iron deficiency anemia?
    • Soluble transferrin receptor test,
    • erythrocyte protoporphyrin testing or bone marrow biopsy
  • You prescribe ferrous sulfate 300 mg three times a day. How long should this be maintained?
    • Three months after the anemia is corrected

9. 13yoF with scoliosis (curved spine). No issue

  • What are the classic findings of scoliosis on examination? List two.
    • Shoulder / scapular asymmetry
    • Waist and trunk asymmetry
    • Rib prominence on forward flexion on the ADams test
  • The vast majority of patients with idiopathic scoliosis have a convex curvature that is right thoracic or left lumbar. True
  • Patients with idiopathic scoliosis typically complain of pain that disturbs sleep. False
  • Scoliosis deformity that is less than 30 degrees at the end of growth usually worsens in adulthood. False
  • You examine pt and she has features suggestive of scoliosis. What diagnostic test should you order?
    • PA x-ray of the spine from C7-iliac crest
  • What are the indications for ordering an MRI? List two.
    • Onset before 10yo
    • Clinically significant pain
    • Kyphotic apex of the scoliosis
    • A neurologic abnormality
  • Before proceeding further, you decide you need to assess her skeletal maturity. Name two ways you can do this.
    • The growth velocity (serial height measurements)
    • Radiograph to estimate bone age
  • Pt’s X-ray shows a 35-degree curvature. Your assessment determines she has not yet finished growth. You refer her to an orthopedic surgeon. What non-surgical treatment can be considered?
    • Bracing
  • What are the indications for surgery? List two.
    •  immature skeleton: progressive scoliosis >45o
    • After skeletal maturity: progression or associated pain
  • “Flat back syndrome” occurs less commonly with newer surgical techniques. True
  • Spinal fusion extending into the lumbar spine is associated with development of degenerative arthritis. True
  • Long-term, patients with idiopathic scoliosis treated with either bracing or fusion experience more back pain than do age-matched controls. True

10. Unintentional Childhood injury Prevention

  • What are some effective drowning-prevention strategies? List three.
    • Pool fencing,
    • Touch supervision (adult able to reach and grad a child in water)
    • Use of approved flotation devices
    • Formal swimming lessons (>4yo)
    • CPR training
  • Susan is worried about the risk of suffocation for her newborn. What are some effective suffocation prevention strategies? List two.
    • no co-sharing of the bed
    • Sleeping on backs
    • Use properly assembled, approved cribs and playpens
    • Avoidance of loose bedding
  • Susan is wondering if her two older children should sleep in bunk beds. Would you recommend this? no, not for children <6yo
  • Susan is wondering if her youngest child would eventually benefit from a walker. Would you recommend this? no (fall prevention)
  • Susan is worried about accidental poisoning and would like to have syrup of ipecac at home. Would you recommend this? no, prevention by locking access to medications and contact poison control in poisoning cases

11. Memory Difficulties

  • After looking at her medication list, your first step is to consider possible cognitive side effects, including delirium, due to the medications or other causes. List two criteria that can be used to detect delirium.
    • Acute onset over 24hr * fluctuating course
    • Inattention & disorganized thinking / altered LOC
  • Mrs. Simpson does not meet the criteria for delirium. What condition that often mimics dementia should be ruled out?
    • Depression
  • Mrs. Simpson has no other symptoms. You now plan a basic workup to rule out reversible causes of memory difficulties. Which tests should you order? List five.
    • CBC, B12, TSH, electrolytes, Creatinine /eGFR, calcium & albumin
    • Cranial imaging 
      • age
      • rapid or unexplained decline in cognition or function;
      • dementia of relatively short duration (
      • recent, serious head trauma; history of cancer; use of anticoagulants or history of a bleeding disorder;
      • history of urinary incontinence and gait disorders early in the course of dementia;
      • unexplained neurological symptoms; presence of any new localizing sign;
      • unusual or atypical cognitive symptoms or presentation;
      • gait disturbance; or if the presence of unsuspected cerebrovascular disease would change clinical management
  • The workup appears to be normal. The next step is to determine whether Mrs Simpson’s memory difficulties represent normal cognitive aging, mild cognitive impairment or dementia. What are the characteristics of these three conditions?
    • Normal cognitive aging: independent with IADLs and ADLs & normal MMSE
    • MCI: Pt c/o of memory issues. slightly decreased MMSE, no impairment of ADLs or IADLs
    • Dementia:  ADLs impairment & abnormal MMSE
  • If Mrs. Simpson is found to have dementia, it will be important to diagnose its type, since treatment and prognosis can differ. If her clinical picture consisted mainly of early loss of executive function and relative preservation of memory and visuospatial skills, which type of dementia would be most likely?
    • Frontotemporal dementia
  • Typical Alzheimer disease is characterized by early episodic memory loss (deficits in recall of recently learned information, often referred to as short-term memory loss), followed by later involvement of executive dysfunction and visuospatial impairment as the pathology spreads from the medial temporal lobe and hippocampus to other areas of the brain.
  • At present, vascular dementia remains a clinical radiologic diagnosis: in addition to vascular risk factors, there must be neuroimaging evidence of cerebrovascular involvement. Typically, there is early loss of executive function owing to vascular disease affecting primarily the frontal lobes and their subcortical connections.
  • Frontotemporal dementias typically present in the middle years of life with early progressive changes in behavior, personality, or language functioning. Behavioral changes include loss of social skills, emotional blunting, loss of insight, and lack of concern.Patients presenting with language forms of frontotemporal dementia might have word-finding difficulties and speech that is nonfluent (sparse, agrammatic, containing primarily nouns, with frequent word-finding pauses) or fluent but with impaired comprehension. On cognitive testing, there is often early loss of executive function with relative preservation of memory and visuospatial skills.
  • Lewy body spectrum disorders represent a continuum of diseases associated with Lewy body pathology; they include Parkinson disease dementia and dementia with Lewy bodies. These conditions share common clinical features of bradykinesia and other symptoms of parkinsonism, fluctuating alertness and cognition, and often the presence of well-formed visual hallucinations. Although it is an arbitrary distinction, Parkinson disease dementia and Lewy body dementia have been differentiated by the “one year rule”: Parkinson disease dementia is suspected if onset of dementia occurs after a year or more of parkinsonism; in Lewy body dementia, onset is before or within a year of the development of parkinsonism symptoms. Often, findings on cognitive testing demonstrate early loss of executive and visuospatial function with relative sparing of memory and language functions until the later stages of illness.

CFFM Memory Clinic clinical reasoning model
  1. Is it delirium?
    • Use the Confusion Assessment Method:
      • Acute onset and fluctuating course +
      • Inattention +
      • Disorganized thinking OR altered level of consciousness
  2.  Is it depression?
    • Consider atypical presentations: anxiety, irritability, unexplained physical complaints, worsening cognition
  3. Is there a reversible cause?
    • Measure CBC, TSH, creatinine, electrolytes, calcium, glucose, and vitamin B12;
    • consider cranial imaging*
  4. Is it dementia, MCI, or normal aging?
    •  Dementia: objective findings of cognitive loss with impairment of ADLs
    •  MCI: objective findings of cognitive loss without impairment of ADLs
    •  Normal cognitive aging: no objective findings of cognitive loss
  5. If it is dementia, what type or types?
    • AD: initial short-term memory loss
    • VaD: vascular risk factors; neuroimaging evidence of cerebrovascular involvement
    • FTD: younger age, behavioral symptoms, or language impairment
    • DLB: bradykinesia or features of parkinsonism, fluctuating cognition, visual hallucinations
    • PDD: dementia occurring > 1 y after onset of Parkinson disease motor symptoms
  6. How will you manage this?
  7. Is driving a concern?

12. 15yoF, no menses. healthy, no meds, no xs exercise, and proper diets.

  • What is the most likely diagnosis?
    • Primary amenorrhea
  • What initial laboratory tests would you order to confirm your diagnosis? List four.
    • Pregnancy test, LH, FSH, prolactin, TSH
  • What initial diagnostic imaging investigation would you order?
    • pelvic u/s r/o anatomical abn
  • Pt’s sister, aged 18, had menarche at age 13. She came to the office today with her sister. She was having menses every 28 days up until the last three months. She is not taking birth control pills and has never been sexually active. Polly is healthy and does not exercise excessively. She plays hockey and soccer. She is not on any special diet. She has secondary amenorrhea. List three likely causes of secondary amenorrhea.
    • PCOS
    • Hypothalmamic amenorrhea
    • Hyperprolactinemia
    • Primary ovarian insufficiency

References:

  • CFPC Self-Learning Modules
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Posted in SAMP
2 comments on “CFPC SAMP 2013-2015
  1. Naeem says:

    Whats is c/i? is it clinical features?

    Like

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