SAMP 2005-2010 Book 1 ( 6 questions)
1. Mother of 4yo & 18mo old ask about proper nutrition for her children. 2-3 servings of milk per day. Asks if she should give low fat or whole milk? She is concerned that if her children drink a higher fat milk, it may cause them to become obese.
- Whole milk (vs lower fat) doesn’t cause a difference in height, wt, body fat % in children aged 12-24mo.
- How much juice her children should drink daily? (obesity, dental caries, poor nutrient intake)
- 4-6 oz daily of 100% fruit juice w/ no added sugar
- whole fruits and vegetables should be offered as much as possible
- What % of total calories should be from fat (for energy, growth, rapid brain development)? 30%
- Does her children need to take vitamin supplement? (eat good portions of food from all 4 food groups) No
- toddlers consume
- Is it normal to have a hard time introducing new foods? How many times children usually refuse new foods before accepting them? At least 10 repeated exposures
2. Common Newborn rashes
- Reticulated mottling of the skin that symmetrically involves the trunk and extremities. It is caused by a vascular esponse to cold & generally resolves when the skin is warmed.
- Cutis Marmorata
- Erythema of the dependent side of the body with simultaneous blanching of the contralateral side, developing suddenly and persisting for 30sec to 20min. It resolves with increased muscle activity or crying.
- Harlequin color change
- Closed comedones on the forehead, nose, and cheeks, although other locations are possible. Open comedones, inflammatory papules, and pustules can also develop.
- Acne neonatorium
- Erythematous, 2-3mm macules & papules that evolve into pustules. Each pustule is surrounded by a blotchy area of erythema, leading to what is classically described as a “flea-bitten” appearance. Lesions usually occur on the face, trunk, and proximal extremities. Palms and soles are not involved.
- erythema toxicum neonatorum
- Pearly white or yellow 1-2mm papules caused by retention of keratin within the dermis, most often on the forehead, cheeks, nose, and chin, but also on the upper trunk, limbs, penis, or mucous membranes.
- Erythema and greasy scales occurring most commonly on the scalp. Other affected areas may include the face, ears, and neck. Erythema tends to predominate in the flexural folds and intertriginous areas, whereas scaling predominates on the scalp.
- seborrheic dermatitis
3. Insomnia, requesting a sleeping pill.
- Insomnia is defined as difficulty initiating or maintaining sleep, early awakening or nonrestorative sleep despite adequeate opportunity, accompanied by at least one of the following forms of daytime impairment. List 4:
- Fatigue or daytime sleepiness
- Impairment of attention, concentration, or memory
- Poor social, occupational, or academic performance
- Mood disturbance or irritability
- Less motivation, energy, or initiative
- Proneness to errors or accidents at work or while driving
- Tension H/A or GI distress due to sleep loss
- Worries about sleep
- List 4 medications that can cause insomnia
- Antidepressants (SSRI, SNRI – venlafaxine)
- Stimulants (methylphenidate, dextroamphetamine)
- Hormones: Synthroid, cortisone
- sympathomimetics: salbutamol, pseudoephedrine
- When asking about sleep history, what issues should be discussed? List 4
- Habitrual sleep and wake times
- Time to sleep onset
- Number of nocturnal awakenings and their cause
- Activities done in bed during periods of wakefulness
- Daytime consequences of insomnia
- Other sleep disorders: OSA, restless leg syndrome
- CBT has proven benefit and outlasts drug therapy. PEx- tired appearnce, head nodding, yawning, nystagmus, tremor, ptosis, and dysarthia. Sleep hygiene advice should inlcude List 4:
- Think positively
- Establish fixed bed and wake times
- Maintain a comfortable sleep environment
- Avoid clock-watching
- 20min toss and turn rule – get up if don’t fall asleep within 20min
- use the bedroom only for sleep and sex
- Avoid daytime naps, caffeine, alcohol, nicotine within 6hr of sleep
- Regular exercise, but not within 3hr of sleep
- Basic principles of drug Tx for insomnia were presented. List 4
- No hypnotic drugs by themselves – tx should include sleep hygiene & behavioral therapies
- start hypnotics at low dose and titrate upward prn
- Avoid long term BZD
- Use hypnotics (BZD) cautiously in pt with a hx of abuse/dependence
- Monitor regulalry for signs of tolerance, dependence, and withdrawal
- Avoid long-actiing preparations & advice potential for hangover effects & accident while driving or working
- Taper hypnotics gradually to avoid withdrawal symptoms & rebound insomnia
4. 55F with myelodysplasia & chronic A fib, requires an urgent surgery for a hip fracture. She has been taking warfarin. Initial b/w includes the following: WBC 3.2, Hb 75, INR 5.5, Plt 5. Reverse anticoagulation with FFP & transfuse her with pRBC + Plt.
- During the FFP transfusion, pt develops a patchy itchy rash on face, chest, arms, and legs. The transfusion is stopped immediately. Stable VS throughout the episode. Symptoms resolved in 45min after Tx with antihistamine. Which kind of transfusion reaction was this?
- Benign allergic reaction
- During plt transfusion, pt develops f/c. Temp has risen from 37.4 to 38.5. Other VS are stable. The plt transfusion is stopped and samples are taken to the blood bank for analysis. The direct antiglobulin test is negative & no free hemoglobin is observed on visual exam. What type of transfusion reaction is occuring?
- Febrile nonhemolytic transfusion reaction
- Pt asks about infectious dz transmitted by transfusion. Which of the following infectious agents is most prevalent?
- Hep B > HepC/HIV
- TRALI (Transfusion-related acute lung injury) 1/5000, occurs within 30min-2hr post-transfusion.
- Sudden onset of respiratory failure, severe hypoxemia, pulmonary edema, despite normal cardiac function.
5. Gout – 53M started HCZ 2/52 ago for HTN, in with a warm, painful and swollen 1st MTP.
- List 3 modifiable risk factors for acute gouty arthritis
- Obesity & dyslipidemia
- Diuretics: HCZ therapy in our pt
- EtOH use
- High Purine diet: red meat, sea food
- List 3 triggers that could have precipitated gout.
- Initiation of diuretic: HCZ
- AKI from the contrast die
- Acidosis / trauma, surgery, chemo initiation, start / stop allopurinol
- List 2 first line Tx for acute gouty arthritis
- NSAIDs – Advil / naproxen, indocin
- 2nd line: corticosteroids
- 60% pt exp a gout attack will have another within 12mo. List 3 interventions to help pt avoid having a recurrent attack of gout
- Lifestyle modifications – lose weight
- Limit intake of red meat
- Avoid Thiazide
- Avoid EtOH
- List 2 situations where urate-lowering pharmacotherapy (ALLOPURINOL > PROBENECID) would be recommended.
- >3 gouty attacks / year, wait 1-2wk after resolution of an acute attack
- Tophi & JT damage seen on x-ray
List 3 mechanisms of action of probiotics
- Lower Intestinal pH and inhibit growth of pathogenic bacteria
- Prevent adhesion and colonization of pathogenic bacteria
- Induce or enhance immune responses
- Inhibit the pathogenicity of bacterial toxins
List 4 clinical conditions that probiotics have been studied successfully, though on a limited basis?
- Prevent C diff and other antibiotic-associated diarrhea
- Infectious diarrhea & traveler’s diarrhea
- IBS, UC, Crohn’s
Potential adverse effects of probiotics. List 2
- Gas, bloating
- Infectious complications including sepsis and liver abscess in immunosupresssd and critically ill pt
SAMP CFPC self learning 2010
1. Dry Eyes
Susan Desert, aged 39, comes to your office today complaining of dryness and grittiness of her eyes for the past three months. She also has been experiencing dryness of her mouth. She has some difficulty speaking and needs frequent sips of water. On physical examination, you notice that the patient has conjunctival injection of her eyes and clouding of the cornea. Furthermore, oral examination reveals that she has dry mucous membranes with some fissures present. She also has some arthralgia and some problems with reflux.
- What is the most likely diagnosis?
- Sjogren’s syndrome (dry mouth – xerostomia, dry eyes – xerophthalmia / keratoconjunctivitis sicca)
- What laboratory investigations would you order to confirm your diagnosis? List three.
- RF – Rheumatoid factor,
- ANA – Antinuclear antibody
- Anti-SSA (Ro) and Anti-SSB (La) or positive biopsy of a salivary gland is required for dx of Sjogren’s
- Name an eye test that could evaluate this patient’s eye symptoms.
- Schirmer test
- sterile filter paper strip beneath the lower eyelid for five minutes. If the moistened area measures less than 5 mm, the test is positive.
- Rose bengal test
- stain devitalized corneal and conjunctival epithelial cells
- Schirmer test
- What are the treatment options for dryness of the eyes? List two.
- Artificial tears
- Pilocarpine (muscurinic)
- Cevimeline (muscurinic)
- muscurinic is contraindicated in angle-closure glaucoma and uncontrolled asthma
- What are the treatment options for dryness of the mouth? List three.
- Sugar-free gums and sour lemon lozenges
- Daily fluoride use and antimicrobial mouth rinses
- OTC salivary substitutes
- Ddx for enlarged parotid glands
- mumps, tuberculosis
2. Ovarian Cancer
Eva Ryan, aged 50, is visiting your office today because she has been experiencing abdominal pain and bloating for the past few months. She has also been experiencing fatigue, nausea, constipation and early satiety. You perform a pelvic examination and detect an adnexal mass. You suspect that she might have ovarian cancer.
- What test should be done initially?
- Transvaginal ultrasound and CA-125
- CA-125 is a good screening test for ovarian cancer. Flase
- Testing confirms that Eva has ovarian cancer. What is the conventional treatment for this condition?
- Tumor cytoreduction (debulking surgery) then platinum + nonplatinum chemotherapy
- If Eva were diagnosed with stage 1 ovarian cancer (limited to ovaries), what would the prognosis be?
- Very good – 90% 5 year survival rate
- If Eva were diagnosed with stage 4 ovarian cancer (distant metastatic), what is the approximate five-year survival rate?
- Poor – <10% 5 yr survival rate
3. Suprapubic Pain, Urgency and Frequency
Mrs. Woods, aged 37, is scheduled for a periodic health exam. She is generally healthy; however, she has noticed suprapubic pain, urinary urgency and frequency for which she has gone to the walk-in clinic at least five times since her visit with you last year. She was diagnosed with urinary tract infections, but the antibiotics did not change her symptoms and several urine cultures failed to identify a significant pathogen.
- Based on this history, what is the likely diagnosis?
- Interstitial cystitis / painful bladder syndrome
- What is the differential diagnosis of this condition? List four.
- STD / urinary or vaginal infections
- Bladder cancer
- Neurologically mediated bladder hyperactivity
- Prostatitis in man
- Some patients have exacerbations of their symptoms after ingesting certain foods or drinks. What drinks should Mrs. Woods avoid?
- Caffeine, alcohol,
- Carbonated drinks
- Juices / Fruits containing citrate (grapefruit, lemon, cranberry, orange, pineapple)
- What is the only oral treatement currently approved in the U.S. for this patient’s condition?
- Pentosan polysulfate sodium 100mg po tid x 6mo
- replaces the deficient inner lining of the bladder wall glycosaminoglycans and inhibits mast cell degranulation. It may take up to six months for symptoms to improve, however, so patients must be prepared for this initial delay.
- Other medications: Amitriptyline, Hydroxyzine, gabapentin
- Pentosan polysulfate sodium 100mg po tid x 6mo
4. Obsessive-Compulsive Disorder: Diagnosis and Management
Luc, aged 23, comes to your office at the request of his girl friend because he spends too much time washing his hands and worries abnormally about his health problems. He took some over-the-counter medications with no benefit. He feels ashamed to talk about this and needs your help.
- You wonder if he might have obsessive-compulsive disorder (OCD). List two symptoms of OCD (recurrent distressing thoughts and repetitive behaviours or mental rituals performed to reduce anxiety).
- Recurrent Obsession & compulsion that are severe enough to be time-consuming (>1hr/day) or to cause marked distress or significant impairment.
- Pt recognizes that the obsessions and compulsions are excessive or unreasonable
- The disturbance is not a result of physiologic effects of a substance or medical condition.
- List three psychiatric comorbid diagnoses that frequently occur in people with OCD.
- Social phobia, specific phobia
- Depression – Major Depressive Disorder
- Panic disorder
- Substance abuse
- high suicide risk
- You decide to refer Luc to a psychologist. Which proven effective method of psychotherapy is most often used?
- Three months later, Luc has partially improved. He still spends a lot of time washing his hands, over-checking appliances and doors before leaving home. He is quite distressed about this. Which category of medications would you offer Luc?
- antipsychotic augmentation after 3mo trial of SSRI at the max dose
5. Statin-Related Myopathy
Mae O. Pathy, a 55-year-old patient who began taking atorvastatin (Lipitor) 20 mg daily two months ago, is in the office for a follow-up visit. She is complaining of severe cramps and weakness in her legs, worse after starting the exercise program you recommended. Mrs. Pathy is 147 cm in height and weighs 44.45 kg. She is being treated for hypothyroidism and paroxysmal atrial fibrillation. Mrs. Pathy also has mild osteoarthritis in her hands and knees. Medications include levothyroxine 0.05 mg daily, ASA coated 81 mg daily and amiodarone 200 mg daily. Azythromycin was prescribed three weeks ago when she presented to the emergency room with fever and a cough.
- You suspect statin-related myopathy. List two measures that are helpful, before starting statins, in evaluating future muscle pain.
- Document pre-Tx myopathy on a scale of 1-10 with location & type of pain
- Determine baseline Creatine Kinase level
- Mrs. Pathy presents several risk factors for statin-related myopathy. Name three patient-related factors and two medication-related factors for statin-related myopathy.
- Patient-related factors:
- Advanced age, Female, small body frame & frailty,
- Excessive physical activity
- Hx of myopathy with lipid-lowering Tx
- Hx of CK elevation
- Family hx of myopathy
- unexplained cramps
- Multisystem dz (particularly liver, kidney)
- Medication-related factors:
- High dose statin tx
- Interactions with concomitant drugs
- Fibrate, antifungals, macrolide abx, amiodarone, HIV PI
- Patient-related factors:
- What is a common symptom trigger for this problem?
- Unusually heavy physical exertion
- You discontinue atorvastatin but are convinced your patient needs lipid-lowering medication. She asks when she should expect her muscle symptoms to resolve. What is the mean duration until symptom resolution after discontinuation of statin therapy?
- 10 weeks
- Some statins have a lower myopathy risk, especially in the context of polypharmacy. Name two.
- Rosuvastatin, Fluvastatin
- What other lipid-lowering management options are available to you? Name two.
- Use a lower-myopathy risk statin or altered dosing of atorvastatin / rosuvastatin
- Add nonstatin eg. Exetimibe or bile acid-binding resin
- ? coenzyme Q10
- Some patients with mixed dyslipidemias require the addition of a fibrate to statin therapy. Which combination is safer, gemfibrozil plus a statin, or fenofibrate plus a statin and why?
- Fenofibrate plus a statin
6. Diagnosis of Acute Stroke
Mrs. Tia Stroker, aged 64, presents with a sudden onset “dizziness” and “a funny feeling” in her left arm which has persisted for four hours. You suspect she is having an acute stroke.
- What are the two categories of acute stroke?
- hemorrhagic (intracerebral or subarachnoid) and ischemic
- What is the most common historical feature of ischemic stroke?
- acute onset of focal neurological deficits
- What are the two most common physical findings?
- Slurred speech
- Focal weakness, eg. arm > leg > facial droop
- History and physical examination can reliably distinguish between intracerebral hemorrhage and ischemic stroke.
- 2. False
- What is the most common symptom of subarachnoid hemorrhage?
- Thunderclap (sudden, max onset, severe) headache – “worse headache of one’s life”
- What are the two most common stroke mimics?
- In patients aged 44 and over presenting with isolated dizziness symptoms and no signs, what percentage have an ultimate diagnosis of stroke or transient ischemic attack (TIA)?
- 1. Less than 1%
- Vertigo from a central cause eg stroke, is normally associated with nystagmus or other cerebellar signs
- Most TIAs resolve within one hour.
- 1. True
- What are the two primary purposes of neuroimaging in a patient with suspected ischemic stroke?
- rule out hemorrhagic stroke
- rule out tumor and other CNS lesions
- A normal CT rules out the diagnosis of ischemic stroke.
- 2. False
- What finding on lumbar puncture confirms the diagnosis of subarachnoid hemorrhage?
- xanthochromia – presence of bilirubin (only RBC in body breaks down to bilirubin, RBC from a traumatic tap becomes oxyhemoglobin)
- LP recommended until 12 hr after the initial onset of symptoms (RBC breakdown can take up to 12hr)
7. Erectile Dysfunction
- inability to achieve or maintain an erection sufficient for satisfactory sexual performance
Eric Diss, a 50-year-old divorced male, is visiting your office because over the past few months he has been experiencing erectile dysfunction (ED). This problem has been causing significant personal stress and has affected his relationship with his girlfriend. You plan to do a thorough history and physical examination to confirm this diagnosis.
- What are the risk factors for ED? List four.
- Hormonal disorder: hypogonadism, hypothyroidism, hyperprolactinemia
- Psych: Depression, performance anxiety, guilt, Hx of sexual abuse, marital or relationship problems, stress
- Neuro: Alzheimer dz, MS, Parkinson disease, paraplegia, quadriplegia, stroke
- Cardiovascular dz, HTN, Dyslipidemia, Diabetes mellitus
- Advancing age
- Obesity, sedentary lifestyle
- Cigarette smoking, illicit drug use (cocaine, methamphetamine)
- Peyronie dz – development of fibrous scar tissue inside the penis that causes curved, painful erections
- venous leakage, hx of pelvic irradiation or surgery eg. radical prostatectomy
- Eric wonders if some of the medications that he is presently taking might be causing his ED. What classes of medications may cause or contribute to ED? List four.
- antihypertensives: Betablocker, CCB, thiazide, hydralazine
- Diuretics: spironolactone, thiazides
- antidepressants: TCA
- Antihistamine (Gravol, benadryl), anticholinergics,
- anticonvulsants (phenytoin), anti-parkinson agents (bromocriptine, Levodopa)
- Hormones – estrogens, anti-androgens (5-a reductase inhibitor), corticosteroids
- Analgesics: opiates
- Cytotoxic agents: methotrexate
- Illicit drugs: amphetamines, barbiturates, cocaine, heroin, marijuna
- Tranquilizers: BZD
- Your physical examination and laboratory investigations confirm that Eric has ED. What are the two first line therapies for this condition?
- PDE5 (PhosphoDiEsterase 5) inhibitor – Viagra (sildenafil)
- Lifestyle modifications and modifying meds that may contribute to ED
- Tx obesity (BMI <30), diet + exercise, reduce EtOH, eliminate street drugs and smoking
- If Eric had hypogonadism, what treatment would be helpful for this condition?
- Testosterone supplementation
8. 2012 Lipid Guidelines –
You are a family doctor in a busy practice. You are interested in improving the screening and treatment of lipid disorders in your patients.
- Name six patient groups that should be screened.
- Men > 40 and women > 50 or postmenopausal
- Family Hx of premature CAD (MI
- CKD (eGFR<60)
- Inflammatory dz: RA, SLE, psoriatic arthritis, AS, IBD
- Diabetes Mellitus
- Cigarette smoker or COPD
- Obesity (BMI >27)
- Erectile Dysfunction
- Clinical evidence of atherosclerosis, AAA, hyperlipidemia (xanthomas, xanthelasmas, premature arcus cornealis)
- High sensitivity C-reactive protein (hs-CRP) should be measured in which patients?
- Consider (optional) for men >50 or women >60 who are not candidates for statin based on conventional risk factors
- intermediate FRS and not qualify for lipid Tx (LDL <3.5, non-HDL<4.3)
- low FRS, but within 5-9% with LDL <5
- Consider (optional) for men >50 or women >60 who are not candidates for statin based on conventional risk factors
- In these patients, at what level of hs-CRP would you initiate statin therapy? >2mg/L
- > 2mg/L – higher risk repeat in 2-4 weeks and use the lower value
- >3 mg/L – high risk
- The Framingham Risk Score is one system to estimate cardiovascular risk. Name another risk scoring system.
- Cardiovascular age calculation
- Once you have calculated a Framingham Risk Score, by what factor should you multiply it due to a family history of premature coronary artery disease? 2x FRS = modified FRS
- Which one of the following patients is not considered high risk?
- A patient with peripheral vascular disease
- A male aged 48 with diabetes
- A 30-year-old male with diabetes but no other risk factors
- A person whose Framingham risk score is 25%
- At what levels of LDL-C and TC/HDL-C would you treat a low risk patient (Framingham risk score <10%)?
- LDL >5 or family hx of genetic dyslipidemia (eg. familial hypercholesterolemia)
- Which one of the following health behaviors is not recommended for disease prevention?
- Smoking cessation
- Calorie restriction to achieve and maintain ideal body weight
- Psychological stress management
- Alcohol abstinence
- Which fibrate should not be used in combination with a statin?
- Name four types of medications that can be used to lower LDL-C?
- Cholesterol absorption inhibitors: Ezetimibe
- Bile acid reabsorption inhibitors: Cholestyramine
9. Asthma Management
Mary Weese returns to your office for management of her newly diagnosed asthma. You review with her the importance of smoking cessation, the proper use of her salbutamol inhaler, and interventions about environmental control.
- Which one of the following statements about the pharmacological management of her condition is false?
- 1. Low dose inhaled corticosteroid monotherapy is recommended as first line maintenance therapy for most patients.
- 2. The addition of long acting β2 agonists has improved clinical outcomes for patients whose asthma is well controlled with low dose inhaled corticosteroids
- 3. Cigarette smoking typically reduces the response to inhaled steroids.
- 4. Long acting β2 agonists should not be used as monotherapy for asthma.
- 5. Leukotriene antagonists are less effective than inhaled steroids.
- monothreapy reserved for those can’t tolerate ICS
- Adding LABA is better than Leukotriene
- Some pt might respond better: sig inflammation of upper airways, eg. allergic rhinitis / nasal polyposis, sensitivity to ASA, sig exercise-induced bronchoconstriction.
- Name two common adverse effects which might be anticipated from your first line management.
- oral thrush / candidiasis
- Mary’s asthma is still not adequately controlled. Which one of the following statements about the next steps in the management of Mary’s condition is false?
- 1. Adding a long acting β2 agonist to low dose inhaled corticosteroids leads to fewer exacerbations than does doubling the dose of inhaled corticosteroid.
- 2. Adding a leukotriene receptor antagonist to inhaled corticosteroids does not yield better results than the use of either agent alone.
- 3. Some patients may respond better to a leukotriene receptor antagonist than to a long acting β2 agonist.
- 4. Theophylline should be reserved for patients in whom long acting β2 agonist and leukotriene receptor antagonist therapy has failed.
- Additional doses of a budesonide-formoterol combination inhaler can be safely used as a reliever to treat acute exacerbations.
- 1. True 2. False
10. Prevention of Osteoporosis-related Fractures
Raymond Tanguay, aged 75, comes to your office after having been discharged from hospital. He had been admitted for a hip fracture after he fell while walking in the snow. The emergency room doctor told him he needs to be treated for “osteoporosis” and he needs to be seen by his family physician for “follow-up and work-up.”
He is known to have hypertension, high cholesterol and moderate chronic obstructive pulmonary disease (COPD). He is a smoker. He likes to drink three to four glasses of wine daily. His weight is 70 kg, height 170 cm. He has many questions about osteoporosis.
- How can the diagnosis of osteoporosis be made? BMD of lumbar spine / femoral neck with T score <-2.5
- What are the risk factors for osteoporosis?
- Current smoking
- Low body weight <60kg
- Major wt loss >10% since 25yo
- Chronic corticosteroid use (>3mo of >7.5mg daily use)
- High risk medications: aromatase inhibitors, androgen deprivation
- Rheumatoid arthritis
- Xs EtOH use
- Previous fragility fracture after age 40
- vertebral fracture or osteopenia on x-ray
- Parental hip fracture
- Is there any lifestyle measure or nutritional measure that can be taken to lower the risk of osteoporosis?
- Wt-bearing exercise that includes impact
- Adequate Ca (1200mg) and Vit D (800IU) intake
- Smoking cessation and moderate EtOH intake (<3drinks/day)
- Mr. Tanguay asks you about blood sampling and other tests to be sure osteoporosis is not the manifestation of another medical condition. Which blood tests should you order to exclude secondary osteoporosis?
- Calcium corrected for albumin
- SPEP (for pt with vertebral fracture)
- 25-hydroxy-Vitamin D (measure after 3-4mo of adequate supplementation)
- Which patients should be considered for osteoporosis pharmacological therapy? 1,2
- 1. Patient with a ten-year absolute risk above 20% for any osteoporotic fracture (high risk)
- 2. Men and women who have had a fragility fracture and whose T score is −1.5 or lower (> 1 fragility fracture or >50yo with a fragility fracture)
- 3. Patient with a ten-year probability of hip fracture of 3% (low risk – reassess in 5yr)
- Which one of the following statements about osteoporosis pharmacotherapy is true? 2
- 1. Etidronates are as effective as bisphosphonates in preventing vertebral fracture, nonvertebral fracture and hip fracture.
- 2. Nasal calcitonin therapy has been shown to reduce the risk of vertebral fractures among postmenopausal women at high risk of osteoporotic fractures.
- 3. Teriparatide has been shown to reduce risk of fracture in older men. (reduce pain associated with vertebral #)
- evidence only in postmenopausal women, reduce vertebral and nonvertebral #
11. Vocal Cord Dysfunction
Natalie Birdsong, a 20-year-old university student enrolled in music, is at your office today because she has been experiencing recurrent episodes of throat tightness, inspiratory stridor, coughing, and choking sensation for the past few months. You initially thought she had asthma, but she has responded poorly to bronchodilators that you prescribed at her last office visit. Since her major is voice, you suspect that she might have vocal cord dysfunction.
- What precipitating factors are associated with this condition? List three.
- Exercise – r/o exercise-induced asthma
- environmental and occupational irritants: ammonia, dust, smoke, soldering fumes, cleaning chemicals
- GERD / rhinosinusitis
- Psych: anxiety, depression, PTSD, panic attack
- Neuroleptic drug use: with related EPS eg torticollis
- What tests can confirm your diagnosis?
- Flexible laryngoscopy – dx standard
- What are the management options for this condition? List three.
- Tx underlying GERD / Rhinosinusitis: PPi, saline irrigation + nasal steroid
- Avoid known triggers: smoke, airborne irritants, medications
- Speech therapy – mainstay of longterm tx
- Trial of inhaled iprtropium in pt with exercise-induced symptoms
- Unlike asthma, vocal cord dysfunction causes more difficulty with inspiration than expiration, and is commonly associated with a sensation of throat tightness or choking.
12. Cervical Radiculopathy
Mr. S. Oreneck, aged 40, presents to your clinic with neck pain of one month’s duration. There is no clear history of trauma and he is an otherwise healthy personal injury lawyer. Mr. Oreneck reports that his pain is distributed to his neck, right medial forearm, and he complains of paresthesias involving right ulnar fingers. Your first impression is cervical pain with radiculopathy.
- What findings on physical examination would support your diagnostic impression?
- Spurling sign ( axial compression of the spine and rotation to the ipsilateral side of symptoms reproduces or worsens cervical radiculopathy)
- Shoulder abduction relief test (holding the arm above the head decompresses the exiting nerve root)
- What is the differential diagnosis of cervical radiculopathy?
- Intra and extraspinal mass
- Thoracic outlet syndrome
- Cervical spondylotic myelopathy (spinal cord compression – difficult with manual dexterity, gait disturbance, UMN lesion – Hoffman / Babinski, hyper-reflexia, clonus)
- Complex regional pain syndrome
- Entrapment syndrome
- Rotator cuff pathology
- The majority of patients with cervical radiculopathy can be treated non- operatively. True or false?
- 1. True
- What diagnostic tests are helpful in the evaluation of patients with cervical radiculopathy?
- Cervical spine x-ray: AP open-mouth, AP lower cervical, neutral lateral
- CT myelopathy or MRI
- List some commonly utilized nonoperative treatments.
- Traction & immobilization (1wk) – weak evidence
- Tylenol and advils
- Steroid injection
- List two reasons for specialist referral.
- Intractable radicular symptoms unresponsive to nonoperative Tx > 6wk
- Motor weakness persisting for >6wk
- progressive neurologic deficit at any pt after symptom onset
- s/sx of myelopathy, or instability or deformity of the spine
- <20yo, >50yo, with s/sx of systemic disease;
- unrelenting pain at rest; constant or progressive s/sx
- neck rigidity without trauma;
- dysphasia; impaired consciousness; central nervous system signs and symptoms;
- increased risk of ligament laxity or atlantoaxial instability, eg. Down syndrome or heritable connective tissue disorders;
- sudden onset of acute and unusual neck pain or headache with or without neurologic symptoms;
- suspected cervical artery dissection;
- TIA, ? vertebrobasilar insufficiency or carotid artery ischemia or stroke;
- suspected neoplasia;
- suspected infection, such as diskitis, osteomyelitis, or tuberculosis;
- failed surgical fusion; progressive or painful structural deformity, or abnormal laboratory examination results
13. Complications Associated with Gadolinium
Mr. Robinson, aged 70, comes to your office with a pruritic rash on the back of his arms. He underwent a gadolinium contrast-enhanced MRI two weeks ago for a small mass on the left side of his neck. Reviewing his medical chart, you notice that he was hospitalized for pneumonia in the last month. His medical history: high blood pressure, diabetic nephropathy, alcoholism and a left nephrectomy for a hypernephroma. He currently takes metformin, glyburide, rosuvastatin, ramipril and aspirin. You suspect he has nephrogenic systemic fibrosis.
- Which medical conditions could have facilitated this diagnosis? List at least one.
- Diabetic nephropathy
- Gadolinium exposure
- What should you look for while examining this patient?
- Respiratory failure
- Joint contracture
- Erythematous plaques with associated induration and edema on the extremities and trunk
- Which test should you order to confirm your diagnosis?
- skin biopsy
- Identify at least two risk factors for developing this medical condition.
- CKD (eGFR<30), AKI, renal impairment, HD, PD
- Gadolinium exposure
- Pro-inflammatory state
- Infection – PNA, Osteomyelitis, sepsis
- Limb injury, major tissue injury or trauma
- Ischemic events, thrombosis
- Which medical test should you order to help prevent this condition?
14. Vitamin D
Susan Sunshine is at your office today to discuss vitamin D supplementation for her three children: Mike, aged 14, Natalie, aged six, and Justin, aged five months. She breastfeeds her baby and her other children drink less than one liter of milk per day.
- What is the recommended dose of vitamin D for children? 400IU cholecalciferol (Vit D3)
- reduce the risk of autoimmune conditions, infection, and DM2
- Vit D 400IU supplement for breastfed / partial breastfed or
- Susan is concerned that her children are at high risk for vitamin D deficiency. List three risk factors for vitamin D deficiency.
- Darker skin pigmentation; low maternal vit D levels (risk factor for infants)
- Exclusive Breast feeding w/o vit D supplementation
- Insufficient Sun exposure
- Anticonvulsant medication therapy
- chronic dz associated with fat malabsorption
- Which is the best available biomarker for checking vitamin D status?
- 25-hydroxy-Vitamin D (deficient if <20ng/ml)
- ↓ Vit D ⇒ ↑ PTH ⇒ ↑ bone resorption ⇒ Rickets (growth failure, hypocalcemic Sz, decreased bone mass, bone changes with #)
15. Exposure to Fifth Disease in Pregnancy (erythema infectiosum)
Sandra Thibodeau, aged 30, is scheduled for a routine prenatal visit at 20 weeks’ gestation. She has a three-year-old son and this is her second pregnancy. She is in good health and has had an uncomplicated pregnancy to date.
During her appointment, she mentions that her son was exposed to “slapped cheek” disease at daycare that week. She was told by the daycare supervisor to mention this to you as this can be a concern during pregnancy.
- What virus is responsible for erythema infectiosum? Parvovirus B19
- respiratory route, hand to mouth, blood products, or vertical transmission
- List three possible fetal complications of acquiring erythema infectiosum during pregnancy.
- Abortion / fetal demise
- Severe fetal anemia
- Nonimmune fetal hydrops
- CNS – neonatal encephalopathy, encephalitis, meningitis
- Fetal viral myocarditis – cardiac failure or hepatitis
- Sandra wants to know if there is a way to check if she already has immunity. What test would you recommend?
- ParvoViris B19 serology – IgG and IgM
- If this test confirms that she is immune, is further testing indicated? No
- If this test is indeterminate or negative, what further testing is recommended?
- Repeat IgM antibody against ParvoVirus B19 in 2-3 week to exclude seroconversion.
- Weekly u/s up to 12 weeks post exposure
- What is the approximate risk of fetal complications in an infected pregnant woman? 3%
16. Adverse Effects of Antipsychotic Medications
Mr. Kelly, a 27-year-old patient, comes to your clinic for his periodic health exam. He has been hospitalized twice in the last six months for psychosis. He was discharged from the hospital taking olanzapine 7.5 mg od. He has had no recurrence since. He complains about weight gain and constipation. His BMI is 29.
- What are the anticholinergic effects related to this type of medication? List four.
- constipation / urinary retention
- dry mouth
- blurred vision
- cognitive impairment
- Which medical and laboratory monitoring should be offered to your patient in the upcoming year? List four.
- Weight (BMI) and waist circumference
- Fasting Lipid panel
- Fasting serum glucose level
- While you are doing your medical examination, you notice bilateral breast enhancement and an acneiform dermatitis on his face and chest. Which laboratory test should you order to confirm your diagnosis?
- Prolactin level (block normal tonic inhibition of dopamine at pituitary cells produced in the hypothalamus)
- Identify two metabolic complications related to the use of antipsychotic medications.
- Weight gain
- impaired serum glucose from mild insulin resistance to DKA
- Identify three risk factors for developing tardive dyskinesia.
- Long-term Tx with 1st generation antipsychotic at higher dose
- advanced age
- Female sex
- Concurrent affective disorders
- EPS symptoms
- Acute dystonia
- Tardive Dyskinesia – with long term use (involuntary movement disorder)
17. Mild Traumatic Brain Injury
- MTBI is defined as injury to the head resulting in loss of consciousness for less than 30 minutes, alteration in mental status at the time of the accident, or memory loss. At the time of presentation for health care, MTBI patients have GCS scores of 13-15.
On Friday evening, a 22-year-old man is brought to the emergency department. He fell and struck his head on the bathroom floor. According to his wife, he lost consciousness for five to 10 minutes. He was not responsive but was breathing. His cervical spine was immobilized and he was put on a backboard. On arrival at your emergency department, his vitals were BP 125/83, HR 75, B/02 98%, Glasgow 14/15 (he was confused about the date and where he was). There was no sign of suspected skull fracture, and no sign of basal skull fracture. Secondary survey revealed no other injury.
- Is the presentation consistent with mild traumatic brain injury (MTBI)?
- 1. Yes 2. No
- List two elements consistent with MTBI in the clinical case above.
- GCS 14
- Ten minutes after arrival, more than two hours after his head trauma, he had a Glasgow coma score of 14. He did not vomit or have amnesia of the event. This patient should receive a CT scan of his head.
- 1. True
- List four of the five criteria that place the patient at high risk for neurologic intervention according to the Canadian CT Head Rule.
- signs of basal skull fracture: hemotympanum, racoon eye, CSF rhinorrhea or otorrhea, Battle’s sign
- Suspected open or depressed fracture
- V >=2x
18. Serotonin Syndrome (dx – see Hunter’s criteria)
Mrs. Wagner, age 62, comes to your clinic complaining of ‘flu’. She is worried about coughing day and night for the last three days. She has no fever and is not short of breath. Her medical history reveals a breast cancer for which she is still receiving chemotherapy, typical migraine and high blood pressure. She takes venlaflaxine XR 150 mg od, hydrochlorothiazide 12.5 mg od, and zolmitriptan 2.5 od prn. Ondansetron was prescribed for nausea while she is on chemotherapy.
Her physical exam is unremarkable and you decide to prescribe dextromethorphan twice daily for the next four days. The next morning, she is brought by her daughter to the emergency room. Her daughter had found her mother sweating and quite disturbed this morning. You notice that she is quite agitated. Her exam shows that she has fever and ataxia.
- What is the most likely diagnosis in this case?
- Serotonin syndrome
- Which differential diagnosis should be considered for this condition? List three.
- Sepsis / meningitis / encephalitis
- anticholinergic syndrome
- neuroleptic malignant syndrome
- Sympathomimetic overdose
- Thyroid storm
- Which other findings would you look for while you are examining your patient? List five findings.
- Hyperthermia / fever
- Confusion, hypomania
- Tremor, myoclonus, ocular clonus, rhabdomyolysis, shivering
- What would be the major indications to hospitalize your patient? List three indications.
- Autonomic instability
- Progressive cognitive changes
- What is the most widely used antidote for this condition?
- cyproheptadine (serotonin 2A antagonist)
- 2nd line: BZD
|Neuroleptic malignant syndrome||Serotonin syndrome|
|Precipitated By||Dopamine Antagonists||Serotonergic Agents|
|Onset||Variable, 1-3 days||Variable, < 12 hours|
|Identical Features||Vital Signs||Hypertension
Hyperthermia (> 40°c)
Hyperthermia (> 40°c)
|Mental Status||Variable, stupor, coma, alert||Variable, agitation, coma, confusion, hypomania|
|Muscles||‘Lead-pipe’ rigidity in all muscle groups||Increased tone, especially in lower extremities – ataxia, shivering, tremor|
Clonus (unless masked by increased muscle tone)
|Bowel Sounds||Normal or decreased||Hyperactive|
Medications that may contribute to serotonin syndrome
- Amphetamines, Analgesics (opioid), antidepressants / mood stabilizers
- Antiemetics (metoclopramide, ondasetron), antimigraine (ergot, triptans)
- Cocaine, dextromethorphan
19. Palpable Breast Lump
Mrs. Walters, age 32, comes to the walk-in clinic today because she detected a palpable breast lump two days ago. Her mother was diagnosed with breast cancer last year, so she fears this diagnosis.
- What would be your initial management if the lump were a hard, irregular mass fixed to the skin, palpable ipsilateral nodes or peau d’orange were present? (Check all that apply).
- 1. Ultrasound to determine if the lump is cystic or solid
- 2. Ultrasound with core biopsy
- 3. Mammography
- 4. Fine-needle aspiration in your office
- 5. Referral to a breast surgeon
- Mrs. Walters does not have the features outlined in question. What might your initial management be? (Check all that apply).
- 1. Ultrasound to determine if the lump is cystic or solid
- 2. Ultrasound with core biopsy
- 3. Mammography
- 4. Fine-needle aspiration in your office – the cyst’s location should be documented precisely (clock position & distance from the nipple)
- 5. Referral to a breast surgeon
- You perform a fine-needle aspiration and find nonbloody aspirate. The lump disappears completely after the procedure. What is the next step with this patient?
- discard aspirate and follow up in 6-8 wk to monitor recurrence of the cyst
- What would you have done differently if you had found bloody aspirate, lump recur, or if the lump did not disappear after the procedure?
- Pathology of the aspirate & u/s / mammography + ref to a surgeon
- If Mrs. Walters’ lesion were solid, you would send the aspirate to pathology, and order imaging. Which imaging test(s) should you order?
- ultrasound & mammography because >30yo
- Will your aspiration increase the rate of false positive results of her mammography?
- no, if the radiologist is advised about the site of aspiration
- 10% of malignant lesions in young women have features consistent with a fibroadenoma – thus, new palpable masses of any age should be thoroughly evaluated.
- CFPC Self Learning