CCFP Pre-Course Activity: SAMP Practice Review

Mrs. Backed Up, 55, presents complaining of constipation over several weeks.  She has experienced intermittent constipation throughout her adult life. Her bowel pattern until recently consisted of a soft, brown, well-formed bowel movement every 2 days.  Now, her stool is firm, small, round, and difficult to pass.  She has been taking acetaminophen nightly for a sprained ankle which she suffered a month ago.  She also takes amlodipine and levothyroxine. Her last TSH, done a year ago, was normal.

1. What other symptoms would you ask about on history? Name EIGHT.  (8 points)

• Abdominal pain
• Nausea
• Vomiting
• Cramping
• Weight change
• Melena
• Rectal bleeding/hematochezia
• Rectal pain
• Fever
• Night sweats
• Fatigue
• Hair loss
• Cold intolerance
• Anorexia/loss of appetite
• Bloating
• Dry skin
• Depression

2. Name FOUR lifestyle measures that might help Mrs. Backed Up return to her usual pattern. (4 points)

• Decrease acetaminophen
• Increase physical activity
• Increase oral fibre intake
• Increase oral fluid intake
• Bowel retraining exercises/regular toilet time/scheduled BM
• Decrease refined foods

3. Name FOUR classes of medications for constipation and name one medication from each class. (8 points)

• Stool softeners – docusate (colace)
• Osmotic laxatives – lactulose, Mg salts, sorbitol, PEG
• Bowel stimulants (motility agents) – senna, bisacodyl, cascara, prune juice
• Bulking agents – psyllium, bran (Metamucil ok)
• Bowel lubricants – mineral oil, castor oil, glycerine
• Enemas – tap water, saline, sodium phosphate (fleet), oil

Mrs. Backed Up applies your suggestions for lifestyle change and her bowel function reverts to normal.  Two years later, she presents for her periodic health exam.  Her bowel movements are regular and soft.  She denies weight loss, fatigue, or constitutional symptoms.  She has maintained the dietary changes that she started two years ago. You offer her screening for colon cancer.

4. What ONE laboratory investigation do you order? (1 point)

• Fecal immunochemical test (FIT)

5. How often do you suggest that she has this test? (1 point)

• Every 1-2 years

6. If the result of the above test is positive, what is your next course of action? Name ONE. (1 point)

• Refer for colonoscopy

No points for abdominal ultrasound or CT colonography

Source: AMA Toward Optimized Practice Guidelines, 2013

Mr Key is a 34 year old healthy patient of yours who is travelling to Thailand in 3 months and he states he will be an area where malaria is prevalent.  He comes to you for travel counselling.

1. What are THREE non-pharmacologic strategies to protect against malaria? (3 points)

• Insect repellents containing DEET (30% DEET recommended)
• Use treated bed nets/sleep tents
• Wear clothes that cover exposed skin

2. Name FOUR pharmacologic agents that can be taken to protect against malaria? (4 points)

• Atovaquone/proguanil (Malarone)
• Chloroquine/quinine
• Mefloquine (Larium)
• Doxycycline

3. Mr. Key is fair-skinned and burns easily. What medication would you prefer to avoid in him? (1 point)

• doxycycline

4. Mr. Key reports that he has had periods of time in his life when he required treatment for depression and suicidal ideation. Which medication would you avoid prescribing to him? (1 point)

• Mefloquine/larium

5. Mr. Key returns to your office 2 weeks after his trip presenting with fever of unknown origin. When you ask him if he completed the prophylactic medication you had prescribed, he states he forgot to take it.  What investigation will confirm your suspected diagnosis of malaria? (1 point)

• Thick and thin blood smear (also acceptable: Giemsa stain)

Source: Therapeutic Choices 6^th edition

Rachelle, age 16, presents at the after-hours clinic on Sunday afternoon. She had unprotected intercourse and a friend told her she could prevent pregnancy with a pill. She has no allergies and is taking no medications.

1. As you consider whether the morning-after pill is appropriate, what is the most important question to ask Rachelle? State ONE. (1 point)

• When/how long ago did you have intercourse?

2. What is the most common side effect of oral post-coital contraception? State ONE. (1 point)

• Nausea
• Vomiting
• Either answer correct

3. Excluding allergy, what is an absolute contraindication to treatment with oral post-coital contraception? State ONE. (1 point)

• Pregnancy

4. Rachelle is concerned about the possible side effects of oral post-coital contraception. What other option exists for morning-after contraception? State ONE. (1 point)

•  Insertion of copper intrauterine device up to seven days post-coitally (Mirena/prog containing IUD not acceptable – not approved for this use)

5. What other subjects do you discuss with Rachelle? List THREE. (3 points)

• Contraceptive use/Condoms/The birth control pill (BCP)/Norelgestromin and ethinyl estradiol transdermal system (Evra)/Any contraception
• Sexually transmitted infections (STIs)/Human immunodeficiency virus (HIV) infection
• Timing of commencement of cervical cancer testing/Pap test
• Human papillomavirus (HPV) vaccine
• Following up if she has no menses/Doing beta-human chorionic gonadotropin (β-hCG) testing if she has no menses/Possible failure of the morning-after pill
• Whether sexual intercourse was consensual

A 20-year old competitive female basketball player presents with a knee injury.  She was playing basketball the evening before and injured her knee while attempting a rapid pivot.  Her knee gave out and she heard a pop.  She required help to leave the playing surface and did not return to the game. Her knee started to swell within an hour.

1. What diagnosis do you suspect? (1 point)

No correct answer or suggested answer is given for this question.

2. List THREE points from the history which support this diagnosis. (3 points)

• pivot mechanism, non-contact mechanism
• heard a pop
• early/immediate swelling
• unable to continue playing
• knee buckled/gave way

3. Name TWO maneuvers on physical exam which test for this condition. (2 points)

• Anterior drawer test
• Lachman test
• Pivot shift test

Two weeks later, she tells you that the swelling is improving but that she “doesn’t trust” the knee, feeling as if it will give out on her.  In fact, there has been one episode of painless buckling.  Your physical exam confirms the diagnosis.

4. What are the indications for surgical repair in this patient? (3 points)

• desire to compete at high level in at risk sports
• instability
• occupational need for ACL-stabilized knee
• age

Source: SAMPs, self-learning modules, 2009;NEJM 2008; 359: 2135-2142

A 66 year-old female comes into the office for an exam.  She had recently slipped on ice and fell on her back.  She complains of pain in her lower back but denies any neurological symptoms or lower extremity weakness.  She is a smoker and weighs 58kg.  She is menopausal and has celiac disease but is otherwise healthy.  She takes a multivitamin but otherwise takes no other medications.

1. Name FIVE risk factors for osteoporosis? (5 points)

• Age >65 yrs old
• Fragility fracture after age 40
• Corticosteroid use (7.5mg OD x 3mo)
• Aromatase inhibitor use
• Androgen deprivation therapy
• Parental hip fracture
• Vertebral fracture on xray
• Current smoking
• Alcohol >3 drinks/day
• Weight <60kg
• Loss of 10% body weight from age 25
• Premature menopause (<45yo)
• Hypogonadism
• Malabsorption/chronic malnutrition
• Inflammatory bowel disease
• Cushing’s disease
• Primary hyperparathyroidism
• Uncontrolled hyperthyroidism
• Chronic liver disease
• Rheumatoid arthritis (and other chronic inflammatory conditions)
• Female

2. Name THREE findings you could look for on physical exam in someone with risk factors for low bone mineral density? (3 points)

• Weight  loss  (loss of >10% since age 25)
• Height loss   (loss of 2 cm or >6cm historically) /kyphosis
• Rib to pelvis distance being <2 fingers breadth
• Occiput to wall distance >5cm
• Gait
• “Get up and Go Test”

3. What is the definition of osteoporosis on bone mineral density testing? (1 point)

• T-score ≤ 2.5

4. What laboratory investigations would you order to rule out secondary causes of osteoporosis? Name FIVE. (5 points)

• Calcium
• Albumin
• Creatinine
• Hemoglobin
• White blood cell count and diff
• Alkaline phosphatase
• Thyroid stimulating hormone
• Serum protein electrophoresis
• 25-hydroxyvitamin D (25-OH-D)

5. Not including vitamin and mineral supplementation, what lifestyle changes would you discuss with this patient? Name THREE. (3 points)

• Weight bearing aerobic and resistance training exercise
• Quit smoking
• Advise to consume <3 alcoholic drinks per day
• Fall prevention strategies/balance exercises
• Limit caffeine to <4/day

6. What is her daily recommended intake of calcium? (1 point)

• 1200mg   (from all sources)

7. If her CAROC/FRAX score indicated that she was high risk for osteoporosis, what classes of medications could you use? Name THREE. (3 points)

• Bisphosphonates
• Antiresorptives
• Selective estrogen receptor modulator
• Hormone therapy
• Calcitonin
• Parathyroid hormone
• Receptor activator for nuclear factor ĸ B (RANK) ligand inhibitor

DF, R2, 2013; Sources: Clinical practice guidelines for diagnosis and mgmt of OP in Canada, CMAJ 2010.

Elizabeth Drolet visits you in your office for a discussion about breast cancer screening.  She is a healthy, non-smoking 51 year-old woman with no family history of breast cancer.  Her BMI is normal.  She has not had a mammogram.

1. Is Ms. Drolet at high, average, or low risk of contracting breast cancer? (1 point)

• Average risk

2. What is the approximate Number Needed to Screen (NNS) to prevent one death from breast cancer for women aged 50 – 69 years? (1 point)

• 721; acceptable answer anywhere between 600-900

3. If you recommend mammography for this woman, how often should she be screened? (1 point)

• Every 2-3 years

4. In counseling Ms. Drolet, what pros and cons of screening would you discuss? Name FOUR. (4 points)

• May find false positive
• May need biopsy to prove false positive
• Relatively small reductions in mortality
• Might permit surgery at earlier stage thus permitting less invasive procedure
• Risk of mastectomy higher among screened woman
• Might find true positive
• Might save life
• Accumulated radiation not a concern/safe

5. Name FIVE qualities of a good screening test? (5 points)

• Acceptable to those eligible
• Inexpensive/reasonable in cost
• High sensitivity: bulk of those with the disease should test positive
• High specificity: bulk of those without the disease should test negative
• Safe to administer
• Lead to improved health outcomes/reduced mortality
• Capable to detecting disease in pre-clinical state
• Be widely available

Source: 2011 Cdn Task Force on Preventive Health Care Guidelines

Mrs. A. brings in her 12 month old, Madelyn to clinic.  She states Madelyn has had a cold for the past 3 days and has been increasingly “fussy” over the past 24h.  She’s not feeding as well and crying more often.  Mrs. A. has also observed the baby pulling at her right ear.

Despite this, Madelyn is feeding well and sleeping normally.  This morning she had an axillary temperature of 38 degrees C.

1. What are THREE signs you would look for on examination of the patient’s ears that would be consistent with a diagnosis of Acute Otitis Media? (3 points)

• Loss of bony landmarks
• Air-fluid levels behind tympanic membrane
• Immobile tympanic membrane
• Opacification of tympanic membrane
• Bulging, discoloured tympanic membrane
• Presence of fluid in external ear canal (otorrhea)

2. What are TWO risk factors for the development of AOM? (2 points)
   • Young age
   • Daycare attendance
   • Not being breast-fed
   • Smoking in the home
   • Presence of upper respiratory infection
   • Immunodeficiency
   • Premature birth
   • Orofacial abnormalities
   • Inuit or Aboriginal ethnicity

3. Name TWO of the three major bacterial pathogens that cause AOM? (2 points)
   • Streptococcus pneumoniae
   • Haemphophilus influenzae
   • Moraxella catarrhalis

4. If you decided to treat this patient with antibiotics, name the first-line agent you would use and the duration of therapy in an uncomplicated case. (2 points)

• Drug:  Amoxicillin
• Duration: for 5 days

Name 2 second-line anti-microbial agents you could choose: (2 points)

• Cefprozil
• Cefuroxime
• Ceftriaxone
• Azithromycin
• Clarithromycin

5. What is the “Watchful Waiting” approach? (1 point)
   • Deferring antibiotic therapy for 48-72 hours and treating with analgesia if appropriate

6. What are the criteria for the “Watchful Waiting” approach? (3 points)

• Age older than 6 months
• Mild signs and symptoms
• Non-toxic looking child
• Fever <38 degrees orally
• Reliable parents

Source:  Janis, R2, 2010

A healthy 45 year-old Caucasian man presents for his periodic health exam.   His father suffers from hemochromatosis and your patient asks about his risk of acquiring this problem.

1. What is the inheritance pattern of familial hemochromatosis? (1 point)

• Autosomal recessive

2. Patients originating from which part of the world are at highest risk? (1 point)

• Northern European descent: 1 point
• British Isles: ½ point

3. What is the mechanism by which familial hemochromatosis causes iron overload? (2 points)

• Regulation of iron absorption in the GI tract is defective
• Accelerated iron absorption, exceeding physiological requirements
• Excess iron is subsequently deposited in the tissues.

4. What is the most common presentation of hemochromatosis? Name TWO. (2 points)

• Asymptomatic
• Fatigue
• Arthralgia
• Incidental elevated ferritin

5. Name FIVE clinical conditions that can result from familial hemochromatosis. (5 points)

• Adult onset diabetes/DM II
• Arthritis
• Cardiomyopathy
• Congestive heart failure
• Hepatomegaly
• Cirrhosis
• Hepatocellular carcinoma
• Increased skin pigmentation
• Elevated liver enzymes/hepatitis
• Hypogonadism/infertility

6. What is the most sensitive lab test to order for a patient suspected of having this condition? (1 point)

• Transferrin saturation (or percent saturation of TIBC)

7. What ONE other investigation could you offer your patient to confirm the diagnosis? (1 point)

• Genetic testing/chromosomal testing
• Liver biopsy

8. What is the treatment for hemochromatosis? (1 point)

• Phlebotomy

9. Which test would you use to monitor your patient’s progress through therapy? (1 point)

• Ferritin

10. What other specific conditions might lead to elevation in the value of this test? Name THREE. (3 points)

• Rheumatoid arthritis
• Hepatitis/liver disease
• Systemic lupus erythematosus
• Infection
• Cancer/lymphoma
• High iron diet/over-supplementation
• Hyperthyroidism
• Still’s disease
• Haemolytic anemias/spherocytosis
• Thalassemia
• Alcoholism
• Recurrent blood transfusion

Source: LB, TOP guidelines, 2008

Mrs. H.T, an otherwise healthy 55 year-old woman, is seeing you in follow-up for essential hypertension.  She has been managed with a thiazide diuretic, and lifestyle modification.  She has achieved and maintained a target BP of 138/84, until her last visit, when her BP was 150/96.  She continues to walk 1 hour per day, has lost 10lbs, and has increased the number of servings of fresh fruits and vegetables in her diet.  Today, her BP is 154/96. Home BP readings have averaged in the 150s/90s.

1. Name FOUR classes of first line agents that can be used in the medical management of hypertension for this patient. (4 points)

• Thiazide diuretics
• Angiotensin converting enzyme inhibitors
• Beta blockers
• Long-acting calcium channel blockers
• Angiotensin receptor blockers

You would like to change her current regimen to achieve better blood pressure control. You decide to start your favourite ACE-I.

2. What two laboratory investigations will you perform in a few weeks to rule out adverse effects of this medication? (2 points)

• Creatinine
• Potassium

Mrs. H.T. tells you her husband has a home BP cuff.  You calibrate the cuff and ensure appropriate fit.

3. What is her target blood pressure when using this cuff? (1 point)

• <135/85

4. You instruct Mrs. H.T. about proper technique for taking blood pressure at home. What do you advise? Name SIX. (6 points)

• take BP when seated
• legs uncrossed/feet flat on floor
• back supported
• arm at level of heart
• sit for 5 minutes before taking BP
• do not talk while taking BP
• do not take BP within 30 mins of smoking
• do not take BP within 2 hours of heavy exercise
• do not take BP within 30 mins of drinking coffee
• do not take BP within 30 mins of light exercise

5. If Mrs. H.T.’s hemoglobin A1C is 7.4%, what is her blood pressure goal? (1 point)

• <130/80

6. Mrs. H.T. is trying to manage her salt intake. What is the current Canadian recommendation for maximum sodium intake per day for a person with hypertension? (1 point)

• <1500 mg/day

Source: CHEP guidelines, 2012

A 58 year-old man presents to your local emergency department with a one-day history of confusion. He has no history of head trauma, no alcohol use and he has no fever. Serum calcium is found to be 5.0 (critically high).

1. List FOUR symptoms of hypercalcemia. (4 points)

• Mental status change - confusion
• Abdominal groans e.g. abdominal pain
• Nausea
• Vomiting
• Fatigue
• Renal colic
• Dehydration
• Polyuria
• Constipation

2. List TWO acute treatments of hypercalcemia. (2 points)

• Hydration with normal saline
• Furosemide (Lasix) IV

3. List the TWO most common causes of hypercalcemia. (2 points)

• Malignancy
• Hyperparathyroidism

4. List THREE blood tests you would order next to help determine the severity and cause of the hypercalcemia. (3 points)

• Albumin
• Parathyroid hormone
• Serum phosphate
• Vitamin D level

5. What are TWO potentially life threatening consequences of hypercalcemia? (2 points)

• Dehydration/volume depletion from polyuria
• Cardiac arrhythmias