SAMP Practice Test

Case 1

Mrs. Backed Up, a 55-year-old woman, presents to your clinic 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 with codeine (Tylenol #3) nightly for a sprained ankle sustained one month ago. She also takes amlodipine and levothyroxine. Her last TSH, done one year ago, was normal. 

1. Which of the following features would be considered red flags that should be specifically asked about in a patient presenting with a change in bowel habits? (Select ALL that apply).

2. Given that this patient takes levothyroxine for a thyroid condition, which of the following groups of symptoms would be most relevant to ask about to assess for undertreated hypothyroidism as a secondary cause of constipation? (Select ONE correct answer)

3. Which of the following first-line measures is MOST appropriate to recommend to help Mrs. Backed Up return to her usual bowel pattern? (Select ALL that apply).

4. For each class of constipation medication listed below, drag and drop the example medication(s)

4. For each class of constipation medication listed below, select the correct example medication(s) from the options.

A. Lubricant

B. Stool Softener

C. Stimulant Laxative

D. Bulk forming laxative

E. Osmotic laxative

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. (Select ONE correct answer)

 5. If she was adopted and does not know her family history, what one investigation do you order for colon cancer screening? 

6. How often do you recommend this screening test be repeated? (Select ONE correct answer)

7. If the result of the above screening test is positive, what is your next course of action? (Select ONE correct answer.)

Case 2

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)

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

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

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)

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)

Case 3

Mrs. Smith, age 56, is a teacher who presents at your office complaining of a sore throat. She describes a sudden onset of symptoms, beginning with some throat fullness this morning that progressed to more discomfort. She also notes that her lips feel a bit “puffy.” A slight dry cough started about a week ago. She denies any fever. 

Her past medical history is significant for polycythemia vera, gastroesophageal reflux disease, and hypertension diagnosed two weeks ago. Her medications include hydroxyurea, esomeprazole, and lisinopril (started two weeks ago). 

Physical examination reveals a temperature of 37°C. The posterior oropharynx, floor of the mouth, and soft palate appear quite edematous and slightly inflamed with no exudate. Her tongue is also slightly swollen. Blood pressure is 120/80 mmHg, heart rate is 90 bpm, respiratory rate is 16/min, and oxygen saturation is 99%. 

1. What is the most likely diagnosis? (Select ONE correct answer)

2. What is the most likely cause of the diagnosis identified in Question 1? (Select ONE correct answer)

3. Which of the following is the most appropriate initial management plan for Mrs. Smith? (Select ONE correct answer)

4. According to Canadian guidelines, which of the following antihypertensive classes is contraindicated as a replacement for lisinopril in Mrs. Smith? (Select ONE correct answer)

5. You counsel Mrs. Smith about the possible symptom resolution. (Select ALL that apply)

6. Which of the following features, if present, would necessitate immediate administration of intramuscular epinephrine and transfer to the emergency department? (Select ALL that apply)

7. Mrs. Smith’s hypertension still requires treatment. According to Hypertension Canada guidelines, which of the following would be the most appropriate first-line replacement antihypertensive for a patient with uncomplicated hypertension? (Select ONE correct answer)

8. Before discharging Mrs. Smith from the office, which of the following patient education points is MOST important to communicate? (Select ONE correct answer)

Case 4

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)

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

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

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)

Case 5

A 66-year-old woman presents for an office visit after slipping on ice and falling onto her back. She complains of lower back pain but denies leg weakness, numbness, or bowel/bladder symptoms. She is a smoker, weighs 58 kg, is postmenopausal, and has celiac disease. She takes only a multivitamin and is otherwise healthy. 

1.Which of the following is NOT an established independent risk factor for osteoporosis? (Select ONE correct answer)

2. Which combination of clinical features in this patient places her at the highest risk for osteoporosis? (Select ONE correct answer)

3. Which physical examination finding is most suggestive of a prior vertebral compression fracture related to osteoporosis? (Select ONE correct answer)

4. Which of the following is LEAST useful as part of the routine physical assessment of a patient suspected of having osteoporosis? (Select ONE correct answer)

5. According to WHO diagnostic criteria, osteoporosis is defined by a DXA T-score of: 

(Select ONE correct answer)

6. Which laboratory investigation is LEAST helpful in the routine evaluation for secondary osteoporosis in this patient? (Select ONE correct answer)

7. Which of the following laboratory panels is most appropriate as an initial evaluation for secondary causes of osteoporosis? (Select ONE correct answer)

8. Which combination of non-pharmacologic interventions has the strongest evidence for reducing fracture risk in patients with osteoporosis? (Select ONE correct answer)

9. For a woman over age 50 with osteoporosis, the recommended total daily elemental calcium intake (diet plus supplements) is: 

(Select ONE correct answer)

10. If this patient’s FRAX/CAROC assessment demonstrates a high 10-year fracture risk, which of the following would generally be considered first-line pharmacologic therapy, assuming no contraindications? (Select ONE correct answer)

11. Which of the following is NOT an approved pharmacologic class for the treatment of osteoporosis? (Select ONE correct answer)

12. Which medication acts by binding RANK ligand, thereby inhibiting osteoclast formation and activity? (Select ONE correct answer)

Case 6

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)

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

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

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

Case 7

Mrs. A. brings in her 12-month-old daughter, Madelyn, to your clinic. She states Madelyn has had a cold for the past 3 days and has been increasingly “fussy” over the past 24 hours. She is not feeding as well and is crying more often. Mrs. A. has also observed the baby pulling at her right ear. Madelyn has been sleeping poorly. This morning she had an axillary temperature of 39.6°C. 

1.Which of the following examination findings would be most consistent with a diagnosis of Acute Otitis Media (AOM)? (Select ALL that apply.)

2. You perform an otoscopic examination on Madelyn’s right ear. which of the following visual findings is the most specific indicator of an acute bacterial infection (AOM) rather than a simple viral otitis media with effusion? (Select ONE correct answer)

3. Which of the following are recognized risk factors for the development of AOM? (Select ALL that apply)

4. Which of the following are among the major bacterial pathogens responsible for AOM? (Select ALL that apply)

5. Madelyn has an intact tympanic membrane with evidence of acute otitis media on exam. She has not received antibiotics before.  

a. If you decided to treat Madelyn with antibiotics, which of the following represents the correct first-line agent for an uncomplicated case of AOM? (Select ONE correct answer)

b. What is the appropriate duration of the above treatment for Madelyn?  (Select ONE correct answer)

6. If Madelyn fails to improve after 2-3 days of first-line treatment, which would be the next appropriate second-line antimicrobial agents for acute otitis media? (Select ONE correct answer)

7. Which of the following best describes the “Watchful Waiting” approach in the management of AOM? (Select ALL that apply)

8. Which of the following are criteria where the “Watchful Waiting” approach would be appropriate? (Select ALL that apply)

Case 8

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)

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

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

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

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

6. What lab tests would you consider for a patient suspected of having this condition, name TWO? (2 points)

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

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

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

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

Case 9

Mrs. H.T., a 55-year-old woman with essential hypertension, was previously well controlled on a thiazide diuretic and lifestyle modification. Her blood pressure has gradually increased to 154/96 mmHg despite continued exercise, weight loss, and dietary improvement. Multiple properly measured home readings average in the 150s/90s. There is no history of diabetes, chronic kidney disease, coronary artery disease, or heart failure. 

1.Which of the following are considered first-line antihypertensive drug classes for uncomplicated hypertension according to current Canadian guidelines? (Select ALL that apply)

2. Two weeks after initiating an ACE inhibitor, which investigations should routinely be repeated? (Select ALL that apply)

3. According to Hypertension Canada, what is the recommended target home blood pressure for patients with heart failure? (Select ONE correct answer)

4. Which instructions are appropriate to ensure accurate home blood pressure measurement? (Select ALL that apply)

5. Her HbA1c returns at 7.4%, confirming type 2 diabetes mellitus. According to Canadian guidelines, what is the recommended office blood pressure target? (Select ONE correct answer)

6. According to Hypertension Canada, what is the recommended daily sodium intake for adults with hypertension? (Select ONE correct answer)

7. Which lifestyle interventions have been shown to reduce blood pressure in adults with hypertension? (Select ALL that apply)

Case 10

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 severely high.

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

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

3. List TWO important causes of hypercalcemia. (2 points)

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

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