SAMP Practice Test

Case 1

Mrs. Backed Up, 55, presents to you in 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 #3 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)

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

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

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)

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

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

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 scratchiness this morning; this scratchiness 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, which she started taking two weeks ago.

A physical examination reveals a temperature of 37 degrees C. The back of her throat and the floor of her mouth and soft palate seem quite edematous, and slightly inflamed with no exudate. Her tongue also is slightly swollen. Her blood pressure measurement is 120/80 mm Hg, her heart rate is 90 bpm, her respiratory rate is 16/min, and oxygen saturation is 99%.

1. What is the most likely diagnosis? State ONE. (2 points)

2. What is the most likely cause of the diagnosis? State ONE. (1 point)

3. What treatments would you prescribe for Mrs. Smith? List THREE. (3 points)

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 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)

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

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

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

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

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

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)

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, 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)

2. What are TWO risk factors for the development of AOM? (2 points)

3. Name TWO of the three major bacterial pathogens that cause AOM? (2 points)

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)

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

6. What is the “Watchful Waiting” approach? (1 point)

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

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, 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)

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 two weeks to rule out adverse effects of this medication?     (2 points)

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)

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

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

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)

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)