LMCC II Compilation Most Recent

The Resident’s Guide to the LMCC II 5th Edition – 2007-2008

The Licentiate of the Medical Council of Canada Exam, part II, also known as the MCCQE II, was the traditional means of qualifying for a general license to practice medicine in Canada. Now that both the internship year and the general license are no longer available, many residents view the exam as a stressful and expensive exercise in futility. While the process is stressful and expensive, it need not be futile. Preparation for the exam can be an enlightening review. Scenarios tend to repeat over the years, the pass rate is greater than 95% on the first attempt, and there is an option to rewrite, so don’t panic.

The exam is an OSCE (Observed Scenario Clinical Exam) in which the candidate progresses through a series of stations. Your starting point is determined alphabetically. At each station there is a physician examiner and either a real person posing as a patient or a telephone over which you must speak to a patient or another physician requesting assistance.

The most recent sessions (since 1997) contain six short cases known as 5-minute couplets, in which the candidate is allotted 5 minutes to assess a patient and 5 minutes to write short answers to questions related to the case. There was also a series of six longer cases in which the candidates were presented with a more involved clinical problem, such as a resuscitation or psychosocial counseling session, lasting 10 minutes each. The physician examiner may ask one or two questions in the last minute of a 10-minute station. There is one minute between stations during which you can look at a brief description of the patient and consider your approach. Occasionally “pilot” questions will be included in the exam, which will not count towards the final mark but are used to test new questions. You will not know which questions are “pilot” questions.

The content of the exam is general medicine. This means family practice & emergency medicine. The following topics appear consistently: Pediatrics – diarrhea, development, neonatal jaundice, asthma

Obs/Gyn – amenorrhea, vaginal blood, abdominal pain, PIH, OCP, elective abortion counseling Suturing – choice of suture, tetanus vaccine

Chest Pain – read CXR, ECG

Resuscitation – fluid resuscitation after blood loss, ABCDs Overdose – ASA, TCA

Needle stick – AIDS, hepatitis, vaccinations Psychiatry – depression, mania, schizophrenia

Neurosurgery – back and neck radiculopathies, carpal tunnel

(Note that every history should include name, age, occupation, past medical history, family history, medications, drugs/alcohol, review of systems)

At each PEP station, there is a sheet listing possible investigations e.g. electrolytes includes Na, Cl, K, etc. Liver enzymes include AST, ALT, ALP, LDH, bilirubin etc. Renal tests include Urea and Creatinine. Coagulation studies include PTT, INR.

The scoring has the mean as 500, with a standard deviation of 100. On this exam you needed to score 374, and pass 9 stations in order to pass the exam. And you have to “demonstrate ethical behaviour and skills appropriate for a physician”

LMCC General Review

History

Key Questions: Adult:

1. Location; Severity; Timing; Aggrevating/Relieving factors; Associated symptoms 2. Why is that a worry to you?

3. What can’t you do now that you can do before? How has it affected your ability to work? 4. Past Hx & Family Hx

5. Medications

6. Tobacco/EtOH/Drugs

7. Psychosocial – eg. home situation 8. Review of Systems

Child:

1. Prenatal

2. Natal – method; complications

3. Prenatal – APGARS; onset of respirations; birthweight 4. Feeding Hx –vit and iron supplements; solids

5. Developmental milestones – eg. head up while prone; roll over, sit, walk, speech, dress alone 6. Sleep, toileting, sexuality if older (HEADSS)

7. Immunizations CAGE Questionnaire

1. Felt the need to Cut down? 2. Annoyed by criticism? 3. Guilty feelings?

4. Eye-opener to steady nerves or get rid of hangover? Abuse:

1. Many women tell me that someone at home is hurting or abusing them. How is it for you? Did somebody hit you?

2. Most parents get upset when their child cries or has been naughty? How do you feel? What do you do to discipline? Are you afraid you may hurt your child?

Sex:

1. Any problems or concerns with your sexual function? 2. Maintained interest/appetite for sex? Setting?

3. Erection (eg. morning erections)? Ejaculation? Masturbation? 4. Changes in relationship or life situation?

5. General health (eg. smoking, peripheral vascular disease, meds, ETOH, depression)

Symptoms & Approaches

1. Abdo pain: assoc. w/ antacids, alcohol, eating, medications, defecation, urination & menstruation

2. Bowel function: nocturnal diarrhea 3. Nausea/vomiting

4. Weight 5. Appetite

6. Jaundice: color of urine/stools; pruritus

: hepatitis risks (blood transfusions, IVDU, sexual contacts, etc.) B. Urinary Tract

1. Voiding: urgency, frequency, dysuria, hesitancy, straining, weaker stream, dribbling, nocturia, polyuria, incontinence; polydipsia

2. Hematuria: beets, medications C. OBSGYNE:

1. Gravida Preterm Term Abortion Living 2. Parity

2. Menarche; Menopause

3. Periods: regularity, duration, onset, amount, premenstrual symptoms (mood, weight, mastodynia, headaches) menstrual discomfort 5. Amenorrhea: r/o pregnancy (frequency, N/V, fatigue)

4. Abdominal or pelvic procedures

5. Infections; Vaginal discharge; Sores or Lumps; Pruritus 6. Partners: number; multiple; high-risk, same-sex 7. Contraceptive Hx

8. PAP smear

9. Menopausal symptoms: hot flushes, dyspareunia, incontinence, depression D. Musculoskeletal:

1. Joints: pain, swelling, redness, heat, stiffness, location, symmetrical, migration, limitation of motion

2. Activities: ADLs; climbing stairs; sitting; standing up from chair; pinch; writing

3.Generalized symptoms: fever, anorexia, weight loss

4. Rashes, Nails, Conjunctivitis, GI, Urethritis, Preceding sore throat E. Nervous

1. Weakness: onset, progression, location, distal vs. proximal (eg. tripping for distal leg weakness)

2. Seizure disorders; Head injuries

Differential Low Back Pain/Leg Pain 1. Common Low Back Pain

-pain relieved by rest, aggravated by moving, lifting or twisting motions -lumbosacral area to posterior thighs but not below knee

2. Sciatica

-shooting pain to below knee in dermatomal distribution (L5, S1) -paresthesia and possible local weakness

-pain on straight leg raising, decreased reflexes esp. ankle jerks 3. Lumbar stenosis

-worse with walking and improves with flexion of spine 4. Nocturnal Back Pain - r/o malignancy

5. Referred Pain - eg. pancreas, aortic aneurysm, peptic ulcer 6. Vascular

-CHECK DISTAL PULSES

-claudication: improves with rest not position, skin trophic changes -in arteriosclerosis obliterans, relief with legs dependant

-in venous insufficiency, may have pigmentation and ulceration; relief with leg elevation Seizures

A. Partial - unilateral or focal

1) Simple - Motor (Jacksonian); Sensory; Autonomic (eg. epigastric discomfort, pallor or flushing); Psychic (flashback or hallucinations)

2. Complex - consciousness impaired; automatism may develop, aura B. General - bilateral, consciousness impaired, no aura

PHYSICAL EXAM: Inspection - Palpation - Percussion - Auscultation

a) Pupils - anisocoria (pupil inequality <0.5 mm) b) Narrow-angle glaucoma - crescentic shadow cast

c) Inspect reflection in corneas for symmetry - strabismus (esotropia vs exotropia) d) Afferent pupillary defect (Marcus Gunn) - swinging flashlight test

e) Argyll Robertson - do not react to light but reacts to near effort = CNS syphilis f) Diabetic retinopathy - microaneurysms, neovascularization, dot/blot hemorrhages g) Hypertension - cotton wool, hard exudates, copper wire arteries

B. Ears

a) Normal range 300 to 3000 Hz b) Weber test (lateralization)

-in conductive hearing loss, sound is heard in impaired ear. -in sensorineural hearing loss, sound is heard in good ear c) Rinne test - AC>BC in sensorineural hearing loss

C. Respiratory

a) lower border: anterior (6th) and posterior (10th) at inspiration b) check for cyanosis and clubbing

c) tactile fremitus - decreased with pleural effusion & pneumothorax; increased with pneumonia

d) normal diaphragmatic excursion = 5-6 cm

e) bronchial breath sounds - loud and long expiratory phase with high pitch f) egophony, whispered pectoriliquy = consolidation

D. Cardiovascular

a) JVP - axvy (atrial contraction-relaxation-filling-emptying); 4 cm ASA -a waves increase with tricuspid stenosis and disappear w/ a.fib.

b) S3 (ventricular gallop) - ventricular overloading (heart failure); S4 (atrial gallop) - increased ventricular stiffness (eg. hypertensive cardiomyopathy)

c) Splitting physiological increases with inspiration; paradoxical split in LBB and widened split in pulmonic stenosis

d) BP -in both arms (differential should not be >10 mm); check for postural hypotension (systolic drop > 20)

-cuff: length equal to 80% and width equal to 40% of limb circumference -pulsus paradoxus - drop of >10 in systolic indicates tamponade, constrictive pericarditis or obstructive airway disease

e) Apical impulse - increase duration w/ hypertension; displacement with enlargement f) Murmurs:

i) Sit up and lean forward to auscultate aortic murmurs; innocent murmurs usually disappear on sitting or leaning

ii) Grade 5 - steth partly off chest; 6 - entirely off chest iii) Pansystolic murmurs - regurg. across AV valves iv) Early diastolic - regurg. across semiluminar or aortic v) Midsystolic - aortic stenosis & innocent murmurs vi) Presystolic & middiastolic - AV valve stenosis vii) Continous - PDA

viii) Increased stroke volume (eg. squatting, no Vasalva) increases intensity of aortic stenosis but decreases hypertrophic cardiomyopathy

g) Pulsus alternans - LVF; Large bounding pulse - aortic regurg. E. Abdomen

a) Check inguinal and femoral areas

b) Listen for bruits (aorta, iliac, renal, femoral)

c) Check upper and lower borders of liver (normal span - 6-7 cm) d) Spleen in Traube's space (should remain tympanic even on inspiration) e) Mention DRE

f) Kidneys, Aorta (normal width no more than 3 cm)

g) Psoas sign - raise thigh against hand; Obturator sign - internal rotation of hip h) Intrabdominal mass obscured by contraction vs mass in wall

F. Genital

a) retroverted vs retroflexed uterus

b) thelarche: 8-13 yrs menarche: 10-16 yrs G. Pregnancy

a) fundus at: pubic symphysis (12 w), umbilicus (20 w)

b) softening of isthmus (Hegar's), engorged bluish cervix (Chadwick) c) breast tenderness, nausea/vomiting, urinary frequency, no menses d) Naegele = minus 3 months and add 7 days

e) Lie, Position & Presentation H. Peripheral Vascular a) size, symmetry & swelling b) venous pattern & engorgement

c) pigmentations, rashes, ulcers; gangrene - medial malleolus for venous insufficiency d) colour, distribution of hair; trophic changes

e) check pulses & lymph nodes; temperature; cap refill; pitting edema f) r/o DVT for leg swelling or pai

-normally, vein fills from below (35 sec)

-release compression (normally, no additional filling) h) Allen's test

i) Marked pallor on elevation suggests arterial insufficiency with unusual rubor on depenency; cyanosis on dependency suggest venous insuffiency

I. Muskuloskeletal General approach:

Inspection - swelling, redness of jts; deformities; surrrounding tissues (eg. atrophy)

Palpation - bony landmarks; heat; tenderness; crepitus; CHECK PULSES Range of Motion

Strength a) Hands & Wrist

i) make a fist

ii) flex & extend, ulnar & radial deviation

iii) Heberden's nodule - OA of DIP; snuff box for scaphoid fracture b) Elbows

i) carrying angle

ii) flex/extension; pronation/supination

iii) lateral epiconylitis (tennis elbow) with pain on extension c) Shoulders

i) landmarks: acromion, coracoid, clavicle, greater tubercle of humerus, scapula

ii) reach behind back to test abduction/adduction & internal & external rotation

iii) Apprehension test; Impingement (supraspinatus weakness [abduction at 50 deg; external rotation weakness; impingment in external & internal rotation) iv) Drop arm test for rotator cuff tear - unable to lower arms smoothly

v) Yergason - for bicipital tendinitis d) Ankle & Feet

i) dorsi/planter flexion (tibiotalar jt); eversion/inversion at two levels (talocalcaneal and transverse talar jts)

ii) drawer sign & Thompson sign

iii) hallux & tallus valgus/varus; pes planus e) Knees

i) bulge sign; balloon sign; ballotment test - effusion

ii) Patellar apprehension test; Patella-Femoral grinding test (chondromalacia); McMurray test (external rotation & valgus stress) & Appley stress test;

Anterior Drawer test & Lachmann & Sag test; Collateral ligaments; Jt line tenderness f) Hip

i) leg length - ACIS to medial malleolus; flex knees ii) Trendelenburg - test gluteus medius

iii) Thomas test - flexion deformity J. Nervous System

a) Corticospinal tracts cross over at medulla; spinothalamic (pain/temp) + crude touch cross over at level of cord; posterior columns (fine touch + vibration) cross over at medulla

b) C3 - back of neck; T4 - nipple; T10 - umbilicus; L1- inguinal; L3- knee; L4- lateral cutaneous; L5- first dorsal interspace (superficial peroneal); S5 - peroneal

c) Trigeminal nerve - facial sensation; jaw clench d) Body position; involuntary movements; muscle bulk e) Tone, Strength (1- flicker; 2 -gravity eliminated) f) Opposition of thumb (median); finger abduction (ulnar) g) Tinel & Phalens for carpal tunnel

h) Coordination - alternate movements (tap hand w/ ball of foot), point-to-point

i) Gait - heel-to-toe (tandem), walk on toes & heels; shallow knee bend, rise from sitting j) Romberg (close eyes for 20 sec) with feet together

Pronator drift - pronation or downward drift suggests contralateral lesion of corticospinal; upward or sideways suggest loss of proprioreception

-tap arms downwards: weak arms easily displaced and remains so; may not correct if loss of proprioreption

k) Start distal when testing sensation

m) Babinski's response (abnormal) - dorsiflexion of big toe

n) Clonus- sharply dorsiflex foot and maintain; asterixis (hepatic encephalopathy) o) Brudzinki's - flex neck causes flexion of hips & knees; Kernig's - bilateral pain on knee extension

p) LMN - ipsilateral upper/lower face paralysis; UMN - contralateral lower face q) Unconcious Patient

-ABC and stabilize C-spine

-pupils (light rxn often intact in metabolic)

-ocular movements (gaze preference towards structural lesions and away from irritative lesions)

-oculocephalic (loss suggests brainstem damage)

-oculovestibular (towards cold stimulus if intact brainstem)

October 2009

1) 42 yo female with low mood. Take a hx.

Q. Diagnosis, investigations, 3 things you would do to manage. A. Depression. ?TSH, exercise, cbt, ssri

2) 55 yo male with 50-100 RBCs on urinalysis. Take hx.

Q. 3 most likely diagnoses, inv, what features on hx most important?

Hx: Patient complained of flank pain, weight loss, + + smoking hx. No signs of infection. A: RCC vs polycystic kidney vs pyelo. Abdo renal U/S. Flank pain, weight loss.

3) 3 yo male. with hx of fever x 2 wks. Take hx

Q. 3 most likely dx, next inv, what phys exam clues are you looking for

Hx: 2 weeks daily fevers, recent red pinpoint rash on chest, easy bruising, pallor, weak, pain in lower extremeties A. leukemia vs ITP vs ? Kawasaki (not sure but maybe HSP?)

4) 35 yo m. with neck and R arm pain. Do Phys exam

Q. Most likely diagnosis. Look at c-spine x-rays any abnormalities? Management? Phys ex: weak triceps, reduced triceps reflexes, decreased sensation middle finger A. C7 radiculopathy, C7 subluxation?, conservative with rehab and NSAIDs 5) 24 yo female with 24 hrs abdo pain and nausea. Do physical exam.

Q. 3 Most likely dx. next 2 investigations. 2 most common long term complications.

Phys ex: percussion tenderness max in LLQ, no HSM, when ask about DRE/Pelvic examiner tells you there is pain on L with rectal and L adnexal tenderness, no cervical motion tenderness.

A. R/O ectopic; βHCG and U/S, complications: fertility and ?bowel obstruction? 6)? Can't remember which of the next stations was 5&5

10 minute stations

1) 55 yo f. Recent colon ca dx now refusing surg. Counsel

2) 35 yo f. with poor sleep and low interest. Take hx. Q. What's the dx: dysthymia 3) 55 yo f. With chest pain in er. Manage. No cath lab available!

Initial ECG doesn’t show much but then pain worsens. Must order repeat ECG! Then show tombstone STEMI

4) 18 mo male. with pallor. Take hx. Respond to mother's questions. Q. What is the most likely dx? Fe-def anemia secondary to too much milk consumption and poor diet.

5) 60 yo male. with 2 yr hx of DM managed by diet only. Now having decreased sensation in feet bilat. Do phys exam for PVD & neuro.

6) 35 yo male. With bipolar on Li for 10 yrs now wants to go off. Take hx and counsel. 7) 17 yo male. with recent head injury. Take hx and px, respond to pt's questions.

8) 45 yo male. Refused insurance for increased LFTs. Take hx and repond to pt's questions. 9) 20 yo female. 35 wks preg with bp 140/90 & 2+ proteinuria. Counsel pt. Giving dx, rx and risks.

October 2008

1) Mom of a 2 year old comes in because of concerns of child’s diet. Wondering if the child is getting too much sugar. Grwoth chart given and child is at 50% Ht and Wt.

Find that child is having temper tantrums Take a history and address Mom’s concerns.

2) Son of a 76 year old mother who is in a nursing home with dementia. Mother has DM II and takes 30/70 15 u ac breakfast and 5 u q hs. She was accidentally given 30 u R at hs and blood sugars OK now. The mistake was just found this morning. The patient has increased confusion this am with marked irritation and mumbling. Prior to this she was able to converse. The son is very upset.

Address his concerns and questions regarding this incident….he wants to know how this happened, what recourse there is and is this mistake why his Mom is now more confused and agitated.

3) 65 year old male with 2 hour history of chest pain…..Manage

Once you ask for an ECG you are given an ECG to read which shows a STEMI. There is a nurse in the room to give orders to. 4) 50 year old male with low back pain for 1 week

Take a history and do a focused physical exam You find he has L5 distribution ridiculopathy. You are asked to make a diagnosis.

5) 42 year old woman in to talk about her Mothers meds. She has a 1 week history of increased confusion with the last 2 days worse as she is not eating. She is now in the ER irritated, combative, disoriented.

The daughter has a list of her mother’s meds and you are to give advice regarding her meds. You find she is on:

trazadone Ativan HCTZ

Detrol…which is a new med over the last week.

6) 60 year old male 6 days post op THR. He developed sudden L sided chest pain nad SOB. Vitals 140/90 HR 120, RR 26 – 28

Do a focused physical exam (pt. is very distraught)

You are asked for a diagnosis and asked what 1 diagnostic test you would send him for. Finding are consistent with a L leg DVT and subsequent PE

7) 17 year old male seen in ER 3 X over the past month with chest pain, SOB, suffocating feeling, anxiety, and feeling as though he is losing his mind. All exams have been and are normal. You have known him for 18years as his family GP and he has always been healthy, active and into sports..

Take a history and counsel. You are asked for a diagnosis.

8) A husband and wife come into ER, because they got into an argument and he pushed her…she fell and lacerated her forehead. She is now being sutured up by another physician and you are sent in to talk to the husband. He is very distraught and anxious and tearful. You find he is remorseful.

Take a history for potential things that may cause family violence and counsel the man.

You find that they have financial problem, behavior problems with their teen age son, the husband is drinking more and the wife is upset over that.

5 + 5 minute stations:

1) 26 year old female with a 7 day history of vaginal discharge. Take a history

2) 30 year old female with pain to posterior neck radiating down arm. Do a focused physical. Written: 10 interpret a lateral c-spine x ray 2) diagnosis 3) recommendations of treatment.

3) 50 year old male who drinks 4-6 beer / day, has vomited blood 1x 6 months ago and again last week. DO a focused physical exam. (you find all the stigmata of liver disease)

Written: 1) What are his risk factors for his problem 2) how will you treat him

4) 3 year old had a first time seizure and is now in ER. You are talking to Mom….take a focused history ( you find child has had a febrile illness).

Written 1) what is the chance this will happen again in the future 2) what tests would you order on the this child 3) what is the likely diagnosis

5) 56 year old male had 10 mins of chest pain 1 week ago. He was seen in ER at the time and had a Normal ECG neg trops, CXR normal. He is now in your office for FU. Take a focused history.

Written: 1) what FU test would you do 2) what are his risk factors 3) what life style changes should he make 4) what meds, if any, would you start him on

6) 67 year old female has found blood in the underwear. Take a focused history (she is post menopausal and you must remember to ask all the screening questions for uterine/endometerial cancer)

October 2007

1. A 30 year old man with Type 1 diabetes for 20 years presents with abdominal pain, nausea and vomiting. Take a history. (He has diabetic ketoacidosis)

PEP station on management plan.

2. A mother has questions about her 18 month old boy who is pale. Take a history. (He has iron deficiency anemia.)

3. A 71 year old woman wonders if she has dementia. Take a history and perform an initial assessment of cognitive functioning. (She has not been taking her B12 shots or her thyroid medication.)

PEP station asking your diagnosis, your initial investigations, and your advice to her about driving.

4 A 30 year old man is brought into the emergency department after losing consciousness. He was revived by two electrical shocks. He now feels fine and wants to leave. Manage. (The initial strip shows vtach. The current strip is normal. He admits to using cocaine.)

5. A 56 year old male with diabetes for 6 years wants to discuss the state of his diabetes. Take a history. (He is diet-controlled, does not monitor his sugars, and has not seen a doctor regarding his diabetes for several years. At a recent eye exam, he was encouraged to see his family doctor to discuss his diabetes.)

6. A 16 year old girl was admitted yesterday for an aspirin overdose. She is now medically cleared. Take a history to assess her fitness for discharge.

7. A 40 year old man is complaining of worsening low back pain. Take a history and perform a focused physical exam. (He has sciatica in an L5 distribution.)

8. A young man fell on a beer bottle an sustained a large laceration to his wrist. Perform a focused physical exam. (He cannot feel or move his thumb.)

PEP station asking which structures have been damanged, and your initial management plan.

9. A 10 year old boy has been brought in by his mother with concerns about frequent illnesses. Take a history, perform a focused physical exam, and counsel. (He has had 6 viral URTIs in the last 10 months.)

10. You take a phone call from a nurse from a small hospital that would like to transfer a 23 year old woman who has had a seizure. She is febrile, tachycardic and her BP is 90/60. No orders have yet been given because the doctor is current involved in a cardiac arrest. Manage. (She has had two brief grand mal seizures. Her neck is stiff, and she has peripheral bruising. She likely has meningococcemia.)

PEP station asking interpretation of the patients ABG.

11. A 45 year old patient has come in to discuss the results of her Pap smear, which showed CINIII; a colposcopy has been recommended. Counsel and assess for risk factors.

12. 50 yo woman c/o severe left lower quadrant pain. Perform a focused physical exam. (LLQ tenderness with peritoneal signs.) PEP station asking for interpretation of an abdominal x-ray, differential diagnosis and initial management.

13. A 30 year old primip at 31 weeks has been sent in by a walk in clinic for elevated blood pressure (140/90). She has 2+ proteinuria. Discuss the diagnosis, its risks and suggest initial management.

14. A 16 year old boy is complaining of diarrhea. Take a history. (For 10 days he has had frequent diarrhea that has become bloody.) PEP station asking for your diagnosis, a major risk of the diagnosis, and your reporting duties if any.

10 minute stations:

1. New diagnosis of a child with T1DM. Get a history from the parent and & counsel.

2. ACS – young male with a suspicious history for MI. Do full ACLS assessment. Don’t forget to ask about cocaine usage! 3. back pain - hx & exam

4. OCP – counsel a young woman on birth control options. Get hx to r/o contraindications. 5. breast feeding - hx & counsel

5+5 minute stations: 1. T2DM - hx

2. kid w/ knee pain - exam 3. nephrotic syndrome - hx

4. abdo pain - exam, X-rays that you need to interpret.

May 2007

1. male loss of interest in pleasurable activities low mood low energy decr conc for 4 yrs but still functioning……dysthymia vs depression treatment

2. panic episodes counseling RX patient phoned after a week and cancelled next appointment what to do? Want a copy of his chart do u give?

3. 10 month child with foster parent s having non specific diarrhea …. Biological mother phone want to ask about his health what would you tell her?

4. 3 yr child with intermittent fever 38.5 for 2 weeks and reddish rash on stomach and chest for 1 day diffential Dx 3 tests to do 5. 21 female for PAP counseling early sexual activity and smoker

6. 41 female infertility menorrhagia dysmenorrhea vaginal bleeding counseling

7. ER station chest pain 2 hours responded partially to nitro first ECG no changes—unstable angina second ECG inf MI 8. Crohns disease repeated vx abdominal pains X-ray multiple fluid levels Mx

9. CHF F/U exam

10. neck pain with radicular pain to the back of arm and forearm and weakness of elbow flexion and extension C6 tenderness limited extension of neck X-rays odontoid, flexion-extension AP Lat Mx

11. 65 male dysphagia to solids progressive hist and PE general, CNS , neck, abdo what is the single diagnostic test. 12. 65 female shoulder and pelvic pain early morning stiffness rx bllod tests

13. young female bloody diarrhea for 2 days 3 most common causes inform public health. 14. smoking cessation counseling

October 2006

1. A 16 y.o. female is asked by her mother to come and see you because of a six month history of vomiting. a. Take a relevant history.

i. (She hands you piece of paper at beginning of station: “5’7, 135lbs”) i. Thinks she is fat, normal BMI, self-induced vomiting

ii. Academic difficulties

iii. Frequent arguments between parents iv. Exercises 1.5 hours/day, abuses laxatives b. 9 min mark - What is your diagnosis?

2. A 25 y.o. female with a history of DM is brought in by her employer unwell and confused. Has had a previous episode 1 year ago. a. Assess and manage concurrently.

i. ABC’s – what IV solution do you want?

ii. Finger-prick glucose = 2.0 – what intervention do you want? iii. Symptoms resolve post intervention, repeat BG = 7.0

iv. On further history, she stayed up most of the night drinking, she took insulin R and N in the am, and she has not had breakfast.

v. What IV solution do you want now?

vi. Turns out her previous episode was just like the current one.

3. A 60 y.o. male POD 3 for colon cancer. Presents with sudden onset left sided sharp chest pain. HR and RR elevated. BP stable. a. Perform a physical exam. Explain your examination and describe your positive/negative findings.

i. ABC’s

ii. Patient is in obvious respiratory distress, clutching L side iii. Left calf markedly tender, positive Homan’s sign. b. 9 min mark – What are your two differential diagnoses? 4. A 25 y.o. male is stabbed in the abdomen. Hypotensive and tachycardic.

a. Physical exam, manage, and investigate concurrently. Explain your examination and describe your positive/negative findings.

i. Primary survey. ABC’s and aggressive resuscitation ii. Pain and nausea management

iii. Order trauma labs, investigation(s), consultation(s) iv. Secondary survey.

b. ABCs, improves with O2 and IV fluid c. Shake tenderness and general surgery consult d. ATLS

5. A 68 y.o. female POD 4 right hip replacement. Patient is confused and depressed. She is refusing heparin. Confusion onset on POD 3, progressive decline since.

a. Take complete history, do focused mental status exam and assess for capacity to consent for treatment. i. Confused and disorientated – Thinks she is in a hotel

ii. Unaware of recent O.R. iii. Visual hallucinations

iv. No medication or alcohol history

b. MMSE 20, seeing spiders on ceiling, clearly poor insight.

c. Examiner says to forego a delirium Hx and Px. You have to address the heparin issue. d. She ends up refusing no matter what you do.

6. A 14 y.o. male presents with 6 months history of headache. Parent is present in the room. a. Take a complete history

i. Bilateral headache, with phono/photophobia, nausea, and vomiting ii. No infections symptoms

iii. No auras, no constitutional symptoms, not stress related iv. Family history of “brain tumors”

7. A 10 y.o. male brought in by his father, with a several day history of rhinorrhea, low-grade fever, and cough.

a. Take a complete history and perform a full physical exam. Explain your examination and describe your positive/negative findings.

i. No G.I. Symptoms

ii. Sore throat, lymphadenopathy, non-productive cough iii. Numerous sick contacts with the same symptoms b. Father’s concerns

i. What is your diagnosis? Is it serious?

ii. How should the child be managed? (not meningitis and can kid go to friend's b-day party?)

8. A 30 y.o. woman has questions of childhood immunizations for her six-week old baby. She emigrated from Eastern Europe 1 year ago. She has heard that shots can make children sick (from Chatelaine magazine)

a. Address her concerns

i. Discuss risks/benefits of vaccinations ii. Discuss the types of vaccinations iii. Discuss schedule of vaccinations b. Questions she asks:

i. Who administers vaccinations?

ii. Is she allowed to refuse immunizations for her child? iii. How much do they cost?

iv. Her husband and her have not had immunizations, which immunizations should they get? 9. 40F chronic constant A/P, seen many doctors without Dx. Hx.

A On Hx she was Dx with IBS, has intermittent constipation/diarrhea.

10. 70 y.o. female unable to cope at home, wondering if should go into nursing home. Take a history and counsel. Dx: Elder abuse (Ques: in this situation, when do you have to report to authority?)

11. 36F would like to quit smoking. Take a history and counsel on smoking cessation aides.

12. 16 y.o. female, ASA overdose. Medically stable. Assess for possible discharge. (Everyone else discharged her with a contract for safety, but I admitted her and asked for a psych consult because this was her second overdose. She didn’t seem certifiable, though, so probably discharge was the right answer.) Be sure to address confidentiality.

13. 80 y.o. female collapses in shopping mall. Manage (history, investigations, physical.) Found to be in 3rd _{degree heart block. Ask about}

advance directive. Get medication history (on digoxin,) give atropine, and ask for pacing pads.

Kinda tricky cause you have to talk to the nurse and order tests, get a history from granddaughter and to physical exam/assess pt. 14. 30ish male with 6 weeks of back pain, worse in AM, improves with activity. Do a focused physical exam.

At the end examiner asks about most likely diagnosis – ankylosing spondylitis.

15. 50ish y.o. female with chronic complaints wants refill of her T-3s and ketorolac. She seems like a “difficult patient.” ½ gave her the prescription and ½ didn’t. At the end you are asked about a differential diagnosis. Possible answers were: depression, fibromyalgia, rheumatoid arthritis, somatitization disorder

16. 40ish y.o. female with chronic aches and pains. Less demanding than previous patient. Most screened for depression. Seemed like a good idea to come up with a management plan to review her records and have her back for a full physical, as she is new to your practice. Lots of FIFE

17. 30ish man with acute abdominal pain. Manage. He looks bad (Vitals 90/60, HR 120, RR 20, 37.8C), and you initially manage as a possible GI bleed/perforated viscous. You find out he has had pancreatitis before and is a heavy drinker. At the end of the station his girlfriend calls and wants to know how he is. He doesn’t want her to know anything. The nurse asks what you want to say. I told her that he was in stable condition and we were taking good care of him, and that she can call back later to talk to her boyfriend herself.

18. 12 y.o. girl with IDDM. New to your practice. Be sure to ask about ER visits, because they didn’t offer this freely, but she had been to ER recently with what sounded to be DKA. Girl is wanting to get more involved in her own management, and both girl and Mom interested in more diabetes education.

5 + 5 minute stations (6)

1. A 35 y.o. male who is HIV positive and on HAART therapy presents with new onset diplopia. CD count is decreased (55), viral load is elevated (30M).

a. Perform a cranial nerve examination. Explain your examination and describe your positive/negative findings. i. Note: they have coffee grounds in the room for your use

b. Multiple-choice questions: i. Describe the lesions

(multiple choice, pick 1)

1. You are given a photograph of a CT scan. (Multiple ring enhancing lesions) 1. What is your differential diagnosis for the lesions?

(multiple choice, pick 3) PML, CNS lymphoma, or TB… lots of choices. ii. How would you manage this patient?

1. Options included referrals, admission to various possible services, admission with consultations, out-patient follow-up.

2. A 14 y.o. boy athletic male presents with anterior right knee pain that is reproducible during physical activities.

a. Perform a focused physical examination. . Explain your examination and describe your positive/negative findings. R tibial plateau pain on exam.

b. Written Questions:

i. What is your diagnosis? (written)

ii. List investigations that you would order, state “none” if none needed (written)

iii. How do you manage this patient? (written)

iv. The father asks you, what is the patient’s prognosis? (written)

3. A 35 y.o. female presents with a 7 month history of amenorrhea a. Take a focused history. Hirsutism

b. Multiple-choice questions:

i. What is your differential diagnosis? (multiple choice, pick 3-4)

ii. What investigations would you order? (multiple choice, pick 3-4)

iii. What immediate intervention would you perform? Folic acid?? (multiple choice, pick 1)

iv. or Main relevant findings from history

4. A 24 y.o. female is several hours post-partum. Her baby had a normal birth weight and was initially doing well. The baby is now becoming lethargic, feeding poorly, and is becoming mildly jaundiced (bilirubin = 210, N < 200)

a. Take a focused history. Prolonged ROM with fever. b. Written questions:

i. What is your diagnosis? (written)

ii. Name 5 investigations you would perform to confirm your diagnosis. (written)

iii. What intervention would you perform for the baby? (written)

5. A 45 y.o. female is several hours post-partum with a low birth weight baby. a. Take a focused history. Concerned re: LBW. Smoker.

b. Despite denying substance abuse, it turns out the mother was using cocaine during pregnancy. Written questions: i. Aside from cocaine use, what are three contributing factors in the history for the birth weight?

(written) ? wrong dates

ii. What intervention would you perform for the baby at this time?

(written) (it has great APGAR scores, and good primitive reflexes, in no respiratorydistress) iii. What intervention would you perform for the mother at this time?

(written)

iv. Woman is depressed that the thinks she hurt her baby 1. How to manage mom

2. How to manage baby

6. A 45 y.o. female who has never had children before, presents with a several month history of menorrhagia (volume and duration) and spotting.

a. Take a focused history. Took TriCyclen 28 in distant past. No Pap x years b. Multiple-choice questions:

i. What is your differential diagnosis? (multiple choice, pick 4)

ii. What investigations would you perform? (multiple choice, pick 4)

iii. Preventive measures

7. 2. 16 y.o girl with heavy menstrual bleeding and cramping, missing school. Sexually active. Otherwise healthy. Take a Hx. No paps PEP; Order 3 lab tests (lots of answers seemed right, but CBC, TSH, swabs and pap were popular responses)

What is the single most likely diagnosis (primary dysmenorrhea) What 1 treatment would you give? (most of us gave the pill)

8. 3 month old infant with vomiting. Non-bilious, non-projectile. Sounds like GERD. You find out that she changed from breast milk to Enfelac with iron 1 month ago. Mom a bit stressed because husband lost his job recently. Take a history.

PEP: Interpret the growth chart given (shows normal length and HC, but decreased wt) What is single most likely diagnosis (gerd)

List 2 non-pharmacological managements (upright after feeds, thicken feeds) 9. 30ish y.o. man with renal colic symptoms. Perform a focused exam.

PEP: What 2 investigations would you do? (CBC, urinalysis, urine cultures, creatinine) CT shows 4mm L ureteric stone

He comes back febrile – list 2 more investigations (blood cultures, CBC etc). c. Patient received Septra but is allergic to sulpha. Upon stopping Septra, rash resolves. What three things do you need to do now?

List 3 management steps (hydration, analgesia, antibiotics)

10. 20ish man with a suspected head injury. Perform a focused cranial nerve and neuro exam. This was a tough station. He was pretty much unresponsive. Most of us forgot fundoscopy, and I forgot babinski reflex. Otherwise, say you’d do corneal and gag reflexes, check peripheral reflexes, do a good head and neck inspection. We were all confused…

You find he has a GCS ~7-8 and C-spine collar on with big laceration to his R forehead. PEP: List two investigations (most of us did CBC, crossmatch)

List two managements for transfer (most did oxygen, foley)

List three important contact before transfer (paramedics, ER doc, family)

What would you need to do before you transfer him? i.e. get approval from the accepting trauma physician, send chart….(MCQ) 11. 20ish woman in her 3rd _{trimester presents with bleeding. Has had cramping as well. Take a history.}

PEP: List 2 features on history that lead to your diagnosis (bleeding + pain) List most likely diagnosis (abruption)

List one management step (U/S)

12. 30F with third trimester bleeding. Take a history. You find out that there is no pain. No problems during pregnancy. a. FHR is OK and Hgb stable. What two things on hx would help you confirm your dx?

b. What is the most likely dx? c. What would you do next?

13. 3 month old infant with vomiting. Non-bilious, non-projectile. Sounds like GERD. Mom a bit stressed because husband lost his job recently. Take a history.

PEP: Interpret the growth chart given (shows normal length and HC, but decreased wt) What is single most likely diagnosis (gerd)

List 2 non-pharmacological managements (upright after feeds, thicken feeds) 14. 27 yo male with nonpainful bilateral leg swelling - likely nephrotic syndrome 15. Counsel young women re: abnormal pap smear (LSIL) (and indications/risk factors)

Spring 2006

1. Middle aged male comes in with wife after having 2 seizures lasting 2min each. Both were tonic clonic, generalized. Assess and manage. Wife there, no nurse.

a. Temp elevated. Rest of vitals normal. GCS ~10

b. Important hx: alcohol abuse, but none in the last 2 days. Used to take ativan prn.

c. Assess and manage (including tests and treatments) for alcohol withdrawal seizures and decreased LOC. d. At the end, you have to tell the wife 2 tests or treatments you would do initially for the patient.

2. VBAC: 29yo female had a previous C section (low transverse incision) emergently for a true knot in the cord. Meconium staining observed. Otherwise, pregnancy was normal. Now 10wks pregnant.

a. Now wanting you to ensure that she will have a vaginal birth. b. Wants to know why she didn’t have a vag birth last time (FIFE)

c. Discuss reasons for not having a VBAC and reasons for a C section and explain that she may or may not be able to have a vag birth this time.

d. Wants a copy of her discharge summary from last time e. Asks why her friend said that “once a C/S, always a C/S” f. Asks if it’s safe for her to have her delivery at home

3. Infertility: 30yo female comes in with concerns about infertility. Hx and Counsel.

a. Trying to get pregnant x 1 ½ yrs. Never pregnant previously. One Chlamydial infection in the past. No PID. b. Periods normal. Now measuring temperature for ovulation and has intercourse 3x/wk.

c. Poor timing during her menstrual cycle. Partner had kids from previous marriage. d. Examiner will ask 2 most likely causes on DDx.

4. 28yo male coming in asking for refill on Percocet for tension headaches. Sees another colleague of yours normally. Very jittery and aggressive

a. Prescription filled out only 4d ago. 50tabs. All taken b. Denies abuse

c. Is not willing to try any other med

5. Approximately 60yo male comes into emerg with lightheadedness and SOB. Vitals stable but HR is >150 and irregularly irregular. Assess. Do not offer investigations or treatment options.

Find out he has some CVS risk factors. Hx of palpitations in the past. Drinks quite a bit of alcohol. HCTZ for HTN, no other meds. No indications this is vaso-vagal or neuro (eg. Meniere’s disease)

a. Do CV and chest exam

6. Mother concerned that daughter not speaking (3 ½ yo) a. Normal pregnancy and birth, reached all milestones b. Speaking some phrases, but only about 5-6 words

c. Multiple AOM/yr (3-4x/yr), not always responding to verbal stimuli d. Doesn’t give a very detailed history on hearing

e. Examiner will ask likely Dx: ?hearing loss due to AOM

7. 16yo male already assessed for accident involving ankle. Only has a sprain with no ligamentous injury. Advise on rehab and the use of crutches and tensor bandage.

a. RICE

b. Crutches and tensor bandage??? c. PT for ankle

8. Middle aged woman comes in with fatigue and insomnia. Recently seen your colleague and has normal CBC, TSH, etc. Assess. a. Lost her job and husband just lost his.

b. Assess sleeping habits

c. R/O depression, anxiety, psychosis, SI d. Did mental status exam minus MMSE e. R/O thyroid and fatigue syndrome anyways.

f. Examiner asks what you would advise: SSRI, adjust sleeping habits, social support for financial situation. 5+5 minute stations

1. 45yo male with hemoptysis. New patient to you. Focused history. a. Smoker

b. B Sx all positive. c. Questions:

ii. Likely Dx (name 2): TB. ?Lung CA iii. Initial management:

1. sputum cytology 2. Acid fast 3. CT?

2. Vaginal discharge x 1wk in young female

a. One episode of PID (not very willing to give info. Only comes up when you ask about surgeries.) b. Fishy, foul smelling. No abdo pain/other symptoms of PID.

c. Sexually active (has had 20 partners). Only on OCP. Partner has no symptoms. Pap 2yr ago normal. Smoking. d. Questions:

i. Microbial causes: name 3 1. Gardnerella vaginalis 2. Trichomoniasis? 3. N. gonorrhea? ii. Investigations

1. C+S of discharge 2. KOH (Whiff) test

iii. 2 causes that would warrant informing public health 1. Gonorrhea

2. Chlamydia

3. (Note: they ask for MICROBIAL causes)

3. Mother coming in concerned about 2yo son who has been having cough x 1mo and no relief with Amoxil from other dr. a. History of eczema. Family history of eczema and atopy

b. Father smokes in house. c. Nocturnal cough

d. No other symptoms (including fever, wheeze, etc) e. Questions:

i. Likely cause: reactive airways

ii. Factors in history supporting this diagnosis: 1. Nocturnal cough

2. Hx of eczema 3. FHx of atopy iii. Management

1. inhaled beta agonists and steroids 2. counsul on smoking cessation

4. Young female with increasing epigastric pain x 1hr. Nauseated. Vitals stable. No temp. Has history of indigestion and takes TUMS. PEx.

a. +peritoneal signs. DRE and vag exam normal b. Questions:

i. During station with patient: what investigation would you do (Xrays only): AXR – 3 views with CXR ii. Interpret CXR: free air under diaphragm

iii. Likely cause: perforated peptic ulcer

iv. 2 most important intial aspects of management (in next 60 min?): 1. Gen surg consult

2. iv PPI (pantoloc)?

5. Middle aged male comes in angry because he has been denied insurance due to elevated LFT (ALT>AST, increased Alk Phos, normal bili). Hx.

a. IVDU – cocaine. Shared needles but did wash them with water inbetween. Only in teens. b. Safe sex practices.

c. Drinks 12 beers/weekend and 2 Rye and cokes/night. i. CAGE: denies alcoholism

d. Forgot to ask about transfusions… e. Works as a housekeeper in a hospital

f. No other systemic symptoms (fever, abdo pain, etc.) g. LFT repeated – no difference. Questions:

i. 2 most likely causes: hep C and alcoholic hepatitis (alcohol, acute hepatitis, chronic hepatitis, fatty liver on the list) ii. without any further investigations back yet, what is your advice to patient:

1. safe sex practice, quit alcohol, test partner, stop driving on the list

2. can’t remember the other 2… ?don’t share toothbrushes, (supposed to be 3 in total) 3. responsibility to public health at this time (no confirmed diagnosis of hep C… only LFTs)

6. Middle aged female coming in because of easy bruising and epistaxis. PEx. a. Lights were off. Turn them on!!!

b. Make-up on: petechiae and bruising and epistaxis c. PEx: skin, lymph nodes, liver, spleen, percuss chest d. Questions:

i. Likely cause: ITP

ii. Points on history that lead to Dx? hx of flu, fever, wt loss on the list. iii. Initial treatment has failed. What do you do now?

1. bone marrow

2. ?coag profile (was done before)/blood smear

7. 62 y o woman with acute onset thoracic back pain. Take Hx. No constitutional symptoms. Find out she had a hx of PMR and was probably on steroids at some point. Also, family hx of early hip # in mother. PEP: list 4 risk factors for osteoporosis in this woman, acute pain management, management of osteoporosis (3 steps with doses of meds).

October 2005

1) 61yo female C/O Radiation leaking to her house x10 yrs (keeping a metal ring to protect her). Focused Hx and Mental state exam Q at 9 minutes: How would yo assess if she is competent to start on antipsychotics?

2) 51 yo woman with back pain. Focused history and focused physical.

Pain is worse with extension and going downhill, better with flexion, normal neuro exam Q at 9 minutes: What is your provisional diagnosis? (spinal stenosis)

3) 30 yo male with 48hr Hx severe R hip pain, wose with ambulation, fever. Focused Hx and focused PEx Q at 9 minutes: provisional Dx? (septic arthritis) What ONE investigation would you do? (aspirate)

4) 80 yo woman collapsed in shopping mall. Brought by EMS to emerg where you see with one RN. Vitals 80/40, hr 40. ACLS Given an EKG: 3rd degree heart block, unable to get code cart for 15 minutes

At 8 min nurse found DNR note in her bag. Advance directive found in wallet if you ask – no intubation, no CPR, no defibrillation) Question: what would you do if she went into Vfib and arrest?

29 yo female 10 weeks pregnant comes in to discuss current pregnancy and possibility of VBAC You are given a copy of the discharge summary from the last delivery – sectioned for decals and meconium/fetal distress. True not in cord. Take a focused history and counsel. She also wants to do a home birth.

6) Foster mother brings in her 10 mo foster child to discuss 8 wk Hx of loose stools. Nurse is weighing pt. Focused Hx and advise. Q at 9 minutes: will you disclose the information to the biological mother if she calls to see how child is doing?

7) 41 yo male with 5yr Hxof asthma comes in to discuss 3 visits to ER in last 2 weeks for SOB, chest pain. Focused Hx,and manage. NOTE: he was started on Metoprolol 2 weeks ago by a physician in Vancouver.

18 yo previously health patient known to you practice with history of recent visits to ER complaining of flushing, palpitations, fear, SOB, chest pain. CXR, EKG, echocardiogram and TSH normal. Take a focused history.

Q at 9 minutes: Provisional diagnosis?

9) Young woman, recent immigrant, poor spoken English and can’t read English wants Rx refill. (none required)

10) 20 something pregnant woman at 37 weeks, first pregnancy. Has had swelling in fingers and ankles for two weeks, and has 2+ protein in her urine. Manage and counsel.

Uncomplicated pregnancy so far, one U/S at 20 weeks which was normal. Past two weeks, has gained 7.5 pounds. Denies headaches, visual changes or RUQ pain. Negative family history. First pregnancy. No medical issues. On materna. I said I would examine for hyperrflexia, do some blood work (CBC, LFTs, Urate), do a NST and an US for BPP.

If all is good, I would manage with labetolol and have pt induced next week, and recommended no work and bed rest at home. Told her to come back if has decreased fetal movement, visual changes, abdo pain or seizures immediately to hospital. If on the other hand the physical and the tests were off, I would admit her and observe her closely and induce her next week. I explained what PIH was, briefly talked about why it happens (placenta producing some toxic material) and talked about risks to mom (seizures, preterm labour, forgot to mention HELLP), and risks to fetus (IUGR, death)

11) A mother finds marijuana in her son’s sock drawer. Hasn’t confronted him. Wants advise.

Mom wondering if using drugs periodically is ok. Kid has some new nasty friends (shop lifters), marks have been declining for 1 year. Stable home environment. I said come back with son and husband and we can talk to him about all this. Also offered resources like drug rehab programs etc.

13) Father and son age 6, poor attention in school, disrespectful to female authority fiqures, marks falling. On further questioning find out mother died of leukemia in past 12 months after fighting it for 2yrs. No social support at home. No FHx ADHD. Advise. 14) 40 yo male, collapsed in a concert, cardiac arrest on route, defibrillated. Now ER, BP 160/90, HR 120, RR 20, 96% RA. Manage.

Nurse in room. Now stable, talking. No SOB now, mild chest pain. Hx shows he did coke twice in the concert. Denies doing any other drugs. Does coke regularly. Had typical chest pain.

You have to read the strip from EMS: v.tach. Also must read the strip after cardioversion: sinus tachy. EKG in ER: no ST elevation, ST depression V1-V4. As you are about to finish, the nurse tells you that the guy was found to have a bag of coke on him. He gets agitated and asks if you are going to call the police.

Most people found this to be a difficult station. The guy was OK already with his ABC’s. I didn’t give him any meds, but I did put him on O2, started an IV with NS at 150 cc/hr, and ran blood work including troponins (although I realized that they will be high as the guy was defibrillated), and tox screen. I also said I would have call cardiology, have him admitted to CCU for observation, and call social worker. Some people gave him nitro and morohine, and beta blockers to slow the heart rate as he was tachycardic. I guess you could also consider calcium channel blockers to relieve the vasoconstriction. I said the guy arrested due to vasoconstriction secondary to cocaine.

15) 20 something girl, comes in with fatigue and depressed mood. Make the diagnosis and come up with management plan.

Positive for depression. No mania features, no psychotic features. No stress in life or in work, supportive husband. I said we should rule out medical conditions like thyroid, send her to counselors or start medications. Make follow up plans.

16) 40-50 something year old woman with diabetes, comes in with pain and tingling in her feet.

Gait is funny, as if walking on glass. Normal motor exam. Sensory exam shows loss of soft touch and pin prick bilaterally in both legs, in stocking distribution. Also no vibration and proproception in feet. Loss of dorsal deep tendon reflexes, normal knee jerks. Q at 9 minutes: what is the diagnosis? What is your management plan?

17) 78 yo female on many medications. Recently seen for ? pneumonia and given Erythromycin. Vomiting and anorexic. For recheck with CXR. Daughter states more confused lately. Presents list of medications. 2-3 benzo’s, Abx, heart medications. Manage meds. Describe CXR (no convincing pneumonia)

(Polypharmacy erythromycin, ibuprofen for OA, cimetidine, digoxin, theophyllin for COPD, furosemide, ativan for anxiety after husband died 8 months ago, triazolam for insonia)

I said we should give mother fluids, stabilize her in ER, do some blood wotk including theophilline levels, and switch her onto inhaled steroids instead, wean off the benzo’s.

18) 58 year old guy with erectile dysfunction. Counsel and manage.

Hx DM x5yr, on Metformin, ASA. Ophtho normal. HTN, on Altace. Hx CP 1yr ago, stress test negative. Not on nitro. Married to wife x 30 years, no relationship problems. Non-smoker. ETOH 2-3 beers/week.

I said we need to control DM, get blood work (A1C, FBS, ACR), cut down ETOH, start Viagra, be aware if goes to hospital with chest pain, let them know about Viagra. I should have also asked him to come back with his wife to talk about this more, but forgot! 5+5 minute stations

24 yo female with LLQ pain and fever. Do PE (Ectopic) (speculum exam IUD thread +, told by examiner when asked), green discharge from cervix, blood at os, L adnexal tender, DRE tender L side

PEP 1) 3 possible DDx 2) 3 investigations

3) 5points in Hx to make the diagnosis

4?) What 2 complications can arise from her condition in the future

61 yo female, increasing SOB for 2wks.PMHx Cardiomyopathy, on ramipril, lasix, and aspirin. Focused Hx (gained 7lb, started eating salted pickles that husband is making) (no symptoms of pneumonia/DVT. + orthopnea, + ankle edema, no PND)

PEP 1) interpretation of CXR (cardiomegaly, no pleural effusion , no Kerley B, no fluid in fissures) 2) diagnosis (CHF)

3) management, 3 points (diet counselling, stop eating pickles, increase po Lasix)

3) 18mo child took mothers ASA tablets at home, mother refusing to speak to anyone except ER doc (you) PEP 1) Management in ER in 5 lines

2) Another sibling had same incidence in 3 yrs ago, what do you do (CAS) 3) What do you tell the mother?

3b) Telephone in the room. Distraught mother wants to talk to ER doc. 3 year old has ingested some drain fluid.

Mother is at home with son. Grand mother present. 10 minutes before, kid found to have ingested some drain fluid from the closet, unknown amount. Original bottle not present. They tried to induce vomiting by giving milk and mustard powder to kid, but no luck! Kid restless and crying now.

PEP 1) FOUR things on PEx when the kid gets to ER (Vitals, orophrayngeal exam, respiratory exam and mental status) 2) Principles of Mx in ER (I said ABC’s, B/W including ABG, osmolality, checking bottle/agent ingested, poison control) 4) 30yo male with MVA and femur/tib # fixed 36 hrs ago. Now c/o SOB, fever. Do PE (had rashes on the chest) (fat embolism)

PEP 1) CXR given Diagnosis

2) What 3 investigations would you order?

5) 65 yo female with bloody nipple discharge. Focused Hx (on Hx pt had mother who died at age 45 of breast Ca) PEP: Mammo normal.

1) Given discharge is from a single duct, what is your next investigation to check for breast cancer? 2) What 3 factors will affect her prognosis?

3) What would you advise her 37 and 39 yo daughters about mammograms?

6) 55 yo male with arterial claudication symptoms. Do a focused Hx (also do screening neuro to r/o neurogenic claudication) PEP 1) What 2 investiation would you do to confirm PVD

2) 5 risk factors for PVD, on Hx 3) Interpret ECG (normal)

7) 40 yo male, manual labourer c/o R shoulder pain after repetitive heavy lifting. Focused PEx Can’t forward flex or abduct R arm, decreased strength, unable to touch shoulder blade PEP 1) Likely diagnosis (rotator cuff tendinopathy)

2) Next 3 steps in management (rest, anti-inflammatory, physio?) 8) 69 yo male with 3 wk Hx of progressive dysphagia. Take a history.

Smoker, 2ppd x50yrs, 6 beers/day, 15lb weight loss in 3wks. Dysphagia for solid and soft solid. FHx lung and stomach Ca PEP 1) Presented with abnormal ba swallow. Described findings (applecore lesion mid-lower esophagus)

2) Likely diagnosis (esophageal Ca) 3) Next 3 investigations (endoscopy, …) 9) 60 yo male with gross hematuria x1 week. Focused Hx

No UTI symptoms, no cancer symptoms, no prostatic symptoms. On warfarin for A fib, INR 2.6. PEP 1) Likely diagnosis?

May 2005

1) Male 48 yrs Leg cramps Hx & PE (PVD) PEP Q1) Diagnosis

Q2) Investigation

Q3) Management in 3 steps

2) Male 60 yrs Hematuria Hx (on Warfarin)

PEP Q1) Describe the IVU findings (ureteric stone) Q2) Management

3) 48 hrs old newborn with jaundice Hx (from mother) PEP Q1) Two DD

Q2) Investigation

Q3) what are the two index you’ll look in the S.Bilirubin report 4) 19 yrs Female with acute lower abd pain Hx and PE (Ectopic)

PEP Q1) 3 DD Q2) Investigation

Q3) what is the next step in her management 5) Male 60yrs acute urinary retention Hx (ca prostate)

PEP Q1) what is the Dx Q2) Three Investigations

6) Male 27 yrs Chest pain, dyspnea,fever and cough Hx and PE (Pneumonia) PEP Q1) Describe the CXR (Middle lobe pneumonia)

Q2) what is the most like etiological agent? Q3) Write an out patient prescription for him 10 minute stations

1) 6 yrs old child admitted after an anaphylaxis (peanut butter), counsel the mother 2) Emergency station: Male 40 yrs Hemet emesis Managemant

3) Female 19 yrs want an abortion counsel her

4) 45 yrs old female Bipolar disorder on Lithium for 10yrs,she want to stop Lithium- Counseling (she had features of hypothyroidism and some polyuria)

5) 35 yrs male with acute mania Hx

At 9 min examiner asked what is the diagnosis and nest step in Mx

6) Emergency Station: Male 55 yrs old brought by paramedics after Cardiac arrest now having chest pain- management (inferior ST elevation MI)

7) Male 35 yrs acute low back pin Hx and PE At 9 min examiner asked Dx and Ix

October 2004

1) 48 yo with fever for the past 3 weeks. Focused Hx.

Night sweats, some weight loss. At an Ontario farm 3 wks ago. Smoked x15 yrs but stopped 10 yrs ago, mother died of lung cancer 2) 20 yo fell off a roof and hit his head. Manage. He is responsive but is a bit drowsy, closing eyes. Has a headache, neck pain.

Q at 9 minutes: lateral C-spine XR (if you ask for it), interpret.

3) 12 yo diabetic, just moved to town. Take a history of diabetes control, counsel

4) 2 wk old infant, breastfed. BW 3.6kg, now 3.9kg. Mother worried not breastfeeding right and not gaining enough weight. Hx, counsel. Or Young F who missed her 6 wk postpartum appt. is here 4 months after delivery. Her baby was fine at delivery with a wt. of 3000g. 5) 80 year old woman collapsed in a shopping mall, comes in with BP 80/60, pulse 40. Manage.

ECG shown with complete heart block, get ready to intubate because poorly responsive and unstable.

Q at 9 minutes: find advanced directive in her purse saying no CPR, etc. What would you do if she went into V-fib?

6) 52 yo woman comes in to review pap smear which shows severe dysplasia suggestive of HPV/CIN III and need to go for colposcopy Explain the findings, take a history for risk factors for cervical cancer, arrange follow-up

Q at 9 minutes: she just applied for life insurance and asks if you have to give them the results of this test.

7) 27 yo male comes in with 3 episodes of going to emerg for chest pain. SOB, palpitations. Diagnosis of panic disorder made Explain panic disorder, answer his questions about if he is going crazy, tell him what kinds of things are available to help him

Q at 9 minutes: He wants a new MD, are you responsible for him until he finds new one? If he requests copy of his chart, do you give it? 8) Man hits wife and she hits her head on edge of table causing laceration. He says this is the first time he has ever done this and wants help

Take a history examining risk factors for family abuse, counsel

Q at 9 minutes: Are you obliged to provide police info regarding the case, and do you have obligation to inform police? 5+5 minute stations

1) 52 year old woman with LLQ pain. Focused physical PEP: 1) Interpret AXR

2) Most likely DDx

3) Choose 5 investigations you would do (choose from a list) 2) 7 month old with diarrhea for 1 week. Focused Hx.

Mom is giving double concentrated formula for last week because she is concerned about how much weight he is gaining, although says that weight checks fine at WBVs. Child also drinking 2 bottles apples juice/day for several months. Child is afebrile and 5% dehydrated PEP: 1) Diagnosis (inappropriate diet vs. osmotic diarrhea)

2) Investigations

3) Management (oral rehydration, dietary advice)

3) 48 yo with shoulder pain after lifting something heavy at work. Do a PEx PEP: 1) Most likely diagnosis (Rotator cuff tear)

2) Management (NSAIDS, physio)

3) What directions do you give him if he wanted to apply for WSIB? Will you give WSIB info about pt if they ask for it? 4) 32 yo with 3 measurements of high blood pressure. BP 160/100 both arms. Do a PEx (don’t need to do BP)

PEP: 1) Most likely causes of the hypertension in him (pick 3) 2) What investigations you would do (pick 5)

3) What do you advise him (pick 3)

5) 6 week old constantly crying, mother in to see you. Focused Hx. Make sure to screen for possibility of abuse PEP: 1) Diagnosis (most likely colic)

2) Risk factors for abuse in this family

3) Investigations, if any, you would do ( ultrasound abdo?)

6) Secondary amennorhea in a 27 yo who wants to have children. Focused Hx (has always had a bit more hair than other women) PEP: 1) Most likely diagnoses (3)

May 2004

1. 30 yo male presents with fall. Has bruise over L side of abdomen. In C-spine collar. Vitals stable. Manage for 1o or 2o survey. DPL shows free fluid in abdomen. Likely splenic rupture. Acute management (type and screen, X-match, conult Gen Sx). SURGERY 2. 40 yo male inferior STEMI. Presents with CP initially, then has CP in ER with inferior ST elevations. Treat medically, consider TNK.

Question: if man wants to leave AMA (after treatment, before seen by cardiology), what do you do? Acute management. MEDICINE 3. 65 yo female with rectal CA does not want OR. Counsel her. Turns out her friend died with the same OR. Offer ostomy nurse to come

in, talk about fears etc. Hx only (counselling /CLEO) SURGERY

4. 35 yo female 8 wks pregnant worried about risk of genetic defects. Counsel. She asks if her husband didn’t want abortion but she did, if the tests were abnormal, who whould have the legal rights? Hx only (counselling / CLEO) OBS/GYN

5. 56 yo male with hemoptysis. On coumadin for A fib. Chronic hemoptysis, now worse. Ex-smoker. No CP, no DVT risks. Hx and Px. Question: what would you do if he is dissatisfied with care and wants to take his chart to go to another MD. Hx and Px. MEDICINE 6. Mother is worried her 3 ½ yo daughter, still at home, not using complex sentences, just single words. Recurrent OM. Other milestones

okay, no social determinants/abuse identified on history. Brother who is 5 is okay. Mother concerned she is developmentally delayed. Question : what is your Dx (hearing loss). History only. PAEDS

7. 49 yo female depressed x 3 wks. No SI/abuse/substance abuse. Insomnia. Soon to be laid off, husband fired. Older children at home. Question: what would you do treatment-wise (SSRI, refer to Psych). History only. PSYCH

5+5 minute stations

1. 40s man presents with abdominal pain and vomiting. One BM before this started, now not passing gas. Pain is colicky, in waves. No one ate with him at last meal. Prior appy. No IBD. Uncomfortable during history. History only. SURGERY

PEP: 1. Shows AXR with dilated SB loops and air-fluid levels. Interpret AXR 2. What is Dx (SBO)

3. How would you manage (NG, IV fluids)

4. If worse pain, acute abdomen, tachycardic, what would you do (3 things): (IV fluids, antibiotics, gen surgery consult) 2. 60 male with claudication. PEx for PVD (U/E and L/E). PEx only (hair distribution, cap refill, bruits). SURGERY

PEP: 1. ECG is normal. Ask you to interpret it.

2. What 2 investigations would you order for PVD (dopplers with ABI, angiography)

3. 5 risk factors for PVD (Hypertension, diabetes, smoking, hypercholesterolemia, CAD, CVD, ESRD)

3. 30 yo male schizophrenic, acute dystonic reaction. Haldol x 5 days, prior other agent. Not psychotic/suicidal. History only. PSYCH PEP: 1. What is the diagnosis (haldol induced dystonic reaction)

2. How would you treat it (benztropine 1-2 mg IM)

3. Mother calls you back after he leaves and says that he is trying to jump off the balcony. What do you do (tell her to call 911, issue a Form 1 which you can do as you had assessed him previously)

4. 40s man presents with elevated AS T (200) and ALT (200) (ALP 110, bili 26) on screening at time of insurance. Wants test repeated. 12 drinks on weekend. CAGE equivocal. Never drank more. IV heroin as teens. Janitor at a hospital. Had perinatal jaundice but nothing since. Previously healthy. Never transfused. No FMHx. History only (explain why Qs about sex, etc. Say must do PEx). MEDICINE PEP: 1. What is his diagnosis (acute hepatitis)

2. What are the three likely etiologies (HBV, HCV, alcohol)

3. What is your reporting responsibility at this time (none, but if HBV or HCV, must report to public health)

5. 27 F with 1 day Hx of LLQ abdominal pain. Physical exam only. Positive rebound, shake, guarding, cough tenderness. Rectal exam reveals L sided tenderness. On pelvic has IUD, L sided tendeness, cervical motion tenderness. No CVAT. OBS/GYN

PEP: 1. What are your 3 diagnoses (ectopic pregnancy, PID, ruptured ovarian cyst) 2. What 2 investigations would you do (abd/pelvic u/s, B HCG)

6. 2 ½ son has persistent cough after having URTI 3 weeks ago treated with amoxil and antitussives. Child has Hx of atopy. Wheezing. Cough worse at night. Wife smokes. Immunizations intact. No one else sick in family. Hx only. PAEDS

PEP: 1. What is your diagnosis (reactive airways)

2. What supports it on history (wheezing, atopy, worse at night)

3. 3 management options (bronchodilators, inhaled steroids, parents stop smoking).

7. 40 yo male can’t weight bear on R hip, pain x1 day, fever. No steroids/trauma/IVDU/STD RFs. ? septic hip. Hx and Px. MEDICINE PEP: 1. What is the diagnosis? Single investigation?

2. How do you manage this?

150. 71 year old female who has not had a family doctor for three years. Her daughter who is your patient and has asked that you see her because her mother is worried about problems with her memory and is worried about developing dementia.

Findings: Previously got a “shot” q month and used to take “thyroid” pills but has not kept up with these since her family doctor moved. PEP: 1. Most likely diagnosis.