Short Answer Management Problems (SAMPs)

Overview
- 6 hours of typed short-answer questions: 3 hours, break, 3 hours
The exam grading
- Physicians grade the answers!
- No abbreviations if possible, but common ones, like AST and ALT are OK, as long as a physician would know it
- Spelling mistakes do NOT matter!
- You can answer most questions in ten words or less.
- Put one answer per box, subsequent answers in the same box will not be considered.
  - Guess! No negative marks for wrong answers.
- If your answer to a question is “none”, please type “none”. Do not leave the answer box empty.
- Give details about procedures ONLY IF DIRECTED TO DO SO.
- When providing values or measures only Systeme Internationale (SI) units will be accepted.

BE SPECIFIC

When relevant, the setting in which you are practicing will be described.
- Office: If patient unstable, next step in management is to Urgent referral to Emergency Department
- Emergency department, list ABC + GMOVIE separately, eg.
  - A = Assess airway and if compromised begin by attempting secure it with chin lift or jaw thrust if necessary
  - B = Assess breathing, and begin to assist with bag and mask if necessary
  - C = Assess pulse, and start high-quality CPR if not palpable
  - G = Measure plasma glucose
  - M = Get monitors: pacing pads, cardiac monitor, BP monitor, SpO2 monitor
  - O = 100% non rebreather mask with O2 set to flush
  - V = Assess vital signs (6!)
  - I = Place large bore IVs x2 (14-16G)
  - E = EKG stat
When ordering laboratory investigations be SPECIFIC.
- For example, CBC, electrolytes, LFTs, lipid profile and arterial blood gases are not acceptable; you must list the specific indices/test you would like for that question
  - eg. CBC (unacceptable) but hemoglobin, mean corpuscular volume individually acceptable
  - eg. serum electrolytes (unacceptable) but serum potassium, serum sodium individually acceptable
  - eg. CT (unacceptable) but CT head acceptable
  - Exceptions (the following are acceptable answers)
    - Urinalysis
    - Urine osmolality
    - WBC with differential
    - Amylase+lipase
    - INR+PTT
    - AST+ALT
    - Lipid screening including TC, LDL-C, HDL-C, TAGs* (only acceptable as screening investigation, not lab test)
    - Midstream urine culture
When ordering other investigations, be SPECIFIC.
- For example, ultrasound is not acceptable, you must specify abdominal ultrasound.
- Image modality + target
  - Pelvic ultrasound
  - CT L-spine
  - CT abdomen with IV and oral contrast
  - CT head with IV contrast
  - Nuclear medicine thyroid scan with uptake
  - Transvaginal U/S of uterus and ovaries
- X-rays, must list all views
  - Cervical spine x-rays: AP, odontoid, lateral
    - If C7-T1 not visualised: Swimmer’s
  - Chest x-rays: PA, and lateral
  - Abdominal x-rays: Supine, Erect (r/o free air)
  - Knee x-rays: AP, lateral
    - r/o patellar #: skyline
    - r/o OA: weight bearing
  - Ankle x-rays: AP, lateral, and mortise (internal oblique)
  - Trauma view x-rays: C-spine AP, chest AP, abdomen AP, pelvis AP
  - http://www.wikiradiography.net/page/Radiographic+Protocol+Guide
  - https://www.radiologymasterclass.co.uk
When writing the diagnosis, be SPECIFIC (Pathology + location/cause)
- Inferior myocardial infarction
- Hyperthyroidism 2/2 graves disease
- Medication side effect
- Side effect of an eating disorder
- Type 2 diabetes
- Iron deficiency anemia (not anemia)
Medications
- The use of generic names or trade names will be accepted.
- When asked to list medications to treat a patient, the following items count as “medications”, include route of administration
  - 100% oxygen via a non-rebreather mask
  - Fluids IV
  - Short-acting inhaled beta-agonist
  - Long-acting inhaled anticholinergic
  - Steroids IV
  - Empiric IV antibiotics urgently
  - Inhaled corticosteroids (for asthma) vs. intranasal corticosteroids (for allergic rhinitis)
Management
- Thumb spica cast
- Thyroid ablation with radioactive iodine
- Refer to ENT for urgent surgical assessment
- Refer to general surgery for urgent biopsy of the temporal artery
- Refer to urology for urgent prostate biopsy

Answers that are NOT accepted

Lifestyle changes
Toxic appearance
Celiac panel
ABG

Examsmanship and Tips

If a question stem says the serum calcium is high, and asks for a diagnosis, the answer is “Hypercalcemia” (so obvious it’s not obvious!!) - not “Hyperparathyroidism. But if a follow-up question asks for the most likely cause, the answer to that is “Hyperparathyroidism”
If a stem mentions one of PUD or H. pylori+, and asks for the diagnosis, the answer the other one that was not mentioned
If a stem states a medication by name, and later asks for management options, it is OK to state classes of medications, including the class of the medication named
When asked for a diagnosis, state: [acute/chronic] disorder secondary to cause, eg. “acute kidney injury secondary to dehydration”
If the question is specific regarding the location of the pain (eg. RUQ), and regarding the etiology (eg. fever) then give a differential diagnosis that fits with this location + fever

When asked what you would do next, state

What I would do
Why I would do it
How I would do it
When I would do it
Where I would do it
eg. “Inhaled oxygen stat in a resuscitation room to treat the patient’s respiratory distress”

Medications classes to know and one medication from each class

6 hypoglycemics: biguanide, sulfonylurea, DPP4i (-gliptin), GLP1r-agonist (-tide), SGLT2i (-flozin), meglitinide, alpha-glucosidase-i, thiazolidinediones, insulin
5 anti-hypertensives: BB, CCB, ACE-i, ARB, thiazide, aldosterone antagonist
4 anti-depressants: SSRI, SNRI, NDRI (buproprion), TCA, TeCA (tetracyclic - Mirtazapine), MAOI (Selegiline used in Parkinsons)
3 anti-HIV: NRTI (tenofovir/emtricitabine), Combination (Truvada), Integrase inhibitor (Raltegravir), NNRTI , Protease inhibitor
3 anti-migraine: NSAIDs, Aniline analgesics (Acetaminophen), Triptan
3 migraine prophylaxis: BB (propranolol), SNRI (venlafaxine), TCA (amitriptyline), anticonvulsants (valproate)
5 anti-Parkinsonian: Dopamine precursor, dopamine agonist, anticholinergic, NMDA-receptor antagonist, MAOI, COMT inhibitor

Side effects of medications to know

Statins: Myalgia, nausea, diarrhea, insomnia
NSAIDs: Dyspepsia, N/V/D, GI bleed, CV risk (MI, stroke)
ACEi: Dry cough, headache, fatigue, angioedema, hyperkalemia, elevated creatinine
HIV meds: Fatigue, nausea, diarrhea
Triptan: Fatigue, dizziness, nausea, palpitations, vertigo, flushing
SSRIs: Headache, nausea, sexual dysfunction, somnolence/insomnia
OCP: Irregular/breakthrough bleeding, headache, nausea, breast tenderness
Morphine: N/V/Constipation, urinary retention, dizziness, sedation, pruritus, resp depression, confusion

New guidelines

If answering a question based on very new information (ie. last 6mo), list the source in the answer (eg. 2018 Diabetes Canada Guidelines)

In a question that asks to manage a FEMALE patient for ANY reason (i.e. trauma, seizure, etc)

ALWAYS do a “serum beta-hCG”

If unstable, FIRST STEP

ABCs + GMOVIE as above (the first step in acute management is NEVER medication)

Management is more than medication: use the acronym “SNOPQRST” for the exam

Safety: ABCs assessed and addressed? Vital signs stable? Admission to hospital? Stop driving?
Next visit: Regular f/u
Offer: Labs, imaging, investigations
Prevention: Diet, weight loss, exercise, safe sex, helmets, vaccines, screening for associated conditions
Quit: Smoking, EtOH, drugs, stress, offending medications
Refer: Specialists, clinics, allied healthcare professionals, multidisciplinary teams
Report to: Health authority for outbreaks, driving authority if unsafe to drive (eg. seizure)
Start: Non-pharmacologic and pharmacologic interventions
Teach: Counsel, refer to online resources, patient handouts; instructions to return sooner if Sx persist or worsen

Common questions asked

Differential diagnosis
Signs and symptoms
Risk factors
Red flags (differentiate from risk factors)
Management: SNOPQRST
Complications

ALWAYS screen for or treat the following if the stem hints at it

HIV
Pregnancy
Pain
Danger to self or others (Suicide)
Abuse
Vaccines
Eating disorders

Medication doses and routes to know

Acetaminophen (child) 10-15mg/kg PO q4-6h
Ibuprofen (child) 4-10mg/kg PO q6-8h in>6mo
Amoxicillin
- Child (duration usually 5-10d)
  - Strep pharyngitis: 50mg/kg/day PO daily
  - UTI: 50mg/kg/day PO div TID
  - AOM/sinusitis: 90mg/kg PO div BID
  - Pneumonia: 90mg/kg PO div TID
- Adult
  - Usually 500mg PO BID-TID
  - Pneumonia 1g PO TID x7d
STI treatment
- Gono/chlam: Cefixime 800mg PO x1 + Azithromycin 1g PO x1 ("fix az" soon as possible)
H. pylori eradication = HP PAC
- PPI (eg. Lansoprazole 30mg PO) BID
- Amoxicillin 1g PO BID
- Clarithromycin 500mg PO BID
Smoking cessation
- Nicotine replacement, Champix 0.5mg/d x2d then BID , Zyban 150mg/d x3d then BID
ACLS drugs and dosages
- Epinephrine 1, Amiodarone 300/150, Atropine 0.5, Adenosine 6/12 push with rapid NS flush
Epinephrine for Anaphylaxis
- Child: 0.01mg/kg IM
- Adults: Epinephrine 0.5mg IM
Vitamin B12 dosage 1mg (1000mcg) PO daily, or IM/deep SC weekly x one month then monthly
Nocturnal enuresis management: Lifestyle, wet alarm
- DDAVP 0.2mg PO qHS (up to 0.6mg)

Other

Level of spinal lesion for foot dorsiflexion (L4), toe dorsiflexion (L5), and foot plantar flexion (S1)
TB=HIV
Be aware of the components of rules (ottawa ankle, knee, subarachnoid hemorrhage, Framingham, CURB65)
Risk factors (age, sex, SES, alcohol, smoking, medication, exercise/activity, IV drugs, prior history, family history)
Review your SAMP: Re-read question, add specification (CT L-spine, Midstream Urine Cx), HIV, **SERUM ** b-HCG, Pain, Danger (driving, guns)

References:

http://www.cfpc.ca/SAMPs/
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