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
  • 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: