CASE1

A previously healthy 45-year-old man is admitted to emergency in a semi-

comatose state. He responds inappropriately to verbal commands and is rousable with
some difficulty. He is lying flat in bed with no signs of respiratory distress, there are no
signs of head injury, localizing signs, neck stiffness, temperature is normal and the pupils
are equal and reactive.

CASE1: QUESTION 1

At this point, which diagnoses would you consider? List up to three.

1.

2.

3.

CASE1: QUESTION 2

With respect to your diagnosis, while the patient is in the emergency department, which of
the following tests would you perform? Select up to five.

Blood gases PT/PTT

Blood glucose Serum creatinine
Chest x-ray Scrum electrolytes
Complete blood count Serum osmolality
CT scan of the head Skull x-ray
Drug screen Stool for occult blood
ECG Thyroid function tests
EEG Urine electrolytes
Gastroscopy urine microscopy
Liver function tests X-ray of the spine and pelvis

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 CASE 2

A 28-year-old medical student returns from Kenya after a 6 week elective. Two
weeks later she complains of fever, rigors, malaise and headache occurring daily for the
past four days.

CASE 2: QUESTION 3

What physical findings would you specifically look for? Select up to three.

Arthritis Papil edema

Ascites Pal or
Crackles Petechiae
Cullen's sign Lymphadenopathy
Erythema chronicum migrans Meningismus
Erythema nodosum Roth spots
Hepatomegaly Scleral icterus
Hypotension Splenomegaly
Osier's nodes Systolic ejection murmur
Palmar erythema Wheezes

CASE 2: QUESTION 4

What laboratory investigations would you order? Select up to five.

Abdominal ultrasound HTV serology

Blood cultures LDH
Chest x-ray Liver function tests
CD4 cell count Lyme serology
Cold agglutinins Malaria serology
Creatinine PPD
CT scan head Platelets
EEG Serology for dengue fever
Hemoglobin Stool cultures
Hepatitis A serology Stool for ova and parasites
Hepatitis B surface antigen Thick smear for malaria
Heterophile antibodies White blood cell count

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 CASE 3

A 40-year-old man is admitted to the Emergency Department with a history of

chest pain of sudden onset while playing basketball with his young children.

CASE 3: QUESTION 5

What diagnoses would you consider at this point? List up to two.

1.

2.

CASE 3: QUESTION 6

With respect to your diagnosis, what elements in the history would you inquire about?
Select up to six.

Chronic headaches and takes aspirin regularly

Consumes 12 beers daily
Family history of chest disease
Family history of diabetes
Had dental extraction 2 months ago
Hemoptysis
Hemorrhoids
History of brr ichiectasis
History of hypertension
History of smoking
On a low salt diet
Pain worse on breathing
Post-prandial abdominal pain
Productive cough of recent onset
Radiation down the arms
Radiation into the jaw
Recurrent nosebleeds
Shortness of breath
Stool is black in colour
Stool is pale in colour

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 CASE 4

An 84-year-old female is brought to the Emergency Department by her daughter

who states that her mother has not been herself over the past three days. Further
questioning reveals that the mother has been less attentive than usual and more
withdrawn, her conversation is often rambling and she has not been sleeping well. Prior
to this, she functioned very well.

CASE 4: QUESTION 7

What diagnoses would you consider at this time? List up to two:

1.

2.

CASE 4: QUESTION 8

What additional aspects of history would be most important to know?

Select up to four:

Alcohol intake
Complete psychiatric history
Family history of Alzheimer's disease
Financial status
History of fever
History of incontinence
History of Osteoarthritis
History of Parkinson's disease
History of previous CVA
Immunization status
Marital status
Medication history
Occupational history
Pattern of symptoms over the course of the day, eg. fluctuations
Presence of hallucinations
Previous history of depression
Previous seizure disorder
Previous surgery
Recent travel
Smoking history

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 CASE 4: QUESTION 9

The interview confirms the daughter's description of the mother. Physical exam
reveals: BP 120/80 supine and 100/70 sitting, RR=22, P=104, T=38.7°C. JVP is at the
sternal angle. Respiratory exam reveals dullness, increased tactile fremitus, crackles and
bronchial breath sounds all in the left base. Heart sounds are normal. The abdominal
exam is normal. CNS exam does not reveal any focal findings.

What would you include in your initial investigations? Select up to four:

ALT Electrolytes
AST HIV test
Blood cultures MRI of head
B12 Protein electrophoresis
CBC PT and PTT
Chest x-ray RBC folate
CPK SPECT scan
CT Scan of Head TSH
Drug screen Urea and creatinine
EEG VDRL

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 CASE 5

A 39 year old male with no fixed address is brought to the emergency department by
ambulance after having a witnessed generalized tonic-clonic seizure of short duration. He is
known to have a history of alcohol abuse in the past. On examination, he is noted to be
drowsy with tachycardia and no focal neurological deficits.

CASE 5: QUESTION 10

What are the most likely possible etiologies of a seizure in this patient? list up to four.

1.

2.

3.

4.

CASE 5: QUESTION 11

Which diagnostic tests would be most useful to determine the etiology of this patient's
seizure? Select up to five.

Abdominal ultrasound EKG

Abdominal X-Ray ESR
Arterial blood gases Glucose
ASA level Liver function tests
CBC Lumbar puncture
Chest X-ray Protein
Creatinine PT/PTT
CT head Serum ethanol, methanol, ethylene glycol level
Drug screen for street drugs Skul X-Ray
Electrolytes Urea
Urinalysis

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 CASE 6
A 36-year-old Gravida I, Para O is seen at 36 week gestational age, complaining
of swelling of her hands and feet as well as gastric pain, all of recent onset. Her blood
pressure taken in the left lateral position is 150/95 (previous it was 120/70).

CASE 6: QUESTION 12

With respect to plausible diagnosis, what elements of history would you enquire about?
Select up to five.

Alcohol intake Headache

Al ergies History of birth control pill use
Blurred vision History of infertility
Constipation History of urinary tract infection
Deepening of voice Number of sexual partners
Dysmenorrhea Previous history of PID
Dyspareunia Previous dilatation and curettage
Family history of ovarian cancer Scotoma
Fetal movement Smoking
Fever Weight gain

CASE 6: QUESTION 13

With respect to investigations, which of the following may be helpful in establishing the
diagnosis? Select up to six.

Amniocentesis LH
Amylase Liver enzyme
CBC (including platelets) Lumbar puncture
Chest x-ray PA flat Obstetrical ultrasound
Creatinine PT/PTT
CT scan of head Thyroxine bindy globulin
ECG Urinary calcium
ESR Urinary protein
Free cortisol Urinary sodium

FSH

CASE 6: QUESTION 14

What is the most likely diagnosis in this patient? List one.

1.

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 CASE 7
A 62 year old woman presents to her family physician with postmenopausal
bleeding.

CASE 7: QUESTION 15

What diagnoses would you consider in this patient? List up to three.

1.

2.

3.

CASE 7: QUESTION 16

With respect to your diagnoses, what elements of her history would you enquire about?
Select up to four.

Alcohol intake Hematemesis

Amount and characteristics of bleeding History of pap smears
Constipation Nocturia
Dyspepsia Palpitations
Estrogen replacement therapy Pelvic pain
Headache Sexual activity
Smoking

CASE 7: QUESTION 17

What would be the most appropriate procedures or investigations in the workup and
management for this patient? Select up to three.

Arterial blood gases Endometrial biopsy

Chest x-ray Fractional D & C
Colposcopy Pap smear
Cone biopsy of cervix Sigmoidoscopy
Electrocardiogram Sputum culture
Vaginal culture

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 CASE 8

A previously healthy seven year old boy complaints of pains in his legs and
shoulders associated with a loss of appetite and listlessness. Over the next few days he
develops a cough and increasing shortness of breath. On examination he is found to be
alert but mildly dyspnoeic. He is afebrile, the respiratory rate is 60 per minute and the
apex rate is 130 per minute. Air entry is good but crackles are heard in both bases. The
precordium is normodynamic. Heart sounds are normal and no murmur is detected. No rub
is heard. The liver is felt 4 cm below the costal margin.

CASE 8: QUESTION 18

Which of the following would be included in the differential diagnosis?

Select up to two.

Acute rheumatic fever Peanut aspiration

Brucel osis Pneumococcal pneumonia
Coxsackie myocarditis Salicylate intoxication
Diphtheria Tuberculosis
Kawasaki's disease Viral pneumonia

CASE 8: QUESTION 19

What are the most appropriate initial investigations? Select up to two.

Antistreptolysin o titre Mantoux test

Blood culture Routine chest x-ray
Brucellin antibody titres Serum electrolytes, calcium
&. magnesium
Electrocardiogram Serum salicylate level
Inspiratory and expiratory x-ray Throat swab for culture and sensitivity

CASE 8: QUESTION 20

What would you include in the treatment of this patient? Select up to two.

Aspirin Intravenous clindamycin

Bed rest Intravenous gamma globulin
Bronchoscopy Penicillin orally
Cardiac monitoring Rifampin and streptomycin
Furosemide (Lasix) Trimethoprim/sulfamethoxazole

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 CASE 9

A two-year-old male presents with a history of fever for the past week associated
with an erythematous maculopapular rash, conjunctivitis, a strawberry tongue, cracked
lips, pharyngitis with cervical lymph node enlargement and palmar erythema.

CASE 9: QUESTION 21

Which of the following would be included in your differential diagnosis?

Select up to three.

Coxsackie viral infection Measles

Drug reaction Rubel a
Henoch-Schonlein vasculitis Scarlet fever
Kawasaki's syndrome Stevens-Johnson Syndrome
Lyme disease Systemic rheumatoid arthritis

CASE 9: QUESTION 22

What would be included in the initial management of this patient? Select up to two.

Acyclovir Methotrexate
Aspirin Penicillin
Cefaclor Prednisone
Diphenhydramine Solu-Cortef
IV gamma globulin Sulfamethoxazole/trimethoprim

CASE 9: QUESTION 23

Long term sequelae could include which of the following? Select one.

Arthritis Mitral stenosis

Bell's palsy Nephritis
Coronary artery aneurysms Neutropenia
Dissecting aortic aneurysm Peripheral neuropathy
Giant cel pneumonia Uveitis

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 CASE 10

An 18-month-old male child is brought to you by his mother with a one month
history of 6-8 watery soft stools per day. Your physical examination reveals a
malnourished child who has fallen off his growth chart.

CASE 10: QUESTION 24

Which of the following would you include in your differential diagnosis?

Select up to six:

AIDS
Celiac disease
Cystic fibrosis
Excessive apple juice intake
Excess water intake
Giardia Lamblia infection
Gut malrotation
Lactose intolerance
Laxative administration
Rotavirus infection
Salmonella infection
Schwachmann-Diamond syndrome (with pancreatic insufficiency)
Sucrase - isomaltose deficiency
Toddler diarrhea

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 CASE 11

A three year old girl presents with a 3 week history of cough. She is generally
well and afebrile. Mother has a similar cough. The child's cough is more pronounced at
night and when she runs about.

CASE 11: QUESTION 25

What common diagnoses would you consider? List up to three.

1.

2.

3.

CASE 11: QUESTION 26

Which of the following would be the most appropriate next investigations?
Select up to three.

Al ergy tests
Broncho-alveolar lavage (BAL)
Blood culture
CBC
CFT for mycoplasma
Chest x-ray
Environmental analysis
Gastric washings for AFB
Nasal smear for eosinophils
NP swab for pertussis
NP swab for RSV and paraflu virus
Sinus x-rays
Sweat chlorides
TB test Throat
culture

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 CASE 12

A babysitter brings a 14-month-old to emergency because of inconsolable crying.

The child appears well cared for and healthy but a "bruise" is noted on the left humerus
and a well-circumscribed small fresh burn is noted on the other shoulder.

CASE 12: QUESTION 27

Which of these physical findings are most suggestive of child abuse?

Select up to four.

Alopecia Hutchison's teeth

Blue sclera Impetigo
Bruises on shins and elbows Large purple roaster lesion on buttock
But ocks wasting Limp
Caput medusa Oral thrush
Clubbing Petechiae
Condylomata acuminata Pitted finger nails
Eczema Proptosis
Pul fontanel e Retinal hemorrhage
Healed laceration on chin Seborrhea

CASE 12: QUESTION 28

You suspect that this is a case of child abuse. Which of the following are appropriate
steps in initial management? Select up to four.

Abdominal ultra-sound Liver spleen scan

Ascorbic acid level MRI (magnetic resonance imaging)
Bone density studies Notify CAS (Children's Aid Society)
CBC Notify police
Chest x-ray Notify public health nurse
Coagulation studies Ophthalmology consult
Creatinine Psychiatry consult
Dietary history Serum calcium, phosphorus & alkaline phosphorus
ECG Skeletal survey
Factor 8 assay Urinalysis

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 CASE 13

Sam is a 25 year old man living with his partner, Jane. He presents to the emergency
department saying he "couldn't go on any longer". He is employed at a bank but has not
reported to work for a week, having called in to say he was ill.

The history revealed that he was feeling sad and tearful most of the time and had been
this way for almost 2 months. He could not sleep and often woke up early in the morning.
His appetite was low and he had lost about 15 pounds. His energy and concentration were
low and he felt that he was not a good person. In fact, many of the things he said about
himself were very self-critical. He had never experienced a major depression before and was
frightened by some suicidal thoughts he had recently.

CASE 13: QUESTION 29

Which of the following steps should be part of the initial work up of the case?
Select up to five.

Assessment of competence of consent to treatment EEG

Assessment of financial competence Electrolytes
Assessment of suicidal risk MRI
Blood and urine screen for alcohol and drugs Neuropsychological testing
CBC Personality testing - MMPI
CT scan PET scan
Dexamethasone suppression test (DST) Physical exam
ECG Thyroid functions

CASE 13: QUESTION 30

Having confirmed a diagnosis of depression with no organic cause, which of the following
components could be part of a treatment plan? Select up to seven.

Arrange short-term disability Genetic counselling

Arrange long-term disability Interpersonal therapy
Cingulotomy Lithium 600 mg bid
Cognitive-behavioural therapy Meet with his partner
Couple therapy Paroxetine 50 mg four times per day
Cytomel 25 micrograms daily Psychoanalysis
Desipramine 50 mg, increasing Sertraline 20 md/day initially,
each week by 25 mg to 150 mg increasing each wk by 20 mg to 80 mg
Hectroconvulsive therapy Supportive therapy
Family therapy
Fluoxetine 40 mg/day for 1 week; then 80 mg/day

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 CASE 14

A 35 year old man has had a liver transplant two weeks ago. Physically he has
been doing well but over the past week has become loud, laughing a lot, sleepless,
irritable and sexually inappropriate with staff. The nurses call you because he is
smashing things on the ward with an IV pole and will not stop when asked.

CASE 14: QUESTION 31

Which of the following are immediate manoeuvres you should take?

Select up to four:

Ask for a psychiatric consultation

Call at least 5 staff together before approaching him
Call family to get permission to give him emergency sedation
Complete a Form 1 and 42
Complete a Form 3 and 26
Complete a Form 9 and 30
EKG stat
Give him 10 mg of diazepam PO
Have nurse draw up 2 mg lorazepam and 5 mg haloperidol in the same syringe
Inject Chlorpromazine 10 mg IM.
Perform a complete physical examination, noting incision site
Personally escort him back to bis room.
Stat abdominal ultrasound
Stat blood gases
Take patient to bis room, with force if necessary

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 CASE 15
A 32-year-old woman developed low back pain during the second trimester of her
first pregnancy. This persisted and she delivered a normal full term male infant.
Following the delivery, she complained of pain in her left leg. This pain progressively
worsened and involved the posterolateral aspect of the leg calf and lateral aspect of the
foot. It resolved over a two-week period.

For approximately one year after the birth of her child, she was well. Then, she
suddenly developed severe back and left leg pain. The pain was severe and radiated into
the lateral aspect of the foot. The pain was associated with numbness in the lateral aspect
of the foot every time she got up to walk.

CASE 15: QUESTION 32

With respect to your diagnosis, what elements of the physical exam would you focus on?
Select up to Four.

Abdominal examination Pelvic examination

Blood pressure Peripheral pulses
Bowstring sign Pulse
Carotid bruits Range of motion of the lumbar spine
Chest auscultation Rectal examination
Examination of the skin Reflexes in the lower limbs
Hearing tests Respiratory rate
Inspection for bulk in the legs Sensory exam of the arms
Motor testing of the arms Sensory exam of the legs
Motor testing of the legs Straight leg raising
Palpation for lymphadenopathy Visual acuity

CASE 15: QUESTION 33

With respect to your diagnosis, what investigations would you consider discussing with
this patient? Select up to three.

Alkaline phosphatase Plain CT scan of the lumbar spine

Audiogram Pregnancy test
Blood cultures Referral to a psychiatrist
CT scan of the abdomen Serium sodium
Electrocardiogram Ultrasound of the abdomen
Electroencephalogram Ultrasound of the pelvis
Erythrocyte sedimentation rate Urinalysis
Lumbar spine x-rays Urine culture
MRI of the spine Urine sodium
Myelogram

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 CASE 16

A 67 year old man is found to have an iron-deficiency anemia. The patient is

feeling completely well and physical examination is within normal limits.

CASE 16: QUESTION 34

Which of the following tests might help to determine the cause of the anemia?
Select up to six.

Abdominal ultrasound Gastroscopy

Air contrast barium enema INR/PTT
Bone marrow biopsy JVP
Bronchoscopy Laparoscopy
CT abdomen/pelvis Serum creatinine
CT thorax Serum electrolytes
CXR - PA &. Lat Serum protein electrophoresis
Colonoscopy UGI XR
Digital rectal examination Urinalysis
Fecal occult blood test Whole body gallium scan

CASE 16: QUESTION 35

The patient is found to have an adenocarcinoma of the ascending colon. Which of the
following tests might help to decide on a treatment plan? Select up to three.

Abdominal/pelvic CT scan Gallium scan

Abdominal U/S INR, PTT
Blood glucose IVP
Bone scan Laparoscopy
CT brain Liver-spleen scan
CT thorax Serum alpha-feto protein level
CXR - PA & Lat Serum carcino-embryonic antigen level
Cystoscopy Serum creatinine
ECT Small bowel enema

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 CASE 17

A 72 year old woman presents in the emergency department complaining of sudden-

onset of severe generalized abdominal pain. Past medical history is unremarkable aside from
stable angina and left leg claudication. Physical exam of the abdomen is normal.

CASE 17: QUESTION 36

What diagnoses would you consider in this patient at this time? List up to three.

1.

2.

3.

CASE 17: QUESTION 37

What laboratory tests may help you to arrive at a definitive diagnosis promptly?
Select up to six.

Abdominal U/S HIDA scan

BUN, creatinine IVP
Cardiac enzymes Laparoscopy
CT scan - abd/pelvis Laparotomy
CBC Liver function tests (ALT, ALP, AST, LDH, bilirubin)
CXR - PA & Lat Serum amylase
Coionoscopy 2-D Echo of heart
ECG 2 Views of abdomen
Electrolytes UGI XR
Gastroscopy Urinalysis

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 CASE 18

A 72 year old man presents to the emergency department with a three day history of
frank hemoptysis. He has a SO pack year smoking history, chronic bronchitis, and a long
history of atrial fibrillation for which he takes Coumadin. He has a low grade fever, chest
pain, and appears short of breath.

CASE 18: QUESTION 38

With this presentation, which diagnoses would you consider? List up to three.

1.

2.

3.

CASE 18: QUESTION 39

What investigations are appropriate within the next 12 hours? Select up to five.

Abdominal ultrasound INR

Blood culture Lung scan
Bone scan Prothrombin time
Bronchoscopy Serum albumin
CBC Serum calcium
Chest x-ray Serum creatinine
CT chest scan Serum phosphorus
CT head scan Sputum cytology
EKG Sputum for stains, culture, sensitivity
Initiation of intravenous antibiotics Urinalysis

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 CASE 19

A 59 year old man presents to the emergency department with a 3 day history of
increasing left lower quadrant abdominal pain. He is tender to palpation in the left lower
quadrant.

CASE 19: QUESTION 40

What diagnoses would you consider in this patient at this time? List up to three.

1.

2.

3.

CASE 19: QUESTION 41

With respect to your diagnosis, what elements of his history would you enquire about?
Select up to five.

Alcohol abuse Hematemasis

Angina Hemorrhoids
Arthritis Hepatitis
Biliary colic Low back pain
Cigaret e smoking Peptic ulcer disease
Constipation (recent) Previous episodes of LLQ pain
Diarrhea Previous surgery
Dysphagia Rectal bleeding
Headache Tuberculosis (remote)
Heartburn Weight loss (recent)

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 CASE 19: QUESTION 42

With respect to your diagnosis, which of the following laboratory tests are likely to help you
make a definitive diagnosis? Select up to four.

Abdominal U/S Gastroscopy

Bone scan Hypaque enema
CT abd/pelvis IVP
CBC . Liver-spleen scan
CXR - PA & Lat Serum amylase
Creatinine/BUN Stool for occult blood
Colonoscopy Two views of abdomen
Electrolytes UGIXRwithsmal bowelfol ow-through
Gallium scan Urinalysis

CASE 20
A 29 year old female is brought to the Emergency Department 20 minutes following a
motor vehicle accident in which one person was killed. She was the driver of the vehicle
which was struch head-on by a truck. Her vital signs at the scene of the accident were: heart
rate 100/min, BP 110/70.

On arrival in the Emergency Department, her heart rate is 125/min and her BP is 100/70. She
remains conscious but confused. There is decreased air entry to her left hemi-thorax.

CASE 20: QUESTION 43

What steps would you take immediately? List up to four:

1.

2.

3.

4.

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 CASE 20: QUESTION 44

Initial investigations/management should include which of the following?

Select up to seven.

Abdominal ultrasound Establish 2 large bore IV's

Administer antibiotics EKG
Administer oxygen Immediate thoracotomy
CBC Left chest tube insertion
Cross & type 2 units of blood Left thoracentesis
CT chest scan Portable chest x-ray
CT head scan Right diagnostic thoracentesis
Diagnostic peritoneal lavage Serum electrolytes
Endotracheal intubation Urinalysis
Establish 1 large bore IV 2D echocardiogram

CASE 20: QUESTION 45

What specific diagnoses are likely? List three.

1.

2.

3.

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 SCORING RECORD
Case Question YourTotal Maximum Value of Proportion Correct
Number of Numberto each per Question
Correct Count in Answer (Number) X (Value)
Answers Scoring

1 1. 3 0.333

2. 5 0.20

2 3. 3 0.333

4. 5 0.20

3 5. 2 0.50
6. 6 0.167

4 7. 1 1.00

8. 4 0.25
9. 4 0.25

5 10. 4 0.25
11. 5 0.20

6 12. 5 0.20

13. 6 0.167
14. 1 1.00

7 IS. 3 0.333

16. 4 0.25
17. 3 0.333

8 18. 2 0.50

19. 2 0.50
20. 2 0.50

9 21. 3 0.333

22. 2 0.50
23. 1 1.00

10 24. 5 0.20

11 25. 3 0.333

26. 3 0.333

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 Case Question Your Total Maximum Value of Proportion Correct
Number of Number to each per Question
Correct Count in Answer (Number) X (Value)
Answers Scoring

12 27. 4 0.25

28. 4 0.25

13 29. 5 0.20

30. 7 0.143

14 31. 4 0.25

15 32. 4 0.25
33. 3 0.333

16 34. 6 0.167

35. 3 0.333

17 36. 3 0.333

37. 6 0.167

18 38. 3 0.333

39. 5 0.20

19 40. 3 0.333

41. 5 0.20
42. 4 0.25

20 43. 4 0.25

44. 7 0.143
45. 3 0.333

SUM OF PROPORTIONS = ______ (Max. 45.0)

SUM
PERCENTAGE CORRECT = -- X 100 = ________ %
45.0

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