We are excited to see so many of you join our spring FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

Just a reminder… pay attention to the questions. Here are our general tips one more time:

1. Pay attention to the questions. Look carefully at how many items you are being asked to list. If the question asks for five items, you will not get more marks if you list eight items; the examiner will look at the first five and allocate marks only for the first five answers – so be careful. On a SAMP, if it is not clearly stated how many items you should list, look at the amount of points/marks being allocated for the question to get an idea of how many answers the examiner may be anticipating you write down.

2. Do not write lengthy answers. Most questions can be answered in 10 words or less!

3. Be specific when writing down investigations (hemoglobin instead of CBC; CT abdomen instead of CT).

4. Remember that trade names and generic names are both acceptable when writing down medications.

5. For more helpful tips, you can refer to CCFP’s SAMP instructions by clicking here.

SAMP

A 32 year old female bank manager comes to see you and says “Doc, my periods are irregular. I got my period when I was 14… and since then, my cycles have been unpredictable. At times I go without a period for more than 6 months… which is kind of great, but is this normal?â€

You review her chart and note that she is overweight (BMI 31) but otherwise healthy. She smokes a pack per day and drinks 1-2 drinks a week. She has been in a serious relationship for the past 5 years and she tells you that she is now starting to think about having kids so this is particularly concerning to her. (15 points)

1. You are suspecting PCOS. How would you make the diagnosis (hint: think Rotterdarm criteria). (3 points)

• • Need two out of the three of the following:
    • Oligo- and/or anovulation
    • Clinical and/or biochemical signs of hyperandrogenism
    • Polycystic ovaries (by ultrasound)

2. What are two physical signs of hyperandrogenism? (2 points)

• • Hirsutism
  • Acne
  • Male-pattern hair loss

3. What is one physical exam finding (aside from signs of hyperandrogenism) that you may see in a patient with PCOS? (1 point)

• • Obesity
  • Acanthosis Nigricans

4. List three lab tests you could order for a patient presenting with anovulation. (3 points)

• • Serum beta human chorionic gonadotropin (β-hCG)
  • Serum total testosterone
  • 17-hydroxyprogesterone
  • Thyroid-stimulating hormone (TSH)
  • Prolactin
  • Luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)
  • Sex hormone-binding globulin (SHBG)
  • Dehydroepiandrosterone sulfate (DHEAS)
  • Estradiol

5. True or false: Free testosterone is a reliable indicator of hyperandrogenemia. (1 point)

• • False. Total testosterone is the preferred marker to measure for PCOS as it is more reliable.

6. What is one imaging investigation you would order for this patient (be specific!)? (1 point)

• • A transvaginal pelvic ultrasound

7. Her investigations come back and along with your physical exam findings, you make the diagnosis of PCOS. What other endocrinologic condition should you screen for that is commonly associated with PCOS? (1 point)

• • Prediabetes/Diabetes

8. She would like to get her periods under better control – what are two options you could offer her to improve her cycle control? (2 points)

• • Combined OCP
  • Lifestyle changes (e.g., weight loss, increased exercise)
  • Cyclic Provera (10mg x10 days every 2-3 months)
  • Metformin

9. You discuss management options with her. She prefers to not take any medication at this time for her infrequent menstrual periods. What should you be concerned about in women with infrequent menses? (1 point)

• • Endometrial hyperplasia