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

Shioban is a 12 week old girl who comes to your family practice office with her mother. Her mother reports a 4 week history of “problems with her stomachâ€. She has repeatedly spit up with every feed. Her oral intake has not changed. Mom is quite concerned. (13 points)

1. What three focused maneuvers on a physical examination you do not want to miss? (3 points)

• • Blood pressure, heart rate, and temperature
  • Growth parameters (plot on the WHO growth chart!)
  • Anogenital exam (remember to look for fissures, anorectal vascular abnormality, or excoriated skin)
  • Abdominal exam

2. What are three additional questions on history you want to ask about Siobhan to rule out red flags for her presentation? (3 points)

• • Family history of Cystic Fibrosis
    
  • Prematurity
    
  • Fever, lethargy
    
  • Known genetic or metabolic syndrome
    
  • Vomiting (bilious, blood, projectile)
    
  • History of seizures and/or neurologic impairment
    
  • Poor weight gain
    
  • Change in stool characteristics (e.g., ribbon-like stools, bloody stools)
    

3. You ask about stool patterns. What are three causes of GI bleeding in infants? (3 points)

• • Anal fissures
  • Cow’s milk protein allergy (this is the most common food allergy in infants! Usually half resolve in the first year and up to 90% resolve by age 5)
  • Coagulopathies (including vitamin K deficiency)
  • Necrotizing enterocolitis (often seen with prematurity)
  • Hirschsprung disease
  • Malrotation with volvulus
  • Intussusception
  • Meckel’s diverticulum
  • Lymphonodular hyperplasia
  • Stress ulcer
  • Infectious etiologies
  • Intestinal duplication (rare)
  • Vascular malformations (rare)

4. You take a thorough history and perform a physical examination. You diagnose GERD and reassure mom. What are two lifestyle modifications for GERD in infants? (2 points)

• • For breastfeeding infants, trial elimination of milk and egg in the maternal diet – reassess at 2-4 weeks. Also consider arranging a breastfeeding assessment with a lactation consultation (important to review infant positioning, attachment, sucking, swallowing)
  • For formula-fed infants, trial extensively hydrolyzed protein-based formula
  • Consider smaller, more frequent feeds
  • Use thickened feedings – up to one tablespoon of dry rice cereal per one ounce of formula or by switching to a commercially thickened formula (use these in your full-term babies without a Cow’s milk protein allergy)
  • Ensure baby is positioned upright post feeds and avoid placing baby in an infant carrier during feedings

5. What two classes of medication could you consider to treat GERD in infants <1 year old? (2 points)

• • Protein pump inhibitor
  • Histamine-2-receptor antagonists

Helpful Resources:
https://www.fmpe.org: Pediatric Snapshots: GI issues