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

52-year-old Jackie Smoke comes into your office for a same-day, urgent appointment. She is brought in by her husband in a wheelchair while holding a bucket as she feels extremely nauseous and dizzy. Her symptoms began this morning. Her past medical history is significant for hyperlipidemia, hypertension, obesity (BMI 33), and a 30-pack-year smoking history. (13 points)

1. List three potential peripheral causes for her presentation. (3 points)

• • Benign paroxysmal positional vertigo
  • Vestibular neuritis
  • Labyrinthitis
  • Meniere’s disease
  • Herpes zoster oticus
  • Perilymphatic fistula
  • Acoustic neuroma
  • Medication toxicity (e.g. aminoglycoside)
  • Otitis media

2. List three potential central causes for her presentation. (3 points)

• • Vestibular migraine
  • Cerebrovascular disease
  • Brainstem ischemia
  • Cerebellar infarction/hemorrhage
  • Multiple sclerosis
  • Chiari malformation

3. What three examination maneuvers could you perform to distinguish peripheral from central vertigo? (3 points)

• • Head Impulse Test: tests the vestibulo–ocular reflex – if the patient is able to maintain focus on the patient’s nose while his/her head is rapidly turned this is a BAD sign and suggests a CENTRAL cause of vertigo. You want to see CORRECTIVE saccades or an ABNORMAL response here.
  • Direction Changing Nystagmus: a horizontal nystagmus is reassuring. If you see their eyes rotating in eccentric directions (vertically or torsionally) and changing direction, start thinking that this may be secondary to a central pathology.
  • Test of Skew: you are alternating between covering each eye – ensure there is no ocular misalignment (ensure there is no vertical strabismus or skew deviation). Practical advice: Small refixations are normal.
  • Here is a helpful link for you to see how these maneuvers are performed: http://sjrhem.ca/resident-clinical-pearl-hints-exam-in-acute-vestibular-syndrome/

4. What is the difference in clinical presentation between vestibular neuritis and labyrinthitis? (1 point)

• • No hearing loss is associated with vestibular neuritis which is contrary to labyrinthitis where we see hearing loss

5. What is Meniere’s disease? (1 point)

• • Theorized to be a disorder of the endolymphatic hydrops of the labyrinthine system characterized by periods of vertigo (lasting 15 minutes to 24 hours), tinnitus, and hearing loss.

6. How do you differentiate between Meniere’s disease, vestibular neuritis, benign paroxysmal positional vertigo, and labyrinthitis? (2 points)

• • Labyrinthitis – single episode of constant vertigo + hearing loss
  • Meniere’s disease – episodic vertigo + hearing loss
  • Vestibular neuritis – single episode of constant vertigo + no hearing loss
  • Benign paroxysmal positional vertigo – episodic vertigo + no hearing loss