Nursemaid’s Elbow

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

SAMP

Amara is an 18-month-old girl brought to clinic by her caregiver after a sudden injury to her right arm earlier today. The nanny reports that Amara began running toward the road, prompting her to grab Amara’s hand and pull her back quickly. Immediately afterward, the child cried and refused to move her right arm. On exam, she holds the arm close to her body with the forearm pronated and elbow slightly flexed. There is no swelling, deformity, or bruising visible. However, she cries and pulls away when attempts are made to supinate the forearm. Her caregiver is anxious and worried that the arm might be broken. (7 points)

1. What structure is commonly affected in nursemaid’s elbow? (1 point)

   Answer: Annular ligament subluxation

2. Describe the typical arm position seen on exam. (1 point)

   Answer: Arm pronated, slightly flexed, held close to body

3. Is imaging required in this classic presentation? (1 point)

   Answer: No, imaging unnecessary if classic features present

4. Name one acceptable reduction maneuver. (1 point)

   Answer: Hyperpronation or supination-flexion maneuvers

5. How quickly should symptoms resolve after reduction? (1 point)

   Answer: Within minutes

6. Provide one prevention strategy to discuss with caregivers. (1 point)

   Answer: Avoid pulling or swinging child by the hands/forearms

7. When should referral be considered? (1 point)

   Answer: Failed reduction attempts or atypical findings (e.g., swelling, deformity, NV concerns)

Concussion

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

SAMP

Emma is a 14-year-old competitive hockey player who was involved in a collision on the ice yesterday. Her helmeted head struck the boards, and although she did not lose consciousness, she immediately felt “dazed” and required help skating off the rink. Today, she complains of a persistent headache, sensitivity to bright lights, and difficulty concentrating during school lessons. She denies vomiting or neck pain. Her neurological examination is normal, and she appears alert and oriented, but her hockey coach is eager for clearance as the provincial championship takes place this weekend. Emma expresses concern about missing the tournament but admits she doesn’t feel like herself. (8 points)

1. Provide a brief definition of concussion. (1 point)

   Answer: A functional brain injury without structural abnormalities

2. List two red-flag symptoms requiring ED-level assessment. (2 points)

   Answer: Worsening headache, repeated vomiting, seizures, focal neuro deficits, declining consciousness (any two)

3. Name one recommended assessment tool for concussion. (1 point)

   Answer: SCAT5 or Child SCAT5

4. Should she undergo a CT scan? Explain briefly. (1 point)

   Answer: No – avoid routine CT; use PECARN criteria to identify need

5. List two appropriate return-to-learn accommodations. (2 points)

   Answer: Reduced workload, shortened day, frequent rest breaks, screen reduction (any two)

6. State one requirement for return-to-play clearance. (1 point)

   Answer: Asymptomatic both at rest and with exertion

Pediatric Asthma Exacerbation

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

SAMP

Lucas is a 9-year-old boy who presents to the clinic in early October with a three-day history of worsening coughing, chest tightness, and wheezing. His symptoms have become more troublesome at night, waking him several times due to shortness of breath and coughing fits. Yesterday, he left his soccer game early because he “couldn’t breathe properly” during running. He has been using his blue inhaler frequently, approximately 4-5 times per day, but is currently without his spacer, which he usually leaves at school. He has no fever, but does have known seasonal allergies. On exam, Lucas is sitting in a slightly forward position, taking visible extra effort to breathe. He speaks in short phrases rather than full sentences and has widespread expiratory wheezing on auscultation. (10 points)

1. List two signs of severe asthma. (2 points)

   Answer: Accessory muscle use, O2 sat <92%, difficulty speaking full sentences, marked wheeze (any two)

2. What initial medication should be administered in the clinic? (1 point)

   Answer: Short–acting beta–agonist (e.g., salbutamol)

3. Provide the dose and route of this medication. (1 point)

   Answer: 2–4 puffs via spacer OR 2.5 mg by nebulizer

4. State one indication for systemic steroids in this case. (1 point)

   Answer: Moderate–severe symptoms or multiple SABA doses required

5. Prescribe one appropriate oral steroid and dose. (1 point)

   Answer: Prednisone 1–2 mg/kg/day (max 40–50 mg) for 3–5 days

6. Identify one test to assess severity in the clinic. (1 point)

   Answer: Peak flow measurement or spirometry, where possible

7. List two components of asthma education. (2 points)

   Answer: Trigger avoidance, inhaler/spacer technique review, provide action plan (any two)

8. When should follow–up occur? (1 point)

   Answer: Follow–up in 2–3 days or sooner if worsening

Chest Pain on the Stairs

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

SAMP

A 54-year-old man presents with intermittent chest pain for 3 months, lasting 10 minutes, precipitated by climbing stairs, relieved by rest. Risk factors: diabetes, hypertension, dyslipidemia. Resting ECG: normal. (8 points)

1. Most likely diagnosis? (1 point)
   1. Stable angina
   2. Unstable angina
   3. Atypical GERD
   4. Costochondritis
   5. Panic attacks

   Answer: A

2. Best initial investigation? (1 point)
   1. Troponin (urgent)
   2. Exercise stress test
   3. Coronary CT angiography
   4. Holter monitoring
   5. D-dimer

   Answer: B

3. Which medication should be initiated for long-term risk reduction? (1 point)
   1. Aspirin
   2. Nitroglycerin patch
   3. Ibuprofen
   4. Digoxin
   5. Clopidogrel (monotherapy)

   Answer: A

4. Which finding reclassifies his chest pain as unstable angina? (1 point)
   1. Pain relieved by rest
   2. Pain only with heavy exertion
   3. Increasing frequency over 3 months
   4. Pain associated with diaphoresis
   5. Pain reproducible on palpation

   Answer: C

5. Evidence-based treatment for stable angina includes. Select all that apply. (4 points)
   1. Beta-blocker
   2. Long-acting nitrate (if symptoms persist)
   3. Calcium-channel blocker
   4. High-intensity statin
   5. Oral corticosteroids

   Answer: A, B, C, D

Falls, Pills, and Perils

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

SAMP

An 83-year-old woman presents with recurrent falls. Medications: lorazepam 1 mg HS, metoprolol, amlodipine, sertraline, omeprazole, and OTC diphenhydramine for sleep. (8 points)

1. Most significant contributor to fall risk? (1 point)
   1. Amlodipine
   2. Sertraline
   3. Metoprolol
   4. Lorazepam
   5. Omeprazole

   Answer: D

2. Which OTC medication should be stopped first? (1 point)
   1. Multivitamin
   2. Diphenhydramine
   3. Calcium
   4. Vitamin D
   5. Magnesium

   Answer: B

3. Best next step to reduce fall risk? (1 point)
   1. Increase omeprazole dose
   2. Switch lorazepam to long-acting benzo
   3. Gradually taper off lorazepam
   4. Add melatonin 10 mg
   5. Stop metoprolol

   Answer: C

4. Which adverse effect is most associated with diphenhydramine in geriatric patients? (1 point)
   1. Hypertensive crisis
   2. Bradycardia
   3. Anticholinergic toxicity
   4. Hepatotoxicity
   5. Renal impairment

   Answer: C

5. Which interventions reduce fall risk? Select all that apply. (4 points)
   1. Home hazard assessment
   2. Strength and balance training
   3. Vitamin D optimization
   4. Routine CT head screening
   5. Polypharmacy reduction

   Answer: A, B, C, E

Headaches That Hide

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

SAMP

A 27-year-old woman presents with headaches occurring 10 days per month. Unilateral throbbing with photophobia, worsened by movement. No neurological deficits. (8 points)

1. Most likely diagnosis? (1 point)
   1. Cluster headache
   2. Migraine without aura
   3. Tension-type headache
   4. Medication-overuse headache
   5. Temporal arteritis

   Answer: B

2. Best first-line acute treatment? (1 point)
   1. Opioids
   2. Triptans
   3. Amitriptyline
   4. Verapamil
   5. Acetazolamide

   Answer: B

3. Which is an indication for migraine prophylaxis? (1 point)
   1. 1 headache/month requiring bed rest
   2. 2 headaches/month relieved by NSAIDs
   3. ≥4 disabling headaches/month
   4. Patient request
   5. Headache triggered by chocolate

   Answer: C

4. Effective prophylactic options include: Select all that apply. (4 points)
   1. Propranolol
   2. Topiramate
   3. CGRP monoclonal antibodies
   4. Oxycodone
   5. Onabotulinum toxin A (if chronic)

   Answer: A, B, C, E

5. Which red-flag feature warrants urgent imaging? (1 point)
   1. Mild nausea
   2. Photophobia
   3. Thunderclap onset
   4. Family history of migraine
   5. Menstruation-related attacks

   Answer: C

The Thyroid Puzzle

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

SAMP

A 55-year-old woman presents with fatigue, weight gain, and constipation. TSH is 12 mIU/L, free T4 low-normal. (8 points)

1. Most likely diagnosis? (1 point)
   1. Subclinical hypothyroidism
   2. Overt hypothyroidism
   3. Hyperthyroidism
   4. Euthyroid sick syndrome
   5. Thyroid nodule

   Answer: B

2. Best initial management? (1 point)
   1. Observation only
   2. Start levothyroxine
   3. Methimazole
   4. Radioactive iodine
   5. High-dose iodine supplementation

   Answer: B

3. Which factor increases levothyroxine requirements? (1 point)
   1. Pregnancy
   2. Sedentary lifestyle
   3. Vitamin D supplementation
   4. Aging
   5. High-fibre diet

   Answer: A

4. Which medications interfere with levothyroxine absorption? Select all that apply. (4 points)
   1. Calcium
   2. Iron
   3. Bisphosphonates
   4. Proton pump inhibitors
   5. Metformin

   Answer: A, B, C, D

5. Target TSH after treatment? (1 point)
   1. <0.1 mIU/L
   2. Within normal range for age
   3. >10 mIU/L
   4. Suppressed below normal
   5. No need to monitor

   Answer: B

Your study plan, simplified 📅

The CCFP exam is quickly approaching, and the FMEP Course is here to help! We know you are juggling many responsibilities, so we made a study calendar to help keep you on track.

Click here to see the calendar.

The Case of the Persistent Cough

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

SAMP

A 48-year-old non-smoking woman presents with an 8-month history of chronic cough. She notes it started at the same time she was diagnosed with hypertension and started on medication. There has been no fever, weight loss, or hemoptysis. She reports occasional heartburn and seasonal allergies. Medications: ramipril, cetirizine PRN. Chest X-ray is normal. (7 points)

1. Most likely diagnosis? (1 point)
   1. ACE-inhibitor-related cough
   2. Non-asthmatic eosinophilic bronchitis
   3. Cough-variant asthma
   4. Gastroesophageal reflux disease (GERD)
   5. Upper-airway cough syndrome (UACS)

   Answer: A

2. Next best step in management? (1 point)
   1. Methacholine challenge test
   2. Switch ramipril to an ARB
   3. Start high-dose ICS
   4. Start PPI trial
   5. Order sinus CT

   Answer: B

3. Which feature least supports cough-variant asthma? (1 point)
   1. Normal spirometry
   2. Response to bronchodilators
   3. Positive methacholine challenge
   4. Eosinophilia in sputum
   5. No history of wheeze

   Answer: A

4. Which is true regarding chronic cough work-up? Select all that apply. (3 points)
   1. ACE inhibitors can cause cough months after initiation
   2. GERD-related cough requires daily heartburn to be likely
   3. Normal chest X-ray rules out chronic sinusitis
   4. UACS can present without rhinorrhea
   5. Trial therapies are acceptable diagnostic tools

   Answer: A, D, E

5. Which medication is least likely to help ACE-I cough? (1 point)
   1. ARB substitution
   2. Inhaled corticosteroid
   3. Cough suppressants
   4. Switching to another ACE-I
   5. Discontinuing ACE-I

   Answer: D

Under Pressure: Recognizing and Managing Eustachian Tube Dysfunction in Primary Care

We are excited to see so many of you join our 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:

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