Henry is a 57 year old man whom you have seen four times in the past ten years because of back pain episodes initially diagnosed as lumbar strain. With each episode, there has been a period of work disability ranging from two to six months. Henry now attends at your office again complaining of longstanding generalized back pain and stiffness. He has pain across the lumbar area, radiating down the lateral aspect of the left thigh, calf and foot and to a lesser extent, the lateral aspect of the right leg. He also has some pain in the shoulder blades, neck, and headaches. He complains of constipation, can't sleep, and spends most of his day lying down, because all activity aggravates his pain.

Novak B. is now 68 years old. He comes to the office today complaining of shortness of breath and fatigue on exertion. While Novak B. denies chest pain, over the last 3-4 weeks he has been getting more short of breath. He first noticed this when he was playing golf with his friends a few weeks ago. He wasn't able to finish his 18-hole game, despite using a cart. He walks his dog about 1 km every evening and usually stops every 250 m due to leg cramps. Lately, however, he has needed to stop every 100 m due to leg cramps as well as at the half-way mark due to fatigue. For the last week, he has been increasingly sleeping in his recliner rather than his bed due to difficulty breathing; however, he denies waking up gasping for air when you ask. He is still struggling with a burning sensation in his feet and legs and wakes up at night to “shake it off”. His once thin legs are becoming increasingly swollen as the day progresses. He denies any cough, fever or night sweats. He feels his heart is running faster at times, especially when physically active. You know that his spouse passed away last year after a long battle with cancer. He has 2 children who live out West. When questioned about alcohol intake, he admits that he has been drinking more alcohol since his spouse passed away.

Susanna Green is a 59-year-old member of the Six Nations of the Grand River. She has a strong family history of type 2 diabetes mellitus. Until two years ago, Susanna had been closely followed since she was diagnosed with diabetes mellitus 28 years ago. Unfortunately, Susanna has not been seen for two years while she was living in the United States. She has self-reported "good" control of her sugars, though she admits that she uses her glucometer only infrequently. Several years ago, she had laser therapy for diabetic retinopathy, but her vision is now stable. She has mild orthostatic hypotension and numbness of her toes. She also has a history of coronary artery bypass grafting following a myocardial infarction six years ago. She has no symptoms to suggest cardiac ischemia, and her exercise tolerance is not restricted. Her medications include metformin, sitagliptin and gliclazide for blood sugar control. Her hypertension, diagnosed about 5 years ago, is currently treated with amlodipine and ramipril. She is taking rosuvastatin to control her cholesterol. Examination reveals a well-looking woman with blood pressure of 155/93 mmHg, BMI of 32.5, increased waist to hip circumference ratio, normal chest and cardiac examination, trace edema to her ankles, normal cardiorespiratory examination. No acute changes are present on fundoscopy, though there the telltale findings of a history of laser photocoagulation are present.

Susanna is an Indigenous woman who lives in the Six Nations of the Grand River Reserve. She is well-known to you. She first met you in the outpatient setting during your day in family medicine rotation two years ago at the beginning of medical school. At that time, Susanna had several issues with the management of diabetes, including regular blood glucose monitoring and appropriate medical management. Susanna has a complex medical history including type 2 diabetes, hypertension, obstructive sleep apnea, and a previous myocardial infarction and subsequent triple coronary bypass graft. After a lengthy stay in ICU six months ago due to pneumonia and septic shock, she developed end stage renal disease and is currently receiving in centre hemodialysis through a tunneled internal jugular catheter twice weekly. You are currently on your clerkship selective on nephrology with Susanna assigned to your team. Susanna has been admitted for a worsening chronic wound on her right heel. Susanna states she was attending the Grand River dialysis outpatient clinic on the Six Nations reserve 2 days ago, when one of the nurses there noticed increasing drainage from her right heel wound. Susanna’s vital signs there revealed she was febrile at 38.1 degrees and tachycardiac at 110 beats per minute with blood pressure 90/50 mmHg, respiratory rate 17 breaths per minute, and oxygen 100% on room air. Bloodwork was then taken, and a septic workup was also ordered.

Henry is a 57 year old man whom you have seen four times in the past ten years because of back pain episodes initially diagnosed as lumbar strain. With each episode, there has been a period of work disability ranging from two to six months. Henry now attends at your office again complaining of longstanding generalized back pain and stiffness. He has pain across the lumbar area, radiating down the lateral aspect of the left thigh, calf and foot and to a lesser extent, the lateral aspect of the right leg. He also has some pain in the shoulder blades, neck, and headaches. He complains of constipation, can't sleep, and spends most of his day lying down, because all activity aggravates his pain.

Melissa is a 35-year-old mother of three who works in marketing. She is being seen in consultation by the Internal Medicine service while admitted to Thoracic Surgery for an empyema. Three months prior she began to have cough with intermittent fevers and chills. She has been treated as an outpatient by her family doctor with Amoxicillin, Azithromycin and Levofloxacin over this time. Her symptoms would initially improve but would return within days of completing her antibiotic course. Her condition continued to worsen until this admission. On review of her past history, she has chronic facial pain and pressure with frequent purulent discharge, and typically has 2-3 sinus infections per year requiring antibiotics. She has never had pneumonia before this year. She has never received pneumococcal vaccination. She received her childhood immunization series and had her last tetanus and diphtheria booster 4 years ago. She has been re-vaccinated for measles, mumps, rubella twice, after prenatal evaluation deemed her non-immune. Prior to onset of these symptoms, her only medication was the oral contraceptive pill. In addition to leaving recommendations to manage her empyema, you wonder about her history of recurrent sinusitis and recent pneumonias. As such, you order some screening bloodwork.

Novak B. is now 68 years old. He comes to the office today complaining of shortness of breath and fatigue on exertion. While Novak B. denies chest pain, over the last 3-4 weeks he has been getting more short of breath. He first noticed this when he was playing golf with his friends a few weeks ago. He wasn't able to finish his 18-hole game, despite using a cart. He walks his dog about 1 km every evening and usually stops every 250 m due to leg cramps. Lately, however, he has needed to stop every 100 m due to leg cramps as well as at the half-way mark due to fatigue. For the last week, he has been increasingly sleeping in his recliner rather than his bed due to difficulty breathing; however, he denies waking up gasping for air when you ask. He is still struggling with a burning sensation in his feet and legs and wakes up at night to “shake it off”. His once thin legs are becoming increasingly swollen as the day progresses. He denies any cough, fever or night sweats. He feels his heart is running faster at times, especially when physically active. You know that his spouse passed away last year after a long battle with cancer. He has 2 children who live out West. When questioned about alcohol intake, he admits that he has been drinking more alcohol since his spouse passed away.

Susanna Green is a 59-year-old member of the Six Nations of the Grand River. She has a strong family history of type 2 diabetes mellitus. Until two years ago, Susanna had been closely followed since she was diagnosed with diabetes mellitus 28 years ago. Unfortunately, Susanna has not been seen for two years while she was living in the United States. She has self-reported "good" control of her sugars, though she admits that she uses her glucometer only infrequently. Several years ago, she had laser therapy for diabetic retinopathy, but her vision is now stable. She has mild orthostatic hypotension and numbness of her toes. She also has a history of coronary artery bypass grafting following a myocardial infarction six years ago. She has no symptoms to suggest cardiac ischemia, and her exercise tolerance is not restricted. Her medications include metformin, sitagliptin and gliclazide for blood sugar control. Her hypertension, diagnosed about 5 years ago, is currently treated with amlodipine and ramipril. She is taking rosuvastatin to control her cholesterol. Examination reveals a well-looking woman with blood pressure of 155/93 mmHg, BMI of 32.5, increased waist to hip circumference ratio, normal chest and cardiac examination, trace edema to her ankles, normal cardiorespiratory examination. No acute changes are present on fundoscopy, though there the telltale findings of a history of laser photocoagulation are present.

Susanna is an Indigenous woman who lives in the Six Nations of the Grand River Reserve. She is well-known to you. She first met you in the outpatient setting during your day in family medicine rotation two years ago at the beginning of medical school. At that time, Susanna had several issues with the management of diabetes, including regular blood glucose monitoring and appropriate medical management. Susanna has a complex medical history including type 2 diabetes, hypertension, obstructive sleep apnea, and a previous myocardial infarction and subsequent triple coronary bypass graft. After a lengthy stay in ICU six months ago due to pneumonia and septic shock, she developed end stage renal disease and is currently receiving in centre hemodialysis through a tunneled internal jugular catheter twice weekly. You are currently on your clerkship selective on nephrology with Susanna assigned to your team. Susanna has been admitted for a worsening chronic wound on her right heel. Susanna states she was attending the Grand River dialysis outpatient clinic on the Six Nations reserve 2 days ago, when one of the nurses there noticed increasing drainage from her right heel wound. Susanna’s vital signs there revealed she was febrile at 38.1 degrees and tachycardiac at 110 beats per minute with blood pressure 90/50 mmHg, respiratory rate 17 breaths per minute, and oxygen 100% on room air. Bloodwork was then taken, and a septic workup was also ordered.

This session focuses on the complex psychosocial issues that underlie addictions and is designed to complement your knowledge of the neurophysiological mechanisms of addiction. This session builds on your understanding of trauma as there is a strong connection between trauma and addiction. It also builds on your understanding of the relationship between gender and health outcomes as gender is an important variable in addiction.

Mr. Johnson is a previously fit, retired 70-year old Afro-Canadian gentleman. His son and daughter-in-law live several hundred miles away in another city and maintain contact with him by telephone. They return home on a Friday evening to surprise him for his birthday and find his apartment in disarray and Mr. Johnson in bed, in too much pain to move. He seems unable to stand independently, though it is hard to tell if this is a result of his overall weakness, or the pain. They call an ambulance and he is taken to the Emergency Department of the local community hospital.

Ali is an 8-year-old boy who is a patient in the pediatric clinic. Ali’s parents have brought him to the clinic today because they are concerned about his ongoing vomiting. You briefly review Ali’s medical record to familiarize yourself with his medical issues: Past Medical History: Cerebral palsy, spastic quadriplegic GMFCS Level V; Severe intellectual disability; Microcephaly; Scoliosis; Visual impairment; Epilepsy; Gastroesophageal reflux disease.

Henry is a 57 year old man whom you have seen four times in the past ten years because of back pain episodes initially diagnosed as lumbar strain. With each episode, there has been a period of work disability ranging from two to six months. Henry now attends at your office again complaining of longstanding generalized back pain and stiffness. He has pain across the lumbar area, radiating down the lateral aspect of the left thigh, calf and foot and to a lesser extent, the lateral aspect of the right leg. He also has some pain in the shoulder blades, neck, and headaches. He complains of constipation, can't sleep, and spends most of his day lying down, because all activity aggravates his pain.

Novak B. is now 68 years old. He comes to the office today complaining of shortness of breath and fatigue on exertion. While Novak B. denies chest pain, over the last 3-4 weeks he has been getting more short of breath. He first noticed this when he was playing golf with his friends a few weeks ago. He wasn't able to finish his 18-hole game, despite using a cart. He walks his dog about 1 km every evening and usually stops every 250 m due to leg cramps. Lately, however, he has needed to stop every 100 m due to leg cramps as well as at the half-way mark due to fatigue. For the last week, he has been increasingly sleeping in his recliner rather than his bed due to difficulty breathing; however, he denies waking up gasping for air when you ask. He is still struggling with a burning sensation in his feet and legs and wakes up at night to “shake it off”. His once thin legs are becoming increasingly swollen as the day progresses. He denies any cough, fever or night sweats. He feels his heart is running faster at times, especially when physically active. You know that his spouse passed away last year after a long battle with cancer. He has 2 children who live out West. When questioned about alcohol intake, he admits that he has been drinking more alcohol since his spouse passed away.

As you head off to lunch after wrapping up your morning clinic, you peruse your afternoon schedule and note that the first patient is someone you have not seen in three years. You therefore grab his chart to review his history. P.J. Peters is a 34-year-old male who immigrated from Uganda 10 years ago. Four years ago, he presented with a dry cough and mild shortness of breath. Given that you had noted a few crackles in his lower lungs bilaterally, you had prescribed him antibiotics for pneumonia. In spite, of therapy his symptoms progressed over a 2-3 week period and he landed in the emergency. A chest x-ray at the time revealed a bilateral interstitial infiltrate. Due to progressive hypoxia he underwent a bronchoalveolar lavage which revealed he had pneumocystis jiroveci pneumonia (PJP or PCP). This raised the suspicion of underlying HIV and his serology was sent off and came back positive. On further questioning, he admitted to a 2 year period in his life in his early 20s where he had unprotected sex with multiple partners.

When you see Mr. Peters next, you learn that he had continued to take his HAART faithfully an additional 6 months after he last saw you. He had been feeling physically well and figured his virus was under control (as he recalled it had last been "non-detectable") and so began questioning the need to continue his medications. He was concerned about long-term side effects of therapy and figured he could diminish his risk by reducing his exposure to HAART. Moreover he had started a new job around that time and did not want anyone to inadvertently find out about his diagnosis of HIV. He therefore elected to stop taking his anti-retrovirals. Mr. Peters was reluctant to tell his physicians about his decision and so he had not come back for his follow ups. He returns today complaining of a new painful rash on his chest that appeared 2 days prior. Additionally he notes a 3-month history of increasing fatigue as well as intermittent fevers, night sweats and a 20 lb weight loss. On examination his temperature is 37.2º C, blood pressure 135/80, pulse 79. There are 2 cm nodes palpable in the cervical and axillary areas bilaterally. His throat is clear. When you examine his chest you notice a vesicular rash over the right side of his chest extending from the midline towards his right axilla at the level of his nipple. Examination of his respiratory and cardiovascular system are unremarkable. His abdomen is soft with no palpable masses or organomegaly. Examination of his extremities is unremarkable.

Mr. Lacologne is a 41 year old man who had a stage II colon cancer resected 3 years prior. He had his annual CT scan, and there was a 3 cm hypoechoic lesion in segment 6. His surgeon referred him to a liver Surgeon and Medical Oncologist. The surgeon explained that this is likely recurrent disease from his colon cancer, and recommended chemotherapy neo-adjuvantly and after surgery. He was started on FOLFOX chemotherapy for 6 cycles, subsequent CT and MRI of his liver showed a partial response to chemotherapy. He underwent a left hepatic lobectomy, and following recovery completed an additional 6 cycles of FOLFOX. Two years later subsequent lung lesions are identified in multiple lobes bilaterally. He returns to the Medical Oncologist, and is recommended to start chemotherapy (FOLFIRI/bevacizumab). He asks why surgery is not an option now, and said he heard on the internet that that this bevacizumab drug can cure cancer.

Susanna Green is a 59-year-old member of the Six Nations of the Grand River. She has a strong family history of type 2 diabetes mellitus. Until two years ago, Susanna had been closely followed since she was diagnosed with diabetes mellitus 28 years ago. Unfortunately, Susanna has not been seen for two years while she was living in the United States. She has self-reported "good" control of her sugars, though she admits that she uses her glucometer only infrequently. Several years ago, she had laser therapy for diabetic retinopathy, but her vision is now stable. She has mild orthostatic hypotension and numbness of her toes. She also has a history of coronary artery bypass grafting following a myocardial infarction six years ago. She has no symptoms to suggest cardiac ischemia, and her exercise tolerance is not restricted. Her medications include metformin, sitagliptin and gliclazide for blood sugar control. Her hypertension, diagnosed about 5 years ago, is currently treated with amlodipine and ramipril. She is taking rosuvastatin to control her cholesterol. Examination reveals a well-looking woman with blood pressure of 155/93 mmHg, BMI of 32.5, increased waist to hip circumference ratio, normal chest and cardiac examination, trace edema to her ankles, normal cardiorespiratory examination. No acute changes are present on fundoscopy, though there the telltale findings of a history of laser photocoagulation are present.

Susanna is an Indigenous woman who lives in the Six Nations of the Grand River Reserve. She is well-known to you. She first met you in the outpatient setting during your day in family medicine rotation two years ago at the beginning of medical school. At that time, Susanna had several issues with the management of diabetes, including regular blood glucose monitoring and appropriate medical management. Susanna has a complex medical history including type 2 diabetes, hypertension, obstructive sleep apnea, and a previous myocardial infarction and subsequent triple coronary bypass graft. After a lengthy stay in ICU six months ago due to pneumonia and septic shock, she developed end stage renal disease and is currently receiving in centre hemodialysis through a tunneled internal jugular catheter twice weekly. You are currently on your clerkship selective on nephrology with Susanna assigned to your team. Susanna has been admitted for a worsening chronic wound on her right heel. Susanna states she was attending the Grand River dialysis outpatient clinic on the Six Nations reserve 2 days ago, when one of the nurses there noticed increasing drainage from her right heel wound. Susanna’s vital signs there revealed she was febrile at 38.1 degrees and tachycardiac at 110 beats per minute with blood pressure 90/50 mmHg, respiratory rate 17 breaths per minute, and oxygen 100% on room air. Bloodwork was then taken, and a septic workup was also ordered.

This session focuses on the complex psychosocial issues that underlie addictions and is designed to complement your knowledge of the neurophysiological mechanisms of addiction. This session builds on your understanding of trauma as there is a strong connection between trauma and addiction. It also builds on your understanding of the relationship between gender and health outcomes as gender is an important variable in addiction.

Mr. Johnson is a previously fit, retired 70-year old Afro-Canadian gentleman. His son and daughter-in-law live several hundred miles away in another city and maintain contact with him by telephone. They return home on a Friday evening to surprise him for his birthday and find his apartment in disarray and Mr. Johnson in bed, in too much pain to move. He seems unable to stand independently, though it is hard to tell if this is a result of his overall weakness, or the pain. They call an ambulance and he is taken to the Emergency Department of the local community hospital.

Ali is an 8-year-old boy who is a patient in the pediatric clinic. Ali’s parents have brought him to the clinic today because they are concerned about his ongoing vomiting. You briefly review Ali’s medical record to familiarize yourself with his medical issues: Past Medical History: Cerebral palsy, spastic quadriplegic GMFCS Level V; Severe intellectual disability; Microcephaly; Scoliosis; Visual impairment; Epilepsy; Gastroesophageal reflux disease.

Henry is a 57 year old man whom you have seen four times in the past ten years because of back pain episodes initially diagnosed as lumbar strain. With each episode, there has been a period of work disability ranging from two to six months. Henry now attends at your office again complaining of longstanding generalized back pain and stiffness. He has pain across the lumbar area, radiating down the lateral aspect of the left thigh, calf and foot and to a lesser extent, the lateral aspect of the right leg. He also has some pain in the shoulder blades, neck, and headaches. He complains of constipation, can't sleep, and spends most of his day lying down, because all activity aggravates his pain.

Novak B. is now 68 years old. He comes to the office today complaining of shortness of breath and fatigue on exertion. While Novak B. denies chest pain, over the last 3-4 weeks he has been getting more short of breath. He first noticed this when he was playing golf with his friends a few weeks ago. He wasn't able to finish his 18-hole game, despite using a cart. He walks his dog about 1 km every evening and usually stops every 250 m due to leg cramps. Lately, however, he has needed to stop every 100 m due to leg cramps as well as at the half-way mark due to fatigue. For the last week, he has been increasingly sleeping in his recliner rather than his bed due to difficulty breathing; however, he denies waking up gasping for air when you ask. He is still struggling with a burning sensation in his feet and legs and wakes up at night to “shake it off”. His once thin legs are becoming increasingly swollen as the day progresses. He denies any cough, fever or night sweats. He feels his heart is running faster at times, especially when physically active. You know that his spouse passed away last year after a long battle with cancer. He has 2 children who live out West. When questioned about alcohol intake, he admits that he has been drinking more alcohol since his spouse passed away.

As you head off to lunch after wrapping up your morning clinic, you peruse your afternoon schedule and note that the first patient is someone you have not seen in three years. You therefore grab his chart to review his history. P.J. Peters is a 34-year-old male who immigrated from Uganda 10 years ago. Four years ago, he presented with a dry cough and mild shortness of breath. Given that you had noted a few crackles in his lower lungs bilaterally, you had prescribed him antibiotics for pneumonia. In spite, of therapy his symptoms progressed over a 2-3 week period and he landed in the emergency. A chest x-ray at the time revealed a bilateral interstitial infiltrate. Due to progressive hypoxia he underwent a bronchoalveolar lavage which revealed he had pneumocystis jiroveci pneumonia (PJP or PCP). This raised the suspicion of underlying HIV and his serology was sent off and came back positive. On further questioning, he admitted to a 2 year period in his life in his early 20s where he had unprotected sex with multiple partners.

When you see Mr. Peters next, you learn that he had continued to take his HAART faithfully an additional 6 months after he last saw you. He had been feeling physically well and figured his virus was under control (as he recalled it had last been "non-detectable") and so began questioning the need to continue his medications. He was concerned about long-term side effects of therapy and figured he could diminish his risk by reducing his exposure to HAART. Moreover he had started a new job around that time and did not want anyone to inadvertently find out about his diagnosis of HIV. He therefore elected to stop taking his anti-retrovirals. Mr. Peters was reluctant to tell his physicians about his decision and so he had not come back for his follow ups. He returns today complaining of a new painful rash on his chest that appeared 2 days prior. Additionally he notes a 3-month history of increasing fatigue as well as intermittent fevers, night sweats and a 20 lb weight loss. On examination his temperature is 37.2º C, blood pressure 135/80, pulse 79. There are 2 cm nodes palpable in the cervical and axillary areas bilaterally. His throat is clear. When you examine his chest you notice a vesicular rash over the right side of his chest extending from the midline towards his right axilla at the level of his nipple. Examination of his respiratory and cardiovascular system are unremarkable. His abdomen is soft with no palpable masses or organomegaly. Examination of his extremities is unremarkable.

Mr. Lacologne is a 41 year old man who had a stage II colon cancer resected 3 years prior. He had his annual CT scan, and there was a 3 cm hypoechoic lesion in segment 6. His surgeon referred him to a liver Surgeon and Medical Oncologist. The surgeon explained that this is likely recurrent disease from his colon cancer, and recommended chemotherapy neo-adjuvantly and after surgery. He was started on FOLFOX chemotherapy for 6 cycles, subsequent CT and MRI of his liver showed a partial response to chemotherapy. He underwent a left hepatic lobectomy, and following recovery completed an additional 6 cycles of FOLFOX. Two years later subsequent lung lesions are identified in multiple lobes bilaterally. He returns to the Medical Oncologist, and is recommended to start chemotherapy (FOLFIRI/bevacizumab). He asks why surgery is not an option now, and said he heard on the internet that that this bevacizumab drug can cure cancer.

Susanna Green is a 59-year-old member of the Six Nations of the Grand River. She has a strong family history of type 2 diabetes mellitus. Until two years ago, Susanna had been closely followed since she was diagnosed with diabetes mellitus 28 years ago. Unfortunately, Susanna has not been seen for two years while she was living in the United States. She has self-reported "good" control of her sugars, though she admits that she uses her glucometer only infrequently. Several years ago, she had laser therapy for diabetic retinopathy, but her vision is now stable. She has mild orthostatic hypotension and numbness of her toes. She also has a history of coronary artery bypass grafting following a myocardial infarction six years ago. She has no symptoms to suggest cardiac ischemia, and her exercise tolerance is not restricted. Her medications include metformin, sitagliptin and gliclazide for blood sugar control. Her hypertension, diagnosed about 5 years ago, is currently treated with amlodipine and ramipril. She is taking rosuvastatin to control her cholesterol. Examination reveals a well-looking woman with blood pressure of 155/93 mmHg, BMI of 32.5, increased waist to hip circumference ratio, normal chest and cardiac examination, trace edema to her ankles, normal cardiorespiratory examination. No acute changes are present on fundoscopy, though there the telltale findings of a history of laser photocoagulation are present.

Susanna is an Indigenous woman who lives in the Six Nations of the Grand River Reserve. She is well-known to you. She first met you in the outpatient setting during your day in family medicine rotation two years ago at the beginning of medical school. At that time, Susanna had several issues with the management of diabetes, including regular blood glucose monitoring and appropriate medical management. Susanna has a complex medical history including type 2 diabetes, hypertension, obstructive sleep apnea, and a previous myocardial infarction and subsequent triple coronary bypass graft. After a lengthy stay in ICU six months ago due to pneumonia and septic shock, she developed end stage renal disease and is currently receiving in centre hemodialysis through a tunneled internal jugular catheter twice weekly. You are currently on your clerkship selective on nephrology with Susanna assigned to your team. Susanna has been admitted for a worsening chronic wound on her right heel. Susanna states she was attending the Grand River dialysis outpatient clinic on the Six Nations reserve 2 days ago, when one of the nurses there noticed increasing drainage from her right heel wound. Susanna’s vital signs there revealed she was febrile at 38.1 degrees and tachycardiac at 110 beats per minute with blood pressure 90/50 mmHg, respiratory rate 17 breaths per minute, and oxygen 100% on room air. Bloodwork was then taken, and a septic workup was also ordered.

At the end of this session, students will be able to: Describe their role and responsibility as physicians with respect to potential organ donors; Describe how the Trillium Gift of Life program supports organ donation; Better manage sensitive communications about brain death and organ donation drawing on SPIKES guidelines; Recognize that circumstances, past experiences, and/or values may render discussions of brain death and organ donation difficult for families and health care professionals.

Hannah Rosen is 18-year-old female who presents to the outpatient clinic after a frantic call to the receptionist earlier during the day. Hannah has been coming to the clinic for the past 16 years for treatment and monitoring of her cystic fibrosis. Her parents, who have been supportive, are out of town on an anniversary cruise and Hannah didn’t know who to call. Hannah states she has been having increased sputum production, low grade fever and difficulty catching her breath over the past few days. She took the action plan of ciprofloxacin she has at home. She takes this when her respiratory symptoms worsen. Hannah states she has been compliant with her antibiotics, but her symptoms suddenly got worse overnight. Hannah does not want her parents to know about this and asks that they not be contacted about her hospital visit. On examination, Hannah appears in distress. She is using her intercostal muscles to help her breathe and appears cyanotic and diaphoretic. Her vitals are taken by the clinic nurse while they are waiting for her pediatric respirologist to finish with the previous patient. Hannah’s temperature is 39.1, oxygen saturation is 91 percent, heart rate is 115 and her blood pressure is 100/60. The nurse calls for immediate help and Hannah is taken to the ICU where she is placed on oxygen. Chest x-ray and additional blood work including ABGs are ordered.

To practice a history and physical exam for low back pain including a focus on red flags and yellow flags (re. CORE Back tool). To recognize symptoms and signs of opioid withdrawal using the Clinical Opioid Withdrawal Scale (COWS). To discuss non-pharmacologic approaches for treatment of chronic non-cancer pain. To discuss the watchful dose for opioids in chronic non-cancer pain, and practice an opioid conversion to determine morphine equivalent daily dose (MEDD). To review risk factors for opioid use disorder using the Opioid Risk Tool (ORT). To review core principles of diagnosis and initial management of opioid use disorder in primary care. Pro Comp Connection – Patients with Addictions.

Ali is an 8-year-old boy who is a patient in the pediatric clinic. Ali’s parents have brought him to the clinic today because they are concerned about his ongoing vomiting. You briefly review Ali’s medical record to familiarize yourself with his medical issues: Past Medical History: Cerebral palsy, spastic quadriplegic GMFCS Level V; Severe intellectual disability; Microcephaly; Scoliosis; Visual impairment; Epilepsy; Gastroesophageal reflux disease.

Henry is a 57 year old man whom you have seen four times in the past ten years because of back pain episodes initially diagnosed as lumbar strain. With each episode, there has been a period of work disability ranging from two to six months. Henry now attends at your office again complaining of longstanding generalized back pain and stiffness. He has pain across the lumbar area, radiating down the lateral aspect of the left thigh, calf and foot and to a lesser extent, the lateral aspect of the right leg. He also has some pain in the shoulder blades, neck, and headaches. He complains of constipation, can't sleep, and spends most of his day lying down, because all activity aggravates his pain.

Myles is a 24-year-old male arriving at a tertiary trauma centre from Manitoulin Island after a witnessed jump off a local railway crossing bridge. Myles was initially brought to the local community hospital where ATLS protocol was initiated by the rural ER physician. He was found to be hypotensive 82/45 mmHG, tachycadiac 120 bpm, and hypothermic at 34.5 C. X-rays revealed a pelvic fracture, a pneumothorax requiring a chest tube and bilateral open calcaneal fractures. Myles was then stabilized and transferred to the nearest tertiary centre 2 hours away via helicopter. Myles is well known to the local ER team in his home community of Zhiibaahaasing First Nations on Manitoulin Island for persistent suicidal ideation episodes. Myles comes from a large close-knit family with many of his relatives reunited over the past few years due to their own issues with being victims of the Residential School Act in their early years. Myles has tried to take his own life on several occasions, stating “I cannot take the pain forward from my ancestors anymore, it must die with me”. According to his sister and uncle, Myles began consuming more illicit substances and marijuana after his father took his own life 10 years ago and his mother was unable to take care of Myles and his siblings. His mother moved away, and Myles and his siblings were split up amongst several family members and placed in foster care. Despite leaving high school in grade 10, Myles has had some landscaping jobs and tree planting jobs over the past few years. Myles has been sent on two occasions to rehabilitation centres in Ottawa for substance abuse, but feels his problems are not addressed in these environments due to lack of cultural awareness. Myles enters the ER setting intubated with a chest tube in situ as well as a pelvic binder on. His lower extremities are in soft splints with dressings applied. The transfer team established additional IV access and has administered 2L of crystalloid fluids on route as well as rewarmed patient as he was quite cold when he left the Manitoulin hospital with a temperature of 35.4 degrees. They also report that Myles was given antibiotics and tetanus before leaving

Yaser is a 36-year-old man who is brought to the emergency room by his wife after feeling quite unwell for the past 2 days with shaking chills and fever, along with some upset stomach. He is extremely weak and unable to provide significant details and his wife does not speak English. In reviewing his chart from a previous visit for a sprained ankle you are able to elicit that he’s a refugee from Syria who came to Canada 18 months ago and has two children. He was not previously taking any regular medications and he does not seem to have a significant past medical history other than a splenectomy secondary to a trauma 8 years ago. On assessment at triage he is found to have a temperature of 39.2 Celsius, a blood pressure of 86/60 and a heart rate of 125 bpm. His oxygen saturation is 85% on room air and he is tachypneic with a respiratory rate of 34. He is very drowsy, but rousable, however unable to engage in significant conversation. He appears diaphoretic and his extremities are warm to touch.