Clinical Skills Practice Sessions: Respiratory Exam

Part 1, Medical Foundation 1

These practice sessions are intended to improve standardization of teaching across groups and to provide tutorial groups with opportunities to focus on areas of particular concern to the group.

Anatomy Demonstrations: Orientation and upper airway

Part 1, Medical Foundation 1, Respirology, Week 1

Nasal skull. The Pharynx and larynx.

Anatomy Lectures: Respiratory System Anatomy

Part 1, Medical Foundation 1, Respirology, Week 3

Control of breathing. Chest wall, diaphragm. The airway.

Tutorial: Wael M. MF1 Cardiovascular

Part 1, Medical Foundation 1, Cardiology, Week 1

Wael M. is a 78-year-old man who is brought to the emergency room after collapsing at the casino. The last thing he recalls before losing consciousness is drawing an ace while sitting at the blackjack table. His past medical history is unremarkable and he is on no medications. On arrival to the ER, his heart rate is 30 bpm with a blood pressure of 80/50 mmHg. He is alert and oriented, but feels lightheaded. His JVP is not elevated, but cannon a-waves are occasionally seen. There are no carotid bruits. The remainder of the physical examination, including a neurological examination, is normal. In the ER, a temporary transvenous pacemaker is inserted via the right internal jugular vein and positioned into the right ventricular apex. The pacemaker is turned on and set to pace at 60 bpm. At this rate, Wael M.'s BP increases to 100/70 mmHg and his light-headedness resolves. The next morning, Wael M. has a dual chamber permanent pacemaker inserted. His 12-lead EKG post implant shows paced ventricular beats with a left bundle branch block pattern.

Clinical Skills Sessions: Head and Neck Exam: Practice Case - Hearing Loss

Part 1, Medical Foundation 1, Cardiology, Week 3

Discuss and to practice the Head and Neck history and physical exam, with a focus on the ear and nose exam. Note: The ENT exam includes the Ear, Nose and Throat. We will not focus on the Thyroid exam as it is covered in MF3, nor the Lymph Node exam as it is explored in MF2.

Clinical Skills Sessions: Head and Neck Exam: Practice Case - Sore Throat

Part 1, Medical Foundation 1, Cardiology, Week 4

Objective: To discuss and to practice the Head and Neck history and physical exam, with a focus on the oropharyngeal exam. Pro-Comp Connection: Poverty - the disproportionate burden of Rheumatic Heart Disease on marginalized populations.

Tutorial: Rana Osman MF1 Respirology

Part 1, Medical Foundation 1, Introduction to Medicine, Week 2

Rana Osman is a 2-year-old girl who has been previously well. She has had a barky, seal-like cough for 2 days but tonight has become acutely worse. In the emergency room, she is found to be sitting "bolt upright", with pronounced stridor on inspiration. Her inspiratory phase is prolonged. She has intercostal indrawing and suprasternal indrawing.

Tutorial: Nabil Assad MF1 Respirology

Part 1, Medical Foundation 1, Introduction to Medicine, Week 2

Salim takes Nabil, his 7-year-old son, to see Dr. Lockwood, his family doctor, because both of them have a sore throat. Nabil’s younger brother had a sore throat and runny nose a week ago, but he improved quickly. Salim is concerned about Nabil because he seems to be taking longer to improve. Dr. Lockwood asks more details and learns that both Nabil and Salim are mostly having swallowing difficulties but feel otherwise quite well. Salim has a mild cough, but Nabil does not. There have been no rigors, just slight chills last night.

Tutorial: Ron Chen MF1 Respirology

Part 1, Medical Foundation 1, Introduction to Medicine, Week 3

Ron Chen is a 25 year old computer sciences post-graduate student who had been previously well. Three weeks ago he suffered a viral gastroenteritis from which he has recovered. Over the past week, he has noticed increasing weakness of his limbs, starting with his legs, and progressing to involve his arms. He reports he has experienced patchy areas of sensory loss, symmetrically. He has also noticed occasional clumsy speech and facial weakness.

Anatomy Lectures: Lymphatic System

Part 2, Medical Foundation 2, Hematology, Week 2

The lymphatic system consists of lymphatic tissues (Thymus, Lymph nodes, Spleen) and lymphatic vessels (vessels which assist in returning tissue fluid to the blood). Thymus Gland. Type of cells in a lymph node. Lymph node and lymphatic vessel. Popliteal lymph nodes and vessels. Femoral and external iliac lymph nodes and vessels. Female and male pelvic lymph nodes.

Clinical Skills Sessions: Introduction and Overview of the Lymph Node Examination

Part 2, Medical Foundation 2, Hematology, Week 2

To discuss and to practice the components of the Lymph Node history and physical examination.

Clinical Skills Sessions: Lymph Node Exam: Practice Case – Lymphadenopathy

Part 2, Medical Foundation 2, Hematology, Week 3

To practice the Lymph Node history and physical examination.

Tutorial: Charlotte Bouchard MF2 Hematology

Part 2, Medical Foundation 2, Hematology, Week 4

Charlotte Bouchard is a 31 year old female who has presented to the ER with new onset shortness of breath. She is previously healthy with no history of medical problems and is not on any medications. She tells you her chest pain and shortness of breath started roughly six weeks prior and have gotten worse to the point she can barely take a few steps without having to stop. She’s also lost about 15 lbs in this time and has noted night sweats such that she has had to change her pajamas during the night. On exam, her pulse is 105, BP 115/87, SpO2 97% on R/A, Temp 37.2. She is not visibly distressed. Respiratory exam reveals decreased air entry on the left and you are able to palpate lymph nodes along her bilateral cervical chains and supraclavicular regions. You also appreciate enlarged lymph nodes in her bilateral axillae and inguinal regions. Her spleen is palpable 5 cm below the costal margin. Chest x-ray performed in the ER reveals a left-sided pleural effusion and is suspicious for a mediastinal mass. You order a follow up CT and this confirms a 15.3 cm mediastinal mass as well as diffuse hilar and axillary adenopathy.

Clinical Skills Practice Sessions: Breast and Lymph Node Examination

Part 3, Medical Foundation 3, Reproduction and Pregnancy

These practice sessions are intended to improve standardization of teaching across groups and to provide tutorial groups with opportunities to focus on areas of particular concern to the group.

Active Large Group Session: Autoimmunity

Part 3, Medical Foundation 3, Gastroenterology and Nutrition, Week 2

Clinical Skills Sessions: Thyroid Exam Practice Case - Thyroid disease

Part 3, Medical Foundation 3, Endocrinology, Week 2

Goiter (hypothyroidism and hyperthyroidism). Observations of a student(s) examining a patient with hyper or hypothyroidism. Discussions of examination of the thyroid by the preceptor. Example: the gland itself, lid lag, tremor. Observation of a student(s) examining a patient with thyroid disorder.

Tutorial: Adam Pajek MF3 Endocrinology

Part 3, Medical Foundation 3, Endocrinology, Week 2

A 40-year old man, Adam Pajek, was seen in a walk-in clinic complaining of palpitations, heat intolerance (felt hot when others were comfortable or cold), sweating, anxiety, weight loss, fatigue, and sleeplessness for two months. He reports that his sister has a hypothyroid problem for which she takes Eltroxin pills.

Tutorial: Pia Meta MF3 Endocrinology

Part 3, Medical Foundation 3, Endocrinology, Week 2

Pia Meta is a 21-year-old female university student with paroxysmal attacks of palpitations, dizziness, blurring of vision and headache over the past 6 months. Each attack persists for a few minutes to half an hour. They occur irregularly with essentially no warning. She reports that during one of her attacks, she went to the emergency department and was found to have a blood pressure of 210/140 mmHg. She was told that she was having a panic attack. She was previously well and has no significant family history. Pia occasionally consumes alcohol on weekends only. She denies the use of any medications or recreational drugs, particularly methamphetamines or other sympathomimetics. She has one cup of coffee per day unless she is studying for exams, in which case she drinks 2-3 cups per day at most. She lives with roommates with whom she attends McMaster University. She has been performing well at school and has an active social life. On examination in the clinic, she has no abnormal physical findings.

Clinical Skills Sessions: Adrenal Exam Practice Case - Adrenocortical disorders

Part 3, Medical Foundation 3, Endocrinology, Week 3

Examples: Cushing’s syndrome, Addison’s disease. Observations of a student(s) taking a history from a patient with adrenocortical disorder. Demonstration by preceptor of examination of a patient with adrenal disorder. Example: blood pressure, skin assessment, pigmentation, weight loss/gain, face and neck assessment. Observation of a student(s) examining a patient with adrenal disorder.

Tutorial: Julian Knight MF3 Endocrinology

Part 3, Medical Foundation 3, Endocrinology, Week 3

Mr. Knight is a 65-year-old obese male of African descent who works as a miner in Yellowknife, NWT. He smokes one pack of cigarettes per day. Outside of work he is generally sedentary and tends not to leave his home unless it is really necessary. He has a past medical history of type 2 diabetes mellitus, chronic kidney disease and COPD. His medications include metformin, sitagliptin and the inhalers ipratropium and fluticasone. He recently completed a course of prednisone for a COPD exacerbation, which he has a few times per year. He presented to the local Emergency Department after a fall at work. He tripped over a drill bit and fell on his outstretched hand. He felt a snap, followed by severe pain in the left wrist with noticeable swelling and bruising.

Tutorial: Brenda Farnett MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 1

Brenda Farnett, an 82-year-old right-handed woman, was reviewed in the stroke prevention clinic for a possible TIA. Her past medical history included hypertension, treated hypothyroidism, and diet-controlled type II diabetes. Her medications included ASA, HCTZ, and eltroxin. She was initially referred from her family physician's office for evaluation of an episode of right-sided weakness and numbness, mostly involving the arm, lasting about 15 minutes. Her examination in the clinic showed her to be mildly hypertensive at 150/90, and with a regular pulse at 76. Her neurological examination was normal. Her EKG done that day was normal (sinus rhythm). An urgent carotid ultrasound was arranged and she was started on clopidogrel 75 mg OD, ramipril 2.5 mg OD, and atorvastatin 10 mg OD. On the following morning she awoke with mild right-sided weakness and an inability to speak. Her husband immediately called 911. She was taken to the nearest hospital.

Tutorial: Neil Wartson (Part 1) MF4 Neuro

Part 4, Medical Foundation 4, Neuroscience, Week 1

Neil Wartson is a 4-year-old boy who is being seen by his family doctor for right-sided hearing loss. According to his mother, his hearing was fine at birth (based on the initial screening tests performed), but seems to have slowly worsened on the left over time. He began complaining of “ringing” in his right ear approximately 6 months ago. It was initially intermittent, but seems to have become more constant over time. He is also reported to have difficulty responding when spoken to on the right side. He is otherwise well and developmentally normal. There is a family history of bilateral hearing impairment in Neil’s father. This has not previously been investigated. On examination, Neil is found to have reduced hearing to whispered words on the right. Rinne and Weber’s tests support sensorineural hearing loss on the right. The family doctor orders formal audiology testing and a sedated MRI. She also suggests that it might be helpful for Neil’s father to be assessed for his hearing loss.

Small Group Session: Neuro Team based learning session #2

Part 4, Medical Foundation 4, Neuroscience, Week 2

Dizziness, meningitis, stroke, headache

Tutorial: Andrea Holmes MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 2

Andrea, an 84-year-old woman, is accompanied by her niece to her family physician's office. Andrea has been living on her own ever since her husband died 10 years ago. Her niece Bev would occasionally pick up some groceries for her aunt. Andrea was always proud to be independent. As she got older, Bev noted that her aunt was a bit forgetful, but put that down to simply getting older. Last month her aunt's neighbour called Bev to tell her that her aunt's hydro was disconnected. Bev was surprised. Her aunt hadn't called her that there was any trouble. Bev noted that her aunt hadn't really called her much over the last few months. Bev went over to her aunt's house. Her aunt greeted her at the door. Her aunt was surprised to see her, even though Bev had called her that day to tell her that she was coming to visit. Bev was surprised to see that her aunt had lost a fair amount of weight. She was even more surprised about the unkempt nature of her aunt's house. This was a woman who prided herself on organization and cleanliness. After much discussion and arguing, Andrea agreed to see her family physician for a routine checkup. She hadn't been to the doctor's for some time.

Tutorial: Ivan Nettar MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 2

Ivan is a 68 year old man who has enjoyed excellent health in the past. His only medication is hydrochlorothiazide for mild hypertension. For the past few weeks he noticed that by the end of the day he had difficulty focusing his eyes and keeping them open. He decided to see his family physician when the other day his vision became double. On the day of the visit, Ivan was feeling even worse. His double vision was present shortly after lunch and he felt generally weak. On observation, it was clear that Ivan had a right-sided ptosis. He kept closing one eye and then the other, complaining that otherwise his vision was double. His voice seemed mildly hoarse. Blood pressure was normal at 135/80. General physical examination of the heart, lungs, and abdomen was normal. Neurological examination showed that the pupils were equal and reactive. A prominent ptosis was present on the right. The extra ocular movements were abnormal with dysconjugate gaze present intermittently and not consistently on lateral, upward, and downward gaze. The other cranial nerves were normal. Tone was normal in the limbs. He had some difficulty holding up his arms in the air for more than a couple of minutes. He had some difficulty doing more that 5 deep knee bends. Sensation was normal and the reflexes were all present and symmetric. The plantar responses were down going. You ask Ivan to close his eyes and rest them for a few minutes while you make some notes. You ask him then to open his eyes and temporarily the double vision is much better and the ptosis is almost gone! A referral is made to the neurologist on call. She asks that you send Ivan to the emergency room so that she can perform a tensilon test to confirm the diagnosis.

Clinical Skills Sessions: Neurology Exam: Practice Cases – Vertigo, Headache

Part 4, Medical Foundation 4, Neuroscience, Week 2

Discuss and practice the components of the history and physical exam for a patient presenting with vertigo. Discuss and practice the components of the history and physical exam for a patient presenting with headache.

Tutorial: Carmen Shellinger MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 3

Carmen Shellinger is a 32-year-old office manager at a local law firm. Her regular office duties include transcription for the senior partner. Over the past few weeks she has noticed pain in the right wrist at the end of the day. On some occasions she has been awakened at night by pain, tingling and numbness in the right hand. After shaking the hand, the symptoms seem to settle down and she has been able to fall asleep. Her symptoms have become more persistent and she decides to seek her doctor's help. Carmen is otherwise healthy and general inquiry identifies only occasional neck and shoulder pain. The results from the neurological examination are normal. Phalen's manoeuvre reproduces her symptoms in the right hand that she has experienced at night. Tinel's sign provokes numbness into the lateral 3 fingers of the right hand.

Tutorial: Petter Khant MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 3

Petter Khant, a 6-year-old boy, is brought to his family doctor by his mother because of concerns that he is not learning in school. He is described as a "high energy child", always on the go. He has a very short attention span. His teacher sent along a note explaining that Petter is well behind the expectations for this age. His classmates are learning the sounds that go with different letters, but Petter does not yet even have a concept of letters or numbers. His vocabulary seems very limited, both receptive and expressive. His mother recalls no concerns about his early development. She remembers him as a generally healthy baby. He started to crawl at 9 months and could walk on his own by 13 months. He only began to use a few single words at 2 years of age. A hearing test done at that time was normal.

Anatomy Lectures: Sensory Systems

Part 4, Medical Foundation 4, Neuroscience, Week 3

Sensory pathways of the somatosensory system. Reflexes. Cross extensor reflex and central pattern generators. Parts of the Central Nervous system: cerebral cortex, diencephalon, brainstem, cerebellum, spinal cord. Peripheral nerves. Skin. Cutaneous nerve receptors. Testing the 5 sensory modalities (pain, temperature, pressure, touch, vibration). Cutaneous receptors. Deep receptors. Sensory Homunculus. Dorsal columns quantitative sensations (touch, pressure and proprioception (position)). Spino-thalamic tract qualitative sensations (pain and temperature). Gate control of pain. Reflex descending control of pain. Role of enkephalins and endorphins. Neuropathic pain. Romberg Test. Olfactory pathways.

Large Group Session: Aphasia

Part 4, Medical Foundation 4, Neuroscience, Week 4

Connections between Wernicke's and Broca's areas, mediating expression of language utterances in speech. Broca's area and the primary motor area. Primary auditory perception and Wernicke's area. Connection between vision and Wernicke's area, mediating reading ability. Somatosensory perception (tactile, pain, cold/hot, position sense) and Wernicke's area. Key aspects to aphasia: Lesion, insult in the dominant hemisphere; Impaired naming; Is repetition impaired? Is comprehension impaired? Is reading and writing impaired?

Active Large Group Session: Antibiotic Prescribing

Part 5, Integration Foundation, Host Defense and Neoplasia, Week 1

Tutorial: P.J. Peters (Part 2) IF Host Defence and Neoplasia

Part 5, Integration Foundation, Host Defense and Neoplasia, Week 2

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.

Clinical Skills Sessions: New Lymphadenopathy and STBBI assessment

Part 5, Integration Foundation, Host Defense and Neoplasia, Week 4

Review and to practice an approach to history and exam for lymphadenopathy and STBBI (sexually transmitted and blood-borne infection) assessment. A 27yo F presents with new lymphadenopathy and concern for STBBI to Emergency room.

e-Learning Module: Integration Foundation Rapid Fire Cases: Medical decision making in the acute care setting

Part 5, Integration Foundation, Maternal Health Risks/Aging-Related Care, Week 4

12-15 cases of rapid action required or immediate clinical decision making. Content of these modules: Internal Medicine, Surgery, Obstetrics, Paediatrics, Geriatrics and Radiology.

Clinical Skills Sessions: Headache and Cough in a Pregnant Patient x 3 days

Transition to Clerkship, Week 2

You are working with a community family physician who works in their clinic and the emergency department at an academic centre in St. Catharines. You are early in your clerkship and haven’t completed your Obstetrics/Gynecology core rotation yet. The clinic is able to do in-house ECGs and Urine dipsticks. They can send a requisition for bloodwork and chest x-ray, completed offsite. Your first patient is Vanessa, a 35 year-old G2P0 patient who is 28 weeks pregnant with exercise-induced asthma and normal prenatal course to date, last seen for prenatal care at 24-weeks where she was sent for a gestational diabetes screen that was normal. She is taking a prenatal vitamin with 1mg folic acid daily. Your clinic is following her for prenatal care within a shared care model for her pregnancy, with an obstetrician in St. Catharines following her with a plan to deliver at Niagara Health St. Catharines hospital. You were due to see her in follow-up later this week (for her 28-week visit) but she has been scheduled as an urgent visit today for headache and cough x 3 days.

Clinical Exposure: EM Medical Expert (presenting problems)

Clerkship, Emergency Medicine Rotation

Demonstrate an approach to patients presenting to the ED with the following problems listed below (including basic differential diagnosis, initial investigations, and initial treatments)

Tutorial: ENT presentations

Clerkship, Family Medicine Rotation

Clinical Exposure: Continuity of care/chronic disease management

Clerkship, Family Medicine Rotation

Clinical Exposure: ENT

Clerkship, Family Medicine Rotation

Tutorial: Neurology

Clerkship, Family Medicine Rotation

Clinical Exposure: Musculoskeletal Presentations

Clerkship, Family Medicine Rotation

Clinical Exposure: Neurology

Clerkship, Family Medicine Rotation

Tutorial: Musculoskeletal presentations

Clerkship, Family Medicine Rotation

Essential Clinical Experience: Dizziness

Clerkship, Family Medicine Rotation

Essential Clinical Experience: Stroke

Internal Medicine Rotation

Clinical Exposure: Parkinson's disease

Clerkship, Internal Medicine Rotation

Clinical Exposure: Hypo/hyperthyroidism

Clerkship, Internal Medicine Rotation

Essential Clinical Experience: Otitis/Pharyngitis

Pediatrics Rotation

Essential Clinical Experience: Otoscopy

Pediatrics Rotation

e-Learning Module: CLIPP Cases: Common Pediatric Conditions

Clerkship, Pediatrics Rotation

Computer simulated pediatric cases will be used to supplement direct patient encounters. A series of 31 e-learning modules is made available to each student. Students are required to complete 15 cases by the end of the rotation.

Tutorial: Pediatrics Peer to Peer teaching session

Clerkship, Pediatrics Rotation

At the end of the third week of your rotation, you are asked to present a brief overview of one of these key topics: Fever (differential, focus on UTI); Headache in children/teens; Neonatal jaundice; Approach to Lymphadenopathy; Abdominal pain (differential, focus on constipation); Growth problems in children

Large Group Session: Pediatric Surgery

Clerkship, Surgery Rotation

Pediatric IV Fluid requirements. Appendicitis. Intussusception. Hernia. Hydrocele. Pyloric stenosis. Umbilical hernia. Neonatal congenital anomalies. Bowel obstruction in newborn. Hirschsprung’s Disease. Congenital neck masses.

e-Learning Module: Thyroid nodule

Clerkship, Surgery Rotation

In this module, you will learn about the presentation, diagnosis, and management of thyroid nodules and specifically of thyroid cancer.

Round Table Discussion: Pediatric Surgery

Clerkship, Surgery Rotation

Round Table Discussion: ENT (Ears, Nose, Throat)

Clerkship, Surgery Rotation

Large Group Session: Head and Neck

Clerkship, Surgery Rotation

Introduction to Head and Neck Surgery: basic clinical exam; relevant anatomy. Review common clinical scenarios in head and neck surgery. Neck Mass. Thyroid Nodules.

Large Group Session: Ear, Nose and Throat

Clerkship, Surgery Rotation

How to evaluate a patient with a sore throat, hearing loss or with nasal obstruction. Acute Tonsillitis. Epiglottitis. Rinne and Weber Tests. Tympanometry.

Essential Clinical Experience: Neck/Back Pain (Incl. Disease)

Clerkship, Emergency Medicine Rotation, Family Medicine Rotation, Orthopedic Surgery Rotation

Concept Integration and Review: Microbiology and Infectious Disease

Post-clerkship, Concept Integration and Review

Infectious diseases. Transmission. Gram Stain. Microbiology. Infections head to toe.

Concept Integration and Review: Pediatric Communicable Diseases

Post-clerkship, Concept Integration and Review

How do you decide what antibiotics to use? Is there an infection? Where is the infection? What pathogens are probably causing the infection? Are there antibiotics that can get to where the pathogens are? kill the pathogens?

Concept Integration and Review: Endocrinology

Post-clerkship, Concept Integration and Review, Week 4

Thyroid disorders: Hypothyroidism; Thyrotoxicosis (Graves, toxic nodule, thyroiditis); Thyroid Nodules. Pituitary Disorders: Pituitary disorder manifests clinically in 3 ways: Hyperfunction: too much hormones; Hypofunction: too little hormones; Local mass effects; Acromegalia. Posterior Pituitary dysfunction: ADH. Adrenal Disorders.