Tutorial: Luke Tomczak MF1 Respirology

Part 1, Medical Foundation 1, Respirology, Week 1

Luke, a 47 year old gentleman with a history of chronic alcoholism and poor eating habits, goes to the ER with a complaint of chest pain. He smokes two packs of cigarettes daily. He has not been feeling well for over one week due to an upper respiratory infection. Two days ago he developed a fever, chills and a sharp pain over his right chest that is worse when he breathes in. Luke had a dry cough initially, but today he has coughed up rusty sputum with some blood in it. Although Luke is not normally short of breath, he has had difficulty climbing the stairs to the office because of breathlessness.

Tutorial: Thomas Gagnon MF1 Respirology

Part 1, Medical Foundation 1, Respirology, Week 2

Thomas Gagnon, a 12 year old boy diagnosed with asthma 1 year ago, traditionally experienced minimal respiratory symptoms. In the past, he had used inhaled salbutamol sparingly, generally during soccer games, with excellent therapeutic effect. During a late September soccer game being held in a rural area, Thomas developed sudden onset dyspnea, wheeze, and chest discomfort. Earlier in the day he had visited with family members who smoke and have three pet cats. His symptoms were mostly relieved with repeated doses of salbutamol. He awakes the following night with ongoing symptoms that are not responsive to inhaled salbutamol, despite frequent dosing. His parents are alarmed and take him to the emergency department.

Tutorial: Teresa J. MF1 Respirology

Part 1, Medical Foundation 1, Respirology, Week 3

Teresa, a 65-year-old woman, is brought to the emergency room by a friend who was unable to arouse Teresa completely. Her friend reports that Teresa had been unwell for three days with persistent vomiting. In the emergency room, Teresa is only semi-rousable. Her pulse is 130 and blood pressure is 100/70. Her breathing is rapid and deep. Teresa’s medical record indicates a history of poorly controlled diabetes and premature coronary artery disease, with a prior myocardial infarction at age 49. She is described as “treatment non-compliant” and is noted to have a “difficult psychosocial situation”.

Tutorial: Arthur N. MF1 Respirology

Part 1, Medical Foundation 1, Respirology, Week 3

Arthur N., a 64-year-old gentleman, presents to his family physician because he is noticing increasing difficulty walking because of breathlessness. He states that he cannot put a finger on when it first began "except that he is aware that he was not as fit" as he should be. Arthur has always enjoyed his walking. However, over the last six months, he has noticed that any incline will make him breathless to the point that friends will remark on it, and he simply has to stop walking. In addition, climbing stairs has become quite difficult. He remarks that he has not been breathless at rest, nor at night-time. He has not noticed any swelling of his ankles. Arthur states that he smoked lightly about twenty years ago. His occupational history is unremarkable and there is no history of heart disease.

Tutorial: Novak B Part 1 MF1 Cardiovascular

Part 1, Medical Foundation 1, Cardiology, Week 3

Novak B. is a 55-year-old man with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia. He presents himself at your office because he has been experiencing chest pain for several days, but has been reluctant to come to the office. He first noted it 6 weeks ago while shoveling snow. The discomfort was mid-sternal and radiated to his jaw. It resolved with rest. Since then, he has noted 3 similar episodes each occurring while climbing the 2 flights of stairs from his basement to the bedroom. Upon further questioning, he also tells you that he feels cramps in both of his calves whenever he walks for more than 500 meters. If he stops walking, his symptoms resolve within 2-3 minutes. On examination, he is mildly obese. His pedal artery and posterior tibial artery pulses are significantly decreased in volume bilaterally. The remainder of the examination is normal. You diagnose him with angina and prescribe aspirin, a beta-blocker, a statin and nitroglycerin. You also make a referral to a dietician.

Tutorial: Amanda VP MF1 Cardiovascular

Part 1, Medical Foundation 1, Cardiology, Week 4

Amanda VP. is a 44-year-old Russian immigrant whom you first meet at family health team where you are completing your core training as a family medicine resident. Amanda presents to the clinic because she’s had a two-week history of fevers, chills, malaise and shortness of breath on exertion. She became particularly concerned earlier today when she experienced a brief episode of left arm weakness that lasted for approximately 5 minutes and then completely resolved. Amanda, one of four children, grew up in the former Soviet Union, in a poor household with her extended family (cousins, aunt and uncle, and grandparents). Amanda VP.’s short stature makes you wonder if she was malnourished as a child and if so, what other effects this may have had on her health. Her past medical history seems unremarkable. She has been hospitalized once when she delivered healthy twin girls twenty years ago. She does recall having been told by her obstetrician that she had a heart murmur. She is married and works as a dental assistant in her husband's office. She smokes one pack of cigarettes daily and has done so for 30 years. She does not drink alcohol. On examination, she looks unwell. She is febrile with a temperature of 38.8 degrees Celsius. Her heart rate is 110 bpm with a BP of 100/65 mmHg. Head and neck examination reveals bilateral conjunctival petechiae. Her JVP is 4 cm above the sternal angle. Her chest is clear. Heart sounds reveal a grade 3/6 pan-systolic murmur best heard at the apex and an S3 with gallop. Her point of maximal impulse is enlarged and palpated in the anterior axillary line. She has mild bilateral pedal edema. Neurological examination, including fundoscopy, is completely normal as is the dermatologic exam. You decide to admit her to hospital, order blood work, a chest X-ray, and an echocardiogram.

Tutorial: Teresa J Part 2 MF1 Cardiovascular

Part 1, Medical Foundation 1, Cardiology, Week 4

You are called to see a patient in the ER who has presented with shortness of breath. You immediately recognize Teresa J, the 65-year-old female who was previously admitted for several weeks with acute lung injury earlier in the year. A quick review of her chart reminds you that she also has a history of poorly controlled diabetes and premature CAD with a prior MI at age 62. She looks distressed and is only able to talk in short phrases. She describes chest pain on the left side that gets worse when she coughs or moves. She has been getting weaker over the last 3 days. Her sputum is yellow, but she denies hemoptysis. She stopped taking all of her medications a week ago (furosemide, ASA, antihyperglycemics, metoprolol).

Active Large Group Session: Introduction to Immunology

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

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: Edwin McKenzie MF1 Respirology

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

Edwin is a 4-year-old boy enjoying a day at the Caledonia Fall Fair. He is walking around, enjoying the sights while eating a hot dog, when he suddenly begins to choke. Bystanders look on, horrified. An alert medical student, who happens to be taking a break from studying, is on the scene. She rushes over, comes up behind Edwin and administers an abdominal thrust. The piece of hot dog is expelled from Edwin, and he takes a big breath.He is fine, the medical student is relieved and congratulations are offered all around at this happy ending. In speaking with Edwin’s parents after the incident, the medical student notices a colorful circular pin on his mother’s jacket. The medical student inquires about the pin, and Edwin’s mother states the pin represents the Medicine Wheel, an important concept for their family’s health.

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: 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.

Tutorial: Celia and Maria MF2 Renal

Part 2, Medical Foundation 2, Renal, Week 1

Maria is a 33 year old single woman who is concerned about the health of her 2 year old daughter Celia. Since three months of age Celia has been treated with multiple course of antibiotics for episodes of fever and irritability. Maria wants the doctor to check a urine sample because she thinks it might be a "urine infection" since Celia's wet diapers have a bad smell

Tutorial: Matthew Clarke MF2 Renal

Part 2, Medical Foundation 2, Renal, Week 1

Matthew Clarke, a 4-year-old boy, developed periorbital edema for the first time three weeks ago, and despite being treated for allergies he showed increasing edema and weight gain. He now has ankle and leg edema, a distended abdomen, and can only sleep at night if propped up with three or four pillows.

Tutorial: Yong Mun Park MF2 Renal

Part 2, Medical Foundation 2, Renal, Week 3

Yong Mun Park is a 22 year old woman who has a 2 year history of recurrent urinary tract infections. These continue despite conservative measures and her family doctor elects to try her on a course of prophylactic antibiotics. She is allergic to sulpha medications, so she is prescribed cephalexin 250 mg daily. She is taking an oral contraceptive, but no other medications. Ten days after starting this antibiotic, she returns to her family doctor with a macular, red rash on her trunk and arms, general malaise, and nausea.

Tutorial: Maxwell Greenfield MF2 Hematology

Part 2, Medical Foundation 2, Hematology, Week 1

Maxwell Greenfield is a 32 M was admitted under the general medicine service last night with gastroenteritis. It is your first day on the hematology rotation and you are called to provide a consult for new onset pancytopenia in Maxwell. Maxwell has a history of Crohn’s disease, diagnosed at the age of 28. He is currently on methotrexate 20 mg subcut weekly to control his disease, which he has been on for the last two years. He does not take any other medications at home. He has no other medical problems. Maxwell initially presented to hospital with nausea, vomiting, and diarrhea after eating some old chicken he found at the back of the fridge. He did not have any blood in his bowel movements or mucous. He has note noted any fever.

Active Large Group Session: Introduction to Pathology

Part 2, Medical Foundation 2, Hematology, Week 2

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.

Tutorial: Jesse Knox MF2 Hematology

Part 2, Medical Foundation 2, Hematology, Week 4

Mr. Knox is a 22-year-old male undergoing chemotherapy treatment for Acute Myeloid Leukemia. He was seen in clinic last week for chemotherapy, and he was relieved to see that his neutrophil count was back up above 1 (ANC 1000). He had no evidence of bleeding, and his platelet count was 110. He tolerated his intravenous chemotherapy and anti-emetics well, and went home to recover for the weekend. Eight days later, Jesse is feeling unwell and checks his temperature as he has been taught to do – it reads 38.5 deg C orally, so he presents to the ER as instructed. Apart from the fever, his only complaint is a sore mouth. He denies cough, shortness of breath, dysuria or change in bowel movements. Physical exam reveals a tired and pale-looking young man. His blood pressure is 105/60, heart rate 125 bpm, respiratory rate 18 and a temperature of 38.9 deg C. His tongue has a white coating and his gums look sore. His central line catheter site appears clean.

Tutorial: Billy Elliot MF2 Hematology

Part 2, Medical Foundation 2, Hematology, Week 5

Billy Elliot, an 18 year old male music store employee was brought into your emergency department after being involved in a motor vehicle accident at about 2:00 a.m. The paramedics that brought him in stated that he was the driver of a vehicle involved in a three car accident. The rescue squad required the "jaws of life" to extricate him from the car. The airbags were deployed, but the car sustained significant damage and the steering wheel was noted to be inches from the front seat after Billy was extricated. The paramedics conveyed that the patient was alert and talking at the scene and an IV was started. However, en route to the hospital, they noted that his pulse rate began to increase and the patient was diaphoretic.

Tutorial: Shalini Mehta MF3 Reproduction

Part 3, Medical Foundation 3, Reproduction and Pregnancy, Week 1

Shalini Mehta is a successful 35-year-old lawyer who married five years ago. Her partner Varun is a 56-year-old judge who left his former wife to be with Shalini. He has three grown children and one grandchild. Varun was never as keen on starting a new family as Shalini, but he loves her and "wants what she wants". For the first three years of their marriage, Shalini continued on the birth control pill, as she wanted to focus on establishing her career further. She states that she had been on the pill since she was 18. Two years ago she stopped the pill and had hopes that she would be trying for her second baby by now.

Tutorial: Mary Jane Morrison MF3 Reproduction

Part 3, Medical Foundation 3, Reproduction and Pregnancy, Week 2

Mary Jane, a healthy 22-year-old woman, is seen in a walk-in clinic for abnormal vaginal discharge. She is otherwise healthy and not taking any medications. Her immunizations are up to date, though she is unsure if she received the HPV vaccination as a teen. Mary Jane has been sexually active for 2 years. She has never had a Pap smear. She tells you that she has tried the birth control pill in the past but is not taking it because it “makes her sad”. She uses condoms instead. Three months ago, she had unprotected sex one time with her current partner. She confides in you that she thinks her current partner "sleeps around" on her and she’s here today because she wants to get “checked”. When taking a detailed sexual history, you discover that she has intermittently experienced pain during sexual intercourse and some post-coital bleeding. Mary Jane minimizes these symptoms and tells you that this is normal for her. On examination she looks well but is very nervous. Vitals signs are within normal limits. Head and neck, respiratory and cardiac examinations are all normal. Abdominal exam does not reveal any masses or areas of tenderness. Skin and joints are all normal. Genital examination does not reveal any lesions. Pelvic examination reveals some purulent discharge from the cervical os. Swabs are collected from the cervical os and result in bleeding. Bimanual examination does not elicit any cervical or adnexal tenderness. You discuss the role of cervical cancer screening and how it relates to HPV, a sexually transmitted infection. Mary Jane agrees to return in 2 weeks for a Pap smear.

Tutorial: JoAnne Wright MF3 Reproduction

Part 3, Medical Foundation 3, Reproduction and Pregnancy, Week 3

JoAnne is a 28-year-old G4T1A2L1 Inuk from Baker Lake, Nunavut. Her last menstrual period was February 11. She has a regular, 28-day cycle and had a positive home urine test on March 14. She tells you that she is concerned because she had a DVT in her last pregnancy and was told that she has antiphospholipid antibody syndrome. She has been on warfarin since her son was born 2 years ago. She had 2 miscarriages at 8 and 10 weeks prior to her son being born. She is concerned about the effect of the medicine on her baby and also her risk of developing another clot.

Tutorial: Li Chin and Baby Albini MF3 Reproduction

Part 3, Medical Foundation 3, Reproduction and Pregnancy, Week 4

Li Chin is a 19-year-old woman from Hong Kong who has been in Canada for one year studying Computer Science at McMaster University. She is a known carrier of Hepatitis B, but is otherwise healthy and on no medication. You are a family physician working at Student Health Services at the university. Li came to see you today for a routine prenatal appointment at 28 weeks gestational age. You inquire as to Li's plans for feeding her baby after birth. She is uncertain and has not yet considered this. When you recommend that she breastfeed her baby, she asks why. She doesn’t know anyone who has breastfed. She is uncertain as to whether or not she would be able to do it.

Tutorial: Nick DeMarco MF3 Gastroenterology and Nutrition

Part 3, Medical Foundation 3, Gastroenterology and Nutrition, Week 1

Nick DeMarco is a 51 year old physical education teacher at a local elementary school. He has noticed increasing fatigue with exertion and complains about feeling exhausted at the end of the school day. He explains that he has been experiencing epigastric discomfort after eating and he has tried taking Advil for pain relief. He states the pain and regurgitation wakes him up at night. He reports that he is usually able to get back to sleep after taking antacids and a glass of milk.

Tutorial: James Cork MF3 Gastroenterology and Nutrition

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

Dr. James Cork, a 26 year old dentist, has been unwell for over 1 year. During this time he reports he has had diarrhea characterized by four to six loose, bulky stools per day without blood, mucus, or pus. He has been up at least once each night to move his bowels. James has lost 7 kg despite a very good appetite. He has not travelled outside of southern Ontario or been camping. His partner of 7 years, Richard, is in good health and has not suffered any of these symptoms, nor has James been in contact with anyone else with similar symptoms. His family physician found that his hemoglobin is low.

Tutorial: Ted Mitchell MF3 Gastroenterology and Nutrition

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

Ted Mitchell is a 38 year old male who is homeless. He has been on and off the streets for the last 15 years. As a teenager, he started hanging out with "the wrong crowd" and his father, Dr. Ted Mitchell Sr. told him he could not return home till "you have cleaned up your act". Ted continues to abuse drugs, and any money he can get, has gone toward purchasing alcohol, his drug of choice.

Tutorial: Mike Bayuk MF3 Gastroenterology and Nutrition

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

Mike Bayuk, a 55 year old businessman, presents to the ER in Hagersville with severe abdominal pain. He indicates that the pain is located in the epigastric area and radiates into his back. He finds the pain is relieved when he sits up with his trunk flexed and his knees bent. He rates the pain as "11 out of 10".

Active Large Group Session: Autoimmunity

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

Tutorial: John Franks MF3 Gastroenterology and Nutrition

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

John Franks is a 66-year-old male with a complicated course of Crohn’s disease over 30 years, requiring multiple surgical resections of his small bowel due to inflammation and obstruction. He has been treated with several immunosuppressive and biological treatments for his IBD, but has had a loss of response to these medications despite some temporary improvement in his disease activity. Despite currently being on ustekinumab (Stelara), John has had evidence of active disease and is currently on a tapering course of prednisone for a recent flare of his IBD. He was recently admitted to hospital with another partial small bowel obstruction and he is worried that he may need further surgery. "They’ve removed so much of my small intestine already that I am worried that I’m going to get short bowel syndrome." You discuss optimizing his dosages of his treatments in an attempt to induce remission of his disease, and to avoid the need for further surgery. He asks: "If I do have short bowel syndrome, what kind of special diet will I need to go on to maximize my nutrition?"

Tutorial: Philip Cheung MF3 Gastroenterology and Nutrition

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

Mr. Cheung presents to the emergency department with a 2 day history of worsening pain in the right upper quadrant of his abdomen. He had been in the ER last year with pain in his right flank, but while that pain was colicky in nature, he currently describes a more constant pain. The right flank pain a year ago was accompanied by hematuria and he ended up passing a kidney stone. Currently, he has felt nauseated but has not vomited and he has been anorexic for over 24 hours. He finally came to ER after developing some fevers and chills.

Tutorial: Vivian Patel MF3 Gastroenterology and Nutrition

Part 3, Medical Foundation 3, Gastroenterology and Nutrition, Week 4

Vivian Patel is a 35-year-old computer programmer who presents to the ER with a 10- hour history of profuse vomiting, watery non-bloody diarrhea and abdominal cramps. She first tried to fight this illness on her own by drinking water, however her symptoms were persistent and her husband brought her to the emergency room. She was first seen by the triage nurse, who noted that she was febrile with a temperature of 38.6 C. Given her presentation, the nurse decided that she should be isolated with "enteric precautions” and she was subsequently seen by the ER physician. Vivian is an otherwise healthy woman with no known medical problems and only takes a multivitamin daily. The day prior to her presentation with these symptoms, she had attended her 5-year-old niece's birthday party. She cannot recall any sick contacts, although is unsure if anyone else from the party has developed similar symptoms. Additionally, she had recently returned from a trip to India 5 days ago. She went on a business trip for a week and stayed to travel the country for another 3 thereafter. She did not receive any pre-travel advice or prophylaxis.

Tutorial: Stephen Golding MF3 Endocrinology

Part 3, Medical Foundation 3, Endocrinology, Week 1

Stephen Golding, a 22 year old man presents to the emergency department with nausea, vomiting, abdominal pain and a 3-day history of polyuria, polydipsia, and weight loss. He states that he has "junvenille insulin-dependent" diabetes but stopped taking his insulin 5-days ago.

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.

Tutorial: Emily Bradstone MF3 Endocrinology

Part 3, Medical Foundation 3, Endocrinology, Week 2

A 55 year old female, Emily Bradstone, is seen by a hematologist for easy bruising. No hematological problem was found. An internist also saw the patient. There has been a one-year history of easy bruising, weight gain, worsening of diabetes, difficulty climbing stairs and edema of the ankles

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: Joan Spaulding MF4 MSK

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 3

Joan Spaulding is a 32 year old lady who arrives at your clinic with a history of joint pains in the hand. The pain in her hands was predated by a viral flu that manifested itself as generalized arthralgias and fatigue. The pain has been ongoing for 10 weeks and transformed itself from generalized arthralgias to symptoms in the hands and feet associated with morning stiffness that lasts approximately 1 hour.

Tutorial: Cindy Edsworth MF4 MSK

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 3

Mrs. Cindy Edsworth is a 30 year old African Canadian lady who describes the onset of joint pains which have been on going for 3 months. She describes that the small joints of her hands are constantly aching and over the past 4 weeks she describes having swelling in the PIP and DIP joints of both hands. Over the past week she points out that she is having significant swelling affecting the feet that reaches the ankles. With the onset of the joint pains she developed alopecia and a scarring type rash over the scalp. She has been quite fatigued. She finds she is exhausted when she awakens in the morning and by 6:00 pm she has to go to bed because of persistent fatigue. Cindy also finds that she has become quite irritable. Her temper is easily disturbed and she is also becoming quite argumentative with her husband. Her husband is disturbed by her recent change in mood.

Tutorial: Jane Young MF4 MSK

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 3

Jane Young is a 3 1/2 year-old girl, brought to the Pediatric Medicine Clinic by her mother. For the past 10 days, her right knee has been swollen and stiff. There was no preceding trauma. She seems to have most symptoms in the morning, getting better when she is up and about playing. She seems to have less energy since the swelling was first noted. Her mother has been giving her children's Tylenol but has not noticed any improvement in her symptoms. Her mother thinks her ankles are also "puffy" at times. On examination, Jane appears well, afebrile and is on the 50th percentile for height and weight. No fever or skin rashes. Cardiovascular, respiratory and abdominal examinations unremarkable. Right knee is swollen, warm and effused and Jane stands with this knee slightly flexed. There are mild effusions of both ankles which are also slightly swollen. The pediatrician decides to order a few investigations. Baseline CBC, renal and liver function is unremarkable. ESR moderately elevated at 30. Rheumatoid Factor is negative, but Antinuclear Antibody (ANA) is positive at 1:160.

Active Large Group Session: Inflammatory Arthritis

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 3

Tutorial: Joseph Collins MF4 MSK

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 3

Joseph is a 34-year-old man who arrives at the emergency room having returned from a vacation to Cuba 3 weeks ago. He had profuse diarrhea for about 5 days while he was in Cuba. The diarrhea settled by the time he returned to Canada. His primary concern now is swelling and pain in his right knee, left ankle, and left elbow. He is worried that infection from the diarrhea has somehow gotten into his joints. He asked whether he should have received antibiotics while in Cuba, and whether he needs any right now.

Tutorial: Theodore McIntyre MF4 MSK

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 4

Mr. McIntyre, a 69 year old man, has developed a new onset right-sided headache for the last 5 days. He has some pain when he chews his food and has been feeling increasingly fatigued. He has had stiffness in his shoulders and his hips so much so that it takes him at least an hour to get up and move around first thing in the morning. He has started to develop some double vision. He has tenderness when he combs his hair on the right side of his temple. Physical exam reveals a BP of 120/70 (right arm) and 126/68 (left arm), HR 75/min, temp 37. He has tenderness along his R temporal region and the R temporal artery feels thickened.

Tutorial: Giuseppe Carnivale MF4 MSK

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 4

Giuseppe Carnivale is a 42 year old construction worker who presents with the complaint of gradually increasing weakness in his legs. He has noted difficulty climbing stairs. He feels the strength in his arms is normal, except when working over his head. He admits to mild aching in his muscles, but has no muscle pain or tenderness. The weakness has been insidious. A rash has been present on his face and upper chest for several months.

Tutorial: Fred Newman MF4 MSK

Part 4, Medical Foundation 4, Musculoskeletal Medicine, Week 4

Fred Newman, a 32-year-old man, complains of severe low back pain of gradual onset over the past few years. The pain is much worse in the morning and gradually decreases during the day. He denies fever or weight loss but does feel fatigued.

Tutorial: Mandy Wallsmith (Part 2) MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 1

Six months after her previous presentation of transverse myelitis, from which she completely recovered, Mandy Wallsmith returns with complaints of bilateral visual loss (worse on the right). The problem started two days ago with pain in and behind her right eye, worse when she would look to the left or right. Yesterday, she began to notice that she wasn't seeing well out of her right eye. Today her vision seems worse, although the pain is a little better. On examination, her visual acuity is found to be 20/80 in the left eye (OS) and 20/400 in the right eye (OD). Visual field appears to be normal in the left eye, but she can only detect hand motion (not finger counting) in all quadrants with the right eye. She finds that colours look less vivid with her right eye - especially red, which looks "kind of gray".

Tutorial: Mandy Wallsmith (Part 1) MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 1

Mandy Wallsmith is a 19-year-old young lady who has been brought to the Emergency Department because of problems walking. Approximately one week ago, she noticed some numbness in her left leg. She thought she had slept on it the wrong way initially, but then the numbness persisted. The next day she fell while skating and landed on her backside. Over the next few days, she reports feeling significant pain in her lower back and progressive “heaviness” in her left leg. She began having difficulty lifting her left leg. She also noticed that her right leg seemed to feel cold when she showered. After speaking to her parents about her symptoms, she was brought to a walk-in clinic where an x-ray of the spine was ordered. This reported no fractures, and Mandy was advised to follow-up with her family doctor if her symptoms did not improve in the next few days. When she started to have episodes of urinary incontinence, her parents became very concerned, and decided to bring her to the Emergency Department.

Tutorial: David Beatty MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 2

David Beatty is a 5 year old boy brought to his family doctor by his mother. She is concerned about his clumsiness. He had always been a little 'slow' with his gross-motor milestones. His mother recalled that he did not start walking until he was 20 months old. As he has gotten older, he has seemed less able to keep up with other children his age. As an example she explains that she sees other kindergarten children at the school playground who all seem to be able to run, climb and hop without difficulty. But not David. He is slow, cannot climb well, and falls very often. He also tires out quickly. She worries that maybe he has a problem with the bones in his legs, or maybe a problem with his hips. On examination, David is 111 cm tall (50th percentile), weighs 21 kg (75th percentile), and has a head circumference of 52 cm (75th percentile). He is a happy boy and is eager to tell stories about his teacher and classmates. When standing he has a prominent lordotic curve to his back. He has difficulty climbing up on the examination table, but insists on doing it himself. His heart, lungs and abdomen appear normal. His joints have full range of motion and he does not appear to have any joint or bone pain. His muscle bulk appears to be good - in fact he has large, muscular-looking calves. His deep tendon reflexes are normal (grade 2 out of 4).

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.

Tutorial: Ron Chen (Part 2) MF4 Neurology

Part 4, Medical Foundation 4, Neuroscience, Week 3

Remember back in MF1... Ron Chen is a 25 year old computer sciences 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 (glove and stocking distribution). He has also noticed occasional clumsy speech and facial weakness. He is admitted to the hospital (medical ward) with a diagnosis of Guillain Barré syndrome. You see him in followup 12 months later. After spending 3 weeks in hospital, 4 weeks in a rehabilitation center and then having physiotherapy for the rest of the year, Ron is almost completely back to normal. He still reports some weakness with extension of his toes on the right, but this does not impair his functioning. During his visit, he asks if he will ever get the strength back in his toes, and whether this could happen again

Tutorial: Yaser Kallas IF Host Defence and Neoplasia

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

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.

Tutorial: Ethel MacConkey IF Host Defence and Neoplasia

Integration Foundation, Host Defense and Neoplasia, Week 1

Ethel is a 76 year old widow. She has a history of hypertension (treated with a thiazide diuretic and a calcium channel blocker), hyperlipidemia (treated with an HMGCoA reductase inhibitor), and obesity. Apart from this, she has been relatively healthy, and plays an active role with her 3 grandchildren as well as her church. Unfortunately, over the past few years, she has had increasing difficulty walking because of pain from osteoarthritis in her hips (especially her right hip) and, to a lesser extent, her knees. She therefore undergoes a right total hip arthroplasty. After 6 days in hospital, she is transferred to the rehab ward for further physiotherapy to improve her mobility. Five weeks into her rehab stay she develops a fever of 38.7 C. Additionally her physiotherapist has noticed that over the past 7-8 days Ethel has been less willing to participate in her exercises due to complaints of pain in her right hip. Concerned about Ethel's fever, the nurses give her acetaminophen and call the attending physiatrist to assess the patient for a potential infectious source.

Tutorial: Melissa Wang IF Host Defence and Neoplasia

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

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.

Tutorial: P.J. Peters (Part 1) IF Host Defence and Neoplasia

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

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.

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.

Tutorial: Grace Tran IF Host Defence and Neoplasia

Part 5, Integration Foundation, Host Defense and Neoplasia, Week 3

Grace is a 50-year-old woman working full-time and busy with her family. She has been feeling exhausted lately and feels like she may have had fevers on and off. She is having difficulty finding the energy to coach her daughter's early-morning hockey games. At the urging of her partner, she sees her family physician who notes that she is afebrile with mild dyspnea and a cough, having faint crackles on the right side of her chest. Suspecting pneumonia, her physician sends Grace for a chest x-ray and she is given an antibiotic prescription to treat community-acquired pneumonia. The x-ray report described a density in the right lower lung zone, and Grace starts her medication with follow up in 3 weeks. When she returns, she mentions that she finished the course of antibiotics but that they “did nothing” and that she feels a bit worse actually. Her exam is unchanged, but given that she has a 30 pack-year smoking history, her physician orders a repeat chest x-ray. This shows mild interval growth of the original opacity. This time, the radiologist states that the area is suspicious for possible malignancy. On further history, Grace was treated for Hodgkin's lymphoma at the age of 18, for which she received 3 cycles of ABVD chemotherapy followed by radiation to the mediastinal lymph nodes. She has been “cancer free” and completely well since, so much so that she stopped going to her AfterCare follow-up appointments. Grace grew up in a middle-class suburban neighbourhood and completed a geosciences degree at a local university. She has spent the last 20 years working for a mining company evaluating many different ore samples. She frequently deals with silica ores and metal-based ores, including iron, nickel, chromium, zinc and aluminum. She wears an N95 dust mask when handling the samples. Grace comes from a family of heavy smokers. Grace's father died 5 years ago from bladder cancer. Her paternal uncle, also a smoker and a heavy consumer of alcohol, had previously died of a throat cancer. Her older sister, yet another smoker, had cancer of the cervix treated successfully with radiotherapy. Due to the x-ray findings, Grace is sent for a CT scan of her chest. This confirms a 2.5 cm lesion in the central right lower lobe well away from the chest wall and the hilum.

Tutorial: Philippe LaCologne IF Host Defence and Neoplasia

Part 5, Integration Foundation, Host Defense and Neoplasia, Week 3

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.

Tutorial: Claire McFadden Part 2 IF Maternal and Child Health Risks

Part 5, Integration Foundation, Maternal Health Risks/Aging-Related Care, Week 1

Claire is a 35-year-old G1 with Type 1 DM. She had an episode of pyelonephritis at 26 weeks gestation and did well following this, and was last seen at 30 weeks. At 32 weeks Claire presents in St. Catharines with a headache and RUQ pain. Her husband says that Claire’s swelling, especially in her face, has worsened over the past 2 days. BP is 160/105. FH is normal. She has 4+ urine protein. Hb 142 g/L, platelets 152, AST 67, ALT 75, INR/PTT normal, fibrinogen 5.8 g/L, glucose 6.5 mM/L, creatinine 100 uM, urea 4.2 mM. Urinary ketones are negative. She is given morphine and oral labetalol. Her symptoms settle and BP is 145/95. Ultrasound shows a cephalic fetus with normal head and femur measurements but the abdominal measurement lags by 3 weeks. There is marked oligohydramnios. Doppler studies are abnormal. MUMC is called and a decision is made to transfer Claire. On arrival, she complains of severe RUQ pain. BP is 170/110. She has made very little urine and it is dark tea coloured. Hb 137 g/L, platelets 100, AST 265, ALT 310. Her urinary protein to creatinine ratio is 500 mg/mmol. She is given a dose of nifedipine and MgSO4 is started. A decision is made to do an immediate C/S with spinal.

Tutorial: McFadden Family IF Maternal and Child Health Risks

Part 5, Integration Foundation, Maternal Health Risks/Aging-Related Care, Week 1

Claire brings infant Marie to her family physician for the 2-month well baby visit, alone. When asked how she and Dave are adjusting, she mumbles “fine.” Marie has been “fussy” during the night, and Claire is finding breast-feeding to be a challenge. Newborn examination is performed, the Rourke baby record is completed and no concerns noted. Claire is motivated to breastfeed but she says Dave thinks formula is better and is worried the baby is not getting enough milk and that is why she is crying. “He says it is my fault.” The benefits of nursing to mom and baby are reviewed, along with formula options, and a referral to a lactation consultant is made. Two weeks later, the office receives an “urgent” call from Claire’s aunt asking that she be seen. Notably, Claire did not bring in baby Marie for a follow-up, in spite of a reminder call from the office. Claire is booked as the last appointment of the afternoon, and reception staff comment they heard screaming in the background while Claire’s aunt made the call. One receptionist says “things are not right” in the McFadden family.

Tutorial: Susanna Green Part 2 IF Chronicity and Complexity

Part 5, Integration Foundation, Complexity and Chronicity, Week 3

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.

Tutorial: Hannah Rosen Part 2 IF Chronicity and Complexity

Part 5, Integration Foundation, Complexity and Chronicity, Week 4

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.

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)

e-Learning Module: Anaphylaxis

Clerkship, Emergency Medicine Rotation

Be able to identify and define anaphylaxis. Know how to manage a patient with an acute anaphylactic reaction in the Emergency Depatment.

e-Learning Module: Family Medicine Pediatric Case

Clerkship, Family Medicine Rotation

Be familiar with Growth and Development Milestones and know how to determine if the child needs early interventions (Rourke, Nippissing). Nippissing has a new name Looksee. Describe the impact the social determinants of health have on health outcomes (young, single mother with little money and time to raise child). Appreciate the role of the Family Physician as an advocate for health - what resources can you leverage in the community to help optimize life for both Ashley and her mother? Be able to discuss contraception planning to prevent another unplanned pregnancy. Be familiar with common skin rashes in children

Essential Clinical Experience: Well baby / Well Child

Clerkship, Family Medicine Rotation

Tutorial: Periodic Health Review

Clerkship, Family Medicine Rotation

Clinical Exposure: HIV infection

Clerkship, Internal Medicine Rotation

Clinical Exposure: Fever

Clerkship, Internal Medicine Rotation

Self-Assessment Quiz: Isoimmunization

Clerkship, Obstetrics and Gynecology Rotation

e-Learning Module: Isoimmunization

Clerkship, Obstetrics and Gynecology Rotation

Clinical Exposure: Fever in Postoperative Patient

Clerkship, Surgery Rotation

Essential Clinical Experience: Fever in postoperative patient

Surgery Rotation

Concept Integration and Review: Obstetrics

Post-clerkship, Concept Integration and Review, Week 1

To review aspects of Obstetrics relevant to the LMCC exam. Clinical pearls for clinical practice. Clinical epidemiology.