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 2 MF1 Cardiovascular

Part 1, Medical Foundation 1, Cardiology, Week 3

Three years have now gone by and Novak B. has done very well. He has used his Nitroglycerin only once since you prescribed it, when he had to run for a bus. One night, you happen to be working an ER night shift at the local hospital when Novak is brought in by an ambulance. He is complaining of severe retrosternal chest pain, which started one hour ago. An EKG is obtained immediately and confirms an acute myocardial infarction (AMI). A chest X-ray is normal, as is his first Troponin T. You give him 162 mg of aspirin to chew, along with 180 mg of ticagrelor and enoxaparin 80 mg subcutaneously every 12 hours, as a starting dose. On examination, he is in distress from the pain and looks dyspneic. His pulse is 90 bpm and his respiratory rate is 24. His blood pressure is 100/70 mmHg in both arms. His O2 saturation is 90% on 2L oxygen via nasal prongs. His JVP is 5 cm above the sternal angle. He has bibasilar inspiratory crackles. His heart sounds are obscured by the ambient noise in the ER, but no obvious murmurs are heard. He has no peripheral edema. You briefly discuss percutaneous coronary intervention (PCI) and thrombolytic therapy. Novak does not consent to thrombolysis, but agrees to PCI.

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: 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: Ivan Horvath MF2 Renal

Part 2, Medical Foundation 2, Renal, Week 2

Ivan Horvath is a 70-year-old male with poorly controlled hypertension for approximately 20 years, dyslipidemia, and peripheral vascular disease. He has a 60 pack-year history of smoking. He has difficulty walking more than one block due to the development of pain in his legs. He has recently moved and you see him with his new family physician. He currently takes amlodipine (calcium channel blocker) and chlorthalidone (thiazide diuretic) for his hypertension.

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: Nancy Jones MF2 Renal

Part 2, Medical Foundation 2, Renal, Week 3

Nancy Jones is a 34-year-old Mohawk, Turtle Clan woman who has been well until four days prior to hospital admission when she developed abrupt onset of chills, rigors, and a productive cough. Subsequently Mrs. Jones became progressively short of breath, was obtunded and bedridden and was brought to the hospital emergency room. On arrival, her vital signs were blood pressure 80/60 mmHg, heart rate 148 beats/min, respiratory rate 42/min, temperature 39.6o C, and oxygen saturation 79% on room air. She was confused. Crackles were heard on auscultation throughout her chest. Heart sounds were normal with no murmur, JVP was flat, mucous membranes were dry and there was no peripheral edema. Abdominal examination was normal. The patient was intubated and transferred to the ICU.

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.

Anatomy Demonstrations: Applied Cardiovascular Pathology

Part 1, Hematology, Week 1

Tutorial: Carmine Garcia MF2 Hematology

Part 2, Medical Foundation 2, Hematology, Week 1

Mr. Garcia is a 57-year-old retired banker who loves to play golf and garden. Despite chronic hip pain for which he takes aspirin on a regular basis, he plays golf 2-3 times a week in the spring and summer. His wife has encouraged him to see you today because over the past 3-4 months he has felt increasingly tired, and in fact, has not done his usual summer plantings. She also finds him very irritable. With some reluctance, Carmine tells you that he has been short of breath on the green on a couple of occasions over the last week, and that he really feels too fatigued to garden for any length of time. This worries him, as he has some friends with cancer, and they seemed to have the same symptoms prior to their diagnosis.

Tutorial: Shane Mosley MF2 Hematology

Part 2, Medical Foundation 2, Hematology, Week 2

Shane Mosley an 18-month-old boy was brought to the emergency room by the baby sitter for treatment of a swollen and tender right knee that had developed suddenly within the previous three hours. The knee began to swell soon after Shane tripped on the family room carpet. Physical examination reveals an apparently healthy child who is crying and favouring his right leg. The knee is swollen and held in partial flexion. Shane has a few old, superficial bruises over shins, chest wall and his back. The physician in the ER concludes that there is fluid in the knee and because of the sudden onset and absence of fever, thinks this is most likely due to a joint bleed. The physician wonders about an underlying systemic bleeding disorder as the cause of Shane's joint bleed. A complete blood count, "hemostasis screen" and an x-ray of the knee are ordered.

Active Large Group Session: Introduction to Pathology

Part 2, Medical Foundation 2, Hematology, Week 2

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: Savita Singh MF3 Reproduction

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

Savita Singh, a 33-year-old married woman, is seeing her physician for amenorrhea. She was suspected of having diabetes mellitus 6 months ago after a round of routine blood tests. The diagnosis of diabetes mellitus was confirmed with repeat testing soon thereafter. Savita was immediately counselled on the importance of lifestyle modification, with special attention to weight loss and exercise at least 3 times per week. Since then, Savita has found it very challenging to integrate these recommendations into her busy lifestyle and says she has “only lost 3 pounds.” Savita has always had irregular menstrual cycles since menarche at age 11, generally having periods once every 1-3 months on average. She could not reliably predict when a period would start or end. Her menses were sometimes very light and sometimes extremely heavy. For the past 6 months, however, she has had no period whatsoever. Savita has never been on any medications. Her family history is significant for type 2 diabetes and premature coronary artery disease, with her father having had a myocardial infarction at the age of 45. On physical examination, Savita has a weight of 77 kg and height of 153 cm. Her abdominal circumference is measured at 93 cm at the umbilicus. There are small skin tags and hyperpigmentation noted at the back of her neck and in both axillae. Her abdomen has some striae but they are pale, thin and not depressed. She has excessive hair growth on the upper arms, upper chest, abdomen, lower back and face with a Ferriman-Gallwey score of 16/36. There is mild acne and her hairline appears to be receding. There are no virilizing signs on exam. Fundoscopic examination reveals changes consistent with early non-proliferative diabetic retinopathy. Examination of the feet does not show any signs of neuropathy.

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: 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: Susanna Green Part 1 MF3 Endocrinology

Part 3, Medical Foundation 3, Endocrinology, Week 1

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.

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: 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: 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.

Clinical Pathology Conferences (CPC): Neuro Week 1

Part 4, Medical Foundation 4, Neuroscience, Week 1

45 yr old male noticed some clumsiness and weakness of the left hand.

Large Group Session: Neuro Toolbox - Muscle/nerve histology, physiology and EMG-NCS

Part 4, Medical Foundation 4, Neuroscience, Week 2

Muscle and nerve neuropathology basics. Clinical examination. Muscle enzymes CPK. Electrophysiology EMG. Muscle biopsy. Type 1 and 2 muscle fibers. Muscular Dystrophies. Inflammatory Myopathies. Congenital myopathies. Metabolic muscle disease. Mitochondrial disease. Peripheral nerve and motor unit. Electromyogram (EMG) and Nerve Conduction Studies (NCS).

Clinical Pathology Conferences (CPC): Neuro Week 2

Part 4, Medical Foundation 4, Neuroscience, Week 2

Harry is a 64-year-old with new-onset seizures (L arm jerking then loss of consciousness) lasting 20min in duration, with 3h before returning to baseline. On context of intermittent headache & blurry vision for few months, 3wks of progressive, insidious onset L arm weakness.

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).

Clinical Pathology Conferences (CPC): Neuro Week 3

Part 4, Medical Foundation 4, Neuroscience, Week 3

67 year-old woman reporting numbness and tingling in feet. Started in toes and has progressed to entire foot over the past 12 months. Feels like “walking on socks” even when her feet are bare. Especially bad at night and in morning upon awakening. Toes have also started feeling “heavy”, hard to wiggle.

Clinical Pathology Conferences (CPC): Neuro Week 4

Part 4, Medical Foundation 4, Neuroscience, Week 4

Nancy: 50-year-old female, one year of involuntary movements. The movements wax and wane during the day, but completely stops while asleep. Movements were initially subtle but progressive over time. Five years ago, she was fired from her job due to impulsivity and anger issues. Since this time, she has been unemployed, withdrawn, and depressed

Tutorial: Arielle D

Part 5, Integration Foundation

Arielle is a 41 yr old female presenting to her family doctors office with concerns of irregular menstrual cycles and painful intercourse. Arielle states she has noticed increased episodes of spotting in between her menstrual cycles over the past 8 months. Arielle has also noticed increased vaginal discharge and abdominal cramping at times with associated swelling of her legs. Arielle thought her lower leg symptoms were a result of her long work hours and standing for long periods of time. Arielle immigrated to Canada from the United States 15 years ago. She works as a daycare attendant and a waitress on the weekends to support her parents who reside with her and her partner. Arielle did not have regular access to healthcare as a teenager while living in Florida with her parents who immigrated to the US from Mexico shortly after Arielle was born. Arielle did not receive any vaccinations as a child or as a teenager. Arielle was sexually active at the age of 14 with multiple partners before her husband. She has been in a monogamous relationship for the past 6 years. Arielle reports she has given birth to 3 children which she gave up for adoption and underwent 2 pregnancy terminations prior to meeting her husband. Her husband does not know about any of the previous pregnancies or procedures she underwent prior to meeting him.

Tutorial: Godlewski Family IF Host Defence and Neoplasia

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

Paula Godlewski is a 50 year old Jewish woman of east European descent. She comes to the appointment with her daughter Anna. She has come to be assessed by a medical oncologist for consideration of systemic therapy following the diagnosis of a node positive breast cancer. Anna, who is 25 years old, asks if this cancer is inherited and whether she will get breast or ovarian cancer. she asks whether she should have prophylactic mastectomies and oophorectomies if her tests were to be positive.

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: Albert Johnson IF Host Defence and Neoplasia

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

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.

e-Learning Module: Integration Foundation Pathology Cases

Part 5, Integration Foundation, Complexity and Chronicity, Week 1

Normal Histology and Disease. Integrating Pathology Into the Clinical Picture. The frozen section (intraoperative consultation).