Opportunity to consolidate knowledge acquired through PBL cases. Review of high yield orthopedic clinical pearls. Opportunity to actively practice relevant clinical skills such as reading imaging (within the confines of virtual learning).

This session is intended to generate a discussion towards formulating a basic early understanding of pain for future physicians. It is also intended to serve as a framework for future learning about how pain manifests in the context of health or disease, be it acute, chronic, or terminal, and to consider how it might be managed. Finally, this session is intended to begin illustrating how psychological, environmental and social factors can influence the experience of pain and its management thus resulting in the potential need for an interdisciplinary approach in that regard.

Epidemiology. Nosology. Brain and behaviour. Medical Psychiatry. PBL cases. Five steps to differential diagnosis. Sub-unit overview.

To review the common movement disorders relevant to psychiatry. A general approach to management of the specific disorders. To review the key components of cognitive assessment.

Interviewing techniques. Review of Psychiatric Interview. Risk Assessment. Cognitive Assessment

Sympathetic toxidrome. Anticholinergic toxidrome. Cholinergic toxidrome. Opioid toxidrome. Sedative Hypnotic toxidrome. Hallucinogens

Consists of 7 days in the OR (maybe less in case of holidays) and 2 on call shifts.

Students must complete 12 x 8 hour clinical ER shifts.

Students will be scheduled to complete one 2 hour triage shift with nursing staff.

Students will be expected to care for up to seven patients, including Alternate Level of Care patients (ALC – awaiting rehab, long term care, palliative care, or other type of care facility). Ideally, a student will care for a blend of patients with “acute” problems as well as those with more chronic issues such as ALC patients.

This may be in the inpatient and/or the outpatient setting based on the specific MSS rotation.

Each student will be assigned to a community Ob/Gyn. Students are expected to participate in 8 half day clinics with exposure to both Gynecology and Obstetrical patient populations.

During the Hospital rotation students participate as part of the Ob/Gyn team. Time spent on L&D, post?partum and gynecology. Students are expected to be present at normal births, caesarean section, ER consults, OR and if appropriate more complex issues presenting to the service. Students will participate in the on call schedule.

Nearly twenty percent of all problems presenting in the Primary or Acute Care setting are based in musculoskeletal pathology. The objectives outlined for this two-week Clerkship must be considered as nominal and must not act as a limit to a student's personal learning in the diagnosis and management of musculoskeletal related diseases. To this end, one of the "attitudes" objectives of this Clerkship is to encourage in the student an enthusiasm for life long learning.

The pediatrics clerkship rotation is a six week rotation during which the clerks are placed in one of 4 tracks and have exposure to both ambulatory and inpatient pediatric care.

Each Hamilton campus clerk will be assigned 2 Psychiatry Emergency Services (PES) shifts.

Each clerk will be assigned to 2-3 primary clinical supervisors. The supervisors will be responsible for the supervision, assignment and evaluation of clinical work. Clinical placements may occur in a variety of settings, including inpatient, outpatient, general psychiatry, or subspecialty settings (e.g. child and adolescent, geriatrics, eating disorders, mood and anxiety, forensics, schizophrenia, dual diagnosis, etc.). These placements can occur in academic hospitals, community hospitals, or community clinics.

During this six week rotation students will be involved in a variety of clinical scenarios and learning opportunities designed to enhance their knowledge and skills. Students will interact with patients and their families in all aspects of surgical care (hospital wards, outpatient clinics, operating room, emergency department, intensive care unit, etc.).

The case: 29 yo Caucasian male; Presents with 8 weeks of bloody diarrhea; What is your differential for bloody diarrhea? What tests would you order to evaluate this patient?

Introduce head and neck cancer. Illustrate using a clinical presentation with pathological correlation. Develop an approach to patients with head and neck symptoms.

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

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

Review an approach to assessment of mood disorders, including exploring unique considerations for adolescent patients. A 14yo M presents with mom to family medicine clinic with concerns for low mood.

Examples: Acute cholycystitis; Acute appendicitis; Traumatic acute abdomen. Observation of student taking a history from a patient with abdominal pain. Demonstration by preceptor of examination of a patient with abdominal pain. Observation of students examining a patient with abdominal pain. Discussion regarding abdominal pain.

Practice the Abdominal history and physical examination. Sam has been feeling unwell for about 4 months. They are complaining of a yellowing of their skin and swelling of their feet which has been getting progressively worse over the last 4 months. Pro Comp connection – Patients with Skin of Colour.

Practice the Abdominal history and physical examination. This case should be used to practice & to consolidate Abdominal history & physical exam as it pertains to Weight Loss/Diarrhea

Standardized case 55 year old female with epigastric pain.

Discuss and practice the components of the Adolescent history. Pro-Comp Connection – Child Maltreatment

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.

Observations of a student(s) interviewing a patient with history of syncope. Demonstration by preceptor of examination of a patient with syncope. Observation of a student(s) examining a patient with  syncope. Discussion regarding syncope. Example: cardiovascular, metabolic and lung causes, blood pressure, EKG, etc.

Assessment of Mood. Key concepts: Symptoms, syndromes, episodes, and disorders. Depressive symptoms. Manic Symptoms. Mood Episodes and Disorders: Major Depressive Disorder, Bipolar Disorder. Screening for depression. Assessment of Anxiety. Main Anxiety Disorders: Specific Phobia; Social Phobia (aka social anxiety disorder); Panic Disorder with/without Agoraphobia; Generalized Anxiety Disorder; Obsessive Compulsive Disorder; Post-traumatic Stress Disorder.

Interviewing psychotic patients. Dealing with psychosis and intense affect. Dealing with poor insight. Dealing with indifference. Screening questions for psychotic-like experiences. Delirium.

Discuss and practice the components of the history and physical exam for the Back and GALS Exam. Demonstrate a focused musculoskeletal examination.

To practice the Cardiac history and physical exam. Pro Comp connection care for Adults with Intellectual and Developmental Disabilities (IDD).

Standardized case of 65 year old male with chest pain.

To learn the Diabetic history & physical examination. Pro Comp connection – Indigenous Health and Diabetes Mellitus – Strengths-Based Approaches: Diabetes Canada, in its 2018 guidelines highlight social determinants of health play an important role in risk of diabetes and complications. It is important to understand more holistically the structural determinants of health, particularly colonialism, and its cascading effects on the social determinants of health including access to nutrition, employment, education and experiences in healthcare, and how these structural and social determinants impact the risk of diabetes in Indigenous population.

To practice a palliative care assessment, including symptom assessment, detailed social and functional history, and practice a goals of care discussion using the Serious Illness Conversation Guide (Click for link) as a template. To practice using likelihood ratios from the JAMA Rational Clinical Exam Article Does this patient have a pleural effusion? to formulate a post-test probability of pleural effusion in this case. To discuss common clinical tools helpful in a palliative care assessment, including the Edmonton Symptom Assessment Scale (ESAS – Click for link), and Palliative Performance Scale (PPS). To discuss core principles of primary palliative approach to care. Pro Comp Connection – Palliative care for marginalized populations.

Practice the history and physical exam as it pertains to edema.

Discuss and practice the components of the Gynecological and Sexual histories. Pro-Comp Connection – LGBT2SQ+ Patients. LGBTQ2S+ patients in Canada experience worse health outcomes than their heterosexual, cisgender peers.

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.

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.

Review and to practice an approach to history and exam of headache including red flags. A 21yo F presents to family medicine clinic with headache.

Standardized case 30 year old female with fatigue.

Discuss and practice the components of the history and physical exam for the Hip and Knee.

To discuss and to practice history taking and patient-centered communication skills.

Learn how to perform the abdominal history and physical examination.

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

To discuss and to practice the components of the Volume status history and physical examination.

To describe and to practice applying effective patient-centered communication skills as part of history-taking to assist with building and strengthening the patient-physician relationship.

To describe how to perform the components of the medical history.

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

Introduce what a physical examination is, and the basics on how to perform one in a patient-centred way as a group discussion. Discuss proper technique, the importance of consent, privacy, draping and use of appropriate medical equipment (i.e., stethoscope, blood pressure cuff, etc.) Introduce Vital Signs, including normal and abnormal values. Discuss factors that affect vital signs. Pro comp connection: Patients of Varying Body Habitus. Patients presenting to medical professionals for clinical care represent a variety of body habituses. Body mass index (BMI) is used as a clinical indicator of body habitus, calculated based on a person’s height and weight. Patients are classified according to their BMI as underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (25.0-29.9) and obese (>30.0). Note that although BMI is used clinically, it was originally a population health measure and was derived from a homogenous group (Belgian population). Therefore, its utility for individual patient care may be limited. Epidemiological studies have shown a correlation where the risk of hypertension, type 2 diabetes, sleep apnea, cancer and a variety of other conditions increases as BMI increases; therefore, the classification system is meant to capture increasing health risks. It is important to note that a causal relationship between BMI and these health conditions has not been shown.

Discuss and practice the components of the history and physical exam for a patient presenting with a loss of consciousness or an altered level of consciousness. Discuss and practice the components of the screening neurological examination.

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.

To discuss and to practice the components of the Newborn history. Pro-Comp Connection – food and housing insecurity.

To discuss and to practice the components of the Obstetrical history as it pertains to Intrapartum Care. To apply key terminology appropriately in intrapartum care, including: Diagnosis and stages of labour, including differentiating term from preterm labour. Diagnosis of rupture of membranes (ROM), including differentiating spontaneous rupture of membranes (SROM), prelabour rupture of membranes (PROM) and preterm prelabour rupture of membranes (PPROM). Practice taking a focused history in an intrapartum care setting, with a focus on four essential triage visit questions (Contractions/labour; Fluid/rupture of membranes; Bleeding; and Fetal Movements). Demonstrate use of gender-inclusive perinatal language (e.g. parental leave, birthing parent, chest-feeding). Practice navigating key challenges in delivery of intrapartum care in rural and remote settings, including recognizing limitations of scope of practice to inform shared decision-making. Pro-Comp Connection – Indigenous Health and Prenatal / Intrapartum Care

Medical students should recognize external and internal structures of the normal human eye and know how to perform a basic eye examination (ICO Curriculum for Ophthalmic Education of Medical Students). Students rotate through eight stations: 1. History taking in Ophthalmology 2. Visual Acuity measurements and pupillary examination. 3. Extraocular muscle movements and visual field guide. 4. External eye and slit lamp examination. 5. Intraocular pressure measurement and pachymetry. 6. Fundoscopy. 7. Pediatric examination and strabismus measurement. 8. Trauma management, lid eversion / foreign body removal and eye patching.

Review an approach to history and physical exam for Parkinson’s Disease, including practicing screening neurological examination. A 70yo F presents to neurology clinic, referred for tremor and falls.

To discuss and to practice the components of the Peripheral Vascular history and physical examination.

Practice the Renal history and physical examination as it pertains to Hematuria. Pro Comp connection Indigenous Health - The case of Brian Sinclair is an important example of a fatal consequence of systemic racism in the Canadian Healthcare System. He was a 45-year-old First Nations man who died of a treatable bladder infection in 2008, after being ignored for 34 hours in the emergency.

Practice the history and physical exam as it pertains to nephrolithiasis. Standardized case of 44 year old male with flank pain.

Discuss and to practice the components of the respiratory history and physical examination. Practice an approach to the environmental exposure history using the CH2OPD2 format. Pro Comp Connection – Health Effects of Climate Change.

Discuss and practice the components of the respiratory history and physical examination. Practice an approach to the environmental exposure history using the CH2 OPD2 format. Pro-Comp Connection – Health Effects of Climate Change: : Climate change presents a fundamental threat to human health, with the potential to undermine and reverse decades of health progress. Increasingly frequent disruptions caused by climate change may overwhelm the efforts of the healthcare system to address social determinants of health, if those latter efforts ignore the changing environment. Climate change impacts health both directly and indirectly and is strongly mediated by structural determinants of health.

Demonstration by preceptor taking a history from a patient with chest pain, cough and fever, hemopytsis, etc. and performing appropriate physical examination. Observation of a student (s) taking history from a patient with chest pain, cough and fever, hemoptysis, etc. and performing appropriate physical examination. Discussion: regarding chest pain, cough and fever, hemoptysis, etc., etiology, differential diagnosis, investigations, etc. (Examples: chest pain, cough and fever, wheezing, hemoptysis)

Observation of a student(s) taking history from a patient with diabetes (polyuria, polydipsia, fatigue, etc.) and performing appropriate physical examination. JAMA article review: Does this patient have diabetic neuropathy?

Discuss and practice the components of the history and physical exam for the Shoulder and Elbow.

By the completion of this presentation, attendees will be able to describe risk factors for suicide; be familiar with key components of a suicide risk assessment; be aware of questions to use in a suicide risk assessment.

3 station Teaching OSCE. Each station is 15 minutes long. Students alternate interviewing and observing a patient.

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.

Practice the history and physical exam as it pertains to vomiting and diarrhea.

Discuss and practice the components of the history and physical exam for the Wrist / Hand and Ankle / Foot.

An interactive, self-directed web-based resource regarding developmental disabilities for medical students and residents. This project includes introductory information about the topic of developmental disabilities, including information about terminology, definitions, adaptive skills, and levels of developmental disability.

Describe an elderly patient's functional status using patient and collateral history. Define "Frailty" in the context of the following common problems as they contribute to functional status decline in the elderly including: Incontinence, Falls, Polypharmacy, Depression, Cognitive impairment (FM approach). Identify important topics of discussion with the elderly patient and family/caregiver meetings including: Advance care planning and Goals of Care discussions, Caregiver burnout, Driving, Community resources, Transition planning.

Describe the palliative care approach to care, and who may benefit from it. Assess and manage pain and other common symptoms in palliative care. Understand the interprofessional approach to providing palliative care. Organize care for the actively dying patient and family. Describe an approach to responding to grief, bereavement, and suffering

This will provide you with a review of the legislation and the methods that are used to bring a person to hospital in Ontario, as well as some of the key aspects of completing the Form 1 of the Mental Health Act, including the examination, criteria for dangerousness, concept of mentor disorder, time-sensitive issues, and invalid Form 1's. A Guided Tour and Examples of the Form 1 and Form 42. Common errors in filling out the Form that we encounter in practice.

Know the role of the Mental Status exam (MSE) in the assessment and management of the patient. Understand the differences between the MSE, the MMSE, and the psychiatric interview. Elicit elements of the MSE during the psychiatric interview. Verbal report and write up of the psychiatric interview, including MSE.

Principles of mood assessment. Mood episodes and disorders: Depressive, manic, mixed, hypomanic. Screening for depression. Psychiatric history. Anxiety.

Psychotic symptoms are common in a wide variety of medical, psychiatric, and substance-induced disorders. They are important to illicit and have important implications for diagnosis, treatment and management.

While psychiatric disorders are common, and many can be deadly, they are also treatable. You can make an enormous difference in morbidity and mortality through proper suicide assessment. Suicidal intent is a medical emergency.

How motor function helps to determine localization in the neuromuscular exam. Relevant neuroanatomy motor system. Clinical importance and clinical Examination. Patterns of weakness with anatomy correlation.

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?

The major topics will be: Nutrition for growth and development; Nutrition for prevention of diabetes and cardiovascular disease; Nutrition for prevention of cancer

Radiology Procedures: Plain Films, Barium Studies, Angiography, US, CT, MRI, Nuclear medicine, Endoscopy, ERCP. Barium Studies: Barium Swallow, Upper GI Series, Small Bowel Follow-Through, Small Bowel Enema, Barium (Large bowel) enema.

How much Neuro do you need to know? What do residency program directors expect? Weekly themes: Week 1:Muscle, NMJ, Nerve. Week 2: spinal cord, brainstem. Week 3: Basal Ganglia, Limbic system. Week 4: Cerebral cortex. Muscle. Localization. Neuromuscular junction. Nerve. Resting potential. Post-synaptic potentials. Anterior horn. Central vs. peripheral nervous system. Spinal cord. Brainstem. Cerebellum. Limbic system. Basal Ganglia. Cerebral cortex.

Introduction to the basic clinical exam, relevant anatomy and common clinical scenarios. Ears, Nose, Sinuses and Nasopharynx, Oral Cavity and Oropharynx, Head and Neck, Neck, Larynx, Thyroid.

The Objectives are to introduce the medical specialty of Physiatry (Physical Medicine and Rehabilitation). To review common medical problems seen by a Physiatrist. To review some cases from a Physiatric perspective.

At the end of this session, students will be able to: Identify common causes of nausea in the palliative care population. Identify some methods of treating nausea based on cause. Identify questions to ask to see if artificial nutrition would be worthwhile for a patient.

What is febrile neutropenia (FN)? What should I ask the patient with respect to potential causes of FN? Which bacteria are most commonly associated with FN? FN Management.

An overview of mental health and consent law in Ontario. Consent and capacity. Consent to treatment doctrine as commonly applied at many Ontario health facilities. Consent to treatment doctrine as required by Ontario law. The Health Care Consent Act (HCCA) sets out a single set of rules for consent to treatment. Failure to obey the rules is defined by CPSO as professional misconduct.

What is the MSE? Component of interview or patient encounter. Structured observations and inquiries regarding signs and symptoms of conditions that affect the CNS. Records observed behaviour, cognitive abilities and inner experiences expressed during the interview.

Anxiety, Depression and Bipolar Disorder. Review types of anxiety and mood disorders. Examine common biological constructs underlying anxiety disorders and mood disorders. Discuss comorbidity between anxiety and depressive disorders and the impact this has on outcomes.

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).

Genomic imprinting. Uniparental disomy. Prader-Willi Syndrome. Angelman Syndrome. Epigenetics. Nucleotide Repeat disorders. Trinucleotide Repeat disorders. Fragile X syndrome. Common characteristics of repeat disorders.

Understand that principles for chronic disease prevention through lifestyle are remarkably similar for diabetes, excess body weight, cardiovascular disease and cancer.

X-ray interpretation of fractures. Growth Plate Injuries. Basic Trauma and Fracture Management. Clinical examination. Upper extremity. Lower extremity. Spine. Emergency conditions

Trauma orthopedics. Pediatric orthopedics and infections. Reconstructive orthopedics.

Past obstetrical history. Gynecologic history. Menstrual history. Contraceptive history. Pregnancy history. Sexual history. Past gynecologic surgeries. Past and current medical history. Family history (familial cancers, gynecological problems, psychiatric history). Occupational and social history.

Chronic physical complaints which suggest a medical condition. Cannot (yet) be understood or explained in terms of an underlying organic pathology. Not intentionally produced. Disabling. Somatization disorder. Hypochondriasis. Conversion disorder. Body dysmorphic disorder. Pain disorder. Factitious disorder / Munchausen's Syndrome.

Acute abdominal pain is a common and notoriously difficult clinical problem to diagnose and manage. Understanding of pathophysiologic pain patterns and innervation anatomy can aid in honing DDx (intra vs. exta abdominal dz.). Epidemiology and pathophysiology of pain. Differential diagnosis of acute abdominal pain. Clinical assessment. Investigations; limitations of diagnostic tests. Likelihood ratios for commonly used tests. Intro to Clinical Practice Guidelines. Hierarchies of Evidence-Methodology. Initial treatment strategies. Disposition.

What is a child psychiatric disorder? The classification scheme of the most common child psychiatric disorders. The etiology, prevalence, outcome, and treatment of the most common disorders. The relationship between child and adult psychiatric illness.

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

This session will provide a population health overview of the key issues related to the aging population as well as highlight the knowledge and skills that physicians need to deal ethically and professionally with older adults.

This session will provide students with their first opportunity to work with Standardized Patients while developing their communication skills.

This is the second session during which students will practice communicating with Standardized Patients.

In this session and the second one later in MF3, students will explore the last three essential tasks/skills in reasonable depth and gradually refine them with increasing complexity as they move through the Program.

During this session, students will demonstrate the ability to apply the final three elements of the Kalamazoo Guidelines for Effective Communication. Elements include: Sharing information, reaching agreement, providing closure.

The developmental disabilities session is designed to generate more capable (comfortable, confident and competent) physicians and partners in person and family - centred care to people with developmental disabilities.

Students will develop an understanding of grief and its diverse forms. Critically examine and reflect on attitudes and beliefs about grief. Develop an appreciation of sociocultural influences on the experience of grief, including grief in the context of COVID-19. Challenge Western concepts of grief and consider cultural variation in the expression and management of grief. Develop an understanding of how to respond to grieving patients.

Students will be introduced to the SPIKES protocol. During tutorial students will practice the application of the SPIKES protocol using role plays .

This session will introduce the concepts of trauma and trauma-informed care to medical students. This session emphasizes the importance of identifying trauma and the impact on health. It builds on and extends the skills learned in the communication domain and reinforces concepts from the session on narrative medicine by emphasizing the importance of respectful and effective interactions with trauma survivors and helping students to appreciate the healing power in these interactions.

The four-week Family Medicine rotation revolves around a one-to-one experience pairing a student with a community-based family physician. The most significant component of the Family Medicine rotation is this time spent with the clinical preceptor in the office setting.

Oxygen delivery. Ventilation. Hypoxemia.

Neuroanatomic Localization, Spinal Cord Pathology, Concussion

Dizziness, meningitis, stroke, headache

Muscle Weakness, Peripheral Neuropathy

Gait Disturbance, Movement disorders, Febrile Seizures

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Amanda, a 12 year old girl, has been accompanied by her mother to see her family doctor for a routine check-up. Her mother is a single mom who works shift work as an R.N. at the local E.R. department. She and Amanda currently reside in a suburban neighbourhood of Hamilton. Amanda attends a public school in her neighbourhood and complains of being constantly teased by her classmates for being "bigger". According to her mom, Amanda participates in gym class, but does not get much more physical activity than that. Amanda spends a lot of time alone while her mother works shifts. She admits to watching approximately 3 hours of television per day on weekdays and 5 hours on the weekends. She is also on the internet, chatting on MSN, for 1-2 hours per day. Her mother is also obese and is not worried about her daughter's current weight or the sedentary lifestyle and is rather pleased that Amanda is a "good girl". Amanda does not express interest in participating in local clubs or extracurricular activities and indicates that she is simply not an "athletic type" of individual.

Amir Boutros is a 30 year old man with a history of Crohn's disease who presents to the hospital with a recent history of increased pain and diarrhea. He is very weak, dizzy and short of breath. His BP is 80/50 with a heart rate of 120 and respiratory rate of 24. His chest X-ray is normal.

Part One: A thin 65-year-old woman presents complaining of back pain that began 5 days ago while lifting her wash. The pain becomes worse when she rolls over in bed or when she stands up. She has noticed that the hems of her skirts seem longer and on measurement she appears to have lost 6 cm in height. Part Two: The patient reports she got over that last "attack" after around 3 months. She was commenced on a bisphosphonate, calcium, and vitamin D. She now returns 2 years later because of another attack of acute back pain after falling on the ground.

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.

Ann Green is a 66-year-old woman who was referred to the rheumatology outpatient clinic by her family physician, Dr. Mac Grad. In his referral note, Dr. Grad states that Mrs. Green has been experiencing joint achiness for the past several years, involving mostly her hands and knees. From time to time, she has also reported low back pain. Her symptoms have always been relatively mild and have never stopped her from carrying on with her general daily activities or her charitable work in the community. What currently concerns Dr. Grad is that Mrs. Green's symptoms have progressed. Usually a rather stoic person, she is now complaining of increased pain in her fingers and both knees. Because of her knee pain, she is having increasing difficulty walking. Whereas previously her pain would always settle after she took some Tylenol, this is no longer the case. On physical examination, Dr. Grad elicits tenderness at several of the proximal (PIP) and distal interphalangeal (DIP) joints of both hands and at the carpometacarpal joint of the left thumb. Heberden's nodes are evident at the DIP joints bilaterally. Tenderness is also present at the joint lines of both knees; and there is (chronic) puffiness on both sides, but more pronounced on the left. Knee flexion is reduced and there is bony crepitus. Radiographs demonstrate osteoarthritic changes at the wrists, the PIP and DIP articulations of the fingers, and moderately severe (tri-compartmental) degenerative changes at both knees.

Beau is a 3-year-old boy, the youngest of three children. His father manages a local bank and his mother is a stay-at-home mom. He has two older sisters, Theresa age 7 and Gracie age 9. His parents are in their late 30s. Beau is the focus of the entire family's attention and the apple of everyone's eye. His sisters behave like 2 additional mothers, to the point that they anticipate his every need. His parents have even noted that his language development seemed slightly slower than his sisters' as he did not need to use language to have his needs met. He now speaks well but it just seemed to be slower than his sisters (who his mother described as early talkers). Beau's mother's pregnancy was unexpected but welcomed. The pregnancy was uneventful with no history of substance use. Beau was full term and the delivery was uneventful. Beau was a cute and cuddly infant. He breastfed well and developed predictable routines for both sleeping and feeding. He appears quite adaptable. For instance, when family visits other family or friends, Beau smiles, plays and amiably engages children and adults alike. He has even slept well at these homes if needed. He needed only his favourite blanket in those situations to assist him with settling down to sleep.

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

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.

Brock is a 25-year-old man who sustained a laceration to the upper third of his right forearm when he accidentally put his arm through a plate glass window. He presents to the emergency room. On examination, the ER physician finds Brock has significant weakness dorsal and palmar interossei, resulting in weakness of abduction and adduction of the index, middle and ring finger of the right hand.

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.

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.

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

Chantal is a 5 year 2 month old child who presents with advanced development of the breasts for the past 7 months, and possible growth of pubic hair. This is associated with rapid growth. She has had intermittent "spotting" during the last two days. Apart from occasional emotional outburts (crying, "fighting" with her 9 year old sister and with her mother) she has no other problems. Chantal's Mom is 36 years old and a school teacher with height at the 50th centile. She had menses at age 13 years. Dad, 44 yrs old, is a lawyer with a height at the 50th centile. He began shaving at ~ 15-16 years of age. He has mild hypertension. The family history is negative for early puberty. The parents are non-consanguineous.

Identify key history and physical examination findings pertinent to the differential diagnosis of acute limp in a child. Review common causes of acute limp in children and formulate an approach for initial diagnostic work-up.

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.

Claire McFadden is a 16- year-old high school student, living with T1D since age 10, who is currently pregnant (G1). Claire has struggled with her diabetes management in the past but is trying to keep her sugars at target now that she knows she is pregnant. Her most recent HbA1C was 7.8%, and she is using an insulin pump. Claire is being followed concurrently by her endocrinologist and has had microalbuminuria and mild non-proliferative retinopathy but no other diabetic complications. She has been normotensive with a usual BP of 110/70. She was told to start prenatal vitamins with extra folate as well as to discontinue her ACE inhibitor when her pregnancy test was found to be positive. Claire was also started on low-dose ASA (LDASA) at 12 weeks. Her partner, Dave, is 18 years old and is unemployed, having graduated high school in the summer. Claire is living with Dave in her aunt’s apartment. Her pregnancy was unplanned, but she is now excited to become a mother. She is planning to take a year off from high school and then return to complete her high school diploma. Dave is unhappy about this and feels she should stay at home to take care of the baby. They have argued about this, and Dave feels it is Claire’s own fault if she does not like making sacrifices as she could have gotten an abortion like he wanted. Claire worries about Dave’s temper, explaining that when he found out she was pregnant, he yelled at her and then disappeared for a week. She thinks he will come around once the baby is born.

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.

Daniel Gatto is a 41-year-old stockbroker. Once a top level soccer player, he now plays the game only over weekends, though he is sometimes able to get out for his club's midweek practice session. He enters your walk-in clinic on a Tuesday morning, limping slightly and reporting that he has been having increasing problems with his right knee over the past month. The knee has been intermittently painful and has seemed swollen from time to time. He has also been concerned about what he describes as "a feeling of weakness" of the knee, as though it was about to "give way"

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).

Desta Ayo is a 42 year old woman, on disability pension and married to a disabled man. She was brought to the hospital by ambulance after she called 911 to report she was dying. After running a few tests, the ER physician could not find anything wrong with her. He referred her to psychiatry because the problem was obviously "all in her head." On interview, Desta sits motionless in the chair, opening her eyes and speaking with dramatic effort. She believes she is again suffering with another kidney infection, like the one that almost killed her 10 years ago. She describes "passing out" almost every day for the last 2 weeks, feeling too weak to walk, and experiencing crippling back pain. She denies anxiety and depression but continues to take paroxetine for chronic pain and Trazodone for sleep. She says she has arthritis throughout her back, frequent migraines, temperomandibular joint pain, chronic fatigue, and recurrent sinusitis that eats away at her nasal bones. She also reports a history of gynaecological problems since age 22, with breast cyst and ovarian cyst surgery, endometriosis, and uterine fibroids. She reports an early childhood history of sexual and physical abuse. She remembers her mother as an alcoholic, a distant and cruel woman. Inquiries about current stress in her life reveal major financial problems and an argument with her mother on the phone 2 weeks ago. She says that she doesn't think her mother will ever talk to her again.

Apply knowledge of the expected changes across the lifespan in the care of patients with psychiatric disorders and medical conditions; Apply knowledge of the major psychiatric disorders in the care of pediatric patients (including but not exclusive to mood disorders, anxiety disorders such as separation anxiety disorder, reactive attachment disorders, etc.); Prioritize a differential diagnosis by applying knowledge of psychopathology and medical illnesses;Apply knowledge of potential signs/symptoms of abuse when developing treatment plans, including when to report suspected abuse.

Elena Christakos is a 54 yr old lady who presents to the Emergency Room with a 48 hr history of fever (temp up to 39.6 degrees celsius), chills, and weakness. Her condition in the ER deteriorates; BP falls to 80/50 and she becomes anuric. She is thought to be developing septic shock and is transferred to the ICU.

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

Fergie is a 23-year-old single woman with no children who lives with her parents. She completed university with difficulty, taking time off frequently but eventually completing her degree. She reports having difficulties with relationships since middle school and not knowing who she really is affects her mood, attention and concentration. This had an impact upon her schooling but she managed to finish with a huge effort. However, she has been unable to ever work in any capacity since finishing University a year ago. Fergie was referred by her family physician for a psychiatric consultation because she frequently presented to the family physician or student health with low mood and suicidal ideations. At times her family doctor had to send her to ER for urgent assessment following disclosure of taking an overdose or cutting her arms. She is hoping that some medications like an antidepressants will be prescribed for her and that you will believe she is unwell and needing help. She has a huge hope that you will see her regularly, and provide her with answers as to why she is not feeling happy, why she feels empty, and why she is unable to control her anger. She is also considering bipolar disorder as she heard from student health counsellor that she may have a bipolar disorder because she reported increased spending, increased sexual activity, and reckless driving. And she also informed you that she has an eating disorder when she binge eats at times. She is well read on mental health and has attended many counsellors since middle school including private therapists that her parents took her to see.

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.

Gayle Parker is a 12-year-old girl who was recently noted by her dance instructor to have shoulder asymmetry. She has no pain, neurological symptoms such as dysesthesias, or bladder/bowel dysfunction. The deformity has not changed since it was first noticed.Gayle has recently started her menses

Demonstrate an understanding of the interface between psychiatry and medicine and the importance of identifying and treating psychiatric illness in medical patients. Discuss how medications can result in mood disorders and how to identify and treat mood disorders in medical patients. Discuss the importance of multi-disciplinary care in the treatment of patients with medical and psychiatric illness as well as issues such as addiction and chronic pain. Discuss the potential medical implications of treatment with SSRI medications. List some pharmacokinetic changes associated with aging. Identify cognitive changes associated with aging. Describe some common bed side cognitive assessment tools.

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.

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.

Hannah, a 1-year-old girl, is brought to the clinic for a routine immunization by her mother. Mr. and Mrs. Rosen have a healthy 5-year-old boy at home. The pregnancy with Hannah was uneventful and a fetal ultrasound done at 16 weeks gestation was normal. The baby was born by spontaneous vaginal delivery, breathed immediately, and was placed on the breast for mom to nurse. Hannah's birth weight was 3.4 Kg. After seeming to feed normally for 24 hours, Hannah vomited bile and the abdomen was noted to be distended. An x-ray was interpreted as showing a distal small bowel obstruction. Further contrast x-rays of the colon showed a microcolon and inspissated meconium in the proximal colon, making a diagnosis of meconium ileus. Genetic testing confirmed cystic fibrosis. After a lengthy hospitalization to correct the bowel obstruction, Hannah was discharged home receiving exclusive breast milk. At 4 months of age, Hannah was switched to a cow's milk formula. Her mother noticed that she cried a lot. Hannah's mom attributed the symptoms to a milk allergy and progressed through a variety of cow's milk and soy formulae. At present Hannah is taking 1 litre of Rice milk and a small variety of foods daily. She has one small formed stool per day. She weighs 8.5 kg and is 74 cm tall.

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

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.

Part One: Jake Gamble, an obese 65-year-old man, presents complaining of back pain that began 5 days ago while shovelling snow. The pain becomes worse when he stands. Part Two: The patient reports he got over that last "attack" in less than a week but has had low back pain ever since. He now returns 2 years later because of another attack of acute back pain after chopping wood. Part Three: The patient returns in 6 weeks because the pain has not decreased. His legs feel "heavy," and he has had some incontinence in the last week.

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.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

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.

Janet Woo is a 50-year-old woman with a history of intermittent palpitations. Over the last five years, she can recall infrequent and transient episodes of her heart "pounding in her chest". These episodes would not produce any other symptoms and would last no longer than a couple of minutes at a time, so she never sought medical attention. Earlier this evening, while watching television, she developed palpitations that did not resolve. She became diaphoretic, felt dizzy and somewhat short of breath and so called 911 and was brought to the ER.

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.

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.

Joshua is a 48-year-old man who suffered a motor vehicle accident while riding his motorcycle. Joshua was unable to stop in time at a red light and rear-ended into an SUV, causing him to be thrown from his motorcycle, landing on his right side. He has a large laceration to the lateral thigh. He also notices some weakness to certain movements of his right lower extremity. He is taken to the trauma centre and the physical exam reveals that he is unable to dorsiflex his ankle, evert the foot, and extend the toes on the right side. All other muscles are normal. On sensory examination, it is noted that sensation is slightly impaired over the front of the leg and foot. An x-ray reveals that he has sustained a mid-femur shaft non-displaced fracture.

Judy Patterson is a 22 year-old university student who presented to the Student Health Clinic with a rash on her lower legs. Her past medical history is unremarkable except for a urinary tract infection diagnosed 6 days ago for which she is taking trimethoprim-sulfamethoxazole. The only other medication she takes is the occasional dose of ibuprofen for headaches. She has never had any dental extractions or surgeries. On examination, she has no lymphadenopathy or splenomegaly, but she does have petechiae on her lower legs. You ask to look inside her mouth and there you see a blood blister on the inside of her cheek. She says she must have bitten it by accident.

Kate Smith is a 15 year old girl. Her mother brings her to the family physician because she has not yet had her first menstrual period. Kate has been well throughout her childhood. Kate has a healthy appetite and weight. She does not receive any medications.

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Malcolm Lowry presents to the ED of the Hamilton General Hospital accompanied by his wife, Vita. He is seen by a second-year resident in Emergency Medicine and a clinical clerk. Mr. Lowry is a 47-year-old businessman. This afternoon, he collapsed in front of his wife, who observed that both arms and legs were shaking and that his eyes were rolled back. After 30-60 seconds the shaking stopped, but he was unresponsive for several minutes and remained drowsy and confused for half an hour. Vita called 911 and Malcolm was taken to the Emergency Department. The patient states that this has never happened to him before. He had no warning symptoms prior to collapsing. He does not remember collapsing. He did not soil himself or bite his tongue, but his muscles are sore. His past health has been good. He does not have hypertension, diabetes or other chronic health problems. He has never been hospitalized and he is not on any medications. He denies recent head trauma, febrile illness, headache or neurological symptoms. He has no family history of epilepsy. Vita states that Malcolm has been drinking alcohol heavily for a number of months but stopped two days ago after she removed all the alcohol from the house. Today he was so tremulous that he could hardly button his shirt. Malcolm points out that he has stopped alcohol for a day or two several times in the past few months, and although he has felt shaky he has never had a seizure.

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.

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".

Manuel Pereira and his wife have been trying to conceive a child for 16 months. After 12 months of trying, Michelle sought medical advice and so far, her investigations have been negative. You have suggested that since it takes two to make a baby, Manuel should undergo evaluation. Manuel reluctantly attends your clinic. He is quite certain that their inability to conceive can not be "his fault" because he fathered a child, by mistake, when he was 18

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.

Mr. Dupois is a 35-year-old French-Canadian man born in rural Quebec who moved to Hamilton with his wife a few years ago. His family physician noted a persistent rash around his eyes that he identified as xanthelasma. This prompted some blood tests and a referral to the Lipid Clinic. He is rather reluctant to see you at the Lipid Clinic because he is completely asymptomatic. He denies any significant medical history and is taking no medications. He is a lifelong non-smoker who faithfully walks to work for 1 km with no problems. A family history indicates that Mr. Dupois’ father died suddenly at the age of 46 with no clear explanation. He has multiple family members on his father’s side had a history of heart attacks, some at an unusually young age. His mother is healthy. On physical exam he has soft, velvety, yellowish, non-tender plaques in the palpebral area. Thickening of the Achilles tendons bilaterally were also noted. His blood pressure was 145/90 and waist circumference 98 cm.

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".

Mike is a 45 year old man who has worked as a labourer at one of the steel plants in Hamilton for years. The work requires frequent heavy lifting, particularly overhead. Mike smokes 1 pack of cigarettes per day. He has had a 1 year history of shoulder pain, which seems to be getting gradually worse. He has had to give up baseball and now is having trouble performing his job. He has not tried any treatment for his shoulder, other than Tylenol plain and icing it. On physical exam there is no muscle wasting. He is tender over the anterolateral aspect of the humeral head. Range of motion is good, but terminal flexion and abduction reproduce his typical pain. Muscle strength testing shows weakness in abduction, which also reproduces his typical pain. Provocative tests for impingement syndrome are positive, but provocative A-C joint and biceps tendon tests are negative. X-rays are done to evaluate the bony anatomy, and an ultrasound is performed to evaluate the rotator cuff.

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.

Neil Wartson is brought back to his family doctor 6 months later. The MRI has still not been performed, but the audiology testing confirmed severe sensorineural hearing loss on the right. Upon entering the office, Neil’s mother is very upset and agitated. Over the last month, she has noticed that Neil has become clumsier and is falling frequently. He also has started to rub his eye a lot and complains that things are “fuzzy”. She also reports that, since the last visit, Neil’s father has been investigated for his hearing loss. He is currently being worked up for Neurofibromatosis Type II. Neil’s mother has looked this up on the internet and is convinced that Neil has this as well.

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.

Using 2 patient/case examples, students will work in pairs to practice CBT skills taking turns to play the role of the patient and the therapist working together using the sample cases and materials provided.

Qamar is a 16-year-old female presenting to your office with her mother. Her mother indicates she is very worried about Qamar as she has lost 30 pounds over the last 3 months. Qamar herself is not concerned and says her mom is too controlling and should mind her own business. Qamar reports she just wanted to "get healthy" and there is no reason to be worried. Her mother reports that Qamar has been more active lately, running on their treadmill at home for at least an hour every day. Her mother also believes that she has heard Qamar vomiting in the bathroom, but when questioned, Qamar adamantly denies this. Her mother also has noted that Qamar has dramatically cut back on her intake in terms of the amount, but also that she will avoid certain foods like chips and ice cream completely. She used to like these foods. When she does eat, Qamar only picks at her food, cutting it into small pieces and pushing it around on her plate. She has also started to become concerned about contamination of food, and states that the food is "bad". She has started washing her hands repeatedly before and after eating. Qamar does admit that she has had trouble sleeping lately, and wakes up early in the morning, but she states her mood is good. Her mother feels her mood has been irritable and that she has been withdrawing from her family and friends. Qamar's mother also reports that she has not had a menstrual period in over 4 months.

Rachel is a 15-year-old grade 9 student who has come to the walk-in clinic requesting ‘the pill’. She has been dating John, who has not accompanied her, for 6 months and she feels that it is time for them to have sex. She has never had intercourse. John is 18 and will finish grade 12 this year. Rachel lives with her mother and two younger brothers. She has always been healthy and is on no medications. She states that she smokes occasionally and sometimes drinks. After a discussion regarding the implications of her decision and the issues of the options available, Rachel is given three months of oral contraceptives (OCP) and instructions. There is a plan to follow-up with her family doctor for a refill and a pap smear. Three months later, Rachel experiences heavy vaginal bleeding accompanied by suprapubic pain. She is very frightened and comes to the ER with her mother. She states that she thinks her last period was a month ago but it was not really normal and she has had spotting intermittently since starting the pill. She says that she is not on any other medications but two months ago she was on an antibiotic for 5 days for a bad cough. The antibiotic made her very nauseated.

Richard Strang, a 50-year-old male with a two-day history of sudden onset of acute pain and swelling of the left great toe, is seen at his family physician's office. It seemed to suddenly start when he awoke two days ago. It is so painful that he could not even tolerate the bed-sheet touching it. Richard works in construction, and routinely enjoys a few beers at the end of the day with his buddies. He had a similar attack in the right knee about 3 months ago, and right 1st MTP about 6 months. He was told that he had "the gout".

A healthy 3.6-kg baby boy, Riley, is born to a 25-year-old nulliparous mother in a community hospital. The family doctor notes that the boy's genital development is somewhat atypical. Her examination reveals that the infant has hypospadias, chordee and undescended testes. A plan is put in place for the infant to be seen by a pediatric urologist in 6 weeks with a view to eventual surgical correction. At one week of age, the infant is brought to the family physician's office for routine follow up. Riley's mother comments that he seems to be breastfeeding poorly. She describes him as increasingly uninterested in feeding and is concerned that he seems to be "spitting up" a lot. The infant now weighs 3.1 kg. A recommendation is made to begin some formula supplementation to help support weight gain. At 10 days of age, Riley's mother finds him in his crib, non-rousable, cool, mottled and covered in vomit. Riley is rushed to the emergency department via ambulance. In the emergency room, resuscitative measures are initiated. The airway is suctioned. He is intubated and hand-bagged to achieve ventilation. A 20 mL/kg bolus of normal saline is administered.

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

Ronnie Olchuk is a 6-year-old boy who was hit by a car while crossing the street. A witness at the scene said he was hit on the left side and thrown approximately 20 m. He is healthy, has no allergies, and has never had surgery. He last ate eight hours ago. He has been stabilized by the trauma team, is alert and oriented, and has no injuries except to his right forearm and left thigh. His distal right forearm is badly deformed. His left thigh has a 2 cm laceration located medially and is also badly deformed. He is in excruciating pain, especially in the right forearm.

Ryan Smith is a two week old baby brought to your office by his parents. He was noted to have bilateral feet abnormalities on prenatal ultrasound. Family is anxious and worried about whether the child "Will walk, play soccer etc." Physical exam show that both feet are adducted, supinated, equines and the hindfoot is in varus. The feet are moderately flexible but not completely correctable

Samira Shah is a 27 year old woman who works as a waitress in a local restaurant and is in her first pregnancy. She is slightly overweight (pre-pregnancy BMI 28.5). Her prenatal care has been unremarkable although she was found to be rubella non-immune and had a positive glucose challenge test (GCT) followed by a negative glucose tolerance test (GTT). Now at 38 weeks, she has abdominal cramping and slight bright red vaginal bleeding. Her husband, Sunny, informs Hanna’s midwife of this. Her midwife comes to their apartment to assess Samira.

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.

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.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Today, Siobhan came in sobbing, dragging a reluctant 8-year-old Skylar behind her. She wailed, "He's turning out just like his Dad. Before you know it he'll be in jail for assault, I'm scared of both of them." Siobhan explains that Skylar punched a boy in the face today and was suspended for 3 days. Evidently, there have been numerous incidents at school where the Grade 3 teacher claimed Skylar was the aggressor. This implied information about Skylar 's father was news to you and you suspect that there was more going on in the home than Siobhan had shared with you in the past. You wonder how to approach Siobhan about this.

Susan Weiss is a 53 year old woman (G3P3) who presents to her family doctor stating she is having difficulty sleeping. She is waking up drenched through the night. She complains of having sweating episodes throughout the day that are debilitating and embarrassing. She is irritable with her family and states they do not understand "the change". It has been 18 months since her last period. She has no libido and when she tries to be intimate with her partner, she is extremely dry.

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

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

Mrs. Tammy Polk is very difficult to interview. She is an extremely vague and difficult historian. Her family tell you that she was diagnosed with breast cancer 5 years ago and had a mastectomy at that time. Her husband died 6 months ago and she has never really recovered. Over the past week, the family have been worried that she is "developing Alzheimer's" because of memory problems and agitation. Past psychiatric history is notable for mild depression, treated with paroxetine 20mg daily, and sleep difficulties that are chronic and date back to her days as an alcoholic. One month ago, she was started on 50 mg of quetiapine at bedtime for sleep by her family doctor. Two weeks ago, she was given Oxybutinin (Ditropan) to help with some urinary incontinence, with good effect on her bladder problem. She is admitted to hospital for further medical work-up. The 1 pm nursing note reads: "quiet, resting comfortably, oriented x 3." The results of CBC, serum electrolytes and urinalysis are pending. The medical resident calls for psychiatric consultation at 4:05 pm because the patient has become agitated and has voiced suicidal ideation. The consult note reads: "medically cleared, please transfer to psychiatry for treatment of emotional instability and psychotic depression." The psychiatric resident arrives at 5 pm and finds that the patient is visually hallucinating and disoriented.

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.

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.

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.

The theme for this part of the tutorial is “Trauma and its impact in Psychiatry”. You are responsible for developing a “case presentation” for interactive learning and discussion. The case(s) can be completely made up, or based on a patient you have seen. You have one hour for your case presentation, discussion, and MCQ response/review. In preparation for this, please be familiar with and draw out the concept of Trauma- informed Care, the role of trauma in addictions (in particular) and other psychiatric presentations, and the role of psychotherapy and medication in management of trauma. The theme for this part of the tutorial is “Addictions”. The focus should be on addiction in physicians. You are responsible for developing a “case presentation” for interactive learning and discussion.

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.

Each student will be evaluated doing one of the MSK exams: Cervical spine; Lumbar spine and pelvis/sacroiliac joints (excludes hip focussed exam); Shoulder; Hand and wrist; Knee; Foot and ankle; GALS and gait.

Domains assessed: Fund of Knowledge, Knowledge Integration, History taking, Clinical Examination, Clinical Management, Learning Skills, Communication Skills, Professional Responsibility and Integrity, Pursuit of Excellence and Insight, Personal Interactions.

Each Clerk is required to successfully complete 10 cervical checks.

Must be completed by 2 colleagues on labour and delivery rotation.  1 L&D Assessment must be completed by chief resident, 1 by a faculty member other than your preceptor.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

Periodically, students may be asked to complete a Pro Comp Integrative Exercise. This will be in the form of a case scenario(s) to which students will respond in writing. The exercise will allow students to display their understanding of the Pro Comp concepts studied to date. The exercises will be assessed by the students’ own LFs.

Periodically, students may be asked to complete a Pro Comp Integrative Exercise. This will be in the form of a case scenario(s) to which students will respond in writing. The exercise will allow students to display their understanding of the Pro Comp concepts studied to date. The exercises will be assessed by the students’ own LFs.

Periodically, students may be asked to complete a Pro Comp Integrative Exercise. This will be in the form of a case scenario(s) to which students will respond in writing. The exercise will allow students to display their understanding of the Pro Comp concepts studied to date. The exercises will be assessed by the students’ own LFs.

Students create the ‘On-demand’ evaluation on MedSIS for each clinical day and for each call shift. Unless there is a holiday, there should be a total of 9 'On-demand' clinical evaluations at the end of your rotation. It is the student's responsibility to generate the form on MedSIS and bring it to the supervisor to fill it out near the end of the day.

Students must receive a satisfactory evaluation for their PES call experience.

Complete pelvic examination simulation.

In a simulation initially assess a labouring patient, manage a normal delivery and provide immediate postpartum care of the mother.

Postpartum Hemorrhage (PPH) simulation.

Opportunity to consolidate knowledge acquired through PBL cases. Review of high yield orthopedic clinical pearls. Opportunity to actively practice relevant clinical skills such as reading imaging (within the confines of virtual learning).

This session is intended to generate a discussion towards formulating a basic early understanding of pain for future physicians. It is also intended to serve as a framework for future learning about how pain manifests in the context of health or disease, be it acute, chronic, or terminal, and to consider how it might be managed. Finally, this session is intended to begin illustrating how psychological, environmental and social factors can influence the experience of pain and its management thus resulting in the potential need for an interdisciplinary approach in that regard.

Consists of 7 days in the OR (maybe less in case of holidays) and 2 on call shifts.

Students must complete 12 x 8 hour clinical ER shifts.

Students will be scheduled to complete one 2 hour triage shift with nursing staff.

Students will be expected to care for up to seven patients, including Alternate Level of Care patients (ALC – awaiting rehab, long term care, palliative care, or other type of care facility). Ideally, a student will care for a blend of patients with “acute” problems as well as those with more chronic issues such as ALC patients.

This may be in the inpatient and/or the outpatient setting based on the specific MSS rotation.

Each student will be assigned to a community Ob/Gyn. Students are expected to participate in 8 half day clinics with exposure to both Gynecology and Obstetrical patient populations.

During the Hospital rotation students participate as part of the Ob/Gyn team. Time spent on L&D, post?partum and gynecology. Students are expected to be present at normal births, caesarean section, ER consults, OR and if appropriate more complex issues presenting to the service. Students will participate in the on call schedule.

Nearly twenty percent of all problems presenting in the Primary or Acute Care setting are based in musculoskeletal pathology. The objectives outlined for this two-week Clerkship must be considered as nominal and must not act as a limit to a student's personal learning in the diagnosis and management of musculoskeletal related diseases. To this end, one of the "attitudes" objectives of this Clerkship is to encourage in the student an enthusiasm for life long learning.

The pediatrics clerkship rotation is a six week rotation during which the clerks are placed in one of 4 tracks and have exposure to both ambulatory and inpatient pediatric care.

Each Hamilton campus clerk will be assigned 2 Psychiatry Emergency Services (PES) shifts.

Each clerk will be assigned to 2-3 primary clinical supervisors. The supervisors will be responsible for the supervision, assignment and evaluation of clinical work. Clinical placements may occur in a variety of settings, including inpatient, outpatient, general psychiatry, or subspecialty settings (e.g. child and adolescent, geriatrics, eating disorders, mood and anxiety, forensics, schizophrenia, dual diagnosis, etc.). These placements can occur in academic hospitals, community hospitals, or community clinics.

During this six week rotation students will be involved in a variety of clinical scenarios and learning opportunities designed to enhance their knowledge and skills. Students will interact with patients and their families in all aspects of surgical care (hospital wards, outpatient clinics, operating room, emergency department, intensive care unit, etc.).

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

Provide an overview of key medico-legal issues. Provide an awareness of your role in mitigating or minimizing risk exposures. Knowledge of where and when to seek assistance should you find yourself in potential risk-laden situations. A reminder to take care of yourself when coping with the stress of patient outcomes, complaints and legal actions.

Patient safety is about managing and reducing risk to ensure that the care patients receive is as safe as possible. In clerkship, students will become actively involved in the delivery of patient care. As members of the health care team, students at the clerkship level need to be aware of key concepts in patient safety. They also need to develop an understanding of how to communicate about patient safety issues to each other, to health care team members and to patients.

The four-week Family Medicine rotation revolves around a one-to-one experience pairing a student with a community-based family physician. The most significant component of the Family Medicine rotation is this time spent with the clinical preceptor in the office setting.

Oxygen delivery. Ventilation. Hypoxemia.

Adrian Scholtz is a 33 yr old male patient presenting at the Shelter Medical Outreach centre. He complains of a dry cough, fever, shortness of breath and worsening fatigue. He was seen at a walk-in clinic a few days ago for similar symptoms. He states he underwent testing for influenza A and COVID, but did not stay around to see what the results were. Adrian was encouraged to take Tylenol and rest, but did not receive any antibiotics or other treatment. Past medical history includes intravenous drug use, mechanical valve replacement (3 years ago), and is a current smoker. Concerned that Adrian appears quite sick, the medical clinic staff arranges for Adrian to be sent to the local ER department for evaluation.

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

A healthy 3.6-kg baby boy, Riley, is born to a 25-year-old nulliparous mother in a community hospital. The family doctor notes that the boy's genital development is somewhat atypical. Her examination reveals that the infant has hypospadias, chordee and undescended testes. A plan is put in place for the infant to be seen by a pediatric urologist in 6 weeks with a view to eventual surgical correction. At one week of age, the infant is brought to the family physician's office for routine follow up. Riley's mother comments that he seems to be breastfeeding poorly. She describes him as increasingly uninterested in feeding and is concerned that he seems to be "spitting up" a lot. The infant now weighs 3.1 kg. A recommendation is made to begin some formula supplementation to help support weight gain. At 10 days of age, Riley's mother finds him in his crib, non-rousable, cool, mottled and covered in vomit. Riley is rushed to the emergency department via ambulance. In the emergency room, resuscitative measures are initiated. The airway is suctioned. He is intubated and hand-bagged to achieve ventilation. A 20 mL/kg bolus of normal saline is administered.

One hour after giving birth to baby Varkey, Mrs. Shah states that she feels lightheaded as she sits upright for the first time. Her midwife who has been monitoring her closely following the delivery helps her to lay back down. She notes that Samira is somewhat pale and that her pulse is rapid and thready. She palpates the uterus and finds the fundus is above the umbilicus. As the midwife massages the fundus, a large grapefruit size blood clot is expressed followed by blood that soaks the bed sheets. As summoned help arrives, Samira’s BP is found to be 85/50 and her heart rate 120.

The theme for this part of the tutorial is “Trauma and its impact in Psychiatry”. You are responsible for developing a “case presentation” for interactive learning and discussion. The case(s) can be completely made up, or based on a patient you have seen. You have one hour for your case presentation, discussion, and MCQ response/review. In preparation for this, please be familiar with and draw out the concept of Trauma- informed Care, the role of trauma in addictions (in particular) and other psychiatric presentations, and the role of psychotherapy and medication in management of trauma. The theme for this part of the tutorial is “Addictions”. The focus should be on addiction in physicians. You are responsible for developing a “case presentation” for interactive learning and discussion.

Domains assessed: Fund of Knowledge, Knowledge Integration, History taking, Clinical Examination, Clinical Management, Learning Skills, Communication Skills, Professional Responsibility and Integrity, Pursuit of Excellence and Insight, Personal Interactions.

Students create the ‘On-demand’ evaluation on MedSIS for each clinical day and for each call shift. Unless there is a holiday, there should be a total of 9 'On-demand' clinical evaluations at the end of your rotation. It is the student's responsibility to generate the form on MedSIS and bring it to the supervisor to fill it out near the end of the day.

Students must receive a satisfactory evaluation for their PES call experience.

Prevalence of Abnormal Uterine Bleeding. Impact of Abnormal Uterine Bleeding (AUB) on Women. Clinical, Economic, and Lifestyle. Pathogenesis of AUB. A brief look at causality. Investigation and treatment of women with AUB. What to do, when to do it.

What are Pulmonary Function Tests? Noninvasive measure of lung volume, capacity, flow rates and gas exchange.

Essentials of gastrointestinal and gynecologic imaging.

Understand the two major physiological functions of the hepatobiliary system. Secretory and excretory functions of the liver. Control of energy metabolic function of liver. Examine measures of hepatobiliary function and dysfunction. Review examples of hepatobiliary disease.

Opportunity to consolidate knowledge acquired through PBL cases. Review of high yield orthopedic clinical pearls. Opportunity to actively practice relevant clinical skills such as reading imaging (within the confines of virtual learning).

Intrapartum management of spontaneous labour. Fetal health surveillance in labour. Operative vaginal birth. Indications for caesarean sections. Management of pregnancy at 41+0 to 42+0 weeks

To learn how to approach common imaging in the emergency department. A review of: Salter Harris Classification; MSK Xrays (shoulder, elbow, wrist, ankle, foot); C-spine xrays; CXR; Abdominal Xray; FAST U/S; CT Head

Consists of 7 days in the OR (maybe less in case of holidays) and 2 on call shifts.

Students must complete 12 x 8 hour clinical ER shifts.

Students will be scheduled to complete one 2 hour triage shift with nursing staff.

Students will be expected to care for up to seven patients, including Alternate Level of Care patients (ALC – awaiting rehab, long term care, palliative care, or other type of care facility). Ideally, a student will care for a blend of patients with “acute” problems as well as those with more chronic issues such as ALC patients.

This may be in the inpatient and/or the outpatient setting based on the specific MSS rotation.

Each student will be assigned to a community Ob/Gyn. Students are expected to participate in 8 half day clinics with exposure to both Gynecology and Obstetrical patient populations.

During the Hospital rotation students participate as part of the Ob/Gyn team. Time spent on L&D, post?partum and gynecology. Students are expected to be present at normal births, caesarean section, ER consults, OR and if appropriate more complex issues presenting to the service. Students will participate in the on call schedule.

Nearly twenty percent of all problems presenting in the Primary or Acute Care setting are based in musculoskeletal pathology. The objectives outlined for this two-week Clerkship must be considered as nominal and must not act as a limit to a student's personal learning in the diagnosis and management of musculoskeletal related diseases. To this end, one of the "attitudes" objectives of this Clerkship is to encourage in the student an enthusiasm for life long learning.

The pediatrics clerkship rotation is a six week rotation during which the clerks are placed in one of 4 tracks and have exposure to both ambulatory and inpatient pediatric care.

Each Hamilton campus clerk will be assigned 2 Psychiatry Emergency Services (PES) shifts.

Each clerk will be assigned to 2-3 primary clinical supervisors. The supervisors will be responsible for the supervision, assignment and evaluation of clinical work. Clinical placements may occur in a variety of settings, including inpatient, outpatient, general psychiatry, or subspecialty settings (e.g. child and adolescent, geriatrics, eating disorders, mood and anxiety, forensics, schizophrenia, dual diagnosis, etc.). These placements can occur in academic hospitals, community hospitals, or community clinics.

During this six week rotation students will be involved in a variety of clinical scenarios and learning opportunities designed to enhance their knowledge and skills. Students will interact with patients and their families in all aspects of surgical care (hospital wards, outpatient clinics, operating room, emergency department, intensive care unit, etc.).

A. Calcium Homeostasis 1. Organs involved (bone, gut, kidney) 2. Hormonal regulation (PTH, vitamin D, OPG, calcitonin, PTHrP) B. Hypercalcemia 1. Approach to differential diagnosis through serum PTH level 2. Management C. Hyperparathyroidism 1. Biochemical diagnosis 2. Preoperative localization: value of sestamibi scanning D. PTHrP (parathyroid hormone related peptide) 1. Normal physiological role 2. Associated with paraneoplastic malignancy E. Examination of the spleen 1. Castelle’s sign. Imaging of Hyperparathyroidism.

The case: 29 yo Caucasian male; Presents with 8 weeks of bloody diarrhea; What is your differential for bloody diarrhea? What tests would you order to evaluate this patient?

Introduce head and neck cancer. Illustrate using a clinical presentation with pathological correlation. Develop an approach to patients with head and neck symptoms.

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

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.

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.

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

Clinical presentation of a 36 year old woman with painful left eye, red, vision blurred, no trauma. Minor cough, no sputum, no hemoptysis, no chest pain, no dyspnea, no wheeze. Clinical presentation of a 49 year old music teacher. Short of breath when cycling, singing in concerts or at church, progressive over 6 months, not variable. Minor cough, no sputum or wheeze or chest pain, no fever.

Case presentation of megaloblastic anemia with objective of making a unified diagnosis, understanding the pathophysiology and reviewing the appropriate diagnostic and therapeutic strategies.

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.

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.

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.

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.

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.

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.

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.

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.

Examples: Acute cholycystitis; Acute appendicitis; Traumatic acute abdomen. Observation of student taking a history from a patient with abdominal pain. Demonstration by preceptor of examination of a patient with abdominal pain. Observation of students examining a patient with abdominal pain. Discussion regarding abdominal pain.

Practice the Abdominal history and physical examination. Sam has been feeling unwell for about 4 months. They are complaining of a yellowing of their skin and swelling of their feet which has been getting progressively worse over the last 4 months. Pro Comp connection – Patients with Skin of Colour.

Practice the Abdominal history and physical examination. This case should be used to practice & to consolidate Abdominal history & physical exam as it pertains to Weight Loss/Diarrhea

Standardized case 55 year old female with epigastric pain.

Discuss and practice the components of the Adolescent history. Pro-Comp Connection – Child Maltreatment

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.

Observations of a student(s) interviewing a patient with history of syncope. Demonstration by preceptor of examination of a patient with syncope. Observation of a student(s) examining a patient with  syncope. Discussion regarding syncope. Example: cardiovascular, metabolic and lung causes, blood pressure, EKG, etc.

Discuss and practice the components of the history and physical exam for the Back and GALS Exam. Demonstrate a focused musculoskeletal examination.

To practice the Cardiac history and physical exam. Pro Comp connection care for Adults with Intellectual and Developmental Disabilities (IDD).

Standardized case of 65 year old male with chest pain.

To learn the Diabetic history & physical examination. Pro Comp connection – Indigenous Health and Diabetes Mellitus – Strengths-Based Approaches: Diabetes Canada, in its 2018 guidelines highlight social determinants of health play an important role in risk of diabetes and complications. It is important to understand more holistically the structural determinants of health, particularly colonialism, and its cascading effects on the social determinants of health including access to nutrition, employment, education and experiences in healthcare, and how these structural and social determinants impact the risk of diabetes in Indigenous population.

Practice the history and physical exam as it pertains to edema.

Discuss and practice the components of the Gynecological and Sexual histories. Pro-Comp Connection – LGBT2SQ+ Patients. LGBTQ2S+ patients in Canada experience worse health outcomes than their heterosexual, cisgender peers.

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.

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.

Standardized case 30 year old female with fatigue.

Discuss and practice the components of the history and physical exam for the Hip and Knee.

Learn how to perform the abdominal history and physical examination.

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

To discuss and to practice the components of the Volume status history and physical examination.

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

Introduce what a physical examination is, and the basics on how to perform one in a patient-centred way as a group discussion. Discuss proper technique, the importance of consent, privacy, draping and use of appropriate medical equipment (i.e., stethoscope, blood pressure cuff, etc.) Introduce Vital Signs, including normal and abnormal values. Discuss factors that affect vital signs. Pro comp connection: Patients of Varying Body Habitus. Patients presenting to medical professionals for clinical care represent a variety of body habituses. Body mass index (BMI) is used as a clinical indicator of body habitus, calculated based on a person’s height and weight. Patients are classified according to their BMI as underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (25.0-29.9) and obese (>30.0). Note that although BMI is used clinically, it was originally a population health measure and was derived from a homogenous group (Belgian population). Therefore, its utility for individual patient care may be limited. Epidemiological studies have shown a correlation where the risk of hypertension, type 2 diabetes, sleep apnea, cancer and a variety of other conditions increases as BMI increases; therefore, the classification system is meant to capture increasing health risks. It is important to note that a causal relationship between BMI and these health conditions has not been shown.

Discuss and practice the components of the history and physical exam for a patient presenting with a loss of consciousness or an altered level of consciousness. Discuss and practice the components of the screening neurological examination.

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.

To discuss and to practice the components of the Newborn history. Pro-Comp Connection – food and housing insecurity.

To discuss and to practice the components of the Obstetrical history as it pertains to Intrapartum Care. To apply key terminology appropriately in intrapartum care, including: Diagnosis and stages of labour, including differentiating term from preterm labour. Diagnosis of rupture of membranes (ROM), including differentiating spontaneous rupture of membranes (SROM), prelabour rupture of membranes (PROM) and preterm prelabour rupture of membranes (PPROM). Practice taking a focused history in an intrapartum care setting, with a focus on four essential triage visit questions (Contractions/labour; Fluid/rupture of membranes; Bleeding; and Fetal Movements). Demonstrate use of gender-inclusive perinatal language (e.g. parental leave, birthing parent, chest-feeding). Practice navigating key challenges in delivery of intrapartum care in rural and remote settings, including recognizing limitations of scope of practice to inform shared decision-making. Pro-Comp Connection – Indigenous Health and Prenatal / Intrapartum Care

Medical students should recognize external and internal structures of the normal human eye and know how to perform a basic eye examination (ICO Curriculum for Ophthalmic Education of Medical Students). Students rotate through eight stations: 1. History taking in Ophthalmology 2. Visual Acuity measurements and pupillary examination. 3. Extraocular muscle movements and visual field guide. 4. External eye and slit lamp examination. 5. Intraocular pressure measurement and pachymetry. 6. Fundoscopy. 7. Pediatric examination and strabismus measurement. 8. Trauma management, lid eversion / foreign body removal and eye patching.

To discuss and to practice the components of the Peripheral Vascular history and physical examination.

Practice the Renal history and physical examination as it pertains to Hematuria. Pro Comp connection Indigenous Health - The case of Brian Sinclair is an important example of a fatal consequence of systemic racism in the Canadian Healthcare System. He was a 45-year-old First Nations man who died of a treatable bladder infection in 2008, after being ignored for 34 hours in the emergency.

Practice the history and physical exam as it pertains to nephrolithiasis. Standardized case of 44 year old male with flank pain.

Discuss and to practice the components of the respiratory history and physical examination. Practice an approach to the environmental exposure history using the CH2OPD2 format. Pro Comp Connection – Health Effects of Climate Change.

Discuss and practice the components of the respiratory history and physical examination. Practice an approach to the environmental exposure history using the CH2 OPD2 format. Pro-Comp Connection – Health Effects of Climate Change: : Climate change presents a fundamental threat to human health, with the potential to undermine and reverse decades of health progress. Increasingly frequent disruptions caused by climate change may overwhelm the efforts of the healthcare system to address social determinants of health, if those latter efforts ignore the changing environment. Climate change impacts health both directly and indirectly and is strongly mediated by structural determinants of health.

Demonstration by preceptor taking a history from a patient with chest pain, cough and fever, hemopytsis, etc. and performing appropriate physical examination. Observation of a student (s) taking history from a patient with chest pain, cough and fever, hemoptysis, etc. and performing appropriate physical examination. Discussion: regarding chest pain, cough and fever, hemoptysis, etc., etiology, differential diagnosis, investigations, etc. (Examples: chest pain, cough and fever, wheezing, hemoptysis)

Observation of a student(s) taking history from a patient with diabetes (polyuria, polydipsia, fatigue, etc.) and performing appropriate physical examination. JAMA article review: Does this patient have diabetic neuropathy?

Discuss and practice the components of the history and physical exam for the Shoulder and Elbow.

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.

Practice the history and physical exam as it pertains to vomiting and diarrhea.

Discuss and practice the components of the history and physical exam for the Wrist / Hand and Ankle / Foot.

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

How motor function helps to determine localization in the neuromuscular exam. Relevant neuroanatomy motor system. Clinical importance and clinical Examination. Patterns of weakness with anatomy correlation.

The adrenal cortex in health and disease. Adrenal anatomy. Adrenal histology. What is a steroid? Characteristics of corticosteroid secretion. Cushing's Syndrome. The Hypothalamic Pituitary Adrenal axis. Causes of primary adrenal insufficiency (Addison’s Disease). Causes of hypopituitarism. Congenital Adrenal Hyperplasia.

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?

What is a red blood cell? What is anemia? How are red blood cells measured in the lab? What are the causes of anemia? My patient is anemic, how do I determine the underlying cause?

Quick Review of Normal Hemostasis: Vasoconstriction, Primary Hemostasis, Secondary Hemostasis, Clot Stabilization. How to Measure Hemostasis - Clinical methods & laboratory methods. How to Manage Bleeding

The major topics will be: Nutrition for growth and development; Nutrition for prevention of diabetes and cardiovascular disease; Nutrition for prevention of cancer

Understand autosomal dominant inheritance. Understand the factors that complicate this inheritance pattern. Understand the main psychosocial issues in predictive testing (presymptomatic diagnosis).

Epidemiology of osteoporosis. Types of bone and bone cells. Physiology of bone (bone turnover). Regulators of bone turnover. Peak bone mass. Osteoporotic bone: appearance and clinical assessment.

Radiology Procedures: Plain Films, Barium Studies, Angiography, US, CT, MRI, Nuclear medicine, Endoscopy, ERCP. Barium Studies: Barium Swallow, Upper GI Series, Small Bowel Follow-Through, Small Bowel Enema, Barium (Large bowel) enema.

Growth assessment: Population standards; Disease-specific standards; Measurements; You and your parents, How do you shape up? Growth in the fetus and newborn. Growth in childhood. Puberty. Growth patterns in disease. Nutrition, hormones, and the world around you.

Understand the principle types of gene mutations. Understand the nomenclature used to describe gene mutations. Understand the importance of test sensitivity for interpreting results. Understand the problem of unclassified variants/variants of unknown clinical significance.

How much Neuro do you need to know? What do residency program directors expect? Weekly themes: Week 1:Muscle, NMJ, Nerve. Week 2: spinal cord, brainstem. Week 3: Basal Ganglia, Limbic system. Week 4: Cerebral cortex. Muscle. Localization. Neuromuscular junction. Nerve. Resting potential. Post-synaptic potentials. Anterior horn. Central vs. peripheral nervous system. Spinal cord. Brainstem. Cerebellum. Limbic system. Basal Ganglia. Cerebral cortex.

Understand definition and mechanisms of arrhythmogenesis. Recognize major arrhythmias. Tachyarrhythmia types. Bradyarrhythmia and conduction abnormalities.

The Objectives are to introduce the medical specialty of Physiatry (Physical Medicine and Rehabilitation). To review common medical problems seen by a Physiatrist. To review some cases from a Physiatric perspective.

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).

Genomic imprinting. Uniparental disomy. Prader-Willi Syndrome. Angelman Syndrome. Epigenetics. Nucleotide Repeat disorders. Trinucleotide Repeat disorders. Fragile X syndrome. Common characteristics of repeat disorders.

Understand that principles for chronic disease prevention through lifestyle are remarkably similar for diabetes, excess body weight, cardiovascular disease and cancer.

Shoulder Dystocia. Post Partum Hemorrhage. Cord Prolapse.

X-ray interpretation of fractures. Growth Plate Injuries. Basic Trauma and Fracture Management. Clinical examination. Upper extremity. Lower extremity. Spine. Emergency conditions

Trauma orthopedics. Pediatric orthopedics and infections. Reconstructive orthopedics.

Anterior Pituitary, Prolactin (PRL), Growth Hormone, Posterior Pituitary, Pituitary Function. Case Scenario: Panhypopitutarism. Case Scenario: Acromegaly. Case Scenario: Hyperprolactinemia. Case scenario: Diabetes Insipidus. Case scenario: Syndrome of Inappropriate ADH SIADH.

Modalities for imaging of urinary tract. Which modality to use when. What are advantages and disadvantages of each modality. Plain film radiography. Ultrasound. Intravenous urography (IVU). Computed Tomography (CT). Magnetic resonance imaging (MR). CT Urograpy. MR urography.

Acute abdominal pain is a common and notoriously difficult clinical problem to diagnose and manage. Understanding of pathophysiologic pain patterns and innervation anatomy can aid in honing DDx (intra vs. exta abdominal dz.). Epidemiology and pathophysiology of pain. Differential diagnosis of acute abdominal pain. Clinical assessment. Investigations; limitations of diagnostic tests. Likelihood ratios for commonly used tests. Intro to Clinical Practice Guidelines. Hierarchies of Evidence-Methodology. Initial treatment strategies. Disposition.

What is a child psychiatric disorder? The classification scheme of the most common child psychiatric disorders. The etiology, prevalence, outcome, and treatment of the most common disorders. The relationship between child and adult psychiatric illness.

Use of ultrasound in Obstetrics. Assess gestational age, fetal anatomy & growth, fetal wellbeing, etc. Invasive procedure: diagnostic/therapeutic. Labour and Delivery

The four-week Family Medicine rotation revolves around a one-to-one experience pairing a student with a community-based family physician. The most significant component of the Family Medicine rotation is this time spent with the clinical preceptor in the office setting.

Oxygen delivery. Ventilation. Hypoxemia.

Neuroanatomic Localization, Spinal Cord Pathology, Concussion

Dizziness, meningitis, stroke, headache

Muscle Weakness, Peripheral Neuropathy

Gait Disturbance, Movement disorders, Febrile Seizures

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.

Adrian Scholtz is a 33 yr old male patient presenting at the Shelter Medical Outreach centre. He complains of a dry cough, fever, shortness of breath and worsening fatigue. He was seen at a walk-in clinic a few days ago for similar symptoms. He states he underwent testing for influenza A and COVID, but did not stay around to see what the results were. Adrian was encouraged to take Tylenol and rest, but did not receive any antibiotics or other treatment. Past medical history includes intravenous drug use, mechanical valve replacement (3 years ago), and is a current smoker. Concerned that Adrian appears quite sick, the medical clinic staff arranges for Adrian to be sent to the local ER department for evaluation.

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Amanda, a 12 year old girl, has been accompanied by her mother to see her family doctor for a routine check-up. Her mother is a single mom who works shift work as an R.N. at the local E.R. department. She and Amanda currently reside in a suburban neighbourhood of Hamilton. Amanda attends a public school in her neighbourhood and complains of being constantly teased by her classmates for being "bigger". According to her mom, Amanda participates in gym class, but does not get much more physical activity than that. Amanda spends a lot of time alone while her mother works shifts. She admits to watching approximately 3 hours of television per day on weekdays and 5 hours on the weekends. She is also on the internet, chatting on MSN, for 1-2 hours per day. Her mother is also obese and is not worried about her daughter's current weight or the sedentary lifestyle and is rather pleased that Amanda is a "good girl". Amanda does not express interest in participating in local clubs or extracurricular activities and indicates that she is simply not an "athletic type" of individual.

Amir Boutros is a 30 year old man with a history of Crohn's disease who presents to the hospital with a recent history of increased pain and diarrhea. He is very weak, dizzy and short of breath. His BP is 80/50 with a heart rate of 120 and respiratory rate of 24. His chest X-ray is normal.

Part One: A thin 65-year-old woman presents complaining of back pain that began 5 days ago while lifting her wash. The pain becomes worse when she rolls over in bed or when she stands up. She has noticed that the hems of her skirts seem longer and on measurement she appears to have lost 6 cm in height. Part Two: The patient reports she got over that last "attack" after around 3 months. She was commenced on a bisphosphonate, calcium, and vitamin D. She now returns 2 years later because of another attack of acute back pain after falling on the ground.

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.

Ann Green is a 66-year-old woman who was referred to the rheumatology outpatient clinic by her family physician, Dr. Mac Grad. In his referral note, Dr. Grad states that Mrs. Green has been experiencing joint achiness for the past several years, involving mostly her hands and knees. From time to time, she has also reported low back pain. Her symptoms have always been relatively mild and have never stopped her from carrying on with her general daily activities or her charitable work in the community. What currently concerns Dr. Grad is that Mrs. Green's symptoms have progressed. Usually a rather stoic person, she is now complaining of increased pain in her fingers and both knees. Because of her knee pain, she is having increasing difficulty walking. Whereas previously her pain would always settle after she took some Tylenol, this is no longer the case. On physical examination, Dr. Grad elicits tenderness at several of the proximal (PIP) and distal interphalangeal (DIP) joints of both hands and at the carpometacarpal joint of the left thumb. Heberden's nodes are evident at the DIP joints bilaterally. Tenderness is also present at the joint lines of both knees; and there is (chronic) puffiness on both sides, but more pronounced on the left. Knee flexion is reduced and there is bony crepitus. Radiographs demonstrate osteoarthritic changes at the wrists, the PIP and DIP articulations of the fingers, and moderately severe (tri-compartmental) degenerative changes at both knees.

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.

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

Mr. Hau is a 56-year-old male, married with two teenaged children. He is employed as a pharmacist and his wife is a receptionist in a dental office. He has no formal psychiatric history. About three months ago, Binh's personality began to change in subtle ways. Previously an optimistic, outgoing individual, he gradually became serious, irritable and socially withdrawn. His family noticed that he was sleeping poorly, sometimes pacing the house all night. At times he was observed mumbling to himself as if he were conversing with someone who wasn't there. His family grew increasingly concerned.

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.

Mr. Palmer, 67 years old and previously well, has had several months of poorly localized upper abdominal pain, decreased appetite, and weight loss. His family physician performs a thorough physical exam and can palpate the liver edge 7 cm below the right costal margin. There is no other abnormal finding on physical exam. He orders a CT scan, which demonstrates that Mr. Palmer's liver is grossly enlarged with multiple lesions throughout the liver, consistent with metastatic malignancy. There is no other abnormality seen on the CT abdomen, and further imaging of the chest and pelvis is also normal.

Brock is a 25-year-old man who sustained a laceration to the upper third of his right forearm when he accidentally put his arm through a plate glass window. He presents to the emergency room. On examination, the ER physician finds Brock has significant weakness dorsal and palmar interossei, resulting in weakness of abduction and adduction of the index, middle and ring finger of the right hand.

Mr. Silva went to his family physician due to a lump he noticed on the right side of his neck while shaving. His only past history was one of recurrent kidney stones. His only family history of disease is that his father died of a stroke at 40 years of age. Mr. Silva is married with a 5 year-old son. He works as a plumber. Physical examination reveals a firm 2.3 cm nodule in the right side of his thyroid gland. There are also some palpable nodes in his right cervical chain. BP was elevated at 180/90 but his family doctor did not want to diagnose him with hypertension based on one reading. A recommendation was made for a low sodium diet, blood work sent for TSH and calcium profile and referral made to an endocrinologist for the thyroid lump.

Dr. Jones has been following Calvin Shin for several years for obstructive sleep apnea. He had been doing well with reduced symptoms of daytime sleepiness since he had been using his CPAP machine. Dr. Jones was reviewing John's chart in his clinic. He missed his appointment several months ago but booked an urgent appointment through his family doctor. Calvin explains that he thinks his tongue, nose and lips have been getting thicker. He also states that he seems to be sweating and his skin feels thicker and oilier than it used to.

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.

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.

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

Chantal is a 5 year 2 month old child who presents with advanced development of the breasts for the past 7 months, and possible growth of pubic hair. This is associated with rapid growth. She has had intermittent "spotting" during the last two days. Apart from occasional emotional outburts (crying, "fighting" with her 9 year old sister and with her mother) she has no other problems. Chantal's Mom is 36 years old and a school teacher with height at the 50th centile. She had menses at age 13 years. Dad, 44 yrs old, is a lawyer with a height at the 50th centile. He began shaving at ~ 15-16 years of age. He has mild hypertension. The family history is negative for early puberty. The parents are non-consanguineous.

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.

Claire McFadden is a 16- year-old high school student, living with T1D since age 10, who is currently pregnant (G1). Claire has struggled with her diabetes management in the past but is trying to keep her sugars at target now that she knows she is pregnant. Her most recent HbA1C was 7.8%, and she is using an insulin pump. Claire is being followed concurrently by her endocrinologist and has had microalbuminuria and mild non-proliferative retinopathy but no other diabetic complications. She has been normotensive with a usual BP of 110/70. She was told to start prenatal vitamins with extra folate as well as to discontinue her ACE inhibitor when her pregnancy test was found to be positive. Claire was also started on low-dose ASA (LDASA) at 12 weeks. Her partner, Dave, is 18 years old and is unemployed, having graduated high school in the summer. Claire is living with Dave in her aunt’s apartment. Her pregnancy was unplanned, but she is now excited to become a mother. She is planning to take a year off from high school and then return to complete her high school diploma. Dave is unhappy about this and feels she should stay at home to take care of the baby. They have argued about this, and Dave feels it is Claire’s own fault if she does not like making sacrifices as she could have gotten an abortion like he wanted. Claire worries about Dave’s temper, explaining that when he found out she was pregnant, he yelled at her and then disappeared for a week. She thinks he will come around once the baby is born.

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.

Daniel Gatto is a 41-year-old stockbroker. Once a top level soccer player, he now plays the game only over weekends, though he is sometimes able to get out for his club's midweek practice session. He enters your walk-in clinic on a Tuesday morning, limping slightly and reporting that he has been having increasing problems with his right knee over the past month. The knee has been intermittently painful and has seemed swollen from time to time. He has also been concerned about what he describes as "a feeling of weakness" of the knee, as though it was about to "give way"

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).

Desta Ayo is a 42 year old woman, on disability pension and married to a disabled man. She was brought to the hospital by ambulance after she called 911 to report she was dying. After running a few tests, the ER physician could not find anything wrong with her. He referred her to psychiatry because the problem was obviously "all in her head." On interview, Desta sits motionless in the chair, opening her eyes and speaking with dramatic effort. She believes she is again suffering with another kidney infection, like the one that almost killed her 10 years ago. She describes "passing out" almost every day for the last 2 weeks, feeling too weak to walk, and experiencing crippling back pain. She denies anxiety and depression but continues to take paroxetine for chronic pain and Trazodone for sleep. She says she has arthritis throughout her back, frequent migraines, temperomandibular joint pain, chronic fatigue, and recurrent sinusitis that eats away at her nasal bones. She also reports a history of gynaecological problems since age 22, with breast cyst and ovarian cyst surgery, endometriosis, and uterine fibroids. She reports an early childhood history of sexual and physical abuse. She remembers her mother as an alcoholic, a distant and cruel woman. Inquiries about current stress in her life reveal major financial problems and an argument with her mother on the phone 2 weeks ago. She says that she doesn't think her mother will ever talk to her again.

A 55 year-old lady is reviewed in the Respirology clinic because she has become increasingly breathless and can no longer keep up with her friends when walking. The referral letter notes that she has no history of heart disease. She denies any cough, wheezing, or chest pain. She does say that she spends a lot of her time lying down in bed because this eases her breathlessness.

Diane Bainbridge, a 32 year old woman, complains of fatigue and weakness, lower back, and hip pain which she describes as a gnawing ache. She has noticed that this has become progressively worse over the past few months and she finds that getting up from a chair is difficult. She has noticed that her gait has changed. She has known celiac disease and has had associated weight loss and intermittent diarrhea

Apply knowledge of the expected changes across the lifespan in the care of patients with psychiatric disorders and medical conditions; Apply knowledge of the major psychiatric disorders in the care of pediatric patients (including but not exclusive to mood disorders, anxiety disorders such as separation anxiety disorder, reactive attachment disorders, etc.); Prioritize a differential diagnosis by applying knowledge of psychopathology and medical illnesses;Apply knowledge of potential signs/symptoms of abuse when developing treatment plans, including when to report suspected abuse.

Elena Christakos is a 54 yr old lady who presents to the Emergency Room with a 48 hr history of fever (temp up to 39.6 degrees celsius), chills, and weakness. Her condition in the ER deteriorates; BP falls to 80/50 and she becomes anuric. She is thought to be developing septic shock and is transferred to the ICU.

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

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

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.

Gayle Parker is a 12-year-old girl who was recently noted by her dance instructor to have shoulder asymmetry. She has no pain, neurological symptoms such as dysesthesias, or bladder/bowel dysfunction. The deformity has not changed since it was first noticed.Gayle has recently started her menses

Mr. Haycock is a 20-year-old student who presented to ER with a 5 day history of diarrhea and vomiting which started at the end of his trip to the Caribbean. Past medical history is significant for epilepsy controlled with carbamazepine. Vital signs: HR – 100/min, RR – 15/min, BP – 80/50 mmHg, Saturation – 99% in room air. Physical examination revealed dry mucous membranes, prolonged capillary refill time of 4 seconds.

Demonstrate an understanding of the interface between psychiatry and medicine and the importance of identifying and treating psychiatric illness in medical patients. Discuss how medications can result in mood disorders and how to identify and treat mood disorders in medical patients. Discuss the importance of multi-disciplinary care in the treatment of patients with medical and psychiatric illness as well as issues such as addiction and chronic pain. Discuss the potential medical implications of treatment with SSRI medications. List some pharmacokinetic changes associated with aging. Identify cognitive changes associated with aging. Describe some common bed side cognitive assessment tools.

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.

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.

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.

Hannah, a 1-year-old girl, is brought to the clinic for a routine immunization by her mother. Mr. and Mrs. Rosen have a healthy 5-year-old boy at home. The pregnancy with Hannah was uneventful and a fetal ultrasound done at 16 weeks gestation was normal. The baby was born by spontaneous vaginal delivery, breathed immediately, and was placed on the breast for mom to nurse. Hannah's birth weight was 3.4 Kg. After seeming to feed normally for 24 hours, Hannah vomited bile and the abdomen was noted to be distended. An x-ray was interpreted as showing a distal small bowel obstruction. Further contrast x-rays of the colon showed a microcolon and inspissated meconium in the proximal colon, making a diagnosis of meconium ileus. Genetic testing confirmed cystic fibrosis. After a lengthy hospitalization to correct the bowel obstruction, Hannah was discharged home receiving exclusive breast milk. At 4 months of age, Hannah was switched to a cow's milk formula. Her mother noticed that she cried a lot. Hannah's mom attributed the symptoms to a milk allergy and progressed through a variety of cow's milk and soy formulae. At present Hannah is taking 1 litre of Rice milk and a small variety of foods daily. She has one small formed stool per day. She weighs 8.5 kg and is 74 cm tall.

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

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.

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.

Part One: Jake Gamble, an obese 65-year-old man, presents complaining of back pain that began 5 days ago while shovelling snow. The pain becomes worse when he stands. Part Two: The patient reports he got over that last "attack" in less than a week but has had low back pain ever since. He now returns 2 years later because of another attack of acute back pain after chopping wood. Part Three: The patient returns in 6 weeks because the pain has not decreased. His legs feel "heavy," and he has had some incontinence in the last week.

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.

Jane Deglutinato is a 50-year-old female with a 4-month history of progressive dysphagia, symptomatic heartburn and regurgitation that has not responded to the use of regular non-prescription oral antacid medications. She has also noticed some general joint discomfort and painful swelling of her fingers with occasional pain and discoloration of the fingertips. She also reports having lost approximately 9 lbs of weight over that period of time related to a reduction in her appetite. Her bowel movements continue to be formed with no evidence of blood or fatty stool. On examination, her vitals are within normal limits and she is afebrile. Her weight is 55 kg. You notice that she has some tightening of the skin around her mouth as well as her fingers and toes, with pitting and some ulceration of the fingertips on both hands and toes of both feet. You also note several telangiectasias over her chest and upper torso. Cardiac and respiratory as well as abdominal examinations are unremarkable.

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.

Janet Woo is a 50-year-old woman with a history of intermittent palpitations. Over the last five years, she can recall infrequent and transient episodes of her heart "pounding in her chest". These episodes would not produce any other symptoms and would last no longer than a couple of minutes at a time, so she never sought medical attention. Earlier this evening, while watching television, she developed palpitations that did not resolve. She became diaphoretic, felt dizzy and somewhat short of breath and so called 911 and was brought to the ER.

You are seeing Jean La Barre in your clinic this afternoon. He has had a complicated course of Crohn’s disease requiring multiple surgical resections of his small bowel due to inflammation and obstruction. His type 2 diabetes mellitus is normally well controlled by metformin but whenever he requires prednisone for acute flare ups of his Crohn’s, his blood sugars become very high, particularly after meals.

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.

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.

John Fumer is a 54 year old man who began smoking at the age of 14 and has averaged a pack a day since then. Five years ago, he noticed that heavy exertion such as climbing 2 flights of stairs would leave him more "winded" than usual but there was no major impact on his lifestyle (including smoking!) Over the last 18 months, he has noticed increasing restriction on his activities. When a friend pointed out that he could no longer "walk and talk at the same time", he decided to seek help from his family physician.

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.

Joshua is a 48-year-old man who suffered a motor vehicle accident while riding his motorcycle. Joshua was unable to stop in time at a red light and rear-ended into an SUV, causing him to be thrown from his motorcycle, landing on his right side. He has a large laceration to the lateral thigh. He also notices some weakness to certain movements of his right lower extremity. He is taken to the trauma centre and the physical exam reveals that he is unable to dorsiflex his ankle, evert the foot, and extend the toes on the right side. All other muscles are normal. On sensory examination, it is noted that sensation is slightly impaired over the front of the leg and foot. An x-ray reveals that he has sustained a mid-femur shaft non-displaced fracture.

Judy Patterson is a 22 year-old university student who presented to the Student Health Clinic with a rash on her lower legs. Her past medical history is unremarkable except for a urinary tract infection diagnosed 6 days ago for which she is taking trimethoprim-sulfamethoxazole. The only other medication she takes is the occasional dose of ibuprofen for headaches. She has never had any dental extractions or surgeries. On examination, she has no lymphadenopathy or splenomegaly, but she does have petechiae on her lower legs. You ask to look inside her mouth and there you see a blood blister on the inside of her cheek. She says she must have bitten it by accident.

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.

Kate Smith is a 15 year old girl. Her mother brings her to the family physician because she has not yet had her first menstrual period. Kate has been well throughout her childhood. Kate has a healthy appetite and weight. She does not receive any medications.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Lauren Bick is a 13-year-old girl who presents to her family physician's office with a 6-month history of weight loss. Her mother is concerned because she has noticed that Lauren has lost at least 10 pounds since her last doctor's visit which she had just before she started at her new school. Although Lauren has always been a "petite" girl, she is now the shortest in her class. The doctor asks Lauren's mom to give her a few minutes alone with Lauren. Once Lauren's mom has left the room, the doctor reviews the limits of confidentiality with Lauren and asks her about her weight loss. Lauren explains that she has met a new group of friends who do not believe that it is healthy to eat animals so she has joined them in following a vegan diet. She also reports that she's recently joined the long distance running club at her school. Lauren indicates that despite her mother's wishes, Lauren's goal is to get her weight down to 25 kg in the next few months. Lauren requests that you don't tell her mother this as it will likely cause them to argue. Lauren's menarche was at age 11 and she had been having regular menstrual periods but in the last 4 months, she has not had a period. Lauren indicates that she has not been sexually active. On questioning, she reports some constipation and says that she often feels cold.

Malcolm Lowry presents to the ED of the Hamilton General Hospital accompanied by his wife, Vita. He is seen by a second-year resident in Emergency Medicine and a clinical clerk. Mr. Lowry is a 47-year-old businessman. This afternoon, he collapsed in front of his wife, who observed that both arms and legs were shaking and that his eyes were rolled back. After 30-60 seconds the shaking stopped, but he was unresponsive for several minutes and remained drowsy and confused for half an hour. Vita called 911 and Malcolm was taken to the Emergency Department. The patient states that this has never happened to him before. He had no warning symptoms prior to collapsing. He does not remember collapsing. He did not soil himself or bite his tongue, but his muscles are sore. His past health has been good. He does not have hypertension, diabetes or other chronic health problems. He has never been hospitalized and he is not on any medications. He denies recent head trauma, febrile illness, headache or neurological symptoms. He has no family history of epilepsy. Vita states that Malcolm has been drinking alcohol heavily for a number of months but stopped two days ago after she removed all the alcohol from the house. Today he was so tremulous that he could hardly button his shirt. Malcolm points out that he has stopped alcohol for a day or two several times in the past few months, and although he has felt shaky he has never had a seizure.

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.

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".

Manuel Pereira and his wife have been trying to conceive a child for 16 months. After 12 months of trying, Michelle sought medical advice and so far, her investigations have been negative. You have suggested that since it takes two to make a baby, Manuel should undergo evaluation. Manuel reluctantly attends your clinic. He is quite certain that their inability to conceive can not be "his fault" because he fathered a child, by mistake, when he was 18

Maria Rossi is a 21-year-old woman who comes to the emergency department for treatment of a headache. She has been having worsening headaches for several weeks and today the pain is severe and has not responded to Tylenol. The triage nurse measures her blood pressure and finds it to be 220/110. Maria is put on a monitor and full examination by the emergency room physician reveals retinal exudates and an abdominal bruit. Blood work is sent to the lab.

Martin Barratt is a 40-year-old male with Autosomal Dominant Polycystic Kidney Disease (ADPKD). He was diagnosed at the age of 15 years when he was found to have bilateral cysts on renal MRI. The diagnosis was confirmed genetically (see attached result) and there is a strong family history of this condition. His mother is on dialysis and maternal grandfather had a kidney transplant and died from a ‘brain bleed’. Martin’s creatinine was elevated for a number of years and was measured at around 350 µmol/L (eGFR 18 ml/min/1.73m2) 3 years ago. Unfortunately, he was lost for nephrology follow up and was recently re-referred by his FD. He is seen by the nephrologist today and complains of fatigue and pruritus. Current medications include allopurinol 75 mg/daily. ROS was significant for erectile dysfunction and recent forearm fracture after a minor fall. He is also worried that his 15-year-old daughter could have the same condition and asks whether she needs to be tested. Physical examination shows a pale, malnourished male with BP of 169/92 mm Hg.

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.

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.

Mr. Dupois is a 35-year-old French-Canadian man born in rural Quebec who moved to Hamilton with his wife a few years ago. His family physician noted a persistent rash around his eyes that he identified as xanthelasma. This prompted some blood tests and a referral to the Lipid Clinic. He is rather reluctant to see you at the Lipid Clinic because he is completely asymptomatic. He denies any significant medical history and is taking no medications. He is a lifelong non-smoker who faithfully walks to work for 1 km with no problems. A family history indicates that Mr. Dupois’ father died suddenly at the age of 46 with no clear explanation. He has multiple family members on his father’s side had a history of heart attacks, some at an unusually young age. His mother is healthy. On physical exam he has soft, velvety, yellowish, non-tender plaques in the palpebral area. Thickening of the Achilles tendons bilaterally were also noted. His blood pressure was 145/90 and waist circumference 98 cm.

Ms. Broyer is a 22-year-old female who moved to the local area and enrolled in your practice. Past medical history is significant for several episodes of muscle cramps and intermittent muscle weakness.

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".

Mike is a 45 year old man who has worked as a labourer at one of the steel plants in Hamilton for years. The work requires frequent heavy lifting, particularly overhead. Mike smokes 1 pack of cigarettes per day. He has had a 1 year history of shoulder pain, which seems to be getting gradually worse. He has had to give up baseball and now is having trouble performing his job. He has not tried any treatment for his shoulder, other than Tylenol plain and icing it. On physical exam there is no muscle wasting. He is tender over the anterolateral aspect of the humeral head. Range of motion is good, but terminal flexion and abduction reproduce his typical pain. Muscle strength testing shows weakness in abduction, which also reproduces his typical pain. Provocative tests for impingement syndrome are positive, but provocative A-C joint and biceps tendon tests are negative. X-rays are done to evaluate the bony anatomy, and an ultrasound is performed to evaluate the rotator cuff.

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.

Neil Wartson is brought back to his family doctor 6 months later. The MRI has still not been performed, but the audiology testing confirmed severe sensorineural hearing loss on the right. Upon entering the office, Neil’s mother is very upset and agitated. Over the last month, she has noticed that Neil has become clumsier and is falling frequently. He also has started to rub his eye a lot and complains that things are “fuzzy”. She also reports that, since the last visit, Neil’s father has been investigated for his hearing loss. He is currently being worked up for Neurofibromatosis Type II. Neil’s mother has looked this up on the internet and is convinced that Neil has this as well.

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.

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.

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

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.

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.

A 32-year-old female was seen in emergency department for abdominal pain, nausea and diarrhea. Her serum calcium was found to be elevated at 2.94 mmol/L (normal 2.15-2.55 mmol/L). She was treated with intravenous fluids. Her calcium improved to 2.65 mmol/L and she was discharged home to care for her 6-year-old son. She was referred urgently to an outpatient clinic to investigate her elevated calcium. She was also prescribed pantoprazole for worsening heartburn. In the clinic, Ms. Parapan reported a 2-year history of abdominal pain that was getting worse over time. The pantoprazole she was prescribed was modestly helpful in easing her heartburn and abdominal pain. She denied symptoms of polyuria, polydipsia, confusion or mood changes. There is no history of kidney stones. She had a fracture of her humerus at age 15 due to a ski accident. She was taking pantoprazole and a multivitamin daily. Ms. Parapan’s family history is significant for a father who had a pancreatic tumour, though she does not know any more details about his condition. Both her sister and her paternal aunt had a parathyroidectomy. The same aunt had a pituitary tumour requiring surgery.

Qamar is a 16-year-old female presenting to your office with her mother. Her mother indicates she is very worried about Qamar as she has lost 30 pounds over the last 3 months. Qamar herself is not concerned and says her mom is too controlling and should mind her own business. Qamar reports she just wanted to "get healthy" and there is no reason to be worried. Her mother reports that Qamar has been more active lately, running on their treadmill at home for at least an hour every day. Her mother also believes that she has heard Qamar vomiting in the bathroom, but when questioned, Qamar adamantly denies this. Her mother also has noted that Qamar has dramatically cut back on her intake in terms of the amount, but also that she will avoid certain foods like chips and ice cream completely. She used to like these foods. When she does eat, Qamar only picks at her food, cutting it into small pieces and pushing it around on her plate. She has also started to become concerned about contamination of food, and states that the food is "bad". She has started washing her hands repeatedly before and after eating. Qamar does admit that she has had trouble sleeping lately, and wakes up early in the morning, but she states her mood is good. Her mother feels her mood has been irritable and that she has been withdrawing from her family and friends. Qamar's mother also reports that she has not had a menstrual period in over 4 months.

Rachel is a 15-year-old grade 9 student who has come to the walk-in clinic requesting ‘the pill’. She has been dating John, who has not accompanied her, for 6 months and she feels that it is time for them to have sex. She has never had intercourse. John is 18 and will finish grade 12 this year. Rachel lives with her mother and two younger brothers. She has always been healthy and is on no medications. She states that she smokes occasionally and sometimes drinks. After a discussion regarding the implications of her decision and the issues of the options available, Rachel is given three months of oral contraceptives (OCP) and instructions. There is a plan to follow-up with her family doctor for a refill and a pap smear. Three months later, Rachel experiences heavy vaginal bleeding accompanied by suprapubic pain. She is very frightened and comes to the ER with her mother. She states that she thinks her last period was a month ago but it was not really normal and she has had spotting intermittently since starting the pill. She says that she is not on any other medications but two months ago she was on an antibiotic for 5 days for a bad cough. The antibiotic made her very nauseated.

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.

Richard Strang, a 50-year-old male with a two-day history of sudden onset of acute pain and swelling of the left great toe, is seen at his family physician's office. It seemed to suddenly start when he awoke two days ago. It is so painful that he could not even tolerate the bed-sheet touching it. Richard works in construction, and routinely enjoys a few beers at the end of the day with his buddies. He had a similar attack in the right knee about 3 months ago, and right 1st MTP about 6 months. He was told that he had "the gout".

A healthy 3.6-kg baby boy, Riley, is born to a 25-year-old nulliparous mother in a community hospital. The family doctor notes that the boy's genital development is somewhat atypical. Her examination reveals that the infant has hypospadias, chordee and undescended testes. A plan is put in place for the infant to be seen by a pediatric urologist in 6 weeks with a view to eventual surgical correction. At one week of age, the infant is brought to the family physician's office for routine follow up. Riley's mother comments that he seems to be breastfeeding poorly. She describes him as increasingly uninterested in feeding and is concerned that he seems to be "spitting up" a lot. The infant now weighs 3.1 kg. A recommendation is made to begin some formula supplementation to help support weight gain. At 10 days of age, Riley's mother finds him in his crib, non-rousable, cool, mottled and covered in vomit. Riley is rushed to the emergency department via ambulance. In the emergency room, resuscitative measures are initiated. The airway is suctioned. He is intubated and hand-bagged to achieve ventilation. A 20 mL/kg bolus of normal saline is administered.

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

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.

Ronnie Olchuk is a 6-year-old boy who was hit by a car while crossing the street. A witness at the scene said he was hit on the left side and thrown approximately 20 m. He is healthy, has no allergies, and has never had surgery. He last ate eight hours ago. He has been stabilized by the trauma team, is alert and oriented, and has no injuries except to his right forearm and left thigh. His distal right forearm is badly deformed. His left thigh has a 2 cm laceration located medially and is also badly deformed. He is in excruciating pain, especially in the right forearm.

Rosemary, a 38-year-old G2A1, is seen with her 42-year-old husband for their first antenatal visit. She is 10 weeks 1 day pregnant by an LMP of January 18th. She is sure of the date and her periods were 4 days every 28-30 days. She states that she is trying to eat quite well because she does not believe in taking vitamins. She says that she tries to have a gluten-free diet. Rosemary had a therapeutic abortion when she was 27. She and her husband are both healthy. She is on no medications. Both of their families are from Ireland and they do not know of any family health problems. Their GP discusses issues regarding the pregnancy with them, including dietary issues and the potential benefits of a prenatal vitamin and an iron supplement. Rosemary’s prenatal bloodwork is normal. She is booked for an ultrasound, which is done at 12 weeks. The ultrasound is normal and shows a single embryo with measurements consistent with her LMP. At 17 weeks, her GP calls to tell her that her IPS test is positive for Down syndrome and she would like the couple to go to the University hospital to discuss their options. They are devastated with the news and do not know what to do as they are both Roman Catholic.

Ryan Smith is a two week old baby brought to your office by his parents. He was noted to have bilateral feet abnormalities on prenatal ultrasound. Family is anxious and worried about whether the child "Will walk, play soccer etc." Physical exam show that both feet are adducted, supinated, equines and the hindfoot is in varus. The feet are moderately flexible but not completely correctable

Samira Shah is a 27 year old woman who works as a waitress in a local restaurant and is in her first pregnancy. She is slightly overweight (pre-pregnancy BMI 28.5). Her prenatal care has been unremarkable although she was found to be rubella non-immune and had a positive glucose challenge test (GCT) followed by a negative glucose tolerance test (GTT). Now at 38 weeks, she has abdominal cramping and slight bright red vaginal bleeding. Her husband, Sunny, informs Hanna’s midwife of this. Her midwife comes to their apartment to assess Samira.

One hour after giving birth to baby Varkey, Mrs. Shah states that she feels lightheaded as she sits upright for the first time. Her midwife who has been monitoring her closely following the delivery helps her to lay back down. She notes that Samira is somewhat pale and that her pulse is rapid and thready. She palpates the uterus and finds the fundus is above the umbilicus. As the midwife massages the fundus, a large grapefruit size blood clot is expressed followed by blood that soaks the bed sheets. As summoned help arrives, Samira’s BP is found to be 85/50 and her heart rate 120.

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.

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.

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.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Today, Siobhan came in sobbing, dragging a reluctant 8-year-old Skylar behind her. She wailed, "He's turning out just like his Dad. Before you know it he'll be in jail for assault, I'm scared of both of them." Siobhan explains that Skylar punched a boy in the face today and was suspended for 3 days. Evidently, there have been numerous incidents at school where the Grade 3 teacher claimed Skylar was the aggressor. This implied information about Skylar 's father was news to you and you suspect that there was more going on in the home than Siobhan had shared with you in the past. You wonder how to approach Siobhan about this.

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.

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

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

Mrs. Tammy Polk is very difficult to interview. She is an extremely vague and difficult historian. Her family tell you that she was diagnosed with breast cancer 5 years ago and had a mastectomy at that time. Her husband died 6 months ago and she has never really recovered. Over the past week, the family have been worried that she is "developing Alzheimer's" because of memory problems and agitation. Past psychiatric history is notable for mild depression, treated with paroxetine 20mg daily, and sleep difficulties that are chronic and date back to her days as an alcoholic. One month ago, she was started on 50 mg of quetiapine at bedtime for sleep by her family doctor. Two weeks ago, she was given Oxybutinin (Ditropan) to help with some urinary incontinence, with good effect on her bladder problem. She is admitted to hospital for further medical work-up. The 1 pm nursing note reads: "quiet, resting comfortably, oriented x 3." The results of CBC, serum electrolytes and urinalysis are pending. The medical resident calls for psychiatric consultation at 4:05 pm because the patient has become agitated and has voiced suicidal ideation. The consult note reads: "medically cleared, please transfer to psychiatry for treatment of emotional instability and psychotic depression." The psychiatric resident arrives at 5 pm and finds that the patient is visually hallucinating and disoriented.

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.

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.

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.

Usha L. is a 16 year-old male who attended a routine follow up visit at his family doctor’s office. He would like to start playing competitive soccer and the coach asked for a doctor’s clearance. The patient’s family was pleased with the proactive approach the coach demonstrated, as they were also worried about the small but real risk of sudden collapse sometimes resulting in death in young elite athletes without previous diagnosis of heart disease. The coach was particularly concerned about ruling out any type of heart disease. Usha is active, athletic and asymptomatic. His past medical history is unremarkable. There is no family history of cardiac disease. He doesn’t smoke or use street drugs.

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.

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.

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.

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

Demonstrate competency in performing the following interpretive skills

One hundred multiple choice questions via the web. The exam is timed.

Each student will be evaluated doing one of the MSK exams: Cervical spine; Lumbar spine and pelvis/sacroiliac joints (excludes hip focussed exam); Shoulder; Hand and wrist; Knee; Foot and ankle; GALS and gait.

Domains assessed: Fund of Knowledge, Knowledge Integration, History taking, Clinical Examination, Clinical Management, Learning Skills, Communication Skills, Professional Responsibility and Integrity, Pursuit of Excellence and Insight, Personal Interactions.

National Board MedicalExaminer Subject Examination, a standardized US examination for clinical clerks.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

Students create the ‘On-demand’ evaluation on MedSIS for each clinical day and for each call shift. Unless there is a holiday, there should be a total of 9 'On-demand' clinical evaluations at the end of your rotation. It is the student's responsibility to generate the form on MedSIS and bring it to the supervisor to fill it out near the end of the day.

Students must receive a satisfactory evaluation for their PES call experience.

Fetal bradicardia simulation.

In a simulation initially assess a labouring patient, manage a normal delivery and provide immediate postpartum care of the mother.

Postpartum Hemorrhage (PPH) simulation.

Provide an introduction to the field of clinical pharmacology and therapeutics. To discuss what will be covered throughout the MD Program curriculum. To discuss pharmacodynamics and pharmacokinetic concepts.

Opportunity to consolidate knowledge acquired through PBL cases. Review of high yield orthopedic clinical pearls. Opportunity to actively practice relevant clinical skills such as reading imaging (within the confines of virtual learning).

This session is intended to generate a discussion towards formulating a basic early understanding of pain for future physicians. It is also intended to serve as a framework for future learning about how pain manifests in the context of health or disease, be it acute, chronic, or terminal, and to consider how it might be managed. Finally, this session is intended to begin illustrating how psychological, environmental and social factors can influence the experience of pain and its management thus resulting in the potential need for an interdisciplinary approach in that regard.

Compare and contrast how various imaging modalities can be best utilized to image the different components of the musculoskeletal system. Develop an approach to the interpretation of MSK radiographs. Develop an approach to the interpretation of the cervical spine radiograph. Compare and contrast the appropriate use of various imaging modalities in the work up of the following cases: Scaphoid fracture; Acute knee pain; Ankle trauma; C-spine trauma.

To review the common movement disorders relevant to psychiatry. A general approach to management of the specific disorders. To review the key components of cognitive assessment.

Consists of 7 days in the OR (maybe less in case of holidays) and 2 on call shifts.

Students must complete 12 x 8 hour clinical ER shifts.

Students will be scheduled to complete one 2 hour triage shift with nursing staff.

Students will be expected to care for up to seven patients, including Alternate Level of Care patients (ALC – awaiting rehab, long term care, palliative care, or other type of care facility). Ideally, a student will care for a blend of patients with “acute” problems as well as those with more chronic issues such as ALC patients.

This may be in the inpatient and/or the outpatient setting based on the specific MSS rotation.

Each student will be assigned to a community Ob/Gyn. Students are expected to participate in 8 half day clinics with exposure to both Gynecology and Obstetrical patient populations.

During the Hospital rotation students participate as part of the Ob/Gyn team. Time spent on L&D, post?partum and gynecology. Students are expected to be present at normal births, caesarean section, ER consults, OR and if appropriate more complex issues presenting to the service. Students will participate in the on call schedule.

Nearly twenty percent of all problems presenting in the Primary or Acute Care setting are based in musculoskeletal pathology. The objectives outlined for this two-week Clerkship must be considered as nominal and must not act as a limit to a student's personal learning in the diagnosis and management of musculoskeletal related diseases. To this end, one of the "attitudes" objectives of this Clerkship is to encourage in the student an enthusiasm for life long learning.

The pediatrics clerkship rotation is a six week rotation during which the clerks are placed in one of 4 tracks and have exposure to both ambulatory and inpatient pediatric care.

Each Hamilton campus clerk will be assigned 2 Psychiatry Emergency Services (PES) shifts.

Each clerk will be assigned to 2-3 primary clinical supervisors. The supervisors will be responsible for the supervision, assignment and evaluation of clinical work. Clinical placements may occur in a variety of settings, including inpatient, outpatient, general psychiatry, or subspecialty settings (e.g. child and adolescent, geriatrics, eating disorders, mood and anxiety, forensics, schizophrenia, dual diagnosis, etc.). These placements can occur in academic hospitals, community hospitals, or community clinics.

During this six week rotation students will be involved in a variety of clinical scenarios and learning opportunities designed to enhance their knowledge and skills. Students will interact with patients and their families in all aspects of surgical care (hospital wards, outpatient clinics, operating room, emergency department, intensive care unit, etc.).

The Clinicopathology Conference (CPC) is a longstanding practice where clinicians are informed of the pathological findings that may have accounted for the clinical features of their patients. Such findings may be in the form of surgical specimens or autopsies. It is the most efficient way of learning the pathophysiologic process of disease.

The case: 29 yo Caucasian male; Presents with 8 weeks of bloody diarrhea; What is your differential for bloody diarrhea? What tests would you order to evaluate this patient?

Introduce head and neck cancer. Illustrate using a clinical presentation with pathological correlation. Develop an approach to patients with head and neck symptoms.

Case presentation of megaloblastic anemia with objective of making a unified diagnosis, understanding the pathophysiology and reviewing the appropriate diagnostic and therapeutic strategies.

By the end of this session students should be able to: Critically appraise at least one clinical decision rule or tool fully and be able to explain its application and limitations; Identify the role of clinical decision rules in the management of key disorders presenting to the emergency department; Discuss the role of clinical decision rules in ensuring judicious use or preventing misuse of certain outcomes, such as diagnostic test usage (e.g. PERC to decrease use of D-Dimer, or some of the Ottawa rules for decreasing X-rays); Deliver an effective oral presentation; Critique peers’ presentations and presentation style.

Describe an elderly patient's functional status using patient and collateral history. Define "Frailty" in the context of the following common problems as they contribute to functional status decline in the elderly including: Incontinence, Falls, Polypharmacy, Depression, Cognitive impairment (FM approach). Identify important topics of discussion with the elderly patient and family/caregiver meetings including: Advance care planning and Goals of Care discussions, Caregiver burnout, Driving, Community resources, Transition planning.

Describe the palliative care approach to care, and who may benefit from it. Assess and manage pain and other common symptoms in palliative care. Understand the interprofessional approach to providing palliative care. Organize care for the actively dying patient and family. Describe an approach to responding to grief, bereavement, and suffering

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

Demystifying ECT (Electroconvulsive Therapy): A discussion of ECT, TMS (transcranial magnetic stimulation) , DBS (deep brain stimulation) and VNS (vagal nerve stimulation)

The major topics will be: Nutrition for growth and development; Nutrition for prevention of diabetes and cardiovascular disease; Nutrition for prevention of cancer

The Objectives are to introduce the medical specialty of Physiatry (Physical Medicine and Rehabilitation). To review common medical problems seen by a Physiatrist. To review some cases from a Physiatric perspective.

Anxiety, Depression and Bipolar Disorder. Review types of anxiety and mood disorders. Examine common biological constructs underlying anxiety disorders and mood disorders. Discuss comorbidity between anxiety and depressive disorders and the impact this has on outcomes.

Shoulder Dystocia. Post Partum Hemorrhage. Cord Prolapse.

X-ray interpretation of fractures. Growth Plate Injuries. Basic Trauma and Fracture Management. Clinical examination. Upper extremity. Lower extremity. Spine. Emergency conditions

Trauma orthopedics. Pediatric orthopedics and infections. Reconstructive orthopedics.

Burden of pain. Acute vs. chronic pain. Neurobiology of pain - links with other pathways (pain experience). Research "Pain is in the Brain". Explaining chronic pain and management.

To assess genetic risk factors in the family history; when to refer a patient for genetic counselling. To understand age related risks for fetal aneuploidy. To review current standards of practice for Prenatal Screening and Diagnostic testing for fetal aneuploidy. To learn about the evolving landscape of Prenatal Screening in light of new technologies. To be aware of the underlying theme of empowering informed decision making for all women.

Acute abdominal pain is a common and notoriously difficult clinical problem to diagnose and manage. Understanding of pathophysiologic pain patterns and innervation anatomy can aid in honing DDx (intra vs. exta abdominal dz.). Epidemiology and pathophysiology of pain. Differential diagnosis of acute abdominal pain. Clinical assessment. Investigations; limitations of diagnostic tests. Likelihood ratios for commonly used tests. Intro to Clinical Practice Guidelines. Hierarchies of Evidence-Methodology. Initial treatment strategies. Disposition.

Physicians tend to focus on diagnosis and treatment, while patients care about etiology - "why did this happen to me?" and prognosis - "what will this mean for me?" The evidence around diagnosis and treatment is clearer to collect, evaluate and summarize; gathering the evidence around prognosis, and translating it to apply and communicate it to a particular patient is much trickier. We hope this session will help you to: Answer patients' questions about "What does this mean to me?" (prognosis); Realize that even with evidence there is uncertainty but that information still needs to be communicated; Understand that physicians play a supportive role in interpreting test results, planning the future and monitoring symptoms.

This session will explore issues related to how we incorporate various pieces of information (i.e. from research, from patients) to make medical decisions.

Practice advising a patient on the risks and benefits of screening, using screening mammography as an example. Use differing approaches to the decision making process (including paternalism and shared decision making), to understand how different approaches may lead to different decisions. Be aware of the “framing effect” and how it might affect the way a patient is advised of the research evidence.

The four-week Family Medicine rotation revolves around a one-to-one experience pairing a student with a community-based family physician. The most significant component of the Family Medicine rotation is this time spent with the clinical preceptor in the office setting.

Oxygen delivery. Ventilation. Hypoxemia.

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.

Adrian Scholtz is a 33 yr old male patient presenting at the Shelter Medical Outreach centre. He complains of a dry cough, fever, shortness of breath and worsening fatigue. He was seen at a walk-in clinic a few days ago for similar symptoms. He states he underwent testing for influenza A and COVID, but did not stay around to see what the results were. Adrian was encouraged to take Tylenol and rest, but did not receive any antibiotics or other treatment. Past medical history includes intravenous drug use, mechanical valve replacement (3 years ago), and is a current smoker. Concerned that Adrian appears quite sick, the medical clinic staff arranges for Adrian to be sent to the local ER department for evaluation.

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Amanda, a 12 year old girl, has been accompanied by her mother to see her family doctor for a routine check-up. Her mother is a single mom who works shift work as an R.N. at the local E.R. department. She and Amanda currently reside in a suburban neighbourhood of Hamilton. Amanda attends a public school in her neighbourhood and complains of being constantly teased by her classmates for being "bigger". According to her mom, Amanda participates in gym class, but does not get much more physical activity than that. Amanda spends a lot of time alone while her mother works shifts. She admits to watching approximately 3 hours of television per day on weekdays and 5 hours on the weekends. She is also on the internet, chatting on MSN, for 1-2 hours per day. Her mother is also obese and is not worried about her daughter's current weight or the sedentary lifestyle and is rather pleased that Amanda is a "good girl". Amanda does not express interest in participating in local clubs or extracurricular activities and indicates that she is simply not an "athletic type" of individual.

Amir Boutros is a 30 year old man with a history of Crohn's disease who presents to the hospital with a recent history of increased pain and diarrhea. He is very weak, dizzy and short of breath. His BP is 80/50 with a heart rate of 120 and respiratory rate of 24. His chest X-ray is normal.

Part One: A thin 65-year-old woman presents complaining of back pain that began 5 days ago while lifting her wash. The pain becomes worse when she rolls over in bed or when she stands up. She has noticed that the hems of her skirts seem longer and on measurement she appears to have lost 6 cm in height. Part Two: The patient reports she got over that last "attack" after around 3 months. She was commenced on a bisphosphonate, calcium, and vitamin D. She now returns 2 years later because of another attack of acute back pain after falling on the ground.

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.

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.

Benjamin Nuri is a 45 year old Caucasian male who presents at the emergency room accompanied by his wife. He has been to the emergency room on two occasions prior to today . He reports that for the past year and a half he has experienced transient episodes of chest pain, shortness of breath, sweating nausea, numbess in the left side of his face and left arm as well as dizziness.

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.

Mr. Silva went to his family physician due to a lump he noticed on the right side of his neck while shaving. His only past history was one of recurrent kidney stones. His only family history of disease is that his father died of a stroke at 40 years of age. Mr. Silva is married with a 5 year-old son. He works as a plumber. Physical examination reveals a firm 2.3 cm nodule in the right side of his thyroid gland. There are also some palpable nodes in his right cervical chain. BP was elevated at 180/90 but his family doctor did not want to diagnose him with hypertension based on one reading. A recommendation was made for a low sodium diet, blood work sent for TSH and calcium profile and referral made to an endocrinologist for the thyroid lump.

Dr. Jones has been following Calvin Shin for several years for obstructive sleep apnea. He had been doing well with reduced symptoms of daytime sleepiness since he had been using his CPAP machine. Dr. Jones was reviewing John's chart in his clinic. He missed his appointment several months ago but booked an urgent appointment through his family doctor. Calvin explains that he thinks his tongue, nose and lips have been getting thicker. He also states that he seems to be sweating and his skin feels thicker and oilier than it used to.

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.

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.

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.

Claire McFadden is a 16- year-old high school student, living with T1D since age 10, who is currently pregnant (G1). Claire has struggled with her diabetes management in the past but is trying to keep her sugars at target now that she knows she is pregnant. Her most recent HbA1C was 7.8%, and she is using an insulin pump. Claire is being followed concurrently by her endocrinologist and has had microalbuminuria and mild non-proliferative retinopathy but no other diabetic complications. She has been normotensive with a usual BP of 110/70. She was told to start prenatal vitamins with extra folate as well as to discontinue her ACE inhibitor when her pregnancy test was found to be positive. Claire was also started on low-dose ASA (LDASA) at 12 weeks. Her partner, Dave, is 18 years old and is unemployed, having graduated high school in the summer. Claire is living with Dave in her aunt’s apartment. Her pregnancy was unplanned, but she is now excited to become a mother. She is planning to take a year off from high school and then return to complete her high school diploma. Dave is unhappy about this and feels she should stay at home to take care of the baby. They have argued about this, and Dave feels it is Claire’s own fault if she does not like making sacrifices as she could have gotten an abortion like he wanted. Claire worries about Dave’s temper, explaining that when he found out she was pregnant, he yelled at her and then disappeared for a week. She thinks he will come around once the baby is born.

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.

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).

Dorothy Little is a 69 year old woman who underwent a modified radical mastectomy three years ago for a 4 cm, grade II infiltrating ductal carcinoma of the left breast. Three lymph nodes were involved and lympho-vascular invasion was seen. The tumour was both estrogen and progesterone receptor positive but Her2/neu negative. She declined adjuvant hormonal therapy and has been assessed regularly by her family physician

Apply knowledge of the expected changes across the lifespan in the care of patients with psychiatric disorders and medical conditions; Apply knowledge of the major psychiatric disorders in the care of pediatric patients (including but not exclusive to mood disorders, anxiety disorders such as separation anxiety disorder, reactive attachment disorders, etc.); Prioritize a differential diagnosis by applying knowledge of psychopathology and medical illnesses;Apply knowledge of potential signs/symptoms of abuse when developing treatment plans, including when to report suspected abuse.

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

Emily Slott is a 10-year-old girl who has been brought to the Emergency Department with a new onset of seizures. Emily is reported by her parents to have been previously healthy and developmentally normal. She began complaining of headache and fatigue yesterday. She was given some acetaminophen and went to bed. When her mother checked on her, she had an oral temperature of 39.9°C. She was very sleepy, but took more acetaminophen. This morning, when her mother was going past Emily’s room, she heard some unusual thumping and gurgling noises. When she entered the room, she found Emily laying in bed “stiff as a board”, “frothing at the mouth”, with “her whole body shaking” and “her eyes rolled back in her head”. From when her mother found her, the event lasted an additional 2-3 minutes. After the shaking stopped, Emily became limp and unresponsive. She was still febrile. EMS was called and Emily was brought to the hospital.

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.

Demonstrate an understanding of the interface between psychiatry and medicine and the importance of identifying and treating psychiatric illness in medical patients. Discuss how medications can result in mood disorders and how to identify and treat mood disorders in medical patients. Discuss the importance of multi-disciplinary care in the treatment of patients with medical and psychiatric illness as well as issues such as addiction and chronic pain. Discuss the potential medical implications of treatment with SSRI medications. List some pharmacokinetic changes associated with aging. Identify cognitive changes associated with aging. Describe some common bed side cognitive assessment tools.

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.

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.

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.

Hannah, a 1-year-old girl, is brought to the clinic for a routine immunization by her mother. Mr. and Mrs. Rosen have a healthy 5-year-old boy at home. The pregnancy with Hannah was uneventful and a fetal ultrasound done at 16 weeks gestation was normal. The baby was born by spontaneous vaginal delivery, breathed immediately, and was placed on the breast for mom to nurse. Hannah's birth weight was 3.4 Kg. After seeming to feed normally for 24 hours, Hannah vomited bile and the abdomen was noted to be distended. An x-ray was interpreted as showing a distal small bowel obstruction. Further contrast x-rays of the colon showed a microcolon and inspissated meconium in the proximal colon, making a diagnosis of meconium ileus. Genetic testing confirmed cystic fibrosis. After a lengthy hospitalization to correct the bowel obstruction, Hannah was discharged home receiving exclusive breast milk. At 4 months of age, Hannah was switched to a cow's milk formula. Her mother noticed that she cried a lot. Hannah's mom attributed the symptoms to a milk allergy and progressed through a variety of cow's milk and soy formulae. At present Hannah is taking 1 litre of Rice milk and a small variety of foods daily. She has one small formed stool per day. She weighs 8.5 kg and is 74 cm tall.

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

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.

Part One: Jake Gamble, an obese 65-year-old man, presents complaining of back pain that began 5 days ago while shovelling snow. The pain becomes worse when he stands. Part Two: The patient reports he got over that last "attack" in less than a week but has had low back pain ever since. He now returns 2 years later because of another attack of acute back pain after chopping wood. Part Three: The patient returns in 6 weeks because the pain has not decreased. His legs feel "heavy," and he has had some incontinence in the last week.

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.

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.

Janet Woo is a 50-year-old woman with a history of intermittent palpitations. Over the last five years, she can recall infrequent and transient episodes of her heart "pounding in her chest". These episodes would not produce any other symptoms and would last no longer than a couple of minutes at a time, so she never sought medical attention. Earlier this evening, while watching television, she developed palpitations that did not resolve. She became diaphoretic, felt dizzy and somewhat short of breath and so called 911 and was brought to the ER.

You are seeing Jean La Barre in your clinic this afternoon. He has had a complicated course of Crohn’s disease requiring multiple surgical resections of his small bowel due to inflammation and obstruction. His type 2 diabetes mellitus is normally well controlled by metformin but whenever he requires prednisone for acute flare ups of his Crohn’s, his blood sugars become very high, particularly after meals.

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.

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.

Judy Patterson is a 22 year-old university student who presented to the Student Health Clinic with a rash on her lower legs. Her past medical history is unremarkable except for a urinary tract infection diagnosed 6 days ago for which she is taking trimethoprim-sulfamethoxazole. The only other medication she takes is the occasional dose of ibuprofen for headaches. She has never had any dental extractions or surgeries. On examination, she has no lymphadenopathy or splenomegaly, but she does have petechiae on her lower legs. You ask to look inside her mouth and there you see a blood blister on the inside of her cheek. She says she must have bitten it by accident.

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.

Kate Smith is a 15 year old girl. Her mother brings her to the family physician because she has not yet had her first menstrual period. Kate has been well throughout her childhood. Kate has a healthy appetite and weight. She does not receive any medications.

Katherine is a 16-year-old female attending high school who presents to you with complaints of depressed mood, increased appetite, and weight gain of 30 pounds. She lives with her parents and is an only child. Her mother indicates that her problems started less than one year ago when she was admitted to the hospital for several weeks after fighting at school. She was getting less than 4 hours of sleep for ten days because she was working on her new YouTube videos about fashion. She started getting suspicious of her family and friends, believing they were trying to poison her, so she stopped eating and lost 10 pounds in less than a week. She had several days of irritability and agitation to the point of pacing all night for three nights in a row before her admission. She was also yelling at family and friends (on her cellphone) all hours of the night. She had been using marijuana daily for about two years leading up to this hospitalization but stopped using while in hospital. She has not returned to marijuana use. Her psychiatrist treated Katherine with lithium 1200 mg po qhs and olanzapine 10 mg po qhs in hospital. She stopped her olanzapine after about two months but remained on the lithium. She had been taking her medications consistently until she gained 30 pounds. She is 5’4” and weighs 170 pounds.

You are a family doctor in Thunder Bay. On your day schedule you note that Lan Chen is booked to see you about "fatigue". She is a devout, hardworking nurse who has in the past year developed hypertension, hypercholesterolemia and Type II Diabetes. She is 45, has been married for 18 years and has three healthy sons, ages 10, 8, and 6. The patient presents as tense, tired, and clearly distressed. Ms. Chen complains of feeling "wiped out", constantly fatigued despite sleeping up to 12 hours at a time. She describes herself as feeling "useless" because she is falling behind on her work at home and is worried about her work at the hospital because she is having trouble focusing: "my thoughts keep jumping around and I'm never really sure what I've done. I keep checking things over and over to make sure I'm not making mistakes". She feels overwhelmed by the many decisions she has to make every day in the hospital, and the demands on her at home. She used to love her work, her family, and coaching soccer. Now she describes feeling intense dread driving to work, at times crying in the car, knowing how busy and intense the day will be. She likewise dreads coaching her soccer team: "This year's group is different, they're a bunch of lazy little brats". She is very upset because she yelled at two of the girls at the last game, and is even more upset because she is yelling at her own sons "all the time".

Lauren Bick is a 13-year-old girl who presents to her family physician's office with a 6-month history of weight loss. Her mother is concerned because she has noticed that Lauren has lost at least 10 pounds since her last doctor's visit which she had just before she started at her new school. Although Lauren has always been a "petite" girl, she is now the shortest in her class. The doctor asks Lauren's mom to give her a few minutes alone with Lauren. Once Lauren's mom has left the room, the doctor reviews the limits of confidentiality with Lauren and asks her about her weight loss. Lauren explains that she has met a new group of friends who do not believe that it is healthy to eat animals so she has joined them in following a vegan diet. She also reports that she's recently joined the long distance running club at her school. Lauren indicates that despite her mother's wishes, Lauren's goal is to get her weight down to 25 kg in the next few months. Lauren requests that you don't tell her mother this as it will likely cause them to argue. Lauren's menarche was at age 11 and she had been having regular menstrual periods but in the last 4 months, she has not had a period. Lauren indicates that she has not been sexually active. On questioning, she reports some constipation and says that she often feels cold.

Malcolm Lowry presents to the ED of the Hamilton General Hospital accompanied by his wife, Vita. He is seen by a second-year resident in Emergency Medicine and a clinical clerk. Mr. Lowry is a 47-year-old businessman. This afternoon, he collapsed in front of his wife, who observed that both arms and legs were shaking and that his eyes were rolled back. After 30-60 seconds the shaking stopped, but he was unresponsive for several minutes and remained drowsy and confused for half an hour. Vita called 911 and Malcolm was taken to the Emergency Department. The patient states that this has never happened to him before. He had no warning symptoms prior to collapsing. He does not remember collapsing. He did not soil himself or bite his tongue, but his muscles are sore. His past health has been good. He does not have hypertension, diabetes or other chronic health problems. He has never been hospitalized and he is not on any medications. He denies recent head trauma, febrile illness, headache or neurological symptoms. He has no family history of epilepsy. Vita states that Malcolm has been drinking alcohol heavily for a number of months but stopped two days ago after she removed all the alcohol from the house. Today he was so tremulous that he could hardly button his shirt. Malcolm points out that he has stopped alcohol for a day or two several times in the past few months, and although he has felt shaky he has never had a seizure.

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.

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".

Manuel Pereira and his wife have been trying to conceive a child for 16 months. After 12 months of trying, Michelle sought medical advice and so far, her investigations have been negative. You have suggested that since it takes two to make a baby, Manuel should undergo evaluation. Manuel reluctantly attends your clinic. He is quite certain that their inability to conceive can not be "his fault" because he fathered a child, by mistake, when he was 18

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.

Tutorials are held at least once every two weeks, for two to three hours per session. They are attended by all clerks in the MSS rotation, the tutor and may include a subspecialty resident. Format of the tutorial will be interactive and not didactic and would require clerks to prepare for the tutorial. The tutorials should be clinically focused and an emphasis may be placed on diagnostic and therapeutic issues. Tutorials can also be used to improve oral presentations, group and communication skills, and to develop a deeper understanding of the principles of the roles of a physician.

Mei Wang, a 24-year-old fitness instructor, stopped taking the oral contraceptive pill (OCP) 12 months ago, in order to conceive. She has remained amenorrheic since then. Mei's puberty was appropriate in terms of timing and secondary sexual development. However, she has always had infrequent and at times extremely heavy menstrual bleeding. As a teenager, she was prescribed the OCP to regulate her periods. She has been on the OCP ever since.

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.

Mr. Dupois is a 35-year-old French-Canadian man born in rural Quebec who moved to Hamilton with his wife a few years ago. His family physician noted a persistent rash around his eyes that he identified as xanthelasma. This prompted some blood tests and a referral to the Lipid Clinic. He is rather reluctant to see you at the Lipid Clinic because he is completely asymptomatic. He denies any significant medical history and is taking no medications. He is a lifelong non-smoker who faithfully walks to work for 1 km with no problems. A family history indicates that Mr. Dupois’ father died suddenly at the age of 46 with no clear explanation. He has multiple family members on his father’s side had a history of heart attacks, some at an unusually young age. His mother is healthy. On physical exam he has soft, velvety, yellowish, non-tender plaques in the palpebral area. Thickening of the Achilles tendons bilaterally were also noted. His blood pressure was 145/90 and waist circumference 98 cm.

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".

Mike is a 45 year old man who has worked as a labourer at one of the steel plants in Hamilton for years. The work requires frequent heavy lifting, particularly overhead. Mike smokes 1 pack of cigarettes per day. He has had a 1 year history of shoulder pain, which seems to be getting gradually worse. He has had to give up baseball and now is having trouble performing his job. He has not tried any treatment for his shoulder, other than Tylenol plain and icing it. On physical exam there is no muscle wasting. He is tender over the anterolateral aspect of the humeral head. Range of motion is good, but terminal flexion and abduction reproduce his typical pain. Muscle strength testing shows weakness in abduction, which also reproduces his typical pain. Provocative tests for impingement syndrome are positive, but provocative A-C joint and biceps tendon tests are negative. X-rays are done to evaluate the bony anatomy, and an ultrasound is performed to evaluate the rotator cuff.

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.

Neil Wartson is brought back to his family doctor 6 months later. The MRI has still not been performed, but the audiology testing confirmed severe sensorineural hearing loss on the right. Upon entering the office, Neil’s mother is very upset and agitated. Over the last month, she has noticed that Neil has become clumsier and is falling frequently. He also has started to rub his eye a lot and complains that things are “fuzzy”. She also reports that, since the last visit, Neil’s father has been investigated for his hearing loss. He is currently being worked up for Neurofibromatosis Type II. Neil’s mother has looked this up on the internet and is convinced that Neil has this as well.

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.

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.

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.

Using 2 patient/case examples, students will work in pairs to practice CBT skills taking turns to play the role of the patient and the therapist working together using the sample cases and materials provided.

Qamar is a 16-year-old female presenting to your office with her mother. Her mother indicates she is very worried about Qamar as she has lost 30 pounds over the last 3 months. Qamar herself is not concerned and says her mom is too controlling and should mind her own business. Qamar reports she just wanted to "get healthy" and there is no reason to be worried. Her mother reports that Qamar has been more active lately, running on their treadmill at home for at least an hour every day. Her mother also believes that she has heard Qamar vomiting in the bathroom, but when questioned, Qamar adamantly denies this. Her mother also has noted that Qamar has dramatically cut back on her intake in terms of the amount, but also that she will avoid certain foods like chips and ice cream completely. She used to like these foods. When she does eat, Qamar only picks at her food, cutting it into small pieces and pushing it around on her plate. She has also started to become concerned about contamination of food, and states that the food is "bad". She has started washing her hands repeatedly before and after eating. Qamar does admit that she has had trouble sleeping lately, and wakes up early in the morning, but she states her mood is good. Her mother feels her mood has been irritable and that she has been withdrawing from her family and friends. Qamar's mother also reports that she has not had a menstrual period in over 4 months.

Richard Strang, a 50-year-old male with a two-day history of sudden onset of acute pain and swelling of the left great toe, is seen at his family physician's office. It seemed to suddenly start when he awoke two days ago. It is so painful that he could not even tolerate the bed-sheet touching it. Richard works in construction, and routinely enjoys a few beers at the end of the day with his buddies. He had a similar attack in the right knee about 3 months ago, and right 1st MTP about 6 months. He was told that he had "the gout".

A healthy 3.6-kg baby boy, Riley, is born to a 25-year-old nulliparous mother in a community hospital. The family doctor notes that the boy's genital development is somewhat atypical. Her examination reveals that the infant has hypospadias, chordee and undescended testes. A plan is put in place for the infant to be seen by a pediatric urologist in 6 weeks with a view to eventual surgical correction. At one week of age, the infant is brought to the family physician's office for routine follow up. Riley's mother comments that he seems to be breastfeeding poorly. She describes him as increasingly uninterested in feeding and is concerned that he seems to be "spitting up" a lot. The infant now weighs 3.1 kg. A recommendation is made to begin some formula supplementation to help support weight gain. At 10 days of age, Riley's mother finds him in his crib, non-rousable, cool, mottled and covered in vomit. Riley is rushed to the emergency department via ambulance. In the emergency room, resuscitative measures are initiated. The airway is suctioned. He is intubated and hand-bagged to achieve ventilation. A 20 mL/kg bolus of normal saline is administered.

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

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.

Ronnie Olchuk is a 6-year-old boy who was hit by a car while crossing the street. A witness at the scene said he was hit on the left side and thrown approximately 20 m. He is healthy, has no allergies, and has never had surgery. He last ate eight hours ago. He has been stabilized by the trauma team, is alert and oriented, and has no injuries except to his right forearm and left thigh. His distal right forearm is badly deformed. His left thigh has a 2 cm laceration located medially and is also badly deformed. He is in excruciating pain, especially in the right forearm.

Samira Shah is a 27 year old woman who works as a waitress in a local restaurant and is in her first pregnancy. She is slightly overweight (pre-pregnancy BMI 28.5). Her prenatal care has been unremarkable although she was found to be rubella non-immune and had a positive glucose challenge test (GCT) followed by a negative glucose tolerance test (GTT). Now at 38 weeks, she has abdominal cramping and slight bright red vaginal bleeding. Her husband, Sunny, informs Hanna’s midwife of this. Her midwife comes to their apartment to assess Samira.

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.

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.

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.

Shelley Clerke is a 72-year-old woman who has had Parkinson's disease for over 10 years. Initially the disorder presented with tremor on her right side. She has been managed by her family doctor and local neurologist. Over the years her medications have been adjusted and new medications added to control her symptoms. More recently, she is experiencing increasing difficulty with activities such as eating and signing her name due to the tremor. Two years ago she started using a rollator walker when her balance and overall mobility made it difficult for her to ambulate in the community with just a cane. Today she has an appointment with her neurologist. The neurologist notes the increase in tremor and her poor overall mobility compared to when he last reviewed her 6 months ago. Her Parkinson medications include: Levodopa/carbidopa 250/25 mg QID, entacapone 200 mg QID, ropinirole 3 mg QID, and amantidine 100 mg BID. On examination she has an obvious and severe right-sided resting tremor that does not completely stop when she raises her arms. She has difficulty getting out of the chair and on to the examination table.

Today, Siobhan came in sobbing, dragging a reluctant 8-year-old Skylar behind her. She wailed, "He's turning out just like his Dad. Before you know it he'll be in jail for assault, I'm scared of both of them." Siobhan explains that Skylar punched a boy in the face today and was suspended for 3 days. Evidently, there have been numerous incidents at school where the Grade 3 teacher claimed Skylar was the aggressor. This implied information about Skylar 's father was news to you and you suspect that there was more going on in the home than Siobhan had shared with you in the past. You wonder how to approach Siobhan about this.

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.

Susan Weiss is a 53 year old woman (G3P3) who presents to her family doctor stating she is having difficulty sleeping. She is waking up drenched through the night. She complains of having sweating episodes throughout the day that are debilitating and embarrassing. She is irritable with her family and states they do not understand "the change". It has been 18 months since her last period. She has no libido and when she tries to be intimate with her partner, she is extremely dry.

Mrs. Tammy Polk is very difficult to interview. She is an extremely vague and difficult historian. Her family tell you that she was diagnosed with breast cancer 5 years ago and had a mastectomy at that time. Her husband died 6 months ago and she has never really recovered. Over the past week, the family have been worried that she is "developing Alzheimer's" because of memory problems and agitation. Past psychiatric history is notable for mild depression, treated with paroxetine 20mg daily, and sleep difficulties that are chronic and date back to her days as an alcoholic. One month ago, she was started on 50 mg of quetiapine at bedtime for sleep by her family doctor. Two weeks ago, she was given Oxybutinin (Ditropan) to help with some urinary incontinence, with good effect on her bladder problem. She is admitted to hospital for further medical work-up. The 1 pm nursing note reads: "quiet, resting comfortably, oriented x 3." The results of CBC, serum electrolytes and urinalysis are pending. The medical resident calls for psychiatric consultation at 4:05 pm because the patient has become agitated and has voiced suicidal ideation. The consult note reads: "medically cleared, please transfer to psychiatry for treatment of emotional instability and psychotic depression." The psychiatric resident arrives at 5 pm and finds that the patient is visually hallucinating and disoriented.

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.

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.

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.

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.

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

Demonstrate competency in performing the following interpretive skills

One hundred multiple choice questions via the web. The exam is timed.

By the end of this session students should be able to: Critically appraise at least one clinical decision rule or tool fully and be able to explain its application and limitations; Identify the role of clinical decision rules in the management of key disorders presenting to the emergency department; Discuss the role of clinical decision rules in ensuring judicious use or preventing misuse of certain outcomes, such as diagnostic test usage (e.g. PERC to decrease use of D-Dimer, or some of the Ottawa rules for decreasing X-rays); Deliver an effective oral presentation; Critique peers’ presentations and presentation style.

Domains assessed: Fund of Knowledge, Knowledge Integration, History taking, Clinical Examination, Clinical Management, Learning Skills, Communication Skills, Professional Responsibility and Integrity, Pursuit of Excellence and Insight, Personal Interactions.

National Board MedicalExaminer Subject Examination, a standardized US examination for clinical clerks.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

The OSCE Objective Structured Clinical Examination is a mandatory evaluation exercise in which students individually rotate through a number of stations and are observed performing history or physical examinations or performing some other medically relevant task. It is mainly used for the evaluation of clinical skills that include professional deportment and patient interaction.

Periodically, students may be asked to complete a Pro Comp Integrative Exercise. This will be in the form of a case scenario(s) to which students will respond in writing. The exercise will allow students to display their understanding of the Pro Comp concepts studied to date. The exercises will be assessed by the students’ own LFs.

Periodically, students may be asked to complete a Pro Comp Integrative Exercise. This will be in the form of a case scenario(s) to which students will respond in writing. The exercise will allow students to display their understanding of the Pro Comp concepts studied to date. The exercises will be assessed by the students’ own LFs.

Periodically, students may be asked to complete a Pro Comp Integrative Exercise. This will be in the form of a case scenario(s) to which students will respond in writing. The exercise will allow students to display their understanding of the Pro Comp concepts studied to date. The exercises will be assessed by the students’ own LFs.

Students create the ‘On-demand’ evaluation on MedSIS for each clinical day and for each call shift. Unless there is a holiday, there should be a total of 9 'On-demand' clinical evaluations at the end of your rotation. It is the student's responsibility to generate the form on MedSIS and bring it to the supervisor to fill it out near the end of the day.

Students must receive a satisfactory evaluation for their PES call experience.